What are the surgical intervention options for a patient with subtalar and talonavicular arthritis?

Surgical Intervention Options for Subtalar and Talonavicular Arthritis

For patients with symptomatic subtalar and talonavicular arthritis, the primary surgical option is arthrodesis (fusion) of the affected joints, which can be performed as either a double arthrodesis (subtalar + talonavicular) or triple arthrodesis (adding calcaneocuboid joint), depending on the extent of disease and deformity. 1, 2

Primary Surgical Options

Double Arthrodesis (Subtalar + Talonavicular)

• Double arthrodesis is the preferred option when the calcaneocuboid joint is not involved in the primary disease process 2
• This procedure provides significant improvement in pain and function while preserving the calcaneocuboid joint, potentially reducing stress on adjacent joints 2
• Clinical outcomes show improvement in AOFAS Ankle-Hindfoot Scale from 44.7 preoperatively to 77.0 postoperatively (p < 0.01) 2
• All patients in one series reported satisfaction and would undergo the procedure again under similar circumstances 2
• This is a reasonable treatment specifically for symptomatic hindfoot malalignment when the calcaneocuboid joint is uninvolved 2

Triple Arthrodesis (Subtalar + Talonavicular + Calcaneocuboid)

• Triple arthrodesis should be used when all three joints are involved or when significant fixed deformity requires correction across all hindfoot joints 1, 3
• This procedure involves fusion of the subtalar, talonavicular, and calcaneocuboid joints 1, 4
• Historically evolved for paralytic deformities but now primarily performed for posttraumatic arthritis, rheumatoid arthritis, or end-stage posterior tibial tendon rupture with fixed bone deformity 1
• When proper alignment is obtained, predictable and significant improvement in symptoms occurs 1
• The procedure can be performed through either a double-incision approach or single-incision lateral approach with similar outcomes 3

Indications for Surgery

Surgery should be considered when:

• Painful, fixed deformity exists that is refractory to conservative treatment 1
• Disabling instability is present 1
• Symptomatic hindfoot malalignment with arthritis affects quality of life 2
• Stage III planovalgus deformity with involvement of these joints 3

Technical Considerations

Surgical Approach

• Single-incision lateral approach reduces operative time (86 minutes vs 95 minutes, p = 0.0395) compared to double-incision technique 3
• Both approaches show equivalent deformity correction, union rates, wound healing, and complication rates 3
• Rigid internal fixation with screws is the standard technique 2

Concomitant Procedures

• Gastrocnemius recession should be performed concurrently when equinus contracture is present (performed in 15 of 16 feet in one series) 2
• This addresses the biomechanical contribution to hindfoot pathology 2

Expected Outcomes and Complications

Benefits

• Significant improvement in pain, function, cosmesis, and shoewear 2
• Predictable symptom relief when proper alignment is achieved 1
• High union rates across all joints when modern fixation techniques are used 5

Complications to Anticipate

• Residual discomfort and secondary arthrosis of the ankle and tarsometatarsal joints should be expected 1
• Loss of hindfoot motion is an inevitable consequence 1
• Potential complications include residual deformity, pseudarthrosis, avascular necrosis of the talus, and adjacent joint arthritis 1
• Radiographic evidence shows increased arthritic changes in six ankle joints, six calcaneocuboid joints, and five midfoot joints postoperatively 2
• Nonunion rates are low but can occur, particularly in rheumatoid patients 2
• The calcaneocuboid joint shows low rates of symptomatic nonunion even when fused, suggesting its fusion may not be critical for symptom relief 3

Special Populations

Charcot Neuro-Osteoarthropathy

• In patients with active Charcot neuro-osteoarthropathy affecting the subtalar or talonavicular joints with instability, deformity at high risk of ulceration, or intractable pain, surgical intervention should be considered 6
• Proximal deformities of the hindfoot are especially difficult to manage with casting due to coronal plane deformities 6
• Reconstructive surgery includes realignment arthrodesis but is associated with high complication rates 6
• Surgery is indicated when deformities result in impending skin ulceration, severe instability, intractable pain, or inability to immobilize in a cast, as these can increase amputation risk six to 12-fold 6

Clinical Caveats

• Triple arthrodesis should be used as a salvage operation primarily in older patients due to the significant complications and loss of motion 1
• The procedure is technically demanding with prolonged recovery time 1
• Despite complications, most patients with appropriate indications report significant improvement in symptoms and function 1
• The decision between double and triple arthrodesis hinges on calcaneocuboid joint involvement—spare it if uninvolved 2, 3