Patients suffering from severe arthritis of the ankle or foot, or patients with pes planus, or “flat foot,” commonly undergo fusion of the hind-foot joints (triple arthrodesis). When successful, such arthrodeses can eliminate or substantially decrease pain associated with weight-bearing activities.
“Patients can expect almost normal activity following hind-foot arthrodesis, although side-to-side motion is limited,” explains Paul Juliano, M.D., chief of foot and ankle orthopaedics at Penn State Hershey Bone and Joint Institute. “A potential negative consequence of this procedure is that the joints above and below the fused area take extra stress, and as a result, arthritis can progress in the ankle and the mid-foot,” explains Juliano.
Pantalar arthrodesis (the addition of an ankle arthrodesis to a previously performed hind-foot arthrodesis) has been traditionally performed as a salvage procedure, to alleviate severe pain and stabilize an unstable ankle or foot. Juliano notes, however, “While the pantalar arthrodesis can alleviate pain, it leaves the patient with something very similar to a ‘peg-leg’, with no ability to flex the foot forward and back or side-to-side. Functionality is poor. One could also expect arthritis and pain to progress in the knee and hip.”
Total ankle replacement has emerged as an alternative to hind-foot fusion; it also may be performed as an alternative to pantalar arthrodesis for patients with a previous hind-foot fusion and progressive arthritis. “Total ankle replacement is done at many academic medical centers, but is still not performed in large numbers,” says Juliano. He has performed 130 ankle replacements in the last ten years, approximately twenty of which were replacements over previous hind-foot fusions.
Shown here are images of a case for which Juliano performed a total ankle replacement on top of hind-foot fusion. “With a total ankle replacement, motion of the ankle is maintained (dorsiflexion and plantarflexion). While wound complications can occur for patients who had previous arthritis surgery, they can be usually managed for successful limb salvage. Compared to pantalar arthrodesis, this procedure offers an increased quality of life due to better mobility and improvements in the total ankle prosthesis,” says Juliano. An ideal candidate for this procedure is anyone with a previous hind-foot fusion and with ankle arthritis in the same extremity.
Paul J. Juliano, M.D.
Chief, Foot and Ankle Orthopaedics
Vice-chair and Residency Program Director, Department of Orthopaedics
Professor, Foot and Ankle Orthopaedics
Fellowships: Orthopaedic surgery, Union Memorial Hospital, Baltimore, Maryland and University of Maryland Medical System, Baltimore, Maryland
Residency: Orthopaedic surgery, National Naval Medical Center, Bethesda, Maryland
Medical School: Georgetown University School of Medicine, Washington, D.C