Triple fusion: For calcaneal fracture malunion



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The triple Fusion is an effective procedure to treat both severe arthritic symptoms and deformity of the hindfoot. The joints addressed in this operation are the subtalar, the talonavicular and the calcaneocuboid joint. Key to the procedure is joint preparation and correction of the deformity, aiming to achieve a solidly united foot in the correct alignment in order to restore the mechanical axis and provide a foot the fits adequately it into a shoe.

Hind foot pain and arthritis following calcaneal fractures can be challenging to treat. There are though a limited number of well recognised potential causes for pain, that should be carefully enquired about in every patient suffering after calcaneal fracture, whether they have been treated primarily by operative reduction and fixation, or not. Lateral hindfoot pain, in the region of the fibular tip, can occur secondary to subtalar fibrosis, subtalar arthritis or lateral wall impingement, or all of these. Pain from the plantar aspect of the heel can occur due to malunion of the plantar surface of the calcaneus or disruption of the heel fat pad at the time of injury. A loss of support for the talus, secondary to flattening of Bohlers angle, can lead to a dorsiflexed talus and anterior ankle impingement.

When surgically salvaging a malunited calcaneal fracture there can be a number of novel challenges, including a “blown-out”, widened lateral calcaneal wall that can make access to the subtalar joint difficult and causes subfibular impingement. Bone loss and impaction of the posterior facet of the subtalar joint that may leave bone voids and also effect produce dorsi-flexion of the talar body, leading to anterior ankle impingement (that needs to be addressed by resupporting the talus with a structural bone graft inserted intothe posterior aspect of the subtalar joint). Partial unions associated with the fracture, such as of the anterior process, may need to be addressed at the same time as the arthrodesis procedure.

Careful consideration should be given to accessing the relevant joints, malunions, and nonunions prior to surgery, in order to plan the optimal approach to address each of these issues. Access may be different to the standard sinus tarsi approach employed for the primarily degenerate subtalar joint.

The lateral approach to the calcaneum is well established in treatment of calcaneal fractures and  incorporates the angiosome of the peroneal artery. The same extensile approach  can be utilised for a subtalar arthrodesis where the dorsal flap is elevated along with the peroneal tendons up to the tip of the fibula to expose the lateral wall of the calcaneum and the subtalar joint. The subtalar joint is often obscured in cases where the lateral wall has been particularly blown-out and once the lateral wall is excised an excellent exposure to the subtalar joint can be achieved.


Functionally patients with their triple arthrodesis can perform very well during standard activities of daily living although they may encounter some stiffness and difficulty on uneven ground. However, it should be put into context that function is often very restricted prior to surgery in any case. Such limitations as may occur post-operatively can be minimised with an appropriate orthotic and shoewear combination.

OrthOracle readers will also find the following associated techniques of interest:

Calcaneal fracture: fixation with extended lateral approach and ZimmerBiomet ALPS plate

Calcaneal fracture: Percutaneous fixation of Tongue-type fracture.

Calcaneal fracture fixation: Extended lateral approach and locking plate fixation

Calcaneal fracture fixation : Internal fixation of sustentaculum tali fracture (Acutrak screws)

Triple Fusion

Subtalar fusion and Talonavicular arthrodesis (open technique) using Stryker anchorage 2 plating system

Arthroscopic subtalar fusion


Author: Nick Cullen FRCS (Tr & Orth)

Institution: The Royal National Orthopaedic Hospital, Stanmore, London, UK.

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