My suggestion is to perform a double TN/STJ
arthrodesis. You can avoid additional trauma by
simply extending your TN incision proximally and
resecting the STJ through the medial incision.
I suggest this for a few reasons. First, the
patient is a healthy 75 year old with documented
radiographic signs of arthritis in the STJ. It
seems that your only reason not to do it is to
spare her the pain. I postulate that not fusing
the joint will leave her with arthritic pain in
the hindfoot for years to come.
Second, fusing the TNJ has been shown to reduce
STJ ROM by 90%. This residual ten degrees of
motion strains your TNJ fusion and increases the
risk of non-union. If you're eliminating the
majority of the motion anyway, it seems prudent
to fuse the other arthritic joint.
Third, the patient has already had a previous
surgery to fix this problem. I always try to
give my patients the peace of mind that I will
do what I can to make the next surgery the last
one.
Finally, repositioning an arthritic joint will
strain it further and make it more painful. It
was the position of the foot (calcaneal valgus
and forefoot abduction) which led to the
arthritis. Repositioning the heel into 5 degrees
of valgus and plantarflexing and adducting the
medial column eliminates or reduces the
positional component of the deformity, leading
to fewer future problems.
Also, performing the arthrodesis from a medial
approach aids in repositioning the heel as it is
easier to resect the more bone from the medial
aspect of the joint. Below is an article by Dr.
Michael Lee describing the procedure in detail.
Clin Podiatr Med Surg. 2007 Oct;24(4):735-44,
ix. Medial approach to the severe valgus foot.
Lee MS.
Peter Walimire, DPM, Fort Myers, FL,
pwalimire@gmail.com
