fortin - posterior tibial tendon insufficiency isolated fusion of the talonavicular joint

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ADULT ACQUIRED FLATFOOT DEFORMITY 1083–7515/01 $15.00 .00

POSTERIOR TIBIALTENDON INSUFFICIENCY

Isolated Fusion of the Talonavicular Joint

Paul T. Fortin, MD

Isolated fusion of the talonavicular joint has been shown to correctthe components of flatfoot deformity in the clinical setting and in ca-daver flatfoot models.9, 15 Fusion of the talonavicular joint imparts asignificant restriction of motion on the hindfoot, however, and has thepotential consequence of arthrosis of adjacent joints. Isolated fusion ofthis joint has been reported to have a higher incidence of nonunion thanfusion of other joints in the foot.13, 24 Concomitant soft tissue balancingprocedures and osteotomies sometimes can be helpful in improving theresults of talonavicular fusion. With careful operative technique andappropriate patient selection, talonavicular fusion can be a useful meansof producing a painless plantigrade foot in patients with flatfoot de-formity secondary to posterior tibial tendon dysfunction.

ANATOMY AND MECHANICS

The talonavicular joint is a ball-and-socket joint. The talar head iscovered completely with articular cartilage. The navicular articular sur-face is biconcave and smaller than the corresponding talar head surface.The navicular bone slides, rolls, and spins on the talar head. The deepsocket that receives the talar head is a complex articulation that has beenreferred to as the acetabulum pedis. It is formed by the navicular bone,

From the William Beaumont Hospital, Royal Oak, Michigan

FOOT AND ANKLE CLINICS

VOLUME 6 • NUMBER 1 • MARCH 2001 137



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anterior and middle calcaneal facets, bifurcate ligament, and calcaneo-navicular (spring) ligaments. The flexibility of the acetabulum pedisallows it to change in form and size to accommodate to displacements

of the talar head, calcaneus, and navicular bone. The calcaneonavicularcomplex can be considered as a functional unit moving around the talus.Any instantaneous motion between the calcaneus and the talus occurssimultaneously at the anterior and posterior talocalcaneal joints and atthe talonavicular joint. In other words, there is coupled motion betweenthe hindfoot and forefoot.21 The talonavicular joint has the greatest rangeof motion of the triple joint complex.1

At heel-strike, the eccentric position of the calcaneus with respectto the talus creates a valgus thrust on the subtalar joint, the axes of thecalcaneocuboid and talonavicular joints are parallel or unlocked, and the

navicular bone moves laterally on the talar head.3, 17

The posterior tibialtendon passes posterior to the axis of the ankle joint and medial to theaxis of the subtalar joint. As a result of this course, the tendon acts toplantar flex the ankle and invert the hindfoot.20 Contraction of theposterior tibial tendon during normal gait inverts the hindfoot, and theaxes of the talonavicular and calcaneocuboid joints become nonparallelor locked, creating a rigid lever for forward propulsion of the foot. Withposterior tibial tendon dysfunction, the hindfoot remains in valgus, andthe navicular bone remains dorsolaterally displaced on the talar head.With normal loading of the foot, there is an increase in the contact area

of the talonavicular joint and a uniform distribution of contact acrossthe joint surface. In a simulated flatfoot model, Kitaoka et al10 showed adecrease in talonavicular joint contact area and an increase in contactfrequency in the dorsal aspect of the joint; this may help explain whypatients with long-standing flatfoot deformity can develop degenerativechanges of the talonavicular joint.

O’Malley et al15 evaluated the ability of various arthrodesis proce-dures to correct the components of an experimentally created flatfootdeformity. The amount of correction that was obtained with selectivehindfoot fusions was measured radiographically. Isolated fusion of the

talonavicular joint was shown to correct forefoot abduction, longitudinalmidfoot collapse, and hindfoot valgus to the same extent as a triplearthrodesis. In contrast, isolated fusion of the subtalar joint failed tocorrect forefoot abduction. This study shows the key role that the talona-vicular joint has in controlling the triple joint complex. Correction ofdeformity with talonavicular fusion entails a significant loss of motion,however. Astion et al1 evaluated the range of motion of the subtalar,calcaneocuboid, and talonavicular joints after various simulatedarthrodesis procedures. These authors found that any combination ofsimulated arthrodeses that included the talonavicular joint severely lim-

ited the motion of the remaining joints to about 2 and limited theexcursion of the posterior tibial tendon to about 25% of the preoperativevalue. Talonavicular fusion also decreases ankle range of motion. Harperand Tisdel9 reported an average loss of ankle motion of 10. Most of theankle motion lost after fusion was plantar flexion.



POSTERIOR TIBIAL TENDON INSUFFICIENCY 139

PATIENT SELECTION

No consensus exists as to which patients with flatfoot deformity are

suited best for talonavicular fusion. Patient age, severity and flexibilityof the deformity, and the existence of degenerative changes are im-portant factors in the decision-making process. In younger patients withflexible deformity, joint-sparing procedures involving osteotomies andsoft tissue balancing have the potential advantage of preserving motionand limiting adjacent joint arthrosis.14 In patients with lower physicaldemands, loss of hindfoot motion is not likely to have the same func-tional implications. Older patients with more severe or fixed deformitygenerally are candidates for arthrodesis. Triple arthrodesis is the histori-cal standard for correction of hindfoot deformities and has been reported

to be an acceptable method for treatment of late-stage flatfoot deformity.7,

8, 19 The decision whether to perform a triple arthrodesis or a morelimited fusion, such as a subtalar, double, or isolated talonavicularfusion, is largely a matter of surgeon preference. There are aspects ofeach deformity, however, that should be taken into account when choos-ing the appropriate procedure. A mobile subtalar joint that is free ofany significant degenerative changes typically is required for isolatedtalonavicular joint fusion to be effective. Severe fixed hindfoot valgusmay not correct adequately with reduction and fusion of the talonavicu-lar joint alone. These patients may be treated best with a triple

arthrodesis to correct the deformity. With triple arthrodesis, however,excessive residual heel valgus sometimes can persist and lead to valgustilt of the ankle and persistent lateral hindfoot pain.8 Adjunctive proce-dures, such as gastrocnemius-soleus lengthening and medial displace-ment calcaneal osteotomy, may be necessary in these patients to balancethe foot properly. Isolated talonavicular joint fusion and medial displace-ment calcaneal osteotomy is an alternative to triple arthrodesis in casesof severe planovalgus deformity when the remaining hindfoot joints arefree of degenerative changes (Fig. 1).

EVALUATION

Patients that are candidates for talonavicular fusion have severepainful deformity refractory to orthotic management. Whether the footis fixed or flexible is one measure of the severity of a deformity. Degener-ative changes and soft tissue contracture can lead to fixed peritalarsubluxation. If the talonavicular joint can be passively reduced, theposition of the heel with the joint reduced should be assessed. Thisassessment gives an indication of how well isolated fusion of the talona-

vicular joint would correct the deformity. Commonly, patients withsevere deformity have residual heel valgus despite a well-positionedtalonavicular joint, and this may require simultaneous correction at thetime of talonavicular arthrodesis. This correction can be accomplished by concomitant medial displacement calcaneal osteotomy (see later).



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Figure 1. Preoperative anteroposterior (AP) (A and B ) and postoperative lateral (C and D )radiographs of severe acquired flatfoot with degenerative changes of the talonavicular joint.Subtalar and calcaneocuboid joints were without significant degenerative changes. Isolated

talonavicular fusion and medial displacement calcaneal osteotomy was used as an alterna-tive to triple arthrodesis with improvement in the radiographic parameters of deformity.Illustration continued on opposite page

Patients often have tightness of the gastrocnemius-soleus complex; thisis assessed by testing ankle dorsiflexion with the talonavicular jointreduced and the knee flexed and extended. Limited ankle dorsiflexiononly when the knee is extended suggests tightness only in the gastrocne-mius, whereas limited ankle dorsiflexion with the knee flexed suggeststhat the gastrocnemius and the soleus are tight. Isolated gastrocnemiustightness can be treated by recession of the gastrocnemius muscle,whereas tightness of both should be treated by Achilles tendon lengthen-ing. It is important and sometimes difficult to determine all of the




Figure 1 (Continued).

components of a deformity when considering surgical intervention for asevere flatfoot.

Peritalar subluxation seen in patients with acquired flatfoot oftencan be accompanied by significant abnormality at the ankle, intertarsal,and tarsometatarsal joints that contribute to the deformity and canaffect the results of talonavicular fusion. The radiographic parameters ofperitalar subluxation have been well described.18 More subtle signs of

secondary or concomitant deformity also are important. This deformitymay be evidenced by gapping or sagging of the more distal midfoot joints on the standing lateral radiograph. Standing anteroposterior ankleradiographs can show tilting of the talus and lateral tibiotalar joint spacewear (Fig. 2). Hindfoot alignment views can be used to assess thecalcaneal-tibial axis. These views allow side-by-side comparison withthe opposite side and can be helpful to confirm that the heel valgus isnot the result of abnormal tibial alignment. Assessment of the deformityshould be systematic. The overall lower extremity alignment is im-portant. In patients with concomitant knee deformity, there is no consen-

sus as to whether the foot or knee is corrected first. Usually the moresymptomatic joint is approached first. Hindfoot fusion that is donewithout consideration of knee malalignment can lead to a poorly posi-tioned foot when the patient later undergoes total knee replacement ortibial osteotomy. Moving distally, the ankle joint is assessed for stability,



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Figure 2. Standing AP ankle radiograph of patient with severe flatfoot deformity revealsattenuation of medial ligamentous support, valgus talar tilt, and lateral tibiotalar jointspace wear.

Figure 3. Maintaining the normal contour of the talonavicular joint and the use of compres-sion screws maximize the rate of talonavicular union.

deformity, and degenerative changes. Occasionally, patients with long-standing flatfoot deformity secondary to posterior tibial tendon insuffi-ciency have unstable degenerative ankles as a result of excessive valgushindfoot alignment, which also may require treatment. Finally, the mid-foot and forefoot need to be evaluated. This area can be assessed byexamining carefully the position of the forefoot and the amount of

sagittal plane motion of the first metatarsal when the talonavicular jointis held reduced. Instability and collapse of the more distal medial col-umn joints of the foot can be the cause of residual pain and deformityafter talonavicular arthrodesis.

SURGICAL TECHNIQUE

Regardless of the method chosen to correct a flatfoot deformity, themechanics of correction are similar among various procedures. Surgical

technique involves restoration of medial column support, correction ofthe calcaneal tibial axis, and balancing of the soft tissues. In the author’sexperience, patients best suited for talonavicular arthrodesis are thosethat have more advanced deformity, typically with severe heel valgus.Although slight residual heel valgus is desirable, excessive residual heel




valgus after hindfoot fusion can lead to progressive valgus tilt of thetibiotalar joint and lateral joint space wear.4, 7 Because of this concern,medial displacement calcaneal osteotomy is done routinely on patients

undergoing talonavicular fusion for flatfoot deformity.The patient is placed in a semilateral position to facilitate lateralhindfoot exposure. Once the limb is anesthetized, tightness of the gas-trocnemius-soleus complex is assessed. The ankle is dorsiflexed with thetalonavicular joint held maximally reduced. The knee is flexed andextended to determine the need for gastrocnemius recession versusAchilles tendon lengthening. Achilles tendon lengthening is performedpercutaneuously using a triple hemisection technique. Gastrocnemiusrecession is performed through a longitudinal incision made in themiddle of the calf. Care is taken to avoid injury to the medial sural

cutaneous nerve. The aponeurotic tendon of the gastrocnemius is identi-fied and separated from the underlying soleus muscle. The aponeurotictendon of the gastrocnemius is divided, leaving the underlying soleusundisturbed. The foot is dorsiflexed carefully to allow the appropriateamount of ankle dorsiflexion. The lateral wall of the calcaneus is ex-posed, and the calcaneal tuberosity is osteotomized and displaced medi-ally in the manner described by Koutsogiannis.11

Talonavicular joint arthrodesis for severe flatfoot is more technicallydemanding than fusion in situ, such as with an arthritic hindfoot.Arthrodesis must be performed meticulously to position the foot accu-

rately, avoid shortening of the medial column, and stabilize the fusionadequately. The talonavicular joint is approached through a longitudinaldorsomedial incision just medial to the tibialis anterior tendon. Subcap-sular dissection proceeds dorsally to expose the talonavicular joint. Ag-gressive stripping of the talar neck and navicular bone should beavoided so as to preserve blood supply to the area. Cartilage andsubchondral bone are removed with attention to the navicular bone because of its often sclerotic nature. A lamina spreader in the jointfacilitates exposure of the lateral most aspect of the talonavicular joint.A power bur is used to contour the navicular surface and remove the

dense subchondral bone. Care is taken to maintain the normal contourof the navicular bone and the talus to facilitate reduction of the jointand maximize apposition of the bone surfaces (Fig. 3).

Accurate joint reduction is the most difficult and important part ofthe procedure. In patients with long-standing posterior tibial tendoninsufficiency with severe peritalar subluxation, the navicular bone restssubluxated on the dorsolateral aspect of the talar head. Mobilizing itfrom this position constitutes most of the reduction maneuver. A later-ally directed force is applied to the talar head, and the navicular bone isswung medially and plantar to cover the talar head. The degree of

talonavicular coverage can be verified radiographically. Cancellous bonegraft from the iliac crest or calcaneus is used to fill in small areas wherethere is lack of perfect bone apposition. Once proper position has beenestablished, lag screw fixation is used to secure the fusion site. Twoscrews offer the advantage of better rotational control and are preferable.



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Figure 4. A, Correction of forefoot abduction seen with peritalar subluxation is accomplishedby adducting the forefoot and centering the navicular on the talar head. B, The forefootshould be derotated simultaneously in the direction shown (arrow) to correct forefoot varus.

As the navicular bone is swung medially, there is a tendency for the footto supinate as a result of forefoot varus that often exists in severeplanovalgus deformities. Forefoot varus must be corrected by rotating

through the arthrodesis site, and the adequacy of this reduction is judged clinically (Fig. 4). In some patients, despite a properly positionedtalonavicular fusion site, medial column support may remain inade-quate. This inadequacy may be evidenced by hypermobility of the me-dial tarsometatarsal or naviculocuneiform joints that require extendedmedial column arthrodesis (Fig. 5). Postoperatively, patients are immobi-lized in a non–weight-bearing cast for 6 weeks followed by a walkingcast for 4 weeks.

RESULTS

Much of the literature regarding isolated talonavicular fusion has been in patients with rheumatoid arthritis and is of limited value whencomparing use of isolated talonavicular fusion in adult flatfoot defor-




Figure 5. A, Preoperative lateral radiograph of patient with severe peritalar subluxation andconcomitant instability of the distal midfoot with plantar gapping of the first metatarsalcuneiform joint. B, Postoperative lateral radiograph after talonavicular arthrodesis, calcanealosteotomy, and plantar flexion fusion of the first metatarsal cuneiform joint shows restorationof the longitudinal arch.

Illustration continued on following page

mity.2, 12 There are no long-term follow-up studies on isolated talonavicu-lar fusion specifically for adult flatfoot deformity. Intermediate-termfollow-up studies of its use for traumatic disorders as well as short-termfollow-up of talonavicular fusion for posterior tibial tendon insufficiency

suggest that results are comparable to other hindfoot fusion tech-niques.7–9, 19

Fogel et al5 reported on 11 patients treated with isolated talonavicu-lar arthrodesis for talonavicular arthrosis with follow-up 2.5 to 21 years.None of the patients had arthrosis of the talonavicular joint specificallyas a result of acquired flatfoot deformity. All patients had satisfactorypain relief, but all had some difficulty walking on uneven groundsecondary to pronounced reduction of subtalar motion. The authorsnoted diminished terminal stance phase plantar flexion. There was onenonunion. Three of the 11 patients developed adjacent joint arthrosis at

the subtalar or intertarsal joint after talonavicular fusion. None of thepatients were noted to have developed ankle arthrosis after fusion.

Scranton22 reported on the results of a series of 41 patients undergo-ing subtalar, talonavicular, or triple arthrodesis. Good results were ob-tained in all 4 patients undergoing isolated talonavicular fusions. There



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Figure 5 (Continued). C, Hindfoot alignment view shows severe heel valgus. D, Postopera-tive hindfoot alignment view shows correction of heel valgus.

were no nonunions using an inlay tricortical iliac crest graft technique.The authors did not specify the type of preoperative deformity or thespecific reason for talonavicular fusion.

Harper and Tisdel9 reported on 27 patients with posterior tibialtendon insufficiency treated with isolated arthrodesis of the talonavicu-lar joint. There was a wide range of patient ages (39 to 74 years) withan average age of 57 years. All patients had an asymmetric planovalgusdeformity. The severity of the deformity was not specified clinically orradiographically. Good-to-excellent results were obtained in 24 of 27patients. Patients were followed for a minimum of 1 year. Progressive

adjacent joint arthrosis of the naviculocuneiform or talocalcaeal joint wasnoted in 4 patients. None of the patients were noted to have progressiveankle arthrosis after the arthrodesis.

Fortin and Grant6 reported on isolated talonavicular fusion andcalcaneal osteotomy for severe peritalar subluxation secondary to poste-




rior tibial tendon insufficiency. Because of the severity of the heel valgus,medial displacement of the calcaneus was performed in all patients.Fourteen patients were followed for a minimum of 1 year. Patients had

pain and deformity for more than 1 year and more advanced deformitywith lateral talometatarsal and talonavicular coverage angles of 30 orgreater. Bone grafting and compression screw fixation were performedin all patients. Twelve of 14 patients were satisfied without reservation.Thirteen of 14 patients had resolution of pain that was present preopera-tively.

Lateral midfoot pain has been reported to occur after isolated talon-avicular joint fusion for posterior tibial tendon insufficiency. Harper andTisdel9 did not specify the frequency of lateral midfoot pain but statedthat it was the most common cause for patient dissatisfaction after

isolated talonavicular fusion. Mann and Beaman13

suggested that thisproblem be addressed by inclusion of the calcaneocuboid joint in thefusion mass (i.e., double arthrodesis).13 Gapping of the lateral aspect ofthe calcaneocuboid joint can occur once the talonavicular joint is reduced(Fig. 6). Eight of 14 patients undergoing talonavicular fusion and calca-neal osteotomy were noted to have gapping of the lateral calcaneocuboid joint measuring 2 to 5 mm.6 The gapping resolved in some patients, andnone of the patients in that series had pain localized to the calcaneocuboid joint at latest follow-up. It is not known whether distraction of this joint that occurs when the talonavicular joint is reduced would lead to

accelerated degenerative changes.

Figure 6. Gapping of the calcaneocuboid joint (arrow) seen after talonavicular fusion.



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COMPLICATIONS

Malposition

Inaccurate reduction of the talonavicular joint at the time of fusioncan lead to abnormal weight-bearing transfer and is likely to be toleratedpoorly. There is a significant association between patient satisfactionand postoperative alignment after hindfoot fusion.16 Proper positioningrequires intraoperative clinical and radiographic confirmation. Failure toreduce completely the lateral subluxation of the navicular bone on thetalar head leaves the heel in valgus and can be associated with persistentlateral hindfoot pain from subfibular impingement. In cases of moresevere deformity, there may be fixed heel valgus that persists despite an

adequately reduced talonavicular joint. This problem may be addressed by Achilles tendon lengthening or medial displacement calcaneal osteot-omy (or both). Leaving the navicular dorsally displaced fails to restorethe longitudinal arch configuration and may lead to excessive weight bearing on the plantar medial midfoot region. Overcorrection can resultin varus alignment of the heel and lateral overload of the foot. Probablythe most common pitfall in positioning the talonavicular joint is leavingthe forefoot in varus or supinated. This pitfall can be prevented bypronating or derotating the forefoot through the talonavicular joint atthe time of fusion (see Fig. 4).

Nonunion

Higher rates of nonunion have been reported with talonavicularfusion than with fusion of the other hindfoot joints.13, 23, 24 Reported ratesof nonunion vary from 0% to 70%.2, 5, 9, 24 In earlier series, methods offixation were variable, or in some cases fixation was not used. Traditionaltechniques often involved the removal of large wedges of bone to effect

correction. Compression screw fixation, the use of bone graft, and main-taining the normal contour of the joint have diminished the incidence oftalonavicular nonunion in hindfoot fusion. Harper and Tisdel9 reportedone nonunion in 27 patients who underwent isolated talonavicular fu-sion using iliac crest graft. In the series reported by Fortin and Grant,6

bone graft and compression screw fixation were used in all patients.There was one apparent nonunion that subsequently went on to unionwithout further surgery. The union rate of isolated talonavicular fusioncompares favorably with the rate of union of the talonavicular jointwhen it is fused as a part of a double or triple arthrodesis. Mann and

Beaman13 reported a 25% nonunion rate of the talonavicular joint in16 patients undergoing double arthrodesis for posterior tibial tendoninsufficiency. Bone graft was not used, and staple fixation rather thancompression screw fixation was used in all of the patients with talona-vicular nonunion in this series.




Adjacent Joint Arthrosis

Because of the significant restriction of motion and alteration of

foot mechanics after talonavicular fusion, patients are at risk for thedevelopment of progressive arthrosis of adjacent joints. This risk must be considered when contemplating an arthrodesis procedure for correc-tion of adult flatfoot deformity. The ankle, subtalar, and remainingmidfoot joints all have been reported to have developed arthrosis aftertalonavicular fusion.5, 6, 9 Degenerative changes after hindfoot fusion areasymptomatic in most patients and do not correlate with patient out-come.5, 9, 16 Commonly, patients with severe peritalar subluxation alsohave radiographic evidence of more distal midfoot instability and arthro-sis that can be seen on preoperative radiographs (Fig. 7). Degenerative

changes seen after talonavicular fusion in some of these patients may bethe result of unrecognized instability or degeneration of these moredistal midfoot joints. Progressive degenerative ankle arthrosis character-ized by valgus tilt of the talus and lateral tibiotalar joint space narrowinghas been reported to occur after hindfoot fusion for adult flatfoot defor-

Figure 7. A, Preoperative radiograph of patient with severe flatfoot. Distal midfoot collapseand arthrosis is present in addition to the typical findings of peritalar subluxation secondaryto posterior tibial tendon insufficiency. B, Following talonavicular fusion, calcaneal osteot-omy, and first metatarsal cuneiform fusion, the longitudinal arch is restored. A solid fusionis present despite early fatigue failure of one of the talonavicular screws.



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mity.4, 7, 8 Progressive deformity and arthrosis of the ankle in a patientwho already has had the hindfoot made rigid with an arthrodesis ofthe triple joint complex presents a significant dilemma. Salvage often

necessitates pantalar fusion or ankle replacement. Valgus collapse of theankle joint is believed to occur as a result of residual heel valgus andcan occur despite a properly reduced talonavicular joint in patients withsevere deformities.7 Because of this concern, the author performs amedial displacement calcaneal osteotomy in all patients undergoingtalonavicular fusion for adult acquired flatfoot deformity.

References

1. Astion DJ, Deland JT, Otis JC, et al: Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am 79:241–246, 1997

2. Elbaor JE, Thomas WH, Weinfeld MS, et al: Talonavicular arthrodesis for rheumatoidarthritis of the hindfoot. Orthop Clin North Am 7:821–826, 1976

3. Elftman H: The transverse tarsal joint and its control. Clin Orthop 16:41–45, 19604. Fitzgibbons TC: Valgus tilting of the ankle joint after subtalar (hindfoot) fusion:

Complication or natural progression of valgus hindfoot deformity. Orthopedics 19:415–423, 1996

5. Fogel GR, Katoh Y, Rand JA, et al: Talonavicular arthrodesis for isolated arthrosis 9.5year results and gait analysis. Foot Ankle Int 3:105–113, 1982

6. Fortin PT, Grant AM: Limited midfoot fusion with calcaneal osteotomy for adultflatfoot. Presented at the American Orthopaedic Foot and Ankle Society summer

meeting, Monterey, CA, 19977. Fortin PT, Walling AK: Triple arthrodesis. Clin Orthop 365:91–99, 19998. Graves SC, Mann RA, Graves KO: Triple arthrodesis in older patients: Result after

long term followup. J Bone Joint Surg Am 75:355–362, 19939. Harper MC, Tisdel CL: Talonavicular arthrodesis for the painful adult acquired flatfoot.

Foot Ankle Int 17:658–661, 199610. Kitaoka HB, Zong PL, Kai-nan A: Contact features of the talonavicular joint of the

foot. Clin Orthop 325:290–295, 199611. Koutsogiannis E: Treatment of mobile flat foot by displacement osteotomy of the

calcaneus. J Bone Joint Surg Br 53:96–100, 197112. Ljung P, Kalj J, Knutson K, et al: Talonavicular arthrodesis in the rheumatoid foot.

Foot Ankle Int 13:313–316, 1992

13. Mann RA, Beaman DN: Double arthrodesis in the adult. Clin Orthop 365:74–80, 199914. Manoli A, Beals T, Pomeroy G: The role of osteotomies in the treatment of posterior

tibial tendon disorders. Foot Ankle Clin 2:309–317, 199715. O’Malley MJ, Deland JT, Lee KT: Selective hindfoot arthrodesis for the treatment of

adult acquired flatfoot deformity: An in vitro study. Foot Ankle Int 16:411–417, 199516. Pell RF, Myerson MS, Schon LC: Clinical outcome after primary triple arthrodesis. J

Bone Joint Surg Am 82:47–57, 200017. Perry J: Anatomy and biomechanics of the hindfoot. Clin Orthop 177:9–15, 198318. Sangeorzan BJ, Mosca V, Hansen ST: Effect of calcaneal lengthening on relationships

among hindfoot, midfoot, and forefoot. Foot Ankle Int 14:136–141, 199319. Sangeorzan BJ, Smith D, Veith R, et al: Triple arthrodesis using internal fixation in

treatment of adult foot disorders. Clin Orthop 294:299–307, 1993

20. Sarrafian SK: Functional characteristics of the foot and plantar aponeurosis undertibiotalar loading. Foot Ankle Int 8:4–18, 1987

21. Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional,ed 2. Philadelphia, JB Lippincott, 1993

22. Scranton PE: Results of arthrodesis of the tarsus: Talocalcaneal, midtarsal, and subtalar.Foot Ankle Int 12:156–164, 1991




23. Schon LC, Bell W: Fusion of the transverse tarsal and midtarsal joints. Foot Ankle Clin1:93–108, 1996

24. Wulker N, Flamme CH, Muller A, et al: 10 years followup of arthrodesis of thehindfoot and upper ankle joint. Z Orthop Ihre Grenzgeb 135:509–515, 1997

Address reprint requests to

Paul T. Fortin, MDWilliam Beaumont Hospital

30575 Woodward AvenueRoyal Oak, MI 48073

e-mail: [email protected]

fortin - posterior tibial tendon insufficiency isolated fusion of the talonavicular joint

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