Arthrodesis of the Hindfoot

What is a Hindfoot Arthrodesis?

When the joints between the small talar bones in the foot are causing pain or have become severely deformed, a fusion operation (‘arthrodesis’) may be required to stabilise the foot.

Joints that form the hindfoot include:

Subtalar & talonavicular joints – the talus is the key bone linking the ankle to the foot. It has a number of joints with other bones in the foot.
Calcaneocuboid Joints – the calcaneus is the bone that forms the heel. The cuboid is a small bone directly in front of the calcaneus.

Fusion operations involve placing screws or plates across joints so that the bones grow together to form a single effective unit. This is a very effective method of relieving pain, straightening and stabilising the foot. In the foot, doctors and surgeons will often refer to double and triple arthrodesis – this simple refers to the number of joints that are fused.

It can take many weeks or months for the bones to fuse after an arthrodesis, and during this period the foot needs to be protected in a plaster cast and boot. It is important that you pre-plan and pre-arrange any help you will need with everyday tasks to make your recovery period as easy as possible. You may also be assisted by physiotherapists and occupational therapists who will:

Assess you for an appropriate mobility aid (e.g. crutches or zimmer frame)
Teach your how to walk and do the stairs without putting your operated leg to the floor
Assess your home

The disadvantage of fusion is that all movement in the fused joints is lost. When the hindfoot is fused the ability to twist the foot in or outwards (inversions and eversion) is decreased or lost altogether. This can make walking on uneven ground and running more difficult.

Who is this operation for?

There are often three reasons why this operation is performed:

Pain – from osteoarthritis (OA) and rheumatoid arthritis (RA).
Change of shape of foot or deformity (eg flatfoot).
- Causes of deformity may include rheumatoid arthritis, diabetes or Charcot-Marie-Tooth disease
Occasionally, arthrodesis is used after a severe fracture of the bones of the foot or ankle.

What are the benefits of the operation?

Most people who have arthrodesis are able to return to activities they have been unable to perform for many months. While the fused foot may not perform all the functions of a normal foot, it is a stable painless structure which facilitates walking.

Complications

Complications from hindfoot fusion include:

Non-union or mal-union – sometimes, the bone fails to heal around the screws. If this occurs, you may need to remain in a cast for a longer period of time, or may need revision surgery.
Pain and swelling after the operation.
- Swelling may persist for months after the operation. You can help relieve swelling by keeping your foot elevated as much as possible in days following the operation.
Damage to nerves around the foot – this can cause numbness, tingling or weakness in the foot. While this is usually temporary it may persist in some people.
Bleeding – there is usually minimal bleeding from foot surgery.
Blood clots in the leg and the lung (see DVT).
Infection

Longterm complications of arthrodesis include persistent pain in the foot. The heel will also be rigid from the screws and may cause some difficulty walking on uneven surfaces.

Occasionally, screws used in the surgery may cause irritation or become infected. In these cases you may need revision surgery to remove the hardware.

Before the operation

You will probably have a number of consultations with your surgeon before deciding on arthrodesis. During this time your surgeon will need to assess:

The health of the bones in your foot. Bones with significant osteoporosis, infection (osteomyelitis) or dead bone (osteonecrosis) are usually not appropriate for arthrodesis.
The exact position of the bones and joints in your foot. This usually involves a series of X-Rays, including weight-bearing exercises where the technician asks you to stand on one foot during the X-Ray.
The status of the blood vessels in your leg. Usually, your surgeon can assess your blood vessels by feeling the pulses in your feet. In some cases, it may be necessary to have further tests like angiograms.

Preadmission Clinic | Preparing for Surgery

Before your operation, you will be seen at the Preadmission clinic to make sure you are fit for the operation and all the necessary tests are performed in preparation for the operation.

During the visit, you will be seen by a

doctor
nurse
anaesthetist (if necessary)

Tests

Tests that may be ordered for you include:

blood tests
Xray of your Chest
Urine Test
ECG

Preparing Your Skin

Your skin should not have any infections or irritations before surgery. If either is present, contact your orthopaedic surgeon for a program to improve your skin before surgery.

Tip

Carry a list of your medications with you including the name, dosage and how often you take it.

Medications

Our doctors will advise you which medications you should stop or can continue taking before surgery.

Please notify your doctor if you are taking any blood-thinning medications, including aspirin and warfarin.

Get some help from your friends and family

Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry. If you live alone, your orthopaedic surgeon’s office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at your home. A short stay in an extended-care facility during your recovery after surgery also may be arranged.

About the Operation

There are a number of different types of fusion in the hindfoot. Your surgeon will discuss which is most appropriate for you, depending on which of your joints is affected and what level of activity you expect after the operation.

In a typical fusion operation, your surgeon makes a cut on one or both sides of the ankle to reach the joints. Once the tissues beneath the skin have been carefully pushed aside the joints can be visualised. From here, your surgeon will trim away any damaged or unnecessary bone and cartilage. He or she will then drill shallow holes into the involved bones to expose the ‘fresh’ bone beneath.

Once this step is completed, your surgeon will position screws across the bones. The exposed ‘fresh’ bone is compressed together, stimulating the previously separate bones to grow into one another and form a single unit. The screws will usually be left in place for life, even after the bones have healed together.

The soft tissues can then be returned to their normal position and the incisions closed with stitches.

After the Operation

You will wake up in recovery with your leg elevated in a half-plaster called a backslab. From here you will be returned to the wards and will need to remain in hospital for several days.

During your stay in hospital you will taught to use crutches and get around without putting any weight through your foot. When not moving around, you will need to keep your foot elevated above the level of your heart for 50 minutes of every hour to avoid swelling and infection.

Stitches can usually be removed after two weeks and the backslab plaster replaced with a full plaster. This will remain in place for around four weeks when you have a follow-up appointment.

Right throughout this early period, you will need to avoid putting ANY weight on your foot. This means you will need to rely on crutches or some other walking aid to move around. You will also need to keep your foot elevated as often as possible – with multiple pillows at nighttime and by keeping your foot up on a chair when sitting down.

What about pain?

Whilst you are in hospital you will be monitored and the medical staff will give you painkillers as required and prescribed. You will be given painkillers and instructions on management of the pain by nursing staff before you leave hospital.

What should I do when I leave hospital?

Swelling is quite common, so in order to reduce swelling, your foot should be elevated (above the level of your heart) for 50 minutes in every hour for the first two weeks. Your activities will be initially affected whilst you are in a cast particularly when you have to non-weight bear. This includes household and work activities. You will not be expected to return to a normal level of activity until you have been advised on your progress.

Recovery and Rehabilitation

After 6 weeks

If your surgeon is satisfied that your bones are showing adequate healing on X-Rays, you can have the plaster cast replaced with a walking boot.

Your physiotherapists will show you how to use walk without putting too much weight through your foot. They will also show you exercises to strengthen and maintain the muscles in your legs.

F.A.Q.s | Frequently Asked Questions

When can I return to work?

Your own circumstances will determine when you feel ready to go back to work. If you have an office-type job and you can elevate your leg then you should be able to return to work within 7 days. If your job requires a lot of walking or is strenuous then you may need 2-3 weeks off work. Patients can self-certificate their sick leave for 7 days. If you require a sick certificate please ask your GP.

When can I return to driving?

You must be free of pain and able to perform an emergency stop. This will also depend on which foot was operated on (right or left). If you have had left sided surgery and drive an automatic car you may be able to drive 2-4 weeks following surgery. Your insurance company must be notified regarding the type of operation that you have undergone to ensure that cover is valid. Approximate Recovery Guide: 12-14 days post-op Stitches out New light-weight cast applied 6-8 weeks post op Check x-ray performed Cast changed to a removable boot as required Allowed to increase weight bearing 12 weeks post op Check x-ray performed Out of cast and full weight-bearing walking and perhaps physiotherapy 3-6 months Most patients are back to regular shoes and activities Note: this is an approximate guide and will depend on how well you as an individual heal and if there are any complications.

What should I do if I have a problem?

If you experience severe pain, excessive swelling, inflammation or discharge please report it to your GP. If you cannot contact your GP you should contact A&E.

References

Greisberg, J., Sangeorzan, B., ‘Surgical Technique: Hindfoot Arthrodesis’, Journal of American Academy of Orthopaedic Surgeons, Vol. 15, No. 1, Jan 2007, pp 65-71.