Hindfoot fusion

Subtalar fusion, Calcaneocuboid fusion, Talonavicular fusion, Triple arthrodesis
Summary

This operation is performed for arthritis affecting one or more of the joints around the heel or hindfoot.  Increasing pain and stiffness occurs as the joint surfaces get damaged.  With worsening arthritis, the pain can get so bad that it interferes with your life.  Pain killers may not help anymore and you struggle to walk any distance.  Uneven ground can be particularly difficult.  Surgery involves removing the joint surfaces and fusing the joint to prevent any movement in the joint.  This does stiffen the joint further but has the benefit of eliminating pain from the joint.

Factors to Consider

You have been diagnosed with arthritis to the hindfoot.  It is likely that you have already tried non-surgical treatments for your foot such as pain killers, footwear modification, physiotherapy and injections.  

If these measures have not improved your symptoms then the next logical step is to consider surgery.  Surgery is very good at reducing pain that you experience from the arthritis.  It may, however, cause further stiffness to the joint as this is fused together.  Fusion is a good option as there is minimal movement in the joints anyway (even less in the presence of arthritis) and so patients cope well with any further stiffening.

Description of Surgery

The operation is performed under a general anaesthetic and you will spend 3-4 hours in the operating department.  The operation itself takes approximately 2 hours.  

The incision depends on which joint requires fusion but normally is on the outer aspect of your foot.  The surgeon identifies the joint and removes the remaining joint cartilage.  The joint surfaces are then pressed together and secures with plates and/or screws.  The fixation may be different if more than one joint needs to be fused.

Anaesthetic

The operation is usually performed under a general or spinal anaesthetic and so you will be given instructions as to when you need to stop eating and drinking (normally the night before) before you come into hospital.  

Your pain can be well controlled with local anaesthetic given during the operation.

What are the risks?

All operations involve an element of risk.  The risks for this particular operation are small but it is important that you are aware of them.

The main risk for this operation is a failure of fusion and consequently failure of fixation.  The surgeon is attempting to fuse two bones together which naturally are not fused.  Surgery provides the stability for the fusion to occur but you need to provide the “biology” to ensure the bones fuse together.  Smoking can affect this and so you should stop before surgery if you do smoke.  

The risk of infection is small and is thought to be about 1%.  Most infections will settle simply with antibiotics.  Damage to nerves and blood vessels around the foot can occur but this is rare.  

Any surgery to the foot potentially increases the risk of developing a clot in your leg (DVT).  Your surgeon will assess your risk of this prior to surgery and may offer you blood thinning medication if your risk is considered high.

After Surgery

Pain

Local anaesthetic will be used during the operation and so you will feel comfortable when you first wake up.  This can last up to 12 hours but the foot may be sore after it wears off.  You will be given a combination of pain killers to go home with.  

Plaster

You will wake up with your foot in a plaster.  This is kept on for the first 2 weeks until the sutures are removed and then changed to a lightweight cast. You will not be allowed to weight bear during the first 6 weeks.  At 6 weeks you will be seen again and a x-ray taken and, all being well you will be changed into an air walker boot and encouraged to weight bear in your boot for the next 6 weeks.  The surgeon will give you instructions specific to your operation regarding your weight bearing status.

Physiotherapy

The physiotherapist should see you before the operation to explain some simple exercises you can do after the operation.  They will also ensure a physiotherapy appointment is made for you within 3 weeks of the operation.  Physiotherapy can be arranged local to you.  

Driving

You can drive when you feel you are safe to drive.  This means that you feel confident that you have full control of your car and are able perform an emergency stop.  This will vary between patients but normally takes 12 weeks unless the surgery was to your left foot and you drive an automatic car.  

Return to work

This depends on what your job is.  You should be able to return to a “desk job” within a few weeks of your surgery.  If you have a more manual job it can over 12 weeks before you feel ready to return to work.  Please discuss this further with your surgeon or physiotherapist if you feel unsure.  A sick note can be given to you at the time of your surgery if required.  Please ask the nurses on the ward if you need one.

What to expect

Recovery following surgery can be quite variable.  Your symptoms should be take “three months to be fair, six months to be good and twelve months to be right”.