Comparative Results of Triple Arthrodesis for the Management of Stage III Posterior Tibial Tendon Dysfunction between Rheumatoid and Non-Rheumatoid Patients

doi:10.21203/rs.3.rs-3421091/v1

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Comparative Results of Triple Arthrodesis for the Management of Stage III Posterior Tibial Tendon Dysfunction between Rheumatoid and Non-Rheumatoid Patients

https://doi.org/10.21203/rs.3.rs-3421091/v1

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Objective

Although the recommended treatment for stage III posterior tibial tendon dysfunction (PTTD) is triple joint complex fusion, the literature is limited on this topic. No study has specifically investigated the influence of rheumatoid arthritis (RA) on the outcomes of triple arthrodesis. This study aimed (1) to report mid-to-long-term results of triple arthrodesis for stage III PTTD and (2) to investigate the difference in the results of triple arthrodesis between rheumatoid and nonrheumatoid patients.

Methods

Thirty feet of 25 patients (16 females, 9 males; mean age 53, (39-71)) with stage III PTTD who were treated by triple arthrodesis were retrospectively analyzed. The mean follow-up was 82 (28 – 144) months. Patients were divided into two groups based on etiology: group ID (idiopathic PTTD) and group RA (PTTD secondary to RA). All clinical and radiographic outcomes were compared. The mean American Orthopedic Foot and Ankle Society (AOFAS) score was measured preoperatively and at the final follow-up. The 36-Item Short Form Survey (SF-36) and visual analog scale (VAS) were measured at the final follow-up.

Results

The mean AOFAS score improved from 57±6.81 (46–68) and 49±14.66 (18–79) preoperatively to 82±15.57 (44–94) and 77±14.46 (48–94) in group ID and group RA, respectively, with no significant difference between thepre- and postoperative values between the groups (p <.001). The mean VAS score at rest was 0.45±0.68 (0–2) in group ID and 1±1.08 (0–3) in group RA (p =.23). There was no significant difference in any SF-36 domain(p >.05) except for physical health, which was lower in the RA group (p =.002).

Conclusion

Although rheumatoid patients present with radiographically more severe flatfoot deformity, triple arthrodesis can provide similar satisfactory clinical and radiological outcomes with a low complication rate for stage III PTTD in rheumatoid patients as much as nonrheumatoid patients in long-term follow-up.

Level of Evidence: Retrospective cohort study, Level 3 Evidence

Posterior tibial tendon dysfunction

stage III

adult‑acquired flatfoot deformity

triple arthrodesis

idiopathic

rheumatoid arthritis

Posterior tibial tendon dysfunction (PTTD) is a clinically well-defined foot and ankle pathology and represents the most common cause of acquired flatfoot deformity in adults.^1,2 Although the pathophysiology underlying PTTD remains uncertain, the available histological data point out chronic degenerative changes (tendinosis) leading to dysfunction in the posterior tibial tendon.^3,4 Corresponding to the histological features, the etiologic factors responsible for PTTD can be mainly divided into three categories: overuse or age-related chronic microtrauma (mechanical causes), seronegative spondyloarthropathies, and rheumatoid arthritis.^5,6

To date, four stages of PTTD have been defined based on clinical and radiographic evidence. The management of this disorder has been typically structured around this evolving staging system.^7,8,9 Stage I represents a symptomatic foot without deformity, whereas stage II implies a flexible flatfoot deformity with more intense symptoms. Stage III PTTD clinically presents with rigid deformity affecting the triple joint complex (i.e., subtalar, calcaneocuboid, and talonavicular joints), and stage IV results in ankle valgus with arthritic changes in addition to foot deformity.^7,8,9 While nonoperative or joint-preserving surgery can be applied in the early or flexible stages of the disorder, rigid deformities require fusion procedures to yield a stable and plantigrade foot. The typical recommended treatment for stage III PTTD is fusion of the triple joint complex (triple arthrodesis).⁸ However, to the best of our knowledge, there is a lack of published literature explicitly focusing on the surgical results of triple arthrodesis in such patients.

Rheumatoid arthritis (RA) is a well-established causal factor of acquired flatfoot deformity in adults. Although the pathophysiology of flatfoot in RA is controversial, PTTD has been implicated as the primary contributor to this condition. ^{5, 10–12} Hindfoot problems are a significant cause of disability in patients with RA, and triple arthrodesis has been suggested as a suitable treatment choice to correct stage III PTTD secondary to RA in adults.^{5, 13} Nonetheless, such fusion procedures may be compelling and fraught with complications in patients with systemic inflammatory diseases due to poor bone quality, destruction of adjacent joints, and failure of the ligamentous structures.¹³ According to our literature review, no study to date has specifically investigated the influence of RA on the surgical outcomes of triple arthrodesis in the management of stage III PTTD.

The primary aim of this study was to report mid-to-long-term results of triple arthrodesis for the management of stage III PTTD in a consecutive group of patients from a single tertiary referral center. The secondary aim was to investigate whether there is a difference in the surgical results of triple arthrodesis for stage III PTTD between rheumatoid and nonrheumatoid patients. We hypothesized that triple arthrodesis might provide less satisfactory clinical and radiographic results with a higher rate of complications at mid-to-long-term follow-up in rheumatoid patients than in nonrheumatoid idiopathic PTTD patients.

The medical records of 28 patients in whom stage III PTTD was diagnosed and treated by triple arthrodesis from 2008 to 2018 at our institution were retrospectively identified. This study received ethical approval from the Ethics Committee of Istanbul University Istanbul Medical School. The inclusion criteria for the study were as follows: a diagnosis of stage III PTTD; a minimum follow-up of 24 months; complete medical records and radiographic images; and willingness to participate in the study. The exclusion criteria were loss to follow-up, inadequate medical records, and unwillingness to participate in the study.

Based on the above eligibility criteria, after excluding three patients (one was lost to follow-up, and two had inadequate medical records), the remaining 25 patients (30 feet) meeting the inclusion criteria were included in the study and invited to a final follow-up appointment. Approval from the institutional review board was obtained prior to data collection, and informed consent was obtained from all participants.

Based on the Myerson classification,¹⁴ the senior author established the diagnosis of stage III PTTD clinically and radiographically. In the physical examination, all patients exhibited characteristic features of stage III PTTD, consisting of rigid midfoot abduction and hindfoot valgus that were not passively correctable to a neutral position, along with an inability to perform a single heel raise. Furthermore, the radiographic evaluation revealed concomitant degenerative arthritis of the triple joint complex in all patients.

Study protocol

Part I = Clinical and radiographic assessment of the entire study population

Demographic and clinical data were collected from the hospital electronic database and the medical records, including age at the time of surgery, sex, follow-up duration, involvement side as well as etiology of PTTD, comorbidities (diabetes mellitus, hypertension, or cardiovascular disease), and smoking history at baseline. Intra- and postoperative complications were also recorded.

Clinical outcome measures

The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score was measured immediately preoperatively and at the final follow-up. The 36-Item Short Form Survey (SF-36) and visual analog scale (VAS) during daily activities were measured at the final follow-up.

The AOFAS Ankle-Hindfoot Score,¹⁵ which is a region-specific outcome measure, includes nine items that could contribute a maximum of 100 points: pain (1 item, 40 points), function (7 items, 50 points), and foot alignment (1 item, 10 points). The SF-36, which is a validated generic measure of health-related quality of life, consists of 8 health domains: physical functioning (10 items), bodily pain (2 items), physical role limitations (4 items), general health perceptions (5 items), energy/fatigue (4 items), emotional role limitations (3 items), social functioning (2 items), and mental health (5 items). Each domain is scored from 0 to 100, with a higher score indicating better health. The VAS used in the current study is a modified and simplified measure wherein pain intensity during daily activity is rated from 0–10, where 0 indicates no pain and 10 indicates the worst pain.

Radiographic outcome measures

All radiographic assessments were performed on the weight-bearing anteroposterior (AP) and lateral radiographs of the foot by a single orthopedic surgeon with a particular interest in foot and ankle surgery using Osirix software (University of Geneva, Geneva, Switzerland). Solid fusion was defined as an osseous bridging of at least three cortices across the arthrodesis site on the standard postoperative radiographs; the fusion of each component of the triple joint complex was examined. On the AP radiographs, the talo-first metatarsal, talocalcaneal, and talonavicular coverage angles were measured (Fig. 1). On the lateral radiographs, the talo–first metatarsal (Meary's angle) angle, talocalcaneal angle, calcaneal inclination, and talar declination were examined (Fig. 2). Changes between preoperative and postoperative measurements were recorded to evaluate the correction of the flatfoot deformity following surgery. The radiographic measurements were categorized relative to normal values as follows ^16,17: AP talo-first metatarsal angle less than 15 degrees, AP talocalcaneal angle less than 25 degrees, talonavicular coverage angle less than 20 degrees; lateral talo–first metatarsal angle from − 5 to 5 degrees, calcaneal inclination angle from 15 to 21 degrees, talar declination angle less than 21 degrees, and talocalcaneal angle from 35 to 50 degrees.

Part II: Assessment of the influence of RA on surgical outcomes

The diagnosis of PTTD secondary to overuse or age-related chronic microtrauma (mechanical causes) was defined as an idiopathic disorder based on the relevant literature. ^5,6 All study populations were first categorized into two groups based on the etiology of PTTD: group ID (idiopathic PTTD) and group RA (PTTD secondary to RA). All clinical and radiographic outcome measures were then compared between the two groups.

Operative technique

Each operation was performed by the same surgeon specializing in foot and ankle surgery using a standardized surgical technique. Under general or spinal anesthesia, patients were placed supine on a radiolucent operating table, and a pneumatic tourniquet was applied to the thigh. The C-arm was positioned to obtain imaging of the triple joint complex in both anteroposterior and lateral views. If tightness of the Achilles tendon was present, Achilles tendon lengthening was performed.

The posterior subtalar joint was first exposed through a longitudinal incision made from the tip of the lateral malleolus and directed distally to the fourth metatarsal base. The calcaneocuboid joint was also accessed through the same lateral incision. The talonavicular joint was approached via a dorsomedial incision centered over the joint. Articular surfaces of the triple joint complex were prepared for fusion using osteotomes, curettes, and rongeurs. All cartilage and necrotic or sclerotic bone was removed from each joint until viable subchondral bone was obtained. The relevant subchondral bone was fenestrated with multiple small drill holes to enhance the fusion. Bone grafting was not routinely performed. If needed, any defects at the fusion sites were filled with a local bone graft from the resected articular surfaces.

After the preparation of the surfaces, triple joint complex reduction was carried out in a stepwise manner. Based on the surgeon's preference, the subtalar joint was first reduced to a neutral to slightly valgus position and then fixed securely with one or two headless, fully threaded compression screws (Acutrak plus, Acumed®, 6.5 mm, Beaverton or Tasarımmed®, 6.5 mm, Istanbul, Turkey). Following subtalar stabilization, the talonavicular joint was reduced to proper axial and rotational alignment with respect to the midfoot and hindfoot and then fixed with two headless compression screws (Acutrak standard, Acumed® or Tasarımmed®, 4.5 mm). After positioning and securing the subtalar joint and proper coverage of the talonavicular joint, the calcaneocuboid joint was last fixed with one staple or one headless screw (Acutrak standard, Acumed® or Tasarımmed®, 4.5 mm) from the calcaneus into the cuboid. Finally, anatomical foot alignment was confirmed clinically and with the image intensifier. At the end of the procedure, the patient was placed into a well-padded below-knee cast.

Postoperative follow-up protocol

Patients were kept in a nonweight bearing short leg circular cast for 6 to 8 weeks following the operation and then allowed to walk with toe-touch weight-bearing in a boot walker for an additional four weeks. Radiographs were taken at the 12-week follow-up visit, and if adequate consolidation and proper clinical picture were obtained, patients were encouraged to walk with full weight-bearing.

Statistical analysis

All statistical analyses were performed using SPSS software (version 25, Armonk, NY: IBM Corp.). A P value < .05 was regarded as significant. Normality tests were conducted using the Shapiro–Wilk test and histogram graphics. Data are presented as "arithmetic mean" ± " standard deviation (SD)" and "range" from "minimum" to "maximum" or "median" (interquartile range) and "minimum" to "maximum" based on the data distributions. Between-group comparisons were performed using Student’s t test for parametric variables and the Mann–Whitney U test for nonparametric variables. For categorical variables, Fisher's exact test was used. A paired sample T test was used for within-group differences from pre- to final follow-up.

Part I: Demographic characteristics and results of the entire study population

Overall, 30 feet of 25 patients (16 females, nine males) were analyzed. Five patients presented bilateral foot involvement, while 20 had a unilateral disorder. The mean age was 53 (range, 39–71) years, and the mean follow-up was 82 (range, 28–144) months (Supplemental Table 1).

Comorbidities were present in five patients (20%), including chronic hypertension in two (8%) and diabetes mellitus in three (12%). All comorbidities were in the control group at baseline. None of the patients was currently smoking, whereas two patients were ex-smokers with 15 and 20 pack-years (Supplemental Table 1).

No major intra- or postoperative complications were observed. However, one patient developed a superficial wound infection that resolved upon treatment with antibiotics, and one patient suffered from complex regional pain syndrome treated with medical therapy (Supplemental Table 1).

Clinical outcomes

The mean AOFAS improved 51 ± 13.03 (range, 18–79) preoperatively to 79 ± 14.59 (range, 44–94) at the final follow-up (p < 0.001). The mean VAS score was 0.76 (range, 0–3) at rest and 2.52 (range, 0–7) during daily activities at the final follow-up. Supplemental Table 2 details the results of the SF-36 domains at the final follow-up.

Radiographic outcomes

In all feet, radiographic solid fusion was achieved with triple arthrodesis in each component of the triple joint complex (100%), with an average time to fusion of 14 ± 4. 83 weeks (range, 8–24). In the AP radiographic measurements, the talo-first metatarsal angle, talocalcaneal angle, and talonavicular coverage angle significantly decreased from 34 degrees ± 13.05 (range, 10–66), 42 degrees ± 13.04 (range, 17–67), and 43 degrees ± 21.35 (range, 1–86) to 10 degrees ± 8.64 (range, 1–39), 20 degrees ± 10.97 (range, 6–40), and 6 degrees ± 7.48 (range, 0–28), respectively, at the final follow-up. In the lateral radiographic examination, the talo-first metatarsal angle, talocalcaneal angle, and talar declination angle decreased from 21 degrees ± 12.80 (range, 2–46), 42 degrees ± 10.12 (range, 23–55), 34 degrees ± 9.39 (range, 20–49) preoperatively to 7 degrees ± 9.84 (range, -6–37), 30 degrees ± 9.25 (range, 11–49), and 20 degrees ± 8.39 (range, 9–41) at the final follow-up (Table 1).

Table 1

Pre- and postoperative radiographic measurements of all the study participants
	Preoperative	Postoperative	P value
AP talo-first metatarsal angle	34 ± 13.05 (10–66)	10 ± 8.64 (1–39)	< .001
AP talocalcaneal angle	42 ± 13.04 (17–67)	20 ± 10.97 (6–40)	< .001
Talonavicular coverage angle	43 ± 21.35 (1–86)	6 ± 7.48 (0–28)	< .001
Lateral talo-first metatarsal angle	21 ± 12.80 (2–46)	7 ± 9.84 (-6–37)	< .001
Calcaneal inclination angle	8 ± 5.09 (0–19)	12 ± 4.67 (6–21)	< .001
Lateral talocalcaneal angle	42 ± 10.12 (23–55)	30 ± 9.25 (11–49)	< .001
Talar declination angle	34 ± 9.39 (20–49)	20.35 ± 8.39 (9–41)	< .001
AP = Anteroposterior All measurements are angles calculated in degrees. Data are given as mean degree ± standard deviation (min to max). Paired t-test was performed for the comparison of pre-and postoperative measurements.

Part II: Comparison of the results between the two groups

There were 17 feet of 16 patients in the ID group and 13 feet of 9 patients in the RA group. No significant difference was found between treatment groups in baseline demographic and clinical characteristics or complication rates (p > 0.05 for each variable) (Table 2).

Table 2

Comparison of demographic characteristics between the two groups
Variables	Group ID (16 patients; 17 feet)	Group RA (9 patients; 13 feet)	P values
Age (year), (median) (IQR) (min to max)	54 (47–60) (42–67)	56 (48–59) (39 − 61)	.975^a
Gender (female/male)	8/6	8/3	.209^b
Follow-up (month), (median) (IQR) (min to max)	74 (60–101) (28–137)	80 (69–101) (51–144)	.458^a
Comorbidities (%)	2 patients ◊ DM 2 patients ◊ HT	1 patient ◊DM	.326^b
Smoking History	2 patients	—	.220 ^b
Complications	1 case (Complex regional pain syndrome)	1 case (Superficial wound infection)	—
^a Mann-Whitney U test; p < 0.05 ^b Fisher’s exact test; p < 0.05*

Table 3 details the intra- and intergroup comparisons of clinical outcomes at the preoperative and final follow-up assessments. AOFAS scores were significantly improved after surgery in both groups, with no significant difference in the preoperative values between the two groups. In the final follow-up between-group comparison, there were no significant differences in AOFAS and VAS scores. No significant differences were observed in any SF-36 domains at the final follow-up, except for the physical health component, which was significantly lower in group RA than in group ID.

Table 3

Comparison of clinical outcome measures between the two groups
Variables	Group ID			Group RA			Follow-up Comparisons between Groups
Variables	Preoperative	Final Follow-up	P values	Preoperative	Final Follow-up	P values	Preoperative P values	Final Follow-up P values
AOFAS score, (mean) ± SD (min-max)	57 ± 6.81 (46–68)	82 ± 15.57 (44–94)	< .001^a	49 ± 14.66 (18–79)	77 ± 14.46 (48–94)	< .001^a	.32^b	.41^b
VAS score, (mean) ± SD (min-max)	—		—	—		—
at rest		0.45 ± 0.68 (0–2)			1 ± 1.08 (0–3)			.23^c
during daily activities		2.91 ± 2.58 (0–7)			2.23 ± 1.69 (0–5)			.65^c
SF-36 Domains (mean) ± SD (min-max)
Physical functioning		69 ± 18.63 (35 − 100)			68 ± 15.34 (45– 95)			.88^b
Bodily pain		56 ± 28.71 (23– 85)			61 ± 18 (23–80)			.56^b
Physical health		85 ± 27.22 (25– 100)			50 ± 27.13 (25– 100)			.002^b
General health		56 ± 16.12 (35– 77)			47 ± 12.67 (35– 75)			.70^b
Energy/fatigue		48 ± 24.63 (15– 100)			61 ± 7.01 (50– 70)			.12^b
Emotional problems		90 ± 22.31 (33– 100)			80 ± 18.78 (55– 100)			.16^b
Social functioning		70 ± 19.55 (25– 100)			64 ± 23.77 (38– 88)			.31^b
Mental health		66 ± 17.58 (36– 88)			77 ± 4.92 (72– 84)			.46^b
Health Change		54 ± 8.18 (50– 75)			46 ± 10.02 (25– 55)			.81^b
VAS = Visual Analgous Scale ^a For within-group differences from pre- to final follow-up, a paired sample T-test was used; p < 0.05 ^{b, c} For between-group differences at baseline and the final follow-up assessment, the Student t-test for normally distributed data^b, and Mann–Whitney U test^c for non-normally distributed data was used; p < 0.05

Table 4 outlines comparisons of radiographical outcomes between the groups. All the AP and lateral radiographic parameters demonstrated significant correction in both groups (Figs. 3 and 4).

Table 4

Comparison of radiographic outcomes between the two groups
Variables	Group ID			Group RA			Follow-up Comparisons between Groups
Variables	Preoperative	Final Follow-up	P values^a	Preoperative	Final Follow-up	P values^a	Preoperative P values^b	Final Follow-up P values^b
AP talo-first metatarsal angle	26.76 ± 8.56 (10–39)	8.32 ± 4.84 (1–19)	^{< .001}	42.20 ± 12.82 (15–66)	13 ± 11.64 (1–39)	^{< .001}	.001	.402
AP talocalcaneal angle	42 ± 10.87 (17–59)	19 ± 13 (6–40)	^{< .001}	43 ± 15.87 (23–67)	22 ± 8.63 (6–35)	^{< .001}	.900	.315
Talonavicular coverage angle	33 ± 14.5 (1–52)	4 ± 4.95 (0–16)	^{< .001}	56 ± 22 (5–86)	8 ± 9.62 (0–28)	^{< .001}	.003	.379
Lateral talo-first metatarsal angle	16 ± 10.24 (1–32)	4 ± 7.33 (-6–21)	^{< .001}	27 ± 13.57 (2–46)	10 ± 11.84 (-2–37)	^{< .001}	.018	.187
Lateral talo-calcaneal angle	41 ± 8.77 (29–53)	26 ± 8.46 (11–37)	^{< .001}	42 ± 12.02 (23–55)	34 ± 0.06 (20–49)	^{< .001}	.645	.154
Calcaneal inclination angle	10 ± 4.33 (2–19)	14 ± 4.51 (6–21)	^{< .001}	6 ± 5.41 (0–18)	10 ± 4.03 (5–21)	.004	.04	.01
Talar declination angle	33 ± 8.57 (20–44)	16 ± 3.67 (8–24)	^{< .001}	36 ± 10.49 (19–49)	26 ± 9.32 (9–41)	.005	.315	.001
	^Preoperative			^{Final Follow−up}			P value
Fusion rate	100%			100%
Time to union (week) (mean) (min–max)	13 ± 4.54 (8–22)			15 ± 4.85 (9–24)			.27
^a For within-group differences from pre- to final follow-up, a paired sample T-test was used; p < 0.05 ^b For between-group differences at baseline and the final follow-up assessment, Mann–Whitney U test was used; p < 0.05

In the preoperative between-group comparison, the AP talo-first metatarsal, talonavicular coverage, and lateral talo-first angles were significantly higher in the RA group than in the ID group. While the RA group showed significantly lower calcaneal inclination angles, similar values were preoperatively recorded for the rest of the parameters between the groups. In the final follow-up between-group comparison, the two groups exhibited similar values for most of the radiographic parameters, except for a lower calcaneal inclination angle and a higher talar declination angle in group RA than in group ID.

With overall favorable results, triple arthrodesis has been recommended to manage different foot deformities secondary to diverse etiologies, including polio, residual clubfoot deformities, myelomeningocele, Charcot-Marie-Tooth disease, and painful pes planus.^18–20 The current study differs from most of the previous reports, in which it focused on the assessment of a specific group of adult patients with stage III PTTD that is considerably different from the foot deformities seen in children and adolescents.

Stage III PTTD is typically characterized by a rigid valgus deformity of the hindfoot accompanied by forefoot deformities, usually consisting of abduction and supination. The consensus on the treatment is to correct the rigid hindfoot deformity with triple arthrodesis, especially in cases of osteoarthritic changes in the triple joint complex⁷. Nonetheless, to the best of our knowledge, few studies^{13, 18, 21–23} have investigated the role of triple arthrodesis in managing patients with stage III PTTD, and the patient groups examined in those studies are not homogenous in terms of etiology and treatment method. Unlike the literature, the current study included two homogenous groups of patients, consisting of idiopathic PTTD and secondary RA cases.

A more specific issue investigated in this study was to explore the influence of RA on the surgical outcomes of triple arthrodesis in the management of stage III PTTD. Although triple arthrodesis has been suggested as a proper choice of treatment to correct flatfoot deformity in the RA patient population, the relevant literature, to our knowledge, is limited to a few outdated studies using old-fashioned instruments such as staples for performing triple arthrodesis.^{13, 24} The present study confirmed the findings of earlier studies demonstrating good results in the RA population regarding pain relief and improved level of function with high union rates. Furthermore, unlike previous studies, we compared the clinical and radiographic features of RA patients with those of nonarthritic patients to determine the effectiveness of triple arthrodesis more accurately in this specific group of patients.

Considering the poor bone quality, destruction of adjacent joints, and failure of ligamentous structures in RA patients, we hypothesized that triple arthrodesis might provide less satisfactory clinical and radiographic results with a higher rate of complications than idiopathic nonrheumatoid patients. However, the findings of this study failed to support this hypothesis. The preoperative functional status of rheumatoid patients obviously improved as much as that of nonrheumatoid patients, as reflected by the AOFAS score. In terms of quality of life, no significant differences were observed in any SF-36 domains at the final follow-up, except for the physical health component, which was significantly lower in rheumatoid patients than in nonrheumatoid patients. This difference can be attributed to the systemic inflammatory nature of RA that could have potentially altered the patients' physical health status.

Radiographic analysis showed that although the flatfoot deformity was more severe in RA patients, it could be corrected by triple arthrodesis in most rheumatoid patients as successfully as in nonrheumatoid patients. Apart from calcaneal inclination and talar declination angles, there were no significant differences in other radiographic parameters between groups. In PTTD deformities, both the calcaneus and talus are positioned in plantar flexion, with a decreased calcaneal inclination angle and an increased talar declination angle. The deformity correction results in dorsiflexion of the calcaneus and talus with the increase in the calcaneal inclination angle and the decrease in the talar declination angle. Thus, the lateral talocalcaneal angle may not be significantly altered before and after surgery.

Bone grafting during triple arthrodesis remains questionable. Triple arthrodesis has historically had high nonunion rates, having been reported in up to 23% of cases.^25–27 Several studies have recommended routine bone grafting from the iliac crest in all cases.^28,29 However, Rosenfeld et al.²⁷ performed triple arthrodesis on 100 patients with different foot deformities using a local bone graft from the resected subchondral bone. The authors reported a nonunion rate of as low as 4% and inferred that routine bone grafting is unnecessary in most cases. Using local bone graft (when required), all patients in our case series achieved radiographic solid fusion in each component of the triple joint complex (100%). Therefore, the findings from the present study support filling any defect at the fusion sites with the local bone graft from the resected articular surfaces instead of routine iliac crest bone grafting.

Several important limitations should be considered when interpreting the results of this study. The major limitations of the study were its retrospective nature and limited sample size. Additionally, measurement of postoperative foot radiographic parameters was difficult in some cases because of bony fusion or hardware. Thus, a single experienced orthopedic surgeon blinded to the patients' clinical status measured all the parameters. Despite these limitations, our study is one of few studies that present the long-term results of triple arthrodesis in patients with stage III PTTD. Moreover, to our knowledge, this is the first study to specifically explore the effectiveness of triple arthrodesis in RA patients by comparing it with idiopathic nonrheumatoid patients.

In conclusion, this study has shown that triple arthrodesis is an effective procedure in relieving pain and improving function and quality of life in patients with stage III PTTD when proper foot position, alignment, and union are obtained. Furthermore, although rheumatoid patients present with radiographically more severe flatfoot deformity, triple arthrodesis can provide similar satisfactory clinical and radiological outcomes with a low complication rate for stage III PTTD in rheumatoid patients as much as nonrheumatoid patients.

Ethical Approval and Consent to Participate: Institutional board approval was obtained before the study. All participants were informed about the study and a written informed consent was obtained.

Conflicts of Interest: No potential conflict of interest relevant to this article was reported.

Availability of Data and Materials: The data that support the findings of this study are not openly available, they are available from the corresponding author upon reasonable request

Competing Interest: The authors declare that they have no competing interests.

Funding: This research did not receive any specific funding.

Authors’ Contribution: MD: contributions to the conception, design of the work, the acquisition, analysis and interpretation of data for the work, FS: contributions to the conception, design of the work, the acquisition, analysis and interpretation of data for the work, LM: Writing article, the acquisition, analysis and interpretation of data for the work, DK: Analysis and interpretation of data for the work, ME: Analysis and interpretation of data for the work, MA: Analysis and interpretation of data for the work, OK: contributions to the conception, design of the work, and final approval of the version to be published. All authors read and approved the final manuscript.

Acknowledgements: Not applicable

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No competing interests reported.

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Comparative Results of Triple Arthrodesis for the Management of Stage III Posterior Tibial Tendon Dysfunction between Rheumatoid and Non-Rheumatoid Patients

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Abstract

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Introduction

Materials and Methods

Study protocol

Part I = Clinical and radiographic assessment of the entire study population

Clinical outcome measures

Radiographic outcome measures

Operative technique

Postoperative follow-up protocol

Statistical analysis

Results

Part I: Demographic characteristics and results of the entire study population

Clinical outcomes

Radiographic outcomes

Discussion

Declarations

References

Additional Declarations

Supplementary Files

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