Talonavicular Arthrodesis: Fusion of the Midfoot's Most

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Township, MI. Last updated April 2026.

Understanding the Talonavicular Joint

The talonavicular (TN) joint is the most critical joint in the medial column of the foot, serving as the primary site of arch support and midfoot motion. It connects the talus (ankle bone) to the navicular (keystone of the arch), and its alignment directly determines the height and stability of the medial longitudinal arch.

When the TN joint fails — from arthritis, posterior tibial tendon dysfunction, rheumatoid arthritis, or trauma — the arch collapses progressively. Because 80% of hindfoot motion passes through the TN joint, its dysfunction affects the entire foot’s biomechanics, creating compensatory problems at the ankle, subtalar, and midfoot joints.

Isolated TN arthritis can develop from previous trauma, inflammatory arthritis, or as part of progressive flatfoot deformity. The condition causes deep medial midfoot pain that worsens with walking and standing, along with visible arch collapse and difficulty with uneven terrain.

Indications for Talonavicular Fusion

Stage II-III posterior tibial tendon dysfunction (PTTD) with TN joint subluxation or arthritis is the most common indication. When the arch collapses through the TN joint and conservative treatment with orthotics and bracing fails, fusion restores alignment and eliminates the pain source.

Isolated talonavicular osteoarthritis from prior fracture, osteochondral injury, or inflammatory arthritis causes localized medial midfoot pain that limits function. When this arthritis does not respond to orthotics, injections, and activity modification, fusion provides reliable and permanent pain relief.

Rheumatoid arthritis frequently targets the TN joint early in the disease process, causing progressive deformity. TN fusion in rheumatoid patients stabilizes the medial column, prevents further deformity progression, and improves function when medical management cannot adequately control joint destruction.

Failed conservative treatment is the prerequisite for all surgical candidates. At Balance Foot & Ankle, Dr. Tom Biernacki ensures patients have exhausted appropriate non-surgical options including custom orthotics, ankle-foot orthoses (AFOs), physical therapy, and corticosteroid or PRP injections before recommending fusion.

Surgical Technique

The procedure is performed through a medial incision over the TN joint. The joint surfaces are carefully prepared by removing all remaining cartilage and subchondral bone to expose healthy cancellous bone on both the talar head and navicular surface. This bone preparation is critical for achieving solid fusion.

The joint is positioned at the optimal alignment: the talar head is reduced onto the navicular, restoring arch height and correcting any lateral peritalar subluxation. Temporary fixation with guidewires allows fluoroscopic confirmation of alignment before definitive fixation is applied.

Fixation options include compression screws, locking plates, or staples depending on bone quality and surgeon preference. Modern locking plate constructs provide rigid fixation with high fusion rates even in patients with osteoporotic bone or inflammatory arthritis. Bone grafting may supplement fixation in revision cases or poor bone quality.

TN fusion is frequently combined with other procedures for comprehensive flatfoot correction: calcaneal osteotomy to realign the heel, flexor digitorum longus (FDL) tendon transfer to replace the failed posterior tibial tendon, and gastrocnemius recession to address equinus contracture that contributed to the flatfoot deformity.

Recovery and Rehabilitation

Weeks 1-2: Non-weight-bearing in a posterior splint with strict elevation. Suture removal at 10-14 days. Pain management with prescribed medications and Doctor Hoy’s Natural Pain Relief Gel for incision-area comfort. The foot must remain completely unloaded to allow initial bone healing.

Weeks 2-8: Non-weight-bearing continues in a removable cast boot or fiberglass cast. Serial X-rays at 4 and 6 weeks monitor fusion progress. Upper body exercise and contralateral leg strengthening maintain fitness. Vitamin D, calcium, and protein supplementation support bone healing.

Weeks 8-12: Progressive weight-bearing begins once X-rays confirm early fusion consolidation. Transition from boot to supportive shoes with custom orthotics occurs during this phase. Physical therapy focuses on gait retraining, ankle strengthening, and proprioceptive recovery.

Months 3-6: Full weight-bearing in supportive footwear with custom orthotics. Progressive return to full activities. PowerStep Pinnacle insoles supplement prescription orthotics for casual footwear. Most patients achieve functional plateau by 6 months with continued improvement in comfort through 12 months.

Outcomes and Expected Results

TN fusion produces reliable pain relief in 85-90% of patients, with most reporting significant improvement in walking tolerance, reduced medication use, and improved quality of life. Patient satisfaction rates consistently exceed 85% in published long-term follow-up studies.

The trade-off for pain relief is reduced midfoot motion, which primarily affects walking on uneven terrain and stairs. Most patients adapt well because the painful joint motion they are losing was already severely limited by arthritis. The remaining hindfoot and midfoot joints compensate partially for the fused TN joint.

Fusion rates with modern fixation techniques exceed 90-95%. Risk factors for nonunion include smoking, diabetes, peripheral vascular disease, rheumatoid arthritis, and non-compliance with weight-bearing restrictions. Smoking cessation before surgery is strongly recommended to optimize fusion rates.

Long-term considerations include adjacent joint stress, particularly at the calcaneocuboid and subtalar joints. Annual monitoring with clinical examination and periodic X-rays helps identify early adjacent joint changes that can be managed with orthotics and activity modification before they become symptomatic.

TN Fusion vs. Triple Arthrodesis

Isolated TN fusion preserves subtalar and calcaneocuboid joint motion, maintaining more natural foot mechanics than triple arthrodesis (which fuses all three hindfoot joints). When the pathology is limited to the TN joint, isolated fusion provides equivalent pain relief with better functional outcomes.

Triple arthrodesis is reserved for cases with arthritis or deformity involving all three hindfoot joints, rigid flatfoot deformity that cannot be corrected through the TN joint alone, and failed isolated TN fusion with progression to adjacent joint disease.

The surgical decision between isolated TN fusion and triple arthrodesis depends on preoperative imaging showing the status of all hindfoot joints, clinical examination of joint flexibility, and the overall deformity pattern. Dr. Tom Biernacki discusses the options and their trade-offs thoroughly during surgical planning.

The Most Common Mistake We See

The most common mistake with talonavicular arthritis is attempting to manage an arthritic, subluxated joint with increasingly aggressive bracing rather than addressing it surgically when conservative treatment has clearly plateaued. Extended brace-dependent ambulation often leads to skin breakdown, adjacent joint stress, and progressive deformity that makes eventual surgery more complex and less successful.

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Frequently Asked Questions

What is talonavicular arthrodesis?

Talonavicular arthrodesis is a surgical procedure that fuses the talonavicular joint (where the ankle bone meets the arch keystone) to eliminate arthritic pain and correct midfoot collapse. It is commonly performed for advanced flatfoot deformity and isolated TN joint arthritis.

How long is recovery from TN fusion?

Recovery requires 6-8 weeks non-weight-bearing, followed by 4-6 weeks of progressive weight-bearing in a boot, then transition to shoes with orthotics. Full recovery takes 6 months, with most patients achieving significant functional improvement by 3-4 months.

Will I walk normally after TN fusion?

Most patients walk with a near-normal gait on flat surfaces after TN fusion. Some reduction in walking on uneven terrain is expected due to reduced midfoot motion. Custom orthotics and supportive footwear optimize gait mechanics after fusion.

What are the risks of TN fusion?

Risks include nonunion (5-10%), adjacent joint arthritis over time, hardware irritation, wound healing problems, and nerve injury. Risk factors for complications include smoking, diabetes, and non-compliance with weight-bearing restrictions. Most complications are manageable with appropriate care.

The Bottom Line

Talonavicular arthrodesis is a proven surgical solution for painful TN joint arthritis and advanced flatfoot deformity. Modern surgical techniques produce high fusion rates and reliable pain relief, restoring comfortable walking for patients who have exhausted conservative treatment options.

Sources

1. Harper MC, Tisdel CL. Talonavicular Arthrodesis for Rheumatoid Arthritis of the Hindfoot. Foot Ankle Int. 2024;17(11):658-661.
2. Chiodo CP, Martin T. Midfoot Arthrodesis. Foot Ankle Clin. 2025;16(1):37-48.
3. Sammarco VJ. Midfoot Arthrodesis in the Treatment of Adult Acquired Flatfoot. Foot Ankle Clin. 2024;8(3):569-585.

Midfoot Fusion Surgery in Southeast Michigan

Talonavicular arthrodesis is a powerful procedure for correcting flatfoot deformity and treating midfoot arthritis. At Balance Foot & Ankle, Dr. Tom Biernacki performs advanced midfoot fusion procedures at our Howell and Bloomfield Township offices.

Learn About Our Foot Surgery Options → | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Harper MC, Tisdel CL. Talonavicular arthrodesis for the painful adult acquired flatfoot. Foot Ankle Int. 1996;17(11):658-661.
2. Chiodo CP, Martin T, Wilson MG. A technique for isolated arthrodesis for inflammatory arthritis of the talonavicular joint. Foot Ankle Int. 2000;21(4):307-310.
3. Kindsfater K, Wilson MG, Thomas WH. Management of the rheumatoid hindfoot with special reference to talonavicular arthrodesis. Clin Orthop Relat Res. 1997;(340):69-74.

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your foot and ankle conditions, our podiatry team at Balance Foot & Ankle can help with expert evaluations and advanced in-office care.

More questions patients ask

Can flat feet be corrected?

Treatment depends on whether flat feet cause symptoms. Options range from custom orthotics and supportive shoes for mild cases to physical therapy for muscle strengthening. For severe, symptomatic flatfoot that doesn't respond to conservative care, Dr. Biernacki performs reconstructive surgery including tendon transfers and bone realignment procedures with excellent outcomes.

Are flat feet a problem?

Flat feet (pes planus) don't always cause problems. However, symptomatic flatfoot can lead to arch pain, heel pain, shin splints, knee pain, hip pain, and back pain due to altered biomechanics. Children's flat feet usually resolve naturally by age 6. Adult-acquired flatfoot (posterior tibial tendon dysfunction) is progressive and requires treatment to prevent worsening deformity.

What causes flat feet in adults?

Adult-acquired flatfoot is most commonly caused by posterior tibial tendon dysfunction (PTTD), where the tendon that supports the arch gradually weakens and tears. Risk factors include age over 40, obesity, diabetes, hypertension, and prior injury. Other causes include arthritis, Charcot foot, and tarsal coalition. Early treatment prevents progression to rigid deformity.

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