J Am Podiatr Med Assoc. 2018 Nov;108(6):487-493. doi: 10.7547/17-042.
Safety of Deep Sedation in Patients Undergoing Full-Thickness Skin Graft Harvesting and Skin Graft Reconstruction for Limb Salvage An Outcome Analysis.
Studies on obtaining donor skin graft using intravenous sedation for patients undergoing major foot surgeries in the same operating room visit have not previously been reported. The objective of this retrospective study is to demonstrate that intravenous sedation in this setting is both adequate and safe in patients undergoing skin graft reconstruction of the lower extremities in which donor skin graft is harvested from the same patient in one operating room visit.
Medical records of 79 patients who underwent skin graft reconstruction of the lower extremities by one surgeon at the Yale New Haven Health System between November 1, 2008, and July 31, 2014, were reviewed. The patients' demographic characteristics, American Society of Anesthesiologists class, comorbid conditions, intraoperative analgesic administration, estimated blood loss, total operating room time, total postanesthesia care unit time, and postoperative complications within the first 72 hours were reviewed.
This study found minimal blood loss and no postoperative complications, defined as any pulmonary or cardiac events, bleeding, admission to the intensive care unit, or requirement for invasive monitoring, in patients who underwent major foot surgery in conjunction with full-thickness skin graft.
We propose that given the short duration and peripheral nature of the procedures, patients can safely undergo skin graft donor harvesting and skin graft reconstruction procedures with intravenous sedation regardless of American Society of Anesthesiologists class in one operating room visit.
Authors: Stephen M Schroeder, DPM, FACFAS, Enzo Sella, MD, Peter A Blume, DPM, FACFAS
As with most cases, nonsurgical measures should be exhausted before surgical intervention is considered. This is especially true in planning a salvage procedure like a triple arthrodesis. Conservative treatment consists of physical therapy, strapping and tapping, nonsteroidal anti-inflammatory drugs (NSAIDs), steroid injections, and bracing.
Most triple arthrodesis procedures are performed by removing all of the cartilage from the three joints involved—that is, the talocalcaneal (TC) joint (also referred to as the subtalar joint), the talonavicular (TN) joint, and the calcaneocuboid (CC) joint—and fusing them with bone-to-bone contact. Positional corrections can usually be achieved by rotating the foot along the natural contours of the joint surfaces prior to fusion. In cases of severe deformity, however, wedges of bone may have to be removed from or added to the joints to achieve the desired correction. [2, 4, 6, 7, 8, 9, 10, 11, 12]
One area of controversy regarding this procedure has to do with using external fixation devices. Proponents would argue that this is a stable fixation method that allows patients to ambulate with partial to full weightbearing on the operative side. Others would argue that the risk of pin-tract infections is high and could be disastrous to the procedure's outcome. A study that assessed 87 patients using a ring-style external fixation device reported a 97% fusion rate at 6-8 weeks, with a 36% rate of superficial pin-site infections. 
Orthobiologics are playing a growing role in augmenting these procedures. Autologous bone grafting is still the product of choice for filling voids; however, it is associated with a certain degree of morbidity. Allograft bone and other orthobiologic materials are safe and effective alternatives that reduce risks to the patient.
The double arthrodesis has gained popularity over the last few years and involves fusion of the TN and TC joints only.  It can be done through a single medial incision, preserves a nonarthritic CC joint, maintains the length of the lateral column, and has been shown to be a reliable method for correcting planovalgus deformity.  It is especially beneficial in cases where concern exists for lateral incision wound breakdown, as with compromised skin from previous trauma or a severe valgus deformity. [5, 15, 16, 14]
Arthroscopic arthrodesis is an accepted technique for the ankle but is less commonly reported for multiple hindfoot joints. A case series review by Jagodzinski et al found that arthroscopic double and triple arthrodeses appear to be feasible salvage options for pain and deformity, though late adjacent joint pain and arthrosis may develop.  Arthroscopic triple arthrodesis may be more commonly performed in the future.