Chapter 21: Surgery of theCongenital FootFlatfoot Surgery (flexible)Subtalar Joint Blocking Procedures:

(Arthroereisis and Arthrodesis) Flatfoot Surgery (rigid): Convex Pes Piano Valgus Metatarsus Adductus SurgeryCavus Foot SurgeryClubfoot Surgery

SURGERY OF THE CONGENITALFOOT

Flatfoot Surgery (Flexible),1. Etiology of Flexible Flatfoot (pes planovalgus):a. Rare syndromes: (Down's, Ehler's-Danlos, Marfan's, and Morquio's syndromes)b. Calcaneovalgus: (not all cases)c. Biomechanical:i. Forefoot varusii. Forefoot valgusiii. Equinusiv. Torsional abnormalitiesv. Muscle imbalance (weakness of the supinators) vi. Ligamentous laxityd. Neurotrophic feet (early stages)e. Enlarged or accessory navicularf. Limb length inequality

2. Biomechanical alterations:a. The subtalar joint is pronatedb. The midtarsal joint becomes unstable and unlocked: this is because the STJ is in a pronated position with the calcaneus everted, the T-N joint and the C-C joint become divergent from each other, their axes become more parallel. This allows for independent range of motion of each of these joints and increases the range of motion of the MTJ itself. The pronated STJ allows for compromised function of the peroneus longus and tibialis posterior muscles.This results in loss of osseous stability as the heel comes off the ground. The reactive force of gravity produces a dorsiflexory force on the forefoot. The following are the changes to the foot:i. Arch fatigueii. Hypermobile first metatarsaliii. Subluxation of the first rayiv. Contraction of the digitsv. A medial distribution of body weight when the calcaneus everts beyond 4-5° of eversion.vi. Collapse of the MTJvii. The axis of the STJ in the normal patient is approx. 42° from the transverse plane 16° from the sagittal plane. Any change in this will result in changes to motion on the various planes. In clinically examining each patient, it may be necessary to estimate the primary plane of motion of the STJ to predict the ability (biomechanically or surgically) to control the STJ. In examining the ROM of the joints of the foot, the predominant axis of motion can be estimated.

3. Radiographic Alterations:a. If transverse plane dominance:i. Increase in the dorsoplantar T-C angleii. Increase in the cuboid abduction angleiii. Decrease in the percentage of T-N congruency b. If frontal plane dominance:i. Widening of the lesser tarsus on dorsoplantar view ii. Decrease of the first metatarsal declination angle iii. Decrease in the height of the sustentaculum tallc. If sagittal plane dominance:i. Increase in the talar declination angleii. Naviculocuneiform breachiii. Increased T-C angle on the lateral viewiv. Decreased calcaneal inclination angled. The stress dorsiflexion lateral view (charger view) is used to determine osseus blocks of the ankle joint.e. Harris-Beath views are helpful in determining T-C coalitions (taken from posterior and superior with the x-ray beam at 35°, 40°, and 45° to the perpendicular).

4. Evaluation, Criteria. and Goals:a. First ascertain the available range of motion: then differentiate rigid vs. flexible flatfoot.

b. Determine the planar dominance: because the foot that presents a high degree of transverse plane motion is extremely difficult to control nonsurgically.c. Surgery must be avoided in the normal low arched foot (pes planus), which must be distinguished from the collapsing pes planovalgus deformity as we are describing.d. Consider the age of the patient and the percentage of bone growth remaining.e. Consider the presence of other related medical conditionsf. Consider the presence of other superstructural deforming forces (tibial torsion)g. Other surgical criteria for flexible flatfoot:

NOTE* IF frontal plane motion (inversion/eversion) is predominant the joint axis will be more horizontal. If transverse plane motion (abduction/adduction) is more predominant, the joint axis is more vertical. If sagittal plane motion (dorsiflexion/plantarflexion) is more predominant, the axis will lie closer to the frontal and horizontal planes.

Note* Procedures that are effective for flexible flatfoot are usually ineffective for rigid flatfoot, and the foot with bony adaptation secondary to forefoot varus/supinatus also requires a different approach

i. Symptoms are resistant to conservative therapyii. The unstable foot is not controllable by mechanical devices iii. Secondary changes are present or can be definitely predictedh. Goals of surgery:i. Relief of painii. Biomechanical control of excessive pronation iii. Prevention of progression of the deformity

5. Soft Tissue Approaches: (Medial Column Procedures) a. Kidner procedure:i. Requires the removal of an accessory navicular (changes the leverage of the tibialis posterior ms.).ii. Removal of any hypertrophied tuberosity of the naviculariii. Transposition of the insertion of the tibialis posterior tendon into the underside of the navicular.b. Lowman procedure:i. Achilles tendon lengtheningii. T-N wedge arthrodesisiii. Rerouting the tibialis anterior tendon under the navicular and suture to the spring ligament.iv. Tenodesis of the medial arch with a slip of the Achilles tendon, which is left attached to the calcaneus and folded forward along the medial arch as an accessory ligament (this helps maintain the calcaneus and forefoot in adduction).v. Desmoplasty of the T-N ligaments

c. Young procedure:i. Tendoachilles lengtheningii. Rerouting of the tibialis anterior tendon through a slot in the navicular without detaching the tendon from its insertion. iii. Tibialis posterior reattachment beneath the navicular

6. Osseous Approaches: (medial column procedures) a. Hoke arthrodesis:i. Tendo achilles lengtheningii. navicular to the medial and intermediate cuneiform

b. T-N

arthrodesis:i. Generally used in combination with other procedures (TAL, calcanealosteotomies, medial column tendon balancingii. Blocks all MTJ motion and almost all STJ motioniii. When the T-N joint is wedged the procedure can reduce someforefoot varus deformity, and can be combined with an Evans calcanealosteotomy.iv. Most useful in degenerative joint changes/severe collapse at the T-N joint, part of a repair of a ruptured tibialis posterior, and paralytic deformity. c. Miller procedure:i. Lengthening of the tendo achillesii. Raising an osteoperiosteal flap left in place proximally, along themedial arch (this includes the spring ligament and tibialis posterior tendoninsertion) and reattaches in an advanced position.

Note * The Hoke procedure is now used as an adjuctive procedure in combination with a TAL, calcaneal osteotomy, or arthroereisis. It is utilized in the presence of severe N-C sagging, and is reserved for patients whose bone growth is complete and when secondary changes. have occurred in a joint

iii. Arthrodesis of the navicular-medial cuneiform jointiv. Arthrodesis of the 1st metatarsal-medial cuneiform jointd. Osteotomies of the talus:i. Stokes:ii. Perthes: closing wedge at the talar necke. Osteotomies of the medial cuneiform:i. Anderson and Fowler: plantar flexory wedge in conjunction with an Evans calcaneal osteotomy.ii. Cotton: opening wedge to produce plantarflexion of the medial column

7. Osseous Approaches: Calcaneal osteotomies (3 types): Calcaneal osteotomies allow some margin for error, because joint motion is still present. You must be specific in choosing procedures for the appropriate problem. You must correct the etiology, not the symptoms. During the procedure, dorsiflex the foot and make sure it is in neutral in all planes before being satisfied on wedge size and fixation. These procedures are basically designed to replace the triple arthrodesis and allow maintenance of joint motion after the foot is corrected.a. Extra-articular:i. Chambers: A procedure to limit STJ motion by placing a bone graft under the sinus

tarsi (similar to arthroereisis)ii. Baker-Hill: (to reduce heel valgus and excessive pronation) A refined Chambers concept for use in patients with CP They used a vertical-lateral approach to perform a horizontal osteotomy

inferior to the posterior facet of the STJ A wedge shaped graft is inserted.iii. Selakovich: Through a medial approach performing an osteotomy and grafting of the

sustentaculum tali Tightening of the spring ligament Repositioning of the tibialis posterior Transfer of all/part of the tibialis anterior into the navicular

b. Anterior:i. Evans (refined by Ganley): good when the forefoot abducts severely when the STJ is in neutral. This procedure is contraindicated in neurological disorders that may generate spasticity and varus due to functional overcorrection. The rationale for this procedure is that as the lateral column is lengthened, the entire forefoot is forced to pivot around the head of the talus, effectively adducting the forefoot and tightening the structures of the arch

Due to scarring the incision has been changed, to one parallel to the skin

NOTE* If there is excess lengthening of the lateral column, an equinus may be produced (talus abducts and dorsiflexes)

tension lines in an oblique/transverse fashion on the lateral side of the foot over the C-C joint (avoid the sural nerve inferiorly and the intermediate dorsal cutaneous nerve superiorly; they are found at the extreme poles of the incision)

The peroneals are retracted inferiorly Reflection of the EDB ms. dorsally while preserving the dorsal

calcaneocuboid ligament

Osteotomy of the calcaneus parallel and 1.5 cm proximal to the C-C joint from lateral to medial

insertion of tibial bone graft or bone bank iliac crest, which is tapped into position, and any void filled with bone chips

Suture the EDB back into place: impossible to achieve good closure of this muscle layer

Complications include undercorrection/overcorrection, delayed/nonunion, and if there is a met. adductus present It will be made worse.

When the Evans procedure is done in conjunction with a medial arch tenosuspension the cuboid abduction angle is decreased, the forefoot abduction angle is decreased by an average of 170 and the calcaneal inclination angle is increased by 7°.

c. Posterior (varus producing osteotomies): Are designed to place the weight-bearing surface of the calcaneus in neutral or varus, preserve STJ motion while changing the ratio of available inversion/eversioni. Gleich Oblique calcaneal osteotomy displaced anteriorly, helps increase the

calcaneal inclination angleii. Dwyer Most commonly performed as an opening wedge (can be closing wedge

NOTE* This ligament is critical in limiting the dorsal shift of the anterior beak of the calcaneus

Note* This procedure straightens the lateral column with reduction of heel valgus. In most cases it is still necessary to reduce the amount of forefoot varus and stabilize the medial column by doing a T-N fusion, wedge osteotomy of the cuneiform, naviculocuneiform fusion, or medial arch tenosuspension (predominant)

Note* One of the most difficult pes planovalgus foot types to treat is one with a vertical STJ axis. This foot compensates for deforming forces mainly in the transverse plane. This foot is recalcitrant to mechanical control and medial column procedures. Lateral column lengthening procedures are indicated (Evans procedure)

also) from the lateral side Slightly overcorrect with the osteotomyiii. Silver Lateral opening wedge osteotomy with the direction from just posterior to

the posterior facet running inferiorly.iv. Koutsogiannis Lateral approach with a transection osteotomy of the calcaneus (oblique) -

Posterior fragment is medially displaced until it lies below the sustentaculum tali

v. Additional procedures: Sullivan (a dorsal anterior sliding osteotomy of the posterior aspect of the

calcaneus to treat equinus) Moeller (triplane closing wedge osteotomy of the lateral cortex, for cavus

foot) Keck and Kelly (dorsal closing wedge osteotomy just anterior to the

achilles; it will decrease the inclination angle and remove pressure from a Haglund's deformity)

Reinhart (for pes cavus deformity where a through and through osteotomy is done)

8. Ancillary Procedures:a. Tendo Achilles lengthening: is indicated in almost all of the above flatfoot procedures

9. Rearfoot Arthrodesis: Is usually used with severe DJD, severe triplane deformity with pain, paralytic deformity, or for long-standing rupture of the tibialis posterior, with collapse of the foot.a. Subtalar arthrodesis: Restores the appropriate T-C relationship while preserving midtarsal motioni. The procedure involves resection of the sinus tarsi with packing with autologous bone chips, and screw fixation.ii. Objections to this procedure include: Fusion of one portion of the STJ results in DJD of the other joints No correction occurs in the forefoot which is usually in varus Potential for fatigue failure of the screw Long term loss of the correction

b. Triple arthrodesis: Because this is a long-standing and reliable procedure, it will be discussed in great detail.i. Definition: fusion of the T-C, C-C, and T-N jointsii. History: originally used for paralytic deformities, modified by Ryerson in 1923 with a two incision approach/internal fixation/above knee casting.

Note* Posterior calcaneal osteotomies are most useful in the least prevalent type of pes planovalgus, where there is frontal plane dominance. These osteotomies are most useful in conjunction with medial column procedures

iii. Indications: pain, instability, structural deformity (rigidity) iv. Specific etiological conditions: Valgus foot deformity Collapsing pes valgus deformity Ruptured posterior tibialis tendon Tarsal coalitions Tarsal arthritis Cavus foot Talipes equinovarusvi. Preoperative considerations: Procedure must be delayed until the patient reaches skeletal maturity Patient must have adequate ankle dorsiflexion available Due to the amount of dissection prophylactic antibiotics should be

considered Hemostasis necessary during the procedurev. Surgery: The dissection is started laterally passing between the sural and the

intermediate dorsal cutaneous nerves. The contents of the sinus tarsi are vacated, the extensor digitorum brevis muscle is reflected distally, and the peroneals are mobilized and protected from the lateral surface of the calcaneus. This gives exposure to the posterior facet, the C-C joint, and the lateral aspect of the T-N joint. The medial incision is dissected down to the dorsomedial aspect of the T-N joint. The periosteum and posterior tibial tendon are dissected inferiorly off the navicular, and the periosteum is reflected off the dorsal surface of the navicular and the head and neck of the talus until it connects with the lateral incision. If a subtalar wedge is to be taken, the medial incision dissection is carried posteriorly, reflecting the periosteum and the deltoid ligament of the sustentaculum tali, exposing the anterior and middle facets.

A minimal amount of bone is resected off all joint surfaces. The MTJ -is resected first, which relaxes tissues and makes it easier to manipulate the foot. Any wedging of the MTJ should be done after the STJ is resected and temporarily fixed. In any wedging of the STJ, the most bone should come off the calcaneus.

The rearfoot and forefoot must be fixed in slight valgus, because a valgus foot can be accommodated to be comfortable and a varus foot can rarely be made comfortable. If inadequate dorsiflexion is available at the ankle then jamming of the anterior ankle will occur causing development of chronic synovitis and degenerative destruction of the foot. Too much resection posterior to the STJ will cause dorsiflexion of the ankle joint and jamming. Anterior displacement of the talus on the calcaneus will plantarflex the forefoot, while posterior displacement of the talus will dorsiflex the forefoot. Plantarflexion of the forefoot will cause more ankle joint dorsiflexion and jamming of the ankle. The forefoot can be rotated on the rearfoot to accommodate frontal plane problems.

Temporary fixation is achieved with K-wires or Steinmann pins. The STJ is fixated first. Rigid compression fixation gives more constant joint fusion. A 6.5mm cancellous or cannulated screw is used to fixate the STJ. Using

screws in the MTJ is difficult due to the angulation, and so staples may be used for fixation of the T-N and C-C joints. Fluoroscopy or intraoperative x-rays must be taken to assure proper position.

vi. Postoperative management: Jones compression cast for 2-3 days Drain pulled at 48-72 hours A B-K NWB cast is applied for 8 weeks Change cast and suture removal at 2-3 weeks Change cast every 2-3 weeks thereafter Take serial x-rays to evaluate healing every 4 weeks A B-K WB cast is then used for 4 weeks Physical therapy continued for 3 months Goal is a return to normal function 6 months postoperativelyvii. Complications: Fracture Wound dehiscence Peroneal tendonitis Entrapment neuropathy Nonunionviii. Postoperative gait pattern: Abducted gait Shorter stride Difficulty in going down stairs

Subtalar Joint Blocking Procedures (Arthroereisisand Arthrodesis) for FlatfootThere are 2 major categories: extra-articular arthrodesis which actually fuses the joint by means of a bone graft eliminating all motion, and arthroereisis which limits excessive valgus motion of the STJ and retains the varus range of motion.

1. Arthrodesis:a. Grice Green (EASTA: extra-articular subtalar joint arthrodesis): Thisprocedure allows you to fuse the STJ without disturbing growth.i. Indications Paralytic instability and equinovalgus Peroneal spastic flatfoot Unresectable tarsal coalitions Age bracket 3-14 years oldii. Contraindications Ankle valgus flatfootiii. Procedure Use corticocancellous graft placed at 900 to the STJ axis

2. Arthroereisis:a. Indicationsi. To see if a patient needs an arthroereisis: have the patient stand on the toes, the heel must supinate

ii. Age is 4-8 yearsiii. Cavovalgus footiv. A foot that has been unresponsive to treatment for 2 years v. Eversion of the heel at least 8°vi. Predominant frontal plane deformityvii. Flexible forefoot varus deformity above 10° b. Contraindicationsi. Rigid flatfootii. Significant arthritis/trackbound tarsal jointsiii. Ankle valgusiv Equinus (must be released)v. Skewfootvi. Torsional problemsvii. Frontal plane knee deformityc. 3 typesi. Self-locking wedge Viladot Valenti Addante Valgus stopii. Axis altering (not for adults): elevates a low STJ axis STA-peg iii. Direct impact (can be used for all ages) Sgarlato Pisanid. Anatomical placementi. Sinus tarsi Valgus stop STA-peg Sgarlatoii. Canalis tarsi Valenti Viladote. Postoperative carei. Cast for 2 weeksii. Orthoses and high top sneakers for 1 yearf. Complicationsi. Extrusion of the implant ii. Fracture of the implantiii. Fracture of the calcaneusiv. Improper placement of the implantv. Over/undercorrectionvi. Infectionvii. Erosion of the bone-implant interface

Flatfoot Surgery (rigid): Convex Pes Planovalgus1. Etiology of Rigid Flatfoot: a. Vertical talus

b. Congenital T-N dislocation c. Arthrogryphosisd. Tarsal coalition/peroneal spastic flatfoot e. Tarsal arthrosis caused by trauma f. Cerebral palsyg. Spina bifidah. Improper correction of clubfoot i. Post-traumaticj. Neurotrophic (late stages)2. Clinical Presentation of Convex Pes Planovalgus (vertical Talus): (see pediatrics)a. Rocker-bottom deformity with prominent talar head bulge on the medial and plantar aspect of the foot.b. The forefoot may actually touch the anterior surface of the tibia c. Valgus rearfoot that is in equinus

3. Radiographic Presentation of Convex Pes Planovalgus:a. Definitive diagnosis when it is evident that the tarsal navicular is dorsally dislocated on the neck of the talus even when the foot is maintained in a stress plantarflexed attitude (forced plantarflexion and inversion will not reduce the dislocation of the T-N joint in a true convex pes piano valgus deformity).b. Talus is vertical, lying parallel to the longitudinal axis of the tibia c. Calcaneus is in an equinus positiond. T-C angle is abnormally increased on the D-P view

4. Pathology of Convex Pes Planovalgus:a. Severe dislocation of the T-N joint (navicular is articulating with the dorsal aspect of the talusb. Neck of the talus is hypoplastic

c. Talar head is flattenedd. Calcaneus is displaced posteriolaterallye. Calcaneus is convex on its plantar surfacef. The tibialis posterior and peroneals are located anterior to their normal position and are contractedg. The tibialis anterior, EHL, EDL, and the triceps surae are contractedh. The tibionavicular ligament and dorsal talonavicular ligament are contracted (the problem in the repair of this foot type)

Surgery of the Convex Pes Planovalgus Foot: Surgery is dependent upon patient's age, clinical and radiographic features, type and degree of previous treatment, and experience of the surgeon. The common objective of all procedures is release of all soft tissue contractures, establishment of a rectus forefoot to rearfoot relationship, and the production of equal medial and lateral foot columns. a. Talar procedures: resect the head and neck of the talus b. Navicular procedures: naviculectomyc. Tendon transfers: transfer of the tibialis anterior/posterior and peroneals d. Open surgical reduction: T-N joint reduction along with a peritalar release, heel cord lengthening, extensor and peroneal tendon lengthening, STJ and ankle joint capsulotomy, calcaneocuboid joint reduction, and transfer of the tibialis anterior into the navicular (K-wires removed at 6 weeks and A-K cast removed at 3 months)

Metatarsus Adductus1. Indicationsa. Failure to respond to conservative treatmentb. Residual deformity after treatment of talipes equinovarus c. Newly diagnosed metatarsus adductus deformity

2. Considerations: (see section Pediatrics) a. Age of patientb. Osseous development c. Severity of deformityd. Presence of concomitant deformities e. Extent of malfunction and disability

3. Soft Tissue Surgery:a. Heyman, Herndon, and Strong:i. Indications: For flexible met. adductus which is reducible on manipulation (stress x-

ray) Usually children less than 5 years old Deformity present at Lisfranc's joint, without significant bowing present in

the proximal portion of the metatarsal bones themselves ii. Procedure: 2 or 3 longitudinal dorsal incisions, or a transverse incision Release of the dorsal, interossei, and plantar ligaments of the

tarsometatarsal joints and intermetatarsal joints

Preserve the plantar-lateral ligaments, especially 5th metatarsocuboid articulation and the peroneus brevis tendon

Manipulate the foot into abduction K-wire fixation of the first met-cuneiform joint and 5th met-cuboid joint Release of the naviculocuneiform and intercuneiform joints is rarely

needed Consider abductor hallucis release or tenotomy in conjunction with HH&Siii. Precautions Avoid damage to the 1st metatarsal epiphyseal growth plate (do not

confuse this with the met-cuneiform joint) Be careful not to introduce latrogenic dorsal dislocations at the met-

cuneiform jointsiv. Postop care Cast for 6-12 weeks Manipulate the foot and recast every 3-4 weeks depending upon the

severity Monitor the foot carefully for the development of a flatfoot deformity v. Complications Dorsal dislocation Degenerative arthritis Damage to the growth plates

b. Thompson procedure (modified):i. Indications Congenital hallux varus primarily Flexible met. adductus secondarily Hyperactivity of the abductor hallucis ms.ii. Procedure Medial longitudinal 1st m.p.j. skin incision approach Dissection to level of deep fascia over the abductor hallucis muscle Transection of the abductor hallucis tendon with resection of a segment of

the tendon and portion of the distal muscle Consider lesser m.p.j. release medially if lesser digits are also adducted Release of the medial head of the flexor hallucis brevis if adduction of the

hallux is still presentiii. Precautions Do not reduce varus of the hallux without insuring correction of any

adduction deformity of the first metatarsal Place the medial incision over the 1st m.p.j. strategically; if too superior or

inferior, may damage the medial neurovascular bundle Avoid the procedure as a primary mode of correction for met. adductus

unless clinical findings and x-rays strongly support hyperactivity of the abductor hallucis as the primary etiology

iv. Postoperative care Weightbearing in a surgical shoe for 3-6 weeks Splinting of the hallux and the first rayv. Complications Hallux abductovalgus

Hallux hammertoe (hallux malleus)

c. Johnson osteochondrotomy: cartilaginous procedure i. Indications Met. adductus deformity in children between the ages of 5-8 years (can be

younger)ii. Procedure 3 dorsal longitudinal incisions Closing abductory base wedge osteotomy of the 1st metatarsal Wedge resection of cartilage and bone from the bases of the lesser

metatarsals, distal to the proximal articular surface (base is lateral with the apex medial)

Fixation of the osteotomies with stainless steel wire, k-wires, or staples iii. Precautions Avoid damage to the epiphyseal growth plate of the 1st metatarsal Overcorrection/undercorrection of individual ray segments iv. Postoperative care Non-weightbearing with cast immobilization for 6-8 weeks Serial x-rays to assess healing

4. Osseous Surgery:a. Modified Berman-Gartland procedure:i. Indications Met. adductus in the child older than 6-8 years old Residual deformity following treatment of talipes equinovarusii. Procedure 3 dorsal longitudinal incisions Transverse or oblique-type closing abductory wedge osteotomy of the 1st

metatarsal Similar type of osteotomies of the lesser metatarsals with the cortical

hinge medially Fixation of osteotomies with SS wire, K-wires, staples, AO screws or

combinationsiii. Precautions Avoid damage to growth plate of 1st metatarsal Meticulous subperiosteal dissection is critical to avoid heavy callus

formation and undesirable synostosis between adjacent metatarsals Preservation of the medial cortical hinge is important to insure stability Careful planning to avoid over/undercorrectioniv. Postoperative care Non-weightbearing cast immobilization 6-8 weeks Convert the cast to posterior splint and start PT Orthotics when patient resumes weightbearing Serial x-rays to assess bone healing at 6 weeks, 12 weeks, 24 weeks and 1

yearv. Complications Over/undercorrection Delayed union/nonunion/pseudoarthrosis

Fracture of cortical hinge Damage to growth plate Elevatus of metatarsals latrogenically induced flatfoot deformityb. Lepird procedure:i. Indications Met. adductus in the child greater than 6-8 years old Residual talipes equinovarus deformityii. Procedure 3 dorsal longitudinal incisions Oblique closing-abductory wedge osteotomy (Juvara type) of the 1st

metatarsal with AO/ASIF screw fixation Rotational osteotomy of each lesser metatarsal with AO/ASIF screw

fixation (2.7 mm cortical used mostly) perpendicular to the plane of the osteotomy

An oblique closing wedge osteotomy may be used on the 5th metatarsal in place of the rotational type (if preferred)

Rotational osteotomies are performed from dorsal-distal to plantar-proximal with temporary preservation of the cortical hinge (facilitates fixation). The osteotomy is approximately 45° from the weightbearing surface. The precise angle will depend on the declination of the metatarsal segment. As the declination of the metatarsal increases, the osteotomy will be more parallel to the weightbearing surface of the foot

Area of the cortical hinge preserved is most commonly proximal/plantar The screws are then removed and the osteotomy is completed The screws are reinserted, the distal fragments are rotated laterally, and

the screws are tightened The alignment of the foot is assessed; if realignment is necessary the

screw(s) can be loosened and the bone adjustediii. Postoperative care Same as Berman-Gartlandiv. Complications Same as Berman-Gartland if the osteotomy is performed too vertically the rotation of the osteotomy

will be around the longitudinal axis of the metatarsal bone itself, resulting in inversion/eversion of the bone itself

v. Advantages This procedure is amenable to rigid internal fixation and primary bone

healing Over/undercorrection can be corrected during surgery Biplanar correction can be achieved Eliminates pin tract infections

5. Ancillary Procedures:a. Equinus Deformityi. TALii. Gastrocnemius recessionb. Flatfoot Deformity:

i. STJ arthroereisisii. Evans calcaneal osteotomyiii. Modified Young's tenosuspension/ Modified Kidner procedure iv. T-N joint arthrodesis/ N-C arthrodesis

Cavus Foot Type1. Description: Pes cavus is primarily a sagittal plane deformity and can best be described by the area of involvement.a. Anterior pes cavus: Typesi. Metatarsus cavus (at Lisfranc's joint)ii. Lesser tarsal cavus (lesser tarsus)iii. Forefoot cavus (Chopart's joint)iv. Combined anterior cavus (occurring at 2 or more of the aforementioned areas)b. Rearfoot cavus: may not truly be a separate cavus deformity. It may be a compensation for anterior cavus. It etiology is:i. Pseudoequinus: reverse buckling of the ankle joint ii. Muscle weakness/spasticityiii. Congenitalc. Combined: both rearfoot and forefoot

2. Etiology:a. Neuromuscular: 66%

i.

Muscle lesion: muscular dystrophyii. Peripheral nerve lesion: Charcot-Marie-Tooth, polyneuritis, traumaticlesioniii. Spinocerebellar tract: Friedreichs ataxiaiv. Anterior horn cell: poliomyelitis, cord tumors v. Pyramidal/extrapyramidal: cerebral palsy vi. Cerebral cortex: hysteriab. Congenitali. Pes arcuatus (rare) ii. Spina bifidaiii. Myelomeningocele iv. Clubfoot v. Congenital syphilisc. Idiopathic: 33%i. Trauma ii. Infectioniii. Ledderhose's disease

Note* The apex of the deformity should be located on a lateral x-ray

Note* Because there is such a high correlation between neuromuscular disease and pes cavus, and because the cavus foot is often an early manifestation of such disease, a neurology consult is mandatory prior to any surgical intervention

iv. Spinal cord tumors

3. Classification:a. Flexible deformity (mild): Non-weight bearing, contracted digits, high arch and varus deformity of the heel may be noticed. With loading, digits appear normal, arch is flattened and heel may go into valgus. Minimal clinical symptoms at this pointb. Semi-rigid deformity (moderate): Weight-bearing does not completely reduce the contracture of the digits, arch appears higher and heel is in more varus attitude. Soft tissue contractures and bony adaptation begin to take place. Symptoms are more prominent.c. Rigid deformity (severe): Joint motion is limited. The foot is similar in appearance both weight/non-weight bearing. Digits are contracted dorsally and painful keratomas are present. Difficult to fit shoes.d. Progression of deformity: Often progresses from flexible to rigid as the patient gets older.

4. Compensation for Anterior Cavus:a. Retraction of the toes at the m-p joints (due to extensor substitution) b. Reverse bucking of the m-p jointsc. Forefoot reduction of the "flexible" anterior cavus d. Ankle joint dorsiflexion

5. Associated Conditions: a. Forefoot varus b. Forefoot valgus c. Plantarflexed 1st ray d. Metatarsus adductuse. Rearfoot pseudoequinus f. Rearfoot varus

6. Principles of Surgical Judgement:a. The presence of neurological disease will dictate what types of procedures you can and cannot do. You must determine whether the disease is progressiveb. For idiopathic pes cavus the following flow chart from McGlamry ED (ed) Comprehensive Textbook of Foot Surgery , 2 ed, Williams & Wilkins, (with permission) illustrates the surgical decision making plan best.c. You must determine whether the deformity is flexible or rigid and follow the preceding flow chartd. You must consider the age of the patient (soft tissue procedures are best in the child)

7. Preoperative Evaluation:a. Neurology consultb. Spinal x-raysc. EMG's and nerve conduction studiesd. X-rays of the foot (lateral)

i. Calcaneal inclination angle > 30°ii. Talar-1st metatarsal angle > 6° (Meary's angle) iii. Increased pitch of the 5th metatarsal iv. Note apex of the deformityv. Cyma line broken posteriorly (can be normal) vi. Sinus tarsi is clear and accentuatedvii. Coalition views should be used to assess the subtalar jointviii. An axial view of the calcaneal angle should be taken to rule out a structural varus

8. Pathogenesis:a. With weak tibialis anterior the long extensors substitute for ankle dorsiflexion, causing hyperextension of the MPJ's and retrograde pressure on the metatarsal heads (extensor substitution)b. Weak peroneus brevis and strong posterior tibial ms. will create a varus heelc. Paralysis of intrinsics causes the development of clawtoesd. Weak gastrocnemius causes flexor substitution which causes clawtoes. 9. Surgery: Soft tissuea. Plantar releasei. Subcutaneous fasciotomyii. Steindler stripping: through a medial incision the abductor hallucis, -flexor digitorum brevis, and the abductor digiti quinti are stripped from the periosteum of the calcaneus. The plantar fascia is released and the long plantar ligament is released.iii. Tachdjian: describes a plantar medial approach used with a fixed anterior cavus. Includes releasing the long/short plantar ligaments, spring ligament (calcaneonavicular), the calcaneonavicular portion of the bifurcate ligament, and the plantar fascia. Lengthening of the long flexors and the tibialis posterior is performed if on intraoperative reduction of the cavus foot bow-stringing of these tendons is notediv. Complications: Plantar fasciitis Forefoot may become splayed

b. Tendon transfers (give best results when the patient is > 10 years old)i. Jones suspension: transfer of the extensor digitorum longus to theneck of the 1st metatarsal with i.p.j. fusionComplications: Transfer lesion to the 2nd metatarsal if 1st ray is raised too high Hallux limitus Tendon may not hold the correction Failure of the fusion siteii. Heyman procedure: transfer of all five extensor tendons to theirrespective metatarsal heads. Complications: Clawtoes may result Tendonitis of the EDL Tendons may not hold the correction Same as Jones complications iii. Hibbs procedure (modified): transfer of the long extensors to thesecond and third cuneiform, a Jones transfer of the EHL, anastomosis ofthe distal stumps of the long extensors to the EDB tendons. This procedurehelps load the midtarsal joint in dorsiflexion.

(Note * These procedures are followed by serial casting

iv. Split tibialis anterior tendon transfer (STATT): the lateral half of the tibialis anterior tendon is sectioned and anastomosed to the peroneus tertius tendon near its insertion into the base of the 5th metatarsal.v. Peroneus longus tendon transfer vi. Tibialis posterior tendon transfer

10. Surgery: Osseous

a. Cole procedure: dorsal wedge tarsal osteotomy to reduce a fixed anterior cavus, which extends from the cuboid laterally through thenaviculocuneiform joints medially. The width of the wedge is determined by the severity of the deformity.

Note* Although the Hibbs procedure is a classic procedure described for the correction of anterior cavus, it should not be performed for pes cavus, because it fails to provide the dynamic force necessary to elevate the metatarsal heads

Note* The above procedures are utilized with flexible deformities

b.

Japas procedure: a midtarsal V-osteotomy (apex of the V is proximal and at the highest point of the cavus). The lateral limb of the V extends through the cuboid, and the medial limb of the V extends through the cuneiform

c. 1st ray Dorsal Wedge Flexory Osteotomyd. DWFO all metatarsalsComplications:i. If 1st metatarsal is done alone, may get transfer lesion to 2nd ii. May decrease ROM of 1st MPJiii. May get a metatarsal on different planese. Truncated tarsometatarsal wedge osteotomies: first described by Jahass, excision of a truncated wedge of bone. across the tarsometatarsal articulations. This procedure is contraindicated in subtalar joint abnormalities, moderate-severe rearfoot varus, or muscular imbalance secondary to Charcot-Marie-Tooth diseasef. McElvenny-Caldwell procedure: elevation of the first metatarsal by fusing the 1st met-cuneiform joint. If the deformity is too severe then fusion of the N-C joint is added.g. Calcaneal osteotomies (Dwyer: opening or closing and biplane):

h. Triple arthrodesis: previously described under Section: Flatfoot Deformity i. Hoke procedure: a combination of subtalar arthrodesis with a resection/reshaping/reimplantation of the head and neck of the talus j. Dunn procedure: a tarsal arthrodesis that obtained posterior displacement of the foot by excising the navicular and part of the head and neck of the talus

Talipes Equinovarus (clubfoot)The reason to treat a clubfoot is to obtain a pliable, plantargrade, cosmetically acceptable foot in a short treatment time with minimal risk. The indications for operative treatment are incomplete correction of the varus and equinus components, and you may see the bony pathology progressing if

Note* The disadvantage of the Cole procedure is that it can result in a shorter, wider, and thicker foot

Note* Difficult to control the amount of correctionNote* The primary difference in indications between the Cole and Japas is that the Cole is for more severe deformities and is only performed in the skeletally mature foot

Note* The biplane osteotomy permits reduction of the calcaneal inclination angle or sagittal plane deformity, as well as frontal plane varus

Note* The Dunn and Hoke procedures are useful when posterior displacement of the calcaneus beneath the talus is needed

continued conservative treatment is followed. When surgery is done early there is less deformity to the talus1. Types:a. Rigidb. Non-rigidc. Neural component foot with joint problems

2. Etiology:a. Unknown- but many theories (see Chapter: Pediatrics)

3. Anatomical Presentation:a. The talus is supinated over the top of the distal calcaneus so that the calcaneus is plantarflexed and invertedb. Master Knot of Henry is the deforming force on the medial side of the foot. It is the fibrous junction of the FHL/FDL sheaths to the navicular and fascia of the FHB. It must be severed to allow the navicular to re-establish itself laterally with the calcaneusc. The talus is usually deformed: the head and neck are medially displaced and downward (this is consistent in rigid clubfoot) d. The T-N joint is subluxed with the navicular medially e. Posterior medial structures are tight along with the STJ tissues f. Cuboid is displaced inwardly along with the navicular at the M-T joint and the anterior calcaneus following to go down and under the talar head g. The anterior surface of the calcaneus faces more medially, so the lateral column must be corrected to give a rectus footh. Two accessory joints are regularly foundi. The navicular rests on the anterior portion of the medial malleolusii. The posterior-lateral calcaneus rests on the posterior fibular malleolus i. The tendo achilles is slightly medial on the calcaneus j. The most consistent bony deformity is at the talar neck. It is short and medially deviatedk. Arteriography:

Idiopathic: only the foot is deformed, the musculoskeletal system is otherwise normal. In this foot type you will probably go on to surgical intervention before a non-idiopathic foot since the disorder should be known and the progression of the disease should be known. You should wait to treat this foot till the full deformity has developed as the treatment is more effective

Non-idiopathic: the deformity is a local manifestation of a systemic skeletal syndrome. The foot deformity and associated skeletal anomalies are due to the same etiologic factors that caused the failure of normal musculoskeletal development. Can be caused by: a. Congenital diseases: congenital constricting band syndrome (Streeter disease), hereditary onycho-osteodysplasia (nail-patella syndrome), arthrogryphosis multiplex congenitab. Neurologic diseases: meningomyelocele, spina bifida, hydrocephalus, CP c. Myopathy: muscular dystrophy

i. PT artery is most prominent (so must protect during surgery)ii. Deep plantar arch is supplied primarily by the PT not the DP (as in the normal foot)iii. A majority of the TEV feet develop without the DP arteryl. The calcaneofibular and posterior talofibular ligaments are tight due to the equinus positionm. The medial submalleolar skin is contracted and heals poorly

4. Pre-operative Evaluation:a. Angle of Kite (normal= 20-40°) approaches 00

b. A-P view shows talar bisection lateral to 1 st metatarsalc. If foot has marked forefoot adductus, corrective surgery is indicated for thisd. Flat-top talus may be present due to aggressive conservative treatment, which may later produce osteochondral fracture and later arthritise. Preoperative vascular assessment is important to determine the amount of correction able to be done: the limiting factor to any correction is the stress placed on the medial soft tissue and the neurovascular bundlef. Make sure the preoperative x-ray is taken with the knee/leg/foot vertical and not abductedg. A lateral stress dorsiflexion view is the most accurate judge of a clubfoot correctionh. The long axis of the talus is directed downward toward the 3rd met instead of medial to the 1st metatarsal as in the normal footi. Should consider a plantar release in children older than 6 due to cavus deformity that progresses from accommodation contractures of the plantar fascia, abductor hallucis, intrinsic toe flexors, and abductor digiti minimij. Talus is too far forward in the mortise, therefore, increased equinus and decreased dorsiflexionk. Tibia shows increased lateral torsionl. Ossification centers usually appear later in the clubfoot m. Parallel talus and calcaneusn. No overlap of the anterior ends of the talus and calcaneuso. In the normal foot the T-C angle increases with dorsiflexion, but with the clubfoot this angle does not changep. If surgery is delayed till after the age of 10, many adaptive changes will have taken place, and a triple arthrodesis may be the procedure of choice

5. General Symptoms:a. Lateral callositiesb. Tiring easilyc. Thin calf ms. on the affected sided. Smaller foote. Small 1st metatarsal with larger 4th and 5th metatarsalsf. Limb length difference with adaptive scoliosis g. Hyperextended kneesh. Metatarsus adductusi. No wrinkles over the achilles insertion (this helps diagnosis idiopathic from

non-idiopathic as so if wrinkles are present the foot did have plantar/dorsiflexion at one time indicating a non-idiopathic clubfoot)j. Genu valgumk. External rotation of the leg

6. General Order of Surgical Corrections: a. Posterior releaseb. Posterior medial releasec. Plantar released. Subtalar releasee. Metatarsus adductus proceduref. Tendon transfersg. Calcaneal osteotomiesh. Triple arthrodesis with soft tissue releasei. Amputation (if all else fails)7. Surgical Treatment (soft tissue): Performed after 3 months of failed conservative care- the next step.a. Posterior Medial Subtalar Release (TURCO procedure)i. Skin incision is classically a hockey stick incision from the base of the 1st metatarsal continuing under the medial malleolus and partially up the medial

aspect of the leg. Due to severe skin necrosis from this, a linear incision is now usedii. Isolate the posterior tibial ms., FHL, FDL, neurovascular bundle, and medial achillesiii. Loosen the abductor hallucis from the medial calcaneal tuberosity iv. Release the Master Knot of Henry (this obstructs a good view of the medial side of the foot)v. Posterior release is done first to allow good visualization of anatomical structures

vi. Medial release now tries to reposition medially displaced navicular laterally onto the talar head

vii. Plantar release

viii. Subtalar release allows the anterior calcaneus to move lateral-dorsal so the talus may reposition to a more appropriate pronated position Evert the heel and intersect the interosseous talocalcaneal ligament May need to sever the bifurcate ligament to help reposition the talus and

calcaneusix. After all soft tissue releases and the foot is corrected, the T-N and T-C joints should be stabilized with K-wiresx. Resected tendons should now be repaired except the posterior tibialxi. Skin closure: may need skin graft in the severely deformed foot or overly corrected footxii. If metatarsus adductus present now do HHS procedure

Inferior/posterior achilles release with sagittal plane Z TAL Release FHL sheath and retract with the neurovascular bundle medial and

anterior Apply dorsiflexory pressure and transect ankle and STJ capsule Resect calcaneofibular and posterior talofibular ligaments Resect posterior superficial part of the deltoid ligament (talotibial) Lengthen the FDL to prevent clawtoe deformity

Posterior tibial ms. is sectioned retaining good control of the distal segment to help isolate the T-N joint and medial structures

Resect the calcaneofibular ligament (spring) Resect the superficial part of the deltoid leaving the deep tibiotalar intact

anteriorly

incise the plantar fascia incise the first layer of intrinsics incise the long plantar ligament

b. Tendon transfers: usually done as an adjunctive procedure, and not primary ones. Transfers are only useful to help hold the correction of the flexible footi. Stewart TALii. STATTiii. Anterior tibial transferiv Posterior tibial transfer

8. Surgical Treatment (osseous): Usually done after the child is 4 or if soft tissue surgery has faileda. Evans calcaneal osteotomy (corrects the anterior medial position of the anterior calcaneal surface-an adaptive change)b. Dwyer calcaneal osteotomy (tries to establish a perpendicular heel and a weight bearing center of gravity)c. Triple arthrodesis is the procedure of choice when all else failsd. Talectomy is a possibility in the severely deformed foote. Amputation can be a viable alternative when most other procedures fail. With the aid of bracing, many times the extremity is more functional with a good device as compared to a very deformed and painful foot

9. Postoperative Evaluation:a. Calcaneus is rotated out of plantarflexion to dorsiflexionb. Posterior tubercle moves down when the anterior process moves up and laterally away from under the talusc. T-C angle now approx. 400 (lateral x-ray) and 250 on A-P viewd. Intraoperative lateral should shoe dorsiflexion of the calcaneus, overlap of the talus on the anterior calcaneus if correction achieved

10. Postoperative Care:a. Cast in neutralb. Prophylactic antibiotics givenc. Change cast every month, first cast change at 3 weeks-remove sutures d. At second cast change, remove K-wirese. Weight bearing allowed when wires removed f. Straight last shoes used for 1 yearg. Physical therapy

11. Complications:

Note* Turco states that best results are obtained when:a. the child is 1-2 years oldb. Good results decrease with agec. Good results if the child is walking due to Wolfs Law to help bone remodeld. Previous surgery is a hindrance

Note* Failure of the calcaneus to dorsiflex is evidence of incomplete subtalar correction regardless of what the A-P x-ray and clinical exam reveal

a. Rocker bottom foot if conservative treatment of equinus is corrected before the varus component or if the internal fixation is removed too soonb. Flap/skin necrosisc. Inability to close the skin after reductiond. Damage to growth platese. Relapse of the deformityf. Loss of the longitudinal archg. Stiffnessh. Hammertoe deformitiesi. Skewfoot can develop secondary to a valgus correction of the forefoot

12. General Facts:a. Treatment must be related to the type of clubfoot and ageb. The first step in the correction of clubfoot should be the replacement of the navicular on the talusc. Soft tissue procedures will fail if secondary bony changes are presentd. In the older child an adaptive contracture can produce a cavus foot. This is different from the average cavus foot because the calcaneus is plantarflexed in clubfoot-cavus and usually dorsiflexes in idiopathic or neuromuscular cavus. This is due to plantar contracture of the aponeurosis, abductor hallucis, intrinsics, and deep plantar ligaments