Essential Foot

and Ankle Surgical

Techniques
A Multidisciplinary Approach
Christopher F. Hyer
Gregory C. Berlet
Terrence M. Philbin
Patrick E. Bull
Mark A. Prissel
Editors

123
Essential Foot and Ankle Surgical
Techniques
Christopher F. Hyer • Gregory C. Berlet
Terrence M. Philbin • Patrick E. Bull
Mark A. Prissel
Editors

Essential Foot and Ankle

Surgical Techniques
A Multidisciplinary Approach
Editors
Christopher F. Hyer, DPM, MS, FACFAS Gregory C. Berlet, MD, FRCS(C), FAOA
Fellowship Director Orthopedic Foot & Ankle Center
Orthopedic Foot & Ankle Center Worthington, OH
Worthington, OH USA
USA
Patrick E. Bull, DO, FAOAO
Terrence M. Philbin, DO, FAOAO Orthopedic Foot & Ankle Center
Fellowship Director Worthington, OH
Orthopedic Foot & Ankle Center USA
Worthington, OH
USA

Mark A. Prissel, DPM, FACFAS

Orthopedic Foot & Ankle Center
Worthington, OH
USA

ISBN 978-3-030-14777-8    ISBN 978-3-030-14778-5 (eBook)

https://doi.org/10.1007/978-3-030-14778-5

© Springer Nature Switzerland AG 2019

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Foreword

A dramatic evolution in our understanding of foot and ankle disorders, both

its pathophysiology and treatment, has occurred over recent years. Both of us
have been involved in a paradigm shift of foot and ankle management from
one fairly conservative and nonoperative, even reactionary, to a more proac-
tive mindset that attempts to preserve motion in the active individual, lessen-
ing long-term disabilities. Our collective 55+ years of experience in this field
have witnessed advances in not only the basics of patient management but
also technological opportunities. Further, our ability to teach others based on
our past experiences has expanded with the number and quality of foot and
ankle fellowships, subspecialty societies, industry partnerships, and even
social media. All of these changes have helped us take better care of our
patients, and quite simply, we are better providers than we were years ago.
However, we have also been humbled in this learning experience—the abso-
lute truth about foot and ankle surgery is that “this stuff is not easy!!!” The
reality of repairing an extremity that repetitively hits an uneven ground with
full body weight is one that challenges us—whenever we are certain of a suc-
cessful treatment regiment, our patients prove us wrong.
There is a reason that this humbling nature of foot and ankle surgery is par-
ticularly relevant when asked to introduce this comprehensive text, Essential
Foot and Ankle Surgical Techniques. The reason is a purpose: The physicians at
The Orthopedic Foot and Ankle Center in Columbus, Ohio, decided a number of
years ago that the best way to help our collective patients was to create a pro-
vider group with multiple backgrounds. From educational backgrounds that
encompass MDs, DOs, and DPMs to the necessary ancillary expertise of pros-
thetists, orthotists, and physical therapists, this truly represents a “collaboration.”
Patients are best managed with a “team approach,” and this text represents that.
This group of talented practitioners has created a venue where all views and
backgrounds are valued. The chapters delve into difficult topics and treatment
options, introducing a number of management options influenced by the authors’
backgrounds, but with the priority being the patients’ best interest. That is the
value and the timeliness of this text. In a time where there is a stated need to
celebrate excellence, each chapter comes at the reader from a purpose and desire
to aid us in this difficult career choice of foot and ankle. We applaud the editors
and all of the contributors for this true multidisciplinary collaboration.

Charlotte, NC, USA W. Hodges Davis, MD

 Robert B. Anderson, MD

v
Preface

The specialty of foot and ankle surgery is a diverse amalgamation of orthope-

dic surgical principles, biomechanics and kinesiology, sports medicine, phys-
ical therapy and rehabilitation, as well as the psychology of patient and
surgeon expectations. This is also a unique specialty because surgeons of
different training backgrounds, including Doctors of Podiatric Medicine
(DPM), Doctors of Osteopathic Medicine (DO), and Doctors of Allopathic
Medicine (MD), practice it nationally and internationally. It is our belief that
when knowledge and experience is shared among these diverse surgeons, the
specialty of foot and ankle surgery, and ultimately patient care, continues to
improve. It is for these reasons that we have brought together these surgeons
and past fellows to produce this innovative and unique text.
This textbook is a reflection of our unique foot and ankle specialty prac-
tice and our surgical fellowship program at The Orthopedic Foot and Ankle
Center in Columbus, Ohio. Our practice is comprised of fellowship-trained
MD, DO, and DPM foot and ankle surgeons dedicated to the subspecialty
of foot and ankle surgery. We practice in a fully collaborative environment
encompassing all aspects of education, research, and patient care—with the
primary goal of constantly improving patient care and surgical outcomes.
We continue to “spread the word” nationally and internationally through
our interaction with other surgeon colleagues and are humbled to see many
like-­
minded surgeons who understand the benefit of this collaborative
approach.
We are honored to have our dear friends, mentors, and world-renowned
giants in foot and ankle surgery—Drs. Robert Anderson and Hodges Davis—
contribute the Foreword of this text. We individually and collectively learned
so much from them both; thus, it is an absolute honor to have their words of
wisdom attached to this textbook.
In this text, we have tried to reveal our unique multidisciplinary perspec-
tive and approach to the most common foot and ankle surgical topics. We
believe that both careful preoperative planning and discussion among the
treatment team are key tenets of our multidisciplinary approach. This leads
to deliberate and careful consideration of operative efficiency and excellence
so that the day of surgery is simply the execution of a well-thought-out plan.
You will note “callouts” throughout the text of key steps and operative
“pearls” to assist with the efficiency and performance of critical surgical
steps.

vii
viii Preface

This textbook is not meant to be a historical review or an all-encompassing

encyclopedia of foot and ankle pathologies; rather, it is a careful description
of current techniques and approaches to the most common surgical ­treatments.
We have attempted to reveal “what works well in our hands” and the evolu-
tion of techniques that produce consistently successful outcomes. We hope
you find the direct and focused approach refreshingly practical and useful in
the care of your patients.

Worthington, OH, USA Christopher F. Hyer

Contents

1 Preoperative Considerations, Surgical Planning,

and Postoperative Protocols������������������������������������������������������������   1
Robert D. Santrock and Christopher F. Hyer
2 Hallux Valgus Correction Osteotomies������������������������������������������ 15
Maria Romano McGann, David S. Buchan,
and Christopher F. Hyer
3 Lapidus HAV Correction���������������������������������������������������������������� 27
W. Bret Smith, B. Collier Watson, and Christopher W. Reb
4 Hallux Interphalangeal Joint Arthrodesis
and Jones Tendon Transfer ������������������������������������������������������������ 39
Jeffrey S. Weber
5 Hammertoes and Claw Toes: Primary and Revision�������������������� 51
Roberto A. Brandão and David Larson
6 Plantar Plate Instability������������������������������������������������������������������ 57
Jeffrey E. McAlister and Mark A. Prissel
7 1st MTP Fusion: Primary and Revision���������������������������������������� 69
William T. DeCarbo and Michael D. Dujela
8 Interpositional Arthroplasty for the First
Metatarsophalangeal Joint�������������������������������������������������������������� 85
Patrick E. Bull, James M. Cottom, and Geoffrey Landis
9 First Metatarsal Cheilectomy and Osteochondral Defect
Treatments���������������������������������������������������������������������������������������� 93
Bryan Van Dyke and Terrence M. Philbin
10 Neuroma�������������������������������������������������������������������������������������������� 101
Travis Langan, Adam Halverson, and David Goss Jr.
11 Turf Toe and Sesamoid Injuries������������������������������������������������������ 109
Matthew M. Buchanan
12 Tarsometatarsal Joint Arthrodesis ������������������������������������������������ 121
Mark A. Prissel and Jeffrey E. McAlister
13 Cotton Osteotomy���������������������������������������������������������������������������� 137
Jeffrey S. Weber

ix
x Contents

14 Fourth and Fifth Tarsometatarsal Degenerative

Joint Disease Management�������������������������������������������������������������� 149
Maria Romano McGann, Bryan Van Dyke,
and Gregory C. Berlet
15 Tibialis Anterior Tendon Ruptures������������������������������������������������ 153
Corey M. Fidler and Patrick E. Bull
16 Charcot Midfoot ������������������������������������������������������������������������������ 157
W. Bret Smith and Justin Daigre
17 Naviculocuneiform Joint Fusion���������������������������������������������������� 167
Jeffrey E. McAlister, Roberto A. Brandão, Bryan Van Dyke,
Maria Romano McGann, and Christopher F. Hyer
18 Posterior Tibial Tendon Repair: Kidner, FDL Transfer,
and Medial Displacement Calcaneal Osteotomy�������������������������� 175
Kyle S. Peterson and Michael D. Dujela
19 Lateral Column Lengthening��������������������������������������������������������� 189
Kyle S. Peterson, David Larson, and Roberto A. Brandão
20 The Medial Double Arthrodesis������������������������������������������������������ 197
Bradly W. Bussewitz, Christopher W. Reb, and David Larson
21 Isolated Talonavicular Joint Arthrodesis �������������������������������������� 209
Jeffrey E. McAlister and Gregory C. Berlet
22 Isolated Subtalar Joint Arthrodesis������������������������������������������������ 217
Michael D. Dujela, Ryan T. Scott, Matthew D. Sorensen,
and Mark A. Prissel
23 Two-Incision Triple Arthrodesis ���������������������������������������������������� 233
J. George DeVries
24 Tarsal Coalition�������������������������������������������������������������������������������� 249
Daniel J. Cuttica and Thomas H. Sanders
25 Achilles Procedures�������������������������������������������������������������������������� 261
Gregory C. Berlet, Roberto A. Brandão, and Bryan Van Dyke
26 Ankle Arthrodesis: Open Anterior and Arthroscopic
Approaches �������������������������������������������������������������������������������������� 275
Michael D. Dujela and Christopher F. Hyer
27 Tibiotalocalcaneal Arthrodesis ������������������������������������������������������ 291
J. George DeVries and Matthew D. Sorensen
28 Cavus Foot Reconstruction ������������������������������������������������������������ 307
Jeffrey E. McAlister, Mark A. Prissel, Christopher F. Hyer,
Gregory C. Berlet, Terrence M. Philbin, and Patrick E. Bull
29 Surgical Treatment of Peroneal Tendon Disorders ���������������������� 325
Terrence M. Philbin, B. Collier Watson,
and Christopher F. Hyer
Contents xi

30 Plantar Fasciitis and Tarsal Tunnel������������������������������������������������ 337

Corey M. Fidler and Gregory C. Berlet
31 Supple Equinus, Equinovarus, and Drop Foot Surgical
Strategies������������������������������������������������������������������������������������������ 343
Roberto A. Brandão, Maria Romano McGann,
and Patrick E. Bull
32 TAR Primary Options �������������������������������������������������������������������� 357
W. Bret Smith and P. Pete S. Deol
33 Revision Total Ankle Arthroplasty ������������������������������������������������ 365
Christopher W. Reb and Gregory C. Berlet
34 Surgical Management of Talar Avascular Necrosis���������������������� 377
Jeffrey S. Weber
35 Hindfoot and Ankle Charcot Reconstruction�������������������������������� 391
Roberto A. Brandão, Justin Daigre, and Christopher F. Hyer
36 Ankle and Subtalar Joint Arthroscopy������������������������������������������ 411
Ryan T. Scott and Mark A. Prissel
37 Open Treatment of Osteochondral Lesions of the Talus�������������� 421
Daniel J. Cuttica and Christopher W. Reb
38 Collateral Ankle Ligament Repair ������������������������������������������������ 431
Ryan T. Scott, James M. Cottom, Matthew D. Sorensen,
and Mark A. Prissel
39 Amputations ������������������������������������������������������������������������������������ 447
Premjit Pete S. Deol and Robert D. Santrock
40 Grafting and Biologics�������������������������������������������������������������������� 459
Ryan T. Scott, Christopher F. Hyer, Gregory C. Berlet,
Terrence M. Philbin, Patrick E. Bull, and Mark A. Prissel

Index���������������������������������������������������������������������������������������������������������� 469
Contributors

Gregory C. Berlet, MD, FRCS(C), FAOA Orthopedic Foot & Ankle

Center, Worthington, OH, USA
Roberto A. Brandão, DPM, AACFAS The Centers for Advanced
Orthopaedics, Orthopaedic Associates of Central Maryland Division,
Catonsville, MD, USA
David S. Buchan, DPM Orthopedic Foot & Ankle Center, Worthington,
OH, USA
Matthew M. Buchanan, MD Center for Sports Medicine and Orthopaedics,
Chattanooga, TN, USA
Patrick E. Bull, DO Orthopedic Foot & Ankle Center, Worthington, OH,
USA
Bradly W. Bussewitz, DPM Steindler Orthopedic Clinic, Iowa City, IA,
USA
James M. Cottom, DPM, FACFAS Florida Orthopedic Foot & Ankle
Center, Sarasota, FL, USA
Daniel J. Cuttica, DO Assistant Professor of Clinical Orthopaedic Surgery,
Georgetown University School of Medicine, The Orthopaedic Foot & Ankle
Center, a Division of Centers for Advanced Orthopaedics, Falls Church, VA,
USA
Justin Daigre, MD Decatur Morgan Hospital, Decatur Orthopaedic Clinic,
Decatur, AL, USA
William T. DeCarbo, DPM St. Clair Hospital, Department of Podiatric
Surgery, Pittsburgh, PA, USA
P. Pete S. Deol, DO Panorama Orthopedics & Spine Center, Section of Foot
& Ankle, Golden, CO, USA
J. George DeVries, DPM BayCare Clinic, Manitowoc, WI, USA
Michael D. Dujela, DPM, FACFAS Washington Orthopaedic Center,
Centralia, WA, USA
Corey M. Fidler, DPM Carilion Clinic, Department of Orthopaedic Surgery,
Roanoke, VA, USA

xiii
xiv Contributors

David Goss Jr., DO Orthopedic Foot and Ankle Center, Orthopedic Foot
and Ankle Surgery, Worthington, OH, USA
Adam Halverson, DO Orthopedic Foot and Ankle Center, Orthopedic Foot
and Ankle Surgery, Worthington, OH, USA
Christopher F. Hyer, DPM, MS, FACFAS Orthopedic Foot & Ankle
Center, Worthington, OH, USA
Geoffrey Landis, DO Northwest Medical Center/Oro Valley Hospital,
Department of Orthopedic Surgery, Tucson, AZ, USA
Travis Langan, DPM Orthopedic Foot and Ankle Center, Orthopedic Foot
and Ankle Surgery, Worthington, OH, USA
David Larson, DPM Steward Health Care, Department of Podiatry,
Glendale, AZ, USA
Jeffrey E. McAlister, DPM Arcadia Orthopedics and Sports Medicine,
Phoenix, AZ, USA
Maria Romano McGann, DO Romano Orthopaedic Center, Oak Park, IL,
USA
Kyle S. Peterson, DPM, FACFAS Suburban Orthopaedics, Division of Foot
and Ankle Surgery, Bartlett, IL, USA
Terrence M. Philbin, DO Orthopedic Foot & Ankle Center, Worthington,
OH, USA
Mark A. Prissel, DPM Orthopedic Foot & Ankle Center, Worthington, OH,
USA
Christopher W. Reb, DO University of Florida, Department of Orthopedics,
Division of Foot and Ankle Surgery, Gainesvilles, FL, USA
Thomas H. Sanders, MD Assistant Professor of Clinical Orthopaedic
Surgery, Georgetown University School of Medicine, The Orthopaedic Foot
& Ankle Center, a Division of Centers for Advanced Orthopaedics, Falls
Church, VA, USA
Robert D. Santrock, MD West Virginia University/Ruby Memorial
Hospital, Department of Orthopaedics, Robert C. Byrd Health Sciences
Center, Morgantown, WV, USA
Ryan T. Scott, DPM The CORE Institute, Phoenix, AZ, USA
W. Bret Smith, DO, MS Foot and Ankle Division Palmetto Health-USC
Orthopedic Center, Palmetto Health, Department of Orthopedic Surgery,
Lexington, SC, USA
Matthew D. Sorensen, DPM, FACFAS Weil Foot and Ankle Institute, Foot
& Ankle Surgery, Chicago, IL, USA
Contributors xv

Bryan Van Dyke, DO Summit Orthopaedics, Idaho Falls, ID, USA

B. Collier Watson, DO The Hughston Clinic, Columbus, GA, USA
Jeffrey S. Weber, DPM Birch Tree Foot and Ankle Specialists, Traverse
City, MI, USA
 Preoperative Considerations,
Surgical Planning,
1
and Postoperative Protocols

Robert D. Santrock and Christopher F. Hyer

1.1 Introduction The remainder of the chapter will focus on

­several key perioperative steps: the preoperative
Modern medicine has provided tremendous tools indications and planning conference, the day of
to help a broad spectrum of patients with a vari- surgery checklist and surgical team huddle, and
ety of diseases and deformities. Certainly, today’s the use of postoperative protocols.
foot and ankle surgeon has benefited from tech-
nology and advancements that have broadened
the reach of our services. However, technology 1.2 Preoperative Optimization
can also lull any surgeon into a feeling of comfort
and complacency. Perhaps among all of the disci- Nutritional Status Many patients appear grossly
plines of orthopedics, foot and ankle reconstruc- healthy but may be subtly malnourished, espe-
tion is uniquely at risk for a greater level and cially if they have a chronic disease. As a matter
greater frequency of complications based on the of fact, many diabetic patients are malnourished
patient’s physiology, the weight-bearing stress on [1]. This is reflected in such readings as prealbu-
the postoperative limb, and often multilevel min, albumin, and total lymphocyte counts.
deformities. Therefore, a systematic approach to Knowing these numbers can be predictive of
preparing for foot and ankle surgery is paramount mortality and morbidity of surgery. For example,
to ensuring a successful outcome for each and the below-the-knee amputation (BKA) is a well-­
every patient. In this chapter, we will first lay out known procedure that has a significant mortality
some of our specific preoperative optimization risk. However, this risk is not inherent to the pro-
parameters. These are guidelines that we use cedure but rather a reflection of the patient’s
based on our best understanding of the available overall health. The nutritional status parallels the
literature and based on our collective experience. patient’s health and therefore can serve as a risk
assessment of a pending surgery. It is in general
recommended that the lower extremity surgical
R. D. Santrock (*) patient has a preoperative albumin of >2.5 g/dL
West Virginia University/Ruby Memorial Hospital, and a total lymphocyte count of >1500/μL in
Department of Orthopaedics, Robert C. Byrd Health
order to proceed with a significant foot and ankle
Sciences Center, Morgantown, WV, USA
e-mail: [email protected] surgery [2]. These numbers are only a guideline
and based on a patient with chronic disease such
C. F. Hyer
Orthopedic Foot & Ankle Center, as diabetes, who is facing a serious surgery such
Worthington, OH, USA as a BKA.

© Springer Nature Switzerland AG 2019 1

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_1
2 R. D. Santrock and C. F. Hyer

Blood Glucose Control To further elaborate on An ABI of >1.25 indicates a possibility of calci-
the importance of overall health, the diabetic fied, non-compliant vessels. Therefore, if this
patient needs additional parameters to be met for supranormal value is present, triphasic wave-
elective surgery. An ideal diabetic patient will forms are needed to be visualized on the Doppler
have an A1c reading at 7.0% or less. Since the to ensure vessel response. However, if the ABI is
A1c percentage is a reading over time, it may be <0.5 or the triphasic waveforms are not seen in
hard to see that direct change during a hospital- the ABI >1.25, then this warrants arteriography
ization. Therefore, it is generally recommended to evaluate and/or perform intervention on the
to have a blood glucose reading to be a normal as proximal vessels prior to foot and ankle surgery.
possible (less than 150 mg/dL) to optimize heal- A vascular medicine consult and clearance for
ing. This is best achieved to have the admitting elective surgery is often obtained in patients con-
medical service remove all maintenance diabetes sidered at risk and with concern of significant
medications and have the patient managed with peripheral artery disease.
sliding scale insulin if it is a relatively urgent sit-
uation. However, scheduled elective foot and Anticoagulation Medications/DVT Risks There
ankle cases probably should be delayed until the are a number of patients on anticoagulant medica-
A1c reflects good blood glucose control. At an tions today. These drugs are used for a variety of
A1c of 7.0%, there is likely no physiologic dam- ailments such as atrial fibrillation and prior cere-
age occurring, and therefore the patient is best bral vascular events. Most all of the m ­ edications
prepared to heal from elective surgery [3–5]. In can cause problems in the immediate postopera-
cases with chronic poor glycemic control, a con- tive period. The main local concern is postopera-
sult with endocrinology may be warranted. tive bleeding that causes hematoma and/or skin
Obviously, nonelective cases such as infection necrosis from internal pressure. Our recommen-
management may need to move forward despite dation is to stop all anticoagulants if possible
elevated A1c levels but typically are done with except for 81 mg aspirin. However, we ask the
hospitalization and medical team management to prescribing physician to approve and manage this
maximally optimize the patient. change. Typically if the prescribing physician
requires a substitute, we only agree to Lovenox
Vascular Assessment It is appropriate to assume (enoxaparin). It is our opinion that this is the only
that surgery on the foot and ankle is risky as it drug in my opinion that has a short enough half-­
pertains to vascular status. After all these invasive life to halt a dangerous development quickly. The
procedures are being performed on the most newer drugs of Xarelto (rivaroxaban), Eliquis
remote portion of the body, furthest from the (apixaban), and Arixtra (fondaparinux) all claim
heart. In a healthy patient who is having a rela- a short half-life, but our experience is that this
tively simple surgery, a normal pulse exam may is not uniform. Nor do these newer drugs have
be enough to feel safe for surgical healing. a reversal agent; therefore, our recommendation
However, larger surgeries (bigger dissections or is to lobby the prescribing physician away from
incisions) or surgeries with a prolonged tourni- using these in the first 3 weeks postoperatively.
quet time (2 hours) may require a more thorough DVT risk stratification is a subject with a wide
evaluation. This is also true for patients who have range of methods and opinions. The AOFAS and
a personal risk of peripheral vascular disease the AAOS are in agreement to follow the local
(PVD). While a patient with PVD may be non-­ standards of care and to stratify patients accord-
symptomatic preoperatively, the increased physi- ing to your hospital’s risk assessment. In general,
ologic demand of the surgical healing may exceed if we have patients needing prescriptions beyond
the capabilities of the narrowed arteries postop- 325 mg of aspirin, we recommend that the pri-
eratively. In these patients, it is recommended to mary care physician or hematologist pre-certify
start with an ankle-brachial index (ABI). An ABI and manage this medication. And again, we rec-
of >0.5 should be sufficient for healing [2]. ommend Lovenox (enoxaparin) for the quick
1 Preoperative Considerations, Surgical Planning, and Postoperative Protocols 3

half-life. Risk factors such as prior DVT, tobacco body, and every foot and ankle surgery will pro-
use, and the need for prolonged postoperative duce additional swelling. Therefore, the patient
immobilization are all taken into account when with pre-existing chronic venous insufficiency
deciding on the need for chemical prophylaxis. (CVI) should be approached with additional cau-
Mechanical options such as anti-embolism stock- tion. There are two issues with CVI: increased
ings and pneumatic calf cuffs are also often use in infection risk and increased wound complica-
conjunction with chemical agents. tions. The latter issue is obvious; the CVI patient
is more prone to drainage. This drainage is acidic
Rheumatoid Arthritis Today’s treatment of and thus caustic to the skin edge; this leads to
rheumatoid arthritis depends much more heavily skin edge necrosis and wound dehiscence. To
on the modern disease altering drugs. However, avoid this issue, it is recommended to have metic-
these drugs are significant immunosuppressant ulous skin handling and closure. We recommend
compounds. Furthermore, these drugs also stringent elevation postoperatively. And finally, it
decrease the normal healing cascade needed to is also our habit to bring these patients into the
recover from surgery. For patients on disease-­ office for more frequent dressing changes and
modifying antirheumatics drugs (DMARD), it is wound checks. We have found Unna wraps
recommended to work with the prescribing rheu- ­beneficial on these patients, changing the wrap
matologist to create the best “window” or gap in weekly.
dosing to give the patient the lowest risk of
infection and wound healing complications. As a The other issue of increased infection risk is
general concept, the risk diminishes greatly once somewhat related to the aforementioned increased
the wound has healed, usually within 3 weeks of wound complications. However, there are other
the procedure. Additional time may be taken reasons to be concerned for increased infection
when joint arthrodesis and fracture healing is risk: an increased epithelial layer, an increased
concerned. surface flora, and chronic draining wounds. The
The traditional medications of prednisone, CVI patient is often using Unna wraps or com-
methotrexate, and plaquenil are utilized less pression stockings. These devices prevent the
often than in the past. However, these drugs too natural sloughing of the epithelial layer of the
can impede postoperative healing. There are no skin. This simply increases the thickness of the
definitive recommendations for stopping these epithelial layer, which is harder to penetrate with
medications in the perioperative period; again, sterilization prep solutions. This thicker epithe-
consult with the prescribing physician. Often if lium provides a higher bacterial load or surface
patients are on chronic prednisone therapy, they flora. The same issue exists with chronic wounds.
have fairly resistant disease and may not be able The chronic wounds of CVI are almost always
to titrate off altogether. It is recommended to con- contaminated with multiple species of bacteria.
sult the treating rheumatologist to get to the low- Our recommendation is to do a “pre-scrub” and
est does possible in an effort to decrease wound exfoliation, if needed, and then perform the stan-
healing complications. Typically these patients dard surgical prep. Additionally it is recom-
may require a dose of hydrocortisone prior to sur- mended to use a bacteriostatic or bactericidal
gery, but we leave the decision for the onetime dressing postoperatively. The dressings with
“stress dose” steroid administration up to the metal ions tend to be very effective in assisting in
anesthesiologist. Typically medications such as prevention of postoperative wound infections.
methotrexate and plaquenil can be carried
through surgery without significant increased Nicotine Use As with all surgeries, nicotine use
healing risk. is heavily discouraged. There is abundant scien-
tific evidence that nicotine is detrimental to surgi-
Chronic Edema The foot and ankle region is cal healing – both to skin healing and to bone
already the most gravity-dependent part of the healing. Nicotine is a vasoconstrictor and an
4 R. D. Santrock and C. F. Hyer

inhibitor to angiogenesis; therefore all forms of longed crutch use are helpful, such as knee scoot-
nicotine should be avoided during the periopera- ers and wheelchairs with elevated leg rests.
tive period. By technical measure, nicotine In many cases, a home health agencies and
metabolites are detectible in the blood for occupational therapist can be sent out to the
6 weeks post last exposure. And secondhand patients home prior to surgery to assess the post-
smoke is indeed nicotine exposure. It is impor- operative equipment needs such as shower chairs,
tant to properly counsel and document the educa- bedside commodes, and home entry assistive
tion of the patient as to the detrimental effects ramps.
and increased risk of continued use of nicotine
products.
1.3 The Surgical Team
Caution is recommended with patients with Communication
nicotine consumption/exposure due to the delete-
rious effects on healing. In some specific surger- Communication with the entire surgical team is
ies with high-risk incisions (i.e., anterior total not a one-time event. It is a process that has many
ankle arthroplasty), even remote history of nico- episodes. Maintaining this communication is
tine use may be dangerous. In a study by Whalen vital to the success of any foot and ankle surgery.
et al. in 2010, it was shown that the anterior total Our experience has shown that this process
ankle arthroplasty approach had a 35% chance of extends beyond the surgeon and the operation
surgical wound complication if a patient had room staff but also includes administrative assis-
>12ppy smoking history, no matter how remote tants, surgical schedulers, clinic staff, insurance
the patient had smoked [6]. Referral to tobacco specialists, durable medical good suppliers, pros-
cessation programs, referral to primary care phy- thetists, physical therapists, anesthesiologists,
sician for pharmacologic management and sim- medical consultants, residents/fellows, orthope-
ply delay of surgery to allow patients to quit are dic sales representatives, and hospital administra-
all plausible options in elective cases. tion. Below are three tools we use to assist in
communication.
Social Support All foot and ankle surgeries pro-
duce a significant life disruption, merely because The Screening Checklist Much akin to the pre-
our surgeries affect locomotion. No matter how flight checklist commercial pilots use just before
strong and health a patient is preoperatively, takeoff, this tool is used before booking a patient
some preparation is needed to accommodate for surgery. The purpose of this checklist is to
decreased locomotion during recovery. In some screen for deficits in the preoperative optimiza-
patients this may require a change in living quar- tion factors outlined above. Therefore, if a defi-
ters or a hiatus in work. ciency is found, it can be addressed before the
patient is placed onto the operation room sched-
Obviously some surgeries, such as the BKA, ule and before a preventable complication occurs
require more planning than others. The patient (Fig. 1.1).
and family should be given an opportunity to
meet with Social Services and Prosthetic Services The Surgical Request The second tool is the
prior to the BKA when possible. This eases anxi- s­ urgical request form. This form is used to com-
ety and allows for equipment planning. municate with the surgical schedulers, medical
Careful consideration and discussion with the consultants, anesthesiologist, the operating room,
patient about the postoperative restrictions should the orthopedic sales representative, insurance
be had with the patient and family if possible. In specialists, and residents/fellows. This can be
non-weight-bearing recoveries, options to pro- used to dictate an “operative plan” that includes
1 Preoperative Considerations, Surgical Planning, and Postoperative Protocols 5

1. Do you smoke, chew, or use vapor? YES NO

2. Have you ever smoked? YES NO

a. if yes, did you quit < 6 weeks ago? YES NO

WVU Foot & Ankle

b. If yes, was it for more than 12 years? YES NO

Mini Screening

3. Are you around 2nd hand smoke? YES NO

4. Do you have diabetes? YES NO

a. If yes, was the A1c within 3 months at 7.0 or higher? YES NO

5. Do you take NSAIDs, Steroids, BC, HRT, or drugs for RA? YES NO

a. If yes, are you prepared to have these stopped? YES NO

6. Do you take anticoagulants? YES NO

7. Have you ever had a blood clot in the leg or lungs? YES NO

8. Has anyone in your family ever had a blood clot? YES NO

9. Have you ever been diagnosed with PVD? YES NO

10. Are there scars on the operative foot? YES NO

11. Are the pulses to the operative foot normal? NO YES

12. Are you prepared to come to WVU for all of your care? NO YES

13. Do you agree in the use of a surgical team, including residents? NO YES

14. Are you filed under WC? YES NO

15. Are you signed up for MyChart? NO YES

Fig. 1.1 Example of a screening tool used to schedule elective foot and ankle surgery

the information on this form and an indication for final sign-off tool as to correct patient, side and
the procedure. This dictation is a powerful tool in site of surgery, and the surgical plan.
pre-authorizing the surgery. It is also a fantastic
tool in communicating with the residents and The Patient Passport Written patient instruc-
­fellows as they prepare for the case (Figs. 1.2 and tions are an important document to supplement
1.3), and we use this sheet intraoperatively as a the preoperative surgeon-patient meeting. This
6 R. D. Santrock and C. F. Hyer

Fig. 1.2 Surgical F&A PRE-OP PLAN

request worksheet used
to make a preoperative
Date of Service:
dictation (WVU)
Indication for Surgery (diagnosis):

Conservative Measures (and how long?):

Screening Tool Abnormalities:

Planned Procedure:

Operative Side:

Planned Admission Status:

Planned WB Status:

Estimated Surgical Time:

Anesthesia Type:

Position:

Fluoroscopy Type:

Equipment & Implants:

Planned Bone Stimulator:

Special Surgery Notes (i.e. hold antibiotics, no betadine, special date requested, etc.):

Special H&P Notes (i.e. medical clearance, cardiac clearance, A1c, Albumin, Nicotine,
ABI, WBCT, Prophecy CT, Bootwalker, special anticoagulation arranged by PCP, stop
certain drugs, etc.):

Planned Follow-Up:

Pre-Operative CPT Codes:

Signed

document should be concise and clear on the h­ ealing. We have made this into an interactive
postoperative instructions that the patient is booklet. In some centers this is called the patient
expected to follow. The appropriate contact passport, and we encourage the patient to bring
phone numbers should be included. This docu- this booklet with them to all interactions and
ment can be expanded to give some rationale appointments in the perioperative period. This
behind certain restrictions, such as an explana- creates a sense of “ownership” for the patient,
tion of the addictive nature of narcotics or the and this has been a positive tool in the success of
deleterious effects of secondhand smoke on our patients after surgery.
1 Preoperative Considerations, Surgical Planning, and Postoperative Protocols 7

Fig. 1.3 Surgical request and planning sheet (OFAC)

8 R. D. Santrock and C. F. Hyer

1.4  he Preoperative Indications

T
and Planning Conference

It is our belief that a planning conference is ben-

eficial to be performed once per week and is a
vitally important tool. During this conference,
each case is reviewed with members of the
­surgical team and other attending surgeons. This
process serves an educational function for
administrative assistants, schedulers, orthopedic
sales representatives, and residents and fellows.
It is also an important efficiency and safety
check that the proper equipment has been
Fig. 1.4 Case example, preoperative lateral ankle x-ray
requested and the surgical consent matches the
request form and the clinical documentation.
This conference also serves as a final “curb
side consult” with partners and fellow surgeons
to discuss difficult cases and get outside opinions
to benefit the overall result. It is not infrequent
that a fresh and unbiased perspective from a col-
league reviewing the case may bring out an
important consideration that may alter or adjust
the surgical plan. In our busy practices where we
might not see our partners all week, the preopera-
tive planning conference is one that is rarely
missed. Even in cases when the attending can’t
make the live conference, it is always “made-up”
after the fact with the residents and fellows who
attended the live event to confirm any changes or
discussion.
The surgical planning documents and notes
are carried forward from the planning confer-
ence and into the operating room on the day of
surgery. During the room preparation, the surgi-
cal request sheet, the pertinent last clinical note
Fig. 1.5 Case example, preoperative lateral CT image
with the surgical plan and the key images from
the patient’s latest imaging studies are all posted
on the view box or easy to view location. This is surgical booking sheet, last clinical note,
reviewed again during room turnover and is ­consent, surgeon signature on the limb, and the
available for all involved in the case to easily patient wristband ID all match up. This is the
review as well (Figs. 1.4, 1.5, 1.6, 1.7, 1.8, and final safety check before the case starts and
1.9). During the “time-out process” with also again gets the entire team focused on the
­everyone in the room, we review that the images, surgical plan.
1 Preoperative Considerations, Surgical Planning, and Postoperative Protocols 9

Fig. 1.6 Case example, preoperative AP ankle x-ray

1.5 Postoperative Protocols

Another equally important tool is to establish post-

operative protocols and to adhere to them. Much
like the efficiencies and clarity the preoperative
planning conference and the surgical booking
sheet bring to the operative experience, established
postoperative protocols do the same for the recov-
ery and rehabilitation process. We have separated
our surgeries at OFAC into six unique groups and
discuss the postoperative protocol with the patient
during the surgical consent visit (Fig. 1.10). This Fig. 1.7 Case example, preoperative AP CT image
document is part of the electronic patient chart so
anyone in contact with the patient during the post-
operative course can review and discuss any ques- visit more efficient and streamlined. Research and
tions as to next steps in care. The patient is also data collection is also improved in a group practice
given a copy so they are aware of the plan as well. if all providers follow standard postoperative pro-
This reduces patient confusion and anxiety as to tocols so larger volume collection can be done and
the postoperative course and makes each office comparative studies can be performed.
10 R. D. Santrock and C. F. Hyer

Fig. 1.8 Case example, completed surgical request form

1 Preoperative Considerations, Surgical Planning, and Postoperative Protocols 11

Fig. 1.9 Case example, recent clinical note indicating surgical plan
12 R. D. Santrock and C. F. Hyer

Name:

OFAC Surgical Protocols

Group 1 (NWB Splint 1 Week, WBAT Boot 3 Weeks, Physical Therapy @ 4-6 weeks PRN)

Ankle Scope Debridement* Cheilectomy* Tenotomy, Toe

Flexor/Extensor
Ankle Arthrotomy* Mass Excision
Excision Exostosis
Hardware Removal* Neuroma Excision
Topaz PF***
Synovectomy* Excision Coalition

Group 2 (NWB Splint 1 Week, WBAT Boot 4-5 Weeks, Physical Therapy @ 6-8 weeks PRN)

Arthrodesis, 1st MTPJ Bunionette Hammertoe Correction***

Bunion, Met Osteotomy*** Metatarsal Head Excision Plantar Plate repair***

Group 3 (NWB Splint 1 Week, NWBC 3 Weeks, WBAT Boot 4 Weeks, Physical Therapy)

Ankle OCD Drill/Graft ORIF Fibula*** 1st TMT Lapidus***

ORIF Syndesmosis*** Tarsal Tunnel Release*** TAR**

Peroneal Repair*** Achilles Repair** Brostrom***

Group 4 (NWB Splint 1 Week, NWBC 3 Weeks, WBC 2 Weeks, WBAT Boot 4 Weeks, PT W/Brace)

Brostrom Evans*** Chrisman-Snook*** Isolated ORIF Metatarsal***

Group 5 (NWB Splint 1 Week, NWBC 3 Weeks, NWBC 3 Weeks, WBAT Boot 4 Weeks, PT W/Brace)

PTT Repair w/ transfer w/ or Subtalar Arthrodesis Lisfranc ORIF/Arthrodesis

w/o LCL, MDCO***
TMT and Midfoot ORIF Multiple Metatarsals
ORIF Bimal/Tibial Arthrodesis
Osteotomy***
Group 6 (NWB Splint 1 Week, NWBC 3 Weeks, NWBC 3 Weeks, WBC 3 Weeks, WBAT Boot, Arizona
Brace)
Ankle Arthrodesis Pantalar Arthrodesis TN Arthrodesis

TTC Arthrodesis Triple Arthrodesis ORIF Calcaneus

ORIF Talus Medial Double

* PT @ 4 Weeks ** PT @ 6 Weeks ***PT @ 8 Weeks

NWB = Non Weight Bearing NWBC = Non Weight Bearing Cast

WBAT = Weight Bearing as Tolerated WBC = Weight Bearing Cast

Fig. 1.10 OFAC postoperative protocols

1 Preoperative Considerations, Surgical Planning, and Postoperative Protocols 13

In subsequent chapters, you may see other 2. Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich
Z. Syme ankle disarticulation in patients with diabe-
authors refer to this chapter for postoperative tes. J Bone Joint Surg Am. 2003;85:1667–72.
protocols for the content they are covering. The 3. Garber AJ, Moghissi ES, Bransome ED Jr, et al.
protocols we present here are merely a American College of Endocrinology position state-
­suggestion and have come from our practical ment on inpatient diabetes and metabolic control.
Endocr Pract. 2004;10(1):77–82.
experience and consensus among the surgeons 4. Clement S, Braithwite SS, Magee MF, et al.
at OFAC. Management of diabetes and hyperglycemia in hospi-
tals. Diabetes Care. 2004;27(2):553–91.
5. American Diabetes Association. Standards of medical
care in diabetes: 2008. Diabetes Care. 2008;31(suppl
References 1):S12–54.
6. Whalen J, Spelsberg S, Murray P. Wound break-
1. Via M. The malnutrition of obesity: micronutrient down after total ankle arthroplasty. Foot Ankle Int.
deficiencies that promote diabetes. ISRN Endocrinol. 2010;31(4):301–5.
2012;2012:103472.
 Hallux Valgus Correction
Osteotomies
2
Maria Romano McGann, David S. Buchan,
and Christopher F. Hyer

Hallux valgus is one of the most common fore- addressed. It is the authors’ opinion that this be
foot disorders that causes pain and dysfunction. reassessed intraoperatively as radiographic
The overall prevalence is approximately 30% in appearance of an increased DMMA may not be
females and 13% in males [9]. This is a complex as evident in the actual cartilage itself. Another
deformity with a variety of treatment options. useful angle is the intermetatarsal angle (IMA)
When evaluating patients for bunion surgery, 1–2 which is the angle between long axis of 1st
there are a few radiographic and clinical param- and 2nd MT. In addition, both clinical and radio-
eters that are used to determine the surgery. The graphic evaluation for 1st ray hypermobility/
hallux valgus angle (HVA) is the measurement of instability as well as painful arthritis of either the
the long axis of the 1st metatarsal and proximal 1st MTP or 1st TMT joints is advised. Also, care-
phalanx. This is useful to assess the degrees of ful consideration should be taken for an increase
hallux valgus at the 1st MTP joint and gain in the hallux interphalangeus angle (HIA), which
insight into how much soft tissue correction or is the longitudinal bisection of the long axis of
release may be needed to gain correction. The the proximal phalanx of the hallux and the base
distal metatarsal articular angle (DMAA), also the distal articular cap of the proximal phalanx.
known as the proximal articular set angle (PASA), This, in addition to the clinical appearance of the
is the angle between the 1st metatarsal (1st MT) hallux distal to the 1st MTP joint, may indicate
long axis and the base of the distal articular cap need and use for the Akin osteotomy.
of the 1st MT. This represents the angle at which
the articular facet of the metatarsal is aiming. In
long-standing deformities, adaptive change to the 2.1 Presentation
articular surface may place a role in the valgus
deviation of the joint and may need to be Hallux valgus is a progressive triplane foot
­deformity in which the proximal phalanx moves
into valgus and the first metatarsal into varus
[12]. The toe becomes pronated and dorsiflexed
due to the lateral deviation of extensor hallucis
longus and flexor creating an adductor moment.
M. R. McGann (*)
Romano Orthopaedic Center, Oak Park, IL, USA Contractures of the adductor hallucis, the lateral
capsule, and the lateral head of flexor hallucis
D. S. Buchan · C. F. Hyer
Orthopedic Foot & Ankle Center, longus further exacerbate the deformity. The
Worthington, OH, USA sesamoids subluxate l­aterally [8, 11, 12]. Each

© Springer Nature Switzerland AG 2019 15

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_2
16 M. R. McGann et al.

of these deformities needs to be addressed in She works on her feet all day and states she has
order to correct the foot and not create secondary gotten to the point that she cannot live with it any
deformities [3, 10]. Patients complain of medial longer. She has tried anti-inflammatories, various
prominence and lateral deviation of their great types of shoes, and padding, with no relief. On
toes with difficulty wearing shoes. There is pain physical exam, she has a hallux valgus deformity
located along the medial eminence as rubbing in with deviation of her great toe laterally. Full
shoes occurs and a bursitis develops. Later stages motion of the 1st MTP is present. The great toe is
have hammering of their second toes due to over- manually reducible. There is no medial column
crowding. Ultimately, with joint malposition, instability and minimal pronation deformity of
osteoarthritic changes develop leading to joint the 1st ray. X-rays demonstrate an intermetatarsal
pain and limitation in range of motion. angle (IMA) greater than 12°. Hallux valgus
Below are case examples of different patients angle (HVA) is moderate to severe.
and our treatment preference for these patients.
Case 4 1st MTP fusion case: The patient is an
Case 1 Modified Reverdin case: The patient is 80-year-old female returning to clinic with a
a 60-year-old female with a painful bunion severe hallux valgus deformity with hallux
deformity that has progressively worsened DJD. Her toes have gotten worse. She does not
over the years. On physical exam, the patient care about wearing fashionable wedge shoes. On
has a hallux valgus deformity with lateral devi- physical exam, the patient has a hallux valgus
ation of her great toe. The great toe is manually deformity that is manually reducible with mini-
reducible and the medial column is stable. mal medial column instability. 1st MTP motion is
Radiographically, there is an increased DMAA limited and painful throughout the range of
and a mild to moderately increased hallux motion. Radiographs demonstrate a hallux valgus
­valgus angle. deformity with joint space narrowing of the 1st
MTP joint and sclerosis. Hammering of her 2nd
Case 2 Mau case: The patient is a 50-year-old and 3rd toes is noted.
female presenting to the clinic with painful bun-
ion deformity over several years that has progres-
sively gotten worse. She states pain is 4–5 during 2.2 Indications
the day when she is active and in shoes. At night,
her pain can be up to 8/10. She has started to off-­ 2.2.1 Modified Reverdin Osteotomy
load her great toe by walking on the outside of
her foot. On physical exam, the patient has a hal- A modified Reverdin osteotomy is a biplanar
lux valgus deformity with deviation of the great osteotomy performed on patients with hallux val-
toe laterally. The toe is manually reducible with- gus and an increased DMAA. This is a medially
out medial column instability. There is not a sig- based closing wedge osteotomy that is performed
nificant pronation deformity of the toe. 1/8 inch proximal to and parallel to the articular
Radiographs demonstrate an increased IMA of surface of the 1st metatarsal to correct DMAA
approximately 17° and a mild to moderately (Fig. 2.1). It is often performed with inferior arm
increased HVA. There is lateralization of the ses- of chevron osteotomy for stability and ease of
amoids and slight hallux interphalangeus defor- internal fixation. Originally this was an incom-
mity noted. plete cut with the lateral cortex remaining intact;
however, we usually complete the cut from
Case 3 Scarf case: The patient is a 60-year-old medial to lateral to allow lateral translation of
female presenting to the clinic with a 20-year the capital fragment to further reduce the IM
­history of a painful progressive bunion deformity. deformity.
2 Hallux Valgus Correction Osteotomies 17

2.2.2 Mau Osteotomy the plantar flare of the 1st metatarsal (Fig. 2.2).
This is still long enough to provide inherent sta-
A Mau osteotomy is an oblique osteotomy that is bility and allow two screw fixations across the
performed at times for moderate to severe osteotomy.
increased first IMA. This osteotomy is more sta- Similar to a scarf, a Mau allows translation
ble than a Reverdin and easy to perform and fix- and rotation of the distal fragment. It provides a
ate compared to other proximal osteotomies [6, broad surface for fixation to help primary bone
15, 16]. The osteotomy is directed from dorsal-­ healing. Correction of moderate to severe bunion
distal on the 1st metatarsal starting in the distal deformities is able to be made with high union
1/3 and direct plantar and proximal to end in the rates. This also has a low incidence of transfer
proximal 1/3 of the 1st metatarsal. We use a mod- metatarsalgia that can be complications of other
ified technique and make the osteotomy slightly proximal osteotomies [7]. This should also be
more vertical and start it dorsal-distal in the prox- performed in patients with stable 1st TMT and
imal 1/3 to ½ of the metatarsal and direct it into intercuneiform joints (Fig. 2.3).

Fig. 2.1 Mau osteotomy

a b

Fig. 2.2 (a–d) Mau: Pre- and post-op x-rays for Mau osteotomy
18 M. R. McGann et al.

c d

Fig. 2.2 (continued)

a b c

d e

Fig. 2.3 (a–e) Mau and Akin osteotomy: Pre- and post-op x-rays from Mau and Akin osteotomy

2.2.3 Scarf Osteotomy osteotomy performed by the senior authors to

correct bunion deformities. The greater the defor-
Scarf osteotomies can be performed for a wide mity, the longer the transverse arm is required. If
range of bunion patients. This is the workhorse the patient has a moderately to severely increased
2 Hallux Valgus Correction Osteotomies 19

HVA and IM 1–2, this may be supplemented with spurring in addition to an obvious HAV defor-
an Akin procedure for additional correction. mity (Fig. 2.4). Clinically, patients have painful,
Patients are examined for hypermobility between first MTP joint with limited range of motion.
their first and second rays. Stable first tarsometa- Functionally, patients report a significant
tarsal and intercuneiform joints are required for improvement in their activities of daily living [4].
success with this osteotomy and maintained cor- The vast majority of patients are limited for wear-
rection. Similar to first MTP fusions, satisfaction ing comfort shoes after the procedure, and 55%
scores are high with Scarf osteotomies [5]. Not were limited in their high heel height. The major-
only are patients more likely to return to more ity of patients were able to return back to their
complex athletic activity such as gymnastics, recreational activities such as running, golf, hik-
cycling, and skiing with this type of osteotomy ing, and tennis [1, 4].
compared to 1st MTP fusion patients, but they
also functionally have less difficulty doing most
athletic activities [5]. If the first ray needs to be 2.2.5 Akin Osteotomy
shortened in its correction, this may also be done
through this osteotomy by angling the proximal The Akin osteotomy is primarily an adjunct pro-
and distal arms of the “Z” toward the base of the cedure to “dial-in” final corrections of the bunion
5th metatarsal. deformity, after the proximal osteotomy is made
to correct the intermetatarsal angle, ­ DMAA/
PASA, and hallux valgus angles [2]. This medial
2.2.4 First Metatarsophalangeal wedge, closing osteotomy is performed at the
Fusion base of the proximal phalanx. The lateral cortex
is used as a hinge on which to close the osteot-
Patients who benefit from a first metatarsopha- omy [13]. Corrections may be made in the coro-
langeal (MTP) fusion have a significant arthritic nal and sagittal planes to allow frontal plane
component to their bunion deformity or have corrections. Fixation may be done with either a
severe deformities that have high chance of recur- single staple or compression screw [2]. Patients
rence. Radiographically, there may be joint space requiring Akins often have larger preoperative
narrowing, flattening of the joint, and dorsal HVAs or increased HIA deformity. There are two

a b

Fig. 2.4 (a–d) MTP fusion case: Pre- and post-op x-rays
20 M. R. McGann et al.

c d

Fig. 2.4 (continued)

common techniques to perform the Akin: (1) a either through the medial incision at the first
transverse osteotomy medial to lateral with MTP or through a separate dorsal incision in the
removal of a small medially based wedge to first webspace. The first webspace incision is pre-
achieve correction – this technique is usually fix- ferred in cases when significant rotation of the
ated with staple fixation either medially or dor- sesamoid into the interspace or along the lateral
sally – and (2) an oblique medially based closing 1st metatarsal head is seen on AP radiographs.
wedge osteotomy directed from distal medial to Care is taken to avoid the deep peroneal nerve
proximal lateral. This osteotomy lends itself well during dissection and to only release the lateral
to an oblique lag screw fixation from proximal sesamoid suspensory ligament. In most cases, the
medial to distal lateral perpendicular to the oste- adductor hallucis tendon is not released from the
otomy. Either technique is acceptable, but the lateral phalangeal base in an effort to avoid post-
authors find the long oblique osteotomy more operative hallux varus deformity.
stable and easier to achieve large corrections
when needed.
2.3 Imaging

2.2.6 Distal Soft Tissue Procedure There are four standard x-rays that are obtained
on all of our bunion patients. These are an AP,
Distal soft tissue procedures can be performed in lateral, and oblique weight-bearing views of the
solitary for a very mild increase in hallux valgus affected foot along with a sesamoid view. These
angle. The majority of the time, this is done as an set of x-rays allow the surgeon to assess the
adjunct procedure to the osteotomies to help cor- extent of the deformity and arthritis present in the
rect the deformity and to help reduce the sesa- joints. The sesamoid view assesses the extent of
moids. It is typically performed in a juvenile the rotational component to the overall defor-
hallux valgus or when the sesamoid position is 4 mity. These are all necessary for preoperative
or more on an AP radiograph. It can be completed planning.
2 Hallux Valgus Correction Osteotomies 21

2.4 OR Setup 2.5.2 Mau Osteotomy

Thigh tourniquet 1. Medial capsulotomy performed using a stan-

Weitlaner self-retaining retractor dard medial approach which can be split into
10 × 15 oscillating saw on TPS two segments, one for medial 1st MTP
Baby Hohmann ×2 ­exposure and a second one from proximal 1/3
Small rongeur metatarsal and 1st TMT exposure.
Seeburger ribbon retractor 2. Access the proximal aspect of 1st MT through
McGlamry elevator 3 cm dorsal medial incision.
2.5 mm and 3.0 mm headless compression screws 3. Identify 1st TMT joint and make oblique oste-
for osteotomy sites otomy 1 cm distal to joint. The joint does not
Mini-fluoro need to be opened or released.
Place pt at foot of the bed 4. Oblique osteotomy from dorsal-distal
Small bump under ankle diaphysis-­metaphysis junction to plantar-­
Hardware selection proximal metaphysis as parallel to the weight-­
bearing surface as possible but being mindful
• 2.5 headless screw for Akin × 1 to terminate the osteotomy in the plantar flair
• 3.0 headless screw × 2 for Scarf or Mau of the metatarsal and not extend into the 1st
• 4.0 headless screw for MTP fusion with dorsal TMT joint.
locking compression plate 5. A “biplanar wedge” can be removed from the
osteotomy to allow front plane rotation and
correction of the first metatarsal if needed.
2.5 Operative Technique 6. Rotate the distal fragment to reduce the
IMA less than 9°. This is accomplished by
2.5.1 Reverdin using a baby human retractor on the proxi-
mal lateral base of the first metatarsal and
1. Medial capsulotomy using a standard medial driving this medially while at the same time
approach. using your hand on the medial first metatar-
2. Perform transverse osteotomy approximately sal head and driving the distal fragment
1 cm proximal and parallel to the articular sur- laterally.
face of the metatarsal head. 7. This osteotomy can be both translated from
3. Feather lateral cortex. May complete cut to medial to lateral as well as rotated on the
lateral cortex if translation of the metatarsal transverse plane (like the blades of a pair of
head is required. scissors) to further correct IM angle as well as
4. Make distal cut at the angle required to correct dial in DMAA deformity as needed.
the DMAA, typically parallel to the articular 8. A bone clamp can be used to temporarily
surface of the 1st metatarsal head. reduce the osteotomy and place a guide wire
5. It is also performed with inferior arm of chev- from the proximal dorsal to distal plantar, per-
ron osteotomy for stability and ease of inter- pendicular to the osteotomy.
nal fixation. 9. Drill and place 3.0 mm cannulated headless
6. Confirm per fluoro that head rotates around screws × 2.
and reduced DMAA after removal of medial
wedge and completion of inferior arm of oste-
otomy. Additional “feathering” can be per- 2.5.3 Scarf Osteotomy
formed medially along the transverse
osteotomy to allow further closure of the 1. A medial incision is made along the first
DMAA. MTP joint (Fig. 2.5).
22 M. R. McGann et al.

Fig. 2.5 A medial-based incision over the 1st MTP joint

and extending proximally along the first metatarsal for the
Scarf osteotomy

2. With care to protect the dorsal medial cuta-

neous nerve, elevate the plane between skin
Fig. 2.6 Insertion of K-wire into the metatarsal head as a
and capsule.
cut guide for the Scarf osteotomy
3. Next a medial longitudinal capsulotomy is
made in line with the skin.
4. Subperiosteally elevate the capsule off the 10. Proximal plantar cut parallel to dorsal cut.
metatarsal head and shaft. 11. Cut small wedge of bone proximally to the
5. Release along the plantar surface of the most proximal cut to allow for rotation of the
metatarsal. MT and correction of the DMAA/PASA.
6. Release lateral structures with knife from 12. A shift of up to 50% of width of MT can be
medial side. Passively correct the great toe to made. Can use a towel clamp to help create
at least 45°. shift (Fig. 2.7).
7. Insert a guide pin in metatarsal (MT) head 13. Secure the osteotomy with two headless
for resection guide. This sets center of axis compression screws (Fig. 2.8).
as well as protecting from the excursion of 14. Take a fluoro image of the correction that is
blade. Use the pin that will be used for can- made at this point. Carefully assess the
nulated headless screw which will be placed reduction of the sesamoids as well.
for fixation (Fig. 2.6). 15. Use towel clamp medially to assess if cap-
8. Make dorsal cut distally with oscillating saw sule closure will reduce toe and sesamoids
aimed at 5th MT head to help shorten shaft or if an Akin and DSTP are required. If
with shift. Increase angle, if more shortening there’s any question or it seems that the cap-
is desired. Decrease the angle to make the sular repair must be very tight to keep every-
cut more transverse if little to no shortening thing in alignment, have a low threshold to
is necessary. perform one or both of these adjunct
9. Midshaft longitudinal cut. A shorter cut is procedures.
used for less correction. A longer cut down 16. Medial capsular imbrication performed with
the metatarsal shaft is required for a larger pants-over-vest repair. Remove the redun-
correction. dant tissue medially. Think of the sesamoids
2 Hallux Valgus Correction Osteotomies 23

Fig. 2.7 Towel clips may be used to aid in the shift of the
osteotomy to help reduce the IM and HV angles

Fig. 2.9 Sesamoid view

2.5.4 Akin Osteotomy

1. Perform after proximal osteotomy and soft

­tissue release are completed.
2. Insert guide wire from medial mid-diaphysis
angling toward lateral flare of proximal pha-
lanx. This is used as a cut guide.
3. Confirm proper trajectory with c-arm.
4. Use oscillating saw to take a small wedge of
bone. Make sure to keep axis of hinge vertical
AND perpendicular to the weight-bearing sur-
Fig. 2.8 Guide wires inserted into the metatarsal head
and vertically in metatarsal shaft. 3.0 mm headless com-
face. Remember, as the osteotomy closes, it
pression screws are then placed after wire position is con- will follow this hinge. If the hinge is angled, it
firmed and adequate reduction achieved may cause unwanted DF as it closes.
5. Feather lateral cortex. Take care to go
as a sling that we are stabilizing in the fron- through dorsal and plantar cortex along
tal plane to keep sesamoids reduced plan- length of the cut. Use baby Hohmann to pro-
tarly. Think of sesamoid axial view x-rays tect dorsal and plantar structures especially
(Fig. 2.9). EHL and FDL.
24 M. R. McGann et al.

6. Use the same cut-guide pin to fixate osteot-

omy site. Pearls
7. Insert 2.5 mm headless screw. Usually, drill- Potential Complications
ing only the medial cortex is necessary. • Recurrent hallux valgus, especially with
adjunct akin [14].
• Hallux varus is a strong possibility if the
2.5.5 Distal Soft Tissue Procedure following triad occurs: removal of the
fibular sesamoid, staking the head (or
1. May attempt to release lateral structures removal too much of the medial emi-
through medial incision if possible to get nence), and creating a negative intermeta-
enough release. tarsal angle. Two out of three of these are
2. Traditionally a separate 1st webspace incision required to develop hallux varus.
is made to provide more of a release. • Wound complications.
3. Use 15-blade to cut skin. Then use the blunt
end of the knife handle to bluntly dissect down
to lateral structures.
4. Release adductor hallucis insertion, including References
attachment to fibular sesamoid.
5. Release transverse intermetatarsal ligament. 1. Brodsky JW, Passmore RN, Pollo FE, Shabat
6. Pie crust lateral capsule with multiple vertical S. Functional outcome of arthrodesis of the first meta-
cuts through the cortex. tarsophalangeal joint using parallel screw fixation.
Foot Ankle Int. 2005;26(2):140–6.
7. If done through medial approach, carefully 2. Bussewitz BW, Levar T, Hyer CF. Modern techniques
use blade to release intermetatarsal ligament in hallux abducto valgus surgery. Clin Podiatr Med
and allow sesamoid to sling over medially. Surg. 2011;28(2):287–303.
Then, hug the bone on the metatarsal to release 3. Dayton P, Feilmeier M, Kauwe M, Hirschi
J. Relationship of frontal plane rotation of first
adductor insertion. metatarsal to proximal articular set angle and hal-
8. Apply varus stress. If less than 45° of correc- lux alignment in patients undergoing tarsometatarsal
tion achieved in MTP, further releases may arthrodesis for hallux abducto valgus: a case series
need to be made. and critical review of the literature. J Foot Ankle Surg.
2013;52:348–54.
4. DeSandis B, Pino A, Levine DS, Roberts M, Deland J,
O’Malley M, Elliott A. Functional outcomes follow-
2.6 Post-op Protocol ing first metatarsophalangeal arthrodesis. Foot Ankle
Int. 2016;37(7):715–21.
5. Desmarchelier R, Bessea JL, Fessya MH, The French
A standard sterile address is applied consisting of Association of Foot Surgery (AFCP). Scarf oste-
adaptic, 4 × 4s, abdominal pads, and webril otomy versus metatarsophalangeal arthrodesis in
loosely applied circumferentially. A Bulky-Jones forefoot first ray disorders: comparison of functional
posterior mold splint is applied by rolling the cot- outcomes. Orthop Traumatol Surg Res. 2012;98(6,
Supplement):S77–84.
ton roll out and placing 10 slabs of 4 × 30cm 6. Glover JP, Hyer CF, Berlet GC, Lee TH. Early results
plaster splint over the top. of the Mau osteotomy for correction of m ­ oderate
2 Hallux Valgus Correction Osteotomies 25

to severe hallux valgus: a review of 24 cases. J 12. Robinson AH, Limbers JP. Modern concepts in
Foot Ankle Surg. 2008;47(3):237–42. https://doi. the treatment of hallux valgus. J Bone Joint Surg.
org/10.1053/j.jfas.2008.02.004. Epub 2008 Apr 2. 2005;87(8):1038–45.
7. Hyer CF, Glover JP, Berlet GC, Philbin TM, Lee 13. Sabo D. Correction osteotomy of the first phalanx of
TH. A comparison of the crescentic and mau oste- the great toe (Akin osteotomy). Int Surg. 2007;2:66–9.
otomies for correction of Hallux Valgus. J Foot Ankle 14. Shibuya N, Thorud JC, Martin LR, Plemmons BS,
Surg. 2008;47(2):103–11. Jupiter DC. Evaluation of hallux valgus correction
8. Kim Y, Kim JS, Young KW, Naraghi R, Cho HK, Lee with versus without Akin proximal phalanx osteot-
SY. A new measure of tibial sesamoid position in hal- omy. J Foot Ankle Surg. 2016;55(5):910–4.
lux valgus in relation to the coronal rotation of the first 15. Trnka HJ, Parks BG, Ivanic G, Chu IT, Easley ME,
metatarsal in CT scans. AOFAS. 2015;36(8):944–52. Schon LC, Myerson MS. Six first metatarsal shaft
9. Nix S, Smith M, Nix BV, et al. Prevalence of hallux osteotomies: mechanical and immobilization com-
valgus in the general population: a systematic review parisons. Clin Orthop Relat Res. 2000;381:256–65.
and meta analysis. J Foot Ankle Res. 2010;3:21. 16. Vora AM, Myerson MS. First metatarsal oste-
10. Paley D, Herzenber JE, editors. Principles of defor- otomy nonunion and malunion. Foot Ankle Clin.
mity correction. Berlin: Springer; 2005. 2005;10(1):35–54.
11. Perera AM, Mason L, Stephens MM. The
Pathogenesis of Hallux Valgus. J Bone Joint Surg-Am.
1994;93(17):1650–61.
 Lapidus HAV Correction
3
W. Bret Smith, B. Collier Watson,
and Christopher W. Reb

When Paul Lapidus described his technique for fixation, specifically locked constructs have been
arthrodesis of the 1st TMT (tarsometatarsal) joint evaluated [8–11].
in 1934, he was building on the work of others With a bunion deformity, the fundamental
(most notably Albrecht and Truslow) [1, 2]. problem is deviation of the hallux at the
Lapidus felt that the basis of the hallux abducto ­metatarsophalangeal joint (MTP) and deviation
valgus deformity was centered at the TMT joint of the first metatarsal at the tarsometatarsal joint
and was related to hypermobility [3–5]. The rec- (TMT). Traditionally we prioritized anterior-pos-
ommendations by Dr. Lapidus at the time were to terior (AP) radiograph findings such as the inter-
take down and prepare the 1st TMT joint as well metatarsal angle (IMA), hallux valgus angle
as the interspace between the 1st and 2nd MT (HVA), tibial sesamoid position (TSP), and joint
(metatarsal). Correction was to address the trans- surface angle known both as distal metatarsal
verse and sagittal deformities and fixate the joint articular angle (DMAA) and proximal articular
in the new position. set angle (PASA). It is vital to recognize that
Obviously, over the course of many decades, since the AP radiograph is a two-dimensional
there have been numerous modifications and representation of the true three-dimensional anat-
comments on the procedure based at the 1st TMT omy, deviation in the other planes, such as frontal
joint. Later dissertations on the procedure began plane rotation of the first metatarsal, can substan-
to focus on fixation of the arthrodesis. Initially tially change all visible cues on the AP radio-
this was in the form of screw osteosynthesis graph. Pronation of the first metatarsal changes
[6, 7]. More recently with the addition of plate the appearance of the DMAA, TSP, medial emi-
nence and the shape of the lateral metatarsal
head. To identify and characterize the contribu-
tion of the frontal and sagittal plane deviations to
W. B. Smith (*) the radiographic cues on the AP radiograph, we
Foot and Ankle Division Palmetto Health-USC must look at different landmarks and anatomy on
Orthopedic Center, Palmetto Health, Department axial and lateral radiographic views.
of Orthopedic Surgery, Lexington, SC, USA
In addition to recognizing the individual planar
B. C. Watson components, we must also focus our corrective
The Hughston Clinic, Columbus, GA, USA
procedure on the apex of the deformity or the ana-
C. W. Reb tomic CORA (Paley). The apex of the metatarsal
University of Florida, Department of Orthopedics,
Division of Foot and Ankle Surgery, component of the deformity in a bunion has been
Gainesvilles, FL, USA described by many surgeons and researchers to be

© Springer Nature Switzerland AG 2019 27

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_3
28 W. B. Smith et al.

not in the metatarsal but at the TMT [12–15]. The

triplane tarsometatarsal corrective arthrodesis spe-
a
cifically uses all three planes to both evaluate and
correct the deformity. Using a triplane framework
for evaluation and procedure selection and focus-
ing on the apex of the deformity will help in a
more anatomic and complete correction.

3.1 Surgical Management

3.1.1 Positioning and Equipment

(a) Place patient in supine position on a radiolu-

cent table.
(b) Well-padded upper thigh tourniquet to opera-
tive leg.
(c) Bump placed under ipsilateral hip so that
toes are pointed to the ceiling.
(d) Surgical assistant and instrument table are on
side of OR table opposite to the surgical foot.
(e) We prefer use of mini C-arm and position it
on the same side as operative foot. b
(f) Surgeon sits at either foot of bed or on same
side of operative foot.
(g) Preoperative xrays should be viewable in the
operating room. (Fig. 3.1a, b)

3.1.2 Approach

(a) Using a 15-blade knife, a medial longitudinal Fig. 3.1 (a, b) AP and lateral radiographs demonstrating
incision is made along the 1st metatarsopha- hallux valgus deformity
langeal joint (MTP) (Fig. 3.2).
(b) Identify the dorsomedial branch of the super-
ficial peroneal nerve as well as the vessels mal phalanx, make a medial longitudinal
coursing along the medial aspect of the 1st incision through the capsule and in line with
metatarsal. Using the knife or tenotomy scis- the incision toward the distal aspect of the 1st
sors, gently tease the neurovascular bundle metatarsal. There is typically redundant cap-
off of the underlying fascia, and retract the sular tissue present. Excision and imbrica-
bundle dorsally. tion of this redundant tissue will be discussed
later in the chapter.
(b) Using the knife, sharply release the capsule
3.1.3  istal Soft Tissue Procedure
D from around the dorsal and plantar aspects of
(DSTP) the joint particularly beneath the 1st metatar-
sal head (Fig. 3.4).
(a) The medial capsule around the 1st MTP joint (c) To prevent having to make a separate lateral
can be clearly visualized at this point incision in the 1st webspace, place a small
(Fig. 3.3). Starting at the base of the proxi- “baby” Gelpi retractor underneath the 1st
3 Lapidus HAV Correction 29

Fig. 3.2 A sharp knife is used to make a longitudinal

incision along the medial aspect of the 1st MTP joint

Fig. 3.4 Medial capsule is released dorsally and plan-

tarly around the 1st metatarsal head

metatarsal head, and distract the plantar soft

tissues away from the metatarsal. This
increases the view of the position of sesa-
moids. We can typically see the lateral
metatarso-­sesamoidal ligament at this point
(Fig. 3.5).
(d) By placing the knife under the metatarsal
head, it can be used to release the lateral
metatarso-sesamoidal ligament. Apply a 45°
varus stress of the 1st MTP joint to relax the
contracted lateral capsular tissues.
(e) A Freer elevator can be used to palpate the
sesamoids, and at this point, they should be
freely mobile.
• If we are unable to release the lateral
metatarso-sesamoidal ligament through
the medial incision, then we make a sepa-
rate dorsal incision at the 1st webspace.
Fig. 3.3 The medial capsule at the 1st MTP joint is • Carefully, dissect down to the lateral 1st
visualized MTP joint capsule.
30 W. B. Smith et al.

Fig. 3.5 Small Gelpi retractor is placed underneath

the1st metatarsal head to distract the sesamoids. This
allows visualization of the lateral metatarso-sesamoidal
ligament for release

Fig. 3.6 (a, b) A towel clip is placed around the medial

• Fenestrate the capsule with a 15-blade capsule to simulate imbrication of the medial capsule. An
knife. AP fluoroscopic image confirms that the sesamoids are
• Apply a 45° varus stress to the 1st MTP reduced underneath the 1st metatarsal head
joint to release the contracted tissue, which
allows for the sesamoids to mobilize. • If the sesamoids are not reduced beneath
(f) To confirm that we have adequate release of the metatarsal head, release more of the
the sesamoids, a towel clip is placed around lateral capsule, and then reassess sesa-
the medial capsular tissue, and we tighten moid reduction again with the same tech-
down the medial capsule with the towel clip nique mentioned above.
(Fig. 3.6a, b). (h) At the end of the case, we turn our atten-
(g) An AP fluoroscopic image is obtained to tion back to the DSTP to imbricate the cap-
assess whether or not the sesamoids have sule, which is discussed later in this
reduced beneath the metatarsal head. chapter.
3 Lapidus HAV Correction 31

3.1.4  artial Excision 1st Metatarsal

P • Keep in mind that the sural nerve is within
Head (Silver Osteotomy) the anterior skin flap of the incision.
(c) We use a 5 mm bone graft harvester to obtain
(a) Using the same medial incision, and after the 5–8 cc of bone graft from the calcaneus. The
medial capsule has been released from the graft is placed in a specimen cup for later use
1st MTP joint, use an oscillating saw to at the Lapidus fusion site.
remove the medial eminence. This results in (d) The wound is thoroughly irrigated to remove
a smooth medial border along the 1st meta- bone debris from the subcutaneous tissues.
tarsal head (Fig. 3.7). (e) Skin is closed with 3-0 Nylon suture.
• Be careful not to excise part of the articu-
lar cartilage.
3.1.6 1st Tarsometatarsal Joint
Fusion (Lapidus)
3.1.5 Calcaneus Autograft Harvest
(a) After completion of the distal soft tissue pro-
(a) A 1–2 cm oblique incision is made over the cedure and partial excision 1st metatarsal, we
lateral aspect of the calcaneal tuberosity. then proceed with the Lapidus portion of the
(b) Blunt dissection is carried down to the lateral case.
wall of the calcaneus using a Key periosteal (b) To confirm exact location of the joint, we
elevator. mark out the joint using a Freer elevator and
an AP fluoroscopic x-ray.
(c) Using a 15-blade knife, a dorsomedial inci-
sion is centered over the 1st TMT joint.
(d) A Bovie is used for hemostasis within the
subcutaneous tissues.
(e) Look for the medial branch of the superficial
peroneal nerve within the incision, and
retract it either medially or laterally.
(f) With the nerve protected, incise the extensor
hallucis longus (EHL) tendon sheath, and
retract the EHL tendon laterally.
(g) Now incise the 1st TMT joint capsule in line
with the incision. Carefully reflect the capsu-
lar tissue medially and laterally around the
joint.
• Be careful with the lateral dissection as
the dorsalis pedis artery and anterior tibial
nerve dive between the base of the 1st and
2nd metatarsals.
• Assuming we have good exposure of the
joint, we try to leave a cuff of the medial
capsule attached to the joint to contain our
autograft at the fusion site.

A Hintermann retractor is placed over the dor-

sal aspect of the joint and fixed to the medial
Fig. 3.7 Partial excision 1st metatarsal is completed
using an oscillating saw to remove the large prominent cuneiform and base of 1st metatarsal with pins
medial eminence (Fig. 3.8). The Hintermann is used for distraction
32 W. B. Smith et al.

Fig. 3.8 After dorsomedial approach to the 1st TMT Fig. 3.9 The 1st TMT joint cartilage is removed. A series
joint, a Hintermann retractor is used to distract the 1st of perforations is made at the joint surface with a small
TMT joint to prep the joint for fusion solid drill bit followed by fish scaling the area with an
osteotome

to increase the access to the 1st TMT articular (k) A solid drill bit is used to make a series of
surface. perforations on each side of the joint
­followed by “fish scaling” the surfaces with
(h) If more distraction is needed to gain expo- an osteotome. We also drill the medial base
sure to the joint, a ¼ inch osteotome can of the 2nd metatarsal to get a spot-weld
be used to divide the plantar ligament/cap- fusion to lessen the risk of hallux valgus
sule at the inferior aspect of the 1st TMT recurrence (Fig. 3.10).
joint. (l) The calcaneus autograft is now packed into
(i) With the joint now fully exposed, the carti- the fusion site.
lage is removed with curettes and osteo- (m) The Hintermann retractor is removed and
tomes (Fig. 3.9). the 1st TMT joint is reduced.
(j) The joint is thoroughly irrigated with nor- (n) Next, the 1–2 intermetatarsal angle is
mal saline to remove the cartilage debris. reduced using a large bone reduction clamp.
3 Lapidus HAV Correction 33

Fig. 3.10 The medial base of the 2nd metatarsal is drilled

with a solid drill bit to get a “spot-weld” fusion

• A small, stab incision is made of the lat-

eral aspect of the 2nd metatarsal neck.
• The large bone reduction clamp is then
placed around the 2nd metatarsal neck
and the medial eminence of the 1st meta-
tarsal (Fig. 3.11a).
• The 1st MTP joint is maximally
dorsiflexed to recreate the windlass
­
mechanism. Fig. 3.11 (a, b) A large bone reduction clamp is placed
• The large reduction clamp is then closed around the 2nd metatarsal neck and medial eminence of
down tightly to reduce the 1–2 intermeta- the 1st metatarsal head to reduce the 1–2 intermetatarsal
angle. Reduction and alignment is confirmed with a fluo-
tarsal angle. Reduction is confirmed with roscopic AP image
AP fluoroscopic x-ray (Fig. 3.11b).
34 W. B. Smith et al.

a b

Fig. 3.12 (a, b) A guidewire is placed obliquely from the base of the 1st metatarsal to the middle cuneiform. Placement
of the guidewire is confirmed with fluoroscopy

–– Our goal is to get the 1st metatarsal c­annulated screw to get excellent com-
parallel with the 2nd metatarsal. pression and fixation across the 1st TMT
–– Assess for sesamoid reduction under- joint (Fig. 3.13).
neath the 1st metatarsal head. –– Confirm screw length and placement
• Next, place a guidewire for a 4.0 mm par- with AP and oblique fluoroscopic
tially threaded cannulated screw from the views.
medial base of the 1st metatarsal and aim • Next, a Lapidus fusion plate is centered
for the center aspect of the middle cunei- over the dorsomedial aspect of the 1st
form. Confirm guidewire placement with TMT joint.
AP, oblique, and lateral fluoroscopic –– Confirm plate position with fluoro-
images (Fig. 3.12a, b). scopic images.
• Measure screw length and drill the over • Fixate the plate to the medial cuneiform
the guidewire through the 1st metatarsal with locking screws.
base only, and then place the a­ ppropriately –– Confirm that the plate position, screw
measured 4.0 mm partially threaded length, and hallux valgus correction
3 Lapidus HAV Correction 35

is appropriate with AP, oblique,

and lateral fluoroscopic images
(Fig. 3.14a, b).
• The wound is irrigated with normal
saline. 2-0 Vicryl is used to close the sub-
cutaneous tissues, and 3-0 Nylon hori-
zontal mattress stitches are used to close
the skin.
(o) Attention is then turned back to the medial
incision along the 1st MTP joint to complete
the distal soft tissue procedure.
• Redundant medial capsular tissue is
excised.
• 0-Vicryl suture is used to imbricate the
medial capsular tissue using a pants-­
over-­vest stitch. Start each stitch on the
dorsal side of the capsule (Fig. 3.15). We
recommend closing the capsule from
proximal to distal.
• The subcutaneous tissue is then closed
with 2-0 Vicryl followed by skin clo-
Fig. 3.13 The appropriately measured 4.0 mm partially
cannulated screw is placed over the guidewire for sure with 3-0 Nylon horizontal mattress
compression stitch.

a b

Fig. 3.14 (a, b) Confirm plate position, screw length, and hallux valgus correction with fluoroscopic images
36 W. B. Smith et al.

6–8 weeks based on patient comfort and soft

tissue edema.
• Routine imaging studies are completed at
week 5 and week 8 postoperatively.
• Patients are encouraged to transition to accom-
modative soft-sided shoewear at approxi-
mately 6–8 weeks if no issues are noted with
healing.
• Return to fitness walking activities is allowed
at the 3-month mark and unrestricted run-
ning sports allowed after 4–6 months
postoperatively.

Callouts/Pearls
• It is recommended to get weight-­bearing
sesamoid axial radiographs preopera-
tively along with the standard three view
foot films to allow for assessment of
frontal plane rotation.
• During correction of the HAV defor-
mity, if instability at the intercunei-
form region is identified, consider
arthrodesis of the medial to middle
cuneiform.
Fig. 3.15 0-Vicryl suture is used to imbricate the medial
capsule at the 1st MTP joint using a pants-over-vest tech- • Activating the windlass mechanism dur-
nique. The stitch is begun on the dorsal side of the capsule ing reduction and fixation can signifi-
with the sutures being tied from proximal to distal cantly assist in stabilizing the area
during the placement of the implants.
• Several commercial systems have
3.2 Postoperative Protocol recently become available that assist in
triplanar reduction of the bunion defor-
• The patient is placed into a sterile nonadherent mity and may be helpful with correction
dressing with a soft compressive bulky dress- of the HAV deformity.
ing overtop. Based on preference a posterior
splint of postoperative shoe can be utilized.
• The patient is instructed to be non-weight-­
bearing until the peripheral block has resolved. References
Ice and elevation are encouraged for the first
several weeks after surgery. 1. Albrecht GH. The pathology and treatment of hallux
• After the patient has sensation in the operative valgus (in Russian). Russk Vrach. 1991;10:14–9.
limb, they may do protected weight-bearing 2. Truslow W. Metatarsus primus varus or hallux val-
gus? J Bone Joint Surg. 1925;7:98.
with assistive devices in the postoperative 3. Lapidus P. Operative correction of the metatarsus
period. varus primus in hallux valgus. Surg Gynecol Obstet.
• Sutures are removed at 10–14 days 1934;58:183–91.
postoperatively. 4. Lapidus PW. A quarter of a century of experi-
ence with the operative correction of the metatarsus
• Protected weight-bearing in a low CAM boot varus primus in hallux valgus. Bull Hosp Joint Dis.
our postoperative shoe is encouraged for 1956;17:404–21.
3 Lapidus HAV Correction 37

5. Lapidus PW. The author’s bunion operation from 1931 study of fixation methods. Foot Ankle Int.
to 1959. Clin Orthop Relat Res. 1960;16:119–35. 2009;30(4):341–5.
6. Sangeorzan BJ, Hansen ST. Modified Lapidus proce- 12. Dayton P, Feilmeier M, Kauwe M, Hirschi J.
dure for hallux valgus. Foot Ankle. 1989;9:262–6. Relationship of frontal plane rotation of first meta-
7. Myerson M, Allon S, McGarvey W. Metatarso­ tarsal to proximal articular set angle and hallux
cuneiform arthrodesis for management of hallux alignment in patients undergoing tarsometatarsal
valgus and metatarsus primus varus. Foot Ankle. arthrodesis for hallux abducto valgus: a case series
1992;13(3):107–15. and critical review of the literature. J Foot Ankle Surg.
8. Cottom JM, Vora AM. Fixation of Lapidus arthrod- 2013;52(3):348–54.
esis with a plantar interfragmentary screw and medial 13. Okuda R, Kinoshita M, Yasuda T, Jotoku T, Kitano
locking plate: a report of 88 cases. J Foot Ankle Surg. N, Shima H. Postoperative incomplete reduc-
2013;52:465–9. tion of the sesamoids as a risk factor for recur-
9. Klos K, Gueorguiev B, Mückley T. Stability of medial rence of hallux valgus. JBJS-Am. 2009;91(7):
locking plate and compression screw versus two 637–1645.
crossed screws for Lapidus arthrodesis. Foot Ankle 14. Mortier J-P, Bernard J-L, Maestro M. Axial rotation
Int. 2010;31(2):158–63. of the first metatarsal head in a normal population and
10. Klos K, Simons P, Hajduk A, Hoffmeier KL. Plantar hallux valgus patients. Orthop Traumatol Surg Res.
versus dorsomedial locked plating for Lapidus 2012;98(6):677–83.
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Int. 2011;32(11):1081–5. ZM. Correction of Frontal Plane Rotation of Sesamoid
11. Scranton PE, Coetzee JC, Carreira D. Arthrodesis Apparatus During the Lapidus Procedure: a novel
of the first metatarsocuneiform joint: a ­comparative approach. J Foot Ankle Surg. 2014;53(2):248-51.
 Hallux Interphalangeal Joint
Arthrodesis and Jones Tendon
4
Transfer

Jeffrey S. Weber

4.1 Patient History and Findings high-impact athletic activities such as competi-
tive dancing, running, and soccer may also pre-
Pathology of the hallux interphalangeal joint dispose a patient to degenerative changes within
(HIPJ) may stem from a number of disorders. the HIPJ.
Neurological disease, such as Charcot-Marie-­ The combination of HIPJ arthrodesis with
Tooth, can cause claw toe deformity that becomes transfer of the extensor hallucis longus into the
progressively rigid over time. Rigid deformity is 1st metatarsal neck, also known as the Jones ten-
no longer amenable to soft tissue balancing pro- don transfer, is a predictable procedure with a
cedures in later stages of the disease and will relatively small learning curve that serves to alle-
likely require arthrodesis of the HIPJ. Reducible viate pain, prevent ulceration, and restore the
deformity in the presence of a progressive neuro- alignment of the distal first ray.
logical disease is also not amenable to soft tissue
balancing procedures due to the high likelihood
of deformity recurrence. Patients will present 4.2 Clinical Case Example
with pain in the hallux and sometimes ulceration
at the tip of the hallux from increased pressure A 47-year-old poorly controlled Type II diabetic
when weight-bearing or rubbing in shoe gear. As female presents with worsening plantar ulceration
the claw toe deformity worsens, a hallux malleus underlying her 1st metatarsophalangeal joint. She
deformity may occur in which the extensor hal- has been treated in the wound care center with
lucis longus (EHL) tendon contracts. This causes various forms of offloading including total con-
a retrograde force at the first metatarsophalangeal tact casts as well as various wound care products.
joint (MTPJ) in which the first metatarsal She is morbidly obese and unable to maintain
becomes plantarflexed which may eventually complete non-weight-bearing to the affected limb.
lead to ulceration under the metatarsal head. Clinically, she has a hallux malleus contracture,
Trauma is another cause of pain and deformity ankle equinus, and a flexible forefoot valgus.
of the HIPJ. Intraarticular fractures will predis- Vascular status was within normal limits. Her pro-
pose a patient to arthritic changes, joint instabil- tective sensation was absent. MRI has been nega-
ity, and deformity. Subtle, repetitive trauma from tive for osteomyelitis. After wound debridement
with cultures and an appropriate course of antibi-
otics, she was taken for definitive surgical correc-
J. S. Weber (*)
Birch Tree Foot and Ankle Specialists, tion of the deformity to off-load this 1st MTPJ
Traverse City, MI, USA which involved a hallux IPJ fusion with EHL

© Springer Nature Switzerland AG 2019 39

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_4
40 J. S. Weber

a of hindfoot deformity that might also require

simultaneous correction.

4.4 Surgical Management

4.4.1 Preoperative Planning

A thorough history is obtained from the patient

well in advance of the surgical procedure to be
performed. The assessment of any medical
comorbidities must be well-documented and
understood in order to optimize the patient for
surgery. Diabetes mellitus (DM), peripheral arte-
rial disease (PAD), vitamin D deficiency, kidney
disease, rheumatoid and psoriatic arthritis, neuro-
b logical disease, and tobacco usage are all factors
that may prove detrimental to having a successful
outcome. Preoperative lab values are routinely
performed to assess a patient’s general state of
health. Typical lab values include a basic meta-
bolic panel and a complete blood count. At times,
the author will perform a comprehensive
­metabolic panel in any patient who is suspected to
be malnourished. Vitamin D levels are obtained
for surgical patients with a history of vitamin D
deficiency, previous stress fracture, or known his-
Fig. 4.1 (a, b) AP and lateral postoperative radiographs
after hallux IPJ fusion, EHL tendon transfer, peroneal and tory or suspicion of osteoporosis. Hemoglobin
tendoachilles lengthening in a diabetic patient with a neu- A1C values are obtained on all diabetic patients,
ropathic sub-first MTPJ ulceration and surgery is delayed for an elective procedure if
the A1C value is greater than 8.0. Nicotine levels
t­endon transfer to the first metatarsal, a peroneus are also routinely drawn prior to elective surgery
longus lengthening, and Achilles tendon lengthen- on patients with a history of tobacco abuse.
ing. She was kept in a total contact cast for 4 weeks The type of anesthesia to be administered is
postoperatively and eventually transitioned into an determined by the anesthesiologist and the sur-
extra-depth diabetic shoe. She has remained ulcer geon. The author prefers for most elective foot
free at 8 months postop (Fig. 4.1a, b). and ankle cases that a popliteal and saphenous
nerve block be administered preoperatively by the
anesthesiologist. This allows for an extended
4.3 Imaging and Diagnostic period of analgesia postoperatively compared to
Studies an ankle block administered by the surgeon and
may decrease the consumption of oral narcotics
Routine imaging for hallux IPJ pain and defor- by the patient in the postoperative period.
mity includes three weight-bearing radio-
graphic views (AP, lateral, and medial oblique)
to assess the degree of deformity and level of 4.4.2 Positioning and Equipment
arthrosis. Other deformities, overall bone qual-
ity, and cystic changes that may require graft- • Hardware required for this procedure includes:
ing are assessed simultaneously. A calcaneal –– 2 × 2.5 mm cannulated headless screws for
axial view may also be helpful in the presence the HIPJ fusion
4 Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer 41

–– Biotenodesis anchor if the Jones tendon #15 blade is utilized to make an incision through
transfer is to be performed the subcutaneous tissue (Fig. 4.3). Adson forceps
–– General instrument set are used to carefully raise a full thickness flap,
–– Sagittal saw and the EHL tendon is exposed and transected
distal to the HIPJ and tagged with 0-Vicryl for
The patient is brought to the operating room later transfer into the first metatarsal. The dorsal
and placed supine on the table so that the heels HIPJ is incised and the collateral ligaments are
are at the edge but not overhanging on the end of released (Fig. 4.4).
the table. General anesthesia is administered to
the patient. A well-padded thigh tourniquet is
applied and set to 300 mmHg. The foot is then 4.4.4 Technique(s)
prepped and draped in the normal sterile fashion,
the foot is elevated and exsanguinated with an 4.4.4.1 HIPJ Fusion
Esmarch bandage, and the tourniquet is inflated. A 9.5 mm sagittal saw blade is used to resect the
head of the proximal phalanx and the base of the
distal phalanx (Figs. 4.5 and 4.6). Any transverse
4.4.3 Approach plane deformity will be addressed at this time by
making bone cuts that are perpendicular to the axis
A skin marker is used for incision placement of both the proximal and distal phalanges. Care
planning. The author prefers an S-shaped inci- must be taken to make cuts that are perpendicular
sion in which the corners of the “S” are nearly to the sagittal plane of each bone to ensure rectus
90° (Fig. 4.2). An “S” style incision is centered alignment of the digit after internal fixation is
over the IPJ flexion crease with proximal and dis- placed. The surgeon should be mindful of the
tal extensions from opposite sides per surgeon underlying flexor hallucis longus tendon when
preference or as dictated by local soft tissues. A making the cuts so as not to transect it. The amount

Fig. 4.2 A skin marker is used to mark the proposed Fig. 4.3 A full thickness flap is raised down to the level
incision of the EHL tendon
42 J. S. Weber

Fig. 4.6 The proximal end of the distal phalanx is

resected

of bone resection required to expose subchondral

bone without taking excess bone must be carefully
considered so that stable congruent surfaces are
available for secure internal screw fixation.
Bone ends are further prepared by fenestrating
them with a 0.062 K-wire to promote subchon-
Fig. 4.4 The dorsal HIPJ is incised and the collateral
dral bleeding. Internal fixation techniques for
ligaments released. The EHL tendon is transected at the
level of the HIPJ. If the Jones transfer is to be performed, HIPJ fusion vary among surgeons. Over the
the tendon is whip stitched with 0-Vicryl to be passed into years, the author has adopted the use of two par-
a more proximal incision made over the metatarsal neck allel headless cannulated screws as the preferred
method of fixation. The two-screw construct pro-
hibits any rotational forces across the fusion site.
Anecdotally, the author has seen an increased
union rate with the two screw technique as
opposed to one central screw. Furthermore, inter-
nal fixation avoids any pin tract infection or irri-
tation that is seen with the more traditional
crossed K-wire fixation. The hallux is plan-
tarflexed at the level of the HIPJ, and two parallel
guide wires are driven from proximal to distal
through the distal phalanx and out the tip of the
toe (Fig. 4.7a). The wires are then retrograded
into the proximal phalanx. AP and lateral fluoro-
scopic views are obtained to confirm wire place-
ment (Fig. 4.7b, c). A 1 centimeter transverse
incision is made over the wires at the distal end of
the toe, and a cannulated drill is used to drill the
cortex of the distal phalanx to allow for 2.5 mm
screw placement. (Depending on the size of the
bone, larger screws may be used up to 3.5 mm.)
With the joint coapted manually, the screw is
driven by hand across the HIPJ. The second
Fig. 4.5 The proximal phalangeal cut is made. Any angu- 2.5 mm screw is then inserted in the same fashion
lar deformity is corrected through this cut (Fig. 4.8a, b).
4 Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer 43

a b

Fig. 4.7 (a) Two guide wires are driven antegrade and lanx. (c) A lateral radiograph confirms wire position
parallel with one another at the end of the hallux. (b) The within both the proximal and distal phalanges
wires are then driven retrograde into the proximal pha-
44 J. S. Weber

a b

Fig. 4.8 (a) 2.9 mm screws are placed parallel to one lateral radiograph confirms the position of both screws
another for increased stability, resistance to rotational within the medullary canal with good bone apposition
forces, and equal compression across the fusion site. (b) A

4.4.4.2 Jones Tendon Transfer a

The EHL, which was transected at the level of the
HIPJ during the initial part of the case, is whip
stitched with 0-Vicryl (Fig. 4.9a, b). A 1 cm
­incision is made dorsally at the level of the 1st
metatarsal neck overlying the EHL (Fig. 4.10).
The tendon sheath is incised, and the transected
tendon is pulled proximally into this incision
exposing the metatarsal neck (Fig. 4.11a, b). A
tendon sizer is used to measure the width of the
EHL tendon, and the appropriate size drill is
selected (Fig. 4.12). Typically, a 4 mm × 10 mm
biotenodesis anchor is used. A guide wire is
Fig. 4.9 (a, b) The EHL tendon is transected at the level
placed from dorsal to plantar within the metatar- of the HIPJ, gaining exposure to the joint, and then whip
sal neck perpendicular to the c­ ortex and passed stitched
4 Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer 45

b a

Fig. 4.9 (continued)

Fig. 4.11 (a, b) A hemostat is used to lasso the EHL ten-
don which is brought up through the proximal incision. If
there is difficulty passing the EHL proximally, a small
tendon stripper may be used to free the EHL from sur-
rounding soft tissue attachments

Fig. 4.10 A skin marker is used to mark the proposed Fig. 4.12 The tendon is sized and the appropriate biote-
1 cm incision over the metatarsal neck nodesis anchor is selected
46 J. S. Weber

a a

b
b

Fig. 4.14 (a, b) Fluoroscopy confirms the position of the

guide wire in the metatarsal neck

(Fig. 4.15a, b). The reamer is removed, and the

guide wire, which has a nitinol loop on its end, is
left within the pilot hole. The whip stitched
Fig. 4.13 (a, b) The guide wire is placed in the metatar-
sal neck perpendicular to the bone
0-Vicryl on the end of the EHL is then placed
within the nitinol loop, and the guide wire is
pulled manually out the plantar foot bringing the
out the plantar aspect of the foot (Fig. 4.13a, b). suture with it (Fig. 4.15a–d). The foot is held
The position of the wire is ­confirmed with AP with the ankle in neutral, and the tendon is placed
and lateral fluoroscopic views (Fig. 4.14a, b). under anatomic tension, while the biotenodesis
A 5 mm reamer is placed over the guide wire and anchor is inserted from dorsal to plantar adjacent
driven across both cortices with care being taken to the EHL tendon within the bone tunnel
not to violate underlying soft tissue structures (Figs. 4.16a–d and 4.17a–c).
4 Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer 47

a The distal end of the EHL is sutured to the

extensor hallucis brevis tendon using 0-Vicryl in
order to maintain a level of muscular balance
across the MTPJ.
Layered closure is performed with 3-0 Vicryl
for subcutaneous tissue and 3-0 Nylon simple
interrupted suture for skin. Postoperative dress-
ings include ADAPTIC, 4 × 4 gauze, two
ABD pads, sterile WEBRIL, and a posterior
mold plaster splint.

Intraoperative Pearls and Pitfalls

b • Full thickness dissection during initial
incision and meticulous handling of the
soft tissue are paramount to incision
healing. Self-retaining retractors should
be avoided. The use of double prong
skin hooks by a surgical assistant is uti-
lized throughout the case.
• Two screw fixation with headless com-
pression screws which are inserted
parallel to one another allows for uni-
form compression and stability across
the fusion site and limits rotational
forces.
• Skin closure consists of typically no
more than five subcutaneous absorbable
sutures and six to seven simple inter-
rupted nonabsorbable suture to avoid
excess tension on the incision and limit
the potential for reaction to the absorb-
able suture.

Fig. 4.15 (a, b) The cannulated reamer is placed over the

guide wire, and bicortical drilling is performed
48 J. S. Weber

a b

c d

Fig. 4.16 (a–d) The suture is passed through the eyelet in the guide wire, and the EHL tendon is pulled through the
metatarsal neck
4 Hallux Interphalangeal Joint Arthrodesis and Jones Tendon Transfer 49

a b

Fig. 4.17 (a–c) The biotenodesis anchor is inserted with the ankle at 90° and the EHL being held under anatomic
tension

4.5 Postoperative Care smallest allowable reamer will decrease the

risk of fracture. If fracture occurs, open
• Please refer to Chap. 1 for postoperative pro- reduction internal fixation of the metatarsal
tocols for this procedure. may be necessary, and the appropriate hard-
ware should be available.
• Poor bone stock may not allow for adequate
4.6 Potential Complications purchase of the biotenodesis anchor. If this is
the case, select an anchor one size larger and
• Wound healing problems can be limited by augment the repair by suturing the EHL ten-
meticulous soft tissue handling and limited don to the 1st metatarsal periosteum with
use of suture during skin closure. 0-Vicryl. Consider prolonging the patient’s
• Fracture of the first metatarsal may occur dur- course of non-weight-bearing to allow for
ing reaming. Ensuring the guide wire is cen- adequate consolidation of the anchor and
tralized with fluoroscopy and selecting the screw fixation across the HIPJ.
 Hammertoes and Claw Toes:
Primary and Revision 5
Roberto A. Brandão and David Larson

Abbreviations biomechanical compensation of the digits and

MTPs. Subsequent plantar forefoot pain or meta-
DIPJ Distal interphalangeal joint tarsalgia can manifest from plantar plate tearing;
EDL Extensor digitorum longus attenuation or complete rupture can occur due to
FDL Flexor digitorum longus these deformities, further complicating treatment
MTP Metatarsophalangeal joint plans. Hammertoes can be associated with a pes
PIPJ Proximal interphalangeal joint planus foot type due to excessive flexor stabiliza-
tion from the long flexors firing for a longer
period which overpower the interosseous mus-
5.1 Introduction cles and can lead to 4th and 5th toe adductovarus
rotation. Claw toes are typically associated in
Hammertoe and claw toe deformities are com- patients’ cavus foot type or neuromuscular dis-
mon problems treated by all foot and ankle sur- ease with extensor overcompensation secondary
geons. Hammertoes present with dorsiflexion at to a weak posterior complex musculature in
the MTP, plantarflexion at the proximal interpha- which the extensor gains advantage over the
langeal joint (PIPJ), and extension at the distal intrinsic lumbricals.
interphalangeal joint (DIPJ). Claw toes present
with dorsiflexion at the MTP and plantarflexion
at both the PIPJ and DIPJ. Hammertoes and claw 5.2 Case Example
toes are caused by an imbalance between the
extrinsic and intrinsic pedal musculature that can A 50-year-old female with main complaints of a
further lead to instability of the less MTPs. 2nd digital hammer toe with plantar forefoot-­
Hallux valgus, equinus, and neuropathic disor- associated pain at the 2nd metatarsal head. She
ders lead to increased forefoot loads that cause has a hammertoe deformity with concerns for a
plantar plate tear. The patient has a reducible toe
deformity, and a negative Lachman’s test of the
2nd MTP without a hallux valgus or planus
R. A. Brandão (*)
The Centers for Advanced Orthopaedics, Orthopaedic deformity. Plain film radiographs reveal a digit
Associates of Central Maryland Division, with elevation seen on the lateral view and a “gun
Catonsville, MD, USA barrel” sign on anteroposterior (AP) viewing.
D. Larson There is no angular deformity present, but there
Steward Health Care, Department of Podiatry, is a concomitant elongated 2nd metatarsal. The
Glendale, AZ, USA

© Springer Nature Switzerland AG 2019 51

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_5
52 R. A. Brandão and D. Larson

patient has exhausted nonoperative treatments syndrome or plantar plate injury should also be
including shoe gear change, custom orthotics, excluded, especially when a hallux valgus
and physical therapy. Magnetic resonance imag- deformity is present. An intermetatarsal neu-
­
ing demonstrates no tear of the plantar plate and roma, inflamed bursa, or capsulitis must also be
no neuroma present in the 3rd interspace. ruled out as a contributing factor in any global-
ized forefoot pathology.
Preoperative labs should be considered to
5.3 Presentation/Diagnosis evaluate nutritional status (prealbumin, albumin),
diabetic control (if applicable), and electrolyte
Digital hammertoe and claw toe deformities can balance (basic metabolic panel).
affect patients of all ages and level of activity. Tobacco use should be discontinued prior to
Patients will typically present with complaints any surgical intervention as this can increase the
of toe pain from either dorsal or distal calluses risk of complications in foot and ankle surgery
that form secondary to shear forces and repeti- (Bettin [1]). Hammertoes and claw toe deformities
tion friction in shoe gear. Additionally, patient can be treated by either arthroplasty or arthrodesis
with neurological or spastic disorders may have of the affected joints. For arthrodesis, your choice
difficulty wearing certain bracing or shoe gear of equipment can vary based on adjunctive proce-
due to the severe deformity. As previously dures and cosmesis. These choices are part of the
noted, hammertoes and claw toes often present preoperative planning stage, and one must have all
with other associated foot deformities including needed instruments in the room.
equinus contracture, metatarsalgia, and bunion
deformity. Flexor stabilization is the most com-
mon type of mechanism that results in a ham- 5.3.1 Arthroplasty
mertoe which can be evaluated and seen in
patients as the flexor digitorum longus (FDL) Digital arthroplasty is the resection of the proxi-
muscle overpowers interosseous muscles. mal phalanx head in isolation and can indicate
During a gait analysis, compensation of the semirigid or rigid hammertoes with no other
FDL muscle attempting to supinate the foot can associated varus/valgus angulation or contracture
ultimately lead to this deformity. The least com- at the MTP. Arthroplasties of the DIPJ and PIPJ
mon mechanism is flexor substitution, a com- shorten the length of the digit and weaken the
pensation likley due to a weak triceps surae pull of the flexor complexes which reduce further
muscle group. The FDL muscle tries to compen- hammering (Boberg [2]). Arthroplasties are less
sate for the weak triceps surae and as a result, definitive than an arthrodesis and best for isolated
overpowers the interossei muscles. This may digit deformities and can provide symptomatic
been seen clinically with a chronic Achilles ten- relief. One common use for arthroplasty has been
don tear or overlengthened Achilles tendon from for the treatment of the adductovarus 5th digit
a previous surgery. As noted prior, extensor sub- deformity.
stitution is seen in patients with a pes cavus foot
type or neuromuscular disease which often
results in claw toes. This deformity is seen dur- 5.3.2 Arthrodesis
ing the swing phase of gait, and patients typi-
cally have some degree of equinus deformity. Arthrodesis of either the PIPJ or DIPJ represents
All hammertoe and claw toe deformities gen- a more definitive procedure with longer lasting
erally follow a three-stage pathology from reduc- results. Whether a bony union or a fibrous stable
ible to semirigid to a final rigid state. A thorough union, it offers more stability and less chance of
exam should include a history or family history recurrence. Additionally, eliminating the deform-
of a neuromuscular disease, gait analysis, and ing force of the digit may prevent further issues at
complete lower extremity exam. Predislocation the MTPJ level such as plantar plate injury or
5 Hammertoes and Claw Toes: Primary and Revision 53

metatarsalgia. It is effective in both extensor- and 5.3.7  Note on Plantar Plate

A
flexor-based deformities and preferred when Pathology
multiple digits need to be stabilized in the fore-
foot (Boberg). Multiplanar digital deformities or plantar plate
treatments will not be addressed here. Treatment
options and discussion can be found in Chap. 6.
5.3.3 Flexor Tendon Transfer

A seldom used procedure in modern surgical 5.4 Imaging

practice, it can afford added stabilization without
the need for internal fixation of the digit. X-rays AP and lateral plain film radiographs can
Transferring power of the flexor dorsally cre- be used to assess evident contractures by noting a
ates a straight lever arm at the MTP. “gun barrel” sign which is associated with a ham-
mertoe deformity as the viewer is seeing the
medullary canal of the proximal phalanx. This is
5.3.4 Flexor Tenotomy similar in claw toe deformities as one can look
down the central axis of the distal phalanx. A lat-
A flexor tenotomy is best utilized for flexible eral view is helpful in evaluating the elevation of
flexion deformities at either the DIPJ or PIPJ the digit which may indicate plantar plate insuf-
level. If a claw toe deformity is present, the FDL ficiency or associated pathologies.
should be released at the DIPJ; if a hammertoe is
present, releasing both long and short flexors at MRI A magnetic resonance imaging series of the
the PIPJ will reduce the deformity. forefoot can be useful to evaluate the plantar plate as
well as rule out any soft tissue pathology or inter-
digital neuromas that may be also present.
5.3.5 Extensor Tenotomy Additionally, this form of advanced imagining can
help detect other osseous pathology including carti-
This technique is used for moderate to severe lage defects or the presence of the avascular necro-
extension deformities of the lesser digits. The sis of the 2nd metatarsal head (most common).
release is generally completed proximal to the
MTPJ to reduce the contracture prior to the joint Noninvasive vascular studies Noninvasive arte-
level. It can provide relief for flexible hammertoe rial studies may be warranted based on patient
or in conjunction with other digital surgical comorbidities including diabetes mellitus,
correction. peripheral vascular disease, history of vasculopa-
thies, or distal peripheral neuropathy. Surgical
intervention on digits in immunocompromised or
5.3.6 A Note on Local Skin Plasty fragile hosts for ulcer prevention may require this
full work-up for the healing assessment.
Z, V–Y, or rotational skin plasty techniques can
be used both in the primary setting or revsion if
concerns for skin contracture are present when 5.4.1 Operating Room Setup
treating a multilevel deformity. Most commonly,
a “derotational arthroplasty” can be used on The patient is brought into the operative room the-
adductovarus 5th digit deformities using an ellip- atre and placed on the operating table. General
tical incision in a distal, medial to proximal lat- anesthesia is then performed via LMA or general
eral direction. Subsequent pinning of the digit intubation. A thigh tourniquet should be applied to
can be done for added stabilization but has been the operative extremity. A sequential compression
described without this addition successfully. device is placed on the nonoperative extremity. All
54 R. A. Brandão and D. Larson

appropriate equipment should be present. An ipsi- tal saw is then used to remove the head of the
lateral hip “bump” can be valuable as many proximal phalanx or middle phalanx. If only
patients are externally rotated in the lower extrem- performing an arthroplasty, the procedure will
ity. Typically, an ortho minor or small procedure end here with layer closure and application of
tray has all the equipment needed for the proce- sterile dressing.
dure. A No. 15 blade is used to incise the skin in an If performing an arthrodesis, a rongeur and
elliptical or liner fashion over the proximal head curette is used to resect the cartilage on the respec-
allowing access to proximal phalanx for resection, tive bases. The fixation for hammertoes includes a
and a curette and rongeur are used to resect the 0.062” K-wire that is placed in a retrograde fashion
cartilage off the base of the middle phalanx. through the digit distally and then inserting the wire
into the proximal phalanx. Prior to advancing the
K-wire into the associated metatarsal, the digit is
5.4.2 Equipment generally positioned in a slightly plantarflexed posi-
tion. If using an implant device, implantation should
Hammertoes occur after the area is flushed with good retraction.
1. A 0.062” K-wire is used in a retrograde fash- Various implant systems exist and may contain 2 or
ion through the end of the digit to fixate the 1 component implants that require slightly different
PIPJ fusion. compression techniques based on the technology.
2. Hammer toe implant of the surgeon’s choice. Appropriate planning and practice should be con-
sidered prior to use (Figs. 5.1 and 5.2).
Claw toes
1. 2.5 mm or 3.0 mm fully threaded cannulated
screw for intramedullary fixation of the sur-
geon’s choice. It has been the experience at
our institution that this helps to prevent recur-
rence seen in some patients with claw toe
deformities, especially when the etiology is
neurogenic in nature.

5.5 Operative Technique

For both hammertoes and claw toes, the surgical

technique is similar but can vary based on inci-
sional placement and the materials used for
fixation.
A 2–3 cm curvilinear incision is made dor-
sally over the MTP. Dissection is carried down
to the extensor tendon, and a Z-lengthening can
then be performed. A capsulotomy of the MTP
is performed releasing the associated extensor
contracture. Next a full thickness elliptical inci-
sion is then made dorsally over the PIPJ or DIPJ
of the digit. Alternatively, a linear incision is
made over the PIPJ or DIPJ, and the extensor
tendon is reflected off the bone. (This may be Fig. 5.1 A 52-year-old neuropathic male with flexion
contractures at the level of both the DIPJ and PIPJ treated
best when preparing both joints to reduce dis-
with intramedullary fixation for dual arthrodesis. The
section time.) The entire ellipse of skin with the patient is now 8 months post-op in normal shoe gear with-
associated extensor tendon is removed. A sagit- out complications. (Photo credit: G. Berlet MD)
5 Hammertoes and Claw Toes: Primary and Revision 55

Fig. 5.2 A 60-year-old male s/p 2nd and 3rd digital PIPJ
fusions approximately 7 years ago with good osseous
union and stability

Fig. 5.4 A 42-year-old female with 2nd PIPJ fusion via

an intramedullary screw not crossing the
DIPJ. Concomitant metatarsal osteotomy and a modified
Lapidus were also performed

is thinner and is not placed into the metatarsal to

breakage. Intraoperative fluoroscopy is used in
both AP and lateral viewing to determine optimal
placement of the guide wire prior to measuring
and pre-drilling. Finally the screw is inserted with
good compression across both joints. The digits
are instead splinted in a plantarflexed position
using sterile 4 × 4 dressings. Closure consists of
either 2-0 or 3-0 Vicryl for the deep layers and a
3-0 Monocryl running subcuticular technique or a
3-0 nylon in an interrupted horizontal technique.
The tourniquet is let down prior to bandage appli-
cation to assess for capillary refill. Patients are
then placed in a well-padded posterior Jones
splint postoperatively (Figs. 5.3 and 5.4).
Fig. 5.3 A 73-year-old male 2 weeks status post from a
modified Lapidus bunionectomy with a 2nd digit PIPJ
fusion, 2nd metatarsal Weil osteotomy, and direct plantar 5.6 Postoperative Protocol
plate repair. (Photo credit: T. Philbin DO)
1. All patients are placed into a posterior splint
The fixation for claw toes consists of a 2.5 mm immediately postoperatively. They are seen
or 3.0 mm cannulated screw placed in a retro- 5–7 days after surgery, and the incision(s) are
grade fashion. The guide wire for this screw type checked, and a new sterile dressing is applied.
56 R. A. Brandão and D. Larson

2. If no other procedures were performed that

require the patient to remain non-weight-­ placement of the wire in the center aspect
bearing, then patients are placed into a pneu- of the proximal phalanx when driving the
matic cam walking boot and are advised that wire back in a retrograde direction from
they can bear weight as tolerated in the boot. the distal aspect of the digit.
They are required to wear the boot until the • When correcting multiple digits, perform
K-wires are removed and/or fusion is seen all the incisions and dissection at the
radiographically which is typically 4–6 weeks. same time. This allows for an assembly
At that time, if K-wires were placed, they are line type joint resection which is more
pulled, and patients can begin weight-bearing efficient and reduces the surgical time.
in a regular shoe as tolerated. • For claw toe correction, a 2.5 mm fully
3. Radiographs are obtained at the first postop- threaded cannulated screw is used in lieu
erative visit and at 4 and 8 weeks, 6 months, of a 0.062” K-wire. This has been shown
and 1 year. to decrease the rate of recurrence.

Additional Callout/Pearls and Pitfalls for

Resident/Fellow Readers References
• Use a thigh tourniquet to prevent artifi-
cial buckling of the digits as when using 1. Bettin CC, Gower K, McCormick K, Wan JY,
an ankle tourniquet. Ishikawa SN, Richardson DR, Murphy GA. Cigarette
smoking increases complication rate in forefoot sur-
• When using a 0.062” K-wire for fixation,
gery. Foot Ankle Int. 2015;36(5):488–93.
create a pilot hole down the center in the 2. Boberg J, Willis JL. Digital deformities: etiology,
proximal phalanx prior to driving the procedural selection and arthroplasty (Chap. 13).
wire in antegrade fashion out the distal In: Banks AS, Downey MS, Martin DE, editors.
McGlamry’s forefoot surgery. Philadelphia: Wolters
phalanx. This allows more accurate
Kluwer Health; 2015.
 Plantar Plate Instability
6
Jeffrey E. McAlister and Mark A. Prissel

6.1 Introduction 6.2 Patient Presentation

The understanding of lesser metatarsophalangeal A thorough patient history and physical examina-
joint (MTP) instability has evolved over the years tion are always performed. In the acute setting,
with a better understanding of the pathoanatomy patients will have a history of traumatic injury to
and greater attention to the soft tissue derange- the forefoot whereby the toes were forcibly dor-
ment. Historically, lesser MTP pathology was siflexed. Patients will have obvious immediate
often managed by addressing the osseous pathol- swelling and typically present in an urgent fash-
ogy alone, with oversight regarding the soft tis- ion. In the subacute or chronic setting, plantar
sue stabilizing structures [1]. The plantar plate is plate instability is most commonly present as a
a fibrocartilaginous structure which is a dorsal complaint of pain to the ball of the foot or con-
restraint to the MTP. Deformity occurs when the cern about a hammertoe. Discussions will typi-
plantar plate is torn or attenuated. Crossover toe cally involve prior history of trauma, inappropriate
and MTP instability often occur with multiplanar shoe gear, and concomitant deformities.
deformity, most commonly with dorsal contrac- Understanding a patient surgical history is also
ture of the second toe and medial drift over the important with lesser MTP instability as it is
hallux. Although plantar plate instability can common to have increased pain after a first ray
occur secondary to acute injury, the aim of this procedure. Discussing any history of rheumato-
article is to describe cases where by chronic logic disorders is also important in the patient
attenuation causes metatarsalgia and digital preoperative work-up.
deformities and elaborate on preoperative work- It is imperative with digital and forefoot-­
­up and surgical correction. driven pathology to assess patients in a loaded
and unloaded fashion. We recommend having the
patient cycle through a normal gait and assess the
patient in a seated position. As with most forefoot
issues, assessing posterior lower leg muscle
group tightness is crucial and done first. A stan-
J. E. McAlister (*) dard Silverskoild test is performed to assess for
Arcadia Orthopedics and Sports Medicine,
Phoenix, AZ, USA gastroc-soleal equinus. In stance, the hindfoot is
assessed for underlying pathology which may be
M. A. Prissel
Orthopedic Foot & Ankle Center, overloading the lesser MTP, such as a pes plano
Worthington, OH, USA valgus foot type with an insufficient medial col-

© Springer Nature Switzerland AG 2019 57

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_6
58 J. E. McAlister and M. A. Prissel

umn. The medial column is then assessed for

instability, and the first MTP is assessed for range
of motion. Hallux valgus deformity is frequently
present and must be graded clinically and radio-
graphically prior to discussions of lesser MTP
correction. Clinical presentation and surgical
management of hallux valgus deformity are not
the aim of this chapter but are taken into account
in the operative algorithm.
Focusing on the lesser MTP deformity and
pathology is next and most commonly involves the
second MTP [8, 10]. One should assess for soft tis-
sue edema and tenderness around the second
MTP. In the acute setting, ecchymosis and edema
are present plantarly as well as dorsally. Range of
motion of the MTP is typically limited and very
painful in extreme dorsiflexion. In a crossover toe
deformity, a patient will typically have tenderness
and pain directly under the metatarsal head. Most
often this pain is biased toward the plantar lateral
corner of the MTP joint, as the attenuation to the
plantar plate occurs to the lateral extent of the struc-
ture when a medial crossover toe is present. There
also may be a hyperkeratotic lesion plantar to the
metatarsal head. A digital contracture is typically
involved in both the sagittal and transverse planes,
so one should Assess for the flexibility of the PIPJ
and DIPJ. In a chronic situation, patients typically
have a PIPJ joint contracture and arthritic changes.
Clinically, a crossover toe is non-­ reducible and Fig. 6.1 Preoperative examination demonstrates a posi-
abuts the great toe laterally. Patient also may have a tive Lachman test of the second metatarsophalangeal joint
small hyperkeratotic lesion or ulceration on the lat- (MTP) and rigid deformity at the proximal interphalan-
eral side of great toe [2, 3] (Fig. 6.1). geal joint. Associated findings of digital contractures may
also involve the hallux and posterior leg muscle group [4]
If a single digit or ray is involved, the other
MTPs can be assessed in the sagittal plane. The
plantar plate acts as a dorsal restraint, and any approach is undertaken including the associated
small tear along the margin of the plantar plate complications. It is imperative to have a discus-
can cause instability and pain [6]. Specifically, sion regarding expectations of digital and fore-
with a dorsal translation of the proximal phalanx foot surgery.
on the metatarsal, a “Lachman maneuver or test”
will elicit extreme pain. Compared with unin-
volved joints, a positive test is at least 50% trans- 6.3 Diagnostic and Imaging
lation of the width of the proximal phalanx. Work-Up
A discussion is typically regarding concomi-
tant medial column procedures (e.g., first ray) Upon initial examination, a standard series of three
and the associated lesser MTP instability [7]. foot radiographs are taken weight-bearing also
Discussion regarding dorsal versus plantar including sesamoid axial and calcaneal axial
6 Plantar Plate Instability 59

views. Anteroposterior radiographs typically dem- and sagittal saws are utilized for metatarsal oste-
onstrate transverse plane deformity of the proxi- otomies when indicated. The authors prefer small
mal phalanx on the metatarsal and will give the cannulated screws (2.0, 2.4) or snap-off screws
surgeon better detail as to the appropriate proce- (2.0) for the metatarsal osteotomy and a 2-0 non-
dure choice. The associated hallux valgus is absorbable braided suture for collateral ligament
assessed. Studies have shown an association of soft tissue repairs when needed. The plantar plate
metatarsal length, parabola, and deviation of the itself may either be repaired with nonabsorbable
lesser toe on the metatarsal with plantar plate tears braided (2-0) or absorbable (0) suture. The ham-
(Klein [15, 16]). An elongation of the second mertoe, when present, is fixed with the surgeon’s
metatarsal greater than 4 millimeters relative to the preferred method. One may also encounter a
first has been shown as a radiographic risk factor plantar plate which is completely nonviable and/
for plantar plate tear (Fleischer-Nilsonne method). or avulsed from the phalangeal base; in these
In a primary case, the authors typically do not instances the surgeon will need a small suture
perform a Weil osteotomy unless the second anchor.
metatarsal length is greater than 2–3 mm com-
pared to the first metatarsal, to not create a pre-
dictable transfer lesion [11]. The authors do 6.5 Operative Technique: Key
recommend advanced imaging if there is concern Operative Steps
for plantar plate tear. Ultrasound and magnetic
resonance imaging is useful in determining the Based on preoperative radiographs and clinical
status of the plantar plate and associated struc- exam, the surgeon applies the appropriate surgi-
tures. MRI can also be utilized to identify any cal algorithm:
cartilage defects in the metatarsal head, AVN, or
other differential diagnoses. Multiple studies • If there is purely sagittal plane deformity and
have shown utility of both modalities. Coughlin a long metatarsal, then the authors will typi-
et al. have a grading scheme for the severity and cally start dorsally and commence with a
location of the tear. The surgeon can appropri- shortening metatarsal osteotomy and direct
ately plan for surgical intervention with an appro- plantar approach plantar plate repair.
priate grading scheme, advanced imaging, and • If the metatarsal parabola is appropriate and
clinical work-up [13]. anatomic, then a direct plantar approach
plantar plate repair is performed in isolation
without dorsal exposure or shortening
6.4 OR Setup and osteotomy.
Instrumentation: Hardware • If the second toe is a medial crossover toe with
Recommendations plantar plate insufficiency, then a translational
metatarsal osteotomy (translational Weil or
Patients are typically on the operating room table TCMO) is performed, followed by a direct
in a supine position. A sandbag bump is placed plantar approach plantar plate repair.
under the patient’s ipsilateral hip. Typically, gen- • The associated hammertoe deformity is often
eral anesthesia and a preoperative popliteal block corrected prior to the plantar plate repair; this
are utilized during this type of case, and thigh allows for accurate assessment of the amount
tourniquet is applied to the patient’s operative of correction required to the plantar plate
limb. The small (mini) fluoroscopy unit should be repair and allows the soft tissue fixation of
on the same side as the operative leg. the plantar plate repair to be performed sub-
Instrumentation typically involves appropriate sequent to all of the osseous components,
suture material for lateral collateral ligament therefore, limiting the risk for loss of
repair and plantar plate prepare. Power drivers correction.
60 J. E. McAlister and M. A. Prissel

As with most plantar plate pathology, there is identify at the level of the MTP or more proxi-
typically an associated digital deformity. Of note, mally, if not located distally first. A plantar inci-
the digital deformity is typically addressed prior sion that extends slightly onto the toe itself may
to any metatarsal osteotomy, plantar plate repair, help with prevention of floating toe complica-
or associated procedures. We recommend man- tions, as a small amount of contracture on the
agement of the hammertoe through a transverse plantar surface is actually beneficial to maintain
converging semielliptical incision, which helps toe purchase to the ground. The flexor tendon
prevent any longitudinal contracture on the dor- sheath is sharply opened. A small Weitlander
sal surface of the joint. The hammertoe incision retractor is utilized to retract the flexor tendons.
should not be continuous with the metatarsal Once the tendons are retracted, the plantar plate
osteotomy incision, if an osteotomy is performed. is visualized. Frequently attenuated, dystrophic
For this chapter, we will assume the digital defor- and hypertrophied tissue is identified rather than
mity was addressed first. a frank full-thickness tear of the tissue [6, 12–
14]. The surgeon will often find a small punctate
stellar lesion within the planter plate which is
6.6 Direct Plantar Plate Repair typically excised. The surgeon should take the
time to identify the plantar plate attachment onto
The authors do not routinely perform a dorsal the proximal phalanx. If one does not have
approach to the plantar plate. A direct plantar enough fibrocartilage or soft tissue on the plantar
approach is easy to perform with adequate direct aspect of the proximal phalanx, then a small soft
visualization of the pathology. This approach tissue anchor is required for adequate correction
also does not overutilize lesser metatarsal oste- (Fig. 6.2a–e).
otomies, as an osteotomy is not required to When the base of the proximal phalanx is
improve visualization of the plantar plate from identified and the appropriate amount of soft tis-
the plantar approach, as is common to dorsal sue is available for repair, the surgeon proceeds
techniques. with resection and direct apposition. The degen-
After appropriately prepping the operative erated portion of the plantar plate is debrided and
limb to the level of the tourniquet and limb exsan- excised. This can either occur as a rectangular
guination, attention is directed toward the plantar resection if no transverse plane deformity is pres-
aspect of the foot. Another pearl for this specific ent or as a wedge when transverse plane defor-
procedure is to maneuver the operating table into mity exists (base lateral, apex medial for the
Trendelenburg position. A small gauge K-wire medial crossover toe). The resected tissue vol-
can be advanced from the dorsal aspect of the ume is based on the degree of degeneration pres-
second MTP through the plantar aspect of the ent, but in most instances 2–3 mm of tissue is
foot to aid in identification of the proper level of removed. The digit is appropriately plantarflexed
the joint at the plantar skin. A linear or curvilin- at the MTP, and the plantar plate is directly
ear incision is then made across the plantar MTP. repaired with a pants-over-vest suture repair. The
The incision is carried out on the plantar incision is then closed in layers with absorbable
aspect of the foot with care to avoid superficial and nonabsorbable sutures. The skin layer is typi-
retraction. The incision is carried down through cally closed in a horizontal mattress fashion to
subcutaneous adipose tissue to the level of the provide appropriate eversion of the plantar skin
flexor tendon sheath. The flexor sheath is most edges. The final toe position of the involved digit
easy to identify at the distal extent of the incision should be slightly more plantar than the adjacent
at the level of the phalangeal base. Often in cross- toes. The authors avoid pinning across the MTP
over toe deformities, the flexor tendons are sub- to further stabilize the joint, except in cases of
luxed medially and can be difficult to initially severe instability (Fig. 6.3a–c).
6 Plantar Plate Instability 61

a b c

d e

Fig. 6.2 (a) Intraoperative photograph of a 2.5 cm curvi- (d) Directly underneath, or deep, to the flexor tendons lies
linear incision on the plantar aspect of the affected second the plantar (volar) plate. In this case, the planned plantar
MTP. This allows for less soft tissue contracture and plate resection is highlighted in marker. (e) Carefully, a
avoidance of a painful plantar scar. One may also place wedge of the thick fibrocartilaginous plantar plate is
the incision between the metatarsal heads. (b) Initial dis- excised with a blade. Care is taken to avoid resecting off
section will typically involve adipose tissue, and adjacent of the proximal phalanx. When the surgeon encounters a
to the joint capsule lie the plantar interdigital nerves. (c) small punctate tear or no residual plate available on the
After careful dissection, the flexor tendon sheath is visual- proximal phalanx, a small anchor (2.0–3.0 mm) may be
ized, and the flexor tendons are mobilized. This can typi- utilized to secure the proximal leading edge
cally be accomplished with a small Gelpi-type distractor.
62 J. E. McAlister and M. A. Prissel

a b

Fig. 6.3 (a) After excising the wedge of soft tissue, a 2–0 while performing the repair. (b) Final construct with the
nonabsorbable suture is utilized to repair the defect. second toe slightly plantarflexed. (c) Skin closure
Typically the toe is held in a slightly overcorrected a­ ttitude
6 Plantar Plate Instability 63

6.7 Metatarsal Osteotomy 6.8 Triplane Correctional

Metatarsal Osteotomy
The shortening Weil metatarsal osteotomy is
described in detail within the relevant chapter. Crossover toe correction can be performed in a
When appropriate, the metatarsal osteotomy is sequential manner. The following steps are for a
completed prior to correction of the plantar plate. dorsomedial crossover toe deformity.
Some subtle modifications of this utilitarian oste- A standard curvilinear incision is performed
otomy can be applied to aid in correction of plantar over the affected MTP. Dissection is carried
plate pathology and crossover toe deformities. Mild down through the superficial fascia cauterizing
abnormalities in the metatarsal parabola can exac- superficial vessels. Care is taken specifically to
erbate the force through the pertinent MTP and isolate the medial collateral ligaments as well as
result in chronic plantar plate deformity and pain lateral collateral ligaments. With this deformity,
when the deformity only involves the sagittal plane the lateral collateral ligament is typically attenu-
a shortening Weil osteotomy. More commonly, ated, while the medial collateral ligament is
especially in the instance of the crossover toe, trans- ­contracted [9]. Once this is performed, a dorsal
verse plane deformity is present. One option is to transverse tenotomy and MTP capsulotomy are
perform a standard Weil osteotomy with typically performed which allow for reduction in the sagit-
shortening of 2–3 mm, but prior to fixation the capi- tal plane. Next, care is taken to transect the
tal fragment can be translated up to 50% (with care medial and lateral collateral ligaments in the mid-­
taken not to rotate the cartilaginous surface) to substance of the ligament. If the collateral liga-
assist in relocating the toe to a neutral position in ment is transected too close to the phalanx, then
the transverse plane. In the example of a medial there will be very little collateral ligament to
crossover toe, the capital fragment is translated repair. This is most acutely important on the lat-
medially, and in a laterally deviated deformity, the eral aspect of the MTP.
capital fragment is translated laterally. Ancillary Next, the dorsal aspect of the metatarsal head
procedures are often involved, regardless of the is cleared of capsular tissue with the rongeur or
presence of transverse plane deformity. The exten- sharp blade. An osteotomy is then performed at
sor tendons can be Z-lengthened or tenotomized the metatarsal neck about 3–4 mm proximal to
based on surgeon preference. The authors typically the dorsal cartilage. The sagittal sawblade is
perform a tenotomy or lengthening of the extensor angled dorsal to plantar toward the deformity of
digitorum longus and brevis as they are a strong the toe, most commonly medially. Typically, the
deforming force. The dorsal capsule is often con- surgeons recommend also slight angulation prox-
tracted and a sagittal plane deforming force, so a imal to distal. The capital fragment is then trans-
capsulotomy is essential to perform the osteotomy lated: medial, proximal, and dorsal. The
and lesser toe correction; however, as appropriate a recommended amount of translation is typically
dorsal capsulotomy can be considered regardless of one third of the width of the metatarsal, or about
the requirement for an osteotomy. When fixating 3 mm. The osteotomy lends itself to a screw
the osteotomy, the authors prefer two points of fixa- being placed from medial distal to lateral proxi-
tion to prevent rotation of the capital fragment, mal. The capital fragment is first temporarily fix-
especially when medial (or lateral) translation is ated with a small K-wire and visualized under
employed. Final position is then confirmed on intraoperative fluoroscopy. The MTP should be
intraoperative fluoroscopy for translation and cor- relocated and a clear joint line should be seen.
rection. The redundant dorsal metatarsal is then The digit should be seen well aligned with the
resected with a small bone cutter or rongeur. capital fragment. The capital fragment is then fix-
Upon closure, the MTP capsule is not closed, ated with a small cannulated screw or snap-off
as this will cause a reformation of the deformity. screw. The redundant lateral metatarsal neck is
Closure is performed in layers based on surgeon’s not typically resected, as this will inherently
preference. remove the remaining lateral collateral ligament.
64 J. E. McAlister and M. A. Prissel

The toe is then held in an appropriate position, daging the affected digit and surgical site in slight
and the lateral collateral ligament is repaired with plantar flexion with these procedures is para-
a 2-0 nonabsorbable suture. The operative pearl mount (Fig. 6.5a, b). Specific to these procedures,
during this procedure is to place the lateral col- the authors recommend a period of non-weight-­
lateral ligament repair on the plantar lateral bearing approximately 7–10 days and then transi-
aspect of the MTP. Typically, only one suture is tioning the patient to a pneumatic walking
needed. The MCL is not repaired. The authors do boot with protected weight-bearing until week 6.
not routinely use K-wires during this approach, A removable stabilizing splint can be applied to
and this avoids necessity of K-wires traversing maintain slight plantarflexion position and stabil-
the MTP and possibly causing a AVN or arthritis ity. Sutures are then removed based on patient’s
(Fig. 6.4a–c). healing potential and when the incisions have
The incision is then closed in layers with healed appropriately. At week 6, the patients are
absorbable sutures and skin closure based on sur- transitioned back into a stiff-soled athletic shoe
geon’s preference. and physical therapy initiated to aid in range of
motion and gait. A main focus of physical ther-
apy is to prevent dorsal scar contractures and
6.9 Postoperative Protocol maintain appropriate motion in plantarflexion, as
normal walking will provide appropriate motion
This surgery falls into postoperative protocol #2. for dorsiflexion. Custom fabricated orthoses are
The standard dressing applied to the operative typically fashioned at 6–8 weeks postoperative.
limb is a sterile well-padded Jones compression Serial radiographs are used to confirm healing of
dressing with posterior splint. Appropriately ban- the osteotomies and that no complications

Fig. 6.4 (a) Transverse plane deformity may also be cor- deformity. The collateral ligaments are repaired appropri-
rected as seen here. This illustration depicts an angular ately. (b) Anteroposterior preoperative and postoperative
osteotomy in the metadiaphyseal portion of the distal (c) weight-bearing radiographs of a strictly transverse
metatarsal. This angled cut is made perpendicular to the plane deformity corrected with an oblique osteotomy
proximal phalanx and is shifted in the direction of the
6 Plantar Plate Instability 65

b c

Fig. 6.4 (continued)

a b

Fig. 6.5 (a) Clinical photograph 1 week postoperative (b) Clinical photograph 1 week postoperative demonstrat-
demonstrating intentional positional overcorrection of the ing incision placement and suturing technique for wound
second toe. Note dorsal Weil osteotomy incision does incisional closure
not extend beyond the MTP joint or onto the second toe.
66 J. E. McAlister and M. A. Prissel

have occurred. Patients are appropriately fol-

lowed for 6–12 months for maintenance of cor- Pearls, Pitfalls, and Resident Resource
rection and improved functional outcome • When performing a metatarsal osteot-
measures (Figs. 6.6a, b and 6.7a, b). omy and hammertoe correction along
with a plantar plate repair, the osseous
procedures (i.e., hammertoe and meta-
tarsal osteotomy) should be performed
a
prior to the plantar plate repair to mini-
mize the risk of attenuating the repair.
• Dorsal incisional planning is critical.
The advantage of the direct plantar
approach is that the dorsal incision can
be strategically placed and minimal as
extensive dorsal dissection is not
required. A Weil osteotomy can be prop-
erly performed with an incision that
does not extend distally beyond the
MTP (i.e., extension onto the toe is not
necessary and can increase iatrogenic
dorsal contracture). If extending across
the MTP, a curvilinear incision is the
most important aspect of the technique,
which prevents contracture over the
MTP. In revision cases, a V-to-Y or
Z-plasty is commonly utilized to correct
for soft tissue contractures.
• With a shortening metatarsal osteotomy,
Weil osteotomy, only 2–3 mm of decom-
b
pression is necessary for adequate cor-
rection. A shortening Weil osteotomy
can be translated up to 50%. Especially
when translated, consideration for two
points of fixation is warranted.
• With a triplanar correctional metatar-
sal osteotomy (TCMO), translate at
least one third of the width of the
metatarsal. The capital fragment can
also be translated dorsally approxi-
mately 1–2 mm.
Fig. 6.6 (a) Clinical photograph of same patient in Fig. 6.5
• An easy way to determine the angle of
3 months postoperative demonstrating barely visible
mature plantar incision without hyperkeratotic formation. the TCMO is to face the sagittal saw in
(b) Clinical photograph of same patient in Fig. 6.5 3 months the direction of the deformed digit.
postoperative demonstrating appropriate alignment and • The translational triplanar angular
purchase of the second toe. Note the dorsal incision for the
osteotomy of the metatarsal can also
Weil osteotomy is more visible than the plantar approach
plantar plate repair incision
6 Plantar Plate Instability 67

be utilized for a lateral crossover toe as • Interestingly in cases where both dorsal
well. This can be accomplished by per- and plantar incisions are utilized, the plan-
forming the techniques in reverse tar incision actually heals with less hyper-
attitude. trophy and is more difficult to visually
• Weight-bearing is allowed at 7–10 days appreciate. The heavy plantar epidermal
following surgery with boot immobiliza- layer typically sloughs at approximately
tion and removable splintage of the 6 weeks, revealing an underlying thin and
affected toe. supple mature scar.

a b

Fig. 6.7 Clinical photographs 3 months postoperative does not extend across the MTP or onto the second
dorsal (a) depicting mature incisional healing of trans- toe with appropriate deformity correction and plantar (b)
verse converging semielliptical second digit incision for depicting mature, healed, barely visible incision for sec-
PIP fusion and separate Weil osteotomy incision which ond MTP plantar plate repair with direct plantar approach
68 J. E. McAlister and M. A. Prissel

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4. Deland JT, Sung IH. The medial crossover toe: a cadav-
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eric dissection. Foot Ankle Int. 2000;21(5):375–8.
876–85.
5. Deland JT, Lee KT, Sobel M, DiCarlo EF. Anatomy
14. Prissel MA, Hyer CF, Donovan JK, Quisno
of the plantar plate and its attachments in the
AL. Plantar plate repair using a direct plantar
lesser metatarsal phalangeal joint. Foot Ankle Int.
approach: an outcomes analysis. J Foot Ankle Surg.
1995;16(8):480–6.
2017;56(3):434–9.
6. Devos Bevernage B, Deleu PA, Leemrijse T. The
15. Roukis TS, Landsman AS. Hypermobility of the first
translating Weil osteotomy in the treatment of an
ray: a critical review of the literature. J Foot Ankle
overriding second toe: a report of 25 cases. Foot
Surg. 2003;42(6):37–390.
Ankle Surg. 2010;16(4):153–8.
16. Rush SM, Christensen JC, Johnson CH. Biomechanics
7. Doty JF, Coughlin MJ. Hallux valgus and hypermo-
of the first ray. Part II: metatarsus primus varus as a
bility of the first ray: facts and fiction. Int Orthop.
cause of hypermobility. A three-dimensional kine-
2013;37(9):1655–60.
matic analysis in a cadaver model. J Foot Ankle Surg.
8. Ellis SJ, Young E, Endo Y, Do H, Deland JT. Correction
2000;39(2):68–77.
of multiplanar deformity of the second toe with meta-
17. Trnka HJ, Nyska M, Parks BG, Myerson
tarsophalangeal release and extensor brevis recon-
MS. Dorsiflexion contracture after the Weil
struction. Foot Ankle Int. 2013;34(6):792–9.
­osteotomy: results of cadaver study and three-dimen-
9. Goforth WP, Overbeek TD, Odom RD, Roe TG,
sional analysis. Foot Ankle Int. 2001;22(1):47–50.
McDonald DK. Lesser-metatarsal medial displace-
 1st MTP Fusion: Primary
and Revision
7
William T. DeCarbo and Michael D. Dujela

7.1 Introduction risk the potential for residual pain and need for
revision surgery in the future. If the patient is not
The gold standard surgical management of tolerant of the potential for revision or additional
advanced degenerative 1st metatarsophalangeal procedures, 1st MTP fusion should be the index
arthritis is arthrodesis. Additionally, geriatric operation for moderate to severe degenerative
patients with hallux valgus deformities are well arthritis.
served by fusion of the 1st MTP joint which pro-
vides a definitive solution with a high rate of suc-
cess. The primary benefit of fusion is resolution 7.2  atient History and Physical
P
of pain, increased stability of the entire medial Examination
column, and enhanced gait [1]. Refinement of
fusion alignment and fixation has resulted in a A thorough history and physical examination is
dependable, reproducible procedure with high performed. The history should elicit whether pain
patient satisfaction [2]. is present throughout range of motion or primar-
An important consideration in the decision-­ ily at end range of motion. Specific triggers such
making in surgical management of hallux rigidus as flexible shoe gear, elevated heels, or impact
or deformity patients is to determine a patient’s activities should be noted. It is important to
tolerance for more than one surgery. In some assess whether there is a history of a single trau-
instances, a patient with moderate to significant matic episode, episodic injuries, or chronic recur-
arthritis may be a good candidate for an attempt rent abuse such as specific sports or dance. An
at joint preservation via cheilectomy. The discus- important consideration is whether there is a his-
sion should center around the probability for pro- tory or physical findings consistent with an
gression of the disease and high likelihood of inflammatory arthropathy which could increase
additional surgery in the future. Through mutual the risk of healing complication such as non-
agreement, a determination of whether a patient union. This may impact the choice of fixation.
is a “one and done” personality or is willing to The patient is evaluated while both weight-­
bearing and non-weight-bearing. Specific atten-
tion is given to quantitative range of motion of
W. T. DeCarbo (*) the 1st MTP, quality of motion, and level of dis-
St. Clair Hospital, Department of Podiatric Surgery, comfort elicited with palpation and motion. It is
Pittsburgh, PA, USA
important to differentiate true structural limita-
M. D. Dujela tion versus functional hallux limitus/rigidus
Washington Orthopaedic Center, Centralia, WA, USA

© Springer Nature Switzerland AG 2019 69

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_7
70 W. T. DeCarbo and M. D. Dujela

which occurs during gait only. True structural not validated, it remains useful as it guides deci-
limitus is associated with altered morphology of sion-making when combined with the clinical
the joint including narrowing and marginal osteo- findings. Another classification was proposed by
phyte formation that restricts joint motion. Coughlin and Shurnas and combines radio-
Functional limitus is due to altered first ray graphic assessment of osteophytes with clinical
mechanics or soft tissue restriction. range of motion [4]. This is sufficient for the vast
Joint-preserving procedures such as cheilec- majority of patients; however, in patients with
tomy are best reserved for pain at end range of significant deformity, prior trauma, or bone loss,
motion or mild to moderate disease primarily a CT scan is a valuable adjunct. When patients
affecting the dorsal one-third of the articular sur- present with vague pain and minimal radio-
face. When pain and in many cases crepitus is graphic findings, an MRI can often elucidate
present at various points throughout the arc of whether a subtle osteochondral defect or plantar
motion, rather than exclusively at maximum dor- sesamoid disease is present as evidenced by car-
siflexion, cheilectomy is contraindicated. tilage loss, cystic formation, and bone marrow
Significant pain, limitation of dorsiflexion, edema.
antalgic gait as well as radiographic features con-
sistent with degenerative arthritis are indications
for fusion. It is important to assess dorsiflexion 7.4 OR Setup/Instrumentation/
and plantarflexion as well as plantar MTP tender- Hardware Selection
ness which can indicate metatarsal-sesamoid dis-
ease. Prognosis is poor with cheilectomy alone in The patient is placed in a supine position with a
the presence of arthritic sesamoid involvement. bump under the ipsilateral hip so the foot and
It is crucial to evaluate for presence of defor- ankle are rectus on the operating room table. A
mity, crepitus, and edema and to assess the qual- thigh tourniquet is utilized to keep the surgical
ity of range of motion of adjacent joints. Specific field clear from the drapes. General anesthesia is
attention is given to the 1st tarsometatarsal and preferred with a popliteal block to reduce postop-
hallux interphalangeal joints to determine if erative pain.
arthritis, deformity, or pain is present which may The preferred instrumentation is power driv-
be magnified after 1st MTP fusion. ers with cup and cone reamers. The preferred
Weight-bearing static analysis is performed to fixation technique is a dorsal locking plate/screws
assess for associated deformity or malalignment. with a 3.0 cannulated screw used for interfrag-
Gait analysis is performed to assess if lateral mentary compression.
overload is occurring due to compensation sec-
ondary to pain during propulsion.
7.4.1 Operative Technique

7.3 Imaging and Diagnostic Once the patient is prepped and draped in nor-
Studies mal fashion, attention is directed to the dorsal
medial aspect of the fist metatarsophalangeal
A complete series of weight-bearing radiographs joint. A full-thickness incision is made just
in angle and base of gait is the gold standard for medial to the extensor hallucis longus tendon
evaluation of 1st MTP osteoarthritis or deformity. approximately 5 cm in length (Figs. 7.1 and 7.2).
The most commonly used classification proposed Full-thickness dissection without layers is com-
by Hattrup and Johnson describes the presence of pleted through the capsule. Hemostasis is
osteophytes, joint space narrowing, sclerosis, and achieved with electrocautery, and care is taken
cystic formation [3]. While this classification is to protect the medial dorsal cutaneous nerve.
7 1st MTP Fusion: Primary and Revision 71

Fig. 7.2 Dorsal medial incision

Fig. 7.1 Dorsal medial incision

Once the joint is accessed, a self-retaining

retractor is utilized (Figs. 7.3 and 7.4). A sagittal
saw is used to resect the medial, lateral, and dor-
sal exostosis off the 1st metatarsal head (Figs. 7.5
and 7.6). These portions of the bone are removed
and passed from the operative site. Attention is
then directed to the base of the proximal phalanx
where any bony exostoses are removed with a
rongeur. Care is taken to preserve the integrity of
the base of the proximal phalanx and to maintain
the cortical integrity to allow stable apposition
with the head of the 1st metatarsal. Cup and
cone reamers are then utilized to denude any
remaining cartilage from the head of the 1st
metatarsal and base of the proximal phalanx and
Fig. 7.3 Full-thickness subperiosteal dissection
72 W. T. DeCarbo and M. D. Dujela

Fig. 7.6 Medial eminence removed with a sagittal saw

to debride the subcondral bone plate and decom-

Fig. 7.4 Access into the joint press the joint to facilitate positioning of the 1st
MTP and reduction of deformity without inter-
ference of any soft tissue-­deforming forces. A
guide wire is placed in the central aspect of the
1st metatarsal head and driven into the medul-
lary canal (Figs. 7.7 and 7.8). The appropriate-
sized cup reamer which closely matches the
contour and size of the 1st metatarsal head is
chosen. This is usually an 18 mm, 20 mm, or
22 mm cup reamer. The cup is then placed over
the guide wire to denude the articular surface of
the 1st metatarsal (Figs. 7.9 and 7.10). Care is
taken to gently debride this area again being
mindful to maintain the integrity of the bone.
Excessive pressure may result in inadvertent
shortening, particularly in patients with poor
quality bone. Once completed, a rongeur is used
to remove any remaining bone prominences
from the 1st metatarsal head. The guide wire is
then removed and utilized to fenestrate the 1st
Fig. 7.5 Dorsal exostosis removed with a sagittal saw metatarsal head (Fig. 7.11). An alternative is a
7 1st MTP Fusion: Primary and Revision 73

Fig. 7.7 Guide wire for cone reamer placed in center of

1st metatarsal head

Fig. 7.9 Cone reamer utilized to denude remaining artic-

ular cartilage

Fig. 7.10 1st metatarsal head of cone reamer

Fig. 7.8 Guide wire for cone reamer placed in center of
1st metatarsal head extending down metatarsal canal
74 W. T. DeCarbo and M. D. Dujela

Fig. 7.11 1st metatarsal head fenestrated with a drill tip

wire

Fig. 7.13 Cup reamer is used to denude cartilage. Hallux

must be in maximal plantarflexed position to avoid the
reamer hitting the 1st metatarsal head

more concave plantarly, the guide wire is placed

slightly dorsal to the center point of the joint
(Fig. 7.12). The corresponding size to the cup
reamer is used to denude the cartilage/subchon-
dral bone of the base of the proximal phalanx.
Care is taken to maintain the integrity of the cor-
tical base of the phalanx to ensure good apposi-
tion of the joint and to accept the land of the
interfragmentary screw for compression
(Figs. 7.13 and 7.14). Once the cone is com-
pleted, the guide wire or drill bit is again used to
fenestrate the base of the proximal phalanx
(Fig. 7.15). Once complete, a ¼ inch osteotome
is used to “fish-scale” both the head of the 1st
Fig. 7.12 Guide wire for cup reamer placed
metatarsal and the base of the proximal phalanx
small diameter drill bit such as a 2.0 to penetrate (Fig. 7.16). This has to be done gently to create
the subchondral plate. The guide wire is then bleeding surface areas of cancellous bone, how-
placed into the base of the proximal phalanx of ever with care taken to avoid completely frag-
the hallux to align the cone reamer. Because of menting the site where the morphology is altered
the morphology of the proximal phalanx being creating uneven fit.
7 1st MTP Fusion: Primary and Revision 75

Fig. 7.16 1st metatarsal head “fish-scaled”

Fig. 7.14 Careful attention is taken to maintain the corti-

cal rim of the base of the proximal phalanx

Fig. 7.17 Prepared 1st metatarsal head

A straight plate is preferred for the 1st MTP

fusion. A pearl for alignment is to reduce the
prepared 1st MTP joint and place the 1st MTP
Fig. 7.15 Base of the proximal phalanx fenestrated with straight fusion plate dorsally spanning the area
drill tip wire (Fig. 7.17). If the plate does not sit flush, a
76 W. T. DeCarbo and M. D. Dujela

Fig. 7.18 Plate positioned with temporary fixation pins

to set the proper fist MTP alignment. Guide wire for intra-­
fragmentary screw placed while dorsal plate is setting the
position

r­ongeur can be utilized to remove any bony

prominences. Once the plate sits flush over the
dorsal segment, it is temporarily stabilized with
provisional fixation. This ensures the correct Fig. 7.19 Guide wire can be thrown under C-arm
alignment of the 1st MTP. The guide wire for the fluoroscopy
3.0 cannulated screw is then placed across the
joint for interfragmentary compression. This will not be pulled out by the over-drill during this
wire can be placed from any orientation to cross step. The screw is then inserted over the wire into
the joint. The authors’ preferred orientation is two-finger tightness (Fig. 7.19). Care is taken not
from the medial base of the proximal phalanx to to over-tighten the screw and lose the compres-
the lateral cortex of the 1st metatarsal (Figs. 7.17 sion/stability of the fixation. A 3.0 mm cannu-
and 7.18). Once the guide wire is placed, the lated screw is chosen to allow as much bone
dorsal plate can either be completely removed or surface apposition between the base of the proxi-
the surgeon can just remove one of the provi- mal phalanx and the 1st metatarsal head as pos-
sional fixation pins to allow joint compression as sible for bony trabeculation. That said, a 4.0 mm
the screw is inserted. screw can also be used per the surgeon’s
The guide wire is measured for appropriate preference.
screw size allowing a bi-cortical bite for added Once the interfrag screw is placed, the dorsal
compression and stability. Another pearl is once 1st MTP plate is reapplied with bi-cortical lock-
the wire is measured to advance the wire through ing screws (Figs. 7.20 and 7.21).
the lateral cortex of the 1st metatarsal and attach Deep and subcutaneous layers are closed
a hemostat to the wire. This will ensure the wire with absorbable suture and the skin with nylon or
7 1st MTP Fusion: Primary and Revision 77

Fig. 7.22 Final construction with interfragmentary screw

and locking plate

Fig. 7.20 Intra-fragmentary screw placed. The distal

provisional fixation pin is removed to allow compression surgeon’s preference (Fig. 7.22). A well-padded
Jones compression dressing with posterior splint
is applied (Figs. 7.23, 7.24, 7.25, and 7.26).

7.4.2 Revision Surgery

For revision surgery of the 1st MTP, the same

setup and surgical approach as described above
is utilized. The primary difference in the tech-
nique is removing all previous hardware and
nonviable bone. Attention has to be made to
restore any bone segmental loss at the nonunion
or malunion site.
If a nonunion or malunion occurs with mini-
mal bone loss, a revision surgery can be per-
formed in a straightforward fashion similar to the
primary surgery (Figs. 7.27, 7.28, and 7.29).
Consideration should be given to the selection of
alternative fixation choices for the revision
surgery.
In cases where there is or will be substantial
bone loss due to the revision, the length of the
Fig. 7.21 Locking screw placement into the plate first ray must be maintained. This is typically
78 W. T. DeCarbo and M. D. Dujela

Fig. 7.23 Final closure and clinical position

done with bone grafting. The surgeon can use Figs. 7.24 and 7.25 AP and lateral pre-op x-rays
either autogenous bone from the iliac crest or cal-
caneus or allograft bone from the bone bank. The
authors prefer allograft iliac bone to minimize and the fibrous tissue is resected until bleeding
second-site morbidity in the patients. bone margins are obtained. The graft, if needed, is
Once the joint is exposed in the fashion previ- then fashioned to fit the defect while maintaining
ously described, all of the current hardware is the appropriate length of the first ray and ensuring
removed. The non- or malunion site is assessed, good bone to graft apposition of the graft-1st
7 1st MTP Fusion: Primary and Revision 79

Figs. 7.26 and 7.27 AP and lateral post-op x-rays

metatarsal and graft-base interface of the proximal

phalanx (Figs. 7.30, 7.31, 7.32, and 7.33). Often a
longer more robust plate is utilized in revision
cases (Fig. 7.34). If possible an interfragmentary
compression screw is again utilized not only to
provide compression across the bone segments but
also to provide stability to the graft and prevent Figs. 7.28 and 7.29 AP and lateral x-ray of a mal-/non-­
any shear forces at the graft-bone interfaces. union 1st MTP
80 W. T. DeCarbo and M. D. Dujela

Fig. 7.30 Clinical photo of malunion with abnormal

pressure at the tip of the hallux

Fig. 7.32 Size of graft determined once deformity and

fibrous tissue resected

Fig. 7.33 Graft fashioned according to bone defect and

Fig. 7.31 Osteotomy made at the apex of the deformity placed into bone void
7 1st MTP Fusion: Primary and Revision 81

Fig. 7.37 Photo of clinical alignment depicting toe pur-

chase with lack of abnormal pressure at tip of the hallux
Fig. 7.34 Intraoperative picture with plate spanning the
joint and bone graft

Once the bone segments are compressed and

stabilized, a dorsal locking plate is utilized to
span the surgical site. External fixation may be
considered or needed if the amount of bone resec-
tion required does not allow for appropriate inter-
nal fixation (Figs. 7.35, 7.36, and 7.37).

7.5 Postoperative Management

The initial postoperative dressing applied in the

operating room consists of a well-padded sterile
dressing with a modified Jones compression
dressing and posterior splint. The patient is seen
for first postoperative visit between 10 and
14 days after the procedure, and sutures are
removed. Radiographs are taken at this visit to
confirm appropriate alignment and hardware
placement. The patient is placed in a full-length
fracture (cam) walker, and if the wound is dry
and stable, full heel-touch weight-bearing is
encouraged, and gentle forefoot pressure (weight
of leg) is possible to tolerate with crutch or
walker assistance. The patient is encouraged to
remove the boot several times per day to work on
foot and ankle ROM exercises.
Several studies have shown high union rate
with immediate weight-bearing after this tech-
nique. Berlet and Hyer reported 91% clinical and
radiographic union in 37 patients after immediate
weight-bearing protocol for 1st MTP arthrodesis
[5]. After sutures are removed, the patient may
Figs. 7.35 and 7.36 AP and lateral post-op x-rays progress to full WB as tolerated while wearing
82 W. T. DeCarbo and M. D. Dujela

the boot. Radiographs are repeated at 6 weeks ideal to discuss potential need for hardware
post-op, and patient may gradually transition removal during the preoperative consent visit.
back to a supportive shoe with orthotic support or A pseudoarthrosis can occur after 1st MTP
carbon fiber insert when there is radiographic arthrodesis, and while this may be well tolerated
evidence of early consolidation. Patients are fol- in many patients, over time fatigue failure of the
lowed for 6–12 months postoperatively to ensure plate can occur. When the fixation or surrounding
satisfactory outcome. bone fails, the previously asymptomatic fusion
site may become symptomatic and require
­revision. Careful observation is indicated with
7.6 Potential Complications serial radiographs recommended for the first
12–18 months in these cases. Nonunion is rare
Complications are similar to arthrodesis proce- and the frequency has traditionally been over-
dures at other locations in the foot and can be stated. This is typically due to poor apposition of
divided into the following categories: the arthrodesis site, insufficient joint preparation,
or inappropriate fixation. Poor intrinsic patient
1. Malunion factors such as a vitamin D deficiency or dense
2. Nonunion neuropathy can increase the risk of nonunion.
3. Hardware-associated complications Lifestyle factors such as poor nutrition, alcohol
abuse, or smoking can also increase the risk of
Malunion – Position is key to a successful nonunion. A systematic review of the literature
outcome after 1st MTP arthrodesis. The defor- by Roukis et al. demonstrated an overall non-
mity can be over or under corrected, and trans- union rate of 5.4%; however the rate of symptom-
verse plane adduction can result in excessive atic nonunion was only 1.8% [7]. With appropriate
pressure to the distal medial hallux resulting in joint preparation, modern fixation techniques,
poor tolerance of shoe wear. In the case of a sig- and recognition of patient factors that can be
nificant hallux valgus deformity, residual modified, the rate of nonunion is very low.
malalignment can remain when the deformity is
under corrected. Recent studies have demon-
strated that a significant reduction in the hallux Pearls
valgus angle and IM 1–2 can occur [6]; however 1. Cup and cone reamer allows positioning
if the intermetatarsal angle is beyond the limits and deformity correction in all three
of the procedure, correction may be insufficient planes.
and a residual deformity may persist. Care is 2. Must denude all cartilage through the
taken to parallel the second toe, but to avoid subchondral bone plate, fenestrate and
pressure against it which can result in an over- fish-scale. “Make it look like a bomb
lapping second digit or ulceration between the went off.”
toes. Excessive dorsiflexion can result in over- 3. Use dorsal plate to “set” the position of
load to the 1st metatarsal and sesamoid appara- the 1st MTP.
tus, as well as hammering of the hallux at the 4. Attach hemostat to intra-fragmentary
IPJ. Insufficient dorsiflexion will result in exces- guide wire above measuring to prevent
sive pressure to the distal hallux and potential wire being removed by the over-drill.
for IPJ pain and arthritis. There is increased risk 5. Remove one of the dorsal plate tempo-
of distal skin lesions that may progress to rary fixation pins when inserting intra-
ulceration. fragmentary screw for compression.
Hardware pain – A dorsal plate can be irritat- 6. A thin carbon fiber insert post-op can
ing and palpable requiring removal in a moderate stress from the surgical site until com-
percentage of patients. This is quite common in plete union is achieved.
females with minimal subcutaneous fat, and it is
7 1st MTP Fusion: Primary and Revision 83

References 4. Coughlin MJ, Shurnas PJ. Soft-tissue arthroplasty for

hallux rigidus. Foot Ankle Int. 2003;24(9):661–72.
5. Berlet GC, Hyer CF, Glover JP. Retrospective
1. Brodsky JW, Baum BS. Prospective gait analy-
review of immediate weightbearing after first meta-
sis in patients with first metatarsophalangeal joint
tarsophalangeal joint arthrodesis. Foot Ankle Spec.
arthrodesis for hallux rigidus. Foot Ankle Int.
2008;1(1):24–8.
2007;28(2):162–5.
6. McKean RM, Bergin PF, Watson G, et al. Radiographic
2. Goucher NR, Coughlin MJ. Hallux metatarsophalan-
evaluation of intermetatarsal angle correction follow-
geal joint arthrodesis using dome-shaped reamers and
ing first MTP joint arthrodesis for severe hallux val-
dorsal plate fixation: a prospective study. Foot Ankle
gus. Foot Ankle Int. 2016;37(11):1183–6.
Int. 2006;27(11):869–76.
7. Roukis TS. Nonunion after arthrodesis of the first
3. Hattrup SJ, Johnson KA. Subjective results of hallux
metatarsal-phalangeal joint: a systematic review. J
rigidus following treatment with cheilectomy. Clin
Foot Ankle Surg. 2011;50(6):710–3.
Orthop Relat Res. 1988;(226):182–91.
 Interpositional Arthroplasty for
the First Metatarsophalangeal Joint
8
Patrick E. Bull, James M. Cottom,
and Geoffrey Landis

8.1 Introduction technique also resurfaces the metatarsosesamoid

joints, which are left untreated by nearly all other
Treatment of advanced first metatarsophalangeal surgical treatments and have potential to produce
joint (MTPJ) arthritis has many options. Choosing postoperative pain [2]. In this chapter we will
the appropriate treatment strategy for first MTPJ review our preferred method for first MTPJ inter-
arthritis is dependent upon many factors. The use positional arthroplasty utilizing an allograft
of an interpositional arthroplasty is an attractive regenerative tissue matrix (RTM).
option for younger and active patients with severe
(Coughlin and Shurnas Grade III and IV) MTPJ
arthritis as it preserves motion and avoids the 8.2 Patient History/Preoperative
activity limitations, restricted shoewear options, Work-Up/Case Examples
and stiffness associated with arthrodesis [1–5].
Interposition arthroplasty procedures allow the Patients with advanced hallux rigidus consis-
surgeon to successfully address both the pain and tently present with progressively worsening first
discomfort resultant from arthritic first MTPJ MTPJ pain, swelling, and stiffness. Patients will
changes without compromising joint bone stock, complain of reduced quality of life due to MTPJ
metatarsal length, and joint stability as are com- pain-mediated restriction of weight-bearing
monly encountered after joint hemi- and total activities. Stiff shoe insoles, oral and/or topical
arthroplasty [2, 3]. Furthermore, joint arthrode- pain relievers, and even intra-articular cortico-
sis complications such as nonunion, among steroid injections may have been utilized to tem-
­others, are avoided [2, 6]. In addition, interposi- porarily reduce symptoms. Many cases will have
tion arthroplasty techniques allow for future a history first MTPJ trauma, with some injuries
­arthroplasty or arthrodesis at a later date should being surprisingly remote. Patients may have
further joint deterioration occur [2]. Lastly, our already undergone first MTPJ surgery, albeit
unsuccessfully. Lastly, it is not uncommon to
have hallux MTPJ deformity and lesser MTPJ
P. E. Bull (*) transfer pathology coincident with advanced hal-
Orthopedic Foot & Ankle Center,
lux rigidus.
Worthington, OH, USA
Physical exam classically reveals a first
J. M. Cottom
MTPJ with obvious (Fig. 8.1) and tender dorsal
Florida Orthopedic Foot & Ankle Center,
Sarasota, FL, USA osteophytes, restricted passive joint motion, most
notably in dorsiflexion, and MTPJ pain with hal-
G. Landis
Northwest Medical Center/Oro Valley Hospital, lux weight-bearing during propulsion.
Department of Orthopedic Surgery, Tucson, AZ, USA Comparison to the contralateral hallux, if unaf-

© Springer Nature Switzerland AG 2019 85

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_8
86 P. E. Bull et al.

sary in the setting of obvious advanced radio-

graphic joint destruction changes.
Injections are often utilized during the nonsur-
gical treatment phase of advanced hallux rigidus.
Beyond strengthening the diagnosis, corticoste-
roid injection also can provide a substantial
period of pain relief. Multiple injections are dis-
couraged as thinning of the subdermal fat can
sometimes result, and, therefore, complicate
future incisional healing.

8.3 Surgical Technique

The surgery is performed with the patient supine

and the heel at the end of the bed. An ipsilateral
hip bump is typically utilized. Monitored anes-
thesia and an ultrasound-guided popliteal
regional nerve block together provide pain relief,
and a thigh tourniquet provides intraoperative
hemostasis. Special equipment to have available
includes Hewson suture passers and standard cup
and cone reamers used for first MTPJ arthrodesis
procedures. Two excellent RTM options include:
GRAFTJACKET Matrix (Wright Medical
Fig. 8.1 Pre-operative photo with dorsal joint promi-
Technology Inc., Memphis, Tennessee, and
nence due to underlying osteophytes
ArthroFLEX®, Arthrex Inc., Naples, Florida).
A standard dorsal approach to the first MTPJ is
fected, can be used to quantify the percentage of utilized. The incision is made slightly medial to the
motion restriction. extensor hallucis longus (EHL) tendon and cen-
Commonly, standard weight-bearing foot tered over the jointline. The interval between the
radiographs are used to assess hallux rigidus. As EHL and the dorsomedial neurovascular bundle is
the degree of joint space narrowing and size and identified. Gentle blunt retraction protects both
number of periarticular osteophytes increases, so structures, and a capsulotomy is performed in line
does the condition’s grade/class. Advanced dis- with the incision. Medial and lateral capsular liga-
ease is typically defined radiographically as a ments are subperiosteally released proximally fol-
first MTPJ with osteophytes dorsally, medially, lowed by a thorough joint synovectomy (Fig. 8.2).
and laterally, involving the sesamoid articula- Despite adequate capsular release, substantial joint
tions with moderate to severe joint space loss [1]. stiffness often remains; therefore, a McGlamry
Radiographs will reveal evidence of previous sur- elevator is passed plantarly, and through the meta-
gical intervention and can be used to quantify tarsal-sesamoid joints, to release adhesions and
coincident joint malalignment and deformity. fibrosed sesamoid suspensory ligaments (Fig. 8.3).
Magnetic resonance imaging (MRI) may be indi- The joint exposure is now complete.
cated if attempts at cartilage restoration surgery Periarticular osteophytes are removed with the
are being considered, but it typically is not neces- ultimate goal of achieving a spherical metatarsal
head while minimizing metatarsal shortening.
8 Interpositional Arthroplasty for the First Metatarsophalangeal Joint 87

Fig. 8.2 MTPJ has been released yet sustanstial contrac-

tures continue to limit exposure, especially in flexion
b

Fig. 8.4 Cheilectomy has been performed and head

reamer guidewire has been placed

medullary guidewire (Figs. 8.4a, 8.5, and 8.6a).

The prepared head is then drilled to improve graft
bio-ingrown and incorporation (Fig. 8.6b). If
additional joint decompression is needed, a mod-
ified Keller proximal phalanx basilar osteotomy
could be considered. If utilized, disruption of
plantar capsule, flexor hallucis brevis insertions,
and plantar plate is avoided by minimizing plan-
tar bone resection during the Keller osteotomy
Fig. 8.3 McGlamery elevator utilized to release the plan- (Fig. 8.7b).
tar metatarsosesamoid joints and fascilitate full joint Securing the RTM graft to the prepared meta-
mobilization and exposure
tarsal head begins with placement of two vertical
drill holes, one medial and one lateral, through
Overaggressive cheilectomy is discouraged as the metatarsal and just proximal to the sesamoids
bone stock may be necessary for future opera- (Fig. 8.7b). Absorbable grasping sutures are
tions. A standard metatarsal head reamer is placed along one side of the graft (Figs. 8.7b
­ideally suited to shape the metatarsal, and it is and 8.8). Either looped wires (Fig. 8.9a) or
operated over a carefully placed retrograde intra- Hewson suture passers (Fig. 8.9b) can be utilized
88 P. E. Bull et al.

Fig. 8.5 Reamers are utilized to remove metatarsal head cartilage

a b

Fig. 8.6 The metatarsal head is drilled to fascilitate graft bio-ingrowth and incorporation
8 Interpositional Arthroplasty for the First Metatarsophalangeal Joint 89

Fig. 8.7 Drill holes are placed in the metatarsal neck being sure to remain proximal to the metatarsosesamoid articula-
tions. Shaded region of hallux phalanx in (b) indicates appropriate Keller osteotomy bone resection

to shuttle the grasping sutures under the metatar-

sal head taking care to orient the “shiny” reticular
graft surface to interface with the metatarsal
head. Tensioning these sutures draws the graft
into the metatarsal-sesamoid joints (Fig. 8.10).
Typically, one suture from each side is sutured to
the other to secure the graft. The remaining distal
graft is now draped dorsally and proximally to
cover the metatarsal head. Strategically placed
absorbable sutures are placed to pull the graft
tightly to the head. Securing to the previously
tied suture bridge works well (Figs. 8.11, 8.12,
8.13, and 8.14). Some small “dog-ears” may Fig. 8.8 Grasping sutures are placed through the leading
occur and should be trimmed. Once a snug con- edge of the graft to fascilitate plantar shuttling
90 P. E. Bull et al.

a b

Fig. 8.9 Looped wires (a) or Hewson suture passers (b) can be utilized to shuttle graft passing sutures from plantar to
dorsal throgh the metatarsal neck

8.4 Postoperative Care

Please refer to Chap. 1 for a complete descrip-

tion of all postoperative protocols. Patients are
discharged home with instructions to remain
­non-­weight-­bearing for the first week. After
initial follow-up, 7–10 days postoperatively,
progression to full weight-bearing in a remov-
able walking cast is allowed. Compression
spica dressings are utilized to minimize swell-
Fig. 8.10 Grasping sutures have been tensioned and graft ing that may cause pain and therefore delay
has been interposed into the metatarsosesamoid joints joint mobilization exercises. Patients are typi-
cally ready to transition to a stiffened shoe by
4 weeks postoperatively. Physical therapy
toured fit is achieved, passive range-of-motion is begins at this point and continues 4–6 weeks.
checked. If restriction is encountered that was not Transition to jogging and eventual aggressive
present prior to graft placement, one of the secur- activities requiring first MTPJ dorsiflexion and
ing sutures will likely need replaced. Confirm push-off can occur anywhere between 3 and
graft stability, and consider suturing the graft to 6 months.
the metatarsal head or adjacent capsule if graft
instability is observed. The joint is irrigated and
the capsule repaired with 0 caliber absorbable References
suture. Subdermal tissue is closed with 2-0
absorbable suture and skin with 3-0 nylon suture. 1. Coughlin MJ, Shurnas PS. Hallux rigidus. Grading
and long-term results of operative treatment. J Bone
A light compressive spica dressing is applied Joint Surg Am. 2003;85-A(11):2072–88.
under a protective Jones splint. 2. Berlet GC, Hyer CF, Lee TH, Philbin TM, Hartman
JF, Wright ML. Interpositional arthroplasty of the first
8 Interpositional Arthroplasty for the First Metatarsophalangeal Joint 91

a b

Fig. 8.11 Sutures are placed to secure the graft to the dorsal metatarsal head

a b

Fig. 8.12 Further suturing of the graft to the dorsal metatarsal

a b

Fig. 8.13 Dorsal view of the dorsal graft suturing technique

92 P. E. Bull et al.

a b

Fig. 8.14 Completed interposition clinical photograph and representative drawing

MTP joint using a regenerative tissue matrix for the

Intraoperative Pearls/Pitfalls treatment of advanced hallux rigidus. Foot Ankle Int.
2008;29(1):10–21.
It is our opinion that a common problem 3. Brage ME, Ball ST. Surgical options for sal-
related to this procedure is postoperative vage of end-stage hallux rigidus. Foot Ankle Clin.
stiffness due to overstuffing of the joint. This 2002;7(1):49–73.
can be avoided by adequately releasing and 4. Coughlin MJ, Shurnas PJ. Soft-tissue arthroplasty for
hallux rigidus. Foot Ankle Int. 2003;24(9):661–72.
decompressing the joint, using the modified 5. Hamilton WG, O’malley MJ, Thompson FM, Kovatis
Keller osteotomy if necessary, and by per- PE, Roger Mann Award 1995. Capsular interposition
forming frequent intraoperative passive arthroplasty for severe hallux rigidus. Foot Ankle Int.
ROM assessments. Do not expect ROM to 1997;18(2):68–70.
6. Johnson JE, Mccormick JJ. Modified oblique Keller
improve postoperatively. In addition, it is capsular interposition arthroplasty (MOKCIA) for
felt that postoperative joint malalignment treatment of late-stage hallux rigidus. Foot Ankle Int.
can occur due to poor intraoperative graft 2014;35(4):415–22.
control. Suturing the graft to the capsule and
into the metatarsal head can help stabilize
the graft and avoid this complication. Lastly,
it is critical that the graft be completely
interposed between the sesamoids and the
metatarsal head to avoid postoperative pain
production from those joints.
 First Metatarsal Cheilectomy
and Osteochondral Defect
9
Treatments

Bryan Van Dyke and Terrence M. Philbin

9.1 Introduction inciting event, but often these symptoms are the
result of repetitive microtrauma over time.
Degenerative joint disease in the first metatarso- The patient should be examined for overall range
phalangeal joint is a progressive disease ulti- of motion of the first MTP joint as well as pain with
mately leading to end-stage hallux rigidus. We motion. A grind test may also be positive.
commonly use the Coughlin grading system for For patients with predominantly plantar pain,
hallux rigidus from grade 1 to grade 4 [1]. sesamoid injury and turf toe injuries should be
Bussewitz et al. showed successful results at investigated.
3-year follow-up with cheilectomy for grades 1, If there is any history of an open wound,
2, and 3 hallux rigidus [2]. More recent atten- fevers, chills, erythema, drainage, or warmth, a
tion to treating focal cartilage defects of the septic joint should be interrogated further and
first metatarsal head has also shown excellent may require joint aspiration for synovial fluid
results at 3-year follow-up [3]. Identifying and analysis. Crystalline arthropathy such as gout is
­intervening earlier in this disease can reduce also common in the first MTP joint.
pain, preserve function, and delay or prevent
progression.
9.3 Imaging and Diagnostic
Studies
9.2 Patient History and Findings
Standard three-view (AP, oblique, lateral) weight-­
Patients will generally present with the complaint bearing radiographs should be obtained of the
of pain and stiffness in the first metatarsophalan- foot. It is important to obtain weight-bearing
geal joint. They may experience swelling as well. films as the overall alignment of the foot may dif-
These symptoms are often exacerbated by fer from the resting position. The first metatarso-
­activity. Patients may recall a specific traumatic phalangeal joint should be evaluated for
concentricity of the joint space, joint space nar-
rowing, osteophyte formation, articular defects,
B. Van Dyke (*)
and subchondral cysts. These abnormalities may
Summit Orthopaedics,
Idaho Falls, ID, USA be present on both the metatarsal head and pha-
lanx base. Typically with low-grade hallux rigi-
T. M. Philbin
Orthopedic Foot & Ankle Center, dus, there will be some joint space narrowing and
Worthington, OH, USA dorsal metatarsal head osteophytes.

© Springer Nature Switzerland AG 2019 93

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_9
94 B. Van Dyke and T. M. Philbin

With standard radiographs we are interpreting tendon is kept within its sheath. The joint capsule
the quality of the cartilage based upon the joint is incised longitudinally dorsomedially in line
space maintained. Focal osteochondral defects with the incision. The capsule is elevated and
may not be apparent, especially if there is no sub- protected for repair at closure.
chondral bone loss. MRI is useful for evaluating There is typically synovitis within the joint
the first MTP joint to look at the quality of the that is debrided with either the scalpel or a ron-
articular cartilage, the presence of subchondral geur. Small Hohmann retractors are placed medi-
cysts, and bone edema. ally and laterally, the toe is plantarflexed, and the
articular surfaces are inspected.
For closure, we repair the capsule with 0 vic-
9.4 Surgical Management ryl suture, typically using a figure-8 stitch. If
there is some degree of hallux valgus, then the
9.4.1 Preoperative Planning medial capsule can be imbricated and repaired
with a pants over vest technique to improve sesa-
Appropriate discussion should be had with patient moid alignment. The subcutaneous layer is closed
regarding the progressive nature of joint disease. with interrupted 2-0 vicryl, and the skin is closed
We always discuss that there is no true cure for with a running subcuticular 3-0 monocryl.
arthritis and that it may become worse over time
even with surgery. Our short-term goals are pain
relief and improved function, but there is likelihood 9.5 Surgical Techniques
that this disease will progress and may need further
treatment in the future. Often we do not fully know 9.5.1 Cheilectomy
the extent of cartilage damage until we are able to
visualize the joint intraoperatively. It may be neces- Typically there are large dorsal osteophytes on both
sary to consent the patient for additional surgery, the metatarsal head and the proximal phalanx base.
such as microfracture or cartilage allograft, if there We will expose the joint as described above and
appears to be a lesion intraoperatively that is not evaluate the joint surfaces. Often there is denuded
amenable to dorsal cheilectomy alone. cartilage, especially dorsally. This can be addressed
with the dorsal cheilectomy. We will use a micro-
sagittal saw to resect the dorsal portion of the meta-
9.4.2 Positioning and Equipment tarsal head. Up to 33% of the dorsal joint surface
may be removed without creating instability [4].
We utilize standard supine positioning on the Care is taken to exit along the dorsal aspect of the
operative room table. Most patients will need a metatarsal shaft to create a smooth transition. You
small bump underneath the ipsilateral hip to posi- may need to angle the cut slightly dorsally to avoid
tion the foot vertically. Having the first metatarsal notching the dorsal shaft of the metatarsal. The
vertical is especially helpful if performing carti- microsagittal saw can be used to remove the cor-
lage implantation where gravity can help keep ners of the cut as well to avoid prominent edges.
the graft within the defect. We typically use a The rongeur is used to further remove any promi-
thigh tourniquet throughout the case. nent bone. The rongeur is used to remove the dorsal
osteophytes of the proximal phalanx as well. The
toe should be taken through a range of motion to
9.4.3 Approach make sure there is smooth motion without impinge-
ment. If there is a large medial eminence, it may be
We use a standard dorsomedial incision centered resected with the microsagittal saw as well.
over the first metatarsophalangeal joint. Care is A McGlamry elevator can be used to carefully
taken to identify and protect the dorsomedial release the sesamoid suspensory ligaments taking
cutaneous nerve. The extensor hallucis longus care to avoid damaging the cartilage.
9 First Metatarsal Cheilectomy and Osteochondral Defect Treatments 95

9.5.1.1 Case Example 9.5.2 Subchondral Drilling

A 45-year-old male presents with left great toe
pain for many years. He has a prominent bump For focal articular defects, not amenable to
on the dorsum of her first metatarsal head. He removal by dorsal cheilectomy, we perform sub-
has pain with dorsiflexion. He has tried shoe chondral drilling for marrow stimulation. The
modifications, activity restrictions, and NSAIDs loose or damaged cartilage is removed sharply
and has not obtained relief. He is active in mar- with a curette or scalpel to create stable cartilage
tial arts and is adamant about maintaining first borders circumferentially. The subchondral bone
metatarsophalangeal motion. Physical exam is should be examined for integrity. If there is a sub-
relatively normal except dorsal mass over first chondral cyst, it may need to be filled with can-
metatarsophalangeal joint, positive crepitus, cellous autograft. We will typically harvest this
and pain with motion. Range of motion is sig- from the calcaneus.
nificantly limited. Radiographs show large dor- For the microfracture, we will perform a sub-
sal osteophytes from both the metatarsal head chondral drilling using a 0.062 k-wire with a wire
and proximal phalanx base. driver to perforate the subchondral plate and
Nonoperative and surgical treatment options stimulate marrow. This is expected to produce
were discussed, and he elected to proceed with fibrocartilage in the area of the defect.
first metatarsophalangeal cheilectomy. He had
an uneventful recovery. He participated in physi-
cal therapy. Preoperative and 3-month postoper- 9.5.3 Cartilage Allograft
ative radiographs are displayed below. He is
doing well and returning to martial arts. A dis- In cases of failed microfracture or unstable
cussion was had regarding eventual definitive lesions with known subchondral cyst, we advo-
treatment in the form of arthrodesis with the cate for allograft cartilage implantation. The
hope of 5–10 years of good relief beforehand implants have reported cartilage formation more
(Figs. 9.1 and 9.2). similar to hyaline cartilage than the fibrocartilage

Fig. 9.1 Preoperative radiographs of left first metatarsophalangeal joint demonstrating significant dorsal osteophytes
of both the metatarsal head and proximal phalanx base
96 B. Van Dyke and T. M. Philbin

Fig. 9.2 Three-month postoperative radiographs of left first metatarsophalangeal joint after cheilectomy

typically created by subchondral drilling alone She has diffuse tenderness in her first metatarso-
[5]. If you are considering using an allograft phalangeal joint and pain throughout passive
implant, you should notify your facility in range of motion. Her radiographs demonstrate
advance to make sure it is available on the day of moderate hallux rigidus. She was actually seen in
surgery. the office 2 years prior and offered a dorsal chei-
Particulated juvenile articular cartilage (PJAC) lectomy, but she decided that she was able to
is a commercially available product that has manage her symptoms nonoperatively at that
given us excellent results [3]. The focal defect is point. Now the pain is much worse, and she is
exposed as described previously. Any denuded or requesting the surgery that was discussed 2 years
loose cartilage is removed to create a circumfer- ago. An MRI was obtained which demonstrated a
ential stable border of healthy cartilage. The lateral metatarsal head osteochondral defect
manufacturer’s guidelines do not recommend reported as 5 × 4 mm full thickness cartilage loss
performing subchondral drilling in conjunction with underlying edema. The options of arthrode-
with PJAC implantation. The surface should be sis versus cheilectomy with cartilage allograft
dry. A thin coat of fibrin glue is placed into the were discussed. Despite presenting arthrodesis as
defect. The minced cartilage pieces are laid into the most definitive single surgical treatment, the
the defect, and a freer elevator can be used to patient elected for cheilectomy with cartilage
gently lay the pieces flat. Another thin layer of allograft.
fibrin glue is placed overtop of the allograft and Intraoperatively the dorsal osteophytes were
allowed to dry. The joint is reduced and closed as removed with a sagittal saw. The osteochondral
described above (Fig. 9.3). defect was located centrally and laterally and was
only partially amenable to removal by cheilec-
9.5.3.1 Case Presentation tomy. After removing loose cartilage flaps, the
A 51-year-old female presents with right great osteochondral defect measured 10 mm wide and
toe pain. She complains of pain that is worse with 12 mm tall. The particulated juvenile articular
activity, especially running. She has tried rest, cartilage was applied to the defect (Figs. 9.4, 9.5,
ice, NSAIDs, and a Morton’s extension splint. and 9.6).
9 First Metatarsal Cheilectomy and Osteochondral Defect Treatments 97

Fig. 9.3 Focal osteochondral defect of the first metatarsal head after dorsal cheilectomy and defect preparation.
Implantation of particulated juvenile articular cartilage allograft with fibrin glue coating

Fig. 9.4 Preoperative standing radiographs AP and lateral demonstrating moderate joint space narrowing with large
dorsal osteophyte on the metatarsal head
98 B. Van Dyke and T. M. Philbin

Fig. 9.5 Preoperative T2 MRI coronal and sagittal slices demonstrating focal osteochondral defect involving the cen-
tral and lateral portion of the metatarsal head. There is increased signal in the subchondral bone

Fig. 9.6 Postoperative weight-bearing radiographs demonstrating decompression of the first metatarsophalangeal
osteophytes
9 First Metatarsal Cheilectomy and Osteochondral Defect Treatments 99

9.7 Potential Complications

Intra-operative Pearls and Pitfalls
• Evaluate and note the range of motion • Stiffness
of the first MTP with the patient sedated • Recurrence and/or hallux rigidus progression
prior to making an incision. This will
help you determine the amount of
improvement you have achieved and if References
additional decompression is necessary.
• Educate patient on the progressive 1. Coughlin MJ, Shurnas PS. Hallux Rigidus: grading
nature of hallux rigidus and that even and long-term results of operative treatment. JBJS.
2003;85:2072–88.
with surgery they may need future treat- 2. Bussewitz BW, Dyment MM, Hyer CF. Intermediate-­
ment, including possible arthrodesis. term results following first metatarsal cheilectomy.
Foot Ankle Spec. 2013;6(3):191–5.
3. Van Dyke B, Berlet GC, Daigre JL, Hyer CF, Philbin
TM. First metatarsal head osteochondral defect treat-
9.6 Post-op Care ment with particulated juvenile cartilage allograft
transplantation: a case series. FAI. 2018;39(2):236–41.
Patients are placed into a standard well-padded 4. Coughlin MJ, Shurnas PS. Hallux Rigidus: surgi-
cal techniques (cheilectomy and arthrodesis). JBJS.
posterior splint and kept non-weight-bearing ini- 2004;86(suppl 1, pt 2):119–30.
tially. They follow the OFA Group 1 Protocol: non- 5. Farr J, Tabet SK, Margerrison E, Cole BJ. Clinical,
weight-bearing splint for 1 week, weight-­bearing as radiographic, and histological outcomes after carti-
tolerated in a boot for 3 weeks, and then transition lage repair with particulated juvenile articular carti-
lage: a 2-year prospective study. Am J Sports Med.
to regular shoe wear. Physical therapy is initiated at 2014;42(6):1417–25.
week 4 as needed to improve range of motion.
 Neuroma
10
Travis Langan, Adam Halverson, and David Goss Jr.

10.1 Introduction heads. Some patients may say they feel like they
are “walking on a pebble” or “balled-up sock.”
The third web space is the most common (66%) There is often radiation of pain or tingling into the
location for an interdigital neuroma. In 21% of corresponding toes. Frequently, narrow shoes and
patients, neuromas are present bilaterality [4]. high heels intensify symptoms. Patients will often
The pathogenesis is thought to be nerve entrap- massage the area when describing the location of
ment due to repetitive compressive trauma of their discomfort. Some patients may report a
plantar nerve against transverse intermetatarsal recent increase or change in activity level.
ligament [5, 8]. A neuroma is actually best It is imperative with digital and forefoot-­
described as perineural fibrosis in most instances driven pathology to assess patients in a loaded
rather than a true neuroma, as a true neuroma and unloaded position. The authors recommend
shows irregular histologic nerve tissue prolifera- evaluating the patient as they cycle through a nor-
tion [3]. What is commonly referred to as a pri- mal gait and assess the patient in a non-weight-­
mary interdigital neuroma usually histologically bearing position. As with most forefoot issues,
shows signs of nerve degeneration, including assessing the gastrocnemius and soleus muscle
degeneration of myelinated fibers, thickening of complex for tightness is crucial. A standard
the epineurium and perineurium, thickening and Silfverskiold test is performed to assess for
hyalinization of the walls of the neural vessels, gastroc-­soleal equinus.
and concentric edema within the nerve [2, 3, 11]. Clinically, one can often palpate a firmness or
fullness between the associated metatarsal heads
(Fig. 10.1). This can be a chronic and fibrotic feel-
10.2 Patient Presentation ing or acute and boggy. Typically, the metatarsal
heads themselves are non-painful. Pain will be
A thorough patient history and physical examina- associated with squeezing the intermetatarsal space
tion are always performed. Patients frequently from dorsal to plantar (Fig. 10.2). Pain may worsen
complain of burning pain in the plantar forefoot or when the toes are dorsiflexed. Side-to-­side com-
a sensation of fullness between the metatarsal pression of the metatarsal heads (Fig. 10.3) will
reduce the space between metatarsal heads and can
produce the a palpable and/or audible click
T. Langan (*) · A. Halverson · D. Goss Jr.
(Mulder’s sign) [9]. This test has sensitivity of
Orthopedic Foot and Ankle Center, Orthopedic Foot
and Ankle Surgery, Worthington, OH, USA 94–98% [6, 10]. The pain and nerve sensations will
e-mail: [email protected] be localized to the affected web space and toes.

© Springer Nature Switzerland AG 2019 101

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_10
102 T. Langan et al.

It is important to differentiate between neu-

roma pain and other potential pathologies. Most
commonly, clinicians will differentiate between
Morton’s neuroma and metatarsophalangeal
(MTP) joint pathologies. Evaluate for joint pain,
MTP joint instability, and/or metatarsal pain. If
there is pain while manipulating the joint, press-
ing directly on the metatarsal head or base of the
proximal phalanx, or while palpating the metatar-
sal, the pain is likely not due to a neuroma, and
the patient should be worked up for metatarsal or
plantar plate injury. Always remember though,
there may be concomitant pathologies present.
Fig. 10.1 Palpating the intermetatarsal space

10.3  iagnostic and Imaging

D
Work-Up

Upon initial examination, a standard series of three

weight-bearing foot radiographs are taken. These
images primarily serve to rule out any structural
cause of symptoms that could mimic neuroma.
Differential diagnoses that can be observed radio-
graphically include bone and soft tissue malignancy,
other space-occupying lesions, metatarsophalangeal
arthritis, Freiberg’s disease, stress fracture, toe defor-
mity, and metatarsophalangeal instability.
Advanced imaging used for diagnosis of
Morton’s neuroma includes ultrasound and MRI.
MRI has a reported sensitivity of 93% and speci-
Fig. 10.2 Palpating the intermetatarsal space dorsal to
ficity of 68% [13]. Ultrasound sensitivity was
plantar
found to be 90% with specificity of 88% [13].
Availability of quality ultrasound can vary by
institution. While clinical diagnosis remains the
gold standard for diagnosis of Morton’s neuroma,
MRI is often employed in our practice prior to
surgical intervention to ensure no other space-­
occupying lesions are contributing. It is also ben-
eficial at assessing other web spaces and ruling
out stress fracture and Freiberg’s disease.
Injection also plays a key diagnostic role. It is
usually performed if patients are refractory to ini-
tial non-operative modalities including topical
nonsteroidal anti-inflammatory drug (NSAID)
and shoe modification. Injection can simply
involve local anesthetic for diagnostic purposes,
Fig. 10.3 Side-to-side compression of the metatarsal but we typically include corticosteroids to add
heads some durable therapeutic benefit. Injections are
10 Neuroma 103

ceiling. For a plantar approach, the surgeon may

elect to have the patient in a prone position.
Typically, general anesthesia and preoperative
popliteal and saphenous blocks are utilized dur-
ing this type of case. A thigh tourniquet is applied
to the patient’s operative limb, and the limb is
prepped and draped in the usual standard
fashion.

10.6 Operative Technique: Key

Operative Steps
Fig. 10.4 Injection 1–2 cm proximal to metatarsal heads
from dorsal approach 10.6.1 Dorsal Approach Neurectomy

Most patients with first time neuroma excision

generally performed from a dorsal approach are treated with dorsal approach in our practice.
1–2 cm proximal to the metatarsal heads This incision allows for a more rapid recovery
(Fig. 10.4). Repeat injections are used judiciously and more proximal visualization.
to avoid complications such as local tissue atro- The incision is longitudinal and placed in the
phy and ligamentous laxity. We find most patients dorsal recess between metatarsal heads, working
who get relief but have recurrent symptoms are proximally (Fig. 10.5). Dissection is carried
eventually treated surgically. through skin and any bleeders are cauterized. The
dorsal intermetatarsal ligament is identified
(Fig. 10.6) and transected sharply (Fig. 10.7).
10.4 Non-operative Treatment A self-retaining retractor or small lamina spreader
is gently placed between metatarsal necks and is
Conservative treatments consist of orthoses with used to improve visualization. Careful dissection
offloading metatarsal pads, shoe gear modifica- is performed to identify the nerve (Fig. 10.8).
tion, anti-inflammatories, and physical therapy. Digital palpation externally at the distal inter-
Injections of corticosteroid can be utilized with space can allow the neuroma to protrude distal to
some success. The authors strictly avoid scleros- the deep transverse metatarsal ligament, and
ing alcohol injections. In our experience, alcohol probing with freer elevator is used to locate the
injections generally have little success and can bulbous plantar nerve. The deep transverse meta-
even result in worsening symptoms. When con- tarsal ligament is incised to visualize the neu-
servative treatments fail, operative intervention is roma fully. Dissection continues along the nerve
considered. Up to 80% of cases will eventually distally into the base of each toe. The associated
require surgical resection [7]. digital branches are isolated and each transected
sharply with a fresh blade. Care is then taken to
ensure the nerve and its branches are dissected as
10.5  R Setup and
O proximal as possible into the plantar intrinsic
Instrumentation musculature. At the discretion of the surgeon,
and Hardware prior to transecting the proximal aspect of the
Recommendation neuroma, an epineural injection of corticosteroid
can be considered. Distal traction is applied to
Patients are typically on the operating room table the nerve and transected sharply as proximal as
in a supine position. A bump is placed under the possible allowing the residual nerve to retract
patient’s ipsilateral hip until the patella faces the into the intrinsic muscles. The nerve should be
104 T. Langan et al.

Fig. 10.6 Identification of the deep transverse intermeta-

tarsal ligament

Fig. 10.5 Dorsal incisional placement for a second inter-

metatarsal neuroma

resected at least 3 cm proximal to the proximal

edge of the transverse metatarsal ligament. This
is done to avoid tethering of the nerve stump and
allow the nerve stump to be off the weight-­
bearing surface [1]. Some surgeons will send the
transected nerve (Fig. 10.9) for pathological
specimen. The tourniquet is deflated to achieve
proper hemostasis as a hematoma in the site can
cause complications postoperatively. The site is
irrigated and layered closure is performed.

10.6.2 P
 lantar Approach for Revision
Neurectomy

The patient may be placed supine or prone for Fig. 10.7 Following transection of the deep transverse
this approach; however, the authors will routinely intermetatarsal ligament
10 Neuroma 105

Fig. 10.10 Plantar incisional approach

Fig. 10.8 Identification and dissection of the plantar
interdigital nerve
prevent longitudinal scar contraction. Dissection
is carried down through the plantar fat, and
venous bleeders are coagulated (Fig. 10.11). The
metatarsal heads are used as a reference for the
appropriate trajectory as the dissection is carried
deeper. The plantar aponeurosis is exposed, and
Weitlaner retractor is used to retain the surround-
ing plantar fat for visualization. The plantar apo-
neurosis is then incised longitudinally with a
No.15 blade, and tenotomy scissors are used to
Fig. 10.9 Resected nerve tissue and its branches dissect out the nerve proximally and trace it dis-
tally to the neuroma stump (Fig. 10.12). Unlike
do this approach with the patient supine. The bed the dorsal approach, the intermetatarsal ligament
is elevated to a comfortable level with the sur- should not need to be transected as this lies dorsal
geon seated at the foot of the bed. The limb is to the nerve. Once identified, the digital nerve is
prepped and draped in the usual standard fashion, gently pulled distally into the wound and clamped
and a thigh tourniquet is elevated after limb with a hemostat (Fig. 10.13). Dissection ­continues
exsanguination. distally to identify its digital branches. It is then
A 3–4 cm incision is made longitudinally over transected proximally and distally (Fig. 10.14).
the patients’ preoperatively determined point of After transection the ankle can be fully dorsi-
tenderness (Fig. 10.10). This is done in the inter- flexed to facilitate further retraction of the nerve
metatarsal space staring at the metatarsal heads into the midfoot. Some surgeons will use a hemo-
and working proximally. Alternatively, a horizon- stat on the nerve to transplant it deep into the
tal incision can be utilized; however, our pre- plantar musculature (Fig. 10.15).
ferred approach is longitudinal. The longitudinal The wound is then irrigated and the tourniquet
incision can have a curvilinear or lazy S shape to deflated to obtain hemostasis and prevent
106 T. Langan et al.

Fig. 10.13 Nerve is pulled distal and clamped with

Fig. 10.11 Plantar fat pad dissection hemostat

Fig. 10.12 Dissection and identification of the nerve Fig. 10.14 The nerve is transected proximally and dis-
tally with the stump clamped in the hemostat
10 Neuroma 107

and the patient is encouraged to heel weight bear

in a protective boot until the sutures are ready for
removal. Sutures are then removed based on
patient’s healing potential and when the inci-
sions have healed appropriately. At week 4, the
patients are transitioned back into a fully weight-
bearing shoe. Physical therapy is rarely needed
but initiated as necessary to aid in range of
motion and gait. A main focus of physical ther-
apy is to prevent painful scar or scar contrac-
tures. Recurrent neuromas may need a more
conservative postoperative protocol. These
patients may need a longer non-weight-bearing
period and more aggressive soft tissue massage.
Patients are appropriately followed for 6 to
12 months for close monitoring of improved
functional outcome measures.

Pearls, Pitfalls, and Resident Resource

Fig. 10.15 The nerve stump is transpositioned into the • Conservative treatments consist of
deep musculature orthoses with metatarsal pads, modifica-
tion of shoe gear, anti-inflammatories,
and corticosteroid injections.
h­ ematoma formation. The wound is then closed • Dorsal incision is generally used in pri-
in a layered fashion. mary cases and plantar incision gener-
Of note, at the surgeon’s discretion, some ally reserved for revision cases.
extra considerations may be utilized in recurrent • Careful dissection of the nerve is key for
neuroma surgery. Transposition of the nerve proper resection.
stump into the adjacent plantar foot muscle belly • Hemostasis is important for prevention
has been used with success, and some recom- of hematoma.
mend epineural injection or bathing the nerve • A period of non-weight-bearing is used
stump with corticosteroid prior to closure to early, followed by a period of protected
avoid excess inflammation [11, 12]. weight-bearing until the incision heals.
• In recurrent surgeries, consider transpo-
sition of the nerve stump into the adja-
10.7 Postoperative Protocol cent muscle belly and adding
corticosteroid intraoperatively.
This surgery falls into postoperative protocol #1.
The standard dressing applied to the operative
limb is a sterile well-padded Jones compression
dressing with posterior splint. For a primary dor- References
sal approach, the authors recommend a period of
non-weight-bearing approximately 7 to 10 days 1. Amis JA, Siverhus SW, Liwnicz BH. An anatomic
and then transitioning the patient to a pneumatic basis for recurrence after Morton’s neuroma excision.
Foot Ankle. 1992;13(3):153–6.
walking boot with protected weight-bearing 2. Giannini S, Bacchini P, Ceccarelli F, Vannini
until week 4. For plantar approach surgeries, the F. Interdigital neuroma: clinical examination and his-
patient is non-weight-bearing for 7 to 10 days, topathologic results in 63 cases treated with ­excision.
108 T. Langan et al.

Foot Ankle Int. 2004;25(2):79–84. https://doi. 8. Morscher E, Ulrich J, Dick W. Morton’s intermetatar-
org/10.1177/107110070402500208. sal neuroma: morphology and histological substrate.
3. Johnson JE, Johnson KA, Unni KK. Persistent Foot Ankle Int. 2000;21(7):558–62.
pain after excision of an interdigital neuroma. 9. Mulder JD. The causative mechanism in mor-
Results of reoperation. J Bone Joint Surg Am. ton’s metatarsalgia. J Bone Joint Surg Br.
1988;70(5):651–7. 1951;33-B(1):94–5.
4. Kasparek M, Schneider W. Surgical treatment of 10. Pastides P, El-Sallakh S, Charalambides C. Morton’s
Morton’s neuroma: clinical results after open exci- neuroma: a clinical versus radiological diagno-
sion. Int Orthop. 2013;37(9):1857–61. https://doi. sis. Foot Ankle Surg. 2012;18(1):22–4. https://doi.
org/10.1007/s00264-013-2002-6. org/10.1016/j.fas.2011.01.007.
5. Lee M-J, Kim S, Huh Y-M, et al. Morton neuroma: 11. Richardson DR, Dean EM. The recurrent Morton neu-
evaluated with ultrasonography and MR imaging. roma: what now? Foot Ankle Clin. 2014;19(3):437–
Korean J Radiol. 2007;8(2):148–55. https://doi. 49. https://doi.org/10.1016/j.fcl.2014.06.006.
org/10.3348/kjr.2007.8.2.148. 12. Wolfort SF, Dellon AL. Treatment of recurrent neu-
6. Mahadevan D, Venkatesan M, Bhatt R, Bhatia roma of the interdigital nerve by implantation of the
M. Diagnostic accuracy of clinical tests for proximal nerve into muscle in the arch of the foot.
Morton’s neuroma compared with ultrasonography. J Foot Ankle Surg. 2001;40(6):404–10.
J Foot Ankle Surg. 2015;54(4):549–53. https://doi. 13. Xu Z, Duan X, Yu X, Wang H, Dong X, Xiang Z. The
org/10.1053/j.jfas.2014.09.021. accuracy of ultrasonography and magnetic resonance
7. Mann RA, Reynolds JC. Interdigital neu- imaging for the diagnosis of Morton’s neuroma: a
roma–a critical clinical analysis. Foot Ankle. systematic review. Clin Radiol. 2015;70(4):351–8.
1983;3(4):238–43. https://doi.org/10.1016/j.crad.2014.10.017.
 Turf Toe and Sesamoid Injuries
11
Matthew M. Buchanan

11.1 Introduction plate is a thickening of this capsule on the plantar

surface of the 1st MTP joint and has a firm attach-
Injuries to the capsuloligamentous structures of ment on the proximal phalanx and a weaker
the 1st metatarsophalangeal (MTP) joint were attachment on the metatarsal head [5]. Next, liga-
first described by Ryan in 1975 [1] and named ment support provides additional stability to the
“turf toe” by Bowers and Martin in 1976 [2]. This MTP joint. These ligaments include the broad
term generally includes injury occurring to the medial and lateral collateral ligaments, medial
capsular, ligamentous, and osseous structures of and lateral metatarsal-sesamoid ligaments, and
the 1st MTP joint. Originally, this injury was transverse intermetatarsal ligament. The intrinsic
described in football players and attributed to the tendons inserting into the base of the proximal
increased traction afforded by the new artificial phalanx provide additional support medially
turf playing fields in combination with a light- (abductor hallucis), laterally (adductor hallucis),
weight, flexible shoe. Turf toe injuries are debili- and plantarly (flexor hallucis brevis). The sesa-
tating sports injuries because the hallux is pivotal moid bones are embedded within the FHB ten-
to an athlete’s ability to accelerate and cut [3]. don and are connected by a thick intersesamoid
These injuries are occurring with increasing fre- ligament that makes up the central component of
quency at all levels of competition [4]. the plantar plate of the first MTP joint [6, 7]
The osseous structures of the 1st MTP joint (Fig. 11.1).
include the shallow concave base of the proximal The 1st MTP joint typically supports more
phalanx articulating with the convex head of the than 50% of bodyweight with normal weight-­
first metatarsal. Due to the lack of significant bearing, 200–300% with athletics, and increases
bony congruity, this is an inherently unstable to 800% with jumping [8–11]. The sesamoid
joint. Joint stability is improved by the capsular bones articulate with the plantar surface of the 1st
and ligamentous structures connecting the meta- metatarsal and withstand tremendous forces as a
tarsal head to the base of the proximal phalanx. result of their location. The medial and lateral
The first layer of soft tissue support comes sesamoid bones provide a number of advantages
from the fibrous MTP joint capsule. The plantar to the function of the great toe. The sesamoid
bones serve to elevate the 1st metatarsal head,
improving the biomechanical advantage of the
FHB and FHL tendons. With weight-bearing, the
M. M. Buchanan (*) medial and lateral sesamoid bones provide pro-
Center for Sports Medicine and Orthopaedics,
tection to the FHL tendon, which runs between
Chattanooga, TN, USA

© Springer Nature Switzerland AG 2019 109

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_11
110 M. M. Buchanan

Fig. 11.1 Anatomy of

the plantar aspect of the
1st MTP joint.
(Modified image from
Richard D. Ferkel)

Flexor hallucis
Lateral phalangeo- longus tendon
sesamoid ligament
Lateral metatarso-
sesamoid ligament Medial phalangeo-
sesamoid ligament
Lateral sesamoid

Medial metatarso-
sesamoid ligament

Medial sesamoid

Intersesamoid
Adductor hallucis: ligament
Transverse
Oblique Flexor hallucis brevis:
Lateral head

Medial head

these two bones. Additionally, the dorsal surface side of the 1st MTP joint but also has been
of each sesamoid bone is covered in cartilage, described from the 1st metatarsal head.
articulating with the plantar surface of the meta- Chronic overuse injuries result from repetitive
tarsal head. This joint surface reduces friction of stress applied to the plantar surface of the fore-
the FHB tendons as they pass plantar to the 1st foot as seen in high-impact running and jumping
MTP joint. sports and occupations where standing and walk-
The enormous forces encountered by this part ing are prevalent. Excessive stress applied to the
of the foot can lead to a variety of injuries rang- sesamoids over a prolonged period of time leads
ing from acute rupture of the plantar soft tissues to a spectrum of pathology starting with sesa-
to chronic overuse injuries. In the acute setting, moiditis and progressing to sesamoid stress frac-
patients will often describe a mechanism that tures and ultimately avascular necrosis (AVN).
includes axial loading of the 1st MTP joint while Chronic overuse syndromes involve the medial
in a forced dorsiflexion position. This specific sesamoid bone more often than the lateral sesa-
injury mechanism can lead to complete rupture moid bone due to the larger size of the medial
of the plantar plate with proximal sesamoid sesamoid and increased forces that it supports
retraction, partial rupture of the plantar plate during weight-bearing. Certain biomechanical
without instability, acute sesamoid fractures, factors (achilles contracture and pes cavus) and
diastasis of bipartite sesamoids, and metatarsal improper footwear (high heels and shoes lacking
head impaction injuries. The tear in the plantar sufficient protection/support) may predispose
plate typically occurs on the proximal phalanx patients to plantar forefoot overload syndromes.
11 Turf Toe and Sesamoid Injuries 111

11.2 Clinical Case Examples

11.2.1 C
 ase Example #1: Medial
Sesamoid Excision and Repair
of Torn Medial Collateral
Ligament
Fig. 11.3 Sagittal MRI view with chronic ununited
Twenty-two-year-old male 2 years after a motorcy- medial sesamoid fracture
cle accident with 1st MTP medial collateral liga-
ment injury and chronic ununited medial sesamoid
fracture. Failed 2 years of conservative treatment
including boot, post-op shoe, custom orthotics, ses-
amoid off-loading pads, carbon fiber plantar plate,
shoe changes, and activity modification. Patient
describes development of hallux valgus deformity
and pain over medial sesamoid with push-off
(Figs. 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9,
11.10, 11.11, 11.12, 11.13, 11.14, and 11.15).

Fig. 11.4 Axial MRI scan showing medial collateral lig-

ament injury and intra-articular damage

Fig. 11.5 Preoperative simulated weight-bearing

Fig. 11.2 Chronic ununited medial sesamoid fracture
assessment
with subtle hallux valgus deformity
112 M. M. Buchanan

Fig. 11.6 Medial approach between dorsomedial and

plantar medial cutaneous nerve branches Fig. 11.9 Excised medial sesamoid with cartilage loss
and fragmentation of proximal fragment

Fig. 11.7 Capsular exposure from 12 o’clock to 6 Fig. 11.10 Medial eminence removal with distal meta-
o’clock with retraction of cutaneous nerves and visualiza- tarsal osteotomy utilizing longer dorsal arm
tion of abductor hallucis tendon

Fig. 11.8 L-shaped capsulotomy with visualization of Fig. 11.11 Lateral shift neutralizing valgus forces and
medial sesamoid bi-cortical screw fixation
11 Turf Toe and Sesamoid Injuries 113

Fig. 11.12 Multiple interrupted sutures repairing FHB

tendon and advancing abductor hallucis into defect

Fig. 11.13 Capsular repair and advancement of abductor

hallucis tendon

Fig. 11.15 Weight-bearing AP x-ray at 1st post-­operative

visit

11.2.2 C
 ase Example #2: Plantar
Plate Repair Through
L-shaped Extensile Plantar
Approach

Intraoperative photographs demonstrate the skin

incision and exposure of the plantar 1st MTP
Fig. 11.14 Repeat simulated weight-bearing joint made possible through an L-shaped exten-
examination sile plantar approach (Figs. 11.16 and 11.17).
114 M. M. Buchanan

repetitive loading of the plantar forefoot (distance

running, dancing, rock climbing). They may have
occupations that require frequent use of stairs or
ladders. A thorough history often reveals an
increase in the amount of force applied to the
sesamoids as seen with runners who switch to
lighter shoes and adopt a “forefoot-loading” run-
ning style. Prolonged use of high-heeled shoes
can also lead to sesamoid overload syndromes.

Fig. 11.16 L-shaped plantar incision

11.4 Diagnosis

Inspection of the foot in the acute setting will

include assessment of the resting posture of the
toe (hyperextension may occur with a loss of the
static plantar stabilizers) and the location and
degree of edema, erythema, and ecchymosis.
Carefully palpate the medial and lateral MTP
joint line, each sesamoid bone, and the plantar
plate. Assess the degree of dorsal 1st MTP joint
tenderness as severe dorsiflexion of the phalanx
on the 1st metatarsal can cause metatarsal head
impaction fractures. Look for signs of lesser
MTP joint injuries. Patients may have an antalgic
gait or could be completely unable to ambulate
on the ball of the injured foot.
Chronic injuries will tolerate a more focused
physical exam. Weight-bearing inspection may
reveal varus/valgus malalignment or pronation/
supination deformities. Palpate both the medial
Fig. 11.17 Exposure of the plantar plate and FHL
tendon and lateral sesamoid bones. Assess the stability
of the MTP joint to varus/valgus stress testing
and drawer examinations. Compare the full
11.3 Presentation active and passive range of motion of the great
toe to the contralateral side. Perform a gait anal-
In the acute setting, patients will describe a hyper- ysis looking for antalgic patterns such as toe
extension injury followed by pain and swelling of walking or diminished stance phase on the
the 1st MTP joint. Walking will be difficult if not symptomatic side.
impossible. Varying degrees of ecchymosis on
both the dorsal and plantar aspects of the foot will
be present. Symptoms may localize to the plantar 11.5 Imaging
surface of the 1st MTP joint although a more
severe injury creates dorsal impaction fractures of Radiologic imaging of the foot includes weight-­
the 1st MT head. Patients may describe hearing a bearing anteroposterior, oblique, and lateral foot
“pop” at the time of injury. x-rays. Bilateral AP foot weight-bearing views
In the chronic setting, patients often describe may be required to assess normal sesamoid
involvement in sports or activities that require position (Fig. 11.18). Lateral foot x-rays can
11 Turf Toe and Sesamoid Injuries 115

Fig. 11.20 Dorsiflexion lateral foot XR showing lack of

distal sesamoid migration with dorsiflexion, consistent
with complete plantar plate rupture

Fig. 11.18 Bilateral AP foot x-ray with left diastatic

bipartite medial sesamoid and proximal retraction of the
lateral sesamoid

Fig. 11.21 Sagittal MRI view showing complete plantar

plate rupture

stability of the sesamoid complex. With active

dorsiflexion, an immobile sesamoid on the plan-
tar aspect of the 1st metatarsal confirms an unsta-
Fig. 11.19 Lateral foot XR shows plantar plate rupture ble injury to the sesamoid complex.
with increased distance from sesamoid to proximal Magnetic resonance imaging (MRI) provides
phalanx
the unequaled ability to thoroughly evaluate the
degree of both bone and soft tissue pathology.
reveal proximal retraction of the sesamoids MRI evaluates the integrity of the plantar plate,
(Fig. 11.19), and forced dorsiflexion lateral presence of chondral injuries, and the condition
views assess the integrity of the plantar plate/ of the surrounding osseous structures (stress inju-
sesamoid complex (Fig. 11.20). Finally, axial ries and dorsal impaction fractures). MRI may
sesamoid views provide a unique look at the show a complete plantar plate rupture (Fig. 11.21)
sesamoids and their position on the plantar sur- or an acute sesamoid fracture (Fig. 11.22).
face of the metatarsal head. Computed tomography (CT) is another help-
Fluoroscopic evaluation includes all the previ- ful modality, particularly when highly detailed
ously described x-ray techniques but adds the evaluation of bony anatomy is indicated. CT
ability to perform a dynamic assessment of the scans pick up on subtle avulsion fractures and
116 M. M. Buchanan

lamina spreaders, small pin-type joint distrac-

tors, bone reduction forceps, and specialty scal-
pel blades (Beaver blades). The surgeon should
also have a variety of nonabsorbable sutures
available to perform end-to-end ligament repair.
Specialty suture passing instruments (Suture
Lasso and Mini Scorpion (Arthrex, Inc. Naples,
FL)) may be useful to pass sutures in areas that
are difficult to access [12]. Additionally, small
Fig. 11.22 Sagittal MRI shows acute sesamoid fracture suture anchors may be needed to reattach avulsed
with gapping at the fracture site
ligament to the bone. If the anatomy does not
support the use of suture anchors, sutures can be
help differentiate acute from chronic injuries. passed through bone tunnels and tied on the
Newer weight-bearing CT scans may reveal foot opposite side. This will require the use of small
alignment abnormalities that contribute to suture passers.
chronic sesamoid overload syndromes.

11.7 Operative Technique

11.6 OR Setup
A complete understanding of the turf toe and
Three approaches are commonly used to treat sesamoid pathology guides the surgeon’s choice
turf toe and sesamoid injuries: medial, dorsolat- of available surgical approaches (medial, dorso-
eral, and direct plantar. A medial approach will lateral, and/or plantar). The surgical plan may
use a smaller hip bump to maintain some external involve direct repair of the plantar plate involving
rotation of the lower limb. A dorsolateral end-to-end suture repair or reattachment with
approach will use a larger hip bump to internally suture anchors, partial or complete medial and/or
rotate the leg, improving exposure of the 1st web lateral sesamoid excision, medial collateral liga-
space. For a direct plantar approach, the patient is ment repair, flexor hallucis brevis repair, abduc-
positioned supine with a bump under the tor hallucis advancement, MTP joint debridement
­ipsilateral hip to point the toes toward the ceiling. with marrow stimulation, and/or cartilage repair
The use of the bone foam ramp (https://www. techniques and collateral ligament repair/
bonefoam.com/product/positioners/the-ramp- stabilization.
positioner/) elevates the operative leg above the
contralateral leg. This elevation facilitates surgi-
cal exposure and improves the ease of intraopera- 11.8 Medial Approach
tive fluoroscopic imaging. Hemostasis is
performed with Esmarch exsanguination and The medial approach to the 1st MTP joint opti-
inflation of a tourniquet. A surgical assistant mizes exposure for medial sesamoid fracture
holds the leg during the case to optimize patient excision and/or medial collateral ligament repair.
positioning, notably ankle dorsiflexion during It opens the interval between the dorsomedial
plantar surgical approaches. cutaneous nerve (distal branch of the superficial
Instrumentation necessary for surgery will peroneal nerve) and plantar medial cutaneous
depend on the type of approach utilized and the nerve (distal branch of medial plantar nerve). The
pathology encountered. In addition to a com- medial capsule is exposed from dorsal (12
plete foot tray, specialty instruments available to o’clock) to plantar (6 o’clock). Careful evalua-
the surgeon should include sharp Weitlander tion and inspection of the medial capsule reveals
retractors, Gelpi retractors, small single-action the extent of any medial collateral ligament
rongeurs, battery drill and small drill bits, Inge rupture.
11 Turf Toe and Sesamoid Injuries 117

Once the medial approach has been com- tension on the plantar soft tissues. Following
pleted, thorough inspection of local soft tissues excision, the adductor tendon and FHB are
is performed. Capsulotomy may not be neces- advanced into the defect using multiple inter-
sary in the acute setting as the traumatic liga- rupted sutures.
ment rupture may afford exposure of the 1st
MTP joint and medial sesamoid. Chronic inju-
ries may require a formal capsulotomy. 11.10 Plantar Approach
Capsulotomy techniques vary, but the author
prefers an L-shaped capsulotomy as it offers an For plantar approaches, the surgeon has the
extensile approach to the joint. The vertical choice of an L-shaped extensile incision
limb is in line with the joint surface and extends (Fig. 11.16) or a two-incision (medial and lateral)
plantarly down to the medial sesamoid. The surgical technique. The two-incision approach
horizontal limb is parallel to the mid-shaft of allows improved visualization of the lateral
the metatarsal. The L-shaped flap is retracted, aspect of the plantar plate [8]. A plantar approach
creating excellent visualization of the sesamoid is the preferred technique to address a complete
sling and MTP joint. This approach allows plantar plate rupture with proximal retraction of
direct repair of medial collateral ligament the sesamoids. Either technique requires careful
injury and facilitates advancement of the abduc- exposure and protection of the plantar medial
tor hallucis tendon during medial sesamoid digital nerve (medial exposure) and the common
excision [13]. plantar digital nerve (lateral exposure) [5]. If a
dorsal joint-impaction injury is present, a com-
bined dorsal and plantar approach will be neces-
11.9 Dorsolateral Approach sary to address all involved pathology. A small
pin-type joint distractor may be necessary to dis-
A dorsolateral approach is the authors’ pre- tract the joint in order to evaluate and treat intra-­
ferred approach for a lateral sesamoid excision articular injuries.
[14]. This approach avoids a plantar incision Once the plantar approach has been com-
through exposure of the dorsal aspect of the first pleted, the extent of the tear is determined. If a
web space. An Inge lamina spreader serves to mid-substance tear is present, multiple inter-
spread the 1st and 2nd metatarsals, optimizing rupted sutures may be passed to reapproximate
surgical exposure. Long-handled tenotomy scis- the torn tissue. If the plantar plate ruptures off
sors facilitate a deeper dissection. If a lateral the base of the proximal phalanx, the plantar
collateral ligament injury is encountered, a plate is repaired to the proximal phalanx through
TightRope (Arthrex, Inc. Naples, FL) or alterna- the use of suture anchors or bone tunnels. The
tive suture-button construct may assist in collat- base of the proximal phalanx is “roughened”
eral ligament repair. using a small single-action rongeur. This tech-
The dorsolateral approach is utilized most nique produces a bleeding bony bed ideal for
often for lateral sesamoid excisions. Once the ligamentous healing [12]. Locking sutures are
approach is performed, care is taken to avoid placed in the plantar plate and advanced through
injury to the common digital nerve below the drill holes passed from plantar to dorsal. A sepa-
intermetatarsal ligament [14]. A Beaver blade rate dorsal incision is utilized to mobilize the
is used to make an incision through the inters- EHL during tying of the sutures. Typically, three
esamoid ligament on the medial side of the drill holes are utilized with two separate sutures
fibular sesamoid. This allows lateral retraction passing through the central tunnel and one each
of the sesamoid while preventing retraction of on the medial and lateral tunnels. Knots are tied
the fibular sesamoid under the metatarsal head on the medial and lateral aspect of the EHL ten-
[14]. Care is taken to avoid injury to the FHL don with the toe held in a plantarflexed
tendon. Plantarflexion of the MTP joint relaxes position.
118 M. M. Buchanan

11.11 Post-op Protocol The dorsolateral approach to the lateral sesa-

moid allows for complete excision of the lateral
Upon completion of the procedure, patients are sesamoid while avoiding a plantar incision.
placed in a well-padded posterior splint position- Fragmentation of the sesamoid can be avoided by
ing the toe in a gentle plantarflexed position. careful “shelling out” of the sesamoid utilizing
Patients are instructed to limit weight-bearing by sharp Beaver blade scalpels. Avoid excessive
the use of a wheelchair and/or knee scooter. traction on the sesamoid with rongeurs or Kocher
Patients are encouraged to elevate “toes to nose” clamps. One or two sutures placed in the lateral
for 50 minutes of each hour during the initial soft tissues allow lateral retraction during inci-
2 weeks after surgery. sion of the intersesamoid ligament, the “key
At 2 weeks post-op, sutures are removed and move” of this procedure [14].
patients may progress to heel weight-bearing in a With plantar approaches for plantar plate
bootwalker. Boot may be removed when sitting repairs, the surgeon should have available a
and sleeping, and a gentle passive range-of-­ ­number of minimally invasive suture placing and
motion program is initiated, avoiding excessive suture passing instruments to allow repair of deep
stress on the repair site. If tissue quality is com- structures that can be difficult to access.
promised or patient compliance is a concern, a Depending on the chronicity of the injury, careful
fiberglass cast with foot plate extending past the mobilization of the plantar plate will allow reat-
toes may be considered. tachment to the base of the proximal phalanx.
At 6 weeks post-op, formal physical therapy Direct repair of the plantar plate to the base of the
begins with a goal of restoring full joint strength proximal phalanx requires the use of small drills
and range of motion. With the guidance of the and suture passers as well as a dorsal approach to
physical therapist, patients may wean from the tie down the repair sutures. Alternatively, small
boot into a stiff postoperative surgical shoe. suture anchors can be utilized to secure the plan-
At 10 weeks post-op, patients transition into tar plate to the proximal phalanx.
supportive athletic or hiking shoes with wide toe Patients are educated that any surgical inter-
box and/or carbon fiber plates. vention involves the risk of infection and injury
to arteries and nerves. Complications specific to
this surgery include painful plantar scars, re-­
Pearls and Pitfalls rupture of repaired ligaments, recurrence of the
When utilizing the medial approach to preoperative deformity, cartilage damage from
repair torn medial collateral ligaments or acute joint trauma, and development of chronic
resect a diseased sesamoid, the surgeon pain. Patients should be educated that they may
must ensure that the forces affecting the 1st not return to their pre-injury level of function.
MTP joint have been balanced upon com- Nonsurgical treatment of plantar plate and
pletion of the procedure. The surgeon sesamoid injuries to the 1st MTP joint may also
should be prepared to release the adductor be associated with complications. These compli-
tendon or perform a realignment osteot- cations could include failure of the injury to heal
omy. Advancement of the abductor tendon with non-operative treatment, chronic joint insta-
into the defect created by medial sesamoid bility, re-rupture of injured ligaments, progres-
excision helps to prevent a postoperative sive toe alignment abnormalities, and cartilage
hallux valgus deformity [13]. Careful pre- damage from the initial joint trauma. If left
operative imaging including weight-bear- untreated, an unstable injury to the plantar plate
ing x-rays will assist with intraoperative complex develops into a hallux claw deformity
decision-making. with MTP joint extension, IP joint flexion, and
MTP joint dislocation (Figs. 11.23 and 11.24).
11 Turf Toe and Sesamoid Injuries 119

References
1. Ryan AJ, et al. Artificial turf: pros and cons (round-­
table). Physician Sports Med. 1975;3:41–50.
2. Bowers KD, Martin RB. Turf-toe: a shoe-surface
related football injury. Med Sci Sports Exerc.
1976;8:81–3.
3. Frimenko RE, Lievers W, Coughlin MJ, Anderson
RB, Crandall JR, Kent RW. Etiology and biomechan-
ics of first metatarsophalangeal joint sprains (turf toe)
in athletes. Crit Rev Biomed Eng. 2012;40:43–61.
4. Anderson RB, Hunt KJ, McCormick JJ. Management
of common sports-related injuries about the foot and
ankle. J Am Acad Orthop Surg. 2010;18(9):546–56.
5. McCormick JJ, Anderson RB. Surgical correction
of the recalcitrant turf toe. Tech Foot Ankle Surg.
2013;12:29–38.
6. Dedmond BT, et al. The hallucal sesamoid complex. J
Am Acad Orthop Surg. 2006;14:745–53.
7. Richardson EG. Injuries to the hallucal sesamoids in
the athlete. Foot Ankle. 1987;7:229–44.
8. McCormick JJ, Anderson RB. The great toe: failed
turf toe, chronic turf toe, and complicated sesamoid
injuries. Foot Ankle Clin. 2009;14:135–50.
9. Nigg BM. Biomechanical aspects of running. In:
Nigg BM, editor. Biomechanics of running shoes.
Champaign: Human Kinetics Publishers; 1986.
p. 1–25.
10. Nigg BM, Yeardon MR. Biomechanical aspects of
playing surfaces. J Sports Sci. 1987;5:117–45.
11. Stokes IA, Hutton WC, Stott JR, et al. Forces under
the hallux valgus foot before and after surgery. Clin
Orthop Relat Res. 1979;142:64–72.
12. Doty JF, Coughlin MJ. Turf toe repair: a technical
note. Foot Ankle Spec. 2013;6(6):452–6.
Fig. 11.23 AP foot x-ray of neglected plantar plate 13. Anderson RB. Turf toe injuries of the hallux meta-
rupture tarsophalangeal joint. Tech Foot Ankle Surg.
2002;1(2):102–11.
14. Kurian J, McCall DA, Ferkel RD. Dorsolateral exci-
sion of the fibular sesamoid: techniques and results.
Tech Foot Ankle Surg. 2014;13(4):226–33.

Fig. 11.24 Lateral foot x-ray of neglected plantar plate

rupture
 Tarsometatarsal Joint Arthrodesis
12
Mark A. Prissel and Jeffrey E. McAlister

Tarsometatarsal (TMT) joint arthrodesis is per- weight-bearing foot and ankle radiographs are
formed for a variety of etiologies including pri- performed. The AP foot radiograph is important
mary midfoot osteoarthritis, post-traumatic to assess transverse plane (i.e., adduction/
arthritis, complex multiplanar foot deformity, abduction)-associated deformities. The oblique
neuromuscular disease, and Charcot neuroar- foot radiograph provides the best visualization of
thropathy. Several of these etiologies and their the TMT joint lines and is the best initial assess-
associated management are covered in alternate ment of the extent of arthritic change present.
pertinent chapters. The main focus of this chap- The lateral foot radiograph is helpful to assess for
ter will be TMT arthrodesis related to primary plantar gapping and longitudinal collapse, which
osteoarthritis, post-traumatic arthritis, and some is often present in more advanced cases, as well
discussion regarding the procedures as they as evaluation of the overall foot structure for arch
relate to associated foot deformities. TMT type. The lateral radiographic also provides
arthrodesis can be considered for an isolated, excellent visualization of the dorsal osteophyto-
affected ray (i.e., 1st, 2nd, or 3rd), or for multi- sis and bossing that frequently coincides with
ple adjacent rays. advancing arthrosis.
Preoperative considerations often include ini- Advanced imaging is helpful for preoperative
tial conservative strategies including supportive planning. Most commonly MRI is utilized prior
shoe gear, rocker bottom shoe gear, altered lacing to surgery to understand the extent of cartilage
patterns, custom-molded orthoses, NSAIDS, top- loss and specific joint segment involvement. In
ical medications, and immobilization. Imaging is cases of more severe deformity, additional imag-
paramount to understanding the associated defor- ing can be utilized including CT with or without
mities present and extent of arthritic change pres- 3-D reconstruction. Injection therapy with fluo-
ent in the affected joint segments. Standard roscopic guidance can also be a useful adjunct
therapy providing useful diagnostic information
and temporizing therapeutic relief. When an
injection is performed in the small joints of the
M. A. Prissel (*) midfoot, we recommend fluoroscopic guidance
Orthopedic Foot & Ankle Center, to confirm the specific location, to help guide sur-
Worthington, OH, USA gical planning based on extent of patient relief.
e-mail: [email protected]
Use of contrast dye for the guided injection can
J. E. McAlister be a helpful tool, but is at the discretion of the
Arcadia Orthopedics and Sports Medicine,
surgeon.
Phoenix, AZ, USA

© Springer Nature Switzerland AG 2019 121

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_12
122 M. A. Prissel and J. E. McAlister

12.1 Indications verified on both an AP and oblique view. Upon

making the incision, care is taken to avoid and
• Primary TMT osteoarthritis appropriately retract the dorsal neurovascular
• Post-traumatic arthritis structures (Fig. 12.1a, b). An interval is identified
• Complex multiplanar foot deformity to deepen the dissection to the level of the joint of
• Neuromuscular disease interest. Weitlaner retraction is most efficient
• Charcot neuroarthropathy once dissection is deepened. The appropriate joint
is identified and a transverse capsulotomy is per-
formed (Fig. 12.1c). As a reminder, the 2nd TMT
12.2 Operating Room Setup is relatively more proximal (as the “keystone”)
than the adjacent 1st or 3rd TMT joints.
The patient is positioned on the operative table in Verification of the correct joint is paramount prior
the supine position. We recommend general anes- to moving forward with the procedure. A ronguer
thesia with an ipsilateral popliteal/saphenous is utilized to excise all dorsal hypertrophy. At this
nerve block. Following onset of appropriate anes- point the joint borders should be well defined. A
thesia, a thigh tourniquet is applied. A hip bump Hintermann distractor is placed from the metatar-
is placed, neutralizing any external rotation of the sal to the proximal extent of associated cuneiform
hip. The extremity is prepped to the tourniquet (Fig. 12.1d). Care is taken not to place the distrac-
and draped with exposure of the operative limb tor too close the TMT joint surface, to prevent cut
including the knee. out into the joint, which can compromise fixation
Power equipment is available and utilize options. Cartilaginous surfaces are denuded with
including corded electric sagittal saw and power hand instrumentation including curettes, ronguer,
rasp. Cordless drivers are utilized to aid in main- and 1/4 inch curved osteotome (Fig. 12.1e). Once
tenance of efficiency and limit the frequency of all cartilage is removed, the exposed subchondral
equipment exchanges. plate is fenestrated with a solid core drill (2.0–
A mini-fluoroscopy unit is draped and posi- 2.5 mm), and the surfaces are then fish-scaled
tioned on the same side of the table as the opera- with an osteotome to complete the preparation of
tive limb. The back table is positioned opposite the subchondral plate (Fig. 12.1f, g). Often, calca-
the fluoroscopy unit and operative limb. All neal autograft is procured prior to debridement of
required hardware and associated instrumenta- the joint and mixed with bone marrow aspirate.
tion is available and ready for use. Additional Following the joint preparation, the bone graft
case-specific instrumentation includes an AO and BMA are placed within the fusion site. The
quick connect 7 mm bone harvester, Hintermann-­ Hintermann retractor is removed. Provisional fix-
type retractor, curettes, and osteotomes. ation is applied. The authors preferred construct is
to initially place a 4.0 mm screw and dorsal-based
compression staple. The guide wire for the can-
12.3 Isolated TMT Arthrodesis nulated screw is placed initially as the provisional
fixation from the lateral metatarsal base into the
A linear, longitudinal incision is planned over the associated cuneiform. Care is taken to appropri-
appropriate interval. Care is taken to not inappro- ately drop one’s hand to ensure the proper trajec-
priately place the incision. Most commonly the tory of the screw, which should be nearly parallel
error is to estimate too medial for the location of to the ground to avoid suboptimal placement in
the joint of interest. Topographic anatomy can be the cuneiform (i.e., too plantar). Fluoroscopic
utilized to aid in positioning; the 3rd toe longi- verification of intended trajectory is obtained. The
tudinally lines up with the 2nd TMT, and the 4th appropriate length screw is then inserted. A
toe longitudinally lines up with the 3rd headed or headless screw can be considered at the
TMT. Fluoroscopic confirmation can be utilized surgeon’s discretion. Supplemental dorsal com-
to confirm appropriate position and should be pression staple is then placed in standard fashion
12 Tarsometatarsal Joint Arthrodesis 123

a b

Fig. 12.1 (a) Incision is approximately 3 cm in length joint preparation is key to this procedure with elevation of
centered over the TMT. (b) Incision is approximately the cartilage with an osteotome and curette. (f) A solid
3 cm in length centered over the TMT. (c) The incision is 2–3 mm drill is then utilized to fenestrate the subchondral
taken down to the joint capsule. The joint capsulotomy is bone on both surfaces of the joint. (g) A small straight
performed and periosteum elevated with an elevator. (d) A osteotomy is then utilized to “fish scale” the joint surfaces
pin-to-pin joint distractor is utilized to allow for joint as well
visualization and preparation for arthrodesis. (e) A proper
124 M. A. Prissel and J. E. McAlister

e f

Fig. 12.1 (continued)

in line with the long axis of the foot. The screw 12.4  ombined First and Second
C
fixation is relatively oblique to the staple. An TMT Arthrodesis
alternate fixation construct is an anatomically
contoured single-column TMT plate employing Either a single incisional approach or dual inci-
an eccentric drilling technique to provide com- sional approach can be considered for this com-
pression (Fig. 12.2a, b). Closure is obtained of the bined arthrodesis. If a single incision is selected,
subcutaneous layer and skin by the surgeon’s pre- a longitudinal linear or curvilinear incision is
ferred method. planned over the lateral extent of the 1st TMT. If
12 Tarsometatarsal Joint Arthrodesis 125

and BMA are utilized as well in this instance.

a
Often, the authors will include preparation of the
intercuneiform joint (medial/intermediate) in the
fusion construct essentially creating a “four cor-
ner fusion” of the medial column. Once appropri-
ate preparation of the involved joint segments is
completed, provisional fixation is inserted and
position is verified fluoroscopically. The joint
segments are provisionally stabilized with guide
wires for 4.0 mm cannulated screws. The typical
construct for the compression screws is a medial
cuneiform to 2nd metatarsal base screw (i.e.,
b Lisfranc screw, 1C–2M), an intercuneiform
screw (1C–2C), and a 1st metatarsal to interme-
diate cuneiform screw (1M–2C). Once the appro-
priate length screws are placed, supplemental
fixation is applied with a locking plate construct
to the dorsal medial 1st TMT joint and a dorsal
compression staple to the 2nd TMT joint
(Fig. 12.3a, b). An alternate fixation construct is
an anatomically contoured 1st & 2nd TM-specific
locking plate with eccentric drilling ability
(Fig. 12.3c, d). Closure is obtained of the subcu-
taneous layer and skin by the surgeon’s preferred
method.

12.5  ombined Second and Third

C
TMT Arthrodesis

A dorsal linear or curvilinear is recommended for

this combined arthrodesis. The incision is
planned over the lateral extent of the 2nd TMT or
Fig. 12.2 (a, b) Isolated 2nd TMT/LisFranc injury with over the 3rd TMT. The most common error is
a comminuted 2nd MT base which was bridge plated with to too medially estimate the appropriate inci-
allograft
sional location. Position should be verified
fluoroscopically.
a dual incisional approach is preferred, a medial The incision(s) are deepened and structures are
linear incision is planned about the 1st TMT, and protected identical to the description above. The
a dorsal linear incision is approximated over the proper joint segments are confirmed fluoroscopi-
lateral extent of the 2nd TMT taking care to cally. The involved joints are prepped in standard
maintain a skin bridge of at least 3 cm. fashion as described above. Bone autografting
The incisions are deepened and structures are and BMA are utilized as well in this instance.
protected identical to the description above. The Often, the authors will include preparation of the
proper joint segments are confirmed fluoroscopi- intercuneiform joint (intermediate/lateral). Once
cally. The involved joints are prepped in standard appropriate preparation of the involved joint seg-
fashion as described above. Bone autografting ments is completed, provisional fixation is
126 M. A. Prissel and J. E. McAlister

a c

b d

Fig. 12.3 (a, b) Postoperative weight-bearing AP (A) weight-bearing AP (A) and lateral (B) radiographs dem-
and lateral (B) radiographs demonstrating 1st & 2nd TMT onstrating plate fixation for 1st & 2nd TMT fusion with
fusion with described construct. (c, d) Postoperative modified construct
12 Tarsometatarsal Joint Arthrodesis 127

inserted and position is verified fluoroscopically. the cuneiforms a third staple can be utilized in a
The joint segments are provisionally stabilized transverse orientation to compress and stabilize
with guide wires for 4.0 mm cannulated screws. the intercuneiform space. Alternate fixation con-
The typical construct for the compression screws structs can be considered, including a dual ray
is similar to the isolated TMT screw fixation from anatomically contour joint-specific 2nd and 3rd
the lateral base of each involved metatarsal to the TMT plate or a single-column TMT anatomically
associated cuneiform, for both the 2nd and 3rd contoured plate for each the 2nd and 3rd
TMT joints. Once the screw fixation is placed, TMT. Closure is obtained of the subcutaneous
supplementary dorsal compression staple fixation layer and skin by the surgeon’s preferred method
is applied to each TMT. At the proximal extent of (Figs. 12.4a–g and 12.5a–f).

a b

Fig. 12.4 (a, b) Preoperative AP (A) and lateral (B) foot the plantar half of the fusion surfaces. (e) Final fixation
radiograph demonstrating significant 2nd & 3rd TMT construct with headless screw fixation and dorsal staple
arthritis. (c) Hintermann retractor based distraction for for the 2nd and 3rd TMT joints. (f, g) Mature fusion of
joint preparation. (d) Cannulated screw headless fixation 2nd and 3rd TMT arthrodesis
for the 2nd and 3rd TMT joints providing compression to
128 M. A. Prissel and J. E. McAlister

d f

Fig. 12.4 (continued)

12 Tarsometatarsal Joint Arthrodesis 129

a b

Fig. 12.5 Preoperative radiographic imaging of neglected Postoperative AP (d), oblique (e), and lateral (f) radio-
subtle Lisfranc injury with 2nd and 3rd metatarsal base graphic imaging of primary fusion for neglected subtle
fractures with AP (a), close up oblique (b), and lateral (c). Lisfranc injury, sparing the 1st TMT articulation
130 M. A. Prissel and J. E. McAlister

d e

Fig. 12.5 (continued)

12 Tarsometatarsal Joint Arthrodesis 131

12.6 Multiple TMT Fusion intercuneiform spaces is performed to provide

with Wedge Resection further stability to the construct. The joint sur-
faces are bone grafted, as described above.
For instances of more complex deformity (e.g., Provisional fixation is applied with guide wires
neglected Lisfranc fracture/dislocation), a mul- for the 4.0 mm screws. The position of the fixa-
tiple TMT fusion (1st, 2nd, 3rd TMT) with tion is dependent on the specific deformity pres-
wedge resection can be considered. A dual inci- ent, but often some combination of longitudinal
sional approach is preferred for this technique (e.g., 1M–1C) and oblique (e.g., 1C–2M) is
with a linear medial incision about the 1st TMT required. Supplemental fixation is then applied
and a linear dorsal incision over the 3rd most commonly with a medially based locking
TMT. Preoperative deformity correction plan- plate construct to the 1st TMT and dorsal fixa-
ning is helpful for this technique to understand tion across the 2nd and 3rd TMT joints with
the apex, extent, and multiplanar orientation of either compression staples or anatomically con-
the deformity. In this application more extensive toured locking plates. Closure is obtained of the
dissection is often required taking care to expose subcutaneous layer and skin by the surgeon’s
the dorsal surface of the TMT joints between the preferred method (Figs. 12.6a–e and 12.7a–g).
incisions protecting the anterior neurovascular
bundle throughout. An Army-Navy retractor or
ribbon retractor should be able to be placed 12.7 Postoperative Management
between the incisions protecting the dorsal skin
and soft tissues prior to execution of the wedge The patient is placed into a well-padded posterior
resection. Once the incisions have been verified, splint. They are clinically evaluated at 7–10 days
completed, and the dissection is deepened to postoperative and converted to short-leg casting
expose the involved joints, K-wires can be at that time. Casting is continued and changed at
placed as cut guide references for the joint 3-week intervals for 6 weeks (i.e., cast change at
resection. Fluoroscopic position of the intended 4 weeks postoperative). At 7 weeks postopera-
resection is verified orthogonally. The wedge tive, consideration is made for weight bearing to
resection is typically performed with an appro- tolerance in a pneumatic walking boot versus
priately sized sagittal saw maintaining proper weight-bearing cast. Interval radiographs are
retraction of the dorsal and plantar soft tissues. obtained at each visit to monitor interval osseous
Alternatively, the resection can be performed integration, maintenance of correction, and hard-
with osteotomes. In the instance of significant ware positioning.
concomitant frontal plane deformity, the resec- Physical therapy is typically initiated at
tion can be extended laterally across the cuboid 8 weeks postoperative, so long as bone healing is
to make a through-­and-­through osteotomy to aid appropriate and the patient is no longer cast
in derotation. The 4th and 5th TMT joint should immobilized. By 10 weeks the patient is transi-
be maintained whenever possible. Once the tioned into a supportive ankle brace and stiff-­
osteotomy is completed, the wedge is excised soled shoe gear. Once postoperative edema has
and joint preparation is completed as noted resolved, the patient is fit for custom-molded
above. Often supplemental preparation of the orthoses.
132 M. A. Prissel and J. E. McAlister

a c d

b e

Fig. 12.6 Preoperative AP (a) and lateral (b) demonstrating TMT arthritis. Postoperative weight-bearing AP (c),
oblique (d), and lateral (e) radiographs following multiple TMT (1–3) arthrodesis via plate fixation constructs
12 Tarsometatarsal Joint Arthrodesis 133

a b

Fig. 12.7 Preoperative AP (a) and lateral (b) weight-­ placement for wedge osteotomy resection (d), sagittal saw
bearing radiographs demonstrating severe TMT arthritis and wedge excision (e), and pre-reduction wedge excision (f).
deformity from chronic, untreated Lisfranc injury. Steinman Postoperative AP (f) and lateral (g) radiographs demonstrat-
pin placement placed as cut guide for wedge resection oste- ing stable union and restoration of the medial arch via wedge
otomy (c). Intraoperative imaging demonstrating wire resection multiple TMT fusion
134 M. A. Prissel and J. E. McAlister

d f

Fig. 12.7 (continued)

12 Tarsometatarsal Joint Arthrodesis 135

12.8 Complications
Pearls
• Postoperative infection • Initial incisional planning is paramount
• Incisional dehiscence/delayed skin healing to successful procedural execution.
• Sensory nerve injury/neuropraxia • Calcaneal autograft and bone marrow
• Injury to the anterior neurovascular structures aspirate aid in excellent fusion surface
• Nonunion apposition.
• Painful or prominent hardware • Low-profile fixation is preferred as the
dorsal soft tissue envelope is minimal.
• Include intercuneiform fixation to pro-
vide more robust arthrodesis constructs.
 Cotton Osteotomy
13
Jeffrey S. Weber

13.1 Patient History and Findings 13.2 Clinical Case Example

The Cotton osteotomy is a medial cuneiform dor- A 41-year-old female with no significant medical
sal opening wedge osteotomy which is utilized in comorbidities presents with the chief complaint
the treatment of the collapsing pes planovalgus of “fallen arches” for several years. She is now
foot type, metatarsus primus elevatus deformity, experiencing pain along the course of the poste-
the overcorrected clubfoot, and forefoot varus rior tibial tendon and within the sinus tarsi. She
deformity. The procedure addresses sagittal plane was referred to the senior author from another
deformity, allowing the surgeon to plantarflex the podiatric surgeon in the area who had tried both
medial column. over-the-counter and custom orthotics. Clinical
The Cotton osteotomy is most commonly per- exam revealed a flexible pes planus deformity
formed as an adjunct procedure to hindfoot with ankle equinus contracture. Radiographic
reconstruction for congenital or adult-acquired views were consistent with adult-acquired flat-
pes planovalgus. In stage II posterior tibial ten- foot (Fig. 13.1a, b). MRI confirmed chronic
don dysfunction (PTTD), the hindfoot progres- thickening of the posterior tibial tendon with
sively falls into valgus and the forefoot and, at tenosynovitis, inflammation within the sinus
times, will compensate by rotating into varus. In tarsi, and no evidence of degenerative joint dis-
stage II, the deformity remains flexible, and ease or tarsal coalition. Surgical intervention
reconstructive procedures focus on joint-sparing included a lateral column lengthening, medial
osteotomies of the calcaneus in conjunction with calcaneal displacement osteotomy, Cotton oste-
a flexor digitorum longus (FDL) tendon transfer otomy, gastrocnemius recession, posterior tibial
with either debridement or repair of the posterior tendon debridement/synovectomy, and FDL ten-
tibial tendon. The decision to perform the Cotton don transfer to the navicular bone (Fig. 13.1c, d).
osteotomy is reserved for after all hindfoot proce-
dures have been performed and a residual fore-
foot varus persists. 13.3 Imaging and Diagnostic
Studies

Weight-bearing radiographs of the foot and ankle

are obtained to assess the degree of deformity
J. S. Weber (*)
Birch Tree Foot and Ankle Specialists, (Figs. 13.2a, b, 13.3a, b, and 13.4a). In the patient
Traverse City, MI, USA with adult-acquired flatfoot, ankle films are uti-

© Springer Nature Switzerland AG 2019 137

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_13
138 J. S. Weber

a c

Fig. 13.1 (a) Preoperative AP radiograph of a 41-year-­ (c) Postoperative AP radiograph of a 41-year-old female
old female with stage II PTTD. (b) Preoperative lateral with stage II PTTD. (d) Postoperative lateral radiograph
radiograph of a 41-year-old female with stage II PTTD. of a 41-year-old female with stage II PTTD
13 Cotton Osteotomy 139

a c

b d

Fig. 13.2 (a) Lateral radiograph of a 50-year-old female Cotton wedge with staple fixation. A Z-cut calcaneal oste-
with stage II PTTD. Note the elevated 1st ray deformity. otomy was used to correct transverse and frontal plane
(b) AP radiograph of a 50-year-old female with stage II deformity. (d) Postoperative AP radiograph with allograft
PTTD. Note the increased amount of talar head uncover- Cotton wedge with staple fixation
ing. (c) Postoperative lateral radiograph with allograft

lized to assess for the possibility of stage IV or of a tarsal coalition if there is obliquity between
ankle valgus deformity in which the deltoid liga- the middle and posterior facets of the subtalar
ment has become attenuated [1]. A calcaneal joint. The lateral foot radiograph may show an
axial view is also obtained to assess the degree of elevated first ray when compared to the lesser
hindfoot valgus and may also aid in the diagnosis rays. A loss of congruency of the dorsal cortices
140 J. S. Weber

a c

b d

Fig. 13.3 (a) A 54-year-old obese female with stage II allograft 11 months post-op. (d) Postoperative AP radio-
PTTD. (b) AP radiograph of the same patient. Note the graph status post-subtalar and talonavicular arthrodesis
increased talar head uncovering. (c) Postoperative lateral with Cotton wedge allograft
radiograph showing complete incorporation of the

of the first tarsometatarsal joint with plantar gap- medial column joints will also favor arthrodesis
ping is suggestive of instability of this joint. In as opposed to the Cotton osteotomy.
this case, along with the clinical finding of a Advanced imaging studies such as MRI and CT
hypermobile first ray, a first tarsometatarsal joint scan will give insight into any subtle arthritic
arthrodesis is favored to address the instability of changes within medial column joints that are not
the medial column as opposed to the Cotton oste- seen on plain films. Arthritic changes, as stated
otomy. Arthritic changes in the hindfoot or before, would then favor a plantarflexory arthrodesis
13 Cotton Osteotomy 141

a of either the first tarsometatarsal or naviculocunei-

form joint (Fig. 13.5a–d). Differential corticosteroid
injections into these joints utilizing live fluoroscopy
may also aid in surgical decision-making.

b 13.4 Surgical Management

13.4.1 Preoperative Planning

Oftentimes, the decision to perform the Cotton

osteotomy is reserved for after hindfoot correc-
c tion has been obtained and a forefoot varus per-
sists when the hindfoot is held in neutral position.
Surgical consent for reconstruction of the pes
planovalgus deformity often notes the possibility
of the Cotton osteotomy, and the patient is edu-
cated on the possibility of this prior to surgery.
The proper equipment for the procedure is made
readily available on the day of surgery.

13.4.2 Positioning and Equipment

If a medial calcaneal displacement osteotomy

(MCDO) or lateral column lengthening osteot-
omy (Evans osteotomy) is to be performed prior
to the Cotton osteotomy, the patient is placed first
in the lateral decubitus position for the initial part
of the case. Upon completion of one or both cal-
caneal osteotomies, the patient remains draped,
and the operating room staff assist in reposition-
ing the patient into the supine position to address
the posterior tibial tendon pathology and any
residual forefoot supinatus deformity.

Equipment
• Sagittal saw with 9 mm saw blade
• Cotton wedge options
–– Allograft
• Bone
• Metallic
–– Autograft
• Fixation options
–– Staple
Fig. 13.4 (a) Preoperative lateral radiograph of patient
with stage II PTTD. (b, c) Postoperative AP and lateral –– Two-hole locking plate
radiograph status post Z-cut calcaneal osteotomy, FDL –– Wedge plate
transfer, PT tendon debridement, and Cotton osteotomy
142 J. S. Weber

a c

b
d

Fig. 13.5 (a–d) A naviculocuneiform fusion was performed in conjunction with a Z-cut calcaneal osteotomy, flexor
digitorum longus tendon transfer, and posterior tibial tendon tenotomy
13 Cotton Osteotomy 143

There are many commercially available Cotton metallic wedge allograft that accommodates its
osteotomy wedge plates, as well as titanium and own internal fixation with one or two stabilizing
pre-contoured allograft spacers. Each system var- screws that purchase both the graft and medial
ies in graft material and fixation construct, and cuneiform (Figs. 13.2c–d, 13.3c–d, and 13.4b–c).
most have trials which are helpful in sizing in
order to obtain the desired amount of correction.
Cotton-specific opening wedge plates of varying 13.4.3 Approach
sizes allow for internal fixation with the option of
packing the osteotomy site with cancellous bone Incision planning is typically performed with the
autograft, allograft, or other readily available use of intraoperative fluoroscopy and a freer ele-
demineralized bone matrix products. Some sur- vator to identify the central location of the medial
geons have shown excellent correction of forefoot cuneiform on an AP foot view (Fig. 13.6a–c). A
varus with Cotton allograft wedges without the skin marker is then used to draw a “cross-shaped”
use of internal fixation [2]. The author typically mark in the center of the cuneiform (Fig. 13.7a–d).
employs the use of either an allograft fixated with The naviculocuneiform joint and first metatarso-
a two-hole locking plate, a Nitinol staple, or a cuneiform joint boundaries may also be marked

a b

Fig. 13.6 (a–c) A freer elevator or k wire is used with fluoroscopy to mark incision placement on the skin. A lateral
radiograph with a line drawn medially on the foot aids in directing the sagittal saw during the osteotomy
144 J. S. Weber

a b

c d

Fig. 13.7 (a–d) Skin markings are made to outline incision placement and direction of the sagittal saw

to aid in sagittal saw placement when performing a

the osteotomy. The incision, typically 3–4 cm in
length, is carried out in a longitudinal fashion just
medial to the extensor hallucis longus (EHL) ten-
don which is retracted laterally with a self-­
retaining retractor (Fig. 13.8a, b). A periosteal
incision is then made parallel with the skin inci-
sion, and a periosteal elevator is used to free the
periosteum medially and laterally in the central
portion of the medial cuneiform. Care is taken to
avoid any excess stripping of the periosteal blood
supply to the bone.

b
13.4.4 Technique(s)

A 9 mm microsagittal saw blade is held perpen-

dicular to the dorsal cortex of the cuneiform
bone, and a lateral radiograph confirms this
position in the central portion of the bone
(Fig. 13.9a–c). A unicortical osteotomy is then
performed from medial to lateral with small
sweeping passes of the blade to ensure not to
violate the plantar cortex of the medial cunei-
form or the medial c­ ortex of the intermediate Fig. 13.8 (a, b) Dissection is carried down medial to the
cuneiform. A heart-shaped distractor is inserted EHL tendon which is retracted laterally
13 Cotton Osteotomy 145

a b

Fig. 13.9 (a–c) Fluoroscopy aids in proper placement of the osteotomy cut and to ensure the plantar cortex is left intact

into the osteotomy and distracted several milli-

meters to accommodate the smallest trial Intraoperative Pearls and Pitfalls
allograft sizer (Fig. 13.10a, b). The sizer is • Intraoperative fluoroscopy aids in inci-
inserted and the subtalar joint is held in its neu- sion placement. The osteotomy will typi-
tral position (Fig. 13.11a–c). The fifth metatar- cally fall 2 mm proximal to the second
sal head is loaded manually with the surgeon’s tarsometatarsal joint which is used as a
hand locking the calcaneocuboid joint, and the landmark [3]. The incision tends to be
residual amount of forefoot varus can be more lateral than would be initially
assessed. Sequential trial sizers are inserted assumed.
until the appropriate amount of correction is • Avoid extensive periosteal dissection to
achieved. Typical graft size is 5–6 mm. The trial maintain blood supply, and avoid tran-
sizer is removed, and the heart-shaped distractor secting the dorsal ligaments that stabi-
is inserted and slightly over-distracted to lize the naviculocuneiform joint (NCJ)
allow for ease of insertion of the allograft and 1st TMT joints.
wedge. Fixation of choice is then performed • A set of baby Hohmann retractors is
(Fig. 13.12a–h). very helpful in identifying the medial
AP and lateral radiographs are taken to ensure and lateral margins of the cuneiform to
proper graft placement and fixation have been aid in the osteotomy.
achieved. Layered closure is performed with 2–0 • High union rates with allograft wedges
Vicryl for subcutaneous tissue and 3–0 Nylon for limit donor site morbidity of autograft
the skin in horizontal mattress fashion. wedges.
146 J. S. Weber

a
• If the plantar cortex of the medial cunei-
form is violated, the graft stability will
become compromised. In this situation a
two-hole locking plate is recommended
for fixation to stabilize the medial
cuneiform.
• Oversizing the graft may lead to a rigid
forefoot valgus. Take care to assess the
amount of correction needed with trial
sizers to obtain the proper amount of
correction.

Fig. 13.10 (a, b) The heart-shaped distractor is inserted

into the osteotomy and distracted to accommodate the
trial size Cotton wedge
Fig. 13.11 (a–c) Trial wedges are inserted until the
appropriate size is determined. The trial is removed and the
distractor left in place to aid in the insertion of the allograft
13 Cotton Osteotomy 147

a b c

d e

f g

Fig. 13.12 (a–h) The Cotton metal wedge is inserted. Fluoroscopy confirms the position of the graft which is then
fixated with a staple
148 J. S. Weber

this risk. Over-distracting the osteotomy

h before allograft insertion also reduces the
need to tamp the graft into place and thus
reducing graft collapse. Also, thoroughly
rehydrating allograft bone makes it less brittle
and less prone to fragmentation.
• Graft dislocation is also rare and may be
avoided with the use of internal fixation.
• Graft nonunion may occur and may require
revision. The author routinely soaks allograft
in bone marrow aspirate drawn from the
patient’s calcaneus at the beginning of the
procedure to decrease the incidence of
Fig. 13.12 (continued) nonunion.

13.5 Postoperative Care

References
• Please refer to Chap. 1 for postoperative pro-
tocols for this procedure. 1. Bluman EM, Myerson MS. Posterior tibial tendon
rupture: a refined classification system. Foot Ankle
Clin. 2007;12(2):233–49.
2. Myerson MS, et al. Tendon transfer combined with
13.6 Potential Complications calcaneal osteotomy for treatment of posterior tibial
tendon insufficiency: a radiological investigation. Foot
• Graft subsidence and loss of correction are Ankle Int. 1995;16(11):712–8.
3. Yarmel D, Mote G, Treaster A. The cotton osteotomy:
rare with cadaveric allograft but may occur. a technical guide. J Foot Ankle Surg. 2009;48(4):
The use of titanium Cotton wedges decreases 506–12.
 Fourth and Fifth Tarsometatarsal
Degenerative Joint Disease
14
Management

Maria Romano McGann, Bryan Van Dyke,

and Gregory C. Berlet

Arthritis in the fourth and fifth tarsometatarsal located on the lateral aspect of her foot. On phys-
(TMT) joints is an uncommon but challenging ical exam, there are calluses present on the lateral
problem to treat. As the mobile portion of the aspect of her foot. Weight-bearing x-rays of her
lateral column of the foot, the 4th and 5th TMT foot demonstrate significant joint space narrow-
joints are responsible for forefoot accommoda- ing and sclerosis along the 4th and 5th TMT
tion to uneven ground during ambulation. The joints.
lateral column normally experiences about 10°
degrees of motion in both the flexion-extension Case 2 A 55-year-old female with history of
and pronation-supination planes [2]. There is rheumatoid arthritis presents with pain on the
reluctance to fuse this area due to unpredictable lateral aspect of her foot worse in the morning
results [4–6]. A 4th and 5th TMT resection and after standing/walking for long periods of
arthroplasty and tendon interposition is an time. On exam the patient is tender laterally and
excellent technique for lateral column pain in had pain with motion of her 4th and 5th toes.
active patients with significant arthritis in these Radiographs demonstrate significant joint col-
joints [3]. lapse of the 4th and 5th TMT joints.
Corticosteroid injections to these joints have
provided symptomatic pain relief in the past,
14.1 Case Presentation however, only give her a few hours of relief
currently.
Case 1 A 40-year-old female with a remote his-
tory of a foot injury where she sustained a lis-
franc fracture and underwent ORIF. Pain in her 14.2 Presentation
foot has progressively gotten worse and is now
Arthrosis along the lateral column of the foot in
the 4th and 5th tarsometatarsal (TMT) joints is
M. R. McGann (*) rare yet problematic in the young, active
Romano Orthopaedic Center, Oak Park, IL, USA patients. Patients will present with pain on the
B. Van Dyke lateral aspect of their foot. There may be cal-
Summit Orthopaedics, Idaho Falls, ID, USA luses present on the bottom of their feet due to
G. C. Berlet uneven ground loading of the forefoot. A
Orthopedic Foot & Ankle Center, remote history of a lisfranc injury may be pres-
Worthington, OH, USA ent, where an undiagnosed injury to the lateral

© Springer Nature Switzerland AG 2019 149

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_14
150 M. R. McGann et al.

column likely occurred. Patients may also have 14.3 Imaging and Diagnostic
a history of inflammatory arthropathy. There Studies
also may have been an isolated “nutcracker”
injury where the 4th and 5th metatarsals force- The standard radiographs that should be obtained
fully abduct compressing the cuboid against the are three weight-bearing views of the foot,
calcaneus. including an AP, lateral, and oblique view. The
Surgical options for these patients include oblique view may allow the physician to best
interpositional arthroplasty and arthrodesis. evaluate the 4th and 5th TMT joints. Differential
Raikin and Schon reported on arthrodesis for injections may also be useful to localize which
lateral column arthrosis in severe TMT arthritis joints are causing the most pain for patients. To
which can help with pain relief as a joint oblit- ensure exact placement of the injections, fluoros-
eration technique [1]. This is only indicated in copy is used. Radiopaque dye is utilized in the
the situation of profound instability such severe injection to confirm intra-articular placement.
lisfranc fracture/dislocation or Charcot arthrop- Pain diaries can be given to patients for 1 week to
athy. Otherwise, arthrodesis in an active patient document response to the injection. A positive
is not tolerated well, and it creates a stiff lateral response to the differential injection is prognostic
column that cannot accommodate the ground. for the amount of pain relief expected with a sur-
Interpositional arthroplasty of the 4th and 5th gical intervention.
TMT joints has been described with several dif-
ferent techniques. Berlet and Anderson pub- Preferred Technique Soft Tissue Interpositional
lished good results utilizing primarily the Arthoplasty for 4th and 5th TMT Joints
peroneus tertius tendon [3]. This technique uti-
lizes nearby autogenous tissue and showed little
postoperative collapse of the joint space. Pain 14.4 OR Setup
improved on average 35% and average AOFAS
scores were 64.5 at over 2 years. Allograft inter- Preoperative planning is imperative for the
position with commercially available products patient. Active patients with stable, arthritic joints
such as regenerative tissue matrix has been are excellent candidates for this procedure.
described in other joints, and we have had suc- Position the patient at the foot of the bed with a
cess with this for the 4th and 5th TMTs as well bump on the ipsilateral hip. Preoperative popli-
[7]. Another described technique utilizes a teal block helps with postoperative pain control.
spherical ceramic implant for the interposition The equipment required include:
[8]. A burr is used to create a hemispherical
recess in the opposing joint surfaces. Typically 1. Weitlaner self-retainer
an 11 mm ceramic sphere is utilized as the final 2. Hintermann retractor
implant. They advocate that this procedure is 3. Mini fluoro
simpler to perform than tendon interposition and 4. Drill
still provides the benefits of preserved motion 5. 1/4 inch curved osteotome
compared to arthrodesis. In recent years at our 6. Allograft implant if not performing tendon
institution, soft tissue interposition with allograft interposition
is most commonly performed. 7. Pineapple burr
14 Fourth and Fifth Tarsometatarsal Degenerative Joint Disease Management 151

Procedure
Intraoperative Pearls and Pitfalls
1. Exsanguinate limb and inflate the tourniquet.
• It is important to preserve the lateral cap-
2. A dorsal lateral incision paralleling the long
sule between the 5th metatarsal and the
axis of the foot centered on over 4th metatar-
cuboid that acts as a collateral ligament
socuboid joint.
stabilizer of the lateral column TMT
(a) Take care to avoid the sural nerve.
joints.
(b) Full-thickness skin flaps are created, and
• Take care to insure the interpositional
peroneus tertius and EDL of 4th toe are
material stays secured with joint during
exposed.
closure. A free-floating graft, regardless
3. For tendon interposition:
of the material type, will tend to create a
(c) Peroneus tertius or 4th extensor longus
foreign body-like reaction and associ-
can be utilized. Release peroneus tertius
ated swelling.
tendon proximally and retract it out of the
wound. (Use 4th EDL when peroneus ter-
tius is absent.)
4. Perform a dorsal capsulotomy over 4th and
14.6 Potential Complications
5th TMT joints.
5. Debride the joint, with care to maintain plantar
• Sural nerve injury
and medial ligaments as well as lateral capsule
• Persistent pain; may address with arthrodesis
for support. Consider creating a recess to
in severe cases
accommodate the ball shape of the graft.
6. Debride the joint down to subchondral bone
of MTs to create 1 cm space in proximal-­
References
distal direction.
7. For tendon interposition, roll up tendon into 1. Raikin SM, Schon LC. Arthrodesis of the fourth and
“anchovy” and place across the joint in neu- fifth tarsometatarsal joints of the midfoot. Foot Ankle
tral position in coronal and pronation/supi- Int. 2003;24(8):584–90.
nation planes. If using allograft, implant may 2. Ouzounian TJ, Shereff MJ. In vitro determination of
midfoot motion. Foot Ankle. 1989;10:140–6.
be secured within joint by using 0-vicryl 3. Berlet GC, Anderson RB. Tendon arthroplasty for
suture through the plantar capsule. basal fourth and fifth metatarsal arthritis. Foot Ankle
8. 0.062 K wire from distal-lateral to proximal-­ Int. 2002;23(5):440–6.
medial through interpositional tissue to help 4. Komenda GA, Myerson MS, Biddinger
KR. Results of arthrodesis of the tarsometatarsal
further secure it in place. joints after traumatic injury. J Bone Joint Surg.
9. If possible, close capsule dorsally with 1996;78A:1665–76.
absorbable suture. 5. Mann RA, Prieskorn D, Sobel M. Mid-tarsal and
10. Routine skin closure and well-padded posterior tarsometatarsal arthrodesis or primary degenerative
osteoarthrosis or osteoarthrosis after trauma. J Bone
splint applied with ankle in neutral position. Joint Surg. 1996;78A:1376–85.
6. Sangeorzan BJ, Veith RG, Hansen ST. Salvage of
Lisfranc’s tarsometatarsal joint by arthrodesis. Foot
14.5  ost-Op Care (See Protocol
P Ankle Int. 1990;10(4):193–200.
Chapter) 7. Berlet GC, Hyer CF, Lee TH, Philbin TM, Hartman
JF, Wright ML. Interpositional arthroplasty of the
first MTP joint using a regenerative tissue matrix
(d) NWB 6–8 weeks in splint, then pull pins. for the treatment of hallux rigidus. Foot Ankle Int.
Once pins are removed, may begin WBAT. 2008;29(1):10–21.
(e) Slow recovery over a year with x-rays that 8. Shawen SB, Anderson RB, Cohen BE, Hammit
continue to appear as arthritis. The x-ray MD, Davis WH. Spherical ceramic interposi-
tional arthroplasty for basal fourth and fifth
appearance should not be too disconcerting metatarsal arthritis. Foot Ankle Int. 2007;28(8):
as the clinical picture often is asymmetric to 896–901.
the x-ray appearance.
 Tibialis Anterior Tendon Ruptures
15
Corey M. Fidler and Patrick E. Bull

15.1 Introduction/Case Examples digits may also be present as the long extensor
tendons attempt to compensate for the lack of
Ruptures of the tibialis anterior tendon are ankle dorsiflexion. In the cases of chronic rup-
uncommon but will typically present after an tures, there may be contracture of the heel cord
acute injury or as either an acute or chronic foot which must be addressed if surgical intervention
drop. In the setting of an acute injury, the injury is pursued by adding a gastrocnemius or Achilles
mechanism is typically blunt tendon trauma or tendon lengthening to the procedure selection.
laceration. Acute ruptures of a healthy tendon Clinical examination alone is usually suffi-
are rare [1, 2]. Atraumatic ruptures tend to occur cient for diagnosis of a tibialis anterior tendon
in older individuals with underlying chronic rupture; however, in chronic tendon ruptures with
tendinopathy. Those patients with diabetes mel- no history of trauma, a MRI may be useful in
litus, inflammatory arthropathy, or gout, or who determining the extent of pre-existing tendinopa-
are undergoing treatment with corticosteroids, thy and the amount of tendon retraction. Plain
are at higher risk for spontaneous ruptures [3]. film radiographs are rarely valuable unless the
A minor traumatic event may involve an eccen- intent is to rule out bony pathology or if there is
tric load applied to a plantar-flexed ankle. suspicion that a foreign body produced the
Physical findings include the presence of a rupture.
foot drop with a steppage gait, swelling, and dis- In the case of an atraumatic rupture, imaging
continuity of the tibialis anterior tendon sheath. studies should be reviewed to identify any pre-
Sometimes an anterior ankle palpable mass or existing tendinopathy that may pursuade the sur-
pseudotumor may be the chief complaint. In the geon to consider a tendon transfer. In addition, a
case of acute injuries, osseous or other soft tissue MRI may show the presence of a plantaris or
injuries may accompany the findings of foot peroneus tertius tendon that may be harvested if a
drop. An extension deformity of the hallux and/or graft is needed. The amount of ankle equinus
should be fully evaluated, and if the patient is
unable to achieve 10° of dorsiflexion, an Achilles
tendon or gastrocnemius lengthening should be
C. M. Fidler (*)
Carilion Clinic, Department of Orthopaedic Surgery, performed.
Roanoke, VA, USA
e-mail: [email protected]
P. E. Bull
Orthopedic Foot & Ankle Center,
Worthington, OH, USA

© Springer Nature Switzerland AG 2019 153

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_15
154 C. M. Fidler and P. E. Bull

15.1.1 Surgical Technique able braided high stength suture using a Krakow
with gift-box suture pattern.
The patient is placed in the supine position. The proximal aspect of the EHL tendon is in
General anesthesia is administered with the addi- a separate tendon sheath adjacent to the tibialis
tion of a popliteal and saphenous nerve block. A anterior tendon. A separate 4-cm incision is
thigh tourniquet is used and the leg is exsangui- made over the distal EHL tendon. Identify both
nated for hemostasis. Once the patient is under the EHL and extensor hallucis brevis (EHBr)
general anesthesia, and complete muscle relax- tendons. The EHL tendon is harvested just prox-
ation is achieved, the presence of equinus is imal to the first metatarsal phalangeal joint while
tested utilizing the Silfverskiold test. A gastroc- ensuring adequate length remains for EHBr
nemius recession or Achilles tendon lengthening tenodesis. The EHL can be pulled proximally
is performed if necessary (Chap. 31). into the tibialis anterior exposure field. Place a
Surgical management is indicated in younger, whip stitch with 0 nonabsorbable suture through
more active patients, while lower-­ demand the distal end of the harvested EHL tendon.
patients can be treated either surgically or conser- Abundant EHL length is the norm, but if graft
vatively with a custom ankle-foot orthosis (AFO). length is compromised, many fixation options
Surgical options include direct apposition of the exist to complete the transfer. A short EHL ten-
tendon or repair with either autograft tendon don can be secured to the medial cuneiform with
transfer or allograft reconstruction. Our preferred a suture anchor or an interference screw. Ideally,
technique for tendons that are unable to be the EHL is secured through a drill hole placed
directly apposed is to transfer the adjacent exten- from dorsal to plantar through the medial cunei-
sor hallucis longus tendon. form. The tendon is passed from dorsal to plan-
A standard anterior medial incision is made tar and looped through the bone, brought dorsally
directly over the course of the tibialis anterior ten- along the medial cuneiform, and sutured back on
don that begins proximally at the level of the supe- itself. We prefer to pass the tendon through the
rior extensor tendon retinaculum and ends distally medial cuneiform, place an interference screw,
at the level of the medial cuneiform. Meticulous and then sew the looped tendon back upon itself
soft tissue handling is utilized to help prevent in a “belt and suspenders” technique. It is impor-
wound complications along the anterior ankle. The tant to secure the transfer with the foot in approx-
superior and inferior extensor retinaculum is imately 10° of ankle dorsiflexion. Use a
incised and tagged with suture for repair during high-strength nonabsorbable braided suture 2–0
closure to help prevent adhesions after repair. or larger for the tenodesis. The proximal tibialis
Occasioanlly, the superior extensor retinaculum anterior tendon stump is then tensioned and
can be preserved by isolating the proximal stump sutured side-to-side to the adjacent EHL tendon
and shuttling it inferiorly and deep to the retinacu- with 0 nonabsorbable suture. A side-to-side
lar layer. This ensures an intact superior retinacu- anastomosis is also performed between the distal
lum and decreases the liklihood of post-operative EHL stump and the EHBr tendon with the hallux
scarring and tendon “bowstringing”. The tibialis maintained in 10–15° of dorsiflexion. Tenodesis
anterior sheath is incised and the proximal and dis- with the hallux in neutral dorsiflexion can lead to
tal stumps are isolated. Occasionally there is suf- disappointing hallux extensor lag postopera-
ficient existing tendon for direct apposition; tively. To avoid wound healing complications
however, if there is concern that the repair will be and tendon “bowstringing,” take care to close the
incompetent, or if no tendon excursion is appreci- tibialis anterior tendon sheath and extensor reti-
ated, then proceed with the extensor hallucis lon- nacula with absorbable suture. The ankle is then
gus (EHL) tendon transfer. Direct tendon repair, splinted in 10° of dorsiflexion (Figs. 15.1, 15.2,
when possible, is performed with a 2-0 nonabsorb- 15.3, and 15.4).
15 Tibialis Anterior Tendon Ruptures 155

Fig. 15.1 A separate 2–4-cm incision is made over the

distal extensor hallucis longus (EHL) tendon. The tendon
is harvested proximal to the first metatarsal phalangeal
joint with care taken to leave a distal stump large enough
to attach to the EHB tendon. A side-to-side anastomosis is Fig. 15.3 Proximally, a side-to-side anastomosis is per-
performed to the extensor hallucis brevis tendon formed to the EHL and tibialis anterior tendons using 0
nonabsorbable suture

Fig. 15.2 A whip stitch is placed with 0 nonabsorbable

suture through the end of the harvested extensor hallucis
longus tendon. Gentle traction is applied to ensure there is Fig. 15.4 The completed repair
adequate length of the tendon for its attachment to the
medial cuneiform
156 C. M. Fidler and P. E. Bull

15.2 Post-Op Care

the tendon reconstruction under excessive
Please refer to Chap. 1 for a detailed description tension during early healing. To reduce
of the postoperative protocols for all procedures. postoperative hallux extensor lag, place a
gauze bumper under the distal hallux to
hold it in extension during early healing.
Pearls and Pitfalls Wound healing issues have been well
documented in reference to anterior ankle
In cases of chronic tibialis anterior rupture, incisions but can be mitigated with meticu-
before proceeding with surgical recon- lous soft tissue handling, minimal use of
struction, it is critical to identify and treat self-retaining retractors, and anatomic
all conditions that may have attributed to repair and closure of the extensor retinac-
the tendon degeneration, and those that ula and tendon sheaths. The relative
may affect healing negatively. Nicotine use strength of the EHL muscle is much less
must be eliminated. Diabetics must demon- compared to the tibialis anterior, so we rec-
strate effective blood sugar control by ommend sewing the remaining tibialis
maintaining their hemoglobin A1c < 7.5%. anterior tendon stump to the EHL tendon
Nutritional markers including total protein, under tension. If the foot is unable to be
albumin, and vitamin D should be tested dorsiflexed 10–15° beyond neutral, a gas-
and deficiencies corrected. trocnemius or Achilles tendon lengthening
Prior to inflating the thigh tourniquet, must be performed.
palpate and mark out the dorsalis pedis Failure of the tendon transfer at its
artery as a reminder to its location through- attachment distally to the medial cuneiform
out the case. While passing the EHL can be seen which is why we prefer the
through the medial cuneiform, it can be “belt and suspenders” approach. Weakness
challenging to have the tendon make the in hallux dorsiflexion is not uncommon
sharp turn plantarly prior to redirecting it after EHL tendon transfer. It is important to
dorsally. Take some time to bluntly develop retain a distal stump large enough to be
a robust extra-periosteal soft tissue plane adequately anastomosed to the EHB with
along the medial cuneiform to allow turn- the hallux in 10–15° of dorsiflexion which
ing and passage of the graft. A pre-bent will help prevent toe drop.
Hewson suture passer works well to facili-
tate passage of a looped suture into the
cuneiform that can then be used to shuttle
the EHL whip stitch suture through and References
around the anchor site. Lastly, when drill-
1. Sammarco VJ, Sammarco GJ, et al. Surgical repair of
ing the cuneiform tunnel, plan to have the acute and chronic tibialis anterior tendon ruptures. J
plantar tunnel aperture as medial as possi- Bone Joint Surg Am. 2009;91:325–32.
ble to minimize graft passage difficulties. 2. Ouzounian TJ, Anderson R. Anterior tibial tendon
While applying the postoperative splint, rupture. Foot Ankle Int. 1995;16:406–10.
3. Markarian GG, Kelikian AS, et al. Anterior tibi-
carefully hold the ankle in dorsiflexion alis tendon ruptures: an outcome analysis of opera-
until it is completely dry to avoid having tive versus nonoperative treatment. Foot Ankle Int.
1998;19:792–802.
 Charcot Midfoot
16
W. Bret Smith and Justin Daigre

Charcot arthropathy (CA) is well established in the advanced deformity is most often achieved via
literature as a destructive and disabling condition of internal and/or external fixation. Risk stratification
the foot and ankle [1–4]. A defining characteristic of of patients considered for surgical reconstruction
CA is the initial insidious, cumulative onset of clini- is important since complications (infection, hard-
cal symptoms, which are often uncorrelated with ware failure and limb loss) related to these proce-
negative radiographic observation [2, 4]. Quite dures can be significant [10–12]. Typically the risk
often, affected neuropathic patients are oblivious to of limb loss from an infection or gross midfoot
recurrent tissue microtrauma, leading to disruption instability with inability to ambulate forces the
of bony architecture, structural instability, recurrent surgeon and patient alike to accept the high surgi-
plantar ulceration, and ultimately increased ampu- cal risks. While these procedures are relatively
tation risk [2, 4, 5]. In its most benign form, the clas- common, the superiority of any specific surgical
sic rocker-bottom CA midfoot deformity can have a technique has yet to be established [4].
profound negative effect on patient function and Midfoot Charcot is the most common ana-
quality of life [5]. As an advanced pathology, CA tomic type and frequently affects the Lisfranc
can lead to severe infection with a reported 28–37% joint and adjacent tarsometatarsal joints [13, 14].
increase in patient mortality [6–8]. These deformities affect all three planes resulting
Recent data suggests that surgical measures are in sagittal plane collapse with resultant rocker-
only warranted once deformity has progressed to a bottom deformity, transverse plane abduction and
non-plantigrade foot at high risk for ulcer forma- varying frontal plane deformity. The medial and
tion [9]. With newer techniques, such as beaming, plantar bony prominences from deformity cause
addressing these deformities earlier may lead to the patient to be at risk for ulceration.
better patient outcomes. Specific techniques to CA of the midfoot can also involve the navicu-
remove bony prominence and reduce tissue strain locuneiform joints and the transverse tarsal joint.
can include exostectomy and tendo-Achilles As the CA deformity progresses proximally, there
lengthening (TAL). However, correction of is a blur between midfoot and hindfoot Charcot.
Technically, transverse tarsal joint deformity is
W. B. Smith considered both hindfoot and midfoot and needs to
Foot and Ankle Division Palmetto Health-USC be addressed as both. Although this chapter is sep-
Orthopedic Center, Palmetto Health, Department of arate from the hindfoot Charcot chapter, there can
Orthopedic Surgery, Lexington, SC, USA often be a mixed picture of Charcot midfoot and
J. Daigre (*) hindfoot. Both deformities need to be addressed to
Decatur Morgan Hospital, Decatur Orthopaedic achieve the best outcome.
Clinic, Decatur, AL, USA

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C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
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158 W. B. Smith and J. Daigre

16.1 Clinical Example and E). A Hintermann distractor was used, and the
talonavicular and first tarsometatarsal joints were
A 58-year-old male with long-standing diabetes pre- prepared by denuding all the cartilage and drilling
sented to clinic with a swollen, erythematous foot. the subchondral bone. Because of the multiplane
Total contact casting was pursued for several weeks deformity, a biplanar wedge was resected around
to decrease his swelling and his erythema resolved. the naviculocuneiform joints (Figs. F and G). The
After nonoperative treatment he still had significant midfoot was reduced in a corrected position (Fig.
pes planus and a rocker-­bottom deformity. We dis- H) and pinned into place. A dorsal incision was then
cussed options including CROW boot and surgical made at the first and second metatarsophalangeal
intervention, he elected for surgical correction. (MTP) joints, and beaming screws were inserted to
Figures A and B reveal the preoperative defor- hold the correction. Two-month postoperative
mity. A medial approach was used, and the tibialis images (Figs. I and J) show good correction of fore-
anterior was released from its insertion and tagged foot abduction and restoration of Meary’s angle.
(Fig. C). The talonavicular, naviculocuneiform, and
first tarsometatarsal joints were exposed (Figs. D c

b
16 Charcot Midfoot 159

f i

h
160 W. B. Smith and J. Daigre

16.2 Midfoot Charcot Reconstruction

16.2.1 OR Setup

• The patient is positioned supine on the OR

table. A thigh tourniquet is usually utilized
to decrease blood loss. The ideal position of
the foot is about 45° of external rotation so
the medial midfoot is easily accessible. It
may be necessary to place a bump under the
contralateral hip to externally rotate the
operative foot.
• It helps with imaging to elevate the operative
foot above the nonoperative foot. This can
be accomplished with blankets or OR
positioners.
• Fluoroscopic imaging setup is very important.
For midfoot and some hindfoot CA patients, a
mini C-arm may be sufficient. The large C-arm
is useful if any hardware needs to extend up
into the tibia. Fluoroscopic imaging needs to
come in on the same side as the operative leg
since the surgeon will be sitting facing the
medial midfoot. This will give you access to
the medial midfoot during fluoroscopy.
• The leg is then prepped with the surgeon’s
preference of antiseptic. For non-ulcerated
patients, we generally use a chlorhexidine
scrub brush on the operative area followed by
a commercially available chlorhexidine gluco-
nate with isopropyl alcohol prep. For patients
with large ulcerated areas, we use povidone-­
iodine 7.5% scrub followed by povidone-­
iodine 10% solution (Figs. 16.1 and 16.2).
Fig. 16.1 Common example of a preoperative radio-
graphs of midfoot Charcot
16.3 Hardware
and Instrumentation
ance issues. For ulcerated cases we generally use
For midfoot CA patients, we will generally have a combination of internal fixation and external
available varying sizes of cannulated and non-­ fixation depending on the severity of contamina-
cannulated beaming screws, medial midfoot tion from the ulcer and the presence or absence of
plates/screws, and Ilizarov-type external fixator. osteomyelitis. If infection is present or suspected,
For most non-ulcerated cases, we generally use staging the procedure can be done with osteoto-
all internal fixation. “Combo” fixation with a mies and debridement done at first setting with
static external fixator over top of internal fixation all fine wire external fixation and lateral staged
is often utilized to provide additional strength with internal beaming once ulcer and infection
and support to resist any postoperative compli- issues are resolved.
16 Charcot Midfoot 161

eliminate the attenuated tissue. If the defor-

mity is mobile enough with joint preparation
alone, the TA tendon is generally preserved.
• Once the medial column is exposed, assess-
ment is made whether to perform a wedge
resection osteotomy versus joint preparation
and reduction.
–– For large rocker-bottom deformities, a
wedge resection osteotomy is usually per-
formed. The osteotomy is biplanar and cor-
rects foot abduction and the rocker-bottom
deformity. Restoring Meary’s angle is
largely the target of the osteotomy. There
are several cutting guides available to help
with this, but ultimately it is surgeon
expertise to get the osteotomy correct.
Intraoperatively, Steinman pins can be
placed under fluoroscopic imaging to act as
cut guides for the planned wedge resection.
One wire is placed medial to lateral at the
distal aspect of the level of transverse plane
deformity and perpendicular to the long
Fig. 16.2 Standard medial-based incision for midfoot axis of the forefoot (the midline of the 2nd
Charcot, other incision may be required based on
deformity
metatarsal). The second wire is placed
medial to lateral at the proximal aspect of
It is usually a good practice to have antibiotic the level of deformity, this time perpendicu-
beads available for all CA cases just in case there lar to the long axis of the hindfoot (talar
is infection present unexpectedly. neck bisection). This will give the medially
based closing wedge dimensions. The sur-
geon will need to decide how large the
16.4 Operative Technique wedge will need to be plantarly to correct
the sagittal plane deformity. Preoperative
• In most Charcot midfoot corrections, a triple-­ planning is essential in these cases. Knowing
cut Achilles lengthening is performed. This is what angle and how much to resect is based
usually performed near the beginning of the off preoperative weight-bearing radio-
procedure to help with deformity correction. graphs. CT imaging preoperatively is also
• A medial incision is utilized from the talar helpful in fully assessing levels of instabil-
head to the first metatarsal base. Care is taken ity and bone loss.
to avoid injury to the tibialis anterior (TA) –– One challenge with the osteotomy is it rou-
tendon. tinely needs to fully transect across the foot
• The TA tendon can be retracted and preserved from medial to lateral. Use a Cobb or similar
throughout the case, or the tendon can be elevator to create a full-thickness soft tissue
tenotomized and tagged for repair at the end flap dorsally and plantarly across the foot at
of the case. In many cases the TA tendon can the planned level of osteotomy. Protect and
be incompetent and attenuated secondary to retract the tissue during the osteotomy.
deformity collapse. After deformity correction Several saw blades can be used to accom-
using wedge resection, the TA tendon is rou- plish the osteotomy. The long 515 sagittal
tinely advanced to restore resting tension and saw blade will only make it about half-way
162 W. B. Smith and J. Daigre

across the foot. The rest of the osteotomy There are three main constructs to consider:
will need to be finished with a ½ inch osteo- external fixation, medial column plating, and
tome. Alternatively, one can use the longer beaming technique.
saw blades used in ankle arthroplasty which –– External fixation is mainly used in conjunc-
will be long enough to cross the foot but tion with wounds and/or infection. The ben-
have a much wider sweep effect. Care with efit of external fixation is that all the hardware
the soft tissue and use of the saw guide cap- is planned to be removed. In the face of
tures are recommended with use of these infection, this is a great option. This is also a
blades. Once the osteotomy is performed good “belt and suspenders” option to use to
and the wedge is removed, the foot is protect the internal fixation, to resist any
reduced and confirmed by fluoroscopy. non-compliance weight bearing, and to help
Temporarily pinning the osteotomy reduced protect/resist any recurrent postoperative
will help you obtain simulated weight-bear- Charcot flare-ups. Typically we recommend
ing views in the OR. Restoration of Meary’s a static external fixator though dynamic fixa-
angle on the lateral view is ideal, and the AP tion can be done on a case-by-case basis.
view should show improvement in the • There are now many external fixator
patient’s foot abduction. options on the market. Each company
–– Patients with a somewhat flexible defor- has different techniques and styles for
mity, mild to moderate deformity, or frank applying the fixator. The general princi-
dislocation may be amenable to correction ples are still the same though.
without an osteotomy. All joints involved • We start with a pre-built frame and place
are prepped for fusion. Hintermann’s are it on the leg in the desired position. Use
used to distract the joints. If multiple joints towels or holders to elevate the foot to
are being fused (e.g., talonavicular and the middle of the fixator. Once the foot
naviculocuneiform), place one of the and ankle are in the desired position
Hintermann pins in the navicular and allow inside the fixator, the first pin is drilled
it to be used for both joints. Denude the across the proximal aspect of the frame.
cartilage and rough up the subchondral Confirm that this pin is perpendicular to
bone with a drill and osteotome as with a the tibial axis.
fusion. After all joints are prepped, reduce • Using Illizarov technique, drill multiple
the deformity and temporarily pin the foot half-pins attaching them to the circular
in place. Fluoroscopic imaging is now used rings. Once all the tibial half-pins are in,
to confirm reduction. As mentioned above, then shift focus to the foot. Our preference
the fluoroscopic goal is restoration of is to use half-pins and/or wires in the mid-
Meary’s angle and neutral foot abduction/ tibia with increasing usage of thin wires as
adduction. It is strongly recommended that we move closer to the ankle. Thin wires
all joints in which fixation is crossing be are preferred for fixation on the foot.
prepared and taken down. This is especially • If using only external fixation, all com-
true with beaming across the medial col- pression is through the wire construct.
umn. If wedge resection was down through Crosspin the forefoot and bend the wires
Lisfranc joint, the NC and TN joints are down and attach to the frame. Compress
still recommended to be prepared if medial the wires by tensioning in the bended
column fixation is to be utilized. position. This will compress the joints
• Once reduction of the deformity is confirmed and/or osteotomy and hold the position.
and all joints are prepped, fixation can begin. Multiple wires attached to the frame
16 Charcot Midfoot 163

may be necessary to keep the foot well the guidewire in the first metatarsal to
reduced. If the plan is to use the external obtain good purchase in the talus. Follow
fixator over internal fixation, it is rec- closely with fluoroscopic imaging in the
ommended the internal fixation is placed AP and lateral planes as you advance the
first and then the frame over top of that. guidewire to gain maximum purchase in
It is much easier to redirect fine wires as all bones being crossed.
needed to avoid internal fixation than • Once the wire has been advanced as
the other way around. proximal as needed to span the area of
–– Internal fixation is either with beaming tech- fixation, the reaming process begins.
nique or medial column plating. The trend is Most of the time the wire is advanced
toward beaming secondary to wound com- from the first metatarsal head to the pos-
plications associated with medial column terior talus.
plating. Beaming is also load sharing as • After completion of sequential ream-
opposed to plating. Anecdotally, we have ing, the length for the beam is mea-
found beams to be better than plates at with- sured. The intermedullary beam is then
standing forces longterm if there are delayed placed and secured in such a way as to
unions or nonunions. span the zone of injury from the Charcot
• There are two approaches to inserting process.
the beaming screws at the MTP joint: • Additional beams can be added as needed
dorsal and plantar. The advantage of the based on the deformity present, but at least
plantar approach is it tends to be more two beams should be considered. Beams
of a direct line to get the screw directly in the second metatarsal usually still
into the metatarsal without manipulat- obtain good purchase in the talus unless
ing the phalanx. There is increased risk significant deformity precludes it. Fourth
of damaging the FHL tendon by going metatarsal beaming can stabilize the lat-
plantar, resulting in a floating hallux eral column especially if there is instabil-
deformity. The dorsal approach poses ity at the calcaneo-cuboid joint. Sometimes
minimal risk to surrounding structures the metatarsals have such deformity that
but can sometimes be challenging get- precludes good purchase in proximal
ting the proximal phalanx down enough bone. In these cases, we start the beaming
to get a straight shot. screws at the base of the metatarsals and
• Using a guidewire, direct the wire along direct them into the talus or calcaneus to
the central axis of the selected metatar- obtain good bony purchase.
sal. This part can be very difficult. It is • There are cannulated and solid beams.
recommended to temporarily pin the We try and use only solid beams if pos-
reduced midfoot across all joints and sible. If your reduced position of the
osteotomies before advancing the guide- midfoot is provisionally pinned well,
wire. The first metatarsal canal is fairly then removing the guidewire and plac-
large allowing for variable positions of ing a solid beam screw should not shift
the guidewire. Before starting the guide- your reduction.
wire, look closely at your reduced mid- • Routinely, larger beams (6.5/7.0 mm)
foot on fluoroscopic imaging. Pay are used for the first metatarsal. 5.0 mm
particular attention to the talar-first meta- beams are commonly used for the lesser
tarsal angle to make sure the guidewire is metatarsals (Figs. 16.3, 16.4, 16.5, 16.6,
not going to cut out of the talus. Angle 16.7, and 16.8).
164 W. B. Smith and J. Daigre

Fig. 16.3 Exposure of the medial column of the Charcot Fig. 16.6 Medial beam placement
midfoot

Fig. 16.4 Placement of guide pin for medial column Fig. 16.7 Placement of medial clip for additional distal
beam (notice anterior tibialis has been maintained as you fixation
can see with the retractor)

Fig. 16.5 Placement of guide pin for lateral column Fig. 16.8 Placement of lateral beam
beam
16 Charcot Midfoot 165

16.5 Postoperative Protocol After approximately 4 weeks of non-weight-­

bearing casts, the patient is transitioned into a
Initial postoperative protocol consists of a Jones CAM walker boot. Based on the specific
dressing applied with a posterior splint in the ­deformity and patient factors, early, protected,
operative suite (exception would be if an external limited weight bearing can begin in the protec-
fixator was applied, then posterior splint is tive boot.
unnecessary). Often 8–10 weeks of non- or limited pro-
The patient is seen at their routine postopera- tected weight bearing is recommended prior to
tive follow-up of approximately 10–14 days. Soft allowing full weight bearing in a protective
tissue evaluation is completed, and sutures are CAM walker.
removed if applicable. It is not uncommon to Once the patient has achieved full weight
leave sutures up to 4 weeks in these patients due bearing in the CAM boot, they are transi-
to their underlying medical condition and soft tis- tioned into an appropriate diabetic shoe with
sue compromise. AFO. The AFO will vary based on numerous
Routinely the patient is placed into a non-­ factors, but it is recommended that all patients
weight-­bearing short leg cast at the first postop- who have undergone Charcot reconstruction
erative visit. The exception would be patients of their foot/ankle are braced moving
who are undergoing external fixation protocols. forward.
The cast is maintained for 1–3 weeks based on Proprioceptive rehabilitation programs may
numerous factors such as patients comorbidities, start when the patient is full weight bearing in the
soft tissue, retained sutures, etc. CAM walker or AFO (Fig. 16.9).

Fig. 16.9 Postoperative radiographs demonstrating beaming technique

166 W. B. Smith and J. Daigre

Additional Callouts/Pearls • Critically evaluate the subtalar joint

• Do not hesitate to consider staged recon- when looking at rocker-bottom-type
struction in the event of a long-standing deformity to assess whether fusion of
plantar ulcer. Often an initial aggressive the ST joint is required at the same time.
debridement and soft tissue manage- Our trend is moving toward stabilizing
ment will be completed with the appli- the subtalar joint with fusion on patients
cation of a thin wire fixator to off-­load with CA of the midfoot.
and control the plantar soft tissue. • Be aware of associated instability in
• Aggressive resection of all nonviable bone adjacent regions of the foot such as the
and soft tissue is required during attempted hindfoot or ankle that may need to be
limb salvage and reconstruction. addressed. Have a low threshold to
• Open and honest discussion with the include the subtalar joint in the recon-
patient about the risks inherent to Charcot struction of midfoot Charcot.
reconstruction is key to managing • Always span well past the zone of
expectations. Discussion of need for pos- Charcot damage with the selected
sible amputation is important prior to any fixation.
salvage efforts.

in patients with Charcot foot. Foot Ankle Surg.

References 2009;15(4):187–91.
8. Sohn MW, Lee TA, Stuck RM, Frykberg RG,
1. Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic Budiman-Mak E. Mortality risk of Charcot arthrop-
foot disorders. A clinical practice guideline (2006 revi- athy compared with that of diabetic foot ulcer and
sion). J Foot Ankle Surg. 2006;45(5 Suppl):S1–66. diabetes alone. Diabetes Care. 2009;32(5):816–21.
2. Molines L, Darmon P, Raccah D. Charcot’s foot: 9. Sohn M-W, Stuck RM, Pinzur M, Lee TA, Budiman-­
newest findings on its pathophysiology, diagnosis and Mak E. Lower-extremity amputation risk after char-
treatment. Diabetes Metab. 2010;36(4):251–5. cot arthropathy and diabetic foot ulcer. Diabetes Care.
3. Saltzman CL, Hagy ML, Zimmerman B, Estin M, 2010;33(1):98–100.
Cooper R. How effective is intensive nonoperative 10. Eschler A, Gradl G, Wussow A, Mittlmeier T. Late
initial treatment of patients with diabetes and Charcot corrective arthrodesis in nonplantigrade diabetic
arthropathy of the feet? Clin Orthop Relat Res. charcot midfoot disease is associated with high
2005;(435):185–90. complication and reoperation rates. J Diabetes Res.
4. Wukich DK, Sung W. Charcot arthropathy of the foot 2015;2015:246792.
and ankle: modern concepts and management review. 11. Pinzur MS, Sostak J. Surgical stabilization of non-
J Diabetes Complicat. 2009;23(6):409–26. plantigrade charcot arthropathy of the midfoot. Am J
5. Capobianco CM, Stapleton JJ, Zgonis T. The role of an Orthop. 2007;36(7):361–5.
extended medial column arthrodesis for Charcot mid- 12. Pinzur MS. Neutral ring fixation for high-risk non-
foot neuroarthropathy. Diabet Foot Ankle. 2010;1(0). plantigrade charcot midfoot deformity. Foot Ankle
6. Boyko EJ, Ahroni JH, Cohen V, Nelson KM, Int. 2007;28(9):961–6.
Heagerty PJ. Prediction of diabetic foot ulcer occur- 13. Brodsky JW. The diabetic foot. In: Coughlin MJ,
rence using commonly available clinical informa- Mann RA, Saltzman CL, editors. Surgery of the foot
tion: the Seattle Diabetic Foot Study. Diabetes Care. and ankle. St Louis: Mosby; 2006. p. 1281–368.
2006;29(6):1202–7. 14. Schon LC, Easley ME, Weinfeld SB. Charcot
7. Pakarinen TK, Laine HJ, Maenpaa H, Mattila P, Neuroarthropathy of the Foot and Ankle. Clini
Lahtela J. Long-term outcome and quality of life Orthopa Relat Res. 349:116–31.
 Naviculocuneiform Joint Fusion
17
Jeffrey E. McAlister, Roberto A. Brandão,
Bryan Van Dyke, Maria Romano McGann,
and Christopher F. Hyer

17.1 Introduction joint in all three planes of motion. This chapter

aims to describe the pathomechanics of medial
Selective arthrodeses of the medial column are column fault at the NC joint and how to success-
commonly performed for adult-acquired flat foot, fully provide operative correction of this
posterior tibial tendon dysfunction, and painful deformity.
degenerative arthritis. The correction of fixed or
rigid cavus foot deformity and post-traumatic or
idiopathic AVN may also require midfoot 17.2 Case Example: (Fig. 17.1)
arthrodesis. The naviculocuneiform (NC) joint
fusion is a common source of frustration for the A 47-year-old female with a main complaint of
reconstructive foot and ankle surgeon due to its midfoot pain for greater than 2 years. She has a
high nonunion rate and complex morphology. previous history of ORIF of a talar neck fracture
The three separate facets of the joint may become with successful subsequent talonavicular fusion
problematic when debriding the articular carti- and hardware removal by an outside physician.
lage, fixating across these contoured surfaces, The patient presented with consistent midfoot
and evaluating definitive arthrodesis. There also pain and plain films with evidence of arthritis of
needs to be careful reduction of this collective the NC joint. MRI demonstrated subchondral
cyst formation at the NC joint. She had a cavus
foot type with a varus heel. The plan was NC
joint arthrodesis with bone graft and a lateraliz-
J. E. McAlister (*)
Arcadia Orthopedics and Sports Medicine, ing calcaneal osteotomy (Fig. 17.1).
Phoenix, AZ, USA
R. A. Brandão
The Centers for Advanced Orthopaedics, Orthopaedic 17.2.1 Patient Presentation
Associates of Central Maryland Division,
Catonsville, MD, USA
Patients typically present with medial column
B. Van Dyke pain and possibly symptoms associated with
Summit Orthopaedics, Idaho Falls, ID, USA
stage II and stage III posterior tibial tendon dys-
M. R. McGann function (PTTD). To differentiate from PTTD, a
Romano Orthopaedic Center, Oak Park, IL, USA
focused medical history and thorough physical
C. F. Hyer examination is performed. Reconstruction for
Orthopedic Foot & Ankle Center,
PTTD is covered more thoroughly in Chap. 18.
Worthington, OH, USA

© Springer Nature Switzerland AG 2019 167

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_17
168 J. E. McAlister et al.

a b

c d

Fig. 17.1 Case example pre-op/post-op. (a–d) Pre- and ing screw, plate, and staple fixation with a lateralizing cal-
post-operative images of the patient presented earlier with caneal osteotomy due to hindfoot varus
NC arthritis and continued pain. Fixation methods includ-

For patients with isolated NC pathology, the sur- may be problematic in the surgical management
geon must rule out any neuropathic process of the disease process. If neuropathy is present, a
including uncontrolled diabetes leading to thorough skin examination is performed to con-
Charcot neuroarthropathy. Be aware of any col- firm lack of ulcerations and pre-ulcerative
lagen elastic or rheumatologic disorders which lesions.
17 Naviculocuneiform Joint Fusion 169

Patients typically present with pain that begins 17.3 Preoperative Planning
in the medial arch and progresses laterally to the
sub-fibular/sinus tarsi region. During a weight-­ Preoperative labs should be considered to evalu-
bearing examination, the patient and surgeon typi- ate nutritional status (prealbumin, albumin), dia-
cally notice a distinct collapse in the medial betic control (hemoglobin A1c, blood glucose),
column with a bowing effect. Pain is directed to and electrolyte balance (basic metabolic panel).
the mid arch plantarly and dorsally. Tobacco use should be discontinued prior to any
Radiographically, bone exostosis dorsally and surgical intervention as this will increase the risk
medially is often seen in degenerative cases as of complications in foot and ankle surgery
well as larger plantar and medial prominence with (Bettin). Proper preoperative planning is neces-
sagging of the medial longitudinal arch in cases of sary to assess for bone quality which may influ-
significant instability. Lack of deformity may be ence the hardware choices for optimal fixation.
present in primary arthritis or post-­ traumatic Preoperative patient counseling regarding expec-
cases warranting a focused evaluation to differen- tations and procedure choice is crucial to
tiate from a stress reaction or avascular process. ­long-­term expectation management. This type of
It is difficult to isolate and assess the range deformity or degenerative arthritis state will typi-
motion of the NC joint while the patient is non-­ cally lend itself to making necessary intraopera-
weight-­ bearing. While weight-bearing, the tive decisions, and the consent should reflect as
patient is typically asked to perform a single-leg such.
heel rise on the unaffected and affected limb to
assess the PTT. Additionally, the anterior tibial
tendon (ATT) should be evaluated. In most 17.4 Diagnosis and Imaging
advanced aged patients, there may be chronic
degenerative changes and attenuation of the Standard three-view weight-bearing radiographs
insertional segment of the ATT. This can lead to of the foot should be taken for baseline examina-
graduate loss of medial column height and exac- tion. A calcaneal axial view or Saltzman view can
erbate NC and medial column degenerative be helpful to fully assess hindfoot deformity.
changes [16]. This allows for visualization of the posterior
The NC joint in uniquely positioned within tuberosity and its alignment with the long axis of
the medial longitudinal arch and often times will the tibia. The lateral and anteroposterior (AP)
be burdened with extra reactive forces leading to foot radiographs are the most important for visu-
instability. Unrecognized equinus contracture of alizing joint deformity and arthritis. Again, the
the posterior compartment structures should be lateral radiographs are typically assessed for
considered. The NC joint is critical, yet often medial column collapse, and this can be seen
overlooked, within the medial column. This joint anywhere along be medial column, specifically
will typically develop dorsal osteophytes as the the midfoot and hindfoot joints. As the tibialis
stress and deformity increases. Pain over a dorsal anterior begins to overpower, the medial cunei-
prominence is a common complaint noted by form elevates above the navicular creating visual
patients with worsening pathology. As these instability of the joint in the form of plantar gap-
deformities involve multiple planes and multiple ping [1, 2]. This can clearly be seen on radio-
joints, it is also worthwhile to assess the range of graphs and should not be disregarded. Avascular
motion of the first metatarsophalangeal joint, changes of the navicular or post-traumatic arthri-
assess any digital contractures, and specifically tis of the NC joint can be seen on lateral and AP
evaluate the posterior muscle group for equinus. films. An AP view of the foot will give a clear
170 J. E. McAlister et al.

picture of any arthritic changes to the joint as place the foot in a rectus position. If any ankle
well as any periarticular deformities. procedures are being performed, a large intraop-
Advanced imaging modalities, such as mag- erative fluoroscopy unit can be requested, but is
netic resonance imaging (MRI), are typically uti- not necessary.
lized in preoperative planning for NC joint Preoperative briefing with the operating room
fusion. MRI images can be used to assess for ten- team involves discussions regarding instrumenta-
don integrity as well as the viability of the navic- tion. Reconstructive foot and ankle surgery is
ular especially in post-traumatic or avascular dynamic and lends itself to intraoperative
cases. This may aid in planning the optimal tech- decision-­making, so over-preparation is a surefire
nique for arthrodesis including the use of struc- way to gain confidence. The most commonly
tural graft, biologic augmentation, or site-specific requested instrumentation can include two cord-
hardware choices [3]. If one desires to assess a less power drivers, a Hintermann distractor, and/
specific degree of arthritic changes surrounding or lamina spreader. A corded sagittal saw with a
the midfoot, computed tomography (CT) scans long saw blade may be requested if significant
maybe performed preoperatively. This is most deformity correction is required.
common with severe deformities and Charcot There are many different hardware configura-
neuroarthropathy [9]. If available, weight-bear- tions for this type of procedure such as cannu-
ing CT scans may give a better functional assess- lated screws, locking compression plates, staples,
ment of the joints [17]. and external fixation. The authors advocate for
rigid internal fixation and compression with
­cannulated headed or headless screws often sup-
17.5  R Setup, Instrumentation,
O plemented with staples to provide dorsal com-
and Hardware Selection pression. Biologics are typically utilized during
these cases due to reported higher risk of non-
Arthrodesis of the NC joint is typically com- union with the poor vascularity of the navicular.
bined as part of a hindfoot reconstruction, The authors advocate for either calcaneal or tibial
although it may be indicated as the primary pro- autograft and/or commercially available bone
cedure in isolated arthritic cases. In general, morphogenetic protein (BMP) or plate-derived
these procedures are outpatient procedures built growth factor (PDGF) based on the patient’s
on efficiency and operating cost-effectiveness. healing potential. Greater details on biologics
These cases are typically booked for 1–2 hours will be discussed in Chap. 40. The biologics or
of block time. The authors prefer a preoperative grafts should be placed within the arthrodesis site
popliteal block with general anesthesia, unless prior to removal of main distraction (i.e.,
neuropathy is present in the operative limb. A Hintermann) to allow for equal distribution
supine position is most common unless exten- across the site.
sive lateral ankle and calcaneal osteotomy pro-
cedures are performed. In that instance, the
authors will utilize a lateral to supine approach, 17.6 Operative Technique
starting lateral and converting to supine position
after the calcaneal osteotomy or lateral recon- 17.6.1 Naviculocuneiform Joint
struction is complete. A thigh tourniquet is Fusion
applied to the ipsilateral thigh and set to
300 mmHg. A small, or mini, intraoperative flu- Multiple approaches can be utilized to visualize
oroscopy unit is most commonly used during the joint based on ancillary procedures and indica-
these procedures and positioned on the same tions. Anatomic studies have shown that the medial
side as the operative limb. A bump sandbag, or and central NC facets occupy two thirds of the
blanket, is placed under the ipsilateral hip to joint (Renner [4]). This assists surgeons with deci-
17 Naviculocuneiform Joint Fusion 171

Fig. 17.2 Dorsal incision

sion-making and the importance of joint resection

of at least this amount. If performing the proce-
dure for a cavus foot reconstruction or isolated NC
arthritis, a dorsal medial incision over the NC joint
is utilized. If performing the procedure as a selec-
tive arthrodesis for PTTD, an incision can be made
Fig. 17.3 (a, b) Hintermann distractor placement and
medially. Both approaches allow for visualization
joint distraction
of the joint, although the dorsal approach allows
for more lateral joint resection [13–15].
A 2–3 cm incision is made and dissection car- services. Care is taken to avoid excessive bone
ried down to the joint level. The tibialis anterior resection to avoid excessive medial column
and extensor hallucis longus tendons traverse this shortening causing lateral column overload.
joint dorsally and should be retracted throughout Once the cartilage is removed, a solid drill bit
the procedure (Fig. 17.2). If a medial incision is (2.0–3.0 mm) is used to fenestrate to subchondral
chosen, tibialis anterior should be retracted and bone, and a small osteotome is used to fish scale
may need to be elevated off the navicular to place the joint as well.
hardware. A capsulotomy is performed at the If significant deformity correction is required
joint level, and a pin-to-pin Hintermann retractor for a transverse plane deformity, a medial
(Fig. 17.3) or lamina spreader is utilized to help approach is performed, and two converging
visualize the extent of the joint surfaces during K-wires from the medial with apex lateral are
joint preparation. A quarter-inch curved osteo- used to resect an appropriately sized wedge from
tome and small curette are used to debride the the joint. More bone from the cuneiforms is
remaining articular cartilage from the joint resected, and the pin position reflects this.
172 J. E. McAlister et al.

Typically the wedge avoids taking bone from the

cuboid to reduce lateral column instability, but
may be necessary for severe deformities. The pin
placement is visualized under fluoroscopy and
resected to the apex with a large sagittal saw. A
bone wedge is removed with a rongeur and osteo-
tome. The site is irrigated and bone graft impacted
into the joint as needed. Reduction of this joint is
important [10–12].
In a cavus foot type, the reduction is per-
formed by closure of the osteotomy by dorsiflex-
ion of the forefoot on the hindfoot. Additionally,
reciprocal planing is usually performed for close
apposition. In the collapsed foot type, the medial
cuneiform is dorsal to the navicular and must be
repositioned to a rectus or slightly plantar atti-
tude. By dorsiflexing the first ray, the windlass
mechanism is activated, the forefoot is loaded,
and the joint is provisionally pinned into
position.
The fixation choice depends on ancillary pro- Fig. 17.4 NC fusion construct
cedures, adjacent joint fusions, indications for
the procedure, and surgeon preference. For the medial-based locking compression plates, dorsal
purposes of this chapter, an isolated NC fusion is plating, and staples. Closure is then undertaken
described. There are no studies at this time with absorbable layered closure and surgeon
assessing appropriate fixation, and no standard preference for the skin (Figs. 17.5 and 17.6).
exists for constructs [5, 6, 8]. With the joint
reduced, two stacked guidewires are inserted
from the navicular tuberosity into the medial and 17.6.2 Postoperative Protocol
intermediate cuneiform, respectively. A third
guidewire is placed in the distal-most aspect of A standard postoperative compressive bulky
the medial cuneiform into the lateral pole of the Jones dressing is applied with a posterior splint.
navicular. Alternatively two screws may be Generally, patients are seen at 7–14 days postop-
placed from the navicular into the medial and lat- eratively and placed into a short-leg non-weight-­
eral cuneiforms followed by a third screw from bearing cast. Sutures are removed when the
the medial cuneiform into the lateral navicular incisions have healed and the patient is placed
pole. At minimum, place two screws from the into a weight-bearing cast followed by a cam
navicular into the medial and intermediate cunei- walker boot. Serial radiographs are used to con-
forms to assist with fusion mass (Fig. 17.4). In a firm healing of the performed osteotomies.
cavus foot, especially after a dorsal closing Physical therapy typically begins after the patient
wedge osteotomy, fixation in the lateral cunei- begins weight-bearing in a brace and resumes
form is necessary for stability. Guidewire place- until the patient can comfortably bear weight in a
ment is then confirmed on intraoperative supportive shoe with an accommodative custom
fluoroscopy. Talar head uncoverage and Meary’s fabricated orthosis. CT scans are often taken
angle reduction is then confirmed on fluoroscopy around 4–6 months to confirm osseous healing
and clinical examination for reduction in arch [17]. The remainder of the postoperative protocol
collapse. Optional fixation techniques include is described in detail in Chap. 1.
17 Naviculocuneiform Joint Fusion 173

Fig. 17.5 A 52-year-old male with isolated NC arthritis who underwent NC joint arthrodesis with bone graft and bone
marrow aspirate augmentation

Pearls and Pitfalls: Resident Resource • It is important to place the forefoot in

• The naviculocuneiform joint is complex valgus when reducing the forefoot varus
and its motion is important to understand. deformity.
• An arthrodesis of the NC joint spares • Due to the inherent complication rate,
the transverse tarsal joint and allows the steadfast use of cost-effective biologics
forefoot to remain less rigid. is prudent intraoperatively.
• Use a Cobb elevator to open and free the • The NC joint is a triplanar joint, and
lateral NC joint capsule as the surgeon care must be taken to manipulate the
works from medial to lateral. corrected position in all three planes.
174 J. E. McAlister et al.

4. Renner K, McAlister JE, Galli MM, Hyer

CF. Anatomic description of the naviculocuneiform
articulation. J Foot Ankle Surg. 2017;56(1):19–21.
5. Aiyer A, Dall GF, Shub J, Myerson
MS. Radiographic correction following reconstruc-
tion of adult acquired flat foot deformity using the
cotton medial cuneiform osteotomy. Foot Ankle Int.
2016;37(5):508–13.
6. Ajis A, Geary N. Surgical technique, fusion
rates, and planovalgus foot deformity correction
with naviculocuneiform fusion. Foot Ankle Int.
2014;35(3):232–7.
7. Jordan TH, Rush SM, Hamilton GA, Ford
LA. Radiographic outcomes of adult acquired flatfoot
corrected by medial column arthrodesis with or with-
out a medializing calcaneal osteotomy. J Foot Ankle
Surg. 2011b;50(2):176–81.
8. Barg A, Brunner S, Zwicky L, Hintermann
B. Subtalar and naviculocuneiform fusion for
extended breakdown of the medial arch. Foot Ankle
Clin. 2011;16(1):69–81.
9. Lee DG, Davis BL. Assessment of the effects of dia-
betes on midfoot joint pressures using a robotic gait
simulator. Foot Ankle Int. 2009;30(8):767–72.
10. Rush SM, Jordan T. Naviculocuneiform arthrodesis
for treatment of medial column instability associated
with lateral peritalar subluxation. Clin Podiatr Med
Surg. 2009;26(3):373–84.
11. Budny AM, Grossman JP. Naviculocuneiform
arthrodesis. Clin Podiatr Med Surg. 2007;24(4):753–
63, ix-x.
12. Cohen BE, Ogden F. Medial column procedures in
Fig. 17.6 A 76-year-old female with a tibialis anterior the acquired flatfoot deformity. Foot Ankle Clin.
tendon rupture who underwent and extensor hallucis ten- 2007;12(2):287–99.
don transfer and concurrent NC and first tarsometatarsal 13. Greisberg J, Assal M, Hansen ST Jr, Sangeorzan
joint arthrodesis with bone graft. She was ambulating in BJ. Isolated medial column stabilization improves
normal shoes and pain-free at 10-month follow-up alignment in adult-acquired flatfoot. Clin Orthop
Relat Res. 2005;435:197–202.
Complications 14. Greisberg J, Hansen ST Jr, Sangeorzan B. Deformity
and degeneration in the hindfoot and midfoot
• Nonunion (8.5% Jordan) [7] joints of the adult acquired flatfoot. Foot Ankle Int.
• Malalignment 2003;24(7):530–4.
15. Giannini S, Ceccarelli F, Benedetti MG, Faldini C,
• Hardware removal
Grandi G. Surgical treatment of adult idiopathic cavus
• Neuritis foot with plantar fasciotomy, naviculocuneiform
• Infection arthrodesis, and cuboid osteotomy. A review of thirty-­
nine cases. J Bone Joint Surg Am. 2002;84-A(Suppl
2):62–9.
16. Roling BA, Christensen JC, Johnson
References CH. Biomechanics of the first ray. Part IV: the effect
of selected medial column arthrodeses. A three-­
1. Jordan TH, et al. Radiographic outcomes of adult dimensional kinematic analysis in a cadaver model. J
acquired flatfoot corrected by medial column arthrod- Foot Ankle Surg. 2002;41(5):278–85.
esis with or without a medializing calcaneal osteot- 17. de Cesar Netto C, Schon LC, Thawait GK, da Fonseca
omy. J Foot Ankle Surg. 2011a;50(2):176–81. LF, Chinanuvathana A, Zbijewski WB, Siewerdsen
2. Metzl JA. Naviculocuneiform sag in the acquired flat- JH, Demehri S. Flexible adult acquired flatfoot
foot: what to do. Foot Ankle Clin. 2017;22(3):529–44. deformity: comparison between weight-bearing
3. Boffeli TJ, Schnell KR. Cotton osteotomy in flatfoot and non-weight-bearing measurements using cone-­
reconstruction: a review of consecutive cases. J Foot beam computed tomography. J Bone Joint Surg Am.
Ankle Surg. 2017;56(5):990–5. 2017;99(18):e98.
 Posterior Tibial Tendon Repair:
Kidner, FDL Transfer, and Medial
18
Displacement Calcaneal
Osteotomy

Kyle S. Peterson and Michael D. Dujela

18.1 Introduction despite the fact that many of these procedures are
not considered to be “arch restoring” [4]. The
Pes planus deformity, whether associated with an postoperative recovery after surgical management
accessory navicular syndrome or an adult-­ of both the recalcitrant symptomatic PTTD and
acquired flatfoot deformity, is a major source of accessory navicular syndrome is a significant
disability across a broad spectrum of patients. undertaking. It is crucial to assess the ability of
Posterior tibial tendon dysfunction (PTTD) is the each patient individually to successfully navigate
most common etiology for a progressive flatfoot the process and withstand several months of reha-
in the adult population [1]. Patients frequently bilitation. While the initial recovery is approxi-
present with a complaint of “ankle pain” demon- mately 12 weeks, time to maximal medical
strating variable hindfoot alignment issues. In the improvement may be as long as 12–18 months.
acute onset, mild to moderate tenosynovitis with- The surgical outcomes are very good with appro-
out major deformity may be the typical finding. priate patient selection, planning, and execution.
Without treatment, continued inflammatory
changes lead to progressive degenerative changes,
tendinosis, tearing, and elongation which result in 18.2 Patient Presentation
structural changes [2]. Johnson and Strom classi-
fied three stages of PTTD which can serve as a Posterior Tibial Tendon Dysfunction Patients
guide to treatment based on structural integrity with posterior tibial tendon dysfunction fre-
and function of the tendon [3]. Most frequently quently present with pain to the medial ankle in
patients present with long-standing symptoms, early stages of the disease. Edema or fullness
and often the tendon has lost structural integrity, along with posterior tibial tendon sheath and
and surgical intervention is frequently necessary. pain on palpation typically along the distal
Multiple options for joint preservation via tendon aspect of the tendon are common findings. In
transfers and osteotomies exist which allow the majority of cases of mild disease, the medial
reduction of symptoms and enhanced function longitudinal arch height may be unchanged. In
fact, many patients do not seek medical care
with early disease, instead believing the symp-
K. S. Peterson (*) toms will improve with time. In stage I poste-
Suburban Orthopaedics, Division of Foot and Ankle
rior tibial tendon dysfunction, the patient is
Surgery, Bartlett, IL, USA
able to perform a single-leg heel raise test as
M. D. Dujela
function is still maintained. The typical
Washington Orthopaedic Center, Centralia, WA, USA

© Springer Nature Switzerland AG 2019 175

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_18
176 K. S. Peterson and M. D. Dujela

p­rogression to stage II occurs slowly often cases of pure gastrocnemius equinus and is often
times over several years, and many patients do via an open medial or endoscopic approach.
not live long enough to develop a rigid stage III Recovery from a GSR is typically faster than an
deformity. As the posterior tibial tendon contin- Achilles tendon lengthening and carries a lower
ues to degenerate, the tibia begins to internally risk of complications such as rupture or plan-
rotate, the talus adducts, and progressive hind- tarflexion weakness.
foot valgus develops. In this stage, the patient
will often develop lateral pain in the sinus tarsi
region due to impingement in the lateral subta- 18.2.1 Accessory Navicular
lar joint and sinus tarsi [4]. Sub-fibular impinge- Syndrome
ment symptoms are common, and subtle edema
of the sinus tarsi may develop. In some cases, Adults and children can both develop symptoms
the forefoot may begin to abduct relative to the associated with accessory navicular syndrome.
hindfoot resulting in a “too many toes sign” The most frequent presentation in a symptomatic
when viewed from posterior [5, 6]. patient is a type II ossicle that is attached to the
During ambulation, the patient generally main body of the navicular by a distinct synchon-
remains fully pronated throughout the gait cycle, drosis. In children, this may be associated with a
including late midstance and propulsive phases. pes planus deformity and is often associated with
With acute disease, tenosynovitis may be present, physical activities such as sports participation. In
and pain is often noted both on and off weight-­ adults, in many cases, there may be no history of
bearing, particularly after activity as an “after- prior symptoms during childhood or adolescence.
burn.” With time, the tendon itself may not be Frequently, overtraining or a recent injury may be
painful, and discomfort is often associated with responsible for converting a previously asymp-
impingement and malalignment. Magnetic reso- tomatic accessory navicular into a symptomatic
nance imaging is not completely necessary for foot. While children may respond well to non-­
PTTD, the diagnosis is clinical. The patient is operative care, adults often are less likely to
assessed for flexibility of the deformity, noting improve and may frequently require surgical
whether or not the foot can be realigned by the intervention. It is important to note that accessory
examiner to neutral or simply by having the navicular syndrome can occur not only in a pes
patient invert the hindfoot during static stance planus foot type but is also often seen in a cavus
weight-bearing examination. Equinus is essen- foot type. This is potentially due to poor torque
tially always present in cases of PTTD and may conversion or rigidity associated with pes cavus.
be one of the predisposing factors leading to pro- Tenderness is typically well localized directly at
gressive deformity and tendinopathy [7]. The the medial aspect of the navicular and is often
range of motion of the ankle is checked with the associated with a visible prominence. The dis-
knee flexed and extended (Silfverskiold test) to comfort is often associated with pressure directly
determine if the dorsiflexion improves with the over the ossicle itself. Attempting a single-leg
knee flexed or not [8]. In the case of gastroc- heel raise test may be painful or difficult similar
soleus equinus, an Achilles tendon lengthening to a patient presenting with PTTD. However, in
via triple hemisection is often performed at the patients presenting with posterior tibial tendinop-
beginning of the procedure to facilitate reduction athy, symptoms and pain typically occur over a
of the deformity and realignment of the foot. several centimeter segment. This frequently
Care is essential to avoid rupturing the length- begins in the retro malleolar groove or near the
ened tendon during the course of the operation, distal tip of the medial malleolus and extends
particularly during hindfoot realignment proce- along the course of the tendon to the insertion
dures such as a calcaneal osteotomy or tendon onto the navicular and in some cases into the
transfer. A gastrocnemius recession (GSR) such plantar arch. In both cases, exhaustive non-­
as a modified Strayer procedure is indicated in operative treatment is typically recommended for
18 Posterior Tibial Tendon Repair: Kidner, FDL Transfer, and Medial Displacement Calcaneal Osteotomy 177

3 months prior to considering surgery unless the 18.4  perating Room Setup
O
tendon is nonfunctional. In the case of stage II and Instrumentation
posterior tibial tendon dysfunction, it is impor-
tant to consider surgical treatment while the The patient is first placed on the operating room
deformity is still reducible. Over time, the defor- table in a lateral decubitus position with a bean
mity may become rigid; the opportunity is lost to bag and a well-padded thigh tourniquet. This
surgically manage the foot with joint-preserving allows access to the lateral wall of the calcaneus
procedures such as osteotomies and tendon trans- to perform the medial displacement calcaneal
fers. The only remaining option is arthrodesis osteotomy (MDCO). Following the MDCO, the
which places the patient at risk for adjacent joint bean bag can be deflated by the operating room
arthritis and potential for nonunion or malunion. staff, and the patient can be positioned supine
When contemplating surgery for accessory while maintaining sterility to perform the Kidner
navicular syndrome, simply excising the symp- and/or flexor digitorum longus transfer.
tomatic ossicle and advancing the posterior tibial Once the calcaneal osteotomy is started with a
tendon via a modified Kidner procedure may be power sagittal saw, a key instrument utilized to
insufficient to achieve long-lasting symptom complete the osteotomy is a one half-inch broad
reduction. When structural deformity exists, osteotome. This protects the medial anatomic
adjunct procedures such as a calcaneal osteot- structures from injury by the saw while complet-
omy, flexor digitorum longus (FDL) transfer, and ing the osteotomy. A lamina spreader should be
gastrocnemius recession should be considered, utilized next to distract the osteotomy and soft
particularly in the adult patient. tissues prior to the medial shift in order to obtain
adequate correction.
The authors preferred hardware selection is
18.3 Diagnostic and Imaging the use of two cannulated screws for fixation of
Work-Up the calcaneal osteotomy. A low-profile lateral
calcaneal plate can also be utilized for fixation if
Patients presenting with symptoms suspicious for desired.
accessory navicular syndrome or PTTD should be Fixation of the posterior tibial tendon follow-
evaluated with standard weight-bearing radio- ing the removal of the os tibiale externum during
graphs including AP, medial oblique, and lateral the Kidner procedure is frequently completed
views [9]. Additionally, a lateral oblique image is with either a metallic or bioabsorbable 3.5–
recommended for the assessment of an accessory 4.0 mm suture anchor.
navicular as it “uncovers” the ossicle which is fre- A bioabsorbable interference screw is com-
quently not well visualized in other views. In the monly utilized by the authors for fixation of the
presence of deformity, a hindfoot alignment view flexor digitorum longus transfer into the navicu-
is important when possible reconstruction is con- lar. A tendon-sizing paddle is used to measure the
sidered [10, 11]. Radionuclide imaging such as a width of the tendon in order to fixate the tendon
triphasic scan can demonstrate increased uptake into the bone with the proper anatomic tension.
at the accessory ossicle; however this is generally
not necessary. Magnetic resonance imaging may
allow direct visualization of the tendon to assess 18.4.1 Surgical Techniques
the degree of degenerative features or to evaluate
bone marrow edema. It is also possible to evaluate 18.4.1.1 Kidner Procedure
fluid accumulation associated with inflammatory The incision for the Kidner procedure is made
changes either in the tendon sheath or at the acces- medially over the distal posterior tibial tendon
sory navicular. In many cases advanced imaging and navicular tuberosity and is approximately
is not performed as diagnosis is adequately 4–5 cm in length (Fig. 18.1). The dissection is
assessed by clinical assessment alone. carried through the subcutaneous tissue, and the
178 K. S. Peterson and M. D. Dujela

Fig. 18.1 Medial incision approach for the modified

Kidner procedure Fig. 18.3 The distal attachment of the posterior tibial
tendon is reflected inferior off the navicular tuberosity,
and the accessory navicular bone is exposed (at the freer
elevator)

flush bone surface with smooth edges is fash-

ioned (Fig. 18.5a, b).
The posterior tibial tendon is then advanced
distally, and tension is added to the repair with
the use of one or two bone suture anchors for
secure fixation (Fig. 18.6a–d). The foot is held
with a slight amount of inversion in order to
advance the posterior tibial tendon distally at the
navicular tuberosity. The posterior tibial tendon
sheath and anatomic layers are closed.
Fig. 18.2 The posterior tibial tendon sheath is incised
longitudinally, and the attachment of the posterior tibial 18.4.1.2 Medial Displacement
tendon is exposed at the medial navicular (at the Adson
Calcaneus Osteotomy
forceps)
(MDCO)
The incision for the MDCO is made on the lateral
posterior tibial tendon sheath is incised longitudi- aspect of the heel posterior to the peroneal ten-
nally to expose the attachment and the accessory dons and the sural nerve (Fig. 18.7). Sharp dis-
navicular bone (Fig. 18.2). section is performed, and the periosteum of the
The distal attachment of the posterior tibial calcaneus is exposed (Fig. 18.8). Hohmann
tendon is then reflected off the navicular tuber- retractors are utilized both in the superior and
osity in continuity (Fig. 18.3). Intraoperative inferior aspects of the incision to protect the
imaging is then utilized to identify the synchon- Achilles and plantar fascia, respectively.
drosis between the navicular body and the A sagittal saw is utilized to perform the oste-
accessory os tibiale externum. With the use of a otomy from lateral to medial with the saw blade
freer elevator or small key elevator to initially at 90° to the lateral wall of the calcaneus
mobilize the bone, the synchondrosis is sharply (Fig. 18.9). It is important to protect the neuro-
excised with a scalpel, and the accessory navic- vascular and tendinous structures while complet-
ular bone is removed (Fig. 18.4a, b). Additional ing the osteotomy on the medial side. Often, if
hypertrophic navicular tuberosity can then be the saw blade courses too far on the medial side
resected with a power micro-sagittal saw, and a of the calcaneus, the toes will often plantarflex.
18 Posterior Tibial Tendon Repair: Kidner, FDL Transfer, and Medial Displacement Calcaneal Osteotomy 179

a b

Fig. 18.4 Utilizing an Allis or Kocher forceps, the accessory navicular bone is sharply excised with a scalpel (a) and
completely removed in one piece (b)

a b

Fig. 18.5 A micro-sagittal saw is utilized to remove any excessive hypertrophic navicular bone (a), and a smooth, flat
bone surface is created for suture anchor insertion (b)

In order to protect these vital structures, it is rec- straight medial shift is performed of the posterior
ommended to complete the osteotomy with a one tuberosity with a maximum shift of 1 cm needed
half-inch broad osteotome (Fig. 18.10). Once the for correction. Finally, two-headed, cannulated
osteotomy is completed, a lamina spreader can be lag screws ranging from 5.5 to 6.5 mm are used
used to distract the osteotomy to relax the soft for fixation of the calcaneal osteotomy (Fig.
tissue attachments on the calcaneus in order to 18.13a, b). Alternatively, a low-profile stepped
get a proper medial correction of the posterior lateral calcaneal plate can be utilized in order to
tuberosity (Fig. 18.11). With the lamina spreader avoid the plantar incision and pain associated
still intact, the guidewires for screw fixation can with cannulated lag screws (Fig. 18.14).
be started in the posterior tuberosity and directly An intraoperative lateral and calcaneal axial
visualized entering the osteotomy prior to medi- views are helpful to ensure placement of fixa-
alizing the osteotomy (Fig. 18.12). Next, a tion and to visualize a vertical heel is obtained
180 K. S. Peterson and M. D. Dujela

a b

c
d

Fig. 18.6 The posterior tibial tendon is advanced distally at the medial navicular and is secured with a single- or
double-­loaded suture anchor (a–d)

Fig. 18.7 The incision for an MDCO is made in a longi-

tudinal fashion on the lateral aspect of the calcaneus
Fig. 18.8 Dissection is carried down to the lateral wall,
and a longitudinal incision is made through the
periosteum
18 Posterior Tibial Tendon Repair: Kidner, FDL Transfer, and Medial Displacement Calcaneal Osteotomy 181

Fig. 18.9 A micro-sagittal saw is utilized to perform the

osteotomy

Fig. 18.11 A lamina spreader can be utilized following

the completion of the osteotomy to relax the soft tissue
structures prior to the medial shift of the tuberosity

Fig. 18.10 Completion of the MDCO osteotomy through

the medial cortex with a broad osteotomy to protect the
neurovascular structures

Fig. 18.12 With the lamina spreader still intact, the

guidewires are started in the posterior tuberosity and
directly visualized through the osteotomy before shifting
the tuberosity medially
182 K. S. Peterson and M. D. Dujela

Fig. 18.14 Alternate fixation of the MDCO with a low-­

profile locking step plate

Fig. 18.13 (a, b) Final fixation of the MDCO with two,

5.5 mm cannulated screws

without creating an iatrogenic varus deformity Fig. 18.15 A calcaneal axial image is obtained to ensure
(Fig. 18.15). Layered closure is then performed no iatrogenic calcaneus varus was created
and a posterior splint is applied, or the patient is
repositioned supine and additional medial col- (Fig. 18.16). Dissection is carried deep through
umn procedures are performed. the subcutaneous tissues where significant venous
structures cross the plane of dissection. Care is
18.4.1.3  lexor Digitorum Longus
F taken to address the venous tributaries to ensure
Transfer appropriate hemostasis, enhancing visibility and
A longitudinal incision is made from the distal diminishing risk of wound healing complications.
aspect of the medial malleolus extending to the Dissection is carried deep to the level of the pos-
first metatarsal cuneiform articulation following terior tibialis tendon sheath which is easily identi-
the contour of the posterior tibial tendon fied. A linear incision is made just proximal to the
18 Posterior Tibial Tendon Repair: Kidner, FDL Transfer, and Medial Displacement Calcaneal Osteotomy 183

Fig. 18.16 Incision from medial malleolus extends just Fig. 18.18 The flexor digitorum longus tendon is identi-
distal to navicular tuberosity following the course of the fied immediately deep to the posterior tibial tendon via a
posterior tibial tendon. Significant venous tributaries are small incision in the tendon sheath
encountered and ligated and cauterized

Fig. 18.19 The FDL tendon is confirmed by placing

gentle traction on it proximally and observing plantar
flexion of the lesser digits
Fig. 18.17 The posterior tibial tendon is exposed demon-
strating severe tendinosis
made, the FDL tendon is rapidly identified; how-
tendon insertion onto the navicular. The tendon is ever, in some instances a careful probe and
readily identified, and dissection is carried along spread maneuver using a mosquito hemostat
the sheath to evaluate the PT tendon (Fig. 18.17). may be needed if the tendon is not initially
It is not uncommon to see tendinopathy of the PT located. Once the FDL tendon is located, it is
tendon in conjunction with an accessory navicular confirmed by grasping the tendon with a retrac-
syndrome, particularly distally near the insertion tor or hemostat and gently placing traction on it.
at the navicular. Thickening and tendinosis proxi- With the correct tendon identified, flexion of dig-
mal to the insertion as well as partial or complete its 2–5 is noted (Fig. 18.19). Dissection is car-
longitudinal tears may be visible. Complete rup- ried along the sheath of the FDL tendon either
ture is rare; however, elongation to the point of with a scalpel or surgical scissors depending on
loss of function is common. the surgeon’s comfort level. The abductor hallu-
Immediately deep to the posterior tibial ten- cis muscle is retracted inferiorly during this deep
don, the FDL tendon is readily identified. dissection. Distal dissection is carried to the
Initially, the PT tendon is retracted dorsally, and level of the master knot of Henry (Fig. 18.20). In
a small 1–2 cm incision is made in the FDL ten- nearly all cases, a large nest of veins is located in
don sheath, located deep to where the PT tendon this region, and it is common to experience mod-
was located (Fig. 18.18). This is a key maneuver erate bleeding which can be disconcerting if not
and easily reproduced once the surgeon becomes familiar with this. Gentle pressure and electro-
familiar with its location. Once the incision is cautery are generally sufficient to achieve
184 K. S. Peterson and M. D. Dujela

Fig. 18.20 FDL tendon identified and dissected distally

to the knot of Henry Fig. 18.22 Guidewire placed from dorsal to plantar in
navicular for cannulated drill using interference screw

Fig. 18.23 Cannulated drill over guidewire with plantar

Fig. 18.21 FDL tendon released at the knot of Henry and soft tissue retract with Army-Navy retractor to protect soft
prepared with “whipstitch” suture technique for transfer tissue

hemostasis. Dissection along the plantar arch (Fig. 18.21). The tendon is sized to select the
should follow the contour of the FDL tendon appropriate sized anchor. The dorsal navicular is
directly to avoid damage the neurovascular exposed, and a guidewire is driven from dorsal
structures immediately adjacent. A large retrac- to plantar (Fig. 18.22). This can be difficult to
tor such as an Army-Navy or Sofield retractor retrieve at the plantar aspect; therefore very
can be used to enhance visualization. The FDL slight angulation in a dorsal to plantar medial
tendon is grasped and placed under traction to orientation can facilitate passing eventual suture
confirm it is the intended target, confirmed by pass. The corresponding cannulated drill is used
plantarflexion of toes 2–5 at the MTPJ, PIPJ, and to drill from dorsal to plantar (Fig. 18.23). The
DIPJ level. The tendon is transected just proxi- nitinol wire with suture-­ retrieving loop or
mal to the master knot of Henry. We do not rou- Hewson suture passer is passed from dorsal to
tinely suture the two tendons together. The distal plantar. The ends of the suture are passed through
end of the FDL tendon is “whipstitched” using a the wire which is then pulled in a retrograde
nonabsorbable suture in preparation for transfer fashion through the navicular (Fig. 18.24). Next,
18 Posterior Tibial Tendon Repair: Kidner, FDL Transfer, and Medial Displacement Calcaneal Osteotomy 185

Fig. 18.24 Nitinol wire suture passer placed from dorsal

to plantar through drill hole. Suture tails are passed Fig. 18.26 FDL tendon transfer is secured in position
through wire loop for retrieval and retrograde pass through using an appropriate sized interference screw with the ten-
drill hole in navicular from plantar to dorsal don under desired tension

Fig. 18.27 FDL tendon is secured with absorbable suture

distally. The PT tendon is repaired under appropriate ten-
sion after debridement to the anatomic insertion

Fig. 18.25 FDL tendon is passed from plantar to dorsal firmly but not to over tension. The appropriate
through the navicular and is appropriately tensioned with sized biocomposite anchor is then placed in an
foot held in an adducted position interference fashion to anchor the tendon
(Fig. 18.26). With sufficient length of tendon,
the tendon is passed through the drill hole from the remaining length of tendon visible from the
plantar to dorsal with care taken to avoid the ten- drill hole is sutured back to the main segment of
don being caught in the hole, damaged, or the the posterior tibial tendon using “0” absorbable
sutures breaking due to excessive pull or nonabsorbable suture (Fig. 18.27). The ten-
(Fig. 18.25). A pearl is used to reflect a small dons of the FDL and posterior tibial are sutured
amount of soft tissue around the plantar drill together proximally and the tendon sheath is
hole so the tendon can easily pass. Often the dif- repaired. The wounds are copiously irrigated
ficulty lies in initiating the tendon into the hole; with normal saline and closed in layers. Care is
once that occurs, the transfer is straightforward. taken with skin closure to have perfect coapta-
The tendon is tensioned with the foot adducted, tion of the skin edges which will diminish the
in slight plantarflexion. Care is taken to tension risk of wound dehiscence.
186 K. S. Peterson and M. D. Dujela

18.5 Postoperative Protocol

tinely perform a gastroc-soleus reces-
This surgery falls into postoperative protocol #5. sion prior to the calcaneal osteotomy.
All patients are placed into a well-padded poste- • Accurate identification of the FDL ten-
rior splint immediately postoperatively for don immediately deep to the PT tendon
5–7 days. At the first postoperative visit, they are via 1–2 cm incision in the sheath is
placed into a non-weight-bearing short leg cast. important to avoid excessive dissection
The short leg cast is maintained until osseous and probing, thereby reducing tissue
healing of the MDCO at approximately 7 weeks damage.
postoperative. A pneumatic walking boot is • When drilling through the navicular,
applied after the cast for 3 weeks, and physical maintain a sufficient medial rim of bone
therapy is started. An athletic shoe can be worn at to avoid fracture of the transfer site.
approximately 10 weeks postoperative, typically • Angle drill hole very slightly from dor-
with an ankle brace until physical therapy is sal central to plantar medial to facilitate
completed. retrieval of the sutures by aiding visual-
ization of the Hewson suture passer or
nitinol wire.
Additional Pearls and Pitfalls • Reflect a small amount of tissue to the
• It is important to remember the MDCO plantar aspect of the navicular drill hole
is purely a translational shift of the pos- to facilitate pass and retrieval of the
terior tuberosity in the medial direction. tendon.
It is recommended not to apply an addi- • Refrain from excessive tension of the
tional varus force to the tuberosity dur- FDL tendon transfer to avoid a tenode-
ing the medial shift. sis effect.
• The posterior tibial tendon must be
advanced distally following the removal
of the accessory navicular bone in order
to provide satisfactory reattachment and References
tension of the tendon to the navicular
bone. 1. Lee MS, Vanore JV, Thomas JL, et al. Diagnosis
and treatment of adult flatfoot. J Foot Ankle Surg.
• For patients with a gorilloid navicular, 2005;44:78–113.
the amount of navicular resected during 2. Hentges MJ, Moore KR, Catanzariti AR, Derner
the Kidner should be in line with the R. Procedure selection for the flexible adult
medial edge of the medial cuneiform acquired flatfoot deformity. Clin Podiatr Med Surg.
2014;31:363–79.
bone on an anteroposterior radiograph. 3. Johnson KA, Strom DE. Tibialis posterior tendon dys-
• A Hewson suture passer is utilized to function. Clin Orthop Relat Res. 1989;239:196–206.
pass the whipstitch from the FDL ten- 4. Brodsky JW. Preliminary gait analysis results after
don from plantar to dorsal in the navicu- posterior tibial tendon reconstruction:a prospective
study. Foot Ankle Int. 2004;25:96–100.
lar. This allows both manual tension to 5. Myerson MS. Adult acquired flatfoot deformity: treat-
be applied and the ability to deliver the ment of dysfunction of the posterior tibial tendon. J
Bio-Tenodesis screw from dorsal to Bone Joint Surg Am. 1996;78:780–92.
plantar in the navicular. 6. Weinraub GM, Heilala MA. Adult flatfoot/posterior
tibial tendon dysfunction: outcomes analysis of surgi-
• Ensure to evaluate the posterior muscle cal treatment utilizing an algorithmic approach. J Foot
complex during stage II posterior tibial Ankle Surg. 2000;39(6):359–64.
tendon reconstruction. The authors rou- 7. Giza G, Cush G, Schon LC. The flexible flatfoot in the
adult. Foot Ankle Clin. 2007;12:251–71.
18 Posterior Tibial Tendon Repair: Kidner, FDL Transfer, and Medial Displacement Calcaneal Osteotomy 187

8. Silvferskiold N. Reduction of the uncrossed two-joint graphic views for frontal plane assessment. J Am
muscles of the leg to one joint muscles in spastic con- Podiatr Med Assoc. 2008;98(1):75–8.
ditions. Acta Chir Scand. 1924;56:315–30. 11. Lamm B, Mendicino R, Catanzariti A, et al. Static
9. Younger AS, Sawatzky B, Dryden P. Radiographic rearfoot alignment: a comparison of clinical and
assessment of adult flatfoot. Foot Ankle Int. radiographic measures. J Am Podiatr Med Assoc.
2005;26(10):820–5. 2005;95(1):26–33.
10. Mendicino RW, Catanzariti AR, John S, et al. Long
leg calcaneal axial and hindfoot alignment radio-
 Lateral Column Lengthening
19
Kyle S. Peterson, David Larson,
and Roberto A. Brandão

Abbreviations metatarsalgia, hallux valgus, and hammertoe

deformities.
CCJ Calcaneocuboid joint In 1975, Evans described a lateral column
LCL Lateral column lengthening lengthening (LCL) osteotomy procedure that
MDCO Medial displacement calcaneal produced triplane correction in pes planovalgus
osteotomy deformities [1]. This osteotomy and its variant, a
PTTD Posterior tibial tendon dysfunction calcaneal Z lengthening osteotomy, are now
PTT Posterior tibial tendon commonly utilized to correct forefoot abduction
and hindfoot valgus in patients with PTTD and
pediatric pes planovalgus deformity.
19.1 Introduction The LCL osteotomy allows for correction of
the abducted forefoot which helps to reestablish
Adult-acquired flatfoot deformity and pediatric the medial longitudinal arch. The osteotomy is
pes planovalgus are commonly encountered made approximately 1.5 centimeters proximal to
musculoskeletal conditions encountered by foot the calcaneocuboid joint (CCJ) in the calcaneus.
and ankle surgeons. Insufficiency of the poste- Multiple forms of fixation including tricortical
rior tibial tendon (PTT) and collapse of the allograft or interpositional, opening wedge plat-
medial longitudinal arch ultimately lead to a pes ing have been described to successfully fixate
planovalgus foot deformity and associated foot this osteotomy.
and ankle symptoms including plantar fasciitis, The calcaneal Z osteotomy was first intro-
duced by Malerba and De Marchi which involved
a lateral closing wedge resection for the treat-
ment of hindfoot varus; this procedure was then
modified by Weil and Roukis to treat hindfoot
K. S. Peterson (*)
Suburban Orthopaedics, Division of Foot and Ankle valgus by shifting the posterior calcaneus medi-
Surgery, Bartlett, IL, USA ally and incorporating laterally based wedge
D. Larson grafts in the dorsal and/or plantar arms of the Z
Steward Health Care, Department of Podiatry, osteotomy [2, 3].
Glendale, AZ, USA
R. A. Brandão
The Centers for Advanced Orthopaedics, Orthopaedic
Associates of Central Maryland Division,
Catonsville, MD, USA

© Springer Nature Switzerland AG 2019 189

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_19
190 K. S. Peterson et al.

19.2 Case Example intervention as this can increase the risk of com-
plications in foot and ankle surgery. Proper pre-
The patient is a 50-year-old female who pre- operative planning is necessary to assess for bony
sented to the office with complaints of the pain to real estate the hardware choices that will be uti-
her ankle and points below her fibula. She notes lized for optimal fixation. Preoperative patient
that her “foot has been turning out for some counseling regarding expectations and proce-
time.” She has tried several orthotics and presents dural choice are crucial to long-­term expectation
to the office for a second opinion. Her foot is management. This type of deformity can be dif-
flexible, and she is able to do a single heel rise ficult to treat and may require intraoperative deci-
test and she has an asymptomatic bunion. She is sion-making and implementation, and the consent
nondiabetic and otherwise healthy, active should reflect as such.
professional.

19.4 Imaging
19.3 Presentation/Diagnosis
Radiographs AP and lateral plain film radio-
Patients typically present with a painful, swollen graphs can be used to assess standard weight-­
pes valgus deformity with pain at the posterior bearing radiographs of the foot, ankle, and
tibial tendon and/or lateral hindfoot/sinus tarsi calcaneal axial which are obtained to evaluate the
region. Patients will often state “my ankle hurts” osseous deformity. The planar dominance can be
when the true source may be in fact the subtalar evaluated, and preoperative plans can be made
joint. The flatfoot must be a supple and flexible for the optimal correction osteotomies or soft tis-
deformity in order for reconstruction in both sue balancing approaches. Initial images can help
adults and children. Generally, an element of to rule out degenerative joint disease of the hind-
equinus may be present and must be thoroughly foot and ankle. Ankle views can be helpful to
evaluated prior to surgical intervention. asses for any ankle angular deformity (i.e., val-
Associated pathology may include hallux valgus, gus), thus necessitating different surgical
plantar fasciitis, and metatarsalgia. planning.
The flatfoot evaluation should include both a
dynamic gait analysis and a static weight-bearing
stance examination. The range of motion of the MRI A magnetic resonance imaging series of
hindfoot will elicit the amount of flexibility pres- the hindfoot and ankle can be useful to evaluate
ent and pain that may be associated in the poste- the integrity of the tendons and supportive liga-
rior tibial tendon and the hindfoot joints. The mentous structure including the deltoid and
strength of the PTT can be tested with resisted spring ligament complexes. Additionally, MRIs
inversion and plantar flexion of the ankle as well can help rule out a tarsal coalition in the pediatric
as through the single and double heel rise. The or adult populations.
affected lower extremity should be compared to
the contralateral extremity. The use of the lateral
column lengthening procedure is commonly used 19.5  perating Room Setup
O
in both the stage II adult-acquired flatfoot defor- and Instrumentation
mity and in reconstruction of a pediatric flatfoot
deformity. The patient is placed on the operating room
Preoperative labs should be considered to table in a lateral decubitus position with a bean
evaluate nutritional status (prealbumin, albumin), bag and a well-padded thigh tourniquet. This
diabetic control (if applicable), and electrolyte allows access to the lateral wall of the calcaneus
balance (basic metabolic panel). Tobacco use and easy use of the mini C-arm for intraopera-
should be discontinued prior to any surgical tive radiographs. If additional medial column
19 Lateral Column Lengthening 191

procedures are needed following the lateral col- radiograph is performed to verify the wire is
umn lengthening, the bean bag can be deflated placed parallel to the CCJ. Hohmann elevators
by the operating room staff, and the patient can are placed into the sinus tarsi plantarly to retract
be positioned supine while maintaining sterility. and protect the peroneal tendons and sural nerve.
Once the osteotomy is performed, a key instru- Using a sagittal saw, the osteotomy is performed
ment utilized to distract the osteotomy is either a along the guide wire, and a ¼ or ½ inch osteo-
pin-based distractor (Hintermann type) or a lam- tome is then used to free up the osteotomy site
ina spreader. This allows the surgeon the ability (Fig. 19.2). Using either a pin-based distractor or
to dial-in the desired correction with the interpo- a lamina spreader to distract the osteotomy, trial
sitional wedge in order to achieve realignment of spacers are placed in the osteotomy site, and an
the foot at the talonavicular joint on the antero- anteroposterior radiograph is performed
posterior radiograph. (Fig. 19.3). When the desired amount of talar
The authors preferred hardware selection head coverage is achieved with reduction in the
which is the use of an interpositional low-profile forefoot abduction, either a porous titanium or
titanium wedge plate, porous metal wedge, or allograft wedge graft is tamped into the osteot-
structural allograft wedge, all with various incre- omy site (Fig. 19.4). Typically, most patients
ment sizes increasing by 2 millimeters. It is don’t receive a graft larger than 0.8–1.0 centime-
important to combine additional orthobiologics ters. Fixation consists of a low-profile plate or
when using these wedges and plates. We rou- staple laterally over the osteotomy site.
tinely use bone marrow aspiration from the calca-
neus to hydrate the titanium wedges/allograft
wedges and crushed cancellous bone chips to
backfill the osteotomy when using an interposi-
tional wedge plate. It is important to also remem-
ber to use the lowest-profile plate and screws
available in order to decrease the irritation and
scarring at the peroneal tendons.

19.6 Operative Technique

Fig. 19.1 Incisional approach for the lateral column
lengthening. A transverse incision is made at the CCJ and
19.6.1 T
 raditional Lateral Column travels proximally along the anterior calcaneus for 3–5
Lengthening centimeters

Using intraoperative fluoroscopy, the CCJ is

marked, and a 3–5 centimeter transverse incision
is placed laterally over the anterior process of the
calcaneus, extending distally to the CCJ (Fig.
19.1). Dissection is carried down through the
subcutaneous tissue while protecting the sural
nerve. The peroneal sheath is incised, and the
peroneal tendons are retracted either dorsally or
plantarly out of the surgical field. Using a key
elevator, the soft tissues are mobilized exposing
the lateral process of the calcaneus and the CCJ.
A 0.062 inch Kirschner wire can then be placed
Fig. 19.2 A micro-sagittal saw is utilized to perform the
1.0–1.5 centimeters proximal to the CCJ from a osteotomy from lateral to medial approximately 1.0–1.5
lateral to medial direction. An anteroposterior centimeters proximal to the CCJ
192 K. S. Peterson et al.

Alternatively, the authors also prefer an opening

wedge plate fixation (Fig. 19.5a, b).
The peroneal tendons are then placed back in
their anatomic position, and the peroneal sheath is
closed with either vicryl or monocryl suture. The
remaining layers are closed with suture of choice
and a sterile dressing is applied. The patient is
then placed in a well-padded posterior splint.

19.6.2 Calcaneal Z Osteotomy

Fig. 19.3 A pin-based distractor is utilized to facilitate
the distraction of the osteotomy in order to “dial-in” the
desired correction which can be confirmed on
An 8 centimeter linear incision is made lateral just
fluoroscopy posterior and inferior to the distal tip of the fibular
and extends distally to the CCJ (Fig. 19.6).
Dissection is carried down through the subcutane-
ous tissue while protecting the sural nerve. The
peroneal tendon sheath is incised, and the pero-
neal tendons are retracted out of the surgical field.
Using a key or periosteal elevator, the soft tissues
are mobilized distally to allow visualization of the
CCJ. A measurement of 1.0–1.5 centimeter proxi-
mal to the CCJ is made and is the location of the
plantar arm of the Z osteotomy (Fig. 19.6). The
dorsal arm is drawn from the same starting point
as a medial displacement calcaneal osteotomy
(MDCO). The central arm of the osteotomy is
marked starting from the plantar arm of the oste-
otomy and extends proximally to the dorsal arm
Fig. 19.4 A tricortical allograft wedge is placed into the of the Z osteotomy. It is placed centrally over the
anterior process of the lateral column lengthening anterior process of the calcaneus and exits superi-
osteotomy orly, completing the osteotomy.

a b

Fig. 19.5 (a) Fixation of the lateral column lengthening osteotomy with an opening wedge plate (b) Radiographic
lateral image demonstrating the opening wedge plate fixation
19 Lateral Column Lengthening 193

Fig. 19.8 Following the medial shift and temporary pin-

Fig. 19.6 Incisional approach for the calcaneal Z osteot- ning of the tuberosity portion of the osteotomy, a pin-­
omy. A transverse incision distally is made over the ante- based distractor is applied to facilitate distraction of the
rior calcaneus, while the proximal aspect is carried over anterior portion of the calcaneal Z osteotomy
the posterior tuberosity. The ruler then marks the location
of the plantar arm of the Z osteotomy approximately 13
centimeters proximal to the CCJ The calcaneal tuberosity is translated medi-
ally as done in a traditional MDCO. It is then
provisionally fixated with two vertical guide
wires, which are later used for the cannulated
screws. Lateral and calcaneal axial radiographs
are performed to ensure that the wires are not
entering the subtalar joint and are placed cen-
trally in the calcaneus. A pin-based distractor or
a lamina spreader is then used to distract the
calcaneus along the osteotomy site (Fig. 19.8).
Once distracted, an anteroposterior radiograph
is performed to evaluate the amount of talar
Fig. 19.7 Once the osteotomy has been started with a head coverage. The distractor is used to manip-
micro-sagittal saw, it is completed with a broad ½ inch ulate the amount of talar head coverage by
osteotome either increasing or decreasing the amount of
distraction. When the desired amount of cover-
Using a Hohmann elevator, the peroneal ten- age is achieved with reduction in the forefoot
dons are split, and the peroneus brevis tendon is abduction, trial sizers are placed into the plan-
retracted dorsally, and the peroneus longus ten- tar arm of the osteotomy (Fig. 19.9). After
don is retracted plantarly. Next, a sagittal saw is selecting the appropriate size graft, either a
used to perform the cut through the central arm porous titanium or allograft wedge is placed
of the osteotomy in a lateral to medial direction. into the plantar arm of the osteotomy
Hohmann elevators are then repositioned to (Fig. 19.10). Per standard technique, a 5.5 mil-
retract the peroneal tendons plantarly and limeter cannulated screw is then placed at each
another into the sinus tarsi. The plantar arm cut of the guide wires to fixate the dorsal arm of the
is then performed in a parallel fashion to the CC Z osteotomy (Fig. 19.11).
joint, and care is taken to avoid cutting into the The peroneal tendons are then placed back in
talus medially. A Hohmann elevator is then their anatomic position, and the peroneal sheath
placed anterior to the Achilles tendon on the is closed with either vicryl or monocryl suture.
superior aspect of the calcaneus, and the dorsal The remaining layers are closed with suture of
arm of the osteotomy is then completed. Using a choice, and a sterile dressing is applied. The
¼ or ½ inch osteotome, the osteotomy is freed patient is then placed in a well-padded posterior
and mobilized at all points (Fig. 19.7). splint.
194 K. S. Peterson et al.

Fig. 19.9 A trial sizer is placed in the anterior, plantar

arm of the calcaneus Z osteotomy b

Fig. 19.11 (a) Intraoperative images of the final fixation

of the calcaneal Z osteotomy with two cannulated screws
in the dorsal arm and the titanium wedge graft in the plan-
tar arm. (b) Six-week status post a surgical correction of
Fig. 19.10 A porous titanium wedge is placed in the dis- another patient who underwent the same procedure
tal plantar arm of the Z calcaneal osteotomy

exits inferiorly, completing the plantar arm of the

19.6.3 A
 nterior Calcaneal Z Z osteotomy.
Osteotomy Using a Hohmann elevator, the peroneal ten-
dons are split, and the peroneus brevis tendon is
A 6 centimeter transverse incision is made lateral retracted dorsally, and the peroneus longus ten-
just inferior to the distal tip of the fibular and don is retracted plantarly. Next, a sagittal saw is
extends distally to the CCJ. Dissection is carried used to perform the cut through the central arm of
down through the subcutaneous tissue while pro- the osteotomy in a lateral to medial direction.
tecting the sural nerve. The peroneal tendon Hohmann elevators are then repositioned to
sheath is incised, and the peroneal tendons are retract the peroneal tendons plantarly and another
retracted out of the surgical field. Using a key or into the sinus tarsi. The dorsal arm cut is then
periosteal elevator, the soft tissues are mobilized performed in a parallel fashion to the CCJ, and
distally to allow visualization of the CCJ. A mea- care is taken to avoid cutting into the talus medi-
surement of 1.0–1.5 centimeter proximal to the ally. The peroneal tendons are then retracted dor-
CCJ is made and is the location of the dorsal arm sally, and plantar arm of the osteotomy is then
of the Z osteotomy. The central arm of the oste- completed. Using a ¼ or ½ inch osteotome, the
otomy is marked starting from the dorsal arm of osteotomy is freed and mobilized at all points,
the osteotomy and extends proximally measuring and either a pin-based distractor or a lamina
1.5–2.0 centimeter in length. It is placed centrally spreader is used to distract the calcaneus along
over the anterior process of the calcaneus and the osteotomy site.
19 Lateral Column Lengthening 195

Fig. 19.13 Pre- and postoperative lateral foot films of a

patient who is status post 10 months from an anterior Z
cut and MCDO with FDL transfer

The remaining layers are closed with suture of

choice and a sterile dressing is applied. The
patient is then placed in a well-padded posterior
splint.

Fig. 19.12 An example of an anterior Z cut calcaneal

osteotomy with allograft bone wedges. The lateral radio- 19.7 Postoperative Protocol
graph demonstrates the optimal osteotomy placement.
Notice the correction of the talonavicular joint on the AP
image 1. All patients are placed into a posterior splint
immediately postoperatively. They are seen
Once distracted, an anteroposterior radiograph 5–7 days after surgery, and the incision(s) are
is performed to evaluate the amount of talar head checked, and a new sterile dressing and
coverage. The distractor is used to manipulate the ­non-­weight-­bearing below-knee fiberglass
amount of talar head coverage by either increas- cast is applied.
ing or decreasing the amount of distraction. 2. They are seen back in the clinic at 3 weeks
When the desired amount of coverage is achieved for suture removal and reapplication of a
with reduction in the forefoot abduction, trial siz- non-­weight-­bearing below-knee fiberglass
ers are placed into the dorsal arm of the osteot- cast.
omy. After selecting the appropriate size graft, 3. At the beginning of the seventh week follow-
either a porous titanium or allograft wedge is ­up, the patient is transitioned into a pneumatic
placed into both the dorsal and plantar arms of walking boot for 4 weeks. At 4 weeks in the
the osteotomy (Fig. 19.12). Fixation consists of a pneumatic walking boot, they are transitioned
low-profile plate or staples laterally over each to a regular shoe, and physical therapy is
arm of the osteotomy (Fig. 19.13). started for 4–6 weeks.
The peroneal tendons are then placed back in 4. Radiographs are obtained at the first postop-
their anatomic position, and the peroneal sheath erative visit and at 4 and 8 weeks, 6 months,
is closed with either vicryl or monocryl suture. and 1 year.
196 K. S. Peterson et al.

Additional Pearls and Pitfalls and it is beyond any easy correction.

• Patients are placed in the lateral decubi- Lateral column overload pain is usually
tus position to allow for better visualiza- negative on all imaging and injections
tion and help reduce issues with foot and only responds (somewhat) to a tri-
position as seen in the prone position. ple arthrodesis.
• It is vital to protect the sural nerve and • Remember the other foot. If you make
peroneal tendons. one foot perfect, you are compelling the
• Utilize a Hintermann-type retractor to patient to have the other foot recon-
help dial-in your lateral column structed as well. The authors recom-
correction. mend aiming for a middle ground
• Complications from lateral column instead of gunning for a perfect x-ray
lengthening are common and approach every time.
20%. This surgery has a much higher • Non-unions are more common with tra-
burden on both patient and surgeon than ditional lateral column lengthening than
a MCDO with flexor tendon transfer. advertised. The non-union rate
• Peroneal tendons have to be carefully approaches 20% even in the experienced
protected and cannot be left to rub on hands.
the hardware. Based from the author’s
experience, this will create adhesions
and ultimately require hardware
removal. The authors have experimented 19.8 Complications
with lock plates (lower profile), wedges
with screws from anterior process to the • Non-union
current technique of porous metal • Sural neuritis
wedge with nothing external to the • Wound dehiscence
bone. • Peroneal tendinitis/ irritation due to hardware
• Overcorrection is worse than undercor-
rection. An overcorrected talonavicular
joint will lock the transverse tarsal joint, References
and the patient will be miserable. The
authors have evolved to the Z cut as it 1. Evans DE. Calcaneo-valgus deformity. JBJS.
can usually get the correction but not 1975;57:270–8.
2. Malerba F, De Marchi F. Calcaneal osteotomies. Foot
powerful enough to overcorrect.
Ankle Clin. 2005;10(3):523–40.
• Lateral column pain is related to a too 3. Weil LS Jr, Roukis TS. The calcaneal scarf oste-
aggressive lateral column lengthening, otomy: operative technique. J Foot Ankle Surg.
2001;40(3):178–82.
 The Medial Double Arthrodesis
20
Bradly W. Bussewitz, Christopher W. Reb,
and David Larson

Abbreviations into three stages by Johnson and Strom and later

modified by Myerson to include a fourth stage [1,
AAFD Adult-acquired flatfoot deformity 2]. PTTD classification schemes, based primarily
AP Anterior posterior on the deformity flexibility and extent of ankle
CT Computed tomography joint involvement, have proven useful to surgeons
DBM Demineralized bone matrix as treatment strategy guides. Treatment ranges
FDL Flexor digitorum longus broadly across a myriad of conservative strategies
FHL Flexor hallucis longus including physical therapy, medications, and brac-
NWB Non-weight-bearing ing in the early stages to surgical management
PTT Posterior tibial tendon strategies utilizing both joint-­ sparing techniques
PTTD Posterior tibial tendon dysfunction and joint-sacrificing rearfoot fusions in later stages.
STJ Subtalar joint Typically, joint-sparing osteotomies are reserved
TNJ Talonavicular joint for flexible deformities, and rearfoot fusions are
reserved for arthritic rigid rearfoot deformities.
Triple arthrodesis, the historical standard surgi-
20.1 Introduction cal treatment for stage III AAFD, remains today as
the accepted standard for complex rearfoot defor-
Adult-acquired flatfoot deformity (AAFD) is most mity surgical correction. Recently, there has been
commonly a result of posterior tibial tendon dys- surgeon interest in performing medial double
function (PTTD), and treatment for this foot type arthrodesis in lieu of triple arthrodesis for stage III
can be challenging. PTTD was originally classified PTTD. Due to studies showing that joints adjacent
to a triple arthrodesis have a higher incidence of
postsurgical arthritis, the concept of the adjacent
joint arthritis sparing medial double arthrodesis
was conceived [3]. The medial double technique
B. W. Bussewitz (*)
has the advantage of a single medial incision that
Steindler Orthopedic Clinic, Iowa City, IA, USA
has been shown to have a decreased risk of wound
C. W. Reb
complications when compared to the standard
University of Florida, Department of Orthopedics,
Division of Foot and Ankle Surgery, two-incision triple arthrodesis. The medial double
Gainesvilles, FL, USA not only allows for equal joint exposure when
D. Larson compared to the triple arthrodesis but also offers
Steward Health Care, Department of Podiatry, more a­ccurate STJ reduction and for superior
Glendale, AZ, USA ­clinical and functional outcomes [4–11].
© Springer Nature Switzerland AG 2019 197
C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_20
198 B. W. Bussewitz et al.

20.2 Case Examples (Figs. 20.1, 20.2 and 20.3)

a c

b d

Fig. 20.1 (Case 1) 60-year-old male demonstrating AP and lateral (a, b) preoperative and (c, d) postoperative x-rays
following medial double arthrodesis
20 The Medial Double Arthrodesis 199

a c

b d

Fig. 20.2 (Case 2) 57-year-old male demonstrating AP and lateral (a, b) preoperative and (c, d) postoperative x-rays
following medial double arthrodesis
200 B. W. Bussewitz et al.

A thorough physical exam to determine if the

a
deformity is flexible or rigid is paramount when
diagnosing and treating patients with adult-­
acquired flatfoot. The strength of the PTT is eval-
uated as well as the amount of motion available
in the rearfoot. It is also important to look for any
adaptive deformities such as forefoot supinatus
or rearfoot equinus during the exam. In stage II
and stage III PTTD, patients will have a “too
many toes” sign, wherein exaggerated forefoot
abduction allows visualization of the lesser toes
laterally when the foot is viewed from posterior.
Typically, in stage II PTTD, patients are able to
perform a single heel rise, and rearfoot inversion
is seen; however, the maneuver can be difficult
b and painful to perform. With stage III PTTD,
patients are not able to perform this test and no
hindfoot inversion is observed.
Weight-bearing radiographs of both the foot
and the ankle are needed to further evaluate adult-­
acquired flatfoot. Ankle radiographs are needed
to rule out any type of ankle deformity, which can
be present in the later stages of the deformity.
Typically, one will see forefoot abduction and
peritalar subluxation on the anteroposterior (AP)
radiograph. On the lateral view, you will see a
Fig. 20.3 Clinical example showing a 3-month post cor-
decrease in the calcaneal inclination angle and an
rected right foot from (a) anterior and (b) posterior increase in the talar declination angle. It is also
important to identify any faults in the medial col-
umn with the use of Meary’s angle and to take
20.3 Presentation/Diagnosis/ those into account if addressed surgically. An
Imaging MRI to evaluate the integrity of the PTT and
computed tomography (CT) scan to evaluate the
In the beginning stages of adult-acquired flatfoot, presence of arthritis are useful tools in the surgi-
patients typically present with pain along the pos- cal workup and plan.
terior tibial tendon (PTT) and have pain and
weakness with certain activities, especially those
involving propulsion push-off power. As the con- 20.4 Operating Room Setup
dition progresses, the PTT becomes attenuated
and, in some cases, ruptures, and a visible pes pla- The medial double can routinely be performed as
novalgus foot type develops. Eventually, compen- an outpatient procedure. This is best accom-
sation, evident by worsening forefoot abduction plished with the use of general anesthesia and a
and ankle equinus, occurs. Over time, the defor- popliteal block, which can offer predictable post-
mity will progress from a flexible flatfoot defor- op pain control for up to 24 hours or more.
­
mity to a rigid one, with associated arthritis. It is However, the comorbid health of the patient may
important to realize that later in the progression of require the patient to be admitted following the
the deformity, the ankle joint can begin to com- medial double for monitoring or comorbid health
pensate and an ankle valgus deformity can result. optimization.
20 The Medial Double Arthrodesis 201

The patient should be brought to the operating tendon, identified prior to elevating the tourni-
room and placed on the table in standard supine quet to minimize wasted time under tourniquet.
position with the feet at the end of the bed. An Esmark is applied and the tourniquet is
Having the heel at the end of the bed allows eas- inflated, typically to 300 mmHg.
ier entry of the posterior to anterior guide wire(s)
and screw(s). A thigh tourniquet allows hemosta-
sis without the binding down of lower leg mus- 20.5 Operative Technique
cles/tendons or obscuring sterility below the
knee. Typically, the foot and limb externally To allow reduction of the long-standing deformed
rotate with the underlying pes planovalgus defor- foot, a release of the posterior compartment is
mity; therefore, no need for a bump as the necessary. Attention is directed to the posterior
approach is medial and allowing the foot to exter- leg. If the Silfverskiold test shows only the gas-
nally rotate facilitates ideal visualization and trocnemius to be contracted, a gastrocnemius
limb stability throughout the case. Prepping and recession (Strayer procedure) can be performed.
draping should be performed to the level of the Typically, however, a tendo-Achilles lengthening
knee to allow visualization of the foot relative to (TAL) is needed for adequate deformity reduc-
the tibia and knee prior to final fixation. tion and ankle dorsiflexion once the deformity is
A bone pan including self-retaining soft tissue corrected. The three-stab Hoke TAL is easily per-
retractors, pin-based joint retractors, Cobb eleva- formed at the start of the case. The limb is held
tors, osteotomes, solid core ~2.5 mm drill bit for securely by an assistant while maintaining con-
joint preparation, curettes both straight and trolled dorsiflexion to keep the Achilles under
curved, lamina spreaders with teeth, and power tension (Fig. 20.5). The percutaneous release is
drivers are useful. Hardware includes 6.5–7.0 mm performed, and the stab incisions do not typically
cannulated screws for the subtalar joint (STJ) require closure (posterior lengthenings are dis-
fusion and 4.0–5.5 mm cannulated screws and a cussed further in Chap. 31).
locking plate for the talonavicular joint (TNJ)
fusion. Biologics may be beneficial to aid in opti-
mizing fusion at both STJ and TNJ.
Incisions should be drawn out (Fig. 20.4) from
the tip of the medial malleolus to the medial
cuneiform and landmarks, medial navicular, the
medial malleolus, and the borders of the Achilles

Fig. 20.5 The foot is held in controlled dorsiflexion,

Fig. 20.4 Incision planning. Markings include the while the triple hemisection is performed of the Achilles
medial malleolus, PTT course, navicular, medial cunei- tendon midsubstance. Notice the medial incision planned
form, and the tibialis anterior tendon course along the medial foot
202 B. W. Bussewitz et al.

Fig. 20.6 As the incision is deepened, the spring liga- Fig. 20.7 The PTT is mobilized dorsally, while the FDL
ment and capsule are seen to be hypertrophied and thick- tendon is a point of retraction for the Weitlaner
ened from chronic abduction and pronatory stresses

With the posterior compartment adequately

released, attention is now directed to the medial
foot where a longitudinal straight incision is
made from the tip of the medial malleolus to the
distal navicular. Along the dorsal incision mar-
gin, expect to encounter a network of superficial
crossing veins that may also include the saphe-
nous vein and nerve. The larger veins can typi-
cally be mobilized and retracted. The navicular
serves as a good landmark, particularly with the
often severely deformed foot. It is not uncommon
to encounter thickened medial soft tissue includ-
ing the spring ligament (Fig. 20.6) and superficial Fig. 20.8 The Cobb elevator is used to lever the talar
deltoid ligament. The PTT or its sheath will be head into full exposure for joint preparation
apparent attaching to the navicular and should be
used as a dissection guide while moving proxi- neurovascular and tendinous structures, a
mal. One can choose to retract the PTT plantarly Hohmann retractor works well here. The talar
utilizing it as a plantar retraction point, or, as an head is easily visualized since the underlying
alternative, the interval between the PTT and the midfoot abduction forces it medially. A Cobb ele-
flexor digitorum longus (FDL) tendon can be vator can be used as a fulcrum within the joint,
used to access the STJ. The tendons serve as and the entire talar head and navicular c­ artilaginous
good soft tissue retraction points (Fig. 20.7). If surfaces can be accessed (Fig. 20.8). If the lateral
the PTT is mild or moderately diseased, one can portion of the joint is not easily accessed, a pin-
debride and repair the tendon, but, more com- based joint distractor will aid in access (Fig. 20.9).
monly, it is severely diseased, and excision of the Avoid using a lamina spreader at the TNJ, as the
remaining tendon or stump is favored. The initial medial talar head is soft and may collapse when
dissection is now complete. exposed to the pressure required to distract the
If the PTT is preserved and repaired, it is joint. The talar head is easily denuded of its carti-
retracted plantarly, and the TNJ should be pre- lage and subchondral plate. A combination of
pared first. The medial TNJ capsule and ligaments osteotomes, rongeurs, and curettes makes quick
should be incised sharply allowing access. work of talar head preparation. Be observant of
Caution should be used to retract the dorsal foot how soft the talar head may be and avoid
20 The Medial Double Arthrodesis 203

Fig. 20.10 The PTT is retracted plantarly. The medial

STJ joint capsule is identified and ready to be incised

Fig. 20.9 The pin-based Hintermann distractor is used to

access the TN joint

overaggressive debridement. The navicular will

have a much more dense subchondral bone plate;
therefore, a more aggressive debridement is
required. Small curved osteotomes and curettes are
sufficient for preparation. Make certain to remove
debrided cartilage pieces from the joint. Drilling
the fusion bed with a solid core ~2.5 mm drill bit
and fish scaling with an osteotome will complete Fig. 20.11 The medial facet is identified and the intact
the fusion preparation. The TNJ is now prepped interosseous ligament is identified
and the retractors can be removed. We have found
that by performing the TNJ preparation first, the transected with a 1/4″ osteotome (Fig. 20.12). As
access to the STJ seems easier, most likely due to the ligament is transected, an audible and palpa-
improved soft tissue relaxation medially. ble pop is often noted. A Cobb elevator is then
With the PTT and FDL serving as the dissec- used to complete the release, and the joint can be
tion interval margins, the medial STJ can easily pried open allowing a lamina spreader with teeth
be identified (Fig. 20.10). Incising the deep del- to be inserted. Be careful to avoid excessive force
toid at the level of the STJ is necessary to allow against the talar neck as iatrogenic fracturing can
adequate STJ exposure. Take care to incise the occur. Often times the joint will be tight; there-
capsule and ligaments such that sufficient plantar fore, creating a working space by starting medial
and dorsal cuffs remain for reapproximation dur- and working deep is beneficial. Prior to joint
ing joint closure. By palpating the sustentaculum preparation, protect the medial neurovascular
tali and keeping the deltoid release slightly dorsal structures by placing a Hohmann retractor medi-
to it, a robust ligament layer will be available at ally. A combination of osteotomes, curettes, and
the case conclusion. The interosseous ligament rongeurs works well to remove the STJ cartilage
(Fig. 20.11) will need to be transected to allow and subchondral plate. As cartilage is sequen-
insertion of lamina spreaders into the STJ. The tially removed, the laminar spreaders can be
interosseous ligament is sharply and carefully placed deeper allowing greater visualization.
204 B. W. Bussewitz et al.

Fig. 20.12 The medial view into the STJ. Notice the PTT Fig. 20.14 The peroneal tendons can be seen at the
retracted plantarly depths of the lateral aspect of the STJ

Fig. 20.13 The FHL tendon is visualized at the medial

posterior facet joint line

The FHL tendon (Fig. 20.13) should be identi-

fied via visualization or palpation. In patients
with relatively loose STJ ligaments, the increased
distraction of the STJ may allow direct visualiza-
tion of the peroneal tendons deep in the lateral
joint (Fig. 20.14). Use both rongeur and aggres-
sive bulb-syringe flushing to aid in cartilage frag- Fig. 20.15 The STJ is fenestrated with a solid core drill
ment removal. To maximize efficient joint bit and soft tissue protector. The laminar spreader can be
preparation, it is beneficial to utilize two lamina seen holding retraction in the joint
spreaders. One spreader is moved to a new posi-
tion, while the second maintains joint distraction. calcaneus sustentaculum tali as over aggressive
A protected solid core ~2.5 mm drill bit is then pressure can produce iatrogenic fracture.
used to fenestrate the joint surfaces (Fig. 20.15). Complete the joint preparation by carefully fen-
Joint surface preparation is completed by fish estrating the joint starting from the deepest point
scaling with a ¼″ curved osteotome. One should and moving medially. Progressing in this manner
practice caution when preparing the posterior minimizes debris in the visual field. A joint
most talus, the lateral talar process, and over the fusion-promoting graft and/or biologic, such as a
20 The Medial Double Arthrodesis 205

Fig. 20.16 The biologic, in this case DBM, is fashioned Fig. 20.17 The left hand is seen holding reduction of the
into a disc to be placed into the STJ prior to final fixation STJ, while the guide wire is inserted at the posterior cal-
caneus. Notice the thumb holding the talar head and the
ring finger stabilizing the lateral calcaneal wall. Also,
calcaneal autograft, or demineralized bone matrix notice the limb elevated on a bump to allow better poste-
(DBM) can be placed at this time and prior to rior calcaneal access
retractor removal (Fig. 20.16).
The STJ should be fixated first. The joint can A lateral foot image will show the talus is well
be reduced by pressing the prominent medial talar positioned and that the wire is central within the
head laterally while stabilizing the calcaneus. talar dome. A calcaneal axial image verifies that
Appreciate that the talus can be rotated laterally at the screw has not violated the medial calcaneal
its distal aspect and reduced back onto the ante- wall and also confirms neutral calcaneal align-
rior and middle calcaneal facets via a scissor-type ment. If desired, a second wire for a second screw
action. Hold the reduction with your non-domi- can be placed parallel to the original. When mea-
nant hand, or have your assistant maintain the suring the screw, be aware the screw typically
reduced position in preparation for fixation compresses the STJ up to 5 mm during insertion.
(Fig. 20.17). The calcaneus should be in a neutral The screw is then drilled and placed in standard
position at this point, and varus positioning is to fashion. A partially threaded short-thread screw is
be avoided to prevent locking of the midtarsal placed while manually holding correction. Nearly
joints. A guide wire for a 6.5–7.0 mm headed or all cannulated screw manufacturers offer screws
headless screw is now placed from posterior to with thread lengths of 18 mm or less. Given the
anterior starting within the interim bordered by limited talar bone available to the screw, the short-
the Achilles insertion and the plantar weight-bear- thread length is critical to ensure that all the threads
ing surface. The wire is advanced toward the cen- are able to cross the joint and properly compress.
tral body of the talus and across the STJ. Once the Joint compression can often be visualized directly.
wire is placed, an AP ankle view is necessary to A lateral x-ray confirms joint and screw position.
make certain the ankle joint is not violated. Attention to the screw head verifies that it does not
206 B. W. Bussewitz et al.

The construct should be solid and complete at

this point. Fluoroscopy and clinical observation
are used to confirm final hardware and foot posi-
tion. Although it is beyond the scope of this chap-
ter, residual forefoot varus is occasionally
observed at this juncture. Numerous remedies to
this situation exist and include extending the
medial column fusion to the navicular-cuneiform
joint, plantarflexion fusion of the first tarsometa-
tarsal joint, and medial cuneiform Cotton osteot-
omy. All or some of these options may be
necessary to ensure a stable and plantigrade
medial column.
The deltoid ligament and STJ capsule should
Fig. 20.18 The windlass maneuver to reduce the foot. be closed tightly. With the flatfoot deformity
Particularly useful when placing TN joint fixation
reduced, the redundant tissue layers are typically
easily closed using pants-over-vest sutures. All
remain proud near the weight-­ bearing surface.
incisions should be flushed and closed in layers.
Stability after stressing ankle inversion and ever-
If the PTT had been completely ruptured, an FDL
sion provides confidence in the fixation construct.
transfer may be considered. A compressive splint
If stability is questioned, a second screw can be
should be applied and tourniquet let down.
placed either parallel to the first or from the dorsal
talar neck down into the calcaneus body or ante-
rior process.
Once the STJ is fixated and stable, attention 20.6 Postoperative Protocol
should be directed to the TNJ. If not already
placed, autograft and/or a biologic healing Please see Chap. 1 for postoperative protocols.
adjunct should be placed into the joint prior to
reduction. The reduction maneuver is designed to
Additional Callout/Pearls-Pitfalls for
adduct the forefoot and eliminate forefoot varus.
Resident/Fellow Readers
The forefoot is adducted and the windlass mech-
anism is activated to properly reduce the TNJ • Having the heel at the end of the bed
(Fig. 20.18). A guide wire for ~5.0 mm cannu- allows easier entry of the posterior to
lated screw is driven from the distal aspect of the anterior guide wire(s) and screw(s).
medial navicular toward the central talar body. • The talocalcaneal interosseous ligament
The wire position and joint position are con- attachments must be sharply transected
firmed on lateral and AP foot images as well as an with either an osteotome or blade prior
AP ankle image. The ~5.0 mm screw is placed to deep retraction placement.
and TNJ compression is visualized. Either a • Place your initial STJ lamina spreader
­second screw or a dorsal−/medial-locking plate into tarsal canal to prevent subchondral
should be placed to strengthen the construct. The bone penetration.
plate should be preliminarily fixed to confirm that • Posterior subtalar joint and inferior talo-
it does not impinge on the anterior-medial ankle navicular joint capsules are often sec-
joint during stressed dorsiflexion. Place a finger ondary restraints to joint distraction and
on the proximal plate and maximally dorsiflex can be released using an osteotome.
the ankle to verify no impingement occurs. • Be cautious with the talar head, particu-
Confirmed impingement requires adjusting the larly the medial head, in pes planovalgus
plate position or choosing a shorter plate design.
20 The Medial Double Arthrodesis 207

deformity as the subchondral and can-

cellous bone is soft and easily damaged
due to unloading from midfoot abduc-
tion. The head is often not strong enough
to withstand a lamina spreader.
• When roughening subchondral bone
with a drill bit, wire, or osteotome, be
cautious to limit depth of penetration, as
bone thickness is only a few millimeters
at the posterior aspect of the talus, lat-
eral process of the talus, and over the
sustentaculum tali of the calcaneus.
• Plantigrade foot reduction is often eas-
ily achieved by tensioning the windlass
mechanism while rotating the midfoot
out of abduction and supination.
• When positioning guide wires for can-
nulated screws across the subtalar artic-
ular facets, one can visualize wire
location from within the joint before
final reduction and advancement.
• One can use a curved hemostat to pre- Fig. 20.19 The curved stat is used to secure the guide
wire as the drill is removed from the calcaneus
vent inadvertently pulling the guide
wire out at the completion of drilling
(Fig. 20.19).
• Exposure can be carried distally along References
medial column or curved dorsally to the
1,2 metatarsal interspace if extended 1. Johnson KA, Strom DE. Tibialis posterior tendon dys-
function. Clin Orthop Relat Res. 1989;239:196–206.
medial column arthrodesis is necessary. 2. Myerson MS. Adult acquired flatfoot deformity: treat-
• The tibial neurovascular bundle, flexor ment of dysfunction of the posterior tibial tendon.
digitorum longus, and flexor hallucis Instr Course Lect. 1997;46:393–405.
longus are all at risk during the surgery 3. Angus PD, Cowell HR. Triple arthrodesis: a
critical long-term review. J Bone Joint Surg Br.
and must be carefully protected and 1986;68:260–5.
actively avoided at all times. 4. Anand P, Nunley JA, DeOrio JK. Single-incision
• A “watertight” capsular closure is medial approach for double arthrodesis of hindfoot in
achievable with meticulous dissection posterior tibialis tendon dysfunction. Foot Ankle Int.
2013;34:338–44.
and results in healthier appearing skin at 5. Brilhault J. Single medial approach to modified dou-
first follow-up. ble arthrodesis in rigid flatfoot with lateral deficient
• In larger deformities, redundant, at skin. Foot Ankle Int. 2009;30:21–6.
times bulky, medial soft tissue is com- 6. Jeng CL, Tankson CJ, Myerson MS. The single
medial approach to triple arthrodesis: a cadaver study.
mon and will remodel over the first year. Foot Ankle Int. 2006;27:1122–5.
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7. Knupp M, Schuh R, Stufkens SA, Bolliger L, lar joints for correction of symptomatic hindfoot
Hintermann B. Subtalar and talonavicular arthrodesis malalignment. Foot Ankle Int. 2006;27:661–6.
through a single medial approach for the correction of 10. Saville P, Longman CF, Srinivasan SC, Kothari
severe planovalgus deformity. J Bone Joint Surg Br. P. Medial approach for hindfoot arthrodesis with a
2009;91:612–5. valgus deformity. Foot Ankle Int. 2011;32:818–21.
8. Philippot R, Wegrzyn J, Besse JL. Arthrodesis of the 11. Weinraub GM, Schuberth JM, Lee M, Rush S, Ford L,
subtalar and talonavicular joints through a medial Neufeld J, Yu J. Isolated medial incisional approach
surgical approach: a series of 15 cases. Arch Orthop to subtalar and talonavicular arthrodesis. J Foot Ankle
Trauma Surg. 2010;130:599–603. Surg. 2010;49:326–30.
9. Sammarco VJ, Magur EG, Sammarco GJ, Bagwe
MR. Arthrodesis of the subtalar and talonavicu-
 Isolated Talonavicular Joint
Arthrodesis
21
Jeffrey E. McAlister and Gregory C. Berlet

21.1 Introduction with Clinical 1 year prior, and the healthy 66-year-old female
Case Examples had pain with all weight-bearing activities. She
underwent a revision arthrodesis with a stronger
Hindfoot arthrodeses, in particular talonavicular construct and, most importantly, copious ipsilat-
(TN) joint arthrodeses, are versatile procedures eral distal tibial bone graft. These are two exam-
which allow for dramatic positional correction in ples of typical patients requiring an isolated
multiple planes. The indications range from post-­ talonavicular joint fusion. Furthermore, the
traumatic arthropathy, moderate to severe hind- authors will discuss the patient work-up, optimal
foot valgus, posterior tibial tendon dysfunction, surgical approach, and pertinent pearls for suc-
Mueller-Weiss syndrome, and rheumatoid arthri- cessful outcomes of an isolated talonavicular
tis. These various disease processes and patholo- joint arthrodesis.
gies are discussed in detail in previous chapters.
The talonavicular joint is complex with its ball
and socket shape which allows for various fixa- 21.2 Patient Presentation
tion techniques, which is the primary focus of
this chapter. An example of a talonavicular joint For the specifics of this chapter, we are going to
fusion is seen in Figs. 21.6 and 21.7 where a discuss an isolated talonavicular joint arthrode-
healthy 68-year-old female was seen with a pre- sis. Patients typically present with medial hind-
vious ankle and subtalar joint fusion by means of foot pain and most commonly a valgus heel
a retrograde compression nail. She complained of orientation. A history common to this patient pre-
dorsal foot pain and, following a fluoroscopic-­ sentation reveals a remote trauma or ankle sprain
guided injection, underwent a talonavicular joint or long-standing pes plano valgus deformity.
arthrodesis with a hybrid fixation construct. Patients may also describe a history of hindfoot
Another example of a talonavicular joint arthrod- fracture (i.e., navicular fracture). Tenderness will
esis is seen in Figs. 21.8 and 21.9 and presented be directly over the talonavicular joint with
as a nonunion. Index procedure was a­ pproximately restricted range of motion of the hindfoot, with
and significant lack of active plantarflexion and
J. E. McAlister (*) inversion. Severe pain is usually elicited with
Arcadia Orthopedics and Sports Medicine, attempted TN joint motion.
Phoenix, AZ, USA
Weight-bearing analysis is limited by pain
G. C. Berlet with the pain centered over the TN joint. The
Orthopedic Foot & Ankle Center,
weight-bearing/gait analysis is similar to a patient
Worthington, OH, USA

© Springer Nature Switzerland AG 2019 209

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_21
210 J. E. McAlister and G. C. Berlet

with suspected posterior tibial tendinitis, includ- recently weight-bearing CTs have been advo-
ing a single-leg heel-rise test. cated for alignment considerations. An alterna-
It is imperative to assess the entire hindfoot tive imaging modality may include
complex, heel orientation in stance, and global fluoroscopic-guided injections which can be
ankle stability. From the posterior view, it is done without difficulty in the office.
important to visualize the resting stance of the Surgeons working up a possible talonavicular
calcaneus. The surgeon should attempt to take the joint arthrodesis will easily be able to identify
subtalar joint through full range motion and the sclerotic changes with surrounding osteophytes
midfoot as well. This will help one understand on AP and lateral radiographs. There are instances
the downstream or upstream mechanics and foot where an isolated talonavicular joint fusion may
posture. In advanced talonavicular arthritis, hind- assist with severe deformity correction. On lat-
foot motion is often significantly compromised. eral radiographs, a significant fault may lie at the
Assess the patient’s medial ankle ligament plantar talonavicular joint, whereby the posterior
complex with forced eversion as well as distal tibial tendon has ruptured and the subtalar joint
tibiofibular joint and lateral ankle ligament has not dislocated yet. This may present itself in
complex. an acute situation. Utilizing all the tools neces-
Patients with isolated TN arthritis may also sary will help guide the surgeon with the appro-
have a history of an ankle arthrodesis or adjacent priate procedure choice [3, 4].
joint fusion. This is a known sequela of an ankle
arthrodesis after at least 10 years. The joint
mechanics are reversed and significantly altered 21.4  R Setup, Instrumentation,
O
after an adjacent joint fusion [1]. and Hardware Selection
With previous ankle joint fusions, it is impor-
tant to assess the standing leg position. There are An isolated talonavicular joint arthrodesis may
cases whereby the tibiotalar joint was fused in be performed with other procedures but most
slight plantarflexion which will impact the over- commonly only soft tissue procedures. These
all positioning of the adjacent joint arthrodeses. cases are typically booked for 1–2 hours of block
Of course, if there were no previous fusions, the time. The authors prefer a preoperative popliteal
posterior muscle group should be appropriately block with general anesthesia, unless neuropathy
assessed with a Silfverskiold test [2]. is present in the operative limb. A supine position
Preoperative counseling on expectations and is preferred. A thigh tourniquet is applied to the
procedure choice are crucial. This type of defor- ipsilateral thigh and set to 300 mmHg. A small,
mity will typically lend itself to intraoperative or mini, intraoperative fluoroscopy unit is most
decision-making, and the consent should reflect commonly used during these procedures and
as such. positioned on the same side as the operative limb.
A bump sandbag is placed under the ipsilateral
hip to place the foot in a rectus position. If any
21.3 Diagnosis and Imaging ankle procedures are being performed, a large
intraoperative fluoroscopy unit is requested.
Standard weight-bearing foot and ankle radio- Preoperative briefing with the operating room
graphs are assessed as well as hindfoot alignment team involves discussions regarding instrumenta-
and/or Saltzman views. Anteroposterior and lat- tion. Reconstructive foot and ankle surgery is
eral views of the foot will help the surgeon’s dynamic and lends itself to intraoperative
assessment of medial column instability and decision-­making, so over-preparation is a surefire
adjacent joint arthritis. Contralateral films will way to gain confidence. The most common
also give the surgeon an appreciation for the instrumentation requested includes two cordless
patient’s expected alignment. Advanced imaging, power drivers, a corded sagittal saw, and an oval
computed tomography (CT), is typically helpful burr. A standard foot and ankle or orthopedic set
to assess the degree of adjacent joint arthritis, and is utilized.
21 Isolated Talonavicular Joint Arthrodesis 211

Hardware selection for this type of procedure c­ artilage has been removed, a small (2.0–3.0 mm)
is typically surgeon preference and may include solid core drill is used to fenestrate the subchon-
but not limited to cannulated screws, locking dral bone plate. The joint is then irrigated with
compression plates, staples, and any combination copious amounts of normal saline (Figs. 21.1,
of the above [5–7]. The authors advocate for rigid 21.2, 21.3, 21.4 and 21.5).
internal fixation with either of two constructs:
locking interfragmentary compression plate or a
large cannulated screw and compression plate
[8]. Biologics are typically utilized during these
cases due to reported nonunion rates and to opti-
mize outcomes. The authors advocate for either
calcaneal bone marrow aspirate with demineral-
ized bone matrix or calcaneal autograft based on
the patient’s healing potential. A full chapter
dedicated to biologics is included, Chap. 40.

21.5 Operative Technique Fig. 21.1 A 4-cm incision is made between the tibialis
anterior and tibialis posterior. A dorsal capsulotomy is
Again, a talonavicular joint fusion can be utilized made, and a pin-to-pin spreader is used to open the joint
in isolation as well as in combination, either a for visualization
medial or triple arthrodesis. The latter procedures
are discussed in detail in other chapters. This
technique will focus on a primary arthrodesis.
The authors will always assess preoperatively
and intraoperatively for posterior muscle group
equinus and perform a posterior muscle group
lengthening based on these findings. Typically, a
Strayer lengthening is performed.
Following this, a linear 3–4 cm incision is
centered between the tibialis anterior and tibialis
posterior. The incision is deepened through sub-
cutaneous tissues to the level of the talonavicular
joint capsule. It is very helpful to identify the dis- Fig. 21.2 The articular cartilage is removed with an
osteotome carefully down to the level of the subchondral
tal aspect of the talar dome, which will help with bone
hardware placement. At this time, a Cobb eleva-
tor is used to raise subcutaneous tissues and iden-
tify the dorsolateral aspect of the joint. Next, a
pin-to-pin spreader (Hintermann distractor) is
utilized and is of great assistance with lateral
joint visualization. The remaining cartilage is
denuded from the joint surfaces with a combina-
tion of a rongeur, curette, and 1/4-inch curved
osteotome. An alternative, efficient method is to
utilize an oval burr with irrigation to debride the
cartilage. Care is taken to avoid over-resection of
the talar head and just through the level of sub-
chondral bone; otherwise, iatrogenic shortening Fig. 21.3 A small 2–3 mm solid drill is utilized to fenes-
of the medial column will occur. Once the trate the talar head and navicular surfaces
212 J. E. McAlister and G. C. Berlet

Fig. 21.4 A well-fenestrated talar head is seen here Fig. 21.5 A small ¼ inch osteotome is then utilized to
which allows for bleeding cancellous bone in the fusion “fish-scale” the joint surfaces
site

Next, either autologous bone graft or appro- a­ ppropriate plate positioning. Simultaneous com-
priate allograft with a bone marrow aspirate is pression of plate and medial screw is undertaken.
interposed in the joint. The authors will typically When using a locking interfragmentary compres-
use 1–3 cc of bone graft. Positioning of the joint sion plate, placement should be confirmed under
is often done manually. With severe hindfoot val- fluoroscopy as well. Alternative fixation includes
gus deformities, the surgeon should aim to two crossed partially threaded cannulated screws
­activate the windlass mechanism and plantarflex or a partially threaded cannulated screw and a
the medium column on the hindfoot. This can be staple (Figs. 21.6 and 21.7). The shape of the
done with the non-dominant hand. Care is taken joint lends itself to difficult compression equally
to avoid overcorrection or, clinically, over-­ medial and lateral.
supination of the joint, which is easy to do. This Final intraoperative fluoroscopic images are
can be seen on a loaded AP foot view with a neg- performed, and a standard closure is undertaken
ative Meary’s angle. The central talar neck and with surgeons’ preferred method. The authors
head should be parallel to the first metatarsal long typically do not utilize a drain or like product
axis. The joint is temporarily pinned with a for this procedure. Figures 21.8 and 21.9 dem-
guidewire through the medial central navicular onstrate a previously attempted TN joint
pole. This can be visualized on intraoperative arthrodesis which failed due to lack of joint
fluoroscopy for appropriate position. preparation or poor healing potential. The
Confirmation of foot position is also assessed patient was counseled on the high possibility of
clinically and radiographically. a nonunion and revision surgery. After appropri-
At this point, one can utilize the guidewire for ate joint preparation, bone graft was procured
screw insertion for utilizing a locking interfrag- from the distal tibia and placed in the surgical
mentary compression plate. A 4.0 or 5.0 mm, par- site. Bone graft and a rigid compression plate
tially threaded cannulated screw is inserted over allowed for a successful patient outcome. Care
the guidewire, but before final compression, a is taken not to overcorrect or over-shorten the
dorsal lateral locking compression plate is placed. midtarsal joint, which will excessively load
Intraoperative fluoroscopy is utilized for the lateral column.
21 Isolated Talonavicular Joint Arthrodesis 213

Fig. 21.6 (a, b) A 68-year-old female with a history of an ankle and subtalar joint fusion presents with a painful, rigid
talonavicular joint

a b

Fig. 21.7 (a, b) An arthritic talonavicular joint was denuded and fixated with two crossed compression screws and an
additional dorsal compression staple
214 J. E. McAlister and G. C. Berlet

21.6 Postoperative Protocol

A standard postoperative compressive bulky

Jones dressing is applied with a posterior splint.
Generally, patients are seen at 10–14 days post-
operatively and placed into a short-leg non-­
weight-­bearing cast. Sutures are removed when
the incisions have healed, and the patient is
placed into a weight-bearing cast at 5–8 weeks
and transitioned into a cam walker boot 3 weeks
thereafter. Serial radiographs are used to confirm
healing of the arthrodesis and no hardware fail-
ures. Physical therapy begins at 8–10 weeks and
resumes until the patient can comfortably bear
weight in a supportive shoe with an accommoda-
tive custom-fabricated orthosis. CT scans are
taken at the 4–6-month mark for confirmation of
arthrodesis [9, 10]. This provides a benchmark
for osseous fusion and can be utilized for non-
union situations. The remainder of the postopera-
Fig. 21.8 A healthy, active 66-year-old female with an tive course is described in detail in Chap. 1.
obvious nonunion at the talonavicular joint

a b

Fig. 21.9 (a, b) The talonavicular joint hardware was l­ocking compression plate. Patient healed uneventfully
removed and the joint prepped and augmented with distal with a return to activity
tibial autograft. The joint was fixated with a dorsal,
21 Isolated Talonavicular Joint Arthrodesis 215

2. Stapleton JJ, Zgonis T. Hindfoot arthrodesis for

Pearls and Pitfalls and Resident/Fellow the elective and posttraumatic foot deformity. Clin
Podiatr Med Surg. 2017;34(3):339–46. https://doi.
Resource
org/10.1016/j.cpm.2017.02.005. Epub 2017 Apr 8.
• The shape of the talonavicular joint is a 3. Xie MM, Xia K, Zhang HX, Cao HH, Yang ZJ, Cui
ball and socket. This is important with HF, Gao S, Tang KL. Individual headless compression
appropriate choice of fixation. screws fixed with three-dimensional image processing
technology improves fusion rates of isolated talona-
• Overzealous debridement of the joint vicular arthrodesis. J Orthop Surg Res. 2017;12(1):17.
surfaces can create a short medial col- https://doi.org/10.1186/s13018-017-0516-0.
umn which will inherently cause lateral 4. van den Broek M, Vandeputte G, Somville J. Dual
column overload. window approach with two-side screw fixation for
isolated talonavicular arthrodesis. J Foot Ankle
• In cases of nonunion or revision with a Surg. 2017;56(1):171–5. https://doi.org/10.1053/j.
short medium column, structural how a jfas.2016.03.004. Epub 2016 Jun 9.
graph for autograph is preferred. 5. Chatellard R, Berhouet J, Brilhault J. Efficiency
• As always, “thou shall not varus.” The of locking-plate fixation in isolated talonavicular
fusion. Orthop Traumatol Surg Res. 2016;102(4
patient is unable to compensate for a Suppl):S235–9. https://doi.org/10.1016/j.
varus positioned TN fusion, and this otsr.2016.03.003. Epub 2016 Mar 28.
will result in a very difficult problem. 6. Ma S, Jin D. Isolated Talonavicular arthrodesis.
• The key instruments include pin distrac- Foot Ankle Int. 2016;37(8):905–8. https://doi.
org/10.1177/1071100716641731. Epub 2016 Mar 30.
tor, ¼ inch osteotome, burr, and solid 7. Higgs Z, Jamal B, Fogg QA, Kumar CS. An ana-
drill. tomical study comparing two surgical approaches
• Visualization of the most distal aspect of for isolated talonavicular arthrodesis. Foot
the navicular and the talar dome leading Ankle Int. 2014;35(10):1063–7. https://doi.
org/10.1177/1071100714540886. Epub 2014 Jul 18.
surface will assist with any hardware 8. Granata JD, Berlet GC, Ghotge R, Li Y, Kelly B,
placement. DiAngelo D. Talonavicular joint fixation: a biome-
• Potential pertinent complications: non- chanical comparison of locking compression plates
union, malalignment/malunion, hard- and lag screws. Foot Ankle Spec. 2014;7(1):20–31.
https://doi.org/10.1177/1938640013516791. Epub
ware removal, neuritis, adjacent joint 2013 Dec 30.
arthritis, and infection. 9. Crevoisier X. The isolated talonavicular arthrod-
esis. Foot Ankle Clin. 2011;16(1):49–59. https://doi.
org/10.1016/j.fcl.2010.11.002.
10. Popelka S, Hromádka R, Vavrík P, Stursa P, Pokorný
D, Jahoda D, Sosna A. Isolated talonavicular arthrod-
References esis in patients with rheumatoid arthritis of the foot
and tibialis posterior tendon dysfunction. BMC
1. Sturnick DR, Demetracopoulos CA, Ellis SJ, Queen Musculoskelet Disord. 2010;11:38. https://doi.
RM, Kolstov JCB, Deland JT, Baxter JR. Adjacent joint org/10.1186/1471-2474-11-38.
kinematics after ankle arthrodesis during cadaveric
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Epub 2017 Aug 24.
 Isolated Subtalar Joint Arthrodesis
22
Michael D. Dujela, Ryan T. Scott,
Matthew D. Sorensen, and Mark A. Prissel

22.1 Introduction 84–100% [5]. Because of the high union rate and
low complication rates, the procedure has a high
Isolated subtalar joint fusion is a powerful pro- patient satisfaction coefficient [5].
cedure applied in the engagement of definitive
treatment for hindfoot arthritis and/or deformity.
Because of the importance of the subtalar joint 22.2 Presentation/Diagnosis/
in dynamic biomechanical gait pattern kinemat- Imaging
ics, disease intrinsic to the joint can prove debili-
tating [1]. Pathology associated with this Patients with STJ pathology present with pain
important joint includes post-traumatic arthritis, localized inferior to the ankle mortise and proxi-
flatfoot deformity, cavus foot deformity, inflam- mal to the midtarsal joint. Complaints of discom-
matory arthritis, and tarsal coalition [2]. Late- fort or disability upon engaging sidehill walking
stage STJ arthritis from long-standing residual or weight-bearing on uneven surfaces, such as a
hindfoot deformity or failed joint salvage beach, are common for diseased subtalar joints.
attempts are also indications for definitive fusion Often, patients will present with a complaint of
[3]. Certainly, subtalar joint fusion is often uti- “ankle pain.” Upon further evaluation, however,
lized in conjunction with other joint-modifying the pain is found to be isolated to the sinus tarsi
procedures such as total ankle replacement or and along the lateral border of the STJ articula-
global foot and ankle reconstructive proce- tion, deep to the peroneal tendon course and infe-
dures [4]. Reported union rates are high at rior to the distal fibula. It is of utmost importance
to accurately isolate the precise location of the
pain. A complete understanding of the global bio-
M. D. Dujela (*) mechanical and morphological pathology is nec-
Washington Orthopaedic Center, Centralia, WA, USA
essary prior to the decision for surgical
R. T. Scott intervention. Diagnosis begins with a thorough
The CORE Institute, Phoenix, AZ, USA
physical exam of the foot and ankle and should
M. D. Sorensen include a general orthopedic evaluation of the
Weil Foot and Ankle Institute, Foot & Ankle Surgery,
Chicago, IL, USA patient during gait and static stance. This includes
palpation of the sinus tarsi and medial and lateral
M. A. Prissel
Orthopedic Foot & Ankle Center, joint line in addition to passive inversion and ever-
Worthington, OH, USA sion through the joint. Assessment of the overall

© Springer Nature Switzerland AG 2019 217

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_22
218 M. D. Dujela et al.

alignment of the lower extremity should also be is desired, a large bump should be used under the
performed. Radiographic evaluation using ipsilateral hip to internally rotate the foot for the
weight-bearing AP, medial oblique, and lateral lateral exposure. If lateral decubitus position is
views of the foot and ankle are important to assess preferred, the use of a large beanbag is recom-
frank degenerative change or morphological defi- mended. Full lateral decubitus with an axillary
ciency in and around the subtalar joint [6]. roll is important for patient comfort and safety. A
Additionally, calcaneal axial, hindfoot alignment, stack of blankets distally at the level of the calf
and Broden’s views are commonly employed in should also be employed to alleviate stress from
radiographic evaluation. Further definitive exam the knee and provide a stable working surface for
components include obtaining a CT scan or MRI, the anticipated surgery. Prep of the leg up to the
and a low threshold for ordering advanced imag- knee is performed to allow for adequate visualiza-
ing in these scenarios should be maintained. tion of the lower extremity alignment.
Additionally, diagnostic injections are recom- Instrumentation is very important in hindfoot
mended in an effort to ensure that clear isolation reconstruction. A pin distractor or lamina
of the pain nidus has been achieved. spreader will provide visualization in the subta-
lar joint allowing for preparation of the joints for
arthrodesis. A large curette and osteotome will
22.3 Indications allow for removal of the cartilage in a timely
fashion. The use of a rotatory burr will allow
• Subtalar osteoarthritis/post-traumatic arthritis access into the posterior aspect of the subtalar
• Sinus tarsi syndrome joint for joint preparation. Large power instru-
• Hindfoot valgus mentation is also recommended to not only drive
• Tarsal coalition the hardware selected for the fusion but to also
• Select cases of posterior tibial tendon aid in joint prep – fenestration of the joint.
dysfunction Hardware selection is one of the most impor-
tant decisions one should make for subtalar
fusions. We recommend large cannulated screws.
22.3.1 O
 R Setup and Instrumentation
and Hardware
Recommendation
22.5  ubtalar Joint Arthrodesis
S
The listed instrumentation is important to effi-
Surgical Technique
cient execution of the procedure including the
The patient is placed on the operating table in a
following: ½ inch and ¼ inch curved sharp Smith
supine position. A bump is utilized under the hip
Peterson osteotomes, curettes, smooth and
to internally rotate the lower leg which facilitates
toothed lamina spreaders, Gelpi and large
access to the hindfoot. A pneumatic thigh tourni-
Weitlaner self-retaining retractors, fenestration
quet is applied for hemostasis. A general anes-
drill bit, and large power instrumentation.
thetic with popliteal nerve block is preferred to
provide long-lasting postoperative analgesia.
22.4 Setup
22.5.1 Incision and Preliminary
Subtalar joint arthrodesis can be set up in multiple Dissection
ways depending on ancillary surgery being per-
formed. For this section, we will focus solely on A longitudinal incision is made from the distal
isolated subtalar joint arthrodesis. General anes- tip of the fibula to the base of the fourth metatar-
thesia with a popliteal block is recommended. sal (Fig. 22.1). Dissection is carried deep with
Positioning can be either lateral decubitus or care taken to avoid injury to the sural nerve in
supine depending on surgeon preference. If supine the inferior flap. The extensor digitorum brevis
22 Isolated Subtalar Joint Arthrodesis 219

(EDB) muscle belly is identified, and the pero-

neal tendons are protected. A large Weitlaner or
Gelpi retractor is placed to maintain retraction of
the wound edges (Fig. 22.2).

22.5.2 Exposure of the Sinus Tarsi

The deep fascia over the EDB muscle is incised,

and the muscle belly is sharply elevated off the
calcaneus using a #15 scalpel to expose the
sinus tarsi (Fig. 22.3a, b). The vascular supply is

Fig. 22.2 The incision is created, and dissection is car-

ried down to the extensor digitorum brevis muscle. A self-­
retaining retractor is used
Fig. 22.1 The proposed incision from the distal fibula
to the level of the fourth metatarsal base crossing the
sinus tarsi

a b

Fig. 22.3 (a) Incision is planned to elevate the EDB muscle from the floor of the sinus tarsi. (b) Elevation of EDB
muscle belly from the sinus tarsi to enhance visualization and access to the subtalar joint
220 M. D. Dujela et al.

at the distal aspect of the muscle and can result 22.5.3 Technique of Joint
in moderate bleeding although hematoma after Preparation
this procedure is rare with careful technique.
The soft tissues of the sinus tarsi obscure visi- The OFAC method of joint preparation is via
bility of the middle and posterior facets of the curettage and follows the same approach
subtalar joint and are removed with a rongeur. regardless of the joint that is fused (Fig. 22.6a–
The anterior leading edge of the posterior facet g). The curettage technique is the mainstay and
is easily visualized at this point (Fig. 22.4). A maintains joint congruity and anatomic charac-
key maneuver is sharp release of the calcaneal teristics. The sequence involves the use of a
fibular ligament which readily allows distrac- curved ½ or ¼ inch osteotome to sharply
tion of the posterior facet via a lamina spreader remove large segments of cartilage (Fig. 22.7a,
placed within the sinus tarsi (Fig. 22.5). A sec- b) followed by curettage of remaining portions
ond lamina spreader is placed at the posterior (Fig. 22.8). Irrigation is performed to remove
aspect of the posterior facet for improved loose fragments followed by drill fenestration
visualization. of the subchondral plate in a grid-like pattern
(Figs. 22.9 and 22.10) followed by fish scaling
with a ¼ inch curved osteotome to “connect
the dots” prior to fixation placement
(Fig. 22.11).

22.5.4 Positioning the Arthrodesis

A combination of rotation and sliding of the talus

relative to the calcaneus is performed to realign
the subtalar joint. The optimum position is neu-
tral to slight valgus alignment of the hindfoot.
The heel is grasped with the non-dominant hand,
and the calcaneus is maximally inverted in the
case of significant hindfoot valgus (Fig. 22.12).
Fig. 22.4 After the contents of the sinus tarsi removed, In the case of significant hindfoot valgus, the
the anterior aspect of the posterior facet is now readily authors’ opinion is that it is difficult to overcor-
visualized

a b

Fig. 22.5 (a) The calcaneal fibular ligament is identified and talar components of the posterior facet with joint
and released to facilitate visualization and prep of the pos- release and dual lamina spreaders
terior facet. (b) Excellent visualization of the calcaneal
22 Isolated Subtalar Joint Arthrodesis 221

a b c

d e f

Fig. 22.6 (a–f) OFA joint preparation sequence a–f as inch curved Smith Peterson osteotome followed by small
demonstrated on a talonavicular joint for better visualiza- curette and ¼ inch curved osteotome for “fish scaling”
tion. (g) Instrument sequence for cartilage removal; ½
222 M. D. Dujela et al.

b
Fig. 22.9 An extensive grid pattern is created via sub-
chondral drilling to both the calcaneal and talar subtalar
joint surfaces

Fig. 22.10 Subchondral drilling using a small-diameter

drill bit with sleeve or fenestrating drill bit

Fig. 22.7 (a) A ½ inch curved osteotome facilitates rapid

removal of large segments of cartilage. (b) 1/2 inch osteo-
tome utilized to denude large cartilaginous segment from
the posterior facet of the subtalar joint, prior to curettage

Fig. 22.11 “Fish scaling” the articular surfaces as a final

step of joint preparation for arthrodesis

Fig. 22.8 A curette is used to remove remaining cartilage

followed by copious saline irrigation to remove remnants
that could impair healing
22 Isolated Subtalar Joint Arthrodesis 223

Fig. 22.12 Position the subtalar joint for fixation. Fig. 22.13 Fluoroscopic imaging scout view obtained to
Inversion of the valgus hindfoot to neutralize using the confirm correct trajectory of guidewire for large diameter
non-dominant hand. A fluoroscopic image can be per- cannulated screw. A second guidewire may also be placed
formed to check the reduction if two-screw fixation is desired

rect into varus even with significant inversion of Once satisfactory trajectory is confirmed, the
the foot during this maneuver. If there is minimal wire is advanced to the subchondral bone at the
malalignment preoperatively, the subtalar joint is talar dome. Position is confirmed with AP and
placed in neutral and will not require significant lateral views of the ankle; in addition an axial
inversion of the heel to place it into the desired calcaneal view is obtained. A #15 blade is uti-
neutral position. lized to create a small incision to accept a drill at
the skin puncture site of each guidewire. A drill
with sleeve is placed, and the drill is advanced
22.5.5 Fixation Placement across the posterior facet, and the talar compo-
nent of the posterior facet is penetrated just
The guidewire is inserted into the posterior infe- through the subchondral bone to avoid pullout of
rior aspect of the calcaneus with a scout fluoro- the threaded guidewire. Fluoroscopic imaging is
scopic view to assess the correct trajectory of the useful in confirming depth of drill penetration
wire prior to committing to the position (Fig. 22.15). Self-drilling screws are utilized
(Fig. 22.13). This is checked on a lateral fluoro- which will avoid need for drilling full depth.
scopic image, and once the correct entry point In the region of the posterior heel, exten-
and trajectory are confirmed, the guidewire is sive countersinking is performed to avoid a
advanced just through the posterior facet articular prominent painful screw head which may
surface where placement can be confirmed under require subsequent removal. In poor-quality
direct visualization (Fig. 22.14a, b). bone, a washer may be used. The appropriate
224 M. D. Dujela et al.

a b

Fig. 22.14 (a) Direct visualization of guidewire crossing suspended, and stack of towels is placed under lower leg
central aspect of posterior facet. Lamina spreader is then to facilitate positioning of the hindfoot while advancing
removed, subtalar joint is positioned, and guidewire is the guidewire
advanced into the talus. (b) An alternative view, the heel is

sized screw should be selected with care minimize the chance of burying the screw head
taken to ensure there is s­ ufficient clearance into the calcaneus and potentially penetrating the
of all screw threads across the joint to avoid ankle joint. A second screw is generally placed to
distraction force which may result in gapping add additional compression and to provide an
at the joint surface. Alternatively, headless anti-rotation effect.
screws can be considered at the surgeon’s The wounds are irrigated and closed in layers,
discretion. and the patient is placed in a well-padded poste-
The screw is initially driven under power rior splint with modified Jones compression
(Fig. 22.16) and finished by hand (Fig. 22.17) to dressing.
22 Isolated Subtalar Joint Arthrodesis 225

Fig. 22.15 Drill sleeve is used to protect soft tissues as

drill is advanced just across talar articular surface

Fig. 22.17 Final screw insertion completed by hand

22.6 Postoperative Protocol

This surgery falls into postoperative protocol #5.

With isolated subtalar joint arthrodesis, the
patient will be placed into a non-weight-bearing
splint for the first 7 days. The patient will then be
transitioned to a NWB short-leg fiberglass cast
for the next 6 weeks. Pending radiographic exam,
the patient may be transitioned either into a
weight-bearing cast or cam walking boot and
allowed to weight bear immediately. If concomi-
tant surgery is performed, the postoperative
course is dictated by the larger procedure.
Physical therapy will be initiated once the
patient is transitioned into the cam walking boot.
The focus of PT will include mobilization of the
talonavicular and tibiotalar joint, edema control,
and early gait training.

Fig. 22.16 Large diameter cannulated screw placed

under power until at the level of the skin
226 M. D. Dujela et al.

22.7 Complications • Hardware failure

• Rare wound complications
• Postoperative infection
• Nonunion
• Malunion 22.8 Cases

Preop images Post op images

b d

a f

c e

Fig. 22.18 Significant deformity with STJ arthritic change and subsequent definitive fusion in conjunction with con-
comitant procedures in a long-standing recalcitrant flatfoot

Preoperative images Post op images

a c d

Fig. 22.19 Definitive STJ fusion secondary to post-traumatic arthritic change and calcaneal body collapse with
decreased talar declination angle
22 Isolated Subtalar Joint Arthrodesis 227

a b c

Fig. 22.20 An adult acquired pes plano valgus deformity in Stage II Posterior Tibial Tendon Dysfunction with subse-
quent correction via hindfoot arthrodesis
228 M. D. Dujela et al.

a b

c d

Fig. 22.21 A 44 year-old patient with a middle facet tarsal coalition and chronic hindfoot pain underwent isolated
subtalar joint arthrodesis resulting in complete resolution of pain
22 Isolated Subtalar Joint Arthrodesis 229

a b

c d

e f

Fig. 22.22 A joint depression fracture calcaneus fracture grafting and subtalar joint arthrodesis. Final outcome
in a 55 year-old rheumatoid patient with lonstanding his- images demonstrate solid union and the patient experi-
tory of tobacco use. The patient experienced a non-union enced full resolution of symptoms
which was subsequently revised with extensive bone
230 M. D. Dujela et al.

g h

Fig. 22.22 (continued)

Pearls access to take down coalition and

• Aggressive joint prep with osteotomes, improve mobility of the subtalar joint.
curette, and burr. • Be mindful of the neurovascular bundle
• Fenestration of the subchondral bone posterior medial when prepping the joint.
with a 2.5–3.0 drill bit or solid fenestra- • Placement of subtalar screws too close
tion bit, “fish scale” with ¼ inch curved to articular surface of ankle can create
osteotome. weight-bearing discomfort.
• Refrain from wedge resection of the • In cases of soft bone, a washer can be
posterior facet. Sliding and rotation can considered to avoid sinking screw into
reduce the joint into desired alignment the bone on posterior heel.
and avoids bone voids. • Invert hindfoot to correct subtalar joint
• Adequate preparation of the middle valgus when initiating guidewire fixation.
facet (spot-weld of the subtalar joint • Stack of towels placed under calf to sus-
fusion). pend heel to facilitate access to posterior
• Use of biologics in the arthrodesis site heel for fixation and positioning.
when indicated. • Female patients with small talus may
• Alignment in the neutral (or mild val- benefit from a single-screw fixation of
gus) position relative to the long axis of the talus particularly if there is plan for
the tibia. TN arthrodesis due to the minimal area
• Do not fuse the joint in varus. to accept multiple screws.
• Release of the CF ligament is important • Two-screw fixation in male patients
to facilitate access to the joint and allows anti-rotation with second screw.
improve mobility. • “Metronome” concept of OFA. To
• Double lamina spreaders one in sinus ensure efficient momentum and forward
tarsi and one posterior to posterior facet progression in a case, devote equal time
enhance visibility. to dissection and exposure, joint prep,
• Medial accessory incision for middle fixation, and closure/splinting to avoid
facet tarsal coalition will allow direct excessive time in the OR.
22 Isolated Subtalar Joint Arthrodesis 231

References 4. DiDomenico L, Wargo-Dorsey M. Tibiotalocalcaneal

arthrodesis using a femoral locking plate. J Foot
Ankle Surg. 2012;51:128–32.
1. Rockar P. The subtalar joint: anatomy and joint motion.
5. Diezi C, Favre P, Vienne P. Primary isolated subtalar
J Orthop Sports Phys Ther. 1995;21(6):361–72.
arthrodesis: outcome after 2 to 5 years followup. Foot
2. Kulik S, Clanton T. Tarsal coalition. Foot Ankle Int.
Ankle Int. 2008;29(12):1195–202.
1996;17(5):286–96.
6. Isherwood I. A radiological approach to the subtalar
3. Carr J, Hansen S, Benirschke SK. Subtalar distraction
joint. J Bone Joint Surg. 1961;43B(3):566–74.
bone block fusion for late complications of os calcis
fractures. Foot Ankle. 1998;9(2):81–6.
 Two-Incision Triple Arthrodesis
23
J. George DeVries

23.1 Introduction 23.2 Case Examples

The traditional two-incision (medial and lateral) 23.2.1 P

 osterior Tibial Tendon
triple arthrodesis is a classic procedure that can Dysfunction
be used for all manner of hindfoot pathology. The
three joints for which the procedure derives its Seventy-two-year-old male with hindfoot col-
name include the talonavicular, subtalar, and cal- lapse (Fig. 23.1a). The deformity is incompletely
caneocuboid joints. These encompass essentially reducible. A lack of inversion of the heel on heel
all the motion from the hindfoot and thus can be rise indicates this is a rigid hindfoot deformity,
used to effect dramatic positional change and related to posterior tibialis tendon grade 3
lasting realignment. It was first described by (Fig. 23.1b). Patient has been through conserva-
Ryerson in 1923 [1]. It is a consistent procedure tive treatment options including custom-made
and has shown reliable and predictable results for orthotics, ankle bracing, and physical therapy.
patients [2]. However, the resulting loss of motion Radiographs show typical findings for this condi-
in the hindfoot will affect gait changes and also tion: decreased calcaneal inclination, increased
will cause stress and eventual arthritis to the sur- talar declination, anteriorly displaced cyma line,
rounding joints [3]. talar head uncoverage, and obscured visualiza-
Because of the corrective capabilities of the tion of the subtalar joint (Fig. 23.1c). Triple
two-incision triple arthrodesis, it can be used in arthrodesis was undertaken for realignment and
treatment of hindfoot malalignment for varus or stability of the hindfoot (Fig. 23.1d)
valgus feet from any cause, primary or posttrau-
matic arthritis, and progressive/spastic deformi-
ties such as upper motor neuron injury or disease. 23.2.2 Cavus
It is also a powerful revision operation in cases of
previous failed surgery. While traditionally Fifty-one-year-old male with hindfoot cavus
reserved in the adult population, in certain malalignment and forefoot lateral overload
instances, it can be employed in a pediatric popu- (Fig. 23.2a). He has previously been treated with
lation as well. Dwyer calcaneal osteotomy, first metatarsal pha-
langeal arthrodesis, and lesser metatarsal head
resection (Fig. 23.2b). He presents in a custom
J. G. DeVries (*) ankle-foot orthosis and has been seen by a
BayCare Clinic, Manitowoc, WI, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 233

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_23
234 J. G. DeVries

a b

Fig. 23.1 (a) Anterior clinical view of case study show- (c) Lateral foot radiograph demonstrating overall hindfoot
ing substantial hindfoot collapse and forefoot abduction. collapse. (d) Lateral foot radiograph demonstrating
(b) Posterior clinical view of the calcaneal alignment. improved overall alignment after triple arthrodesis
Persistent valgus positioning is seen even with heel rise.

wound care specialist. He complains of pain, 23.2.3 Previous Surgery

instability, difficulty with shoes due to hallux
elevation, and a sub-fifth metatarsal head ulcer- Twenty-three-year-old male with history of
ation (Fig. 23.2c). His foot is rigid in this posi- clubfoot corrected through extensive postero-
tion. Triple arthrodesis was performed to realign medial release as an infant (Fig. 23.3a). Chronic
the hindfoot and midfoot, and realignment of the pain in the foot makes it unable for him to work,
first ray was performed at the same time with and he has tried medications, orthotics, and
dorsiflexion osteotomy of the base of the first ankle bracing. Radiographs reveal diminutive
metatarsal and plantarflexion osteotomy of the talus, likely as a result of injury to the talus dur-
first metatarsal phalangeal joint malunion ing surgery. This has now resulted in dorsal dis-
(Fig. 23.2d). location through the talonavicular and
23 Two-Incision Triple Arthrodesis 235

a c

Fig. 23.2 (a) Posterior clinical view of case study show- prominence of the fifth metatarsal phalangeal joint with
ing varus heel alignment and medial exposure of the fore- persistent and recurrent ulcerations. (d) Lateral foot radio-
foot. (b) Lateral foot radiograph of cavus foot after graph after triple arthrodesis and first ray realignment
previous reconstruction. (c) Inferior clinical view showing

calcaneocuboid joints, with arthritis at the sub- 23.3 Presentation/Diagnosis/

talar joint (Fig. 23.3b) and coalitions medially Imaging
(Fig. 23.3c). Compensatory plantarflexion of
the first ray has developed. Triple arthrodesis Clinical presentation is varied based on the spe-
was performed to relocate the tarsal joints, with cific diagnosis that will be corrected with a triple
dorsiflexion osteotomy of the first metatarsal arthrodesis. Several points are consistent through-
(Fig. 23.3d). out all cases. First, all reasonable conservative
236 J. G. DeVries

a c

Fig. 23.3 (a) Medial clinical view of case study after malalignment. (d) Lateral foot radiograph after triple
clubfoot release as a child showing high arch and plan- arthrodesis and dorsiflexion osteotomy of the first meta-
tarflexed hallux. (b) Lateral radiograph showing dorsal tarsal showing relocation of the talonavicular joint and
talonavicular dislocation and diminutive talus. (c) AP foot improved alignment
radiograph showing multiple synostoses and hindfoot

care should be undertaken and exhausted. motion and biomechanics of the foot as possible.
Second, the pathology must not be able to be cor- Similarly, if arthrodesis of only selected joints
rected with a less restrictive procedure. For (such as an isolated subtalar joint arthrodesis)
example, if there are joint-preserving options can take care of the problem, then surgeons
such as osteotomy with tendon work that would should strongly consider the less involved
be able to adequately and predictably correct the procedure.
specific pathology, consideration should be given When comparing traditional triple arthrodesis
to this first as a means to maintain as much to a double arthrodesis of the talonavicular and
23 Two-Incision Triple Arthrodesis 237

specific joint injections. Even in the case of a

rigid hindfoot deformity, careful and specific
evaluation of each of the hindfoot joints, the
naviculocuneiform joints, and the ankle joint
must be specifically palpated and mobilized.
Specific diagnostic joint injections done under
ultrasound or fluoroscopic guidance can be a very
powerful tool in the diagnostic workup when
considering triple arthrodesis. Again, if one or
more of the joints can be spared, every effort
should be made to do so.
Imaging workup for a patient always begins
with weight-bearing plain film radiographs. This
includes the foot as well as the ankle in all cases.
This will give insight into the magnitude and
apex of deformity, evidence of arthritis, and other
joint involvement. Even when patients present
with previous non-weight-bearing films from
other offices, the foot and ankle must be evalu-
Fig. 23.4 Patient that has substantial hindfoot collapse ated in the weight-bearing state, and new films
on weight-bearing. Once the hindfoot alignment is placed
back into place, the forefoot demonstrates significant
need to be obtained (Fig. 23.5a, b). In cases of
residual varus hindfoot deformity, weight-bearing films of the
ankle must be obtained as well to determine if
there is any involvement in this joint or fibula
subtalar joints, the decision between the two pro- (Fig. 23.5c). Axial calcaneal films or hindfoot
cedures is somewhat difficult. Both have been alignment films are also critical in cases of defor-
shown to greatly improve radiographic alignment mity. This is the best way to objectively measure
[4] even in significant deformity. Triple arthrod- the degree of deformity of the calcaneal align-
esis is typically performed over a double arthrod- ment to the leg (Fig. 23.5d). Where there has
esis in cases of true calcaneocuboid arthritis, been previous surgery, any iatrogenic bony defor-
those benefitting from lateral column shortening mity and remaining hardware can often be seen
(such as a cavus foot structure), and when added on radiographs.
stability to the entire construct is deemed desir- Advanced imaging can also be very useful
able such as obesity or poor bone quality. during the workup of a patient. Magnetic reso-
The surgeon must pay close attention to the nance imaging (MRI) is very useful in determin-
forefoot in cases requiring triple arthrodesis. ing the level of soft tissue damage. This is
Often the forefoot has undergone adaptive important when deciding between realignment
changes in compensation to long standing and osteotomy and arthrodesis. If the supporting
rigid hindfoot deformity and can be seen with a structures such as the posterior tibialis tendon,
forefoot varus with hindfoot collapse (Fig. 23.4). flexor digitorum tendon, spring ligament, or del-
A realignment of the forefoot with osteotomy or toid ligament are extensively damaged, a recon-
limited arthrodesis must be considered in these struction may not be possible. Subtle fibrous
cases. In general, the triple arthrodesis will coalitions that have led to hindfoot deformity can
realign the heel to the leg, and then the forefoot accurately be detected with MRI. Early onset of
must be aligned with the hindfoot. arthritis or even bone marrow edema can be
In addition to the clinical presentation, diag- detected with MRI as well, useful in deciding the
nosis of the specific joints involved can be eluci- joints that are involved. Computed axial tomog-
dated through palpation, joint mobilization, and raphy (CT) may be even more useful in
238 J. G. DeVries

a b

Fig. 23.5 (a) Lateral weight-bearing foot radiograph uncoverage, and lateral calcaneocuboid arthritis and spur-
demonstrating severe collapse of the hindfoot with exten- ring. (c) AP weight-bearing ankle radiograph demonstrat-
sive degenerative joint disease, first tarsometatarsal plan- ing mild valgus incongruency, talar head uncoverage, and
tar gapping, and healed fibula stress fracture due to fibula fibular stress fracture due to lateral impingement. (d)
impingement. (b) AP weight-bearing foot radiograph Calcaneal axial weight-bearing radiograph showing val-
demonstrating substantial forefoot abduction, talar head gus orientation of the calcaneus
23 Two-Incision Triple Arthrodesis 239

the ankle. This will require an arthroscopic setup

d that can be taken down for the open portion of the
case. Additional hardware will need to be on
hand during the procedure as well for any adjunct
procedures.
Once in the room, the patient is placed in a
supine position with a bump under the ipsilat-
eral hip in order to position the toes directly up
or in slight internal rotation, as this will allow
for easy lateral exposure while still allowing for
dorsal exposure of the talonavicular joint. The
drape needs to be brought above the tibial tuber-
osity to allow for accurate rotation of the foot to
the leg. The use of a thigh cuff is necessary as a
lengthening of the posterior muscle group is
often needed. The foot should be at the end of
the operative table to allow for posterior inser-
tion of a subtalar screw and for subtalar
positioning.

23.5 Operative Technique

In most cases that involve deformity, the first step

is a posterior muscle group lengthening. This can
either be a gastrocnemius or gastroc-soleal reces-
sion or traditional Hoke triple Achilles hemisec-
tion. This will allow for later repositioning of the
STJ, and failure to do so may impede realign-
Fig. 23.5 (continued) ment. These are done with the patient in the
supine position.
d­ etermining the extent and specific joints that are Incisions for the dual-incision triple arthrode-
arthritic. Oftentimes the foot may be so deformed sis consist of a lateral and dorsal incision. The
that accurate visualization of the specific joints is lateral incision is straight and runs from the tip of
difficult or impossible on plain film radiography. the fibula toward the fourth metatarsal base. In
cases of severe abduction and concern for lateral
incision tension, a curvilinear incision can be uti-
23.4 OR Setup lized to allow for relaxation of skin tension on
closure. This does require more undermining of
Preoperative planning for the two-incision triple the soft tissues and is not typically needed except
arthrodesis is the culmination of the workup. The for the most severe cases, and in those instances,
triple arthrodesis and any additional procedures a complete medial approach may be more appro-
that are planned or even possible in that case need priate. The dorsal incision is straight and located
to be taken into consideration. Incisions will need along the tibialis anterior tendon. Typically this
to be planned and may need to be adjusted to will run along the medial border of the tibialis
incorporate extensions into the ankle or midfoot. tendon in a valgus deformity due to the external
In addition, ankle arthroscopy may precede the rotation of the forefoot and lateral in a cavus
open procedure if there are spurs or synovitis of deformity (Fig. 23.6a, b).
240 J. G. DeVries

a b

Fig. 23.6 (a) Lateral clinical view showing lateral inci- ankle joint over the dorsal talonavicular joint. The lateral
sion from tip of fibula toward fourth metatarsal base. (b) incision is seen as well
Dorsal clinical view showing dorsal incision from the

Lateral dissection is carried out first. expose the CC joint capsule. Pearl: Attention can
Dissection is deepened through the subcutaneous then be directed to the sinus tarsi, and this can be
layer with care being taken to watch for and pro- initially cleared of fat with the use of a rongeur,
tect the sural nerve. This is identified and exposing the interosseous ligament and joint cap-
retracted. The incision should be inferior to the sule of the posterior facet of the subtalar joint
course of the intermediate dorsal cutaneous (STJ). These are sharply released with a 1/2″
nerve. The muscle belly of the extensor digito- curved osteotome. The osteotome is then used
rum brevis (EBD) will be encountered deep to along the lateral aspect of the posterior facet of
this layer. The fascia is opened and plantar to the the STJ all the way to the posterior aspect to fully
muscle belly the peroneal tendons are encoun- release joint. The CC joint is opened sharply with
tered. An interval between the EBD muscle and a scalpel blade starting plantarly and carrying the
the peroneal tendons is made, and dissection is release dorsally. The dorsal aspect of the anterior
carried to the bone. The tendons are elevated process of the calcaneus extends distally and
from the deep structures and retracted plantarly. needs to be dissected out. This is often overgrown
The origin of the EBD off the anterior process of and can be initially removed with osteotome or
the calcaneus is released and dissected distally to rongeur (Fig. 23.7).
the calcaneocuboid (CC) joint. The muscle belly The STJ is then prepared for arthrodesis.
and fascia are elevated and retracted distally to Pearl: Initially a sharp toothed lamina spreader
23 Two-Incision Triple Arthrodesis 241

Fig. 23.8 Toothed lamina spreader placed into the sinus

tarsi allows for exposure and distraction of the posterior
facet of the subtalar joint. Initial joint preparation is car-
ried out with 1/2″ curved osteotome

Fig. 23.7 Lateral dissection showing calcaneocuboid

and subtalar joints. The peroneal tendons are seen along
the plantar aspect of the incision

is placed in the sinus tarsi, one arm in the critical

angle of Gissane on the calcaneus, and the other
under than talar neck. The lamina spreader will
need to be placed deeply within this area to reach
the talus, particularly in the face of a valgus
deformity. Once in place, the lamina spreader can
be opened maximally. This will expose the poste-
rior facet of the STJ. Initially, a curved 1/2″
osteotome is used to remove the articular sur-
faces of the calcaneus and talus (Fig. 23.8). A
rongeur is used to remove debris and any imping-
ing osteophytes. The posterior curvature of the
calcaneal articular surface is cleared with an
angled curette (Fig. 23.9). Pearl: Once the poste-
Fig. 23.9 After joint preparation of the posterior facet of
rior facet is prepared for fusion past the subchon-
the subtalar joint is complete with osteotomy, curettes,
dral plate, a second lamina spreader is placed and rongeur, then the joint surface is fenestrated with a
into the posterior facet and opened, and the first small drill or large wire
one is removed. This exposes the middle and
anterior facets of the STJ for preparation and can prepared (Fig. 23.10). The joints are then fenes-
be undertaken in likewise fashion. Once the trated with a large wire or small bore drill,
entire joint is prepared, the area is flushed to 2.0 mm or less, leaving the drill shavings in the
remove any remaining loose articular cartilage. joint (Fig. 23.11). Finally, the area is fish scaled
Pearl: Examination of the posterior medial extent throughout with a 1/4″ curved osteotome.
of the joint should expose the flexor hallucis lon- The CC joint is prepared in a similar fashion.
gus (FHL) tendon. This exposure ensures that the Instead of a lamina spreader in the joint, a small
entire extent of the joint has been opened and joint wire distractor, such as a Hintermann retrac-
242 J. G. DeVries

Fig. 23.10 Exposure of the flexor hallucis longus (FHL) Fig. 23.12 A small joint retractor such as a Hintermann
tendon in the posterior medial aspect of the posterior facet retractor is used to distract and expose the calcaneocuboid
of the subtalar joint. This exposure ensures complete joint joint
preparation throughout the extent of the joint

Fig. 23.11 Toothed lamina spread switch into the poste- Fig. 23.13 After joint preparation of the calcaneocuboid
rior facet of the subtalar joint to facilitate preparation of joint is complete with osteotomy, curettes, and rongeur,
the middle and anterior subtalar facets. Here a large wire then the joint surface is fenestrated with a small drill or
is being used to fenestrate the joints large wire

tor, is used to open and expose the joint from this shortening. Joint fenestration and fish
(Fig. 23.12). The joint has a saddle shape, and the scaling are undertaken again (Fig. 23.13).
deep aspects of the joint are sometimes difficult The lateral incision is then flushed and atten-
to fully expose. In addition, the use of a 1/4″ tion is directed to the dorsal incision. Dissection
osteotome may be preferred due to the small size is carried deeply adjacent to the tibialis anterior
and curvature of the joint. Pearl: Conversely, a tendon, either medial or lateral depending on
sagittal saw can be used to resect the joint sur- foot structure (Fig. 23.14). A linear capsulotomy
faces. This will result in more shortening than is then used from the ankle joint and onto the
debridement and curettage of the joint and should ­navicular body. Exposure of the talonavicular
be reserved for cavus foot types that can benefit (TN) joint is then carried out medially and later-
23 Two-Incision Triple Arthrodesis 243

Fig. 23.16 A small joint distractor is needed to open the

Fig. 23.14 Dorsal talonavicular joint incision is made joint enough to access the concave surface of the navicular
parallel to the tibialis anterior tendon. Once exposed this bone
can be retracted medially or laterally depending on defor-
mity and exposure needed

Fig. 23.17 The prepared talar head after removal of

articular surface past subchondral bone and fenestration
Fig. 23.15 Once exposed, the talar head can be accessed with a 2.0 mm drill
by using a curved osteotome or Cobb elevator. Preparation
of the talar head can be performed once it is dislocated out
of the talonavicular joint

ally. Pearl: A Cobb elevator or osteotome in the The joint surface is prepared in similar fashion.
talonavicular joint can be inserted and used to Again, the small size and concave nature of the
dislocate the talar head out of the TN joint joint surface may make a smaller osteotome
(Fig. 23.15). This will allow for preparation of more useful during joint preparation. Flushing,
the talar head for fusion, carried out with a simi- fenestrating, and fish scaling of the joint are then
lar technique and use of osteotome, rongeur, and carried out (Fig. 23.17). The foot should be com-
curettes. The talus is then relocated, and wires pletely reducible into proper alignment at this
are placed into the talus and navicular with a point.
small joint distractor again utilized to expose the Once the joints are opened and prepared for
articular surface of the navicular (Fig. 23.16). arthrodesis, the decision can be made on any
244 J. G. DeVries

additional orthobiologic supplementation.

Generally speaking, the joints are augmented
with bone marrow aspirate mixed in with a
demineralized bone matrix. This provides some
colony-forming stem cells from the bone marrow
aspirate, as well as osteoconductive and osteoin-
ductive elements from the demineralized bone
matrix. In addition, the joints have most often
gone through adaptive changes over time and
may not have complete contact when placed into
an aligned position.
Positioning starts with realignment of the
TN joint as most of the hindfoot motion is
determined through this joint [5]. In broad
terms, the goal is to establish alignment of the
talar-first metatarsal line on both the sagittal
Fig. 23.18 Reduction and realignment of the talonavicu-
and transverse planes. Pearl: The reduction lar joint are performed first after joint preparation and
maneuver involves using the same hand as the application of orthobiologics. The maneuver places one
operative side (right hand for right foot) and hand on the heel with thumb at the talar head. The other
grasping the heel with your hand and placing hand then rotates and realigns the forefoot to the hindfoot
through the talonavicular joint. A pin is then driven percu-
your thumb under the talar head. The other taneously from the plantar-medial direction through the
hand is then used to rotate the navicular and navicular tuberosity into the talus. This pin can be placed
forefoot into proper alignment on the talar head into the navicular tuberosity first, then the joint can be
(Fig. 23.18). For a valgus deformity, this reduced and held, and a surgical technician or assistant
can drive the placed wire into the talus to hold correction
involves internal transverse rotation, supina-
tion, and plantarflexion. The opposite is true for
a varus hindfoot. Once aligned, a guidewire for
a 4.0–5.0 mm cannulated screw is driven percu-
taneously into the plantar distal portion of the
navicular tuberosity and placed in a lateral and
dorsal direction into the talus. If being per-
formed without assistance, the wire can be
placed into the navicular tuberosity first, then
position the foot, and finally have the surgical
technician drive in the wire. Position should be
held, and a second wire is placed dorsally from
the center-lateral aspect of the navicular into
the talus either parallel to the plantar aspect of
Fig. 23.19 Once the first talonavicular pin is placed, a
the foot or slightly plantar (Fig. 23.19). Care is second dorsal pin is placed to hold correction and prevent
taken not to project into the subtalar joint as any rotation through the joint
this will restrict positioning of the
STJ. Intraoperative fluoroscopy is performed to Once the TN joint is aligned and pinned into
assess deformity correction, including AP and position, the subtalar joint is positioned and
lateral foot images to assess talar-first metatar- pinned into place. Standing at the end of the bed
sal alignment. Pearl: An AP of the ankle is to assess the tibial-calcaneal position, your non-­
needed to ensure that the wires have not pene- dominant hand will grasp the heel and hold it into
trated into the ankle, particularly at the lateral alignment. Then, your dominant hand will place
gutter. a guidewire for a 6.5 mm or greater diameter
23 Two-Incision Triple Arthrodesis 245

screw from the talar neck, anterior to the ankle The TN screws are placed first. In almost all
joint surface, into the calcaneus. Pearl: The palm cases, 45 mm screws will be used to cross the TN
of the positioning hand should be placed cen- joint and obtain good purchase in the talus with-
trally at the heel at the target of the guidewire. out extending into other joints. The plantar-­
This proprioceptive technique can assist in medial screw is countersunk, but the dorsal screw
proper placement of the wire (Fig. 23.20). Once does not require this. These are placed in lag
placed, intraoperative fluoroscopy is used to technique and usually partially threaded screws
check position and wire placement. A lateral are used. After secure fixation of the TN joint, the
image ensures placement across the subtalar joint STJ screw is measured, drilled, countersunk, and
in an acceptable angle, and a calcaneal axial placed, ensuring good purchase and compres-
image checks placement within the central por- sion. Pearl: If either of these joints does not have
tion of the calcaneus. good solid purchase and compression, additional
There is very little range of motion in the fixation can be placed at this point. Finally, a lat-
hindfoot complex at this point, and positioning of eral plate (such as a 4-hole H-plate style) is used
the CC joint usually has very little room for to fixate the CC joint (Fig. 23.21). Most plates
maneuvering. Pearl: Most often all that is needed can be placed with eccentric drilling of the screws
is plantar pressure along the lateral column of to allow for compression of the joint through the
the foot. The cuboid has a tendency to sublux plate. Final inspection is then given clinically and
plantarly and needs to be realigned and pinned fluoroscopically. Four images are required: lat-
into place with temporary fixation. eral foot, AP foot, AP ankle, and calcaneal axial

Fig. 23.20 Reduction, realignment, and pinning of the

subtalar joint are performed after pinning of the talona-
vicular joint. The maneuver places the palm of one hand
on the posterior aspect of the heel where the surgeon
would like to direct the pin. The other hand can then drive
a guidewire for a large cannulated screw from the talar
neck anterior to the ankle articular surface into the calca- Fig. 23.21 Fixation of the calcaneocuboid joint is per-
neus across the subtalar joint. Proprioception between the formed with a lateral compression plate. Pressure applied
two hands should allow for predictable placement of the along the plantar surface of the cuboid is often needed to
wire prevent plantar subluxation
246 J. G. DeVries

a b

Fig. 23.22 (a) Intraoperative lateral fluoroscopic image for more robust fixation. This is the same foot as
demonstrates placement of hardware and correction of Fig. 23.5b. (c) Intraoperative AP ankle fluoroscopic image
deformity. An additional talonavicular screw was placed demonstrates placement of hardware and correction of
for more robust fixation. This is the same foot as deformity. This is the same ankle as Fig. 23.5c. (d)
Fig. 23.5a. (b) Intraoperative AP foot fluoroscopic image Intraoperative calcaneal axial fluoroscopic image demon-
demonstrates placement of hardware and correction of strates placement of hardware and correction of
deformity. An additional talonavicular screw was placed deformity
23 Two-Incision Triple Arthrodesis 247

d 23.6 Post-op Care

Immediately after surgery, the patient is placed

into a well-padded plaster splint, applied under
the foot and posteriorly as well as side to side
along the foot and ankle. The patient can be
admitted overnight to work with physical therapy
for non-weight-bearing gait and ensure that pain
is managed adequately and for postoperative pro-
phylactic antibiotics. Most often patients are able
to be discharge home the next day. In healthy
patients that receive a popliteal block, this proce-
dure can be performed as an outpatient. In
patients that are unable to safely be non-weight-­
bearing per physical therapy, placement into a
skilled nursing facility may be required until
patient can safely transfer.
Follow-up at 2 weeks will have non-weight-­
bearing radiographs, remove the sutures, and
place the patient into a non-weight-bearing fiber-
glass cast for 1 month. Weight-bearing in a cast is
instituted at 6 weeks post-op and then into a
removable walking boot at 8 weeks. Weight-­
bearing will be done in a boot for 1 month with
dorsiflexion and plantarflexion at the ankle at this
point. Physical therapy is instituted at this point
as well. At 3 months post-op, the patient will be
given an articulated ankle brace to support the
hindfoot but allow for ankle range of motion.
Once swelling is controlled, the patient is casted
for custom orthoses, typically between the 4- and
Fig. 23.22 (continued) 6-month postoperative time period.

(Fig. 23.22a–d). At this point, if there is residual

forefoot deformity compared to the hindfoot, 23.7 Complications
additional procedures such as a Cotton osteotomy
or dorsiflexion osteotomy of the first metatarsal Two-incision triple arthrodesis is a major hind-
can be undertaken as needed. foot arthrodesis procedure, and complications
The area is then flushed with saline. Any graft- can occur. Although the majority of patients are
ing materials left at this point are packed into the improved and satisfied with the outcome, this is
sinus tarsi, but this area does not require grafting related to alignment and presence of complica-
if none is left over. Deep closure is obtained later- tions [2].
ally by placing the fascia of the EBD back into Wound complications are most often associ-
place. Subcutaneous closure and deep closure are ated with the lateral incision, especially in the
vital to prevent hematoma formation and also face of a significant valgus correction.
must be placed carefully to avoid superficial Recognition of early dehiscence is important, and
nerves. most often can be treated with local wound care.
248 J. G. DeVries

Patients will be placed into a non-weight-bearing morphogenetic protein-2) should be used. In

boot to facilitate daily dressing changes. If the addition, more robust fixation from different
wound continues to deteriorate, prompt referral hardware and approaches will need to be used as
to wound care should be instituted. well. Solid union in a poor position can be prob-
Nerve injury also is more common laterally. lematic not only at the triple arthrodesis site but
The sural nerve runs along the lateral incision also at the adjacent joints. If the position is such
line, especially distally as the incision course that it is unbraceable, or causing other issues in
toward the fourth metatarsal base. Prompt treat- the surrounding joints, revision should be offered.
ment with gabapentin or pregabalin should be Depending on the exact location, this can be
instituted if there is burning or tingling pain. This undertaken with either take down of the fused
will often resolve over time. If not, cortisone joints, or peri-arthrodesis osteotomies to correct
injections into the area can be considered. the malalignment.
Permanent numbness can occur if the nerve is
severed in surgery. Although a complication, this
nerve does not have any muscle innervation yet at References
this level, and no weakness or atrophy should
occur. 1. Ryerson EW. Arthrodesing operations on the feet. J
Bone complications fall largely into nonunion Bone Joint Surg. 1923;5:453–71.
2. Pell RF 4th, Myerson MS, Schon LC. Clinical out-
or malalignment and can occur together if the come after primary triple arthrodesis. J Bone Joint
deformity correction is not maintained due to Surg. 2000;82(1):47–57.
nonunion or delayed union. If deformity correc- 3. Saltzman CL, Fehrle MJ, Cooper RR, Spencer EC,
tion is maintained and the hardware is stable, Ponseti IV. Triple arthrodesis: twenty-five and forty-­
four-­year average follow-up of the same patients. J
continued immobilization potentially along with Bone Joint Surg Am. 1999;81(10):1391–402.
external bone stimulation can be instituted. If 4. DeVries JG, Scharer B. Hindfoot deformity cor-
deformity is progressive, or there is a loss of rected with double versus triple arthrodesis:
hardware stability due to loosening or breakage, radiographic comparison. J Foot Ankle Surg.
2015;54(3):424–7.
revision surgery should be offered. The addition 5. Astion DJ, Deland JT, Otis JC, Kenneally S. Motion
of autogenous bone grafting or advanced of the hindfoot after simulated arthrodesis. J Bone
­orthobiologics (such as recombinant human bone Joint Surg Am. 1997;79(2):241–6.
 Tarsal Coalition
24
Daniel J. Cuttica and Thomas H. Sanders

24.1 Introduction development of degenerative joint disease in

these adjacent joints.
Tarsal coalition is an abnormal osseous, cartilagi-
nous, or fibrous connection between adjacent
bones in the hindfoot or midfoot. Its prevalence is 24.2 Clinical Presentation
1–2% of the population, with 50% occurring
bilaterally [1–3]. It occurs due to failure of Most tarsal coalitions are asymptomatic [4]. In
embryonic mesenchymal segmentation during those that develop symptoms, the onset of is usu-
development, which leads to an abnormal con- ally in late childhood or adolescence. CN coali-
nection between two or three tarsal bones [2, 4]. tions present between 8 and 12 years of age,
Tarsal coalition has an autosomal dominant while TC coalitions present between 12 and
inheritance with variable penetrance [4]. 15 years of age. The onset of symptoms corre-
The two most common types of tarsal coali- lates with ossification of the involved bones,
tions are calcaneonavicular and talocalcaneal which cause the hindfoot to stiffen, alter the kine-
coalitions. Calcaneonavicular (CN) coalitions matics of the involved joint, and cause pain.
occur along the anterior process of the calcaneus Histologically, microfracture at the ossifying
and the inferolateral aspect of the navicular. coalition-bone interface is thought to be the
Talocalcaneal (TC) coalitions occur most com- source of pain [5, 6].
monly at the middle facet of the subtalar joint. Hindfoot pain and a limitation of subtalar
Subtalar motion in patients with tarsal coalition motion are the most common presentation. In
is limited, which often leads to difficulty accom- adults, symptoms are often triggered by an acute
modating on uneven ground and can result in fre- event such as an ankle sprain. Patients often have
quent ankle sprains. The presence of a pain and difficulty on uneven ground and recur-
long-standing coalition can result in increased rent ankle sprains, due to the inability of the hind-
stresses on adjacent joints and ultimately to foot to accommodate uneven ground from limited
subtalar motion. In addition, pain is typically dif-
fuse but can be localized to the sinus tarsi in CN
coalitions and the subtalar region or distal to the
D. J. Cuttica (*) · T. H. Sanders
Assistant Professor of Clinical Orthopaedic Surgery, medial malleolus in TC coalitions. There is a pes
Georgetown University School of Medicine, planovalgus foot alignment that does not correct
The Orthopaedic Foot & Ankle Center, a Division with heel rise or when non-weight-bearing. Tarsal
of Centers for Advanced Orthopaedics, Falls Church,
VA, USA

© Springer Nature Switzerland AG 2019 249

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_24
250 D. J. Cuttica and T. H. Sanders

coalition can also be associated with peroneal

a
spasticity.

24.3 Imaging

Weight-bearing plain radiographs should include

anteroposterior, oblique, and lateral views of the
foot and an axillary view of the heel. A CN coali-
tion is best seen on the oblique view. In a CN
coalition, radiographs reveal an elongated anterior
process of the calcaneus, often referred to as an
“anteater’s nose” (Fig. 24.1). In a TC coalition,
there is loss of definition of the subtalar joint line.
A “C-sign” is often present in TC coalitions, which
is a c-shaped arc formed by the medial outline of
the talar dome and the inferior aspect of the susten-
taculum (Fig. 24.2). Dorsal talar beaking is often
present but is a nonspecific finding. Advanced
imaging is also valuable when evaluating tarsal
coalitions. CT scan is helpful to evaluate the size,
extent, and location of the coalition and is neces-
sary for preoperative planning. MRI is useful in
diagnosis for fibrous or cartilaginous coalitions.

24.4 Case Example

A 15-year-old male presents with complaints of

chronic medial hindfoot pain and pes planoval-
gus. The pain is aching in nature and worse with
activity. Physical exam reveals a pes planovalgus
foot alignment when weight-bearing. The arch
does not reform when seated or upon single-­ b
stance heel rise. There is tenderness to palpation
just inferior to the medial malleolus. Subtalar
motion is limited.
Radiographs reveal pes planus with a C-sign
consistent with subtalar coalition (Fig. 24.3a). A CT
scan reveals a complete bony coalition of the mid-
dle facet of the subtalar joint. No degenerative
changes are present (Fig. 24.3b). The patient is ini-
tially treated with several months of nonoperative
Fig. 24.1 (a, b) A CN coalition is best seen on the
treatment, including casting, orthotics, bracing, and oblique view of the foot. The lateral view reveals an elon-
physical therapy. After failure of nonoperative treat- gated anterior process of calcaneus, often referred to as an
ment, he underwent subtalar coalition resection. “anteater’s nose”
24 Tarsal Coalition 251

24.5 Treatment with anti-inflammatory medications, activity

modification, and an accommodative orthotic
Tarsal coalitions that are asymptomatic do not with medial arch support. If symptoms persist, a
require surgical treatment. In symptomatic period of immobilization with casting is often
patients, nonsurgical treatment should begin helpful. A high top shoe or supportive ankle
brace to provide stability can also decrease
symptoms.

24.6 Surgical Indications

Surgery is indicated in those patients with contin-

ued symptoms despite a prolonged course of
nonoperative treatment. Contraindications to
coalition resection include advanced degenera-
tive changes, active infection, or poor vascular
status.
Fig. 24.2 In a TC coalition, there is loss of definition of
the ST joint line. The “C-sign” present is a c-shaped arc
formed by the medial outline of the talar dome and the
inferior aspect of the sustentaculum

a b

Fig. 24.3 (a) Lateral view of the ankle reveals pes planus with a C-sign, consistent with ST coalition. (b) CT scan
reveals a complete bony coalition of the middle facet of the ST joint
252 D. J. Cuttica and T. H. Sanders

24.7 Calcaneonavicular Coalition tissue handling and dissection are performed.

Resection The dorsal intermediate branch of the superficial
peroneal nerve crosses the surgical exposure and
24.7.1 Positioning should be protected. A branch of the sural nerve
is often encountered at the proximal portion of
The patient is placed supine with the foot at the the incision and should also be protected. The
end of bed. A bump is placed under the ipsilateral extensor digitorum brevis (EDB) muscle belly is
hip, and a thigh tourniquet or calf tourniquet is identified. Sharp dissection is performed to ele-
utilized. The mini C-arm is placed on the same vate the EDB from its origin, and it is retracted
side as the operative extremity, while the instru- dorsal and distally as a large flap (Fig. 24.4).
ment table should be on the side opposite of the After the EDB is retracted, the coalition is
operative extremity. exposed (Fig. 24.5). Identifying the anterior pro-
cess of the calcaneus and tracing it to the navicu-
lar aids in identifying the coalition. Intraoperative
24.7.2 Equipment fluoroscopy should be utilized at this time to con-
firm the location of the coalition (Fig. 24.6).
Essential equipment necessary for the procedure
include the following: osteotomes, rongeurs, bone
wax, Senn retractors or self-retaining retractors, 24.7.4 Coalition Resection
small Hohmann retractors, and a mini C-arm.
The borders of the coalition are defined via sub-
periosteal dissection. Next, utilizing a straight
24.7.3 Approach quarter-inch osteotome, the coalition is resected
by removing a 1–2 cm block of bone (Fig. 24.7a,
The patient is supine with a bump placed under b). The osteotome cuts should be parallel to each
the ipsilateral hip to internally rotate the foot and other, and not convergent so as to avoid resecting
allow adequate exposure of the lateral foot and a trapezoidal block of bone. Care should be taken
coalition. The incision begins just inferior to the so as not to resect or damage the nearby talar
tip of the fibula and extends distally toward the head or cuboid. Hohmann retractors should be
base of the third metatarsal. Alternatively, an placed on either side of the coalition to protect
Ollier incision can be utilized. Meticulous soft the surrounding structures. Any additional boney

Fig. 24.4 The EDB is elevated from its origin and is Fig. 24.5 After the EDB is retracted, the coalition is
retracted dorsally and distally as a large flap exposed
24 Tarsal Coalition 253

Fig. 24.6 Intraoperative fluoroscopy is utilized to con- Fig. 24.8 An oblique fluoroscopic image of the foot is
firm location of the coalition used to confirm complete resection

Fig. 24.9 The EDB muscle belly is interposed between

the two ends to prevent coalition recurrence

b fragments or fibrous tissue at the resection site

can be removed at this time with a rongeur or
pituitary rongeur. An oblique fluoroscopic image
of the foot is used to confirm complete resection
at this time (Fig. 24.8).

24.7.5 Tissue Interposition

The EDB muscle belly can be interposed between

the two ends of the resected coalition to prevent
coalition recurrence (Fig. 24.9). An absorbable
suture with a Keith needle is placed through the
Fig. 24.7 (a, b) The coalition is resected by removing a
1–2 cm block of bone
254 D. J. Cuttica and T. H. Sanders

proximal portion the EDB muscle belly and fas- ipsilateral hip to internally rotate the leg to
cia. The needle is passed plantarward, pulling the improve visualization during the lateral approach
EDB into the coalition resection site. It can then and removed later during the procedure to allow
be sutured in place over a small bolster or over easier access for a medial approach. A thigh tour-
the plantar fascia through a small separate inci- niquet or calf tourniquet is utilized. The mini
sion. Alternatively, materials such as bone wax, C-arm is placed on the same side as the operative
local fat, gel foam, or amniotic tissue can be used extremity, while the instrument table should be
as interposition material to prevent coalition on the side opposite of the operative extremity.
recurrence.

24.8.4 Approach
24.7.6 Wound Closure
The surgical incision should begin laterally at the
The deep fascial layer is closed with absorbable tip of the fibula and progress toward the base of
suture, followed by subcutaneous layer and skin. the fourth metatarsal (Fig. 24.10). Meticulous
The patient is placed in a bulky Jones compres- soft tissue handling and dissection are performed.
sive dressing until the first postoperative visit. Branches of the superficial peroneal nerve and
sural nerve are identified and protected. The EDB
muscle belly is retracted dorsally, while the pero-
24.8  ubtalar Coalition Resection
S neal tendons are retracted inferiorly. The subtalar
(Dual Incision Approach)

24.8.1 Background

While a single medial or lateral approach can be

used, a two-incision technique should be consid-
ered for any coalition involving more than 50%
of the articular surface. In general, progressing
from known (normal joint surface) to unknown
(coalition) leads to less soft tissue disruption and
a more reliable resection.

24.8.2 Equipment

Essential equipment necessary for the procedure

include the following: osteotomes, rongeurs,
Hintermann distractor, lamina spreader, Senn
retractors or self-retaining retractors, small
Hohmann retractors, interpositional graft (if not
using autograft muscle, tendon, or fat), and a
mini C-arm.

24.8.3 Positioning
Fig. 24.10 The surgical incision should begin laterally at
The patient is placed supine with the foot at the the tip of the fibula and extend toward the base of the
end of the bed. A large bump is placed under the fourth metatarsal
24 Tarsal Coalition 255

joint capsule is identified and a capsulotomy is Fluoroscopy can be used at this point to confirm
performed, exposing the subtalar joint. Next, the location of the coalition.
identify the posterior facet as it is often spared
from coalitions, which more commonly affect the
anteromedial facet. A Hintermann distractor is 24.8.5 Coalition Resection
utilized to distract the joint, which prevents any
damage to the chondral surface during joint dis- If the coalition is small (<20%), it can be fully
traction (Fig. 24.11). The K-wires for the resected from the single lateral approach and can
Hintermann distractor should be placed into the be done with osteotomes at this point. However, a
talus and calcaneus on either side of the visual- more complete resection can be done with direct
ized articular surface. Distraction of the joint will visualization and a second medial incision. Use a
allow for better visualization of the coalition. The K-wire from the lateral side, and place it through
native position of the joint surface and the the coalition and then through the skin on the
coalition should be visualized at this point.
­ medial side (Fig. 24.12a). Then, approach the
medial side of the subtalar joint based on where
the K-wire exits medially (Fig. 24.12b). A medial
incision is made at the point of K-wire exit, usu-
ally 1–2 cm distal to the medial malleolus.
Identify and incise the posterior tibial tendon
sheath (Fig. 24.13) and retract the tendon dor-
sally. Next, identify and incise the flexor digito-
rum longus (FDL) tendon sheath, and retract the
tendon inferiorly with a retractor (Fig. 24.14).
Flexing and extending the toes will confirm FDL
location. The FDL protects the neurovascular
bundle, and care should be taken to protect the
neurovascular bundle. The coalition should now
be exposed.
The soft tissue and periosteum over the coali-
tion are incised and elevated to ensure adequate
Fig. 24.11 A Hintermann distractor is utilized to distract
the joint, which prevents any damage to the chondral sur- visualization (Fig. 24.15). With the coalition
face during joint distraction visualized from each side, use osteotomes and

a b

Fig. 24.12 (a, b) Use a K-wire from the lateral side, and place it through the coalition and then through the skin on the
medial side. The medial side of the subtalar joint is approached where the K-wire exits medially
256 D. J. Cuttica and T. H. Sanders

Fig. 24.15 After the coalition is exposed, the soft tissue

Fig. 24.13 The PTT and FDL tendon sheaths are identi- and periosteum over the coalition are incised and elevated
fied and incised, exposing the PTT and FDL tendons to ensure adequate visualization

Fig. 24.14 The PTT is retracted dorsally and FDL

retracted inferiorly, exposing the coalition
Fig. 24.16 With the coalition visualized from each side,
a 1 × 1 cm wedge of bone is resected

rongeurs to resect a wedge of bone. A 1 × 1 cm both sides of the coalition to ensure full
resection is usually adequate (Fig. 24.16). A resection.
more generous resection will allow a greater After the coalition is resected, a smooth lam-
chance at restoration of motion postoperatively ina spreader can be placed to further distract the
while also allowing for more interpositional joint and ensure adequate resection medially. The
material to be placed. With dual approaches, joint will typically “pop” open if the coalition is
osteotomes can be passed back and forth from completely excised. Inverting and everting the
24 Tarsal Coalition 257

subtalar joint is performed to ensure adequate 24.9.3 Positioning

motion.
The patient is placed supine with the foot at the
end of the bed. A bump is placed under the ipsi-
24.8.6 Tissue Interposition lateral hip. A thigh tourniquet or calf tourniquet
utilized. The mini C-arm should be placed on
Interpositional material such as bone wax can same side as operative extremity, while the instru-
then be placed in the area of resection over ment table should be on side opposite of the oper-
the bleeding bone surfaces to prevent recur- ative extremity.
rence. Local or harvested fat, muscle, partial
FHL tendon, or amniotic tissue can also be
used. 24.9.4 Approach

A medial incision is made just inferior to the tip

24.8.7 Wound Closure of the medial malleolus over the posterior tibial
tendon (PTT). The PTT sheath is identified and
The deep fascial layer is closed with absorbable incised. The PTT is retracted dorsally. Next,
suture, followed by subcutaneous layer and identify and incise the FDL tendon sheath and
skin. The patient is placed in a bulky Jones retract it inferiorly with a retractor. Flex and
compressive dressing until the first postopera- extend the toes to confirm proper identification of
tive visit. the FDL. The FDL protects the neurovascular
bundle, and care should be taken to protect the
neurovascular bundle throughout the procedure.
24.9  ubtalar Coalition Resection
S The coalition should now be exposed. The soft
Utilizing a Cannulated tissue and periosteum over the coalition are
Guide [7] incised and elevated to allow adequate visualiza-
tion of the coalition and its borders.
24.9.1 Rationale

This technique allows intraoperative identifica- 24.9.5 Coalition Resection

tion and resection of talocalcaneal coalitions with
a cannulated guide introduced from the sinus After the coalition is exposed, a 1 cm incision is
tarsi. The advantage of this approach is that by made laterally over the sinus tarsi. A hemostat is
opening the coalition through the sinus tarsi, the used to bluntly dissect the soft tissue. Next, a
surgeon is able to identify the extent of the coali- guide pin from a subtalar arthroereisis system is
tion and allow a reliable resection with less soft placed into the sinus tarsi. It is advanced from an
tissue disruption. anterolateral to posteromedial direction through
the coalition. An arthroereisis sizing guide is then
placed over the guidewire from a lateral to medial
24.9.2 Equipment direction through the sinus tarsi. The arthroere-
isis sizer will open up the coalition as it is
Essential equipment necessary for the procedure inserted.
include the following: osteotomes, rongeurs, a In cases of a complete boney coalition, resec-
smooth lamina spreader, Senn retractors or self-­ tion is initially carried out using osteotomes and
retaining retractors, small Hohmann retractors, rongeurs medially, with the guidewire acting as a
subtalar arthroereisis system, interpositional guide to its location. As the coalition is resected,
graft (if not using autograft, tendon, or fat), and a the sizing guide can be advanced, further opening
mini C-arm. the subtalar joint and the coalition. With the
258 D. J. Cuttica and T. H. Sanders

arthroereisis guide in place, the coalition is fully convergent so as to avoid resecting a trapezoi-
resected allowing visualization of the articular dal block of bone. Care should be taken so as
cartilage. The joint can be completely opened up not to resect or damage the nearby talar head
with larger arthroereisis guides or a smooth lami- or cuboid. Hohmann retractors placed on
nar spreader. The joint will typically “pop” open either side of the coalition will protect the sur-
if the coalition is completely excised. After resec- rounding structures.
tion is completed, the guide can be removed, and • To facilitate a EDB muscle interposition, use a
subtalar motion should be confirmed. Keith needle to pass suture through the proxi-
mal portion the EDB muscle belly. The needle
is passed plantarward, which will pull the
24.9.6 Tissue Interposition EDB into the coalition resection site.

Interpositional material can then be placed in the

area of resection, such as bone wax. Local or har- 24.11.2 T
 C Coalition Resection (Dual
vested fat, muscle, partial FHL tendon, or amni- Incision)
otic tissue can alternatively be used.
• A two-incision technique should be consid-
ered for any coalition involving more than
24.9.7 Wound Closure 50% of the articular surface. Progressing from
known (normal joint surface) to unknown
The deep layer is closed with absorbable suture, (coalition) leads to less soft tissue disruption
followed by subcutaneous layer and skin. The and a more reliable resection.
patient is placed in a bulky Jones compressive • A Hintermann distractor is utilized to distract
dressing until the first postoperative visit. the joint, which prevents any damage to the
chondral surface during joint distraction, and
will allow for better visualization of the coali-
24.10 Postoperative tion. The K-wires for the Hintermann distrac-
tor should be placed into the talus and
A non-weight-bearing, bulky Jones splint is calcaneus on either side of the visualized
placed. The patient is placed into CAM boot, and articular surface.
weight-bearing and early motion begin as soon as • Use a K-wire from the lateral side, and place it
the soft tissues are healed, as outlined in the post- through the coalition and then through the
operative protocol in Chapter 1. skin on the medial side. This allows for easier
localization of the coalition medially during
dissection.
24.11 Technique Pearls • Flexing and extending the toes will confirm
FDL location. The FDL protects the neurovas-
24.11.1 CN Coalition Resection cular bundle, and care should be taken to pro-
tect the neurovascular bundle throughout the
• Be sure to elevate the EDB as a large flap, resection.
which will ensure adequate exposure of the • With the coalition visualized from each side,
coalition, but also allow for its use as interpo- osteotomes and rongeurs are used to resect a
sition at the coalition resection to prevent wedge of bone. A 1 × 1 cm resection is usually
recurrence. adequate.
• Identifying the anterior process of the calca- • After the coalition is resected, a smooth lam-
neus and tracing it to the navicular aids in ina spreader is placed to further distract the
identifying the coalition. joint and ensure adequate resection medially.
• During CN coalition resection, the osteotome The joint will typically “pop” open if the
cuts should be parallel to each other, and not coalition is completely excised.
24 Tarsal Coalition 259

24.11.3 T
 C Coalition Resection References
Utilizing a Cannulated
Guide 1. Stormont DM, Peterson HA. The relative incidence of
tarsal coalition. Clin Orthop. 1983;181:28–36.
2. Kulik SA, Calnton TO. Tarsal coalition. Foot Ankle
• During coalition exposure and resection, the Int. 1996;17:286–96.
FDL tendon protects the neurovascular 3. Vincent KA. Tarsal coalition and painful flatfoot. J
­bundle. Flex and extend the toes to confirm Am Acad Orthop Surg. 1998;6:274–81.
4. Leonard MA. The inheritance of tarsal coalition and
proper identification of the FDL. Care should
its relationship to spastic flatfoot. J Bone Joint Surg.
be taken to protect the neurovascular bundle 1974;56B:520.
throughout the resection. 5. Lemley F, et al. Current concepts review: tarsal coali-
• The guidewire is passed from the sinus tarsi in tion. Foot Ankle Int. 2006;27(12):1163–9.
6. Kumai T, et al. Histopathological study of nonosseous
an anterolateral to posteromedial direction
tarsal coalitions. Foot Ankle Int. 1998;19:525–31.
through the coalition, followed by the arthro- 7. Humbyrd CJ, Myerson MS. Use of a cannulated guide
ereisis sizing guide. in talocalcaneal coalition resection: technique tip.
• In cases of a complete boney coalition, resec- Foot Ankle Int. 2015;36(2):225–8.
tion is initially carried out medially, with the
guidewire acting as a guide to its location. As
the coalition is resected, the sizing guide is
advanced, further opening the subtalar joint
and the coalition.
• The joint can be completely opened up with
larger arthroereisis guides or a smooth laminar
spreader. The joint will typically “pop” open
when the coalition is completely excised.
 Achilles Procedures
25
Gregory C. Berlet, Roberto A. Brandão,
and Bryan Van Dyke

Abbreviations tion. Surgical interventions involving rupture

repair, retrocalcaneal exostectomy with detach-
AT Achilles tendon ment, and reattachment with or without flexor hal-
FHL Flexor hallucis longus tendon lucis longus transfer are described surgical
IAT Insertional Achilles tendinosis treatments yielding good functional results [3–7].
NIAT Non-insertional Achilles tendinopathy Acute midsubstance repairs have traditionally
been treated in an open approach with a larger
incision, and recently utilization of mini-open or
25.1 Introduction even percutaneous techniques has become an
option for repair. The aim of the chapter is to high-
The Achilles tendon (AT) is considered to be the light the surgical treatment of the various Achilles
largest tendon in the body responsible for transfer- tendon injuries seen in everyday practice that have
ring large contractile forces of the gastroc-­soleus exhausted a conservative treatment plan.
complex during plantar flexion of the ankle in the
gait cycle [1, 2, 7]. Injuries of the AT are common
across all age groups including the elderly patients 25.2 Clinical Cases
and competitive athletes [1, 2]. Pathology covers a
spectrum including tendonitis, tendinosis, and rup- 1. Acute Rupture
ture at either the insertion or midsubstance of the • The patient is a 32-year-old male who sus-
tendon. These symptoms may be acute (<6 weeks) tained a posterior leg injury after playing
or chronic (>6 weeks). Persistent symptomology basketball over the weekend. He thought
of the AT despite nonoperative treatment may he was kicked from behind as he tried to
require surgical intervention for functional restora- jump for a rebound. There is now an inabil-
ity to ambulate without pain and decreased
G. C. Berlet (*) push-off strength during weight-bearing.
Orthopedic Foot & Ankle Center, Worthington, The patient presented to the office after
OH, USA being placed in a posterior non-weight-­
B. Van Dyke bearing splint with crutch assist from the
Summit Orthopaedics, Idaho Falls, ID, USA local emergency room. A palpable dell,
R. A. Brandão positive Thompson squeeze test, and
The Centers for Advanced Orthopaedics, Orthopaedic reduced plantar flexion are now present on
Associates of Central Maryland Division, physical exam. Ecchymosis is present to
Catonsville, MD, USA

© Springer Nature Switzerland AG 2019 261

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_25
262 G. C. Berlet et al.

the posterior ankle but no lacerations or on the insertion. He is still able to compete
soft tissue complications. but has noticed decreased performance and
2. Insertional Achilles Tendinosis stamina. He has been recalcitrant to con-
• The patient is a 51-year-old male who pres- servative care, immobilization, and activity
ents with sustained pain to the posterior modification.
aspect of the left heel for a duration of
6 months. No acute injury is noted. He is
unable to ambulate without pain in the 25.3 Patient Presentation
absence of assistive shoe gear or heel raise
insert modification. On exam, no pain is 25.3.1 Acute Rupture
reproduced to the inferior plantar heel and
no tarsal tunnel symptomatology. Pain on History Achilles ruptures can affect a wide
palpation noted to the insertion of the demographic with increased incidence in males,
Achilles tendon with large exostosis pres- from 30 to 40 years of age, young athletes,
ent on lateral radiograph. Irritation is noted elderly patients, and classic “weekend warrior”
to the posterior lateral aspect of the heel with overuse injuries [8, 9] . Typically, for an
with some minor soft tissue edema and his- acute rupture (<6 weeks), there is memorable
tory of a recent blister. The patient has trauma with painful “pop” sensation or a descrip-
attempted to lose weight due to his hyper- tion of “being kicked in the back of the leg.”
tension and recent prediabetes diagnosis. Oftentimes, patients report this as posterior pain
An MRI reveals significant insertional dis- with limited ability to push off or ambulate
ease with >50% degeneration of the normally.
Achilles tendon and a prominent inflamed
calcaneal exostosis. Findings All physical exam testing must be
3. Chronic Rupture compared to the unaffected limb. On physical
• The patient is a 78-year-old female with exam, a palpable dell may be present, represent-
complaints of heel pain for several years. ing the defect of the rupture. Ruptures commonly
She has difficulty ascending and descend- occur in the “watershed area” approximately
ing stairs. Approximately 4 months ago, 2–6 cm above the level of the insertion of the
she felt an acute pain to the area but it had AT. Diffuse edema and ecchymosis are common
dissipated. About 2 weeks ago, she began initially. A Thompson squeeze test can be per-
having increased pain to the area with formed with a positive test indicating a rupture
increased inferior heel pain. The patient due to the lack of plantar flexion from the Achilles
notes a blister formation to the inferior heel tendon complex when compared to the contralat-
fat pad and the inability to ambulate nor- eral extremity. A falsely negative result is possi-
mally. Reduced plantar flexion is noted on ble; one must look at resting tension with the
exam and she has poor balance. An MRI patient in a prone position. Additionally, a Matles
workup reveals a chronically torn Achilles exam is completed in the prone position with
tendon with a 5 cm defect at the central knee bent to 90° and the foot elevated. The
aspect of the tendon. affected side will be more dorsiflexed (dorsal
4. Non-insertional Achilles Tendinopathy foot is able to touch the anterior tibia in severe
• A 22-year-old male college high jumper cases) with slight downward pressure or in a rest-
comes to your office complaining of poste- ing state compared to the unaffected limb. It is
rior ankle pain after each practice over the important to remember that the patient may have
last 2 weeks. He is tender along the Achilles some degree of weak plantar flexion present even
tendon about 4 cm proximal to the inser- with a complete AT rupture. This can lead to
tion. There is a palpable thickening of the common misdiagnosis as a strain by initial
tendon with no pain or prominence distally providers.
25 Achilles Procedures 263

25.3.2 Insertional Achilles Tendinosis p­ resent, although the defect may be filled with
fibrocollagenous regrowth. Edema can be diffuse
History Insertional Achilles tendinosis affects along the tendon with proximal tenderness. A
patients in their fourth to fifth decade of life, calcaneal gait presents with the inability to plan-
slightly more commonly in women [10]. tar flex with normal strength on passive testing.
Persistent chronic posterior heel pain and a large Passive yet weak plantar flexion may be present
posterior prominence are common complaints. due to the deep flexor compartment compensa-
Obesity (BMI > 30), repetitive exercise, and ill-­ tion. Blistering or even ulcerations (i.e., diabetic
fitting shoe wear may predispose patient to this chronic ruptures) can be present in patients due to
disease [10]. Patients complain of pain at the the increased load to the inferior heel pad.
insertion and its surrounding area with edema. Concomitant plantar fasciitis may be present or
previously relayed to the patient as a cause of the
Findings Comparing to the contralateral extrem- inferior heel pain.
ity can be beneficial in obtaining an accurate
diagnosis. Pain is located to the level of insertion
of the AT or just slightly proximal. Proximal calf 25.3.4 Non-insertional Achilles
pain or pain along the proximal tendon is typi- Tendinopathy
cally absent on exam. A degree of equinus is usu-
ally present and should be evaluated with History Non-insertional or midsubstance
Silfverskiöld testing. Prominent calcification Achilles tendinopathy is common among ath-
may be palpable within the distal insertion of the letes especially runners with increased pain with
Achilles, or a large posterior calcaneal tuberosity activity. This is the most common type of
exostosis may be present (Haglund’s deformity) Achilles tendon pathology, generally found in
[11]. Edema, local irritation, or blistering can be younger males or athletes. Patients present with
present secondary to increase friction from shoe pain in the main aspect of the tendon, typically
gear. 3–6 cm from the insertion of the calcaneus.
Advanced age, obesity, corticosteroid or fluoro-
quinolone use, ligamentous laxity, and competi-
25.3.3 Chronic Rupture tive sports can be considered predisposing
factors [3].
History A chronic Achilles rupture is generally
defined as greater than 6–8 weeks from the initial Findings Clinically, a firm, thickened section of
incident. Patient may have had previous treatment the Achilles tendon can often be palpated at the
for midsubstance tendinopathy with a conserva- midsubstance. Pain is elicited with palpation
tive course treatment and immobilization in the along with decrease strength in plantar flexion.
past. Incidence is increased and oftentimes misdi- Local edema and redness can be present second-
agnosed, in the elderly [11]. Symptoms resolve ary to shoe gear irritation. The pain is not gener-
over time after an acute minimally painful injury ally continuous, but it is exacerbated with
but can be easily exacerbated during prolonged increased activity.
activity. Patients may note increased difficulty
walking in their normal gait pattern as well as Acute/Chronic Rupture
inferior heel pain secondary to increased pressure. • Patient selection: Ruptures can occur in
Balance is often compromised and gait instability healthy athletic population or in complicated
may be witnessed by friends or family. comorbid patients with diabetes, neuropathy,
or chronic immunosuppression. Open surgical
Findings The midsection to the distal aspect of repair should be thoroughly weighed versus
the tendon may be thickened or bulbous and nonoperative management in high-risk
painful on exam. A palpable dell can still be patients. A full workup including nutritional
264 G. C. Berlet et al.

labs (albumin, prealbumin, vitamin C, vitamin 25.4 Imaging and Diagnostic

D) should be considered along with hemoglo- Studies
bin A1c (%) and normal preoperative labs.
Nicotine use should be discontinued prior to X-ray
any surgical intervention. • Lateral radiographs are helpful to assess for
• Preop: Preoperative planning may include plain any osseous involvement of the calcaneus
film radiographs and MRI evaluation for the including a tuberosity avulsion fracture with
presence and location of rupture. The diagnosis possible intra-articular subtalar joint
is made clinically but supplemental imaging is involvement.
useful. MRI should be reviewed for fatty infil- –– A traumatic history of a fall or direct injury
tration of the gastroc-soleus complex muscle would lend the diagnosis to a more severe
group which will influence the ability to mobi- pathology.
lize the chronically torn tendon. MRI should • The Haglund’s deformity, a prominent supe-
also confirm that the FHL tendon is intact. rior posterolateral calcaneal tuberosity, is
Often the FHL will have tenosynovitis because associated with insertional Achilles tendinosis
of its enhanced role in plantar flexing the ankle. can be seen on plain films views
• Positioning and equipment: All Achilles surgi- • Calcinosis may be visible within the substance
cal repairs are performed in the prone position of the Achilles.
typically with a Wilson frame. A pillow or • Toyger’s angle can be evaluated by noting the
bump is placed underneath both shins to ele- posterior skin line at the level of the Achilles
vate the feet off the bed. This allows ankle tendon. An angle less than 150° generally
motion without interference from the table. A indicates a rupture.
non-sterile thigh tourniquet is utilized. The • A soft tissue defect or discontinuity of the
extremity should be prepped to the level of the Achilles tendon can often be seen on plain
knee. film assessment.

Expectations: Full return to function and activ- MRI

ity within 6 months to 1 year postoperatively • T2-weighted sagittal views on magnetic reso-
nance imaging are useful for the evolution of
Insertional and Non-insertional the size of the defect and its level or rupture
• Patient selection: Operative intervention (insertional, “watershed,” proximal). MRI not
should be pursued in those who have exhausted only has value in location determination but
conservative treatment. A full workup includ- can be used to evaluate quality of the tendon
ing nutritional labs (albumin, prealbumin, or preexisting tendinosis.
vitamin C, vitamin D) should be considered • Axial views of the leg can help determine the
along with hemoglobin A1c (%) and normal location of the tear as well as confirm more
preoperative labs. Nicotine use should be dis- questionable injuries as the tendon will begin
continued prior to any surgical intervention. to round with increased signal intensity
• Preop: Preoperative planning may include instead of a uniform convex shape at the rup-
plain film radiographs and MRI evaluation for ture level. In addition, in “proximal” ruptures,
the presence of longitudinal tear and distal one can evaluate the proximity to the myoten-
calcifications within the tendon. Avulsion of dinous junction.
the distal Achilles tendon off the bone is com-
mon and can be seen on MRI. A greater than Ultrasound
50% rupture of the insertion is an indication • Can identify areas of disease as hypoechoic or
for an FHL tendon transfer. darker tissue that correlate with degenerated
• Positioning and equipment: Same as above tendon
• Can be useful for the diagnosis of non-­
Expectations: Same as above insertional Achilles tendinopathy
25 Achilles Procedures 265

25.5 Nonoperative Management 25.6 Operating Room Setup

25.5.1 Acute Rupture 25.6.1 Patient Positioning

• Most ruptures can be treated nonoperatively • The patient is brought into the operative
and may be desirable to avoid surgical compli- room theater and intubated by our anesthe-
cations [14]. sia colleagues while still on the transfer
• Increased re-rupture rates in nonoperatively gurney.
treated patients. • A thigh tourniquet should be applied to the
• Limited role in active, athletic, and younger operative extremity prior to the conversion
patient populations. into the prone position.
• Early functional rehabilitation protocols may • The operative table will have the appropriate
approach similar outcomes to surgery. head, chest, knee, and leg padding prior to the
conversion. A contralateral sequential com-
pression device is placed.
25.5.2 Chronic Rupture • Open Achilles ruptures may require a pre-­
scrub prior to standard aseptic preparation
• For patients with a previously misdiagnosed techniques.
rupture or failed nonoperatively managed tears, • All appropriate equipment should be present
surgical intervention is recommended for with an anterior ankle “bump” applied for
improved pain and functional outcomes [15]. elevation of the extremity once the aseptic
• Limited role in younger, active patients. preparation is complete.

25.5.3 Insertional Achilles Tendinosis 25.6.2 Instrumentation

• Nonsteroidal anti-inflammatory medial Additionally helpful instrumentation

therapy
• Activity Modification (reduce activity that • Gelpi retractor
places Achilles under increased tension) • Weitlaner Retractor
• Heel lift • Power instrumentation (needed for saw blade
• Orthotic with heel support and drill)
• Open back shoe to reduce soft tissue irritation • Nonabsorbable and absorbable suture (pri-
• Physical therapy – eccentric programs mary or augmentation of repair or tendon
• Extracorporeal shockwave therapy transfer)
• Avoid steroid injection, risk of rupture • Bone rasp

25.5.4 Non-insertional Achilles 25.6.3 Hardware

Tendinopathy
• Suture anchors
• Nonsteroidal anti-inflammatory medical –– Double row: the proximal row would
therapy consist of single or double loaded, with
• Activity modification (reduce activity that or without loading needles. The distal
places Achilles under increased tension) row incorporates the proximal row suture
• Heel lift or insert with a cross pattern into each individual
• Topical glyceryl trinitrate distal anchor held at appropriate
• Eccentric training [14]. tension.
266 G. C. Berlet et al.

• Tendon interference screw (endobutton tech- • Avoid sural nerve and lesser saphenous injury
nique if needed) for tendon transfer when present in the incisional site.
• Autograft/synthetic graft/amniotic graft • Limit the use of superficial retraction until a
deeper dissection is established.
• A Gelpi retractor is the most useful deep once
25.7 Operative Technique the full tendon is exposed. This can be used
the entirety of the care.
25.7.1 Approach

25.7.1.1 Posterior Midline Incision 25.7.3 Techniques

This incision is placed midline on the AT. The
benefit of this incision is that its placement is 25.7.3.1 Acute Rupture
between two angiosomes, described in the litera- The patient in a prone position, the extremity is
ture [7]. It offers full medial and lateral exposure exsanguinated and the thigh tourniquet inflated.
to the posterior superior aspect of calcaneus A longitudinal incision is made posterior
along with good visualization of deep compart- medial or midline using a 15 blade with limited
ment and FHL. Risk of direct friction contact in dissection to the level of the tendon. Incision
cast/boot is a risk of this incisional locations. placement should be centered over the defect and
Generally this incision avoids sural nerve injury may extend distally for FHL transfer (see below).
due to central position.
Direct Open Repair
25.7.1.2 Posterior Medial Incision • The proximal and distal aspect of the rupture
This incision is placed generally on the direct is debrided of the tenuous “mop-end” appear-
medial border of the AT or within 1 cm of the ance of the acutely injured tendon.
medial border. This incision avoids direct place- • FHL fasciotomy is performed prior to repair;
ment of the incision over a potential frictional this allows easier repair of paratenon upon
midline surface. It offers good exposure to the wound closure.
posterior superior aspect of calcaneus and good • The use of a nonabsorbable suture, preferably
visualization of deep compartment and FHL. The braided for increased strength, should be
sural nerve is avoided in this technique due to its chosen.
medial placement. • Starting with the proximal stump, the suture is
passed in thru the rupture site exiting
25.7.1.3 Posterolateral Incision superficially.
Least utilized incision of the three. Notable risk • The suture then reenters from either side but
of sural nerve interference. Can be helpful for from deep to superficial and is locked in a
posterolateral calcaneal exostosis but offers less Krakow style pattern for ~6 throws.
medial exposure if need for FHL transfer • It is then passed through the tendon to the
other side and sutured in the same fashion dis-
tally toward the rupture site.
25.7.2 Dissection (General) • This is then completed on the distal stump
with the two end tied at physiologic tension
• Avoid dissection superficial to the paratenon with the foot held in 5–10° of plantar
as this can be detrimental to the tenuous blood flexion.
supply present. –– Gift Box [16]: using a free needle, each of
• A full-thickness envelope should be main- the suture ends at the rupture site is passed
tained with sharp dissection to the tendon with across rupture and tied (see suture tech-
limited undermining of the medial and lateral nique diagram).
soft tissue. • Tendon Defects (2–5 cm)
25 Achilles Procedures 267

–– Strayer gastrocnemius recession can • FHL Tendon Transfer

improve ability to restore tendon –– Low threshold to add FHL tendon transfer
continuity. to improve push-off strength, especially if
–– V-Y Advancement direct repair is not obtainable
• Requires larger non-cosmetic incision. –– Technique as described for insertional
• After the initial incision and assessment tendinosis
is made, incision is increased to gain • See below.
access to the gastrocnemius aponeurosis
for a V-Y advancement flap.
• Carrying the incision proximally, one 25.8 Insertional Tendonitis
must avoid the sural nerve and its com-
municating branches. A longitudinal incision is made posterior medial
• Gap defect measured with knee in 30° or midline using a 15 blade with limited dissec-
flexion and ankle in 20° plantar flexion. tion to the level of the tendon. After dissection is
• Arms of the V should be at least 1.5 taken down to the tendon Gelpi retractor, placed
times the length of the defect. in the deep tissues, is most useful for visualiza-
• Inverted V incision through tendinous tion with limited skin injury. This can be used the
portion of gastroc-soleus complex. entirety of the care.
• Inverted Y is repaired side to side with
number 2 nonabsorbable suture. • Two common methods for exposing
• Patients commonly lose as much as tendinosis:
30% plantar flexion strength; FHL ten- –– A longitudinal split of the AT can be made
don transfer typically still needed for with a sharp blade to expose the distal cal-
push-off strength [15]. caneus and deep compartment. The medial
• The V-Y advancement is rarely used in and lateral slips of the AT are maintained at
our practice but as times can be a useful all times which maintains tension.
tool for difficult primary or revisional –– A “U”-shaped incision can be made ele-
cases. vated and completely detach the AT from
• Mini-Open the calcaneus. This offers a greater operat-
–– Various systems have been recently devel- ing field and can adjust Achilles tension
oped for mini or even percutaneous fixation when repairing tendon to calcaneus.
methods for the acute Achilles tendon rup-
ture repair.
–– A small linear incision, biased proximally, 25.8.1 Direct Insertional Repair
is made over the defect to expose the rup-
ture segment. • Palpate and debride diseased tendon with scal-
–– A locking double locked suture repair is pel as needed
made from within the rupture site proxi- • Remove Haglund’s deformity – protect wound
mally, grabbing healthy tendon using a edges from harm and thermal necrosis from
nonabsorbable suture. power tools, especially power rasp.
–– Two suture anchors are then inserted into • Avoid intra-articular STJ penetration as some
calcaneus at the level of its insertion. patients have small calcaneal lengths.
–– Once these are in place, the suture attached • The AT can be secured with a single or double
to each anchor is passed through the tendon row repair with use of suture anchors placed in
using various methods and then brought up the calcaneus.
to meet the proximal row repair. • The anchors are secured in a perpendicular
–– This is tied down at good tension. plane to the tendon based on manufacture
–– The skin is closed in the standard fashion. guidelines and techniques.
268 G. C. Berlet et al.

• The nonabsorbable suture is then passed • Anchors can be used to secure the AT in a per-
through each side of the tendon and tied over- pendicular plane to the tendon based on manu-
top of each anchor facturer’s guidelines and techniques.
• Pass these sutures with enough tendon • The nonabsorbable suture is then passed
between them to prevent cut out when tying. through each side of the tendon.
• Can run 0 Vicryl to repair longitudinal split. • Pass these sutures with enough tendon
• Closure: see below. between them to prevent cut out when tying.
• Closure: see below.

25.8.2 FHL Tendon Transfer Non-insertional Tendinopathy

• A medial or midline incision is made in the
A FHL tendon transfer can be employed for area of the thickened tendon.
patients with >50% tendon involvement. With • Dissect the paratenon prior to debridement of
the Achilles tendon retracted in some fashion, the degenerated tissue.
dissection down through subcutaneous tissue • A Gelpi retractor can be used in the deep tis-
and Bovie crossing vessels in retrocalcaneal sues around the tendon from retraction to
fat. reduce the use of superficial manual retraction.
• Palpate and debride diseased tendon with a
• Dissection is carried through the deep fascial fresh 15 blade in an elliptical pattern using a
compartment, and the FHL muscle belly is central longitudinal approach.
present. DF and PF the hallux for • Avoid a “button hole” in the tendon or iatro-
confirmation. genic laceration.
• Harvest through same incision as distally as • Two skin hooks, one medial and one lateral on
possible with the ankle maximally plantar the tendon, can offer a good field for adequate
flexed to increase excursion and length. debridement of the diseased tendon.
• Use army-navy to protect tibial nerve sharply • If extensive debridement is required, one must
transect with scalpel. assess the viability of tendon moving
• Whip stitch the tendon with 0 Vicryl or a non- forward.
absorbable suture. • Conversion to a FHL (as above) may be
• A guidewire for the interference screw is needed for preservation of strength.
placed central on the superior dorsal aspect of • Application of a graft or BMA can be added at
the calcaneus, avoiding the STJ. this time for augmented healing.
• Drive the wire out of the bottom of the foot • The tendon can be closed with absorbable
(avoid WB surface and plantar fascia monofilament suture or a non-bulky nonab-
insertion). sorbable suture with the knots buried.
• Drill the hole to the size measured of the FHL • Closure: see below.
tendon with the goal size being either the same
size of the tendon or one size larger. Do not Chronic Rupture
drill the plantar cortex. • Direct end to end repair are possible for gaps
• Place the cut end of the sutures attached to the <2 cm, plantarflexion should be less than 30
FHL through the slot in the guidewire. degrees to achieve apposition of tendon ends;
Hemostat the sharp end of the wire distally. often not possible in chronic ruptures.
• Pull on the wire distally out of the bottom of • Gastroc-soleus recession is helpful to appose
the foot; pull on the sutures to dial in precise the torn tendon ends. We tend to avoid V-Y
tendon of FHL. advancement because of poor functional
• Insert interference screw centrally with foot in power and poor cosmesis.
10–15° of PF. • FHL transfer is generally used for almost all
• Run 0 vicryl suture to repair the longitudinal cases, especially when direct repair not
split. possible.
25 Achilles Procedures 269

–– This is the best chance to restore power and

function.
• Use the described technique noted previously.
• We do not routinely sew the FHL tendon side
to side to the Achilles in order to leave each
individual tendon under its own tension.

Wound Closure
• 3-0 Vicryl to repair paratenon which can be
done separately from the subcutaneous
layer.
• 3-0 Vicryl in an interrupted fashion for the
subcuticular layer.
• 3-0 Silk/Nylon suture for skin in a horizontal
mattress pattern; avoid staples.

25.9 Postoperative Protocol

Operatively treated Achilles patients are placed

into an OFAC Group 3 Protocol (Figs. 25.1,
25.2, 25.3, 25.4, 25.5, 25.6, 25.7, 25.8, and
25.9). Fig. 25.2 Intraop view of the rupture Achilles with
planned V-Y advancement

Fig. 25.1 Sagittal MRI view of the acute ruptured Fig. 25.3 After proximally gastrocnemius recession with
Achilles tendon with an approximate 4 cm gap distal tension
270 G. C. Berlet et al.

Fig. 25.4 Post advancement Fig. 25.5 Posterior medial or paramedial incision for
insertion or distal achilles disease

a b

Fig. 25.6 (a) Intraoperative dissection with the paratenon of the Achilles exposed overlying a midsubstance degenerated
t­ issue. (b) Correlating MRI axial view with location (increased signal intensity) of the intrasubstance collagen degeneration
25 Achilles Procedures 271

a b

Fig. 25.7 (a) Central incision of the Achilles with elliptical debridement of the symptomatic tissue, picture in (b)

Fig. 25.9 An example of a double row repair for the treatment

Fig. 25.8 Final closure repair using braided absorbable of the chronically pain insertional Achilles tendinosis with
suture a Haglund’s deformity. The proximal row has been inserted,
and the suture has been placed back through the needed and
tied down. Next, a strand from each of the proximal anchors
with cross as they are tensioned into the distal row
272 G. C. Berlet et al.

• They are non-weight-bearing in their initial

splint for 1 week. • Complete preoperative screening and
• Then they are placed into a non-weight-­ considerations should be made to review
bearing cast for 3 weeks. the post-op complication and known
• Weight-bearing in a boot with a heel lift begins risk factors of each patient.
at 4 weeks. • Re-rupture is less common with open
• Formal physical therapy is initiated at 6 weeks. repair compared to nonoperative man-
• Patients are advanced to full weight-bearing agement [12, 13].
without the heel lift by the 8-week mark. • Sural nerve injury – general avoidable
• The boot is then weaned. based on incisional patterns and meticu-
• The majority of the recovery is complete by lous dissection techniques.
12 weeks. Sport-specific training may
require further conditioning before returning
to play.
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 Ankle Arthrodesis: Open Anterior
and Arthroscopic Approaches
26
Michael D. Dujela and Christopher F. Hyer

26.1 Introduction arthroscopic ankle arthrodesis center around cre-

ating excellent bleeding bone interfaces.
The ankle is a highly constrained joint which is Typically, this is created via curettage technique
exposed to significant impact forces during the which retains the structure and shape of the anat-
gait cycle. Because of these significant forces, omy and significantly reduces the risk of shorten-
ankle arthritis is a tremendously disabling condi- ing, malunion, or nonunion. In cases of severe
tion with functional quality of life impact much deformity or posttraumatic malunion, closing
worse than knee or hip degenerative changes [1]. wedge flat cuts may be utilized instead.
Despite the presence of numerous publications Minimally invasive or arthroscopic arthrode-
showing long-term success associated with ankle sis is appropriate in patients without significant
arthroplasty, ankle arthrodesis has long been con- deformity and in those with good bone stock. For
sidered the gold standard for treatment of end-­ this approach, we advocate a tripod screw fixa-
stage ankle arthritis. Traditionally, fusion has tion technique. Fusion rates are very high with
been preferred in younger patients, in those who this method due to the preservation of blood sup-
demonstrate elevated BMI or who are deemed to ply and the minimal dissection of soft tissues
simply be “too active” for replacement. Potential involved. Union rates above 95% have been
candidates for ankle fusion include patients who reported in retrospective studies [3, 4].
have failed diverse non-operative care of In cases in need of significant deformity cor-
sufficient duration and are unable to tolerate rection and hardware removal or require the use
­
bracing. Non-operative strategies may include of more significant internal fixation, we favor a
rigid non-­articulated ankle-foot orthosis, rocker direct midline anterior open approach with lag
sole shoe modifications, anti-inflammatory medi- screw compression and anterior plating.
cations, and corticosteroid injections. Indications for ankle arthrodesis include post-
Rigid internal fixation remains the mainstay traumatic arthritis, severe deformity, neurogenic
of imparting stability to ankle fusions [2]. Our disorders, inflammatory arthropathy, congenital
techniques for both open and minimally invasive deformity, iatrogenic derangement from prior
surgery, severe instability, and failed total ankle
arthroplasty (Fig. 26.1). Ankle arthrodesis in
M. D. Dujela (*) cases of avascular necrosis of the distal tibia or
Washington Orthopaedic Center, Centralia, WA, USA
talus can be considered on a case-by-case basis
C. F. Hyer versus possible tibio-talo-calcaneal fusion
Orthopedic Foot & Ankle Center,
(Fig. 26.2). Septic arthritis or osteomyelitis once
Worthington, OH, USA

© Springer Nature Switzerland AG 2019 275

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_26
276 M. D. Dujela and C. F. Hyer

Fig. 26.2 Open approach demonstrating successful

union with anterior plating and internal bone stimulator in
partial avascular necrosis of the talus in a prior complex
trauma involving talar neck fracture and pilon variant.
Retained hardware from prior trauma remains

Fig. 26.1 Anterior approach arthrodesis with anterior lat-

eral plate and crossed compression screws demonstrating or naviculocuneiform joint should be carefully
solid union of ankle fusion for posttraumatic arthritis in evaluated and may be better suited for ankle joint
prior malreduced syndesmosis injury replacement if other factors permit. Progression
of adjacent joint arthritis and pain after ankle
treated with antibiotics can in some cases be fusion could result in further issues in the future
treated by fusion. requiring pantalar fusion, which should be
Relative contraindications include smoking, avoided whenever possible.
metabolic deficiencies such as low vitamin D lev-
els, or a poor-quality skin envelope from prior
trauma, wounds, or surgery. Additional contrain- 26.2 History
dications include uncontrolled or poorly man-
aged diabetes with HgbA1C above 7.5%. Patients with significant degenerative changes
Advanced age (suggested increase in nonunion within the ankle often present with pain and dis-
rate), history of noncompliance, excessive alco- comfort throughout the ankle and hindfoot which
hol use (suggested increase in nonunion rate), can be difficult to differentiate without an exten-
and patients with dense sensory neuropathy war- sive physical examination. Ankle pain may be
rant special consideration prior to proceeding as present with first steps in the AM which is exac-
the risk of nonunion increases. erbated with activity; however, patients may
Patients with ankle arthritis coupled with adja- experience aching or “afterburn” at times of rest
cent joint arthritis in the subtalar, talonavicular, after sufficient aggravating activity. Common
26 Ankle Arthrodesis: Open Anterior and Arthroscopic Approaches 277

complaints include a sensation of aching, lock- option if the patient has no significant
ing, catching, or grinding, and in some cases contraindications.
where the osteophytes become large, shoe fit may Clinical evaluation of adjacent joints for
become problematic. It is imperative to assess the pathology such as a varus or valgus deformity of
adjacent joints and soft tissue structures to deter- the knee or hip pathology is imperative as it may
mine if the subtalar or midtarsal joints are also require correction prior to ankle fusion.
involved in the process. Assessment of the soft tissue envelope is cru-
Often there is significant loss of range of cial to determine if there is a risk of postoperative
motion as a result of the degenerative changes complication or wound compromise. Particularly
and osteophyte formation within the ankle joint. problematic is the presence of stiff, scarred skin
The majority of ankle degenerative changes are a envelope which may be adhered to the ­underlying
result of posttraumatic problems within the tib- bone structures. In these cases, in the absence of
iotalar joint. Many patients have had previous deformity, consideration may be given to an
surgical intervention and may still have retained arthroscopic or mini-incisional approach. An
hardware in or around the ankle joint which must uncompromised supple soft tissue envelope with
be considered in surgical planning. In addition, a well-developed subcutaneous fat layer is most
patients with autoimmune disorders and rheuma- desirable.
tologic conditions often can develop significant It is important to assess the patient for the
degenerative changes within the ankle. Patients presence of any neuropathy as this can some-
with a history of deformity may also develop times be subtle and not reported by the patient.
significant problems related to the ankle joint The presence of dense peripheral neuropathy has
and may require ankle arthrodesis for treatment been associated with increased risk of nonunion.
of significant equinus, varus, or valgus Gait analysis is important to assess for any
deformities. dynamic disturbances that could suggest underly-
ing neurologic issues, muscle weakness, or bal-
ances issues that could compromise outcome
26.3 Diagnosis resulting in postoperative fall or noncompliance.
In cases where balance issues are present or sug-
A thorough physical examination is the mainstay gestion of possible underlying neurologic issues
in evaluating a patient with ankle arthritis. With are present, a consultation with a physiatrist or
moderate arthritis, subtle findings such as crepi- neurologist may be indicated. Consideration
tus and reduced motion, may not be appreciated. should also be given to upper extremity strength
It is common that the midtarsal joint or subtalar and agility to determine if the patient will have
joint may demonstrate compensatory changes sufficient ability to maintain non-weightbearing
such as increased motion that can be deceptive. status for several weeks or to perform simple
Mild to moderate coronal plane deformities can activities like transferring from bed to the rest-
be underappreciated on static stance examination room facilities or to move in and out of a vehicle.
especially when subtalar joint compensation for If there is concern, the patient should be referred
malalignment exists unless the clinician has the for “prehab” or physical therapy gait training to
benefit of standard weightbearing ankle radio- assess potential for postoperative risk, i.e., fall.
graphs. Adjacent joint arthritis should be care-
fully assessed prior to choosing ankle arthrodesis.
Over time, ankle arthrodesis will lead to adjacent 26.4 Imaging and Diagnostic
joint degenerative changes because of increased Studies
strain being placed on them. If the patient dem-
onstrates adjacent level degenerative changes A complete series of weightbearing radiographs
prior to ankle fusion, the surgeon may wish to are needed for evaluation of ankle osteoarthritis
consider ankle replacement as a possible viable or deformity. Standard radiographic views of the
278 M. D. Dujela and C. F. Hyer

ankle including AP, mortise, and lateral images needed as well as a solid 3.0–3.5 drill bit for joint
are obtained. In addition, a hindfoot alignment preparation.
view or Saltzman view should be considered to Autogenous bone graft is typically used in
assess the limb position. It is not uncommon to primary arthrodesis of the ankle in an effort to
develop a valgus deformity of the hindfoot in improve fusion rate. Depending on the patient’s
combination with a varus deformity of the ankle medical comorbidities and, in the presence of
that is best appreciated on the hindfoot alignment bone voids and bony deformities, one may how-
views. Advanced imaging such as single-photon ever choose to select autograft, allograft, and
emission CT (SPECT) or standard computed occasionally bulk allograft in charcot or
tomography can be also utilized to aid in evalua- advanced talar AVN. In compromised patients or
tion of prior deformity and/or potential bone in cases of nonunion revision, ancillary bone
voids, i.e., cystic changes which may affect the healing tools such as Rh-BMP or Rh-PDGF
outcome of surgical treatment. The benefit of products are often used. Bone marrow aspirate is
SPECT is the ability to assess the status of the also used in virtually all cases to supplement
adjacent joints for early arthritic changes, which healing.
may aid in decision-making regarding the surgi-
cal plan. In certain instances, MRI may be benefi-
cial for evaluation of potential avascular necrosis 26.6 Operative Technique:
and/or evaluation of talus viability. Diagnostic Anterior Approach
anesthetic blocks to the joint clarifies the degree
of involvement and allows the surgeon to assess A stack of surgical towels is placed under the
if pain may be coming from adjacent joint ankle. The incisional approach for anterior ankle
involvement, particularly in long-standing arthri- arthrodesis utilizes the interval between the tibi-
tis or presence of deformity. alis anterior tendon and the extensor hallucis ten-
don for exposure across the anterior aspect of the
ankle joint. The standard incision is approxi-
26.5  perating Room Setup/
O mately 10 cm in length to allow sufficient expo-
Instrumentation/Hardware sure to place the hardware (including plate) and
Selection (Anterior to minimize skin tension with extensive retrac-
Approach) tion on a tight soft tissue envelope (Fig. 26.3).
This is a common utilitarian surgical approach
The patient is placed on the operating table in a that can be extended if there are additional proce-
supine position with a bump under the ipsilateral dures that may need to be carried out within the
hip so the foot and ankle are rectus on the operat- area the midfoot. In addition, this approach
ing room table. A thigh tourniquet is utilized to allows for excellent visualization of the neuro-
keep the surgical field clear from the drapes. vascular bundle and retraction and protection of
General anesthesia is preferred with a popliteal these structures. Patients with prior trauma may
block to reduce postoperative pain. Fluoroscopy have retained hardware in the anterior aspect of
is positioned on the operative side of the room. the ankle joint. This approach may allow for
Important instrumentation for proceeding removal of the hardware in conjunction with the
with ankle arthrodesis primarily focuses on joint ankle arthrodesis.
preparation and distraction of the joint for visual- The skin is incised; dissection is carried
ization. We recommend equipment that will through the subcutaneous tissues with care to
allow for distraction across the ankle joint to protect the medial branches of the superficial
facilitate visualization during joint preparation. peroneal nerve and vessels. The extensor retinac-
Pin-based distractors are useful to allow access ulum is divided just lateral to the anterior tibialis
for thorough joint preparation. A full assortment tendon and tagged with sutures for later repair to
of long-handled curettes and osteotomes are prevent bowstringing of the tendons. In addition,
26 Ankle Arthrodesis: Open Anterior and Arthroscopic Approaches 279

Fig. 26.3 Incision site marked immediately lateral to the

anterior tibialis tendon approximately 7 cm in length
Fig. 26.4 The soft tissues are elevated from the anterior
tibia with a large Cobb elevator. A self-retaining large
utilizing the sheath of the EHL tendon prevents Gelpi retractor is inserted, and a “no touch” technique is
potential wound/skin breakdown over the tibialis used for the wound edges
anterior tendon which can create significant
wound healing difficulties. technique with the retractors to minimize risk of
Once the interval between the EHL and tibia- a wound healing complication. The joint capsule
lis anterior tendon has been identified, identifica- can be elevated both medially and laterally along
tion of the neurovascular structures should be the tibia and talus with a Cobb elevator to allow
performed. Deep retraction of these structures is visualization of the ankle joint and ability to pre-
maintained with Gelpi or large Weitlaner self-­ pare the joint successfully. Removal of osteo-
retaining retractors (Fig. 26.4). It is imperative to phytes from the anterior ankle is performed with
avoid extensive manual traction on the skin an osteotome and mallet which facilitates visual-
edges, and we advocate a “minimal or no touch” ization of the joint.
280 M. D. Dujela and C. F. Hyer

A self-retraining retractor is placed in the joint

to facilitate visualization and joint preparation. A
lamina spreader or Hintermann distractor is used.
In long-standing arthritis, distraction can some-
times be difficult due to stiffness.
Our joint preparation technique for large joints
is the same regardless of the joint involved. The
joint is first mobilized using a Cobb elevator. A
pin-based distractor is applied with a pin in the
distal tibia and one in the talus in this case.
Alternatively, lamina spreaders can be used but
may slip out of the joint or need to be frequently
moved to allow full access to the joint.
A sharp 1/2 inch curved osteotome is used to
debride the cartilage in large segments from the
tibia and talus including the medial gutter. This
should peel off the bone with relative ease and
should require minimal effort. Next, a large
curette is used to debride away any small remain-
ing amounts of cartilage. Particular care is taken Fig. 26.5 Anterior approach with bone grafting using
to prepare the posterior aspect of the joint. Next, allograft cancellous chips to fill any visible voids. The
copious irrigation with normal saline is per- typical approach is to mix bone marrow aspirate with the
graft material. Graft is shown prior to mixing bone mar-
formed to flush out any cartilaginous debris that
row aspirate
could interpose at the fusion site and result in
nonunion. Extensive fenestration is undertaken
via subchondral drilling of all joint surfaces with position and to elevate the heel off the bed. This
a 3.0–3.5 mm drill bit and drill sleeve to mini- step is essential in obtaining the proper position
mize chance of drill bit breakage. A 1/4 inch for ankle arthrodesis. The ankle is placed in
sharp curved osteotome is then used to cross proper anatomic alignment including neutral sag-
hatch or extensively “fish scale” all areas of the ittal plane position. Care is taken to medialize the
joint. The surgeon should see bleeding subchon- talus as much as possible. The talus is then moved
dral/cancellous bone to aid in successful arthrod- in a posterior direction to avoid anterior transla-
esis. No further irrigation of the bone is tion which is often present in advanced arthritis.
recommended to avoid washing away any of the The talus is positioned so the lateral process of
bone material. BMA is injected into the joint sur- the talus is in line with the tibial bisection on a
faces, and if any grossly apparent voids exist, lateral fluoroscopic view. Multiple fluoroscopic
bone graft is packed within the area (Fig. 26.5). images are taken at this point to confirm
Care is taken to insure that the joint is freely ­appropriate position of the joint before provi-
mobile and can be appropriately positioned in sional fixation.
neutral dorsiflexion and the foot can be slightly Once appropriate position is confirmed, the
posteriorly translated within the ankle mortise. In joint is compressed with a large 6.5/7.0 cannu-
some cases, a Hoke TAL may be needed at this lated screw placed from medial tibia at the
point to address any equinus that may be prevent- metaphyseal flare into the lateral talar body. A
ing reduction. second 6.5/7.0 lag screw can be utilized from
A bump is placed under the patient’s Achilles superior lateral on the tibia, just in front of the
tendon to facilitate placing the ankle in neutral fibula and directed to the anterior medial talar
26 Ankle Arthrodesis: Open Anterior and Arthroscopic Approaches 281

neck. We do not routinely use a posterior to ante-

rior lag screw when utilizing anterior plating.
An anterior lateral anatomic locking com-
pression plate or straight anterior plate is selected
and positioned in the most appropriate location
based on bone congruity. The plate is fixated dis-
tally to the talus using locking or non-locking
screws depending on the needs of the patient
based on bone quality (Fig. 26.6). A compres-
sion slot hole on the tibial side exists in most
fusion plates and can be used per physician pref-
erence. The remaining plate holes are filled with
locking or non-locking screws again based on
the needs of the patient. Fluoroscopic imaging is
obtained throughout the procedure to confirm
appropriate position of fixation. Once stable fix-
ation has been placed, the wounds are irrigated
and a multi-­layered closure is performed. Care is
taken to repair the retinaculum.(Figs. 26.7 and
26.8). The patient is placed in a sterile dressing
and a well-­ padded posterior splint (Case
Example 1 – Fig. 26.9a–d).
Fig. 26.7 Deep closure including extensor retinaculum

Fig. 26.6 Anterior lateral plating in place demonstrating

solid multiplanar fixation Fig. 26.8 Final Closure of the anterior incision
282 M. D. Dujela and C. F. Hyer

a c

b d

Fig. 26.9 Case Example 1. (a) An AP radiograph of post- 4-month postoperative radiographs demonstrating solid
traumatic ankle arthritis in an 80-year-old diabetic patient arthrodesis with anterior lateral plate and crossed screw
with peripheral neuropathy who underwent ankle arthrod- technique. (d) 4-month postoperative lateral radiographs
esis via anterior approach open fusion with crossed screws demonstrating solid arthrodesis with excellent position.
and anterior plating (Figures courtesy of Mark Prissel, Autograft donor harvest site from calcaneus is noted
DPM, FACFAS). (b) Preoperative lateral radiograph. (c)

26.7 Complications the potential for nonunion (Case Example 2 –

Fig.26.10a–c). This is often a result of poor joint
There are complications that relate to surgery in preparation or poor/unstable fixation which
general. These include the risks associated with results in increased mechanical strain (Fig. 26.11).
anesthesia, infection, damage to nerves and blood In addition, it can be attributable to previously
vessels, excessive bleeding, or blood clots. mentioned medical comorbidities. Appropriate
One of the most common complication fixation with bone grafting can minimize the risk
directly associated with an ankle arthrodesis is of nonunion or poor outcome.
26 Ankle Arthrodesis: Open Anterior and Arthroscopic Approaches 283

a b c

Fig. 26.10 Case Example 2. (a) An Ankle arthrodesis fixation imparting a solid revision construct. (c) Coronal
demonstrating frank nonunion with three screw fixation CT image demonstrating solid union of a revision ankle
technique. (b) Post-op revision open ankle arthrodesis arthrodesis at 6 months postoperative
with anterior plating, bone grafting, and crossed screw

Another associated complication with ankle

arthrodesis is potential for nerve injury. The ante-
rior ankle approach does allow for potential for
traction neuropraxia to the area of the deep pero-
neal nerve. In addition, there have been docu-
mented cases of nerve injury with percutaneous
screw fixation across the ankle joint. The surgeon
must also be careful to utilize good surgical tech-
nique in placement of screws around the area of
the ankle joint to avoid subtalar or adjacent joint
violation and impingement (Fig. 26.12).
Wound healing complications can be severe
and result in need for multiple surgeries, possible
need for plastic surgery to perform free tissue
transfer and infrequently, potentially even limb
loss. Care is taken to maintain moist soft tissues
with periodic irrigation and minimal manipula-
tion of the soft tissue edges. Careful attention and
consideration of the soft tissue can significantly
reduce postoperative wound issues.
Adjacent level joint arthritis and gait distur-
bance is also a potential known complication
related to ankle arthrodesis. Careful positioning
of the fusion is key to minimizing these issues
Fig. 26.11 AP radiographs of a neuropathic patient with
insufficient fixation resulting in poor stability and grossly (Fig. 26.13). Also the use of shoe-wear modifica-
apparent aseptic nonunion tions such as a rocker bottom sole may aid
284 M. D. Dujela and C. F. Hyer

patients in avoiding additional discomfort

through these other joints. This should also be
considered when choosing the appropriate sur-
gery for the patient’s ankle arthritis.
In summary, the use of an anterior ankle
approach for ankle arthrodesis is a very success-
ful approach to aid the surgeon in treating signifi-
cant deformity and addressing prior trauma and
the need for additional hardware removal. It also
ensures excellent visualization of the ankle joint
and ability to properly prepared the joint which is
vital to successful ankle arthrodesis. In the unfor-
tunate event of an ankle nonunion, this incision
can also be utilized if the patient is converted to
total ankle arthroplasty. This approach also pre-
serves the fibula and prevents problems related to
fibular excision and/or osteotomy. Preservation
of the fibula allows for potential conversion to
ankle arthroplasty when adjacent joint arthritis
develops.

26.8 Arthroscopic Ankle

Fig. 26.12 Anterior plating with crossed lag screws
Arthrodesis
showing violation of the subtalar joint requiring subse-
quent hardware removal 26.8.1 Indications
and Contraindications

Candidates for arthroscopic ankle arthrodesis

include patients with degenerative or inflamma-
tory arthritis of the ankle, posttraumatic arthritis
without significant deformity, and history of
treated infectious or septic arthritis. The same
indications apply to arthroscopic fusion as open
ankle arthrodesis with the exception of defor-
mity. It is difficult to correct significant deformity
with an arthroscopic ankle fusion, and the open
approach is favored in these cases. Coronal plane
deformities and anterior or posterior talar transla-
tion are relative contraindications to arthroscopic
intervention. Other relative contraindications
include retained hardware that cannot be easily
percutaneously retrieved, poorly controlled dia-
betes, active smoking, dense peripheral neuropa-
Fig. 26.13 Clinical appearance after fixation demon-
thy, metabolic derangements, and nutritional
strating neutral alignment in an anterior approach ankle deficiencies such as hyperparathyroidism and
low levels of vitamin D.
26 Ankle Arthrodesis: Open Anterior and Arthroscopic Approaches 285

26.8.2 O
 perating Room Setup/
Instrumentation/Hardware
Selection (Arthroscopic
Approach)

The patient is placed on the operating table in a

supine position with a bump under the ipsilateral
hip so the foot and ankle are rectus on the operat-
ing room table. A thigh tourniquet is utilized to
keep the surgical field clear from the drapes.
General anesthesia is preferred with a popliteal
block to reduce postoperative pain. Fluoroscopy
is positioned on the operative side of the patient.
Our technique involves use of a noninvasive
ankle distractor in all cases. The operative thigh
is placed in a well-padded Ferkel-type leg holder
with the hip slightly flexed (Fig. 26.14). The limb Fig. 26.15 Patient positioned, draped, and prepped with
is then prepped, scrubbed, and draped in the ankle distractor in place for arthroscopic ankle
usual sterile fashion using arthroscopy drapes to arthrodesis
facilitated fluid collection and drainage. The limb
is then elevated and exsanguinated with a 6 inch
Esmarch bandage, and the tourniquet is inflated
at the thigh. The ankle is then placed under gentle
distraction using an ankle distractor and a Guhl
ankle strap (Fig. 26.15). Care is taken to position
the dorsal strap appropriately to minimize risk of
dorsal nerve injury. 10 cc of local anesthetic is
infiltrated into the ankle joint through the anterior
medial portal. Standard anterior arthroscopic
portals are used including anterior medial and
anterior lateral, and an additional outflow portal
can be used posterior laterally (Fig. 26.16). We

Fig. 26.14 Patient positioning for arthroscopic ankle Fig. 26.16 Arthroscopic portals for anterior ankle
arthrodesis using a Ferkel leg holder. Note patient dis- arthroscopy have been marked in the preoperative holding
tance from end of bed to allow distractor placement area in indelible marker
286 M. D. Dujela and C. F. Hyer

prefer the use of a 30° 4.0 mm arthroscopic cam- stitution for drilling (Fig. 26.19). If using a
era. Standard arthroscopic evaluation is per- burr, it is imperative to avoid changing the joint
formed. A 3.5 mm full radius shaver is introduced contours to avoid creating voids or areas of
through a lateral portal, and a partial synovec- poor articulation. Next, extensive fenestration
tomy is performed to facilitate visualization. is undertaken via subchondral drilling of all
Next, using arthroscopic instrumentation, the joint surfaces with a drill bit and drill sleeve to
cartilage is removed using standard joint prepara- minimize chance of drill bit breakage. An alter-
tion techniques exactly as described in the open native option is to use a small size ball burr
arthrodesis technique. The curved osteotomes are such as a 3.0 mm. A 1/4 inch sharp curved
well suited to remove the cartilage and follow the
contour of the tibia and talus anterior to posterior
(Fig. 26.17). Angled and ring curettes are well
excellent options (Fig. 26.18). All visible carti-
lage fragments must be removed from the joint to
avoid interposition and increased risk of non-
union. A posterior lateral portal is ideally suited
to drain all of these small fragments. It is also
useful to have a second 3.5 mm shaver attach-
ment ready to exchange as needed during the
case as they will often become clogged with car-
tilage debris. Having the second shaver to
exchange will keep the case moving in an effi-
cient manner as the back-table staff works to
clear the first shaver.
Particular care is taken to prepare the poste-
rior aspect of the joint. Alternatively, a burr can
Fig. 26.18 After a sharp osteotome is used, a curette is
be used to remove small remaining areas of car- then introduced via an arthroscopic portal to remove any
tilage and penetrate the joint surfaces as a sub- remaining cartilage

Fig. 26.19 Arthroscopic removal of small areas of

Fig. 26.17 Arthroscopic preparation of the ankle joint remaining cartilage performed with a power burr. Care is
demonstrating osteotome technique for removal of taken to avoid excessive bone resection which can result
cartilage in incongruity of the joint surface and gapping
26 Ankle Arthrodesis: Open Anterior and Arthroscopic Approaches 287

osteotome is then used to cross hatch or exten-

sively fish scale all areas of the joint. The sur-
geon should see bleeding subchondral/
cancellous bone to aid in successful arthrode-
sis. The posterior lateral portal can also be used
to allow debridement of the posterior aspect of
the ankle as needed.
BMA is injected into the joint surfaces, and if
any grossly apparent voids exist, bone graft sup-
plementation can be considered.

26.8.3 Positioning and Fixation

of the Arthrodesis Site

Appropriate positioning for an ankle arthrodesis Fig. 26.20 Guidewire placement for large 7.0 mm can-
is critical for a successful outcome. The ankle is nulated screw under direct arthroscopic visualization
removed from the distractor, placing the leg on a
stack of towels, which allows the heel to float off i­mmediately adjacent to the fibula, to posterior
the operating table. This allows the talus to be medial talus. A homerun screw from the poste-
moved posteriorly within the mortise. The tibial rior lateral tibia to the central talar neck can also
bisection should be in line with the lateral pro- be used with sufficient help from an assistant and
cess of the talus on the lateral radiographic view. provide stable fixation. Divergence of the screws
Neutral dorsiflexion is preferred, and the ankle is is imperative to provide excellent even compres-
placed in 5–10° of external rotation to match the sion forces across the arthrodesis site and to
contralateral side. Slight valgus position is pre- avoid “central stacking” of the three screws in
ferred; however, consideration of the hindfoot the mid portion of the talus (Case Example
and ankle alignment on preoperative hindfoot 3 – Fig. 26.21a–e).
alignment views and standing clinical examina-
tion will help determine ideal position.
Temporary fixation with crossed K-wires allows 26.9 Postoperative Care
the surgeon to confirm appropriate position with
fluoroscopic imaging. Three guidewires are The patient is placed in a well-padded posterior
placed percutaneously in tripod fashion in prepa- splint for 7–10 days at which point the sutures
ration for final fixation (Fig. 26.20). Standard are removed. At the first postoperative visit, if
sized 6.5–7.3 cannulated partially threaded edema is well controlled and the wound is heal-
screws are selected to create “lag by design” ing well, a below knee cast is applied with care
compression. Short or longer thread screws are taken to pad all bone prominences. A cast
selected based on the anatomic characteristics of change visit occurs in 3 weeks at which point
the patient. Two wires are placed medially and the patient is either converted to a fracture boot
one laterally. The first screw is placed approxi- or an additional cast at the surgeon’s discretion.
mately 3 cm proximal to the joint at the metaph- Partial weight bearing begins at 6–8 weeks post-
yseal flare of the tibia into the lateral talar op and based on radiographic appearance is pro-
process region; the second screw is placed gressed from there. Typical time to union is
approximately 1 cm proximal to the first medial approximately 3 months. Full return to activity
screw into the central or central lateral talus. The usually occurs between 3 and 6 months
final screw is placed from anterior lateral, postoperatively.
288 M. D. Dujela and C. F. Hyer

a b

Fig. 26.21 Case Example 3. (a) An AP view of a 48-year-­ view demonstrating appropriate guidewire placement
old male with posttraumatic arthritis after prior ORIF of a avoiding subtalar joint penetration. (d) 6-month postop-
Weber C ankle fracture 20 years prior. Patient developed erative AP and lateral radiographs demonstrating solid
pain and stiffness and failed to improve with non-­operative union of the arthroscopic ankle arthrodesis. (e) Long-term
care. Due to well-aligned mortise with no deformity, an postoperative lateral radiograph demonstrating solid
arthroscopic ankle arthrodesis was performed with mini- union with excellent alignment and well-positioned
mal approach for hardware explant. (b) Preoperative lat- fixation
eral radiograph of the same patient. (c) Lateral fluoroscopic
26 Ankle Arthrodesis: Open Anterior and Arthroscopic Approaches 289

Pearls Open Ankle Arthrodesis Anterior

Approach
• Consider bone healing adjuvants in
high-risk fusions or nonunion revisions.
This may include a combination of auto-
graft, Rh-BMP, Rh-PDGF, and/or exter-
nal or internal electrical or ultrasonic
bone growth stimulation.
• A transfibular approach is rarely used in
isolated ankle fusions except in some
cases of severe deformity that is difficult
to correct through an anterior approach
alone (Fig. 26.22). Maintenance of the
fibula is preferred when possible for
improved cosmesis, diminished risk of
late-term valgus drift of the ankle and Fig. 26.22 Example of transfibular approach for a 30°
hindfoot, and preservation of future rigid varus deformity. In most cases, we try to avoid the
option of fusion takedown and conver- transfibular approach
sion to arthroplasty.
• Intraoperative positioning of the fusion
is key. Use stack of towels to “float the Pearls for Arthroscopic Ankle Arthrodesis
heel” off the table to prevent anterior • Ankle arthritis with significant anterior
translation of the foot on the leg and talar translation on a lateral radiograph
help facilitate preferred slight posterior may be poor candidates for an
translation. arthroscopic approach due to inability to
• The combination of large caliber com- release tight scar or capsular
pression lag screw fixation with anterior contractures.
anatomic plating produces a stable fixa- • Regional nerve block with popliteal and
tion construct and improved fusion adductor canal approach will facilitate
rates. This construct may also be stable an outpatient procedure.
enough to maintain symptom-free non- • Mark out arthroscopic portals in the
unions in cases when this occurs. holding area with indelible surgical
• The size of the talus should be consid- marker to enlist patient help in activat-
ered when choosing fixation. Many of ing tendons such as tibialis anterior
the commercially available anterior which may be difficult to locate under
ankle fusion plates have multiple lock- general anesthesia.
ing screw sizes and variable angle • Anterior medial and anterior lateral por-
options, which can be helpful when tals should be as centralized as possible
working with limited “real estate” and to the midline of the ankle to ensure
avoiding the large cannulated screws good working position and minimizing
already placed. soft tissue damage to portals from
instrument traction.
290 M. D. Dujela and C. F. Hyer

• Nerve structures can translate up to • Consent patient for possible gastrocne-

4 mm laterally from dorsiflexion to mius recession or percutaneous Achilles
plantarflexion. Consider this when tendon lengthening if equinus prevents
marking proposed portals to minimize positioning.
risk. • Initial postoperative radiographs can be
• Use of a distractor is beneficial to facili- somewhat disconcerting after an
tate joint preparation and access in a arthroscopic ankle fusion as it is not
tight arthritic joint. unusual to see some mild gapping at the
• The surgeon may consider synovectomy arthrodesis site. This is not something to
and exostosis removal prior to tourni- be concerned about in the early phase as
quet inflation and distractor use to healing typically progresses rapidly.
ensure adequate time for joint prepara-
tion and fixation. The authors wish to recognize Dr.
• Ensure adequate cartilage removal from Geoffrey S. Landis for his contribution to
all areas encompassed in the fusion this chapter.
using osteotomes and curettes. We pre-
fer only occasional use of the burr use to
avoid contour issues.
• Removal of osteophytes to the anterior
References
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fusion allowing posterior translation of Comparison of health-related quality of life between
the talus to neutral alignment. patients with end-stage ankle and hip arthrosis. J Bone
• Positioning the lower leg on a stack of Joint Surg Am. 2008;90(3):499–505.
2. Schuberth JM, Ruch JA, Hansen ST Jr. The tripod
towels once removed from the distractor fixation technique for ankle arthrodesis. J Foot Ankle
helps to position the fusion site, avoid- Surg. 2009;48(1):93–6.
ing anterior translation of the talus. Use 3. Jones CR, Wong E, Applegate GR, Ferkel
of a distractor is beneficial to facilitate RD. Arthroscopic ankle arthrodesis: a 2-15 year fol-
low up study. Arthroscopy. 2018;34(5):1641–9.
joint preparation and access in a tight 4. Quayle J, Shafafy R, Khan MA, et al. Arthroscopic
arthritic joint. versus open ankle arthrodesis. Foot Ankle Surg.
2018;24(2):137–42.
 Tibiotalocalcaneal Arthrodesis
27
J. George DeVries and Matthew D. Sorensen

27.1 Introduction fibula as well as significant ankle valgus. Pain

was progressive and began to affect every step.
Limb salvage in the context of lower extremity Options from a surgical perspective included STJ
deformity, posttraumatic arthritis, diabetic neuro- fusion with tibial and fibular osteotomy, BKA or
arthropathy, osteomyelitis, and failed total ankle TTC fusion. We chose TTC fusion with
arthroplasty can pose a challenging clinical and ­intramedullary nail fixation with lateral approach
surgical picture. Few definitive options are avail- (Fig. 27.1c–e).
able to the foot and ankle surgeon in effort to pre- Case 2 includes a 64-year-old male with perti-
vent amputation, yet provide pain relief. nent history of progressive stage IV PTTD and
Tibiotalocalcaneal (TTC) arthrodesis is a power- debilitating pain and nondiabetic, non-­
ful intervention available toward the effort to pro- neuropathic, yet unstable hindfoot, severely val-
vide such challenging patients with a viable limb gus ankle with severe arthritis (Fig. 27.2a–c). The
that is functional, stable, and predictable in the patient’s desire was for ankle replacement and a
near term as well as long term. It has been staged approach was decided upon. After signifi-
explored extensively in the literature through a cant hindfoot, midfoot reconstructive work in
wide range of clinical presentations [1–7]. addition to allograft deltoid ligament reconstruc-
tion, the ankle remained in severe valgus
malalignment upon weight-bearing. Secondary
27.2 Case Examples to the persistent valgus ankle, a TTC arthrodesis
was performed (Fig. 27.2d–g).
Case 1 involves a 34-year-old otherwise healthy
female with a neglected trimalleolar ankle frac-
ture sustained 2 years prior to presentation. 27.3 Presentation/Diagnosis/
Figure 27.1a, b are radiographs that indicate Imaging
degenerative change within the ankle and subta-
lar joints in addition to a short and malrotated Presentation most commonly includes pain and/
or instability associated with arthritis affecting
J. G. DeVries (*) the ankle and subtalar joint. This can arise from
BayCare Clinic, Manitowoc, WI, USA posttraumatic scenarios or deformity residua.
e-mail: [email protected]
Failed total ankle replacement or arthrodesis,
M. D. Sorensen avascular necrosis of the talus, charcot
Weil Foot and Ankle Institute, Foot & Ankle Surgery,
Chicago, IL, USA

© Springer Nature Switzerland AG 2019 291

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_27
292 J. G. DeVries and M. D. Sorensen

a c

Fig. 27.1 (a, b) Preoperative radiographs showing a arthrodesis with intramedullary nail. Complete resection
neglected trimalleolar ankle fracture that resulted in sub- of the fibula was performed in this case, and stable non-
stantial bony deformity and posttraumatic arthritis. (c–e) union of the subtalar joint was noted
Postoperative radiographs showing tibiotalocalcaneal
27 Tibiotalocalcaneal Arthrodesis 293

d e

Fig. 27.1 (continued)

n­euroarthropathy, and neuromuscular disorders bone quality evaluation including the presence
are other directives that may require TTC fusion. of intramedullary cyst formation or avascular
Diagnosis begins with clinical evaluation of necrosis.
any gross deformity and pathobiomechanical gait
pattern evaluation if possible. Additionally diag-
nostic injections are prudent, with real-time func- 27.4 OR Setup
tional, patient reporting, in effort to isolate the
affected joints. Typically, the patient is placed in the supine posi-
The neurovascular status must be assessed. tion on the OR bed with a bump underneath the
When neuromuscular disease is suspected, EMG/ ipsilateral hip so that the foot is directed verti-
NCV testing may be important to evaluate the cally and perpendicular to the OR bed. A stack of
viability of surrounding lower extremity muscle four or five blankets (Fig. 27.3a, b) or other
groups and inherent pertinence to the functional equivalent bump is placed underneath the opera-
outcome of surgical intervention. When periph- tive limb and taped into place. This will keep the
eral arterial disease is suspected, workup should nonoperative limb out of the X-ray field and
begin with ankle-brachial indices to ensure ade- decrease the amount of intraoperative manipula-
quate blood flow to the area for healing. tion of the surgical limb. The large C-arm should
Imaging is imperative and begins with plain be placed on the contralateral side of the surgical
film weight-bearing X-rays. Advanced imaging limb to maintain adequate access to the fusion
such as MRI or CT scan is necessary in the eval- sites with simultaneous fluoroscopic capacity
uation period and for potential preoperative during the procedure. A thigh tourniquet is neces-
planning. Advanced imaging can prevent sary as sterile access to the entire tibia is impor-
unwanted intraoperative surprises and allows for tant throughout the procedure. Popliteal block
294 J. G. DeVries and M. D. Sorensen

a b

c d

Fig. 27.2 (a–c) Preoperative radiographs showing an struction that still resulted into unstable ankle valgus.
arthritic incongruent valgus ankle with hindfoot arthritis Therefore an anterior approach and plated tibiotalocalca-
and midfoot collapse. (d–g) Postoperative radiographs neal arthrodesis was performed
showing first an attempted midfoot and hindfoot recon-
27 Tibiotalocalcaneal Arthrodesis 295

e g

Fig. 27.2 (continued)

with general anesthesia is preferred in effort to ment. These are done with the patient in the
mitigate postoperative pain. supine position.
Several incision options are possible for a tib-
iotalocalcaneal (TTC) arthrodesis. Traditionally,
27.5 Operative Technique the approach we will discuss in this chapter is a
long (15–20 cm) lateral incision over the fibula
In most cases that involve deformity, the first step extending over the sinus tarsi and a 5–7 cm
is a posterior muscle group lengthening. This can anteromedial ankle gutter incision for the medial
either be a gastrocnemius or gastro-soleal reces- ankle joint (Fig. 27.4a, b). This allows for fibular
sion or traditional Hoke triple Achilles hemisec- osteotomy and graft harvest and excellent expo-
tion. This will allow for later repositioning of the sure to the ankle joint and subtalar joint (STJ)
STJ, and failure to do so may impede realign- and facilitates any deformity correction that may
296 J. G. DeVries and M. D. Sorensen

a plane deformity or in which an anterior incision

was used previously such as total ankle replace-
ment or pilon fracture fixation. Lastly, a posterior
incision approach can be used in cases where the
other approaches are not feasible, such as previ-
ous graft or flap placement, or if there is specific
pathology that is addressed most directly from a
posterior approach.
For the traditional lateral and anteromedial
approach, lateral dissection is carried out first.
Care is taken to identify the superficial pero-
neal nerve as it crossed from posterior to ante-
rior approximately 10 cm proximal to the tip of
b
the fibula. The sural nerve should be posterior
to the fibula at this level. Dissection is carried
onto the fibula. Release of the anterior and dis-
tal soft tissue is performed with a scalpel blade,
including the calcaneofibular ligament, ante-
rior talofibular ligament, and anterior-inferior
tibiofibular ligament. Dissection is carried dis-
tally parallel to the peroneal tendons past the
subtalar joint. The peroneal tendons should be
identified and retracted distally. The level of
fibular resection is determined at this level and
is at least 5 cm proximal to the ankle joint. This
may need to be higher in the case of plate
fixation.
An oblique fibular osteotomy from lateral-­
proximal to medial-distal is performed
(Fig. 27.5a). Pearl: A second osteotomy 1 cm
away is performed parallel to the first. This will
remove a 1 cm cylinder of the fibula and prevents
impingement of the fibula after shortening from
ankle and STJ preparation. This cylinder can be
ground up for graft material or potentially can be
left for structural graft if needed (Fig. 27.5b). The
syndesmosis is released from the osteotomy dis-
Fig. 27.3 (a, b) Clinical images showing leg positioning
tally. A 1/2″ curved osteotomy is placed running
with ipsilateral hip bump and stack of towels under the along the medial surface of the fibula and is used
operative leg to provide access for surgery and to release the syndesmosis to free up the fibula
fluoroscopy (Fig. 27.6). Any remaining connections along the
ankle lateral ligaments are also released with the
be needed. The medial incision can be used to osteotome. This will allow the entire fibula to be
prepare the medial ankle joint, but also to allow distracted away from the tibia, talus, and calca-
for medialization of the talus. Alternatively, an neus, hinging on the posterior soft tissue attach-
anterior approach to the ankle, and sinus tarsi ments. Pearl: A lamina spreader can be placed
incision for the STJ can be used. This is most between the fibula and talus to facilitate this
often appropriate in cases with primarily coronal (Fig. 27.7).
27 Tibiotalocalcaneal Arthrodesis 297

a b

Fig. 27.4 (a) Lateral clinical view of the foot and ankle ation at the ankle, resulting in the deformity seen here. (b)
showing the lateral incision coursing from the fibula and Medial clinical view of the foot and ankle showing the
curving distally toward the fourth metatarsal base. This medial incision along the medial ankle gutter
patient has talar avascular necrosis with anterior sublux-

a b

Fig. 27.5 (a) Fibular osteotomy above the ankle joint first, thus removing a cylinder of bone to prevent impinge-
from proximal-lateral to distal-medial. (b) A second fibu- ment after fusion of the ankle and subtalar joints
lar osteotomy is made approximately 1 cm proximal to the

Fig. 27.6 A curved osteotome is used to free the fibula

from the syndesmosis, anterior-inferior tibiofibular liga- Fig. 27.7 Once free anteriorly, a toothed lamina spreader
ment, and lateral ankle ligaments is placed between the tibia and talus and used to rotate the
freed fibula laterally
298 J. G. DeVries and M. D. Sorensen

a b

Fig. 27.8 (a) A sagittal saw is used to osteotomize the morcellized into small autogenous bone graft fragments to
distal fibula into medial and lateral halves. (b) Once split, pack into the fusion sites
the medial portion of the distal fibula is removed. It is then

Once the fibula is laterally distracted, the

medial half is removed. A sagittal saw is used
along the anterior margin of the fibula to split into
medial and lateral halves (Fig. 27.8a, b). The
medial half is then removed from the incision,
and a bone mill can be used to morcellize the
fibula into cortico-cancellous autogenous graft
chips. The lateral half, attached posteriorly, will
be retracted out of the way for the remainder of
joint preparation and is used as an onlay graft at
the end of the case. In cases where a lateral plate
is used, the entire distal fibula can be removed
and morcellized. The lateral surface of the tibia
and talus is addressed at this time. Very often
these areas are overgrown with bony exostoses. A
1/2″ curved osteotome can be used to remove the
Fig. 27.9 The anterior medial incision will expose the
anterolateral lip of the tibia and the lateral pro- medial ankle joint. Resection of the lateral half of the
cess of the talus. This will make a flat, healthy medial malleolus is performed with a sagittal saw in order
fusion bed for fibula onlay graft or lateral plate if to medialize the foot, and preparation of the medial sur-
face of the talus is performed as well. The resection of the
used.
medial malleolus is taken proximally to intersect the tibial
The medial ankle joint is then accessed resection from the lateral side
through the anteromedial incision. This is made
along the medial ankle gutter. The saphenous Attention is now directed to ankle and subtalar
nerve and greater saphenous vein should be pos- joint preparation. Pearl: A 7″ sharp Gelpi retrac-
terior and medial to the incision. A medial tor is placed along the medial border of the fibula
arthrotomy is performed to expose the joint and anterior soft tissue. The ankle and STJ
(Fig. 27.9). Pearl: A deltoid release can be per- should be accessible (Fig. 27.10). The STJ is pre-
formed with a 1/2″ curved osteotome to allow for pared in standard fashion. The contents of the
more mobility of the joint. sinus tarsi are removed with a rongeur, and a
27 Tibiotalocalcaneal Arthrodesis 299

Fig. 27.11 Lateral exposure of the ankle and subtalar

joints after preparation. The subtalar joint was prepared
Fig. 27.10 Lateral joint exposure of the ankle and subta- with curettage and the ankle with planar resection using a
lar joints after fibular osteotomy, lateral talar process, and sagittal saw
anterolateral tibial resection. A toothed lamina spreader
can be placed into the joints to open them up and hindfoot reduced, the dorsal surface of the
talar dome is resected parallel to the tibial
sharp-toothed lamina spreader is placed between resection.
the talar neck and anterior process of the calca- Through the medial incision, the medial talar
neus. Distraction is applied, and the joint capsule surface and lateral surface of the medial malleo-
can be released with a 1/2″ curved osteotome. lus are prepared. A sagittal saw is used to remove
The posterior facet of the STJ is now prepared for the surface of the medial malleolus and extends
arthrodesis by removing all articular cartilage proximally to the tibial joint preparation. The
past the subchondral bone. Fenestration of the talar surface is typically prepared with a combi-
joint is performed with a large guide wire or nation of osteotome, curette, and rongeur. The
2.0 mm or smaller drill. The ankle joint can be talus can be medialized by resecting more from
prepared in a similar fashion in cases of minimal these surfaces.
deformity. Joint curettage preparation ensures In cases of substantial avascular bone, such as
good bone-to-bone contact. In cases of substan- posttraumatic avascular necrosis of the talus or
tial deformity, a sagittal saw blade is used to Charcot neuroarthropathy, or large bone loss
apply flat surface cuts to correct any deformity. after trauma or failed total ankle replacement,
Holding the foot and ankle in corrected position, bulk allograft may be used. In these cases, the
the distal tibial surface is resected proximal to the incision approach may only require the lateral
subchondral bone (Fig. 27.11). This is taken incision. Complete resection of any avascular
medially to the medial malleolus. Care is taken bone or remnant hardware/cement is removed.
not to cut through the medial malleolus, and The joint surfaces can then be prepared with an
intraoperative fluoroscopy can be used in this acetabular reamer, and the graft is cut, fenes-
step to assess the depth of the cut or can be trated, and fit into the arthrodesis site [8]
assessed from the medial incision. Particular care (Fig. 27.12a–c).
is taken at the posterior medial extent of the Once all joints are resected, they are fenes-
resection to avoid damage to the neurovascular trated with a large bore guidewire or small drill
bundle. The posterior and anterior lips of the dis- and fish scaled with a 1/4″ curved osteotome
tal tibia need to be removed to allow for good along all fusion surfaces. The foot and ankle is
bone contact. Then, while still holding the ankle now very loose and proper positioning is key.
300 J. G. DeVries and M. D. Sorensen

a c

Fig. 27.12 (a) Acetabular reamer used on the tibia in ioned into shape and prepared for fusion. (c) Once placed,
order to prepare for arthrodesis with femoral head the femoral head allograft will have inherent stability in
allograft. Because of the massive bone loss, the foot can the reamed arthrodesis site. The spherical preparation of
be dislocated off the leg in order to facilitate access. (b) the arthrodesis site will allow for easy deformity correc-
After preparation of the tibial and calcaneal surfaces with tion and is amenable to a variety of fixation techniques
the acetabular reamer, a femoral head allograft is fash-

Typically a line is drawn along the tibial crest pression mechanics built into them, such as
and along the second metatarsal shaft. This will eccentric compression holes or compression
help visualize internal and external rotation. This screws that incorporate into the plate. The rec-
arthrodesis can be fixated from this approach ommendation is to pin into place with guide-
with either screws, plates, or intramedullary nail. wires for large (≥6.5 mm) cannulated screws
In cases of plate or screw fixation, the joints are from the medial and inferior angles. The plate is
flushed and packed with any orthobiologic sup- then applied laterally with whatever compres-
plementation the case may require. The joints sion options are available. The medial and/or
are then pinned into proper alignment and con- plantar screws can then be placed to provide
firmed. Compression screw fixation may be additional compression and rotational control
placed at this point, or some plates have com- (Fig. 27.13a, b).
27 Tibiotalocalcaneal Arthrodesis 301

done with the foot and ankle held in proper align-

a
ment [9]. The wire is then checked with AP, lat-
eral, and axial intraoperative images. All of these
images are necessary as the wire can be missed in
a number of directions and must be confirmed. If
the position of the foot is inadequate, the wire is
removed, the foot is repositioned, and the wire is
re-driven. Pearl: However, often the foot and
ankle are in proper alignment, but the wire is off
in some direction. In these cases, leave the first
wire and drive a second guide wire (Fig. 27.14a,
b). This will maintain the position that has been
b obtained, but also the first wire is used as a
­reference to place the second one into proper
position. After the guidewire is in position, the
first one is removed, and the area is flushed at this
point, as the reamings will be used to supplement
the fusion mass (Fig. 27.15).
A plantar incision is made, and an entry drill is
used to break into the tibia. Then reaming is done
in sequential fashion. The goal is to feel cortical
chatter, indicating good fill of the canal, and to
extend more proximally that the anticipated nail
length (Fig. 27.16). The nail is usually then sized
1–1.5 mm under the reaming diameter. The ream-
ings from the canal will act as bone graft in the
fusion sight. Pearl: If additional cancellous graft
is desired, a reamer-irrigator-aspirator (RIA
Reamer, DePuy Synthes, Warsaw, IN) can be used
to harvest graft up into the tibial plateau [10]
(Fig. 27.17a, b). Do not flush the reamings out of
the joint, and any other orthobiologics, as well as
the autogenous graft from the fibula, are now
packed into the joint. The nail is now ready to be
placed.
Placement of the nail is according to the man-
ufacturers guidelines. Each nail has different
sequences of locking screws and varying abilities
Fig. 27.13 (a) Specially designed plate for lateral tibio- to compress the joints, either separately or
talocalcaneal arthrodesis with placement of hardware into together. Once the foot is aligned by rotation to
the tibia, talus, and calcaneus, with an oblique compres- the leg, the nail can be rotated within the canal
sion screw slot. (b) Final lateral plate construct with long
compression screws placed from inferior and medial and
via the external jig (Fig. 27.18). Pearl: Care is
a lateral plate taken at this point in particular to the posterior to
anterior screw. The alignment guide should be
If an intramedullary nail is to be used, several checked for this screw to confirm that it is in the
additional steps are undertaken. Once the joints center of the posterior tuber as it can be possible
are prepared for fusion, a guidewire is placed to place it too medial or lateral and have the
from the calcaneus into the tibia. This must be screw skive of the tuberosity during drilling or
302 J. G. DeVries and M. D. Sorensen

a b

Fig. 27.14 (a) Lateral intraoperative fluoroscopic image AP intraoperative fluoroscopic image of wire placement.
of wire placement. After joint preparation, position is held After joint preparation, position is held and a guide wire is
and a guide wire is placed. The position was adequate, but placed. The position was adequate, but the first wire was
the first wire was found to be angled too far posteriorly found to be slightly lateral, but the lateral image showed
and could not be used for the nail guidewire. This wire significant posterior placement. This wire was left in place
was left in place to hold position and used as a reference to hold position and used as a reference for the intramed-
for the intramedullary guidewire that was placed next. (b) ullary guidewire that was placed next

screw insertion (Fig. 27.19). If there is an imping-

ing end cap, this should be placed to prevent
backout of this screw.
Once the nail is placed, the fibular onlay graft
is placed. It is rotated via the posterior attach-
ments back into position lateral along the tibia,
talus, and calcaneus. Once in position, the fibular
can be secured with either 4.0–5.0 mm cannu-
lated screws or the locking screws for the nail.
Pearl: As the nail is in the center of the medullary
canal, the screws will need to be angled anteri-
orly or posteriorly. Typically the lateral locking
screw in the talus is visible and can give you an
Fig. 27.15 Once the wire is placed correctly and the foot idea where the nail is placed to plan for compres-
and ankle are in proper alignment, the joints can be sion fibular screw placement. One screw above
flushed prior to reaming
27 Tibiotalocalcaneal Arthrodesis 303

Fig. 27.16 Sequential reaming is performed to a diame-

ter that produces cortical chatter, indicating good fill of
the canal

b
the fusion site and one below is all that is
­necessary (Fig. 27.20). The fibula onlay graft
should not articulate with the proximal portion of
the intact fibula because of the 1 cm cylinder that
was removed. No need to attempt fixation
between the two ends to the fibula. Pearl: Final
clinical and fluoroscopic inspection is done at
this point, again with at least AP, lateral, and cal-
caneal axial films (Fig. 27.21a–c).
The area is then flushed with saline. Any graft-
ing materials left at this point are packed into the
joints; in particular there is often room in the
medial gutter, but this area does not require graft-
Fig. 27.17 (a) If additional cancellous autogenous bone
ing if none is left over. Deep closure is obtained graft is desired, a reamer-irrigator-aspirator can be used to
laterally closing the periosteum over the fibula. harvest graft into the tibial plateau. (b) The proximal
Subcutaneous closure and deep closure is vital to reaming can be sucked out of the canal and into a canister
prevent hematoma formation and also must be for later placement
placed carefully to avoid superficial nerves.
304 J. G. DeVries and M. D. Sorensen

Fig. 27.20 Once the nail is placed, the fibula onlay graft
Fig. 27.18 Once the nail is placed into the canal, final
is placed laterally. Two compression screws are placed,
confirmation of rotation of the foot on the leg is assessed.
one above the fusion site and one below. The lateral talar
In addition, the external targeting guide is used to make
locking screw for the nail can be used to assess where the
sure that rotation of the nail in the canal is appropriate as
nail is and guides placement of the compression screws
well
anterior or posterior to the nail

often admitted overnight to work with physical

therapy for non-weight-bearing gait, ensure that
pain is managed adequately, and for postopera-
tive prophylactic antibiotics. Typically patients
are able to be discharged home the next day. In
patients that are unable to safely be non-weight-­
bearing per physical therapy, placement into a
skilled nursing facility may be required until
patient can safely transfer.
Follow-up at 2 weeks will have non-weight-­
bearing radiographs, remove the sutures, and
place the patient into a non-weight-bearing
fiberglass cast for 1 month. Weight-bearing in a
cast is instituted at 6 weeks post-op and then
into a removable walking boot at 8 weeks.
Weight-­ bearing will be done in a boot for
1 month with massage and gentle foot and ankle
motion at this point. Physical therapy is insti-
tuted at this point as well. At 3–4 months post-
Fig. 27.19 Particular care needs to be done for the pos-
op, the patient will be given a lace-up ankle
teroanterior calcaneal screw to make sure that it is enter- brace to support the hindfoot. Once swelling is
ing into the posterior aspect of the tuber, not skiving along controlled, the patient is casted for custom
either side orthoses, typically between the 4–6-month post-
operative time period.
27.5.1 Post-op Care

Immediately after surgery the patient is placed 27.5.2 Complications

into a well-padded plaster splint, applied under
the foot and posteriorly as well as side to side Tibiotalocalcaneal arthrodesis is a major hind-
along the foot and ankle. The patient is most foot and ankle arthrodesis procedure, and com-
27 Tibiotalocalcaneal Arthrodesis 305

a b c

Fig. 27.21 (a) Lateral fluoroscopic image of the final hardware placement. Notice that even with a cylinder of
construct with nail placed with locking screws and the bone removed, the fibula closely abuts to the proximal
fibular only graft with compression screws posterior to the remnant due to shortening from the arthrodesis joint prep-
nail. Be careful to assess length of the posteroanterior cal- aration. (c) Calcaneal axial fluoroscopic image showing
caneal screw to avoid calcaneocuboid joint penetration. good hindfoot alignment with central placement of the
(b) AP fluoroscopic image of the final construct showing nail and the posteroanterior calcaneal screw
good alignment of the ankle and hindfoot with appropriate

plications can occur. Although patients may have this level, and no weakness or atrophy should
improved pain overall, there is substantial stiff- occur.
ness in the hindfoot and ankle that will have func- Bone complications fall largely into nonunion
tional limitations. or malalignment and can occur together if the
Wound complications are most often associ- deformity correction is not maintained due to
ated with the lateral incision as this is where the nonunion or delayed union. If deformity correc-
majority of the work is done. Recognition of tion is maintained and the hardware is stable,
early dehiscence is important and most often can continued immobilization, potentially along with
be treated with local wound care. Patients will be external bone stimulation, can be instituted. If
placed into a non-weight-bearing boot to facili- deformity is progressive, or there is a loss of
tate daily dressing changes. If the wound contin- hardware stability due to loosening or breakage,
ues to deteriorate, prompt referral to wound care revision surgery should be offered. The addition
should be instituted. of autogenous bone grafting or advanced ortho-
Nerve injury also is more common laterally. biologics (such as recombinant human bone mor-
The sural nerve runs along the lateral incision phogenetic protein-2) should be used. In addition,
line, especially distally as the incision course more robust fixation from different hardware and
toward the fourth metatarsal base. Prompt treat- approaches will need to be used as well. Solid
ment with gabapentin or pregabalin should be union in a poor position can be problematic not
instituted if there is burning or tingling pain. This only at the arthrodesis sites but also at the adja-
will often resolve over time. If not, cortisone cent joints. If the position is such that it is
injections into the area can be considered. unbraceable, or causing other issues in the sur-
Permanent numbness can occur if the nerve is rounding joints, revision should be offered.
severed in surgery. Although a complication, this Depending on the exact location, the can be
nerve does not have any muscle innervation yet at undertaken with either takedown of the fused
306 J. G. DeVries and M. D. Sorensen

joints or peri-arthrodesis osteotomies to correct 5. DeVries JG, Berlet GC, Hyer CF. A rertospective
the malalignment. comparative analysis of charcot ankle stabilization
using an intramedullary rod with or without appli-
cation of circular external fixator – utilization of the
RAIN database. J Foot Ankle Surg. 2012;51:420–5.
References 6. Taylor J, Lucas DE, Riley A, Simpson GA, Philbin
TM. Tibiotalocalcaneal arthrodesis nails: a compari-
1. DeVries JG, Philbin TM, Hyer CF. Retrograde intra- son of nails with and without internal compression.
meduallary nail arthrodesis for avascular necrosis of Foot Ankle Int. 2016;37(3):294–9.
the talus. Foot Ankle Int. 2010;31(11):965–72. 7. DeVries JG, Berlet GC, Hyer CF. Predictive risk
2. Bussewitz BJ, DeVries JG, Dujela M, McAlister assessment for major amputation after tibiotalocalca-
JE, Hyer CF, Berlet GC. Retrograde intramedul- neal arthrodesis. Foot Ankle Int. 2013;34(6):846–50.
lary nail with femoral head allograft for large defi- 8. Cuttica DJ, Hyer CF. Femoral head allograft for tib-
cit tibiotalocalcaneal arthrodesis. Foot Ankle Int. iotalocalcaneal fusion using a cup and cone reamer
2014;35(7):706–11. technique. J Foot Ankle Surg. 2011;50(1):126–9.
3. DeVries JG, Nguyen M, Berlet GC, Hyer CF. Effect 9. Hyer CF, Cheney N. Anatomic aspects of tibio-
of recombinant bone morphogenetic protien-2 in revi- talocalcaneal nail arthrodesis. J Foot Ankle Surg.
sion tibitalocalcaneal arthrodesis: utilization of RAIN 2013;52:724–7.
database. J Foot Ankle Surg. 2012;51:462–32. 10. Cuttica DJ, DeVries JG, Hyer CF. Autogenous bone
4. DeVries JG, Berlet GC, Hyer CF. Union rate of tib- graft harvest using reamer irrigator aspirator (RIA)
iotalocalcaneal nails with internal or external bone technique for tibiotalocalcaneal arthrodesis. J Foot
stimulation. Foot Ankle Int. 2012;33(11):969–78. Ankle Surg. 2010;49(6):571–4.
 Cavus Foot Reconstruction
28
Jeffrey E. McAlister, Mark A. Prissel,
Christopher F. Hyer, Gregory C. Berlet,
Terrence M. Philbin, and Patrick E. Bull

28.1 Introduction 28.2 Patient Presentation

Pes cavus deformities have long been known to The cavus deformity differential diagnosis list is
be complicated and require extensive preopera- long and reflects the dynamic and complex nature
tive evaluation, intraoperative surgical acuity, of the condition. A thorough history and physical
and postoperative rehabilitation. The recon- examination are prudent and of the utmost impor-
structive algorithm includes varying combina- tance when working up these patients. Most com-
tions of soft tissue releases, tendon lengthening monly, Charcot-Marie-Tooth disease (CMT),
and transfers, and corrective osteotomies. This cerebral palsy (CP), and other peripheral senso-
is a disease process that evolves with time, and rimotor disorders are involved. Confirming these
patients may present at different stages of the diagnoses will then drive the appropriate proce-
deforming ­process depending on the etiology. dure selection and frequently require additional
Some etiologies are continually progressive, physical medicine and rehabilitation (PM&R)
and this is important to consider when formu- and/or neurology workup prior to surgery. With
lating a corrective plan. Also, some or all of the advancement in genetic testing, early diagnosis
deformity may be rigid which also needs to be in childhood assists with treatment and long-term
appreciated during procedure selection. This prognosis. For instance, soft tissue releases and
chapter aims to cover the full spectrum of cavus tendon transfers are typically utilitarian in child-
reconstruction procedures with technical pearls hood and secondary procedures in adult patients
for each. requiring large osseous correction.
Posttraumatic disease is also a differential
diagnosis that often can be teased out of a
patient’s history and is typically more obvious.
Injuries to the common peroneal nerve at the
knee can develop chronic pes cavus deformities
over time.
J. E. McAlister (*) Each individual case has unique characteris-
Arcadia Orthopedics and Sports Medicine,
tics, but usually they fall into several categories
Phoenix, AZ, USA
of deformity: anterior, posterior, and mixed cavus
M. A. Prissel · C. F. Hyer · G. C. Berlet
[2]. Anterior cavus may be flexible or rigid, and
T. M. Philbin · P. E. Bull
Orthopedic Foot & Ankle Center, the deformity apex is typically at the tarsometa-
Worthington, OH, USA tarsal joints or midfoot. Posterior cavus deformi-

© Springer Nature Switzerland AG 2019 307

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_28
308 J. E. McAlister et al.

Fig. 28.1 A 26-year-old female with a history of Charcot-­ ity and pain. Standing front and rear hindfoot clinical with
Marie-­Tooth. Previous successful right foot surgery gait analysis demonstrates a varus heel, anterior drawer,
included a proximal first metatarsal osteotomy and tibialis and peroneal weakness
anterior tendon transfer. Presents with left ankle instabil-

ties typically have an increased calcaneal pitch of produce an incredibly diverse collection of defor-
greater than 30° from the weight-bearing surface mities, which, in some cases, can include the tib-
of the foot and are hindfoot based with an apex at iotalar joint.
the TN and CC joint level. The mixed type is a A key part of the clinical exam is to assess
combination of both anterior and posterior cavus; the patient’s lower limb both in a weight-bear-
therefore, distinct apexes will be noted in both ing and a non-weight-bearing attitude (Figs. 28.1
regions. There are some common tendon imbal- and 28.2). A thorough gait analysis is also
ances that tend to “drive” most cavus deformities. undertaken. Specific to cavus foot examination,
A “forefoot-driven” cavus results from peroneal both individual manual muscle testing and
tendon imbalance wherein the unopposed pero- assessing the patient’s hindfoot from multiple
neus longus “drives” the first metatarsal in a plan- views while including the Coleman block test
tar direction, thus increasing the varus attitude of are important [1]. The Coleman block test is
the forefoot. This stems from progressive pero- performed by placing a wooden block under the
neus brevis and tibialis anterior tendon weakness lateral forefoot and heel during weight-bearing
so commonly associated with lower extremity (Fig. 28.3). In flexible cavus deformities, the
sensorimotor deficits. The “hindfoot-­ driven” hindfoot will correct to neutral or even slight
deformity results from the unopposed pull of the valgus once weight is applied on the tested foot.
tibialis posterior which locks the transverse-tar- Positioning the forefoot off the edge of a step
sal joint into inversion and the heel into varus. stool while observing the heel from posterior
The Achilles tendon then becomes an additional can also uncover a flexible hindfoot, even in
inverter as its force vector shifts ever more medi- severe deformities. Lastly, for patients that have
ally. Over time, these m ­ uscular imbalances can difficulty standing, a prone passive manual
28 Cavus Foot Reconstruction 309

hindfoot eversion exam can be performed. If, in

any of these scenarios, the calcaneus does not
correct to neutral in the coronal plane, then the
hindfoot is in fixed varus. Equinus is often over-
looked in this patient population, and the
Silfverskiold test is used to identify the source
of contracture. Pseudo-equinus may also be
present and is the result of a decrease in talar
declination leading to early impingement of the
talus on the distal tibia during dorsiflexion.
Assessing the hyperkeratotic lesions on the
plantar aspect of the foot is also important.
These give the surgeon important information
about contact pressures and deforming forces.
For instance, a sub-fifth metatarsal head lesion
is common with forefoot varus deformities. If
any level of neurologic disease exists, it would
be prudent for the surgeon to assess for neuropa-
thy which can be common in patients with cavus
foot deformities.
Digital contractures are typically present as
well, and the surgeon should assess each digit’s
reducibility. Flexible hammertoes will develop
into rigid claw toes over time. Typically, patients
Fig. 28.2 Standing lateral view of a 26-year-old female
demonstrates a left midfoot cavus and proud medial heel complain of metatarsalgia-type pain and have
extensor substitution deformities of the digits.

Fig. 28.3 A Coleman block test is performed in the office non-reducible hindfoot varus deformity. Subsequent proce-
to determine the reducibility of the hindfoot varus by remov- dure choice focused on correcting the hindfoot and forefoot
ing the forefoot component, which, in this case, shows a alignment as well as soft tissue balancing, in that order
310 J. E. McAlister et al.

In addition to foot deformities, ankle deformi- usually greater than 10° of deformity, extrinsic to
ties are also taken into account with cavus recon- the joint, and involves significant instability and
struction. Ligamentous laxity is often noted in insufficiency of the joint’s soft tissue structures.
the cavus foot patient due to either inherent laxity Advanced diagnostic modalities are also
or a history of multiple sprains and is most com- important in the cavus workup [3]. Magnetic
monly appreciated in the lateral ankle ligament resonance imaging (MRI) is utilized to discern
complex. A comprehensive ankle stability exam ligamentous and tendon pathology, as well as
must be performed. Lateral instability is fre- chondral defects of the involved joints.
quently noted, and a stabilization strategy must Computed tomography (CT) can also be utilized
be a part of the cavus reconstruction plan. Options to grade arthritis and may be better than MRI at
for lateral ankle ligament reconstruction are cov- visualizing subchondral cysts. Weight-bearing
ered in more detail in Chap. 38. CT scans can also be performed to assess
Preoperative counseling on expectations and dynamic alignment and to give the surgeon an
procedure choice are crucial. This type of defor- inside look into the pathologic attitude of the
mity will typically lend itself to some intraopera- foot and ankle.
tive decision-making, and the consent should If the patient has a progressive neurologic
reflect as such. condition or if the diagnosis has yet to be made,
nerve conduction velocities (NCVs) and electro-
myographies (EMGs) should be obtained.
28.3 Diagnostics and Imaging Individual muscular testing is a helpful adjunct to
these tests and is useful when attempting to
Preoperative standard weight-bearing foot and decide which tendons are appropriate for transfer.
ankle radiographs are taken along with calcaneal We usually obtain a formal consult with PM&R
axial and Saltzman views. On anteroposterior or neurology in cases of suspected neuropathy or
(AP) foot views, coronal plane deformity is other neurological conditions.
assessed by the amount of talar head coverage as
well as sesamoid position. Transverse plane
deformity on AP foot view will present as fore- 28.4 OR Setup
foot adduction and/or midfoot adduction. The and Instrumentation
calcaneal axial and Saltzman views will be used
to assess calcaneus position. A lateral foot view is These cases are typically outpatient procedures
important in assessing the apex of each deformity booked for a 1-hour to 2-hour time slot.
with close attention paid to the medial column Depending on the individual case’s surgical plan
and calcaneal pitch. complexity, special equipment needs, and patient
AP and mortise ankle views are also important comorbidities, the case may also be admitted
to discern if the deformity is isolated to the foot overnight for a 23-hour observation stay. The
or if it extends to the tibiotalar joint. Additionally, authors prefer a preoperative popliteal/saphenous
arthritic changes of involved segments should be nerve block with general anesthesia. The excep-
noted, as this is relevant to both the “reducibility” tion would be for the patient who has had com-
of the deformity and corrective procedure mon peroneal nerve trauma in which case we
­selection. Rigid arthritic segments may warrant prefer to not disturb the nerve.
use of selective arthrodeses for corrective pur- A supine position is most common unless
poses. Ankle varus malalignment may be congru- extensive lateral ankle and calcaneal osteotomy
ent or incongruent. Congruent varus is usually procedures are performed. In these cases, the
less than 10° of deformity and is intrinsic to the authors will utilize a lateral to supine approach,
joint, with the deformity most often being starting lateral and converting to supine. A thigh
“driven” by bone deformity. Incongruent varus is tourniquet is applied to the ipsilateral thigh and
28 Cavus Foot Reconstruction 311

set to 300 mmHg. A mini intraoperative fluoros- Secondary Procedures

copy unit is most commonly used during these
procedures and is positioned on the same side as • Midfoot fusion (Cole): large cannulated
the operative limb. Our typical surgical recon- screws (5.0, 6.5 mm) or compression plates
struction plan begins with proximal procedures • Tibial osteotomies: large cannulated screws
and progresses distally. (6.5, 7.0, 7.3 mm), plates
Preoperative briefing with the operating room • Hindfoot fusion: large cannulated screws
team involves discussions regarding instrumenta- (4.5/5.0 for TN, CC: 6.5, 7.0, 7.3 mm for STJ),
tion. It warrants restating that cavus foot recon- supplemental fixation with staple or compres-
struction is dynamic and lends itself to sion plate
intraoperative decision-making; therefore, over-­ • Split tibialis anterior tendon transfer or poste-
preparation, a “team” culture, and open commu- rior tibial tendon transfer through interosse-
nication are critical to remaining efficient and ous membrane: interference screw (PEEK,
safe throughout the case. The most common 5.0 or 6.0), soft tissue anchor of choice (see
instrumentation requested includes two cordless Chap. 31)
power drivers and a TPS electric sagittal saw with • Hallux IPJ fusion and Jones tenosuspension:
both short and long saw blade options such as the small cannulated screws (3.0, 3.5 mm), inter-
S5 and the 515. ference screw, and/or soft tissue anchor of
Hardware selection is based on procedure choice (see Chap. 4)
choice, and a myriad of excellent options exist in • Hammertoe/claw toe correction: surgeon pref-
the modern market. With efficiency in mind, erence of PIPJ intraosseous implant or 0.062”
choosing a vendor that carries implants able to K-wires or in cases of neuropathic claw toes
cover most, if not all, of the planned procedures (cannulated 2.5 headless compression screws
is ideal. Listed below, with care to avoid industry (see Chap. 5))
bias, are the most common implants utilized dur-
ing cavus reconstruction procedures.
28.5 Operative Technique
Primary Procedures
Not all procedures are performed for every
• Dwyer calcaneal osteotomy with or without case. A surgical plan should be created and
lateral translational slide: large cannulated mentally rehearsed once a surgical strategy has
screws (6.5, 7.0, 7.3 mm, or, in some cases, been finalized. Again, the most common proce-
5.0 screws) dures performed are, in sequence, gastrocne-
• Dorsiflexion closing wedge first metatarsal mius recession, lateralizing calcaneal
osteotomy: small cannulated screws (3.5, osteotomy with or without closing wedge,
4.0 mm), nitinol staple, small compression plantar fascia release, dorsiflexion proximal
plate—all are options first metatarsal osteotomy, peroneal “switch,”
• Lateral ankle ligament reconstruction and lateral ankle ligament reconstruction.
(Brostrom): small anchors if needed per sur- Secondary procedures, described in other
geon preference (see Chap. 38) chapters as notated, include hindfoot fusion
• Allograft tendon or synthetic alternatives for (Chaps. 20, 21, 22, and 23), midfoot fusion
extra-articular ligament reconstructions (mod- (Cole), Jones tenosuspension and hallux IPJ
ified Watson-Jones- or Chrisman-Snook-type fusion (Chap. 4), claw toe correction (Chap. 5),
procedures): gracilis or peroneus longus deep tendon transfers (Chap. 31), primary and
allograft, synthetic “strips” revision lateral ankle reconstruction (Chap.
• Peroneal tendon repair: absorbable and non- 38), and peroneal tendon transfers and repair
absorbable sutures (Chap. 29) (Figs. 28.4 and 28.5).
312 J. E. McAlister et al.

ate subdermal tissue. Blunt or finger dissection to

the crural fascia is effective and avoids damaging
the sural nerve and/or lesser saphenous vein. At
this point, an army-navy retractor is utilized
medially and laterally to help visualize the fascia.
The fascia is sharply opened in line with the inci-
sion, and the aponeurosis is inspected. Cadaver
studies have shown the sural nerve to be deep to
this fascial layer in up to 58% of specimens and
adhered to the gastrocnemius in 15%; therefore,
always anticipate the nerve, and take care to pro-
tect it (Pinney, FAI, [8]). Blunt digital dissection
is used so one can clearly see the myotendinous
junction and the medial and lateral tendon bor-
ders. The aponeurosis is transected in a trans-
Fig. 28.4 Incisions can be seen here for an endoscopic
gastrocnemius recession, split tibialis anterior tendon
verse cut with the knee extended. One should
transfer, and proximal first metatarsal osteotomy. Care is immediately visualize the soleus muscle deep to
taken to avoid the medial dorsal cutaneous nerve the aponeurosis as the gastrocnemius separates.
Intraoperative Silfverskiold assessment is then
performed to confirm adequate release. Attaining
approximately 10° of ankle dorsiflexion with the
knee extended is the goal. If additional dorsiflex-
ion is needed, consider transecting the soleus ten-
don at the same level and then repeating the
Silfverskiold exam. Closure is performed in a
layered fashion.
Surgical pearl: If the patient is in a supine
position, a straight medial incision can be per-
formed, which may reduce the possibility of
injury to the sural and sural cutaneous nerves.

Fig. 28.5 Incision placement for concomitant proce- 28.5.2 Plantar Fascia Release
dures: split tibialis anterior transfer, lateralizing calcaneal
osteotomy, Brostrom lateral ankle reconstruction, pero- Cavus deformities typically involve contracted
neus longus to brevis transfer
ligaments including the plantar fascia. Multiple
approaches to the plantar fascia release have been
28.5.1 Gastrocnemius Recession described. The authors typically prefer a trans-
verse linear incision along the plantar aspect of
Per the surgeon, either an open or endoscopic the foot, just distal to the weight-bearing heel pad
technique can be used. For an open gastrocne- which facilitates a plantar fascial band “instep”
mius recession, a 2.5 cm incision on the posterior release (see Chap. 30). The incision is carried
leg, just distal to the gastrocnemius muscle belly, down through subcutaneous tissue to the level of
and slightly medial to the midline, is made. With the plantar fascia. The medial fascial band is eas-
the patient in a lateral position, a single operating ily identified. To tension the fascia, the windlass
surgeon can easily perform this procedure. Sharp mechanism is activated, after which the medial
dissection is only necessary for skin and immedi- band is transected transversely. The flexor
28 Cavus Foot Reconstruction 313

h­ allucis brevis muscle belly is visualized as the Hohmann retractors are placed. The Hohmann
plantar fascia is lengthened. The incision is then retractors can serve to guide both the sagittal and
irrigated and closed with absorbable sutures. coronal osteotomy cut angles. Prior to making
Surgical pearl: The authors typically excise a the osteotomy, a c-arm view should be taken to
0.5–1 cm section of the planter fascia from confirm the osteotomy angle while using the
medial to lateral to help prevent recurrence of Hohmann as a reference. A small bump is placed
medial band contracture. underneath the medial ankle to elevate the foot
off the bed. The hindfoot is held with the non-­
dominant hand, and the calcaneal body is posi-
28.5.3 Lateralizing Calcaneal tioned parallel to the floor. The saw blade is then
Osteotomy With or Without oriented in line with the Hohmann retractors and
Wedge at 90° to the calcaneal body. The heel is held with
the non-dominant hand while the osteotomy is
Studies have shown that the most powerful calca- performed to get tactile feedback during cutting
neal osteotomy for cavus correction is a lateral- and to avoid saw blade overpenetration. One can
izing calcaneal osteotomy. In one particular easily feel the saw blade hitting the medial cortex
study, a 5–10 mm lateral calcaneus shift resulted and either carefully fenestrate through or choose
in a 2 and 3 mm shift in force distribution and stop short of completion and then complete with
41% and 49% reduction in peak pressure at the an osteotome. A straight 1 inch osteotome is then
ankle, respectively (Schmid) [5]. We will often used to confirm osteotomy completion and to
utilize a wedge resection with a lateral base, a carefully perforate the medial periosteum to
true Dwyer osteotomy [6], when significant cal- improve posterior fragment mobility. A smooth
caneal varus is present. In these cases, the lateral lamina spreader is inserted into the osteotomy
shift is also still performed. A lateral calcaneal and opened, which allows the medial periosteum
shift not only converts the Achilles force vector to attenuate. This maneuver also facilitates easier
from inversion to eversion but also reduces calca- translation of the capital fragment. The goal is to
neal inclination. translate the osteotomy laterally. If a closing
Preference is for the patient to be in the lateral wedge is desired, a converging osteotomy is
decubitus position, as it allows for better visual- begun 1 cm distal and directed so as to terminate
ization, easier control of the osteotomy, and at least three quarters the way across. The frag-
unencumbered placement of osteotomy fixation. ment is removed and osteotomy reduction is con-
An oblique incision 1 cm posterior to the fibula firmed manually. With the laminar spreader back
and 45° to the long axis of the calcaneus is made. in the osteotomy and distracted, guidewires for
This incision is carried down through subcutane- large cannulated screws are inserted from the
ous layers taking care to avoid the highly variable posterior tuber and across the osteotomy.
sural nerve. The incision is parallel to the pero- Guidewires are placed midline in the tuber as the
neal tendons which are not typically visualized heel will be shifted laterally. Visually confirm
during this procedure. Surgical pearl: If both a guidewire position in the center of the tuber, and
lateral ankle ligament reconstruction and a lateral drive them across the osteotomy after it has been
calcaneal osteotomy are to be performed, mark successfully translated and reduced. Confirm
out each incision preoperatively, and maximize your osteotomy reduction and guidewire position
the skin bridge to avoid postoperative skin necro- with intraoperative fluoroscopy. Screws are then
sis. Dissection is carried down to the lateral cal- measured, drilled, and inserted using standard
caneal wall, and the periosteum is elevated at the technique. Calcaneal axial views are typically
level of the osteotomy using either a Key or Cobb taken to assess fixation placement and degree of
elevator. Dissection is extended with an elevator correction. A layered closure is then performed
to the dorsal and planter osteotomy margins, and per surgeon preference (Fig. 28.6).
314 J. E. McAlister et al.

a b

Fig. 28.6 (a) Beginning with the most proximal osseous may be inserted at this time to confirm screw placement in
procedure, lateralizing calcaneal osteotomy, a small 3 cm the center of the tuber. (b) The author’s preferred tech-
incision is made on the lateral aspect of the calcaneus. nique is to lateralize the calcaneal proximal fragment and
After the osteotomy has been performed, a lamina fixate with screws or staples, as seen here. One can also
spreader is inserted to clear the periosteum from the shift the calcaneal tuber proximal as well as lateral to
medial calcaneal wall. Guidewires or provisional fixation decrease the calcaneal pitch

28.5.4 M
 alerba Calcaneal Z 28.5.5 D
 orsiflexory First Metatarsal
Osteotomy Osteotomy

An alternate, but powerful, approach to the cal- A forefoot-driven cavus foot will have a severely
caneal osteotomy in the cavus foot is the plantarflexed medial column, and this is typically
Malerba Z. This osteotomy employs several of “driven” by unopposed peroneus longus medi-
the same above principles to achieve correction ated plantar flexion of the first metatarsal. In the
while allowing for increased stability of the case of a flexible deformity, correction with a first
osteotomy and more aggressive correction. A metatarsal joint preserving dorsiflexion wedge
similar oblique lateral incision is utilized, with osteotomy is indicated and preferred.
slight distal extension of the inferior aspect. The osteotomy incision is placed parallel to
Caution is taken to avoid and protect the sural the extensor hallucis longus tendon from the first
nerve. Lateral translation greater than 10 mm metatarsal base to the mid-shaft. Careful subcuta-
can be achieved, and a lateral-based wedge of neous dissection medial to the tendon will avoid
the horizontal arm is removed, to correct for medial dorsal cutaneous nerve injury. The exten-
calcaneal varus. If required, shortening of the sor tendon is mobilized laterally and retracted,
lateral column can be achieved by removing thus exposing the osteotomy site. The angle of
bone from the perpendicular/vertical arms of osteotomy is selected based on degree of correc-
the osteotomy. The Z has a long horizontal arm tion needed, surgeon preference, and preference
that affords a broad osseous surface for predict- of fixation. Vertical osteotomies lend themselves
able healing and is stable to weight-bearing. well to fixation with staples and/or plates. An
The perpendicular arms extend posterior supe- oblique closing wedge osteotomy directed from
rior and anterior inferior at 90° angles from the dorsal distal to plantar proximal is preferred
horizontal cut. Fixation is typically maintained when using screw fixation. The osteotomy is typ-
with two 5.0–6.5 mm cannulated screws ically performed by making proximal cut approx-
(Fig. 28.7). imately 1–1.5 cm distal and parallel to the first
28 Cavus Foot Reconstruction 315

a b

c d e

Fig. 28.7 (a) Incisional location for Malerba osteotomy. horizontal markings which create the lateral-based wedge.
Note slightly distal curvature of the inferior aspect. (c) Completed osteotomy prior to mobilization and dis-
Additional parallel incision is for Brostrom-Gould proce- placement. (d) Distraction and mobilization of the oste-
dure, maintaining appropriate skin bridge and avoiding otomy with resection of the horizontal wedge. (e)
the expected course of the sural nerve. (b) Dissected lat- Completed osteotomy with visible osseous lateral dis-
eral wall of the calcaneus with osteotomy planned and placement and compression across the osteotomy site cor-
marked out with electrocautery. Note the two parallel recting the cavovarus deformity in multiple planes

tarsometatarsal joint. The second cut is made based closing wedge. This option is useful if
approximately 2–3 mm distal and angled to con- additional intermetatarsal malalignment needs to
verge on the plantar aspect of the proximal cut. It be corrected. Completing the osteotomy medially
is critical to maintain the plantar cortex when and laterally while leaving the plantar cortex
making the osteotomy. Inadvertent osteotomy intact will typically be enough to allow osteot-
completion will destabilize the metatarsal and omy reduction manually. Use fluoroscopy to con-
warrant more extensive internal fixation. firm that Meary’s angle is reduced, then proceed
Alternatively, the initial osteotomy can be made to osteotomy fixation. The authors’ preferred
like a Mau bunionectomy cut (Chap. 2), and a technique is a small dorsal locking compression
second cut is used to make a long, thin, dorsally plate or staples for the traditional vertical closing
316 J. E. McAlister et al.

a b

Fig. 28.8 (a) A proximal first metatarsal closing wedge applying a plantar forefoot load. This will close the oste-
is then created about the guidewire. A 2–3 mm wedge is otomy and fixation can be performed by a staple, screw, or
resected. The size of the wedge will vary depending on the plate. The key is to maintain a plantar cortical bridge
case. (b) The proximal closing dorsal wedge is closed by

wedge cut and 2 × 3.0 cannulated screws for the in a full-thickness flap. After subcutaneous dis-
Mau-type oblique closing wedge. Confirmation section, the surgeon should be able to easily visu-
of fixation placement and correction is performed alize the entire navicular cuneiform joint and
via fluoroscopy. The incision is then closed in dorsal cuboid [4].
layers taking care to avoid tethering of the exten- Next, two Steinmann pins are driven from the
sor tendon (Fig. 28.8). dorsal navicular and the intermediate cuneiform
to the plantar aspect of this joint.
Surgical pearl: The Steinman pins will be
28.6 Secondary Procedures 1–2 mm proximal to the joint and 2–4 mm distal
to the joint. Pin placement is then confirmed on
28.6.1 M
 idfoot Fusion (Cole fluoroscopy and adjusted as needed. A large
Osteotomy) sagittal saw is then used to resect a dorsally
based wedge while following the pins. Care is
In a mixed cavus deformity with the apex of the taken to excise the appropriate amount from the
deformity at the midfoot and the foot is rigid, a mid-­cuboid; otherwise the surgeon will create a
midfoot corrective osteotomy is best utilized for varus foot type by asymmetrically shortening
acute correction. This is often combined with only the medial column. Once the wedge has
other osseous procedures to reduce forefoot pres- been removed, the Steinmann pins are removed
sure and reduce the apex of deformity in the sag- and the osteotomy is reduced. Typically this
ittal plane. correction is realized in the sagittal plane and
A central midfoot incision is centered over the serves to dorsiflex the forefoot. In some cases
naviculocuneiform (NC) joint. This 5 cm incision with significant forefoot adduction, this wedge
is made over the extensor digitorum longus, and can be made “biplanar” with a wider wedge lat-
dissection is carried down through the extensor erally than medially for added, double apex,
hallucis brevis. The brevis is tenotomized and correction.
mobilized laterally. The periosteum is elevated, Fixation is important with this osteotomy.
and the anterior neurovascular bundle is ­protected This is a large and broad osteotomy, but there is a
28 Cavus Foot Reconstruction 317

fair amount of healthy cancellous bone apposi- 28.6.1.1  edial Double and Triple
M
tion. The authors prefer multiple large cannulated Arthrodesis
screws for fixation. Supplemental dorsally based These procedures are utilized when correcting
compression staples are also useful although not rigid and/or arthritic cavus foot deformities that
strong enough as the sole fixation option. The have a hindfoot apex. These are described earlier
central and medial columns are reduced, and in the text, Chaps. 20 and 23, respectively.
guidewires are inserted from the proximal medial
pole of the navicular into the cuneiforms. From 28.6.1.2  plit Tibialis Anterior Tendon
S
distal to proximal, two screws are inserted from Transfer
the medial and lateral cuneiforms into the navicu- This secondary procedure is performed with a
lar. Once reduction and fixation placement are subtle anterior cavus deformity with concomitant
fluoroscopically confirmed, the incision is closed lateral ankle instability. See Chap. 31 for further
in layers. information (Fig. 28.9).

a b

Fig. 28.9 (a) The insertion of the tibialis anterior is dis- functional muscle grade. (e) The splint tibialis anterior
sected free and isolated. (b) A proximal incision about tendon transfer is performed next by drilling a pilot hole
4–6 cm from the tibiotalar joint is made just lateral to the into the lateral cuneiform. Confirm placement of drill hole
tibial crest. Dissection down through the anterior crural with intraoperative fluoroscopy. (f) A tendon suture passer
fascia reveals the tibialis anterior. An umbilical tape is is used to transfer the lateral half of the tibialis anterior
used to split the tendon proximally and brought into the from the proximal incision to the distal midfoot incision.
distal medial incision through the tendon sheath. (c) The Again, the authors prefer a subcutaneous method and have
umbilical tape can be seen here splitting the tibialis ante- not seen previously observed skin tenting or necrosis. A
rior lateral strands. One can also visualize a guidewire in sub-retinacular passing can be considered at surgeon dis-
the proximal first metatarsal, about 10–12 mm distal to the cretion. (g) The tibialis tendon is then inserted in to the
first tarsometatarsal joint. (d) After the lateral half of the lateral cuneiform with the foot held in at neutral. It is
tibialis anterior is brought through the proximal incision, important that all osteotomies are completed and posterior
the length is then confirmed. The authors prefer a subcuta- muscular recessions/lengthenings are performed prior to
neous transfer when possible, so as not to lose another setting the tendon transfer(s)
318 J. E. McAlister et al.

e f

Fig. 28.9 (continued)

28.6.1.4 Peroneal “Switch” (Transfer)

Quite often, the cavus foot will have associated
pathology of one, or both, of the peroneal tendons.
Surgical reconstruction may include any one of the
following procedures: simple synovectomies and
tenolysis, direct repairs of the brevis and/or longus,
peroneal repairs with graft augmentation, peroneus
longus to brevis transfer, and peroneal tenodesis.
The peroneal longus to brevis tenodesis is useful as
it reduces the longus’ forefoot cavus producing
force while simultaneously increasing to reciprocal
everting brevis force. The full scope of peroneal
tendon surgery is covered in Chap. 29 (Fig. 28.11).
Fig. 28.10 Next, a lateral ankle stabilization is performed
with anchors in the anterior distal fibula. Keys are to avoid
28.6.1.5  osterior Tibial Tendon
P
large incisions and maintain ankle neutral position
Transfer
This secondary procedure is commonly per-
28.6.1.3  rimary and Revision Lateral
P formed in patients with drop foot and significant
Ankle Reconstruction midfoot inversion. One of the main deforming
This secondary procedure is commonly per- forces in these patients is an unopposed posterior
formed secondary to chronic ligamentous laxity tibial tendon. In conjunction with a posterior tib-
exacerbated by the ankle and hindfoot deformi- ial tendon transfer, usually a talonavicular joint
ties. These procedures are covered in-depth in capsulotomy is concomitantly performed which
Chap. 38 (Fig. 28.10). allows for the midfoot to unlock and pronate.
28 Cavus Foot Reconstruction 319

a b

Fig. 28.11 (a) A peroneus longus to brevis transfer can ered. (b) A small anchor is utilized in the base of the fifth
be performed at this time. Authors’ preferred technique is metatarsal. One may also consider a drill hole and looping
to transfer the peroneus longus in to the base of the fifth the tendon through. A small anchor should be utilized so as
metatarsal. Alternately, a side-to-side tenodesis/transfer of not to cause an iatrogenic fracture. (c) Peroneus longus to
the longus to brevis at the retrofibular level can be consid- fifth metatarsal base tendon transfer with peroneal switch

This can be done through the same incision. This tar pressure overload at the distal hallux and
is described in Chap. 31. sub-first metatarsal head. These procedures are
often combined with other cavus balancing pro-
28.6.1.6 Claw Toe Correction cedures including instep PF release, DF first
This secondary correction is typically performed metatarsal osteotomy, and Achilles lengthening
at the end of the procedure and is further described or GSR. The hallux IPJ fusion and Jones EHL
in Chap. 5. In neurogenic deformities, a combi- transfer are further described in Chap. 4.
nation balancing procedure including digital
flexor tenotomy, MTP capsulotomy with exten-
sor tendon lengthening, and PIPJ and DIPJ fusion 28.7 Surgical Goals
is often performed to provide stability and lon-
gevity to the correction. In many cases the toe As stated throughout the above sections, numer-
correction is scheduled for a different surgical ous (sometimes overlapping) procedural options
procedure in the spirit of managing operative exist as part of the surgeon’s armamentarium. The
risks and anesthetic risk. success of the patient outcomes in cavus foot sur-
gery is directly related to the surgeon accurately
28.6.1.7  allux IPJ Fusion and Jones
H diagnosing the various deformities present within
Tenosuspension the cavus foot and ankle and selecting the correct
This procedure is utilized to correct a hallux con- combination of procedures to execute (Figs. 28.12,
tracture, stabilize the first MTP, and reduce plan- 28.13, 28.14, 28.15, 28.16, and 28.17).
320 J. E. McAlister et al.

Weight-bearing

Weight-bearing

a b

Fig. 28.12 (a) Lateral and (b) AP preoperative radiographs with an increased calcaneal pitch, increased coverage of
the talar head, and forefoot adduction

a b Weight-bearing

Weight-bearing

Fig. 28.13 (a) Lateral and (b) AP 6 months postoperative radiographs demonstrating a corrected hindfoot and first
metatarsal with healed osteotomies
28 Cavus Foot Reconstruction 321

Lossy compression 20:1

28.8 Postoperative Protocol

A standard postoperative compressive bulky

Jones dressing with a posterior splint and sugar-
tong are applied. Integrated cold therapy is
added per surgeon preference. Generally,
patients are seen 1–2 weeks postoperatively
and placed into a short leg non-weight-bearing
cast. Sutures are removed when the incisions
have healed, and the patient is placed into a
weight-bearing cast at 4–6 weeks depending on
healing. Patients are transitioned into a CAM
walker boot at 8 weeks. Serial radiographs are
used to confirm osteotomy healing. Physical
therapy begins at 8–10 weeks and continues
until the patient can comfortably bear weight in
a supportive shoe with an accommodative cus-
tom fabricated orthoses. The remainder of the
Weight-bearing
postoperative course is described in detail in
Chap. 1.
Fig. 28.14 A postoperative calcaneal axial view demon-
strating a lateral tuber shift of at least 6 mm with dual
stepped staple fixation

a b

Fig. 28.15 (a) Lateral and (b) AP preoperative radiographs with an increased calcaneal pitch, increased coverage of
the talar head, and forefoot adduction
322 J. E. McAlister et al.

a b

Fig. 28.16 (a) Lateral and (b) AP 1 year postoperative izing calcaneal osteotomy is laterally translated and varus
radiographs demonstrating a corrected hindfoot and first derotated removing a lateral-based wedge from the hori-
metatarsal with healed osteotomies. The Malerba lateral- zontal arm

Pearls and Pitfalls and Resident Resource mended to carefully evaluate the deformity
• Cavus foot reconstruction requires a thor- and to identify each deformity apex [7].
ough preoperative workup paying close • In severe cases, consider staging forefoot
attention to neuromuscular function and procedures at a later date to allow the foot
contracture, deformity flexibility, and pres- to rebalance and heal.
ence of joint arthritis. • The goal is control of a difficult deformity
• The cavus foot can present with varying and not a onetime cure. It is common to
degrees of deformity and in multiple have to address residual or recurrent defor-
planes. Comprehensive imaging is recom- mity later in the patient’s life.
28 Cavus Foot Reconstruction 323

a b

Fig. 28.17 (a) Preoperative and (b) 1 year postoperative rection of the foot deformity is visualized without the
hindfoot alignment views of patient in Fig. 28.15. Note requirement for tibial/fibular osteotomies. Additional soft
the neutral position of the calcaneal tuber relative to the tissue procedures included peroneus longus to peroneus
tibial axis when appropriately combined with the dorsi- brevis transfer, Brostrom-Gould lateral ankle stabiliza-
flexion first metatarsal osteotomy. Also, improvement in tion, endoscopic gastrocnemius recession, and partial
the preoperative posterior rotation of the fibula with cor- plantar fascial release

References 5. Schmid T, Zurbriggen S, Zderic I, Gueorguiev B,

Weber M, Krause FG. Ankle joint pressure changes
in a pes cavovarus model: supramalleolar valgus oste-
1. Coleman SS, Chestnut WJ. A simple test for hindfoot
otomy versus lateralizing calcaneal osteotomy. Foot
flexibility in the cavovarus foot. Clin Orthop Relat
Ankle Int. 2013;34(9):1190–7.
Res. 1977;123:60–2.
6. Dwyer FC. Osteotomy of the calcaneum for pes cavus.
2. Perera A, Guha A. Clinical and radiographic evidence
J Bone Joint Surg Br. 1959;41:80–6.
of the cavus foot: surgical implications. Foot Ankle
7. DeVries JG, McAlister JE. Corrective osteotomies
Clin. 2013;18(4):619–28.
used in cavus reconstruction. Clin Podiatr Med Surg.
3. Gould N. Surgery in advanced Charcot-Marie-Tooth
2015;32:375.
disease. Foot Ankle. 1984;4:267–73.
8. Pinney SJ, Sangeorzan BJ, Hansen ST. Surgical anat-
4. Cole WH. The classic. The treatment of claw-foot.
omy of the gastrocnemius recession (Strayer proce-
By Wallace H. Cole. 1940. Clin Orthop Relat Res.
dure). Foot Ankle Int. 2004;25(4):247–50.
1983;181:3–6.
 Surgical Treatment of Peroneal
Tendon Disorders
29
Terrence M. Philbin, B. Collier Watson,
and Christopher F. Hyer

29.1 Case Presentation 29.2 Patient History and Findings

• A 43-year-old female presented to the clinic • Peroneal tendon disorders are a common
with left posterolateral ankle after landing cause of posterolateral ankle pain.
awkwardly on the ankle when she missed the • Patients typically describe pain behind the dis-
bottom step while coming down a flight of tal fibula along the retromalleolar groove,
stairs. swelling about the lateral aspect of the ankle,
• On exam, she had pain and swelling along the soreness after activity, and weakness with
peroneal tendon sheath, pain with resisted eversion.
inversion and eversion. • Tears are often overlooked by referring clini-
• Radiographs of the ankle were normal. cians due to their unfamiliarity with this
• Initially, she was treated weight-bearing to pathology as a cause of chronic lateral ankle
tolerance in a walker boot along with rest and pain.
NSAIDs; she was progressed to a lace-up • On exam, patients will have swelling and pain
brace and physical therapy 4 weeks after the to palpation along the peroneal tendon sheath
injury; therapy lasted for 8 weeks; however, particularly at the retromalleolar groove and
her symptoms did not improve. tip of the distal fibula.
• MRI was ordered and showed a tear of the • There may be weakness and/or pain with
peroneal brevis tendon as well as resisted eversion of the foot.
tenosynovitis. • Instability or snapping of the tendons around
• At this point, surgical options were discussed, the tip of the distal fibula may be noted with
and she elected to proceed with repair. circumduction motion of the ankle or resisted
• She was doing well at her 6-month post-op dorsiflexion/eversion of the ankle.
visit; she was back to all activities without any –– Instability of the tendons is likely due to
limitations. attenuation or tearing of the superior exten-
sor retinaculum (SPR).
• Assessing hindfoot alignment is also important.
Increased stress across the peroneal tendons is
T. M. Philbin · C. F. Hyer noted in patients with hindfoot varus deformi-
Orthopedic Foot & Ankle Center, ties. If this is the case, the hindfoot varus should
Worthington, OH, USA
be corrected at time of surgery as well.
B. C. Watson (*)
The Hughston Clinic, Columbus, GA, USA

© Springer Nature Switzerland AG 2019 325

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_29
326 T. M. Philbin et al.

29.3 Imaging and Diagnostic (b) In the full lateral position, the nonoperative
Studies leg is placed anterior to the operative leg.
Soft pads are placed beneath the fibular
• We recommend weight-bearing radiographs head at the knee as well as beneath the lat-
of the foot and ankle. eral malleolus to protect the common and
–– On the ankle X-rays, look for a “fleck sign” at superficial peroneal nerves. A blanket is
the distal fibula which could represent avul- placed between the legs at the level of the
sion of the superior extensor retinaculum. knee. A stack of blankets is placed beneath
–– An os peroneum can be found on foot the sterile field at the level of the operative
X-rays and is most commonly located foot. If blankets are not use, then a stack of
within the peroneal longus tendon. This can sterile towels can be placed under the oper-
contribute to tearing the longus tendon. ative foot within the sterile field.
• Magnetic resonance imaging (MRI) is com- (c) A well-padded thigh tourniquet is placed.
monly obtained to confirm peroneal tendon C. Approach
pathology and fluid within the tendon sheath. (a) Using a 15-blade knife, a longitudinal
It can identify fluid within an os peroneum if incision is made along the course of the
present, which can be a source of pain as well. peroneal tendons. We begin the incision
The MRI can also identify any other associ- 2–3 cm proximal to tip of fibula and
ated pathology of the ankle (Fig. 29.1a–e). extend it 4–5 cm distal to the tip of the
• Ultrasound can be used to identify peroneal fibula (Fig. 29.2).
tendon pathology; however, it is not com- (b) A Bovie is used for hemostasis in the
monly used in our practice. subcutaneous tissues.
–– We prefer MRI since it can identify other (c) A Weitlaner retractor is used to protect
pathologies about the ankle. the skin.
(d) Palpate the tip peroneal tendon sheath
right at the posterior aspect of the tip of
29.4 Surgical Management the distal fibula (Fig. 29.3).
(e) Make a small 1 cm incision along the
A. Preop Planning tendon sheath to identify the peroneal
(a) Review radiographs to assess for any tendons (Fig. 29.4).
malalignment, fractures, or degenerative ◦◦ Making this small incision in the
changes. sheath confirms that you are in the
(b) Use the MRI images to determine exact correction location and are not too
location of pathology and plan incisions anterior or to posterior.
accordingly. (f) Once the tendons are identified, extend
(c) Look for any incisions or scaring around the incision within the sheath distally
the lateral side of the ankle from prior about 4 cm from the tip of the fibula.
surgeries or injuries. ◦◦ The inferior peroneal retinaculum
B. Positioning and Equipment may need to be incised to gain further
(a) We prefer the patient to be placed in the access to the peroneal longus tendon.
full lateral decubitus position on a bean- (g) We slide a Freer elevator underneath the
bag with the operative extremity up. SPR to assess for any attenuation of the
◦◦ Alternatively, the patient can be placed SPR that may result in peroneal tendon
in the supine position with a large instability or subluxation (Fig. 29.5).
bump placed beneath the ipsilateral ◦◦ If the Freer elevator can easily slide
hip to help internally rotate the leg for over the anterior half of the distal
better exposure of the peroneal ten- fibula, then we typically perform an
dons. The bump can be a large bag of SPR repair to imbricate the tissue and
saline or rolled up blankets. prevent any tendon instability.
29 Surgical Treatment of Peroneal Tendon Disorders 327

(h) A Ragnell retractor is used to pull each knife. We also excise any low-lying
tendon into the wound for close inspec- peroneal tendon muscle belly that
tion for any pathology (Fig. 29.6). could cause impingement and crowd-
(i) The hypertrophic and/or inflamed tis- ing within the sheath at the retromalle-
sue encompassing the tendon is olar groove.
debrided with tenotomy scissors, ◦◦ The tendon can now be further
Metzenbaum scissors, or a 15-blade inspected for any tears.

a b

c d

Fig. 29.1 (a–b) T2-weighted sagittal MRI demonstrat- distal fibula. Notice the oval shape of the intact peroneal
ing a peroneal brevis tendon tear just distal to the tip of the longus tendon. (d) Signal change noted within the pero-
distal fibula. Notice the intact peroneal longus tendon. neal brevis tendon at the tip of the distal fibula. (e) Just
(c–d) T2-weighted axial MRI images demonstrating a tear distal to the tip of the fibula, more extensive signal change
in the peroneal brevis tendon. (c) Flattening of the pero- is noted within the peroneal brevis tendon representing a
neal brevis tendon adjacent to the posterior aspect of the tear of the tendon
328 T. M. Philbin et al.

Fig. 29.1 (continued)

Fig. 29.2 A curvilinear incision is made over the distal Fig. 29.4 A small incision is made in the peroneal tendon
fibula sheath to identify the tendons prior to opening up the
entire sheath

(l) If more than 50% of the tendon is

debride, then the tendon is tenodesed to
the other peroneal tendon, assuming that
tendon is healthy also.
(m) If both tendons are not salvageable, then
we have to consider tendon reconstruc-
tion using either a tendon transfer or
allograft.
D. Tenolysis
Fig. 29.3 The peroneal tendon sheath is exposed
(a) Have the assistant pull each tendon out of
the incision using a Ragnell retractor.
(j) Once a tear is identified, a 15-blade knife This allows the surgeon to fully inspect
is used to debride/excise the tear. each tendon.
(k) If 50% of healthy tendon remains after (b) With the assistant retracting each tendon
debridement, the tendon is repaired. out of the wound, it is easier to debride
29 Surgical Treatment of Peroneal Tendon Disorders 329

Fig. 29.5 A Freer elevator is placed underneath the supe-

rior peroneal retinaculum (SPR)

Fig. 29.7 Longitudinal split tear in the peroneal brevis

tendon. Notice the hypertrophy of the tendon

thus that torn segment of tendon is

excised (and at least 50% of healthy ten-
don remains), we repair the tendon by
tubularizing it with a running 3-0
Fig. 29.6 Each peroneal tendon is pulled into the wound
with a Ragnell retractor to assess for any pathology. In this
Monocryl suture (Figs. 29.7, 29.8, and
picture, the peroneal brevis has a low-lying muscle belly 29.9).
1. We recommend placing a ½ inch
malleable retractor underneath the
each tendon with either tenotomy or tendon at the level of the tear which
Metzenbaum scissors removing the hyper- stabilizes the tendon and makes it
trophic and inflamed tissue (Fig. 29.6). easier to repair.
(c) If a low-lying muscle belly is present, we ◦◦ If the torn segment of tendon is not
excise it with a 15-blade knife to prevent excised and a split remains in the cen-
crowding of the tendon sheath at the ret- tral portion of the tendon, we use a 2-0
romalleolar groove. Vicryl suture to run a buried core
E. Peroneal Tendon Repair stitch, which allows the central por-
(a) Options that can be performed for the tion of the tendon to come together.
repair: 1. Next, we tubularize the tendon using
◦◦ If the torn segment of the tendon does not a running 3-0 Monocryl suture to
appear healthy enough for repair and is finish the repair.
330 T. M. Philbin et al.

Fig. 29.8 The peroneal brevis split tear has been debrided Fig. 29.9 Peroneal brevis tendon repair and tubularized
with over 50% of healthy tendon remaining with 3-0 Monocryl

◦◦ For cases in which the tear within the 0-Vicryl stitches in a pants-over-
tendon extends proximally underneath vest fashion. Begin the pants-­over-­
the SPR, the SPR has to be opened up vest stitch on the distal fibula so as
to complete the repair. to not allow for any tendon sublux-
1. Using a Freer elevator, we slide it ation when the SPR is repaired.
underneath the SPR and place it 5. After the SPR is repaired, we slide
flush against the posterior aspect of the Freer elevator underneath the
the distal fibula. SPR to confirm stability as well as
2. A 15-blade knife is used to sharply to make sure that either of the pero-
incise through the SPR along the neal tendons did not inadvertently
Freer elevator which protects the get sown into the SPR repair.
tendons below. ◦◦ In rare cases in which the peroneal
3. The SPR can be tagged with a brevis tendon has ruptured from its
0-Vicryl stitch so that it can be eas- insertion onto the base of the fifth
ily identified for later repair. metatarsal, we create a bleeding bed
4. Once the tendon has been repaired, of bone with a rongeur and then repair
the SPR is repaired back to the dis- the tendon back to the metatarsal base
tal fibula using two or three using a 3.0 or 3.5 mm suture anchor.
29 Surgical Treatment of Peroneal Tendon Disorders 331

F. Peroneal Tenodesis
(a) For tendons with greater than 50% dam-
age and irreparable:
◦◦ The torn segment of tendon is excised
with a knife.
◦◦ The proximal and distal stumps of the
tendon are tenodesed to the other
peroneal tendon (assuming that ten-
don is healthy).
1. With the foot held in neutral posi-
tion, we tenodese the proximal ten-
don stump to the other tendon just
proximal to the SPR (this prevents
triggering of the tenodesed area at
the SPR with ankle motion).
2. Again, with the foot held in a neutral
position, the distal stump is teno-
desed to the other tendon about
2–3 cm distal to the tip of the fibula.
3. We use 2-0 Vicryl for the tenodesis
and use three figure-of-eight stitches
at each tendon stump.
Fig. 29.10 Incision through the superior peroneal reti-
G. Superior Peroneal Retinacular Repair naculum. (Forceps are grasping the retinaculum)
(a) Using a Freer elevator, we slide it under-
neath the SPR and place it flush against
the posterior aspect of the distal fibula. vents us from moving the insertion
(b) With the Freer elevator underneath the point more anteriorly, which could
SPR, we assess the attenuation of the lead to continued tendon instability
SPR by trying to slide the Freer over the (Fig. 29.11).
anterior aspect of the distal fibula. In ◦◦ Pass 2–3 stitches of the 0-Vicryl suture
cases in which the SPR is torn or attenu- (Figs. 29.12 and 29.13).
ated, the Freer will easily slide toward the ◦◦ A Freer elevator is placed underneath
anterior aspect of the distal fibula. the SPR and used to push the peroneal
◦◦ In cases of chronic tendon instability or tendons posteriorly to make sure that
subluxation, the SPR will be the tendons do not get inadvertently
hypertrophied. sewn into the SPR repair.
(c) With the Freer held flush against the pos- ◦◦ Hold the ankle in a neutral position
terior aspect of the distal fibula where the when tying down the sutures.
SPR inserts, we incise the SPR directly ◦◦ Slide the Freer underneath the repair,
down to the Freer with a 15-blade knife. and test the strength and stability of the
Cutting down on the Freer helps to pro- repair by trying to slide the Freer over
tect peroneal tendons below (Fig. 29.10). the anterior aspect of the distal fibula.
(d) We imbricate and repair the SPR with 1. With a successful imbrication/
0-Vicryl suture in a pants-over-vest repair of the SPR, anterior transla-
fashion. tion of the Freer should not occur.
◦◦ We begin the stitch on the fibular side H. Fibular Groove Deepening for Peroneal
of the SPR attachment. Tendon Instability
1. By starting the stitch on the fibular (a) Follow the same steps mentioned above
side of the attachment, this pre- for SPR repair.
332 T. M. Philbin et al.

Fig. 29.11 The SPR is repaired in a pants-over-vest fash- Fig. 29.13 The suture is tied and completes the SPR
ion with 0-Vicryl suture. Begin the stitch on the fibula side repair with imbrication of the tissue
of the retinaculum

(b) Once the SPR has been incised and the

peroneal tendons retracted posteriorly,
we use our index finger to palpate the ret-
romalleolar groove to assess its contour.
◦◦ If the groove is flattened or doesn’t
have a deep recess, then we proceed
with a fibular groove deepening.
(c) A 3.5 mm solid drill bit is used to deepen
the groove (Fig. 29.14).
◦◦ Place the tip of the drill bit at the tip of
the distal fibula.
◦◦ Aim the drill bit parallel along the
posterior distal fibula cortex.
◦◦ Use the drill to create a path along the
subcortical bone of the retromalleolar
groove being mindful not to exit the
cortex.
◦◦ Using the same starting point, make a
couple of passes with the drill staying
in subcortical bone.
◦◦ The bone beneath the cortex is now
weakened.
Fig. 29.12 Place 2–3 sutures prior to tying the suture
29 Surgical Treatment of Peroneal Tendon Disorders 333

Fig. 29.14 3.5 mm solid drill bit placed at the tip of dis- Fig. 29.15 A bone tamp is placed along the retromalleo-
tal fibula lar groove to deepen the concave surface

◦◦ Using a bone tamp and mallet, gently ◦◦ Look for longitudinal split tears within
tap along the retromalleolar groove, the tendon that arise at the os and
which will allow the groove to deepen extend proximally.
and create a concave surface (b) Using a 15-blade knife, carefully
(Fig. 29.15). excise/“shell out” the os peroneum start-
◦◦ Palpate the final deepened groove with ing from superior to inferior (Fig. 29.18).
your finger. (c) Once the os has been excised, there is typi-
(d) Repair the SPR as mentioned above. cally thinning of the tendon in this area
I. Excision of Os Peroneum with Tendon Repair. (d) The tendon can be repaired by tubulariz-
(a) In cases of painful os peroneum syn- ing it with 3-0 Monocryl as described in
drome, the os can be excised and the ten- the tendon repair section of this chapter
don repaired. In the majority of cases, the (Fig. 29.19)
os peroneum can be found within the J. Peroneal Tendon Reconstruction with Tendon
peroneal longus tendon. Transfer vs Allograft (see cases)
(b) Using the same approach as mentioned (a) In cases of severe combined pathology of
above for peroneal tendon repair, the both peroneus longus and brevis, recon-
inferior peroneal retinaculum is incised struction and even tenodesis may not be
in line with the peroneal longus tendon possible. If viable muscle belly and ten-
down to the inferior aspect of the cuboid sion remain, an allograft tendon recon-
(Fig. 29.16). struction could be considered with
◦◦ The os is often located deep in the foot anastomosis from the proximal myoten-
as the peroneal longus tendon passes dinous junction and the distal insertional
beneath the cuboid (Fig. 29.17). stumps.
334 T. M. Philbin et al.

Fig. 29.16 Incision is made over the location of the os

peroneum

Fig. 29.19 The tendon is tubularized and repaired with

3-0 Monocryl suture

(b) In our experience, this severity of chronic

tendon pathology usually has significant
compromise of the entire muscle-tendon
Fig. 29.17 The os peroneum within the peroneal longus unit and typically requires an autograft
tendon tendon transfer for improved outcomes.
MRI is useful to assess for chronic pero-
neal tendinosis with chronic tearing and
no visible tendon structure. Typically
there is chronic hindfoot varus from loss
of the peroneal everted function as well
as other structural foot deformities that
must be addressed (Fig. 29.20).
(c) Most often, a true Dwyer lateral closing
wedge calcaneal osteotomy with lateral
translation is performed to reduce any
varus hindfoot tendencies and lateral col-
umn overload. It is our preference to use
two screws to reduce the closing wedge
instead of a single screw typically used
Fig. 29.18 The os peroneum is excised (“shelled out”) for the MDCO (Fig. 29.21).
with a knife
29 Surgical Treatment of Peroneal Tendon Disorders 335

Fig. 29.20 MRI demonstrates chronic peroneal tendinosis and chronic tearing with no viable tendon structure
remaining

(d) A standard peroneal tendon exposure is

utilized but must include above the SPR
and down to at least the cuboid. Ideally,
there will be enough FHL length to reach
the fifth metatarsal base but definitely to
the cuboid. The SPR needs to be tagged,
released, and later repaired.
(e) A medial incision just below the PTT
insertion at the medial navicular is uti-
lized. The dissection is similar as used in
FDL harvest for PTT reconstruction. The
knot of Henry is identified; the first MTP
is taken through a range of motion to
accurately identify FHL vs FDL. The toe
is maximally plantarflexed, and the FHL
is harvested just proximal to the knot.
This will still allow some distal slip func-
tion of the FHL with function of FDL.
(f) The harvested FHL is brought proximal
Fig. 29.21 Lateral X-ray demonstrating Dwyer calca-
out of the surgical site. A second medial
neal osteotomy fixed with two screws incision is created just posterior to the
336 T. M. Philbin et al.

medial margin of the tibia, above the

medial malleolus. This should be perpen- Postoperative Care
dicular in height from the lateral “above A. Patients are initially placed in a well-­
the SPR” exposure, so the transfer of padded posterior splint for 1 week and
FHL will be easily achieved. Frequently then placed into a short leg nonweight-­
a straight hemostat is used to dilate the bearing cast for 3 weeks.
flexor canal around the medial malleolus B. At the 4-week post-op visit, the cast
to allow the FHL harvest to be pulled into and sutures are removed, and the patient
the proximal medial incision. is fitted for a walker boot and is allowed
(g) Once this is done, careful blunt dissec- to weight-bear as tolerated in the boot.
tion is performed along the posterior tibia We allow them to begin gentle ankle
from medial to lateral to allow transfer of range of motion exercises.
the FHL to the peroneal tendon sheath C. At 8 weeks post-op, the walker boot is
laterally. The FHL is pulled along the removed, and the patient is fitted with a
posterior fibula as far distally along the lace-up ankle brace. Formal physical
peroneal tendon course as possible while therapy is prescribed for focus on func-
holding the foot with maximal ankle dor- tional rehabilitation.
siflexion and hindfoot eversion.
(h) The FHL should at least reach the cuboid
if not to the fifth metatarsal base and then
anchored with fixation device of choice.
Complications
A. Wound healing issues
B. Re-rupture
Pearls and Pitfalls
C. Sural neuralgia or nerve injury
A. Address any malalignment issues and
D. Scarring of the tendons which can
ankle instability at the time of tendon
cause chronic pain
repair.
B. Thoroughly debride the tendon and
tubularize it; check for tendon
instability.
C. Be mindful of the sural nerve just
behind the tendons.
D. Place incision along posterior 1/3 of
distal fibula; allow for repair of lateral
ligaments in combination with tendon
repair.
 Plantar Fasciitis and Tarsal Tunnel
30
Corey M. Fidler and Gregory C. Berlet

30.1 Introduction 30.2 Patient History and Findings

Plantar fasciitis is one of the most common foot Patients will have symptoms that are consistent
conditions affecting individuals both with a high with both plantar fasciitis and neuritis. The
level of activity and those with a high level of patient population is diverse affecting men and
inactivity [1–3]. While the diagnosis is frequently women of a wide age range and individuals
clear, the etiology has remained controversial. including both athletes and runners with a high
Up to 90–96% of plantar fasciitis cases resolve level of activity and more sedentary individuals
with nonoperative management including non- with a higher BMI [6]. Occupation can play a
steroidal anti-inflammatory drugs (NSAIDs), factor, and those employed in positions that
stretching, orthotics, oral/injectable steroid, require prolonged walking or standing have a
physical therapy modalities, rest, night splints, tendency to be affected with greater frequency.
and immobilization [4, 5]. When patients who Plantar fasciitis is considered chronic when
present with the characteristic enthesopathy of symptoms persist after 6–9 months. Most com-
plantar fasciitis develop neurogenic symptoms, monly referred to as post-static dyskinesia, pain
other etiologies need to be investigated. A com- that occurs after a period of rest presents itself
monly overlooked source of inferomedial heel first thing in the morning and/or after prolonged
pain recalcitrant to nonoperative management is sitting. The symptoms, while intense at first,
chronic plantar fasciitis associated with entrap- tend to resolve after ambulating for moment or
ment of the lateral plantar nerve and its first after a period of non-weight-bearing. Symptoms
branch. are not typically progressive or increasingly
painful with activity or at rest. Physical exami-
nation reveals a reproducible point of maximal
tenderness along the medial band of the plantar
fascia at its origin from the plantar medial tuber-
cle. Overall tautness of the plantar fascia can be
C. M. Fidler (*) palpated during activation of the windlass mech-
Carilion Clinic, Department of Orthopaedic Surgery, anism (described as the winding of the plantar
Roanoke, VA, USA fascia by dorsiflexion of the metatarsal phalan-
e-mail: [email protected] geal joint thereby functionally shortening the
G. C. Berlet distance between the calcaneus and metatarsals)
Orthopedic Foot & Ankle Center, in cases of chronic plantar fasciitis as
Worthington, OH, USA

© Springer Nature Switzerland AG 2019 337

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_30
338 C. M. Fidler and G. C. Berlet

­ icrotrauma and damage ­continue at a rate that

m occult pathology or space-occupying lesions can
exceeds the bodies’ capacity to heal. Generally be beneficial. Electrodiagnostic studies are bene-
clinical signs of inflammation such as edema and ficial for differentiating between entrapment neu-
erythema will be absent. ritis, radiculopathy, and peripheral neuropathy.
Distal tarsal tunnel syndrome can present Unfortunately, the accuracy of lower extremity
with more subtle neuritic findings such as numb- studies is deficient compared to its use in upper
ness, burning, pulling, or tingling sensations extremity pathology. The quality is also operator-­
around the posterior medial ankle, plantar dependent which can lead to unreliable results. A
medial, and/or plantar lateral aspect of the heel positive result, however, can provide confirma-
(along the course of the first branch of the lateral tion to the clinical diagnosis.
plantar nerve) and the plantar arch. This pain dif- Many conservative treatment options are
fers in presentation from plantar fasciitis in that available with encouraging results. Our nonop-
prolonged activity exacerbates symptoms that erative protocol for a patient presenting with heel
are not necessarily relieved with resting. It also pain representing plantar fasciitis begins with
differs in location, as the medial border of the topical NSAIDs +/− oral methylprednisolone
heel at the “porta pedis” tends to be the area of (Medrol Dosepak©) combined with a home exer-
maximal tenderness which corresponds with the cise plan. Relative rest, ice, stretching, dorsiflex-
lateral plantar nerve and its first branch coursing ory night splint, over-the-counter insert, and
over the lower edge of the abductor hallucis fas- supportive shoe recommendations are initiated as
cia. The presence of a hypertrophied abductor well. At the next follow-up visit if there is less
hallucis muscle belly, which can sometimes be than 50% improvement, an ultrasound-guided
seen in athletes or patients with vocations that corticosteroid injection is considered along with
involve frequent standing or walking, can predis- a semirigid accommodative custom orthotic. A
pose a patient to this syndrome. MRI may be ordered at this time as well if symp-
toms persist. In 4–6 weeks at the next follow-up
visit if symptoms persist along with neuritic find-
30.3 Imaging and Diagnostic ings, increasing suspicion of a distal tarsal tunnel
Studies component is considered. A fracture boot or cast
may also be considered while advanced electro-
The general consensus for the usage of imaging diagnostic studies are obtained. If EMG/NCS
and diagnostic studies has been toward ruling out studies are positive or if the pain is primarily
associated pathologies such as radiculopathy, medial over the lateral plantar nerve, a surgical
space-occupying lesions, and generalized periph- consult is obtained for a distal tarsal tunnel
eral neuropathy. Weight-bearing plain film radio- release with neurolysis of the medial and lateral
graphs are useful for ruling out hindfoot plantar nerves and partial plantar fascia release
arthropathy, stress fractures, and bone lesions. via percutaneous bipolar radiofrequency (bRf)
With a history of posttraumatic arthritis involving microtenotomy.
the ankle and/or subtalar joint, one should con-
sider a compressive neuritis arising from tenosy-
novitis of the tibialis posterior, flexor digitorum 30.4 Surgical Management
longus, or flexor hallucis longus or external com-
pression via osteophytes [7]. Computed tomogra- 30.4.1 Preoperative Planning
phy (CT) can help further evaluate posttraumatic
arthritis and deformity, but its benefit in surgical Attention must be given to the patient’s history
planning is minimal. Magnetic resonance imag- and presentation, specifically the anatomic loca-
ing (MRI) is not always indicated and can often tion, onset, and duration of symptoms. Diagnostic
demonstrate signs of pathology in patients who imaging can be helpful for ruling out associated
are asymptomatic. Its ability to demonstrate pathologies and can direct treatment plan.
30 Plantar Fasciitis and Tarsal Tunnel 339

30.4.2 Positioning and Equipment

The patient is positioned supine on the operating

table with a bump under the contralateral leg to
facilitate external rotation hip. Before adminis-
tration of any anesthesia or peripheral nerve
block, the area of maximal tenderness on the
plantar heel is palpated. An indelible surgical
marker is used to mark out a grid pattern situated
in 5 mm intervals in preparation of the skin per-
forations needed to perform the bRf microde-
bridement fasciotomy. Multiple folded towels are
placed under the foot which is placed near the
Fig. 30.1 Incision placement over the tarsal tunnel. It is
end of the table but not overhanging the edge to carried distal to allow for release of the medial band of the
give the surgeon and assistants adequate room for plantar fascia
resting of the forearms and retracting while oper-
ating. We operate in the seated position on a roll-
ing surgical stool for comfort. General anesthesia
is typically utilized in addition to a popliteal and
saphenous nerve block. The foot is then scrubbed,
prepped, and draped in the usual aseptic manner.
A thigh tourniquet is used for hemostasis and is
inflated at this point after the leg is
exsanguinated.

30.4.3 Approach and Technique

30.4.3.1 Part 1: Tarsal Tunnel Release

A standard posterior medial incision is made at
the halfway point between the posterior medial
aspect of the medial malleolus and the medial
border of the medial malleolus extending
Fig. 30.2 Dissection is carried down to the adductor hal-
approximately 3 cm proximal and distal from lucis muscle. The porta pedis is released below the muscle
the level of the medial malleolus along the belly
course of the tibial nerve (Fig. 30.1). Dissection
is carefully carried through the subcutaneous belly is identified and carefully teased away
tissues, and superficial vessels are identified and from its deep fascia with a freer elevator
cauterized with a bipolar cautery. Self-retaining (Fig. 30.2). The long arm of a Senn retractor is
retractors are placed within the wound to pro- then placed on either side of the deep fascia pro-
vide exposure of the deep structures and to free tecting the neurovascular structures. Next the
up the hands of the assistant. The flexor retinac- deep fascia to the abductor hallucis is released
ulum (laciniate ligament) is identified distally at with a #15 blade which is overlying the plantar
the level of the abductor hallucis muscle and is fascia (Fig. 30.3). Attention is then redirected
sharply released with a #15 blade. No attempt is proximally, and the flexor retinaculum is identi-
made to isolate the tibial nerve during the proce- fied and released. Care is taken to cauterize and
dure which is located posteriorly and laterally to ligate any space-occupying or tributary veins
the posterior tibial artery. The abductor muscle within the tarsal tunnel (Fig. 30.4). Next the
340 C. M. Fidler and G. C. Berlet

Fig. 30.3 Dissection to reveal the medial band of the

plantar fascia

Fig. 30.5 The posterior tibial nerve is identified. Not yet

exposed in this image

Fig. 30.4 Next the flexor retinaculum is identified and

released. Care is taken to cauterize any space-occupying
and/or tributary veins within the tarsal tunnel

posterior tibial nerve, its medial and lateral

branches, and the medial calcaneal branches are
sequentially identified and released of adhe-
sions (Figs. 30.5 and 30.6). After a complete
Fig. 30.6 The posterior tibial nerve and its branches fully
release is performed, the tourniquet is released, released: (a) Posterior tibial nerve. (b) Medial branch. (c)
and m­ eticulous hemostasis is achieved in an Lateral branch. (d) Medial calcaneal branch
effort to prevent postoperative hematoma for-
mation. A standard layered closure is performed inch Kirschner wire is then used to create a series
without the routine use of a drain. of full-thickness percutaneous micro-incisions,
ranging from 10 to 50 in number, mirroring the
30.4.3.2  art 2: Percutaneous bRf
P grid pattern depicted. The incisions traverse the
Microtenotomy subcutaneous tissue, fat, and plantar fascia. The
Attention is then directed to the plantar aspect of bRf unit is set to 175 volts, ensuring that an ade-
the heel to the grid pattern previously marked in quate amount of energy is delivered during the
the preoperative holding bay. A smooth 0.062 preset time of one half second (500 millisec-
30 Plantar Fasciitis and Tarsal Tunnel 341

onds). A normal saline sterile drip set at 1 drop 30.6 Intraoperative Pearls
every 2–3 seconds is attached to the bRf probe and Pitfalls
which is then introduced through the previously
made channels, thereby effecting microfasciot- Meticulous dissection and hemostasis will allow
omy. A dual-depth delivery technique is utilized accurate visualization of vital structures. This will
with the first application occurring at the junction help mitigate complications associated with post-
of the superficial and deep fascia layers and the operative bleeding which can increase ­ scarring
subsequent application through the entire thick- around the nerves. Failure to properly visualize the
ness of the plantar fascia. The plantar heel is then complete release of all soft tissue adhesions or
bandaged with adhesive skin strips followed by a entrapments by engorged venous plexus about the
modified Jones compressive bandage and a pos- tibial nerve and its branches in the distal tarsal tun-
terior splint. nel will ultimately lead to a poor outcome.

Acknowledgement We would like to acknowledge

30.5 Postoperative Care Travis Langan for the intraoperative photographs.

Patients remain non-weight-bearing for a week

until their first postoperative visit when the References
bandage is removed and the incisions are
inspected followed by a below-knee non- 1. Johal KS, Milner SA. Plantar fasciitis and the
calcaneal spur: fact or fiction? Foot Ankle Surg.
weight-bearing fiberglass cast for 3 weeks. At 2012;18:39–41.
1 month postoperatively, the patient is allowed 2. League AC. Current concepts review: plantar fasciitis.
to weight bear as tolerated in an immobilizing Foot Ankle Int. 2008;29:358–66.
walking boot (“CAM” walker). Deep venous 3. Riddle DL, Schappert SM. Volume of ambulatory
care visits and patterns of care for patients diagnosed
thrombosis prophylaxis is instituted for 4 weeks with plantar fasciitis: a national study of medical doc-
of non-weight-­bearing and consists of aspirin tors. Foot Ankle Int. 2004;25:303–10.
325 mg twice daily unless otherwise contrain- 4. Baxter DE, Pfeffer GB. Treatment of chronic
dicated or the patient is at a higher risk for a heel pain by surgical release of the first branch of
the lateral plantar nerve. Clin Orthop Relat Res.
thromboembolic event in which low-molecular- 1992;279:229–36.
weight heparin or equivalent is given. Patients 5. Sorensen MD, Hyer CF, Philbin TM. Percutaneous
are encouraged to continue stretching and are bipolar radiofrequency micro- debridement for recal-
prescribed custom orthotics for long-term func- citrant proximal plantar fasciosis. J Foot Ankle Surg.
2011;50:165–70.
tional biomechanical support. Formal physical 6. Di Caprio F, Buda R, Mosca M, Calabro A, Giannini
therapy is initiated at 8 weeks postoperatively S. Foot and lower limb diseases in runners: assessment
and consists of strengthening, range of motion of risk factors. J Sports Sci Med. 2010;9:587–96.
exercises, stretching, modalities (such as ultra- 7. Gould JS, DiGiovanni BF. Plantar fascia release in
combination with proximal and distal tarsal tunnel
sound, transcutaneous electrical stimulation, release. In: Easley ME, Wiesel SW, editors. Operative
whirlpool, ice, massage), and a self-directed techniques in foot and ankle surgery. Philadelphia:
home exercise plan. Lippincott; 2011. p. 431–9.
 Supple Equinus, Equinovarus,
and Drop Foot Surgical Strategies
31
Roberto A. Brandão, Maria Romano McGann,
and Patrick E. Bull

Abbreviations results [1, 3–5]. This text serves, first and fore-
most, as a surgical technique guide; therefore,
EDL Extensor digitorum longus in the paragraphs below, we will focus primar-
EHL Extensor hallucis longus ily on the clinical and technical aspects of these
GR Gastrocnemius recession valuable procedures rather than on the scientific
GSR Gastrocsoleus recession literature.
PT Posterior tibial Flexible drop foot and equinovarus deformi-
TA Tibialis anterior ties, although relatively rare, are quite reward-
TAL Tendo-Achilles lengthening ing to treat. We have had great success utilizing
tendon releases and transfers for these patients
over the years. Unlike equinus, equinovarus
and drop foot require both sagittal and coronal
31.1 Introduction plane tendon balancing; therefore, these multi-
step and complex procedures can seem intimi-
Lengthening procedures for the leg’s superficial dating. The chapter will provide technical
posterior compartment musculature have surgical pearls and complete preoperative clini-
gained in popularity over the past two decades, cal work-up for these unique and challenging
not only due to evidence indicating highly prev- patients.
alent equinus contracture in neurologically nor-
mal patients with foot and ankle pathology, but
also because release of these contractures is 31.2 Clinical Cases
safe and associated with excellent clinical
31.2.1 Equinus

R. A. Brandão (*) Our patient is a 50-year-old female who presents

The Centers for Advanced Orthopaedics, Orthopaedic with chronic worsening pain to her heel over the
Associates of Central Maryland Division, last 6 months. She complains of painful calluses
Catonsville, MD, USA
under her hallux and fifth metatarsophalangeal
M. R. McGann joint. She has tried calf-stretching exercises pro-
Romano Orthopaedic Center, Oak Park, IL, USA
vided by a physical therapist friend of hers and
P. E. Bull has consistently taken anti-inflammatory medica-
Orthopedic Foot & Ankle Center,
Worthington, OH, USA
tions, yet no pain relief has been noted. The pain

© Springer Nature Switzerland AG 2019 343

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_31
344 R. A. Brandão et al.

causes her to limp most days and has forced her even the presence of persistent diabetic ulcers.
to decrease her weight-bearing activities. She is Oftentimes patients have tried various types of
frustrated and looking for relief. padding or changes to in shoe gear with no relief.

Physical Exam The key to making the diagno-

31.2.2 Drop Foot sis is to look for it. Always perform a Silfverskiold
maneuver during your passive ankle range-of-­
Our patient is a 62-year-old male who presents motion exam, and if less than 10° of dorsiflexion
with complete loss of left lower extremity com- is noted, you have a positive result. We elaborate
mon peroneal nerve function secondary to knee on our technique and how to interpret the exam
trauma 14 months prior. He has chronic foot and results in the Sect. 31.4.3 below.
ankle instability despite absolute compliance
with a well-made ankle foot orthosis (AFO) and 31.3.2 Equinovarus
extensive physical therapy. He has consistent
gait instability, decreased cadence, and nearly History Patients typically present with com-
absent active dorsiflexion. Regular physical plaints of pain to the involved heel, metatarsal
therapy has failed to improve active ankle dorsi- heads, and lateral column with a noted history of
flexion. Serial neurological testing has revealed a “turned in” foot and ankle. The “ankle gives out
consistent absent function of the peroneals and with ambulation” is a common presenting com-
tibialis anterior muscles. Functional capacity of plaint. A history of persistent callosities or even
the posterior tibialis remains intact. ulcerations of the foot and toes may be noted.
Patients often relate being told that they have
high arches and that immediate family members
31.3 Patient Presentation share this trait. Many patients may present with a
diagnosis of idiopathic distal symmetrical poly-
31.3.1 Equinus neuropathy. Most patients will have undergone a
frustratingly ineffective combination of NSAIDs,
History Patients are rarely aware of their gas- bracing, and physical therapy prior to surgical
trocnemius and/or soleus tightness. They will consultation (Fig. 31.1).
often report any combination of heel pain, Achilles
midsubstance or insertional pain, arch pain, fore- Physical Exam Findings A pes cavus defor-
foot overload pain, plantar callus formation, and mity with associated lateral column overload, a

Fig. 31.1 Preoperative image of a patient with an equinovarus deformity

31 Supple Equinus, Equinovarus, and Drop Foot Surgical Strategies 345

plantarflexed medial column, a painful fifth EDL function will be preserved in cases of both
metatarsal base, and first and fifth metatarsal acute and chronic TA rupture and results in
head callosities are all often present. Severe cases weak dorsiflexion with lack of inversion power.
can see callosities progress to ulcers, especially In neuropathic cases, posterior tibialis overac-
over the hallux. Overpowered, absent, or weak tivity produces hindfoot inversion and inability
ankle everters result in predictable hindfoot to evert on stance. As seen with equinovarus
varus, which, for the purposes of this chapter, but cases, EDL and EHL compensatory dorsiflexion
not so in every case, is flexible. Genu recurvatum overactivity often produces hammertoe, claw
is sometimes noted and serves to compensate for hallux, and claw toes deformities. Awkward and
the equinus mediated functional leg length fatiguing steppage gait will be observed in the
inequality. Anterior leg compartment muscle unbraced patient.
weakness with inadequate dorsiflexion during
gait will produce falls, stress reactions, and even 31.3.4 Imaging and Diagnostic
metatarsal ­fractures. Neuropathy, whether hered- Studies
itary or idiopathic, is often present. Manual neu-
rological testing including a Semmes Weinstein X-ray: Equinovarus, Equinus, Drop Foot –
monofilament exam, vibratory sensation testing, Standard weight-bearing ankle and foot radio-
and deep Achilles tendon reflex should be per- graphs are required to assess alignment and to
formed. Claw hallux, claw toe, and hammertoe rule out fractures and degenerative changes.
deformities are common and are due to extensor Determining the specific deformity contribu-
digitorum longus (EDL) and extensor hallucis tions of the ankle and all foot regions must be
longus (EHL) tendon compensatory overactivity rigorously considered. In addition, we rou-
during attempted dorsiflexion. tinely obtain weight-bearing bilateral hindfoot
alignment views to assess tibiotalocalcaneal
alignment. This view is easy to perform in the
31.3.3 Drop Foot office and does not require any special posi-
tioning equipment or film cassette holders like
History Patients often present with persistent those needed for a traditional Saltzman view
“foot slapping” and clumsiness when barefoot or (Fig. 31.2).
when wearing unsupportive footwear. A history MRI: Equinovarus and Drop Foot – We typi-
of increasingly frequent ankle sprains may be a cally obtain preoperative hindfoot MRI to con-
complaint. The feeling of walking on the lateral firm adequacy of tendons (i.e., severe degeneration
foot is frequently reported with complaints of or rupture) to be transferred and rule out degen-
painful lateral foot callosities that limit activity erative joint disease that might require treatment
tolerance. Interestingly, some drop foot patients and therefore alter our surgical plan.
will present late and show an incredible array of Others: Drop Foot – Nerve conduction and/or
gait compensation strategies and bracing electromyographic studies may be warranted to
­techniques. Some patients may present after an determine the level of nerve function and the
isolated ankle sprain or “stumble” with a chronic presence of unilateral or bilateral neuropathy.
tibialis anterior (TA) rupture. If these patients Serial examination is utilized to confirm that no
present late, the reconstruction options of this chance for nerve recovery remains in affected
chapter may be required to restore plantigrade muscles. Individual muscle testing establishes
posture. Primary tibialis anterior reconstruction that adequate power exists in tendon units to be
procedures are reviewed in Chap. 15. transferred. Botox injections into deformity pro-
ducing spastic muscles can facilitate bracing,
Physical Exam Findings Poor or absent active improve ambulation, decrease pain, and prevent
ankle dorsiflexion is always observed. EHL and ulceration, albeit temporarily.
346 R. A. Brandão et al.

Fig. 31.2 Example of patient positioning for a hindfoot alignment view

31.4 Surgical Treatment outcome and patient dissatisfaction. Eligible

patients are not only capable of complying with
31.4.1 S
 upple Equinus, Equinovarus, up to 12 weeks of weight-bearing restrictions and
and Drop Foot many more months of protective bracing but will-
ing to endure such hardship. Every effort must be
Patient Selection: Once a patient has confirmed exercised to minimize surgical risk; therefore,
equinus contracture and then fails an exhaustive tobacco use must be discontinued prior to any
course of nonsurgical treatment, the appropriate elective surgery, and preoperative nicotine/coti-
lengthening procedure is indicated. The majority nine testing is routinely obtained to confirm com-
of our gastrocnemius release cases are done to pliance in at-risk patients.
treat recalcitrant plantar fasciitis, non-insertional Preoperative Planning: A complete imaging
Achilles tendinopathy, and forefoot overload work-up including plain foot and ankle films,
syndrome. Gastrocsoleus releases are more com- hindfoot alignment images, hip-knee-ankle lower
monly used to treat contractures due to rearfoot extremity alignment films, and MRI are used to
arthritis, flatfoot deformities, and neurologic determine the apex of the deformity. Flexible
mediated equinus, to name a few. Clinical indica- deformities addressed in this chapter are
tions for surgical correction of equinovarus and approached using joint-sparing strategies, whereas
drop foot include a painful, deformed, physically rigid deformities require the addition of osteoto-
limiting extremity that has failed medication, mies and/or arthrodesis covered in Chap. 28 with
therapy, bracing, and all other nonsurgical treat- cavus reconstruction procedures. The degree and
ment attempts. Establishing realistic postopera- level of equinus must both be determined. If addi-
tive pain and functional expectations is a critical tional procedures are planned to address hindfoot
part of operative planning and the patient selec- varus, plan to have them completed prior to final
tion process. Unrealistic expectations, especially tendon balancing. Prior to surgery, coordination
within the patient, can almost guarantee a poor with primary care physicians, internists, endocri-
31 Supple Equinus, Equinovarus, and Drop Foot Surgical Strategies 347

nologists, and neurologists is done to facilitate not monly, isolated gastrocnemius contracture is
only tight sugar control strategies in diabetic noted thus indicating open proximal gastrocne-
patients but to optimize the patient for surgery. In mius recession procedure. When both the gas-
order to minimize diabetes-related surgical com- trocnemius and soleus are contracted, any of the
plications, a preoperative hemoglobin A1c level following procedures are preferred: an endo-
less than 8% is necessary. Additionally, screening scopic gastrocsoleus recession, an open proximal
for complication prone patients includes nutri- gastrocsoleus recession, or a percutaneous tendo-­
tional labs (albumin, prealbumin, vitamin C, vita- Achilles lengthening. We recognize that numer-
min D) and vascular studies. ous well-described additional posterior
lengthening techniques exist; however, as of this
writing, if they are not a standard part of our
31.4.2 Operating Room Setup treatment algorithm, they will not be discussed
further in this chapter. Complex multi-procedure
Positioning: The vast majority of these cases are cases that include a posterior lengthening, as in
completed with the patient in the supine position. the case of a Bridle transfer, usually have the pos-
Some exceptions to this rule include: terior lengthening procedure completed first. A
documented and practiced operative plan must be
• Hindfoot osteotomies are done in the lateral completed before entering the operating room
position at the beginning of the case. Once with such cases. There are few surgeries that can
completed, we deflate the beanbag and trans- challenge the number of incisions, number of
fer the patient to a supine position while surgical steps, and number of intraoperative
avoiding the need for redraping. adjustments required by a Bridle transfer case. To
• Proximal Achilles lengthening procedures, minimize the risk of intraoperative struggles and
when combined with distal Achilles proce- to maximize surgical decision-making efficiency
dures, are done in the prone position. during these complex and relatively rare proce-
dures, we recommend writing down and practic-
The supine position allows for adequate access ing your operative plan multiple times.
necessary to complete both proximal and distal
posterior lengthening procedures while also
affording excellent access to the multitude of 31.5 Posterior Lengthening
incisions necessary for anterior tendon transfers. Procedures
The leg can be held by an assistant for posterior
group procedures if necessary. The tibial tubercle 31.5.1 Percutaneous Tendo-Achilles
must be prepped into the surgical field for intra- Lengthening (TAL)
operative leg rotation and alignment assessment.
The patient is typically supine, and the ankle is ten-
sioned into maximal dorsiflexion by an assistant.
31.4.3 Approach Overview Three small stab incisions, starting distally and
moving proximally, are utilized. Incisions must be
Determining which posterior lengthening proce- separated by at least 3 cm in order to avoid inadver-
dure is ideally suited to treat each patient requires tent tenotomy. Insert a No. 15 blade through the
multiple careful and deliberate clinical assess- center of the tendon at each incision level. Turn the
ments of the gastrocnemius, soleus, and ankle blade either laterally or medially once it is com-
joint to quantify each muscle’s contribution to the pletely through the skin and the tendon. The thumb
plantarflexion contracture. The Silfverskiold of the opposite hand is used to gently press the ten-
maneuver is our preferred exam technique, and it don onto the blade and a palpable, and sometimes
is important to take care to supinate the subtalar audible, popping is noted as the tendon fibers are
joint during the passive dorsiflexion assessment sectioned. The incision sequence is typically
to avoid false-negative results [9, 10]. Most com- medial distally, lateral centrally, and medial again
348 R. A. Brandão et al.

proximally. This sequence best avoids sural nerve sometimes too short to properly execute the
injury. Once all incisions are complete, gentle pro- release and either a second incision becomes nec-
gressively increasing passive dorsiflexion is applied essary or the endoscopic technique is abandoned
until a release is confirmed. A skin stapler is used to in favor of an open approach. The position is
close the three stab incisions. supine, and the incision in many ways mirrors
that of the open GSR, vertical posteromedial, and
at the junction of the middle and distal thirds of
31.5.2 O
 pen Gastrocsoleus Recession the leg. The incision is different in that it is
(GSR) smaller, only 1 cm in length, and it must be
slightly medial to the tendo Achilles medial mar-
A vertical posteromedial 3–4 cm incision is made gin. Sharply dissect through the subdermal fat to
at the junction of the middle and distal thirds of the identify the superficial fascia with the assistance
leg. At this level, the gastrocnemius tendon has of Ragnell retractors. Vertically incise the fascia
fused with the soleus tendon. Once through skin and place the endoscopic spatula deep to the fas-
and subdermal fat, finger palpation is used to cia but superficial to the tendon. Sweep the spat-
divide fat adherent to the crural fascia. Army-­Navy ula proximal, distal, and lateral while manually
retractors are placed to identify the fascia and a palpating it under the skin to confirm its superfi-
vertical fascial incision is made in line with the cial location. Slide the endoscope down the spat-
skin incision. The long arms of the retractors are ula and into the same tissue plane, and ensure the
advanced deep to the fascia and the gastrocsoleus sural nerve is not within the path of the endo-
combined tendon is easily visualized. We prefer to scope. Visualize the white shining tendon through
confirm we are 3–4 cm distal to the gastrocnemius the scope slot and confirm its identity by pas-
muscle belly by passively plantarflexing and dorsi- sively plantarflexing the ankle and observing ten-
flexing the ankle and visualizing the muscle. The don motion. Deploy the surgical blade at the
sural nerve should be protected by the retractor at lateral tendon margin, and drag it medially while
this point, but the sural nerve can be deep to the observing tendon division. The foot should be
fascia in some cases and must always be antici- against the scope operators abdomen and main-
pated and carefully avoided during tendon section- tained in dorsiflexed tension during tendon divi-
ing [7]. Starting medially and heading proximal sion. A release is easily felt once complete. We
and lateral, and while maintaining the ankle in tend not to divide the deep central raphe so as to
moderate passive dorsiflexion, divide the tendon avoid over lengthening and subsequent weakness
under direct visualization while always aware of postoperatively. Irrigate the wound, and close
the sural nerve. Once the medial 50–75% is sec- with skin suture or staples.
tioned, a release will be felt. Be sure to complete
the release laterally despite the perceived release.
Irrigate the wound with saline and close in layers 31.6 Gastrocnemius Recession,
being sure to close the deep fascia to prevent a Strayer Procedure
potentially painful muscular herniation.
The goal of this procedure is to isolate and release
the gastrocnemius. The level of the incision is
31.5.3 Endoscopic Gastrocsoleus critical as it must be at the distal margin of the
Recession (Endo-GSR) gastrocnemius muscle belly. In most patients,
this point is midway between the fibular head and
This procedure is discouraged in patients with a lateral malleolus [12]. Pinney and colleagues rec-
high BMI as the incision needed to adequately ommended starting 2 cm distal to the gastrocne-
identify the proper surgical plane becomes so mius muscular prominence and extending 3 cm
large that an open procedure can be performed, proximal [7]. We prefer a vertical 3–4 cm inci-
thus eliminating the main benefit of the endo- sion made posteromedial central to improve safe
scopic technique. Also, the instrumentation is visualization of the lateral portion of the release.
31 Supple Equinus, Equinovarus, and Drop Foot Surgical Strategies 349

Subdermal tissue is carefully dissected to avoid

sural nerve injury. Once the superficial fascia is
identified, it is sharply divided in line with the
skin incision. Army-Navy retractors are placed
deep to the fascia, and the distal gastrocnemius
muscle belly is visually identified. After 44 com-
pleted gastrocnemius recessions, Pinney and col-
leagues observed the sural nerve to lie superficial
to the deep fascia only 43% of the time. The
nerve was deep to the fascia in the remaining
57% of cases and actually adherent to the tendon
surface in 13% [7]. Given this variable anatomy,
every surgeon should anticipate the sural nerve
deep to the fascia and confirm that it is not adher-
ent to the tendon prior to performing the release.
A finger is passed medially and hooked over the
medial gastrocnemius. The finger is drawn inferi-
orly to identify the fusion point of the gastrocne-
mius tendon to that of the soleus. Once the
interval has been established, a malleable retrac-
tor can be placed into the interval. The gastrocne-
mius tendon is then divided from medial to
lateral, just distal to the muscle, while the mal- Fig. 31.3 Open strayer procedure, as described above;
note the isolated sectioning of the medial gastrocnemius
leable retractor protects the deeper soleus tendon tendon, proximal to the convergence of the gastro-soleus
and an angled retractor protects the sural nerve complex
and fascia (Fig. 31.3). The release will extend
more proximally as the division heads laterally. made. Cheat the incision slightly more distal
Once a release is noted, the wound is irrigated as you will want to acquire as much tendon
and closed in layers. Care is taken to avoid pain- harvest length as possible. Expect numerous
ful muscular herniation by reapproximation of crossing veins and cauterize until you encoun-
the superficial fascia prior to skin closure. ter the tendon sheath. Incise the distal sheath
and expose the tendon. I hook the tendon with
a Ragnell and retract medially to confirm ten-
31.6.1 B
 ridle Procedure, Posterior don excursion and to aid in identifying the dis-
Tibial Tendon Transfer tal release margins. Meticulous subperiosteal
tendon detachment distally will often add up
In an effort to save valuable tourniquet time, all to 10 mm of additional length (Fig. 31.5a).
incisions should be marked (Fig. 31.4a, b), and Whip stitch the tendon stump with an 0 caliber
the exact location of the palpable dorsalis pedis suture of your choice.
artery should be marked prior to tourniquet • Step 3: A vertical 4 cm incision paralleling the
inflation. posterior tibial margin, extending proximally,
and starting at the junction of the middle and dis-
• Step 1: Given that both the gastrocnemius and tal leg thirds is made. Isolation of the posterior
soleus are typically contracted in these cases, tibial tendon is facilitated by gentle alternating
either an open or endoscopic GSR is per- pressure on the distal stump. Pull the tendon out
formed first. Both procedures are described through the proximal incision (Fig. 31.5b).
earlier in this chapter. • Step 4: Just lateral to the anterior tibial crest
• Step 2: A short 3 cm, longitudinal incision and placed just proximal to the medial PT
paralleling the posterior tibialis insertion is exposure incision, a vertical 6 cm incision is
350 R. A. Brandão et al.

a b

Fig. 31.4 (a, b) Guide for incisional placement for a posterior tibial tendon transfer

performed. After incising the fascia in line margin is made. Isolate the two tendons, and
with the incision, expose the interosseous critically evaluate the caliber of the peroneal
membrane (IO) by sweeping the anterior com- brevis. If it is robust at this level, it is tenoto-
partment musculature, along with the neuro- mized as it is our preferred tendon for the
vascular bundle, laterally. A dry sponge is Bridle transfer given its favorable force vector.
helpful to clean the IO and dry the muscula- If the brevis is mostly muscular at this level,
ture thus facilitating better visualization for perform the traditional peroneal longus tenot-
windowing the IO. Create a window in the IO omy. The remaining tendons are tenodesed
with a scalpel taking care to only barely incise side to side with 0 caliber absorbable suture.
the membrane along its medial, superior, and • Step 6: A 3 cm incision along the dorsal pero-
lateral margins. A Cobb elevator is typically neal brevis insertion margin is made to isolate
passed from medial to lateral and tight to the the tenotomized peroneal tendon. Expect the
posterior tibia into the IO window. A long sural nerve to be close to the incision, and pro-
curved tendon passer then follows the Cobb as tect it when encountered. Pull the tendon dis-
it is retracted medially. Straight instruments tally out of the incision, and whip stitch its end
are challenging to pass from lateral to medial with an 0 caliber suture.
as they impinge on the fibula, the anterior leg • Step 7: The PT must now be passed through a
musculature, and, most importantly, the neu- vertical incision in the tibialis anterior (TA),
rovascular bundle. The passer is now in the and properly tensioning this interface is criti-
medial leg incision and positioned to deliver cal. The ankle is held in slight dorsiflexion,
the PT into the IO window. Once this is com- and the PT is tensioned distally. The PT and
pleted (Fig. 31.5c), PT excursion is again TA should intersect well proximal to the
tested, and the IO window enlarged manually superior extensor retinaculum. At the tendon
if impingement is noted (If performing an iso- intersection, incise the central TA, in line
lated PT transfer, move ahead to Step 9). with its fibers, and pull the PT through the
• Step 5: A vertical incision 8 cm proximal to TA from posterior to anterior. Ensure the
the fibular tip and along the posterior fibular ankle remains in slight dorsiflexion and teno-
31 Supple Equinus, Equinovarus, and Drop Foot Surgical Strategies 351

a b

Fig. 31.5 (a–c) Intraoperative harvest of the posterior tibial tendon with routing through the interosseous membrane

dese the tendons with a high strength nonab- lateral cuneiform or cuboid. The Bridle’s
sorbable suture 2-0 or larger. PT-TA tenodesis will result in some shorten-
• Step 8: Direct the curved tendon passer from ing of the PT; therefore, transfer lateral to the
the anterior leg IO incision distally to the middle cuneiform is typically not feasible. A
peroneal insertion incision. Stay superficial to 3 cm vertical incision is made over the appro-
the extensor retinaculum. Grasp the peroneal priate cuneiform taking care to remain lateral
tendon whip stitch and pull the tendon into the to the marked dorsalis pedis artery.
anterior leg incision. Extraperiosteal exposure of the bone is per-
• Step 9: I prefer to transfer the PT as far later- formed, and the starting point for a tenodesis
ally as possible, so, at this point, I will tension screw guidewire is marked using fluoroscopy.
the PT distally over the dorsal foot and gauge The guidewire is driven through the bone from
how much length I have (Fig. 31.5c). In an dorsal to plantar and out the bottom of the
isolated PT transfer, I can typically reach the foot. Protect the wire’s tip immediately with a
352 R. A. Brandão et al.

sutures with a hemostat and tension the trans-

fer by rolling the instrument over its suture.
Once at least 5° of dorsiflexion is obtained,
place the tenodesis screw. Consider reinforc-
ing the transfer if the cuneiform bone is soft.
The plantar sutures can be tied over a well-
padded bolster, and/or a small suture anchor
can be placed adjacent to the tenodesis site to
improve the transfer fixation.
• Step 11: Obtaining final Bridle procedure cor-
onal plane foot balance is achieved through
completion of the peroneal tendon transfer. A
small coronal incision is made through the TA
just proximal to the PT-TA tenodesis site.
With the foot held in slight eversion, the ten-
don is tensioned and sutured to the TA with
2-0 or larger nonabsorbable suture. The
Fig. 31.6 Plain film radiograph demonstrating the guide
wire placement for the tendon interference anchor in the remaining peroneal stump can then be sutured
lateral cuneiform proximally to the TA for 1–2 cm. As suggested
by Richardson et al., a “box stitch” should be
hemostat or protective cap. Confirm with fluo- placed in the TA both proximal and distal to
roscopy that the wire is perfectly centered the PT and peroneal transfers to reduce ten-
through the desired cuneiform (Figs. 31.6 and sion at the transfer sites during early healing.
31.7a-c). Based on the measured caliber of the When each is tied, “accordion effect” should
PT tendon stump, drill the appropriately sized be noted confirming de-tensioning [11].
tenodesis screw tunnel over the guidewire. • Step 12: If the resting ankle tension is in any
Irrigate bony debris from the transfer site. degree of plantarflexion at this point in the
• Step 10: The curved tendon passer is directed procedure, it is unrealistic to expect an opti-
proximally from the cuneiform window mal surgical result long term. Correct the posi-
toward the anterior leg incision containing the tion by re-tensioning the proximal tenodesis if
PT while also remaining superficial to the necessary. Once a resting ankle position of 5°
extensor retinaculum. Pull the PT distally to of dorsiflexion is achieved, all wounds are irri-
its transfer site. The PT whip stitches are gated and closed in layers. A bulky Jones
passed through the tenodesis guidewire eyelet splint is applied with a focus on supporting the
and pulled out the plantar foot. Grasp the ankle’s dorsiflexed position (Fig. 31.8).

Procedure Pearls and Pitfalls so as to avoid overlengthening and postop-

Posterior Lengthenings erative weakness. Anticipate variable anat-
The importance of a properly performed omy of the sural nerve and always identify
Silfverskiold exam where concern for equi- it. Make every attempt to suture the fascial
nus contracture is suspected cannot be over- layers during closure as it will prevent an
emphasized. One must determine which often frustratingly persistent and painful
tendons should be released and at what level muscular herniation.
31 Supple Equinus, Equinovarus, and Drop Foot Surgical Strategies 353

Bridle Procedure and Posterior Tibial bearing, and carefully monitor the foot posi-
Tendon Transfers tion throughout the procedure. Resist the
Do not operate on a patient with unrealis- temptation to accept residual deformity if it
tic expectations of the procedure. As the sur- is noted. If you accept suboptimal intraopera-
geon, it is your responsibility to educate your tive correction, it will not improve postopera-
patient preoperatively regarding expected tively. Another possible complication is drop
functional limitations, bracing requirements, foot from failure of the tendon transfer. Even
etc. Unless you have already performed doz- after successful transfers, patients may con-
ens of these procedures, I would suggest tinue to exhibit a slappage gait pattern during
respecting the procedures’ complexity by the first postoperative year. This should be
physically writing down a complete opera- braced and monitored for improvement rather
tive plan well ahead of the scheduled case than being seen as a sign of tendon transfer
and taking time to read it regularly. This failure. Although dorsiflexion strength is
exercise commits the procedures’ multiple- expected to only be about 30–33% of a nor-
step progression to memory and helps to mal ankle, studies have shown that this
avoid unnecessary intraoperative hesitation strength still is seen as a significant improve-
and indecision. Such procedural inefficien- ment from preoperative levels [2, 13]. Some
cies drain valuable tourniquet time and patients may require a tightening of their ten-
unnecessarily expose the patient to complica- don transfers due to inadequate intraopera-
tion risk. If your staff is unfamiliar with the tive tensioning or loss of tendon tension
procedure, take time to walk them through postoperatively [11]. It is possible that
the case during the pre-case huddle, or, pref- decreases in both strength and tendon excur-
erably, well in advance of the case. This will sion can occur due to postoperative adhe-
keep them thinking one step ahead and mini- sions. An aggressive rehab protocol involving
mize surgical delays. Anticipate suboptimal tendon manipulation and activation is impor-
tendon and bone quality in chronic drop foot tant and aims to minimize this complication
patients. Have available multiple suture [2]. A more common complication is leg and
options and bone anchoring options in the foot dysesthesias including hypesthesia in
event of poor fixation intraoperatively. In 77% of patients, paresthesias in 61% of
cases of common peroneal nerve injury with patients, and causalgia in 38% of patients.
anterior muscular compartment weakness, Wound complications occurred in 5.9–13.2%
the Bridle’s tenodesis effect provides a stable of patients, with an increase seen in over-
well-balanced foot despite the weak TA. Do weight patients [2, 11]. Per Cho et al., despite
not accept any amount of plantarflexion when the Bridle procedures complexity, its high
you observe the final foot position. The time percentage of postoperative dysesthesias, and
spent re-tensioning will be well worth it in its inability to completely restore full dorsi-
the long run. flexion strength, patient satisfaction rates
Potential Complications remained exceptionally high. In their report,
There are a few potential complications to 80.6% of patients reported willingness to
note related to this procedure. Residual undergo this procedure again. This was addi-
equinovarus deformity is always a possibility tional support by Johnson et al. in their study
and is best managed intraoperatively. Load who follow patient for two years after the
the foot on a flat plate to simulate weight procedure [2, 6, 11] (Figs. 31.7 and 31.8).
354 R. A. Brandão et al.

Fig. 31.7 Postoperative radiographs following PTT transfer. Images (a) and (b) show the placement of the tendon in
the intermediate cuneiform. Image (c) shows guidewire placement in the intermediate cuneiform
31 Supple Equinus, Equinovarus, and Drop Foot Surgical Strategies 355

Fig. 31.8 Intra- and postoperative imaging of a patient that underwent a Bridle procedure

31.6.2 Post-op Care 6. Johnson JE, Paxton ES, Lippe J, et al. Outcomes of
the bridle procedure for the treatment of foot drop.
Foot Ankle Int. 2015;36(11):1287–96.
Please refer to Chap. 1 for detailed descriptions 7. Pinney SJ, Sangeorzan BJ, Hansen ST. Surgical anat-
of each of the different procedures covered in this omy of the gastrocnemius recession (Strayer proce-
chapter. dure). Foot Ankle Int. 2004;25(4):247–50.
8. Richardson DR, Gause LN. The bridle procedure.
Foot Ankle Clin. 2011;16(3):419–33.
9. Silfverskiold NI. Reduction of the uncrossed
References two-­joints muscles of the leg to one-joint mus-
cles in spastic conditions. Acta Chir Scand.
1. Anderson JG, Bohay DR, Eller EB, Witt 1924;56(315):1923–4.
BL. Gastrocnemius recession. Foot Ankle Clin. 10. Silver CM, Simon SD. Gastrocnemius-muscle reces-
2014;19(4):767–86. sion (Silfverskiold operation) for spastic equinus
2. Cho B-K, Park K-J, Choi S-M, Im S-H, SooHoo deformity in cerebral palsy. J Bone Joint Surg Am.
NF. Functional outcomes following anterior trans- 1959;41-A:1021–8.
fer of the tibialis posterior tendon for foot drop 11. Steinau HU, Tofaute A, Huellmann K, et al.
secondary to peroneal nerve palsy. Foot Ankle Int. Tendon transfers for drop foot correction: long-
2017;38(6):627–33. term results including quality of life assessment,
3. Cychosz CC, Phisitkul P, Belatti DA, Glazebrook MA, and dynamometric and pedobarographic measure-
Digiovanni CW. Gastrocnemius recession for foot and ments. Arch Orthop Trauma Surg. 2011;131(7):
ankle conditions in adults: evidence-based recom- 903–10.
mendations. Foot Ankle Surg. 2015;21(2):77–85. 12. Tashjian RZ, Appel AJ, Banerjee R, Digiovanni
4. Digiovanni CW, Kuo R, Tejwani N, et al. Isolated CW. Endoscopic gastrocnemius recession:
gastrocnemius tightness. J Bone Joint Surg Am. evaluation in a cadaver model. Foot Ankle Int.
2002;84-A(6):962–70. 2003;24(8):607–13.
5. Jastifer JR, Marston J. Gastrocnemius contracture in 13. Yeap JS, Birch R, Singh D. Long-term results of tibia-
patients with and without foot pathology. Foot Ankle lis posterior tendon transfer for drop-foot. Int Orthop.
Int. 2016;37(11):1165–70. 2001;25(2):114–8.
 TAR Primary Options
32
W. Bret Smith and P. Pete S. Deol

The first reported series of implantation of an Plainsboro, NJ), the Trabecular Metal Total
ankle replacement was by Lord and Marotte in Ankle (Zimmer, Warsaw IM), and the Vantage
1970 [1]. They published their initial results in Ankle Replacement (Exactech, Gainesville, FL).
1973 about a prosthesis that was implanted in
12 patients. The implant consisted of a long
tibial stem and polyethylene talar replacing 32.1 Indications
component that required a subtalar fusion. This
simple hinge-­type design was modeled after hip Currently ankle arthroplasty is seeing unprece-
implants; unfortunately the complex motion dented amount of data becoming available, as
and stress across the ankle joint led to poor this information of reviewed indications will
outcomes. likely evolve as well. The common indications
Over the last several decades, there has been a for total ankle replacement are end-stage ankle
continued development in ankle replacement arthritis that have failed conservative manage-
prosthesis and understanding. This has been ment. Post-traumatic, osteoarthritis, and rheuma-
accelerating at an increased pace over the last toid arthritis are usually the most commonly
15 years. sighted reasons for offering a patient an ankle
Currently, in the United States, there are seven replacement. Ankle replacements may also be
FDA-approved total ankle replacement systems: considered in those patients with severe adjacent
the Agility (DePuy, Warsaw IN), the STAR joint arthritis that may require a pantalar arthrod-
(Scandinavian Total Ankle Replacement, Small esis. In these setting the patient may be offered a
Bone Innovations, Morrisville PA), the Salto-­ triple arthrodesis procedure along with an ankle
Talaris Total Ankle (Tornier, Stafford TX), the replacement as either a single procedure or staged
Inbone Ankle Replacement System (Wright procedures.
Medical Technology, Arlington TN), the Cadence Since there are not hard and fast rules, it is
Total Ankle System (Integra LifeSciences, important to have patients understand the risks
inherent to ankle arthroplasty and how that fits
W. B. Smith (*) with the expectations for demand and lifestyle.
Foot and Ankle Division Palmetto Health-USC In addition to age and activity issues, the
Orthopedic Center, Palmetto Health, Department patient must have sufficient bone stock to allow
of Orthopedic Surgery, Lexington, SC, USA for the implantation of the prosthesis. They must
P. P. S. Deol also have a healthy soft tissue envelope that will
Panorama Orthopedics & Spine Center, Section allow for adequate coverage after completion of
of Foot & Ankle, Golden, CO, USA

© Springer Nature Switzerland AG 2019 357

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_32
358 W. B. Smith and P. P. S. Deol

the procedure. Soft tissue compromise or signifi- treatment of the ankle. Additionally, any history
cant vascular disease may be reasons for discus- of infection in the region should be extensively
sion of alternative options. It will need to be evaluated. During the physical examination, par-
studied further if alternative approaches may ticular attention should be directed at the distal
offer improved results when soft tissue issues are perfusion and soft tissue envelope. Prior incisions
encountered. should be noted since they might affect planning.
Examination of the patient’s gait and any associ-
ated proximal or distal deformities should be con-
32.2 Contraindications sidered and incorporated into any plan.
Initial imaging should consist of at a mini-
Contraindications to total ankle replacement mum a standard three-view weight-bearing radio-
would consist of active ankle sepsis, osteomyeli- graphic series. The authors also feel strongly that
tis, Charcot or neuropathic joint involvement, a three-view weight-bearing foot films should
complete paralysis of the affected limb, large also be captured if the discussions turns toward
area of avascular necrosis of the talus or distal the possibility of surgical intervention. In addi-
tibia, vascular insufficiency, inappropriate soft tional the standard radiographs, CT scans and
tissue coverage, severe deformities that cannot be MRI imaging studies may be considered in
corrected, and skeletal immaturity. selected cases.
Relative contraindications include ligament
instability, history of infection, diabetes, morbid
obesity, osteoporosis, malalignment, poor soft 32.4 OR Setup/Instrumentation/
tissue, smoking, and neuropathy. Also patients Hardware
that have high demand employment or activity
requirements may require an ankle arthrodesis. Success in the operative room is contingent upon
Patients that cannot comply with postoperative establishing an efficient working environment
protocols may also be considered a relative where the team members work toward a unified
contraindication. goal. This process starts by creating an operative
space in which the surgeon is able to focus on the
task of surgery. The authors ensure that the scrub
32.3 Presentation/Diagnosis/ technician scheduled for the case is accustomed to
Imaging total joint arthroplasty and has discussed the surgi-
cal plan and any potential needs of the surgeon
The majority of patients will present with persis- prior to the start of the case. A surgeon “wish list”
tent ankle pain that has likely been long-standing is given to the scrub team to ensure all necessary
and possibly increasing in severity. Often there equipment is open on the table or available in the
will have been a history of prior trauma to the room to avoid having staff leaving during the case.
affected ankle. Patients will often describe the pain The main instrument table is set up to the specifi-
as deep in the ankle and persistent in quality. Often cations of the scrub tech and surgeon as it would
they will describe times where the pain will be for any case. A second instrument table is con-
increase significantly and will often complain of venient to utilize for the instrumentation specific
edema and swelling in the ankle region. Complaints to the total ankle to minimize congestion onto a
of associated gait abnormalities and other regions single table. The author also prefers to use a Mayo
of the body being affected are quite common. stand during the case on the operative side of the
A through history and physical is required dur- table at the level of the thigh for easy access to
ing the consultation on ankle arthritis. Particular routinely used instruments during the case to allow
attention should be noted about the history of the surgical tech to focus on next steps. The Mayo
injury to the affected joint, treatments they may stand will be laid out with scalpels, pickups, nar-
have employed in the past, and any prior surgical row-tipped mosquito clamps, right-angled retrac-
32 TAR Primary Options 359

tors, self-­retaining retractors, rongeurs, curettes, fashion to end distal to the talonavicular joint
Freer elevators, TPS saw with oscillating blade, (Fig. 32.1). Adequate incision should be used to
sponges, bovie cautery, and suction. This allows decrease tension on the skin during retraction and
the surgeon and surgical assist quick and easy allow for adequate visualization. The interval
access to the main instruments used during the between the anterior tibialis and extensor hallucis
case. Specific instrumentation related to the total longus is developed (Fig. 32.2). Attention is
ankle replacement system chosen by the surgeon given to the anterior neurovascular bundle, which
should be provided by the vendor present at the should be mobilized and protected. Minimal han-
case. Should the need for adjunct procedures arise dling of the tissue and judicious usage of retrac-
as outlined by the pre-surgical plan, it is important tors is warranted to limit undo pressure in the soft
to have associated instrumentation available and tissue, since wound complications have been
present in the operative suite. reported as high as 28% [2, 3].
The need for intraoperative fluoroscopy man- Once the approach has been developed to the
dates consideration for placement of this equip- level of the ankle, a complete debridement is
ment in the operative suite so as to not create done to expose the osseous architecture
congestion for the surgeon in his or her working (Fig. 32.3). Based on the system used, osteo-
space. This author’s preference is to place the phytes may be debrided at this time to allow bet-
fluoroscopy monitor at the head of the bed on the ter visualization of the joint. Prior to beginning
non-operative side of the table. This allows the the bone cuts to prepare the joint for implant, it is
surgeon to glance upward toward the monitor and the author’s preference to release the tourniquet
avoids unnecessary head motion. The C-arm flu- and confirm hemostasis. At this time the cuts are
oroscopy unit is positioned exactly perpendicular completed per the manufacturer’s suggested
to the limb or the table to avoid unnecessary techniques based on the implant being placed
adjustments during the case which require extra (Figs. 32.4, 32.5, 32.6, and 32.7).
imaging. In performing lateral imaging of the Several key areas of concern outside of the
ankle, C-Armor drape or additional three-quarter limited soft tissue envelope are the anterior ten-
surgical drape may be used. Care should be taken dons. These must be protected judiciously during
that the Mayo stand or instrument table does not the cutting of the bone. They are at risk of being
interfere with the transition from AP view to lat- damaged by the sagittal saw and must be repaired
eral view with C-arm unit. if accidently injured. Also, special attention must
be given to the posterior medial corner as the pos-
terior neurovascular bundle, posterior tibialis,
32.5 Surgical Treatment and flexor hallucis longus are at risk. If any of
these posterior medial structures are damaged,
32.5.1 Technique every attempt should be made to repair them.
Once implantation of the prosthesis has been
A peripheral nerve block is preferred by the completed (Figs. 32.8 and 32.9), a meticulous
author and is completed prior to the patient being layered closure is completed (Fig. 32.10). The
taken to the operative suite. The patient is then patient is then placed into a well-padded Jones
positioned supine on a radiolucent surgical table. dressing and awakened from anesthesia. Care
The operative hip is bumped to allow for the foot should be taken that there is not undo pressure on
to be positioned straight. A thigh tourniquet is the incision line after the dressing is applied.
applied, and the operative limb is prepped and
draped to the level of the knee.
An anterior approach is the most commonly 32.5.2 Concomitant Procedures
used incision for ankle arthroplasty. The incision
should start approximately 10–15 cm proximal to Ankle arthritis often does not exist as a lone
the ankle joint and proceed distal in a curvilinear pathology. Retained hardware is often one of
360 W. B. Smith and P. P. S. Deol

Fig. 32.3 Complete subperiosteal dissection and syno-

vectomy of the tibiotalar joint to begin preparation for the
ankle implant

Fig. 32.1 Incision marking for standard anterior ankle Fig. 32.4 Setting initial rotation and resection height
approach for TAR with the external jig. The medial gutter device should
align with the second ray

Fig. 32.2 The anterior tibialis tendon sheath is incised.

Maintain dissection close to the lateral edge of the AT, and
dissect subperiosteally to the lateral side to protect the NV Fig. 32.5 Tibial bone resection is completed with the
bundle and EHL assistance of the cutting jig
32 TAR Primary Options 361

Fig. 32.6 Talar cuts are then completed through the talar Fig. 32.9 Final poly spacer is placed and locked into
cutting jig position

Fig. 32.7 Trial sizers are placed, and tensioning and bal-
ancing are initially assessed

Fig. 32.8 Tibial and talar components are placed, and

final trialing is evaluated for completion of the case. At Fig. 32.10 Closure of TAR incision
this time it is essential the ankle is well aligned and
balanced
362 W. B. Smith and P. P. S. Deol

the most common issues may need to be bone as it has integrates onto the implant. This
addressed in the face of post-traumatic arthritis. author has migrated away from the universal
Adjacent joint arthritis, deformities, equinus approach of the 6-week non-weight-bearing
contractures, and bone stock issues may all period postoperatively for every patient to a more
need to be considered when thinking about a aggressive weight-bearing program beginning at
total ankle replacement. 2 weeks in select patients. The consideration for
Since hardware removal is so common with an early weight-bearing program is predicated
ankle arthroplasty, it is essential to have the antic- upon the quality of host bone documented during
ipated removal instruments available during these the procedure, in addition to the stability of the
procedures. Careful preoperative evaluation of implant and compliance of the patient to adhere
the planned hardware to be removed is critical to our limitations.
since additional complications can be created, Immediately following the procedure patients
such as stress risers. are placed into a bulky Robert Jones dressing
Once the ankle joint is prepared for the with a postoperative splint. The splint is of par-
implant, it is essential to evaluate any residual ticular importance when associated procedures of
equinus contracture of the ankle. Procedures such the Achilles tendon are necessary for sagittal
as Strayer or Baumann procedures to release the plane balancing. Patients are seen for follow-up
gastrocnemius fascia may need to be completed. within 1 week following surgery to monitor heal-
A direct lengthening of the Achilles, such as a ing of the incision and for edema reduction tech-
Hoke procedure, may be utilized, but is not niques. Once the ankle is able to accommodate
favored by the authors. transition into a CAM boot, patients are gradu-
Adjacent joint arthritis is also often associated ated into the boot for institution of an immediate
with these procedures. Often fluoroscopic-guided range of motion program while remaining non-­
injections may assist in differentiating if adjacent weight-­bearing until cleared by the physician.
joints may be contributing to the patient’s pain. Physical therapy to maximize motion, stimulate
Subtalar, talonavicular, and triple arthrodesis muscular contraction, and improve edema reduc-
procedures are common additional procedures tion is initiated in the first 7–10 days.
done in coordination with ankle replacement. If Nonabsorbable sutures used for skin closure are
additional arthrodesis procedures are required, it generally removed between 10 days and 3 weeks
is at the surgeons’ discretion to do as a single-­ after surgery based upon healing of the incision
stage or multiple-staged procedure. and swelling around the ankle. Weight-bearing is
Soft tissue reconstruction can also be consid- first allowed in the CAM boot with a subsequent
ered either in conjunction with osseous proce- transition to an ankle lacer brace between the 6-
dures or in isolation. Medial or lateral ligament and 8-week mark.
reconstructions are the most commonly encoun- Radiographs are used to monitor implant posi-
tered. Usually these will be allograft reconstruc- tion and to identify any potential iatrogenic frac-
tions with or without malleolar osteotomies. tures potentially created with prosthesis
implantation. Subtle callus formation can occa-
sionally be noted around the proximal aspect of
32.6 Post-op Protocol the medial malleolus as a sign of healing from a
cortical stress response. Radiographs are obtained
Postoperative protocols for total ankle arthro- at 1 week, 6 weeks, and 3 months postopera-
plasty will differ upon the surgeon, the implant tively. Follow-up visits with additional radio-
utilized, and patient-specific factors. The basis graphs are encouraged in asymptomatic patients
for stability in joint arthroplasty is the integration at 1 year, 3 years, and 5 years to monitor for any
which occurs between the prosthesis and the host potential short-term or mid-term failures.
32 TAR Primary Options 363

Callouts/Pearls of postoperative joint motion is the motion

–– As with any form of joint arthroplasty, documented to be present during the preop-
experience yields considerable knowledge erative evaluation. It is important to empha-
on techniques that can improve both short- size to patients that chronically stiff ankles
and long-term outcomes. The keys to a suc- are unlikely to have normal motion re-­
cessful total ankle replacement can be established with an ankle replacement.
divided into three periods: preoperative, –– The basic principles and techniques of ankle
intraoperative, and postoperative. joint replacement are generally standardized
–– The criteria for selecting a patient as an among most major implants. However, sev-
appropriate candidate for a total ankle eral subtle technical alterations during the
replacement have been outlined earlier in procedure can help to ensure more predict-
this chapter. During the preoperative phase able outcomes while minimizing complica-
of patient selection, careful evaluation of tions. The distal tibial bone cut is generally
alignment of the lower extremity is of par- made toward the posteromedial neurovascu-
ticular importance. Patients with lower lar structures without direct visualization
limb deformities can jeopardize the longev- and can be a source of consternation. To
ity of the implant due to application of avoid overaggressive excursion of the saw
asymmetric stress to the prosthesis. blade during resection of the posterior tibial
Proximal deformities of concern include cortex in particularly porous bone, this
accentuated Q angle of the knee, coexis- author uses his free hand to palpate the pos-
tence of adjacent joint arthritis with associ- teriormedial corner of the ankle to feel for
ated genu valgum or varum deformities and penetration of the saw blade. If due to ana-
prior malunions from non-operative frac- tomic variation the posteriormedial soft tis-
tures of the tibia or ankle. Similarly, defor- sues are difficult to palpate, the bony cuts
mity of the foot is concerning where can be completed with an osteotome under
midfoot or hindfoot alignment does not fluoroscopy. A second source for intraopera-
establish weight bearing through the tive complications can occur during the
mechanical axis. Full-length weight-bear- impaction process of the tibial implant.
ing radiographs of the limb are the most Due to the press-fit nature of most tibial
useful tool in determining alignment dis- trays, bony overgrowth or incomplete
crepancies between the mechanical axis bone resection may lead to an incongru-
and anatomic axis. As previously men- ent space into which to seat the implant.
tioned, the presence of a plantigrade foot is Overenthusiastic efforts to impact the
of paramount importance in maximizing tibial tray may lead to a stress riser along
implant survivorship. These deformities the medial malleolus and can risk creat-
may be addressed with a single-stage or ing an unstable fracture. Scrutinizing the
two-stage procedure based upon the sur- position of the tibial tray during the trial-
geon’s discretion and the degree of defor- ing phase of the procedure, with visual
mity present. confirmation of a congruent trial on fluoros-
–– In counseling patients about their surgical copy, offers the best opportunity to ensure
expectations, certain preoperative and the final implant will be seated without
intraoperative characteristics will help to requiring unreasonable effort.
shape their surgical outcomes. Many –– Degenerative arthritis of the ankle can
patients present to the office with years of heavily involve the gutters of the ankle in
joint disease which lead to a progressive some patients. Retained gutter osteo-
deterioration in motion. The best predictor phytes may be a significant source of pain
364 W. B. Smith and P. P. S. Deol

for many patients during their postopera- can be tagged during the exposure to aid in
tive course despite an otherwise well-per- closure of the appropriate layer. A secure
formed surgery. During the process of closure of the retinaculum will prevent
gutter osteophyte debridement, it is bowstringing of extensor tendons, which
important to ensure that all residual bone can prevent both cosmetic dissatisfaction
that may lead to bony impingement is from skin adhesions and can reduce wound
removed to allow unrestricted motion. It is complications by minimizing pressure on
helpful to perform this portion of the pro- the incision.
cedure prior to implantation of the pros- –– As with any surgical endeavor, attention to
thesis, but a second look to confirm the detail with a comprehensive understanding
gutters are clear once the total ankle is of the procedure and its risks will maximize
inserted is also recommended. the success of the patient and the satisfac-
–– A meticulous closure of the incision with tion of the surgeon. To avoid patient dissat-
attention to defined layers will greatly isfaction due to unrealized expectations, a
improve the likelihood of successful inci- through discussion must occur preopera-
sion healing. The first layer of closure tively to outline their expectations with the
focuses on the extensor retinaculum, which recovery.

References
1. Lord G, Marotte JH. Total ankle prosthesis: technic
and first results. Aprosos in 12 cases [French]. Rev
Chir Orthop Reparatrice Appar Mot. 1973;59:139–51.
2. Gougoulias N, Khanna A, Maffulli N. How success-
ful are current ankle replacements? Clin Orthop Relat
Res. 2010;468:199–208.
3. Whalen JL, Spelsberg SC, Murray P. Wound break-
down after total ankle arthroplasty. Foot Ankle Int.
2010;31:301–5.
 Revision Total Ankle Arthroplasty
33
Christopher W. Reb and Gregory C. Berlet

Total ankle arthroplasty like all forms of joint arthritis. The goal is not to return the patient to
replacement may fail by a multitude of mecha- “normal” function.
nisms. Failure may in fact be difficult to define as Range of motion for a well-functioning total
the definition of failure may vary based on the ankle arthroplasty is around 30–40° of com-
perspective of the surgeon, the patient, and the posite sagittal motion. Dorsiflexion is always
patient’s supporters. easier to achieve than plantarflexion. Improved
Ankle arthritis is a unique disease that range of motion correlates well with most vali-
affects young people. The average age of inter- dated patient outcome scoring systems like the
vention for ankle arthritis is much younger FAAM but not well with general wellness out-
than the hip and knee, occurring in the mid- come systems like SF-12. This could be inter-
50s. Post-­ traumatic arthritis is the defining preted to show that functional scores improve
pathology for the large majority of ankle arthri- but patients continue to view themselves as
tis patients, and the trauma on average occurred having a disease that continues to need
20–25 years prior when the patients were rela- management.
tively young. This is important as patients have If the patient does not achieve the goals or
had a 10–20 years to think about their injury loses function once obtained, it becomes para-
and disease progression and develop opinions mount to carefully dissect what goals are not
about their treatment. being achieved and why. Some of these may be
A clearly defined goal of the index primary misperception of the anticipated outcomes, and if
ankle arthroplasty is a good place to start. A sim- that is the problem, no amount of revision sur-
plified goal of ankle arthroplasty is to improve gery is going to meet with satisfaction for the
pain and function for the patient with ankle patient or medial provider.
If there are mechanical and quantifiable
problems that seem to correlate with the dis-
satisfaction, then the quest for improvement
with a revision total ankle arthroplasty can be
C. W. Reb (*)
University of Florida, Department of Orthopedics, considered.
Division of Foot and Ankle Surgery,
Gainesvilles, FL, USA
e-mail: [email protected]
G. C. Berlet
Orthopedic Foot & Ankle Center,
Worthington, OH, USA

© Springer Nature Switzerland AG 2019 365

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_33
366 C. W. Reb and G. C. Berlet

33.1 General Concepts Minimal resection implants depend on qual-

to Consider in the Patient ity bone in the distal tibia. The subchondral
with a Mechanical Cause plate is the main strength of the distal tibia, and
of Failed TAR every centimeter of proximal migration of the
tibial cut decreases the quality of the bone. One
Analysis of failure must include: key decision point that is often overlooked is
distal tibial bone quality. There are some
1. Patient selection patients and situations in which a minimal
2. Implant design resection implant is not indicated, and a
3. Surgeon error stemmed prosthesis is a better choice.
4. Normal wear Multi-chamfer cut talus designs are difficult to
5. Bad luck get consistent seating of the implant on the bone.
Every extra cut introduces error for edge loading
and incomplete seating of the implant. A single
33.1.1 Patient Selection flat cut progressing to two, three, four, and five
different cuts leads to an exponential increase in
We must always start by best reviewing the situa- the odds of having a talus implant that is incom-
tion when the decision was made for the primary pletely seated on the cut talus.
TAR as a treatment option. Was this patient a
good candidate based on expectations, body hab-
itus, age, activity demands, and soft tissue 33.1.3 Surgeon Error
balancing?
Far too often, the surgeon erroneously over- Learning curves exist, and OFAC data shows that
emphasizes the implant decision and implanta- an experienced arthroplasty surgeon who
tion when the biggest challenge is creating a switches implants will have a new learning curve
stable foot and soft tissue balancing. A TAR that is unique to that implant. Learning curves are
simply cannot be expected to be the solution only partially transferrable between implants. An
for an unbalanced ankle. The ankle must be in honest accounting of where the surgeon is on
an environment that is “friendly” with a foot their learning curve will help identify some of the
that would stay neutral with or without the decisions that were made in the index
ankle in place. procedure.
A careful conversation on what the patient Jet pilots plan for their flights by doing a pre-
was told to expect will often yield unexpected, flight routine and planning session. Post-flight
erroneous, and often naïve understanding of what they discuss how their systems performed and
to expect with their total ankle arthroplasty. debrief on their mission. The TAR is our mission,
and we must approach it with similar diligence.
Pre-op planning that considers bone alignment,
33.1.2 Implant Design bone quality, and soft tissue balancing must be
done diligently. Postoperative analysis must be
Each implant has its own strengths and weak- done, most importantly when the procedure did
nesses. It is imperative that we understand each not flow as expected. This is a life-long learning
prosthesis and understand their own unique pat- curve and a casual approach without diligence
terns of wear. will lead to unpredictable and disappointing
Mobile-bearing prosthesis is less tolerant of results.
coronal instability. Edge loading and AP transla- Tibial components, regardless of stemmed or
tion can result in gutter pain that is not impinge- minimal resection implants, must load the ante-
ment from bone overgrowth but rather rior and posterior cortex of the tibia. Sizing tem-
impingement from instability. plates of modern implants all account for this
33 Revision Total Ankle Arthroplasty 367

truism, and under-coverage is a surgeon mistake experience will be poor range of motion with a
that will often lead to implant migration and pos- generalized pain in the ankle. Early x-ray films
sible failure. will fail to show the ossification which only
occurs later in the maturity process. Strategies
including perioperative radiation, copious irri-
33.1.4 Normal Wear gation, amniotic tissue membranes, and oral
anti-inflammatories have been tried. There is
Cysts and osteolysis are often used no good data to prove out strategies to prevent
interchangeably. or treat when this is the etiology for patient
Osteolysis is common in ankle arthroplasty. It dissatisfaction.
is best to think of osteolysis as a continuum to
loosening. Osteolysis is an osteoclast-mediated
bone resorption. Polyethylene wear is one vari- 33.2 Imaging and Diagnostic
able, but implant design can have a large influ- Studies
ence as well.
There are two patterns of osteolysis, one Where possible, all relevant imaging and their
occurring early and the other occurring late. It is reports should be reviewed. Critical review of
likely that the early osteolysis is a response to the past films should include assessment of pre-­
injury of the surgery with bone resorption. Late arthroplasty limb alignment, mechanical axis,
osteolysis is likely a particle-mediated response and the characteristics of the arthritic ankle.
to polyethylene debris. This osteolysis pattern is Elements to consider include coronial, sagittal,
unique, very different from hip arthroplasty oste- and axial plane deformity, joint line height,
olysis and most closely related to what we know locations of erosions, characteristics of the foot
about knee arthroplasty osteolysis. shape, and appearance of adjacent joints.
Each implant will have a unique pattern for Serial images of all implants should be
how the bone bonds to the prosthesis, where the obtained. For your own practice, it is considered
implant tends to promote stress shielding and standard of care to follow your patients with
which imaging modalities will be most useful for serial x-rays when performing total joint arthro-
detecting and classifying these defects. plasty. There is no end point to this burden for
One commonly accepted trigger for revision is follow-up. Changes over time should be noted
a progressively enlarging cyst that is greater in its such as implant position change, bony remodel-
maximal diameter of 1 cm. ing, radiolucency formation, changes of the
apparent joint space, and the presence of hetero-
topic ossification.
33.1.5 Bad Luck A current set of images should include mini-
mum weight-bearing views of the ankle, com-
There are some patient where the surgeon has parison views if potentially helpful, and
been thoughtful, skillfully applied the best weight-bearing flexion and extension views.
available technology and the result is disap- Additional views of the foot or long leg weight-­
pointing to everyone. This will be the exception. bearing views to establish the limb’s mechanical
It is normal to expect 80–90% survival at axis may be warranted.
10 years for modern-­generation TAR designs. Adjunctive imaging modalities may include
The survival curve will slowly slope down from selective use of CT scan for characterization of
here, but there are outliers with implant surviv- bony ingrowth or radiolucency size such as bone
als beyond 20 years. cysts. SPECT has been demonstrated to provide
Heterotopic ossification is common in value in cases of suspected subtle implant insta-
TAR. It most commonly lays down along the bility by identifying localized activity at the
posterior capsule of the ankle. The clinical bone-implant interface consistent with failure of
368 C. W. Reb and G. C. Berlet

biological fixation. MRI, or nuclear imaging Classification systems are evolving for both
modalities, may be appropriate for evaluation of the tibia and talus defects. On the talus side, one
osteomyelitis particularly if the patient has under- classification developed with OFAC divides the
gone explant with stabilization by polymethyl- talus into quadrants and size of the primary cyst
methacrylate spacer. and then designates as contained or uncontained.
Laboratory data should be used strategically
to rule in or out items on the differential diagno-
sis. Common studies such as hemogram, meta- 33.3.2 F
 oot Deformity Must
bolic panels, and inflammatory markers can be Be Corrected
used in series to indicate the body’s response to
the condition. Joint aspirate is highly valuable but An implant that has failed in a coronal or sagittal
more variably obtained in the ankle than in larger imbalance is almost always the result of imbal-
joints such as the hip or knee. Image guidance ance. The key is to have an ankle that is balanced
may be needed. When low virulence or atypical without the ankle implant in place. You cannot
organisms are to be considered, immune assay of use an implant to stuff a joint to make up for liga-
the joint fluid may be useful. Biopsy including ment or bone alignment problems.
frozen section to confirm adequate tissue sam- Residual forefoot varus is the most common
pling for pathologic analysis should also be deformity that will drive a TAR into valgus. The
considered. deltoid may become incompetent, but the fixed
forefoot varus in this example is the primary
problem that must be addressed.
33.3 Revision Concepts Foot deformity is often staged in the revision
ankle environment. In the above example with
33.3.1 Native Bone fixed forefoot varus and deltoid incompetence
with a failed TAR, the first stage would be to fix
Native bone is best to provide support for the the foot shape, reconstruct the deltoid, and place
revision prosthesis. The goal is a new cut that is a temporary spacer into the space of the previous
perpendicular to the mechanical axis on both implant. The second stage is the revision ankle
the tibia and the talus. This new cut will hope- where you know now that you have a balanced
fully deliver bone that is biologically active and foot.
can participate in helping secure the implant to
the host bone. Ingrowth surfaces along with
cement will provide the initial and long-term 33.3.3 E
 arly Intervention at the First
fixation. Signs of Loosening
Structural allograft have not been shown to
be resilient with time and able to serve as load TAR implants can coexist with cysts in the tibia
bearing structures. It is likely that through and talus. One of the largest challenges in the
creeping substitution, the ingrowth into the assessment is whether the implant is solidly fixed
allograft weakens the support. Reconstruction to the bone or not. A solidly fixed implant, with a
of uncontained bone defects using cement has progressively enlarging cyst over 1 cm, can be
not demonstrated long-term durability. There treated with bone grafting and biologic stimulation
are some that advocate for rebar in the cement and preserve the implant. This option and opportu-
with k-wires or screws, but the data is lacking. nity is gone as soon as the implant starts to sag into
In the event of anterior bone loss on the tibia, it the defect. A contained defect is the goal when
is better to get a tibial cut proximal that delivers revising implants. Impaction grafting with bio-
native bone than to consider anterior wedging logic stimulation has worked well for contained
strategies. peri-implant cysts on both the tibia and the talus.
33 Revision Total Ankle Arthroplasty 369

33.3.4 Realistic Expectations training in revision ankle arthroplasty and should

be utilized prior to undertaking this type of pro-
A revision implant will not be as functional as a cedure. The above notwithstanding, one should
typical primary TAR. Range of motion is gener- also utilize a peer network to confer with col-
ally quoted in the 20–30° instead of the 30–40 for leagues about the case prior to presenting a defin-
a primary TAR. itive plan to the patient.
Preoperative surgical planning may include
3D rendering of the ankle with the goal of estab-
33.4 Surgical Management lishing the location of the bone cuts which may
be facilitated by patient specific guides in some
33.4.1 Pre-op Planning cases.

The preoperative plan should include a clearly

articulated goal. Most commonly this is to restore 33.4.2 Communication
a stable, painless, well-aligned ankle, with as with the Patient
much range of motion as possible. Working back-
ward, the process should be outlined first in terms Planning for revision total ankle arthroplasty
of major procedures and then in terms of adjunc- often occurs across several patient encounters.
tive techniques. From this, the necessary equip- The patient should be engaged with a plain lan-
ment, time, and factors for convalescent care can guage discussion of treatment options, especially
be determined. if clinical conditions indicate an elective nature
The plan of care must be communicated ahead to additional surgery. Essential elements to
of time to the patient and concerned parties such include and document include the diagnoses,
the operating room coordinator, vendors, and hos- expected natural history of the condition, nonsur-
pital case managers. Indeed, revision total ankle gical treatment options, the recommended proce-
arthroplasty may require deviations from custom- dures including how each is intended to contribute
ary operations that should be worked out in antici- to the overall surgical effect, and their associated
pation of the surgical event. It is advisable to benefits and risks. It is important to provide clear
explicitly request experienced staff and to plan the postoperative instructions, seek and answer the
surgery during their customary work hours. patient’s questions, and discuss their expecta-
Preserving bone stock is critically important tions. It is appropriate to inform the patient that
at all stages of the case. However, the final bone no guarantee on outcome can be made even
stock available for revision total ankle arthro- despite the best possible planning and technique
plasty is only known once explanation is com- execution.
plete. The revision implant must be set on a stable Given the resource investment required for
and healthy bone base; therefore, preoperative such a surgery, it is important to assist the patient
plan should be developed with contingencies in in obtaining advice from treating physicians
mind. Joint line restoration is necessary to about the perioperative management of their
achieve function of the ankle, and the restoration comorbidities. This is essential to minimize
of the joint line will require both tibial and talar unexpected but preventable case delays or post-
strategies. ponements from items like chronic anticoagula-
When developing a preoperative plan, one tion, glycemic control, or timing of other
should become familiar with the available knowl- procedures such as endoscopies or catheteriza-
edge base associated with their patient’s case. tions which would make one ineligible for anes-
There are published techniques for removing dif- thesia on the day of surgery. Appropriate and
ferent implant designs which may be incorpo- experienced second opinions should be encour-
rated into the plan. Further, specialty technique aged, and their commentary should be taken into
courses are available for one to gain advanced consideration.
370 C. W. Reb and G. C. Berlet

33.4.3 Positioning and Equipment 33.4.4 Approach

Because revision total ankle arthroplasty may A revision approach to the ankle nearly always
require intraoperative improvisation, an expan- requires reentry through an anterior longitudinal
sive list of instrument and implant options may approach to the ankle. As with any approach, con-
need to be prepared. A standard instrument tray sideration of structures at risk should result in
for general foot and ankle surgical procedures extra attention to detail. Helpful strategies include
should be supplemented with a full set of osteo- extending the approach into virgin tissue, identify-
tomes, curettes, Steinmann pins and/or Kirschner ing structures at risk in this area, and dissecting
wires. Especially if backup trays are unavailable, them free through the scar bed. Soft tissue han-
all revision total ankle arthroplasty instrument dling must be meticulous and gentle. The use of
and implant trays must be checked for sterility self-retaining retractors on the skin should be
before the patient enters the operating room. avoided but may be permissible for deeper expo-
Bone graft options and polymethymethacrylate sure. Even with tourniquet inflated, one should
and related preparation materials should be avail- anticipate slow bleeding from vascularized scar
able. Where delicate or complicated bone resec- tissue. Since blood is water-soluble, a moistened
tion may be required, a high speed burr should be lap sponge may help to better remove blood to
available. help differentiate a nerve from a similar appearing
The room setup should include space for a area of fascia. On the approach, one should
larger than usual back table array, possibly develop the plan for closure including identifying
including more than one table or a second level closable layers and communicate this plan to staff.
for instrument trays. A large C-arm is customary
and should be positioned opposite the side of sur-
gery. Any reference materials like surgical plan 33.4.5 Technique(s)
or preoperative imaging should be easily viewed
from the surgical field. It is often necessary to remove deep scar tissue
Patient preparations should be made with the from about the ankle and to debride the gutters in
potential for a long case in mind. This implies order to mobilize the ankle. Most commonly this
discussion with the anesthesia team including entails removing scarred in joint capsule and
considering a combination of regional and gen- chronically inflamed synovial tissue. A combina-
eral anesthesia. Intraoperative positioning should tion of osteotomes, curettes, and rongeur is usu-
include ample padding of bony prominences, ally sufficient for this purpose.
ensuring a functioning serial compressive device If bony resection is required, simple excision
on the nonsurgical limb, if appropriate, at the case be achieved with osteotomes and rongeur.
time of anesthesia induction, and appropriately This is adequate for removing lose bone frag-
positioned safety straps. A thigh tourniquet is ments, overhanging osteophytes, or a thin shell of
used, and pressure should be set to the lowest ankylosed bone. However, preoperatively, con-
level that achieves a bloodless field. sideration should be made as to whether or not a
The preoperative time-out should include burr will be needed for more advanced circum-
closed loop communication about key factors stances such as bone removal around a well-fixed
such as antibiotic dosing and the appropriate tim- implant, in the case of a thick shell of a bone in
ing of additional doses, tourniquet duration the posterior ankle, or when the gutters are filled
including length of tourniquet breaks, anticipated in with bone.
blood loss, and the total anticipate duration of the When the revision plan allows for mainte-
case. Additionally, it is often helpful to define nance procedures in order to retain a prior
times during the procedure when staff handoffs implant, ensuring stability and protection of the
are most permissible. implant is necessary before proceeding with
33 Revision Total Ankle Arthroplasty 371

explanting the other components. For example, cific implants and adjust your surgical technique
addressing tibial-sided peri-implant cysts with accordingly.
bone graft, medial malleolus reinforcement with Strategies for removing polymethylmethacry-
retrograde intramedullary screws or a buttress late, especially from intramedullary locations,
plate, or filling a void with polymethylmethacry- include using specialty curettes designed to work
late should be performed. At this time, adjunct by pulling backward against the cement mantle
procedures such as to address gastrocnemius or and ultrasonic instrumentation which temporar-
Achilles tightness may be necessary in order to ily depolymerizes the polymethylmethacrylate.
minimize forces on the retained implant during For cement mantles on the cut ends of the tibia
the remainder of the procedure. and talus, careful use of osteotomes and standard
Polyethylene removal strategies vary accord- curettes to fracture and dislodge the mantle are
ing to the circumstances. One should be familiar often sufficient.
with the manufacturer’s recommended technique Following removal of implants, debridement
for removal whenever possible. Simple polyeth- of fibrous tissue, devitalized or infected bone,
ylene exchange requires precise use of instru- and unincorporated bone graft should be under-
ments to unlock and remove the implant without taken with meticulous technique to avoid unin-
damaging the metal components. The same tended bone removal. Due to many factors, bone
applies when inserting the new implant as the quality may be regionally variable such as soft
manufacturer’s equipment should be used in and friable on the side of stress shielding but
preference to an improvised technique. Most extremely hard on the side of stress loading or
polyethylene components are removed by break- around a cyst. Therefore, a moment to moment
ing the lock detail with an osteotome or drill the assessment of bone material properties must be
side rails to release the lock. A threaded guide maintained.
wire can then be placed into the polyethylene In most instances, the revision components
which is used as a joy stick to remove the poly. can be implanted using the standard instrumenta-
For cases where all implants will be removed, tion provided by the manufacturer with minimal
a more destructive approach to the polyethylene improvisation. Adjunctive techniques required
may be permissible, such as fracturing it with an most commonly are limited to strategies to pre-
osteotome. In this case, however, one should vent iatrogenic bone fracture such as inserted
always bear in the mind the importance of not screws into the medial malleolus or applying a
further complicating the circumstances by dis- buttress plate to the tibial distal medial
placing the other components which could cause metaphysis.
peri-implant fracture or further bone stock Where large bone defects are present, custom
compromise. or modular devices may be required. Examples
An array of techniques may be required for include a revision modular implant system with
metal implant removal. The fundamental princi- metal blocks designed to restore the joint line by
ples are to disrupt the fixation between the filling tibia resection defects, three-dimensional
implant and either bone or polymethylmethacry- porous metal implants designed to fill complex
late while causing the least amount of additional contained and uncontained defects, and custom-­
bone stock loss as possible. The most common fabricated total talus replacements designed to
strategy to employ is utilizing thin osteotomes mate with a particular total ankle arthroplasty
along the prosthesis to dislodge the implant. system. The key consideration when putting
Where fixation extends into the metaphysis or together the revision construct is that the revision
proximal, a cortical window proximal to the implant must sit on stable, healthy bone and the
implant may be needed in order to instrument joint line must be restored. Contralateral ankle
around the components. It is key to understand x-rays can be helpful to best understand where
the most common form of bone bonding to spe- the normal joint line is located.
372 C. W. Reb and G. C. Berlet

33.4.6 Joint Line Restoration

able for these cases. If they are not avail-
The calcaneofibular and posterior medial deltoid able, the case should not proceed.
act as the isometric ligaments of the ankle. To It is strongly recommended to have peer
restore isometry of an ankle, the goal is that these input accessible intraoperatively. This may
ligaments neither lengthen nor shorten during a be a colleague who can be available to co-­
comprehensive arc of ankle motion. To achieve scrub or a consultant available by phone.
this the joint line must be restored. Comparison Safety must be of the utmost impor-
views from the other ankle can help better under- tance during the case. Keep in mind that
stand where the joint line is ideally located. Like the most dangerous steps are likely to be
revision knee arthroplasty, there is the ability those in which instrumentation is occur-
with modern implants to build the tibia down ring from anterior to posterior due to the
from the residual defect after removal of the pri- proximity of the neurovascular and tendi-
mary TAR. This can be done with oversized poly- nous structures anterior and posterior to
ethylene or metal augments. the ankle joint.
On the talus side, there are also defects that It is advisable to have the surgical plan
need management to build the joint lineup. written out as bulleted steps and posted in
Options with modern implants include aug- the room for reference by the surgical team.
mented talus plates that allow the surgeon to This both cues the team to your progress in
come up to the idealized joint line. the case and helps to prevent steps out of
order or omission of key steps.
If working with a trainee, clearly defin-
Intraoperative Pearls and Pitfalls ing intraoperative roles and responsibilities
The key to successful execution is meticu- is essential. This includes defining which
lous preoperative planning and training. steps the trainee with be allowed to per-
Whenever possible, arranging in-service form and providing opportunities before-
training for staff participating in the revi- hand to practice them.
sion total ankle arthroplasty is elemental to Revision surgical wounds over the ante-
intraoperative efficiency. rior ankle have a higher risk of complica-
The sales and technical representatives tions from delayed healing. Meticulous
from the companies related to the current closure of deeper tissues is important to
and revision implant systems should be allowing use of the minimum necessary
engaged in the plan. For companies with an suture on the skin.
expert in revision ankle arthroplasty, time Consider the use of an incisional wound
may be needed to arrange for their involve- vacuum-assisted closure in complicated
ment with the case or with engagement of cases.
consulting surgeons from the company’s
consultant pool.
Consider the use of topical thrombin if
hemostasis is difficult to achieve 33.5 Post-op Care
post-tourniquet.
Discuss tourniquet time durations with In general, revision total ankle arthroplasty con-
your surgical team including the OR coor- valescence follows the same process steps as pri-
dinator and if necessary the physician mary arthroplasty.
director of surgical services to be clear on Multiple postoperative dressings have been
institutional policies related to the use of described in the literature with limited outcome
tourniquet. data to support one over another.
One must insist on having backup or The surgical dressing most commonly con-
alternative instruments and systems avail- sists of nonadherent gauze, 4x4 gauze, and
33 Revision Total Ankle Arthroplasty 373

absorptive padding overwrapped with absorptive • Painful or cosmetically displeasing scar

padding. • Infection, including the possibility of requir-
The limb is protected in neutral dorsiflexion ing unplanned surgical management
with a very well-padded posterior stabilized short • Deep vein thrombosis with possibility of pul-
leg splint. monary embolism
Until the time of suture removal at office fol- • Nerve or blood vessel injury possibly with
lows, usually around 10–14 days, the patient is permanent effects
instructed regarding bedrest with bathroom privi- • Implant fracture, migration, or development
leges, maintaining non-weight-bearing, elevation of peri-implant radiolucency such as cysts
of the limb above heart level, use of the pre- • Side effects from any medications
scribed anticoagulation begin first day after sur- • Compartment syndrome
gery, and adhering to a healthy diet supplemented • Dressing or immobilization-related
with calcium, vitamin D, and protein. Alcohol, complications
nicotine products, and intoxicants are explicitly • Death
disallowed.
Once wound healing, pain, and welling are suf-
ficient to allow it, protected weight-bearing begins 33.7  ase Examples, Analysis,
C
with use of orthoses and ambulatory assistive and Options
devices as needed. At this time, initial stages of
rehabilitation are overseen by a physical therapist. 33.7.1 A
 septic Loosening of Minimal
Clinic visits with x-rays are obtained at 2, 6, Resection Implant
and 12 weeks, then 6 months, and 1 year.
Follow-up continues with x-rays every year (Figs. 33.1 and 33.2).
until 4 years, then every 2 years until 10 years,
and then yearly thereafter. This plan is informed
by the bimodal failure curves reported in the 33.7.2 Problem Analysis Tibia
literature for various types of total ankle
arthroplasty. • Multiple cysts but not expansile.
• Porous ingrowth into barrels.
• Stress shielding around base plate.
33.6 Potential Complications • Bone quality is unknown but could be com-
promised secondary to old fracture.
Potential complications specific to total ankle • Hardware.
arthroplasty include:

• Persistent or worsened pain, swelling, and 33.7.3 Problem Analysis Talus

stiffness
• Less than desired functional recovery • Expansile cysts
• Need for long-term use of orthoses or foot- –– A2 cyst (larger than 12 mm, multifocal, but
wear limitations no peripheral compromise)
• Skin reactions such as blistering in response to • No fractures
suture material or dressings • No subtalar compromise
• Wound problems like delayed healing and • TN is OK (Fig. 33.3)
dehiscence
374 C. W. Reb and G. C. Berlet

Fig. 33.1 Aseptic loosening 9 years post-TAR for post-traumatic ankle arthritis

Fig. 33.2 CT showing contained cysts of both the tibia and talus. Bone quality of the distal tibia is concerning. No
obvious problems with the hardware from ORIF
33 Revision Total Ankle Arthroplasty 375

a b

Fig. 33.3 (a, b) Revision with stemmed tibial implant to ing of contained talus defects and perimeter support talus
bypass poor tibia metaphysis, joint line re-established revision implant
with poly insert. Talus reconstructed with impaction graft-

33.8  ey Points in Revision Total

K p­ reference whether to remove the talus or the
Ankle Arthroplasty tibia first.

33.8.1 Pre-op Planning 33.8.3 Native Bone

• Get good imaging so that you understand • Clearly establish what is good bone to work
residual defects as best as possible. with for your revision implant remembering
• Be hypercritical of the alignment of the limb. that native bone is best.
• Make an assessment of distal tibia bone qual- • All implants remove most of the functional
ity, and decide if a stemmed prosthesis is nec- metaphysis of the tibia upon removal of the
essary to achieve vertical fixation. implant
• In some cases you need to fuse the talonavicu-
33.8.2 Removal lar joint to create more functional bone stock
to sit the talus revision implant on. Revision
• Polyethylene is generally changed any time talus implants will almost always depend on
you are back in a TAR for any reason. peripheral loading as the center of the talus
Disengage the poly taper with the tibia, and has been somewhat compromised by the
remove as the first step of your operation. removal of the primary implant.
• Most implants will come out relatively easy
with gentle levering. It is the surgeon’s
376 C. W. Reb and G. C. Berlet

33.8.4 Cyst Management 33.8.6 Initial Fixation Is Important

• Impaction grafting of contained cysts • Initial fixation of the implants is key. In some
situations, press fit with a revision prosthesis
33.8.5 Restoring the Joint Line can achieve this. In other situations, cement is
a good option. Antibiotic cement is supported
• Have a strategy to restore the joint line, either by the literature as a good option for revision
building down from the tibia up for the talus arthroplasty.
or both.
 Surgical Management of Talar
Avascular Necrosis
34
Jeffrey S. Weber

34.1 Patient History and Findings radiographs and was diagnosed ankle arthritis. He
has no significant past medical history and denies
A number of etiologies for avascular necrosis of any trauma to the affected limb. He had failed oral
the talus have been described and include trauma, anti-inflammatories, an AFO, and multiple joint
long-term corticosteroid use, alcohol abuse, hyper- injections. After standing radiographic images,
lipidemia, hyperuricemia, hypertension, rheuma- MRI of the left ankle was ordered confirming the
toid arthritis, systemic lupus erythematosus, diagnosis of talar AVN (Fig. 34.1a, b). He eventu-
sickle-cell disease, and occlusive vascular disease. ally underwent tibiotalocalcaneal arthrodesis
A thorough history, obtained from the patient (Fig. 34.1c, d).
who presents with hindfoot pain, may allude to one
of the abovementioned causes for talar avascular
necrosis (AVN). A history of trauma accounts for 34.3 Imaging and Diagnostic
the overwhelming majority of talar AVN cases. In Studies
addition to pain, which is often debilitating, inter-
mittent swelling is also a frequent symptom. Weightbearing radiographs of the ankle are the ini-
Extended weightbearing will exacerbate symptoms. tial imaging modality to assess for talar AVN. Initial
The location of the pain may not be able to be pin- radiographs taken early in the disease process may
pointed by the patient, as the talus articulates with be read as negative. As the disease progresses,
the tibia, fibula, navicular, and calcaneus. The sclerotic and/or cystic changes can be seen on
degree of articular surface involvement often corre- plain films. In later stages of the disease, subchon-
lates with level of discomfort [1]. Patient may relate dral collapse, joint space narrowing, and marginal
clicking, locking, or grinding of the ankle as the dis- osteophytes can be observed. Unfortunately,
ease progresses and the talar body collapses. radiographic evidence of talar AVN suggests
advanced progression of the disease that is often
not amenable to nonsurgical intervention.
34.2 Clinical Case Example A high suspicion for the disease leads the sur-
geon to order advanced imaging, most often MRI,
A 59-year-old male presents with the chief com- to assess the degree and location of the osteone-
plaint of left ankle pain for 6 months. He initially crosis. Low signal intensity on T1-weighted and
saw his primary care physician who had obtained high signal intensity on T2-weighted imaging can
be seen due to the high fat content in trabecular
bone in the talar body which is indicative of
J. S. Weber (*) osteonecrosis.
Birch Tree Foot and Ankle Specialists,
Traverse City, MI, USA

© Springer Nature Switzerland AG 2019 377

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_34
378 J. S. Weber

34.4 Surgical Management ized allograft. When significant collapse of

the talus is seen, salvage options include tib-
The degree of talar AVN dictates the surgical iotalocalcaneal fusion or talectomy with tib-
treatment course. Early stages of the disease iotalocalcaneal fusion. At times, below knee
may be amenable to arthroscopic debridement amputation must also be considered in the face
and core decompression. Latent stages may of severe deformity or in patients who may not
require vascularized autograft or nonvascular- be able to withstand or are not good surgical

a c

Fig. 34.1 (a–d) Pre- and postoperative radiographs of a patient underwent TTC arthrodesis after failing conserva-
59-year-old male with no significant past medical history tive management
or remote trauma with avascular necrosis of the talus. The
34 Surgical Management of Talar Avascular Necrosis 379

34.7 Vascularized Extensor

d
Digitorum Brevis Flap

This procedure may be performed in the absence

of any underlying peripheral arterial disease in a
non-tobacco user. It may serve as a primary
means of revascularization for talar AVN or in
revision cases of stage I and II AVN where core
decompression has failed.

34.8 Fresh Talar Bulk Allograft

Fig. 34.1 (continued)

Partial AVN of the talus may be amenable to sur-
gical excision of nonviable, sclerotic bone in
exchange for an anatomically matched, fresh fro-
candidates for the aforementioned attempts at zen cadaveric donor talus with healthy overlying
limb salvage including patients with uncon- articular cartilage. Preoperative planning requires
trolled diabetes mellitus, severe osteoporosis, advanced imaging studies to locate the extent of
peripheral arterial disease, elderly patients, the AVN. This procedure may be selected when
the morbidly obese, heavy tobacco users, and focal talar AVN resides on the medial or lateral
the immunocompromised. Surgical treatment shoulder of the talar dome that has either sub-
options for talar AVN are explored in this sided or when a large overlying articular defect is
section. present.

34.5 Preoperative Planning 34.9 Tibiotalocalcaneal (TTC)

and Tibiocalcaneal (TC)
Surgical treatment plan is guided by the degree of Arthrodesis
talar AVN. MRI will guide procedure selection.
A preoperative history and physical is obtained, Global talar AVN involving both the subtalar
and the patient is medically optimized prior to (STJ) and tibiotalar (TTJ) joint or AVN with
undergoing surgery. This includes a thorough significant collapse or deformity of these joints
workup for any metabolic bone disease or nutri- may not be amenable to the surgical options pre-
tional deficiencies that may affect surgical viously discussed. In this circumstance, further
outcome. attempts at limb salvage involve arthrodesis.
When arthrodesis is selected as the procedure of
choice, further surgical planning involves care-
34.6 Arthroscopic Debridement ful evaluation of the degree of deformity and
and Core Decompression whether or not an in situ fusion is possible
verses the necessity for significant osseous
This procedure selection is based on surgical resection or, at times, talectomy. In situ TTC
management of AVN of the femoral head. Stage I with preservation of the majority of the avascu-
and II talar AVN without collapse is amenable to lar talar body is met with skepticism as the bio-
revascularization attempts through arthroscopic logical environment is challenged with the task
evaluation and debridement of the ankle and or of fusing living bone to dead bone (Fig. 34.2a–d).
subtalar joint coupled with retrograde drilling of On the other hand, the option of removing the
the talus via the sinus tarsi. talar body and replacement with femoral head
380 J. S. Weber

a d

Fig. 34.2 (a–d) Pre- and postoperative radiographs of a apy, the patient stated she suffered an ankle sprain which
4-year-old female with a history of long-term prednisone went on to cause persistent ankle pain. Preoperative MRI
use secondary to complications of severe pneumonia. shows global talar AVN
Several months after discontinuation of prednisone ther-

allograft is met with the same challenge with the use of fibular autograft that is placed
(Fig. 34.3a, b). Historically, the authors have through a bone mill, an orthobiologic graft with
preferred native talus that is meticulously osteoinductive, osteoconductive, and osteogenic
denuded of all remaining cartilage and fenes- properties, and an internal bone stimulator.
trated to promote vascular ingrowth coupled More recently, we have used the medullary
34 Surgical Management of Talar Avascular Necrosis 381

a gaining popularity in this circumstance is the

utilization of a three-dimensional titanium truss
system that is tailored to the patient in order to
maintain limb length. These systems can accom-
modate an intramedullary nail and allow for
osseous ingrowth of the implant in the absence
of the talus. Stainless steel talar prosthesis is
now being used for AVN and talar crush inju-
ries. Satisfactory results have been reported [1].
However, long-term outcome studies are
lacking.
b

34.10 Positioning and Equipment

34.10.1 Arthroscopic Debridement

and Core Decompression

Advanced imaging studies are made readily

available in the OR prior to the beginning of the
case to serve as a guide for drill placement later
on during the procedure. Regional anesthesia in
the form of a popliteal and saphenous nerve block
is administered preoperatively by the anesthesia
team. The patient is brought to the operating
Fig. 34.3 (a, b) Femoral head allograft serves to main- room and placed supine on the operating room
tain limb length when the talectomy is performed. The
talar head is left intact to maintain its articulation with the table and administered general anesthesia. The
navicular bone patient is positioned so that the feet are at the
edge of the table. A thigh tourniquet is applied.
The operative extremity is placed into a thigh
reamings of the tibia harvested during the drill- holder to elevate and bend the knee and is then
ing preparation for an intramedullary nail for prepped and draped up to the tourniquet. A non-
graft with the rationale that this material is invasive ankle distractor is applied.
almost purely cancelous bone as opposed to
morselized fibula which is mostly cortical bone.
The preservation of the talus in hindfoot arthrod- 34.10.2 Vascularized Extensor
esis maintains the talonavicular joint articula- Digitorum Brevis Flap
tion in contrast to femoral head allograft which
is typically not fixated to the remaining talar The anterior process of the calcaneus is partially
head when left in place and goes on to form a vascularized by the extensor digitorum brevis
pseudoarthrosis. (EDB) muscle belly and several small arterial
Late-stage talar AVN with significant col- branches that may be transferred into the talar
lapse of the talar body leaves little to no remain- body. The patient is brought to the operating room
ing native talus. The surgeon is then left with the and placed supine on the operating room table and
option to perform tibiocalcaneal (TC) arthrode- administered general anesthesia. The patient is
sis leaving the limb functionally shorter to the positioned so that the feet are at the edge of the
contralateral side or utilizing femoral head table. A thigh tourniquet is applied. The operative
allograft as a physiologic spacer. Another option extremity is and draped up to the tourniquet.
382 J. S. Weber

34.10.3 Fresh Talar Bulk Allograft –– Sagittal saw blade for fibular osteotomy
and access to ankle and subtalar joint
Advanced imaging studies are made readily –– Femoral head allograft or prefabricated
available in the OR prior to the beginning of titanium truss cage when indicated
the case to serve as a guide for drill placement –– IM nail or lateral TTC arthrodesis plate
later on during the procedure. Regional anes- –– Optional external fixator for added stability
thesia in the form of a popliteal and saphenous in osteopenic bone, the neuropathic, or
nerve block is administered preoperatively by noncompliant patient
the anesthesia team. The patient is brought to the –– Orthobiologic of choice
operating room and placed supine on the oper- –– Bone mill in order to morselize fibula
ating room table and administered general anes- –– Internal bone stimulator
thesia. The patient is positioned so that the feet
are at the edge of the table. A thigh tourniquet
is applied. The operative extremity is placed into 34.11 Approach
a thigh holder to elevate and bend the knee and
is then prepped and draped up to the tourniquet. 34.11.1 Arthroscopic Debridement
Surgical instrumentation required consists of the and Core Decompression
following:
An 18 gauge spinal needle is inserted into the
• General instrument set medial gutter of the ankle and 10 cc of 1% lido-
• Sagittal saw blade: 42 × 13.3 mm for medial caine with epinephrine (1:100,000) is used to
malleolar osteotomy insufflate the joint. Standard anteromedial and
• Sagittal saw blade: 25 × 9 mm for talar anterolateral scope portals are made. A full joint
osteotomy inspection is performed to assess the articular car-
• 4.0 mm partially cannulated headed screws tilage for lesions and collapse. A 4.0 mm shaver
for medial malleolar osteotomy wand is inserted into the lateral portal, and hyper-
• 1/ 3 tubular fibula plate with 3.5 mm locking trophic and hemorrhagic synovitis is debrided. A
and nonlocking screws for lateral malleolar 2.7 mm arthroscope and shaver are the preferred
osteotomy sizes if subtalar arthroscopy is to be performed.
• Resorbable headless screws for graft fixation After arthroscopy, the operative extremity is taken
out of the thigh holder and ankle distractor.

34.10.4 TTC or TC Arthrodesis

34.11.2 Vascularized Extensor
Preoperative radiographs are reviewed and Digitorum Brevis Flap
made readily available prior to the beginning
of the case (Fig. 34.4a–d). The patient receives A modified Ollier’s incision is made over the
regional anesthesia in the form of a popliteal sinus tarsi approximately 2 cm anterior to the distal
and saphenous nerve block and brought to tibia curving toward the base of the third metatar-
the operating room and placed in the supine sal and overlying the EDB muscle belly.
position on the operating table. A well-pad- Dissection is carried through the inferior extensor
ded thigh tourniquet is applied. The operative retinaculum to expose EDB muscle belly and the
leg is prepped and draped in the usual sterile dorsal lateral aspect of the calcaneocuboid joint.
fashion.

• Necessary equipment includes: 34.11.3 Fresh Talar Bulk Allograft

–– General instrument set
–– Curved curettes, osteotomes, and a mallet For AVN of the medial talar dome requiring
for joint preparation medial malleolar osteotomy, a curvilinear medial
34 Surgical Management of Talar Avascular Necrosis 383

a d

Fig. 34.4 (a–d) Patient with neglected talar body fracture which went on to develop talar AVN. An additional 7.0 mm
screw was outside of the IM nail to provide additional stability across the subtalar and ankle joints
384 J. S. Weber

ankle incision is made splitting the difference approach allows access to all areas of the talus
between the anterior and posterior tibial cortices. without potentially compromising the medial
Care is taken to protect the deltoid ligament in neurovascular structures. A 3/32 Steinman pin/
order to expose the anterior ankle gutter. A small guide wire is used within a wire driver. The MRI
incision is made in the posterior tibial tendon images should be readily available for reference
sheath as it courses behind the medial malleolus to assess the location of AVN. These images are
in order to protect it during the osteotomy. displayed on a computer preoperatively in the
For AVN of the lateral talar dome requiring a operating room. A mini C-arm is used in multiple
lateral malleolar osteotomy, a linear incision is planes to triangulate the area of interest. The
made over the fibula curving anteriorly at the guide wire is inserted into the sinus tarsi under
inferior aspect of the fibula. Dissection is carried live fluoroscopy to ensure proper trajectory and
down to periosteum. Care is taken to avoid the that the articular surface of the talar dome is not
sural nerve. violated. Several passes into the area may be
An anterior approach is used for central talar required depending on the extent of AVN in order
AVN and is the same exposure that is used for to allow to new vascular channels to form. The
total ankle arthroplasty. An incision is made guide wire is then placed in the center of AVN
between the extensor hallucis longus (EHL) and and a 4.0 mm drill bit is placed over the wire. A
tibialis anterior (TA) tendons. The extensor reti- small incision is made over the guide wire to
naculum is tagged with 0 Vicryl for easy identifi- allow passage of the drill bit. Fluoroscopy is
cation and closure at the end of the procedure. again utilized to make on pass with the drill in the
Care is taken to leave the TA tendon within its area of interest in order to core out sclerotic, non-
sheath. The anterior ankle capsule is incised and viable bone. The drill and wire are removed.
a Cobb elevator is utilized to gain exposure to the Demineralized bone matrix (DBM) soaked in
anterior and central aspect of the talar dome. autologous platelet-rich plasma is injected via
trocar into the channel made by the drill.
Typically, 1–2 cc of DBM is all that is required.
34.11.4 TTC or TC Arthrodesis The incision is irrigated to remove any osseous
debris and then closed with 3–0 nylon suture.
A lateral linear incision is made over the distal 1/ 3
of the fibula and curving in a J shape distally over
the sinus tarsi. Full-thickness dissection is carried 34.12.2 Vascularized Extensor
down to the fibula. The author also prefers and Digitorum Brevis Flap
anteromedial ankle incision in order to gain full
access to the medial gutter for the purpose of joint A guide wire for a 4.0 mm cannulated drill is
preparation in this area. At times, the medial mal- introduced through the same incision used to
leolus must be resected in order to medialize the expose the EDB and sinus tarsi and place into the
talus. In this circumstance, the medial incision is area of talar AVN under fluoroscopy. The drill bit
made directly over the midpoint of the medial is then placed over the guide wire and advanced
malleolus. into the talus. The wire and drill are removed, and
the drill hole may be curetted to remove any more
sclerotic bone within the talar body. New vascu-
34.12 Technique(s) lar channels may be created using the guide wire
making multiple passes through this pilot hole.
34.12.1 Arthroscopic Debridement An osteotomy of the anterior calcaneal process is
and Core Decompression performed with a ½ inch straight osteotome with
care being taken to preserve the attachment of the
Retrograde drilling is performed percutaneously EDB on the anterior process. The vascularized
through a lateral sinus tarsi approach. This graft is then rotated superiorly into the 4.0 mm
34 Surgical Management of Talar Avascular Necrosis 385

pilot hole and delicately press fit with an Adson Nonviable bone margins are identified with a
forceps. If additional length is required to trans- skin marker, and a sagittal saw is used to make
pose the graft, the EDB is subperiosteally stripped square cuts in the talus. An osteotome is used to
from the calcaneus using a freer elevator. No fix- finish bone cuts. Sclerotic bone is excised down
ation is required as it would likely compromise to healthy bleeding subchondral bone. A K-wire
the vascularity of the graft. Layered closure is is used to fenestrate the bone to encourage vas-
performed with 2–0 Vicryl and 3–0 nylon. cular channel formation to the donor graft.
Measurements of the talar deficit are recorded
and used to mark out an equivalent section on the
34.12.3 Fresh Talar Bulk Allograft corresponding fresh bulk talar allograft which is
held in a vice on the back table to secure the
With the medial malleolus exposed, two guide graft. When marking out measurements on the
wires are placed into the medial malleolus, and allograft, it is recommended to slightly oversize
their position is confirmed with mini C-arm. A the graft. A sagittal saw under drip irrigation is
cannulated drill bit is then placed over each utilized to harvest the appropriately sized
wire and then underdrilled to a depth several allograft from the fresh talus. The allograft may
centimeters beyond the planned osteotomy. be soaked in bone marrow aspirate for several
Pre-drilling ensures anatomic alignment of the minutes. It is then press fit into the talar defect.
medial malleolus with screw fixation at the end Proper contouring of the allograft may require
of the case. A guide wire is placed from the slight modification by feathering the graft with
superomedial margin of the medial malleolus the sagittal saw to ensure an anatomic fit. With
extending inferolateral to the apex of the medial the graft well-­aligned at the recipient site, it is
ankle gutter. This wire serves as an osteotomy held in place with one hand and secured to the
guide. Two Hohmann retractors are used to talus with either 2.0 mm headless screws or bio-
define the anterior and posterior margins of the absorbable chondral darts.
tibia. The posterior Hohmann is used to protect Closure of the lateral or medial malleolar oste-
the posterior tibial tendon. Anteriorly, the sec- otomies is accomplished with relative ease with
ond Hohmann is placed in the medial ankle gut- plates and screws that were implanted and
ter. A chevron-type osteotomy is performed removed prior to the osteotomy being performed.
with care taken to not violate the surface of the The lateral collateral ligaments are repaired with
talar dome. The osteotomy may be completed 0 Vicryl. The AITFL may be repaired with 0
with an osteotome and mallet. Vicryl, or at times, a small bone anchor with 0
If a lateral malleolar osteotomy is to be per- nonabsorbable suture. Layered closure is per-
formed in order to gain access to lateral talar formed with 0 Vicryl for deep fascia and retinac-
AVN, a 5 or 6 hole 1/ 3 tubular plate is con- ular tissue, 2–0 Vicryl for subcutaneous tissue,
toured and predrilled prior to making the oste- and 3–0 nylon for the skin.
otomy in order to ensure anatomic reduction of
the fibula. The osteotomy is performed with a
sagittal saw in a transverse fashion at the level 34.12.4 TTC or TC Arthrodesis
of the ankle joint. The anterior inferior tibio-
fibular ligament must be released in order to An osteotomy of the fibula is made just proximal
posteriorly rotate the lateral malleolus to to the ankle joint using a sagittal saw directed lat-
expose the lateral talar dome. The fibula may eral, proximal to distal medial. This ensures no
be temporarily pinned with a K-wire to hold it prominence of the fibula remains after resection.
out of the way during the procedure. Surrounding soft tissue attachments are dissected
Visual inspection of the exposed talus is cor- off the fibula and the distal ankle syndesmosis
related with the MRI that is readily available in with bovie and osteotome. A bone hook placed
the operating room during the procedure. within the canal of the distal fibula with lateral
386 J. S. Weber

Fig. 34.5 Lateral exposure to fibula with osteotomy Fig. 34.6 Once the distal fibula has been excised, the
above the level of the tibiotalar joint. A bone clamp is used subtalar and ankle joints are exposed and prepared.
to aid in excision of the distal fibula Talectomy may be performed in the case of severe col-
lapse if femoral head allograft or a titanium truss is to be
used
traction allows for ease of dissection until the lat-
eral malleolus is freely removed (Figs. 34.5 and drilled with a 2.0 mm drill bit to promote vascu-
34.6). All bleeders are tied off or cauterized as lar ingrowth. The talus is sacrificed at the talar
necessary. neck, leaving the talonavicular articulation.
Further exposure of the ankle and subtalar Fixation of the allograft to the remaining talar
joint is accomplished with release of ligamentous head is not routinely performed. Tibiocalcaneal
and capsular attachments with a 15 blade, osteo- arthrodesis is another option if allograft or a tita-
tome, and rongeur. Lamina spreaders or a nium truss cage is not used; however this leads to
Hintermann distractor allow access to both joints. a functionally shorter limb with severely impaired
All remaining articular cartilage is denuded with biomechanics.
curved curettes. With talar AVN, large areas of An ankle arthrotomy is made medial to the
sclerotic bone must be resected to the point of tibialis anterior tendon with care taken to avoid
viable bleeding subchondral bone. The distal fib- the great saphenous vein and nerve. Exposure
ula, which was removed in order to gain access to to the medial gutter through this approach
the ankle and STJ, is morselized on the back table allows for further joint preparation that was not
in a bone mill. This graft may be used for filling reachable from the lateral incision. Flat cuts of
bone voids. Further joint preparation is per- the tibia, or resection of the medial malleolus,
formed with subchondral drilling with a 2.0 mm are made in the case of appreciable deformity
drill bit followed by fish scaling the joints with an in order to restore the alignment of the talus
osteotome and mallet. directly under the tibia only when necessary as
If talectomy is to be performed, the void may gratuitous dissection in this area may compro-
be filled with femoral head allograft which is mise the medial arterial supply to the talus and
34 Surgical Management of Talar Avascular Necrosis 387

thus the fusion site. Autograft and biologics are

placed in both joints at this time. The talus and
calcaneus are situated directly under the tibia
and translated slightly posterior to decrease the
lever arm of the foot. The ankle should be in
the neutral position with 5° of external rotation
and 5° of heel valgus. Provisional fixation may
be accomplished with Steinman pins in the
periphery of the t­ibiotalocalcaneal articula-
tions in order to allow central access for the
entry wire if an intramedullary nail (IM) is to
be used. The entry wire is inserted, and its
position is confirmed with AP and lateral ankle
views as well as a calcaneal axial views.
Several authors have described how to deter-
mine the entry point for the wire [2–6]. After
proper placement of the guide wire, a vertical
incision is made on the plantar aspect of the
foot in the longitudinal plane approximate
2 cm. Sequential reaming is then performed in
0.5–1.0 cm increments just proximal to the
isthmus of the tibia to allow for adequate resec-
Fig. 34.7 Lateral TTC arthrodesis plate. The combina-
tion and accommodate for the length of the
tion of locking and eccentric nonlocking holes allow for
nail. The IM nail is inserted per the guidelines sequential compression across the ankle and subtalar
specific to that implant. A lateral TTC locking joints
plate may also be used (Figs. 34.7 and 34.8). A
static external ring fixator may be used in iso-
lation with wire tension technique or more
commonly in combination with internal fixa-
tion. A combination of internal and external
fixation is typically reserved for neuropathic
patients or in patients with a history of non-
compliance as weightbearing in the early post-
operative period may lead to hardware failure
and compromise of the arthrodesis.
Internal bone stimulators are used primarily in
patients with poor bone stock, diabetes, a history
of tobacco abuse, or the immunocompromised
(Figs. 34.9a, b). External bone stimulators are
routinely used in all remaining TTC patients. The
authors prefer a pulsed electromagnetic field
bone stimulator as the efficacy of ultrasound
bone stimulators in the presence of orthopedic
hardware has come into question.
Layered closure of deep fascia is performed
with 0 Vicryl, subcutaneous closure with 2–0
Vicryl, and skin with 3–0 nylon in a horizontal
mattress fashion.
Fig. 34.8 Lateral radiograph with TTC locking plate
388 J. S. Weber

a
Intraoperative Pearls and Pitfalls
• Arthroscopic debridement and core
decompression
–– Live fluoroscopy should be utilized
when performing core decompression
in order to avoid violating the articular
surface of the talar dome. An AP radio-
graphic may be obtained for initial
entry into the talus. Further advance-
ment of the wire should occur with a
lateral radiograph due to the convex
shape of the talar dome in order to
truly gauge the depth of the wire.
• Vascularized extensor digitorum brevis
b flap
–– The sural nerve and peroneal tech-
nique tendons should be carefully
protected with this approach.
–– Avoid excessive dissection of the
EDB to avoid compromising the vas-
cularity of the graft.
–– If the graft does not appear to fit
snugly into its pilot hole in the talus,
use 2–0 Vicryl to suture the edge of
the EDB to the graft/talus interface.
–– Place bone wax over osteotomy site
to avoid postoperative hematoma
formation.
• Fresh talar allograft
–– Fibular osteotomy should be on the
superior margin of the ankle joint to
allow full inspection of the articular
surface of the talar dome.
–– A malleable retractor can be useful to
protect the articular surface of the
talus when making the medial mal-
leolar osteotomy.
–– Slightly oversize the allograft at first
and fine-tune sizing for an exact
contour.
• TTC and TC arthrodesis
–– It is important to prep the skin above
the knee to assess for the correct
amount of external rotation of the
foot prior to definitive fixation.
Fig. 34.9 (a, b) Internal bone stimulators are used pri-
–– Avoid extensive dissection of the
marily in patients with poor bone stock, diabetes, a history medial structures to avoid compro-
of tobacco abuse, or the immunocompromised mising the medial talar blood supply.
34 Surgical Management of Talar Avascular Necrosis 389

• Postop week 7, the patient is transitioned into

–– Accurate placement of the entry wire a below knee fiberglass walking cast.
for the IM nail will dictate the final • Postop week 11, the patient is transitioned
position of the nail. AP, lateral, and into a high surgical walking boot.
calcaneal axial views are imperative • Postop week 15, the patient is transitioned
prior to reaming. into an orthopedic shoe with or without an
–– Utilization of the dynamized screw Arizona brace or AFO.
slot allows for some subsidence at
the arthrodesis site over time. This is
not advisable in the setting of 34.15 Potential Complications
osteopenic bone.
• Arthroscopic debridement and core
decompression
–– Neuritis from scope portals. Careful inci-
34.13 Postoperative Care sion placement is advised.
–– Violation of articular cartilage. Use of live
The patient is placed in a bulky Jones compression fluoroscopy will mitigate this.
dressing with posterior mold plaster splint with the • Vascularized extensor digitorum brevis flap
ankle in the neutral position for 1 week. They are –– Sural nerve irritation
then made nonweightbearing in a below knee fiber- –– Hematoma formation at osteotomy site
glass cast for 3 weeks. At postoperative week 4, • Fresh bulk talar allograft
sutures are removed and is then transitioned into a –– Improper fit of the allograft will lead to
patellar tendon brace (PTB) but still kept non- abnormal contact surface area within the
weightbearing. Physical therapy is initiated at this tibiotalar joint causing continued pain and
time for nonweightbearing active and passive range excessive articular wear.
of motion to prevent arthrofibrosis and promote –– Nonunion at the osteotomy site may be a
movement of synovial fluid to stimulate nutrient source of continued pain and need for sec-
flow within the surgically created bone tunnels to ondary surgery.
encourage new vascular ingrowth. At postoperative –– Nonunion of the allograft with native bone
week 8, ankle films are obtained to assess for heal- may require secondary surgery in the form
ing, and the patient is allowed partial weightbear- of joint arthrodesis.
ing in the PTB for transferring and balancing. • TTC and TC arthrodesis
Gradual transition to weightbearing in the PTB is –– With extensive dissection required for this
permitted for several more weeks followed by procedure, postoperative hematoma may
weightbearing in an ankle-­foot orthosis (AFO) or lead to wound complications. A surgical
rigid ankle brace until 6 months after surgery. drain for the first 24–48 hours is advised.
Repeat MRI is obtained around the 6-month post- –– Nonunion of either the tibiotalar or
operative mark to assess the healing response. subtalar joint may require an extended
period of nonweightbearing or revision
arthrodesis.
34.14 TTC and TC Arthrodesis

• The patient is made NWB in a bulky jones References

compression dressing with posterior plaster 1. Harnroongroj T, Harnroongroj T. The talar body pros-
mold splint. thesis: results at ten to thirty-six years of follow-up. J
• Postop weeks 1 and 4, the patient maintains Bone Joint Surg Am. 2014;96:1211–8.
NWB in a below knee fiberglass cast. Sutures 2. Roukis T. Determining the insertion site for retrograde
intramedullary nail fixation of tibiotalocalcaneal
are removed at postop week 4.
390 J. S. Weber

arthrodesis: a radiographic and intraoperative land- 5. Mader K, et al. Calcaneotalotibial arthrodesis with
mark analysis. J Foot Ankle Surg. 2006;45(4):227–34. a retrograde posterior-to-anterior locked nail as a
3. Quill G. Tibiotalocalcaneal arthrodesis with salvage procedure for severe ankle pathology. JBJS.
medullary rod fixation. Tech Foot Ankle Surg. 2003;85(suppl_4):123–8.
2003;2(2):135–43. 6. Belczyk RJ, Combs DB, Wukich DK. Technical tip:
4. DiDomenico L, Adams H. Intramedullary nailing a simple method for proper placement of an intra-
for Charcot arthroplasty of the hindfoot and ankle. medullary nail entry point for tibiotalocalcaneal
Philadelphia: Lippincott Williams and Wilkins Co; or tibiocalcaneal arthrodesis. Foot Ankle Online J.
2005. 2008;1(9):4–11.
 Hindfoot and Ankle Charcot
Reconstruction
35
Roberto A. Brandão, Justin Daigre,
and Christopher F. Hyer

35.1 Introduction amputations by a factor of 6 compared to patients

without wounds. A 5-year mortality rate in dia-
Charcot neuroarthropathy (CN) is a devastating betic patients after lower extremity amputation
illness. The destructive process leads to foot and varies from around 39–68% [4]. As foot and
ankle deformities possibly resulting in ulcer- ankle surgeons, preventing ulcerations and
ations, subsequent infections, and poor quality of obtaining successful limb salvage are paramount
life. The prevalence of CN is estimated at around in treating this difficult patient population.
0.3% per thousand per year [1]. The incidence is CN of the hindfoot and ankle is particularly
probably higher than reported because of the destructive and often leads to profound and
increase in diabetes seen over the past few severe instability which may be unbraceable
decades. (Fig. 35.1). Charcot of the ankle, especially in
Quality of life is often poor for patients with cases where the talus is essentially resorbed,
CN of the foot/ankle. Successful nonoperative can lead to below-knee amputation rates of
treatment has failed to improve quality of life 30–50% [5]. The treatment of hindfot and ankle
measures in CN patients [2]. Recent studies have CN is a challenging problem that can be asso-
shown successful limb salvage and improvement ciated with higher complication rates [6]. This
in quality of life following Charcot reconstruc- rate may be higher in the unfortunate cases that
tion [3]. In light of the recent evidence, foot and have CN of both the ankle/hindfoot and midfoot.
ankle surgeons need to be prepared to treat CN Additionally, patients who have CN collapse in
patients with surgical reconstruction. the setting of deep infection or ulceration are at
Wounds associated with CN of the foot/ankle higher risk for amputation.
have been shown to increase lower extremity This chapter will review surgical techniques
in patients with ankle and hindfoot CN defor-
mities. Midfoot CN deformities are covered in
R. A. Brandão (*) Chap. 16.
The Centers for Advanced Orthopaedics, Orthopaedic
Associates of Central Maryland Division,
Catonsville, MD, USA
35.2 Clinical Presentation
J. Daigre
Decatur Morgan Hospital, Decatur Orthopaedic
Clinic, Decatur, AL, USA During the acute phase (Eichenholtz stage 0),
C. F. Hyer patients present with a swollen, erythematous
Orthopedic Foot & Ankle Center, foot that is usually mistaken for infection or
Worthington, OH, USA sometimes even gout. Pain may or may not be

© Springer Nature Switzerland AG 2019 391

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_35
392 R. A. Brandão et al.

Fig. 35.1 Clinical view profound unbraceable CN valgus

ankle instability

present. Radiographs can be normal. As the pro- Fig. 35.2 Clinical view profound unbraceable CN valgus
cess advances, subsequent bony fragmentation ankle instability
(Eichenholtz stage I) occurs leading to deformity.
Patients tend to present with a clinically deformed bone remodeling or consolidation has occurred,
hindfoot or ankle. Gross instability may be pres- the deformity may be rigid with significant bone
ent depending on the amount of bony and soft hypertrophy. This nonreducible deformity is sec-
tissue destruction. Pre-ulcerative lesions and ondary to osseous impingement, or long-term
frank ulcerations should be checked for and doc- adaptation of the deformity may be custom-brace-
umented. Blood flow should be assessed using able but likely will have “at-risk” areas of tissue.
palpation of pedal pulses, Doppler, noninvasive Pre-ulcerative lesions or frank ulcerations are
arterial studies, or angiography. common on the lateral or medial malleoli (particu-
Patients may present with gross hindfoot and larly with ankle joint Charcot deformity), navicu-
ankle instability with or without crepitus of the lar tuberosity, or inferior to the cuboid, depending
affected joints. A valgus (Fig. 35.2) or varus on level of deformity (Figs. 35.5 and 35.6).
(Fig. 35.3) ankle deformity can be present, with Ipsilateral edema secondary to the inflammatory
valgus a bit more commonly seen. Depending on nature of the disease process is often present with
the chronicity and bone remodeling, the deformity or without concomitant venous stasis disease.
may present as rigid or profoundly unstable with Morbid obesity is a common physical exam find-
dislocation of the ankle and/or hindfoot joints ing as well as loss of protective sensation and
(Fig. 35.4). In cases of talar resorption, the foot frank neuropathy. All aspects of motor, sensory,
will seemingly be hanging from the leg by the skin and autonomic neuropathic changes in the foot
and soft tissue structures. In other cases, where should be recognized and documented.
35 Hindfoot and Ankle Charcot Reconstruction 393

Fig. 35.5 Clinical lateral ankle view: Pre-ulcerative

lesion due to varus CN ankle instability

Fig. 35.3 Clinical view of unbraceable varus ankle

from CN

Fig. 35.6 Chronic hypertrophic lateral ankle ulcer with

granulation tissue. Wound has had multiple I&Ds and
wound grafts but remains secondary to instability

35.3 Nonoperative Treatment

Nonoperative treatment may be attempted in

patients with mild to moderate deformities and
Fig. 35.4 Lateral WB radiograph: Fragmentation and acute Charcot with no deformity, patients without
dislocation of the talus secondary to CN wounds or wounds that do not probe to bone, and
patients with multiple comorbidities that greatly
increase the risk of surgery. Management of ulcer-
394 R. A. Brandão et al.

Fig. 35.8 Example of Arizona-type custom AFO

Fig. 35.7 Example of patellar tendon weight-bearing

custom brace

ations requires local debridement and off-­loading

usually in the form of total contact casting (TCC).
After initial casting, most patients can be transi-
tioned to either a CROW boot, double upright brace,
patellar tendon weight-bearing brace (PTB), or dia-
betic shoe with accommodative inserts with possi-
ble Arizona or custom AFO bracing (Figs. 35.7,
35.8 and 35.9). Other off-­loading options include
complete nonweightbearing on the affected limb
with the help of a wheelchair or knee scooter. This
sequence of nonoperative treatment is to success-
fully move patients from Eichenholtz stages 0 and I
to coalescence at stage II and finally reconstruction
at stage II or III. A stable, shoe-able foot that is not
at risk for ulceration is the goal of nonoperative
treatment.

35.4 Operative Treatment

Indications for surgical intervention in CN

patients have expanded over the past decade. Fig. 35.9 Example of custom-fixed AFO with diabetic
Failure of nonoperative treatment to improve liner
35 Hindfoot and Ankle Charcot Reconstruction 395

quality of life is one of the main reasons surgical

intervention is more commonly performed.
Surgery is often performed for patients with
wounds that probe to the bone, acute Charcot that
are not great candidates for casting, and moderate
to severe deformities. Additionally, surgery is
indicated in those with active infection, abscess
and chronic pathology that has failed nonopera-
tive treatment. Timing of surgical intervention is
controversial. Some have recommended treating
Eichenholtz stage 0 and I with nonoperative inter-
vention before proceeding with surgery. That rule
of thumb has been challenged, and some are treat-
ing more acute Charcot with surgical intervention.
Currently the literature is not clear on timing to
surgical intervention.

35.5 Preoperative Planning

35.5.1 Imaging

Radiographs of the foot and ankle, preferably

weight-bearing radiographs, are essential in the
monitoring and surgical planning of CN cases.
Radiographs are used for preoperative planning,
and the surgeon must be able to visualize the three-

Fig. 35.11 AP WB radiograph: Partially consolidated

ankle and hindfoot CN. Note vascular calcifications

dimensional (3D) deformity from two-­dimensional

(2D) imaging (Figs. 35.10 and 35.11). Three-view
standing radiographs of the foot and ankle should be
obtained. A hindfoot alignment view can be helpful
in assessing varus/valgus hindfoot deformities.
Advanced imaging is sometimes beneficial in
treating Charcot deformities. CT is probably the
most useful to evaluate bone loss, bone cysts, dis-
locations, subluxations, and erosive changes.
Although not widely used, weight-bearing CT
imaging can be very useful in visualizing the
deformity in situ (Fig. 35.12).
MRI can be used to assess vascularity, fluid
collections, bone marrow lesions, and edema as
well as rule out abscess formation (Fig. 35.13).
Fig. 35.10 Lateral WB radiograph: Partially consoli- MRI is not great as a stand-alone test for diagnos-
dated ankle and hindfoot CN ing osteomyelitis as it is difficult to determine
396 R. A. Brandão et al.

35.5.2 Laboratory

Consideration should be given to optimizing

laboratory levels preoperatively if possible.
Preoperative laboratory testing is essential for
assessing healing potential. Standard CBC,
BMP, prealbumin, albumin, vitamin D levels,
ESR, CRP, and A1C are obtained prior to sur-
gery. Ideally surgical intervention should be
undertaken once appropriate glucose control is
met with some research suggesting an A1C of
less than 7.5 and 8.0 [7, 8]. Tobacco use should
be discontinued prior to any surgical interven-
tion if possible. Many patients affected with
hindfoot and ankle Charcot are not ideal surgi-
cal candidates, so expectations must be man-
aged appropriately in regard to overall
outcomes, need for revisional surgery, and the
Fig. 35.12 AP view CT scan noting CN fragmentation possible loss of limb.
and dislocation at TN joint Given the medically complex nature of this
patient subset, it is important to engage the
entire medical team including primary care;
endocrinology; vascular, cardiac, and infectious
disease; plastics; social care and home health;
and orthotics/prosthetics in the management of
these difficult cases. All aspects of this medical
management, beyond the surgery itself, play
pivotal roles in the overall success.

35.6 Operating Room Setup

1. The patient is positioned supine on the operat-

ing table. A thigh tourniquet is usually applied
to the operative extremity to decrease blood
loss. An ipsilateral hip bump is commonly
used since many patients have externally
rotated lower extremities.
2. OR positioners or blankets can be used to ele-
Fig. 35.13 Lateral view MRI T2 image of CN foot with vate the operative extremity above the contra-
dorsal foot fluid collection and likely abscess lateral leg. This will help with fluoroscopic
imaging.
whether increased bone signal is from Charcot 3. A mini or large C-arm can be used in hind-
breakdown or osteomyelitis. foot/ankle Charcot. Large C-arm imaging
Tagged white blood cell scans and SPECT CT may be more useful in cases of external fixa-
scans can be useful for diagnosing osteomyelitis. tion or retrograde TTC nailing.
Bone biopsy is still the gold standard for sus- 4. For mini-fluoroscopic imaging, it needs to
pected osteomyelitis. come in from the ipsilateral side with the sur-
35 Hindfoot and Ankle Charcot Reconstruction 397

are plating options as well. Our preference is

the retrograde TTC fusion nail to a 20 or
25 cm length.
2. Equipment for screw fixation should also be
made avilable if the need for extending the
fusion to the medial or lateral columns or add-
ing supplemental fixation outside the TTC
nail is preferable. Our preference is cannu-
lated 6.5/7.0/8.0 titanium alloy screws outside
the nail to fixate across the STJ and sometimes
from calcaneus to tibia as well. Often the infe-
rior screw in the nail that targets posterior to
anterior in the calcaneus can be taken longer
to cross the CC joint if needed.
3. External fixation equipment is also commonly
used and should be available for all ankle/
hindfoot Charcot cases. We prefer pre-built
static frame constructs to fixate proximal in
Fig. 35.14 Operative view of mini fluoroscopy position-
the tibia, above the nail and distally to anchor
ing for retrograde nail placement the foot. Antibiotic beads or cement should be
available for all cases.
4. Large osteotomies and wedge resections may
geon, and back table will be on the opposite be needed in these cases. The use of electric
side and at the end of the table. This will allow sagittal saws as well as cordless drills/reamers
the surgeon to take the leg off the side of the will be required.
bed to facilitate easier imaging (Fig. 35.14). 5. Biologic augments should be considered for
5. The leg is prepped above the knee with the these salvage cases and readily available if
surgeon’s preference of antiseptic. For nonul- needed.
cerated extremities, we commonly use a
chlorhexidine scrub brush followed by
chlorhexidine gluconate with isopropyl alco- 35.7 Approaches
hol. For patients with ulcerations, we recom-
mend povidone-iodine 7.5% scrub followed 35.7.1 General Rules
by povidone-iodine 10% solution.
Dissection
• Avoid undermining and dissection planes on
35.6.1 Equipment approach as this may violate the healthy vas-
cularized subcutaneous layer. Attempt should
Since these cases are technically difficult and be made to maintain a full-thickness envelope
operative plans may change intraoperatively, the at all times.
surgeon should confirm that all equipment that • Be aware and reduce the use of extensive man-
may be used is present for the case before the ual or self-retaining retractor on tenuous inci-
patient is taken to the operating room. sional areas including the anterior ankle and
sinus tarsi incisions. Be aware of areas of prior
1. Most ankle cases will need a tibiotalocalca- ulcers and infections and avoid if possible.
neal (TTC) fusion system. An intramedul- • Limited periosteal dissection and devascular-
lary device is most commonly used for ization of the soft tissue surrounding the talus
ankle/hindfoot Charcot fixation, but there given its inherent poor vascularity.
398 R. A. Brandão et al.

• Avoid thermal injury with the placement of

wire and pin fixation (especially in external
fixation applications).
• Be sure to decompress boney deformity and
remove the exuberant fibrous and synovitic
tissue that is common in Charcot. The foot
must be destabilized, and reduction of the
deformity is paramount.
• Take care to prepare all joints that are intended
for fusion using standard joint prep techniques
using combination of curettes, osteotomes,
rongeurs, and solid drill bits. Prepare the joints
for fusion by drilling the subchondral bone. Fig. 35.15 Operative lateral view of lateral approach for
Using an osteotome to fenestrate or “fish ankle and STJ exposure
scale,” the subchondral bone helps expose
good bleeding bone that is optimal for fusion.
Simply placing fixation across intact joints
will often lead to late term complications of
hardware failure and loss of deformity
correction.
• These are long and complex cases. Have a
solid surgical plan ahead of time, and be effi-
cient with your tourniquet and surgical time.
Frequently, the Ex Fix is applied with the inci-
sions closed and the tourniquet deflated.

35.7.2 Lateral Approach

• The lateral curvilinear incision is the most Fig. 35.16 Operative lateral view demonstrating fibular
common approach used. A lateral longitudinal osteotomy
incision is made along the distal aspect of the
fibula using a 15 blade maintaining a full soft injury. The fibula is resected and removed
tissue envelope to the level of periosteum. A from the soft tissues using a combination of
slight curve can be applied to the distal aspect an osteotome and sharp dissection
of the incision over the sinus tarsi for access to (Fig. 35.17). This can then be morcelized as
the subtalar joint (Fig. 35.15). Dissection of autograft if the bone is in good health and
the soft tissues of fibula can be accomplished there isn’t suspicion of chronic infection
with sharp dissection and a Cobb elevator cir- (Fig. 35.18). Once the fibula is resected, the
cumferentially. Gelpi or Weitlaner retractors ankle joint can be visualized with anterior and
are placed deep for visualization. posterior capsular attachment released with
• A fibular osteotomy is made with sagittal saw Cobb elevator and use of laminar spreader
from proximal lateral to distal medial, (Fig. 35.19).
approximately 5–6 cm above the distal tip of • Take the dissection distally to the subtalar
the fibula (Fig. 35.16). A Hohmann retractor joint staying just above the peroneal tendons.
is placed on the anterior and posterior aspect The subtalar joint should be mobilized as to
of the osteotomy to protect the soft tissues, allow full reduction and realignment of the
blood supply, and the tibia from iatrogenic hindfoot and ankle. The Cobb elevator can be
35 Hindfoot and Ankle Charcot Reconstruction 399

Fig. 35.19 Operative lateral view with fibula resected.

Laminar spreader opening ankle joint for fusion
Fig. 35.17 Operative lateral view of excision of distal
preparation
fibula and exposure of ankle joint

Fig. 35.20 Operative view of Charcot ankle deformity

with fragmented and missing talus

helpful here. Often in the valgus hindfoot,

significant fibrosis within the STJ will need to
be removed as well. If the fibula wasn’t
resected, be sure to fully release the calca-
neal-fibular ligament (CFL) as it is frequently
scarred in and keeping the hindfoot in
valgus.
• In some instances of significant Charcot of
the ankle, the talus may be fragmented and
nonviable, in which case either the entire
talus is removed or the collapsed body is
Fig. 35.18 Operative view of morcelization of fibular
autograft using power reamer removed, while the viable head and neck of
the talus is left intact (Fig. 35.20). In these
400 R. A. Brandão et al.

cases, preoperative planning to use either

bulk femoral head allograft or titanium cage
to replace the diseased talus must have been
done and then performed. Another option in
this type of case would be to perform a direct
tibia calcaneal (TC) fusion.

Pearls
• The surgeon can access for the ankle
and subtalar joint through one incision.
• Removal of the fibula allows soft tissue
closure without tension.
• Lateral wounds can be resected entirely
usually allowing for primary closure.
• Large dead spaces need to be avoided,
or a negative pressure dressing or drain
can be applied to reduce chance of
hematomas or seromas.

35.7.3 Anterior Approach

Fig. 35.21 Operative view of anterior ankle exposure

• The anterior incision may be used in isolated

if the STJ is already fused or as coupled • Frequently, flat tabletop cuts of the distal tibia
approach with a standard sinus tarsi lateral and talar dome are used. These cuts can be
approach for the STJ. A standard anterior inci- adjusted to resect intrinsic angular deformity if
sion is made at the level of the ankle using 15 needed. Flat cut on the distal tibia is helpful to
blade maintaining a good soft tissue envelope. resect the posterior malleolar confines and allow
Care is taken to avoid the superficial peroneal the foot to be posteriorly translated on the tibia
nerve branches at the distal end of the incision for optimal positioning. It is also recommended
as they cross lateral to medial. Take care to to adequately debride the medial ankle gutter, so
identify, elevate, and retract/protect the ante- the foot can be slightly medialized within the
rior neurovascular bundle. ankle mortise to aid in alignment of the tibia
• Sharp arthrotomy to bone is performed, and canal and the central body of the calcaneus, par-
dissection of the soft tissues to the fibula and ticularly if a retrograde TTC nail is to be used.
medial malleolus is accomplished with a Cobb
elevator. The joint is mobilized as much as
possible using an osteotome or Cobb elevator Pearls
to break up adhesions to allow for deformity • Well-known incision for foot and ankle
correction. Take care in varus deformity to surgeon with excellent visualization to
release adhesions and fibrosis in the medial correct varus and valgus deformities
gutter and similarly in the lateral gutter in val- • This incision may facilitate easier reduc-
gus deformity. Avoid excessive retraction tion of foot into optimal biomechanical
superficially. Once deep dissection begins, a position of slightly posteriorly translated
Gelpi retractor is placed for visualization in regard to the tibia
(Fig. 35.21).
35 Hindfoot and Ankle Charcot Reconstruction 401

35.7.4 Posterior Ankle Approach

• The posterior approach is usually used if there

soft tissue issues with the anterior or lateral
ankle soft tissue envelopes. An incision is
made at the posterior medial interval of the
Achilles, just medial to the midline of the
Achilles tendon with dissection through the
skin and paratenon.
• Typically the Achilles is split in a frontal
plane “Z” fashion and tagged for later repair
(Fig. 35.22). The deep fascia is dissected
until the FHL fascia and muscle are exposed

Fig. 35.23 Operative view of posterior ankle and STJ

exposure. Freer elevator confirming location of posterior
STJ. Cartilage of posterior ankle is visible superior to
Freer

and retracted medially. Care is taken to stay

lateral to the FHL tendon since the neuro-
vascular structures lie medial. Transverse
veins can be present on the posterior joint
capsule; electrocautery hemostasis is used if
needed taking care to avoid indirect ligation
or injury to the posterior neurovascular
bundle.
• Sharp arthrotomy to both joints is under-
taken and exposed (Fig. 35.23). This
approach will allow good assessment of
varus and valgus hindfoot deformities. It can
be a bit challenging to fully access the ante-
rior and middle facets of the STJ as well as
the anterior recess of the ankle. Pin-based
distractors or large laminar spreaders are
often helpful to improve access and visual-
ization (Fig. 35.24).
Fig. 35.22 Operative view of posterior ankle approach • This approach is useful if posterior TTC
with split “Z” trans-Achilles approach fusion plating is desired. This position/
402 R. A. Brandão et al.

35.7.5 Medial Ankle

• The medial approach is usually used in combi-

nation with the lateral approach. The medial
approach is often needed if there is significant
medial dislocation and varus contracture and
if significant resection of hypertrophic medial
bone is needed. A flattop medial to lateral tib-
ial osteotomy or medially based wedge can be
used through this incision to help correct sig-
nificant boney valgus deformity.
• A curvilinear medial malleolar incision is made
longitudinally, anterior to the posterior tibial
(PT) tendon and posterior to the saphenous
vein. This incision is paralleled to the saphe-
nous vein and brought down to the medial gut-
ter of the ankle. It can be used to debride the
medial gutter to allow for talar reduction and
for resection of the medial malleolus to gain
access to the ankle joint. Hohmann retractors
are used to retract the PT tendon posteriorly
and protect the neurovascular bundle.
Fig. 35.24 Operative view of posterior ankle and STJ • If a medial to lateral tibial osteotomy or
approach. Pin-based distractor in use to assist with joint medial-based wedge resection is needed,
prep access 2.4 mm Steinman pins are driven from medial
to lateral across the planned resection margins
approach is not ideal in cases of retrograde and confirmed under C-arm. These pins can
TTC nailing and/or circular external fixa- serve as cut guides and offer added protection
tion which would likely necessitate redrap- from the long sweep of the saw blade.
ing and repositioning patient to the supine
position.
Pearls
• Approach is good for medially based
Pearls ulcers that require removal of the medial
• Good approach if lateral or anterior tis- malleolus.
sues are compromised from previous • Useful adjunctive incision to the lateral
surgeries or poor soft tissue quality. approach to facilitate medial gutter
• Ankle and subtalar joints are accessed preparation and reduction, as well as to
through one incision. allow medial wedge-based tibial osteot-
• Approach lends itself well to posterior omy and resection.
TTC fusion plating. • Care should be taken in cases of long-
• The flexor hallucis longus (FHL) can be standing varus contracture as the soft
your guide for the medial neurovascular tissues may also be contracted and have
structures as they will be medial and difficulty in closing. This is not the case
anterior on this approach. It may be a in long-standing valgus deformities as
consistent landmark when approaching the tissues will be lax after deformity
the joint via arthrotomy lateral to FHL. correction.
35 Hindfoot and Ankle Charcot Reconstruction 403

35.7.6 Fixation Options 35.8 Internal Fixation (IF)

Surgical fixation of CN deformities of the hind- Retrograde intramedullary nailing, plate-

foot and ankle usually involves fusion of both the screw fixation, and screw/beam fixation are
ankle and subtalar joints. Depending on the options for treating hindfoot and ankle CN
deformity, fixation may need to extend past the deformities. For TTC fusion, we prefer retro-
transverse tarsal joint and into the midfoot or grade TTC nailing with supplemental screw
across the CC joint in the lateral column. fixation as well as combination circular ring
Fusion of the STJ and/or TN joint may be cou- fixation. For hindfoot Charcot without ankle
pled with TTC fusions for ankle/hindfoot CN but involvement, the plate-­screw and/or screw/
also may be done in conjunction with midfoot CN beam fixation plus/minus external fixation is
and medial column instability. In cases of cou- the usual choice.
pling with midfoot CN, fixation of the STJ is usu-
ally done with 7.0 cannulated screws or beams
and combined with medial and lateral c­olumn 35.8.1 Intramedullary Implants
beam/bolt fixation with the ankle being spared.
Thankfully it is rare to have cases requiring pan- Once all joint prep has been accomplished and
talar fusions of the ankle, STJ, CC, and TN joints any and all wedge resections performed,
in addition to medial and lateral column beaming. reduce the joint deformities, and temporarily
In those rare instances, strong consideration pin the joints with smooth Kirschner wires
should be taken for a primary BKA with func- (K-wires). Once optimal position is confirmed
tional prosthesis as perhaps a better alternative. with fluoroscopic imaging, then fixation can
As a general rule of thumb for fixation of CN, be added.
more fixation is better, and layering fixation in dif- For CN deformities that involve the ankle or
ferent planes also adds to overall construct strength. the hindfoot, fixation begins first here and then
works forward into the foot as neededWe favor
the use of intramedullary nailing and beam/
Pearls bolt to give a “rebar” effect and allow dynam-
• Consider reduction and fusion of the ization over time as bone quality and fusion
subtalar joint on large deformities potential are often poor. Intramedullary devices
involving the talonavicular joint for seem to be able to withstand cyclic loading
additional stability and support. better than plate and screw constructs and also
• Considered “layered” fixation with mul- more easily allow external fixation and other
tiple fixation devices in multiple planes supplemental fixation devices around them
for added strength. (Fig. 35.25).
• Since CN frequently will have delayed For beam/bolt fixation, there are solid and
union or even non-union, selection of cannulated option and in different diameters
robust fixation is a must as well as fixa- depending on the applications. We prefer
tion that can potentially dynamize over solid options for medial column beaming with
time. Beams/bolts and nails in many larger diameters of 6.5 or 7.0. For mid-ray
cases will perform better than plate/ beaming down the second or third, a 5.0 solid
screw constructs for this reason. beam works well here. STJ fusions usually
have 2 × 6.5 or 7.0 cannulated screws, and the
TTC nails vary from 10 to 13 mm diameters
Hindfoot and ankle CN deformity fixation is depending on manufacturer, but lengths over
divided in two major categories: internal fixation 20 cm are recommended for added mid-tibial
and external fixation. fixation.
404 R. A. Brandão et al.

35.9 External Fixation (Ex Fix)

External circular ring fixation can be a work-

house in CN surgery and is highly utilitarian. It
can be customized for the specific indications
and purposes such as infection and wound man-
agement and primary fixation of CN or as supple-
mentary fixation of CN in addition to internal
fixation. Ex Fix is the fixation of choice if an
I&D, cement spacers, or other infection manage-
ment options are needed. Internal fixation can be
added at a later date if needed, or the Ex Fix may
be used alone in these cases.
Dynamic corrective, “hinged” Ex Fix can be
used to allow gradual correction of the CN defor-
mity. This requires building hinges and “motors”
into the construct in specific locations and to
make adjustments at specific points and specific
time schedule. This can be labor-intensive for
both surgeon and patient alike, and there is con-
cern with having wires pulling against Charcot
skin as adjustment and movements are made.
It is our preference to utilize a static Ex Fix
that is applied and left intact until removal at
around 3 months postoperative (Fig. 35.26). This
static Ex Fix is most often an augment to internal
Fig. 35.25 Lateral radiograph of retrograde TTC fusion
nail with proximal dynamic locking screw
fixation as well. In cases of active or presumed

35.8.2 Plate Constructs

Bridge plate constructs can be used to span bone

grafts and other defects. There are now specifi-
cally designed titanium alloy plate systems with
CN in mind with improved strength and yield
characteristics compared to traditional trauma
plates. Many of the plates have internal com-
pression “ramps” to allow some compression
along the construct to assist in fusion
apposition.
Many specific plate options excision for CN
include anterior, lateral, and posterior TTC fusion
plates, medial column fusion, and utility fusion
plates. Many of the Charcot plate systems also
have more robust locking screw options to be
used in these challenging cases. Sometimes plate
constructs can be used “overtop” internal beam Fig. 35.26 Clinical AP view of static circular ring exter-
fixation as well for added stability. nal fixator construct used for Charcot reconstruction
35 Hindfoot and Ankle Charcot Reconstruction 405

infection or significant soft tissue issues, the Next, a medial to lateral calcaneal wire is
static frame is used alone but with a “bent-wire” placed to be later secured into the foot frame.
technique to gain compression of the fusion sites. Either divergent smooth wires, one from medial
to lateral and another from lateral to medial, can
be used to secure the calcaneus to the frame.
35.9.1 Circular Frame Parallel opposing olive wires can also be used
with one olive on the medial cortex and the other
A pre-built construct is typically used. Several on the lateral cortex.
sizes are pre-built and sterilized and can be more Fixation of the midfoot and forefoot can be
efficiently applied in many cases. A standard done off the frame or guided by the frame.
two-ring tibial fixation is often used with exten- Crossed olive wires are preferred and can be
sion to a foot plate or midfoot/forefoot rings via “walked back” to allow compression through the
threaded rods. tensioning of the wires.
Positioner blocks, stacks of towels, or In the forefoot, generally the first and second
scrubbed assistants are helpful to maintain the leg metatarsals are captured with one olive wire, and
and foot in a centered position within the frame at three to five are captured by another opposing
all times until the wires and pins are set. We wire. Some variability may be needed if internal
­typically have closed all incisions and deflated fixation is present, and the wires may be redi-
the tourniquet during Ex Fix application. rected as necessary.
We prefer fixation of the proximal tibial ring
with two divergent smooth wires and one
HA-coated half-pin in the center of the medial 35.10 T
 echnique Step by Step:
face. The midshaft tibial ring is also fixated with Charcot Ankle/STJ TTC Nail
two wires and one half-pin but with care to place
the half-pin off axis to the proximal one, usually • If no active infection, plan for use of retro-
on the tibial crest (Fig. 35.27). grade TTC nail, supplemental screw fixation
outside the nail, and circular ring external fix-
ation over top.
• Utilize the described lateral and medial
approaches to the ankle and STJ. If the medial
malleolus does not need to be resected and
there isn’t a need for a medially based closed
wedge osteotomy of the distal tibia, the medial
approach can be a simple medial arthrotomy
of the ankle to allow thorough debridement of
the medial ankle gutter.
• Confirm thorough joint preparation of the
ankle and STJ with standard joint prep tech-
niques. Reduce ankle and hindfoot deformi-
ties to neutral with the foot slightly posteriorly
translated in the ankle as well as slightly
medialized. Often there is gastroc-soleal equi-
nus presence which may fight reduction. A
percutaneous Hoke-type triple section TAL is
then performed.
Fig. 35.27 Clinical lateral view of static circular ring
• If a talectomy is performed and a TC direct
external fixator construct. Note foot and leg are centered fusion is planned, a beveled cut off the ante-
in ring in all planes rior and posterior tibia should be considered
406 R. A. Brandão et al.

Fig. 35.29 Operative view of insertion of entry wire for

retrograde TTC nail. Note stabilization of corrected posi-
tion by the assistant and use of bump behind the Achilles
Fig. 35.28 Lateral CT scan showing anterior and poste- to “float” the heel off the table
rior beveled cuts on the distal tibia when performing a
tibio-calcaneal fusion. (Imaging provided by Hodges
Davis, MD)

with the power sagittal saw to allow a better fit

between the tibia and calcaneus. This tech-
nique has been described by Hodges Davis,
MD (Fig. 35.28).
• If talectomy and femoral head allograft is
planned, our preference is to use the cup and
cone acetabular reamers to prepare the distal
tibia, the calcaneal facets, and the opposing
cortical surfaces of the femoral head allograft.
The intent is not to totally decorticate the
allograft but just those surfaces that will be
pressed against the fusion surfaces of the cal-
caneus and tibia. Fig. 35.30 Intraoperative fluoroscopic lateral view dem-
• Use entry wire from TTC nail system from onstrating ideal guidewire placement bisecting the lateral
inferior to superior across the STJ and ankle talar process and colinear with the midline of the tibia
joints. It is helpful to have the leg and ankle on
a bump of towels and have the heel float off • It is also helpful to have an assistant view
the table. This allows the foot to posteriorly the trajectory of the wire placement from
translate and keeps the table from pushing the 90 degrees to the side to help with the
heel forward (Fig. 35.29). On the lateral foot, alignment. If solo, drive the wire across
this wire should enter in line with the lateral both joints, and take the 90 degree view
process of the talus, just at the junction of the yourself to visualize. This limits a lot of
sinus tarsi and posterior facet and parallel to back and forth with the C-arm and radiation
the midline of the tibia (Fig. 35.30). From the exposure.
plantar view, the entry point is slightly lateral • Once position of the foot and wire seems
to dead center in the heel. appropriate, take multiple views with the
35 Hindfoot and Ankle Charcot Reconstruction 407

C-arm to confirm, including a calcaneal 28–30 cm are often available too and are only
axial to make sure you’re bisecting the used in case external fixation is not planned.
calcaneus. • Prior to nail insertion, biologic adjunctives of
• At this point, incision is made on the plantar choice are added to both joints and often in a
heel and blunt dissection down to the calca- periosteal sleeve around the anterior and pos-
neus along the entry wire. The soft tissue pro- terior tibia.
tection sleeve is then applied. • Careful insertion of the nail is performed and
• The entry reamer is then used across the STJ confirmed with C-arm. Check proximally for
and ankle joints per guidelines of the individ- any stress risers, and confirm reduced position
ual nail manufacturer. Take care to maintain has been maintained.
reduction of the foot and placement of the • Transfixation screws through the nail are then
femoral head (if needed). A supplemental 2.0 applied per guidelines of the specific nail. We
Steinman pin or two as temporary fixation can prefer dynamic screw fixation in the proximal
be useful. nail when possible. We also prefer nail fixa-
• The entry wire is exchanged for a bead-tipped tion that allows distal fixation that compresses
guidewire and inserted up to leg. C-arm views within the nail and also has multi-planar screw
should be taken to confirm placement of the fixation within the calcaneus for improved
wire and continued good positioning of the bone purchase.
ankle and hindfoot. • If fixation across the CC joint is also needed,
• Sequential reaming over the guidewire is then most retrograde nails have a posterior- ante-
performed under standard technique. Care rior screw in the calcaneus that can be taken
should be taken here to avoid thermal necrosis long to cross the CC joint. In these cases,
or iatrogenic injuries. Upsize reaming until make sure to prepare the CC joint under stan-
chatter suggests good sizing (Fig. 35.31). A dard technique and elevate the cuboid as it is
longer length nail of 20–25 cm is recom- frequently dropped as part of the rocker bot-
mended. Longer IM nails in lengths of tom foot. We find using a Cobb elevator under-
neath the cuboid to lift it as the screw inserted
is a helpful pearl.
• Once the TTC nail is inserted and fixated, sup-
plemental screw fixation is utilized to add addi-
tional stability across the STJ and sometime
across the TTC segments. We prefer a cannu-
lated 6.5/7.0/8.0 screw for this. This is usually
done from a posterior-inferior to anterior-­
superior direction across the STJ and toward
the anterior tibia. A cannulated guidewire is
used and may need to be redirected a few times
to miss the nail. It is felt that this supplemental
screw fixation improved the STJ fusion rate and
adds additional torsional stability (Fig. 35.32).
• Standard wound closures are performed.
Incisional wound vac or JP drains can be used
if needed.
• In most cases, a static external fixator is now
applied overtop the TTC nail as described
above. This is felt to give added stability to the
overall construct, allows soft tissue wound
Fig. 35.31 Operative view of sequential reaming over
guidewire in preparation for nail insertion. Note assistant care and incisions management to be per-
maintaining correct alignment formed, and avoids casting. This “belt and
408 R. A. Brandão et al.

• A medial utility incision is created as part of

the medial column fusion. This incision is
placed at the inferior border of the posterior
tibial tendon and the medial STJ and carried
forward to the TN joint where it courses
slightly more superiorly.
• Dissection is carried down to the PTT and this
is followed to the TN joint. The TN joint is
exposed and then mobilized with a Cobb
elevator.
• A Gelpi or Weitlaner is used to elevate and
retract the PTT. The floor of the flexor canal is
incised and the FDL is identified. This is
retracted inferiorly.
• The Cobb is placed in the TN joint and
rounded into the plantar joint and back into
the anterior and middle facet of the STJ. The
Cobb and ½ inch curved osteotome are used to
release any fibrosis as well as the interosseous
Fig. 35.32 Intraoperative fluoroscopic lateral view dem-
onstrating “outside the nail” supplementary fixation using ligament.
a fully threaded, cannulated 7.0 titanium screw crossing • The Cobb is used to open the joint and a lami-
through a femoral head allograft nar spreader is used for distraction. Standard
joint prep principles are used for both the STJ
suspender” technique of using both internal and TN joints.
and external fixation has worked well in our • At this point, full reduction of the hindfoot
Charcot reconstruction cases. deformity should be possible. A TAL is per-
formed when necessary. In some severe val-
gus cases, lengthening of the peroneal
35.11 T
 echnique Step by Step: tendons may also be necessary. Additional
Charcot STJ/ TN fusion biologics is usually added prior to fixation as
well.
• A STJ fusion for CN is never done in isola- • Fixation of the STJ is performed first. Care is
tion but is coupled as part of the TTC fusion taken to insure the calcaneus is spun back
for ankle CN or as part of the midfoot/medial under the talus and the talus and medial col-
column fusions in midfoot/hindfoot CN. umn are back in line. Temporary pin fixation
• The STJ fusion provides added stability and can be used, and C-arm imaging is used to
overloading of the medial column and seems confirm position.
to stress shield the medial column reconstruc- • Our preference is to use one or two cannu-
tion from failure and breakdown. lated 7.0 titanium alloy screws from inferior
• STJ fusion as part of the TTC fusion has to superior across the STJ for fixation. Care
already been covered. If part of the medial is taken to keep the screws at the axial mid-
column fusion, the STJ can be fused through line or slightly lateral in the talar body to
the medial approach like one would with a allow clearance for medial column bolt fixa-
medial double arthrodesis. This can be diffi- tion coming down the talar neck and into the
cult if there is severe hindfoot valgus disloca- medial midline of the talar body (Fig. 35.33).
tion. A traditional lateral sinus tarsi approach • Once the STJ is stabilized, attention is directed
can also be used. We prefer the medial to the TN joint. If the TN is to be fused with a
approach when possible. TTC fusion behind it, two 5.0 cannulated
35 Hindfoot and Ankle Charcot Reconstruction 409

the area of concern and to fill dead space

defects. These can be exchanged as needed
and in some cases are left permanently.

35.12.2 Negative Pressure Wound

Therapy

• Negative Pressure wound therarpy is often

utilized to reduce bioburden, drainage col-
lection and enhancement the wound bed
environment. If this type of wound manage-
Fig. 35.33 Lateral radiograph demonstrating two fully ment is needed, this may be done in a staged
threaded cannulated 7.0 screws used in Charcot STJ fashion before definitive reconstruction is
fusion coupled with medial column beaming with 6.5 undertaken.
solid bolt and central ray beaming with 5.0 solid bolt
• In cases where severe bone deformity precludes
wound healing secondary to pressure, an aggres-
screws as well as a locking plate or dynamic
sive cheilectomy with I&D or osteotomy with
metal staple are used for fixation.
circular Ex Fix may be done to decompress the
• In most TN Charcot fusions, this fusion is part of
tissue and improve chances of healing. The neg-
the larger medial column beams and external
ative pressure device can be applied and man-
fixation construct. Care should be taken to
aged around the external fixator.
reduce the TN joint in all planes but especially in
• Incisional negative pressure devices can be
the frontal plane. This is frequently mobilized
used in case when the wounds or incisions are
and reduced at the same time with the CC joint
expected to have significant drainage.
to insure full resolution of forefoot or medial
column varus and plantarflexed lateral column.
• Temporary pin fixation is used at both the TN 35.12.3 Biologic Augments
and CC joint in preparation for definitive
beam/bolt/screw fixation. Medial column • Addition of biologic agents such as PRP,
beaming and reconstruction are covered in BMA, stem cell allograft, BMPs, PDGF, and
Chap. 16, Charcot Midfoot. autograft are all on the table in Charcot limb
salvage cases. There are pros and cons to each
and left at discretion of the surgeon.
35.12 Adjunctive Procedures • Reaming and collection of tibial marrow con-
tents can also be utilized in addition to mor-
35.12.1 I & D celization of the distal fibula when available.

• In cases of abscess and/or suspected osteomyeli-

tis, I&D and appropriate infectious disease man- 35.13 Postoperative Care
agement are needed. Deep cultures should be
taken to direct antibiotic therapy. Bone biopsy in • Prolonged NWB is needed. Patients are
cases of suspected OM is recommended. instructed to remain NWB for 12 weeks. This
Circular external fixation placement is usually is often a difficult issue in this patient subset.
considered to provide soft tissue and limb stabi- Care is taken to reaffirm this point at each
lization during the process of infection office visit and its importance.
clearance. • Consider inpatient rehab admission if possible
• Antibiotic beads and/or spacers are often uti- to assist in wound and pin care and to assist in
lized to increase antibiotic concentration in remaining NWB.
410 R. A. Brandão et al.

• In home discharge situations, a home evalua- 35.14 Summary

tion by an occupational therapist is recom-
mended before surgery to help with placement Charcot neuroarthopathy of the ankle and/or
of assistive devices and plans. hindfoot can produce profound instability and
• In cases of external fixation, after 1 week destruction of bone and soft tissue structures.
patients are instructed to paint the pin and Very often the limb is left with marginal func-
wire sites daily with Betadine. Normal show- tionality and is prone to breakdown, infections,
ering and hygiene is permitted but no soaking and a high rate of amputation. Functional recon-
is allowed. struction and salvage takes a concerted effort by
• In cases of infections, PICC IV antibiotic the surgeon, the patient, and the full team of
management is done by infectious disease medical specialists to achieve optimal results.
specialists. In non-infected cases, prophy- Preoperative planning and technique is of the
lactic oral antibiotics are used for 2 weeks utmost importance if one is to achieve limb sal-
or until all incisions or ulcerations are vage. The goal remains to have a functional,
closed. braceable foot and ankle.

Intraoperative Pearls and Pitfalls References

• Thorough preoperative workup of infec-
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up in diabetic Charcot feet with spontaneous onset.
deformity planning are recommended. Diabetes Care. 2000;23(6):796–800.
• A staged approach including eradication 2. Kroin E, Schiff A, Pinzur MS, Davis ES,
of infection followed by definitive fixa- Chaharbakhshi E, DiSilvio FA Jr. Functional
tion should be considered. impairment of patients undergoing surgical correc-
tion for Charcot foot arthropathy. Foot Ankle Int.
• Careful consideration is given to fixa- 2017;38(7):705–9.
tion needs and use of biologic adjuvants 3. Pinzur MS, Schiff AP. Deformity and clinical out-
to help assist in healing. comes following operative correction of Charcot foot:
• Minimal soft tissue dissection when a new classification with implications for treatment.
Foot Ankle Int. 2018;39(3):265–70.
possible with full-thickness approaches. 4. Gök Ü, Selek Ö, Selek A, Güdük A, Güner MÇ.
• Consider the use of adjunctive proce- Survival evaluation of the patients with diabetic major
dures, and confirm deformity reduction lower-extremity amputations. Musculoskeletal Surg.
prior to implantation of hardware. 2016;100(2):145–8.
5. Pakarinen TK, Laine HJ, Mäenpää H, Mattila P,
• Internal and external fixation can be Lahtela J. Long-term outcome and quality of life
used concurrently. Consider layered in patients with Charcot foot. Foot Ankle Surg.
fixation with more than you think you 2009;15(4):187–91.
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D. Surgical management of Charcot neuroarthropathy
of the ankle and hindfoot in patients with diabetes.
Diabetes Metab Res Rev. 2016;32(S1):292–6.
7. Wukich DK, Crim BE, Frykberg RG, Rosario
Potential complications BL. Neuropathy and poorly controlled diabe-
tes increase the rate of surgical site infection after
• Patient noncompliance foot and ankle surgery. J Bone Joint Surg Am.
• Wound complications 2014;96(10):832.
• External fixation component irritation, infec- 8. Cancienne J, Cooper M, Werner B. The Association
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ankle/hindfoot Charcot
 Ankle and Subtalar Joint
Arthroscopy
36
Ryan T. Scott and Mark A. Prissel

36.1 Ankle Arthroscopy 2.7 to 4.0 mm. A 30° camera is preferred for
ankle arthroscopy.
36.1.1 Introduction Once the appropriate equipment has been
decided upon, the surgeon must consider the use
Ankle arthroscopy is a commonly employed sur- of ankle distraction. If distraction is warranted,
gical technique to provide a minimally invasive there are several devices currently on the market
approach to managing intra-articular ankle that will significantly aid in this. We recommend
pathology. Common indications include osteo- distraction for most anterior ankle arthroscopy,
chondral defect, ankle synovitis, impingement not only to allow for better visualization but for
syndrome, early arthritis, chronic ankle pain, ease of the procedure. Distraction allows for
intra-articular assessment of ankle trauma, pain- access to the central and even the posterior distal
ful os trigonum (posterior hindfoot endoscopy), tibia and posterior talus in management of osteo-
and ankle instability. Additionally ankle arthrod- chondral lesions. Distraction is difficult from a
esis can be performed arthroscopically. posterior approach and is not routinely recom-
mended or necessary.
36.1.1.1  R Setup, Instrumentation,
O A Ferkel thigh holder may also be considered
and Hardware for positioning and to aid in distraction. The thigh
Recommendation holder is attached to the bed, mid-thigh level. The
Ankle arthroscopy can be set up in multiple ways height and position are then adjusted to allow the
depending on the specific procedure performed. knee to flex 45°. Adequate padding is applied to
Anterior and posterior arthroscopy is extremely protect the popliteal fossa from compression.
versatile for the management of several etiolo- Our typical ankle arthroscopy setup consists of
gies. First and foremost, arthroscopy size must be a Ferkel thigh holder and ankle distractor, 4.0 mm
determined. Typically, ankle arthroscopy can be 30° arthroscopy, and small joint instrumentation
performed with either a 2.7 mm or a 4.0 mm (probe, biters, graspers, and microfracture picks).
arthroscope. Instrumentation will also vary from For posterior arthroscopy, a 4.0 mm 30° scope is
used without distraction (Fig. 36.1).

R. T. Scott
The CORE Institute, Phoenix, AZ, USA 36.1.2 Surgery
M. A. Prissel (*)
Orthopedic Foot & Ankle Center, Once setup is complete, insufflation of the joint is
Worthington, OH, USA performed. We recommend 1% lidocaine with
e-mail: [email protected]

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412 R. T. Scott and M. A. Prissel

intermediate dorsal cutaneous nerve can be easily

identified by transillumination of the lateral gut-
ter and arthroscope to aid in prevention of iatro-
genic nerve injury and proper portal placement.
Plantarflexing the third and fourth digit will also
allow the nerve to become prominent. Following
the nick and spread technique, the trocar can then
be placed to create the lateral portal. The instru-
mentation will then be placed through this portal
initially.
Initial inspection of the joint is performed.
Debridement may be required based on the
pathology to identify the articulating surface
(Figs. 36.2, 36.3, 36.4, and 36.5). Be aware
of your surroundings and orientation of the
Fig. 36.1 Arthroscopy setup. Ankle distractor, 4.0
30-degree camera in the medial ankle and arthroscopic
shaver

epinepherine, to distend the joint capsule. We

routinely use the location of the anterior medial
portal for insufflation. We recommend epineph-
rine to help control the intra-articular bleeding
especially if there is a significant amount of vil-
lonodular synovitis. The ankle joint is insufflated
with 20 cc on an 18-gauge spinal needle. Back
pressure should be noted during the insufflation
to ensure adequate placement of the needle into
the ankle joint. Obviously, there will be ankle
joints which will only allow for a small amount
of volume insufflation. Fig. 36.2 Visualization of the medial shoulder
Following insufflation of the ankle joint, the
anterior medial and ankle arthroscopy portals are
created using a nick and spread style technique.
The anterior medial portal should be created first
(medial to the tibialis anterior tendon), and the
cannula and trocar are placed into the ankle joint.
The trocar can then be replaced by the arthro-
scope. Irrigation (normal saline) should then be
hooked up to the inflow portal on the cannula.
The pump may be started to aid in further insuf-
flation of the ankle joint. We prefer 0.5 liters/min-
ute at 30 mmHg.
Once this is completed, the anterior lateral
portal may be initiated. Emphasis should be noted
not to place the lateral portal close to the interme-
diate dorsal cutaneous nerve. Identification of the Fig. 36.3 Central aspect of the tibiotalar joint
36 Ankle and Subtalar Joint Arthroscopy 413

Fig. 36.4 Lateral shoulder

Fig. 36.6 The use of probe for inspection of cartilagi-
nous surface

Fig. 36.5 Lateral gutter. Note the impingement in the

anterior lateral gutter

shaver during insertion, to prevent iatrogenic

­cartilaginous insult. Inspection of the articular
surface of the tibia and talus should be performed
with the assistance of a probe (Fig. 36.6). This
will help identify soft spots or osteochondral
defects in the cartilage. Inspection of the medial Fig. 36.7 Insertion of a 4.0 camera for identification of
chronic lateral ankle ligament instability
and lateral ankle joint gutters are then performed
to ensure any impingement-type lesions. With
arthroscopic instrumentation away from the periarticular osseous hypertrophy, all of which
cartilage surfaces, the ankle joint can be placed should be appropriately resected (Figs. 36.7,
through a sagittal plane range of motion to evalu- 36.8, 36.9, 36.10, 36.11, 36.12, and 36.13).
ate for anterior impingement, such as hypertro- When osteochondral defects are encoun-
phic capsule/synovium, Bassett ligament, or tered, inspection of the location and size of the
414 R. T. Scott and M. A. Prissel

Fig. 36.10 Ankle arthroscopy demonstrating syndes-

motic injury

Fig. 36.8 Radiographic view of chronic lateral ankle

instability

Fig. 36.11 Arthroscopic-assisted ORIF syndesmosis

Fig. 36.9 Chronic injury to the lateral collateral liga-

chondral plate should be performed at that time
ments is noted with the inflammatory changes
(Figs. 36.14 and 36.15). If the subchondral plate
is insufficient, bone grafting is imperative (this
lesion is important to determine the progno- may require an open, extended portal approach to
sis. Arthroscopic debridement of the lesion is effectively manage the bone void). Once debride-
performed with a series of small curettes and ment of the osteochondral defect is performed,
the arthroscopic shaver. Inspection of the sub- microfracture of the area is completed with small
36 Ankle and Subtalar Joint Arthroscopy 415

Fig. 36.12 Loose bodies within the ankle joint

Fig. 36.15 The use of a probe to identify the osteochon-

dral defect on the lateral talus

Fig. 36.13 Example of numerous loose bodies removed

from the ankle joint

Fig. 36.16 The use of the microfracture awl for manage-

ment of the lateral osteochondral defect

joint awls (Figs. 36.16 and 36.17). Direct visual-

ization is recommended during this aspect of the
procedure to ensure appropriate penetration of
the awl into the subchondral bone and to ensure
that they are not skiving off the area of interest.
If the osteochondral defect is larger in nature
and allograft supplementation is appropriate, the
Fig. 36.14 Direct visualization of osteochondral defect graft maybe delivered through the arthroscopic
on the lateral talus portal. Following microfracture of the lesion, the
416 R. T. Scott and M. A. Prissel

Fig. 36.18 Arthroscopic instrumentation to deliver carti-

lage graft into the osteochondral defect post debridement
and microfracture

Fig. 36.17 Insertion of the arthroscopic microfracture

awls into the lateral portal

fluid is removed from the ankle joint. The area is

then dried with cotton-tipped applicators. If your
arthroscopy system allows for CO2 insufflation,
the pump maybe turned on at this point to dry out
the joint. Application of the allograft directly to
the microfractured subchondral plate is per-
formed. Fibrin glue is applied over the allograft
and allowed to dry per manufacturer’s specifica-
Fig. 36.19 Cartilage graft, mixed with bone marrow
tions (Figs. 36.18, 36.19, and 36.20). aspirate in osteochondral defect
Posterior hindfoot endoscopy can aid in the
management of posterior osteochondral defects
or for the management of the symptomatic os tals are employed, per the technique of Van
trigonum. The patient is positioned in the prone Dijk [1, 2]. Topographic landmarks are critical
position with the operative foot hanging slightly to proper placement of the posterior portals.
off the end of the bed or off of folded blankets. The distal tip of the lateral malleolus is identi-
The authors prefer to not pad or support the fied, and a line is drawn parallel to the sole of
anterior tibia with pillows as it can create a the foot from the lateral malleolus across the
trampoline effect resulting in excessive motion Achilles tendon. The portals are placed imme-
of the operative limb during the surgical case diately proximal to this line just medial and lat-
(Figs. 36.21 and 36.22). Posterior portals are eral to the Achilles (Figs. 36.23 and 36.24). The
created in a similar fashion to the anterior ankle lateral portal is created first, and the camera is
joint portals. With posterior hindfoot endos- inserted and pointed toward the lateral aspect of
copy, posterior medial and posterior lateral por- the posterior ankle and subtalar joints. The
36 Ankle and Subtalar Joint Arthroscopy 417

Fig. 36.20 Osteochondral defect following insertion of

cartilage graft and fibrin glue

Fig. 36.22 Posterior view of proper posterior hindfoot

endoscopy positioning. Note posterior leg site marking
location for prone case

Fig. 36.21 Prone positioning with knee slightly flexed

and well padded. Note foot is hanging off of folded
blankets

medial portal is then created, and the shaver is

angled toward the camera. Care is taken to not
work in a medial direction until the joint line is
visualized and never medial to the FHL tendon.
This approach can be useful for removal of os
trigonum, FHL tenosynovectomy, posterior
capsular release, and management of far poste-
rior talar osteochondral defects (Figs. 36.25
and 36.26).
Portal closure is performed with either a 3.0 or
4.0 nylon in a simple interrupted or box-type
suture closure. A compressive dressing consist-
ing of a nonadherent dressing, 4 × 4 gauze, and Fig. 36.23 Two portal entry sites for posterior hindfoot
an elastic bandage is applied. endoscopy
418 R. T. Scott and M. A. Prissel

36.1.3 Postoperative Protocol

With isolated arthroscopy, the surgery falls into

postoperative protocol #1. The patient will be
placed into a posterior splint for 7 days and then
transitioned into a pneumatic walking boot for
3 weeks. If concomitant surgery is performed,
the postoperative course is dictated by the proce-
dure. Typically, if an osteochondral defect drill-
ing is performed, a non-weight-bearing status
will be maintained for 3–4 weeks before mobili-
zation in the cam walking boot (postoperative
Fig. 36.24 Lateral landmark for posterior hindfoot protocol #3). Physical therapy will be initiated
endoscopy portal placement at inferior extent of fibular based on the procedures performed with the
malleolus arthroscopy.

36.1.4 Complications

• Postoperative infection
• Portal sinus formation
• Injury to the intermediate dorsal cutaneous
nerve
• Injury to the anterior neurovascular structures
• Injury to the flexor hallucis longus tendon

36.2 Subtalar Arthroscopy

36.2.1 Introduction

Subtalar joint arthroscopy can be a useful limited

Fig. 36.25 Arthroscopic probe verification of os trigonum incision procedure for early subtalar joint arthri-
tis debridement, treatment of sinus tarsi syn-
drome, and arthroscopic joint preparation for
subtalar arthrodesis.

36.2.2 Setup

Subtalar arthroscopy is most commonly per-

formed from the lateral position. Joint distraction
is typically not required for subtalar arthroscopy.
We recommend 2.7 mm-diameter arthroscopes
with either 30° or 70° viewing angles. As an
alternative a 1.9 mm-diameter arthroscope can be
considered. Similar small joint arthroscopic
Fig. 36.26 4.0 mm arthroscopic inspection of resected equipment is employed for subtalar joint arthros-
symptomatic os trigonum copy as is used in ankle arthroscopy.
36 Ankle and Subtalar Joint Arthroscopy 419

36.2.3 Surgery

The standard lateral portals include anterior, cen-

tral, and posterior locations. The distal tip of the
fibula is an important topographic landmark to
identify. The posterolateral portal is located 1 cm
proximal and 2 cm posterior to the tip of the fib-
ula. The central lateral portal is located just ante-
rior to the tip of the fibula. The anterolateral
portal is 1 cm distal and 2 cm anterior to the tip of
the fibula. Depending on the location of the
pathology requiring attention, commonly only
two of the three described portals are required
(Figs. 36.27, 36.28, 36.29, and 36.30). Loose
bodies, soft tissue impingement, and osteochon-
dral defects can all be addressed with subtalar
joint arthroscopy with similar principles as
Fig. 36.28 Sinus tarsi and anterior subtalar joint
described above.

36.2.4 Postoperative Protocol

With isolated arthroscopy the surgery falls into

postoperative protocol #1. The patient will be
placed into a posterior splint for 7 days and then
transitioned into a pneumatic walking boot for

Fig. 36.29 Lateral shoulder subtalar joint

3 weeks. If concomitant surgery is performed, the

postoperative course is dictated by the procedure.
Typically, if an osteochondral defect drilling is
performed, a non-weight-bearing status will be
maintained for 3–4 weeks before mobilization in
the cam walking boot (postoperative protocol
#3). Physical therapy will be initiated based on
Fig. 36.27 Medial aspect of the posterior facet the procedures performed with the arthroscopy.
420 R. T. Scott and M. A. Prissel

36.2.5 Complications

• Postoperative infection
• Portal sinus formation
• Injury to the adjacent superficial neurovascu-
lar structures

References
1. van Dijk CN, Scholten PE, Krips R. A 2-portal endo-
scopic approach for diagnosis and treatment of poste-
rior ankle pathology. Arthroscopy. 2000;16(8):871–6.
2. Scholten PE, Sierevelt IN, van Dijk CN. Hindfoot
endoscopy for posterior ankle impingement. J Bone
Joint Surg Am. 2008;90(12):2665–72. https://doi.
org/10.2106/JBJS.F.00188.
Fig. 36.30 Lateral aspect of the subtalar joint
 Open Treatment of Osteochondral
Lesions of the Talus
37
Daniel J. Cuttica and Christopher W. Reb

37.1 Introduction lesion. Lateral OLTs occur from an inversion

and dorsiflexion force as the anterolateral
Osteochondral lesion of the talus (OLT) is a aspect of the talar dome impacts the fibula.
broad term describing an isolated injury or abnor- They are usually shallow, wafer-like, and dis-
mality of talar articular cartilage and adjacent placed and occur more central or anterior on
bone. It was originally described by Konig in the talus.
1888 and first described in the ankle by Kappis in
1922. Both attributed OLTs to an ischemic necro-
sis of the subchondral bone [1, 2]. However, con- 37.2 Clinical Presentation
temporary data supports a more traumatic event
or repetitive microtrauma as the most common Patients will typically present with complaints
cause [3, 4]. OLTs represent 4% of all osteochon- of a chronic dull, often vague ankle pain. There
dral lesions [5]. Bilateral lesions occur with a is often a history of an inversion injury or other
10% incidence [6]. trauma to the ankle, which has been reported
OLTs can occur on both the medial and lat- to occur in 76% of OLTs [7]. Recurrent swell-
eral aspect of the talar dome. Medial OLTs ing, especially with increased activity occurs.
typically occur from a plantarflexion-inver- Many patients also will complain of mechani-
sion injury as the medial talar dome impacts cal symptoms such as catching or locking
against the tibia. They are located more poste- and giving way. An ankle effusion is often
rior on the talus and are a deeper, cup-shaped present.

37.3 Imaging
D. J. Cuttica (*)
Assistant Professor of Clinical Orthopaedic Surgery,
Weight-bearing radiographs of the ankle
Georgetown University School of Medicine,
The Orthopaedic Foot and Ankle Center, a division should be performed. They are often normal,
of Centers for Advanced Orthopaedics, however may show a subtle lucency or bony
Falls Church, VA, USA fragmentation. Advanced imaging such as MRI
C. W. Reb or CT scan can be used to identify an OLT not
University of Florida, Department of Orthopedics, apparent on plain radiographs. These imaging
Division of Foot and Ankle Surgery,
studies are also essential for preoperative
Gainesvilles, FL, USA
e-mail: [email protected] planning.

© Springer Nature Switzerland AG 2019 421

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_37
422 D. J. Cuttica and C. W. Reb

37.4 Case Example longed nonoperative treatment, the patient under-

went ankle arthroscopy with debridement,
A 57-year-old female with a history of a prior dis- followed by open treatment of the cystic OLT. The
tal fibula fracture 4 years ago was treated and OLT was exposed utilizing a plafondplasty. It was
healed with nonoperative treatment. She had treated with bone grafting of the cystic defect, fol-
complaints of continued vague ankle pain, aching lowed by repair with cartilage grafting.
in nature even after the fracture had healed. In
addition, intermittent swelling and mechanical
symptoms were present. Weight-bearing radio- 37.5 Treatment
graphs revealed an old, well-healed distal fibula
fracture. There is a small lucent area at the medial Nonsurgical treatment should initially be
talar dome consistent with an osteochondral attempted, whenever possible. Nonsurgical treat-
lesion of the talus (Fig. 37.1) A CT scan without ment includes a period of immobilization in a
contrast revealed a cystic medial OLT, at the cen- cam boot or cast, as well as nonsteroidal anti-­
tral third of the talus (Fig. 37.2). The patient was inflammatory medications. Physical therapy for
previously treated with a period of immobiliza- strengthening and proprioception can be helpful.
tion and physical therapy, without improvement Finally, a high top shoe or lace up ankle brace can
in symptoms. She received temporary relief from provide added stability and decrease symptoms.
a diagnostic injection. Because of failure of pro- Nonoperative treatment in OLTs has been shown
to have a 40–50% success rate [4].

37.6 Surgical Indications

Indications for surgery include symptomatic,

focal OLTs that have failed nonoperative treat-
ment; an acute, displaced fragment; and mechan-
ical symptoms.

37.7 OR Setup/Instrumentation/

Hardware Selection

The patient is positioned supine on a radiolucent

table. A pneumatic tourniquet at the thigh is used
on the operative extremity, and a sequential com-
pression device is placed on the contralateral
extremity. The mini-C-arm should be placed on
the ipsilateral side of the bed, while the instru-
ment table is placed on the contralateral side of
the bed.
Required equipment includes a basic instru-
mentation tray; a Hinterman pin distractor with
2.4 mm pin holes; osteotomes, curved and
straight, ¼ inch and ½ inch, respectively; curettes,
Fig. 37.1 Plain radiograph revealing old, well-healed
distal fibula fracture. There is a small lucent area within
usually sizes 1–3 are sufficient; Steinmann pins
the medial talar dome consistent with osteochondral and Kirchner wires; a bone tamp and small mal-
lesion of the talus let; a dowel reamer or trephine for autograft bone
37 Open Treatment of Osteochondral Lesions of the Talus 423

Fig. 37.2 (a, b)

Coronal and sagittal a b
views of CT scan
without contrast
revealing cystic medial
OLT located at the
central third of the talus

graft harvest; cordless power; a high-speed saw;

and sagittal saw blade 10 mm wide with cut depth
between 25 and 45 mm.
Required hardware includes 3.5 mm or
4.0 mm partially threaded cannulated screws; a
nonlocking 1/3 tubular plate and screws (as
backup).
Required biologics include 5 cc of cancellous
allograft bone graft (if not using autograft); carti-
lage graft; and implantable fibrin glue.

37.8  edial Malleolus Osteotomy

M
Operative Technique Fig. 37.3 Midline medial approach beginning just distal
to the tip of the medial malleolus and extending
The procedure is done under pneumatic tourni- proximally
quet, typically between 250 and 350 mmHg. A
midline medial approach is utilized, with atrau- tibialis posterior tendon sheath 2 cm above the
matic soft tissue handling, of about 5 cm extend- medial malleolus groove.
ing from the tip of the medial malleolus After adequate exposure, prepare to perform a
(Fig. 37.3). Utilize a meticulous layered approach Chevron-type medial malleolar osteotomy. First,
while mobilizing the saphenous structures anteri- establish the apex of the Chevron osteotomy
orly. Leave the periosteum and superficial deltoid using 1.6 mm K-wire. On the medial face of the
attached to the medial malleolus. An anterome- distal tibia metaphysis, usually near the apex of
dial ankle joint arthrotomy is required to reflect the exposure, identify and mark the midpoint
the medial malleolus osteotomy. Next, open the between the tibialis posterior tendon and the
424 D. J. Cuttica and C. W. Reb

Use a ½ inch osteotome to complete the oste-

otomy and reflect it distally (Figs. 37.5 and 37.6).
Hold the osteotomy with a pin distractor posi-
tioned to allow freedom of access to the joint
from the midline and posterior lines of sight
(Fig. 37.7). Exposure of the OLT should now be
complete.
Next, the OLT is debrided and repaired. Use
curettes to meticulously remove loose cartilage
and bone. A freer elevator or no. 15 blade knife
can be helpful to establish sharp, vertical mar-
gins. Irrigate and aspirate the lesion site to con-

Fig. 37.4 The medial malleolar osteotomy is marked out,

with the osteotomy limbs at 90° to one another, extending
distally anteriorly and posteriorly. This represents the
apex-proximal Chevron osteotomy

anterior ankle joint margin. On the AP fluoro-

scopic view, orient the wire in the midcoronal
plane between the marked point and the articular
surface of the distal tibia just lateral to the osteo-
chondral lesion. Insert the wire to subchondral
bone and check on AP and lateral views.
Mark the osteotomy limbs at 90° to one
another, extending distally anteriorly and posteri-
orly. This represents the apex-proximal Chevron
osteotomy (Fig. 37.4). Next, predrill the path-
ways for the cannulated screws. Insert two guide
wires for the partially threaded cannulated screws Fig. 37.5 A ½ inch osteotome is used to complete the
osteotomy and reflect it distally
retrograde in parallel to one another through the
medial malleolus.
Insert one additional wire from medial to lat-
eral, parallel to the weight-bearing surface of the
tibia about 10 mm proximal (approximately
within the physeal scar). Measure the length of
the screws. Drill over the wires using the cannu-
lated drill bit for the cannulated screws. Remove
the wires for the screws but leave the k-wire.
Place Hohmann retractors anteriorly and posteri-
orly to protect the saphenous structures and the
skin anteriorly and the tendon and neurovascular
structures posteriorly. Use the sagittal saw to cut
along the anterior and posterior limbs of the oste-
otomy down to subchondral bone, but do not cut
Fig. 37.6 After the osteotomy is completed, it is reflected
through the cartilage. distally, and the talar dome is visualized
37 Open Treatment of Osteochondral Lesions of the Talus 425

Fig. 37.7 Hold the osteotomy with a pin distractor posi- Fig. 37.8 Medial malleolar osteotomy fixation includes
tioned to allow freedom of access to the joint from the one medial to lateral screw proximally parallel to the tibia
midline and posterior lines of sight joint line and two parallel screws beginning at tip of
medial malleolus. Insert the medial to lateral screw first to
seat the osteotomy, but save final tightening until all
screws are placed
firm a thorough debridement. If the lesion is
amenable to microfracture, perforate the sub-
chondral bone around the perimeter of the lesion ally to seat the osteotomy, but save final tighten-
every 3–4 mm with a microfracture awl oriented ing until all screws are in. Insert the two retrograde
obliquely away from the center of the osteochon- screws into the medial malleolus until nearly
dral lesion. Perforations should be deep enough seated. Sequentially tighten each screw by
to surpass the subchondral bone. If the defect cre- cycling between the three screws until the oste-
ated by debridement leaves a defect more than otomy is fully compressed (Fig. 37.8). Confirm
5 mm, cancellous bone graft may be used to using AP, mortise, and lateral ankle fluoroscopic
restore the bone stock before cartilage grafting. views (Fig. 37.9).
Gently impact the bone graft with a small tamp,
and avoid allowing any excess to fall into the
joint space or become entrapped in the soft 37.9 Tibia Plafondplasty
tissues. Operative Technique
The OLT is now prepared for cartilage graft-
ing. Apply the cartilage graft according to sup- A distal tibia plafondplasty provides sagittal
plier’s prescribed technique. The OLT must be plane access of up to 82% medially and 81% lat-
dry prior to fibrin glue and cartilage graft erally of the talar dome [7]. It can be a useful
application. exposure when perpendicular access to the OLT
When utilizing cartilage graft, perform micro- is not required and avoids the potential morbidity
fracture prior to application only if recommended that can occur with an osteotomy.
for the specific graft. In some cases, microfrac- The plafondplasty is performed under pneu-
ture just prior to application of the cartilage graft matic tourniquet, typically between 250 and
may limit healing to the subchondral bone and 350 mmHg. It can be performed at the antero-
cause subsequent delamination. medial or anterolateral aspect of the tibia,
Finally, the osteotomy is repaired. Remove the depending on the location of the OLT. In an
pin distractor. Reduce the osteotomy, and reinsert anteromedial approach, a 4–5 cm incision is
the guide wires for the cannulated screws, and made just medial to tibialis anterior tendon,
confirm their correct locations using fluoroscopic which is an extension of the anteromedial
views. Insert the screw oriented medially to later- arthroscopy portal if ankle arthroscopy was per-
426 D. J. Cuttica and C. W. Reb

a retaining retractor or Hohmann retractors are

used to retract the deep tissues.
In an anterolateral approach, a 4–5 cm inci-
sion is made just lateral to peroneus tertius ten-
don, which is an extension of the anterolateral
arthroscopy portal if arthroscopy was performed
prior. The superficial peroneal nerve is at risk and
must be protected to prevent a postoperative neu-
roma. Meticulous dissection is performed
through the tissue layers down to the joint cap-
sule. The extensor tendons are retracted medially.
The joint capsule is incised and elevated medially
and laterally to better expose ankle joint. A self-­
retaining retractor or Hohmann retractors are
used to retract the deep tissues.
After the joint is exposed, the plafondplasty is
performed. Beginning 1 cm proximal to the distal
tibia articular surface, a ¼ inch osteotome is
placed at angle 45° relative to the tibia. A mallet
is used to impact the osteotome, and a triangular
1 cm × 1 cm wedge of distal tibia is resected
(Figs. 37.12 and 37.13). Care is taken not to
b plunge with the osteotome to prevent damage to
the talar articular cartilage. A malleable retractor
can be placed to protect underlying cartilage. In
addition, care is taken to avoid placing the osteo-
tome at too large of an angle, so as not to resect
too much tibia and cause iatrogenic instability.
Plantarflexing the foot allows better exposure of
more posterior lesions, and a bump can be placed
under the ankle to allow added plantarflexion. If
bone graft is needed, a trephine can be used to
harvest autograft from the distal tibia, which
should be angled proximally to avoid intra-­
articular violation.
After the plafondplasty, the OLT is debrided
and repaired. Curettes are used to meticulously
Fig. 37.9 Mortise and lateral ankle fluoroscopic views
demonstrating medial malleolar osteotomy stabilization remove loose cartilage and bone. A freer eleva-
and screw orientation tor or no. 15 blade knife can be helpful to estab-
lish sharp, vertical margins. Irrigate and aspirate
the lesion site to confirm a thorough debride-
formed prior (Fig. 37.10). Meticulous dissection ment. If the lesion is amenable to microfracture,
is performed through tissue layers down to the perforate the subchondral bone around the
capsule. The tibialis anterior tendon is retracted perimeter of the lesion every 3–4 mm with an
laterally, and care is taken to protect the saphe- awl oriented obliquely away from the center of
nous vein and nerve medially. Next, the capsule the osteochondral lesion. Perforations should be
is incised and elevated both medially and later- deep enough to surpass the subchondral bone. If
ally to expose the joint (Fig. 37.11). A self- the defect created by debridement leaves a
37 Open Treatment of Osteochondral Lesions of the Talus 427

Fig. 37.11 The anteromedial joint capsule is incised and

elevated both medially and laterally to expose the joint. A
self-retaining retractor or Hohmann retractors are used to
retract the deep tissues

Fig. 37.10 Anteromedial arthrotomy incision is located

just medial to tibialis anterior tendon. This is an extension
of the anteromedial arthroscopy portal

defect greater than 5 mm, cancellous bone graft

may be used to restore the bone stock before
cartilage grafting. Gently impact the bone graft
with a tamp and avoid allowing any excess to
fall into the joint space or become entrapped in
the soft tissues.
Next, cartilage grafting can be performed.
Apply the cartilage graft according to supplier’s
prescribed technique. When utilizing cartilage
graft, perform microfracture prior to application
only if recommended for the specific graft. In
some cases, microfracture just prior to application Fig. 37.12 The plafondplasty is performed beginning
of the cartilage graft may limit healing to the sub- 1 cm proximal to the distal tibia articular surface. A quarter-­
chondral bone and cause subsequent delamination. inch osteotome is placed at angle 45° relative to the tibia
428 D. J. Cuttica and C. W. Reb

ing a “nick and spread” technique. Vertical inci-

sions are made through the skin only, followed by
blunt dissection with a mosquito clamp through
the subcutaneous tissue and joint capsule.
During the arthroscopy, identify the OLT with
a probe. Excise the unstable cartilage and bone,
and create a stable vertical border at the OLT uti-
lizing a ring curette. If indicated, a microfracture
technique can be performed at this time. A micro-
fracture awl is used to penetrate the subchondral
bone. Start at the periphery and work toward the
center of the lesion. The subchondral bone should
be perforated with the awl with a 2–4 mm depth,
3–4 mm apart.
Cartilage grafting can then be performed.
Inflow is shut off, and all arthroscopic fluid is
aspirated from the joint, and the defect is dried
with multiple pledgets or cotton-tipped applica-
tors. A Frazier-tip suction device is often helpful
Fig. 37.13 A triangular 1 cm × 1 cm wedge of distal tibia in drying the lesion. This is an important step, as
is resected, and the OLT is exposed a wet environment makes application and visual-
ization of the cartilage graft difficult. The carti-
lage allograft is prepared according to supplier’s
37.10 Arthroscopic Treatment specific technique. The graft can be placed into
with Grafting an arthroscopic cannula sheath and pushed down
the cannula with a blunt trocar and carefully
The patient is placed supine with a bump under delivered to the lesion. A freer elevator is used to
the ipsilateral hip. A thigh tourniquet is placed contour the graft. The lesion should be filled to
and inflated between 250 and 350 mmHg. The 1 mm beneath the articular surface. A thin layer
operative extremity is placed in a well-leg holder of fibrin glue is applied to the surface of the
with the knee flexed 60° and the foot approxi- lesion and allowed to set for approximately
mately 4 inches off bed. Ensure the leg holder 5 minutes. After the fibrin glue has set, the ankle
does not rest in popliteal crease as pressure on can be dorsiflexed and plantarflexed to ensure
popliteal vein can increase bleeding. Noninvasive stability of the graft.
ankle distraction is utilized.
Standard anteromedial and anterolateral por-
tals are utilized. The anteromedial portal is made 37.11 Post-op Protocol
just medial to the tibialis anterior tendon at the
level of the ankle joint, with the long saphenous A non-weight-bearing, bulky Jones splint is
vein and nerve at risk. The anterolateral portal is placed. The patient is placed into a cam boot and
made just lateral to the peroneus tertius tendon, nonweightbearing, but early active motion begins
with the superficial peroneal nerve branches at as soon as the soft tissues are healed, as outlined
risk. The arthroscopic portals are created utiliz- in the postoperative protocol in Chap. 1.
37 Open Treatment of Osteochondral Lesions of the Talus 429

Procedure Pearls Osteochondral Lesion Repair

Medial Malleolus Osteotomy Operative • If the defect created by debridement
Technique leaves a defect deeper than 5 mm, cancel-
• Leave the periosteum and superficial lous bone graft should be used to restore
deltoid attached to medial malleolus, the bone stock before cartilage grafting.
which can act as a hinge when reflecting • The OLT must be dry prior to fibrin glue
the medial malleolus. and cartilage graft application.
• The osteotomy limbs are placed at 90° to • When utilizing cartilage graft, perform
one another, extending distally anteri- microfracture prior to application only
orly and posteriorly, with the apex at the if recommended for the specific graft.
midpoint between the tibialis posterior In some cases, microfracture just prior
tendon and anterior ankle joint margin. to application of the cartilage graft may
• Predrill the pathways for the cannulated limit healing to the subchondral bone
screws before the osteotomy is made, and cause subsequent delamination.
which will allow for more accurate Arthroscopic Treatment with Grafting
reduction and fixation when repairing • It is essential that the OLT is dry prior
the osteotomy. to cartilage grafting. Be sure to shut off
• Hold the osteotomy with a pin distractor inflow and aspirate all arthroscopic fluid.
positioned to allow freedom of access to The OLT can be dried using multiple
the joint from the midline and posterior pledgets or cotton-tipped applicators.
lines of sight. • A freer elevator is very useful to contour
• When repairing the osteotomy, insert the the graft.
medial to lateral screw first to seat the • The lesion should be filled to 1 mm
osteotomy, but save final tightening until beneath the articular surface, to prevent
all screws are in. Sequentially tighten graft hypertrophy.
each screw by cycling between the three
screws until the osteotomy is fully
compressed.
Tibia Plafondplasty Operative Technique References
• The plafondplasty is performed with a
¼ inch osteotome, 1 cm proximal to the 1. Kappis MK. Weitere beitrage zur traumatisch-­
distal tibia articular surface and at a 45° mechanischen entstehung der “spontanen” knorpela
angle relative to the tibia, resecting a biosungen. Dtsch Z Chir. 1922;171:13–29.
2. Konig F. Uber freie Korper in den gelenken. Dtsch Z
1 cm × 1 cm wedge of distal tibia. Chir. 1888;27:90–109.
• Care is taken not to plunge with the 3. Berndt AL, Harty M. Transchondral fractures (osteo-
osteotome to prevent damage to the talar chondritis dissecans) of the talus. J Bone Joint Surg
articular cartilage. A malleable retractor Am. 1959;41-A:988–1020.
4. Tol JL, Struijs PA, Bossuyt PM, Verhagen RA, van
can be placed to protect underlying Dijk CN. Treatment strategies in osteochondral
cartilage. defects of the talar dome: a systematic review. Foot
• Avoid placing the osteotome at too large Ankle Int. 2000;21(2):119–26.
of an angle, so as not to resect too much 5. Alexander AH, Lichtman DM. Surgical treatment of
transchondral talar-dome fractures (osteochondritis
tibia and cause iatrogenic instability. dissecans). Long-term follow-up. J Bone Joint Surg
• Plantarflexing the foot allows for better Am. 1980;62(4):646–52.
exposure of more posterior lesions, and 6. Stone JW. Osteochondral lesions of the talar dome. J
a bump can be placed under the ankle to Am Acad Orthop Surg. 1996;4(2):63–73.
7. Peters PG, Parks BG, Schon LC. Anterior distal tibia
allow added plantarflexion. plafondplasty for exposure of the talar dome. Foot
Ankle Int. 2012;33(3):231–5.
 Collateral Ankle Ligament Repair
38
Ryan T. Scott, James M. Cottom,
Matthew D. Sorensen, and Mark A. Prissel

38.1 Introduction and simultaneous management of any peroneal

tendon pathology. In recent years however,
Patients with chronic lateral ankle instability may numerous authors have described and advocated
become surgical candidates when they have not for arthroscopic and arthroscopically assisted
responded favorably to non-operative care. techniques for lateral ankle stabilization [4–7].
Lateral ankle stabilization procedures are often These techniques have the advantage over tradi-
grouped into two general groups, anatomic and tional open techniques of addressing intra-­
nonanatomic repairs [1]. Anatomic repair of the articular pathology at the same time as the
anterior talofibular ligament was first described ligamentous instability. Both open and
by Broström in 1966 [2]. Gould later modified arthroscopic techniques will be detailed within
this technique in 1980 [3]. Traditionally, lateral this chapter. Beyond lateral ankle ligament stabi-
ankle stabilization is performed via an open lization, surgical repair may be required for del-
approach. The open techniques remain accept- toid insufficiency and/or ligamentous injury to
able, predictable, and efficient with the advantage the syndesmosis secondary to isolated soft tissue
of direct visualization of all targeted structures injuries, not involving malleolar fracture.

38.2 Patient Presentation

R. T. Scott (*) Patients initially present with ankle instability

The CORE Institute, Phoenix, AZ, USA and/or pain directly over the anterior talofibular
J. M. Cottom ligament (ATFL). A drawer test is performed on
Florida Orthopedic Foot & Ankle Center, all patients and positive for reproducible pain or
Sarasota, FL, USA anterior subluxation. Nonsurgical care consists
e-mail: [email protected] of rest, ice, immobilization with a tall cam walker
M. D. Sorensen boot, sport ankle braces, anti-inflammatory medi-
Weil Foot and Ankle Institute, Foot & Ankle Surgery, cations, and formal physical therapy. If the
Chicago, IL, USA
patients fail to improve, they are considered for
M. A. Prissel surgical repair.
Orthopedic Foot & Ankle Center,
Worthington, OH, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 431

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_38
432 R. T. Scott et al.

38.2.1 O
 R Setup and Instrumentation, ankle stabilization. Extra-articular pathology,
Hardware Recommendation such as peroneal tendon pathology, is typically
addressed after the lateral ankle stabilization
Each patient receives a popliteal nerve block by ­procedure. Attention is then directed toward the
the anesthesia department preoperatively and is anterolateral gutter, where extensive debridement
then brought into the operating room and placed in is carried out in order to remove any synovitis that
a supine position. General anesthesia is then may result in impingement. Debridement of the
administered. A well-padded thigh tourniquet is distal fibula to bone is undertaken using an ablator
applied at set at either 250 or 300 mmHg pending to facilitate capsular and ligamentous adhesions
surgeon preference. For the open technique, the (Fig. 38.3a, b). Lateral stabilization of the ankle
lateral position (or supine position with large ipsi- joint is then obtained with one of two constructs.
lateral hip bump) is assumed. For the arthroscopic In the first group, the drill guide for the first
technique, the supine position is maintained. anchor is then placed through the anterolateral
portal directly midline in the coronal plane and
approximately 1 cm superior to the distal aspect
38.3  rimary Lateral Ankle
P of the fibula. A guide hole is drilled, and the
Stabilization anchor was then inserted and seated in place with
a mallet. The placement of the anchor can be con-
38.3.1 Arthroscopic Broström firmed with the arthroscope (Fig. 38.4). The
Procedure Technique anchor system used is a 3.0 mm bioabsorbable
anchor. The drill guide was removed, with the
A thigh holder was positioned to have the foot sutures now visualized exiting the anterolateral
elevated a few inches off the operating table portal. A microsuture lasso was then used to cap-
(Fig. 38.1). The distal fibula, peroneal tendons, ture the anterior talofibular ligament, ankle cap-
and intermediate dorsal cutaneous nerves are sule, and inferior extensor retinaculum
then outlined with a surgical marker (Fig. 38.2). (Fig. 38.5a, b). The microsuture lasso is placed
A noninvasive ankle distractor is then applied, percutaneous and angled toward the anterolateral
and manual traction is used to distract the ankle. portal, with the first pass placed approximately
Standard anteromedial and anterolateral por- 1.5–2 cm inferior and anterior to the distal fibula.
tals are placed, and ankle arthroscopy is per- The nitinol wire was then advanced and used to
formed. Extensive arthroscopic debridement is capture one strand from the suture anchor which
performed using a 4 mm camera and shaver. Any was then pulled back through the skin exiting site
intra-articular pathology is addressed at the time
of arthroscopy before proceeding to the lateral

Fig. 38.1 The patient is positioned in the operating room Fig. 38.2 Landmarks are drawn out prior to starting the
in the supine position with the operative extremity in a procedure, including the distal fibula, peroneal tendons,
thigh holder and the course of the intermediate dorsal cutaneous nerve
38 Collateral Ankle Ligament Repair 433

a b

Fig. 38.3 (a) Extensive, chronic synovitis is noted within fibula is debrided down to bone to help facilitate capsular
the ankle joint, which is removed using an arthroscopic and ligamentous adhesions to bone
shaver as well as the arthroscopic ablator. (b) The distal

b
Fig. 38.4 Placement of the first anchor in the double-­
row, three-anchor technique can be confirmed
arthroscopically

1. Approximately 1 cm anterior and superior to

site 1, the lasso is advanced percutaneous in the
same manner as described above and exiting the
anterolateral portal. Strand 2 from the suture
anchor is then pulled back through the skin exit-
ing site 2. A second bone anchor was inserted
using the same technique with placement in the
fibula at the level of the lateral talar dome
(Fig. 38.6). The strands exit the anterolateral
Fig. 38.5 (a) The entry point for the second pass with the
­portal, and a microsuture lasso is again used to curved suture passer. Note that this is approximately 1 cm
capture the individual strand approximately 1 cm anterior and superior to the first suture. (b) The suture
anterior and superior to the previous strand for passer being brought through the anterolateral portal
434 R. T. Scott et al.

Fig. 38.6 The two anchors have been placed into the
anterior face of the distal fibula, as seen through the
arthroscope Fig. 38.8 An accessory incision is made between suture
strands 2 and 3, and a hemostat is used to bluntly dissect
down to the inferior extensor retinaculum

Fig. 38.7 With the bone anchors now in place in the ante-
rior distal fibula, the sutures have been passed through
anterior talofibular ligament, inferior extensor retinacu-
lum, and ankle capsule and are seen exiting the skin. Note
that each strand is spaced out about 1 cm apart from each
other Fig. 38.9 An arthroscopic probe is then used to gather all
sutures into the accessory incision

site 3 as well as site 4. Four individual strands are

now exiting the skin (Fig. 38.7). An accessory priate tension (Fig. 38.10). The ATFL, ankle cap-
portal is then made between sites 2 and 3 using a sule, and inferior extensor retinaculum are now
blade to incise only the skin. A hemostat is then advanced and secured to the anterior fibula. The
used for blunt dissection until the inferior exten- strands are not to be cut at this point. A separate
sor retinaculum is probed (Fig. 38.8). A probe is 1–2 cm incision is made approximately 3 cm
then used to gather the strands subcutaneously proximal to the distal fibula laterally in the mid-
with all strands exiting the accessory portal line of the bone. The fibula is visualized, and
(Fig. 38.9). The extremity is released from dis- using the 2.9 mm bioabsorbable anchor system, a
traction. With the assistant holding the foot in a drill hole is made into the fibula (Fig. 38.11). A
dorsiflexed and everted position, the strands for curved ­hemostat is then directed subcutaneously
each individual bone anchor are tied to the appro- through the incision, as close to fibula as possible
38 Collateral Ankle Ligament Repair 435

Fig. 38.10 While the surgical assistant holds the foot in

a dorsiflexed and everted position, the sutures are tied Fig. 38.12 After the knots have been tied, the four suture
onto themselves. This tightens the ankle capsule, anterior strands are brought into the proximal accessory incision
talofibular ligament, and inferior extensor retinaculum using a hemostat. Note the 18-gauge spinal needle that has
and re-approximates it to the anterior distal fibula been placed in the drill hole for the additional suture
anchor

Fig. 38.13 The four suture strands are then gathered and
anchored into the lateral fibula using an additional suture
Fig. 38.11 Through a second accessory incision placed
anchor, thus creating a double-row, three-anchor
approximately 3 cm proximal to the tip of the fibula, a
construct
drill hole is created in the lateral fibula for the third anchor

38.3.2 Arthroscopic Broström

and exiting the accessory portal where the knots Postoperative Protocol
were tied. The hemostat is then used to capture
the strands and advanced proximally exiting at For all patients, a soft compression bandage was
the fibular incision (Fig. 38.12). The strands are applied to the operative ankle, and the patient
then secured into the fibula using the 2.9 mm bio- was placed directly in a controlled ankle motion
absorbable anchor with additional tension applied (CAM) boot. They were kept non-weight-bearing
to the sutures (Fig. 38.13). This technique creates for 3 days to allow the popliteal nerve block to
a double row construct using three suture anchors. dissipate. On the third postoperative day, the
patient was allowed to crutch weight-bear on the
operative extremity with the CAM boot. Fourteen
436 R. T. Scott et al.

days postoperatively the patient returned to the is performed allowing for visualization of the
clinic for suture removal. We continued a com- ATFL. When incising into the capsule, ensure
pressive bandage and allowed continued pro- adequate tissue on both sides of the incision for
tected weight-bearing in the CAM boot for an later closure. If soft tissue anchors are used, cheat
additional 2 weeks. Twenty-one days after the the capsular incision closer to the fibula leaving a
procedure, the patient began formal physical full-thickness capsule for advancement.
therapy. On day 28 the patient returned to the We prefer the posterior approach for lateral
clinic and was advanced from the CAM boot to a ligament reconstructions. This incision starts at
sport ankle brace. The patient continued therapy the distal aspect of the fibula extending distally
for a total of 4 weeks, two sessions per week. We over the sinus tarsi, just superior to the peroneal
advise all patients to wear the ankle brace while tendon sheath (Fig. 38.15). Dissection is taken
ambulating up to 3 months post-op, and they may down to, but not through, the extensor retinacu-
return to full sport/activity at 8–10 weeks. lum. Care is taken to effectively mobilize the
transverse-oriented fibers of the inferior extensor
retinaculum from the underlying capsular struc-
38.3.3 Open Broström-Gould tures (Fig. 38.16). Dissection can then be taken
Procedure Technique posterior and inferior to examine the peroneal
tendons (Fig. 38.17). Ensure to reapproximate
There are two generally accepted approaches for the peroneal tendon sheath. Similar capsular dis-
the open lateral ligament reconstruction, anterior section is performed to view the ATFL in the
and posterior (Fig. 38.14). The anterior approach anterior ankle. A capsulotomy is performed fol-
is a curvilinear approach following the anterior lowing the contour of the distal fibula (Fig. 38.18).
face of the distal fibula extending distally to the The ATFL will be identified at the inferior aspect
level of the sinus tarsi. The extensor retinaculum of the fibula, intra-capsular. Debridement of the
is then mobilized allowing for visualization of distal fibula is performed with a ronguer to
the ankle joint capsule. Incision into the capsule “roughen” up the bone for reattachment of the
capsule after a cuff of periosteal tissue has been
elevated from the distal fibula (Fig. 38.18). A pri-
mary repair of the capsular structures and ATFL
can be achieved with absorbable suture (0-vicryl)
(Fig. 38.19). In revision cases, patients with
severe laxity, or insufficient capsular/ligamen-
tous tissue, anchors may be considered to advance
the ATFL and redundant capsule back to the
­distal fibula (Fig. 38.20). If anchors are not uti-
lized, the standard pants-over-vest suture tech-
nique beginning with the fibular cuff is
recommended. Care is taken with the initial row
of suturing to only include the capsular/ATFL
layer (Broström procedure). When tying the ini-
tial row of sutures, the foot is held in a dorsiflexed
and everted position. If an assistant is not present,
a wrapped towel bump can be utilized to maintain
the desired foot position. The extensor retinacu-
lum is then advanced over the articular repair
again using a pants-over-vest technique, but this
Fig. 38.14 Incision placement. (1) Anterior curvilinear time in the opposite direction from the inferior
incision placement. (2) Lateral incision placement extensor retinaculum to mobilize the retinaculum
38 Collateral Ankle Ligament Repair 437

Fig. 38.15 Preferred incisional placement and initial dissection down to the inferior extensor retinaculum

Fig. 38.17 Exposure of the peroneal tendons for teno-

synovectomy. This approach can be extended, as needed,
based on patient-specific pathology
Fig. 38.16 Elevation of the inferior extensor retinaculum
from the underlying capsular tissue with a key elevator
fibula and neck of the talus. The sutures are ten-
sioned appropriately. An anterior drawer test is
and underlying extensor digitorum brevis muscle performed to ensure that the reconstruction is not
belly up to the fibula (Gould tissue advancement) overtightened. A traditional Broström advances
(Fig. 38.21). A layered closure of subcutaneous the redundant ankle joint capsule back the distal
tissue and skin is then performed. fibula with a pants-over-vest-type suture fashion
An alternative approach is using a series of (Figs. 38.22 and 38.23). The extensor retinacu-
zero-stretch suture anchors placed in the distal lum should be advanced in a Gould fashion
438 R. T. Scott et al.

(­similar to the description above) enhancing the

Broström repair. A layered closure is then per-
formed (Fig. 38.24).

38.3.4 Open Broström-Gould

Postoperative Protocol

This surgery falls into postoperative protocol #3.

A non-weight-bearing posterior splint will be
placed in the OR. A short leg cast (or CAM boot
Fig. 38.18 Visualization of the lateral talar dome follow- with non-weight-bearing) is applied 1 week after
ing lateral arthrotomy through the ATFL. Additionally, a surgery for 2 weeks. The patient can remain
cuff of tissue is created on the distal fibula, and a ronguer
is utilized to create a raw-bleeding surface to bolster immobilized with a cast or CAM boot until
against the repaired ligament 4 weeks postoperative at the surgeon discretion,

a b

Fig. 38.19 (a) Placement of multiple pants-over-vest sutures for the ATFL repair. (b) Once the row of sutures is placed,
the everted and dorsiflexed foot posture is held for tying of the sutures

Fig. 38.20 Broström repair with suture anchors

38 Collateral Ankle Ligament Repair 439

but not beyond. Protected weight-bearing will

begin at 2–3 weeks postoperative. At 7 weeks
postoperative, they will then be transitioned to an
ankle brace and encouraged to increase their
activity level with the guidance of physical ther-
apy, which typically starts at week 6. The goal
would be return to sports-level activity at
10–12 weeks postoperative.

38.4  evision Lateral Ankle

R
Stabilization
Fig. 38.21 A second row is tied for the Gould advance-
ment. This image depicts the completed repair. Often the
In revision cases, or in patients with collagen vas-
Gould advancement is a pants-over-vest suture in the oppo- cular disease/ligamentous hyperlaxity, where a
site direction (starting distally in the inferior retinaculum, Broström-Gould-type ligamentous repair either
whereas the Broström layer is started in the fibular cuff) has failed or will not provide appropriate ­stability,

a b

Fig. 38.22 (a) Bone tunnel being created in the neck of the talus. (b) Visualization of the talus bone tunnel and suture
tape pre-anchored to the fibula

a b

Fig. 38.23 (a) Suture limbs from the distal fibula are advanced to the neck of the talus and fixated with interference
screw. (b) The soft tissue is then advanced over the ligament repair in a traditional Broström fashion
440 R. T. Scott et al.

additional surgical considerations are warranted. incision for Broström-Gould) is performed

Frequently either a Chrisman-Snook procedure (Fig. 38.25). The inferior extensor retinaculum is
or modified Evans peroneal transfer is consid- identified and tagged. The peroneal tendons are
ered. The OR setup is largely the same. protected and any offending tenosynovitis is
Arthroscopy can be independently considered at debrided. The peroneal tendons are inspected; if a
the discretion of the surgeon based on concomi- tear is present, it is repaired. The ATFL ligament
tant pathology. is identified via an anterolateral ankle arthrotomy,
raising a cuff of tissue from the distal fibula. The
lateral aspect of the talar neck is identified. The
38.4.1 A
 natomic Allograft Lateral superior peroneal retinaculum is maintained at its
Ligament Reconstruction distal extent and partially transected slightly more
Procedure Technique proximal allowing visualization of the posterior
fibula. The lateral wall of the calcaneus, near the
A curvilinear incision over the distal extent of the insertion of the CFL ligament, is identified. Guide
fibular and peroneal tendons (posterior approach wires for the utilized interference screw set can be
placed through the talus, fibula, and calcaneus to
simulate the anticipated trajectory for the ana-
tomic allograft ligament repair for both the ATFL
and CFL ligaments (Fig. 38.26). The authors pre-
fer to use either gracilis or semitendinosus
allograft tendon. The tendon is stretched, or a pre-
stretched tendon can be utilized. A whipstitch is
placed in the tendon allograft. The tendon is sized
prior to drilling osseous tunnels. The appropriate
sized osseous tunnels can be drilled over the guide
wires p­ rovisionally placed to determine angular
reconstruction of the lateral ligaments. The
authors prefer to have a separate tunnel through
the fibula for each of the ATFL and CFL liga-
Fig. 38.24 A layered closure is then performed with
Vicryl and nylon ments that the tendon allograft will pass over an

a b

Fig. 38.25 (a) Incisional scar from failed Broström-Gould procedure. (b) Incisional plan for anatomic allograft lateral
ankle ligament reconstruction
38 Collateral Ankle Ligament Repair 441

a b

Fig. 38.26 (a) Fluoroscopic image of talar guide wire parallel to the ankle joint line. (b) Clinical image of guide wire
placement in the talus

a b

Fig. 38.27 (a) Drilling of the ATFL tunnel over placed guide wire. (b) Orientation of the CFL guide wire relative to
the ATFL tunnel trajectory

osseous bridge on the posterior fibula (Fig. 38.27). through the ATFL fibular tunnel. A second anchor
The tendon is passed through the CFL tunnel is placed in the fibula through the ATFL tunnel
within the fibula and inserted with a blind tunnel from the anterior fibula, again with tension applied
technique into the lateral calcaneus, and the (Fig. 38.29). Having two independent interfer-
appropriate sized interference screw is placed. ence screws within the fibula ensures independent
Next, tension is applied from the posterior fibula tension and stability of each of the reconstructed
while recreating the CFL, and an interference ATFL and CFL ligaments. The tendon is then
screw is placed into the fibula from the inferior passed through the talar neck tunnel in an open
aspect (alternatively, the allograft tendon can be technique, applying tension from the medial
passed through both fibular tunnels prior to plac- aspect of the hindfoot. The final interference
ing any interference fixation) (Fig. 38.28). The screw is placed from the lateral talar neck
tendon is then passed over the osseous bridge and (Fig. 38.30). Redundant tendon allograft can be
442 R. T. Scott et al.

a b

Fig. 38.28 (a) Passage of the allograft through the CFL tunnel. (b) Passage of the allograft through the ATFL tunnel
following passage through the CFL tunnel

a b

Fig. 38.29 (a) Placement of interference screw or suture screw has already been placed. Note the slightly everted
anchor within the calcaneus. (b) Placement of the ATFL position maintained by the assistant
interference screw in the fibula after the CFL interference

sharply transected at the medial aspect of the neal retinaculum is then re-­approximated in a
talar neck, if required. Stress drawer and tilt pants-over-vest technique. With the foot in an
exams are performed to verify appropriate integ- everted position, the above described Gould tis-
rity of repair, and range of motion is assessed to sue advancement is performed. A layered closure
evaluate for overtightening. The superior pero- is then performed.
38 Collateral Ankle Ligament Repair 443

a b

Fig. 38.30 (a) Passage of the allograft through the talus tunnel. (b) Placement of the talus interference screw with foot
held in everted position, setting final tension

38.5 Deltoid Ligament When chronic instability is present, the sur-

Reconstruction geon must determine the involvement of the
superficial and deep deltoid. If the superficial del-
In the acute disruption of the deltoid ligament, a toid is incompetent, then a similar approach to the
curvilinear incision is made over the central acute deltoid ligament disruption can be followed.
aspect of the distal medial malleolus following If the instability involves both the superficial and
the course of the posterior tibial tendon. The inci- deep, then much larger reconstruction is war-
sion will follow the superior aspect of the tendon. ranted. Similar incision is performed exposing the
The incision will be deepened with care to iden- deltoid and posterior tibial tendon sheath. This
tify the greater saphenous vein and branches, as time the posterior tibial tendon sheath is incised.
well as the saphenous nerve. Dissection will then Dissection is then taken lateral to the posterior
be carried down to the deltoid ligament. In the tibial tendon following the bony contour of the
acute setting, the deltoid is typically avulsed off medial aspect of the talus. Dissection is taken
the medial malleolus. Debridement of the deltoid deep down to the level of the sustentaculum tali. A
is performed, and removal of any loose bodies is suture anchor loaded with tape can then be
completed. Two or three larger suture anchors inserted into the sustentaculum tali. The suture
(4.5 mm or larger) are inserted into the medial tape arms are then advanced superior to the medial
malleolus. The first anchor is placed in the ante- malleolus. One of the arms is secured to the distal
rior face of the medial malleolus, with the second aspect of the medial malleolus with an interfer-
off the inferior aspect. Full-thickness advance- ence screw and the other to the anterior face. Be
ment of the superficial and deep deltoid is then sure to position the ankle in a neutral and mildly
performed reattaching the deltoid to the medial inverted position when tensioning the suture ends.
malleolus. Less commonly, the deltoid avulses If less dissection is decided, then a suture
from the medial talar neck and sustentaculum anchor loaded with tape may be inserted into the
tali; in this instance the repair strategy can be anterior face of the medial malleolus and secured
reversed with an anchor placed in the medial into the medial neck of the talus. The postopera-
talus and sustentaculum, rather than in the tibia. tive course is the same as for the open Broström-­
A layer closure should be performed. Gould procedure.
444 R. T. Scott et al.

38.6 Syndesmotic Ligament medial malleolar metaphysis and at the same fib-
Injury Surgical Description ular juncture. Manual manipulation can be
engaged in lieu of a clamp depending on surgeon
Ligamentous syndesmotic injury can occur as an comfort and expertise. Prior to engaging the
isolated “high ankle sprain” injury or as a compo- clamp, care should be taken to dorsiflex the foot
nent of a rotational ankle fracture. Evaluation to 90° to the leg, preventing overtightening the
consists of clinical assessment via the medial/ tibia-fibula articulation and in effort to direct the
lateral squeeze test and/or external rotation stress fibula in the axial plane into the incisura.
test. Pain is elicited directly overlying the syndes- The authors often elect to use a three- or four-
mosis and exacerbated by the above maneuvers. hole plate on the fibula to essentially function as
These clinical confirmations are supplemented a large washer for the transyndesmotic fixation,
with plain film X-ray of the ankle and MRI to in the case of an isolated ligamentous syndes-
confirm diagnosis. If a distal ankle fracture is not motic injury. The lateral plate is placed to opti-
visualized, when pain is over the syndesmosis, mize the height of the syndesmotic fixation points
the proximal fibula should be palpated, and tib-­ at 15 and 25 mm from the ankle joint. Although
fib radiographs should be obtained. choice of fixation is surgeon dependent, we typi-
Upon confirmation of syndesmotic disruption, cally use flexible suture button fixation, unless
surgical intervention should not be delayed. there is a proximal fibular fracture or if there is
In the isolated syndesmotic ligament disrup- medial malleolar comminution. In a proximal
tion injury, the goal of treatment is re-­establishment fracture, screw fixation is preferred to avoid any
of the normal articulation and stability between potential fibular shortening and loss of correc-
the fibula and tibia. Notable anatomical goals tion. Regardless of the type of fixation, the fixa-
involved in reduction include ensuring appropri- tion is oriented parallel to the tibial plafond and
ate reduction of axial rotational, as well as any approximately 25–30° posterior relative to the
fibular length deficit in the case of high fibula frontal plane. Prior to drilling the fixation trajec-
fracture. Additionally, ensuring adequate reduc- tory from the fibula into the tibia, we recommend
tion of the fibula into the incisura of the tibia is a small open medial incision to protect and retract
paramount for normal ankle articulation and to the saphenous nerve and vein from injury. When
avoid anterior-posterior malreduction. suture buttons are utilized, the small open medial
Surgically speaking, the authors prefer an approach allows for direct placement of the aper-
arthroscopically aided approach to syndesmotic ture on the medial tibial cortex in a vertical orien-
reduction and stabilization. The impetus for tation, thus avoiding any impingement of the
arthroscopy in this setting is twofold, both to uti- medial soft tissues and/or neurovascular struc-
lize the scope to debride the ankle joint globally tures. We typically recommend placing two
and then to evaluate and debride the syndesmotic points of fixation for syndesmotic stabilization
ligament itself. This is important in both the (Fig. 38.31). When the first suture button is
acutely and chronically injured patient and allows placed and tensioned, the second suture button
for important debridement of the syndesmotic should be placed and tensioned before cutting the
articulation, removing scar tissue and creating a sutures laterally for either point of fixation, as
vascularized environment necessary for healing. sometimes the initially placed button requires
Debridement of the syndesmosis, specifically, retightening. Caution is recommended not to
should be performed with the use of live intraop- overtighten the syndesmotic reduction, as widen-
erative fluoroscopy to ensure that the shaver has ing of the lateral gutter can occur especially when
reached at least 2 cm proximal to the ankle joint. the fibula is fractured.
Following the debridement, a large double The incisions are closed in a layered fashion.
sharp tenaculum bone clamp is used to hold ana- A posterior splint is applied. The postoperative
tomic reduction of the syndesmosis. The clamp course mirrors that of the above open
should be carefully placed just proximal to the procedures.
38 Collateral Ankle Ligament Repair 445

a b

Fig. 38.31 AP (a) and lateral (b) ankle radiograph dem- Note the vertical placement of the medial apertures to
onstrating proper placement for flexible syndesmotic fixa- minimize the risk of neurovascular injury/entrapment
tion utilizing a four-hole locking plate as a large washer.

4. Acevedo J, Mangone P. Arthroscopic lateral ankle

References ligament reconstruction. Tech Foot Ankle Surg.
2011;10:111–6.
1. Colville M. Surgical treatment of the unstable ankle. J 5. Corte-Real N, Moreira R. Arthroscopic repair of
Am Acad Orthop Surg. 1998;6:368–77. chronic lateral ankle instability. Foot Ankle Int.
2. Broström L. Sprained ankles, VI: surgical treatment 2009;30:213–7.
of “chronic” ligament ruptures. Acta Chir Scand. 6. Nery C, Raduan R, Del Buono A, Asaumi I, Cohen M,
1966;243:551–65. Maffulli N. Arthroscopic-assisted Broström-Gould for
3. Gould N, Seligson D, Gassman J. Early and late repair chronic ankle instability: a long-term follow-up. Am J
of the lateral ligaments of the ankle. Foot Ankle. Sports Med. 2011;39:2381–8.
1980;1:84–9. 7. Cottom JM, Rigby RB. The “All Inside” arthroscopic
Broström procedure: a prospective study of 40 con-
secutive patients. J Foot Ankle Surg. 2013;52:568–74.
 Amputations
39
Premjit Pete S. Deol and Robert D. Santrock

39.1  he Standard Below-the-­

T use of a tourniquet for these cases, some blood
Knee Amputation loss does occur with the removal of the limb. And
postoperatively, the hemoglobin tends to drift
39.1.1 Indications downward. Furthermore, these patients are often
unhealthy, and extra attention to the blood counts
The vast majority of BKAs performed are for is warranted.
complications associated with diabetes and Nutritional status – Many diabetic patients are
peripheral vascular disease. Uncontrolled infec- malnourished [1]. This condition is reflected in
tion, gangrene, severe trauma, non-repairable such readings as prealbumin, albumin, and total
deformity, nonfunctional foot, and chronic lymphocyte counts. Knowing these numbers are
uncontrollable pain may also be indications for still predictive of mortality and morbidity of the
the BKA. BKA. It is, in general, recommended that the
patient have an albumin of >2.5 g/dL and a total
lymphocyte count of >1500/μL in order to pro-
39.1.2 Preoperative Optimization ceed with an amputation [2].
Blood glucose control – An ideal diabetic
Although most BKA cases are semi-urgent and patient will have an A1c reading of 7.0% or less.
require operating in less-than-optimal patient Since the A1c percentage is being read over
conditions, some parameters can be used to pre- time, it may be hard to see that direct change
dict and improve outcomes. during a hospitalization; therefore, we recom-
Hemoglobin and hematocrit count – This mend blood glucose reading to be as normal as
should be known and optimized. As foot and possible (less than 150 mg/dL) to optimize heal-
ankle surgeons, we are not used to significant ing. This is best achieved by having the admit-
blood loss. And, even though we recommend the ting medical service remove all maintenance
diabetes medications and having the patient
managed with sliding-­scale insulin or continu-
P. P. S. Deol (*)
Panorama Orthopedics & Spine Center, Section ous intravenous insulin [3–5].
of Foot & Ankle, Golden, CO, USA Vascular assessment – To determine the
e-mail: [email protected] appropriate level of amputation, it is most appro-
R. D. Santrock priate to perform a vascular assessment. Now in
West Virginia University/Ruby Memorial Hospital, most cases, a simple pulse exam or ankle-­
Department of Orthopaedics, Robert C. Byrd Health brachial index (ABI) is enough to determine
Sciences Center, Morgantown, WV, USA

© Springer Nature Switzerland AG 2019 447

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_39
448 P. P. S. Deol and R. D. Santrock

s­ uccess. An ABI of >0.5 should be sufficient for

healing [2]. However, if the exam warrants arte-
riography to evaluate and/or perform interven-
tion on the femoral or iliac vessels, this should
be planned ahead of the BKA if possible.
Cardiopulmonary reserves – In the case where
the BKA is more elective, such as in the case of
chronic deformity or pain, one must consider the
patient’s cardiopulmonary reserves. A BKA will
require energy expenditure to ambulate com-
pared to a preserved limb [6].
Nicotine use – As with all foot and ankle sur-
geries, nicotine use is prohibited. By technical
measure, nicotine metabolites are detectible in
the blood for 6 weeks post last exposure, and sec-
ondhand smoke is indeed nicotine exposure. It is
recommended that no patient undergoes BKA Fig. 39.1 Dressing out the foot with draining wounds
with nicotine consumption due to the deleterious with an impervious stockinette and Coban wrap
effects on wound healing.
Social support – The patient and family should 39.1.4 B
 ack Table and Mayo
be given an opportunity to meet with social ser- Stand Setup
vices and prosthetic services prior to the BKA
when possible. This eases anxiety and allows for In general, there will be the need for a separate
equipment planning. set of tools and instruments to perform a BKA. An
amputation kit has larger instruments than typi-
cally seen in a foot and ankle kit. Such instru-
39.1.3 Positioning, Tourniquet ments that may be useful are large skin rakes,
Placement, and Sterile large Homan retractors, a large bone rasp, a large
Preparation key elevator, and an amputation knife. Since
speed and efficiency are important factors in per-
The patient’s position is supine for this proce- forming BKA, attention to the proper setup of the
dure. It is recommended to place a hip bump to Mayo stand should be done before incision. This
point the foot vertically. will allow for the necessary instruments to be
A thigh tourniquet is standardly applied in the readily available in the early part of the proce-
normal position at the top of the thigh, as close to dure. In general, the Mayo stand will house #10
the crease of the hip/groin as possible. We sug- scalpel blades, periosteal key elevators, retrac-
gest 300 mm Hg, never to exceed 2 hours of con- tors, and a saw.
tinuous tourniquet time. Additional equipment for the standard BKA
The sterile preparation can be done from the include silk suture ties and/or vascular clips for
malleoli to the thigh tourniquet drape. Should the hemostasis.
foot have active infection and/or an open wound,
it is recommended to keep this part of the limb
isolated from the sterile field. This isolation is 39.1.5 Procedure
done with an impervious stocking drape and
Coban wrap (see Tip below). 39.1.5.1 Incision
There are multiple descriptions and calculations
Tip The impervious stocking and Coban drape in the literature designed to help the surgeon plan
of the foot (Fig. 39.1). the incision for a BKA. The standard BKA is a
39 Amputations 449

posterior flap brought anterior with a myoplasty after the limb is amputated; therefore, the sur-
of the gastrocnemius to the anterior-proximal geon should keep as much of the posterior flap as
tibia. Therefore, the incision is an anterior trans- possible at this stage.
verse incision (4 fingerbreadths ~ 8 cm) below The incision is full thickness with a #10 blade.
the tibial tubercle, then linear down the medial The incision is carried down cleanly to the deep
and lateral lower leg, and, finally, transverse pos- tissues, including the muscle and periosteum.
teriorly connecting the medial and lateral linear The incision should be started anteriorly, then
incisions (Figs. 39.2 and 39.3). down each side of the lower leg, and finally
The width of the anterior incision is deter- across the posterior leg. Posteriorly, the incision
mined by the width of the lower part of the lower does not usually complete the amputation. This
leg. In other words, the maximum width proxi- will be done with an amputation knife after the
mally is determined by the minimum width dis- bone cuts are made.
tally. The length of the posterior flap is adjusted
39.1.5.2 Amputation
A large rake retractor is placed proximally over
the tibia, and subperiosteal elevation on the ante-
rior tibial periosteum is done to a level 2 cm
proximal to the skin incision. A power saw is
then used to transversely cut through 90% of the
tibia. By leaving 10% of the tibia intact, this
keeps the leg stable while the remaining dissec-
tion is performed (see Tip below). The rake is
then moved laterally to help expose the fibula.
The saw is then used to transact the fibula slightly
more proximal than the tibial cut. The fibular cut
is also angled from medial-distal to proximal-­
lateral creating a bevel that is more suited to fit-
Fig. 39.2 Incision planning of the length from the tibial ting in the prosthetic socket.
tubercle

Tip Incomplete tibial resection for stability

(Fig. 39.4).

Now the remaining 10% of the tibia is either

transected or fractured by bending the osteotomy

Fig. 39.3 Incision planning showing the fully drawn-out Fig. 39.4 Incomplete tibial resection maintains stability
incision until the limb is ready to be removed
450 P. P. S. Deol and R. D. Santrock

Fig. 39.5 The posterior “peel”

site over the surgeon’s arm. The tibia and fibula are
then pulled anteriorly stripping the lower leg from
the gastrocnemius muscle. The gastrocnemius
muscle is what is left behind to create the posterior
Fig. 39.6 The medium Hemovac drain and Opsite
flap. This “peel” technique allows for a clean dis-
dressing
section that is actually less traumatic (see Tip
below). The remaining crural fascia and Achilles
tendon is transected using the amputation knife. major vessels to ensure no other sources of sig-
The leg is then removed and sent to pathology. nificant bleeding are identified.
The tibial nerve, common peroneal nerve, and
Tip The posterior flap peel technique (Fig. 39.5). sural nerve should all be put on stretch and trun-
cated short of the bone cuts. This should be done
The saw can now be used to make an anterior sharply with a scalpel. This technique diminishes
bevel on the tibia if desired. A rasp may be used the likelihood of painful neuroma formation.
to smooth the edges of the bone where necessary. The last step in this portion of the surgery is
It is important that the fibula remains shorter than to place a drain if necessary. It is particularly
the tibia for proper prosthetic fit and comfort. useful to have a drain in place for 24–48 hours
postoperatively if coagulation parameters are
39.1.5.3  emostasis and Nerve
H not normal. The preferred drain is a medium
Identification Hemovac drain that lies against the tibial bone
Hemostasis is an important step and should not cut end and exits proximal-laterally. It is secured
be ignored. The three major vessels of the lower with an Opsite dressing to protect it from prema-
leg (anterior tibial, posterior tibial, and peroneal ture removal while allowing for ease of removal
arteries) should be identified and clamped with without having to disrupt the dressings or splint
hemostats. Silk sutures or vessel clips should be (see Tip below).
used for the permanent hemostasis. It is preferred
to let the tourniquet down after isolating the three Tip Hemovac drain security (Figs. 39.6 and 39.7).
39 Amputations 451

control postoperative swelling, it is recom-

mended to place a long leg split. Rigid postopera-
tive immobilization is also the best form of pain
control prevention of phantom pains.

39.1.6 Immediate Postoperative Care

The rigid splint is kept in place for approximately

3 weeks. The drain however can be removed at
24–48 hours postoperatively. In general, the
sutures are removed at roughly 3 weeks. Most
patients will be immediately fitted for stump
Fig. 39.7 The drain secured
shrinkers at this point.

39.1.5.4  yoplasty and Flap Length

M
Adjustment 39.1.7 P
 rosthesis Fitting and Long-­
The posterior flap is secured by the myoplasty Term Care
technique. The crural fascia is sutured to the ante-
rior tibial periosteum after adjusting the length of The fitting of the stump shrinkers begins the pro-
the posterior flap. The posterior flap adjustment cess of shaping the stump to accept a prosthetic
is done by bringing the flap forward with Kocher leg. Usually the prosthetists take over the timing
clamps and then using a marking pen to measure of the fitting of the prosthetic leg at this point.
and adjust the length. Sharp dissection is done There are certain factors in determining the fit-
with a #10 scalpel. ting of the prosthetic leg (swelling, pin, wound
A watertight closure is done with size 0 or #1 healing, etc.). Some patients will be fitted with a
Vicryl suture. After this fascial closure, the skin temporary leg that allows them to stand and
will be approximated in layers. transfer early in the postoperative period.
Provided that the patient is doing well, most
39.1.5.5 Closure will be walking at around 2 months postopera-
The skin is closed in two layers. The subcuticular tively. Younger patients, whose amputations were
layer is approximated with size 2.0 Vicryl suture, performed for reasons such as trauma and/or
and the final layer is closed with the surgeon’s severe deformity, may actually walk within days
choice of staples or sutures. to weeks of the surgery.
The final position of the incision should be
anterior to the distal end of the stump. And should
the surgeon encounter “dog ear” deformity at the 39.2 Ertl Modification of the BKA
corners, it is best advised not to adjust or make
additional incisions. Adjusting for these deformi- 39.2.1 Indications
ties is often associated with additional wound
breakdown. As with below-the-knee amputations, the indica-
tions for the Ertl modification are similar. Most
39.1.5.6 Dressing and Immobilization patients have complications leading to the need
An antimicrobial contact dressing is applied to for amputation, including diabetes or peripheral
the incision. Gauze and/or ABD dressings are vascular disease with non-healing wounds. Of
then applied and secured using rolled cotton bat- particular concern with the Ertl modification is
ting. To prevent contracture at the knee and to the viability of the residual distal fibula. Patients
452 P. P. S. Deol and R. D. Santrock

described, a well-padded tourniquet is placed

about the upper thigh and set to 250 mm Hg, not
to exceed 2 hours of continuous inflation.

39.2.4 Surgical Technique

The standard approach to a below-the-knee ampu-

tation is described earlier in this chapter. In the
Ertl approach, care must be exercised to avoid
stripping the soft tissues off of the fibula distally.
Preservation and appropriate handling of the peri-
Fig. 39.8 Anterior-posterior X-ray of the Ertl osteal tissue is of the utmost importance to avoid
modification avascular changes of the distal bone. Maintaining
the proximal periosteal attachment to the fibula
preserves the peroneal arterial supply to the bony
presenting with pathology that jeopardizes the bridge. Periosteal flaps are developed distal to the
health of the fibula are excluded, including level of the planned osteotomies to use for incor-
patients presenting with proximal extension of poration around the fibular bone bridge. These
infection or vascular insufficiency (Fig. 39.8). flaps are created in anterior-to-­posterior direction,
creating a medial- and lateral-­based flap off the
tibia and the fibula. The periosteal layers are ele-
39.2.2 Preoperative Assessment vated off the tibia and fibula while maintaining
cortical bone attachments to the periosteal layer to
In order to ensure the success of the Ertl proce- facilitate bony union.
dure, full-length plain radiographs are necessary
of the tibia and fibula. This allows for thorough Tip It is recommended to use a 45° chisel to
surgical planning should any anatomic variations elevate the periosteum to avoid cutting the tissue.
or retained hardware exist. An MRI of the extrem- The use of an osteotome for elevation risks cut-
ity may be useful in the setting of prior infection ting the periosteal tissue.
or concerns of osteomyelitis. An angiogram is
obtained for concerns regarding distal perfusion Unlike in a traditional BKA, the tibial and
that may impair healing of the osteomyoplastic fibular osteotomies are created at the same level.
reconstruction. The general medical workup and The surgeon’s preference is used in guiding the
optimization of the patient is identical to that per- orientation of the osteotomies.
formed for a BKA and is presented earlier in this
chapter. Tip The author’s preference is to maintain the
lateral cortex of the fibula and medial cortex of
the tibia once transverse osteotomies are made.
39.2.3 Patient Positioning These cortical struts then allow the rotated fibular
graft to be sandwiched between the cortical bones
Patient positioning on the surgical table is identi- to create a “press-fit” construct.
cal to that of a BKA, with a large positioning
bump fashioned and placed under the ipsilateral The use of internal fixation to secure the fibu-
hip to internally rotate the lower leg and to better lar graft is at the discretion of the surgeon. The
present the fibula. A black foam ramp pad is used original description of the Ertl procedure
to slightly elevate the lower leg to minimize requires no internal fixation; however, options
venous congestion and bleeding. As previously for fixation vary from small fragment screws to
39 Amputations 453

suture-button fixation or nonabsorbable suture 39.2.7 Complications

via bone tunnels. Once the bone bridge is ade-
quately secured, focus turns to the closure of the Although every surgical procedure has the poten-
periosteal flap. The tibial and fibular flaps are tial for complications, there are several unique
sutured together in a tubelike fashion around the concerns that arise with the Ertl technique. The
fibular bridge. The lateral fibular periosteum is creation of an osseous bridge as a primary feature
sutured to the medial tibial periosteum creating a of the procedure introduces the risk of non-union.
180° vascular soft tissue sling inferior to the Careful attention to dissection with preservation
graft. The corresponding superior tissues are of the periosteal flap, meticulous closure, and
secured in a similar fashion enveloping the fibu- stable fixation will help to reduce this risk.
lar graft. Reconstruction with closure of the Certain modifications of the technique call for
medullary canals allows the restoration of the the use of internal fixation devices to secure the
intramedullary pressure and reduces the inci- osseous bridge, which may introduce the poten-
dence of a crown sequestrum. tial for hardware irritation. With a sufficient soft
The myoplasty step requires suture fixation of tissue envelope and care to avoid prominence of
the posterior flap to the osteoperiosteal bridge to the hardware, this risk is reduced. Heterotopic
anchor the myodesis. ossification may be seen in cases in which there
is an incomplete closure of the medullary canal
Tip The author’s preference is to create a myo- of the tibia or fibula. More common complica-
desis between the posterior compartment and the tions can include delayed wound healing or sinus
anterior/lateral compartment musculature tract formation, skin adherence to the bone, joint
through suture fixation. This step improves contractures, insensate skin, and residual pain.
venous return from the extremity through restora-
tion of the pumping actions of the agonist-­
antagonist muscular relationship. 39.3 Midfoot Amputations

39.3.1 Indications
39.2.5 Closure
Anatomically the foot can be segregated into
The closure of the Ertl below-the-knee amputa- three areas when considering a midfoot amputa-
tion is similar to the closure of the standard tion. These areas dictate the level of amputation
below-the-knee amputation. Attention must be and the anatomic structures that can be spared.
paid to obtaining adequate soft tissue coverage The Chopart joints describe the transverse tarsal
from the myodesis over the fibular strut graft due joints between the midfoot and hindfoot, specifi-
to the end bearing nature of the procedure. cally addressing the talonavicular and calcaneo-
cuboid joints. Distally, the transition between the
midfoot and forefoot occurs between the metatar-
39.2.6 Postoperative Care sals and the tarsal bones, which is referred to as
the Lisfranc joint complex.
In addition to the standard postoperative care As with other types of amputations, the indi-
described earlier in this chapter, the surgeon must cations for midfoot amputations are similar. Most
continue to monitor the healing and stability of patients present with a variety of risk factors that
the osteoplastic reconstruction. Serial radio- predispose them to a compromised soft tissue
graphs are obtained in the office every 4 weeks envelope around the forefoot. Systemic diseases
until sufficient callus formation is noted to ensure including diabetes, neuropathy, and/or peripheral
a stable bone bridge. Weight-bearing on the limb vascular disease are most commonly associated
is generally allowed between 6 and 8 weeks but with wound development and a subsequent fail-
made on a case-by-case basis. ure to heal.
454 P. P. S. Deol and R. D. Santrock

39.3.2 Preoperative Assessment 39.4 Transmetatarsal Amputation

Preoperative workup of the patient requires a A full-thickness transverse incision is developed in

complete understanding of barriers that may a curvilinear fashion across the central portion of
interfere with success of the operation. Plain the metatarsals. Cutaneous branches of the pero-
radiographs are obtained of the foot and ankle to neal nerve are identified and transected sharply
identify potential anatomic variations or retained under light traction with the nerve end buried in the
hardware. An MRI of the extremity may be use- adjacent muscle. The dorsalis pedis artery is identi-
ful in the setting of prior infection or for concerns fied with an attempt to preserve the continuity of
of osteomyelitis. An angiogram may be obtained the artery as it passes plantarly to complete the arte-
when distal perfusion of the limb is suspected to rial anastomosis with the posterior tibial artery. The
be impaired. The general medical workup and artery should be ligated proximal to the skin mar-
optimization of the patient is identical to that per- gin to protect the residual vessel. The extensor ten-
formed for a BKA and is presented earlier in this dons are placed under tension by plantarflexing the
chapter. forefoot prior to transecting sharply and allowing
them to retract proximally. The metatarsals are then
visualized, and the level of osteotomy is deter-
39.3.3 Patient Positioning mined. With the use of an oscillating saw, the meta-
tarsals are individually resected attempting to
Patient positioning on the surgical table is per- maintain approximately half to one-third of the
formed with a positioning bump placed under the proximal metatarsal.
ipsilateral hip to internally rotate the foot until it
is directly pointed upward. A black foam ramp Tip Metatarsal resections are best done with a
pad is used to slightly elevate the lower leg to beveled cut at 30–45° angling from dorsal-distal
minimize venous congestion and bleeding. In to plantar-proximal, maintaining the normal cas-
order to achieve vascular control during the pro- cade of the metatarsal lengths. This direction of
cedure, a tourniquet is typically utilized. The osteotomy reduces plantar pressure on the resid-
preference of a well-padded thigh tourniquet or ual foot and reduces the potential risk of future
an Esmarch tourniquet around the ankle is left to ulceration. It is suggested that the first and fifth
the discretion of the surgeon but should not be metatarsals are evaluated for residual sharp
allowed to exceed 2 hours. edges following osteotomy that may create addi-
tional pressure on the skin.

39.3.4 Surgical Technique The plantar portion of the incision is then

completed at a 45° distal-plantar direction from
The approach to a midfoot amputation is based the dorsal incision to allow the longer plantar flap
upon the level of the amputation determined dur- of the incision to be rotated dorsally to avoid
ing the preoperative planning. Although the level placing pressure on the incision during weight-­
of bony resection will differ, a similar surgical bearing and with placement of a shoe. The plan-
approach is used for the incision and soft tissue tar neurovascular structures are ligated and cut
dissection. Initially the limb is exsanguinated to sharply as they are identified. Sharply divide
limit blood loss. flexor tendons while under tension to allow ten-
dons to retract proximally.
Tip Amputations performed in the setting of a
localized infection are best done with gravity Tip In distal midfoot amputations, skin quality
exsanguination to avoid using the Esmarch over can oftentimes be marginal. It is important to
the infected area and risking manual expression remember that the quality of the soft tissues out-
of infection into adjacent areas. weighs the importance of the quantity of the soft
39 Amputations 455

tissue available for closure. Therefore, if poor-­ sals, connecting the midpoint of the first metatar-
quality tissue is available for the closure of a sal base medially to the base of the fifth metatarsal
transmetatarsal amputation, the surgeon should laterally. These landmarks are adjusted slightly
consider amputation at a more proximal level. If more proximal with the Chopart amputation with
a long plantar flap is unable to be developed due a dorsal curvilinear incision placed over the
to soft tissue quality, a fishmouth incision may Lisfranc joints but starting medially just distal to
also be used. the talonavicular joint and terminating laterally at
the calcaneocuboid joint.
Prior to closure, the tourniquet is released to Although the location of the incision may
ensure adequate hemostasis. If excessive oozing vary, the surgical approach is identical for both
from the bony resection is encountered, a small procedures. Once a dorsal full-thickness flap is
percutaneous drain deep to the fascia may be developed, the cutaneous branches of the pero-
placed. The short-term success of the procedure neal nerve are identified and transected sharply
is based upon meticulous closure of the soft under light traction. The dorsalis pedis artery is
tissue envelope with edge-to-edge skin re-­ identified and ligated proximal to the skin mar-
­
approximation. The closure is performed in a lay- gin. The extensor tendons are placed under ten-
ered fashion with absorbable deep sutures and sion by plantarflexing the forefoot prior to
nonabsorbable superficial sutures, to include the transecting sharply and allowing them to retract
fascia, subcuticular layer, and skin. proximally.
Amputations through the Lisfranc joints
Tip Contracture of the Achilles tendon is often expose the individual tarsometatarsal joints.
found to coexist in patients with plantar forefoot These joints are then disarticulated sharply until
ulcerations. When performing any midfoot ampu- the forefoot is detached from the midfoot. The
tations, the surgeon should evaluate for the pres- area of disarticulation in Chopart amputations
ence of a contracture and consider performing a occurs between the talonavicular and calcaneo-
simultaneous Achilles lengthening procedure. cuboid joints in a similar fashion, detaching the
The lengthening procedure chosen is at the dis- midfoot from the hindfoot. Any prominent areas
cretion of the surgeon but should take into con- of bone are removed to avoid excessive pressure
sideration the severity of the contracture, on the soft tissues. Sharp edges can be smoothed
postoperative wound care needs, subsequent and beveled with a rasp or saw.
weight-bearing status, and overall function of the
patient. Tip Dependent upon the anatomy of the patient’s
foot, the prominence of the talar head medially or
the anterior process of the calcaneus laterally
39.5 Lisfranc and Chopart may require partial resection to avoid pressure
Amputations on the incision during closure.

Surgeons specializing in the foot and ankle The plantar portion of the incision is then
should be familiar with several options for mid- completed at a 45° distal-plantar direction from
foot amputations in order to accommodate the area of disarticulation to develop a longer
patients presenting with varying traumatic inju- plantar flap. This longer flap typically extends to
ries or soft tissue complications of the forefoot. the level of the metatarsals and can then be
Patients should be assessed on an individual basis rotated dorsally to take advantage of the thicker
to determine their potential benefits and risks plantar skin to protect the residual foot with
associated with each of these options. weight-bearing.
The anatomic landmarks for Lisfranc amputa-
tions are based on a dorsal curvilinear incision Tip Should the quality of the skin plantarly be of
placed along the proximal third of the metatar- concern, a fishmouth-shaped incision may be
456 P. P. S. Deol and R. D. Santrock

required with adjustments made to the level of consideration the severity of the contracture,
skin incision dorsally. As with any type of ampu- postoperative wound care needs, subsequent
tation, the quality of the soft tissues strongly out- weight-bearing status, and overall function of the
weighs the importance of the quantity of tissue patient.
available for closure.
A meticulous layered closure of the soft tissue
The plantar neurovascular structures are envelope around the residual foot with edge-to-­
ligated and cut sharply as they are identified. edge skin re-approximation helps to avoid early
Sharply divide flexor tendons while under ten- postoperative complications. A combination of
sion to allow tendons to retract proximally. With absorbable deep sutures and nonabsorbable
division of the plantar soft tissues, the skin inci- superficial sutures allows repair of the fascia,
sion is completed plantarly to complete the subcuticular layer, and skin.
amputation.

Tip Amputations through the Chopart joints 39.5.1 Postoperative Care

result in the release of the tibialis anterior and
posterior tibial tendons which can lead to a pro- Immediately postoperatively the patient is placed
gressive plantar flexion deformity of the residual into a protective surgical dressing. The incision is
limb. Each of these tendons is tagged when protected until sutures are safe to remove based
released to perform a dynamic transfer of the ten- upon swelling and healing, which occurs between
dons. To avoid the foot being pulled into inver- 10 days and 3 weeks. Immobilization of the
sion and plantar flexion, the posterior tibial residual limb in a postoperative rigid dressing or
tendon can be rerouted through the interosseous splint is necessary in cases of Chopart amputa-
membrane and transferred to the dorsal neck of tions to protect the tendon transfers. Care is taken
the talus. The tibialis anterior tendon can also be with a Chopart amputation to avoid dorsiflexion
used as a dynamic transfer to the dorsal-lateral of the foot until the tendon transfers are healed.
neck of the talus to aid in dorsiflexion. Weight-bearing is generally restricted for the
first few weeks to limit swelling and to protect
Prior to closure the tourniquet is released to the incision. Weight-bearing is typically initi-
ensure meticulous hemostasis. The use of a per- ated during the 2–4-week mark with the use of a
cutaneous drain placed deep to the fascia is left to controlled ankle motion (CAM) boot walker
the discretion of the surgeon. In an effort to once the surgeon determines that the incision
appropriately tension the tissues around the and soft tissues are mature enough to tolerate
amputation site and maximize postoperative tension on the skin.
function, the plantar flap is myodesed to the tar-
sal bones (Lisfranc amputations) or the talus/cal-
caneus (Chopart amputations) through bone 39.5.2 Complications
tunnels.
Patients undergoing surgical amputations have
Tip The contracture of the Achilles tendon is similar risk factors, including wound dehiscence,
often found to coexist in patients with plantar infection, and the need for further surgery or
forefoot ulcerations. When performing any mid- higher level of amputation. In addition, the risks
foot amputations, the surgeon should evaluate for of heterotopic ossification, sinus tract formation,
the presence of a contracture and consider per- skin adherence to the bone, joint contractures,
forming a simultaneous Achilles lengthening pro- insensate skin, and residual pain continue to be
cedure. The lengthening procedure chosen is at present but are less likely with amputations of the
the discretion of the surgeon but should take into midfoot.
39 Amputations 457

References ment on inpatient diabetes and metabolic control.

Endocr Pract. 2004;10(1):77–82.
4. Clement S, Braithwite SS, Magee MF, et al.
1. Via M. The malnutrition of obesity: micronutrient
Management of diabetes and hyperglycemia in hospi-
deficiencies that promote diabetes. ISRN Endocronol.
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2012;2012:103472.
5. American Diabetes Association. Standards of medical
2. Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich
care in diabetes: 2008. Diabetes Care. 2008;31(suppl
Z. Syme ankle disarticulation in patients with diabe-
1):S12–54.
tes. J Bone Joint Surg Am. 2003;85:1667–72.
6. Pinzur MS, Gold J, Schwartz D, Gross N. Energy
3. Garber AJ, Moghissi ES, Bransome ED Jr, et al.
demands for walking in dysvascular amputees as
American College of Endocrinology position state-
related to the level of amputation. Orthopedics.
1992;15:1033–7.
 Grafting and Biologics
40
Ryan T. Scott, Christopher F. Hyer,
Gregory C. Berlet, Terrence M. Philbin,
Patrick E. Bull, and Mark A. Prissel

Key Points
1. Nonunion is a common complication
associated with arthrodesis procedures
of the ankle and foot frustrating both
patients and surgeons.
2. Allograft biologics, such as PDGF, are a
viable alternative to autogenous bone
grafting with reports indicating equivo-
cal outcomes.
3. Allografts (cancellous chips, DBM)
provide structural graft for large
Fig. 40.1 Bulk allograft from a fresh frozen talus to be
deficits. used to an allograft transplant in the management of an
osteochondral lesion of the talus

40.1 Indications for Grafting • Failed midfoot fusions

and Biologics (Fig. 40.1) • Failed first metatarsophalangeal joint fusion
• Large osteochondral defects of the talus
• Nonunions
• Malunions
• Failed total ankle replacement 40.2 Bone Grafting
• Distraction arthrodesis of the subtalar joint
• Evans calcaneal osteotomy An array of biologics have been widely utilized in
• Cotton osteotomy ankle and hindfoot arthrodesis for the past several
decades. Historically, foot and ankle surgeons
have faced significant challenges with regard to
R. T. Scott (*) achieving a successful arthrodesis. Nonunions
The CORE Institute, Phoenix, AZ, USA
lead to poor patient outcomes, chronic disability,
C. F. Hyer · G. C. Berlet · T. M. Philbin · P. E. Bull and increased healthcare expenditure. Literature
M. A. Prissel
reports up to a 40% nonunion rate for ankle
Orthopedic Foot & Ankle Center,
Worthington, OH, USA arthrodesis, 16% for subtalar joint ­arthrodesis, and

© Springer Nature Switzerland AG 2019 459

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5_40
460 R. T. Scott et al.

17–30% for tarsometatarsal joint arthrodesis [1–

4]. More recently, a study by Arner and Santrock
[5] reported nonunion rates of approximately 10%
in ankle and hindfoot fusions. He noted a signifi-
cant increase in nonunion rate associated with
smoking, avascular necrosis, and surgical error.
Delayed union also remains problematic, espe-
cially among patients with known risk factors.
Fortunately, documented rates of tobacco use are
declining in the United States; however, diabetes
and other clinical risk factors are still prevalent. Fig. 40.2 DBM placement for a second and third tarso-
metatarsal joint fusion

40.2.1 P
 atients with Increased Risk 3. Osteogenic
of Nonunion (a) Synthesize new bone from within the
graft.
1. Smokers Bone grafting (allograft – DBM, cancellous
2. Diabetics chips) (Fig. 40.2) will contain osteoconductive
3. Posttraumatic arthritis and osteogenic properties which will help aid in
4. Revision surgery arthrodesis. Autograft remains the “gold stan-
5. Renal impairment dard” in providing all three properties. However,
bone graft harvest does carry some risk of
Optimizing arthrodesis rates has brought increased morbidity to the patient. Recently, the
increased emphasis on mechanical stabilization. use of platelet-derived growth factor (PDGF),
Arthroscopic techniques along with new locking bone morphogenic proteins (BMPs), and mesen-
plate constructs are attempts to facilitate improved chymal stem cells (MSC) has gained favor among
arthrodesis outcomes; however, modern tech- surgeons attempting to minimize nonunions and
niques demand biologic augmentation in some avoid complications associated with autograft.
patients for increasing surgical success. There are
four key points in determining the indications for Negatives associated with autograft:
biologics in foot and ankle surgery [6]:
1. Chronic pain at the harvest site
1. What are the specific indications? 2. Seroma/hematoma
2. Where do biologics belong? 3. Wound complications
3. Which biologics belong? 4. Increased surgical time
4. How is this pertinent to my practice?
The use of bone marrow aspirate (BMA)
Once the appropriate patient has been identi- added to bone allograft has been an alternative to
fied for surgery and a biologic is considered, an autologous bone graft harvest [7]. The concept
autograft or allograft is selected. When determin- here is to supplement the osteoconductive prop-
ing the type of biologic, we should also consider erties of the demineralized bone matrix with
the three bone graft properties: osteoprogenitor cells from the BMA. BMA is
typically easy to harvest from multiple sites and
1. Osteoinductive carries less morbidity than autologous bone graft
(a) Direct mesenchymal stem cells to differ- harvest. Daigre et al. [8] noted there was no sig-
entiate into osteoblasts. nificant chronic pain from the BMA harvest in
2. Osteoconductive the distal tibia and iliac crest; however, they did
(a) Provide a scaffold/latticework for new find some residual pain from calcaneal BMA
bone formation. which may be confounded by the ipsilateral sur-
40 Grafting and Biologics 461

gical site. Hyer et al. [9] noted the highest con-

centration of osteoprogenitor cells stemmed from
the iliac crest when compared to the tibia and
calcaneus. These aspirate-matrix composites
may be combined with allograft preparations,
resulting in a product that promotes osteoconduc-
tion, osteoinduction, and osteogenesis with lim-
ited morbidity.
Products such as BMP, MSCs, and PDGF
bone graft are indicated for use as an alternative
to autograft in arthrodesis of the ankle (tibiotalar
joint) and/or hindfoot (including subtalar, talona-
vicular, and calcaneocuboid joints, alone or in Fig. 40.3 Bone marrow aspirate harvest from the
combination). These biological grafts are typi- calcaneus
cally used in those patients with high risk of non-
union and cases of revision surgery. There are
numerous studies demonstrating efficacy of each
of the respective biologics.
Bulk allografts can be used in revision surgery
of the forefoot and hindfoot. We typically think
of the use of an allograft Cotton or Evans wedge
in the reconstruction of a symptomatic flexible
flatfoot deformity; however, bulk allograft may
also be utilized during a distraction arthrodesis of
the subtalar joint or a joint salvage procedure
after a failed first ray surgery (first MTP implant).
Larger bulk allografts (femoral heads and fresh
frozen talus) are used in the ankle for chronic
Fig. 40.4 Calcaneal autograft harvest from the calca-
osteochondral defects of the talus or even for a neus. A lateral window was created with a trephine
failed ankle fusion, total ankle replacement, or
hindfoot intramedullary nail. We typically rec-
ommend soaking these larger bulk allografts in
either BMA or PDGF to increase the likelihood
of graft incorporation.

40.3 Surgical Technique: BMA

(Fig. 40.3)

A Jamshidi needle is used to penetrate the donor

site (calcaneus, distal tibia, proximal tibia, iliac
crest). A 20 cc syringe is then used to extract the
bone marrow aspirate. A larger syringe can be
considered if additional volume is required for
concentrating. If a large volume of BMA is being
extracted, make sure to redirect the needle every
5 cc to ensure maximal MSC harvest. The BMA
may then be placed into a centrifuge and spun Fig. 40.5 Autograft harvest instruments. Hollow tre-
down if desired. phine used to create a cortical window and to aid in the
harvest of cancellous autograft
462 R. T. Scott et al.

40.4 Surgical Technique: on the market measuring up to 2 cm in length.

Autograft Harvest (Figs. 40.4 These grafts may be either cortical or cancel-
and 40.5) lous. We recommend fenestrating the graft and
soaking the graft in bone marrow aspirate. If
Autograft harvest all depends on the harvest site autogenous bone graft is harvested, the graft
and the required graft volume. When 5 cc of auto- should initially be placed in the medullary
graft is needed, the calcaneus and distal tibia are canal to backfill the deficit from the previous
optimal. When larger volumes are needed, we rec-
ommend the proximal tibia and iliac crest. An inci-
sion is made over the harvest site on the lateral wall
of the calcaneus, medial distal tibia, proximal tibial
tubercle (Gerdy’s tubercle), or iliac crest. The inci-
sion is deepened carefully to the level of the cortex.
A trephine or saw is used to create a “window” in
the cortex which is placed on the back table. Once
the cortex has been breached, the autograft may be
harvested through the use of a trephine, curette, or
power harvester. The resultant deficit may be back-
filled with DBM or cancellous chips if desired. The
cortical wall is then reapproximated and the wound
closed. Alternatively, at the discretion of the sur-
geon, a power harvester can be utilized to penetrate Fig. 40.7 Extraction of a failed first metatarsophalangeal
joint arthroplasty
the cortex and capture cancellous bone in a single
step. We find a 7 mm power harvester, when used
to harvest calcaneal autograft, does not require
replacement of the lateral wall.

40.5 Surgical Technique: Large

Bulk Allografts

40.5.1 F
 ailed First MTP Fusion
(Figs. 40.6, 40.7, 40.8, 40.9, 40.10,
40.11, 40.12, 40.13, and 40.14)

Once the implant has been removed, a struc-

tural graft must be fashioned to fill the deficit. Fig. 40.8 Bony deficit in the first metatarsal shaft follow-
There are several prefashioned grafts available ing removal of silicone first metatarsophalangeal implant

Fig. 40.6 Removal of a

fractured silicone first
metatarsophalangeal
joint arthroplasty
40 Grafting and Biologics 463

Fig. 40.10 Bulk allograft placement for revision of the

failed first metatarsophalangeal implant

Fig. 40.9 Large deficit at the level of the metatarsopha-

langeal joint

implant. The allograft is then placed into the

deficit and hardware is placed. A fully threaded
cancellous screw may be placed obliquely
across the fusion site. We recommend either a
partially or fully threaded screw to ensure that
minimal to no compression is placed across the
allograft. Dorsal plating is then utilized with Fig. 40.11 Insertion of a partially threaded screw
locking and non-locking screws to stabilize the obliquely across the allograft. Carefully place this screw
construct. to ensure not to overtighten and crush the graft
464 R. T. Scott et al.

40.5.2 F
 ailed Ankle Replacement
(Figs. 40.15, 40.16, 40.17, 40.18,
40.19, 40.20, and 40.21)

Explant of a failed ankle replacement leaves a large

void at the tibiotalar joint. Preparation of the distal
tibia and the talar dome is performed by fenestrat-

Fig. 40.12 Spanning stable fixation across the bulk

allograft

Fig. 40.15 Large bony deficit following the removal of

failed total ankle

Figs. 40.13 and 40.14 AP and lateral radiograph of fixation spanning the bulk allograft in a failed first metatarsopha-
langeal arthroplasty
40 Grafting and Biologics 465

Fig. 40.18 Placement of the guidewire through the cen-

Fig. 40.16 Insertion of the calcar bulk allograft for failed tral aspect of the femoral calcar for the insertion of intra-
total ankle replacement medullary nail placement

Fig. 40.19 Placement of cancellous chips to fill any

voids prior to placement of the intramedullary fixation

ing the bones. A large bulk allograft, typically a

femoral head, is utilized. We recommend using the
calcar as the structural graft due to its high-density
cortical shell. The femoral head can then be decon-
Fig. 40.17 Sizing of the femoral calcar for previously structed removing the cancellous bone and packing
failed total ankle
any remaining bony voids. We recommend soaking
the graft in bone marrow aspirate, platelet-derived
466 R. T. Scott et al.

Figs. 40.20 and 40.21 Anterior and lateral radiograph demonstrating calcar femoral bulk allograft with intramedul-
lary nail placement for failed total ankle

growth factor, or bone morphogenic proteins.

Intramedullary fixation with a hindfoot nail, with
or without external fixation, is suggested.

40.5.3 D
 istraction Subtalar Joint
Fusion (Figs. 40.22, 40.23,
and 40.24)

Distraction subtalar joint fusion is typically employed

in collapsed open reduction internal fixation of the
calcaneus, nonunion of previous subtalar joint fusion,
malunion, or chronic deformity of the hindfoot. We
typically approach the subtalar joint distraction
fusion either from a lateral or posterior approach.
The lateral approach follows the technique described
in the subtalar joint arthrodesis section. Once the
joint is prepped, the tricortical allograft is inserted
from the lateral side and into the posterior subtalar
joint for measurement. The use of a pin distractor Fig. 40.22 Measuring a bulk allograft for a subtalar joint
will allow ease of graft placement. Once the proper distraction arthrodesis
size is determined, the allograft is trimmed to match
the articulating surfaces. The tricortical graft can be Achilles tendon. Dissection is taken down to the
fenestrated and soaked in BMA or synthetic biolog- subtalar joint. Preparation of the joint is performed
ics. The graft is then impacted and fixation is placed. in a standard fashion. The tricortical wedge (pre-
When the posterior approach is preferred, an soaked in BMA/synthetic biologics) is then inserted
incision is placed along the lateral aspect of the from posterior to anterior. Cancellous autograft or
40 Grafting and Biologics 467

References
1. Frey C, Halikus NM, Vu-Rose T. Ebramzadeh. A
review of ankle arthrodesis: predisposing factors to
nonunion. Foot Ankle Int. 1994;15:581–4.
2. Scranton PE. Use of internal compression in arthrodesis
of the ankle. J Bone Joint Surg Am. 1985;67-A:550–5.
3. Easley ME, Trnka HJ, Schon LC, Myerson
MS. Isolated subtalar arthrodesis. J Bone Joint Surg
Am. 2000;82-A:613–24.
4. Glazebrook M, Beasley W, Daniels T, Evangelista
PT, Donahue R, Younger A, Pinzur MS, Baumhauer
JF, DiGiovanni CW. Establishing the relationship
between clinical outcome and extent of osseous bridg-
ing between computed tomography assessment in
isolated hindfoot and ankle fusions. Foot Ankle Int.
2013;34(12):1612–8.
Fig. 40.23 Soaking a bulk allograft in bone marrow aspi- 5. Arner JW, Santrock RD. A historical review of com-
rate prior to implantation mon bone graft materials in foot and ankle surgery.
Foot Ankle Spec. 2014;7(2):143–51.
6. Lin SS, Montemurro NJ, Krell ES. Orthobiologics
in foot and ankle surgery. J Am Acad Orthop Surg.
2016;24:113–22.
7. Ozaki Y, Nishimura M, Sekiya K, Suehiro F, Kanawa
M, Nikawa H, Hamada T, Kato Y. Comprehensive
analysis of chemotactic factors for bone mar-
row mesenchymal stem cells. Stem Cells Dev.
2007;16(1):119–29.
8. Daigre JL, DeMill SL, Hyer CF. Assessment of bone
marrow aspiration site pain in foot and ankle surgery.
Foot Ankle Spec. 2016;9(3):215–7.
9. Hyer CF, Berlet GC, Bussewitz BW, Hankins T,
Ziegler HL, Philbin TM. Quantitative assessment of
the yield of osteoblastic connective progenitors in
bone marrow aspirate from the iliac crest, tibia, calca-
neus. J Bone Joint Surg Am. 2013;95(14):1312–6.

Fig. 40.24 Implantation of a bulk allograft soaked in

BMA for a distraction subtalar joint arthrodesis

allograft can be placed anterior to the structural tri-

cortical wedge prior to its insertion. Similar to the
lateral approach, a pin distractor is helpful for graft
placement. Standard fixation is applied.

Pearls
• Adequately prepare arthrodesis site
prior to insertion of bone graft.
• Use bone marrow aspirate or other
growth factors on large bulk allografts.
• Measure twice and cut once.
• Apply stable fixation across bone graft
placement.
 Index

A positioning and equipment, 264

Accessory navicular syndrome, 176, 177 preoperative planning, 264
Acetabular reamer, 299, 300 techniques, 268
Achilles tendon (AT) injuries, 153, 154, 156, 161, 176, 308 operating room setup
acute rupture, 261 hardware, 265, 266
direct open repair, 266 instrumentation, 265
FHL tendon transfer, 267 patient positioning, 265
finding, 262 operative technique
mini-open, 267 posterior medial incision, 266
nonoperative management, 265 posterior midline incision, 266
patient history, 262 posterolateral incision, 266
patient selection, 263 pathology, 261
positioning and equipment, 264 post-operative protocol, 269, 272
preoperative planning, 264 Sural nerve injury, 272
tendon defects, 267 Adjunctive procedures
chronic rupture, 262 biologic augments, 409
findings, 263 I and D, 409
nonoperative management, 265 negative pressure wound therapy, 409
patient history, 263 Adult acquired flatfoot deformity (AAFD), 189, 190,
patient selection, 263 197, 175, 189, 200
positioning and equipment, 264 Akin osteotomy, 19, 20, 23, 24
preoperative planning, 264 Allis/Kocher forceps, 179
techniques, 268, 269 Allograft regenerative tissue matrix (RTM), 85
wound closure, 269 Anatomic allograft lateral ligament reconstruction
dissection, 266 procedure technique, 440–443
gelpi retractor/Weitlaner retractor, 272 Ankle
imaging and diagnostic studies adjunctive procedures
MRI, 264 biologic augments, 409
ultrasound, 264 I and D, 409
Xray, 264 negative pressure wound therapy, 409
insertional Achilles tendinosis, 262 ankle/STJ TTC nail, 405–408
direct insertional repair, 267 anterior approach, 400
FHL tendon transfer, 268 clinical presentation, 391–393
findings, 263 dissection, 397, 398
nonoperative management, 265 dynamic, 404
patient history, 263 equipment, 397
patient selection, 264 external fixation, 404, 405
positioning and equipment, 264 imaging, 395, 396
preoperative planning, 264 internal fixation, 403
non insertional Achilles tendinopathy, 262 intramedullary implants, 403
findings, 263 plate constructs, 404
nonoperative management, 265 intraoperative, 410
patient history, 263 lateral approach, 398, 399
patient selection, 264 medial approach, 402

© Springer Nature Switzerland AG 2019 469

C. F. Hyer et al. (eds.), Essential Foot and Ankle Surgical Techniques,
https://doi.org/10.1007/978-3-030-14778-5
470 Index

external fixation (cont.) Anterior cavus deformities, 307, 317

nonoperative treatment, 393, 394 Anterior talofibular ligament (ATFL), 431
operating room setup, 396, 397 Anterior tibial tendon (ATT), 169
operative treatment, 394 Arch restoring, 175
posterior approach, 401, 402 Army Navy retractor, 184
postoperative care, 409 Arthrodesis, 52, 150
preoperative laboratory testing, 396 Arthroscopic ankle arthrodesis, 290
quality of life, 391 anterior medial and anterior lateral portals, 289
static, 404 contraindications, 284
STJ/ TN fusion, 408, 409 indications, 284
surgical fixation, 403 instrumentation/hardware selection, 285–287
Ankle arthritis, 275, 282, 289, 359 operating room set up, 285–287
Ankle arthrodesis osteophytes, removal of, 290
anterior approach synovectomy and exostosis removal, 290
large caliber compression lag screw fixation with Arthroscopic Broström postoperative protocol, 435
anterior anatomic plating, 289 Arthroscopic Broström procedure technique, 432–435
operating room set up/instrumentation/hardware Arthroscopic debridement
selection, 278 approach, 382
operative technique, 278–281 intraoperative, 388
trans fibular approach, 289 postioning and equipment, 381
arthroscopic ankle arthrodesis, 276 (See Also potential complications, 389
Arthroscopic ankle arthrodesis) preoperative planning, 379
complications, 282–284 technique, 384
diagnosis, 277 Articular surface involvement, 377
imaging and diagnostic studies, 277, 278 Atraumatic ruptures, 153
patients history, 276, 277 Autogenous bone graft, 278
positioning and fixation of arthrodesis site, 287 Autograft harvest, 461, 462
post-operative care, 287 Avascular necrosis (AVN), 110
Ankle arthroplasty, 275, 284, 359 arthroscopic debridement
Ankle arthroscopy approach, 382
complications, 418 intraoperative, 388
instrumentation, 411, 416 postioning and equipment, 381
operative room setup, 411, 412 potential complications, 389
postoperative protocol, 418 preoperative planning, 379
surgical technique technique, 384
arthroscopic assisted ORIF syndesmosis, 414 articular surface involvement, 377
arthroscopic micro fracture awls, 416 clinical findings, 377
arthroscopic probe verification, 418 core decompression
cartilage graft, mixed with bone marrow approach, 382
aspirate, 416 intraoperative, 388
cartilaginous surface, 413 postioning and equipment, 381
chronic lateral ankle ligament instability, 413 potential complications, 389
lateral gutter, 413 preoperative planning, 379
lateral osteochondral defect, 415 technique, 384
lateral shoulder, 413 etiologies, 377
loose bodies removed ankle joint, 415 fresh talar bulk allograft
loose bodies within ankle joint, 415 approach, 382, 384
medial shoulder, 412 intraoperative, 388
osteochondral defect, 415, 417 positioning and equipmemt, 382
portal entry sites, 417 potential complications, 389
posterior hindfoot endoscopy portal placement, 418 preoperative planning, 379
prone positioning with knee, 417 technique, 385
proper posterior hindfoot endoscopy positioning, imaging and diagnostic studies, 377
417 patient history, 377
resected symptomatic os trigonum, 418 pre and postoperative radiographs, 377, 378, 380
syndesmotic injury, 414 preoperative planning, 379
tibiotalar joint, 412 surgical treatment, 378, 379
Ankle-brachial index (ABI), 2, 447 TTC and TC arthrodesis
Ankle-foot orthosis (AFO), 154 approach, 384
Anteater’s nose, 250 intraoperative, 388
Anterior calcaneal Z osteotomy, 194, 195 positioning and equipment, 382, 383
Index 471

postoperative care, 389 Bone grafting

potential complications, 389 in ankle and hindfoot arthrodesis, 459
preoperative planning, 379, 381 autograft, associated with, 460
technique, 385–388 autograft harvest, 461, 462
vascularized extensor digitorum brevis flap bone marrow aspirate, 460, 461
approach, 382 delayed union, 460
intraoperative, 388 indications, 459
postioning and equipment, 381 large bulk allografts, 461
potential complications, 389 distraction subtalar joint fusion, 466, 467
preoperative planning, 379 failed ankle replacement, 464–466
technique, 384 failed first MTP fusion, 462–464
nonunion, 460–461
osteoconductive and osteogenic properties, 460
B Bone marrow aspirate (BMA), 460, 461
Below knee amputation (BKA), 1 Bone morphogenic proteins (BMPs), 170, 460, 461
back table and mayo stand set-up, 448 Bridle procedure, posterior tibial tendon transfer,
Ertl modification 349–352, 354, 355
anterior-posterior X-ray, 452 Brostrom lateral ankle reconstruction, 312
closure, 453
complications, 453
indications, 451 C
patient positioning, 452 Calcaneal fibular ligament, 220
postoperative care, 453 Calcaneal osteotomy, 176, 177, 179, 186
preoperative assessment, 452 Calcaneal Z osteotomy, 189
surgical technique, 452–453 Calcaneocuboid joint (CCJ), 189, 191–194, 233, 235,
immediate post-operative care, 451 240–242, 245
indications, 447 Calcaneonavicular (CN) coalitions
preoperative optimization coalition resection, 252, 253
blood glucose control, 447 equipment, 252
cardiopulmonary reserves, 448 patient positioning, 252
hemoglobin and hematocrit count, 447 radiographs, 250
nicotine use, 448 surgical approach, 252
nutritional status, 447 tissue interposition, 253, 254
patient’s position, 448 wound closure, 254
social support, 448 Calcaneus autograft harvest, 31
sterile preparation, 448 Calcinosis, 264
tourniquet placement, 448 Capsulotomy, 117
vascular assessment, 447 Cartilage allograft, 95, 96
wound dressing, 448 Cavus, 233, 234
procedure Cavus foot reconstruction, 171, 322
closure, 451 corrected hindfoot and first metatarsal with healed
drain security, 451 osteotomies, 320, 322
dressing and immobilization, 451 diagnosis and imaging, 310
flap length adjustment, 451 hindfoot alignment, 323
hemostasis, 450 lateral tuber shift, 321
incision, 449 operative techniques
incomplete tibial resection, 449 dorsiflexory first metatarsal osteotomy,
medium HemoVac drain and opsite dressing, 450 314–316
myoplasty technique, 451 gastrocnemius recession, 312
nerve identification, 450 lateralizing calcaneal osteotomy with/without
posterior flap peel technique, 450 wedge, 313, 314
silk suture ties and/or vascular clips, 448 Malerba calcaneal Z osteotomy, 314
prosthesis fitting and long-term care, 451 plantar fascia release, 312, 313
Belt and suspenders approach, 154, 156, 162 OR setup and instrumentation
Bioabsorbable interference screw, 177 hardware selection, 311
Biologics primary procedure, 311
in foot and ankle surgery, 460 secondary procedure, 311
indications, 459 supine position, 310
osteoconductive, 460 patient presentation, 307–310
osteogenic, 460 postoperative protocol, 321
osteoinductive, 460 secondary procedures, 316–319
472 Index

Cerebral palsy (CP), 307 Claw toe deformities, see Hammertoe and clawtoe
Charcot arthropathy (CA), 150 deformities
characteristic of, 157 Cobb elevator, 202
exostectomy, 157 Cole osteotomy, 311, 316–319
Hintermann distractor, 158 central midfoot incision, 316
tendo-Achilles lengthening (TAL), 157 fixation, 316, 317
Charcot-Marie-Tooth disease (CMT), 307, 308 peroneal switch (transfer), 319
Charcot midfoot primary and revision lateral ankle reconstruction, 318
hardware and instrumentation, 160, 161 split tibialis anterior tendon transfer, 317
operative technique Steinmann pins, 316
Achilles lengthening, 161 Coleman block test, 308, 309
belt and suspenders approach, 162 Collateral ankle ligament repair
external fixation, 162 anatomic repair, 431
guide pin placement, 164 deltoid ligament reconstruction, 443
Hintermann to distract, 162 hardware, 432
internal fixation, 163 instrumentation, 432
lateral beam placement, 164 lateral ankle stabilization, 431
for large rocker-bottom deformities, 161 non-anatomic repairs, 431
medial beam placement, 164 operating room setup, 432
medial clip placement, 164 patient presentation, 431
medial column of, 164 primary lateral ankle stabilization
osteotomy, 161, 162 arthroscopic Broström postoperative protocol, 435
postoperative radiographs, 165 arthroscopic Broström procedure technique,
preoperative radiographs, 160 432–435
TA tendon, 161 open Broström Gould post-operative protocol,
wedge resection osteotomy, 161 438–439
OR setup, 160 open Broström-Gould procedure technique,
postoperative protocol, 165 436–440
post-operative protocol, 165 revision lateral ankle stabilization, 439–443
ST joint, 166 syndesmotic ligament injury surgical description,
Charcot neuroarthropathy (CN), 121, 122, 168, 170, 444, 445
291–293, 299 Complex multiplanar foot deformity, 121, 122
hindfoot and ankle Computed tomography (CT), 115, 310
adjunctive procedures, 409 Core decompression
ankle/STJ TTC nail, 405–408 approach, 382
anterior approach, 400 intraoperative, 388
clinical presentation, 391–393 postioning and equipment, 381
dissection, 397, 398 potential complications, 389
equipment, 397 preoperative planning, 379
external fixation, 404, 405 technique, 384
imaging, 395, 396 Coronal plane deformities, 284, 310
internal fixation, 403, 404 Cotton osteotomy, 247
intraoperative, 410 cotton allograft insertion, 145, 147
lateral approach, 398, 399 fluoroscopy aids, 144, 145
nonoperative treatment, 393, 394 heart-shaped distractor insertion, 145, 146
operating room setup, 396, 397 imaging and diagnostic studies, 137–141
operative treatment, 394 intraoperative pearls and pitfalls, 145
posterior approach, 401, 402 patient history and findings, 137
postoperative care, 409 posterior tibial tendon, 137
preoperative laboratory testing, 396 postoperative care, 148
quality of life, 391 potential complications, 148
STJ/ TN fusion, 408, 409 surgical management
surgical fixation, 403 approach, 143, 144
prevalence, 391 positioning and equipment, 141, 143
Cheilectomy, 70, 93–96 preoperative planning, 141
Chronic overuse syndromes, 110 trial wedges insertion, 145, 146
Chronic tendinopathy, 153 unicortical osteotomy, 144
Chronic venous insufficiency (CVI), 3 Coughlin grading system, 93
Claw toe correction, 319 Crystalline arthropathy, 93
Index 473

D gastrocnemius recession, strayer

Deltoid ligament reconstruction, 443 procedure, 348, 349
Demineralized bone matrix (DBM), 205 open gastrocsoleus recession, 348
Direct plantar plate repair, 60–62 percutaneous tendo-Achilles lengthening,
Disease modifying anti-rheumatics drugs (DMARD), 3 347–348
Distal soft tissue procedure (DSTP), 20, 24, 28–30 surgical treatment
Distal tarsal tunnel syndrome, 338 endoscopic gastrocsoleus recession, 347
Distraction subtalar joint fusion, 466, 467 open proximal gastrocsoleus recession, 347
Dorsal approach neurectomy, 103, 104 patient selection, 346
Dorsal capsulotomy, 151 percutaneous tendo-Achilles lengthening, 347
Dorsal cheilectomy, 94, 95, 97 positioning, 347
Dorsiflexion closing wedge first metatarsal preoperative planning, 346
osteotomy, 311 Silfverskiold maneuver, 347
Dorsiflexion osteotomy, 234–236, 247 X-ray, 345, 346
Dorsiflexory first metatarsal osteotomy, 314–316 Equinus, 176, 190, 346
Dorsolateral approach, 116–118 Ertl modification
Drop foot anterior-posterior X-ray, 452
complications, 353 closure, 453
history, 345 complications, 453
left lower extremity common peroneal nerve function, indications, 451
344, 350–352 patient positioning, 452
MRI, 345 postoperative care, 453
nerve conduction/electromyographic studies, 345 preoperative assessment, 452
physical examination, 345 surgical technique, 452–453
posterior lengthening procedures Erythematous foot, 158
bridle procedure, posterior tibial tendon transfer, Evans osteotomy, 141
349–352, 354, 355 Exostectomy, 157
endoscopic gastrocsoleus recession, 348 Extensor digitorum brevis (EDB) muscle belly, 218–219,
gastrocnemius recession, strayer procedure, 240, 247, 252
348, 349 Extensor hallucis brevis (EHBr) tendons, 154
open gastrocsoleus recession, 348 Extensor hallucis longus (EHL) tendon, 86, 144, 154,
percutaneous tendo-Achilles lengthening, 156, 314
347–348 External fixation (Ex Fix), 404
surgical treatment circular frame, 405
endoscopic gastrocsoleus recession, 347 dynamic, 404
open proximal gastrocsoleus recession, 347 static, 404
patient selection, 346 Extracorporeal shock wave therapy, 265
percutaneous tendo-Achilles lengthening, 347
positioning, 347
preoperative planning, 346 F
Silfverskiold maneuver, 347 Fibular autograft, 380, 399
X-ray, 345, 346 Fibular osteotomy, 295–297, 398
Dual incision approach, see Subtalar coalition resection First metatarsocuneiform joint, 143
Dwyer calcaneal osteotomy, 311 First metatarsophalangeal cheilectomy and osteochondral
Dwyer osteotomy, 313 defect treatments, 93, 95
imaging and diagnostic studies, 93, 94
intra-operative pearls and pitfalls, 99
E patient history and findings, 93
Ecchymosis, 261 postoperative radiographs of, 96
Extensor hallucis longus (EHL) tendon, 41, 42, 279 post-up care, 99
Endoscopic gastrocsoleus recession (endo-GSR), 348 potential complications, 99
Equinovarus preoperative radiographs of, 95
complications, 353 surgical management
history, 344 approach, 94
MRI, 345 positioning and equipment, 94
physical exam findings, 344, 345 pre-operative planning, 94
posterior lengthening procedures surgical technique
bridle procedure, posterior tibial tendon transfer, cartilage allograft, 95, 96
349–352, 354, 355 cheilectomy, 94, 95
endoscopic gastrocsoleus recession, 348 subchondral drilling, 95
474 Index

First metatarsophalangeal (MTP) joint, 93, 158 after dorsal cheilectomy and defect preparation, 97
anatomy of plantar aspect, 110 preoperative T2 MRI coronal and sagittal slices, 98
capsuloligamentous structures, injuries to, 109 Foot and ankle reconstruction, 1
hallux rigidus, 69 Foot deformity, 368
history and physical examination, 69, 70 Foot injury, 149
imaging and diagnostic studies, 70 Forefoot-driven cavus, 308
interpositional arthroplasty Forefoot supinatus deformity, 141
case examples, 85, 86 Forefoot varus deformity, 137
GRAFTJACKET Matrix, 86 Fourth and fifth tarsometatarsal (TMT) joints
Hewson suture passers, 87 athrosis, 149
intraoperative pearls/pitfalls, 92 dorsal capsulotomy, 151
joint synovectomy, 86 dorsal lateral incision, 151
Keller osteotomy, 87 imaging and diagnostic studies, 150
looped wires, 87 interpositional arthroplasty, 150
McGlamry elevator, 86 intra-operative pearls and pitfalls, 151
metatarsal head, 87 OR set-up, 150–151
metatarsal-sesamoid joints, 89 post Op care, 151
patient history, 85, 86 potential complications, 151
post-operative care, 90 soft tissue interpositional arthoplasty, 150
pre-operative work up, 85, 86 subchondral bone of MTs, 151
retrograde intramedullary guidewire for tendon interposition, 151
placement, 87 Fresh talar bulk allograft
operative techniques approach, 382, 384
access into joint, 72 intraoperative, 388
AP and lateral pre-op x-rays, 78, 79 positioning and equipment, 382
denude cartilage, 74 potential complications, 389
dorsal exostosis removal, 72 preoperative planning, 379
dorsal medial incision, 71 technique, 385
final closure and clinical position, 78
fish-scaled, 75
full thickness sub-periosteal dissection, 71 G
guide wire placement, 72, 73 Gait analysis, 52, 70, 114, 190, 277, 308
intra-fragmentary screw placement, 77 Gastrocnemius equinus, 176
locking screw placement, 77 Gastrocnemius recession (GSR), 176, 201
plate positioned with temporary fixation pins, 76 strayer procedure, 348, 349
proximal phalanx, 75 Gelpi retractor, 219, 298
OR setup/instrumentation/hardware selection, 70
osseous structures of, 109
revision surgery, 81 H
AP and lateral post-op x-rays, 81 Haglund’s deformity, 263, 264
complications, 82 Hallux interphalangeal joint (HIPJ), 311, 319
graft fashioned, 80 achilles tendon lengthening, 40
intraoperative picture with plate spanning, 81 arthrodesis, 39
nonunion/malunion, 77–80 complications, 49
osteotomy, 80 diagnosis, 40
postoperative management, 81, 82 EHL tendon transfer, 39–40
size of graft, 80 internal fixation techniques, 42–44
sesamoid bones, 109 intraoperative pearls and pitfalls, 47
First metatarsophalangeal osteophytes, 98 Jones tendon transfer, 39, 44–49
First tarsometatarsal (TMT) joints, 145 pathology of, 39
Fleck sign, 326 patient history, 39
Fleischer-Nilsonne method, 59 postoperative care, 49
Flexor digitorum longus (FDL) tendon, 137, 182–185, surgical management
202, 203, 206 Adson forceps, 41
transfer, 182–185 extensor hallucis longus (EHL) tendon
Flexor hallucis brevis (FHB) tendons, 109, 110, 113, 117 transection, 41, 42
Flexor hallucis longus (FHL) tendon, 109, 114, 117 incision placement planning, 41
transfer, 264, 266–269, 272 patient positioning and equipment, 40
Flexor stabilization, 52 preoperative planning, 40
Focal cartilage defects, 93 S-shaped incision, 41
Focal osteochondral defect, 94 transverse plane deformity, 41
Index 475

Hallux rigidus, 69, 85, 86, 93, 96 imaging, 395, 396

Hallux valgus internal fixation, 403
Akin osteotomy, 19, 20, 23, 24 intramedullary implants, 403
clinical and radiographic evaluation, 15 plate constructs, 404
clinical presentation, 15, 16 intraoperative, 410
complications, 24 lateral approach, 398, 399
distal metatarsal articular angle (DMAA), 15 medial approach, 402
distal soft tissue procedure, 20, 24 nonoperative treatment, 393, 394
first metatarsophalangeal (MTP) fusion, 16, 19 operating room setup, 396, 397
hallux interphalangeus angle (HIA), 15 operative treatment, 394
hallux valgus angle (HVA), 15 osteotomies, 347
imaging, 20 posterior approach, 401, 402
intermetatarsal angle (IMA), 15 postoperative care, 409
Mau osteotomy, 16, 17, 21 preoperative laboratory testing, 396
modified Reverdin osteotomy, 16, 17, 21 quality of life, 391
OR setup, 21 static, 404
post-op protocol, 24 STJ/ TN fusion, 408, 409
prevalence, 15 surgical fixation, 403
proximal articular set angle (PASA), 15 valgus deformity, 212
scarf osteotomies, 16, 18, 19, 21, 22 varus deformities, 325
Hammertoe and claw toe correction, 311 Hintermann distractor, 211, 254, 255
Hammertoe and claw toe deformities Hintermann retractor, 31, 241–242
associated foot deformities, 52 Hohmann elevator, 191, 193, 194
causes, 51 Hohmann retractor, 202, 203, 252
clinical examination, 52 Hypertrophied abductor hallucis muscle
diagnosis, 51, 53 belly, 338
flexor stabilization, 52
K-wire fixation, 56
non operative treatments, 52 I
operative room set-up, 53, 54 Idiopathic distal symmetrical
post-operative protocol, 55, 56 polyneuropathy, 344
surgical technique, 54, 55 Illizarov technique, 162
3 stage pathology, 52 Inflammatory arthropathy, 150, 153, 275
treatment Insertional Achilles tendinosis (IAT), 262
arthrodesis, 52 direct insertional repair, 267
arthroplasty, 52 findings, 263
extensor tenotomy, 53 nonoperative management, 265
flexor tendon transfer, 53 patient history, 263
flexor tenotomy, 53 patient selection, 264
plantar plate pathology, 53 positioning and equipment, 264
skin plasty techniques, 53 preoperative planning, 264
Hardware pain, 82 Interdigital neuroma, 101
Hemostasis, 448, 450 Interpositional arthroplasty
Heterotopic ossification, 367 for first MTPJ
Hewson suture passer, 184 case examples, 85, 86
Hindfoot GRAFTJACKET Matrix, 86
adjunctive procedures Hewson suture passers, 87
biologic augments, 409 intraoperative pearls/pitfalls, 92
I and D, 409 joint synovectomy, 86
negative pressure wound therapy, 409 Keller osteotomy, 87
ankle/STJ TTC nail, 405–408 looped wires, 87
anterior approach, 400 McGlamry elevator, 86
clinical presentation, 391–393 metatarsal head, 87
deformity, 169 metatarsal-sesamoid joints, 89
dissection, 397, 398 patient history, 85, 86
dynamic, 404 post-operative care, 90
equipment, 397 pre-operative work up, 85, 86
external fixation, 404, 405 retrograde intramedullary guidewire
fracture, 209 placement, 87
fusion, 311 4th and 5th tarsometatarsal (TMT) joints, 150
hindfoot-driven deformity, 308 Intersesamoid ligament, 109
476 Index

J Lateral column lengthening osteotomy, 141

Jones tendon transfer, 39, 44–49 Lateral metatarsal head osteochondral defect, 96
Jones tenosuspension, 311, 319 Lateral sesamoid fracture, 117
Lateralizing calcaneal osteotomy, 167, 312–314
LisFranc fracture, 129, 131, 133, 149
K Lisfranc & Chopart amputations
Keith needle, 253, 258 anatomic landmarks, 455
Kidner procedure, 177, 178 closure, 456
complications, 456
dorsalis pedis artery, 455
L incision, 455
Lachman maneuver/test, 58 ligation and cut, 456
Lapidus HAV correction postoperative care, 456
anterior-posterior (AP) radiograph findings, 27 post-operative care, 456
hallux abducto valgus deformity, 27 L-shaped extensile incision, 117
surgical management L-shaped extensile plantar approach, 113–114
calcaneus autograft harvest, 31
distal soft tissue procedure, 28–30
1st tarsometatarsal joint fusion, 31–36 M
medial longitudinal incision, 28, 29 Magnetic resonance imaging (MRI), 86, 94, 96, 102,
positioning and equipment, 28 115, 121, 170, 264, 310, 326
post-operative protocol, 36 Malerba calcaneal Z osteotomy, 314
silver osteotomy, 31 Malerba osteotomy, 315
tarsometatarsal corrective arthrodesis, 28 Malreduced syndesmosis injury, 276
transverse and sagittal deformities, 27 Malunion, 82
Large bulk allografts Matles exam, 262
distraction subtalar joint fusion, 466, 467 Mau osteotomy, 16, 17, 21
failed 1st MTP fusion, 463 Meary’s angle, 200, 212
failed ankle replacement, 464–466 Medial calcaneal displacement osteotomy
failed first MTP fusion, 462–464 (MCDO), 141
Lateral ankle ligament reconstruction (Brostrom), 311 Medial cuneiform, 137, 143, 144, 146, 156
Lateral ankle stabilization, 431 Medial displacement calcaneus osteotomy (MDCO),
Lateral column lengthening (LCL) osteotomy 177–182
anterior calcaneal Z-osteotomy, 194, 195 Medial double and triple arthrodesis, 317
calcaneal Z Osteotomy Medial double arthrodesis
final fixation, 193, 194 Achilles tendon, 201
incisional approach, 192, 193 clinical presentation, 200
micro-sagittal saw, 193 Cobb elevator, 202
pin-based distractor, 193 curved stat, 207
porous titanium wedge, 193, 194 demineralized bone matrix, 205
trial sizers, 193, 194 FHL tendon, 204
flatfoot evaluation, 190 imaging, 200
instrumentation, 191 incision planning, 201
MRI, 190 interosseous ligament, 203
operating room set-up, 190, 191 operating room set-up, 200, 201
patient history, 190 peroneal tendon, 204
post-operative treatment, 195 physical examination, 200
preoperative lab evaluation, 190 pin-based hintermann distractor, 202, 203
procedure, 189 postoperative protocol, 206
radiographs, 190 postoperative x rays, 198, 199
symptoms, 190 preoperative x rays, 198, 199
traditional technique retraction points, 202
incisional approach, 191 spring ligament, 202
opening wedge plate, 192 STJ, 203–205
pin based distractor, 191, 192 3 month post corrected right foot, 200
sagittal saw, 191 TNJ, 206
tricortical allograft wedge, 191, 192 windlass maneuver, 206
Index 477

Medial malleolus osteotomy, 423–426, 429 dorsal approach neurectomy, 103, 104
Medial sesamoid, 118 plantar approach for revision neurectomy, 104,
Medial sesamoid fracture, 116, 117 105, 107
Mesenchymal stem cells (MSC), 460, 461 pathogenesis, 101
Metatarsal-sesamoid disease, 70 patient presentation, 101, 102
Metatarsosesamoid joints, 85 postoperative protocol, 107
Midfoot amputation resident resource, 107
patient positioning, 454 Nicotine, 156
preoperative workup, 454 Nitinol wire suture passer, 185
surgical technique, 454 Non insertional Achilles tendinopathy (NIAT), 262
Midfoot cavus, 309 findings, 263
Midfoot fusion (Cole osteotomy), 311, 316–319 nonoperative management, 265
central midfoot incision, 316 patient history, 263
fixation, 316, 317 patient selection, 264
peroneal switch (transfer), 319 positioning and equipment, 264
primary and revision lateral ankle preoperative planning, 264
reconstruction, 318 techniques, 268
split tibialis anterior tendon transfer, 317 Nonsteroidal anti-inflammatory drug (NSAID), 95, 96,
Steinmann pins, 316 102, 121, 325
Midsubstance Achilles tendinopathy, see Noninsertional Nonsteroidal anti-inflammatory medical therapy, 265
Achilles tendinopathy (NIAT) Non-weightbearing, 69, 99
Mild to moderate coronal plane deformities, 277
Minimally invasive/arthroscopic arthrodesis, 275
Modified Kidner procedure, 178 O
Modified Reverdin osteotomy, 16, 17, 21 Occupation, 110, 114, 337
Modified Strayer procedure, 176 Open ankle arthrodesis, 283, 284, 289
Modified Watson-Jones or Chrisman-Snook-type Open Broström Gould post-operative
procedures, 311 protocol, 438–439
Morton’s extension splint, 96 Open Broström-Gould procedure technique, 436–440
Morton’s neuroma, 102 Open gastrocsoleus recession (GSR), 348
Mulder’s sign, 101 Os peroneum syndrome, 333
Muller-Weiss syndrome, 209 Osteochondral lesion of the talus (OLT)
Multiplanar deformity, 57 arthroscopic treatment with grafting, 428, 429
Myoplasty technique, 451 clinical presentation, 421
distal fibula fracture, 422
hardware, 423
N imaging, 421
Naviculocuneiform (NC) joint, 143, 145, 316 instrumentation, 422
Cobb elevator, 173 medial malleolus osteotomy, 425
complications, 174 operative technique
diagnosis and imaging, 169, 170 medial malleolus osteotomy, 423–426
instrumentation and hardware selection, 170 medial malleolus osteotomy operative
midfoot pain, 167 technique, 429
operative technique, 170–174 tibia plafondplasty, 425–427, 429
OR set-up, 170 OR setup, 422
patient presentation, 167, 169 osteochondral lesion repair, 429
post-operative protocol, 172 postoperative protocol, 428
preoperative planning, 169 surgical indications, 422
Negative pressure wound therapy, 409 treatment, 422
Neuroma Osteochondral lesion repair, 429
definition, 101 Osteolysis, 367
diagnosis, 102, 103 Osteomyelitis, 275
hardware recommendation, 103
imaging work-up, 102, 103
non-operative treatment, 103 P
operating room setup and instrumentation, 103 Particulated juvenile articular cartilage (PJAC), 96
operative technique Pediatric pes planovalgus deformity, 189
478 Index

Percutaneous tendo-Achilles lengthening (TAL), 347–348 triplane correctional metatarsal osteotomy, 63, 64
Periosteal elevator, 192, 194 Weil metatarsal osteotomy, 63
Peripheral nerve block, 359 Platelet derived growth factor (PDGF), 460, 461
Peroneal switch (transfer), 318 Polyethylene removal strategies, 371, 375
Peroneal tendon disorders, 325 Popliteal and adductor canal approach, 289
complications, 336 Posterior cavus deformities, 307–308
imaging and diagnostic studies Posterior lengthening procedures, 352
MRI, 326 bridle procedure, posterior tibial tendon transfer,
ultrasound, 326 349–355
weightbearing radiographs, 326 endoscopic gastrocsoleus recession, 348
patient history and findings, 325 gastrocnemius recession, strayer procedure, 348, 349
postoperative care, 336 open gastrocsoleus recession, 348
surgical management percutaneous tendo-Achilles lengthening, 347–348
approach, 326, 328 Posterior tibial tendon dysfunction (PTTD), 137, 167,
excision os peroneum with tendon repair, 333 171, 197, 200, 233
fibular groove deepening, 331, 333 accessory navicular syndrome, 176, 177
peroneal tendon repair, 329, 330 diagnostic procedure, 177
peroneal tenodesis, 331 edema, 175, 176
positioning and equipment, 326 equinus, 176
preoperative planning, 326 flexor digitorum longus transfer, 182–185
superior peroneal retinacular repair, 331 imaging, 177
tendon transfer vs allograft, reconstruction with, instrumentation, 177
333–336 Kidner procedure, 177, 178
tenolysis, 328, 329 MDCO, 178–182
Peroneal tendon instability, 331 operating room set-up, 177
Peroneal tendon repair, 311 post operative protocol, 186
Peroneus longus, 333 stages, 175
brevis transfer, 312 Posterior tibial tendon (PTT), 141, 189, 190, 318
Pes cavus deformities, 307 Posterior tibial tendon transfer thru interosseous
Pes planovalgus deformity, 141, 189, 209 membrane, 311
Pes planovalgus foot type, 137 Post-operative protocols, 9, 12, 13
Pes planus deformity, 175, 176 Post-static dyskinesia, 337
Physical medicine and rehabilitation (PM&R), 307 Post-traumatic arthritis, 121, 122, 217, 218
Physical therapy, 362 Posttraumatic disease, 307
Plantar approaches, 104, 105, 107, 117, 118 Preoperative indications and planning conference, 8–11
Plantar fascia release, 312, 313 Preoperative optimization
Plantar fasciitis anti-coagulation medications, 2
clinical findings, 338 blood glucose control, 2
imaging and diagnostic studies, 338 chronic edema, 3
patient history, 337 DVT risk stratification, 2
post-operative care, 341 nicotine use, 3, 4
surgical management nutritional status, 1
intri-operative, 341 rheumatoid arthritis, 3
percutaneous bRf Microtenotomy, 340 social support, 4
positioning and equipment, 339 vascular assessment, 2
pre-operative planning, 338 Primary and revision lateral ankle reconstruction, 318
tarsal tunnel release, 339, 340 Primary interdigital neuroma, 101
Plantar plate instability Primary lateral ankle stabilization
diagnosis, 58, 59 arthroscopic Broström postoperative protocol, 435
direct plantar plate repair, 60–62 arthroscopic Broström procedure
Lachman maneuver/test, 58 technique, 432–435
operating room setup, 59 open Broström Gould post-operative protocol, 438–439
operative technique, 59, 60 open Broström-Gould procedure technique, 436–440
pathology, 57 Primary midfoot osteoarthritis, 121
patient history, 57 Proud medial heel, 309
post operative protocol, 65–67 Proximal first metatarsal closing wedge, 316
postoperative protocol, 64 Proximal first metatarsal osteotomy, 312
preoperative examination, 58 Pseudoarthrosis, 82
standard Silverskoild test, 57 Pseudo-equinus, 309
Index 479

R clinical presentation, 217

Rearfoot deformity, 197, 200 complications, 226
Revision lateral ankle stabilization, 439–443 diagnosis, 217
Revision neurectomy, plantar approach hardware selection, 218
for, 104, 105, 107 imaging, 218
Rheumatoid arthritis, 149 incision, 218
Rocker-bottom deformity, 161 instrumentation, 218
joint preparation, 220
curettage technique, 220, 222
S fish scaling, 220, 222
Scarf osteotomies, 16, 18, 19, 21, 22 OFAC method, 220, 221
Second metatarsophalangeal (MTP) joints, 158 subchondral drilling, 220, 222
Self-retaining retractors, 252, 254, 257 operation room setup, 218
Senn retractors, 252, 254, 257 pathology, 217
Septic arthritis, 275 post operative protocol, 225
Sharp arthrotomy, 400 preliminary dissection, 219
Silfverskiold assessment, 312 screw fixation, 223–225
Silfverskiold maneuver, 347 sinus tarsi, 219, 220
Silfverskiold test, 101, 154, 176, 201, 210, 263 Subtalar joint (STJ) arthroscopy
Silver osteotomy, 31 complications, 420
Single-leg heel raise test, 175, 176 postoperative protocol, 419
Single-photon emission (SPECT) CT, 278 setup, 418
Sinus tarsi, 219, 220 surgery, 419, 420
Small Hohmann retractors, 252 Superior extensor retinaculum (SPR), 325, 326, 330,
Small Homan retractors, 254, 257 331, 333, 335, 336
Smith Peterson osteotome, 218, 221 Superior peroneal retinacular
Soffield retractor, 184 repair, 331
Soft tissue interpositional arthoplasty, 150 Supple equinus
Solid arthrodesis, 282 chronic worsening pain, 343, 349
Split tibialis anterior tendon, 312 complications, 353
transfer, 311, 317 history, 344
Strayer lengthening, 211 physical examination, 344
Strayer procedure, 201 posterior lengthening procedures
Subchondral drilling, 95, 96 bridle procedure, posterior tibial tendon transfer,
Sub-fibular impingement symptoms, 176 349–352, 354, 355
Subtalar coalition resection gastrocnemius recession, strayer
cannulated guide procedure, 348, 349
advantage, 257 open gastrocsoleus recession, 348
arthroereisis sizing, 257 percutaneous tendo-Achilles lengthening,
equipment, 257 347–348
patient positioning, 257 surgical treatment
post-operative care, 258 endoscopic gastrocsoleus
surgical approach, 257 recession, 347
tissue interposition, 258 open proximal gastrocsoleus
wound closure, 258 recession, 347
definition, 254 patient selection, 346
equipment, 254 percutaneous tendo-Achilles
K-wire, 255 lengthening, 347
1x1 cm wedge of bone, 256 positioning, 347
patient positioning, 254 preoperative planning, 346
PTT and FDL tendon sheaths, 255, 256 Silfverskiold maneuver, 347
soft tissue and periosteum, 255 X-ray, 345, 346
surgical approach, 254, 255 Sural nerve injury, 272
tissue interposition, 257 Surgical team communication
wound closure, 257 patient passport, 5, 6
Subtalar joint (STJ), 197, 201–206 screening checklist, 4, 5
Subtalar joint (STJ) arthrodesis surgical request, 4–7
arthrodesis positioning, 220, 223 Syndesmotic ligament injury surgical
clinical indications, 218 description, 444, 445
480 Index

T post operative care, 156

Talonavicular joint (TNJ), 201–203, 206 surgical technique, 154–156
Talonavicular joint (TNJ) arthrodesis wound healing issues, 156
computed tomography, 210 Tibia plafondplasty operative technique, 425–427, 429
diagnosis, 210 Tibial osteotomies, 311
hardware selection, 211 Tibiocalcaneal (TC) arthrodesis
instrumentation, 210 approach, 384
operation room set-up, 210 intraoperative, 388
patient history, 209, 213, 214 positioning and equipment, 382, 383
patient presentation postoperative care, 389
ankle joint fusions, 210 potential complications, 389
hindfoot complex, 210 preoperative planning, 379, 381
medial ankle ligament complex, 210 technique, 385–388
preoperative counseling, 210 Tibiotalocalcaneal (TTC) arthrodesis, 377
symptoms, 209 acetabular reamer, 299, 300
weightbearing/ gait analysis, 210 ankle and subtalar joints lateral joint
postoperative protocol, 214 exposure, 299
radiography, 210 approach, 384
surgical technique, 211, 212 arthritic incongruent valgus ankle, 291, 294
Talonavicular joint (TNJ) fusion, 209–211 calcaneal axial films, 305
Tarsal coalition clinical presentation, 291
clinical presentation, 249–250 complications, 305, 306
CT scan, 250, 251 compression screw fixation, 300, 301
definition, 249 curved osteotome, 297
imaging, 250 diagnosis, 293
pes planus with a C-sign, 251 distal fibula removal, 298
surgical indications, 251 fibular osteotomy, 296, 297
symptoms, 250 imaging, 293
treatment, 251 intramedullary nail fixation, 291, 292
types, 249 intraoperative, 388
Tarsometatarsal (TMT) joint arthrodesis, 140 lateral dissection, 296
calcaneal autograft and bone marrow aspirate aid, lateral incision, 295, 297
135 medial arthrotomy, 298
complications, 135 medial incision, 295, 297
1st TMT, 124, 125 midfoot and hindfoot reconstruction, 291, 294
indications, 122 nail fixation, 302
injection therapy with fluoroscopic guidance, 121 operating room setup, 293, 295
intercuneiform fixation, 135 positioning and equipment, 382, 383
isolated, 122, 124 postoperative care, 389
low-profile fixation, 135 post-operative care, 304
MRI, 121 potential complications, 389
operating room set up, 122 preoperative planning, 379, 381
post-operative management, 131 reamer-irrigator-aspirator, 301, 303
preoperative considerations, 121 sequential reaming, 301, 303
2nd TMT, 125, 127 technique, 385–388
3rd TMT, 125, 127 toothed lamina spreader, 296, 297
wedge resection, fusion with, 131 wire placement, 301, 302
Tendo-Achilles lengthening (TAL), 157, 201 Tibiotalocalcaneal (TTC) fusion system, 397
Tenodesis, 154 Too many toes sign, 176
Tenolysis, 328, 329 Total ankle arthroplasty (TAR)
Tenosynovitis, 175, 176 aseptic loosening, 373, 374
Thompson squeeze test, 262 complications, 373
Tibialis anterior (TA) tendon, 161, 278, 279 diagnostic studies, 368
Tibialis anterior (TA) tendon ruptures, 153, 174 heterotopic ossification, 367
belt and suspenders approach, 156 imaging, 367
chronic, 156 implant design, 366
clinical examination, 153 initial fixation, 376
nicotine, 156 intraoperative, 372
physical findings, 153 patient selection, 366
Index 481

polyethylene wear, 367 medial sesamoid excision and torn medial collateral
postoperative care, 372, 373 ligament repair, 111–113
pre-op planning, 375 Abductor Hallucis into defect, 113
revision concepts Abductor Hallucis tendon, 113
cyst management, 376 bi-cortical screw fixation, 112
foot deformity, 368 capsular exposure, 112
loosening, 368 capsular repair, 113
native bone, 368, 375 chronic ununited medial sesamoid fracture, 111
range of motion, 369 excised medial sesamoid with cartilage loss, 112
surgeon error, 366 FHB tendon, 113
surgical management fragmentation of proximal fragment, 112
adjunctive techniques, 371 lateral shift neutralizing valgus forces, 112
array of techniques, 371 L-shaped capsulotomy, 112
equipment, 370 medial approach, 112
joint line restoration, 372, 376 medial collateral ligament injury and intra-­
patient communication, 369 articular damage, 111
polyethylene removal strategies, 371, 375 medial eminence removal, 112
polymethylmethacrylate removal, 371 weight-bearing AP x-ray, 113
positioning, 370 weight-bearing assessment, 111
preoperative planning, 369 weight-bearing examination, 113
revision approach, 370 non-surgical treatment, 118
Total ankle replacement (TAR) operative technique, 116
C-arm fluoroscopy unit, 359 OR setup, 116
clinical presentation, 358 plantar plate, 109
concomitant procedures, 359–362 plantar plate repair, 113–114
contraindications, 358 post operative protocol, 118
history, 358 presentation, 114
imaging, 358 Two-incision triple arthrodesis
indications, 357 cavus, 233, 234
instrumentation, 359 clinical presentation, 235, 236
operative room setup, 358 complications, 247, 248
physical examination, 358 diagnosis, 237
postoperative protocols, 362 dorsal talonavicular dislocation and diminutive talus,
technique 235, 236
anterior approach, 359 high arch and plantarflexed hallux, 234, 236
anterior tibialis tendon sheath, 359, 360 imaging, 237
complete subperiosteal dissection, 359, 360 multiple synostoses and hindfoot malalignment,
extensor hallucis longus, 359 235, 236
incision marking, 360 operating room setup, 239
initial rotation and resection, 359, 360 posterior tibial tendon dysfunction, 233
meticulous layered closure, 359, 361 post-operative care, 247
patient positioning, 359 surgical technique
prosthesis, 359, 361 calcaneocuboid joint fixation, 245
synovectomy, 360 dorsal talonavicular joint incision, 242, 243
talar cuts, 359, 361 FHL tendon exposure, 241, 242
tibial bone resection, 359, 360 flushing, fenestrating, and fish scaling, 243
Total contact casting (TCC), 394 Hintermann retractor, 242
Trans fibular approach, 289 incision, 239, 240
Transmetatarsal amputation, 454, 455 intra-operative fluoroscopic images, 244–246
Transverse plane deformity, 310 joint fenestration and fish scaling, 242
Triplane correctional metatarsal osteotomy, 63, 64 lamina spreader, 241
Triple arthrodesis, 197 lateral dissection, 240, 241
Turf toe, 109 orthobiologic supplementation, 244
Turf toe and sesamoid injuries, 118 posterior facet of STJ, 241
diagnosis, 114 reduction and realignment of subtalar joint, 245
dorsolateral approach, 117 reduction and realignment of talonavicular joint, 244
imaging, 114, 115 small joint distractor, 243
medial and lateral sesamoid bones, 109 talar head preparation, 243
medial 1st MTP joint approach, 116, 117 triple arthrodesis and dorsiflexion osteotomy, 235, 236
482 Index

U potential complications, 389

Unctional limitus, 70 preoperative planning, 379
Unicortical osteotomy, 144 technique, 384

V W
Valgus deformity, 238, 239, 241, 244 Wedge resection osteotomy, 161
Varus deformity, 233, 237, 244 Weightbearing, 69, 70, 81, 93, 98, 169, 209
Vascularized extensor digitorum brevis flap Weil metatarsal osteotomy, 63
approach, 382 Weitlander retractor, 60, 219
intraoperative, 388 Windlass mechanism, 206
postioning and equipment, 381