Challenges in Foot and Ankle Reconstructive Surgery A Case
based Approach
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Humbly, as a child growing up in a small rural
town in Northeast Ohio called Huntsburg, I
can say that a major source and force in my
life was from my mother. Without her, I do not
believe this book would have been created or
my professional goals would have been met.
She was like a storm that gathers its coming fury
She was there as I made the stand
Crafting its nebula with a sharp cavalcade
She would not allow any situation to blight
but would see there is constant progression
She reminded me always that I will become
erumpent
I also owe great gratitude to my wife,
Melody. Her constant assurance and love
were a driving force for the completion of this
book. She made my life easy and assured, as I
sacrificed full weekends of time with her
support. Such is my wife jocose
I am also fortunate that my son Jared has
followed in my footsteps. He has been a
source of great personal and professional joy.
My son Tyler also has been a source of pride,
serving as a Pedorthist in our practice.
I am also in great debt to my profession that
allowed me to serve as a Residency Director
for 35 years training over 100 residents.
Acknowledgments
The following is the list of contributors who were essentials for the composition and
formation of the book. Without their praxis, knowledge, and parlance, the book
would have never come to fruition. I would truly like to thank each and every one of
them for their time and devotion.
Editors
Blake T. Savage, DPM
Rekha Kouri, DPM
Nicole M. Smith, DPM
Case Management
Raul Aviles, DPM
References
Robert K. Duddy, DPM
Carmina Quiroga, DPM
Jared J. Visser, DPM
Shirley C. Visser, DPM
Brittany R. Staples, DPM
Joshua Wolfe, DPM
Melinda Nicholes, DPM
Hannan Zahid, DPM
Kalen Farr, DPM
Kiera Benge-Shea, DPM
vii
Contents
Part I Forefoot Maladies
1
Case #1: Revision of a Scarf Osteotomy and Lapidus Procedure with
Antibiotic Polymethylmethacrolate Spacer for an Infected Second
Metatarsophalangeal Joint Implant�������������������������������������������������������� 3
2
Case #2: Utilization of a Cancellous Titanium Wedge for a Revisional
Reconstruction of a Lapidus Procedure�������������������������������������������������� 11
3 Case #3: Revision of Displaced Capital First Metatarsal Head
Osteotomy with Intramedullary K-wire & Dual Locking Plates���������� 15
4 Case #4: Management of First Metatarsal Head Capital
Osteotomy with Secondary Avascular Necrosis Utilizing a
Fresh Frozen Femoral Head Allograft for Arthrodesis�������������������������� 23
5 Case #5: Revision of a Silastic Flexible Hinged Implant
Involving the First Metatarsophalangeal Joint with
Arthrodesis Utilizing a Fresh Frozen Femoral Head Allograft ������������ 31
6 Case #6: Management of Stage 3 Hallux Limitus Deformity
with Acellular Dermal Allomatrix for Resurfacing of the
First Metatarsal Head�������������������������������������������������������������������������������� 37
7 Case #7: Management of Brachymetapody with Multiple
Metatarsal Osteotomies and Autograft���������������������������������������������������� 49
8 Case #8: Management of Severe Congenital Hallux Varus
and Digital Adductus Deformity with 1st Metatarsophalangeal
Arthrodesis, Metatarsal Head Resection, and Closed Digital
Osteoclasis�������������������������������������������������������������������������������������������������� 55
9 Case #9: Rheumatoid and Psoriatic Forefoot Deformity:
First MPJ Arthrodesis, Metatarsal Head Reduction with
Hoffman Incision and Closed Digital Osteoclasis ���������������������������������� 59
10 Case #10: Fat Pad Augmentation with Acellular Dermal
Allomatrix Involving Submetatarsal Heads 2 and 3������������������������������ 67
ix
x Contents
Part II The Varus Foot and Ankle
11 Case #11: Reconstruction of the Lateral Foot Column due to
Loss of the Cuboid and Anterior Calcaneus Secondary to
Gunshot Trauma with Hemi-Fibular Strut Graft
and Reattachment of the Peroneus Brevis Tendon �������������������������������� 73
12 Case #12: Loss of Peroneus Brevis Tendon Insertion Secondary
to Failed Surgery of the Epimetaphyseal Styloid Process
with Subsequent Development of Adductovarus Deformity������������������ 77
13 Case #13: Two-Staged Allograft Reconstruction of the Peroneal
Tendon with Subsequent Adductovarus Foot Deformity Utilizing a
Hunter Rod for Loss of Gliding Function of the Peroneal Groove������� 83
14 Case #14: One Stage Allograft for Dual Peroneal Tendon
Ruptures and Subsequent Adductovarus foot Deformity���������������������� 91
15 Case #15: Flexor Digitorum Longus Transfer to the Fifth
Metatarsal for Dual Loss of Peroneal Tendon and Muscle
Function and Subsequent Adductovarus Foot Deformity���������������������� 97
16 Case #16: Supramalleolar Osteotomy for Ankle Varus
Malunion Post Ankle and Subtalar Joint Arthrodesis���������������������������� 109
17 Case #17: Tendon Transfer and Balancing for Combined Upper
Motor Neuron and Lower Motor Neuron Equinoadductovarus
Foot and Ankle Deformity ������������������������������������������������������������������������ 117
18
Case #18: Tendon Lengthening Management of Rigid
Equinoadductovarus Foot Deformity Post CVA ������������������������������������ 123
19 Case #19: Management of Avascular Necrosis of the Navicular
Secondary to Mueller-Weiss Disease by Midtarsal Joint
Arthrodesis ������������������������������������������������������������������������������������������������ 129
20 Case #20: Management of Adductocavovarus Foot Deformity
Secondary to Post Talar Neck Fracture Malunion��������������������������������� 135
21 Case #21: Revision of the STAR Total Ankle Replacement
with Iliac Autograft������������������������������������������������������������������������������������ 143
Part III The Valgus Foot and Ankle
22 Case #22: Reconstruction of Adult-Acquired Flatfoot Deformity
with Ruptured Tibialis Posterior Tendon and Spring Ligament���������� 151
23 Case #23: Reconstruction of Long-Standing Adult Flatfoot
Deformity and Associated Peroneal Muscle Tendon
Contractures ���������������������������������������������������������������������������������������������� 157
Contents xi
24 Case #24: Management of a Spontaneous Peritalar
Dislocation with Talocalcaneal Arthrodesis Utilizing an
Intramedullary Nail ���������������������������������������������������������������������������������� 163
25 Case #25: Management of Oblique Talus Deformity with
Talar Neck Wedge Osteotomy������������������������������������������������������������������ 171
26 Case #26: Management of Severe Peritalar Dislocation
Secondary to Rheumatoid Arthritis by Double Arthrodesis
Utilizing a Medial Incision������������������������������������������������������������������������ 179
27 Case #27: Management of a Calcaneal and Subtalar Joint
Malunion with Osteotomy and Bone Block Arthrodesis������������������������ 183
28
Case #28: Revision of Triple Arthrodesis Malunion with Severe
Osteopenia�������������������������������������������������������������������������������������������������� 189
Part IV The Charcot Foot and Ankle
29 Case #29: Revision of Neuropathic Lis Franc Joint Dislocation
with Trans-Pedal Wedge Arthrodesis ������������������������������������������������������ 195
30 Case #30: Management of Charcot Midfoot Deformity
with Trans-cuneonaviculocuboid Wedge�������������������������������������������������� 203
31 Case #31: Management of Severe Charcot Foot and Ankle
Deformity with Posterior Tendon Group Lengthening
and Capsulotomies with Arthrodesis and Tarsometatarsal
Joint 4 and 5 ���������������������������������������������������������������������������������������������� 209
32 Case #32: ORIF of Neuropathic Ankle Fracture Utilizing
Multiple Tetracortical Syndesmotic Screw Fixation������������������������������ 213
33 Case #33: Management of a Neuropathic Ankle Fracture
with Ankle Arthrodesis Utilizing an Intramedullary Nail���������������������� 219
34 Case #34: Management of End-Stage Rigid Equinoadductovarus
Foot and Ankle Deformity Secondary to Charcot-Marie-Tooth
Disease with Talectomy and Tibiocalcaneal Arthrodesis������������������������ 227
35 Case #35: Management of Neuropathic Avascular Necrosis
of the Talus and Severe Ankle Varus Dislocation with Femoral
Head Allograft and Lateral Anatomic Locking Plate���������������������������� 237
36 Case #36: Management of Neuropathic Talar Avascular
Necrosis with Talectomy and Arthrodesis Utilizing a Femoral
Locking Plate���������������������������������������������������������������������������������������������� 243
37
Case #37: Talocalcaneal Arthrodesis with Severe Neuropathic
Equinoadductovarus Foot and Ankle Deformity Secondary
to L5-S1 Radiculopathy���������������������������������������������������������������������������� 249
xii Contents
Part V Tendinopathies
38 Case #38: Management of an Infected Achilles Tendon
Rupture with Local Excision, V-Y Gastrocnemius Aponeurotic
Lengthening and Flexor Hallucis Transfer���������������������������������������������� 261
39 Case #39: Management of an Infected Achilles Tendon Rupture
with Secondary Allograft Associated with a Severe Allergic
Dermatitis by Excision of Allograft and Transfer of the Flexor
Hallucis Longus Tendon and Peroneus Brevis���������������������������������������� 269
40 Case #40: Repair of an Attritional Rupture of the Tibialis
Anterior Tendon ���������������������������������������������������������������������������������������� 275
Part VI The Cavus Foot and Ankle
41 Case #41: Management of Cavus Foot Deformity by a
Two-Staged Approach—Stage 1: Correction of Rearfoot
and Midfoot Deformities, Stage 2: Correction of Forefoot
Deformities�������������������������������������������������������������������������������������������������� 283
Part VII Complex Foot Deformity Correction with Hexapod
External Fixator
42 Case #42: Two Stage Correction of Midfoot Charcot
Deformity—Stage 1: Gradual Distraction and Correction
of Deformity, Stage 2: Minimally Invasive Definitive
Internal Fixation���������������������������������������������������������������������������������������� 293
43 Case #43: Utilization of Hexapod Frame Following Failed
Tibiocalcaneal Arthrodesis for the Treatment of Talar Body
Avascular Necrosis ������������������������������������������������������������������������������������ 299
Index�������������������������������������������������������������������������������������������������������������������� 309
Part I
Forefoot Maladies
Case #1: Revision of a Scarf Osteotomy
and Lapidus Procedure with Antibiotic 1
Polymethylmethacrolate Spacer
for an Infected Second
Metatarsophalangeal Joint Implant
Case Presentation
This is a 60-year-old female patient who presents with a recurrent bunion
deformity. The original procedure was SCARF osteotomy of the first metatar-
sal. Also there were three prior operations performed for a second toe ham-
mertoe deformity that included an intramedullary implant and a silastic
flexible hinge lesser toe implant.
Diagnosis and Assessment
The patient presents with the main problem of a recurrent hallux abductovalgus
deformity after a failed (Scarf joint) shaft type osteotomy. The osteotomy did not
excessively shorten the first metatarsal and produced proper plantarflexion. Thus,
there was no need for an interpositional bone graft. Correction needed to reduce the
intermetatarsal angle and provide triplane stability. Interestingly, despite the opera-
tion for a “floating toe” for a probable unrecognized plantar plate rupture, the toe
remains well aligned noted on the weight bearing (WB) lateral view and is not
excessively shortened (Fig. 1.1).
Management
The recurrent hallux valgus deformity was managed with a Lapidus type first meta-
tarsal—medial cuneiform arthrodesis (Fig. 1.2) [1]. Preparation of the joint was by
cartilage curettage and subchondral fragmentation of the joint surface. Positioning
is critical with medial to lateral compression to reduce the intermetatarsal angle
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 3
H. J. Visser, Challenges in Foot and Ankle Reconstructive Surgery,
https://doi.org/10.1007/978-3-031-07893-4_1
4 1 Case #1: Revision of a Scarf Osteotomy and Lapidus Procedure with Antibiotic…
Fig. 1.1 Post recurrent
hallux abducto valgus
deformity post Scarf
osteotomy, left foot
Fig. 1.2 Revision with
Lapidus arthrodesis
Outcome 5
Fig. 1.3 Kerfing
technique for further
closure of intermetatarsal
angle
(transverse plane). The hallux was dorsiflexed to produce retrograde plantarflexion
of the first metatarsal (sagittal plane). Inversion (internal rotation) of the hallux cor-
rected the frontal plane position. This creates a retrograde eversion of the first meta-
tarsal. Further correction of the IM angle can be attained with a kerfing technique
(Fig. 1.3). Fixation included a locking plate, placed dorsal medial and a 4.0 mm
compression screw (Fig. 1.4a, b) [2]. Patient was kept non-weight bearing (NWB)
for 2 weeks then followed by WB for further 4 weeks in a controlled ankle motion
(CAM)boot [3].
Outcome
Postoperatively, the patient did well with the Lapidus arthrodesis but developed
problems with the second metatarsophalangeal joint (MPJ) which was not involved
in the revision operation. When physical therapy began, the patient did well initially
for the first 4 weeks. However, at 10 weeks the patient presented with swelling,
pain, and erythema about the second MPJ. No drainage or fistula was noted
(Fig. 1.5). The patient was treated initially with prednisone for possible gouty
arthropathy and doxycycline for possible infection. The patient returned in 1 week
and demonstrated no positive response. Laboratory work up noted a normal white
blood cell (WBC) (8.2, no left shift) count. The sedimentation rate (ESR) was
45 mm/h and C-reactive protein (CRP) was 3.0 mg/L, these were elevated.
Due to obvious concern for infection, radionuclear imaging involving a Ceretec
scan (Tc99m HMPAO—Hexamethyl Propylene Amine Oxime) was performed
(Fig. 1.6) [4]. As can be seen the scan uptake was positive for potential osteomy-
elitis of second metatarsal, proximal phalanx, and implant of the left foot.
6 1 Case #1: Revision of a Scarf Osteotomy and Lapidus Procedure with Antibiotic…
a b
Fig. 1.4 (a, b) Post-operative revision Lapidus arthrodesis with triplane first metatarsal cuneiform
correction
Fig. 1.5 Swelling, pain, erythema, second
MPJ, left foot
Outcome 7
a b
Fig. 1.6 (a) Technetium 99 MDP scan showing increased focal uptake of the second MPJ, during
the stage 3 bone phase (b) Ceretec Tc 99 HMPAO scan showing symmetrical uptake of the
second MPJ
Fig. 1.7 Removal silastic
implant, debridement of
intramedullary canals in
preparation for PMMA
spacer
Percutaneous bone biopsy with a Jamshidi needle confirmed osteomyelitis.
Cultures grew methicillin—resistant staphylococcus aureus (MRSA). The silastic
implant was removed and the second metatarsal was debrided (Fig. 1.7). A poly-
methylmethacrylate (PMMA) spacer impregnated with vancomycin was inserted
[5]. The size of the spacer was such to maintain digital length by ligamentotaxis.
Oral antibiotics with doxycycline for 14 days led to complete healing. The patient
has done extremely well and is currently 2 years now functioning with the spacer
as a “form of “implant (Fig. 1.8a–c).
8 1 Case #1: Revision of a Scarf Osteotomy and Lapidus Procedure with Antibiotic…
a b
Fig. 1.8 (a–c) Post-operative revision of Lapidus arthrodesis and insertion of PMMA spacer to
the second MPJ for a septic joint
Clinical Pearls and Pitfalls
Revision of a failed prior (SCARF) procedure usually is due to failure of the initial
procedure [6]. The SCARF is described as a bone cut osteotomy originating from
architecture and carpentry. It refers to fastening two pieces of bone by notching and
grooving. While designed for higher IM (intermetatarsal) angles, often attributed