Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • narrow sagittal saw
  • smooth pins
  • 1.6 or 2.0mm wires
  • straight osteotomes
  • calcaneal spreader with smooth teeth
  • Joker and/or freeer elevator
  • Hohman retractors
  • narrow Crego retractors


Room setup and equipment

  • standard radioluscent OR table
  • tourniquet
  • c-arm fuoroscopy


Patient positioning

  • supine
  • place a bump under the ipsilateral hip for internal rotation of the foot
  • have a sterile bump available to place under knee to assist with foot placement and imaging

Modified Ollier Incision


Mark and make the skin incision

  • make a modified ollier incision in a langer skin line from the superficial peroneal nerve to the sural nerve


Expose the sinus tarsi

  • elevate the soft tissues from the sinus tarsi
  • avoid exposing or injuring the capsule of the calcaneocuboid joint
  • protect branches of the sural nerve and superficial peroneal nerve


Release the peroneal tendons

  • release the peroneus longus and the peroneus brevis from there tendon sheaths on the lateral surface of the calcaneus
  • resect the intervening tendon sheath
  • if the peroneal tubercle is large then resect as well


Lengthen the peroneus brevis

  • Z lengthen the peroneus brevis
  • place Krackow suture with 2.0 suture in each limb of lengthened peroneus brevis tendon
  • do not lengthen the peroneus longus


Divide the aponeurosis of the abductor digiti minimi

  • divide the aponeurosis of the abductor digiti minimi at a point approximately 2 cm proximal to the calcaneocuboid joint

Deep Dissection


Identify the anatomy of the subtalar joint

  • identify the interval between the anterior and middle facets of the subtalar joints with a freer elevator


Place freer elevator

  • insert the freer elevator into the sinus tarsi , perpendicular to the lateral cortex of the calcaneus at the level of the isthmus
  • this is the lowest point of the dorsal cortex in the sinus tarsi proximal to the beak and distal to the posterior facet
  • the middle facet should be visualized at this point
  • slowly angle the freer distally until it falls into the interval between the anterior and middle facets


Place Retractors

  • replace the freer with an instrument of choice(Joker or Hohmann retractor)
  • place a second retractor around the plantar aspect of the calcaneus in an extraperiosteal plane in line with the dorsal retractor

Osteotomy Preparation


Make the medial skin incision

  • make a longitudinal incision along the medial border of the foot
  • this should start just distal to the medial malleolus and continue to the base of the first metatarsal


Release the tibalis posterior from its tendon sheath

  • identify and protect the posterior tibialis
  • the posterior tibialis may be cut and imbricated later in the procedure (though the need for this is controversial)


Incise the talonavicular capsule

  • incise the talonavcular joint capsule including in the spring ligament
  • incise this from dorsal lateral to plantar lateral
  • resect a 5 to 10 mm wide strip of capsule from the medial and plantar aspects of the redundant tissue


Assess the need for gastrocnemius recession

  • assess the equinus contracture by the Silfverskiold test with the subtalar joint inverted to neutral and the knee both flexed and extended
  • perform a gastrocnemius recession if 5-10 degrees of dorsiflexion cannot be achieved with the knee extended and hindfoot inverted, even if this can be achieved with the knee flexed
  • perform an achilles lengthening if 5-10 degrees of dorsiflexion can not be achieved with the knee flexed


Reintroduce the retractors between the anterior and middle calcaneal facets

  • replace the retractors both dorsal and plantar to the isthmus of the calcaneus
  • these retractors should meet in the interval between the anterior and middle facets of the subtalar joint



Perform the osteotomy

  • use a sagittal saw or osteotome to perform the calcaneus osteotomy
  • this is an osteotomy from proximal lateral to distal medial that starts 2-2.5 cm proximal to the CC joint and exits between the anterior and middle facets
  • this is a complete osteotomy through the medial cortex
  • the plantar periosteum and the long plantar ligament are cut (but not the plantar fascia)
  • these are cut under direct vision if tight with distraction of the osteotomy

Calcaneus Correction


Place calcaneocuboid stabilizing pin

  • place a 2 mm smooth pin retrograde from the dorsum of the foot passing through the cuboid, across the center of the calcaneocuboid joint and stopping at the osteotomy
  • perform this insertion with the foot in the original deformed position before distraction of the osteotomy


Place calcaneal distraction pins (optional step)

  • place a single 1.6mm pin from lateral to medial in eachnof the calcaneal fragments immediately adjacent to the osteotomy site
  • these will be used as joysticks to distract the osteotomy at the time of the graft insertion


Perform distraction of the calcaneus

  • a smooth toothed calcaneal spreader is placed in the osteotomy and distract maximally
  • avoid crushing the bone


Assess the degree of correction

  • assess the correction both clinically and radiographically
  • check to see that the axes of the talus and first metatarsal are collinear in both the AP and Lateral Planes


Perform measurements

  • the distance between the lateral cortical margins of the calcaneal fragments is measured
  • this is the lateral length dimension of the trapezoid shaped iliac crest graft that will be obtained from either the iliac crest or from the bone bank
  • the trapezoid should taper to a medial length dimension of 35-40% to of the lateral length


Remove lamina spreaders

  • remove the lamina spreader and use the Steinmann pins to distract the calcaneal fragments

Graft Placement and Fixation


Obtain bone graft from the iliac crest or bone bank

  • see seperate procedure in orthobullets for harvesting iliac crest bone graft


Place the graft in the appropriate alignment

  • insert and impact the graft with the cortical surfaces aligned from proximal to distal in the long axis of the foot
  • this will place the cancellous bone of the graft in contact with the cancellous bone of the calcaneal fragments


Advance pins (optional step)

  • advance the previously inserted Steinmann pin (across the CC joint) in a retrograde fashion through the graft and into the proximal calcaneal fragment
  • bend the pin at the insertion on the dorsum of the foot for later ease of retrieval in the clinic


Assess need for medial cuneiform osteotomy/perform osteotomy

  • evaluate alignment of forefoot to remaining foot after lengthening osteotmy and reefing of the talonavicular joint
  • if forefoot is persistently supinated then a plantar based closing wedge osteotomy of the medial cuneiform should be performed
  • can be done through the medial incision
  • perform a plantar based, closing wedge osteotomy with the sagittal saw ,the base of the osteotomy can be from 4-7 mm depending on size of patient and deformity.
  • close the osteotomy site down and hold with 1.6mm wire or a staple

Soft Tissue Repair and Wound Closure


Repair the peroneus brevis tendon after 5 to 7 mm of lengthening

  • repair with side to side interrpted 2-0 nonabsorbable sutures after lengthening tendon to appropriate tension


Plicate the talonavicular joint capsule planatarmedially only

  • plicate capsule with size 1 absorbable or non-absorbable suture in an interrupted or figure-8 fashion


Advance the posterior tibialis (optional step)

  • advance the proximal slip of the tibialis posterior approximately 5 to 7 mm through a slit in the distal slump of the tendon using a pulvertaft weave with an absorbable suture material
  • alternatively sew tendon in a side to side fashion with 2.0 interrupted sutures


Deep Closure

  • 2-0 or 3-0 absorbable suture for subcutaneous tissue


Superficial closure

  • 3-0 absorbable, undyed running monofilament for medial incision
  • 3-0 non-absorbable mattress sutures are used for the lateral, calcaneal incision


Dressings and immobilization

  • steri-strips
  • felt padding around pins
  • place in a bivalved non weightbearing short cast
Postoperative Patient Care
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options