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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Radiographic templating


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

  • oscillating saw
  • 1/4 and 1/2 inch straight osteotomes
  • 1.6 mm and 2.0 mm smooth pins
  • bone staples
  • chandler retractors
  • hohman retractors
  • tourniquet


Room setup and equipment

  • standard radiolucent OR table
  • c-arm fluoroscopy


Patient positioning

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

Skin Incision for Closing Wedge Osteotomy of the Cuboid


Identify the cuboid

  • use imaging to confirm the placement of the cuboid


Make the skin incision

  • make a longitudinal incision over the dorsal lateral border


Develop full thickness skin flaps

  • identify and protect branches of the sural nerve
  • place retractors plantarly and dorsally to protect the soft tissues
  • this should protect the toe extensors dorsally and the peroneals plantarly

Osteotomy Preparation


Incise the periosteum of the cuboid

  • make the incision in an H shape with a longitudinal cut and 2 transverse cuts
  • stay away from the calcaneocuboid joint proximally and the cuboid-fifth metatarsal joint distally
  • elevate the periosteum dorsally and plantarly

Cuboid Osteotomy and Fixation


Remove a lateral triangle of bone

  • use a small oscillating saw or a half inch osteotome to the remove the laterally based triangle of bone
  • using an oscillating saw generally makes a more precise cut and facilitates harvesting of the excised bone in one piece
  • this is very important when harvesting a bone graft for an opening wedge osteotomy
  • the medial cortex of the cuboid should be cut to facilitate the mobilization as well as the closure of the osteotomy
  • when using a saw irrigate to prevent necrosis of bone


Reduce and fix the cuboid

  • fix the cuboid site using 1.6 or 2.0 mm pins or staples
  • place the pins eccentrically in the cuboid (close to the lateral cortex) to hold the osteotomy during healing
  • after closing the osteotomy the heel bisector line should fall between the second and third toe

Exposure of the Medial Cuneiform


Make a skin incision over the medial cuneiform

  • make a straight line longitudinal medial incision over the medial aspect of the medial cuneiform


Identify and expose the anterior tibialis tendon

  • carry the dissection down with tenotomy scissors
  • identify the anterior tibialis tendon over the first medial cuneiform


Expose the cuneiform

  • retract the tendon dorsally
  • identify the center of the cuneiform


Incise the periosteum

  • incise the periosteum using cautery or a number 15 blade from dorsal to plantar

Osteotomy of the Cuneiform


Elevate the periosteum

  • elevate the periosteum proximally and distally 5 mm in both directions
  • be sure to protect the capsules of both the proximal and distal joints
  • the joints can be identified with a small gauge needle or under imaging


Perform the osteotomy of the cuneiform

  • if the osteotomy is for a rigid supination deformity the osteotomy should extend across the entire midfoot including the cuboid and all three cuneiforms and exit the middle of the medial cuneiform
  • if the osteotomy is for persistent adductus after a closing wedge osteotomy of the cuboid the osteotomy only extends across the medial cuneiform in preparation for receipt of an opening wedge graft
  • during the osteotomy place tissue retractors plantar and dorsal across the midfoot immediately adjacent to the tarsal bones to protect the dorsalis pedis artery, the superficial and deep peroneal nerves and tendons

Cuneiform Fixation


Perform the cuneiform osteotomy


Place the foot in the corrected position

  • once the osteotomy is completed across the midfoot, pronate the distal aspect of the foot until it is perpendicular to the long axis of the tibia
  • if the osteotomy is to correct adductus, a triangular bone graft is placed in the medial cuneiform after the closing wedge cuboid osteotomy. A large enough graft is inserted to correct foot alignment placing the heel bisector line between the second and third toes.


Place the fixation

  • place one or two 1.6 to 2.0 mm smooth pins in the appropriate position

Wound Closure


Deep closure

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


Superficial closure

  • running absorbable monofilament for skin
  • interrupted retention sutures should be used with nonabsorbable suture in patients where healing may be compromised


Dressings and immobilization

  • steri-strips for running closures
  • place in a non weightbearing short cast
Postoperative Patient Care
Private Note

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