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Operative Treatment of Resistant Clubfoot

Planning

B

Preoperative Plan

1

Radiographic templating

2

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
C

Room Preparation

1

Surgical instrumentation

  • sterile tongue blades for lengthening tendons
  • vessel loops
  • right angle clamp
  • .062 and 2.0 smooth steinman pins

2

Room setup and equipment

  • standard OR radiolucent table
  • C-arm Foursoscopy

3

Patient positioning

  • prone
  • flex the knee when performing the achilles tendon lengthening
  • supine if limited internal rotation of hips

Technique

D

Cincinnati Incision

1

Mark and make incision

  • start the incision medially at the base of the first metatarsal and extend it posteriorly centering it over the TN joint
  • continue it posteriorly, it should fall distal to the tip of the medial malleolus
  • extend the incision posteriorly at the level of the subtalar joint
  • continue the incision distally to the lateral subtalar joint
  • continue the incision of the posterior ankle to finish distal to the tip of the lateral malleolus
E

Achilles Tendon Lengthening

1

Expose the Achilles tendon

  • incise the Achilles tendon sheath to expose the Achilles tendon
  • if the child is less than 18 months old, lengthen the Achilles by tenotomy
  • if older than 18 months old, lengthen with Z lengthening
  • lengthen the medial half of the Achilles tendon distally to reduce the amount of varus force

2

Release any fibrotic tssue

  • release the fibrotic bands in this region and in the tendon sheath
F

Capsular and Ligaments Release

1

Identify the neurovalscular and tendon structures

  • identify the sural nerve and vessels laterally
  • identify the posterior tibial bundle medially
  • place vessel loop around bundle and FHL
  • identify and retract the FHL posteromedially
  • keep FHL with bundle it serves well to protect the bundle at the ankle

2

Release the capsules

  • release the capsules in the posterior aspect of the subtalar and ankle joints

3

Identify the ankle capsule

  • incise from the postermedial corner to the posterolateral corners to allow dorsiflexion of the talus in the ankle mortise

4

Identify the subtalar joint

  • incise posteriorly, then medially, then laterally to the interosseous ligament
  • when incising medially use a senne retractor to gently protect neurvascular bundle it is vulnerable at this point in dissection

5

Release the fibulotalar and fibulocalcaneal ligaments

  • check to see if the foot and ankle joint can be dorsiflexed at least 20 degrees above neutral
  • if the great toe is tightly flexed when ankle is dorsiflexed, lengthening of the flexor hallicus longus can be performed by Z lengthening
  • Often FHL and FDL are too small to z lengthen alone. Can lengthen them in combination in the plantar foot by suturing the two tendons together and then z lengthening them in comination after tethered together.
G

Tendon Release and Lengthening

1

Extend the incision

  • extend the Cincinnati incision medially to the medial aspect of the navicular

2

Identify the posterior tibial neurovascular bundle and protect

  • this should be done before any fascia is released

3

Identify tendons

  • identify and protect the FHL tendon

4

Identify the posterior tibialis tendon just distal to flexor digitorum longus (FDL)

  • lengthen using a Z-plasty technique

5

Identify the FDL tendon just anterior to the PT neurovascular bundle

  • lengthen the FDL using a Z-plasty technique

6

Identify the abductor hallicus muscle

  • lengthen to help improve correction of the forefoot varus
  • lengthen the abductor hallucis muscle proximally or the abductor hallucis tendon distally

7

Identify and release the Plantar fascia

  • retract the subcutaneous tissue on plantar foot and palpate plantar fascia, clear tissue away from it's dorsal and plantar surface bluntly using a freer elevator or other elevator
  • cut plantar fascia with scissors after the soft tissue has been safely cleared

8

Anterior tibialis tendon (ATT) lengthening

  • if the ATT appears contracted after anatomic correction, then the ATT should be Z lengthened

9

Tag sutures

  • while lengthening the tendons on the medial side of the foot each end of the lengthened tendon should be tagged with a suture
  • each group of the proximal and distal sets of clamps can be held in proper order by a safety pin
  • release joint capsules and reduce foot before tendons are repaired
H

Talonavicular (TN) Joint Capsule Release

1

Identify the TN joint

  • trace distal stump of the posterior tibial tendon to its insertion on the navicular

2

Release the TN joint

  • release the TN capsule on the medial, plantar and dorsal aspects and as far laterally as can be reached safely

3

Release the medial subtalar capsule

  • release the medial subtalar capsule from the TN joint to the interosseous ligament medially, including a release of the spring ligament

4

Detach the EDB

  • dissect through the plantar aspect to the medial aspect of the calcaneocuboid joint
  • extend the posterior aspect of the Cincinnati incision laterally at the level of the subtalar joint to the lateral subtalar joint
  • identify the EDB over the sinus tarsi and detach its plantar edge from the lateral calcaneus
  • elevate the muscle to expose the sinus tarsi and neck and head of the talus

5

Expose and release the lateral capsule of the TN joint

  • palpate the beak of the calcaneus
  • from the lateral aspect of the TN joint cut the lateral subtalar capsule between the beak of the calcaneus and the talar neck proximally to the interosseous ligament
I

Foot Realignment, Fixation and Confirms Reduction

1

Realign the foot

  • place a finger over the talar head dorsolaterally
  • rotate the foot while being held in a position of slight supination
  • rotate the foot until the first metatarsal is just lateral to the talar dome axis
  • this maneuver should correct the convex lateral border to a straight position
  • position the heel in slight valgus and reduce the talar head under the navicular without wedging open the sutalar joint
  • A wire can be placed in the talus posteriorly and used as a joystick to rotate the talus into position under the navicular

2

Place fixation

  • hold the anatomically corrected position with 0.062 inch Kirschner wires that are passed from the posteromedial talus, through the center of the talar head, into the navicular and medial cuneiform, and out of the skin in the region of the first web space
  • Optional step: pin the subtalar and tibiotalar joint in place with 0.062 Kirschner wire with the foot dorsiflexed 5 degrees prior to suturing tendons back in lengthened positions. Talocalcaneal angle should be greater than 25 degrees on the lateral.

3

Confirm the reduction

  • take intraoperative radiographs to confirm the reduction
  • radiographs and clinical examination should show
  • lateral border of the foot is straight, heel bissector line falls between the second and the third toe.
  • the heel is in slight valgus with the foot dorsiflexed to neutral
  • prior to repair of the tendons, range of motion of the ankle should be 20 degrees of dorsiflexion and 30 degrees of plantar flexion
  • after repair of the tendons ankle dorsiflexion should be 0 or neutral degrees and the talar head should be reduced under the navicular
  • the TN joint should be flush dorsally and plantarly
  • the first metatarsal should be in line with the talus on the lateral radiograph and should be in 0 to 30 degrees valgus relative to the talar axis on the AP radiographs
  • the talocalcaneal angle should be greater than 25 degrees on the lateral and AP radiographs
  • In a older child with clubfoot it may be necessary to perform a closing wedge osteotomy on the cuboid to acheive adequate reduction of the talonavicular joint in the coronal plane. This can be held closed with an .062 smooth k wire

4

Repair Z-legnthened tendons

J

Wound Closure

1

Deep closure

  • 3-0 vicryl for subcutaneous tissue

2

Superficial closure

  • Surgeon Choice
  • interrupted suture with nylon or chromic if some tension, never accept blanching of wound edges
  • running monocryl
  • may need to leave open portion of incision if large correction performed, cover open portion with sterile nonstick dressing prior to casting

3

Dressings and immobilization

  • steri-strips used only with a running closure
  • long cast with knee flexed to near 90 degrees and foot maintained in corrected position
  • felt placed over pins and sterile nonstick dressing wrapped around pins
  • small cut made next to pins with 11 blade if there is any skin tenting or blanching to release tension
  • sterile foam placed in cast to accommodate swelling, if not available use extra padding or splint. The foot will swell post-operatively so care should be taken to pad the cast or splint adequately.

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check range of motion

2

Screen medical studies to identify and contraindications for surgery

3

Orders appropriate initial imaging and laboratory studies

  • standing radiographs of the foot

4

Perform operative consent

  • describe complications of surgery including
  • undercorrection
  • overcorrection
  • recurrent deformity
  • wound complications
  • vascular injury
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • IV fluids
  • pain control

2

Discharges patient appropriately

  • pain control
  • schedule follow up in 1 week
  • non weightbearing for 6 weeks
  • wound care
M

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • symptoms
  • physical exam
  • recognizes factors that could predict complications or poor outcome

2

Orders and interprets required diagnostic studies

  • radiographs

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Postop: 1 Week Postoperative Visit

  • check cast
  • diagnose and management of early complications

5

Postop: 6 week Postoperative Visit

  • change cast at this visit
  • remove the K wires
  • measure for brace
  • start weightbearing
N

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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