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Calcaneal Lengthening Osteotomy

Planning

B

Preoperative Plan

1

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

  • 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

2

Room setup and equipment

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

3

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

Technique

D

Modified Ollier Incision

1

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

2

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

3

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

4

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

5

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
E

Deep Dissection

1

Identify the anatomy of the subtalar joint

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

2

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

3

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
F

Osteotomy Preparation

1

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

2

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)

3

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

4

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

5

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
G

Osteotomy

1

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
H

Calcaneus Correction

1

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

2

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

3

Perform distraction of the calcaneus

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

4

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

5

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

6

Remove lamina spreaders

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

Graft Placement and Fixation

1

Obtain bone graft from the iliac crest or bone bank

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

2

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

3

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

4

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
J

Soft Tissue Repair and Wound Closure

1

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

2

Plicate the talonavicular joint capsule planatarmedially only

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

3

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

4

Deep Closure

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

5

Superficial closure

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

6

Dressings and immobilization

  • steri-strips
  • felt padding around pins
  • place in a bivalved non weightbearing short cast

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • asses flatfoot flexibility by looking at foot in weightbearing and non- weight bearing
  • a flexible foot with regain an arch when non- weight bearing
  • check toe standing
  • check to see if the flatfoot is flexible by observing the creation of the longitudinal arch and the hindfoot valgus to varus with toe standing
  • perform the Silfverskiold test to asses tightness of gastrocnemius/achilles
  • check the thigh foot angle and transmalleolar axis
  • check range of motion of subtalar joint

2

Screen medical studies to identify and contraindications for surgery

3

Orders appropriate initial imaging and laboratory studies

  • standing radiographs of the foot
  • look at reduction of the talonavicular joint on AP view and lateral view
  • look at talus 1st metatarsal angle on AP and lateral views
  • check the hindfoot valgus alignment, depression of the longitudinal arch and the outward rotation of the foot
  • weight bearing AP of ankles
  • asses if there is ankle valgus present
  • oblique foot xrays
  • asses for presence of tarsal coalition(ant eater sign on oblique xray and C sign on lateral xray)

4

Perform operative consent

  • obtain informed consent for a lateral column lengthening of the calcaneus with allograft versus autograft bone with soft tissue reconstruction including tendon lengthening and possible need for a medial cuneiform osteotomy and internal fixation
  • describe the standard potential complications of surgery including death, neurovascular damage, pain, and infection
  • subluxation of the calcaneocuboid joint
  • incomplete deformity correction
  • persistent equinus
  • wound complications
  • persistent supination deformity of the forefoot may become evident after the hindfoot and midfoot deformity(ies) corrects
  • nonunion/delayed union osteotomy site(s)
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • IV fluids
  • pain control
  • neurovascular checks
  • physical therapy
  • gait training for strict non weight bearing on operative side
  • cast care
  • non weightbearing for 3-4 weeks
  • heel off of bed
  • do not get cast wet or insert anything into cast

2

Discharges patient appropriately

  • pain control
  • schedule follow up
  • 1-2 weeks follow up
  • 6-8 week follow up
  • cast care
M

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • persistent pain/callusing under talar head despite non operative measures
  • shoe inset/orthotic
  • physical therapy to work on heel cord stretching
  • symptoms
  • pain with ambulation under talar head +/- callusing
  • calf/muscle pain after walking long distance/ inability to walk long distance
  • physical exam
  • documents neurovascular examination foot
  • asses flexibility of flatfoot by evaluating foot weight bearing and non- weight bearing
  • asses recreation of arch with toe walking
  • asses subtalar flexibility
  • asses ROM of tendoachilles complex with the Silverskiold test
  • recognizes factors that could predict complications or poor outcome
  • tarsal coalition
  • poor vascular supply
  • pre- existing complex regional pain syndrome
  • multiple previous failed surgeries

2

Orders and interprets required diagnostic studies

  • radiographs
  • weight bearing ap/ lateral foot xray
  • oblique foot xray
  • weight bearing ap ankle xray
  • ct scan of foot if suspect a tarsal coalition

3

Makes informed decision to proceed with operative treatment

4

Preoperative Workup Planning and Documentation

  • documents failure of nonoperative management
  • shoe inserts/orthotics
  • physical therapy for stretching of gastrocnemius/achilles contrtacture
  • describes accepted indications and contraindications for surgical intervention
  • indications
  • Painful/flexible flatfoot with subluxation of talonavicular joint demonstrated on weight bearing foot films that has failed nonoperative treatments
  • contraindications
  • painless flexible flatfoot
  • painful flexible flatfoot that has not had nonoperative treatment
  • rigid flatfoot

5

Postop:1-2 week Postoperative Visit

  • ap lateral foot xrays in cast
  • assess for signs/symptoms of infection
  • assess for signs symptoms of neurovascular injury

6

Postop:3-4 Week Postoperative Visit

  • wound check
  • ap and lateral foot x-rays out of cast
  • remove sutures and change to short leg walking cast
  • measure foot orthotic if one will be worn after cast removal

7

Postop:6-8 week Postoperative Visit

  • wound check
  • diagnose and management of early complications
  • delayed healing osteotomy site(s)
  • infection
  • signs/symptoms of complex regional pain syndrome
  • wound breakdown/necrosis
  • check simulated weightbearing radiographs
  • remove steinmann pins
  • apply another non weightbearing cast for 2 more weeks
  • use over the counter arch supports indefinitely
  • consider orthotics if patient has a neuromuscular condition
N

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
  • asses radiographs for healing of osteotomy site
  • evaluate positionweight bearing foot/rom of ankle
  • consider orthotic to improve foot position
  • physical therapy to work on rom of tendoachilles
  • return to OR as needed
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

  • nonunion/delayed union osteotomy site
  • rule out infection with laboratory work
  • apply a bone stimulator
  • return to OR for bone grafting and internal fixation with screw or plate
  • infection/wound breakdown
  • evaluate lab work cbc with diff, sed rate, crp
  • obtain cultures if possible
  • treat with dressing changes and oral antibiotics when appropriate
  • return to OR for irrigation, debridement, and IV antibiotices when necessary
  • complex regional pain syndrome
  • treat with early mobilization and physical therapy for desensitization
  • refer to Pain Management if patient does not respond quickly to mobilization and desensitization
 

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