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Midfoot Osteotomy

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

  • 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

2

Room setup and equipment

  • standard radiolucent OR table
  • c-arm fluoroscopy

3

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

Technique

D

Skin Incision for Closing Wedge Osteotomy of the Cuboid

1

Identify the cuboid

  • use imaging to confirm the placement of the cuboid

2

Make the skin incision

  • make a longitudinal incision over the dorsal lateral border

3

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
E

Osteotomy Preparation

1

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
F

Cuboid Osteotomy and Fixation

1

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

2

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
G

Exposure of the Medial Cuneiform

1

Make a skin incision over the medial cuneiform

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

2

Identify and expose the anterior tibialis tendon

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

3

Expose the cuneiform

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

4

Incise the periosteum

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

Osteotomy of the Cuneiform

1

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

2

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
I

Cuneiform Fixation

1

Perform the cuneiform osteotomy

2

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.

3

Place the fixation

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

Wound Closure

1

Deep closure

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

2

Superficial closure

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

3

Dressings and immobilization

  • steri-strips for running closures
  • place in a non weightbearing short cast

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check range of motion, ankle, subtalar joint, midfoot, forefoot.
  • neurovascular examination of the leg
  • evaluate patient's gait, including foot alignment in stance
  • evaluate shoe for wear pattern
  • evaluate skin on foot for callusing

2

Screen medical studies to identify and contraindications for surgery

  • obtain medical clearances as necessary

3

Orders appropriate initial imaging and laboratory studies

  • standing radiographs of the foot

4

Perform operative consent

  • describe complications of surgery including
  • undercorrection
  • pain
  • extrusion of the medial cuneiform graft
  • recurrent deformity
  • wound complications
  • vascular injury
  • nerve injury
  • delyed union/nonuinion
  • anesthetic risks, including death
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • IV fluids
  • pain control
  • physical therapy
  • non weight bearing on operative extremity
  • cast management
  • keep cast elevated
  • keep heel off bed
  • neurovascular checks

2

Discharges patient appropriately

  • dispense oral pain medication for 14 days
  • schedule follow up in 1-2 weeks
  • appropriate cast management instructions
M

Intermediate Evaluation and Management

1

Obtains focused history and physical

  • history
  • tripping
  • intoeing
  • symptoms
  • pain/callusing and difficulty with shoe wear
  • physical exam
  • neurovascular exam
  • able to asses normal and abnormal structural alignment of foot when standing and walking
  • recognizes factors that could predict complications or poor outcome
  • neurovascular compromise
  • previous surgeries
  • tarsal coalitions
  • history of poor wound healing
  • midfoot arthritis
  • weight bearing radiographs foot
  • ct scan if tarsal coalitions are suspected
  • gait analysis if available

2

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • failure of orthotic intervention and/or shoe wear modification
  • failure of physical therapy
  • describes accepted indications for surgical intervention
  • continued pain and disability despite orthotic intervention
  • continued pain and disability after physical therapy intervention
  • describes accepted contraindications for surgical intervention
  • absence of pain and/or disability
  • no history of non operative treatment
  • tarsal coalitions that prevent midfoot mobility
  • midfoot arthritis

3

Postop: 3-4 Week Postoperative Visit

  • performs and documents
  • review of symptoms for signs of infection and neurovascular injury
  • physical examination to asses for neurovascular injury and wound integrity
  • pin site appearance and any evidence of pin loosening
  • evaluates and documents
  • non weight bearing foot xrays in cast for foot and hardware alignment
  • short leg cast is changed
  • foot or ankle foot orthotic is measured if these are to be used post-op

4

Postop:4-6 Week Postoperative Visit

  • orders, evaluates, and documents
  • non weight bearing foot xrays out of cast
  • notes osteotomy healing
  • foot alignment

5

Evaluates and documents the following

  • wound healing
  • postoperative orthosis is placed at this visit
  • postoperative physical therapy is prescribed
  • diagnosis and management of early complications
  • wound healing complications
  • delayed union osteotomy
  • infection
  • signs/symptoms of complex regional pain syndrome

6

Pin removal

  • pins are removed in the office at this visit
N

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
  • nonunion of osteotomy site
  • development of complex regional pain syndrome
  • development of postoperative infection
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

  • nonunion of osteotomy
  • treatment with bone stimulator
  • surgical correction nonunion with bone gract and internal fixation with screws and or plate and screws
  • complex regional pain syndrome in the postoperative setting
  • recognizes the condition
  • limits immobilization and orders physical therapy for densitization
  • makes referral to a pain management specialist for patients who don't readily respond to desensitization
  • postoperative Infection
  • recognizes signs/symptoms of infection and documents it in the record
  • obtains cultures and laboratory workup
  • treats infection appropriatly
  • antibiotics and dressings in outpatient setting
  • returns to operating room for surgical irrigation and debridemnent when appropriate
 

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