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Surgical Treatment of Cavus Foot

Preoperative Patient Care

A

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: 3-4 Week Postoperative Visit

  • wound check
  • diagnose and management of early complications
  • place in walking cast until radiographic signs of healing present
B

Advanced Evaluation and Management

1

Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
C

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
  • wound dehiscence
  • pressure sores
  • rocker bottom foot deformity
  • wound complications
  • nonunion

Operative Techniques

E

Preoperative Plan

1

Examine subtalar motion under anesthesia

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
F

Room Preparation

1

Surgical instrumentation

  • oscillating saw
  • 1/4 inch and 1/2 inch osteotomes
  • 1.6 mm and 2.0 mm smooth steinmann pins
  • Chandler retractors
  • Hohman retractors

2

Room setup and equipment

  • standard OR table

3

Patient positioning

  • supine
  • place a bump under the ipsilateral hip for internal rotation of the foot
G

Plantar Release

1

Make the skin incision

  • make a longitudinal incision medially of the plantar fascia

2

Perform dissection

  • use sharp knife dissection through the skin and the subcutaneous fat

3

Expose the deep fascia

  • identify and release the abductor hallucis off of the deep fascia
  • expose the fascia that is deep to the abductor hallucis

4

Identify the neurovascular structures

  • identify the posterior tibial nerve and artery proximally
  • follow distally by releasing the overlying fascia

5

Expose the plantar fascia

  • expose the plantar fascia where it attaches to the medial tubercle of the calcaneus

6

Release the tendons

  • use Mayo scissors to release the flexor digitorum brevis, quadratus plantae and the abductor digiti quinti muscles at the their proximal origins

7

Loosely close the wound

  • close the wound loosely with interrupted sutures to allow drainage of blood for prevention of hematoma
H

Proximal Dorsal Based Oblique Closing Wedge Osteotomy (Medial Column Osteotomy)

1

Make the skin incision

  • make a longitudinal incision over the proximal metatarsal
  • be careful to protect and identify the dorsal digital nerve

2

Perform subperiosteal dissection of the proximal metatarsal

  • be sure to leave the plantar periosteum and soft tissue intact

3

Place pins

  • place 2 small diameter Steinmann pins with a drill at the site of the bone cuts
  • these pins should converge at the plantar apex
  • the apex of the cut should be very proximal and plantar

4

Perform the osteotomy

  • use a small oscillating saw to make the cuts
  • use the wires as guides for the cuts

5

Remove the cut bone

  • use a small osteotome and rongeur to remove some of the bone at the apex
  • leave a bony and soft tissue hinge intact so that this is an incomplete closing wedge osteotomy

6

Reduce the osteotomy

  • slowly close the ends together while maintaining the bone hinge

7

Apply fixation

  • secure the osteotomy with a wire, screw or dorsal plate

8

Close the wound

  • close the wound with loose interrupted sutures
I

Interphalangeal Joint Fusion (Modified Jones Procedure)

1

Make a transverse incision

  • make a transverse incision over the interphalangeal joint of the great toe

2

Expose the articular surface

  • carry the incision down to the extensor hallucis tendon
  • transect the tendon at the level of the IP joint
  • transversely incise the joint capsule
  • continue with a no. 15 blade to expose the articular distal aspect of the proximal phlanx

3

Remove the articular surface

  • use a rongeur to remove the articular cartilage and a small amount of subchondral bone on both sides of the IP joint

4

Place a guidewire

  • place a guidewire in a retrograde fashion through the center of the distal phalax so that it exits distally just plantar to the nail

5

Reduce the joint

  • reduce the joint in a neutral position

6

Place fixation

  • insert the screw
  • provide compression at the IP joint
  • the proper length will place the tip of the screw into the proximal aspect of the proximal phalanx

7

Close the wound

  • close the wound with loose interrupted sutures
J

Transfer of the EHL Tendon to the Metatarsal Neck (Modified Jones Procedure)

1

Make the skin incision

  • make a longitudinal incision over the distal first metatarsal

2

Expose the EHL

  • identify and isolate the extensor hallucis tendon
  • this should be done until its cut end can be pulled into the incision

3

Prepare the EHL

  • place a 0 whipstitch suture into the distal tendon

4

Expose the distal metatarsal

  • subperiosteally expose the distal metatarsal

5

Prepare the metatarsal neck

  • make a transverse drill hole in the metatarsal neck
  • the drill diameter should be the same diameter as the extensor hallucis tendon

6

Pass the tendon

  • pass the tendon with the assistance of wire or suture passer

7

Secure the tendon

  • after the appropriate osteotomy is reduced and final fixation has been placed, secure the EHL to itself

8

Close the wound

  • close the wound with loose interrupted sutures
K

Midfoot Osteotomy

1

Make the skin incision

  • make a long dorsomedial skin incision at the apex of the deformity

2

Place the retractors

  • place hohmann retractors dorsally and plantarly to expose the entire midfoot

3

Place Steinmann pins

  • insert smooth Steinmann pins to define the proximal and distal aspects of the osteotomy

4

Perform the osteotomy

  • make the osteotomy with an oscillating saw
  • complete the osteotomy with rongeurs
  • remove a dorsal based wedge

5

Reduce the osteotomy

6

Place fixation

  • place two threaded Steinman pins for fixation

7

Close the wound

  • close the incision with loose interrupted sutures
L

Calcaneal Osteotomy

1

Make a lateral oblique skin incision

  • make a lateral oblique incision just posterior to the peroneal tendons

2

Identify the fibulocalcaneal ligament

  • section this ligament along with the periosteum

3

Use an oscillating saw to perform osteotomy

  • create a laterally based wedge on the calcaneus
  • this should be immediately posterior to the peroneus longus tendon

4

Close the wedge

5

Perform fixation

  • fixation of the wedge can be performed with a Steinmann pin or cannulated 7.3 mm screw
  • introduce the screw percutaneously in the trajectory that is perpendicular to the osteotomy
N

Immobilization

1

Place in a non weightbearing cast

  • leave in place for 4 weeks

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • IV fluids
  • pain control
  • physical therapy
  • wound management
  • remove dressings POD2

2

Discharges patient appropriately

  • pain control
  • schedule follow up in 2 weeks
  • wound care
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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