Preoperative Patient Care
Operative Techniques

Preoperative Plan


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

  • 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


Room setup and equipment

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


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

Modified Ollier Incision


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


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


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


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


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

Deep Dissection


Identify the anatomy of the subtalar joint

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


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


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

Osteotomy Preparation


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


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)


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


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


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



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

Calcaneus Correction


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


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


Perform distraction of the calcaneus

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


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


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


Remove lamina spreaders

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

Graft Placement and Fixation


Obtain bone graft from the iliac crest or bone bank

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


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


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


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

Soft Tissue Repair and Wound Closure


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


Plicate the talonavicular joint capsule planatarmedially only

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


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


Deep Closure

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


Superficial closure

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


Dressings and immobilization

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

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