Preoperative Patient Care A 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 B 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 C 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) Operative Techniques E 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 F 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 G 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 H 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 I 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 J 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 K 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 L 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 N 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 Postoperative Patient Care O 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 R 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
A 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 B 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 C 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)
E 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 F 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 G 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 H 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 I 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 J 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 K 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 L 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 N 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
O 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 R 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