A Intermediate Evaluation and Management 1 Obtains focused history and physical history varus foot position or forefoot supination, either static or dynamic in patients with cerebral palsy. overpull of the anterior tibial tendon that causes dynamic foot deformity in children with other neurologic problems. residual forefoot supination, adduction, or varus deformity either static or dynamic, with overpowering of anterior tibial tendon function after initial clubfoot treatment. loss of eversion power of foot secondary to trauma or disorders such as Charcot-Marie-Tooth disease symptoms intoeing, tripping callusing under 5th metatarsal difficulty with shoe wear and brace wear physical exam observational gait analysis shows excessive supination in swing phase of gait, intoeing alignment of foot noted with weight bearing and non-weight bearing range of motion ankle and subtalar joint documented strength of anterior tibialis tendon noted should be at least grade 4/5 recognizes factors that could predict complications or poor outcome rigid foot deformity preventing the foot from being manipulated into a neutral position weak anterior tibialis tendon grade 3 or less progressive neurologic disease that will result in weakness of the anterior tibialis in the future 2 Orders and interprets required diagnostic studies AP and lateral weight bearing foot radiographs oblique foot radiographs 3 Makes informed decision to proceed with operative treatment documents failure of nonoperative management mitchell shoe and bar wear, orthotics physical therapy serial casting describes accepted indications and contraindications for surgical intervention indications residual forefoot supination, adduction, or varus deformity either static or dynamic, with overpowering of anterior tibial tendon function after initial clubfoot treatment or with a neurologic condition such as cerebral palsy. loss of eversion power of foot secondary to trauma contraindications rigid foot deformity preventing the foot from being manipulated into a neutral position weak anterior tibialis tendon grade 3 or less progressive neurologic disease that will result in weakness of the anterior tibialis in the future 4 Postop: 3-4 Week Postopereative visit evaluate for signs or symptoms of infection evaluate for signs or symptoms of neurovascular injury cast change and wound check any orthotics, if needed, are measured before the new cast is placed 5 Postop: 6 Week Postoperative Visit wound check diagnose and management of early complications infection wound complications remove the walking cast remove the plantar anchoring button measure for articulating AFO with plantarflexion stop to be worn for for 6 months in the clubfoot patient maybe lifetime wear in the neurologic patient depending on condition place in weight bearing cast while waiting for brace B Advanced Evaluation and Management 1 Modifies post-operative plan based on response to treatment patient fails to improve post-operatively evaluate tension on tendon transfer, ensure it hasn't ruptured asses strength of transferred tendon physical therapy for strengthening and gait training return to OR as needed C Preoperative H & P 1 Obtains history and performs basic physical exam check range of motion asses motion of subtalar joint asses dorsifexion of ankle asses the ability of the hindfoot to be placed in a neutral position 2 Screen medical studies to identify and contraindications for surgery 3 Orders appropriate initial imaging and laboratory studies standing ap lateral xrays of the foot oblique xray foot 4 Perform operative consent describe complications of surgery including death, loss of limb, neurovascular damage rupture of the transferred tendon pressure sores insufficient tension of the transferred tendon wound complications
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 Sterile button felt pad Keith needles right angle retractor Ober tendon passer 2 Room setup and equipment standard OR table tourniquet c-arm fluoroscopy if transfer is to the cuboid 3 Patient positioning supine place a bump under the ipsilateral hip for internal rotation of the foot G First Skin Incision 1 Mark and make an oblique incision make a 1.5 cm oblique incision at the insertion of the anterior tibialis tendon at the medial cuneiform and first metatarsal 2 Expose the anterior tibialis tendon incise the tendon sheath to expose the tendon with a 15 blade 3 Dissect and detach the tendon dissect the tendon to the insertion at the cuneiform and first metatarsal detach the medial/plantar half of the tendon with sharp dissection use an 0 or 2-0 vicryl to place a Bunnel suture in the cut end of the tendon H Second Incision 1 Make a second incision make a second 1 cm incision at the anterior distal tibia directly over the anterior tibial tendon just lateral to the crest the location of the tendon can be easily identified by pulling on the distal tendon while palpating over tibia incise the tendon sheath to expose the tendon 2 Transfer the tendon use a hemostat or Ober tendon passer to pull the tendon until the tendon's distal end is pulled into the proximal incision (take care to stay under the retinaculum and in the tendon sheath while retrieving and transporting the tendon) protect the tendon with a wet sponge wrap I Third Incision 1 Make a third incision this incision should be 1 cm long at the dorsum of the foot directly over the lateral cuneiform, found at the base of the third metatarsal alternatively this incision is overlying the peroneus tertius which is found just lateral to the lesser toe extensor tendons 2 Expose the cuboid retract the extensor tendons of the toes to expose the lateral cuneiform incise periosteum at the center of the lateral cuneiform can use c-arm to confirm the location of the cuboid 3 OR Exposure of Peroneus Tertius open sheath overlying peroneus tertius tendon The peroneus tertius is immediately lateral to the toe extensors confirm it is the tertius tendon. The foot should evert and dorsiflex when the tendon is pulled and the toes do not extend 10% of people do not have a peroneus tertius 4 Create a subcutaneous tunnel use a large curved hemostat or dissecting scissors to make a subcutaneous tunnel from the distal wound to the lower leg wound use the hemostat or a tendon passer to grasp the sutures in the tendon stump 5 Transfer the tendon to the third incision using the hemostat or tendon passer, pull the tendon distally and laterally into the third incision J Tendon Passage and Fixation 1 Fixation through the cuboid drill a hole in the cuboid use a drill bit that is slightly larger than the transferred tendon to make a drill hole through the lateral cuneiform in a dorsal to plantar direction keep a finger on the plantar area to prevent penetration of the drill bit through the skin prepare the tendons for passage through the drill holes attach the two ends of the suture in the anterior tibial tendon to separate long straight Keith needles push the Keith needles through the drill holes from the dorsal to plantar surface the exits of the 2 Keith needles should be 3 to 5 mm apart attach the sterile button with the needles attached to the two sutures, pierce through a small square of felt pad and a sterile button pass the tendons gently pull the tendon into the drill hole in the lateral cuneiform 2 Transfer to the peroneus tertius pull distally on the split anterior tibial tendon transfer place a right angle clamp under the split tendon transfer and the peroneus tertius complete the side-to-side transfer with a 2-0 non-absorbable suture K Suture Tying 1 Tie the sutures hold the foot in neutral or mild dorsiflexion and eversion as the sutures are tied on top of the button which overlies a thick piece of felt to protect the skin alternatively the foot is held in neutral or mild dorsiflexion and eversion as the sutures are ties in a figure-8 fashion side by side to the peroneus tertius tendon L Wound Closure 1 Deep closure 2-0 or 3-0 absorbable suture for subcutaneous tissue 2 Superficial closure 3-0 running monofilament for skin 3 Dressings and immobilization steri-strips place in a non weight bearing short leg cast if there is a button on the foot as they can develop a pressure sore with weight bearing place in a weight bearing short leg cast if the split anterior tibialis tendon was transferred to the peroneus tertius tendon
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated IV fluids pain control neurovascular checks physical therapy strict non-weight bearing on operative foot if patient has a button may weight bear as tolerated in cast if tendon transferred to peroneus tertius cast management cast elevation, keep heel off of bed 2 Discharges patient appropriately pain control pt should be discharged with prescriptions for oral narcotics and diazepam to be taken as needed for two weeks for pain and spasm schedule follow-up at 3-4 weeks and 6 weeks cast care instructions keep heel off of bed, do not get cast wet, do not put anything inside cast R Complex Patient Care 1 Develops unique, complex post-operative management plans Rupture of Tendon transfer Return to OR for reconstruction pressure sore from button wound care initiated in clinic