@ebookers Operative Techniques Foot

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t
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keerrss keerrss
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PROCEDURE hht
Hallux
r ss Valgus Correction With Modified
r s s Chevron
o k ee r
Osteotomy
k o kkee r
ooo
eebb ooo / e bb / e b o
b o
m ee /e m ee / e
Glenn B. Pfeffer
: / t
///t. . m : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp t
hht
PITFALLS
t p
t p
• Moderate arthritic changes of the joint are usually
INDICATIONS a contraindication to hallux valgus surgery.
• Painful hallux valgus deformity • A compromised blood supply.
k e rs
rs
• Failure of shoe modification
e k er
erss • Ulceration over the bunion prominence.
• An IMA of >13–15°.
b ooook b ooook
• Symptoms that interfere with daily activities
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• A mild to moderate deformity (hallux valgus angle <30º; intermetatarsal angle [IMA]
• An extremely hypermobile first ray.
• Osteoporosis makes this specific procedure
eeb <13–15°)
ee/ e
/ e b ee/ e
/ e b more difficult because of poor screw fixation.
• Patients with an excessively short first metatarsal
// t/ tm
. m
otomy with the addition of a closing wedge
: : / /t/ tm
• Patients with a high distal metatarsal articular angle (DMAA) require a chevron oste-
. . . m may do better with a basilar opening wedge
t p
EXAMINATION/IMAGING ss
p : / tp pss : / procedure (using an Arthrex low-profile plate)
that does not further shorten the metatarsal.
t
hht t t
hht t
• Standing examination of the foot demonstrates a hallux valgus deformity (Fig. 1.1).
• Avascular necrosis of the metatarsal head
is a reported complication of the chevron
osteotomy but rarely occurs if the procedure is
• The bunion prominence is usually erythematous from footwear irritation.
performed with precision.
• Examine the interphalangeal (IP) joint to determine if a hallux interphalangeus is pre- • Hallux valgus deformity will recur, to
sent (valgus IP angle >10°). A closing wedge osteotomy of the proximal phalanx may some degree, without some postoperative
keerrss be needed for these cases.
keerrss modification of high-heeled, tight-fitting shoes.
b ooook be required, but not commonly.

b ooook
• Evaluate hypermobility of the first ray. A fusion of the metatarsal-cuneiform joint may
b oo CONTROVERSIES
eeb /e e b /e e
• Pes planus may be present in association with valgus of the heel. Simultaneous sur-
ee /
gery for this condition is almost never required.
ee / b • Hallux valgus correction with a proximal first
metatarsal osteotomy is a much more powerful
/ t m
.t.m / t m
.t.m
• Standing anteroposterior (AP; Fig. 1.2) and lateral (Fig. 1.3) radiographs of the foot:
: / / : / /
correction than a distal chevron. A proximal
• Measure the first metatarsal-phalangeal angle and IMA (see Fig. 1.2B). Determine osteotomy (see Procedure 3) is a preferable
procedure for moderate to severe bunion
t
hhtt t
hhtt
if metatarsus adductus is causing a spuriously low IMA.
deformities. While it is possible to “push”
the indications for a chevron, there is little
point given the superb results of alternative
procedures that involve a proximal osteotomy
of the metatarsal base.
• A patient with metatarsus adductus will have a
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e k e rrss
e
spuriously low IMA on radiographs. A proximal
o o
o o k o o
o o k o o
osteotomy is often required in these patients,
despite a low IMA.
eebb ee/ e
/ b
e b ee/ e
/ b
e b • Simultaneous bilateral bunionectomies are
technically possible but present a very difficult
: / / t
/ m
.t.m : / / t
/ m
.t.m recovery for the patient and are usually not
recommended.
t p ss:
p / t p ss:
p / • A self-drilling/tapping screw negates the
t
hht t t
hht t difficult step of drilling across the osteotomy.
TREATMENT OPTIONS
• Shoe modification, with lower heels (<2.5 in.)
and a wider toe box. Stretch the shoes over
the bunion prominence.
k e r
e s
rs k eers
rs • Shoes should be purchased at the end of
o o
o o k o o
oo k oo
the day or after exercise, when the foot is
most swollen.
eebb ee/ e
/ b
e b ee/e/ebb • A soft upper material is preferable. The
shoe should stretch to fit the foot (i.e., do
: / / t
/ .
tm.m : / / t
/.tm
. m not deform the foot to fit the shoe).
• A medial longitudinal arch support may be
t p ss
p : / FIG. 1.1
t p ss
p : / helpful in athletic footwear.
t
hht t t
hht t 3
t t p
t ss:
p t t p
t ss:
p
4 hht
PROCEDURE 1 Hallux Valgus Correction With Modified Chevron Osteotomy hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb / e
Hallux
ee /
valgusebb ee/ e
/ b
e b
: / / t
/ .
t m
. mangle
: / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Distal
phalanx
k eers
rs k er
erss
Insertion of extensor
hallucis longus tendon
Proximal
phalanx
Dorsal sling
eeb ee/ e
/ e b
Intermetatarsal
angle
ee/ e
/ e b
Tendon of
Sesamoid
A
: // t/.tm
. mB
: / /t/.tm.
abductor hallucis
m and insertion
Tendon of adductor
hallucis contributing
t p ss
p : /
FIG. 1.2
tp pss : / fibers contributing
to extensor sling
to dorsal sling
t
hht t t
hht t
keerrss keerrss
Deep fibers of
extensor hallucis
b ooook b ooook longus tendon
b oo
First metatarsal

Superficial fibers of
: / / t
/ m
.t.m : / / t
/ m
.t.m
extensor hallucis
t ppss : / t ppss : / longus tendon

Extensor hallucis
Second metatarsal
t
hhtt FIG. 1.3
t
hhtt brevis tendon
FIG. 1.4
k e rrss
e k rrss
• Measure the DMAA, which may require correction if >10°. Slight rotation of the
e e
foot can affect this radiographic angle, and intraoperative fluoroscopic evaluation
o o
o o k o o o k
may be needed.
o o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
• Evaluate arthritic changes of the first metatarsophalangeal joint and the sesa-
moid-metatarsal articulation. Determine the station of the sesamoid (degree of
: / / t
/ m
.t.m ANATOMY : / / t
/ m
.t.m
subluxation from beneath the metatarsal head).
t p ss:
p / SURGICAL
t p ss:
p /
t
hht t t
hht t
• Bones and tendons of the great toe (Fig. 1.4)
• Vascular supply to the great toe (Fig. 1.5A)
• Nerve supply to the first and second metatarsals and toes (Fig. 1.5B)
POSITIONING
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e s
rs k eers
rs
• The patient is in the supine position.
o o
o o k oo k
• A bump under the contralateral hip will externally rotate the leg, which will improve
o o oo
eebb ee/ e
/ b
e b e /e/ebb
the exposure to the medial side of the foot.
• An ankle or thigh tourniquet may be used.
e
: / / t
/ .
tm.m : / / t
/.tm
. m
• The procedure is performed on an outpatient basis under a regional block (femoral-
t p ss
p : / t p ss : /
sciatic or popliteal-saphenous) to achieve maximal pain control postoperatively and
reduce the amount of general anesthetic used.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 1 Hallux Valgus Correction With Modified Chevron Osteotomy 5
k e r
e s
rs Dorsal pedis
k eers
r s
o o
o o k artery
oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Dorsal metatarsal
t p
arteries
ss
p : / t p ss
p : /
t
hht t t
hht t Medial dorsal
cutaneous nerve
A B
FIG. 1.5
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook b oo ook b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt A

t
hhtt
FIG. 1.6
B
k eerrss k e rrss
e
oooo k o o
o o k o o
eebb PORTALS/EXPOSURES ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m PEARLS
t p ss:
p / t p ss:
p /
• Make a longitudinal incision over the medial eminence of adequate length to expose
the metatarsal head and base of the proximal phalanx (Fig. 1.6A).
• During surgery document any arthritic changes
that may not have been visible on radiographs.
t
hht t t
hht t
• Isolate and protect the dorsal cutaneous sensory nerve (see Fig. 1.5B).
• Identify the medial plantar sensory nerve so that it is not injured during the
Evaluate both sesamoids and the entire joint
surface of the metatarsal head. Mild arthritis
may cause symptoms that do not resolve
procedure. postoperatively.
• A 2-cm longitudinal incision in the first web space is usually required to release the
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lateral capsule and adductor tendon (Fig. 1.6B).
rs k eers
rs STEP 1 PEARLS
o o
o k
PROCEDURE
o o o
oo k oo
• Only a small portion of the medial eminence has
to be excised. The head will be shifted laterally,
eebb Step 1
ee/ e
/ b
e b ee/e/ebb and the medial portion will no longer be
prominent, regardless of the amount resected.
: / / t
/ .
tm.m : / / /.tm
• Make a longitudinal incision in the capsule and expose the medial aspect of the
t . m • The wider the head, the more it can be shifted
laterally, allowing for a greater correction of
t p ss : /
• Expose the sagittal groove (Fig. 1.7).
p t p ss
p : /
metatarsal head. Keep the proximal and distal capsular attachments intact.
the IMA.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
6 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss B
Sagittal groove
b ooook b o o
o o k FIG. 1.7
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t ppss : / Bunion cut
t
hhtt t
hhtt Sagittal
groove
A B
k e rrss
e k e rrss
e
FIG. 1.8
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t Step 2 t
hht t
• Excise the medial eminence with a cut slightly medial to the sagittal groove (Fig. 1.8). The
cut is parallel to the medial metatarsal shaft, or angled slightly toward the medial border
of the foot (Fig. 1.9). Avoid resection of the medial cortex of the shaft.
k e r
e s
rs
STEP 3 PEARLS
k eers
• A microsagittal saw blade should be used for this case to minimize bone loss with
rs
each cut.
o o
o o k
• Always inspect the lateral sesamoid for arthritic
o o
oo
Step 3k oo
eebb changes. Excise the sesamoid if advanced
arthritis is present or it cannot be reduced
ee/ e
/ b
e b e /e/ebb
• Deepen the incision in the first web space using blunt dissection with the tip of a
e
beneath the metatarsal head. Excision of the
/ / t .
t
sesamoid is rarely required, however, and will
: / m.m : / / t
/.tm
. m
finger. This approach will avoid damage to branches of the superficial peroneal nerve
ss : /
significantly increase the risk of a varus deformity.
t p p t p ss : /
and first dorsal metatarsal artery.
• Expose the lateral capsule.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
b ooook b o o
eeb FIG. 1.9
ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
ss : / s : /
t t p
t p hht s
t tptp FIG. 1.10
hht
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
Sesamoid
bone
t
hhtt t
hhtt
A
k e rrss
e k e r
B
e ss
r
o o
o o k
FIG. 1.11
o o
o o k STEP 4 PEARLS
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
• A Kirschner wire placed into the metatarsal
head under fluoroscopic guidance will help
: / / t
/ m
.t.m : / / t
/ m
.t.m
ensure that the osteotomy cuts are parallel to
the joint line. The wire and cuts can be angled
Step 4
t p ss:
p / t p ss:
p / slightly distally or proximally if lengthening or
shortening of the metatarsal is needed.
t
hht t t
hht t
• Place a Weitlaner retractor or lamina spreader between the first and second meta-
tarsals.
• The long plantar arm prevents damage to the
primary blood supply to the metatarsal head,
which is plantar lateral.
• Locate the lateral sesamoid and incise the capsule with a horizontal cut just dor-
sal to the sesamoid (Fig. 1.10).
k e e s
rs neath the metatarsal head (Fig. 1.11).
k eers
• Free up the sesamoid proximally and distally so that it can later be reduced be-
r rs STEP 4 PITFALLS
o o
o o k oo k
• The flexor hallucis longus runs just medial to the sesamoid, and care should be taken
o o o
• An osteotomy angle of <70° will produce
o either an excessively long plantar arm or a
eebb e / b
e b
to not injure the tendon during this part of the procedure (see Fig. 1.4).
/ e
• Release the adductor attachment onto the sesamoid and proximal phalanx (Fig.
e ee/e/ebb dorsal arm that does not leave sufficient bone
for the compression screw.
: / / t
/ .
tm.m : / / t
/.tm
. m
1.12). Avoid further dissection of the lateral capsule, which can compromise blood • Avoid damaging the vascular leash that runs
in the first metatarsal space by gently cutting
t p ss
p : /
supply to the metatarsal head (see Fig. 1.5A).
t p ss : /
• Division of the transverse metatarsal ligament is usually not required (Fig. 1.13).
p
through the lateral cortex.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
8 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / Release of
ss :
adductor attachment
t p p / Web space
t
hht t t
hht t incision
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / ss : /
First metatarsal
tp p
t
hht t t
hht t Second metatarsal
A B
FIG. 1.12
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t
FIG. 1.13
t
hht t FIG. 1.14
Step 5
k e r
e s
rs k eers
rs
• Perforate (chicken hatch) the lateral capsule at the level of the joint with a scalpel
o o
o o k oo k
blade (Fig. 1.14).
o o oo
eebb ee/ e
/ b
e b e /e/ebb
• While holding the metatarsal heads together, bring the toe into varus until the cap-
sule ruptures. This usually occurs with a definitive pop (Fig. 1.15).
e
: / / t
/ .
tm.m : / / t
/.tm
. m
• At this point, the lateral sesamoid should easily reduce when the first and second
t p ss
p : / t p ss
p : /
metatarsals are compressed together.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b o ook
o b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : /
tp
FIG. 1.15
pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
A B
k e rrss
e k e rrss
e
FIG. 1.16
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e bSTEP 6 PEARLS
: / / t
/ m
.t.m : / / t
/ m
.t.m • The metatarsal head can be displaced up
t p ss:
p / t p ss:
p / to one half of its width without the risk of
an unstable construct. The exact amount
Step 6
t
hht t t
hht t
• With a marking pen, outline a V-shaped chevron osteotomy in the metatarsal
of displacement, therefore, depends on the
width of the head. A smaller head may only
tolerate 3 mm of displacement, whereas the
head (Fig. 1.16). The apex should be at least 1 cm proximal to the joint line.
larger head of a man may be displaced up to a
The plantar limb of the osteotomy is approximately twice the length of the short
centimeter.
dorsal limb. The apex of the chevron is just dorsal to the longitudinal axis of the
k e r
e ss
metatarsal.
r k eers
rs
• The angle is between 70° and 80°. Under cool saline irrigation, use the microsagittal
o o
o o k saw to cut through the head.
o o
oo k oo
STEP 6 PITFALLS
eebb ee/ e b
e b
• The plantar arm should exit proximal to the sesamoid articulation (Fig. 1.17).
/ ee/e/eb
• Great care should be taken to protect the extensor hallucis longus and the dorsal and
b • Avoid excessive pressure on the metatarsal
head. The osteotomy can fracture into the joint
plantar sensory nerves.

: / / t
/ .
tm.m : / / t
/.tm
. m
through the apex of the cut.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
10 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 1.17
b oooo k
b o o
FIG. 1.19
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
A B
k e rrss
e k e rrss
e
FIG. 1.18
o o
o o k o o
o o k o o
eebb b
Step 7
b b b
STEP 7 PEARLS
• Before using the cannulated depth gauge,
ee/ e
/ e ee/ e
/ e
• The metatarsal head is stabilized while the metatarsal shaft is pulled medially with a
: / / /
that the pin does not breach the articular m
.t.m
always directly inspect the joint to make sure
t : / / t
small towel clip (Fig. 1.18).
/ m
.t.m
t p ss:
p /
surface. Because of the curvature of the
head.
t p ss:
p /
• The head can be displaced 5–10 mm, depending on the width of the metatarsal
t
hht t
metatarsal head, the pin may appear to be
in the correct position by Fluoroscan while
actually penetrating into the joint (Fig. 1.19).
t
hht t
• If the head does not easily displace laterally, the microsagittal saw may have to be
reintroduced. The proximal-plantar portion is often not complete.
• It may be helpful to drill before measuring the • If the DMAA is high, a small (1–3 mm) oblique wedge should be excised from the
depth over the cannulated pin because this
distal aspect of the dorsal metatarsal. The blade itself resects at least 1 mm, so great
will allow the depth gauge to better sit on the
k e r
e s
rs
dorsal cortex and produce a more accurate
measurement.
k eers
care should be taken to not resect too large a wedge.
rs
o o
o o k
• Before placing the screw, make sure the Step 8
o o
oo k oo
eebb b b
metatarsal articular surface is not in a
valgus position, which can occur because
of an uncorrected DMAA, a poorly directed
ee/ / e b e /e/e b
• A 0.045-inch guide pin is placed across the osteotomy from dorsal-medial to plantar-
e lateral (Fig. 1.20). The pin should extend to, but not beyond, the articular surface.
e
osteotomy, or lateral impaction.
: / / t
/ .
tm.m : / / t
/.tm
. m
Measure the screw length using a depth gauge. The actual screw used is usually 2–4
t p ss
p : / t p ss : /
mm shorter to avoid penetration of the joint as the bone pieces compress.
• Check the pin and metatarsal head position by Fluoroscan.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 1.20
b oooo k b o o
FIG. 1.22
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t
hhtt
t
hhtt
B
FIG. 1.21
STEP 9 PEARLS
k e rrss
e k e rrss
e • If hallux interphalangeus causes the great toe
o o
o o k o o
o o k o o
to impinge on the second toe, a closing wedge
osteotomy of the proximal phalanx may be added
eebb ee/ e
/ b
e b ee/ e
/ b
e b (Fig. 1.26). Keep the lateral cortex intact and only
remove 1–2 mm of bone. Fix the osteotomy with
Step 9
: / / t
/ m
.t.m : / / t
/ m
.t.m a small 2.4-mm cannulated screw.
t p ss:
p / t p ss:
p /
• Drill only the hard dorsal cortex of the metatarsal. No further drilling is required for
t
hht t t
hht t
the self-drilling/tapping screw system. Place an appropriately sized miniscrew (Figs.
1.21 and 1.22). Holding the osteotomy closed with a small towel clip or manual axial
STEP 9 PITFALLS
• Inadequate bony correction may lead a
compression will help obtain maximal compression during introduction of the screw. surgeon to overtighten the medial capsule in
• Smooth down the prominent medial metatarsal with a microreciprocating rasp an effort to bring the toe out of valgus. This
can cause postoperative stiffness of the joint.
k e r
e s
r
(Fig. 1.23).
s k eers
rs
• Excise redundant portions of the joint capsule (Fig. 1.24). Vertical cuts in the cap-
o o
o o k oo k
sule, just proximal to the joint line, can be used to tighten the capsule (Fig. 1.25).
o o oo
eebb b b CONTROVERSIES
e / / e b
Use an absorbable 2-0 suture. Derotate the toe out of pronation while the capsule is
e
repaired. Place the joint through a range of motion (ROM).
e ee/e/e b • Various capsular incisions are possible,
: / / t
/ .
tm.m : / / /.tm
• Release the tourniquet. Achieve meticulous hemostasis and close with a few 4-0
t . m including L-shaped incisions with dorsal or
plantar cuts, or Y-cuts. No capsular incision
t p ss
p : /
Vicryl subcutaneous sutures and 4-0 nylon in the skin.
t p ss : /
• Apply a bunion spica splint, holding the toe in a slightly overcorrected position.
p
has been shown to be superior.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
12 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eer
A
s
rs k er
erss B
b ooook b o o
o o kFIG. 1.23
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 1.24
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
A
t p ss
p : / B
t p ss
p : /
t
hht t t
hht
FIG. 1.25
t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eer
A
s
rs k er
erss B
b ooook b oo oo k FIG. 1.26

b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
A B
FIG. 1.27
FIG. 1.28
k e rrss
e k e rrss
e
o o
o k
POSTOPERATIVE CARE AND EXPECTED OUTCOMES
o o o
o o k o o
eebb ee e
/ b
e b
• The patient remains non–weight bearing until the first clinic visit, 10–12 days postop-
/ ee/
eratively. At that time, the sutures are removed and a spica wrap of Kling and Cobane
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
is applied, with slight abduction and supination of the toe (Fig. 1.27). AP and lateral POSTOPERATIVE PEARLS
t p ss:
p / t p ss:
p /
radiographs in the dressing confirm the position. At this point, the patient can use
a postoperative shoe or cast boot to start weight bearing as tolerated. The superb
• The rigid fixation obtained by the Acutrak
t
hht t
fixation of the osteotomy allows early weight bearing. t
hht
• The patient starts ROM of the toe within the toe spica dressing.
t screw allows early ROM and markedly
diminishes postoperative pain and swelling
compared with procedures that do not use
rigid internal fixation.
• Every 7–10 days the dressing is changed. The radiographs are repeated at the third
• Some recurrence of hallux valgus may occur,
postoperative visit. The patient is allowed to apply an Ace bandage spica starting depending on the patient’s ultimate postoperative
k e r
e s
rs
started at this point.
k eers
4 weeks after surgery. If the toe is stiff, which is unusual, physical therapy can be
rs footwear. Hallux varus, avascular necrosis of the

metatarsal head, and malunion are also known
o o
o o k oo k
• A shoe with a wide toe box is used at 6 weeks postoperatively, with tighter fitting shoes
o o oo
complications. Patients who have mild arthritic
changes in the joint may also experience some
eebb ee / b
e b
allowed 4 weeks later. The patient should use a spacer (silicone or folded Webril) in
/ e e /e/ebb
the first web space until 10 weeks after surgery. AP (Fig. 1.28A) and lateral (Fig. 1.28B)
e
chronic discomfort. These problems are unusual,
however, with the vast majority of patients
: / / / .
tm m : / / /.
radiographs confirm an appropriate correction and healing of the osteotomy.
t . t tm
. m reporting long-term satisfaction. Persistent
swelling and joint stiffness are probably the two
t p ss
p : / t p ss :
See also Video 1.1, Hallux Valgus Correction With Modified Chevron Osteotomy.
p / most common complaints. Early ROM helps avoid
t
hht t t
hht t both of these problems.
t t p
t ss:
p t t p
t ss:
p
14 hht
EVIDENCE
k e r
e s
rs rs
r s
Buciuto R. Prospective randomized study of chevron osteotomy versus Mitchell’s osteotomy in hallux
k ee
valgus. Foot Ankle Int 2014;35(12):1268–76.
o o
o o k o oo k o
A prospective study that compares the Mitchell and chevron osteotomies. Results were superior
o o
eebb bb b b
with the chevron osteotomy (Level I evidence).
ee/ e
/e e / e
/ e
Jeuken RM, Schotanus GM, Kort NP, Deenik A, Jong B, Hendrickx R. Long-term follow-up of a rand-
e
: / / t
/ .
t m
. mInt 2016;37(7):687–95.
: / / t
/ t m
omized controlled trial comparing scarf to chevron osteotomy in hallux valgus correction. Foot Ankle
. . m
t p ss
p : / dence).
t p ss
p : /
The chevron and scarf osteotomies had comparable results at 14-year follow-up (Level II evi-
t
hht t t
hht t
Malal JJG, Shaw-Dunn J, Kumar CS. Blood supply to the first metatarsal head and vessels at risk with a
chevron osteotomy. J Bone Joint Surg Am 2007;89:2018–22.
This study confirms that a chevron with a long plantar limb will diminish risk of injury to the major
blood supply to the head, which is plantar lateral.
Mitchell LA, Baxter DE. A chevron-Aiken double osteotomy for correction of hallux valgus. Foot Ankle
k eers
rs
1991;12:7–14.
k er
erss
A series of patients with hallux valgus and concomitant hallux interphalangeus (Level IV evidence).
b ooook ooook
Nery C, Barroco R, Ressio C. Biplanar chevron osteotomy. Foot Ankle Int 2002;9:792–8.
o o
Thirty-two patients with a DMAA of >8° had a biplanar chevron osteotomy. The hallux valgus angle
b b
eeb e / e
/ e b
(Level IV evidence).
e ee/ e
/ e b
was improved from an average of 25° to 14°, the IMA from 12° to 8°, and the DMAA from 15° to 5°
: // t/.tm
. m / /t/.tm. m
Shi G, Henning P, Marks RM. Correlation of postoperative position of the sesamoids after chevron
osteotomy with outcome. Foot Ankle Int 2016;37(3):274–80.
:
t p ss
p : / ss : /
Combining distal web space release with a distal chevron osteotomy did not delay healing or in-
tp p
t
hht t t t
crease risk of avascular necrosis of the metatarsal head, but it did not significantly improve angular
hht
measurements or sesamoid position (Level III evidence).
Trnka HJ, Zembsch A, Easley ME, et al. The chevron osteotomy for correction of hallux valgus: com-
parison of findings after two and five years of follow-up. J Bone Joint Surg Am 2000;82:1373–8.
This study followed 66 feet for 5 years after a chevron correction for hallux valgus. Between
the 2-year and 5-year follow-up evaluations, there was only a minimal change in overall patient
keerrss keerrss
satisfaction, and the average score on the hallux-metatarsophalangeal-interphalangeal scale was
unchanged (Level IV evidence).
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh2t
PROCEDURE hht
Scarf
rssOsteotomy for Correction rofssHallux Valgus
kkee r
ooHans-Jörg Trnka and Peter Bock k
oo e
ke r
b
eeboo / e bboo / e b o
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht
Objective Indications
• Moderate to severe hallux valgus deformities with
hht
INDICATIONS PITFALLS
• Increased hallux valgus angle (HVA) ≤50°
• Severe metatarsus primus varus deformity
• Increased intermetatarsal angle (IMA) ≤20°
k eers
rs k er
er
• Increased distal metatarsal articular angle (DMAA) ≤10°ss (IMA > 20°)
• Increased medial slope of the first
b ooook b ooook
• Hallux valgus revision surgery for recurrence (Bock, 2009)
• Bunionette deformity of fifth metatarsal (type 3, increased fourth–fifth IMA)
b o o
tarsometatarsal articular surface (higher risk of
recurrence)
eeb ee/ e
/ e b /
• Modular corrections are feasible via the great versatility of the Scarf osteotomy
ee e
/ e b • Increased DMAA
• Hypermobile first tarsometatarsal joint
// t/ tm
• Lateralization of head-shaft fragment to reduce IMA
. . m
• Transverse plane rotation to correct increased DMAA
: : / /t/.tm. m (ligamentous laxity)
ss : /
• Plantar displacement to increase first ray load
t p p tp pss : / • Symptomatic osteoarthritis of first
metatarsophalangeal joint (1MTP) joint
t
hht t
• Shortening in cases of long metatarsal t
hht t
• Elongation in cases of short metatarsal (congenital, iatrogenic) • Reduced bone mineral density (severe
osteoporosis)
• Rheumatoid arthritis
• Dorsal displacement to decrease first ray or sesamoid load
• Medialization of first metatarsal head (1MTH) in cases of hallux varus
kee rs
Examination/Imaging
r s
Physical Examination
keerrss CONTROVERSIES
b ooook b ooook
• Palpation and range of motion (active and passive) of hindfoot, midfoot, and forefoot
b oo • Other techniques exist for operative correction
eeb joints
ee/e/e b
• Alignment of great toe (an additional Akin osteotomy might be necessary)
ee/e/e b of mild to moderate hallux valgus deformities
(Easley and Trnka, 2007)
/ t m
.t.m
• Clinical assessment of first ray hypermobility
: / / : / / t
/ m
.t.m • Distal procedures: Chevron, Kramer,
Boesch
• Posture of foot, presence of plantar callosities, bursal or skin irritation at bunion • Proximal procedures: crescentic metatarsal
t
hhtt t
hhtt
• Tightness of gastrocnemius-soleus (assessed with flexed and extended knee, foot
maintained with talonavicular joint reduced to eliminate transverse tarsal or subtarsal
motion)
osteotomy, Ludloff osteotomy, proximal
closing wedge osteotomy, proximal opening
wedge osteotomy
• Combined procedures: double/triple
• Pedobarography osteotomies
k rrss
Radiographic Assessment
e e k e rrss
e
• Standard weight-bearing anteroposterior and lateral radiographs
o o
o o k o o o k
• Evaluate (Fig. 2.1) HVA, IMA, and DMAA hallux interphalangeal angle
o o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m Hallux valgus
interphalangeus
HVA
t p ss:
p / t p ss:
p /
t
hht t t
hht t
DMAA
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb b b
IMA
ee/ e
/ e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss : /
FIG. 2.1 DMAA, Distal metatarsal articular angle; HVA, hallux valgus angle; IMA, intermetatarsal angle.
p
t
hht t t
hht t 15
t t p
t ss:
p t t p
t ss:
p
16 hht
PROCEDURE 2 Scarf Osteotomy for Correction of Hallux Valgus hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eer
As
rs er
erss B
ook okk
b
eeboo e b o
b o o FIG. 2.2
e b o
b o
m ee/ / e m ee/ / e
: ///t/.t. m : / /
/t/.t . m
t t p
t ss
p : t tptpss :
hht hht
keerrss FIG. 2.3

keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt hht tt
FIG. 2.4
k e rrss
e k e rrss
e
o o
o o k
o o o k o
• Articular shape (curved, chevron, or flat) and congruency of the 1MTP joint
o o
eebb

ee e
/ b
e b
• Evidence of arthritic changes
ee/ e
/ b
e b
• Metatarsal index (length of first metatarsal in comparison with second metatarsal)
/
: / / t m
.t.m ANATOMY
SURGICAL
/ : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• Vascular supply of first metatarsal (Figs. 2.2 and 2.3)
t
hht t t
hht t
• Dorsal and plantar metatarsal artery
• Superficial branch of the medial plantar artery
• Extensive network on the dorsal and lateral capsular aspects
• Nerve supply to the first metatarsal (Fig. 2.4)
k e r
e s
rs k eers
• Superficial peroneal nerve
rs
• Deep peroneal nerve
o o
o o k oo k
• Distal branch of the saphenous nerve
o o oo
eebb e / e
/ b
e b
• Lateral soft tissues to be released
e ee/e/ebb
• Dorsal and plantar sensory nerve branches around first metatarsal
: / / t
/ .
tm.m : / / t
/.tm
. m
• Lateral suspensory and anterior fibular sesamoid ligaments
t p ss
p : / • 1MTP joint capsule
t p ss : /
• Lateral collateral ligament
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 2 Scarf Osteotomy for Correction of Hallux Valgus 17
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 2.5
k er
erss
b ooook b oooo k
b o o FIG. 2.6
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
POSITIONING
t p ss
p : / tp ss
p : /
t
hht t
• Supine position t
hht t
• Heel at the edge of table
• Standardized prepping and draping of the foot
• Tourniquet is generally not needed
keerrss keer
• At the level of the ankle in case of local anesthesia
rss
ANESTHESIA PEARLS
• Application of 3 mL benzodiazepine prior to
b ooook b ooook
• At the thigh in case of general or spinal anesthesia
b oo the ankle block reduces the pain sensation of

the patient.
eeb Anesthesia
ee/e/e b
• Local ankle block (tibial nerve, superficial and deep peroneal nerve)
ee/e/e b
• General anesthesia (rarely used)
: / / t
/ m
.t.m : / / t
/ m
.t.m PORTALS PEARLS
Portals/Exposures
t ppss : / t ppss : / • To perform an additional Akin osteotomy
•
t
hhtt t
hhtt
Make a medial longitudinal incision across the 1MTP joint, running from the
proximal half of the proximal phalanx to the proximal third of the first metatarsal
(proximal medial closing wedge osteotomy of
the great toe), the incision has to be extended
more distally.
(Fig. 2.5).
• Expose the capsular structures, paying attention not to injure the plantar and dorsal
STEP 1 PITFALLS
k erss
sensory nerve branches.
e r k e rrss
e • Care has to be taken that the vascular
o o
o o k
PROCEDURE
o o
o o k o o
insertion into the metatarsal head distal
eebb b b dorsally and plantarly at the neck of the first

Step 1
ee/ e
/ e b ee/ e
/ e b metatarsal is preserved.
: / / t
/ m
.t.m
• The capsule of the 1MTP joint is incised longitudinally (Fig. 2.6).
: / / t
/ m
.t.m
t p ss:
p /
base of the proximal phalanx, first metatarsal head, and shaft.
t p ss:
p /
• The capsule and periosteum are reflected dorsally along the medial aspect of the STEP 1 PEARLS
Step 2
t
hht t t
hht t • Preliminary careful resection of the 1MTH
pseudoexostosis facilitates the correct
positioning of the starting point of the
Z-osteotomy.
• Lateral soft-tissue release is necessary for complete repositioning of the metatarsal
head over the sesamoids.
k e s
• Accomplished through the same medial incision.
r rs e rs
rs
• In order to perform the transarticular lateral soft-tissue release properly, the capsule is el-
e k e
STEP 2 PEARLS
o o
o o k oo k
evated from the medial plantar (Fig. 2.7) and dorsal base (Fig. 2.8) of the proximal phalanx.
o o oo
• According to Schneider (Schneider, 2012),
transecting the lateral metatarso-sesamoid
eebb e / b
e b
• It is necessary to dissect the lateral sesamoid suspensory and anterior fibular sesa-
/ e
moid ligaments as well as the lateral collateral ligament.
e ee/e/ebb suspensory ligament is the key to a successful
lateral release in this model. Release of the
: / / t
/ .
tm.m : / / t
/.tm
. m
• Scissors are inserted medially into the joint just proximal to the sesamoids and deep transverse metatarsal ligament and the
adductor hallucis muscle tendon does not
ligament.
t p ss
p : / t p ss
p : /
aimed to a soft spot on the lateral capsule proximal to the metatarso-sesamoid
contribute to hallux valgus correction.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
18 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 2.7
b oooo k
b o FIG. 2.8
o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
eeb ee/e/e b FIG. 2.9
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
FIG. 2.10 FIG. 2.11
k e r
e s
rs k eers
rs
• A Beaver blade is inserted distal (Fig. 2.9) and parallel to the scissors, and the met-
atarso-sesamoid ligament (Fig. 2.10) and the lateral collateral ligament of the 1MTP
o o
o o k o oo k
are dissected.
o oo
eebb / e b b /e bb
• To demonstrate that the lateral release is sufficient, the hallux has to be placed
ee / e ee /e
into 20° of varus (Fig. 2.11). If this is not possible, the lateral release has to be
: / / t
/ .
tm.m extended.
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 2.12
b oooo k
b o o FIG. 2.13
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp p ss : /
t
hht t t
hht t
keerrss keerrss
b ooook b ooook b ooSTEP 3 PEARLS
eeb ee/e/e b ee/e/e b • Only a small portion of the medial eminence
: / / t
/ m
.t.m : / / t
/ m
.t.m
should be excised. The wider the head is
after the resection, the more first metatarsal
t ppss : / t ppss : / head can be shifted laterally, allowing greater

correction of the IMA angle.
t
hhtt t
hhtt
STEP 4 PITFALLS
FIG. 2.14
• The guidewires are not parallel
k e rrss
e k e rrss
e
• If the guidewires are divergent inserted the
cuts are not parallel and thus the plantar
o o
o o k o o
o o k o o
fragment cannot be displaced.
• The osteotomy is more unstable if the
eebb Step 3
ee/ e
/ b
e b ee/ e
/ b
e b guidewires are placed convergent, and with
this the cuts are convergent.
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The medial eminence is minimally resected with a microsagittal saw blade. This cut • If the longitudinal cut is not done from distal
dorsal to plantar proximal but in the midline of
t p ss:
p / t p ss:
p /
is medial to the sagittal sesamoid groove; it should only be a reference for the distal
the metatarsal shaft, the risk for “troughing” is
Step 4
t
guidewire of the z-type osteotomy.
hht t t
hht t more likely.
• If the proximal guidewire is placed too dorsally
and consequently the proximal osteotomy goes
• A 1.0- to 1.2-mm Kirschner guidewire is placed at the upper one third of the resected too dorsally on the first metatarsal shaft, the
risk of proximal stress fracture is increased.
medial eminence (Fig. 2.12). This wire is directed to the fourth metatarsal head with
k e e s
a plantar declination between 15° and 20° (Fig. 2.13).
r rs k eers
rs
• A second pin marking the proximal edge of the z-cut is placed at the plantar medial
o o
o o k o o
oo k
edge of the metatarsal parallel to the first guidewire approximately at the border of
oo
STEP 4 PEARLS
eebb ee / b
e b
the middle and proximal third of the first metatarsal (Fig. 2.14). This will lead to a
/ e e /e/
more oblique longitudinal cut of the metatarsal. The larger the IMA angle, the longer
e ebb • A Scarf osteotomy cutting guide can be used
to place the guidewires.
: / / / .
tm m
the distance between the guidewires is needed.
t . : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
20 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 2.15
b oooo k
b o o FIG. 2.16
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t pp s:
s / ps
t p s : /
t
hhtt FIG. 2.17
t
hhtt FIG. 2.18
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
STEP 5 PITFALLS
t
hht t
• As the longitudinal cut is made through the
shaft in a lateral direction, careful attention is
t
hht t
paid to avoid burying the saw blade into the
intermetatarsal space, thus preserving the vital
structures in this area.
k e r
e s
rs k r
ee s
rs FIG. 2.19
o o
o o k o o
oo
Step 5 k oo
eebb b b
STEP 6 PITFALLS
• In osteoporotic bones, the squeezing effect
ee/ e
/ e b e /e/e b
• After placing two Hohmann retractors, the proximal (Figs. 2.15 and 2.16) and distal
e
of a reduction bone clamp may facilitate
/
troughing. In these cases we recommend
: / t
/ .
tm.m : / / t
/.tm
. m
vertical (Figs. 2.17 and 2.18) cuts of the osteotomy are performed using a reciprocat-
ss : /
preliminary fixation with two Kirschner wires.
t p p
ing saw (Fig. 2.19).
t p ss : /
• The osteotomy is finished by performing the horizontal cut (Figs. 2.20 and 2.21).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 2.20
b oooo k
b o o FIG. 2.21
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t pps :
s / t s
pp s : /
t
hhtt
FIG. 2.22
t
hhtt
FIG. 2.23
INSTRUMENTATION/IMPLANTATION
• Two guidewires for the screws are placed from
dorsal to plantar (Fig. 2.23). The distal one
rrss rrss
is either directed into the metatarsal head or
o k e
k e o k e
k e
straight from dorsal to plantar.
• Using the small bone innovation (SBI) AutoFIX
o
eebb o o e b o
b o o e b o
b o screws, the countersink (Fig. 2.24) is used,
and after length measurement the screws are
Step 6
m ee/ / e m ee/ / e inserted flush with the dorsal cortex.
: / /
/ t
/ .t.m : / /
/ t
/ .t.m • Any redundant bone at the medial aspect of the
first metatarsal head and shaft is removed and
t t p
t ss:
• The osteotomy is now mobile.
p
• A small bone clamp is placed on the dorsal shaft (Fig. 2.22).
t t p
t ss:
p
smoothed with an oscillating saw (Fig. 2.25).
hht hht
• While grabbing the clamp with the middle and ring finger, the dorsal metatarsal is
pulled medially. The plantar fragment is pushed laterally with the index finger.
STEP 7 PEARLS
• A weight-bearing situation is simulated to
• The plantar fragment is displaced laterally as much as possible until resistance is
assess the final position of the hallux before
encountered. capsular closure. If there is a remaining valgus
• Final corrections of the DMAA ≤10° are feasible by rotation of the plantar fragment
k e r
e s
rsduring the lateral displacement.
k eers
rs deviation of the hallux, an additional Akin
osteotomy is performed.
o o
o o k oo k
• With axial compression the osteotomy fragments become wedged and the oste-
o o oo
eebb b b STEP 7 PITFALLS
e / / e b
otomy is initially stable. The guidewires can be immediately inserted to secure the
e
position of the correction (for position, see Step 7).
e ee/e/e b • Visual control of the position of the distal and
Step 7
: / / t
/ .
tm.m : / / t
/.tm
. m proximal screws is mandatory as overlength
might irritate the sesamoid apparatus or the
t p ss
p : / t p ss : /
• The osteotomy is fixated with two Herbert-type screws (see Figs. 2.14 and 2.19).
p
flexor tendons, respectively.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
22 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 2.24
b oooo k
b o o FIG. 2.25
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
FIG. 2.27
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t pps s : / t ppss : /
t
hhtt
FIG. 2.26
t
hhtt FIG. 2.28
STEP 8 PITFALLS
Step 8
• Although tensioning of the repair is important
• Closure and reefing of the joint capsule is accomplished with three 1-0 absorbable
to correct the deformity, it should not cause a
k e rrss
postoperative hallux varus. The final bandage
e
should not be another attempt at correction.
k eerrss
sutures that are placed in a U-type fashion placed medially (Fig. 2.26).
• Redundant portions of the joint capsule are resected.
o o
o o k
• Proximal stress fractures: the proximal vertical cut
o oo k o
• The wound is closed with 3-0 absorbable intracutaneous or 3-0 nonabsorbable sutures.
o o
eebb of the osteotomy should not exceed the plantar
/
third of the metatarsal shaft (Figs. 2.27 and 2.28).
ee e
/ b
e b ee/ e
/ b
e b
• The forefoot is bandaged with the great toe in slight adduction.
• Troughing (i.e., an impaction of the two
: / t
osteotomy fragments), resulting in functional
/ / m
POSTOPERATIVE
.t.m CARE AND EXPECTED OUTCOMES
: / / t
/ m
.t.m
t ss:
p /
elevation with or without rotation of the first
p
ray (Figs. 2.29 and 2.30): the longitudinal cut
t p ss:
p
surgery (Fig. 2.32). /
• Clinical appearance presurgery (Fig. 2.31) compared with clinical appearance post-
t
hht t
should not be horizontal in the middle of the
metatarsal, it should be from distal dorsal to
t
hht t
• The bandage (Fig. 2.33) is replaced by a special postoperative hallux valgus sock
(Fig. 2.34) at 2 weeks after suture removal.
plantar proximal.
• Prominent hardware interfering with sesamoid • The patient is allowed to walk fully weight bearing from the beginning, using a post-
bones: need to visualize the length of the distal operative hallux valgus shoe (Fig. 2.35) with a rocker bottom sole (Schuh, 2010) for 4
k e r s
implant.
rs
• Avascular osteonecrosis of the first metatarsal
e e rs
weeks; after that a comfortable sneaker is recommended.
rs
• The patient is instructed to increase the duration of walking activities according to
k e
o o
o o khead: the insertion of the dorsal and plantar
blood-supplying vessels has to be preserved.
o o
oo k the residual amount of pain and swelling.
oo
eebb • Postoperative joint stiffness: at 4 weeks intense
physiotherapy is mandatory to achieve good range
ee/ e
/ b
e b e / /ebb
• Four weeks following surgery, radiographs are taken to confirm maintenance of fixa-
e
tion and sufficient consolidation of the osteotomy (Figs. 2.36, 2.37, and 2.38).
e
/ / t
/ .
t
• Hallux varus: lateral soft-tissue release and
: m
of motion and normal gait pattern (Schuh, 2010).
.m : / / t
/.tm
. m
• At 4 weeks after surgery physiotherapy, with 4–6 appointments on average, is per-
ss :
capsular suture must be balanced—do not
t p p / t p ss : /
formed (Schuh, 2010).
• Running activities and high impact sports are allowed 10 weeks after surgery.
p
t t
excise the lateral sesamoid bone.
hht t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t

FIG. 2.30
k eers
rs FIG. 2.29
k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss

: / /
FIG. 2.31
t
/ m
.t.m
/
FIG. 2.32
: / t
/ m
.t.m
t ppss : / t p s
p s : /
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
FIG. 2.34
o o
o o k o oo
o k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t
FIG. 2.33
t
hht t
t t p
t ss:
p t t p
t ss:
p
24 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 2.35
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ps s : /
t
hht t t
hht t FIG. 2.36
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb b b
FIG. 2.37 FIG. 2.38
ee/ e
/ e b ee/ e
/ e b
: / / / m
.t.m
EVIDENCE
t : / / t
/ m
.t.m
t p ss:
p / t p ss: /
Bock P, Kluger R, Kristen KH, Mittlbock M, Schuh R, Trnka HJ. The Scarf osteotomy with minimally
p
t
hht t t
hht t
invasive lateral release for treatment of hallux valgus deformity: intermediate and long-term results.
J Bone Joint Surg Am 2015;97:1238–45.
Of 108 patients (115 feet) who underwent a Scarf osteotomy, 93 patients (93 feet) were examined at
an average duration of follow-up of 124 months. Clinical examination before surgery and at the time
of final follow-up included an evaluation of range of motion, pain as measured with a visual analog
scale, and American Orthopaedic Foot and Ankle Society (AOFAS) scores. The median overall
k e r
e s
rs k eers
rs
AOFAS score improved from 57 points preoperatively to 95 points at the time of final follow-up. All
radiographic measurements (HVA, IMA, DMAA, and sesamoid bone position) showed significant
o o
o o k oo k
(P < .05) improvement at the time of final follow-up compared with preoperatively. The rate of recur-
o o oo
eebb b b
rence (an HVA of ≥20°) at the time of final follow-up was 30%; it could not be determined if recurrence
ee/ e
/ e b ee/e/e b
resulted in functional impairment or consequences for quality of life (Level IV evidence [case series]).
Bock P, Lanz U, Kröner A, Grabmeier G, Engel A. The Scarf osteotomy. A salvage procedure for recur-
: / / t
/ .
tm.m : / / t. m
. m
rent hallux valgus in selected cases. Clin Orthop Relat Res 2010;468:2177–87 (Level IV evidence
/ t
t p ss
p : / [case series]).
t p ss : /
The authors investigated whether the Scarf osteotomy could reduce pain, improve the AOFAS
p
t
hht t t
hht t
score, reduce the deformity, and prevent further recurrence when used as a revision procedure.
t t p
t ss:
p t t p
t ss:
p
hht hht
With a minimum follow-up of 24 months, it could be demonstrated that the Scarf as a revision pro-
cedure clinically and radiographically corrected recurrent hallux valgus deformity in most patients.
k e r
e s
rs k eers
r s
Coetzee JC. Scarf osteotomy for hallux valgus repair: the dark side. Foot Ankle Int 2003;24:29–33.
o o
o o k o oo k
Twenty patients were followed, and multiple potential pitfalls were observed, the most common of
o
which was “troughing” of the metatarsal with loss of height (35%). Forty-five percent were unsatis-
o o
eebb fied at 1 year (Level IV evidence [case series]).
e / e
/ebb e /
Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot
e e e
/ b
e b
Ankle Int 2007;28:759–77.
: / / t .
t m
. m : / / t .
t m
. m
A comprehensive evaluation of physical examination and radiographic data, important for deci-
/ /
ss : / ss : /
sion making in bunion surgery, based on a postoperative follow-up study in 103 patients (Level V
t p p t p p
t
evidence [expert opinion]).
hht t t
hht t
Deenik A, van Mammeren H, de Visser E, de Waal Malefijt M, Draijer F, de Bie R. Equivalent correction
in Scarf and Chevron osteotomy in moderate and severe hallux valgus: a randomized controlled trial.
Foot Ankle Int 2009;29:1209–15.
Followed 136 feet, which were classified as exhibiting mild, moderate, or severe IMA and underwent 66
Scarf and 70 Chevron osteotomies. Chevron osteotomy is at least as effective as Scarf osteotomy in
k ee s
rs k er
ers
correction of HVA and IMA. Scarf seems to have a higher incidence of chronic regional pain syndrome,
r s
Chevron a higher incidence of avascular necrosis. There is no significant difference in secondary 1MTP
b ooook ooook
joint subluxation (19%) between the two groups (Level I evidence [prospective randomized study]).
o o
Easley ME, Trnka HJ. Current concepts review: hallux valgus part II: operative treatment. Foot Ankle Int
b b
eeb 2007;28:748–58.
ee/ e
/ e b ee/ e
/ e b
Overview of distal (simple bunionectomy, distal soft-tissue procedure, Chevron osteotomy, Keller
: // /.tm
. m : / /t/.tm. m
resection arthroplasty) and proximal first metatarsal procedures (crescentic osteotomy, proximal
t
Chevron osteotomy, opening and closing wedge osteotomies, Ludloff oblique osteotomy, Scarf
ss : / ss : /
osteotomy, first tarsometatarsal joint arthrodesis, double/triple osteotomies and first MTP joint
t p p tp p
t t t t
arthrodesis). Clinical, radiographic, and biomechanical aspects are discussed. Levels of evidence
hht hht
and grades of recommendation are assessed, based on published articles on these different pro-
cedures (Level V evidence [expert opinion]).
Schneider W. Influence of different anatomical structures on distal soft tissue procedure in hallux valgus
surgery. Foot Ankle Int 2012;33(11):991–6.
Transecting the lateral metatarso-sesamoid suspensory ligament was the key to a successful
keer ss keerrss
lateral release in this model. Release of the deep transverse metatarsal ligament and the adductor
r
hallucis muscle did not contribute to hallux valgus correction. The authors believe that the lateral
b ooook b ooook
short sesamophalangeal ligament and the plantar attachment of the articular capsule should be
preserved to minimize the risk of possible joint instability.
b oo
Schuh R, Hofstaetter SG, Adams Jr SB, Pichler F, Kristen KH, Trnka HJ. Rehabilitation after hallux
valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the
stance phase. Phys Ther 2009;89:934–45.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss / t ppss : /
Thirty patients who underwent Austin (n = 20) and scarf (n = 10) osteotomy for correction of mild to
:
moderate hallux valgus deformity were included in this study. Four weeks postoperatively they re-
t
hhtt t
hhtt
ceived a multimodal rehabilitation program once per week for 4 to 6 weeks. Plantar pressure analy-
sis was performed preoperatively and at 4 weeks, 8 weeks, and 6 months. The results suggest that
postoperative physical therapy and gait training may lead to improved function and weight bearing
of the first ray after hallux valgus surgery.
Schuh R, Adams S, Hofstaetter SG, Krismer M, Trnka HJ. Plantar loading after Chevron osteotomy
combined with postoperative physical therapy. Foot Ankle Int 2010;31:980–6.
k rrss
e k rrss
The results suggest that postoperative physical therapy and gait training with a Chevron osteotomy
e e e
may help to improve weight bearing of the great toe and first ray.
o o
o o k o o o k o
Schuh R, Trnka HJ, Sabo A, Reichel M, Kristen KH. Biomechanics of postoperative shoes: plantar pres-
o o
eebb Surg 2011;131:197–203.
ee/ e
/ b
e b ee/ e
/ b
e b
sure distribution, wearing characteristics and design criteria: a preliminary study. Arch Orthop Trauma
: / / t
/ m : / / t m
The Rathgeber modified model revealed the most favorable results concerning plantar pressure
.t.m .t.m
distribution and subjective wearing characteristics. After adding an extra layer of high elastic and
/
t ss:
p / t p ss:
p /
springy material for shock absorption at the hallux region, forefoot relief and wearing characteris-
p
tics showed improved results. The results of the present study indicate that damping material in the
t
hht t t
hht t
hallux region of postoperative shoes minimizes stress in this region and improves patient’s comfort.
Stamatis ED, Huber MH, Myerson MD. Transarticular distal soft-tissue release with an arthroscopic
blade for hallux valgus correction. Foot Ankle Int 2004;25:13–8.
The use of a flexible curved arthroscopic Beaver blade allows for complete release of the lateral
sesamoid ligament, lateral 1MTP capsule, and the adductor insertion onto the proximal phalanx.
k e e s
rs k eers
Lacerations of the lateral head of the flexor hallucis brevis tendon occurred in 6% of the speci-
r rs
mens. There were no injuries to the first web space neurovascular bundle, nor to the 1MTH carti-
o o
o o k
lage (Level V evidence [expert opinion, technique tip]).
o o
oo k
Weil LS. Scarf osteotomy for correction of hallux valgus. Foot Ankle Clin 2000;5:559–80.
oo
eebb e e
/ b
e b e /e
A comprehensive representation by one of the most expert DPM’s, popularizing the use of the
/ /ebb
Scarf osteotomy, especially in Europe, since 1984. Scarf bunionectomy is a technically demanding
e e
/ / / .
tm.m /
outcome for both surgeon and foot surgeon (Level V evidence [expert opinion]).
: : / t
/.tm
. m
procedure that has a long learning curve. Once mastered, it provides a predictable and satisfying
t
ss : / ss : /
These and the favorable results from numerous other case series support a grade B recommenda-
t p p t p p
t
hht t t
hht t
tion for the use of the Scarf osteotomy in the treatment of hallux valgus.
t t p
t ss:
p t t p
t ss:
p
hh3t
PROCEDURE hht
HalluxrssValgus Correction With Metatarsal
rs s
k ee
Opening
o k r Wedge and Proximal o k ee r
Phalangeal
k
b oo o
eeb Osteotomies e bboo o e b o
b o
ee/ /e ee/ / e
.m
m : / /
/ t
/ t . : / /
/ t
/ .
t m
. m
Glenn B. Pfeffer ttpt ss
p : t t p
t ss
p :
hht hht
k eers
rs
• Moderate to severe arthritic changes of the
INDICATIONS
k er
erss
b ooook joint are a contraindication to hallux valgus
surgery.
b ooook
• Painful hallux valgus deformity
• Failure of shoe modification
b o o
eeb • Blood supply to the foot is compromised.
• Ulceration over the bunion prominence needs
ee/ e
/ e b ee/ e
/ e b
• Symptoms that interfere with daily activities
to be treated prior to surgery.
: // t/.tm
. m / /t/ tm
• A moderate to severe bunion deformity, with an intermetatarsal angle of ≥13°
. . m
• Hallux interphalangeus (HI) that causes great toe impingement on the second toe
:
t p ss : /
• A first tarsometatarsal (TMT) joint is
hypermobile and requires a Lapidus fusion.
p tp pss : /
INDICATIONS CONTROVERSIES
t
hht t t
Examination/Imaging
hht t
• Examine the weight-bearing foot (Fig. 3.1).
• Examine the interphalangeal joint to determine if an HI is present.This is best appre-
• An opening wedge osteotomy may increase ciated when the interphalangeal joint is flexed.
pressure on the first metatarsophalangeal • Evaluate hypermobility of the first TMT joint, both in the sagittal and coronal
keerrs
(MTP) joint.
s keerrss
planes.
b ooook b ooook
• Pes planus may predispose to hallux valgus, but rarely requires simultaneous correc-
tion.
b oo
• Standing anteroposterior (AP) radiographs of the foot should be obtained. Measure
the 1–2 intermetatarsal, distal metatarsal articular, and hallux valgus angles. Evalu-
: / / t
/ m
.t.m : / / t m
.t.m
ate any metatarsus adductus that may spuriously narrow the intermetatarsal angle
/
measurement (Fig. 3.2).
t
hhtt t
hhtt
• Oblique views of the foot can help evaluate possible arthritic changes in the great toe
MTP or first TMT joints.
TREATMENT OPTIONS
• There are multiple techniques available to close an increased 1–2 intermetatarsal
k e rrss
e k e rrss
angle, including a closing wedge osteotomy.
e
o o
o o k o o
o o k
SURGICAL ANATOMY
o o
eebb ee/ e
/ b
e b
• See Procedures 1 and 4.
ee/ e
/ b
e b
: / / t
/ m
POSITIONING
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• The patient is in the supine position.
• A bump under the contralateral hip may improve exposure of the medial side of the
t
hht t foot. t
hht t
• The procedure is performed on an outpatient basis with a regional block.
k e r
e s
rs FIG. 3.1
k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
26 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 3 Hallux Valgus Correction With Metatarsal Opening Wedge 27
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
A B
keerrss keerrss FIG. 3.2
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o o oo k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m FIG. 3.3
: / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
Portals/Exposures
t
hht t t
hht t
• Make a longitudinal incision over the medial foot, from the mid portion of the proxi-
mal phalanx to the TMT joint (Fig. 3.3).
k e e s
rs e rs
• At the end of the case, if an Aiken osteotomy is needed, the incision may have to be
r r
extended distally to expose the proximal phalanx shaft.
k e s PORTALS/EXPOSURES PEARLS
o o
o o k oo k
• Isolate and protect the dorsal cutaneous sensory nerve.
o o oo
• Make sure that the entire incision is inferior
eebb b b enough that it will not be visible when looking
ee/ / e b e /e/e
• A small incision in the first web space is required to release the adductor, lateral
e b
• Identify the medial plantar sensory nerve to prevent injury during capsular imbrication.
e down on the foot from above. It is a more
cosmetic result.
: / / / .
tm m
capsule, and fibular sesamoid (see Procedure 1).
t . : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
28 hht
PROCEDURE 3 Hallux Valgus Correction With Metatarsal Opening Wedge hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 3.4
k r
eerss FIG. 3.5
b ooook b oooo k b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
STEP 1 PEARLS PROCEDURE
• While making the cut at the base of the
metatarsal, place lateral pressure on the Step 1
keerrss
first metatarsal head. The osteotomy will
start to open slightly as the lateral cortex is
keerrss
• Make a longitudinal incision over the medial foot, from the mid portion of the proxi-
b ooook approached with the blade.

ooookmal phalanx to the TMT joint.
oo
• Divide the capsule, excise the medial eminence of the metatarsal, make an incision
b b
in the first intermetatarsal space, free up the sesamoid, detach the adductor, and
place two 2-0 ethibond stitches from the first to the second metatarsal heads. Tag
STEP 1 PITFALLS
: / / t
/ m
.t.m : / / t m
.t.m
the ends. (See Procedure 1.)
/
p ss /
• Perforation of the lateral cortex should be
:
avoided. If it occurs, the osteotomy can be held
t p t ppss : /
• Identify the first TMT joint. A few millimeter arthrotomy to clearly identify the joint will
t
hhtt
with a Kirschner wire while the plate is applied.
An additional 3.5-mm screw may be required
across the osteotomy for added stability. It is
t
hhtt
help avoid inadvertant penetration of the joint during the osteotomy. Under fluoro-
scopic guidance make an osteotomy at the base of the first metatarsal with a micro-
sagittal saw. The cut is perpendicular to the shaft of the metatarsal, or angled slightly
extremely uncommon, however, to violate the toward the joint. Use copious cool water irrigation during the cut (Fig. 3.4).
lateral cortex if the cut is made slowly, while
checking progress with the fluoroscan. • The cut should be 12–15 mm distal to the joint line, making sure there is enough
k e rrss
e k rrss
room to fix the proximal portion of the Arthrex low-profile plate.
e e
• Cut approximately four-fifths across the metatarsal. Keep the lateral cortex intact.
o o
o o k
STEP 3 PEARLS
o o
o o k o
• Until you are accustomed to this cut, use the fluoroscan to check the progress of the blade.
o
eebb • Every millimeter of opening corrects the
intermetatarsal angle by approximately 3º.
ee/ e
/ b
e b
Step 2
ee/ e
/ b
e b
/ t
• Lateral pressure on the first metatarsal head
: / / m
.t.m : / / t
/ m
.t.m
• Once the medial to lateral cut is complete, a small osteotome can be used to gently
placement of the plate.

t ss:
p /
will create a gap at the osteotomy site to allow
p t p ss:
p /
pry open the osteotomy. This is most easily done with pressure placed on the plantar
cortex, where the bone is hardest. A crack may be heard but is invariably of no con-
t
hht t
• Place the plate as inferior as possible along
the medial shaft, so the upper edge of the
proximal plate is not prominent.
t
hht t
sequence (Fig. 3.5).
• In a patient with metatarsus adductus, the final Step 3

intermetatarsal angle may be negative a few • Once the osteotomy is loosened, the Arthrex plate can be slid in place. The most
degrees.
k e r
e s
rs k eers
commonly used size is 3.5 mm. It is very uncommon to use a plate smaller than 3
rs
mm or larger than 4 mm. The plates are marked left and right. The plate should fit
o o
o o k
STEP 3 PITFALLS
o o
oo k
snugly into the osteotomy.
oo
eebb • Overcorrection of the intermetatarsal angle can
lead to postoperative hallux varus.
ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 3.6
k r
eerss FIG. 3.7
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
STEP 4 PEARLS
• The final screw should be placed
keerrss keerrss perpendicular to the bone, not to the plate. The
plate will bend to fit the contour of the bone as
the screw is tightened (Fig. 3.7).
eeb ee/e/e b ee/e/e b • When the depth gauge is used in the final
hole, subtract 2 mm from the measured size,

: / / t
/ m
.t.m : / / t
/ m
.t.m which will account for the bend of the plate
that occurs (Fig. 3.8).
t ppss : /
FIG. 3.8
t ppss : /
t
hhtt t
hhtt
STEP 4 PITFALLS
• The two most proximal screws should not
penetrate the far cortex and enter the 1–2
intermetatarsal articulation.
k e rrss
e k e rrss
e
STEP 5 PEARLS
o o
o o k o o
o o k o
• Some of the graft material may extrude on
o
eebb b b the lateral aspect of the osteotomy. A small
ee/ e
/ e b ee/ e
/ e b amount is of no consequence.
Step 4
: / / t
/ m
.t.m : / / t
/ m
.t.m STEP 5 PITFALLS
p ss: / p ss: /
• First, place the screws that are closest to the osteotomy, followed by the most distal
t p t p • If the chips are not ground finally, a large piece
t
hht t t
hht t
screw. These should be placed perpendicular to the plate, which is flush with the cortex.
• The final screw placed is the most proximal and dorsal (Fig. 3.6).
can lodge in the V-shaped osteotomy site
and block the graft from reaching the farthest
lateral aspect.
Step 5
• Very finally ground cancellous chips are placed into the osteotomy site (Fig. 3.9). It
k e r
e s
rs k eers
rs
can take 10 minutes to grind down the chips using a small rongeur. Moisten the chips
STEP 5 INSTRUMENTATION/
IMPLANTATION
o o
o o k o o
oo k
with a few drops of water, causing them to adhere together, before packing into the
osteotomy. They are packed in tightly with a small freer elevator (Fig. 3.10).
oo
• Irrigate away any loose graft material and
eebb b b close the soft tissue over the plate with a
this during graft application. ee/ e

/ e b ee/e/e
• Try not to have any of the graft extrude laterally. A fluoroscopic image can help gauge
b running 2-0 Vicryl suture. Stop distally at the
plantar boarder of the MTP capsule.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
30 hht
PROCEDURE 3 Hallux Valgus Correction With Metatarsal Opening Wedge hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 3.9
k r
eerss FIG. 3.10
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
eeb
FIG. 3.11
ee/e/e b
ee/e/e b FIG. 3.12
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / Step 6
t ppss : /
STEP 6 PEARLS
t
hhtt
• Placement of the osteotomy can be deceptive
because of the concavity of the proximal
t
hhtt
• The hallux valgus correction should be assessed after the intermetatarsal ethibond
sutures are tied together (see Procedure 1). Simulated weight-bearing and fluoro-
phalanx. Make sure to be distal enough to scopic images should be used. If the great toe continues to impinge on the second
avoid the joint and leave sufficient bone toe, an Aiken closing wedge osteotomy is needed.
proximally to place the screw.
k rrss
• Place the screw across the osteotomy from the
e e k e rrss
• Use a microsagittal saw to make a medial to lateral cut at the proximal one-third
e
of the phalanx that is perpendicular to the axis of the bone. Apply continuous cool
o o
o o kplantar medial aspect of the proximal phalanx
to the dorsal lateral aspect. This inclination is
o o
o o k o
water irrigation. Great care must be taken to avoid the MTP joint.
o
eebb necessitated by the curvature of the phalanx.
• Dissect away the capsule where the screw
ee/ e
/ b
e b ee/ e
/ b
e b
• The second cut is made 2–3 mm distally and angled so as to create a closing wedge.
The lateral cortex should be kept intact, as the osteotomy will become very unstable
(Fig. 3.12).
: / / t
/ m
enters the bone to ensure that it seats properly
.t.m : / / t
/ m
.t.m
if it is divided. Cut no more than four-fifths across the bone, and gently hinge the
t p ss:
p / t p ss:
osteotomy closed.
p /
• Place a cannulated pin from a 2.4-mm cannulated screw set. The osteomed screws
POSTOPERATIVE PEARLS
t
hht t t
hht t
work very well for this osteotomy. Drill all the way into the lateral cortex and insert the
screw, which should close down the osteotomy (Fig. 3.11).
• Start gentle MTP range of motion after the Step 7

sutures are removed.
k e r
e s
• If the desired range of motion is not obtained
rs
by 6 weeks, a short course of physical therapy
k eers
• The capsular and skin closure are similar to the chevron procedure (see Procedure 1).
r s
• The postoperative dressing is also similar.
o o
o o kmay be needed.
POSTOPERATIVE o oo
CARE
o kAND EXPECTED OUTCOMES oo
eebb b b
• It is extremely rare to have to remove a plate
postoperatively for any reason.
ee/ e
/ e b e /e/e b
• The postoperative protocol is similar to the chevron procedure (see Procedure 1).
e
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
EVIDENCE
r s
rs rs
r s
Iyer S, Demetracopoulos CA, Sofka CM, Ellis SJ. High rate of recurrence following proximal medial
k e e k ee
opening wedge osteotomy for correction of moderate hallux valgus. Foot Ankle Int 2015;36(7):
o o
o o k
756–63.
oooo k o o
eebb bb b b
A retrospective review of 17 patients. There was a high rate of recurrence in those with a high distal
metatarsal articular angle.
ee/ e
/e ee/ e
/ e
: / / t
/ t m
. m
profile plate. Foot Ankle Int 2009;30(10):976–80.
: / / t
/ t m
Saragas NP. Proximal opening wedge osteotomy of the first metatarsal for hallux valgus using a low
. . . m
t p ss
p : / t p ss
p : /
A retrospective review of excellent results with and opening wedge plate (Level IV evidence).
Shurnas PS, Watson TS, Crislip TW. Metatarsal opening wedge osteotomy with a low profile plate. Foot
t
hht
Ankle Int 2009;30(9):865–72.
t t
hht t
The authors concluded that the proximal metatarsal opening wedge osteotomy was near ideal in
terms of reliable, predictable correction and healing (Level IV evidence).
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh4t
PROCEDURE hht
Modified
rss “Lapidus” Procedure: Tarsometatarsal
rs s
k ee r
Corrective
o k Osteotomy and o k e
Fusion
o ke rWith First
b oo o
eeb MetatarsophalangealeJoint e bb o o e b o
b o
m /
e /e Correction m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
and Realignment
tppss : tppss :
hhttt hhttt
Michael P. Swords and Andrew K. Sands
k eers
rs k er
ers
INDICATIONSs
b ooook
TREATMENT OPTIONS
b ooook b o o
• Moderate to severe foot deformity, including
eeb • Several recent papers have questioned the
ee/ e
/ e b e / e
/ e b
• Hallux valgus with metatarsus primus varus
e
existence and significance of hypermobility
of the medial column. Tarsometatarsal
: // t/.tm
. m : / /t/.t
• Pes plano abductovalgus m
• Hypermobility of the medial column
. m
: /
ss EXAMINATION/IMAGING
(TMT) fusion is important in the realignment
t p p tp pss : /
t
hht t
and stabilization of the medial column. If
hypermobility is not present or significant, then
other metatarsal osteotomies can be used
t
hht t
to correct the deformity. However, if a basal
osteotomy is chosen, the medial column can • Upon weight bearing, hallux valgus is observed toward a more severe deformity.
be stabilized without a fusion by driving the • Proper examination of the foot often will reveal associated hypermobility of the me-
keerrs
screw across the osteotomy site and through
s
the first TMT joint (1TMT).
keerrss
dial column and an equinus contracture of the gastrocnemius. There may also be
b ooook b o
IMAGING STUDIESoook
flatfoot deformity (pes plano abductovalgus).
b oo
eeb CONTROVERSIES
ee/e/e b
• Radiographs
ee/e/e b
• The term hypermobility can be difficult to
/ / t m
.t.m
define. An easy way to visualize it is to think
: / : / / t m
.t.m
• Anteroposterior, oblique, and lateral plane radiographs show the deformity, along
/
t ppss : /
of the TMT/intertarsal region moving in two
t ppss : /
with subluxation of the flexor complex/sesamoids.
t
planes causing a bunion. The bunion with
hhtt
medial column hypermobility is found to have
medial–lateral instability as well as dorsiflexion
t
hhtt
• On the anteroposterior view, the medial TMT joints will often show a gap between
the first metatarsal (1MT) and second metatarsal (2MT), which may be indicative
of hypermobility.
instability. This medial column dorsiflexion can
also cause flatfoot, leading to the complex • The oblique view may show lesser metatarsal overload with cortical hypertrophy
problem of bunion with flatfoot. (further indicating lack of proper weight bearing by the medial column/1MT).
k e rrss
• Correction of the bunion via TMT/intertarsal
ecorrective osteotomy and fusion addresses the

k rrss
• The lateral view may show slight upward subluxation of the 1MT base on the me-
e e
dial cuneiform with dorsiflexion of the medial column (which can be seen at the
o o
o o k bunion deformity as well as flatfoot.
o o
o o k
TMT and calcaneonavicular joints).
o o
eebb POSITIONING PEARLS
ee/ e
/ b
e b other imaging studies.
ee e
/ b
e b
• There is no indication for magnetic resonance imaging, computed tomography, or
/
/ t
• Using the towel bump lifts the foot up off the
: / m
.t.m ANATOMY
SURGICAL
/ : / / t
/ m
.t.m
t ss: /
operating room table and allows easier access
p
to the foot. A firm towel bump can be made
p t p ss:
p /
• The plane of approach is a dorsomedial one along the top of the foot (Fig. 4.1). Care
using operating room towels.
t
hht t
• Fold five towels into thirds the long way,
then into quarters to make squares. Stack
t
hht t
should be taken to avoid the sensory nerve (to the first web space) along with the
dorsalis pedis artery.
five of these and wrap another long-thirds- • The approach is made between the extensor hallucis longus and the extensor hallucis
folded towel around the other five. Pull brevis (Fig. 4.2). Distally, the approach to the first metatarsophalangeal (1MTP) joint can
tightly on the wrapping towel to densely
k e r
e s
rspack the interior. It should form a cube.
e rs
be made medially or dorsally. The dorsal approach places the distal sensory nerve at risk.
rs
It allows access to the lateral aspect of the 1MTP joint (capsule and attached structures).
k e
o o
o o k
• Next wrap the whole cube in a Kerlix
gauze or Coban (from prefabricated packs;
oo k
• The medial utility approach allows safe access to the 1MTP joint and the flexor com-
o o oo
eebb whichever is available in the operating
room can be used).
ee/ e
/
POSITIONING
b
e b plex/sesamoids.
ee/e/ebb
• Because the towel bump often falls off the
/ / t .
tm.m
table, it is helpful to clamp it to the drape with
: / : / / t
/.tm
. m
a large Kelly clamp.
t p ss
p : / t p ss : /
• The patient is placed in the supine position with the ipsilateral bump under the buttock.
• A separate towel bump is used to elevate the foot off the operating room table.
p
32 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 4 Modified “Lapidus” Procedure 33
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Extensor hallucis
longus tendon
k eers
rs k er
ers
Extensor
s
expansion
b ooook b ooook
Extensor hallucis
b o o
eeb ee/ e
/ e b
brevis tendon
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss A B
keerrss
b ooook b oook
FIG. 4.1
o b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p / Extensor hallucis
brevis tendon
t
hht t Extensor hallucis
t
hht t
longus tendon
k e r
e s
rs k eers
rs Tarsometatarsal
o o
o o k o o oo k joint
oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : /
FIG. 4.2
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
34 hht
PROCEDURE 4 Modified “Lapidus” Procedure hht
PORTALS/EXPOSURES PEARLS PORTALS/EXPOSURES
k e r
e ss
• If just the 1MTP is being addressed, the
r
dorsomedial incision can be on the medial side
k eers
r s
• Two incisions are used: dorsomedial and straight medial.
• Dorsomedial incision
o o
o o kof the first web space, then down along the
o oo k o
• The incision is started at the interspace between the medial and intermediate
o o
eebb lateral aspect of the 1MTP joint.
• If a procedure is coincidentally planned for
ee/ e
/ebb cuneiform.
ee/ e
/ b
e b
• The incision is brought distally to the first web space and then deepened along
: / / t
/ t
deformity), then the incision can be brought m
the second toe (i.e., correction of lesser toe
. . m : / / t . m
. m
the lateral capsule of the 1MTP. Firm thumb pressure along the capsule allows for
/ t
t p ss
down the center of the web space and
p : /
continued distally along the medial border ss : /
blunt exposure of the capsule.
t p p
interphalangeal releases).
t
hht t
of the second toe (for tendon transfer and
t
hht t
• The proximal part of the incision allows access to the 1TMT and intertarsal joints.
If there is a significant amount of hypermobility, the intertarsal area can be fused
as well to increase stability.
PROCEDURE
k e rs
rs
STEP 1 PEARLS
e Step 1
k er
erss
b ooook
• Use a blue operating room marker to mark
the capsule and periosteum. At the end of the
b ooook b o
• The dorsomedial incision is carried down between the extensor hallucis longus and
o
eeb case, it makes it much easier to find this layer
to close over the fusion site and bone graft,
ee/ e
/ e b e / e
/ e b
extensor hallucis brevis tendon, taking care to avoid the dorsalis pedis artery and
sensory branch of the superficial peroneal nerve.
e
which promotes bony healing.
: // t/.tm
. m : / /t/.tm m
• The capsule and periosteum are marked and then incised axially (Fig. 4.3).
.
• Pocket hole
p ss : /
• Make the pocket hole at least 2 cm distal
t p tp pss : /
• The 1TMT is entered, and the soft tissues are reflected medially and laterally, expos-
ing the TMT and intertarsal area along with the medial base of the 2MT.
t
hht t
to the 1TMT joint to make sure there is
good leverage. Placing it too close to the
joint does not allow good screw purchase
t
hht
Step 2: Osteotomy
t
and hold. • The pocket hole is made on the dorsal base of the 1MT 2 cm distal to the joint before
• The pocket hole should have a near-vertical the osteotomy is cut (Fig. 4.4).
wall proximally and a slope going distally.
keerrss This allows the screw head to slide down

the slope before engaging the 1MT base,
keerrs
• The osteotomy is then cut using a straight saw (Fig. 4.5A). The depth of the joint and
s
cut is 3 cm, and the blade should be that long.
b ooook which prevents dorsal “blowout” of the
b ooook
• The osteotomy is performed in a slightly lateral and plantar-based direction, which
b oo
allows for correction at the TMT (Fig. 4.5B–C).
eeb b b
base of the 1MT.
• The pocket hole should be made with
ee/e/e e /e/e
• The first cut is made at the base of the 1MT.
e
a round burr laid on its side. The slope
: / t m
.t.m
portion should be slightly larger than the
/ / : / / t
/ m
.t.m
• The second cut, in with a slightly lateral and plantar-based wedge to prevent medial
t p : /
size of the screw head. The pocket hole
ss
is made prior to the osteotomy. Once the
p t ppss : /
column dorsi flexion, is made laterally to correct the intermetatarsal angle.
• The cut can be completed with a thin chisel. The TMT is then carefully distracted
t
hhtt
osteotomy is performed, the metatarsal
becomes less stable and making the burr
pocket hole is more difficult.
t
hhtt
with a lamina spreader. A pituitary rongeur can be used to remove the waste of the
cut.
k e rrss
e
STEP 1 PITFALLS
k e rrss
e
o o
o o k
• Care must be taken while cutting the 1TMT to
o o
o o k o o
eebb not cut the shaft of the 2MT.
• Make sure to remove all waste cut from the
ee/ e
/ b
e b ee/ e
/ b
e b
depths of the 1TMT. If by-products of the cut
/ / t
/ m
.t.m
are left in the depths of the cut, it will result
: : / / t
/ m
.t.m
t p ss:
p /
in pathologic dorsiflexion at the 1TMT and
t p ss:
p /
t t
upward displacement of the medial column.
hht t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss
p : / FIG. 4.3
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b oo ook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
FIG. 4.4
t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e
A
k e rrss
e
o o
o o k Intermetatarsal
o o
o o k o o
eebb angle
ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p / Medial
Navicular
t
hht t t
hht t
1st metatarsal
cuneiform Talus
1st metatarsal
Cut to correct 1st
k e r
e s
rs 1st cut
k eers
rs
metatarsal elevation
deformity by bringing
1st cut
2nd cut
o o
o o k 2nd cut
o o
oo k
1st metatarsal
oo
eebb b b
plantar grade
Medial cuneiform
ee/ e
/ e b ee/e/e b
B
: / / t
/ .
tm.m C
: / / t
/.tm
. m
t p ss
p : / FIG. 4.5
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
36 hht
Step 3: Preparing the Fusion
k e r
e s
rs k eers
r s
• The 1TMT is distracted gently with a lamina; spreader and the soft tissue along the me-
dial base of the 2MT are removed. The joint surfaces, medial base of the 2MT, and lateral
o o
o o k o oo k o
area of the 1MT base are drilled with a 2-mm wire to prepare them for fusion (Fig. 4.6).
o o
eebb ee/ e
/ebb ee/ e
/ b
e b
• Distally, the dissection is carried down along the lateral capsule. The capsule is then
incised axially. The lateral tendons are not released as this destabilizes the joint and
: / / t
/ .
t m
. m t . m
. m
can lead to hallux varus complications.
: / / / t
t p ss
p : / t p ss
p : /
• The medial utility incision is made along the midaxial line, centered over the 1MTP joint.
• The capsule and periosteum are reflected dorsally and plantarward. The adhe-
t
hht t t
hht t
sions between the flexor complex and the underside of the 1MT are released
(Fig. 4.7). These sometimes are vascular, and cautery can be used as long as the
articular cartilage is protected.
• The dorsal capsule is released along the shaft. This allows the MT head to shift
k eers
rs k er
ers
back over the flexor complex/sesamoids when the osteotomy is reduced.
s
• An elevator should be passed under the 1MT head from one incision to the other
b ooook b ooookto make sure that the adhesions are released and that the head is correctable
b o o
eeb STEP 4 PEARLS
ee/ e
/ e b above the flexor complex.
ee/ e
/ e b
: // t/.t
• When closing the 1MTP medial capsule, placem
. m Step 4: Reduction and Fusion
: / /t/.tm. m
t p ss
p : /
a stitch in each of the two flaps and hold
each with a clamp. Gently pull the superior
tp ss : /
• Reduction of the deformity
• The flexor complex is grasped with a clamp and pulled medially while a thumb is
p
t
hht t
arm distally and the inferior one proximally,
shifting the capsule and further correcting the
t
hht t
used to push the metatarsal laterally over the sesamoids. At the same time, the
osteotomy is reduced with a dental pick and pointed reduction clamp.
deformity at the 1MTP. Closure can then be • The reduced deformity can be provisionally fixed with Kirschner wires, but care
completed with 0 braided absorbable suture.
must be taken to not place the wires in the path of the screws.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e FIG. 4.6
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t 1st tarsometatarsal
joint
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb Flexor complex
A
: / / t
/ .
tm.m : / / t
/.
B
tm
. m
t p ss
p : /
t p ss
FIG. 4.7
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e ss k eers
r s
• The drills should be long shaft. This allows them to be used without the drill chuck
r
impacting the toes. In addition, it is important to have the drill bit lay flat relative to
o o
o o k o oo k
the foot. Using a short drill bit would prevent the holes from being drilled horizontally
o o o
eebb / e bb
as the drill bit forces the surgeon’s hand upward away from the foot.
ee /e
• The reduction of the osteotomy can be made using a pointed reduction clamp and
ee/ e
/ b
e b
: / / t
/ . m
. m : / / t . m
.
then held with the clamp or Kirschner wires. Two small drill holes can be made to
t / t m
ss : /
prevent the ends of the clamp from moving or sliding.
t p p t p ss
p : /
t
hht t
• The screws are then placed.
t
hht t
• The first screw is placed from the pocket hole into the plantar medial aspect of
the medial cuneiform (Fig. 4.8). The screw is placed in a lag fashion.
• A second screw is then placed from the medial cuneiform to the plantar base of
the 1MT.
eers
rs k er
ers
• A third screw is sometimes needed if there is excessive hypermobility or, as in
s
the case of revision surgery, more stability is needed.
b ooook
o ook
• Fixation can also be done using a plate (Fig. 4.9).
b o b o o
eeb
e e
/ e b
• However, the cost of a plate greatly exceeds that of solid screws, and this
/
should be kept in mind when that choice is being made.
e ee/ e
/ e b

: // t/.tm m : / /t/.tm. m
• Mechanical studies have shown that a screw placed below the equator of the
.
t
fusion results.
p ss
p : / tp pss : /
bone with a plate dorsomedial allows earlier weight bearing and more reliable
t
hht t t
hht t
• Plates are also useful in salvage for a dorsal breakout of the pocket hole or
any soft bone problems.
• The medial capsule of the 1MTP is then reefed and advanced and closed
with a 0 braided absorbable suture. The superior capsule can be advanced
keerrss more.
keerrs
distally and the inferior capsule proximally to shift and straighten the hallux
s
b ooook • Bone grafting

b ooook
• Small burr holes should be made dorsomedially and dorsolaterally along the
b oo
eeb ee/e/e b e /e/e b
TMT fusion. These “shear strain relief” holes are filled with morselized bone graft
e
and serve as “spot welds.”
: / / t
/ m
.t.m : / / t
/ m
.t.m

p ss : / p ss : /
• These small areas heal quickly; they hold the rest of the joint, preventing it from
shearing up and down (this shearing can cause fibrous tissue growth and nonunion).
t p t p
t
hhtt t
hhtt
• The blue-marked capsule/periosteum is then closed with a 2-0 braided absorbable
suture.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k o ooo k FIG. 4.8
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
38 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss A
keerrss B
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k C
o ooo k o o
eebb ee/ e
/ b
e b FIG. 4.9
ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t t
hhtOUTCOMES
POSTOPERATIVE CARE AND EXPECTED
• Because rigid internal fixation is holding the osteotomy, fancy dressings are not re-
quired. Bacitracin/Xeroform gauze are placed on the wounds. Sterile dressings and
k e r
e s
rs k eers
rs
Webril wrap are then placed. A three-sided plaster splint is placed and overwrapped
o o
o o k o o
oo k
with elastic bandages.
oo
eebb b b
• The splint is left in place for 2 weeks. It is then removed in the office, and the patient
ee/ e
/ e b ee/e/e b
is placed into a cam boot. The boot can be removed for washing.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
• Progression to full function is as follows:

k e e s
rs e rs
• Non–weight bearing for 6–8 weeks with two crutches or walker or scooter.
r r s
• If the patient is trustworthy, they may begin weight bearing on their heel when
k e
o o
o o k comfortable.
oooo k o o
eebb weeks.
ee /ebb
• Weight bearing in cam boot with cane assistance as needed for another 6–8
/ e ee/ e
/ b
e b
: / / / .
t m m
• Running sneakers with medial-supported orthotic from then on (for 1 year).
t . : / / t
/ .
t m
. m
for 2 years.
t p ss
p : / t p ss
p : /
• Patients may expect swelling and discomfort for 1 year with continuing improvement
t
hht t
• Patients can return to full sports, even marathon running.
t
hht t
See also Video 4.1, Modified “Lapidus” Procedure.
EVIDENCE
k eers
rs k er
erss
Bednarz PA, Manoli A. Modified Lapidus procedure for the treatment of hypermobile hallux valgus. Foot
b ooookAnkle Int 2000;21:816–21.
ooook
This study is a review of 26 patients who underwent a modified Lapidus procedure. Outcome was
b b o o
eeb (Level IV evidence [case series]).
ee/ e
/ e b ee/ e
/ e b
determined by patient satisfaction, pain relief, clinical joint stiffness, and radiographic assessment
// /.tm
. m
ment of hallux valgus. J Bone Joint Surg Am 2003;85:60–5.
: : / /t/.tm. m
Coetzee JC, Resig SG, Kuskowski M, Saleh KJ. Lapidus procedure as salvage after failed surgical treat-
t
ss : / ss : /
This study is a retrospective review of 24 patients with symptomatic recurrences of hallux valgus
t p p tp p
t t t t
after previous procedures that were subsequently treated with a Lapidus procedure. Follow-up
hht hht
averaged 24 months. Outcome was determined by American Orthopaedic Foot and Ankle Society
scale, visual analog pain scale, and radiographic assessment (Level IV evidence [case series]).
Haas Z, Hamilton G, Sundstrom D, Ford L. Maintenance of correction of first metatarsal closing base
wedge osteotomies versus modified Lapidus arthrodesis for moderate to severe hallux valgus de-
formity. J Foot Ankle Surg 2007;46:358–65.
keer ss keerrss
This study is a retrospective review of 57 feet with moderate to severe valgus deformity treated by
r
either a modified Lapidus or a 1MT closing base wedge osteotomy. At 11 months postoperatively,
b ooook b ooook
the radiographs were reviewed for both procedures (Level IV evidence [case series]).
b oo
Kopp FJ, Patel MM, Levine DS, Deland JT. The modified Lapidus procedure for hallux valgus: a clinical
eeb /e e b
and radiographic analysis. Foot Ankle Int 2005;26:913–7.
ee / ee/e/e b
This study is a retrospective review of 32 patients treated with the modified Lapidus procedure.
: / / t
/ m
.t.m : / / t
/ m
.t.m
Follow-up averaged 42 months. Outcome was determined by radiographic results, postoperative
t ppss /
questionnaires, and physical examination (Level IV evidence [case series]).
: t ppss : /
Manoli 2nd A, Hansen Jr ST. Screw hole preparation in foot surgery. Foot Ankle 1990;11:105–6.
t
hhtt t
hhtt
This is a technical review on the proper way to make a pocket hole.
McInnes BD, Bouche RT. Critical evaluation of the modified Lapidus procedure. J Foot Ankle Surg
2001;40:71–90.
This study is a retrospective review of 34 patients treated with the modified Lapidus procedure by
the senior author. Follow-up averaged 39 months. Outcome was determined by subjective ques-
tionnaire, physical examination, and radiographic assessment (Level IV evidence [case series]).
k rrss
e
in 227 cases. J Foot Ankle Surg 2004;43:37–42.
k rrss
Patel S, Ford LA, Etcheverry J, Rush SM, Hamilton GA. Modified Lapidus arthrodesis: rate of nonunion
e e e
o o
o o k o o o k o
This study is a retrospective review of 211 consecutive patients treated with a modified Lapidus
o o
eebb b b b b
procedure. For a minimum of 6 months’ follow-up, the radiographic results were reviewed (Level IV
evidence [case series]).
ee/ e
/ e ee/ e
/ e
: / / t
/ m : / / t m
Shi K, Hayashida K, Tomita T, Tanabe M, Ochi T. Surgical treatment of hallux valgus deformity in
.t.m .t.m
rheumatoid arthritis: clinical and radiographic evaluation of modified Lapidus technique. J Foot Ankle
/
Surg 2000;39:376–82.
t p ss:
p / t p ss:
p /
This study is a retrospective review of 21 rheumatoid hallux valgus deformities treated by a modi-
t
hht t t
hht t
fied Lapidus procedure. Outcome was determined by subjective improvement of pain, footwear
comfort, and radiographic assessment (Level IV evidence [case series]).
Thompson IM, Bohay DR, Anderson JG. Fusion rate of first tarsometatarsal arthrodesis in the modified
Lapidus procedure and flatfoot reconstruction. Foot Ankle Int 2005;26:698–703.
This study is a retrospective review of 182 patients who had either a modified Lapidus procedure
k e e s
rs k eers
or a TMT joint arthrodesis as part of a flatfoot reconstruction. At a follow-up of 6 months, the
r rs
radiographic evidence of union was reviewed between the two procedures (Level IV evidence [case
o o
o o k
series]).
o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh5t
PROCEDURE hht
Proximal
r ss Long Oblique (Ludloff ) rFirst
ss Metatarsal
o kkee r
Osteotomy With Distal k
Soft-Tissue
o k r
ee Procedure
eebbooo ooo / e bb / e b o
b o
m ee /e m ee / e
: / .
Mark E. Easley and Hans-JörgtTrnka
///t . m : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp
INDICATIONS PITFALLS INDICATIONS
t
hhtt p
t p
• Contraindications to surgical correction of • Symptomatic moderate to severe hallux valgus (first/second intermetatarsal angle
hallux valgus deformity: peripheral vascular [1/2 IMA] >15°) failing nonoperative treatment
k eers
rs
disease and peripheral neuropathy
k er
erss
EXAMINATION/IMAGING
ook ook
• Contraindication to surgical correction of hallux
b
eeboo
valgus with a metatarsal osteotomy: hallux
rigidus (degenerative joint disease of the first
/ e b o
bo / e b o o
• Relatively wide forefoot with a tender, prominent medial eminence (medial 1MT
b
metatarsophalangeal [1MTP] joint)
• Relative contraindications to the Ludloff
m ee / e m ee / e
head). Fig. 5.1 shows a patient in a weight-bearing stance with one foot corrected
with a Ludloff osteotomy and distal soft-tissue procedure and the other foot uncor-
: //
osteotomy: narrow first metatarsal (1MT;
/t/.t. m rected.
: / /
/t/.t . m
t ss
limited surface area for healing) and
p p
osteopenia (risk for poor fixation)
t t : t t tpss :
• Hallux valgus deformity (lateral deviation of the hallux) is noted.
p
CONTROVERSIES
hht hht
• Weight-bearing anteroposterior radiograph showing moderate to severe hallux val-
gus deformity (an increased 1/2 IMA exceeding 15°) is shown in Fig. 5.2A.
• Weight-bearing lateral radiograph without plantar gapping at the first tarsometatarsal
• Hypermobility of the first ray: some surgeons (1TMT) joint (suggestive of hypermobility) is shown in Fig. 5.2B.
recommend a 1TMT joint arthrodesis (modified
keerrss
Lapidus procedure) in lieu of a metatarsal
osteotomy.
keerrs
SURGICAL ANATOMY
s
b ooook b ooook
• Dorsomedial sensory cutaneous nerve to the hallux (terminal branch of the superfi-
cial peroneal nerve; Fig. 5.3A)
b oo
eeb TREATMENT OPTIONS
ee/e/e b /e e b
• Medial position of the 1MT head relative to the anatomically positioned sesamoid
complex (Fig. 5.3B)
ee /
/
• One of over 130 corrective procedures for
: / t
/ m
.t.m / t m
.t.m
• Lateral capsule with important blood supply to the 1MT head (Fig. 5.3C)
: / /
t p s : /
symptomatic hallux valgus; with moderate
s
to severe deformity, a proximal osteotomy or
p
• 1TMT joint
t ppss : /
t
hhtt
modified Lapidus procedure is favored. POSITIONING t
hhtt
• Supine position on the operating room table
TREATMENT PEARLS
• Unlike many other 1MT osteotomies, periosteal
k e rrss
e
stripping is not required and should be
avoided.
k e rrss
e
o o
o o k o o
o o k o o
eebb TREATMENT PITFALLS
ee/ e
/ b
e b ee/ e
/ b
e b
• Making the medial incision too plantar
/ /
may limit exposure of the 1MT and lead to
: t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p /
excessive skin retraction and potential skin
t p ss:
p /
t t
necrosis at the dorsal wound margin.
hht t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m
: / / t
/.tm
. m
t p ss
p : / t p ss
p : / FIG. 5.1
40 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure 41
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
A
t
hht t B
t
hht t
FIG. 5.2
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o o oo k o o
eebb A B ee/ e
/ b
e b C ee/ e
/ b
e b
: / / t
/ m
.t.m
: / / t
/ m
.t.m
t p ss:
p / FIG. 5.3
t p ss:
p /
t
hht t t
hht t
PORTALS/EXPOSURES
k e e s
rs k eers
• Two exposures should be considered: (1) a dorsal first web space incision to
r rs
perform the lateral release and (2) a longitudinal medial approach to perform
o o
o o k oo k
the medial capsulotomy and 1MT osteotomy. Alternative to the dorsal first web
o o oo
eebb e / b
e b
space incision, the lateral suspensory ligament between the lateral metatarsal
/ e
head and the lateral sesamoid may be released via the medial approach with
e ee/e/ebb
: / / / .
tm m : / / /.
a blade passed between the plantar aspect of the 1MT head and the sesamoid
t . t tm
. m
complex.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
42 hht hht
PROCEDURE 5 Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With Distal Soft-Tissue Procedure
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss FIG. 5.4
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t
hhtt
t
hhtt
FIG. 5.5
B
PORTALS/EXPOSURES PEARLS
k rrss
• With long-standing hallux valgus deformity,
e e
an audible “pop” indicative of a successful
k e rrss
e
o o
o o krelease is typically experienced and desirable.
o o
o k
Dorsal First Web Space Incision
o o o
eebb However, overrelease of the lateral capsule
must be avoided.
ee/ e
/ b
e b ee/ e
/ b
e b
• A 3- to 4-cm incision is made between the distal first and second metatarsals. The
superficial neurovascular structures are protected.
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The enveloping fascia (innominate fascia) is split longitudinally, and blunt dissection
PORTALS/EXPOSURES PITFALLS
t p ss:
p / t p ss:
p /
(with a finger) is performed to access the lateral aspect of the 1MTP joint. A lamina
spreader may be placed between the first and second metatarsals to improve ac-
t
hht t
• If the lateral capsule is tight, then the lateral
capsule may be fenestrated. We recommend
performing the lateral capsular fenestration
t
hht t
cess to the first web space (Fig. 5.4).
distal to the metatarsal head to preserve Medial Midaxial Longitudinal Approach

the metatarsal head’s blood supply, in the • A longitudinal incision is made from the 1MTP joint to the 1TMT joint, directly over
event where a distal osteotomy is required
k e r
e ss
in conjunction with the proximal Ludloff
r
osteotomy (risk of 1MT head avascular
k eers
the 1MT (Fig. 5.5A). A tendency to make the incision slightly more dorsal than plantar
rs
will facilitate exposure of the 1MT for the osteotomy.
o o
o o knecrosis).
o o
oo k
• The dorsomedial cutaneous sensory nerve to the hallux and extensor hallucis
oo
eebb • Avoid overreleasing the lateral capsule to
limit the risk of hallux varus (multiple small
ee/ e
/ b
e b (Fig. 5.5B).
ee/ /ebb
longus (EHL) tendon must be identified and protected throughout the procedure
e
fenestrations and a varus stress of only 20°
typically suffice).
: / / t
/ .
tm.m : / / t
/.tm
. m
• The medial 1MTP joint capsule should be exposed but not violated during the surgi-
t p ss
p : / cal approach.
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss FIG. 5.6
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb A
ee/e/e b B
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
PROCEDURE
t
hhtt t
hhtt
Step 1: Lateral Release and Medial Capsulotomy
k rrss
Lateral Release
e e k e rrss
e
• The ligament between the lateral capsule and the lateral sesamoid is released sharp-
o o
o o k o o o k
ly by introducing the scalpel blade directly into the articulation between the plantar
o o o
eebb ee e
/ b
e b
metatarsal head and the lateral sesamoid (Fig. 5.6). This maneuver can be performed
/ ee/ e
/ b
e
from the proximal end to the distal end and, if carefully controlled, may be continued b
: / / t
/ m
.t.m : / / t
/ m
.t.m
distally and slightly laterally to simultaneously release the adductor hallucis tendon
t ss:
p /
from the base of the first proximal phalanx (Fig. 5.7A).
p t p ss:
p /
• Next, the adductor hallucis is directly released from the lateral sesamoid (Fig. 5.7B),
t
hht t t
hht t
thereby fully detaching both aspects of the adductor hallucis to the 1MTP joint and
sesamoid complex (Fig. 5.7C).
C
FIG. 5.7
• Then, the lateral capsule is weakened distal to the lateral metatarsal head by fenes-
trating it with multiple scalpel blade stab incisions (Fig. 5.8).
k e e s
rs k eers
• Depending on surgeon preference, the transverse intermetatarsal ligament may be
r rs
carefully elevated from the underlying common digital artery and nerve and divided
o o
o o k oo k
while protecting these neurovascular structures; we do not routinely release this liga-
o o oo
eebb ment.
e / e
/ b
e b e /e/eb
• Alternatively, the lateral release may be performed through a single medial approach,
e e b
: / / t
/ .
tm.m : / / t
/.tm
. m
releasing the lateral suspensory ligament between the lateral metatarsal head and
lateral sesamoid.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
44 hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 5.8
b ooook
b o o
eeb ee/ e
/ e b ee/ e
/ e b FIG. 5.9
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t ppss : / t ppssB : /
t
hhtt t
hhttFIG. 5.10
STEP 1 PEARLS • Finally, a varus stress is applied to the hallux while applying medially directed
• We recommend cooling the microsagittal saw counterpressure on the 1MT to complete the lateral release (Fig. 5.9). Provided
k e rrss
blade with cool saline irrigation to limit heat
e k e rrss
adequate multiple fenestrations were performed laterally, a varus stress of 20° is
e
o o
o o kthat may create areas of osteonecrosis along
the osteotomy.
o o o k
sufficient.
o o o
eebb b b
• Of note, with satisfactory correction of the IMA, our experience is that it is typically
• Hold the forefoot with the opposite hand
while performing the 1MT osteotomy; this will
ee/ e
/ e b ee/ e
/ e b
not necessary to perform an extensive lateral release. In fact, releasing the suspen-
the osteotomy properly.

: / / t
/ m
provide greater stability and facilitate orienting
.t.m : / /
tion typically suffices.
t
/ m
sory ligament between the lateral metatarsal head and the lateral sesamoid in isola-
.t.m
t p ss:
p / t p ss:
p /
Medial Capsulotomy and Medial Eminence Resection
STEP 1 PITFALLS t
hht t
• Do not make the osteotomy too short; a longer
t
hht t
• With the medial capsule fully exposed and the EHL tendon and the cutaneous nerve
branch to the hallux protected, the medial capsulotomy is performed.
osteotomy typically leads to greater stability.
• We favor an L-shaped capsulotomy (Fig. 5.10), but any one of a number of described
techniques is applicable. It is important that sufficient tissue remains at the time of
k e r
e s
rs k eers
rs
closure to perform a satisfactory capsulorrhaphy.
• The medial eminence may be resected at this point or immediately before cap-
o o
o k
CONTROVERSIES
o o o
oo k o
sulorrhaphy. The medial eminence is resected in line with the medial 1MT shaft
o
eebb b b bb
• Alternatively, the lateral release may be
performed through the medial approach, but
ee/ e
/ e may promote hallux varus).
ee/e
(Fig. 5.11), immediately medial to the medial sulcus, avoiding overresection (which
/e
contracted lateral soft tissues.
: / / t
/ tm
this may not provide full visualization of the
. .m : / / t. m
. m
• In addition, the microsagittal saw must be held in the proper sagittal plane to avoid
/ t
t p ss
p : / ss : /
overresection of the plantar aspect of the 1MT head, which articulates with the me-
t p p
t
hht t t
dial sesamoid.
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss FIG. 5.11
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
A
: / / t
/ m
.t.m
: / / t
/
B
m
.t.m
t ppss : / t ppss :
FIG. 5.12
/
t
hhtt
Step 2: Proximal Oblique (Ludloff) First Metatarsal Osteotomy t
hhtt
• The 1MT is fully exposed. The sensory cutaneous terminal branch of the superficial
peroneal nerve and the EHL tendon are protected.
• With minimal periosteal stripping, a small blunt Hohmann retractor is positioned on
k e rrss
e rrss
the lateral side of the 1MT. To define the 1TMT joint, a small-diameter Kirschner wire
e e
may be placed in the joint and its position confirmed on intraoperative fluoroscopy.
k
o o
o o k o o k
• Dissection plantar to the metatarsal may be kept to a minimum, but some expo-
o o o o
eebb access to place a second screw.
ee / b
e b
sure is required to define the exit point of the osteotomy and to create adequate
/ e ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• With the 1MT exposed, the planned osteotomy is marked and/or scored (Fig. 5.12).
p ss:
p / t p ss: /
The desired osteotomy should originate at or just distal to the dorsal aspect of the
1TMT joint and extend obliquely and plantarward to a point just proximal to the
t p
t
hht t t
hht t
metatarsal head–sesamoid complex. A long osteotomy provides the greatest surface
area for healing and readily permits fixation with two screws. In our experience, a
short osteotomy tends to be less stable than a long osteotomy.
• The greatest challenge with this osteotomy is achieving its ideal orientation and con-
gruency.
k e r
e s
rs k eers
rs
• The osteotomy must be performed from the direct medial aspect of the 1MT,
o o
o o k o o
oo k
avoiding the tendency is to start the osteotomy too dorsally.
oo
eebb b b
• Staying in the same plane for the entire length of the osteotomy is facilitated by
ee/ e
/ e b
not allowing the saw blade to completely exit the osteotomy when it is advanced
ee/e/e b
distally and plantarward.
/ / t
/ .
tm.m / / t
/.tm
. m
• To avoid a tendency to elevate the distal fragment during IMA correction, the saw
: :
ss : / ss : /
blade may be inclined 10° in a plantarward direction, to promote slight plantar
t p p t p p
t
hht t
flexion of the distal fragment.
t
hht t
t t p
t ss:
p t t p
t ss:
p
46 hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 5.13
k r
eerss FIG. 5.14
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m / /t/.tm. m
• With the ideal osteotomy marked/scored on the medial aspect of the 1MT and a
:
t p ss
p : / ss : /
small blunt Hohmann retractor protecting against accidental overpenetration of the
tp p
t
hht t t
hht t
saw blade through the lateral cortex, the microsagittal saw is fully seated through
the proximal aspect of the planned osteotomy. The distal corner of the saw blade is
then retracted, leaving the proximal aspect of the blade within the osteotomy, and
the saw blade is then fully seated through both cortices more distally than the initial
cut. This process is repeated multiple times to advance the saw along the proximal
keerrss keerrss
two-thirds of the planned osteotomy (Fig. 5.13).
b ooook b ooook
• After completing the proximal two-thirds of the osteotomy, the saw is removed and
oo
a small-fragment lag screw is inserted perpendicular to the completed portion of the
b
eeb ee/e/e b
osteotomy (Fig. 5.14).
ee/e/e b
• The proximal two-thirds of the osteotomy must be fully completed before insert-
: / / t
/ m
.t.m : / / t m
.t.m
ing this screw because access to the lateral cortex will be limited once the screw
/
t ppss : / is in position.
t ppss : /
t
hhtt t
hhtt
• This position of this screw should not violate the 1TMT joint, not fracture the thin-
ner dorsal fragment, and be proximal enough to allow for insertion of a second
screw across the more distal aspect of the osteotomy.
• When using a fully threaded solid screw, the proximal (dorsal) cortex will need
to be overdrilled to create a lag effect. We routinely use a dual-pitch or partially
k e rrss
e k rrss
threaded cannulated screw.
e e
• With compression of the proximal osteotomy confirmed, the screw is temporarily
o o
o o k o o o k o
released a few turns to allow completion of the osteotomy.
o o
eebb ee e
/ b
e b ee/ e
/ b
e b
• The microsagittal saw is reintroduced into the osteotomy, and in a manner similar
/ to that described earlier, the distal portion of the osteotomy is completed (Fig.
: / / t
/ m
.t.m : / / t
/ m
.t.m
5.15). The plantar soft tissues must be protected as the saw blade exits the plantar
t p ss:
p / t p ss:
p /
cortex. A tendency may be to advance the saw blade too distally, potentially creat-
ing an exit point in the metatarsal head or one that violates the sesamoid complex,
t
hht t t
hht t
and therefore it is essential that the target remains the planned exit point of the
scored/marked osteotomy.
• The IMA is corrected by rotating the distal fragment on the proximal fragment, pivot-
ing about the screw that has been inserted across the proximal aspect of the oste-
k e r
e s
rs k eers
otomy (Fig. 5.16).
rs
• Occasionally the soft tissues at the proximal-most and distal-most aspects of the
o o
o o k o oo k
osteotomy need to be carefully released to permit the osteotomy to mobilize. A
o oo
eebb ee/ e
/ b
e b e /e/ebb
towel clip attached to the distal aspect of the proximal fragment provides stability
as manual pressure is applied to the medial 1MT head. With desired correction,
e
: / / t
/ .
tm.m : / / t
/.tm
. m
the proximal screw is secured and the towel clip is positioned to temporarily pre-
t p ss
p : / t p ss : /
vent loss of correction (Fig. 5.16). IMA correction is confirmed with intraoperative
fluoroscopy (Fig. 5.17).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss FIG. 5.15
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t
hhtt t
hhtt B
FIG. 5.16
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
A
t p ss
p : / B
t p ss
p : /
t
hht t t
hht t
FIG. 5.17
t t p
t ss:
p t t p
t ss:
p
48 hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 5.18
k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t FIG. 5.19
• With overcorrection or undercorrection of the IMA, the proximal screw and towel
clip may be readily released, further correction can be made, and the screw and
keerrss
ke rrss
towel clip can again be secured.
e
b ooook
• Microsagittal saw
b ooook
• A second lag screw is placed over the distal aspect of the metatarsal shaft (Fig. 5.18).
b oo
• We prefer to direct this screw from plantar to dorsal. With the plantar soft tissues
eeb • Small-fragment screws (solid or cannulated)
• Towel clip
ee/e/e b ee/e/e b
retracted and retraction of the dorsal soft tissues released, the plantar screw can
• Small fluoroscopy unit
: / / t
/ m
.t.m / / t
/ m
be safely inserted. If the screw is placed obliquely from medial to lateral, its com-
.t.m
pression may promote loss of correction as the distal fragment is pulled medially.
:
Therefore the distal screw should be directed as much as is possible from plantar
t
hhtt t
hhtt
to dorsal while remaining perpendicular to the osteotomy.
• This screw should be started centrally on the distal aspect of the plantar fragment,
avoiding the risk of medial or distal fracture as the screw is compressed. In addition,
the screw should not penetrate the dorsal cortex of the distal fragment more than a
STEP 2 PEARLS millimeter or two because this may create symptomatic hardware postoperatively.
e rrss
• Even without complete repair of the medial
k e k rrss
• We recommend intraoperative fluoroscopy to confirm satisfactory correction of
e e
o o
o o kcapsule, the hallux position should be nearly
anatomic with appropriate correction of the
o o
o o k
the IMA (Fig. 5.19).
o o
eebb IMA.
ee/ / b
e b
Step 3: Medial Capsulorrhaphy and Closure
e ee/ e
/ b
e b
• Typically, distal and proximal prominences remain on the medial aspect of this
: / / t
/ m
.t.m : / / t m
.t.m
osteotomy upon completion of the IMA correction. These should be removed
/
t p ss:
p / t p ss:
p /
with the microsagittal saw (Fig. 5.20). While protecting the sensory cutaneous
STEP 2 PITFALLS
t
hht t t
hht t
nerve to the hallux, the medial capsule is repaired, typically with imbrication (Fig.
5.21). We use a combination of absorbable and nonabsorbable suture to close
the capsule.
• The operation is not over until the hallux is
• In order to rebalance the hallux on the 1MT head, slight supination and varus are
properly positioned; greater tightening of the
medial capsulorrhaphy is rarely the solution. applied to the hallux during the medial capsulorrhaphy. Intraoperative fluoroscopy
k e r
e ss
• If the IMA is undercorrected, the proximal
r
osteotomy will need to be repositioned.
k eers
rs
confirms that the hallux is balanced in an anatomic position and that the metatarsal
head is properly repositioned on the sesamoid complex (Fig. 5.22).
o o
o o k
• If the distal metatarsal articular angle (DMAA)
o oo k o
• We deem a minimal amount of varus positioning optimal as this tends to correct to an
o o
eebb b b
is increased, a supplemental distal, medial
closing wedge 1MT osteotomy must be added.
ee/ e
/ e b ee e/e b
anatomic position; however, a true varus positioning of the hallux should be avoided.
/
• In the event that overcorrection has occurred, either the IMA is overcorrected
: / / t
/ .
tm.m t. m
. m
(necessitating repositioning of the 1MT osteotomy) or the lateral capsule has been
: / / / t
t p ss
p : / overreleased.
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
r
A
s k er
erss B
b ooook b ooook FIG. 5.20
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : /
t ppss : /
t
hhtt
FIG. 5.21
t
hhtt

k e rrss
e e rrss
• With overrelease of the lateral capsule, one option is to attach the residual adduc-
e
tor hallucis tendon to the distal lateral capsular tissues.
k
o o
o o k o o k
• If the metatarsal head, sesamoid, and hallux relationship is not anatomic, then the
o o o o
eebb e / b
e b
IMA correction is inadequate, the capsular closure is not appropriate, or the patient
/ e
has an increased DMAA. The surgeon should not leave the operating room until the
e ee/ e
/ b
e b
hallux is properly positioned.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss: /
• Rarely is the problem related to an inappropriate medial capsular closure.

• If the IMA proves to be undercorrected, then the proximal osteotomy will need to
p
FIG. 5.22
t
hht t
be realigned to achieve appropriate IMA correction. t
hht t
• With an increased DMAA, a supplemental distal 1MT osteotomy is warranted,
either a medial closing wedge osteotomy (Reverdin) or a biplanar distal chev-
ron osteotomy, to reestablish the proper alignment of the 1MT’s articular sur-
face on the 1MT shaft. Because of the potential need for a distal osteotomy in
k e r
e s
rs k eers
rs
addition to a proximal correction, the lateral capsular release must always be
o o
o o k o o
oo k
performed judiciously in order to prevent compromising the blood supply to
oo
eebb b b
the 1MT head.
ee/ e
/ e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
50 hht hht
STEP 3 PEARLS • Occasionally, deeper soft tissues may be repaired over the osteotomy and at the
k e r
e ss
• Edema will persist for a minimum of 6 months.
r
• Routine bunion strapping may not be required;
k eers
1TMT joint, but typically the only layers that can be closed are the subcutaneous
r s
tissue and the skin. The sensory nerve to the hallux must be protected during this
o o
o o kpostoperative radiographs determine hallux
oooo k
closure. The dorsal first web space incision is closed as well (Fig. 5.23).
o o
eebb position and guide the need for bunion
strapping.
ee/ e
/e
POSTOPERATIVE
bb CARE AND EXPECTED OUTCOMES ee / b
e b
• A sterile dressing is applied to the wounds.
/ e
• The metatarsal osteotomy ideally heals by
: / / t
direct bone healing. Radiographic evidence
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : /
for callus formation at the osteotomy site is
suggestive of inadequate or loss of fixation.
t p ss : /
• Bunion strapping and surgical dressing are applied.
• Weekly follow-up is scheduled for 1MTP joint manipulation, bunion strapping, and
p
t
hht t
If correction is maintained, we recommend
casting and limited weight bearing until
healing is satisfactory.
t
hht t
radiographs to assess 1MTP joint position and healing.
• Bunion strapping is recommended for 6 weeks and a toe spacer for an additional 4–6
weeks to unload the medial capsulorrhaphy while it heals.
• Protective weight-bearing status, with heel weight bearing only and limiting weight
bearing on the forefoot, should be maintained until there is radiographic evidence for
eers
rs
POSTOPERATIVE PITFALLS
k k errss
healing of the osteotomy (typically 6 weeks).
e
b ooook
• Postoperative callus formation at the
b ooook
• Fig. 5.24 shows the final follow-up of a proximal 1MT osteotomy 7 years postop-
b o o
eratively in a clinical view (Fig. 5.24A) and a weight-bearing lateral radiograph (Fig.
eeb osteotomy site (Fig. 5.25A) indicates
inadequate fixation, motion at the osteotomy
ee/ e
/ e b ee/ e
/ e b
5.24B). In a weight-bearing anteroposterior radiograph (Fig. 5.24C), note the ideal
: //
recommend casting and protective weight-
t/ tm
site, and potential for loss of correction. We
. . m : / /t/.tm
1MT head position centered over the sesamoid complex.
. m
t p ss
p :
for healing (typically 8–10 weeks from /
bearing until there is radiographic evidence
ss : /
See also Video 5.1, Proximal Long Oblique (Ludloff) First Metatarsal Osteotomy With
tp p
t
hht t
time of surgery). Note the relatively short
osteotomy (lacking stability) in Fig. 5.25B. After
t
hht t
Distal Soft Tissue Procedure.
casting and delaying weight bearing, callus

consolidation is achieved with minimal loss of
correction (Fig. 5.25C). On follow-up at 1 year,
keerrs
there is satisfactory maintenance of correction
s
and healing with callus resorption (Fig. 5.25D).
keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m A
: / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
FIG. 5.23
t
h ht t B
h
t
ht t FIG. 5.24
C
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p :
B
/
tp pss : / C D
t
hht t t
hht tFIG. 5.25
EVIDENCE
ke rss
hallux valgus. Foot Ankle Int 2004;25:532–6.
e keerrs
Chiodo CP, Schon LC, Myerson MS. Clinical results with the Ludloff osteotomy for correction of adult
r s
b ooookLevel IV evidence).
b ooook
Peer-reviewed article on the clinical results of the Ludloff osteotomy (grade B recommendation;
b oo
Hofstaetter SG, Riedl M, Glisson RR, Trieb K, Easley ME. The influence of patient age and bone mineral
density on osteotomy fixation stability after hallux valgus surgery: a biomechanical study. Clin Bio-
mech 2016;32:255–60.
: / / t
/ m
.t.m : / / t
/ m
.t.m
in hallux valgus correction.
t ppss / t ppss : /
Study addressing the patient age and bone density as they pertain to first metatarsal osteotomies
:
t
hhtt t
hhtt
Nyska M, Trnka HJ, Parks BG, et al. The Ludloff metatarsal osteotomy: guidelines for optimal correction
based on a geometric analysis conducted on a sawbone model. Foot Ankle Int 2003;23:34–9.
Biomechanical study that provides a better understanding of how to perform the Ludloff
osteotomy.
Robinson AH, Bhatia M, Eaton C, Bishop L. Prospective comparative study of the SCARF and Ludloff
osteotomies in the treatment of hallux valgus. Foot Ankle Int 2009;30(10):955–63.
k rrss
e k rrss
This study compared two diaphyseal osteotomies (Scarf and Ludloff) that correct moderate to
e e e
severe metatarsus primus varus and found that patients who had a Scarf osteotomy had a superior
o o
o o k
outcome at 6 and 12 months.
o o
o o k o o
eebb b b
Trnka HJ, Hofstaetter SG, Easley ME. Intermediate-term results of the Ludloff osteotomy in one hundred
e/ e
/ e b
and eleven feet. Surgical technique. J Bone Joint Surg Am 2009;91(Suppl 2):156–68.
e
Detailed surgical technique of the Ludloff osteotomy.
ee/ e
/ e b
: / / t
/ m
.t.m : / / t m
.t.m
Trnka HJ, Hofstaetter SG, Hofstaetter JG, Gruber F, Adams Jr SB, Easley ME. Intermediate-term results
/
t ss: / t p ss: /
of the Ludloff osteotomy in one hundred and eleven feet. J Bone Joint Surg Am 2008;90:531–9.
p
Peer-reviewed article on the clinical results of the Ludloff osteotomy (grade B recommendation;
p p
Level IV evidence).
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh6t
PROCEDURE hht
Revision
rss Hallux Valgus Surgery rss
o kkee r er o kke
o o
eebboAlastair Younger and Kelly Hynes ee/e bboo o e b o
b o
m /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t p :
ss INDICATIONS t t p
t ss
p :
hht
• Understanding the cause of symptoms
is paramount to selecting an appropriate
• Ongoing pain symptomatic enough to merit surgery
• Recurrent hallux valgus deformity
hht
procedure. • Second metatarsalgia or overload
• Understanding why the index procedure failed
• Elevated first ray
k eers
(i.e., technical, patient factors, complications)
rs
is critical to the success of any revision
k er
e s
r s
• Plantar flexed first ray
b ooook surgery.
• Be certain to rule out any symptomatic
booook
• Hallux varus
b o o
• Avascular necrosis of the first metatarsal (MT) head
eeb metatarsophalangeal (MTP) arthritis before
offering a joint sparing procedure.
ee/ ee b
/ AND IMAGING ee/ e
/ e b
• Nonunion of osteotomy or arthrodesis
ruled out.
: // /.tm
• As in any revision scenario, infection must be
t m
EXAMINATION
. : / /t/.tm. m
t p ss
p : / ss : /
• Location of pain (i.e., medial, plantar, transfer metatarsalgia, first MTP, first tarso-
tp p
t
hht t t
hht t
metatarsal [TMT], prominent hardware)
• Degree of deformity
• Consider overall foot alignment (i.e., associated pes planus; Fig. 6.1)
• Treating a deformity in the absence of pain is
discouraged. • Anteroposterior radiograph: assess for location of deformity, nonunion, avascular
• Smoking in the setting of a nonunion is necrosis of MT head, arthrosis, length of MTs, remaining hardware and sesamoid
keerrss
considered a relative contraindication by some
experts.
keerrss
position, intermetatarsal angle, and hallux valgus angle
b ooook b ooook
• Lateral radiograph: assess for union of osteotomies, first MT or TMT arthritis, pres-
oo
ence of pes planus, and plantar gapping of the first TMT joint (Fig. 6.2)
b
eeb ee/e/e b nosis (Fig. 6.3)
ee/e/e b
• Computed tomography scan may be required if a nonunion is in the differential diag-
: / / t
/ m
.t.m OPTIONS
TREATMENT
: / / t
/ m
.t.m
t
hhtt t
hhtt
• MTP arthrodesis: arthritis or unstable MTP joint
• Lapidus procedure: hypermobile first ray or undercorrected intermetatarsal angle
• First MT osteotomies: undercorrected intermetatarsal angle
• Aiken procedure: undercorrected or uncorrected hallux interphalangeus
•
Additional procedures may be required to address lesser toe MT length or
k e rrss
e k e rrss
deformities
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b
ee/e/ebb
FIG. 6.1
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
52 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 6 Revision Hallux Valgus Surgery 53
SURGICAL ANATOMY
k e r
e ss k eers
r
• Protect cutaneous branches of the superficial peroneal nerves
• Dorsal longitudinal incision for the first TMT or MT joint (Fig. 6.4)
r
o o
o o k o oo k
• Retract the extensor hallucis longus tendon laterally (Fig. 6.5)
o o o
eebb / e bb
• Protect the dorsal neurovascular bundle medially
ee /e ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 6.3
k
A
eerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
FIG. 6.4
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p pss: /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb B
ee/ e
/ b
e b ee/e/ebb

FIG. 6.2
: / / t
/ .
tm.m
: / / t
/.tm
. m FIG. 6.5
t p ss
p : / t p pss : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
54 hht
PROCEDURE 6 Revision Hallux Valgus Surgery hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 6.7
FIG. 6.6
k eers
rs k er
erss
eeb POSITIONING PEARLS
ee/ e
/ e b ee/ e
/ e b
imaging.
: // /.
• A radiolucent table is key for intraoperative
t tm
. m : / /t/.tm. m
ss
• Consider a calf tourniquet if regional
t p p : / tp pss : /
anesthesia can be used.
t
hht t t
hht t
POSITIONING PITFALLS
kee rs
• Ensure that the foot is at the end of the
r s
operating table for easy access.
keerrss
b ooook b ooook
b oo FIG. 6.8

POSITIONING EQUIPMENT
• Pneumatic tourniquet
: / / t
/ m
.t.m : / / t
/ m
.t.m
ss
• Vacuum beanbag positioner (optional)
t pp : / t ppss : /
t
hhtt t
hhtt
POSITIONING CONTROVERSIES
POSITIONING
• Some patients can bend the knee to allow better
• Place the patient in the supine position, as shown in Fig. 6.6.
visualization of the forefoot in a seated position,
k e rrss
whereas others prefer supine positioning only.
e k e rrss
• Elevate the ipsilateral hip with a beanbag or “bump” to allow for neutral rotation of
e
the limb.
o o
o o k o o o k o
• Pad any bony prominences or peripheral nerves at risk.
o o
eebb PORTALS/EXPOSURES PEARLS
ee/ e
/ b
e b ee e
/ b
e b
• Expose and landmark the iliac crest if a structural bone graft is required.
/
• Apply a pneumatic tourniquet to ensure adequate access to the surgical field, as
• Consider any previous incisions in the planning
/ / t
/
approach; additionally, narrow skin bridges can
: m
.t.m shown in Fig. 6.7.
: / / t
/ m
.t.m
add to the risk of skin necrosis.
t p ss:
p / PORTALS/EXPOSURES
t p ss:
p /
PORTALS/EXPOSURES EQUIPMENT
t
hht t t
hht t
• Dorsal approach to the first TMT joint (Fig. 6.8)
• Dorsal approach to the MTP joint
• Dorsal approach to the second MT head
• Small self-retaining retractor
• Dorsal or medial approach to the first MT
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
A
t p ss
p : / t p ss
p : /
t
hht t t
hht t A
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
B
:/ / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : /
FIG. 6.9
t p s
p s :B/
t
hhtt t
hhtt FIG. 6.10
STEP 1 PEARLS
• Consider an interpositional bone graft in the
setting of bone loss or avascular necrosis.
k e rrss
e k e rrss
e
• Use a Kirschner wire (K-wire) to provisionally
fixate the first MT onto the second.
o o
o o k o o
o o k o o
eebb b b b b STEP 1 PITFALLS
ee/ e
/ e ee/ e
/ e • Failure to restore the MTP joint to correct
PROCEDURE
: / / t
/ m
.t.m : / / t
/ m
.t.m alignment. The first ray needs to be out to
length, correctly rotated, correctly aligned in
t p ss:
p / t p ss:
p / varus and valgus, and correctly aligned in
Step 1: MTP Fusion
t
hht t t
hht t
• For some failed hallux valgus surgery, such as the case shown in Fig. 6.9 with a distal
flexion and extension.
• Failure to get adequate fixation on both sides
of the joint. This can be particularly difficult in
chevron with avascular necrosis and infection, a fusion is required. cases of bone loss.
• Incise skin dorsally over the first MTP in line with first ray or using prior incisions if
required.
k e r
e s
rs k eers
rs
• Identify the extensor hallucis longus tendon and incise the joint capsule medial to the
IMPLANTATION
• A custom first MTP fusion plate with locking
o o
o o k tendon.
o o
oo k oo
options is an excellent adjuvant for this
eebb b b
• Release the joint capsule proximally and distally along with the collateral ligaments
to expose the joint (Fig. 6.10).
ee/ e
/ e b ee/e/e b technique, particularly for patients with bone
loss requiring an interpositional graft.
/ / t
/ tm
• Check the clinical position of reduced MTP with a flat plate.
. .m / / t
/.tm
. m
• Insert fixation of surgeon’s choice (crossed screws or plate with cross screw).
: :
STEP 1 CONTROVERSIES
t p ss
p : / t p ss
p : /
• The MTP fusion can be done in isolation, or after the first TMT fusion has been • Patients with infection may require a two-stage
t
hht t t
hht
performed if the MTP joint could not adequately be reduced.
t procedure using a temporary antibiotic spacer.
t t p
t ss:
p t t p
t ss:
p
56 hht
STEP 2 PEARLS
k e r
e ss
• Puncture the capsule with an osteotome to
r
make more space for débridement.
k eers
r s
o o
o o k
• Make sure that the cartilage is removed from
oooo k o o
eebb the plantar lateral side of the joint. This can be
visualized using distraction.
ee/ e
/ebb ee/ e
/ b
e b
• The first ray can be held reduced by flexing
: / / t
the first MTP joint, holding the MT lateral,
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : /
holding the MT plantar flexed, and cupping
the reduced joint and MT in the left hand for a
t p ss
p : /
t
hht t
right foot and in the right hand for a left foot.
• The author prefers to use crossed 3.5-mm
cortical screws. The first is placed distal to
t
hht t
proximal in a recess made in the first ray. The
2.5-mm drill is then placed eccentrically in the
k e s
first hole to increase the correction.
rrs
• The second screw is placed from the dorsal
e k er
erss
b ooook side of the medial cuneiform. The 3.5-mm drill
is placed direct dorsal and drilled down until it
b ooook b o o
eeb hits the first screw. The 2.5-mm drill bit is then
e
placed just lateral to the first screw and drilled
e/ e
/ e b ee/ e
/ e b
// t/.
out through the plantar cortex with the first
tm
. m
ray held in a corrected position. The screw will
: : / /t/.tm. m
ss : /
increase correction as it is placed and will also
t p p tp pss : /
t t
push on the first screw, thus increasing stability.
hht
• A third screw is placed medially with the first
ray in the reduced position with a 2.5-mm drill
t
hht t
bit only. No compression is required, and this
screw will assist in maintaining stability.
keerrss
STEP 2 PITFALLS
k eerrss FIG. 6.11
b ooook
• Failure to correct the deformity of the first ray
b o
oo o k b oo
eeb • Overcorrection of deformity of the first ray
• Inadequate cartilage débridement or
ee/e/e b ee/e/e b
inadequate fixation resulting in nonunion
: / / t
/ m
.t.m
• Malreduction of the first ray in the dorsal and
: / / t
/ m
.t.m
plantar planes
t
hhtt t
hhtt
IMPLANTATION
• Small curettes and osteotomes
k rrss
• A mini C-arm for screw placement and
e e
confirmation of screw position
k e rrss
e
o o
o o k
• Custom first TMT fusion plates
o o
o o k o o
eebb ee/ e
/ b
e b
ee/ e
/ b
e b
FIG. 6.12
: / / t
/ m
.t.m Step 2: First TMT Fusion
: / / t
/ m
.t.m
t p ss: /
• First TMT fusion is thought to cause excessive
shortening of the first ray. However, this will
p t p ss:
p /
• In many cases the first ray is undercorrected secondary to deformity recurrence
t
hht t
only occur if bone cuts are used. In some
cases bone cuts are preferable as the first
ray may in fact be excessively long. If the
t
(Fig. 6.11).
hht t
• The first TMT joint is exposed dorsally (Fig. 6.12).
• The joint is stripped of cartilage in preparation for fusion.
second ray is long after correction, then a • Puncture the subchondral plate using a K-wire, osteotome, or small drill bit.
lengthening osteotomy of the first ray or a • Once débrided, the first ray is held in the reduced position with respect to rotation,
shortening osteotomy of the second ray can be
k e r s
rs
considered. These are discussed later.
e eers
plantar flexion, and varus and valgus deformities.
rs
• Fixation is then achieved using cross screws or a custom plate.
k
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 6.13
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t STEP 3 PEARLS
• Make sure that the second interphalangeal joint
is adequately excised to prevent overtensioning
keerrss keerrss of the toe that can cause a dysvascular toe.

• For the second MT osteotomy, make sure that
the cut starts within the joint and is almost
parallel to the floor.
eeb ee/e/e b ee/e/e b • If plantar plate repair is considered, do this
after the osteotomy.
: / / t
/ m
.t.m : / / t
/ m
.t.m • Ensure that the MTP joint is placed into plantar
t ppss : / t ppss : / flexion during fixation.
t
hhtt
FIG. 6.14 t
hhtt STEP 3 PITFALLS
• Failure to reduce or transfix the MT
k e rrss
e k e rrss
e
o o
o o k o o
o o k STEP 3 INSTRUMENTATION/
o
IMPLANTATION
o
eebb e / e
/ b
e b
Step 3: Claw Toe Correction/Osteotomy of the Second Ray
e ee/ e
/ b
e b
• A plantar plate repair kit can be considered.
• A mini fragment (1.6-mm or 2.0-mm screw)
: / / t
/ m
.t.m : / / t m
.t.m
• The second MTP joint is approached using an incision over either the first or second
/
can be used to transfix the osteotomy.
• In most cases 0.45-mm double-ended K-wires
t p ss:
web space (Fig. 6.13).
p / t p ss:
p / are used to transfix the ray.
t t t t
• The MTP joint is identified and the extensor tendons lengthened as required.
hht
• The interphalangeal joint is excised (Fig. 6.14).
• The MTP joint is reduced using an elevator if required.
hht STEP 3 CONTROVERSIES
• The second ray osteotomy is performed at this point if required.
• A second MT shortening osteotomy and a
• A K-wire is placed up the toe and up the second MT shaft and through the shortened dissection to reduce a dislocated joint may
k e r
e s
rs MT head.
k eers
r
• Screw fixation can also be performed at this point. s excessively strip the blood supply to the MT head.
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
58 hht
STEP 4 PEARLS
k e r
e ss
• Plan your incisions based on which MTP joints
r
need to be accessed.
k eers
r s
o o
o o k
• Ensuring a very oblique osteotomy will give
oooo k o o
eebb more flexibility on the amount of shortening
and also increase the healing surface area.
ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
IMPLANTATION
t p ss
p : / t p ss
p : /
t
hht t
• Multiple options for fixation of the shortening
osteotomy are available.
t
hht t
• Using a K-wire can add additional rotational
stability to fixation if a single screw is used.

k eers
rs
STEP 5 PEARLS
k ee s
rrs
FIG. 6.15
b ooook
• Ensure that the osteotomy is bridged with a
b ooook
Step 4: Lesser Metatarsal Shortening Osteotomy
b o o
eeb plate to prevent fracture.
• Make sure that not only the length is restored,
ee/ e
/ e b ee/ e
/ e b
• The second MTP joint is approached using an incision over the first or second
web space; the third MTP can also be approached through the second web-
flexion with the lengthening.
: // /.
but also the MT has not drifted into plantar
t tm
. m space incision.
: / /t/.tm. m
t p ss
p : / ss : /
• The MTP joint is identified and the extensor tendons are lengthened as required.
tp p
STEP 5 PITFALLS t
hht t t
hht t
• The saw is placed on the edge of the MT head, as shown in Fig. 6.15.
• A microsagittal saw is aimed dorsal-distal to proximal-plantar in orientation at the
level of the MT neck.
• Failure to adequately reduce or transfix the
first ray • The MT is shortened as much as required and fixed in position with a single or two
mini-fragment screws.
eerrss
k keerrss
• If there is a concurrent claw toe correction, the MT osteotomy is also cross-pinned
with a K-wire.
b ooook
IMPLANTATION
• A small fragment set will usually be
b ooook
Step 5: First Ray Lengthening Osteotomy
b oo
eeb appropriate for this technique.
• A locking plate set can also be used. ee/e/e
•
b ee/e/e b
If the first ray is excessively short, it can be lengthened by an osteotomy
• Bone graft may be required for the cuts.
: / / t
/ m
.t.m (Fig. 6.16).
: / / t
/ m
.t.m
• The osteotomy can be performed distally to lengthen the first ray into the first MTP
t
hhtt
• Elevation of the foot for 2 weeks to minimize
fusion.
t
hhtt
• Alternatively, the first ray can be lengthened through the first TMT fusion using
a transverse osteotomy and using a step cut through the first TMT joint and out
wound complications through the plantar cortex in the distal one-third of the MT shaft (Fig. 6.17).
• A first ray lengthening osteotomy can also be performed through a fused first TMT
k rrss
e e k e rrss
joint using a long oblique osteotomy.
e
o o
o k
• Make sure that the patient understands the
o postoperative course and instructions.
o o
o o k
o o
eebb • Wound issues should be followed closely and
monitored.
ee/ / b
e b
• Non–weight bearing for 4–6 weeks
e e / e
/ b
e b
• Start range of motion of ankle/foot/toes at 2 weeks
e
• Make sure that patients with diabetes maintain
good sugar control.
: / / t
/ m
.t.m : / / / m
.t.m
• Full weight bearing in shoe at 10 weeks
t
t ss:
p /
• Treat patients at risk of vitamin D deficiency
p t p ss: /
See also Video 6.1, Revision Hallux Valgus.
p
with oral vitamin D.
t
hht t
• Ensure that smokers quit smoking.
EVIDENCE t
hht t
Ellington JK, Myerson MS, Coetzee CC, Stone RM. The use of the Lapidus procedure for recurrent hal-
POSTOPERATIVE INSTRUMENTATION/ lux valgus. Foot Ankle Int 2011;32:674–80.
IMPLANTATION A review of 32 feet undergoing revision of hallux valgus surgery for recurrence using the Lapidus
k e r s
rs
• A walker boot can be used.
e k eers
rs
procedure. Union rate was 96%. Most prior procedures were distal osteotomies. Good to excellent
results were reported in 87% of cases. The authors concluded that the procedure had a high fusion
o o
o o k oo k
rate with excellent radiographic correction, resulting in patient satisfaction.
o o oo
eebb b b
Kitaoka HB, Patzer GL. Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin
ee/ e
/ e b
Orth Rel Res 1998;347:208–14.
ee/e/e b
A review of 18 patients with 20 procedures for failed hallux valgus. Ten patients had resection
: / / t
/ .
tm.m : / / t
/.tm
. m
arthroplasty (Keller procedure) and eight had fusions. Complications were more common in the
t p ss
p : / t p ss : /
resection arthroplasty group. Because of more rapid remobilization, resection arthroplasty was
recommended in older patients.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
A t
hht t t
hht t A
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
B
t pps s : / t p s
p s : / B
t
hhtt
FIG. 6.16 t
hhtt FIG. 6.17
k rrss
e
Ankle Clin 2014;19(3):361–70.
k rrss
Lee KT, Park YU, Jegal H, Lee TH. Deceptions in hallux valgus: what to look for to limit failures. Foot
e e e
o o
o o k o o k
A review article outlining techniques to reduce failure by careful preoperative assessment and cor-
o o o o
eebb b b
rect procedure selection.
/ e e b / e e b
Raikin SM, Miller AG, Daniel J. Recurrence of hallux valgus: a review. Foot Ankle Clin 2014;19(2):
259–74.
ee / ee /
: / / t
/ m
.t.m : / / t m
.t.m
A review of assessment and treatment of recurrent hallux valgus. The authors recommend the
/
ss: /
correct the deformity than the initial procedure.
t p t p ss:
p /
identification of the cause of the recurrent hallux valgus and the use of a procedure more able to
p
t
hht t t
hht t
Sammarco GJ, Idusuyi OB. Complications after surgery of the hallux. Clin Orthop Relat Res
2001;391:59–71.
A review article looking at the complications and treatment of hallux valgus surgery. A complication
should be recognized early and treated appropriately.
Speight Grimes J, Coughlin MJ. First metatarsophalangeal joint arthrodesis as a treatment for failed
hallux valgus surgery. Foot Ankle Int 2006;27:887–93.
k r s
rs rs
rs
Twenty-nine patients with 33 procedures were available for review of first metatarsophalangeal joint
e e k ee
fusion as a treatment of failed hallux valgus. This was reported as being a reliable treatment for a
o o
o o k o oo k o
number of complications of hallux valgus procedures. The authors cautioned that the outcomes of
o o
eebb ee / b
e b
revision procedures were not as good as primary procedures.
/ e ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh7t
PROCEDURE hht
Correction
rss of Acquired Hallux Varus
rss
k ke
oGlenne r k
oo e
ke r
eeb o B. Pfeffer
b oo
ee/ e
/ebboo
ee/ e
/ b
e
o
b o
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / INDICATIONS
t p ss
p : /
t
hht t
• Hallux varus must be reducible. Malunion of the
metatarsal or proximal phalanx may preclude
a simple soft-tissue correction. A negative
• Symptomatic deformity
• Difficulty with footwear
t
hht t
intermetatarsal angle may require correction. • Flexible deformity
Consider a fusion for an arthritic joint. • Nonarthritic first metatarsophalangeal (MTP) joint
k eers
rs
k er
ers
EXAMINATION/IMAGING
s
b ooook
• There are no long-term studies published on
b ooook
• Weight-bearing examination of the toe as shown in Fig. 7.1.
b o o
• Flexible great toe interphalangeal and MTP joints. A fixed deformity may require a
eeb the outcome of this procedure.
ee/ e
/ e b fusion of either joint.
ee/ e
/ e b
TREATMENT OPTIONS
: // t/.tm
. m / /t tm
• Standing anteroposterior (AP), lateral, and both oblique radiographs of the foot.
. . m
Oblique views are helpful in the evaluation of the joint and sesamoids for arthritic
: /
t p ss : /
• Stretching out the shoe toe box can diminish
p tp pss : /
changes (Fig. 7.2).
irritation of the toe.
t
hht t
• Several other procedures exist for the correction
of hallux varus, all of which require fusion of the
t
hht t
• Standing AP and lateral radiographs of the normal foot (helpful as in intraoperative
template).
SURGICAL ANATOMY
adjacent interphalangeal joint, bony procedures,
or consist of one of the local extensor tendons
(Johnson and Spiegel, 1984; Lau and Myerson, • Lateral collateral ligaments of the great toe (Fig. 7.3)
keerrss
2002). Another option is a reconstruction of the
lateral collateral ligament with an allograft.
keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
FIG. 7.2
k e r
e s
rs FIG. 7.1
k eers
rs Collateral ligaments
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
60 t
hht t t
hht t FIG. 7.3
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 7 Correction of Acquired Hallux Varus 61
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 7.4
k r
eerss FIG. 7.5
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t Incision
keerrss keerrss
eeb ee/e/e b ee/e/e b 5 mm Sesamoid
bone
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t ppss : / t p
B
pss : /
t
hhtt
t
hhtt
FIG. 7.6
POSITIONING
k rrss
• The patient is placed in the supine position.
e e k e rrss
e
• A bump under the ipsilateral hip may be helpful to position the foot.
o o
o o k o o o k o
• An ankle tourniquet can be used, but a thigh tourniquet is preferable so that no pres-
o o
eebb procedure.
ee e
/ b
e b ee/ e
/ b
e b
sure is placed on the long extensors and flexors as the toe is balanced during the
/
PORTALS/EXPOSURES
: / / t
/ m
.t.m : / / t
/ m
.t.m PORTALS PEARLS
t p ss:
p / t
• A medial incision over the first MTP joint (Fig. 7.4).
p ss:
p / • The plantar medial sensory nerve can easily be
t
hht t t
hht t
• Expose the capsule, in preparation for a vertical capsulotomy.
• Locate and protect the dorsal and plantar sensory nerves.
injured during the dissection and capsulotomy.
It must be clearly identified, dissected free,
and protected.
• A 3- to 4-cm incision in the first intermetatarsal space.
PORTALS PITFALLS
PROCEDURE
k e r
e s
rs k eers
rs • Previous incisions may preclude the use of two
incisions. Sometimes a single dorsal-lateral
o o
o o k
Step 1
o o
oo k oo
incision has been used for a bunionectomy.
eebb b b Correction through this single incision is
e / / e b
and extending to the dorsal capsular attachment (Fig. 7.5).
e ee/e/e b
• Make a vertical incision in the medial capsule, starting at the tibial sesamoid inferiorly
e more difficult, but possible, if it is extended
proximally and distally, and medial and lateral
: / / / .
tm.m : / / t
/.tm
. m
• The incision should be 1 cm proximal to the joint line, which allows the joint to remain
t flaps are created.
t p ss
p : / t p ss
p : /
covered as the toe is brought into a corrected varus position (Fig. 7.6).
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
62 hht
PROCEDURE 7 Correction of Acquired Hallux Varus hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 7.7
er
kkerss FIG. 7.8
b ooook b oooo b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
FIG. 7.9 t
hhtt
FIG. 7.10
STEP 2 PEARLS Step 2
k rrss
• A release of the medial capsule is a key step
e e
in balancing out the joint. A wide release is
•

k e rrss
The abductor hallucis tendon is located at its insertion on the base of the
e
proximal phalanx. A complete release of the tendon is usually required
o o
o o kessential.
o o o k
(Fig. 7.7).
o o o
eebb STEP 2 INSTRUMENTATION
ee/ e
/ b
e b
Step 3
ee/ e
/ b
e b
: / / t
• The repair requires the use of the Arthrex
/ m
.t.m : / / t
/ m
.t.m
• Deepen the incision in the first web space. Expose the lateral capsule. Protect the
implant with 2-0 FiberWire.

t ss:
(Naples, FL) Mini TightRope Endobutton
p p / t p ss:
p /
plantar neurovascular bundle.
• Divide the capsule with a vertical incision. Create distal and proximal capsular flaps
t
hht t t
hht t
that can be repaired after correction of the varus (Fig. 7.8).
STEP 3 PEARLS
Step 4
• An excision of the tibial sesamoid may be • Place a 1.2-mm guidewire across the base of the proximal phalanx from medial to
required if it blocks reduction of the toe.
k e r
e ss
However, with adequate soft-tissue release this
r
is rarely required.
lateral.
k eers
rs
• The medial entry point is 1 cm distal to the joint line, in the concave portion of the
o o
o o k o o
oo k
proximal phalanx. The pin should exit just plantar to the longitudinal axis of the
oo
eebb ee/ e
/ b
e b e /e/ebb
phalanx, approximately 5 mm from the joint line (Fig. 7.9).
• The goal is to have the FiberWire anatomically recreate the location of the lateral
e
: / / t
/ .
tm.m : / / t
/.tm
. m
collateral ligament, as best as possible.
t p ss
p : / t p ss
p : /
• Overdrill the pin with a cannulated Arthrex 2.7-mm drill bit (Fig. 7.10).
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 7.11
b oooo k
b o o
FIG. 7.12
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : /
t ppss : /
t
hhtt t
hhtt
FIG. 7.13
Step 5 STEP 5 PEARLS
k rrss
e
mal phalanx.
k rrss
• Pass the 1.6-mm guide pin with the attached suture through the tunnel in the proxi-
e e e
• The intermetatarsal plantar neurovascular
o o
o o k o o o k
• The Arthrex Endobutton and FiberWire are passed from medial to lateral (Fig.
o o o
bundle may be more dorsal than expected, and
vulnerable to injury. This distorted anatomy
eebb 7.11).
ee/ e
/ b
e b
• The phalanx can be externally rotated to help expose the lateral portion of the
ee/ e
/ b
e b results from previous bunion surgery in which
the adductor attachment and the transverse
: / / t
/ m
.t.m
tunnel, allowing the Endobutton to be pulled out (Fig. 7.12).
: / / t
/ m
.t.m metatarsal ligament were released.
Step 6
t p ss:
p / t p ss:
p /
t
hht t t
hht t
• A similar approach is taken to the metatarsal tunnel. The medial entry site is 1–2 cm
proximal to the joint line, and the exit site laterally is 5 mm (Fig. 7.13). STEP 6 PEARLS
• As opposed to the tunnel in the proximal phalanx, the metatarsal tunnel is angled • The lateral capsular reefing is an important
dorsally. It should exit laterally, just dorsal of the longitudinal axis, to recreate the part of the procedure as it reinforces the repair
and may stabilize the joint if the FiberWire
k e r s
origin of the lateral collateral ligament.
rs e rs
rs
• The Endobutton is then passed from lateral to medial (Fig. 7.14).
e k e
construct loosens over time.
o o
o o k
Step 7 o o
oo k oo
eebb e / e
/ b
e b e /e/
• The lateral vertical capsular flaps are repaired with several figure-of-8 sutures using
e e ebb
2-0 absorbable suture (Fig. 7.15).
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
64 hht
PROCEDURE 7 Correction of Acquired Hallux Varus hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A
k eers
rs k er
erss FIG. 7.15
eeb ee/ e
/ e b ee/ e
/ e b
1 cm 1 cm
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
Just dorsal to
longitudinal axis
t
hht t t
hht t
Just plantar to
Sesamoid bone FiberWire longitudinal axis
keerrss keerrss
b ooook
B
b ooook b oo
eeb
FIG. 7.14
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t

p s
p s : / FIG. 7.16
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
FIG. 7.17
Step 8
k e r
e s
rs k eers
• The FiberWire and Endobutton are tightened (Fig. 7.16). Six half-hitches with a long
rs
tail allow the knot to be adequately buried.
o o
o o k oo k
• Reduction of the joint is confirmed by fluoroscopy (Fig. 7.17). The proximal Endobut-
o o oo
eebb ee/ e
/ b
e b
nent position.
ee/e/ebb
ton should be turned parallel to the metatarsal, which usually creates the least promi-
: / / t
/ .
tm.m : / / t
/.tm
. m
• The white pull-through suture is cut and removed.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : / B
tp pss : /
t
hht t t
hht t FIG. 7.18

keerrss keerrss
b ooook bandages between the first and second toes.
b ooook
• A bunion spica dressing is applied that holds the hallux in a valgus position, without
b oo
eeb /e e b
• The patient should be non–weight bearing for 2 weeks. At 2 weeks postoperatively,
ee / e
weight bearing is begun in a postoperative shoe. Range-of-motion exercises can be
e/e/e b
: / / t
/ m
.t.m : / / t m
.t.m
started as early as 2 weeks after surgery. Normal footwear can be used at 6 weeks
/
after surgery.
t
hhtt
months postoperatively. t
hhtt
• Standing AP (Fig. 7.18A) and lateral (Fig. 7.18B) radiographs should be obtained 3
• Potential complications include stiffness of the joint. Overcorrection of the hallux

should also be avoided.
EVIDENCE
k e rrss
e k e rrss
e
Johnson KA, Spiegel PV. Extensor hallucis longus transfer for hallux varus deformity. J Bone Joint Surg
o o
o o k
Am 1984;66:681–6.
o o
o o k o o
eebb b b b b
A retrospective review of a technique that uses the extensor hallucis longus passed beneath the
ee/ e
/ e ee/ e
/
transverse metatarsal ligament into the base of the proximal phalanx (Level IV evidence [case
e
series]).
: / / t
/ m
.t.m : / / t m
.t.m
Lau JT, Myerson MS. Modified split extensor hallucis longus tendon transfer for correction of hallux
/
t ss:
p /
varus. Foot Ankle Int 2002;23:1138–40.
p t p ss:
p /
A retrospective case series of a technique that used a split extensor hallucis longus tendon (Level
IV evidence).
t
hht t t
hht t
Pappas AJ, Anderson RB. Management of acquired hallux varus with an Endobutton. Tech Foot Ankle
Surg 2008;7:134–8.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh8t
PROCEDURE hht
Arthroscopy
rss of the Great Toe rs s
o kkee r o kkee r
o
eebb o o
Alastair Younger and Kelly Hynes
e bboo o e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t p :
t ss
p :
hht
• For some indications the surgery can be
combined with an open procedure, such
hht
• Loose bodies
• Hallux valgus: synovitis
as assessment for turf toe (confirm the • Hallux valgus: lateral release
plantar plate rupture prior to surgery) or
• Turf toe: assessment of plantar plate
k eers
r
sesamoidectomy (confirm the arthritic
s
change).
k er
erss
• Sesamoid to metatarsal head arthritis
b ooook • Arthroscopic cheilectomy will not work if

there is extensive arthritis of the sesamoid to
b ooook
• Gout
• Dorsal osteophytes
b o o
eeb metatarsal head articulation.
ee/ e
/ e b • Hallux rigidus
ee/ e
/ e b
: // t/.tm
. m
• Chondral defect
/ /t/.tm. m
• Arthroscopic first metatarsophalangeal (MTP) fusion
:
t p ss
p : / • Synovitis
tp pss : /
t
hht t
• Hallux valgus can be addressed by either a
synovectomy or an arthroscopic lateral release
and arthroscopic Lapidus.
t
hht t
• Diagnostic arthroscopy for recurrent pain or swelling localized to the MTP joint
• Arthrofibrosis
• Osteochondral defects
• Advanced degenerative change may not • Pigmented villonodular synovitis
benefit from an arthroscopic débridement.
• Ganglion excision
keerrss keerrss
EXAMINATION AND IMAGING
b ooook b ooook oo
• A standing anteroposterior view of a dorsal osteophyte is shown in Fig. 8.1.
b
eeb ee/e e b /e e b
• A standing lateral view of a dorsal first MTP osteophyte is shown in Fig. 8.2.
/•

ee /
Patients are observed standing with both feet bare. The forefoot alignment is
: / / t
/ m
.t.m : / / t m
.t.m
inspected, as well as hallux valgus deformity. Claw toes may indicate lesser toe
/
t ppss : / overload.
t ppss : /
t
hhtt t
hhtt
• The gait pattern is observed. Patients may walk on the lateral border of the foot to
avoid weight on a painful first MTP joint.
• Patients may not be able to walk on tip toes because of MTP joint pain or loss of
dorsiflexion range.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m

FIG. 8.1
t p ss
p : /
t p ss
p : / FIG. 8.2
66 t
hht t hhtt t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 8 Arthroscopy of the Great Toe 67
• Inspection may demonstrate a callus under the interphalangeal (IP) joint because of
k e r
e s
rs
loss of range of motion.
k eers
r s
• The first ray may be unstable because of ligament laxity. This may cause elevation of
o o
o o k oo k
the first ray and failure of weight bearing through the sesamoids.
oo o o
eebb e /ebb
• Range of motion is measured with a goniometer and compared with the opposite
/ e
side. The range of motion is also measured at the IP joint level.
e ee/ e
/ b
e b
: / / / .
t m m
• The sesamoids are palpated to determine if they are a source of discomfort.
t . : / / t
/ .
t m
. m
t p ss : /
• The flexor and extensor tendons are tested for integrity.
• The neurovascular examination is performed.
p t p ss
p : /
t
hht t t
hht t
• Imaging should include a standing anteroposterior and lateral view of the foot,
and on occasion a sesamoid view.
• Magnetic resonance imaging can be useful for assessment of the sesamoids and
articular surfaces.
• A computed tomography scan can be of value in assessing osteophyte anatomy
k eers
rs and joint space narrowing.
k er
erss
b oo k
ooTREATMENT OPTIONS
b ooook b o o
eeb • Rocker sole shoe
ee/ e
/ e b ee/ e
/ e b
// t/ tm
• Rigid sole shoe with a rocker
. . m / /t/.tm. m
• Orthotic with a metatarsal pad, or a Morton’s extension for an elevated first ray
: :
ss : / ss : /
• Orthotic with a metatarsal head cut out for metatarsal head overload
t p p tp p
t
hht t
• Medical management of gout
• Physiotherapy and gait training t
hht t
• Local anesthetic and steroid injection into the MTP joint
• Topical or oral antiinflammatories
SURGICAL ANATOMY
keerrss keerrss
b ooook b ooook
• Anatomy of the first MTP joint from the dorsal side can be seen in Fig. 8.3.
• Anatomy of the dorsal portals is shown in Fig. 8.4.
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t
ppss : / Distal phalange
t
hhtt t
hhtt
Proximal phalange
Dorsomedial
portal
Dorsolateral
rrss rrss
portal
Medial
o k e
k e o k e
k e
portal
Dorsal sling
o
eebb o o Tendon of abductor
e b o
b o o e b o
b o
Perforating fibers
e/ / e
hallucis and insertion
e
fibers contributing
m m ee/ / e
arising from plantar
aponeurosis
: / /
/ t
/ .t.m
to dorsal sling
: / /
/ t
/ .t.m
t t p
t ss:
p
Deep fibers of extensor
t t p
t ss:
p
Tendon of adductor
hht Metatarsal
hht to dorsal sling
Superficial fibers of extensor

k e r
e s
rs k eers
rs Extensor hallucis
o o
o o k o o oo k brevis tendon
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss :
FIG. 8.3
p /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
68 hht
PROCEDURE 8 Arthroscopy of the Great Toe hht
• First MTP joint arthroscopy is relatively easy to perform from the dorsal side in a
k e r
e s
rs k eers
mobile joint.
r s
• The joint space not only includes the proximal phalanx and metatarsal head but also
o o
o o k oooo k
the two sesamoid to metatarsal head articulations that can be visualized during the
o o
eebb ee/ e
/ebb procedure.
e / e
/ b
e b
• The extensor hallucis longus provides the landmark for the dorsal medial and dorsal
e
: / / t
/ .
t m
. m lateral portals.
: / / t
/ .
t m
. m
t p ss
p : / t p ss : /
• The joint margin can usually be palpated from the dorsal side. The thumb of the left
hand is used to feel for the joint margin, while the right hand grasps and pulls the
p
t
hht t t
hht t
phalanx to open the joint. Dorsiflexion and plantar flexion range will also allow the
bone margins to be felt.
• Structures at risk are illustrated in Fig. 8.4. The dorsal medial and dorsal lateral nerves
are variable in location and anatomy, hence the need for blunt dissection within the
subcutaneous space where the nerves lie.
k eers
rs k er
erss
• The plantar medial and plantar lateral nerves lie in a deeper plane and next to the
b ooook b ooook
sesamoids. As they are on weight-bearing surfaces, damage to these nerves can
b o o
result in considerable disability. However, they are a distance away from any likely
eeb ee/ e
/ e b portal placement.
ee/ e
/ e b
: // t/.tm
. m / /t/ tm
• The short flexor tendons insert into the medial and lateral sesamoids. The flexor hal-
. . m
lucis longus passes between the sesamoids in a flexor sheath and passes distally
:
t p ss
p : / ss : /
under the phalanx. The short flexors insert distal to the sesamoids by two tendons
tp p
t
hht t t
hht t
(a medial and lateral) into the base of the proximal phalanx. They form part of the
plantar plate that stabilizes the MTP joint.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e Dorsomedial
k e rrss
e
o o
o o k portal
o o
o o k o o
eebb ee e
/ b
Medial portal
/ e b e /
Dorsolateral
e e
/ b
e b
: / / t
/ m
.t.m : /
portal
/ t
/ m
.t.m
t p ss:
p /
Superficial peroneal
nerve and branches
t p ss:
p /
t
hht t t
hht t Deep peroneal
nerve and branches
Branch saphenous
nerve
k e r
e s
rs k eers
rs
o o
o o k o o
o o k FIG. 8.4
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
POSITIONING POSITIONING PEARLS
k eerss k eers
• Positioning of the patient on the table is shown in Fig. 8.5.
r r s
• The surgery can be done with local nerve block, such as spinal or general anesthetic.
• Bring the patient to the foot of the bed so that
the great toe can be arthroscoped from the
oooo k o oo k
• A mini C-arm may be used and should be placed on the same side of the bed as the
o o o
bottom of the bed.
eebb PORTALS/EXPOSURES
surgical side.
ee/ e
/ebb ee/ e
/ b
e b • Ensure that the foot is rotated so that the toes
are vertical to the floor to improve access to
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
the lateral portal.
t p ss
p : /
• Finding the medial portal is shown for the left leg in Fig. 8.6.
t p ss
p : / POSITIONING PITFALLS
t
hht t t
hht t
• Developing the lateral portal is shown for the right leg in Fig. 8.7.
• There are two main portals which can be used, and up to four or five accessory
portals.
• If the arthroscopy tower is on the same side of
the bed as the operative side, the surgeon may
have a hard time seeing the monitor if sitting
• The two main portals are the dorsal medial and dorsal lateral portals. These are on the side of the bed.
placed on each side of the extensor hallucis longus at the level of the joint line. • Make sure the calf tourniquet is low enough to
k eers
rs k er
ers
• A plantar medial portal just above and distal to the medial sesamoid can be used to
s
visualize or instrument the plantar side of the metatarsal head, or see the sesamoid
avoid the peroneal nerve at the fibular head.
b ooook to metatarsal head articulations.
b ooook b o o
eeb of the joint on the lateral side.

ee/ e
/ e b ee/ e
• A lateral first web space portal can be used to visualize and access the lateral side
/ e b • A bean bag is used to elevate the surgical hip.

• A contoured calf tourniquet is placed midcalf.
: // t/.tm m : / /t/.tm. m
• Accessory dorsal portals can be placed more proximally to assist in the removal of
.
dorsal osteophytes.
t p ss
p : / tp pss : /
• Accessory dorsal portals can also be used carefully. These can be placed just adja-
t
hht t
ditional instrumentation.
t
hht t
cent to the primary portals, either just medial or lateral, and at the joint line, for ad-
• Toe traction can be used. We personally
prefer not to use it as the joint can be better
visualized by plantar flexing the toe. The
traction will prevent this motion.
keerrss keerrss PORTALS/EXPOSURES PEARLS

• Palpate the portals from the dorsal side. The
b ooook b ooook b oo joint line can be felt with a little distraction and
eeb ee/e/e b ee/e/e b motion at the MTP joint.
: / / t
/ m
.t.m : / / t
/ m
.t.m PORTALS/EXPOSURES PITFALLS
t ppss : / t ppss : / • The portals may be misplaced if dorsal
t
hhtt t
hhtt
osteophytes are present, and the osteophyte
may be confused with the joint line. Flexion
and extension of the joint will define the joint
line.
• Avoid sharp dissection deep to the dermis as
the dorsal medial and dorsal lateral digital
k e rrss
e FIG. 8.5
k e rrss
e
nerves are subcutaneous in this position.
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
FIG. 8.6
t
p ss
p : / FIG. 8.7
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
70 hht
k e r
e ss
• The MTP joint is relatively easy to arthroscope
r
similar to the ankle.
k eers
r s
Step 1: Joint Visualization and Portal Establishment
o o
o o k
• Placement of the scope and blunt trocar in the
oooo k
• The instruments in both portals are shown in Fig. 8.8.
o o
eebb over-the-top position will allow easy access.
• In patients with osteopenia, a C-arm x-ray of the
ee/ e
/ebb e / / b
e b
• Plantar plate rupture is shown in Fig. 8.9.
e
• An initial diagnostic arthroscopy is performed. The medial and lateral sides as well as
e
: / / t
/ t m
foot should be taken if there is concern about the
. . m
positioning of implants. It is easier to place the
: / / / .
t m
. m
the dorsal and plantar sides of the joint are re-reviewed.
t
ss : /
instruments into the soft bone than into the joint.
t p p t p ss : /
• The gutters are also visualized and débrided of synovium to allow visualization.
• On the dorsal side the synovium will often prevent easy visualization and will require
p
STEP 1 PITFALLS
t
hht t t
hht
removal. t
• Avoid performing an interosseous placement
of the scope by careful palpation of the joint
line.
k eers
rs k er
erss
b ooook
IMPLANTATION
b ooook b o o
eeb • A 1.9-mm, 2.4-mm, or 2.9-mm 30°
arthroscope can be used. The 2.9-mm 30°
ee/ e
/ e b ee/ e
/ e b
t . m
. m
with a narrow sheath will fit in a larger patient.
: // / t : / /t/.tm. m
• A 2.9-mm or 3.5-mm shaver blade.
t p ss
• Small joint curettes, 2-mm osteotomes.
p : / tp pss : /
t
hht t
• C-arm to assess resection if required.
• Small joint grasper.
• Inflow can be achieved using the arthroscope
t
hht t
via gravity or using an intravenous tubing and
hand-pumping fluid into the joint.
keerrss keerrss
b ooook
• Once a cartilage defect has been visualized, its
b ooook b oo
eeb correct treatment is still to be determined.
ee/e/e b ee/e/e b
• Compared with the ankle, the MTP joint has
/
usually got some cartilage delamination as
: / t
/ m
.t.m
: / / t
/ m
.t.m
t p s : /
opposed to a combined osteochondral defect.
s
• Débridement is less likely to work in patients
p t ppss : / FIG. 8.8
t
hhtt
with disease on both sides of the joint, with
more extensive cartilage damage.
t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb b b FIG. 8.9
ee/ e
/ e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Step 2: Dorsal Cheilectomy STEP 2 PEARLS
k e r
e ss
• Placement of K-wires is shown in Fig. 8.11.
k eers
r s
• Appearance of a joint with dorsal arthritis is shown in Fig. 8.10.
r • Use K-wires to determine the extent of
resection.
o o
o o k o
• Appearance on C-arm views can be seen in Fig. 8.12.
ooo k o o
eebb formed.
ee e
/ebb
• After arthroscopy and inspection of the joint, a dorsal cheilectomy can be per-
/ ee/ e
/ b
e b STEP 2 PITFALLS
t . m
. m t . m
. m
• Many techniques exist to perform this procedure arthroscopically with removal of the
: / / / t : / / / t
• Make sure that adequate bone resection is
t p p : /
excess dorsal bone using a burr.
ss t p ss
p : /
• Because it is hard to clearly orientate in the joint, K-wires can be placed along the
performed.
• A cheilectomy may also need to be performed
t
hht t t
hht t
shaft of the metatarsal into the joint, with two parallel wires being placed.
• The location of the tips of the wires within the joint can be confirmed using the arthro-
on the proximal phalanx.
• The medial and lateral gutters may need
resection at the same time.
scope. Ideally, the wires should penetrate the joint at the edge of the intact cartilage • Make sure the tendon or soft tissues above the
margin. osteophyte are not damaged. Dorsiflexing the
MTP joint during the resection will reduce this risk.
k eers
rs until both wires are clearly seen.
k er
ers
• A burr (2.9 mm or 3.5 mm) is then used from a dorsal portal to remove the exostosis
s • A second more proximal portal can be used at
the same time.
eeb ee/ e
/ e b ee/ e
/ e b STEP 2 INSTRUMENTATION/
: // t/.tm
. m : / /t/.tm. m
IMPLANTATION
• A small joint burr (2.9 mm or 3.5 mm) or a
t p ss
p : / tp pss : / 2-mm osteotome will be required as well as a
t
hht t t
hht t small grasper.
• For some patients, cheilectomy is advised,
keerrss keerrss whereas for others possible fusion is

recommended. This means that the joint may
b ooook b ooook b oo have advanced arthritic changes not visible on
eeb ee/e/e b ee/e/e b a preoperative x-ray.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
FIG. 8.10
t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb
FIG. 8.11
ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m
: / / t
/.tm
. m FIG. 8.12
t p ss
p : / t p pss : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
72 hht
STEP 3 PEARLS Step 3: Chondral Débridement
k e r
e ss
• Dorsiflexion and plantar flexion of the MTP
r
joint bring different parts of the metatarsal
k eers
r s
• If an isolated chondral defect is identified, it can be managed arthroscopically with
débridement and possible chondral picking.
o o
o o khead into contact with the instruments.
o oo k o
• For an isolated chondral defect, this usually resides on the metatarsal head centrally.
o o
eebb ee/ e
/ebb ee/ e
/ b
e b
It can therefore be fairly easily visualized.
• A curette is used through the opposite dorsal portal to curette the edges and deter-
STEP 3 PITFALLS
/ / t
/ .
t m
. m
• If the cartilage defect is too extensive, involves
: t . m
. m
mine the extent of the lesion.
: / / / t
ss :
both sides of the joint, or is associated
t p p / t p ss
p : /
• The cartilage and bone are débrided back to stable cartilage and bone.
• Finally, view the plantar side of the joint and ensure that there are no loose bodies.
t t
with a major deficit in dorsiflexion, then the
hht
débridement is unlikely to work. t
hht t
Step 4: Visualization and Assessment of Sesamoids
• The sesamoid to metatarsal head articulation can usually be seen during first MTP
STEP 3 INSTRUMENTATION/ joint arthroscopy.
IMPLANTATION
rs
rs
• A 30° chondral awl
k ee k eerrs
• The sesamoids can be seen by plantar flexing the MTP joint and looking back toward
s
the sesamoids; the articulation can usually be seen.
b ooook b ooook
• The plantar medial portal is often needed during this view to remove synovium to
b o o
eeb STEP 3 CONTROVERSIES
• In the future, the degree of cartilage damage
ee/ e
/ e b allow visualization.
e / e
/ e b
• If needed, the arthroscope can be placed in the plantar medial portal to see the sesa-
e
: // t/.tm
that can be successfully débrided will hopefully
. m : / /t/.tm. m
moid to metatarsal head articulation.
ss :
benefit from débridement can be correctly
t p p /
be determined so that those patients who can
tp ss : /
• A probe can be placed in a separate portal to determine the integrity of the flexor
structures. Disruption can exist either at the sesamoid level or at the insertion of the
p
identified.
t
hht t t
hht t
flexor tendons into the base of the phalanx.
STEP 4 PEARLS
• For all the aforementioned procedures early mobilization can be achieved.
• The sesamoid arthroscopy can be used in
• A nylon suture is placed in each portal to prevent sinus formation.
keerrs
conjunction with an open procedure. This can
s
include a sesamoid excision or a plantar plate
keerrss
• Patients are kept non–weight bearing for a week after surgery to prevent sinus for-
b ooook repair.
• Sesamoid excision has good results if done
b ooook mation in the portal site.
b oo
• After this point the patients can be mobilized, weight bearing as tolerated.
eeb carefully, and therefore may be the most
appropriate procedure if there is extensive
ee/e/e b ee/e/e b
• The outcomes are not well described in papers to date. However, most case series
sesamoid to metatarsal head arthritis.
: / / t
/ m
.t.m / / t
/ m
show promising results, with few wound complications and successful achievement
.t.m
of the surgical goals with excellent patient satisfaction.
:
t ppss : / EVIDENCE
t ppss : /
STEP 4 PITFALLS
t
hhtt
• The sesamoid to metatarsal head articulation
t
hhtt
Ahn JH, Choy WS, Lee KW. Arthroscopy of the first metatarsophalangeal joint in 59 consecutive cases.
J Foot Ankle Surg 2012;51:161–7.
may not be seen if there is extensive arthritis in
the rest of the joint, or if the MTP joint is stiff. In 59 cases of first MTP joint arthroscopy there was one case of temporary nerve palsy, and satis-
faction was reported in 95% of cases. American Orthopedic Foot and Ankle Scores improved from
rrss rrss
69 to 92 points.
o k e e
k o k e
Chan PK, Lui TH. Arthroscopic fibular sesamoidectomy in the management of the sesamoid osteomy-
k e
elitis. Knee Surg Sports Traumatol Arthrosc 2006;14:664–7.
o
eebb o o
• Best treatment for the sesamoid to metatarsal
head articulation has still to be well studied.
e b o o o o o
A description of an arthroscopic removal of the lateral sesamoid.
b e b b
Davies MS, Saxby TS. Arthroscopy of the first metatarsophalangeal joint. J Bone Joint Surg Br
m ee/ / e 1999;81:203–6.
m ee/ / e
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
One of the original papers on arthroscopic treatment of the first MTP joint. Despite normal inves-
tigations in 6 of the 12 patients, intraarticular pathology was found in all patients and all patients
t p ss:
• Early range of motion and remobilization
t t p t t p
t ss:
demonstrated improvement in outcome.
p
Hunt KJ. Hallux metatarsophalangeal (MTP) joint arthroscopy for hallux rigidus. Foot Ankle Int
hht
should be encouraged after the first week.
hht
2015;36:113–9.
A description of a technique for arthroscopic débridement of hallux ridigus.
Siclari A, Decantis V. Arthroscopic lateral release and percutaneous distal osteotomy for hallux valgus: a
POSTOPERATIVE PITFALLS preliminary report. Foot Ankle Int 2009;30:675–9.
• Failure to start early range of motion may A percutaneous distal osteotomy was combined with an arthroscopic lateral release for hallux
k e r
e ss
reduce the chance of the patient having a good
r
result or rapid recovery from this procedure.
k eers
rs
valgus in 59 procedures with encouraging results.
van Dijk CN, Veenstra KM, Nuesch BC. Arthroscopic surgery of the metatarsophalangeal first joint.
o o
o o k o o
oo k
Arthroscopy 1998;14:851–5.
oo
eebb b b
A series of 24 patients were treated with dorsal débridement for hallux rigidus. Good results were seen
POSTOPERATIVE INSTRUMENTATION/
IMPLANTATION
ee/ e
/ e b ee/e/e b
but with worse outcomes in patients with cartilage defects or with the need for sesamoid resection.
Wang CC, Lien SB, Huang GS, et al. Arthroscopic elimination of monosodium urate deposition of the
/ /
• A walker boot or postoperative shoe may be
: t
/ .
tm.m : / / t
/.tm
. m
first metatarsophalangeal joint reduces the recurrence of gout. Arthroscopy 2009;25:153–8.
ss : /
required for the first 2 weeks after surgery.
t p p t p ss : /
A description on arthroscopic removal of gouty tophi in 15 patients compared with 13 patients re-
ceiving medical treatment alone. The arthroscopic treatment group showed better outcome scores.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh9t
PROCEDURE hht
Hallux
r ss Rigidus: Cheilectomy Withr s and Without a
s
o k ee r
Dorsiflexion
k Phalangeal k ee
Osteotomy
o k r
ooo
b o
m e e /e m ee / e
Christina Kabbash and Leslie
: / t
///t. m
Grujic
. : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp t
hhtt p
t p
INDICATIONS
• Cheilectomy of the first metatarsophalangeal joint (MTPJ) is indicated for painful
k eers
rs k er
erss
hallux rigidus with impinging bone spurs. Most frequently indicated for grade I and
b ooook b ooook
grade II hallux rigidus, but may also be utilized for grade III.
• Grade I includes mild to moderate osteophyte formation with joint space preser-
b o o
eeb vation.
ee/ e
/ e b ee/ e
/ e b
// t/ tm
. m / /t/ tm
• Grade II includes moderate osteophyte formation with joint space narrowing.
. .
• Grade III includes extensive osteophyte formation with loss of joint space.
: : . m
ss : / ss
• A dorsal closing wedge phalangeal osteotomy (Moberg) is indicated.
t p p tp p : /
t
hht t t
hht t
• When there is loss of cartilage on the remaining aspect of the first metatarsal (MT)
head after cheilectomy.
• When dorsiflexion of the first MTPJ remains limited after cheilectomy.
• A dorsal closing wedge osteotomy shifts the phalangeal base to the plantar as- INDICATIONS CONTROVERSIES
pect of the first MT head where the cartilage is usually in better condition and • Grade III hallux rigidus can be treated with
keerrss keerrss
unloads the dorsal aspect of the first MTPJ allowing increased dorsiflexion. It also cheilectomy and associated procedures,
b ooook ooook
places the proximal phalanx of the hallux in slight dorsiflexion relative to floor.
oo
• In cases of grade III hallux rigidus with extensive cartilage loss, where the patient
b b
fusion, or joint replacement. Fusion is generally
recommended as the best procedure for
eeb osteotomy can be performed.

ee/e/e b ee/e/e b
prefers motion to fusion, a combination of cheilectomy with a dorsal closing wedge pain relief and correction of accompanying
deformity for a stage III hallux rigidus.
TREATMENT OPTIONS
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
• Conservative treatment of hallux rigidus involves icing, nonsteroidal antiinflamma-
tory drugs, and cortisone injections for inflammation. Stiff soled, rocker bottom-type
footwear to protect the great toe from dorsiflexion and avoidance of activities that
require dorsiflexion of the hallux are recommended.
k rrss
EXAMINATION/IMAGING
e e k e rrss
e
o o
o k
o o o
o o k o o
eebb ee e
/ b
e b
• Swelling of the first MTPJ with palpable and often visible osteophytes.
/
• Overlying skin may demonstrate pressure ulcers, bursitis, or hyperkeratosis.
ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Tenderness to palpation over the dorsal first MTPJ and often over the first web space.
t ss:
p /
is 30° of plantar flexion and 90° of dorsiflexion).
t p ss:
p /
• Restricted range of motion (ROM) compared with the unaffected side (normal ROM
p
t
hht t t
hht t
• Pain with axial loading of the joint, dorsiflexion, and plantar flexion.
• May have a Tinel sign to tapping over the dorsal medial first MTPJ and decreased
sensation over the dorsomedial hallux.
• Rule out gout and other forms of inflammatory arthritis.
r s
r
Imaging
k e e s k eers
rs
o o
o o k oo k
• Weight-bearing anteroposterior, lateral, and oblique radiographs of the foot may show
o o oo
eebb e / b
e b
first MTPJ line sclerosis, narrowing, flattening, subchondral cysts, prominent osteo-
/ e
phytes, and fractured osteophytes. Degenerative sesamoids may also be noted.
e ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
• Magnetic resonance imaging is indicated for painful ROM of the first MTPJ that does
t p ss : /
chondral injuries should be assessed.
p t p ss
p : /
not correspond to radiographic findings. Plantar plate, dorsal capsule, and osteo-
t
hht t t
hht t 73
t t p
t ss:
p t t p
t ss:
p
74 hht
PROCEDURE 9 Hallux Rigidus: Cheilectomy With and Without a Dorsiflexion Phalangeal Osteotomy hht
Dorsomedial branch
superficial peroneal
k e r
e s
rs k eers
r s Extensor
nerve
o o
o o k oooo k Extensor
o
hallucis
obrevis
eebb b b
hallucis
ee/ /e b
Flexor
e
hallucis
longus
ee/ e e
longus
/ b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / Flexor
hallucis
t p ss
p : /
t
hht t brevis
Sesamoids
t
hht t Abductor
Flexor
hallucis brevis
Flexor
hallucis
muscle with sesamoid longus
FIG. 9.2
k eers
rs k er
erss
b ooook FIG. 9.1
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 9.3
k e rrss
e k e rrss
e
o o
o o k o o
o o k
SURGICAL ANATOMY
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
• Note insertions of the extensor hallucis longus (EHL), flexor hallucis longus (FHL), ex-
tensor hallucis brevis (EHB), flexor hallucis brevis (FHB), abductor halluces, adduc-
: / / t
/ m
.t.m : / / t
/ m
.t.m
tor hallucis; dorsomedial cutaneous branch of the superficial peroneal nerve; distal
t p p /
ss: POSITIONING t p ss:
p /
branches of the saphenous nerve. Sesamoids are shown in Figs. 9.1 and 9.2.
t
hht t t
hht t
• The patient should be positioned supine with a hip bump as needed to place the foot
in neutral. A bump can be used under the ankle to stabilize the foot and elevate for
• Medial exposure as opposed to dorsal ease of performing fluoroscopy intraoperatively.
exposure for cheilectomy allows for sesamoid
k e r
e s
rs
exposure and mobilization, ease of performing
a dorsomedial closing wedge osteotomy to
k eers
rs
PORTALS/EXPOSURES
o o
o o kcorrect both hallux valgus interphalangeus
o o
oo k
• A medial incision is made over the first MTPJ extending from the interphalangeal
oo
eebb and increase hallux dorsiflexion, less dorsal
contracture limiting postoperative plantar
ee/ e
/ b
e b e / /ebb
joint of the hallux to the first MT metaphysis (Fig. 9.3).
e
• Fig. 9.3 shows an incision over the medial aspect of the first MTPJ extending to
e
incision.
: / / t
/ tm
flexion, and a more cosmetic position of the
. .m : / / t
/.tm
. m
the interphalangeal joint. The dorsomedial cutaneous branch of superficial peroneal
t p ss
p : / nerve is visualized.
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 9 Hallux Rigidus: Cheilectomy With and Without a Dorsiflexion Phalangeal Osteotomy 75
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b

: // t/.tm
. m : / /t/.tm. m
FIG. 9.5
t
FIG. 9.4
p pss : / tp pss : /
t
hht t t
hht t
PROCEDURE
Step 1
keerrss keerrss
• The medial capsule is divided and dissected off of the dorsal and plantar aspects of
b ooook o ook
the first MT head and dorsal proximal phalanx with a scalpel and elevator.
b o b oo
eeb e e/e b
• Homan retractors are placed on the lateral aspect of the first MT head and the base
/ e /e/e b
of the proximal phalanx to retract the EHL, EHB, and dorsal capsule laterally to allow
e e
: / / t
/ m
.t.m : / / t
/ m
.t.m
visualization of the entire dorsal surface. Plantar flexion of the great toe will improve
t ppss /
visualization of the joint (Fig. 9.4).
: t ppss : /
• The cartilage of the first MTPJ is examined for wear. Up to one-third of the dorsal
t
hhtt t
hhtt
aspect of the first MT head can be removed with a microsagittal saw.
• Dorsal osteophytes from the base of the proximal phalanx are easily removed with
a rongeur. Medial and lateral osteophytes may be removed with a narrow rongeur or
microsagittal saw (Fig. 9.5).
rrss rrss
• Intraoperative fluoroscopy can be utilized to confirm resection of all impinging osteo-
o k e
k e phytes.
o k e
k e
• Once the osteophytes have been resected and the head is restored to its anatomic
o
eebb o o shape, ROM should be examined.
e b o
b o o e b o
b o
m ee/ / e m e / / e
• If dorsiflexion is still limited to less than 90°, the sesamoids should be examined for
e
: / /
/ / .t.m : / / t
/
bridement of osteophytes from sesamoids may also be performed if needed.
/ .t.m
plantar adhesions and releases performed with a scalpel or periosteal elevator. Dé-
t
t p
t ss:
p t t p
t ss:
• If dorsiflexion remains limited after sesamoid release, a dorsal closing wedge
t p
hht hht
osteotomy of the hallux proximal phalanx can be performed. This will unload the
dorsal aspect of the joint and sublux the base of the proximal phalanx to a more
plantar position where the cartilage is usually in better condition. The hallux is
also placed in a position of dorsiflexion relative to the floor such that it decreases
the amount of dorsiflexion required during activities that involve dorsiflexion of STEP 1 PITFALLS
k e r
e s
rs the great toe.
k eers
rs • Removing dorsal osteophytes to increase ROM
can also increase pain in a degenerative joint.
o o
o o k o o
o k
• Intraoperatively, the goal is to achieve 90° of dorsiflexion. Much of this will be lost
o oo
The greater the arthropathy, the greater the
eebb b b
in the immediate postoperative period, but at least 45° of dorsiflexion should be re-
gained with ROM exercises.
ee/ e
/ e b ee/e/e b risk of persistent postoperative pain.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
76 hht hht
PROCEDURE 9 Hallux Rigidus: Cheilectomy With and Without a Dorsiflexion Phalangeal Osteotomy
Step 2
k e r
e s
rs k eers
r s
• The dorsiflexion osteotomy of the proximal phalanx, also known as a Moberg os-
teotomy, is performed using a periosteal elevator to free the soft tissues from the
o o
o o k o oo k o
dorsal and plantar aspects of the metaphysis of the proximal phalanx.
o o
eebb ee e
/ebb ee/ e
/ b
e b
• A mini Hohmann retractor is then placed over the dorsal surface of the proximal pha-
/ lanx to retract and protect the EHL tendon, and a second mini Hohmann retractor is
: / / t
/ .
t m
. m t . m
. m
placed over the plantar surface of the metaphysis to retract and protect the FHL ten-
: / / / t
t p ss
p : / t p ss
p : /
don. The attachments of the EHB, FHB, adductor, and abductor hallucis are left intact.
• A dorsal closing wedge osteotomy is then performed with the microsagittal saw dis-
t
hht t t
hht t
tal to the insertions of the EHB and FHB. The more proximal cut is made parallel to
the joint surface and the more distal cut at an angle that produces a 1–5 mm dorsal
wedge. The plantar cortex is left scored but intact for stability (Fig. 9.6A–B).
• The wedge is then removed and the gap closed and held with a 0.045-mm Kirschner
k eers
rs k er
ers
wire. The wire is inserted from the medial base of the proximal phalanx across the
s
osteotomy exiting the lateral cortex.
b ooook b ooook
• The great toe is then ranged, and the osteotomy cut can be enlarged to increase
b o o
eeb ee/ e
/ e b e / e
/ e b
dorsiflexion to 90° if flexion is still limited.
• Alignment of the toe and positioning of the osteotomy are then checked intraopera-
e
: // t/.tm
. m tively with fluoroscopy.
: / /t/.tm. m
t p ss
p : / tp ss : /
• Fixation of the osteotomy can be achieved using a bicortical screw, by inserting
FiberWire through bone tunnels, or using a staple (Fig. 9.6C). Great toe dorsiflexion
p
t
hht t t
hht t
to 90° can then be achieved (Fig. 9.6D).
Step 3
• Remaining areas of exposed denuded bone can be treated with microfracture. A
2-mm or smaller drill bit or a Kirschner wire may be used to microfracture denuded
keerrss keerrss
bone. This will stimulate the formation of overlying fibrocartilage (Fig. 9.7).
b ooook Step 4
b ooook b oo
• Copiously irrigate the wound to remove bony debris.
: / / t
/ m
.t.m : / / t
/ m
• Release the tourniquet and achieve hemostasis (Fig 9.8A).
.t.m
• Wound closure is achieved by closing the capsule with an absorbable suture (Fig. 9.8B).
• Close the subcutaneous tissue and skin according to the surgeon’s preference.
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : / FIG. 9.6
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 9 Hallux Rigidus: Cheilectomy With and Without a Dorsiflexion Phalangeal Osteotomy 77
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook C
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.
D
tm. m
t p ss
p : / tp pss : /
t
hht t t
FIG. 9.6, cont’d
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
A
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
FIG. 9.7
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t
B
p ss
p : /
t
hht t t
hht t FIG. 9.8
t t p
t ss:
p t t p
t ss:
p
78 hht hht
PROCEDURE 9 Hallux Rigidus: Cheilectomy With and Without a Dorsiflexion Phalangeal Osteotomy
k e r
e s
rs k eers
r s
• Grade I and grade II patients with adequate remaining cartilage and good intraopera-
tive ROM should expect good to excellent results.
o o
o o k o oo k o
• Grade III patients have more variable outcomes. Increasing ROM in a tight arthritic
o o
eebb ee/ e
/ bb / e
joint with poor cartilage may increase pain.
e ee / b
e b
• Elevation and icing in the immediate postoperative period are recommended. Weight
: / / t
/ .
t m
. m : / / t . m
. m
bearing is allowed in a flat postoperative shoe. Gentle ROM exercises of the first
/ t
t p ss
p : / ss : /
MTPJ are initiated in all patients at 2 weeks postoperatively.
t p p
t
hht t t t
• The postoperative shoe is maintained for 6 weeks in all patients with a Moberg oste-
otomy.
hht
EVIDENCE
Deland JT, Williams BR. Surgical management of hallux rigidus. J Am Acad Orthop Surg
k eers
rs k er
ers
2012;20(6):347–58.
s
Review of current treatment and surgical techniques. Grades I and II are best treated with cheilec-
b ooook b ooook
tomy without proximal phalanx osteotomy. Grade III is best treated with arthrodesis or arthroplasty.
b o o
Karasick D, Wapner KL. Hallux rigidus deformity: radiologic assessment. AJR Am J Roentgenol
eeb e / e e b
1991;157(5):1029–33.
e / ee/ e
/ e b
Discusses and illustrates the grades of radiologic changes in hallux rigidus.
: // t/.tm
. m : / /t/.tm. m
Kim PH, Chen X, Hillstrom H, Ellis SJ, Baxter JR, Deland JT. Moberg osteotomy shifts contact
t p ss
p : / 2016;37(1):96–101.
tp pss : /
pressure plantarly in the first metatarsophalangeal joint in a biomechanical model. Foot Ankle Int
t
hht t t
hht t
Cadaveric study demonstrating plantar shifting of contact pressures on the first MT head after
Moberg osteotomy.
Perez-Aznar A, Lizuar-Utrilla A, Lopez-Prats FA, Gil-Guillen V. Dorsal wedge phanageal osteotomy for
grade II-III hallux rigidus in active patients. Foot Ankle Int 2015;36(2):188–96.
This study was a level 4 prospective case series of 42 feet in 40 active patients with an average
age of 55 years and an average follow-up of 2.7 years. Improvements in American Orthopedic Foot
keerrss keerrss
and Ankle Scores (from 51.7 to 88.8) and dorsiflexion (from 20.3° to 55.7°) were achieved.
Warganich T, Harris T. Moberg osteotomy for hallux rigidus. Foot Ankle Clin 2015;20(3):433–50.
b ooook b oook
Discussion on etiology, current treatment, and surgical techniques.
o b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh10
PROCEDURE
t hht
Interpositional
rss Arthroplasty of the
rssGreat Toe
kkee r
ooStuart D. Miller k
oo e
ke r
b
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t ss
p : t t p
t ss
p :
INDICATIONS hht
• Arthritis of the first metatarsophalangeal (MTP) joint beyond cheilectomy treatment
hht
• Very stiff joints may be better fused; do not
expect as much motion.
• Infected joints may need a two-stage
• Concomitant arthritis of the sesamoid bones procedure.
• Failed cheilectomy • Hallux varus or other severe instabilities
k eers
rs
k er
erss may require simultaneous ligamentous
• Anteroposterior foot longstanding hallux rigidus in a 62-year-old woman (Fig. 10.1)
reconstruction (see Stein, Miller article).
eeb SURGICAL ANATOMY ee/ e e b

• Lateral foot films of the same 62-year-old woman (Fig. 10.2)
/ ee/ e
/ e b INDICATIONS CONTROVERSIES
: // t/.tm
. m : / /t/.tm. m
• Very stiff joint may do better with fusion
• Very unstable joints may do better with fusion
ss : /
• Dorsomedial cutaneous nerve (Fig. 10.3)
t p p tp pss : / • Perhaps a good option for nonunion of prior
first MTP fusion
t
hht t
• Extensor hallucis longus (EHL) tendon
• MTP joint capsule t
hht t • Prior hemiarthroplasty may do well with simple
implant removal
TREATMENT OPTIONS
• Footwear modifications
keerrss keerrss • Antiinflammatory medications
• Cheilectomy with or without microfracture
• Arthrodesis

: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m
: / / t
/ m
.t.m FIG. 10.2
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
.m
//t/t.m / t.tm
. m
s:/: ss: /
: / /
t
hht p
t p s
FIG. 10.1
t t

hht t p
t p FIG. 10.3
79
t t p
t ss:
p t t p
t ss:
p
80 hht
PROCEDURE 10 Interpositional Arthroplasty of the Great Toe hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t FIG. 10.5
FIG. 10.4
POSITIONING PEARLS
k e rs
rs
• Occasionally a small bump under the
e k er
erss
b ooook ipsilateral hip helps to position the foot.
b ooook b o o
eeb POSITIONING EQUIPMENT
ee/ e
/ e b ee/ e
/ e b
• A small bump or beanbag may be helpful.
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
• Keep the incision midline to stay lateral to the
dorsomedial cutaneous nerve.
t
hht t
• Capsule incision can be medial to the EHL
to allow later closure; if this is not easy, then
expose and release the EHL tendon, and then
keerrss
retract it laterally.
k r
eer ss FIG. 10.6
b ooook
• Make the incision generous, at least to the
midphalanx.
b oooo k b oo
: / /
• Previous surgery can entrap the dorsomedial t
/ m
.t.m : / / t
/ m
.t.m
ss :
cutaneous nerve in scar tissue, which can
t pp / t ppss : /
easily lead to nerve damage.
t
hhtt
• An Esmarch tourniquet provides a relatively
bloodless field but may limit hallux excursion;
t
hhtt
final evaluation of range of motion should
be performed without an ankle-compressive
restriction on tendons.
k e rrss
e k e rrss
e
o o
o k
o o o
o o k o o
eebb • Small Weitlaner retractor
ee/ e
/ b
e b ee/ e
/ b
e b
PORTALS/EXPOSURES CONTROVERSIES
: / / t
/ m
.t.m : / / t
/ m
.t.m
FIG. 10.7
t p ss:
• Sometimes it is possible to close the MTP
p / POSITIONING
t p ss:
p /
t
joint capsule; unclear of clinical importance,
hht t
many cases had only simple closure of
subcutaneous tissues and skin.
t
hht
• Supine (Fig. 10.4)
t
PORTALS/EXPOSURES
STEP 1 PEARLS • Midline dorsal exposure
k e e s
• Removing the dorsal aspect of the proximal
r rs
phalanx aids with visualization (Fig. 10.8). PROCEDURE
k eers
rs
o o
o k
• A McGlamry elevator helps with exposure and
o Step 1
o o
oo k oo
eebb b b
release of the first metatarsal head plantarly.
ee/ e e b /e e b
• Dorsal midline approach should be performed.
/ ee /
• Incise the capsule along the line of incision directly down to the bone and joint as
STEP 1 PITFALLS
: / / t
/ .
tm.m shown in Fig. 10.5.
: / / t
/.tm
. m
the base of the phalanx.
t p p : /
• Do not interrupt the short flexor attachment to
ss ss : /
• Peel the periosteum from the metatarsal head and phalanx as shown in Fig. 10.6.
t p p
t
hht t t
hht t
• Visualize the MTP joint and gauge extent of arthritis as can be seen in Fig. 10.7.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t A
FIG. 10.8
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
B
keerrss FIG. 10.10
k r
eer ss FIG. 10.9
b ooook b oooo k b oo
STEP 2 PEARLS
eeb ee/e/e b ee/e/e b • Ream the cartilage and round the metatarsal
: / / t
/ m
.t.m : / / t
/ m
.t.m
head only to the subchondral bone; try to
minimize shortening of the first ray.
t ppss : / t pp ss : / • Continuous irrigation of the reamer with saline

helps prevent thermal damage to the bone of
t
hhtt t
hhtt the metatarsal head.
• The guidewire should be in the center of
the metatarsal head and down the center of
the bone shaft. A small amount of valgus is
desired for toe position.
k e rrss
e k e rrss
e STEP 2 PITFALLS
o o
o o k o o
o o k o
• Excessive bone resection can lead to instability
o
eebb ee/ e
/ b
e b ee/ e
/ b
e b and transfer metatarsalgia.
/t.
: / / tm. m : / / t
/ m
.t.m STEP 2 INSTRUMENTATION/
IMPLANTATION
t p ss:
p /
FIG. 10.11
t p ss:
p / • McGlamry elevator
t
hht t t
hht t • Metatarsal head reamers: a “closed” reamer is
often used to prevent damage of open splines
cracking the bone
Step 2
• Remove osteophytes from the metatarsal head and perform cheilectomy as shown STEP 2 CONTROVERSIES
k e r
e s
r
in Fig. 10.9.
s k eers
rs
• This procedure often helps to perform a medial exostectomy (Fig. 10.10).
• So far, no studies have investigated the
benefits of cheilectomy or medial exostectomy
o o
o o k o o
oo k
• A McGlamry elevator aids in freeing the metatarsal head and gaining full exposure
oo
versus simple resurfacing.
eebb b b • More shortening performed with reaming

(Fig. 10.11).
ee/ e
/ e b e /e
• Place the reamer guidewire in the center of the metatarsal head and use the reamer
e /e b allows better motion but at the cost of first ray
shortening and risks of transfer metatarsalgia.
: / / / .
tm m
to remove cartilage (Fig. 10.12) to subchondral bone.
t . : / / t
/.tm
. m • Excessive stripping of the first metatarsal head
p ss
p / t p ss : /
• Puncture the metatarsal head subchondral bone with the guidewire on the previously
:
articular surface, which allows bleeding into the graft and fibrocartilage formation
t p
theoretically increases the risk of avascular
necrosis of the bone and collapse of the joint
(Fig. 10.13).
t
hht t t
hht t (not yet clinically seen).
t t p
t ss:
p t t p
t ss:
p
82 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 10.12 FIG. 10.13
k eers
rs k er
erss
eeb STEP 3 PEARLS
ee/ e
/ e b ee/ e
/ e b
: //
lip of the phalanx aids tremendously in
/.
• A small Hohmann retractor under the plantar
t tm
. m : / /t/.tm. m
exposing the base of the phalanx.
t p ss
p : / tp pss : /
t t
• Do not resect the insertion of the flexor brevis
hht
tendon on the base of the phalanx; remove any
bone here with great care.
t
hht t
• Resect only enough bone to gain good
dorsiflexion.
keerrss keerrss
eeb STEP 3 PITFALLS
ee/e/e b ee/e/e b
: /
• The reamer can easily damage the distal
/ t
/ m
.t.m : / / t
/ m
.t.m
t ppss : /
metatarsal head and often needs to be lifted past
t ppss : /
t
the head to engage the base of the phalanx.
hhtt
• An open reamer can catch on a rough
bone of the phalanx and fracture the bone
t
hhtt
(catastrophically!).
k e rrss
e k e rrss
e
o o
o o k o o
o o k
o o
FIG. 10.14
eebb STEP 3 INSTRUMENTATION/

IMPLANTATION
ee/ e
/ b
e b ee/ e
/ b
e b
• Small Hohmann retractor
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p /
• Matching convex reamers, same size as used
t p ss:
p /
for the metatarsal head
t
hht t Step 3
t
hht t
• Expose the base of the proximal phalanx, plantar flexing the toe, as shown in Fig.
10.14.
r s
rs
k e e k eers
• Place the guidewire in the base of the phalanx, slightly oblique to remove more bone
rs
dorsally than plantar, as presented in Fig. 10.15.
o o
o k
• No definitive guidelines exist on the amount of
o o
•

oo k o
Select the same size convex reamer to ream the base of the phalanx as in
o o
eebb b b
bone to be resected from the phalanx.
ee/ e
/ e b Fig. 10.16.
ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 10 Interpositional Arthroplasty of the Great Toe 83
STEP 4 PEARLS
k e r
e s
rs k eers
r s • Moderate tension helps drape the graft over
the metatarsal head; the length always needs
o o
o o k oooo k o o
to be trimmed at this step.
eebb ee/ e
/ebb ee/ e
/ b
e b • In tight joints, a simple suture in the plantar
proximal lateral corner of the graft (before sliding
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
under the metatarsal head) allows easy connection
to the dorsal proximal lateral corner of the graft
t p ss
p : / t p ss
p : / and helps secure the graft in place. Leave the
needle attached to the suture while placing the
t
hht t t
hht t central sutures and securing the graft (Fig. 10.22).
k eers
rs k er
erss
ook ook
STEP 4 PITFALLS
b
eeboo / e b o
bo / e b o
b o • Some allografts need adequate soaking in
m ee / e m ee / e saline prior to application over the metatarsal

head; otherwise, they may be very stiff.
: ///t/.t. m : / /
/t/.t . m • Be sure the biologic “rough” side gets placed
on the metatarsal head surface.
t t p
t ss
p :
FIG. 10.15
t tptpss : • Plantar soft tissues can prevent sliding of the
hht hht
graft proximally and need to be débrided if
impeding placement.
keerrss keerrss
IMPLANTATION
eeb ee/e/e b ee/e/e b • Graft should be decellularized human skin
: / / t
/ m
.t.m : / / t
/ m
.t.m
such as ArthroFlex (Arthrex, Naples, FL, USA),
DermaSpan (Zimmer Biomet, Warsaw, IN,
t ppss : / t ppss : / USA), or GRAFTJACKET (Wright Medical,

Memphis, TN, USA).
t
hhtt t
hhtt • A bioresorbable suture (0 Vicryl; Ethicon, NJ,
USA) was used in this case; the author hopes
to avoid any discomfort with permanent suture
knots on the dorsum of the toe.
• A curved free needle, fairly stout, should be
rrss rrss
available to bring the suture through the graft
o k e
k e o k e
k e
after passing through the metatarsal neck.
• The suture passer can be either straight
o
eebb o o
e b o
b o o e b o
b o (Houston suture passer) or a thinner wire
(Arthrex, Naples, FL, USA) to transport the
m ee/ e
FIG. 10.16
/ m ee/ / e plantar sutures in the graft to the dorsum of
: / /
/ t
/ .t.m : / /
/ t
/ .t.m the metatarsal neck.
Step 4
t t p
t ss:
p t t p
t ss:
p
hht hht
• With the guidewire, drill two holes in the metatarsal neck, dorsal to plantar, exiting
just proximal to the sesamoids (Fig. 10.17).
• Attach 2-0 Vicryl sutures to the base of the allograft, approximately 1 cm apart STEP 4 CONTROVERSIES
(through the rough side to smooth and back through the rough side; Fig. 10.18).
• Many companies tout the benefits of their
k e e s
rs k eers
• Place the allograft under the metatarsal head, just proximal to the sesamoids, and
r rs
bring sutures through the holes in the neck with a suture passer (Fig. 10.19).
allograft; this author has seen little difference.
• Some surgeons have balked at the stripping
o o
o o k o o
oo k
• Flap the allograft over the metatarsal head; use free needles to bring sutures through
oo
of the metatarsal head and possible loss of
eebb b b blood supply; major centers have not seen this

tarsal head (Fig. 10.20).
ee/ / e b ee/e/e b
the allograft on the dorsum, getting a slight stretch fit of the allograft over the meta-
e complication to any great extent.
• Allografts are available in several thicknesses;
: / / / .
tm.m : / / t
/.tm
. m
• Trim the “dog ear” and then cinch down lateral and then medial sides of the allograft
t however, the difference has not been noted
graft (Fig. 10.21).

t p ss
p : / t p ss
p : /
with simple sutures of 2-0 Vicryl to ensure a glove-like fit and prevent slippage of clinically.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
84 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b FIG. 10.17
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e
A
k e rrss
e
FIG. 10.18
B
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / FIG. 10.19
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eA
ers
rs B
k er
erss
b ooook b ooook
FIG. 10.20
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t ppss : / B
t ppss : /
t
hhtt
FIG. 10.21
t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
FIG. 10.22
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
86 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t FIG. 10.24
FIG. 10.23
k eers
rs k er
erss
b ooook
STEP 5 PEARLS
b ooook b o o
eeb • The author uses a 4-0 horizontal mattress
ee/ e
/ e b ee/ e
/ e b
// t/.tm
suture, either running or interrupted, to close
. m
the skin. Monocryl (Ethicon, NJ, USA) provides
: : / /t/.tm. m
ss : /
a reasonably strong closure and alleviates the
t p p tp pss : /
t
need and risk of suture removal.
hht t t
hht t
ke rrss
STEP 5 PITFALLS
e keerrss
b ooook
• The EHL tendon is at risk of scarring down
b ooook b oo
eeb without early range of motion. If previous
surgery left a damaged bed, wrapping the
ee/e/e b ee/e/e b
tendon with a gliding sheath may be helpful.
/ t
(TenoGlide, Integra LifeSciences, NJ, USA).
: / / m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
IMPLANTATION
e rrss
• Sutures as noted, resorbable 2-0 and 4-0, and
k e k e rrss
e
o o
o o k skin closure of choice
o o
o o k o o
eebb b b
• Postoperative shoe
ee/ e
/ e b
ee/ e
/ e b
FIG. 10.25
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
STEP 5 CONTROVERSIES t
hht t Step 5 t
hht t
• Close the capsule, if possible, with 2-0 Vicryl suture as shown in Fig. 10.23.
• Aggressive range of motion may lead to slight
dehiscence of the incisions. • Perform simple subcutaneous tissue closure with 4-0 Vicryl and skin closure with
• Coban bunches up less than an elastic Ace- running horizontal mattress suture of 4-0 Monocryl as shown in Fig. 10.24.
k e s
type wrap but provides less compression.
r rs
• Radiographs are rarely indicated.
e k eers
rs
• Apply Xeroform gauze dressing over the incision followed by a dry gauze dressing
and wrapping with Coban; then, place in a postoperative shoe (DARCO; Fig. 10.25).
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
POSTOPERATIVE CARE AND EXPECTED OUTCOMES POSTOPERATIVE PEARLS
k e r
e ss
• Elevation is encouraged strongly.
k eers
r s
• Patients are weight bearing as tolerated in a postoperative shoe.
r • Stress the importance of elevation of the foot
during the first 2 days. “Toes to the nose!”
o o
o o k o oo k
• The patient should return to the doctor’s office in 1 week, at which time he/she be-
o o o
• Elevation of the foot above the heart for 15–20
eebb / e bb
gins an aggressive passive range-of-motion routine, especially in dorsiflexion.
ee /e
• In most cases, showering is allowed after 1 week.
ee/ e
/ b
e b minutes at a time, several times a day, will
help lessen swelling in the postoperative
: / / t . m
. m
• The patient is allowed to return to sports, etc., at 6 weeks.
/ t : / / t
/ .
t m
. m
period.
• Placing the forefoot on the ground, while
EVIDENCE
t p ss
p : / t p ss
p : / seated in a chair, and dorsiflexing the great
toe against the floor can help with range of
t
hht t t
hht t
Akgun RC, Sahin O, Demirors H, Tuncay IC. Analysis of modiﬁed oblique Keller procedure for severe
hallux rigidus. Foot Ankle Int 2008;29(12):1203–8.
motion.
Berlet GC, Hyer CF, Lee TF, Philbin TM, Hartman JF, Wright ML. Interpositional arthroplasty of the first
MTP joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus. Foot Ankle POSTOPERATIVE PITFALLS
Int 2008;29(1):10–21.
• Overly zealous range-of-motion exercises may
k eerss
rigidus. Foot Ankle Int 2009;30(6):494–9.
k er
erss
Hahn MP, Gerhardt N, Thordarson DB. Medial capsular interpositional arthroplasty for severe hallux
r be quite painful.
b ooook b ooook b o
Johnson JE, McCormick JJ. Modified oblique Keller capsular interposition arthroplasty (MOKCIA) for
o
• Aggressive motion may allow for some
dehiscence of the incision. Such motions
eeb b b
treatment of late-stage hallux rigidus. Foot Ankle Int 2014;35(4):415–22.
e/ e
/ e ee/ e
/ e
Lau JRC, Daniels TR. Outcomes following cheilectomy and interpositional arthroplasty in hallux rigidus.
e
should be ceased and local wound care
provided.
Foot Ankle Int 2001;22(6):462–70.
: // t/.tm
. m : / /t/.tm. m
Mackey RB, Thomson AB, Kwon O, Mueller MJ, Johnson JE. The modified oblique Keller capsular
t p ss
p : / tp pss : /
interpositional arthroplasty for hallux rigidus. J Bone Joint Surg Am 2010;92(10):1938–46.
Mroczek K, Miller SD. Modified oblique Keller procedure: a technique for dorsal approach interposition POSTOPERATIVE CONTROVERSIES
t
hht t t
hht t
arthroplasty sparing the flexor tendons. Foot Ankle Int 2003;24(7):521–2.
Simpson A, Hembree WC, Miller SD, Hyer CF, Berlet GC. Surgical strategies: hallux rigidus surgical
techniques. Foot Ankle Int 2011;32(12):1175–86.
• Patient satisfaction does not appear to be
directly related to range of motion, that is, it
might not be worth the pain to achieve 10°
more of dorsiflexion.
• Timing of recovery can be varied and difficult;
keerrss keerrss some younger men have taken 6–9 months

for resolution of MTP pain.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh11t
PROCEDURE hht
Polyvinyl
r ss Alcohol Hemiarthroplasty
r s s for First
o k ee r
Metatarsophalangeal
k k
Arthritis
o kee r
b o
m e
Alastair Younger and Timothyt.Danielse /e m ee / e
: / ///t . m : / /
/ t
/ .
t . m
tpss : ss :
hhtttp t
hhtt p
t p
• A plantar flexed first MTP joint will likely not be • Symptomatic first metatarsophalangeal (MTP) joint arthritis
k eers
rsable to move into dorsiflexion
• Sepsis
k er
e s
r s
• Maintenance of functional motion of the first MTP joint
b ooook • Charcot arthropathy with risk of bone collapse

• Bone loss unable to support the implant
b ooook
• Minimal first ray deformity (valgus, varus, elevation)
b o o
• Arthritis of appropriate severity (K–L grades III or IV)
eeb e / e
/
EXAMINATION
e e b
AND IMAGING
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
• A preoperative x-ray of suitable degenerative change to consider a hemiarthroplasty
t p ss
p : / (Fig. 11.1)
tp pss : /
t
• Realignment of the first ray may allow a
hht t
hemiarthroplasty to be used in a deformity.
• Freiberg disease may be treatable by a
t
hht t
• Arthritis too severe to consider a hemiarthroplasty with sesamoid to metatarsal head
involvement (Fig. 11.2)
• A first ray too deformed with bone loss to be appropriate for a hemiarthroplasty
hemiarthroplasty.
• In the Food and Drug Administration study (Fig. 11.3)
(Baumhauer et al., 2016), the revision rate
keerrsto fusion was just under 10% at 2 years. The

s
outcome measures are equivalent to fusion,
keerrss
b ooook with fusion giving slightly better pain relief, and
the implant providing better range of motion.
b ooook b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m : / / t
/.
B
tm
. m
t p ss
p : /
t p ss
FIG. 11.1
p : /
88 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 11 Polyvinyl Alcohol Hemiarthroplasty for First Metatarsophalangeal Arthritis 89
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m //t
: /.tm. m
t p ss
p : /
FIG. 11.2
tp pss : / FIG. 11.3
t
hht t t
hht t Distal phalange
keerrss keerrss Proximal phalange
eeb ee/e/e b
Dorsal exposure
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
Dorsal sling
t ppss : /
Tendon of abductor
hallucis and insertion
t ppss : / Perforating fibers
t
hhtt fibers contributing
to dorsal sling t
hhtt
arising from plantar
aponeurosis
Tendon of adductor
Deep fibers of extensor hallucis contributing
hallucis longus tendon to dorsal sling
k e rrss
e k eerrss
Metatarsal
o o
o o k o ooo k
o o
eebb ee e
/ b
e b
/ e / e
/ b
e b
Extensor hallucis
e
: / / t
/ m
.t.m : / / t
/ mbrevis tendon
.t.m
t p ss:
p / t p ss:
p /
t
hht t hht t t
FIG. 11.4 POSITIONING PEARLS
• The implant may be placed too medial if the
k eers
rs
SURGICAL ANATOMY
k eers
rs
leg is left externally rotated.
• Make sure that the foot is placed close enough
oooo k oo k
• The first ray is approached from the dorsal side as presented in Fig. 11.4.
o o oo
to the end of the bed.
eebb POSITIONING ee / b
e b
• The medial and lateral dorsal digital nerves have to be avoided in dissection.
/ e ee/e/ebb POSITIONING EQUIPMENT
: / / t
/ .
tm.m : / / t
/.tm
. m • A bean bag is helpful to ensure correct rotation
t p ss : /
• A calf tourniquet can be used with regional anesthesia.
p t p ss
p : /
• The foot is placed vertically oriented on the operating room table as shown in Fig. 11.5.
of the foot.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
90 hht
PROCEDURE 11 Polyvinyl Alcohol Hemiarthroplasty for First Metatarsophalangeal Arthritis hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 11.5
k eers
rs k r
eerss FIG. 11.6
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
FIG. 11.7
: / / t
/ m
.t.m
: / / t
/ m
.t.m FIG. 11.8
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t
t
hht t
FIG. 11.9
PORTALS/EXPOSURES
k e r
e s
rs k eers
rs
• A direct dorsal approach is used. Once through the skin and the superficial approach
o o
o o k o oo k
has been performed, the capsule of the MTP joint is incised medial to the extensor
o oo
eebb b b
• Make sure that the metatarsal head is fully
ee/ e
/ e btendons (Fig. 11.6).
e /e/e b
• Dissection is carried through the extensor hood medial to the extensor hallucis lon-
e
released to ensure that the reamer can be
: / / t
/ .
tm.m
perpendicularly placed on the metatarsal head
: / / t
/.tm
. m
gus tendon and onto the dorsal capsule (Fig. 11.7).
(Fig. 11.9).
t p ss
p : / t p ss : /
• Once within the joint the capsule is released medially and laterally to allow full plantar
flexion of the MTP joint (Fig. 11.8).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 11.10
k r
eerss FIG. 11.11
eeb ee/ e
/ e b ee/ e
/ e b
STEP 1 PEARLS
: // t/.tm
. m : / /t/.tm. m • Make sure that the metatarsal head is well
t p ss
p : / tp p ss : / exposed to remove the osteophytes.
• Ensure that the metatarsal head is congruent
t
hht t t
hht t at the end of the débridement.
• Removal of the osteophyte on the dorsal side
of the proximal phalanx will assist in shoe
fitting and patient comfort. However, this will
not restrict range of motion after surgery.
keerrss keerrss
eeb ee/e/e b ee/e/e b STEP 1 PITFALLS
• Removal of too much dorsal osteophyte may
: / / t
/ m
.t.m : / / t
/ m
.t.m prevent the implant from being contained on
t ppss : / t ppss : / the metatarsal head.

• If there is significant osteophyte formation
t
hhtt t
hhtt around the sesamoids or arthritis, the release
and removal of these osteophytes will not
restore motion. In patients with significant
osteophyte formation a preoperative consent
for possible MTP fusion may be more
appropriate.
k eerrss FIG. 11.12
k e rrss
e
oooo k o o
o o k o o
eebb PROCEDURE ee/ e
/ b
e b ee/ e
/ b
e b
Step 1: Removal of Osteophytes

: / / t
/ m
.t.m : / / t
/ m
.t.m
IMPLANTATION
t p ss:
p / t p ss:
p /
• As can be seen in Fig. 11.8, dorsal, medial, and lateral osteophytes often exist around
• Straight and curved osteotomes are used to
remove the osteophytes.
t
hht
the metatarsal head.
t t
hht t
• The dorsal osteophytes should be removed so that the joint can move into dorsiflex-
• A small rongeur can also assist in removal of
the osteophytes.
ion, eventually making it congruent (Fig. 11.10).
• The medial and lateral gutter osteophytes should be removed to allow range of mo-
tion, and the osteophyte on the top of the proximal phalanx may also need to be
k e r
e ss
removed (Fig. 11.11).
r k eers
rs STEP 1 CONTROVERSIES
o o
o o k
Step 2: Preparation of the Prosthesis Bed
o o
oo k o
• The amount of motion required to allow a
o
eebb b b successful outcome is not clear. However, if
ee/ e
/ e b
• The drill guide is placed centrally on the metatarsal head. The guide is moved into
ee/e/
flexion/extension and varus/valgus until the neutral position is identified. The guidee b the preoperative range will not allow dorsal
MTP motion to prevent overload of the
: / / t
/ .
tm.m : / / t
/.t
should be placed centrally with 1–2 mm of the subchondral bone surrounding them
. m interphalangeal joint, then a fusion into the
ss : /
bed to ensure that the replacement is contained (Fig. 11.12).
t p p t p ss
p : / dorsiflexed position will be more successful.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
92 hht
PROCEDURE 11 Polyvinyl Alcohol Hemiarthroplasty for First Metatarsophalangeal Arthritis hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb STEP 2 PEARLS
• Ensure that the guide is made resting evenly
ee/ e
/ebb ee/ e
/ b
e b
on the metatarsal head.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss : /
• Make sure that the metatarsal head is well
exposed to ensure that the reamer remains
p t p ss
p : /
t
hht t
perpendicular to the metatarsal head. The
proximal phalanx should be held down into
flexion by the assistant to ensure appropriate
t
hht t
exposure and retractors are carefully used.
k eers
rs k er
erss
eeb STEP 2 PITFALLS
ee/ e
/ e b ee/ e
/ e b
: // t/.
• The retractors can penetrate the metatarsal
tm
. m : / /t/.tm. m
head and catch on the reamer. This can
t p ss : /
cause a metatarsal head fracture, and so the
p tp p :
ss /
t
hht t
retractors should be carefully placed.
• Failure to expose the metatarsal head
may result in an oblique placement of the
t
hht t
FIG. 11.13 FIG. 11.14
prosthesis.
• A deficient bed can result in subsidence of the
implant.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
IMPLANTATION
t
• Two instrument trays exist, one for an 8-mm
hhtt
implant and one for a 10-mm implant. Usually, an
MTP joint arthroplasty requires a 10-mm implant
t
hhtt
unless the patient is very small, or the dorsal
osteophyte removal mandates a smaller implant.
• The instrument tray contains a K-wire for
e rrss
placement of the reamer.
• The reamer has a stop to prevent over-
k e k e rrss
e
o o
o o kreaming of the bone bed.
• The wire guide is sized to an 8- or 10-mm
o o
o o k FIG. 11.15
o o
eebb diameter with a concavity on the distal end to
ee
assist in sizing. It is also conical in shape to/ e
/ b
e b ee/ e
/ b
e b
: / / / m
.t.m
assist in the delivery of the hemiarthroplasty.
t : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• Once the position is optimized, a Kirschner wire (K-wire) is placed through the guide
t
hht t t
hht t
and drilled into the metatarsal head. It should be advanced 2–3 cm into the head
(Fig. 11.13).
• The reamer is then used for reaming down to the base or ridge of the reamer
STEP 2 CONTROVERSIES (Figs. 11.14 and 11.15).
• Check the bone bed to ensure that reasonable bone is present (Fig. 11.16). In
k e s
• An osteoporotic patient may not be a
r rs
candidate for the procedure. For a more
e k eers
rs
older and osteoporotic patients, the bone in the base can be minimal. If the bed
o o
o o kosteoporotic patient a smaller implant might
be required as an 8-mm prosthesis will
o o
oo k
is found to be deficient, reamings can be used from the reamer and placed into
oo
the base and tamped into place using the wire guide as a tamp. The depth from
eebb have shallower reaming and may result in a

stronger bone bed.
ee/ e
/ b
e b the correct amount.
ee/e ebb
the reamer can be marked on the guide to ensure that the tamp is impacted to
/
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 11.16
k er
erss FIG. 11.17
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : / STEP 3 PEARLS
t
hht t t
hht t • Wear testing has shown that the implant
material (polyvinyl alcohol) has minimal wear
and fragmentation unlike silastic prostheses
previously used.
• Practice delivering the prosthesis using the
keerrss keerrss device provided by the distributor to ensure

smooth delivery.
• If the prosthesis is not at the correct height,
remove it with a K-wire, discard the damaged
eeb ee/e/e b ee/e/e b prosthesis, check the preparation of the bone
bed, and deliver a new prosthesis.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt FIG. 11.18 t
• The implant may be placed too proud. If this
is the case, the range of motion of the MTP
joint may be restricted. In this case the bed will
require further reaming or impaction to ensure
rrss rrss
that the prosthesis is at the correct height.
o k e e
Step 3: Delivery of the Implant
k o k e
k e
• The implant may be delivered too deep. If
under 1 mm of the implant is proud, then it
o
eebb o o e b o o o
• The implant is square on the deep surface and rounded on the joint surface. The
b e b o
b o should be removed, bone reamings from the
reamer placed in the base of the bone bed,
m ee/ / e
delivery to fit the diameter of the bone bed (Fig. 11.16).
m ee/
delivery tube compresses the implant to ensure that it is made small enough during
/ e impacted in place, and the implant redelivered.
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
• Once removed from the packaging, the implant is placed in the wider end of the
t t p
t ss:
p t t p
t ss:
delivery tube with some fluid for lubrication of the tube. The prosthesis is advanced
p STEP 3 INSTRUMENTATION/
hht
the guide on a flat surface (Fig. 11.17). hht
down to the bottom of the delivery tube using the narrow end of the wire guide with
• The delivery tube is placed centrally over the bed, and the implant is delivered
IMPLANTATION
• An internally conical delivery tube with a
shoulder is used to place the implant.
in a smooth motion. The delivery tube is best held in place by the nondominant • The wire guide is also conical and is used
hand, and the top of the tube is held with the thumb, index, and middle fingers inverted to deliver the prosthesis.
k e r
e s
rs k eers
rs
of the dominant hand. Once all lined up the palm of the dominant hand is used
o o
o o k (Figs. 11.18 and 11.19).
o o
oo k
to advance the wire guide, forcing the implant out of the tube and into the bed
oo
eebb b b STEP 3 CONTROVERSIES
/ e e b
• Once delivered ensure that the prosthesis is approximately 1–2 mm proud of the
ee /
majority of the joint surface (Fig. 11.20).
ee/e/e b • The correct depth of the prosthesis is not clear.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
94 hht
PROCEDURE 11 Polyvinyl Alcohol Hemiarthroplasty for First Metatarsophalangeal Arthritishht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 11.19
k r
eerss FIG. 11.20
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt FIG. 11.21
t
hhtt FIG. 11.22
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
Step 4: Closure
e b ee/ e
/ b
e b
• Once delivered the height of the prosthesis is confirmed before closure (Fig. 11.20).
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The dorsal capsule is repaired using absorbable suture. The tendon sheath is also
t p ss:
p / t p ss:
repaired (Fig. 11.21).
p /
• Vancomycin paste or powder can be placed subcutaneously to potentially re-
STEP 4 PITFALLS
t
hht t
• Avoid staples as they might increase the risk
t
hht t
duce the rate of wound complications. The skin is closed using interrupted nylon
(Figs. 11.22 and 11.23).
of wound complications.
• Dressings are applied.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s • Review the patient at 2 weeks to ensure that
the wound is healing appropriately, and to
o o
o o k oooo k o o
initiate physiotherapy.
eebb ee/ e
/ebb ee/ e
/ b
e b • Initiate vitamin D immediately after surgery.
Any patient with diabetes must have good
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
sugar control (hemoglobin A1c < 7), and this
must be maintained after surgery. Smoking
t p ss
p : / t p ss
p : / should be stopped around the time of surgery
to assist in wound healing.
t
hht t t
hht t
k eers
rs k er
erss
FIG. 11.23 • Failure to recognize and treat a wound
complication.
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
POSTOPERATIVE CARE
t p sAND
p s : /
EXPECTED OUTCOMES
tp pss : / POSTOPERATIVE INSTRUMENTATION/
IMPLANTATION
t
hht t t
hht t
• Weight bearing can be initiated immediately or after a week depending on the com-
fort level of the surgeon and patient.
• A short walker boot or postoperative shoe can
be used.
EVIDENCE
keer ss keerrss
Baumhauer JF, Singh D, Glazebrook M, et al. Prospective, randomized, multi-centered clinical trial
r
assessing safety and efficacy of a synthetic cartilage implant versus first metatarsophalangeal arthro-
b ooook o ook
desis in advanced hallux rigidus. Foot Ankle Int 2016;37(5):457–69.
b o b oo
eeb b b
A randomized prospective study looks at the outcomes of polyvinyl alcohol implant versus fusion
ee/e/e ee/e/e
and demonstrates maintenance of motion in the study group and equivalent outcomes to fusion.
/ t m
indications. Techn Foot Ankle Surg 2013;13(3):164–9.
: / / : / / t
/ m
Younger AS, Baumhauer J. Polyvinyl alcohol hydrogel hemiarthroplasty of the great toe: technique and
.t.m .t.m
t pps : /
A description of the technique of the hemiarthroplasty procedure.
s t ppss : /
Younger A, Glazebrook M, Baumhauer J. Polyvinyl alcohol hydrogel implant for the treatment of hallux
t
hhtt
rigidus. Curr Orthop Pract 2013;24(5):493–7.
t
hhtt
A description of the technique of the hemiarthroplasty procedure.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh12t
PROCEDURE hht
Arthrodesis
rss of the Great Toe Metatarsophalangeal
rs s
k ee r k ee r
eebboooJoint
ok ooook / e bb / e b o
b o
m ee /e m ee / e
Glenn B. Pfeffer
: / t
///t. . m : / /
/ t
/ .
t . m
s
tps : ss :
INDICATIONS
hhtttp t
hhtt p
t
CONTROVERSIES
p
• Chronic joint pain from advanced arthritis • Arthrodesis is the most commonly performed
• Severe deformity that limits activity or footwear procedure for advanced symptomatic arthritis
k eers
rs
EXAMINATION/IMAGING
k er
erss or severe deformity of the great toe. The
end result is highly predictable, alleviates
b ooook b ooook
• There is limited and painful motion of the great toe.
b o o
symptoms, and restores excellent function.
• Unreliable surgical options include resection
eeb • Large dorsal osteophytes are often present.
ee/ e
/ e b ee/ e
/ e b arthroplasty, hemiarthroplasty, or total joint
arthroplasty.
// t/ tm
• An incision from a previous surgery may dictate the operative approach.
. . m / /t/.tm. m
• Standing anteroposterior (AP; Fig. 12.1A) and lateral (Fig. 12.1B) radiographs should
: :
• A polyvinyl alcohol implant may be considered
ss : / ss : /
be taken. Oblique views often provide the best visualization of the joint.
t p p tp p
in certain specific patients (see Procedure 11)
but does not provide superior function.
operatively. t
hht t t
hht t
• Arthritic changes in the sesamoid may be present but rarely have to be addressed • Concomitant arthritic changes of the inter-
phalangeal joint are not an absolute contrain-
dication to metatarsophalangeal (MTP) fusion.
SURGICAL ANATOMY • A first MTP fusion will cause the intermeta-
tarsal angle to narrow by approximately 4°. A
• Anatomy of the MTP joint of the great toe (Fig. 12.2) simultaneous osteotomy of the first metatarsal
keerrss keerrss base is therefore rarely needed.
b ooook b ooook b
• A sesamoid may be arthritic but rarely has to
oo be excised at the time of the fusion.

: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t ppss : / • High-heeled shoes will be limited to

approximately 2 inches after surgery, which
t
hhtt t
hhtt
may be unacceptable to some patients.
• Infection, inadequate blood supply, and severe
osteopenia are contraindications to the procedure.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : /
t p
FIG. 12.1
ss
p : /
96 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 12 Arthrodesis of the Great Toe Metatarsophalangeal Joint 97
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t First proximal
phalange
Extensor hallucis
t
hht t
longus tendon
Articular
capsule
k eers
rs joint
k er
erss
Metatarsophalangeal
eeb e / e
/ e b
First metatarsal
e ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 12.2 FIG. 12.3
ke rrss
TREATMENT OPTIONS
e k eerrss
b ooook
• A medial longitudinal arch support may
decrease pressure on the great toe.
POSITIONING
b ooook b oo
eeb • A stiff-soled shoe will decrease motion of the
great toe during ambulation. Patients have
ee/e/e b /
• The patient is placed supine.
ee e/e b
• A small bump under the ipsilateral hip will help bring the foot into an upright position.
: / t
/ m
.t.m
often tried this approach on their own, prior to
/ : / / t m
.t.m
• An ankle or thigh tourniquet is used.
/
seeking consultation.
p ss : / PORTALS/EXPOSURES
• A rocker sole, which stiffens the shoe sole and
t p t ppss : /
t
hhtt
takes stress off of the forefoot, can be added
to a walking shoe by a pedorthist or orthotist.
Although highly effective, all of the patient’s
t
hhtt
• Make a 5-cm longitudinal incision over the dorsal aspect of the great toe, just medial
to the extensor hallucis longus (EHL; Fig. 12.3).
shoes will require this modification. • Loupe magnification may be helpful.
• A cortisone injection may improve symptoms
• The procedure is performed under a femoral/sciatic or popliteal block to help maxi-
for a short period of time.
k e rrss
e k e r
e ss
mize postoperative pain control.
r
o o
o o k
PORTALS/EXPOSURES PEARLS PROCEDURE
o o
o o k o o
eebb • Hyperflexion of the MTP will help expose the
metatarsal head during the initial approach.
ee/ e
/ b
e b Step 1
ee/ e
/ b
e b
• Injury to the tendon can occur if the EHL
: / / t
/
is forcefully retracted while the joint ism
.t.m : / / t
/ m
.t.m
• Divide the dorsal capsule with a longitudinal incision 2 mm medial to the EHL.
hyperflexed.
t p ss:
p / t p ss:
p /
Retract the tendon laterally throughout the case.
• Remove any loose bodies that often sit on the dorsum of the joint.
STEP 2 PEARLS
t
hht t t
hht t
• Elevate the capsule medially and laterally while protecting the EHL tendon (Fig.
12.4A). Divide the collateral ligaments, mobilize the plantar plate, and expose the
• A goal of surgery is to end up with a great toe entire metatarsal head and base of the proximal phalanx (Fig. 12.4B).
that is within 1 cm of the overall length of the • Use a small dental rongeur to remove osteophytes.
second toe.
r s
rs
• Attempt to preserve the weight-bearing
k e e
Step 2
k eers
rs
o o
o o k function of the first metatarsal head by
maintaining adequate length.
o oo k
• Use a microsagittal saw to remove the articular surfaces (Fig. 12.5). Only 1–2 mm of
o oo
eebb • Use cool-water lavage on the bone surfaces
while reaming, to avoid heating the bone.
ee/ e
/ b
e b e / /ebb
bone is removed with these initial cuts, which are perpendicular to the long axis of
e
the metatarsal and to the proximal phalanx.
e
/ / t tm
• The fusion surfaces can be drilled with a small
. .m
Kirschner wire (K-wire) to maximize surface area
: / : / / t
/.tm
. m
• Place a pin from the Stryker great toe reamer set (Stryker, Kalamazoo, MI) into the
ss : /
and remove small portions of sclerotic bone.
t p p t p ss :
tral on the head.
p /
central metatarsal head and several inches down the shaft. It is important to be cen-
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
98 hht
PROCEDURE 12 Arthrodesis of the Great Toe Metatarsophalangeal Joint hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Divided
collateral
ligament
Base of
proximal phalange
Mobilized
k eers
rs k er
erss plantar plate
b ooook b ooook b o o Metatarsal
eeb ee/ e
/ e b ee/ e
/ e b head
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
A B
FIG. 12.4
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k FIG. 12.5
o o
o o k
o o
FIG. 12.6
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
t ss:
p / t p ss:
p /
• Ream the head with the appropriately sized barrel-shaped reamer while holding
p
the joint in maximal plantar flexion (Fig. 12.6). Carefully protect the tendon. The
• Protect the EHL during reaming. The tendon
can easily be cut by the sharp edge of the
t
hht t t
hht t
chosen reamer should be approximately equal to the width of the metatarsal shaft
(Fig. 12.7).
reamers.
• The concave-shaped reamer should then be used to remove the remaining cartilage CONTROVERSIES
and sclerotic bone (Fig. 12.8). Minimize bone resection (Fig. 12.9). • Flat cuts are another option for fusion. Perfect
bone apposition and fusion position are
k e e s
rs e rs
• Remove the pin and drill it into the central longitudinal axis of the proximal phalanx.
r rs
Use the convex-shaped reamer to prepare the fusion site (Fig. 12.10).
k e
much more difficult with this approach, often
o o
o o k oo k
• This reamer should be of the same size as the one used for the metatarsal shaft.
o o oo
requiring multiple cuts. Spherical reaming
allows meticulous positioning of the fusion in a
eebb e / b
e b
This reamer has the sharpest edges and can most easily damage the EHL.
/ e
• Ream into the proximal phalanx until the reamer is completely seated into the
e ee/e/ebb stable construct.
• The toe reamer technique is not appropriate
: / / t
/ .
tm.m : / / /.tm
bone (Fig. 12.11A). Otherwise, a gap will occur circumferentially when the con-
t . m for a patient with a failed implant. These
patients require a graft both to fill the defect
pin (Fig. 12.11B).
t p ss
p : / t p ss
p : /
cave metatarsal is seated into the convex phalanx. Remove the proximal phalanx
and to preserve as much length as possible.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 12.7
k er
erss
b ooook b oooo k
b o
FIG. 12.8
o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
eeb
FIG. 12.9
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb b b
FIG. 12.10
ee/ e
/ e b ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p pss: /
t
hht t t
hht t
Surface prepared for fusion
k e r
e s
rs k e r
e s
rs
o o
o o k o o
o o kMetatarsal
oo
eebb ee/ e
/ b
e b ee/e/ebb
Proximal phalanx
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : /
FIG. 12.11
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
100 hht
PROCEDURE 12 Arthrodesis of the Great Toe Metatarsophalangeal Joint hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
First metatarsal
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : /
Proximal phalanx
t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
10° dorsiflexion
b ooook A
b oo ook B
b o o
eeb ee/ e
/ e b FIG. 12.12
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : / First metatarsal
t
hht t t
hht t Proximal phalanx
keerrss keerrss 10° dorsiflexion
b ooook b ooook
b oo FIG. 12.14

: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t pp ss : / STEP 3 PEARLS
t
hhtt FIG. 12.13
t
hhtt • There is great variation in first metatarsal
declination, depending on the degree of pes
planus or cavus of the foot. For this reason,
Step 3 there is no definitive phalangeal–metatarsal
bone fusion angle. Intraoperative fluoroscopy
• Accurate positioning of the toe is essential.
should be used to evaluate the bony position of
k e rrss
e k e
on the second toe nor creates a gap between the toes.rrss
• The great toe should be positioned in sufficient valgus so that it neither impinges
e
the fusion, but the external posture of the toe is
what counts. An oblique 4-0 lagged screw can
o o
o o k o o o k
• The great toe should be in 10° of dorsiflexion relative to the floor, which usually
o o o
be added to the fusion construct, if needed.
eebb ee e
/ b
e b
correlates with 5 mm elevation off of the weight-bearing surface (Fig. 12.12A).
/
A rigid plate, such as the top of an instrument box, can be used to simulate a
ee/ e
/ b
e b • Two crossed screws may be used instead of
the dorsal plate in patients who have excellent
: / / t
/ m
.t.m
weight-bearing position of the foot (Fig. 12.12B).
: / / t
/ m
.t.m
bone stock.
t ss:
p / t p ss:
p
fused in too much plantar flexion, normal toe off will be compromised. /
• If the toe is fused in too much dorsiflexion, it will rub on the top of the shoe; if it is
p STEP 3 PITFALLS
t
hht t t
hht t
• The radiographic bone angles are usually 10–20° of valgus and 20–25° of dorsiflex-
ion. A short toe commonly requires less valgus.
• A plantar shelf of bone can prevent the
metatarsal head from seating into the proximal
phalanx. It can also block the appropriate
• The toe should be in neutral rotation, which can be judged by the position of the nail. position of fusion.
• Place a temporary percutaneous 0.62-inch K-wire across the fusion site (Fig. 12.13). Use • The plate should be exactly contoured.
k e r
e s
rs e rs
a 4- to 6-hole low-profile plate for fixation (Fig. 12.14). Several different types of fusion
rs
plates are available. No plate has been shown to be superior. A simple, low-profile con-
k e
Otherwise, the fusion angle can change as
the screws are tightened. Always assess the
o o
o o k oo k
struct is best. The K-wire can be left in place for 3–4 weeks if needed for added stability.
o o oo
position of the fusion after each screw is
placed.
eebb ee / b
e b
• Contour the plate to the dorsal surface of the bone. A very slight dorsal bend is all
/ e e /e/
that is usually needed. Check the screw lengths and fusion position by fluoroscopy.
e ebb • There is little leeway in positioning the fusion.
The end result must allow the patient to walk
: / / t
/ .
tm.m : / / t
/.tm
. m
• The percutaneous K-wire can be left in for 3 weeks to obtain increased stability, comfortably in flats or a small heel. The toe
should not be placed in excessive dorsiflexion
t p ss
p : /
or an oblique 4-0 cannulated screw can be added.
t p ss : /
• Close the capsule with interrupted 3-0 Vicryl sutures (Ethicon, Blue Ash, OH). Deflate
p
to accommodate someone who wishes to wear
t
hht t
the tourniquet and achieve hemostasis.
t
hht t higher heels.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k eerrss
b ooook booook b o o
eeb A
ee/ e
B
e
/ b ee/ e
/ e b
: // t/.tm
. m FIG. 12.15
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t POSTOPERATIVE CARE AND hhtt
EXPECTED t
OUTCOMES
• Apply a sterile toe spica dressing (see Procedure 1).
• The patient is non–weight bearing until the first postoperative visit 12 days after the
procedure. At that point, the sutures are removed and AP and lateral radiographs
keerrss keerrss
are taken. The patient is placed in a rigid postoperative shoe and is allowed to bear
b ooook b ooook
weight on the heel or lateral side of the foot. A RollerAid can help with ambulation, by
b oo
allowing the patient to bear weight on a flexed knee.

• By 8 weeks after the procedure, the fusion has invariability healed and the patient is
: / / t
/ m
.t.m : / / t m
allowed to start normal weight bearing in a walking shoe. AP (Fig. 12.15A) and lateral
.t.m
(Fig. 12.15B) radiographs should be taken to document the fusion. Oblique views
/
may be helpful if a delayed union is suspected. If the fusion is slow to heal, a weight-
t
hhtt t
hhtt
bearing cast boot can be used for several weeks.
• Patients can expect an excellent result and return to painless activity. Most patients will
be able to golf, ski, play doubles tennis, swim, and use an elliptical trainer. Running,
soccer, football, and basketball are usually not possible, although the addition of a
rocker sole on an athletic shoe may allow some degree of participation in these sports.
k e rrss
e k e rrss
• It is unlikely that symptomatic arthritis will develop in adjacent joints.
e
o o
o o k EVIDENCE
o o
o o k o o
eebb ee/ e b
e b ee/ e b
e b
Doty J, Coughlin M, Hirose C, Kemp T. Hallux metatarsophalangeal joint arthrodesis with a hybrid lock-
/ /
ing plate and a plantar neutralization screw: a prospective study. Foot Ankle Int 2013;34:1535–40.
: / / t
/ m
.t.m : / / t
/ m
.t.m
Outcome scores for this study indicate that first MTP joint arthrodesis with a precontoured dorsal
t p ss:
p / t p ss: /
titanium plate with locking screws in the phalanx and nonlocking screws in the first metatarsal is
both reliable and reproducible with a very high bony union rate (Level IV evidence).
p
t
hht t t
hht t
Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers
and dorsal plate fixation: a prospective study. Foot Ankle Int 2006;27:869–76.
Fifty-four patients who underwent fusion of the great toe were studied prospectively. There was
a 96% satisfaction rate in 49 patients. There was an 8% nonunion rate. This is an excellent study
(Level IV evidence).
Raikin SM, Ahmad J, Pour AE, Abidi N. Comparison of arthrodesis and metallic hemiarthroplasty of the
k e r
e s
rs k eers
rs
hallux metatarsophalangeal joint. J Bone Joint Surg Am 2007;89:1979–85.
A study of 46 patients who had either fusion or metallic hemiarthroplasty of the great toe. After a
o o
o o k oo k
mean of 79 months’ follow-up, the authors concluded that arthrodesis is a preferable procedure for
o o oo
eebb b b
patients with arthritis of the MTP joint (Level III evidence).
e/ e
/ e b
2002;23:625–8.
ee/e/e b
Vertullo CJ, Nunley James A. Participation in sports after arthrodesis of the foot or ankle. Foot Ankle Int
e
: / / t
/ .m.m : / / t. m
. m
This paper reports on the responses of orthopedic foot and ankle surgeons and professional train-
t / t
t p ss
p : / t p ss : /
ers about return to sports after various fusion procedures in the foot and ankle. Golf, skiing, and
tennis were recommended sports activities after an MTP fusion (Level V evidence).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh13t
PROCEDURE hht
Arthroscopic
rss Fusion of the GreatrToe
ss
kk ee
oAlastair r k
oo e
ke r
b
eeboo o Younger and Kenneth John Hunt boo
e b e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t
t p
t ss
p : INDICATIONS
t t p
t ss
p :
hht
• Arthroscopic fusion is limited to minimal
deformity as an open release of soft-tissue
contractures would prevent the joint being
hht
• End-stage arthritis of the first metatarsophalangeal (MTP) joint
• End-stage arthritis of the sesamoid to metatarsal head articulation
• Disruption of the plantar plate
appropriately exposed.
• Gouty arthritis
k eers
rs
INDICATIONS CONTROVERSIES rrss
k ee
b ooook • Some deformity can be corrected with an
b ooook b o
• A standing anteroposterior view of end-stage MTP joint arthritis is shown in Fig. 13.1.
o
eeb arthroscopic fusion, and some authors have
advocated using arthroscopic fusion with an
ee/ e
/ e b e / e
/ e b
• A standing lateral view of a patient with isolated MTP joint arthritis is shown in Fig. 13.2.
• Patients are observed standing with both feet bare. The forefoot alignment is inspect-
e
deformity.
: // t/.tm
endoscopic release in patients with underlying
. m : / /t/.tm. m
ed, as well as hallux valgus deformity. Claw toes may indicate lesser toe o verload.
t p ss
p : / tp ss : /
• The gait pattern is observed. Patients may walk on the lateral border of the foot to
avoid weight on a painful first MTP joint.
p
TREATMENT OPTIONS
• Rocker sole shoe
t
hht t t
hht t
• Patients may not be able to walk on tip toes because of MTP joint pain or loss of
dorsiflexion range.
• Rigid sole shoe with a rocker • A magnetic resonance imaging can be useful for assessment of the sesamoids and
• Orthotic with a metatarsal pad, or a Morton’s articular surfaces.
extension for an elevated first ray
• A computed tomography can be of value in assessing osteophyte anatomy and joint
keer ss
• Orthotic with a metatarsal head cut out for
r metatarsal head overload
keerrss
space narrowing.
b ooook • Local anesthetic and steroid injection into the

MTP joint
o
SURGICAL ANATOMY
b oook b oo
eeb • Topical or oral antiinflammatories
ee/e/e b e /e/e b
• Anatomy of the first MTP joint from the dorsal side can be seen in Fig. 13.3.
e
: / / t
/ m
.t.m : / / / m
.t.m
• Anatomy of the dorsal portals is shown in Fig. 13.4.
t
• First MTP joint arthroscopy is relatively easy to perform from the dorsal side in a
t ppss : / t p
mobile joint.
pss : /
t
hhtt t
hhtt
• The joint margin can usually be palpated from the dorsal side. The thumb of the left
hand is used to feel for the joint margin, while the right hand grasps and pulls the
phalanx to open the joint. Dorsiflexion and plantar flexion range will also allow the
bone margins to be felt.
• The dorsal medial and dorsal lateral nerves are variable in location and anatomy, hence
k e rrss
e k e rrss
the need for blunt dissection within the subcutaneous space where the nerves lie.
e
o o
o o k o o
o o k
• The plantar medial and plantar lateral nerves lie in a deeper plane and next to the
o o
eebb b b
sesamoids. As they are on weight-bearing surfaces, damage to these nerves can
ee/ e
/ e b ee/ e
/ e b
result in considerable disability. However, they are a distance away from any likely
: / / t
/ m
.t.m
portal placement.
: / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
FIG. 13.1
t p ss
p : /
t p ss
p : / FIG. 13.2
102
hhtt t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 13 Arthroscopic Fusion of the Great Toe 103
k e r
e s
rs k eers
r
Insertion of extensor s
Distal phalange
o o
o o k oo k
oo o o
eebb ee/ e
/ebb
Dorsomedial
ee/ e
/ b
e b
Proximal phalange
: / / t
/ .
t m
. m portal
: / / t
/ .
t m
. m
Dorsolateral
t p ss
p : / Medial
t p ss
p : / portal
t
hht t
Tendon of abductor
portal
t
hht t Dorsal sling
Perforating fibers
hallucis and insertion arising from plantar
fibers contributing aponeurosis
to dorsal sling
k eers
rs k er
er
Deep fibers of extensorss Tendon of adductor
b ooook b ooook
b o
to dorsal sling
o
eeb ee/ e
/ e b
Metatarsal
ee/ e
/ e b
: // t . m
. m
/ t : / /t/.tm. m
t p ss
p : /
tp pss : / Extensor hallucis
t
hht t t
hht t brevis tendon
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m
Dorsomedial
: / / t
/ m
.t.m
t p ss:
p / portal
t p ss:
p /
t
hht t Medial portal
t
hht t Dorsolateral
portal
nerve and branches
k e r
e s
rs k eers
rs Deep peroneal
nerve and branches
o o
o o k o ooo k oo
eebb Branch saphenous
e /
nerve
e e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss
FIG. 13.4
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
104 hht
PROCEDURE 13 Arthroscopic Fusion of the Great Toe hht
POSITIONING PEARLS • The short flexor tendons insert into the medial and lateral sesamoids. The flexor hal-
k e r
e ss
• Bring the patient to the foot of the bed so that
r
the great toe can be arthroscoped from the
k eers
lucis longus passes between the sesamoids in a flexor sheath, and passes distally
r s
under the phalanx. The short flexors insert distal to the sesamoids by two tendons
o o
o o kbottom of the bed.
oooo k
(a medial and lateral) into the base of the proximal phalanx. They form part of the
o o
eebb • Ensure that the foot is rotated so that the toes
are vertical to the floor to improve access to
ee/
POSITIONINGe
/ebb ee/ / b
e b
plantar plate that stabilizes the MTP joint.
e
the lateral portal.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss : /
• Positioning of the patient on the table is shown in Fig. 13.5.
• The surgery can be done with local nerve block such as spinal or general anesthetic.
p
t
hht t t
hht t
• A mini C-arm may be used and should be placed on the same side of the bed as the
surgical side.
• If the arthroscopy tower is on the same side of PORTALS/EXPOSURES

the bed as the operative side, the surgeon may
• Finding the medial portal is shown for the left leg in Fig. 13.6.
k ee s
have a hard time seeing the monitor if sitting
rrs
on the side of the bed.
k er
erss
• Developing the lateral portal is shown for the right leg in Fig. 13.7.
b ooook
• Make sure the calf tourniquet is low enough to
avoid the peroneal nerve at the fibular head.
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
• A bean bag is used to elevate the surgical hip.
• A contoured calf tourniquet is placed midcalf.
t
hht t
keerrss keerrss
b ooook
b ooook b oo
eeb • Toe traction can be used. We personally
prefer not to use it as the joint can be better
ee/e/e b ee/e/e b
visualized by plantar flexing the toe. The
traction will prevent this motion.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 13.5
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb

FIG. 13.6
: / / t
/ .
tm.m
: / / t
/.tm
. m FIG. 13.7
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
• There are two main portals which can be used, and up to four or five accessory portals. PORTALS/EXPOSURES PEARLS
k e e s
rs k eers
• The two main portals are the dorsal medial and dorsal lateral portals. These are
r r s
placed on each side of the extensor hallucis longus at the level of the joint line.
• Palpate the portals from the dorsal side. The
joint line can be felt with a little distraction and
o o
o o k oooo k
• A plantar medial portal just above and distal to the medial sesamoid can be used to
o o
motion at the MTP joint.
eebb to metatarsal head articulations.

ee /ebb
visualize or instrument the plantar side of the metatarsal head, or see the sesamoid
/ e ee/ e
/ b
e b
: / / / .
t m
. m : / / t
/ .
t m
. m
• A lateral first web space portal can be used to visualize and access the lateral side
t PORTALS/EXPOSURES PITFALLS
t p ss
p : /
of the joint on the lateral side.
t p ss : /
• Accessory dorsal portals can be placed more proximally to assist in the removal of
p
• The portals may be misplaced if dorsal
t
hht
dorsal osteophytes.
t t
hht t
• Accessory dorsal portals can also be used carefully. These can be placed just adja-
osteophytes are present and the osteophyte
may be confused with the joint line. Flexion and
extension of the joint will define the joint line.
cent to the primary portals, either just medial or lateral, and at the joint line, for ad- • Avoid sharp dissection deep to the dermis as
ditional instrumentation. the dorsal medial and dorsal lateral digital
nerves are subcutaneous in this position.
k eers
rs
PROCEDURE
k er
erss
b ooook
Step 1: Joint Visualization and Portal Establishment
b ooook b o o STEP 1 PEARLS
eeb / e e b
• The instruments in both portals are shown in Fig. 13.8.
ee / ee/ e
/
• An initial diagnostic arthroscopy is performed. The medial and lateral sides as well ase b • The MTP joint is relatively easy to arthroscope
: // t/.tm
. m
the dorsal and plantar sides of the joint are re-reviewed (Fig. 13.9).
: / /t/.tm. m
similar to the ankle.
• Placement of the scope and blunt trocar in the
ss : / ss : /
• The gutters are also visualized and débrided of synovium to allow visualization.
t p p tp p
over-the-top position will allow easy access.
• In patients with osteopenia, a C-arm x-ray of the
removal. t
hht t t
hht t
• On the dorsal side the synovium will often prevent easy visualization and will require
foot should be taken if there is concern about the
positioning of implants. It is easier to place the
instruments into the soft bone than into the joint.
• If the joint is tight and clearly arthritic, a
curette can be placed into the joint to free up
keerrss keerrss
the joint margins.
b ooook b ooook b oo STEP 1 PITFALLS
eeb ee/e/e b ee/e/e b • Avoid performing an interosseous placement of

the scope by careful palpation of the joint line.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt STEP 1 INSTRUMENTATION/
IMPLANTATION
• A 1.9-mm, 2.4-mm, or 2.9-mm 30°
arthroscope can be used. The 2.9-mm 30°
rrss rrss
arthroscope with a narrow sheath will fit in a
o k e
k e o k e
k e
larger patient
• A 2.9-mm or 3.5-mm shaver blade
o
eebb o o
b
FIG. 13.8
e o
b o o e b o
b o • Small joint curettes, 2-mm osteotomes
• A C-arm to assess resection if required
m ee/ / e m ee/ / e • A small joint grasper
: / /
/ t
/ .t.m : / /
/ t
/ .t.m • Inflow can be achieved using the arthroscope
via gravity, or using an intravenous tubing and
t t p
t ss:
p t t p
t ss:
p
hand-pumping fluid into the joint
hht hht STEP 1 CONTROVERSIES

• Complete cartilage débridement is likely to be
associated with a higher fusion rate.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm
. m
FIG. 13.9
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
106 hht
STEP 2 PEARLS Step 2: Cartilage Removal
k e r
e ss
• Drill the subchondral bone to improve the
r
chance of fusion.
k eers
r s
• The cartilage is sequentially removed as shown in Fig. 13.10.
• K-wires can be used to drill the subchondral bone as shown in Fig. 13.11.
o o
o o k o oo k o
• A plantar medial portal may be required to remove all of the plantar cartilage.
o o
eebb ee/ e
/ebb ee/ e
/ b
e b
• A complete débridement is confirmed from all portals.
STEP 2 PITFALLS
: / / t
/ .
t m
. m : / / t
/ .
t m
Step 3: Reduction of the First MTP Joint
. m
ss : /
• Incomplete débridement may result in failure
t p p t p ss
p : /
• The first ray must be fused in the correct position. A flat surface is used on the plan-
tar side of the foot to ensure that the correct degree of dorsiflexion is achieved.
of fusion.
t
hht t t
hht t
• The first MTP joint also has to be reduced in the correct degree of varus and valgus.
The great toe should be placed in enough valgus to ensure it will fit in a shoe. However,
it should not crowd the second toe.
STEP 3 PEARLS • The rotation of the first ray should also be checked. The interphalangeal (IP) joint
k eerss
• Make sure the first ray is correctly reduced. A
r
malreduction is poorly tolerated, and this is the
k er
ers
should flex and extend perpendicular to the floor, and the first toe nail should point
s
vertically up. Once correctly reduced, the first ray is held reduced with a K-wire from
b ooook time at which the reduction can be changed.
b ooookthe medial aspect of the first ray to the first metatarsal (Fig. 13.12).
b o o
eeb ee/ e
/ e b ee/ e
/ e b
• The final position is then checked.
: // t/.tm
. m : / /t/.tm. m
STEP 3 PITFALLS
t p ss
p : /
• Malreduction in extension will result in an IP
tp pss : /
t
hht t
joint that will rub on the shoe. A malreduction
in flexion will result in overload of the IP joint.
t
hht t
• Malreduction in varus will result in rubbing
on the shoe. A valgus malreduction will result
in crowding of the second toe and potential
ke rrs
callus formation.
s
• A rotational malrotation into internal rotation
e keerrss
b ooook (pronation) then flexion of the IP joint will result
in the tip of the toe moving toward the second
b ooook b oo
eeb toe causing an apparent valgus deformity.
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
• Some surgeons argue for a greater degree of
extension to accommodate a heeled shoe in a
t
hhtt
female patient.
FIG. 13.10
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
: /
FIG. 13.11
p t
p ss
p : / FIG. 13.12
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Step 4: Fixation of the Fusion STEP 4 PEARLS
k eerss
used to transfix the subchondral bone.
k eers
r s
• We prefer to use three screws for arthroscopic fusion. Full thread screws should be
r • Only one screw needs to be compressed. A 3.5-
mm drill can be used to overdrill the first screw,
o o
o o k oooo k o o
which is best to place from distal to proximal.
eebb POSTOPERATIVE CARE AND EXPECTED OUTCOMES

ee/ e
/ebb
• A nylon suture is placed in each portal to prevent sinus formation.
ee/ e
/ b
e b • The remaining screws can be placed without
lagging so that the screw can transfix both
t . m
. m t . m
. m
• Patients are kept non–weight bearing for a week after surgery to prevent sinus for-
: / / / t : / / / t
sides of the joint through the subchondral bone.
t p p : /
mation in the portal site (Fig. 13.15).
ss t p ss
p : /
• After this point the patients can be mobilized weight bearing as tolerated.
t
hht t
surgery to ensure fusion.
t
hht t
• A rigid sole shoe or walker boot should be used for the initial 6–10 weeks after
STEP 4 PITFALLS
• The screws may fail to correctly transfix the
bone, particularly in osteoporotic bone. In this
case it is worthwhile to consider opening the
joint and adding a plate.
• We would not recommend partial thread
k eers
rs k er
erss cancellous screws as the fixation is inferior to
the full thread screw in this construct.
eeb ee/ e
/ e b ee/ e
/ e b
IMPLANTATION
: // t/.tm
. m : / /t/.tm. m • Screw fixation can be achieved using full
t p ss
p : / tp pss : / thread cortical screws or full thread headless
cannulated compression screws (Figs. 13.13
t
hht t t
hht t and 13.14).
• The benefit of the increased cost of the
keerrss keerrss headless compression screw in fusion rate has

not been demonstrated.
eeb ee/e/e b ee/e/e bPOSTOPERATIVE PEARLS
: / / t
/ m
.t.m : / / t
/ m
.t.m • Early range of motion and remobilization
should be encouraged after the first week.
t
hhtt
FIG. 13.13
t
hhtt POSTOPERATIVE PITFALLS
• Patients should be well counselled and
educated after surgery to protect the fusion.
• Patients should avoid smoking and should take
vitamin D during the recovery period.
k e rrss
e k e rrss
e
o o
o o k o o
o o k POSTOPERATIVE INSTRUMENTATION/
o o
eebb b b
IMPLANTATION
ee/ e
/ e b ee/ e
/ e b
• A walker boot or postoperative shoe may be
: / / t
/ m
.t.m : / / t
/ m
.t.m required for the first 2 weeks after surgery.
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss : /
FIG. 13.14
p t
p ss
p : / FIG. 13.15
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
108 hht
EVIDENCE
k e r
e s
rs rs
r s
Ahn JH, Choy WS, Lee KW. Arthroscopy of the first metatarsophalangeal joint in 59 consecutive cases.
k ee
J Foot Ankle Surg 2012;51:161–7.
o o
o o k o oo k o
In 59 cases of first MTP joint arthroscopy there was one case of temporary nerve palsy, and satis-
o o
eebb bb b b
faction was reported in 95% of cases. American Orthopedic Foot and Ankle Scores improved from
e / e
/e
69 to 92 points.
e ee/ e
/ e
: / / t
/ .
t m
. m : / / t
/ t m
Chan PK, Lui TH. Arthroscopic fibular sesamoidectomy in the management of the sesamoid osteomy-
. . m
elitis. Knee Surg Sports Traumatol Arthrosc 2006;14:664–7.
t p ss
p : / t p ss
p : /
A description of an arthroscopic removal of the lateral sesamoid.
Davies MS, Saxby TS. Arthroscopy of the first metatarsophalangeal joint. J Bone Joint Surg Br
t
hht t 1999;81:203–6.
t
hht t
One of the original papers on arthroscopic treatment of the first MTP joint. Despite normal inves-
tigations in 6 of the 12 patients, intraarticular pathology was found in all patients and all patients
demonstrated improvement in outcome.
Hunt KJ. Hallux metatarsophalangeal (MTP) joint arthroscopy for hallux rigidus. Foot Ankle Int
k eers
rs
2015;36:113–9.
k er
erss
A description of a technique for arthroscopic débridement of hallux rigidus.
b ooook ooook
Siclari A, Decantis V. Arthroscopic lateral release and percutaneous distal osteotomy for hallux valgus:
o o
a preliminary report. Foot Ankle Int 2009;30:675–9.
b b
eeb e / e
/ e b e / e
/ e b
A percutaneous distal osteotomy was combined with an arthroscopic lateral release for hallux
valgus in 59 procedures with encouraging results.
e e
: // t/.tm
. m Arthroscopy 1998;14:851–5.
: / /t/.tm. m
van Dijk CN, Veenstra KM, Nuesch BC. Arthroscopic surgery of the metatarsophalangeal first joint.
t p ss
p : / ss : /
A series of 24 patients were treated with dorsal débridement for hallux rigidus. Good results were
tp p
t
hht t t t
seen but with worse outcomes in patients with cartilage defects or with the need for sesamoid
resection.
hht
Wang CC, Lien SB, Huang GS, et al. Arthroscopic elimination of monosodium urate deposition of the
first metatarsophalangeal joint reduces the recurrence of gout. Arthroscopy 2009;25:153–8.
A description on arthroscopic removal of gouty tophi in 15 patients compared with 13 patients re-
ceiving medical treatment alone. The arthroscopic treatment group showed better outcome scores.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh14
PROCEDURE
t hht
Forefoot
rss Reconstruction for Rheumatoid
rss Disease
kkee r
ooGlenn B. Pfeffer k
oo e
ke r
b
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht
• Chronic pain and deformity of the forefoot from rheumatoid arthritis
• Recurrent ulceration
hht
• Active infection or ulceration should be
eradicated prior to surgery.
• Failure of nonoperative measures, including shoe modification and orthotics • Severe skin fragility may preclude operative
intervention.
k ee s
EXAMINATION/IMAGING
rrs k er
erss • Medications that interfere with bone and
wound healing, especially methotrexate and
b ooook b ooook
• All patients require a comprehensive preoperative history and physical examination.
• A detailed examination of the foot and ankle is required, including skin condition,
b o o
tumor necrosis factor antagonists, should be
stopped 2 weeks prior to surgery. They can be
eeb ee/ e
/ e b
joint stability, tendon function, neurovascular status, and gait.
ee/ e
/ e b started again when the wounds have healed.
• Cervical spine stability should be established
// t/ tm
• Specifically evaluate the function of the posterior tibial tendon.
. . m / /t/.tm. m
• Synovitis, subluxation, or dislocation of the metatarsophalangeal (MTP) joints should
: :
preoperatively (flexion and extension views
ss : / ss : /
be documented. If dislocated, determine if the joints are passively reducible.
t p p tp p
may be required).
• Patients on prednisone will often need
t
hht t t
hht t
• The most common symptomatic deformity includes hallux valgus, claw toes, dislo-
cations of the lesser MTP joints, and metatarsalgia from pressure on the metatarsal
perioperative supplementation.
• A preoperative physical therapy evaluation
is very helpful, both to determine a patient’s
heads (Fig. 14.1).
•
Radiographs should include standing anteroposterior (Fig. 14.2A) and lateral ability to ambulate after surgery and to provide
training with ambulatory aids.
(Fig. 14.2B) views of the foot. Oblique views of the foot will help visualize arthritic
keerrss keerrss
changes of the MTP and midfoot joints. Standing views of the ankle can be obtained
b ooook b ooook
to make sure there is no medial laxity of the joint.
• Magnetic resonance imaging is helpful in detecting early joint involvement.
b oo
eeb b b INDICATIONS CONTROVERSIES
ee/e/e ee/e/e • New medical management has altered
: / / t
/ m
.t.m : / / t
/ m
.t.m the previously inevitable progression of
autoimmune disease.
t ppss : / t ppss : / • While patients with extensive forefoot
t
hhtt t
hhtt
involvement require the reconstruction
discussed in this procedure, others may
benefit from a more limited procedure
(e.g., isolated great toe fusion, single MTP
synovectomy, or a metatarsal osteotomy to
reduce a dislocated joint).
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : /
t p ss :
FIG. 14.1
p /
t
hht t t
hht t 109
t t p
t ss:
p t t p
t ss:
p
110 hht
PROCEDURE 14 Forefoot Reconstruction for Rheumatoid Disease hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb /
Arthritic MTP joint
ee e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t Inflammation/
synovitis
Dislocated
phalanges
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook b oooo k b oo
FIG. 14.3

B
/ t m
.t.m / t m
.t.m
s:/: / / s : /
: / /
t
hhtt pp s
FIG. 14.2
t t t
hhtt pp s
SURGICAL ANATOMY
• Arthritic change of the great toe MTP. Erosion of the lesser metatarsal head often
k e rrss
e k e rrss
associated with MTP dislocation (Fig. 14.3).
e
o o
o o k o o
o o k
TREATMENT OPTIONS
o o
eebb ee e
/ b
e b
• Extra-depth shoes with rocker soles
/
• Cushioned Plastizote orthotic inserts
ee/ e
/ b
e b
: / / t
/ m
.t.m • Metatarsal pads (Hapad)
: / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• Silicone toe-caps for painful toe deformities (Silipos)
• A Budin splint (Alimed) can help reduce a passively correctable claw toe
t
hht t t
hht
• Medical management
• Physical therapy
t
• Corticosteroid injection into a symptomatic joint
POSITIONING
k e r
e s
rs k eers
rs
• Place the patient in the supine position.
o o
o o k oo k
• A small bump under the ipsilateral hip may help position the foot. Place the foot 5
o o oo
eebb ee/ e
/ b
e b
forefoot from all sides.
ee/e/ebb
cm from the end of the table, which allows the surgeon to have easy access to the
: / / t
/ .
tm.m : / / t
/.tm
. m
• A well-padded ankle or thigh tourniquet is used.
t p ss
p : / t p ss : /
• In most cases the procedure can be done on an outpatient basis, using a femoral-
sciatic or popliteal block for postoperative pain control.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 14 Forefoot Reconstruction for Rheumatoid Disease 111
PORTALS/EXPOSURES PORTALS/EXPOSURES PEARLS
k ee s
rs k eers
• Three longitudinal incisions are used to gain access to all of the MTP joints (Fig. 14.4).
r r s
• The first incision is 5–6 cm over the dorsal aspect of the great toe and first metatarsal.
• Careful soft-tissue technique is required to
avoid skin injury. Gentle skin retraction with
oooo k oooo k
• The other two incisions are 3–4 cm in the second and fourth intermetatarsal spaces.
o o
double hooks or small retractors is best. Avoid
eebb PROCEDURE ee/ e

/ebb ee/ e
/ b
e b squeezing the skin edges with a pickup, and
minimize the use of self-retaining retractors.
Step 1
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
p ss
p : / t p ss : /
• Start with a longitudinal incision in the second intermetatarsal space using a #15
t p
• Transverse plantar or dorsal incisions can be used.
t
hht t
blade. Loupe magnification can be helpful.
t
hht t
• Use blunt dissection to locate the extensor tendons. Divide the extensor digitorum
Longitudinal incisions provide the greatest ease of
access with few skin problems.
longus (EDL) and excise a 3- to 5-mm segment (Fig. 14.5). A Z-lengthening of the
tendon is another option.
• Locate the dorsal aspect of the proximal phalanx at the MTP joint, which is often
k eers
rs subluxed or dislocated dorsally (Fig. 14.6).
k er
erss
b ooook ooook
• Divide the capsule longitudinally and carefully expose the metatarsal head. Protect
the neurovascular bundle, which may be displaced, especially when the MTP joint is
b b o o
eeb dislocated.
ee/ e
/ e b ee/ e
/ e
• Divide the collateral ligaments and free up the plantar plate with a small elevator.
b
: // t/.tm
. m : / /t/.tm. m
• Using a microsagittal blade, divide the metatarsal obliquely, usually at the neck from
ss : / ss : /
distal-dorsal to plantar-proximal. The cut is made approximately 30° to the longitudinal
t p p tp p
t
hht t t
hht t
axis of the metatarsal, in order to avoid a sharp plantar bone prominence (Fig. 14.7).
keerrss keerrss
: / / t
/ m
.t.m : / / t m
.t.m
Proximal phalanx
/
subluxed/dislocated
dorsally
t
hhtt t
hhtt FIG. 14.4
k e rrss
e k e rrss
e
o o
oA
o k B
o o
o o k o o
eebb
e / e
/ b
e
FIG. 14.6
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm. m : / / t
/.tm
. m
t p ss
p : / FIG. 14.7
t p ss
p : /
FIG. 14.5
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
112 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 14.8
k r
eerss FIG. 14.9
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
STEP 1 PEARLS
t
hht t
• If the toe is deviated laterally, another option is
t
hht t
• Grasp the distal metatarsal head with a towel clip and carefully excise it using
sharp dissection. Stay close to the bone to avoid injury to adjacent structures
(Fig. 14.8).
to divide the deforming force of the extensor
digitorum brevis and Z-lengthen the EDL. • Use a microreciprocating rasp to smooth down the bone edges (Fig. 14.9). Be care-
• An irreducible MTP joint may make it ful, as this instrument will rapidly remove the osteoporotic bone of a patient with
keerrs
impossible to expose the distal-most aspect of
s
the metatarsal. If so, the metatarsal osteotomy
keerrss
rheumatoid arthritis.
b ooook will have to be performed proximal to the neck.

In this case, excision of the distal metatarsal
b oook
Step 2
o b oo
eeb can be very difficult and time consuming.
Careful traction on the toe by an assistant will
ee/e/e b ee/e/e b
• Once the second MTP is adequately decompressed, make cuts in the adjacent
metatarsals from medial to lateral. Each cut should be more proximal than the next,
help expose the metatarsal.
: / / t
/ m
.t.m : / / t
/ m
.t.m
creating a gentle arc. Each metatarsal must be shortened sufficiently to decompress
p ss /
• It is essential to adequately decompress the
:
MTP space. Resect as much of the metatarsal
t p
the MTP space.
t ppss : /
t
hhtt
as needed to leave a 1-cm to 1.5-cm, finger-
sized gap between the base of the proximal
phalanx and the cut distal metatarsal.
t
• The cut in the fifth metatarsal neck is angled slightly to avoid any bony prominence
hhtt
on the lateral border of the foot (Fig. 14.10).
• Use the microreciprocating rasp sequentially on each metatarsal.
• The level of the second metatarsal cut usually
dictates the level of the other metatarsal cuts Step 3
and, ultimately, the great toe MTP fusion.
k e rrss
It is for this reason that the second MTP
e
is addressed first. Rarely, a more severely
k e rrss
• At this point, the toe deformities should be corrected sequentially. Closed osteocla-
e
sis is easy and efficient, and usually possible because of osteoporotic bone. Gently
o o
o o k dislocated and contracted third MTP joint
o o
o o k
hold the toe on each side of the proximal interphalangeal (PIP) joint, and forcibly
o o
eebb b b b b
should be addressed first, which in turn will straighten it.
affect the level of the other bone cuts.
ee/ e
/ e e / e
/ e
• An open procedure may be required in a younger patient with good bone stock.
e
: / / t
/ m
.t.m : / / t
/ m
.t.m
• In such a case, make a transverse incision on the toe a few millimeters proximal
t p ss:
p / t p ss: /
to the level of the PIP joint.
• Divide the extensor tendon transversely. Divide the collateral ligaments with a #15
p
STEP 1 PITFALLS
t
hht t
• Avoid penetration of the saw blade beyond
t
hht t
blade, while keeping the toe hyperflexed to keep the neurovascular bundle out of
the way.
the plantar border of the metatarsal. The • Remove approximately 5 mm of the distal aspect of the proximal phalanx to ad-
neurovascular bundle lies just beyond. equately decompress the PIP joint. A small rongeur easily removes the necessary
• Neither resection of the proximal phalangeal bone and is safer than a power saw (Fig. 14.11).
k e r
e ss
base nor syndactylization of the toes is
r
required in this procedure. Leaving the base
k eers
rs
• When the toe is extended into a neutral position, the cut end of the proximal pha-
o o
o o k of the proximal phalanx intact increases the
o o
oo k lanx and the middle phalanx should not rub.
oo
eebb b b
stability of the reconstruction and minimizes • Starting in the PIP space, insert a 0.062-mm Kirschner wire (K-wire) in a retrograde
recurrent postoperative deformity.
• When performing the osteoclasis, be careful not
ee/ e
/ e b ee/e/e b
fashion out the tip of the toe, exiting just below the nail.
: / / t .m.
to rupture the fragile plantar skin of the toe.
/ t m : / / t
/ tm
• Run the K-wire out the base of the proximal phalanx into the metatarsal shaft
. . m
(Fig. 14.12). The metatarsal and phalanx should be aligned longitudinally.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs
A
k er
erss B
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
A
: / / t
/ m
.t.m
: / / t
/ m
.t.m FIG. 14.12
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p pss: /
B
t
hht t t
hht t FIG. 14.13
FIG. 14.11
STEP 3 PEARLS
• Occasionally a toe will have poor arterial flow
k e r
e s
rs k e rs
rs
• Drive the wire into the bone at the base of the metatarsals to gain adequate fixa-
e
after the tourniquet is deflated. Shifting the toe
o o
o o k oo k
tion and minimize postoperative motion (Fig. 14.13). Fluoroscopic guidance can
o o oo
either proximally or distally on the pin can resolve
this problem. Slight rotation of the toe can also
eebb be helpful.
e / e
/ b
e b
• Bend the pin and apply a cap. Place two 3-0 Vicryl sutures into the extensor of
e ee/e/ebb help. If not, apply warm saline-soaked sponges
to the forefoot for several minutes. Nitro paste on
: / / / .
each toe. Excise redundant skin.
t tm.m : / / t
/.tm
. m the plantar aspect of the foot can also be used.
If there is no resolution, pulling the pin of the
t p ss : /
able suture after the K-wire has been placed.
p t p ss
p : /
• If a Z-plasty of the EDL has been performed, repair the tendon with a simple absorb-
affected toe will invariably restore good circulation.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
114 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
A
t
hht t t
hht
B
t
FIG. 14.14
Step 4
keerrss keerrss
• Fuse the great toe MTP joint, if required (see Procedure 12). Fusion is almost always
b ooook o ook
required (Fig. 14.14).
b o b oo
• The first and second metatarsals should be cut at approximately equal levels.
• Ideally, at the end of the procedure the tips of the first and second toes will be
: / / t
/ m
.t.m : / / t
/ m
.t.m
within 1 cm of each other in length.
t ppss : / t pp s : /
• A fusion is almost always possible, even in a patient with severe osteoporosis. A
s
resection arthroplasty (modified Keller) of the base of the proximal phalanx is an op-
t
hhtt t
hhtt
tion, especially if there is involvement and loss of motion of the interphalangeal joint.
An arthrodesis, however, will always produce a better result.
• Drop the tourniquet and obtain meticulous hemostasis. Carefully close the skin in
layers. Apply a bulky dressing and a posterior splint.
k e rrss
e k e rrss
e
o o
o o k o o k
• Most surgeries can be done on an outpatient basis, unless there is a medical indica-
o o o o
eebb ee/ e
/ b
e b
tion for postoperative hospitalization.
e / e
/ b
e b
• The first office visit is at 10–12 days after surgery. Until that time, no weight bearing
e
: / / t
/ m
.t.m : / / t
/ m
.t.m
should be allowed on the operated foot. Radiographs are taken (Fig. 14.15).
t p ss:
p / t p ss: /
• Once the wound is healed and the sutures are removed, the patient can start to bear
weight on the heel, as able. A non–weight-bearing cast may be required in a patient
p
t
hht t t
hht t
who has poor fixation of the first MTP fusion.
• The pins are pulled in the office 3 weeks after surgery. One-quarter inch paper tape
is used to hold them in position for an additional 9 weeks. The tape extends from the
plantar aspect of the toe, onto the dorsum of the foot. Keep the PIP and MTP joints
in neutral position.
k e r
e s
rs k eers
rs
• By 8 weeks after surgery, or once radiographs confirm a successful fusion of the
o o
o o k o o
oo k
great toe (Fig. 14.16), the patient can return to normal shoewear, as tolerated. Swell-
oo
eebb b b
ing may persist for 6 months.
ee/ e
/ e b ee/e/e b
• A patient can expect to have an excellent result, with the elimination of forefoot pain
: / / t
/ .
tm.m had surgery).
: / / t
/ tm
and an improvement in function and shoewear (Fig. 14.17; the foot on the right has
. . m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
See also Video 14.1, Forefoot Reconstruction for Rheumatoid Disease.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 14.15 FIG. 14.16
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m
: / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
FIG. 14.17
t
hht t t
hht t
EVIDENCE
Coughlin M. Rheumatoid forefoot reconstruction. J Bone Joint Surg Am 2000;82:322–41.
This study showed 96% good to excellent results and 100% fusion rate at an average follow-up of
k e r
e ss
6.2 years (Level IV evidence).
r k eers
rs
Jeng C, Campbell J. Current concepts review: the rheumatoid forefoot. Foot Ankle Int 2008;29:959–68.
o o
o o k
An excellent review of this topic.
o o
oo k oo
eebb b b
Mann R, Schakel M. Surgical correction of rheumatoid forefoot deformities. Foot Ankle Int 1995;16:1–6.
e/ e
/ e b
results were obtained in 90% of patients (Level IV evidence).
ee/e/e b
A retrospective study of metatarsal head resection and arthrodesis of the great toe MTP. Excellent
e
: / / t
/ .m.m : / / t. m
. m
Rosenbaum D, Timte B, Schmiegel A, Miehlke R, Hilker A. First ray resection arthroplasty versus arthro-
t / t
t p ss
p : / t p
A comparative study of first metatarsal head resection and joint fusion.
ss
p :
desis in the treatment of the rheumatoid foot. Foot Ankle Int 2011;32:589–94.
/
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh15t
PROCEDURE hht
FifthrMetatarsal
ss Osteotomy for Correction
r s s of
o k ee r
Bunionette
k Deformity o kkee r
b o
m ee /e m ee / e
Mark E. Easley
: / t
///t. . m : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp t
hhtt p
t p
INDICATIONS
k eers
rs k er
e
fifth toerss
• Wide forefoot with symptomatic fifth metatarsal (5MT) head and medial deviation of
b ooook b ooook b o
• Failure of nonoperative treatment (shoe modifications)
o
eeb TREATMENT OPTIONS
ee/ e
•

/ e b ee e
/ e b
Weight-bearing anteroposterior (AP) foot radiograph demonstrating a widened
/
fourth-fifth intermetatarsal angle (4/5 IMA)
: / t .tm
.
• Distal 5MT osteotomy typically reserved for
/ m
EXAMINATION/IMAGING
/ : / /t/.tm. m
IMA (type I deformity)
t p ss
p : /
prominent 5MT head without increased 4/5
• Wide forefoot
tp pss : /
t
hht t
• Minor increase in 4/5 IMA (Fig. 15.2A)
• Readily corrected with a distal chevron
t
hht t
• Symptomatic 5MT head and medial deviation of fifth toe
• Widened 4/5 IMA (type II or type III bunionette deformity) on a weight-bearing AP foot
osteotomy (Fig. 15.2B)
radiograph (Fig. 15.1)
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo kA B
oo
eebb
FIG. 15.1
ee/ e
/ b
e b
ee/e/ebb
FIG. 15.2
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
116 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 15 Fifth Metatarsal Osteotomy for Correction of Bunionette Deformity 117
Widened fourth-fifth
metatarsal space
k e r
e s
rs k eers
r s
o o
o o k Fifth metatarsal
oooo k o o
eebb bb b b
deviated medially
ee/ e
/e ee/ e
/ e
: / / t
/ .
t m
. m : / / t
/ .
t m
Nutrient artery
. m Metaphyseal
arteries
t p ss
p : / t p ss
p : /
Prominent fifth
t
hht t t
hht t
metatarsal head
k eers
rs k er
erss
ook ook
Periosteal blood supply
b
eeboo / e b o
bo / e b o o
“Avascular Zone”
b
m ee / e m ee / e
: ///t/.t. m : / /
/t/.t . m Metaphyseal
arteries
t t p
t ss
p : t

t p
tpss : FIG. 15.4
hht hht
keerrss FIG. 15.3

keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
SURGICAL ANATOMYpss:
t p / t ppss : /
t
hhtt t
hhtt
• Essentially a mirror image of a bunion deformity
ANATOMY PITFALLS
• Avoid injuring the sural nerve.
• An incision too plantar will make screw
• Widened 4/5 IMA, prominent 5MT head, and medial deviation of the fifth toe
(Fig. 15.3) insertion more difficult.
• Ligamentous attachments between fourth and fifth MT bases
k errss k
• Commonly associated with Jones fracture rrss
• Watershed area of poor vascular supply at 5MT base (Fig. 15.4)
e e e
oooo k o o o k
• Osteotomy should be distal to this watershed area
o o o
eebb POSITIONING / e b b
• Sural nerve courses on dorsolateral aspect of 5MT
ee / e ee/ e
/ b
e b • A longer osteotomy will provide a greater
surface area for healing and permit fixation
: / / t
/ m
.t.m : / / t
/ m
.t.m with two screws.
t p ss:
p / t p ss:
p /
• Supine position with a bolster under the ipsilateral hip to provide optimal exposure to
t t
the lateral foot.
hht
PORTALS/EXPOSURES
t
hht t PORTALS/EXPOSURES PITFALLS
• A longitudinal lateral incision is made over the dorsolateral aspect of the 5MT ex-
• To ensure that the osteotomy will mobilize
tending from the fifth metatarsophalangeal (5MTP) joint to the junction of the middle adequately, plan the osteotomy to originate just
k e r
e s
and distal thirds of the 5MT (Fig. 15.5A).
rs k eers
rs
• The sural nerve is at risk and should be retracted dorsally and medially if within the
distal to the stout ligamentous attachments of
the proximal 5MT.
o o
o o k operative field (Fig. 15.5B).
o o
oo k oo
• Extending the osteotomy too close to the
eebb b b 5MTP joint may violate the lateral capsule and

sure (see Fig. 15.5B).
ee e
/ b ee e
• The lateral 5MTP joint capsule should be identified but not violated during the expo-
/ e / /e b make capsular closure difficult.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
118 hht
PROCEDURE 15 Fifth Metatarsal Osteotomy for Correction of Bunionette Deformity hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A FIG. 15.6
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
Sural nerve retracted
dorsally and medially
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
ook ook
5MTP joint capsule
B
b
eeboo
/e bboo
/e bboo
FIG. 15.5
m ee /e m ee /e FIG. 15.7
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
t t ppss : t t ppss :
STEP 1 PEARLS
hhtt
• Minimal periosteal stripping is required.
• To create a congruent osteotomy, only
PROCEDURE
Step 1
hhtt
the distal corner of the saw blade exits • An L-shaped lateral capsulotomy is performed in the 5MTP joint capsule (Fig. 15.6).
the osteotomy each time the saw blade is The sural nerve is in close proximity and must be carefully retracted dorsally. Through
k e rrss
advanced along the course of the planned
osteotomy.
e k rrss
the joint, a medial capsulotomy can be performed to improve the fifth toe alignment,
e e
similar to a lateral release performed for hallux valgus correction.
o o
o k
• If elevation of the 5MT is desired with
o o o o k o
• The lateral eminence is resected in line with the 5MT shaft (Fig. 15.7).
o o
eebb b b
correction of lateral deviation, the saw blade
can simultaneously be angled dorsally.
ee/ e
/ b ee/ e
/ e b
• The lateral MT is scored (with the saw blade) to mark the planned oblique osteotomy.
e
• Intraoperative fluoroscopy may be used to determine the proximal extent of the oste-
: / / t
/ m
.t.m : / / t m
.t.m
otomy to avoid encroaching on the watershed area of the proximal 5MT and to avoid
/
STEP 1 PITFALLS
t p ss:
p / t p ss:
p /
the relatively immobile aspect of the 5MT bound by tight ligamentous attachments
t
hht t
• This is a diaphyseal osteotomy, and the heat
generated by the saw blade should be kept
to a minimum (consider using cool saline Step 2
t
hht t
to the fourth MT.
irrigation). • The majority of the periosteum may be left intact, which may aid in healing this dia-
physeal osteotomy.
k e r
e s
rs k eers
• The microsagittal saw should be passed through both cortices over the proximal-dor-
rs
sal two-thirds of the osteotomy (Fig. 15.8). The osteotomy should not be completed at
o o
o o k o oo k o
this stage in order to maintain control of both fragments throughout the procedure.
o o
eebb ee/ e
/ b
e b
mal portion of the osteotomy.
ee/e/ebb
• A mini-fragment screw is inserted from dorsal to plantar across the completed proxi-
: / / t
/ .
tm.m : / / t
/.tm
. m
• When using solid screws, a standard lag technique is used.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 15.8 FIG. 15.9
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss

: / / t
/
FIG. 15.10 m
.t.m
: / / t
/ m
.t.m FIG. 15.11
t ppss : / t p s
p s : /
t
hhtt t
hhtt
• After compression is confirmed for either solid or cannulated (dual-pitch or par-
k e rrss
e e rrss
tially threaded) screws, the screw is slightly released to allow for repositioning of
k e
o o
o o k o o
o o k
the saw blade to complete the osteotomy (Fig. 15.9).
o o
eebb b b
• The saw blade never completely exits the osteotomy as it is advanced to maintain
ee/ e
/ e b
a congruent cut along the entire length of the osteotomy (Fig. 15.10).
ee/ e
/ e b
/ / t
/ m
maintained with the proximal lag screw in place.
: : / / t
/ m
• The distal portion of the osteotomy is completed with control of the osteotomy being
.t.m .t.m INSTRUMENTATION/IMPLANTATION
t ss:
p / t p ss:
p /
• With a towel clip carefully securing the distal aspect of the proximal fragment and
p • Microsagittal saw
t
hht t t
hht t
medially directed pressure applied on the distal fragment at the 5MT head, the 4/5
IMA is corrected.
• Mini-fragment set (cannulated or solid screws)
• Towel clip
• The proximal screw is tightened to secure the osteotomy.
• The towel clip can be repositioned to temporarily block any potential loss of
reduction.
k r s
rs rs
rs
• Intraoperative fluoroscopy in the AP plane confirms an adequate reduction. If in-
e e k ee STEP 2 PITFALLS
o o
o o k repeated, and the screw is again tightened.
o o
oo k
adequate, the proximal screw is slightly loosened and the reduction maneuver is
oo • If correction of the bunionette deformity
eebb ee/ e b
e b
• With a satisfactory reduction, a second screw is placed across the distal aspect
/ ee
of the osteotomy. I prefer to place this screw from a plantar to dorsal direction/e/ebb requires considerable tension on the lateral
capsular repair, then most likely the 4/5 IMA is
(Fig. 15.11).
: / / t
/ .
tm.m : / / t
/.tm
. m undercorrected.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
120 hht
PROCEDURE 15 Fifth Metatarsal Osteotomy for Correction of Bunionette Deformity hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B
k eers
rs k er
erss
FIG. 15.12
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook
FIG. 15.13
b ooook
b ooFIG. 15.14

: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt Step 3 t
hhtt
• The lateral prominences, both distal (Fig. 15.12A) and proximal (Fig. 15.12B), are
resected evenly with the realigned MT using a microsagittal saw to limit the risk of a
pressure area with footwear.
k e rrss
e e rrss
• The lateral capsulotomy is imbricated at its new resting tension (Fig. 15.13). A surgi-
k e
o o
o o k o ooo k
cal sponge can be placed between the fourth and fifth toes to relax any tension on
o o
eebb b b
the lateral capsule during closure.
ee/ e
/ e b ee/ e
/ e b
• The subcutaneous tissue and skin are reapproximated to a tensionless closure
: / / t
/ m
.t.m (Fig. 15.14).
: / / t
/ m
.t.m
t p ss:
p / POSTOPERATIVE CARE AND EXPECTED OUTCOMES
t p ss:
p /
t
hht t t
hht t
• The fifth toe is supported in a “reverse” bunion dressing, maintaining slight valgus
alignment, and the foot and ankle are supported in a splint.
• With stable fixation and adequate wound healing, a walking boot or postsurgical
FIG. 15.15 shoe will allow heel weight bearing at 10–14 days.
• A toe spacer may be maintained between the fourth and fifth toes for 6–8 weeks,
r s
rs
STEP 3 PITFALLS
k e e rs
rs
analogous to a bunion procedure (Fig. 15.15).
k ee
o o
o k
• Because this is a diaphyseal osteotomy, a
o delay in healing is occasionally observed;
o o
oo k
• Full weight bearing on the forefoot may be initiated with radiographic evidence of
oo
healing of the osteotomy (typically 5–6 weeks); protected weight bearing is main-
eebb protected weight bearing on the forefoot

should be maintained until there is
ee/ e
/ b
e b ee/e e
tained if there is any delay in healing.
/ bb
• AP (Fig. 15.16A) and lateral (Fig. 15.16B) radiographs at final follow-up will demon-
radiographic evidence for healing.
: / / t
/ .
tm.m : / / t
/.tm
. m
strate correction of the 4/5 IMA and healing of the osteotomy.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : /
B
tp pss : /
t
hht t t
hht t
FIG. 15.16
EVIDENCE
keerrss keerrss
Cohen BE, Nicholson CW. Bunionette deformity. J Am Acad Orthop Surg 2007;15:300–7.
b ooookExcellent overview of the problem.
o ook
Cooper MT, Coughlin MJ. Subcapital oblique osteotomy for correction of bunionette deformity:
b o b oo
eeb e e/e
Meaningful follow-up study of the oblique osteotomy.
e b
medium-term results. Foot Ankle Int 2013;34(10):1376–80.
/ ee/e/e b
: / / m
.t.m
Koti M, Maffulli N. Bunionette. J Bone Joint Surg Am 2001;83:1076–82.
/ t : / / t
/ m
.t.m
Radl R, Leithner A, Koehler W, Scheipl S, Windhager R. The modified distal horizontal metatarsal oste-
t ppss : / t pps
otomy for correction of bunionette deformity. Foot Ankle Int 2005;26:454–7.
s : /
t
hhtt
Follow-up paper of surgical correction.
t
hhtt
Vienne P, Oesselmann M, Espinosa N, Aschwanden R, Zingg P. Modified Coughlin procedure for surgi-
cal treatment of symptomatic tailor’s bunion: a prospective followup study of 33 consecutive opera-
tions. Foot Ankle Int 2006;27:573–80.
Follow-up study for the oblique osteotomy.
Weitzel S, Trnka HJ, Petroutsas J. Transverse medial slide osteotomy for bunionette deformity: long-
k rrss
term results. Foot Ankle Int 2007;28:794–8.
e e rrss
Grade B recommendation for the oblique 5MT osteotomy for bunionette correction, as there is only
e k e
o o
o o k o o
level IV and level V evidence to support this technique.
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh16t
PROCEDURE hht
Plantar
rss Plate Repair of the First Metatarsophalangeal
rs s
k ee r k ee r
eebboooJoint
ok (Turf Toe) ooook / e bb / e b o
b o
m ee /e m ee / e
: / / t
/ .
Juan Bernardo Gerstner and Andrew
/ t . m K. Sands
: / /
/ t
/ .
t . m
t ppss : t p ss
p :
hhttt
t
hht t
• Capsular-ligamentous injuries of the first metatarsophalangeal (MTP) joint are caused
by sudden hyperextension of the joint while playing sports or during motor vehicles
• Positive magnetic resonance imaging scans
without instability accidents, as well as when falling from a height.
k e rs
rs
• Osteochondral lesions of one or both joint
e r s
r s
• Traditionally, stretching and partial tears are managed by conservative treatments,
k ee
b ooook surfaces
b ooook
whereas totally detached and avulsion fractures are treated using surgical intervention.
o o
However, there is a controversial dilemma of treatment on athlete’s moderate instability.
b
eeb e / e
/
INDICATIONS
e e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
• Large capsular avulsion with unstable joint and positive Lachman test
• Loose bodies of the joint
t p ss
p : / tp pss : /
• Avulsion fracture of the inferior rim of the proximal phalanx of the hallux complex and
t
hht t
• Avulsion injuries with moderate instability in
high-profile athletes
t
hht t
unstable joint
• Ecchymosis and edema after a hyperextension trauma of the first MTP joint (Fig.
16.1) should be examined.
ke rrss
TREATMENT OPTIONS
e keerrss
• A positive result in Lachman test.
• Comparative range of motion should be assessed.
b ooook • Rest, ice, and compression with elevation in a

90° large brace is used initially.
b o ook oo
• X-rays should show comparative proximal migration of sesamoids as well as dis-
o b
eeb • Conservative treatment using tapping or a cast
with the toe spica in plantar flexion.
ee/e/e b (Fig. 16.2).
ee/e/e b
placement of accessory sesamoids with dorsiflexion in the anteroposterior view
: / / t
• Perform surgery when severe instability or
/ m
.t.m : / / t
/ m
.t.m
• Rule out sesamoid fracture, avulsion fracture, and osteochondral lesion (Fig. 16.3).
conservative treatment fails.
t ppss /
fractures are present in the original lesion or
: t ppss : /
• Magnetic resonance imaging should include a short-TI inversion recovery sagittal
view of the joint to confirm clinical and x-ray findings (Fig. 16.4).
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
.m m . m m
ss: /
: /
/ t
/ t .
FIG. 16.1
:
ss /
: /
/ t
/ t. FIG. 16.2
122 t
hhtt p
t p t
hhtt p
t p
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 16 Plantar Plate Repair of the First Metatarsophalangeal Joint (Turf Toe) 123
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 16.3
b oooo k
b o o FIG. 16.4
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m POSITIONING PEARLS
t p ss
p : / tp p ss : / • Prone position can also be used with a bump
t
hht t t
hht t under the ankle.
• The Trendelenburg position can be used when
it is available.
Plantar plate
FIG. 16.5 POSITIONING PITFALLS
keerrss keerrss • Assess the patient’s range of motion of both

hip and knee before prepping the extremity.
b ooook b ooook b oo • A lateral position would make it difficult to

access the lateral sesamoid and perform
eeb ee/e/e b ee/e/e b plantar plate repair.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt FIG. 16.6 t
hhtt POSITIONING EQUIPMENT
• Tourniquet can be used to prevent bleeding
but must be released before closure.
SURGICAL ANATOMY
k rrss
e k rrss
• Plantar plate structure related to the sesamoids: the complex also includes the col-
e e e
lateral ligaments, the distal insertion of the flexor hallucis brevis tendon, the adductor
o o
o o k o o o k
and abductor hallucis, and the intersesamoid ligament.
o o o
eebb ee e
/ b
e b
phalanx and limits hyperextension of the MTP joint (Fig. 16.5).
ee/ e
/ b
e b
• The plantar plate runs from the metatarsal neck to the plantar aspect of the proximal
/
• Supine versus prone depends on the
tridimensional skills of the surgeon.
: / / t
/ m
.t.m
• Plantar digital nerves and vessels at risk (Fig. 16.6).
: / / t
/ m
.t.m
POSITIONING
t p ss:
p / t p ss:
p /
t
hht t t
hht t
• Supine position with a bump under the thigh is recommended to let the foot move freely.
• Trendelenburg position is desired to get to the level of the surgical field while the
surgeon is seated. PORTALS/EXPOSURES PEARLS
• Mark the skin including the proximal phalanx
PORTALS/EXPOSURES and the distal part of the first metatarsal.
k e r
e s
rs k e rs
rs
• The plantar medial extended approach (“L” approach) is best used to expose both
e
• Carefully dissect both medial and lateral digital
o o
o o k oo k
the medial and lateral sides of the plantar plate, because a neurovascular medial
o o oo
neurovascular bundles (Fig 16.9).
• Usually the plantar plate damage is distal,
eebb ee / b
e b
bundle is between these sides. The transverse arm is located at the proximal flexion
/ e e /
crease of the hallux, whereas the longitudinal arm is located along the union of the
e e/ebb so start the dissection distally to proximally
(Fig. 16.10).
plantar and medial skin (Fig. 16.7).
: / / t
/ .
tm.m : / / t
/.tm
. m • Make sure the length of the volar plate will
reach the point of insertion in a neutral
t p ss : /
lesion is confirmed to be on those sides (Fig. 16.8).
p t p ss
p : /
• Use the plantar medial isolated approach or plantar lateral approach when a partial
position (Fig. 16.11).
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
124 hht hht
PROCEDURE 16 Plantar Plate Repair of the First Metatarsophalangeal Joint (Turf Toe)
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 16.7
b oooo k
b o oFIG. 16.8
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p p ss : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
FIG. 16.9 t
hhtt FIG. 16.10
k rrss
• Deep skin cuts can harm the digital
e e
neurovascular bundles.
k e rrss
e
o o
o o k
• Too much proximal positioning of the coronal
o o
o o k o o
eebb b b
arm while performing this approach limits the
dissection on the distal plantar plate.
ee/ e
/ e b ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
• Skin retractors and soft-tissue retractors must
hht t
be used without excessive tension.
• Fluoroscopy availability is desired.
t
hht t
r s
rs
• Both lateral plantar and medial approaches
k e e k eers
rs
o o
o o kcan be used, but care must be taken not to
compromise the blood supply.
o o
oo k oo
eebb • Arthroscopy inspection should be performed
prior to open approach in neglected and
ee/ e
/ b
e b ee/e/ebb
subacute lesions.
: / / t
/ .
tm.m : / / t
/.tm
. m
FIG. 16.11
t p ss
p : / t p pss : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
STEP 1 PEARLS
k e r
e s
rs k eers
r s • Longitudinal traction and a superiorly
positioned Hohmann retractor will expose the
o o
o o k oooo k o o
majority of the joint’s area.
eebb ee/ e
/ebb ee/ e
/ b
e b • The distal stump of the plantar plate should be
handled with care. Otherwise, you will end up
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
with a poor quality tissue to stitch any suture.
t p ss
p : / t p ss
p : / STEP 1 PITFALLS
t
hht t t
hht t • Failure to check the joint will compromise the
prognosis if a hidden lesion is missed.
• Unnecessary dissection will lead to a big
scar and retraction of soft tissues, thus
compromising the range of motion.
k eers
rs k er
erss • Sesamoid fractures should be addressed while
performing the repair.
b ooook
FIG. 16.12
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b STEP 1 CONTROVERSIES
: // t/.tm
. m : / /t/.tm. m • Excision of the distal pole of the sesamoid if a
fracture is found and it is not amenable to be
t p ss
p : / tp pss : / fixed, or if it is a part of a bipartite sesamoid
t
hht t t
hht t along with plantar plate damage.
STEP 2 PEARLS
keerrss keerrss
• If an avulsion fracture is present, bony anchors
can be used but the fracture must be wrapped
around instead of trying to penetrate it through
holes.
eeb ee/e/e b ee/e/e b • Use an extensor graft from the fourth toe when
no tissue can be found.
: / / t
/ m
.t.m : / / t
/ m
.t.m • Flexor to extensor transfer can be used if no
soft tissue can replace the plantar plate, or if
t ppss : / t ppss : / the repair is not strong enough.
t
hhtt
FIG. 16.13 t
PROCEDURE • Too much tension will lead to a hallux flexus.
• No soft tissue replacing the plantar plate.
k rrss
Step 1: Dissection of the Plantar Plate
e e k e rrss
e
o o
o k o o
o o k
• Subcutaneous dissection of the skin exposes the digital neurovascular bundles, and
o o o
eebb b b
thus it is necessary to handle with care (Fig. 16.12).
ee/ e
/ e b /
• Performing dissection from distal to proximal regions at the medial and lateral sides
ee e
/ e b STEP 2 INSTRUMENTATION/
IMPLANTATION
: / / t
/ m
of the plantar plate will show the defect of the structure (Fig. 16.13).
.t.m : / / t
/ m
.t.m
• Range of motion is then checked to ensure that no loose bodies will block the joint.
• Mini bony anchors with super sutures are
needed.
t p ss:
p / t p ss:
p /
• Inspection of the whole joint is mandatory to rule out osteochondral or chondral le- • Use bony tunnels when no anchor can be
t
hht t
sions as well as sesamoid fractures.
Step 2: Repair of the Plantar Plate

t
hht t placed, osteoporotic bone is found, or anchors
are not available.
• If the rupture is located within the substance of the plantar plate, mini Krackow or
figure 8 suture must be tried. STEP 2 CONTROVERSIES
k e r
e ss k eers
rs
• If the rupture is located distally, anchor sutures or drilling tunnels from dorsal to plan-
r • When it is not possible to reach the insertion
o o
o o k o o
oo k
tar are desirable, but the insertion site must be prepared with burring in order to get
some bony bleeding on the plantar aspect of the proximal phalanx, to ensure that
oo
point with the remaining plantar plate,
implement soft-tissue transfer, especially in
eebb repair will occur naturally (Fig. 16.14).

ee/ e
/ b
e b
• Tension of the repair must be double checked to ensure correct range of motion
ee/e/ebb neglected or chronic lesions.
• Harvesting extensor tendons will lead to
(Fig. 16.15).
: / / t
/ .
tm.m : / / t
/.tm
. m another morbility site.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
126 hht
PROCEDURE 16 Plantar Plate Repair of the First Metatarsophalangeal Joint (Turf Toe) hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 16.14
b oooo k
b o o FIG. 16.15
eeb ee/ e
/ e b ee/ e
/ e b
STEP 3 PEARLS
: // t/.tm
. m : / /t/.tm. m
ss : /
• Bulky padding will allow edema to go away in
t p p tp p ss : /
a few days.
t
hht t
• 10° flexion of the joint will let the repair to
start healing in a proper position.
t
hht t
keerrss
STEP 3 PITFALLS
keerrss
b ooook
• Noninterrupted sutures can cause bleeding to
b ooook b oo
eeb accumulate and cause extreme pain.
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
IMPLANTATION
t
hhtt t
hhtt
• A 90° boot or splinting will help to prevent
swelling.
k e rrss
e k e rrss
e
o o
o o k o o
o o k FIG. 16.16
o o
eebb POSTOPERATIVE PEARLS
ee/ e
/ b
e b ee/ e
/ b
e b
/ t
with the ankle in plantar flexion to release
: / / m
• Start passive motion below 10° of dorsiflexion
.t.m : / / t
/ m
.t.m
t p ss:
gastrocnemius and plantar fascia pull.
p / Step 3: Closure
t p ss:
p /
t
hht t t
hht t
• Release the tourniquet to ensure that there is no major bleeding source.
• Isolate sutures to avoid bleeding complications.
• Anesthetic block will diminish the need for opioids.
• Intraoperative x-rays must show restoration of the sesamoid’s height (Fig 16.16).
• Weight bearing before 4 weeks
k e r
e s
rs k eers
• Comparative x-rays are desirable.
rs
o o
o o k o o
oo k oo
eebb b b
• Postoperative dressings must be changed every 7–10 days, and tapping or a cus-
POSTOPERATIVE CONTROVERSIES
ee/ e
/ e b e /e/e b
tom-made splint must be used to ensure the dorsiflexion of the joint for the first
e
• Keep taping for 8 weeks
: / / t
/ .
tm.m 4 weeks.
: / / t
/.tm
. m
• Patients can weight bear at 4 weeks.
• Impact activities after 12 weeks
t p ss
p : / t p ss : /
• Pool active exercises to neutral as soon as the stitches from the skin are removed.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
EVIDENCE
r s
rs rs
r s
Anandan N, Williams PR, Dalavaye SK. Turf toe injury. Emerg Med J 2013;30(9):776–7.
k e e
A case description and review of the current literature.
k ee
o o
o o k o oo k
Childs SG. The pathogenesis and biomechanics of turf toe. Orthop Nurs 2006;25(4):276–80. quiz
o o o
eebb bb b b
281–282.
ee/ e
/e e / e
/ e
Analysis of the sprain injury to the first metatarsophalangeal joint secondary to the type of athletic
e
: / / t
/ t m
field and the flexibility of the toe box in athletic shoes.
. . m
Clanton TO, Ford JJ. Turf toe injury. Clin Sports Med 1994;13(4):731–41.
: / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
Description of a the long-term effect of turf toe injury in 20 athletes over a 5-year period.
Coughlin MJ, Kemp TJ, Hirose CB. Turf toe: soft tissue and osteocartilaginous injury to the first metatar-
t
hht t
sophalangeal joint. Phys Sportsmed 2010;38(1):91–100.
t
hht t
Classification based on clinical and radiologic features leads to the best treatment to avoid long-
term sequela.
Doty JF, Coughlin MJ. Turf toe repair: a technical note. Foot Ankle Spec 2013;6(6):452–6.
Description of a case and the surgical technique to simplify operative treatment.
k ee s
rs k er
ers
Frimenko RE, Lievers W, Coughlin MJ, Anderson RB, Crandall JR, Kent RW. Etiology and biomechanics
r s
of first metatarsophalangeal joint sprains (turf toe) in athletes. Crit Rev Biomed Eng 2012;40(1):43–61.
b ooook ooook
This review summarizes the literature on the anatomy of the first metatarsophalangeal joint, on
o
biomechanical studies of the first metatarsophalangeal joint, and on the incidence, mechanisms,
b b o
eeb and treatment of turf toe.
e / e
/ e b
Mason LW, Molloy AP. Turf toe and disorders of the sesamoid complex. Clin Sports Med
e ee/ e
/ e b
2015;34(4):725–39.
// t/.tm
. m / /t/.tm. m
Review of the classification systems and description of severe injuries that may require surgical
: :
ss : /
management, including failed conservative treatment.
t p p tp pss : /
t t t t
McCormick JJ, Anderson RB. The great toe: failed turf toe, chronic turf toe, and complicated sesamoid
hht
injuries. Foot Ankle Clin 2009;14(2):135–50.
hht
A systematic approach to evaluation of injuries, treatment, and rehabilitation protocols for athletes.
McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health 2010;2(6):487–94.
This article describes the anatomy, diagnosis, and treatment algorithm for turf toe injury by review-
ing relevant studies and presenting information useful to clinicians, therapists, and athletic trainers.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh17t
PROCEDURE hht
Plantar
r ss Plate Repair for Subluxedrss
k e e r k ee r
eebboooMetatarsophalangeal
o k Jointoooo k
/ e bb / e b o
b o
m ee /e m ee / e
Caio Nery and Daniel Baumfeld
: / t
///t. . m : / /
/ t
/ .
t . m
tpss : ss :
hhtttp
t
hhtt p
t p
• Lesser MTP joint instability is a new concept • Lesser metatarsophalangeal (MTP) joint instability with toe deformity and metatarsalgia
that addresses all the components behind the
k eers
rs
old concept of “crossover toe.”
errs
• Plantar plate rupture
s
• Subluxated lesser MTP joint
k e
b ooook • The toe can present subtle or gross instability
with different tears of the plantar plate.
o ook
EXAMINATION/IMAGING
b o b o o
eeb Lesser MTP Joint Drawer Test
ee/ e
/ e b e / e
/ e b
• Clinical observation and physical examinations should be carefully performed and
e
: // t/.tm
. m : / /t/.tm. m
graded using the clinical staging system. This grading has a close relationship with
t p ss
p : / tp ss : /
intraoperative findings (Table 17.1).
• Lesser MTP joint drawer test is one of the most important tests that help to grade
p
t
hht t t
hht t
the amount of instability (Fig. 17.1): G0, stable joint; G1, mild instability (subluxable
<50%); G2, moderate instability (subluxable >50%); G3, gross instability (dislocat-
able); and G4, dislocated joint.
keerrss keerrss
eeb G0 Stable
ee/e e b
TABLE
17.1 Clinical Grading System
/ ee/e/e b
: / / t
/ m
.t.m Grade 0
/ t m
.t.m
Metatarsal phalangeal (MTP) joint alignment; pain with no deformity
: / /
Plantar pain, thickening or swelling under MTP joint, reduced toe
purchase, negative drawer test
G1
<50%
t
hhtt Grade 1 t
hhtt Mild misalignment, widening of web space, medial toe deviation
MTP joint pain and swelling, loss of toe purchase, mild positive
drawer test (<50% subluxable)
Grade 2 Moderate misalignment; medial, lateral, dorsal, or dorsomedial
deformity; hyperextension of toe
k e rrss
e k e rrss
e
MTP joint pain, reduced swelling, no toe purchase, moderate
o o
o o k >50%
o o
o o k positive drawer test (>50% subluxable)
o o
eebb b b
Grade 3 Severe misalignment, dorsal or dorsomedial deformity, crossover
ee/ e
/ e b / e e b
toe, or flexible hammertoe
ee /
MTP joint and toe pain, little swelling, no toe purchase, very positive
G2
: / / t
/ m
.t.m : / / t
/ m
.t.m
drawer test (dislocatable MTP joint), and flexible hammertoe
t
Luxable
p ss:
p / Grade 4
t p ss:
p /
Dorsomedial or dorsal dislocation, severe deformity, fixed
t
hht t t
hht t hammertoe
MTP joint and toe pain, little or no swelling, no toe purchase,
dislocated MTP joint, fixed hammertoe
G3
k e r
e s
rs Dislocated
k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
G4
: / / t
/ .
tm.m : / / t
/.tm
. m
FIG. 17.1
t p ss
p : / t p ss
p : /
128
hhtt t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 17 Plantar Plate Repair for Subluxed Metatarsophalangeal Joint 129
• Digital toe purchase is used to analyze the balance and function of the muscles INDICATIONS CONTROVERSIES
k e r
e s
across the lesser MTP joint (Fig. 17.2).
rs k eers
r s
• With the patient standing, a narrow strip of paper (1 cm wide and 8 cm long) is
• There are no comparative studies between the
different treatments to address lesser MTP
o o
o o k oooo k
placed beneath the affected toe, and the patient is asked to plantar flex the digit.
o o
joint instability.
eebb e /ebb
If the patient is able to prevent the paper strip from being pulled out from beneath
/ e e / e
/
the digit, this is considered a positive test. When the patient is able to resist in
e e
b
e b
• Lesser metatarsal osteotomy alone has a high
percentage of floating toe, persistent pain, and
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
some way to the pulling out of the paper strip but not so efficiently so that the functional impairment of the lesser toes after
treatment.
t p ss
p : / t p ss : /
paper can be removed, the result is considered reduced, and when the power
exerted on the paper strip is so weak that it can be easily removed, the test is
p
t
hht t
considered negative.
t
hht t
• Anteroposterior weight-bearing comparative plain, lateral, and oblique radiographs
are necessary to evaluate the MTP joint and exclude osseous pathology.
• An anteroposterior weight-bearing radiograph can demonstrate second metatarsal
pathologic protrusion, altered metatarsal parabola, splaying of the affected and ad-
k eers
rs k er
erss
jacent toe, or a subluxated toe with overlapping of the proximal phalanx over the
b ooook metatarsal head (Fig. 17.3A).
b ooook
• A lateral weight-bearing radiograph can demonstrate a toe elevation with the proxi-
b o o
eeb ee/ e
/ e b
mal phalanx lying dorsally at the metatarsal head (Fig. 17.3B).
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 17.2
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
A
t p ss
p : / t
B
p ss
p : /
t
hht t t
hht t
FIG. 17.3
t t p
t ss:
p t t p
t ss:
p
130 hht
PROCEDURE 17 Plantar Plate Repair for Subluxed Metatarsophalangeal Joint hht
• Ultrasonography is a very good method to identify plantar plate tears. As always,
k e r
e s
rs k eers
the accuracy and specificity of this diagnostic tool depend on the experience of the
r s
examiner, and this could be an obstacle to its use.
o o
o o k oo k
• Magnetic resonance imaging can present an eccentric pericapsular soft-tissue thick-
oo o o
eebb ee/ e
/ebb e / e
/ b
e b
ening (STT; Fig. 17.4), increase of lesser metatarsal supination (Fig. 17.5), and rup-
ture of the plantar plate (arrows) in sagittal and coronal images (Fig. 17.6).
e
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• There are reproducible differences in the measurement of metatarsal axis rotation
t p ss
p : / t p ss : /
and second metatarsal protrusion and their relation with plantar plate tears. Lesser
metatarsal supination >36° or second metatarsal protrusion >4 mm trends toward
p
t
hht t t
hht t
a correlation with plantar plate tear. Lesser metatarsal supination <24° is a strong
negative predictor, and second metatarsal protrusion >4.5 mm is a strong positive
predictor of plantar plate tear.
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss

FIG. 17.4
: / / t
/ m
.t.m
: / / t
/ m
.t.m FIG. 17.5
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb A
ee/ e
/ b
e b B
ee/e/ebb
: / / t
/ .
tm.m FIG. 17.6
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Anatomic Grading System
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Plantar
t p ss
p : / G0 G1
t p ss
p : / G2
plate
t
hht t t
hht t
TREATMENT OPTIONS
• Each type of plantar plate tear has a particular
treatment.
k eers
rs k er
erss • The Anatomic Grading System is a
classification that addresses plantar plate
b ooook b oooo k
G3 G4
b o o
dysfunction and matches the Clinical Staging
System. This anatomic grading helps in the
eeb
ee/ e
/
FIG. 17.7
e b ee/ e
/ e b surgical planning and management of an
instable lesser MTP joint (Fig. 17.7).
: // t/.tm
. m : / /t/.tm. m • G0 represents plantar plate attenuation or
t p ss
p : / tp pss : / discoloration, 23%.
• G1 represents a transverse distal tear
t
hht t t
hht t (adjacent to the insertion into the proximal
phalanx), <50%; medial or lateral, 12%.
• G2 represents a transverse distal tear
(adjacent to the insertion into the proximal
phalanx) complete or almost complete,
15%.
keerrss keerrss • G3 represents combined transverse and
b ooook Proper collateral

b ooook b oo
longitudinal extensive tears; can assume
the “7” shape, inverted “7” shape, or “T”
eeb ligament
ee/e/e b ee/e/e b shape, 33%.

• G4 represents an extensive tear with a
: / / t
/ m
.t.m / / t
/ m
.t.m
Accessory collateral ligament
:
button hole (protrusion of the metatarsal
head through the defect) resulting from the
Lateral deep
intermetatarsal
t ppss : / t ppss : / combination of transverse and longitudinal

ligament
t
hhtt t
hhtt
Plantar fascia bands tears, 17%.
Medial deep POSITIONING PEARLS
k e rrss
e k e rrss
e
intermetatarsal ligament • To avoid external rotation of the foot, one can
o o
o o k o o
o o k
Plantar plate
o o
use a small pad under the back.
• We do recommend the use of a pad under the
eebb / e b b
Flexor digitorum brevis and
e / e
flexor digitorum longus tendons
e ee/ e
/ b
e b ankle and distal end of the leg to allow free
movements around the forefoot during the
: / / t
/ m
.t.m
FIG. 17.8
: / / t
/ m
.t.m surgical procedure.
• The surgeon starts the procedure facing the
t p ss:
p / t p ss:
p / dorsal aspect of the forefoot while the first
t
hht t t
hht t assistant faces the sole of the foot. In some
steps of the procedure, they will change their
positions to make the surgical maneuvers
feasible.
POSITIONING
• The patient is placed supine on the operating table with a tourniquet applied at the
k eerss k eers
rs
shin or thigh level and inflated to 300 mmHg after exsanguination.
r
• Surgery can be performed under regional block anesthesia and sedation.
o o
o o k o o
oo k oo
eebb SURGICAL ANATOMY

ee/ e
/ b
e b ee/
• Fig. 17.8 shows the anatomy of the lesser MTP joints in dorsomedial view.e/ebb • Radiolucent table
• Tourniquet
: / / t
/ .m.m : / / t. m
. m
• Fig. 17.9 shows the anatomy of the lesser MTP joints in coronal view.
t / t
• Silicone pads
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
132 hht
k e r
e ss
• The dorsal portals are made transversely to
r
allow their encompassing by the main incision
k eers
r s
Extensor digitorum
brevis tendon Extensor digitorum
o o
o o kafter the arthroscopic procedure.
oooo k o o
longus tendon
eebb ee/ eebb

Extensor hood
/ ee/ e
/ b
e b
Second
: / / t
/ .
t m
. m Proper lateral
: / / t
/ .
t m
. m metatarsal
head (right)
Proper medial
t p ss
p : / collateral
ligament
t p ss
p : / collateral
ligament
t
hht t Accessory
collateral
t
hht t
ligament
PORTALS/EXPOSURES PITFALLS Dorsal

Plantar
rs
rs
• The dorsal longitudinal incision is against
k eethe skin line forces, so skin contractures and

k errs
interosseus
s
muscle
e
interosseous
ook ook
muscle
b
eeboo
retractions are more common after its use.
• Care must be taken with the dorsal tendon
/ e b o
bo Deep
intermetatarsal
/ e b o
b o Lumbrical
e
when performing the dorsal arthroscopic portals.
m e / e ligament
m ee / e tendon
: ///t/.t. m : / /
/t/.t . m Neurovascular
t t p
t ss
p : t tptpss :
Plantar plate
Flexor tendons
tunnel
bundle
hht hht FIG. 17.9
keerrss keerrss
b ooook
b ooook b oo
eeb • Lightweight camera
• Pump system
ee/e/e b
PORTALS/EXPOSURES
ee/e/e b
• Small joints shaver blade
: / / t
/ m
.t.m / / t m
• A diagnostic arthroscopy is done as the first step with two dorsal portals (medial and
.t.m
lateral) placed over the affected MTP articular space (Fig. 17.10).
: /
• Small joint radiofrequency wand
• McGlamry elevator
• If the plantar plate presents a less extensive tear with subtle instability (grades 0 and
t
hhtt t
hhtt
1), the treatment proposed is a radiofrequency shrinkage of the plantar plate and a
Weil metatarsal osteotomy to correct the disruption of the metatarsal parabola.
• In the case of a plantar plate with an extensive tear (grade II or III), an open repair is
required to restore the MTP stability and a Weil metatarsal osteotomy to correct the
disruption of the metatarsal parabola.
k e rrss
e k rrss
• A dorsal longitudinal incision centered over the MTP joint can be done when the
e e
arthroscopic step of the procedure is not performed.
o o
o o k o o o k o
• If the arthroscopic procedure is performed, an “S”-shaped dorsal incision encom-
o o
eebb ee/ e
/ b
e b / e b b
passing the arthroscopic portals is made over the involved digit or a long “S”-shaped
ee / e
dorsal incision encompassing all the arthroscopic portals is made when more than
: / / t
/ m
.t.m / t m
.t.m
one MTP joint is involved (Fig. 17.11).
: / /
t p ss: /
• There is no consensus regarding the initial
p t p ss:
p /
• The incision is deepened in the space between the extensor digitorum longus and
t
hht
evaluation using arthroscopy.
t
• There is no consensus regarding the best
approach to the lesser MTP joint and
t
hht t
brevis while care is taken to protect the vascular supply.
• Both extensor digitorum tendons are retracted medially or Z elongated depending on
the amount of deformity and tendon retraction.
longitudinal or transverse incision. • A dorsal longitudinal MTP capsulotomy is performed followed by a partial collateral
• Some authors prefer the plantar approach to the ligament release of the proximal phalanx.
plantar plate. There is no consensus regarding
k e r s
rs
the use of dorsal or plantar approach.
e k eers
• A McGlamry elevator can help to expose the plantar plate and release all inflamma-
rs
tory adhesions without compromising the local vascular supply.
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b ooook B
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
C A B
FIG. 17.10 FIG. 17.11
k eerss
r k e rrss
e
o o
o o k
PROCEDURE
o o
o o k o o
eebb ee/ e
/ b
e b
Step 1: MTP Joint Arthroscopy and Plantar Plate Radiofrequency
ee/ e
/ b
e b STEP 1 PEARLS
: / / t
/ m
.t.m : / / t
• Arthroscopic evaluation of the involved lesser MTP joint is performed through two
/ m
.t.m • A lightweight camera is preferred as well as
t ss:
p / t
2.7-mm or 1.9-mm, 30° arthroscope can be used (see Fig. 17.10).
p ss:
p /
dorsal portals (medial and lateral portals placed over the MTP articular space), and a
p
small light cords.
• A small joint shaver system with 2.0-mm
t
hht t t
hht t
• Two dorsal arthroscopic portals are used to access the lesser MTP joints (the dor-
sal–medial and dorsal–lateral portals). Both of these portals were placed at or slightly
full-radius blades is very important, as is a set
of small surgical instruments such as probes,
baskets, graspers, and curettes.
distal to the MTP articular joint line, equidistant (4–5 mm) medially and laterally from • High-frequency alternating current thermal
the extensor digitorum longus tendon. probes (maximum temperature of 60°C)
should be used in this procedure.
k e e s
rs k eers
• With an 18-gauge needle, the adequate penetration point was marked and 2–3 mL
r rs
of saline solution was injected into the joint to confirm the proper placement. A #11
o o
o o k oo k
scalpel blade was used to incise the skin only, and a mosquito clamp is used to enter
o o oo
eebb e / b
e b
the joint, preventing injury to the neurovascular structures.
/ e e /e
• A pump system is used to provide adequate intraarticular saline flow and joint dis-
e e /ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
tention. We assumed the small joint arthroscopy levels of 35 mmHg and 100% flow
t p ss : /
visibility of the anatomic structures.
p t p ss
p : /
rate. Pressure and flow levels may be adjusted during the procedure to ensure good
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
134 hht
STEP 1 PITFALLS
k e r
e ss
• Care must be taken when preparing the
r
medial portal of the second MTP joint because
k eers
r s
o o
o o kthe dorsal digital branch of the deep peroneal
oooo k o o
eebb nerve runs in the first intermetatarsal space
very close to the medial border of the joint. For
ee/ e
/ebb ee/ e
/ b
e b
first.
: / / t
/ t m
this reason, the lateral portal is established
. . m : / / t
/ .
t m
. m
t p ss
p : /
• Articular traction is important to avoid
iatrogenic injuries at the metatarsal head
t p ss
p : /
t
hht t
during the insertion of the arthroscope.
t
hht t
k eers
rs k er
erss
b ooook
b oooo k
o
FIG. 17.12
b o
eeb b b
IMPLANTATION
• Arthro-Care Short Bevel 25°, 2.3 mm
ee/ e
/ e ee/ e
/ e
(Andover)
: //
• One small snap-off (Spin Screw, Integra)t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
ke rrss
• Radiofrequency in supraphysiologic
e keerrss
b ooook temperatures can result in active wound
healing by triggering the cellular response.
b ooook b oo
eeb At 60°C, tissue contraction is noted due to
coagulation; however, when temperatures
ee/e/e b ee/e/e b
: / / t
exceed 100°C, tissue vaporizes and ablation
/ m
.t.m : / / t
/ m
.t.m
can occur.
t
hhtt t
hhtt
STEP 2 PEARLS
e rrss
• Metatarsal osteotomy is needed to address the
k e k e rrss
e
o o
o o kmetatarsal parabola alteration and to permit A
o o
o o k B
o o
eebb b b
the visualization of the plantar plate when
open repair is required.
• One must keep the osteotomy as parallel
ee/ e
/ e b
ee/ e
/ e b
FIG. 17.13
as possible with the ground, avoiding the
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Light manual traction is applied to the toe so that the central and distal portions of
descending of the metatarsal head.
p ss: /
• Remove a thin slice of bone if you intend to
t p t p p /
the plantar plate could be visualized, inspected, and then palpated with a probe.
ss:
• Synovectomy of the affected joint is performed, and the plantar plate lesions grades
t
hht t
elevate the metatarsal head and reduce its
overloading. t
hht t
0 and I were treated with radiofrequency shrinkage (Arthro-Care Short Bevel 25° 2.3
mm; Andover, MA, USA). The unit was automatically set to deliver a temperature of
60°C (Fig. 17.12).
• After the arthroscopic radiofrequency shrinkage and sealing of the plantar plate le-
k e r
e s
rs k eers
sions, a Weil osteotomy through a dorsal approach using a sagittal saw is performed.
rs
• The Weil osteotomy is then fixed in the desired position with one small snap-off (Spin
o o
o o k
STEP 2 PITFALLS
o o
oo k
Screw, Integra, Plainsboro, NJ, USA) self-tapping screw.
oo
eebb • Attention to the saw position during the
osteotomy is necessary, as an incorrect cut
ee/ e
/ b
e b
Step 2: Metatarsal Osteotomy
ee/e/ebb
can alter the osteotomy objective.
/ / t .
tm
• Attention so as not to shorten the metatarsal
: / .m : / / t
/.tm
• A distal Weil metatarsal osteotomy is performed using a sagittal saw.
. m
• The saw cut is made parallel to the plantar aspect of the foot, starting at a point 2–3
>3 mm is also necessary.
t p ss
p : / t p ss : /
mm below the top of the metatarsal articular surface (Fig. 17.13).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
IMPLANTATION
• Small sagittal saw
o o
o o k oooo k o • One small snap-off self-tapping screw (Spin
o
eebb b b Screw, Integra)
ee/ e
/e b ee/ e
/ e b • K-wires
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
• The Weil osteotomy is not undisputed. In fact,
there are many other types of osteotomies
that can be performed to avoid the lower
displacement of the central rotation of the MTP
eeb ee/ e
/ e b ee/ e
/ e b joint.
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
A t
hht t B t
hht t

FIG. 17.14
STEP 3 PEARLS
keerrss keerrss
• Release the remaining inferior border of the
plantar plate to create space to place the
b ooook ooook
• In the presence of a plantar keratosis beneath the metatarsal head, a small slice of
bone is removed to achieve a subtle elevation of the metatarsal head.
b b oo
sutures.
• There are many ways to place sutures in the

• When the plantar plate lesion is arthroscopically treated, the Weil osteotomy is fixed in
the desired position with one small snap-off self-tapping screw (Spin Screw, Integra).
longitudinal tears, and this can involve using a
specific suture passer or small needle holders
: / / t
/ m
.t.m : / / t m
.t.m
• If an open plantar plate repair is desired, the distal fragment (metatarsal head) is
/
available with regular surgical instruments.
• Suturing the longitudinal tears can help to
pushed proximally as far as possible—8–10 mm—and held in this position temporarily correct transverse plane malalignment.
t
hhtt t
hhtt
with a small vertical Kirschner wire (K-wire). It is recommended to resect 2 mm or 3 mm
of the distal metaphyseal flare to improve the plantar plate visualization (Fig. 17.14).
• Longitudinal traction to the toe helps to distract the joint, creating space to the next
steps of the procedure.
Step 3: Preparing the Plantar Plate and the Phalanx
k e rrss
e k e rrss
e
• After the dorsal exposure and the Weil osteotomy, the plantar plate is inspected and
o o
o o k the type of lesion is confirmed.
o o
o o k o o
STEP 3 PITFALLS
eebb ee e
/ b
e b
• If any portion of the plantar plate is still connected to the inferior border of the
/ ee/ e
/
proximal phalanx, it is cut carefully, avoiding lesions to the flexor digitorum longus
b
e b • The MTP plantar plate is 2.0–2.5 mm thick
in its anterior border, and care must be taken
tendon.
: / / t
/ m
.t.m : / / t
/ m
.t.m not to delaminate the plantar plate during the
t ss:
p /
tissue adhesions, creating space to place the sutures.
t p ss:
p /
• It is very important to release the distal margin of the plantar plate from any soft-
p
intent to free the margins of the lesion at the
base of the proximal phalanx.
t
hht t t
hht t
• The plantar margin of the proximal phalanx is prepared, freeing it of any residual tis-
sue with a small rongeur or curette.
•
If a longitudinal tear of the plantar plate is detected (grade III “T”-shaped or
“7”-shaped lesions), it may be repaired through nonabsorbable 3-0 sutures placed
k e r
e s
rs k eers
with the help of a small needle holder, a small cannulated suture passer (Mini Suture
rs
Lasso, Arthrex, Naples, FL, USA), or a VIPER suture passer (Arthrex, Naples, FL,
o o
o o k USA).
o o
oo k oo
eebb b b IMPLANTATION
/
Step 4: Suture Passing Through the Plantar Plate
ee e
/ e b ee/e/e b • VIPER suture passer (Arthrex)
: / / t
/ .
tm.m : / / t
/.tm
. m
• There are different and efficient ways to suture the distal border of plantar plate. In • Small cannulated suture passer (Mini Suture
Lasso, Arthrex)
t p ss : /
proximal as possible at the free borders of the plantar plate.
p t p ss
p : /
any of these methods, the main objective is to attach the sutures in a viable tissue as
• Small needle holder
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
136 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
A t
hht t B t
hht t C
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o o oo k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
D
: / / t
/ m
.t.mE
: / / t
/ m
.t.mF
t p ss:
p / FIG. 17.15
t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
• A joint distractor can be used to help with the visualization of the plate. It is placed
rs
over the proximal phalanx and the retracted metatarsal head with K-wires to support
o o
o o k oo k
the distraction.
o o oo
eebb ee/ e
/ b
e b e /e/ebb
• To perform the suture, one can use a mechanical suture passer or a micro “pig-tail”
suture passer (Mini Suture Lasso, Arthrex), and with those we can easily and safely
e
: / / t
/ .
tm.m : / / t
/.tm
. m
place horizontal or longitudinal mattress sutures in the plantar plate. The mechanical
t p ss
p : / Arthrex (Fig. 17.15).
t p ss
p : /
suture passer that can be used is the Mini Scorpion or the VIPER suture passer from
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
STEP 4 PEARLS
k e r
e s
rs k eers
r s • It is very important to reach the plantar plate
as proximal as possible, to pass the suture into
o o
o o k oooo k o o
a healthy tissue.
eebb ee/ e
/ebb ee/ e
/ b
e b • Be sure to identify and suture any longitudinal
tear of the plantar plate.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• A mechanical suture passer can shorten the
procedure time.
t p ss
p : / t p ss
p : / • Leave, at least, 1 mm of bone between the
articular cartilage and the bone hole at the
t
hht t t
hht t proximal phalanx.
FIG. 17.16
k eers
rs k er
erss
b ooook b ooook b o o STEP 4 PITFALLS
eeb ee/ e
/ e b ee/ e
/ e b • The ugly technique is an effective way to place
: // t/.tm
. m : / /t/.tm. m sutures at the plantar plate, but requires more
dissection of the soft tissue involved and a
t p ss
p : / tp pss : / longer surgical procedure.
t
hht t
technique called ugly technique is available. t
hht t
• When the mechanical or manual suture passer is not available, an alternative surgical
• According to this technique, before starting to pass the main sutures to the anterior
• Be careful to make the bone holes at the base
of the proximal phalanx when orienting the
K-wire or the drill bit so as not to compromise
the articular surface of the proximal phalanx.
border of the plantar plate, we have to build a “snakehead” NINJA instrument with
a 1.0-mm K-wire, which will work to pull the sutures underneath the plantar plate
keerrss (Fig. 17.16).
keerrss
• The head of the NINJA instrument is positioned under the anterior border of the
b ooook o ook oo
plantar plate, in its lateral or medial half, taking care to avoid injuries to the flexor
b o b
eeb tendons.
ee/e/e b ee/
• A straight hand-held suture passer (Mini Suture Lasso, Arthrex) or an 18-gauge nee-e/e b STEP 4 INSTRUMENTATION/
: / / t
/ m
.t.m : / / t
/ m
.t.m
dle is passed from dorsal to plantar through the plantar plate, into the “snake-head”
IMPLANTATION
of the NINJA instrument and through the soft tissue of the sole until it exteriorizes at • K-wires (1 mm)
• 18-gauge needle
t
the plantar face of the foot.
hhtt t
hhtt
• A flexible wire loop is introduced into the needle or suture passer from dorsal to
plantar.
• Small needle holder
• Mechanical suture passer or a micro pig-tail
suture passer (Mini Suture Lasso, Arthrex)
• A folded #2-0 nonabsorbable suture (FiberWire; Arthrex, Naples, FL, USA) is passed • FiberWire (Arthrex)
through the wire loop and pulled up through the plantar plate. • Mini Scorpion (Arthrex) or VIPER suture passer
(Arthrex)
k e rrss
e rrss
• The loop of the suture involves the handle of the NINJA instrument while the free
e e
suture tails are firmly kept in the plantar face of the foot by the assistant. With this
k
o o
o o k o o k
maneuver, a lace will be created while the NINJA instrument is pulled out of the surgi-
o o o o
eebb e / b
e b
cal field at the same time the suture tails are released by the assistant.
/ e e / e
/ b
e b
• Tightly pulling the suture firmly locks it into the distal margin of the plantar plate.
e e
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The same sequence is repeated for the other half of the plantar plate. At the end, we
t p ss: /
plantar plate (Fig. 17.17).
p t p ss:
p /
have two sutures firmly passed through the remaining healthy tissue from the MTP
t
hht t t
hht t
• Then, two vertical drill holes—using a 1.5-mm K-wire or a drill bit—are made
medially and laterally in the base of the proximal phalanx from the dorsal cortex
• There is no perfect way to place sutures in
to the plantar rim. the plantar plate; one should choose the
• The same flexible wire loop used in the previous steps is passed from dorsal to plan- best option regarding the availability of the
tar through the holes of the phalanx base and then used to catch and pull the sutures mechanical passer and the ability to use the
k e r
e s
rs through the dorsal side (Fig. 17.18).
k eers
rs ugly technique.
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
138 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss A
keerrss B
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
C D
k e r
e s
rs k eers
rs
FIG. 17.17
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook E
b ooook F
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs G
k eers
H
rs
FIG. 17.17, cont’d
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
140 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook
A B
b ooook C
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
D
k e r
e s
rs E

k eers
rs F
o o
o o k o o oo k
FIG. 17.18
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Step 5: Fixing the Weil Osteotomy, Tying the Sutures Over the STEP 5 PEARLS
Proximal Phalanx, and Finishing
k e r
e s
rs k eers
r s
• The Weil osteotomy is fixed in the desired position with one small snap-off self-
• Beware of rotational deviation of the
metatarsal head while fixing the osteotomy.
o o
o o k tapping vertical screw.
oooo k o o
Use two screws if you feel it is necessary.
eebb ee e
/ebb
• The metatarsal shortening is determined in the preoperative planning step to achieve
/ e
a regular metatarsal parabola. Normally, only 2 mm or 3 mm of metatarsal shortening
e/ e
/ b
e b
is required.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
• Once the Weil osteotomy is fixed, the plantar plate sutures are tied over the dorsal
bone bridge at the proximal phalanx attaching the plantar plate at the base of the
t
hht t t
hht t
phalanx while the toe is held in 20° of plantar flexion (Fig. 17.19).
• Lateral soft-tissue reefing is performed when necessary to repair any lateral collateral
ligamentous insufficiency and transverse plane deformities.
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
A
t
hhtt B
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k o o
o o k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht
C
t
t
hht tD
FIG. 17.19
t t p
t ss:
p t t p
t ss:
p
142 hht
STEP 5 PITFALLS • The articular capsule is closed, and the extensor digitorum longus tendon is sutured
k e r
e ss
• Importantly, bleeding can result from the small
r
dorsal vessels and the hematoma formed can
k eers
in the appropriate length if elongation was performed.
r s
• At this moment, it is important to release the tourniquet and to proceed to a careful
o o
o o kcompromise the skin coverage of the region
oooo k
hemostasis of the dorsal region of the MTP joints.
o o
eebb with potential skin and soft-tissue necrosis
with dehiscence or adhesion of the surgical
ee/ e
/e
POSTOPERATIVE
bb CARE AND EXPECTED OUTCOMES ee / b
e b
• As the final step of the procedure, the wound is closed as usual.
/ e
incision.
: / / t
• Be gentle while bending the screwdriver of
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p
insertion to avoid bone fractures. : /
the powered machine at the end of the screw
weeks (Fig. 17.20).
t p ss
p : /
• We recommend keeping the toes in 20° of flexion in a postoperative shoe for 4–6
t
hht t t
hht t
• An aggressive rehabilitation program starts at the end of the first week to reduce
scarring of the surgical incision and to strengthen the flexor tendons and maintain
joint mobility.
• It is crucial to avoid passive and active dorsiflexion of the toes for 6 weeks to prevent
damage to the plantar plate sutures.
k ee s
IMPLANTATION
rrs
• Small snap-off self-tapping vertical screw
k er
erss
• High-impact sports activities should be avoided during the 4–6 months after surgery.
b ooook b ooook
Return to play should occur gradually and carefully to protect the surgical repair and
prevent reinjury.
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A t
hhtt t
hhtt B
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
C
t p ss
p : / t
D
p ss
p : /
t
hht t t
hht t
FIG. 17.20
t t p
t ss:
p t t p
t ss:
p
hht hht
• A prospective study of direct plantar plate repair using a dorsal approach reported POSTOPERATIVE PEARLS
k e e s
rs k eers
excellent pain relief with improved digital strength and realignment at an average
r r s
follow-up of 1.5 years. Recently, favorable results were reported for radiofrequency
• We recommend short postoperative sandals
without support to the toes, to allow flexion of
o o
o o k oooo k
shrinkage of the plantar plate and Weil osteotomy for treatment of subtle MTP joint
o o
toes during ambulation.
eebb e /ebb
instability that outperformed reported outcomes for correction of gross instability.
/ e
These results suggest that surgical treatment of MTP joint instability in the early
e ee/ e
/ b
e b
stages might yield better outcomes.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
EVIDENCE
t p ss
p : / t p ss
p : / • The ambulation with postoperative sandals
has an extensor mechanism acting over the
t
hht t t
hht t
Coughlin MJ, Baumfeld DS, Nery C. Second MTP joint instability: grading of the deformity and descrip-
tion of surgical repair of capsular insufficiency. Phys Sportsmed 2011;39(3):132–41.
toe. It is important to stimulate active flexor
mechanism and avoid extensor mechanism
with toe tapping.
The authors proposed a clinical staging system for lesser toes plantar plate lesions that perfectly
correlates with an anatomic grading system.
Nery C, Coughlin MJ, Baumfeld D, et al. Lesser metatarsal phalangeal joint arthroscopy: anatomic
k ee s
rs k er
ers
description and comparative dissection. Arthroscopy 2014;30(8):971–9.
r s
The authors describe the normal arthroscopic anatomy of the lesser metatarsophalangeal joints
b ooook ooook
compared with the gross anatomy. The overall arthroscopic accuracy for lesser MTO joints was 96%.
o o
Nery C, Coughlin MJ, Baumfeld D, Mann TS. Lesser metatarsophalangeal joint instability: prospective
b b
eeb e / e
/ e b e / e
/ e b
evaluation and repair of plantar plate and capsular insufficiency. Foot Ankle Int 2012;33(4):301–11.
The results of the treatment of 55 metatarsophalangeal unstable joints was presented. The second
e e
// t/.tm
. m / /t/.tm. m
metatarsophalangeal was the most commonly affected joint (63%); the Grade III type of tear (trans-
verse with a longitudinal extension tear) was the most frequent type. With the treatment protocol
: :
ss : / ss : /
applied, the authors found an average of 92 points on the postoperative AOFAS forefoot score.
t p p tp p
• Long immobilization of the toe in plantar
flexion can lead to a loss of toe extension.
2013;34(3):315–22.
t t t
hht t
Nery C, Coughlin MJ, Baumfeld D, Mann TS, Yamada AF, Fernandes EA. MRI evaluation of the
hht
MTP plantar plates compared with arthroscopic findings: a prospective study. Foot Ankle Int
For this reason, an aggressive rehabilitation
program should be done after the
immobilization period.
Authors evaluated the clinical findings, MRI scans, and arthroscopic findings of 35 patients with
lesser metatarsophalangeal joint instability. Using the anatomic grading system, a distinct improve-
• During the first 6 weeks of the postoperative
ment in the radiologic evaluation and interpretation by the radiologists occurred.
period, the MTP joints extension must be
avoided as well as sportive activities that have
keer ss eerrss
Nery C, Coughlin MJ, Baumfeld D, Raduan FC, Mann TS, Catena F. Classification of metatarsophalan-
r
geal joint plantar plate injuries: history and physical examination variables. J Surg Orthop Adv
k
an impact on the metatarsal heads.
b ooook2014;23(4):214–23.
b ooook b
Using the clinical findings of 100 unstable metatarsophalangeal (MPT) joints graded into five
oo
• The use of high-heeled shoes is prohibited for
4–6 months.

groups, the authors found the positive correlations between clinical findings and anatomical le-
sions. The MPT joint drawer test is the most reliable and accurate tool to classify and grade the
: / / t
/ m
.t.m
plantar plate lesion, followed by ground touch and rotational deformities.
: / / t
/ m
.t.m
t ppss / t ppss : /
Nery C, Coughlin MJ, Baumfeld D, Raduan FC, Mann TS, Catena F. Prospective evaluation of protocol
:
for surgical treatment of lesser MTP joint plantar plate tears. Foot Ankle Int 2014;35(9):876–85.
t
hhtt t
hhtt
The authors presented a treatment algorithm for the treatment of metatarsophalangeal joint insta-
bility and plantar plate lesions. Based on the anatomic grading system, the surgical procedures
proposed were as follows: thermal shrinkage with radiofrequency for grades 0 and I; direct reinser-
tion and repair of the plantar plate for grades II and III; tendon transfer (FDL to EDL) for grade IV. All
surgical procedures were associated with a Weil distal metatarsal osteotomy. All groups of treated
patients had significant improvement with regard to subjective and objective parameters. Grades 0
k rrss
and II show better results than the other groups.
e e k e rrss
e
Nery C, Raduan FC, Catena F, Mann TS, de Andrade MA, Baumfeld D. Plantar plate radiofrequency and
o o
o o k o o o k
Weil osteotomy for subtle metatarsophalangeal joint instability. J Orthop Surg 2015;10:180.
o o o
eebb b b b b
The authors presented the results of 19 patients with 35 unstable metatarsophalangeal joints—
ee/ e
/ e ee/ e
/ e
grades 0 and I—treated with radiofrequency shrinkage of the plantar plate. After treatment, 83%
/ t m
significant improvements in the postoperative period.
: / / : / / t
/ m
of the joints became stable and 97% were congruent. All studied parameters showed statistically
.t.m .t.m
t ss:
p / t p ss:
p /
Umans H, Srinivasan R, Elsinger E, Wilde GE. MRI of lesser metatarsophalangeal joint plantar plate
p
tears and associated adjacent interspace lesions. Skeletal Radiol 2014;43(10):1361–8.
t
hht t t
hht t
The authors studied 100 magnetic resonance imaging scans of 96 patients with metatarsalgia and
found out that 40% of them have plantar plate tears, 90% of which occurred at the second meta-
tarsophalangeal joint. Almost all coexisted with nonneuromatous second intermetatarsal space
lesions.
Umans R, Umans B, Umans H, Elsinger E. Predictive MRI correlates of lesser metatarsophalangeal joint
k e e s
rs k eers
(MPJ) plantar plate (PP) tear. Skeletal Radiology 2016;45(7):969–75.
r rs
The authors compared magnetic resonance imaging (MRI) scans of 50 patients who had plantar
o o
o o k o oo k
plate lesions with 50 normal controls. They concluded that eccentric pericapsular soft tissue thick-
ening is the MRI finding that most strongly correlates with plantar plate tears.
o oo
eebb e e
/ b
e
osteotomy approach. Foot Ankle Spec 2011;4(3):145–50.
e b ee/e/ebb
Weil Jr L, Sung W, Weil Sr LS, Malinoski K. Anatomic plantar plate repair using the Weil metatarsal
/
/ / t
/ .
tm.m / / t
/.tm
The authors presented the retrospective review of the early results of 13 consecutive patients who
. m
underwent the plantar plate repair through the Weil metatarsal osteotomy approach; 85% of the
: :
ss : / ss : /
patients showed an improvement in function, and 77% were satisfied or very satisfied with the
t p p t p p
outcome.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh18t
PROCEDURE hht
Morton
rss Neuroma rs s
o k ke e r o kkee r
o
eebb o o
Leslie Grujic and Christina Kabbash
e bboo o e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t p :
t ss
p :
hht
• It is important not to confuse symptoms of
hht
• Excision of a Morton or interdigital neuroma is indicated for neuritic forefoot pain not
responsive to conservative means of treatment. A Morton neuroma:
second or third metatarsophalangeal joint • Is more common in women
synovitis/metatarsalgia/plantar plate pathology • Is usually footwear related
k eers
rs
with the symptoms of an interdigital neuroma.
k eerrss
• Is most common in the third web space
b ooook b ooook
• Is less common in the second web space
b o o
eeb ee e
/ e b
HISTORY/EXAMINATION/IMAGING
/ ee/ e
/ e b
: // t/.tm
. m History
: / /t/.tm. m
t p ss
p : / • Footwear-related pain
tp pss : /
t
hht t t t
• Need to remove shoe/massage foot
hht
• Sharp nerve pain
• Tingling or numbness in toes
• Occasionally, feel a “click” when weight bearing
keerrss keerrss
• Swelling is not usually noted.
b ooook o ook oo
• Pain to palpation “between” metatarsal heads in the second or third web space,
b o b
which increases with concurrent lateral compression of the forefoot.
• Altered sensation in appropriate plantar digital nerve distribution is common.
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Mulder click (i.e., a palpable click with ballottement of neuroma between metatarsal
t ppss : / heads) is noted.
t ppss : /
t
hhtt Imaging t
hhtt
• Usually a clinical diagnosis
• Ultrasound
• Magnetic resonance imaging (Fig. 18.1)
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss
p : / FIG. 18.1
144 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 18 Morton Neuroma 145
k e r
e s
rs k eers
r s
o o
o o k
Interdigital
nerve
oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
Neuroma
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
Digital
branches t
hht t t
hht t
Transverse metatarsal
k eers
rs
ligament
k er
erss
b ooook FIG. 18.2
b oo ook b o o
eeb ee/ e
/ e b
ee/ e
/
FIG. 18.3e b
TREATMENT OPTIONS
: // t/.tm
. m : / /t/.tm. m
t p ss
• Wider flat shoes
p : / tp p :
ss /
hhtt t
• Orthotic with metatarsal dome/pad
• Corticosteroid injection
t
hht t FIG. 18.4
• Surgery
SURGICAL ANATOMY
keerrss keerrss
• Note the position of the interdigital nerve, transverse metatarsal ligament, and divi-
b ooook sion into digital branches.
b ooook b oo
• The neuroma lies closer to the plantar surface of the foot under the transverse meta-
eeb POSITIONING
tarsal ligament (Fig. 18.2).
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The patient should be positioned supine with a hip bump as needed to place the foot
t
hhtt
in a neutral position.
PORTALS/EXPOSURES
t
hhtt FIG. 18.5
• A dorsal or plantar approach can be utilized.
• A dorsal approach is preferred due to faster healing, less weight-bearing pain, and
k eerrss
ment in the appropriate web space.
k rrss
less risk of a painful plantar scar. It is centered over the transverse metatarsal liga-
e e
o o
o o k o o
o o k o o
eebb PROCEDURE
ee/ e
/ b
e b ee/ e
/ b
e b
Step 1
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ss:
p /
• A tourniquet is used for best visualization.
p t p ss:
p
• A dorsal 3-cm incision is placed in the appropriate web space (Fig. 18.3). /
t
hht t
• Cauterize dorsal veins to minimize postoperative bleeding. t
hht t
• Blunt dissection through the fat layer protects the dorsal digital nerves and exposes
the distal neuroma and the transverse metatarsal ligament.
• A small laminar spreader is inserted between the metatarsal heads/necks and distracted.
k e r
e s
rs k e r
nar spreader for better visualization (Fig. 18.4).
e s
• Divide the transverse metatarsal ligament longitudinally and further distract the lami-
rs
o o
o o k oo k
• Plantar pressure in the web space will cause the neuroma to appear between the
o o oo
eebb metatarsal heads (Fig. 18.5).
e / e
/ b
e b e /e/e
• Grab the nerve with a pair of forceps while an assistant provides plantar pressure
e e
bb
: / / / .
tm m
with a finger to deliver the nerve more dorsally.
t . : / / t
/.tm
. m
t p ss
p : /
• Divide the nerve distally at each of the digital branches.
t p ss : /
• Grasp the neuroma firmly with distal tension and dissect the nerve as far proximally as
p
t
hht t t
hht t
exposure allows such that the stump lies proximal to the metatarsal heads (Fig. 18.6). FIG. 18.6
t t p
t ss:
p t t p
t ss:
p
146 hht
PROCEDURE 18 Morton Neuroma hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 18.7
k eers
rs k er
erss
b ooook
CONTROVERSIES
b o ook
o
b o o
eeb • Release of transverse metatarsal ligament
ee/ e
/ e b FIG. 18.8
ee/ e
/ e b
alone has been advocated, though with
unreliable results.
: // t/.tm
. m : / /t/.tm. m
ss : /
• Alcohol injection is unreliable and may cause
t p p tp pss : / FIG. 18.9
t t
damage to adjacent soft-tissue structures.
hht t
hht t
• Sharply divide the proximal nerve trunk and remove the neuroma.
• Clear web space following excision (Fig. 18.7).
• A dorsal approach is preferred for faster Step 2
healing, earlier return to weight bearing, and
keerrss
less chance of problems with scarring.
• Distraction of the web space with a laminar
k eer ss
• Release the tourniquet and ensure hemostasis.
r
• Place an absorbable suture into the capsule of the adjacent metatarsophalangeal joint.
b ooook spreader or distraction device is essential.

b ooook b oo
• Have the assistant squeeze the foot gently as the suture is tied. This “restores” the
eeb • Only remove neural and bursal tissue. Avoid

removing plantar fat or lumbricals.
ee/e/e b ee e/e b
transverse metatarsal ligament and closes the intermetatarsal dead space.
/
• Close the subcutaneous tissue and skin as per surgeon’s preference. Fig. 18.8
• With dual (second and third web spaces)
: / t
neuromas, excise the more symptomatic lesion
/ / m
.t.m : / / t
/ m
.t.m
depicts skin closure with interrupted sutures.
t ppss : /
only. Address the less symptomatic lesion
sequentially rather than simultaneously.POSTOPERATIVE CARE
t ppss : /
t
hhtt
• Division of the nerve such that the proximal
stump retracts to the level of the muscle
t
hhtt
• Padded dressing to absorb bleeding
• Postoperative surgical shoe with weight bearing as tolerated
bellies will help prevent a painful stump
neuroma. • Reduction of padded dressing at 4 days and application of light occlusive dressing
allowing sandal-style footwear
rrss rrss
• Suture removal 10–14 days
o k e
k e o k e
• Increase activity and footwear as tolerated after suture removal
k e
o
eebb o o
• A plantar incision has a higher risk of painful
scarring.
EXPECTEDe b o
b o o
• Scar massage
e b o
b o
• Fig. 18.9 shows a painful plantar scar after
a plantar approach for a third web space
m ee/ OUTCOMES
/ e m ee/ / e
neuroma.
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
• Generally good results are reported.
• The patient should expect permanent numbness in the affected web space (one-half
t p ss:
• Small risk of vascular compromise and
subsequent necrosis of the third toe with dual
t t p t t p
t ss:
of each toe), though this is rarely a problem.
p
hht
web space neuroma excisions.
• Excision of the plantar fat pad may cause
metatarsal overload.
hht
• A small percentage of patients may be slow to settle with neuritic pain from the re-
sected nerve stump.
EVIDENCE
Gurdezi S, White T, Ramesh P. Alcohol injection for Morton’s neuroma: a five-year follow-up. Foot Ankle
k e r
e s
rs k eers
rs
Int 2013 Aug;34(8):1064–7.
o o
o o k o oo k
This study demonstrates that alcohol injection does not offer permanent resolution of symptoms
o
for most patients with Morton neuroma and can be associated with considerable morbidity.
o o
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh19
PROCEDURE
t hht
Revision
r ss Surgery Through a Plantar
r s s Approach for
o k ee r
Recurrent
k Interdigital k
Neuroma
o kee r
ooo
b o
m ee /e m ee / e
Glenn B. Pfeffer
: / t
///t. . m : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp t
hhtt p
t p
• The incidence of continued forefoot pain
after primary interdigital neuroma excision is
k e rs
rs
INDICATIONS
e k er
erss approximately 10%.
b ooook ooook o o
• Recurrent or persistent pain in the intermetatarsal space following excision of a Mor-
b b
• Determining if the pain is from an inadequate
excision, a recurrent neuroma, or another
eeb ton neuroma

ee/ e
/ e b
• Exclusion of other sources of forefoot pain
ee/ e
/ e b undiagnosed condition.
: // t/.tm
. m
• Transient relief from a focal injection of lidocaine
: / /t/.tm. m TREATMENT OPTIONS
t p ss
p : / tp pss : / • One cortisone injection, given through a dorsal
approach
t
EXAMINATION/IMAGING
hht t t
hht t
• A patient will have focal pain on the plantar aspect of the foot, over the stump of the
• A cushioned orthotic pad (felt pad) with
pressure relief over the neuroma stump
nerve, usually in the second or third intermetatarsal space. • Footwear with a wide toe box; the addition of a
rocker sole
• If the pain and tenderness are in more than one intermetatarsal space, or in both feet, • A program of physical therapy for
the diagnosis of a neuroma is unlikely.
keerrss keerrss
• Percussion over the nerve may reproduce symptoms and cause dysesthesias in the
desensitization
• A plantar lidocaine patch
b ooook b oook
nerve distribution. This is not always the case. Often there is only deep pain with
o b
direct pressure over the nerve end, which is less definitive and may be from another
oo
• Gabapentin or an equivalent medication
eeb diagnosis.
ee/e/e b ee/e/e b
: / / t
/ m : / / t
/ m
• It is important to assess the length of the initial incision. Did the previous incision
.t.m .t.m
extend sufficiently proximal to allow transaction of the nerve in a non–weight-bearing
part of the foot?
•

t
hhtt t
hhtt
Exclude subluxation or synovitis of the adjacent metatarsophalangeal joints
(especially the second), Freiberg infraction, a stress fracture of the metatarsal,
metatarsalgia, inflammatory or degenerative arthritis, tarsal tunnel syndrome, and
complex regional pain syndrome. An adjacent neuroma, although possible, is
highly unusual.
k e rrss
e k e rrss
• An injection of 0.5 mL of lidocaine in the area of maximal pain at the stump of the
e
o o
o o k o o
o o k
nerve should provide near-complete relief of symptoms for at least 1 hour. Use a
o o
25-gauge needle. Without this confirmation of the diagnosis, it is highly unlikely that
eebb ee/ e b
e b
a revision surgery will have a successful outcome.
/ ee/ e
/ b
e b
• Standing anteroposterior/lateral and both oblique radiographs of the forefoot will
: / / t
/ m
.t.m : / / t m
.t.m
help exclude other diagnoses, as will magnetic resonance imaging. Ultrasonography
/
t p ss:
p /
may have a diagnostic role.
t p ss:
p /
t
hht
SURGICAL ANATOMY t t
hht t
• A stump neuroma will be found proximal to the metatarsal head (Fig. 19.1).
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
FIG. 19.1
t
hht t t
hht t 147
t t p
t ss:
p t t p
t ss:
p
148 hht
PROCEDURE 19 Revision Surgery Through a Plantar Approach for Recurrent Interdigital Neuromahht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
A B
FIG. 19.2
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
POSITIONING PEARLS
t ppss : / POSITIONING t ppss : /

t
hhtt
• The surgery may be performed in the supine
position, with the operating room table in a
slight Trendelenburg position, if the patient is
• Prone
t
hhtt
not able to tolerate a prone position. • An ankle or thigh tourniquet should be used.
PORTALS/EXPOSURES
k rrss
CONTROVERSIES
e e k e rrss
• The plantar longitudinal incision should begin 1 cm distal to the area of maximal pain,
e
o o
o k
• Performing the surgery in the supine position,
o o o
o o k
which is usually just proximal to the metatarsal heads.
o o
eebb b b
with the table in slight Trendelenburg position. • The incision is centered between the metatarsal heads (Fig. 19.2).
ee/ e
/ e b ee/ e
/ e b
• Extend the incision proximally into a non–weight-bearing area, where the nerve
INSTRUMENTATION
: / / t
/ m
.t.m incision.
: / / t
/ m
will be divided. This excellent exposure is not possible with a transverse or dorsal
.t.m
• Loupe magnification
t p p /
ss: PROCEDURE t p ss:
p /
t
hht t Step 1
t
hht t
• If the patient has already had a plantar incision • Identify the plantar fascia. At the most proximal aspect of the incision, carefully di-
for the original surgery, curve the new incision vide the fascia longitudinally with a #15 blade (Fig. 19.3).
k e s
as far back as necessary to place the nerve
r rs
stump off of the weight-bearing aspect of the
e k eers
rs
• Identify a normal portion of the common digital nerve in an area that is free of scar
tissue from the previous surgery (Fig. 19.4). Tag the nerve with a small rubber dam
o o
o o kfoot.
o oo k
cut from a Penrose drain.
o oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 19 Revision Surgery Through a Plantar Approach for Recurrent Interdigital Neuroma 149
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 19.3 FIG. 19.4
keerrss keerrss CONTROVERSIES
b ooook b ooook b oo • A painful, hypertrophic scar may develop after
eeb ee/e/e b ee/e/e b a plantar incision, but is extremely rare.

• The neuroma is plantar, and should almost
: / / t
/ m
.t.m : / / t
/ m
.t.m always be operated on from a plantar
approach.
t ppss : / t ppss : / • It is very rare to have a problem with a plantar

Step 2
t
hhtt t
hhtt
• Identify the distal pathology. Often the distal nerve end will be scarred down to the
incision.
• The nerve cannot be exposed adequately from
a dorsal incision.
transverse metatarsal ligament or plantar plate (Fig. 19.5). A stump neuroma may be • In the extremely rare situation in which
present more proximally. In either case, sharply transect the nerve in a non–weight- there is a concomitant problem with the
bearing aspect of the foot. metatarsophalangeal joint (e.g., synovitis or
k rrss
e k e rrss
• Place gentle traction on the nerve and sharply divide it in the most proximal as-
e e
instability), an additional dorsal incision can be
used.
o o
o o k pect of the incision.
o o
o o k
• Cut down on a wet tongue depressor (Fig. 19.6). Allow the nerve to retract into
o o
eebb normal tissue.
ee/ e
/ b
e b ee/
• In a salvage situation, an intrafascicular dissection of the common digital nerve will
e
/ b
e b STEP 2 PEARLS
• Never dissect directly onto a scarred nerve.
/ t m
.t.m / t m
.t.m
allow its branches to be separated proximally. In this way, the neuroma can be dis-
: / / : / /
Identify a more proximal portion of the nerve in
t p ss:
p / t p ss:
p /
sected back to a non–weight-bearing aspect of the arch, while preserving innerva- normal tissue and begin your distal dissection
from this point.
t
hht t
tion to the adjacent web space (Fig. 19.7).
t
hht t
• Make sure that the incision extends into the non–weight-bearing aspect of the arch
(Fig. 19.8). STEP 2 PITFALLS
• In a patient with pes planus, where the nerve end will still have direct pressure on it, • The common digital nerve lies directly beneath
bury the stump in the deep muscles of the foot using a 6-0 nonabsorbable epineural the plantar fascia, superficial to the arteries.
k e r
e s
rs
suture.
k eers
rs
• Make sure there is no tension on the nerve as the foot and ankle are placed through
Careful dissection is required. If the intrinsic
muscles are reached, the dissection is too
o o
o o k a full range of motion.
o o
oo k oo
deep.
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
150 hht
PROCEDURE 19 Revision Surgery Through a Plantar Approach for Recurrent Interdigital Neuroma hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/ .
t.
mm B
: / /t/.tm. m
t p ss
p : / FIG. 19.5
tp pss : /
t
hht t t
hht t FIG. 19.6
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m

t p ss:
p / t p ss:
p /
FIG. 19.7
hhtt t A
h
t
ht t B
FIG. 19.8
STEP 3 PEARLS
• If the proximal portion of the nerve is
transected in a non–weight-bearing aspect of Step 3
k e r
e ss
the arch, especially in a patient with a cavus
r
foot, there is no need to bury the nerve.
k eers
rs
• Drop the tourniquet. Obtain meticulous hemostasis, and close the wound with one
o o
o o k o o
oo k
layer of 3-0 nylon (Fig. 19.9). If necessary, alternate simple and horizontal mattress
oo
sutures to assure excellent apposition of the skin edges. Subcutaneous sutures
eebb CONTROVERSIES
ee/ e
/ b
e b /e
should not be used in most cases.
ee /ebb
• Apply a bulky sterile dressing. A posterior plaster splint may be added to further
: / / t
/ t
a painful stump neuroma from developing. Nom
• Numerous techniques have been tried to prevent
. .m protect the wound.
: / / t
/.tm
. m
ss
one technique has proven superior.
t p p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 19 Revision Surgery Through a Plantar Approach for Recurrent Interdigital Neuroma 151
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 19.9
keerrss
keerrss
b ooook b oook
• The patient is kept non–weight bearing until the wound is completely healed. The
o b oo
eeb e /e/e b
sutures are usually removed 2–3 weeks after surgery.
• Steri-Strips should be used for an additional 2 weeks to prevent the incision from
e ee/e/e b
spreading apart.
: / / t
/ m
.t.m : / / t
/ m
.t.m POSTOPERATIVE PEARLS
p ss / p ss : /
• Once the sutures are removed, the patient can start to bear weight in a cast boot until
:
4 weeks postoperatively. Immobilization helps achieve appropriate wound healing.
t p t p
• A small dehiscence of the wound should be
t
hhtt t
hhtt
• Most patients will experience significant improvement, although up to 25% will con-
tinue to experience some discomfort.
treated with several weeks of moist dressing
changes. Excellent healing will occur.
EVIDENCE
Akermark C, Crone H, Saartok T, Zuber Z. Plantar versus dorsal incision in the treatment of primary
k e rrss e rrss
intermetatarsal Morton’s neuroma. Foot Ankle Int 2008;29:136–41.
e k e
o o
o o k o o o k
An excellent study of 125 patients among whom one group had a dorsal approach and the other a
plantar approach for a primary neuroma excision. Both had similar outcomes, although the dorsal
o o o
eebb e e
/ b
e b
sions. The authors concluded that a plantar approach is preferable (Level IV evidence).
e ee/ e
/ b
e b
incision group had more complications. There were no significant problems with the plantar inci-
/
1988;9:34–9.
: / / m
.t.m : / / / m
.t.m
Beskin JL, Baxter DE. Recurrent pain following interdigital neurectomy—a plantar approach. Foot Ankle
/ t t
t p ss:
p /
Supports a plantar approach for recurrent neuroma (Level IV evidence).
t p ss:
p /
t
hht
tion of Morton neuroma. Foot Ankle Int 2014;35(10):1002–5. t
Claassen L, Bock K, Ettinger M, Waizy H, Stuckenborg-Colsman C, Plaas C. Role of MRI in the detec-
t hht t
MRI may be helpful in making the diagnosis of a neuroma, but clinical examination continues to be
the most accurate (Level IV evidence).
Johnson J, Johnson K, Unni K. Persistent pain after excision of an interdigital neuroma. J Bone Joint
Surg Am 1988;70:651–7.
k e e s
rs k eers
A study of 33 feet with persistent pain following excision of an interdigital neuroma. The revision
r rs
surgery was performed through a plantar longitudinal incision. Only one patient had a minor prob-
o o
o o k o o
oo k
lem with an intermittent callus at the proximal edge of the scar (Level IV evidence).
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh20
PROCEDURE
t hht
Metatarsal
rss Lengthening rs s
o k kee r o kkee r
o
eebb o o
Mark E. Easley and James A. Nunley II
e bboo o e b o
b o
m ee / /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t
t p
t ss
p : INDICATIONS
t t p
t ss
p :
hht
• Contraindicated for a dorsiflexion malunion of
the 1MT, unless an adjunctive procedure can
be performed to plantar flex the first ray.
hht
• Relatively short metatarsal (brachymetatarsia; Fig. 20.1*)
• Overload/transfer metatarsalgia to an adjacent metatarsal head
• Short first metatarsal (1MT) following corrective surgery for hallux valgus
• Contraindicated in patients noncompliant with
a protective weight-bearing status, pin care,
EXAMINATION/IMAGING
k eers
rs
and proper distraction (metatarsal lengthening)
protocol.
k er
erss
• Short metatarsal clinically and radiographically, based on weight-bearing examinations
b ooook b oook
• Radiographic evidence of short fourth metatarsal (4MT; brachymetatarsalgia)
o b o o
eeb CONTROVERSIES
• Metatarsal lengthening of shortened
ee/ e
/ e b (Fig. 20.2)
ee/ e
/ e b
• Radiographic evidence of short 1MT following corrective surgery for hallux valgus
metatarsal versus shortening of adjacent
: // t/.tm
. m : / /t/.tm m
• Adjacent metatarsal heads may have tenderness and callus formation from overload
.
t p ss /
metatarsals; we advise against shortening a
: SURGICAL
physiologically normal anatomy when possible.
p
ANATOMY
tp pss : /
TREATMENT OPTIONS
t
hht t t
hht t
• Determine associated elevation of the affected metatarsal head.
• Determine the amount of metatarsal shortening (i.e., the amount of lengthening required).
• Shortening of all metatarsals experiencing • Assess prior surgical scars for preoperative planning.
overload • Identify exact location of tarsometatarsal (TMT) joints for planning of pin placement.
• Acute lengthening with interpositional
• Adjust the external fixator relative to the 1MT (Fig. 20.3A).
keerrss
structural autograft or allograft bone
keerrss
• Define the location of the first metatarsophalangeal (MTP) joint (Fig. 20.3B).
b ooookANATOMY PEARLS
b ooook
• Define the location of the first TMT joint (Fig. 20.3C).
b oo
• At-risk structures include the following:
eeb • After making the skin incision, use a hemostat to
spread the soft tissues down to the periosteum.
ee/e/e b e /e/e b
• 1MT: the dorsomedial cutaneous sensory nerve to the hallux and the extensor
e
: / / t
/ m
.t.m : / / t
/ m
.t.m
hallucis longus tendon, as can be seen in Fig. 20.4A.
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb
e / e
/ b
e b
FIG. 20.1
e

ee/e/ebb FIG. 20.2
: / / t
/ .
t m
.m : / / t
/.tm
. m
t p ss
p : / t p ss : /
* All figures in this chapter are courtesy Mather R III, Hurst J, Easley M, Nunley JA. First metatarsal
lengthening. Tech Foot Ankle Surg 2008;7:25–30.
p
152 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 20 Metatarsal Lengthening 153
• 4MT: lateral branch of the superficial peroneal nerve and the extensor digitorum ANATOMY PITFALLS
k e r
e s
longus tendons, as can be seen in Fig. 20.4B.
rs k eers
r s
• Assess-associated MTP joint deformity (claw toe or varus/valgus deviation); this
• Skin tension at the pin sites is undesirable; only
make the skin incision when the exact location
o o
o o k oooo k
associated deformity will not be corrected with metatarsal lengthening unless an
ofor a particular pin has been determined.
o
eebb adjunctive procedure is performed.
ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : /A
tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt B t
hhtt C
FIG. 20.3
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b
Extensor hallucis
ee/ e
/ b
e b
: / / t
/ m
.t.m
longus tendon
: / / t
/ m
.t.mSuperficial
peroneal nerve
t p ss:
p / 1st metatarsal
t p ss:
p /
t
hht t t
hht t 4th metatarsal
Dorsomedial Extensor digitorum

cutaneous longus tendon
sensory nerve
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p
A
: / t
B
p ss
p : /
t
hht t
t
hht t
FIG. 20.4
t t p
t ss:
p t t p
t ss:
p
154 hht
PROCEDURE 20 Metatarsal Lengthening hht
POSITIONING
k e r
e s
rs k eers
r s
• Supine position
• Foot on edge of operating table to allow easy access to fluoroscopy unit
o o
o o k o oo k o
• For 4MT lengthening: bump under ipsilateral hip
o o
eebb PORTALS/EXPOSURES PEARLS
ee/ e
/ebb needed
ee/ e
/ b
e b
• For 1MT lengthening: no bump under ipsilateral hip because access to medial foot is
• Place the first pin while simultaneously
: / / t
/ .
t m
. m
PORTALS/EXPOSURES
: / / t
/ .
t m
. m
t p
for placing the subsequent pins.
ss
p : /
determining the ideal external fixator position
t p ss
p : /
t
hht t
• The external fixator must be placed in line with
the desired axis of lengthening.
• Placing the first (and thus second) pin slightly
t
hht t
• Four pins are placed through small stab incisions under fluoroscopic guidance.
• The surgical approach for the metatarsal corticotomy is performed between the two
pins closest to the proposed corticotomy.
plantar in the medial 1MT typically avoids 1MT • The incision for the osteotomy is made in line with the respective metatarsal and, if
dorsiflexion during distraction.
possible, should avoid the pin sites.
k eers
rs k e
PROCEDUREr
erss
Step 1: Percutaneous Placement of the First (Distal) Pin
eeb ee/ e
/ e b e / e
/ e b
• The external fixator is typically a monorail device.
e
: // t/.tm
. m : / /t/.tm. m
• The four pins are placed in the same plane, within the bone to be lengthened, while
t p ss
p : / tp ss : /
avoiding the adjacent joints.
• The pins must be perpendicular to the bone and achieve a bicortical purchase in the
p
t
hht t t
hht t
affected metatarsal.
• The distal pins must be separated adequately from the proximal pins to allow for the
osteotomy to be performed safely.
• We typically place the distal-most pin first; it must be as distal as possible in the
metatarsal to be lengthened without violating the MTP joint.
keerrss keerrss
• The first pin determines monorail external fixator alignment; we recommend holding the
b ooook b ooook external fixator in the ideal position to determine optimal first pin placement (Fig. 20.5A).
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb A
ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
B
: / / t
/ .
tm.m : / / t
/.tm
. m C
t p ss
p : /
t p ss
p :
FIG. 20.5/
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
• Fluoroscopic guidance is needed to ensure that, following first pin placement, the STEP 1 PITFALLS
k e r
e s
rs
the adjacent joints (Fig. 20.5B–C).
k eers
other pins can be placed in proper position in the involved metatarsal while avoiding
r s • Poor first pin positioning generally leads to

difficulties with proper monorail external fixator
o o
o o k
• 1MT lengthening should be performed.
oooo k o o
position.
eebb e /ebb
• Place the first pin at the site determined clinically and fluoroscopically (Fig. 20.6A).
/ e
• Drive the first pin using adapter and power drill, as shown in Fig. 20.6B.
e ee/ e
/ b
e b • Fluoroscopic guidance assures bicortical pin
positioning and that the subsequent pins are
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• Anteroposterior (AP) fluoroscopic view of the first pin in the proper position should placed in the proper and safe positions.
• If a tapered pin system is used, the pin should
p ss
p /
be obtained as in Fig. 20.6C.
: t p ss : /
• Lateral fluoroscopic view of the first pin in the proper position should be obtained
t p
be driven to its proper position in the bone and
not reversed or it will lose purchase.
t
hht
as in Fig. 20.6D.
t
• 4MT lengthening should be performed.
t
hht t
• Determining proper first pin positioning for 4MT is necessary (Fig. 20.7B). INSTRUMENTATION/IMPLANTATION
• An initial pin is inserted for 4MT lengthening, as shown in Fig. 20.7A. • Pin driver that easily slides over the pin without
• The external fixator must be adjusted to the proper setting that will still allow some the need for tightening with a chuck
k eers
rs k er
erss
mild compression and adequate distraction to appropriately lengthen the metatarsal • Small-diameter self-tapping/drilling pins
(typically 2.5-mm or 3.0-mm pins)
b ooook distracted setting).

b ooook
(i.e., do not complete the initial external fixator position with the fixator in its fully
b o o
• Monorail external fixation system
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t
hhtt t
hhtt B
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / D
t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb C
ee/ e
/ b
e b FIG. 20.6
ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
156 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m : / /t/.
B
tm. m
t p ss
p : /
tp pss : /
t
hht t t
hht t
FIG. 20.7
Step 2: Inserting Remaining Pins
keerrss keerrss
• Percutaneous insertion with fluoroscopic guidance is used for placement of the re-
b ooook b ooook maining pins.
oo
• With the monorail external fixator loosely attached to the first pin, the proximal-most
b
eeb ee/e/e b guide.
ee/e/e b
pin is placed through a small stab incision, using the monorail external fixator as a
: / / t
/ m
.t.m : / / t m
.t.m
• Ideally, the proximal pin is in the bone immediately proximal to the respective TMT
/
t ppss : / joint.
t ppss : /
t
hhtt t
hhtt
• Before securing the proximal pin, fluoroscopic guidance must confirm that the
other two intermediate pins can be placed with bicortical purchase through the
monorail external fixator and will allow for adequate surface on the metatarsal to
safely create the corticotomy. Fig. 20.8A shows the fluoroscopic determination of
proper external fixator and residual pin positions for 4MT lengthening, based on
k e rrss
e k e rrss
e
the external fixator loosely secured to the first pin.
• After placing the proximal pin, the two intermediate pins are placed, again using the
o o
o o k o o
o o k o
monorail external fixator as a guide. Fig. 20.8B shows a fluoroscopic view of four
o
eebb STEP 2 PEARLS
ee/ e
/ b
e b ee e
/ b
e b
pins and external fixator in place for 4MT lengthening.
/
• The monorail is secured to the four pins to assure proper alignment and that no skin
: / / t
• If necessary, the proximal pin may be placed
/ m
.t.m impingement occurs.
: / / t
/ m
.t.m
p ss: /
in the corresponding cuneiform, such that
the two proximal pins safely straddle the TMT
t p t p ss:
p /
• 1MT lengthening: proximal pin placement is performed.
• Determine proper proximal pin location, as indicated in Fig. 20.9A.
t
hht t
joint without either pin violating the joint (Fig.
20.11). t
hht t
• Confirm proper location for the pin using fluoroscopy, as indicated in Fig. 20.9B–C.
• Insert the second pin into the proximal 1MT, as indicated in Fig. 20.9D.
• Fig. 20.9E shows the proximal pin inserted and external fixator attached (note the
STEP 2 PITFALLS
slightly relative plantar flexion of the external fixator relative to the 1MT).
• If the proximal pin is not placed in proper
k e r s
rs
alignment, the two intermediate pins may not
e k e rs
• Placing the residual pins in the 1MT is necessary, and includes the steps noted
rs
below.
e
o o
o o kachieve bicortical purchase in the metatarsal.
• If the other three pins are not aligned with the
oo k
• Insert the third pin, as indicated in Fig. 20.10A.
o o oo
eebb first, the monorail external fixator cannot be
properly secured to the pins. If a tapered pin
ee/ e
/ b
e b
•
e /ebb
• Insert the fourth pin and secure external fixator, as indicated in Fig. 20.10B.
/e
Fig. 20.10C shows a fluoroscopic view of all four pins in the 1MT.
e
/ / t tm
system is used, the pin should be driven to its
. .
proper position in the bone and not reversed or
: / m : / / t
/.tm
. m
• An additional “floating pin” can be inserted to further stabilize the external
it will lose purchase.
t p ss
p : / t p ss :
(Fig. 20.10D).
p /
fixator to the pins, avoiding eccentric compression about the two distal pins
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
A B

FIG. 20.8
t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb b b
A B C
ee/ e
/ e b ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb D
ee/ e
/ b
eEb ee/e/ebb
: / / t
/ .
tm.m
FIG. 20.9
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
158 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A C
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrs
B
s keerr
Dss
b ooook b ooook
FIG. 20.10
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m
FIG. 20.11
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B C
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss D
keerrss E
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k F
o o
o o k o o
eebb ee/ e
/ b
e b FIG. 20.12
ee/ e
/ b
e b
Step 3: Corticotomy
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ss:
p /
may lose control of the two metatarsal fragments).
t p ss:
p /
• Attempt to make the corticotomy with the external fixator in place (otherwise you
p
t
hht t t
hht t
• While the external fixator can be removed to facilitate access to the corticotomy site,
repositioning the external fixator, despite best efforts, may lead to slight malalign- STEP 3 PEARLS
ment of the corticotomy. • The external fixator must be preset to ensure
• Corticotomy for the 1MT should be performed as follows: that slight compression is still possible after
the corticotomy (i.e., do not have the external
k e e s
rs k e rs
• Determine proper location for corticotomy (Fig. 20.12A).
r rs
• Confirm proper corticotomy location on AP (Fig. 20.12B) and lateral (Fig. 20.12C)
e
fixator completely compressed when the
corticotomy is performed because one needs
o o
o o k fluoroscopic views.
o o
oo k oo
to account for the saw blade thickness).
eebb e / b
e b
• The corticotomy may be performed with a microsagittal saw while cold sterile
/ e e /e/ebb
water or saline is irrigated onto the saw blade (Fig. 20.12D). Alternatively, a Gigli
e e
saw may be used.
: / / t
/ .
tm.m : / / t
/.tm
. m
STEP 3 PITFALLS
• Removing the external fixator to perform
t p ss
p : / t p ss : /
• Regardless of technique, no periosteal stripping is required and this should be
avoided. Fig. 20.12E shows the minimal exposure and minimal periosteal strip-
p
the corticotomy may lead to an inability to
t
hht t
ping for corticotomy.
t
hht t reposition the corticotomy anatomically.
t t p
t ss:
p t t p
t ss:
p
160 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B
k eers
rs k er
erss FIG. 20.13
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb A
ee/e/e b FIG. 20.14

e
B
e/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o o oo k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t p ss:
p / B
t p ss:
p /
t
hht t t
hht t
FIG. 20.15
• The corticotomy is made with adequate bone bridges to the adjacent intermedi-
ate pins (ideally at least 2–3 mm).
k e r
e s
rs
•
e rs
Fig. 20.12F shows the corticotomy being completed and mobilized with an osteotome.
rs
• Gently distract the external fixator to confirm that the corticotomy is complete, both
k e
o o
o o k
o o
oo k
clinically (Fig. 20.13A) and fluoroscopically (Fig. 20.13B).
oo
eebb • Microsagittal saw or Gigli saw, depending on
surgeon preference
ee/ e
/ b
e b e / /ebb
• Then compress the corticotomy fully (Fig. 20.14), check that the 1MT external fixator is in
e
place without skin impingement (Fig. 20.15A), and perform wound closure (Fig. 20.15B).
e
/ / / .
tm
• Sterile cold saline/water irrigation to cool
t
the saw blade while the corticotomy is being
: .m : / / t
/.tm
. m
• 4MT corticotomy should be performed as presented in Fig. 20.16.
created
t p ss
p : / •
t p ss : /
Fig. 20.16A shows the clinical view of a 4MT corticotomy. Note that the pins clos-
est to the osteotomy are in the surgical approach because the 4MT is particularly
p
t t
• Proper wrenches to adjust the external fixator
hht t
hht t
short in this patient.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
:
B
/ / t
/ m
.t.m : /
C
/ t
/ m
.t.m
t ppss : /
t ppss :
FIG. 20.16
/
t
hhtt t
hhtt
• Slightly distract the corticotomy to confirm it is complete using fluoroscopy (Fig.
20.16B).
• Fully compress the corticotomy, as indicated in Fig. 20.16C.
k rrss
e e k e rrss
e
o o
o o k o o o k
• The patient is placed on non–weight-bearing status until adequate healing and exter-
o o o
eebb nal fixator removal.
ee/ e
/ b
e
• Maintain compression for approximately 10 days. b ee/ e
/ b
e b
: / / t
/ m
.t.m
• Begin incremental distraction on postoperative day 10.
: / / t
/ m
.t.m
t ss:
p /
• Distract 0.50–0.75 mm/day, in 0.25-mm increments.
p t p ss:
p /
• This typically corresponds to one quarter turn two or three times daily.
t
hht t
• Clear instructions and patient compliance are mandatory. t
hht t
• Close follow-up (at least weekly) in the first several weeks is necessary to ensure that
distraction is occurring at the proper rate.
• Daily pin care is mandatory.
k e r
e s
rs
•
e rs
• The external fixator is distracted until desired metatarsal length is achieved.
rs
Fig. 20.17 shows a 4MT external fixator at 4 weeks’ follow-up without skin im-
k e
o o
o o k pingement.
o o
oo k oo
eebb •
in Fig. 20.1.
ee / b
e b ee/ /ebb
Fig. 20.18 shows serial AP radiographs for a 4MT lengthening in the patient shown
/ e e

: / / t
/ .
tm.m : / / t
/.tm
. m
□ Obtain a radiograph after 10 days of compression and 7 days of distraction (Fig.

20.18A).
t p ss
p : / t p ss : /
□ Obtain a radiograph after 3 weeks of distraction (Fig. 20.18B).
p

t
hht t t
hht t
□ Obtain a radiograph after 7 weeks of distraction (Fig. 20.18C).
t t p
t ss:
p t t p
t ss:
p
162 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
FIG. 20.17
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
A B C
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
D
t p ss
p : / E F
t p ss
p : /
t
hht t
FIG. 20.18 t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b ooook B
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
C
t
hhtt FIG. 20.19
D
□ Obtain a radiograph after external fixator removal at 10 weeks (Fig. 20.18D).

k e rrss
e
□ Final
fourth toe deformity.
k e rrss
follow-up at 2 years (Fig. 20.18E). Note that there is no correction of the
e
o o
o

o k o o o k o
□ Clinical view of final follow-up with slight lateral deviation of the fourth toe (Fig.
o o
eebb 20.18F).
ee/ e
/ b
e b ee
• The external fixator is maintained until an adequate callus forms to allow fixator and/ e
/ b
e b
pin removal.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ss:
p / t p ss:
p /
• A controlled ankle movement walker or casting may be considered for 2–3 more weeks
p
while the pin sites heal, followed by advancement to full weight-bearing on the forefoot.
t
hht t t
hht t
• Serial follow-up of 1MT lengthening in the example patient in this procedure included
the following:
• Reinforced patient instructions and review with
• Obtaining a preoperative radiograph (Fig. 20.19A). a family member will often prevent inadvertent
• Follow-up after 10 days of compression and 14 days of distraction (Fig. 20.19B). inappropriate distraction technique.
k e r
e s
rs e rs
• Follow-up after 8 weeks of distraction (Fig. 20.19C); note comparison with the
rs
contralateral foot to determine ideal length restoration.
k e
• Close initial follow-up is important to identify
potential problems.
o o
o o k
• Final follow-up (Fig. 20.19D).
o o
oo k oo
eebb in Fig. 20.2) included the following:
ee / b
e b
• Serial follow-up of another patient with 1MT lengthening (see preoperative evaluation
/ e ee/e/ebb POSTOPERATIVE PITFALLS
• Miscommunication leads to undesirable
: / / / .
tm m
• Clinical picture of external fixator in place (Fig. 20.20A).
t . : / / t
/.tm
. m accelerated distraction (risking failure of
bone regenerate formation and nonunion),
t p ss : /
• After 10 days of compression and 3 weeks of distraction (Fig. 20.20B).
• After 6 weeks of distraction (Fig. 20.20C).
p t p ss
p : / distraction that is too slow (early undesirable
t
hht t
• After 11 weeks of distraction (Fig. 20.20D).
t
hht t consolidation), or inadvertent compression.
t t p
t ss:
p t t p
t ss:
p
164 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
B t
hhtt C

t
hhtt
FIG. 20.20
D
k e rrss
e
EVIDENCE
k e rrss
e
o o
o o k o o
o o k
Given multiple Level IV series with relatively consistent successful outcomes of distraction osteo-
o o
eebb b b
genesis for metatarsal lengthening, a grade B recommendation for metatarsal lengthening may be
/ e e b
provided.
ee / ee/ e
/ e b
Baek GH, Chung MS. The treatment of congenital brachymetatarsia by one-stage lengthening. J Bone
: / / t
/ m
.t.mJoint Surg Br 1998;80:1040–4.
: / / t
/ m
.t.m
t p ss:
p / t p ss: /
Choi IH, Chung MS, Baek GH, Cho TJ, Chung CY. Metatarsal lengthening in congenital brachymetatar-
sia: one-stage lengthening versus lengthening by callotasis. J Pediatr Orthop 1999;19:660–4.
p
t
hht t t
hht t
Huang SM, Song JK, Kim HT. Metatarsal lengthening by callotasis in adults with first brachymetatarsia.
Foot Ankle Int 2012;33(12):1103–7.
Hurst JM, Nunley 2nd JA. Distraction osteogenesis for the shortened metatarsal after hallux valgus
surgery. Foot Ankle Int 2007;28:194–8.
Kim HT, Lee SH, Yoo CI, Kang JH, Suh JT. The management of brachymetatarsia. J Bone Joint Surg Br
2003;85:683–90.
k e r
e s
rs k eers
rs
Kim JS, Baek GH, Chung MS, Yoon PW. Multiple congenital brachymetatarsia: a one-stage combined
shortening and lengthening procedure without iliac bone graft. J Bone Joint Surg Br 2004;86:1013–5.
o o
o o k oo k
Kucukkaya M, Kabukcuoglu Y, Tezer M, Kuzgun U. Correcting and lengthening of metatarsal deformity
o o oo
eebb b b
with circular fixator by distraction osteotomy: a case of longitudinal epiphyseal bracket. Foot Ankle
e/ e
/ e b
Int 2002;23:427–32.
e ee/e/e b
Lee KB, Park HW, Chung JY, Moon ES, Jung ST, Seon JK. Comparison of the outcomes of distraction
: / / t
/ .
tm.m : / / t. m
. m
osteogenesis for first and fourth brachymetatarsia. J Bone Joint Surg Am 2010;92(16):2709–18.
/ t
t p ss
p : / t p ss :
Foot Ankle Int 2009;30(10):981–5.
p /
Lee KB, Suh JS, Moon JS, Kim JY. Treatment of brachymetatarsia of the first and fourth ray in adults.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Masada K, Fujita S, Fuji T, Ohno H. Complications following metatarsal lengthening by callus distraction
for brachymetatarsia. J Pediatr Orthop 1999;19:394–7.
k e r
e s
rs k eers
r s
Oh CW, Satish BR, Lee ST, Song HR. Complications of distraction osteogenesis in short first metatar-
o o
o o k
sals. J Pediatr Orthop 2004;24:711–5.
o oo k
Oh CW, Sharma R, Song HR, Koo KH, Kyung HS, Park BC. Complications of distraction osteogenesis
o o o
eebb e e
/ebb
in short fourth metatarsals. J Pediatr Orthop 2003;23:484–7.
/ e / e
/ b
e b
Oznur A, Alpaslan AM. Lengthening of short great toe and correction of all lesser toe deformities by
e e
: / / t t m
distraction-lengthening. Foot Ankle Int 2003;24:345–8.
. . m : / / t .
t m
. m
Robinson JF, Ouzounian TJ. Brachymetatarsia: congenitally short third and fourth metatarsals treated
/ /
ss : / ss : /
by distraction lengthening—a case report and literature summary. Foot Ankle Int 1998;19:713–8.
t p p t p p
t
hht
Ankle Int 2003;24:706–11.
t
Song HR, Oh CW, Kyung HS, et al. Fourth brachymetatarsia treated with distraction osteogenesis. Foot
t hht t
Wada A, Bensahel H, Takamura K, Fujii T, Yanagida H, Nakamura T. Metatarsal lengthening by callus
distraction for brachymetatarsia. J Pediatr Orthop B 2004;13:206–10.
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh21t
PROCEDURE hht
Internal
rss Fixation of the Sesamoid rBone
ss of the Hallux
kkee
oJasmin r k
oo e
ke r
b
eeboo o E. Diallo and Beat Hintermann boo
e b e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t ss
p : INDICATIONS
t t p
t ss
p :
hht
• Differential diagnosis of sesamoid pathology:
• Capsular tear (first metatarsophalangeal joint)
• Flexor hallucis longus and brevis tendinitis
hht
• Symptomatic acute sesamoid fracture, fracture-delayed union or nonunion, and con-
genital bipartite sesamoid bone after failure of conservative treatment for at least 6–8
weeks
• Entrapment of the interdigital nerve
• Ganglion • Acute sesamoid bone fracture or disruption of the synchondrosis between the sesa-
• Gout moid fragments of a bipartite sesamoid with a displacement >5 mm
k eerss
• Hallux valgus
r
• Hallux rigidus
k er
erss
EXAMINATION/IMAGING
b ooook • Metatarsalgia
b ooook
• Clinical examination
b o o
eeb • Osteoarthritis
• Submetatarsal bursitis
ee/ e
/ e b ee/ e
/ e b
• Functional and structural assessment of the foot:
: // t/.tm
• Turf toe (metatarsal plantar plate disruption)
. m
• Fracture fragments <3 mm are too small for

: / /t .tm
• Risk factors for a sesamoid injury/stress include cavus foot, plantar-flexed foot,
. m
short or long first ray, and hallux valgus deformity
/
t p ss
p : /
screw fixation and should be excised.
• Most painful sesamoid fragmentations into

ss : /
• Swelling and tenderness over the symptomatic sesamoid
tp p
t
hht t
two fragments (fracture, nonunion, congenital
bipartite sesamoid) are transverse to the long
axis of the first metatarsal.

t
hht t
• Pain on forced dorsiflexion of the great toe (Fig. 21.1)
• Radiologic investigations
• Routine radiographs:
• Longitudinal or multiple sesamoid fragmentation • Weight-bearing dorsoposterior and lateral view of the foot such as anteroposte-
may be unstable for screw fixation.
rior, lateral, and Saltzman views of the ankle
keerrss
keerrss
• Radiographs provide enough information to evaluate structural abnormalities
in the ankle and foot, but limited information about the sesamoid bones. For a
b ooookINDICATIONS CONTROVERSIES
• A surgical treatment may be considered,
b ooook oo
better visualization of the medial and lateral sesamoids, a medial oblique view
b
eeb particularly in high-performance athletes (e.g.,
runners, dancers). ee/e/e b ee/e/e b
and a lateral oblique view, respectively, can be acquired. An axial sesamoid
view can provide a better assessment of both sesamoids with their metatarsal
/ t
• Radiologically, it is difficult to distinguish
: / / m
.t.m / t m
.t.m
articulations and number of fragments (Fig. 21.2)
: / /
between a fracture nonunion and a
t p ss : /
symptomatic congenital bipartite sesamoid.
p t ppss : /
t
hhtt
Differentiation of both entities is not necessary
because the treatment strategy is the same. t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p
A /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
.m
//t/t.m B
/ t.tm
. m
s:/ : ss: /
: / /
166 t
hht p
t p s
FIG. 21.1
t
hhtt t p
t p FIG. 21.2
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 21 Internal Fixation of the Sesamoid Bone of the Hallux 167
• Computed tomography

k e r
e s
rs e rs
• Very helpful to differentiate sesamoid acute and stress fractures from a de-
r s
layed union; also useful to assess vitality of the fracture site in case of avas-
k e
o o
o o k oo k
cular necrosis. The differentiation between an acute sesamoid fracture and a
oo o o
eebb e /ebb
bipartite sesamoid can also be achieved with a computed tomography scan.
/ e
Contrary to the acute fracture with sharp edges, the bipartite sesamoid has
e ee/ e
/ b
e b
blunt edges
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• Isotope bone scan

t p ss
p : / t p ss : /
• Is not regularly performed but can help detect a sesamoid pathology. In 25%
p
t
hht t t
hht t
of the active population, there is an increased radionuclide uptake without
sesamoid symptoms
• Magnetic resonance imaging
• Provides additional information about the surrounding ligaments and tendons,
for example, in a turf toe injury
eers
rs
TREATMENT OPTIONS
k k er
erss
b ooook
• Strapping
b ooook b o o
eeb • Immobilization in a cast for 6–8 weeks
ee/ e
/ e b ee/ e
/ e b
• Modification of activity
// t/.tm
. m /
• Electrical stimulation and low-intensity pulsed ultrasound in nonunion
: : /t/.tm. m
ss : / ss : /
• Healing rates similar to surgical procedures could be revealed in fresh fractures,
t p p tp p
t
hht t t
hht t
arthrodesis, and nonunion fractures of long bones, such as the tibia
• Bone grafting of nonunion
• In chronic sesamoid conditions with <3-mm fragment displacement
• Débridement and bone packing of the fracture site with autologous bone from the
first metatarsal head
keerrss
• Complete or partial resection
keerrss
b ooook b ooook
• The total sesamoid excision results reasonable in pain management and re-
oo
turn to activity. Although in 10–20% of the cases hallux valgus, hallux varus,
b
hallux rigidus, and cock-up deformities are reported. Weakness of the great
toe occurs in 50% of cases and the inability to stand on tip toe in up to 30%
of cases
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Partial sesamoidectomy can be used for significant fragment separation or dia-
t
hhtt
stasis of bipartite sesamoids
t
hhtt
• Percoutaneous fixation or open reduction and internal fixation
SURGICAL ANATOMY
• There are two sesamoids, medial (tibial) and lateral (fibular), and the length is 13.5
k e rrss
e (Fig. 21.3).
k rrss
± 3 mm. The medial sesamoid is elliptic, whereas the lateral one is more circular
e e
o o
o o k o o o k
• The sesamoid bones are contained within the tendons of the flexor hallucis brevis
o o o
eebb ee e
and form a portion of the plantar plate.
/ / b
e b ee/ e
/
• The plantar plate is the continuation of the flexor hallucis brevis tendon and connects
b
e b
: / / t
/ m
.t.m
the sesamoid bones to the plantar aspect of the distal phalanx.
: / / t
/ m
.t.m
t ss:
p / t p ss:
p /
• There is an articulation between the dorsal facet of the sesamoids and the plantar
p
facet of the metatarsal head. A crista divides this surface into two parts and provides
t
hht t
intrinsic stability to the complex. t
hht t
• The flexor hallucis longus tendon runs between the sesamoids but has no connec-
tion to them.
• The abductor and adductor hallucis tendons have fibrous insertions into the medial
k e r
e s
rs
and lateral sesamoids, respectively.
k eers
rs
• The deep transverse metatarsal ligament attaches to the lateral sesamoid.
o o
o o k oo k
• The blood supply to the sesamoids is tenuous and variable. Mostly, the perfu-
o o oo
eebb distal part.
ee / b
e b
sion enters from the proximal part, leading to a more tenuous blood supply of the
/ e ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
• First and second digital nerves run close to the outer side of the medial and lateral
sesamoids.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
168 hht
PROCEDURE 21 Internal Fixation of the Sesamoid Bone of the Hallux hht
Flexor hallucis longus
k e r
e s
rs Medial
phalangeosesamoid
k eers
r
Proximals
o o
o o k ligament
oooo k
phalanx
o o
eebb Sesamoids
ee/ e
/ebb Plantar plate
ee/ e
/ b
e b
: / / t
/ .
t m
. m Lateral
: / / t
/ .
t m
. m
Medial
metatarsosesamoid
t p ss
p : / phalangeo-
sesamoid
t p ss
p : /
ligament
t
hht t ligament
t
hht
Intersesamoid
t
First metatarsal ligament
Lateral
Medial flexor
k eers
rs hallucis brevis
k er
ers
metatarso-
s
sesamoid
ligament
b ooook b ooook
Lateral
b o o
eeb ee/ e
/ e b flexor hallucis
brevis
ee/ e
/ e b

: // t/.tm
.
FIG. 21.3
m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t FIG. 21.4
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e
FIG. 21.5
k eerrss FIG. 21.6
o o
o o k POSITIONING o o o
o k o o
eebb POSITIONING PITFALLS
• Fixation of the leg to the operation table will
ee/ e
/ b
e b ee/ e
/ b
e b
• Supine position of the patient is suitable for isolated sesamoid bone fixation and
: / / t
/ m
.t.m
not allow fluoroscopy to be performed properly
: / / t
combined deformity corrections.
/ m
.t.m
during surgery.
t p ss:
p / t p ss:
p /
• A bump under the ipsilateral hip may be helpful to prevent external rotation of the leg.
• A tourniquet is needed except for percutaneous fixation of the sesamoid bone.
POSITIONING EQUIPMENT t
hht t PORTALS/EXPOSURES
t
hht t
• Image intensifier with draping for sterile use • The surgical approach to internal sesamoid fixation depends on the concomitant
morbidities
k e r s
rs
e e rs
• Percutaneous screw fixation
rs
• Acute or chronic lateral or medial sesamoid fractures without comorbidities (Fig. 21.4)
k e
o o
o o k
• Strapping of the great toe in maximal
o o
oo k
• Open approach via medial internervous skin incision over the first metatarsophalan-
oo
eebb b b
dorsiflexion is performed by several authors to
stabilize the sesamoids and render them more
superficial. ee/ e
/ e b geal joint
e /e/e b
• Chronic medial sesamoid fracture combined with hallux valgus
e
: / / t
/ .
tm.m : / / t
/.tm
. m
• Chronic medial sesamoid stress fracture with metatarsus primus flexus
t p ss
p : / t p ss : /
• Expansion of the open approach to an L-shaped incision
• Bilateral sesamoid fracture dislocation
p
t
hht t t
hht t
• Turf toe: tear to the capsular–ligamentous–sesamoid complex (Figs. 21.5 and 21.6)
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 21 Internal Fixation of the Sesamoid Bone of the Hallux 169
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b oooo k
b o
FIG. 21.8
o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 21.7
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hh tt FIG. 21.9
k rrss
PROCEDURE
e e k e rrss
e
STEP 2 PEARLS
o o
o k
Step 1
o o o
o o k • If an open approach is used because of the
o ocomorbidities, the screw can also be inserted
eebb superficial (Fig. 21.7).

ee e
/ b
e b
• The great toe is dorsiflexed to stabilize the sesamoids and to render them more
/ ee/ e
/ b
e b over a guidewire through arthrotomy.
: / / t
/ m
.t.m
• A stab incision is made over the distal part of the affected sesamoid.
: / / t
/ m
.t.m
t ss:
p /
• The soft tissues are divided bluntly by a clamp.
p t p ss:
p / STEP 4 PITFALLS
Step 2 t
hht t t
hht t
• A guidewire is inserted under radiologic control into the axial and lateral mid-
• The inserted screw should engage the
proximal and distal cortices to enhance
stability of the osteosynthesis.
diameter of the sesamoid perpendicular to the fracture line and subchondral to the
sesamoid joint line (Fig. 21.8).
r
Step 3
k e e s
rs k eers
rs STEP 4 INSTRUMENTATION/
IMPLANTATION
o o
o o k o o
oo k
• Insert a second guidewire of the same length through the same incision positioned
oo
• An appropriate screw is, for example, a
eebb at the distal cortex of the sesamoid.
ee/ e
/ b
e b e /e/
• Compare the protruding length of the wires and select the appropriate screw length.
e ebb 2.5-mm cannulated self-drilling/tapping
compression screw (In2bones, Écully, France).
Step 4
: / / t
/ .
tm.m : / / t
/.tm
. m • For this screw, a 0.8-mm guidewire has to be
inserted.
t p ss
p : / t p ss : /
• Insert an appropriate self-drilling/tapping headless cannulated compression screw
p
• The usual length of the screw is between 12
(Fig. 21.9).
t
hht t t
hht t and 16 mm.
t t p
t ss:
p t t p
t ss:
p
170 hht
PROCEDURE 21 Internal Fixation of the Sesamoid Bone of the Hallux hht
Step 5
k e r
e s
rs k eers
r s
• Close the stab incision with a Steri-Strip (3M Schweiz GmbH, Rüschlikon, Switzerland).
• In case of an additional deformity correction with an open approach, perform the
o o
o o k o oo k
wound closure as described in Procedure.
o o o
eebb ee e
/ebb ee/ e
/ b
e b
• Apply a compression dressing in neutral hallux position.
/
: / / t
/ t m
POSTOPERATIVE
. . m CARE AND EXPECTED OUTCOMES
: / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
• Postoperative care for isolated percutaneous screw fixation:
• Allow full weight bearing using a shoe with a stiff and convex sole for 6 weeks.
t
hht t t
hht t
• No active and passive dorsiflexion of the first metatarsophalangeal joint for 6 weeks.
• Clinical and radiologic follow-up at 6 weeks postoperatively is recommended.
• Full weight bearing in normal shoes after 6 weeks is recommended.
• Return to full athletic activity is not recommended before 8–12 weeks after surgery.
A
k eers
rs k er
ers
• Postoperative care for screw fixation in combination with deformity correction is dic-
s
tated by the deformity correction procedure.
b ooook b ooook
• Blundell and colleagues (2002) fixed nine sesamoid fractures in athletes with percu-
b o o
eeb ee/ e
/ e b e / e
/ e b
taneous cannulated screws and revealed excellent results.
• Pagenstert and colleagues (2006) performed screw fixation in eight athletes and su-
e
: // t/.tm
. m : / /t/.tm. m
ture fixation with grafting in two nonathletes and reported excellent results. Clinical
t p ss
p : / tp ss : /
healing was documented with pedobarography (Fig. 21.10). Osseous healing was
proved by a computed tomography scan in three cases (Fig. 21.11).
p
t
hht t t
hht t
• Postoperative persistent sesamoid pain may be caused by
• Unrecognized foot deformity and continuous stress to the hallux sesamoids
• Development of an arthritis
• Avascular necrosis
• Screw irritation
keerrss keerrss
• In these cases, a focused therapy such as deformity correction or screw removal can
b ooook
B
EVIDENCE b o ook
prevent the sesamoidectomy as definite treatment for persistent sesamoid pain.
o b oo
eeb
FIG. 21.10
ee/e/e b ee/e/e b
: / / t
/ m
.t.m
1997;18:293–6.
: / / / m
.t.m
Anderson RB, McBryde Jr AM. Autogenous bone grafting of hallux sesamoid nonunions. Foot Ankle Int
t
This study describes the authors’ technique to repair painful fracture nonunions without the use
t
hhtt t
of internal fixation material. It includes the results of 21 athletes with an average follow-up of 4.6
hhtt
years. In two cases, union was not achieved because of hypermobility at the fracture site. These
sesamoids were excised. All athletes went back to activity. (Level IV evidence [case series])
Anglen J. The clinical use of bone stimulators. J South Orthop Assoc 2003;12:46–54.
This article is a review of the clinical literature regarding treatment of long bone nonunion with bone
stimulators.
k e rrss
e rrss
Aper RL, Saltzman CL, Brown TD. The effect of hallux sesamoid excision on the flexor hallucis longus
e
moment arm. Clin Orthop Relat Res 1996;325:209–17.
k e
o o
o o k o o
o o k
This is a biomechanical cadaver study including 12 feet. Decreased moment arm of the flexor hal-
o o
eebb b b
lucis longus was noted with excision of one or both sesamoid bones.
/ e e b / e e b
Biedert R, Hintermann B. Stress fractures of the medial great toe sesamoids in athletes. Foot Ankle Int
ee /
2003;24:137–41.
ee /
: / / t
/ m
.t.m : / / t
/ m
.t.m
This study presents the authors’ technique of proximal sesamoid pole excision in painful sesa-
t p ss:
p / t p ss:
p /
moid nonunions. It includes the results of six patients with an average follow-up of 4.2 years. Five
athletes returned to previous activity. (Level IV evidence [case series])
FIG. 21.11
t
h ht t t
hht t
Blundell CM, Nicholson P, Blackney MW. Percutaneous screw fixation for fractures of the sesamoid
bones of the hallux. J Bone Joint Surg Br 2002;84:1138–41.
This study describes the authors’ technique to repair painful bipartite sesamoid conditions (frac-
tures, nonunions) with the use of a self-tapping cannulated compression screw. It includes the
results of nine athletes. All athletes went back to previous activity. (Level IV evidence [case series])
Inge GAL, Ferguson AB. Surgery of sesamoid bones of the great toe. Arch Surg 1933;27:466–89.
k e r
e s
rs k eers
rs
This is a retrospective radiographic study including 1025 radiographs of consecutive feet. Inci-
dence, anatomy, epidemiology, and development of bipartite and multipartite sesamoid bones of
o o
o o k oo k
the hallux were studied. (Level II evidence [prognostic study])
o o oo
eebb b b
Pagenstert GI, Valderrabano V, Hintermann B. Medial sesamoid nonunion combined with hallux valgus
ee/ e
/ e b /
in athletes. Foot Ankle Int 2006;27:135–40.
ee e/e b
This study reports the authors’ technique of combined surgical treatment of hallux valgus and
: / / t
/ .
tm.m : / / t. m
. m
chronic sesamoid fracture in professional athletes. It includes the results of two athletes. Full ath-
/ t
t p ss
p : / t p ss
p : /
letic activity was reported after 10 and 12 weeks. (Level IV evidence [case series])
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
e r s
rs SECTION
r s
r s PART II
III
o o
o
k
o k e okkee
oo o o o
eebb ee/ e
/ebb ee/ e
/ b
e b
/ / t .
t m
. m / / t .
t m
. m
t
hhtt p
t ss
p
: : / /
tMidfoot
hhtt p
t ss
p
: : / /
k eers
rs PROCEDURE 22
k errss
pen Reduction and Internal Fixation of Lisfranc/
O
e
b ooook b ooook
Tarsometatarsal Injuries 172
b o o
eeb / e
/
PROCEDURE 23
ee e b ee/ e
/ e b
pen Reduction and Internal Fixation of Navicular
O
: // t/.tm
. m : / / /.
and Cuboid Fractures 180
t tm. m
t p ss
p : /PROCEDURE 24 O
tp pss : /
pen Reduction and Internal Fixation of Proximal
t
hht t t
hht t
Fifth Metatarsal (Jones or Stress) Fracture 189
PROCEDURE 25 Mueller-Weiss Treated With Limited Fusion 196
PROCEDURE 26 Mueller-Weiss Treated With Pan-Navicular
keerrss keerrs
Fusion 210
s
b ooook PROCEDURE 27
b ooook
Charcot Neuropathy of the Midfoot 216
b oo
eeb /e
PROCEDURE 28
ee /e b ee/e/e b
ainful Accessory Navicular: Augmented Kidner
P
Procedure With Flexor Digitorum Longus
: / / t
/ m
.t.m Transfer 229
: / / t
/ m
.t.m
t
hhtt
PROCEDURE 29
t
ainful Accessory Navicular Treated With Fusion
P
hhtt
of the Synchondrosis 237
PROCEDURE 30 Posterior Tibial Tendon Dysfunction 243
PROCEDURE 31 pring Ligament Repair With Suture Tape
S
k e rrss
e e rrss
Augmentation 253
k e
o o
o o k PROCEDURE 32
o o
o
T o k o o
he Z-Shaped Elongating and Varisizing Osteotomy
eebb ee/ e
/ b
e b ee/ e
/ b
e b
(ZEVO) Calcaneal Osteotomy for Pes Plano Abducto
: / / t
/ m
.t.m Valgus 257
: / / t
/ m
.t.m
t p ss:
p /PROCEDURE 33
t p ss:
p /
L ateral Calcaneal Lengthening Osteotomy for
t
hht t t
hht t
Supple Adult Flatfoot 264
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t 171
t t p
t ss:
p t t p
t ss:
p
hh22
PROCEDURE
t hht
Open rssReduction and Internal Fixation
rs s of
o k ee r
Lisfranc/Tarsometatarsal
k k ee
Injuries
o k r
b o
Andrew K. Sands and Michaelt.P.m
ee /e m ee / e
: / ///t . m
Swords
: / /
/ t
/ .
t . m
s
tps : ss :
hhtttp
t
hhtt p
t p
• Displaced injuries lead to midfoot arthritis and • Lisfranc/tarsometatarsal (TMT) injuries with instability and displacement
k eers
often require later reconstruction with midfoot
rs
fusion.
k er
erss
TREATMENT OPTIONS
b ooook b ooook
• There is often an associated equinus contracture with this injury pattern, requiring
b o o
eeb INDICATIONS CONTROVERSIES
ee/ e
/ e b e / e
/ e b
a calf lengthening at the time of open reduction and internal fixation (ORIF). It is
thought that performing a calf lengthening at this time helps prevent degeneration in
e
: // t/ tm
• ORIF versus immediate fusion. In the cervical
. .
spine, if one is treating a purely ligamentous
m the midfoot.
: / /t/.tm. m
t p ss
p :
C1–C2 injury, immediate fusion would be
/
advocated. Similarly, purely ligamentous injuries
tp ss : /
• Newer ideas on treatment include immediate fusion in the case of pure ligamen-
tous injuries. The technique, approach, choice of implant and screw pattern, and
p
t
hht t
to the midfoot are treated with immediate
fusion. Conversely, fractures/avulsions will heal
t
hht t
technique are the same. The joint surfaces are prepared for fusion instead of pure
ORIF.
better when treated with ORIF. • In the case of a nondisplaced injury, closed cast or controlled ankle movement (CAM)
walker treatment (strict non–weight bearing) can be tried as long as the patient is
warned that future fusion may be more likely.
ke rs
TREATMENT OPTIONS
r s
CONTROVERSIES
e keerrss
EXAMINATION/IMAGING
b ooook
• Associated fracture of the plantar base of the
second metatarsal (2MT) has been reported.
b ooook b oo
• On examination, the patient will report severe pain, worse than for a typical twisting
eeb • Before the midfoot is reduced, some advocate
ORIF of the 2MT base. Others believe that the
ee/e/e b ee/e/e b
injury. There will be midfoot swelling and ecchymosis (often with a plantar medial
/ t m
.t.m
bony injury will be adequately reduced and will
: / /
pattern).
/ / t
/ m
.t.m
• Plain radiographs are usually obtained.
:
t pp : /
allow bony healing without specific ORIF.
ss t ppss : /
• Anteroposterior, oblique, and lateral views with weight bearing are obtained as
t
hhtt t
hhtt
tolerated.
• On the anteroposterior view, the first TMT (1TMT) and second TMT (2TMT) joints
are assessed for alignment and displacement. There is often a gap between the
bases of the first metatarsal (1MT) and 2MT (Fig. 22.1).
• The third TMT (3TMT) can be best viewed on the oblique view. It should line up
k e rrss
e k e rrss
with the lateral cuneiform (Fig. 22.2). The fourth MT (4MT) and fifth MT (5MT)
e
o o
o o k o o
o o k bases are also viewed. The 4MT should line up with the cuboid border in this
view.
o o
eebb ee/ e
/ b
e
b ee/ e b
e b
• On the lateral view, dorsal displacement at the TMT can be seen, indicating a
/
higher energy pattern (Fig. 22.3).
: / / t
/ m
.t.m : / / t m
.t.m
• Intertarsal injuries and displacement should also be looked for. If they exist, they
/
t p ss:
p / t p ss:
p /
should be addressed first.
t
hht t t
hht t
• Stress view is taken.
• Obtaining this view is painful and should be done under an ankle block in the
operating room before ORIF.
• The heel can be grasped with the contralateral hand and the forefoot with the
ipsilateral hand. A gentle valgus stress can be applied (Fig. 22.4).
k e r
e s
rs
k eers
rs
• In a typical homolateral pattern, the midfoot will displace (under radiograph
views for documentation).
o o
o o k o oo k
• Computed tomography may be useful.
o oo
eebb ee/ e
/ b
e

b ee/e/ebb
• Can be helpful in assessing other associated tarsal injuries
• Also provides good bony resolution
: / / t
/ .
tm.m t. m
. m
• Magnetic resonance imaging (MRI) is useful in nondisplaced, purely ligamentous
: / / / t
t p ss
p : / t p ss
p : /
injuries (Fig. 22.5).
172 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 22 Open Reduction and Internal Fixation of Lisfranc/Tarsometatarsal Injuries 173
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
1TMT lateral
k eers
rs
disruption displaced
k er
erss
b ooook 2TMT lateral
displaced
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t Oblique - 2TMT and 3TMT
are slightly lateral displaced
FIG. 22.1 FIG. 22.2
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs Intraoperative fluoroscopy valgus stress at forefoot
lateral displacement becomes obvious.
o o
o o k
FIG. 22.3
o o
oo k
oo FIG. 22.4
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
174 hht
PROCEDURE 22 Open Reduction and Internal Fixation of Lisfranc/Tarsometatarsal Injuries hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
B
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t C
A
FIG. 22.5
keerrss keerrss
SURGICAL ANATOMY
• The main stabilizer of the midfoot is the plantar ligament, which goes from the plantar

base of the medial cuneiform to the plantar medial base of the 2MT. The amount of
: / / t
/ m
.t.m : / / t m
force required to disrupt this ligament is considerable. However, the dorsal ligaments
.t.m
are not as strong and can be disrupted more easily. If ORIF is performed, it is often
/
possible to repair these dorsal ligaments at the time of closure for added stability.
t
hhtt t
hhtt
• Because there is essentially no soft tissue on the dorsum of the foot, care must be
taken with the approach. Double dorsal incisions allow access to every area needed.
Healing is without problem unless the area between the incisions is violated. The
dorsal flap between the incisions is protected by the dorsalis pedis artery.
k rrss
e e k e rrss
PORTALS/EXPOSURES
e
o o
o k
• Take care to protect the dorsalis pedis artery in
o the central area between the incisions. If it is
o o
o o k
Dorsomedial
o o
eebb disrupted, the entire dorsal flap of the foot can
become necrotic.
ee/ e
/ b
e b ee/ e
/ b
e b
• The incision is placed over the 1MT and centered over the TMT area (Fig. 22.6). The
incision is deepened between the extensor halluces longus and extensor halluces
: / / t
/ m
.t.m brevis tendons.
: / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• The capsule over the 1TMT as well as the periosteum is incised and reflected, although
it is frequently disrupted by the injury. Closure of this layer later can help with healing.
PORTALS/EXPOSURES
t
hht t t
hht t
• The subperiosteal dissection is carried medially and laterally, taking care to avoid the
communicating branch of the dorsalis pedis artery as it goes plantar between the
CONTROVERSIES 1MT and 2MT.
• A common approach used in Europe that is • This allows access to the 1TMT and the medial half of the 2TMT (Fig. 22.7).
not as popular in North America is the straight
k e r s
rs
incision from the base of the second toe,
e r
Dorsolateral
k ee s
rs
o o
o o kstraight up the foot, across the ankle, and up
the anterolateral leg, if needed. This approach
oo k
• The incision is placed over the 4MT, also centered over the TMT area. Attempts
o o oo
eebb is especially useful in limb-sparing procedures
for injuries resulting from massive trauma. The
ee/ e
/ b
e b (see Fig. 22.6).
ee/ /ebb
should be made to maintain as wide a bridge as possible between the two incisions
e
/ / t tm
soft tissue on the top of the foot can be shifted
.
medially and laterally to allow access to the
: / .m : / / t
/.tm
. m
• The incision is deepened through the extensor digitorum brevis, and the extensor
entire midfoot.
t p ss
p : / t p ss : /
digitorum communis tendons are retracted. The lateral half of the 2TMT, as well as
the 3TMT and fourth TMT (4TMT), is now visible.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Dorso-medial along axis of medial column/1MT
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Disrupted 1TMT
joint
k eers
rs k er
erss
2TMT
joint
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t A
t
hht t B
Dorso-lateral along 4th MT shaft
FIG. 22.6 FIG. 22.7
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt 1 MT head
t
hhtt
Axis of the 1st
MT with the
k e rrss
e
1st TMT joint
Medial utility
k e rrss
e
o o
o o k incision
o o
o o k o o
eebb Area of medial
cuneiform
ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m
Navicular
: / / t
/ m
.t.m
t p p /
prominence
ss: t p ss:
p /
t
hht t
Medial malleolus
t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k FIG. 22.8
oo
eebb Medial ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
base of the 2MT (Fig. 22.8).
p : / t p ss
p : /
• A small incision is made to allow screw placement from the medial incision to the
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
176 hht
STEP 1 PEARLS PROCEDURE: DUAL DORSAL APPROACH
k e r
e ss
• Despite many techniques, there is one constant:
r
perfect anatomic reduction. This gives the best
k eers
r s
Step 1: Reduction of Base of 2TMT Fracture
o o
o o kresult and helps prevent future arthritis.
oooo k
• After the approach is made, work back and forth to clear out the joints. Remove any
o o
eebb ee/ e
/ebb e / e
/ b
e b
flakes or pieces impeding perfect anatomic reduction.
• Address any intertarsal instability by reduction and using Kirschner wires (K-wires).
e
: / / t
/ .
t m
. m : / / / .
t m
. m
Screws can be placed transversely but should be aimed over the transverse arch so
t
• Percutaneous versus ORIF: because the
p ss : /
main principle in treating this injury is perfect
t p t p ss : /
as not to injure the neurovascular structures.
• Reduce the base of the 2TMT into the keystone at the lateral TMT area.
p
t
hht t
anatomic reduction (thought to decrease
subsequent arthritic degeneration), it is
imperative that ORIF with direct visualization
t
hht t
• Hold the reduction with a Weber clamp placed from the lateral base of the 2MT
to the medial surface of the medial cuneiform (Fig. 22.9). Gently apply reduction
be done. Percutaneous cannulated screws are pressure to bring the keystone into correct reduction.
not adequate to make sure this is achieved. • Place a 4.0-mm solid cortical fully threaded screw from the medial cuneiform to
the base of the 2MT by drilling, using a 4.0-mm drill bit through the medial cunei-
k eers
rs k er
erss
form. Then use the 2.5-mm drill bit through the base of the 2MT (Figs. 22.9B and
b ooook
STEP 2 PEARLS
• Pocket hole: why and how to make it. Just as
b ooook Fig. 22.10). Use the ligament aiming guide if assistance is needed in aiming the
b o o
screw direction. Gently tighten the lag screw, reducing the base of the 2MT.
eeb in building a bookcase, if one is butt-joining
two surfaces, the pocket hole is used to
ee/ e
/ e b ee/ e
/ e b
Step 2: Reduction of 1TMT With Internal Fixation
/ t . m
.
prevent breakout at the joint. If there is no
: / / t m : / /t/.tm. m
• Reduce the 1TMT and place two K-wires from the base of the 1MT into the medial
t p : /
pocket hole, the screw head would engage
ss
the bottom and a dorsal torque would cause
p tp ss : /
cuneiform. Place the wires wide enough so as not to interfere with the screw.
p
t
hht t
breakout and loss of fixation. Use the 6-mm
round burr to make a “ramp” for the screw
head to come down as it engages the base of
t
hht t
• Use the 8-mm round burr to make a pocket hole 2 cm from the base of the 1MT
(Fig. 22.11). Drill 4.0 mm, then 2.5 mm, and then place a lag screw from the base
of the 1MT into the plantar medial aspect of the medial cuneiform (Fig. 22.12).
the MT (see Fig. 22.9B–C).
• If more stability is needed, a lag screw can also be placed from the dorso-medial
cuneiform to the plantar base of the 1MT.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
A
e s
rs B
k eers
rs C
o o
o o k o
ooo k FIG. 22.9
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht Base of 2nd
hht
metatarsal
Talus
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
A
1st metatarsal
: / / t
/ .
t m
. m
Medial
: / / t
/ .
t m
. m
t p ss
p : / cuneiform Navicular
t p ss
p : /
Pocket hole t
hht t 2cm
t
hht t
4.0 2.5
k eers
rs k er
erss
b ooook 1st metatarsal Medial
oo
cuneiform
b ook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
B No pockethole, bone breaks
FIG. 22.10 FIG. 22.11
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t pps
long
s : / t ppss : /
t
hhtt2.5 mm
drill bit t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m 1TMT reduced
: / / t
/ m
.t.m
and provisionally
t p ss:
p / t p ss:
p /
held with K-wires
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm. m : / / t
/.tm
. m
t p ss
p : / FIG. 22.12
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
178 hht
STEP 3 PEARLS
k e r
e ss
• Why long drill bits? Because the angle of the
r
drilling is very flat (so the screw goes into the
k eers
r s
o o
o o kcuneiforms and does not miss by being too
oooo k o o
eebb plantar), the bit must be long. If a short bit is
used, the chuck will grind into the toes. The long
ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ t m
bit allows the chuck to be distal to the toes.
. . m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
• Starting point: 1TMT versus 2MT base. While
not as important as a perfect reduction, some
k ee s
think that the starting point is not the base
rrs
of the 2MT being pulled into the keystone
er
kkerss FIG. 22.13
b ooook but rather the 1TMT injury being reduced.

This leads to a reduced and stabilized medial
b oooo b o o
eeb column from which the reduction of the other
joints can be based around.
ee/ e
/ e b ee/ e
/ e b
• ORIF of the 4MT and 5MT may be needed.
• Percutaneous K-wire is adequate for
: // t/.tm
. m : / /t/.tm. m
ss : /
stabilization of the 4TMT and fifth TMT (5TMT),
t p p tp pss : /
t t
and it makes for easier removal. Another
hht
option (used more in Europe) is screw fixation
of the 4TMT and 5TMT.
t
hht t
keerrss keerrss
b ooook
IMPLANTATION
b ooook b oo
eeb • Dental instrument
e
• Pointed reduction (Weber) clamps: big and small
e/e/e b ee/e/e b
• Aiming guide (ACL)
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Long drill bits
• 6-mm round burr
• K-wires
t
hhtt h
t
htt FIG. 22.14
Step 3: Reduction of 3TMT, 4TMT, and 5TMT
rrss rrss
STEP 4 CONTROVERSIES • Now working through the lateral incision, reduce the 3TMT and insert a K-wire. Drill
o k e e
• Lag screws versus nonlag screw technique:
k o k e e
4.0/2.5 mm and place a lag screw from the base of the third MT (3MT) into the mid-
k
o
eebb o o Lag screws compress across the joint. This
could damage the articular surface and
e b o
b o o e b o
foot (either the middle or lateral cuneiform; Fig. 22.13).
b o
• The 4MT and 5MT usually come medial with the 3MT. If not, reduce them using the den-
perhaps cause fusion. The nonlag screw
technique can have a distracting effect if not
m ee/ / e ee/ / e
tal tool. Fixation can be accomplished with K-wires, one or two as needed (Fig. 22.14).
m
: /
/ t
/ .t.m
done properly, leaving the joints malpositioned.
/ : / /
/ t
/ .t.m
Step 4: Closure and Technique Summary
t p ss:
As these are (for the most part) nonmobile
joints, and because any motion is atavistic,
t t p t t p
t ss:
p
• Close the periosteum and joint capsule layer if they are present and not too badly
hht
loss of motion is not a negative and may yield
more stability to the reconstruction.
• Solid versus cannulated screws: The thought
hht
shredded by the injury. This will help healing.
• Because there is no subcutaneous layer in the foot, extensive closure can lead to
is that cannulated screws are easier to place. nerve injury. A few 2-0 simple stitches are placed to draw the skin edges together
While this may be true initially, if one takes a and reduce tension. The skin should then be closed using an absorbable suture in a
bit of time to practice placing screws in this
k e r s
rs
area, one finds that the proper placement
e k eers
running, everting tension-relieving mattress stitch.
rs
o o
o o kof screws is not difficult. Then, the use of
cannulated screws is not needed. This is
o o
oo k
Technique Summary
oo
eebb an advantage as cannulated screws are far
weaker (especially in resisting bending forces)
ee/ e
/ b
e b
• Starting point: 2MT into keystone
e /e/ebb
• Screw and technique: solid 4.0-mm fully threaded large core/small-head (cortical)
e
and more expensive than solid screws.
/ / t
• In more comminuted fractures, dorsal bridge
: / .
tm.m screw and lag technique
: / / t
/.tm
. m
plating can also be considered.
t p ss
p : / t p ss : /
• Plates can offer better stability and a higher fusion rate but at an increased cost
• Plates are also useful for bridging MT base fractures
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
POSTOPERATIVE CARE AND EXPECTED OUTCOMES POSTOPERATIVE CONTROVERSIES
k e r
e ss k eers
r s
• For 2 weeks, the patient is kept non–weight bearing in a three-sided splint with the
r
ankle in neutral, especially if calf lengthening has been performed.
• Removal of hardware: what and when? When
3.5-mm screws were used, there was much
o o
o o k o oo k
• Then for 4–6 weeks, a CAM walker boot with a nighttime ankle L-shaped splint at
o o o
more incidence of screw breakage if they
eebb / e bb /
90° is used, still with strict non–weight bearing. In addition, the patient should begin
ee /e
range-of-motion exercises (hyperflexion range of motion and biomechanical ankle
ee e
/ b
e b were left in place. Since the advent of 4.0-mm
solid screws, with the associated increased
: / / t . m
. m
platform system, ankle range of motion, complex range of motion).
/ t : / / t
/ .
t m
. m
resistance to bending failure, the incidence of
screw failure in areas such as the midfoot, in
ss : / ss : /
• After 6–8 weeks, if follow-up radiographs are satisfactory, the K-wires are pulled. The
t p p t p p
particular, has markedly decreased. In light of
this, 1TMT, 2TMT, and 3TMT screws can be
t t
a visco-cushioned sole “running sneakers.”
t
hht t
patient may then begin weight bearing in a CAM walker with cane assistance outside
hht
the home and barefoot weight bearing inside the home. The patient is also fitted for
left in place and never routinely removed.
• The K-wire across the 4TMT and 5TMT should
be removed at 8 weeks, as some motion at
• After 8–10 weeks, if radiographs are still satisfactory, the patient may begin full this area is desirable. In cases in which screws
weight bearing in sneakers and orthotics and progress to formal physical therapy. are placed across the 4TMT and 5TMT, these
rs
rs
EVIDENCE
k ee k er
erss
screws are removed at 8 weeks. Sometimes
Europeans also remove all the TMT screws
b ooook b ooook b o
Alberta FG, Aronow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ. Ligamentous Lisfranc joint
o
at 8 weeks. However, this can lead to loss of
fixation and redisplacement.
eeb 2005;26:462–73.
ee/ e
/ e b ee/ e
/ e b
injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int
: // t tm
. m : / /t tm
This study evaluates 10 matched pairs of cadaveric lower limbs to assess the biomechanical com-
. . . m
parison of dorsal plate versus transarticular screw fixation. Measurements were made in the loaded
/ /
ss : /
and unloaded conditions (Level V evidence [cadaveric study]).
t p p tp pss : /
t
hht t
Coetzee JC, Ly TV. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis com-
t hht t
pared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg
Am 2006;88:514–20.
This prospective study evaluates 41 patients randomized to either ORIF of Lisfranc injuries or
primary arthrodesis. Follow-up averaged 42.5 months. Outcome was determined by American Or-
thopedic Foot and Ankle Society (AOFAS) scores, visual analog pain scale, and a clinical question-
kee rs
naire (Level I evidence [randomized controlled trial]).
r s keerrss
Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation
b ooook2009;30:913–22.
b ooook
versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int
b oo
eeb ee/e/e b ee/e
Prospective randomized trial of 40 patients receiving primary arthrodesis versus primary open
/e b
reduction internal fixation. Functional results along with subsequent surgical procedures were com-
: / / m
.t.m : / / / m
.t.m
pared between the two groups (Level I evidence [prospective, randomized controlled trial]).
/ t t
Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of Lis-
ss : /
franc joint injuries. J Bone Joint Surg Am 2000;82:1609–18.
t pp t ppss : /
t
hhtt t
hhtt
This study is a retrospective review of 48 patients treated with open reduction and screw fixation.
Follow-up averaged 52 months. Outcome was determined by AOFAS and Musculoskeletal Func-
tional Assessment scores (Level IV evidence [case series]).
Lee C, Birkedal JP, Dickerson EA, Vieta P, Web LX, Teasdall RD. Stabilization of Lisfranc joint injuries: a
biomechanical study. Foot Ankle Int 2004;25:365–70.
This study examined 10 matched-pair cadaveric limbs to assess the average stiffness of cortical
k rrss
e k rrss
screw fixation versus K-wire fixation (Level V evidence [cadaveric study]).
e e e
Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfranc injuries: primary arthrodesis or ORIF?
o o
o o k
Foot Ankle Int 2002;23:902–5.
o o
o o k o o
eebb b b
This study is a retrospective review of 28 patients treated with ORIF or with complete arthrodesis.
/ e e b
Follow-up averaged 30.1 months. Outcome was determined by the Baltimore Painful Foot Score
(Level III evidence [case cohort]).
ee / ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
Raikin SM, Elias I, Sachin D, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in
p ss:
J Bone Joint Surg Am 2009;91:892–9.
t p / t p ss:
p /
the subtle Lisfranc injury: comparison of magnetic resonance imaging with intraoperative findings.
t
hht t t
hht t
This study is a retrospective review of 21 feet in 20 patients, who were evaluated with MRI and
subsequently underwent stress radiography under anesthesia, and when indicated, operative
fixation. Results of MRI findings were compared with intraoperative findings (Level II evidence
[retrospective review]).
Richter M, Wippermann B, Krettek C, Schratt HE, Hufner T, Thermann H. Fractures and fracture dislo-
cations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001;22:392–8.
k r s
rs rs
rs
This study is a retrospective review of 155 patients with midfoot fractures treated either nonopera-
e e k ee
tively or with open reduction. Follow-up averaged 9 years for 97 patients. Outcome was deter-
o o
o o k o oo k
mined by AOFAS, AOFAS-Midfoot, Hannover Scoring system, and Hannover Questionnaire scores
o oo
eebb b b bb
(Level III evidence [retrospective cohort]).
ee/ e
/ e e /e/e
Teng AL, Pinzur MS, Lomasney L, Mahoney L, Havey R. Functional outcome following anatomic resto-
e
: / / t
/ tm
ration of tarsal-metatarsal fracture dislocation. Foot Ankle Int 2002;23:922–6.
. .m : / / t
/.tm
. m
This study is a retrospective review of 11 patients treated operatively. Follow-up averaged 41.2
t p ss
p
(Level IV evidence [case series]). : / t p ss
p : /
months. Outcome was determined by AOFAS score, clinical alignment, and radiographic analysis
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh23
PROCEDURE
t hht
Open rssReduction and Internal Fixation
r s s of Navicular
o k
and
k r
eeCuboid Fractures o kkee r
b o
m ee /e m ee / e
: / t
John Shank and Andrew K. Sands
///t. . m : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp
t
hhtt p
t p
• Examination of the soft envelope is critical • Injuries to the talonavicular and calcaneocuboid joints (Chopart joints) are severe
k eers
to success in treating midfoot injuries. All
rs
dislocations should be treated acutely with
k errs
injuries often associated with an abduction force to the talonavicular joint and a
s
lateral compression injury to the lateral column resulting in a “nutcracker” pheno
e
b ooook particular attention given to impending skin
necrosis.
b ooookmenon.
b o o
eeb • It is important to maintain motion along the
e
cuboid/metatarsal joints, as these are essential
e/ e
/ e b e / e
/ e b
• Precise examination and imaging, including computed tomography scan, are essen
tial to defining the injury pattern and presence of articular incongruity.
e
normal foot function.
: // /.tm m
joints, and maintaining motion is critical for
t . : / /t/.tm. m
• Articular subluxation and step-off, loss of lateral column length, and the presence
ss : /
• Careful attention should be given to Chopart
t p p options.
tp pss : /
of smaller avulsion fractures need to be adequately identified to define treatment
t
hht t
injuries, as midfoot arthrosis can be
disabling, with no great salvage procedure for
cuboid-4,5 metatarsal arthrosis.
t
hht t
• Anatomic restoration of medial and lateral column anatomy is critical in obtaining
reduction of these complex injuries.
• Reduction and restoration of the articular surface of the talonavicular, naviculocunei
INDICATIONS CONTROVERSIES form, calcaneocuboid, and cuboid-4,5 metatarsal joints are essential to good outcomes.
keerrss
• The role of primary arthrodesis in the
treatment of Chopart fracture dislocations has
keerrs
EXAMINATION/IMAGING
s
b ooook not been well defined.
• Primary arthrodesis may play a role in treating
b ooook
• Obtain three-view radiographs of the injured and contralateral foot including anter
b oo
oposterior (Fig. 23.1A), oblique (Fig. 23.1B), and lateral (Fig. 23.1C). The radiographic
eeb severely comminuted injuries or severe injuries
with significant bone loss.
ee/e/e b ee/e/e b
anatomy of the uninjured extremity is critical in defining normal medial and lateral
: / / t
/ m
.t.m column anatomy.
: / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / /B
t
/ .
tm.m C
: / / t
/.tm
. m
t p ss
p : /
t p ss
FIG. 23.1
p : /
180 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 23 Open Reduction and Internal Fixation of Navicular and Cuboid Fractures 181
• Radiographs should precisely identify the anatomy of the medial column and the
k e r
e s
rs
joint incongruity.
k eers
cuboid-4,5 metatarsal junction. Poor imaging quality can miss impaction injuries and
r s
o o
o o k oo k
• Computed tomography, including 3D-reconstruction views, provides a topographi
oo o o
eebb e / e
/ebb e / e
/ b
e
luxation, degree of comminution, and presence of avulsion injuries (Fig. 23.2).
e e b
cal map detailing the injury pattern, articular impaction and displacement, joint sub
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• Magnetic resonance imaging is usually not indicated in the evaluation of Chopart
injuries.
t p ss
p : / t p ss
p : /
t
SURGICAL ANATOMY
hht t t
hht t
• The navicular articulates proximally with the talus at the talonavicular joint and serves
as a socket for the talar head, forming an essential joint that contributes up to 80%
of subtalar motion (Fig. 23.3).
• Distally, the navicular articulates with the cuneiforms at three separate articulations,
k eers
rs k er
erss
forming the nonessential naviculocuneiform joints.
b ooook b ooook
• The navicular articulates laterally with the cuboid bone.
b o o
• The cuboid articulates proximally with the calcaneus at the calcaneocuboid joint and
eeb ee/ e
/ e b
distally with the fourth and fifth metatarsals (see Fig. 23.3).
ee/ e
/ e b
navicular.
: // t/ tm
. m : / /t/ tm
• The medial surface of the cuboid articulates with the lateral cuneiform and the
. . . m
ss : / ss : /
• The plantar surface of the cuboid bone contains the peroneal sulcus, a groove
t p p tp p
t
ht t
through which the peroneal longus passes.
POSITIONING h
t
hht t
• The patient can be positioned supine with a bump placed beneath the knee and hip
to control access to the medial and lateral columns of the foot.
keerrss keerrss
• A lateral position with a foam wedge can be used when the injury is isolated to the
b ooook b ooook
lateral column or during access to the cuboid bone if the surgery is being staged.
• Lesser degrees of internal rotation are desired if a medial column injury is being
b oo
eeb treated simultaneously.
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs Cuboid bone
o o
o o k o o
oo k oo Calcaneus
Calcaneocuboid
eebb b b joint
e / e
/ e b e /e/e b
me e
A B
: / / t
/ .
tm.
FIG. 23.2
: / .m
/ t
/ t. m FIG. 23.3
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
182 hht
PROCEDURE 23 Open Reduction and Internal Fixation of Navicular and Cuboid Fractures hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
:
A
// t/.tm
. m B
: / /t/.tm. m
t p ss
p : /
ss
FIG. 23.4
tp p : /
t
hht t t
hht t
PORTALS/EXPOSURES
keerrss keerrss
• A medial utility incision can be used for navicular fractures isolated to the medial
b ooook b ooook aspect of the navicular body and navicular tuberosity. The incision is located between
b oo
the interval of the tibialis anterior and posterior tibial tendons.
• The medial approach to the navicular can be extended proximally and distally to
: / / t
/ m
.t.m / / t
/ m
allow exposure of more complex injuries.
.t.m
• A more lateral midfoot incision directed over the lateral one-third of the navicular
:
p ss /
• Staging the approach to complex midfoot
:
fracture dislocations can be critical to
t p t ppss : /
body can be used for more lateral-based injuries, lateral to the dorsal neurovas
t
hhtt
achieving a good outcome and in avoiding
complications.
• Application of a spanning external fixator
t
hhtt
cular bundle and medial to the lateral branch of the superficial peroneal nerve
(Fig. 23.4A).
• The extensor digitorum longus is retracted to expose the lateral one-third of the
can greatly assist in the treatment of these
injuries by improving soft-tissue swelling navicular (Fig. 23.4B).
and alignment and by disimpacting articular • The saphenous nerve and vessels and all branches of the superficial peroneal nerve
k e rrss
fragments.
e
• The medial column injury should be treated
k e rrss
should be protected throughout these exposures.
e
o o
o o kfirst, if the soft-tissue envelope allows.
o o
o o k
• A combination approach can be used for more complex navicular fractures.
o o
• A lateral approach is used to treat fractures of the cuboid bone, with a longitudinal
eebb ee/ e
/ b
e b ee/ e b
e b
incision placed midline within the cuboid body (Fig. 23.4C).
/
• The extensor digitorum brevis is superiosteally elevated off of the dorsolateral foot to
: / / t
/ m
.t.m : / / t m
.t.m
allow for exposure of the cuboid body (Fig. 23.4D).
/
t p ss: /
• The patient should be forewarned that the
lateral approach to the cuboid bone can
p t p ss:
p /
• The sural nerve should be carefully protected during exposure and is usually plantar
t
hht
jeopardize the sural nerve.
t
• The risk of lateral foot numbness should be
discussed with the patient preoperatively.
•
t
hht t
to the incision.
The peroneal tendons are located lateral and plantar and should be carefully
protected throughout the approach to the cuboid bone.
• This approach can be extended proximally, to allow for direct visualization of the
PORTALS/EXPOSURES EQUIPMENT calcaneocuboid joint and sinus tarsi, protecting the peroneal tendons and sural
k e r
e ss
• A headlamp, Freer Elevator (Sklar Surgical
r
Instruments, West Chester, PA), dental pick,
k eers
rs
nerve in a plantar flap.
• The exposure should allow full access to the cuboid body, from lateral to medial, with
o o
o o kand intraoperatively placed distractor can
o o
oo k o
exposure of the separate articulations of the cuboid-4,5 metatarsal joints and the
o
eebb b b
assist with reduction.
ee/ e
/ e b ee/e/e b
calcaneocuboid joint proximally (Fig. 23.4E).
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs C
k er
erss D
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ E m
.t.m : / / t
/ m
.t.m
FIG. 23.4, cont’d
t
hhtt t
hhtt
PROCEDURE
Step 1
k rrss
e k e rrss
• A bicolumnar external fixator can assist with soft-tissue swelling and reduction of the
e e
o o
o o k lateral and medial columns (Fig. 23.5).
o o
o o k
• Fracture pattern and surgeon preference can dictate whether to approach the lateral
o o
eebb ee/ e b
e b
or medial column injury first, and whether to stage the operative procedure.
/ ee
• A medial approach is made between the posterior tibial tendon and tibialis anterior/ e
/ b
e b
/ t m
.t.m
tendon to access the medial navicular body and tuberosity.
: / / : / / t
/ m
.t.m STEP 1 PEARLS
t p ss:
p / t p ss:
p /
• A second more lateral incision can be utilized lateral to the dorsal neurovascular • Cuboid bone and navicular fractures often
t
hht
complex injuries. t t
hht t
bundle and medial to the lateral branch of the superficial peroneal nerve for more
• A lateral incision is made over the cuboid bone between the extensor digitorum
lead to severe impaction of the articular
surfaces. It can be difficult to anatomically
reduce these injuries secondary to bony loss.
An attempt should be made to reconstruct
brevis and peroneal tendons. This incision can be carried proximally to the calcaneo the articular surfaces and the overall bony
cuboid joint, sinus tarsi, and subtalar joint. anatomy, to bone graft any defects, and finally
k e r
e ss k eers
rs
• A Freer Elevator and Key Elevator (Sklar Surgical Instruments) can be used to care
r fully expose the fracture site, taking care to protect the surrounding soft tissues and
to stabilize the construct with stable fixation. It
is imperative to preserve length and alignment
o o
o o k blood supply.
o o
oo k oo
of the medial and lateral columns, even if
eebb b b treatment eventually leads to arthrosis.
ee e
/ e b
• The fractures can now be examined for articular step-off and comminution.
/ ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
184 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : / B
tp pss : / C
t
hht t t
hht t FIG. 23.5
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb A
ee/ e
/ b
e b
B
FIG. 23.6
ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
Step 2
• An external fixator can be essential in treating Chopart injuries. Either unilateral
k e r
e s
rs
STEP 2 PEARLS
k eers
placement or a bicolumnar fixator can assist in reduction of the column lengths and
rs
assist with articular visualization.
o o
o o k
• Without external fixation, the plate is expected
o o
oo k
• Schanz pins (Depuy Synthes, New Brunswick, NJ) are placed in the calcaneus, the
oo
eebb to hold a crushed bone without much
structural support.
ee/ e
/ b
e b e / /ebb
first metatarsal, and the fourth/fifth metatarsal bases. External fixator bars can be
e
placed plantar to the surgical incision to allow for visualization of the navicular and
e
/ / t tm
• An intraoperatively placed distractor can assist
. .
in restoring length of the medial and lateral
: / m : / / /.tm
cuboid bone (Fig. 23.6).
t . m
columns.
t p ss
p : / t p ss : /
• A distractor can now be used to restore length of the medial and lateral columns and
to disimpact the fracture.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hhtA
t t
hht t B
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb C
ee/ e
/ b
e b D
ee/ e
/ b
e b
: / / t
/ m
.t.m FIG. 23.7
: / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
Step 3 t
hht t t
hht t
• The joint surfaces are extracted from the central crushed portion of the navicular and
cuboid bone and buttressed against adjacent joint surfaces.
• Periarticular fragments should be pinned using small Kirschner wires (K-wires), re
k e r
e s
rs k eers
ducing the articular surface under direct visualization (Fig. 23.7).
rs
• Medial and lateral distraction can be manually controlled to allow for improved visu
o o
o o k alization of the articular surface.
o o
oo k oo
eebb e / b
e b
assist with reduction of cortical fragments to achieve an anatomic reduction.
e ee/ /eb
• A Freer Elevator can be used to assess the articular reduction, and a dental pick can
/ e e b
: / / t
/ .
tm.m : / / t
/.tm
. m
• Once anatomic reduction is achieved with K-wires, the fracture void can be filled
cortices.
t p ss
p : / t p ss
p : /
with your bone graft of choice. This should be followed by reduction of the blown-out
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
186 hht hht
PROCEDURE 23 Open Reduction and Internal Fixation of Navicular and Cuboid Fractures
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m
t p ss
p : / FIG. 23.8
tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb
FIG. 23.9
ee/ e
/ b
e b
ee/ e b b
FIG. 23.10
/ e
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / Step 4
t p ss:
p /
t
hht t t
hht t
• The appropriate plate is placed around the K-wires, keeping them in place, to main
tain reduction (Fig. 23.8).
• The plate is secured with screws under fluoroscopy, as shown in Fig. 23.9.
• K-wires can be retained around smaller, unstable articular fragments, as shown in
Fig. 23.10.
k e r
e s
rs Step 5
k eers
rs
o o
o o k o o
oo k oo
eebb b b
• Final intraoperative radiographs can be obtained to assess the final reduction (Fig.
ee/ e e b
23.11).
/ ee/e/e b
: / / t
/ .
tm.m : / / t
/ tm
• A meticulous closure with modified Allgöwer–Donati sutures is performed.
. . m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b ooook
B
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : /C
t ppss : /
t
hhtt t
hhtt
FIG. 23.11
k eerrss k e rrss
e
oooo k o o
o o k o o
eebb POSTOPERATIVE CARE AND EXPECTED ee/ e
/ b
e b
OUTCOMES ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
p ss:
p / t p ss: /
• An external fixator can be kept on to assist in maintaining reduction for 6–8 weeks.
Cast coverage is encouraged in this setting to prevent an equinus deformity.
t p
•

t
hht t t
hht t
The external fixator should be removed at 6–8 weeks postoperatively with
serial radiographic images obtained to ensure reduction has been maintained
(Fig. 23.12).
• Non–weight bearing is recommended for 8–12 weeks with early emphasis on ankle
and complex hindfoot range of motion with the biomechanical ankle platform
k e r
e s
rssystem.
k eers
rs
o o
o o k o o
oo k
• After weight bearing ensues, early physical therapy can assist in preventing joint
oo
eebb b b
contracture and stiffness.
/ e e b /e
• After 3 months, the construct should be stable enough to begin progressive weight
ee / ee /e b
: / / t
/ tm
bearing in a cushioned “running sneaker” with a visco-cushioned orthotic.
. .m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
188 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
A B
FIG. 23.12
keerrss keerrss
eeb ee
EVIDENCE/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
Benirschke SK, Meinberg EG, Anderson SA, Jones CB, Cole PA. Fractures and dislocations of the
midfoot: Lisfranc and Chopart injuries. Instr Course Lect 2013;62:79–91.
t
hhtt t
hhtt
This is a book chapter detailing techniques and treatment options involved in the treatment of
Chopart fracture dislocations (instructional course lecture).
Borrelli J, De S, VanPelt M. Fractures of the cuboid. J Am Acad Orthop Surg 2012;20:472–7.
This is a journal article discussing treatment of cuboid fractures.
Cronier P, Frin JM, Steiger V, Bigorre N, Talha A. Internal fixation of complex fractures of the tarsal
navicular with locking plates. A report of 10 cases. Orthop Traumatol Surg Res 2013;99:S241–9.
k e rrss
e k rrss
This is a study describing 10 patients with navicular fractures treated with locking plate fixation
e e
over a 4-year period (Level IV evidence [case series]).
o o
o o k o o k
Evans J, Beingessner DM, Agel J, Benirschke SK. Minifragment plate fixation of high-energy navicular
o o o o
eebb b b
body fractures. Foot Ankle Int 2011;32:S485–92.
e / e e b / e e b
This study is a retrospective review of 24 patients with navicular body fractures treated opera
e / ee /
tively with minifragment plate fixation at a level I trauma center over a period of 6 years (Level IV
: / / t
/ m
.t.m evidence [case series]).
: / / t
/ m
.t.m
t p ss:
p / 1990;72:376–8.
t p ss:
p /
Sangeorzan BJ, Swiontkowski MF. Displaced fractures of the cuboid. J Bone Joint Surg Br
t
hht t t
hht t
This study is a series of four patients with cuboid bone fractures treated operatively (Level IV
evidence [case series]).
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh24
PROCEDURE
t hht
OpenrssReduction and Internal Fixation
r s s of Proximal
o k
Fifth
k r
ee Metatarsal (Jones or Stress)
o kk r
ee Fracture
b o
m ee /e m ee / e
: / /
/ /.
Mark E. Easley and James A.tNunley
t . m II
: / /
/ t
/ .
t . m
t
tttppss : t t p
t ss
p :
INDICATIONS
h h hht
• Fracture in zone II or III of the proximal fifth metatarsal (5MT; Fig. 24.1)
• Varus hindfoot alignment maintaining a
k e s
• Acute fracture in an athlete
rrs
• Delayed union
e k er
erss continued risk to 5MT overload.
b oo k
ooTREATMENT OPTIONS
b ooook b o o
eeb e / e
/ e b
• Nonoperative treatment with casting, protected weight bearing
e ee/ e
/ e b
: // /.tm m
• Intramedullary screw fixation
t . : / /t/.tm. m
t p ss : /
• External bone stimulation
• Tension band technique/plating
p tp pss : /
t
hht t
EXAMINATION/IMAGING t
hht t
• Tenderness at the base of the 5MT
• Hindfoot alignment
• Radiographs demonstrating fracture in zone II of the 5MT
keerrss keerrss
• Fracture in the base of the 5MT extending into articulation of fourth MT and 5MT bases
b ooook b oook
on anteroposterior (Fig. 24.2A), oblique (Fig. 24.2B), and lateral (Fig. 24.2C) views
o b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : /
III
t ppss : /
I
t
hhtt
II
t
hhtt
A B
rrss rrss
Tuberosity avulsion fracture
o k e
k e o
kkee
Jones’ fracture
Diaphyseal stress fracture
o
eebb o o e b o
b o o FIG. 24.1
e b o
b o
m ee/ / e m ee/ / e
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
A t
hht t B

t
hht t
FIG. 24.2
C
189
t t p
t ss:
p t t p
t ss:
p
190 hht hht
PROCEDURE 24 Open Reduction and Internal Fixation of Proximal Fifth Metatarsal (Jones or Stress) Fracture
SURGICAL ANATOMY
k e r
e s
rs k eers
r s
• There is a watershed area of relatively less perfusion in zone II of the 5MT base
(Fig. 24.3A).
o o
o o k •

o oo k o
The 5MT is a curved bone (relevant to fixation with a straight implant [screw];
o o
eebb POSITIONING PEARLS
ee/ e
/ebbFig. 24.3B).
ee/ e
/ b
e b
• At-risk structures include the peroneus brevis and longus and the sural nerve (Fig.
: / / t
/ .
• Bump under ipsilateral hip to improve access
t m
. m 24.3C).
: / / t
/ .
t m
. m
to the lateral foot.
ss : /
• Patient’s operated foot on the edge of table to
t p p POSITIONING
t p ss
p : /
t
hht t
facilitate passing instruments/implants and to
allow shifting the foot over the edge of table
for easy fluoroscopic access.
t
hht t
• Supine in a modified lateral position with the foot on the edge of the operating table
to allow easy access to the lateral foot
• Bump under the operated foot to improve • Bump/bolster under the ipsilateral hip
ability to pass instruments/implants.
• Bump/bolster under the operated foot
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t Nutrient artery
keerrss Metaphyseal
arteries
keerrss
eeb ee/e/e b “Avascular zone”
ee/e/e b
Periosteal blood supply
: / / t
/ m
.t.m A
: / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e B
k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
Peroneus
/ m
.t.m
t p ss:
p / t p ss:
p /
longus tendon
Peroneus
t
hht t t
hht t brevis tendon
k e r
e s
rs C
k eers
rs
Sural nerve
o o
o o k o o k
o o FIG. 24.3
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 24 Open Reduction and Internal Fixation of Proximal Fifth Metatarsal (Jones or Stress) Fracture 191
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B
k eers
rs
k er
erss FIG. 24.4
b oo k
ooPORTALS/EXPOSURES b oo ook b o o
eeb ee/ e
/ e b ee/ e
/ e b
• The approach is 2–4 cm proximal to the 5MT base, in line with the 5MT on the lateral
• The surgeon may wish to mark the 5MT based
on palpation to optimize the incision.
: / t/.tm
. m : / /t/.tm. m
foot (Fig. 24.4A). This approach allows optimal positioning of drill guide (Fig. 24.4B).
/
• Exposure must be adequate to place the drill
and drill guide at the superior and medial
t p ss
p : /
• Establish protection of structures at risk.
tp pss : / aspects of the 5MT base.
t
hht t t
hht t
• Identify sural nerve and carefully retract dorsally/superiorly.
• Identify peroneus brevis tendon and retract dorsally/superiorly.
• Identify peroneus longus tendon and retract plantarward/inferiorly.
• Be sure to identify the sural nerve and
peroneal tendons to ensure they are protected
PROCEDURE from the drill and implant.
ke rrss
Step 1
e keerrss STEP 1 INSTRUMENTATION
b ooook b ooook
• Optimal guide pin placement is high and inside on the proximal 5MT, without soft-
b oo • Standard blunt retractors
eeb tissue obstruction (Fig. 24.5A).
e /e/e b e /
• Guide pin placement requires verification in the 5MT intramedullary canal in anter-
e e e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
oposterior (Fig. 24.5B), oblique (Fig. 24.5C), and lateral (Fig. 24.5D) intraoperative STEP 1 PEARLS
fluoroscopic views.
t ppss : / t ppss : / • Use a high and inside (superior and medial)

starting point on the 5MT base.
Step 2 t
hhtt t
hhtt
• Determine ideal screw diameter by successively drilling and tapping with increas-
• There is no need to pass the guide pin the
full length of the 5MT; it can be passed just
enough to get the threads of the screw across
ingly greater drills and corresponding taps. the fracture site.
• The drill should pass over the guide pin (Fig. 24.6).
• The tap is introduced into the metatarsal (Fig. 24.7).
k e rrss e rrss
• Overdrill guide pin with smaller-diameter cannulated drill.
e k e
STEP 2 PITFALLS
• All three fluoroscopic views/angles must
o o
o o k o o
o k
• The ideal tap size provides proper intramedullary interference to allow adequate
o o o
be obtained to confirm that the guide pin is
eebb b b
screw purchase (Fig. 24.8).
ee/ e
/ e b ee/ e
/
• If a 4.5-mm diameter tap has purchase in the distal fragment, then that is the ideal
e b contained in the 5MT.
• The sural nerve and peroneal tendon must be
/ / t
/ m
screw; if not, go to the next greater diameter.
.t.m / /
• Most 5MTs will accommodate 5.5-mm taps, and many will require 6.5-mm taps
: : t
/ m
.t.m
protected every time an instrument or implant
is passed.
p ss:
for adequate purchase.
t p / t p ss:
p / • Advancing the screw too far and unnecessarily
into the 5MT risks gapping at the fracture
t
hht t t
hht
• A calibrated tap may aid in determining ideal screw length.
t site as a straight implant is advanced into the
curved bone.
Step 3 • The starting point must be ideal or the distal
• Based on ideal tap diameter, the screw diameter is selected. fragment’s medial cortex may be violated,
creating a stress riser.
• Screw length is determined by a calibrated tap and confirmed with a cannulated or
k e r
e s
rs noncannulated depth gauge.
k eers
rs
• Follow the guide pin with the drill to avoid
shearing the pin within the 5MT (difficult to
o o
o o k • The guide pin is removed.
o o
oo k
• Before implanting the selected screw, it may be held immediately adjacent to the
oo
retrieve).
eebb ee/ e
/ b
e b ee/e/e
bone to roughly determine if it appears appropriate, that all threads will cross thebb
fracture site, and that the screw will not need to pass excessively into the metatarsal
IMPLANTATION
/
to be fully seated (Fig. 24.9).
: / t
/ .
tm.m : / / t
/.tm
. m • Satisfactory fluoroscopy unit
ss : /
• A soft-tissue protector is placed.
t p p t p ss
p : / • Soft-tissue protector for guide pin
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
192 hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrs
B
s C
keerrss D
b ooook b

ooook FIG. 24.5
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb A
ee/ e
/ b
e b B
ee/ e
/ b
e b
: / / t
/ m
.t.m FIG. 24.6
: / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
A
t
hht t
t
hht
FIG. 24.7
t B
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B
k eers
rs k er
erss
FIG. 24.8
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/
A
m
.t.m : / / t
/ m
.t.m B
FIG. 24.9
t ppss : /
t ppss : /FIG. 24.10
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
A B C
FIG. 24.11
k e r
e s
rs k eers
rs STEP 2 PEARLS
o o
o o k o o
oo k
• Screw insertion is done while holding the distal fragment (Fig. 24.10).
o
• The threads of the tap/screw only need to cross
o
eebb ee/ e b
e b
• When the same interference noted with the tap is achieved, fluoroscopic confirma-
/ e
tion of proper screw fixation is made (Fig. 24.11). The screw head should be in full
e/e/ebb the fracture site; there is no need to place the
screw the entire length of the metatarsal.
: / t
/ .
tm.m : / / t
/.tm
.
contact with the 5MT base, and all threads should be crossing the fracture site.
/ m • Hold the distal fragment as the tap is advanced;
once the distal fragment begins to torque with
t p ss
p : / t p ss
p : / each turn, proper screw diameter is determined.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
194 hht hht
STEP 3 INSTRUMENTATION/ Step 4
k e e s
IMPLANTATION
r rs
• Soft-tissue protector that accommodates all
k eers
r s
• If heel varus is present, consideration should be given to correction of cavus/varus
foot alignment to prevent 5MT overload.
o o
o o kdrill and tap sizes
o oo k o
• Possible lateralizing/valgus-imparting calcaneal osteotomy is recommended.
o o
eebb b b
• Multiple cannulated drill bits and taps that
correlate with 4.5-, 5.5-, and 6.5-mm screws
• Consider a comprehensive 5MT fracture kit
ee/ e
/ b varus is recommended.
ee e
/ b
• Possible dorsiflexion first metatarsal osteotomy for a forefoot-driven hindfoot
e / e
• Solid or cannulated screws
: / / t .
t m
. m
POSTOPERATIVE
/ CARE AND EXPECTED OUTCOMES
: / / t
/ .
t m
. m
p ss :
does not need to be long to advance the
t p /
• Average thread length: 16 mm (thus the screw
t p ss
p : /
• The patient is restricted to protected weight bearing in a controlled ankle movement
t
hht t
threads completely across the fracture site)
t
hht t
(CAM) walker, splint, or cast for approximately 4 weeks.
• Begin progressive advancement of weight bearing in a CAM walker for an additional
STEP 3 CONTROVERSIES 3–4 weeks.
• Cannulated screws may be used; we, however, • If there is radiographic evidence for 5MT base healing, the patient may advance to
k eers
recommend solid screws.
rs er
ers
full weight bearing in a regular shoe.
s
• If there is a delay in healing, consider external bone stimulation.
k
b ooook
STEP 4 PEARLS
b ooook
• The patient is restricted from sports participation until the fracture site is nontender
b o o
eeb • The screw should only be long enough to allow
ee/ e
/ e b e / e
/ e b
and radiographic healing is evident (approximately 10–12 weeks).
• Fig. 24.12 shows the anteroposterior (Fig. 24.12A), oblique (Fig. 24.12B), and lateral
e
the threads to cross the fracture site.
: // t .
• The screw should torque the distal fragment
/ tm
. m : / /t/.tm. m
(Fig. 24.12C) radiographs of a healed 5MT fracture at 4 months’ follow-up.
interference fit.
t p ss
p : /
as it is fully inserted to confirm proper
tp ss : /
See also Video 24.1, Open Reduction and Internal Fixation of Proximal Fifth Metatarsal
p
t
hht t t
hht t
(Jones or Stress) Fracture.
STEP 4 PITFALLS
• A screw that is too long will potentially begin
gapping the lateral fracture site (straight
keer ss
implant in a curved bone) and may create a
r
distal fragment stress fracture.
keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs A B
k eers
rs C
o o
o o k o o k
o o FIG. 24.12
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
EVIDENCE POSTOPERATIVE PEARLS
r s
rs rs
r s
Chuckpaiwong B, Queen RM, Easley ME, Nunley JA. Distinguishing Jones and proximal diaphyseal
k e e k ee
fractures of the fifth metatarsal. Clin Orthop Relat Res 2008;466:1966–70.
• Support above the ankle (CAM boot or cast) for
at least 6 weeks is recommended to limit the
o o
o o k o oo k
Huh J, Glisson RR, Matsumoto T, Easley ME. Biomechanical comparison of intramedullary screw ver-
o o o
pull of the peroneal tendons and stress of the
eebb bb b b lateral plantar fascia on the base of the 5MT.

sus low-profile plate fixation of a Jones fracture. Foot Ankle Int 2015;37(4):411–8.
ee/ e
/e e / e
/ e
Lareau CR, Hsu AR, Anderson RB. Return to play in National Football League players after operative
e
• Plate fixation with dedicated 5MT base plates,
: / / t
/ t m
Jones fracture treatment. Foot Ankle Int 2016;37(1):8–16.
. . m : / / t
/ .
t m
. m
Nunley JA. Fractures of the base of the fifth metatarsal: the Jones fracture. Orthop Clin North Am
particularly in revision cases, has gained some
interest among surgeons who treat these
2001;32:171–80.
t p ss
p : / t p ss
p : /
Ochenjele G, Ho B, Switaj PJ, Fuchs D, Goyal N, Kadakia AR. Radiographic study of the fifth metatarsal
injuries.
t
hht t t
hht t
for optimal intramedullary screw fixation of Jones fracture. Foot Ankle Int 2015;36(3):293–301.
Porter DA, Rund AM, Dobslaw R, Duncan M. Comparison of 4.5- and 5.5-mm cannulated stainless steel
screws for fifth metatarsal Jones fracture fixation. Foot Ankle Int 2009;30:27–33. POSTOPERATIVE PITFALLS
Portland G, Kelikian A, Kodros S. Acute surgical management of Jones’ fractures. Foot Ankle Int
• Do not advance weight bearing or recommend
2003;24:829–33.
return to activity until there is radiographic
k e s
rs errs
Sides SD, Fetter NL, Glisson R, Nunley JA. Bending stiffness and pull-out strength of tapered, variable
r s
pitch screws, and 6.5-mm cancellous screws in acute Jones fractures. Foot Ankle Int 2006;27:821–5.
e k e
evidence for healing.
b ooook(Grade I recommendation; Level IV/V evidence).
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh25
PROCEDURE
t hht
Mueller-Weiss
rss Treated With Limited
rss Fusion
kke
oRoxa e r k
oo e
ke r
b
eeboo o Ruiz and Beat Hintermann
e bboo e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t p :
t ss
p :
hht
hht
• Advanced stage of Mueller-Weiss syndrome (Fig. 25.1) with
• Symptomatic osteoarthritis
• Charcot neuroarthropathy • Progressive destabilization of the foot
• Fusion of the talonavicular joint in a not- • Secondary peritalar and midfoot pain due to tarsal destabilization
k eers
rsaligned position
k er
erss
• Loss of neutral foot position that cannot be compensated by shoe modifications
b ooook b ooook
EXAMINATION/IMAGING
b o o
eeb b b
• Crucial for success, e.g., to obtain a
e / e
/ e
Clinical Investigation
e ee/ e
/ e
plantigrade and stable foot, are
: // t/.tm
. m : / /t/.tm. m
• Careful and thorough assessment of history and complaints, in particular
• Appropriate positioning of the talus on
t p ss : /
top of the calcaneus, thereby correcting a
p ss : /
• Disability in daily activities and sports
tp p
hindfoot varus position
t
hht t
• Restoring talonavicular alignment in the
sagittal and horizontal planes, thereby
t
hht t
• Impairment by pain
• Effect of previous conservative measures
• Careful clinical assessment of
achieving realignment of the naviculo- • Hindfoot alignment when standing (posterior view; Fig. 25.2A)
cuneiform and tarsometatarsal joints • Ankle, midfoot, and forefoot alignment (anterior view; Fig. 25.2B)
• In most instances, this can be achieved with
keerrss
isolated talonavicular fusion
keerrss
• Painful pseudo-exostosis over the dorsolateral Chopart joint
• Ankle and subtalar range of motion with the patient sitting
b ooook o ook oo
• Ankle stability with the patient sitting and hanging feet
b o b
• Pain using a visual analog scale of 0–10 points
• Pain is typically located over the lateral navicular bone (pseudo-exostosis)
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Peritalar motion is typically
• Restricted for eversion/pronation
s
• Preserved for inversion/supination
t
hhtt t
hhtt
Assessment by Imaging
• Bilateral plain weight-bearing radiographs, including anteroposterior views of the
foot and ankle, lateral view of the foot, and alignment view, should be used to rule out
k e rrss
e rrss
• Articular configuration and integrity of the subtalar and talonavicular joints
e e
• Collapse of the lateral navicular and tilt of the navicular toward medial (Fig. 25.3)
k
o o
o o k o o k
• Angular deviation of talus in all horizontal planes (e.g., exorotation)
o o o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
• Presence of arthritic changes at the ankle and subtalar joint
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
Cuneiform
k e r
e s
rs
bones
Navicular
k eers
rs
o o
o o k o o
bone
oo k oo
eebb b b
Talus
ee/ e
/ e b
Calcaneus
ee/e/e b
: / / t
/ .
tm.m Stage I
: / / t
/. m
. m
Stage II
t Stage III Stage IV/ V
t p ss
p : /
t p ss
p : / FIG. 25.1
196 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : / B
tp pss : /
t
hht t
FIG. 25.2
t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : /
FIG. 25.3
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
198 hht
PROCEDURE 25 Mueller-Weiss Treated With Limited Fusion hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
C
: / / t
/ m
.t.m : / / t
D
/ m
.t.m
t ppss : / t ppss :
FIG. 25.3, cont’d /
t
hhtt t
hhtt
k e rrss
e k rrss
• Computed tomography scans, if possible while weight bearing, are initiated to
e e
• Assess articular configuration of the ankle, subtalar, and talonavicular joints
o o
o o k o o o k o
• Assess collapse, osteoarthritic changes, and fragmentation of the lateral talona-
o o
eebb e / e
/ b
e bvicular joint
e / e
/ b
e
• Detect other bony abnormalities (Fig. 25.4)
e e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Magnetic resonance imaging can be used to
t p ss:
p / t p ss:
p /
• Determine the activity of avascular necrosis of the lateral navicular, for example,
presence and extent of perifocal edema
t
hht t t
hht t
• Assess surrounding soft tissues
• Single-photon emission computed tomography with superimposed bone scan may
be used to visualize
• Morphologic pathologies and associated activity process (Fig. 25.5)
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
A B
FIG. 25.4
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb A
e
B
e/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m
FIG. 25.5
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
200 hht
TREATMENT OPTIONS
k e r
e s
rs k eers
r s
• Isolated talonavicular fusion
• Triple fusion
o o
o o k o oo k o
• Extended triple fusion, including naviculo-cuneiform joints
o o
eebb SURGICAL
ee/ e
/ebb
ANATOMY
ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t . m
. m
• Relevant structures to be protected in the medial and dorsolateral approaches
/ t
t p ss
p : / ss : /
• The posterior tibial tendon is running over the medial talonavicular joint to its in-
t p p
t
hht t t t
sertion at tuberosity of the navicular bone
hht
• The anterior tibial tendon is running over the dorsomedial talonavicular joint to its
insertion at medial cuneiform
• The long extensor tendons are running over the dorsal talonavicular joint to their
insertion at the toes
k eers
rs k er
ers
• The neurovascular bundle courses between the extensor longus tendons of the
s
great toe and lesser toes
b ooook b ooook
• Relevant osseous anatomy
b o o
eeb ee/ e
/ e b ent joint surfaces
ee/ e
/ e b
• The navicular forms with the talar head a ball-and-socket joint with highly congru-
: // t/.tm
. m : / /t/.tm. m
• In Mueller-Weiss disease, there are typical structural changes with tilting of
t p ss
p : / head
tp pss : /
the navicular medially, resulting in a subluxed position with regard to the talar
t
hht t t
hht t
• The lateral navicular can be broken and fragmented, resulting in a pseudo-exostosis
on the dorsolateral aspect of the foot
• Relevant ligamentous structures are
• The talonavicular ligament that crosses the joint dorsally in an oblique direction
keerrss keerrs
from the talar head to the navicular; in advanced stage of Mueller-Weiss disease
s
is typically disconnected from the navicular due to bony fragmentation at its distal
b ooook b ooook insertion
b oo
• The bifurcate ligament runs with its dorsal part from the anterior process of the
eeb ee/e/e b e /e/e b
calcaneus to the lateral aspect of the navicular; in advanced stage Mueller-Weiss
e
: / / t
/ m
.t.m : / / t
/ m
.t.m
disease, it is typically disconnected from the navicular due to bony fragmentation
at its distal insertion
POSITIONING PEARLS
t
hhtt POSITIONING
• The use of a radiolucent table will facilitate
t
hhtt
• Talonavicular arthrodesis is performed in a supine position.
intraoperative fluoroscopy. • The tourniquet is mounted on high thigh.
• The leg is left free, so the foot can be moved
in the desired position when working medially • The iliac crest is also draped if its use is considered.
rrss rrss
or laterally.
PORTALS/EXPOSURES
o k e
k e o k e
k e
• The talonavicular joint is first exposed through a medial approach
o
eebb o o e b o
b o o e b o o
• A 4–6-cm long incision is made approximately 1 cm dorsally and parallel to the
b
m ee/ / e posterior tendon
m ee/ / e
• Arthrotomy is done by dissection of the capsular posterior tibial tendon (Fig. 25.6)
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
• Second, the talonavicular joint is exposed through a dorsolateral approach
t p
t ss:
• Exposure of the talonavicular through a single
t p t t p
t ss:
• A 3–4-cm long incision is made over the lateral talar head
p
hht
dorsal approach can also be considered;
exposure of the lateral aspect and fixation after
débridement might be difficult and necessitate
hht
• Careful dissection of soft-tissue structures is done laterally to the long extensor
tendon of the fifth toe
• Exposure of the lateral navicular and fragmented bone, respectively
critical tension to soft-tissue structures.
• Arthrotomy of the lateral talonavicular joint (Fig. 25.6A)
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook A B
b ooook b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p
C / t p ss:
p /
t
hht t
FIG. 25.6 t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
202 hht
k e r
e ss
• The contracture of the posterior tibial tendon
r
can typically be overcome with the use of the
k eers
r s
Step 1: Débridement of the Medial Talonavicular Joint
o o
o o kHintermann distractor, so no release of the
oooo k
• One 2.5-mm Kirschner wire (K-wire) is inserted medially in the talar head, and anoth-
o o
eebb tendon will be necessary.
ee/ e
/ebb tilting of the navicular.
ee/ / b
e b
er one into the navicular in a divergent angle corresponding to the amount of angular
e
: / / t
/ .
t m
. m : / / / .
t m
. m
• A Hintermann distractor is used for distraction of the joint over the two K-wires,
t
t p ss
p : / t p ss : /
thereby correcting the navicular tilting (Fig. 25.7A).
• The articular surfaces on the talar and navicular sides are denuded of their cartilage
p
IMPLANTATION
• Sharp chisel
• Curette
t
hht t t
hht t
using a chisel and a curette (Fig. 25.7B–C).
• The bony surfaces are feathered with a small chisel or drilled with a 2.5-mm drill bit
to break the subchondral plate and get good bleeding bone (Fig. 25.7D).
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A t
hhtt t
hhtt B
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e
C
s
rs k eers
rs D
o o
o o k o o
oo k FIG. 25.7
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Step 2: Débridement of the Lateral Talonavicular Joint
k e r
e ssaspect are removed.
k eers
r s
• In the case of fragmentation of the lateral navicular, the bony fragments on the dorsal
r
o o
o o k
• The inferior main fragment is left untouched.
oooo k o o
eebb ee e
/ebb
• While distraction of the talonavicular joint on the medial side is preserved, a 2.5-mm
/ ee/ e
/ b
e b
K-wire is inserted laterally in the talar head, and another one parallel into the navicular.
t . m
. m
• Distraction is achieved using a Hintermann distractor (Fig. 25.8A).
: / / / t : / / t
/ .
t m
. m STEP 2 PEARLS
t p p : /
using a chisel and a curette (Fig. 25.8B).
t p p : /
• The articular surfaces on the talar and navicular sides are denuded of their cartilage
ss ss • Often, the lateral aspect of the talonavicular
joint can sufficiently be exposed by distraction
t
hht t t
hht t
to break the subchondral plate and get good bleeding bone (Fig. 25.8C).
on the medial side, so no additional distraction
on the lateral side will be necessary.
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A t
hhtt t
hhtt B
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e
C
s
rs k eers
rs
o o
o o k o o
oo k FIG. 25.8
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
204 hht
STEP 3 PEARLS Step 3: Reduction of the Talonavicular Over the Talar Head and
Internal Fixation
k e r
e ss
• While with the reduction maneuver, the talar
r
head is rotated medially and the navicular
k eers
r s
• With maximal distraction on the medial side, the navicular is pushed manually toward
o o
o o kbrought into an aligned position over the talar
oooo k
the lateral side (Fig. 25.9).
o o
eebb head, the heel can typically be seen moving
into a neutral or slightly valgus position.
ee/ e
/ebb ee/ e
/ b
e b
• This maneuver can be supported with a reduction forceps mounted to the medial na-
vicular and lateral talar head, respectively, or with the use of a compression forceps
• Bone matrix substance can be used to fill
potential gaps at the fusion site.
: / / t
/ .
t m
. m t . m
. m
mounted laterally over two K-wires (Fig. 25.10).
: / / / t
t p ss
p : / t p ss
p
liminary fixation. : /
• Once the desired talonavicular alignment is achieved, a K-wire can be used for pre-
STEP 3 PITFALLS
t
hht t t
hht t
• A Uni-CP (Integra, Plainsboro, NJ, USA) is first fixed by a screw into the lateral na-
vicular, and then by a second screw into the lateral talar neck (Fig. 25.11).
• Insufficient reduction of the talonavicular • Compression is applied by the special clamp (Fig. 25.12).
alignment will leave the foot in malposition, for • While the distractor on the medial side and any transfixation K-wires are removed,
example, the hindfoot in varus and the forefoot
k eers
rs
in abduction.
k er
ers
the medial aspect of the talonavicular fusion comes typically under compression by
s
the pull of the posterior tibial tendon. The compression can also be increased with
b ooook b ooook the use of a compression forceps mounted over the two K-wires (Fig. 25.13).
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t
hhtt B
t
hhtt
k e rrss
e k eerrss C
o o
o o k o
ooo k FIG. 25.9
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss
FIG. 25.10
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b ooook B
b o o
eeb ee/ e e b
FIG. 25.11
/ ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
FIG. 25.12
t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k o o
o o k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
A
t p ss
p : / B
t p ss
p : /
t
hht t
FIG. 25.13 t
hht t
t t p
t ss:
p t t p
t ss:
p
206 hht
STEP 3 INSTRUMENTATION/ • The remaining 2.5-mm K-wires are used as joysticks for frontal plane adjustments of
k e r
e s
IMPLANTATION
rs
• Fluoroscopy
k eers
the forefoot, for example, to receive a strictly neutral position of forefoot.
r s
• A 1.6-mm K-wire is inserted from the medioplantar aspect of the navicular into the
o o
o o k oo k
talar head (Fig. 25.14), and a 5.5-mm cannulated screw is inserted (Fig. 25.15).
oo o o
eebb ee/ e
/ebb ee/ e
/ b
e b
• With the same technique, a second screw is inserted more dorsally and laterally.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb A
ee/e/ b
e B
ee/e/e b
: / / t
/ m
.t.m FIG. 25.14
: / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs A
k eers
rs B
o o
o o k o o k
o o FIG. 25.15
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m
t p ss
p : /
tp pss :
FIG. 25.16 /
t
hht t t
hht t
• Adding a fusion at the naviculo–cuneiform site
and/or at the subtalar site has been advocated
keerrss keerrss by several authors; however, appropriate

reduction of talonavicular alignment does, to
b ooook b ooook b oo our experience, sufficiently reduce these joints,

thus functioning normally. In particular, we did
eeb ee/e/e b ee/e/e b not see in any case subsequent degenerative
disease requiring further treatment in these
Step 4: Wound Closure
: / / t
/ m
.t.m : / / t
/ m
.t.m joints.
• Step-by-step wound closure is done with interrupted 3-0 sutures for the skin, as
shown in Fig. 25.16. t
hhtt
• A compressive dressing is applied.
t
hhtt STEP 4 CONTROVERSIES
• We do not use drainage for fear of
• The foot is positioned in a neutral position. exsanguination of the bleeding bone.
k e rrss
e k e rrss
• The ankle is protected for 8 weeks by a removable splint in a neutral position at rest,
e POSTOPERATIVE PEARLS
o o
o o k o o
o k
and by a boot while walking. In noncompliant patients, a Scotchcast (3M, Rüschlikon,
o o • Wearing compression stockings is
o
eebb b b
Switzerland) is used instead of a boot.
ee/ e
/ e b
• Once safe wound healing is achieved, weight bearing is permitted as tolerated.
ee/ e
/ e b recommended in the first months after the
immobilization.
: / / t
/ m : / / t
/ m
• Radiographic control is obtained by 8 weeks (Fig. 25.17) and in the case of any doubt
.t.m .t.m
about bone healing; a computed tomography scan control is obtained 4 months after
surgery.
t p ss:
p / t p ss:
p / POSTOPERATIVE PITFALLS
permitted.
t
hht t t
hht t
• After complete healing of the arthrodesis, usually after 8 weeks, free ambulation is • Possible complications include
• Wound healing problems with superficial
infection
• A rehabilitation program including active and passive motion, muscular strengthen-
ing, proprioception, and gait training is then also started. • Loss of correction by too aggressive
• Return to work ability is allowed for sedentary workers after 2–3 weeks and for heavy mobilization/weight bearing with/without
k e r
e s
rs laborers after 3–4 months.
k eers
rs
implant failure
• Nonunion
o o
o o k o o
oo k
• Return to full sports activity depends on the individual and the desired sport, but
generally occurs at 3–6 months from the operation.
oo
• Malunion
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
208 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb A Bee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eer s
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
C
: / / t
/ .
tm.m : / / t
/.tm
. m
D
t p ss
p : /
t p ss : /
FIG. 25.17
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
EVIDENCE
r s
rs rs
r s
Cao HH, Tang KL, Xu JZ. Peri-navicular arthrodesis for the stage III Müller-Weiss disease. Foot Ankle Int
k e e
2012;33(6):475–8.
k ee
o o
o o k o oo k
The authors concluded from a case series of nine patients that peri-navicular arthrodesis with au-
o o o
eebb bb b b
tologous iliac bone graft resulted in a good outcome for stage III Mueller-Weiss disease with good
ee/ e
/e e /
clinical outcomes, high fusion rate, and obvious improvement of the longitudinal arch height.
e e
/ e
Int 2012;33(4):275–81.
: / / t
/ t m
. m : / / t
/ t m
Doyle T, Napier RJ, Wong-Chung J. Recognition and management of Müller-Weiss disease. Foot Ankle
. . . m
t p ss
p : / t p ss
p : /
The authors concluded that the Mueller-Weiss syndrome is much more common than previously
reported, and they did not find conditions of extreme environmental stress or poverty in their
t
hht t t
hht t
patients. They advocate surgical management of the condition by triple arthrodesis and extend it
to include a naviculo–cuneiform fusion whenever indicated according to computed tomography
findings.
Fernández de Retana P, Maceira E, Fernández-Valencia JA, Suso S. Arthrodesis of the talonavicular-
cuneiform joints in Mueller-Weiss disease. Foot Ankle Clin 2004;9(1):65–72.
k ee s
rs k er
ers
The authors concluded that talonavicular-cuneiform arthrodesis is a safe and effective technique
r s
for the treatment of the Mueller-Weis disease and can be performed with a dorsal or medial
b ooookapproach.
ooook o o
Fornaciari P, Gilgen A, Zwicky L, Horn Lang T, Hintermann B. Isolated talonavicular fusion with tension
b b
eeb e e
/ e b
band for Mueller-Weiss syndrome. Foot Ankle Int 2014;35(12):1316–22.
/ e / e
/ e b
Using the technique described in this chapter the authors found excellent results and overall very
e e
// /.tm m
satisfactory angular correction of the foot in 10 patients.
t . / /t/.tm. m
Lui TH. Arthroscopic triple arthrodesis in patients with Müller Weiss disease. Foot Ankle Surg
: :
2009;15(3):119–22.
t p ss
p : / tp pss : /
t t t t
The authors report in a case series of six patient’s successful results with arthroscopic triple arthro-
hht hht
desis in Mueller-Weiss disease based on bone healing, but not with regard to angular correction of
deformity.
Maceira E, Rochera R. Müller-Weiss disease: clinical and biomechanical features. Foot Ankle Clin
2004;9(1):105–25.
The authors discuss risk factors, evolution, and clinical presentation of Mueller-Weiss disease.
keer ss keerrss
They conclude that the disease is not the consequence of an osteonecrotic process but results
r
from impaired development of the bone, and they found that the plantar arch may correspond to
b ooookthat of a normal, cavus, or flatfoot.
b ooook b oo
Yu G, Zhao Y, Zhou J, Zhang M. Fusion of talonavicular and naviculocuneiform joints for the treatment
eeb /e e b
of Mueller-Weiss disease. J Foot Ankle Surg 2012;51(4):415–9.
ee / ee/e/e b
The authors report on a case series of seven patients who were treated with surgical fusion of
: / / t
/ m
.t.m : / / t
/ m
.t.m
the talonavicular and naviculo-cuneiform joints for Mueller-Weiss disease and concluded that this
t ppss : /
extended fusion is a safe and effective procedure.
t ppss : /
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh26
PROCEDURE
t hht
Mueller-Weiss
rss Treated With Pan-Navicular
rss Fusion
kke
oGlenne r k
oo e
ke r
eeb o B. Pfeffer
b oo
ee/ e
/ebboo
ee/ e
/ b
e
o
b o
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p p : /
ss INDICATIONS t p ss
p : /
INDICATIONS CONTROVERSIES t
hht t t
hht t
• Talonavicular-cuneiform arthritis requires a • Chronic midfoot pain that has failed orthotic treatment
fusion of all of these joints • Advanced Mueller-Weiss disease with pain or deformity
• Charcot neuroarthropathy • Fragmentation of the navicular
k eers
rs k er
erss
• Peri-navicular arthritis
b ooook b ooook
EXAMINATION/IMAGING
b o o
eeb ee/ e
/ e b ee/ e
/ e b
• Is the patient suffering from arthritic joints, deformity, or both?
• Evaluate hindfoot and midfoot alignment. In advanced cases of Mueller-Weiss dis-
: // t/.tm
. m : / /t/.tm. m
ease, there can be pes planus and hindfoot varus, which occurs as the navicular
t p ss
p : / ss : /
collapses and the talar head moves laterally.
tp p
t
hht t t t
• A weight-bearing anteroposterior radiograph of the foot demonstrates advanced
hht
Mueller-Weiss disease, with collapse of the lateral navicular (Fig. 26.1).
• A weight-bearing lateral radiograph of the foot demonstrates fragmentation of the
navicular (Fig. 26.1B).
• A computed tomography scan of the foot demonstrates sclerosis and fragmentation
keerrss keerrss
of the navicular (Fig. 26.2).
• Magnetic resonance imaging demonstrates pan-navicular arthritis with avascular
b ooook b ooook oo
fragments. The advanced naviculo-cuneiform arthritis is only evident on magnetic
b
eeb ee/e/e b resonance imaging (Fig. 26.3).
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb A
ee/ e
/ b
e b B
ee/e/ebb
: / / t
/ .
tm.m FIG. 26.1
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
210 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 26 Mueller-Weiss Treated With Pan-Navicular Fusion 211
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
A B
FIG. 26.2
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
A
t
hht t
B
t
hht t
FIG. 26.3
TREATMENT OPTIONS
k e r
e s
rs
• Isolated talonavicular fusion
k eers
rs
o o
o o k
• Double fusion
o o
oo k oo
eebb • Triple arthrodesis
ee/ e
/ b
e b ee/e/
• None of these options address the naviculo-cuneiform arthritic changes or preserveebb
medial length
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
212 hht
PROCEDURE 26 Mueller-Weiss Treated With Pan-Navicular Fusion hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m
: / /t/.tm. m
t p ss
p : / tp pss : / FIG. 26.4
t
hht t t
hht t
SURGICAL ANATOMY
• See Chapter 25.
keerrss POSITIONING
keerrss
• The patient is placed supine, often with a bump under the ipsilateral hip.
eeb ee/e/e b
• Use a thigh tourniquet.
ee/e/e b
: / / t m
.t.m
PROCEDURE
/ : / / t
/ m
.t.m
t
hhtt Step 1
•

t
hhtt
The surgery is performed under general anesthesia with a regional popliteal
block.
• A mini C-arm is used throughout the case.
• Loupe magnification is very helpful.
k e rrss
e k e rrss
• Defrost a tricortical fresh frozen allograft.
e
o o
o o k o o
o o k
• Make a dorsal approach to the talonavicular-cuneiform joints (Fig. 26.4).
o o
• Isolate and protect branches of the superficial peroneal nerve.
eebb ee/ e
/ b
e b ee/ e b
e b
• The joints are approached between the anterior tibial and the extensor hallucis lon-
/
gus tendons. The incision should be sufficiently long to gain exposure of the distal
: / / t
/ m
.t.m : / / t m
.t.m
talar neck and the medial–middle intercuneiform articulations. The deep peroneal
/
t p ss:
p / t p ss:
p /
nerve and dorsalis pedis artery are retracted laterally.
t
hht t t t
• A fluoroscopic image of the navicular with a Kirschner wire (K-wire) placed into the
hht
body will help with localization of the involved joints.
Step 2
• All of the joints are prepared for fusion, including the naviculo-cuneiform and talona-
k e r
e s
rs k eers
rs
vicular joints.
• The cartilage is removed with a small curette. Then use a low-speed burr under cool
o o
o o k o oo k o
water to expose the bleeding subchondral bone. An alternative is to use a small drill
o o
eebb ee/ e
/ b
e b
bit to make multiple drill holes.
ee/e/ebb
• Small necrotic portions of the navicular may have to be excised, but with careful
: / / t
/ .
tm.m t. m
. m
débridement most of the body can usually be preserved, even if fragmented.
: / / / t
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e ss
fresh frozen iliac crest graft (Fig. 26.5).
k eers
r s
• Under cool-water irrigation, a microsagittal saw is used to create a slot to receive a
r • Think of the procedure as a talar to cuneiform
fusion. The fragmented navicular is essentially
o o
o o k o oo k
• It is essential to correct any deformity and preserve the appropriate length of the
o o o
an intercalary graft held out to length by the
eebb medial column.
ee/ e
/ebb
• The slot should be of sufficient width to receive the tricortical graft.
ee/ e
/ b
e b iliac crest allograft.
t . m
. m t . m
. m
• The length of the slot should extend from 0.5 cm into the talar head to 0.5 cm into
: / / / t : / / / t
t p p : /
the medial–middle cuneiform joint.
ss t p ss
p : /
• The depth of the slot should extend to the plantar aspect of the navicular, with pres-
t
hht t
ervation of the plantar cortex if it is still intact. t
hht t • An iliac crest autograft can be used but has
no proven efficacy compared with fresh frozen
allograft.
Step 4 • A fresh frozen iliac crest graft is used in this
• The width of the fresh frozen iliac crest graft can be narrowed by removing some of procedure, but other options are available.
k eers
rs k er
ers
the cortical walls with the microsagittal saw under cool-water irrigation. Add multiple
s
drill holes into the walls to promote bony ingrowth (Fig. 26.6).
b ooook b ooook
• Another option is to split the graft and place the cancellous portions outward
b o o STEP 4 PEARLS
eeb (Fig. 26.7).
e / e
/ e b
• Use a tamp and mallet to impact the graft into the prepared slot (Fig. 26.8).
e ee/ e
/ e b • The key is that the iliac crest graft be of
: // t/.tm
. m : / / /.tm
• Harvest fresh allograft from the ipsilateral proximal tibia (see Chapter 77).
t . m
adequate length to press fit into the slot.
• Correction of deformity and preservation of
p ss
p / tp ss : /
• Pack the morcellized cancellous autograft around the allograft and into the me-
:
dial and lateral aspects of the talonavicular joint and naviculo-cuneiform joints
t p
medial column length are essential.
• Preserve the correction as the graft is inserted.
(Fig. 26.9). t
hht t t
hht t
Step 5
STEP 4 PITFALLS
• There are several options to hold the graft in place. Several transverse 4.0-mm can-
nulated screws will compress the graft to the medial and lateral portions of the na- • Shortening of the medial column
keerrss keerrss
vicular body and prevent a longitudinal split in the navicular. These are usually placed • Failure to correct sagittal collapse of the
medial column
b ooook b ooook
through separate medial stab holes. If the navicular is already split, the screws will
add rigid fixation to the medial and lateral portions.
b oo
eeb ee/e/e b
• A large cannulated screw placed from the medial cuneiform into the talus provides
ee/e/e b
/ / t
/ m
excellent stability and compression (Fig. 26.10).
.t.m / / t
/ m
.t.m
• Multiple small screws and/or plates are another option. Dorsal plates, however, tend
: :
STEP 5 PEARLS
ss : /
to be bulky and require removal after a successful fusion.
t pp t ppss : / • Make sure to keep the foot in a corrected
plantigrade position during insertion of the
t
hhtt t
hhtt
screws. Temporary 0.62-mm K-wires can be
used to hold the reduction.
• Do not compress the fusion site during the
screw insertion. Medial column length must be
preserved.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb

FIG. 26.5
: / / t
/ .
tm.m
: / / t
/.tm
. m FIG. 26.6
t p ss
p : / t p ss
p : /
hhtt t t
hht t
t t p
t ss:
p t t p
t ss:
p
214 hht
PROCEDURE 26 Mueller-Weiss Treated With Pan-Navicular Fusion hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
//t
: /.tm
. m : / /t/.tm. m
t p ss
p : /
FIG. 26.7
tp pss : / FIG. 26.8
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m
: / / t
/ m
.t.m
t p ss:
p / t p ss:
p /FIG. 26.9
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
A
t p ss
p : / B
t p ss
p : /
t
hht t t
hht
FIG. 26.10
t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e ss
point sutures are removed.
k eers
r s
• A bulky postoperative dressing/splint is used until 2 weeks after surgery, at which
r
o o
o o k o oo k
• A short leg non–weight bearing cast is used until 6–8 weeks after surgery, at which
o o o
eebb / e bb
point the patient is placed in a weight-bearing cast for an additional month.
ee /e
• Full weight bearing is allowed when anteroposterior, lateral, and both oblique radio-
ee/ e
/ b
e b
: / / t . m
. m
graphs of the foot confirm progression of the fusions.
/ t : / / t
/ .
t m
. m
EVIDENCE
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Cao H, Tank K, Xu J. Peri-navicular arthrodesis for the stage III Müller-Weiss disease. Foot Ankle Int
2012;33:475–8.
A review of nine cases of peri-navicular arthrodesis.
Klein SE, Putnam RM, McCormick JJ, Johnson JE. The slot graft technique for foot and ankle arthrode-
sis in a high-risk patient. J Foot Ankle Int 2011;32:686–92.
k eerss
New York, NY: Raven Press; 1989.
k er
erss
Johnson k. Arthrodeses of the foot and ankle. In: Johnson K, editor. Surgery of the Foot and Ankle.
r
b ooook b ooook
A review of the split iliac crest graft fusion technique.
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh27
PROCEDURE
t hht
Charcot
rss Neuroarthropathy of thersMidfoot
s
k
oLewkee r k
oo e
ke r
b
eeboo o e b oo
C. Schon, Su-Young Bae, and Alireza Mousavian
b e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t p :
ss CHARCOT NEUROARTHROPATHY ttp t ss
p :
hht Definition
hht
• Charcot described neuroarthropathic arthropathy typically due to syphilis in the late
1880s.
k eers
rs k er
erss
• Although most current cases are due to diabetes, 20–30% of cases occur as a re-
b ooook b ooook
sult of other neuropathic conditions: alcohol neuropathy, rheumatologic neuropathy,
b o o
hereditary neuropathy, steroid-induced neuropathy, spinal injury, spinal tumor, spina
eeb ee/ e
/ e b ee/ e
/ e b
bifida (syringomyelia), and many coexisting conditions.
: // t/ tm
. m / /t/ tm
• Refers to aggressive destruction of the bones and joints as a result of repetitive
. . . m
microtrauma, recognized or unrecognized acute trauma, arthritis, or avascular ne-
:
t p ss
p : / ss : /
crosis. Often there is an inciting event that goes unrecognized, and the destructive
tp p
t
hht t t
hht t
process is magnified by repetitive trauma.
• Charcot neuroarthropathy:
• May present in an acute or chronic fashion
• Can involve any portion of the foot and ankle
• Can lead to severe deformities with risk for ulcers and infection and possibly
keerrss keer
osteomyelitis
rss
b ooook Pathogenesis
b ooook b oo
• Neuropathic patients have either acute trauma (fracture, ligament injury, tendon dis-
ruption, or dislocation) or repetitive microtrauma or spontaneous avascular necrosis
: / / t
/ m
.t.m : / / t m
.t.m
of either the navicular or the talus. Arthritis may also be a precursor by triggering
/
inflammation or destruction that may also lead to Charcot collapse.
t
hhtt t
hhtt
• The situation that begins as above is compounded by the patient’s activity coupled
with lack of awareness that the foot is swelling and deforming.
• Often comorbidities such as obesity, renal disease, vitamin D deficiency, and vas-
cular disease will aggravate the situation by increasing the mechanical and biologic
stresses to these vulnerable bones and joints.
k e rrss
e k rrss
• Ulceration and infection increase the inflammatory environment and further lead to
e e
destructive arthropathy.
o o
o o k o o o k o
• The synovium plays a critical role in producing cytokines that mediate the bone and
o o
eebb ee e
/ b
e b
joint destruction.
/ ee/ e
/ b
e b
: / / t
/ m
Natural History
.t.m : / / t
/ m
.t.m
t p ss:
p / become destroyed.
t p ss:
p /
• Without mechanical relief for the foot and ankle, the bones and joints progressively
t
hht t t
hht t
• The foot becomes deformed and unstable. The midfoot can develop a rocker-bottom
deformity. There may be abduction or adduction of the forefoot or midfoot. The hind-
foot may assume a varus or valgus deformity.
• Bony prominences occur at the apex of the deformities, and over fragmented, dislo-
k e r
e s
rs k eers
cated, or displaced bones.
rs
• The hindfoot and midfoot joints collapse, leading to equinus of the talus in the ankle
o o
o o k oo k
joint and relative dorsiflexion of the metatarsals or cuneiforms on the more proximal
o o oo
eebb e / b
e b
midtarsus or transverse tarsus.
/ e e /e/
• Progressive Achilles tendon contracture occurs.
e e ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
• The foot contacts the shoe or ground with vulnerable bony prominences.
t p ss
p : / t p ss : /
• These pressure areas become ulcerated.
• The ulcers lead to superficial and deep infection.
p
216 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 27 Charcot Neuroarthropathy of the Midfoot 217
• Osteomyelitis and septic joints may develop.
k e e s
• Uncontrolled infection leads to limb loss.
r rs
INDICATIONS k eers
r s
o o
o o k oooo k o o
eebb • Recurrent ulcer
• Deep infection
ee/ e
/ebb ee/ e
/ b
e b
• Instability
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• Severe malalignment
t p ss : /
• Unbraceable deformity
p t p ss
p : /
t
hht t
• Inability to wear shoes
t
hht t
EXAMINATION/IMAGING
Physical Findings
rs
rs
• Acute
k ee k er
erss
b ooook ooook
• A swollen, warm, erythematous foot and ankle are seen.
• Gross foot deformities include rocker-bottom foot, severe abduction and prona-
b b o o
eeb / e e
tion, or less often adduction and supination.
• Deformity can be flexible and unstable.
ee / b ee/ e
/ e b
• Equinus contracture may occur.
: // t/.tm
. m : / /t/.tm. m
ss : /
• Bony prominences occur at the apex of deformities.
t p p tp pss : /
t t
• Ulcers manifest over the prominences.
• Chronic hht t
hht t
• Deformities include rocker-bottom foot (Fig. 27.1A) and severe abduction, adduc-
tion, supination, and/or pronation (Fig. 27.1B).
• Deformities are not reducible.
keer ss keerrss
• If destruction occurs through fracture, the deformity can be stiff and stable.
r
• If the deformity is through a dislocation, the deformity can be unstable.
b ooook • Additional findings include:

b ooook b oo
eeb

• Mild swelling
• Mild warmth
ee/e/e b ee/e/e b
• Mild to no erythema
: / / t
/ m
.t.m : / / t
/ m
.t.m
t pp s : /
• The foot tends to be thicker due to soft-tissue and bony changes.
s t ppss : /
• General
t
hhtt t
hhtt
• Evaluate the patient for systemic infection.
• Peripheral vascular status should be assessed; pulses should also be checked.
rrss
• Cardiac/renal/pulmonary function may be impaired.
e e
• Local
k k e rrss
e
o o
o o k o o k
• Charcot type: location, that is, which joints are involved
o o o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : / FIG. 27.1
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
218 hht
PROCEDURE 27 Charcot Neuroarthropathy of the Midfoot hht
• Charcot stage: clinical severity of deformity
k e r
e s
rs k eers
• Charcot phase (Eichenholtz): acute, subacute, chronic
r s
• Neuropathy: decrease in two-point discrimination; decrease in sensitivity to light
o o
o o k oo k
touch, vibration, and temperature
oo o o
eebb
ee /ebb
• Ischemia
/ e e / e
/ b
e b
• Dorsalis pedis and posterior tibialis pulses may be decreased; perform a side-
e
: / / t
/ .
t m
. m to-side comparison
: / / t
/ .
t m
. m
t p ss
p : /
t p ss /
• Additional signs and symptoms include cool foot, painful ulcer, gray base,
:
eschars, odor, weak or absent pulses
p
t
hht t t
hht t
• Depth of ulcer and infection
• Rule out
• Deep venous thrombosis
• Osteomyelitis (probe the ulcer to see whether it contacts the bone)
k eers
rs Radiographs
k er
erss
b ooook b ooook
• Acute Charcot Neuroarthropathy
b o o
• Subluxation, dislocation, and/or fracture of any part of the midfoot and hindfoot
eeb ee/ e
/ e b ee/ e
/ e b
may not be distinguishable from normal acute trauma
: // t/.tm
. m
• Chronic Charcot Neuroarthropathy
/ /t/.tm. m
• Deformity: resulting from fracture and/or dislocation
:
t p ss
p : / ss
• Hypertrophic arthritis
tp p : /
t
hht t t
hht t
• Avascular changes to bone with sclerosis and fragmentation, deformity (loss of
normal shape)
• Consolidation of bone fragmentation
• Zones of radiodensity with bone remodeling
• Joint subluxation/dislocation
keerrss keerrss
• Bone fractures with hypertrophic malunions and nonunions
b ooook b oook
Location of Charcot Process
o b oo
eeb ee/e/e b
joints of toes
ee/e/e b
• Forefoot: metatarsal heads and metatarsophalangeal joints, proximal phalangeal
: / / t
/ m
.t.m • Midtarsus
: / / t
/ m
.t.m
• Common location; involves complex pattern types described in the following
t
hhtt • t
hhtt
midfoot classification
Fig. 27.2 illustrates a type I deformity with abduction and collapse of the arch oc-
curring at the metatarsal–cuneiform joints medially and the fourth and fifth meta-
tarsal–cuboid joints laterally
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : / FIG. 27.2
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
• Peritalar region: avascular necrosis of the talus, subtalar destruction results in TREATMENT OPTIONS
k eers
r
varus/valgus of the hindfoot
s k eers
r s
• Calcaneus: avulsion fracture of posterior tuberosity
• Postoperative shoe for toe ulcers or forefoot
plantar ulcers (add unloading orthotic device)
oooo k oooo k
• Ankle: fracture can lead to destructive arthritis, avascular necrosis of distal tibia
o o
• Ankle foot orthosis (AFO) for stability and to
eebb DIFFERENTIAL DIAGNOSIS: INFECTION

• Tibia
ee/ e
/ebb
VERSUS CHARCOT ee/ e
/ b
e b accommodate deformity
• Débridement of ulcer
NEUROARTHROPATHY
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• Consider Achilles lengthening or Strayer
procedure for forefoot overload and ulcers
p ss
p : / t p ss : /
Clinical and paraclinical manifestations of Charcot foot may be different according to
t p
associated with ankle contracture
• Casting for a nonhealing ulcer, acute or
t
hht t t
hht t
the stage of neuroarthropathy. Acute Charcot is a more challenging dilemma as there
is no single test or study that can distinguish it from acute osteomyelitis. Clinician
subacute phase of Charcot neuroarthropathy,
unbraceable or unshoeable deformity
• Treatment of underlying Charcot
should sum up all the clinical, imaging, and laboratory results for more accurate diag-
neuroarthropathy
nosis and decision making.1 • Immobilization
• Assess the ulcer
k e rs
rs
• Neuropathic ulceration: result of repetitive pressure
e k er
erss
• Crutches, walkers, and wheelchairs to off-
load foot and ankle
b ooook

• Pink-based ulcer
• Warm foot with pulses
b ooook b o o
• Maintenance of stable, ulcer-free foot
• Footwear adaptations: higher wider toe box,
eeb • Not typically painful

ee/ e
/ e b ee/ e
/ e b thick cushioned sole
• Accommodative insoles
• Vascular ulcer (result of ischemia)

// t/.tm
. m
• Gray, yellow-based ulcer or eschar
: : / /t/.tm. m • Custom-molded AFO or Charcot rocker
orthotic walker

ss : /
• Cool foot with decreased pulse
t p p tp pss : / • Double-metal upright AFO with shoe with

t
hht t
• Can be painful
t
hht t
• Probe the wound: osteomyelitis is diagnosed if bone is felt at the base of the ulcer
steel shank and rocker sole; consider
Steven Craig modification for added
strength (additional L-shaped bracket
• Palpate for deep abscess; if uncertain, aspirate the area, avoiding if possible a cel- supports metal upright-to-shoe caliper
lulitic or grossly infected entry point connection)
• Look for signs of spreading infection
keerrss keerrss
• Cellulites: warm, red, swollen with tenderness, and streaking
b ooook b ooook
• Systemic: fever, chills, malaise, nausea, vomiting, confusion, elevated blood glucose,
oo
white blood cell count with shift, erythrocyte sedimentation rate, C-reactive protein
b
eeb ee/e/e b
will decrease, which does not occur with infection
ee/e/e
• Elevation test: when the foot is elevated, the erythema in a Charcot neuroarthropathy
b
: / / t
/ m
.t.m : / / t m
.t.m
• Mechanical test: as with elevation, off-loading, resting, bracing, or casting will de-
/
crease the swelling, redness, and warmth associated with a Charcot neuroarthropa-
t
hhtt
thy, but not with infection
t
hhtt
• Radiologic clues of infection include more osteolysis (large ovoid shape), bone ero-
sions, fluffy periosteal changes, and gas in soft tissues
• Bone scan: when in doubt, get a scan
• Uptake on technetium-99m and indium-111 scans in osteomyelitis
k e rrss
e none on marrow test in osteomyelitis
k rrss
• Technetium-99m sulfur colloid scan shows uptake on white blood cell count with
e e
o o
o o k o
• Technetium-Tc99m exametazime may be useful
o
o o k o o
eebb ee e
/ b
e b
• Magnetic resonance imaging (MRI): marrow changes and bony destruction with in-
/ ee/ e
/ b
e b
fection are the same as with Charcot neuroarthropathy; particularly useful to look for
soft-tissue abscess
: / / t
/ m
.t.m : / / t
/ m
.t.m DIAGNOSIS PITFALLS
t ss:
p
differential key points: / t p ss:
p /
MRI findings in acute Charcot are the same as acute osteomyelitis, but with some
p
• A swollen, warm Charcot foot in a patient with
glucose control problems warrants further
t
hht t
osteomyelitis from acute Charcot2
t
hht t
• T2 changes without concomitant signal intensity change in T1 do not distinguish
evaluation to rule out an occult foot infection.
If there is a callus, ulcer, or eschar, débride it
to potentially unroof an abscess. If there are
• Subchondral bone marrow edema and enhancement are more suggestive of acute no skin lesions, an abscess can be hidden in
Charcot3 the deep fascial spaces in the arch or along
tendons. In this situation, MRI or needle
k eers
rs e rs
• Subchondral cysts, low signal changes in both T1 and T2, extensive fragmentation,
rs
debris, and intraarticular bodies are manifestations of chronic Charcot4,5
k e
aspiration can reveal an abscess.
o o
o o k
SURGICAL ANATOMY o o
oo k oo
eebb • Bony anatomy
ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
• Metatarsal–cuneiform joints make up the arch of the foot and are vulnerable to
t p ss
p : /
destruction in Charcot neuroarthropathy.
t p ss : /
• The second metatarsal–cuneiform joint is recessed relative to the first and the
p
t
hht t
third metatarsocuneiform joints.
t
hht t
t t p
t ss:
p t t p
t ss:
p
220 hht
• The fourth and fifth metatarsal–cuboid joints have more mobility than the first,
k e r
e s
rs k eers
second, and third metatarsal–cuneiform joints.
r s
• The three cuneiforms are wedge-shaped bones between the navicular and the
o o
o o k oo k
medial three metatarsals.
oo o o
eebb ee/ e
/ebb e / e
/ b
e b
• The talonavicular and calcaneocuboid joints are responsible for inversion and
eversion of the foot in conjunction with the subtalar joint and also are often in-
e
: / / t
/ .
t m
. m volved in the Charcot process.
: / / t
/ .
t m
. m
t p ss
p : / • Soft-tissue anatomy
t p ss : /
• The anterior tibialis tendon inserts on the medial cuneiform.
p
t
hht t t
hht t
• The peroneus brevis inserts on the fifth metatarsal tuberosity.
• The abductor hallucis takes origin along the navicular, medial cuneiform, and first
metatarsal medially.
• The posterior tibialis tendon inserts on the navicular medially.
• The dorsalis pedis artery is dorsal to the second metatarsal–cuneiform joint.
k eers
rs k eerrss
• The medial and lateral plantar nerves run under the midtarsus. When the bones
b ooook b oo ook
have dislocated or deformed, these nerves are compromised by being com-
b o o
pressed between the plantar prominence and the floor during standing or walking.
eeb ee/ e
/ e b ee/ e
/ e b
• The deep peroneal nerve and the superficial peroneal nerve run dorsal to the me-
: // t/.tm
. m
dial and middle cuneiforms.
: / /t/.tm. m
t p p : / CLASSIFICATION
ss NEUROARTHROPATHY OF MIDFOOT CHARCOT
tp pss : /
t
hht t t
hht t
• Deformity is classified as types I–IV (Fig. 27.3).
• Type I includes deformity at the metatarsal–cuneiform joints medially and the
fourth and fifth metatarsal–cuboid joints laterally.
• Type II includes deformity at the navicular–cuneiform joint medially and the fourth
keerrss keerrss
and fifth metatarsal–cuboid joints laterally.
b ooook b ooook
• Type III includes major deformity in the perinavicular region, with prominence
plantar centrally or plantar laterally.
b oo
• Type IV includes deformity at the transverse tarsal joints with variable prominences.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b
Type I
ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p / Type IV
t
hht t
Type II
t
hht t Type III
Type II
Type III
Type IV Type I
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : / t p ss : /
FIG. 27.3 Modified with permission from Schon LC, Weinfeld SB, Horton GA, Resch S. Radiographic and clinical classification of acquired midtarsus
p
t
hht t t
hht t
deformities. Foot Ankle Int. 1998;19:394–404. Copyright 2008 by the American Orthopaedic Foot and Ankle Society, Inc.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb b b
Stage A Stage B Stage C
ee/ e
/e b ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
A t
hht t B hht t t C
FIG. 27.4
• The type I foot typically has abduction and plantar prominence under the medial
k eers
rs cuneiform.
k er
erss
CLASSIFICATION PEARLS
• Stage A feet have a high success rate with
b ooook b ooook
• The type II foot typically has a plantar lateral prominence under the cuboid.
• The type III foot typically has a prominence under the cuboid or fifth metatarsal and
b o o
nonoperative treatment, whereas stage C
feet have a very high incidence of ulcers,
eeb may be supinated and adducted.
ee/ e
/ e b ee/ e
/ e b infections, and osteomyelitis and difficulty with
modified shoes and braces. Therefore stage C
// t/ tm
.
lum and the distal plantar calcaneus.
: m : / /t/ tm
• The type IV foot will often have pronation and plantar prominence under the navicu-
. . . m feet often require surgical reconstruction.
t p ss
p : / tp pss : / • Stage B feet are a challenge, but with great
effort and compliance can have successful
t
Radiographic Severity Features (Schon Acquired Midtarsus
hht t
Deformity Classification System) t
hht t nonoperative treatment.
• Beta stage if one of the following criteria is found:

• A dislocation
• The lateral talar–first metatarsal angle is ≥30°
keer ss
• The lateral calcaneal–fifth metatarsal angle ≥0° or
r keerrss
• The anteroposterior talar–first metatarsal angle is ≥35°
b ooook b ooook
• An alpha stage assigned in the absence of all four features
b oo
eeb ee/e/e b
tion, and more typically may require surgery.
ee/e/e b
• An alpha has a lower risk of progression. A beta has a higher risk of instability, ulcera-
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : /
Clinical Staging Based on Severity of the Deformity
t ppss : /
t
hhtt
mine prognosis (Fig. 27.4). t
hhtt
• The clinical severity of the rocker-bottom deformity can be assessed to help deter-
• In stage A, the midtarsus is above the metatarsal–calcaneal plane.

• In stage B, the midtarsus is coplanar with the metatarsal–calcaneal plane (mild to
moderate rocker bottom).
k errss
bottom).
k rrss
• In stage C, the midtarsus is below the metatarsal–calcaneal plane (severe rocker
e e e
o o
o o k o o
o o k o o
eebb EXPOSURES
ee/ e
/ b
e b ee
• A curvilinear incision is made along the plantar margin of the medial bony prominence/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
of the midfoot Charcot deformity (Fig. 27.5). Full-thickness skin flaps are preserved,
t ss:
p / t p ss:
p /
and the deep dissection proceeds to the fascia of the abductor hallucis muscle.
p
• The muscle is retracted plantarly to identify the first metatarsal, medial cuneiform,
t
hht t
and navicular or talus as needed (Fig. 27.6). t
hht t
• The periosteum is incised and elevated longitudinally at the junction of the medial
and plantar aspects of the medial ray using an electrocautery blade, and the plantar
soft tissues are then dissected from the bone using a periosteal elevator across the
k e r
e s
rs
midfoot (Fig. 27.7).
k eers
rs
• The insertion of the anterior and posterior tibial tendons may be identified and preserved
o o
o o k oo k
as part of the thick soft-tissue sleeve, but complete detachment should be avoided.
o o oo
eebb e / e
/ b
e b
case of a dislocation of the fourth and fifth metatarsal–cuboid joints.
e ee/e/ebb
• Sometimes a lateral incision may be used to expose the lateral rays, especially in the
: / / t
/ .
tm.m : / / t
/.tm
. m
• A lateral incision is made over the dorsal aspect of the fourth and fifth metatar-
seen proximally).
t p ss
p : / t p ss
p : /
sal–cuboid joints (Fig. 27.8; the metatarsal bases are on the left, and the cuboid is
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
222 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss FIG. 27.6
b ooook
FIG. 27.5
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p s

s : /
FIG. 27.7
p t
p s
p s : / FIG. 27.8
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
FIG. 27.9
k e r
e s
rs k eers
rs
o o
o o k oo k
• Through the dorsolateral exposure, the periosteal elevator is inserted into the
o o oo
eebb e / / b
e b
fourth and fifth metatarsal–cuboid joints.
e e /e/ebb
• The elevator is angled to go under the subluxed bases of the fourth and fifth
e e
: / / t
/ .
tm.m : / / t
/.tm
. m
metatarsals (Fig. 27.9; the metatarsal bases are on the left). The distal articular
t p ss
p : / t p
its plantar position.
ss
p : /
surface of the cuboid can then be released and levered dorsally to reduce it from
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE
k e r s
rs
Preoperative Planning and Principles
e k eers
r s
o o
o o k
• Consider Achilles lengthening.
oooo k o o
eebb • Identify the plane of the deformity.
e / e
/ebb
• Use techniques including anatomic arthrodesis, derotational osteotomies, and clos-
e ee/ e
/ b
e b
ing wedge arthrodesis.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : /
• Apply rigid fixation (screws, plates, or external fixators).
t p ss
p : /
t
hht t
Internal Versus External Fixation t
hht t
• There are studies on midfoot Charcot regarding internal or external fixation, yet with-
out specific guideline or consensus. There are no randomized clinical trials address-
ing these challenges.
• Lee and colleagues6 in a meta-analysis literature review showed increased risk of
k eers
rs k er
erss
infection, limb amputation, and wound complication in internal fixation methods,
b ooook b ooook
but risk of nonunion is eight times higher in external fixation techniques. The senior
author of this chapter has specific guidelines regarding the best fixation technique
b o o
eeb ee/ e
/ e b ee/ e
/
to increase rigidity and union rate with a lower rate of infection and complications.
e b
: // t/.tm
. m
General Principles of Correction of the Midfoot Charcot Deformity
: / /t/.tm. m
t p ss
p : / tp ss : /
• Mild-to-moderate deformity: correction through anatomic midfoot fusion, resection
p
t
hht t
of joint surfaces without wedge
t
hht
• No infection, no ulcer: internal fixation with plantar plate
t
• Noninfected superficial ulcer or marginal infection (history of infection or suspi-
cious infection): minimal internal fixation with screws and added external ring fixa-
tor as a neutralization frame
k rrss
• Active infection or deep ulcer: external frame only
ee keerrss
b ooook b ooook
• Severe deformity: correction though transpedal wedge resection
• No infection, no ulcer: internal fixation with plantar plate with or without screws
b oo
eeb /e e b /e
• Noninfected superficial ulcer or marginal infection: minimal internal fixation with
ee /
screws and added external ring fixator as a neutralization frame ee /e b
: / / t
/ m
.t.m : / / t m
.t.m
• Active infection or deep ulcer: external frame only. Consider using antibiotic
/
t ppss : /
calcium sulfate–impregnated beads in these cases
t ppss : /
t
hhtt
Step 1: Transpedal Wedge Resection t
hhtt
• The soft-tissue envelope is protected during removal of the wedge of midtarsal
bones and joints through the medial approach.
• The transpedal wedge is planned using Kirschner wires (K-wires) across the apex of
k e rrss
e k rrss
the deformity and by checking the placement using the mini C-arm.
e e
• In Fig. 27.10, the K-wires are seen at the bases of the metatarsals and the distal
o o
o o k o o o k
aspect of the cuneiforms and cuboid. This is the plane of the deformity in this type
o o o
eebb I foot.
ee/ e
/ b
e b
• The saw blade penetrates the bones within the boundary of the deformity to
ee/ e
/ b
e b
: / / t
remove a medially based wedge.
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• In the sagittal plane, the wedge is trapezoidal with a wider plantar base to address
t
the rocker-bottom deformity.
hht t t
hht t
• It is critical to save as much bone stock as possible at the bases of the metatar-
sals.
• The wedge of bone removed should be designed to correct the rocker-bottom and
abduction deformities.
k e e s
rs removed.
k eers
• If both are corrected, a plantar-based and medially based wedge of bone is
r rs
o o
o o k oo k
• If only a rocker-bottom deformity is corrected, a plantar-based wedge is removed.
o o oo
eebb e / b
e b
• If there is an adduction deformity, then a laterally based wedge is planned.
/ e
• Figs. 27.11–27.14 illustrate the transpedal wedge resection.
e ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
• In this foot (also shown in Fig. 27.2) with a type I deformity, the saw is seen cutting
t p ss :
hindfoot (see Fig. 27.11).
p / t p ss
p : /
the proximal aspect of the wedge with the blade positioned perpendicular to the
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
224 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k r
eerss FIG. 27.11
eeb
FIG. 27.10
ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e r
e ss
r
o o
o o k
FIG. 27.12
o o
o o k FIG. 27.13
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / FIG. 27.14
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
• The wedge is defined with a chisel in the proximal osteotomy and the saw blade STEP 1 PEARLS
k e r
e s
rs k eers
detached from the handle in the distal cut (see Fig. 27.12). The distal cut is made
r s
perpendicular to the axis of the forefoot. A trapezoidal wedge is removed to ad-
• Cannulated screws (6.5 mm) can be placed
from the posterolateral aspect of the talus into
o o
o o k oooo
dress the abduction and the rocker-bottom deformity.
k o o
the naviculum or cuneiforms when dealing
eebb e /ebb
• In Fig. 27.13, the wedge is seen from the dorsal perspective. Note the dorsolateral
/ e
incision. The saw blade can be watched as it cuts the distal end of the cuboid, or
e ee/ e
/ b
e b with a type III or IV deformity. The guidewire is
placed 2–4 cm proximal to the dorsal aspect
: / / t
/ .
t m
. m
the microsagittal saw can be used through the dorsal approach to complete the
: / / t
/ .
t m
. m
of the calcaneus, just lateral to the Achilles
tendon, spreading the soft tissue to avoid the
transpedal wedge.
p ss
p : / t p ss : /
• The wedge of bone, which includes the damaged articular surfaces, is removed
t p
sural nerve. As long as the placement stays
lateral to the midline, the risk to the tibial
t
hht
(see Fig. 27.14).
t t
hht t nerve is very low. Mini-fluoroscopic guidance
is necessary.
Step 2: Screw Insertion • If a prior hallux amputation was performed,
the 6.5–8.0-mm cannulated screws can be
• Each joint fused should be stabilized by one to two 4.0–5.0-mm cannulated or solid placed from the first metatarsal head into the
screws. Whenever possible, the screws should be nearly perpendicular to the sur-
k eers
rs faces.
k er
erss
medial cuneiform. If needed, these screws can
run all the way to the talus.
b ooook b ooook
• Medially, one screw is placed from the dorsomedial cortex of the first metatarsal
shaft to the medial cuneiform or even into the navicular.
b o o
eeb ee/ e
/ e b /
• We usually add the second screw plantar to the first screw but directed toward the
ee e
/ e b
second cuneiform.
// t/.tm
. m / /t/.tm. m
• A third screw is inserted from the medial cuneiform or navicular toward the second
: :
ss : / ss : /
metatarsal base; it may go further into the third metatarsal base.
t p p tp p
t
hht t t
hht t
• An additional screw may be used to fix the third metatarsal to the lateral cuneiform.
• The lateral two screws are inserted from the plantar lateral cortex of the fifth
STEP 2 PEARLS
• Although the semitubular plate is commonly
metatarsal toward the cuboid. The more distal of the two screws may start on the used plantarly, if fixation is needed under the
fifth metatarsal and go through the fourth metatarsal into the cuboid (Fig. 27.15). navicular and/or the talus, a plate that has a
• If the calcaneocuboid joint is to be fused, one or two 6.5-mm axial screw(s) from wider area for screw placement can be used.
keerrss keerrss
the calcaneal tuberosity to the cuboid and into the fourth metatarsal can be placed Several plating systems have features that are
well suited for this application (see Fig. 27.16).
b ooook (Fig. 27.16).
b ooook b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb A
ee/ e
/ b
e b B
ee/e/ebb

FIG. 27.15
: / / t
/ .
tm.m
: / / t
/.tm
. m
FIG. 27.16
t p ss
p : / t p ss
p : /
hhtt t t
hht t
t t p
t ss:
p t t p
t ss:
p
226 hht
Step 3: Plate Application
k e r
e s
rs k eers
r s
• A plantar medial column plate can be applied under the joints to be fused. This plate
is on the tension side of the construct, making it a very rigid means of fixation.
o o
o o k o oo k o
• Typically, in a type I deformity, the plate is placed under the medial cuneiform and
o o
eebb ee/ e
/ebb ee/ e
/ b
e b
under the first metatarsal. A four- to six-hole small-fragment plate is used with two
screws into the medial cuneiform and the other two into the first metatarsal (see
: / / t
/ .
t m
. m Fig. 27.15).
: / / t
/ .
t m
. m
t p ss
p : / t p ss
p :
pole of the naviculum. /
• In a type II deformity, the plate is placed under the medial cuneiform and medial
t
hht t t
hht t
• In a type III deformity, the plate is placed under the head of the talus and under
the remaining naviculum, ending under the medial cuneiform.
• In a type IV deformity, the plate can be placed under the talus and navicular.
• At times it is necessary to span all the medial joints for stability (see Fig. 27.16).
k e rs
rs
STEP 3 PEARLS
e er
ers
• Although the application of the lateral plantar plates to the underside of the cuboid
s
and fourth and/or fifth metatarsals, he has used a dorsal plate for the last 15 years.
k
b ooook
• Avoid placing the wires in a parallel fashion.
Convergence or divergence of the wires
b oook
This plate does not provide the same rigidity as the plantar plate, which is on the
o b o o
eeb creates better construct stability.
ee/ e
/ e b e / e
/ e b
tension side of the construct. In general, this dorsolateral plate is used for additional
stability when the screws are insufficient.
e
: // t/.tm
. m Step 4: External Fixation
: / /t/.tm. m
t p ss
p : / tp ss : /
• A fine wire frame can be applied for fixation in the face of an active ulcer or osteomy-
p
t
hht t t
hht t
elitis (Fig. 27.17). In addition, it can be useful when there is poor bone stock for screw
fixation.
• When used in active infection, no internal screws should be used.
• If used with a resected chronic osteomyelitis or resected ulcer, supplementary
screws may be used as determined by the surgeon.
keerrss keerrss
• Begin with an olive wire from the medial aspect of the head of the first metatar-
b ooook b ooook
sal, aiming at the head of the fifth metatarsal laterally. The surgeon should hold the
b oo
metatarsals in alignment to facilitate the wire’s passage through as many metatarsal
heads as possible. The ring frame is now attached above the wire and held in place
: / / t
/ m
.t.m : / / t
/ m
with wire holders. It is very important to make sure that the frame is equidistant from
.t.m
the foot on each side and that the sole and frame are in the same plane.
• Next, using an olive wire, starting below the ring, go from the lateral posterior calca-
t
hhtt t
hhtt
neus (distal to the peroneal tendons), aiming medial to just posterior to the neurovas-
cular bundle. The pin holder attached to the ring should be used to help guide the
placement of the wire.
• The third wire (without olive) is started on the medial aspect, above the ring from the
medial cuneiform aiming toward the fifth metatarsal base or toward the fifth head,
k e rrss
e k e rrss
depending on bone quality or technical issues. The wire should be placed through
e
o o
o o k o o
o o k
the pin holder so it is parallel to the ring.
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss
FIG. 27.17
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
• The fourth wire is started posteromedially, just posterior to the tibial neurovascular
k e r
e s
rs
of the ring from the second wire.
k eers
bundle. This wire is directed posterolaterally. The wire should be on the opposite side
r s
o o
o o k oo k
• To tension the wires, always tighten the pin holders in one side and then tension on
oo o o
eebb e / e
/ebb e / e
/ b
e
tightened first) and long in the other (where the tensioning maneuver is done).
e e b
the other side. The wires should be left short in one side of the frame (where they are
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• If an osteotomy was done and there is a need for additional compression of the
t p ss
p : / t p ss : /
site, advance the pin holders one hole closer to the site of the osteotomy prior to
tensioning. A compressive force will be exerted across the osteotomy when the
p
t
ht t
fixator is tensioned.
t
hht t
COMPLICATIONSh
• Inadequate correction
• Broken hardware
k e rs
rs
• Loss of fixation
e k er
erss
b ooook • Osteonecrosis of the talus
b ooook
• Extension of Charcot neuroarthropathy into adjacent joints
b o o
eeb • Pin site infection
ee/ e
/ e b ee/ e
/ e b
• Deep infection
// t/.tm
. m
• Incomplete or delayed union
: : / /t/.tm. m
t
POSTOPERATIVE CAREp sAND
p s : /
EXPECTED OUTCOMES tp pss : /
t
hht
Postoperative Care
t t
hht t
• Protect the foot with non–weight bearing for 3 months.
• When a frame is used, it is typically removed at 3 months.
keer ss
• Cast or brace for an additional 3–12 months.
r keerrss
• Use of crutches, walker, or canes is helpful until full healing is achieved.
b ooook
Outcomes
b ooook b oo
eeb ee/e/e b
• Favorable results with surgical correction are based on appropriate indication,
ee/e/e b
: / / t
/ m
.t.m
planning, and applying appropriate fixation.
: / / t
/ m
.t.m
• In our study, outcomes included improved footwear, no amputation at 5–8-year fol-
t
hhtt t
low-up, and easier foot maintenance in 60 transpedal arthrodesis cases.
hhtt
• Review of 250 (including those 60 cases) of our Charcot midfoot and hindfoot cases
performed over the last 18 years revealed few failures. Most patients have improved
foot function, better footwear, and fewer ulcers or hospital visits for foot problems.
• Approximately 10% of cases will develop a proximal or distal Charcot neuroarthrop-
k eerrss
athy in the same limb within 10 years.
e rrss
e
• There is still an increased risk of amputation in neuroarthropathy cases, especially if
k
oooo k o o k
accompanied by peripheral arterial disease, infection, history of previous infection,
o o o o
eebb EVIDENCE ee / b
e b
trauma, impaired vision, poor glycemic control, older age, and male sex.7
/ e ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
p ss: /
the calcaneocuboid joint. Foot Ankle Int 1999;20:33–6.
t p t p ss:
p /
Kann JN, Parks BG, Schon LC. Biomechanical evaluation of two different screw positions for fusion of
t
hht t t
hht t
Biomechanical study demonstrating the superiority of an axially placed calcaneocuboid screw from
posterior to anterior versus an obliquely placed screw (controlled biomechanical study).
Marks RM, Parks BG, Schon LC. Midfoot fusion technique for neuroarthropathic feet: biomechanical
analysis and rationale. Foot Ankle Int 1998;19:507–10.
Study demonstrating the superiority of a plantar plate versus multiple oblique screws for midfoot
fixation (controlled biomechanical study).
r s
rs rs
rs
Molligan J, Barr CR, Mitchell R, Schon LC, Zhang Z. Pathological role of fibroblast-like synoviocytes in
k e e
Charcot neuroarthropathy. J Orthop Res 2016;34:224–30.
k ee
o o
o o k o oo k
The synovium in the joints of Charcot neuroarthropathy has fibroblast-like synoviocytes (FLSs),
o oo
eebb e / e
/ b
e b e /e/ebb
which are invasive and lead to inflammation and tissue destruction. The synovium has reduced in-
nervation and intense expression of cadherin-11. The FLSs, particularly when activated with tumor
e e
: / / t
/ tm.m : / / t
/ tm
necrosis factor-α, were more invasive and had increased expression of ADAM metallopeptidase
. . . m
with thrombospondin type 1 motif 4, interleukin-6, and receptor activator of nuclear factor kappa-B
cartilage explants.
t p ss
p : / t p ss
p : /
ligand. Addition of a neuropeptide into the cell culture neutralized the catabolic effect of the FLS on
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
228 hht
Pinzur MS. Neutral ring fixation for high risk non-plantigrade Charcot midfoot deformity. Foot Ankle Int
2007;28:961–6.
k e r
e s
rs k eers
r s
Using a prospective algorithm, 26 patients had correction of Charcot midfoot with stabilization with
o o
o o k o oo k
a three-ring external fixator. At a minimum 1-year follow-up, 24 patients were able to ambulate with
o
shoes with custom insoles. There was one unrelated death, one amputation, four patients with
o o
eebb e e
/ebb
case series]).
e ee/ e
/ b
e b
recurrent ulcerations, and two stress fractures related to the wires (Level IV evidence [uncontrolled
/
: / / t
/ .
t m
. m : / / t t m
Schon LC, Easley ME, Cohen I, Lam PW, Badekas A, Anderson CD. The acquired midtarsus deform-
. . m
ity classification system—interobserver reliability and intraobserver reproducibility. Foot Ankle Int
/
t p ss
p : / 2002;23:30–6.
t p ss
p : /
t
hht t t
The authors presented a classification scheme for midtarsal deformities based on clinical and
hht t
radiographic assessment of Charcot cases. They demonstrated intraobserver reproducibility (97%)
and interobserver reliability (81%) based on testing 75 American Orthopaedic Foot and Ankle Soci-
ety members supplied with a teaching booklet and two examination booklets.
Schon LC, Easley ME, Weinfeld SB. Charcot neuroarthropathy of the foot and ankle. Clin Orthop Relat
Res 1998;349:116–31.
k eers
rs k er
ers
The authors characterized 50 ankles, 22 hindfeet, 131 midfeet, and 18 forefeet and made recom-
s
mendations for treatment of Charcot neuroarthropathy in these areas (retrospective review).
b ooook ooook
Schon LC, Weinfeld SB, Horton GA, Resch S. Radiographic and clinical classification of acquired mid-
o o
tarsus deformities. Foot Ankle Int 1998;19:394–404.
b b
eeb ee/ e
/ e b ee/ e
/ e b
A total of 131 radiographs of feet were analyzed and clinical records reviewed to determine a
classification for assessing these deformities. Radiographic types I–IV were identified and clinical
: // t/.tm
. m stages A–C were defined.
: / /t/.tm. m
Simon SR, Tejwani SG, Wilson DL, Santner TJ, Denniston NL. Arthrodesis as an early alternative
t p ss
p : / ss : /
to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am
tp p
t
hht t 2000;82:939–50.
t
hht t
A total of 14 patients with stage I Eichenholtz Charcot feet without ulceration underwent successful
fusion with return to independent ambulation (Level IV evidence [uncontrolled prospective study]).
CITED REFERENCES
keerrss keerrs
1 Dalla Paola L, Carone A, Baglioni M, Boscarino G, Vasilache L. Extension and grading of osteomy-
s
elitis are not related to limb salvage in Charcot neuropathic osteoarthropathy: a cohort prospective
b ooook b ooook
study. J Diabetes Complications 2016;30(4):608–12.
oo
2 Beltran J, Campanini DS, Knight C, McCalla M. The diabetic foot: magnetic resonance imaging
b
eeb e /e/e b e /e/e b
evaluation. Skeletal Radiol 1990;19(1):37–41.
3 Peterson N, Widnall J, Evans P, Jackson G, Platt S. Diagnostic imaging of diabetic foot disorders.
e e
: / / t
/ m
.t.m : / / / m
.t.m
Foot Ankle Int 2016;38(1):86–95.
t
4 Ergen FB, Sanverdi SE, Oznur A. Charcot foot in diabetes and an update on imaging. Diabet Foot
t ppss : / Ankle 2013:4.
t ppss : /
t
hhtt t
hhtt
5 Sella EJ, Barrette C. Staging of Charcot neuroarthropathy along the medial column of the foot in the
diabetic patient. J Foot Ankle Surg 1999;38(1):34–40.
6 Lee DJ, Schaffer J, Chen T, Oh I. Internal versus external fixation of Charcot midfoot deformity rea-
lignment. Orthopedics 2016;39(4):e595–601.
7 Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al. Diabetic foot disor-
ders. A clinical practice guideline (2006 revision). J Foot Ankle Surg 2006;45(Suppl. 5):S1–66.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh28
PROCEDURE
t hht
Painful
r ss Accessory Navicular: Augmented
rs s Kidner
o kkee r
Procedure With Flexor k
Digitorum
o k r
ee Longus Transfer
b o
m ee /e m ee / e
Andrew K. Sands and Edward
: / t
///t. m
Southard
. : / /
/ t
/ .
t . m
t t p
t s
p s : t t p
t ss
p :
hh t hht
INDICATIONS
• Presence of a painful accessory navicular with or without flatfoot.
k ee s
rs k er
ers
• Often associated with equinus contracture as well. Posterior tibial tendon function is
r s
usually intact but may be weakened secondary to pain.
b ooook b ooook
• The enlarged area of the medial hindfoot may also cause problems with regular foot-
b o o
eeb TREATMENT OPTIONS ee/ e
/ e b
wear and footwear for sports activities, such as ski boots.
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss : /
union can be achieved.
p tp pss : /
• Initial treatment can consist of immobilization of the foot and ankle to see if bony
t
hht t
hht t
• There is a bony prominence along the medial hindfoot. This can cause problems
with shoe fitting and sports, especially when a tight boot is worn, such as in skiing/
snowboarding or roller skating. Pain can be present if a twisting injury causes motion
keerrssat a previously securely-bound bony interface.

keerrss
b ooook • Plain radiographs are obtained.
b ooook
• Standing anteroposterior (AP; Fig. 28.1A) and lateral (Fig. 28.1B) views will show
b oo
eeb the deformity.
ee/e/e b ee/e/e b
: / / t
/ m
• The accessory navicular may be attached to the medial navicular by bone or
.t.m : / / t
/ m
.t.m
fibrous tissue, or may be unattached within the posterior tibialis tendon.
t
hhtt Accessory
t
hhtt
Navicular navicular
k e rrss
e k e rrss
e Navic Talus Tibia
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A .m
//t/t.m B
/ t.tm
. m
s:/ / /
AP WB foot Talus Accessory navicular Calcaneus
t p s : p ss: : /
FIG. 28.1 Anteroposterior (AP) and lateral weight-bearing (WB) radiographs of the foot.
t
t
hht t p t
hht t p 229
t t p
t ss:
p t t p
t ss:
p
230 hht hht
PROCEDURE 28 Painful Accessory Navicular: Augmented Kidner Procedure With Flexor Digitorum Longus Transfer
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m Second, third,
t p ss
p : / t p ss
p : / fourth
metatarsals
t
hht t t
hht t Cuneiforms
Cuboid
Navicular
Navicular
k eers
rs k er
erss Tibialis posterior
tendon
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / Tibialis posterior
tp pss : /
A t
hht t tendon
hht t t
B
FIG. 28.2
keerrss keerr
SURGICAL ANATOMYss
b ooook b ooook oo
• The posterior tibialis tendon comes distally into the foot just behind the medial malleolus.
b
• It makes a sharp bend when it goes from vertical to horizontal (Fig. 28.2A). This can
also be a zone of circulatory compromise that can lead to tendinopathy.
: / / t
/ m
.t.m : / / t m
.t.m
• The tendon then travels distally to the medial navicular area, continues under the
/
foot, and fans out to form a medial support for the foot. It inserts onto the navicular
t
hhtt t
hhtt
and the cuneiforms, the cuboid, and the bases of the middle metatarsals (Fig. 28.2B).
• It is thought that, when the accessory navicular is present, this distal extension is
weaker and less extensive.
• Care must be taken to maintain a shell of bone in the posterior tibialis tendon when
performing a repair. The bony shell can be reapproximated to the medial navicular
k e rrss
e k rrss
with a screw and washer. Attempting to attach the stripped posterior tibialis tendon
e e
to the bone does not result in good healing and bonding.
o o
o o k o o o k o
• A medial utility incision can give good exposure of the posterior tibialis and flexor
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
digitorum longus (FDL) tendons as well as the bony structures.
: / / t
/ m
POSITIONING
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• The patient is placed supine with a contralateral bump under the pelvis.
• This “super”-supine position allows excellent exposure to the medial foot for the
t
hht t hht t t
medial utility incision.
PORTALS/EXPOSURES
• A medial utility incision allows excellent access to the surgical field. The medial promi-
k e r
e s
rs k eers
nence of the navicular is marked. A point 1 cm below the medial malleolar tip is marked.
rs
The center of the first metatarsal head is marked. A straight line can then be drawn
o o
o o k oo k
connecting these three points, approximately along the medial border of the plantar
o o oo
eebb e / e
/ b
e b e /e/ebb
skin pattern. The proximal half of the marked line can be used for this procedure.
• The incision is carried down through the subcutaneous tissue (Fig. 28.3). The vertical
e e
: / / t
/ .
tm.m : / / t
/.tm
. m
veins along the medial aspect of the foot are cauterized.
t p ss
p : / t p ss : /
• The FDL is found just posterior and inferior to the posterior tibialis tendon. A small
clamp can be placed behind it. Confirmation can be obtained by moving the lesser
p
t
hht t t
hht t
toes; the correct tendon will be seen gliding over the clamp.
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 28 Painful Accessory Navicular: Augmented Kidner Procedure With Flexor Digitorum Longus Transfer 231
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb / e b b
Tibialis posterior
ee / e
tendon
: / / t
/ .
t m
. m : / / t . m
. m
Flexor digitorum
/ t
Accessory
navicular
t p ss
p : / t p ss
p : / longus tendon
t
hht t t
hht t Flexor hallucis
longus tendon
k eers
rs k er
erss Medial
cuneiform
b ooook A
b oo oo k B
b o o
eeb b b
FIG. 28.3
ee/ e
/ e ee/ e
/ e
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp
Dorsal
pss : /
t
hht t t
hht t Distal
keerrss Proximal
keerrss
eeb e /e
FDL tendon
e /e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
Plantar
A
rrss rrss
Posterior tibialis tendon Master knot of Henry
o k e
k e o k e e
Flexor digitorum
k
Accessory
o
eebb o o e b o
b o o
longus tendon navicular
e b o
b o
m ee/ / e m ee/ / e
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
t t p
t ss:
p t t p
t ss:
p
hht hht
Medial
cuneiform
B
k e r
e s
rs k eers
rs FIG. 28.4
o o
o o k o o
oo k oo
eebb e / b
e b
• Once the FDL is found, it is followed distally to the master knot of Henry (Fig. 28.4).
/ e e /
There are often large veins along the deep medial border, and care must be taken to
e e e/ebb
: / / / .
tm m : / / /.
cauterize them as the dissection is carried toward the master knot of Henry.
t . t tm
. m
t p ss
p : / t p ss : /
• Once the master knot is found, the FDL is again confirmed and transected (Fig. 28.5).
The paratenon is stripped and is used for the augmented tendon transfer once the
p
t
hht t
bony procedure is completed.
t
hht t
t t p
t ss:
p t t p
t ss:
p
232 hht hht
Distal
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : /
Medial accessory
navicular
t p ss
p : /
t
hht t Proximal (ankle)
FDL released at
Master knot of Henry
t
hht t
k eers
rs k er
erss
b ooook b o o
o o k FIG. 28.5
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m
PROCEDURE
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
Step 1: Exposure of the Posterior Tibial Tendon Sheath
hht t
• Carry the incision deep through the subcutaneous tissue to the tendon sheath.
• Enter the sheath, but take care to avoid injury to the posterior tibialis tendon. Follow
it distally to the accessory navicular.
• Using a sharp chisel or osteotome, cut down into the gap between the bones (or, if
keerrss keerrss
fused, make a plane along the medial border of the cuneiform), and flip the posterior
b ooook b ooook
tibialis and attached accessory navicular outward, taking care to keep it attached
oo
along the plantar aspect if possible (Fig. 28.6).
b
eeb STEP 2 PEARLS
ee/e/e b e /e/e b
Step 2: Excision of Accessory Navicular and Augmentation of
e
/ / t
/ m
.t.m
• When drilling the pilot hole into the navicular,
: : / / / m
.t.m
Posterior Tibial Tendon Insertion
t
t ppss : /
take care to aim distally. The talonavicular joint
t ppss : /
• The bony prominence is removed with a rongeur, taking care to maintain the bony
t
hhtt
is spherical, and if one drills straight across
from the medial navicular border, the joint will
be entered and damaged. This can also be
t
hhtt
shell of cortical bone along the tendon (Fig. 28.7).
• The medial navicular can also be shaved down to just below the medial border of the
cuneiform. This allows the resulting medial border of the foot to be flushed once the
done under fluoroscopic control. The trajectory
and depth of the drill can be aimed using the repair is completed.
mini-fluoroscopy machine (Fig. 28.11). • The shell of bone is predrilled in the middle portion of the bony shell. The navicular is
k e rrss
e k e rrss
also predrilled, taking care so as not to enter the talonavicular joint (Fig. 28.8).
e
• The screw with washer is inserted through the shell of bone and into the navicular
o o
o o k o o
o o k o
body until the bony shell is in contact with the medial navicular (Fig. 28.9). The ten-
o
eebb STEP 2 CONTROVERSIES
ee/ e
/ b
e b ee e
/ b
e b
don profile should be even with the medial cuneiform.
/
• The FDL can then be transferred into a bony trough on the underside of the navicu-
/
• Trough with suture versus drill hole with
: / t
/ m
.t.m : / / t
/ m
.t.m
lar–cuneiform joint, further augmenting the posterior tibialis tendon (Fig. 28.10).
interference screw.
t p ss: /
• The tendon either can be attached to the
p t p ss:
p /
• The bony trough can be made on the underside medial ridge of the navicular–cu-
neiform joint with a rongeur. A 2.5-cm drill hole can be made from dorsal to plantar
t
hht t
underside of the navicular–cuneiform joint
in a bony trough with suture only through
the bone or can be brought through a
t
hht t
through the body of the cuneiform.
• A suture (0 monofilament absorbable on a large needle) is fed backward down
drill hole into the bone and fixed with an through the drill hole. The suture is then whip-stitched from distal to proximal for
interference screw. The author’s preference approximately 2 cm.
is to use a trough with a suture, with no
k e r
e s
rs
experience of the problem of pull-out. A
k eers
• Another drill hole is made through the body of the navicular into the trough. The
rs
same suture is then passed upward and is tied by dorsally pulling the FDL up into
o o
o o k similar notion is presented by Levy et al.
(2000) for biceps repair. The biceps repair
o o
oo k the bony trough.
oo
eebb is tacked to the paratenon, where the
tendon stays and adheres.
ee/ e
/ b
e b e / /ebb
• Supplemental sutures can be added along the side to further secure the transfer.
e
• Use of suture anchor-type devices can be considered if the quality of the bone or
e
• A large pull-through tunnel with
an interference screw may also be
: / / t
/ .
tm.m : / / t
/.tm
. m
tendon is less than ideal. The attached sutures can be whip-stitched up the FDL
unnecessarily expensive.
t p ss
p : / t p ss : /
tendon and include the posterior tibial tendon for more secure reconstruction. This,
however, must be weighed against the increased cost of the implant.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Posterior tibialis tendon Medial boder of navicular
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
A FDL Accessory navicular
Tibialis
keerrss posterior tendon
keerrss Navicular
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
Flexor digitorum Accessory
longus tendon navicular
B
k e rrss
e k e rrss
e FIG. 28.6
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / / m
.t.m
Accessory navicular posterior tibialis tendon
t : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t t
Rongeur shelling out cancellous bone from accessory navicular
hht
FIG. 28.7
t t p
t ss:
p t t p
t ss:
p
234 hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 28.8
keerrss keerrss
b ooook b ooook
Accessory navicular brought
b oo
eeb ee/e/e b back up into place
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs
Screw with washer
k eers
FDL
rs
FIG. 28.9
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 28 Painful Accessory Navicular: Augmented Kidner Procedure With Flexor Digitorum Longus Transfer 235
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : /
Accessory navicular bony shell in
tp pss : / FDL transfer into bony trough
t
hht t place held by screw/washer
t
hht t
FIG. 28.10
keerrss keerrss
b ooook b ooook b
Postoperative lateral weight bearing
oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
A t
hht t
Postoperative AP foot weight bearing B hht t t
FIG. 28.11
k e r
e s
rs k eers
rs
• The patient is placed into a three-sided plaster splint with the ankle and hindfoot in
o o
o o k neutral.
o o
oo k oo
eebb b b
• At the first postoperative visit another cast or a controlled ankle movement (CAM)
/ e e b /
walker can be applied. The patient should be non–weight bearing but can be allowed
ee / ee e/e b
/ / t tm.m
foot and ankle are protected in the splint or the CAM walker boot.
: / : / / t
/ tm
to place the foot down gently during activities such as tooth brushing as long as the
. . . m
ss : / ss : /
• After 6 weeks gentle range of motion begins. Weight bearing is progressed to full.
t p p t p p
t
hht t t
hht t
More aggressive physical therapy is begun at 12 weeks if needed.
t t p
t ss:
p t t p
t ss:
p
236 hht hht
EVIDENCE
k e r
e s
rs rs
r s
Bennett GL, Weiner DS, Leighley B. Surgical treatment of symptomatic accessory tarsal navicular.
k ee
J Pediatr Orthop 1990;10:445–9.
o o
o o k o oo k o
This study is a retrospective review of surgical treatment of 50 consecutive patients with sympto-
o o
eebb bb b b
matic accessory tarsal naviculars that failed conservative treatment. Outcome was determined by
ee/ e
/e e / e
/ e
clinical and subjective assessment (Level IV evidence [case series]).
e
: / / t
/ .
t m
. mFoot Ankle Int 2004;25:27–30.
: / / t
/ t m
Kopp FJ, Marcus RE. Clinical outcome of surgical treatment of the symptomatic accessory navicular.
. . m
t p ss
p : / t p ss
p : /
This study is a retrospective review of surgical treatment of 13 consecutive patients for sympto-
matic accessory navicular. Follow-up averaged 103.4 months, and outcome was judged by clinical
t
hht t t
hht t
results utilizing American Orthopedic Foot and Ankle Society-Midfoot scores (Level IV evidence
[case series]).
Levy HJ, Mashoof AA, Morgan D. Repair of chronic ruptures of the distal biceps tendon using flexor
carpi radialis tendon graft. Am J Sports Med 2000;28:538–40.
This study is a case series of five patients with chronic distal biceps tendon ruptures treated with
k eers
rs k er
ers
flexor carpi radialis tendon graft through suture anchors. Follow-up was a minimum of 2 years, and
s
outcome was determined by clinical assessment (Level IV evidence [case series]).
b ooook ooook
Macnicol MF, Voutsinas S. Surgical treatment of the symptomatic accessory navicular. J Bone Joint
Surg Br 1984;66:218–26.
b b o o
eeb e / e
/ e b
IV evidence [case series]).
e ee/ e
/ e b
This study is a retrospective series of the treatment of 47 patients with the Kidner operation (Level
: // t/.tm
. m / /t/.tm. m
Prichasuk S, Sinphurmsukskul O. Kidner procedure for symptomatic accessory navicular and its relation
to pes planus. Foot Ankle Int 1995;16:500–3.
:
t p ss
p : / ss : /
This study is a case series of surgical treatment of symptomatic accessory navicular in relation to
tp p
t
hht t t t
pes planus in 28 patients. Follow-up averaged 3.2 years, and outcome was determined by radio-
hht
graphic and clinical assessments (Level IV evidence [case series]).
Ray S, Goldberg VM. Surgical treatment of accessory navicular. Clin Orthop Related Res 1983;177:
61–6.
This study is a retrospective review of surgical management of the accessory navicular using the
Kidner procedure in 29 feet. Follow-up averaged 4.5 years, and outcome was judged by subjective
keerrss keerrss
assessment (Level IV evidence [case series]).
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh29
PROCEDURE
t hht
Painful
rss Accessory Navicular Treated
r s s With Fusion of
o k
the
k r
eeSynchondrosis o kkee r
ooo
b o
m ee /e m ee / e
Glenn B. Pfeffer
: / t
///t. . m : / /
/ t
/ .
t . m
t t p
t s
p s : t t p
t ss
p :
h h t hht
INDICATIONS INDICATIONS PITFALLS
• Painful type II accessory navicular • The accessory navicular has to be of sufficient
size to accept a screw without fragmentation.
k ee s
• Failure of conservative care
rrs
EXAMINATION/IMAGING k er
erss If increased heel valgus has developed on
the symptomatic side, a calcaneal osteotomy
should be added to the procedure.
eeb e / e
/ e b
• The hallmark of the examination is focal pain over the accessory navicular.
• Posterior tibial tendon function may be compromised by pain at the accessory na-
e ee/ e
/ e b
: // /.tm m
vicular, although unassisted toe rise is still possible.
t . : / /t/.tm. m INDICATIONS CONTROVERSIES
t p ss
p : / tp ss : /
• A flatfoot deformity, with increased heel valgus, may develop in advanced cases.
• Standing anteroposterior (Fig. 29.1A), lateral (Fig. 29.1B), and oblique (Fig. 29.1C)
p
• A high rate of failure has been reported after
simple excision of a large type II accessory
t
hht t
views of the foot should be obtained.
t
hht t
• A computed tomography scan through the navicular helps determine if the acces-
navicular, with or without advancement of the
posterior tibial tendon. Fusion of the painful
synchondrosis preserves the normal anatomy
sory piece is of sufficient size to accept a screw. of the foot and function of the posterior
• Magnetic resonance imaging is helpful if concomitant posterior tibial tendinopathy is tibial tendon, without the need for additional
present, which is unusual. procedures.
keerrss keerrss • Heel valgus should be corrected with a

medializing calcaneal osteotomy in cases
b ooook b ooook b oo where the navicular fragment is excised (see
eeb ee/e/e b ee/e/e b Procedure 28).
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m C
t p ss
p : /
t p ss
FIG. 29.1
p : /
t
hht t t
hht t 237
t t p
t ss:
p t t p
t ss:
p
238 hht
PROCEDURE 29 Painful Accessory Navicular Treated With Fusion of the Synchondrosis hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
Navicular
t
hht t t
hht t
k eers
rs A I
k er
erss II III
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m
Posterior tibial
tendon
: / /t/.tm. m
t p ss
p : / tp pss : /
Type II accessory
t
hht t t
hht t
navicular
keerrss keerrss
b ooook b o
oo o k FIG. 29.2
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt TREATMENT OPTIONS
t
hhtt
• Orthotics may be helpful for mild symptoms.
• A walking cast for 4–6 weeks should be tried prior to operative intervention.
k e rrss
e k e rrss
• Physical therapy may be beneficial in select cases.
e
o o
o o k o o
o o k
SURGICAL ANATOMY
o o
eebb ee/ e
/ b
e b e / e
/ b
e b
• There are three types of accessory navicular (Fig. 29.2A).
• This procedure is used for type II accessory navicular (Fig. 29.2B).
e
: / / t m
.t.m
POSITIONING
/ : / / t
/ m
.t.m
t p ss:
p / t p ss: /
• The patient is placed supine.
p
t
hht t
• The incision should not be curved along
the course of the posterior tibial tendon. A
longitudinal incision facilitates placement of
t
hht t
• A bump under the contralateral hip will help externally rotate the leg.
• An ankle tourniquet may be used, but a thigh tourniquet is preferable as it places no
the pin and cannulated screw. tension on the posterior tibial muscle or tendon during the repair.
PORTALS/EXPOSURES
k e e s
r rs
• Loupe magnification will be helpful.
k eers
rs
• The longitudinal incision starts 1.5 cm distal to the anterior edge of the medial malle-
o o
o o k o o
oo k
olus and extends 2 cm distal to the accessory navicular (Fig. 29.3).
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 29 Painful Accessory Navicular Treated With Fusion of the Synchondrosis 239
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 29.3
k er
erss
FIG. 29.4
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t pps :
s / t s
pp s : /
t
hhtt
FIG. 29.5
t
hhtt
FIG. 29.6
PROCEDURE STEP 2 PEARLS

• It is essential to evaluate the oblique angle
Step 1
k e rrss
e k e rrss
e
• Open the posterior tibial tendon sheath along its superior border (Fig. 29.4).
of the synchondrosis from the preoperative
radiographs. Otherwise, a false plane may be
o o
o o k o o o k
• A mild synovitis may be present, which should be débrided.
o o created as the accessory navicular is detached
o
eebb b b from the navicular.
Step 2
ee/ e
/ e b ee/ e
/ e b
• The attachment of the posterior tibial tendon
: / / t
/ m
.t.m
• Locate the synchondrosis of the navicular.
: / / t
/ m
.t.m
must be kept intact. Care is taken not to
damage the spring ligament.
t p ss:
p / t p ss:
p
between the body of the navicular and the accessory piece (Fig. 29.5). /
• Walk along the bone with a round-tipped Beaver blade to identify the junction • The underlying approach to this procedure is
similar to that of a scaphoid nonunion in the
Step 3
t
hht t t
hht t wrist, including removal of fibrous tissue and
sclerotic bone, bone graft to fill the defect, and
application of internal rigid fixation.
• Remove the fibrocartilaginous tissue from each bony piece.
• Sclerotic bone often caps the bone ends and should be lightly débrided with a 3-mm
k e r
e s
burr while irrigating with cool saline (Fig. 29.6).
rs k eers
rs
o o
o o k
Step 4
o o
oo k oo
eebb (Fig. 29.7).
ee / b
e b
• Use a 2–3-mm curette to débride the bone pieces back to healthy cancellous bone
/ e ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
• Care must be taken to keep the cortical shell of the accessory navicular intact.
t p ss
p : / t p ss : /
• Adequate cancellous bone must be preserved in the tip of the accessory navicular to
hold the proximal portion of the cannulated headless screw (Fig. 29.8).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
240 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 29.7
k er
erss
FIG. 29.8
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t pp s:
s / t ps
p s : /
t
hhtt FIG. 29.9
t
hhtt FIG. 29.10
Step 5
k e rrss
e k rrss
• Cancellous bone is morcellized and placed into the concave defects in each piece.
e e
• The graft should be easily compressible so that it can contour to the space (Fig.
o o
o o k o o o k
29.9).
o o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
• Either the lateral calcaneus or proximal tibial are excellent harvest sites.
: / / t
/ m
.t.m Step 6
: / / t
/ m
.t.m
STEP 6 PEARLS
t p ss:
p / t p ss:
p /
• Using a mini-driver, position a 0.045-inch guidewire for an appropriately sized
headless screw across the reduced pieces (Fig. 29.10). Confirm the placement by
t
hht t
• A small incision in the posterior tibial tendon
provides the best access for the screw, without
removing any of the posterior tibial tendon
fluoroscan. t
hht t
• Determine the appropriate screw length. The screw does not have to engage the
attachment into the accessory navicular (Fig. far cortex as it will have excellent compression in the dense cancellous bone of the
29.11).
navicular.
k e r
e s
rs Step 7
k eers
rs
o o
o o k oo k
• Compress the pieces with a towel clip, and drill as needed. Often just the cortical
o o oo
eebb ee/ e
/ b
e b e /e/ebb
bone of the accessory navicular piece requires drilling.
• Carefully place the Acutrak 2 miniscrew and confirm final position by fluoroscopy.
e
: / / t
/ .
tm.m : / / t
/.tm
. m
• Compression of the pieces will be evident as the screw enters (Fig. 29.12).
t p ss
p : / t p ss : /
• Place the ankle in plantar flexion and the foot in supination during screw place-
ment to relax the posterior tibial tendon and diminish pull on the accessory piece.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 29 Painful Accessory Navicular Treated With Fusion of the Synchondrosis 241
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
Posterior tibial
tendon
keerrss keerrss
b ooook b ooook Type II accessory
navicular
b oo
eeb ee/e/e b Cannulated
screw
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t
hhtt t
hhtt B
FIG. 29.12
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
• The tendon can be repaired with two 3-0 Ethibond sutures, burying the knots within
: / / t
/ m
.t.m
the tendon. Repair the tendon sheath using similar sutures.
: / / t
/ m
.t.m
sutures.
t ss:
p / t p ss:
p /
• Deflate the tourniquet, obtain hemostasis, and close the skin with simple nylon
p
hht t t hht t t
• Place a bulky splint with the foot in supination and the ankle in slight plantar flexion.

• The patient is seen 10–12 days postoperatively, and the sutures are removed. Apply
k e r
e s
rs k eers
a non–weight-bearing cast with the foot in supination and the ankle in neutral.
rs
• Change the cast at 1 month after surgery and bring the foot into a neutral position.
o o
o o k oo k
The patient is kept non–weight bearing for 6 weeks postoperatively. At 6 weeks, the
o o oo
eebb e / b
e b
cast is removed and weight bearing is allowed in a cast boot, if healing is evident
/ e e /e/
clinically and by radiography (Fig. 29.13). Physical therapy may be beneficial to re-
e e ebb
store range of motion and strength.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss :
union of the attempted fusion.
p / t p ss
p : /
• All patients can be expected to do well and be symptom free, unless there is a non-
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
242 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : / B
tp pss : /
t
hht t t
hht t
FIG. 29.13
keerrss keerrss
b ooook EVIDENCE
b ooook b oo
Kidner FC. The pre hallux (accessory scaphoid) in its relation to flat foot. J Bone Joint Surg
: / / t
/ m
.t.m 1929;11:831.
: / / t
/ m
.t.m
The first description of a surgical procedure to treat a painful accessory navicular (Level IV evi-
t ppss : / dence).
t ppss : /
t
hhtt t
hhtt
Knupp M, Hintermann B. Reconstruction in posttraumatic combined avulsion of an accessory navicular
and the posterior tibial tendon. Tech Foot Ankle Surg 2005;4:113–8.
This technical article reviews a modification of the Kidner procedure first published by Malicky
et al. in 1999. The technique involves fusion of the accessory navicular piece to the body of the na-
vicular, with more bone resection than the method described in this procedure (Level IV evidence).
Kopp FJ, Marcus RE. Clinical outcomes of surgical treatment of the symptomatic accessory navicular.
k e rrss
e k rrss
Foot Ankle Int 2004;25:27–30.
e e
This study reviews 14 feet that underwent surgical treatment for symptomatic accessory navicular
o o
o o k o o k
with excision of the piece and advancement of the posterior tibial tendon (Kidner procedure). The
o o o o
eebb b b
clinical status of each patient improved significantly. The authors use the American Orthopedic
e / e e b / e e b
Foot and Ankle Society Midfoot scale to evaluate the results in the study (Level IV evidence).
e / ee /
Malicky ES, Levine DS, Sangeorzan BJ. Modification of the Kidner procedure with fusion of the primary
: / / t
/ m
.t.m : / / t
/ m
.t.m
accessory navicular bones. Foot Ankle Int 1999;20:53–4.
t p ss:
p / t p ss: /
The authors fused the accessory navicular to the body in an effort to avoid the complications
associated with excision of the piece (Level V evidence).
p
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh30
PROCEDURE
t hht
Posterior
rss Tibial Tendon Dysfunction
rss
kkee r
ooMark E. Easley and Andrew Harston boooo kkee r
b
eeboo / e b / e b o
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht
• Patient must first fail nonoperative measures for a minimum of at least 3–6 months.
• Stage I includes tenosynovitis without deformity that has been refractory to con-
hht
• Ensure radiographs are full weight bearing to
accurately measure talar head uncovering on
the anteroposterior (AP) projection.
servative treatment.
• Do not be fooled by congenital pes planus.
• Stages II–IV includes painful deformity with medial and/or lateral foot pain. Posterior tibial tendon dysfunction (PTTD) is an
k eers
rs presses the lateral structures.
k er
ers
• Lateral pain is classically subfibular impingement as the valgus hindfoot com-
s acquired, progressive deformity with specific
etiology and treatment algorithms.
b ooook b oook
• Note that in the later stages of disease, the patient may no longer complain of
o b o o
• The deformity must be flexible (fully passively
correctable on examination) to consider joint-
eeb EXAMINATION/IMAGING ee/ e
/ e b ee/ e
/ e b
medial pain because of the chronicity of the posterior tibial tendon (PTT) tear.
sparing procedures.
• Rigid deformities must be managed with
: // t/.tm
. m : / /t/.tm. m hindfoot arthrodesis.
• What to look for:
t p ss : /
• “Too many toes sign”
p tp pss : / INDICATIONS CONTROVERSIES
t
hht t
• Inability to perform a single heel rise t
hht t
• Inability to bring the hindfoot into varus or neutral when standing on toes
• Stage I: Is tenosynovectomy enough, or is transfer
of flexor digitorum longus (FDL) necessary?
• Pain along the PTT (especially around the medial malleolus) • Stage II: When is a medializing calcaneal
• Subfibular impingement pain osteotomy necessary?
• History of progressive foot deformity • Stage IIb: When to pursue joint-sparing
keerrss keerrss
• Fig. 30.1 shows stage IIb PTTD seen on AP radiograph. Note the talar head uncover-
operations versus arthrodesis?
• Stage III: Is a triple arthrodesis the only option?
b ooook ing and forefoot abduction.
b ooook
• Fig. 30.2 shows stage IIb PTTD seen on lateral radiograph. Note the loss of Meary
b
• Stage IV: Is a pantalar arthrodesis the only option?
oo
eeb ee/e/e b /e
line, calcaneal pitch, and medial cuneiform height (now more plantar than the base
ee /e b TREATMENT OPTIONS
of the fifth metatarsal).
: / / t
/ m
.t.m : / / t
/ m
.t.m • Every operation includes a Silfverskiöld test
t ppss : / t ppss : / with a gastrocnemius release or tendo-Achilles

lengthening as necessary. This is performed first.
t
hhtt Weight bearing t
hhtt • Treatment options traditionally follow the Johnson
and Strom (1989) classification system:
• Stage I: Tenosynovectomy
• We do not recommend FDL transfer
• Surgery is very rarely indicated for stage I
• Stage IIa: PTT débridement
k e rrss
e k e rrss
e
• FDL transfer
o o
o o k o o
o o k o
• Spring ligament repair versus
o reconstruction
eebb ee/ e
/ b
e b ee/ e
/ b
e b • Medial displacement calcaneal osteotomy
(MDCO)
: / / t
/ m
.t.m : / / t
/ m
.t.m • Possible Cotton procedure (opening wedge
osteotomy of the medial cuneiform)
t p ss:
p / t p ss:
p / • Stage IIb: PTT débridement
t
hht t t
hht t • FDL transfer
• Spring ligament repair versus reconstruction
• Lateral column lengthening
• MDCO
• Possible Cotton procedure (opening wedge
osteotomy of the medial cuneiform)
k e r
e s
rs k eers
rs • Possible peroneal brevis to longus tendon
transfer
o o
o o k o o
oo k oo
• Stage III: Triple arthrodesis
• Rarely, isolated joint arthrodesis is possible
eebb ee/ e
/ b
e b ee/e/ebb • Stage IV: Pantalar arthrodesis
• May consider triple arthrodesis with deltoid
: / / t
/ .
tm. m : / / t
/.tm
. m ligament reconstruction
• This procedure will focus on the surgical
t p ss
p : /
FIG. 30.1
t p ss
p : / treatment options of stages IIa and IIb
t
hht t t
hht t 243
t t p
t ss:
p t t p
t ss:
p
244 hht
PROCEDURE 30 Posterior Tibial Tendon Dysfunction hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 30.2
k er
erss
b ooook b oooo k
b o o FIG. 30.3
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss

: / / t
/ m
.t.m : / / t
/ m
.t.m
t pps s : /
FIG. 30.4
ps
t p s : /
POSITIONING PEARLS
t
hhtt
• Thigh tourniquet recommended
t
hhtt
FIG. 30.5
SURGICAL ANATOMY
• Patient’s foot placed at the very end of the bed
• Severely diseased PTT (Fig. 30.3)
k rrss
e e k e rrss
• Torn spring ligament (Fig. 30.4)
e
• Peroneal tendons directly overlying the lateral column lengthening osteotomy site
o o
o o k
• A standard bump is often insufficient to allow
for easy access to the lateral foot.
o o
o o k
(Fig. 30.5)
o o
eebb / e
POSITIONING
ee / b
e b ee/ e
/ b
e b
: / / t
/
• A large or mini C-arm may be used, depending m
.t.m • Supine
: / / t
/ m
.t.m
on the surgeon’s preference.
t p ss:
p / t p
internal rotation ss:
p /
• “Sloppy lateral” on a beanbag to have the foot resting in approximately 25–45° of
• We use a mini C-arm.
t
hht t PORTALS/EXPOSURES
t
hht t
PORTALS/EXPOSURE PEARLS • Stage IIa:
• Perform Silfverskiold test and necessary • Medial approach for the PTT exposing from behind the medial malleolus and
tendon releases first.
r s
rs
• Expose the medial side first to assess the
k e e e rs
down the medial aspect of the medial column of the foot
rs
• Oblique incision over the lateral calcaneus in the same orientation of the subse-
k e
o o
o o kpathology, but do not repair, reconstruct, or
transfer any structures until the laterally based
o o
oo k
quent calcaneal osteotomy
oo
eebb osteotomies are completed.
• Stage IIb: when performing a lateral calcaneal
ee/ e
/ b
e b for a Cotton osteotomy
ee/ /ebb
• Possible dorsal, medial incision over the midfoot to access the medial cuneiform
e
/ / t tm
lengthening, consider cutting the peroneal brevis
. .
tendon at its insertion to improve exposure if
: / m • Stage IIb:
: / / t
/.tm
. m
ss : /
transferring to the peroneal longus tendon.
t p p t p ss : /
• The same approaches as for stage IIa, as well as separate sinus tarsi incision over
the neck of the calcaneus
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 30.6
b oooo k
b o o FIG. 30.7
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
PROCEDURE
t p ss
p : / tp ss
p : /
t
hht t
Achilles lengthening as necessary. This is performed first.
t
hht t
• Every operation includes a Silfverskiold test with a gastrocnemius release or tendo-
PORTALS/EXPOSURE PITFALLS
• We prefer to evaluate the spring ligament
before proceeding with lateral incisions and
osteotomies. Conversion to an arthrodesis may
Step 1 (Medial Approach) be considered based on your findings.
• When planning both the lateral column
keer ss
• Use a medial approach for the PTT.
r keerrss
• This usually starts on the posterior–distal aspect of the medial malleolus and runs
lengthening and medializing calcaneal
osteotomy, keep both incisions small to ensure
b ooook o ook
distally along the plantar–medial surface of the medial column of the foot.
b o b oo they do not connect.
eeb • The incision is typically 8–10 cm long.
ee/e/e b
• Take care to avoid the saphenous vein and large branches of the saphenous nerve.
ee/e/e b PORTALS/EXPOSURE EQUIPMENT
: / t
/ m
.t.m : / / t
/ m
.t.m
• This incision should be anterior and distal enough to avoid exposure of the neu-
/ • Laminar spreaders and Hintermann retractors
t pps
rovascular bundle.
s : / t ppss : / to assist with a controlled lateral column
t
extent of disease. t
• Inspect the PTT, making the decision to repair, débride, or excise depending on the
hhtt hhtt
• We typically resect the diseased tendon portion, leaving 2 cm distally of the stump
lengthening and Cotton osteotomy.
PORTALS/EXPOSURE CONTROVERSIES
and 2 cm proximally before the musculotendinous junction (Fig. 30.6).
• Assess the excursion of the PTT proximally. • The order of procedures is often debated.
Going medial first to assess the PTT and the
k e rrss
e k e rrss
• Its mobility will dictate whether to tenodese the FDL or not.
e
• Free up the tendon distally to the knot of Henry as shown in Fig. 30.7.
spring ligament is our preferred approach.
Others will start with the bony work laterally
o o
o o k o o
o o k
• Inspect the spring ligament to determine if it is repairable or nonrepairable. Place
o o
so that the final position of the hindfoot is set
eebb e / b
e b
sutures in the ligament now, but do not tie them yet.
/ e e /
• Reconstruction options include autograft or allograft tendon or synthetic/suture
e e e
/ b
e b once the medial side is opened.
substitute.
: / / t
/ m
.t.m : / / t
/ m
.t.m STEP 1 PEARLS
t p ss:
p /
• See Figs. 30.8 and 30.9 for primary repair.
t p ss: /
• Note: Leave the medial side now to perform all necessary lateral procedures. Plan to
p
• The final fixation of the tendon transfer will be
t
hht t
return for final fixation of the medial structures.
• FDL transfer:
t
hht t performed once all bony work in the operation
is complete.
• Ensure that 2 cm of the distal stump of the
• We have come to prefer an in situ side-to-side transfer/substitution of the FDL PTT remains to assist with FDL transfer.
without a distal harvest. • Débride diseased spring ligament in an
• The FDL tendon can be found inferior to the PTT just distal to the medial malleolus. elliptical shape to help assist with repair.
k e r
e s
rs
k e rs
rs
• Free up the tendon distally to the knot of Henry.
e
o o
o o k
o o
oo k
• Split the distal stump of the PTT longitudinally. Then incorporate the FDL tendon
oo
STEP 1 PITFALLS
eebb b b
into the central portion of split PTT using nonabsorbable sutures (Fig. 30.10).
ee/ e
/
• Another option is to harvest the FDL.
e b ee/e/e b • After débriding/resecting the PTT, assess the
proximal stump for excursion. If no excursion is

: / / t
/ tm.m : / / t
/.tm
• FDL augmentation of PTT is traditionally done by harvesting at the knot of Henry
. . m
and transferring into the navicular using a suture anchor (see final postoperative
found, do not transfer the FDL to the proximal
stump; otherwise, you will produce a myodesis
t p ss : /
AP radiograph; Fig. 30.28).
p t p ss
p : / effect.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
246 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 30.8
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m
: / /t/.tm. m
t p ss
p : / tp p ss : / FIG. 30.9
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e
FIG. 30.10
k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b
ee/ e
/ b
e b FIG. 30.11
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
STEP 1 INSTRUMENTATION
t
hht t t
hht t
Step 2: Lateral Column Lengthening; Evans Procedure
• A sinus tarsi approach is made.
• If performing a complete transfer of the FDL to the • This starts at the tip of the fibula and runs longitudinally down the lateral column
medial navicular, suture anchors may be used. of the foot to the calcaneal cuboid joint.
k e r
e s
• In some cases the tendon can be passed
rs
through a dorsal-to-plantar drill hole and
eers
• This is about 3 cm long.
rs
• The peroneal tendons are retracted, and the lateral calcaneal neck is exposed.
k
o o
o o k sutured back to itself.
oo k
• A vertical osteotomy 1.5–2 cm posterior to the calcaneocuboid joint (CC joint) is
o o oo
ee/ e
/ b
e b •
e /ebb
made under fluoroscopy using a sagittal saw.
/e
Fig. 30.11 shows an intraoperative fluoroscopic view. Note the wire across the
e
/ /
• The need to repair/reconstruct the spring
: t
/ .
tm.m : / / t
/.tm
. m
CC-Joint to help maintain proper foot alignment. In addition, see the wire proximal
ligament is controversial.
t p ss
p : / t p ss
p : /
to the future osteotomy site that is used to ensure proper trajectory.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b

: // t/.tm
. m
: / /t/.tm. m
t
FIG. 30.12
p ss
p : / tp ss
p : / FIG. 30.13
t
hht t t
hht t
STEP 2 PEARLS
• Recommend placing a temporary Kirschner
wire (K-wire) across the CC-Joint before
keerrss keerrss performing the lateral column lengthening.

• This helps to reduce oversupination of the
b ooook b ooook b oo forefoot.

• The foot must be held in a neutral position
eeb ee/e/e b ee/e/e b when placing this wire.
• For both the medial cuneiform osteotomy and
: / / t
/ m
.t.m : / / t
/ m
.t.m lateral column lengthening, we recommend not
t ppss : / t ppss : / breaching the far cortex, but to greenstick it open.

• Perform osteotomies under fluoroscopy.
t
hhtt t
hhtt • In severe cases of forefoot abduction, consider
a peroneal brevis to peroneal longus transfer to
decrease abduction pull on the foot (Fig. 30.15).
STEP 2 PITFALLS
k e rrss
e k e rrss
e
• If the graft/wedge is too prominent superiorly,
o o
o o k o o
o o k o o
it can impinge the subtalar joint, causing pain.
• If plating over the graft/wedge, prominent
eebb
ee/ e
/ b
FIG. 30.14
e b ee/ e
/ b
e b irritating hardware can occur.
• Care should be taken to keep this incision
: / / t
/ m
.t.m : / / t
/ m
.t.m small as to not interfere with the incision,
if necessary, for the medializing calcaneal
t p ss:
p / t p ss:
p / osteotomy (Fig. 30.16).
•
t
hht t t
hht t
Fig. 30.12 shows the osteotomy. Note the wire across the CC-Joint to help main-
STEP 2 INSTRUMENTATIONS/
IMPLANTATION
tain proper foot alignment. In addition, see the wire proximal to the osteotomy site • Tricortical graft (autograft or allograft) or
that is used to ensure proper trajectory. metallic equivalent (i.e., wedges)
e e s
rs
• Do not cut the medial cortex.
k k eers
• We recommend placing the osteotomy site at the inferior apex of Gissane angle.
r rs STEP 2 CONTROVERSIES
o o
o o k o oo k
• Using laminar spreaders or Hintermann retractors, gap the lateral cortex until the
o oo • Some have argued that lateral column
eebb ee e
/ b
e b
foot’s position is corrected (assessed radiographically and clinically).
/ e /e/ebb
• Place either a tricortical graft (autograft or allograft) or metallic equivalent to maintain
e
lengthening is an overutilized procedure. None
doubt that it is a powerful tool to swing the
: / / t
/ .
tm m
the opening osteotomy (Figs. 30.13 and 30.14).
. : / / t
/.tm
. m foot out of abduction, but prettier radiographs
do not always mean happier patients.
t p ss
p : / t p ss
p : /
• The surgeon may consider a small plate over the graft to prevent displacement.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
248 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b

: // t/.tm
. m
: / /t/.tm. m
t p ss
p : /
FIG. 30.15
tp p ss : / FIG. 30.16
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e FIG. 30.17
k e rrss
e
o o
o o k o o
o o k
o o FIG. 30.18
eebb STEP 3 PEARLS

• A medializing calcaneal osteotomy is not ee/ e
/ b
e b ee/ e
/ b
e b
always necessary in stage IIB surgery.
: / / t
/ m
.t.m : / / t
/ m
.t.m
Step 3: Medial Displacement Calcaneal Osteotomy
t ss: /
• Perform the lateral column lengthening first
p
and then assess for residual heel valgus. If
p t p ss:
p /
• After the lateral column lengthening, analyze the forefoot for correction and hindfoot
t
hht t
present, medialize the calcaneus.
• Try to plantarly shift the posterior tuberosity of the
calcaneus to try to increase the calcaneal pitch.
t
hht t
for residual valgus.
• If the heel is still in valgus, we recommend an MDCO.
• A provisional pin may be placed to help hold • The incision is obliquely oriented over the lateral calcaneus in the same orientation of
the position of the osteotomy. the subsequent calcaneal osteotomy. Often 4–5 cm long.
• A trick is to slide a pin along the lateral
k e r
e s
rs
surface of the posterior fragment and, once
e rs
• Care must to be taken to not injure the sural nerve, or its branches, during dissection.
rs
• The deeper dissection is plantar and posterior to the course of the peroneal tendons.
k e
o o
o o k the slide is complete, then pass the pin into
the anterior calcaneal segment.
o o
oo k
• A periosteal key is typically used to expose the lateral surface of the calcaneus.
oo
eebb • Careful not to make the screws too long,
as to not interfere with the lateral column
ee/ e
/ b
e b e / /ebb
• Small Hohmann retractors are placed at the superior and inferior surfaces of the pos-
e
terior tuberosity of the calcaneus. These will mark the trajectory of the osteotomy.
e
lengthening.
/ / t
• Ensure that the screw threads are fully across
: / .
tm.m : / / t
/.tm
. m
• Fluoroscopy is used to confirm their position (Fig. 30.17).
ss : /
the osteotomy to help facilitate compression.
t p p t p ss : /
• A microsagittal saw is then used to perform most of the bony cut (Fig. 30.18).
• Complete the osteotomy with an osteotome as to not injure any medial structures.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b
ee/ e
/ e b FIG. 30.20

: // t/.tm
. m : / /t/.tm. m
FIG. 30.19
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt

rrss s FIG. 30.22
k e e k eerrs
o o
o o k
FIG. 30.21
o oo
o k o o
STEP 3 PITFALLS
eebb ee/ e
/ b
e b ee/ e
/ b
e b • Do not make the osteotomy too distal, as to not
interfere with the lateral column lengthening.
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Manually reduce the osteotomy, to create a medial slide of at least 1 cm, but often
• Bury the screw heads to ensure they are not
prominent on the calcaneus posteriorly.
2 cm.
t p ss:
p / t p ss:
p /
• K-wires for cannulated screws are then passed from plantar–posterior to dorsal–
t
hht t
anterior across the osteotomy (Fig. 30.19). t
hht t
• Lateral and Harris heel views will confirm their position and the extent of the medial
• We typically use two cannulated 6.5-mm screws.
• These can be headless or headed screws.
slide. • Compression can be achieved by design of
• Intraoperative fluoroscopic view shows the wires being placed (Fig. 30.20). Note the the screw or using a partially threaded screw.
• Plates with built-in “steps” can be used to hold
k e r
e s
rsneal pitch.
k eers
plantar shift of the posterior tuberosity of the calcaneus to try to increase the calca-
rs the medial slide as well.
o o
o o k o o
oo k
• Intraoperative fluoroscopic view shows the medial displacement of the calcaneus
oo STEP 3 CONTROVERSIES
eebb •

(Fig. 30.21).
e / e
/ b
e b
Once the osteotomy is fixated, tamp down the prominent bone edge laterally
e ee/e/ebb • Different osteotomies can be used. Oblique
and step cuts are the most common.
(Fig. 30.22).
: / / t
/ .
tm.m : / / t
/.tm
. m • We now recommend returning to the medial
(LCL; Fig. 30.23).

t p ss
p : / t p ss
p : /
• Intraoperative fluoroscopic view shows the MDCO and lateral column lengthening incision to complete the repairs and transfers
as necessary.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
250 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb FIG. 30.23
ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ps s : /
t
hht t t
hht t FIG. 30.24
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
FIG. 30.25 t
hhtt
STEP 4 PEARLS
• A pin may be placed initially along the
k e rrss
projected path of the osteotomy and checked
under fluoroscopy to ensure a proper path in
e k r
eer ss FIG. 30.26
o o
o o kboth the sagittal and axial planes.
o o
o o k o o
eebb b b
• For both the medial cuneiform osteotomy and
Step 4: Cotton Osteotomy
lateral column lengthening, we recommend
not breaching the far cortex, but to greenstick
ee/ e
/ e b ee/ e
/ e b
• Once that the forefoot has been brought out of abduction and the heel out of valgus,
it open.
: / / t
/ m
.t.m : / / t
/ m
.t.m
the forefoot must then be inspected for residual supination.
• Perform osteotomies under fluoroscopy.
p ss: /
• The alignment and position of the foot must
t p t p pss: /
• If the foot is not plantargrade and the first ray is elevated, a dorsal opening wedge
osteotomy (Cotton) is recommended (Fig. 30.24).
t
hht t
be assessed with simulated weight-bearing
analysis to confirm proper correction. t
hht t
• This is performed through a dorsal incision about 3 cm long directly over the medial
cuneiform.
• Be sure to protect the extensor hallucis longus, extensor hallucis brevis, neurovascu-
STEP 4 PITFALLS lar bundle, and tibialis anterior tendon during dissection and instrumentation.
k e r s
• Confirm on orthogonal views that the
rs
osteotomy is not intraarticular.
e e rs
• A dorsal-to-plantar osteotomy is made in the middle of the medial cuneiform.
rs
• Using laminar spreaders or manual traction, gap the dorsal cortex until the foot’s
k e
o o
o o k o o
oo kposition is corrected (assessed radiographically and clinically; Fig. 30.25).
oo
eebb STEP 4 INSTRUMENTATIONS/
IMPLANTATION
ee/ e
/ b
e b the opening osteotomy.
ee /ebb
• Place either a tricortical graft (autograft or allograft) or metallic equivalent to maintain
/e
/ / t
• Tricortical graft (autograft or allograft) or
: / .
tm.m : / / t
/.tm
. m
• A plate is typically used to buttress the graft in place (Fig. 30.26).
metallic equivalent (i.e., wedges).
t p ss
p : / t p ss : /
• The alignment and position of the foot must be assessed with simulated weight-
bearing analysis to confirm proper correction (Fig. 30.27).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 30.27
k er
erss
ook k FIG. 30.28
b oo b oooo b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / Weight bearing
tp ss
p : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k eers
rs
k e rrss
FIG. 30.29
e
oooo k o o
o o k o o
eebb POSTOPERATIVE CARE AND EXPECTED ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m OUTCOMES
: / / t
/ m
.t.m
t ss:
p /
LCL, and Cotton osteotomy.
t p ss:
p /
• Fig. 30.28 shows representative lateral radiograph 6 months status post MDCO,
p
t
hht t t
hht t
• Fig. 30.29 shows a representative AP radiograph status post bilateral LCL (tricortical
wedge seen on left, metallic wedge seen on right) and suture anchors seen for FDL
• A plantar closing wedge osteotomy is
biomechanically more stable, but the relative
transfers—in this bilateral case, without first cuneiform cotton osteotomies. ease of the dorsal approach makes it the
• Wounds are closed in a layered, step-wise fashion using interrupted stitches. preferred procedure.
k e e s
• The patient is placed into a well-padded splint.
r rs k eers
rs
• We typically used a drain for 24 hours in the medial wound.
o o
o o k o o
oo k
• At the 2-week follow-up appointment, they are placed into a short leg cast for
oo
eebb 4 weeks.
ee/ e
/ b
e b e /e/ebb
• At 6 weeks postoperatively, the patient can transition to a controlled ankle movement
e
• These patients typically benefit from long-term
postoperative orthotic use with a semirigid
: / / t
/ .
tm.m : / / t
/.tm
. m
boot where gradual weight bearing, range of motion, and strengthening can begin. longitudinal arch support.
• Preoperative consultation with the patient and
t p ss
p : / t p ss : /
• At 3 months the patient is weaned from the boot to regular footwear.
• We counsel patients that the total recovery time for this procedure is 1 year.
p
orthotist is recommended.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
252 hht
EVIDENCE
k e r
e s
rs rs
r s
Deland JT. The adult acquired flatfoot and spring ligament complex, pathology and implications for
k ee
treatment. Foot Ankle Clin 2001;6:129–35.
o o
o o k o oo k o
Deland JT, de Asla RJ, Sung I-H, et al. Posterior tibial tendon insufficiency: which ligaments are
o o
eebb bb b b
involved? Foot Ankle Int 2005;26:427–35.
ee/ e
/e e / e
/ e
Funk DA, Cass JR, Johnson KA. Acquired adult flat foot secondary to posterior tibial tendon pathology.
e
: / / t
/ .
t m
. m
J Bone Joint Surg Am 1986;68A:95–102.
: / / t
/ .
t m
. m
Hirose CE, Johnson JE. Plantarflexion opening wedge medial cuneiform osteotomy for correction of
t p ss
p : / t p ss
p : /
fixed forefoot varus associated with flatfoot deformity. Foot Ankle Int 2004;25:568–74.
Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Relat Res 1989;239:196–206.
t
hht t t
hht t
Mann RA, Thompson FM. Rupture of the posterior tibial tendon causing flatfoot: surgical treatment.
J Bone Joint Surg Am 1985;67A:556–61.
Mosier-LaClair S, Pomeroy G, Manoli II A. Intermediate follow-up on the double osteotomy and tendon
transfer procedure for stage 2 posterior tibial tendon insufficiency. Foot Ankle Int 2001;22:283–91.
Mosier-LaClair S, Pomeroy G, Manoli II A. The difficult stage 2 adult acquired flatfoot deformity. Foot
k eers
rs k er
ers
Ankle Clin 2001;6:95–119.
s
Myerson MS, Badekas A, Schon LC. Treatment of stage II posterior tibial tendon deficiency with flexor
b ooook ooook
digitorum longus tendon transfer and calcaneal osteotomy. Foot Ankle Int 2004;25:445–50.
o o
Wacker JT, Hennessy MS, Saxby TS. Calcaneal osteotomy and transfer of the tendon of flexor digito-
b b
eeb ee/ e
/ e b
Br 2002;84B:54–8.
ee/ e
/ e b
rum longus for stage-II dysfunction of tibialis posterior: three- to five-year results. J Bone Joint Surg
: // t/.tm
. m / /t/.tm. m
Zanolli DH, Glisson RR, Nunley JA, Easley ME. Biomechanical assessment of flexible flatfoot correction:
comparison of techniques in a cadaver model. J Bone Joint Surg Am 2014 Mar 19;96(6):e45.
:
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh31
PROCEDURE
t hht
Spring
rss Ligament Repair With Suture
rs s
k ee r k ee r
eebbooooTape
k Augmentation ooook / e bb / e b o
b o
m ee /e m ee / e
Timothy Charlton and Danielle
: / t
///t. . m
Thomas
: / /
/ t
/ .
t . m
t t p
t s
p s : t t p
t ss
p :
hh t hht
• Flatfoot undergoing concomitant posterior tibial tendon (PTT) reconstruction with • Concurrent navicular–cuneiform joint laxity
or sag
k e rs
rs
torn spring ligament
errs
• Sag at the level of the talonavicular joint
e k e s • A very significantly exposed talar head
b ooook b ooook
• As an adjunct to medial column osteotomy and lateral column lengthening (if
b o o
eeb EXAMINATION/IMAGING
indicated)
ee/ e
/ e b ee/ e
• Any requirement for lateral column lengthening
: // t/.tm
. m : / /t/.tm. m • Long-term efficacy and retention of correction
t p ss
p : / tp ss : /
• Obtain anteroposterior (AP), lateral, and oblique views of the foot to assess for un-
coverage and talonavicular overhang. It is also recommended to obtain AP/lateral
p
t
hht t t
hht t
views of the ankle to assess deltoid integrity (Fig. 31.1).
• Magnetic resonance imaging is also obtained, as necessary.
TREATMENT OPTIONS
• Nonoperative treatment with orthotics and
• Intraoperative examination is recommended, as necessary. physical therapy
• Repair
• Reconstruction
keerrss keerrss • Arthrodesis of the talonavicular joint
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm. m : / / t
/.tm
. m
t p ss
p : /
FIG. 31.1
t p ss
p : /
t
hht t t
hht t 253
t t p
t ss:
p t t p
t ss:
p
254 hht
PROCEDURE 31 Spring Ligament Repair With Suture Tape Augmentation hht
POSITIONING PEARLS SURGICAL ANATOMY
k e r
e ss
• Elevate the leg on a platform of blankets or
r
bone foam to allow better exposure medially.
k eers
r s
• The spring ligament gives restraint to excessive motion of the talonavicular joint.
• The superomedial calcaneonavicular ligament is the largest and strongest compo-
o o
o o k
• Ensure fluoroscopic AP view of the foot is
oooo k o
nent and includes the medial talonavicular capsule. Its origin is the superomedial
o
eebb easily obtained to visualize the navicular.
ee/ e
/ebb / e b b
aspect of sustentaculum tali and anterior facet of the calcaneus. The insertion is the
edge of the navicular facet.
ee / e
: / / t
/ .
t m
. m : / / t . m
. m
• The inferior (plantar) calcaneonavicular ligament is a narrower, fibrous structure. The
/ t
ss : /
• A chronic spring ligament can be associated
t p p t p ss
p : /
origin is the anterior aspect of the sustentaculum tali, and the insertion is the inferior
t
hht t
with a torn and retracted PTT leading to
“empty nest” syndrome, in which the PTT is
not in the expected location in the surgical
t
hht t
surface of the middle of the navicular.
• The third ligament is also a contributor. It originates from the notch between the an-
terior and middle calcaneal facets and inserts onto the navicular tuberosity.
field. This can mislead the surgeon to
mistakenly think that the flexor digitorum POSITIONING
longus (FDL) tendon is the PTT and drift near
k eerss
the neurovascular bundle. The “empty nest”
r
syndrome almost never happens without an
k er
ers
• The patient is positioned supine on the operating room table.
s
• A tourniquet is placed on the thigh.
b ooook associated spring ligament tear.

ooook
PORTALS/EXPOSURES
b b o o
eeb ee/ e
/ e b e / e
/ e b
• A medial incision is made over the inferior border of the bony ridge consistent with
e
STEP 1 PEARLS
: //
• The FDL is inferior and deep to the PTT.t/.tm
. m : / /t/.tm. m
palpation of the talus, navicular, medial cuneiform, and first metatarsal for direct
t p ss
p : / tp pss : /
repair of the spring ligament. The landmark for the incision is the bone–soft-tissue
interface at the level of the talus, navicular, medial cuneiform, and first metatarsal.
STEP 1 PITFALLS
t
hht t t
hht t
Using this approach and not drifting plantarly will allow for excellent exposure and
prevents getting into muscle which can block visualization.
• Caution should be exercised while harvesting
the FDL tendon in the setting of a spring PROCEDURE
keerrs
ligament tear as there could also be a
s
chronically torn and retracted PTT, leading Step 1
keerrss
b ooook to the anatomically confusing “empty nest”
syndrome.
b oook
• Typically, the FDL tendon is also being harvested during this procedure, so a medial
o b oo
incision of approximately 10 cm over the talus, navicular, medial cuneiform, and first
metatarsal is made. Attention is paid to protect the saphenous vein and neurovascu-
STEP 2 PEARLS
: / / t
/ m
.t.m lar bundle.
/ / t
/ m
.t.m
• The PTT is identified and examined for tears.
:
ss : /
• The FDL is plantar to the flexor hallucis longus
t pp ss : /
• The FDL tendon is identified.
t pp
at the knot of Henry.
t
hhtt
• Be careful of the interconnecting bands of the
flexor hallucis longus and FDL.
t
hhtt
• The spring ligament is examined for tears (Fig. 31.2).
Step 2
• The FDL tendon is harvested. It is identified in the knot of Henry and incised. The
medial and lateral plantar nerves are protected at the knot of Henry. A whipstitch is
k e rrss
e k e rrss
placed for later transfer into the navicular, and the tendon is measured to determine
e
o o
o o k o o
o o k
what size hole will be drilled into the navicular, usually between a 4.75-mm and 5.5-
mm hole (Fig. 31.3).
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
• The PTT is débrided if necessary and possibly cut if a lack of excursion is identified.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
: /
FIG. 31.2
p
t p ss
p : / FIG. 31.3
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 31 Spring Ligament Repair With Suture Tape Augmentation 255
k e r
e ss
• The spring ligament is prepared.
r k eers
r s
• The ligament is imbricated with nonabsorbable 0 braided sutures such as Ethibond
• The internal brace is placed in the middle facet
aiming slightly posterior and slightly plantarly
o o
o o k o
or FiberWire (Arthrex, Naples, FL) (Fig. 31.4).
ooo k o o
to avoid the subtalar joint and to allow insertion
eebb ee e
/ebb
• A braided tape suture such as an Arthrex FiberTape is placed to function as an in-
/ ee
ternal brace into the sustentaculum tali. A Kirschner wire is used to determine the/ e
/ b
e b into the solid bone.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
desired position of the internal brace and is confirmed using fluoroscopic imaging STEP 3 PITFALLS
(Fig. 31.5).
t p ss
p : / t p ss
p : /
• Depending on the specifics of the device preferred, it may be tapped and then in-
• Do not enter the subtalar joint with the internal
t
hht
serted (Fig. 31.6). t t
hht t
• The limbs of the suture bridge will later be secured into the navicular hole (Fig. 31.7).
brace by aiming posteriorly and plantarly.
Step 4
k ee s
rs k er
ers
• The aforementioned hole is drilled into the navicular for FDL transfer (Fig. 31.8).
r s
• The FDL is then transferred into the drill hole along with the limbs of the internal
b ooook b ooook
brace fixing the spring ligament, exiting dorsally (Figs. 31.9 and 31.10).
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb
FIG. 31.4
ee/e/e b
ee/e/e b FIG. 31.5
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t p s
p s : /
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b

: / / t
FIG. 31.6
/ m
.t.m
: / / t
/ m
.t.m FIG. 31.7
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
FIG. 31.8
t
p ss
p : / FIG. 31.9
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
256 hht
PROCEDURE 31 Spring Ligament Repair With Suture Tape Augmentation hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 31.10
k eers
rs k er
erss
eeb STEP 4 PEARLS
ee/ e
/ e b ee/ e
/ e b
• The tendon and the internal brace are tensioned with the foot inverted and plantar-
flexed, and an appropriately sized tenodesis screw is secured.
: // t/ tm
• A drill hole typically ranges from 4.75 mm to
. . m
5.5 mm in size. It very rarely exceeds 5.5 mm.
t . m. m
• If a supplemental flatfoot option is being performed (e.g., Cotton osteotomy, calca-
: / / / t
: /
• Avoid penetration into the cuneiform–navicular
t p p
or talonavicular joint, and do not blow out
pp : /
neal slide), those steps are taken at this time.
ss POSTOPERATIVE CARE AND EXPECTEDttOUTCOMES
ss
t
hht t
the medial wall of the navicular. This must be
confirmed fluoroscopically. hht t
• The patient is placed in a short leg splint.
• The splint is changed and the wounds are examined at the 1-week postoperative
visit, and a splint is applied.
eerrs
STEP 4 PITFALLS
s
• Do not penetrate the medial wall of the
k keerrs
• The sutures are removed at 2 weeks, and patients are placed in a cast.
s
• At 6–8 weeks postoperatively, the cast is removed and the patient is allowed to par-
b ooook navicular with the drill hole.

• Do not enter the cuneiform–navicular or
b ooook
tially bear weight in a controlled ankle movement (CAM) walker with an arch support.
b oo
eeb talonavicular joint.
ee/e/e b e /e/e b
Non–weight-bearing ankle and triple joint range of motion can be started at this time.
• The CAM walker is continued for 12 weeks.
e
: / / t m
.t.m
EVIDENCE
/ : / / t
/ m
.t.m
t ppss : / t p ss : /
Deland JT, Arnoczky SP, Thompson FM. Adult acquired flatfoot deformity at the talonavicular joint:
p
t
hhtt t
hhtt
reconstruction of the spring ligament in an in vitro model. Foot Ankle 1992;13:327–32.
Ellis SJ, Williams BR, Yu JC, et al. Spring ligament reconstruction for advanced flatfoot deformity with
the use of an Achilles allograft. Oper Tech Orthop 2010;20:175–82.
Gazdag AR, Cracchiolo A. Rupture of the posterior tibial tendon. Evaluation of injury of the spring
ligament and clinical assessment of tendon transfer and ligament repair. J Bone Joint Surg Am
rrss
1997;79:675–81.
k e e k e rrss
Johnson JE, Cohen BE, DiGiovanni BF, et al. Subtalar arthrodesis with flexor digitorum longus transfer
e
o o
o o k o o o k
and spring ligament repair for treatment of posterior tibial tendon insufficiency. Foot Ankle Int
2000;21:722–9.
o o o
eebb ee/ e
/ b
e b
Orthopedics 2014;37:467–71.
ee/ e
/ b
e b
Lee WC, Yi Y. Spring ligament reconstruction using the autogenous flexor hallucis longus tendon.
: / / t
/ m
.t.m : / / / m
.t.m
Palmanovich E, Shabat S, Brin YS, et al. Anatomic reconstruction technique for a plantar calcaneona-
t
vicular (spring) ligament tear. J Foot Ankl Surg 2015;54:1124–6.
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh32
PROCEDURE
t hht
TherZ-Shaped
ss Elongating and Varisizing
r ss Osteotomy
o k r
ee Calcaneal Osteotomy
(ZEVO)
k o k
for
k r
ee Pes Plano Abducto
eebboooValgus ee/ e
/ebboo o
ee/ e
/ b
e
o
b o
.m
m : / /
/ t
/ t . . m
m : / /
/ t
/ t .
t t p
t ss
p : t t p
t ss
p :
hht
Per-Henrik Ågren hht
eers
rs
INDICATIONS
k k er
erss
b ooook b ooook
• Alternative to double osteotomy in acquired flatfoot deformity (AFFD)
b o o
INDICATIONS PEARLS
• Avoids the need for bone graft and keeps
eeb ee/ e e b ee/ e
/ e b
• When a combination of lengthening of anterior process and medial shift of tuber
/ segments of calcaneus in line
radiographs)
: // t/ tm
. m : / /t/ tm
is indicated (usually in case of dorsolateral peritalar subluxation on weight-bearing
. . . m
t p ss
p : /
• When deformity is still reducible/flexible
tp pss : / INDICATIONS PITFALLS
t
hht t
hht t • In a nonflexible foot this is not an appropriate
procedure; for example, a late case with
• There is a hindfoot flatfoot valgus deformity, possibly with abduction in midfoot degenerate joints or possibly a combination
• On toe raising there is no inversion of the heel with a fixed deformity like a coalition.
• Often there are clinical signs of midfoot instability and contracted gastrocnemius • Concomitant problems such as diabetes
keer ss weight-bearing plain films

keerrss
• Radiographic signs of flatfoot with dorsolateral peritalar subluxation on standing
r
mellitus or poor vascular supply are risk
factors that should be assessed.
b ooook o ook
• No signs of secondary arthrosis in subtalar joints
b o b oo
• On the medial side of calcaneus there
are several important structures. It is
eeb ee/e/ b ee/e/e
• Often radiographic signs of tarsal instability on weight-bearing films
b
• Inversion at the Chopart joint level is close to normal (foot is reducible)
e thus important not to overpenetrate with
instruments or implants on the medial side.
SURGICAL ANATOMY
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
• The calcaneus articulates the talus with the posterior subtalar joint and the anterior
subtalar joint. It also articulates the cuboid in the calcaneo-cuboid joint. Between the
posterior and anterior subtalar joints is the canalis tarsi, which laterally opens into the
• This procedure has now been in clinical use
for 20 years. It is a variant of other procedures:
sinus tarsi, just distal to the lateral malleolus. the lateral column lengthening osteotomy
• As flatfoot deformity develops, no matter the exact pathology, a dorsolateral described by Hintermann et al. (1999) and
rrss rrss
peritalar subluxation develops. the Koutsogiannis sliding tuber osteotomy in
o k e e o k e e
• The coxa pedis is the center of this biomechanical development.
k k
combination.
• As such this procedure is part of a pes plano
o
eebb o o e b o
b o
• The coxa pedis consists of the navicular joint, the anterior subtalar joints of calca-
o e
neus, and the spring ligament, which is the strong ligament between these. The latter
b o
b o abductovalgus (PPAV) reconstruction and is
rarely, if ever, intended to be used alone.
might be torn in the case of an AFFD.
m ee/ / e m ee/ / e
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
• An anatomic specimen showing calcaneus’s joints from above, after the talus is
t t p
t ss:
removed, is presented in Fig. 32.1.
p t t p
t ss:
p
TREATMENT OPTIONS
Aim of Reconstruction
hht hht
• By altering the shape and the forces around the coxa pedis, it has been shown that
• A joint-preserving procedure with calcaneal
osteotomy (sliding tuber or distal calcaneal/
lateral column or double osteotomy [both])
a correction or realignment of the AFFD is achieved. together with medial tendon replacement
• By lengthening of the distal calcaneus (part of calcaneus from the canalis tarsi to the transfer (flexor digitorum longus), and
reefing of spring and deltoid ligaments, and
k e r
e s
rs k e r
that aligns the talar head into the talonavicular joint.
e s
calcaneocuboid joint [CC-Joint]), a rotational moment is achieved in the coxa pedis
rs possibly gastrocnemius release and midfoot

stabilization (Lapidus or naviculocuneiform
o o
o o k o o
o k
• By the medialization acquired by the osteotomy, a medialization of the insertion of
o oo
fusion)
eebb b b
the Achilles tendon and plantar fascia is acquired and thus alignment correction
occurs.
ee/ e
/ e b ee/e/e b • A triple or more often a double fusion
incorporating the subtalar and talonavicular
: / / / .
tm
• Fig. 32.2 shows a diagram of Z-shaped elongating and varisating osteotomy
t .m : / / t
/.tm
. m
joints and necessary soft-tissue balancing
around this region
(ZEVO).
t p ss
p : / t p ss
p : /
t
hht t t
hht t 257
t t p
t ss:
p t t p
t ss:
p
258 hht
PROCEDURE 32 The Z-Shaped Elongating and Varisizing Osteotomy (ZEVO) Calcaneal Osteotomy hht
Achilles tendon
k e r
e s
rs k eers
r s Talus
o o
o o k oooo k o o
eebb ee/ e
/ebb
Posterior
ee/ e
/ b
e b Cuboid
: / / t
/ .
t m
. m subtalar joint
: / / t
/ .
t m
. m
t p ss
p : / “Gissane angle”
t p ps
s
: /
t
hht t t
hht
Middle and anterior
subtalar joints
(on sustentacular
t FIG. 32.2
part of calcaneus)
k eers
rs k er
erss
Spring ligament
b ooook o ook
Calcaneocuboid
joint
b o b o o
eeb ee/ e
/ e b
Navicular bone
ee/ e
/ e b

: // t/.tm
. m : / /t/.tm. m
t p ss
p : /
FIG. 32.1
tp pss : /
t
hht t t
hht t
keerrss k r
eer ss FIG. 32.3
ook k
POSITIONING PEARLS
b oo • If positioned sideways on a pillow that is stable

b oooo b oo
eeb and flat, it is easier to assess the amount
of correction needed and gained to make a
ee/e/e b ee/e/e b
correct alignment of the hindfoot.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss /
• With training this can be done supine, which
:
would facilitate the whole reconstruction.
p t ppss : /
t
hhtt t
hhtt
• It is more difficult to see the axis of the altered
calcaneus and to insert the implants in its new
k e rrss
axis if the patient is supine.
e
• Thus there seems to be a higher risk of medial
k e rrss
e
o o
o o kpenetration with implants.
o o
o o k o o
eebb b b
• When the osteotomy is finished, the patient is
turned supine, which needs to be considered
before draping is carried out.
ee/ e
/ e b ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
FIG. 32.4
t p ss:
p / POSITIONING
t p ss:
p /
t
hht t
• If positioned sideways, a pillow is
recommended together with holding brackets
t
hht t
• For this part of the procedure, patients are always positioned sideways with their foot
on a pillow (Fig. 32.3).
at the back and front of the patient. •
Under general anesthesia and with a tourniquet in place the skin is marked
• These are all removed when patient is turned (Fig. 32.4).
supine.
k e r
e s
rs k eers
rs
PORTALS/EXPOSURES
o o
o o k o o
oo k
• Two types of approaches are possible:
oo
eebb b b
POSITIONING CONTROVERSIES • Extensile lateral incision (gives full access to osteotomy)
• Repositioning of the patient during surgery
ee/ e
/ e b
•
e /e/e b
Short sinus tarsi plus vertical dorsal incision (working under the skin bridge
e
might be considered bothersome, and in very
: / t
heavy patients several people are needed to
/ / .
tm.m between these)
: / / t
/.tm
. m
• The tip of the lateral malleolus and CC-Joint are marked as well as the chosen
achieve a good position.
t p ss
p : / t p
incision point.
ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 32 The Z-Shaped Elongating and Varisizing Osteotomy (ZEVO) Calcaneal Osteotomy 259
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t s
ps
p : /
t
hht t FIG. 32.5 t
hht t FIG. 32.6
• In order to avoid the sural nerve, an estimation
of its position is made.
k eers
rs k er
erss
• The sural nerve is usually a finger width
behind lateral malleolus.
b ooook b ooook b o o PORTALS/EXPOSURES PITFALLS
eeb ee/ e
/ e b ee/ e
/ e b • The skin flap should be developed from the layer
between the bone and the periosteum to maintain
: // t/.tm
. m : / /t/.tm. m the fasciocutaneous blood supply in the flap.
t p ss
p : / tp pss : / PORTALS/EXPOSURES EQUIPMENT
t
hht t t
hht t • Small knife blade 15, sharp osteotomes or
bone rasps, and mini-Hohmann retractors
• There might be a risk for wound dehiscence
FIG. 32.7
keerrss keerrss problems if the flap is not prepared carefully.
STEP 1 PEARLS
eeb ee/e/e b ee/e/e b • The osteotomy is usually started with the

horizontal part. The oscillating saw is pushed
: / / t
/ m
.t.m : / / t
/ m
.t.m toward the medial cortex and then with proper
control pushed just through. This might tingle
t ppss : / t ppss : / on the tendons of the toes so be careful.
t
hhtt t
hhtt
• The proximal cut is done similarly.
• The distal cut is done with a short and narrow
blade, which makes it impossible to cut all the
way through. Therefore the cut needs to be
finished with an osteotome. At this level, this
means that it is not possible to cut most of the
k e rrss
e k e rrss
e
way through the bone and finish the cut with
the osteotome. To avoid cutting into the subtalar
o o
o o k o o
o o k o o
joint, a blunt dissector is held against the talus
into the canalis tarsi and the saw cut is directed
eebb
ee/
FIG. 32.8 e
/ b
e b ee/ e
/ b
e b distally to this dissector (Figs. 32.7 and 32.8).
: / / t
/ m
.t.m : / / t
/ m
PROCEDURE
t p ss:
p / t p ss:
p / • The intention is to follow the canalis tarsi in
front of the talus in the subtalar joint.
t
hht t
Step 1: Extensile Lateral Skin Flap
t
hht t • As the alignment is maintained with the long
horizontal cut, the leveling of the distal anterior
osteotomy will not be a problem.
• Skin flap is developed skin to bone, and subperiosteal dissection is carried out with
the tendons and the sural nerve elevated in the flap up to sinus tarsi-Gissane’s angle. STEP 1 INSTRUMENTATION/
IMPLANTATION
k e s
rs
• Planned osteotomy cuts are marked with cauterization.
e k eers
• A space anterior to the talus is cleared for visualization.
r rs • For the first two parts of the osteotomy, an
o o
o o k oo k
• The vertical distal cut should be a maximum of 50% of the height of the calcaneus at
o o oo
oscillating saw with a 45–50 × 20 mm-blade
eebb b b is used.
this level.
ee/ e
/ e b e /e/e b
• The distal vertical cut is the plantar part of a 45° transverse cut; it starts more poste-
e
• For the distal osteotomy a 25–30 × 12 mm-
blade is used.
: / / / .
tm m
riorly and ends distal to the plantar fascia insertion plantarly.
t . : / / t
/.tm
. m • Any blunt instrument with a narrow handle can be
t p ss
p : / t p ss : /
• The horizontal cut binds the two vertical cuts. It is directed slightly obliquely from
proximal downward to a distal vertical osteotomy (Figs. 32.5 and 32.6).
p
placed distal of the talus to guide the distal cut.
• A narrow 10–12-mm osteotome is used to
t
hht t t
hht t crack open the osteotomy at the Gissane level.
t t p
t ss:
p t t p
t ss:
p
260 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb
FIG. 32.9
ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
FIG. 32.10
• There is a minor risk for overpenetration medially.
keerrss
• If the distal osteotomy is brought too far plantar,
there is a risk that it will break. At least 50% of
keerrs
Step 2: Distal Vertical Cut
s
b ooook the width at that level should be maintained.
b ooook
• The distal vertical cut is finished with an osteotome.
oo
• If done properly, a laminar or pin-type spreader or distractor is mounted around the
b
distal vertical osteotomy (Fig. 32.9).
• Correction is carried out with distraction to the desired amount.
STEP 2 PEARLS
: / / t
/ m
.t.m : / / t m
.t.m
• By twisting the handle of the distractor device distraction compression of the hori-
/
• Effect of the ZEVO lengthening:
p ss : /
• Twists the medial forefoot; thus plantar flexion
t p t ppss : /
zontal part of the osteotomy is controlled.
t
hhtt
of the first metatarsal (MT 1) is gained.
• Pushes the foot around the talar head. As a
result, the vertical talus can become almost
t
hhtt
• To further shift the tuber medially, a mini-Hohmann retractor can be used in the proxi-
mal vertical part of the osteotomy, thus rotating the calcaneus into even more of a
“bent bean shape” (Fig. 32.10).
horizontal.
• The ZEVO always keeps in line as the Step 3: Fixation
horizontal osteotomy secures the alignment
k e rrss
e
of the calcaneus.
• The osteotomy is positioned using the
k e rrss
• With the horizontal part under compression and the osteotomy distracted as far as
e
desired, two screws are mounted.
o o
o o kdistractor until the desired position is achieved.
o o o k o
• The first is a position-drilled 6.5-mm fully threaded cancellous screw countersunk at the
o o
eebb b b
• Twisting the distraction device controls and
compresses the horizontal part of the osteotomy.
ee
• If properly tensioned/distracted, there is usually/ e
/ e b ee e
/ b
insertion. The screw direction is from tuber aiming at the CC-joint laterally. Avoid medial
/ e
penetration. The screw tends to be 70 ± 5 mm depending on foot size (Fig. 32.11).
enough correction.
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The second screw is a lag screw: a 4.0-mm cortical screw compressing the horizon-
t ss: /
• For the distraction and sliding of the proximal
p
part of the osteotomy, use a Hohmann retractor
p t p ss:
p /
tal part of the osteotomy. It is also countersunk going from plantar to dorsal (behind
the subtalar joint; Figs. 32.12 and 32.13).
t
hht t
or osteotome or a second laminar spreader.
t
hht t
• Check fixation with a C-arm and remove the distractor (Figs. 32.14 and 32.15).
Step 4: Finalizing the Osteotomy

IMPLANTATION • The tuber part of the osteotomy can be shifted medially, which moves the tuber into
k e r
e ss
• A bone-spreading device is mandatory to
r
manipulate the osteotomy.
k eers
varus. However, a lateral bony shelf will then protrude.
rs
• Remove this with a rongeur (if large, do it subcortically and push the cortex in) and
o o
o o k o o
oo kput the bone into the vertical limbs of the osteotomy to speed the healing.
oo
ee/ e
/ b
e b e /ebb
• Bone graft other than this is not used.
/e
• The flap is laid back, and the periosteum is closed meticulously with interrupted
e
/ / t
as much as in a double osteotomy. This need,
: / tm
• The tuber part of the osteotomy cannot be shifted
. .m resorbable sutures.
: / / t
/.tm
. m
ss : /
however, seems to be a very rare problem.
t p p t p ss : /
• Possibly interrupted subcutaneous sutures are used to form an ideal bed for the skin
suture, done without overtightening (see Fig. 32.15).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp p :
ss /
t
hht

FIG. 32.11 t t
hht
FIG. 32.12 t FIG. 32.13
STEP 3 PEARLS
• The large screw is a position screw. It holds
keerrss keerrss
the new axis. Aim laterally and distally at the
CC-Joint when drilling for it.
b ooook b ooook • Aim behind the subtalar joint with second
b oo
compressing screw.

: / / t
/ m
.t.m : / / t
/ m
.t.m
STEP 3 PITFALLS
• Avoid joint penetration and medial
t ppss : / t ppss : / overpenetration.
t
hhtt t
hhtt STEP 3 INSTRUMENTATION/
IMPLANTATION
• Large 6.5-mm fully threaded cancellous screw
(possibly headless)
k e rrss
e k e rrss
e
• 3.2-mm drill bit and countersink bit
• 4.0-mm cortical screw
o o
o o k
o o
o o k • 4.0-mm lag hole and 2.5-mm compression-
o o
eebb b b
FIG. 32.14 hold drilling in the far side
ee/ e
/ e b ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m STEP 3 CONTROVERSIES
t p ss:
p / t p ss:
p / • Several other implant techniques could be used.
t
hht t t
hht t STEP 4 PEARLS
• Bone plasty makes the lateral calcaneus
smooth again.
• At the end, there is a lateral gap that will fill
k e r
e s
rs k eers
rs
out eventually with healing.
• Close the flap in layers; periosteum is
o o
o o k o o
oo k especially important to close in order to
o
release stress on the skin edge.
o
eebb ee/ e
/ b
e b ee/e/ebb
STEP 4 PITFALLS
: / / t
/ .
tm. m : / / t
/.tm
. m • If the flap is handled carelessly, there is an
t p ss
p : /
FIG. 32.15
t p ss
p : / abundant risk for wound problems.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
262 hht
STEP 4 INSTRUMENTATION/ ALTERNATIVE DOUBLE-INCISION TECHNIQUE
k e e s
IMPLANTATION
r rs
• Resorbable sutures 2-0 or 3-0 are used in the
k eers
r s
• Sinus incision is carried out. Angle of Gissane is dissected and the lateral wall of the
calcaneus is dissected to show 50% of height at the distal part.
o o
o o kperiosteum and nylon monofilament in the skin.
•

oooo k o
Distal/plantar point of distal vertical osteotomy is marked with Kirschner wire
o
eebb ee/ e
/ebb (K-wire).
ee/ e
/ b
e b
• Proximal incision is performed straight as for tuber osteotomy.
: / / t
/ .
t m
. m : / / t . m
. m
• Subperiosteal dissection is made to connect incisions.
/ t
ss : /
• A double-incision technique with skin bridge
is probably (although not proven) a way to
t p p Cutting the Osteotomy
t p ss
p : /
minimize skin problems.
t
hht t t
hht t
• Start with a horizontal cut.
• Aim from a proximal incision to the K-wire distally.
STEP 1 PEARLS • The K-wire can be used as a cutting guide.
• Correction–manipulation–reduction and • Develop vertical cuts the same way as open approach.
k eerss
fixation can be done in the same way as with
r
an extensile incision.
k er
erss
Adjunctive Procedures
b ooook b ooook b o
• Once the skin is closed normally, other procedures are undertaken on the medial
o
ee/ e
/ e b foot.
e / e
/ e b
• The patient is therefore rolled over to the supine position.
e
t .
• These are the same incisions as used for a
: // / tm
. m • Generally, we do:
: / /t/.tm. m
p ss /
double osteotomy, but instead of harvesting
:
and implanting bone, a longitudinal osteotomy
t p tp pss : /
• Reefing of the spring ligament if slack
• Flexor digitorum longus transfer if the tibialis posterior tendon is tendinotic
t
hht t
is made, and thus the avoidance of bone
grafting is achieved. t
hht t
• Tarsal fusion (naviculocuneiform/intercuneiform/cuneometatarsal [Lapidus]) where
unstable, in conjunction with correction of bunion pathology
• Gastrocnemius lengthening, if the foot cannot be held in 90° after the surgery
(according to Silfverskiöld)
ke rrss
• Non–weight bearing typically 6 weeks
e keerrss
b ooook
• Protected weight bearing in Walker-boot for
another 6 weeks (total 12 weeks)
b oook
• After finishing surgery, the foot is dressed in a dry, sterile wound dressing and a fluffy
o b oo
well-padded splint. We use either a dorsal fixed-splint or a dorsal cast-splint for 3
eeb • Physiotherapy started as wounds are healed (3
weeks)
ee/e/e b e /e/e b
weeks until wound healing occurs.
e
: / / t
/ m
.t.m : / / t
/ m
.t.m
• After removal of sutures, we use compressive stockings and an orthosis like a
t ppss : / p ss : /
Velcro-secured below-knee orthotic boot.
• Weight bearing is avoided until 6 weeks postoperatively; early active movements are
t p
t
hhtt
• Wound healing problems will slow up the
procedure.
t
hhtt
encouraged as early as possible.
• Most patients ambulate with a knee walker or hands-free crutch for the first 6 weeks.
• After 6 weeks, physiotherapy is started and weight bearing is started as tolerated
(without pain) in orthoses.
POSTOPERATIVE INSTRUMENTATION/ • Water rehabilitation is encouraged as soon as wound healing makes it feasible.
k rrss
IMPLANTATION
e e e rrss
• The patient sleeps in the orthoses or cast for the first 6 weeks.
k e
o o
o o k
• If pain related to implants occurs, the implants
can be removed when stable healing is
o o
o o k
• Preoperative (Fig. 32.16) and postoperative (Fig. 32.17) radiographs are studied.
o o
eebb observed, usually not before 6 months.
ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
hands. t
• Early weight bearing has not been tried in our
hht t
• The postoperative rehabilitation should be
t
hht t
expected to take a minimum of 6 months,
usually up to 12 months.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
A
t
hht t t
hht t A
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
B
B
k eerrss FIG. 32.16

e
kke rrss FIG. 32.17
o o
o o k o o
o o o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
EVIDENCE
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss: / t p ss: /
Hintermann B, Valderrabano V. Lateral column lengthening by calcaneal osteotomy. Tech Foot Ankle
p p
Surg 2003;2:84–90.
t
hht t t
hht t
Hintermann B, Valderrabano V, Kundert H-P. Lengthening of the lateral column and reconstruction of
the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the
posterior tibial tendon. Foot Ankle Int 1999;20(10):622–9.
Mosier-LaClair S, Manoli II A, Pomeroy G. The double osteotomy and tendon transfer procedure for
stage II posterior tibial tendon insufficiency. Tech Orthop 2000;15(3):204–10.
k e r
e s
rs k eers
rs
Myerson MS, Badekas A, Schon LC. Treatment of stage II posterior tibial tendon deficiency with flexor
o o
o o k o oo k
digitorum longus tendon transfer and calcaneal osteotomy. Foot Ankle Int 2004;25(7):445–50.
Sangeorzan BJ, Mosca V, Hansen Jr ST. Effect of calcaneal lengthening on relationships among the
o oo
eebb ee e
/ b
e b
hindfoot, midfoot, and forefoot. Foot Ankle 1993;14(3):136–41.
/ ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh33
PROCEDURE
t hht
Lateral
rss Calcaneal Lengthening Osteotomy
r s s for
o k r
ee Adult Flatfoot
Supple
k o kkee r
ooo
b o
m ee
Victor Valderrabano and Beatt.Hintermann
/e m ee / e
: / ///t . m : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp t
hhtt p
t p
• Calcaneal lengthening osteotomy is not • Posterior tibial tendon insufficiency (PTTI), stage II to stage II–III
k eerss
indicated in cases of:
r
• Rigid pes planovalgus et abductus
k er
erss
• Medial ankle instability
b ooook deformity (PTTI stage III or IV)
b ooook
• Both must be accompanied by supple pes planovalgus et abductus deformity with
o o
forefoot supination and subfibular impingement, and preserved subtalar and talona-
b
eeb • Osteoarthritis of the subtalar and/or
Chopart joints
ee/ e
/ e b vicular joints
ee/ e
/ e b
• Isolated valgus deformities without
abductus component
: // t/.tm
. m
EXAMINATION/IMAGING
: / /t/.tm. m
t p ss
p : / ss : /
• The standard clinical examination of a patient requiring a lateral calcaneal lengthen-
tp p
INDICATIONS CONTROVERSIES t
hht t
• It has been postulated that lateral column
t
hht t
ing osteotomy includes:
• History for differential diagnosis between PTTI (female, >40 years of age, continu-
ous deformity with posterior tibial [PT] tendon inflammation, etc.) and medial an-
lengthening osteotomy will cause overload kle instability (trauma history, such as accompanied with lateral ankle instability/
in the calcaneocuboid joint and thus lead to
degenerative disease (Phillips, 1983). More rotational ankle instability, etc.)
keerrss
recent work, however, did not prove increased
joint pressure (Benthien et al., 2007). We also
keerrss
• Quantification of pain (visual analog scale score, 0–10)
• Flattening of arch
b ooook did not see any degenerative disease over time

o ook
• Swelling over PT tendon (Fig. 33.1)
b o b oo
eeb in our patients with a follow-up of up to 12
years.
ee/e/e b ee/e/e b
• Pes planovalgus et abductus deformity (Fig. 33.2A)
• Too-many-toes sign (abductus deformity)
: / / t
/ m
.t.m : / / t m
.t.m
• Documentation of tender points
/
• PT tendon strength test (weakness)
t
hhtt t
• Functional tests
hhtt
• Single heel-rise test: hindfoot remains in valgus while on tiptoes as evidence for
PTTI
• Double heel-rise test: hindfoot valgization while on tiptoes position as evidence
for PTTI (see Fig. 33.2B)
k e rrss
e rrss
• Ankle instability tests (lateral [inversion stress test and drawer test] and medial [eversion
e e
stress test])
k
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss
p : / FIG. 33.1
264 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 33 Lateral Calcaneal Lengthening Osteotomy for Supple Adult Flatfoot 265
• Radiologic assessment includes: TREATMENT OPTIONS
k e e s
• Weight-bearing radiographs
r rs k eers
r s
• Anteroposterior (AP) view of the foot: abductus deformity, subluxation of the
• Myerson calcaneal medial sliding osteotomy:
indicated for correction of isolated hindfoot
o o
o o k oooo k
talonavicular joint, pathologic AP talus–first metatarsal angle, bunion deformity
o o
valgus deformity
eebb (Fig. 33.3A)
e / e
/ebb e / e
/
• Lateral view of the foot: flatfoot deformity, plantar subluxation of the talonavicular
e e
b
e b
• Hintermann lateral calcaneal lengthening
osteotomy: osteotomy along and parallel to the
: / / t
/ .
t m
. m
joint, pathologic lateral talus–first metatarsal angle (see Fig. 33.3B)
: / / t
/ .
t m
. m
posterior subtalar joint facet
• Evans osteotomy: 10 mm proximal to the
p ss
p / t p ss
medial joint laxity, lateral fibular impingement (see Fig. 33.3C)
t p : /
• AP view of the ankle joint: ev. talar valgus tilt, involvement of the ankle joint with
: calcaneocuboid joint between the middle and
anterior subtalar joint facets; commonly done
t
hht t t
hht t
• Saltzman hindfoot view: quantification of hindfoot alignment angle
• Magnetic resonance imaging: detection of tendon degeneration and ligament in-
in children for congenital flatfoot
• Hansen calcaneocuboid interposition
arthrodesis: arthrodesis with lateral column
volvement (spring ligament, deltoid ligament); to rule out possible chondral, osteo-
lengthening effect
chondral, or osteoarthritic hindfoot changes
• Computed tomography scan: assessment of possible osseous defects, impinge-
k eers
rs k er
erss
ments (sinus tarsi, calcaneofibular), and osteoarthritis
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A t
hhtt hht tt B
FIG. 33.2
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
a
k e r
e s
rs k eers
rs
o o
o o k o ooo k B
oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: /B
/ t
/ .
tm.m : / / t
/.tm
. m C
t p ss
p : /
t p ss
FIG. 33.3
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
266 hht
PROCEDURE 33 Lateral Calcaneal Lengthening Osteotomy for Supple Adult Flatfoot hht
k e r
e s
rs
• Heel at the edge of the table
k eers
r s
• Lateral hindfoot anatomy (Fig. 33.4A):
• Sinus tarsi
o o
o o k o oo k
• Peroneal tendons
o o o
eebb POSITIONING PITFALLS
• No wedge underneath the ipsilateral hip with
ee/ e
/ebb • Sural nerve
e
• Posterior subtalar joint facet
e/ e
/ b
e b
lower leg external rotation
: / / t
/ .
t m
. m : / / t . m
. m
• Anterior process of the calcaneus
/ t
t p ss
p : / ss : /
• Medial midfoot anatomy (see Fig. 33.4B):
t p p
• Positioning wedge
t
hht t t
hht t
• Spring ligament
• Posterior tibial tendon
• Flexor tendons
• Neurovascular structures
POSITIONING
k eerss
• Ipsilateral iliac crest for harvesting an autograft
r
versus no approach to iliac crest by use of
k er
erss
• Supine position with wedge underneath the ipsilateral hip, placing the leg and foot in
b ooook fresh dried bone allograft.
b ooookinternal rotation
b o o
eeb PORTALS/EXPOSURES PEARLS
ee/ e
/ e b e / e
• Tourniquet at the thigh (350 mmHg)
/ e b
• Free draping of the ipsilateral iliac crest for harvesting an autograft (Alternative: fresh
e
// t
• Landmarks: tip of fibula, peroneal tendons,
: /.tm
. m : / /t
dried bone allograft)
/.tm. m
sinus tarsi, calcaneocuboid joint
t p p : /
ss PORTALS/EXPOSURES tp pss : /
• Preparation of a sterile covered fluoroscan for intraoperative radiographic imaging
t
hht t t
hht t
• Make a slightly curved 5-cm incision starting at the tip of fibula and following the
• Injury to sural nerve and peroneal tendons peroneal tendons to the anterior process of the calcaneus.
PROCEDURE
keer ss
r keerrss
Step 1: Exposure
ook ook
• Fluoroscan
b
eeboo /e b oo b oo
• Expose the sinus tarsi with an incision above the peroneal tendons.
b /e b
m ee /e dorsally.
m ee /e
• Position a small Hohmann retractor into the sinus tarsi to retract the soft tissues
: / t
/
with periosteal preparation versus extensile.t.m
• Straight approach to the lateral calcaneal wall
/ / : / /
/ t
/ .t.m
• Perform a subperiosteal exposure of the lateral calcaneal wall with a raspatorium
p ss :
approach with searching and preparation of
t t p t t ppss :
and position a small plantar Hohmann retractor, protecting the peroneal tendons and
the sural nerve
STEP 1 PEARLS
hhtt hhtt
sural nerve (Fig. 33.5).
• Identify the anterior border of the posterior subtalar joint facet.
• Use a spreader at the osteotomy site to define
rrss rrss
the intraoperative amount of lateral column
Sural nerve
o k e
k
lengthening.
e o k e
k e Posterior Sinus tarsi
o
eebb o o
STEP 1 PITFALLS
e b o
b o o subtalar
joint facet
e b o
b o
• Avoid osteotomy of the medial calcaneal
m ee/ / e Peroneal
m ee/ / e
cortex.
: / /
/ t
/ .t.m
• Dislocation of bone graft because of critical
tendons
: / /
/ t
/ .t.m Anterior process
of the calcaneus
t p
t ss:
bone quality (e.g., osteoporotic bone).
t p t t p
t ss:
p
IMPLANTATION
hht hht A
• Retractors Flexor tendons

• Spreader
k e r
e ss
• Oscillating saw
r
• Osteotome
k eers
rs Tibial artery
o o
o o k o o
oo k oo
eebb b b bb Tibial nerve
ee/ e
/ e ee/e/e
: / / t
/ .
tm.m : / / t
/.tm
. m Spring
t p ss
p : / t p ss
p : / B
ligament
t
hht t t
hht t FIG. 33.4
t t p
t ss:
p t t p
t ss:
p
hht hht
Step 2: Performance of Osteotomy STEP 2 PEARLS
k e r
e ss k eers
r s
• Perform an osteotomy along and parallel to the posterior facet with the oscillating
r saw, from lateral to medial, leaving the medial cortex intact (Fig. 33.6).
• Compliant patients with normal body mass
index and no risk factors (smoking, diabetes)
o o
o o k o oo k
• Insert two 2.5-mm Kirschner wires approximately 5 mm anterior and posterior to the
o o o
may be treated functionally in a removable
eebb ee
gra ILS, Plainsboro, NJ) (Fig. 33.7). e
/ebb ee/ e
planned osteotomy, and insert a double-pin distractor (Hintermann distractor; Inte-
/ / b
e b boot or orthosis.
t . m
. m t . m
. m
• Open the osteotomy with the distractor (Fig. 33.8A) until the forefoot abductus and
: / / / t : / / / t
STEP 2 PITFALLS
t p p : /
medial longitudinal arch seem to be restored (see Fig. 33.8B).
ss t p ss
p : /
• Measure the gap (usually 8–12 mm) and harvest a corresponding tricortical iliac crest
• Patients with high risks of complications:
• Smokers
t
hht t t
hht t
wedge autograft (Alternative: use a fresh dried bone allograft wedge).
• Insert the graft into the osteotomy site (Fig. 33.9) and remove the spreader.
• Patients with diabetes mellitus
• Patients with vitamin D insufficiency
• Patients with osteoporosis
• With intrinsic compression, usually no internal fixation is necessary. However, a • Complications:
3.5-mm cortical screw from anterior to posterior across the graft may prevent the • Infection
k eers
rs
•

er
ers
graft from plantar dislocation, especially in osteoporotic bone.
s
Check the correction and positioning of the graft and screw with fluoroscan
k
• Migration of the inserted graft
• Malunion
b ooook b o o
• Nonunion
• Hardware failure
eeb ee/ e
/ e b
• Irrigate the wound, and perform subcutaneous tissue and skin closure.
ee/ e
/ e b • Sural nerve problems
• Peroneal tendon lesions/dysfunction
: // t/.tm
. m : / /t/.tm. m • Complex regional pain syndrome
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 33.6
k e rrss
e k e rrss
e
o o
o o k
o o
o o k o o
eebb b b
FIG. 33.5
ee/ e
/ e b ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p s s
p : / t pAss
p : / B
t
hht tFIG. 33.7 t
hht t FIG. 33.8
t t p
t ss:
p t t p
t ss:
p
268 hht
PROCEDURE 33 Lateral Calcaneal Lengthening Osteotomy for Supple Adult Flatfoot hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs er
erss
ook okk
b
eeboo e b o
bo o FIG. 33.9
e b o
b o
m ee/ / e m ee/ / e
: ///t/.t. m : / /
/t/.t . m
t t p
t ss
p : t tptpss :
hht hht
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t ppss : / t ppss :
B /
t
hhtt t
hhttFIG. 33.10
• Level of the osteotomy:
k rrss
• A more distal osteotomy, as proposed by
e e Evans, may cause instability of the anterior
k e rrss
Step 3: Medial Soft-Tissue Reconstruction
e
o o
o o k process of the calcaneus with a tendency
o o
o k
• In cases of PTTI and medial ankle instability, medial soft-tissue surgical procedures
o o o
eebb b b
to rise up, thereby causing incongruency are subsequently performed, including:
at the calcaneocuboid joint. A complete
osteotomy is also needed in this procedure ee/ e
/ e b
• PT tendon reconstruction:
ee/ e
/ e b
/ t m
.t.m
because of its relationship to the center of
: / /

/ / t m
• Débridement and shortening
.t.m
• Flexor digitorum longus tendon transfer
: /
rotation of the talonavicular joint.
t p
• Osteotomy through the sinus tarsi, as
p /
ss: POSTOPERATIVE CARE AND EXPECTEDttOUTCOMES
p ss:
p /
• Deltoid ligament repair and/or spring ligament repair
t
hht t
described here, permits an incomplete
osteotomy and keeps the complex capsular
and ligamentous structures intact, which
hht t
• The patient is maintained in a lower leg cast or lower leg orthosis (e.g., Aircast Walker
ensures stability of the anterior process or VACOped; OPED, Cham, Switzerland) for 6 weeks with 15-kg partial weight bear-
of the calcaneus and preservation of
ing and antithrombosis prophylaxis.
congruency at the calcaneocuboid joint.
r s
rs
• Potential damage to the intermediate and anterior
k e e k eers
rs
• Radiographic follow-up is done at 6 weeks postoperatively for assessment of bony
union. Rule out graft collapse, malunion, and hardware failure (especially in smokers,
o o
o o kjoint facets of the subtalar joint by the osteotomy
was claimed to be a potential reason for
o o
oo k o
diabetic patients, and patients with vitamin D insufficiency).
o
eebb degenerative disease. However, we found no such
e /
complication in any of our patients. A specific trial
e e
/ b
e b /e bb
• Thereafter, start an intensive physical therapy program.
ee /e
(20 patients) with computed tomography scan
/ / t .
tm
controls 2 years after surgery did not show any
: / .m : / / t
/.tm
. m
ss : /
degenerative disease at the subtalar joint.
t p p t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
EVIDENCE
r s
rs rs
r s
Arangio GA, Chopra V, Voloshin A, Salathe EP. A biomechanical analysis of the effect of lateral column
k e e k ee
lengthening calcaneal osteotomy on the flat foot. Clin Biomech 2007;22:472–7.
o o
o o k o oo k
This three-dimensional multisegment biomechanical model study showed that a 10-mm lateral col-
o o o
eebb bb b b
umn lengthening calcaneal osteotomy reduced the excess force on the medial arch in adult flatfoot
e / e
/e
and added a biomechanical rationale to this clinical procedure.
e ee/ e
/ e
: / / t
/ t m
. m : / / t
/ t m
Benthien RA, Parks BG, Guyton GP, Schon LC. Lateral column calcaneal lengthening, flexor digitorum
. . . m
longus transfer, and opening wedge medial cuneiform osteotomy for flexible flatfoot: a biomechanical
t p ss
study. Foot Ankle Int 2007;28:70–7.
p : / t p ss
p : /
In this in vitro biomechanical study of 12 cadaver specimens (physiologically loaded) with radio-
t
hht t t
hht t
graphic and pedobarographic evaluation, lateral column lengthening increased lateral forefoot
pressures in a severe flatfoot model. An added medial cuneiform osteotomy provided increased
deformity correction and decreased pressure under the lateral forefoot.
Hintermann B. Lateral column lengthening osteotomy of calcaneus. Oper Orthop Traumatol
2015;27(4):298–307.
k e s
rs
nique.
e k er
ers
A description of the principles and technique of lateral column lengthening by this surgical tech-
r s
b ooook ooook
Hintermann B, Valderrabano V, Kundert HP. Lengthening of the lateral column and reconstruction of
o o
the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the
b b
eeb e e
posterior tibial tendon. Foot Ankle Int 1999;20:622–9.
/ / e b e / e
/ e b
This was a study of 19 patients treated with lengthening of the proximal lateral column by calcaneal
e e
// /.tm m
osteotomy and reconstructing the medial soft tissue.
t . / /t/.tm. m
Müller SA, Barg A, Vavken P, Valderrabano V, Müller AM. Autograft versus sterilized allograft for
: :
ss : / ss : /
lateral calcaneal lengthening osteotomies: comparison of 50 patients. Medicine (Baltimore)
t p p tp p
2016;95(30):e4343.
t
hht t t
hht t
Compared with autografts, sterilized allografts do not increase the risk for loss of hindfoot align-
ment in lateral column lengthening of the calcaneus. With respect to mechanical resistance, al-
lografts thus mean an equal and valid alternative without risk of donor-site morbidities.
Phillips GE. A review of elongation of os calcis for flat feet. J Bone Joint Surg Br 1983;65:15–8.
Between 1959 and 1974, the late Dillwyn Evans treated severe symptomatic flatfoot by elongating
keer ss keerrss
the os calcis. The long-term follow-up of 20 of these patients with a total of 23 feet was presented
r
in this study 7–20 years after the operation. At review, 17 of the 23 feet showed very good or good
b ooookpears to stand the test of time.

b ooook
results, and it was concluded that this is a useful procedure for severe cases of flatfoot that ap-
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
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k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t

k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
e r s
rs SECTION
r s
r s PART III
III
o o
o
k
o k e okkee
oo o o o
eebb ee/ e
/ebb ee/ e
/ b
e b
/ / t .
t m
. m / / t .
t m
. m
t
hhtt p
t ss
p
: : / /
Hindfoot
t
hhtt p
t ss
p
: : / /
k eers
rs PROCEDURE 34
k errss
avovarus Correction in Charcot-Marie-Tooth
C
e
b ooook b ooook
Disease 272
b o o
eeb / e
/
PROCEDURE 35
ee e b Z-Osteotomy for Varus Heel 287
ee/ e
/ e b
: // t/.tm
. m
PROCEDURE 36
: / /t/.tm. m
alcaneus Fractures: Treatment Using Extensile
C
t p ss
p : / ss : /
Lateral Approach and Open Reduction Internal
tp p
t
hht t t
hht
Fixation 293
t
PROCEDURE 37 Intraarticular Calcaneus Fractures 307
PROCEDURE 38 onextensile Techniques for Treatment of
N
keerrss keerrs
Calcaneus Fractures 319
s
b ooook
Sinus Tarsi Approach for Calcaneal Fractures 327
b oo
eeb /e
PROCEDURE 40
ee /e b ee/e/e b
Percutaneous Fixation of Talus Fracture 337
: / / / m
.t.m
PROCEDURE 41
t : / / / m
.t.m
Arthroscopic Talus Fracture Fixation 345
t
t ppss : /PROCEDURE 42
ss : /
Arthroscopy of the Subtalar Joint 353
t pp
t
hhtt PROCEDURE 43 t
hhtt
Distraction Subtalar Fusion 361
PROCEDURE 44 Triple Arthrodesis 371
PROCEDURE 45 ingle Medial Approach for Triple
S
k e rrss
e k e rrss
Arthrodesis 378
e
o o
o o k PROCEDURE 46
o o
o o k o
he Valgus Malaligned Triple With Subtalar and
T
o
eebb ee/ e
/ b
e b Transverse Tarsal Deformity 386
ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t 271
t t p
t ss:
p t t p
t ss:
p
hh34
PROCEDURE
t hht
Cavovarus
rss Correction in Charcot-Marie-Tooth
rs s
k ee r k ee r
oooDisease
eebb ok ooook / e bb / e b o
b o
m ee /e m ee / e
Glenn B. Pfeffer
: / t
///t. . m : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp t
hhtt p
t p
PITFALLS INDICATIONS
• Charcot-Marie-Tooth (CMT) disease includes • Chronic pain or deformity that interferes with activities of daily living
k eerss
a wide spectrum of hereditary motor and
r
sensory neuropathies. These diseases are
er
ers
• Failure of conservative measures, including bracing, shoe modification, and physical
s
therapy
k
b ooook often progressive, which can compromise the
long-term results of a surgical reconstruction.
b ooook b o
• A relatively flexible deformity without arthritic changes in the involved joints
o
eeb • The feet of older adolescents and adults
usually require simultaneous osteotomies, / e e b
EXAMINATION/IMAGING
ee / ee/ e
/ e b
: // t/.
tendon transfers, and soft-tissue balancing.
tm
. m Physical Examination
: / /t/.tm. m
p ss /
Young adolescents and children may benefit
:
from soft-tissue procedures alone, especially
t p
•

p ss : /
CMT disease can also affect the hips (dysplasia), spine (scoliosis), and upper
t p
t
hht t
in the early stages of the disease.
t
hht t
extremities (Fig. 34.1). Weakness of the first dorsal interosseous muscle in the hand
is one of the earliest signs of upper extremity involvement.
• A complete orthopedic examination of the lower extremities is required. There is
INDICATIONS CONTROVERSIES often atrophy of the anterior and lateral compartments of the leg.
• Examine the foot from all sides while the patient is standing (Fig. 34.2).
keer ss
• Early surgical intervention may prevent
rthe progression of deformity and minimize
keerrss
• Closely examine the lateral foot to evaluate the apex of the sagittal deformity
b ooook impairment. There are no established

guidelines, however, that address the
b oo
• Document the calluses on the plantar aspect of the foot (Fig. 34.4).
eeb appropriate age for surgery. Each case should
be dealt with on an individual basis.
ee/e/e b ee/e/e b
• Determine if claw toes are passively correctable (Fig. 34.5).
• In children <14 years of age, it is often
: / / t
/ m
.t.m driven heel varus.
: / / t
/ m
• A Coleman block test (Paulos et al., 1980) can be helpful in sorting out forefoot-
.t.m
p ss /
preferable to take an incremental approach to
:
surgery, rather than correcting all deformities
t p t ppss : /
• When the patient stands with a block beneath the lateral border of the foot, the
t
hhtt
at once. This chapter examines the surgical
options most appropriate for the older
adolescents and adults with CMT disease.
t
hhtt
medial column is unsupported and the first metatarsal head drops off the side of
the block (Fig. 34.6A).
• If the subtalar joint is flexible and there is no fixed varus deformity of the heel, the
• Patients with mild to moderate involvement
hindfoot will no longer be in varus when viewed from behind (see Fig. 34.6B).
can often be treated successfully with
nonoperative care. Cushioned shoes for shock
k e rrss
absorption, soft inserts for metatarsalgia, high-
e
topped shoes and lace-up ankle braces for
k e rrss
e
o o
o o k ankle instability, and bracing for foot drop can
o o
o o k o o
eebb help avoid surgery. Physical therapy for range
of motion, strength, and proprioception can
ee/ e
/ b
e b ee/ e
/ b
e b
also be helpful.
• The overarching goals of surgery are
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ss:
p /
preservation of joint motion, creation of a
p
plantigrade foot, and balance of muscle forces.
t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b
ee/e/ebb
FIG. 34.1
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
272 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 34 Cavovarus Correction in Charcot-Marie-Tooth Disease 273
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k e
A
ers
rs k er
erss
b ooook b oooo k FIG. 34.3
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp p ss : /
t
hht t t
hht t
keerrss keerrss
eeb B
ee/e/e b ee/e/e b

FIG. 34.2
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t s
pp s : /
t
hhtt t
hhtt
FIG. 34.4
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o oo
Bo k oo
eebb b b
A
ee/ e
/ e b
FIG. 34.5
ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
274 hht
PROCEDURE 34 Cavovarus Correction in Charcot-Marie-Tooth Disease hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: /
A
/ t/.tm
. m B
: / /t/.tm. m
t p ss
p : /
ss
FIG. 34.6
tp p : /
t
hht t t
hht t
• Document motor strength, including knee flexion and extension. Measure sensibility.
keerrss keerrss
• Typically, the peroneus longus, long toe extensors, and posterior compartment
b ooook b ooook muscles will maintain strength long after the foot intrinsics, peroneus brevis, and
tibialis anterior become weak.
b oo
• Evaluate the imbalance between muscle agonists and antagonists (i.e., peroneus
longus and tibialis anterior; posterior tibial and peroneus brevis; toe intrinsic flex-
: / / t
/ m
.t.m : / / t m
.t.m
ors and extrinsic extensors).
/
• Overpull of the posterior tibial tendon should be carefully evaluated and often has to
t
hhtt t
hhtt
be corrected at the time of surgery.
• Observe the patient’s gait. A foot drop is often effectively treated with an ankle foot
orthosis. The addition of an anterior tibial shelf often provides better balance to the
patient. Surgery may still be required if a nonplantigrade foot deformity precludes
effective bracing.
k e rrss
e k rrss
• A dynamic electromyogram may be particularly helpful when evaluating potential
e e
tendon transfers preoperatively.
o o
o o k o o o k o
• Multiple incisions are frequently required, which can create problems with skin heal-
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
ing. In patients with previous surgery, make sure that both the dorsalis pedis and
posterior tibial pulses are present. If not palpable, a Doppler evaluation is indicated.
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Spasticity, asymmetric reflexes, or marked hyperreflexia is not typical of CMT dis-
t p ss:
p / be obtained.
t p ss:
p /
ease. If these symptoms are noted, magnetic resonance imaging of the spine should
t
hht t •
t
hht t
A neurologic consultation with electromyography/nerve conduction study and
genetic testing (Athena Diagnostics, Worcester, MA, USA) is often appropriate. What
is often considered idiopathic cavovarus is probably a form of CMT disease.
• Document ankle laxity. Although patients often complain of instability during gait,
k e r
e s
rs k eers
objective ankle laxity is not often present. Extreme varus laxity can masquerade as
rs
normal subtalar motion.
o o
o o k oo k
• Is the foot flexible? During the non–weight-bearing examination, the subtalar, trans-
o o oo
eebb ee/ e
/ b
e b e /e/ebb
verse tarsal, and tarsal–metatarsal joints should be reasonably flexible. A fixed
deformity will most commonly require a triple arthrodesis, which is not appropriate in
e
: / / t
/ .
tm.m : / / t
/.tm
. m
a foot that has some preservation of motion in the hindfoot.
t p ss
p : / t p ss : /
• Evaluate gastrocnemius and soleus tightness. Typically, both the gastrocnemius and
the soleus will have to be surgically lengthened at the level of the Achilles tendon.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 34.8
k eers
rs k er
erss
eeb A
ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook B
b ooook b oo
eeb
FIG. 34.7
ee/e/e b ee/e/e b
: / / t
/ m
.t.m
: / / t
/ m
.t.m FIG. 34.9
t ppss : / t p s
p s : /
t
hhtt t
hhtt TREATMENT OPTIONS
• Many surgical options are used to address the
wide array of deformity and motor imbalance
k e rrss
e k e rrss
e
that occurs. This chapter presents one of
the most common operative approaches,
o o
o o k o o
o o k o o
which includes Achilles lengthening, triplane
eebb b b calcaneal osteotomy, Steindler release of the
ee/ e
/ e b ee/ e
/ e b plantar fascia, peroneus longus-to-peroneus
brevis transfer, closing wedge metatarsal or
Imaging
: / / t
/ m
.t.m : / / t
/ m
.t.m midfoot (Cole) osteotomy, correction of claw
t p ss:
p / t p ss:
p /
• Standing anteroposterior (Fig. 34.7A) and lateral (see Fig. 34.7B) radiographs of
the foot and ankle should be carefully examined to evaluate arthritic changes and
toes, interphalangeal fusion of the great
toe, and extensor tendon transfers to the
t
hht t t
hht t
determine the need for corrective osteotomies. Standing anteroposterior and lateral
images of the foot should be repeated using a Coleman block, which presents a
metatarsal necks. While often performed at
the same time, forefoot reconstruction can
be performed during a separate operative
more accurate view of the foot and its true deformity. procedure.
• The calcaneal pitch angle (normal <30°) and the talus–first metatarsal angle (Meary • With the hindfoot held in neutral, evaluate
forefoot cavus (valgus) caused by flexion of
k e r
e s
rs e rs
line; normal = 0°) are particularly useful in preoperative planning. If the calcaneal
rs
pitch corrects with the Coleman block in place, a corrective osteotomy of the heel
k e
the medial metatarsals from overpull of the
o o
o o k may not be needed.
o o
oo k oo
peroneus longus (Fig. 34.9). Commonly, only
the first metatarsal is involved, although the
eebb ee / b
e b e / /
tarsal–cuneiform joint or the midfoot. The deformity should be surgically corrected
e eb
• On the lateral standing radiograph, determine if the apex of the cavus is at the meta-
/ e e b second and third may be as well. Involvement
of the fourth and fifth metatarsals that requires
through its apex.
: / / t
/ .
tm.m : / / t
/.tm
. m operative correction is rare. If a plantar-flexed
metatarsal is not corrected, the surgical
t p ss
p : / t p ss
assessment of complex deformities and revision surgery (Fig. 34.8).
p : /
• A three-dimensional computed tomography reconstruction can be helpful in the
outcome will be poor.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
276 hht
SURGICAL ANATOMY
k e r
e s
rs k eers
r s
• Varus heel (Fig. 34.10A)
• Valgus forefoot (see Fig. 34.10B)
o o
o o k o oo k
• High calcaneal pitch angle (Fig. 34.11A)
o o o
eebb e / e bb
• Meary line (see Fig. 34.11B)
e /e ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb ee/e/e b A
e
B
e/e/e b
: / / t
/ m
.t.m
: / / t
/ m
.t.m
t ppss : / t ppss : / FIG. 34.10
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : / FIG. 34.11
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
POSITIONING
k e r
e ss k eers
r s
• Place the patient in a partial lateral decubitus position to gain easy exposure to the
r
lateral side of the foot. A deflated beanbag is placed behind the ipsilateral hip to help
POSITIONING PEARLS
• The patient should be very well padded because
o o
o o k o oo k o
support the patient in this position. The beanbag can easily be removed during the
o o
of potential susceptibility to pressure palsies.
eebb / e bb
surgery, allowing the patient to drop down into a supine position.
• Use a thigh tourniquet.
ee /e ee/ e
/ b
e b
•

: / / t
/ . m
. m : / / t . m
. m
A femoral-sciatic or popliteal block will help with postoperative pain control
t / t
ss : / ss : /
(Fig. 34.12). CMT disease is not a contraindication to a regional block.
t p p t p p
• Once the patient is under anesthesia, perform
a fluoroscopic examination of the ankle for
t
hht
PORTALS/EXPOSURES t t
hht t
• If indicated, perform a triple-cut lengthening of the Achilles tendon using a #11 blade,
laxity. The surgical approach can be modified
depending on the results of this examination.
• If ankle laxity has to be corrected, two
leaving the lateral insertion intact (Fig. 34.13). It is usually not sufficient to perform a incisions are preferable: one for the ligament
reconstruction and tendon transfer, and the
Strayer procedure to lengthen the gastrocnemius alone. other for the calcaneal osteotomy. With one
k eers k er
ers
• Begin the incision with a #15 blade just proximal to the tip of the fibula.
rs s
• Extend it distally over the calcaneal tuberosity, along the posterior border of the
incision, too large a flap has to be dissected
to expose both the calcaneal tuberosity and
b ooook b ooook
peroneal sheath. The incision should have a straight component over the portion of
b o o
the anterior ankle. It is unusual, however, to
find pathologic ankle laxity in these patients,
eeb the calcaneus that will be osteotomized.
ee/ e
/ e b e / e
/
• Extend the incision distally over the peroneals, ending at the insertion of the per-
e e b and one incision can almost always be used to
expose the heel and the peroneal tendons.
: // t/.tm m : / /t/.tm. m
oneus brevis (Fig. 34.14). If a midfoot osteotomy is required, the incision can be
.
t p p : /
extended distally over the lateral axis of the cuboid bone.
ss
• Identify and protect the sural nerve (Fig. 34.15).
tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e
FIG. 34.12
k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b
ee/ e
/ b
e b FIG. 34.13
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss : /
FIG. 34.14
p t p pss : /
t
hht t t
hht t FIG. 34.15
t t p
t ss:
p t t p
t ss:
p
278 hht
k e r
e ss
• The calcaneal osteotomy is performed as
r
anteriorly as possible in the tuberosity, to allow Step 1
k eers
r s
o o
o o kfor maximal correction of the heel deformity.
oooo k
• Expose the lateral wall of the calcaneus. Under fluoroscopic guidance, determine the
o o
eebb The osteotomy is usually located at the
posterior border of the peroneal sheath.
ee/ e
/ebb sheath.
ee/ / b
e b
appropriate position of the osteotomy. This is usually just posterior to the peroneal
e
• A centimeter of bone is the most that can
usually be removed from the calcaneus
: / / t
/ .
t m
. m : / / / .
t m
. m
• Under cool water lavage, use a microsagittal saw to cut perpendicular to the axis
t
t p ss
p : /
without shortening the heel unduly. Superior
displacement of the tuberosity adds some
t p
talar joint. ss
p : /
of the tuberosity (Fig. 34.16A). Superiorly, it should exit 1 cm posterior to the sub-
t
hht t
length to the calcaneus because of the
obliquity of the cut.
• When the calcaneus is displaced superiorly,
t
hht t
• The osteotomy should be angled obliquely (see Fig. 34.16B–C), from supe-
rior–proximal to inferior–distal, to allow rotation of the heel out of varus (as
the Achilles tendon is effectively lengthened, opposed to a medial displacement osteotomy used in the correction of pes
and an additional triple-cut lengthening may planus, which is oriented closer to the axis of the tibia). Avoid the subtalar joint
superiorly.
k e s
not be required.
rrs
• If there is 4+ strength of the posterior tibial
e errss
• If a simple closing wedge is all that is needed (which is not usually the case), leave
k e
b ooook tendon, but little peroneus brevis function
or peroneus longus function, an excellent
b ooookthe medial cortex intact; compress the osteotomy, and place three 16 × 25-mm
b o o
staples (Fig. 34.17). Excellent rigid fixation will be obtained without the need for
eeb surgical option is a closing wedge fusion of the
subtalar joint (to correct hindfoot varus), and
ee/ e
/ e b compression screws.
ee/ e
/ e b
// t
the interosseous membrane onto the dorsum
: /.tm
transfer of the posterior tibial tendon through
. m : / /t/.tm
• Many patients require correction of both heel varus and a high calcaneal pitch
. m
angle (hindfoot cavus) by a triplane osteotomy. In such a case, continue the cut
t p ss
p : /
of the foot (lateral cuneiform or cuboid). A
tp ss : /
through the medial cortex, being very careful not to damage the neurovascular
p
be required. t
hht t
simultaneous osteotomy of the heel may still
t
hht
bundle.
t
• Carefully make the distal cut of the osteotomy first, as there are several structures
at risk anteriorly (peroneal tendons, neurovascular bundle, and subtalar joint). The
second cut is made posterior and parallel to the first, removing the appropriate
STEP 1 PITFALLS amount of bone (usually 7–10 mm).
ke rrss
• A simple lateral displacement or Dwyer
e rrss
• Gently widen the osteotomy with a lamina spreader to facilitate displacement of
kee
b ooook osteotomy of the tuberosity is rarely sufficient.
The posterior tuberosity should be displaced
b ooook the tuberosity (Fig. 34.18). The medial nerves will not be stretched by this maneu-
ver.
b oo
eeb superiorly, laterally, and rotated out of varus.
A closing wedge of up to 1 cm may also be
ee/e/e b ee/e/e b
• Displace the osteotomy approximately 1 cm superiorly and 1 cm laterally, to cen-
tralize the weight-bearing axis of the heel.
required.
: / / t
/ m
.t.m : / / t m
.t.m
• Close the osteotomy laterally and hold it with one or two fluoroscopically placed
/
6.5–7.3-mm cannulated screws (Fig. 34.19A). One screw may be sufficient if good
t
hhtt t
hhtt
bone purchase is obtained (see Fig. 34.19B).
• Use a reciprocating power rasp to smooth down the lateral wall of the calcaneus
(Fig. 34.20).
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
1–1.5 cm
laterally based
closing wedge 1 cm
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m C
t p ss
p : /
t p ss :
FIG. 34.16
p /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm.
FIG. 34.18
m
t p s s
p : / tp p ss : /
t
hht t
FIG. 34.17
t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
A
e k e rrss
B
e
o o
o o k o o
o o k
FIG. 34.19
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k o o
o o k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
FIG. 34.20
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
280 hht
STEP 2 PITFALLS Step 2
k e r
e ss
• Stay close to the calcaneus during the
r
dissection to avoid inadvertent injury to the
k eers
r s
• If a peroneal tendon transfer is planned, extend the incision over the peroneals, as
noted earlier (Fig. 34.21). Use the skin marker to note the resting length of both ten-
o o
o o klateral plantar nerve.
oooo k o
dons, which will help place the longus at the appropriate resting length. Protect the
o
eebb • To avoid injury to the medial neurovascular
structures as the saw advances make sure the
ee/ e
/ebb sural nerve that crosses obliquely.
ee/ e
/ b
e b
• Divide the peroneus longus as it passes beneath the cuboid. Use a Pulvertaft weave
to the lateral wall of the calcaneus.
: / / t
/ t m
blade is not tilted and remains perpendicular
. . m t . m
. m
to transfer the longus into the distal most aspect of the brevis. Three weaves of the
: / / / t
t p ss
p : / t p ss
p : /
tendon create a very strong transfer. Use 3-0 Ethibond sutures to secure the transfer
(Fig. 34.22). The fibrous tunnel of the distal peroneal sheath may have to be removed,
t
hht t t
hht t
and the trochlear process smoothed down, to facilitate unobstructed motion of the
transfer.
• If a midfoot osteotomy is not required, the wound is irrigated and closed in layers,
using an absorbable subcutaneous suture and alternating horizontal mattress and
k eers
rs k er
ers
simple 3-0 nylon sutures in the skin.
s
• At this point evaluate the posterior tibial tendon. It is often a cause of deformity. If the
b ooook b ooook
posterior tibial tendon has four-fifths strength, it is preferable not to simply release.
b o o
eeb ee/ e
/ e b e / e
/ e b
Why waste a functioning muscle in a patient with CMT? The tendon can be length-
ened through a separate incision proximal to the ankle joint, or transferred to assist
e
: // t/.tm
. m : / /t/.tm. m
with ankle dorsiflexion or hindfoot eversion.
STEP 3 PEARLS
t p ss
p : / Step 3
tp pss : /
t
hht t
• If the first metatarsal is not adequately
corrected, a simultaneous closing wedge
t
hht t
• Remove the beanbag and place the patient into a supine position with the foot slight-
ly externally rotated.
osteotomy of the medial cuneiform can be • Make a 3-cm oblique incision over the medial heel where the plantar fascia attaches.
added. This incision will avoid the medial calcaneal nerve branch, which is easily injured with
• Occasionally, an osteotomy of the second a longitudinal incision.
keer ss
metatarsal will be required (approximately
r
10% of cases). If two osteotomies are
keerrss
• Divide the superficial abductor fascia and strip the abductor muscle and its deep
b ooook anticipated, base the initial incision more

laterally, between the metatarsals. If more than
b ooookfascia from their attachments on the medial calcaneus (Fig. 34.23). Avoid injury to the
b oo
first branch of the lateral plantar nerve, which runs deep to the abductor.
eeb two basilar osteotomies are needed, a better
correction will be obtained with a midfoot
ee/e/e b ee/e/e b
• Locate the medial edge of the plantar fascia and divide the fascia with small ten-
: / / t
/ m
.t.m
osteotomy (see later). A midfoot osteotomy will
/ / t
/ m
otomy scissors, pushing from medial to lateral. Use a small key elevator to strip the
.t.m
calcaneal attachments of the plantar intrinsic muscles.
:
deformity.
t ppss /
also facilitate the correction of an adduction
: t ppss : /
• Irrigate and close the skin with simple nylon sutures.
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb
FIG. 34.21
ee/ e
/ b
e b
ee/e/ebb FIG. 34.22
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e ss
osteotomy at the base of the first metatarsal.
k eers
r s
• Most frequently, the forefoot cavus (valgus) can be corrected with a closing wedge
r • Small plates can also be used to secure the
Cole midfoot osteotomy, although they tend
o o
o o k o oo k
• Make a 4-cm incision over the base of the first metatarsal (Fig. 34.24). Identify the
o o o
to be bulkier and are more likely to require
eebb ee e
/ebb
extensor hallucis longus and retract it laterally.
/
• Identify the first metatarsal–cuneiform joint and, with a microsagittal saw, make a
ee/ e
/ b
e b removal in the future.
t . m
. m t . m
. m
cut in the metatarsal 1.5 cm distal and parallel to the joint (Fig. 34.25). Irrigate with
: / / / t : / / / t
t p ss
p : / t p ss
p : /
cool water lavage when using the power saw. During the cut, place slight plantar
pressure on the distal metatarsal, which will start to hinge open the osteotomy
t
hht t t
hht t
prior to completion of the cut. It is essential to leave the plantar cortex intact.
• Make a second oblique cut several millimeters distal to the first cut (see Fig.
34.25B). Initially, only a small amount of bone (3–5 mm) should be removed. It is
difficult to close the osteotomy if more than 7–8 mm is removed.
k ee s
rsnot seat it completely.
k er
ers
• Place a 4.0 partially threaded screw into the proximal fragment (see Fig. 34.25B). Do
r s
b ooook b ooook
• Use a 0.062-inch Kirschner wire (K-wire) or comparable drill to make a transverse
b o o
eeb e / e
/ e b
hole 1 cm distal to the osteotomy, just dorsal to the longitudinal axis of the metatar-
e / e
/
sal (see Fig. 34.25B). Pass a 20-gauge wire through the hole from medial to lateral.
e e e b
: // t/.tm
. m : / /t/.tm. m
Use a small hemostat to grab the wire in the first metatarsal space. Place the wire in
t p ss : /
allows the wire to seat securely beneath the screw head.
p tp pss : /
a figure-of-8 configuration around the screw head. Using a partially threaded screw
t
hht t t
hht t
• Carefully close the osteotomy, tighten the wire, and advance the screw (Fig. 34.26).
Do not overtighten the screw, which can cause the wire to break. Carefully examine
the transverse alignment of the metatarsal heads. Repeat a similar osteotomy on ad-
ditional metatarsals, as needed.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb
FIG. 34.23
ee/ e
/ b
e b
ee/e/ebb FIG. 34.24
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
282 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : /
/t/.tm. m
t p ss
p : / tp pss : / FIG. 34.26
A
t
hht t
B
FIG. 34.25
t
hht t
keerrss keerrss
ee/e/e b
Step 5
ee/e/e b
• If the apex of the sagittal foot deformity is in the midfoot, the best correction is with
• Some surgeons are concerned about the rate
/ t
of nonunion from this osteotomy. The broad
: / / m
.t.m : / / t m
.t.m
a Cole osteotomy through the navicular–cuneiform joints medially and the cuboid
/
t ppss : /
cancellous surfaces, however, have little
trouble healing. A nonunion is very rare if good
laterally.
t ppss : /
t
hhtt
bone apposition is obtained at the time of
surgery.
• Others are concerned about potential arthritis
t
• This truncated closing wedge osteotomy provides excellent multiplanar correc-
hhtt
tion of the deformity. It also places the incisions on either side of the foot, away
from the multiple dorsal incisions that may be needed to correct claw toes.
of the adjacent joints because of inadvertent • This osteotomy should be used if more than two metatarsals require an oste-
injury during the osteotomy cuts. Careful otomy, or an adduction of the midfoot needs correction.
rrss rrss
placement of the K-wires under fluoroscopic • The lateral incision should be extended over the longitudinal axis of the cuboid.
o k e
k
guidance completely avoids this potential
e
complication. The decrease of motion that
o k e
k e
Medially, an incision is made over the navicular–cuneiform joint, in the plane between
o
eebb o o results from fusion of the navicular–cuneiform
joints is insignificant.
e b o
b o o e b o
the tibialis posterior and tibialis anterior tendons. Protect both of these tendons, par-
b o
ticularly the tibialis anterior, which is vulnerable during the saw cuts.
m ee/ / e m e / / e
• Under fluoroscopic guidance, place two 0.062-inch K-wires approximately 1.5 cm
e
: / /
/ t
/ .t.m : / / t
/ .t.m
apart, from medial to lateral (Fig. 34.27A).
/
• The pin placement is oblique, as the cuboid is inferior to the medial navicular–cu-
t t p
t ss:
p t p ss:
neiform joint.
t t p
hht hht
• The more distal pin passes through the medial cuneiform and exits through the
distal cuboid; the more proximal pin passes medially across the navicular and
exits through the proximal cuboid (see Fig. 34.27B–C).
• Avoid penetration of the fourth and fifth metatarsal–cuboid joints.
• Using blunt dissection and a small key elevator, completely dissect the soft-tissue
k e r
e s
rs k eers
rs
envelope around the bone of the midfoot. Protect the neurovascular structures dor-
o o
o o k o o
oo ksally and plantarly with small Hohmann retractors.
oo
eebb b b
• Cut along the inside of each pin, removing a trapezoidal wedge of bone that includes
ee/ e
/ e b e /e/e b
the navicular–cuneiform joints (Fig. 34.28). Irrigate with cool saline lavage.
e
: / / t
/ .
tm.m : / / t
/.tm
• Make every effort to create flat cuts, without redirecting the saw blade. Imagine
. m
that the apex of the wedge is at the plantar fascia, which enables a trapezoidal
t p ss
p : / t p ss : /
piece of bone to be resected.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb A B
ee/ ee
/ b e
C
e/ e
/ e b
: // t/.tm
. m FIG. 34.27
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ m
.t.m
t p ss:
p /
FIG. 34.28
t p ss:
p / FIG. 34.29
t
hht t t
hht t
• Adduction of the midfoot can be corrected with appropriately placed bone cuts.
• Remove the K-wires.
k e e s
rs k eers
• The forefoot can now be dorsiflexed and rotated into the correct position. Make
r rs
sure that the transverse metatarsal arch is well aligned and that the forefoot val-
o o
o o k gus is corrected.
o o
oo k oo
eebb e / b
e b
• Place the two K-wires temporarily across the osteotomy and place three 16 ×
/ e
20 mm 3M power staples across the osteotomy sites both medially and laterally.
e ee/e/ebb
: / / / .
tm m
Excellent fixation can be obtained in this manner (Fig. 34.29).
t . : / / t
/.tm
. m
t p ss
p : / t p ss : /
• Deflate the tourniquet. Obtain hemostasis and close the wounds in two layers,
with alternating 3-0 nylon horizontal mattress and simple sutures in the skin.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
284 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m Sutures
: / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht
Periosteum of t
distal metatarsal
Extensor
tendon
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss
: /
t
hht t FIG. 34.30
t
hht t FIG. 34.31
STEP 6 PEARLS Step 6
rrss
• A bulk transfer of the long toe extensors
kee into the lateral cuneiform or cuboid may

keer ss
• Claw toes should be corrected using standard techniques that involve resection of
r
the distal aspect of the proximal phalanx (see Procedure 14). The extensor digito-
b ooook provide more effective ankle dorsiflexion than
b ooook oo
rum longus tendon of each toe is transferred to the distal metatarsal using a deep
b
eeb individual transfers into the metatarsal necks.
ee/e/e b ee e/e b
periosteal stitch (Fig. 34.30). A small drill hole in the bone can be used but is time
/
consuming and probably unnecessary, given that the foot will be immobilized for at
: / / t
/ m
.t.m : / / t
/ m
.t.m
least 6 weeks in neutral position.
• If clawing of the great toe is present, the interphalangeal joint should be fused
s
through a transverse incision. The extensor hallucis longus is transferred into the
t
hhtt t
hhtt
distal metatarsal through a transverse drill hole.
• Correction of the forefoot deformity, by either metatarsal or midfoot osteotomy, can
create extrinsic flexor tightness, especially in the lesser toes. Even after the clawing
is corrected, hyperflexion of the toe may persist. A closed or open tenotomy of the
k e rrss
e k rrss
flexor digitorum longus to the toe will correct this problem (Fig. 34.31).
e e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b e / e
/ b
e b
• A bulky dressing and a three-sided splint are applied in the operating room after all
of the osteotomies are checked for a final time by fluoroscan.
e
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The patient returns to the office 10–12 days after surgery for the placement of a
t p ss:
p / t p ss: /
short-leg non–weight-bearing cast. Sutures are removed at this point, if the wounds
are completely healed. Anteroposterior (Fig. 34.32A) and lateral (see Fig. 34.32B)
p
t
hht t t
hht t
radiographs are taken in the cast.
• Six weeks after surgery, the cast is removed and radiographs are taken. An additional
short-leg, nonremovable cast is applied. The patient can start weight bearing as
tolerated. This second cast is removed at 10 weeks postoperatively. Physical therapy
should be started at this point, along with appropriate footwear.
k e r
e s
rs k eers
rs
• An excellent and enduring correction of the deformity can be expected (Fig. 34.33;
o o
o o k o o
oo k
the right foot has had surgery).
oo
eebb ee/ e
/ b
e b /e/ebb
See also Video 34.1, Cavovarus Correction in Charcot-Marie-Tooth Disease.
ee
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb A
ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb B
ee/e/ b
e ee/e/e b
: / / t
/ m
.t.m FIG. 34.32
: / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k
A
e r
e s
rs B
k eers
r
FIG. 34.33 s
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
286 hht
EVIDENCE
k e r
e s
rs rs
r s
Cole WH. The treatment of claw-foot. J Bone Joint Surg Am 1940;22:895–905.
k ee
Original description of the Cole osteotomy for midfoot cavus (Level V evidence).
o o
o o k o oo k o
Guyton GP. Current concepts review: orthopaedic aspects of Charcot-Marie-Tooth disease. Foot Ankle
o o
eebb bb b b
Int 2006;27:1003–10.
ee/ e
/e e / e
/ e
An excellent review of the topic and the literature.
e
: / / t
/ .
t m
. m1988;(234):221–8.
: / / t
/ t m
Mann RA, Missirian J. Pathophysiology of Charcot-Marie-Tooth disease. Clin Orthop Relat Res
. . m
t p ss
p : / t p ss
p : /
This paper examines CMT deformity and the contribution of muscle imbalance (Level V evidence).
Nagel MK, Chan G, Guille JT. Prevalence of Charcot-Marie Tooth disease in patients who have bilateral
t
hht t t
hht t
cavovarus feet. J Pediatr Orthop 2006;26:438–43.
Seventy-eight percent of children with “idiopathic” cavovarus feet were diagnosed with CMT
disease by neurophysiologic and genetic testing (Level IV evidence).
Paulos L, Colemann SS, Samuelson KM. Pes cavovarus: review of surgical approach using selective
soft-tissue procedures. J Bone Joint Surg Am 1980;62:942–53.
k eers
rs k er
ers
Review of 39 feet in children with cavovarus deformity. The use of the Coleman block test to distin-
s
guish forefoot-driven heel varus is described (Level IV evidence).
b ooook ooook
Pfeffer GP, Michalski MP, Basak T, Giaconi J. The Use of 3D Prints to Compare the Efficacy of Three
o o
Different Calcaneal Osteotomies for the Correction of Heel Varus. In American Academy of Orthopae-
b b
eeb ee e
/ e b
dic Surgeons Annual Meeting 2017.
/ ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh35
PROCEDURE
t hht
Z-Osteotomy
rss for Varus Heel rs s
o kkee r o kkee r
o
eebb o o
Nicola Krähenbühl and Markus Knupp
e bboo o e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht
• Rigid varus hindfoot deformity hht INDICATIONS PITFALLS
• If an underlying neurologic disease is
suspected, a neurologic assessment should be
EXAMINATION/IMAGING considered before surgery is performed.
• Analyze the patient’s gait and assess the entire alignment of the lower extremity
k eers
rs (Fig. 35.1).
k er
erss INDICATIONS CONTROVERSIES
b ooook b ooook
• Perform a lateral Coleman block test to differentiate between a forefoot induced
(flexible) and a true (rigid) hindfoot varus deformity.
b o o
• Consider a dorsiflexion osteotomy of the
metatarsal if the hindfoot varus is due to the
eeb / e e b
• Ask the patient for lateral giving way or instability when walking.
ee / ee/ e
/ e b plantar flexed first ray.
• Consider peroneus longus to brevis transfer in
: // t/ tm
. m : / /t/ tm
• While the patient is sitting with free-hanging feet, perform the anterior drawer test and
. . . m
talar tilt test to assess ankle joint stability. Furthermore, assess the inversion/eversion
case of an excessively pronated forefoot.
ss : / ss : /
force (function of posterior tibial and peroneal muscles) and subtalar range of motion.
t p p tp p
•

t
hht t t
hht t
Weight-bearing plane radiographs (anteroposterior, lateral, dorsoplantar, and
Saltzman views) should be obtained (Fig. 35.2).
TREATMENT OPTIONS
• Conservative treatment (i.e., pain medication,
• To analyze the deformity, (weight-bearing) computed tomography (CT) scans can shoe modification, orthoses) should always be
also be performed. considered before surgery is performed.
• If brace management is chosen, a short-leg
SURGICAL ANATOMY
keerrss keerrss
• The lateral dorsal cutaneous branch of the sural nerve proceeds on the lateral aspect
ankle foot orthosis with an outside (varus
correcting) T-strap is recommended. Stretching
b ooook o ook
of the calcaneus. The peroneal tendons lie retromalleolar and can be damaged dur-
b o b oo
of the heel cord and the plantar fascia has also
shown to be useful.
eeb ing the skin incision.
ee/e/e b
• Care should be taken not to compromise the medial soft-tissue structures. The
ee/e/e b
/ t m
.t.m
medial neurovascular bundle lies next to the posteromedial corner.
: / / : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e
FIG. 35.1
b ee/e/ebb
: / / t
/ .
tm. m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t 287
t t p
t ss:
p t t p
t ss:
p
288 hht
PROCEDURE 35 Z-Osteotomy for Varus Heel hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 35.2
keer ss
POSITIONING PEARLS
r
• More space for the surgeon is available if the
keerrss
b ooook operated leg is elevated with cushions or the
b ooook b oo
eeb opposite leg is lowered. In addition, lateral
radiographs can be taken more easily.
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
• The surgeon should control the draping to
ensure an appropriate implementation of the
procedure.
t
hhtt
• Draping should not avoid radiographic
assessment by a C-arm intraoperatively.
e rrss
k e k e rrss
e
o o
o o k
• Radiolucent operating table
o o
o o k o o
eebb • A tourniquet can be used to ensure optimal
conditions during surgery
ee/ e
/ b
e b ee/ e
/ b
e b
FIG. 35.3
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t
• To assess the alignment of the foot and ankle
intraoperatively, the contralateral ankle may be
draped additionally. POSITIONING
t
hht t
• The patient is placed supine on the operating table with a sandbag under the buttock
PORTALS/EXPOSURES PEARLS of the affected side to bring the lateral aspect of the hindfoot forward.
k e r
e ss
• To avoid injury of the sural nerve, a
r
subperiosteal exposure of the calcaneus
k eers
• A support can be placed on the opposite iliac crest to improve access.
rs
• The limb is exsanguinated.
o o
o o kshould be done.
o o
PORTALS/EXPOSURES
oo k oo
eebb PORTALS/EXPOSURES PITFALLS
ee/ e
/ b
e b e /e/ebb
• The lateral aspect of the calcaneus is exposed through a curved incision, parallel and
e
/ / t .
tm.
• Neurinoma and persistent pain postoperatively
: / m : / / t
/.tm
about 1 cm posterior to the peroneus longus tendon (Fig. 35.3).
. m
• The periosteum is stripped from the lateral wall of the calcaneus.
ss : /
may be possible if the sural nerve is injured.
t p p t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 35 Z-Osteotomy for Varus Heel 289
k e r
e s
rs k eers
r s
o o
o o k oooo k o
o
eebb b b • Small Hohmann retractors
ee/ e
/e b ee/ e
/ e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m PORTALS/EXPOSURES
CONTROVERSIES
t p ss
p : / t p ss
p : / • Do not compromise the medial soft-tissue
t
hht t t
hht t structures.
STEP 1 PEARLS
• The posterior vertical cut should not be too
k eers
rs k er
erss far posteriorly to avoid interference with the
insertion of the Achilles tendon, which is
b ooook
FIG. 35.4
b ooook b o o
protected with a Hohmann retractor.
• Hohmann retractors are also used for
eeb ee/ e
/ e b ee/ e
/ e b protection of plantar structures.
: // t/.tm
. m : / /t/.tm. m STEP 1 PITFALLS
t p ss
p : / tp pss : / • Use water during the osteotomy to reduce
t
hht t t
hht t osteonecrosis due to thermal injury.
IMPLANTATION
keerrss keerrss
• Hohmann retractors to protect the Achilles
tendon and plantar structures.
• K-wires to mark the corner of the bony wedge.
eeb ee/e/e b ee/e/e b STEP 1 CONTROVERSIES
: / / t
/ m
.t.m : / / t
/ m
.t.m • Calcaneal osteotomies are not without
t ppss : / t ppss : / liabilities. They endanger the lateral dorsal

cutaneous branch of the sural nerve, peroneal
t
hhtt
FIG. 35.5 t
hhtt tendons, and medial soft-tissue structures.
STEP 2 PEARLS
PROCEDURE
• Compared with other techniques, there is no
Step 1: Osteotomy of the Calcaneus shortening of the foot.
k e rrss
e k e rrss
e
• The horizontal part of the osteotomy is about 2 cm long and parallel to the plantar fascia.
• Correction in the frontal plane (wedge removal)
o o
o o k o o o k
• The anterior vertical cut is made slightly anterior to the tuberosity. A Hohmann retrac-
o o o
and additional lateral translation of the
tuberosity are possible.
eebb ee e
/ b
e b
tor is used to protect the plantar structures (see Fig. 35.4).
/ ee/
• The posterior cut is placed in the posterior half of the concavity of the tuberosity.e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Kirschner wires (K-wires) are used to mark the corners of the bony wedge. The oste-
STEP 2 PITFALLS
• Be aware of the screw length to avoid damage
t p ss:
p
• The bony wedge is removed. /
otomy is performed using an oscillating saw (Fig. 35.5).
t p ss:
p / to the subtalar joint.
t
hht t
Step 2: Mobilization of the Osteotomy and Fixation
t
hht t STEP 2 INSTRUMENTATION/
IMPLANTATION
• The osteotomy is mobilized with a distracter, such as a laminar spreader (Figs. 35.6
and 35.7). • Laminar spreader
• K-wires and cannulated screws
k e e s
rstion (Fig. 35.8).
k eers
• The tuberosity can be displaced laterally, and the gap is closed in the desired posi-
r rs
o o
o o k o o
oo k
• Optionally, the calcaneus can also be lengthened by displacing the tuberosity posteriorly.
oo
eebb • Rotation is also possible (see Fig. 35.8).
e / e
/ b
e b
• The Hohmann retractors are then removed, and the osteotomy is secured with one
e ee/e/ebb • Many calcaneal deformities consist of a frontal
and transverse plane deformity. We therefore
or two K-wires.
: / / t
/ .
tm.m : / / t
/.tm
. m modified current procedures and added some
rotation to the tuberosity and, where needed,
t p ss : /
screws are placed over the K-wires (Fig. 35.9).
p t p ss
p : /
• The position is checked under a C-arm as well as clinically. One to two cannulated
dorsal lengthening.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
290 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 35.6
b oooo k
b o o FIG. 35.7
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t p pss : /
t
hht t t
hht t
keerrss keerrss
Bone wedge to
be removed
eeb STEP 3 PEARLS
ee/e/e b ee/e/e b
/
• Rigorous bleeding control is recommended
: / t
/ m
.t.m : / / t
/ m
.t.m
hematoma.
t pp :
to avoid wound healing problems due to
ss / t ppss : /
t
hhtt t
hhtt
STEP 3 PITFALLS
• To avoid the bony prominence resulting from Medial Lateral Medial Lateral
translation, this may be tapped down.
e rrss
• The combination of wedge removal and lateral
k e k e rrss
e
o o
o o ktranslation minimizes the resulting tension on
the surrounding soft tissues.
o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
IMPLANTATION
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
• Absorbable sutures for the subcutaneous
p / t p ss:
p /
t
hht t
tissue and nonabsorbable sutures for the skin.

t
hht t FIG. 35.8
• A continuous compressive dressing may be
k e r s
rs
used to apply continuous pressure during the
e rs
rs
Step 3: Skin Closure
k ee
o o
o o kfirst 2 days postoperatively.
• In case of remaining ankle instability, lateral
oo k
• The different layers of the skin are closed under rigorous bleeding control (Fig. 35.10).
o o oo
eebb ligament reconstruction or peroneal tendon
transfer (longus to brevis) may be necessary.
ee/ / b
e b
• The tourniquet is deflated.
ee/ /ebb
• A thick compressive dressing is applied, and the foot is placed in a removable splint.
e e
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 35 Z-Osteotomy for Varus Heel 291
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss FIG. 35.9
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t ppss : / POSTOPERATIVE PEARLS
t
hhtt
FIG. 35.10
t
hhtt • In our series, all patients showed consolidation
on radiographs 6 weeks postoperatively.
• Intermediate follow-up shows good to excellent
results with reduction of pain and increasing
function.
k eerrss k e rrss
e
o o
o o k o o
o o k o o
eebb POSTOPERATIVE CARE AND EXPECTED

ee/ / b
e b
OUTCOMES
e ee/ e
/ b
e b
• A short-leg walking cast for a total of 6 weeks and full weight bearing are permitted,
• Wound healing problems due to tension on the
skin after the osteotomy.
/ t m
.t.m
unless associated procedures require a different management.
: / / : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• A clinical and radiographic assessment is done 6 weeks postoperatively Fig. 35.11. POSTOPERATIVE INSTRUMENTATION/
IMPLANTATION
t t t t
If the fusion is sufficient, the patient can continue with custom shoes.
hht hht • Removable synthetic cast and a short-leg
walking cast.
k e r
e s
rs k eers
rs • Shoe modification may be necessary
o o
o o k o o
oo k oo
postoperatively.
• In case of prominent hardware, removal is
eebb ee/ e
/ b
e b ee/e/ebb possible after bony healing occurred.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
292 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 35.11
EVIDENCE
keerrss keerrss
Bariteau JT, Blankenhorn BD, Tofte JN, DiGiovanni CW. What is the role and limit of calcaneal oste-
b ooook o ook
otomy in the cavovarus foot? Foot Ankle Clin 2013;18:697–714.
oo
A review article giving an overview of different types of calcaneal osteotomies. Z-osteotomies
b o b
eeb e /e/e b e /e/e b
should be performed in case of a severe and complex varus deformity (level IV evidence).
Dwyer FC. Osteotomy of the calcaneum for pes cavus. J. Bone Joint Surg Br. 1959;41B:80–6.
e e
: / / t
/ m
.t.m : / / / m
.t.m
A retrospective study of 41 children aged from 3 to 16 years treated with a lateral displacement
t
calcaneal osteotomy. The author reported improvement in gait and shoe wear (level IV evidence).
Knupp M, Horisberger M, Hintermann B. A new Z-shaped calcaneal osteotomy for 3-plane correction of
t
hhtt t
hhtt
severe varus deformity of the hindfoot. Tech Foot Ankle Surg 2008;7:1–7.
A retrospective study of 18 patients treated with a Z-shaped osteotomy of the calcaneus. The
author reported satisfactory short-term results. The osteotomy provides correction in the frontal
and transverse plane, which is superior compared with other osteotomies of the calcaneus (level IV
evidence).
Krause FG, Sutter D, Waehnert D, Windolf M, Schwieger K, Weber M. Ankle joint pressure changes in a
k e rrss
e rrss
pes cavovarus model after lateralizing calcaneal osteotomies. Foot Ankle Int 2010;31:741–6.
e e
A biomechanical study showing a significant lateral shift of the center of force and tibiotalar peak
k
o o
o o k o o
o o k
pressure reduction if a lateral displacement osteotomy of the calcaneus is performed. The authors
o o
eebb b b
suggest that calcaneal osteotomies help to normalize ankle contact stresses in pes cavovarus
e / e e b
(level IV evidence).
e / ee/ e
/ e b
Malerba F, De Marchi F. Calcaneal osteotomies. Foot Ankle Clin 2005;10:523–40. vii.
: / / t
/ m
.t.m : / / t
/ m
.t.m
A review article giving an overview of different types of calcaneal osteotomies for treatment of
t p ss:
p / t p ss: /
cavovraus deformity (level IV evidence).
Schmid T, Zurbriggen S, Zderic I, Gueorguiev B, Weber M, Krause FG. Ankle joint pressure changes in a
p
t
hht t t
hht t
pes cavovarus model: supramalleolar valgus osteotomy versus lateralizing calcaneal osteotomy. Foot
Ankle Int 2013;34:1190–7.
A biomechanical study comparing the peak pressure in the ankle joint between supramalleolar val-
gus osteotomies and lateralizing calcaneal osteotomies. The unloading effects of both osteotomies
were equivalent (level IV evidence).
Tennant JN, Carmont M, Phisitkul P. Calcaneus osteotomy. Curr Rev Musculoskelet Med 2014;7:271–6.
k e r
e s
rs k eers
rs
A review article giving an overview of the different types of calcaneal osteotomies. Calcaneal
osteotomies are powerful joint-preserving surgical procedures that are common components of the
o o
o o k oo k
correction of planovalgus and cavovarus foot deformities (level IV evidence).
o o oo
eebb b b
Vienne P, Schoniger R, Helmy N, Espinosa N. Hindfoot instability in cavovarus deformity: static and
ee/ e
/ e b ee/e/e b
dynamic balancing. Foot Ankle Int 2007;28:96–102.
A retrospective study of 8 patients treated for lateral ankle instability with a lateral calcaneal
: / / t
/ .
tm.m : / / t. m
. m
osteotomy, tendon transfer, and ligament reconstruction. The authors concluded that recurrent
/ t
t p ss
p : / t p ss : /
chronic lateral ankle instability is often associated with chronic hindfoot malalignment and leads to
functional impairment and patient discomfort (level V evidence).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh36
PROCEDURE
t hht
Calcaneus
rss Fractures: Treatment rUsing
s s Extensile
o k r
ee Approach and OpenoReduction
Lateral
k k ee
k r Internal
b oo o
eeb Fixation e bboo o e b o
b o
ee/ /e ee/ / e
.m
m : / /
/ t
/ t . . m
m : / /
/ t
/ t .
t p p
Stefan Rammelt,tMichael
t :
ss P. Swords, and Andrew K. Sands ttp t ss
p :
hht hht
INDICATIONS
k eers
rs k er
erss
• Intraarticular calcaneal fractures with ≥2 mm step off of the posterior facet, and in-
• Use of a foot pump to decrease edema prior to
operative intervention
b ooook b ooook b o
traarticular calcaneal fractures with Böhler angle <15° on lateral radiographs of the
o
• Age, smoking, workman’s compensation,
substance abuse, extensive comminution,
eeb foot or ankle
ee/ e
/ e b ee/ e
/ e b
• Contraindications: vascular insufficiency, poorly controlled diabetes, smokers, and
poor vascular supply, and various medical
comorbidities including uncontrolled diabetes,
t
noncompliant patients
: // /.tm
. m : / /t/.tm. m heart disease may be relative or absolute
ss : / ss : /
• Relative contraindications may include various medical comorbidities
t p p tp p
contraindications to open reduction internal
fixation (ORIF)
hht t t hht
• Surgical intervention with extended lateral incision may be performed urgently before
t t
swelling occurs, or within 1–3 weeks with the resolution of swelling and fracture blisters TREATMENT OPTIONS
EXAMINATION/IMAGING Closed Fractures

• Examination of the foot for closed calcaneal fractures often reveals significant swelling, • Calcaneal fractures may be treated nonopera-
tively with bulky Jones dressings and splinting
keerrss eerrs
ecchymoses, and fracture blisters, which may be serous or serosanguinous. Patients
s
are unable to load their heels. Open fractures often indicate greater energy of impact.
k
for comfort. The foot should be kept level,
b ooook b oook
Open fractures are typically medial although may be lateral or plantar. Pain with passive
o b oo
avoiding a dependent position. Early foot and
ankle range-of-motion exercises should be
eeb e /e/e b
motion of the toes may indicate an impending compartment syndrome, which may be
e
confirmed by monitoring deep plantar and calcaneal compartment pressures. Late signs
e e/e/e b initiated as soon as tolerated at 1–3 weeks to
decrease stiffness; additionally, cool Epsom
: / / t
/ m
.t.m : / / t
/ m
.t.m
of compartment syndrome include pallor, paresthesia, and loss of pulses. As much as soaks may further reduce the swelling. Weight
bearing is started at 3 months.
t p ss / t p ss : /
10% of calcaneal fractures are associated with spine fractures and 25% with additional
:
lower extremity fractures. A thorough physical examination should be performed.
p p
• Complications associated with nonoperative
Plain Radiographs
t
hhtt t
hhtt
protocols include subtalar stiffness, pain,
posttraumatic arthritis, loss of foot dorsiflexion,
widening and/or axial deviation of the heel,
• Lateral views of the calcaneus and foot should be obtained in both the injured and peroneal dislocation, lateral wall impingement,
calcaneofibular abutment, and difficulty
contralateral feet. Lateral radiographs may show fractures of the calcaneus associated
walking on uneven ground.
with a double contour at the level of the subtalar joint or below, flattening of Böhler
k e rrss e rrss
angle, normally 25–40°, and loss of calcaneal pitch (Fig. 36.1). If a calcaneal fracture
e k e
• Operative treatment of closed fractures with
an extensile lateral incision may be performed
o o
o o k o o
o o k
is suspected or seen on the lateral view, a computed tomography (CT) scan should
o o
immediately, or with resolution of swelling and
fracture blisters (positive wrinkle test).
eebb b b
be obtained to analyze the fracture pathology and make a treatment plan (Fig. 36.2).
ee/ e
/ e b
Other radiographic projections are optional: Harris views may show fractures through
ee/ e
/ e b • Percutaneous or mini-open reduction
techniques should be performed within the
: / / t
/ m : / / t
/ m
the posterior facet, widening of the calcaneus with lateral wall impingement, and loss
.t.m .t.m
of calcaneal height. Dorsoplantar (anteroposterior) views with the tube tilted 20° may
first week, while the fracture fragments are still
easily mobilized. Some surgeons utilize lateral
p ss:
p / t p ss: /
demonstrate fractures of the calcaneocuboid joint. Anteroposterior Brodén views with
t p
incisions over the sinus tarsi, or medial incisions,
t
hht t t
hht t
the foot internally rotated 45° and the foot plantar flexed 10–40° will show dislocation
of the posterior facet and are useful for intraoperative fluoroscopic control of reduction.
which will be discussed in separate chapters
(see Procedures 38 and 39).
Open Fractures
Computed Tomography • Open fractures should be emergently
irrigated and débrided. Repeat irrigation and
• Axial cuts (1 mm) with large overlap should be obtained with the following recon-
k e r s
rs
structive views oriented:
e k eers
rs
débridement should be performed as needed.
• If primary closure is not an option, then a
o o
o o k o o
oo k
• Perpendicular to the posterior facet to visualize gapping or step off and identify
the constant fragment containing the sustentaculum tali (Fig. 36.3A–B)
oo
preliminary reduction may be obtained and
held with Kirschner wires (K-wires) or a medial
eebb cuboid joint (Fig. 36.3C) ee/ e b

e b
• Parallel to the plane of the floor to obtain cuts perpendicular to the calcaneo-
/ ee/e/ebb three-point distractor until definitive fixation
and wound closure are performed.
: / t
/ .
tm.m : / / t
/.tm
. m
• Sagittal views to visualize the orientation of the fracture fragments of the posterior
/
• In Gustilo type III fractures, early soft-tissue
coverage with local or free flaps can prevent
facet (Fig. 36.3D)
t p ss
p : / t p ss
p : / infection and poor functional outcome.
t
hht t t
hht t 293
t t p
t ss:
p t t p
t ss:
p
294 hht
PROCEDURE 36 Calcaneus Fractures: Treatment Using Extensile Lateral Approach hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Tibia
k eers
rs k er
erss
eeb ee/ e
/ e b Talus
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t Cuboid
keerrss keerrss
eeb A ee/e/e b ee/e/e b
Posterior facet now down here instead of under talus and tilted
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / Böhler
t ppss : /
t
hhtt angle
t
hhtt
k e rrss
e
20-40 degrees
k eerrss
o o
o o k o ooo k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
B
p / t p s
p s : /
t
hht t t
hht t
FIG. 36.1
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 36 Calcaneus Fractures: Treatment Using Extensile Lateral Approach 295
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
CT reconstruction - 20° semicoronal
hht t
k eers
rs k er
erss
b ooook Tibia
b ooook b o o
eeb ee e
Talus
/ / e b ee/ e
/ e b
: // t/.tm
. mFibula
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t Posterior facet
with step-off
t
hht t
Calcaneus
keerrss keerrss
: / / t
/ m
.t.m A
: / / t
/ m
.t.m
t
hhtt t
hhtt
PF
PF
SU SU SU
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb b b
TU
ee
TU/ e
/ e b ee/ e
/ e b TU
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
B
FIG. 36.2 Oblique primary fracture line and secondary fracture line resulting in reproducible main fragments. PF, Lateral part of the posterior facet to the
talus; SU, sustentacular fragment (carrying the medial part of the posterior facet to the talus); TU, tuberosity.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
296 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t A
t
hht t
D
Depressed and fragmented
k eers
rs k er
erss
posterior facet (PF)
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t C
t
hht t B
FIG. 36.3 The anterior process (PA) is a fourth reproducible fragment. It may be split longitudinally, producing a fifth, anteromedial fragment. SU, Sustentacular
fragment; TU, tuberosity.
keerrss keerrss
eeb b b
Peroneal
tendon
sheath
ee/e/e Sural nerve
ee/e/e
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb b b
A B
ee/ e
/ e b FIG. 36.4
ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p p /
ss: SURGICAL ANATOMY t p ss:
p /
t
hht t t
hht t
• The lateral calcaneal artery, peroneal tendons, and sural nerve cross the lateral as-
pect of the calcaneus and are not at risk with the lateral extensile incision (see Fig.
36.5) if a full-thickness flap is raised carefully. The peroneal tendons emerge from the
k e r
e s
rs k eers
peroneal tendon sheath at the inferior and posterior aspects of the fibula (Fig. 36.4A).
rs
The peroneus brevis then inserts on the tuberosity of the fifth metatarsal while the
o o
o o k o oo k
peroneus longus crosses under the cuboid on the way to its insertion on the base of
o oo
eebb ee/ e
/ b
e b the first metatarsal.
e /e/ebb
• The sural nerve often courses just posterior to the peroneal tendons and then along
e
: / / t
/ .
tm.m : / / t
/.tm
. m
the lateral aspect of the foot (Fig. 36.4B). The sural nerve is often encountered in both
t p ss
p : / t p ss : /
the proximal and distal arms of the extensile incision. When transected, it is best to
cut the nerve as proximally as possible to avoid a stump neuroma.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Lateral wall Base of fifth

blow out metatarsal
k e r
e s
rs k eers
r s
o o
o o k oooo k Sural
nerve
o o
eebb Anterior
ee/ e
/ebb Sural
ee/
saphenouse
/
Lesser b
e b
calcaneal
process
: / / t
/ .
t m
. m nerve
: / / t
/ .
t m
. m vein
Fibula
t p ss
p : / t p ss
p : / Lateral
calcaneal
Peroneals
Achilles
t
hht t Top of tuber t
hht t artery
tendon
k eers
rs Vertical arm of
k er
erss
Plantar arm of
b ooook A extensile lateral approach
b ooook
extensile lateral approach B
b o o
eeb ee/ e
/ e b FIG. 36.5
ee/ e
/ e b
POSITIONING
: // t/.tm
. m : / /t/.tm. m POSITIONING PEARLS
t p ss
p : / tp pss : /
• The patient is positioned in a lateral decubitus position. An axillary roll is placed • Position the down leg such that it does not
t
hht t t
hht t
along with extra padding under the knee/peroneal nerve of the down leg with addi-
tional padding between the knees. A thigh tourniquet is applied. Utilization of pillows
interfere with fluoroscopic visualization.
• While a large C-arm allows for increased
resolution, it may be difficult to obtain Harris
or large foam blocks between the legs allows for a stable surface. If a large C-arm and oblique views.
is used, it is positioned anteriorly. Three-dimensional fluoroscopy is most useful for • By contrast, a mini-C-arm allows for greater
checking reduction intraoperatively. This requires a radiolucent extension of the op- flexibility but with decreased resolution and a
keerrss
erating table.
keerrss smaller field.
b ooook
PORTALS/EXPOSURE
b ooook b oo
eeb /e e b /
• Extensile lateral incision, as shown in Fig. 36.5, should be performed.
ee / ee e/e b
• The distal fibula is outlined as well as the entire calcaneus. With respect to the calca-
: / t
/ m
.t.m : / / t m
.t.m
neus, careful attention is paid to the posterior and plantar outlines, calcaneocuboid
/ /
• An operating room table with a radiolucent
extension
joint, lateral neck, and sinus tarsi. The approximate course of the peroneal tendons • Lateral decubitus hip positioners
• Foam blocks
t
hhtt t
hhtt
and sural nerve is detailed as well. The incision is marked starting at the level of the
ankle joint coursing just anterior to the Achilles tendon, along its insertion on the tu-
ber, and curving anteriorly along the plantar surface of the calcaneus (see Fig. 36.5A).
• Either a large C-arm or a mini-C-arm
• Thigh tourniquet
If the calcaneocuboid joint requires reduction, the distal aspect of the incision may
be veered superiorly to better expose the calcaneocuboid joint.
k rrss
e k rrss
• Make a longitudinal incision parallel and just anterior to the Achilles tendon and its
e e e
insertion on the calcaneus starting at the level of the ankle joint and curving anteriorly
• The sural nerve is often encountered on both
o o
o o k o o o k
to the plantar aspect of the calcaneus. The incision is then extended distally along
o o o
arms of the incision and should be protected.
eebb b b b Curving the incision anteriorly to expose the
ee/ e
the plantar aspect of the calcaneus, just past the calcaneocuboid articulation. The
/ e ee
incision is made sharply through the skin and then is carried down to the bone over/ e
/ e b calcaneocuboid joint increases the risk of sural
: / / t
/ m
.t.m : / / t
/ m
.t.m
the tuber. Careful dissection is made at the proximal and distal aspects of the inci-
nerve transection in the distal arm. Rounding
out the corner decreases the incidence of
t p ss:
p /
sion to avoid transection of the peroneal tendons and sural nerve.
t p ss:
p / wound dehiscence and necrosis in this area.
The advantage of the extensile incision is
PROCEDURE t
hht t t
hht t adequate visualization of the lateral neck,
sinus tarsi, and posterior facet with decreased
skin tension during the reduction. If carried out
Step 1 as described above, the incision respects the
• Starting at the rounded corner, a thick flap is sharply raised off of the lateral wall of angiosome of the lateral calcaneal artery (see
the calcaneus until the sinus tarsi, neck, and posterior facet are visualized. K-wires Fig. 36.5B). K-wires may be drilled into the
k e r
e s
rs k e rs
rs
(1.6 mm) may be drilled into the talus and bent to gently retract this flap. Fracture-
e
talus and bent to allow for adequate retraction
o o
o o k o o
oo k
associated peroneal tendon displacement may be noted during the approach.
oo
of the thick lateral flap.
eebb Step 2
ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
• The lateral wall is either reflected on a periosteal hinge or removed and set aside for
. m
later replacement. Soft tissues are sharply removed with a scalpel or rongeur to allow
t p ss : /
adequate visualization of the posterior facet.
p t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
298 hht
Anterior process
k e r
e s
rs
• With an extensile lateral exposure, restoration
of Böhler angle and anatomic reduction of the
k eers
r s fragment
o o
o o kposterior facet have both been shown to be
oooo k o
Sustentacular
fragment carrying
o
eebb bb b b
associated with improved outcomes. However, the medial
percutaneous and mini-incision techniques
ee/ e
/e ee/ e
/ e posterior facet
have also demonstrated good or equal results
with approximate anatomic reductions,
: / / t
/ .
t m
. m : / / t
/ .
t m
. m Fragments of
the posterior
t p ss
p : /
possibly due to less soft-tissue trauma and
scar formation. For the latter techniques, the
t p ss
p : / facet
t
hht t
reader is referred to the respective chapter of
this book (see Procedure 38).
t
hht t Schanz screw
in the main
tuberosity
fragment
STEP 1 EQUIPMENT A
rs
rs
• Scalpel
k ee
• Cobb Elevator
k er
erss
b ooook • K-wires
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
STEP 1 PEARLS
: // t/.tm
. m : / /t/.tm. m
t p ss
• Avoid elevators with sharp corners.
p : /
• If the sural nerve is transected, trace it
tp pss : /
t
hht t
proximally and transect to avoid a stump
neuroma.
t
hht t
STEP 1 PITFALLS
ke rrss
• Mobilization of the peroneal tendons may be
e keerrss
b ooook difficult.
• The peroneal tendons are detached from the
b ooook b oo
eeb peroneal tubercle and distal retinaculum and
mobilized gently within their sheet together
ee/e/e b ee/e/e b
with the raised soft-tissue flap.
/ / t
/ m
.t.m
• If possible, avoid placing the incision through
: : / / t
/ m
.t.m
t ppss : /
fracture blisters as this may increase the risk
t ppss : /
of perioperative infection.
t
hhtt B
h
t
htt FIG. 36.6
STEP 2 EQUIPMENT
• 4.5-mm Schanz half pin • The fracture fragments are identified, cleared from old hematoma, and loosened with
k rrss
• T-handle chuck
e e
• Osteotomes
k e rrss
either osteotomes or Cobb Elevators to allow for their manipulation and reduction.
e
The articular fragments are identified, and the posterior joint facet is cleared from
o o
o o k
• Cobb Elevator
o o o k
debris (Fig. 36.6A).
o o o
eebb b b
• Freer Elevator
ee/ e
/ b e e
/ e b
• A 4.5-mm Schanz pin is inserted into the lateral or posterior aspect of the posterior
e /
tuber to alleviate mobilization of the fragments and manipulation of the main tuberos-
e
STEP 2 PEARLS
: / / t
/ m
.t.m ity fragment (Fig. 36.6B).
: / / t
/ m
.t.m
p ss:
• Fracture fragments must be adequately
t p / t p ss:
p /
• Longitudinal traction and valgus force are applied to the Schanz pin to correct for
the varus malpositioning and shortening and widening of the heel. First, the tuber-
t
hht t
identified and mobilized to allow for reduction.
• Mark lateral wall orientation prior to removal. t
hht t
osity fragment is reduced beneath the sustentacular fragment and the medial wall
is restored. This creates room for anatomic reduction of the lateral posterior facet
fragment(s) (Fig. 36.7A). K-wires (1.8 mm) are inserted from the plantar aspect to hold
the reduction (Fig. 36.7B).
STEP 2 PITFALLS
r s
rs
• Fracture fragments may have increased
k e e
comminution, chondral damage, osteoporotic
Step 3
k eers
rs
o o
o o kbone, or old fractures with partial healing.
o o
o k
• A blunt lamina spreader is inserted into the sinus tarsi and opened to reduce the
o oo
eebb b b
lateral neck and restore the Böhler angle. With the lamina spreaders engaged, the
Small fragments that cannot be fixed reliably
have to be removed to avoid the presence of
ee/ e
/ e b e /e/e b
anterior half of the posterior facet should be visualized. The subtalar joint is reduced
e
: / t
/ .
t
will prevent anatomic reduction of the joint
/ m
loose bodies. Failure to restore the medial wall
.m : / / t
/.tm
stepwise from medial to lateral (Fig. 36.8). Bone tamps and elevators may be used
. m
to obtain an anatomic reduction. K-wires may be partially drilled into fragments to
fragment(s).
t p ss
p : / t p ss : /
joystick the fragment into place. If an intermediate fragment is present (Sanders type
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
STEP 3 EQUIPMENT
A
k eers
rs k er
erss • Blunt lamina spreader
• Dental pick
• 1.6-mm K-wires
eeb ee/ e
/ e b ee/ e
/ e b • Rongeur
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : / STEP 3 PEARLS
t
hht t t
hht t • Removal of fat from the sinus tarsi and
distraction of the subtalar joint with blunt
lamina spreaders will usually allow improved
visualization.
• If visualization is still inadequate, a thin
elevator may be passed over the articular
keerrss B
keerrss surface to confirm reduction.

• Rebuild the posterior facet starting with the
b ooook FIG. 36.7
b ooook b oo
most medial fragment in continuity with the
sustentaculum.
eeb ee/e/e b ee/e/e b • Use of a dental pick may help reduce the
smaller fragments.
: / / t
/ m
.t.m : / / t
/ m
.t.m • Because of the convex shape of the subtalar
joint facet, direct visual control of reduction
t ppss : / t ppss : / is difficult once the lateral fragments are
t
hhtt t
hhtt
reduced.
• Introduction of a dry small joint arthroscope is
a quick and reliable means of adequate control
of joint reduction (Fig. 36.10).
k e rrss
e k e rrss
e
STEP 3 PITFALLS
o o
o o k o o
o o k o • Loss of articular cartilage may make anatomic
o
eebb b b reduction difficult.
ee/ e
/ e b ee/ e
/ e b • Calcaneocuboid comminution may make it
difficult to restore and maintain Böhler angle.
: / / t
/ m
.t. m : / / t
/ m
.t.m
t p ss:
p / FIG. 36.8
t p ss:
p /
t
hht t t
hht t STEP 3 CONTROVERSIES
• Comminution of the posterior facet may make
anatomic reduction impossible.
III–IV fractures), it is reduced to the medial joint-bearing fragment first. Once the frag- • It is controversial whether to proceed with a
ment is reduced, the K-wire is advanced through the medial skin until it is flush with primary subtalar fusion, or plate and screw
fixation in this situation.
k e s
rs e rs
the lateral end of the fragment. The lateral joint fragment is then reduced, and the K-
r rs
wire is brought back by grasping the other end to allow stacking of all joint fragments
e k e
• The order of fixation is also controversial.
o o
o o k(Fig. 36.8).
o o
oo k oo
• Some surgeons prefer to start with reduction
of the anterior process while most surgeons
eebb b b
• The joint fragments are fixed at this stage with a small fragment screw that is directed
ee/ e
/ e b e
to the sustentaculum tali to obtain maximum purchase and stability (Fig. 36.9A). If
e/e/e b prefer a “joint first” strategy.
• ORIF of calcaneal fractures is fraught with
: / / t
/ .
tm.m : / / t
/.tm
the fragments are too small to hold a screw, the K-wire may be cut flush with the
. m
lateral wall and remain as a “lost K-wire” (Fig. 36.9B). Alternatively, resorbable pins
a considerable learning curve, and every
surgeon should apply the technique he/she is
may be used.
t p ss
p : / t p ss
p : / comfortable with.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
300 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss
Screws
keerrss
b ooook b ooook oo
Sustentaculum
b
eeb ee/e/e b
Reduced
fragments
ee/e/e b
tali
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt B h t tt
1. Reduce joint <2 mm
h
2. Aim screws for sustentaculum tali
FIG. 36.9
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
M
k e r
e s
rs k eers
rs
o o
o o k o o
oo k I
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p :L
/
t
hht t t
hht t
FIG. 36.10 Fragment of the posterior facet after anatomic reduction. I, Intermediate fragment; L, lateral fragment; M, medial fragment.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss B
FIG. 36.11
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
A B
k e rrss
e k e rrss
e
FIG. 36.12
o o
o k
Step 4
o o o
o o k o o
eebb ee e
/ b
e b
• Fine reduction of the tuberosity fragment to the reconstructed posterior joint block is
/
achieved with the help of the Schanz screw at this stage, if needed.
ee/ e
/ b
e b STEP 4 CONTROVERSIES
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Reduction of the posterior part of the calcaneus regularly alleviates reduction of the
• The need to fill the void with bone
morphogenic protein, bone graft, or bone graft
t p ss:
p / t p ss:
p /
anterior process. If there is a remaining incongruity at the calcaneocuboid joint, the
anterior facet of the calcaneus is reduced under direct vision and fixed with K-wires
substitutes is highly controversial.
• Some surgeons advocate filling the void with
t
hht t t
hht t
introduced from lateral to medial. The anterior process is moved plantarly with the
help of a laminar spreader or hook to counteract the pull of the bifurcate ligament.
bone cement with/without antibiotics and
having the patient bear weight at 3 weeks.
• Other surgeons may not utilize bone graft or
• Reduction of the posterior and anterior portions of the calcaneus is held temporarily bone morphogenic proteins at all and refer to
with K-wires introduced from the tuberosity into the anterior process. the regenerative capacities of cancellous bone.
k e r s
• The Schanz pin is removed.
rs e rs
rs
• The lateral wall is folded back and should fit anatomically after proper reduction of the
e k e
• Sinus formation has been reported with the
use of calcium phosphate bone substitutes.
o o
o o k o o
oo k
shape of the calcaneus. An appropriate-sized calcaneal plate is applied to the lateral
oo
• Locking versus nonlocking plates: There was
no difference in load to failure with either plate
eebb ee/ e
/ b
e b e /e/ebb
aspect of the calcaneus and contoured accordingly. At least one of the screws through
the plate should lag the sustentaculum tali constant fragment. A minimum of two screws
e
in cadavers or sawbones.
• If an interlocking plate is used, the first screws
: / / t
/ .
tm.m : / / t
/.tm
. m
are placed into the anterior process and tuberosity fragments each (Fig. 36.11). should be introduced in a nonlocking manner
to compress the plate down to the bone, thus
t p ss
p : / t p ss : /
• Anatomic reduction, implant position, and screw length are checked fluoroscopically
with a lateral, axial, and 10–40° Brodén views (Fig. 36.12). Alternatively, these are
p
increasing friction between bone and plate and
t
hht t
checked with a three-dimensional fluoroscopic scan.
t
hht t avoiding soft-tissue irritation by an overlaying plate.
t t p
t ss:
p t t p
t ss:
p
302 hht
STEP 5 PITFALLS Step 5
k e r
e ss
• Blanching of the skin indicates increased skin
r
tension. If advancement of the deep layers of
k eers
r s
• The goal is to achieve a tension-free closure of the skin and subcutaneous tissues
to limit the potential for corner necrosis and dehiscence. The deep fascial layer of
o o
o o kthe flap is insufficient to obtain a tension-free
o oo k o
the flap is closed with an absorbable braided 0 suture from either end of the incision
o o
eebb skin closure, pie crusting of the skin may be
performed. Usually, anatomic reduction of the
ee/ e
/ebb ee/ e
/ b
e b
advancing the flap with each stitch. This ensures that the corner will close and be
tension free. The subcutaneous tissues and skin are closed according to surgeon’s
calcaneus takes away the lateral bulging and
allows for a tension-free wound closure.
: / / t
/ .
t m
. m t . m
. m
preference. Sterile dressings and a three-sided splint with the foot in neutral are ap-
: / / / t
t p p : / plied.
ss POSTOPERATIVE CARE AND EXPECTEDttOUTCOMES
p ss
p : /
t
hht t hht t
• The operative dressing is left intact for 2 weeks and removed at the first postopera-
tive visit.
• A controlled ankle movement walker boot is placed; alternatively, compliant patients
k eers
rs k er
erss
are mobilized in their own shoes.
• The patient is non–weight bearing or allowed to put the affected leg to the ground
b ooook b ooook without loading (which equals about 20 kg) with two crutches or a walker for 6–12
b o o
eeb ee/ e
/ e b eral radiographs.
ee/ e
/ e b
weeks until resolution of swelling and evidence of consolidation are present on lat-
: // t/.tm
. m : / /t/.tm. m
• Early active range of motion exercises of the ankle and subtalar joints are shown and
t p ss
p : / tp ss : /
initiated early to avoid excessive scarring.
• The most common postoperative complication is tissue necrosis and wound de-
p
t
hht t t
hht t
hiscence of the corner area. There is also a 5% infection rate for closed calcaneal
fractures with ORIF. This infection rate is increased with open calcaneal fractures.
• With superficial wound edge necrosis, local wound care with a 30–50% peroxide
solution, bacitracin, and sterile dressings is taught.
• Sural nerve transection or retraction may result in postoperative paresthesia.
keerrss keerrss
• Painful hardware, malreduction, or subtalar arthritis may require later arthrodesis or
b ooook b ooook removal of hardware.
b oo
• With restricted range of motion, implant removal and arthrolysis of the subtalar joint
may be carried out at approximately 1 year postoperatively.
: / / t
/ m
.t.m : / / t
/ m
• Improvement will continue over a 2-year period.
.t.m
• With anatomic reduction and careful soft-tissue handling, good to excellent results
can be expected in 65–80% of cases as shown in clinical studies with large patient
t
hhtt t
hhtt
cohorts (Fig. 36.13).
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m C
t p ss
p : /
t p ss
FIG. 36.13
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
EVIDENCE
r s
rs rs
r s
Ågren PH, Mukka S, Tullberg T, Wretenberg P, Sayed-Noor AS. Factors affecting long-term treatment
k e e k ee
results of displaced intra-articular calcaneal fractures a post-hoc analysis of a prospective, rand-
o o
o o k o oo k
omized, controlled multicenter trial. J Orthop Trauma 2014;28(10):564–8.
o o o
eebb bb b b
Eight to twelve years of results from a randomized controlled multicenter trial of operative
ee/ e
/e e /
versus nonoperative treatment (n = 56) were divided into two groups: the superior 50% results
e e
/ e
: / / t
/ t m
. m : / / t
/ t m
(n = 28) and the inferior 50% results (n = 28), regardless of the treatment given. Patients in the
. . .
superior group had higher physical 36-Item Short Form Survey (SF-36), American Orthopae-
m
t p ss
p : / t p ss
p : /
dic Foot and Ankle Society (AOFAS), and Olerud–Molander scores than those in the inferior
group. Operative treatment, better Böhler angle and articular surface restoration, light labor/
t
hht t t
hht t
retirement, and absence of injury insurance were more common in the superior group. Age,
sex, pretreatment Böhler angle, and fracture type were comparable in the superior and inferior
groups.
Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J
Orthop Trauma 2004;18(1):1–6.
k ee s
rs k er
ers
A retrospective study of 341 closed and 39 open calcaneal fractures. Of these, 1.8% with closed
r s
fractures and 7.7% with open fractures experienced serious infections that required intervention
b ooookbeyond oral antibiotics.
ooook o o
Brenner P, Rammelt S, Gavlik JM, Zwipp H. Early soft tissue coverage after complex foot trauma. World
b b
eeb J Surg 2001;25(5):603–9.
e / e
/ e b e / e
/ e b
A retrospective study of 28 complex open foot injuries with multiple fractures. Definitive wound
e e
// /.tm
. m / /t/.tm. m
closure with free tissue transfer was achieved as an emergency procedure within 24 hours in 2 of
t
28 cases, as urgent revision within 72 hours in 9 of 28 cases, and as early revision within 120 hours
: :
ss : / ss : /
in 15 of 28 patients. As much as 17 of 28 patients were seen at a minimum 1-year follow-up. The
t p p tp p
t t t t
average Maryland Foot Score was 74.2 (of 100) points, indicating “good” to “sufficient” foot func-
hht hht
tion. The outcome was superior compared with a series of 18 consecutive open calcaneus frac-
tures with delayed soft-tissue coverage (64.4 points). The overall infection rate could be lowered to
7.1% after complex foot injuries with early soft-tissue coverage compared with 26 open calcaneus
fractures (19.2%).
Buch BD, Myerson MS, Miller SD. Primary subtalar arthrodesis for the treatment of comminuted calca-
keer ss
neal fractures. Foot Ankle Int 1996;17:61–70.
r keerrss
A retrospective series of 16 patients with severely comminuted calcaneal fractures treated by
b ooook b ooook
ORIF and primary subtalar arthrodesis through an extensile lateral approach. The authors rou-
b oo
tinely used iliac crest autograft, and they used a femoral distractor intraoperatively to facilitate

restoration of calcaneal height and alignment. Fixation consisted of one or more lateral neutrali-
zation plates, and either a single fully threaded cannulated screw or a noncompressed partially
: / / t
/ m
.t.m : / / t
/ m
.t.m
threaded cannulated screw, depending on the broad cancellous surface area to achieve union
t ppss / t ppss : /
of the arthrodesis. They reported a 100% union rate, and all but one of the patients employed
:
at the time of injury returned to their original occupation at an average of 8.8 months following
injury.
t
hhtt t
hhtt
Buckley R, Leighton R, Sanders D, Poon J, Coles CP, Stephen D, et al. Open reduction and internal
fixation compared with ORIF and primary subtalar arthrodesis for treatment of sanders type IV calca-
neal fractures: a randomized multicenter trial. J Orthop Trauma 2014;28(10):577–83.
A randomized prospective multicenter trial of 31 Sanders type IV displaced intraarticular
calcaneal fractures. Seventeen patients were treated with a standard protocol involving a
k rrss
e k rrss
lateral approach for ORIF. Fourteen patients were treated with a standard protocol involving a
e e e
lateral approach with ORIF + primary subtalar arthrodesis. Twenty-six patients were followed
o o
o o k o o o k
for a minimum of 2 years. No statistical difference was found between the results for ORIF
o o o
eebb b b b b
compared with ORIF + primary subtalar arthrodesis with respect to the mean SF-36, Short
ee/ e
/ e
Musculoskeletal Function Assessment (SMFA), AOFAS Ankle–Hindfoot Scale, and Visual Ana-
ee/ e
/ e
fusion.
: / / t
/ m : / / t
/ m
logue Scale scores. Only 1 of 17 patients randomly allocated to ORIF went on to a secondary
.t.m .t.m
t ss:
p / t p ss:
p /
Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with
p
nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized,
t
hht t t
hht t
controlled multicenter trial. J Bone Joint Surg Am. 2002;84A(10):1733–44.
A prospective, randomized study of 206 patients with 249 fractures that were treated operatively
with screw, plate, or with Kirschner wire fixation via an extensile lateral approach; 218 patients with
262 fractures were treated nonoperatively. The average follow-up in their study was 3 years, and
73% of patients were followed for a minimum of 2 years. Statistical analysis revealed significantly
k e e s
rs k eers
better results in certain subgroups treated operatively: women, younger patients, patients with a
r rs
lighter workload, patients not involved in workers’ compensation claims, patients with a higher
o o
o o k o oo k
initial Böhler angle (less severe initial injury), and those with an anatomic reduction on postopera-
o
tive CT evaluation. Overall, there was no significant difference in outcome between the operative
o o
eebb e e
/ b
e b e /e/ebb
and nonoperative groups. However, patients undergoing nonoperative treatment of their fracture
/
were 5.5 times more likely to require a subtalar arthrodesis for posttraumatic arthritis than those
e e
treated operatively.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
304 hht
Heier KA, Infante AF, Walling AK, Sanders RW. Open fractures of the calcaneus: soft tissue injury deter-
mine outcome. J Bone Joint Surg Am. 2003;85A(12):2276–82.
k e r
e s
rs k eers
r s
A retrospective series of 503 calcaneal fractures, 43 of which were open (8.5%), treated at one in-
o o
o o k o oo k
stitution. Seven of nine (77%) type I open fractures treated with open reduction and internal fixation
o
or primary fusion had no major complications and a good-to-excellent short-term result. A total of
o o
eebb e e
/ebb e / e
/ b
e b
3 of 8 (38%) type II open fractures, 3 of 12 (25%) type IIIA open fractures, and 10 of 13 (77%) type
/
IIIB open fractures were complicated by an infection. Six of the infections associated with a type
e e
: / / t
/ .
t m
. m : / / t t m
IIIB open fracture progressed to osteomyelitis, and three of those cases led to an amputation.
. . m
Herscovici Jr D, Widmaier J, Scaduto JM, Sanders RW, Walling A. Operative treatment of calcaneal
/
t p ss
p : / ss : /
fractures in elderly patients. J Bone Joint Surg Am. 2005;87(6):1260–4.
t p p
t
hht t t
A retrospective series of 44 patients >60 years and followed for an average of 44 months; 97%
hht t
of the fractures healed at an average of 110 days. The average AOFAS, SF-36, and SMFA scores
were similar to those reported for younger patients. Posttraumatic subtalar arthritis developed
in 12 patients. There were 12 minor complications and four major complications (three cases of
osteomyelitis and one nonunion), all of which were treated successfully. Open reduction appears to
be an acceptable method of treatment for displaced calcaneal fractures in elderly patients.
k eers
rs k er
ers
Myerson MS, Juliano PJ, Koman JD. The use of a pneumatic intermittent impulse compression device
s
in the treatment of calcaneus fractures. Military Medicine 2000;165(10):721–5.
b ooook ooook
A retrospective review of records of 55 patients treated preoperatively with an intermittent com-
o o
pression foot pump and surgical treatment by open reduction and internal fixation. Average times
b b
eeb ee/ e
/ e b ee/ e
/ e b
were as follows: injury to admission, 6.04 days; admission to surgery, 1.35 days; and surgery to
discharge, 3.38 days. Hospital stay averaged 4.73 days. In 27 patients with suspected compart-
: // t/.tm
. m : / /t/.tm. m
mental ischemia, admission and preoperative pressures in three compartments were averaged and
compared: 18.22 and 3.81 mmHg, respectively (P < .001). The authors concluded that the intermit-
t p ss
p : / ss : /
tent compression pump appears to rapidly reduce swelling of the foot and decrease elevated
tp p
t
hht t t t
compartment pressures associated with calcaneus fractures.
hht
Rammelt S, Gavlik JM, Barthel S, Zwipp H. The value of subtalar arthroscopy in the management of
intra-articular calcaneus fractures. Foot Ankle Int 2002;23(10):906–16.
Open subtalar arthroscopy was performed to evaluate the quality of reduction after open reduction
and internal fixation of intraarticular calcaneus fractures in 59 cases. Arthroscopy was performed
after seemingly exact reconstruction of the posterior facet as judged visually and fluoroscopically.
keerrss keerrss
In 13 of 59 cases (22.0%) during ORIF, despite seemingly accurate reduction, steps between 1 and
2 mm were detected arthroscopically in the posterior calcaneal facet, and reduction was repeated
b ooook b ooook
subsequently in these cases.
b oo
In the same study, the subtalar joint was inspected arthroscopically in 28 patients during hardware

removal 1 year after ORIF. This procedure was accompanied by subtalar arthrolysis in all cases.
Clinical results after ORIF of intraarticular calcaneus fractures were highly correlated with the
: / / t
/ m
.t.m : / / t
/ m
.t.m
degree of residual incongruities and chondromalacia of the posterior facet as seen arthroscopically
t ppss : / during hardware removal.
t ppss : /
Rammelt S, Zwipp H, Schneiders W, Dürr C. Severity of injury predicts subsequent function in surgically
t
hhtt t
hhtt
treated displaced intraarticular calcaneal fractures. Clin Orthop Relat Res. 2013;471(9):2885–98.
A retrospective study reporting long-term results (average of 8 years) of 127 patients with 149 displaced
intraarticular calcaneal fractures. At latest follow-up, the median AOFAS score was 77, the median Foot
Function Index was 27, and the median SF-36 physical component summary (PCS) and mental compo-
nent summary scores were 44 and 55, respectively. The foot-related scores and the SF-36 PCS negative-
ly correlated with the severity of injury, work-related injuries, and bilateral fractures. A trend toward inferior
k e rrss
e k rrss
results was seen with residual articular steps >2 mm and loss of Böhler angle of >30% as compared with
e e
the uninjured side. The Sanders and Zwipp classifications both proved to be of prognostic value.
o o
o o k o o o k o
Redfern DJ, Oliveira ML, Campbell JT, Belkoff SM. A biomechanical comparison of locking and non-
o o
eebb e / e
/ b
e b e / e
/ b
e b
locking plates for the fixation of calcaneal fractures. Foot Ankle Int 2006;27(3):196–210.
A biomechanical study on 10 pairs of cadaver feet showing no statistically significant differences
e e
: / / t
/ m
.t.m : / / t m
with respect to cycles to failure between locking and nonlocking plates.
.t.m
Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular cal-
/
t p ss:
p / t p
Relat Res. 1993;290:87–95. ss:
p /
caneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop
t
hht t t
hht t
A retrospective report on 120 displaced, intraarticular calcaneal fractures (Sanders types II–IV) us-
ing an extensile lateral approach, lag screw fixation of the articular surface, and neutralization plate
fixation of the calcaneal body. Postoperative CT evaluation revealed full restoration of calcaneal
height, length, and width in all fracture types; restoration of Böhler and Gissane angles to within
5° of normal in all but three patients; and an anatomic articular reduction in 86% of Sanders type
k e r
e s
rs k eers
II and 60% of Sanders type III fractures, but in none in the Sanders type IV fractures. Their results
rs
confirmed that full restoration of calcaneal anatomy was attainable through an extensile lateral
o o
o o k o o
o k
approach. They noted a temporal learning curve requiring up to 50 cases or 2 years’ experience
o oo
before consistent, predictable results could be expected for type II and type III fractures. Fourteen
eebb e e
/ b
e b e /e/ebb
of their 17 type II and type III fractures requiring subtalar arthrodesis had an anatomic articular re-
/
duction at the time of arthrodesis, indicating that articular damage at the time of the original injury
e e
: / / t
/ .
tm.m / / t
/.tm
. m
can lead to posttraumatic arthritis despite an anatomic reduction.
Sanders R, Vaupel Z, Erdogan M, Downes K. The operative treatment of displaced intra-articular
:
t p ss
p : / ss : /
calcaneal fractures (DIACFs): long term (10–20 years) results in 108 fractures using a prognostic CT
t p p
t
hht t t
hht t
classification. J Orthop Trauma 2014;28(10):551–63.
t t p
t ss:
p t t p
t ss:
p
hht hht
A retrospective long-term report on 108 fractures in 93 patients at a minimum follow-up of 10

years (range, 10.5–21.2 years). On immediate postoperative CT scan, posterior facet reduction was
k e r
e s
rs k eers
r s
anatomic in 103 fractures (95%), near anatomic in three fractures (1–3 mm), and approximate in
o o
o o k o oo k
two fractures (3–5 mm step). Long-term results indicated that only three fractures settled, but no
o
plates failed. There was one missed peroneal tendon dislocation. Seven patients had sural neuritis.
o o
eebb e e
/ebb
Twelve fractures (11%) required local wound care for apical necrosis. One patient had a dehis-
/ e / e
/ b
e b
cence resulting in osteomyelitis, requiring a subtalar (ST) fusion. Thirty-one fractures (29 patients)
e e
: / / t t m
. m : / / t t m
developed ST arthritis, requiring an arthrodesis, resulting in an overall long-term failure rate of
. . . m
29%. Type III fractures were four times more likely to need a fusion compared with type II fractures.
/ /
ss : / ss : /
Of the remaining 66 patients (77 fractures) who did not require a fusion, only 1 patient used a cane
t p p t p p
t
hht t
and had a limp; 77% of the nonfused group (51/66) were within the US norm for the SF-36 PCS,
t hht t
with 46% (30/66) above the norm. The average AOFAS Ankle–Hindfoot Scale score was 75. The
average Visual Analog Scale score was 1.75, with scores of 0–1 (very little or no pain) seen in 56%
of this subset of patients (37/66).
Schildhauer TA, Bauer TW, Josten C, Muhr G. Open reduction and augmentation of internal fixation
with an injectable skeletal cement for the treatment of complex calcaneal fractures. J Orthop Trauma
k ee s
2000;14(5):309–17.
rrs k er
erss
A retrospective series of 36 joint depression-type calcaneal fractures in 32 patients were augment-
b ooook ooook
ed with a calcium phosphate cement after standard open reduction with internal fixation. Postoper-
o o
ative full weight bearing was allowed progressively earlier, and as early as 3 weeks postoperatively
b b
eeb ee/ e
/ e b ee/ e
/ e
with full weight bearing before or after 6 weeks postoperatively. The infection rate was 11%. b
without loss of reduction. There was no statistical difference in clinical outcome scores in patients
: // /.tm
. m
neus. Arch Orthop Trauma Surg 1998;177(8):442–7.
: / /t/.tm. m
Seibert CH, Hansen M, Wolter D. Follow-up evaluations of open intra-articular fractures of the calca-
t
ss : / ss : /
A retrospective analysis of 36 open intraarticular fractures with follow-up 44 months after the injury,
t p p tp p
t t t t
on average. Five amputations (14%) of the affected extremity and four ankle arthrodeses had
hht hht
been carried out. A total of 23 patients were able to bear weight on the affected hindfoot and had
a functional ankle joint, but no excellent results were documented. As many as 17 patients (73%)
had a poor functional or radiographic score. Devastating results were seen in the course of 15
third-degree open fractures: 9 cases of osteomyelitis, 5 amputations, 1 partial calcanectomy, and
1 arthrodesis.
keer ss
calcaneus fracture. J Orthop Trauma 1999;13(1):43–6.
keerrss
Thordarson DB, Greene N, Shepard L, Perlman M. Facilitating edema resolution with a foot pump after
r
b ooook b ooook
A prospective randomized trial of 28 patients with excessive edema precluding operative interven-
b oo
tion upon admission after an intraarticular calcaneus fracture. In the control group, 15 patients had

a bulky compression dressing, posterior splint, and elevation while awaiting surgery. In the study
group, 13 patients had a foot pump applied to the foot with a posterior splint and elevation while
: / / t
/ m
.t.m : / / t
/ m
.t.m
awaiting surgery. All tolerated the foot pump. The volumetric changes of the feet between day 1
t ppss / t ppss : /
(baseline), day 2, and day 3 were significantly greater for the foot pump group (P = .02). A signifi-
:
cantly progressive decrease in the foot volume was noted during the first 48 hours after application
of the foot pump.
t
hhtt t
hhtt
Thordarson DB, Krieger LE. Operative vs. nonoperative treatment of intra-articular fractures of the
calcaneus: a prospective randomized trial. Foot Ankle Int 1996;17(1):2–9.
A total of 30 patients with displaced, intraarticular calcaneus fractures (Sanders type II or III) were
randomized to operative or nonoperative treatment. Nonoperative treatment included early mobiliza-
tion and delayed weight bearing. Operative treatment involved open reduction and rigid internal
k rrss
e k rrss
fixation with a plate and screws through an extensile, L-shaped lateral approach followed by early
e e e
mobilization and delayed weight bearing. A total of 15 operative patients were evaluated at an aver-
o o
o o k o o o k o
age of 17 months’ follow-up, and 11 nonoperative patients were seen at 14 months’ average follow-
o o
eebb e / e
/ b
e b e / e
/ b
e b
up. In the operative group, there were seven excellent results, five good results, two fair results, and
one poor result, and in the nonoperative group there was one excellent result, three good results, one
e e
: / / t
/ m : / / t m
fair result, and six poor results (P < .01). The average functional score for the operative group was far
.t.m .t.m
superior at 86.7, compared with 55.0 for the nonoperative group (P < .0001). Subtalar range of mo-
/
t ss:
p / t p ss:
p /
tion averaged 20° for the operative group and 17° for the nonoperative group, with pain on extremes
p
of motion in 25% of the operative patients compared with 100% in the nonoperative patients.
t
hht t t
hht t
Thornton SJ, Cheleuitte D, Ptaszek AJ, Early JS. Treatment of open intra-articular calcaneal fractures:
evaluation of a treatment protocol based on wound location and size. Foot Ankle Int 2006;27(5):
317–25.
A retrospective study of 31 open intraarticular calcaneal fractures in 29 patients. All fractures were
treated with a standard protocol based on the appearance of the traumatic wound after initial
k e e s
rs k eers
débridement and stabilization. Fracture stabilization was determined by the wound characteris-
r rs
tics and was either standard internal fixation or percutaneous fixation. Overall, there was a 29%
o o
o o k o o
o k
soft-tissue complication rate with this protocol. Two of 4 laterally based traumatic wounds had
o
complications; 27 wounds were medial; 9 were considered unstable and were treated with aggres-
oo
eebb e e
/ b
e b e /e
sive wound management and percutaneous fixation of the tuberosity reduction; 2 (22%) devel-
/ /ebb
oped deep infections and required amputation; and 7 returned to full weight bearing. A total of 18
e e
/ / / .
tm.m / / t
/.tm
. m
fractures with medial wounds were treated with standard internal fixation; soft-tissue complications
t
occurred in 5 (27%). Initial size >4 cm was associated with an increased complication rate in this
: :
ss : / ss : /
group. The authors concluded that medial wounds <4 cm can be treated with open reduction and
t p p t p p
t
hht t t
hht t
standard internal fixation of the wound can be closed and remain stable off antibiotics.
t t p
t ss:
p t t p
t ss:
p
306 hht
Varela CD, Vaughan TK, Carr JB, Slemmons BK. Fracture blisters. Clinical and pathological aspects.
J Orthop Trauma 1993;7(5):417–27.
k e r
e s
rs k eers
r s
A retrospective study of 53 blisters in 51 patients. They occurred most commonly overlying the
o o
o o k o oo k
tibia, ankle, and elbow and arose within 24–48 hours of acute injury in most instances. Those pa-
o
tients with acute fractures who underwent ORIF within 24 hours of injury had the lowest incidence
o o
eebb e e
/ebb e / e
/ b
e b
of fracture blisters (2.0%) compared with those delayed for >24 hours (8.0%; P < .001). In those
/
patients with fracture blisters present at the time of surgery, patient care was affected in 10 of 13
e e
: / / t
/ .
t m
. m : / / t t m
cases (71%). Two of these were major complications occurring as postoperative wound infections.
. . m
Other management problems consisted of delaying surgery and changes in the operative plan.
/
t p ss
p : / ss : /
There were no adverse effects on patient care when the fracture blister developed postoperatively.
t p p
t
hht t t
Twenty-one fractures with blisters were treated by closed means, with the presence of fractures
hht t
blisters delaying closed reduction and casting in two. Biopsy examination of 15 blisters supported
the clinical impression that fracture blisters are subepidermal vesicles. The blister fluid was found
to be a sterile transudate. Microbial evaluation of 11 ruptured fracture blisters demonstrated
colonization (primarily with skin pathogens), occurred soon after blister rupture, and continued until
reepithelialization.
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh37
PROCEDURE
t hht
Intraarticular
rss Calcaneus Fractures
rss
kkee r
ooMatthew DeOrio and Mark E. Easley boooo kkee r
b
eeboo / e b / e b o
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht
• Nonoperative management is indicated for nondisplaced calcaneal fractures or ex-
traarticular calcaneal fractures with near-physiologic hindfoot alignment (computed
hht
• When the soft tissues allow, operative
treatment should be performed within 2–3
tomography [CT] confirmation is recommended). weeks from injury, before the fracture heals in
a malunited position.
• Operative treatment of calcaneus fractures is indicated for displaced intraarticular
k eers
rs
and open calcaneal fractures.
k er
erss • Operative treatment should be delayed until
a positive skin wrinkle test is observed (the
b oo k
ooEXAMINATION/IMAGING b ooook b o o
skin should wrinkle with ankle dorsiflexion and
hindfoot eversion) and pitting edema has resolved.
eeb ee/ e
/ e b ee/ e
/ e b
• The soft-tissue envelope about the hindfoot must be amenable to surgery: edema
// t/ tm
. m / /t/ tm
and fracture blisters (at the operative site) must have resolved.
. . . m
• Plain foot and ankle radiographs should be obtained (anteroposterior, lateral, and
: :
ss : / ss : /
oblique foot; Harris axial heel view; Brodén view; and ankle series to rule out con-
t p p tp p
• Relative contraindications:
• Peripheral vascular disease
t
hht t
comitant ankle fracture).
t
hht t
• The lateral foot radiograph in Fig. 37.1 demonstrates posterior facet depression.
• Type 1 diabetes mellitus
• Medical comorbidities/life-threatening
injuries preventing surgery
• The mortise view of the ankle in Fig. 37.2 illustrates lateral calcaneal wall displace-
• Soft-tissue compromise/massive edema
ment with resultant widening of the heel. • Nonambulatory patients
• Associated lower back pain and tenderness necessitate lumbar spine radiographs
keerrss keerrss
given the association of calcaneal and lumbar spine fractures.
TREATMENT OPTIONS
b ooook ooook
• Preoperative fine-section CT is mandatory and defines the intraarticular (posterior
oo
facet) fracture pattern, as shown in the posterior facet’s intraarticular comminution in
b b
• Closed treatment
eeb Fig. 37.3.

ee/e/e b ee/e/
• The fracture pattern is determined on the coronal images, using the Sanders clas-e b • Open reduction and internal fixation (ORIF)
• Minimally invasive surgery: closed reduction
sification.
: / / t
/ m
.t.m : / / t
/ m
.t.m and internal fixation with limited skin incisions;
especially applicable to tongue-type fractures
• Sagittal and axial images provide further detail of the fracture pattern. (intraarticular fractures exiting the posterior
t
hhtt t
hhtt
calcaneal tuberosity), for which the Essex–
Lopresti maneuver can be employed
• Closed reduction and external fixation
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
:

/ / / .
tm
FIG. 37.1
t .m
: / / t
/.tm
. m FIG. 37.2
t p ss
p : / t p pss : /
t
hht t t
hht t 307
t t p
t ss:
p t t p
t ss:
p
308 hht
PROCEDURE 37 Intraarticular Calcaneus Fractures hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
r
As e
Br
erss C
ook okk
b
eeboo e b o
bo o FIG. 37.3
e b o
b o
m ee/ / e m ee/ / e
: ///t/.t. m : / /
/t/.t . m
t t p
t ss
p : SURGICAL ANATOMY
t tptpss :
hht hht
Relevant Vascular Anatomy
• A lateral soft-tissue flap of hindfoot skin and subcutaneous tissue must be elevated
directly from the calcaneus in the lateral extensile approach.
• This flap receives its blood supply from the laterally located calcaneal, malleolar, and
keerrss keerrss
tarsal arteries (Fig. 37.4A).
• The commonly used extensile L-shaped incision to the calcaneus respects the vas-
b ooook b o ook
cular anatomy (angiosomes) of the flap.
o b oo
eeb ee/e/e b ee/
calcaneus are shown in Fig. 37.4B.e/e b
• Relevant lateral structures to be protected in the lateral extensile approach to the
: / / t
/ m
.t.m : / / t m
.t.m
• The peroneal tendons and sural nerve are both elevated with the lateral soft-tissue
/
flap during exposure. The lateral wall includes the peroneal tubercle, which bisects
t
hhtt t
hhtt
a groove for the peroneus brevis and longus tendons; the brevis tendon courses
anterior to the tubercle.
• The calcaneofibular ligament attaches posterior to the peroneal tubercle and lies
deep to the tendons. Typically, the calcaneofibular ligament is elevated with the lat-
eral soft-tissue flap from the calcaneus (despite this, ankle instability is rare following
k e rrss
e k rrss
surgical management of calcaneus fractures).
e e
• The sural nerve courses parallel and posterior to the peroneal tendons before pass-
o o
o o k o o o k o
ing superficially at the inferior peroneal retinaculum to course along the lateral border
o o
eebb ee/ e
/ b
e bof the foot.
ee/ e
/ b
e b
: / / t
/ mRelevant Osseous Anatomy
.t.m : / / t
/ m
.t.m
t p ss:
p / •
t p ss:
p /
Comminuted, intraarticular fractures of the calcaneus typically fracture into four
distinct fragments (Fig. 37.5): (1) sustentaculum tali (constant fragment), (2) lateral
t
hht t t
hht t
wall fragment (typically with the lateral posterior facet articular surface attached),
(3) anterior process fragment, and (4) posterior tuberosity.
• The “constant fragment” includes the sustentaculum tali and its middle facet. The
medial ligamentous structures, including the interosseous talocalcaneal, medial talo-
k e r
e s
rs k eers
calcaneal, and deltoid ligament complex, typically maintain the position of the frag-
rs
ment relative to the talus and ankle, hence the name constant fragment.
o o
o o k o o
oo k
Articular Surfaces oo
eebb e / e
/ b
e b e /e/ebb
• The superior surface (Fig. 37.6A) includes the calcaneal tuberosity and the anterior,
e e
: / / t
/ .
tm.m : / / t
/.tm
middle, and posterior facets. In 60% of patients, the anterior and middle facets are
. m
t p ss
p : / t p ss
p : /
confluent. The posterior facet is the largest and supports the talar body.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Medial
malleolar
k e r s
rs
branches
e k eers
r s
Sural nerve
o o
o o k oooo k o o
Calcaneal fibular
eebb b b ligament
e
Perforating
e/ e
/e b ee/ e
/ e b
: / / t
/ t m
peroneal artery
. . m : / / t
/ .
t m
. m Peroneus brevis
tendon
t p ss
p : /
Calcaneal branches
Tarsal branches
t p ss
p : /
t
hht t t
hht t Peroneus longus
tendon
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b Calcaneal tubercle
A
: // t/.tm
. m
B
: / /t/.tm. m
t p ss
p : / FIG. 37.4
tp pss : /
t
hht t (1) Sustentaculum tali
t
hht t
“constant fragment”
keerrss (2) Lateral wall
keerrss
b ooook fragment
b ooook b oo
eeb e e/e b
(3) Anterior
/
process fragment
e ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / (4) Posterior
tuberosity
t ppss : /
t
hhtt t
hhtt
Superior
POSITIONING PEARLS
• The patient may be positioned prone with
the lower extremities externally rotated and
supplemental armboards augmenting the
k e rrss
e k e rrss
e
operating table’s width to allow simultaneous
surgical approaches to bilateral calcaneal
o o
o o k Lateral
o o
o o k o o
fractures.
eebb
e /
FIG. 37.5
e e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m POSITIONING PITFALLS
calcaneocuboid joint.
t ss:
p / t p ss:
p /
• The anterior surface (see Fig. 37.6B) is entirely covered with cartilage and forms the
p
• Scissor the legs with the operative extremity
posterior to improve access to the fracture and
t
hht t
that may be disrupted with high-energy trauma.
t
hht t
• The heel pad is composed of highly specialized adipose tissue with fibrous septa
unobstructed fluoroscopic visualization.
• A radiolucent operative table is recommended.
• An axillary roll is recommended.
POSITIONING
k e r
e s
rs
patient positioned in the prone or lateral position.
k eers
• ORIF using the extensile lateral L-shaped approach may be performed with the
rs
EQUIPMENT
• Beanbag
o o
o k o o k
• We favor a full lateral decubitus position with the patient’s torso safely secured within
o oo o • Protective padding below the contralateral limb
o
eebb of folded sheets or towels.
ee / b
e b
a beanbag and the operative extremity carefully supported on a well-padded bump
/ e ee/e/ebb and axilla to protect the peroneal nerve and
brachial plexus, respectively
: / / t
/ .
tm.m : / / t
/.tm
. m
• The knee is flexed, and the heel of the patient rests at the posterior corner of the • Fluoroscopy (mini or standard C-arm)
• Thigh-level pneumatic tourniquet
operating table.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
310 hht
k e r
e ss
• Identify the sural nerve at the most proximal
r
and distal aspects of the wound. Once it is
k eers
r s
• The calcaneus is approached through an extensile lateral approach.
• The vertical limb of the incision is made approximately 2 cm proximal to the tip of
o o
o o kidentified and protected, sharp dissection
oooo k o
the fibula and halfway between the anterior border of the Achilles tendon and the
o
eebb may be carried down to bone with the scalpel
blade.
ee/ e
/ebb posterior border of the fibula.
ee/ e
/ b
e b
• The corner of the incision may be rounded or fashioned at a right angle.
• Determine during the approach whether
: / / t
the peroneal tendons have been dislocated
/ .
t m
. m : / / t . m
. m
• The plantar limb of the incision is made just proximal and parallel to the demarcation
/ t
t p ss
p : /
anteriorly from the injury (this may also be
evident on the preoperative CT scan). The ss : /
between the thickened skin of the plantar heel and the thinner skin of the lateral heel.
t p p
t
hht t
tendons will need to be reduced and the
superior peroneal retinaculum repaired prior to
t
hht t
• The sural nerve is protected, and subperiosteal elevation of all tissue off the lateral
aspect of the calcaneus is performed.
• The calcaneofibular ligament is elevated with the flap, along with the peroneal
wound closure.
tendons within their sheath.
• The full-thickness flap is then retracted using a “no-touch” technique with 0.062-
k eers
rs k er
ers
inch Kirschner wires (K-wires) placed up the fibular shaft, in the talar neck, and in
s
the cuboid (Fig. 37.7), exposing the lateral wall. An additional wire may be placed
b ooook b ooook b o
in the talar body if there is difficulty visualizing the posterior facet.
o
eeb ee/ e
/ e b e / e
/ e b
• A short Schanz pin is placed into the posterior aspect of the calcaneal tuberosity or
the posteroinferior corner of the calcaneus to use as a joystick for the reduction of
e
: // t/.tm
. m the tuberosity.
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrs
Anterior facet
s
eeb ee/e/e b Medial facet
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
Posterior facet
Talus
Calcaneal Articular surface of

tuberosity calcaneocuboid joint
k e rrss
e k e rrss
e Calcaneus
o o
o o k o o
o o k o o
eebb ee/ e
/ b
A
e b ee/ e
/ b
e b B
: / / t
/ m
.t.m : / / t
/ m
.t.m FIG. 37.6
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss
p : / FIG. 37.7
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE STEP 1 PITFALLS
k e r s
rs
Step 1: Fracture Reduction
e k eers
r s • Avoid using dissection scissors other than at
the proximal and distal aspects of the wound
o o
o o k oooo k
• The thin lateral wall is either reflected or removed and placed on the back table
o o
when locating the sural nerve. A sharp knife
eebb (Fig. 37.8).
e / e
/ebb
• Irrigation of the wound and removal of organized clots will expose the fracture
e ee/ e
/ b
e b will preserve a full-thickness flap for superficial
wound closure and a thick periosteal layer for
lines in the posterior facet.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
deep wound closure.
• To restore the articular congruity of the
t p ss / t p ss : /
• The articular surface of the posterior facet is elevated, and the depressed articular
:
fragments are visualized and rotated out of the body of the calcaneus (Fig. 37.9).
p p
posterior facet, do not reduce the fragments
to the talar articular surface. This may lead to
moist gauze.
t
hht t t
hht t
Loose articular fragments may be removed and placed on the back table in a overreduction of the posterior facet and varus
positioning of the articular fragment. The facet
should be visualized and reduced to the medial
• To mobilize the fracture fragments, restore calcaneal height, and initiate the correc- (constant) articular fragment.
tion of varus malalignment, a periosteal elevator is placed into the “primary fracture
line,” that is, the fracture common to most intraarticular calcaneal fractures, between
k eers
rs k er
erss
the calcaneal tuberosity and sustentacular (constant) fragment. The elevator is used
b ooook taculum tali.

b ooook
to lever the tuberosity fragment down and medial to reposition it below the susten-
b o o
eeb ee/ e
/ e b
• Once the fragments have been mobilized, a Schanz pin may be placed in the
ee/ e
/ e b
: // t/ tm
. m
relative to the constant fragment (Fig. 37.10).
: / /t/ tm
calcaneal tuberosity to be used to lever the tuberosity into the proper position
. . . m
t p ss
p : / tp ss : /
• One or two K-wires should then be placed from the medial tuberosity across the
p
t
hht t t
hht t
reduced primary fracture line into the constant fragment, without blocking sub-
sequent reduction of the lateral articular and wall fragments. If greater support is
required, the K-wires may be driven into the talar body. (However, care must be
taken to avoid breaking these wires during the remainder of the procedure be-
cause they will be nearly impossible to retrieve from the talus.)
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k A
o ooo k B
o o
eebb ee/ e
/ b
e b FIG. 37.8
ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm. m : / / t
/.tm
. m
t p ss
p : /
FIG. 37.9
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
312 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B
k eers
rs k er
erss FIG. 37.10
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
p ss : /
• Use a no-touch technique to elevate the lateral
t p
A
t ppss : / B
t
hhtt
flap by avoiding forceps on the lateral skin
flap. A sharp two-pronged skin hook placed
deep to the periosteum is useful to retract the

t
hhtt FIG. 37.11
subperiosteal flap. • Confirm tuberosity positioning and reduction of the medial wall with a Harris axial
heel view. Frequently, it may take several attempts at reduction to anatomically
k e rrss
e
STEP 1 PEARLS
k rrss
reduce the medial calcaneal wall. Fig. 37.11A demonstrates malreduction of the
e e
medial wall, which has been corrected in Fig. 37.11B.
o o
o o k
• Aggressively mobilize the primary fracture line
o o
o o k o
• Once the medial wall is reduced and the height of the calcaneus has been reestab-
o
eebb before attempting reduction (particularly if the
fracture is >10–14 days old).
ee/ e
/ b
e b e / e
/ b
e b
lished, the articular fragments may be reduced to the medial sustentacular fragment.
These have been cleared of all clots to allow for anatomic reduction.
e
• When placing a Schanz pin from a lateral
: / / t
/
direction, remember that the calcaneus has m
.t.m : / / t
/ m
.t.m
• If there is more than one superolateral articular fragment, these may be assem-
t p ss:
p /
assumed a varus position, and therefore aim
t p ss:
p /
bled on the back table with K-wires (Fig. 37.12) or bioabsorbable pins, and then
subsequently reduced as a unit to the medial sustentacular fragment.
perpendicular to the heel. t
hht t
the Schanz pin slightly cephalad rather than
• Do not proceed with further fracture reduction

t
hht t
• The lateral articular fragments should be secured to the constant fragment with a
minimum of two pins to prevent rotation of the articular segment (however, these
until the medial calcaneal wall (primary pins must be placed outside of the intended path for final screw fixation of the articu-
fracture line) is anatomically reduced. lar fragments).
• If the articular reduction is difficult,
k e r
e ss
occasionally the lateral wall fragments may
r
need to be temporarily reassembled to guide
k eers
• Should the lateral wall include a superolateral articular segment of the posterior
rs
facet (i.e., one with the lateral wall fragment), the articular and lateral wall reduc-
o o
o o kthe articular reduction.
o o
oo ktion is performed simultaneously.
oo
eebb b b
• In simple terms, the Brodén view is a mortise • Anterior reduction of the lateral articular fragment (with or without a lateral wall frag-
view of the ankle angled into the articulating
plane of the subtalar joint.
ee/ e
/ e b e /e/e b
ment attached) must also be confirmed with the anatomic restoration of the angle
e
: / / t
/ .
tm.m : / / t
/.tm
of Gissane (fracture reduction between the anterior aspect of the lateral articular
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook FIG. 37.12
b oooo k
b o o
FIG. 37.13
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t. m : / / t
/ m
.t.m
t ppss : / FIG. 37.14
t ppss : /
t
hhtt t
hhtt
fragment and the anterior process fragment). This step in the reduction reestablishes
the proper relationship between the anterior and posterior calcaneal fragments. Re-
k e rrss
duction is confirmed on a lateral fluoroscopic image.
e k e rrss
e
• Posterior facet reduction should be confirmed not only under direct visualization, but
o o
o o k o o o k
also with a Freer elevator to obtain tactile feedback of the articular congruency, as
o o
CONTROVERSIES
o
eebb ee e
/ b
e b
well as with intraoperative fluoroscopic Brodén views (Fig. 37.13).
/ e
• The articular fragments are secured to one another with a lag screw placed from the
e/ e
/ b
e b
• There are studies that both support and refute
the use of bone graft or bone graft substitutes.
: / / t
/ m
.t.m : / / t
/ m
.t.m
lateral fragment into the constant fragment. Alternatively, the lateral wall fragment In cases of severe comminution, we typically
t p /
placed through the superior plate (see Step 2).
t p p /
may be reduced, a lateral plate applied, and the lag screw for the articular fragments
p ss: ss:
add cancellous allograft bone with or without a
platelet-rich product.
t
hht t
Step 2: Plate and Screw Placement
t
hht t STEP 2 PEARLS
• Bone graft may be packed into the fracture, into the space formerly occupied by the
displaced articular fragments (Fig. 37.14), but is not essential. • During articular fixation, direct the lag screws
for the posterior facet in a slightly distal and
k e e s
rs k eers
• The lateral wall fragments are anatomically reduced relative to the lateral articular
r rs
and anterior fragments and provisionally fixed with K-wires.
plantar direction to capture the sustentacular
(constant) fragment and avoid the articular
o o
o o k o o
oo k
• Most surgeons prefer to use a multihole lateral plate designed specifically for the
oo
surface of the posterior facet. (The surgeon
eebb b b
calcaneus (Fig. 37.15); several plate designs are commercially available. may wish to carefully place a finger of the
ee/ e
/ e b e /e/e
• The articular fragments may be secured with lag screw(s) either above or through the
e b nondrilling hand on the medial aspect of the
sustentaculum tali to serve as a guide.)
plate.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
314 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b oo oo k B
b o o
eeb ee/ e
/ e b FIG. 37.15
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A t
hhtt
t
hhtt
FIG. 37.16
B
k e rrss
e k rrss
• For fixation of the articular fragments, 3.5-mm cortical lag screws are aimed slightly
e e
distal and plantar from the lateral cortex into the sustentacular fragment.
o o
o o k o o o k o
• Fully threaded screws placed in standard lag fashion may allow for better pur-
o o
eebb STEP 2 PITFALLS
ee/ e
/ b
e b ee e
/ b
e b
chase in the subchondral bone of the articular fragments.
/
• Further stabilization of the calcaneus fracture is obtained with screws placed through
/ t m
.t.m
• If provisional K-wires were placed across the
: / /
the plate.
: / / t
/ m
.t.m
t ss:
p /
subtalar joint, they must be avoided during
p
drilling or screw placement. If a wire breaks,
t p ss:
p /
• Several screws are placed in the anterior and tuberosity fragments; typically,
screws placed directly inferior to the posterior facet have poor purchase (we gen-
t
hht t
it may not be possible to retrieve it from the
talus.
t
hht t
erally leave these holes open).
• Cortical screws are usually possible for the anterior process; cancellous screws
• Remember to look for potential peroneal
tendon dislocation preoperatively, both may provide better purchase in the tuberosity fragment.
clinically and on preoperative CT scanning. • Once the plate is secured to the anterior, sustentacular, and tuberosity fragments,
k e r
e s
rs k eers
the provisional K-wires may be removed (Fig. 37.16).
rs
o o
o o k o o
oo k
Step 3: Repair of Peroneal Tendon Dislocation
oo
eebb ee/ e
/ b
e b e /e/ebb
• Occasionally, a high-energy calcaneal fracture displaces the peroneal tendons with
the lateral calcaneal wall enough to disrupt the superior peroneal tendon retinacu-
e
: / / t
/ .
tm.m : / / t
/.tm
. m
lum, leading to peroneal tendon dislocation.
t p ss
p : / t p ss : /
• Typically, peroneal tendon dislocation can be diagnosed on preoperative physical
examination. When the superior peroneal retinaculum is disrupted, the tendons
p
t
hht t t
hht t
are subluxated or dislocated anterior to the fibula (Fig. 37.17).
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 37.17
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
A B
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb b b
A B
ee/ e
/ e b FIG. 37.19
ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m

CT scans.
t p ss:
p / t p ss:
p /
• This can be visualized on preoperative axial (Fig. 37.18A) and coronal (Fig. 37.18B)
t
hht t t
hht t
• A recommended routine is to check peroneal tendon reduction when ORIF of the
calcaneal fracture is complete.
• Following ORIF of the calcaneal fracture into its anatomic alignment, the subfibular
recess is restored, allowing for reduction of the peroneal tendons.
k e e s
rs k eers
• The vertical limb of the incision is taken slightly more proximally, the sural nerve is
r rs
protected, and the vacant fibular groove is visualized with the tendons dislocated
o o
o o k anteriorly (Fig. 37.19).
o o
oo k oo
eebb e / b
e b
• The tendons are carefully separated from the soft tissues, elevated for exposure
/ e e /e
without damaging the integrity of the soft-tissue flap, and reduced into the fibular
e e /ebb
groove.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss : /
• Retinacular tissue and periosteum are then utilized to reconstruct at least a
portion of the superior peroneal retinaculum (a suture anchor may be used;
p
Fig. 37.20).
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
316 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss C
keerrss
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b

FIG. 37.21
: / / t
/ m
.t.m
: / / t
/ m
.t.m FIG. 37.22
t p ss:
p / Step 4: Wound Closure
t p ss:
p /
STEP 4 PEARLS
t
hht t
• Skin tension at the corner of the wound may
be minimized by progressively closing the
t
hht t
• The wound is closed using 2-0 Vicryl sutures by reapproximation of the deep peri-
osteal layer over a deep suction drain that is brought either through the lateral skin
incision from the ends of the wound to the anterior to the Achilles tendon (posterior to the sural nerve) or outside the distal as-
corner. pect of the foot (dorsal to the sural nerve).
• Maintaining the tourniquet until the dressing
k e r s
rs
and splint are applied and the drain is
e k eers
rs
• The deep layer is reapproximated first at the proximal and distal aspects of the
wound to decrease tension at the apex of the wound (Fig. 37.21).
o o
o o kfunctioning reduces the potential for
deleterious hematoma formation.
o o
oo k o
• The skin is closed with 4-0 nylon interrupted Allgöwer–Donati sutures (Fig. 37.22).
o
eebb • The Allgöwer–Donati suture places the knot
of the suture away from the lateral flap of
ee/ e
/ b
e b ee/e/ebb
• A sterile dressing is placed on the wound. With the hip and knee flexed to allow the
ankle to be easily positioned in a neutral position, a posterior/sugar tong splint is ap-
skin and subcutaneous tissue, theoretically
/ / t
decreasing ischemic pressure from the knot
: / .
tm.m t
plied over adequate padding.
: / / /.tm
. m
(see Fig. 37.22).
t p ss
p : / t p ss
p : /
• With the suction drain functioning, the tourniquet is let down after wound closure.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m C
t p ss
p : /
tp pss : / FIG. 37.23
t
hht t t
hht t
POSTOPERATIVE CARE AND EXPECTED OUTCOMES STEP 4 PITFALLS
• We routinely remove the skin sutures between 2 and 3 weeks, but may delay suture • To prevent potential skin necrosis, the skin
keerrss removal for up to an additional 3 weeks if necessary.
keerrss
• If calcaneal fracture fixation was deemed stable, we recommend a removable boot
edges should not be pinched with the forceps
and the tourniquet time should not exceed 2.5
b ooook o ook
so that the patient can perform range-of-motion exercises for the ankle and foot,
b o b oo
hours (preferably <2 hours).
eeb ee/e/ b
provided the wound is healed. If there is any concern regarding the wound, immobi-
e ee/e/e
lization in a short-leg cast is preferred and sutures remain until the 6-week follow-up
b POSTOPERATIVE PEARLS
appointment.
: / / t
/ m
.t.m : / / t
/ m
.t.m • Wound healing is often delayed following
• Progressive weight bearing is allowed at 10–12 weeks, if radiographs suggest ad- ORIF of calcaneal fractures. Without evidence
t
hhtt
equate fracture consolidation.
t
hhtt
• Fig. 37.23 shows postoperative radiographs including a Brodén view (Fig. 37.23A),
Harris axial heel view (Fig. 37.23B), and lateral view (Fig. 37.23C) demonstrat-
for infection, continued immobilization and
protective weight bearing typically lead
to progression toward satisfactory wound
healing.
ing anatomic reduction of the posterior facet, medial wall, and Böhler angle, • Function may be enhanced with early range of
respectively. motion of the ankle and foot while continuing
k eerrss
See also Video 37.1, Intraarticular Calcaneus Fractures.
k e rrss
e
strict non–weight-bearing status, provided the
wound and fracture are stable.
o o
o o k
EVIDENCE o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e
Aldridge 3rd JM, Easley M, Nunley JA. Open calcaneal fractures: results of operative treatment. J b POSTOPERATIVE PITFALLS
Orthop Trauma 2004;18:7–11.
: / / t
/ m
.t.m : / / t
/ m
.t.m • A wound that fails to improve or exhibits
signs of infection should prompt early
t p ss:
p / t p ss: /
In this study, all patients were treated with intravenous antibiotics, tetanus prophylaxis, and imme-
diate and repeat irrigation and débridement. Definitive fracture reduction was performed at an aver-
p
infection workup, irrigation and débridement,
t
hht t t
hht t
age of 7 days after injury (range, 0–22 days). For the patients with Gustilo type II and type III open
calcaneal fractures, there was an 11% complication rate with higher-than-expected health-related
quality-of-life indices. The treatment group did not reflect as high a complication rate for open
and infectious disease and plastic surgery
consultation in select cases.
• Weight bearing should be restricted until
calcaneal fractures as previously reported, and the results support previous claims that definitive satisfactory fracture healing is suggested on
hardware placement at the time of initial irrigation and débridement probably is not warranted: postoperative radiographs.
definitive fracture stabilization can and should wait until soft-tissue coverage is fully assessed.
k e r
e ss
Orthop Trauma 2005;19:360–4.
k eers
rs
Bajammal S, Tornetta 3rd P, Sanders D, Bhandari M. Displaced intra-articular calcaneal fractures. J
r
o o
o o k oo k
This study was designed to determine the effect of operative treatment compared with nonop-
o o oo
eebb b b
erative treatment on the rate of union, complications, and functional outcome after intraarticular
calcaneal fracture in adults.
ee/ e
/ e b ee/e/e
Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with
b
: / / t
/ .m.m : / / t. m
. m
nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized,
t / t
t p p : /
controlled multicenter trial. J Bone Joint Surg Am. 2002;84:1733–44.
ss t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
318 hht
Without stratification of the groups, the functional results after nonoperative care of displaced in-
traarticular calcaneal fractures were equivalent to those after operative care in this study. However,
k e r
e s
rs k eers
r s
after unmasking the data by removal of the patients who were receiving workers’ compensation,
o o
o o k o oo k
the outcomes were significantly better in some groups of surgically treated patients. Patients who
o
were not receiving workers’ compensation and were managed operatively had significantly higher
o o
eebb e e
/ebb e / e
/ b
e b
satisfaction scores (P = .001). Women who were managed operatively scored significantly higher
/
on the Short Form-36 than did women who were managed nonoperatively (P = .015). Patients who
e e
: / / t
/ .
t m
. m : / / t t m
were not receiving workers’ compensation and were younger (<29 years old) and had a moderately
. . m
lower Böhler angle (0–14°), a comminuted fracture, a light workload, or an anatomic reduction or a
/
t p ss
p : / ss : /
step-off of ≤2 mm after surgical reduction (P = .04) scored significantly higher on the scoring scales
t p p
t
hht t t
after surgery compared with those who were treated nonoperatively.
hht t
Herscovici Jr D, Widmaier J, Scaduto JM, Sanders RW, Walling A. Operative treatment of calcaneal
fractures in elderly patients. J Bone Joint Surg Am. 2005;87:1260–4.
Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures
in elderly patients.
Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Complications following
k eers
rs k er
ers
management of displaced intra-articular calcaneal fractures: a prospective randomized trial compar-
s
ing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241–9.
b ooook ooook
This study determined that complications occur regardless of the management strategy chosen
o o
for displaced intraarticular calcaneal fractures and despite management by experienced sur-
b b
eeb ee/ e
/ e b ee/ e
/ e b
geons. Complications were a cause of significant morbidity for patients. Outcome scores in this
study tended to support ORIF for calcaneal fractures. However, ORIF patients were more likely to
: // t/.tm
. m : / /t/.tm. m
develop complications. Certain patient populations (worker’s compensation and Sanders type IV)
developed a high incidence of complications regardless of the management strategy chosen.
t p ss
p : / ss : /
Huang PJ, Huang HT, Chen TB, Chen JC, Lin YK, Cheng YM, Lin SY. Open reduction and internal fixa-
tp p
t
hht t t t
tion of displaced intra-articular fractures of the calcaneus. J Trauma 2002;52:946–50.
hht
The authors recommended that Sanders type II and type III fractures be treated with ORIF. Despite
the results of type IV fractures being significantly worse than those of type II and type III fractures,
the authors also recommended ORIF for type IV fractures to restore the hindfoot architecture and
the subtalar joint, if possible. When the disrupted subtalar joint is so comminuted that it is beyond
the surgeon’s ability to reconstruct, primary subtalar arthrodesis should be performed in addition
keerrss to ORIF.
keerrss
Longino D, Buckley RE. Bone graft in the operative treatment of displaced intraarticular calcaneal frac-
b ooook b ooook
tures: is it helpful? J Orthop Trauma 2001;15:280–6.
b oo
The authors found no objective radiographic or functional benefit to the use of bone graft supple-

mentation in the operative treatment of displaced intraarticular calcaneal fractures.
Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calca-
: / / t
/ m
.t.m : / / t
/ m
.t.m
neal fractures: results using a prognostic computed tomography scan classification. Clin Orthop Relat
t ppss : / Res 1993;290:87–95.
t ppss : /
To evaluate the results of this study, a classification for intraarticular calcaneal fractures was devel-
t
hhtt t
hhtt
oped based on standardized coronal and transverse CT scans of both feet. Excellent or good clini-
cal results occurred in 58 of 79 (73%) type II fractures, 21 of 30 (70%) type III fractures, and 1 of 11
(9%) type IV fractures. When excellent and good clinical results were compared by year, a distinct
learning curve appeared (1987, 27%; 1988, 54%; 1989, 74%; 1990, 84%). Despite an improved
outcome for type II and III fractures with increasing surgical experience, the results of operative
intervention in type IV fractures were no better, even after 4 years.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh38
PROCEDURE
t hht
Nonextensile
r ss Techniques for Treatment
r s s of
o k ee r
Calcaneus
k Fractures o kkee r
b o
m ee /e m ee / e
: / /
/ t
/ .
Michael P. Swords, Stefan Rammelt,
t . m and Andrew K. Sands
: / /
/ t
/ .
t . m
t t p
t ss
p : t t p
t ss
p :
INDICATIONS h
ht hht INDICATIONS PITFALLS
• Inexperience with calcaneus fracture reduction
• Displaced intraarticular calcaneus fractures techniques
• Simpler patterns • Fractures treated beyond 2–3 weeks
k e rs
rs
• Early fixation
e k er
b ooook ooook
• Patients at high risk for wound healing complications with extensile approaches in-
cluding smokers, diabetics, and those with medical comorbidities
b b o o • Which fractures are best suited for this

/ e b ee/ e
/ e b treatment?
• Can this technique be used for all fracture types?
: / t/.tm
. m : / /t/.tm. m
• Computed tomography scan images demonstrate a displaced comminuted intraar-
/ TREATMENT OPTIONS
t p ss
p : /
ticular calcaneus fracture (Figs. 38.1 and 38.2).
tp pss : / • Nonoperative treatment

t
hht
hht t
• The calcaneus will be approached just distal and above the peroneal tendons along
• Percutaneous fixation (see alternative
technique at the end of this chapter)
• Surgical fixation using a lateral extensile approach
the lateral aspect of the subtalar joint (Fig. 38.3).
POSITIONING PEARLS
POSITIONING
keerrss keerrss
• The patient is placed in the lateral position with the injured extremity up and at the
• Care should be taken to pad the peroneal
nerve of the down leg.
b ooook o ook
end of the operative table (Fig. 38.4).
b o b oo
• A positioning foam pillow or blankets may
be used to elevate the operative extremity to
eeb PORTALS/EXPOSURES ee/e/e b ee/e/e b improve the ability to obtain C-arm images.
• The C-arm monitor is positioned on the
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The incision begins 1 cm below and 1 cm distal to the tip of the fibula and is typically opposite side of the table for ease of viewing.
t pps : /
3–4 cm in length (Fig. 38.5).
s t ppss : / POSITIONING PITFALLS
t
hhtt t
• Elevate the peroneal tendons off the lateral wall of the calcaneus sharply.
hhtt
• The peroneal tendons are sharply released at the peroneal tubercle. • Be sure the end of the table is radiolucent.
• Prone position or lateral positioning may be
used for bilateral injuries.
k e rrss
e k e rrss
e
• C-arm may provide better images, but the
mini-C-arm produces less radiation and can
o o
o o k o o
o o k o o
be operated by the surgical team.
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
s s : / s : /
t t p p hht ps
t t p
FIG. 38.1
hht t t FIG. 38.2

319
t t p
t ss:
p t t p
t ss:
p
320 hht
PROCEDURE 38 Nonextensile Techniques for Treatment of Calcaneus Fractures hht
k e r
e ss
• Sinus tarsi fat may be removed to improve
r
visualization.
k eers
r s
o o
o o k
• The lateral subtalar joint capsule may be
oooo k o o
eebb sharply incised from inside the joint to improve
visualization.
ee/ e
/ebb ee/ e
/ b
e b
• Removing hematoma using a small suction
: / / t
tip, or micropituitary rongeur will improve
/ .
t m
. m : / / t
/ .
t m
. m
visualization and ease reduction.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
• Care should be taken to avoid injury to the
peroneal tendons in the posterior portion of the
k e s
incision.
rrs
• Injury to the sural nerve should be avoided.
e k er
erss
eeb PORTALS/EXPOSURES EQUIPMENT
ee/ ee
/ b ee/ e
/ e b
• Small retractors
• Irrigation
: // t/.tm
. m : / /t/.tm. m
• Sharp knife
t p ss
p : / tp pss : /
FIG. 38.3 FIG. 38.4
STEP 1 PEARLS
t
hht t t
hht t
• Broad elevators should be used in osteoporotic
patients to avoid cutting through the bone.
keer ss
• Malalignment of the tuberosity can be
r
rotational and may need to be corrected by
keerrss
b ooook rotating the Schanz pin anteriorly or posteriorly.
• Threaded K-wires may be used if severe
b ooook b oo
eeb medial wall comminution is present to
maintain height.
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
STEP 1 PITFALLS
t
hhtt
• Malreduction of the tuberosity will result in
malreduction at the posterior facet.
t
hhtt
• Restoring height allows room for the lateral
portions of the posterior facet to be reduced.
FIG. 38.5
k e rrss
e k e rrss
e
o o
o k
o
IMPLANTATION
o o
o o k o o
eebb • K-wires: smooth and threaded
• Schanz pin /
PROCEDURE
ee e
/ b
e b ee/ e
/ b
e b
• T handle chuck
: / / t
/ m
.t.m : / / t m
.t.m
Step 1: Reduce the Medial Wall and Restore Height
/
• Elevators
t p ss:
p / t p ss: /
• Two Kirschner wires (K-wires) are inserted from the tuberosity just inside the medial
p
STEP 1 CONTROVERSIES t
hht t t
hht t
wall up to the fracture (Fig. 38.6).
• The fracture is reduced using a Schanz pin in the tuberosity, and an elevator is in-
• Use of the sinus tarsi approach over the serted through the fracture of the calcaneus (Fig. 38.7).
extensile lateral approach for complex/ • Once reduced the wires are advanced across the fracture into the sustentaculum to
comminuted fractures and fractures with maintain reduction and tuber height (Fig. 38.8).
k e r
e ss
delayed presentation
r k eers
rs
Step 2: Reduce the Posterior Facet
o o
o o k o o
oo k oo
eebb b b
STEP 2 PEARLS • Reconstruct the posterior facet by reducing more lateral fragments to the restored
• Drill sleeves inserted over the K-wires may be
ee/ e
/ e b /e e b
medial aspect of the articular surface (Fig. 38.9).
ee /
used to manipulate fragments.
/ / t .
tm.m
• Direct articular reduction is best viewed using
: / : / / t
/.tm
. m
a headlight for the procedure.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 38 Nonextensile Techniques for Treatment of Calcaneus Fractures 321
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp p ss : /
t
hht t t
hht t

FIG. 38.6 FIG. 38.7
keerrss keerrss
eeb ee/e/e b ee/e/e b STEP 2 INSTRUMENTATION/
: / / t
/ m
.t.m : / / t
/ m
.t.m IMPLANTATION
t ppss : / t ppss : / • K-wires

• Drill sleeves
t
hhtt t
hhtt STEP 3 PEARLS
• The bone at the critical angle is quite dense
and usually provides an accurate read for
k e rrss
e k eerrss reduction.
• At least two wires are necessary to maintain
o o
o o k o o
o o k o o
reduction.
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
IMPLANTATION
ps
t p s : /
t p ss:
p / • K-wires
t
FIG. 38.8
hht t t t
FIG. 38.9
hht
• Dental picks or a small hook
STEP 4 PEARLS
Step 3: Reduce the Anterior Process • Be sure the plate is seated over the lateral
e r s
rs e rs
• Place additional wires percutaneously into the anterior process (Fig. 38.10).
rs
• Reduce the anterior process at the critical angle and advance the wires to maintain
k e k e
wall.
• If a gap is present in the articular reduction,
o o
o o k reduction (Fig. 38.11).
o o
oo k oo
lag screws should be used initially.
eebb Step 4: Insert the Plate

ee/ e
/ b
e b ee/e/ebb STEP 4 PITFALLS
: / / / .
tm.m : / / t
/.tm
. m
• The plate is then inserted along the lateral margin of the joint, and wires are inserted
t • Care should be taken to ensure the peroneal
t p ss : /
• The plate is secured to bone with screws (Fig. 38.13).
p t p ss
p : /
to hold the plate while the position is checked with a C-arm (Fig. 38.12).
tendons are not under the plate.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
322 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook FIG. 38.10
b oooo k
b o o
FIG. 38.11
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 38.12
rrss s FIG. 38.13
k e e k eerrs
o o
o o k o oo
o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb
FIG. 38.14
ee/ e
/ b
e b
ee/e/ebb
FIG. 38.15
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Superior view
k eers
rs k er
erss FIG. 38.16
eeb ee/ e
/ e b
Step 5: Place Screws Along the Medial Wall to Secure Tuberosity ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m STEP 4 INSTRUMENTATION/
IMPLANTATION
t p ss
p : / tp pss : /
• 4-mm Cortical screws are inserted inside the medial wall of the tuberosity (Fig. 38.14).
• Plate
t
hht t
Step 6: Place Screws From the Tuberosity to the Anterior Process
t
hht t
• Long screws are placed from the tuberosity to the anterior process (Fig. 38.15).
• Drills
• Screws, both locking and nonlocking
ALTERNATIVE TECHNIQUE: PERCUTANEOUS REDUCTION STEP 5 PEARLS

AND ARTHROSCOPICALLY/FLUOROSCOPICALLY ASSISTED
kee rs
FIXATION
r s keerrss • The two screws should be placed just inside
the medial wall for maximal stability.
b ooook b ooook
• In simple Sanders type II fractures without deep impaction of the posterior facet
fragment, anatomic reduction can be achieved with purely percutaneous manipula-
b oo
eeb ee/e/e b ee/e/e
tion, further reducing the surgical impact. This is most easily achieved in tongue-typeb STEP 5 PITFALLS
: / / t
/ m : / / t
/ m
fractures (Sanders type IIC) in which the posterior joint facet of the calcaneus is
.t.m .t.m
displaced as a whole. In these cases, reduction is achieved with the modified West-
• Maintain two points of fixation in the tuberosity
at all times to prevent loss of reduction.
hues/Essex-Lopresti maneuver, that is, the Schanz screw with T chuck is introduced
t
hhtt t
hhtt
in a posteroanterior direction into the displaced fragment, parallel to the superior
margin of the tuberosity. The screw is moved downward and the tongue fragment STEP 5 INSTRUMENTATION/
IMPLANTATION
reduced (Fig. 38.16).
• In Sanders type IIA or IIB fractures the articular reduction is controlled arthroscopi- • Screws
cally (Fig. 38.17). In these cases, the joint and the intraarticular fractures are cleared
k e rrss
e k rrss
of debris and small avulsed fragments treated arthroscopically. Tongue-type frac-
e e STEP 6 PEARLS
o o
o o k o o
o o k
tures extending into the joint are reduced as described above. In joint depression
fractures, the depressed lateral fragment is manipulated percutaneously with a K-
o o
• Usually two screws are placed. One screw to
eebb ee/ e b
e b
wire, or periosteal elevator. A curved reduction clamp may be placed percutane-
/
ously on the sustentaculum and the lateral wall to achieve compression across the
ee/ e
/ b
e b raft the reduction at the critical angle and a
second screw to bridge from the tuberosity to
fragments.
: / / t
/ m
.t.m : / / t
/ m
.t.m the anterior process for additional stability and
to prevent rotation.
t p ss:
p / t p ss:
p /
t
hht t t
hht t STEP 6 PITFALLS
• Avoid starting screws in the Achilles tendon
as it will cause irritation. If necessary to
start screws in the Achilles footprint, slightly
countersinking the screws may be necessary.
k e r
e s
rs k eers
rs • Avoid prominent screws at the posterior
o o
o o k o o
oo k oo
margin of the tuberosity.
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
324 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb A
ee/ e
/ e b B
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
C
t
hhtt t
hhtt D
FIG. 38.17
e rrss
k e k e rrss
e
o o
o o k
• Early range of motion is important to minimize
o o o k o
• Screw fixation under fluoroscopic control is achieved according to the individual
o o
eebb b b
posttraumatic stiffness.
ee/ e
/ e b e e
/ e b
fracture pattern as described above (Fig. 38.18).
/
• If anatomic reduction cannot be achieved with percutaneous methods, conversion
e
: / / t
/ m
.t.m : / / t
/ m
.t.m
to a sinus tarsi approach including the arthroscopic portals may become necessary,
stiffness.
t p ss:
p /
• Delay in range of motion may lead to excessive
t p p /
especially in cases of severe impaction of the lateral joint fragment or if surgery is
ss:
delayed more than 10 days.
t
hht t
• Range of motion begins when the wound
t t
hhtOUTCOMES
has stabilized. Wound problems can occur if
motion begins too soon.
• The patient is placed in a postoperative splint.
• Subtalar motion exercises are started on the second postoperative day.
k e r
e s
IMPLANTATION
rs
• Implant removal is rarely needed after
k eers
• Sutures are removed at 2 weeks.
rs
• No weight bearing until the fracture is healed. This is usually 9–12 weeks.
o o
o o kpercutaneous or minimally invasive fixation of
o o
o k
• Compliant patients can be treated with partial weight bearing (15–20 kg), which
o oo
eebb b b
calcaneal fractures. is equivalent to the foot touching the ground but not being loaded, in their
• It is indicated only in cases of prominent
ee
screws, peroneal tendon irritation, or restricted/ e
/ e b own shoe.
ee/e/e b
motion of the subtalar joint.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss : /
• In these cases, hardware removal is combined
with peroneal tenolysis, arthroscopy, and
p t p ss
p : /
t
hht t
arthrolysis of the subtalar joint.
t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss B
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t ppss : /D
t
hhtt
t
hhtt FIG. 38.18
EVIDENCE
Minimally Invasive Fixation via the Sinus Tarsi Approach
rrss rrss
Nosewicz T, Knupp M, Barg A, et al. Mini-open sinus tarsi approach with percutaneous screw fixation
o k e
k e
2012;33:925–33.
o k e
of displaced calcaneal fractures: a prospective computed tomography-based study. Foot Ankle Int
k e
o
eebb o o o o o
Twenty-one consecutive patients with 22 calcaneal fractures underwent open reduction internal
e b b e b o
b o
m ee/ / e m ee/
fixation with minimal exposure through the sinus tarsi for reduction, lateral plate fixation, and per-
/ e
cutaneous screw fixation. There were 9 Sanders type II fractures and 13 type III fractures. Sixteen
: / t
/ .t.m : / / t
/ .t.m
fractures had calcaneocuboid joint involvement. Nineteen patients (19 fractures) were available
/ / /
for follow-up (mean, 32 ± 14 months). Postoperative posterior facet and calcaneocuboid joint
t t p
t ss:
p t t p
t ss:
reduction as controlled with computed tomography scanning were good (step <1 mm, defect <5
p
mm, angulation <5°) or excellent (no step, defect, angulation) in 14/22 (64%) and 11/16 fractures,
hht hht
respectively. At follow-up, no loss of joint reduction was noted. More than 5° of Böhler angle de-
crease was found in three patients.
Rammelt S, Sands A, Swords M, Amlang M. New techniques in the operative treatment of calcaneal
fractures. Unfallchirurg 2016;119:225–36. [in German].
An up-to-date review on recent techniques (open, minimally invasive, percutaneous) in the opera-
k e r
e ss
process).
k eers
rs
tive treatment of calcaneal fractures including peripheral fractures (sustentaculum tali, anterior
r
o o
o o k oo k
Schepers T. The sinus tarsi approach in displaced intra articular calcaneus fractures: a systematic
o o oo
eebb b b
review. Int Orthop 2011;34:697–703.
/ e e b /e e
A review of 271 displaced fractures in 256 patients with a focus on outcomes obtained demon-
ee /
strating that sinus tarsi approach is a viable treatment option for these injuries.
ee / b
: / / t
/ .m.m : / / t. m
. m
Xia S, Lu Y, Wang H, Wu Z, Wang Z. Open reduction and internal fixation with conventional plate via
t / t
t p ss
p : / t p ss : /
L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach
for calcaneal fractures: a randomized controlled trial. Int J Surg 2014;12(5):475–80.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
326 hht
In this randomized trial, shorter surgical times, a decrease in wound complications, and higher
Maryland Foot Scores were seen in the sinus tarsi group.
k e r
e s
rs k eers
r s
Percutaneous, Arthroscopically Assisted Reduction
o o
o o k oooo k o o
eebb b b
Nehme A, Chaminade B, Chiron P, Fabie F, Tricoire JL, Puget J. Percutaneous fluoroscopic and
/ ee b / e e b
arthroscopic controlled screw fixation of posterior facet fractures of the calcaneus. Rev Chir Orthop
ee / ee /
Reparatrice Appar Mot 2004;90:256–64. [in French].
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Thirteen patients with 15 displaced posterior facet fractures of the calcaneum were treated with
t p ss
p : / t p ss : /
percutaneous fixation under fluoroscopic and arthroscopic control. No complications were seen. At
20 months, the overall functional and physical results were excellent or good in the majority of the
p
t
hht t t
hht t
cases. Böhler angle was corrected to 83% of the uninjured side.
Rammelt S, Amlang M, Barthel S, Gavlik JM, Zwipp H. Percutaneous treatment of less severe intraar-
ticular calcaneal fractures. Clin Orthop Relat Res 2010;468:983–90.
Percutaneous reduction and screw fixation were performed in 61 patients with Sanders type II cal-
caneal fractures. In 33 of 61 patients with displaced intraarticular fractures, anatomic reduction of
the subtalar joint was confirmed arthroscopically. No wound complications or infections were seen.
k eers
rs k er
erss
In two patients, one prominent screw was removed after 1 and 3 years, respectively. In one patient,
arthroscopic arthrolysis was performed 1 year after the index procedure. Twenty-four of 33 patients
b ooook b ooook
(73%) were followed for a minimum of 24 months (mean, 29 months; range, 24–67 months). The
b o o
average American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Score at last
eeb ee/ e
/ e b ee/ e
/ e b
follow-up was 92.1. Böhler angle and calcaneal width were reduced close to the values of the un-
injured side. When compared with a historical cohort of 18 patients with Sanders type II fractures
: // t/.tm
. m : / /t . m. m
treated with lateral plate fixation via an extensile lateral approach, patients treated with percutane-
/ t
t p ss
p : / tp ss : /
ous reduction had significantly better hindfoot motion and less time off work.
Rammelt S, Gavlik JM, Barthel S, Zwipp H. The value of subtalar arthroscopy in the management of
p
t
hht t t
hht t
intra-articular calcaneus fractures. Foot Ankle Int 2002;23:906–16.
In a first study on this subject, arthroscopically assisted percutaneous reduction and screw fixa-
tion were performed in 18 patients with Sanders type II fractures. Reduction was achieved with a
Schanz screw introduced percutaneously into the tuberosity fragment and controlled fluoroscopi-
cally, while fine corrections were made under arthroscopic guidance. Fifteen patients who under-
went arthroscopically guided percutaneous reduction and screw fixation were reevaluated after a
keerrss keerrss
minimum of 1 year with excellent clinical results (94.1 patients with the AOFAS scales). No wound
ook ook
complications were seen.
b
eeboo e bboo e bboo
Schuberth JM, Cobb MD, Talarico RH. Minimally invasive arthroscopic-assisted reduction with percuta-
neous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases. J Foot
/ /
m e /e
Ankle Surg 2009;48:315–22.
e m ee /e
A retrospective analysis of 24 cases of minimally invasive, open reduction, and internal fixation of
: / /
/ t
/ .t.m : / / t .t.m
intraarticular calcaneal fractures is presented. Arthroscopic assistance was used in 10 of the cases.
/ /
t t ppss : t t pps :
The articular step-off of the posterior facet, medial wall displacement, and Böhler angle all dis-
s
played statistically significant change between the preoperative and postoperative periods. There
hhtt hhtt
were no soft-tissue complications. Of the 18 patients who were followed for more than 1 year, none
went on to subtalar fusion.
Woon CY, Chong KW, Yeo W, Eng-Meng Yeo N, Wong MK. Subtalar arthroscopy and fluoroscopy
in percutaneous fixation of intra-articular calcaneal fractures: the best of both worlds. J Trauma
2011;71:917–25.
rrss rrss
A prospective analysis of 22 consecutive patients with Sanders type II intraarticular calcaneal frac-
o k e
k e o k e
tures who underwent subtalar arthroscopic- and intraoperative fluoroscopic-guided percutaneous
k e
fracture fixation with a minimum follow-up of 2 years. Maximum accepted postreduction step-off
o
eebb o o o o o o o
was 1 mm. Fractures were fixed definitively with four to eight percutaneous cancellous screws.
e b b e b b
m ee/ / e m ee/
There was significant correction of Böhler tuberosity-joint angle from 4.2° preoperatively to 21.3°
/ e
on immediate postoperative radiographs, with minimal subsidence to 20.1° at 2 years. Anatomic
: / /
/ t
/ .t.m : / / t
/ .t.m
reduction could not be achieved percutaneously in one patient with an impacted, depressed joint
fragment. There was significant improvement in mean Visual Analog Scale, AOFAS Ankle Hindfoot
/
t t p
t ss:
p t t p
t
improvement up to 2 years. ss:
Score, and 36-Item Short Form Health Survey (Physical Function) scores at 3 months, with further
p
hht hht
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh39
PROCEDURE
t hht
Sinus
rssTarsi Approach for Calcaneal
rssFractures
kkee r
ooRoxa Ruiz and Beat Hintermann k
oo e
ke r
b
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht
• Displaced tongue-type fractures
• Large extraarticular fractures (>1 cm) with detachment of Achilles tendon and/or >2 mm
hht
• Heavy smokers
• Vasculopathies
displacement
• Urgent if skin is compromised
k eerss
• Sanders type II and III
r k er
b ooook lignment of the tuberosity

b ooook
• Posterior facet displacement >2–3 mm, flattening of Böhler angle, or varus mala-
b o o
• Initial Böhler angle <0°
eeb EXAMINATION/IMAGING ee/ e e b ee/ e

/ e b
• Anterior process fracture with >25% involvement of the calcaneocuboid joint
/
• Primary subtalar arthrodesis for Sanders type IV
: // t/.tm
. m : / /t/.tm. m
t p ss :
Clinical Investigation
p / tp pss : /
t
hht
• Symptoms
• Pain
t t
hht t
• Physical examination
• Diffuse tenderness to palpation
keerrs
• Ecchymosis and swelling
s
• Shortened, widened heel with a varus deformity
keerrss
b ooookAssessment by Imaging
b ooook b oo
eeb • Radiographs
ee/e/e b ee/e/e b
: / / / m
.t.m
• Required: lateral (Fig. 39.1A) and axial calcaneus (Fig. 39.1B)
t : / / t
/ m
.t.m
• Optional: Brodén view

p ss : /
• Allows visualization of the posterior facet
t p t ppss : /

t
hhtt t
hhtt
• Useful for evaluation of intraoperative reduction of the posterior facet
• With ankle in neutral dorsiflexion, take x-rays at 40°, 30°, 20°, and 10° of internal
rotation
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m C
t p ss
p : /
t p ss
p : /
t
hht t t t
FIG. 39.1
hht 327
t t p
t ss:
p t t p
t ss:
p
328 hht
PROCEDURE 39 Sinus Tarsi Approach for Calcaneal Fractures hht
• Optional: Harris view
k e r
e s
rs

k eers
• Visualizes tuberosity fragment widening, shortening, and varus positioning
r s
• Place the foot in maximal dorsiflexion and angle the x-ray beam 45°
o o
o o k
oooo k • Optional: anteroposterior ankle (Fig. 39.1C)
o o
eebb
e / e
/ebb
• Findings
e ee/ / b
e b
• Demonstrates lateral wall extrusion causing fibular impingement
e
: / / t
/ .
t m
. m
: / / / .
• Reduced Böhler angle
t t m
. m
t p ss
p : /

t p ss : /
• Increased angle of Gissane
• Calcaneal shortening
p
t
hht t
t
hht t
• Varus tuberosity deformity
• Measurement
• Böhler angle (normal is 20–40°)
• Measured from lateral foot x-ray
• Flattening (decreased angle) represents collapse of the posterior facet
k eers
rs
k er
erss • Double density highlights subtalar incongruity
b ooook

b ooook • Angle of Gissane (normal is 130–145°)
b o o
• An increase represents collapse of the posterior facet
eeb ee/ e
/ e b
• Computed tomography
ee/ e
/ e b
: // t/.tm
. m
• Gold standard
• Views
: / /t/.tm. m
t p ss
p : /
ss : /
• 30° semicoronal (Fig. 39.2A)
tp p
t
hht t
t
hht t
• Demonstrates posterior and middle facet displacement
• Axial
TREATMENT OPTIONS • Demonstrates calcaneocuboid joint involvement (Fig. 39.2B)
• Open reduction and internal fixation through • Sagittal
• An extended approach • Demonstrates tuberosity displacement (Fig. 39.2C)
keerrss
• A limited sinus tarsi approach
• Percutaneous reduction and fixation
keerrss
• Magnetic resonance imaging
b ooook
• Conservative treatment
b ooook • Used only to diagnose calcaneal stress fractures in the presence of normal radio-
oo
graphs and/or uncertain diagnosis
b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o
A k B
o ooo k C
oo
eebb ee/ e
/ b
e b FIG. 39.2
ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 39 Sinus Tarsi Approach for Calcaneal Fractures 329
Sural nerve
k e r
e s
rs k eers
r
Calcaneal fibulars
o o
o o k ligament
oooo k o o
eebb ee/ e
/ebb
Peroneus brevis
ee/ e
/ b
e b
: / / t
/ .
t m
. m tendon
: / / t
/ .
t m
. m
t p ss
p : / Peroneus longus
t p ss
p : /
t
hht t tendon
t
hht t
k eers
rs k er
erss
b ooook booook
Calcaneal tubercle
b o o
eeb A
ee/ ee
/ b B
ee/ e
/ e b
: // t/.tm
. m FIG. 39.3
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb SURGICAL ANATOMY ee/e/e b ee/e/e b POSITIONING PEARLS
: / / t
/ m
.t.m : / / t m
.t.m
• Relevant lateral structures to be protected in the lateral and posterolateral a
/ pproaches • The use of a radiolucent table will facilitate
• The peroneal tendons are running over the posterior lateral subtalar joint intraoperative fluoroscopy.
t
hhtt
deep to the tendons t
hhtt
• The calcaneofibular ligament attaches posterior to the peroneal tubercle and lies • An axillary roll is recommended and helps
to prevent compression of neurovascular
structures at risk.
• The sural nerve courses parallel and posterior to the peroneal tendons before
passing superficially at the inferior retinaculum (Fig. 39.3A)
• Relevant osseous anatomy
rrss rrss
• The superior surface of the calcaneus includes the anterior, middle, and posterior
o k e
k e k e e
facets. In 60% of patients, the anterior and middle facets are confluent. The pos-
o k
• Beanbag
o
eebb o o e b o
b o
terior facet is the largest and supports the talar body
o e b o
b o
• Protective padding below the contralateral limb
and axilla to protect the peroneal nerve and
m ee/ / e m ee/
• The inferior surface of the talus includes the corresponding articular surfaces,
/ e
with a high congruency in the posterior facet and a low congruency in the middle
: / /
and anterior facets
/ t
/ .t.m : / /
/ t
/ .t.m
t t p
t ss:
p t t p
t ss:
• The talus forms with its head a ball-and-socket joint with the navicular (Fig. 39.3B)
p
POSITIONING
hht hht
• Open reduction and internal fixation of calcaneal fracture is performed in the lateral
• The patient may be positioned supine if
surgical approach to the medial calcaneus is
considered during the same surgery; in this
position. case, elevation of the ipsilateral back will allow
• We favor a full lateral decubitus position with the patient’s torso safely secured within internal rotation the foot.
k e r
e s
rs
sheets or towels.
k eers
a beanbag and the operative extremity supported on a well-padded bump of folded
rs
o o
o o k o oo k
• The knee is flexed, and the heel of the patient rests at the posterior corner of the
o oo
eebb operating table (Fig. 39.4).
ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
330 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss A
b ooook
FIG. 39.4
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb ee/e/e b B
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Identification of the sinus tarsi under
t p ss: /
fluoroscopy will facilitate determination of the
p ps
t p s
C
: /
incision position.
t
hht t t
hht t FIG. 39.5
• The fibulo-calcanear ligament can be PORTALS/EXPOSURES
damaged when the lateral approach is
k e r s
rs
extended too posteriorly.
e
• The sural nerve can be damaged; thus,
k e rs
• Make a slightly curved incision (4–6 cm long) from tip of fibula to the sinus tarsi (Fig.
rs
39.5A).
e
o o
o o k it might be wise to identify it during
o o
o k
• Expose the sinus tarsi (Fig. 39.5B).
o oo
eebb b b
• Evacuate the hematoma.
subcutaneous preparation.
ee/ e
/ e b e /e/e b
• A 2.5-mm Kirschner wire (K-wire) is brought into the talar neck, and another one in
e
: / / t
/ .
tm.m : / / t
/.tm
the lateral tuber of the calcaneus.
. m
• The Hintermann distractor is mounted over the K-wires.
• Hintermann distractor
t p ss
p : / t p ss : /
• The subtalar joint is gradually distracted (Fig. 39.5C).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b ooook B
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
C D
FIG. 39.6
e rrss
PROCEDURE
k e k e rrss
e
STEP 1 PEARLS
o o
o o k o o
o o k o o
• The reduced fragments of the posterior facet
can be preliminary fixed to the talus by K-wires
eebb Step 1: Reduction of Articular Surface

ee/ e
/ b
e b
• The articular surface is step-by-step reduced (Fig. 39.6A).
ee/ e
/ b
e b inserted from the plantar aspect of the foot
(Fig. 39.6C).
•
: / / t
/ m
.t.m
The medial fragment is elevated by a raspatory and reduced to the talar
: / / t
/ m
surface.
t p ss:
p /
• If present, the intermediate fragment is reduced.
t p ss:
p / • Not appropriate reduction of an intermediate
t
hht t
• The lateral wall fragment is reduced. t
hht t
• K-wires may be used to keep the reduced fragments in place (Fig. 39.6B).
fragment may result in insufficient reduction of
the posterior facet, as seen in the Brodén view
(Fig. 39.6D).
• The anterior fragment is reduced to the posterior fragment at the fracture site. • Not appropriate reduction of the posterior facet
• A K-wire is used for preliminary fixation. may result in a deficient Böhler angle.
r s
rs
Step 2: Fixation of Articular Surface
k e e k eers
rs STEP 1 CONTROVERSIES
o o
o o k oo k
• A 2.5-mm plate is contoured at one end to the round shape of the posterior calca-
o o oo
• The use of bone grafting supports the
eebb b b reduction and stability of the posterior facet.

neus (Fig. 39.7A).
ee/ e
/ e b e /e
• The plate is fixed first at its posterior site with two to three screws (Fig. 39.7B).
e /e b • We agree with others that grafting provides no
added benefit; it has also the potential risk of
: / / / .
tm m
• Thereafter, the plate is fixed to the anterior fragment of the calcaneus.
t . : / / t
/.tm
. m displacement of a medial fragment that might
t p ss
in the sustentaculum tali.
p : / t p ss
p : /
• Internal fixation is completed by insertion of a screw just posterior to the sinus tarsi compromise the neurovascular bundle in the
tarsal tunnel.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
332 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b oo ook B
b o o
eeb ee/ e
/ e b FIG. 39.7
ee/ e
/ e b
STEP 2 PEARLS
: // t/.tm
. m : / /t/.tm. m
t p ss : /
• The use of an anatomically contoured plate
p tp pss : /
t
hht
may facilitate the fixation.
t
• The use of nonlocking screws allows to
press the plate against the bone and to apply
t
hht t
interfragmentary compression, and thus
enhances the stability of the construct.
keerrss
STEP 2 PITFALLS
keerrss
b ooook
• A plate that has not been contoured may
b ooook b oo
eeb displace the reduced fragment while it is fixed.
ee/e/e b ee/e/e b
Step 3: Reduction and Fixation of Calcaneal Tuberosity
: / / t
/ m
.t.m : / / t
/ m
• Usually, the calcaneal tuberosity is well reduced after reduction following restoration
.t.m
of Böhler angle and articular surface of the posterior facet (see Fig. 39.7B).
t p ss : /
• The use of locking screws provides no benefit.
p t ppss : /
• In the case of remaining varus or/and shortening, reduction can be obtained with
STEP 3 PEARLS
t
hhtt t
hhtt
distraction on the lateral side or with manipulation of the heel over a Steinmann pin.
• One K-wire is inserted from the tuberosity into the anterior process of the calcaneus
(Fig. 39.8A).
• To enhance the stability of the construct against • One K-wire is inserted from the inferior tuberosity in an oblique direction to the sub-
varus deviation and shortening, a second screw chondral bone of the posterior facet.
k e rrss
can be inserted from the inferior tuberosity into
e
the inferior anterior process of the calcaneus.
k e rrss
• Usually, 4.5- or 5.5-mm full-treated cannulated screws are inserted (Fig. 39.8B).
e
o o
o k
• A large extraarticular fracture with
o o o k
Step 4: Wound Closure
o o o o
eebb b b
detachment of Achilles tendon and/or >2 mm
displacement is reduced by a percutaneously
applied compression forceps and fixed by a
ee/ e
/ e
•

b / e e b
Step-by-step wound closure is done, with interrupted 3-0 sutures for the skin
(Fig. 39.8D).
ee /
: / t
screw from the posterior superior tuberosity
/ / m
.t.m : / / t m
.t.m
• A compressive dressing is applied.
/
t p ss:
p /
directed inferior and distal (Fig. 39.8C).
t p ss:
p /
• The foot is positioned in a neutral splint (Fig. 39.8E).
STEP 3 PITFALLS t
hht t t
hht t
• Failure to support the posterior facet with a
screw might result in secondary subsidence
posterior facet fragment at its posterior aspect
k e r
e s
and thus result in a loss of Böhler angle.
rs k eers
rs
o o
o o k
o o
oo k oo
eebb IMPLANTATION
• Reduction forceps
ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b o
B
oook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
C D
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k E
o ooo k oo
eebb ee/ e
/ b
e b
FIG. 39.8
ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
334 hht
STEP 3 CONTROVERSIES POSTOPERATIVE CARE AND EXPECTED OUTCOMES
k e r
e ss
• Insertion of an additional plate from sinus
r
tarsi-directed posterior, distal, and fixed
k eers
r s
• The ankle is protected for 8 weeks by a removable splint in a neutral position at
rest, and by a boot while walking. In noncompliant patients, a Scotchcast (3M,
o o
o o kto posteroinferior tuberosity enhances the
oooo k o
Rueschlikon, Switzerland) is used instead of a boot.
o
eebb stability of the construct (see Fig. 39.8C).
• Such construct is only indicated in highly
e / e bb / e b b
• During these first 8 weeks, only partial weight bearing (e.g., 15–20 kg) is permitted.
e /e ee / e
• Radiographic control (Fig. 39.9A–B) is made 8 weeks and a computed tomography
communitive fractures.
: / / t
/ .
t m
. m : / / t . m
. m
scan control (Fig. 39.9C–E) is made 4 months after surgery.
/ t
t p ss
p : / ss : /
• After complete healing of the arthrodesis, usually after 8–12 weeks, full weight bear-
t p p
t
hht t
• We do not use drainage in fear of
exsanguination of the bleeding bone.
t
hht t
ing and free ambulation are permitted.
• A rehabilitation program including active and passive motion (Fig. 39.9F), muscular
strengthening, proprioception, and gait training is then also started.
• Return to work is allowed for sedentary workers after 2–3 weeks and for heavy labor-
ers after 3–4 months. Heavy laborers may use rigid protective footwear continuously.
k ee s
rrs
• The use of passive continuous motion
k er
ers
s
b ooook including pronation/supination will support

EVIDENCE
b ooook b o o
eeb b b
functional recovery.
• Wearing compression stockings and stretching
ee/ e
/ e ee/ e
/ e
Abdelazeem A, Khedr A, Abousayed M, Seifeldin A, Khaled S. Management of displaced intra-articular
the Achilles tendon are strongly recommended
: // t/.tm
.
in the first months after the immobilization.
m : / /t/.tm. m
calcaneal fractures using the limited open sinus tarsi approach and fixation by screws only technique.
t p ss
p : / Int Orthop 2014;38(3):601–6.
tp ss : /
Treatment involving the sinus tarsi approach and fixation by screws was shown in 33 patients (15
p
POSTOPERATIVE PITFALLS t
hht
• Possible complication includes
t t
hht t
Sanders type II patients and 18 Sanders type III patients) to be successful, as it allows for ad-
equate visualization and reduction. It also showed that fixation by screws only is sufficient.
Basile A, Albo F, Via AG. Comparison between sinus tarsi approach and extensile lateral approach for
• Wound healing problem with superficial treatment of closed displaced intra-articular calcaneal fractures: a multicenter prospective study. J
infection Foot Ankle Surg 2016;55(3):513–21.
• Loss of correction by too aggressive In this comparison study, the group with limited sinus tarsi approach had a lower incidence of
keerrssmobilization/weight bearing with/without

implant failure
keer ss
wound complications (P ≥ .05), the surgical procedure was faster, and the waiting time to surgery
r
was shorter (P ≤ .05).
b ooook
• Nonunion
b ooook
Ebraheim NA, Elgafy H, Sabry FF, Freih M, Abou-Chakra IS. Sinus tarsi approach with trans-articular
b oo
fixation for displaced intra-articular fractures of the calcaneus. Foot Ankle Int 2000;21(2):105–13.
eeb • Malunion
ee/e/e b ee/e/e b
In this retrospective analysis of 106 intraarticular calcaneal fractures (99 patients), the sinus tarsi
approach showed very satisfactory results overall. The authors concluded that following the
: / / t
/ m
.t.m : / / t m
.t.m
principle of minimal soft-tissue damage and minimal internal fixation may be a good option for
/
t ppss : / t p s : /
management of calcaneus fractures.
s
Feng Y, Shui X, Wang J, Cai L, Yu Y, Ying X, et al. Comparison of percutaneous cannulated screw
p
t
hhtt t
hhtt
fixation and calcium sulfate cement grafting versus minimally invasive sinus tarsi approach and plate
fixation for displaced intra-articular calcaneal fractures: a prospective randomized controlled trial.
BMC Musculoskelet Disord 2016;17:288.
In this comparison study with cannulated screw fixation and calcium sulfate cement (42 patients),
the sinus tarsi approach (38 patients) was shown to have its own advantages in improving the cal-
caneal width, providing a more clear visualization, and accurate reduction of the articular surface,
k e rrss
e k e rrss
especially for Sanders type III.
e
o o
o o k o o o k
Nosewicz T, Knupp M, Barg A, Maas M, Bolliger L, Goslings JC, Hintermann B. Mini-open sinus tarsi
o
approach with percutaneous screw fixation of displaced calcaneal fractures: a prospective computed
o o
eebb ee/ e
/ b
e b e / e
/ b
e b
tomography-based study. Foot Ankle Int 2012;33(11):925–33.
A limited sinus tarsi approach used for the treatment of 22 intraarticular calcaneal fractures (Sand-
e
: / / t
/ m
.t.m : / / t m
ers type II, 9; Sanders type III, 13) showed that even complex calcaneal fractures can be sufficient-
.t.m
ly exposed by a minimally invasive sinus tarsi approach for anatomic reduction and stable fixation.
/
t p ss:
p / t p ss:
p /
Most patients had good or excellent functional results, which may have resulted from minimal
t
hht t t
soft-tissue disruption.
hht t
Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of displaced intraarticular calcaneal
fractures: long-term (10–20 years) results in 108 fractures using a prognostic CT classification. J
Orthop Trauma 2014;28(10):551–63.
Based on the results of this comparative analysis, the Sanders classification remains prognostic;
after a minimum of 10 years, type III fractures were four times more likely to need a fusion than
k e r
e s
rs k eers
type II fractures. Secondarily, it seems that neither a locked plate nor a bone graft is required to
rs
maintain a reduction over time, as virtually no loss of reduction was seen in this series (3/108,
o o
o o k 0.9%).
o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e
C D
k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
E
t
hht t F

FIG. 39.9
t
hht t
t t p
t ss:
p t t p
t ss:
p
336 hht
Xia S, Lu Y, Wang H, Wu Z, Wang Z. Open reduction and internal fixation with conventional plate via
L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach
k e r
e s
rs k eers
r s
for calcaneal fractures – a randomized controlled trial. Int J Surg 2014;12(5):475–80.
o o
o o k o oo k
In 117 intraarticular fractures, the sinus tarsi approach for the reduction and internal fixation with
o
percutaneous plate was found to be more safe and effective, with satisfactory clinical therapeutic
o o
eebb e e
/ebb e
displaced intraarticular calcaneal fractures.
e e/ e
/ b
e b
effects and without postoperative complications than the L-shaped lateral approach treatment of
/
: / / t
/ .
t m
. m : / / t t m
Zhang T, Su Y, Chen W, Zhang Q, Wu Z, Zhang Y. Displaced intra-articular calcaneal fractures treated
. . m
in a minimally invasive fashion: longitudinal approach versus sinus tarsi approach. J Bone Joint Surg
/
t p ss
p : / Am 2014;96(4):302–9.
t p ss
p : /
t
hht t t
In a cohort of 167 patients, outcomes are similar for the minimally invasive longitudinal and sinus
hht t
tarsi surgical approaches in the treatment of Sanders type II and type III displaced intraarticular
fractures of the calcaneus, with the benefit of a lower complication rate and shorter operative time
for the minimally invasive technique. For Sanders type IV fractures, however, the sinus tarsi ap-
proach appears to be the treatment of choice.
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
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hht t
keerrss keerrss
: / / t
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.t.m : / / t
/ m
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t
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hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
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: / / t
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p / t p ss:
p /
t
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k e r
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o o
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eebb ee/ e
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e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
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t t p
t ss:
p t t p
t ss:
p
hh40
PROCEDURE
t hht
Percutaneous
rss Fixation of Talus Fracture
rss
kkee r
ooJoe Wagener and Beat Hintermann boooo kkee r
b
eeboo / e b / e b o
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
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• Acute talar neck fractures (Hawkins type I–III)
• Nonunited talar neck fractures (<9 months after injury)
hht
• Closed reduction is not feasible (e.g.,
interposed fragment that cannot be removed
arthroscopically).
EXAMINATION/IMAGING • Extended defect on the anterior talar neck
(comminuted area) that requires open
k ee s
• Check for neurovascular deficits and skin conflicts
rrs
• Exclusion of compartment syndrome
k er
erss visualization for reduction and grafting.
b ooook b ooook
• Exclusion of additional injuries that may promote another strategy (e.g., associated
b o o INDICATIONS CONTROVERSIES
eeb ankle fracture or tendon injury)
ee/ e
/ e b e / e
/ e
• Appropriate radiographic imaging to assess the fracture of the talus and exclude ac-
e b • Open fractures
• Comminuted fracture at the subtalar joint side
: // /.tm m
companying injuries to the surrounding bony structures (Fig. 40.1)
t . : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
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o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
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. m
A
t p ss
p : / B
t p ss
p : / C
t
hht t t
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FIG. 40.1 337
t t p
t ss:
p t t p
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p
338 hht
PROCEDURE 40 Percutaneous Fixation of Talus Fracture hht
k e r
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rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 40.2
keerrss keerrss
TREATMENT OPTIONS
: / / t
/ m
.t.m / / t
/ m
• Mandatory computed tomography (CT) scan to fully understand the fracture type, to
.t.m
recognize extent of lesions to the articular structures, and potential interposed frag-
:
t pps :
• Conservative treatment for nondisplaced
s /
fractures (e.g., cast for 8 weeks with non–
t ppss : /
ments (Figs. 40.2 and 40.3)
weight bearing)
t
hhtt
• Primary open reduction and internal fixation
t
hhtt
• Magnetic resonance imaging in rare cases where injuries to surrounding soft tissues
cannot be excluded through clinical investigation

• Close the contact area between the articular surfaces at the ankle and subtalar joint
rrss rrss
• Use of a knee holder that does not fix the leg,
that makes visualization difficult without extended ligament release.
o k e
k
allowing the knee to be extended and the foot
e
to be manipulated as desired.
k e
k e
• As 60–70% of the talar surface is covered by cartilage, open exposure should be
o
o
eebb o o
• Positioning of the patient slightly elevated on
the affected side may facilitate arthroscopic
e b o
b o o o o
minimized to avoid secondary joint dysfunction.
e b b
access to the subtalar joint if it becomes
m ee/ / e m ee/ / e
• Main vascular supplies are provided from lateral to the talar head (through afferent
vessels from the lateral capsule) and talar neck and body (through afferent vessels
necessary during surgery.
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
from sinus tarsi), and from medial to the talar body (through afferent vessels through
t t p
t ss:
p t t p
t ss:
the posteromedial capsule/deltoid).
p
• Complex ligamentous apparatus that covers the talar body and neck on the medial
hht
• Rigid fixation of the leg may hinder external
manipulation for fracture reduction and
insertion of screws over Kirschner wires
hht
(deep and superficial deltoid) and lateral sides (lateral ankle ligaments).
• Limited insight into ligamentous apparatus in sinus tarsi (interosseous and cervical
(K-wires). ligaments).
POSITIONING
k e r s
rs
e k eers
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• Supine position with the patient’s feet at the edge of the table
o o
o k
• Knee holder
o o oo k
• Tourniquet at the ipsilateral thigh
o oo
eebb POSITIONING CONTROVERSIES
ee/ e
/ b
e b ee e
into a hanging position (Fig. 40.4)
/ebb
• A commercially available knee holder to support the distal femur and bring the foot
/
• Lateral decubitus position for an easier
: / / t
/ .
tm.m t. m
. m
• This allows free movements to the foot and lower limb for closed reduction, and all
: / / / t
t p ss
p : /
arthroscopic approach to the subtalar joint.
ss : /
anterior portals to the ankle and subtalar joints are possible
t p p
t
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t t p
t ss:
p t t p
t ss:
p
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PROCEDURE 40 Percutaneous Fixation of Talus Fracture 339
k e r
e s
rs k eers
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o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k
C D
o o
o o k o o
eebb ee/ e
/ b
e b
FIG. 40.3
ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
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o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t
FIG. 40.4
t
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t t p
t ss:
p t t p
t ss:
p
340 hht
k e r
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• Use fluoroscopy to determine the ideal portal
r
position if there is any doubt (e.g., alteration of
k eers
r s
o o
o o ksurrounding soft tissues by swelling).
oooo k o o
eebb • Inflate the joint with Ringer saline to better
visualize the joint and avoid soft-tissue injuries
ee/ e
/ebb ee/ e
/ b
e b
while inserting the scope.
: / / t
/ .
t m
.
• Check for the superficial peroneal nerve before
m : / / t
/ .
t m
. m
t p ss
p : /
placing the lateral portal to avoid injuries.
• The anterior central portal can be enlarged for
t p ss
p : /
t
hht t
mini-open exposure if necessary with optimal
view to fracture area (e.g., comminuted
fracture area on medial neck).
t
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rs
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• Inappropriate position of portals hindering
k eeoptimal insight into the ankle and visualization

k er
erss
b ooook
• Injury to the superficial peroneal nerve
b ooook b o o
FIG. 40.5
eeb PORTALS/EXPOSURES
ee/ e
/ e b
PORTALS/EXPOSURES ee/ e
/ e b
INSTRUMENTATION
: // t/.tm
. m : / /t/.tm. m
• Use a shaver for hematoma evacuation and
visualization of fracture
t p ss
p : / tp ss : /
A central approach (e.g., at the lateral border of the anterior tibial tendon) is used for
insertion of arthroscope into the ankle (Fig. 40.5).
p
t
hht t t
hht t
• One or two additional portals (e.g., anterolateral and anteromedial) can be used, as
required, for fracture reduction and débridement (see Fig. 40.5).
• The use of an anteromedial or anterolateral • Additional portals can be used to expose the sinus tarsi or the posterior facet of the
portal may necessitate an additional central subtalar joint.
approach should open visualization of the
keerrss
fracture become necessary.
keer
PROCEDURE
rss
b ooook
STEP 2 PEARLS
b ooook
Step 1: Primary Fracture Care
b oo
eeb • Two percutaneously inserted K-wires from
medial into the talar body and talar head may
ee/e/e b /e e b
• Hawkins type I and II fractures: positioned in a splint
ee /
• Hawkins type III fracture: closed reduction and positioned in a splint
be used for reduction of the fracture.
: / / t
/ m
.t.m : / / t m
.t.m
• Immobilization and elevation until primary swelling has disappeared
/
t p ss /
• A special distractor (Hintermann distractor) may be
:
helpful to compress the fracture after reduction.
p t p ss : /
Step 2: Fracture Reduction and Internal Fixation
p
t
hhtt
• Insertion of the screws with a distance as big
as possible between the screws may increase
rotational stability of the osteosynthesis.
t
hhtt
• After insertion of the scope, perform evacuation of hematoma and careful visualiza-
tion of intraarticular structures and fracture.
• A fully threaded screw is used in the case of a • Reduction of the fracture by moving the foot into abduction and pronation.
comminuted fracture, to ensure for the length
• If reduction is hindered by an interposed fragment, opening of the fracture by adduc-
of the talar neck (which is typically the case on
k e rrss
the medial side).
e
• A remaining defect in the area of a comminuted
k e rrss
tion and supination of the foot and removal of the fragment with appropriate instru-
e
ments are necessary.
o o
o o kfracture (e.g., on the dorsomedial neck after
o o o k o
• Once appropriate reduction is achieved, as visualized under arthroscopy and fluor-
o o
eebb fragment removal) may be filled with fibrin glue.
ee/ e
/ b
e b ee/ e
/ b
e b
oscopy, a first K-wire is inserted from the dorsomedial edge of the talar head and
directed to the posteromedial aspect of the talar body (Fig. 40.6A).
STEP 2 PITFALLS
: / / t
/ m
.t.m : / / t
/ m
.t.m
• A second K-wire is inserted accordingly from the dorsolateral edge of the talar head
t ss: /
• The use of a compression screw may shorten the
p
talar neck and thus cause a malunion with short-
p t p ss:
p /
to the posterolateral aspect of the talar body (Fig. 40.6B).
• After having determined the length of screws, a 4.5-mm (in bigger individuals
t
hht t
ening of the medial column and foot supination.
t
hht t
5.5-mm) cannulated screw is inserted over each of the K-wires (Fig. 40.6C–F).
• Fig. 40.7 shows arthroscopic image before reduction (Fig. 40.7A) and after reduction
IMPLANTATION (Fig. 40.7B).
• Cannulated screws 4.5–5.5 mm, depending Step 3: Closed Reduction Is Not Possible
k e r
e ss
on the body size
r k eers
rs
• The arthroscope is removed and the central portal is enlarged by a longitudinal inci-
o o
o o k
o o
oo ksion up to 4–5 cm along the midline of the foot.
oo
eebb • The subtalar joint may or may not be
approached separately through the sinus tarsi,
ee/ e
/ b
e b
• The extensor retinaculum is incised.
e /e/ebb
• The fracture is exposed through arthrotomy.
e
t .m.
but as long as overall sufficient reduction has
: / / / t m : / / t
/.tm
. m
• Open fracture reduction is performed.
t p ss : /
been achieved, further portals at this level may
harm the precarious blood supply to the talar
p t p ss : /
• Preliminary fixation of the fracture is performed using K-wires and two screws analo-
gous to the arthroscopic technique.
p
t
hht t
neck and should be placed with precaution.
t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook A
b o
B
oook b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
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C D
k e r
e s
rs FIG. 40.6
k eers
rs
o o
o o k o o
oo k oo
Continued
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
342 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
E
t p ss
p : / F
tp pss : /
t
hht t t
hht t
FIG. 40.6, cont’d
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
A
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / /
B
t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / FIG. 40.7
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
POSTOPERATIVE CARE AND EXPECTED OUTCOMES POSTOPERATIVE PEARLS
k e r
e ss k eers
r s
• Compressive dressing and splint fixation in neutral position for the first 48 hours.
r
• From the third day onward, protection in a soft cast and boot (VACOped), respectively,
• Continuous passive motion may be the key
to success for regaining unlimited ankle and
o o
o o k o oo k
and passive continuous motion (Kinetec; OPED), including dorsi/plantar flexion and
o o o
subtalar motion.
eebb eversion/inversion movement.
ee/ e
/ebb
• Partial weight bearing (15–20 kg) during the first 8 weeks.
ee/ e
/ b
e b
/ t . m
. m
• CT scan control postoperatively and after 8 weeks.
: / / t : / / t
/ .
t m
. m • Inappropriate rehabilitation program may result
ss : / ss : /
• When bone healing is confirmed, as is usually the case after 8 weeks, full weight
t p p t p p
in functional impairment (e.g., stiffness).
t
hht t t
hht t
bearing is permitted and a rehabilitation program is started.
• Step-to-step return to sport activities according to the rehabilitation progress.
• Fig. 40.8 shows a weight-bearing CT scan at 12 months postoperatively.
• Advantages of motion against immobilization
• Fig. 40.9 shows a radiograph at 6 months postoperatively.
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb A
ee/e/e b B
ee/e/e b
: / / t
/ m
.t.m
: / / t
/ m
.t.m
t ppss : / FIG. 40.8
t ppss : /
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m : / / t
B
/.tm
. m
t p ss
p : /
t p ss
FIG. 40.9
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
344 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
C
o o
o o k o o
o o k FIG. 40.9, cont’d
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m
EVIDENCE
: / / t
/ m
.t.m
t p ss:
p / t p ss: /
Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am 1970;52(5):991–1002.
p
t
hht t t
hht t
Retrospective case series (57 fractures) introducing the largely used Hawkins classification for talar
neck fractures type I–III.
Rammelt S, Zwipp H. Talar neck and body fractures. Injury 2009;40(2):120–35.
Comprehensive review of history, anatomy, assessment, classification, and treatment of talar neck
fractures.
Vallier HA, Reichard SG, Boyd AJ, Moore TA. A new look at the Hawkins classification for talar neck
k e r
e s
rs k eers
rs
fractures: which features of injury and treatment are predictive of osteonecrosis? J Bone Joint Surg
Am 2014;96(3):192–7.
o o
o o k oo k
Retrospective review of 81 cases (Level III) considering the amount of initial fracture displacement
o o oo
eebb b b
to predict the development of avascular osteonecrosis.
ee/ e
/ e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh41
PROCEDURE
t hht
Arthroscopic
rss Talus Fracture Fixation
rss
kkee r
ooAlastair Younger k
oo e
ke r
b
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht
• Talar neck fractures that can be reduced without making an incision using traction or
manipulation only
hht
• Talar neck fractures with lateral comminution
• Talar body fractures not reducible closed
• Lateral talar process fractures • Talar neck fractures with talar body dislocations
that cannot be reduced via traction
• Medial talar fractures
k e rs
rs
• Posterior body fractures
e k er
erss
b oo k
ooEXAMINATION/IMAGING b oook
• Minimally comminuted talar body fractures
o b o o INDICATIONS CONTROVERSIES
eeb ee/ e
/ e b ee/ e
/ e b • No outcome data to date
: // t/.tm
• Examine the skin for compound wounds
. m / /t .tm. m
• Fig. 41.1 depicts examination to determine hindfoot and forefoot varus
: /
• Likely allows better preservation of blood
supply to the talar fragments
ss : /
• Determine the degree of displacement of the fracture
t p p tp pss : /
t
hht t t
hht t
• Fig. 41.2 shows a radiograph of a talar neck fracture
• Perform a distal neurologic assessment, including a computed tomography scan
TREATMENT OPTIONS
• Closed reduction and casting for minimally
displaced fractures
(Fig. 41.3)
• Ensure there are no other fractures in the foot or elsewhere as these are high-energy • Closed reduction and external fixation
• Open reduction and internal fixation
injuries
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m : / / t
B
/.tm
. m
t p ss
p : /
t p ss
FIG. 41.1
p : /
t
hht t t
hht t 345
t t p
t ss:
p t t p
t ss:
p
346 hht
PROCEDURE 41 Arthroscopic Talus Fracture Fixation hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : / tp pss : / B
t
hht t
t
hht t
FIG. 41.2
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhttFIG. 41.3

• The figure 4 position with the leg crossed over • The talus has no tendon attachments (Fig. 41.4).
k e rrss
the nonoperative leg and the surgeon working
e
seated from the other side of the table works
e rrss
• The body of the talus is mainly surfaced by cartilage on the dorsal, medial, lateral,
k e
o o
o o kfor some medial fixation.
o o
o o k
and posterior sides with the majority of the blood supply coming from the anterior
o o
eebb b b
• Make sure that the arthroscopy camera is region from the neck.
positioned on the opposite side of the table.
• Use a thigh tourniquet to prevent tightening of
ee/ e
/ e b / e e b
• Structures at risk are the tibial nerve and artery posterior medial to the talar body,
ee /
the leg muscles.
: / / t
/ m
.t.m anteriorly.
: / / t
/ m
and the dorsalis pedis artery and deep branch of the peroneal nerve in the midline
.t.m
t p ss:
p / t p ss:
p /
• The blood supply of the talus comes from the artery of the tarsal canal, the dorsalis
t
hht t
• Failing to position so that the fracture can be
adequately approached during the case
t
hht t
pedis artery, and from the limited soft-tissue attachments. This includes the deltoid
ligament and the posterior capsule.
• The flexor hallucis longus tendon passes close to the talar body in a tendon tunnel
behind and medial to the posterior process and is held in a fibro-osseous tunnel.
r s
rs
• A beanbag is useful as it will allow the patient’s
k e e k eers
rs
o o
o o kposition to be changed during the procedure.
o o
oo k oo
eebb POSITIONING CONTROVERSIES
ee/ e
/ b
e b ee/e/ebb
• Some surgeons advocate prone followed by
/ / t
supine positioning if both the anterior and
: / .
tm.m : / / t
/.tm
. m
ss : /
posterior aspects of the talus require approach.
t p p t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 41 Arthroscopic Talus Fracture Fixation 347
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs er
erss
ook okk
b
eeboo e b o
bo o FIG. 41.4
e b o
b o
m ee/ / e m ee/ / e
: ///t/.t. m : / /
/t/.t . m
t t p
t ss
p : t tptpss :
hht hht
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t p s
p s : /
t
hhtt t
hhtt

FIG. 41.5 FIG. 41.6
k e rrss
e
POSITIONING
k e rrss
e PORTALS/EXPOSURES PEARLS
o o
o o k o o
o o k o o
eebb b b
• The patient is positioned on the table with the hip elevated and the foot at the bottom • The sinus tarsus makes a good landmark
of the table (Fig. 41.5).
ee/ e
/ e b ee/ e
/ e b in a swollen fractured ankle for subtalar
arthroscopy.
/ /
more or less internally rotated.
: t
/ m
• Depending on the site of the foot needed to be reached, the foot may need to be
.t.m : / / t
/ m
.t.m • Palpate the joint lines and move the two bones
t p ss:
p / t p ss:
p /
• Occasionally (for posterior body fractures), the patient can be positioned prone.
on each side of the joint to correctly identify
the level of the portal.
t
hht t t
hht t
• The patient can also be positioned in the lateral position if all the work required in the
talus is anterior or lateral. PORTALS/EXPOSURES PITFALLS
• Use the nick-and-spread technique for all
PORTALS/EXPOSURES portals around the talus as skin nerves are
• A dorsal medial ankle portal will allow visualization of a talar neck fracture (Fig. 41.6). variable in position around the ankle.
k e r
e ss k eers
rs
• A dorsal lateral portal can be used to instrument and reduce a talar neck fracture.
r PORTALS/EXPOSURES EQUIPMENT
o o
o o k need to be used for fixation.
o o
oo k
• A talar body fracture can be visualized by the same portals, but separate portals may
oo • A 2.9-mm arthroscope can be used for most
eebb ee/ e b
e b /
• A lateral talar process fracture can be visualized and reduced using a sinus tarsi
/
portal or portals, and a lateral subtalar portal.
ee e/ebb talar body fractures. The larger cannula this
arthroscope has allows better inflow and
: / t
/ .
tm.m : / / t
/.tm
. m
• A posterior talar body fracture can be visualized through the sinus tarsi and screws
/
removal of blood clots from the joint.
• Foot- and ankle-specific instruments are
ss :
placed from the medial side.
t p p / t p ss
p : / valuable for the case.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
348 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 41.7 FIG. 41.8
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb
FIG. 41.9
ee/e/e b ee/e/e b
: / / t
/ m
.t.m
: / / t
/ m
.t.m FIG. 41.10
STEP 1 PEARLS
t pps s : / t p s
p s : /
t
hhtt
• A talar neck reduction can be performed
PROCEDURE
using traction and positioning of the foot
while observing the fracture site through the
t
hhtt
arthroscope.
• Once the fracture is reduced, the fixation can
Step 1: Talar Neck Fracture Reductions
be achieved using medial talar screws from • The talar neck fracture can be reached using the anterior medial and anterior lateral
k e rrss
the talar neck region. A lateral screw can
be placed from the talar body forward, with
e k rrss
portals (Fig. 41.7).
e e
• Once the fracture is reduced via intraarticular visualization and confirmation, the
o o
o o kconfirmation of the screw placement using a
o o
o o k
screws can be placed (Fig. 41.8).
o o
eebb b b
posterior portal.
ee/ e
/ e b ee e
/ e
of the screws (Figs. 41.9 and 41.10). b
• An anteroposterior view of the foot will need to be obtained to confirm the placement
/
STEP 1 PITFALLS
: / / t
/ m
.t.m : / / t
/ m
.t.m
Step 2: Posterior Medial Talar Fracture Reductions
may not be reducible.
t p ss:
p /
• If the fracture is very displaced, the fracture
t p ss:
p /
• A posterior medial fragment can be reduced and held provided it is not too commi-
t
hht t
• If the fracture is very comminuted, the fracture
may not be transfixed by a percutaneous
screw and may require a plate.
t
hht t
nuted or displaced and rotated (Fig. 41.11).
• The fracture fragment can be seen from the subtalar joint either from the sinus tarsi
or from the posterior lateral portal (Fig. 41.12).
• If the flexor hallucis longus tendon is visualized, then the tibial nerve will be safe as
k e r
e s
rs
IMPLANTATION
e rs
long as surgery remains anterior to this tendon (Fig. 41.13).
rs
• A percutaneous reduction can be performed after débridement using a pelvic reduc-
k e
o o
o o k
• A full-thread cannulated screw system is
usually required.
o o
oo k
tion clamp.
oo
eebb • Large fragment forceps and a pelvic reduction
clamp can be used to assist in reduction.
ee/ e
/ b
e b ee/ /eb
Step 3: Posterior Talar Fracture Reductions
b
• Kirschner wires (K-wires) and headless screws can be placed after reduction.
e
/ / t tm
• A shaver will be required to clean blood clots
. .
and damaged joint capsules for visualization.
: / m : / / t
/.tm
. m
• A fluid pump is not required.
t p ss
p : / t p ss : /
• Posterior talar body fractures can be reached in the supine or prone position. The
prone position is preferable if all of the fracture is posterior (Fig. 41.14).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s • There is little outcome information on arthroscopic
talar fracture reductions. As a result, the surgeon
o o
o o k oooo k o
should be confident that the fixation hardware
o
eebb ee/ e
/ebb / e
/ b
e b
is solid and the reduction is anatomic. If there is
concern, then the fracture site may require an
ee
: / / t
/ .
t m
. m : / / t
/ t m
open procedure to check or place hardware.
. . m
t p ss
p : / t p ss
p : /
STEP 2 PEARLS
t
hht t t
hht t • Try and get to the fracture within the first week
to increase the ease of reduction. Remember
that risk of wound breakdown is not a reason
to delay surgery in this case.
k eers
rs FIG. 41.11
k er
erss
STEP 2 PITFALLS
• If the fracture is too comminuted or displaced
b ooook b ooook and malrotated to allow reduction, medial
b o o
malleolar osteotomies will not allow exposure
eeb ee/ e
/ e b ee/ e
/ e b
to these fragments.
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : / IMPLANTATION
t
hht t t
hht t • 2.4-mm or 2.9-mm scope
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 41.12 FIG. 41.14
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t s
ps
p : /
t
hht t
FIG. 41.13 t
hht t FIG. 41.15
t t p
t ss:
p t t p
t ss:
p
350 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b FIG. 41.16
ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
A B
k e rrss
e k e rrss
e FIG. 41.17
o o
o o k
o o
o o k o o
eebb • The positioning can be problematic for
posterior medial fracture reductions as the
ee/ e
/ b
e
•
b ee/ e
/ b
e b
The fracture can be visualized through both the ankle and the subtalar joint
arthroscope will need to be inserted anterior
: / / t
/ m
.t.m
medial and anterior lateral while the fixation
(Fig. 41.15).
: / / t
/ m
.t.m
needs to be posterior medial.
t p ss:
p / t p ss:
p /
• After provisional reduction with K-wires and/or reduction forceps, the screw posi-
tions can be guided by the arthroscope as the posterior talus is a narrow target
t
hht t
• The fracture fragments can be reached by a
mini open approach but may require section and
repair of the flexor tendons as exposure also
t
hht t
(Figs. 41.16 and 41.17).
requires dorsiflexion of the foot to get access. Step 4: Lateral Talar Process Fracture Reductions
• The lateral talar process is approached through the sinus tarsi.
STEP 3 PEARLS
k e r s
rs
• Avoid dissection of the posterior capsule if
e e rs
• The lateral talar process is injured in isolation after a dorsiflexion eversion injury.
rs
• Arthroscopic treatment allows maintenance of the lateral process blood supply and
k e
o o
o o kpossible as this may be the remaining blood
supply to the fracture fragments.
o o
oo k
assessment of the rest of the cartilage surface of the posterior facet that may affect
oo
ee/ e
/ b
e b the outcome of the patient.
e /e/ebb
• Medial talar process fractures can also be seen and reduced arthroscopicaly. For
e
/ / t .
tm
• The posterior lip of the talus can be hard to
: / .m : / / t
/.tm
. m
these fractures there may be signficant cartilage damage, and medial fixation can be
ss : /
transfix with a screw as it has a narrow lip.
t p p t p ss
p : /
challenging (Figs. 41.18 and 41.19).
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
STEP 4 PEARLS
k e r
e s
rs k eers
r s • Place the patient in a partial lateral position so
the sinus tarsi can be easily accessed.
o o
o o k oooo k o
• Use a small cannulated screw system as the
o
eebb ee/ e
/ebb ee/ e
/ b
e b
fragment can be comminuted or small.
: / / t
/ .
t m
. m : t . m
. m
STEP 4 PITFALLS
/ / / t
t p ss
p : / t p ss
p : /
• The fragment may be too small or too
comminuted to transfix at which point it may
t
hht t t
hht t be better to excise the fragment.
IMPLANTATION
k eers
rs k er
erss
• 2.4-mm or 2.9-mm arthroscope
• A mini fragment cannulated screw system.
b ooook b ooook This fracture is more amenable to a headed
o o
rather than a headless screw system
b
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/ tm
. . m
t p ss
p : /
tp pss : /
• It is not clear at what size the fragment should
be retained or excised.
t
hht t FIG. 41.18
t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k o o
o o k oo
eebb A
ee/ e
/ b
e b
B
ee/e/ebb
: / / t
/ .
tm.m
FIG. 41.19
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
352 hht
STEP 5 PEARLS
k e r
e ss
• An external fixator to distract the ankle may be
r
helpful to reduce the fragments.
k eers
r s
o o
o o k
• The patient should be consented for a medial
oooo k o o
eebb malleolar osteotomy or open reduction if it
becomes clear during arthroscopy that the
ee/ e
/ebb ee/ e
/ b
e b
reduction cannot be performed.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
STEP 5 PITFALLS
t
hht t
• The fragments are too comminuted to transfix
percutaneously.
t
hht t
• The fragments cannot be reduced using
FIG. 41.20 FIG. 41.21
percutaneous techniques.
k eers
rs k er
erss
b ooook
IMPLANTATION
ooook
Step 5: Talar Body Reductions
b b o o
eeb • 2.9-mm scope
• An external fixator to distract the ankle
ee/ e
/ e b e / e
/ e b
• Talar body fractures may be amenable to arthroscopic fixation (Fig. 41.20).
e
: // t .
• A small fragment and mini fragment headed
/ tm
. m : / /t/.tm. m
• The reduction of the fragments may be difficult depending on the displacement and
and headless screw system
t p ss
p : / tp pss : /
rotation of the fragments (Fig. 41.21).
• Arthroscopic treatment allows assessment of the reduction and percutaneous fixa-
t
hht t t
hht t
tion may better preserve the blood supply than open treatment.
• A postoperative computed tomography scan is helpful to confirm correct reduction
of the fracture fragments and should be done within 1 week after surgery so that the
• There is no outcome information on fracture can be revised if required.
arthroscopic treatment of talar body fractures
keerrs
so clear indications and contraindications
s
exist.
keerrs
s
b ooook b ooook
• Patients are seen back at 2 weeks, 6 weeks, and 3 months.
• The sutures are removed at 2 weeks.
b oo
eeb POSTOPERATIVE PEARLS
ee/e/e b ee/e/e b
• Patients are kept non–weight bearing for 6 weeks, and an x-ray is obtained at that
• Make sure that the patient is correctly
/ / t
/
educated about the postoperative care. With
: m
.t.m point.
: / / t
/ m
.t.m
• A further x-ray is obtained at 3 months and the fracture assessed.
ss : /
arthroscopic treatment, the swelling can be
t pp t ppss : /
t
hhtt
minimal and patients may weight bear too
early because the ankle does not feel tender.
EVIDENCE
t
hhtt
See also Video 41.1, Arthroscopic Talus Fracture Fixation.
Funasaki H, Hayashi H, Sugiyama H, Marumo K. Arthroscopic reduction and internal fixation for fracture
POSTOPERATIVE PITFALLS of the lateral process of the talus. Arthrosc Tech 2015;4:e81–6.
k rrss
• Failing to educate the patient and the patient
e e
returning too soon to weight bearing
k e rrss
A techniques article showing how to reduce the lateral talar process through the scope.
e
Monllau JC, Pelfort X, Hinarejos P, Ballester J. Combined fracture of the talus: arthroscopic treatment.
o o
o o k
• Failing to advise the patient on quitting
o o
o k
o o o
eebb b b
A case report of arthroscopic treatment of a talus dome fracture.
smoking
• Failing to ensure that all patients at risk
ee/ e
/ e b / e e b
Saltzman CL, Marsh JL, Tearse DS. Treatment of displaced talus fractures: an arthroscopically assisted
ee
approach. Foot Ankle Int 1994;15:630–3.
/
of vitamin D deficiency get vitamin D
supplementation
: / / t
/ m
.t.m : / / t
/ m
.t.m
Subairy A, Subramanian K, Geary NP. Arthroscopically assisted internal fixation of a talus body fracture.
t p ss:
p / Injury 2004;35:86–9.
t p ss: /
A case report of arthroscopic treatment of a talus body fracture.
p
t
hht t t
hht t
Wajsfisz A, Makridis KG, Guillou R, Pujol N, Boisrenoult P, Beaufils P. Arthroscopic treatment of a talar
neck fracture: a case report. Knee Surg Sports Traumatol Arthrosc 2012;20:1850–3.
A case report of arthroscopic treatment of a Hawkins type III talar neck fracture.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh42
PROCEDURE
t hht
Arthroscopy
rss of the Subtalar Joint
rss
k e
k e r
ooJuan Bernardo Gerstner k
oo e
ke r
b
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t ss
p : t t p
t ss
p :
INDICATIONS
hht hht
• Posterior subtalar impingement syndrome due to symptomatic os trigonum • Active infections
• Severe subtalar malalignment
k e s
• Flexor hallucis longus tenosynovitis
rrs
• Arthrofibrosis
e k er
erss
b ooook • Subtalar arthrosis
b ooook
• Calcaneal/talar fracture reduction control
b o o
eeb • Osteochondral lesions

ee/ e
/ e b ee/ e
/ e b • Talocalcaneal coalitions
• Triple arthrodesis
EXAMINATION/IMAGING
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss : /
• Range of motion of the subtalar joint must be addressed and compared with the
p
TREATMENT OPTIONS
t
hht t t
hht t
opposite side, and pain must be evaluated either on physical examination or after
anesthetic injection (Fig. 42.1).
• Open procedures
• Steroid shots in case of noninfectious disease
• Anteroposterior, lateral, and oblique (Brodén) views of the ankle should help to evalu-
ate subtalar architecture (Fig. 42.2).
• Computed tomography scan must be ordered with axial and semicoronal cuts to
keerrss evaluate all three subtalar facets (Fig. 42.3).
keerrss
b ooook intraosseous subchondral compromise.
b ooook
• Magnetic resonance imaging can rule out soft-tissue pathology and better evaluate
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : /
t p ss
FIG. 42.1
p : /
t
hht t t
hht t 353
t t p
t ss:
p t t p
t ss:
p
354 hht
PROCEDURE 42 Arthroscopy of the Subtalar Joint hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 42.2
b ooook A
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
POSITIONING PEARLS
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p :
• Supine position with a sandbag under the
ss /
ipsilateral knee if suspecting a talocalcaneal
p t ppss : /
t
hhtt
coalition that may end in an open medial
approach.
• Decubitus prone position if the pathology is
t
hhtt B
located in the back of the joint, or if an Achilles
augmentation is required. FIG. 42.3
k e rrss
e
k e rrss
e
o o
o o k
• Unidentified pathology at the opposite side
o o
o o k o o
eebb of the subtalar joint will lead to troublesome
positioning issues.
ee/ e
/ b
e b ee/ e
/ b
e b
• Decreased range of motion of the ipsilateral
/ / t
/ m
.t.m
hip will not be favorable for rotating positions.
: : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
POSITIONING EQUIPMENT t
hht t SURGICAL ANATOMY
• Radiolucent operating table is desirable when
t
hht t
subtalar fusion is needed to control screw • Three facets of the subtalar joint: posterior, medial, and anterior (Fig. 42.4A [talar
positioning side], Fig. 42.4B [calcaneal side])
• Pneumatic tourniquet if needed
k e r
e s
rs k eers
• Oblique and curved fashion of the subtalar joint (Fig. 42.4C)
rs
• Peroneal tendons, flexor hallucis longus tendon, and interosseous ligament (Fig. 42.5)
o o
o o k
POSITIONING oo
oo k oo
eebb • Decubitus lateral will not be an ideal position in
case of a concomitant midfoot medial column
ee/ e
/ b
e b e /e/ebb
• Decubitus lateral with the opposite knee flexed and a sandbag under the ankle to
e
surgery.
/ / t .
tm
• Manual traction would interfere with posterior
: / .m : / / t
/.tm
. m
achieve inversion (Fig. 42.6)
ss : /
portals. If needed, skeletal traction will help.
t p p t p ss : /
• Arthroscopy monitor on the opposite side (Fig. 42.7)
• C-arm at the same side of the subtalar joint
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 42 Arthroscopy of the Subtalar Joint 355
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B C
FIG. 42.4
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
At
hhtt
B
FIG. 42.5
t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm. m : / / t
/.tm
. m
t p ss
p : /
FIG. 42.6
t p ss
p : /
FIG. 42.7
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
356 hht
k e r
e ss
• Always draw fibula landmarks, sinus tarsi,
r
peroneals, and Achilles.
k eers
r s
• Anterior (medial and lateral) and true lateral portals (Fig. 42.8)
• Posterolateral (para-peroneal and para-Achilles tendon) and posteromedial (para-
o o
o o k
• Inject saline to determine the level of the joint:
oooo k o
Achilles tendon) portals are set to avoid damage to the sural nerve (Fig. 42.9)
o
eebb if there is a scar or redundant soft tissue, use
the C-arm.
ee/ e
/ebb ee/ e
/ b
e b
• Direction of the portals should be in line with
an open procedure if needed.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t
• Place the portal slightly above the level of the
t
hht t
joint.
• Portals placed too close will lead to skin
breakdown.
k eers
rs k er
erss
b ooook
b ooook b o o
eeb • A 4.0-mm scope can be used in either anterior
or posterior approaches.
ee/ e
/ e b ee/ e
/ e b
• In general, 1.9- and 2.7-mm scopes will
: //
enhance visualization when situated in the
t/.tm
. m : / /t/.tm. m
not to break them.
t p p : /
joint, but should be handled with care so as
ss tp pss : /
t
hht t
• A lamina spreader can be placed in the
sinus tarsi through the anteromedial portal
if constant distraction is needed (e.g., in
t
hht t
a talocalcaneal coalition) and will not alter
healing of the other portals.
keerrs
• Manual or skeletal traction can be used as well.
s keerrss
b ooook
PORTALS/EXPOSURES
b ooook b oo
eeb CONTROVERSIES
• Exposure of the medial and anterior facets
ee/e/e b
A
ee/e/e bB
• True medial portals
: / / t
/ m
.t.m
: / / t
/ m
.t.m FIG. 42.8
STEP 1 PEARLS
t
hhtt
• Inject saline to distend the joint and situate the
t
hhtt
level of the portal.
• Use a C-arm if there is difficulty locating the joint.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m A
: / / t
/.tm
. m B
t p ss
p : /
t p ss
p : / FIG. 42.9
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE STEP 1 PITFALLS
k e r s
rs
Step 1: Draw Landmarks and Portals
e k eers
r s • Portals above the level of the joint
• Missing osteophytes at the level of portals
o o
o

o k• Anterolateral portals (Fig. 42.10)
oooo k o o
eebb • Posterior portals (Fig. 42.11)
ee/ e
/ebb ee/ e
/ b
e b
IMPLANTATION
Step 2: Anterior Scope
: / / t
/ .
t m
. m : / / t
/ .
t m
. m • Start with the lamina spreader in the sinus
tarsi portal if the joint is not mobile
t p ss
p : / t
• Anterior impingement débridement (sinus tarsi syndrome; Fig. 42.13)
p ss
p : /
• Alternate between portals to improve visualization and instrumentation (Fig. 42.12)
• Appropriate shavers and burrs according to
t
hht t t
hht t
• Anterior removal of osteophytes or loose bodies in case of synovectomy or fusion
the size of the scope
• Timing to convert scope in an open procedure
• Dry scopes to ensure the quality of the
k eers
rs k er
erss reduction in a fracture of either the talar or the
calcaneal surface
eeb ee/ e
/ e b ee/ e
/ e b
STEP 2 PEARLS
• Once the anterior joint is clear, the medial and
: // t/.tm
. m : / /t/.tm. m anterior facets can be cleaned as well.
t p ss
p : / tp pss : / • Lateral joint inspection after synovectomy is
performed.
t
hht t t
• Strong manipulation of small scopes will
damage the equipment: gentle movements
and patience are key
keerrss keerrss • Excessive timing to reach the anterior joint will

lead to extravasation of the fluids and more
pain during the postoperative period.

: / / t
/ m
.t.m : / / t
/ m
.t.m IMPLANTATION
t ppss : / t ppss : / • Three portals are needed if a lamina spreader

is placed in the sinus tarsi.
t
hh tt
FIG. 42.10 t
hhtt
FIG. 42.11
• Triple scoping arthrodesis
• Secondary subtalar instability after sinus tarsi
rrss rrss
syndrome débridement
o k e
k e o k e
k e
o
eebb o o e b o
b o o e b o
b o
m ee/ / e m ee/ / e
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss : /
FIG. 42.12
p t
p ss
p : / FIG. 42.13
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
358 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A
k eers
rs k er
erss
eeb ee/ e
/ e b
ee/ e
/ e b FIG. 42.15
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
keerrss keerrss
b ooook B
b oooo k b oo
eeb
FIG. 42.14
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
STEP 3 PEARLS t
hhtt
• Use small scopes and gentle manipulation on
t
hhtt FIG. 42.16
the shape of the joint.
• Lamina spreader or traction will help to control
the size of the space in the joint.
k e rrss
e k e rrss
e
o o
o o k
STEP 3 PITFALLS
o o
o o k o o
eebb • Forcing the entrance of the joint will damage
the scope and instruments.
ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
• Transverse lateral portals can damage the
/ m
.t.m : / / t
/ m
.t.m
underlying peroneal tendons.
t p ss:
p / t p ss:
p /
IMPLANTATION
t
hht t t
hht t
Step 3: Lateral Scope
• Small ring curettes to remove cartilage will
open up the joint for fusion. • Intraarticular view of the joint: inspection of the anterior and posterior pathologies
k e r
e s
• Small-size osteotomes can be used from the
rs
posterior portals to break the talocalcaneal
k eers
(Fig. 42.14)
rs
• Alternate portals for instrumentation: anterior and posterior (Fig. 42.15)
o o
o o kcoalitions.
o o
oo k
Step 4: Posterior Subtalar Scope oo
ee/ e
/ b
e b e /e/ebb
• Avoid the track of the sural nerve (Fig. 42.16)
e
• Coalition resection
: / / t
/ .
tm.m : / / t
/.tm
. m
• Place the portals at the level of the joint (Fig. 42.17)
• Revision of subtalar nonunion
t p ss
p : / (Fig. 42.18)
t p ss
p : /
• Place the portals slightly above the level of the joint if the ankle needs to be reached
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
STEP 4 PEARLS
k e r
e s
rs k eers
r s • Start with posterolateral portals.
• Avoid the posteromedial portal when a hindfoot
o o
o o k oooo k o o
deformity in valgus is present: this will place
eebb ee/ e
/ebb ee/ e
/ b
e b the tibialis posterior neurovascular bundle
slightly close to the midline, thus making it
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
prone to damage.
• Stay close to the bony margins, as this will
t p ss
p : / t p ss
p : / keep you safe from tendon and neurovascular
structures.
t
hht t t
hht t
STEP 4 PITFALLS
• A saline injection, if not in the joint, will
produce edema at the retrocalcaneal bursa.
k eers
rs k er
erss • Cleaning the path to the joint takes time; any
rush can cause damage to the neurovascular
bundle and tendons.
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m STEP 4 INSTRUMENTATION/
t p ss
p : / FIG. 42.17
tp pss : / IMPLANTATION
t
hht t t
hht t • Burrs and shavers should be placed face down
to avoid damage.
• Alternate radiofrequency and shavers to
perform tenosynovectomy and bursectomy.
• Small osteotomes will decrease the time of
resection of an os trigonum or an osteophyte.
keerrss keerrss
b ooook b ooook b oo STEP 4 CONTROVERSIES
eeb ee/e/e b ee/e/e b • Peroneal tendon repair
: / / t
/ m
.t.m : / / t
/ m
.t.m • Flexor hallucis longus transfer
t
hhtt t
hhtt POSTOPERATIVE PEARLS
• Compression socks are helpful to prevent
postoperative edema and clot.
• Early hip and knee mobilization would
decrease muscle atrophy.
k eerrss k e rrss
e
o o
o o k o o
o o k o o
eebb b b
FIG. 42.18
ee/ e
/ e b ee/ e
/ e b Early take out of the splint would produce pain
instead of comfort. Allow at least a week for the
: / / t
/ m
.t.m OUTCOMES
: / / t
/ m
.t.m symptoms to improve.
p ss: /
• Regional anesthetics will decrease the use of opioids.
t p t p ss:
p /
t
hht t t
hht t
• A well-padded brace or slab will make a difference in comfort. POSTOPERATIVE INSTRUMENTATION/
IMPLANTATION
See also Video 42.1, Subtalar Arthroscopy. • Weight bearing in soft-tissue pathology at
1 week will enhance pneumatic control of
EVIDENCE residual edema.
k e r
e s
rs k eers
rs
Ahn JH, Lee SK, Kim KJ, Kim YI, Choy WS. Subtalar arthroscopic procedures for the treatment of sub-
• Arthrodesis will need at least a 4-week period
of non–weight bearing.
o o
o o k o oo k
talar pathologic conditions: 115 consecutive cases. Orthopedics 2009;32(12):891.
o
Description of a variety of clinical conditions in which a subtalar arthroscopy was performed and
o o
eebb the results from each.
e / e
/ b
e b e /e/ebb
Bonasia DE, Phisitkul P, Saltzman CL, Barg A, Amendola A. Arthroscopic resection of talocalcaneal
e e
/ / / .
tm.m / / t
/.tm
. m
coalitions. Arthroscopy 2011;27(3):430–5. http://dx.doi.org/10.1016/j.arthro.2010.10.018.
t
Illustrative article regarding subtalar arthroscopy to reduce the complications of the traditional open
: :
• Early pool weight bearing in arthrodesis
ss :
resection in talocalcaneal coalitions.
t p p / t p ss
p : / • Antiembolic prophylaxis
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
360 hht
Deng DF, Hamilton GA, Lee M, Rush S, Ford LA, Patel S. Complications associated with foot and ankle
arthroscopy. J Foot Ankle Surg 2012;51(3):281–4. http://dx.doi.org/10.1053/j.jfas.2011.11.011.
k e r
e s
rs k eers
r s
Description of the complications of ankle and subtalar arthroscopy in more than 400 cases.
o o
o o k o oo k
Jagodzinski NA, Hughes A, Davis NP, Butler M, Winson IG, Parsons SW. Arthroscopic resection of talo-
o
calcaneal coalitions—a bicentre case series of a new technique. Foot Ankle Surg 2013;19(2):125–30.
o o
eebb e e
/ebb
http://dx.doi.org/10.1016/j.fas.2013.03.001.
/ e / e
/ b
e b
A posterior arthroscopic technique for posterior-facet talocalcaneal coalition excision gives the
e e
: / / t
/ .
t m
. m ficult to position.
: / / t
/ t m
control of the subtalar release, but the learning curve is long and the interposition material is dif-
. . m
t p ss
p : / ss : /
Lintz F, Guillard C, Colin F, Marchand JB, Brilhault J. Safety and efficiency of a 2-portal lateral ap-
t p p
t
hht t t
proach to arthroscopic subtalar arthrodesis: a cadaveric study. Arthroscopy 2013;29(7):1217–23.
hht t
http://dx.doi.org/10.1016/j.arthro.2013.04.016.
A cadaveric study showing that more than 90% freshening of the posterior subtalar articular facets
can be achieved through a 2-portal lateral (anterior and middle) approach in a secure way for
nerves ans vessels.
Lui TH, Tong SC. Subtalar arthroscopy: when, why and how. World J Orthop 2015 Jan 18;6(1):56–61.
k eers
rs k er
ers
http://dx.doi.org/10.5312/wjo.v6.i1.56. eCollection 2015.
s
Review for subtalar arthroscopy pathologies, techniques, and complications.
b ooook ooook
Spennacchio P, Cucchi D, Randelli PS, van Dijk NC. Evidence-based indications for hindfoot endos-
o o
copy. Knee Surg Sports Traumatol Arthrosc 2016;24(4):1386–95.
b b
eeb ee/ e
/ e b ee/ e
/ e b
A comprehensive review for posterior ankle impingement syndrome, subtalar arthritis, and retrocal-
caneal bursitis managment through posterior subtalar scope.
: // t/.tm
. m 2006;55:555–64.
: / /t/.tm. m
Tasto JP. Arthroscopy of the subtalar joint and arthroscopic subtalar arthrodesis. Instr Course Lect
t p ss
p : / ss : /
Review article presented in the instructional course of AAOS for complete information about sub-
tp p
t
hht t talar scope.
t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh43
PROCEDURE
t hht
Distraction
rss Subtalar Fusion rs s
o kkee r o kkee r
o
eebb o o
Beat Hintermann and Roxa Ruiz
e bboo o e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t ss
p : t t p
t ss
p :
INDICATIONS
hht hht INDICATIONS PITFALLS
• Symptomatic osteoarthritis of the subtalar joint • Avascular necrosis of the talar body
• Fusion of the subtalar joint in a nonanatomic
k e s
• After calcaneal fracture
rrs
• In peritalar instability
e k er
erss position of the talus
b ooook talus
b ooook
• Symptomatic anterior ankle impingement/ankle osteoarthritis due to horizontalized
b o o
eeb e / e
/ e b
• Symptomatic valgus instability of the ankle in peritalar instability
e ee/ e
• Crucial for success, for example, obtaining a
: // t/.tm
• Painful tarsal coalition
. m : / /t/.tm. m plantigrade and stable foot, are
EXAMINATION/IMAGING
t p ss
p : / tp pss : / • Appropriate positioning of the talus on top
of the calcaneus
t
hht t
Clinical Investigation t
hht t • Restoring talocalcaneal angle in the sagittal
and horizontal planes
• Realigning properly the talus within the
ankle mortise
• Previous injuries and surgeries • Restoring the length of medial pillar of the
• Disability in daily activities and sports foot
keerrss
keerrss • In most instances, this can be achieved only by

distraction arthrodesis
b ooook • Effect of previous conservative measures

b ooook b oo
eeb • Hindfoot alignment when standing
ee/e/e b
• Ankle and subtalar range of motion with the patient sitting
ee/e/e b TREATMENT OPTIONS
/ t m
.t.m
• Ankle stability with the patient sitting and hanging feet
: / / : / / t
/ m
.t.m • In situ subtalar fusion
t ppss : /
• Pain using a Visual Analog Scale score of 0–10 points
t ppss : / • By arthroscopy

• Open approach
anterior ankle t
hhtt
• Subtalar motion can be
t
hhtt
• Pain is typically located subfibular and along the subtalar joint, and often also in the • Interposition subtalar fusion through
• Classic lateral approach
• Posterolateral approach
• Restricted (e.g., in osteoarthritis)
• Increased (e.g., in peritalar instability)
k e rrss
Assessment by Imaging
e k e rrss
e
o o
o o k o o o k
• Bilateral plain weight-bearing radiographs, including anteroposterior views of the
o o o
eebb ee e
/ b
e b
• Articular configuration and integrity of the ankle and subtalar joint
ee/ e
/ b
foot and ankle, lateral view of the foot, and alignment view, should be used to rule out
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Angular deviation of the talus in all three planes as compared with the not-affected
contralateral foot
t p ss:
p / t p ss:
p
• Presence of arthritic changes at the ankle and subtalar joint (Fig. 43.1)/
t
hht t t
hht t
• Computed tomography scans, if possible while weight-bearing, are initiated to
• Assess articular configuration of the ankle, subtalar, and talonavicular joints
• Assess osteoarthritic changes (e.g., subchondral sclerosis, cyst formation)
k e e s
r rs k eers
rs
• Determine the activity of degenerative changes, for example, presence and extent
o o
o o k of perifocal edema
o o
oo k oo
eebb • Assess surrounding soft tissues (Fig. 43.3)
e / e
/ b
e b
e ee/e/ebb
be used to visualize
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
• Morphologic pathologies and associated activity process
t p ss
p : /
t
hht t t
hht t 361
t t p
t ss:
p t t p
t ss:
p
362 hht
PROCEDURE 43 Distraction Subtalar Fusion hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrssA B
keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
C D
FIG. 43.1
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 43 Distraction Subtalar Fusion 363
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m
t p ss
p : /
FIG. 43.2
tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
A B
k e r
e s
rs FIG. 43.3
k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
364 hht
Sural nerve
k e r
e s
rs k eers
r s
Calcaneal fibular
o o
o o k oooo k
ligament
o o
eebb ee/ e
/ebbPeroneus brevi
ee/ e
/ b
e b
: / / t
/ .
t m
. m tendon
: / / t
/ .
t m
. m
t p ss
p : / Peroneus longus
t p ss
p : /
t
hht t tendon
t
hht t
k eers
rs k er
erss
b ooook booook
Calcaneal tubercle
b o o
eeb A
ee/ ee
/ b B
ee/ e
/ e b
: // t/.tm
. m : / /t
FIG. 43.4
/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
SURGICAL ANATOMY
keerrss keerrss
• Relevant lateral structures to be protected in the lateral and posterolateral approaches
b ooook b ooook
• The peroneal tendons are running over the posterior lateral subtalar joint
b oo
• The calcaneofibular ligament attaches posterior to the peroneal tubercle and lies
eeb ee/e/e b deep to the tendons
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
• The sural nerve courses parallel and posterior to the peroneal tendons before
.t.m
passing superficially at the inferior retinaculum (Fig. 43.4A)
t ppss : / t ppss :
• Relevant osseous anatomy/
t
hhtt t
hhtt
• The superior surface of the calcaneus includes the anterior, middle, and posterior
facets. In 60% of patients, the anterior and middle facets are confluent. The pos-
terior facet is the largest and supports the talar body
• The inferior surface of the talus includes the corresponding articular surfaces,
POSITIONING PEARLS
with a high congruency in the posterior facet, and little congruency in the middle
k rrss
• The use of a radiolucent table will facilitate
e e
intraoperative fluoroscopy.
k e rrss
and anterior facets
e
o o
o k
• An axillary roll is recommended and helps
o o o
o o k
• The head of the talus forms a ball-and-socket joint with the navicular (Fig. 43.4B)
o o
• The following ligaments can be involved in peritalar instability, thus allowing the talus
eebb b b
to prevent compression of neurovascular
structures at risk.
ee/ e
/ e b / e e b
to experience tilting and translational movement on top of the calcaneus
• Lateral ankle ligaments
ee /
: / / t
/ m
.t.m • Medial ankle ligaments
: / / t
/ m
.t.m
t p ss:
p / t p ss:
• Interosseous ligament
p /
• Beanbag
t
hht t
• Protective padding below contralateral limb
POSITIONING
and axilla to protect the peroneal nerve and
t t
• Talonavicular ligament
hht
• Subtalar arthrodesis may be performed in the lateral or prone position.
• We favor a full lateral decubitus position with the patient’s torso safely secured within
k e r
e ss
r
• The patient may be positioned supine if other
k eers
rs
a beanbag and the operative extremity supported on a well-padded bump of folded
sheets or towels.
o o
o o ksurgical procedures on the medial ankle and
o o
oo k o
• The knee is flexed, and the heel of the patient rests at the posterior corner of the
o
eebb foot are considered during the same surgery;
in this case, elevation of the ipsilateral back
ee/ e
/ b
e b operating table.
ee/
• A tourniquet is placed thigh high.e/ebb
will allow internal rotation of the foot.
: / / t
/ .
tm.m t. m
. m
• The iliac crest is also draped if the use of iliac crest is considered.
: / / / t
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 43.5
b oooo k
b o o FIG. 43.6
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
• In an osteoarthritic stiff subtalar joint,
keerrss keerrss dissection of interosseous ligament facilitates

distraction of the joint.
b ooook b ooook b oo • Mounting a Hintermann distractor on the
eeb ee/e/e b ee/e/e b medial and lateral sides of the posterolateral

approach helps to keep the soft tissues
: / / t
/ m
.t.m : / / t
/ m
.t.m away, thus facilitating insight in the posterior
subtalar joint (see Fig. 43.7). It also helps to
t ppss : / t ppss : / control varus valgus position of the heel while

distracting the subtalar joint.
t
hhtt t
hhtt PORTALS/EXPOSURES PITFALLS
• The fibulocalcaneal ligament can be damaged
FIG. 43.7 when the lateral approach is extended too
posteriorly.
e rrss
PORTALS/EXPOSURES
k e k e rrss
e
• The sural nerve can be damaged; thus,
o o
o o k o o
o o k o o
it might be wise to identify it during
subcutaneous preparation.
eebb Lateral Approach
e / e
/ b
e b e / e
/
• About 5–6 cm long slightly curved incision from the tip of the fibula to the sinus tarsi
e e
b
e b
(Fig. 43.5)
: / / t
/ m
.t.m : / / t
/ m
.t.m PORTALS/EXPOSURES EQUIPMENT
• Débridement of the sinus tarsi
t p ss:
p / t p ss:
p
• Identification and exposure of the posterior facet of the subtalar joint/ • Hintermann distractor
t
hht t t
hht t
• A 2.5-mm Kirschner wire (K-wire) is brought into the talar neck, and another one in
the lateral calcaneus PORTALS/EXPOSURES CONTROVERSIES
• The Hintermann distractor is mounted over the K-wires • Distraction of the posterior subtalar joint and
• The subtalar joint is gradually distracted (Fig. 43.6) insertion of a graft >10 mm are difficult to
achieve through a lateral standard approach.
k e r
e ss
Posterolateral Approach
r k eers
rs • With a lateral approach, wound closure may
o o
o k o o
oo k
• Longitudinal incision approximately 0.5 cm behind the peroneal tendons
o oo
also be critical after distraction arthrodesis, in
particular after calcaneal fractures.
eebb b b
• Careful dissection of subcutaneous tissue to the fascia, paying attention not to dam-
age the sural nerve
ee/ e
/ e b ee/e/e b • We thus use a posterolateral approach for:
• Distraction arthrodesis with an angular
: / / t
/ .
tm
• Dissection of the fascia and identification of the subtalar joint
.m
• Insertion of a 2.5-mm K-wire into the talus and calcaneus
: / / t
/.tm
. m correction >15°
• Critical soft-tissue conditions after previous
t p ss : /
• The subtalar joint is gradually distracted (Fig. 43.7)
p t p ss
p : / trauma and/or surgery
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
366 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 43.8
b oooo k
b o o FIG. 43.9
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
STEP 1 PEARLS
t
hhtt
• Meticulous cartilage removal is essential for
bony fusion. t
hhtt
STEP 1 PITFALLS
rrss s
• Constant attention should be paid to the
k eposteromedial side to not damage the

e k r
eer s FIG. 43.10
o o
o o kneurovascular bundle and the flexor hallucis
longus tendon. PROCEDURE
o o
o o k o o
eebb ee/ e
/ b
e b e
Step 1: Débridement of the Subtalar Joint
e/ e
/ b
e b
IMPLANTATION
: / / t
/ m
.t.m : / / t m
.t.m
• The articular surfaces on the calcaneal and talar sides are denuded of their cartilage
/
• Sharp chisel
t p ss:
p / t p ss:
p /
using a chisel and a curette (Fig. 43.8).
• Curette
t
hht t t t
hht
to break the subchondral plate and get good bleeding bone (Fig. 43.9).
STEP 1 CONTROVERSIES Step 2: Positioning of the Talus and Graft Insertion

• Débridement and denuding of all three • The talus is positioned using the Hintermann distractor and Hohmann retractor to
articular surfaces of the subtalar joint
k e r s
rs
increases the fusion surface, but it needs to
e k eers
achieve the desired position in all three planes (Fig. 43.10):
rs
• Sagittal plane: by applying distraction on the posterior aspect of the subtalar joint
o o
o o kdissect the interosseous ligament. This, in turn,
can destabilize the talar head on the anterior
o o
oo k o
• Coronal plane: by manual forces applied to the heel and/or an additional Hinter-
o
eebb calcaneus, which may become critical for
e
appropriate positioning of the talus thereafter.
e/ e
/ b
e b e /e
mann distractor on the medial side
/ebb
• Horizontal plane: by pushing the talar head medially with the aid of a Hohmann
e
• We thus prefer to preserve the interosseous
/ / t .
tm
ligament in highly unstable situations, as is
: / .m : / / t
/.tm
. m
retractor inserted into the sinus tarsi
ss : /
typically the case for peritalar instability.
t p p t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t STEP 2 PEARLS
A B • In the case of lifting up of the talar head
while applying distraction to the posterior
subtalar joint, a reduction forceps is applied
k eers
rs k er
erss percutaneously with one branch to the top of
the talar head and with the other branch to the
anterolateral calcaneus, respectively.
eeb ee/ e
/ e b ee/ e
/ e b • The insertion of a screw on the anterior
arthrodesis side before distracting the
: // t/.tm
. m : / /t/.tm. m
posterior aspect of the subtalar joint may
facilitate appropriate positioning of the talus in
t p ss
p : / tp pss : / the sagittal plane (Fig. 43.12).
• The talus can be pushed forward and rotated
t
hht t t
hht t internally on the calcaneus by applying a
torque on the Hintermann distractor mounted
on the lateral side of the subtalar joint. The
standard radiographs of the contralateral foot
serve as guidelines for the position of the talus
keerrss C D
keerrss
with respect to the calcaneus.
• Autologous bone grafts or osteoinductive bone
b ooook
FIG. 43.11
b ooook b oo
matrix substance can be used to fill gaps.

: / / t
/ m
.t.m : / / t
/ m
.t.m
STEP 2 PITFALLS
• Not positioning the talus appropriately before
t ppss : / t ppss : / insertion of the graft will result in a malposition
t
hhtt t
hhtt
of subtalar arthrodesis. In most instances, the
talus is rotated too much externally and/or too
posterior, resulting in a supination–adduction
malunion.
k e rrss
e k e rrss
e
IMPLANTATION
o o
o o k o o
o o k o o • Graft impactor
eebb ee/ e
/ b
e b ee/ e
/ b
e b • Fluoroscope
: / / t
/ m
.t.m : / / t
/ m
t p ss:
p /
• One or two 2.5-mm K-wires can be used for preliminary fixation:
t p ss:
p / • The use of screws <6.5 mm may result in
t
hht t
• From the anterior calcaneus in the talar head
• From the heel into the talar neck t
hht t
• An autograft or allograft is shaped according to the gap between the posterior talus
failure of the implants.
and the calcaneus and then inserted using an impactor (Fig. 43.11)
• After having removed the distraction, the inserted graft is trimmed to obtain a smooth • Although it is generally believed that
compression may result in higher fusion
k e r
e s
bony surface
rs k eers
rs rate of an arthrodesis, the concept of using
o o
o k
Step 3: Screw Insertion
o o o
oo k oo
positioning screws as a tripodal construct
is probably more reliable in distraction
eebb e e
/ b
e b e /e/ebb
• Two parallel K-wires are inserted from the heel into the posterior aspect of the talar body.
/
• The K-wire inserted from the anterior calcaneus into the talar head is left if its position
e e
arthrodesis, as it protects the interposed graft
from crumbling.
: / / t
/ .
tm m
is appropriate; if not, it is repositioned.
. : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
368 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m
: / /t/.tm. m FIG. 43.12
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss k eerrss
• A compression or full-threaded screw is inserted over the anterior K-wire.
b ooook o ook oo
• Full-threaded 6.5–7.5-mm screws are inserted over the posterior two K-wires under
b o b
• We do not use drainage due to risk of
ee/e/e bfluoroscopic control (Fig. 43.13).
ee/e/e b
exsanguination of the bleeding bone.
: / / t
/ m
.t.m Step 4: Wound Closure
: / / t
/ m
.t.m
• Step-by-step wound closure is done, with interrupted 3-0 sutures for the skin.
s
• A compressive dressing is applied to the wound.
POSTOPERATIVE PEARLS t
hhtt
• Wearing compression stockings and stretching
hht tt
• The foot is placed in a neutral position.

the Achilles tendon are strongly recommended
in the first months after the immobilization. • The ankle is protected for 8 weeks by a removable splint in a neutral position at rest,
rrss rrss
and by a boot while walking. In noncompliant patients, a Scotchcast (3M, Rüschlikon,
o k e
k e o k e
Switzerland) is used instead of a boot.
k e
o
eebb o o
• Possible complications include
e b o
b o o
• During these first 8 weeks, only partial weight bearing (e.g., 15–20 kg) is permitted.
e b o
b o
• Radiographic control is made at 8 weeks, and a computed tomography scan control
• Wound healing problem with superficial
infection
m ee/ / e m e
is made 4 months after surgery.
e/ / e
/
• Loss of correction by too aggressive
: /
/ t
/ .t.m : / /
/ t
/ .t.m
• After complete healing of the arthrodesis, usually after 8–12 weeks, full weight bear-
ing and free ambulation are permitted.
implant failure
t t p
t ss:
mobilization/weight bearing with/without
p t t p
t ss:
• A rehabilitation program including active and passive motion, muscular strengthen-
p
• Nonunion
• Malunion hht hht
ing, proprioception, and gait training is then also started.
• Return to work is allowed for sedentary workers after 2–3 weeks, and for heavy
laborers after 3–4 months. Heavy laborers may use rigid protective footwear continu-
ously.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrssA B
keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
C D
FIG. 43.13
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
370 hht
EVIDENCE
k e r
e s
rs rs
r s
Banerjee R, Saltzman C, Anderson RB, Nickisch F. Management of calcaneal malunion. J Am Acad
k ee
Orthop Surg 2011;19(1):27–36.
o o
o o k o oo k o
Review article on the management of malunited calcaneal fractures.
o o
eebb bb b b
Henning C, Poglia G, Leie MA, Galia CR. Comparative study of subtalar arthrodesis after calcaneal
ee/ e
/e e / e
/ e
fracture malunion with autologous bone graft or freeze-dried xenograft. J Exp Orthop 2015;2(1):10.
e
: / / t
/ .
t m
. m : / / t
/ t m
http://dx.doi.org/10.1186/s40634-015-0024-2. Epub 2015 May 7.
. . m
A case series of about 12 interposition arthrodesis for treatment of malunited calcaneal fracture in
t p ss
p : / t p ss
p : /
which the authors did not find a difference with the use of autologous graft and xenograft.
Hintermann B, Knupp M, Barg A. Peritalar instability. Foot Ankle Int 2012;33(5):450–4.
t
hht t t
hht t
http://dx.doi.org/10.3113/FAI.2012.0450.
Review article on peritalar instability with anatomic and biomechanical analysis.
Huang PJ, Fu YC, Cheng YM, Lin SY. Subtalar arthrodesis for late sequelae of calcaneal fractures: fu-
sion in situ versus fusion with sliding corrective osteotomy. Foot Ankle Int 1999;20(3):166–70.
A comparative study in which the authors reported better outcomes after distraction arthrodesis.
k eers
rs k er
ers
Jackson 3rd JB, Jacobson L, Banerjee R, Nickisch F. Distraction subtalar arthrodesis. Foot Ankle Clin
s
2015;20(2):335–51. http://dx.doi.org/10.1016/j.fcl.2015.02.004. Epub 2015 Apr 11.
b ooook ooook
The authors reported successful results with this technique.
o o
Nosewicz TL, Knupp M, Bolliger L, Henninger HB, Barg A, Hintermann B. Radiological morphol-
b b
eeb e / e
/ e b e / e
/ e b
ogy of peritalar instability in varus and valgus tilted ankles. Foot Ankle Int 2014;35(5):453–62.
http://dx.doi.org/10.1177/1071100714523589. Epub 2014 Mar 17.
e e
: // t/.tm
. m / /t/.tm. m
Morphologic analysis of peritalar instability.
Pollard JD, Schuberth JM. Posterior bone block distraction arthrodesis of the subtalar joint: a review
:
t p ss
p : / ss : /
of 22 cases. J Foot Ankle Surg 2008;47(3):191–8. http://dx.doi.org/10.1053/j.jfas.2008.01.003. Epub
tp p
t
hht t 2008 Mar 10.
t
hht t
This case series showed excellent results in restoring the hindfoot after malunited calcaneal frac-
tures, talar necrosis, and Charcot neuroarthropathy.
Schepers T. The subtalar distraction bone block arthrodesis following the late compli-
cations of calcaneal fractures: a systematic review. Foot (Edinb) 2013;23(1):39–44.
http://dx.doi.org/10.1016/j.foot.2012.10.004. Epub 2012 Nov 21.
keerrss keerrss
This review showed that subtalar distraction bone block arthrodesis is a technically demanding
procedure which, in the right hands, provides an overall good result. This is reflected in a signifi-
b ooook b oook
cant increase in outcome scores postoperatively.
o b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh44
PROCEDURE
t hht
Triple
rssArthrodesis rs s
o kkee r o kkee r
o
eebb o o
Adam Breceda and Andrew K. Sands
e bboo o e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
p ss : p ss :
INDICATIONS htt t p t t t p
ht
• Fixed hindfoot deformities
hht
• Symptomatic hindfoot arthritis
• Salvage procedure of the foot
k e rs
rs
TREATMENT OPTIONS
e k er
erss
b ooook b ooook
• Nonoperative treatments include hindfoot and ankle bracing
b o o
/ e b ee/ e
/ e b
• Physical therapy and nonsteroidal antiinflammatory drugs may help alleviate pain
: // t/.tm
. m : / /t/.tm. m
ss : / ss : /
• Weight-bearing physical examination reveals hindfoot range of motion, if any, and
t p p tp p
t t
alignment.
hht t
hht t
• Weight-bearing radiographs are obtained in anteroposterior (AP; Fig. 44.1A) and lat-
eral (Fig. 44.1B) views to evaluate for degenerative changes in ankle hindfoot and
midfoot joints.
• Computed tomography is helpful if evaluating for coalition or impingement if more
keerrss advanced reconstruction options are to be eliminated.
keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
tibia
forefoot
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b talus
: / / t
/ m
.t.m : / / t
/ m
.t.m navicular
calcaneus
t p ss:
p /
TN joint
t p ss:
p /
t
hht t t
hht t
talus
B
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss : /
FIG. 44.1 The forefoot rotates lateral and dorsal while the talus is held firmly in the fork of the ankle. This leads to lateral peritalar subluxation at the TN joint.
p
t
hht t t
hht t 371
t t p
t ss:
p t t p
t ss:
p
372 hht
PROCEDURE 44 Triple Arthrodesis hht
k e r
e s
rs k eers
r s Extensor
o o
o o k Extensor
oooo k digitorum brevis
o o
eebb b b
digitorum brevis
ee/ e
/e b ee/ e
/ e b
: / / t
/ .
t m
. m
Calcaneus
: / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Peroneus tertius
tendon
k eers
rsA
k er
erss B
b ooook Lateral
b ooook b o o
eeb b b
malleolus
Extensor
ee/ e
/ e ee/ e
/ e
/ t
digitorum brevis
: / /.tm
. m Common
: / /t/.tm. m
t p ss
p : / tp pss : /
peroneal sheath
t
hht t t
hht t
keerrss keerrss
b ooook Peroneus brevis
and longus tendons
b ooook b oo
eeb C
ee/e/ b
e ee/e/e b
: / / t
/ m
.t.m / /
FIG. 44.2
: t
/ m
.t.m
t
hhtt t
hhtt
Navicular Bifurcate SURGICAL ANATOMY
k e rrss
e
ligament
e rrss
• The extensor digitorum brevis (EDB) originates on the superolateral surface of the
k e
o o
o o k o o
o o k
calcaneus and branches to three tendons that insert to the lateral sides of the sec-
o o
eebb b b
ond, third, and fourth toes at the metatarsophalangeal joint level (Fig. 44.2A).
ee/ e
/ e b e / e
/ e b
• The neurovascular (NV) bundle enters approximately 1.5 cm medial and distal to the
e
: / / t
/ m
.t.m : / / / m
.t.m
anterior process of the calcaneus.
t
• Lateral to the EDB is the peroneus tertius tendon, which originates from the distal
t p ss:
p / t p ss: /
third of the surface of the fibula and intermuscular septum and attaches to the dorsal
p
Cuboid Talus t
h ht t t
hht t
surface of the base of the fifth metatarsal (Fig. 44.2B).
• Lateral to the EDB are the peroneal tendons (Fig. 44.2C). Both the peroneus longus
FIG. 44.3 and brevis course through the common peroneal synovial sheath about 4 cm proxi-
mal to the lateral malleolus.
• The bifurcate ligament originates on the upper surface of the calcaneus and branch-
k e r
e s
rs k eers
rs
es in a “Y” shape, with one branch inserting on the medial side of the cuboid and the
o o
o o k o o
oo k other branch inserting on the lateral side of the navicular (Fig. 44.3).
oo
eebb b b
• Often a coexisting equinus contracture will prevent reduction of the hindfoot to prop-
ee/ e
/ e b ee/e/e b
er position. A calf lengthening or three-step tendo-Achilles lengthening is needed
: / / t
/ .
tm.m : / / t
/ tm
before the reduction and reconstruction can be carried out.
. . m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Dissector is in the anterior facet PORTALS/EXPOSURES EQUIPMENT

between talus and calcaneus (medial approach)
k e r
e s
rs k eers
r s • Lamina spreaders with and without teeth
• Distractor: cervical distractor with pins can be
o o
o o k Navicular
oooo k o o
helpful in achieving reduction/positioning
eebb ee/ e
/ebb ee/ e
/ b
e b
Talus
: / / t
/ .
t m
. m : / / t
/ .
t m
. m • Choice of lateral incision: Ollier versus axial:
Ankle
t p ss
p : / t p ss
p : / • Traditionally the Ollier incision was used.
This incision is oblique along the skinfolds
Calcaneus t
hht t t
hht t approximately over the sinus tarsi, inferiorly
bordered by the peroneals and superiorly
bordered by the extensors. This incision is
more cosmetically appealing but does not
allow extension to the midfoot if needed. It can
also make visualization of the calcaneocuboid
k eers
rs k er
erss joint (CC-joint) more difficult. Finally, this
transverse incision is more likely to result in
b ooook A
b ooook b o o
injury to the sural or anterior sensory nerves.
eeb ee e
/ e b
Dissectors in the talonavicular joint (medial approach)
/ ee/ e
/ e b • The axial incision, by contrast, allows
unlimited extension distally if needed. This
: // t/.tm
. m : / /t .tm.
Distal
/ m
incision is deepened between the EDB
muscle belly (which is elevated superiorly)
t p ss
p : / tp pss : / and the peroneals inferiorly. Access to the
subtalar area, the CC-joint, and the midfoot
Navicular
t
hht t t
hht t is easily obtained. Furthermore, the nerves
course parallel to this incision, making
sensory nerve injury less likely.
Talus • Currently, arthroscopic preparation of the
joint fusion is gaining popularity, but still
keerrss keerrss
controversial in terms of risk.
b ooook Proximal
b ooook b oo PORTALS/EXPOSURES PEARLS
eeb Calcaneus
ee/e/e b ee/e/e b • Avoid dorsal dissection above the talus neck to

prevent injury to the blood supply to the talus.
B
: / / t
/ m
.t.m : / / t
/ m
.t.m • When débriding the posteromedial aspect of
the joint, use a curette instead of the drill to
t ppss : /
t ppss : / avoid transecting the NV bundle.
t
hhtt
FIG. 44.4
t
hhtt
• Flexing the great toe will result in movement of
the flexor hallucis longus tendon. This is helpful
in determining the exact location of the NV
bundle, which lies anteromedial to the flexor
hallucis longus at the level of the subtalar joint.
k eerrss k e rrss
e
STEP 1 PEARLS
o o
o o k o o
o o k o o
• Avoid excessive bone resection as this will
eebb b b decrease the subtalar joint height and disrupt

POSITIONING
ee/ e
/ e b ee/ e
/ e b
• The patient is placed in the supine position with the ankle propped on a soft roll padding.
the articular relationship of the TN joint.
• Care should be taken to ensure excision of
/ t m
.t.m /
• An ipsilateral bump rotates the foot to a more vertical position.
: / / : / t
/ m
.t.m articular cartilage from the anterior, middle,
t p ss:
p /
• A tourniquet is placed on the upper calf.
t p ss:
p / and posterior subtalar facets.
• All of the nonarticular surfaces are decorticated.
t
hht
PORTALS/EXPOSURES t
• Two incisions are made: medial and lateral.
t
hht t • An easy way to align the hindfoot is to place a
fingertip into the sinus tarsi. The calcaneus is then
pushed forward and distal, with careful attention
• The medial incision allows access to the talonavicular (TN) joint as well as to the not to rock the heel into varus or valgus. When
anterior and middle facets of the talocalcaneal (TC) joint (Fig. 44.4). properly aligned, the sinus tarsi is usually open
enough to allow a fingertip to be placed in it.
k e r
e ss k eers
rs
• The posterior tibial tendon can be elevated; this allows access to the medial joints
r (Fig. 44.5). However, because the posterior tibial tendon is often grossly pathologic,
• Correct not just the varus but also the internal
o o
o o k the tendon is resected.
o o
oo k oo
rotation of the calcaneus underneath the talus
when reducing the subtalar joint in the case of
eebb • The saphenous vein should be dorsal.
ee/ e
/ b
e b ee/e/eb
• The proximal portion of the medial utility incision is used. This allows extension dis-b a planovalgus foot.
t .m.m t. m
.
tally if an extended triple arthrodesis (which includes the midfoot) is needed.
: / / / t : / / / t m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
374 hht
Talonavicular
k e r
e s
rs k eers
r s
joint
Talus
o o
o o k Talonavicular
oooo k o o
Posterior
eebb bb b b
Navicular facet of
joint
ee/ e
/e ee/ e
/ e calcaneus
Navicular
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t
Talus
p ss
p : /
t
hht t t
hht tCalcaneus
Cuboid Calcaneocuboid Calcaneus

Cuboid Calcaneocuboid
k eers
A
rs joint
k er
erss B
joint
b ooook b ooook
Lateral approach - into sinus tarsi
b o o
eeb ee/ e
/ e b ee/ e
/ e b Lateral
: // t/.tm
Distal
. m : / /t/.tm. m
TN joint
Talus
t p ss
p : / tp pss : / Proximal
t
hht t t
hht t Navicular
Posterior
facet
keerrss keerrss
eeb C
ee/e/e b CC-joint
ee/e/e b
: / / t
/ m
.t.m
: / / t
/
FIG. 44.5 m
.t.m
t
hhtt t
hhtt
Talus Calcaneus
Talus
k e rrss
e
Navicular
k e rrss
e
Navicular
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
A Calcaneus B
FIG. 44.6
k e r
e s
rs k eers
rs
• The lateral incision allows access to the posterior facet of the TC joint, as well as the
o o
o o k o o
oo k
CC-joint, the lateral part of the TN joint, and the anterior and middle facets of the TC
oo
eebb ee/ e
/ b
e b joint (Fig. 44.6).
e /e/ebb
• The sinus tarsi should be débrided of all soft tissue and can be later packed with
e
: / / t
/ .
tm.m : / / t
/.tm
. m
graft material to further aid in fusion.
t p ss
p : / t p ss : /
• The sural nerve courses approximately along the peroneal tendons before branching
along the distal calcaneus. It is at risk with the lateral incision, especially if the Ollier
p
t
hht t t
hht t
incision is chosen.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b oo o k
o FIG. 44.7
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t Denuded
articular
surface Drill
holes
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t ppss : / Drill guide
A
t
hhtt t
hhtt B
Drill bit 2.5 mm
FIG. 44.8
k eerss
r k e rrss
e
o o
o k
PROCEDURE
o o o
o o k o o
eebb Step 1: Preparing the Joint Surfaces
ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Each joint surface is denuded of articular cartilage carefully so as to not damage or
t ss:
p /
deform the subchondral bony architecture (Fig. 44.7).
p t p ss:
p /
• The denuded surfaces are then carefully drilled with a series of small holes, extend-
t
hht t t
hht t
ing into the subchondral bone and thereby enhancing fusion (Fig. 44.8).
• The central area of each joint can be further prepared by making a cavity that is filled
with bone graft. This acts as a shear-strain relief graft that ultimately further aids in STEP 2 PITFALLS
fusion of the entire construct. • After fixation of the subtalar joint, check the
r s
rs
Step 2: Internal Fixation
k e e k eers
rs
AP ankle view by fluoroscopy to make sure
the screw is in the body and not in the lateral
o o
o k o o
oo k
• Align the TC joint. The hindfoot should be corrected to the desired alignment.
o oo
gutter, which is a common mistake.
• During fixation of the CC-joint, the drill should
eebb b b
• Once aligned, fixation across the subtalar joints is achieved by drilling from the heel
e / e
/ e b
into the talus, with one screw into the body and the other into the neck.
e ee/e/e b be aligned with the axis of the foot and under
the lateral malleolus. This allows the screw to
: / / t
/ .
tm.m : / / t
/.tm
• The body screw is placed from the lateral part of the inferior tuberosity into the cen-
. m go across the CC-joint into the cuboid. If the
angle of the drill is too high, it will miss the
tral body.
t p ss
p : / t p ss : /
• The neck screw starts more medial (as the neck is medial) and is aimed at the central
p
cuboid. For this reason and ease of insertion,
t
hht t
portion of the talar neck.
t
hht t staples are sometimes used at the CC-joint.
t t p
t ss:
p t t p
t ss:
p
376 hht
STEP 2 CONTROVERSIES • The subtalar joint should now be rigidly fixed in proper alignment.
k e r
e ss
• Screw technique for the TC joint (anterior to
r
posterior vs. posterior to anterior):
k eers
• Align the TC joint. The hindfoot should be corrected to the desired alignment.
r s
• Once aligned, fixation across the subtalar joints is achieved by drilling from the heel
o o
o o k
• Starting anteriorly from the dorsal talus into
oooo k into the talus, with one screw into the body and the other into the neck.
o o
eebb the calcaneus is one option, but this can
be a problem as it can damage the dorsal
ee/ e
/ebb tral body.
ee/ / b
e b
• The body screw is placed from the lateral part of the inferior tuberosity into the cen-
e
blood supply to the talus. Because the
: / / t
/ .
t
plantar blood supply is already damaged bym
. m : / / t
/ .
t m
. m
• The neck screw starts more medial (as the neck is medial) and is aimed at the central
t p ss
p : /
the fusion preparation, the talus could have
problems (avascular necrosis) as well as
t p ss : /
portion of the talar neck.
• The subtalar joint should now be rigidly fixed in proper alignment.
p
t
hht t
fusion problems in other joints. It can also be
performed posterior to anterior, starting from
the heel pad and ending in the distal tibia.
t
hht t
• The TN joint is then fixed. Two screws are placed in a lag fashion from the navicular
into the talus. If possible, crossed screws can also be used.
• The CC-joint is more of an expansion joint and is not as important for stability in the
• The advantage of the former technique
is better fixation due to longer threaded fusion. Sometimes, one screw will suffice. It can be placed from the distal calcaneus
process into the cuboid.
k eers
rs
screws, while the disadvantage is the risk
of ankle impingement from a screw too
k eerrss
Step 3: Bone Grafting
b ooook close to the talar head. The advantage

of the latter technique is avoiding
b oo ook b o o
• Allograft bone graft is placed into the remaining gaps of the subtalar joints.
eeb impingement by crossing the subtalar joint
into the distal tibia. The disadvantage is
ee/ e
/ e b ee/ e
/ e b
• It is common to find a gap at the CC-joint that will require bone grafting. This is in
//
these screws are going from a larger
: /.
using smaller threaded lag screws because
t tm
. m : / /t/ tm
essence performing a lateral column lengthening.
. . m
ss : /
fragment of the calcaneus to a smaller
t p p
tp pss : /
fragment of the talus.
t
hht
• Fixation (screws vs. staples): t
• Screws are easier to control in their
t
hht t
• The postoperative short-leg three-sided splint is removed at the first postoperative
visit (2 weeks). A controlled ankle movement boot is placed and used for 6 weeks.
trajectory and the amount of compression Patient is kept non–weight bearing. Radiographs are taken at this point.
placed. Staples cannot reliably provide • At 6–8 weeks, weight-bearing status is progressed in the controlled ankle movement
compression across the joints. Whichever boot using a cane.
keerrssmethod is chosen, two fixation points

across each joint are needed to prevent
keerrss
• Physical therapy is used only for gait training purposes and lower extremity rehabili-
b ooook rotation or sliding, which would lead to

nonunion at the fusion site.
b ooooktation.
oo
• Fig. 44.9 shows the 1-year postoperative appearance in the AP (Fig. 44.9A), lateral
b
(Fig. 44.9B), and oblique (Fig. 44.9C) views.
: / / t
/ m
.t.m : / / t m
.t.m
See also Video 44.1, Triple Arthrodesis.
/
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.
B
m : / / t
/.tm
. m C
t p ss
p : /
t p ss :
FIG. 44.9
p /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
EVIDENCE
r s
rs rs
r s
Astion D, Deland J, Otis J, Kenneally S. Motion of the hindfoot after simulated arthrodesis. J Bone Joint
k e e
Surg Am 1997;79:241–6.
k ee
o o
o o k o oo k
This study described a laboratory evaluation of 10 cadaveric foot specimens. The authors fused
o o o
eebb bb b b
different subtalar joints and determined by three-dimensional magnetic resonance imaging that
e / e
/e
joint limited the motion of the triple joint complex (Level IV evidence [case series]).
e ee/ e
/ e
Bone Joint Surg Am 1992;74:903–9.
: / / t
/ t m
. m : / / t
/ t m
Cracchiolo A, Cimino W, Lian G. Arthrodesis of the ankle in patients who have rheumatoid arthritis. J
. . . m
t p ss
p : / t p ss
p : /
This study was a retrospective review of cases of arthrodesis by internal fixation and external fixa-
tion. The authors determined the postoperative duration to fusion and the complication rates (Level
t
hht
IV evidence [case series]).
t t
hht t
Glanzmann MC, Sanhueza-Hernandez R. Arthroscopic subtalar arthrodesis for symptomatic osteoar-
thritis of the hindfoot: a prospective study of 41 cases. Foot Ankle Int 2007;28:2–7.
This is a prospective review of 41 patients, looking at the results of arthroscopic subtalar fusion.
Fusion rate, clinical outcomes, and complication rates were evaluated (Level III evidence [prospec-
k ee s
tive cohort study]).
rrs k er
erss
Graves SC, Mann RA, Graves KO. Triple arthrodesis in older adults: a long term follow-up. J Bone Joint
b ooookSurg Am 1993;75:355–62.
ooook
This study was a retrospective review of 17 patients. Follow-up averaged 3.5 years, and the
b b o o
eeb appearance (Level IV evidence [case series]).
ee/ e
/ e b ee/ e
/ e b
outcome was judged by patient pain scores, level of activity, footwear, and patient satisfaction with
// /.tm
. m / /t/.tm. m
Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and long-term out-
t
comes of total ankle arthroplasty and ankle arthrodesis. J Bone Joint Surg Am 2007;89:1899–905.
: :
ss : / ss : /
This study was a systematic review of 49 studies of ankle arthroplasty and 39 studies of ankle
t p p tp p
t t t t
arthrodesis. The authors determined the intermediate outcomes of both procedures based on the
hht hht
American Orthopaedic Foot and Ankle Society scale system and revision rates (Level III evidence
[retrospective cohort]).
Papa J, Myerson M, Girard P. Salvage, with arthrodesis, in intractable diabetic neuropathic arthropathy
of the foot and ankle. J Bone Joint Surg Am 1993;75:1056–66.
This study was a retrospective review of 29 patients with diabetic neuropathy. Follow-up averaged
keer ss
series]).
keerrss
almost 4 years, and the outcome was judged by physical examination (Level IV evidence [case
r
b ooook2000;82:47–57.
b ooook
Pell R, Myerson M, Schon L. Clinical outcome after primary triple arthrodesis. J Bone Joint Surg Am
b oo
eeb ee/e/e b ee/e/e
This study was a retrospective review of 160 patients. Follow-up averaged 5.7 years, and the
outcome was judged by patient satisfaction and physical examination (Level IV evidence [caseb
series]).
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss / t ppss : /
Saltzman C, Fehrle M, Cooper R, Spencer E, Ponseti I. Triple arthrodesis: twenty-five and forty-four year
:
average follow-up of the same patients. J Bone Joint Surg Am 1999;81:1391–402.
t
hhtt t
hhtt
This study was a retrospective review of 57 patients. Follow-up averaged 21 years, and the out-
come was judged by the Angus and Cowell assessment system (Level IV evidence [case series]).
Smith R, Shen W, DeWitt S, Reischl S. Triple arthrodesis in adults with non-paralytic disease: a mini-
mum ten-year follow-up study. J Bone Joint Surg Am 2004;86:2707–13.
This study was a retrospective review of 27 patients. Follow-up averaged 14 years, and the out-
come was judged by Short Form-36 scores, physical examination, and functional tests such as the
k rrss
e k rrss
6-minute walk and 3-m up-and-go test (Level IV evidence [case series]).
e e e
Stegeman M, Louwerens JWK, van der Woude JT, Jacobs WCH, van Ginneken BTJ. Outcome after
o o
o o k o o o k
operative fusion of the tarsal joints: a systematic review. J Foot Ankle Surg 2015;54:636–45.
o o o
eebb b b b b
Systematic review of 16 prospective studies involving arthrodesis of one or more hindfoot joints.
ee/ e
/ e ee/ e
/ e
The investigators looked at clinical outcome with regard to pain, function, and complications (Level
II evidence [meta-analysis]).
: / / t
/ m
.t.m : / / t m
.t.m
Wetmore R, Drennan J. Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J Bone
/
Joint Surg Am 1989;71:417–22.
t p ss:
p / t p ss:
p /
This study was a retrospective review of 16 patients with Charcot-Marie-Tooth disease treated with
t
hht t t
hht t
triple arthrodesis. Follow-up averaged 21 years, and the outcome was judged by the Patterson
clinical assessment system (Level IV evidence [case series]).
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh45
PROCEDURE
t hht
Single
rssMedial Approach for TriplersArthrodesis
s
k ke
oJuliane r k
oo e
ke r
b
eeboo o Röhm and Markus Knupp
e bboo e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t p
t t ss
p : INDICATIONS
t t p
t ss
p :
hht
• Any kind of infection of the foot is an absolute
contraindication for a hindfoot fusion.
• Posterior tibial tendon-dysfunction stage IV
hht
• Symptomatic adult rigid flatfoot deformity due to dysfunction of the posterior tibial
tendon (stage III according to the classification of Johnson and Storm), which is not
responding to conservative treatment
with tilt in the tibiotalar joint with/without
arthritic joint deformity comes with a higher • Tarsal coalitions
k eers
r
risk for failure and progressive deformity.
s k er
ers
• Inflammatory or posttraumatic arthritis of the hindfoot
s
b ooookINDICATIONS CONTROVERSIES
b ooook
EXAMINATION/IMAGING
b o o
eeb • Talonavicular and subtalar fusion is sufficient if
e /
the calcaneocuboid joint (CC-Joint) is not involved
e e
/ e b Clinical Examination
ee/ e
/ e b
// t
wound complications on the lateral side and
: / tm
in the degenerative progress. This is to prevent
. . m / /t/.tm
• Trophic status of the foot and skin condition including vascular status
. m
• Remaining flexibility in the hindfoot and midfoot
:
t p ss
p : /
minimize risk of degeneration of adjacent joints.
tp ss : /
• Muscular strength and/or shortening (particularly the Achilles tendon)
p
t
• Traditional triple arthrodesis is indicated in case
hht t
of CC-Joint degeneration and if treatment of the
sequelae of paralytic disease is necessary.
t
hht t
Plain Radiographs (Weight-Bearing)
• Cavovarus/varus feet are easier to correct through • Bilateral anteroposterior (Fig. 45.1A) and lateral (Fig. 45.1B) views of the foot, in ad-
the traditional lateral dual incision technique. dition to mortise view of the ankle (Fig. 45.2) and a Saltzman view
• Evaluation of the talocalcaneal, talometatarsal, and talonavicular angles
keer ss
TREATMENT OPTIONS
r
• Conservative treatment consists of orthotics and
keerrss
• Additional deformities of the midfoot and forefoot
b ooook footwear modifications, which can be used to

b ooook • Assessment of the degree of joint degeneration and bone density
oo
• Computed tomography (CT)-scan or magnetic resonance imaging is rarely needed
b
eeb relieve pain if surgical correction is not possible.
e
• In the case of involvement of the tibiotalar joint
e/e/e b of the talar body.
ee/e/e b
in decision making but might help in assessing avascular necrosis (AVN), particularly
/ t m
(valgus arthritis of the ankle joint), additional
.t.m
total ankle joint replacement or inclusion of the
: / / : / / t m
.t.m
• Weight-bearing CT scans may help in better understanding of complex hindfoot
/
t ppss : /
ankle into the fusion should be considered.
• No true surgical alternatives exist for treating a
t ppss : /
deformities.
t
hhtt
painful rigid adult flatfoot. t
hhtt
• Single-photon emission CT may help to assess the arthritic changes of the in-
volved joints.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
A
t p ss
p : / B
t p ss
p : /
378 t
hht t FIG. 45.1
t
hht t FIG. 45.2
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 45 Single Medial Approach for Triple Arthrodesis 379
SURGICAL ANATOMY
k e r
e ss
• The deltoid ligament consists of two main layers:
r k eers
r s
• The anterior superficial layer (Fig. 45.3A) consists of the tibionavicular, tibiospring,
o o
o o k o oo k
and tibiocalcaneal ligaments, and it extends from the anterior aspect of medial
o o o
eebb / e bb
malleolus toward the navicular bone, the spring ligament, and the sustentaculum
tali of the calcaneus.
ee /e ee/ e
/ b
e b
: / / t
/ . m
. m : / / t .
• The posterior deep layer (Fig. 45.3B) consists of three bundles, and it runs from
t / t m
. m
ss : / ss : /
the posterior colliculus of the medial malleolus posteriorly and distally to the talus.
t p p t p p
t
hht t
on the medioplantar aspect of the navicular bone. t
hht t
• The posterior tibial tendon runs behind the medial malleolus with the main insertion
• The anterior tibial tendon runs dorsally over the talonavicular joint to insert at the
POSITIONING PEARLS
• Draping to the knee joint is essential if an
additional Achilles tendon lengthening is
medial aspect of medial cuneiform bone (Fig. 45.4). planned or necessary.
POSITIONING
k eers
rs k er
erss
• Supine positioning with a pillow underneath the lower leg on the affected side is preferred.
b ooook
• A tourniquet is installed at the thigh.
b ooook b o o
• Using an Esmarch wrap to create a bloodless
foot is recommended for good intraoperative
eeb scopic control during surgery.
ee e
/ b
• A fluoroscan should be placed on the operating side to obtain easy and quick fluoro-
/ e ee/ e
/ e b visualization.
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
Tibionavicular
ligament
keerrss keerrss Tibiocalcaneal

ligament
: / / t
/ m
.t.m A
Tibiospring
ligament
: / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb ee/ e
/ b
e b
B ee/ e
/ b
e b
: / / t
/ m
.t.m
: / / t
/ m
.t.m
t p ss:
p / t
FIG. 45.3
p ss:
p /
t
hht t t
hht t
Anterior tibial
tendon
Posterior tibial
tendon
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
A
t p ss
p : / B
t p ss
p : /
t
hht t
t
hht t
FIG. 45.4
t t p
t ss:
p t t p
t ss:
p
380 hht
PROCEDURE 45 Single Medial Approach for Triple Arthrodesis hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 45.5
b oooo k
b o o FIG. 45.6
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t pp :
ss /
FIG. 45.7
t
hhtt t
hhtt
Portals/Exposures
• A longitudinal 4–6-cm skin incision is made starting at the navicular tubercle along
the superior border of the posterior tibial tendon, paying attention to not expand
k e rrss
e k e rrss
over the longitudinal axis of the tibia to preserve the integrity of the deep layer of the
e
deltoid ligament (Fig. 45.5).
o o
o o k
o o o k o
• The posterior tibial tendon sheath is opened, and the tendon is inspected; in the case
o o
eebb b b
• The deep tibiotalar layer of the deltoid ligament
/ e
is at risk if the incision is extended too posteriorly.
ee / e b ee/ e
/ e b
of any tendinitis, the tendon is excised.
• A partial superior release of the tendon at the level of its insertion on the navicular
: / / t
/ m
.t.m : / / t m
.t.m
bone provides better visualization of the deeper structures.
/
PORTALS/EXPOSURES
CONTROVERSIES
t p ss:
p / t p ss:
p /
• The talonavicular and subtalar joints are exposed by a horizontal cut above the pos-
t
hht t
• The risk for AVN or nonunion due to the single
PROCEDURE
medial approach is controversially discussed in
t
hht t
terior tibial tendon (Fig. 45.6).
the literature.
Step 1
k e r
e s
rs k eers
• Two 2.5-mm Kirschner wires (K-wires) are placed in the dorsomedial aspect of the
rs
navicular bone and in the talar neck.
o o
o o k o oo k
• The talonavicular joint is exposed by opening the spreader; dissection of the talo-
o oo
eebb ee/ e
/ b
e b e /e/ebb
navicular ligament may help to open the joint (Fig. 45.7).
• The talonavicular joint surfaces are denuded of their cartilage using a chisel and a
e
: / / t
/ .
tm.m curette (Fig. 45.8).
: / / t
/.tm
. m
t p ss
p : / t p ss : /
• The bony surfaces are feathered with a small chisel or drilled with a 2.5-mm drill
bit in order to break the subchondral plate and get good bleeding bone.
p
t
hht t t
hht t
• The spreader is removed, but the two K-wires are left in place.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 45.9
b oooo k
b o o FIG. 45.10
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt FIG. 45.11
t
hhtt FIG. 45.12
•
The sustentaculum tali is exposed by using a small Hohmann retractor, and a STEP 1 PEARLS
k e rrss
2.5-mm K-wire is put in place.
e k e rrss
e
• The spreader is put in place using the K-wires on the talar neck and sustentaculum
• Meticulous cartilage removal is essential for
bony fusion. Since the posterior surface of the
o o
o o ktali (Fig. 45.9).
o o
o o k o o
navicular bone is concave, it is necessary to
eebb ee e
/ b
e b
• The subtalar joint is exposed by opening the spreader; dissection of the interos-
/
seous ligament helps to open the joint (Fig. 45.10).
ee/ e
/ b
e b place the K-wire for the spreader distally to
prevent penetration of this surface. Special
: / / t
/ m
.t.m : / / t
/ m
.t.m
• After visualization, the anterior, middle, and posterior facets of the calcaneus and
attention should be paid in denuding the
lateral aspect of the talonavicular joint.
t p ss:
p
and a curette (Fig. 45.11). / t p ss:
p /
the corresponding surface of the talus are denuded of their cartilage using a chisel • Autologous bone grafts or osteoinductive bone
matrix substance can be used to fill gaps after
t
hht t t
hht t
• To break the subchondral sclerosis a 2.5-mm drill bit can be used in order to get
bleeding bone.
preparing the surface for fusion (Fig. 45.12).
STEP 1 PITFALLS
Step 2 • Constant attention should be paid to the deep
k e e s
rs
is necessary.
k eers
• Prior to fixation of the talonavicular and subtalar joints, sufficient reduction of the foot
r rs deltoid ligament in order not to damage it and
therefore risk progression of hindfoot valgus
o o
o o k oo k
• This can be achieved by the following step-by-step reduction:
o o oo
and failure of this procedure.
eebb • The ankle is held in a 90° neutral position.
ee/ e
/ b
e b e /e
• The heel is held manually in neutral or slight valgus position with the talus being
e /ebb STEP 1 INSTRUMENTATION/
: / / / .
reduced on top of the calcaneus.
t tm.m : / / t
/.tm
. m
IMPLANTATION
t p ss
p : /
• The talonavicular joint is reduced to address the abduction deformity.
t p ss : /
• Guiding K-wires are used, first to transfix the talonavicular joint (Fig. 45.13A–C) and
p
• Using a special joint-spreader for K-wires is
recommended to get good exposure of the
t
hht t
then the subtalar joint (Fig. 45.13D). t
hht t talonavicular and subtalar joint.
t t p
t ss:
p t t p
t ss:
p
382 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b ooook B
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
C
t
hhtt t
hhtt
k e rrss
e k e rrss
e
D
o o
o o k o o
o o k FIG. 45.13
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• Fluoroscopy is used for control (Fig. 45.14).
• Two to three talonavicular screws are used, spread from medial to lateral on the na-
t
hht t
• The CC-joint is not fused in modified triple
arthrodesis. If in any case it still needs to be
fused, it can be reached and denuded through
t
hht t
vicular side and converging toward each other on the talar side (Fig. 45.15A).
• The subtalar joint is also fixed with one or two screws.
the talonavicular joint. • One screw runs from the tuber calcanei through the posterior facet into the talar
body (Fig. 45.15B).
k e r
e s
rs
STEP 2 PEARLS
k e rs
• An optional second screw is placed from the plantar lateral side of the calcaneus
rs
(approximately 1 cm proximal to the calcaneocuboid joint) toward the talar head
e
o o
o o k
• The K-wires initially used for spreading the
talonavicular and subtalar joint can be used
o o
oo k
dorsomedially.
oo
eebb b b
• Finally, fluoroscopic control of the correct reduction and proper positioning of the
as “joysticks” to make proper reduction of the
bones easier.
ee/ e
/ e b e /e/
screws is mandatory (Fig. 45.16).
e e b
/ / t
reduction in the frontal plane in order to
: / .
tm
• Special attention should be paid to a sufficient
.m : / / t
/.tm
• In case of persisting Achilles tendon shortening, an additional percutaneous Achilles
. m
tendon lengthening (“triple hemisection”) or a mini-open gastrocnemius slide proce-
t p ss
p : /
correct a supination forefoot deformity.
t p ss : /
dure can be performed, depending on the shortening of the soleus.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
A B
k eers
rs k er
FIG. 45.14
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
A B
FIG. 45.15
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k o o
o o k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / /
B
t
/ .
tm.m C
: / / t
/.tm
. m
t p ss
p : /
FIG. 45.16
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
384 hht
STEP 2 INSTRUMENTATION/ Step 3
k e e s
IMPLANTATION
r rs
• A minimum thickness of 6.5 mm is needed for
k eers
r s
• Closure of the longitudinal incision of the capsule and ligaments from the navicular
bone to the medial malleolus is performed with 2-0 absorbable sutures.
o o
o o kscrews used for subtalar fixation. The smaller
o oo k o
• Interrupted nonabsorbable 3-0 sutures are used for skin closure.
o o
eebb b b
screws should be cannulated 4.0 mm or more,
depending on bone sizes.
ee
• Other fixation methods, like staples, are possible/ e
/e b ee e
/ b
• The use of a drain is usually not necessary.
/ e
• A thick compressive dressing is applied, and the foot is placed in a reusable prefab-
t . m
.
as long as the basic principles are respected.
: / / / t m ricated splint.
: / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t
• AVN of the talar body is a rare complication of
modified triple arthrodesis. Placing the screws
Additional Steps t
hht t
• If sufficient reduction of the subtalar joint with remaining valgus deformity of the
posterolaterally might increase this risk. hindfoot is impossible, a medial displacement osteotomy of the calcaneus can easily
be performed through an additional lateral approach. An additional screw may be
k eers
STEP 3 PEARLS
rs
• Special attention should be paid to careful
k er
ers
used to secure the osteotomy.
s
b ooook closure of the capsular and ligamentous
b ooook b o o
eeb structures to avoid postoperative swelling and
therefore wound complications.
ee/ e
/ e b e / e b
• On the second postoperative day, the compressive dressings and prefabricated
/ e
splint are replaced by a removable (synthetic) cast. This allows the use of an inflat-
e
PITFALLS
: // t/.tm
. m : / /t/.tm. m
able foot pump in case of substantial postoperative swelling.
t p ss : /
• If an additional medial displacement osteotomy
p tp ss : /
• After subsidence of the swelling (mostly between days 6 and 14 postoperative), a
below-the-knee walking cast is applied and left in place through the eighth postop-
p
t
hht t
is performed, injury of the sural nerve should
be avoided when performing a lateral incision.
t
hht t
erative week.
• Removal of the stitches should not be done before the 14th postoperative day; if the
walking cast is applied earlier, the stitches may be left in place upon removal of the
POSTOPERATIVE PEARLS cast.
• Once the walking cast is applied properly, weight bearing is allowed as tolerated;
kee rs
• Wearing compression stockings and
r s
accompanying physiotherapy for strengthening
keerrss
usually full weight bearing is achieved after 10–14 days postoperatively.
b ooook of the lower leg and stretching the Achilles

tendon are strongly recommended.
b ooook
• At 8 weeks, the cast is removed and standard radiographs are taken. If bony fusion is
b oo
considered not to be sufficient, a removable walking cast is applied for another 4–6
weeks. If the fusion is considered to be sufficient, the patient is allowed free ambula-
: / / t
/ m
.t.m
• Possible complications include nonunion of the
: / / t
/ m
tion in custom-made shoes.
.t.m
• At 4 months postoperative, final clinical and radiographic evaluation is carried out.
ss : /
fused joints and progression of planovalgus
t pp ss : /
• Hardware removal, which is rarely necessary, is considered not earlier than 6 months
t pp
t
hhtt
deformity (loss of correction). In very rare
cases overcorrection of deformity and AVN of
the talar dome as well as wound problems and
t
hhtt
after the initial triple arthrodesis surgery.
• A lasting pain-free and plantigrade foot is the final result in the majority of cases.
infection can occur.
• Subsequently, arthrodesis of adjacent joints EVIDENCE
can occur. De Wachter J, Knupp M, Hintermann B. Double-hindfoot arthrodesis through a single medial approach.
k e rrss
e k rrss
Tech Foot Ankle Surg 2007;Vol. 6(Issue 4):237–42.
e e
This article describes the technique that is used in this chapter. Details on indications, preopera-
o o
o o k
o o o k o
tive planning, technique, complications, and postoperative management are provided (Level V
o o
eebb b b
• The recent literature on modified triple
arthrodesis procedures supports our
experience that fusing the CC-joint is not
ee/ e
/ e b
evidence [expert opinion]).
ee/ e
/ e b
Hyer CF, Galli MM, Scott RT, Bussewitz B, Berlet GC. Ankle valgus after hindfoot arthrodesis: a
routinely necessary.
: / / t
/ m
.t.m 2014;53-1:55–8.
: / / t
/ m
radiographic and chart comparison of the medial double and triple arthrodeses. J Foot Ankle Surg
.t.m
t p ss:
p / t p ss: /
This retrospective study compares the frequency and severity of ankle valgus after the medial
double arthrodesis is compared with the triple arthrodesis. Seventy-seven patients (78 feet) were
p
t
hht t t
hht t
included. Mean age was 61.3 years old. Mean follow-up 15.7 months. A significant difference in
postoperative ankle valgus has been noticed with 3.64 higher odds for the triple arthrodesis group
(Level III evidence).
Knupp M, Schuh R, Stufkens SA, Bolliger L, Hintermann B. Subtalar and talonavicular arthrodesis
through a single medial approach for the correction of severe planovalgus deformity. J Bone Joint
k e r
e s
rs k eers
Surg Br 2009;91-5:612–5.
rs
In this retrospective study, 32 feet in 30 patients underwent hindfoot correction through a single
o o
o o k o oo k
medial approach. The main follow-up was 21 months. Significant improvement was observed in
o
all angular measurements. Nonunion and wound healing problems did not occur in this collective
o o
eebb ee/ e
/ b
e b e /e/ebb
during the follow-up (Level IV evidence).
Röhm J, Zwicky L, Horn Lang T, Salentiny Y, Hintermann B, Knupp M. Mid- to long-term outcome
e
: / / t
/ .
tm.m B-5:668–74.
: / / t
/.tm
of 96 corrective hindfoot fusions in 84 patients with rigid flatfoot deformity. Bone Joint J 2015;97-
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
This study presented the radiologic and clinical mid- to long-term outcome of 96 double
hindfoot fusions with single medial approach. The mean age of the patients was 66 years, and
k e r
e s
rs k eers
r s
the mean follow-up was 4.7 years. The American Orthopedic Foot and Ankle Score (AOFAS)
o o
o o k o oo k
hindfoot score and the Foot and Ankle Outcome Score have been evaluated and showed good
clinical outcomes. Nonunion and secondary loss of correction were the most common complica-
o o o
eebb e e
/ebb
tions (11.5 % and 12 %). AVN of the talus is a rare complication (Level IV evidence).
/ e / e
/ b
e b
Sammarco V, Magur E, Sammarco G, Bagwe MR. Arthrodesis of the subtalar and talonavicular joints for
e e
: / / t t m
correction of symptomatic hindfoot malalignment. Foot Ankle Int 2006;27:661–6.
. . m : / / t .
t m
. m
Sixteen double arthrodeses (subtalar and talonavicular joint) in 14 patients (indication: painful
/ /
ss : / ss : /
hindfoot deformity without calcaneocuboid joint involvement) were retrospectively reviewed with a
t p p t p p
t
hht t
minimum follow-up of 18 months. A combined lateral and medial incision was used. AOFAS ankle–
t hht t
hindfoot scores improved from 44.7 to 77 points. Radiographically, secondary arthritic changes
occurred in some of the adjacent joints (Level IV evidence).
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh46
PROCEDURE
t hht
The Valgus
r ss Malaligned Triple WithrsSubtalar
s and
o k ee r
Transverse
k Tarsal Deformity o kkee r
b o
m ee /e m ee / e
Michael P. Clare
: / t
///t. . m : / /
/ t
/ .
t . m
s :
tps INDICATIONS ss :
INDICATIONS PITFALLS hhtttp t
hhtt p
t p
• Skin breakdown or ulceration in the medial arch • Residual lateral subfibular impingement, medial ankle, or medial arch pain
• Diabetic or nondiabetic peripheral neuropathy • Radiographic valgus tilt of the talus in the ankle mortise
• Peripheral vascular disease
k rs
rs
• Other medical comorbidities precluding
ee surgery
k er
ers
• Secondary lateral knee pain, gait changes, or imbalance related to foot deformity
s
• Symptoms interfering with normal daily activity
b ooook b ooook
EXAMINATION/IMAGING
b o o
ee/ e
/ e b e / e
/ e b
• Standing examination of the foot and ankle reveals an asymmetric severe flatfoot deformity.
e
t .
• The most common cause of failure of a triple
: // / tm
. m : / /t/.tm. m
• The skin and soft tissue envelope are assessed for previous incisions, presence or
p ss : /
arthrodesis is undercorrection of deformity. The
most common residual deformity is residual
t p tp ss : /
absence of peripheral pulses, and overall condition.
• Manual examination of the hindfoot demonstrates a fixed, rigid flatfoot, with tender-
p
t
hht t
(subtalar/hindfoot) valgus with (transverse
tarsal) supination.
• Medializing calcaneal osteotomy and
t
hht t
ness to palpation in the lateral subfibular region and medial ankle, as well as bony
prominence and tenderness in the medial arch area. In severe cases, there may also
transverse tarsal derotational osteotomy be tenderness along the lateral joint line of the ankle.
may provide some deformity correction and • The foot is externally rotated relative to the lower leg. The tibial-foot axis (tibial tubercle to
is technically easier to perform. However, it forefoot line) falls medial to the first ray, rather than aligning with the second ray (Fig. 46.1).
keerrss
does not have near the corrective power of
arthrodesis takedown and revision fusion.
ke rrss
• The Achilles and the peroneus brevis were previously deforming forces when the de-
e
b ooook
• Concomitant arthritic change in the ankle:
b ooookformity was flexible, and are now chronically contracted because of the fixed deformity.
b oo
eeb if mild to moderate and the ankle joint is
salvageable, correction of the hindfoot
ee/e/e b ee/e/e b
deformity may ultimately preserve the ankle
/ t m
.t.m
joint long term; if severe and the ankle joint
: / / : / / t
/ m
.t.m
t pps : /
is not salvageable, correction of the hindfoot
s
deformity should still be performed but may
t ppss : /
t
hhtt
need to be combined with ankle arthroplasty in
a staged fashion. Extension of the arthrodesis
t
hhtt
to include the ankle (pantalar arthrodesis) may
provide pain relief but would significantly limit
function.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / A
t p ss
p : / B
386 t
hht t t
hht t FIG. 46.1
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 46 The Valgus Malaligned Triple With Subtalar and Transverse Tarsal Deformity 387
• The medial column should be assessed for hypermobility/instability.
k e e s
rs k eers
• Weight-bearing radiographs of the ankle and foot show residual implants in place. There
r r s
is residual, excessive valgus through the subtalar arthrodesis, with residual midfoot ab-
o o
o o k oo k
duction and residual plantar flexion sag through the talonavicular arthrodesis, with or
oo o o
eebb e /ebb e
talus in the ankle mortise, with or without associated arthritic change (Fig. 46.2).
e e/ / b
without further sag in the medial column of the foot. There may also be valgus tilt of the
/ e e e b
: / / / .
t m m
• A computed tomography scan is invaluable in assessing arthrodesis healing and
t . : / / t
/ .
t m
. m
t p ss
p : / t p ss : /
the extent to which the bony architecture of the hindfoot joints have been re-
modeled. The scan also provides additional information as to the extent of the
p
deformity.
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb A
ee/ e
/ b
e b B
ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / C
t p ss
p : /
t
hht t t
hht t
FIG. 46.2
t t p
t ss:
p t t p
t ss:
p
388 hht hht
PROCEDURE 46 The Valgus Malaligned Triple With Subtalar and Transverse Tarsal Deformity
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb D
ee/e/e b E
ee/e/e b
: / / t
/ m
.t.m FIG. 46.2, cont’d
: / / t
/ m
.t.m
t ppss : / SURGICAL ANATOMY
t ppss : /
t
hhtt t
hhtt
• Bones and tendons of the hindfoot
• Nerve supply to the hindfoot
POSITIONING
k e rrss
e k rrss
• The patient is placed in the supine position, with a bump under the ipsilateral hip to
e e
internally rotate the leg, such that the anterior knee is perfectly perpendicular to the
o o
o o k o o o k o
floor, which facilitates access to the medial and lateral aspects of the hindfoot.
o o
eebb ee e
/ b
e b ee/ e
/ b
e b
• A thigh tourniquet is essential to create a dry surgical field.
/
• The procedure is typically performed under general anesthesia with a supplemental
: / / t
/ m
.t.m : / / t
/ m
.t.m
regional block (femoral–sciatic or popliteal) to optimize postoperative pain control.
t p ss:
p / Soft Tissue Balancing
t p ss:
p /
t
hht t t
hht t
• The Achilles is lengthened, either by isolated gastrocnemius recession (Baumann
procedure), gastrocnemius and soleus recession (Strayer procedure), or percutane-
ous triple hemi-cut lengthening.
• The peroneus brevis is fractionally lengthened at the musculotendinous junction.
k e r
e s
rs k eers
• Balancing the deforming forces facilitates deformity correction and prevents recur-
rs
rence or progression of the deformity.
o o
o o k o o
oo k
Portals/Exposures oo
eebb e / e
/ b
e b e /e/ebb
• Depending on the location of previous incisions and the overall condition of the soft
e e
: / / t
/ .
tm.m : / / t
/.tm
. m
tissue envelope, the previous incisions may be reutilized medially and laterally. If the
t p ss
p : / t p ss : /
soft tissue envelope allows, a modified Ollier approach is preferred laterally.
• A lazy S-shaped incision is made along the skin folds, centered over the sinus tar-
p
t
hht t t
hht t
si, and continued to the extensor retinaculum, which is also incised. The peroneal
t t p
t ss:
p t t p
t ss:
p
hht hht
tendons are protected at the posterior aspect of the incision, and the extensor digi-
k e r
e s
rs k eers
torum longus and peroneus tertius tendons are protected at the anterior aspect of
r s
the incision. The extensor digitorum brevis muscle is reflected distally at the anterior
o o
o o k oo k
process of the calcaneus, thereby exposing the joint capsules of the subtalar and
oo o o
eebb e /ebb
calcaneocuboid joints, which are additionally incised.
/ e
• Subperiosteal dissection continues dorsally at the calcaneocuboid joint to expose
e ee/ e
/ b
e b
: / / / .
t m m : / / / .
t m
and release the so-called quadruple point, which represents the confluence of the
t . t . m
t p ss
p : / t p ss : /
talus, calcaneus, navicular, and cuboid (white arrow; Fig. 46.3). Further dissection
continues dorsally to expose the lateral aspect of the talonavicular joint, and plan-
p
t
hht t
tarly underlying the calcaneocuboid joint.
t
hht t
• A linear incision is made medially (through the previous incision) centered over the
navicular tuberosity and between the anterior tibial and posterior tibial tendons, and
continued to the extensor retinaculum, which is then incised in line with the incision.
The talonavicular joint capsule is incised and elevated in subperiosteal fashion dor-
k eers
rs k er
erss
sally and plantarly, thus creating full-thickness flaps, and facilitating protection of the
b ooook b ooook
tendinous and neurovascular structures during the arthrodesis takedown.
• All previous implants are removed under fluoroscopic assistance.
b o o
eeb PROCEDURE ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
Step 1: Arthrodesis Takedown
t p ss
p : / tp pss : /
t t t t
• The talonavicular arthrodesis is taken down first through the medial approach, using
hht hht
a curved osteotome and under fluoroscopic assistance, whereby the curvature of the
talar head is followed. As with nonunions and malunions of fractures, the advance-
ment of the osteotome is gentle and largely finesse, allowing the osteotome to find
its path, and can be confirmed with fluoroscopy (Fig. 46.4).
keer ss
following a similar finesse approach (Fig. 46.5).
keerrss
• The calcaneocuboid arthrodesis is next addressed, using a straight osteotome and
r
b ooook o ook
• The subtalar arthrodesis is taken down last, using a straight osteotome. For long-
b o b oo
eeb ee e/e b
standing fusions, a supplemental posteromedial approach may be used to facili-
/ ee/e
tate protective retractors for the neurovascular bundle. It is preferred to start at
/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
the crucial angle of Gissane, recreating the natural “V” shape and working slightly
plantarward distally into the middle and anterior facets of the subtalar joint. The
t t
osteotome is then brought slightly dorsalward proximally into the posterior facet.
hhtt hhtt
The path of the osteotome can be assessed fluoroscopically by obtaining Broden
views, in which the leg is internally rotated and the beam is angled 10–40° cephalad FIG. 46.3 CA, Calcaneus; CU, cuboid bone, N,
off the vertical (Fig. 46.6). navicular bone; T, talus.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
p
t ss
p : / t p ss
p : /
t
hht t
FIG. 46.4 t
hht t FIG. 46.5 FIG. 46.6
t t p
t ss:
p t t p
t ss:
p
390 hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook
A B
b ooook b oo C

ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Once completed, the three joints are assessed for any remaining soft tissue or bone
s
adhesions; the hindfoot should be easily mobile and flexible.
t
hhtt t
hhtt
• Unless the arthrodesis is not definitively healed, it should not be necessary to further
prepare the joints for arthrodesis or add supplemental bone graft or bone graft sub-
stitute, as the broad surfaces of the hindfoot should provide ample surface area for
healing.
k e rrss
e k e rrss
Step 2: Subtalar Joint Reduction and Fixation
e
o o
o o k o o k
• In the event of subtle valgus tilt of the talus, the talus should be temporarily pinned in a
o o o o
eebb e / e
/ b
e b e / e
/ b
e b
neutral, symmetric position prior to reduction of the hindfoot deformity (Fig. 46.7A–B).
• Two parallel terminally-threaded guide pins are then placed in the calcaneal tuberos-
e e
: / / t
/ m
.t.m : / / t
/ m
.t.m
ity and advanced in diverging fashion, with the lateral guide pin angled more posteri-
t p ss:
p / t p ss: /
orly and the medial guide pin angled more anteriorly. The guide pins are advanced to
the subchondral plate of the calcaneus, and provisional placement is confirmed on
p
t
hht t t
hht t
the lateral, axial, and mortise fluoroscopic views.
• With the subtalar joint held in neutral position, the guide pins are advanced into the
talus, stopping shy of the far cortex. Definitive placement is again confirmed in the
lateral, axial, and mortise fluoroscopic views. In the lateral view, with the calcaneus
positioned more “beneath” the talus, the talar head should now protrude slightly dor-
k e r
e s
rs k eers
rs
sally relative to the navicular (Fig. 46.8). The lateral guide pin should be assessed in
o o
o o k o o
oo k
the mortise view to ensure sufficient bone remains so as to not violate the talofibular
oo
eebb b b
articulation of the ankle joint.
ee/ e
/ e b ee/e/e b
• Once confirmed, two large cannulated screws are placed; in this instance, the medial
: / / t
/ .
tm.m : / / t
/ tm
screw is placed first to limit settling back into valgus.
. . m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t FIG. 46.8
t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss : /
Step 3: Talonavicular Joint Reduction and Fixation
p t ppss : /
t
hhtt t
hhtt
• Next, the navicular is adducted and derotated relative to the talar head, restoring
rotational alignment of the leg relative to the foot and restoring the weight-bearing
function of the first ray and medial column. One or two 2.0-mm Kirschner wires are
placed across the talonavicular joint as provisional fixation.
k rrss
e rrss
• Provisional alignment is confirmed in the lateral and anteroposterior fluoroscopic
e e e
views. In the lateral view, the talo-first metatarsal angle should be neutral, such that
k
o o
o o k o o k
the weight-bearing first ray and medial column are restored (Fig. 46.9). In the anter-
o o o o
eebb e / b
e b
oposterior view, the navicular should symmetrically cover the talar head, and the
/ e
talo-first metatarsal angle should also be neutral.
e ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Clinically, the tibial-forefoot axis (tibial tubercle to forefoot line) should align with the
t p ss: /
second ray, and the medial arch should be restored.
t p ss: /
• Two parallel 4.0-mm cortical lag screws are placed in retrograde fashion across the
p p
t
hht t t
hht t
talonavicular joint. A third 4.0-mm screw is placed dorsally and laterally, and angled
plantarly and slightly medially, providing additional fixation at the lateral portion of
the joint.
Step 4: Calcaneocuboid Joint Fixation
k e r
e s
rs k eers
rs
• With the subtalar and talonavicular joints reduced and stabilized, no further reduc-
o o
o o k o o
oo k
tion should be necessary. Two additional 4.0-mm screws are placed from the anterior
oo
eebb b b
process of the calcaneus into the cuboid. Alternatively, a large cannulated screw may
ee/ e
/ e b /
be placed along the longitudinal axis of the calcaneus from posterior to anterior, and
ee e/e b
in line with the fourth ray.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
392 hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
A B
k e rrss
e k eerrss
FIG. 46.9
o o
o o k o ooo k o o
eebb ee/ e
/ b
POSTOPERATIVE
e b CARE/EXPECTED OUTCOMES
ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
• The wounds are closed in a routine layered fashion, and a bulky cotton dressing and
.t.m
protective splint is applied. The splint is then converted to a short leg cast at 2 weeks
t p ss:
p / t p ss:
p /
following surgery, at which point sutures are generally removed. The patient is kept
t
hht t t
hht t
strictly non–weight bearing to the involved limb for 10 weeks following surgery.
• Standing radiographs of the involved ankle and foot are obtained at 10 weeks fol-
lowing surgery, which should reveal sufficient bony healing to initiate weight bearing.
The patient is converted to a removable walking boot, and weight bearing is ad-
vanced. Once able to fully weight bear without pain, the patient may wean from the
k e r
e s
rs k eers
rs
boot to a regular shoe with soft, supportive arch support as tolerated.
o o
o o k o o
oo k
• Serial standing radiographs of the involved ankle and foot are obtained for a mini-
oo
mum of 6 months following surgery, to ensure maintenance of alignment of the hind-
eebb ee/ e
/ b
e b ee/e ebb
foot, as well as a stable symmetric ankle mortise (Fig. 46.10). In the event of previous
/
valgus tilt of the talus, a lace-up style ankle brace may be used for extended standing
: / / t
/ .
tm.m and walking activities.
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
A B
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k C
o o
o o k oo
eebb ee/ e
/ b
e b FIG. 46.10
ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
394 hht
PROCEDURE 46 The Valgus Malaligned Triple With Subtalar and Transverse Tarsal Deformity hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
D
: / / t
/ m
.t.m E
: / / t
/ m
.t.m
FIG. 46.10, cont’d
t
hhtt t
hhtt
EVIDENCE
Haddad SL, Myerson MS, Pell RF. 4th, Schon LC: Clinical and radiographic outcome of revision surgery
rrss rrss
for failed triple arthrodesis. Foot Ankle Int 1997 Aug;18(8):489–99.
o k e
k e o k e
Case series of patients who underwent revision surgical correction for failed triple arthrodesis using
k e
calcaneal and transverse tarsal osteotomies, with or without tricortical bone wedges.
o
eebb o o o o o o o
Mäenpää H, Lehto MU, Belt EA. What went wrong in triple arthrodesis? An analysis of failures in 21
e b b e b b
m ee/ / e m ee/
patients. Clin Orthop Relat Res 2001 Oct;(391):218–23.
/ e
Case series of rheumatoid arthritis patients with failed triple arthrodesis who underwent revision
: / /
/ t
/ .t.m surgical correction.
: / /
/ t
/ .t.m
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
e r s
rs SECTION
r s
r s PART IV
III
o o
o
k
o k e okkee
oo o o o
eebb ee/ e
/ebb ee/ e
/ b
e b
/ / t .
t m
. m / / t .
t m
. m
ss: : / / sAnkle
: : / /
t
hhtt p
t p hht s
t t p
t p
k eers
rs PROCEDURE 47
k errss
Ankle Arthroscopy From a Posterior Approach 397
e
b ooook
O
b o
steochondral Lesion of the Ankle: OATS
o
eeb ee/ e
/ e b Procedure 404
ee/ e
/ e b
: // t/.tm
. m
PROCEDURE 49
: / /t/.tm. m
ascularized Bone Graft for Extended
V
t p ss
p : / ss : /
Osteochondral Lesion of Talus 411
tp p
t
hht t PROCEDURE 50 t
hht t
Anterior Ankle Impingement 419
PROCEDURE 51 ealignment Surgery for Valgus Ankle
R
Osteoarthritis 425
keerrss PROCEDURE 52
rrss
Osteotomies for the Correction of Varus Ankle 433
kee
b ooook
Arthroscopic Ankle Arthrodesis 442
b oo
eeb e /e/e
PROCEDURE 54
e b e /e/e b
igid Fixation for Ankle Arthrodesis Using Double
R
e
: / / t
/ m
.t.m Plating 451
: / / t
/ m
.t.m
t ppss : /PROCEDURE 55
ss : /
nkle Arthrodesis Using Ring/Multiplanar External
A
t pp
t
hhtt t
hhtt
Fixation 458
PROCEDURE 56 ibiotalocalcaneal Arthrodesis With a Retrograde
T
Intramedullary Nail 469
k e rrss
e
PROCEDURE 57 T
k e rrss
otal Ankle Arthroplasty With a Current Three-
e
Component Design (HINTEGRA Prosthesis) 483
o o
o o k o o
o o k o o
eebb PROCEDURE 58
ee/ e
/ b
e b e
Approach (Zimmer Prosthesis) 499
e/ / b
e b
otal Ankle Arthroplasty Through a Lateral
T
e
: / / t
/ m
.t.m
PROCEDURE 59
/ / t
/ m
.t.m
Salvage of Failed Total Ankle Arthroplasty 510
:
t p ss:
p / t p ss:
p /
t
hht t PROCEDURE 60 A
t
hht t
nkle Arthrodesis for Salvage of the Failed Total
Ankle Arthroplasty 523
PROCEDURE 61 alvage of Ankle Large Bony Defect With Spinal
S
Cage 535
k e r
e s
rs PROCEDURE 62
k e rs
rs
Charcot Ankle Fractures 542
e
o o
o o k PROCEDURE 63
o o
oo k
ercutaneous Lateral Ligament
P
oo
eebb ee/ e
/ b
e b Reconstruction 548
ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t 395
t t p
t ss:
p t t p
t ss:
p
396 hht
SECTION IV Ankle hht
k e r
e s
rs PROCEDURE 64
eers
odified Brostrom Procedure for Lateral Ankle
M
r s
Laxity, With and Without an Internal Brace 555
k
o o
o o k oooo k o o
eebb b b
PROCEDURE 65 L ateral Ankle Ligament Reconstruction Using
ee/ e
/e b Plantaris Autograft 564
ee/ e
/ e b
: / / t .
t m
. m
PROCEDURE 66
/ : / / t
/ .
t m
. m
Salvage of a Failed Lateral Ligament Repair 574
t p ss
p : / t p ss
p : /
eroneal Tendon Tears: Débridement and
P
t
hht t PROCEDURE 67
Repair 581 t
hht t
PROCEDURE 68 Peroneal Tendinopathy With Allograft 587
PROCEDURE 69 hronic Peroneal Tendon Subluxation-
C
k eers
rs k er
erss
Dislocation 593
b ooook b o
L igament Reconstruction for Chronic Medial Ankle
o
eeb ee/ e
/ e b Instability 599
ee/ e
/ e b
: // t . m
. m
PROCEDURE 71
/ t : / /t/.tm. m
alcaneoplasty for Insertional Tendinopathy of
C
t p ss
p : / ss
Achilles Tendon 611
tp p : /
t
hht t PROCEDURE 72 A
Nail 619
t
hht t
rthroscopic Fracture Reduction With Fibular
PROCEDURE 73 Malunion of Fibula Fracture 626
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh47
PROCEDURE
t hht
Ankle
rssArthroscopy From a Posterior
rss Approach
kkee r
ooAlastair Younger k
oo e
ke r
b
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht
• Isolated posterior ankle pathology such as flexor hallucis longus (FHL) tendonitis,
posterior impingement from a Stieda process, an os trigonum, or soft tissue
hht
• Anterior ankle pathology that requires
treatment at the same time
• Posterior osteochondral defects • Open procedures not easily performed in
the prone position such as lateral ligament
• Ankle fusion, or combined ankle and subtalar fusion
k eers
rs k er
erss
• Typically posterior ankle arthroscopy is performed in the prone position, although a
reconstruction
b ooook position using a leg holder

b ooook
full lateral position can be used on occasion, or two posterior portals in the supine
b o o INDICATIONS CONTROVERSIES

/ e b ee/ e
/ e b • A clear distinction between an osteochondral
: // t/.tm
. m : / /t/.tm. m
• A typical patient history will reveal complaints of posterior ankle pain on activity.
lesion that can be approached from the
anterior as opposed to the posterior side
ss : / ss : /
Clinical examination will usually reveal posterior ankle tenderness, possible loss of
t p p tp p
cannot easily be made and depends on
surgeon comfort with both approaches.
t
hht t t
hht t
plantar flexion range, or pain on resisted flexion of the FHL tendon. Fig. 47.1 shows
the prominent Stieda process in a ballet dancer and the typical location of the pain.
• Sometimes anterior ankle pathology can be
reached in the prone position with the leg
• Magnetic resonance imaging (MRI) will often demonstrate fluid in the FHL sheath, flexed up.
edema in the posterior talus, a bony prominence, or soft tissue impingement. Fig.
47.2 shows the MRI of the same patient as seen in Fig. 47.1.
keer ss 47.3).
keerrss
• A computed tomography scan is a good way to assess the bone pathology (Fig.
r
TREATMENT OPTIONS
• Activity modification and changes in training
b ooook o ook oo
• On occasion for dancers, a lateral x-ray in the pointe position will allow assessment
b o b
regimen. Many patients with posterior ankle
eeb b b impingement are athletes or dancers.
ee/e
of the posterior ankle bony impingement.
/e ee/e/e • Nonsteroidal antiinflammatory drugs and
SURGICAL ANATOMY
: / / t
/ m
.t.m : / / t
/ m
.t.m
physiotherapy can allow resolution of
symptoms.
• The annotated MRI shows the structures in the posterior ankle and how they relate. • Steroid injection into the posterior ankle
structures (not the tendons or tendon sheaths)
t
hhtt
(Fig. 47.4). t
hhtt
The neurovascular bundle must be avoided by staying lateral to the FHL tendon
to reduce inflammation.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
t.m m t. m m
ss: / / / t .
FIG. 47.1
: /

:
ss /
: /
/ / t. FIG. 47.2
t
hhtt p
t p t
hhtt p
t p 397
t t p
t ss:
p t t p
t ss:
p
398 hht
PROCEDURE 47 Ankle Arthroscopy From a Posterior Approach hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
FIG. 47.4 FDL, Flexor digitorum longus; FHL, flexor hallucis longus.
eeb FIG. 47.3
ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
eerrss
POSITIONING PEARLS
k keerrss FIG. 47.5
b ooook
• Place a thigh tourniquet rather than a calf
b ooook b oo
eeb tourniquet as the tightening of the muscles will
prevent the ankle joint from being visualized.
ee/e/e b ee/e/e b
• Place the patient to the bottom of the bed
: / / t m
.t.m
so that the foot can be held into dorsiflexion
/ : / / t
/ m
.t.m
t pps : /
by the assistant to improve access. The leg
s
can also be lifted to the side of the bed and
t ppss : /
t
hhtt
the foot held into dorsiflexion to complete the
exposure.
t
hhtt
k rrss
• Failing to ensure appropriate padding
e e
and protection of the patient during prone
k e rrss
e
o o
o o kpositioning
o o
o o k
o o
FIG. 47.6
eebb b b
• Use of a calf tourniquet
• Failure to consider anterior pathology or
approaches
e / e
/
POSITIONING
e e b ee/ e
/ e b
: / / t
/ m
.t.m : / / t m
.t.m
• For the prone position the patient is placed face down on the table with appropriate
/
t p ss:
p / t p ss:
p /
bolsters, padding, and precautions (Fig. 47.5).
• Thigh tourniquet
t
hht t
• A Mayfield bolster or equivalent t
hht t
• In the full lateral position the patient is positioned similar to a total hip arthroplasty,
and the surgeon sits behind the ankle with the video tower on the opposite side of
the bed (Fig. 47.6).
k e r
e ss
• Place the arthroscope onto the back side of the
r
ankle laterally, and bring the shaver next to the
k eers
rs
• Medial to the Achilles tendon, 2 cm above the calcaneus as shown in this annotated
MRI view (Fig. 47.7)
o o
o o karthroscope by feel. Ensure that both are lateral
o oo k o
• Lateral to the Achilles tendon, 2 cm above the calcaneus as shown in this clinical
o o
eebb b b
to a line between the Achilles tendon and the
second toe. Point the shaver away from the
ee
arthroscope, turn the suction on, and shave until/ e
/ e b ee e/ b
view. The thumbs of the surgeon are 2 cm above the calcaneus, which can be pal-
/ e
pated, and the accessory portal is marked (Fig. 47.8)
: / / t
/ .
tm.m
the shaver tip can be seen with the suction off.
t. m
. m
• Just behind the medial malleolus and anterior to the flexor digitorum longus (FDL)
: / / / t
p ss /
• Enter the ankle or subtalar joint, and work
:
medial until the FHL tendon can be seen in the
t p t p ss
p : /
tendon (accessory portal)
• Just behind the peroneal tendons laterally (accessory portal)
medial side of the joint.
t
hht t t
hht t
• A portal 2–3 cm above the Achilles tendon portals
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 47 Ankle Arthroscopy From a Posterior Approach 399
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b
ee/ e
/ e b FIG. 47.8
FIG. 47.7
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t PORTALS/EXPOSURES PITFALLS
• Avoid damage to the tibial nerve that lies
medial and posterior to the FHL tendon.
• Ensure that the arthroscope is placed lateral
enough to avoid the nerve prior to use of the
keerrss keerrss
shaver.
b ooook b ooook b oo STEP 1 PEARLS
eeb PROCEDURE ee/e/e b ee/e/e b • If the view is suboptimal, change portals as
necessary.
: / / t
/ m
.t.m : / / t
/ m
.t.m
sue Impingement
t ppss /
Step 1: Arthroscope Insertion and Débridement of Posterior Soft Tis-
: t ppss : / STEP 1 PITFALLS
t
hhtt t
hhtt
• After insertion of the arthroscope, the posterior ankle is débrided. In this view the
shaver is in the posterior medial corner of the right ankle from a portal next to the
• Always stay lateral to the FHL.
• Make sure that the area anterior and medial to
the FHL tendon is débrided.
FDL and the arthroscope in a portal just behind the peroneal tendons while the syno-
vitis around the posterior process is débrided (Fig. 47.9).
k rrss
e k rrss
• The posterior side of the talus, tibia, and calcaneus is visualized.
e e e
• All impinging tissue is removed. In this view the right subtalar joint is seen with the
IMPLANTATION
o o
o o k o o o k
posterior process of the talus being in the 9 o’clock position and the shaver being
o o o
• Use a 2.9-mm scope with a high flow cannula.
eebb b b • Use a 3.5-mm shaver to remove the soft tissue.
ee e
/ e b
advanced towards the ankle through the posterior ligaments (Fig. 47.10).
/ ee/ e
/ e b
: / / / m
.t.m
Step 2: Removal of Stieda Process or Os Trigonum
t : / / t
/ m
.t.m STEP 2 PEARLS
t p ss:
p / t p ss:
p /
• Once the soft tissue has been removed, the os trigonum or Stieda process will be • Make sure that the back of the ankle is well
t
hht
right and the ankle joint above (Fig. 47.11). t
visible. In this view the shaver is next to the FHL tendon with the os trigonum to the
t hht t
• Use a combination of burrs, curettes, and pituitary rongeur to remove the bone and
visualized before resection.
• Ensure that all bone fragments are removed.
bone fragments. In this view the burr is being placed on the os trigonum just beside
STEP 2 PITFALLS
the FHL tendon (Fig. 47.12).
• Failure to completely remove all bone
k e e s
rs k eers
• Make sure that resection is flush with the back of the talus and no further bone may
r rs
impinge in plantar flexion. In the ballet dancer shown in this example a complete
fragments.
• Make sure that the FHL tendon is released.
o o
o o k oo k
excision can be seen with the ankle in dorsiflexion (Fig. 47.13A) and plantar flexion
o o oo
eebb e / b
e b
to the dorsal lateral side, or in the 12-o’clock to 3-o’clock position.
e ee /ebb
(Fig. 47.13B). In the plantar flexed position the posterior tibiofibular ligament is seen
/ e /e STEP 2 INSTRUMENTATION/
IMPLANTATION
: / / / .
tm m : / / /.tm
• The excision can also be checked using a fluoroscopic view to ensure complete
t . t . m • 4.5-mm burr
excision.
t p ss
p : / t p ss
p : / • Pituitary rongeur
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
400 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 47.9 FIG. 47.10
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs FIG. 47.11
k eers
rs
o o
o o k o oo
o k FIG. 47.12
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb A
ee/ ee
/ b B
ee/ e
/ e b
: // t/.tm
. m : /
FIG. 47.13
/t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb
FIG. 47.14
ee/ e
/ b
e b
ee/ e
/ b
e b FIG. 47.15
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t
Step 3: Débridement and Release of the FHL Tendon t
hht t
• The FHL tendon lies medial to the os trigonum or Stieda process (Fig. 47.14).
STEP 3 PEARLS
• Ensure that the full release is performed and
• It has a fibroosseous tunnel that requires a complete release. follow the FHL towards the foot.
Step 4: Débridement of an Osteochondral Defect
k e r
e s
rs k eers
rs
• After exposure of the back of the ankle, dorsiflex the ankle and view the osteochon-
STEP 3 PITFALLS
• Be careful not to get too close to the tibial nerve.
o o
o o k dral defect (Fig. 47.15).
o o
oo k oo
eebb e / b
e b
• Use a curette, shaver, or burr to remove all unstable cartilage and bone. Fig. 47.16
/ e
shows the curette and the burr being used. The picture of the curette shows the
e ee/e/ebbSTEP 3 INSTRUMENTATION/
IMPLANTATION
: / / / .
tm.m : / / t
/.tm
. m
curette passing lateral to the FHL tendon, and also shows the size and extent of the
t • 3.5-mm burr
t p
rior side of the ankle.
ss
p : / t p ss
p : /
lesion. The lesion extends to the midpoint of the medial side, and 75% of the poste- • Meniscal basket cutter
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
402 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m
t p ss
p : /
tp pss : /
STEP 4 PEARLS
t
hht t tFIG. 47.16
hht t
• Dorsiflex the ankle to improve the exposure.
• Graft revision osteochondral defect lesions
keerrs
arthroscopically with either bone graft, bone
s
graft substitute, or a cartilage preparation.
keerrss
b ooook
STEP 4 PITFALLS
b ooook b oo
eeb /
• Failure to remove all unstable cartilage and bone.
ee e/e b ee/e/e b
• Failure to recognize an osteochondral defect.
: / / t
/ m
.t.m : / / t
/ m
.t.m
IMPLANTATION
t
hhtt
• 3.5-mm shaver, 4.5-mm burr, and chondral
picks or a 2.5-mm drill
t
hhtt
• Juvenile cartilage graft or bone graft substitute
e rrss
• For primary débridement, no graft is usually
k e k e rrss
e
o o
o o krequired.
o o
o o k o o
eebb b b
• For revision procedures or large primary
lesions bone graft, bone graft substitute,
cartilage products, or platelet-rich plasma may
ee/ e
/ e b ee/ e
/ e b
: / t
/ m
.t.m
be considered as this may assist in the healing
/
: / / t
/ m
.t.m
of the defect.
t p ss:
p / t p ss:
p / FIG. 47.17
t
hht t
• Vitamin D deficiency may exist in dancers;
t
hht t
• Use a drill or pick in the base of the bone if required. In this case the base was
drilled with a 2.5-mm drill and injected with platelet derived growth factor as a revi-
therefore it is advisable to ensure that they get sion case. Fig 47.17 shows the metal needle in the drill hole.
appropriate vitamin D supplementation.
• Antiinflammatory medication may assist POSTOPERATIVE CARE AND EXPECTED OUTCOMES
k e r
e ss
in reducing pain and inflammation
r
postoperatively.
k eers
rs
• The patient is placed in a walker boot or cast for 2 weeks non–weight bearing.
o o
o k
• A compression stocking can be used to reduce
o oo k
• Weight bearing as tolerated is initiated at 2 weeks with physiotherapy and range of
o o oo
eebb b b
postoperative swelling.
ee/ e
/ e b motion.
e /e/e b
• For patients undergoing débridement of an osteochondral defect non–weight bear-
e
IMPLANTATION
: / / t
/ .
tm.m : / / t
/.tm
. m
ing for 6 weeks should be considered.
• A knee-high walker boot
t p ss
p : / t p ss : /
See also Video 47.1, Posterior Ankle Arthroscopy.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
EVIDENCE POSTOPERATIVE CONTROVERSIES
r s
rs rs
r s
Allegra F, Bonacci E, El Boustany S, Zannoni R, Maffulli N. Endoscopy of the posterior aspect of the
k e e k ee
ankle: Double posteromedial portals. Sports Med Arthrosc 2016;24:24–8.
• For posterior osteochondral defects, weight
bearing may be delayed for 6 weeks after
o o
o o k o oo k o
A description of two portals, one superior and one inferior, to assist in the access and viewing of
o o
surgery to assist in bone healing. However the
eebb bb b b non–weight bearing protocol for 6 weeks has

the posterior aspect of the ankle. The portals are placed posterior medial, and the patient is kept in
the supine position.
ee/ e
/e ee/ e
/ e not been well studied, but maintaining non–
: / / t
Clin Orthop Relat Res 2010;468:996–1001.
/ t m
. m : / / t
/ t m
Allegra F, Maffulli N. Double posteromedial portals for posterior ankle arthroscopy in supine position.
. . . m
weight bearing may assist in bone healing of
the base of the defect.
t p ss
p : / t p ss
p : /
A description of two portals, one superior and one inferior, to assist in the access and viewing of
the posterior aspect of the ankle. The portals are placed posterior medial, and the patient is kept in
the supine position.
t
hht t t
hht t
Amendola A, Lee KB, Saltzman CL, Suh JS. Technique and early experience with posterior arthroscopic
subtalar arthrodesis. Foot Ankle Int 2007;28:298–302.
A description of arthroscopic ankle arthrodesis from posterior in the prone position. A review of 11
patients.
k ee s
rs k er
ers
de Leeuw PA, Hendrickx RP, van Dijk CN, Stufkens SS, Kerkhoffs GM. Midterm results of posterior
r s
arthroscopic ankle fusion. Knee Surg Sports Traumatol Arthrosc 2016;24:1326–31.
b ooook ooook
A review of 40 patients undergoing posterior ankle arthroscopy and fusion with a 100% fusion rate
and no nerve complications. Two screw removals were required.
b b o o
eeb e / e
/ e b e / e
/ e b
Dinato MC, Luques IU, Freitas Mde F, et al. Endoscopic treatment of the posterior ankle impingement
syndrome on amateur and professional athletes. Knee Surg Sports Traumatol Arthrosc 2016;24:1396–
e e
401.
// t/.tm
. m / /t/.tm. m
A review of 32 patients undergoing posterior ankle arthroscopy and removal of bone impingement.
: :
ss : / ss : /
A 94% success rate with most patients returning to their prior level of sport. Return to sport took
t p p tp p
15 weeks on average.
t
hht t t
hht t
Lopez Valerio V, Seijas R, Alvarez P, et al. Endoscopic repair of posterior ankle impingement syndrome
due to os trigonum in soccer players. Foot Ankle Int 2015;36:70–4.
Endoscopic excision of the os trigonum in 20 soccer players. All returned to the same level of
sport, and the mean return to sport time was 47 days.
Ogut T, Ayhan E, Irgit K, Sarikaya AI. Endoscopic treatment of posterior ankle pain. Knee Surg Sports
keer ss
Traumatol Arthrosc 2011;19:1355–61.
r keerrss
Fifty-nine patients underwent posterior ankle arthroscopy for various etiologies. Two sural nerve
b ooook b ooook
complications were seen, and three patients with posttraumatic arthritis were dissatisfied.
b
Ribbans WJ, Ribbans HA, Cruickshank JA, Wood EV. The management of posterior ankle impingement
oo
eeb /e e b
syndrome in sport: a review. Foot Ankle Surg 2015;21:1–10.
ee / ee/e/e b
A review of posterior ankle impingement and its treatment. Soccer players recovered faster than
ballet dancers.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss / t ppss : /
Song B, Li C, Chen Z, et al. Combined anterior and dual posterolateral approaches for ankle arthros-
:
copy for posterior and anterior ankle impingement syndrome. Foot Ankle Int 2016;37:605–10.
t
hhtt t
hhtt
A review of 28 patients undergoing combined anterior and posterior ankle arthroscopy, with 15
undergoing the procedure with the supine position used only. The single stage procedure resulted
in shorter operating times and similar results.
Weiss WM, Sanders EJ, Crates JM, Barber FA. Arthroscopic excision of a symptomatic Os Trigonum.
Arthroscopic excision of the os trigonum in the prone position in 24 patients with successful out-
k rrss
come and one transient nerve palsy.
e e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh48
PROCEDURE
t hht
Osteochondral
rss Lesion of the Ankle:
rs s
k ee r k ee r
eebboooOATS
ok Procedure ooook / e bb / e b o
b o
m ee /e m ee / e
Juan Bernardo Gerstner
: / t
///t. . m : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp
• Panarticular arthritis conditions
t
hhtt p
t p
Osteochondral autograft transfer system (OATS) procedure consists of transplanting
• Smokers one or various osteochondral cylinders from a donor site to a osteochondral defect to
• Patients >50 years old supply the smoothness and support of the articular surface that has been lost.
k eerss
• Donor site with previous pathology
r
• Adjacent medial or lateral wall defect
k er
erss
INDICATIONS
• Stage III–IV osteochondral lesions of the talus

• Diameter of the lesion between 11 and 15 mm
ee/ e
/ e b
• Diameter of <10 mm
ee/ e
/ e b
• Previous failure of microfracturing or retrograde grafting
• Active >50 years old
: // t/.tm
. m
EXAMINATION/IMAGING
: / /t/.tm. m
t p ss : /
• Fresh osteochondral frozen graft: is a good
option to avoid donor site complications, but
p tp pss : /
t
hht t
has a slow incorporation timing and a high
collapse rate
• Single 10-mm block versus two small blocks
t
hht t
• Plain x-rays: anteroposterior, lateral, and mortise view (Fig. 48.1)
• Magnetic resonance imaging (Fig. 48.2)
• Computed tomography scan (Fig. 48.3)
TREATMENT OPTIONS
• Autologous talar graft
keer ss
• Autologous knee graft
r
• Allograft
keerrss
b ooook • Microfracture
b ooook b oo
eeb • Matrix-induced autologous chondrocyte
implantation
ee/e/e b ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
FIG. 48.1
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p s s
p : /
404 t
hht t FIG. 48.2
t
hht t FIG. 48.3
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 48 Osteochondral Lesion of the Ankle: OATS Procedure 405
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hh t
FIG. 48.4
t t
ht
h
t FIG. 48.5
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt POSITIONING PEARLS
• Use a radiolucent operating bed.
• Image intensifier must be available at all times.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
• With no pillow under the leg, it is difficult to
eebb b b externally rotate the ankle and thus approach the

ee/ e
/ e b
FIG. 48.6
ee/ e
/ e b lateral side (for lateral ligament reconstruction).
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p / POSITIONING EQUIPMENT
t
hht
hht t • Arthroscopy tower at the contralateral ankle
side
• C-arm at the same ankle side
• Dorsal aspect of the ankle joint (Fig. 48.4) • Ankle traction equipment
• Medial aspect of the ankle joint (Fig. 48.5)
• Lateral aspect of the ankle joint (Fig. 48.6)
eers
rs
POSITIONING
k k eers
rs POSITIONING CONTROVERSIES
• Lateral decubitus if the lesion is lateral or a
o o
o o k o o
oo k oo
ligament repair is needed.
eebb b b
• Decubitus supinus (Fig. 48.7)
• Knee slightly flexed
ee/ e
/ e b ee/e/e b
• Prone decubitus if the lesion is purely central
and posterior, or there is a kissing lesion at the
• Bean pillow under the leg
: / / t
/ .
tm.m : / / t
/.tm
. m
tibial posterior site.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
406 hht
PROCEDURE 48 Osteochondral Lesion of the Ankle: OATS Procedure hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
FIG. 48.7
: // t/.tm
. m : / /t/.tm. m FIG. 48.8
t p ss
p : / tp pss : /
t
hht t t
hht t
• Whenever available draw the track of the
superficial peroneal nerve.
ke rs
• Avoid the saphenous vein and nerve.
r s
• Portals should be a little below the ankle level
e keerrss
b ooook to ensure talar dome visualization.
b ooook b oo
eeb PORTALS/EXPOSURES PITFALLS
ee/e/e b ee/e/e b
/ / m
.t.m
• Anterior fat precludes visualization of the nerves.
/ t
• Portals at the same level of the ankle preclude
: : / / t
/ m
.t.m
visualization of the dome.
PORTALS/EXPOSURES EQUIPMENT t
hhtt h t
htt FIG. 48.9
• Sagittal saw
• Screw fixation for medial malleoli osteotomy
• Adequate mosaicplasty equipment
k rrss
• Bone grafting harvesting set (for filling the
e e
donor site)
k e rrss
e
o o
o k
• Ipsilateral knee prepared for portals and
o o o
o o k o o
eebb b b
become a donor site
ee/ e
/ e b ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Type of osteotomy at the medial malleoli
p ss: /
• Lateral osteotomy (in case of purely central
t p t p ss:
p /
lateral lesions)
t
hht t t
hht t
STEP 1 PEARLS
FIG. 48.10
• Perform anterior synovectomy and Bassett
ligament release.
r s
rs
• Resect anterior tibial and talar neck osteophytes.
k e e k eers
rs
PORTALS/EXPOSURES
o o
o o k o o
oo k oo
eebb b b
STEP 1 PITFALLS • Anteromedial ankle scope portal (Fig. 48.8)
• Medial and lateral portal at the same level of
ee/ e
/ e b e /e/e b
• Anterolateral ankle scope portal (Fig. 48.9)
e
the ankle line.
/ /
• Poor visualization due to anterior tibial
: t
/ .
tm.m : / / /.tm
• Extended medial approach with osteotomy (Fig. 48.10)
t . m
osteophytes.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ ee
/ b ee/ e
/ e b

: // t/.tm
. m : / / t
/ .
t m
. m
FIG. 48.11
t p ss
p : / FIG. 48.12
tp pss : / FIG. 48.13
t
hht t t
hht t
IMPLANTATION
keerrss keerrss • Traction to gain ankle space and palpation of

the lesion to continue the preoperative plan.
b ooook b ooook b oo • Determine the exact position of the lesion.

• Verify the optional harvesting of the medial
eeb ee/e/e b ee/e/e b anterior talar cartilage donor site.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t ppss : / STEP 1 CONTROVERSIES
t
hhtt t
hhtt
• Soft or external fixation distraction.
• Choose the adequate size of graft.
STEP 2 PEARLS
FIG. 48.14
rrss rrss
• Chevron osteotomy can be predictable to
o kke
PROCEDURE
e o k e
k e
secure. Make the screw paths before cutting
the malleoli.
o
eebb o o
Step 1: Standard Ankle Scope
e b o
b o o e b o
b o
• A Kirschner wire can be located at the upper
level of the chevron cut guided by an image
• Medial ankle portal (Fig. 48.11)
m ee/ / e m ee/ / e intensifier; irrigation while cutting would avoid
• Lateral ankle portal (Fig. 48.12)
: / /
/ t
/ .t.m : / /
/ t
/ .t.m bone necrosis.
• Use a Steinmann pin as a joystick to improve
• Traction if needed
t t p
t ss:
p t t p
t ss:
p
visualization.
• A lamina spreader can also give some extra
hht
Step 2: Malleolar Osteotomy Upon Request
hht
If the medial lesion cannot be reached in full plantar flexion of the ankle, a medial
access.
• Plan your fibula fixation ahead in case of an
osteotomy.
osteotomy is needed. Lateral osteotomy should be done if needed when a central or
posterolateral lesion is present.
e s
• Medial extended approach (Fig. 48.13).
r rs e rs
rs
• Medial malleolar osteotomy preserving the deltoid fibers and vascularity (Fig. 48.14).
k e k e
STEP 2 PITFALLS
o o
o o k oo k
• Direct the malleoli downwards to ensure visibility of the medial rim of the talus
o o oo
• Too-low osteotomy will blur the vision of the
talar medial or lateral ridge.
eebb (Fig. 48.15A).
ee/ e
/ b
e b e
• Lateral extended approach and osteotomy can be done if the lateral lesion cannot
e/e/ebb • Too high medial osteotomy will become a tibial
plafond fracture.
: / / t
/ .
tm.m : / / t
/.tm
. m
be reached by a standard anterolateral or posterolateral ankle portal. The aim of this • Too high lateral osteotomy will become a very
unstable situation.
t p ss
p : / t p ss : /
osteotomy is to preserve the attachment of the anterior talofibular and the fibulocal-
caneal ligament to the fibula, creating a three part osteotomy that can be fixed when
p
t
hht t
the procedure is done (Fig. 48.15B).
t
hht t
t t p
t ss:
p t t p
t ss:
p
408 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m
t p ss
p : /
tp pss : /
t
hht t t
FIG. 48.15
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e
FIG. 48.16
k r
eer ss FIG. 48.17
o o
o o k o o
o o k o o
eebb b b
IMPLANTATION
• Measure the exact diameter of the lesion to
ee/ e
/ e b ee/ e
/ e b
• In general, medial osteotomy is preferred when the medial lesion cannot be reached
fulfill it with one or two bone pegs.
: / / t
/ m
.t.m : / / t
/ m
.t.m
by using a #21 needle right in the medial shoulder of the ankle, positioning it as verti-
osteochondral grafts.
t ss:
p /
• Choose the right source of the autologous
p t p ss:
p /
cal as possible. Some central medial lesions can be reached by this tip, so an ante-
rior arthrotomy can be done. Some very posterior lesions can also be reached by a
t
hht t
• Make sure to have the complete set of drills
and bone pegs impaction instruments.
• Note the curvature of the defect to ensure the
t
hht t
posteromedial ankle approach, but there is a hazard of compromising the posterior
neurovascular bundle.
graft has the same.
Step 3: Removing the Lesion From the Talar Surface and Body and
Graft Impaction
e r
e s
rs
k k e rs
rs
• Define a sharp ream with stable cartilage, using a curette or a sharp knife blade.
e
o o
o o k
• Number of bony pegs
o o
oo k
• Remove the lesion using the appropriate peg width and measure the depth (Fig. 48.16).
oo
eebb • How to reconstruct the shoulder of the medial
e
or lateral talar ridge if both dorsal and medial
e/ e
/ b
e b length is about 25 mm.
ee/ /ebb
• Take into consideration the ideal curvature to select the donor site and make sure the
e
surfaces are compromised
: / / t
/ .
tm.
• How to deal with kissing lesions of the tibial
m : / / t
/.tm
. m
• Select and cut the appropriate length of the peg, a little higher than measured.
plafond
t p ss
p : / (Fig. 48.17).
t p ss
p : /
• Impact gently into the defect so as not to create new cartilage damage in the graft
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
STEP 3 PEARLS
k e r
e s
rs k eers
r s • Select between 4.5 mm, 6.5 mm, and 10 mm
of peg diameter to cover the size of the lesion.
o o
o o k oooo k o • Impact the graft perpendicular to the talar surface
o
eebb ee/ e
/ebb ee/ e
/ b
e b and above the level of the surface to compensate
reabsorption at the base and peg sink.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• Drill the base of the defect to promote the
healing process from the talar native circulation.
t p ss
p : / t p ss
p : /
t
hht t t
• Impact the peg to below the level of the surface.
• Incline the track of the peg so impaction is no
longer achieved.
• Fracture of the adjacent wall of the talus.
k eers
rs k er
erss STEP 3 INSTRUMENTATION/
IMPLANTATION
eeb ee/ e
/ e b ee/ e
/ e b • Single use precise cutting instrument set
• Harvesting OATS from the knee can result in a
: // t/.tm m
FIG. 48.18
. : / /t/.tm. m painful experience if not discussed in advance.
Prepare your patient for donor site pain and
t p ss
p : / tp pss : / bleeding, and thus follow-up will be expected to
t
hht t t
hht t be easy. This technique is not recommended in
worker’s compensation or noncompliant patients;
a fresh talus allograft is a reasonable alternative
option, although slow incorporation and collapse,
and viral infections are major concerns
keerrss keerrss STEP 3 CONTROVERSIES
b ooook b ooook b oo • Donor site graft/morbidity
eeb b b • Use of platelet-rich plasma and other repairing
ee/e/e ee/e/e cell induced substances at the base of the defect
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Use of fibrin glue or a periosteal flap over a
graft on the donor site
t
hhtt t
hhtt STEP 4 PEARLS
• Plan your osteotomy and hardware for final
fixation ahead of time.
• Confirm your fixation with x-ray before leaving
the operating room.
k e rrss
e FIG. 48.19
k e rrss
e
o o
o o k o o
o o k o
STEP 4 PITFALLS
o
eebb b b • Screw failure usually means poor preoperative
ee/ e
/ e b ee/ e
/ e b planning.
• Poor soft tissue handling or excessive force to
: / / t
/ m
.t.m : / / t
/ m
.t.m retract the medial malleoli will end up in an avas-
t p ss:
p / t p ss:
p /
• When in presence of a tall shoulder lesion, the donor site should be taken from either
cular episode, a neuritic disease, or an infection.
t
hht t
surface of the medial or lateral condyle.
t
hht t
the curved surface of the intercondylar notch or the interface of the non–weight-bearing STEP 4 INSTRUMENTATION/
IMPLANTATION
• The lateral or medial talar wall should be intact to hold the bony pegs from the do- • Use compression and antirotational screw
nor site. In case the wall is damaged, a cortical graft (autograft or allograft) must be techniques.
• For lateral side fixation use plates or screws as
k e e s
rs k eers
placed before the pegs and secured ideally with countersank screws.
r rs needed.
o o
o o k
Step 4: Final Fixation of the Osteotomy
o o
oo k oo
eebb b b STEP 4 CONTROVERSIES
e /
• Lateral fixation with screws and/or plates
e / e b
• Medial malleoli fixation using two solid screws (Fig. 48.18)
e ee/e/e b • Single versus double cut for lateral malleoli
: / t
/ .
tm.m
Step 5: Lateral Ankle Ligament Reconstruction if Needed
/ : / / t
/.tm
. m osteotomy.
• Predrill versus postprocedure fixation to avoid
t p ss
p : / t p ss : /
• Arthroscopic talofibular lateral ankle ligament reconstruction (Fig. 48.19).
p
pressure over the ridge of the mosaicplasty.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
410 hht
POSTOPERATIVE PEARLS POSTOPERATIVE CARE AND EXPECTED OUTCOMES
k e r
e ss
• Do not instruct swimming-pool exercises until
r
skin healing has been achieved and stitches
k eers
r s
• Non–weight bearing bulky splint for 4 weeks to allow careful inspection of wounds.
• Controlled ankle movement boot walker and progressive weight bearing as toler-
o o
o o kare removed.
oooo k
ated.
o o
eebb • Pain control starts with local anesthesia blocks
immediately postsurgery.
ee/ e
/ebb / e b b
• Range of motion exercises are conducted 3 weeks postoperatively at a swimming
pool.
ee / e
: / / t
/ .
t m
. m
EVIDENCE
: / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t
• Delay in weight bearing and failure to manage
pain can cause arthrofibrosis and complex
regional pain syndrome.
t
hht t
Ferkel RD, Zanotti RM, Komenda GA, et al. Arthroscopic treatment of chronic osteochondral lesions of
the talus: Long-term results. Am J Sports Med 2008;36(9):1750–62.
A case series of 50 patients followed after scope treatment of chronic osteochondral lesions found
instability of the lesion as one of the persistent pain variables.
Gross, Christopher E, Adams, Samuel B, Easley, Mark E. Role of fresh osteochondral allografts for large
POSTOPERATIVE CONTROVERSIES talar osteochondral lesions. JAAOS 2016;24(1):e9–17.
k e rs
rs
• Timing of weight bearing
e k er
erss
Large-volume osteochondral lesions of the talus (area >150 mm2) involve sizable portions of the
weight-bearing section of the talar dome. Fresh structural osteochondral allograft is an alternative
b ooook
• Hyaluronic acid and platelet-rich plasma shots
• Donor site morbidity
b oook
viable treatment option.
o b o o
Guney A, Yurdakul E, Karaman I, Bilal O, Kafadar IH, Oner M. Medium-term outcomes of mosaicplasty
eeb • Different rehabilitation protocol upon the size

of the defect
ee/ e
/ e b ee/ e
/ e b
versus arthroscopic microfracture with or without platelet rich plasma in the treatment of osteochon-
dral lesions of the talus. Knee Surg Sports Traumatol Arthrosc 2016;24(4):1293–8.
: // t/.tm
. m t . m. m
Prospective three arm study offering microfracture surgery, microfracture surgery plus platelet-rich
: / / / t
t p ss
p : / tp ss : /
plasma (PRP), and mosaicplasty. All the three treatment modalities resulted in good medium-term
functional results, but mosaicplasty procedure seems to be preferred in patients where pain control
p
t
hht t t
hht
is important.
t
Hahn DB, Aanstoos ME, Wilkins RM. Osteochondral lesions of the talus treated with fresh talar allo-
grafts. Foot Ankle Int 2010;31(4):277–82. http://dx.doi.org/10.3113/FAI.2010.0277.
Fresh talar allograft is a reasonable procedure for younger adult patients with focal osteochondral
talar defects that cannot be corrected with curettage and microfracture.
Lin SS, Montenurro NJ, Krell ES, Ethan S. Orthobiologics in foot and ankle surgery. JAAOS
keerrss rrss
2016;24(2):113–22.
kee
Extensive revision of orthobiologics include platelet-derived growth factor, bone morphogenetic
b ooook b o ook oo
proteins, and platelet-rich plasma. More studies are needed to support or oppose the specific ap-
o b
eeb b b
plication of growth factors in foot and ankle surgery.
ee/e/e e /e/e
Murawski CD, Kennedy JG. Operative treatment of osteochondral lesions of the talus. J Bone Joint
e
: / / t
/ m
.t.m : / / t m
Surg Am 2013;95(11):1045–54. http://dx.doi.org/10.2106/JBJS.L.00773.
.t.m
Extensive review about the multiple options for treatment of osteochondral lesion, indications and
/
contraindications, and pitfalls.
Thomas M, Jordan M, Hamborg-Petersen E. Arthroscopic treatment of chondral le-
t
hhtt t
hhtt
sions of the ankle joint: evidence-based therapy. Unfallchirurg 2016;119(2):100–8.
http://dx.doi.org/10.1007/s00113-015-0136-2.
This article gives an overview and critical analysis of the current concepts for treatment of chondral
and osteochondral injuries and lesions of the talus based on review of the literature from the
arthroscopic to open procedures, including OATS and MACI, grow factors, and implantation of
rrss rrss
stem cells.
o k e
k e o k e
Zengerink M, Szer I, Hangody L, et al. Current concepts: Treatment of osteochondral ankle defects.
k e
Foot Ankle Clin N Am 2006;11:331–59.
o
eebb o o e b o o o o o
Review of the literature from 1966 to 2006 regarding the treatment of osteochondral lesions of the
b e b b
talus in which the authors conclude that débridement and bone marrow stimulation is the most ef-
m ee/ / e m e / / e
fective treatment strategy for symptomatic osteochondral lesions of the talus at that time.
e
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh49
PROCEDURE
t hht
Vascularized
rss Bone Graft for Extended
rs s
k ee r k ee r
ooooOsteochondral
eebb
k Lesion of Talus
ooook / e bb / e b o
b o
m
Beat Hintermann, Roxa Ruiz,t.and
ee /e m ee / e
: / /
/ / t . mDirk J. Schäfer
: / /
/ t
/ .
t . m
t ppss : t p ss
p :
hhttt t
hht t
INDICATIONS
k eers
rs k er
erss
• Large osteochondral lesions (OCLs) that are bigger than one third of the articular
• Ankle osteoarthritis grade II and III (Takakura)
b ooook o ook
surface in at least one plane (sagittal and/or coronal)
b o b o o
• Presence of a tibial osteochondritis dissecans
eeb cal treatment

ee e
/ e b ee e
/ e b
• A history of persistent pain for >1 year after conservative treatment or previous surgi-
/ /
(OCD) opposite to the talar OCD (kissing lesion)
EXAMINATION/IMAGING
: // t/.tm
. m : / /t/.tm. m INDICATIONS CONTROVERSIES
t p ss
p : / tp pss : / • Patients <16 years of age
t
hht
• Previous injuries and surgeries
• Disability in daily activities and sports
t
t hht t TREATMENT OPTIONS
• Arthroscopic or open débridement of the lesion
• Effect of previous conservative measures with or without microfracturing
kee rs
r s
• Ankle alignment when standing
keerrss • Osteochondral autograft transfer system
(Al-Shaikh et al., 2002)
b ooook b oook
• Ankle range of motion with the patient sitting and standing
o b oo
• Hangody mosaicplasty (Hangody and Füles,
2003)
eeb e /e/e b
• Ankle stability with the patient sitting and feet hanging
• Pain using a visual analog scale of 0–10 points
e ee/e/e b • Fresh allograft transplantation (Adams et al.,
2011)
: / / / m
.t.m : / / / m
.t.m
• Plain weight-bearing radiographs, including anteroposterior views of the foot
t t • Vascularized autograft (Hintermann et al.,
out
and ankle, lateral view of the foot, and alignment view, should be used to rule 2015)
t
hhtt t
hhtt
• Articular configuration and integrity of the ankle joint
• Primary or secondary deformity of the foot
• Presence of malformation
• Presence of arthrotic changes (Fig. 49.1)
• Computed tomography (CT) scans, if possible while weight bearing, are initiated to
k e rrss
• Determine location and size of the lesion
e k e rrss
e
o o
o o k o o
o o k
• Assess the lesion pattern, e.g., the condition of the bone in and around the
o o
eebb b b
lesion
• Detect cyst formation
ee/ e
/ e b ee/ e
/ e b
• Detect loose bodies
: / / t
/ m
.t.m
: / / t
/ m
.t.m
p ss: /
t p t p ss:
p /
t
hht t t
hht t
• Determine the activity of the lesions, e.g., presence and extent of perifocal
edema
• Assess the lesion pattern, e.g., the condition of the bone in and around the
lesion
• Detect cyst formation
k e r
e s
rs
• Detect other joint abnormalities (Fig. 49.3)
k eers
rs
o o
o o k be used to visualize
o o
oo k
oo
eebb ee/ e b
e b
• Morphologic pathologies and associated activity process (Fig. 49.4)
/ ee/e/e
• Doppler sonography or angiography may be used in the case of uncertain blood flow
bb
/
through the tibial artery
: / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t 411
t t p
t ss:
p t t p
t ss:
p
412 hht hht
PROCEDURE 49 Vascularized Bone Graft for Extended Osteochondral Lesion of Talus
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook A
b ooook
B
b oo
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
C D
FIG. 49.1
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 49 Vascularized Bone Graft for Extended Osteochondral Lesion of Talus 413
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m
t p ss
p : /
tp pss : /
t
hht t FIG. 49.2
t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
A
rs B
k eers
rs
o o
o o k o o
oo k
FIG. 49.3
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
414 hht
PROCEDURE 49 Vascularized Bone Graft for Extended Osteochondral Lesion of Talus hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m :B
/ /t/.tm. m
t p ss
p : /
tp pss : /
POSITIONING PEARLS
t
hht t t
hht
FIG. 49.4
t
SURGICAL ANATOMY
• Positioning of the tourniquet as proximal as
possible to allow for draping the of distal part • OCLs of the medial talus necessitates a transmalleolar approach through osteotomy
ke rrs
of femur
s
• Positioning of the extremity on a cuboidal
e keerrss
for exposure.
• OCLs of the lateral talus are accessible by anterolateral subluxation of the talus after
b ooook support to facilitate surgeon’s access from the

medial side
b ooook oo
detachment of lateral ankle ligaments.
b
eeb PORTALS/EXPOSURES PEARLS
ee/e/e b ee/e/e b
• The medial condyle of femur is easily accessible, has a constant afferent artery, and
an ideal contour with periosteal cover vascularized.
/ t
• Drilling of two parallel drill holes prior to
: / / m
.t.m
POSITIONING
: / / t
/ m
.t.m
t p : /
osteotomy of medial malleolus will facilitate
ss
reduction and screw fixation at the end of surgery.
p t ppss : /
t
hhtt
• An L-shaped osteotomy with an open angle of
150° provides better insight to the medial talar
dome and provides also better stability after
t
• Supine position
hhtt
• Tourniquet at the ipsilateral thigh (320–350 mmHg)
screw fixation. PORTALS/EXPOSURES

• Detachment of ATFL with a small piece of bone • Exposure of a medial OCL of the talus
may allow for better and faster healing of the
k e rrss
ligament after reattachment after surgery.
e k rrss
• A 5-cm long, slightly curved incision
e e
• Exposure of medial malleolus
o o
o o k
o o
o o k o
• Identification of anteromedial corner of the ankle
o
eebb • A procedure too proximal of the medial
malleolus may result in damaging of the
ee/ e
/ b
e b e e
/ b
e b
• Retraction of posterior tibial tendon by a small Hohmann
/
• Incomplete osteotomy of medial malleolus by using a saw
e
articular integrity of tibial pilon.
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Finalization of osteotomy using a chisel
p ss: /
• A too distal osteotomy of medial malleolus may
result in limited accessibility to the OCL.
t p t p /
• Exposure of medial talus by using a Hintermann distractor over two 2.5 mm
ss:
Kirschner wires (K-wires; Fig. 49.5)
p
t
hht t
• Injury to the ramus descent of the genicular nerve
may result in a painful and disabling neuroma. t
hht t
• Exposure of a lateral OCL of the talus
• A 5–6 cm long slightly curved incision
PORTALS/EXPOSURES EQUIPMENT • Exposure of lateral ankle ligaments
• Subperiosteal detachment of the anterior talofibular ligament (ATFL)
• The Hintermann distractor over two K-wires is
k e r s
very helpful to expose the OCL from both the
rs
medial and lateral approach.
e k eers
• Anterolateral subluxation of the talus out of the mortise with the use of a Hinter-
rs
mann distractor over two 2.5-mm K-wires (Fig. 49.6)
o o
o o k o o
oo k
• Exposure of a medial femur condyle
oo
eebb b b
PORTALS/EXPOSURES CONTROVERSIES • A 12–15 cm longitudinal incision
• Fibular osteotomy to expose an OCL of
ee/ e
/ e b e /e/e b
• Identification of the descending genicular artery
e
lateral talus has been proposed by several
: / t
authors; though easy to perform, it damages
/ / .
tm.m : / / t
/.tm
• Exposure of this artery to its branch to the superficial femoral artery
. m
• Exposure of the medial femur condyle paying attention to preserve the integrity of
t p ss
p
necessitates a more extended approach.: /
the integrity of syndesmotic ligaments and
t p ss : /
periosteum and medial collateral ligament (Fig. 49.7)
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 49.5
b oooo k
b o o FIG. 49.6
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt FIG. 49.7 t
hhtt FIG. 49.8
STEP 1 PEARLS
PROCEDURE • A groove is made in the remaining articular
e rrss
Step 1: Preparation of Talar Dome and Tibial Artery
k e k e rrss
e
surface posterior to the lesion to accomplish
the afferent vessel to the graft.
o o
o o k o o o k
• Débridement of OCL lesion to stabilize articular margins and bleeding cancellous
o o
• Deep cystic lesions are cleaned and débrided
o
eebb b b to get filled by cancellous bone prior to graft
bone (Fig. 49.8).
ee/ e
/ e b ee/
• The edges are cut square with a fine chisel for correct geometric fitting of the allo-e
/ e b insertion.
• If the perifocal bone is very sclerotic, multiple
graft.
: / / t
/ m
.t.m : / / t
/ m
.t.m drilling and/or microfracturing are done to
t p ss:
p /
• The dimensions of the lesion are measured and marked (Fig. 49.9).
t p ss:
p /
• The tibial artery is exposed through a longitudinal incision and exposure of the tarsal
ensure for better bone healing.
tunnel. t
hht t t
• Incomplete débridement to stable articular
Step 2: Harvesting of Vascularized Graft From Medial Femur Condyle margins may result in unstable fixation of the
graft and thus failed incorporation.
• Size and location of the graft are carefully determined and marked with four K-wires
e r
e s
rs eers
according to the shape needed to reconstruct the talar edge.
rs
• A fine saw and chisels are used to harvest the graft, paying attention not to damage
k k
STEP 2 PEARLS
o o
o o k the periosteal cover and the afferent vessels.
o o
oo k oo
• The medial condyle of the femur was identified
to fulfill the criteria of easy accessibility,
eebb 49.10).
ee / b
e b
• The graft is carefully developed from its bed with the use of four osteotomes (Fig.
/ e ee/e/ebb constant afferent artery, and ideal contour
with periosteal cover vascularized (Hintermann
: / / t
/ .
tm.m : / / t
/.tm
. m
• After having obliterated the descending genicular artery as proximal as possible by a et al., 2015).
• Slightly convergent bone cuts around the graft
t p ss : /
ligature, the artery branch is cut.
• Step-by-step wound closure is performed.
p t p ss
p : / may facilitate its development “en bloc.”
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
416 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 49.9
b oooo k
b o o FIG. 49.10
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt
t
hhtt
FIG. 49.11
k rrss
STEP 2 PITFALLS
e e k e rrss
e
o o
o o k
• Incomplete osteotomy of all four sides of the
bone block may result in a fracture of the graft. o o k
Step 3: Graft Insertion
o o o o
eebb ee/ e
/ b b / e b b
• The corticoperiosteal graft is inserted into the OCL in a press-fit manner, paying
e attention:
ee / e
: / / t
/ m
.t.m : / / t m
.t.m
• To get a surface without any step.
/
STEP 3 PEARLS
t p ss:
p / t p ss:
p /
• To preserve the periosteum layer on the articulating surface (Fig. 49.11).
t
hht t
• In most instances, the contours of inserted
graft overtop slightly the surrounding articular
surface, as seen in a fluoroscopic check. This
t
hht t
• If primary stability is critical, a screw fixation is used (2.5 mm cannulated headless
screw; Fig. 49.12).
• The periosteum is fixed by interrupted 2-0 sutures to the base of deep deltoid
will disappear by the remodeling process
ligament.
following the incorporation.
• The afferent vessel is brought through the prepared groove to the posterior aspect
k e r
e s
rs k eers
of the talus and through a hole in the posterior capsule between the flexor digitorum
rs
longus and flexor hallucis longus tendon into the tarsal tunnel.
o o
o o k
STEP 3 PITFALLS
o oo k o
• The Hintermann distractor is removed.
o o
eebb • A too big graft will overtop significantly the
articular surfaces and thus hinder a regular
ee/ e
/ b
e b e /e/ebb
• The medial malleolus is reduced, and fixation by two screws is performed.
• For a lateral OCL, the talus is reduced within the mortise and the ATFL is reattached
e
reposition of medial malleolus and a smooth
joint movement.
: / / t
/ .
tm.m to the fibula.
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : /
B
tp pss : /
t
hht t t
hht t FIG. 49.12
ke rrss
Step 4: Microsurgical Anastomosis
e keerrss
b ooook o ook oo
• Microsurgical anastomosis of the artery pedicle to the tibial artery is done (Fig.
b o b
eeb 49.13).
e /e/e b
• If possible, also the accompanying veins are anastomosed.
e ee/e/e b
: / / t
/ m
.t.m OUTCOMES
: / / t
/ m
.t.m
POSTOPERATIVE CARE s
t pp
AND
s : /
EXPECTED
t ppss : /
t
hhtt t
hhtt
• The foot is kept strictly immobilized and elevated during the first 4 days to prevent
mechanical failure at the anastomosis site.
• Low molecular heparin is used to prevent thrombosis during 4–8 weeks.
• A soft cast is used to protect the ankle during the first 8 weeks.
rrss rrss
• Only partial weight bearing is permitted during the first 8 weeks.
o kkee the healing and remodeling process.

o k e
• Standard radiographs and CT scan are used after 8 weeks and 4 months to assess
k e
oo o
eebb EVIDENCE e b o o o
• Athletes should anticipate a return to sports in 6–9 months after surgery.
b e b o
b o
m ee/ / e
m ee/ / e FIG. 49.13
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
Adams Jr SB, Viens NA, Easley ME, Stinnett SS, Nunley II JA. Midterm results of osteochondral lesions
t t p
t ss:
p t t p
t ss:
of the talar shoulder treated with fresh osteochondral allograft transplantation. J Bone Joint Surg [Am]
p STEP 4 INSTRUMENTATION/
hht hht
2011;93-A:648–54.
IMPLANTATION
A retrospective study of eight patients in which the authors reported very satisfactory midterm
results, indicating that structural fresh allograft transplantation can be a successful surgical option • A microscope and skills in microscopic surgery
in the treatment of large osteochondral defects of the talar shoulder (Grade I recommendation; are mandatory to perform the microsurgical
Level IV evidence). anastomosis.
Al-Shaikh RA, Chou LB, Mann JA, Dreeben SM, Prieskorn D. Autologous osteochondral grafting for
k e r
e ss
talar cartilage defects. Foot Ankle Int 2002;23:381–9.
r k eers
rs
A retrospective study of 19 patients in which the authors reported very satisfactory midterm results,
o o
o o k oo k
indicating that autologous osteochondral grafting is an effective salvage procedure following failed
o o oo
eebb b b
previous procedures and for patients with longstanding symptoms (Grade I recommendation; Level
IV evidence).
ee/ e
/ e b ee/e/e b
Hangody L, Füles P. Autologous osteochondral mosaicplasty for the treatment of full-thickness defects
• Continuous passive motion, as started on the
fifth day and continued during 8 weeks, may
: / / t
/ .
tm.m : / / t. m
. m
of weight-bearing joints: ten years of experimental and clinical experience. J Bone Joint Surg [Am]
/ t
improve restoration of articular function and
remodeling process at the graft site.
2003;85-A(Suppl. 2):25–32.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
418 hht
A 10-year follow-up study of 831 patients in which the authors reported very promising results,
indicating that autologous osteochondral mosaicplasty appears to be an alternative for the treat-
k e r
e s
rs k eers
r s
ment of small- and medium-sized focal chondral and osteochondral defects of the weight-bearing
o o
o o k o
evidence).
ooo k
surfaces of the knee and other weight-bearing synovial joints (Grade I recommendation; Level IV
o o
eebb e e
/ebb e / e
/ b
e b
Hintermann B, Wagener J, Knupp M, Schweizer C, J Schaefer D. Treatment of extended osteochondral
/
lesions of the talus with a free vascularised bone graft from the medial condyle of the femur. Bone
e e
: / / t
/ .
t m
. m
Joint J 2015 Sep;97-B(9):1242–9.
: / / t .
t m
. m
A prospective study of 14 patients in which the authors reported very satisfactory midterm
/
t p ss
p : / ss : /
results, indicating that treatment of a large OCL of the shoulder of the talus with a vascularized
t p p
t
hht t t
corticoperiosteal graft taken from the medial condyle of the femur may be a safe, reliable method
hht t
of restoring the contour of the talus in the early- to mid-term (Grade I recommendation; Level IV
evidence).
Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular
techniques. Plast Reconstr Surg 1975;55:533–44.
The authors reported on two cases demonstrating the potential promising use of a vascularized
k eers
rs k er
ers
bone graft in limb salvaging (Grade I recommendation; Level V evidence).
s
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh50
PROCEDURE
t hht
Anterior
rss Ankle Impingement rs s
o kkee r o kkee r
o
eebb o o
Juan Bernardo Gerstner and Christina
e b oo o
Kabbash
b e b o
b o
m e e/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht hht
• Painful ankle dorsiflexion due to impingement of bone and/or soft tissue in the ante-
rior ankle joint
• Severe anterior ankle arthritis with loss of
anterior joint space, or anterior subluxation of
• Loss of ankle dorsiflexion due to anterior tibiotalar spurs the talus, will do poorly with decompression.
• Not recognizing subtle cavus and associated
k eers
EXAMINATION/IMAGING
rs k er
erss instability.
• Neglected calcaneal fractures with talar angle
b ooook b ooook
• Physical examination is consistent with anterior ankle joint swelling, anterior ankle
b
joint tenderness to palpation, and pain with forced dorsiflexion of the ankle. Passive
o o
declination causing anterior impingement
without osteophytes.
eeb / e e b
ankle dorsiflexion may be restricted secondary to a bony block. Crepitus may be
ee / ee/ e
: // t/ tm
present with passive and active ankle range of motion (ROM).
. . m / /t .tm. m
• Lateral weight-bearing radiographs will often demonstrate tibial and corresponding
: / • For anterior tibiotalar spurs associated with
ss : / ss : /
talar spur(s). Loose bodies and nondisplaced fractures of the spurs may be noted in
t p p tp p
chronic instability, lateral ligament reconstruction
t
hht t
the anterior ankle gutter (Fig 50.1A).
t
hht t
• Magnetic resonance imaging (MRI) will show anterior ankle effusion and synovitis
may also be indicated after decompression.
• Decompression of hypertrophied anterior
inferior talofibular ligament, Bassett’s ligament.
as well as osteophytes (Fig. 50.1B). Hypertrophied Bassett’s ligament may be • Inflammatory arthropathy.
noted (Fig 50.1C). • Concurrent talar and tibial osteochondral lesions.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k A
o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
B
t p ss
p : / t p ss
p :
C /
t
hht t t
hht t
FIG. 50.1
419
t t p
t ss:
p t t p
t ss:
p
420 hht
PROCEDURE 50 Anterior Ankle Impingement hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs FIG. 50.2
k er
erss FIG. 50.3
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp p ss : /
t
hht t t
hht t
keerrss keerrss
FIG. 50.4

TREATMENT OPTIONS
: / / t
/ m
.t.m / t m
.t.m
• Osteochondral cysts and cartilage lesions may be noted throughout the ankle
: / /
• Cortisone injections
joint, indicating more severe disease and a worse long-term prognosis.
t
hhtt
• Platelet rich plasma and hyaluronic acid
where available as standard, not experimental
procedures
t
hhtt
• Computed tomography (CT) will show size and location of spurs that may affect por-
tal placement, as well as subchondral cyst and sclerotic bone formation in the ankle
joint and possibly in adjacent joints as well.
• Brace for ankle immobilization • A positron emission tomography scan can be useful.
• Anterior ankle débridement (open or
arthroscopic) SURGICAL ANATOMY
k rrss
• Anterior ankle débridement with distraction
e earthroplasty
k e rrss
e
• The superficial and deep peroneal nerves and saphenous nerve are at risk with inci-
o o
o o k
• Total ankle replacement
o o
o o k o
sions and portal placement (Fig 50.2).
o
eebb • Ankle fusion
ee/ e
/ b
e b ee/ e
/ b
e b
• The dorsolateral branch of the superficial peroneal nerve is often at risk with the an-
terolateral portal. It can often be visualized with traction on the fourth toe (Fig 50.3).
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The saphenous nerve runs along the anterior aspect of the medial gutter and is at risk
t p ss:
p / t p ss:
p /
with the anteromedial portal.
• The tibialis anterior serves as a landmark for the anteromedial incision or portal
t
hht t t
hht
placement. t
• The peroneus tertius or the extensor digitorum longus (EDL) serves as a landmark for
the anterolateral incision or portal placement.
POSITIONING PEARLS
POSITIONING
k e r
e ss
• A spinal needle placed with fluoroscopic
r
guidance and subsequent insufflation of the
k eers
rs
• The patient is positioned supine with a bump under the hip to place the foot into a
o o
o o kankle joint with normal saline may be useful
o o
oo k
neutral rotation. A sterile bump is placed under the posterior ankle for stability and to
oo
eebb b b
for creating portals.
• Releasing traction and dorsiflexion of the ankle
creates more working space for anterior ankle
ee/ e
/ e b e /e/e b
raise the leg for ease of intraoperative fluoroscopy.
• A thigh tourniquet is applied prior to prepping and draping.
e
spur débridement.
: / / t
/ .
tm.m : / / t
/.tm
. m
• If arthroscopy is to be performed, a well-padded well-leg holder is utilized to keep
t p ss
p : / t p ss : /
the hip and knee flexed and provide resistance to a sterile ankle traction apparatus.
• A C-arm may be positioned for lateral imaging (Fig 50.4).
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 50 Anterior Ankle Impingement 421
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m C
t p ss
p : /
tp pss : /
t
hht t t
hht
FIG. 50.5
t
ke rrss
PORTALS/EXPOSURES
e keerrss
b ooook
Open
b ooook b oo
eeb ee/e/e b ee/e/e
• For severe anterior ankle arthritis, or if arthroscopy is not an option, an open anteriorb
: / / t
/ m
.t.m : / / t
ankle débridement may be performed. The anteromedial incision is about 3 cm in
/ m
.t.m POSITIONING PITFALLS
t pp : / t pp s : /
length, centered over the tibiotalar joint, and is medial to the tibialis anterior. This will
ss s
allow for visualization of the medial gutter. The anterolateral ankle incision is made
• Not dorsiflexing the ankle for spur débridement
places the anterior neurovascular structures
t
hhtt t
hhtt
lateral to the peroneus tertius or EDL, also 3 cm in length and centered over the ankle
joint.
at risk – both for open and arthroscopic
procedures.
Arthroscopic POSITIONING EQUIPMENT
rrss rrss
• With the ankle in traction, the anterior medial portal is placed about 1 cm in length,
Arthroscopy
o k e
k e o k e
centered over the tibiotalar joint, and medial to the tibialis anterior. Inserting a spinal
k e • Well-leg holder
o
eebb o o saline distracts the ankle joint.
e b o
b o o
needle prior to portal placement and insufflating the ankle with 10–15 cc of normal
e b o
b o • Ankle distractor
• 2.7-mm or 4.0-mm arthroscope, shaver, and
e / / e
• Intraoperative fluoroscopy may help with the placement of this needle.
m e m ee/ / e burr with protection sleeve
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
• The incision is made with a scalpel through the skin only. Clamps are used to dissect
down to the capsule and to protect the saphenous nerve, vein, and tibialis anterior
• Fluoroscopic imaging
Open
t t p
t ss:
p t t p
t ss:
tendon. A blunt obturator is used to penetrate the capsule and enter the ankle joint
p • Gauges, osteotomes, rongeurs
(Fig 50.5).
hht hht
• The anterolateral ankle portal is placed lateral to the peroneus tertius after attempt-
ing to visualize the path of the superficial peroneal nerve. The incision is ≤1 cm in
• Fluoroscopic imaging
POSITIONING CONTOVERSIES
length at the level of the ankle joint and through the skin only. Clamps are used to
dissect down to the ankle capsule, which is then penetrated with a blunt obturator or • Use of an ankle distractor
k e r
e s
rs
spinal needle as for the anteromedial portal.
k eers
rs • Use of a tourniquet
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
422 hht
PROCEDURE PEARLS PROCEDURE
k e r
e ss
• Remove as little as possible from the anterior
r
tibia; remove generously on the talar side.
k e
Step 1: Open
ers
r s
o o
o o kOverresection of the anterior lip of the
oooo k
• The ankle capsule is bluntly dissected off of the anterior ankle joint with the ankle
o o
eebb tibia may result in instability and anterior
subluxation of the talus.
ee/ e
/ebb e / / b
e b
held in a neutral to slight dorsiflexion position to protect the overlying neurovas-
e
cular structures and tendons and improve visualization. A large soft tissue re-
e
• Cavovarus ankle alignment with a history
of instability is often associated with
: / / t
/ .
t m
. m : / / / .
t m
. m
tractor is utilized to elevate the overlying skin flap and protect the neurovascular
t
anteromedial tibiotalar spurs.
t p ss
p : / structures.
t p ss : /
• Bone gauges or osteotomes are used to remove the anterior osteophytes across the
p
PROCEDURE PITFALLS
t
hht t t
hht t
ankle joint with the ankle help in maximum dorsiflexion. Maximum dorsiflexion pro-
tects the anterior talar cartilage. Care is taken not to overresect the tibia as this will
• Excessive removal of the anterior tibial lip result in instability. However, generous resection of the talar spurs can be performed
will often result in further instability and rapid to ensure all impingement is addressed. A bone rasp is utilized to smooth the anterior
resected surfaces.
k e s
progression of ankle arthritis.
rrs
• Increasing ROM in a severely arthritic ankle
e errss
• Intraoperative fluoroscopy is used to check for full resection with the ankle held in
k e
b ooook joint may also increase motion associated
ankle pain.
b ooook dorsiflexion. Rotating the ankle will allow for full visualization of the anterior tibio-
b o o
talar joint. The ankle can be plantar flexed to examine the anterior talar cartilage
eeb ee/ e
/ e b surface.
ee/ e
/ e b
: // t/.tm
. m : / /t/ tm
• Open packing of any large anterior bone cysts identified preoperatively by radio-
. . m
graphs, CT, or MRI can be performed by creating a small bone window in the anterior
t p ss
p : / tp ss : /
tibial metaphysis after extending the incisions if needed, for exposure.
p
t
hht t t
hht t
• Microfracture of talar lesions can also be performed at this time with a 2.0-mm wire
or drill bit.
• The ankle joint is thoroughly irrigated to flush debris and loose bodies.
• The incision area is closed as per surgeon preference.
• The ankle is immobilized in a well-padded dressing (splint, or controlled ankle move-
keerrss keerrss
ment [CAM]).
b ooook o ook
Step 2: Arthroscopic
b o b oo
• A 2.7-mm arthroscope with a high flow system are recommended. Shaver size is
per surgeon preference. However, a 4.0-mm burr with a protective sleeve is recom-
: / / t
/ m
.t.m : / / t m
.t.m
mended for spur removal.
/
• A shaver is used to resect hypertrophic synovium from the anterior ankle joint to
t
hhtt t
hhtt
expose both the tibial and talar spurs. Removal of the foot from traction with ankle
dorsiflexion improves visualization of the spurs and protects the anterior soft tis-
sue.
• A 4.0-mm burr with a protective sleeve is recommended for spur removal.
• Care is taken not to overresect the tibia as this will result in instability. However,
k e rrss
e k e rrss
e
generous resection of the talar spurs can be performed to ensure all impingement is
addressed.
o o
o o k o o o k o
• If talar microfracture is to be performed, it is recommended that this be done first as
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
removal of the spurs is more likely to cloud the field with bleeding.
• The ankle joint is thoroughly irrigated to flush debris and loose bodies.
: / / t
/ m
.t.m : / / t m
.t.m
• Portals are closed as per surgeon preference.
/
t p ss:
p / t p ss:
p /
• The ankle is immobilized in a well-padded dressing (splint or CAM).
t
hht t t
• Fig. 50.6A shows anterior talar spur with the foot in traction. Fig. 50.6B shows an-
hht t
terior tibiotalar “kissing” spurs with the foot in dorsiflexion. Resection anterior tibial
spur with burr is shown in Fig. 50.6C. Fig. 50.6D depicts resection of an anterior talar
spur with burr, and Fig. 50.6E depicts resected spurs with the ankle in maximum
dorsiflexion.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 50 Anterior Ankle Impingement 423
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m B
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
C D
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
E
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
FIG. 50.6
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
424 hht
CONTROVERSIES POSTOPERATIVE CARE AND EXPECTED OUTCOMES
k e r
e ss
• Débridement of spurs may accelerate ankle
r
arthritis and pain in a severely arthritic ankle,
k eers
r s
• The incisions are examined at 1 and 2 weeks postoperative.
• Ankle ROM exercises are initiated at 2 weeks, pending adequate healing of the inci-
o o
o o kor one with chronic instability.
oooo k
sions.
o o
eebb • Whether to partially or completely resect the
anterior tibial spur, it may be providing stability
ee/ e
/ebb / e b b
• In the absence of microfracture or bone grafting of osseous cysts, immediate weight
ee / e
bearing is allowed with the ankle immobilized in a cast or CAM walking boot.
to anterior subluxation.
: / / t
/ .
t m
. m : / / t . m
. m
• Ankles without signs of additional arthritis or talar lesions will be allowed a full return
/ t
t p ss
p : / ss : /
to activity in 10 weeks.
t p p
t
hht t t t
• An ankle with severe arthritis or talar osteochondral lesions will be allowed a full re-
hht
turn to activity at 4–6 months.
See also Video 50.1, Anterior Bony Impingement.
EVIDENCE
k eers
rs k er
erss
Bauer T, Breda R, Hardy P. Anterior ankle bony impingement with joint motion loss: the arthroscopic
b ooook b ooook b o
resection option. Orthop Traumatol Surg Res 2010;96(4):462–8.
o
eeb b b
This study presents an arthroscopic surgery technique for the treatment of bony anterior ankle
ee/ e
/ e ee/ e
/ e
impingement with tibiotalar joint spur resection, anterior release, and immediate rehabilitation
: // t/.tm
. m
protocol.
: / /t/.tm. m
Ferkel RD, Chams RN. Chronic lateral instability: arthroscopic findings and long-term results. Foot
t p ss
p : / tp pss : /
Ankle Int 2007;28(1):24–31.
This article highlighs the presence of intraarticular pathology that can be addressed by scoping it
t
hht t t
hht t
first and then performing a modified Brostrom procedure.
Gerstner JB. Chronic ankle instability. Foot Ankle Clin N Am 2012;17:389–98.
Review of new arthroscopic-assisted procedure for chronic ankle instability.
Moon JS, Lee K, Lee HS, Lee WC. Cartilage lesions in anterior bony impingement of the ankle. Arthros-
copy 2010;26(7):984–9.
keerrss keerrs
A therapeutic case study to find a correlation between spur severity, clinical characteristics, and
s
articular cartilage lesions.
ook ook
O’Kane JW, Kadel N. Anterior impingement syndrome in dancers. Curr Rev Musculoskelet Med
b
eeboo /e bbo
2008;1(1):12–6.
o e bboo
An article regarding a common problem in dancers occurring primarily secondary to the repetitive
/
m ee /e m e /e
forced ankle dorsiflexion inherent in ballet, its progression, and treatment.
e
: / /
/ t
/ .t.m 2008;16(1):29–38. v.
: / /
/ t
/ .t.m
Sanders TG, Rathur SK. Impingement syndromes of the ankle. Magn Reson Imaging Clin N Am
t t ppss : t t pps :
Review article about the six types of ankle impingement, including a description of the typical clini-
s
hhtt hhtt
cal presentation, anatomy, pathophysiology, imaging, and the various treatment options available.
Tol JL, Slim E, van Soest AJ, van Dijk CN. The relationship of the kicking action in soccer and anterior
ankle impingement syndrome: a biomechanical analysis. Am J Sports Med 2002;30(1):45–50.
Biomechanical analysis that demonstrates that spur formation in anterior ankle impingement syn-
drome is related to recurrent ball impact, which can be regarded as repetitive microtrauma to the
anteromedial aspect of the ankle.
k e rrss
e rrss
Ross KA, Murawski CD, Smyth NA, Zwiers R, Wiegerinck JI, van Bergen CJ, Dijk CN, Kennedy JG.
e
Current concepts review: arthroscopic treatment of anterior ankle impingement. Foot Ankle Surg
k e
o o
o o k o o
o o k
2017;23(1):1–8.
o o
eebb b b
This review article summarizes the results of arthroscopic treatment of anterior ankle impinge-
ee/ e
/ e b / e e b
ment syndromes, discussing the etiology, clinical presentation, diagnosis, surgical technique, and
postoperative rehabilitation.
ee /
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh51
PROCEDURE
t hht
Realignment
rss Surgery for ValgusrAnkle
s s
k ee r k ee r
ooooOsteoarthritis
eebb
k ooook / e bb / e b o
b o
m ee /e m ee / e
Nicola Krähenbühl and Markus
: / t
///t. . m
Knupp
: / /
/ t
/ .
t . m
s
tps : ss :
hhtttp t
hhtt p
t p
• Physically active patients with lateral ankle joint degeneration associated with valgus • Loss of >50% of tibiotalar joint surface
k eers
rs k errss
malalignment (e.g., posttraumatic malalignment, ankle joint instability)
e
(anteroposterior radiographs, magnetic
resonance imaging, arthroscopy) may be
b ooook b ooook
• Lateral osteochondritis dissecans of the talus associated with valgus malalignment
• Realignment prior to total ankle replacement (TAR) or ankle fusion
b o o
treated with TAR or ankle fusion.
eeb Examination/Imaging ee/ e

/ e b ee/ e
/ e b • Lack of compliance with the postoperative
non–weight-bearing program caused by
// t/.tm
. m / /t/.tm. m
• Assessment of the patients gait and the entire alignment of the lower extremity.
: :
neurologic disease or poor health status may
be treated with ankle fusion.
ss : / ss : /
• While the patient is sitting with free-hanging feet, perform the anterior drawer test
t p p tp p
t
hht t t
hht t
and talar tilt test to assess ankle joint stability. Furthermore, assess the inversion/
eversion force (function of posterior tibial and peroneal muscles) and subtalar range INDICATIONS CONTROVERSIES
of motion. Evaluate to which a present deformity is correctable. • Inflammatory, systemic joint diseases
• Ask the patient to go to tiptoe position and analyze the foot for varisation of the heel incorporating the ankle joint are usually treated
und supination of the foot. with TAR or ankle fusion.
keerrss
•

r ss
A weight-bearing anteroposterior radiograph of the ankle, lateral and dorso-
kee r
• Tobacco use should be considered as a
relative contraindication for supramalleolar
b ooook b ooook
plantar radiographs of the foot, and a Saltzman hindfoot view are necessary to
assess the nature and location of the deformity (supramalleolar, through the ankle
b oo
osteotomy.
• Operative technique (medial closing vs. lateral
eeb /e e b /e e b
joint, inframalleolar, or a combination). If a deformity at the level of the knee joint or
ee / ee
the femur can not be excluded clinically, long leg radiographs are also necessary /
open wedge, ± fibula osteotomy) used for
the correction depends on the extent of the
(Fig. 51.1).
: / / t
/ m
.t.m : / / t
/ m
.t.m deformity and soft tissue condition.
• The medial distal tibial angle (angle between the tibial axis and the tibial joint surface)
t
hhtt t
hhtt
is measured on weight-bearing anteroposterior radiographs for assessment of the de-
formity. The required correction can be measured out of the radiographs or calculated
with the mathematical formula: tan α = H/W, where α is the angle to be corrected, H
is the wedge height in millimeters, and W is the tibial width.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m FIG. 51.1
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t 425
t t p
t ss:
p t t p
t ss:
p
426 hht
PROCEDURE 51 Realignment Surgery for Valgus Ankle Osteoarthritis hht
TREATMENT OPTIONS • Next to plane weight-bearing radiographs, (weight-bearing) computed tomography
k e r
e ss
r
shoe modification, orthoses) should always be
k eers
(CT) scans and magnetic resonance imaging (MRI) are not routinely required. How-
r s
ever, they could be of value when assessing rotational malalignment, osteochondral
o o
o o kconsidered before surgery is performed.
oooo k
lesions, and tendon disorders.
o o
eebb • Malalignment that is due to forces from
the neighboring structures, such as
ee/ /ebb e / / b
e b
• Combined single-photon emission and computed tomography (SPECT) scan has
e e
been found to be a valuable tool for assessment and staging of ankle osteoarthritis.
e
unbalanced muscle forces, can be treated
: / / t
/ .
t m
.
with physiotherapy or footwear modifications.
m : / / t
/ .
t m
. m
• Distinction between congruent and incongruent joints is helpful in determining the
t p ss
Deforming forces, such as forefoot
p : /
abnormalities, may require other surgical
t p ss : /
type of osteotomy performed (tibia only vs. tibia and fibula).
• The aim of surgical correction is to unload the lateral tibiotalar joint and talofibular
p
t
hht t
procedures than supramalleolar osteotomies.
• An alternative surgical treatment is the medial
calcaneal displacement osteotomy. Commonly,
t
hht t
joint. Most authors recommend an overcorrection of 3–5°.
• Patients with an excessive heel valgus may need an additional calcaneus osteotomy
to shift the heel contact point medially to the mid-diaphyseal tibial axis.
correction of any kind of malalignment is best
performed at the level of the deformity. • After ankle fracture, malunion of the distal fibula with shortening and external rotation
may be the cause of the valgus deformity. An additional fibula osteotomy may be
k ee s
• Resurfacing of destroyed articular surfaces
rrs
by TAR may allow for earlier weight bearing,
k er
erss
necessary in these cases.
b ooook but may not fully correct the deformity and

instability and thus may fail in the case of an
b ooook
• Additional rotational or translational deformities must be taken into consideration
when planning the osteotomy.
b o o
eeb asymmetric wear pattern.
• Ankle fusion may enable high activity, but
e
SURGICAL
e/ e
/ e b
ANATOMY ee/ e
/ e b
compensatory movements of adjacent foot
// t/.tm
.
joints may cause degenerative osteoarthritis.
: m : / /t/.tm. m
• A medial or lateral approach to the distal tibia/fibula is used.
t p ss
p : / ss : /
• In the case of a medial approach, the great saphenous vein and the saphenous
tp p
t
hht t t
hht t
nerve usually lie anterior to the incision. The neurovascular bundle runs along
the anterior border of the medial malleolus. Be also aware of the posterior tibial
tendon, which lies immediately on the posterior aspect of the medial malleolus
(Fig. 51.2).
• In the case of a lateral incision, take care of the sural nerve and the short saphenous
keerrss keerrss
vein. Both run dorsal to the line of incision and are usually not seen during this pro-
b ooook b ooook
cedure. However, extended proximal dissection may require identification, exposure,
oo
and protection of the branches of the superficial peroneal nerve. Cauterization of
b
some of the branches of the peroneal artery, which lie deep to the medial surface of
the distal fibula, may be necessary (Fig. 51.3).
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
Sural nerve
k e rrss
e
Great saphenous vein
k e rrss
e
o o
o o k
and saphenous nerve
o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / Medial
malleolus
t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb
FIG. 51.2
ee/ e
/ b
e b
ee/e/ebb FIG. 51.3
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 51 Realignment Surgery for Valgus Ankle Osteoarthritis 427
POSITIONING POSITIONING PEARLS
k e r
e ss k eers
r s
• Medial approach: Supine, ipsilateral knee in slight flexion with a sandbag under the
r
calf. A support can be placed on the opposite iliac crest to tilt the table away from
operated leg is elevated with cushions or the
o o
o o k the surgeon.
oooo k o o
opposite leg is lowered. In addition, lateral
eebb / e bb
• Lateral approach: Lateral decubitus position or supine with a sandbag under the but-
tock of the affected limb.
ee /e ee/ e
/ b
e b radiographs can be taken more easily.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Portals/Exposures
t p ss
p : / t p ss
p : / POSITIONING PITFALLS
t
hht t t
hht t
• We recommend arthroscopy of the ankle joint before the osteotomy is performed.
• Medial approach: A 10-cm longitudinal incision is made beginning over the medial
malleolus and extending proximally over the distal tibia. The skin flaps are mobilized,
ensure the appropriate implementation of the
procedure.
with care taken not to damage the saphenous vein or nerve, which runs along the
anterior border of the medial malleolus. The posterior tibial tendon, which lies im- POSITIONING EQUIPMENT
k eers
rretracted posteriorly.
k er
ers
mediately on the posterior aspect of the medial malleolus, must be identified and
s s • A radiolucent operating table
• A tourniquet can be used to ensure optimal
b ooook o ook
• Lateral approach: A 10-cm longitudinal, slightly curved incision is made along the
b o b o o
eeb e / e
/ e b e / e
/ e b
anterior margin of the distal fibula. If the incision needs to be extended distally, it is
curved ventrally to the end just distal to and anterior of the lateral malleolus. At the
e e
: // t/.tm m : / /t/.tm m
distal end of the incision, the anterior syndesmosis is exposed. The lateral branch
. . POSITIONING CONTROVERSIES
t p p : / tp p : /
of the sural nerve and the short saphenous vein run dorsal to the line of incision and
ss ss
are usually not seen during this procedure. However, extended proximal dissection
• In order to compare the corrected alignment
of the foot and ankle intraoperatively, the
t
hht t t
hht t
may require identification, exposure, and protection of the branches of the superficial
peroneal nerve. Cauterization of some of the branches of the peroneal artery, which
contralateral ankle may also be draped.
lie deep to the medial surface of the distal fibula, may be necessary.
PROCEDURE 1 • If tibiotalar joint débridement or exostectomy
keerrss
Step 1: Medial Closing Wedge Osteotomy
keerrss is required, an anterior capsulotomy is
b ooook b ooook
• The tibia is exposed with minimal periosteal stripping.
b oo
performed. There is no need to expose the
joint if only a supramalleolar osteotomy is
eeb ee/e/e b
• The plane of the osteotomy is determined using a C-arm. Two Kirschner wires (K-
ee/e/e b planned.
• The ankle joint is covered by an extensive
/ / t
/ m / / t
/ m
wires) are placed from the medial cortex into the physeal scar or, in case of a mal-
.t.m .t.m
union, at the apex of the deformation. K-wire placement is done according to the
: :
fat pad that contains a venous plexus and
requires partial cauterization.
ss : /
planned correction (Fig. 51.4).
t pp t ppss : /
t
hhtt t
hhtt
• The periosteum is then incised at the level of the osteotomy and elevated from the
bone using a scalpel or a periosteal elevator.
• The osteotomy is performed along the K-wires. The bone wedge is removed (Fig. 51.5).
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb K-wires
ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m

FIG. 51.4
t p ss
p : /
t p ss
p : / FIG. 51.5
hhtt t t
hht t
t t p
t ss:
p t t p
t ss:
p
428 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
b ooook
STEP 1 PEARLS
b ooook b oo
eeb • If scar tissue at the anterior syndesmosis has
ee/e/e b ee/e/e b
/ /
manipulation of the distal fibula fragment, a
: m
.t.m
to be débrided or cut off the tibia to facilitate
/ t : / / t
/ m
.t.m
t pps
syndesmosis screw may be necessary.
s : / t ppss : /
t
• Sagittal plane deformity of the distal tibial
hhtt
joint surface can be addressed by adding an
anterior closing wedge osteotomy to correct
t
hhtt Osteotomy
the flexion deformity and a posterior closing
Screws
wedge osteotomy to correct the extension
deformity. The rotational center of the ankle
k e rrss
in the lateral view should be in line with the
mid-diaphyseal axis of the tibia.
e k e rrss
e
o o
o o k o o
o o k o o
ee/ e
/ b
e b ee/ e
/ b
e b
• The loss of the medial hinge mechanism of
/ / t
/ m
.t.m
the far cortex favors the risk for rotational or
: : / / t
/ m
.t.m
Corrected axis
after the closing
t p ss:
p /
translational malpositioning and postoperative
t p ss:
p / wedge osteotomy
t
displacement of the osteotomy.
hht t
• The risk of secondary dislocation can be
lowered by using implants that provide angular
t
hht t
stability and by leaving a hinge of bone
osteotomy and periosteum at the far cortex
when performing the tibial osteotomy.
k e r
e s
rs k r
ee s
rs FIG. 51.7
o o
o o k
o o
oo k oo
eebb b b
IMPLANTATION
• The tibial osteotomy is typically secured with a
ee/ e
/ e b e /e/e b
• After the distal fragment is fixed on an angular stable plate, the osteotomy is closed
e
medial locking plate.
/ /
• The fibula osteotomy can be secured with a
: t
/ .
tm.m : / / t
/.tm
. m
by varus stress to the foot or by using a compression device (Fig. 51.6).
one-third tubular plate.
t p ss
p : / t p ss : /
• Finally, the plate is fixed on the proximal fragment (Fig. 51.7). A C-arm is used to
confirm the overall position of the osteotomy and implant intraoperatively.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k eerrss
o o
o o k o ooo k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p /
t p ss:
FIG. 51.9
p /
t
hht t t
• Correction of the deformity must be performed
• The tendon sheath of the posterior tibial tendon is reapproximated with absorbable at the center of rotation angulation of the
sutures, and the subcutaneous tissues and skin are closed. Do not over-tighten the deformity (CORA) to avoid relative translational
malpositioning of the distal (ankle) and
e r s
rs e rs
posterior tibial tendon sheath because it may create narrowing and tenosynovitis.
rs
• If an additional fibula osteotomy is necessary, a longitudinal lateral skin incision is
k e k e
proximal (tibial shaft) fragments.
o o
o o k oo k
performed. Branches of the superficial peroneal nerve are retracted.
o o oo
• Shortening of the medial tibia by the closing
wedge osteotomy will theoretically decrease
eebb ee / b
e b
• To rotate the fibula, an oblique cut from dorsally-proximally to anteriorly-distally
/ e e /e/e
is performed, which allows rotation, shortening, or lengthening of the distal fibula
e
bb the tension of the posterior tibial tendon,
which is often already impaired in valgus ankle
(Fig. 51.8).
: / / t
/ .
tm.m : / / t
/.tm
. m osteoarthritis. Reevaluation of the heel, posterior
tibial tendon, and the forefoot position has to be
t p ss
ula and tibia (Fig. 51.9).
p : / t p ss
p : /
• Postoperative radiographs are taken to confirm an appropriate correction of the fib-
done after the osteotomy is performed.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
430 hht
k e r
e s
rs k
K-wire
eers
r s Open
o o
o o k
Osteotomy of
oooo k o o
osteotomy
eebb the fibula

(Z-osteotomy)
ee/ e
/ebb Z-osteotomy
ee/ e
/ b
e b
: / / t
/ .
t m
. m Syndesmosis
: / / t
/ .
t m
. m
Wound
edges
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Valgus of the distal
Corrected,
tibial articular surface
neutral axis
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b

: // t/.tm
FIG. 51.10
. m
: / /t/.tm. m FIG. 51.11
t p ss
p : / tp ss
p : /
t
hht t t
hht t
STEP 2 PEARLS PROCEDURE 2
keer ss
• The lateral branch of the sural nerve and the
r
short saphenous vein run dorsal to the line
keerrss
Step 2: Lateral Open Wedge Osteotomy
b ooook of incision and are usually not seen during

this procedure. However, extended proximal
b ooook
• If the medial soft tissue does not allow a medial incision, a lateral opening wedge
b oo
eeb dissection may require identification, exposure,
and protection of the branches of the
ee/e/e b osteotomy can be performed.
e /e/e b
• The fibula is approached with a longitudinal lateral skin incision. Branches of the
e
superficial peroneal nerve.
: / / t
/ m
.t.m : / / / m
.t.m
superficial peroneal nerve are retracted. The distal tibia is exposed by further prepa-
t
t p : /
• Cauterization of some of the branches of the
ss
peroneal artery, which lie deep in the medial
p t p
is exposed.
pss : /
ration anterior to the fibula. At the distal end of the incision, the anterior syndesmosis
t
hhtt
surface of the distal fibula, may be necessary.
t
hhtt
• A Z-shaped osteotomy of the fibula is performed. Alternatively, an oblique osteotomy
(distal anterior to proximal posterior) can be used.
• The length of the Z-shaped fibular osteotomy is approximately 2–3 cm, starting dis-
tally at the level of the anterior syndesmosis.
• For correction of the tibia, a K-wire is drilled through the tibia, with the tip converging
rrss rrss
IMPLANTATION
o k e e
• Tibia: Angular stable plate
k o k e
k
to the medial cortex (Fig. 51.10).
e
• The osteotomy is then performed. A bone wedge is inserted, and stability is achieved
o
eebb o o
• Fibula: Screws or one-third tubular plate
e b o
b o o by plate fixation.
e b o
b o
m ee/ / e tures.
m ee/ / e
• The periosteum is routinely closed over the osteotomy with 2-0 absorbable su-
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
• Once the joint is congruent, the fibula is secured with screws (in the longitudinal limb
t t p
t ss:
p
• To avoid interference with the syndesmotic
t t p
t ss:
of the Z-osteotomy) or a one-third tubular plate (Fig. 51.11).
p
hht
ligaments when performing the Z-osteotomy
ADDITIONAL STEPS
of the fibula, we routinely direct the proximal
transverse cut anteriorly and the distal cut
hht
(which typically sits at the syndesmosis) Calcaneal Osteotomy
posteriorly. • If proper hindfoot alignment is not achieved after supramalleolar correction, a me-
k e s
• The gap of the tibia osteotomy can be filled
r rs
with allograft (i.e., Tutoplast, Tutogen Medical
e k eers
rs
dial sliding osteotomy of the calcaneus might be necessary. The calcaneus is ex-
posed by a lateral oblique approach and the osteotomy performed with a saw
o o
o o kGmbH, Neunkirchen, Germany) or autograft
(iliac crest bone).
o oo k
blade.
o oo
eebb ee/ e
/ b b /e bb
• A laminar spreader is inserted to open the osteotomy and stretch the tight soft tis-
e ee /e
sues. The tuber fragment is displaced medially as much as desired. Preliminary fixa-
: / / t
/ .
tm.m : / / t. m
. m
tion is done with one or two K-wires using a C-arm (Fig. 51.12).
/ t
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 51.12
b oooo k
b o o FIG. 51.13
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 51.14
• The K-wires are subsequently used for guiding a cannulated compression screw. The
rrss rrss
lateral bony step-off is tamped (Fig. 51.13).
o k e
k e k e
k e
• Closure of the skin is accomplished by interrupted sutures (Fig. 51.14).
o
• Insert K-wires over step incisions proximal
to the weight-bearing skin of the calcaneal
o
eebb o o
Correction of Forefoot Supination
e b o
b o o e b o
b o tuber to prevent irritation and necrosis of the
ee/ / e
• Flexible deformity: Repair and imbrication of the anterior delta ligament, spring
m m ee/ / e calcaneal fat pat.
• Usually one screw provides enough stability.
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
ligament and posterior tibial tendon (± augmentation with flexor digitorum tendon However, rotational stability is increased by
using two screws for calcaneal tuber fixation.
transfer).
t t p
t ss:
p t t p
t ss:
p
• Rigid deformity: Perform plantar-flexion osteotomy at the first cuneiform or the base
hht hht
of the first metatarsal. For major correction, perform a plantar-flexing arthrodesis of
the naviculocuneiform I joint.
• Aggressive release of the heel cord may result
Heel Cord Release in pushoff weakness.
• There is no general agreement on whether
k e r
e ss
extension and flexion).
k eerss
• Perform a Sinverskjöld test (assessment of dorsiflexion at the ankle with the knee in
r r or not heel cord release is necessary. There
is evidence that physical therapy may restore
o o
o o k o oo k
• If dorsiflexion of the ankle is decreased only with the knee in extension, a gastrocne-
o oo
the appropriate length of the heel cord in most
eebb ee e
/ b
e b ee/e
mius release is performed until 10° of dorsiflexion (knee in extension) is achieved.
/ /ebb
• If ankle dorsiflexion is decreased with the knee in extension and flexion, the Achilles
instances.
tendon is released.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
432 hht
POSTOPERATIVE PITFALLS POSTOPERATIVE CARE AND EXPECTED OUTCOMES
k e r
e ss
• Apart from perioperative complications such
r
as wound healing problems or infection,
k eers
r s
• The leg is elevated in the immediate postoperative period.
• A compressive dressing and splint are maintained for 2 days to diminish swelling.
o o
o o kpostoperative concerns include delayed union
o oo k o
• A short-leg partial weight-bearing cast is used for 8 weeks.
o o
eebb or nonunion of the osteotomy.
• Another potential complication is malunion,
ee/ e
/ebb / e b b
• If radiologic evidence of consolidation is present after 8 weeks, the patient advances
ee
gradually to full weight bearing. / e
resulting from inaccurate alignment of the
: / / t
osteotomy intraoperatively or postoperative
/ .
t m
. m : / / t . m
. m
• A rehabilitation program for strengthening, gait training, and range of motion is pre-
/ t
loss of position.
t p p : /
ss EVIDENCE ss : /
scribed 8 weeks after surgery, with gradual return to full activities as tolerated.
t p p
t
hht t t
hht t
Hintermann B, Knupp M, Barg A. Joint-preserving surgery of asymmetric ankle osteoarthritis with peri-
talar instability. Foot Ankle Clin 2013;18:503–16.
POSTOPERATIVE CONTROVERSIES Hintermann B, Knupp M, Barg A. Supramalleolar osteotomies for the treatment of ankle arthritis. J Am
• Removal of hardware is not recommended Acad Orthop Surg 2016;24(7):424–32.
k eers
rs
earlier than 8 months after surgery.
rrss
Knupp M, Stufkens SA, Bolliger L, Barg A, Hintermann B. Classification and treatment of supramalleolar
k ee
ook ook
• Between 1999 to 2013, 298 ankles (varus deformities. Foot Ankle Int 2011;32:1023–31.
b
eeboo
and valgus deformity) were treated with
supramalleolar osteotomy due to ankle joint
/ e b o
bo
2017;38:220–9.
/ e b o
Knupp M. The use of osteotomies in the treatment of asymmetric ankle joint arthritis. Foot Ankle Int
b o
fusion and TAR as endpoint) was 88%.
m e
osteoarthritis. The overall survival rate (ankle
e / e e / e
Krahenbuhl N, Zwicky L, Bolliger L, Schadelin S, Hintermann B, Knupp M. Mid- to long-term results of
m e
supramalleolar osteotomy. Foot Ankle Int 2017;38(2):124–32.
Nonunion occurred in seven patients.
: ///t/.t. m : / /
/t/.t . m
Nuesch C, Huber C, Paul J, et al. Mid- to long-term clinical outcome and gait biomechanics after rea-
t t ss
p :
• Risk factors for early failure was a preoperative
t p
Takakura score of 3b and age at the time of
t t pss :
lignment surgery in asymmetric ankle osteoarthritis. Foot Ankle Int 2015;36:908–18.
p
Pagenstert GI, Hintermann B, Barg A, Leumann A, Valderrabano V. Realignment surgery as alternative
t
hht
surgery. A trend for higher failure rate was
evident for elderly patients who smoked at the
time of surgery.
462:156–68. hht
treatment of varus and valgus ankle osteoarthritis. Clinical orthopaedics and related research 2007;
Stufkens SA, van Bergen CJ, Blankevoort L, van Dijk CN, Hintermann B, Knupp M. The role of the
fibula in varus and valgus deformity of the tibia: a biomechanical study. J Bone Joint Surg Br Vol
2011;93:1232–9.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh52
PROCEDURE
t hht
Osteotomies
rss for the Correction rofssVarus Ankle
kkee r
ooNicola Krähenbühl and Markus Knupp boooo kkee r
b
eeboo / e b / e b o
b o
m ee /e m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
INDICATIONS
t t p
t ss
p : t t p
t ss
p :
hht
• Malaligned ankles with medial osteoarthritis
• Malunions after distal tibial fractures or malleolar fractures
hht
• Loss of >50% of tibiotalar joint surface (plain
• Realignment prior to total ankle replacement (TAR) or ankle fusion radiographs, magnetic resonance imaging,
• Corrections after malpositioned TAR or ankle fusion arthroscopy) may be treated with TAR or ankle
k eers
rs
• Medial osteochondritis dissecans of the talus
k er
erss fusion.
• Lack of compliance with the postoperative
b ooookExamination/Imaging
b ooook b o o
non–weight-bearing program caused by
eeb b b neurologic disease or poor health status may
ee/ e
/ e
• Assess the patient’s gait and the alignment of the lower extremity.
ee/ e
/ e be treated by ankle fusion.
: // t/ tm
. m : / /t/ tm
• While the patient is sitting with free-hanging feet, perform the anterior drawer test
. . . m
and talar tilt test to assess ankle joint stability. Furthermore, assess the inversion/
ss : / ss : /
eversion force (function of posterior tibial and peroneal muscles) and subtalar range
t p p tp p
of motion.
t
hht t t
hht t
• Perform the Coleman block test to exclude a forefoot-driven hindfoot deformity.
• Altered bone quality (medication, large cysts,
osteopenia/osteoporosis).
• Tobacco use should be considered a relative
• Weight-bearing radiographs of the foot (dorsoplantar, lateral), the ankle (anteropos-
contraindication.
terior), and a Saltzman view are recommended to assess the nature and location
• Inflammatory, systemic joint diseases
of the deformity. If a deformity at the level of the knee joint or the femur cannot be incorporating the ankle joint are usually treated
keerrss keerrss
excluded clinically, whole lower limb radiographs are obtained (Fig. 52.1).
• Next to radiographs, computed tomography (CT) and magnetic resonance imaging
with TAR or ankle fusion.
b ooook o ook
(MRI) are not routinely required. However, they could be of value when assessing
b o b oo
eeb ee/e/e b ee/e
rotational malalignment, osteochondral lesions, and tendon disorders or when evalu-
/e
ating the ligaments. Weight-bearing CT scans can additionally be performed in case
b
: / / t
/ m
.t.m : / / t m
.t.m
of asymmetric ankle osteoarthritis (tilt of the talus in the ankle joint mortise).
/
• Combined single-photon emission and computed tomography (SPECT) scan is a
t
hhtt
valuable tool for staging of ankle osteoarthritis.
t
hhtt
• Assess the medial distal tibial angle on a weight-bearing anteroposterior radiograph
of the ankle joint (angle between the tibial axis and the tibial joint surface). The wedge
to be corrected can be measured out of the radiograph or calculated with the math-
ematical formula tan α = H/W, where α is the angle to be corrected, H is the wedge
k e rrss
e
height in millimeters, and W is the tibial width.
k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss :
FIG. 52.1
p /
t
hht t t
hht t 433
t t p
t ss:
p t t p
t ss:
p
434 hht
PROCEDURE 52 Osteotomies for the Correction of Varus Ankle hht
TREATMENT OPTIONS • Distinction between congruent and incongruent ankle joints is helpful in determining
k e r
e ss
• Conservative treatment (i.e., shoe
r
modifications, braces, physical therapy for
k eers
the type of osteotomy performed (tibia only vs. tibia and fibula; wedge osteotomy vs.
r s
dome-shaped osteotomy).
o o
o o kperoneal tendon strengthening)
oooo k
• A dome-shaped osteotomy should be considered for deformities that cannot be cor-
o o
eebb • Ankle fusion or TAR in advanced stages of
ankle osteoarthritis
ee/ e
/ebb e / / b
e b
rected at the center of rotation of angulation (CORA) as well as for large corrections
e
(to avoid excessive translation of the distal fragment).
e
• Calcaneal displacement osteotomy is an
: / / t
alternative surgical treatment. Commonly,
/ .
t m
. m : / / t
/ .
t m
. m
• Congruent joints should be considered for dome-shaped osteotomies; incongruent
t
at the level of the deformity
p ss
p : /
correction of malalignment is best performed
t p ss : /
joints usually qualify for wedge osteotomies.
• Additional correction of the length and rotation of the fibula must be considered in
p
t
hht t t
hht t
order to preserve the ankle joint congruency.
POSITIONING PEARLS
SURGICAL ANATOMY
• Medial approach: the great saphenous vein and the saphenous nerve usually lie
anterior to the incision. The posterior tibial tendon runs immediately posterior to the
k ee s
operated leg is elevated with cushions or the
rrs
k er
erss
medial malleolus under the tendon sheet.
b ooook radiographs can be taken more easily.
b oook
• Lateral approach: the sural nerve and the short saphenous vein run dorsal to the line of the
o b o o
incision and are usually not seen during this procedure. Extended proximal dissection may
eeb ee/ e
/ e b ee/ e
/ e b
require exposure of the branches of the superficial peroneal nerve. Cauterization of some
: // t/.tm
. m / /t/
fibula, may be necessary.
: tm
of the branches of the peroneal artery, which lie deep to the medial surface of the distal
. . m
t p ss
p :
• Before the osteotomy is performed, the/ ss : /
• Anterior approach: the neurovascular bundle (deep peroneal nerve and the dorsalis
tp p
t
hht t
surgeon should control the draping to
procedure.
t
hht t
pedis artery) lies lateral to the incision. The ankle joint is covered by an extensive fat
pad that contains a venous plexus requiring partial cauterization.
POSITIONING
POSITIONING EQUIPMENT • Medial approach: place the patient supine on the operating table. The natural exter-
ke rrss
e keerrss
nal rotation of the leg usually exposes the medial malleolus (Fig. 52.2). Alternatively,
b ooook
• A tourniquet can be used to ensure optimal
b ooook
the knee may be held in a slightly flexed position and the hip externally rotated. The
oo
limb is exsanguinated and the tourniquet inflated.
b
• Lateral approach: the patient is placed in a lateral decubitus position or supine with
a sandbag under the buttock of the affected limb. After exsanguinating the leg, a
: / / t
/ m
.t.m / t m
.t.m
pneumatic tourniquet is inflated on the thigh.
: / /
t p ss : /
• The contralateral ankle may be draped in order
p t ppss : /
• Anterior approach: the patient is placed in a supine position with the heel at the edge
t
hhtt
to compare both ankles after the osteotomy is
performed. t
hhtt
of the table, allowing the surgeon to stand at the end of the operating table. The limb
is exsanguinated and the tourniquet inflated.
Portals/Exposures
PORTALS/EXPOSURES PEARLS • Arthroscopy of the ankle joint is recommended to assess the wear pattern of the
k rrss
• If tibiotalar joint débridement or exostectomy
e e
is required, an anterior capsulotomy is made.
k e rrss
ankle joint before the osteotomy is performed.
e
• Medial approach: a 10-cm longitudinal incision is made beginning over the medial
o o
o o kIf only a supramalleolar osteotomy is planned,
o o o k o
malleolus and extending proximally over the distal tibia. The skin flaps are mobi-
o o
eebb b b
there is no need to expose the joint.
• The ankle joint is covered by an extensive
fat pad that contains a venous plexus and
ee/ e
/ e b ee e
/ b
lized, with care taken not to damage the neurovascular bundle, which runs along
/ e
the anterior border of the medial malleolus. The posterior tibial tendon, which lies
requires partial cauterization.
: / / t
/ m
.t.m : / / t
/ m
.t.m
immediately on the posterior aspect of the medial malleolus, must be identified and
t p ss:
p / t p ss:
p /
retracted posteriorly (Fig. 52.3).
• Lateral approach: a 10-cm longitudinal, slightly curved incision is made along the
t
hht t t
hht t
anterior margin of the distal fibula. If the incision needs to be extended distally, it
is curved ventrally to end just distal to and anterior of the lateral malleolus. At the
distal end of the incision, the anterior syndesmosis is exposed. The lateral branch
of the sural nerve and the short saphenous vein run dorsal to the line of inci-
k e r
e s
rs k eers
sion and are usually not seen during this procedure. However, extended proximal
rs
dissection may require identification, exposure, and protection of the branches
o o
o o k o oo k
of the superficial peroneal nerve. Cauterization of some of the branches of the
o oo
eebb ee/ e
/ b
e b necessary (Fig. 52.4).
ee/e/ebb
peroneal artery, which lie deep in the medial surface of the distal fibula, may be
: / / t
/ .
tm.m : / / t
/.tm
. m
• Anterior approach: a longitudinal incision is made between the anterior tibial ten-
t p ss
p : / t p ss
p : /
don and the extensor hallucis longus tendon, starting 10 cm proximal to the
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 52 Osteotomies for the Correction of Varus Ankle 435
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ ee
/ b ee/ e
/ e b
: // t/.tm
. m FIG. 52.2
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
Sural nerve
t
hht t
Great saphenous vein
keerrss keerrss
and saphenous nerve
eeb ee/e/e b ee/e/e b Medial
: / / t
/ m
.t.m : / / t
/ m
.t.m malleolous
t
hhtt t
hhtt
k e rrss
e FIG. 52.3
k e rrss
e
o o
o o k o o
o o k o
FIG. 52.4
o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / / m
.t.m
joint, about midway between the malleoli. Care should be taken not to cut the
t : / / t
/ m
.t.m
p ss:
p / t p ss: /
skin incision too deeply to avoid damage to the underlying neurovascular bundle
(deep peroneal nerve and dorsal pedis artery; Fig. 52.5). After identifying the neu-
t p
t
hht t t
hht t
rovascular bundle and retracting it laterally, the extensor retinaculum is cut in line
with the skin incision between the anterior tibial tendon and the extensor hallucis
longus tendon. The anterior tibial tendon is retracted medially and the tendon of
the extensor hallucis longus laterally without opening the tendon sheaths. The
anterior surface of the tibia can now be exposed after incising the remaining soft
k e r
e s
rs k eers
rs
tissues longitudinally. The joint is usually covered by fatty tissue containing a
o o
o o k o o
oo k
venous plexus. As the approach for osteotomies is usually extraarticular, the joint
oo
eebb b b
itself is not exposed. However, sometimes it is necessary to cauterize some of
ee/ e
/
the veins in the distal part of the incision.
e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
436 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
K-wire
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
FIG. 52.5 FIG. 52.6
keerrss k e e s
rrs FIG. 52.7
b ooook
STEP 1 PEARLS
b ooook b oo
eeb • If scar tissue at the anterior syndesmosis has
e
to be débrided or cut off the tibia to facilitate
e/e/e b ee/e/e b
manipulation of the distal fibula fragment, a
syndesmosis screw may be necessary.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t pps : /
• Sagittal plane deformity of the distal tibial
s
joint surface can be addressed by adding an
t ppss : /
t
hhtt
anterior closing wedge osteotomy to correct t
hhttOSTEOTOMY
PROCEDURE 1: MEDIAL OPENING WEDGE
a flexion deformity and a posterior closing
wedge osteotomy to correct an extension • Using a C-arm, a Kirschner wire (K-wire) is placed from the medial cortex into the
deformity. The rotational center of the ankle in area of the former growth plate, or on the height of the deformation in the case of a
lateral view should be in line with the
malunion (Fig. 52.6).
rrss rrss
mid-diaphyseal axis of the tibia.
o k e
k e o k e
• The periosteum is carefully incised at the level of the osteotomy and elevated from
k e
the bone using a scalpel or a raspatorium. The osteotomy is performed using a wide
o
eebb o o
STEP 1 PITFALLS
e b o
b o o saw blade (Fig. 52.7).
e b o
b o
• If the tendon sheath of the posterior tibial
ee/
tendon is closed too tightly, painful restrictions
m / e m ee/ / e
• The gap can be filled with allograft (Tutoplast Spongiosa; Tutogen Medical GmbH,
Neunkirchen, Germany) or iliac crest bone (Fig. 52.8).
may result.
: / /
/ t
/ .t.m
• The loss of the medial hinge mechanism of the
: / /
/ t
/ .t.m
• The osteotomy is typically secured with a medial locking plate (Fig. 52.9 and 52.10).
t p
t ss:
far cortex introduces the risk for rotational or
t p t t p
t ss:
• The tendon sheath of the posterior tibial tendon is reapproximated with 2-0 absorb-
p
hht
translational malpositioning and postoperative
displacement of the osteotomy. hht
able sutures, and the subcutaneous tissues and the skin are closed with interrupted
sutures. Do not over-tighten the posterior tibial tendon sheath because it may create
stenosing flexor tenosynovitis.
• In some instances, a fibula osteotomy is necessary to preserve the ankle congruency
STEP 1 INSTRUMENTATION/ and/or to correct the position of the fibula. The fibula is approached with a longitu-
k e r
e ss
IMPLANTATION
r
• We typically secure the osteotomy with a
k eers
rs
dinal lateral skin incision. Potential branches of the superficial peroneal nerve are
retracted. To rotate the fibula, an oblique cut from dorsally-proximally to anteriorly-
o o
o o kmedial locking plate.
o o
oo k oo
distally is done, which allows rotation, shortening, or lengthening of the distal fibula.
eebb • We recommend using a wide saw blade to

create a congruent osteotomy.
ee/ e
/ b
e b ee/e
tibia position (Fig. 52.11). ebb
• A postoperative radiograph is taken to confirm appropriate correction of fibula and
/
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
FIG. 52.8
b oooo k
b o
FIG. 52.9
o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t Bone wedge
t
hht t
Screws
keerrss keerrss
eeb ee/e/e b Corrected axis
ee/e/e b
: / / t
/ m
.t.m
after the opening
wedge osteotomy
: / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 52.10
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k o o
o o k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / FIG. 52.11
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
438 hht
k e r
e s
rs k eers
r s K-wires
o o
o o k oooo k Osteotomy of
o o
eebb ee/ e
/ebb the fibula
ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m Syndesmosis
t p ss
p : / Wound
edges
t p ss
p : /
t
hht t t
hht t Varus of the distal
tibial articular surface
k e rs
rs
e k er
erss
b ooook
• The tendon sheath of the posterior tibial tendon is
b ooook b o o
eeb
reapproximated with 2-0 absorbable sutures, and
the subcutaneous tissues and the skin are closed
ee/ e
/ e b ee/ e
/ e b
: / t/.t
posterior tibial tendon sheath because it may
/ m
with interrupted sutures. Do not over-tighten the
. m
: / /t/.tm. m FIG. 52.12
create stenosing flexor tenosynovitis.
t p ss : /
• Alternatively, a chisel or osteotome may be
p tp pss : /
t
hht t
used instead of the oscillating saw to limit
thermal injury to bone.
t
hht t
Bone blocks that need Location of the k-wire to
to be resected mark transverse cuts
keer ss
STEP 2 PEARLS
r
• Placing the wires in a manner that they cross
keerrss
b ooook on the height of the medial cortex will prevent
b ooook b oo
eeb the saw from cutting through the entire bone
and thereby preserve the medial cortex as a
ee/e/e b ee/e/e b Syndesmosis
hinge.
/
• In order to get proper compression on the
: / t
/ m
.t.m : / / t
/ m
.t.m
t pps :
osteotomy, a tension device can be used.
s /
Alternatively, excentric drilling of the proximal
t ppss : /
t
hhtt
screws will provide compression.
• In rare cases, the syndesmosis needs to be
t
hhtt
mobilized. For this purpose, the proximal
attachment of the anterior syndesmosis is
released from the tibia (anterior tibial tubercle
rrss rrss
of Tillaux-Chaput). The tubercle is mobilized
o k e
k
using a chisel. After positioning of the fibula, it
e
is reattached either with a screw and washer
o k e
k e FIG. 52.13
o
eebb o o or with transosseous sutures.
e b o
b o o e b o
b o
m ee/ / e m ee/ / e
: / /
/ t
/ .t.m 2: LATERAL CLOSING WEDGE OSTEOTOMY
: / /
/ t
/ .t.m
STEP 2 PITFALLS
t t p
t ss:
p
PROCEDURE
t t p
t ss:
p
hht
• Deformity correction in posttraumatic cases
needs to be done at the CORA in order to
avoid translational malpositioning.
hht
• Primarily, a fibula osteotomy is performed. In most cases, the fibula needs to be
shortened in order to preserve the congruency in the ankle joint. The shortening can
be done by simple bone block removal or a Z-shaped osteotomy (Fig. 52.12).
• The length of the Z-osteotomy of the fibula is about 2–3 cm, starting distally on the
height of the anterior syndesmosis.
r s
rs
k e e
IMPLANTATION rs
rs
• K-wires can be placed on the height of the transverse cuts to check the localization
k ee
o o
o o k
• Plates that provide angular stability should be
o o
oo kof the osteotomy (Fig. 52.13).
oo
• The osteotomy is performed with an oscillating saw.
eebb used in order to achieve good primary stability

and prevent secondary dislocation.
ee/ e
/ b
e b ee/e ebb
• After the fibula has been mobilized, bone blocks that are sized according to the
/
: / / t
/ .
tm.m : / / t
/ tm
amount of the planned shortening need to be resected on both ends.
. . m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
Closed
o o
o o k oooo k osteotomy
o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Corrected,
neutral axis
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m
FIG. 52.14
: / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
kee rss keerrs

• The distal tibia is exposed anteriorly without stripping of the periosteum. K-wires are
r s
placed according to the preoperative planning. If the deformity is located proximal to
b ooook b oook
the supramalleolar area, the wires are directed proximally from the anterior syndesmo-
o b oo
eeb e /e/e b
sis to the area of the former growth zone on the medial side.
e /e/e
• After verification of the location of the wires with a C-arm, the periosteum is incised
e e b
: / / m
.t.m
and carefully mobilized with a scalpel or raspatorium.
/ t : / / t
/ m
.t.m STEP 2 CONTROVERSIES
t p ss
with a plate (Fig. 52.14).
p / t ppss : /
• The osteotomy is performed using an oscillating saw, and then closed and secured
: • Loss of the hinge on the medial side bears the
t
hhtt t
hhtt
• The periosteum is closed over the osteotomy with 2-0 absorbable sutures.
• Now the position of the fibula needs to be determined with a C-arm. Once the
risk of malpositioning (rotational/translational)
and secondary dislocation. Additional fixation
(i.e., second plate) should be considered.
joint appears congruent, the fibula is secured with screws or a third tubular plate.
• Finally, the subcutaneous tissues and the skin are closed with interrupted sutures.
k rrss
PROCEDURE 3: DOME-SHAPED OSTEOTOMY
e e k e rrss
e
o o
o k
• An anterior approach is used for this procedure.
o o o
o o k o o
eebb b b
• Multiple 2-mm drill holes along the osteotomy line are made. The osteotomy is
ee/ e
/ e b
then completed with a 5-mm chisel. Prior to mobilization of the osteotomy, the
ee/ e
/ e b STEP 3 PEARLS
: / / t
/ m : / / t
/ m
original position of the distal fragment in relation to the proximal fragment is
.t.m .t.m
marked on the anterior surface of the tibia (use a marking pen or electrocautery
• The level of the osteotomy usually lies at
the metaphyseal level, above the tibiofibular
to mark the bone).
t p ss:
p / t p ss:
p / syndesmosis.
t
hht t t
hht t
• The fibula is exposed through a separate lateral incision, and an oblique osteotomy
is performed.
• The osteotomy of the tibia is mobilized, and the deformity corrected as preopera-
tively planned. A 2.5-mm K-wire introduced from the medial malleolus to preliminarily
secure the correction. STEP 3 INSTRUMENTATION/
k e r
e s
rs k eers
rs
• The osteotomy is fixed with one T-shaped plate or two straight (one medial and one
IMPLANTATION
• Plates that provide angular stability should be
o o
o o k o o
oo k
lateral) plates with interlocking screws (Fig. 52.15).
• The length and position of the fibula is adjusted with a C-arm and secured with an
oo
used in order to achieve good primary stability
eebb ee/ e b
e b
additional plate (Fig. 52.16; case courtesy of Beat Hintermann).
/ ee/e/ebb and prevent secondary dislocation.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
440 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
POSTOPERATIVE PITFALLS t
hhtt t
hhtt
• Apart from perioperative complications such
as wound healing problems or infection,
postoperative concerns include delayed union
k e rrss
or nonunion of the osteotomy.
e
• Another potential complication is malunion,
k e rrss
e FIG. 52.15
o o
o o kresulting from inaccurate alignment of
o o
o o k o o
eebb b b
the osteotomy at the time of surgery or
postoperative loss of position.
ee/ e
/ e b ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t
• Removal of hardware is not recommended
earlier than 8 months after surgery.
t
hht t
• Between 1999 and 2013, a total of 298
ankles (varus and valgus deformity) were POSTOPERATIVE CARE AND EXPECTED OUTCOMES
treated with supramalleolar osteotomy due to • The leg is elevated in the immediate postoperative period.
k e r
e ss
ankle osteoarthritis. The overall survival rate
r
(ankle fusion and TAR as endpoint) was 88%.
k eers
rs
• A compressive dressing and splint are maintained for 2 days to diminish swelling.
o o
o o kNonunion occurred in seven patients.
o o
o k
• A short-leg partial weight-bearing cast is used for 8 weeks.
o oo
eebb b b
• If radiologic evidence of consolidation is present after 8 weeks, the patient advances
• Risk factors for early failure were a
preoperative Takakura score of 3b and age at
ee/ e
/ e b /
gradually to full weight bearing.
ee e/e b
: / t
/ .
t
rate was seen for elderly patients who smoke
/ m
the time of surgery. A trend for higher failure
.m / / t
/ tm
• A rehabilitation program for strengthening, gait training, and range of motion is pre-
. . m
scribed 8 weeks after surgery, with gradual return to full activities as tolerated.
:
at the time of surgery.
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
FIG. 52.16
k rrss
EVIDENCE
e e k e rrss
e
o o
o o k
Acad Orthop Surg 2016;24:424–32.
o o
o k
Hintermann B, Knupp M, Barg A. Supramalleolar osteotomies for the treatment of ankle arthritis. J Am
o o o
eebb / e b b / e b b
Knupp M. The use of osteotomies in the treatment of asymmetric ankle joint arthritis. Foot Ankle Int
2017;38:220–9.
ee / e ee / e
: / / m
.t.m
lar osteotomy. Foot Ankle Clin 2012;17:95–102.
: / / / m
.t.m
Knupp M, Bolliger L, Hintermann B. Treatment of posttraumatic varus ankle deformity with supramalleo-
/ t t
t p ss:
p / t p ss:
p /
Knupp M, Stufkens SA, Bolliger L, Barg A, Hintermann B. Classification and treatment of supramalleolar
t t
deformities. Foot Ankle Int 2011;32:1023–31.
hht t
hht t
Knupp M, Stufkens SA, van Bergen CJ, et al. Effect of supramalleolar varus and valgus deformities on
the tibiotalar joint: a cadaveric study. Foot Ankle Int 2011;32:609–15.
Krahenbuhl N, Zwicky L, Bolliger L, Schadelin S, Hintermann B, Knupp M. Mid- to long-term results of
supramalleolar osteotomy. Foot Ankle Int 2017;38:124–32.
Lee WC. Extraarticular supramalleolar osteotomy for managing varus ankle osteoarthritis, alternatives
k e r
e ss
for osteotomy: How and why? Foot Ankle Clin 2016;21:27–35.
r k eers
rs
Stufkens SA, van Bergen CJ, Blankevoort L, van Dijk CN, Hintermann B, Knupp M. The role of the fibula
o o
o o k oo k
in varus and valgus deformity of the tibia: a biomechanical study. J Bone Joint Surg Br 2011;93:
o o oo
eebb b b
1232–9.
ee/ e
/ e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh53
PROCEDURE
t hht
Arthroscopic
rss Ankle Arthrodesis rss
o kke er er o kke
o o
eebboAlastair Younger e bboo o e b o
b o
m ee/ /e m ee/ / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t p :
t ss
p :
hht
• Major bone loss may require a segmental
allograft.
• End-stage ankle arthritis
• Caused by
hht
• Infection may require a more extensive • Hemophilia
débridement than an arthroscopic fusion may
• Hemochromatosis
k eers
achieve.
rs k er
erss
• Trauma
b ooook
b ooook
• Osteochondral defects
• Gout
b o o
eeb • Avascular necrosis of the talus is increasingly
ee/ e
/ e b • Rheumatoid arthritis
ee/ e
/ e b
indicated for arthroscopic fusion.
: / t .
• Hemophilia is an appropriate indication for
/ / tm
. m
• Sepsis
: / /t
• Osteoarthritis
/.tm. m
arthroscopic fusion.
t p ss
p : /
• A poor soft-tissue envelope may be amenable ss : /
• Ankle instability
tp p
t
hht t
to arthroscopic fusion when an open fusion will
require a free flap.
t
hht
Examination/Imagingt
• Patients are examined standing to assess the hindfoot and forefoot alignment.
• The patient is observed walking and the phases of gait examined. The position of the
TREATMENT OPTIONS
foot in stance and swing phase is observed.
keer ss
• Injection – steroid or hyaluronic acid
r
• Activity modification
keerrss
• The remainder of the examination is performed with the patient sitting in a position to
allow easy access of the foot to the examiner.
b ooook • Bracing
• Stabilizer brace
b o ook oo
• The skin is examined for scars from prior surgery or injury. The skin is inspected for
o b
eeb • Arizona brace
• Ankle foot orthosis brace
ee/e/e b ee/e/e b
other abnormalities such as hemosiderin staining and varicosities.
• The position of the ankle and foot on the long axis of the tibia is determined. With the
: / t
/ m
.t.m
• 6-week course of antiinflammatory medication
/ : / / t m
.t.m
knee bent the alignment of the forefoot in the sagittal plane is observed to determine
/
• Physiotherapy
if it is internally or externally rotated.
t
hhtt t
hhtt
• The position of forefoot and hindfoot in varus or valgus on the longitudinal axis of the
tibia is determined.
• The ankle is examined on the longitudinal axis of the tibia to determine if there is a
fixed equinus deformity, or if there is a translational deformity of the foot on the axis
of the tibia in the coronal or the sagittal plane.
k e rrss
e k rrss
• The joint lines of the ankle, subtalar, and talonavicular joints are palpated to feel for
e e osteophytes and to determine if the joint lines are tender. The anterior and posterior
o o
o o k o o
o o k o
margin of the ankle joint is examined.
o
eebb ee/ e
/ b
e b e / e
/ b
e b
• Range of motion is measured with a goniometer. Range of motion is also performed
in isolation of the ankle; subtalar, talonavicular, and calcaneocuboid joints are exam-
e
: / / t
/ m
.t.m : / / t
/ m
.t.m
ined to determine which joints have painful motion.
t p ss:
p / t p ss:
p /
• The tibia is held and the talus moved in dorsiflexion and plantar flexion to assess
the ankle for pain and motion. The talus is held at the talar neck, and the calcaneal
t
hht t t
hht t
tuberosity is moved into varus and valgus to determine if the subtalar joint moves or
hurts.
• The calcaneus is held and the cuboid moved to assess the calcaneocuboid joint.
The talus is held at the talar neck and the navicular moved into internal and external
k e r
e s
rs k eers
rs
rotation to determine if the talonavicular joint hurts.
• The radiographic views (AP and lateral) show end stage ankle arthritis with varus
o o
o o k o o
oo k alignment (Fig. 53.1 and 53.2).
oo
eebb b b
• A magnetic resonance image is used to demonstrate ankle arthritis (Fig. 53.3).
ee/ e
/ e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
FIG. 53.1
t p ss
p : / t p ss
p : /
442
hhtt t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 53 Arthroscopic Ankle Arthrodesis 443
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 53.2
k eers
rs k er
erss
b oo k ANATOMY
ooSURGICAL b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
// t/ tm
. / .m
• The ankle is the junction between the tibia, fibula, and talus. The joint has a larger
. m /t/ t . m
tibiotalar surface that is broader anteriorly and narrower posteriorly.
: :
FIG. 53.3
ss : / ss : /
• The smaller medial joint surface comprises the articular surface between the lateral
t p p tp p
t
hht t t
hht t
side of the medial malleolus of the tibia and the medial facet of the talar body.
• The larger lateral joint surface consists of the medial aspect of the distal fibula and
the lateral side of the body of the talus.
• The medial gutter is the recess between the capsule, the medial malleolus, and the
talar neck.
keerrss keerrss
• The lateral gutter is the recess between the capsule, the fibula, and the talar neck.
b ooook talus, and back of the tibia.

b ooook
• The posterior recess is the space between the posterior capsule, the back of the
b oo
• Anterior to the joint are the extensor tendons (medially tibialis anterior, centrally ex-
tensor hallucis longus, laterally extensor digitorum longus, and most lateral peroneus
: / / t
/ m
.t.m : / / t m
.t.m
tertius). The extensor retinaculum binds these tendons in a superior and inferior por-
/
tion. The deep branch of the peroneal nerve and the anterior tibial artery lie on the
t
hhtt t
hhtt
anterior capsule deeper than the tendons centrally over the joint. More superficial to
the retinaculum and lateral to the joint lies the superficial peroneal nerve, just under
the skin in either one or two branches at the level of the ankle.
• Medial to the ankle close to the medial gutter subcutaneously lie the two branches of
the saphenous nerve around the saphenous vein.
k e rrss
e k rrss
• Posterior medially lies the tibialis posterior tendon. This lies in a tendon sheath and
e e
grove in the medial malleolus and cannot be seen from within the joint.
o o
o o k o o o k
• The flexor digitorum longus tendon lies posterior and lateral to this and next to the
o o o
eebb ee e
/ b
e b ee/ e
/ b
e
extends from the medial malleolus to the calcaneus, with septa penetrating deep tob
posterior joint capsule. It is held in the flexor retinaculum, a thick fibrous sheath that
/
: / / t
/ m
.t.m : / / t
/ m
.t.m
divide the flexor tunnel into sheaths. Behind and lateral to this lies the neurovascular
t ss:
p / t p ss:
p /
bundle consisting of the tibial nerve, the posterior tibial artery, and the venae com-
p
municates. The flexor hallucis longus lies lateral and anterior to the neurovascular
t
hht t t
hht t
bundle. It can be seen within the ankle joint. The tendon passes through a fibro-
osseous tunnel behind the talus, formed by the os trigonum, the posterior medial
surface of the talus, and a fibrous band.
• The peroneal tendons lie to the posterior lateral side of the joint in a grove on the
k e r
e s
rs retinaculum.
k eers
posterior side of the fibula. They are bound by the superior and inferior peroneal
rs
o o
o o k oo k
• The ligaments around the joint include the anterior and posterior tibiofibular liga-
o o oo
eebb e / e
/ b
e b e /e/ebb
ments, which stabilize the syndesmosis. These ligaments lie quite distal and form a
restraint to the talus anteriorly and posteriorly, as well as stabilize the tibia and fibula.
e e
: / / / .
tm m
Both ligaments can be clearly seen within the joint.
t . : / / t
/.tm
. m
t p ss : /
and can clearly be seen within the joint.
p t p ss
p : /
• The posterior talofibular ligament can be seen creating part of the posterior recess
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
444 hht
PROCEDURE 53 Arthroscopic Ankle Arthrodesis hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 53.4
k eers
rs k r
eerss FIG. 53.5
b ooook POSITIONINGbo ooo k b o o

eeb POSITIONING PEARLS
ee/ e
/ e b ee/ e
/ e b
• Make sure the leg is at the foot of the bed.
: // t/.tm
. m / /t/.tm
• A beanbag is used to position the patient so that the foot is vertically orientated. The
. m
foot is placed at bottom edge of the operating room table.
:
t p ss
p : / ss : /
• The arthroscopy tower is placed to the head of the bed on the contralateral side.
t pp
t
hht t
• External rotation of the limb will make the joint
t
hht t
• A thigh tourniquet is used. A calf tourniquet will result in tightening of the leg muscles
and loss of visualization.
much harder to assess. • A traction apparatus is used at surgeon preference.
• The limb is positioned on the bed (Fig. 53.4).
• A leg holder is used (Fig. 53.5).
rrss
kee keerrss
Portals/Exposures
b ooook
• Beanbag
• Traction device
b ooook oo
• Six portals can be used for arthroscopic ankle arthrodesis.
b
• The anterior medial and anterior lateral positions are routine and are the initiating
portals. The anterior medial portal lies in the soft spot between the talar neck and the
: / / t
/ m
.t.m : / / t m
.t.m
distal tibia, just lateral to the lateral malleolus. The portal is medial to tibialis anterior.
/
t ppss : /
• Use as many portals as required to remove all
t ppss : /
Care is taken not to damage the saphenous nerve.
a physical barrier. t
the cartilage. Cartilage is both a biological and
hhtt
• Cartilage contains growth factors preventing
t
hhtt
• The lateral portal lies in the soft spot between the talus, tibia, and fibula on the lateral
joint line. The portal lies close to the superficial peroneal nerve, which is variable in
its anatomy. Some authors feel that a more lateral position is safer. The portal will go
neovascularization and hence will prevent
bone formation; its physical presence will hold through the extensor retinaculum creating resistance to the passing scope or instru-
the joint apart. ments. The portal deep to the extensor retinaculum will go lateral to the peroneus
k e rrss
e k e rrss
e
tertius, the muscle often being visible in the joint.
• I like to make two additional portals to access the medial and lateral sides of the joint.
o o
o o k
o o o k o
• A portal can be made at the tip of the medial malleolus. This is superior to the tibialis
o o
eebb • Ensure that the foot is positioned to allow
e
circumferential access around the joint. This may
e/ e
/ b
e b ee/ e
/ b
e b
posterior and away from any nerves. The portal will extend deep through the deltoid
ligament and into the joint. The portal needs to be distal enough to ensure access to
/ / t
bandage around the surgeon’s waist and around
: / m
involve using a leg holder, or using a dressing
.t.m : / / t
/ m
.t.m
the joint with a shaver.
t p ss:
p /
the ankle to bring the leg away from the bed.
t p ss:
p /
• A lateral portal can be made over the tip of the lateral malleolus or just anterior. This
portal will extend deep through the capsule and should be between the lateral col-
t
• Remove the anterior osteophytes at the
hht t
beginning of the procedure to improve the
access to the joint using a curette placed
t
hht t
lateral ligaments.
• A posterior medial portal as described by Acevedo (Acevedo et al., 2000) is used to
through the portals prior to placement of the
débride the posterior ankle. An incision is made just posterior to the medial malleo-
arthroscope.
lus, posterior to the grove containing the posterior tibial tendon. This is over the soft
k e r
e s
rs
k eers
spot between the medial malleolus, the tibia, and the talus. The portal lies anterior
rs
to the flexor digitorum longus. However, because of the close proximity of the neu-
o o
o o k
• Release the capsule with the curette in tight or
o o
oo k rovascular bundle, all deep dissection is done bluntly. A blunt instrument can be
oo
eebb posttraumatic ankles to improve the access to
the joint.
ee/ e
/ b
e b e / /ebb
passed from outside in and its position in the joint confirmed using anterior ankle
e
arthroscopy, or an instrument placed from posterior lateral out the medial side and a
e
• Remember to remove the osteophytes from
/ / t .
tm.m
the medial and lateral gutters off the talar neck
: / : / / /.
switching stick used.
t tm
. m
ss : /
and malleoli to allow correction of equinus.
t p p t p ss : /
• The anterior medial and anterior lateral portals are used as per Fig. 53.6.
• Fig. 53.7 shows a diagram of the anatomy of the anterior portals.
p
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s Superficial peroneal Great saphenous
o o
o o k oooo k nerve
o o
vein
eebb ee/ e
/ebb ee/ e
/ b
e b Anterior tibial
tendon
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
Anterior tibial
neurovascular bundle
t p ss
p : / t p ss
p : /
Anterolateral
portal
t
hht t t
hht t Peroneus tertius
tendon
Anteromedial
portal
k eers
rs k er
erss
b ooook
FIG. 53.6
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp s
ps
: /
t
hht t t
hht t FIG. 53.7
STEP 1 PEARLS
• Do not dig into the subchondral bone on the
tibia. This will cause bleeding and loss of
keerrss keerrss strength fixation.

• Remove the cartilage close to the portal first
so the scope can be advanced.
• The scope is switched to the lateral portal
eeb ee/e/e b ee/e/e b and the burr to the medial side. The same
sequence as above is followed.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t ppss : / t ppss : / STEP 1 PITFALLS
t
hhtt t
hhtt
• Do not dig into the tibia.
• Avoid damage to the superificial peroneal
nerve by lateral blunt dissection.
IMPLANTATION
k e rrss
e k e rrss
e
• A 2.9-mm, 30° arthroscope with a high flow
o o
o o k o o
o o k o
cannula
• A 4.0-mm arthroscope can also be used for
o
eebb ee/ e
/ b
e b ee/ e
/ b
e b larger patients
• A straight ooo and o curette with a sturdy neck
: / / t
/ m
.t. m : / / t
/ m
.t.m to prevent breakage
• A 3.5-mm shaver
t p ss:
p / FIG. 53.8
t p ss:
p / • A 4.0-mm burr
t
hht t t
hht t • A leg holder if needed
• A beanbag to position the patient
• Gravity or pressure inflow dependent on preference
• A contoured thigh cuff
• A cannulated or solid screw set 4.5 to 7 mm
screw diameter. Full thread screws are preferential
e r
e s
rs
PROCEDURE
k k eers
rs to partial thread to assist in stabilization of the joint
surface. Lengths need to be up to 80 mm.
o o
o o k o o
oo k oo
• A pituitary rongeur for removal of large
eebb b b cartilage and bone fragments

Step 1: Anterior Débridement
ee/ e
/ e b ee/e
• The arthroscope is placed in the medial side and the shaver in the lateral side (see
/e b STEP 1 CONTROVERSIES
Fig. 53.6).
: / / t
/ .
tm.m : / / t
/.tm
. m • Some surgeons argue that a partial cartilage
t p ss
p : / t p ss
p : /
• The completed débridement is seen from the anterior medial portal (Fig. 53.8). excision will result in fusion.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
446 hht
STEP 2 PEARLS
k e r
e ss
• The posterior medial portal allows cartilage
r
removal from the posterior side of the joint.
k eers
r s
o o
o o k
• The portal can also be used for visualization.
oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
STEP 2 PITFALLS
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
this area.
t p ss
p : /
• Care must be taken to use blunt dissection in
t p ss
p : /
t
hht t
• The portal must hug the back of the medial
malleolus.
t
hht t
s
rrs
IMPLANTATION
k ee k er
erss
b ooook
• The scope is placed in the anterior lateral
portal.
b ooook b o o
eeb • The shaver and instruments are placed
posterior and medial.
ee/ e
/ e b
ee/ e
/ e b
FIG. 53.9
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
• The medial portal has been safe in the authors
use with no tibial nerve palsies.
t
hht t
kee rs
STEP 3 PEARLS
r s
• A complete cartilage débridement can be
keerrss
• The scope is inserted into the anterior medial portal, the shaver in to the anterior
lateral portal, and the joint inspected to confirm the arthritic damage. Images are
b ooook performed using the accessory portals.

• The portals must be distal enough so that a
b o ook oo
taken if needed. If the scope will not go into the over the top position within the joint,
o b
eeb straight burr can be brought into the medial
and lateral joint surface.
ee/e/e b ee/e/e b
then the ankle will need to be dorsiflexed and an anterior synovectomy performed
first. Care should be taken to débride on the lateral side to avoid damage to the deep
: / / t
/ m
.t.m : / / t
/ m
.t.m
branch of the peroneal nerve.
• The arthroscope is placed anterior medial and the burr anterior lateral.
STEP 3 PITFALLS
t
hhtt
• The portals, if too proximal, will not allow
access to the joint.
t
• The cartilage is removed sequentially from the lateral side of the joint. The burr is
hhtt
used to remove the cartilage closest to the portal on the anterior lateral side of the ta-
lus and tibia. The burr is then slowly advanced over the tibia and talus in a sweeping
• The anterior osteophytes must be removed motion, removing the cartilage sequentially until the burr cannot be advanced further
from both the medial and lateral gutter as well on the tibia without digging into the subchondral bone. The subchondral bone is left
as anteriorly to allow the ankle to be brought
k e rrss
to the neutral position.
e k e rrss
intact.
e
o o
o o k o o
o o k
Step 2: Posterior Ankle Débridement
o o
eebb STEP 3 INSTRUMENTATION/
IMPLANTATION
ee/ / b
e b e / b
e b
• The shaver is inserted posterior medially and the cartilage removed at the posterior
e / e
medial corner of the talus, then worked anterior and lateral. A similar removal is done
e
/
• The arthroscope is placed in the anterior
: / t
/ m
.t.m on the tibial side.
: / / t
/ m
.t.m
portal.
t p ss:
• The burr and shaver are placed at the
p / t p ss:
p /
• Fig. 53.9 shows the shaver in the posterior medial portal.
malleolar tip portal.

t
hht t t
hht t
Step 3: Medial and Lateral Débridement
• The instruments are placed on the medial side (Fig. 53.10).
• The medial débridement is completed (Fig. 53.11).
STEP 3 CONTROVERSIES • The lateral débridement is completed (Fig. 53.12).
• Complete cartilage removal has been • The leg is removed from traction and the scope inserted anterior medial, with the
k e r s
rs
questioned, but we have found it to be
e
valuable.
k e rs
rs
burr from the tip of the medial malleolus. The cartilage is removed from the talus and
e
o o
o o k o o
oo k
medial malleolus.
oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
//
: t/.tm
. m
: / /t/.tm. m
t p ss : /
FIG. 53.10
p tp ss
p : / FIG. 53.11
t
hht t t
hht t STEP 4 PEARLS
• For a valgus ankle a 2-mm wire placed through
the tip of the fibula into the talus with the ankle
held neutral will correct this deformity. If coaxial
keerrss keerrss with the joint, dorsiflexion can be corrected with
a second wire in the tibia.
• For a varus ankle, the opposite correction is
eeb ee/e/e b ee/e/e b performed from the medial malleolus to the

talus. The ankle can then be brought into
: / / t
/ m
.t.m : / / t
/ m
.t.m dorsiflexion and pinned using a wire from the
medial tibia and down.
t
hhtt t
• A heel cord lengthening may be required if the
ankle cannot be corrected to neutral.
• The heel should not rest on the bed during this
k e rrss
e k e rrss
e
reduction as anterior translation of the talus
o o
o o k o o
o o k o o
may occur.
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t. m : / / t
/ m
IMPLANTATION
t p ss:
p / FIG. 53.12
t p ss:
p / • Two Kirschner wires or drill bits are used to
t
hht t t
hht t hold the ankle in neutral, one to correct varus
and valgus, the other to correct dorsiflexion.
Step 4: Reduction
k e r
e s
rs k eers
rs
• The above steps complete the débridement. The instruments are withdrawn, and the
• Some authors argue that coronal plane
o o
o o k o oo k
ankle is held in a neutral to slight dorsiflexed position.
o oo
deformity cannot be achieved with an
eebb b b arthroscopic fusion, although we have been
e e
/
should be corrected into a neutral position.
e b ee e
• Any hindfoot deformity is corrected. If there is a varus or valgus deformity, the ankle
/ e / /e b able to achieve significant correction.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
448 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
b o o FIG. 53.14
eeb ee/ e
/ e b ee/ e
/ e b

FIG. 53.13
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp ss
p : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e FIG. 53.15
k eerrss FIG. 53.16
o o
o o k o oo
o k o o
eebb STEP 5 PEARLS
ee/ e
/ b
e b ee/ e
/ b
e b
/ t
• Solid screws may be stronger and more cost
: / / m
.t.m : / / t
/ m
.t.m
effective.
t p ss:
p /
• Palpation of the starting point and ending point
t p ss:
p /
t
hht t
will allow fast and accurate placement of screws.
• A small portable C-arm is easier to manoeuver
around the ankle.
Step 5: Fixation t
hht t
• A drill is placed next to Chaput’s tubercle down to the talus (Fig. 53.13).
• A screw is placed into the same drill hole (Fig. 53.14).
• The postoperative AP and lateral view (standing) after fusion are shown (Fig. 53.15
k e r s
rs
IMPLANTATION
e k eers
and 53.16).
rs
• Fixation is then performed. There are a number of percutaneous screw positions that
o o
o o k
• Fully threaded screws may be better at
o o
oo k o
can be used. Two well-placed screws are required to control shear to prevent non-
o
eebb b b
reducing motion at the joint line than partial
thread cancellous screws.
ee/ e
/ e b three screws.
ee e/e b
union. A third screw is well advised to ensure rigid fixation. I, therefore, use at least
/
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
//tt.
: /. m
m : / /t/.tm. m
t p p : /
FIG. 53.17
ss tp

ss
p : / FIG. 53.18
t
hht t t
hht t
keerrss keerrss • The number of screws required for fusion is

not clear. One study demonstrates a higher
b ooook b ooook
• The starting points and anatomy of the screw positions are illustrated (Fig. 53.17 and
b oo fusion rate with three screws instead of two.
eeb 53.18).
ee/e/e b e
• The first screw should be placed with compression with a lag technique, a variable
e/e/e b POSTOPERATIVE PEARLS
: / / m
.t.m : / / / m
.t.m
pitch screw technique, or a partial thread technique. The other screws should be full
/ t t • Patients can undergo daycare surgery with
the subchondral bone.

t ppss / t ppss : /
thread and not lagged to ensure rigid fixation at the joint level using the strength of
: arthroscopic ankle fusions.
• Local anesthetic blocks and pain pumps can
t
hhtt t
hhtt
• Percutaneous cannulated or solid screws can be placed. The screws need to have
the correct start and end points. Screws can be placed distal to proximal starting at
assist in early discharge.
the lateral process of the talus across into the distal tibia or from the medial side of POSTOPERATIVE PITFALLS
the talus just behind the talonavicular joint surface into the tibia. Screws can then • Patients may not have much pain after surgery
be placed proximal to distal from Gerdy’s tubercle aiming medial and anterior into
rrss rrss
and may be tempted to early weight bearing.
o kkee o k e
the talar neck, or from the medial aspect of the distal tibia into the talar neck. The
k e
screw positions are best determined using palpation, and checked using C-arm
• Postoperative education and correct return to
work instructions are critical in the recovery
oo o
views.
e b o
b o o e b o
b o period.
m ee/ / e
OUTCOMES
m ee/ / e POSTOPERATIVE INSTRUMENTATION/
: / /
/ t
/ .t.m : / /
/ t
/ .t.m
• The patient is placed in a walker boot or cast at the end of the procedure. Weight
IMPLANTATION
t t ss:
p t t t ss:
bearing is not initiated until 2 weeks or after for all patients.
t p p p
• A kneeling scooter can be a useful adjunct to
recovery and mobility.
hht hht
• For elderly or patients with immobility issues weight bearing is initiated at 2 weeks
provided the fixation is stable. For all other patients non–weight bearing is continued
for 6 weeks.
• A compression stocking (knee high, 20 mm
Hg of pressure) can reduce postoperative
swelling.
• Sutures are removed at 2 weeks and the patient switched into a walker boot if casted
after surgery.
k e r
e s
rs k eers
rs
• Outcomes for arthroscopic fusions are promising with equivalent or better fusion
• The time to weight bearing can be shorter
o o
o o k and better outcomes at 2 and 5 years.
o o
oo k
rates than open surgery, shorter hospital stay, fewer wound complications, less cost,
oo
according to some authors.
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
450 hht
EVIDENCE
k e r
e s
rs rs
r s
Abicht BP, Roukis TS. Incidence of nonunion after isolated arthroscopic ankle arthrodesis. Arthroscopy
k e
2013;29:949–54.
e
o o
o o k o oo k o
This review of outcome papers showed an 81.6% fusion rate for arthroscopic fusions.
o o
eebb bb b b
Acevedo JI, Busch MT, Ganey TM, Hutton WC, Ogden JA. Coaxial portals for posterior ankle arthros-
ee/ e
/e e / e
/ e
copy: An anatomic study with clinical correlation on 29 patients. Arthroscopy 2000;16:836–42.
e
: / / t
/ .
t m
. m : / / t
/ t m
This cadaver study showed that the posterior portal between the tibialis posterior and flexor digito-
. . m
rum longus was safe using a switching stick method.
t p ss
p : / Int 2015;36:591–7.
t p ss
p : /
Kendal AR, Cooke P, Sharp R. Arthroscopic ankle fusion for avascular necrosis of the talus. Foot Ankle
t
hht t t
hht t
Fifteen patients underwent arthroscopic ankle arthrodesis with successful outcomes and a high fusion rate.
Nielsen KK, Linde F, Jensen NC. The outcome of arthroscopic and open surgery ankle arthrodesis: a
comparative retrospective study on 107 patients. Foot Ankle Surg 2008;14:153–7.
These authors demonstrated a higher fusion rate in patients with arthroscopic fusion compared
with open fusion in a case–cohort study.
k eers
rs k er
ers
Pakzad H, Thevendran G, Penner MJ, Qian H, Younger A. Factors associated with longer length of
s
hospital stay after primary elective ankle surgery for end-stage ankle arthritis. J Bone Joint Surg Am
b ooook ooook
2014;96:32–9.
o o
This length of stay paper demonstrates that after ankle arthritis surgery, the shortest length of stay
b b
eeb e e
/ e b
was after arthroscopic ankle arthrodesis.
/ e / e
/ e b
Townshend D, Di Silvestro M, Krause F, et al. Arthroscopic versus open ankle arthrodesis: a multicenter
e e
: // t/.tm
. m / /t/.tm. m
comparative case series. J Bone Joint Surg Am 2013;95:98–102.
This paper summarizes a comparison of Arthroscopic ankle fusion against open ankle fusion
:
t p ss
p : / ss : /
demonstrating correction of coronal plane deformity, shorter hospital stay, and better outcomes at
tp p
t
hht t 1 and 2 years.
t
hht t
Winson IG, Robinson DE, Allen PE. Arthroscopic ankle arthrodesis. J Bone Joint Surg Br 2005;87:343–7.
This series of 104 patients underwent arthroscopic ankle fusions, with a 92% fusion rate.
Yoshimura I, Kanazawa K, Takeyama A, et al. The effect of screw position and number on the time to
union of arthroscopic ankle arthrodesis. Arthroscopy 2012;28:1882–8.
In a series of arthroscopic ankle fusions the rate of fusion was higher for patients having a fusion
keerrss keerrss
with three screws instead of two.
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh54
PROCEDURE
t hht
Rigid
r ssFixation for Ankle Arthrodesis
r s s Using Double
o k ee r
Plating
k o kkee r
ooo
b o
m ee
Nicola Krähenbühl and Beatt.Hintermann
/e m ee / e
: / ///t . m : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp t
hhtt p
t p
INDICATIONS
• Posttraumatic or idiopathic ankle osteoarthritis with severe bony deformity INDICATIONS PITFALLS
k eers
rs k errss
• Inflammatory ankle arthropathy (i.e., rheumatoid arthritis)
e
• Acute or chronic osteomyelitis has to be
b ooook b oook
• Unmanageable ankle joint instability or neurologic disorders
o b o
• Distinct osseous defects (i.e., posttraumatic, postinfectious, after failed total ankle
o
treated before ankle arthrodesis is performed.
• Smoking may lead to nonunion and wound
eeb replacement)
ee/ e
/ e b ee/ e
/ e b healing problems postoperatively.
Examination/Imaging
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
• Proper clinical assessment of the complete lower extremity is essential. In particular, INDICATIONS CONTROVERSIES
instability. t
hht t t
hht t
the hindfoot should be assessed regarding alignment, functional impairment, and
• Peripheral artery disease is a risk factor
for nonunion or wound healing problems. If
• The adjacent joints, in particular the subtalar and talonavicular joints, should be ex- peripheral pulses are not palpable, noninvasive
amined for degenerative wear pattern or dysfunction. In order to achieve a planti- vascular studies should be performed before
grade and stable foot postoperatively, additional procedures may be necessary if any surgical treatment.
keerrss osteoarthritis or dysfunction are present.
keerrss • Chronic skin ulcers should be treated before

ankle arthrodesis is performed.
b ooook b ooook
• Assessment of the vascular and neurologic status is essential to prevent malunion
or wound healing problems postoperatively. Noninvasive vascular studies may be
b oo
eeb necessary preoperatively.
ee/e/e b ee
• The skin incision may include preexisting scars. If necessary, a plastic surgeon/e/e b
should be counseled.
: / / t
/ m
.t.m : / / t
/ m
.t.m TREATMENT OPTIONS
•

s : / s : /
Plane weight-bearing radiographs (anteroposterior or mortise view, lateral view)
t pp s t pp s
shoe modification, orthoses) should always be
t
hhtt
a severe hindfoot malalignment (Fig. 54.1). t
hhtt
should be done in a standardized setting. A Saltzman view can be added in case of
• In case of a severe osseous defect or severe malalignment, a computed tomography

considered before surgery is done.
• Supramalleolar osteotomy can be considered
in young and healthy patients with early- to
(CT) scan is helpful for preoperative planning. Single-positron electron CT can be mid-stage asymmetric ankle osteoarthritis
without distinct bony deformity.
added for assessment of adjacent joint dysfunction. • Total ankle replacement is a feasible
k rrss
SURGICAL ANATOMY
e e k e rrss
e
alternative for end-stage ankle osteoarthritis.
• Arthroscopic ankle fusion can be considered
o o
o o k o o o k
• The anterior aspect of the ankle is covered by the superior extensor retinaculum, a
o o o
for patients with minor ankle deformity but
eebb b b contraindication for total ankle replacement.
ee e
/ b ee e
/
tibialis anterior, extensor hallucis longus, and extensor digitorum longus (Fig. 54.2). b
thickening of the deep fascia. From medially to laterally, it includes the tendons of the
/ e / e • Retrograde nailing can be considered if
adjacent joints, in particular the subtalar joint,
: / t
/ m
.t.m : / / t
• The neurovascular bundle can be found between the extensor hallucis longus and
/ / m
.t.m also have to be fused.
t ss:
p / t p ss:
p /
the extensor digitorum longus tendon (halfway between the malleoli; Fig. 54.3).
p
• The safe zone while approaching the anterior ankle joint lies beneath the anterior
tibial tendon. t
hht t t
hht t
• Branches of the superficial peroneal nerve cross from lateral to medial and ensure
the sensory skin supply of the dorsum of the foot.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t 451
t t p
t ss:
p t t p
t ss:
p
452 hht
PROCEDURE 54 Rigid Fixation for Ankle Arthrodesis Using Double Plating hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook b ok
oo
o b oo
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt Superior
t
hhtt Tibialis anterior
tendon
Hallucis longus
extensor
tendon
retinaculum
k e rrss
e k e rrss
e
Extensor digitorum
longus tendon
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m
: / / t
/.tm
. m
t p ss
p : / FIG. 54.2
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 54 Rigid Fixation for Ankle Arthrodesis Using Double Plating 453
k e r
e s
rs k eers
r s
o o
o o k oooo k Deep peroneal
o o
eebb Extensor digitorum
ee/ e
/ebb nerve
Anterior tibial
ee/ e
/ b
e b
longus tendon
: / / t
/ .
t m
. m
artery
: / / t
/ .
t m
. m
Neurovascular
t p ss
p : / Hallucis
longus
t p ss
p : / Talonavicular
bundle
t
hht t tendon
t
hht t joint
Superficial
Medial peroneal
Lateral malleolus nerve
malleolus
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
A
: // t/.tm
. m : / /t/
B
.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss Medial
keerrss
b ooook neurovascular
bundle
b ooook b oo
Flexor hallucis POSITIONING PEARLS
: / / t
/ m
.t.m : / / t
/ m
.t.m
longus tendon
t ppss : / t ppss : / operated leg is elevated with cushions or the

t
hhtt t
hhtt radiographs can be taken more easily.
• Free draping of both legs may help to achieve
a proper correction.
k e rrss
e k eerrss Posterior aspect POSITIONING PITFALLS
o o
o o k o ooo k C
o o
eebb ee/ e
/ b
e b FIG. 54.3
ee/ e
/ b
e b procedure.
• Draping should not avoid intraoperative
: / / t
/ m
.t.m : / / t
/ m
.t.m radiographic assessment by a C-arm.
t p ss:
p / t p ss:
p /
hht t t hht t t POSITIONING EQUIPMENT
POSITIONING • A tourniquet can be used to ensure optimal
• A radiolucent operating table should be used. The patient is placed in supine posi-
k e r s
r
tion.
s
• A tourniquet is placed at the thigh.
e k eers
rs POSITIONING CONTROVERSIES
o o
o o k o o
oo k
• Support of the ipsilateral hip with a cushion can be helpful to visualize the axis of the
oo
• To compare the axis of the arthrodesis
eebb e / b
e b
foot. The patella should point upwards for adequate orientation.
/ e
• To achieve a good reduction during surgery, the hindfoot can be positioned on a
e ee/e/ebb intraoperatively, the contralateral ankle may
also be draped.
cushion.
: / / t
/ .
tm.m : / / t
/.tm
. m
• Draping may include the hip if any deformities
above the knee joint are present.
t p ss
p : /
• The leg should be draped free to the knee joint.
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
454 hht
k e r
e ss
• To avoid injury to the neurovascular structures,
r
a subperiosteal exposure of the distal tibia is
k eers
r s
o o
o o krecommended.
oooo k o o
eebb • A self-retaining retractor can be helpul for
proper preparation of the distal tibia.
ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t t
• Avoid injury to branches of the peroneal nerve.
hht
Neurinoma and persistent pain postoperatively
may be possible.
t
hht t
• Avoid dissection laterally to the extensor
hallucis longus tendon. The neurovascular
bundle can be damaged.
k eers
rs k er
erss
b ooook
• Small blunt Hohmann retractors
b ooook b o o
eeb • Self-retaining retractor
ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t
• If done properly, the anterior approach to the
ankle is a safe way to expose the ankle joint.
The tibialis anterior tendon should be used as
t
hht t FIG. 54.4
guide.
• If possible, scars from previous operations
should be included in the anterior approach.
keerrss keerrss
b ooook
STEP 1 PEARLS
• In order to ensure a high contact pressure at
b ooook
Portals/Exposures
b oo
eeb the anterior and posterior aspect of the ankle
during arthrodesis, the anterior and posterior
ee/e/e b e /e/e b
• A longitudinal incision of 10–12 cm length is performed lateral to the tibialis anterior
e
: / / t
rims of the distal tibia should be preserved.
/ m
.t.m tendon.
: / / t
/ m
.t.m
t p ss : /
In addition, the convexity of the talar dome
and the concavity of the tibial plafond should
p t p ss : /
• Under the surface of branches from the medial superficial peroneal nerve and veins,
the extensor retinaculum is prepared.
p
t
hhtt
also be preserved to increase the stability and
resistance against rotational forces.
• The lateral gutter does not need to be cleaned.
t
hhtt
• Dissect the extensor retinaculum along the lateral border of the anterior tibial tendon.
• Expose the distal tibia by retracting the anterior tibial tendon medially. Two small
blunt Hohmann retractors are used for the subperiosteal exposure of the distal
tibia.
STEP 1 PITFALLS
• Arthrotomy of the ankle joint is performed, and scarred capsule is removed (Fig. 54.4).
k rrss
• Incomplete removal of cartilage may increase
e e
the risk for delayed or nonunion.
e rrss
• Expose the neck of the talus and position a self-retaining retractor. Avoid tension to the skin.
k e
o o
o o k PROCEDURE oo
• To assess the blood supply of the bone in case
o o k o o
eebb of talus necrosis, the tourniquet can be opened
during surgery.
ee/ e
/ b
e b ee/ e
/ b
e b
Step 1: Preparation of the Tibial Plafond and the Talar Dome
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Remaining cartilage is removed from the talar dome, tibial plafond, and the medial
IMPLANTATION
t p ss:
p / t p ss: /
gutter using a chisel and curettes (Fig. 54.5).
p
t
hht t
• A curved chisel allows easier removal of the
cartilage and preserves the anatomic shape of
the bone.
t
hht t
• The anatomic configuration of the talus and tibial plafond have to be preserved.
• Sclerotic bone areas are broken by 2.5-mm drill holes.
• Bone cysts are cleaned and filled with cancellous bone, autologous bone matrix, or
• Different allografts are available to fill osseous
an allograft.
cysts.
k e r
e s
rs
k eers
rs
o o
o o k
• The use of a burr may improve the breakdown
o o
oo k oo
eebb of sclerotic bone. Attention should be payed to
heat damage leading to delayed or nonunion.
ee/ e
/ b
e b ee/e/ebb
• There is no evidence in the literature as to
/ / t .
t
whether an autologous bone graft or allograft
: / m.m : / / t
/.tm
. m
ss :
is better in case of an osseous defect.
t p p / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
STEP 2 PEARLS
k e r
e s
rs k eers
r s • The optimal position of the arthrodesis is
neutral dorsiflexion/plantar flexion and slight
o o
o o k oooo k o o
hindfoot valgus. Avoid internal rotation of
eebb ee/ e
/ebb ee/ e
/ b
e b the foot or anterior translation of the talus in
relation to the tibial plafond.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : / STEP 2 PITFALLS
t
hht t t
hht t • If the fibula is too long, lateral impingement
may be possible. Shortening can be easily
done through the same anterior approach.
k eers
rs k er
erss
IMPLANTATION
• A C-arm is necessary to control the reposition.
• Platelet concentrate may be used in addition to
stimulate bone healing.
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m STEP 2 CONTROVERSIES
t p ss
p : / tp pss : / • In order to avoid walking inability or early
t
hht t FIG. 54.5 t
hht t osteoarthritic changes in the adjacent joints,
the reposition has to be done properly.
STEP 3 PEARLS
• The use of a compression device is necessary
keerrss keerrss to achieve appropriate stability.
b ooook b ooook b oo STEP 3 PITFALLS
eeb ee/e/e b ee/e/e b • Appropriate screw length in the talar neck can
: / / t
/ m
Step 2: Reduction Maneuver of the Ankle Joint
.t.m : / / t
/ m
.t.m be checked with a C-arm.
• Be aware of loosing reduction during screw
t p
fore the fusion is done.
pss / t ppss : /
• Optimal positioning of the ankle (axial, sagittal, and coronal planes) is important be-
: tightening.
t
hhtt t
hhtt
• Once the reduction is obtained, one or two 2.5-mm Kirschner wires (K-wires) are
inserted through the distal tibia into the talus. STEP 3 INSTRUMENTATION/
IMPLANTATION
• In order to avoid interference with the plate, the K-wires should be placed in the
center of the tibia. • A lateral and medial plate is used for fixation.
• Use of a C-arm is necessary to check the
k rrss
Step 3: Internal Fixation of the Ankle Joint
e e k e rrss
e
position of the reduction before and after
screw fixation.
o o
o k o o
o o k
• The lateral plate is fixed by three interlocking screws to the lateral aspect of the talar
o o o
eebb b b
neck. Residual osteophytes have to be removed (Figs. 54.6 and 54.7).
ee/ e
/ e b /
• In order to achieve compression of the talus against the tibia and the medial malleo-
ee e
/ e b STEP 3 CONTROVERSIES
lus, a compression device is used.
/ / t
/ m
.t.m / / t
/ m
.t.m
• In case of gross osseous deformity, an iliac crest autograft or an allograft may be
: :
• A single plate can also be used for arthrodesis.
However, biomechanical studies have
necessary.
t p ss:
p / t p ss:
p / suggested that double plating is more rigid
than a single plate.
t
hht t
neck and, thereafter, to the tibia (Fig. 54.8).
t
hht t
• The medial plate is positioned and fixed with three interlocking screws to the talar • Screw fixation is also possible. However,
the stability is lower compared with anterior
• In order to check the final position of the ankle arthrodesis, a C-arm is necessary double plating.
(Fig. 54.9).
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
456 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / t ppss : /
t
hht t FIG. 54.6 t
hht t FIG. 54.7
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k FIG. 54.9
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
FIG. 54.8
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : /
t p ss
p : / FIG. 54.10
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
Step 4: Skin Closure STEP 4 PEARLS
k eerssrupted nonabsorbable suture.

k eers
r s
• The extensor retinaculum is closed by continuous absorbable and the skin with inter-
r • Rigorous bleeding control is recommended in
order to avoid wound healing problems due to
oooo k o oo k o
• A thick compressive dressing is applied, and the foot is placed in a removable splint.
o o
hematoma.

ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m OUTCOMES
: / / t
/ .
t m
. m STEP 4 PITFALLS
t p ss
p : / t p ss
p :
• A removable cast is adjusted at the second postoperative day.
/
• After the swelling is less (typically 10–14 days postoperatively), a nonremovable
• Proper closure of the retinaculum is necessary
to avoid prominent extensor tendons.
t
hht t
below-knee cast for 8 weeks is adjusted. t
hht t
• Full weight bearing is possible after adjustment of the below-knee cast.
• A clinical and radiographic assessment is done 8 weeks postoperatively (Fig. 54.10). IMPLANTATION
If the fusion is sufficient, the patient can continue with custom shoes. If not, a cast • Absorbable sutures for the retinaculum and
k eers
rs
for an additional 4–6 weeks is recommended.
EVIDENCE k er
erss subcutaneous tissue, nonabsorbable suture for
the skin.
eeb viii.
ee/ e
/ e b ee/ e
/ e b
Ahmad J, Raikin SM. Ankle arthrodesis: the simple and the complex. Foot Ankle Clin 2008;13:381–400.
// t .tm
. m
and ankle. J Bone Joint Surg Am Vol 1987;69:1052–62.
: / : / /t/.tm
Buck P, Morrey BF, Chao EY. The optimum position of arthrodesis of the ankle. A gait study of the knee
. m • A suction device may evacuate blood out of

the bone without preventing local hematomea
t p ss
p : /
after ankle arthrodesis. Foot Ankle 1994;15:64–7.
tp pss : /
Cobb TK, Gabrielsen TA, Campbell 2nd DC, Wallrichs SL, Ilstrup DM. Cigarette smoking and nonunion formation. Therefore continuous compressive
t
hht t t
hht t
Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for
post-traumatic arthritis. J Bone Joint Surg Am Vol 2001;83-A:219–28.
dressing may be used to apply continuous
pressure during the first 2 days postoperatively.
Collman DR, Kaas MH, Schuberth JM. Arthroscopic ankle arthrodesis: factors influencing union in 39
consecutive patients. Foot Ankle Int 2006;27:1079–85.
Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and long-term out-
keerrss
Joint Surg Am Vol 2007;89:1899–905.
keerrs
comes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone
s
• Reduction or smoking cessation is recommended.
• Intermediate follow-up shows good to
b ooook arthroplasty. J Bone Joint Surg Am Vol 2009;91:850–8.
b oook
Hintermann B, Barg A, Knupp M, Valderrabano V. Conversion of painful ankle arthrodesis to total ankle
o b oo
excellent results with an increased American
Orthopaedic Foot and Ankle Society (AOFAS)
eeb sions. J Bone Joint Surg Am 2016;98:2006–16.

ee/e/e b ee/e/e b
Krause F, Younger AS, Baumhauer JF, et al. Clinical outcomes of nonunions of hindfoot and ankle fu- score and reduction of pain.
: / / m
.t.m : / / / m
.t.m
Ling JS, Smyth NA, Fraser EJ, et al. Investigating the relationship between ankle arthrodesis and
/ t t
adjacent-joint arthritis in the hindfoot. A systematic review. J Bone Joint Surg Am 2015;97:e43.
Plaass C, Knupp M, Barg A, Hintermann B. Anterior double plating for rigid fixation of isolated tibiotalar
t
hhtt
arthrodesis. Foot Ankle Int 2009;30:631–9.
t
hhtt
• Wound healing problems and delayed or
nonunion.
• Secondary osteoarthritis of the adjacent joints
may occur over time.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
• Footwear modification postoperatively can
reduce the risk for secondary osteoarthritis of
eebb ee/ e
/ b
e b ee/ e
/ b
e b the adjacent joints.
• In case of prominent hardware, removal is
: / / t
/ m
.t.m : / / t
/ m
.t.m possible after bony healing occurs.
t p ss:
p / t p ss:
p /
t
hht t t
hht t POSTOPERATIVE INSTRUMENTATION/
IMPLANTATION
• Removable cast and a below knee cast
• Clinical and radiographic assessment 8 weeks
postoperatively
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh55
PROCEDURE
t hht
Ankler ssArthrodesis Using Ring/Multiplanar
r s s External
o k ee r
Fixation
k o kkee r
b o
m ee /e m ee / e
: / t
///t. m
Mark E. Easley and Stefan G. Hofstätter
. : / /
/ t
/ .
t . m
s
tps : ss :
hhtttp t
hhtt p
t p
• Patient with prior total joint arthroplasty (pin • Ankle arthrodesis
k eers
rs
tract infection may seed joint implant)
• Anticipated noncompliance with pin care
k er
erss
• Symptomatic end-stage ankle arthritis (posttraumatic, inflammatory, primary)
• Failed nonoperative management
b ooook b ooook
• External fixation
b o o
eeb ee/ e
/ e b ee/ e
/
• Compromised soft tissue envelopee b
• History of sepsis/osteomyelitis at the arthrodesis site (Fig. 55.1A–B)
: // t/.tm
. m : / /t . m. m
• Inadequate bone stock to support internal fixation at the arthrodesis site
/ t
t p ss
p : / ss : /
• Failed prior ankle arthrodesis using internal fixation (Fig. 55.1C)
tp p
t
hht t t t
• Failed total ankle arthroplasty (Fig. 55.1D)
hht
• Anticipated noncompliance with non–weight-bearing status
• The case illustrating this procedure is that of a patient with posttraumatic end-stage
ankle arthritis, an inability to comply with a non–weight-bearing status (for other
medical reasons), and adequate support at home to maintain adequate pin care
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/A
e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
B
: / / t
/ .
tm.m C
: / / t
/.tm
. m D
t p ss
p : / t p ss : /
FIG. 55.1 (From Easley M, Looney C, Wellman S, Wilson J. Ankle arthrodesis using ring external fixation. Tech Foot Ankle Surg. 2006,5:1–14)
p
458 t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 55 Ankle Arthrodesis Using Ring/Multiplanar External Fixation 459
Examination/Imaging
k e e s
r rs
• Range of motion (ROM)
k eers
r s
o o
o o k
• Typically limited, painful ankle ROM
oooo k o o
eebb / e bb
• Preferably asymptomatic, full hindfoot ROM (following ankle fusion, greater stress
ee /e
experienced on the hindfoot articulations)
ee/ e
/ b
e b
• Alignment (clinical)
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
ss : /
• Must be assessed with the patient weight bearing
t p p t p ss
p : /
t t t t
• Assess deformity that will need to be corrected to reestablish a plantigrade foot
hht
(equinus, varus/valgus)
hht
• Soft tissue envelope (previous incisions) often less important with external fixation
compared with internal fixation since limited exposure typically suffices to prepare
the tibiotalar joint for arthrodesis
k eers
rs k er
ers
• Vascular examination to confirm that adequate perfusion is present to allow healing
s
b ooook
Imaging
b ooook b o o
eeb • Confirm end-stage tibiotalar arthritis
ee e
• Weight-bearing radiographs of the foot and ankle
/ / e b ee/ e
/ e b TREATMENT OPTIONS
• Assess malalignment
: // t/.tm
. m : / /t/.tm. m • Ankle arthrodesis using internal fixation
• Distraction arthroplasty
t p ss
p : /
• Assess associated deformity and compensatory alignment in the foot
tp pss : /
• If avascular necrosis of the talus is suspected, magnetic resonance imaging to
• Ankle fresh/fresh frozen allograft (ankle
t
hht t t
hht t
predetermine how much bone will need to be resected to achieve viable tibiotalar
surfaces for healing (usefulness may be limited by previously placed hardware)
replacement with allograft ankle)
• Total ankle arthroplasty
SURGICAL ANATOMY POSITIONING PEARLS
kee rss keerrs

• Neurovascular structures must be respected with the surgical approach (ankle) and
r s
half-pin and thin wire placement (lower leg, ankle, and foot).
• Positioning the foot and lower leg with the toes
directed to the ceiling facilitates placing the
b ooook dorsalis pedis artery

b oook
• Anteriorly: superficial peroneal nerve, deep peroneal nerve, and anterior tibial/
o b oo
external fixator congruently on the foot and
ankle.
eeb e /e/e b
• Posteromedially: posterior tibial artery, tibial nerve and its branches
e ee/e/e b
• Laterally: sural nerve
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Ideally, despite external fixation, the muscles and respective tendons should remain
mobile, particularly the ones responsible for toe movement (flexor and extensor digi-
• Be sure to allow enough space for the calf.
t
hhtt t
hhtt
torum longus, flexor and extensor hallucis longus, and intrinsics). Thus, half-pin and
thin wire placement must respect these structures as well.
A bump to support the calf may distort soft
tissues of the lower leg. When the bump under
• Ideally, thin wires should be extraarticular, since potential pin tract infections could the calf is removed, the proximal ring should
not impinge on the skin of the lower leg (be
lead to septic arthritis.
sure to leave adequate space between the
• “Safe” zones have been established for thin wire placement (Fig. 55.2).
rrss rrss
external fixator and the calf).
o k e
k e
POSITIONING
o k e
k e
o
eebb o o e b o o o
• Supine with the foot (toes) directed toward ceiling (Fig. 55.3).
b e b o
b o
EQUIPMENT
m ee/ e
• Bump/bolster under the ipsilateral hip to maintain position.
/ m ee/ /
• Bump/bolster under the ipsilateral calf to suspend foot and ankle and facilitate exter-e • Radiolucent operating table
nal fixator frame placement.
: / /
/ t
/ .t.m : / /
/ t
/ .t.m • Bump/bolsters
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
460 hht
PROCEDURE 55 Ankle Arthrodesis Using Ring/Multiplanar External Fixation hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
.
Anterior
m : / / t
/ .
t m
. m Posterior
t p ss
p : / t p ss
p : /
t
hht t t
hht t
Anterior tibial
artery
Posterior
k eers
rs k er
ers
nerve
s tibial artery
ook ook
Deep peroneal
b
eeboo / e b o
bo
nerve
/ e b o
b o Tibial nerve
m ee / e m ee / e
: ///t/.t. m : / /
/t/.t . m
t t p
t ss
p : t tptpss :
hht A
hht
Tibial nerve
keerrss keerrss
nerve branches Flexor digitorum
b ooook o ook
Deep peroneal nerve
b o b oo
longus tendon
eeb ee/e/e b
Dorsalis pedis artery
ee/e/e b Flexor hallucis

longus tendon
: / / t
/ m
.t.m Extensor hallucis
longus tendon
: / / t
/ m
.t.m
t ppss : / t p
Extensor digitorum
pss : /
t
hhtt t
hhtt
longus tendon
B
Tibial nerve
k e rrss
e k e rrss
e
Extensor digitorum
Sural nerve
o o
o o k o o o k
longus tendon
o o o
Flexor hallucis
longus tendon
eebb ee/ e
/ b
e b Extensor hallucis
longus tendon
ee/ e
/ b
e b Flexor digitorum
: / / t
/ m
.t.m : / / t
/ m
.t.m longus tendon
t p ss:
p / Deep peroneal nerve
t p ss:
p /
t
hht t t
hht t
C
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
FIG. 55.3 (From Easley M, Looney C, Wellman S, Wilson J. Ankle arthro-
o
b o
eeb ee/ e
/ e b
desis using ring external fixation. Tech Foot Ankle Surg. 2006,5:1–14)
ee/ / e b
e
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
Portals/Exposures
t
hht t t
hht t
• The surgical approach is the same as for ankle arthrodesis using internal fixation
• While minimally invasive techniques have
• Open anterior, mini-arthrotomy, arthroscopic, and open transfibular approaches advantages, the surgical approach should not
are all options and are often dictated based on prior surgical approaches. be limited to the point where the joint surfaces
• In this chapter, we highlight an anterior approach (see video) and a mini-arthroto- are inadequately prepared.
keerrss my technique (illustrated here).
keerrss
b ooook
• Dual arthrotomy technique (Fig. 55.4)
b ooook
• While distracting the joint with a lamina spreader through one arthrotomy, the joint
b oo
eeb surfaces are prepared though the other.
ee/e/e b ee/e/e b
: / / t m
tion. Periosteal stripping is kept to a minimum.
/ : / / t
/ m
• The lamina spreader is moved to the other arthrotomy to complete joint prepara-
.t.m .t.m
t ppss : / t ppss :
• In this case, a second spreader is used to further facilitate exposure./
• During the procedure
t
hhtt t
hhtt
• Protect the superficial peroneal nerve, deep neurovascular bundle, and extensor
tendons.
• Maintain careful soft tissue handling; avoid direct tension on wound margins.
• Minimize periosteal stripping at the tibiotalar joint to maintain optimal blood sup-
k eerss
rply at the arthrodesis site.
k e rrss
e
o o
o o k
PROCEDURE
o o
o o k o o
eebb Step 1: Preparation and Provisional Pinning
ee/ e
/ b
e b ee/ e
/ b
e b STEP 1 PEARLS
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Ring external fixation is not substitute for proper joint preparation in ankle arthrode- • The tibial and talar surfaces must be vascular;
sis.
t p ss:
p / t p ss:
p /
• Remove all residual cartilage using an elevator (Fig. 55.5). Following this, a drill and/
neither external fixation nor any other method
of fixation can promote fusion without
t
hht t t
hht
or chisel are introduced to penetrate the subchondral bone.
• Remove any bone suspicious for avascular necrosis.
t adequate vascularity at the arthrodesis site.
• Penetrate subchondral bone to facilitate mesenchymal stem cell migration to the

arthrodesis site.
k e s
rs
• Improves stability of arthrodesis.
e k eers
• Maintain the architecture of the tibiotalar joint subchondral surfaces.
r rs
o o
o o k • May increase surface area for fusion.
o o
oo k oo
eebb e / b
e b
• The surgeon may need to consider a posterior capsular release or tendo-Achilles
/ e
lengthening if a plantigrade foot position cannot be achieved.
e ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
462 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook
o
b o
eeb ee/ e
/ e b
ee/ / e b
e
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
• Bone grafting.
o o
o o k
STEP 1 PITFALLS
o o o k o
• Use cancellous allograft chips mixed with a platelet-rich product (Fig. 55.6).
o o
eebb b b
• Alignment is essential, particularly if a prebuilt
or traditional ring external fixator is used.
• Err into valgus, not varus; err into external
ee/ e
/ b ee e
/ b
• The choice of products used is based on surgeon preference.
e / e
• Provisionally pin the tibiotalar joint in anatomic alignment with appropriate apposition
rotation, not internal rotation.
: / / t
/ m
.t.m : / / t
/ m
.t.m
of tibial and talar fusion surfaces: neutral dorsiflexion/plantar flexion; slight hindfoot
t p ss:
p / t p
• Sagittal plane ss:
p /
valgus; second metatarsal aligned with the tibial crest (Fig. 55.7).
IMPLANTATION t
hht t

t
hht t
• Place ankle and foot in neutral plantar flexion/dorsiflexion.
• Ensure the talar dome is centered under the tibial plafond.
• Chisel or drill to prepare the articular surface • Coronal plane
for fusion.
• Steinmann pin to stabilize ankle arthrodesis • Ensure the foot is kept neutral at the ankle.
k e s
while external fixator is being assembled about
r rs
the foot and ankle.
e

k eers
r
• Maintain slight (5°) hindfoot valgus.
s
• Rotation
o o
o k
• Fluoroscopy unit to confirm satisfactory
o o o
oo

k • The second metatarsal should be aligned with the tibial crest.
oo
eebb b b
alignment and bony apposition at the
arthrodesis site.
ee/ e
/ e b e /e/e b
• Fig. 55.8 shows fluoroscopic images of the ankle provisionally pinned in ideal align-
ment in anteroposterior (Fig. 55.8A) and lateral (Fig. 55.8B) views.
e
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs A
k er
erss B
b ooook b ooook b o
o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m
Step 2: External Fixator Assembly/Attachment to Lower Leg and Foot
: / /t/.tm. m STEP 2 PEARLS
t p ss
p : / tp pss : /
• The surgeon will need to be familiar with the particular frame system he or she uses; • In order to limit heat generation and potential
t
hht t t
hht t
be sure to meet with the frame system’s representative to become familiar with the
intended frame and the recommended tensioning for the thin wires.
skin/bone necrosis and resultant pin infection
and/or loosening, thin wires and half-pins
should be inserted while cold saline is irrigated
• In this example case, a prebuilt frame assembled on a back table is used (Fig. 55.9A).
on them or while they are held with a sponge
The frame is positioned congruently about the lower leg and foot (here with thin wires moistened with cold saline.
already positioned in foot; Fig. 55.9B), while the calf is supported by a bolster and the • To optimize frame construct stability, place
keerrss keerrss
leg is perpendicular to the operating room table to facilitate frame placement. pins in a straight axis and directly on the
frame.
b ooook b ooook
• The frame should allow adequate space for the calf and posterior heel. The bolster
under the calf may give a false sense of adequate space; be sure to check to see
b oo
eeb /e e b /e
if adequate space is available for the calf with the bolster removed. At least 1 cm
ee / ee /
should separate the foot portion of the frame from the posterior heel (Fig. 55.10A).e b
• Securing the foot.
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The plantar aspect of the foot should be inferior to the foot portion of the frame.
t
hhtt t
hhtt
This will facilitate placing the thin wires in the foot in the ideal position, and facili-
tate postoperative weight bearing even without a supplemental foot tread added
to the construct.
STEP 2 PITFALLS
• Adequate space must be left for the calf and
the posterior aspect of the calcaneus.
• A thin wire is placed in the forefoot to “suspend” the frame from the foot (Fig.
• If the calcaneal wires are tensioned first in
55.10B), and the foot is centered in the foot portion of the frame, but not yet an open ring construct, then subsequent
k e rrss
e
tensioned. The wire need only capture.
k e rrss
e
• Two calcaneal wires are placed 60–80° to one another, but not yet tensioned
tensioning of the forefoot or more distal wires
will lead to loss of tension in the calcaneal
o o
o o k (Fig. 55.11A–B).
o o
o o k o o
wires.
eebb b b • All wires and half-pins should achieve
ee e
/ b
• A midfoot/supplemental forefoot wire is placed, typically supported by at least
/ e
one post attached to the frame, but not yet tensioned.
ee/ e
/ e b bicortical fixation. Unicortical drilling and pin
placement leads to excessive heat generation
: / / t
/ m
.t.m : / / t
/ m
.t.m
• The foot portion of the ring may be closed anteriorly to avoid frame distortion dur- and potential pin infection/loosening.
t ss:
ing thin wire tensioning.
p p / t p ss:
p /
• After placing the midfoot wire, all wires are tensioned (the final calcaneal wire is
t
hht t t
hht t
tensioned at this point; Fig. 55.11C). If the surgeon chooses to leave the anterior
foot portion of the ring open, then tensioning should begin with the forefoot wires
that will serve to complete the anterior portion of the ring and permit successful
calcaneal wire tensioning.
k e s
rs e rs
• Securing the proximal ring or proximal ring block to the lower leg.
r rs
• One or more thin wires may be placed across the proximal rings and tensioned.
e k e
IMPLANTATION
o o
o o k oo k
Alternatively, these thin wires may be secured to the proximal ring without ten-
o o oo
• External fixator system with corresponding
wrenches and tensioning device
eebb ee / b
e b
sioning while ideal ring position on the lower leg is established.
/ e ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
464 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b ooook A
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
B
t ppss : / t ppss : / B
t
hhtt t
hhtt
k e rrss
e k rrss
• Again, a prebuilt, traditional ring external fixator construct should be properly posi-
e e
tioned before any of the wires in the foot or lower leg are placed, since further adjust-
o o
o o k o o
o o k o
ments are limited. However, subtle adjustments can be made to the ankle, hindfoot,
o
eebb ee/ e
/ b
e b across the ankle.
ee/ e
/ b
e b
and proximal ring block position at this stage, despite the provisional pin placed
: / / t
/ m
.t.m : / / t
/ m
.t.m
• While maintaining respect for vital structures, the thin wires should be placed as
t p ss:
p / t p ss:
p /
close to 90° to one another as possible.
• As the surgeon holds the external fixator by the foot portion with the proximal ring
t
hht t t
hht t
block centered in the ideal position over the lower leg, an assistant places one
or more thin wires, one or more half-pins, or a combination of half-pins and thin
wires to secure the proximal ring block (Fig. 55.12A).
• Typically, the entire frame construct is secure once one half-pin is simultaneously
k e r
e s
rs k eers
anchored to the tibia and proximal ring block.
rs
• Ideally, two half-pins are placed in the medial tibia and a third in the anterior tibia,
o o
o o k o o
oo k
directed slightly medially to achieve bicortical purchase.
oo
eebb ee/ e
/ b
e b ee/e/ebb
• The proximal ring should be well centered on the lower leg (Fig. 55.12B).
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook A
b ooook B
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
C t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
A
: / / t
/ .
tm.m
B
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
466 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b ooook b o
o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
A
t
hhtt B
t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o o k o
• To augment fixation in the foot, a supplemental half-pin may be placed axially,
o o
eebb b b
STEP 3 PEARLS
• Talar wires must be placed and secured to the
ee/ e
/ e b ee e
/ e b
from posterior to anterior in the calcaneus, and attached to the foot portion of the
/
frame after the proximal ring block is secured (Fig. 55.13).
compression.
: / / t
/ m
foot portion of the frame to avoid subtalar joint
.t.m / / t
/ m
.t.m
Step 3: Talar Wires and Tibiotalar Compression
:
t ss:
p /
• With appropriate compression, the talar wires
p
may bend (noted on fluoroscopic images).
t p ss:
p
• Talar wire placement /
t
hht t t
hht t
• Once the foot portion of the frame and proximal ring block are secured, one or
two talar wires are added and secured only to the foot portion of the frame, not
STEP 3 PITFALLS
the proximal ring block.
• Talar wires maintain the subtalar joint during • An intermediate partial ring, attached to the foot portion of the frame, serves to
compression; if they are not placed, then
k e r
e ss
compression of the foot portion of the frame
r
to the proximal ring block will produce not only
k eers
support the talar wires. Often, the talar wires need to be suspended from the in-
rs
termediate partial ring with posts.
o o
o o kthe desired tibiotalar compression but also
o o
•
oo k
Fig. 55.14A shows the frame with talar wires in place from the perspective of
oo
eebb undesired subtalar compression.
• Placing the talar wires through the malleoli
ee/ e
/ b
e b e / /ebb
the lateral foot and ankle. A close-up view (Fig. 55.14B) demonstrates one talar
e
wire attached directly to the intermediate ring and the second suspended from
e
only penetrate the talus.
: / / t
/ tm
will restrict tibiotalar compression; they should
. .m a post.
: / / t
/.tm
. m
t p ss
p : / t p ss
p : /
• The talar wires need to be tensioned like the other thin wires.
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : / B
tp pss : /
t
hht t t
hht t
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
C D
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
• Tibiotalar joint compression
: / / t
/ m
.t.m : / / t
/ m
t p ss:
p / t p ss:
p /
• With all wires and half-pins secured, the distal ring block (foot and intermediate
portions) is advanced toward the proximal ring block using the threaded rods
IMPLANTATION
t
hht t t
hht t
connecting the proximal and distal portions of the frame. With appropriate com-
pression, this should become increasingly more difficult.
• External fixator system with corresponding
wrenches and tensioning device
• Fig. 55.15A shows the frame construct completed. In Fig. 55.15B, compression
is being applied (advancing threaded rods secured to the distal frame construct
k e r
e s
rs
toward the proximal ring).
k eers
rs
• Intraoperative fluoroscopy confirms that appropriate tibiotalar apposition has been
• Some surgeons consider subtalar joint
o o
o o k achieved (Fig. 55.15C–D).
o o
oo k oo
distraction desirable during tibiotalar
eebb b b compression; we only add this when we
ee/ / e b
• The provisional pin may be left in place during compression to act as an “internal
e e
rail” to guide compression, but is not necessary and may be removed even prior to
e/e/e b identify mild, early arthritic changes in the
subtalar joint.
applying compression.
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
468 hht
POSTOPERATIVE PEARLS POSTOPERATIVE CARE AND EXPECTED OUTCOMES
k e r
e ss
• Typically pins remain clean when the skin
r
immediately surrounding the pin is stable,
k eers
r s
• External fixation is maintained until there is radiographic evidence for healing.
• Occasionally, bridging trabeculation across the tibiotalar joint is obscured by the exter-
o o
o o kthereby reducing the skin irritation.
oooo k o
nal fixator; in this case, a computed tomography scan may be useful to confirm fusion.
o
eebb • Unlike ankle arthrodesis performed with
internal fixation, further tibiotalar compression
ee/ e
/ebb / e b b
• Typically, healing in uncomplicated ankle arthrodesis takes 10–14 weeks.
ee / e
• An advantage of external fixation over internal fixation for ankle arthrodesis is that
can be applied at follow-up visits and early
: / /
weight bearing to tolerance is permitted.
t
/ .
t m
. m : / / t . m
. m
greater compression may be applied at the arthrodesis site postoperatively. We rou-
/ t
t p ss
p : / ss : /
tinely apply further compression at each postoperative visit in the first 6 weeks, par-
t p p
t
hht t site. t
hht t
ticularly when postoperative radiographs suggest any gapping at the arthrodesis
• Once the surgical approach site is healed, weight bearing to tolerance is permitted.
• A persistent pin tract infection, particularly A tread attached to the foot portion of the frame may facilitate weight bearing and
with lucency about the pin on postoperative protect the foot.
k ee s
radiographs, should prompt pin removal
rrs
and placement of another pin in a different
k er
ers
• Once-daily pin care is recommended, with gauze moistened with a 50:50 mixture of
s
saline and hydrogen peroxide to remove any tissue debris that collects at the pin-
b ooook location.
b ooook skin interface.
b o o
eeb ee/ e
/ e b e / e
/ e b
• Skin irritated at a pin site should be carefully cleaned and then stabilized with dress-
ings that apply slight pressure on the skin to limit its movement about the pin.
e
: // t/.tm
. m : / /t/.tm. m
• A short course of an oral antibiotic and a topical antibiotic at the pin site usually
t p ss
p : / tp pss : /
treats minor pin tract infections adequately when combined with dressings that limit
irritated skin motion about the pin.
t
hht t t
hht t
See also Video 55.1, Ankle Arthrodesis Using External Fixation.
EVIDENCE
keerrss keerrs
A grade B recommendation can be made for ankle arthrodesis using external fixation given several
s
Level IV studies that demonstrate satisfactory outcomes using this technique.
b ooook b ooook
Easley ME, Montijo HE, Wilson JB, Fitch RD, Nunley 2nd JA. Revision tibiotalar arthrodesis. J Bone
Joint Surg Am 2008;90:1212–23.
b oo
Katsenis D, Bhave A, Paley D, Herzenberg JE. Treatment of malunion and nonunion at the side of an
ankle fusion with the Ilizarov apparatus. J Bone Joint Surg Am 2005;87:302–9.
: / / t
/ m
.t.m : / / / m
.t.m
Moore J, Berberian WS, Lee M. An analysis of 2 fusion methods for treatment of osteomyelitis following
t
fractures about the ankle. Foot Ankle Int 2015;36(5):547–55.
Ogut T, Gilsson RR, Chuckpalwong B, Le IL, Easley ME. External ring fixation versus screw fixation for
t
hhtt t
hhtt
ankle arthrodesis: a biomechanical comparison. Foot Ankle Int 2009;30:353–60.
Paley D, Lamm BM, Katsenis D, Bhave A, Herzenberg JE. Treatment of malunion and nonunion at
the site of an ankle fusion with the Ilizarov apparatus. Surgical technique. J Bone Joint Surg Am
2006;88(Suppl 1):119–34.
Salem KH, Kinzi L, Schmeiz A. Ankle arthrodesis using Ilizarov ring fixators: a review of 22 cases. Foot
Ankle Int 2006;27:764–70.
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh56
PROCEDURE
t hht
Tibiotalocalcaneal
r ss Arthrodesis With
r s s a Retrograde
o k ee r
Intramedullary
k Nail o kkee r
ooo
b o
m ee /e m ee / e
: / t
Alexej Barg and Beat Hintermann
///t. . m : / /
/ t
/ .
t . m
s
tps : ss :
INDICATIONS
hhtttp t
hhtt p
t p
• Posttraumatic/degenerative/primary/secondary arthritis of tibiotalar and subtalar joints • Contraindications for this procedure
• Acute or chronic infections with/without
k e s
• Rheumatoid arthritis of tibiotalar and subtalar joints
rrs
• Significant osteonecrosis of the talus
e k er
erss osteitis/osteomyelitis
b ooook b oook
• Diabetic patients with unstable Charcot neuroarthropathy or peripheral neuropathy
o b o o
• Severely compromised critical and poor
skin and soft tissue conditions
eeb • Failed ankle arthrodesis

• Failed total ankle replacement
ee/ e
/ e b ee/ e
/ e b • Severe malalignment of the tibia (mostly as
a result of previous trauma) with blocked
: // t/.tm
. m
• Skeletal defects after tumor resection or trauma
: / /t/.tm. m and/or deformed medullary canal of the

tibia
t p ss
p : / tp pss : /
• Severe malalignment or deformities associated with neuromuscular disease or clubfoot
• Severe vascular disease
Examination/Imaging
t
hht t t
hht t
• Clinical examination, particularly to exclude all contraindications
• Reflex sympathetic dystrophy of leg
• Careful evaluation of medical history, particularly with regard to previous injuries and
surgeries, all comorbidities (including metabolic and vascular problems), as well as
acute and chronic infection
keerrss ke rrss
• Detailed assessment of pain, limitations in daily activities, sports/recreation activi-
e
• Presence of a normal subtalar joint is a relative
contraindication for this procedure.
b ooook b ooook
ties, as well as current and previous treatments
• Careful inspection of periarticular soft tissue conditions including possible wounds
b oo • In diabetic patients with Charcot arthropathy
eeb and scars

ee/e/e b ee/e/e b of the tibiotalar joint, the subtalar joint can be
sacrificed to provide good initial stability using
/ / t
/ m
.t.m
sultation with neurology and/or internal medicine
: : / / t
/ m
• Determination of the neurovascular status of the affected leg and, if necessary, con-
.t.m
tibiotalocalcaneal arthrodesis.
• Routine physical examination starting with careful inspection of the foot and ankle
t
hhtt t
hhtt
while walking and standing; all obvious deformities are documented
• Manual assessment of hindfoot stability with the patient sitting
• Assessment of hindfoot alignment with the patient standing
• Clinical measurement of tibiotalar and subtalar joint range of motion using a goniometer
• Conventional weight-bearing radiographs for assessment of malalignment, deform-
k e rrss
e
ity, osteoarthritic changes, and instability
k e rrss
e
o o
o o k o o
o o k
• Weight-bearing anteroposterior and lateral views of the foot and anteroposterior
o o
(mortise) view of the ankle (Fig. 56.1 A 60-year-old male patient with end-stage post-
eebb ee/ e b
e b ee/ e
view of the ankle, weight-bearing anteroposterior and lateral views of the foot)
b
e b
traumatic ligamentous tibiotalar and subtalar osteoarthritis: weight-bearing mortise
/ /
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 56.1 469
t t p
t ss:
p t t p
t ss:
p
470 hht
PROCEDURE 56 Tibiotalocalcaneal Arthrodesis With a Retrograde Intramedullary Nail hht
TREATMENT OPTIONS • Weight-bearing hindfoot alignment view for assessment of the hindfoot axis in rela-
k e r
e ss
• Conservative treatment including medication,
r
shoe modification, and/or orthoses.
k eers
tion to the tibial axis, including inframalleolar deformities (Fig. 56.2 Weight-bearing
r s
hindfoot alignment view; the same patient from Fig. 56.1)
o o
o o k
• Hindfoot arthrodesis using alternative fixation
oooo k
• Computed tomography scan for exact assessment of degenerative changes; a
o o
eebb methods: ankle arthrodesis using two ventral
plates fixation, tibiotalocalcaneal arthrodesis
ee/ e
/ebb e / / b
e b
weight-bearing computed tomography scan can additionally help assess the hind-
e
foot alignment and concomitant deformities (Fig. 56.3 Weight-bearing computed
e
using blade-plate fixation.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
tomography of the hindfoot: axial, coronal, and sagittal planes; the same patient
t p ss
p : / from Fig. 56.1)
t p ss : /
• Single-photon emission computed tomography for assessment of the extent of de-
p
t
hht t t
hht t
generative changes in foot and hindfoot joints, and proper evaluation of their biologic
activity
• Magnetic resonance imaging for assessment of bone vitality and status of periarticu-
lar soft tissues
k eers
rs k er
ers
SURGICAL ANATOMY
s
b ooook b ooook
• Plantar approach to the calcaneus (Fig. 56.4 Plantar anatomy of the calcaneus in-
b o o
cluding fat pad, plantar fascia, and neurovascular structures)
eeb ee/ e
/ e b
• Calcaneal fat pad
ee/ e
/ e b
: // t/.tm
. m
• Plantar fascia
/ /t/.tm. m
• Neurovascular structures (run medial to the insertion area; Fig. 56.5 Plantar approach
:
t p ss
p : / tp ss : /
to the calcaneus. (A) Plantar calcaneal fat pad was removed, (B) plantar soft tissues
p
t
hht t t
hht t
were removed)
• Fig. 56.5 shows insertion area of the nail (crosshairs) with plantar calcaneal fat pad
removed (Fig. 56.5A) and with plantar soft tissue removed (Fig. 56.5B)
• Anterior approach to the ankle (Fig. 56.6: Anterior approach to the ankle)
• Superficial peroneal nerve
keerrss keerrss
• Extensor retinaculum
b ooook b ooook
• Anterior tibial tendon, extensor hallucis longus tendon, extensor digitorum longus
tendon
b oo
• Anterior neurovascular bundle includes anterior tibial artery and the deep peroneal
nerve. It can be found mostly between the extensor hallucis longus and extensor
: / / t
/ m
.t.m : / / t m
.t.m
digitorum longus tendons
/
• Lateral approach to the subtalar joint (Fig. 56.7)
t
hhtt t
hhtt
• Sinus tarsi
• Sural nerve
• Lateral transfibular approach to the tibiotalar and subtalar joints
k e rrss
e k e r
e ss
• Fibula
r
• Anterior talofibular ligament, posterior talofibular ligament, calcaneofibular ligament
o o
o o k FIG. 56.2
o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
hhtt t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
o o k oo
eebb b b
FIG. 56.3
ee/ e
/ e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 56 Tibiotalocalcaneal Arthrodesis With a Retrograde Intramedullary Nail 471
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e
Plantar fascia b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t Neurovascular
structures t
hht t
Fat pad
keerrss keerrss A B
b ooook
FIG. 56.4
b ooook
b oo
FIG. 56.5

: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
Extensor digitorum
longus tendon
Extensor retinaculum
k e rrss
e k e rrss
e
o o
o o k o o o k
Hallucis longus
o o o
eebb b b
tendon
ee/ e
/ e b Neurovascular
bundle
ee/ e
/ e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t Sinus tarsi
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
Peroneal tendons
t p ss
p : /
FIG. 56.6
t
p ss
p : / FIG. 56.7
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
472 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m
: / /t/.tm. m
t p ss
p : / FIG. 56.8
tp pss : /
t
hht t t
hht t
POSITIONING PEARLS POSITIONING
• Positioning of the heel at the edge of the • Supine position with the feet on the edge of the table
keer ss
operating table will facilitate surgery.
r
• We recommend using a regular C-arm for
keerrss
• The ipsilateral back of the patient is lifted until a strictly upward position of the whole
lower extremity is obtained
b ooook easy and more reliable fluoroscopic control

during the surgery.
o ook oo
• Pneumatic tourniquet on the ipsilateral thigh
b o b
eeb • An adjustable lower leg holder helps
to facilitate the plantar approach to the
ee/e/e b e
• Free draping of the whole limb
e/e/e b
• Mini C-arm (at the same side) or regular C-arm (from the opposite side) is placed
calcaneus.
: / / t
/ m
.t.m Portals/Exposures
: / / t
/ m
.t.m
t ppss : / t p ss : /
Anterior Exposure of the Ankle Joint
p
POSITIONING PITFALLS t
hhtt
• In the supine position the leg is usually
t
hhtt
• Intraoperative exposure of the tibiotalar joint using an anterior approach to the ankle
joint (Fig. 56.8)
externally rotated. If the strictly upward • Landmarks
position of the lower extremity is not obtained • Palpate the lateral malleolus at the distal subcutaneous end of the fibula and the
as described above, the lateral approach to the
k e rrss
ankle and/or sinus tarsi is hindered.
e k e rrss
medial malleolus.
e
• Identify the ankle joint line.
o o
o o k o o o k o
• Identify the anterior tibial and extensor hallucis longus tendons.
o o
eebb POSITIONING EQUIPMENT
ee/ e
/ b
e b
• Skin incision
ee e
/ b
• Identify the superficial peroneal nerve.
/ e b
• Radiolucent surgery table
: /
• Sand bag or unsterile towels to lift the
/ t
/ m
.t.m : / / t
/ m
.t.m
• Make a 5–7-cm longitudinal incision in the middle over the distal tibia and ankle joint.
ipsilateral back
• Adjustable lower leg holder
t p ss:
p / nerve.
t p ss:
p /
• Identify the medial branch of the superficial peroneal nerve. Avoid damaging the
t
hht t • Exposure t
hht t
• Incise the extensor retinaculum between the anterior tibial tendon and the exten-
POSITIONING CONTROVERSIES sor hallucis longus tendon.
• Some intramedullary nail suppliers recommend • Deep preparation to the tibiotalar joint is done underneath the anterior tibial ten-
k e r s
the prone position with a lateral transfibular
rs
approach for this procedure.
e e rs
don (safe zone, to avoid injuries to the anterior neurovascular bundle).
rs
• Perform subperiosteal preparation of soft tissues using a rasp. Pay special atten-
k e
o o
o k
• If the posterior approach is chosen for this
o procedure, the patient is positioned prone.
o o
oo ktion to protect the neurovascular structures.
oo
eebb b b
• Perform anterior arthrotomy.
ee/ e
/ e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook b oooo k
b o o
FIG. 56.10
eeb ee/ e
/ e b ee/ e
/ e b

: // t/.tm
. m : / /t/.tm. m
t
FIG. 56.9
p ss
p : / tp pss : /
t
hht t t
hht t
Lateral Exposure of the Subtalar Joint PORTALS/EXPOSURES PEARLS
• Intraoperative exposure of the subtalar joint using the sinus tarsi approach (Fig. 56.9) • A Kirschner-wire based distractor (e.g.,
keer ss
• Landmarks
r keerrss
• Palpate the lateral malleolus at the distal subcutaneous end of the fibula.
Hintermann distractor) can be used to expose
the tibiotalar and subtalar joints (see Figs.
b ooook • Identify the sinus tarsi by palpation.

b ooook b oo 56.8–56.10).
eeb • Identify the peroneal tendons.
ee/e
• Palpate the base of the fourth metatarsal./e b ee/e/e b
• Skin incision
: / / t
/ m
.t.m : / / t
/ m
.t.m PORTALS/EXPOSURES PITFALLS
• Make a short skin incision over the sinus tarsi, anterior to the peroneal tendons. • If necessary, the sinus tarsi approach can be
extended proximally toward the distal fibula
t
hhtt t
hhtt
• Special attention is paid to avoid any damage to the peroneal tendons and sural nerve.
• Exposure
• Perform a sharp dissection of subcutaneous tissue until the sinus tarsi is visible.
tip and distally toward the base of the fourth
metatarsal.
• The fat pad filling the sinus tarsi is partially resected or retracted anteriorly.
• Perform an arthrotomy to expose the subtalar joint.
e rrss e rrss
Lateral Transfibular Exposure of the Ankle and Subtalar Joints
k e k e
o o
o o k o o o k
• Intraoperative exposure of the tibiotalar and subtalar joints using a lateral transfibular
o o o
eebb approach (Fig. 56.10)
• Landmarks
ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m
• Palpate the fibula with its anterior and posterior border.
: / / t
/ m
.t.m
t ss:
p /
• Identify the sinus tarsi by palpation.
t p ss:
p /
• Palpate the lateral malleolus at the distal subcutaneous end of the fibula.
p
t
hht t
• Identify the peroneal tendons.
• Palpate the base of the fourth metatarsal.
t
hht t
• Skin incision
• Make a 12–14 cm longitudinal incision over the fibula distally curved toward the
k e r
e s
rs
base of the fourth metatarsal.
k eers
rs
• Perform a sharp dissection of subcutaneous tissue until the fibula is visible.
o o
o o k o o
oo k
• Special attention is paid to avoid any damage to the peroneal tendons and neu-
oo
eebb b b
rovascular structures.
ee/ e
/ e b ee/e/e b
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
474 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
b ooook
b ooook
b oo
eeb FIG. 56.11
ee/e/e b ee/e/e b FIG. 56.12
PORTALS/EXPOSURES
: / / t
/ m
.t.m : / / t
/ m
.t.m
CONTROVERSIES
t
hhtt
• If an intramedullary nail with valgus bend is
used, the plantar approach to the calcaneus is
modified. The entry point for the intramedullary • Exposure
t
hhtt
nail is slightly lateral of center (Fig. 56.12 • Expose the anterior border of the fibula.
Modified entry point for the intramedullary nail • Perform a sharp dissection of the anterior syndesmosis to mobilize the fibula.
with valgus bend).
rrss rrss
• Perform a sharp dissection of the anterior talofibular and calcaneofibular liga-
• Posterior Achilles tendon-splitting exposure to
o k e
k e
the hindfoot.
o k e
ments. The posterior talofibular ligament should remain preserved.
k e
• Use an oscillating saw with permanent water irrigation to perform the fibular oste-
o
eebb o o
• In patients with compromised soft tissue
anteriorly and laterally around the ankle,
e b o
b o o e b o o
otomy 8–12 cm proximal to the tip of the lateral malleolus.
b
the posterior Achilles tendon-splitting
approach can be used.
m ee/ / e m e / / e
• Remove a 1-cm slice from the fibula using oscillating saw.
e
• Make a 10–12-cm longitudinal, midline,
: / /
/ t
/ .t.m : / / t
/ .t.m
• Flip the distal fibula laterally, while the posterior soft tissues surrounding the fibu-
la, including blood supply, remain preserved.
/
t p ss:
posterior incision over the Achilles tendon.
• Incise paratendon longitudinally and retract
t t p t t p
t ss:
• Optionally (specifically in patients with prominent distal fibula due to severe varus
p
hht
full-thickness flaps medially and laterally.
• If necessary, perform a Z-type lengthening
of the Achilles tendon to achieve the neutral
hht
hindfoot deformity), use an oscillating saw with permanent water irrigation to split
the distal fibula longitudinally.
• The internal part of the fibula is removed and can be morcellized to use as auto-
alignment of the hindfoot in the sagittal
plane. graft on fusion sites.
• Deep dissection to the level of the deep • After the distal fibula is laterally flipped, the tibiotalar joint is efficiently exposed.
k e r
e s
rs
posterior compartment.
rs
rs
• Perform arthrotomy to expose the subtalar joint.
k ee
o o
o o k
• Identify the fascia over the flexor hallucis
longus.
o oo k
Plantar Approach to the Calcaneus
o oo
eebb • Open the fascia and mobilize the flexor
hallucis longus tendon medially to protect
ee/ e
/ b
e b ee/e ebb
• Landmarks (Fig. 56.11 Landmarks for the plantar approach to the calcaneus)
/
the posteromedial neurovascular bundle.
/
• Perform a posterior arthrotomy of the
: / t
/ .
tm.m / / t.tm
• Draw an imaginary line along the tibial shaft through the medial malleolus.
. m
• Draw an imaginary line through the center of the heel to the head of the second
: /
t p ss
tibiotalar and subtalar joints.
p : / metatarsal.
t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
• Skin incision STEP 1 PEARLS
k e s
rs
• Exposure
e k eers
• Make a 3-cm longitudinal incision at the crossing point of the drawn lines.
r r s • Special joint preparation curved chisel set
(including “potato peeler”-like chisel) helps to
o o
o o k oooo k
• Prepare the entry point on the plantar site of the foot.
o o
perform the complete cartilage débridement and
eebb • Make a sharp incision through the fat pad.
e / e
/ebb
• Make a longitudinal incision lateral to the medial part of the plantar fascia.
e ee/ e
/ b
e b to preserve the anatomic curvature of the joints.
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
• Perform a blunt dissection of soft tissues to the plantar medial aspect of the cal- STEP 1 PITFALLS
t p ss
p : /
caneus until the calcaneal surface is palpable.
t p ss
p : / • In patients with previously failed ankle
arthrodesis, a complete removal of hardware
PROCEDURE t
hht t t
hht t (especially hardware that may block the
intramedullary nail) should be done first
(Fig. 56.13 Revision tibiotalocalcaneal
Step 1: Débridement of the Tibiotalar and Subtalar Joints for
arthrodesis. (A) A 67-year-old male patient
Arthrodesis with a tibiotalar nonunion following a tibiotalar
• Complete débridement of the articular cartilage, usually by using a curved chisel. arthrodesis attempt 2 years ago; (B) hardware
k eers
rs k er
erss
• Multiple drill holes should be made with permanent water irrigation to perforate the removal was performed first, (C) followed
by débridement of tibiotalar nonunion and
b ooook subchondral bone.
ooook
• After the joint spreader is removed, the tibia, talus, and calcaneus should be mobile
b b o o
rearthrodesis using an intramedullary nail).
eeb / e e b / e
enough for anatomic reduction of tibiotalocalcaneal fusion and for complete correc-
ee
tion of the deformity in all three planes./ ee / e b STEP 1 INSTRUMENTATION/
: / t/.tm
. m : / /t/.tm. m
• In the case of bone loss, use autograft (iliac crest, proximal tibia, or distal fibula, if
/
IMPLANTATION
• Curved chisels
t p ss
p : /
transfibular approach is used) or allograft.
tp pss : / • 1.5–2.0-mm drill bit
t
hht t t
• We do not recommend the use of high speed
burrs for cartilage débridement due to thermal
effects.
keerrss keerrss
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
A
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k o o
o o k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
B
t
hht t t
hht t
FIG. 56.13
C
t t p
t ss:
p t t p
t ss:
p
476 hht
STEP 2 PEARLS Step 2: Insertion of Intramedullary Nail
k e r
e ss
• Different intramedullary nails are available
r
on the market: with and without option to
k eers
r s
• A guidewire is brought through the calcaneus and talus into the distal tibia under
fluoroscopy. The guidewire should be localized in the middle of the tibial intramedul-
o o
o o kapply compression intraoperatively. However,
oooo k o
lary canal in the frontal and sagittal planes.
o
eebb it has been demonstrated that intramedullary
nails with compression provide better contact
ee/ e
/ebb ee/ e
/ b
e b
• Use a cannulated drill bit over the guidewire. Perform a step-by-step enlargement of
the drilling canal up to the distal tibia.
et al., 2007; Taylor et al., 2016).
: / / t
/ t m
surfaces and higher primary stiffness (Mückley
. . m t . m
. m
• Insert the nail into the medullary canal with the support device.
: / / / t
t p ss
p : /
• In patients with substantial osseous defects,
surgical technique using autologous pillar
t p p : /
• Make a final clinical and fluoroscopic check in all three planes to ensure the appropri-
ss
ate positioning of the nail, especially the distal end, which should be located at the
t
hht t
fibula augmentation is an alternative to
using an allograft (Paul et al., 2015; Fig.
56.14 Tibiotalocalcaneal arthrodesis with
t
hht t
cortical side of the calcaneus.
an intramedullary hindfoot nail and pillar

fibula augmentation. (A) A 29-year-old
k ee s
male patient with a chronic pain syndrome
rrs
after total ankle replacement. (B) A 1-year
k er
erss
b ooook follow-up demonstrated solid fusion following
tibiotalocalcaneal arthrodesis with pillar fibula
b ooook b o o
eeb augmentation).
ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
STEP 2 PITFALLS
keer ss
• If an intramedullary nail with valgus bend is
r
used, the guidewire should be placed with the
keerrss
b ooook hindfoot held in slight varus position. After the
insertion of the intramedullary nail, the distal
b ooook b oo
eeb valgus bend results in 3–5° of valgus hindfoot
alignment. If the guidewire is placed with the ee/e/e b ee/e/e b
/ t m
.t.m
hindfoot in a neutral position, the result can be
: / / : / / t
/ m
.t.m
too much valgus.
t ppss : / A
t ppss : /
t
hhtt t
hhtt
rrss
e
IMPLANTATION
k e k e rrss
e
o o
o o k
• Intramedullary nail (Table 56.1)
o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t
• If an intramedullary nail with valgus bend
t
hht t
is used, special attention should be paid to
neutral rotation of the nail. Malrotation of the
nail can result in fixed equinus position of the
k e s
ankle due to the distal valgus bend of the nail.
r rs
• If an intramedullary nail with valgus bend
e k eers
rs
o o
o o kis implanted incorrectly, this can result in a
significant varus malalignment (Fig. 56.15
o o
oo k oo
eebb Tibiotalocalcaneal arthrodesis with significant
varus malalignment due to the incorrect
ee/ e
/ b
e b ee/e/ebb
placement of nail; 180° malrotation).
: / / t
/ .
tm.m B
: / / t
/.tm
. m
t p ss
p : /
t p ss
p : / FIG. 56.14
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
TABLE
hht hht
56.1 Different Intramedullary Nail Designs
Intramedullary Nail Length Diameter
k e r s
rs
(Manufacturer)
e
Compression
k eers
r sValgus (mm) (mm) Screw Fixation
o o
o o k
Hindfoot Fusion Nail (Synthes, External (mallet)
oooo k 10° 150 10
o o
Two tibial, one PA talus, two PA cal-
eebb b b
West Chester, PA, USA) 180 11 caneus (one of these calcaneus
ee/ e
/e b 240 12
ee/ e
/ e b screws can be spiral blade)
OxBridge Ankle Fusion Nail
Generation II (Ortho Solutions,
: / / / .
t m m
External (spanner)
t .
Straight
: /
150
/ t
/
180 .
t m
. m10
11
Two tibial, one transverse talus, one
PA calcaneus
North Andover, MA, USA)
t p ss
p : / t p ss
p : / 12
USA) t
hht t
Panta (Integra, Plainsboro, NJ, Proximal compression
rods allow external
compression before
t
hht t
Straight 150
180
210
10
11
12
Two tibial, one transverse talus, two
PA calcaneus
screw fixation 240 13

Phoenix Ankle Arthrodesis Nail Internal talus to tibia. Straight 150 10 Two tibial, one transverse talus,
k eers
(Biomet, Warsaw, IN, USA)
rs k er
ers
External subtalar (mallet)
s 180
210
11
12
one transverse calcaneus, one
PA calcaneus. Jig allows another
b ooook b ooook 240

270
b o o
screw bypassing the nail
eeb ee/ e
/ e b 300
ee/ e
/ e b
T2 (Stryker, Kalamazoo, MI, USA)
: // t/.tm
Internal talus to tibia.
. m
External subtalar (mallet)
5°
: / /t/.tm
150
.
200
m
10
11
transverse calcaneus, one PA
t p ss
p : / tp pss : / 300 12 calcaneus
TN, USA)
t
Trigen Hindfoot Fusion Nail
hht
(Smith & Nephew, Memphis,t External (mallet)
t
hht t
Straight 160
200
250
10
11.5
PA calcaneus, one oblique PA
calcaneus to talus
320
340
360
keerrss
Valor Hindfoot Fusion System
e
Internal calcaneus to
k errss Straight 150 10 Two tibial, one transverse talus, one
b ooook (Wright Medical Technology,

Memphis, TN, USA)
talus and tibia
b ooook 200
250
11.5
b oo
PA calcaneus, one oblique PA
calcaneus to talus
eeb Versanail (DePuy, Warsaw, IN,

ee/e/e b
Internal (mallet) Straight
300
150
ee/e/e
10
b Two tibial, one transverse talus, and
USA)
: / / t
/ m
.t.m : / / t
/
200
m
.t.m 12 two transverse calcaneus, or one
t ppss : / t ppss : / 250

300
PA talus and two PA calcaneus
PA, Posteroanterior. t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k e r
e s
rs
o o
o o k o o
o o k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 56.15
t t p
t ss:
p t t p
t ss:
p
478 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
FIG. 56.16
STEP 3 PEARLS
t p ss
p : / tp pss : /
t
hht t
• In some cases, an additional fixation of the
tibiotalar fusion should be performed, e.g.,
using an additional screw (Fig. 56.17 (A) A
t
hht t
Step 3: Application of Compression and Fixation
68-year-old male patient with hindfoot Charcot • First, the calcaneal screws are percutaneously inserted, guided by a radiolucent aim-
arthropathy; (B) tibiotalocalcaneal arthrodesis ing device.
with a supplemental screw was performed). • The compression frame is fixed by rods in the tibia.
keer ss
• Some nail designs allow the use of a spiral
r
blade for calcaneal fixation. However,
keerrss
• The desired tibiotalocalcaneal compression is applied.
b ooook we recommend using it only in patients

with significantly impaired bone quality.
b ooook
• Tibial screws are placed in provided holes of the nail.
• The compression frame is removed.
b oo
eeb Alternatively, a washer for calcaneal screws
should be used (Fig. 56.18 A washer was used
ee/e/e b /e e b
• A compression screw/cap is inserted from plantar into the nail to get the calcaneal
ee /
screws firmly fixed to the nail.
/ t m
.t.m
for one calcaneal screw due to reduced quality
: / / / t m
.t.m
• If a transfibular approach was used, the fibula is fixed to the tibia and fibula using two
: / /
of bone).
t ppss : / screws.
t ppss : /
STEP 3 PITFALLS t
hhtt
• The drilling and bringing in of calcaneal
t
hhtt
• An appropriate position of the entire construct is checked clinically and radiographi-
cally (Fig. 56.16 Final fluoroscopic check of neutral hindfoot alignment and of appro-
priate position of the hardware).
screws should be performed using a lateral
fluoroscopy view, to avoid iatrogenic injury of Step 4: Wound Closure
the calcaneocuboid joint.
k e rrss
e k rrss
• Perform wound closure.
e e
• Use interrupted absorbable 0 sutures for deep layer closure.
o o
o k
STEP 4 PEARLS
o o o o k o
• Use interrupted absorbable 3-0 sutures for subcutaneous closure.
o o
eebb • Topically applied vancomycin powder may
reduce the rate of surgical site infection in
ee/ e
/ b
e b
• Apply a sterile dressing.
ee/ e
/ b
e b
• Use interrupted nonabsorbable 3-0 suture for skin reapproximation.
diabetic patients.
: / / t
/ m
.t.m : / / t
/ m
.t.m
• Apply a lower leg splint in a neutral position.
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
b ooook
A
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
B
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t pp :
ss /FIG. 56.17
t ppss : /
t tt AND EXPECTED OUTCOMES
hhCARE
POSTOPERATIVE
t
hhtt
• Immobilize the foot and ankle in a splint until the wound is completely healed, usually
for 2 weeks.
k rrss
e k rrss
• At 2 weeks follow-up, sutures are removed and the foot is transitioned to a lower leg
e e e
cast for another 4–8 weeks, until radiographically evident osseous consolidation has
o o
o o k o o o k o
occurred. Partial weight bearing is allowed as tolerated for the first 6–10 weeks, until
o o
eebb ee/ e
/ b
e b
radiographically evident osseous consolidation has occurred.
ee/ e
/ b
e b
• At 6–10 weeks clinical and radiographic follow-up, the foot is transitioned to a walker
FIG. 56.18
: / / t
/ m
.t.m
boot for another 4 weeks. Weight bearing is gradually progressed.
: / / t
/ m
.t.m
t ss:
p / t p ss:
p /
• A rehabilitation program, including physical therapy, can be initiated. This includes
p
gait training, strengthening of lower leg muscles, and local measures to reduce the
hh t
swelling.
t t hht t t
CURRENT LITERATURE REVIEW
• Niinimäki et al. (2007) retrospectively reviewed 34 consecutive patients who under-
k e e s
rs k eers
went tibiotalocalcaneal arthrodesis using a straight intramedullary nail. The most com-
r rs
mon indications were rheumatoid arthritis, posttraumatic arthritis, and severe club-
o o
o o k oo k
foot with 10, 10, and 4 cases, respectively. The mean follow-up was 2 years, with
o o oo
eebb e / b
e b
a range between 0.5 and 3.6 years. Osseous union occurred in 26 patients (76%)
/ e
with a mean time to fusion of 16 weeks. The preoperative visual analog scale was
e ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
6.6 and 8.3 points at rest and when walking, respectively. Significant pain relief was
t p ss
and when walking, respectively.
p : / t p ss
p : /
observed, with a postoperative visual analogue scale of 1.9 and 3.2 points at rest
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
480 hht
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
FIG. 56.19
k eers
rs k er
erss
b ooook
b ooook
• Mückley et al. (2011) reported short-term results in 55 patients with a mean age of 51
b o o
years who were treated with tibiotalocalcaneal arthrodesis using a curved intramed-
eeb • Compression socks, grade II, are
recommended to prevent postoperative
ee/ e
/ e b e / e
/ e b
ullary nail. The most common reason for the surgery was end-stage posttraumatic
e
swelling.
: // t/.tm
. m : / /t/.tm
osteoarthritis in 44 patients. The mean follow-up was 1.3 years, with a range between
. m
0.6 and 2.3 years. Complete osseous union was observed in 53 patients (96%). A sig-
t p ss
p : / tp ss : /
nificant functional improvement and improvement in quality of life was observed.
p
t
hht t
• In patients with delayed union or nonunion,
t
hht t
• Wukich et al. (2011) compared the results of tibiotalocalcaneal arthrodesis in 17 pa-
tients with diabetes mellitus and in 23 nondiabetic patients. With the numbers avail-
a computed tomography scan should be able, similar functional outcomes were observed. Postoperative complications were
performed for better assessment of osseous
more common in patients with diabetes than in the nondiabetic patient cohort with
healing (Fig. 56.19 Computed tomography
59% versus 44%, respectively.
keerrs
demonstrated partial union 4 months after the
s
surgery).
keerrss
• DeVries et al. (2013) performed predictive risk assessment for major amputation in
b ooook b ooook179 patients treated with tibiotalocalcaneal arthrodesis. There were 21 major am-
b oo
putations (12%). Higher age, diabetes, revision, and ulcerations were found to be

significantly associated with major complication.
: / / t
/ m
.t.m : / / t m
• Jeng et al. (2013) reported 50% fusion rate in patients with tibiotalocalcaneal arthrode-
.t.m
sis with bulk femoral head allograft, for salvage of large defects in the ankle. Diabetes
/
mellitus was found to be the only negative predictive factor of outcome.
t
hhtt t
hhtt
• Rammelt et al. (2013) performed a multicenter study with 38 patients who underwent
tibiotalocalcaneal arthrodesis using a curved intramedullary nail. The mean follow-up
was 2 years with a range between 0.3 and 3.3 years. The overall union rate was 84%.
A very low rate of superficial wound infection was found, with 2.4%.
• Lucas Y Hernandez et al. (2015) evaluated 63 patients who underwent tibiotaloc-
k e rrss
e k rrss
alcaneal arthrodesis using a straight intramedullary nail. The mean follow-up was
e e
5.9 years with a range between 3.6 and 7.9 years. The complete osseous union
o o
o o k o o
o o k o
was observed in 86% of all patients. The mean time to fusion was 4.5 months. A
o
eebb ee/ e
/ b
e b / e b b
significant improvement of hindfoot alignment was observed. Current smokers had a
ee / e
significantly higher risk of complications.
: / / t
/ m
.t.m : / / t m
.t.m
• Pellegrini et al. (2016) published a retrospective review of 41 tibiotalocalcaneal ar-
/
t p ss:
p / t p ss:
p /
throdesis performed using a posterior Achilles tendon-splitting approach. The mean
t
hht t t t
follow-up was 3.7 years with a minimum follow-up of 2 years. The overall fusion rate
hht
was 80.4%. Complications were observed in 17 patients (41.4%) including ankle
nonunion (19.5%), tibial stress fracture (17%), postoperative cellulitis and superficial
wound breakdown (9.7%), subtalar nonunion (4.8%), and tibiotalocalcaneal nonun-
ion (2.4%). One patient eventually underwent amputation.
k e r
e s
rs k eers
rs
See also Video 56.1, Tibiotalocalcaneal Arthrodesis With a Retrograde Intramedullary
o o
o o k o
Nail.
o
oo k oo
eebb EVIDENCE eb
ee/ / e b ee/e/ebb
: / / t
/ .
tm.m t. m
. m
Berkowitz MJ, Sanders RW, Walling AK. Salvage arthrodesis after failed ankle replacement. Foot Ankle
: / / / t
t p ss
p : / Clin 2012;17:725–40.
t p ss : /
This review article discusses how to determine whether an isolated ankle or ankle-hindfoot fusion
p
t
hht t t
hht t
is indicated in patients with failed total ankle replacement.
t t p
t ss:
p t t p
t ss:
p
hht hht
Chiodo CP, Acevedo JI, Sammarco VJ, Parks BG, Boucher HR, Myerson MS, et al. Intramedullary rod
fixation compared with blade-plate-and-screw fixation for tibiotalocalcaneal arthrodesis: a biome-
k r s
rs
chanical investigation. J Bone Joint Surg Am 2003;85:2425–8.
e e k eers
r s
o o
o o k o oo k
This cadaver biomechanical study analyzes comparison of the stiffness and fatigue endurance of
o
blade-plate-and-screw fixation with intramedullary rod fixation. It has been demonstrated that blade-
o o
eebb e e
/ebb e / e
/ b
e
de Leeuw PA, Golano P, Blankenvoort L, Sierevelt IN, van Dijk CN. Identification of the superficial
e e b
plate fixation is biomechanically superior to intramedullary fixation for tibiotalocalcaneal arthrodoesis.
/
2016;24:1381–5.
: / / t
/ t m
. m : / / t
/ t m
peroneal nerve: anatomical study with surgical implications. Knee Surg Sports Traumatol Arthrosc
. . . m
ss : / ss : /
The purpose of this clinical study, which included 198 ankles, was to determine which clinical test
t p p t p p
t
identifying the superificial peroneal nerve was most reliable.
hht t t
hht t
Deleu PA, Devos Bevernage B, Maldague P, Gombault V, Leemrijse T. Arthrodesis after failed total
ankle replacement. Foot Ankle Int 2014;35:549–57.
This study reports on a series of 17 patients who had a failed total ankle replacement converted to
a tibiotalar or a tibiotalocalcaneal arthrodesis.
DeVries JG, Berlet GC, Hyer CF. Predictive risk assessment for major amputation after tibiotalocalca-
k e s
neal arthrodesis. Foot Ankle Int 2013;34:846–50.
rrs
Please see Current Literature Review.
e k er
erss
b ooookthe talus. Foot Ankle Int 2010;31:965–72.
b ooook
DeVries JG, Philbin TM, Hyer CF. Retrograde intramedullary nail arthrodesis for avascular necrosis of
b o o
eeb ee/ e
/ e b
tibiotalocalcaneal arthrodesis due to avascular necrosis of the talus.
ee/ e
/ e b
This clinical study reports on clinical and radiographic outcomes in 14 patients who underwent a
: // /.tm
. m : / /t/.tm. m
Eingartner C, Weise K. Revision of failed ankle arthrodeses. Oper Orthop Traumatol 2005;17:481–501.
t
This clinical study describes the surgical technique of revision of failed ankle arthrodesis and
ss : /
reports short-term results in 16 patients.
t p p tp pss : /
t t t t
Franceschi F, Franceschi E, Torre G, Papalia R, Samuelsson K, Karlsson J, et al. Tibiotalocalcaneal
hht hht
arthrodesis using an intramedullary nail: a systematic review. Knee Surg Sports Traumatol Arthrosc
2016;24:1316–25.
This is systematic review of 32 studies including patients who underwent a tibiotalocalcaneal arthro-
desis. In general, results suggest that satisfactory outcomes can be achieved by tibiotalocalcaneal
arthrodesis using intramedullary nailing.
keer ss keerrss
Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, et al. Anatomy of the ankle
r
ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 2016;24:644–56.
b ooook b ooook
This outstanding anatomic study highlights grouping and orientation of ankle ligaments.
b oo
Gorman TM, Beals TC, Nickisch F, Saltzman CL, Lyman M, Barg A. Hindfoot arthrodesis with the blade
eeb Relat Res 2016;474(10):2280–99.

ee/e/e b ee/e/e b
plate: increased risk of complications and non-union in a complex patient population. Clin Orthop
: / / t
/ m
.t.m : / / t
/ m
.t.m
This clinical study reports clinical and radiographic outcomes in 40 patients who underwent hindfoot
t ppss / t ppss : /
arthrodesis with the blade plate fixation utilizing a posterior approach. The proportion of patients
:
who were treated with a posterior blade plate hindfoot fusion and had delayed union or nonunion
t
hhtt t
hhtt
was greater than that reported for patients in other series who underwent primary hindfoot arthrode-
sis with other approaches, and the proportion of patients who had complications develop was high.
Hopgood P, Kumar R, Wood PL. Ankle arthrodesis for failed total ankle replacement. J Bone Joint Surg
Br 2006;88:1032–8.
The authors report on results in 23 patients with failed total ankle replacement who underwent
conversion to hindfoot arthrodesis, resulting in successful osseous union in 17 of 23 ankles.
k rrss
e k rrss
Hsu AR, Szatkowski JP. Early tibiotalocalcaneal arthrodesis intramedullary nail for treatment of a com-
e e e
plex tibial pilon fracture (AO/OTA 43-C). Foot Ankle Spec 2015;8:220–5.
o o
o o k o o o k o
In this clinical study the authors present a case of a complex pilon fracture in a patient with multi-
o o
eebb e / b
e b
ple medical comorbidities and socioeconomic disadvantages. The fracture was successfully and
/ e
acutely treated with a retrograde tibiotalocalcaneal hindfoot arthrodesis nail.
e ee/ e
/ b
e b
: / / t
/ m : / / t m
Jeng CL, Campbell JT, Tang EY, Cerrato RA, Myerson MS. Tibiotalocalcaneal arthrodesis with bulk
.t.m .t.m
femoral head allograft for salvage of large defects in the ankle. Foot Ankle Int 2013;34:1256–66.
/
t ss:
p p / t p ss:
p /
Knight T, Rosenfeld P, Jones IT, Clark C, Savva N. Anatomic structures at risk: curved hindfoot arthro-
t
hht t t
hht
desis nail – a cadaveric approach. J Foot Ankle Surg 2014;53:687–91.
t
This anatomic study on seven cadaver specimens demonstrated that no neurovascular structures
were compromised from using a curved hindfoot arthrodesis nail.
Lucas Y, Hernandez J, Abad J, Remy S, Darcel V, Chauveaux D, et al. Tibiotalocalcaneal arthrodesis
using a straight intramedullary nail. Foot Ankle Int 2015;36:539–46.
k e e s
r rs k eers
rs
Mückley T, Eichhorn S, Hoffmeier K, von Oldenburg G, Speitling A, Hoffmann GO, et al. Biomechanical
o o
o o k
2007;28:224–31.
o o
o k
evaluation of primary stiffness of tibiotalocalcaneal fusion with intramedullary nails. Foot Ankle Int
o oo
eebb e e
/ b
e b e /e/ebb
This biomechanical study compares different fixation methods for a tibiotalocalcaneal arthrodesis.
/
Mückley T, Klos K, Drechsel T, Beimel C, Gras F, Hofmann GO. Short-term outcome of retrograde tibio-
e e
/
: / / .
tm.m : / / t
/.tm
. m
talocalcaneal arthrodesis with a curved intramedullary nail. Foot Ankle Int 2011;32:47–56.
t
ss : / ss : /
Nagappa SG, Wood PLR. Use of the Versa nail and anterior ankle arthrotomy to achieve primary tibio-
t p p t p p
t t t
talocalcaneal arthrodesis in rheumatoid arthritis. Foot 2007;17:154–8.
hht hht t
t t p
t ss:
p t t p
t ss:
p
482 hht
This clinical study, which included 11 patients with rheumatoid osteoarthritis, demonstrated that
the tibiotalocalcaneal arthrodesis using Versa nail and anterior approach was an effective proce-
k e r
e s
rs k eers
r s
dure in rheumatoid arthritis.
o o
o o k o oo k
Nickisch F, Avilucea FR, Beals T, Saltzman C. Open posterior approach for tibiotalar arthrodesis. Foot
Ankle Clin 2011;16:103–14.
o o o
eebb e e
/ebb e / e
/ b
e b
This review article discusses the application of the posterior approach to complete a tibiotalar and
/
tibiotalocalcaneal arthrodesis, as well as its use for converting a failed total ankle arthroplasty to an
e e
: / / t
/ .
t m
. m
arthrodesis.
: / / t .
t m
. m
Niinimäki TT, Klemota TM, Leppilahti JI. Tibiotalocalcaneal arthrodesis with a compressive retrograde
/
t p ss
p : / ss : /
intramedullary nail: a report of 34 consecutive patients. Foot Ankle Int 2007;28:431–4.
t p p
t
hht t t
hht t
Ochman S, Evers J, Raschke MJ, Vordemvenne T. Retrograde nail for tibiotalocalcaneal arthrodesis as
a limb salvage procedure for open distal tibia and talus fractures with severe bone loss. J Foot Ankle
Surg 2012;51:675–9.
This clinical study demonstrated that calcaneotibial arthrodesis using a retrograde nail was a good
treatment option for nonreconstructable fractures of the ankle joint with severe bone loss and poor
k eers
rs k er
ers
soft tissue quality in selected patients with multiple injuries—in particular, those involving both
s
lower extremities, such as a salvage procedure.
b ooook ooook
Paul J, Barg A, Horisberger M, Herrera M, Henninger HB, Valderrabano V. Tibiotalocalcaneal arthro-
o o
desis with an intramedullary hindfoot nail and pillar fibula augmentation: technical tip. Foot Ankle Int
b b
eeb ee/ e
/ e b
2015;36:984–7.
ee/ e
/ e b
In this technical tip paper, the authors describe a new method for using an autologous fibula aug-
: // t/.tm
. m : / /t/.tm. m
mentation in combination with an intramedullary hindfoot nail.
Pellegrini MJ, Schiff AP, Adams Jr SB, DeOrio JK, Easley ME, Nunley II JA. Outcomes of tibiotalocal-
t p ss
p : / ss : /
caneal arthrodesis through a posterior Achilles tendon-splitting approach. Foot Ankle Int 2016;37:
tp p
t
hht t 312–9.
t
hht t
Plaass C, Knupp M, Barg A, Hintermann B. Anterior double plating for rigid fixation of isolated tibiotalar
arthrodesis. Foot Ankle Int 2009;30:631–9.
In this clinical study, which included 29 patients, it was demonstrated that the anterior double plat-
ing system was shown to be a reliable method to achieve solid isolated tibiotalar arthrodesis, even
keerrss keerrss
in ankles with difficult conditions such as loss of bone stock due to failed total ankle arthroplasty.
Rammelt S, Pyrc J, Agren PH, Hartsock LA, Cronier P, Friscia DA, et al. Tibiotalocalcaneal fusion using
b ooook b ooook
the hindfoot arthrodesis nail: a multicenter study. Foot Ankle Int 2013;34:1245–55.
b oo
Shah KS, Younger AS. Primary tibiotalocalcaneal arthrodesis. Foot Ankle Clin 2011;16:115–36.
This review article highlights the indications and surgical technique of the primary tibiotalocalca-
: / / t
/ m
.t.m neal arthrodesis.
: / / t
/ m
.t.m
Taylor J, Lucas DE, Riley A, Simpson GA, Philbin TM. Tibiotalocalcaneal arthrodesis nails: a comparison
of nails with and without internal compression. Foot Ankle Int 2016;37:294–9.
t
hhtt t
hhtt
In this clinical study, which included a total of 198 patients, the intramedullary hindfoot arthrodesis
nail was demonstrated as a viable treatment option in degenerative joint disease of the TTC joint.
There appeared to be an advantage using systems with internal compression; however, there was
no statistically significant difference after controlling for diabetes.
Thomas RL, Sathe V, Habib SI. The use of intramedullary nails in tibiotalocalcaneal arthrodesis. J Am
Acad Orthop Surg 2012;20:1–7.
k e rrss
e k rrss
This review article describes indications and contraindications for the use of intramedullary nails in
e e
tibiotalocalcaneal arthrodesis.
o o
o o k o o o k o
von Recum J. Tibiotalocalcaneal corrective arthrodesis in Charcot arthropathy of the ankle with a retro-
o o
eebb ee/ e
/ b
e b e / e
/ b
e b
grade nail. Oper Orthop Traumatol 2015;27:114–28.
This surgical technique paper describes the tibiotalocalcaneal corrective arthrodesis in patients
e
: / / t
/ m
.t.m
with Charcot arthopathy.
: / / t m
.t.m
Wukich DK, Dikis JW, Monaco SJ, Strannigan K, Suder NC, Rosario BL. Topically applied vancomy-
/
t p ss:
p / t p ss:
p /
cin powder reduces the rate of surgical site infection in diabetic patients undergoing foot and ankle
surgery. Foot Ankle Int 2015;36:1017–24.
t
hht t t
hht t
The purpose of this study was to evaluate the efficacy of topically applied vancomycin powder in
reducing the rate of surgical site infections in patients with diabetes mellitus who underwent foot
and ankle surgery.
Wukich DK, Shen JY, Ramirez CP, Irrgang JJ. Retrograde ankle arthrodesis using an intramedullary nail:
a comparison of patients with and without diabetes mellitus. J Foot Ankle Surg 2011;50:299–306.
k e r
e s
rs k eers
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hh57
PROCEDURE
t hht
TotalrssAnkle Arthroplasty With a Current
rs s
k ee r k ee r
ooooThree-Component
eebb
k Designoo
(HINTEGRA
ook
/
Prosthesis)
e bb / e b o
b o
m ee /e m ee / e
Beat Hintermann
: / t
///t. . m : / /
/ t
/ .
t . m
t t p
t s
p s : t t p
t ss
p :
hh t hht
INDICATIONS
• Primary osteoarthritis (e.g., degenerative disease) INDICATIONS PITFALLS
k ee s
• Systemic arthritis (e.g., rheumatoid arthritis)
rrs k er
erss
• Posttraumatic osteoarthritis (if instability and malalignment are manageable)
• Infection
• Avascular necrosis of more than one third of
b ooook b ooook
• Secondary osteoarthritis (e.g., infection, avascular necrosis; if at least two thirds of
b o o
talus
• Nonmanageable instability
eeb the talar surface is preserved)
ee/ e
/ e b e / e
/
• Salvage for failed total ankle replacement or for nonunion and malunion of ankle fu-
e e b • Nonmanageable malalignment
• Neuromuscular disorder
: // /.tm
sion (if bone stock is sufficient)
t . m : / /t/.tm. m • Neuroarthropathy (Charcot arthropathy)
• Relative indications
t p ss
p / tp pss : /
• Low demands for physical activities (e.g., hiking, swimming, biking, golfing)
: • Diabetic syndrome
• Suspected or documented metal allergy or
t
hht t
• Severe osteoporosis
• Immunosuppressive therapy
t
hht t intolerance
• Highest demands for physical activities (e.g.,
contact sports, jumping)
• Increased demands for physical activities (e.g., jogging, tennis, downhill skiing)
Examination/Imaging
ke rrss ke rrss
• While the patient is standing, perform a thorough clinical investigation of both lower
e e INDICATIONS CONTROVERSIES
b ooook extremities to assess

• Alignment
b ooook b oo • Diabetic syndrome without polyneuropathy
eeb • Deformities
ee/e/e b ee/e/e b • Avascular necrosis of talus
• Foot position
• Muscular atrophy
: / / t
/ m
.t.m : / / t
/ m
.t.m
ss : / ss : /
• While the patient is sitting with free-hanging feet, perform an assessment of
t pp t pp
TREATMENT OPTIONS
t
hhtt
• Extent to which a present deformity is correctable
• Preserved joint motion at the ankle and subtalar jointst
hhtt • Medication
• Local therapy
• Shoe modifications and orthoses
• Ligament stability of the ankle and subtalar joints with anterior drawer and tilt tests
• Supination and eversion power (e.g., function of posterior tibial and peroneus
brevis muscles)
k e rrss
e k e rrss
• Plain weight-bearing radiographs, including anteroposterior views of ankle (Fig. 57.1A)
e
o o
o o k o o
o o k
and foot (Fig. 57.1B), and lateral view of the foot (Fig. 57.1C), to determine/rule out
• Extent of destruction of tibiotalar joint (e.g., tibia, talus, fibula)
o o
eebb ee/ e b
e b
• Status of neighboring joints (e.g., associated degenerative disease)
/ ee/ e
/ b
e
• Deformities of the foot and ankle complex (e.g., heel alignment, foot arch, talona-
b
vicular alignment)
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
• Tibiotalar malalignment (e.g., varus, valgus, recurvatum, antecurvatum)
t t
• Bony condition (e.g., avascular necrosis, bony defects)
hht t
hht
• Computed tomography scan may be obtained for assessment of
• Destruction of joint surfaces and incongruency
t
• Bony defects
• Avascular necrosis
k e r
e s
rs •

(Fig. 57.2) may be used to visualize
k eers
rs
Single-photon emission computed tomography with superimposed bone scan
o o
o o k o oo k
• Morphologic pathologies and associated activity process
o oo
eebb ee e
/ b
e b
• Biologic bone pathologies and associated activity process
/
• Magnetic resonance imaging may be used to identify
ee/e/ebb
t .m.m
• Injuries to ligament structures
: / / / t : / / t
/.tm
. m
t p p : /
• Morphologic changes of tendons
ss t p ss
p :
• Avascular necrosis of bones (e.g., talar body, tibial plafond) /
t
hht t t
hht t 483
t t p
t ss:
p t t p
t ss:
p
484 hht hht
PROCEDURE 57 Total Ankle Arthroplasty With a Current Three-Component Design (HINTEGRA Prosthesis)
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
eeb A
ee/e/e b B
ee/e/e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
k e rrss
e k e rrss
e
o o
o o k o o
o o k o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
C
k e r
e s
rs k eers
FIG. 57.1
rs
o o
o o k o o
oo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 57 Total Ankle Arthroplasty With a Current Three-Component Design (HINTEGRA Prosthesis) 485
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t Tibialis anterior
tendon
Superior
Hallucis longus
extensor
tendon
retinaculum
k eers
rs k er
erss Extensor digitorum
longus tendon
b ooook A
b ooook b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
keerrss keerrss
B
/t.
: / / tm. m : / / t
/ m
.t.m
t

p s
p s : / FIG. 57.3
t
hhtt
SURGICAL ANATOMY t
hhtt
• The superior extensor retinaculum is a thickening of the deep fascia above the ankle,
POSITIONING PEARLS
• The affected foot is supported with a block to
running from the tibia to the fibula (Fig. 57.3). It includes, from medially to laterally, the facilitate fluoroscopy during surgery.
tendons of the tibialis anterior, extensor hallucis longus, and extensor digitorum longus. • The contralateral nonaffected leg is also
draped if there is significant deformity to be
k rrss
e k e rrss
• The anterior neurovascular bundle lies roughly halfway between the malleoli (Fig.
e e
57.4A); it can be found consistently between the extensor hallucis longus and exten-
corrected.
o o
o o k sor digitorum longus tendons.
o o
o o k o o
eebb b b POSITIONING/EXPOSURES PEARLS
e e
/ b
• The neurovascular bundle contains the tibialis anterior and the deep peroneal nerve.
/ e e
The nerve supplies the extensor digitorum brevis and extensor hallucis brevis and a
e e/ e
/ e b • The soft tissue beneath the anterior tibial
: / / t
sensory space (interdigital I–II).
/ m
.t.m : / / t
/ m
.t.m tendon is always free from the neurovascular
bundle and thus is called the “safe spot” while
t p ss:
p / t p ss:
p /
• On the height of the talonavicular joint, the medial branches of the superficial pero-
neal nerve cross from lateral to medial (Fig. 57.4B). This nerve supplies the skin of the
approaching the anterior ankle joint.
t
hht
dorsum of the foot. t t
hht t
• On the posterior aspect of the ankle, the medial neurovascular bundle is located be-
• If old scars from previous surgeries or injuries
are not respected, breakdown of critical areas
may occur.
hind its posteromedial corner, and the flexor hallucis longus tendon on its posterior
aspect (Fig. 57.4C). PORTALS/EXPOSURES
INSTRUMENTATION
k e r
e ss
POSITIONING
r k eers
rs • A self-retaining distractor may be helpful; care
o o
o k o o
oo k
• The patient is positioned with the feet on the edge of the table.
o oo
must be taken, however, that no tension is
applied to the skin.
eebb b b
• The ipsilateral back is lifted until a strictly upward position of the foot is obtained.
e / e
/ e b
• The tourniquet is mounted at the ipsilateral thigh.
e ee/e/e b • The Hintermann Distractor, mounted with one
pin to the anteromedial aspect of the distal
Portals/Exposures
: / / t
/ .
tm.m : / / t
/.tm
. m tibia and one pin to the anteromedial talar
neck, serves to provide a better view into the
t p ss
p : / t p ss : /
• An anterior longitudinal incision of 10–12 cm in length is made to expose the reti-
p
tibiotalar joint while the collateral ligaments
t
hht
naculum (Fig. 57.5A–C).
t t
hht t are tightened.
t t p
t ss:
p t t p
t ss:
p
hht hht
k e r
e s
rs nerve
k eers
Deep peroneal
r s
o o
o o k Extensor digitorum
oooo k
Anterior tibial
o o
eebb b b
longus tendon artery
ee/ e
/e b
Hallucis
ee/ e
/ e b
Neurovascular
bundle
: / / t
/ .
t m
. m
longus
tendon
: / / t
/ .
t m
. m Talonavicular
joint
t p ss
p : / t p ss
p : /
Lateral
t
hht t Medial
malleolus
t
hht t Superficial
peroneal
nerve
malleolus
k eers
rs k er
erss
b ooook A
b ooook B
b o o
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
t p ss
p : / tp pss : /
t
hht t t
hht t
Medial
keerrss
neurovascular
bundle
keerrss
b ooook b ooook Flexor hallucis
b oo
eeb b b
longus tendon
ee/e/e ee/e/e
: / / t
/ m
.t.m : / / t
/ m
.t.m
t
hhtt t
hhtt
Posterior aspect
k e rrss
e
C
k e rrss
e
o o
o o k o o
o o k
FIG. 57.4
o o
eebb ee/ e
/ b
e b ee/ e
/ b
e b
: / / t
/ m
.t.m : / / t
/ m
.t.m
t p ss:
p / t p ss:
p /
t
hht t t
hht t
k e r
e s
rs k eers
rs
o o
o o k o ooo k oo
eebb ee/ e
/ b
e b ee/e/ebb
: / / t
/ .
tm.m : / / t
/.tm
. m
t p ss
p : / t p ss
p : /
A
t
hht t B
FIG. 57.5
t
hht t C
t t p
t ss:
p t t p
t ss:
p
hht hht
PROCEDURE 57 Total Ankle Arthroplasty With a Current Three-Component Design (HINTEGRA Prosthesis) 487
k e r
e s
rs k eers
r s
o o
o o k oooo k o o
eebb ee/ e
/ebb ee/ e
/ b
e b
: / / t
/ .
t m
. m : / / t
/ .
t m
. m
t p ss
p : / t p ss
p : /
t
hht t t
hht t
k eers
rs k er
erss
eeb ee/ e
/ e b ee/ e
/ e b
: // t/.tm
. m : / /t/.tm. m
A
t p ss
p : / tp pss : /
t
hht t t
hht t B
FIG. 57.6
keerrss keerrss
b oo k
ooPROCEDURE b ooook b oo
eeb ee/e/e b ee/e/e b STEP 1 CONTROVERSIES
• Some bone and capsular tissue on the
Step 1: Tibial Resection
: / / t
/ m
.t.m : / / t
/ m
.t.m posterior aspect of the joint might be left
• The tibial cutting block, with its alignment rod, is positioned using the tibial tuberosity in place at this stage of surgery (it is much
easier to be removed once the talar cuts are
t
hhtt t
hhtt
as the proximal reference (Fig. 57.6A) and the anterolateral border of the ankle as the
distal reference (e.g., the medial corner of the resection block is supposed to merge
the anterolateral corner of the tibiotalar joint; see Fig. 57.6A).
performed), as long as it does not hinder
insertion of the talar cutting block.
• The final adjustment is made as follows: STEP 1 PEARLS

• Sagittal plane: The rod is moved until a position parallel to the anterior border of • Proper frontal (coronal) plane alignment
k e rrss
e
•
the tibia has been achieved (see Fig. 57.6A).
k e rrss
e
Frontal (coronal) plane: After preliminary fixation of the block with a long pin, the
may best be achieved while pulling the talus
distally with a rasp (placed in the center of the
o o
o o k o o o k
tibi

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t t p

keerrss be needed for these cases.

keerrss modification of high-heeled, tight-fitting shoes.

b ooook be required, but not commonly.

b ooook b ooook longus tendon

eeb ee/e/e b ee/e/e b

t ppss : / t ppss : / longus tendon

o either an excessively long plantar arm or a

plantar sensory nerves.

b ooook b oo oo k FIG. 1.26

rs footwear. Hallux varus, avascular necrosis of the

keerrss FIG. 2.3

b oo the ankle block reduces the pain sensation of

eebb b b dorsally and plantarly at the neck of the first

eeb ee/e/e b ee/e/e b • Only a small portion of the medial eminence

t ppss : / t ppss : / head can be shifted laterally, allowing greater

to be treated prior to surgery.

keerrss keerrss FIG. 3.2

eebb b b enough that it will not be visible when looking

b ooook approached with the blade.

placement of the plate.

• In a patient with metatarsus adductus, the final Step 3

keerrss keerrss perpendicular to the bone, not to the plate. The

eebb b b close the soft tissue over the plate with a

this during graft application. ee/ e

• Start gentle MTP range of motion after the Step 7

ecorrective osteotomy and fusion addresses the

keerrss This allows the screw head to slide down

b ooook which prevents dorsal “blowout” of the

• Progression to full function is as follows:

b ooookAnkle Int 2000;21:816–21.

distal to the metatarsal head to preserve Medial Midaxial Longitudinal Approach

the osteotomy properly.

b ooook b ooook FIG. 5.20

casting and delaying weight bearing, callus

eeb ee/e/e b ee/e/e b

keerrss keerrss of the toe that can cause a dysvascular toe.

t ppss : / t ppss : / flexion during fixation.

eeb the outcome of this procedure.

eebb b b Correction through this single incision is

STEP 2 PEARLS Step 2

implant with 2-0 FiberWire.

Step 5 STEP 5 PEARLS

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

• Potential complications include stiffness of the joint. Overcorrection of the hallux

b ooook • Arthroscopic cheilectomy will not work if

Superficial fibers of extensor

POSITIONING POSITIONING PEARLS

b ooook to metatarsal head articulations.

eeb of the joint on the lateral side.

/ e b • A bean bag is used to elevate the surgical hip.

keerrss keerrss PORTALS/EXPOSURES PEARLS

eeb ee/e/e b ee/e/e b motion at the MTP joint.

t ppss : / t ppss : / • The portals may be misplaced if dorsal

Step 2: Dorsal Cheilectomy STEP 2 PEARLS

keerrss keerrss whereas for others possible fusion is

b ooook b ooook b oo have advanced arthritic changes not visible on

eeb ee/e/e b ee/e/e b a preoperative x-ray.

eeb osteotomy can be performed.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

eeb SURGICAL ANATOMY ee/ e e b

keerrss keerrss • Antiinflammatory medications

eeb ee/e/e b ee/e/e b

eeb ee/e/e b ee/e/e b • Only a small portion of the medial eminence

• In a patient with metatarsus adductus, the final Step 3

• Start gentle MTP range of motion after the Step 7

• Progression to full function is as follows:

• Potential complications include stiffness of the joint. Overcorrection of the hallux

b ooook • Arthroscopic cheilectomy will not work if

/ e b • A bean bag is used to elevate the surgical hip.

t ppss : / t ppss : / • The portals may be misplaced if dorsal

keerrss keerrss • Antiinflammatory medications

t ppss : / t pp ss : / • Continuous irrigation of the reamer with saline

eebb b b • More shortening performed with reaming

t tptpss : • Plantar soft tissues can prevent sliding of the

eeb ee/e/e b ee/e/e b • Graft should be decellularized human skin

b ooook • Charcot arthropathy with risk of bone collapse

t ppss : / t ppss : / • High-heeled shoes will be limited to

b ooook • Local anesthetic and steroid injection into the

• If the arthroscopy tower is on the same side of PORTALS/EXPOSURES

eeb ee/e/e b ee/e/e b • Avoid performing an interosseous placement of

m ee/ / e m ee/ / e • A small joint grasper

ee/e/e ee/e/e • New medical management has altered

t ppss : / t ppss : / • While patients with extensive forefoot

oo • If correction of the bunionette deformity

b ooook • Rest, ice, and compression with elevation in a

keerrss keerrss • Assess the patient’s range of motion of both

b ooook b ooook b oo • A lateral position would make it difficult to

keerrss keerrss • G3 represents combined transverse and