Non Operative
Options
Metatarsalgia
- preMT dome
Claw toes
- wide deep toe box
Foot drop
- AFO
Insensate foot
- custom orthosis
Varus
- lateral heel wedge
- AFO (flexible)
- medial iron with lateral T strap
Operative
Indications
Difficulty with Footwear
Pain
Lateral instability
Contra-Indications
Need to ensure is not progressing
- otherwise surgery will not work
- i.e. does patient need spinal surgery first for dysraphism
Options
Soft tissue surgery
- for dynamic / flexible deformity
Bony surgery
- for static / fixed deformity
Algorithm
Stage 1 / Flexible 1st MT PF
Shoe modification
Stage 2 / Fixed 1st MT + Flexible Hindfoot
Steindler release (plantar fascia release)
Jones / 1st MT osteotomy
Lesser toes as necessary
T post transfer if weak dorsiflexion
PL to PB transfer if weak eversion
Stage 3 / Fixed 1st MT / Fixed Hindfoot
Above +
Lateral Shift Calcaneal Osteotomy
T Achilles lengthening
Stage 4 / STJ and other bony deformities
Triple arthrodesis
Tarsal / MT osteotomy
ForeFoot
Soft tissue
1. Steindler Release / Plantar fascia release
Best < 8 years
- for cavus
Incision
- medial incision extending 1.5 inches anterior to calcaneal tuberosity
Dissection
- separate above and below fascia
- divide plantar fascia & Long Plantar ligament at calcaneum
- excise 1 cm of fascia
- NV lie between 1st & 2nd layers
- if stay on periosteum will avoid damage to NV
- lateral plantar nerve is at lateral edge of fascia
2. Tibialis Posterior transfer
Indicator
- weak dorsiflexion
Technique
- through interosseous membrane to lateral cuneiform
3. P Longus to Brevis transfer
Removal of 1st ray PF & increase eversion
4. First Toe / Jones Procedure
Indication
- great toe clawed
- MTP hyperextended and IP flexion
Technique
A. Leave EDB to P1 intact
- will drive extension toes
B. Harvest distal EHL
- pass through drill hole neck MT
- suture to itself
C. Fusion of IPJ
- K wire
5. Hibbs
EDL transfer
- plug into middle cuneiform
- act as DF instead of weak T Anterior
6. Lesser Claw Toes
A. Girdlestone FETT if flexible
B. Extensor Tenotomy / PIPJ fusion / MTPJ dorsal capsulotomy / Weil's osteotomy if fixed
Bony
1st MT osteotomy
Description
- dorsal closing wedge osteotomy
- extension osteotomy
Indication
- incomplete correction of first ray
- mature patient with closed physis
Technique
- dorsal closing wedge osteotomy
- base of MT
- leave plantar surface intact
- 3-4 mm wedge
- close osteotomy, fixation with K wires
- +/- 2nd and 3rd
Hindfoot
Soft Tissue
1. Tendo achilles lengthening
Indications
- unable to reach plantigrade
Technique
- percutaneous
- 2 medial and one lateral to take out of varus
2. Lateral Ligament reconstruction
If complain of ankle instability
Bony
1. Dwyer lateral closing wedge Calcaneal osteotomy
Indication
- correct fixed hindfoot varus
Problem
- shortens foot further
2. Calcaneal Lateral Shift Osteotomy
Lateral approach
- curve just behind peroneals
- homann in front of tenoachilles
- homann under calcaneum
Oblique osteotomy
- 45o
- behind posterior facet
- osteotome
- open with lamina spreader
- split periosteum medially with osteotome
- this avoids damage to medial structures
- transfer laterally 1 cm
- may need to lengthen T Achilles
Fix with screw or lateral staple
3. Midtarsal Osteotomy / V shaped
Indication
- fixed, difficult cases
Cole Osteotomy
- use ilizarov
4. Triple Arthrodesis
For salvage of rigid deformity