Management

Surgical Algorithm

 

Stage 1 Tendonitis

 

Non-operative

 

Walking cast / NSAIDS

- 6/52

 

UCBL

- 3/12

- worn inside the shoe

- ends under malleoli

- controls the heel (which must be flexible)

- supports the arch

 

Operative / Synovectomy and debridement

(+/- FDL transfer and calcaneal osteotomy +/- T Achilles lengthening)

 

Stage 2  Tendon Rupture

 

Non Operative

- UCBL

 

Operative

 

2A - FDL transfer & calcaneal osteotomy +/- T Achilles lengthening

2B - + Lateral column lenthening to correct abduction

 

Stage 3 Rigid valgus hindfoot

 

Non Operative

 

Rigid AFO

Caliper: Outside iron with inside T strap

 

Operative

 

Triple arthrodesis

 

Stage 4 / Abnormal AKJ

 

Pathology

- valgus angulation of talus

- deltoid ligament gone 

- early degeneration of ankle joint

- degenerative changes in subtalar & midtarsal joints 

- valgus angulation of talus

 

Non Operative

- double metal uprights with PTB

 

Operative

- pan talar fusion 

 

Operations

 

Tibialis Posterior Synovectomy and Debridement

 

Position

- supine on table

- foot falls into ER

- tourniquet

 

Incision

- tip of medial malleolus to navicular

- open tendon sheath

- often fluid and synovitis

 

Synovectomy

 

Repair any fissures

 

Inspect insertion

- if partially avulsed

- FDL transfer

 

Close tendon sheath

 

S/L cast for 3/52

 

Results

- 75% good results

 

Calcaneal Osteotomy / Medial Calcaneal slide

 

Aim

- shifts calcaneum medially

- reduces valgus thrust on hindfoot

- pull of gastoc/soleus is medial to STJ

 

Indications

- stage 1 or 2

- in combination with FDL transfer

 

Timing

- perform osteotomy first, then tension FDL

 

Set up

- sandbag under ipsilateral hip

- table rolled over to expose lateral heel

- then unroll bed to expose medially

 

Calcaneal Sliding Osteotomy LateralCalcaneal Sliding Osteotomy Harris Axial

 

Incision

- lateral incision

- in line with peroneal tendons

- need to protect sural nerve posteriorly

 

Osteotomy

- protect peroneals

- protect T Achilles

- behind posterior facet STJ

- transverse osteotomy at 45o to plane of foot

- complete with osteotome to protect medial structures

- use osteotome to gently break up periosteum

- use lamina spreader to break up final adhesions

- translate 10mm medially

 

ORIF

- K wire lateral to T Achilles, towards CCJ

- check II, 6.5 mm partially threaded cannulated screw

 

Lateral column lengthening

 

Indications

- midfoot abduction

 

Technique

- anterior calcaneal ostetomy

- insertion bone graft wedge

- stabilisation plate or screws

 

FDL transfer 

 

Reasons

- FDL easily found by reflecting abductor hallucis

 

Indications

- foot should be supple with no fixed deformity 

- stage 1 / 2

 

Incision 

- along entire length T posterior

- 10 cm proximal to medial malleolus

- to metatarsal cuneiform joint

 

Superficial dissection

- expose T posterior in sheath

- may be ruptured, avulsed, deficient, fissured

 

Deep dissection

- abductor hallucis reflected plantarward

- find fat / Knot of Henry

- release Master Knot of Henry 

- crossover of FDL & FHL 

- FDL plantar to FHL

- suture together and release proximal FDL 

 

TNJ

- open to visualise

- 4.5mm drill hole through navicular

- Reinsert FDL into underside of navicular

- plantar to dorsal

- pulled tight with ankle in equinus & forefoot in varus 

- close TNJ capsule

- No need to attach proximal T Post to FDL

 

Repair spring ligament

 

Closure abductor fascia

 

Post op

- 6/52 in equinus and inversion NWB

- x-ray to check osteotomy has healed

- 4/52 weight bearing in removable cast with ROM exercises

- may need physio

 

Triple Arthrodesis

 

Indication

- fixed hindfoot deformity with lateral joint pain

 

Aim

- realign hindfoot

- plantigrade surface

- maintain integrity of adjacent jts

- avoid neuromas

 

Issues

 

1.  Fuse TNJ first 

- this should passively align STJ

- need medial approach to reduce TNJ

 

2.  Fuse STJ 

- slight valgus not neutral or varus

- lateral approach

- may need large lateral bone wedge

- may have issues with lateral skin closure