PRINCIPLE: A combination of two or more soft tissue procedures is often needed to correct specific deformities.
Plantar Fasciotomy/Release (PF/PR)
1. Indications
a. Isolated cavus foot deformity (see Chapter 5) without significant hindfoot varus or forefoot pronation
b. Combined with superficial and/or deep medial releases (S-PMR, D-PMR) (see this chapter) as well as osteotomies and tendon transfers for cavovarus deformities (see Chapter 5)
2. Technique
a. Plantar fasciotomy (PF) for mild transtarsal cavus (Figure 7-29):
i. Make a 4-cm longitudinal incision along the medial border of the midfoot/hindfoot just dorsal to the edge of the glabrous skin
ii. Retract the lowest origin of the abductor hallucis muscle dorsally
iii. Isolate the plantar fascia on its plantar and dorsal surfaces from medial to lateral using Metzenbaum scissors
iv. Divide the plantar fascia transversely directly plantar to the head/neck of the talus
v. The muscles of the short toe flexors create a layer of protection to prevent inadvertent injury to the posterior tibial plantar NV structures.
vi. Release the tourniquet and achieve good hemostasis
vii. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
viii. Apply a short-leg non–weight-bearing cast with the neutrally rotated forefoot dorsiflexed against the resistance of the ankle/heel cord. There is no need to bivalve the cast.
Figure 7-29. Plantar release. A. The plantar fascia is exposed plantar and lateral to the abductor hallucis muscle. B. The plantar fascia is isolated on its dorsal and plantar surfaces from medial to lateral using Metzenbaum scissors. C. Following release of the plantar fascia (double-headed white arrow), the short toe flexor muscles are visible as a layer of safety between the released plantar fascia and the NV bundles.D & E. Artist’s sketches of plantar fasciotomy.
ix. Remove the cast after 6 weeks
b. Plantar release for moderate-to-severe transtarsal cavus and cavovarus deformities (see Superficial Plantar-Medial Release, Figure 7-31, below)
i. Make a longitudinal incision along the medial border of the midfoot/hindfoot more dorsal than for an isolated PF (almost to the distal tip of the medial malleolus) and extending posteriorly to the posterior tibial NV bundle
ii. Isolate the posterior tibial NV bundle posterior to the medial malleolus and proximal to the posterosuperior border of the flexor retinaculum
iii. Release the flexor retinaculum (laciniate ligament) vertically in line with the NV bundle for full exposure of these important structures
iv. Release the lowest and largest origin of the abductor hallucis muscle from its origin on the calcaneus while protecting the lateral plantar NV bundle. In moderate-to-severe cavus deformity, the lowest origin of the abductor hallucis muscle is so far plantar that its contracture is similar to that of the plantar fascia, so it must be released.
v. Expose the tunnel through which the lateral plantar NV bundle travels across the foot deep to the flexor digitorum brevis
vi. Bluntly and carefully develop some space between the lateral plantar NV bundle and the plantar roof of this tunnel, which is made up of the flexor digitorum brevis and the plantar fascia
vii. Release the plantar fascia and flexor digitorum brevis from medial to lateral while visualizing and protecting the lateral plantar NV bundle
viii. Release the tourniquet and achieve good hemostasis
ix. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
x. Apply a short-leg non–weight-bearing cast with the neutrally rotated forefoot dorsiflexed against the resistance of the ankle/heel cord. There is no need to bivalve the cast.
xi. Remove the cast after 6 weeks
3. Pitfalls
a. Uncertainty regarding the location of the posterior tibial NV bundles, thereby creating unnecessary caution, concern, and slow progress. Find the NV structures first to improve confidence, accuracy, and speed.
4. Complications
a. Injury to the posterior tibial NV structures
i. Avoid by isolating them proximally and trace them through the plantar tunnel
Limited, Minimally Invasive Soft Tissue Releases for Clubfoot
1. Indications
a. Little (or no) improvement after a long series of clubfoot casts in an infant or young child (and perhaps an older child) with a severe, rigid, resistant, non-surgically treated arthrogrypotic (or idiopathic) clubfoot (see Chapter 5)
i. The presumption is that it would be challenging to stretch the posterior ankle skin and align the foot in the ankle mortis even if a talectomy were performed
ii. The operative expectation is that, following surgery, the deformities will be improved and serial casting will be reinitiated. The deformities might then be corrected with further serial casting or improved enough with further serial casting that subsequent conventional á la carte partial-to-complete circumferential release will be successful.
2. Technique (Figure 7-30)
a. Percutaneous tendo-Achilles tenotomy (TAT) (see this chapter)
b. Limited open plantar fasciotomy (PF) (see this chapter)
c. Limited open posterior tibialis tenotomy
i. Dissect dorsally between the abductor hallucis and the subcutaneous fat to expose the posterior tibialis tendon sheath
ii. Open the sheath and release the posterior tibialis from the navicular
d. Percutaneous tenotomies of FHL and FDL to toes 2 to 5 (see this chapter)
e. Release the tourniquet and achieve good hemostasis
f. Approximate the skin edges of the plantar–medial incision with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
g. Apply a long-leg clubfoot cast without excessive corrective forces on the foot. Allow the tissues to relax
h. Reinitiate serial long-leg clubfoot casting in clinic in 1 to 2 weeks
3. Pitfalls
a. Incomplete TAT (see this chapter)
b. Inserting the tip of the scalpel too rapidly and too deeply into the toe flexor tendon so that it cannot act as a probe to determine the position and limits of the tendon
4. Complications
a. Posterior tibial NV injury
i. Avoid by following the TAT technique exactly as described (see this chapter)
ii. Avoid by releasing the plantar fascia but not the short toe flexor muscles
b. Laceration of a digital nerve or artery
i. Avoid by inserting the tip of the scalpel centrally and carefully into the plantar base of the toe, using it both as a probe and a scalpel (see this chapter).
ii. Avoid excessive medial and/or lateral excursion of the tip of the scalpel
c. Laceration of cartilaginous calcaneal apophysis
i. Avoid by following the TAT technique exactly as described, inserting the scalpel at least 1 cm above the posterior heel crease (see this chapter)
Superficial Medial Release (S-MR)
1. Indications
a. Pain and/or gait instability due to flexible hindfoot varus, i.e., corrects with the Coleman block test (see Assessment Principles #9 and 19, Chapter 3), and without forefoot pronation or cavus
i. Seen in some clubfeet and in some spastic varus feet
• Often used as an adjunct procedure with tendon transfers in these feet
Figure 7-30. Limited, minimally invasive soft tissue releases. A. Medial image of maximum dorsiflexion of a severe, rigid, resistant clubfoot in an infant with arthrogryposis that had undergone eight serial Ponseti-type long-leg casts. The concern was that either (1) a Cincinnati incision might be under too much tension to close at the completion of a circumferential clubfoot release, or (2) a talectomy would be used unnecessarily (and it still might not be possible to bring the foot to a neutral position). B. Limited, minimally invasive soft tissue releases were carried out starting with a percutaneous TAT. C.Improvement following the TAT, but equinus persisted. D. Mini-open PF and posterior tibialis tenotomy. E. Percutaneous tenotomy of FHL. F. Percutaneous tenotomy of FDL to toe 2 (FDL to toes 3 to 5 were subsequently released). Serial casting was reinitiated for this child’s foot. Two months later, a simple posterior release was performed and there was full and lasting deformity correction.
2. Technique (see Superficial Plantar-Medial Release [Figure 7-31], but do not perform the plantar release)
a. Make a longitudinal incision along the medial border of the midfoot/hindfoot just dorsal to the edge of the glabrous skin and extending posterior to the posterior tibial NV bundle
b. Isolate the posterior tibial NV bundle posterior to the medial malleolus and proximal to the posterosuperior border of the flexor retinaculum
c. Release the flexor retinaculum (laciniate ligament) vertically in line with the NV bundle for full exposure of these important structures
d. Release the lowest and largest origin of the abductor hallucis muscle from its origin on the calcaneus while protecting the lateral plantar NV bundle.
e. Expose and release the very thin interfascicular septum (the middle origin of the abductor hallucis on the calcaneus) that separates the medial and lateral plantar NV bundles. It is only 1 to 2 mm long and 1 to 2 mm wide
f. Release from the calcaneus the most dorsal origin of the abductor hallucis, which is the dorsal edge of the tunnel through which the medial plantar NV bundle travels within the abductor hallucis muscle
g. This completes the release of the three origins of the abductor hallucis muscle.
h. Release the tourniquet and achieve good hemostasis
i. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
j. Apply a short-leg non–weight-bearing cast with the ankle joint at neutral and the subtalar joint everted
k. Remove the cast after 6 weeks
3. Pitfalls
a. Uncertainty regarding the location of the posterior tibial NV bundles, thereby creating unnecessary caution, concern, and slow progress. Find the NV structures first to improve confidence, accuracy, and speed.
b. Failure to recognize the need for a D-MR, i.e., the subtalar joint does not fully evert
4. Complications
a. Injury to the posterior tibial NV structures
i. Avoid by isolating them proximally and tracing them between the three origins of the abductor hallucis
Figure 7-31. Superficial plantar-medial release. A. The abductor hallucis muscle has three origins on the medial surface of the calcaneus (labeled 1, 2, and 3 from plantar to dorsal). The posterior tibial NV bundle (with white vessel loop around it) divides into medial and lateral plantar NV bundles immediately before passing into the muscle. The laciniate ligament (flexor retinaculum) has been incised vertically in line with the NV bundles to expose the bundles. The plantar fascia is seen as a white band of dense collagen plantar-lateral to the abductor hallucis. It is sharply separated from the thick layer of plantar fat. B. Metzenbaum scissors are used to enter the tunnel through which the lateral plantar NV bundle passes obliquely across the plantar aspect of the foot. The NV bundle is gently swept away from the muscles on the plantar–medial surfaces of the tunnel. C. The lowest/largest origin of the abductor hallucis muscle (AH 1) and the plantar fascia and short toe flexors are divided. Release of those soft tissues using the tunnel of the NV bundle for guidance obviates injury to those important structures. D. The lateral plantar NV bundle can be seen traversing the foot in a distal–lateral direction. E. The thin septum, and 2nd origin, of the abductor hallucis (AH 2) that separates the medial and lateral plantar NV bundles is exposed. F. It is divided under direct vision. G.The most dorsal origin of the abductor hallucis (AH 3), which is dorsal to the medial plantar NV bundle, is released. H. The three origins of the abductor hallucis muscle have been released from the calcaneus while carefully protecting the medial and lateral plantar posterior tibial NV bundles. The plantar fascia and the flexor digitorum brevis have been released. This completes the S-PMR for a cavovarus foot deformity with flexible hindfoot varus.
Deep Medial Release (D-MR)
1. Indications
a. Pain and/or gait instability due to stiff/rigid hindfoot varus, i.e., does not correct with the Coleman block test (see Assessment Principles #9 and 19, Chapter 3), and without forefoot pronation or cavus
i. Seen in some clubfeet and in some spastic varus feet
• Often used as an adjunct procedure with tendon transfers in these feet
2. Technique (see Superficial Plantar-Medial Release [Figure 7-31] and Deep Plantar-Medial Release [Figure 7-32], but do not perform the plantar release)
a. Make a longitudinal incision along the medial border of the midfoot/hindfoot just dorsal to the edge of the glabrous skin and extending posterior to the posterior tibial NV bundle
b. Perform a superficial medial release exactly as described previously
Figure 7-32. Deep plantar-medial release. A. Standing AP x-ray of a cavovarus foot. The foot-CORA is in the TN joint, confirming that the deformity is hindfoot varus and not midfoot adductus (see Assessment Principle #18, Figure 3-20, Chapter 3). B. The varus deformity does not correct fully, as confirmed by a standing Coleman-type block test x-ray. The foot-CORA is still in the TN joint, but the forefoot axis (and acetabulum pedis) is still medially deviated. This is the indication for a D-PMR. The subtalar joint inversion requires release, just as it would if this were a clubfoot. C. The S-PMR is performed first (see above). Besides providing the necessary release of the contracted more superficial structures, it provides access to the deep structures. D. The posterior tibialis tendon is Z-lengthened and the TN joint is released dorsal to plantar, including release of the spring (calcaneonavicular) ligament. Again consider the analogy to a clubfoot release.
c. Release the posterior tibialis tendon sheath from the tip of the medial malleolus distally
d. Z-lengthen the posterior tibialis, releasing the plantar limb from the navicular
e. Release the TN joint capsule medially and plantar-medially, including release of the spring (calcaneonavicular) ligament, to enable passive eversion of the subtalar joint beyond neutral—confirmed with mini-fluoroscopy
f. Repair the overlapping limbs of the posterior tibialis under minimal tension using 2-0 absorbable sutures with the ankle in maximum dorsiflexion and the subtalar joint fully everted
g. Release the tourniquet and achieve good hemostasis
h. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture.
i. Apply a short-leg non–weight-bearing cast with the ankle in unforced dorsiflexion, the subtalar joint in unforced eversion, and the forefoot in neutral rotation and angulation. Excessive corrective forces could lead to wound edge necrosis, especially in feet that were severely deformed. There is no need to bivalve the cast.
j. Remove the cast after 6 weeks
3. Pitfalls
a. Uncertainty regarding the location of the posterior tibial NV bundles, thereby creating unnecessary caution, concern, and slow progress. Find the NV structures first to improve confidence, accuracy, and speed.
4. Complications
a. Injury to the posterior tibial NV bundles
i. Avoid by isolating them proximally and tracing them between the three origins of the abductor hallucis
Superficial Plantar-Medial Release (S-PMR)
1. Indications
a. Pain and/or gait instability due to cavovarus foot deformity (see Chapter 5) with flexible hindfoot varus, i.e., corrects with the Coleman block test (see Assessment Principles #9 and 19,Chapter 3), and with stiff/rigid forefoot pronation and cavus
2. Technique (Figure 7-31)
a. Make a longitudinal incision along the medial border of the midfoot/hindfoot just dorsal to the edge of the glabrous skin and extending posterior to the posterior tibial NV bundle
b. Isolate the posterior tibial NV bundle posterior to the medial malleolus and proximal to the superior edge of the flexor retinaculum. Tag it with a vessel loop.
c. Release the flexor retinaculum (laciniate ligament) vertically in line with the NV bundle for full exposure of these important structures
d. Release the lowest and largest origin of the abductor hallucis muscle from its origin on the calcaneus while protecting the lateral plantar NV bundle.
e. Expose the tunnel through which the lateral plantar NV bundle travels across the foot deep to the flexor digitorum brevis
f. Bluntly and carefully develop some space between the lateral plantar NV bundle and the plantar roof of this tunnel, which is made up of the flexor digitorum brevis and the plantar fascia
g. Elevate the plantar fat off the plantar fascia
h. Release the plantar fascia and flexor digitorum brevis from medial to lateral while visualizing and protecting the lateral plantar NV bundle (see Plantar release, this Chapter)
i. Expose and release the very thin interfascicular septum (the middle origin of the abductor hallucis on the calcaneus) that separates the medial and lateral plantar NV bundles. It is only 1 to 2 mm long and 1 to 2 mm wide
j. Release from the calcaneus the most dorsal origin of the abductor hallucis, which is the dorsal edge of the tunnel through which the medial plantar NV bundle travels within the abductor hallucis muscle
k. This completes the release of the three origins of the abductor hallucis muscle, the plantar fascia, and flexor digitorum brevis from the calcaneus.
l. Release the tourniquet and achieve good hemostasis
m. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
n. If this is the first of a two-stage reconstruction for a cavovarus foot deformity, use a running subcuticular pull-out 3-0 Proline suture. This will decrease the soft tissue reaction that might otherwise complicate wound closure at the completion of the second stage procedure 2 weeks later
o. Apply a short-leg cast with the ankle in unforced dorsiflexion, the subtalar joint in unforced eversion, and the forefoot in unforced supination and abduction. Excessive corrective forces could lead to wound edge necrosis, especially in feet that were severely deformed. There is no need to bivalve the cast.
p. The cast will be removed (in most cases) 2 weeks later at the start of the second-stage reconstruction of the cavovarus foot deformity.
q. If this is the only procedure to be performed, remove the cast after 6 weeks.
3. Pitfalls
a. Uncertainty regarding the location of the posterior tibial NV bundles, thereby creating unnecessary caution, concern, and slow progress. Find the NV structures first to improve confidence, accuracy, and speed.
b. Failure to recognize the need for a D-MR, i.e., the subtalar joint does not fully evert
4. Complications
a. Wound edge necrosis
i. Avoid by using good tissue handling techniques and/or by limiting exaggerated corrective forces in the cast
b. Injury to the posterior tibial NV bundles
i. Avoid by isolating them proximally and tracing them between the three origins of the abductor hallucis and through the plantar tunnel under direct vision
Deep Plantar-Medial Release (D-PMR)
1. Indications
a. Pain and/or gait instability due to cavovarus foot deformity (see Chapter 5) with stiff/rigid hindfoot varus, i.e., does not correct with the Coleman block test (see Assessment Principles #9 and 19, Chapter 3), and withstiff/rigid forefoot pronation and cavus
2. Technique (Figure 7-32)
a. Make a longitudinal incision along the medial border of the midfoot/hindfoot just dorsal to the edge of the glabrous skin and extending posterior to the posterior tibial NV bundle
b. Perform a S-PMR exactly as described previously
c. Release the FDL tendon sheath plantar-medial to the talus and navicular starting from the medial malleolus and progressing anteriorly
d. Retract the FDL plantarward
e. Release the posterior tibialis tendon sheath plantar-medial to the talus between the tip of the medial malleolus and the navicular
f. Z-lengthen the posterior tibialis, releasing the plantar limb from the navicular
g. Release the TN joint capsule medially and plantar-medially, including release of the spring (calcaneonavicular) ligament, to enable passive eversion of the subtalar joint slightly beyond neutral—confirmed with mini-fluoroscopy. Avoid circumferential release of the TN capsule as excessive instability of the joint could result
h. Repair the overlapping limbs of the posterior tibialis under minimal tension using 2-0 absorbable sutures with the ankle in maximum dorsiflexion and the subtalar joint fully everted
i. Release the tourniquet and achieve good hemostasis
j. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular pull-out 3-0 Proline suture. A deep plantar-medial release (D-PMR) is almost always the first of a two-stage reconstruction. Using the Proline will decrease the soft tissue reaction that might otherwise complicate wound closure at the completion of the second stage procedure 2 weeks later
k. Apply a short-leg cast with the ankle in unforced dorsiflexion, the subtalar joint in unforced eversion, and the forefoot in unforced supination and abduction. Excessive corrective forces could lead to wound edge necrosis, especially in feet that were severely deformed. There is no need to bivalve the cast.
l. The cast will be removed (in most cases) 2 weeks later at the start of the second-stage reconstruction of the cavovarus foot deformity
3. Pitfalls
a. Uncertainty regarding the location of the posterior tibial NV bundles, thereby creating unnecessary caution, concern, and slow progress. Find the NV structures first to improve confidence, accuracy, and speed.
4. Complications
a. Wound edge necrosis
i. Avoid by using good tissue handling techniques and/or by limiting exaggerated corrective forces in the cast
b. Injury to the posterior tibial NV bundles
i. Avoid by isolating them proximally and tracing them between the three origins of the abductor hallucis and through the plantar tunnel under direct vision
Dorsal Approach Release for Congenital Vertical Talus and Congenital Oblique Talus (DR)
1. Indications
a. Failure of the reverse Ponseti (Dobbs) nonoperative method to align the TN joint and, thereby, correct a CVT or congenital oblique talus deformity (see Chapter 5)
2. Technique (Figure 7-33)
a. Make a transverse incision in the anterior ankle crease from the tip of the medial malleolus to the tip of the lateral malleolus
b. Isolate and protect the superficial peroneal nerve and the anterior tibialis NV bundle
c. Z-lengthen the anterior tibialis and the EHL tendons in idiopathic cases. Perform tenotomies of those tendons in children with arthrogryposis and myelomeningocele
d. Retract the EDC tendons unless they are too contracted to retract—in which case they can be released
e. Release the peroneus tertius
f. Bluntly elevate the fat from the dorsal and medial surfaces of the tibio-navicular joint capsule, extending plantar-medially
g. The posterior tibial NV bundle is quite plantar and should be considered and avoided when dissecting far plantarward.
h. Release the posterior tibialis tendon from its sheath. The tendon can be used to help identify the location of the dorsally dislocated navicular
i. Release the peroneus brevis and longus from their tendon sheaths laterally and transect them.
j. The very contracted dorsal “tibio-talo-navicular” joint capsule can now be appreciated by dorsiflexing and plantar flexing the foot and observing as it slightly relaxes and tightens
k. Release the capsule between the navicular and tibia transversely, starting medial to the TN joint and extending laterally into the sinus tarsi. The dome and neck of the talus will be exposed. The head of the talus is not readily visible initially because the talus is so plantar flexed.
l. Release the dorsal capsule of the calcaneocuboid joint if the cuboid is dorsally subluxated (check preoperative lateral x-ray and intraoperative lateral mini-fluoroscopy image)
m. Perform a percutaneous TAT (see this chapter). Consider releasing this initially.
n. Using a Freer or Joker elevator with a dorsal-to-plantar trajectory between the navicular and talus, lever and elevate the head of the talus while depressing the navicular
o. While maintaining this position, insert a 0.062″ smooth Steinmann pin retrograde from the anatomic center of the talar head, along the central axis of the talus, exiting through the skin of the posterior ankle. Use mini-fluoroscopy to ensure that this pin is in the proper position three-dimensionally, repositioning it if necessary
p. With the drill transferred to the exposed wire posteriorly, pull it back until the anterior sharpened tip is flush with the articular surface of the talar head
q. Align the TN joint/subtalar joint anatomically
r. If the dorsal capsule is adequately released and the subtalar joint will not invert, the problem could be contracted soft tissues in the sinus tarsi.
s. Use the wire to dorsiflex the talus while inserting it antegrade across the TN joint. Advance it until it exits the skin on the dorsal forefoot. Confirm anatomic alignment of the foot with mini-fluoroscopy. Realign the foot and reinsert the wire if necessary.
t. Add a second wire across the TN joint from anteriormedial to posterior-lateral. In my experience, a single wire has been known to migrate out of the foot prematurely, so having a backup wire is wise
u. Cut the wires flush with the skin and allow them to retract subcutaneously (for anticipated removal under anesthesia) or bend them at the insertion sites and cut them long (for easy removal in clinic).
v. Repair the anterior tibialis and the EHL tendons with 2-0 absorbable sutures in idiopathic cases. Do not repair them in children with arthrogryposis and myelomeningocele
w. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
x. Apply a long-leg cast with slight inversion molding of the subtalar joint, pronation molding of the forefoot, a well-molded longitudinal arch, and with the ankle at neutral-to-slight dorsiflexion. Flex the knee 90° and set the thigh–foot angle at neutral (0°)
y. Change to a new long-leg cast in clinic in 3 weeks
z. Remove the cast and the two buried pins in the OR, or the exposed pins in the clinic, 6 weeks postoperatively
i. Idiopathic cases: apply a short-leg cast. Three weeks later, remove the cast in clinic and initiate a Ponseti-type FAB with the shoes parallel to each other on the bar. Request that the child wear the FAB 23 hours per day for 3 months and at night/naps till age 2 years
aa. Arthrogryposis and myelomeningocele cases: mold for an AFO with neutral ankle, varus hindfoot, pronated forefoot, and well-molded arch in clinic at 6 weeks. Apply a short-leg cast. Three weeks later, remove the cast and buried pins in the OR and fit the AFO, to be worn 23 hours per day
Figure 7-33. Dorsal release for CVT. A. Transverse anterior ankle incision. B. Exposed extensor tendons and superficial peroneal nerve. C. Following release of the dorsal tibio-navicular joint capsule, a Freer elevator (thin black line) is inserted and used as a lever to elevate/dorsiflex the talus. D. A 0.062″ smooth Steinmann pin is inserted retrograde into the center of the articular surface of the talar head. A Joker elevator can be used to maintain elevation of the talar head during insertion of the pin. E. The pin is advanced retrograde through the center of the body of the talus and out the back of the ankle. F. The pin is then inserted antegrade across the anatomically aligned TN joint and out the dorsum of the forefoot. G. Dorsal appearance of the anatomically aligned foot. H. Medial side appearance of the anatomically aligned foot. I. AP fluoroscopic image. The pin does not have to be in the exact axis of the medial column of the foot, but the talus and the first MT should be aligned, as they are in this foot. J. Lateral fluoroscopic image of the foot showing anatomic alignment.
3. Pitfalls
a. Inadequate release of the anterior capsule and/or peroneus brevis and/or tendo-Achilles, thereby preventing full deformity correction
b. Nonanatomic alignment of the TN and subtalar joints before pinning
4. Complications
a. Injury to the posterior tibial NV bundle
i. Avoid by careful medial dissection and soft tissue retraction before capsulotomy
b. Migration of a single pin out from across the TN joint, resulting in subluxation of the joint with recurrent deformity
i. Avoid by
• having a backup second pin
• cutting the pins immediately subcutaneously, rather than leaving them exposed is very small feet.
3rd Street Procedure (Barnett Procedure)
1. Indications
a. Iatrogenically acquired dorsal subluxation or dislocation of the navicular on the head of the talus in an operatively treated clubfoot (see Chapter 5) in a child under the age of 6 to 7 years
i. In children with this iatrogenic deformity, simple TN joint release and realignment are rarely successful
2. Technique (Figures 7-34 and 7-35)
a. Make a longitudinal incision along the medial border of the midfoot. Incision through the scar from the original clubfoot release is ideal.
b. Release the posterior tibialis tendon from the dense scar tissue surrounding it and cut it in a Z-fashion
c. Release the TN joint capsule circumferentially as completely as possible from this approach. Release intra-articular adhesions with a Freer elevator.
d. Attempt to align the joint anatomically. If it does not easily realign, proceed with the 3rd street procedure.
e. Make a longitudinal incision on the dorsum of the midfoot starting proximally over the navicular–cuboid joint and extending distally over the interval between the base of the 3rd and 4th MTs (the “3rd street”)
f. Identify and protect the superficial peroneal nerve
Figure 7-34. 3rd Street procedure. A. Standing AP x-ray shows severe forefoot adductus in this 5-year-old boy who underwent a circumferential clubfoot release at age 6 months. The relationship of the talus to the calcaneus is normal. B. Standing lateral x-ray shows dorsal subluxation of the navicular on the head of the talus (arrow). The cartilaginous anlage of the navicular is outlined. The relationships of the tibia, talus, and calcaneus are normal. The 1st ray of the foot (including the 1st MT, medial cuneiform, and navicular) is dorsally translated and plantar flexed. C. The “3rd street,” according to Barnett, is the interval between the 3rd MT–3rd cuneiform–navicular bones and the 4th MT–cuboid bones. D. Barnett suggested correcting iatrogenic dorsal subluxation of the navicular on the head of the talus by performing a circumferential release of the TN joint and extending the capsulotomies distally along the dorsal surface of the 3rd street (indicated by the black curved line). The dotted line represents the closing wedge osteotomy of the cuboid that was indicated in this foot to correct the additional rigid adductus deformity of the midfoot that existed. The medial white line is the Steinmann pin that was used for temporary internal fixation of the TN joint. The lateral white line is the Steinmann pin that was used for temporary internal fixation of the lateral column, including the cuboid osteotomy. Correction of the talus–1st MT alignment is shown with the axis lines. E. Lateral intraoperative radiograph shows the reestablished anatomic alignment of the talus and 1st MT (black lines) held in place by the Steinmann pins (white lines). The location of the cuboid closing wedge osteotomy (dotted line) is indicated. F. Standing lateral x-ray obtained 3.9 years later shows maintenance of anatomic alignment. Note the straight alignment of the axes of the 1st MT and the talus. The dorsal surface of the navicular is slightly dorsal to the dorsal surfaces of the medial cuneiform and talus, suggesting dorsal overgrowth of the navicular but with good alignment at the TN joint. The wire staple was inserted during the operation for additional internal fixation of the cuboid after the Steinmann pins were inserted, but before the previous intraoperative x-rays were obtained. G. Standing lateral x-ray taken 13 years after the operation showing good maintenance of alignment in this asymptomatic 18-year-old young man. H. Standing AP x-ray taken at the same time.
Figure 7-35. A–D. Preoperative standing images of the foot of the 5-year-old boy, shown in Figure 7-34, with iatrogenic acquired dorsal subluxation of the navicular on the head of the talus following clubfoot surgery in infancy. E–H. Standing images of his foot 3.9 years after he underwent a 3rd street procedure and concurrent closing wedge osteotomy of the cuboid. I–L. Standing images of his foot 13 years later at age 18 years. He was asymptomatic at the time, despite marked restriction of subtalar motion.
g. Release the lateral TN joint capsule to complete the circumferential release of that joint
h. Release the dorsal capsule of the navicular–cuboid joint
i. Release the dorsal capsule of the lateral cuneiform–cuboid joint
j. Release the dorsal capsule and ligaments between the base of the 3rd and 4th MTs
k. There is now a continuous capsular release from the medial TN joint to the interval between the base of the 3rd and 4th MTs.
l. The navicular will easily align anatomically with the head of the talus by pronating the medial forefoot on the hindfoot
m. Insert 1 to 2 smooth 0.062″ Steinmann pins retrograde across the TN joint. Use mini-fluoroscopy to confirm TN joint alignment and appropriate position of the pins.
n. Bend the pins at their insertion sites on the dorsum of the foot and cut them long for easy retrieval in clinic
o. Perform a deep plantar–medial plication (see this chapter)
p. Apply a long-leg non–weight-bearing cast
q. Change to a short-leg walking cast with exaggerated cavovarus molding after removal of the pins in clinic 6 weeks later. The second cast is worn for 3 weeks
3. Pitfalls
a. Incomplete deformity correction because of inadequate capsular releases.
4. Complications
a. Injury to the superficial peroneal nerve
i. Avoid by careful dissection, identification, and retraction
b. Recurrent deformity
i. Avoid by casting no less than 9 weeks as prescribed above
Butler Procedure for Congenital Overriding 5th Toe
1. Indications
a. Congenital overriding 5th toe (see Chapter 5)
2. Technique (Figure 7-36)
a. Make an elliptical V-shaped dorsomedial and Y-shaped plantar–lateral incision around the base of the 5th toe passing through the 4th and 5 web space medially.
b. After incising the skin, carefully spread the soft tissues with iris or tenotomy scissors to free the skin from the fat that contains the NV bundles, thereby keeping the NV bundles with the toe
c. Expose and Z-lengthen the EDC tendon to the toe
d. Release the dorsal and dorsomedial portions of the MTP joint capsule
e. Release the tourniquet, assess vascularity of the toe, and achieve hemostasis.
f. Gently pronate the toe and reposition it plantar-laterally in line with the 5th MT head/shaft, advancing it into the longitudinal portion of the Y-shaped plantar–lateral skin incision
g. Reposition the toe slowly and gently so as not to overstretch the NV bundles. If the toe loses vascularity, return it to the deformed position and try again more slowly
h. Using 4-0 chromic simple sutures, convert the plantar–lateral incision from a Y-shape to a V-shape to hold the toe in the proper position
i. Using 4-0 chromic simple sutures, convert the dorsomedial incision from a V-shape to a Y-shape to hold the toe in the proper position
j. Wire fixation should not be necessary
k. Apply a short-leg cast over dressings and cast padding that are applied in a way so as to maintain the proper position of the toe. Check the vascularity of the toe by viewing it through the end of the cast
l. Remove the cast after 4 to 6 weeks, based on the age of the patient
3. Pitfalls
a. Inaccurate positioning of the handles of the longitudinal incisions, thereby resulting in less than ideal final position of the toe
Figure 7-36. Butler procedure. A. Top view of a congenital overriding 5th toe in a 7-year-old child with pain and callus formation over the dorsum of the toe from shoe pressure. B. Side view. C. Double racket handle (V-Y, Y-V) incision is marked with plantar–lateral position of the Y-V racket handle. This will ensure plantar–lateral translation and pronation of the toe to correct the dorsomedial malposition and supination.D. Top view after correction. The translational and rotational deformities have been corrected. 4-0 absorbable simple sutures were used. E. Side view shows excellent correction of the deformities and no need for fixation. Comparison with image C reveals the conversion of the dorsal V-shaped incision into a Y-shaped scar. (From Mosca VS. The foot. In: Weinstein S, Flynn J, eds. Lovell and Winter’s Pediatric Orthopaedics, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2013:1493, Figure 29-71.)
4. Complications
a. Vascular compromise to the toe
i. Avoid by:
• careful dissection around the base of the toe
• releasing the tourniquet before repositioning the toe
• assuring good blood supply to the toe after it is repositioned and before/after the incisions are closed and the dressing is applied
Posterior Release (Post-R)
1. Indications
a. Clubfoot (see Chapter 5) with full correction of cavus, adductus, and varus, but with residual or recurrent equinus due to contractures of the tendo-Achilles and the posterior ankle joint capsule
b. Long-standing acquired equinus deformity
2. Technique (Figure 7-37)
a. Make a Cincinnati incision 1 cm proximal to, and parallel with, the posterior heel crease
b. Isolate the posterior tibial NV bundle posterior to the medial malleolus and proximal to the superior edge of the flexor retinaculum. Tag it with a vessel loop.
c. Z-lengthen the tendo-Achilles, releasing its medial fibers from the calcaneus and its lateral fibers proximally
i. In the rare situation in which a posterior release is performed for an equinovalgus deformity, release the lateral fibers from the calcaneus and the medial fibers proximally
d. Identify the FHL posteromedially as the tendon with the most distal musculotendinous junction in the field. It is immediately lateral to the PT NV bundle
e. Release the tendon sheath of the FHL from proximal to distal, following the tendon until it disappears under the sustentaculum tali
f. The sustentaculum tali is directly medial to the posterior facet of the subtalar joint and is, therefore, a good reference point for identifying that joint
g. The posterior facet of the subtalar joint can be partially or completely released posteriorly, based on the severity of deformity at that level
h. Release the calcaneofibular ligament and the adjacent short section of the peroneal tendon sheath from the calcaneus. Do not release the peroneal tendon sheath from the fibula as that could result in anterolateral subluxation of the tendons
i. Identify the ankle joint proximal/cephalad to the subtalar joint taking care not to injure the perichondrial ring of the distal tibial physis, a particular risk in very young children with severe equinus deformity in which the ankle and subtalar joints are essentially unified by a single posterior joint capsule
j. Release the tibiotalar (ankle) joint capsule posteriorly and around both corners of the dome of the talus down to, but not including, the distal-most fibers of the deep deltoid ligament and the distal talofibular ligament
Figure 7-37. Posterior release. The anatomic structures are labeled.
k. Do not release the talocalcaneal interosseous ligament located anterior to the posterior facet
l. Confirm full dorsiflexion of the hindfoot clinically and radiographically
i. on mini-fluoroscopy, the talus should dorsiflex to within 10° of perpendicular to the tibia and the calcaneus to at least 15° above perpendicular to the tibia
m. Repair the overlapping limbs of the tendo-Achilles with 2-0 absorbable sutures under moderate tension with the knee extended and the ankle dorsiflexed 10°
n. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
o. Apply a short-leg cast with 10° dorsiflexion. Use a long-leg cast in infants and young children in whom the cast might otherwise slip off. There is no need to bivalve the cast.
3. Pitfalls
a. Inappropriate release of the subtalar joint rather than the ankle joint, because of inaccurate identification. Tracing the FHL to the subtalar joint for orientation will prevent this error.
b. Incomplete release of the ankle joint, because of failure to release around both corners of the dome of the talus
4. Complications
a. Heel pad slough due to dysvascularity
i. Avoid by ensuring that the Cincinnati incision is at least 1 cm proximal to, and parallel with, the deep posterior heel crease (the crease is usually at the insertion of the tendo-Achilles on the calcaneus)
b. Posterior distal tibial physeal injury with progressive procurvatum deformity, due to imprecise identification of the ankle joint and resultant direct trauma to the physis (see Figure 5-21,Chapter 5)
i. Avoid by tracing the FHL to the subtalar joint and then carefully probing more proximally for the ankle joint. If the ankle joint is incorrectly thought to be the subtalar joint, the more proximal probing for the “ankle joint” could result in damage to the perichondrial ring of the distal tibial physis
Circumferential Clubfoot Release (Postero-Plantar-Medial Release)—Á la Carte (Post-PMR)
1. Indications
a. Failure to achieve full correction of some or all of the clubfoot deformities with serial casting (see Chapter 5)
b. An á la carte approach is used starting posterolaterally and progressing posteromedially and then plantar-medially, releasing only those soft tissue structures that have not fully corrected with the preoperative serial casting
2. Technique
a. Make a Cincinnati incision 1 cm proximal to, and parallel with, the posterior heel crease. Start at the distal tip of the lateral malleolus and pass distal to the tip of the medial malleolus before progressing anteriorly along the medial border of the hindfoot and midfoot ending adjacent to the medial cuneiform.
Posterior release (see Post-R Technique b–k [repeated here for convenience and continuity], Figure 7-37)
b. Isolate the posterior tibial NV bundle posterior to the medial malleolus and proximal to the superior edge of the flexor retinaculum. Tag it with a vessel loop.
c. Z-lengthen the tendo-Achilles, releasing its medial fibers from the calcaneus and its lateral fibers proximally
d. Identify the FHL posteromedially as the tendon with the most distal musculotendinous junction in the field. It is immediately lateral to the posterior tibial NV bundle
e. Release the tendon sheath of the FHL from proximal to distal, following the tendon until it disappears under the sustentaculum tali
f. The sustentaculum tali is directly medial to the posterior facet of the subtalar joint and is, therefore, a good reference point for identifying that joint.
g. The posterior facet of the subtalar joint can be partially or completely released posteriorly, based on the severity of deformity at that level.
h. Release the calcaneofibular ligament and the adjacent short section of the peroneal tendon sheath from the calcaneus. Do not release the peroneal tendon sheath from the fibula as that could result in anterolateral subluxation of the tendons
i. Identify the ankle joint proximal/cephalad to the subtalar joint taking care not to injure the perichondrial ring of the distal tibial physis, a particular risk in very young children with severe equinus deformity in which the ankle and subtalar joints are essentially unified by a single posterior joint capsule
j. Release the tibiotalar (ankle) joint capsule posteriorly and around both corners of the dome of the talus down to, but not including, the distal-most fibers of the deep deltoid ligament and the distal talofibular ligament
k. Do not release the talocalcaneal interosseous ligament located anterior to the posterior facet
Plantar-medial clubfoot release (also see S-PMR Technique c–j and D-PMR Technique c-g [repeated here for convenience and continuity], Figure 7-38)
l. Release the flexor retinaculum (laciniate ligament) vertically in line with the NV bundle for full exposure of these important structures
m. Release the lowest and largest origin of the abductor hallucis muscle from its origin on the calcaneus while protecting the lateral plantar NV bundle.
Figure 7-38. Plantar-medial release for clubfoot. Following a posterolateral release, a plantar-medial release is performed through the medial extent of the Cincinnati incision. A. The posterior tibial NV bundle is isolated behind the medial malleolus and tagged with a vessel loop. The laciniate ligament (flexor retinaculum) is released. B. The tunnel through which the lateral plantar NV bundle travels under the hindfoot/midfoot is carefully and bluntly exposed. C. The lowest and largest origin of the abductor hallucis muscle, which makes up the plantar–medial roof of the tunnel, is released from the calcaneus. D.The plantar fascia and the short toe flexors, which make up the plantar roof of the tunnel, are released from the calcaneus. The lateral plantar NV bundle is now completely exposed. E. The middle and thinnest origin of the abductor hallucis muscle, that separates the medial and lateral plantar NV bundles, is released from the calcaneus. F. The highest (most dorsal) origin of the abductor hallucis, that is dorsal to the medial and lateral plantar NV bundles, is released from the calcaneus. G. An S-PMR has been completed (also see Superficial Plantar-Medial Release, this chapter). The posterior tibialis and FDL tendons have been released from their respective tendon sheaths. H. A D-PMR is completed by Z-lengthening the posterior tibialis tendon and performing a TN joint capsulotomy (also see Deep Plantar-Medial Release, this chapter).
n. Expose the tunnel through which the lateral plantar NV bundle travels across the foot deep to the flexor digitorum brevis
o. Bluntly and carefully develop some space between the lateral plantar NV bundle and the plantar roof of this tunnel, which is made up of the flexor digitorum brevis and the plantar fascia
p. Elevate the plantar fat off the plantar fascia
q. Release the plantar fascia and flexor digitorum brevis from medial to lateral while visualizing and protecting the lateral plantar NV bundle (see Plantar release, this chapter)
r. Expose and release the very thin interfascicular septum (the middle origin of the abductor hallucis on the calcaneus) that separates the medial and lateral plantar NV bundles. It is only 1 to 2 mm long and 1 to 2 mm wide.
s. Release from the calcaneus the most dorsal origin of the abductor hallucis, which is the dorsal edge of the tunnel through which the medial plantar NV bundle travels within the abductor hallucis muscle
t. Release the FDL tendon sheath plantar-medial to the talus and navicular starting from the medial malleolus and progressing anteriorly.
u. Retract the FDL plantarward
v. Release the posterior posterior tibialis tendon sheath plantar-medial to the talus between the tip of the medial malleolus and the navicular
w. Z-lengthen the posterior tibialis, releasing the plantar limb from the navicular
x. Release the TN joint capsule medially and plantar-medially, including release of the spring (calcaneonavicular) ligament, to enable passive eversion of the subtalar joint slightly beyond neutral—confirmed with mini-fluoroscopy. Avoid circumferential release of the TN capsule as excessive instability of the joint could result.
Percutaneous tenotomies of FHL and FDL to toes 2 to 5 (see Perc. FHL/FDL Technique a–d [repeated here for convenience and continuity], Figure 7-4, this chapter)
y. Dorsiflex the ankle to tension the long toe flexor tendons
z. Maximally dorsiflex one toe at a time
aa. Using a #11 scalpel, cut the long flexor tendon to each toe using short-arc sweeping movements starting in the center of the toe at the proximal plantar flexion crease. The tip of the scalpel should be used both as a probe and a scalpel. The incision should be no more than about 3 to 4 mm. There will be a sudden release of tension and the IP joints will extend.
bb. If the DIP joint extends but the PIP does not, the flexor brevis is also contracted and should be released using the same technique.
Final assessment and closure
cc. Confirm full dorsiflexion of the hindfoot clinically and radiographically
i. on mini-fluoroscopy, the talus should dorsiflex to within 10° of perpendicular to the tibia and the calcaneus to at least 15° above perpendicular to the tibia
dd. Confirm full eversion of the subtalar joint clinically and radiographically
i. on mini-fluoroscopy, there should be straight axial alignment of the axis of the 1st MT with the axis of the talus on the lateral image, and straight axial alignment to slight abduction of the axis of the 1st MT with the axis of the talus on the anteroposterior (AP) image
ee. Repair the overlapping limbs of the posterior tibialis under minimal tension using 2-0 absorbable sutures with the subtalar joint fully everted and the ankle dorsiflexed 10°
ff. Repair the overlapping limbs of the tendo-Achilles with 2-0 absorbable sutures under moderate tension with the knee extended and the ankle dorsiflexed 10°
gg. There is no need for pins across the joints unless the joint capsules have been released excessively, rather than sufficiently. Try to avoid that.
hh. Release the tourniquet and achieve good hemostasis
ii. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
jj. First, apply a short-leg cast with 10° of ankle dorsiflexion, full eversion of the subtalar joint, midfoot abduction, and slight forefoot supination—only if the skin edges remained pink following wound closure and assumption of this position (see Complication “e” below). Then extend it to a long-leg cast with the knee flexed 90° and a thigh–foot angle of approximately 45° external. There is no need to bivalve the cast.
3. Pitfalls
a. Uncertainty regarding the location of the posterior tibial NV bundles, thereby creating unnecessary caution, concern, and slow progress. Find the NV structures first to improve confidence, accuracy, and speed.
b. Inappropriate posterior release of the subtalar joint rather than the ankle joint, because of inaccurate identification. Tracing the FHL to the subtalar joint will prevent this error.
c. Incomplete release of the ankle joint, because of failure to release around both corners of the dome of the talus
d. Inserting the tip of the scalpel too rapidly and too deeply into the FHL or FDL tendon so that it cannot act as a probe to determine the position and limits of the tendon during percutaneous tenotomy
e. Excessive release of joint capsules and/or the interosseous talocalcaneal ligament, which will often result in overcorrection of deformities
4. Complications
a. Heel pad slough due to dysvascularity
i. Avoid by ensuring that the Cincinnati incision is at least 1 cm proximal to, and parallel with, the deep posterior heel crease (the crease is usually at the insertion of the tendo-Achilles on the calcaneus)
b. Injury to the posterior tibial NV bundles
i. Avoid by isolating them proximally and tracing them between the three origins of the abductor hallucis and through the plantar tunnel under direct vision
c. Posterior distal tibial physeal injury with progressive procurvatum deformity, due to imprecise identification of the ankle joint and resultant direct trauma to the physis (see Figure 5-21,Chapter 5)
i. Avoid by tracing the FHL to the subtalar joint and then carefully probing more proximally for the ankle joint. If the ankle joint is incorrectly thought to be the subtalar joint, the more proximal probing for the “ankle joint” could result in damage to the perichondrial ring of the distal tibial physis
d. Laceration of a digital nerve or artery during percutaneous tenotomy of the FHL or FDL
i. Avoid by
• inserting the tip of the scalpel centrally and carefully, using it both as a probe and a scalpel
• limiting medial and/or lateral excursion of the tip of the scalpel
e. Wound edge necrosis
i. Avoid by
• using good tissue handling techniques
• limiting exaggerated corrective forces in the cast
• Achieve full correction of all deformities
• Close the incision
• Dorsiflex the ankle and evert the subtalar joint to the point at which the wound edges blanch
• The position for cast molding is slightly less than that.
• If that position is less than the full deformity correction position achieved with the incision open, serial postoperative casting is required.
• The skin will stretch by creep and stress relaxation.
• For slight limitation from the fully corrected position, serial casting can be performed in clinic starting in 2 to 3 weeks.
• For severe limitation from the fully corrected position, serial casting should be performed in the OR starting in 1 to 2 weeks.