Accessory Navicular Resection
1. Indications
a. Pain at the site of the accessory navicular that is not relieved by prolonged attempts at nonoperative treatment (see Chapter 6)
2. Technique (Figure 8-3)
a. Make a 4-cm longitudinal incision along the medial border of the midfoot from the medial cuneiform to the talar neck along the course of the posterior tibialis tendon
b. Incise the soft tissues on the medial surface of the navicular/accessory navicular longitudinally in line with the fibers of the distal extension of the posterior tibialis tendon
c. Continue the incision into the posterior tibialis tendon in the transverse plane for 1 cm
d. Sharply elevate the periosteum/posterior tibialis tendon fibers dorsally and plantarward from the navicular/accessory navicular, exposing the entire accessory navicular and the enlarged medial extension of the main body of the navicular. Preserve these flaps for later repair. Do not release them transversely.
Figure 8-3.Accessory navicular resection (toes to the left and heel to the right of the images). A. The pathology is exposed through a 4-cm longitudinal skin incision directly medial to the bony prominence. An incision is made in the soft tissues on the medial surface of the navicular and accessory navicular in line with the posterior tibialis tendon fibers (dotted blue line). The division of the tendon fibers extends 1 to 2 cm proximally into the posterior tibialis tendon. The button hook is around the tendon as it approaches the navicular from the right side of the image. The green arrows indicate the directions that the dorsal and plantar soft tissue flaps will be elevated. B. The periosteum/tendon fiber flaps (curved green lines) have been sharply elevated both dorsally and plantarward off the navicular and the accessory navicular without detaching them transversely from the navicular. The small four-pronged hooks are shown retracting these soft tissue flaps. The black line indicates the location of the synchondrosis of the accessory navicular with the main body of the navicular. The dotted green line indicates the longitudinal axis of the accessory navicular. The forceps are shown rotating the accessory navicular dorsally at the synchondrosis. C. The forceps are shown rotating the accessory navicular plantarward, thereby demonstrating hypermobility of the accessory navicular at the synchondrosis. D. The accessory navicular has been resected at the synchondrosis. E. The enlarged medial extension of the main body of the navicular is resected flush with the medial surface of the medial cuneiform using an osteotome. F. Forceps are holding the resected bone.G. Multiple vest-over-pants imbrication-type 2-0 absorbable sutures are placed in the flaps in preparation for plantar-to-dorsal plication and tubularization of the tendon. H.Sutures are pulled dorsally to close the dead space that was created by the bone resection. I. The vest-over-pants sutures have been tied. J. A running 2-0 absorbable suture is initiated between the free edge of the plantar flap and the adjacent fibers of the dorsal flap of the posterior tibialis tendon at the proximal (heel) end of the plicated tissues. K. The suture is run along the free edge to smooth the repair. L. Final, smooth imbricated repair.
e. Identify the synchondrosis, incise it, and remove the accessory navicular
f. Using an osteotome, resect the enlarged medial extension of the navicular flush with the medial surface of the medial cuneiform. Confirm adequate resection with mini-fluoroscopy
g. Plicate the soft tissue flaps over the resection site using a dorsal–plantar vest-over-pants technique with 2-0 absorbable sutures
h. Finish the free edge of the superficial flap with a running 2-0 absorbable suture
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
k. Remove the cast after 6 weeks and initiate weight-bearing
3. Pitfalls
a. Failure to resect the enlarged medial/plantar–medial extension of the main body of the navicular
4. Complications
a. Weakening, stretching, or rupture of the posterior tibialis tendon attachment on the navicular
i. Avoid by preserving the dorsal and plantar soft tissue flaps as described earlier
Calcaneonavicular Tarsal Coalition Resection
1. Indications
a. Activity-related pain in the sinus tarsi region, and occasionally under the medial midfoot, caused by a calcaneonavicular tarsal coalition (see Chapter 5) that is not relieved despite prolonged attempts at nonoperative treatment
2. Technique (Figure 8-4)
a. Use a sterile tourniquet and hindquarter prep if the fat graft will be taken from the posterior buttock crease. A nonsterile tourniquet can be used if the fat graft will be taken from the posteromedial distal thigh
b. Make an oblique incision over the midfoot from the dorsal midline of the navicular to the midlateral point of the anterior calcaneus in a Langer’s line
c. Isolate, retract, and protect the superficial peroneal nerve
d. Elevate the extensor muscles from the sinus tarsi and the coalition from posterior to anterior, tagging the proximal margin for ease of reattachment
e. Place Joker elevators posterior and anterior to the coalition with the tips meeting under the coalition, which is usually around 2.5 cm in depth
f. Using a 10-mm osteotome, cut the navicular from dorsolateral to plantar-medial in line with the head and neck of the talus
g. Using a 10-mm osteotome, cut the calcaneus from dorsolateral to plantar-medial in line with the cuboid/lateral cuneiform joint, trying to preserve as much normal calcaneocuboid joint articulation as possible
h. The two cuts should be approximately 10 to 12 mm apart and parallel to nearly parallel
i. The coalition will be in the resected specimen.
j. If necessary, use a Kerrison rongeur to remove bone and bone fragments from the depths of the resection cavity
k. The spring (calcaneonavicular) ligament should be visible at the base of the resection cavity.
l. Cover the exposed bone surfaces with bone wax
m. Obtain a large fat graft from the posterior–medial aspect of the distal thigh or from the posterior buttock crease and overfill the resection cavity
n. Replace the short toe extensors to their origin with 2-0 absorbable sutures, covering the fat graft
o. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
p. Apply a short-leg non–weight-bearing cast. The cast is worn for 2 weeks to allow the soft tissues to heal before initiating range-of-motion exercises
Figure 8-4.Resection of a calcaneonavicular tarsal coalition. A. The EHB is elevated from the sinus tarsi and reflected anteriorly. B. The synchondrosis and adjacent portions of the calcaneus and the navicular are exposed. C. Ten-millimeter osteotomes are positioned 10 to 12 mm apart and parallel to each other for the osteotomies. D. A resected coalition has been bisected to reveal the pathoanatomy. E. The 3D rectangle-shaped resection cavity is visualized with the spring ligament exposed at its base. F. The resection cavity is large enough to accept the surgeon’s index finger. G. The cavity is 2.5 cm deep. H.After the osteotomy surfaces are coated with bone wax, a large free fat graft is inserted to completely fill the cavity. The EHB is pulled over the fat graft and reattached to its origin in the sinus tarsi. I. Preresection oblique intraoperative fluoroscopy image with osteotome in place. J. Postresection oblique image. The navicular osteotomy is made in line with the head/neck of the talus. The calcaneus osteotomy is made in line with cuboid/lateral cuneiform joint.
q. Prescribe a dosage of a nonsteroidal anti-inflammatory drug (NSAID) for 4 weeks
r. Remove the cast after 2 weeks, but continue non–weight-bearing for an additional 4 weeks while the patient regains comfortable range of motion
s. Initiate gradual return to weight-bearing after 6 weeks, using crutches at first to ensure comfort
3. Pitfalls
a. Excessive resection of the articular surface of the calcaneus, resulting in instability at the calcaneocuboid joint
b. Excessive resection of the articular surface of the navicular resulting in instability at the talonavicular (TN) joint
4. Complications
a. Injury to the superficial peroneal nerve
i. Avoid by:
• isolating, retracting, and protecting it
b. Persistence of the coalition
i. Avoid by:
• ensuring that the coalition is completely resected, including at its plantar extent
• Visualize the spring (calcaneonavicular) ligament.
• Probe the depths of the resection cavity with a Freer elevator.
• Obtain an intraoperative oblique fluoroscopic or radiographic image.
c. Recurrence of the coalition
i. Avoid by:
• applying bone wax to the resection surfaces
• inserting a large free fat graft to completely fill the resection cavity and covering it with the EHB
Talocalcaneal Tarsal Coalition Resection
1. Indications
a. Activity-related pain in the medial hindfoot, the sinus tarsi region, and occasionally under the medial midfoot, caused by a talocalcaneal tarsal coalition (see Chapter 5) that is not relieved despite prolonged attempts at nonoperative treatment
b. A coalition of the middle facet in which the size of the coalition is less than 50% the surface area of the posterior facet
c. And with a normal posterior facet, defined as “normal” thickness on coronal CT scan images
2. Technique (Figure 8-5)
a. Use a sterile tourniquet and hindquarter prep if the fat graft will be taken from the posterior buttock crease. A nonsterile tourniquet can be used if the fat graft will be taken from the posteromedial distal thigh
b. Make a longitudinal incision medial to the subtalar joint from the posterior tibial (PT) neurovascular bundle to the TN joint
c. Incise the laciniate ligament (flexor retinaculum) longitudinally directly over the middle facet. Tag the edges with 2-0 absorbable sutures for later identification and repair
d. Retract the flexor digitorum longus (FDL) dorsally or plantarward, depending on the dorsal–plantar location of the coalition and the ease of exposure
e. Retract the flexor hallucis longus (FHL) plantarward from the sustentaculum tali
f. Bluntly identify the posterior edge of the middle facet. Place a baby Hohman retractor there to both identify the posterior extent of the pathologic facet and retract and protect the FHL and PT neurovascular bundle
Figure 8-5. Resection of a talocalcaneal tarsal coalition. A. The FDL is retracted dorsally to expose the middle facet, though it might be easier to retract it plantarward in some feet. B. The FHL is retracted plantarward from the sustentaculum tali. C. The periosteum is sharply elevated from the medial surfaces of the talus and calcaneus at the middle facet. The synchondrosis is exposed. D. The middle facet coalition has been resected. The posterior facet is visualized at the base of the resection cavity. A smooth-toothed laminar spreader in the resected middle facet cavity has been used to distract the posterior facet to ensure that there are no remaining bony or cartilaginous connections between the talus and calcaneus. E. Steinmann pins are inserted in the talus and calcaneus from medial to lateral before resection of the coalition. There is no motion between them with attempted inversion and eversion of the subtalar joint. F. Following resection, convergence and divergence of the pins confirms restoration of subtalar motion. G and H. Direct visualization of the resection cavity during eversion and inversion of the subtalar joint, with widening and narrowing of the resection cavity, further confirms complete resection of the coalition. I. Bone wax is applied to the resected bone surfaces. J. A large free fat graft is inserted. K. The fat graft completely fills the cavity. L. The periosteum is repaired over the fat. The flexor retinaculum is subsequently repaired over the graft and the flexor tendons.
g. Bluntly identify the anterior edge of the middle facet. Place a baby Hohman retractor there
h. Longitudinally (from anterior to posterior) incise the periosteum in the center of the medial face of the middle facet
i. Sharply elevate the periosteum from the middle facet dorsally and plantarward. Try to preserve it for later repair, if possible
j. Identify the synchondrosis
k. Using a high-speed 3- to 4-mm burr, remove the synchondrosis from anterior to posterior and medial to lateral. The height of the resection cavity should be 6 to 8 mm
l. The resection is complete when:
i. the healthy posterior facet is visualized.
ii. the talocalcaneal interosseous ligament and surrounding fat are visualized.
iii. the healthy anterior facet is visualized.
iv. the posterior and anterior facets can be distracted easily with a smooth-toothed laminar spreader in the resection cavity of the middle facet.
v. the subtalar joint can be inverted and everted. Do not expect dramatic improvement in range of motion in long-standing cases, but ensure that there are no pathologic bony or cartilaginous connections remaining between the talus and calcaneus
• Insert parallel 0.062″ smooth Steinmann pins from medial to lateral in the talus and calcaneus adjacent to the resection cavity. Invert and evert the subtalar joint to confirm that there is restoration of motion by observing the movement between the pins. If there is limited or no subtalar motion despite confirmed distraction of the posterior facet with the laminar spreader, release the dorsolateral TN joint capsule through a dorsolateral incision. In long-standing coalitions, a contracture/synchondrosis sometimes develops at that location between a dorsal talar beak and a dorsal navicular osteophyte.
m. Cover the exposed bone surfaces with bone wax
n. Obtain a large fat graft from the posterior–medial aspect of the distal thigh or from the posterior buttock crease and use it to overfill the resection cavity
o. Replace the FHL under the sustentaculum tali
p. Repair the periosteum over the fat graft, if possible
q. Replace the FDL to its normal position medial to the middle facet, and repair the laciniate ligament (flexor retinaculum) with 2-0 absorbable sutures over the fat graft
r. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
s. Apply a short-leg non–weight-bearing cast. The cast is worn for 2 weeks to allow the soft tissues to heal before initiating range-of-motion exercises
t. Prescribe a dosage of an NSAID for 4 weeks
u. Remove the cast after 2 weeks, but continue non–weight-bearing for an additional 4 weeks while the patient regains comfortable range of motion
v. Initiate gradual return to weight-bearing after 6 weeks, using crutches at first to ensure comfort
3. Pitfalls
a. Inappropriate resection in a foot with an unresectable coalition characterized by an ankylosed and narrow posterior facet and/or an extremely large middle facet coalition
b. Failure to correct severe associated valgus hindfoot deformity either concurrently or staged
4. Complications
a. Persistence of the coalition
i. Avoid by:
• ensuring complete resection. See “l” above in the Technique section.
b. Recurrence of the coalition
i. Avoid by:
• making a large resection cavity
• applying bone wax to the resection surfaces
• inserting a large free fat graft to completely fill the resection cavity and covering it with the periosteum and flexor retinaculum
c. Injury to the PT neurovascular bundle
i. Avoid by retracting and protecting it from the burr
Lichtblau Distal Calcaneus Resection
See under Lateral Column Shortening Procedures later.
Longitudinal Epiphyseal Bracket Resection
1. Indications
a. The presence of a longitudinal epiphyseal bracket (LEB; see Chapter 6)
i. LEB is always associated either with congenital hallux varus (see Chapter 5) or with preaxial polydactyly (see Chapter 6)
2. Technique (Figures 8-6 and 8-7)
a. Make a longitudinal incision along the medial border of the forefoot extending from the hallux to the medial cuneiform
b. If preaxial polydactyly exists, continue the incision distally as an ellipse around the duplicate hallux on the medial side. Resect the duplicate hallux
c. The abductor hallucis is contracted and often exists as a fibrous cord/band in a foot with either congenital hallux varus or preaxial polydactyly. Release it distally (or excise it) (see Chapter 7).
d. Expose the 1st metatarsal (MT) shaft extraperiosteally on its dorsal, medial, and plantar surfaces
Figure 8-6. A. AP x-ray of a 1st MT LEB associated with congenital hallux varus in an infant. The lateral cortex of the diaphysis is concave, whereas the medial cortex is convex and poorly ossified. The hallux is in varus alignment. B. The purple and black arc represents the LEB. The black central section represents the abnormal portion of the LEB along the medial side of the 1st MT shaft. The convergent black lines are the 25G needles that were inserted to mark the planned extent of resection. C. One year later, the medial cortex of the 1st MT diaphysis is concave and has the normal density of cortical bone. Longitudinal growth of the MT has been established. It is unknown at this time if catch up longitudinal growth will take place.
Figure 8-7. A. Preaxial polydactyly with a 1st MT LEB in a newborn infant. B. Intraoperative x-ray obtained when the child was 9 months old. The two 25G needles mark the proximal and distal limits of the planned LEB resection (the distal needle was moved further distally before resection). C. The shiny cartilage of the LEB along the medial surface of the MT shaft can be seen between the needles. D. The 1-cm-thick (medial to lateral) abnormally positioned epiphyseal cartilage (held in the forceps) was resected, sharply exposing metaphyseal-type bone where cortical bone should be (purple oval). E. Normal-appearing medial cortex on the 1st MT shaft 2 years later. F. At 4 years postoperatively, the 1st MT appears normal in length and shape, and the mild residual varus alignment of the 1st MTP joint has corrected to physiologic alignment.
e. Using mini-fluoroscopy for guidance, insert a 25G needle from medial to lateral at the transverse level of the normal physis proximally and another at the level of the normal articular cartilage distally
f. Use a scalpel to incise the thick, abnormally placed epiphyseal cartilage on the medial side of the shaft, cutting from dorsal to plantar immediately distal to the proximal needle and immediately proximal to the distal needle. The epiphyseal cartilage extends dorsomedially and plantar-medially approximately to the midsagittal plane of the MT.
g. Identify the junction between the abnormal epiphyseal cartilage and the normal periosteum on the dorsal and plantar surfaces
h. Incise the periosteum longitudinally on the dorsal and plantar surfaces immediately adjacent to the LEB
i. Use a Freer elevator to separate, or “pop off,” the abnormal epiphyseal cartilage from the shaft of the MT. The technique is similar to separating the iliac apophysis from the iliac crest during hip surgery in children. The exposed bone on the MT shaft is not cortex, but instead juxtaphyseal metaphyseal bone as seen at the iliac crest or during operative treatment of a physeal injury. Make sure all abnormal cartilage is removed, leaving only normal periosteum on the dorsal and plantar surfaces of the MT shaft.
j. The subcutaneous fat and abductor hallucis muscle fall into the gap upon closure of the wound, though a deep fat stitch of a 3-0 absorbable material can be used to ensure that soft tissues fill the gap.
k. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
l. If the skin is particularly contracted, the incision can be converted to a Z-plasty (Figure 8-8).
m. It is uncommon to require pin fixation of the metatarsophalangeal (MTP) joint. The articular cartilage of the 1st MT is medially deviated (essentially a reverse, or negative, distal metatarsal articular angle [DMAA]—see Juvenile Hallux Valgus, Chapter 5) and the MTP joint is generally congruous. After establishing longitudinal growth of the MT, the joint tends to reorient itself.
n. Use a long-leg cast (to prevent it from slipping off the infant) for 4 weeks
Figure 8-8. Z-plasty of the skin on the medial side of the forefoot may be necessary when correcting congenital hallux varus or preaxial polydactyly with or without resection of a 1st MT LEB.
3. Pitfalls
a. Failure to release the abductor hallucis contracture
b. Failure to resect the proximal-to-distal and dorsal-to-plantar full extent of the abnormal epiphysis. Whereas taking too much of the epiphysis is not good for the remaining bone ends, resecting too little might result in incomplete establishment of normal growth of the MT.
c. Performing a concurrent angular deformity correction osteotomy in infants. In most cases, the varus deformity of the 1st MT and the varus orientation of the 1st MTP joint correct spontaneously. If they do not, an osteotomy can be performed later in childhood.
4. Complications
a. Incomplete resection of the abnormal epiphysis with persistent deformity
i. Avoid by ensuring that the dorsomedial and plantar–medial extensions of the abnormal epiphysis are resected along with the medial portion. Periosteum must be seen on the dorsal and plantar surfaces of the MT shaft.
b. Incision wound edge necrosis
i. Avoid by performing a Z-plasty if the skin appears to be excessively tight upon wound closure and passive abduction of the hallux to approximately neutral alignment on the 1st MT
Resection of Impinging Portion of Dorsally Subluxated Navicular
1. Indications
a. Painful anterior ankle impingement (see Chapter 5) from dorsal subluxation of the navicular on the head of the talus in an adolescent/young adult who underwent surgical treatment for a clubfoot early in life and does nothave evidence for arthritis in the TN joint
2. Technique (Figure 8-9)
a. Make a 4- to 5-cm longitudinal incision over the anterior aspect of the ankle joint lateral to the anterior tibialis tendon
b. Avoid or retract the superficial peroneal nerve
c. Release the extensor retinaculum longitudinally
d. Incise the anterior ankle joint capsule longitudinally and retract the edges medially and laterally
e. Reshape the prominent dorsal portion of the navicular with an osteotome
f. Debride surrounding thick abnormal callus tissue, if present
g. Maximally dorsiflex the ankle to confirm, under direct visualization, that there is no residual contact between the navicular and the tibia
h. Repair the ankle joint capsule with 2-0 absorbable sutures
Figure 8-9. A. Standing lateral x-ray of the ankle and hindfoot in a skeletally mature adolescent who underwent clubfoot surgery as an infant and presented at age 16 with intractable impingement-type anterior ankle pain. Her symptoms were not consistent with TN joint arthritis; therefore, TN joint arthrodesis was not indicated. Her overall foot shape was acceptable and, although her foot was very stiff, she had no other symptoms. Black line indicates the level of resection of the dorsally subluxated navicular. B. This x-ray image was taken several months later at which time she was asymptomatic and had improved dorsiflexion.
i. Repair the extensor retinaculum with 2-0 absorbable sutures
j. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
k. Apply a non–weight-bearing CAM boot for 2 to 3 weeks to provide comfort during the early healing phase
l. Then initiate active range-of-motion exercises and continue non–weight-bearing for an additional 4 weeks; use of the CAM boot is optional for comfort during this time.
3. Pitfalls
a. Inadequate resection of bone
b. Failure to repair the extensor retinaculum with resultant bow-stringing of the extensor tendons
4. Complications
a. Injury to the superficial peroneal nerve
i. Avoid by isolating and retracting/protecting it
Debridement of Dorsal Talar Neck
1. Indications
a. Painful anterior ankle impingement (see Chapter 5) from a flat-top talar dome with a shallow or flat dorsal talar neck, typically found in a previously treated clubfoot
2. Technique (Figure 8-10)
a. Make a 4- to 5-cm longitudinal incision over the anterior aspect of the ankle joint lateral to the anterior tibialis tendon
b. Avoid or retract the superficial peroneal nerve
Figure 8-10. Multiply operated, stiff clubfoot in a 15-year-old girl with pain from anterior ankle impingement. A. Flat-top talus with shallow/absent dorsal talar neck concavity (and small heterotopic ossicle) causing anterior ankle impingement and pain. B. Sagittal CT scan image confirming the deformity. C.Three-dimensional CT scan image confirming the deformity. D. Lateral x-ray with purple markings indicating the resections to be performed. E. Lateral x-ray of the ankle in plantar flexion following resection of heterotopic ossicle and reshaping of the dorsal talar neck. F. Lateral x-ray of the ankle in dorsiflexion following resection of heterotopic ossicle and reshaping of dorsal talar neck.
c. Release the extensor retinaculum longitudinally
d. Incise the anterior ankle joint capsule longitudinally and retract the edges medially and laterally
e. Reshape the dorsal talar neck with an osteotome and high-speed burr
f. Resect osteophytes from the anterior distal tibial epiphysis, if present
g. Debride surrounding thick abnormal callus tissue, if present
h. Maximally dorsiflex the ankle to confirm, under direct visualization, that there is no residual contact between the talus and the tibia
i. Repair the ankle joint capsule with 2-0 absorbable sutures
j. Repair the extensor retinaculum with 2-0 absorbable sutures
k. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
l. Apply a non–weight-bearing CAM boot for 2 to 3 weeks to provide comfort during the early healing phase
m. Then initiate active range-of-motion exercises and continue non–weight-bearing for an additional 4 weeks; use of the CAM boot is optional for comfort during this time.
3. Pitfalls
a. Inadequate resection of bone
b. Failure to repair the extensor retinaculum with resultant bow-stringing of the extensor tendons
4. Complications
a. Injury to the superficial peroneal nerve
i. Avoid by isolating and retracting/protecting it
Ray Resection
1. Indications
a. Macrodactyly (see Chapter 6)
b. Polydactyly (see Chapter 6)
2. Technique (Figure 8-11)
a. Make a V-shaped incision on both the dorsal and plantar surfaces of the foot with the apices at the tarsometatarsal joint level and connecting distally in the web spaces on both sides of the ray to be removed
Figure 8-11. A. AP x-ray of a 1-year-old with macrodactyly of the 2nd ray of the foot. B. V-shaped incision is marked on the dorsum. C. V-shaped incision is marked on the plantar aspect. D. Dorsal view after the ray has been resected. E. Plantar view after the ray has been resected. F. AP x-ray after the resection. G. Intraoperative appearance of the dorsum of the foot immediately after the resection. Note the markedly improved appearance of the foot and the cosmetic appearance of the subcuticular suture wound closure. H. Intraoperative appearance of the plantar surface of the foot immediately after the resection. I. Dorsal appearance of the foot 18 months later. Note the cosmetic appearance of the scar (disregard the small recent abrasion at the proximal end). J. Plantar appearance of the foot 18 months later. The scar is barely noticeable.
b. From the dorsal approach, incise sharply and directly to the intermetatarsal spaces on both sides of the MT to be removed
c. Expose the common digital neurovascular bundles in the web spaces and transect the branches to the toe being removed
d. Expose the MT shaft extraperiosteally on its dorsal, medial, and lateral surfaces
e. Transect the MT at the proximal meta-diaphysis, rather than disarticulating the MT Removing the entire MT risks upsetting the congruity of the remaining MTs and tarsometatarsal joints
f. Divide the plantar soft tissues in line with the V-shaped skin incision
g. Release the tourniquet and achieve hemostasis
h. Approximate the distal intermetatarsal ligaments of the adjacent MTs with 2-0 absorbable sutures
i. Resect any excess skin and fat
j. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
k. Use a long-leg cast (to prevent it from slipping off the infant) for 4 to 6 weeks
3. Pitfalls
a. Inadequate soft tissue resection, particularly on the plantar surface
4. Complications
a. Necrosis of the lateral toes
i. Avoid by limiting the plantar muscle resection to that under the distal two-third of the MT being resected (the lateral plantar neurovascular bundle travels lateral to the 2nd ray). Resecting plantar subcutaneous fat is generally safe.
b. Progressive overgrowth of residual macrodactyly soft tissues at the resection site
i. Avoid by—it is almost impossible to remove all of the pathological soft tissues because there is no clear demarcation between normal and abnormal. That said, be aggressive and remove all of the soft tissues that appear safe to remove. Prepare the family for the possible need for a debulking procedure (or two) in the future (see Management Principle #10, Chapter 4).
Naviculectomy
1. Indications
a. Neglected/recurrent/residual congenital vertical talus (see Chapter 5) in which:
i. the TN joint is well-aligned or becomes well-aligned in the frontal plane yet the deformity persists (see Figure 5-29, Chapter 5)
ii. or, the TN joint cannot be aligned with a posterolateral soft tissue release because of resistance of the lateral soft tissues or too short a lateral column of the foot
2. Technique (Figures 8-12 and 8-13)
a. Perform a posterior/posterolateral release (see Chapter 7) if indicated
b. Make a longitudinal incision along the medial border of the midfoot from the base of the 1st MT to a point just distal to the medial malleolus
c. Retract the abductor hallucis plantarward
d. Release the posterior tibialis tendon sheath and expose the tendon from the medial malleolus to its insertion on the navicular
e. Z-lengthen the posterior tibialis tendon to expose the TN joint capsule
f. Release the TN joint circumferentially
g. If the navicular is dorsolaterally displaced, try to reduce it onto the head of the talus. If it cannot be reduced, or if the TN joint is already reduced but severe deformity persists, elevate the distally based Z-lengthened slip of the posterior tibialis off the navicular while maintaining its connections with the cuneiform bones.
h. Release the joint capsules between the navicular and the medial, middle, and lateral cuneiforms
i. Remove the navicular from the foot
Figure 8-12. Naviculectomy in a 6-year-old girl with arthrogryposis who was previously treated unsuccessfully with a circumferential release. A. The posterior tibialis is Z-lengthened and the TN joint capsule is released circumferentially. B. The naviculocuneiform joints are released. C. The navicular has been removed from the foot. The articular surfaces of the cuneiform bones are exposed. D. The posterior tibialis tendon is plicated. E. Preoperative standing top image of the foot. F. Intraoperative top image of the foot following naviculectomy. The first of two Steinmann pins is in place across the talocuneiform joint. G. Preoperative standing medial image of the foot. H. Intraoperative medial image of the foot following naviculectomy, plantar–medial soft tissue plication, and Steinmann pin fixation. The incision for the posterior release is visualized.
Figure 8-13. A. Preoperative standing top images of recurrent/residual congenital vertical talus deformities in a 3-year-old with arthrogryposis. B. Preoperative standing posterior images. C. AP x-ray of the right foot immediately following naviculectomy, with Steinmann pin fixation in place. The thick arc represents the navicular. The thin arc represents the talocuneiforms joint that resulted from the naviculectomy. D. Lateral x-ray with Steinmann pin in place. E and F. AP and lateral x-rays 1 year post-op. G and H. AP and lateral x-rays 3 years following naviculectomy. I–K. Top, side, and back views of the feet 3 years post-op.
j. Align the proximal articular surfaces of the 3 cuneiform bones with the articular surface of the talar head. They should be fairly congruous and match fairly well.
k. With the foot deformity corrected, insert two crossed 0.062″ smooth Steinmann pins retrograde across the resection site, using mini-fluoroscopic guidance
l. Bend the pins at the insertion sites and cut them long for easy retrieval in clinic in larger feet, or cut the pins short and bury them under the skin in smaller feet (to prevent spontaneous dislodgement)
m. If there is adequate capsular tissue remaining on the medial cuneiform and the talus, repair this tissue plantar-medially with 2-0 absorbable sutures
n. Advance and plicate the two slips of the posterior tibialis tendon with figure-of-8 2-0 absorbable sutures. The tendon can also be sutured to the capsule, thereby creating additional scar at the talocuneiform joint
o. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
p. Apply a long-leg, bent knee, non–weight-bearing cast if the child will not be compliant with non–weight-bearing in a short-leg cast
q. At 6 weeks, remove the exposed pins in clinic or the buried pins in the OR and apply another non–weight-bearing cast that will be worn for an additional 3 weeks
r. If the child has arthrogryposis or myelomeningocele, an ankle-foot-orthotic (AFO) can be molded at the 6-week cast change and fitted at the 9-week post-op visit
3. Pitfalls
a. Incomplete removal of the navicular
b. Incomplete posterolateral release
c. Inaccurate alignment of the talocuneiform joints
4. Complications
a. Recurrence of deformity
i. Avoid by plicating the plantar–medial soft tissues (see Plantar–Medial Plication, Chapter 7) at the resection site and maintaining cast immobilization for at least 9 weeks
b. Overcorrection of deformity
i. Avoid by ensuring that the navicular cannot be anatomically positioned on the head of the talus before resecting it
c. Incomplete removal of the navicular
i. Avoid by careful dissection using fluoroscopic guidance if necessary
Talectomy
1. Indications
a. Severe, rigid clubfoot in an infant or young child with arthrogryposis that has not responded adequately to serial casting and limited, minimally invasive soft tissue releases, followed by ongoing serial casting (see Severe, Rigid, Resistant Arthrogrypotic Clubfoot in an Infant or Young Child, Chapter 5)
2. Technique (Figures 8-14 and 8-15)
a. First perform a percutaneous tendo-Achilles tenotomy (see Chapter 7)
b. There are several possible incisions to choose from. My recent personal favorite is a curved incision over the dorsum of the midfoot from posterolateral to anteromedial coursing over the prominent talar head.
c. Isolate and retract the superficial peroneal nerve
d. Transect all extensor tendons to the foot and toes
Figure 8-14. A. A curved dorsal incision is centered over the prominent head of the talus. B. The talus is exposed by transection of the extensor tendons and retraction of the superficial peroneal nerve. C. The TN joint is released circumferentially. D. The ankle and subtalar joints are released circumferentially and the talus is extracted from the foot.
Figure 8-15. A. Top view of bilateral clubfoot deformities in a 1-year-old boy with Freeman–Sheldon syndrome. The cavus, adductus, and varus deformities have been corrected after 20 casts. B. But the navicular is plantar to the head of the talus in both feet and the talus is in extreme and rigid plantar flexion, despite two percutaneous Achilles tenotomies in both feet. C. Following talectomy, the calcaneus is positioned in the ankle mortis and a Steinmann pin is inserted retrograde for temporary fixation. D. The foot is dorsiflexed to 90° or higher.
e. Bluntly elevate the soft tissues from the medial side of the hindfoot bones (talus and calcaneus)
f. Isolate and retract the PT neurovascular bundle posteriorly
g. Incise the posterior tibialis tendon sheath distal and anterior to the medial malleolus and follow the tendon to the TN joint
h. Transect the posterior tibialis tendon
i. Transect the FHL and FDL tendons immediately plantar to the posterior tibialis tendon
j. Release the TN joint circumferentially
k. Release the ankle joint anteriorly and medially with release of the deep deltoid ligament
l. Release the lateral collateral ligaments of the ankle joint
m. Release the subtalar joint medially, laterally, and centrally (release the talocalcaneal interosseous ligament)
n. Finally, release the posterior ankle joint and subtalar joint capsules
o. Remove the talus from the operative field
p. Inset the calcaneus into the ankle joint mortis, moving it posteriorly until the navicular abuts the anteromedial aspect of the distal tibial epiphysis
q. Dorsiflex the calcaneus 5° to 10° from perpendicular to the tibia and insert a 0.062″ smooth Steinmann pin retrograde from the center of the heel pad up into the central canal of the tibial shaft
r. Bend the pin at the insertion site for easy retrieval in clinic
s. Resect a strip of excessively redundant skin from the wound edges if necessary
t. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
u. Apply a long-leg bent knee cast with 5° to 10° of ankle dorsiflexion and a neutral thigh–foot angle
v. Change to a fresh long-leg cast at 3 weeks
w. Change the cast again at 6 weeks, at which time the pin can be removed from the heel and a mold can be taken for a 5° to 10° dorsiflexed solid AFO
x. Apply a short-leg cast with 5° to 10° of ankle dorsiflexion and maintain it for 2 to 3 more weeks
y. Remove the cast at that time and replace it with the AFO
3. Pitfalls
a. Incomplete removal of the talus
4. Complications
a. Recurrence of equinus deformity
i. Avoid by:
• first, achieving full deformity correction with 5° to 10° of dorsiflexion held with a retrograde-inserted Steinmann pin
• maintaining deformity correction with full-time use (23 hours per day) of a dorsiflexed AFO
b. Incomplete removal of the talus
i. Avoid by carefully identifying the ankle and subtalar joints with the aid of a Freer elevator and mini-fluoroscopy