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Z-Osteotomy for Varus Heel

Indications Rigid varus hindfoot deformity Indications Pitfalls If an underlying neurologic disease is suspected, a neurologic assessment should be considered before surgery is performed. Indications Controversies Consider a dorsiflexion osteotomy of the metatarsal if the hindfoot varus is due to the plantar flexed first ray. Consider peroneus longus to brevis transfer in case of an excessively pronated forefoot. Examination/Imaging Analyze the patient’s gait and assess the…

Cavovarus Correction in Charcot-Marie-Tooth Disease

Pitfalls Charcot-Marie-Tooth (CMT) disease includes a wide spectrum of hereditary motor and sensory neuropathies. These diseases are often progressive, which can compromise the long-term results of a surgical reconstruction. The feet of older adolescents and adults usually require simultaneous osteotomies, tendon transfers, and soft-tissue balancing. Young adolescents and children may benefit from soft-tissue procedures alone, especially in the early stages of the disease. Indications Chronic pain…

Lateral Calcaneal Lengthening Osteotomy for Supple Adult Flatfoot

Indications Posterior tibial tendon insufficiency (PTTI), stage II to stage II–III Medial ankle instability Both must be accompanied by supple pes planovalgus et abductus deformity with forefoot supination and subfibular impingement, and preserved subtalar and talonavicular joints Indications Pitfalls Calcaneal lengthening osteotomy is not indicated in cases of: Rigid pes planovalgus et abductus deformity (PTTI stage III or IV) Osteoarthritis of the subtalar and/or Chopart joints…

The Z-Shaped Elongating and Varisizing Osteotomy (ZEVO) Calcaneal Osteotomy for Pes Plano Abducto Valgus

Indications Alternative to double osteotomy in acquired flatfoot deformity (AFFD) When a combination of lengthening of anterior process and medial shift of tuber is indicated (usually in case of dorsolateral peritalar subluxation on weight-bearing radiographs) When deformity is still reducible/flexible Indications Pearls Avoids the need for bone graft and keeps segments of calcaneus in line Indications Pitfalls In a nonflexible foot this is not an appropriate…

Spring Ligament Repair With Suture Tape Augmentation

Indications Flatfoot undergoing concomitant posterior tibial tendon (PTT) reconstruction with torn spring ligament Sag at the level of the talonavicular joint As an adjunct to medial column osteotomy and lateral column lengthening (if indicated) Indications Pitfalls Concurrent navicular–cuneiform joint laxity or sag A very significantly exposed talar head Indications Controversies Any requirement for lateral column lengthening Long-term efficacy and retention of correction Examination/Imaging Obtain anteroposterior (AP),…

Posterior Tibial Tendon Dysfunction

Indications Patient must first fail nonoperative measures for a minimum of at least 3–6 months. Stage I includes tenosynovitis without deformity that has been refractory to conservative treatment. Stages II–IV includes painful deformity with medial and/or lateral foot pain. Lateral pain is classically subfibular impingement as the valgus hindfoot compresses the lateral structures. Note that in the later stages of disease, the patient may no longer…

Painful Accessory Navicular Treated With Fusion of the Synchondrosis

Indications Painful type II accessory navicular Failure of conservative care Indications Pitfalls The accessory navicular has to be of sufficient size to accept a screw without fragmentation. If increased heel valgus has developed on the symptomatic side, a calcaneal osteotomy should be added to the procedure. Indications Controversies A high rate of failure has been reported after simple excision of a large type II accessory navicular,…

Painful Accessory Navicular: Augmented Kidner Procedure With Flexor Digitorum Longus Transfer

Indications Presence of a painful accessory navicular with or without flatfoot. Often associated with equinus contracture as well. Posterior tibial tendon function is usually intact but may be weakened secondary to pain. The enlarged area of the medial hindfoot may also cause problems with regular footwear and footwear for sports activities, such as ski boots. Treatment Options Initial treatment can consist of immobilization of the foot…

Charcot Neuroarthropathy of the Midfoot

Charcot Neuroarthropathy Definition Charcot described neuroarthropathic arthropathy typically due to syphilis in the late 1880s. Although most current cases are due to diabetes, 20–30% of cases occur as a result of other neuropathic conditions: alcohol neuropathy, rheumatologic neuropathy, hereditary neuropathy, steroid-induced neuropathy, spinal injury, spinal tumor, spina bifida (syringomyelia), and many coexisting conditions. Refers to aggressive destruction of the bones and joints as a result of…

Mueller-Weiss Treated With Pan-Navicular Fusion

Indications Chronic midfoot pain that has failed orthotic treatment Advanced Mueller-Weiss disease with pain or deformity Fragmentation of the navicular Peri-navicular arthritis Indications Controversies Talonavicular-cuneiform arthritis requires a fusion of all of these joints Charcot neuroarthropathy Examination/Imaging Is the patient suffering from arthritic joints, deformity, or both? Evaluate hindfoot and midfoot alignment. In advanced cases of Mueller-Weiss disease, there can be pes planus and hindfoot varus,…

Mueller-Weiss Treated With Limited Fusion

Indications Advanced stage of Mueller-Weiss syndrome ( Fig. 25.1 ) with Symptomatic osteoarthritis Progressive destabilization of the foot Secondary peritalar and midfoot pain due to tarsal destabilization Loss of neutral foot position that cannot be compensated by shoe modifications Indications Pitfalls Charcot neuroarthropathy Fusion of the talonavicular joint in a not-aligned position Indications Controversies Crucial for success, e.g., to obtain a plantigrade and stable foot, are…

Open Reduction and Internal Fixation of Proximal Fifth Metatarsal (Jones or Stress) Fracture

Indications Fracture in zone II or III of the proximal fifth metatarsal (5MT; Fig. 24.1 ) Acute fracture in an athlete Delayed union Indications Pitfalls Varus hindfoot alignment maintaining a continued risk to 5MT overload. Treatment Options Nonoperative treatment with casting, protected weight bearing Intramedullary screw fixation External bone stimulation Tension band technique/plating Examination/Imaging Tenderness at the base of the 5MT Hindfoot alignment Radiographs demonstrating fracture…

Open Reduction and Internal Fixation of Navicular and Cuboid Fractures

Indications Injuries to the talonavicular and calcaneocuboid joints (Chopart joints) are severe injuries often associated with an abduction force to the talonavicular joint and a lateral compression injury to the lateral column resulting in a “nutcracker” phenomenon. Precise examination and imaging, including computed tomography scan, are essential to defining the injury pattern and presence of articular incongruity. Articular subluxation and step-off, loss of lateral column length,…

Open Reduction and Internal Fixation of Lisfranc/Tarsometatarsal Injuries

Indications Lisfranc/tarsometatarsal (TMT) injuries with instability and displacement Indications Pitfalls Displaced injuries lead to midfoot arthritis and often require later reconstruction with midfoot fusion. Indications Controversies ORIF versus immediate fusion. In the cervical spine, if one is treating a purely ligamentous C1–C2 injury, immediate fusion would be advocated. Similarly, purely ligamentous injuries to the midfoot are treated with immediate fusion. Conversely, fractures/avulsions will heal better when…

Internal Fixation of the Sesamoid Bone of the Hallux

Indications Symptomatic acute sesamoid fracture, fracture-delayed union or nonunion, and congenital bipartite sesamoid bone after failure of conservative treatment for at least 6–8 weeks Acute sesamoid bone fracture or disruption of the synchondrosis between the sesamoid fragments of a bipartite sesamoid with a displacement >5 mm Indications Pitfalls Differential diagnosis of sesamoid pathology: Capsular tear (first metatarsophalangeal joint) Flexor hallucis longus and brevis tendinitis Entrapment of…

Metatarsal Lengthening

Indications Relatively short metatarsal (brachymetatarsia; Fig. 20.1 ) Overload/transfer metatarsalgia to an adjacent metatarsal head Short first metatarsal (1MT) following corrective surgery for hallux valgus Indications Pitfalls Contraindicated for a dorsiflexion malunion of the 1MT, unless an adjunctive procedure can be performed to plantar flex the first ray. Contraindicated in patients noncompliant with a protective weight-bearing status, pin care, and proper distraction (metatarsal lengthening) protocol. Controversies…

Revision Surgery Through a Plantar Approach for Recurrent Interdigital Neuroma

Indications Recurrent or persistent pain in the intermetatarsal space following excision of a Morton neuroma Exclusion of other sources of forefoot pain Transient relief from a focal injection of lidocaine Indications Pitfalls The incidence of continued forefoot pain after primary interdigital neuroma excision is approximately 10%. Determining if the pain is from an inadequate excision, a recurrent neuroma, or another undiagnosed condition. Treatment Options One cortisone…

Morton Neuroma

Indications Excision of a Morton or interdigital neuroma is indicated for neuritic forefoot pain not responsive to conservative means of treatment. A Morton neuroma: Is more common in women Is usually footwear related Is most common in the third web space Is less common in the second web space Indications Pitfalls It is important not to confuse symptoms of second or third metatarsophalangeal joint synovitis/metatarsalgia/plantar plate…

Plantar Plate Repair for Subluxed Metatarsophalangeal Joint

Indications Lesser metatarsophalangeal (MTP) joint instability with toe deformity and metatarsalgia Plantar plate rupture Subluxated lesser MTP joint Indications Pitfalls Lesser MTP joint instability is a new concept that addresses all the components behind the old concept of “crossover toe.” The toe can present subtle or gross instability with different tears of the plantar plate. Indications Controversies There are no comparative studies between the different treatments…

Plantar Plate Repair of the First Metatarsophalangeal Joint (Turf Toe)

Capsular-ligamentous injuries of the first metatarsophalangeal (MTP) joint are caused by sudden hyperextension of the joint while playing sports or during motor vehicles accidents, as well as when falling from a height. Traditionally, stretching and partial tears are managed by conservative treatments, whereas totally detached and avulsion fractures are treated using surgical intervention. However, there is a controversial dilemma of treatment on athlete’s moderate instability. Indications…