Full transcript
0:00Good morning, good afternoon, and good
0:01evening. Welcome all of you to this live
0:03program at Orthopetic Principles. Today
0:05our guest of honor is Dr. Annie Sue from
0:08New York, United States. Dr. Sue is a
0:10orthopedic surgeon specializing in foot
0:12and ankle surgery at the Westchester
0:13Medical Center, New York State. She's
0:15also a clinical assistant professor of
0:17orthopedic surgery at the New York
0:18Medical College. Dr. Sue did her
0:20undergraduate studies at Stanford
0:22University and received a master's
0:24degree in mechanical engineering. She
0:26then went to Cleveland Clinic, learned a
0:28college of medicine at Case Western
0:29Reserve University for her medical
0:31studies. She then completed her
0:33orthopedic surgery residency at the
0:35Columbia University and a foot and ankle
0:37fellowship at the New England Baptist
0:39Hospital. Sue is a member of the
0:41American Orthopetic Foot and Angle
0:42Society. He's candidate member for the
0:45American Academy of Orthopetic Surgeons,
0:47the Ruth Jackson Orthopic Society, and
0:49the Medical Society of the State of New
0:50York. Her clinical interests include
0:53foot and ankle reconstruction, total
0:54ankle replacement, ankle arthoscopy,
0:57minimally invasive foot and ankle
0:58surgery, and lower extremity trauma. So
1:01today, it's my great honor to introduce
1:03you to Dr. Annie Sue from New York,
1:06United States. Over to you, Annie.
1:10All right. Thank you for the
1:11introduction. Um, so today I'll be
1:13talking about cable kibble various foot
1:16deformity correction. And um to start
1:19off with a little bit of background um
1:21the definition of having a pascus
1:23deformity is really for me's angle with
1:26uh dorsy uh with a apex dorsal
1:29angulation but this actually having a
1:32elevated Mary's angle is commonly found
1:35in roughly about 24% of the population.
1:38And here's a clinical picture. You could
1:39see uh it's not just the cavis portion
1:42but also the hind foot is indeening a
1:44very notable various um alignment as
1:47well. So there's several ideology that
1:50can really um cause someone to have
1:53kibbo deformity and a large portion of
1:55this is a neurogenic ideology. So this
1:59can include polio, stroke, shakcomarie
2:02tooth, uh cerebral pulsey, Frederick's
2:05atexia, spinal cord lesion and SMA. For
2:08children, this is commonly a congenital
2:10and noted with um club foot and also
2:13arthriosis.
2:15uh for adult patients that does not have
2:17any underlying neurogenic causes, this
2:20can be an aftermath of some trauma
2:22including burns, compartment syndromes,
2:24crush injuries and very commonly with a
2:27Taylor's fracture malunion um as well as
2:30a paranal nerve injury or paranal tendon
2:32insufficiency.
2:34So um the patients usually are used to
2:38having these deformities and their
2:39complaint coming to the office is
2:41usually of the associated pathologies.
2:44Um so they complain of fenderalgia
2:46sesmoiditis. Um and commonly because
2:49they have been overloading their lateral
2:51ankle they they complain that their
2:54ankle is unstable is rolling in and they
2:57develop pain along the paranal tendon.
3:00Um patients also sometimes have fifth
3:02metatarsal stress fractures from
3:04overloading the lateral border of the
3:06foot. Um and also form these plantar um
3:09fifth metatarsal ulcerations as well. So
3:12if if this continues for a prolonged
3:15period of time, patients can eventually
3:16also develop medial compartment knee
3:19arthritis.
3:22So um just breaking this down into four
3:24main things. Why does cables happen? The
3:27biomechanics the paranal longus is very
3:31hyperactive. So what it does is
3:33essentially planter flex down your first
3:36metatarsal and alters a normal foot
3:39tribot weightbearing effect. So with the
3:42first ring now planter flex um your
3:44subtailor joint is now being pulled into
3:47a vary and then it locks into a fix of
3:50various hind foot deformity.
3:54So um you can see here that the um the
3:59clinical exam you can see what uh was
4:02termed by Manoli back in 1993 as the
4:04peekab-boo heel sign or if you look at
4:06the patient from the front you can see
4:08the heels peeking out immediately. Um
4:11and if you go behind the patient to look
4:14at the hind foot alignment, sometimes
4:15you have to be aware that their
4:17alignment sometimes can um appear to be
4:20neutral, but their subtailor joint is
4:22actually eververted to give that neutral
4:24appearance.
4:26Um the Coleman block test is a tried and
4:29true very um old test but very helpful
4:32because it help us differentiate the
4:34forefoot driven flexible deformity um
4:37where the correcting the forefoot can
4:40help uh neutralize the hind foot
4:42alignment as you see here on this middle
4:44image um versus uh a very fixed
4:48deformity where the hind foot remains
4:50locked in despite um having the block to
4:53correct the forefoot.
4:56So the clinically forfoot pathologist
4:59should also see patients with metatarsal
5:02adductus as well as foroot vgus.
5:06So um in addition to clinical assessment
5:09we also have x-rays to help us u to
5:12further diagnose the patient and I
5:14initially like to break them down to
5:15looking at the hind foot first and then
5:17looking at the midfoot. So the hind foot
5:20looking at the lateral X-ray for cable
5:22sparous deformity you have a increased
5:24calccanous pitch um and looking at the
5:28AP if you focus strictly over on the
5:31calccanous and the tis there's a
5:32decreased tail calccanial angulation
5:36and lastly and perhaps the most obvious
5:39uh sign is to look at the hair's axial
5:41view and you can see that the hind foot
5:44um measuring it the amount of angulation
5:47of the hind foot with respect to the
5:49axis uh of the tibial shaft and you can
5:52measure how much various angulation you
5:54have from this view. Now going back to
5:57our lateral view again you also want to
6:00uh focus on the midfoot as well. So the
6:03height of the nvicular can be noted to
6:06be very elevated with a high arch and
6:09this can also be assessed looking at a
6:11distance between the medial form. If you
6:14draw a uh line parallel to the um the
6:19floor and also comparing that to the one
6:21that touches the fifth metatarsal and
6:23measure the distance which is an
6:25assessment of how uh elevated the arch
6:28of the midfoot is and how um unbalanced
6:31um the medial lateral side of the
6:33forefoot is. Um the tail nvicular joint
6:37is never quite normal. It always have a
6:39slightly sublux appearance. So that be
6:42aware of those parody tailor
6:44abnormalities noted on your AP X-ray. So
6:49with all good uh orthopedic treatments,
6:52you know, as surgeon, we don't jump
6:54right to surgery. So we try conservative
6:56treatment first with gastro stretching.
6:58And for flexible deformities, sometimes
7:00they respond quite well to orthotics
7:03that are especially designed to address
7:05the deformity. So specifically, your
7:08orthotic need to have a lateral hind
7:10foot post. uh and very low arch um that
7:13helps kind of counter the uh hind foot
7:16vary deformity and the first metatarsal
7:19head usually is kind of shallowed out so
7:21there's a depression to allow for the uh
7:24planter flex first ray. So when all else
7:27fails the next thing we think about is
7:30how can we um fix our patient and help
7:33them surgically and there are quite a
7:35lot of factors to think about for
7:37pre-operative planning. So I'll go
7:39through them one by one but these are
7:41very u important because this is a very
7:44complex threedimensional correction um
7:46and it's often easy to miss one small
7:50portion or overlook uh one aspect of the
7:53correction. So first I I spend a while
7:56before talking about the coma block test
7:59because this truly kind of delineates
8:02your pathway of which um how how much
8:05bony work versus soft tissue work you
8:07really should do. So um not just in foot
8:09and ankle but in general when you have a
8:11flexible deformity you can focus more on
8:14your tendon transfer um whereas a very
8:17rigid and fixed deformity and you want
8:20to be a little bit more aggressive to
8:21have a more powerful osteotomy
8:24correction um or an arthodis correction.
8:28The second thing to think about is is
8:30are there any arthritic changes
8:32involved. So I start with the tibial
8:34tailor joint and look at the joint
8:36concurity to assess for any tailor tilt.
8:39Um and with the hind foot sometimes it's
8:42difficult to assess. So I would obtain
8:44CT to see if there's any um other
8:47pantailor joint arthritis uh involved.
8:50So if there is um arthritic changes,
8:53deformity is rigid and patient is
8:56symptomatic then I would jump to an
8:59arthroesis
9:01um to address those arthritic joints. So
9:03that could be either in the form of
9:05subtailor fusion for subtailor arthritis
9:08or triple arthodesis if you also have
9:10degenerative changes in the tailor
9:12nvicular joint and calccanial cuboid
9:15joint.
9:17Um the third question is is Achilles
9:19tendon tight? Do you have any aquinus
9:21contraure? And I would say about 99% of
9:23the time you do. And because if you
9:26think about the heel being in a vary
9:29position um once you want to straighten
9:31out into a neutral alignment, you
9:34inevitably have to have increased length
9:36in your Achilles tendon construct. So
9:39depending on how much of the uh the
9:42quinus contraction you have, you can
9:44either address this with gastromus
9:47recession versus Achilles lengthening.
9:51Um, and last but not least, you don't
9:53want to overlook any concurrent problem
9:55such as lateral ankle instability
9:57because these people presumably have had
10:00developed these deformities for quite
10:02some time especially for the chronic
10:04worsening deformities and they sometimes
10:07wear out their lateral ligament and that
10:09can be uh addressed with the rostrm.
10:14So I think the most important pearl and
10:16pitfall at this point before even going
10:18to surgery is to miss the neurologic
10:21workup because if your patient has an
10:23underlying neurologic cause for
10:25deformity, this can potentially be a
10:28progressive muscle imbalance. So um the
10:31if you do not realize this and rely only
10:34on soft tissue correction, the patient
10:37could uh redevelop the cable for
10:40deformity.
10:43So the next part I'll talk about the
10:45arsenal things we can use a little bit
10:47more in depth before I go on to sort of
10:49my own algorithm and what I do in the O.
10:52So the soft tissue correction for quinus
10:55contraction the main workhorse you think
10:57about are three things gastro recession
11:01perccutaneous Achilles tendon
11:02lengthening um and posterior release for
11:05the very extreme cases. So uh when your
11:08range of motion is um is limited but not
11:11extensively limited um and you can use
11:15the silver skull test to identify you
11:17have gastro tightness then a gastromus
11:20recession can be done. Um and when you
11:24have uh a greater aquinus contraction
11:27involving the Achilles then the
11:28traditional teachings to do a
11:30perccutaneous or open Achilles tendon
11:32lengthening. Um however keep in mind
11:35that you know sometimes you can have
11:36extensive amount of stiffness where your
11:38ankle does not dorsif flex beyond
11:40neutral um but the heel cord doesn't
11:43feel tight and think in this particular
11:45situation it happens with um residual um
11:49club foot deformities that was
11:51previously corrected or post-traumatic
11:54deformities. They can develop very
11:56extensive amount of posterior capsule um
11:59scarring. uh so a posterior capsule
12:02release um is needed and sometimes even
12:05an ankle joint debrisment is needed as
12:06well.
12:08The other things to keep in mind for
12:10soft tissue correction is breaking down
12:13the um cable various deformity into hind
12:16foot and forefoot portion. So the hind
12:18foot portion I think about the cable
12:20various foot being driven by a very
12:23strong inverter and very weak inverters.
12:27So um for me I focus more on the weak
12:30inverters because your pyrene is longest
12:33can be transferred to the breast to
12:35strengthen your weakened uh foot
12:37inverters to help bring the foot out
12:39from cable various deformity. Um
12:42similarly can also address things
12:45medially by weakening your posterior
12:47tibialis tendon either through
12:49lengthening or transferring it dorsally
12:51which I'll talk about a little bit more
12:53later. Um but that uh address that
12:56weakens the strong inverter to help
12:58balance the foot out more. Um for very
13:01severe neurogenic cases and for
13:04congenital cases oftentimes you have
13:06very severe claw toe deformity for your
13:09forefoot and this can be addressed with
13:12drones procedure. Um and for the lesser
13:14toes that a short short flexor releases
13:17may be performed.
13:20Now moving on to more severe rigid
13:22deformities, we have to use something
13:24that is a little bit more powerful in
13:27addition to soft tissue correction. So
13:30for mild to moderate fixed deformities
13:33um the main workhorse would be first
13:35metatarsal dorsif flexion osteotomy to
13:37elevate that planter flex first ray and
13:41also um to do a calccanial osteotomy
13:44which can be done in different flavors
13:46with lateral calccanial slide or a
13:49dwire's closing wedge osteotomy.
13:52Um sometimes even with these two
13:54combined this is simply not enough to
13:56really correct a severe deformity and a
13:58lateral column shortening may also be
14:00performed over the cuboid or the
14:03calccanial cuboid joint.
14:06So for severe deformities other things
14:08to think about uh for post-traumatic
14:11cable various deformities the u the the
14:14axis of rotation is really from a tailor
14:18Taylor's malunion and you can argue that
14:21the strongest and the most effective
14:23correction is abcora. So a tailor neck
14:26osteotomy um can correct the deformities
14:29caused by um very severe tailor
14:32malunion. A very for very high arch uh
14:36extensive severe um well deformities
14:41midfoot dorsal osteotomy wedges can also
14:44be performed as well. This is a much
14:46larger correction uh and a a much
14:49prolonged um recovery process but it
14:52again focuses on correcting things from
14:54their center of rotation.
14:57Um arthroesis portion I had previously
14:59mentioned when you have arthritis uh in
15:01the hind foot joint um and they are
15:03symptomatic instead of doing osteotoies
15:06the overall alignment can be correct
15:08through the joint while you are doing
15:10your arthritis.
15:13I want to emphasize that um before we
15:16dive into the foot, it's always
15:18important to get a standing ankle x-ray
15:20to see if you have any ankle various
15:22deformity because everything is all
15:24connected. So if your ankle is
15:26inversious, your whole foot will appear
15:28to be severe vary deformity. uh and you
15:31must consider a supermalular osteotomy
15:34with a lateral closing wedge first um
15:37before you can truly correct the uh the
15:40residual malignment of the foot.
15:45So next I'll talk about my or setup and
15:48some of the things I think about uh
15:50certain uh some of the workhorse uh
15:52steps that I talked about before that I
15:54use and don't use and as well as some of
15:56the um technical challenges that um I
16:00think it's important to keep in mind as
16:02you go through. So, a very typical foot
16:04and ankle setup in the OS to have the
16:06patient be supine on the bed, the feet
16:08at the end of the bed. Um, and a bump
16:10underneath the hip to help correct for
16:13the external rotation of the lower
16:14extremity. Um, I prep everything up high
16:17to the knee and the there's a tourniquet
16:20on the thigh. And depending on what is
16:23planned, I typically try to have a
16:25minimally invasive um uh surgical
16:28instrumentation, the MIS high-speed bur
16:31to make my osteotomy cuts. Um you can
16:34also do everything with a sagittal open
16:37um cut as well. Um, and I also use for
16:41gastric releases,
16:43um, I would use an endoscopic release as
16:45well. And those would be using as your
16:47standard knee arthoscopic
16:48instrumentation and have a mini C arm in
16:51my room so I can check check for overall
16:53alignment as you correct each step of
16:55the way.
16:58Um, I typically prefer to do bony work
17:01first as I was always taught that your
17:04structural change protects your soft
17:06tissue correction. However, the very
17:09first thing that is typically done is
17:12the Achilles tendon pathology to address
17:14this and that is pime primarily because
17:17this minimize the deforming force and
17:19allows you to have easier um calccenia
17:22asami and heel shift. So um so the first
17:26step for me for a cable vis deformity is
17:29to either do a gastro recession or to do
17:31a perccutaneous killes tendon
17:33lengthening. So you can see um this
17:36upper right picture. This is the
17:37standard mini open incision I would u
17:40make for a gast gastro nemas recession.
17:43Um if I have the instrumentation for a
17:45knee uh arthoscope
17:47uh setup then I would use um a
17:50endoscopic procedure where I have a
17:53sheath that slides right underneath the
17:56uh gastro fascia and you can visualize
17:59these pictures are from um Dr. Giovani's
18:01paper um talking about surgical
18:04techniques to endoscopic gastro
18:06recession where you can visually see
18:08where you're cutting with a small hook
18:09blade and avoid the um disrupting the
18:13sural nerve.
18:15So once the uh killes tendon lengthening
18:18is done or gastric recession is done
18:20next we can go back to uh focusing on
18:24bony correction. So I start from hind
18:26foot first um with the uh calccenius
18:30calccenial osteotomy and I include uh
18:33doer osteotomy um as the first thing to
18:36go over. Um so dyer osteotomy is very
18:40popular in the pediatric uh population
18:43or amongst our pediatric colleagues and
18:47what it is is taking out a lateral wedge
18:50um to correct the overall heel position.
18:52So you can see here this pink u
18:54triangular slice you're resecting a
18:57lateral wedge and then swinging the
18:59remaining calccanous over into a
19:01physiologic valgus position. Um and
19:04after the resection of the bone you
19:06simply have to dorsif flex the foot and
19:08this will close down and then you can uh
19:11fix this either with screws or pins from
19:14the calccanous.
19:15This is wildly done in children but very
19:18in recent years have not been so popular
19:21um for adult foot ankle surgeons
19:23primarily because this weakens the
19:25moment arm of the Achilles and adults uh
19:28do not accommodate for this change as
19:30easily as children do. Um so the
19:33preferred uh calccanial osteotomy at
19:36least for me is for a lateral displaced
19:38calccenial osteotomy. Um and this can be
19:41done open with the sagittal saw. Um or
19:45it can be done with a small um MIS
19:48high-speed bur where through a small
19:51poke hole um the calccanous can be sort
19:54of schematically divided into four
19:55quadrants in your head and the
19:57high-speed bur can be trimming away the
20:00calccanous to create the cut. Um but no
20:03matter how you do your cut, you
20:05essentially have to fix it still. So you
20:07would shift this um calccanous laterally
20:11and for me sometimes if the quinus is
20:13severe enough um I sometimes shift it a
20:16little bit superiorly as well um and
20:18before placing my calccenial screw for
20:21fixation.
20:22One of the technical challenges um of
20:25curls here is that almost always it's
20:27easy to place your screw too lateral
20:30because you are holding the heel with
20:32one hand in the correction and the
20:34tendencies to aim the screw in the
20:36center of the heel. You have to remember
20:39you have to angle it slightly medially
20:41because you can um come out distally
20:44with your lateral shift and this can be
20:47prevented again with adequate amount of
20:49intraoperative um uh imaging to confirm
20:52your alignment.
20:55Um the next part um of the procedure I
20:59typically go to the next um bony work
21:01which would be addressing the first
21:03metatarsal planter flexion. So um in
21:06order to correct the planer flexion
21:08essentially it sounds very
21:10straightforward we are elevating and
21:11dorsif flexing the first ray. So um a
21:14dorsal incision is made over the
21:17proximal first metatarsal and after
21:20retracting the extensors laterally then
21:23you can dissect down uh onto the bone.
21:25Do your perostial dissection. Measure
21:28approximately about 1 cm distal from the
21:32toarsal metatarsal joint and this can
21:34vary based on your choice of fixation
21:36plates versus screws. Um and a dorsal
21:40wedge is removed to elevate the first
21:42ray and they can have you can confirm
21:45checking a weightbearing or simulated
21:48weight bearing position in the O if is
21:51now an even correction. Now this is a
21:54very small bone and sounds very easy but
21:57there are a lot of things that can go
21:59wrong. Um the uh think about um hix vgus
22:05and uh first metatarsal alignment. So uh
22:09subtle changes sometimes can have a a
22:11big effect downstream for the patient.
22:14So do not want to change the rotation or
22:16shorten the first metatarsal too much
22:19with your dorsif flexion osteotomy.
22:22And the way to really minimize or
22:24prevent these from happening is to
22:26ensure that your cut is exactly
22:28perpendicular to the shaft. So you're
22:30not creating new angles and um changing
22:34your first metatarsal in a different
22:36axis. Um, I typically do my first cut
22:40all the 90 degrees, uh, 90% almost all
22:43the way through, leaving a planter
22:45hinge. Uh, and then I, uh, go about
22:48three or four, um, millimeters distally
22:52to create a second cut that's aiming
22:54toward the first cut. So, you can close
22:56it down like a book, and it won't um,
22:59you won't be changing the rotation too
23:01much because you have a intact planter
23:03hinge to help you with the correction.
23:07Um the other thing um here is to notice
23:10is that um it is common to undercorrect
23:15for the first uh um to under under uh
23:19perform your dual flexction osteotomy.
23:21Um you will see this with my own
23:23personal examples later. It's very easy
23:26um to see to think that your um
23:30correction is enough when actually more
23:32can be done. And the way to really check
23:35that is to um to take a flat surface. So
23:40sometimes take the instrumentation tray,
23:41a clear radolucent surface to pretend
23:44and press down on the foot so you can
23:46get a better idea of what a
23:48weightbearing um x-ray is for your
23:51correction. And that way it can give you
23:52a more real life correction of um um
23:56correlation of how overcorrected or
23:59undercorrected you are. Essentially a
24:02overcorrection is a very rare thing to
24:04do because the wedge would have to be
24:05extremely large.
24:08So um at this point um I went back to
24:13soft tissue here because um usually by
24:17the time after calccio osteotomy and
24:20first metatarsal osteotomy the overall
24:23alignment of the foot would be more or
24:25less within the ballpark of an
24:27acceptable range. If that is not true
24:29for a very severe deformity, you would
24:32need to think about adding a lateral
24:34column shortening. Although there's
24:36significant amount of papers written on
24:38lateral column shortening, it's also
24:41been proven that it you are trading in
24:44these uh subtle change with significant
24:47amount of stiffness for patients. Um so
24:49I try to avoid latter column shortening
24:52um if I can. But it is definitely a
24:54useful tool um if you your bony
24:57correction is undercorrected.
25:00Um going back um now to the hind foot
25:04again uh your paraneous longus can be
25:07transferred to the breast to help um
25:09strengthen your verters. Um if you are
25:11doing an open uh calccanial osteotomy
25:15you can use the same incision and one
25:18incision you make is basically
25:20um cheating in between the paraneous and
25:22the calccanous. So making an incision
25:24that's parallel to the paraneous longus
25:27uh but slightly inferior um and that way
25:30you can address your calccanous and your
25:31paraneous tendon. Here you can see the
25:34uh superficial paranal retinacculum that
25:37is intact and uh this portion can be
25:40done by keeping the retinacculum intact
25:42but sometimes you could see paranal
25:45tendon pathology and need to really um
25:48have better sense of evaluating this. So
25:51um at times I would peel off the super
25:54uh superior peracculum from the
25:56posterior part of the fibula
25:59um and um to do my uh tendonous work to
26:02really assess the perinius longus um
26:05remove the degenerative portion and
26:08suture it back um reapproximately into
26:11the brevis uh with o nonresorbable
26:14suture um I will repair the superficial
26:18paranal right tech back to the fibula if
26:21I did end up um peeling it off. Um it's
26:25important here to point out that u this
26:29uh repair over here can be a little bit
26:30bulky. So it's important to test it
26:33before you close your wound uh to ensure
26:35that there's no tightness or impingement
26:38as it travels uh underneath the
26:40ratinaculum.
26:44So part five here I wrote plus and minus
26:47partial planter fasciottomy um because
26:50this is uh very commonly written about
26:53and is certainly a uh a test answer for
26:58a lot of standardized exams but this is
27:00not something that is done um
27:05very commonly or with a light heart I
27:08should say because there uh because it
27:10is a um a very risky procedure to be
27:15done and it can have potentially very
27:17negative uh complications and outcome.
27:20So partial planter fascia uh fasciottomy
27:23can help lower um correct your high arch
27:26deformity after you've done all of the
27:29previous mentioned bony work and soft
27:31tissue releases. It can be done open or
27:34can be done endoscopically.
27:36essentially need to have an incision
27:38that's parallel to the planter heel and
27:41you can identify the medial border um
27:44and transsect about 1 cm from the origin
27:47of the calccanous. Um however uh the
27:50medial calccanial branch of the tibial
27:52nerve is really directly in your
27:54pathway. it's very hard to avoid them
27:57and it's also easy to um affect the
28:00intrinsic muscle in the planter
28:02compartment of the foot um with this
28:04incision
28:06and uh the worst uh complication that
28:08can happen um is that uh patients can
28:12eventually have very weakened planter
28:14fascia develop planter fascia rupture um
28:17and which can be progressively followed
28:20by arch collapse. So um because of this
28:23this is not in in my book I would have
28:25to have a very severe deformity need to
28:28contemplate um adding this on to uh my
28:31um to-do list in the O.
28:36Um Jones procedure is commonly done in
28:38children um or in patients with very
28:41severe neurogenic uh kibble various
28:43deformity. Um the great toe has this
28:45clawed deformity which you can see on
28:48these two clinical pictures here.
28:51So essentially you can make a transverse
28:54incision over the interfallenial joint.
28:56Um excise the EHL tendon your arthrotomy
29:01then going and prepare the surface
29:02curette out the u cartilage um drill the
29:06uh surfaces to penetrate the bone um
29:09before using a kwire to pin across the
29:13um the IP joint. And I typically do do
29:16this by doing this um antigrate um
29:19through the distal fins and then um
29:22closing the um IP joint and then
29:24retrograding the Kwire in place um with
29:28a satisfactory Kwire position. Then I
29:30can replace it with a canulated uh for
29:34partially threaded screw.
29:36Um in terms of the uh tendonous work
29:38with the EHL, I would extend the uh
29:42previous dorsal um uh incision that I
29:45have with my dorsif flexion osteotomy a
29:49little bit distally. Um and then I can
29:52harvest pull back my EHL. Um, and then
29:56drill around the metatarsal neck with a
29:59small 40 millimeter drill both medially
30:01and laterally. And then take my tendon,
30:04loop it from lateral to medial um to
30:06kind of fix the first array down in a
30:09slightly dorsy flex position.
30:11The lesser toes usually are uh not
30:14significant in terms of prominence. Um
30:18so I I do not automatically correct them
30:21because patients tend to uh not have
30:24complaints about them. Although for very
30:26severe and a lot of um um high um
30:30hammertoe corrections, claw toe
30:32corrections, they can certainly be
30:33corrected with flexor tendon tenat.
30:38So additional procedures that I don't
30:40automatically do but I do keep in the
30:41back of my mind if I if needed is I had
30:45previously mentioned the lateral column
30:46shortening which um I want to emphasize
30:49that that is typically done after medial
30:52tail nvicular uh release um because
30:55you're going to have tightened capsule
30:57medially that is preventing your
30:59correction from um from uh from being
31:04realized. So um soft tissue first and
31:07then if that's underpowered during a
31:09lateral column shortening um posterior
31:11table tendon can either be lengthened or
31:13transferred and typically a transfer
31:16onto the lateral cune form um is better.
31:19Um so you can see the posterior tibial
31:23tendon is being harvested on this
31:24picture and then this incision is right
31:27over the lateral cune form and the
31:30harvested posterior tibial tendon um is
31:33seated onto into the lateral form with
31:36interfering screw.
31:38um we are re redirecting the um
31:43mechanical axis um of the posterior
31:45tibial tendon so it no longer acts um as
31:48a very strong inverter. And then lastly
31:51with things corrected you want to check
31:53to see how loose the lateral ligaments
31:55are intraoperatively
31:57because if they are loose
31:58intraoperatively they likely will
32:00continue to be loose after your entire
32:02correction um has healed. Um so you can
32:07um address the lateral ligament laxity
32:10with a repair intraoperatively.
32:13So um with this in mind um after this
32:17their surgery then I typically put them
32:20in a short leg splint for two to three
32:22weeks and they come back for suture
32:24removal and I cast them for three more
32:26weeks. Um by week six they usually come
32:29out of the cast and then put them in a
32:31boot with partial heel down weight
32:33bearing and they can start physical
32:35therapy to gradually advance to weight
32:37bearing in the boot. They can start to
32:39look to work on ankle range of motion
32:41starting with dorsif flexion planter
32:43flexion and by week 10 or 11 they're
32:45full weight bearing in the boot working
32:48on their gate training ankle range of
32:50motion and by week 12 they should be out
32:52of the boot into well supported shoes.
32:55Usually they're not back to sports
32:56activity yet until another uh at least
32:59another month of physical therapy.
33:04So um I have two if we have enough time
33:06I have two um cases um to present. Um
33:11these are two of my cases and you can
33:14see some of the uh challenges and things
33:16that are somewhat undercorrected as
33:18well. So this is a 22-year-old woman
33:21that uh came in with lateral foot pain.
33:25um four years ago she um had a very
33:28significant trauma. She fell from a
33:30cliff and had multiple poly trauma
33:33pelvis fracture and along with those
33:35bilateral tailis fracture and calccanous
33:37fracture sorry right calccanous fracture
33:40but she's coming in to complain about
33:43her left foot because everything else
33:45has somewhat healed. Um, she's now
33:47developed a very painful planter ulcer
33:50underneath the fifth minotaural head and
33:52she's as she said her foot will roll out
33:55under her. She has a hard time walking
33:58and um her pain is predominantly over
34:00the planter aspect of the ulcer. So you
34:04can see on her AP X-ray, she has her
34:06tailis um fixed with the intact implant
34:10in there and the medial column is a
34:13little bit shortened um from the
34:15tailless mal union.
34:18Um and on clinical exam could see that
34:21when she stands her um lateral uh um
34:26column is bearing the majority of her
34:28weight and her first ray is hardly
34:30touching the ground. And you can kind of
34:32get a sense of that from her lateral
34:33X-ray here as well. She has about a 4cm
34:36large callus over the fifth metatarsal
34:38head that's very painful. And her
34:41aversion is weak, four out of five. And
34:43she has focal tenderness also along the
34:46panal tendon in zone three. Um she does
34:49have some subtailor joint um passive
34:51range of motion on exam. Um and you can
34:54see that um this her overall alignment
34:57of the um uh hind foot she does have
35:01hind foot vary deformity as well as a
35:04high arch.
35:08So um her diagnosis she has the cable
35:11vary deformity predominantly from
35:13Taylor's malunion and now also has
35:16plantar ulceration as well. um I didn't
35:19um her ankle uh is is does not have any
35:23various deformity.
35:25So the surgical plan for her was to do
35:28first a perccutaneous Achilles tendon
35:30lengthening and then this is followed by
35:33for me um a minimally invasive lateral
35:36calccanial osteotomy. Um and with the
35:39calccanous fixed in a better alignment
35:42um then I would focus on first
35:43metatarsal dorsif flexion osteotomy.
35:46Then I go back to um to strengthen her
35:49e-verters from par uh tag tagging the
35:52paranal longest to brevis. Um and
35:55intraoperatively I examine her
35:56afterward. She still has significant
35:58lateral ligament um laxity. So a a
36:02brastrm was um performed.
36:06So this is her 3 weeks posttop. You can
36:09see with the calccano osteotomy I
36:11shifted a little bit superiorly as well.
36:13Um, and her um overall uh hind foot
36:18alignment is much straighter now. Um,
36:21and I used a uh a dorsal plate as well
36:26as a nalo staple to help compression
36:29across the metatarsal um osteotomy.
36:33And three months later, she's now
36:35walking and able to run. uh she does not
36:38have any pain and she her ulcer I did
36:41not do anything to address the ulcer but
36:43just by merely offloading and the ulcer
36:45is now gone. Um you can see from the
36:47lateral weightbearing X-ray though that
36:49the dorsif flexion osteotomy could have
36:52been done more because the first rate is
36:54still slightly um uh is is still not
36:58slightly even. Um the uh osteotomy is
37:01now well healed. Um and uh some for some
37:06people the um dorsal plate can be
37:08removed for younger patients. Um but
37:10this patient is is happy and does not
37:13want to um have any more surgery for
37:15this particular foot.
37:17Now the second case that I picked out to
37:19present is um also another young patient
37:22but is is in a slightly different uh in
37:26that u this patient has developed uh
37:30substantial post-traumatic arthritis. So
37:32she's a 27year-old poly trauma patient
37:34after MV MVA and um she had left
37:38calccanous and Taylor's fractury treated
37:41um with open reduction internal fixation
37:43two years ago and now she's coming back
37:46saying she has difficulty walking her
37:48foots rolling and um she has lateral
37:51foot pain as well. So on exam she also
37:54has left hind foot vary and a cable vary
37:57um deformity.
37:59Um and she also has tenderness along the
38:02um the sinus sinus tors as well as along
38:06the tailor nvicular joint and the
38:08calccanial cuboid joint. This particular
38:11patient she has very rigid hind foot um
38:13just no motion at all in the subtailor
38:16and the transverse uh toarsal joints.
38:19So here again you can see she has a very
38:21high arch. Ella you can see uh
38:23overloading the lateral um border of the
38:27foot and you can also see extensive
38:30amount of arthritic changes in the hind
38:32foot which is better visualized um on CT
38:35as well. This is her um Harris view of
38:40axial alignment and her vary deformity
38:43is about 20° on X-ray.
38:46So you can see she has the tailis and
38:48calccanous malunion that substantial
38:50substantially shortened her medial
38:53column and she also now has developed
38:55rigid cable deformity with
38:58post-traumatic arthritis in her
38:59subtailor her tail invicular and
39:02calccanial cuboid joint. So um and she
39:05also has aquinus contraure clinically as
39:08well. Um so in order to address all of
39:11this um we uh performed an endoscopic
39:14strayer procedure to address herinous
39:17contraure remove the uh prior hardware
39:21and then perform a triple arthis to
39:24correct the overall alignment. Um even
39:26with the triple arthodsis um her first
39:29metatarsal um was still planner flex and
39:32a first metatarsal dorsif flexion
39:35osteotomy was performed.
39:38So this is her posttop X-ray. Um you
39:41will see um first and foremost on the
39:44right that her alignment is now
39:46straight. She has a new set of hardware
39:48and quite a lot around her first and
39:50second metatarsal. Um this happened um
39:54because she had very osteopenic bone and
39:57as we were doing the dorsy flexion
39:59osteotomy um she sustained an
40:02intraoperative metatarsal fracture. Um
40:05so in order to address the fracture a uh
40:08a dual plating a medial plate was placed
40:11and the first metatarsal was also um
40:14corrected and fixed onto the base of the
40:16secondaril.
40:18So the patient um has fused across um
40:21her triple fusion um and uh the align uh
40:25overall alignment is better. She's more
40:28stable. she's no longer um overloading
40:30her lateral ray uh and her pain has been
40:34resolved now 3 months after surgery.
40:38Um okay, so those are the two different
40:40variants to address kver deformity. Um
40:43these are some of my resources from the
40:45talk
40:47and I'll be happy to take any questions.
40:51Thank you Annie for that excellent
40:53presentation. You've almost covered the
40:55entire gamut of uh cavas uh feet
40:58reconstructions.
40:59A couple of questions. Any what do you
41:02think is the role for a midfoot dorsal
41:04wedge osteotomy? The one described by
41:06Japas for example if you have the entire
41:09medial as well as lateral elevated. Do
41:13you think uh midoot osteotomy is better?
41:18Um I do think midfoot osteotomy is
41:20better um for very for the deforming
41:23that you were describing um primarily
41:26because that is the that is the center
41:28of rotation as opposed to correcting
41:31your inversion and everversion hind foot
41:33and forefoot which you're really working
41:36around the um the the center focal
41:39problem. A midfoot osteotomy is better
41:43from a mechanical standpoint, but um I
41:46I'm not sure that it is necessarily
41:48better from a patient outcome standpoint
41:51because uh patients after midfoot
41:53osteotomy almost always have very severe
41:56rigid foot and um and because to fix the
42:00osteotomy have to fuse through so many
42:02um hind foot and midfoot joints that
42:05they are left with um higher risk of
42:07developing um you know adjacent joint
42:10arthritic changes.
42:12Thank you honey for that. And do you
42:14always do an electromyiography before
42:17you do any reconstruction for a
42:18cavoera's foot because of the
42:20possibility of an underlying
42:21neurological disease like shakomary
42:23tooth?
42:25Um I do if if a patient has a um a a
42:30known cause like a known trauma I don't
42:32necessarily do that but um for patients
42:36that does not have uh you know it's it's
42:39something that's concerning then I do
42:40and I always um I do a very careful exam
42:44and I ask them about family history. I
42:46think if there's any slight suspicion, I
42:49would send them to get evaluated to rule
42:51out a neurologic um workup.
42:55Thank you for that. And what do you
42:57think is the possibility of getting a
42:58cavoirus feet after club foot while you
43:01treat patients or kids with club foot?
43:04Do they of end up with a complication
43:06like for example while they get a
43:07relapse do they get cavoas feet?
43:11they do and I think they're different uh
43:14club feet has uh depending on different
43:17parts of the country sometime being uh
43:19sometimes are caught at different stages
43:22um so it's very common to see keo
43:24various um deformity but uh usually for
43:28these young adolescents kids um they
43:32they the beauty of correcting them is
43:35that um you may need to do one you know
43:38calccanial osteotomy but the rest can
43:40really be predominantly done by soft
43:41tissue um transfer and children adapt to
43:45them very well. So um you don't hardly
43:48ever need to do a significant amount of
43:50bony work um for children with residual
43:53club foot deformities.
43:55Thank you Annie for that. Just one last
43:57question before we wind up the session.
43:59What do you think is the role for an
44:00illero type of construct for managing
44:02these complex deformities?
44:05Oh, I think um anytime you have a ring
44:08construct for correction um is is
44:10typically great because then you can do
44:13a very large scale correction but it's
44:16typically not needed unless you're
44:18changing a significant amount of length.
44:20So for instance when you do a midfoot
44:22osteotomy um a large correction um then
44:26doing a ring construct would be very
44:28helpful. If you're doing a supermalular
44:30osteotomy having with um a significant
44:33amount of um you know closing wedge
44:36length difference then a ring construct
44:39would be good. Um realistically to have
44:42someone with a ring construct and to
44:44have them come back and have the medical
44:46access to come to your office every week
44:49or every other week sometimes is very
44:51challenging for patients. So um I think
44:54the ring construct is great in theory
44:57and for a certain uh type of population,
45:00a certain type of environment, but not
45:03every patient is uh perhaps ideal for
45:06that. So, um, if I find patients that
45:09need, um, a ring construct, I would tell
45:12them they're at a higher risk of, you
45:13know, surgical complications, um, you
45:16know, for infections and and it's a
45:19general generally on the patient's end a
45:21much more difficult, um, recovery
45:23process, but they can have a very, um,
45:26good and solid, you know, um, mechan
45:30like medical their correction,
45:32mechanical correction.
45:35Thank you Annie for the uh Annie would
45:36you mind stop sharing your screen
45:38actually there's
45:40actually forgot to tell about yeah
45:42thanks
45:42Annie I think that's all the questions
45:44that we have for this session fantastic
45:46lecture and I'm sure this lecture is
45:47going to benefit a lot of people all
45:49over the world thank you so much for
45:50joining in Annie
45:52no problem thank you for inviting