Operative Technique

A and B, Two longitudinal skin incisions are made. The medial incision, approximately 5 cm long, is made over the medial aspect of the navicular and first cuneiform bones in the interval between the anterior tibial and posterior tibial tendons. The subcutaneous tissue is divided. The anterior tibial tendon is retracted dorsally; the posterior tibial tendon is partially detached from the tuberosity of the navicular and retracted plantarward to expose the medial and dorsal aspects of the navicular and first cuneiform bones. The dorsolateral incision, approximately 4 cm long, is centered over the cuboid bone. The extensor brevis muscle is identified, elevated, and retracted distally and laterally with the peroneus brevis tendon. The long toe extensors are retracted medially.

C, Next, through the medial wound, the capsule and periosteum of the navicular and first cuneiform bones are incised and elevated. The soft tissues are retracted dorsally and plantarward with Chandler elevator retractors. The capsule of the talonavicular joint should not be disturbed. If in doubt, the surgeon should obtain radiographs to identify the tarsal bones with certainty.

D and E, With osteotomes, a wedge of bone is excised, including the naviculocuneiform articulation. The base of the wedge is dorsal, its width depends on the severity of the forefoot equinus deformity to be corrected. The wedge osteotomy of the cuboid is completed through the dorsolateral incision.

F, The forefoot is then manipulated into dorsiflexion. If the plantar fascia is contracted, a plantar fasciotomy is performed. In severe cases the short plantar muscles are also sectioned. The first cuneiform bone should be dorsally displaced over the navicular bone. Two Steinmann pins are inserted to transfix the tarsal osteotomy. The medial pin is inserted into the shaft of the first metatarsal and directed posteriorly through the first cuneiform, across the osteotomy site, and into the navicular and head of the talus. The lateral pin is started posteriorly along the longitudinal axis of the calcaneus and directed across the calcaneocuboid joint and into the cuboid and base of the fifth metatarsal. (Meary uses staples to maintain the position of the osteotomy.) Radiographs are obtained to verify the position of the pins and maintenance of correction of the forefoot equinus deformity. The tourniquet is released, and complete hemostasis is obtained. The incisions are closed. The pins are cut subcutaneously, and a below-knee cast is applied.