Surgical Treatments

Surgical Treatments

Khushdeep S. Vig

Andrew J. Rosenbaum


The majority of foot and ankle conditions in children can be successfully treated nonoperatively, but surgical intervention has its role in treating certain painful conditions that fail nonoperative management. The following will be a brief overview of the surgical management of accessory navicular, tarsal coalition, flexible pediatric flatfoot, and Freiberg infraction.

An accessory navicular can cause medial midfoot pain and flexible pes planovalgus deformity and is typically treated with immobilization and anti-inflammatory medication.1,2 Surgical treatment involves excision of the accessory ossicle with a side to side repair of the tibialis posterior tendon, also known as the modified-Kidner procedure.3,4,5 If resection of the navicular disrupts the tibialis posterior, insertion requires reattachment with suture anchors which can occur with large type 2 and type 3 deformities.

Tarsal coalitions are caused by failure of segmentation and can occur in isolation or as a constellation of a genetic syndrome.6,7 The transition of the abnormal tissue from fibrous to cartilage to bone parallels maturation and surgical management involves excision. Calcaneonavicular coalitions are excised via the sinus tarsi approach and full hindfoot motion should be achieved intraoperatively. The extensor digitorum brevis muscle belly and fascia or fat graft can be advanced and interposed into the excision site.8 Talocalcaneal coalitions can be addressed via excision, osteotomy without excision, or an arthrodesis. Resection is classically indicated for a size less than 50% of the posterior facet and hindfoot valgus less than 21° and minimal narrowing of the subtalar joint at the posterior facet.9,10,11 If the coalition is painful and hindfoot valgus is significantly advanced, an arthrodesis is preferred. Excision is performed through a medial approach between flexor digitorum longus (FDL) and flexor hallucis longus. Interposition is enhanced with bone wax and local fat graft and care for the medial neurovascular bundle is taken. Local fat graft can be harvested from the anterior aspect of the Achilles tendon.12

Flexible pes planovalgus deformity or “flatfoot” is a highly prevalent but often asymptomatic or managed nonoperatively, but surgical indications are reserved for persistent pain despite nonsurgical management. Arthroereisis involves insertion of an implant into the sinus tarsi in conjunction with gastrocnemius recession.13 Lateral column calcaneal lengthening osteotomy can also be considered if arthroereisis fails. Talonavicular fusion is reserved for painful neuromuscular pes planus. During a lateral column-lengthening osteotomy, protection of the sural nerve and peroneal tendons is critical during dissection of the calcaneal wall. This is typically done using a saw or osteotome under fluoroscopic guidance for lateral to medial calcaneal osteotomy leaving the medial wall intact. A lamina spreader is then introduced to distract without subluxating the calcaneocuboid joint and then a wedge-shaped autograft or allograft is inserted. This corrects midfoot abduction and residual
supination. This reconstruction is then stabilized with lateral plating or threaded Kirschner wires depending upon bone quality. Dorsal graft within the sinus tarsi must be avoided to prevent impingement. This reconstruction can be augmented with a talonavicular capsulotomy, spring ligament repair, and FDL transfer which gives inversion strength to skeletally mature patients.


Cavovarus deformity is a complex constellation of deformities involving forefoot equinus, calcaneal dorsiflexion, hindfoot varus, forefoot pronation, and claw toe deformity. The surgical management of each deformity can be broken down into soft-tissue procedures and boney procedures and are dependent on the relative flexibility and extent of the deformity.

Plantar fascia release or Steindler procedure involves an oblique incision 3 cm at the glabrous fold medially at the level of the medial insertion point of the plantar fascia. Dissection is carried through the fat and fascia of the abductor hallucis and the fascia is released. A thyroid retractor or Freer elevator isolates the fascia and sharp transection is performed with a scalpel. Gastrocnemius recession is performed if preoperative testing determines if the equinus contracture is originating from the gastrocnemius or the Achilles tendon via the Silfverskiold test. Gastrocnemius recession is via a 4 to 5 cm longitudinal incision in the mid-calf and dissection to the fascia while protecting the saphenous nerve and vein. Fascia is incised and the junction of the gastrocnemius muscle belly where it joins the soleus muscle distally to form the Achilles tendon and the fascia is released medially to laterally as the ankle is held in dorsiflexion. The sural nerve posterior to the fascia must also be protected. Achilles tendon contracture is lengthened percutaneously via 3 small stab incisions 1 to 2 cm apart along the center of the tendon proximal to the tendinous insertion on the calcaneus and 3 transverse cuts are made laterally, then 1.5 cm proximally and medial and finally 1.5 cm proximally and laterally. The ankle is tensioned in dorsiflexion and the tendon is slowly Z-lengthened. Open lengthening can be performed through medial incision directly onto the tendon. To correct hyper dorsiflexion of the first metatarsophalangeal joints (MTP) joint and clawing of the big toe, a Modified Jones Procedure is performed which is an alternative to the Jones procedure where the flexor hallucis longus tendon is harvested and released through a medial incision at the MTP joint distally. The tendon is then fed through a 2.5 mm drill hold in the plantar base of the proximal phalanx and then sewn back to itself or periosteum. The extensor hallucis longus (EHL) may also need lengthening and the MTP capsule may need to be released.14,15 Tendon transfers are common treatment modalities for cavovarus foot deformities. Peroneus brevis to longus tenodesis is used with lateral ligament reconstruction to treat pes cavovarus and involves exposing the peroneal tendons laterally and suturing the longus tendon side to side to the brevis tendon at the level of the ankle joint posterior to the fibula with strong nonabsorbable suture. Distal tenodesis at the insertion site on the fifth metatarsal can be done in cases where the Brevis is intact. Lateral ligaments are imbricated and reattached to their footprints on the distal fibula using suture anchor. The extensor retinaculum can also be mobilized and oversewn to reinforce the repair which is also known as the Brostrom-Gould technique.16 Posterior tibial tendon transfer is done through a medial incision along its broad insertion along the navicular and medial column from which the tendon is harvested. An additional incision is made 10 cm above the ankle joint adjacent to the medial tibia and the tendon is pulled proximally. A separate lateral incision is then made 3 cm distally and the tendon is tunneled through the interosseus membrane exiting anteriorly and finally the tendon is tunneled under soft tissue, retinaculum to the middle or lateral cuneiform and anchored with a biotenodesis screw. The ankle must be held in neutral while tensioning the repair. The anterior tibial tendon and the extensor digitorum longus tendon slips can be used for other specific weaknesses and to correct claw toeing.15

Osteotomies and arthrodesis procedures are used to address cavovarus deformity. First metatarsal dorsiflexion osteotomy corrects a hyperplantarflexed first ray, and it is carried
out through a longitudinal incision over the dorsum of the base of the first metatarsal, and the osteotomy is made 1 cm distal to the first tarsometatarsal joint removing a 5 mm dorsal wedge of bone. The gap is closed and stabilized with plate and screw constructs. Calcaneal osteotomy mentioned previously corrects for hindfoot varus and is done through an incision laterally from anterior to the Achilles insertion to the anterior edge of the calcaneal tuberosity. With the cut, oriented perpendicular to the long axis to the calcaneus. Guidewires mark the osteotomy superiorly and inferiorly, and using a sagittal saw to osteotomize the calcaneus, it can be slid 1 cm laterally and superiorly to decrease calcaneal pitch. Fixation is achieved via 2 screws anteriorly through the tuberosity, and the overhang is resected for bone graft. A z-shaped osteotomy also can correct hindfoot varus in a multiplanar direction with the z-cut laterally. The superior limb is 1.5 cm anterior to the Achilles insertion and the inferior limb is the posterior extent of the posterior facet. The cut limbs are joined, and a lateral wedge is removed to increase valgus.

Claw toes occur from an extensor overload at the MTP joint and flexor overload that proximal interphalangeal joints (PIP) joint. Dynamic deformity is corrected by a flexor to extensor transfer via the Taylor procedure which involves transferring the FDL to the extensor digitorum longus dorsally at the MTP joint.17,18 This is done through a dorsal incision at the MTP joint, and the long flexor is released as distally as possible and passed laterally to the joint or split and sutured with each end to the medial and lateral aspect of the extensor expansion. Rigid claw toes are corrected through MTP capsular release and proximal interphalangeal resections with pinning to fuse and straighten the toes.


Fusion or arthrodesis and arthroplasty are used address painful osteoarthritic conditions. Total ankle arthroplasty is utilized for end-stage ankle arthritis and is performed via an anterior ankle approach through the interval between the anterior tibialis and EHL with the neurovascular bundle laterally retracted with care taken for the superficial peroneal nerve. Debridement of the ankle joint is performed, and the cutting jigs are utilized to make appropriate cuts in the tibia and talus to fit the implants and polyethylene spacer. During bone cutting, care must be taken to protect surrounding tendons and the anterior and posterior neurovascular bundles. Often, this procedure is not in isolation and addressing equinus contractures or adjacent joint arthritis via fusion procedures.19,20,21

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Sep 8, 2022 | Posted by in ORTHOPEDIC | Comments Off on Surgical Treatments

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