REARFOOT SURGERYREARFOOT SIIRGERYREARFOOT SURGERYREARFOOT SURGERYREARF'OOT STJRGERYREARFOOT SURGERYREARFOOT SIJRGERYREARFOOT SURGERYREARFOOT SI.]RGERYREARFOOT SIJRGERYREARFOOT SIJRGERYREARFOOT SIJRGERYREARFOOT SIJRGERYREARFOC}T SURfj |Fr. ' rIti:.{R FOOT' S L;P,rj I Fi -:'

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BONE.GRAETJNG

Bone Grafi lndicatioosI . lndtction of neu' bone formation: the process of oseogenesrs. the stimulation of neu' bone formation rs

an imponant charaaeristic of cenarn bone grafu. The properl- is useful in the rearnent of delavedurions. nonunjons and arthrodesis bl bone pm-ftnrg teclurigues.

2 Immobilizadon: bone gnfnng in combinarion u'irh rigid inremal flxrdon udli aid in srabiiizadon ofanhrcdesis sites and unsable fracnue sites.

-1. Dcfeo replaccment: a major ue of bone graf,s arc to rcplace large segments of uaumaticrllv lost orsurgicallv reseoed bone in order to nraintair firncr,ion and lengh of the affeoai segnient.

Bone Graft BealingIn order for bone €rafts to heal proprlv thel' mus be placed in a rasarlar reipienl bed in close conbc! r'.i*surrounding bone frag:nenu and rigidlv subilized The grafi sire mus be proreaed agains exenul shearingforces- lo insureproper hgq]ug The rneans b'u'irich bone grafu are fncorporared inro hosr tissue diff-en foiaulogenoL( 1'grsu5 allegenic bone and for conical versus cancellous bone- but generallt'involves 6ve processes:l. I'ascular ingronlb: this proccss usualll'occurs sithrn the frm or second u'eck follou'ing gafung

Initialh' henrosusis and irdlammaton cell influarion ocanr. In allogenic gnfis the boni antigeniciqr.rnalprolong trc inllanurulon'process until host blocking alubodies can neutralize the grafi anugens. Vascutarbudding gurckl), follons the inllammalon' response

2. oseoblast proliferation: once tasorlar ingros,th is esablished the oseoprogenitor cells or mesenchrrnalpenqles differenriae inro oseroblasts and begin neu'bone formadon.

3. osteoinduction: tbe proccs tn'u'hich nonossems tissue is infuced to prodrce bone. The exaclmechanism is unlsro$n- hou'ever- Uris descnbes a bone morphogenic protein pres€nl in bone marirthat aos as an induoor subsunce.

4- osreoconduction: the process in which rlre bone g:afi firnnions as a scaffold or conduil for rnigrauon ofneN bone as it replaces necrotic "old" bone. Arluusen used the rerm crccping substirution to descrjbethis process.

5- graft remodcling: a process t}nr ma-r'las for severaj nronl}ts and results in refornution of the gzn inresponse ro biomechanical forces in accordance u'ith Wolffs lau.

Tlpes of Bone Graflsl. auloeenous booe grafts: autogenous prafls are considered to be superior. primarily because of cel;

viabliqv and immunologic compaobilin'. Autogenous bone grafu are considerEd ro be a mrc u-an5planrbecause tre rjssue is r"iable and u'ill conti:rue lo sun'ive and gron'in the recipienr sire. Arnogenousgnfu area primarih'indicated for use in areas u'here rzsctilarif is mos imponant A disadranuge roarnogenous bone grafting is the crsrion of a second surgcal siie and the formation of a bone defect inthar area. Specific qpes of auogenous bone grafis include:

a) cancellous auloeenous bone grafts: a fragile lanice nenlork u'hich provides the largest amornr ofviable cells and ind.rctive morphogenic protein. The lsnice provides an ideal strucnuE ior ingrouth ofneu' r'essels faciliutilg oseogeaesis. Cancellous grafls are far roo fiagle ro lend al4' sabliq'ro thegrafi site- hou'ever- Oq'heal gurckll'and become progressivell'stronger and lherefore morendiodense as thel' heal. This qpe of gnfi is preferred for nonunions especialll' arzsanlar nonunions.b) cortical autogeDous bone grafu: a dense- cornpad suucrur€ u'hich prorides s;r.renglh and srabilil'lo tlre gnfi site. Conical grafu tnnder ven'r'iable cells and incorporare slou'lf'. Vascular'peneradon takes ntice as long as cancelJous bone because oseoclastic resorpion mr.$t precedeoseogenesis. In conuast lo cenceUous gnfls conical gnfis lose suength as rbel'heal and becornesntore radiolucent. Aproximately 4U/" of their suengrh is lost u'ithil a six week to six month peridC-onical grafis are ideal for areas ufiere str€ngh and subilization are reqr.rired Conical gyafu itsoallon'seanre arachment of fixarion devic€s.c) corticocaoccllous sutogenous bone gmfis: rhese qpes of gxafis combine the smngrh of corticalbone u'ith the mpid oseogenic ceFabilities of cancellous bone. Tlre iliac crest is a comrnon donor sitefor this qpe of gnfl.O free vascuJarized auloseDous grafts: this fomr of gxd is a segmenr of bone wi0r irs nrrriemancn'and veins inua. Udlizing mioosngical technigues- the graff is hanrned and reanasromoscd

264

2. allogcnic bone grafts: allografis are considered implanrs because the tissue is. for rhe mo51 FrLnon\rable- Living .allografls are rarelv utilized primarih'because of immunologic incomponbiliq, leadingto host tisoe rejecdon and possible u-ansf,er of infecdor-rs disease. Alr dononrnus -""t srro guidelinesdevelo@ \'the Anrerican Associadon of Tissue Banks. The donor n:ust be fee fionr maligrancr..infection or nansrnisslble disease. The donor mus also have no hisor-r,of viral heparids. qpiitir.'malaria urberculoss- leproq'. severe Fauma drug o'r,erdose or poisoning Mos a1ogpff bone isprocessed to reduce the risk of disease u-ansrnission. There are sevelal di,ff.rent r-rpeiof allogenic bonepn'afu reflecdng the modificadon process urilized,

a) f m;rcn aflo4raft: this rlp. of allograft is removed via serile technique or srerilized follournghan'ening [r'eth1'lene oxide gas. irradiatjon autoclaving or prolonged anobjoric uashes. Freirng ispcrformed to prc\'eil cnzrmatic degrad.rtion. Ttre rempcrarurc utilized- musr be -?0 C or belou..Freezing does not affeo Ore bionrechanical prgpgryqt Allre grafl,horlever._linle_j@ucrion ofanugeruo{' is accomplished"

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b) fntzr*-dried allografus: the process of {reezedr.hg removes 95yo of the moisnye in te grafi.Through a ptocess called l1'ophiliz:tion tbe bone is sored in a.\?curun n,irh infinire shelf life. Theprocess alsorcduces alografi antigenicin'. hou'ever. rorsional and bending srength is sigxfficanu\:&creased rhe rcnsile and compressi'e srengrh are affeaed.,en, liule.c) dcmineralized or decalcified allografts: this form of alJog-aft u"s primarill'designed to promoteoseoinduction rvhile decre.asing antigenicin'. Uris develo@ rlre Aurollzed Antigen - ExracredBone Grafi rvhich strips the minerals fom tlre bone oposiag the bone morphogenic prorein ro ind.rceneu'bone production- This Dpe of grafl is ven'mallerble and incorporatoq-iLll,inro hosr tissue.d) artificid allografts: manv materials hart been proposed- hou,ever- ttre mtsr noreu'ortb1.is tbeh-r'drox1'apatite intplant. This material is oseoconductive- bu does not srimulare o$efgeness oroseoi-nducrjon. Srengr} is excellert and UttJe immunologic incompatibilin,is demonsu-ared-

3. renogenic bone grafts: nol recommended for use nrrrendl,, primarih,because of immunotogcilcompan-biliry leading to_foreipn bodl'reacrion s'hich inhjbirs oseogenesis. Tuo commercrallr.arailabteforms of bovine bone g:rafl are marketed under the narn6 Boplant and Kiel Bone.

4' 4. composhe bone grafts: the combirration of allogenic and aurogenous bone grafu can be usefuJ to takeadrznuge each graff's special propenies. Autogenous bone is highJl'oseogenilc u,hile allogenic bone ishighb' oseoindrctive.

Techniques of Bone Graftingl. onlal' bone grati rechnique: described b-\' cambell, the rechnique u

'rizes a large aurogenous conicaj

bone gnfi to bridge a nonunion. The gnfr sas oren fixared in piace s,ith screus o, ..'iri. hior lo g=ftlng,the nomrnjon fragments were deconicated ria a bone chisel. Pheminer descnbed an onlay Uone giffu'hich qas not fixated and peced Ore grafi ubperioseallr..

2. a) dual onlal'bone graft technique: a modiEcation of the onlal'technigue in u,hich the nonrm:on rscentered benl'een nvo conical gnfu. The technique uas indjcated for use in rrifficult or unuqnlnonunions.

3- inla-v bone graft technique: simplv involves t}e formation of a slot or rrindon. in uiich the bone grafl isplaced4' sliding bone grafi tecbnir;uc originallv described b' GilL rle rechnigue involved syearing a grafi Aom

the shd of5. a long bone approxirnatell' one-half the diamerer in u'idlr. This grdl uas lhen mo'ed fonrard acmss lhe

nonunior/anhrodesis sire onro tlre rrcipient fragment.6. 4' Papineau bone graft tecbnique originalll'descn-bed for reasnenl of chronic osreom'elitis and

infeged nonuniors. The necrotic bone uas excised- rhen tbe rvound uas clernsed and allowed rogranrrl2re. Small pieces of cancellous bone are then pcked inro the bone cayiq' and the wound is closed_The rechnigue nas designed for rapid re\zsc.rrlarizarion.

- ,- usualll' tn areas o,llar3e bonl: defeos. Tle most-cornmon donor-sitesinclude-the-nbsand the shafiofthe fibula. Incorporarjon of this form of graft u'hen rigidll'subiiized follous priman.bone heaSng

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--Dcminerali"ra Bonc nt atri; OB'lin

An autologous bone ahenrabve

Bonc matrir. Organic

. Collagen

. Noncollagenousproteins. Bone Morplrogenerjc horein fBMp)

. Inorganic(mineralized). H]'dro{r'appaure (calcium. phosphorus)

DBM-. AJlografi bone containing o4!l'the organic marj.r. Exposes non-collagenous proreirs rBlnp) to ore oseogenic precursor cells. BMP has been shoun lo be osreoinducrive

DBM function:. Osteoinduction

hocess bv u'hich oseogenic preanrsol (mesenchrrnaf) ceils are sdmulared lo differentiate irro chondroblastsand ujrimarclv inro oseoblass

DBM Produels:I. Grafion

' Gel. Flex. putl,

. Cruncli2. Snagrafi

. Gel

. putt\,3 Osteofil

. Gel1. AlloMatrix

. Putt-\'

Infer ior Calcaneal IJeel Srrur and Plantar Fasci i t is

Diaglosisa) parn on palpation of the medial aspeo of the inferior aspeo of the cajcaneal ulberosin,.b) pos static dlskinesia: pain of rhe insenjon of the planur lascia u'hen fim u,eighr bearing after a period

of rest. The pain is usrulll'partll' relieved b1'funlrer acdviqr .c) li-Er): spur m4'or ma]'nol be present.

PatbogenesisAny or manl'of the follou'ing strucnrres mar- be irvolved in prlling on the periosteum of the ca1canans. Thisleads to periosriris u'hich produces pain.a) planta fiscia ptU (mosr cornrnon)b) abd:oor hallucisc) 0exor digirorum brwisd) long and short planrar lignrnents

266

Dif,crynti_al liagnosisa) calcaneal apophrsitis

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b) caicaneal fracturec) nen€ enuapmenl: usualll,the medial planmr cajcaneal nerved) planur fuscial lear or hernianone) ardsion injur-r'1) rumorg) acromegalic far pad aheradonh) connecuve dssue disorders lvilh associated fat pad aleradors or aurormmune anhrjrjdes (ie-rheumatojdanhdds. Reirer,s sndrome. psoriauc anhrins. ,"l"l".rg ryo"qrmrlj) infecdon: sofi tissue or oseomvelidsj) connrsionk) rendinitis (ie-firs la-ver plantr muscularuE)

TreatmenlInferior heel spur srnilrome artd a planur fascijtis are consrdereo self-limiturg .nriJes and udll resol'e*'ithout treatment' Ho.'e*et- ore course of sponuneoua ,"aotuuon is long and the parn can be 'en.

. debiUunng thus treaunefl is 'ery ofien indicare.l -uvi' 'J rvitts dru ',tr rrun

a) consenztivcl. seroid injecdon-s2. NSAIDs3. padding ald su-apping (ie.lou,dve)a. phrsical therapl.5. i*obit;'rrion: casring 0o*'prionn, since this tr€rrnenl is also debiiiuring)6' onloses: can be used as reatrnent for the chronic.""a - ; o'Ju io, prer,endon of recurrence.b) sureicajI. Griffirh:

planur U-sha@ incision around rhe heel2. Sreindler.

rourles the poserior aspecr of the calcaneus fonrard into a notch in underside of the calcaneusneod ro do a rendo Achilles lengrhening3. Mjchele and lfuuger:

counrersirikiag L-shaped ogeolorn, of the inferjor calcanzusdecreases rhe 'high point"

4. Flassab and El Sherif:severaj drill holes inro tbe calcaneustheory is Orat it redrces verx)us congesdon of rhe caJcaneus

5. Durries:resm inferjor calcaneal qnrr rhrough a medial ilcisjon. -. .. . . . . . -.lascjoromr.

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6. -ENDOSCOPIEPL-A}TTAR+ASC]OTONAL

lndicat ions-surgical altenutjve in padents q'ith recalcirant heel pain/plgnW fasciitis-paDents should have a nrinintum 6 month anempl of consenative care

Advanrages-faster recovery time-less post-op patn

Techniquc-PT and sural nerve blocl-incision placement

-antenor & infenor to medial calcaneal rubercle based on NWB lateral :i-ral-5mm lenical stab incision-blunt drssection ro plantar fascia

-insuumentslEndotrac svstem-fascial elevalor-hook probe-sl oned obruraor/cannula-handles for hook & triangle blades

-resection of medial l/3 to V, of planur fascra

Complications-Lar eral column desubil ization( mosl common)

-calcaneocuboidimidmrsal joint pain-peroneal tenosrrrol'ilis-sinus ursi q:ndrome

-Medial column desubilization-cenral arch pain-intrinsic m1'ositis-hammenoe

-Other-continued beel Pain-infection-incision Pain-nen'e enrapmeil-Iztre-planur fibroma

.MAN A GEMENT OF CALCANEOCT]BOID ] OINT SYNDROME-several w'eeks of restrioed /partid u'eight bearing-shon leg weight bearing cast-srerching-night sPlint-NSAlD/steroid injecti orlsorthosiVcuboid Pad-ph1'sical fterap'-remorzble casl bool-].I\\ts short leg cas 4-6 u'eeks

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(aka-ta$al bossing: peak of Lamoiere)

Eriologra) hlpermobiliq'of-ft. f.rsr ra'r'creares.iamming of the firs meuursocumeiform jorntb) 'lffit-*",1,1"ff;1"""^**ti""" ,oru ",ur.. ooJlir.o* iippi'g ar rbe joinr and an an,'idcc) burqp pin rcndonids of the errensor hallucis longrs rendon and neurids of the dorsar inrcrmedrarecuhneous nen€ qu result fiom shoe pressure on the bump

Difrerential diagnosisa) gangiionb) neuroma

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Trcarmenra) consenzdve

I Tf1e l,!,dl qessur9 oflrjre bunp)i. ilfi"TJtl![il1tJ'ffi,1,1:'::*: sh,oe races doemr pass o'er rhe btrmp)::.Pft

(prEvens hlpermobibn,of rhe tla_,tb) sureicalilrrglcaj

l. Xiil"XT).;T*:t*9.1 1''.t T the bone ro pre'enr recrurence' T}tmg HTy* i o;'' i "o J'; fi #;'# i::#Hffiffi recu rrence or ore ex os os s

(liagJund's osose: os.roc[oiGElrf rhe accessory na*rc,]ar)

Diagnosisa) histolt'and ph1'sical: poserior lateral osseous bump on ore calcaneus. TlpicaLrr.. femares arcs\r.nFornatc due to. irriarion fonr shoe gear.b) differentialdiagnoos

I. calcaneal buntds2. achillcs rendonitis3. rendo Achilles calcifcadon4. rendo Achilles ruDrure5- gou6. turDot7. fi-acnrre8'

#ffi:issue djsease (ie-rheumatoid artiuitis F,eirer's srndrome. psoriatic arrhritis anln,rosinp

Pathogenesisthe osseous bump and sofi tissue o'errf ing are irriurcd b.v shoe geu causrng pain.

Radiologr.a) Fou'ler and ptrilip arrgle: measured on larcral radiograptr-I ' inerscction of a line fa8enr , ti,. il..ryrrioi prominence a rhe insenion of rhe rendo Achilles

2. il*LlrfiHnr ro r.e anrdot ruLJe aod meaii pt*"r, "ioe pranur n$erosin..

. .1 n'ben grearcr rhan 75 = Hagund,s deformin.b)

T"9 ?ogeNeg): measured on larcral.J"g"pbl' the calcancal inclination -gt ."n Jto .onido. to t}e formarion of a ,euocarcaneal bump (Ruch)3l,i,f fl"ilf,1,i,?#it-,qf*"-ff"fgf

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For ler 6o

Dhi l ip Angle

aColconeol f nc l ino l ion Anole

c) Parallel Pitch Lines: measured on lareral mdiographl. the trm pitch ltne (PPLI) is the line un€renl to the anrcrior rubercle and rnedial process of the planrar

ruberosiq'. A perpendicular line is then &aun bcru'een tlre posrcrior lip of the talar artjailar facer andthe firs pircb line (PPLI,1.

2. the second pitch line (PPl2)is drann frrallel to tlre trrs pirch hne and perpendicutar ro tharperpendicular hne.

3. pathologv is dentorstrated if tlre bursal pro.iecoon (tlre mos superior posterior ponion) of lhe calcaneusproJeds superior to the second bne.

Bursal pro.ieaion rouching or beloq'PPL2 is considered normal.

PPLI

d) ValSus Cun'e of tlre Calcaneal Tuberosiq'. demonsrarcd on tlre llarris and Bea$ ueu.

Trcatmenla) corsenztive: heel pads and shoe modificarionb) surgical

l. Keck and KelJl': remove wedge fiom tle poserior superior aspecr of the calcaneus2. Duvries: Iransverse resecrjon of tlr bump thrcnrgh a laaral inoson3. Fos'ler and Philip.

trans\:erse skin incision through poserior heel uirh a Mercedes incision through the rendo Achillesreseo bump tluough this incision

4. Dc*erson: cun'ilinear medial incision from superior-medial ro inferior-lareral

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Complications

II'--Avoia

ahasfiEirithxnp--wrrir uore resecuon a ne* p6mrnd;,s cr*rcdcaref,lh' rourded or addiuo'aj hrrnps *dll be creared with each resecuonThe bump creared should be

Ret rocalcanc^t Erost osis. Ensethoparht'atAchil lesltsenion. Nol Hagiunds disease

Eaglunds discasc' Eniarged bursar peojeoion of the posnerior ard superior carcaneus

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Ret rocalcanp^l Erososis- eliologl. Repetitive trarulul / overuse. Eguinus. FauJl'biomecharucs

Pat hopb.r'siologl'Dvstrophic calcifi cadon -

S.r'mproms and findings. Pain

. Palpable painfirl bonv promirence

. Pain uitlr passive ankJe dorsiJlexon. Srryelling. Thickening of rendon. Possible Equinus

Trcatrncnl - conscn.ativc. Resl .. NSAID's .. Heel lifts / padding / orr}otics .

Trcatmenl - surgica_l

1. lncisional approaches:. Tranwerse. Cenralmjdlinelongirudinal. Medial or lareral longirudinat. Medial or laeral L. l-a4'S

2. Procedures:. Tendon splining - parual deuchmenr. Complere deuchmenr aV' tendon flap. Tendon advancenrenr. Calcanealosteotomies

. Haflurd's defonnin,-' -

. Retrocalcanealbrusins

Phvsical therapr. - metchingCas lmmobilizarionConj cos eroi d in iecdon u.j tr casr immobil iza u on

. calcificarion of sofi tissues uith normal calcium meubolism' Usualh' iniriated by trau-rna *'hich causes tendon fiber drsrupriort- scar formation h1,po'ascularinand uJomalell 'calcif ication

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271

3.---Post-oP{ours€: -. lmmobilizatiol - NWB.1-8 weeli-<. Phrsical therapr'. Orthotics / change shoegear. Change exercise

Eouinus

Dcfinitionsa) funaional equinrx: the foot cannot dorsillex at least l0 degrees pas the right angle relatiorshipberueen

the foor and 0re leg. This degree of doniOexion is required for normal foot frmaion.

b) classical equinus: the foot cannol dorsif ex 90 degrees in ns reladonship to tle leg

T1'pe-eii gatroctt.mius equirus: identi-fied usrng Orc sih'enkiold tes. The silversliiold tes is performed b1'

nreasulng rhe relauorslup of the foot to t}e leg n'ith tre lnee flexed al 90 . If tte equrnus

relationship is demons:zred uil}r the iinee sraigbt and not demonsrated uith the loee bent al X) .

then a gasuocnemius equrnus is present

b) gastrosoleal equinus: rhis form of equinus is nol resoh'ed bt'perfonning fie sill'erskiold test. Osseous and

pseudoequinus must be ruled out before a -easuosoleal egutnus can defnidvell'be identifed

c) osseogs eguinus: identifed b1'bon1'ahrmrenl b€tu'een the talus and the o'bia alteriorll'on a lateral sress

dorsill exi on radiognPh-d) pseudoeguinus: the aparent eguinus is due to an abnormal forefoot ro rearfoot relationship- This is a

carus fmt Dpe-e) combinarion equinus: aqv combination of the above.

Trr:tmenta) €asuocnemius recession

I . indicatiors: gasuocnerniu eguinu-<2. adranuges: gutck rehabiliution period

-3. diszd\"nuge: limited indication and limited deformil'can be corrected

4. pocedures

Vglpirs: "\rli sha@ cul through the aponeuronsis of the gasrrocnemius muscleSu4ver: ranst/erse crr through tlr aponeurosis of tlre gastrocnemius muscleBaker: rongue and groove procedure in the gasuocnemiu aponeurosis lith Ore tongue ponion proximalMcGlam4.and Fulp: loDgue and groove procedrte u'ith t}le rongue ponion disUlSilferskiold les€fl hea& of gsrocnemius muscle releasing them from their origin

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c) tendo Achilles lengnhening: alJ pg{q"!g{ on the co{orned rendon of tbe gzsnoaremius and soleus __- .@l ' indicatiors: gastrosoleal severe €Lia$rcclremius and combirution qpes of equi,u<

2. pmcedres- open Z'lclosed '2,': u-ansl.erse plane- lrauser: s*ion posrerior 26 proximalt_r,ard nrediar 2l3 disulr'- whire: section anrerior 2/3 disaul'and mediar z_r proximarv

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ftased upon anaromical lorgue of rendo Achilles)- Hibbs: section the medial 2R proxmellv and oren a longitudinal splir in a disral direcrion arthe lateral end of the incision: secdon the lareral 26 djsrixv and then ul*gruair,rr splir rnrhe proximar direcrion ar the mediar end of rhe incision- Stenart: for $'hen lendo Achil.les rrsenion is more medial than normal and conraaed-exending anteriorlY on t}e surface of Ore calcaneus. An open ransverse "2" uasperfomred u'ith secdoning of drc nred.ial 7/'2 at theinsenion and lareral lD nroreproximallr..- Sgarlato: 'z-plasrr''' in fionul plane- secdoned anrerjor 2/-r disralll, and posenor 24lproximallv- Hoke: riple herni-section uith frm and las secrjors medialll.and second cur larerallr.

c) rendo Achilles adrancemenr: for qpastic eguinus (i.e. cerebral palsr)see Murphv's triceps adrancemenr under secdon co'eriag *nion-#rrr.r"r,

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Flexible rs Rigid Flarfmt is erahuted b1'the follosrng:I . Acnve and possive range of mouon of ankle. STJ. MTJ

. Flexible feet luve full range of nrotion at tlrc STJ ard MTJ2. Hubscher runeu\€r: passive dorsiliexion of the hallui u'ith the patient sandrng cr€ates the u'indlass

efleo of Hicls in the flexible fladool. Arch ele\ztion. Pianurllexion of fim rar. Suprnarion of rearfoot rn medial arch height. Exenul rotation of leg

Flexible Flatfoot

Etiologt':l. Equinus2. Congeniul: ulipes calcaneoralprus3. Srructural forefoot-to-rearfoot relationship

. Compensated forefoot rarus

. Cnmpensaled forefoot rzlgus

. Rearfoot eguinu<.t. Torsional abnormafities

. Adduction: metatarsus adducnrs- irternal nbiaj torsion

. Abduaion: exemal ubial or femoral lorsiorl etc.5. Frontal Plane abnormalities

. Genu \?rum /ralpum6. Neural-muscular-ligamentous

. Neurorophic

. Musde imblance

. Flaccid paral-vsis

. RuFr:red tibialis poserior lendon accesson: na'r"icular

. Ligamentous laiir."- / hlpermobilrn': Ehlen-Danlos slndrome. Marfan's srndrome

fNole: The flexjble fladoot can evenrualll'become rigid u'it}r the development of tarsal anhrids+r

Radiologr

*r* RqdioE?phic changes u'ill rellea the pnmarl'plane of compensarion (planal donrinance)

l. Trans'r'erse plarc (AP mdiognph). Talocalcaneal anBe increases. Talonayiorlar congnrencv decreases Oalar head uncovering)

. Norrnallll approx 757o of the ular bead is in contact uitb the navicular. Forefool adducns ang:le decreases. Cuboid abdrction increases. Wedge sbaped navicular

2. Sagnal plane flaeral radiognph). Tajar declination angle increases. C-alcaneal indination angJe decreases. Talocajcaneal angle increases. Midfoot saggng naliarjo-cuneiform breach. Talelg meuursaj angle increases (negadre Mean"s angle)

274

t t r l - \ O I C

Frontal piane rcalcancal aval lareral ndrograph-s,. Rearfool evcnrol. Incrc.rsed supcrurrposiuon of lesser ursu:. Decreesed firs rnemurstl declinadon ang.lc. Decrsased hcig.Jrr ol susrcnuculum ta}

ln severe fladoot ankie vrervs sirould alszvs bc obririned to nrle out ankle vajsuc"'

tI

l

II

Suryic.lf ProccdurccCategorDed br. Planal dorrltrancr-. Os.seous vs soft li.ssue proccdurc:. Medial colurrur r.s calqueal orcrcedurt-

Planal *'nttTt:;^ to thc pnnran pla'e of *re fiar,oor dcJonrrn' (1 e.. ole plane rn *.hich rs nrosr

eflecredAltirougdt procedures are djrided rnto t.lre pn,tian' plane of correcuon t;e orhcr plancrlre efieoed ro J ies.ser exrenl therclore eu procedures provide rip)aner correcuon

I ry4srg5gPlancl ' t\'^.'*'ff"?J,l::l:iQrreus

1.5 crn pro.unraj ro crlc:rDeocutnid.ioinr and irrseruon of a i.xrnc-erafi lengrlrcn-< rhe larcral colunrn and reair-erLq dre midarsal iornr

. \4a]' urynask melatiirsrL( adduous? Calcaneal-cuboid-iornr drsrr-anton an]rrod,esu

: ii:X51fl'il:l:ff 3"ilil-,","gr ar carcanear-nrboid.iornr crcared rn.rlre tra,r.: *T'

#n*;,tilffiTtrL1T',"*"rrn o, acccsson,nar.i..rrar and u-a'spos'on o1poscnor tjbial rcndon plantarh rnro tre narrcular

S!-crna]]'irlsI *"1iil,f,*fll**j:g

rui,,'.uro rn,o d,e qa*s,rg;r',enr' \4edjal achilles tendon :ts accesso^'Lgrnrcnr for renodesis of the medial arch

2 Hoke. :-\avicuiecuneifonn fusion

I't

f'l

t

7

Ta

a

-.. N{:illera

lndicared *irh obrrous fau.lt or hr;.trnrobihn.at tJre na.r'iculocuneiform.iolnrC.:rn nrodiJr and fu-se u'ith planuer0e.ron bone gnJi

Na'riculo<unei form-fi rs meraursal fu_qron' Poserior oaial and spri:lg lignnrent adr-ancemenr usi-ng an oseopcrioscal fiap

Cooon' orrning planurficron' u'e<jpe osreoromJ' of $e mediaj cuneiform

I:pidu-<. I'mel - cuneilorm an-hrod,ess

)'oung' Tendosusfrnsion of tle dbial:s anrcnor rhroupfr a kelbole in t1e nayinrlalc l. anrerior reroured frorigh the n:ricular rnor der.ached bom insenion). Posenol obiaj advanced under t}e naricr:la:

)

tt

Ft - .7(

275

Cobb. Hemisectjon of T. anterior lefl inuo al ils insenion then reflected infenor and medial to

the tarsrs and used lo augmenl T. poslenorTendo Achilles lengtherung i Sastroc recession

OrtlroticsChambers

. Artluoereisis concep

. Raises the poserior fucet of the sutxalar joinr rxing a bone g:afr under the sinus tarsjBaker-hill

. Oseoomf inferior to the sutnalar joint poserior facet u'it-b bone graflSelakorich

. Olpening wedge osteolornr of the susenuculunr rqli uith bone grafl u'hiclt restricu<abnorrral sutnalar joint monon

Calcaneal Oseotomies. Gleich: oblique o$eolom]' diglaced anteriorll', I-ord: displaces tbe calcaneus anterior\- inferiorll'and mediallr'. Si)'r'er: lareral opening u'edge uith grafi. Dul'er: medial closing wedge

o Koutsogannis: uanspositional oseotoml'. Straigfrr ant performed prallel to and bchind the peroneal tendoru. Fragment shified medially / can also be shifted anteriorll'. Increases rhe supinarory moment arm of the tendoachilles

STJ Blocking hocedresa) Arthroeresis

r fi,rll1' limis riplane motion at the suhalar joint. Plantarllodon of tbe talu. Transvets€ plane adduction of the talus. Fronul plane eversion oftbe calcaneus

l

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nL)

Iu!B

Frontal Plane1 .2 .

KIDNM

276

. MBA (MarrleU-Branche:u)b) Enra-aniculal STJ anhrcdesrs (EAST.ATGreen-Gnce anhrodesis

' E*n'anicurar Fusron of r].e STr rn dre srnus ursi usrne b,rne. Apixsiuonal Lnne srosth r-c nor dtsurbed. Ilrdrclred ul ages up ro l2- 1.1 r can

Fnrrel Pb-rre Fbtfool Prrrcedurts

Ari]r-rr, e rr s is Pruc ed un s

Plarrr fla tfrrol Calcarred Osrenrnrnies

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--_t-{e__' .1\ )__,,-I I a lI l-j---v

GLECH LOR.D

CongenialOlcrcorreoed 0adoorTarsal coalirion -

Peloncal sposmTrau:rn te.g. Lis Franc's Fracrure i DslcrcauontTarsaj anluosis / Charcor

Etlmptesa

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C}TAI\{BERS

Addante: \4llador unrbrelLSu petSa?rlato nru-shroonr\ralientc

sran

\ -\-+:(.--+\L_,-:BA].M.HILL sE-.c,xo\ncH

( ^ ;==4 eI

- - l l(- ,--,

G; GRrcr

A-r*u'n e rt s is lrrghrrrs

r'',\_./lsphen)

.c,DD.qJ\Tf

€\IILADOf

c>-

ST.{. peg

a.F

SG,{RLATO

Frnrrral

Rigid Flatfoor

Etiologra

a

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rfr'{Nl\_;(y

XOTITSOGIANMS

,t--i I,: !-'i iS;; D\\TIE

Tanal CoalitionI. l )pes

. S)ndesmosis: 6brou-<

. Slnchondrosu:canilaginous

. Sraososrs. osseous

i

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277

I lncidcncc: approxlnratel'r' -50ozo are bihteral. Talocalcaneal trtriddle iacet) - ntost cotl l l lort. Caiqlneonarrcrrlar bar - second nlost coll lnron:

'comn'ta srpt'

Talortarrcuiat - t lt ird nros cQntnton

Clinial f indrrte-.. Sudden otr-sel oJ porn afier tncrql-sed aguvtl\. SvnrpronLc usual'\ occu al unres related to ossificauon of dre coal.luor,. T-N 3-5 rrs: C-N E-12 rrs: T{ I2-lo rrs. \\rith conrpicrc s\'nosrost.( llrere rs no acure prin bccrus no lTlolron occurs at that-ioinr. Decreased STJ RON4. Progre ssrr,e rzlpu< defonnrtl assrciated rvilh i-nu -snurg ;rroneal tendon,< bchind tlre lateral

mallenlu-. - ;'rronesl sfnsuc flat{oot. Usualh secondan'to srnorral rmtation of the STJ andlr.lunrilrc tcnoslnorius. not due lo a srxsnl of the tencior,

R; r dr o eJ-d nhi c fi n dU1.r:I srr l*"1^1Lr..,"*

. irregular nruro\\lnp or absent middle lacer

. Hllo-efleq: sclerosis sunoundrng *re ST-l qrused b-r' rncrce-sed delurrr

. Lare firrchtg<. Talay bcal. Broadenrng and flanening of lercral telar prcrcss. BaU and soc\et anklejoint

Harris and Bcafi calcaneal aniai ueu's. fvaluales nriddle and ;r,csenor facct:. St:rnciard = 35 . 40 . 45 aria] ricu:. Tlrret ucrvs detennincd bv rhe angle of ;rcsenor facet dechnruon relauve to

the uei ehrbcanng surface- l0 above and l0 trelou

. 5ffiSJllll"",,,*,

. \4edial oblrque: rniddle and;rcsenor facets

. Lateral obbgue. ;rosenor facet2 o'on'o*,,*-o;ffiJ::1,,,*rer

s,€r,'l

rs?rrnentI Con-.cnauvc (rc-ortJroses. PT. NSAIDs- BX cas)2' surlca:

Ercre dre coarirron

: :J'H:";39ffffi:i3f,T;*:**o'"

Con:lcnitaj \/cn icaj Talus

R.adroeraphic firdrnE. Nariculat dorsallr dislocatel on the ular necl. DorsiJlered planrarflered suess vieu:

. Df $ress - n=rfoot rematrs in eguinu<

. p[ slress - t-n iornt renrain-< drs]ocated

278

J re;ttnre ntI Senal casr:ng ln tounger F?uenl(:. Surgical

. Relea-se sofl nssue conlrufiurc:

. 'J-errdon lenstherun!

. Relocauon lf ,1. TlN.io,nr rrrD pinrulg

. lf necessan.. trjnle anhrcdesrs

I'I;

7t

I'C.A \TT]S FOOT

Etiolq3'a ) neurolnuscula-r: nros comnlon causc

I nn'opcthr': musarlar dvsrophr,l. J^-nplrcrai nen:e or lunrbosacrai sptnai nen'e root pntlrologr

{harcor -\4ane-T ooth drsczr sc>Dc-t en n e- Sona s's rnr ersri ti aJ hlyrruoph r c n eun u :>yrolrrtcunus>traunratic lesion-< of tle sci::oc ncn.r

1.. :rntenor horn cell>;-nlionl'elius>lrrvclontemngocele>sprnal cord lulnor

4. spi ncrerebcllar uaa-.>Fricdrich's alawz>R ouss-r,-Lcvv srrrdr ome

-i. pr-ramidal or es:zprramidel g-3g1.>cerebrai fnll>e\1r?p\Taltu dai and sgrd c lrenlrpl ecr ir

6 ccrebral coner>h1'serur

b) otler causcs of caurs foorl. infadon. srphills2. idio;rrhrc3. rrauma

>periphereJ ne^'e damaer>tendon ruFnures uith zubsegucnl fibrosrs and conuacrurc

4. congcniul drsorden>m1'elomemngocele>sprna bifi&>nr1'elo{'splasia>clubfoot

Classificariona l anlenor cznll(

I . nreuursr-< carrs: Lisfranc's -iornr2. lcsser larsu-( cl\1ts: lesser Ersaj borres3. forefoor carus: Chopan'sjoinr4. I ocalrg obal,tcombined

b) posenor carr:-.l. nru_scle u,eabess or spasdon' of easuocnenlus or soleu-.2. lxeucioequjnrs: inadequarc aakie.iornt cirrsiflexron seconcian'ro ri-eid anrerior carus deform:n

IIIIrrLFrtIrIv\_

I2 1 9

Cl in ica l Er ' : r lua l ion of lhe Carts Frnta ) subtecuvc

l. age of ;-ndenUaee of onsel of caru-s delonnrtr2. s-rrrqlonrs and pro[tressron of cartL< loot trTx

-ireguent lnverslon ankJe spraurs-crrl'r'faugue u'it} ambulauon or sundrrrl-conrplnrnt of nruscle rvcakness of the lou er e\lrenltl\

- i. nredical and farnih'hrson-luson' of congeniuj spinal drsorden-fanril l Jrr$on'of erru foot nyx and,or rreuronruscular disorciers

b) ob-iecuveI . ncurological exall l lnauon

-nruscle and senson tcsung-a-sscasnr csnt of refl cr es<oordti-,airon lesL.<lecuolrt 'r 'ognphr and tten'e cottducdon srrciic:

2. phvsical c\attlrnaDon-rest for flesble ot ngid medral arch uitlr tle Xeliiean p'.rsh-up tes-:tsscss ank)e cqurnu.<rrluate calcancal prrsirion - fi-rcd r:rru-.n-firs nr': planurflexed fleribie or ngrd'''*drgrral defonrtitrcs. flesible or ngid^

exr erl(or s.rbsu tuu on I'piennr subnrenursal I esr orL<')

3 . rad-rographrc eraluau on-laterai radro-eraph

decrca sed ujocaj aneal ang.lerncrc3-sed calcaneai tncirrutron a-n gl rdecreased talar decbnarion anglcpcserior brcak tn dre cmra ltttr'trullet hole" srnus Larsl

--AP radrograPhdecrca sed tal ocal ancal angl crncrqrsed nreutarsus adducn:s

Principlcs of Canrs Frxrt Surycrya ) detenrune the undcrlrrnp coologrb) addrcss tJre plane of dcfonnjtr and t-lte levei at rr'lrich t}e defonrutr occurs. Esanrples.

>rearfoot \?nL< - Drlet>anlJe equrnu-( - gasuclcncnrrus rescessron or T.AL>plarnr0ercd firs rar - Joncs susfxnslon. DF\\/C)>ngid anterior ca\lr-( - Cole: Japa-.>digiul glpsrocs or lurnrnrenoes - DIPJ and PIPJ anhrod:sis: Hjbb+

c) carrx foor rcguires muldlevel surgen'tre- d:punll-isIrarcvmidJoovrearfoot;

Sofi Tissuc Prrrtrlurcs lindicated for flerible deform:n )a) planur fascial releaseb) Sreindler srnpprng. includ:s fascia- ab'Juoot hallucis. FDB. aMuctor drgjti ouinu ard tJre lorrg plantar

b-eanrentc) Bost and l:rsen

-relcase of nredjal column joiars-relase of planur inrnrsic:

dlGarceau and Brahrn-.-reseq Or motor branches of the medjal and larral plarrar nen'es

280

l-cndon Prtxcclurcra) Jones zusprnsioli

-EHL rs rranslerred ro tite leck of tire firs rrrenurrsal-hallur IPJ fusion

b) Fbhb6 suspcnsron-Sreindler srjpprnt-long crrcnsor tendon-q tran-sferred to lateral cunerform

c) nrodified Hihbs-long exensor tendon-< transterred to the rnterntedrate or lateral curerlornr.'-lones suspcn-sion (EHL ro fim melsnr.,i *ith herur IpJ fusron )-anaslonlosts of tite drstal lorrg erren-ror rcncion slulrps to t}e EDB lelrdons

d) Split Tibialis Anrerjor Tendon 'l'rarsfer (STATTI

-lransler of lareral half of the rendon ro lr.scnion sne oJf)eronerr-( rcnru-< lcndon at hra-se of fifi-h nreraursale) Tibialis Poserior Tendon I nnsf el

-dbiabs poslenor tcndon rs rciqrsedi:rr crosseou-s nr enrbranr

fiorn lL< rn<enion on ile nai:rulu ard rran-slcrred throueh $c

i] ;-rassed doun EDL shqarlr ro Inscn ln dre lcsser ursulc o,ii] half of tibiabs ;roserior tcndon ts yu-ssed cioru dre rxroneus reruus shaarh and dre o1rer half rs

;rrssed doun 0re tibialis anlenor shcadlf) Perolteu-< Longu-. Tendon Transfer

' fEloneus longrus ls reieesed at tJre levcl of tJre cutnid and ransJerred rhroulfr Lhe inrernruscu.larsfxum doun the EDL slrc'ir and rnscncd rnro tlrc rcsser urs.r

- Peloneus Ioneus tlral also tx splir in half- halj aru:-qonroqed ro tiblalrs anrenor at lts rn.s€ruo' arrdthe other half anasonrosed to pe rorreus lenlu(

Osx'ous l)rrrccdrrrcsllrdrcated for unreducible ngid dcfonnrtr a:rd in neulcunuscular cr.seslor subihz-arion of tlre fool: tnav alsorcgurre sofi nssue rcjcasea) CoJe. dorsifleron' u'ed,pe oseol oml

througlr ilre narr oiar-cunei f onn-iorns and orboid

b) Du\/nes: dorsiflexon' fusiontJrou;tr r}le MT-l

c) Ja;xs. displacemenl \z-shefrd os€orom\througlr rhe ctboid naricul:uand nredial cuneilorm

d) Drrler: lareral clostng u'edge oseolom\of ilre qrlcrneus

e) lr4cEh,ennr'{al du,elj : frrs nr curarsal-cuneiform fusron

O DF\\'O of firs meuursajg) triple anluodesis

I

t

t

Czr.us Osrr.orornirs

(rI

rr=Du\tries

/ ' ' l )!n\Rj-

Duler

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l+tri-t L'\ r l

J*l"s

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hlcEr::rrnl 19. Ca-lihrrll

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281

TA RSAL TIIN}TEL S )T\ DR O ]\TI:

. cli.rssicalir.. enrrapprenr of ilre floscnor rjbial ncn,c This cirscussron u'ill be bmited to t}e classcd n1x

ho\\,eyer. an alllenor ursal tunnei srldronte tnvolrrng the decp ;'rroneal nen'e dcles e\lsl

Etiolqg':Tlfr A (dred)

i. jocal d:scasc usuaUv eitlrer prcresses uJrich prc<iuce ecjcnu or sptce occupi'In8 processes

occumng rlrthin the closed corufrnn:ents ulrder the l:rcinrate lt-ea,ntent

I rauma: lo thc lren'e itscU or sruclures surroundr-np thc ncn'(

I 'ancosides: cluses vcnous congcsuon u'ithrn t}e ursal tunnel. N4os cotlutron Gitlse of bilateral ca-ses

: coltgeniul anonralres acccsson ntuscles;t os lrgonunt srrdrorle: inJlanrnrauon grti edenra of the FHL tcncion

-i aMuaor hallucrs nruscle hrTrnrophr': space clccup\rn!

o. q3ce occupyurg leslorx rridun dte ursal tun:rel. rrcuriiettiottta ttcuroftbrottra ltpornzr- Ss:rgiron

aneun'snlI tcrtosrrlorius: Produces edcnu

\ iaUOgcltC: inU:.t-OJX;-aUt'c. ScrOid inlcCUonS. lOunxgtlc: li.)unla ce-sUnl

b) sr srentic drse.a-seI diatrcres mcllrtus uil}r assrrrated neuro;rthr

:. rnflammaton anhrjddes {le-rheunratojd arrirrius. ankvlcsurg spondr'}lUs)

_- cn,sal dcposuon drssses (te-goul- ;xeudogout.;. prcducrng cn'srrls and edema uidrtn the tunnel

J lruxed connecuve ussue drsease tre'SLEt

-Ilf B (funcuonal)

a) pn)1auon: internal roterlon of the leg ruth tipLhteru;rg of llcror rcUnaculunt

Di:rgnosisa) Hison and Plrvsicai. rreurolosjcal sigrrs zrnd s\rlry)lorlts on dte plarltar a:;Prt of t}e loot

l. ;ntn: sirrnttng btrming or eleqnc nT)e sellg3lloll

2 brrmtng setlsaDon3. srrnponu \\'�orsen u'itlr pro)onged u'eipfrt-beanr:g and at rught

a. poJparion of cord-lile su'ellltg

,i. r,enou-s toumlquel les lcauscs srlllplonr*< tQ \\'orsen ciue to conocston.)

6. Trnel's sgl7. \Iallclr-s pornsE. sensor.r'cha:rges: l$o fnlnl uaile- pi-n prick and ptopnocelxron

9 d:ag:rostic tjbial nen'e block should resolve tire Ful tenrprcurilr

I 0. Jophr of tJre pl:rnur rnuinsic nlr-scles and planur cha.lrges tn s\\ cal producuon ( severe cases)

b) Elecgomlographic srudres. prolonged lateno. 6 rlell as decressrd nen'e conduction velocn' suppn dtc

diagnosis of rarsal tunnel srdrome

I elearoml'opraPhr2. nen'e conducoon telcllr

TrcatmcntConsenzrivea ) corucos eroid in ieco on-'b; ynsenor trbial nen'e bloc*t"

c) immobiliz aoon t ie-ca srilg)d) ort}osis: lo PreveDl Proruluon

Sureicajat ."..-rf neurolvsis. con-sis-. of releasing tre laciruate b-uutrent sulpcalll'. The bganrent s not

rcappro\inrared ciunn-e closure. Recurrence rates of 5-2}yo have been repon€d

282

TRII,LE ARTJIRODESIS

Df:niuon: fu-slon of tlrc follourn-e tirec-ioinua) ralocal cineaj t sutxaiar'rbl calelreal-cuhnidc) ulorurrcular

l n r l i ca t i onsa) correct delornritres

J. ra. lgusdcformrn2. r:rru< dclormitr3. flarfoor.l ctrus lrxlt5. talrprs equrno varu-(6. fired eguinus7. fired dorsiflcxon

bt relief of glnI uysal ccxrlirront. anirrius3. rupxured rtriahs poserior lendon-1. sairzge for severe anlqrne^l lracturc:

c ) sabibn'lntprove ntol or fr'r\\,erl. larenl ankje rnsrbibrr2. ncuromuscular dt-sorden

Ilration of Triple Anhrodessa) scre\r':b.,) prnc) surplesdl enernai firarron

Triplc A rt hr<xlcsis prrred u rcra ) Rr erson:"classrc rriple artJucdesis.' srnrpi<

-lornl resecuonb) Jjokc: rcnrove hcad of tajus. resecr anicujar

surJece and replace headc) llaug*rron Dunn: remove naricula-rdt Elnrsbe: indrcared for fxed calqrrreus Ioor

I)TXe) I-antbnnudi: indrcared for frred equngs foor rrgfl Bres'ser. counrersink talu-cI ) Gnce : errra anicuiar fuson of sutxala.r -rornrhj dou,el _eirafi:uses dos,el plugs of bone ro fuse *re ioinu

Compl icat ionra ) rnra-operauve neurorzscujar iniutb) a:rkie an]rrosisc) malabgnment (cln ca[se callosjues)d) malunrone) nonuajon tujorunicular-ioint mos cotnnron)

Jrip le,{rrhrn d e sis p roced urrs

f;g,4irrufi.-H*'

Nauglrron Dtrnrr

," i\ j

,--g=La-rnbriuiU

)L

7I

It

i -_-r'v-) S.. J'-_,L., --.\-. v+j_:

BrelsrerRr.erson

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283

TENDON TILANSFERS

Ob.iectivera,; providc itcuve ntolor po\\'er. rn general. one g.r.rde oi muscle srenpn-h is los tirrough rendon rransfenb) elururnuon of dcfonmng forcec.) prcduce sabilrtrd)cosmesrse) eliminauon of bracrnr

GcrrcmJ indicat ionsa ) rnuscle imhnlancc

l. fle.xible lurturtenoc:2. lullur valgu'3. dorsal bunton

b) parairtc fcrctl . pohomvel ius2. Duchenne's nru-scular d'r srophr3. Charcot-Nlane-Tooth drsease4. cercbral pallr-i. spinal cord uupurgentcnt6. sciauc nen'e pa)sr7. contnron ;rronea.l nen'e paisr' ("Saturdal nigtrt palsr'" tti drop fcnt

c) congeniuJ defornriuesl. recurrent clubfoot2. forefoot equrnu(-1. flexible fladoot

d; rarro-eenic delormi tre:l. hallur raru<

Pnredurcs:

Jones t endosugrnsr on procedure

a) Foc€dure: the exen-sor hallucis longu-< lendon is rranseqed at jts in-seruon and ran-sferred tl'ou6fr atrdnsvers€ hole in tle frrs nreuursal. T}e terrdolr is a:rchored bv surunng ir to juse lf dorsalh .

b) indrcations haliur exen-sus tcock-up halJur dcformjn') due ro flerible cams foor defornun'or Ilexiblepl:rnrar0ered firs ra'r .

c) ad-luncuvc proccdures: fusion of t}c hallur rnterphala.ngcal .fornt lo prevcnl an inrcrphal:urgcal flcxiondcfonruq.

Pannreraursal tendcssrrnsi on procedurc

a) ;rocedurc: anv or all t}e meuursal Jrceds can br zuspended as in t-he Jones sugrensionb) indicauors: flexible hanrmenoesc) adjuncuve procedures: digiul fusions and,or uandel of the disal anached poruon of rhe rencion to the

exensot drgrtorum brerrs

Kidner rrocedure (refer lo 0adoot praedure sefllon )a) proccdure.

resecrion of t}e accc:son' navicular andror b1 p-ruophled navictrlar tuberosr.ru-ansposuon of dre dbialis poserior tendon lnsruon from a more lateral ruricular anschmenr lo a morepla:rrar nariorlar anachment

b) indrcluons: ad.iuncdve procedure for a medial column fladootc) adiuncole procedures: u-suallv performed uith an oss€ous 0adoot corrective praeciure

284

Hrl-,.b-s-1qldqg512gnlgla ) proceciurc

- trarsecdolr of Lire e\le'sor digrrorunr lo'gus renci'lrb) tra:sfer ore tendons to t]rc lltidfcnt rusual.ll rnro a wpirrne holc rn ilre rnrernredjate or lateralcuneliorm)the d:sul r)oruorL( of t]te tendon-s ro ,.sritt renslerred rsurured) ro the EDB rendonc ) indrcttroru: funqronal cqurnus {t}rs 6r'es rhc EDL ,"noon go,,., ,;;;j;;;""i..'nrr. ,circrsifle*ng tJrc foor alrd pre'cnts trre lonrrauon of hanlnrencns )d ) adiunnjve procedures: nrav bc ;rrfonned rrirh a .lones sus1re pslon of rhe hallur andror dipral fusion:

Tib-ialis Anrenor Tendon transfera ) procedure va;lsecuon of Lirc tibiahs antcrior rendon al rE ll.\cnrori and u-.rnsfem-rrg it to tlrctntcntredtale zuprnation dclonnrn'irom nruscle;'cralvsis ire-Cir{Tto, co,,ocnjr.} nl.,o..le imbsian".(,er. ecurrenl clubfoot). Ajso u-qed lo correfl drop foorb) adiuttcu'e procedurcs tcndo Achilles lcngtjrcmn-e or g;lsrrocr)crlrus reccsslon ro *,srlen the;roscnol'iu-scle group andror fusion procedures of nridjcnr or-rearicxri

SttlltJ&t1.lf elf crj or T errdon m n-sfera ) proccdurc

- ittcisrorrs are tltadc over dtc t-rbiahs arrtcrior tetrdon at lL( tllsenrorr and l}3t\ een ure ntiddle arrddrsal rhirds of r}e leg- t]le tendon rs split lrorn tL( ll.\cnlon ro the level of rJre pro.wnral rncisron- t-hc lateral ha]f of Lllc tcncjon ts t'al'.scctcd at lt-s in.rnron and ;xssed Drou6$ rlre propmal rncjsior,- a t}ird inosion rs lnadc at t}e culnid/Jx,oneus terurr.s trL\cruon ar€l- the lateral lulf of the tjbiahs anlq.nol tcncjon rs;xssed eirhcr rirrough rhe rendon shearlr of t ircJrltoneus leruus dren suturcd to ilre ;rrotteus teruus nciai rts rn-scruon or. rr.ircn ure peroneusreruus is absent anached to t}e cuboid rra renodesrs

b) indiq:trorr<: flexible r'3nL< 31dis1 equrnu-q dcJonrriucs at ilre rcarJ..r or nridloot le'eis (rncrea-sesciorsrfierron and eversion )c) ad.iuncuve procedurcs: dorsflcron oscolom\. of the firs nreutrarsal. dguul dcforrnn. correcuotrsrialreal oseolomv and rendo Achillcs Iengdtening

)' ou n e r endosu snensj on ( acnrallr. a rar_sfrosjtr on )a ) proccdure: t}e tibialis anlcnor tendon r-' yrr-'st' througrh a slor rn dre narrcu.lar ..iorout drsurbrng ,.;'relrlsruon' The obiaii< posenor tendon ntus be oeuJea from rt-s rnsruon ro ;rrrorm the procedu-reIr rs rezruched ro Ore planrar surface of Ore nar.rcujar.b) indrcauors: flexible pes planu<cJ aQluncuve procedures. other Iladoot prcrcedures

Tibialis Poserior Tendon rransfelta non-plu-r transfer- can also cluse fladoot )

l. proccdurc' ilrcisions are made dorsall\' over tJte nrjdfoot ard o'er ilre posenor tibial nruscte beru.een ilremiddle and dlsal rhjrds of the leg The tendon rs rrunsrcrcd ar iL< lnsenron and;rissed throupfrpro.vmal rnct.son.

ru'o ;-nrfu for passing dre rendon _I ol'cr technique: the ribialis riosenor tcndon L ps.'csed Irom dre pro.umal incision and broupd'r:uound $e medrai maileorus anci ran^derrcd inro the larerar cunerforml' F\rm techngue: ore tibial:s poslenor tendon is passed from Dre proxima] rncjsion and brougfrrtJuougD ote ilterosseou.s membrare ano u-ansfirreo rnro rhe larerai cunei_form

b) rr,drcai:ons: 0e>ible or sps^srrc e+rnus deformiues

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Pcroneus Lon gus -Tendon rransfel

a.; prcreriurcarr inc isro l r rsr r radeat thelevel of t i reculxr idu ' i tere dteperoneuslor tgusle l tdonis ident- i f rectlre drsal fnruon of Ure peroneus lor)!lu-< tendon rs pulled tilLhr and suturcd to dre peroneu-< brerrsilre pxroneus longus tendon rs rnrrsted.ius prorrmal lo'n'here it x sutured to the brevrsthe rendon is then ransfened through t)re intcmtuscul:u membrane to the lalerai cuneiform

(ahcnrarivell tire telrdon can trc a)it and atuched to tlre pcroneu( tenrus a:rd tlre anterior nbiai

tencions )bt indicauons: flexible egulnus (drop tool) delormltr

MuIt\-mSet?lad.lnlg]]rqfilrccreucallv reduces dre leter arm of ankle planurfiexon b1' 50u,i, u'hile reducrng the lever arm of

propulsion br lS"ti,a.1 prrccdurc

Lrallestron of tlte tendo Achilles at its rn-seruonadvanccnrenr of the tendon antenorll'. .tust f^lscnor to the proscnor lacet of ilre sublalar.ioml

b) nrdrcrtrolu. sfrJ$rc tncefJs rn cerebral ;'nlsr

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ANKLE SURGER' \

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Deltoid llgan:ent in'iunes occur rriten dre foot js forcib)r e'ened on ore leg Chronjc isohred derroid u1l'n ismre' u'suallT an old fibular fraoure is tn'oived or und.ra€uros"o t,t,onuui' drasasrs

a) Alatomv of the dehojd i:ganrenrThe deltoid bgrnrent r-s dirided )nlo. lr'o poruons. *re cieep and zuperficial dehojd lganrenu. l-hesupcrliciaj poruon rs conrposed of r-irc tibiosrl-;;;;;cnl The decp poruon is cor';rcsd of. fron;anlenor lo r^,slenor- dte antenor dbroular. ubio'ar.rculzu. rnrenred:are tibioular and rrrsenortibiotalar lrurnrenls. Fronml piane rnsabiiitr, rs denror.,sr.reO br sress eversion 'lon)se radograpfu.Generall' lo-or greater degrees of ul1 rilt is consiJer"a *no',,. and indrcrres ruprure of rlrctibi ocal crneai and rnrcnnedrare ubi otalar L e;lrrenl..

b) Surgca.l proceduresi. Sclroolficlci s procedure: rhe ciamaged cjclrojci iilrrnrenr js cjerached ar lhe ongrn tn rhe dbia. Thcioot ts Gen forcibl'tn'cned and rhe derroid t. *rr.o'-J;ffi;:il'Jfrr,o, ,o,r,.dcra c'nrcnr sr re. Thrs efl ccu'el r. a dr.urccs Ur. J"i, oiO.t,rrr,r.n,:' Du\/nes'procedure: the dehoid Lgzmenr ,. o.';oJ'i.-nicalir-and hon-z,onuli.r cr€Lln[: a cruclarc

,fhil]:5lJ:*;T::* DuVnes'"ur*J ri-'.,.-*t,,,,r-,L,;";;;; rs srro,,e c,rousrr-1 \\;tnberger s-nd lr4allon"s procedure: the procedure uilues a spbr poruon of ilre rjbiaj.rs poserioriis a lendon -el-afi to relnlorce dle rnedial ankie Lg.anren,, .eppro',mater.r-5 cnr pro.rrnraj to tllc-arrkje 'ron:se one half of rrre tibia.rrs rrcsenor " l'r^.""o J#;;;;;i.;,il'^on u,' ,r,.narrcuiar' The poruon oi tencion rs dien prssed ,nr.r,ori.'ro su;rnorlr-*rrougii a drip hore in iliedrsal dbia and surured bscr onro rrseu uirrr ilre foor ror.iur., r'r,ened

l-:rt cral A nklc I nsr all i l in. Sur:cn

l-areral collareral ligarnenl ;latJrologv rs exrenrel-r, contluon and rs cau-sed br re;xuuve inr.s1-5y65 i:tlun.to tlrtankle cirroruc lnq'lbiirn' of t}e iareraj ankle x a di-vbl,g condruon u,hich cm predrspose r'e piiuent ro anrrJefi::crures. oseochondraj rejar donre fraqures and degenerau\;e lomt drscase

a) A_''torn' of t,,e lareral col.latera, atkle bgar'ent. 're lareralcollareral ankle hg;nrenr is conr;rcsed ofinree seDaraleb-canenrous srruflures. Tlre anrcnor uJofibular i-gan-r"n, o arrrnrraqrrxuiar slruqure *'hich resrss anrenor drsplacerncnt of t,.,culus *'il}rrn the ankJe-iornr monise. Tlrc calcaneofibular frgrrrr"n,,s e\-uztcztpsular and onenreci approrrnrarelr, 105 from ,f,a "r,,*o,ulofibular uga:nent.Jt resisrs rni,enron of tlre uru< rriti'n rhc_

-

ankie moruse. The posenor uJofibular ligamenr rs a stroncrnuaqrFxuiar blanrenr *'hich is siruared'r a nearrr. lronzonLplane' This blanrenr resists posenor drspracenrenr of .'e uru_< rnrire ankle nronise

b) Diagnosis of laeraj collarenl por}ologr.. rufxur€ or u.eal,rress of rhe ATF c2n be confrmed u,jth a::antenor drarlel or prsh-Frlj lareral suiss radrogzph en -r.r,o, osplacemenr of 2 cm or [yearer ascotnrnred to dte cotttralarenj ljmb is considerei +r",-.o]-ilriur. o, *.ealoress of r1e cF r-rr::arrrcrrr q.nbe confrmed urilizirg sLress in'ersion moni-se radro;raphs. AA;rjJr of 10 gr%rer ilran rlre unaflecredconrralateraj limb js consjdered abnormal. aaHe aii'o-or;;;r"near renograph.r,are onlr.ind:caredrn scue llSamentous ruFrute rri$ podcnr nho ha'e "" p;;;;;;;. of ank]e Eaume. A percncalleno€!-aru ts -sre:tler ld:En 95on' accumle for determi:rauon of r*" Lo"-6bular b_eament ru$ures.

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c)-S qgi cal-oroc.eduresProcedures m2i' be grouped Into l'hich irparnent or i.llarrrent-< thel are d:srgned to replace

] dclavedpnnran'lrg:rncnrousre;rlr' Usrnll'r' rndrcated tn acule b;arrentou< rnyun'. ln qlses of chronrc rn-stebi}n.|hc

Lgrnrcnu nul'bc sretchcd and nol rorn. lnrbnqruon of tlre irg:;rnrcns utiizrngrionabsoftuble surure rs tJren pe rJorntedfBlosuonr )

' Gould ntodificatron: reinforcement of rerru uith e5erusor reriraculun

Il :rnlcnor uloJtbular i:gmrcnt rcp)accmenr= As a group titcse procedures reconslrucr r}e ATF urili?rns vanous slnrctures usralh ;rsseci

tJuouglr tlrc fibtrla ulus and occasronalll t}e'calcaneus follourng Lire aruronuc onenurrlonof thc ATF l.rgrnrcnt

. >\\:al-son--)ones procedure: utjlizes 1^-roneus breus

. >lnini \\;alson-.lolres procedure : udlues perorrcus brerr:

. >Nlcl:urhltn pracdure : udlizes a sp)n pcrorrcus brerrs

. )Lrx prrredure: rrtilves pxroneus brert.

. )Pouzel plcredure. utilv,es peroneus longu:

. )Sroren l. urilv-es a f)f,ruon of tlre Achilles rendon

. )\\/clrcl procedure. rrtilues planuns rencion

. >SeJron procedure. udlv_es plennns ol ]onc e\1el.L(on

. >]larg procedure: reinsen_< ilte ATF Lsarrrelrr' >Drrken. I crrt-halcl and Suplxn. utjlrzcs spbt ;xroneus breus and renru.

lll. anrcnor ulofibulal and calqaneofibr:lar replaccntenr= T}cxe prcrcedures reconslrucr the ATF and CF bsznrent.< uri[zrng rarjou-s slnrclurcs Fr-ssed

tlrrouglr and r-Lll'een t-he fibula Ulus and c:iqtneu-s folloqrne dte enalornlc oncnUlUon Of tleATF and CF blanrenr

. >Elmslreprrcedure urilv,es {asqala:a

. )Clmsnan-Snook urilzes spbt prroneus breus

. >\\/infield procedure. udlDes peroneus brerrs

. )Sroren Il: urilv,es a free rendon graft of Achilles tendon

. >Altllren-l-ar:son. a subperioseal adra;rcenrenl of horlr ATF an CF benrenrs' > spri'� P'':ffi'*T;l'ff***:*T;'":""-

l\;. ATF. CF and PTF bElanrenr replacemenr=' Destgned to replace all three liEaments in a;raromrc or neijr :tnalorruc f)osrnor')

. >Spotofl: utilues fa<cia lau

. >Rosendahl-Jenren. udiu_es fa-scia lau,

\/ Errra-aruromic l-ereraj Ankle Subiluation= Tlrese procedures reinforce ilre lateral ankle rritJrout follourng sleofic anarornicalll correcl

l ieamentous orienurron. >Nil-sonne proccdure: urilzes prroneus breris. )Evans procedure: udLzes peroneus brerrs. )I-ar:en procedure : utilzes peroneu_< bleris. )\trerrrser.n prmedure. utjlizes r*roneus breris

288

S,hlurarcd or l ) is l .c : r red Pcr .ncd rcndon Rcn:r i r } ) r t rcdurcs:

Dislocauolt atrd srblu'rauon of 0te ;xrolte-el leltdons rs usual^ rcen *'itlr sporu irtunes lrr *,lrich 1orced ankirnrotron ukes places rrlrile dre ;-rcroneaj lendon_c are unciel rrut\n.lunl rert.sron

a) Sureical nroccduresl. Xelh' and \\;at.son-Jones prcrcedure: an oseoyrnoseal

fiap rs crelted in the rxrsenol alTtefl of the iarcra] nralieolus The pmcedure efiecdr,eh dee;xn-< thcsul nr.s prevenlrng renurent dislocau on2' DuVnes prcredure' a wecjee-sha;led osleolonrv rs creared rn tJre poserior aspect of t;e lareral malieolus*.hiclr Jontx a bone grafi Tite borte grai r.s d:splaced pcsenorh'ard fisared ionrulg a bonr blocklo pre\.enl dislocauon3. Dirnunt-Berger: phcared and reinforced rhe ;rroneal rendon slreati4' Folrlr'ciller: utihzed a pcnoseal flap to rcrnlorce dre shceilr and redireq rJre pcroneal rcndorL.

i-roseriorh' '"'l:fi:.T":re 'qabilzed dre;rro'e;rl tertdorx br. reconsrrucun€: the reurucular b!:.a'rerrr *idr a flap o1

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.{T}. Cf snd PfF Lisarneni Ig]:S_lSg_

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AN}<LE ART]]ROSCOP)'

1n I920 Takagc of the Uruversin' of Tokr o rla-q lhe frrs to rieu'the rn<icie of a -iornr rrrlh an anhroscope. Sincctlrat ulnc grcat srrides )rave uken place rn ecJurpmenl and technrques nhicb contlnue to develop todar-. Tlrcsurgrcal moriridrn' assoctaled uiOr anJvoscopn' is exremelr- lou'and t}e porendal trnefits ro Ote pauent arelupJr

Anhroscopic Equi ; lmcnta) anlroscope: a lers conuirung lig:hl-transmirung rube uhich allou: tlre rarsmjssion of a piaurc

to a television monitor or to tJre sue€on's eve. The anJuoscopcs of rodat contain GRDJtGradrent Refracdve hdex) lenses This len-< rs a soljd relal' lens rod coared rvirh black painru'hjcb allous the le.aq anlounl of light loss currenlh'arailable. The up of dre ar0uoscope rsangled from 0 to 90 . The obbque anlde on r}le tip of r}e sco;r allou's for a -erearcr field of rieu.q'hich allou's the zurgeon to peer around bcnds injoinu. Anlyoscopes are avaiJable il ourerd:amerers of 1.7 rnrn 2.2 mn 2.i mm 3.5 mm and 4.0 mm

b) bpfrt sources: tbere are three q'pes of [gbt sourc€s a]J of l'hich uznsrnil Igirr rnro tre jornr r:afibcrotric cables.

. tun_s$en lampr: color lemltenlures of 2900 K lcas pouerful

. metal hali& lamFrs' color temlxrarrue of 5800 K rnrermed:ale po\\'et

. )ieDoD lanps: color tenryxrarure of 6000 K n'hich corresponds to davlight_ mosporverful

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290

cemeftIs: nvo nTEs arc used'_T}re S:ucon rubrc qlntenr firncrion-< r'en' 'n'ell in lo.n. light but r-s norstbmersible for sterihn. The CCD ine-{lraled-clrculr canreras are submcrsible and lm'e nruchless br:Ik but reourre ruore lighrhand trrtrurttenu: tnclude - lrocars. obturators and cannula-< lor elrrenng.iolnl sfxces FrrLr:kruves. r.:sF srssors- curenes and gBspult l0rceps or bssket l0rceps are also used Aven'uscfi:J hand lnsruntent i-< th( sufllon punch ulrich enables dre surgeon lo lu-dspussue and asprrar it lronr the.ioint uit]rout relDoYrnp tirc ul.slrunrenl

e.) fF\\,er tn.qrujlrents: lrroronzed cuners. shaven and airruston bum u,hich allos anirroscopltdcbridcnrent to procede at a much Ja-sler rarc

f) nrtscellarreous egupment: leg holciers nre pldded U-shefrd derrces u'hjch secure tlre lee dunlrsurgery. Jornt dtsracrron derrces are aiso availabic

.Anhroscol)ic Pon-als of tbc .Ankk'Thc ankle js dil'idcd lnlo froslcnol and antcnor.iornt qrvirrcs cech n'iti r medial. ccnrral and lrrcrajcoll'lJ^Yiruttenl Tiieli are fite ciassrc;nnals of tlic- ankle iorni. Tluee are jocated anrenorlr-and nr.c,rxrst eriorlr

snlenor ponds. antercrenlrai ;lond ts pleced fctl'een the crtenrcr tendors end g.rre rs exerosedtrot to inlure dtc antcnor dbial ancn or deep;rronerJ lren,c. ir losl an-lroscopic s-ur-een.ma]-b,(conducled througfr tJls ponal Tltc anlcronredial end anrcrolareral ;nnds are desrgncd for\-le\\lne medial or laterai gunet sruqures and 1or placentent of h:rnd or po\\.er lrsttlyllsn6gnnfxlsenor ;rcna-is. prserolarerai ilrd ;nserolrredral ;rcnals are placed.tus lareral or rnedial ro rjtc.Acltilles tendon Thesc are ancillan'yrcnals for eranijnrne dre ;-nsenor ankJe-iornt srucrures a1dlor rc:clung deep;rosenor lesron-.accessor-\'ponajs: an a€€sson'ponal is placed annlhere rr rs needed Tnru-malleol;u lnruj:have Lrcen descrihcd

.A rt h roscopic Tr:chniqutThrcc basic pnncip)es are rnloJved rn adroscoptc ntalreu\-cnJts

I scannine: a s\\'ecplng rlrolron from sicje-to-side ancj u;>and<ioun. Scanning allon,s a larpe arcato be rieu'ed,

I pisonjnr tno\ln€ t-he scope rn and out rrlich allorls tlrc ficld of rren. ro bc cnl:r.reed o;reduced

lll fqa!e!- tunti,np tJie anJrrosco;x on irs arrs. AIlou's a la;lger field of rreu due ro dre obbquq o1the anJuosco;r up

n;A n lr rosct.rpic Joi nt Pathologl

initjallv tlre anlroscopr \r"s srmpll' a d:agnozuc lr-slnmlent- horver.er uith t}e advent of hand eyrcir)J\\,er rrl.srruDtenurDorr tle udrn'of t}e artluosco;x is b<.corrr:ne nrdent.

I srnovins firger-like rill of hryrruophic srnorium Usuallv indicadve of underlrrng -lornrdrsorden

U. chondromalacra: this conditjon is arr arrlrritjc cirarrge in dre anicular canilage causrng clunges rnconslsenq'. te-rrure.colol and rc:ihence. The aflecred canilage nrus be debrided and dresubchondral bone e.rposed u'hich nill allou' fibroanilage fornuuon

ln. oseochond{al lesiondracrure: classif ed b1'Bernd-Hardr'. r-hese lesions are pinfirl andsolnedntes rlifficult to rrsuaiize. The Jesion lrrus be reseoed b1' probing tbe exenr of tjr-fraqure and abradrng or graqping rhe faoure nseU

l\;. impilgenrent lesions: bvalinized meniscoid bodres or bonds u'hich resno modon and cause pa_rnFasill reseqed uiti lruves €yaspers and/or sucrion furcbes

V erosions: dlscrele fcr:aj area-c of anicular canilage loss u'hiclr nral be abraded to subchondralbone arci replaced nith fibrocanilage

Vl. emerejne anitosropjc techruglles: artlroscopc saplrng or surun::g for chronic lareral anlJeins.abilln'ard anluoscopc ankle fuson rechrugues are berrg der.eloped

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ANKI-E FUS}ONS

l nd i ca r i t l n ra ) anllro$-(!1 5gvere angular defonrutrc) rrrcrnrable acule trdunlir

d) tnne tumore) cluoruc oseornvebDsfl failcd anklc prosthcsrsg ) frirahll c de/ontllu e-'h t ssl'r'age ol avasctrlar n€rosts of taiar kdr

Anklc Fusion Fi rat iona ) scrcl{sb) piatesc) DlrL(d t saP lc 'e ) errernal fi-rauon

I nt r:r- :r r1 icula r G rafira) Hallcrk: Lnne cluPrsb) Clruinard atrd Peterson, ihac u'edgi

c) CantylrcU. coflrco-Glnc€llous ibac -urafi rn vemcal fashton

d) \\;escon: -erafi from Pror:nral trbli:

e) Sutufler: s:Jvape for failed toral ankle pronhests

rnnccllous bone;ncted arouncj a corucal blcrcI:

ft \;an Gordcr and Chen: tihial irone grafi rnto ankle.iolnt u'itilout

Antcr ior Cnrf rsa) Gallie. inJar grafisb) l.'ennedr': aliogeruc,urafu uit} sapie fi'rauon

c) Hau:f;bular sPiked) Bntuln tibial graft through hole rn plafond

Posrrior Grafisa) C:rnrf*rlJ: fish ssieb) \\}irc: ilrac s'edgec) Gill: cajcjneal rvedge

Sl id ing Graf tsa) Cramer: slidrng ubra

b) Soren: sliding ubiac) Bl:lr. slidrng ubia rnto supenot asfeo of neck of ulu-c used fol

rL'sectron of tornt surJace:

avasorlu necro$s of talar trodr

I la l l tn lar Oscotoml 'al MalcuS. Ba]ourrr^< and Heiple : clterron oseolomv of nredial n'nlleolu-'

bt \\;ilson used onll anterior hah'es of both malleoh

c) Brngold' fihiar spike duough caicineu:

d) An&rson:bimalleolar resecdon cnshurg and used for cancellous grafi

e) lr4ead bimalleolarfl Gold-huait: 6hilag) Honrrrz: spljr fbula- ?f|dplact hau anreriorll'and half late raur

ilt a4r-r' spljr fihda- [r larenal haU on to fuson site and nredial hrU used lor ancellous chjpn

i) Gii ssan: mediaj malleolu<j) srerran and Harlq: bimalleolar oseolom.\' presenrng dle ourer coruces

l) Roval Air Force: fihia

292

Dorycl Fusiona) Baou and Fil ibiu. lrredial apirroach Llsng rnuge rnrensifrcauol,b) Hone: dorvel lronr alttenor lo pJ$cnorc) Pridre; nredial appro.rchd) Graiu:n: n.lrndncrJ libuJar grafi

ln tcrnal Frrat iona) Dooor's Hospruj: l lses l\r 'o 6.5 nrnr ancellous scrc\\,s f iom utrla rnro lalus

frrernaJ Fr-rationa) Chalnlerb) Mulierc) Calancirucclo

Posi t ion of Anhrodcsisa) saginal pl:ute rs lreuuzlb) ralgus (0--i dellrees.)c) esemalll roured (5-l0 degrees)d.; posenor drsplaccnrcnr of talus

l. counlenjo pull of rcndo Achil les2. presen'e pronlnence of lreel

Conrpl icar ions3 ) rnua {Ixrauve neurolascular urlunb) malunronc ) l l o t r un to l l

Inor.articulzr Gr:-fu*

Arrierior Tfri2l C'?ns

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. - - -

PLAST]C SIJRGERYPJ-AST]C SIJRGERYPLAST]C STJRGERYP]-AST]C SIJRGT.RYP]-ASTIC SIJRGERYPLAST]C SIJRGtrRYPLASTTC SIJ]TGERYPLAST]C SIJRGE,R)'PLAST]C STJRGTR)'PLAST]C SIJRGtrR)'PLAST]C STJRGER)'PLAST]C STJRGtrRYP]--ASJ-]C STJRGtrRYPLAST]C SIJRGE,R)'D i - r , . 5 1 i { S i - R ( J F F I ' iI r , - ̂ , 5 j j ( SURaji :Fi ' ;i , : _ r , \T l i , \ L r I t i i f F t ' , 'i-'i-.r, :-i i (' S L, Fl il i-: R )i , i A: ,T iC SUR. i ;FF.- :Pi_ i . STi i \ i ' i i { : iJFl , :

i : ' ' , - .1. r l t i : i j Rr_i l_ i , . ,

Plasf ic Sureen

\ \ ,OUND I IEALINGHeal ing b1, . f i rs t t ,uent : is the least compl icated example o1 u,ounci repai r . and is the heahng of a c iean. uninfecredsurgical inc is ion. approximated bv surg ical sutures

a. narrow inc is ion space immedrate l l , f i l ls wi th c loned b lood conta in ing f ibr in and b lood cel ls .b. Dehvdrat ion of the sur face c lot forms lhe scab.c \ \ t i th in 24 hours. neutrophi ls appcar on lhe margin of tbe u,ound

d. \ \ ' i th in 24-48 l rours. lhe cul edpes th icken l rom mrtot rc ac l ivrn,of basal ce l is . epi thel ia l ce l ls f romthe edges nt iprate a iong the cut nrarg ins of the dermis deposi t rng bascnrenl membrane as lhev move.Tl rese cel ls fuse to form a th in but conl inuous epi thel ia l laver

e. l i ' r 'da1 '3. neunophi ls are replaced bvmacrophag'es. Increased granulat ion l issue a l the inc is ion s i rcCol lagen f ihers are bee inning lo l t nranuf i tc tured a lonp lhe nrarg ins. bul do not br idge the gap. Thtrh in epi thel ia l ce l l la l ,er th ickens.

1 l i l 'da1 '5- Neovascular iz- r t ion is mar inra l . Col lagen f ibers begin to br idge the gap. Epidermis is bacLro i ts or i r ina l th ic \ens. and fu l l d i f fer ent ia t ion

t I )ur ing the st ' t ' r lnd u 'ec l i increased col lag 'en and f ibroblasts- Decleased to absent leukocuicinf i l t ra t ion. ec iema. and increased vascular in ' . Bcr : inntngs of b lanching due to increased col lapen andcicrl c:lsed vasculari lr.

h . F-nd of f i rs t nrontb. scar develops. incrcased tcnsi le srrength. rnaximal tensi le s t rength achieved inseveral monlhs

STAGES OF SN]N GRA}-T I]EALINGl. pla:;matic staSe: occurs 2446 hours follou'ing grafi appliultion. A fibrin laver is Jornred brru'txn the grafi and hos

bed utrich serves lo ancltor and allow diffusion of nurients to the grafi: inoscuharion stag'e: tJris sace bcr:ins at 48 hours and involves levascularizarion of the erafied tissue. The grafi uil l

dernonstrate a pink hue dunng this sage. Llmphatic drainage u'ill be established bv the founh to fifth da1,.:. reorganiz-ation st-ace: tlre process of raryanization continues lor nron$s fo)iou'ing grafirng. Connective tissue u'ill

reorganize and regulate vascular ard llmphatic flou.4. reinne .arion sage: crcurs simultaneoush,u'ith the rzurcanization sage. The prcress mal,reguire one to two vears

to comploc.

FACTORS INa/OLVED ]N SCAR l'ROGn-OSIS

lComprehensive Texthook of Foot Surgery]Fa ct ors EfI ects

Apc' ) 'oung patients may hlpenrophrRace' Blacks more l ikeh ' to h lpenrophr

Among u'hites: bJondes have a frnerscarlng l l)an brunenes

Bodv region' Foot and leg heal u'ell: related to\^'ouno lenslon

Wound course and pat tern" (See "Tension")

Wound Length" Ir4ultiple small incisions heal benerlhan one long uninterruptedinc is ion

Tension" ' l-ension

hlpenrophies a scatSkin rension l ines" Paral le l l ines e ive f ine scars.

anti rension l ines hlperuophl

'Factors lhat are unconnolled bv surgeon"Fadors that ate controlJed bv the surgeon

294

FA CTO RS I N- \\'OUN'D -H EA LIn- G- Pre-exis t ing d isease states.- r - \ u t r i t i ona l s ta tu :

l . Sk in C ra f r rThis iorm o1a ciolror sile.Classified as

a .

In fect ionpH

Oxvpenat ionVenous relurn

}TESTING SKIN' TENSION LIN'ES-Hrsron,of sk in l ines is ven,extensive. and verv bor ing..-Basicallr ' . RSTL is recogrized when a reg'ularh'shaped furrou, is creared upon pinching the skin area u,ith inder

f inger and thumb.-These l ines are o l ien perpendicular lo lhe long axis of muscles and thei r rendons. and of len paral le l to the ax is of

. io ints at the level of the. io inr .- )deal scar resul rs can be acguired by p lac ing inc is ions paral le l ro lhese RSTLs.- \ 'o t r u ' i l l qu ick lv not ice that p lac inp inc is ions paral le l to RSTLs u, i l l nor p lov ide adequare exposure to thc

surgical f ie ld. This is overcome br ' "z ig-zaginp ' ' or crear ing an S-s l raped inc is ion. The.se inc is ions havebecome ro be knoun as Anti tension l ines.

\\,OUNI) COVERA GE TECHN] QUES-Opcn u 'ounds musl be provided u ' i th cor 'erage. These coverape rechnrques are son. le of the mosr c lever l ' de* ised

and rechnical lv chal lenginp ro do in a l l o l surgeD,.-\l;ound covel3ge' slrould follou'a step-u'ise approach. The simplesr rechnique should be considered frrsr. lr

should follou'rhis u,ar,: Direo closure -> Grafts -> local f laps -> disranr fiaps-Thcse inc l t rde d i rect c losure. sk in r raf i ing. f iaps ( inc ludinp musculcru laneous and f iee f laps)- arr i f ic ia l sk in-

cul rured cel ls . amni \on. and xenograf is .

u'ound coverape involves rcmoving van,ing thicknesses of epidermis and ciermis fromand del iver ing i r ro rhe u,ound or graf i s i rc .

A ut ografi s. A I lografi s. isografi s. and x enograft s.I ) aurografis: a rissue harvesed and applied u'irhin rhe same indi'idual2) isq5afu: a lissrle h:r.n'esred and applied ujthin a ser of idenrical ru'ins3) allografu: alrc called homografu- tissue is transferred trerr.r,qn individrnls of the same

species4) renolnafu: alrc called hetelografu. tissue is rransfened bcru,een diflsenr species

Xenografu funqion onlv as biologic dressurgs and never area incorporared inro thehosl's rissue

Ful l or sp l i r (0.008-0.012-0.01 6-0.020) rh icknessl) split thickncss skin grafi (STSG): also called parrial rhickness skin grrafu. Onlv aponion of the derrnis is harvesred. Split thickness grafis are rhe mo$ corlmonlv used frergafied tissue. There are four gpes:

a) thin grafu: prafu with a rlrickness of 0.008-0.012 inches. Excellenr hosr rissueincorporation. hoq,ever. this form of -arafi conlracts rhe mog.b) intermediate 1rafu: prafus u'ith a thickness of 0.012-0.016 inclres. This form isnlore durable and conrraq.s less. horvever. hos incorporaricn is slighrly diminished.c) thick grafis: grafu u'ith a thickness of 0.016-0.020 inches. The rhicker rhe gyafiedtissue the less chance of hrn incorporation. due to €real€r tiszue dernands.DurabiJiqv and conrraoion are much improvedd) meshed erafu: this qpe of grafi can tr anl,thiclorress. bur is placed throu5fr ameshing device ufiiclr fenesuates lhe grafi rvith uniformly placed incisi6s. ThisProcess allous the 1rafi to expand permining srearer surf:ce coverage and prevenrss€roma and hernatoma from collecrinp ttneath the prafi. lnrerposed gaces heal b1epithelial mi-erarion fiom tbe surrounding grafi riszue.

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295

2) Full thickncss .skin grafus: involr,es all of tle dermis and pnnions of the superficialfascia. An1'supcrficial fascia or suhculalreous fat harvested musl be renroved pnor rograft applrcarion. The prinran'indicarion for this tlpe of grafi is crweraue ir,rveightharn!: aras or flexion Jxrints. Tire probabilrry of hos incorpnrati<rt is muchlrru,er than that of split thicklress grafts. Drnor sires usually include the rnguinal orpoplrreal fossa areas. Small full thickness grafis mavbe harvested lrom the fmt in tlreare:rs of the medial arch a:nd sinu-c tarsi. hrror site mus be primarilv closed or have asplit thickness skin grafl applied

3 ) Ap l i g ra f (SEE BELOS/ t-Advanrages: permanenl coverage. rechnical l l ,s imple. lou ' r isks. can be appl ied to a lmost anr

area of the bodr.-Disadvantages: increased fa i lure ra le over tcndons and horre. graf i contracture u ' i th spl i t SG.increased fa i lure rate u ' i th fu l l th ick l tess due to vascrr lar iz-at ion d i f i rcu l t ies. in fect ion or non heal ing donol

s i t e .I ns l runre nrat ion lor l ran,est ing: Hand(Bla i r & Humbv k l r i r ,es lor porver(e lect r ic , gas or baner iec jporvgysd dernratonres) instrunrentation. Anotlrer useful devrce is the graft mesher. The grafi mesher

scrves lwo purposes. f i rs t i t a l lou,s the graf i to lc lnarkablY incrcase i ts s ize. and second i t prevcnts thc

bigg 'esr con:p l icat ion f rom forming. seronla and hcnrator t ras. Anolher technique for prevent inp scromir

and hcmatoma bui ld up is v ia p ie-crust ing.

App l i ca t i on o f t hc g ra f i :a . graf i musl be in in t inrate contact u ' i th rec ip ienl t rs ,su( .

b. a l l excess f lu id must be removed f rom rec ip ient s i rec. grafi must slightly overlap the wound edgesd. suture graf i in to p lacc.e. prevcnl shcar ing of revascular ized graf i by bulk dressings{conon bal ls- f lu f fed gauze) securedbv srent l ie-over dressinp. Moistening 'dressincs nrav fac i l i ta te dressing lemoval la te l on.

Exccssive pressure musl he avoided. because r'ascular channels can be occludeci.f. l imb must be immobilized in cast or posterior splint.g. posl-operative dressings remain intacl for 3-4 davs

h. Srorage of skin grafts: a skin grafi should be harvesed and applied immediatelv. horvevet. excrssskm grafi nrav tr soled in saline or antibiotic solution scn\ed pauzr and placed into a 0-5 rcf igcratol

for uP to 2 I dars.l )ostoperal ive Coursc

a- Removal of dressings 3-4 days posl-op is done u'ith great care.

b. hematomas and selomas are recogniz.ed and punctured u ' i th a No. I I b ladc.

c. graft should be revascularizrng and "pinking-up'

d. r.recrotic t issue is to be removed.e.cornpression is maintained over grafi for several nlonlhs

Complications of skin grafu: An1, process uhich cr.rnucls lrelu'r*n grafi and hos bed is intcrrupted u'ill cause

slin grafi death.srrr)n)a: ilre mcR cornnron cause of skin prafi failure. A transudative fluid accumulation hrncath tJre grafi

utrich renrs ir au'av from the host bed. Seroma is prevented b;'proper appiicarion of a presswe dressing usuallv in the

form of a $errl dressing. The technique of "pie crusing" or placement of multiple. small incisicrrs rn the grafi will allou

dre scroma ro escape rhe the dressing. Fluid may also be aspirated from area^s of concaviq'.

hcmatoma: similar ro seroma blcnd collecrion bcncath tlre grafi u'ill also caust graft failwe. Hemosasis of

lalge b)cedrnp vessels is necnsary. however- capillary blecding is normal and leguired fu healing. i.Nqrmal capil)ary

blecding may be conrolled u'it} proper fencsration of the grafi and prcssure dressing applicatior.

infecrron: tneater rhai.;, 9Uh of atl skin grafu u'ill tale uilen the level of lraoer-ia is less than l0 bacreria per gtam o{

rissue however. ccrrain organisms can dcsrov grafu quickly'. Sueptrxrrcus pyoSenes and pseudomonas pyoq"n6

prcduce fibrinollsins ufrich disrupt the fibnin bond and deva-<tate the grafi. Slsemic antibiosis ha-s variable resuls in

preparing recipient r11.5. lrrcal rvound care is far moe imponant in reducing or eliminating infeaior.

296

A}LIGRAF

! )escr ipt ion: a v iable. b i - lavered. sk in construct : the epidermal laver (dul l - nrane f in ish) is formed byhumanlera l inocr les and has a u 'e l l -d i f lerent ia ted s l ra lum corneum: the dermal laver (c lossr , f in ish) rs composed of humanf ibroblasts tn a hovine ' )yne I co l lagen lanice. \ l rh i le the graf i conta ins marr ix prore ins and cvokines found inhuman. Apligraf does nol conlain Langerhans cells. melanoc\res. macrophaees. lrmphocl,tes. blood vessels or ha'fo l l ic les. Apl i -graf is ntanuiactured under asept ic condi t ions f rom human neonaral male foreskin l issue.

\lnd icat ions: for use s ' i th s tandard therapeutrc conrpression for the l reatmenl of non- infected par t ia l and fu l l -th ickness sk in u lcers due to vcnous insuf f ic iencv of greater than I month durar ion and u 'h ich have not adequate l rresponded to convenlional ulcer therap-r'. \

Con t ra i nd i c : r t i ons :. c l in ica l . l l , in feoed wounds' pat ienls u ' i th knoun a l )erg ies to bovine col lagen' pat icnts rv i lh a knoun hypersensi t iv in ' to the conponenls of the Apl igra l a larose shipping medium

Hor l Supn l i ed :' sealed in a heaqr pauge polvetlylene bag uith a I}otn CO.lait armosplrere and atarose nuuienl medium. should he kepr in the scaled bag at 20"C-3 l "C unt i l use ( for s ingle use)' suppl icd as a c i rcu lar d isk approximateh'75 mm in dramerer and 0.7-5 nrm th ic l .. slrould he used u'ithin 5 minures of opening' ' l

o lna in la in cel l v iabi l i r r ' . the product is ascpt ica lh,nranufacrured. bur nor rerminal lv srer j l jzed

l ' rc t rarat ion of l l rc \ / t 'nr tus Ulcer \ l 'ound Red Pr i r l r to Ar l l ipraf Aprr l icat ion:' \ \ 'o t t l td ln lec l ion: graf i should not be appl ied over in lected or derer iorar inp u,ounds unt i l the under lv inp

condition has h,r:en resolved' l lactcr ia l Conla innrr : n l : Anl in t icrobia l apenls mav be used dur inp lhe rveek pr ior ro Apl igraf appl icar ion ro

redtrce the risk of infecrjon. Dakin's solution. lvlafenide Acetare- Scarler Red Dressing- Tincoban. Zinc Sulfarc-Povidone- iodine solut ion- and Chlorhexid ine have been c ierermined lo be crroroxrc to Apl igraf

' Wotrnd Iltd l 'rcparation: prafi should be applied to a clgan. debrided u,ound afier rhorougfrly irrigating thcu'ound s'ith a non-cvtotoxicsolution. Oozirg or bleedinp rcsuhing fiom debridernenl should besroppedth lough lhe use o l gent le pressure. Previous u lcer l leatmenls other lhan srandard rherapeur ic compressionshould tx disconrinued

. C()nt rol of H carl ' Erudation:Hcart exudat ion ntav d isplace Apl igraf and reduce adherence. Exudar ion should be min imized bvappropr iarec l in ica l l rca lnrenl . l f exudat ion pers is ts- Apl igraf should be made permcable ro cxudare by per forar ing the graf ito a l low for dra inal 'e .

Sugge-sted Technique for ADpl icg l ion of Anl igrat :. Prepare a srer i le f ie ld and a l raumal ic inst rumenls: fo lceps' L i f i o f l the t rav l id and note epidermal and dcrmal laver or ienrar ion: Apl iuraf is packaped

(dull. mane finish) layer facing up and the dermal (glossy) laver facinp doulu'ith the epidermal

' When Iif i ing Apligraf u'ith alraumatic forceps- be careful nor roperfcrrare or l i f i rhe polvcarbonare membranebenealh Apl igraf

' Apligraf should be placed such that the dermal laver (the glossv laver closes ro rhe medium) is in direoconlacl u'ith tbe u'ound surface. Trim Apligraf so as lo co\,er the u,ound bc.d u'ith J/8-l/4 inch mareins

' Secure Apli-eraf u'ith a three-laver dressing so as lo assure contad ro u,ound bed

Follorr-un: Tbe u'ound should be inspmed and the dlessi-ng changed al leasl once a rleek during the immediarepos application period. More fieguenl changes may bc reguired on highll, exudarive u,ounds. Additionalapplications of Apligraf ma1'be necessan'. The safeq' and the effectiveness of Apligraf have nol been esrablishedfor patients receiving €rrealer than 5 device applicarions.

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291

2. Skin Flayrs

iiil"iln :l i:"t,'fiiiil ffl:,,? "''' sk rn naps'"r,in r h.i,,'ascu rar suppr.r

thickness. paddrng nue, uon.l,prominences. I p(rcI 'ascularit-v (re' bone and tendon). reconsrrucrion of full

resrorat ion oJ sensat ion to an are€. co\ ,erape of areas regui r ing ,n op_r t ion , , " ; r , . , ' date. and'I

crnrinolr-gt,:Flap - refers to the tongue of t jssuepedicle - refers lo lhe base or stcm of rhe rissueClas.s i f ica l ion: " rL tJ) }ur

A. \ ;ascular Anaroml. Classi f icar ionl ' randonr pancrD (curarrcous flaps)- derive lheir bJood suppry fiom the curaneousj,.ff1il$:l;,ni,.^* 11,.),;;;;,lo'rr;.r aneries. rlese,are rimjred based on rrreirrh;;;;.;ffi ;.#,11.::li,Jilll.l5:;i:il,",Hlhil]i:l;ilfl,,;.;il,;,Hl

proccdure can be used to irroeir-se ,r,. of =uru,rut2' axiar parrrn (aneriar f iaps)- o.rrr. rr,.; ulc'd direcrr-r, ftom aculaneous anerv. Thtsurvi 'al in these flaps are cieyrs'cignl on lhe din)en.,un. oi,},..r,.rr,.no the rength oi*:,ffiT":1:l:,:;'"t'

r)or on the ur'dth of rhe peo;cre. trampres are rhe dorsaris^.,,, ",0, lf l;'J :i'#il:: t,tb' f ree- / rups - r ranslcned f rom disrant s i re. I rJ . l r common in podiatn.

B. 1 ra,r-sprx,,,,, fl"'lil:fJ,t:: rarissimus dorsi r,onrr.'

l . Lrrcal f laps - ad-jacenr lo the derecl.a. Rotationol _/irlps (rotalron. trans

the pedic l t ;post l lon ' mterpolat ion)-p ivot abour

Rorationar -f iop - rdearv the flap shourd be a harf circre. Movemenr isin a lareral orientarion. .J ensron rs relieved b-t,Burorr,,srriangler excision of the rrja7 t onspositio^t ./.ap "#l:l;,*ff:l ';'lr.#::J:113.,,

;, ,,a, arc. Erarnple: bi_lobed flap. Limber* flrp(r;;,boid defea).b' Advoncente nt.fiop: - mo'ed d;;r),foru,ard ro co'er defeq- u,ithourlareral or rotarionai ,nou.r"ni.J"k.. ,d,,rn,rge of skil elasicjn,.Examples: V-y f lap- y-V 0; ; ' o"(dFc u i sxnl

2. Disunr flaps-indirecr disrant.f laps seldom used in pcdiarn.-direo flaps - primaril.v,rf rn frorn l_o.jaccnl areas

#ff*#i[:r".,{& ;;,. *, 0,,* and r ascu,arjnr viabre,*on"i??iJ;ftl:'5T:'o'I:lol:.,,d.,

-''2. poinr "nolrc of rorarion o;;;;;""".rnant

vascular pedicre

3. rbe eflecr of rhe loss "f tu";;";';;rh. ,u...1.

*rrj:.sr}l. size of the cuuneou, ,.plrn.n, ro be rransfened wirh rhe

rhan rhe ,,;t:'rttn:;',r13."iiil, suppon a cura'eous resion 50o% larser

Lou er Enremin, Coverage nitbUppet l/3 of leg. .

Middle ) /3 of )eg.

muscle flaps:gastrocnem ius;soleusmuscle bell iesgasRcrc./soleu strDLt

298

2 . D i s ran t f l aps

N4rddle l /3 of leg

Drsra l l / . i o f le-c.

Heel . .Belou lnedia l mal leolus. . . . . .Belon' larcral malleolus. . . . . .

l - , r ru s; I -rrrcmir l Cor-sp;1.1, u. i th nruscle f laps:l-rprrer l/3 of leg. sasrrcrnen.uus/soleu:

nruscle trellres

-rndlecr drsunt f laps seldorn used rn podrarn^-duect f iaps _ pnnrarih.taken from acjracenr arca:

IUusclc d. l \ t locrr t : r l rcous FlapsTrre ad'alruge of rrre lruscre flap is its' burt arrd 'ascurarin .Preo;-rrarr'e consicierarions for muscle [a;x sirou]d rnc]udc.r. r ' lable ren-rt ' of thc muscre on rhe don,nanr .r.ascuiar pcdicrc2. pornr and arc of tourjon of rhe flan1.. rhe cfJecr of the loss of funoron of rhe lrruscir

I ;nssible sze of the cuti lreous sep.nrcnl to be transferred rrith thctttuscle ' l l ttrscles can- generalh. suprxn a culalleous regron 50026 larperrhan the srze of the muscle Lrclh

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SXIN PLASTIESl. Derorarional Skin plasn.

Jndicarions: congenirar crinodacn'rr '. anhropram,of rhe fif ih rcxccncral Principlc: skin u,ej-ee-rn-ust be placed per;rndicurar ro rhe arrs o1 rourion of rhe roc'AJso' u'edge renlo'al sJrould oti lr 'Lr deepered ro derrnallsutre.tu'crion. rn order lo presen,cneuro\.ascualr com;rcnents _ unless erposure ts crjt jcal

l. Z-Plasrr^t-ssent jallr- a trans;rosition of ru,o trrangular flaptGt,ncral principlcs:

-consider the gain in renlnh at the errrnse of rran-sr.erse shonerungCircu mven red usrng m uJ riple smaller Z-plasrre:-shouJd br planned so rhar lhe scar rs jnrhe RSTL-arms of the Z should be egual-rhe an-ere of f lap rips are idearrr.angurared 60 degreesrro ensure a suffcienrvascular base).-t}e tip is secured u-sir-e lhe Lambodr sururerinurdermal ar rip and manress arslor).

Compl icat ions:-up necrosis due to tension. scar rissue across base. dssue undermining.

299

i- \r-) ' & )'-\ l Plasues^a popular tecluuque for skin lengtitetuttgG t ' nc ra l P r i nc ip l cs :

*]r4arntarn a rr"ide angle \/. lor opumal blood supplr*Apex shouJd be prosrntal*A V-) 's i l l lengthen rn one p lane. and the ) ' - \ ; u i l l lenr lhen in theolherqlerpcndrcdar; planc

{ . Redrrndant Sion Plastetl{en:trn bone renroval procedures rri l l crc-rte s}cn reciuncjancr'. n'hich can causeunacccptable cosnresis. ]r ' larrl of the lrrres tl 'o senri<llrprrcal rrrcisions uil l correcl t lus surgicalprobiem

-i . Double S lnc is ion-use r r ' l rer r inc is ion rs ven la lpc

6. Suciacn'lzatron-Goal is s tabi l r t r ' . Uscd r rhcn one d-rgr t rs f la i l . and the ad. taccnt rs s tablc .-usual.h' a salvage ptocedurt

I )OG f ,AR REPAIR-DoF-ear is a terlr to descri[re the bunched-up l]rsue that rlal der,elop dunrrg uound closure^{an of ien t r avoided tn 'usrnp cross hatch l rnes across p lanned inc isron sr t r^Smsllel dog-c:irs uil. l f letten u'ith trnre. but larger do!-'-err: nral bc cosnrctrcalh drspleasrng-These ale casilv recti.f ied br exendrng the jncisron alon.e the dog eal and allorr-rng tJre flap to

. rotalc-^Orlrcr rcclrnrques describe cunrnp rvedecs out in l lne uith RSTL:^Anot l te l nrcasure used is lhe Bulou ' 's tnanelc

\ \ ,OUN D AI ' I )R OX ITIAT) ONI . Suturesl . Stcnstr i ;x

. 3 Suplcs' advan taoes : Oreduce i nc idence o f i nJec t ron

Oreduces overall cos ol surgrcal prcrcrdtue

, Oreduces pl's e\T)osure to aneshesla and tournrqucl l lnrc. a .

disad' , antagcs: t 'cosmestst: anatomrcal ltmitatrons

. \ \ ;OUND EI)GES - GENERAL PRINCI}LES-To e nsure 699lsssed scar fornration. cenain general pnnciples nrusl be follou'ed

) handle lt ssue -Penllr ': )reapprosintate the dssue anatonricalJr

)close the dc-ep ussues lo decrease tension on s f: i n

)use lcas lc.: icltve u'ound aPproNmallon delicesi )u-se l l ie profrer tauge of suture to rcapprorimate lo remove lhe lensron

)sufruticular closure provides fot ercellent cosmeltc results

)Planur rncisrons uil l regurre sulures to tre lefi ln for 3 n'eek. nons'eightbcannrt

I ' .dT\'AGEI\IINT OF XELOIDS AI\D II)?ERTROPB]C SCAR.S-keloids and hlleruophic scars are berugrr groufr-< characterized bt' an or.erabundancr of col)agen deposiuon

' -borh tend to br prurirrc. raised er.rthematous. and nodula:

. -r11q' drfler rn *rat rhe keloid exends bevond the orig:nal incision stte. AJso. h1';xnrophtc scars s'ill improve in

appearancf,. rlhi|e keloids tnil\' llorsen.

300

-N el oi d-(' occur -most,freguenr h-i n -a dol escen I bl ack-\;en' inrpnn:nt ro do a thorough hrsron.and plrvsical preojL*rali 'e]\' l

rcarnrcnl : there are nran ' r modal i r ies. none of r r .h ich are cor1srsrenth.succec<fu lI rrearnrcnr should nor bcgrn ress i lran 6-12 nronrlx;rcsro;rrari 'elri Surgrcal excisrort ls I ltole applicable to hrlxnlopirrc scars than ro keloids. cornbured uitlr one or r.!roreZ-plasjes ro decrease lhe lensjon-' Use of nonebsortuble sian sulutes rr'ith the lc.:lsr rqrcrirrn'. re poi.rplopllene. su-rgrcal sreel. or nr.lon.Re'o*e sulures in 7 da*s to ' in i l r fze i ' f lar ' rnaron.reacro '

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Stno adherence to at raumarrc rechruouclr4ainrenance of good henrostasrsPosloperattve trradialton and conicosteriods alonp scar rl i l l rrrrpro'e porelrrlal results. Conrcosrenocl<rvil l decrcase the level of coliagenase inhiblron and rherebr' ,n.,"r.. coliagen ciegradarionTnamcinolone acctonide a0 m5r'l(x)ml ts thc prcfened drug c.ere should be uken ro kecp the druguithin dte scar. alrd au'a.r.fronr the surrourrdrne lrealrht rrssue. lrr. iecttons are prefornred 3_5 ueek:a;'ran \\4ien used *ith sulgen- should in-iect i n]o-n-th pror ro.uig.^'. and for l-: l *,eek-< posr-opPressure over t ' l te scar crceedtng 25 nrm Hg for 4-12 nronr)x Thjs decrecs.a.,"..ut-^]. rr.hjclrtherebv reduces cellulal respol)s€ and collagen cjeln-sirron

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N'ETATARSUS ADDT]CTUS

Dcf in i t ion:srrrqural or positional medial cjeriat ron of t ire memursals rn l ire uansvsrs€ piane rrccurring ar t irtutrs{rnr eularsa I an i cu lat ion. Enorrtouslv terrned one-third oJ a clubfcnt deformir.r,as coined bv Xire ( l9-50)

i''H*i#:s a'� nrirrrarsa'� ioin

I nc ide n<'c :. l/ l(X)0 l ive births. Risk to second in famill' 120. 4.stlo lo degrc= relatives similarh'affecled. No scx prtdilmiorr. 50oh bilaleral. \\rircn unilareral fien lefi nrore c()rnmon tlran ria.hr

l l is ton ' :

Henke ( I963). Gcrman literaturc. Fu'st to nrention adduoi<xr of t}e fore pan of the fcrx udt} r,algus;nsirion of the heel

Bankan (1921 ). Firs lo rcfrrt in English literarure. Tlroug.ht dcfonniqv uz-s due to absc'nce of the "inrernal" (medial) cuneiiorm hcne

lr4cCormick and Blount ( 1949). Coined the term 'Skeu{cnt'-

Xr te ( 19-s0). tnonrnuslv termed "Third of a Clubfmt"

Etiolop'- Unknownl

Theories.I. Genelic: Abvislrc medial cuneiform3. Intrauerineposition

. Lrfi sided car4

. Prima Eravida4. Envircnmenul

. sleeping posit'iqrs - trelll'sloeping5. Arres in faal development6. lr4uscie imbalance

. htperactive abduoor hallucis

302

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slroncned muscles (AM hall / T- Pos) .rarn nrclranical advanrage over ienghened muscles(Per oneals')

Abnorm al murcular insenions. N4edial insead of piantarmedial insenron of akirrctor hallucis onto prox.imal phaianl. Tibialis anterior entireil 'onto l" mgtaursal insed of combined insenion u'irh medial cuneiform. Tibiah-c Poserior primaril l .onro mediai cuneiform rnsead of navicular

Abscnt nredia] cuneiform

Condir ionslnternal t ibial torsion ( l6-48%)

Con g'en ital h ip d-rspla-sia ( 1 .5-'l 0%)Clubfocx\\rini-su'epl delonniN (lr4er adducrus on one frni and calcaneal vaiuus on tite other)

Aswrciatcda

Subjrrctive Corrcerns. ]n rmin!. Trippint. Difl iculn,u'taringshoe.. Lrteral shcr u,rar panern. Bunion and lranrmelo+

Cl in iu l Fcaturrs:

i Unconr;rcnvtedr f -s l raf redlcrx. Convex lareral border. Concave medial bordet. Prominent 5d'rnet ba-sc. Separation of Ecat tcr from lcsser toe:. )Jigb arch

2. CcxnpensatedSke'u{o<x (flarfcrot)

. Adduqed forefoot

. Midfcrn larerallv translated

. Hindfmt valgu.. HA\/' Digiul contradute:

Cliniccl Examlr4ust dererrnineI . Fesenc€ of tendon conuactures / hrperaoivin

. Lichtblau test: t-be heel is sabilized -{o met head is braced and larerai pressure is applied ro r}remedial a-gec of the I'meutarsal head (abduqq-r'suess)

. A tight aMuqor hallucis uill ap;rcar bousrruneConcomiunt presence of internal n'bial torsionEouinus?

303

. Component of clubfcni

Flexible rs Rigid?. If rigid then corrservarive thcrapv and rcfi tissue prrccdures are likelv to fail

Rad itryra phic F-r'a I ua tion

I ]r4eraursus Adducn:s Angle - rraditional. l.\onnai = less than 2l deg'rees is a reou-. foot. Pathologic = ;reater than 21 degrees. ConsisLs of the longinrdinal a;i is of the midJmt and the lonuitudinal oiis of the nreuursals

scncond maararsal serves as a reference). Line bisecrrng the talar hcad and cxcndinp disallr' uill fali medial to firs nraahrsal rn

addrrcrus rather than lareraliv as sesn ;n uljpes oqurnovaru(

(ufi ich the

nlelalarsus

lr' lsararsus Adducn:s Angle - Simplif ied [Engle's angle). Uriliz-es the bisecrion of the sccond nremursal and brscxtron of tire middle cuneiforrn inscad of the lq;ser

tarsu-s axls

Taio- Io nremtarsal Angle - (Simons' Argle). N = 0 t o - 2 0. Line histuing the ular head rvill fall nredial to the firsr lneutarsal in nrcraursus adduou-s {ne.r:ative) ratlro

than iarerally'as seen rn taliprs equinovarus lprsitive)

TalocalmncaI angle O(ite's Angle)o ).J = 20 - 35 (AP). pN = 25 - 45 fl-ateral). This angle is normal or inseased in meutarsus adductus and dq:rcased in TE\/

Bisecrion Point-s ofl,esset Tatsu.

l-esser Tarsrs Aris

304

Jr4 q ararsus A dduou-s Ang lc

rs Clubfint CIEV;

Clinical Contnarircn

lr,1 aararsus A dd ucrus An g I cu i l iz in t Encle. 's Ant le

Nlcurtarsrx Adducru<

lr4euursus Adducnr.. Adduoed forefcnr. lareral navicular sublurarion {or normal). ljindfcrx neur'al or rak'u.. No equinu-.

Rad iosraph ic Com parisonMeratarsus Adducru..Simons' a:rgle. PosiriwKite's a::gle. Normal or increasedTa lonavicular relari onship. Normal or lareral lravicular

Crnsen'ative Thcrapr

l. Pessive suaching and manipularion (up ro 3 weeLs old)l. Serial plasa casrrg (up to a€e of ambularicn )-1. Modified Furlong asr4. Modificaricn of sinmg r sleping fnsiriqrs-\. Onhcric: devicer6. Shoes / Splinr-.

Biomecbanicallv sowrd. Ganle)'Splinl. Bebar. \Aheatsr brace

Clubfcnr. Adduoed Forefcn. ir, ledialna.r' icular subluxarion. ]Jindfcrn varu.' Eguintr-'

ClubfmrS imons 'ang le. PositrveKi te 's anple. Dccre-"sedTa lonaviq.rlar relaricrnsh rp. I4edial

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TI-IREE POINTS OF PR.ESSURE:l. Ahducrion at medial side of firs nreutarsal head: Addrroion at lateral side of cuboid

-'. lnversion at heel"' lr4usl bc nraintained to avoid ral-gus lorgue on hindfcn

. The frnt should be nraintained in the c<lneccd ;'rnirion ftx a rilne at lea-q a-s lonp as it tcr* to gain theciesireci correctrc,n

Surgical Considerat i rms

l . A l co \,oung9r paticnl.s more arrtenable to sofi tirsue pltteriure.

: lJas cnnssn'ative drtrapv h*n ancmpted?. _q4ll allempt consen'alive thcrapv up to the alle of -(

:' Corrc'rrrriunt deformitie.. )nl t ibial torsion. residual clrrbfoo;. sevcre p<:s valgu-s uith HAV and hirmnrenrr defornririer

1. Scverirv of deiormin' dre ,)lore s('\,cre the deftrrmin'dre greater t lte lc:isanct ro trcatnlsnl and the nrore altprclisive rne ner:ds to

be in swgeltI CXsrxru-s maruriryo. Flexible or rigid?

. the trvo aLxx'e are related- u'ilt osseou-s maturin' lhe nreurarsal hases sguare ofl zrrd the deformiw b€comesnrore rigid. As the deformil' br,romes more rigid rcfi tissue prmedures are less lileh'ro achieve rhe desiredconcction.

. J-orccful nranipulation of the rigid fcxlt mav force rhe hindfrnr rnro vai-e.u-.

Suryical l-realnrcnl

Guidel ines:l. Ages 2 to 6E vsrrs

. Sofi tissue Prcredure':. Ages 4 ro 8 vean

. Gra-v zone. Too old and tcn advanced osseotl.s manu-in'to perftrrm sofi tissue procedures and vet not quite

marure enough to frrftrrn clrseous produres

. Ossrxlus procedwes

.S pn__!.t$!g_p1 oeedg-€,

I . He.rman. Hcrncion and Suong procedure ( 1958). procedure initially described using a Eansvers€ incision aqoss Lisf-anc's joinr

r tluee dorsal. Iinear long'irudinal incisions nou' useri more cornJr'lonlv to avoid neuon'a-scular crnbarrassment. reltase dcnsal. interos-seou-. and planur ligamens along u'ith the joint capsule. IlJodified HHS nou'more corruncn (len&ick a al.. l9'10'l

306

1

r prer€t-v€ qf_{q }areral ligamarls to prevenl dorsal di.s}oczrion). Compl icar ions

. Dorsal dislocarion

. De-r,elterarive arthriris (Srark el al.. l9E7 t

Thomson prcredure ( I960)' Rq;ecrion of abduoor hallucis mu.scre bcil l ,and medial capsuroromr

Lichtblau proccdure ( I975). lr4odified Tholnson procedure' ' l

elr 'r,rn'or paniar reseqion of ahducror halluos mu.scre

L-aPorra zrrd Sokolofi. Tibialis Jxrsrerior rendon leng,thening, u,ith talona'icular capsprot6mt,- usuallr

H-H&S or Bernran-Gan land prcrctduresused rn con-iuncrion u.itJt

GmL?n e ( Qg4j]dcl it q5praggd ules)

l. .lohnson rvecjle ch<lncjrortxn_v ( I97g). R*r:critxt of larcrall-r, hased chrondrort-ltries

()sl(:)lolltv on the firs meratarsal. iu-s disalh'm the birse. of 'rcrararsars 2- -5 iarerarl'ba-sed crosrng r^,erigrto tlre cpiphrseal ulorrl l plslg

Osseous rrcrlC_\rres:

l . Bankan (1921 ). Advrr:red excision of cul-nid

2. Peabod-r, & lr4uro (l 933). Ercision of the bases of rhe three ccnn_al meutarsals. Oseotornv of the fiflh meuursal' Ir4obirrz;rri'n and rur,-arion of rhe firs mei-aL's:ccuDeiform-ioinr' Con ectton of anl' abnormal inserrion of t}e tibialis anrerior rendon

-1. Mdormick & Blor.rnr 0949'). Arthrodcxis of the firs meuursocuneiform. Os erx om ies of m euursals 2_4' \\/ed!'e ru:eqion of the cuboid

4. Fou'ler ( 1959)' o;,-ninr: r*ed'e oseolomr,of rhe mediar cuneiform with bone srafi

Ste.r'rler & \/an Dr \\'alt 0966)' Ba'se *'ed!'e 'a/ ' shaped" oblique osecxomies of alJ dre meiaursals }atsalorienred base: apex - proximal)

Berman & Canland 0971)' hoximallv oriented crescenc-ic dom+shaped cneoromies of eac} of the me*,or-s?)s' osreorom'made at reas 6 mm disar to glourh ptare of ls meuursal' Firs and fifilr me{aErsal oseotomies 6red u'ith Sreinman pins: secon-d third and foun}r no fixed' Popular prcredwe rodal'

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Modified Bcrman-Ganland laoualll'the StsMler & Van Der \\'ah prcrcedure). -Tran

sver€'ElGing- idu-a on-hase u,edpe os ern om icx of- a l hhe m erararsa i s. lr4ultiple fixation technrt;ues for all the nteraursal oslmlornie:. Popular procedure todar

Irpird prcrcedure ( | 982). Obligue cl<xrng aMucrorv rvecige cxrerxolnies on ls vxnerimes (due ro epiphlsis) and somaimes the -sth

metatarsal:. Rotational oblrque ba^se oseoromies of lnerararsals 2- j

. Rotational oseotomies slrould paraliel the sound sup;nnrnc surlace (thur ua.nsvers€ Dlanrnrorion')

. Technique; medial conical hinpe init iallv prc:en,ed for srabil in,. rire screu' is piaced perpendicularto rhe sup;xrning surface but ncx tighrened the medial conex is ther tra;rsmed and the maaursalrs r orated ro iLc conecled pcxiricn and the screu, is tiehrened

. Popular prncedure todar

E.

9. Brink and kr.itskr, ( I 99-5). CurciJonn and q-rboid wedpe oslcolonre:. perlorrned thrcxrgh ru,o incisions. Sraple and X - ryire fixation

"tNotc: the al-xrvc prrrrxlurtx urn be performed alone or rn crrmbinatron 1ec. Forr,lo and nrodificatirxrs of the Bankanprcredure)

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Jolu-.o:r rstcuub-rndruromia

.lohnsm osr eoch on dr ot om les

308

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Lrpird

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Brink & Levinskr

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309

- -CLURFOO]--

L ConPeni ta l :A. Posrural GxtILq;l!,):

1 . Def in i t ion: Forefoot AdducrusRearfoot \/arusAnkle Equinus

:. Mild flexible defornril 'u' ith normal anarc)nr\

J . Et io logl ' : ln t rautcr ine malposi t ion4. Prognosrs: Gcrd5

' l reamtenl: Conserl 'ative

B. Ia[pes F-ouinovarus (]ntrinsic):

l . Def in i t ion: Forefoot Adductu:Rearfool \/arusAnkle EquinusTo I on at' icu I ar Sublts ar ror'Lueral Rotar ion o_{ Toius tn Ankle }r'lr.trttsi

? . Sevcre- r ig id delormin 'u ' i tb pathologic analotn\

3. Prognosis: Pcnl4.

' l ' l catntcnl: Sureic€l

11 Acqur led:A. Neuromuscular Diiqrders.

l . Pol ioml 'e l i t isI Mcningi t is3. Cerebral Paln4. Spina Bi f ida-\. lr4yelomeningocele6. Pos-CVA

ts. Pos-l rau-qat:ic:l . Spinal Csd I rauma2. PeriPheral Nen'e l-raumar. Tencion Lacelation4, lr4aVn\crr-Union5. Volknran's Contrac lureb. Burn Contracture

l l 1 . H i so r i ca l Rev rcuA. 1210 BC: rvall etchings of pharaoh Siptah u'ith clubfoot deformitl

B. I (100 BC: l" dcscription of clubfoot in lndian l iteralure

C. Cneek Mybologl,: Greek God Hephaesu-< uith bilateral clubfoot deformities

D. Aners: made splints fiom cacrus leavesL. 300-4()0 BC: Hippcrrares thouptrt etiologl'u'as inuauterinc ;xrsit ion and recomnrended manipulation

and band.agingF. 6d - l -st Cenruries "DorA ond ]rliddle ,ages": markcd those u'ilh a clubfoot deformin' as the devil

G. 156 - l6d'Cenrun, "The Renoissoncd': reneu'ed interesl in clubfoot deformil

H. I ?82: Lor enz advocated achiliis lertolomy for D eatment

1. I 803: Scarpa believed osseous changes occuned secondan'to sofi tissue conuacnres

J. I 83 l: Srromel,er performei achil l is tenolom), on a recurTent clubfoot

X. 1839: Liule (Suomel,er's srudenl) had a clubfoot deformiq' secondar-v to an infanrile febrile djsease.

He rlrore the "Tr eanise on tfu |iolure q{ CIuQ{mt & -4nalogctus Distonionr''

L. Lare 1800's: Aggressive. radjcal Deatrent u'it lr forcible manipulation (Thomas Wrench) and resection

of large tnne *'edges

M. 1933: Xire had an 8tj7o success rate u'ith consen'alive tbo-apy consisting of gentle manipulation u'ith

plasa of paris splinring. Xite's angle (talocalcaneal angle).

3 1 0

t-__J \\ .J g ga _ I _9 6 9 : S r . g ed-pi ecem ea I _s o ft - t i.ssu e-r.e I ease

o- I 97 | : 1 urco rec{)mmended a conrprcirensi ve, posr er om edial reieaseta lonavicular - io inr

I ) . 1982: McCay acivocared c i rcumferenr ia l re ieaseO. I98-<: Sinrons a iso advcrcaled crcum jerent ia i re leaseR 1962: Craut 'ord developed rhe Cinc innar i inc is jon

lnc idencc:A . 2 :1 l r 4a le ;Fcma leB. -507o Biiareral lu'hen unilareral fughr > Lefi)C Po l - r r res ian : 6 .81 /1000

N4iddle Eas & Sourh Afr ican Biacks; 3.5/ lOtX)

rr.irh remporan,fixarion of the

R h i r e : 1 . 1 2 l l ( ) 0 0

As ran : 0 .571100 ( )l). ATttst < ttntnton potholugi< , r.ttnytnitul _fttot dcltrmin.: 2.2g/l 0lt() lit,c hinhs

Et io lon, : I l ) )OPATl l lC- possib le lacrors inc lude :A. E:q4fic & lnr:up1rn-C4d faqu1.s

I lnrraurgr ine malposirion: )-i.rppocrares 4f)0BC: Crrmnlon Pcroneal nerve palsv secondan'to intrar-nerine position (anrerior muscle weakness):

\\trre 1919- ' . Anrniot ic sr r iou le:4. Diseases: Diaberes. nrarernal h-rlorlrermia

6. Raci iar ion1 )r,!alnuuir ion6 Viruses9. N4uhiple Ilep-rancres

B. lnu ins ic & Anatomic lacrors:I Gtrm J'losm DcJca: ma)position of head and neck of ralus: lranj & Sherman 1963- & Shapiro a.Glimcher 1979. Tne mol w,idel.t, octepted eriologr..L Anesr of feral de'elopmenr ar -cb *eei of gesuriJn: Bohm 1929:' Ansial d-r'sgenesis: absent or underdeveloped anrerior ribial & medial planur aneries4 ' Anomalous tendon insmions: Planlar insmion of TP or media l insmion of achi l l is & pL5. Muscle maldevelopmenr6 Congcniul constricrion bands: Xeith 19407 Uner,en rare of bone and muscle g,routh: Bechrol & Mossman l9-50E Conu-aqed delroid l igament: Hirsch 196()

C. Herediun, facrors:1. Aurosomal Dominanr

Aurosomal RecessiveSex-linked Recessive

2. Race Predilecrion3. Unaf{eoed By: Birrh Weighr

Birth NumberMaremal Ape

4. lncidence in Twins (ldelberger. 1939): ldenricat: 32.5otoFratemal-.2.9/o

2od degree: 6 fold inoease

6. porvs en ic. m urrifacr oriar inheriran ce *,i,h r."- r;;itflI;iiot " *t'

The nurnber of abnormal Senes Dust erceed the *reshold- Females bave a higher rolerarce:thetefore. it takes more Senes lo creale the deformin,. Srnce so many genes are required- thedeformiry is usuall l 'more sevete in females. Males have a lou,er oreihold: rherefore, Iess genesue needel lo creale l}re deformin' and ui-ren it is present it is usually less severe.

ttIrthI?I

tIII

rt

)

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It

l',

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3 1 1

---_]ll. Pat}oioeic Anatomr':A . Ta lus

l . Reiuced size

vil.

vtlt

:. Head & neck anpulared nredial and plantar

4 . Ta la r Dec l i na r i on Ang le = I l 5 - l 3 -5o Norma l = 150 " t

B C.p-lsa!-9!--':I Normal shape:. Possible underdeveloped susrenraculum talj

1. Planrarmedial angularion beneath taius (equinus & r,arus)C. i .Navicular .

l . Normal shapeI )Jt,Jrcnrophicruberosinr. Plantarmedial sublu;iation1 )r4av aniculate u'ith medial malleolus

D. Sofi TrsSu_91_41,o!ec! in deformi!q-.:I . Skin. la.scia- retinaculum- r' inculi ( lr4aser Xnot of Hcnn,).. ioinr capsule. l ig'zurrenrs- rendons.

nruscles. r,eins & aneries. irnd lrerve:I

' l-endons & lr4uscles.

a. ))osterior: Conrractedb lt4edial: Contraoedc. Plannr: Connaaeid. Peroneals:Elongated( . Antcr ior T ib ia l : Dorsomedia l d iso laccmenr

3. L i .camrnts.a. Calcaneofibular: Cotrracredb Postcrior Talofibular: Conuacredc. Bifurcate: Conrraqedd lntctosseous: Contraoedc. Spring Ligarnent: Conrracred

ilqtlrj,mg$Aarc..:A. l-areral rorarion of talus u'ith head and neck argulared medial & pla:rrarB. Posterior displacement of f ibula (reason for conuacrure of CF lig)

l. Horiz,srtal &eacb (Angle trctueen the bisecti<n of the rearfcn and rbe mal)eolar plane)a. Normal = 7-s - 90'b . T E V = < 7 - 5 '

C. Calcaneus in varus & equinusD. Navicular media l and p lanur tmay,abur media l mal leolus)E. Forefoot adducticn

Cl in ica l Evaiuar ion:A. lJistorr':

l . Pleg'nanry: Gestatist. i l lness- drugs. rrauma:. Deli verr': Duration. anesthesia- com pl i car ions3. Grou'th & Developmerl: Milesrones

B. General Lxarniration:l. r-\eurological: Molor rsre & funcrion. refleres. sersarion:. Bacl & lnees3 . Sk in

- 1 1 ^) t !

1. Appearanced. "Clubl ike"(eouinoadduoovarus)

b. Small draun-up hee)c. Adducred iore loord Calf auophre. Decreased fcnt sizt

: . M e d i a l :a. Skin: creases/furroub. Navicularprorn inenrc. Forefoor adducred

r . Latera l :a. Skm: thin/srretchedb Talus pront inenrc. F ibula poster ior

I ) Rad- io l raphic Evaluar ion:A. Ta localcaneal Ancle fXire'sj_lgp:

l . AI : Normal = 20 - 40 'TEV = l5 ' or )ess

:. l-at: Norrnal = 3-( - -50'TE\/ = 2_5. or lcss

B Talo lo l r4euursaj Analc:I AP: Normal: 0 - (-20) .

' j -EV = l -5 'or moreC Talocalcaneal lndex:

I Add ralcrcalcaneal angles rogerho on Ap & larsa]: Normal is > 40 '

D. Simons Rulc of J5:l- Predicts ptesence of talonavicular subluxation using nlcasurenlenrs on Ap radiopnaph

a Navicular doe-s pe1 ossif-v unril abour age i: Taluravicular sublurarion is present if:

a. Talocalcaneal Angle < 15" ANDb TaloI" Mcurarsal Angle> l -s"

L. Posirioninp for Radioqrapb:l - Position of maxjmum conection: dorsif lexion & aMucrion u'ith foot planrigrade:. Sinrng u,irh hips & knees flexed 90.

I. Sources ofLrror:i. Poor posirion:. ldenrif icaricrr: nNa'icular does nor ossifo unti l aboul 3 r,cars

Ossific nuclei in ulus & calcaneus are eccenuicall l,p)acedG- lndicarions for Radioeraphs:

I . Derermine severiry of deformir-r,1. M<niror respons€ ro therapl,3. la togenic changes4. lnua-operarive reali lu-rmenr

X. Conservative Trearmert:A. Performed on ALL congenital cJubfeerB. Begin immediarellC. h4an4q]arrm:

J . Gen t l ebu t f i rm 10 - l 5m inu res2. Reduce all componenrs: AMuo forefoor

Even HeelDiscract heel t *

{

t

I

i

313

- -D.-.trtal:Cqstinr:-l . Used to mainta in reduct icr ,:. Above-knee cast changed everv I - 2 rveeks

: . Contrnue unt i l sat is lac lon,correc l ion obta ined or unt i l fun i rcr conect ion ts unobta inabic1. Bivalve las cast and use 1or n ight sp l in ts: Monrtor therapl 'u ' i th radro l raphs even' i - 2 months

E. Pos-Rer luct ion:) . N igh t Sp l i n t s:. Preu'aller Shcles-i Onirotlcs4. Stretchrng

] . lomplicqlrons u'ith lr44!114.bllcl1l:l. Rocker-bonom foot: . F la t t oP ta lus: \ \ /ed.ue-s l rapednavicular1. Dorsal d isp lacenrent o i navicular

Xl. -Sqgt!3.!-'l I "rlr,tgDt,A. Sof l T i f sr re Release:

). Cttmltrchrnsivc. t ' irt 'utrt-lt 'rtntial rclrusc'. Posterit>r. medial- iareral. planur: S,ulrrnrirn': General anesthcsia. thigh tourniguet- sofi t issue relcase. reduction. K-uire fixarion of

r a I on a v icu l iu jornt. intra -operat i ve radi ograph s. com pr cssi on ca sr:' ldS?]- -Le: 3 - 12 months

a. No surgerv hcfore 3 months old beczuse 1'ou need conservative therapv ro sretch tire tissuq.and i t is a lso technical lv d i f f icu l t due to the smal l srze of rhe srrucrures

b Dccrcase succcs u'hen age is> 3 y,ears old1 lnc is ion Placement :

e. Posteromedial O urco): decrsrsed visualtzation lareralh,b Cincinnati (Crasdord): Cosnreticallv superior hou,ever great incidence of wound dehiscencec. Poseromedial + I-areral

:.,lggU-ent-tql-8gl-ealg2,. Rerrao tarsal tunnel conlentsh TP tendon lengdrcnrrg (Z-plasq): follou, distal to navicular tubcrosiry,( . Talonavicular jo int capsulotomrd Spring l igamentc. FDL rendon lengthening (Z-plasry'): follou' distal to Masrer Knot of Jlcnn{ FI{L tendon lengthening (Z-plasry)

S Superficial deltoidsh. Jnterosseous ligamenti Calcaneofibularl iganrenti. Achil l istendon lengthening (Z-plasry)

t. P(xrerior ankle.ioint capsulotomy (including poserior talofibular l igament)L P)antar fascia

B. Osseou-s hocedures:1 . l nd i ca t i ons .

a Recurrenceb. Severe. rigid deformitiesc- Performei onlv in the child & adult ].IEVER on infanrs

3 1 4

l . O$eoromies (Aees ? _ 6 vears o ld)__a. l_arera l Coiumn Shoneninc.

!

I

I

] 1902 Ogson: Cuboid clr.rsing u,edet:. I961 Evans: Calcaneocuboij. ioinictosrne u,edge and arrlrcxjesrs_. . 1973 L ichrb lau; Anrer ior ca lcaneus c los ing * ,o iu. - - " - '

b. Ir4eciia.i Coiunn Lenflhenine:l. I959 Fou,ler: Medial ctnreiform opemnf, u,ecige

r . Salvape Prrrcedures:

C .L Wound dehiscencc2. Residual deformln.-' Nat' icular u,edgin-c, & subluxarion4 . F la r rop ta lus

O. Overc<lnect ion: ca lcaleus. pes p ianovaigusD. Residual Deformir res.

l . N4eraursusAdducrus:a. Sof i t issue re lcascb TA rendon lransferc. Osseous procedures

:. Rearloot \/arus:a. Calqmeal osleolom\,: Duryel

- i . Equinus:a. Achi l l is rs tdon lengthcning o, re lo lom\

CALCANEO\/A I .GUS

a. Triple Arthrodcsis ( >b Talccrorrv (4 - 6 vears

m.\,elonteDmg<re leCompl icar ions:

l2 years o ld) : lnocases subi l iq , in severe. r is idold): Used for se'ere. rigid defurm;i;., .r ifr.

delorm i r iesanJuogrlposis d.

t }e ankle and valgus posi r ion of

D

I

t

I

,I

It

It

P_ef'art&e_

Cl in ica l

lncidtnc!:

Et io log\ ' .

Deformi4'idcnrif ied ar binh u'ith rhe foor markedlv dosiflexed arrhe foor u'irh respecr ro rhe leg.

ciorsum of ioot in conucr u.jth anrerolareral leg (..up and out,,)-Severe. l. intirarion of planrarflexion and _..r.,onLareral-loose skin folds belou, lat mall.Medial-skin mached and uup*rr

mosr common congenital malformat isrl :1000 l ive b i r rhsmore common in femalesusuall_r, bilarer.al u,ith .ne l imb more se\,ere rhan the odrer

first born of young molhersCompression of the prima pra'ada *,io smarJ riehr urerusExernal rolztion & conuacn:re of hipsSieeping posirion u,irh en. iorared & abduoed h:ps(priman' deforming slrucnnes = rendons of anrerolareral ankre)

AP- inc.TC angle

-Do, Tlr' congruin,u,ith FF aMuo jonMedial angularion of head & neck of lalu_.

t{

TItIIT.

Begtos4ph:

3 1 5

---Iat- -pianlarj lcxedtaius(rel:rt ive,dueto,dfjoot) ujth-rqspegttol-a-sallnnesBisesion of h&n of ta lus in fer ior to cuhnidtnormal=suner ior hal f rDors i fe ler ion o i ca lcaneus

C\_ff__\!_ radit-ryraph

C\r . \ av med ia l t o t a l usR e l a t i v e P F o f t a l u :lnc. Dl : o l ca lcan

C l i n i c a l

\/T( r,e[icaha]u_s rc iora l to h&n of ta lus ( i l oss i f ied lven ical/PF prrsit irrr of ta luscaic para l le i r r ' i th lou, or nep Cl .A

Reducib le u i th manipulat ron nonreducib ieFoot against anter. Leg fool 90cieg. To iep or eguinu..

D'fl,D), venical talu..Congeni ta l media l posrer ior bou' ing of the t ib iaNeuromuscular d iscasc

I l cat rnenl : cr lnscrvat ivc

lr4anipulation in carlv dx u,ith flexible defonnrnDai lv passtve manrp

PF & I).JV ro srrerct/lengthen dorsolar sofi rissues20-3Ctx in 4 dail.r, sessions

Ser ia l casinrr(Es lo tib ruhcrosinc()rrecr component pans of deformin

loot held pfff adductionrf lreuo'al to inr

{avoid usrnp f f as lever lo czst r f rn rarus)cas weckl-r, or biu,eeklr, 3-6 monrhsgentle gradual persrsenr c.onecrion is rire rule

nosl cas - nraintain u'ith splintstGanler,)l2- I6hr /dav up to 6 months

su rg i ca l

considcrat r rnsrigid deformin'fa i led conscrval ive l )age of pat ientdevelopnrent of secondan art}rir is

opt ionsdivision of soft t issue srrucftlres:rrrterior ankle

peroneus teniu-.EDBEDLA]TFL

Correct val-ru-.Zlengthert paonealsDivide preoneal sheethDir, lat l ig of ST.l

3 1 6

--- -----€orreoff-al-ri uct iorr -

Div l rge of CC. lSeflion fi.I capsuirSingle X-u ' r re i :soss N' lTL

AX cas l 0 -12 weeksOtiter pr<rcedure..

Ca ]caneal osteot onr ies-t vansSTJ anhrceresirArthrodesrs

\ / I ]RTICAL TAI -T ]S

I n t r r d u c t i o n. mos l r i .u id fo r l r o f f ia t loo l. o lher te r rns : c ro l l l cn i la i r r rkc r ' r ronom

f oo l . con . t ' cn i ta l convex pes va igus .

con l 'en i ra l f l a t1 t ' ,o t u ' i1h Ia lonav icu Iar

d is i< ra t lon . "Pcrs ran s l rpper loo t ' .. se \ /e re cases rnvo lve cc io tn t . ies :

favorab le ( )u lc ( ) r 'n (

. 50oro crcrur B,/L. rir:ht > left

. ma les = Jcrna lc :

. 50oro oi.cul as isoiarcd tt-)I t t ,en' i lal

deformin

l ) i f le rcn t ia I I ) iagnrx is. ldiopathic J: lat fot-rt. Paralvt ic Flatfoot. Fial foot in ccrcbral palsr. Obl.ique raiu.

r Talonavicular.ioint subluration rvit lr u'eightb'eanng onhr p lanta-r f iexed v icu ' . to ta l reduct ion of Talonar" icu lar - io intr benig'n flexible flatlootr legui res ordrotrcs. possib le Tendoachi l les lenpn}enrng. ser ia l cast ing. surg ical in lervcnrrc ln rare

Etiologr. -50?o sccondarv ro eithcr spina bifida. artluogrSphosis. or a chrornosomal abn<lrmalin' (trisomr')

o

Neural tuhe defecrs - usual ly r ig id formr Diasremaromvel ia- l rpoma of cauda cguina- wcral agcnesis. mvelomeninprre leArthr ogr-rphosi s m ul tipl er con g enjlaNeurof i brom atos islschio-caicarcal band rare contracture of uiccpsAcguiredr Ccrebral pals lr Po l i omve l i t i sr Spinal muscuiar auophrPan of clinical spectrumr Freenra:r-Sheldonr Smi*r -Leml i -Opiur lr4arfanr Hur ler 'sr DeBarsr. ^ ta i l - pa te l l ae

t

II'IItt,rrt

F

>\

f

!

F

F

/

l.

b

1..

317^-

!a

)'run e-bel lvJL.ag I e- Ban an Stn dr oe s)_l t lu l t in le I ien,u ium Srrrc i r ome:

. ln l rcr l la l )cc. Arr tosomal donl r ranl . rncomDlcte Dcneuancc

l 'a t l ro logic A na I orr r . r. \ l ;eo1,e-shaped navicuiar with h-rpopiasric pizinur sesmenl. Scvcre pli inrarflexi<xr of ankJe.iornr. T i i r ra aniculares rv i th u lus in posrer ior l / i on)r. Calc. t rcLts c iosel l 'approxintates u ' i th drsta l r ip of f ibu la and is evened and p lanrar f iexed. Susr ,unlaculum ra i i is h lpoplasr ic .no suppor l for ra lar head. Abscnt antenor ta iar lacet. l )orsal Tal .na ' icu iar l igamtnts th ickened and b lend r , r ' i t } de l ro id. SuPerro l pcr oncai rc t inaculum - a l tcnrra led. a l lou. ing peroneal sublurat ion' ' l ' l ' tmdrvt

at tcnt tated under ta lar hcad subluxed anrer ior l r ,onto nredia l mal leolu:' l 'c roneus l -onf 'us tnuscle is nra. ior delornr inp force. u. i t l r inoeased l ) lonaron,norenr ia l. ( - on t rac lu rcs sccn i n .

t I ib ia l rs Anrer iorr f\- lensor Hallucis Longusr lxcnsor Digirorum Lturgu-.. Pcroneus Brevist Jr iceps Surae. Pel o l )eus I mius

. Dis lo:ated rencions.. T ib ia l is Posrenorr l)cr olreus Ilrevtso pcroneus Longus

C l i n i ca l Appca rznc t ,. J tor efoot abdrrcte i and p lonated iarera l c lautr res. Convex p):urra-r surlirce. rcrker-hottom frxrr. Palpable ralar hcad mediali l , and planrarl-r. I ' l i nd loo requ inova l t us. Tight heei cord. Crcase or,er nanou,ed sinus tarsi' )Jo l lou anlcrror lo ia tera l mal leolus is helpfu l s ign to d i f le lenr iare \T f rom cal<;antoyalL,us. G a t t

e pelav in ambularion is uncommonr Qlder children rl irh shonened sride. Dc.clca-sed balancc

. Pain mav nol appur unti l adolescence

Rad i t - g raph i c F ind ings. lnclude ankje rn evalr.rarion of fcnr. Ftxced planrarfiexion lateral vieu,paramount in diaElnosis. Talus- calc-:rneus and meutarsals all visualiz_ed in neuborns. Cuboid ossifies uithin firs monrh of birr}. r.Navjcular ossifres in 3 to 5 years. Rcsl rng larera l v ieu.

r l_tse lareral cuneiform as marLer to locare naricular. Dislocation of navicular dorsal to ulus. forfoot follorvs rhe navicularr lnqeased lalar metzwsal anpler falcareus in equinus

3 r 8

! cn i ca l pos i r ron o f r a l u :t- --ReiI

ur!-6o-rsep-lahrar vicu

: , r rcrcased Xire,s anple ( ra localcaneal ansle)lnoeased u lar metaursai a lg l r

' Se 'ere \ /T u ' i r prcsenl * ' i th d isrocared carcaneal-cuboid i . rn;. Osteoci tondr j r is of t l te navicular (Xohler .s dtsease, , t ) )3. \ , 51.r1;1s1111)es occur

Classi f ica t ionsDupont lnsr i rure - Aksu & Xuntar. Group J - Supple fcnt i l rar resemble calcaneovalpus. Group lJ - Rig id t ( )o l . p i in o j a s-wdrorr rc. Group l l l - \ 'T assrrc iarcd u, i rh Tnsomr, l_ i _ l_5 or l t i' Group l \ / - \ / r ass()crareci r ' i r l r l reuromuscuiar d iscase sucr ' , as sprna b i f ic iz

R'cnper & liang. I cralo!'enic - biiarcral sri l l as sLrn in arrluogr;phosis' Ncur<rgenic - r ' r r rsc le imharance. nrore suppre- as sccn rn sprna b i f id i ,' Acnuirer i - marp 's i r ior tn l rcro - a-( seen in chi rdren . , i th l ro orher nr i r . r . r problem:

Colcnran' l ' )?e i - abscrc:e o l assrr iared caicaneai-cuboid. io inr d is i .carron. 1- tpe l l - prcscnce of ca lcznc: l l_cuboid d is locar ion

l'r t:a t nr t 'n t' o.'j'' ili:r:il.f ,rH:;"lr'iil,::i,'J;Ti:'ffi il,:l,..l,T;r;]:ffTlri:,,,:io,.rerrxr

._ , Risrorat jon o1 media l co lumn con)pcter lc \

'

, " t , l t ) . t l ) a t i r 'e dro 'apr{casr ing) is a imed a l s l re lch ing .nf i r i . ru . sr r r rcrures rn prepararron Jor suru icar

' Casting (foreloor in plant:uflexion) - sran al binh anci conlinue for 3 ro 4 ntonths

; t *O* lapp roach :Cinc innar i inc is ion. m id_d<xsal i l rc is ion. rnedia l arch inc is ion

'

.SurSical rreallrenl ntav be perlormed in nvo srapes(forefoor conecrion followed bv hrndlrnr conecrion), 'a;fliffi:J:;:;1il1,::;,JlT#,'.",::.,.

' capsulorrm' of carcar*cuboid -ioinr in .lr l",. .r.".

: tendoachi l les icngheninplr4aintain ali-r_'nmenr of talenavicul:u and ankle.i<_rint u,ith Xirshrrer u,lre:' Relcase of calcaneofibular l igamenr ro aljor.r, dorsif le>iion of the ralus. Relcase of ra lo_calc: rneal l igamenr ro a l lou, reducion' l encion uansfer (pB- TA) ro rarar head or neck has been described' Srrbralar or Tripie an}rodcsis in se'ere cases. order paticntsor if above faiis

)

?\

IIt7t

tItIl?r5?'rg

33 1 9

'ER-E11.*REIUI:IttES

TRA NSVERSE I 'LANE I )EFO}I ] \ ' ] I ' IESi- crn ur. Anrelorsion I retrotorsror-r. l l lp ma)posi t ion / conuactu le:

T ib i r '. ln tcmal / excrnal t ib ia i tors lon. ) rnee l na lpos i t r on / con l rac lu rc :

i-oot. l r4eta larsusAdductus

SUI] . ]ECTIVE CONCERNS. l n l o e / O u t ' l o t '. T r i pp ing / Fa l l i ng. C i u n r s ) , G a i r. Xnee Paur. Knock Nnees. Bou ,Legs

tN ' r ' o l _ lNCl-3 \ 'cars. ln tcrnal T ib ia l I or . . ron. N4etatarsu-s Adduf lus

> 3 \ 'ears. ln temal Fenrora l I ors ior ,

) 'A'I lt ol,H )'sI oLr)G)'] leredr t rlnuautcr ine Posi r ion. Pcrs isrcnt Feta l Al ignlnentl 'ers is tcnt i r4alposture in Postnata l L i fc. S leeprng / S inrng Posi t ronslauogs916

TEIITISI orsron:. Tirc acr or prclcess of nryistin-e: l lrDlnp or roralinp about an oiis\;ersi on :. Tirc :rcl or prcKress of tuming cr chanping diredionAn le. Pl ior to / Before. In Jl ont ofRerro. Ba ck u'ar d. l-ocated hchind

PODI,4TR]C TER},15 I}\Ver sr on . Anl er orsion. R ota l ion at rhe . io int level . Rer t or ers ionI orsron OUT. Rotaticn abnut the lon-p axis of a tnne ' Relrororsion

. Antevers ion

320

t

oRTHOPEDTC TERM

Vcrs ion. Angular diffe r cnce bctu ssn l ire transverse alr:

ol each end of a lonc hrnrI ors ion. Presenl rryhen rhe \,ersron is abnormal ol

excesslve

PQp_rA:r xrcFemora l Rc t rovcrs ron

, t * . l n r . r ' n i r ,

PODlATR lCFemoral Aitteversron

QgrfoPEptcAntc ro rs ion ( l 6 )

No rma l (= l2 l

Retrotorsron (6)

tTIIIItTIltrIltTl

lN TE RnNAL FE N4 ORAL TORSI ON(Fenr oral Anr er orsion,)

l n rema l Dev ia r ron

tI.

t

MORAL ANTE\|ERS)ON - r ransveme ane an . le l ) ( ' r$ t , t , ech and fcnrora l condr ' les

. Normal: = .10 desrees

. Range :31 -52 c iegees

Adu i t. Normal : = E- )6 desrees

.-RanPeT??E-degree:

4 5

a 0

3 5

3 0

15

- a l l \ t n t o l

-----_

5 -

1 l A d u i l

e n d p l g l o n d ( a n k l c a r i s )

i- ct u:' i inrernal / l i4edial

l n l a n l-i +/- Neutral' i N o r m a l : 0 - T D c g r e e :

ch ; l d* Sl ighr lv Exremal ILztera l

A d u l t' i Lateral / Errcrnal' i Normal: 20 - 30 de.gree:

30

25

2 0

r 5

1 0

i

0

-5

R inh 9 r 1

) e a r s

TORSIOn*AL PROFILE'i Foot - hogression Angle'i l ' ' ledial Hip Rotation in Extension.i Lateral Hip Rotation in Enension'i ThiSh - Foot Angle'i ' l

ra:rsmalleolar Aris Angie

\ e rs ion

7t)503 0t 5

322

-. i -Fool4-On f i l , urar lon

B i r t h l 9

Y e a r s

FE i l ORAL .ANTE\ /ERSION - N i czsu r rn rcn rCl in ica l

.i t-\ener nretirod. Par ienr is p iaced Pronc. Palpare G'r. Trcrhilnrer - Femur. ln tcrnal lv ro lare the leg - Xnee bcnr

until Gl. I rcchanrer is rhe mospromrncrr t iarera lJr

. lr4casur e a:rgle beru,een ribra (leg) andven ica l

Radiographr'. i l i4agi l l igan techni gue.1. Dunn lechnlouc

' Both are nol oficn usedComputed tomor:r aphr, / lr4Rl

+ Besr lr4erhod:

Tl l ] lAL I 'ORSION - I r lcasurcmcnrCl in ica l

.i Thigh - loor anple

.i Second nterararsal

.i I r:ursmalieolar ax-rsRadiographv

'i' Huner and Scon liict}lodComputed l omor: raphrLJltrasoun d

I n t e r n a I

E x l e r n a I

2 0

INTERNA L FEIU(]RA l_ t-QRSt ON'i ln-tcrinp > Z-, t"r^

.=-_--

* l r4edia l rorarar ion of rh ighs'i ' Pateliae rurnei rnrvard. i ln l rotarron > l i .xr lorar ion

1AT}- RN-A L FEIU ORA I- I 'O SI TION'!. Shonenei or Spasric lvledial ]-lamsrincs,

Adduoors. i Conracrure of Hip Capulc

' Pubcrcapsular' l l l i o l cmora l

i . Gai t Anah,s is. lnscased Adducrron - Lare N4idsrancc

T]BIAL TORSlONIn tema l

.l Failu-re of nornral cxrernal rotalion to (rccul

Lxternal.l. Concomirant lnrcrnal Femoral Torsiorr

, Illiscrohlc |tlolalignmcnl S-t,ndromt.i lauogenic post uealnent for ITT or lFl

I

t

90

8 0

7 0

60

5 0

4 0

3 0

2 0

1 0

o7 05 03 01 l T

IITtlttI

"t"*t

l!o ro !}c

I

B]RTH

ADUL']

J./-^.

NOR]\lALI

TIRIAL TORSION - TreAlmcnl Considerations.:. Usullv* 4on of adulrs have unreso)ved ITT

' lo/o IncaPaciutinP'l Csreater and Fa$er Coneoion?

*' Decreased Angle of Gait* Supination

Beyond Age of Self A\^'areness:+ Conscious Pronallon+ Pronation

External Deviations+ Heel Conuo honation

'Jll EA TIU EI\'T _ ]'ORSI ON,AI AI]NO)TMALITIIS

CONSERVA TT\'E TR EA T}II}IT.]. Passive Snaching and Manipulation.1. Change Sining / Sleeping Habrts.i Serial Long Leg Casing.!. Bars

' Denis-Bro\\Tlc' Ganly SPlint. Cormler Roution System (CRS)

.l. Braces

.!. r"\heaton Telescoping Brace

.1. Orthotics

SUR G I CAL MA]\A G E]\'ENTlndicat ions

'l Child > 8 Years old* Siprrifi cant Funct icnal Disabilitl''i Severe Cosm et i c Deform iq'

CONSERVATI\rE TREATI\I ENT - Scq ua lc.i. Recunence.t Exernal Tibial Torsion.!. Chond,romalacia of the Patella

' Miserablemala l igrnnrenls lndrome.l.Lonp Term Eflecs Unknoun

SURGICAL MANAGEI\IENTFemu;

.l' R otat inal Oseotom ies' Mul t ip le Locat ions

't l l l izaorvTibia

+ Proximal or Disul Rotational Osteotomr

324