Flatfoot Reconstruction for Spastic Foot Deformity
Colyn J. Watkins
Lateral column lengthening and medial plication with possible medial cuneiform osteotomy is our operation of choice in the mild to moderate neuromuscular flatfoot deformity (Gross Motor Function Classification System [GMFCS] I/II)
Lateral column lengthening with talonavicular (TN) fusion with possible medial cuneiform osteotomy is our operation of choice in the severe neuromuscular flatfoot deformity (GMFCS III/IV/V)
Operative Indications
Feet that can no longer be braced effectively
Lever arm dysfunction in ambulatory children
Pain and medial skin breakdown
Preoperative Evaluation
Anteroposterior (AP), lateral, and oblique weight-bearing films of the affected foot
Preoperative examination should focus on evaluation of flexibility of the foot and evaluate for presence of ankle valgus. If there is concern for true ankle valgus, a weight-bearing AP and lateral image of the ankle should be obtained
Careful examination of the hip, knee, and ankle in concert is necessary
Dose surgery according to functional level
Assess gastrosoleus complex tightness with the hindfoot locked in neutral to slight varus; be aware of midfoot break when examining for calf tightness
In the TN neutral position, assess the midfoot for the presence of supination as residual supination will increase the risk of recurrence
Equipment
C-arm with radiolucent foot extension
2 mm Kirschner wire (K-wire)
Smooth laminar spreader or Hintermann-type retractor
Joker and Crego periosteal elevators
4-mm cannulated screws
Curved and straight osteotomes
Fibular allograft
Positioning
Supine with bump under ipsilateral buttock, which can be removed when operating on the medial side
 Figure 40-1 ▪ A, Medial based incision just inferior to tibialis posterior, extending from medial malleolus to just distal of the talonavicular joint. B, The lateral-based sinus tarsi incision is centered over the sinus tarsi and bordered superiorly by the superficial peroneal nerve and inferiorly by the common peroneal tendons. (Courtesy of Children’s Orthopaedic Surgery Foundation.) |
Lateral Column Lengthening
A straight incision parallel to the plantar aspect of the foot extending from the calcaneocuboid (CC) joint and 5 cm proximal or alternatively an oblique sinus tarsi incision are preferred (Figure 40.1)
Dissect down to the peroneal tendon sheath; the sural nerve is often encountered and retracted plantarly
Isolate both the peroneus brevis and longus tendons. Peroneus brevis will lie deeper in the wound and be against the bone. Brevis will purely evert the foot, while longus will evert the foot and plantarflex the first ray (Figure 40.2)
The peroneus brevis tendon is then Z-lengthened: REMEMBER to tag the proximal end, or it will retract proximally out of your field (Figures 40.3 and 40.4)
A K-wire is placed across the neck of the calcaneus lateral to medial. Check this with imaging to ensure your osteotomy is in the correct location. Generally, 1 cm proximal to CC joint is appropriate (Figure 40.5)Related posts:
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