Title: CADAVER STUDY OF MEDIAL NEUROVASCULAR STRUCTURES FOLLOWING PERCUTANEOUS CALCANEAL DISPLACEMENT OSTEOTOMIES
1CADAVER STUDY OF MEDIAL NEUROVASCULAR STRUCTURES
FOLLOWING PERCUTANEOUS CALCANEAL DISPLACEMENT
OSTEOTOMIES
- Authors
- Joseph M. Anain Jr. DPM, FACFAS (Catholic Health
System, Buffalo, NY) - Lawrence DiDomenico DPM, FACFAS (Forum
Health Northside Medical Center, Youngstown, OH) - Trang Mai Duong DPM
2INTRODUCTION
- Flatfoot deformity is a very common foot problem
with clinical manifestation of posterior tibial
tendon dysfunction (PTTD.) Flatfoot deformity is
characterized by progressive colapsing of the
medial longitudinal arch, forefoot abduction, and
hindfoot valgus.
3Dysfunctional Flatfoot
4Terminology
- Flatfoot
- Pes planus
- Hypermobile flatfoot
- Pes plano-valgus
- Tilipes calcaneal valgus
- Peroneal spastic flatfoot
5Etiologies
- congenital-ligamentous laxity, veritical talus,
coalition, equinus - Acquired
- Biomechanical-torsional,hypermobility
- Systemic disease arthritis, neuromuscular
- Trauma- coalition fx, PT damage, lisfranc
dislocation
6Treatment goals
- Relieve pain
- Reduce deformity
- Improve function
- Prevent progression of deformity
- Decrease postural symptoms
7Medial displacement osteotomy of the Calcaneus
- Medial displacement osteotomies of the calcaneus
is commonly performed for stage II posterior
tibial tendon dysfunction to correct the valgus
deformity of the hindfoot. These procedures in
conjunction with other soft tissue procedures can
lead to restoration of the height of the
hindfoot, and reposition the Achilles tendon,
plantar fascia and the calcaneus.
8- Medial displacement of the calcaneus redirects
the pull of the gastrocnemius-soleus muscle
group slightly medial to the STJ , increasing
varus on the hindfoot. The medial displacement
osteotomies of the calcaneus thus play a
significant role in restoring normal biomechanic
in the flexible pes planovalgus deformity.
9HISTORY
- Gleich first introduced the calcaneal osteotomy
in 1893 as an attempt to restore the calcaneal
pitch angle. - Subsequently, operative management of stage II
posterior tibial tendon dysfunction takes many
forms using medial displacement osteotomy,
lateral column lengthening, calcaneocuboid joint
distraction arthrodesis, and soft tissue
balancing procedures.
10Open calcaneal Osteotomies
- While performing open calcaneal osteotomies in
association with other soft tissue repositioning
few patients develop post-operative medial
hindfoot pain which radiates distally and wound
complications. These can range from hindfoot
pain, numbness, hematoma, and wound dehiscence.
11- Greene et al studied the anatomical relation to
open calcaneal osteotomy and this anatomical
study concluded the extensive dissection of open
calcaneal osteotomies can traumatize the medial
neurovascular structures which may result in
post-operative complications. The authors
recommended breaking medial cortex of the
calcaneus should be done in a control manner to
minimize post-op complictions.
12PURPOSE
- The purpose of our cadaver study is to prove
medial neurovascular structures at the rearfoot
can be safely protected after percutaneous
calcaneal displacement osteotomies (PCDO.) The
PCDO minimizes soft tissue and subperiosteal
dissection to help prevent trauma to the medial
neurovascular structures and post-operative wound
complications.
13PCDO
- PCDO is an extra-articular calcaneal osteotomy in
which violation of medial neurovascular
structures can be prevented by subperiosteal
tunneling, and minimized soft tissue dissection
using four stab incisions.
14ANATOMY posterior tibial tendon
- Origin interosseous membrane and proximal
adjacent surfaces of the tibia and fibula. - Insertion navicular tuberosity, medial
naviculocuneiform and plantar base of 2nd, 3rd,
4th metatarsals.
15Posterior tibial tendon
16Blood Supply
- Proximal area is supplied by branches of the
posterior tibial artery - Distal is the bone-tendon interface supplied by
branches of posterior tibial and dorsalis pedis
arteries
17Nerve supply
18Medial neurovascular structuresA tip of medial
malleous, B medial tubercle of calcaneus, TN
tibial nerve, LPN lateral plantar nerve, MPN
medial plantar nerve, Arrow medial calcaneal
branch.
19Ligaments
- Spring ligament
- Deltoid ligament
- Plantar fascia
- Short plantar ligament
20CLINICAL EVALUATION
- Non weight bearing and weight bearing LE
examination - Dorsal view evaluate for malleolar position. If
symptomatic, will see posterior displacement of
the medial malleoli and internally rotated
position of the malleoli. - Can compare medial and lateral borders (medial
bulging of at the talo-navicular joint and
lateral concavity at the C-C joint
21- Posterior view hindfoot valgus with medial
displacement of the rearfoot
22- While patient is standing
- Single heel rise test holding one foot off the
floor, raise up the ball of the other foot,
lifting heel off the floor. PTTD will cause
unstability at midtarsal joint - Hubscher maneuver test passively DF the
patients hallux to end range of motion. Through
the windlass mechanism and dependent upon
ligamentous integrity of the hindfoot, DF of
hallux causes PF of first ray, supination of the
STJ and external rotation of the tibia.
Attenuation of ligaments will cause no external
rotation of the tibia
23(No Transcript)
24- Non weight bearing test for heel cord tightness
with knee flexed and extended - Non weight bearing standard biomechanical
examination including range of motion and muscle
testing
25DIAGNOSTIC TESTING
- Radiographic evaluation AP, lateral of foot and
AP of the ankle - AP view Forefoot (FF) abduction and navicular
sliding laterally on the head of the talus - Lateral view dislocation of the TN joint,
evaluation of calcaneal inclination angle - Ankle view Osteoarthritis
26Normal and flatfoot
27- MRI evaluation of integrity of ligaments and
posterior tibial tendon - CT scan coalition
28PTTD on MRI
29(No Transcript)
30CLASSIFICATION
- Johnson and Strom, 1989
- Described the three clinical stages of PTTD
31Johnson and Strom Classification
- Stage I normal PT tendon length with some
degenerative changes and peritendonitis - Stage II attenuation and elongation of PT
tendon, flexible STJ, RF valgus, FF abduction - Stage III Rigid hindfoot, degeneration of the
PT tendon, deformity is severe
32TREATMENT
- Stage I Conservative treatment
- Stage II calcaneal osteotomies in conjunction
with other soft tissue procedures - Stage III Arthrodesis
33MATERIALS AND METHODS
- Our study utilized 18 fresh frozen cadaver.
- Meticulous dissection at medial aspect of
- the rearfoot after completion of the PCDO was
performed to examine the integrity of the medial
neurovascular structures
34- PCDO requires four stab incisions and
subperiosteal tunneling - PCDO was performed with the podiatric assistant
while the foot was stabilized and following
sequential steps of the PCDO with fluoroscopic
imaging
35- Initially, plantar medial tubercle of the
calcaneus was palpated and a stab incision made
along the orientation of the planned osteotomy
just distal to the calcaneal tubercle at inferior
medial aspect of the calcaneus. The incision is
deepened bluntly to the bone using a curved
hemostat and a subperiosteal tunneling was made
toward the medial superior aspect of the
calcaneus and tenting of the skin was visualized.
Another stab incision was made parallel with the
plantar aspect of the foot in the natural skin
resting crease at the tented skin (Figure 1) and
a 12 inch Gigli saw was introduced to the tip of
the same curved hemostat and pulled through the
tunnel in retrograded fashion exiting through the
same inferior medial incision (Figure2).
36(No Transcript)
37Figure 2
38- Attention was then redirected to the superior
medial stab incision where a straight hemostat
was used to make another transverse subperiosteal
tunnel at the superior aspect of the calcaneus
and anterior to the Achilles tendon. Another
stab incision was made to the tented skin
parallel to the plantar aspect of the foot within
a resting skin crease posterior to the peroneal
tendons and sural nerve. The tip of the straight
hemostat was visualized at the lateral superior
border of the calcaneus (Figure3). The straight
hemostat was removed upon completion of tunneling
from superior lateral to superior medial of the
calcaneus. A straight hemostat was again
inserted into the original tunneling from
superior lateral of the calcaneus to superior
medial aspect of the calcaneus. The free end of
the Gigli saw was introduced to the tip of the
straight hemostat and pulled from superior medial
to superior lateral aspect of the calcaneus.
39Figure 3
40- The final stab incision was made at the lateral
inferior aspect of the calcaneus in line with the
proposed osteotomy. A curved hemostat was used
to deepen the lateral inferior incision to the
level of the bone and the curved hemostat was
advanced from inferior lateral to lateral
superior connecting the tunnels to create the
final subperiosteal tunneling. The free end of
the Gigli saw was clamped to the tip of the
curved hemostat and pulled in retrograde fashion
from lateral superior to lateral inferior aspect
of the calcaneus (Figure 4).
41Figure 4
42- Fluoroscopy imaging was used to assess the
placement of the Gigli saw and to confirm the
final position of the proposed calcaneal
osteotomy (Figure 56). The handles were hooked
to the loops of the gigli saw at the two ends.
The osteotomy was performed at approximately 45
degree from the plantar surface of the foot with
the foot stabilized and dorsiflexed by the
assistant.
43Figure 5
44Figure 6
45- It is extremely important that the surgical
assistant dorsiflexes the ankle and the digits of
the foot as this act as dynamic stabilization.
Regarding the pull of the Gigli saw, the arms of
the surgeon start out close together and quickly
fan out while performing the osteotomy (Figure7).
As the saw goes from the superior calcaneus to
the inferior aspect of the calcaneus, the gigli
saw goes from an arced position over the superior
posterior calcaneus to a straight position when
it exits the inferior cortices of the calcaneous
46Figure 7
47- Care was taken to prevent kinks in the Gigli saw
and to protect soft tissue prior to completion of
the osteotomy and to protect soft tissue while
the Gigli saw exiting toward the inferior medial
and inferior lateral stab incisions. The Gigli
saw was transected at inferior lateral end and
the remaining of the Gigli saw was pulled down
from the medial inferior incision.
48- Further fluoroscopy imaging confirmed the final
position of the calcaneus before two k-wires
pediatric patients or two guide wires and screws
were driven perpendicular to the osteotomy
49(No Transcript)
50RESULTS
- The cadavers were further examined after each
meticulous dissection at the posteromedial aspect
of the heel. Each neurovascular structure was
identified and followed distally. The medial
plantar nerve, the lateral plantar nerve, the
calcaneal sensory branch of the lateral plantar
nerve, the posterior tibial artery and its
branches were studied in detail at the medial
aspect of the calcaneus after PCDO performance.
All of the mentioned structures were found to be
intact and were able to bluntly dissect distally
without signs of trauma (Figures 11-16).
51(No Transcript)
52(No Transcript)
53(No Transcript)
54(No Transcript)
55Discussion
- Our anatomic dissection at the medial aspect of
the hindfoot confirms that PCDO is a powerful
osteotomy 2,4 which minimizes trauma to the
medial neuromuscular structures and soft tissues.
This surgical procedure can help to reduce
post-operative complications as mentioned
earlier.
56- The surgeon should be well versed in rearfoot
anatomy and rearfoot procedures to perform the
PCDO. Fluoroscopy should be utilized to perform
the osteotomy, to confirm final placement of the
Gigli saw, and to evaluate the correction
post-operatively. -
57CONCLUSION
- The use of percutaneous calcaneal osteotomy is
advocated to correct flatfoot deformities and to
prevent further progression of the deformity.
Our anatomical cadaver study confirms that soft
tissue and medial neurovascular structures are
well protected after PCDO. Thus, post-operative
complications can be prevented in order to
achieve pleasing results. It is the surgeons
choice and proficiency that will dictate the
successful outcomes after PCDO procedure.
58REFERENCES
- Dull J, DiDomenico L. Percutaneous Displacement
Calcaneal Osteotomy. Journal of Foot and Ankle
Surgery 43(5) 336-337,2004. - Greene DL, Thompson MG, Gesink DS, Graves SC.
Anatomic study of the medial neurovascular
structures in relation to calcaneal osteotomy.
Foot Ankle Int 22569-571, 2001. - Koutsogiannis E Treatment of Mobile Flat foot
by Displacement Osteotomy of the Calcaneus.
JBJS, 53B(1), Feb 1971, 96-100. - Didomenico L. A closer look at the Percutaneous
calcaneal Displacement Osteotomy. Podiatry Today
ISSN 1045-7860, Vol 19, May 2006. - Mosier-LaClair S, Pomeroy G, Manoli A 2nd
Operative treatment of the difficult stage 2
adult acquired flatfoot deformity. Foot Ankle
Clin, 6(1)95-119, 2001. - Bluman E, Title C, Myerson M. Posterior Tibial
Tendon Rupture A Refined Classification System.
Foot Ankle Clin N Am 12 233-249, 2007. - Sammarco J, Hockenbury T. Treatment of Stage II
Posterior Tibial Tendon Dysfunction with Flexor
Hallucis Longus Transfer and Medial Displacement
Calcaneal Osteotomy. Foot Ankle Int 200122
305-311. - Mendicino SS Posterior tibial tendon
dysfunction. Diagnosis, evaluation and treatment.
Clin Podiatr Med Surg, 17(1)33-54, 2000. - Myerson MS, Corrigan J Treatment of posterior
tibial tendon dysfunction with flexor digitorum
longus tendon transfer and calcaneal osteotomy.
Orthopedics, 19(5)383-8, 1996. - Myerson MS, Corrigan J, Thompson F, Schon LC
Tendon transfer combined with calcaneal osteotomy
for treatment of posterior tibial tendon
insufficiency a radiological investigation. Foot
Ankle Int, 16(11)712-8, 1995. - Myerson MS Adult Acquired flatfoot Deformity.
JBJS, 78A(5) May 1996, 780-792. - Arangio G, Salathe E. A Biomechanical analysis of
posterior tibial tendon dysfunction, medial
displacement calcaneal osteotomy and flexor
digitorium longus transfer in adult acquired flat
foot. Clinical Biomechanics, 24 385-390, 2009. - Vora AM, Tien TR, Parks BG, Schon LC. Correction
of severe and moderate flexible flatfoot with
medializing calcaneal osteotomy and flexor
digitorium longus transfer. J Bone Joint Surg
88A1726-1734, 2006. - Dollard MD, Marcinko DE, Lazerson A, Elleby DH
The Evans calcaneal osteotomy for correction of
flexible flatfoot syndrome. J Foot Surg,
23(4)291-301, 1984.
59