CADAVER STUDY OF MEDIAL NEUROVASCULAR STRUCTURES FOLLOWING PERCUTANEOUS CALCANEAL DISPLACEMENT OSTEOTOMIES - PowerPoint PPT Presentation

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CADAVER STUDY OF MEDIAL NEUROVASCULAR STRUCTURES FOLLOWING PERCUTANEOUS CALCANEAL DISPLACEMENT OSTEOTOMIES

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Title: CADAVER STUDY OF MEDIAL NEUROVASCULAR STRUCTURES FOLLOWING PERCUTANEOUS CALCANEAL DISPLACEMENT OSTEOTOMIES


1
CADAVER 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

2
INTRODUCTION
  • 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.

3
Dysfunctional Flatfoot
4
Terminology
  • Flatfoot
  • Pes planus
  • Hypermobile flatfoot
  • Pes plano-valgus
  • Tilipes calcaneal valgus
  • Peroneal spastic flatfoot

5
Etiologies
  • congenital-ligamentous laxity, veritical talus,
    coalition, equinus
  • Acquired
  • Biomechanical-torsional,hypermobility
  • Systemic disease arthritis, neuromuscular
  • Trauma- coalition fx, PT damage, lisfranc
    dislocation

6
Treatment goals
  • Relieve pain
  • Reduce deformity
  • Improve function
  • Prevent progression of deformity
  • Decrease postural symptoms

7
Medial 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.

9
HISTORY
  • 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.

10
Open 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.

12
PURPOSE
  • 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.

13
PCDO
  • 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.

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ANATOMY 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.

15
Posterior tibial tendon
16
Blood 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

17
Nerve supply
  • Tibial nerve

18
Medial 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.
19
Ligaments
  • Spring ligament
  • Deltoid ligament
  • Plantar fascia
  • Short plantar ligament

20
CLINICAL 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

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  • 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

25
DIAGNOSTIC 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

26
Normal and flatfoot
27
  • MRI evaluation of integrity of ligaments and
    posterior tibial tendon
  • CT scan coalition

28
PTTD on MRI
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CLASSIFICATION
  • Johnson and Strom, 1989
  • Described the three clinical stages of PTTD

31
Johnson 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

32
TREATMENT
  • Stage I Conservative treatment
  • Stage II calcaneal osteotomies in conjunction
    with other soft tissue procedures
  • Stage III Arthrodesis

33
MATERIALS 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).

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Figure 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.

39
Figure 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).

41
Figure 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.

43
Figure 5
44
Figure 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

46
Figure 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

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RESULTS
  • 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).

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Discussion
  • 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.

57
CONCLUSION
  • 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.

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REFERENCES
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    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
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  • Mosier-LaClair S, Pomeroy G, Manoli A 2nd
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