PROCEDURE: Right cavovarus foot deformity correction consisting of:
1 Right lateralizing calcaneal osteotomy.
2. Right plantar fascial release in the midfoot.
3. Right first metatarsal dorsiflexion osteotomy.
4. Right peroneal tenosynovectomy.
5. Excision of right accessory peroneus quartus muscle.
6. Excision of right peroneus brevis low-lying muscle belly.
7. Excision and debridement of right peroneus longus tendinosis.
8. Excision and debridement of right peroneus brevis tendon tear.
9,. Tenodesis of the right peroneus longus to brevis with peroneus longus
release.
PROCEDURE IN DETAIL: The patient was identified in the preop holding area,
consent was verified, and the operative site was marked. She underwent a
right popliteal nerve block administered by the anesthesiologist. She was
then taken to the operating room, placed supine on the operating table, and
underwent anesthesia with laryngeal mask. A well-padded tourniquet was placed
on the right upper thigh. She was then placed in the lateral decubitus
position with the right leg superior. All bony prominences were well padded.
The right lower extremity was prepped and draped in the normal sterile
fashion with ChloraPrep. A formal timeout was undertaken by all necessary
parties. Using a sterile Esmarch, the right lower extremity was exsanguinated
and the tourniquet was inflated to 280 mmHg.
An incision was made over the lateral aspect of the hindfoot. Her old
surgical incision was partially used at its most proximal aspect. However,
the incision was curved a little posterior from her old incision to address
the calcaneal osteotomy. Dissection was taken down through the subcutaneous
tissues. There was significant scarring of the soft tissues in the lateral
hindfoot. The sheath of the peroneal tendons was identified and incised
distal to the lateral malleolus. There was severe tenosynovitis with
extensive scarring. The peroneus brevis was in multiple strands and scarred
to the calcaneal wall. There was an aspect of the tendon about 40% to 50% of
the tendon, that was intact and in its anatomic position. The scarred in
tendon was removed from the surrounding soft tissue. The longus was also
identified. Distal to the tip of the fibula, there was moderate tendinopathy
of the tendon, but no significant tearing. Next, dissection was taken just
posterior to the sheath down to the periosteum of the calcaneus. Using a
sagittal saw, and under x-ray guidance, a lateral closing wedge osteotomy was
performed to correct the hindfoot varus. Next, using the Stryker Fixos
screws, 2 guidewires were placed from the posterior aspect of the calcaneus
through a second incision across the osteotomy site and into the body of the
calcaneus. Screws were measured and overdrilled. A 60 mm and a 50 mm, 6.5 mm
hindfoot cannulated screws were placed over the guidewires. The osteotomy
site was reduced and compressed in order to place the heel in slight valgus.
The screws were inserted and very good compression both radiographically and
clinically was obtained. Guidewires were removed. The wound was copiously
irrigated with sterile saline.
Next, attention was turned towards plantar fascia release. A third incision
was made over the medial aspect of the midfoot. Dissection was taken down
through subcutaneous tissues, bleeders were cauterized with a Bovie. The
plantar fascia was identified and bluntly released across the foot. Starting
from medial to lateral, the plantar fascia was released in the medial and
central part of the foot, leaving the lateral aspect intact. This allowed for
relaxation of the plantar soft tissues. However, in the simulated
weightbearing position, there was still plantar flexion of the first ray.
Therefore, it was deemed necessary to proceed with dorsiflexion osteotomy.
A fourth incision was made over the proximal first metatarsal from the first
TMP joint distally. Dissection was taken down through the subcutaneous
tissues and the extensor hallucis longus tendon was identified and retracted
laterally. The first metatarsal base was subperiosteally dissected and
Hohmann’s were inserted to protect the surrounding soft tissues. Using a
sagittal saw, a dorsiflexion closing wedge osteotomy was performed.
Approximately 2 mm of bone were removed dorsally. Using the sagittal saw, the
plantar cortex was left intact, and the osteotomy was completed with the
osteotome. This allowed dorsiflexion and closing of the osteotomy. A Stryker
12 mm staple was then placed across the osteotomy site with the osteotomy in
the reduced position. There continued to be mild plantar flexion of the first
ray on the x-ray. Therefore, it was deemed necessary to also add a peroneus
longus transfer.
Attention was turned back towards the lateral aspect of the foot. The
peroneal tendon sheath was then incised marking the superior peroneal
retinacular borders proximal to the tip of the fibula. Again, there was
severe tenosynovitis scarring of the peroneus brevis with multiple tearing.
There was also an accessory muscle identified as peroneus quartus muscle.
This muscle belly had a separate normal appearing tendon that travelled
distally and attached to the lateral calcaneal wall. This was removed and the
muscle belly was excised up to the muscle belly of the peroneus brevis. The
muscle belly of the peroneus brevis also had significant fatty atrophy, most
likely from the ruptured aspects of the tendon. This was debrided to healthy
muscle using cautery. The sheath was incised until the muscle bellies of the
peroneal tendons. All surrounding scar tissue and adhesions of the tendons
were removed from the soft tissues and lateral wall of the calcaneus. This
left approximately 40% to 50% of the peroneus brevis tendon. There was
significant continued degenerative tear of the remaining tendon. The peroneus
longus had areas of tendinopathy, however, there were no discrete or
significant tears. An incision was made in the peroneus longus and the
tendinopathy was removed using Stevens scissors and #15 scalpel. This left
about 80% of the peroneus longus tendon. The peroneus brevis was also
debrided back with all the degenerative tearing removed. Next, the peroneus
longus was followed until we turned into the plantar soft tissues. It was
retracted and released from just below the cuboid bone. Next in a Pulvertaft
weave fashion, the peroneus longus was tenodesed through the peroneus brevis.
Three small slits were made in the peroneus brevis tendon. The longus was
then weaved through the peroneus brevis tendon in alternating fashion. Using
#2 FiberWire, the tendons were sewn together through the Pulvertaft weave
sites. The peroneus longus tip was then debrided back to a small protuberance
just distal to the level of the last tenodesis site. This was about 2 cm
proximal to its insertion to the peroneus brevis insertion on the fifth
metatarsal. The foot was held in the slightly everted position during the
tenodesis. When the foot was released, there was adequate tension on the
peroneus brevis and longus tenodesis. The tendons were placed back into their
anatomic position. There was adequate concavity of the groove behind the
fibula for the tendons. Remaining tenosynovitis was removed with the rongeur.
Repair of the superior peroneal retinaculum was then performed with 3-0
Ethibond in a pants-over-vest fashion. The proximal tendon sheath was closed
with 3-0 Ethibond in a running fashion. Wounds were copiously irrigated with
sterile saline. Deep and subcutaneous tissues were closed with 2-0 and 3-0
Vicryl. The lateral skin incision was closed with staples. The posterior
heel incision was closed with staples, and the dorsal and plantar foot wounds
were closed with 3-0 nylon in a horizontal mattress fashion. Sterile
dressings applied with Xeroform, 4 x 4’s, sterile Webril, and a well-padded
posterior splint with the ankle in neutral dorsiflexion and plantarflexion was
placed to the right lower extremity. The tourniquet was deflated and all
toes immediately became pink with good cap refill. Sponge and instrument
count correct x2 at the end of the case. The patient was reversed from
anesthesia and transferred to the PACU in stable condition. She tolerated the
procedure well.