Transcript CADAVER STUDY OF MEDIAL NEUROVASCULAR …

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
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.
Dysfunctional Flatfoot:
Terminology
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Flatfoot
Pes planus
Hypermobile flatfoot
Pes plano-valgus
Tilipes calcaneal valgus
Peroneal spastic flatfoot
Etiologies:
• congenital-ligamentous laxity, veritical talus,
coalition, equinus
• Acquired:
• Biomechanical-torsional,hypermobility
• Systemic disease: arthritis, neuromuscular
• Trauma- coalition fx, PT damage, lisfranc
dislocation
Treatment goals:
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Relieve pain
Reduce deformity
Improve function
Prevent progression of deformity
Decrease postural symptoms
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.
• Medial displacement of the calcaneus
redirects the pull of the gastrocnemiussoleus 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.
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.
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.
• 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.
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 postoperative wound complications.
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.
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.
Posterior tibial tendon:
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
Nerve supply:
• Tibial nerve
Medial neurovascular structures:
A: tip of medial malleous, B: medial tubercle of calcaneus, TN: tibial nerve, LPN: lateral plantar nerve,
MPN: medial plantar nerve, Arrow: medial calcaneal branch.
Ligaments:
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Spring ligament
Deltoid ligament
Plantar fascia
Short plantar ligament
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
• Posterior view: hindfoot valgus with medial
displacement of the rearfoot
• 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 patient’s
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
• 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
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
Normal and flatfoot
• MRI: evaluation of integrity of ligaments
and posterior tibial tendon
• CT scan: coalition
PTTD on MRI:
CLASSIFICATION:
• Johnson and Strom, 1989
• Described the three clinical stages of
PTTD
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
TREATMENT:
• Stage I: Conservative treatment
• Stage II: calcaneal osteotomies in
conjunction with other soft tissue
procedures
• Stage III: Arthrodesis
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
• 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
• 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).
Figure #2
• 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.
Figure #3
• 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).
Figure #4
• Fluoroscopy imaging was used to assess
the placement of the Gigli saw and to
confirm the final position of the proposed
calcaneal osteotomy (Figure 5&6). 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.
Figure #5
Figure #6
• 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
Figure #7
• 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.
• 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
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).
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.
• 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 postoperatively.
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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 surgeon’s
choice and proficiency that will dictate the
successful outcomes after PCDO procedure.
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