Practical Keys To Improving Fluency In Foot And Ankle Surgery

By Luke D. Cicchinelli, DPM, FACFAS

A Few Thoughts About Midfoot Surgery

Lesson five: Use more compression staples and locking plates. Compression staples make your life easier. For short, squarish, closely packed joints in the midfoot, region staples are ideal internal fixation.
   Practical exercise: Screws invite stress risers and compromised fixation due to the necessity of oblique presentation of the drills and screws. Staples also allow maximal bone-to-bone contact rather than traversing small joints with small surface areas with pins and/or screws, thereby impeding bony union. Locking plates similarly traverse joints and are incredibly stable. When one modifies and cuts up calcaneal locking plates, they can work wonderfully as fixation devices for complicated revisional midfoot and Lisfranc fusions.
   Translation to patient: Yes, the middle of your foot will be stiff after surgery. It already is now but it hurts. You have wear and tear arthritis, and we are trying to get rid of your pain. Unfortunately, no implants exist for these joints.

What You Should Know About Hindfoot Surgery

Lesson six: Position, position, position. “Thou shalt not varus” has been beat into our heads. We get it. One can even correct this, if necessary, with revisional wedging laterally or through the midfoot. Hindfoot and ankle fusions in excessive valgus are even worse. Bracing is difficult due to medial malleolar irritation. Shoeing the foot is difficult due to forefoot to rearfoot malalignment. Revisional surgery is complicated as the axis of correction is medial and underlies the neurovascular bundle.
   Practical exercise: It is better never to get there. Always prep above the knee with hindfoot and ankle fusions to have a proximal reference for alignment for the foot to the leg. Use the position of the lateral process of the talus in relation to the floor of the sinus tarsi as your reference for inversion to eversion within the foot.
   If necessary, use a calcaneal displacement osteotomy in addition to fusion. The heel must contact the ground in a sound and stable positon in gait. The calcaneal displacement osteotomy is essentially a tendon transfer of the Achilles and a tip of the rearfoot axis. Use it to ensure correct alignment intraoperatively if necessary. The deformity of excessive valgus will not forgive you postoperatively.
   Translation to patient: You will have functional limitations after surgery. Other joints will accept more stress. We cannot reverse the average American weight gain of two pounds per year between the ages of 20 to 40 with foot surgery. We want to stop further collapse.


Great article.
I sense the very same thing going on, possibly to an even greater extent (Think the Tower of Bable) in biomechanics.
Do you agree?

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