Practical Keys To Improving Fluency In Foot And Ankle Surgery

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By Luke D. Cicchinelli, DPM, FACFAS

Should You Suspect Peroneal Tendon Tears With Lateral Ankle Instability?


   Lesson seven: Always suspect longitudinal tears of the peroneal tendons and subtalar joint instability with unresolved lateral foot and ankle pain. Peroneal tendon pathology and the adult-acquired cavus foot are the first cousins of the more frequently discussed posterior tibial tendon pathology and adult-acquired flatfoot. Magnetic resonance imaging (MRI) scans can be unreliable. One must suspect the diagnosis clinically. Longitudinal tears in the insertional zone of peroneus brevis and retromalleolar flattening of the brevis with low-lying muscle belly are the most frequent yet undersuspected pathologies.
   Practical exercise: Primary repairs and tubularizations work well but do not address deforming forces. Consider the calcaneal osteotomy as well with lateral displacement or in combination with the Dwyer correction.    Subtalar joint instability is a translational fore and aft instability of the talus above a weightbearing calcaneus. The modified Brostrom-Gould technique works well as the repair crosses the subtalar joint. When tendon transfer are necessary, use free graft or the peroneus longus. The brevis is our main evertor.
   Translation to patient: You will likely still need a lateral ankle brace for high demand activity. We can support a pronating foot more readily than we can control a supinating structure.

What About Retrocalcaneal And Achilles Surgery?

Lesson eight: Stay off the back of the heel. Use medial or lateral incisions when possible for Achilles and retrocalcaneal surgery. Direct midline incisions contract more and are more susceptible to wound complications and shoewear irritation.
   Practical exercise: The medial and lateral supporting arterial vessels do not quite join in the direct midline heel. Although the vast majority of incisions heal without difficulty, the occasional posterior heel breakdown will drag on for one to two years, take five years off your life and require reconstructive plastic surgery with possible free flap transfer. You will also get sued. With substantial Achilles insertional calcific pathology or weakening, use of the FHL tendon to reinforce the insertion can provide functional strength gain. Consider proximal gastrocnemius release in conjunction with posterior heel surgery.
   Translation to patient: Achieving 75 percent improvement in preoperative symptoms a year after surgery is an excellent result. See lesson six.

When Regular Follow-Up Is Not Possible For Patients With Clubfoot

Lesson nine: Ponseti is the gold standard but is not always the best or the most practical option. A complete series of Ponseti casting is ideal for clubfoot correction. There is no argument. However, globally, one stage surgical release is as necessary as ever. If you only do one Ponseti casting of the series and never see the child for follow-up, it is worse than a surgical release. You may only get one chance with a patient living in a remote area.
   Practical exercise: Use zigzag incisions to reduce scar contracture both medially and laterally. Partial recurrence or residual metatarsus adductus is not unusual. Do not beat yourself up. Postoperative splinting is mandatory and still must be insisted upon in developing regions of the world with limited resources. One may even use the bivalved cast.
   Translation to patient: No surgery has ever converted a clubfoot to a normal foot. The goal is a plantigrade, pain-free, shoeable foot.

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