Assessment of medial and lateral neurovascular structures after percutaneous posterior calcaneal displacement osteotomy: a cadaver study

A prospective investigation of the effects on the medial and lateral neurovascular structures of the rearfoot after percutaneous posterior calcaneal displacement osteotomy was performed using 20 below the knee fresh frozen cadaver specimens. This anatomic study aimed to examine the medial and lateral neurovascular structures to determine whether they were jeopardized during execution of the osteotomy. After completion of the osteotomy, the medial plantar, lateral plantar, medial calcaneal, sural, and posterior tibial neurovascular structures, along with their respective branches, were inspected for iatrogenic injury. Our findings demonstrated that the percutaneous, subperiosteal osteotomy minimized trauma to the local soft tissue envelope and protected the adjacent neurovascular structures. Because no iatrogenic injury was observed in the cadaveric specimens, we postulated that percutaneous calcaneal displacement osteotomy is a safe, predictable, and advantageous alternative compared with open techniques for osteotomy and could result in reduced postoperative complications. The results of this investigation remain to be confirmed in the clinical setting.     

Endoscopic flexor hallucis longus decompression: a cadaver study

BACKGROUND: New indications for arthroscopy are being considered because arthroscopy limits incision size and potentially decreases operative morbidity. This cadaver study investigated the utility of performing an all-endoscopic flexor hallucis longus (FHL) decompression. METHODS: Eight fresh-frozen cadaver legs were used. In the simulated prone position with large joint arthroscopic equipment, posterolateral and posteromedial portals were used to perform posterolateral talar process bony excision and FHL sheath debridement and release. We noted the integrity of the sural nerve, FHL tendon, and medial tibial neurovascular bundle. After open dissection, values for sural nerve distance to the posterolateral portal, the amount of FHL sheath released and the proximity of the arthroscopic instrumentation to the medial tibial neurovascular structures were recorded. RESULTS: Three of eight FHL tendons were injured during the attempted FHL release. Furthermore, no FHL sheath was completely released down to the level of the sustentaculum. Although posterolateral portal placement was on average 12.1 mm from the sural nerve, it was only 6.1 mm from the lateral calcaneal branch of the sural nerve. Moreover, in all cases the medial calcaneal nerve and first branch of the lateral plantar nerve were closely juxtaposed and in some cases adherent to the FHL fibro-osseous sheath. CONCLUSIONS: Although os trigonum or posterolateral talar process excision was performed without difficulty, endoscopic release of the FHL tendon proved technically demanding with significant risk to the local neurovascular structures. Given the reliability and low morbidity of open techniques, this cadaver study calls into question the clinical use of complete endoscopic FHL release to the level of the sustentaculum. Moreover, hindfoot endoscopic surgery should be performed by surgeons familiar with open posterior ankle anatomy and experienced in hindfoot endoscopy.     

Posterior calcaneal osteotomy with wedge: cadaver testing of a new procedure for insufficiency of the posterior tibial tendon.

Insufficiency of the posterior tibial tendon is challenging to treat. When the deformity is flexible, treatment options have included tendon transfer, often combined with a medial slide calcaneal osteotomy and/or a lengthening of the lateral column. Posterior calcaneal osteotomy has been shown to give correction, although not full correction. Lengthening of the lateral column also has been shown to give correction and has been used in the more severe flexible deformities, but it involves either fusion of the calcaneocuboid joint or risk of arthritis at this joint. An osteotomy combining the calcaneal medial slide with a lengthening of the lateral column at the same osteotomy site has been tested in the laboratory. This combined osteotomy provides a lengthening of the lateral column, but it is positioned away from the calcaneocuboid joint. In this study, the osteotomy was compared with a medial slide calcaneal osteotomy and an Evans lengthening of the lateral column, using a cadaver flatfoot model. Radiographic measurements were made to evaluate correction of the planovalgus deformity after each of these procedures. There was statistically significant improved correction with the new osteotomy compared with that in a standard medial slide, and correction was comparable to that in the lengthening of the lateral column. This combined osteotomy may be a reasonable alternative when more correction is desired than can be obtained from a medial slide alone and when the surgeon wishes to avoid an osteotomy near the calcaneocuboid joint.     

Percutaneous pin placement in the medial calcaneus: is anywhere safe?

OBJECTIVE: To redefine the medial calcaneal anatomic safe zone for pin placement with respect to reproducible palpable landmarks. DESIGN: Anatomic study. SETTING: Medical school anatomy laboratory. INTERVENTIONS: Thirty-three fresh-frozen adult cadaveric feet were used. Three palpable anatomic landmarks were identified on each ankle and labeled as Point A (posteroinferior medial calcaneus), Point B (inferior medial malleolus), and Point C (navicular tuberosity). The medial neurovascular bundle was carefully dissected, and the medial calcaneal nerve, the most posterior branch of the lateral plantar nerve, the lateral plantar nerve, the medial plantar nerve, and the posterior tibial artery were identified. These structures were recorded at the point at which they transected a line from Point A to B and from Point A to C. Based on the findings of the first thirty-three feet, two pins were placed percutaneously into the medial calcaneus of ten additional feet. Pin 1 was placed one half the distance from Point A to B. Pin 2 was placed one third the distance from Point A to C. The neurovascular structures were then dissected and identified in relation to the pin position. RESULTS: The medial calcaneal, most posterior branch of the lateral plantar, and lateral plantar nerves are at significant risk for abutting the pins or being directly injured at the margins of these relative safe zones. CONCLUSION: The medial calcaneus provides a small window for safe percutaneous pin placement. Posterior to the halfway point from Point A to B and posterior to the one-third mark from Point A to C remain the relatively safest regions; a more posterior placement in the safe zone is safest. Careful blunt dissection and the use of cannulas may help to avoid neurovascular injury.     

Pressure changes in the medial and lateral plantar and tarsal tunnels related to ankle position: a cadaver study

BACKGROUND: Pressure in the tarsal tunnel has been shown to be elevated when the ankle is pronated. We hypothesized that this also would be true for the medial plantar and lateral plantar tunnels because they also are potential sites of nerve compression. Additionally, we hypothesized that decompression surgery, including a release of the superficial and deep fascia of the abductor hallucis muscle and excision of the septum between the medial and lateral plantar tunnels, would decrease the pressure in all three tunnels. METHODS: Twelve fresh cadaver legs were obtained, and pressure measurements were made in a variety of ankle positions in the tarsal and medial and lateral plantar tunnels before and after decompression surgery. For the medial and lateral plantar tunnels, pressures were obtained after tunnel roof (deep fascia of the abductor hallucis) incision and after both roof incision and excision of the septum between the two tunnels. RESULTS: Pressures were significantly elevated in all tunnels with ankle pronation, were significantly decreased in all positions in the tarsal tunnel after decompression, and significantly decreased in most positions in the medial and lateral plantar tunnels after decompression. Septum excision led to additional significant decreases in pressure in some positions. CONCLUSIONS: Pressures within the medial and lateral plantar tunnels and the tarsal tunnel increase significantly with changes in ankle subtalar position. These pressure changes can be significantly decreased by operative release of each of these three tunnels, including excision of the septum between the medial and lateral plantar tunnels. CLINICAL RELEVANCE: Symptoms related to chronic compression of the tibial nerve and its branches at the ankle may be relieved by an operative strategy that targets release of multiple anatomic regions of tightness in the medial ankle rather than focusing on the tarsal tunnel alone.     

Tarsal tunnel syndrome. Nerve compression syndrome in the foot

Pathological changes in sensation over the sole of the foot do not always correspond to the full area of distribution of the posterior tibial nerve. Some neurologists advise separate examination of the tibial nerve, the medial and lateral plantar nerves, in order to ascertain whether either or both might be affected. 60 preparations of cadaveric feet in the Department of Anatomy were examined. Using a measuring grid, the position and size of the nerves in the tarsal tunnel were assessed and the facial band which define and divide the osteofibrous canal delineated. The corners of the measuring grid were the tip of the medial malleolus (A), the tip of the calcaneal tubercle at its greatest distance from the medial malleolus (B) and the tuberosity of the navicular bone (C). These points can also be clearly identified clinically. They define a triangle whose sides A-B and B-C are of constant equal length and whose base A-C varies little. The operative approach includes a T-shaped incision of the retinaculum. The vertical line of the T lies underneath the skin incision. The horizontal line corresponds with the upper border of the abductor hallucis muscle. The upper border of the abductor hallucis is defined and the muscle retracted medially to expose the deep fascia. This layer is removed together with the connective tissue bridge which stretches between the fascia and the calcaneus. The plantar nerves are discovered and run to the sole of the foot without further obstruction.     

Percutaneous Plantar Fascia Release With Needle: Anatomic Evaluation with Cadaveric Specimens

Percutaneous plantar fascia release with needle is a novel procedure for the treatment of plantar fasciitis. The objective of this cadaveric study is to perform an anatomic evaluation of the percutaneous plantar fascia release method using a conventional hypodermic needle. In this study, we used 14 fresh-frozen cadaveric trans-tibial amputation specimens. Percutaneous plantar fasciotomy with a conventional hypodermic needle was performed. After a proper dissection, the width of the plantar fascia, the thickness of the medial border, and the width of the cut segment were measured and recorded. Any muscle damage on the flexor digitorum brevis and damaged area depth were recorded. Any damage on the lateral plantar nerve and the first branch of the lateral plantar nerve, also known as Baxter's nerve, and their distance to fasciotomy were also recorded. Mean width (± standard deviation) of the plantar fascia was measured as 20.34 ± 4.25 mm. The mean thickness of the medial border of the plantar fascia was 3.04 ± 0.54 mm. Partial fasciotomy was performed in all cadavers with 49.47% ± 7.25% relative width of the plantar fascia. No lateral plantar nerve, or its first branch Baxter's nerve, was damaged, and the mean distance from the deepest point of the fasciotomy up to the Baxter's nerve was 8.62 ± 2.62 mm. This cadaveric study demonstrated that partial plantar fasciotomy can be achieved via percutaneous plantar fascia release with a conventional hypodermic needle without any nerve damage.     

Operative treatment of the difficult stage 2 adult acquired flatfoot deformity

In the flexible pes planovalgus deformity of stage 2 posterior tibial tendon dysfunction, osteotomies appear to have a significant role in operative management by restoring more normal biomechanics, allowing tendon transfers to function successfully. The options when considering osteotomies for stage 2 disease include lateral column lengthening, medial displacement calcaneal osteotomy, and combined double osteotomy technique. The tight Achilles tendon should be lengthened as well. Lateral column lengthening has been used extensively for treatment of flexible flatfeet. It has been shown clinically and radiographically to address all 3 components of the pes planovalgus deformity present in stage 2 posterior tibial tendon dysfunction. Lateral column lengthening is used in combination with a medial soft tissue rebalancing procedure. The mechanism of action is still speculative but clearly is not owing to tensioning of the plantar fascia as previously thought. Despite the excellent correction of foot posture obtained by use of lateral column lengthening for adult acquired flatfoot, many clinicians have reservations about its use because of reported secondary increases in the calcaneocuboid joint pressures. This increase in pressure has been shown to occur experimentally, increasing the potential risk of calcaneocuboid joint arthrosis. This experimental evidence is supported by Phillips' study of the original Evans procedure, which resulted in a 65% incidence of calcaneocuboid joint arthrosis at 13-year follow-up. Mosier-LaClair et al reported a 14% incidence of calcaneocuboid joint arthritis at 5-year follow-up after double osteotomy for stage 2 posterior tibial tendon dysfunction. This incidence has not been proved true in the remainder of the literature surrounding this procedure and its use for flexible flatfoot. To address the concern regarding potential calcaneocuboid arthrosis secondary to lateral column lengthening, calcaneocuboid joint distraction arthrodesis has been explored as an alternative technique. The results show good initial correction, but the follow-up is extremely limited, and one study reported loss of correction over time. Longer follow-up is needed to determine whether or not this technique would provide the lasting correction seen with the Evans procedure. Calcaneocuboid joint lengthening arthrodesis does result in some limitation of adjacent hindfoot motion. Although this limitation is significantly less compared with talonavicular and subtalar joint fusion, this procedure may result in increased local pressures and arthrosis of the midfoot or hindfoot. For the above-mentioned reasons, longer follow-up studies are needed to determine whether calcaneocuboid joint distraction arthrodesis would prove to be a reliable and safe alternative for lateral column lengthening in the treatment of adult acquired flatfoot. Medial displacement calcaneal osteotomy has been used for correction of the pes planovalgus foot in posterior tibial tendon dysfunction. It has been used extensively for the surgical treatment of flexible flatfoot throughout the literature. Medial displacement osteotomy, in combination with flexor digitorum longus tendon transfer, can address all 3 components of adult acquired flatfoot. It does not recreate the medial longitudinal arch in all patients, however. Although the mechanism of action of medial displacement calcaneal osteotomy is unknown, it has been proved that it is not through the tightening of the plantar fascia in a windlass effect as previously thought. In contrast to lateral column lengthening, however, medial displacement calcaneal osteotomy does address the deforming valgus force of the Achilles tendon. Functionally transferring the insertion of the Achilles tendon medially removes a constant valgus-deforming force. The osteotomy can then act as a double tendon transfer with the flexor digitorum longus tendon to aid in foot inversion. For stage 2 posterior tibial tendon insufficiency, the authors favor the combination double osteotomy technique with a flexor digitorum longus tendon-to-medial cuneiform tendon transfer, débridement or removal of the posterior tibial tendon, and percutaneous heel cord lengthening. Early results were positive at 1.5 years after surgery with respect to maintenance of correction and functional improvement with no evidence of calcaneocuboid arthrosis. More recently, the intermediate 5-year follow-up has been assessed for this combination of procedures, and similar results were found. There was a high rate of patient satisfaction and functional improvement, and surgical correction of the flatfoot deformity was maintained and compared favorably with the contralateral normal foot. Although the intermediate follow-up found a 14% incidence of calcaneocuboid arthrosis, 50% of these patients had preoperative evidence of calcaneocuboid joint arthritis. (ABSTRACT TRUNCATED)     

Minimally invasive method of harvesting the flexor digitorum longus tendon: a cadaver study

BACKGROUND: The flexor digitorum longus (FDL) tendon is harvested for use in the reconstruction of dysfunctional adjacent tendons such as the posterior tibial and the Achilles tendons. The approach to harvest the FDL tendon in the midfoot region is through an incision along the medial border of the foot. This approach involves dissection quite deep in the foot across neurovascular structures in the vicinity placing them at risk. The purpose of this cadaver study was to test the feasibility and safety of a minimally invasive technique, and also to define the relevant topographical surface and deeper surgical anatomy. METHODS: In 83 cadaver feet, the FDL tendon was harvested proximally in the hindfoot after it was cut through a small plantar incision in the midfoot. All the tissues superficial to the FDL tendon were then reflected to check for damage to the adjacent neurovascular structures. Measurements were obtained to define the location of the point of division of the FDL tendon in relation to the plantar surface of the foot and the adjacent neurovascular structures. RESULTS: In all of the 83 feet it was possible to harvest the FDL using this technique. In 11 feet (13.25%), a connecting band to the flexor hallucis longus tendon (FHL) required division. No damage was apparent to the adjacent neurovascular structures. The FDL division was located topographically on the plantar surface of the foot, approximately midway between the back of the heel and the base of the second toe and at this midpoint, about two-thirds of the width medially from the lateral border of the foot. CONCLUSIONS: The FDL tendon can be harvested in the hindfoot after its division through a small plantar incision in the midfoot. Surface anatomy guides placement of the plantar incision over the FDL division. CLINICAL RELEVANCE: The plantar approach when compared to the medial approach for harvesting the FDL tendon in the midfoot may be associated with a smaller incision, minimal dissection, lesser risk to adjacent neurovascular structures and lesser morbidity.     

Evans Osteotomy and Risk to Subtalar Joint Articular Facets and Sustentaculum Tali: A Cadaver Study

The Evans lateral column lengthening procedure allows correction of abduction, improved talar head coverage, decreased forefoot and rearfoot valgus, and improvement of medial column arch height. However, identifying the structures at risk when performing this osteotomy has proved difficult in vivo. Using 10 cadaveric lower limbs, we performed the Evans calcaneal osteotomy and determined whether violation of the calcaneal facets and the sustentaculum tali occurred. Based on our findings, we recommend directing the osteotomy from posterolateral to anteromedial.     

Anatomic study of the medial neurovascular structures in relation to calcaneal osteotomy

Medial displacement osteotomy of the calcaneous is commonly performed for stage II posterior tibial tendon insufficiency in an effort to improve the valgus deformity of the hindfoot. We performed an anatomic study examining the medial neurovascular anatomy and its relation to the osteotomy in an attempt to determine which structures may be at risk during the procedure. Calcaneal osteotomies were performed through a lateral approach on 22 fresh-frozen cadaver below-knee specimens. Dissection was then performed medially to identify the Medial Plantar Nerve (MPN), the Lateral Plantar Nerve (LPN), the Posterior Tibial Artery (PTA), and their respective branches. Measurements determined either 1) where the structure crossed the osteotomy or 2) if the structure did not cross, the closest perpendicular distance from the osteotomy and at which point along its length this occurred. Perpendicular distances were recorded in millimeters and position along the osteotomy as a percentage of the total length from the posterosuperior aspect. An average of four neurovascular structures crossed each osteotomy site (range 2 to 6), most of which were branches of the LPN or the PTA. The MPN did not cross in any of the specimens studied, the LPN crossed in one specimen, and the PTA crossed in two specimens. The MPN distributed no crossing branches. The calcaneal sensory branch of the LPN was identified and crossed in 86% of the cadavers at 19% (+/- 15%) along the osteotomy length. A more distal second branch of the LPN (Baxter's nerve) was identified and crossed in 95% of the specimens at 61% (+/ 20%) along the osteotomy length. A third crossing branch existed in one specimen. Each PTA distributed from zero to three branches which variably crossed the osteotomy at a point from 2% to 100% along its length. The PTA bifurcated in 77% of the specimens at 49% (+/- 9%) along the osteotomy length. A consistent finding in every specimen was the presence of two veins accompanying the PTA with one on either side. A number of medial neurovascular structures may be at risk when perfoming a calcaneal osteotomy through a lateral approach. A minimum of two structures crossed the osteotomy site at variable positions in this study, although most of these structures represented branches off of the LPN or the PTA, with the LPN and the PTA themselves crossing only infrequently. The authors recommend that the completion of the osteotomy through the medial calcaneal cortex be performed in a carefully controlled manner to reduce the risk of post-operative complications including pain, numbness, and hematoma formation.     

跟骨内移截骨术中跟骨内侧的截骨安全区

目的探讨跟骨内移截骨术中跟骨内侧的截骨安全区。方法 10具防腐成人尸体的20只足部标本上,取跟骨结节内缘最低点为A点,内踝尖最低点为B点,足舟骨结节为C点。显露跟骨内侧各神经血管结构后,用游标卡尺测量AB、AC长度,以及各神经血管结构与AB、AC线段交点与A点间的长度。经统计学检验,各组长度符合正态分布,所以可以用后者的长度均值除以AB、AC长度的均值,计算出各神经血管结构在AB、AC上的分布比例。结果跟骨内侧神经、足底外侧神经、足底内侧神经、胫后动脉在AB线上分别位于A点后的：29%、57%、66%、60%;而在AC线上跟骨内侧神经、足底外侧动脉、足底外侧神经、足底内侧动脉、足底内侧神经分别位于A点后的：20%、45%、50%、60%、66%。结论 AB线上A点后29%-57%,AC线上A点后20%45%的区域无重要神经血管走行,满足跟骨内移截骨术在跟骨中后部截骨的要求,可作为跟骨内移截骨术的手术安全区。 更多还原     

Osteotomies in the midfoot and the calcaneal part of the foot in relapsed clubfoot

There are no clear guidelines on the treatment of relapsed clubfoot, which is a relatively frequent and difficult problem in paediatric orthopaedics. Numerous operative interventions are mentioned in the literature as suitable for correction of a residual deformity of the food. There are numerous soft tissue procedures (release operations, tendon extensions, tendon transfers and redressement by means of a fixateur externe) and osseous interventions (osteotomies, arthrodeses) that can be carried out in isolation or in combination. In the present article two types of osteotomy are described that make it possible to correct the most frequent forms of relapsed clubfoot: combined closing wedge cuboid and opening wedge cuneiform osteotomy for correction of adductus and supination of the forefoot and the calcaneal osteotomy after Dwyer for correction of varus position of the calcaneal part of the foot. The combined osteotomy in the midfoot involves shortening of the lateral ray with simultaneous lengthening of the medial ray, with the wedge out of the cuboid bone inserted into the medial cuneiform bone, which leads mainly to correction of the adductus, but does also make it possible to achieve partial correction of the supination with an osteotomy right through the cuneiform bone. In the case of rigid foot deformities it is advisable to carry out preliminary stretching by means of a fixateur externe, while in the case of a bean-shaped foot a combination of osteotomy and medial and lateral release is recommended. Results of a follow-up study of our own patients treated with this operation have shown that no revision operations were necessary in any of the patients with idiopathic clubfoot. Other types of osteotomy described in the literature as suitable for correction of residual forefoot adductus and supination are also mentioned in this paper. Thecalcaneal osteotomy after Dwyer, for which a lateral approach is always used, generally leads to satisfactory correction of varus position of the calcaneal part of the foot. It the calcaneus is found to have a short posterior part this osteotomy is modified so that instead of taking the form of a wedge osteotomy with lateral closing it is followed by a lateral displacement. In this way it is possible to prevent making the already short posterior calcaneus even shorter. Both the combined midfoot osteotomy and the calcaneal osteotomy after Dwyer can be performed alone or in combination with each other or with different operative interventions.     

跟骨内外侧经皮置针安全区解剖学研究

目的 划定国人跟骨内、外侧外固定针进针位置解剖学相对安全区.方法 解剖14具正常成年人足踝部标本.于跟骨内侧取跟骨最内下后点为A点,内踝最下点为B点,足舟骨结节为C点.解剖出跟骨内侧神经、足底外侧神经最后分支、足底外侧神经、足底内侧神经、胫后动脉、足底外侧动脉和足底内侧动脉.根据各结构行经AB、AC线的位置,确定跟骨内侧的相对安全区;于跟骨外侧取跟骨最外下后点为D点,外踝最下点为E点,解剖出跟骨外侧神经、腓肠神经、小隐静脉主干,同理确定跟骨外侧的相对安全区.结果 跟骨内侧神经、足底外侧神经最后分支、足底外侧神经、足底内侧神经、胫后动脉分别行经AB线后下22%、50%、56%、64%及58%处,跟骨内侧神经、足底外侧神经最后分支、足底外侧神经、足底内侧神经、足底外侧动脉、足底内侧动脉分别行经AC线后下14%、39%、49%、63%、41%及57%处.跟骨外侧神经、腓肠神经、小隐静脉分别行经DE线后下 19%、65%及61%处.结论 在跟骨内侧,AB线后1/2、AC线后1/3所在圆形区域为经皮置针相对安全区.在跟骨外侧,经DE线中点垂线后方的跟骨为经皮穿针相对安全区.     

Plantar fascia release through a transverse plantar incision.

A transverse plantar incision for plantar fascial release was assessed for pain relief, numbness, and subsequent heel pad symptoms. Twenty-seven feet in 26 patients who underwent plantar fascia release were reviewed with a minimum follow-up of 2 years after surgery (average, 37.6 months). Comprehensive data were obtained on 25 feet (24 patients) (93% response rate). The plantar fascia origin was completely transected in all cases. This led to complete resolution of symptoms in 19 feet and residual minor symptoms in six feet. After 2 years, four patients had developed recurrent symptoms, two in the area of surgery and two on the dorsum of the foot, in association with a pes planus foot. Two patients had some continued persistence of heel pain after surgery, although significantly less pain than preoperatively.Thus, 76% of patients had complete relieve of there symptoms, 12% of patients had mild symptoms not affecting daily activities, and 12% of patients had moderate symptoms that limited some activities. No patient suffered heel pad symptoms or numbness after surgery. It is concluded that plantar fascia release through a transverse plantar incision is a successful procedure for long-term relief of symptoms which avoids unnecessary heel pad numbness and scar morbidity. The benefits of a transverse incision include greater intraoperative vision, to ensure adequate release and spur excision, and an incision parallel to the medial calcaneal branches of the tibial nerve.     

Biomechanical Evaluation of a Cadaveric Flatfoot Model and Lateral Column Lengthening Technique

Patients with adult acquired flatfoot have progressive worsening of bony alignment with many being unable to perform a heel rise. Following reconstruction, pathologic skeletal alignment is corrected and the ability to perform a heel rise is often restored. The purpose of this study was to evaluate the relationship between forefoot liftoff forces and skeletal alignment in a cadaveric flatfoot model by assessing the effect of sequential lengthening of the lateral column using an Evans-type calcaneal osteotomy. Bony alignment was measured in 8 cadaveric specimens with the use of a 3-dimensional digitizing system. Transection of the spring ligament, pie-crusting of the plantar fascia, and cyclic axial loading of the foot was performed to create an anatomic and functional flatfoot model. An Evans-type calcaneal osteotomy using 6, 8, 10, and 12 mm wedges was performed. Specimens were mounted to a custom jig that applies tensile loads to the Achilles, peroneus brevis, peroneus longus, and tibialis posterior tendons. Creation of a flatfoot reduced the lateral talo-first metatarsal angle (Meary's angle) by 13° (23.6° ± 2.8° vs 10.6° ± 3.8°, p < .05) and forefoot force by 7% (199.3 N ± 7.3 N vs 185.4 N ± 9 N, p < .05). Sequential lengthening of the lateral column restored skeletal alignment and force transfer to the forefoot (12 mm wedge: Meary's angle 22.7° ± 3.9°, liftoff force 206.8 N ± 7.5 N). The cadaveric flatfoot model demonstrated decreased forefoot forces that were restored with an Evans-type calcaneal osteotomy wedge. This highlights the importance of restoring skeletal alignment when correcting advanced adult acquired flatfoot.     

Calcaneal osteotomy for the treatment of plantar fasciitis

Background  

Plantar fascia release is the main procedure for plantar fasciitis which does not respond to conservative treatment. However, this procedure is sometimes accompanied by lateral column pain due to loss of the longitudinal arch height after surgery. To avoid this complication, we performed calcaneal osteotomy. The aim of this study was to clarify the efficacy of this procedure.     

Endoscopic Plantar Fasciotomy Through Two Medial Portals for the Treatment of Recalcitrant Plantar Fasciopathy

Plantar fasciopathy is a common cause of heel pain. Endoscopic plantar fasciotomy has the advantage of less surgical trauma and rapid recovery. The aim of the present prospective study was to delineate the results of endoscopic plantar fascia release through 2 medial portals. The present study included 2 groups. The first group included 27 feet in 25 patients that had undergone endoscopic plantar fascia release followed up for 19.7 (range 12 to 33) months. The second group, the control group, included 20 feet in 16 patients treated conservatively and followed up for 16.4 (range 12 to 24) months. The results of endoscopic plantar fascia release were superior to the conservative methods. The surgically treated group experienced significantly less pain, activity limitations, and gait abnormality. The presence of a calcaneal spur had no effect on the final postoperative score. In conclusion, endoscopic plantar fascia release through 2 medial portals is an effective procedure for treatment of resistant plantar fasciopathy that fails to respond to conservative management options.     

The contribution of the medial calcaneal osteotomy to the correction of flatfoot deformities

HYPOTHESES/PURPOSE: The success of the medial displacement calcaneal osteotomy in correcting flatfoot deformities is likely to be the result of a shift of the Achilles tendon forces on the hindfoot. The purpose of this study was twofold: 1) to define the contribution of the Achilles tendon to the flatfoot deformity, and 2) to define the effect of a calcaneal medial displacement osteotomy. METHODS: We used six different experimental dynamic stages: 1) intact foot without Achilles loading; 2) intact foot with Achilles loading; 3) flatfoot without medial calcaneal displacement osteotomy and without Achilles loading; 4) flatfoot without medial calcaneal displacement osteotomy but with Achilles loading; 5) flatfoot with medial calcaneal displacement osteotomy but without Achilles loading; and 6) flatfoot with medial calcaneal displacement osteotomy and with Achilles loading. The experimental flaffoot was developed by releasing the posterior tibial tendon, spring ligament, and plantar fascia and applying 7,000 cycles of axial fatigue load (range, 700 to 1,400 N; 1-Hz frequency). To simulate the phase of midstance, the peroneus longus, peroneus brevis, flexor digitorum longus, and flexor hallucis longus tendons were grasped by clamps, connected to pneumatic actuators, and loaded with precalculated forces. Anteroposterior and lateral radiographs were obtained for each stage on which the following measurements were made: talonavicular coverage angle, talar-first metatarsal angle, talocalcaneal angle, and height of the medial cuneiform. These measurements were compared with a one-way ANOVA. RESULTS: Between stages 1 and 2, all measurements were statistically insignificant. Between stages 3 and 4, for all measurements, Achilles tendon loading aggravated the flatfoot deformity (p < 0.05). After medial calcaneal osteotomy (stages 5 and 6), the Achilles tendon contributed less to the arch-flattening. We found that the medial displacement osteotomy plays an important role in reducing and/or delaying the progress of flatfoot deformity. CONCLUSIONS/SIGNIFICANCE: In the flatfoot, loading of the Achilles tendon increases the deformity. Medial calcaneal osteotomy significantly decreases the arch-flattening effect of this tendon and therefore limits the potential increase of the deformity.