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Harold Schoenhaus, DPM,
Surgical Editor for PRESENT e-Learning
Penn-Presbyterian Medical Center
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Male Speaker: About Evans calcaneal osteotomy and arthroeresis. I look back at my cases to try to compare the two procedures and try to identify or even try to classify when I would do one versus the other. I’ve been a proponent of arthroeresis for 40 years and have put everything in that sign as far sight that you could possibly imagine. So let’s take a look at some things with indications for arthroeresis. A lot of this maybe repetitive to what Michael Gram talked about. Uncontrollable hyperpronation. That orthotic that we just see could not be tolerated. Normal to mild cuboid abduction, the presence of forefoot supinatus, sagital plane subluxation of the subtalar joint, minimal calcaneal eversion or abduction, obliteration of the sinus tarsi and mild to moderate talar escape. I’ll just go into these things. The goals of arthroeresis are to realign peritalar subluxation because that is what is happening. Block excessive pronation but allow for normal motion to take place. The younger the patient, the better this procedure’s going to work because you will allow for functional adaptation as long as you can eliminate the deforming force that cause that foot to pronate in the first place. And more times than not, it’s going to be an equinus component. So you’re supporting the talus. You’ll see a reduction in supinatus overtime. You restore muscle balance, pronators versus supinators and you restore arch height. So here’s a good example of that hypermobile flatfoot. We did symptoms. We’re not going to look at that. We’ve tried this device, the DSIS, and now we’re looking for a surgical approach. So we identify the patient that falls into the category of needing surgery. Why do I like arthroeresis? I also like Evans for some of these reasons by the way. It’s extra articular. I don’t like fusing joints if I can avoid it especially in the pediatric adolescent population, unless there’s a neuromuscular component. It’s a reversible procedure. At any time I can go in and pluck that arthroeresis right out. Ease of implantation, ease of removal, and the allowing of early weight bearing. The primary goal again, reposition the subtalar subluxation, block motion that’s excessive. We’ll go into that. Here’s what we’re trying to do. Take the foot that looks right in the middle as neutral. That’s where we’d like to ultimately function. The foot that’s on the left side is that pronated foot that’s dropping down and you never want to overposition the foot or overcontrol it. The worst thing you can do is put a foot into too much supination and block it. The ideal is right in the middle. So we’re realigning the subtalar joint with direct influence on both axes of midtarsal joints as well as first ray repositioning. So oblique and longitudinal axis of the midtarsal joint is going to be significantly affecting. It’s very simple to determine what you’re trying to accomplish. You want a talus that’s dropping down into the sulcus of the sinus tarsi. Pick the talus back up and then stick something in that canal. God gave podiatry this canal. I’m firmly convinced about this. This is what I call a podiatric canal. It’s there for a reason and put something in it. I’ve done everything from silastic to polypropylene to a bone which is not what you want because it will cause a fusion to implants that are metallic in nature with every shape. I’ve used rolled up graft jacket, put tootsie roll pops, horse shoe and splinters, chewing gum. Anything that’s blocking the motion has dramatic influence by the way. What you’re trying to do is simply take that foot that’s hyperpronated and bring it back to its neutral position. You can just see some of these cases and you could see the extent of hyperpronation and abduction. Look at the supinatus. Superposition of all the metatarsals. Talus is obliterating the sinus tarsi. Now I want to point out something that I think a lot of people miss. We talk about anterior break in the cyma line. If you don’t have it, the foot’s not significantly pronated. In transverse dominating forces, in patients who might have internal torques or the axis of motion of the subtalar joint encourages the talus to move more medial than sagittal, you won’t have a significant anterior break in the cyma line but you will still have obliteration in sinus tarsi.
So that becomes more of an important factor to me. Do I put all these lines on my patients? Usually I do so that I can actually be able to look preoperatively, postoperatively, and identify for them what are the important factors that are going to lead me to recommend surgical intervention on this patient. I’ve gone over some of these already. Adjunctive procedures tend to Achilles lengthening, gastroc lengthening, Kidner procedures. And Kidner by itself by the way is not a flatfoot correction but oftentimes it may influence if there’s a gorilla form navicular or a tibiale externum, it may influence the ability of the tibialis posterior to function effectively. So I will do an adjunctive procedure at that level. And okay, how you do your TALs. I make little teardrop incisions. I make little cuts. I try to avoid these bigger incisions now even though I told you big surgeons to make big incisions. I like little ones on these kids. If you want to do a gastroc lengthening, certainly if he was endoscopic you can do that. You can use open. There’s all different types of materials. I’ve even used the absorbable materials in the sinus tarsi. Giannini, an Italian orthopedist from Italy, had developed a bio absorbable material that he used in the sinus tarsi and we have a number of them here and not too many people use those any longer. I don’t care what you’re using in the canal. I don’t know what company you’re using to accomplish it. Choose something that’s going to work very easily for you, meets the criteria of blocking motion, minimally invasive. I don’t want to screw it into the bone. That’s not what you’re trying to accomplish. I think the best thing for these little fluted things and things that look like a screw are to provide some fibrosis. I don’t really want to use that term because it may not even happen to help keep the plug in place. Procedure is a no brainer. This is a five minute procedure. That ligament is critically important. The ligament over the canal is sinus tarsi. You open it up, bluntly open the ligament. That is going to be your entrance into the canal. I usually use a rongeur and remove the fiber fatty plug. If you want to use guide wires to find exactly where the sinus tarsi is or the direction, you certainly can. I just wonder if you have to do that when you park your car in the garage. The opening is pretty big. The same thing with sinus tarsi. If you can’t find the sinus tarsi when the foot is repositioned, you shouldn’t be doing these procedures. There’s a guide wire. It’s nice to be able to show it. Be careful putting those guide wires in by the way because you could put them in too far and it comes right out the medial side, right by the tibialis posterior. I always fear that I could hit the neurovascular bundle medially. So I’m not a big proponent of that. Here’s an example of an MRI showing extrusion of silicone out of the canal. That was almost like a watermelon pit being squeezed out. Silicone is not good. Here’s an example of a position of a plug very nicely in place. I do not like going deep into the canal and I know there are people who say you got to go in medially, go further in, maybe even interfere with the interosseous talocalcaneal ligament. To my opinion that’s a mistake. The neurovascular supply going up to the body of the talus goes right through the interosseous talocalcaneal ligament from the inferior portion. If you violate it, you run the risk of AVN to the talus. I just don’t like that procedure. So ideally the plug is in place. You’ve eliminated the deforming force. You’ve realigned the foot. The talonavicular subluxation is gone. Be very careful not to overcorrect however and be very careful with these procedures that you don’t have adductus present because you can reposition a foot. And if you’ve unmasked a metatarsus adductus or didn’t realize it existed preoperatively as a potential pronatory component, you’re going to have an arch and a foot that’s markedly adducted and a patient who toes in.
Parents don’t like that too much. You could see the dramatic change by simply putting a plug in, how you can reposition the talus very nicely and how you actually will see reduction in forefoot supinatus as well. That’s a great example. These are zero radiographs. You can’t see the plug in place because it’s radiolucent. But look at the change in the relationship if the talus, the talar declination component, sinus tarsi is beautifully visible now. The talus is much higher up. And now we could differentiate from superimposition to a separation of metatarsals. That’s reduction of forefoot supinatus. The triplane soft tissue deformity that reduces. That happens rather rapidly. I’m not a big proponent by the way doing cotton procedures. We run too quick to do too much at one time. Not allowing the repositioning of the rear foot and the function of a peroneous longus to relocate, derotate the supinatus because that’s the muscle that’s got to do it. There’s beware of adductus. The worst thing you could do, I got a beautifully controlled talonavicular articulation. That may be a little too much control. I like a little bit of pronation in that foot but now I’ve got an adductive foot type which makes it very bad for that youngster to walk. Long term results, perceptible change in the arch, reduction of forefoot lateral transposition, reduction of supinatus, improve posture, genu valgum in youngsters gets much better, reduction of elimination of postop orthotic control and you maintain tension on the stretch to lengthened Achilles which you’ve just done to eliminate it as a deforming force. Easier avoidable complications. I’m not even going to read them. You could take a look at those. What about Evans? Let’s do that pretty quick. Evans is simple. Very similar to what we just looked at. Uncontrollable pronation, moderate to severe cuboid abduction. That’s a big difference now. Mild to moderate calcaneal eversion or abduction, forefoot supinatus, obliteration of the sinus tarsi, moderate to severe talar escape, decrease in the CIA and a hypermobile ray. So we see a lot of the things similar. The indication that really separates arhtroereisis from Evans is right here, transverse plane hyperpronation. As I identify, you may have a normal to anterior break in the cyma line. Primary equinus, short lateral column. Overpowering of the peroneus brevis. It’s the antagonist to the TP. So if that foot is abducted, it loves – it keeps that foot abducted in position. Insufficient function of the peroneus longus. With the instability of the rear foot, peroneus longus can do nothing to lower the medial column or hold it down. So what are the goals? You want to elongate the lateral column. This in itself increases the tension on the peroneus longus which will derotate the forefoot so it reduces the forefoot supinatus. You’ll also reduce hypermobile first ray, the peritalar subluxation and allow all these things to happen once again that we saw with arthroeresis. That increased tension on the peroneus longus is critically important in this procedure. A little bit more involved, a little bit more apparent eversion and abduction. Transverse plane dominant. Here’s that lateral view and you don’t see much break in the cyma line, do you? Not an anterior break. I’m just going to zip through this for you. There’s a hallmark. Cuboid abduction. As that cuboid and forefoot move laterally, the medial portion or the talus appears to escape out of the ball and socket joint. There are two ball and socket joints in the foot in my opinion, the talonavicular articulation and the great toe joint.
So there we are just outlining things. So it’s plane ol’ dominance. I look at sagittal plane, cut and osteotomy people do. I’m not a big proponent of it. TAL arthroeresis, transverse plane, forefoot in the position that is abnormal which is supinatus, and I do the Evans. Your location of the Evans is kind of simple. I’ve used two different incisions. One a lateral one that you see which is longitudinal or you can make a vertical incision. Depending upon what else I might be doing will determine my position of the incision. If I combine it with a Koutsogiannis, I just use the long incision and extended back and do both procedures. The difficult part of this procedure is opening up of your osteotomy. The osteotomy in Evans is approximately one to one and a half sonometers promixal to the CC joint. Do not violate the CC joint. Don’t take the extensor brevis and move it out of the way. It’s not necessary. You’re coming into the proximal part. From the CC joint, go right to the sinus tarsi and it’s actually the more distal part of the sinus tarsi where I’m going to make this cut. Obviously you’re just transpositioning by placing something into the calcaneus. You couldn’t put bone. Years ago that’s what we used. Bone bank bone. You carved it to shape. Stuck it into the calcaneus so that you would abduct it. The bone was usually eight to ten millimeters in width that you placed into the canal. One of the problems that happens if you’re not careful with Evans is that you can have the distal aspect of the calcaneus and your graft extend right up into the sinus tarsi. This happens if you have done any dissection over the CC joint. So what I do to prevent that is I actually put a K-wire or a Steinmann pin before I make my osteotomy through the distal part of the cuboid into the proximal part and into the distal part of the calcaneus. That just prevents that from happening. If you need to go into an orthotic postop, you certainly can. TALs are often done simultaneously. There’s that K-wire going into the distal part before I make my osteotomy. Here’s a neat little clamp that I use to open up the osteotomy. It allows for easy access of whatever you’re going to put into the calcaneus. There’s the peroneal tendons by the way underneath. You got to be careful for that. Here we were doing a Koutsogiannis along with it. Stretch the tissues. Very interestingly plantarly, the long plantar ligament, short plantar ligament and plantar fascia try to fight the opening of this osteotomy. So I put these devices on and allow the soft tissues to just relax. Here’s a material that I use. It’s called BioFoam. It’s beautiful templated material that goes right into the canal. It’s actually titanium. It looks like cancellous bone. Comes in various sizes. You determine the appropriate size based upon talonavicular congruity and watching the first ray come down. It’s unbelievable how it works. There it is in place. My clamp holds everything open to allow the titanium piece to go into the calcaneus. On occasion I will put a plate directly over it so that there’s no chance whatsoever of the distal part of the calcaneus slipping. There it is in place. Obviously the goal is to obtain a beautiful arch at the end. There’s the cuts being done simultaneously. I like to use offset plating for the Koutsogiannis and the combination works very well. Then there’s a combination of the Koutsogiannis and the Evans. We relocate the forefoot. We’ve dropped the medial column down. It almost looks like we’ve created a cavus foot in this position. You see the most dramatic changes with an Evans procedure. Again, allow the anatomy and the peroneus longus to derotate. Too many people I think run in and do cut. They got to get that medial column down. The mechanics and biomechanics are important to comprehend and understand.
Look at the difference in this foot compared to the one on the bottom with an Evans procedure. Thank you for your time.