LE SE H AM AM M
YN
XO O cccc u
DI IT
OM
mo mm we w i p ro ro na na t o n a n h yp yp e m ob ob i ay I" ray. (least m m we mu O cccc u a nc nc e p ha ha se se . U su su a wi up na on UB mb b ow ow s n g Oc w in in g h a U su su a wi vu oo Mal et To Cl Cu
oe
a nc nc e p ha h a se se . U su su a
(esp nd D IP IP ] o n ur HP on ps o e u su su a w i o n o e (esp C o n r ac ac tu tu re re s a t M P ] , P IP IP ] a n D IP IP 1 S e w i c av av u o o o r n eu eu ro ro mu m u sc sc u a r se "gun b a e l s ig ig n o n X - a y D IP IP ] o n ur wi o t o n C on on g n i HP on pe of 2-
ARTH ARTH OPLA OPLAST ST
I)
u ro ro p
ot
Will
o nd nd i o n
(pos (pos Proc Proced edur ure) e)
Excise as m uc u c h H P a s p o s ib ib l u s n g a n e l p t c a cut L a g e H P can remain if n o t e xc x c is is e Cu PP hi bo na om nd ur ne D o K e k ia ia n p u h -u -u p e s d ig ig i on tr tr ac ac te te d r e e as as e h e f o o w in in g i n o rd rd e u n r es es o v ed ed : still c on E x e ns ns o T en en do do n H oo oo d Capsule 3. P la la n a r H oo oo d Fi
on
Post-op:
K -w -w i n o w ay a y s d on on e .045 if n t u b h on on d on PP . 06 06 2 i f th th r o u g h M P J n o K -w - w i e , u tu tu r p ro ro x m a e nd nd o n t c ap ap su su l p la la n a r
WB mo ng
shoe 2 - w e ek ek s in h e d u on X-
on
po
op
nt
wi
2.
he
om
.0 absorbable.
oo
or un
Complications: Tx
s y n da da c ty ty 1 iz iz a titi o n i m p la la n t f u si si o ad in in g le ed ed in in g a n f ib ib ro ro si si s increased b le p o o r e cchh n q u e ad Tx a ccee ta ta t s te te ro ro i a n coban wrap Tx c h ec ec k b an a n d ag ag e b . d an an g oe c . r e e x h ea ea t d . b en en d K -w - w i o r p u p ro ro x m a e . L i do do c a in in e f. Nitro Patch g . R em em ov o v e K -w -w i Call f o h el el p
on
ARTHRODESIS
II
A)
n d ~ En En d Tak oITminim oITminimal al or Us Fixate: .04S or .062
smOUI1 smOUI1..tt
he
of cart cartil il be or bo we
PP he
an
base base (t
void void
B) Digital "V" S ta ta r Twi Fixate: .04S
wi
C) Peg-in-Hole Mo R em em o me mo
M ay ay o nd wi
wa
WB BK
fuse th
Ih
he
e xp xp o
DL on h ea ea d o f St P P f o r es es ec ec titi o
4t of ( ar ar th th ro ro pl p l as as ty ty )
WB we f la la i t oe oe , u nd n d er e r co co rr rr ec ec titi o
GI
at al el pt ca Po Comps
la n a r c u intact p la
Ke
th interspace)
do on at al el pt al nc on
IV
of PP w.
digit
III)
Comps
ma no on we
we in.
VE
ne
if
.062
QU NT
V AR AR U
nc on
e xp xp o
h ea ea d o f
nd ng f la la i t oe oe , u n de de rc rc or o r re re cctt io io n
bo
th P P f o r es es ec ec titi o
( ar ar th th ro ro pl p l as as ty ty )
d ay ay s
iJX-'
\~
ARTHRODESIS
II
A)
n d ~ En En d Tak oITminim oITminimal al or Us Fixate: .04S or .062
smOUI1 smOUI1..tt
he
of cart cartil il be or bo we
PP he
an
base base (t
void void
B) Digital "V" S ta ta r Twi Fixate: .04S
wi
C) Peg-in-Hole Mo R em em o me mo
M ay ay o nd wi
wa
WB BK
fuse th
Ih
he
e xp xp o
DL on h ea ea d o f St P P f o r es es ec ec titi o
4t of ( ar ar th th ro ro pl p l as as ty ty )
WB we f la la i t oe oe , u nd n d er e r co co rr rr ec ec titi o
GI
at al el pt ca Po Comps
la n a r c u intact p la
Ke
th interspace)
do on at al el pt al nc on
IV
of PP w.
digit
III)
Comps
ma no on we
we in.
VE
ne
if
.062
QU NT
V AR AR U
nc on
e xp xp o
h ea ea d o f
nd ng f la la i t oe oe , u n de de rc rc or o r re re cctt io io n
bo
th P P f o r es es ec ec titi o
( ar ar th th ro ro pl p l as as ty ty )
d ay ay s
iJX-'
\~
TH
VE
A l h a v t en en o to to m y /c /c aapp su s u lo lo to to m y F ix ix a K -w -w i PF
A) Bu le
"Dou "Doubl bl
weeks
acqu acqu t" ncis ncisio io
p la la nt n t a i nc nc is is io io n is longer that dorsal U n de de rs rs co co r p ro ro x m a l skin mo R e a s d o a l p l n ta ta r a n m ed e d ia ia l a p u l Comps: vascular compromise
Ma
1.
sutu suturi ring ng of skin skin
MP
n'
ni or on ve fi
al ow or ot
on
wn
re on ov rl pp ng ph ge
ft on
C) Lapidus M ak ak e s ma m a I s ta ta b n c o n at m id id - h a o f th et e le le a E D M ak ak e d o a l n c o n o ve ve r M P m d b du du c o r d ig ig i minimi ns o t en en do do n d is is ta ta l y , drill hole inP P b a e , pull n do do n ou Pull Pull e x e ns digiti minimi Comps: vascular c om om p ro ro m is is e
ho
u n de de rc rc o rr rr ee ee titi o
or
.fth he.,.c.
\:~(ldon
th abdu abduct ctor or digi digiti ti quin quinti ti tend tendon on
uVri uVries es echn echn qu
ph lang langea ea
oint oint ar
th
fo ov rlap rlappi ping ng fift fift to
perf perfor or ed he
I,
it
oder oder
sk
cont contra ra ure. ure.
LESSER METATARSAL NEUROMA RA, A V N ( Fr ei bu rg s) , N e ur op a th y , B u rs it is lc ap su li ti s C on se rv a v e T x P ad d n g o r h o e s N SA ID S A ce ta t S te ro i An we ma n c s io n M c Ke ev e d or sa l o ng it ud in a n te rm e ta ta rs a h a r un s u p o nt o e i h e o e P la n a r n c s io n o ng i u d n a o r a ns ve rs e he su cu Pr du Di d ow n D TM L cut d i s ec t o u d ig i a l b ra nc he s h e g o p ro x m a n e u ro n a l t is s ue . F ix a an suture a d a ce n c ap su le s t og e h e ( n a lw a y d on e Po op WB Sx ho w e k s p l n t a pp ro a is N W B ) C om p S tu m u ro m w h o e h em a o m D S if n te ro ss e o r u mb r c a e s w e c u
DORSIFLEXORY
OSTEOTOMIE
.,._ ..
Fo of PK pa L in ea r n c o n d o a l b e w ee n h e E D et ac he L in ea r c ap su l n c o n P o st -o p : W B / N W B S x~ o e3 ~w e ek s C o m p s t ra n sf e l es io n s r ec u rr en c e
pe di al Bo mu
ms go ng p ro x m a
an
B.
free
n o n- un io n /d el ay e d
n d m ed i p la n a r c on dy le s a n
PK
B) Jimenez
ob qu F ix a
w ed g or
wi
c o c a b in g
V e c a w ed g w i c o c a b in g F ix a e : 2 . o r 2 . d o s a p la n a r
o ca te d p la n a r p ro x m a
o ca te d p la n a r
tr
Vertical T h ro u g and F ix a K - p r x im a E) Gianaestru
z:
do
-1'0
g oo d
to distal plantar
.st,~."
Ill)
TA OR
BUN ON
Fallat 4t 1M
L a te r a D e v ia ti o n
6.47 2.64
8.71 8.05
BUCKHOLTZ
nc on a te r Cl we Me ur
ED thebase will d ec re a ow ng
Fixate: 2.
h e b lo o
s up p
2. d o rs a t o p la nt a
(reverse Austin)
F ix a
O th os o
pi
k e Austin
C) R ev er s W i s o (Hohmann) ob qu me p ro x m a de Fixate: .062 K- f ro m p ro x im a l shaft into head
D) W e dg e ( re ve rs e Reverdin)
Fi
m en t
ve
E ) E xo s e d m y
Resection
p a rt ia l o r c o m p le t ct or de
C om ps :
e cu r e nc e
MI'H resection o r with p o b on e
n on -u n o n
weeks delayed
SPLI'ITING mE PERPENDICULA
HA
DI
AL
OC DU
GOALSOFHAVSURGERY
2)
4) S)
R e o r a bn on na l o s e ou s a ng l Congruous or es P F n d S ho r e n r a ( de co m pr es s j oi nt )
1M A ng le : L e h a 14 Sk n c s io n C u rv a n ea r f o o w in g d e o rm i y , d o s om ed ia l n ve rt e L, l en ti cu la r . . Capsular n c s io n B um o my An mo me aspect vo n d c a o ns : E va lu a T o a l (see m e ta ta rs u s a d du c tu s ) Procedure: ll procedures h av e b um p ec to m y a n S i v er lM cB r d e Exercises I! I)
sagittal sulcus (staking)
SILVER/McBRIDE A) Silver 1. resect m e di a e m in en c
2.
L a te ra l r el ea s my
c.
a dd uc to r h aI Iu c a mo i fibular tenotomy
t en ot om y e le a o r d ro p
McBride S i v e p lu s a . A dd uc to r H a u c HB b . F ib ul a s es am o id ec to m y ( m od if ie d M c B ri d S il ve r w i t fibular t en d o r el ea se ) m o dorsal me (Hiss Procedure A b d uc to r h a I1 u ci s transfer- m o
DID, pain on R O M , o ss eo u n di ca ti on s B u m p pain. P o st -o .o : W B S x s ho e 2· weeks C om p h a u x varus, s ti f t oe , u n de rc o rr ec ti o
II
AUSTIN correct 1M, m s ar Ax
length, 60 angle mi
wn
TH
a ng le s W N L , adjunctive
articular
ma
g e o f h e h ea d Gu de
pl ce &CreW, or
at on 2n MT) -w h ro ug h d or sa l h a fragment aiming a t h e crista. Sx shoe 3- weeks 62 K-
p la n a r o s e o o m y
an
i nt o c a pi ta l
A)
oungswic wi
PF co ec a n d s ho rt e na on om do F ix a e : a m Au Ka
Au n)
F ix a e :
C)
co ca
om do sa di al
kALlS(./..
Gerbert-Massad PA
t hr ou g h an h ro ug h w e g e o n h e A u F i xa te : a n y th in g
Ill)
wi
pe
REVERDIN
MI W ed g w i a te ra l c o a l h in ge , c o e c P A C om p s e a mo id i s , D I Fi K -w , o so r p i w s w o p o n t if n o c or t c a b in ge ) P o o p a m a s A us t
P la n a r s he l p ro te c
B)
reen-Laird we
C)
s es am o id s
wi
Green-Laird- Todd mo
Original
me
as
a pe zo i me
c u h a s ho r e n wi we
V)
WATERMANN nd se
O r ig in a l W a te n na n n o s te o to m y
we
st
om
of
i nv o lv e
d o rs a ll y
st me
area.
odif ed
te mann
n te gn t
o f p la nt a c o t e
B. M o e d W a e rm a n a n c a a ge .
and
M od i e d
e m o va l o f e c a ng u a r s ha pe d do sa
nd pl nt
m e n t o r e nh an ce d
cu
wi
os eo omy
m a in t n in g
p ro ce du r
n vo lV E
s e ct io n o f bone. E n la rg in g a n g l
betwe€
e su l
w e ig ht -b ea r n g
G re en -W a e nn an n he f un c o n .
pl nt
exon
o f c ap i
HALLUX PROCEDURES IPJFUSION n d ic at io n s * D ou b l S es am o id ec to m y (FHB n o s ta b z in g p ow e r oe wi w i th o u J on e 's , DID, Hallux varus, Hallux hammertoe, Caws foot, NIM d i se a se , i ns ta b il it y Goal: c o e c u c u r d e o rm i an s to r m us cu lo t n d n ou s b a a nc e b y e a n g gi n c o n E l p t a l o ve r P J o r exposure. Procedure: Resect ge om nt we ge PP c o e c o r Hl pm 3.0 c or ti ca l w i t lag teclmique Fixate: 4.0 partially threaded ifbone is soft. us crossed -w Post-op: BIK, NW 6- weeks C om p s N on /m a l- un io n m a l- po s o n n fe c o n T IB IA L S ES A M O D E C TO M Y I nd ic a ti o ns : a rt h ri ti s h y p er tr o ph i ed , FH a dd uc ti n oe AVN, n c o n m ed ia l a pp ro a o ve r MI'- se s am o i d a r ti cu la ti o n P ro ce du re : e mo v e sa mo id , u tu r MHFHL, n te rs es am o id a i ga m en t With 3.0 suture WB we
1m
IV)
F IB U L A S ES AM O ID EC T OM Y V, A V N , arthritis, hypertrophy Indications: nc on p la n a r o r d o s a a pp ro ac h o ng i u d n a a te r WB we we AKIN F ix a o n on C om p
a b o rb ab l p in , K 6 2 m ed i me HL WB NW yl nd H in g F x P J s t n es s d i a l
do al
an
p la n a r a te ra l
sc ew cy nd ca
A)
V)
KE
LL
BO
o ge th e
h e s es am o
shoe 3 - w e ek s s t f ne s p ro x m a l) , c u E H
roxima c o rr e ct s DASA P ro x im a l d is ta l Di ut pe di P P shaft C)DistaI -corrects Hl D) Cylindrical e" o r l on g p h al an x o b li qu e p ar al le l cuts e" -form c lo s n g o bl iq u w e dg e
c ap su l
on
wi
e ve r
AV H AF T P RO CE DU R
P ro c ed u re : l on g it ud in a l i nc is io n first. d o s a t h w i dt h Icm f ro m c ar ti la g head an base, d o s a c u is d i nd pl nt p r x im a A ng l a x g u d e f o m u l p la na r c or re c i o M o d f ic a o ns : M a k s ho r e r a r m , angle ca a ng e o m 0 -9 0 Fi wo wo O s m ed , w o h r C o m ps : T ro ug h n g S tr es s r is e P os t o p WB NWB 3-6w ROM exercises IIII
P ro ce du re : A x a t m e ta ph ys ea l d ia ph ys ea l j un c o n e x a t h e b as a e p c on dy le , a ng l is 40 F ix a wo or P os t o p WB NWB 6-8w
ca us ax
gu de
d o a l c u first to
UD C) M A F ix a wo KC om p N W P o st -o p : T ro u gh in g , D o rs a d is pl ac em e n t
.,A'fAU
B A S P RO C ED U RE S C o m ps : A lw a y IIII et M T H e le va tu s cast., 6w P os t o p NWB, A)
L O IS ON -B A LA C ES C P r oc e d ur e : t ra n sv e rs e base w e wi me pa al el MT ca ag ur ac F ix a e : a ) 0 6 o ng i u d n a h ro ug h M T shaft an li cuneiform b ) 5 /6 4 m ed ia l d i a l a te ra l p ro x m a h ro ug h c u a n n t
at bo th an us 80
MT
3 rd c u ne i o r
Subtypes
BI Bl Cl
hinge intact
h ro ug h a n ou through an hr ug
h ro ug h w ed g o r c t TP TP, S P a n l en g th e o u h , w ed g we h r u g n o w ed g
P ro ce du re : o b q u w ed g w i h in g m ed ia l- p o x m a l a n 0.5cm from Mm Base o f w ed g a te ra l d is ta l P ro x m a c u is 4O-4sO f ro m l o n gi tu d i n a axis f o f ix a ti o p u rp o se s . Distance wi I"', medial to a te ra l p er pe nd ic u a r t o shaft F ix a e : P ro x m a A n h o go nd b) Di C om p e s o n c r 7 ) perpendicular pl he
PROXIMAL ANCHOR
DISTAL COMPRESSION
C) LAPIDUS n d c a o ns : h yp e m o b " ' r ay , 1 M c or re c o n a ng u a te d s ta b z e m e d a l c o u m n e s o r h e u lc ru m o r b e u n o n n g o f h e p e o ne u o ng u P ro c d u e : u s o n o f h e a n " ' c un ei fo rm . correcting a ng u la t t h c un ei fo rm . U s b on e graft p m ng he C om p s m a p os i o n b on e graft f ai lu re , p la t o p e Fi wo nu PT ws by de d; wo d; 1/ 1 14 tu bu la r p la t m ed ia l a n o n P T a nn u cr om do p ro x m a p la n a r distal cast WB 12 or nt Xhe
D) CRESCENTIC
E)
AM
INUD
CALCANEAL HYPEROSTOSES
Du on w ay s e mp t o r T x O p o n N SA ID S O r h os e
as m on th s n je c o ns , c e S t e tc h n g N ig h S p n ts ,
P ro ce du re : D uV r e s n c s io n m e d a l y , d is se c d ow n a sc ia . c u m e d a l b an d (and c en tr a b an d m ov e p u T) u s o s o to m o r b on e c u C om p s n e v e e n a pm e n c on t n ue d h ee l pain, e x c e ss iv e f ib r o si s Po W B cast, 3-6w
RETROCALCANEALSPUR n c s io n s p h e a ch i e s e nd o o r Z ad e a te ra l h e a ch i e s P ro c d u e : m ov e p u w i o s o to m w ay s p la n a r d o a l o r o ng eu r C om p s e nd on i s , u p u re , s t e s F x P o o p u su a NW
as
Ill)
Assess fo
~3
1)
Patholog al
P h p -F ow l Pa Pa
A ng l
ag und'
p a h o o g a l if> anythiDg a bo v h e s up er io r line is pathological F F A ng l C a lc a ne a ll D cl in a ti o Angl p a th o lo g ic a l if>
P i t c h L in e
m oo t
PAVLOV'.s
.,/'
P ro c d u Za c i o n o n d e w i b um p up d o s a s mo o w i rasp C om p s c ha s n g h e b um p " F x e nd on i up ur P o o p p l n t o r cast
un
KELL n c s io n a te ra l n fe r o r a n p ar a e l p er on ea l e nd on s P ro ce du re : D o e xo r w ed g o s e o o m y w i p la n a r b in g C om ps : e nd on i s , b in g b re ak s p os te r o r b on e a gm en t WB
hi
os
om
pl nt
I~
METATARSUSADDUCTUS
RESULT
Normal MUd Moderate Sever
16 20 35
25
EOUASION (MAA -15) m ea su re d M T IM [predicted] HApo IMpo
Total M=Measured PO =Post-op
IMro
Example: R es u s : 1 ) IM 2) HAro
5 ° h e e fo r n e o s n g base w e dg e o s e o o m y +2 3 2 h e o r m od e a t b un io n to pt (i s e le c t c a se s a lr ig h c lo s m a n eg a v e n um be r
A g e 3 -7 y/ o
nd pp m ed i i n te r sp a c e , 4 t i n te r sp a c e b) n c o n p p o ac h d i c u os P ro c ed u re : R e le a s all s o su an g am e n o u s t u c u re s L i F ra nc ' o in t e xc ep t /3 o f h e p la n a r a te r pe of he ba es of me 1h e th m e ta ta rs a c ub o o in t e f n ta c s ta b y . T h p ro ce du r d es ig ne d e fa sh io n h e a r c u a t o n M o d if ic a ti on : 2 n d m e t o st eo to m y (Harris) C o mp s P a o m s ho eg ea r d is lo ca t o n D ID , e s d ua l d e o rm i y , g ro w t p la t d is tu rb an ce s p e v a lg u s d e fo n ni t recast e ve r e - b du c o o (pes v a g u d e o nn i ca cast, m o fQn.Qp: W B c au se d f ro m c as ti ng )
or
BERMAN-GARTLAND Ag a du l d on e w h g ro w p la t c lo s d ) P ro ce du re : or n c s io n a pp ro ac h C re sc en t o s e o o m ie s o f a l M TB ' cartilage. we wi wi F ix a e : O r g in a l y f ix at e o n S. C o m ps : U n de rc or re c o n m a l- un io n o r n on -u ni o W B B K cast, 6w
III)
e r d is ta l
ar cu ar
LEPIRD A g e 7 -a d ul t Incisions:
d o rs a i nc is io n a p pr oa c h MI 1an o s n g b a w ed g w i b a m ed i 2 ) M I" s O s e o o m y o m d o s a d is ta l p ro x m a a te ra l e av in g a te ra l c o e x n ta c a ng le d 4 5 h e p e p en d c u a r o f h e shaft, p ro x m a p o o n o f o s o to m n o c lo se r t ha n lcrn f ro m b as e x a e d w i o n c re w 3) MI"s ar l ef t i n ta c t an - 4 - O n screw d r v e n t o s o to m n d n o g h n ed , a t a l o r e x b ro ke n a n M r ar m o ve d a te ra l y . S c e w ar tightened F ix a o n 2 .0 , 2 .4 , o r 2 . C om p s s am e as B-G W B B K cast 6w
Diagrammati representation of Lepird procedure for cor rectio of rnetetersusadductus. Obliqu wedg osteotomie of firs an fift metatarsal ar performe with through-,md-throug rotational os
F1gurt: 33.24
teotomie
of second third, an
osteotom
!M
fourth metatarsals.If desired, th same
be employed on fift
metatarsalas well
IV
O TH E
Figure 33.23.
T YP E
A. Diagrammatic representation of Peabod an
Muro procedure. B. McCormic an Procedur of Steytler an Va De Walt D. Bermanand Gartland procedure
Figure 33.31.
Blount procedur
A. I f
e di a a ng ul at io n o f t h
c un e
form isth principa abnormalit (deviated LASA),ope e dg e c un ei fo r t,
o st eo t m y a y w or k e ll . I f a d deepened throug th secbe
metatarsal. B. ay not be p os si b
to ga
cuneifor
alone. Additional correction ma
osteotom
fi a de q a t
ri c or re ct i
vi
be gained by
c ub oi d T h a p
d ir ec te d t ow ar d t h
e d a l c ut .
F LA TF OO T S UR GE R
Lifting) Do mo Us wi ei he K id ne r o r Y 01 U g p ro c d u Trephine tool used mp Goals: I) p re ve n a te ra l talar p ro c om n g n t h e a l a n a l u lc u 2) n c e as e a rc h h e g h TJ ng me m n as well as decreasing h ee l v a g u s n di ca ti on s p os it iv e f am i l Hx HAV, HO or mp e su l a n d e a s a c v i a nd /o r p s w h p l y in g X- ay nc as K i e ' n d taIar d ec l n at io n d ec re as e c al ca ne a i nc li na t o n an
he TNJ articulation
SOO/O
nc on cm Gr nc on P ro ce du r ( ax i a lt er in g a n d d ir ec t impact): C u tarsi p lu g H ok e tonsil) a n e av e a tt ac h e a n te ri or ly , visualize S T s qu a o f p os te r o r wall and o o o f h e a n e r o r c a c an ea l p ro ce ss , d r h o w i e ph in e C o mp s s in u a rs i s , o ve rc o r ec t o n m p la n p ro b e m c em e n a t o ge n c oa l o n e nd on i s , c al ca ne a F x i nf ec ti o
TYPES
V AL EN T MB Ma we Br An El Do mo S cr ew s n t s in u
m)
tarsi
Age3-13 removed May D ri ll e i nt o c al ca ne u
An Do
II
UE
ge mo
CE UR
Adj1Ulctive procedur P r o c e d u r e : resect h yp e r op h n av ic u a r o r e mo v Os Ex its and distal and Ca insertion a dv an c C m n m : i m p ro p e p ro c ed u r (used a lo ne ) T P p ro b e m f2rum: usually casted depending upon other procedures
n um . p ro x m a
TP po on
- - A d j u nc ti v
p r oc e du r u n o na l wo ks h e n av ic u redirect T A n se r o n 2) reinforce plantar arch 3) S ta b z e u lc ru m o r PL by n cr ea s n g s ta b a t lit ra I nc is io n f ro m lit m e - cu ne i o r m ed ia l m a e o u s P ro ce du re : M ak e k ey ho l in n av ic ul ar , l ea v i ns e rt io n intact keyhole. M o di fi ca ti on : S p i t p as s o n half t hr ou g k ey h ol e Post
cast 6w
OSSEOUS PROCEDURES A) MEDIAL COLUMN STABaIZATION Age: late e e a du l
n d c a o ns : o n s ta nd in g f la t o o f au l a n D I o n X - a y rigid i n v a lg u s mp ms d y f un c o n e nd oo i s , a n s in u " ta rs i s . U su a c om b in e w i d e m op la s y . B on e graft u se d p m p r v en t h o e n n g Fixate: 6.5, 7.0, 7. screws, o r s ta p e s C om p m a u n o n b on e graft failure. X1)
LOWMAN
fusion
Navicular,
lit an
Navicular,
lit c un e o rm , a n
B) CALCANEA
2ndc un ei fo r
f us io n li MT
fusion
OSTEOTOMIE
se w it h f la tf oo t c au se d by neurological disorders, Used with Indications: ·00 or fails to lock up when will unstable which po on nd is n eu t abducted (I'P deformity). mn ma CC ST in joint. Insert bone graft w e we un o ck s u p F ix a ti on : o p ti on a l failure, DID, s in u t ar s t is , u ni o p ro b le m s o ve r/ un de rc or re ct io n
2)
SaVER po
J)
o r o p n in g w ed g
DWYER po er or
4) KO
o s n g w ed g
m ed ia l m ed i
UGIA IS a rc u ar c through through p o s e ri o w it h medial transposition
31.36. Original LO'NrT1anrocedure included Achilles tendon lengthening, talonavicular arthrodesis, rerouting the tibialis anterior tendon under the navicula an suture to the spring ligament tenodesi of the Figure
the Achilles tendon whic calcaneu an folded forwar talonavicular ligaments
is left attached to alon medial arch an desmoplast of the
Original Youn procedur included lengthenin of th c h l le s t en d n , r er ou ti n t ib i l i n te ri o t en d t hr o g h s lo t th
Figure 31.37.
navicular, an navicular. Figure
an
Miller procedur involves detachment of medial 05flap alon th medial arch that is left attached proximally
31.38.
teoperiostea
includes th spring ligament an tibialis posterio tendon insertion.
Navicular-firs cuneifor an cuneiform-firs metatarsal joints ar ar throdesed. Osteoperiostea flap is replaced in an advanced position to tighten the spring ligament an tibialis posterio tendon
advancemen of the tibialis posterio tendon beneat
th
Figure 31.59.
eoomy e fo rm i
D ia g a m
on we htbe
us atng th
ng
or es
the f o o t r ei n fo r c in g
p as s m e
P o s t e r i o r view o f h e e a o o p ro d c in g onl
c om p le x
c a c an ea l o s e o o m y
n d e ct l
of moton
ef ec
We htbe
af ec
th
cton
e m on s
on we gh be
o f the S i lv e r c a l c an e a l osng
or es
the v a g u ng ng
pes valgus
at ud
o f foot.
he efec of o rc es . N o
s ub ta la r o in t by e d e c n g
ar sha
h e a va i a b
hi
Figure 31.60.
C a c an ea l o s te o o m y
a s d es c b e
b y K ou ts o g a nn is .
figure 31.51. ing wedge in
D w y e r calcaneal osteotomy performed
a ng e
o f n ve rs io n
Figure 31.44.
J;.. H o k e
fusion
lIS
originelly
IS II
large heel. Th
IaterIII openi~
procedure is
wedge with b o n e gRIft
medial dosc o m m o n l y performed
CAVUSFOOTSURGERY
AVU
Flexible cavus T x R ig i f us io ns , M P RUCD
Cavus
RUCD
R ig i
e le as e H ib bs , o ne s O r h os e
m in g ( Gl ob a l Cavus IM Dz w i C -M -
RF varus
ng he mo
o mm o
S TE IN DL E S TR IP P N G I nc is io n : D u V r ie s m e d ia ll y P ro ce du re : A d u nc t v e w i D wy e a nd /o r FF osteotomies R e e as e p la n a r a sc ia , m u sc l a ye r q u ad ra tu s p la n a e an o n g p la nt a pt un Dw ut he C o m ps : e xc es s v e f ib ro si s n er v e nt ra pm e n m y os i i s f as ci cu li ti s n eu ri ti s P os t o p P ro ce du r d ep en de n if a d u nc t v e u su a N W B B K cast, 6w d on e a lo ne , c as t FF DWYER A ge : u su a 1 0 1 2 y / b ew a o f a po ph ys i s ) nd n: UC Co ma Bl n c s io n p a a l e l a n n fe r o r p er on ea l e nd on s P ro c d u e : a ig h o r o b q u w ed g w i b a er be we he TA nd po ot my he gr mo of or on pe mo m ov ed . T h w i d ec r a s h e u p n a o r o rc e o f h e T A o n h e c a a ne u F ix at e T w o s ta pl e C om p s n on -u n o n e nd on i s , w ed g n t S T D I AK, 6w WB
ac
i ga m en t
Th we ge
llI)
JONES
nd ca on
C om p
R UC H h a u x h am m e o e h a u x v a u s d ou b s e a mo id e o m EH nd ge wi ut 2) Dr ho h ro ug h MTH, e d E H e nd o h ro ug h R ea t c h e nd o el wi 2. or n on -a b o rb ab l Fu ha ux P] wr pr ur gi PF on on no no gh
Post
G~,,~
cast, 6w
on
3,.0
IV
E R N EA L
gh C om p
STAT
;>'1_."_~o'"b. 1<
TO
UC Wi bd ve ot PL an sutured abducted an everted
V)
HL
ds
li
wi ma h e w on '
wh
an
is weaved
ms cast, 4-6w
(Split Tibialis Anterio Tendon Transposition)
nd ca on RUCH ns 1) ne
e qu in ov a u s s w n g p ha s s up in a u s n ve r e r o ve rp ow er in g d o s if le xe r ve bo n d th Mf base MT or do 7 c m p r x im a ma TA me n d n s u me n u nd e h e skin o m m ed i Pl d om in a pe ug Gr he pe wi ns um nd ou ou m ed i nc on Th wi he d o d ow n De ha nd an n s u m en t f ro m h e a te ra l me TA At t er ti u i f p re se n C am p no gh ns nd n, do oc Post 00: cast, 6w 1 . S u t ab l
C as e
5 . P ro pe r n m in g
AtrBu ma tic technique 12. Adequate
tension u p o n fixation
VI)
JAPAS
IM I nd ic at io n : R U C H I I n d s ta g c av u ev I n ci si o ns : I ) l ot c u n e if o rm - n a vi cu la r an cuneiforms-navicular th MTB-cuboid 3) P ro ce du re : h ro ug h a n h ro ug h " V c u w i a pe x n av ic u a r m ed i a te ra l a r h ro ug h h e c ub o d . P la n a r e x h e d is ta l p or t o n F ix a e : T w o 7/64 pins C om p D I W B B K cast, VII)
COLE nd ca on RUC s ev e a n e r o r c av u Incision: three n c s io n k e H H& S P ro c d u e : D o e xo r w ed g o f m id ta r u s w i t hr ou g h a l c u ne if or m -n a v c u la r j oi nt s F ix a e : S ta p e s o r S te in m a p in s C om p s s ho r w id e thick f oo t D I at least WB BK
Japas procedure.
C o le , 1 9 '" '
Japal,1968
h ro ug h a n
an
h ro ug h
h ro ug h c u e x e nd in g
u ne i o rm ,
o m c ub o
Cole procedure fo midtarsa osteotomy
T ib ia l
a nt er io r t en do n t ra ns fe r t ec hn iq ue .
o f t ib ia li s a nt er ia l t en d on . B. R e t e va l o f t en do n ss t en do n
of
en on
gh
p as se r D. A t c hm e n
e x e ns o of
omp
ns er ed
A. D e t a c h m e n t
t h o ug h p ro x m a l m en t
en on
s in g nt
hi
n c s io n et og
c un e o rm .
be s e e c e d n y h e o n dorsal s t c t e s ba nc oe S ur ge r o f th equinus foot. I n M c G la m r y ED Kitting, E D l e dl . R ec on s r uc t v e S ur ge r o f the M i m i , S ym p o s
Th
s it e c a
( Fr o m M c G ll lm r y
S p e c i a l i s t s , 1974,
347.)
.'
F l s u r c 3 0 .3 0 .
Dorsiflcxory truncated Nthrodesis
Usfr!Inc's joint.
~7 T Ib ia l p o s te r o r t en d o t ra ns fe r ttvough interosseous m e m b r a n e ( te c hn i qu e 1). A. Detachment o f b ia l p os te r o r e nd o m e d i a l n a v ic u la r bone. B. E xp o s in g i n te r os s e o u m e m b r a n e a n d l oc a ti n g SUrrounding structures. Retrieving posterior b ia l m u sc l n d e nd on . T ib ia li s p o s te ri o r m u s c l b e ll y l ie s i m m e d ia te l beneath i n te r o s s e o u s m e r n -
brc!ne. N o t l oc at io n o f n e ur ov as c ul a s tr uc tu re s . C a r m u s t b e t ak e n o t nerve a n b lo o d s up p y . D. Passingposterior e t c h m us c om t ib ia l t en d o d is ta ll y t hr ou g e xt en s o r c o m p ar tm e n t b e ne at h r et in ac u a . n t d o s a bony structures. E. A t a ch m en t o f e nd o
Window through interosseous membrane
·Interosseous m e m b r an e
Fibula
Neurovascular bundle
0\
FIgure 50.37. T ib ia l p o s te ri o t en d o t ra ns fe r t hr ou g n te ro s s eo u foot an leg incisions. m e m b r n e t ec hn i 2 ) A. posterior t ib i a t e nd o n at It i n s er ti o n P re s e rv at io n o f Dmchmcnt maxilTUTl 1 e f \' 3 th i s i m p o r ta n t . Retrievel of p o st er io r t ib ia l m u s cl e and e nd o n t p ro x m a l 'M:XXld using two-hand sponge t ec hn iq ue . D . L0 cation of n c s io n s o n h e e n e r o r e g en dorsal foot. E. Tendon is de-
livered ttvough i nt er os s eo u m e m b r an e a n p as s e down e x te n s o r c o rn partment beneath retinacula. F. ft s t c tu re s P os te r o r t ib i e nd o c a b e s p a n attached t o t ib i e n te ri o e n d peroneus t er t u s t en d on s , r es p ec ti ve ly , f o m o r e b a a nc e d suspension.
I n te rp h al an g e a
j oi n
a rt hr o de s i
P a m e t at ar s a o s t eo to m i e s
mi
o ub l e rt b o o es s T r ip l e e r th r o c es i s L e s s e d ig it a
d ef o rm i t
Ha"ux d ef o m i t
I n te r p ha la n g e a a r th r o de s i s H ib b s s u sp en s io n
-- --
Jones suspension
P e ro n e u
+ Flexible -
l on g u
t ra n s fe r t o c a lc a ne u s STAn - - PLTI w ea k TP
A n e r o r g ro u
AL Mu ph
a dv an ce m en t
c ep s
P a m e t at ar s a o s te o to m i e s
Iisfrenc's j o in t a r th r o de s i s
'd
l o
-{
t a
1~1:~~=iS
Valgus Anterior
FI l
cavus Rigid
Plantarflexed
Frontal
e
st m e t a t a r s a l
j
s t c u n e if o r
st ay
plane
P a n m e t at ar s a o s te o to m i e s
Lisfrenc's j o in t a rt h ro d e s i
Ri
L e s s e r t a rs a l o s t e o to m i e s , . .
-{ 5 V
---c
-{ STAn P o st e o m e di a
FI
T r ip l e a rt h ro d e s i
r e e as e ( se e c lu bf oo t
nm T r ip l e a r th r o de S I S
Cavus foot -{
__f
Flexible
t r A b du ct o
h al lu ci s r e e as e ( se e m e ta dd uc tu s
T ib ia li s p o s te ri o P o st e o m e di a
p a
Posterior
-[
l en g th e n in g r e e as e ( se e c lu bf oo t
D o rs o f e xo r c a c an ea l o s te o to m y h o Trip ar IS
( ca ut io n )
pane
ClMJS
ClMJS.
See a b o v e an N o te : S te in d le r s t p p n g u s e fu l a d jl X l Ct iv e
f o U O I N a n t er io r ClMJS fo
management.)
m a y be
procedlKe.
10.17. This scheme represents th logic of t h o u s h t in th S l M ' 9 i c a l epproech to idiopathic c a w s foot SIJIgeIY by plane an level of deformity FIsurc
in skeletally mature patient. S T A T T , Split t ib ia l
a nt e i o
t en do n
t ra ns fe r
PlTT, peroneus longus t e n d o n transfer; T P TT , ti bi al i
p o s te ri o
fer; T A L , tendoAchiliis l en g th en in g ; D FW O , d o s if le xo ry we dg e
t en d o n transo s te o to m y .
R E A R FO O T A R TH R O DE S
Indications;
Comps: Po
op
S ta b i li ty , D I D pain, trauma, failed m p a n AV No
en
ge
a t o o o r c aw s
n f c t o n RA,
o r m a l u n o n v ar us , fuse w ro n g o in t ( d d ia gn o s i c n je ct io n )
we
nc
US
o n K o h e o r o m b eh in d b u mo talus and pl me v o d s w i b on e h ip s
TP SP Talus
II)
ST
ma
pm
1 0 e x e rn a gu
o ta te d o r m a
Om
bi
po nn
nd
h e th MfB
Cr
wi
nc as
p r x im a
o th e
he
d in g d ow n
of
all
he
di
mb
ve pu bo
a n d ec re a
on
bi
FUSION
n c s io n O l e r o r a te ra l n ea r e f e c E H o r e xp os u e ) P ro ce du re : R e e c a r g e o m a lu s a n c a c an eu s u s n g o s e o o m p ow e o r c u e t on po mu ge po bl wi ne hi n c e as e h ea l n g a n m a n ta i h e g h Position at o f v al gu s Fixate: 6.S, 7 . 7 . om do al p la n h ro ug h h e p o or ce or us p le s
om
Ill)
TRIPLE ARTHRODESI
I nc is io n : A ) K o c ke r B ) T w o n c s io n a pp ro ac h Cu me P ro ce du r om do TJ Fusion Rate
o th e
and
do
last
Fixate: 6.5, 7 .0 , 7 .3 , o r u s s ta p e s m a k n g s u
h e d on ' e n e r o th e o in t
.'
'\
Figure 30.37. T h r e t - d i m e n s i o n e l visueliZ8tion o f t r p l a rt hr oc le s is . A and 8. Anticipeted wedges on l at er e v ie w . an D. Antici~ted we dge s o n e n te r o p o st e ri o r view. en F. Anticipeted wedges frontel view.
31
figure
an
B. Triple arthrodesi as describe
by Ryerson, 1923.
Figure 42.i.
F J s u r c 41.3.
A. e n Th l am b r in u d s t ab il iz at io n i s most effectNe in r o f oo t p ro vi d e de qu at e u s l e e r a ve il eb l fo concooent trilnsrer. When th foot ettempts to p1enterf1ex, th posterior d ea li n
w it h
p ro ce s o f h e U l t h e t ib ia .
se ve es
stop ageinst the p o st er io r m e l le o lu s o f
1041
ection 6: Major Arthodesi Procedures
an
Figure
B. D u n
Figure
Figure
B. B re w s te r c o un te rs in k in g
Od
Seiffert,
ope aton.
m o d i fi ca ti o n
beak, triple Clrthrodesis.
33
TENSIO
BANDIN
me ma P ro ce du re : ( no t a lw a y 28 g ag e w ir e w i w i K -w i 1) M a n t F x is 2) n se r w o .062 w i wi o ge th e h e thread 3) T w wi wi or al n d sink i nt o 4) w i w i 5) Kw n and h a m m e r
I)
Wa
on
2)
Christman Shook 6) Elmslie 7) Hambly 8) Whinfield Ke 1 0 S ee bu rg e 11 p l P e o ne u B re v 5)
MP
MI'B
dorsal to plantar p a a l e l m an ne r e av in g Ian w i Ma figure around th Fx hol n t h e b on e
Sect on
F I g ur e 4 0 . 43 . co
er
poun
A. S k i i n ci s io n fo
g am e n
of he
FIsurc 40 46
D ia g a m o f
de
nke. No
su
F i gu r e 4 0 . 44 .
ef miti
ed prma ep o f the lateral the o ca t o n o f h e n te rm e d a t the i n c i s i o n . B. Th
W a s on -J on e
D ia g a m o f
a te ra l a nk l
g am e n
e pa i
N i s o m e a te ra la nk le l ig am e n t repair.
c a c an eo f b u a r
g am e n
ca
be s e e
u nd em e a t
the r et ra c te d p e ro n e a
tendons.
F i gu r e 4 0 . 45 .
F ig u
40 7.
D ia gr a
D ia g a m
of
L e e a te ra l a nk l
s ta b il iz at io n .
E v a n s lateral ankle st&>i1ization.
Chapte
poster nter hr ug he fibu nd su ured he peroneus brev an ongu endons dist y. peri stea psul fl fo de down fr he we fibu re nforc th reconstruction site (Fig. 0. ). Ni sonn (223 de ched he peroneus brevi he us cu otendinou junction, suture th uscleto peroneu longus, an crea ed subper stea gr ov he eral spec he eral eo us fro posterosuper or an eroinferi r. Th ca caneof bu ar ga en wa repa red, nd he er neus brev endo wa ed wi hi he gr ve nd su ured pl ce (F g. 0. 6) Ev ns (2 de he he peroneus brev endo fr th usculotendinou junction, suture he uscle belly to peroneus ngus he re ed ho he fibu fr he of he al eo us ex ng posterosuperiorly, Th endo to posterior wa passed hr ug he unne fr nter nd su ured pl e. Ne he he Ev ns no Ni sonn ro cedures recreate normal anatomical orientatio of th an er al fibu ga en bu each does supp so stability agains inversion (Fig. 0.47). Othe procedures have also been repor ed recrea he anterior alofibular igament These are effect ve fo singl ga en ou chroni spra ns (2 7-251) However, os ns ance doub ga en repairs ar requ re (226). El sl (2 )· erformed hi doub e- ga en re hr ug 12-cmincisioncen ered over he peroneus brev nd beginn ng em ro he er eo us an ending dwaybetween he base of he fift etatarsa an he alleolar tip. Th peronea tendons wer re ra ed nfer rly, nd he er surf es he us neus nd er eo us were ex sed. stri fasc at wa used an pl ce hrough an sseous cana ne fr su ri nfer r, he hr ug cana he fibu fro supero nterior posteroinfer r, en hr gh eu fr ster su ri ro nf ri r. ends were he su ured he se ve (Fig. 40.48).
Christman and
Diagram
o f a n E lm s l
d ou b e - g am e n t
e co ns t u c o n .
noo (253)
1019
odifie Elmslie's procedure
wa ef ntac nser n, passed hrough he al neck he eral eo us fro nter poster r, he su re ri st fl sert he ne fibu ga en Th re ning endo en wa dire ed ri rl su ur ro eu brev ne sertio (Fig. 0.49). to Ha bl (2 sp he peroneus ongu an su ured ra ne k, se he endo fr nter poster or hrough he fibu an fixa ed he ca caneofibular igament insertion Winfiel (2 dev sed si ilar procedur but use peroneu brevi (Figs.40. an 0. 1)
Figure 40.49.
Di gr
of
C h s tm a
Di~ram
of H am b ly '
n d S ho o
er
an
st bi
zation.
FJsurc
F1S'ft 40.41.
0: Chronic Ankl Condition
CedlXe.
40.50.
a te ra l i ga m e n
r ec o ns tr uc ti v
pro-
1010
ec
ompoun
Deform es
Ke ki an Ke ki (2 6) used plan ar endo re re he er ga en s. he pl nt ri nser ef ntac Th endo stripped he pr xi al re an ransec ed hr ug smal nc si n. dr ho ad from th calcaneofibular ligament insertio towar th planris, nd he endo passed fro poster ntero er hr ug he neus he endo ed hr ug fr ri re hrough dr ho he neck Th re aining endo se hr gh he rigina fibu fr
ri ster nd su ured el xi canea drill hole (Fig. 0. 2). eeburger (personal co unication) used hemisectio of th peroneu ongus asfree graft toaccurately reconstruc he na ca or en he an er alof bu an ca caneofibular igaments. Th incision begin 12 em proxal he he er eo us ex ends distal yjust poster or he al eo us he an er rl ward he base of th fift etatarsal. Occasionally,an ancillary incision is eede ju ri he ra us urse ward he he d. he nc si deepened he evel he peroneal endons nd he perone re nacu um re re nacu um nt ct Th peroneus ngus endo dent fied nd he er en nc sed. he endo se ra ed nt wo ha ves. Umbi ed roun ne ha nd used separa he endo he engt of he nc si n. needed before bt ning he gr ft he endo nc se ea en bt he he sect on graf Th er ne endons re re ra ed nfer rl ex se he nser he ne fibu ga en nt he aneus. rephine ho ad hrough he cortex ha ha th sa diameter as smal serra ed washer. This willa lo fo ountersink ng so here wi lbe no pr nenc an possibl rri at on reph ne ho he reated he fibu fr er nfer nter su ri r, nd he ug ed re de hr gh rt of he eral neckth sizeo he washer at he nser on he nter fibu ga en Th free endo gr ft fixa ed he ca caneus wi .0-m cancel ou scre
Figure 40.51.
D ia g a m o f
W h in f e l
d ou b e - g am e n t
a te ra l a nk l s ta -
bilization.
F ls u r
4 0 .5 1 .
A. I II l
nd washer he endo sthen ed hr ug he sseous he fi ul fr er nt ri r. he fo he dors flex an eversi n, nd he slac rem ve fr ro fi
B . D ia gR I m o f
K e li ld m l a n kl e s t ab i li za ti o n .
hapter
he nc si he ke no
ra nt ra no
he su re
re
scre jo nd he surg
wash r. re he scre s. si
su
rd ri st
eigh be ring allowe week fter surgery. Phys to ca herapy he inst uted (Fig 0. ). sp peroneus brev ateral nk st bi iz ti proceur ha so ri he nd fi nd severe fr he sc he roxi sp
FIgure 40.55.
hroni
nd fr ed he hann
st
rone re
Ankl
y. revi
ondition
pproxi nd he
el
1021
ne ha
us ne k, nd he
se ssed hr ug
Figure 40.53
0:
The Seeburger lateral ankl stabilization
TII"'r d o m e f r I I c : t u r e s . It.. lIIterlll lesion demonstrIIted
re hine ho
fr
nter
poster r,
endo he passed hr ug subper stea hannel nt rephin hole at he ca caneof bula igamen nser on of he ca caneus Th reph ne plug isreplaced an he tend ca be re nfor ed wi su ures (F g. 0. ).
Figure 40.54 cedure.
Th spli peroneus brevis latera ankl stabilizin
on this stress inversion radiogrllph. 8. Tomogrem of II ~erallesion.
pro-
TH
SIZE
PITCH
THREAD
CREW
HEAD
(mm)
1.5
1.5
.6
1.3
3.5
SIZE
OVERDRILL
1.5
1.5
3.5
SIZE
(partially
HEAD
THREAD
threaded)
4.0 4.0
(BUNION)
SIZE
-- HEAD
4.0
Usuall hexagona whic . !I ow s f o m e e ff ic ie n t ra ns la ti o o f t or qu e a n reduc CAM·QlTT:lifting th re ri er rr t h s cr e b e
4.0 _(BUNION)
LAND
U nd er su rf ac e o f ( h h ea d o f t h scre whic come ill contact with bone
SHANK
onl present in cancellous
screws
RUNOUT---
w ea ke s
p oi n i n s c re w
-RAKEANGLE
!.E!,CH
distance
T hr ea d t o l Xi ~ a ng l
threads, conic.alscrcwi have
I ID Il le r
c:oncxlloua
p il C
t ha n
ICreWI
THREAD DIAMETER
ilvolue ICRW
IIvud
the between
IC
!he thrcadJ
cIeocribe
Iizo (I.e.
2.7mm oc:rcw Iw 2.7mim_ die
~-.....;.o.;
_ )
,. & 0
.nate
INCISIONS DIGI AL
IN ISIONS
L on g u d n a a c o s c re a e s o n c o nt ra ct io n i s n e ed e d g iv e g oo d x po su r
L on g u d n a
w he n
at
h ea l n ic e
ul no cu bo do o r p la n n eu ro va sc u a r b un d le s o n d ig i
DORSAL INCISION
o ng i u d n a n c s io n u se d m a in l f o n eu re c o m ie s M u l p l l on g it ud in a l i nc is io n s m u s t a t e as t c m a pa r p re se rv e b lo o s up p t ra n sv e rs e c u rv il in e a i nc is io n a c ro s s MT if e v d en c o f vascularDz
PLANTA ot
INCISION
t ra n sv e rs e c u rv i i ne a j us t d is ta l t o h e M TH ' U se d o r n eu re c o m ie s WB we
MEDIAL FOOT INCISION Ob
ur
os
fo
fo
M F a n R F x po su r Wa ch Fo m ed ia l m a g in a v e n . d or sa l p ed is , p os te r o r b ia l N V b un d e , v en ou s n e w o rk , i nf er io r b an d o f n fe r o r e x e ns o r et in ac u u m , a n e r o r a n p o st er io r i bi a e nd o ns . D uV r e s
ob qu p o e r o r c a a ne u o r p la n a r h ee l s pu r
POSTERIO
U se d
HEEL INCISION
Z ad e
u rv e o ng i u d n a c lo s po o r h ee l either lateral o r m ed ia l ch C en t n c s io n c a e a s ho e at on
TOTA
ANKL
Cincinnati
EXPOSURE
