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26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage

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Fig. 26.8 Clinical and radiographic images multiple views—preoperative (a–c) and postoperative (d–j) status post-staged approach to multi-level, multiplanar, multitissue type deformity reconstruction in the face of inciting wound formation with infection to the dorsolateral foot with eradication of infection, optimization of healing

potential, talectomy, midfoot osteotomy, extensive foot and ankle soft tissue releases, soft tissue envelope closure, ofoading and compressive circular external xator and subsequent exchange of external xation for internal xation with pantalar arthrodesis

376

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J. S. Steinberg et al.

Fig. 26.9 Radiographic imaging AP ankle views (a, b)— preoperative (a) and postoperative (b) status post- medially based closing wedge type supramalleolar osteotomy for progressive valgus deformity of the tibia secondary to malunion triple arthrodesis. Note the signicant lateral

occurred in 38 of 45 patients (84.4%) where talectomy was utilized with 6 of 7 patients (85.7%) who ultimately underwent amputation having a history of prior infection [31]. Ultimately, they concluded chronic lower extremity deformities can successfully be treated with a talectomy as a portion of the reconstructive procedures. Admittedly, the loss of height of the talus bone will precipitate structural limb length discrepancy; however, this may be remedied with shoe modication or with concomitant use of distraction osteogenesis limb lengthening procedures.

ankle “gutter” decompression achieved with this osteotomy. Of note, a corrective midfoot osteotomy was performed concomitantly to reduce the malunited triple arthrodesis and reposition the foot

tibia (and bula where warranted) may provide single and multi-dimensional correction of the extremity in order to produce a more functionally ambulatory limb, especially important in the neuropathic population (Fig.26.9). Horn etal. saw signicant improvement in all postoperative radiographic angles in 22 patients with the use of a supramalleolar osteotomy and a dynamic sixaxis external xator [35]. They found this method particularly effective for correction with complex deformities, a compromised soft tissue envelope, or a prior history of infection. Additionally, the Siddiqui etal. also saw enhanced arthrodesis in 14 of 15 patients (93.3%) by combining distal

Supramalleolar Osteotomy

tibial distraction osteogenesis with simultaneous

tibiotalocalcaneal or tibiocalcaneal arthrodesis Outside of strictly isolated planar deformities of the ankle joint, the supramalleolar osteotomy may also be utilized as a useful adjunct in the reconstruction of complex rearfoot and ankle deformities [32–34]. An osteotomy through the

for the rearfoot and ankle in a limb salvage sce-

nario. They concluded that the supramalleolar

osteotomy with distraction osteogenesis supports

enhanced vascularity to their rearfoot and ankle

arthrodesis sites [36].

26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage

377

Soft Tissue andTendon Balancing Procedures

Tendon Lengthening

Equinus deformity has classically been described as limitation of passive ankle joint dorsiexion to less than a right angle of the foot on the leg. This limitation of joint mobility in dorsiexion motion at the ankle has been implicated as a major deforming force in the development and chronicity of plantar wound formations as well as midfoot Charcot collapse, among many other pathologies. Glycation-induced collagen crosslinking secondary to diabetes mellitus sequelae causes general disorganization of the Achilles tendon, decreasing tensile strength and elasticity while increasing stiffness [14]. These changes in addition to the reduction in strength and exibility common in increased sedentary lifestyle and advanced age result in pathologic reduction in ankle dorsiexion during stance and swing phases of gait. This contracture creates profound increases in plantar pressures to the forefoot and midfoot, oftentimes precipitating plantar ulcerations in the neuropathic population [37]. Measuring the maximal passive dorsiexion available at the ankle with the subtalar joint locked and the knee extended and then exed accomplishes this task. Distinction between gastrocnemius or isolated equinus vs. gastrocnemiussoleus or combined equinus is signicant when considering the correct procedure and level to perform surgical lengthening of the posterior group. The Silfverskiold Test is a common and reproducible way to determine the source of ankle contracture [38].

for soft tissue ankle equinus. The authors often

utilize the traditional Hoke [39] style percutane-

ous triple hemi-section of the distal excursion of

the Achilles tendon for patients with either com-

bined gastrocnemius-soleus equinus as well as

those with isolated gastrocnemius equinus, due to

its relatively minimally invasive approach, short

procedure length, and profound effect on improv-

ing ambulatory ankle dorsiexion range of

motion (Figs.26.10 and 26.11).

Procedure

With the foot held in maximal dorsiexion and

the Achilles tendon tensioned, vertical incisions

are made posteriorly at the midline of the skin

and fascia and into the Achilles tendon at 3, 6,

and 9cm proximal to the most superior aspect of

the calcaneus. It is the author’s preference to

Tendo-Achilles Lengthening (TAL)

Tendo-achilles lengthening is a common procedure performed in an assortment of instances of foot and ankle pathology and in a number of ways in order to achieve restoration of the sufcient ankle dorsiexion joint excursion required during normal gait. In the complex wound patient, the TAL is truly a utilitarian procedure

Fig. 26.10 Clinical image posterior view—incision

placements for Hoke style triple hemi-section distally

based tendo-achilles lengthening (TAL). Traditionally, the

Hoke TAL is performed with two medially directed (distal

and proximal) and one laterally directed (central) hemi-

sections; however, surgeon preference dictates actual per-

formance as long as the hemi-sections are performed in

alternating directions

378

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J. S. Steinberg et al.

a b

Fig. 26.11 Clinical images lateral view (a, b)—preoperative (a) and postoperative (b) status post-Hoke style tendo- achilles lengthening (TAL)

mark these intervals using a ruler and skin marker to ensure safe distance is maintained between incisions. At each marked interval the surgeon should palpate the medial and lateral borders of the Achilles tendon and a #15 blade is then inserted mid-substance within the tendon body with the blade facing in-line with the tendon bers. The blade is then rotated 90° and exited the tendon in a sweeping motion alternating between medial and lateral exits at each interval. In effect this creates three separate partial hemisections of the Achilles tendon 50% from midline. Oftentimes a “release” of ankle contracture will be noted with forced dorsiexion of the ankle, and additional partial swipes may be attempted at each tenotomy site to ensure complete hemi-section. This will provide for a correction for both combined gastrocnemius-soleus equinus and isolated gastrocnemius equinus until a sufcient intraoperative Silfverskiold test is conrmed.

Gastrocnemius Recession (GR) andGastrocnemius-Soleus Recession (GSR)

Alternatively, if the Silfverskiold test determines equinus is visualized only with the knee extended but not with the knee exed, patients may have isolated gastrocnemius equinus, and

a gastrocnemius recession alone may be indi-

cated (Fig.26.12). The GR has several added

benets over a distally based TAL procedures,

including direct visualization of surgical anat-

omy, more proximal calf location which may

benet from superior vascularity, avoidance of

procedure in diseased tendon commonly seen

in the comorbid population, and an anecdotally

more “controlled” lengthening of the tissues.

Additionally, access for a GR provides for the

ability to also perform a lengthening of the

soleus muscular fascia in what is termed a gas-

trocnemius-soleus recession, which may be

preferable for patients with combined gastroc-

nemius-soleus equinus and may also be per-

formed via an endoscopic approach (Fig.26.13).

The authors ascribe to a traditional Baumann

[40] type approach to the GR and GSR when

appropriate (Fig.26.14).

Procedure

At 10cm distal to the tibial tuberosity a 6 cm

incision is centered at 50% of the posterior bulk

of the calf between the medial tibial crest and the

posterior aspect of the calf. With the ankle

stressed passively into maximal dorsiexion and

moving from lateral to medial a long-handled

scalpel with #15 blade is utilized to incise the

anterior portion of the gastrocnemius intermus-

cular fascia, including the plantaris tendon,

exposing the underlying gastrocnemius muscle

26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage

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Fig. 26.12 Clinical images medial view (a–f)—preop- erative (a–d) Silfverskiold test performed in a patient after a successful transmetatarsal amputation with free tissue ap for closure displaying formation of isolated gastroc-

nemius equinus. Postoperative (e, f) status post-Baumann

style gastrocnemius recession (GR) shows a reduction of

the passive ankle joint dorsiexion range of motion

380

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J. S. Steinberg et al.

stroke or acquired exible forefoot equinovarus

following partial foot amputation. Patients with

plantar-lateral foot ulcerations, lateral column

amputations with the loss of the peroneus brevis

insertion or loss of peroneal tendon function

often have increased supinatory motion and thus

can benet from the ATTT [43, 44] (Fig.26.15).

Transfer of the anterior tibial (AT) tendon to the

lateral column can effectively balance the foot by

increasing everting forces and decreasing lateral

column pressures (Fig.26.16). Traditionally, the

distal insertion of the tendon is released from its

medial attachment and transferred laterally to the

lateral cuneiform. This aids to balance the power-

ful supinatory force of the posterior tibial tendon

while maintaining active dorsiexion of the foot.

Additionally, lateralizing the transfer on the foot

can increase its everting force, thus can be used

to treated spastic rearfoot varus, spastic

equniovarus, xed equinovarus, and excessive

supination.

Fig. 26.13 Clinical image medial view—incision placement for endoscopic gastrocnemius-soleus recession

belly. This will provide for a correction of isolated gastrocnemius equinus. Additional releases to subsequent portions of the gastrocnemius intermuscular fascia may be performed until a sufcient intraoperative Silfverskiold test is conrmed. As mentioned, additional recession of the soleus intramuscular fascia is also easily accessible from this approach for instances of combined gastrocnemius-soleus equinus for GSR [41].

Tendon Transfers

Anterior Tibial Tendon Transfer

The anterior tibial tendon transfer (ATTT) was rst described in 1940 for the correction of residual pediatric clubfoot [42, 43]. Since then, the indications for the ATTT) have expanded, where it is widely used to counter varus and supinatory forces while maintaining active dorsiexion [43]. This is particularly useful in the treatment of acquired pathology such as dropfoot following

Procedure

The patient is placed in the supine position. A

thigh tourniquet and ipsilateral hip bump is gen-

erally used. As with most tendon transfers, gen-

eral anesthesia with paralysis is recommended.

The transfer of the anterior tibial tendon is gener-

ally performed through three incisions. When

harvesting the tendon, the initial dorsal medial

3–4 cm incision is made over the medial

cuneiform- metatarsal joint (directly over the

insertion of the tendon). Expose and transect the

tendon at its insertion and tag end of the tendon

with a suture. The second incision is placed just

lateral to the myotendinous junction in the distal

lower leg. Palpate the course of the anterior tibial

tendon to just below the muscle belly. A 3–4cm

incision is made just lateral to the tendon. This

incision can be placed about 10–12cm proximal

to the ankle joint. Incise the tendon sheath and

expose the AT tendon. Harvest the transected ten-

don proximally to its origin. Once harvested, a

2-0 prolene can be used) to whip stitch the distal

portion of the tendon. The placement of the third

incision is dependent on the desired function of

the tendon. If pure dorsiexion is desired, then

the incision is placed over the lateral cuneiform

26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage

c d

381

Fig. 26.14 Clinical images medial view (a–d)—intraop- erative Baumann style gastrocnemius recession with (a) incision planning, (b) use of a vaginal speculum for appropriate visualization in the interval between the gastrocnemius and soleus intermuscular septum, (c) anatomic

and the tendon is transferred into bone. If more of an eversion force is needed, a 3–4 cm can be placed over the base of either fourth or fth metatarsal or distal cuboid. The tendon may be transferred into any of these bones. Next a tendon passer is tunneled subfascially from the third incision to the second incision. The tendon is pulled through to the lateral incision. Once the desired location of the transfer is exposed, a drill hole is made through the bone. The suture on a straight needle is fed through the bone tunnel out the plantar foot. The foot is then everted and dorsiexed slightly beyond neutral and a biotenode-

visualization of the soleus, gastrocnemius and plantaris,

(d) status post-recession of the gastrocnemius intermus-

cular fascia, including the plantaris tendon, exposing the

underlying gastrocnemius muscle belly

patient is splinted and non-weight-bearing for 6

weeks.

When planning this transfer, the AT tendon

muscle must have a minimal muscle strength of

4. Anything less will not have the desired result.

Pitfalls to the complete AT tendon transfer

include complete loss of function of the tendon at

its native insertion, over tensioning can cause a

severe pes planovalgus deformity and nerve irri-

tation [43, 44]. It is all also recommended a

tendo-achilles length be performed in conjuga-

tion with the transfer to address any equinus

deformity. sis screw is used to secure the tendon into the bone. The excessive suture is cut. The foot is placed through a gentle range of motion to determine if desired correction) is achieved. Incisions are irrigated and layer closure is performed. The

Split Tibialis Anterior Tendon Transfer

The split tibialis anterior tendon transfer (STATT)

procedure has gained some favor primarily as

half of the transfer remains intact at its native

382

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a b

J. S. Steinberg et al.

Fig. 26.15 Clinical images AP view (a, b)—preopera- tive (a) and postoperative (b) status post-anterior tibial tendon transfer (ATTT) for retained exible forefoot

insertion. The indications for the STATT are similar to the complete tendon transfer. The tendon can be transferred to the same locations as the complete transfer [45]. If the desired location is the base of the fth metatarsal, the tendon may be tenodesed to the peroneus tertius.

Procedure

Patient positioning, anesthesia, incision, and harvest technique are the same for the STATT and AT tendon transfers with one minor difference. After the tendon is exposed in the lower leg, an osteotome or malleable retractor is placed under the tendon and tension is applied to the tendon. After the tendon) is held taut, using a # 15 blade a longitudinal full-thickness stab incision is made in the central aspect of the tendon. A 0–0 prolene or braided suture is fed through the split until equal length suture is on either end of the split. (The authors prefer to use bertape to split the tendon longitudinally.) A tendon passer or suture

varus following transmetatarsal amputation. Note the sig-

nicant correction of the forefoot varus positioning and

maintenance of balanced positioning postoperatively

loop passer is fed through the tendon sheath from

the tendon’s insertion at the medial cuneiform

rst metatarsal joint proximally up to the second

incision. The suture is pulled through the tendon

sheath distally. The foot is slightly plantarexed

and inverted to tension the tendon. In a back-and-

forth sawing motion the suture is pulled distally

toward the tendon insertion splitting the tendon

in half. Care must be taken to pull the suture in

the longitudinal direction of the tendon. If the

suture deviates, it can cause premature transec-

tion of the tendon. This can cause loss of tendon

length. Once the suture exits distally at the inser-

tion, the lateral half of the tendon is identied)

and transected. This portion is pulled proximally.

A 2-0 prolene is whip stitched through the har-

vested tendon. The lateral portion of the tendon is

then tunneled subcutaneously to the lateral foot

and transferred into the base of the fourth, fth

metatarsal or distal cuboid. It may also be teno-

desed to the peroneus brevis. As with the AT ten-

26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage

ab c

def

383

Fig. 26.16 Clinical images multiple views—sequential cadaveric performance of the AT tendon transfer into the lateral cuneiform bone via: (a) three-incision approach, (b) harvesting of the AT tendon at its insertion, (c) passing of the tendon to the anterior leg compartment, proximal to the extensor retinaculum, (d) placement of a passing

don transfer the foot must be slightly everted and dorsiexed beyond neutral before xating. Postoperative course is the same as with the AT tendon transfer. Planning for the STATT is the same as with the AT tendon transfers. The STATT has advantages over the complete tendon transfer

suture in the form of a whip style stitch to the distal ten-

don, (e) nal passing of the tendon to the dorsal foot with

xation via a biotenodesis screw, and (f) additional xa-

tion with external button fashioned from the plunger of a

60cc syringe and dry sterile sponge

as it preserves native anterior tibial tendon func-

tion as well decreases risk of severe pes planoval-

gus deformity. Similarly, a tendo-achilles

lengthening is recommended in conjunction with

the transfer. Pitfalls to the STATT include under

correction and tendon rupture.

384

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Fig. 26.17 Clinical images AP view (a, b)—preopera- tive (a) and postoperative (b) status post-posterior tibial (PT) tendon transfer for combined equinovarus deformity

Posterior Tibial Tendon Transfer

The anterior placed transfer of the posterior tibial (PT) Tendon was rst described by Ober in 1933 [46]. Putti discussed transferring the tendon through the interosseous membrane in 1937, but this procedure was popularized by Watkins in 1955 [47]. Transfer of this tendon to the dorsum of the foot is mainly indicated for dorsiexory weakness or paralysis such as is found in weak or paralyzed anterior muscle group, equinovarus, spastic equinovarus, recurrent clubfoot deformities, dropfoot, CharcotMarie-Tooth disease, peroneal nerve palsy, and Duchenne muscular dystrophy. PT tendon transfers can also be used to reduce deforming supinatory forces and reduce varus recurrence such as in the setting of peroneal tendon weakness.

following Lisfranc level amputation. Note the signicant

correction of the forefoot varus positioning and mainte-

nance of balanced positioning postoperatively

This is commonly seen when osteomyelitis to

the base of the fth metatarsal requires loss of

peroneus brevis insertion point (Fig.26.17). A

four-incision approach is preferred in order to

harvest, prepare, pass, and subsequently secure

the entirety of the PT tendon into a lateralized

position relative to the axis of motion of both

the subtalar joint and long axis of the midtarsal

joint (Fig.26.18). The authors prefer a complete

PT tendon transfer utilizing a four- incision

approach as it provides greater functional action

of the tendon while also completely removing it

from contributing as a deforming force.

Additionally if the spring ligament and capsule

of the talonavicular joint are intact they are

likely not to permit midfoot progression to pla-

nus deformity.

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