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Fig. 23.17 The exor digitorum brevis muscle is commonly used for
closure in large plantar ulcerations following ulcer excision and exostectomy of the offending bone
J. Ceja Solorio and J. M. Giurini
thickness skin graft is then used to cover the donor site in the
medial arch (Fig.23.18).
Six weeks of total nonweightbearing is required for adequate healing and incorporation of the ap. This is followed
by an additional 2–4weeks of protected weightbearing in a
surgical shoe with a molded orthotic device. Long-term care
requires the use of plastizote orthoses and modied shoe gear.
These types of aps in the foot have become relatively
infrequent following the introduction of negative pressure
wound therapy (NPWT), also referred to as vacuum assisted
closure (VAC). Negative pressure wound therapy was rst
introduced in the United States in 1997 [73–75]. Since its
introduction, it has been extensively used in large circumference wounds with signicant depth in order to promote granulation, decrease the number of dressing changes, and avoid
more extensive and morbid procedures. As a result, there has
been a signicant reduction in the number of rotational aps
or free tissue transfers needing to be performed [76].
Lisfranc’s Joint Arthrodesis
When the Charcot process results in signicant bone loss and
instability at the rst TMT joint, an exostectomy may result
in further instability and continued collapse of the medial
column. In these circumstances stabilization of the joint in
the form of primary fusion may be a better alternative.
The joint is best approached through a direct medial incision.
This allows adequate exposure of the dorsum of the joint as well
as the plantar surface. Any remaining articular cartilage is
resected with a sagittal saw. Subchondral drilling with a 2.0mm
Fig. 23.18 Patient 5 years status post cuboid exostectomy with an
interpositional muscle ap and a rotational fasciocutaneous ap
drill bit will stimulate bone bleeding and will facilitate fusion.
Often times the bone cut on the rst metatarsal side can be
slightly angulated from dorsal-proximal to plantar-distal allowing plantarexion of the rst metatarsal, restoring the weightbearing function of the rst ray. In addition, any plantar bony
prominence can also be resected from medial to lateral.
Fixation of the joint can be achieved in a variety of ways.
The author’s preferred method is to use a medial plate and
interfragmentary screw to provide rigid internal xation and
compression (Figs.23.18 and 23.19a, b). This allows spanning
the joint into more normal, healthier bone for more solid xation. Crossed interfragmentary screws can be an acceptable
form of xation if there is minimal fragmentation of the rst
metatarsal and medial cuneiform. Other forms of xation can
include crossed 0.062 Kirschner wires, bone staples, or intramedullary screw (Fig.23.20). However in our experience they
fail to provide adequate compression and stability and are subject to failure, including breakage. Therefore, they are not recommended. It is advisable to insert a Jackson-Pratt drain to
prevent the accumulation of a hematoma.
The postoperative course includes immobilization and
nonweightbearing. While there is no standard length of
immobilization and nonweightbearing, the patient can expect
to be nonweightbearing on average 3months. Partial weightbearing begins when serial X-rays show early trabeculation
across the rst TMT joint. Although recent studies suggest
that postoperative CT scans provide a better measure of joint
fusion and consolidation [77, 78], continued weightbearing
ab
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Fig. 23.19 (a, b) A T-plate with an interfragmentary screw is author’s
preferred form of xation of the rst metatarsal-medial cuneiform joint
in the presence of unstable Charcot joint. Radiograph of patient with
T-plate and interfragmentary screw across the rst metatarsal- medial
cuneiform joint
of severe midfoot instability, stabilization of multiple joints
is often necessary. The surgical approach to these deformities will be covered below under hindfoot procedures.
Calcanectomy
Heel ulcerations in patients with diabetes unfortunately are
very common, are generally of moderate size, of long duration, and are associated with poor outcomes [79]. Due to the
many comorbid conditions most diabetic patients display,
periods of prolonged bed rest are not unusual. Without proper
protection, decubitus ulcerations can occur. However other
causes for heel ulcers include blisters from shoe or cast irri-
Fig. 23.20 Fusion of the rst metatarsal-medial cuneiform joint for an
unstable Charcot joint complicated by recurrent ulceration can be
achieved by use of staples
is allowed as long as both clinical and radiographic evaluations suggest continued healing of the fusion site.
Charcot joint disease will often affect the entire Lisfranc’s
joint complex, i.e., all ve tarsometatarsal joints. In the case
tation and heel ssures resulting from dry skin or puncture
wounds. Regardless of the precipitating cause, the end result
is prolonged disability and morbidity. In cases of bone
involvement (i.e., osteomyelitis), below knee amputation can
be the nal outcome. Attempts to save this extremity and
provide a limb capable of functional ambulation may involve
excision of the ulceration and the calcaneus, either partial or
subtotal.
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J. Ceja Solorio and J. M. Giurini
The goals of a calcanectomy should include excision of
all necrotic and infected soft tissue, resection of any and all
infected bone, and primary closure of the wound whenever
possible. Resection of large amounts of bone may be necessary in order to achieve primary closure. Hindrances to primary closure include the lack of mobility of the surrounding
soft tissue and severe tissue loss from infection. In these
cases, a more creative approach including rotational skin
aps, free tissue transfers, or NPWT may be needed.
The majority of times this procedure is performed for osteomyelitis. It is therefore critical that adequate bone is removed to
eliminate the infection. Various techniques have been described
for resecting the calcaneus. This includes use of an osteotome or
a
saw. Contoured resection of the calcaneus has recently been
described [80, 81]. The primary goals are to remove all infected
bone and not to leave a plantar prominence which could serve as
an irritant to the soft tissue and result in re-ulceration. In resecting the calcaneus, the Achilles tendon is often encountered.
Depending on the extent of infection, it may need to be debrided
or even released. While one may be tempted to reattach the tendon, it is rarely advisable to do so. Advancement of the Achilles
tendon would require the introduction of foreign materials such
as screws or anchors which could serve as a nidus of recurrent
infection. In those cases where the Achilles tendon is detached,
it will often brose to the surrounding tissues and provide some
degree of plantarexion. (Fig.23.21a–c). In cases where a sig-
b
c
Fig. 23.21 (a) Osteomyelitis of the calcaneus with undrained puru-
lence. Control of infection via incision and drainage needed prior to
denitive procedure. Osteomyelitis of the calcaneus is a common cause
for lower limb amputation. (b) Patient in 21a following incision and
drainage and partial calcanectomy. (c) Final debridement of soft tissue
and bone with delayed closure of wound
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Fig. 23.22 In severe infections and bone loss of the calcaneus, free
tissue transfer is often necessary for limb salvage. These tenuous aps
are often protected from pressure with external xation
nicant amount of calcaneus must be resected and there is signicant tissue loss from infection, free tissue transfer to cover
this void may be the only option for limb salvage. These are
typically tenuous aps that require 24hour monitoring for viability. It is often necessary to protect these aps with some form
of external xation for ofoading (Fig.23.22). Even the slightest degree of pressure can lead to pressure necrosis and loss of
the ap.
Hindfoot Procedures
Surgical procedures of the hindfoot are most commonly performed for reconstruction of unstable Charcot joint disease
and can be truly classied as limb salvage procedures. These
include midfoot arthrodesis (TMT joints), triple arthrodesis
(talonavicular, calcaneocuboid, subtalar joints), and pantalar
arthrodesis (subtalar, ankle joints). While not considered
reconstructive surgical procedures, we will also include tendoachilles lengthening in this section as it is often a necessary adjunctive surgical procedure. Indications for these
complex reconstructive procedures include chronic, nonhealing ulcerations with underlying hindfoot deformity or
instability, severe instability of the hindfoot making ambulation difcult at best or are deemed nonbraceable. While there
is high risk associated with these procedures, standard con-
421
servative measures often prove inadequate to provide a stable
plantigrade foot resistant to ulcerations. These procedures
are often performed when the only alternative is a major limb
amputation.
Midtarsal Joint Arthrodesis
As previously stated, the most common location for Charcot
joint disease is the TMT joints, i.e., Lisfranc’s joints. These
are the joints formed by the metatarsal bases and the cuneiforms and cuboid bone. These joints are supported by several
small ligaments that connect these bones to each other. While
the inciting event for the development of Charcot joint disease remains unclear, in the majority of cases, disruption of
these ligaments with or without fractures is a common feature (Fig.23.23a, b). Because of absence of pain, the patient
continues to ambulate on this unstable foot resulting in further destruction, displacement, and instability. The end result
is a foot that is grossly misshapen, unstable to walk on and at
risk for ulceration, infection, and amputation. While initial
treatment should consist of nonweightbearing, immobilization, and bracing, many feet are so unstable that bracing
actually poses a risk to the patient. It is in these cases that
surgical intervention should be contemplated.
We previously described isolated medial column fusion
for single joint involvement. However, in most cases,
Charcot will affect multiple joints. It is not uncommon for
the metatarsals to be dorsally displaced onto the cuneiforms
or for the cuneiforms dorsally displaced on the talonavicular joint. This situation requires a more aggressive approach.
Intramedullary rodding (“beaming”) has become a common method of stabilizing these deformities (Fig.23.24).
Large screws are inserted through the medullary canals of
the rst and 4th (sometimes 3rd) metatarsals. These screws
cross the TMT joints into the respective tarsal bones. In
those cases where the talonavicular joint is also involved, a
single long screw can be used to cross both the rst
metatarsal- medial cuneiform joint and the talonavicular
joint as part of a triple arthrodesis. The screws are inserted
following appropriate resection and realignment of the
involved joints [82, 83].
This beaming technique has the advantage of providing
adequate realignment and compression of the affected joints.
This is a very stable construct. The other advantage is it
avoids excessive dissection of the joints. With the use of cannulated screws and using intraoperative X-rays, these screws
can be accurately placed through small stab incisions, avoiding large wounds and excessive stripping of the periosteum.
Recently, there has been discussion of a “superconstruct”
when performing this type of surgery in patients with Charcot
joint disease [84–86]. This implies that the involved joint(s)
is so severely damaged that the use of xation devices at this
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J. Ceja Solorio and J. M. Giurini
Fig. 23.23 (a) Disruption of
tarsometatarsal ligaments
resulting in lateral subluxation
of Lisfranc’s joint following
rst ray amputation. (b)
Lateral view showing dorsal
subluxation of Lisfranc’s joint
in addition to lateral
subluxation
ab
Fig. 23.24 The intramedullary rodding technique introduces large
diameter screws through the metatarsals and across the hindfoot joints
to achieve stability, primary fusion, and deformity
joint is not possible. Therefore, it is necessary to extend the
zone of fusion proximally and distally in order to achieve
fusion and stability across these joints. Fixation can take the
form of intramedullary screws, i.e., beaming, or large medial
plates that span the entire medial column, i.e., rst metatarsal
base to talus.
Another concept to consider in surgery to stabilize the
midfoot is fusion of the subtalar joint (STJ), even if the joint
is not affected by Charcot joint. The STJ controls supination
and pronation of the foot. Excessive pronation will lead to
increase stress through the midfoot resulting in further collapse of the joint. This abnormal degree of pronation can
lead to failure of any attempt to stabilize and fuse the medial
column. By performing an STJ fusion these forces are
reduced resulting in greater fusion rates and better long- term
outcomes [87].
It is also important to address the Achilles tendon in these
cases. Because of the midfoot collapse, the excessive pronation, and the chronicity of the deformity, the Achilles tendon
becomes shortened and its mechanical axis across the STJ is
changed from a supinatory to a pronatory force (Fig.23.25).
Therefore, lengthening the Achilles tendon is tantamount to
success. This can be done in the form of a percutaneous trisection of the Achilles tendon (Hoke procedure) or a gastrocnemius recession (Strayer procedure). These are described
later in this chapter.
abc
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Fig. 23.25 Changes in the axis of the subtalar joint (STJ) will change
the mechanical effect of the Achilles tendon from a supinatory to a pronatory. This is what occurs in Charcot joint disease when the midfoot
collapses, thus placing even greater pressure on the midfoot. (Figure
originally appeared in Kirby KA.Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA 91:465,2001. Used
with permission from the American Podiatric Medical Association)
Triple Arthrodesis
The incidence of Charcot joint disease involving the tarsal
joints—talonavicular, calcaneocuboid or subtalar—ranges
from 1.8% to 37% depending on the reports [88–90].
Clinically, these feet appear with a rockerbottom deformity
from plantar subluxation of either the talonavicular joint or
the calcaneocuboid joint (Fig.23.26). This can then lead to
chronic ulceration. When faced with a signicant degree of
instability from this destructive process, the approach should
include surgical stabilization of the involved joint or joints.
This often requires fusion of the talonavicular joint, calcaneocuboid joint, and the subtalar joint, i.e., triple arthrodesis.
The goal of a triple arthrodesis is to stabilize the foot and
to reduce the deformity, thereby reducing the risk of recurrent ulceration. It is recommended that surgery be delayed
until the acute phase has resolved and the Charcot joint has
entered the coalescent phase. If an open ulceration is present,
surgery should be delayed until all signs of acute infection
are resolved. However, it is not necessary to wait until the
ulceration is healed.
The triple arthrodesis is performed in a standard fashion.
The STJ and the calcaneocuboid joint are approached
through a lateral incision just inferior to the lateral malleolus and extending distally to the base of the fourth and fth
metatarsals. While it is possible to obtain adequate exposure
Fig. 23.26 Dislocation of the talonavicular joint from Charcot joint
disease resulting in rockerbottom deformity and severe plantarmedial
ulceration
of the talonavicular joint through this incision, a separate
medial incision is often necessary to afford better
exposure.
The cartilage is resected off all joint surfaces until bleed-
ing bone is exposed. This can be accomplished using a vari-
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ety of techniques such as bone curette, osteotome, or drill. It
is also recommended to perform subchondral drilling of the
joints with a 2.0mm drill bit. The joints are then reapproximated. If signicant deformity exists, wedge resections
through the joints may be required to adequately reduce the
deformity. Additionally, signicant bone resorption may
have occurred as a result of the destructive process. In these
cases bone graft may be necessary to ll the gaps between
joint surfaces. This can be obtained from the iliac crest or
from the bone bank. At this stage it is best to temporarily xate the joints with Steinmann pins and assess deformity correction with intraoperative uoroscopic images.
The method of xation is the surgeon’s choice. The STJ is
often xated with two screws crossing the posterior facet
into the body of the talus. These screws can be introduced
through a stab incision on the plantar surface of the heel.
These screws are easily inserted over a guide wire from plantar to dorsal, across the STJ into the body of the talus.
Alternatively, one screw can be introduced from a dorsal
approach through the neck of the talus and one screw through
a stab incision on the plantar surface of the heel (Fig.23.27).
It is important that an intraoperative calcaneal axial X-ray is
obtained to assure that the guide wire is centered in the calcaneus and avoids the medial or lateral wall of the calcaneus
(Fig.23.28). This will avoid potentially fracturing the calcaneus. These views are best facilitated with the use of a large
C-arm as opposed to the smaller, mini-C arm units. The talonavicular joint can be xated with crossed 5.0mm screws:
one from the navicular tuberosity into the head of the talus
and the second screw from the lateral navicular into the head
of the talus. While screws are preferred for the talonavicular
and subtalar joints, staples or small plates can be used in the
Fig. 23.27 Fixation of the subtalar joint can be achieved by a screw
directed from the posterior plantar aspect of the calcaneus directed
anterior and superior across the joint and into the body of the talus
J. Ceja Solorio and J. M. Giurini
Fig. 23.28 An intraoperative calcaneal axial view is critical to assure
the subtalar screw is not too close to the medial or lateral wall of the
calcaneus
calcaneocuboid joint. Minimal to no gapping should be present. This should always be conrmed with an intraoperative
X-ray to conrm the nal position of all xation devices,
adequate joint apposition, and appropriate foot position. The
position of the calcaneus should be neutral to slight valgus.
The goal of surgery is correction of the deformity with good
apposition of all joint surfaces and the creation of a plantigrade foot.
Postoperatively, the patient is placed in a posterior splint
to immobilize the fusion site. The splint is replaced with a
below the knee berglass cast following the rst dressing
change, usually 7–10 days following surgery. Total nonweightbearing is maintained for a minimum of 3–4months.
Patients with neuropathy often need to be protected and nonweightbearing for a longer period than non-neuropathic
patients due to the lack of protective pain sensation. Serial
X-rays are obtained to evaluate bone healing and maintenance of postoperative correction and alignment. The patient
is then advanced to gradual protected weightbearing when
X-rays show signs of bone union. Because the degree of
fusion is difcult to assess clinically, it is current best practice to obtain a CT scan to assess degree of fusion before
ambulation is allowed. Isolated case reports suggest that the
likelihood and rate of fusion may be improved with the use
of electrical bone stimulation although prospective, randomized double-blinded trials are not available to determine
overall efcacy [91].
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Pantalar Arthrodesis
The ankle joint that has undergone severe destruction from
Charcot joint disease is particularly problematic. This typically results in a ail ankle joint that makes ambulation
extremely difcult if not impossible. This deformity may
result from total collapse of the talar body, fractures of the
calcaneus, fractures through the medial malleolus, lateral
malleolus or both. Patients with these types of fractures will
often be found ambulating directly on either the medial or
lateral malleolus. This inherent instability will result in the
development of chronic ulcerations and is extremely difcult
to control with conservative care alone. The prognosis for
these deformities is poor. In order for limb salvage to be
achieved, primary fusion of the ankle and subtalar joints is
necessary.
The surgical approach depends on the level and degree of
destruction. If the primary level of instability and destruction
involves the tibiotalar joint, isolated fusion of this joint may
be sufcient. However most often, destruction of the other
rearfoot joints is present. Therefore fusion of the ankle, talonavicular, subtalar, and calcaneocuboid joints (i.e., pantalar
fusion) is necessary to provide a stable platform for ambulation. Once again, it is best to delay all surgical intervention
until all signs of acute Charcot joint disease have resolved.
Attempted fusion during the active, hyperemic phase of this
disorder will not only make fusion technically difcult but
may also result in failure to fuse.
A lateral incision which begins approximately at the midbula and extends to the tip of the lateral malleolus offers
adequate exposure of the ankle joint. If a pantalar fusion is to
be performed, this incision can be extended distally to the
calcaneocuboid joint. The bula is typically osteotomized
just proximal to the ankle joint line. The anterior aspect of
the bula is dissected free and reected posteriorly. This preserves the vascular supply to the bula. This will also allow
the bula to be used as a vascularized strut graft on the lateral
side of the ankle joint. The ankle joint is now well
visualized.
The articular cartilage is resected down to bleeding cancellous bone from the inferior surface of the tibia and the
dome of the talus. The ankle joint is repeatedly manipulated
so as to assess alignment of the foot. The joint surfaces are
continually remodeled until optimal bone apposition and
foot alignment is achieved. In cases where the talar body is
deemed nonsalvageable, the tibia may be fused to the calcaneus or a bone graft can be inserted to ll the defect and
accommodate for signicant bone loss. Femoral head
allograft may be used to ll this defect. However recent studies/reports have shown mixed long-term results using this
technique [92–94]. If a pantalar fusion is being performed,
the remaining hindfoot joints can be addressed at this time in
the same manner as in a triple arthrodesis.
425
Fig. 23.29 Severe instability of the rearfoot due to Charcot joint often
requires major reconstructive surgery of the hindfoot and ankle. A pantalar fusion was performed in this patient for severe cavoadductovarus
deformity and chronic ulceration resulting from Charcot joint. Two
7.0 mm cannulated screws were used to fuse the subtalar and ankle
joints
After all articular surfaces have been resected, the foot
should be positioned so that all bone surfaces are in good
apposition with minimal to no gapping and the foot is in a
plantigrade position with the ankle joint at 90 degrees. This
can be assessed by temporarily xating the joint and obtaining intraoperative uoroscopic images. Care should also be
taken to avoid any interposition of soft tissue. If the foot cannot be aligned properly or bone surfaces do not appose adequately, further remodeling of the bone should be performed.
Once optimal alignment has been achieved, the ankle joint is
ready for xation. Internal xation of the ankle joint can be
performed in a variety of ways. This can be performed with
the introduction of two 7.0mm cannulated screws. From a
plantar to dorsal direction through the body of the calcaneus
and across the resected ankle joint. This will also xate the
posterior subtalar joint (Fig.23.29). Ideally, the tips of the
screw should purchase the cortex of the tibia. Other techniques may include crossed screws from the distal tibia into
the talus and/or calcaneus, a blade plate on the lateral side of
the calcaneus and across the anterolateral aspect of the tibia.
More commonly, an intramedullary nail can be introduced
across the ankle and subtalar joints from a plantar approach
(Fig.23.30) [93, 94]. When bone quality precludes the use of
internal xation, external devices for xation are appropriate
alternatives [95, 96]. The use of intraoperative imaging is
critical in the placement of guide wires and for nal xation.
It is critical that the calcaneus be positioned either in neutral
or in slight valgus position. Any degree of varus should be
avoided. After xation of the ankle joint, the remaining rearfoot joints can be xated as previously described.
As with triple arthrodesis, the postoperative care is critical to successful limb salvage. Wound infection, dehiscence,
and non-union are the major complications seen with this
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J. Ceja Solorio and J. M. Giurini
Fig. 23.31 Severe Charcot deformity with an open ulceration and
osteomyelitis will require the use of external xation to correct the
deformity and to avoid the use of internal xation at the site of ulceration and osteomyelitis
Fig. 23.30 : X-ray showing Charcot ankle reconstruction using an
intramedullary nail and femoral head allograft
procedure. Immobilization of the extremity immediately
postoperatively can decrease the risks of these complications.
Total nonweightbearing in a below the knee berglass cast is
required for a minimum of 4months and should be changed
frequently to prevent abrasions or cast irritations.
Consolidation or fusion of the joints should be assessed with
a CT scan [77]. Once it is felt fusion is sufcient to support
weightbearing, this should be instituted in a gradual protected manner. A return to protected weightbearing will be
dictated by serial X-rays. The use of adjunctive modalities to
promote fusion, such as electrical bone stimulation, may be
considered in this patient population as these patients and
procedures are considered at high risk for non-union.
Arthrodesis withExternal Fixation
The complex nature of these deformities, open ulcerations
with or without osteomyelitis, and signicant bone loss often
require the use of advanced techniques in external xation.
Signicant bone loss in these hindfoot deformities often
does not allow for dependable use of internal xation devices.
In addition, the presence of an open ulceration and osteomyelitis makes the use of internal xation contraindicated.
Therefore the use of various external xation constructs has
been used to achieve stabilization in these deformities [97–
100]. The most common construct utilizes a combination of
multiplane ne wire ring xators and half pins attached to
the leg and foot at different levels. If possible, this can be
used in conjunction with internal xation (Fig.23.31).
Another use of external xation for the correction of
Charcot joint disease is for gradual correction prior to denitive arthrodesis [101, 102]. In this technique, an external ring
xator with telescoping struts is placed. The struts are
adjusted daily by the patient in order to gradually reduce the
deformity and to stretch the soft tissues that are holding the
deformity in place. This typically takes 1month. When the
deformity has been restored to length, a formal arthrodesis of
the involved joints can be performed in the manner described
above. This can often avoid signicant removal of bone and
shortening of the foot (Fig.23.32a–e).
Tendoachilles Lengthening
The effect of a tight Achilles tendon on foot mechanics, foot
ulcerations, and Charcot joint disease has been well documented [103–105]. A tight Achilles tendon from enzymatic
glycosylation leads to increased plantar foot pressures resulting in foot ulcerations. A tight Achilles tendon is also present
in Charcot joint disease. The majority of clinicians caring for
diabetic foot ulcerations agree that a tight Achilles tendon
contributes to the recurrent nature of diabetic foot ulcerations
and should be addressed via tendon lengthening.
The Achilles tendon is formed by the end bers of the gastrocnemius and soleus muscles and insert into the dorsal posterior aspect of the calcaneus. By virtue of its insertion, the
Achilles tendon functions as a strong plantarexor at the ankle
joint and invertor of the STJ. Its plantarexion motion is
opposed by the extensor muscles crossing the anterior aspect
of the ankle joint and its inversion motion is opposed by the
peroneal muscles laterally. When the calcaneus everts and the
axis of the subtalar joint changes as occurs in patients who
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ac d
b
e
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Fig. 23.32 (a-e) Series of acute Charcot correction showing distrac-
tion technique. (a) Acute Charcot showing dorsal dislocation of cuneiform on navicular; (b) application of external xation for gradual
distraction and correction; (c) 1month post-distraction showing grad-
excessively pronate or whose midfoot has collapsed from
Charcot, the axis of pull of the Achilles tendon changes [106].
It now creates a strong pronatory force of the foot. This can
lead to excessive medial transfer of weight and midfoot collapse as seen in Charcot joint disease. It is for this reason that
the Achilles tendon must be evaluated in every case of Charcot
joint disease and reconstructive surgery. Failure to recognize
this fact can lead to recurrence of the ulceration and failure of
the reconstruction.
There are several techniques to lengthen the Achilles tendon [107–110]. These can be classied as either open or percutaneous. The simplest technique is the percutaneous
approach (Hoke) (Fig.23.33). This technique utilizes three
small stab incisions and minimal soft tissue dissection.
However, this requires an understanding of the anatomy of
the Achilles tendon and the ability to convert to the open
technique when necessary. The procedure can be approached
with the patient lying either supine or prone. Three small
stab incisions are made centrally on the Achilles tendon. The
incisions are spaced approximately 1– 1.5cm apart with the
distal most incision being 1.5cm from the insertion of the
Achilles on the calcaneus. The most proximal and most distal incisions will incise the Achilles centrally and exit medially while the middle incision will incise the Achilles
centrally and exit laterally. Once the three incisions are completed, a gentle dorsiexing force is exerted on the foot until
a gentle stretch can be felt on the Achilles. Care should be
ual realignment of cuneiform-navicular joint; (d, e) removal of external
xation with insertion of intramedullary xation to maintain
correction
taken not to stretch the Achilles beyond 10° of dorsiexion.
The skin incisions are then closed with suture of the surgeons’ choice.
While the percutaneous technique provides adequate correction and is the least morbid technique, there are situations where greater degrees of correction are needed. This is
where the open technique may be needed (Fig.23.34). This
is best performed with the patient in the prone position. An
approximately 8–10cm incision is made along the central
portion of the Achilles tendon. The incision is deepened
until the peritenon is visualized. The peritenon is incised
longitudinally along the line of the skin incision exposing
the Achilles tendon. While there have been several ways
described to lengthen the tendon, our preferred method is to
make one incision approximately 1.0 cm proximal to the
insertion. The blade is inserted into the midsubstance of the
Achilles all the way across and the anterior bers are transected. Attention is then directed approximately 2.5–3.0cm
proximally where the blade is once again inserted into the
midsubstance of the Achilles tendon. The posterior bers of
the tendon are now transected. Once completed, the foot is
once again gently dorsiexed until the tendon can be seen to
lengthen along the central intact bers. In this fashion, the
surgeon can visualize the amount of lengthening achieved
and “dial-in” more dorsiexion if necessary and if feasible.
Closure of the wound, including the peritenon, is performed
in a layered fashion. The Achilles tendon lengthening is pro-
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