Left Posterior tibial tendon repair, flexor digitorum longus tendon transfer, peroneus brevis tendon transfer, spring ligament repair and calcaneal osteotomy.
The patient was placed supine on the Operating Room table and after an epidural/spinal anesthetic was given, the patient's lower leg was prepped with Betadine and draped in the usual sterile fashion. An incision was made over the lateral calcaneous and taken sharply down. This was an oblique incision. It was taken sharply down through the skin and bluntly into the calcaneus.
Care was taken to stay behind the sural nerve. Subperiosteal dissection was done over the lateral calcaneus and retractors were placed and after confirming the location of the cup with a Fluoroscan, a calcaneal osteotomy was done. TL was mobilized and then pushed as far medially as possible which is 1cm.
The pin was left in place and the osteotomy was wedged open and a 5 to 6mm bone graft was placed acting as a lateral wedge for a lateral column lengthening. Good fixation of bone graft was achieved and it was checked under Fluoroscan. A 7.3 cannulated screw and a 4.5 cannulated screw were placed both with good fixation.
An incision was made medially and was taken sharply down through the skin and onto the posterior tibial tendon sheath. The tendon sheath was entered and the tendon was noted to be grossly enlarged with a longitudinal tear. The tendon was considerably bolus and mucinous in appearance.
The tendon was repaired proximally through a separate incision above the level of the medial malleolus. This was repaired using #0 and #1 silky Polydek to the near by tendon.
An SDL tendon transfer was then performed going just underneath to the navicular cuneiform joint being careful to stay just proximal to the vascular lesion and above the medial plantar nerve. The FDL was released being careful to leave any distal attachments. Apparently, in this foot, there were no distal connections between the FDL and FHL.
Suture was made to connect the two but this was felt to endanger the medial plantar nerve.
The FDL tendon was then brough through the FDL sheath through a drill hole in the navicular. At the end of the procedure, this was tied back down upon itself. The FDL tendon was quite small. TL was apparent that this tendon was too small to act as a good tendon transfer. Therefore, the peroneus brevis was used as well.
A separate incision was made at the base of the fifth metatarsal and at the level of the fibula. The tendon was then released at the base of the fifth metatarsal and then passed directly behind the tibia through the old posterior tib tunnel into the navicular tunnel. TL was tied back to the stump of the posterior tib tendon and brought up through the drill hole and the suture tied to the soft tissues on the medial aspect.
The spring ligament repair was done by resecting an ellipse of the spring ligament and then using #1 silky Polydek for repair. The was tied down in inversion. Good correction of the foot was obtained. Fluoroscan x-ray pictures were used to show good position of the osteotomy.
The wounds were then copiously irrigated and closed with 2-0 and 3-0 Vicryl and 3-0 nylon. Apatic, dry gauze, AB dressing was placed as well as copious Webrile and plaster splints. A Hemovac was used in the medial wound. The tourniquet remained elevated for approximately two hours during the procedure. There were no known operative complications.
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