- Discussion:
- circumferential soft-tissue release involving posterior, medial,
lateral, and plantar aspects of the foot;
- its designed particularly to correct the horizontal subtalar rotation
of the calcaneus that is associated with congenital club foot;
- because of this, the posterior aspect of the calcaneus not only is in
position of equinus but also is rotated and displaced laterally
toward the fibular malleolus;
- this can be corrected only by freeing it completely, thus correcting
abnormal rotation;
- complete subtalar soft-tissue release must be done as single procedure
because postop scarring makes subsequent procedures more difficult;
- consider release of interosseous talocalcaneal ligament as well as of
posterior talofibular ligament in all feet;
- this incision provides exposure of the subtalar joint and is useful in
patients with severe internal rotation deformity of the calcaneus;
- potential problem with this incision is the tension on the suture line
when attmepting to dorsiflex foot to apply the postoperative cast;
- to avoid this the foot must be placed in mild plantar flexion in
immediate post operative cast.
- make a medial incision 8 to 9 cm long extending from the base of
1st metatarsal to the tendo calcaneus, curving it slightly just
inferior to the medial malleolus.
- expose the and mobilize by careful disection the tendons of
tibialis posterior,
FDL, and
FHL &
posterior tibial artery, vein,
and
nerve;
- expose the tendo calcaneus;
- incise the sheaths of the tendons as they are exposed;
- free posterior tibial neurovascular bundle and retract it posteriorly
- by continuing incision in sheaths of FDL & FHL, divide master knot of
Henry bundle beneath the Navicular;
- divide calcaneonavicular (spring) ligament and the abnormal origin
of the
Abductor Hallucis.
- of the remaining contractures, release the posterior ones first;
- lengthen tendo calcaneus by Z plasty - detaching medial half of
its tendinous insertion on the calcaneus;
- retract neurovascular bundle and FHL anteriorly & expose posterior
aspect of the ankle and subtalar joints;
- incise the posterior capsule of the ankle joint under direct vision
- if necessary divide the posterior talofibular ligament.
- identify the posterior capsule of the subtalar joint and divide
this along with the calcaneofibular ligament.
- retract the neurovascular bundle posteriorly & divide tibiocalcaneal
part of
deltoid ligament;
- do this by extending the incision in the posterior capsule of the
subtalar joint medially and anteriorly;
- realease the deep medial structures:
- retract neurovascular bundle & lengthen by Z plasty
tibialis posterior tendon
just proximal to the medial malleolus;
- use its distal end as a retractor of the navicular.
- mobilize the navicular by opening the talonavicular joint & excising
that part of the deltoid ligament that inserts on this bone;
- incise talonavicular capsule but avoid damaging articular surface;
- free navicular from tendon attachment to sustenaculum tali &
spring ligament & detach spring ligament from sustenaculum tali;
- evert the foot:
- release posterior part of the incision and evert the foot;
- release superficial layer of
deltoid ligament from
calcaneus posteriorly - under direct vision;
- do not incise the deep layer of this liagment that extends from body
of talus to the medial malleolus because this would cause
flat foot deformity;
- only remaining structures to be released are the subtalar ligaments
- evert the foot and expose the talocalcaneal interosseous ligament,
and cut the ligament under direct vision.
- divide bifurcated (Y) ligament that extends from the calcaneus to
lateral border of the navicular and to medial border of cuboid;
-----------------------------------
The cincinnati incision for the split posterior tibial tendon transfer: a
technical note.
Complete subtalar release in club feet. Part I--A preliminary report.
Complete subtalar release in club feet. Part II--Comparison with less
extensive procedures.
McKay, D. W.: New Concept of and Approach to Clubfoot
Treatment. Section I. Principles and Morbid Anatomy. J. Pediat.
Orthop., 2: 347-356, 1982.
McKay, D. W.: New Concept of and Approach to Clubfoot
Treatment. Section II. Correction of the Clubfoot. J. Pediat.
Orthop., 3: 10-21, 1983.
McKay, D. W.: New Concept of and Approach to Clubfoot
Treatment. Section III. Evaluation and Results. J. Pediat. Orthop.,
3: 141-148, 1983.
