Flatfoot Surgery in Teenage Athletes - Des Moines University
Transcript of Flatfoot Surgery in Teenage Athletes - Des Moines University
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Troy J. Boffeli, DPM, FACFAS Department Head, Foot & Ankle Surgery,
HealthPartners Medical Group
Director, Foot & Ankle Surgical Residency Training, Regions Hospital
I have no financial disclosures and will
not discuss off label or investigative
use of products or devices
Foot & Ankle Surgical Symposium
April 25-26, 2014
Flatfoot Surgery in Teenage Athletes
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Elective Surgery on a 15 y/o sprinter?
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Document Level of Preop Disability
• Sprinter but had to quit track due to foot pain
• Barely made it through football as a running back
• Can not be on his feet for more than 2 hours
• Pain is a 10 both during and after sports
• Can surgery fix this?
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Rearfoot Procedure Selection
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Corrected View Helps with Procedure Selection
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R/O Subtle Coalition (LLA view for standard flatfoot workup)
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Medial Column Procedure Selection
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Flatfoot with Hallux Valgus
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Gastroc Procedure Selection
for Young Athletes
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Location of Scar on Calf
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Gastroc recession or gastroc and
soleus lengthening?
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Surgical Plan 1. Intramuscular gastroc
lengthening
2. Double heel osteotomy
(Evans & Kouts)
3. Cotton osteotomy
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Rearfoot Incisions
• Draw calcaneus and fibula
• Span Sural nerve
• Confirm location of posterior osteotomy before skin incision
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Posterior Incision Down to Bone
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Minimal Periosteal Elevation
• Provided that the incision is properly placed
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Crego Elevator for Dorsal, Medial and
Plantar Periosteal Elevation
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Location of Kouts osteotomy?
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“Posterior” Calcaneal Osteotomy
(vs. Dwyer or Keck and Kelly)
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Posterior Osteotomy
Pearls
• Avoid medial soft tissues
• Mark 3 cm depth on saw
blade
• Perpendicular to the lateral
wall of the calcaneus
• Follow guide pin
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Osteotomy Guide Pin
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90 Degrees to Lateral Wall
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Osteotomy
Guide
Technique
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Medial Displacement
• 1 cm of medial displacement
• Do not elevate or plantarly
displace the posterior
fragment
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Mark Osteotomy to Avoid Elevation
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Stretch Medial Soft Tissues
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Medial Displacement Technique
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Medial Displacement with Joystick
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Does every patient need 1 cm?
• Soft tissue limitations
• Less with Evans?
• Risk of a varus heel?
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Fixation Pearls
• Pin vs. screw fixation
• Orientation of fixation (aim medial to lateral, high and low)
• Stop at the far cortex
• Fixation of double osteotomy
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Start Midline & Aim Lateral
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Fixation Plan Posterior
Osteotomy Only
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Fixation Plan for Combined
Kouts / Evans
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Fixation for
Combination
Kouts / Evans
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Poke Thru, Back up, Insert
Graft, Advance Pins
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Advance Pins to CC Joint
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Screw Fixation (note elevation)
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Location & Angle of
Cotton Osteotomy
(insert guide pin)
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Start with Saw & Finish with Osteotome
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Allograft Wedge
• 7 mm x 22 mm wedge
• Cotton and Evans wedges
from one allograft
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Fixation of Cotton Osteotomy
(2 Threaded 0.062” k-wires)
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Pediatric Cotton Osteotomy
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3 Year Postop
Exam
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Preop and 3 Years Postop
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Preop & 3 Year Postop Lateral
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Can he sprint and play football?
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Three Years
Postop: Captain
of High School
Football Team
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Procedure Selection
in Pre-teen Athlete (AP xray)
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Preop and Postop
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Preop and Postop
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Caution with Isolated Kidner
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Deformity Correction
Along with CN Bar Resection