LESSER DIGITS

I HAMMER
• • •

DIGIT SYNDROME

FLEXOR STABILIZATION (most common) - Due to weak interossei so flexor tendons take over. Occurs in stance phase. Usually with pronation and a hypermobile I" ray. May be a neuropathic foot. FLEXOR SUBSTITUTION (least common) - Due to weak tricep surae muscle so flexors take over. Occurs in stance phase. Usually with supination. EXTENSOR SUBSTITUTION - Due to weak lumbricales so extensors overpower and get a "bowstringing effect." Occurs in swing phase. Usually with a cavus foot.

Mallet Toe = DIP] contracture, HPK on tips of toes, usua1Iy with on toes (esp. 2nd) Claw Toe = Contractures at MP], PIP], and DIP1. Seen with cavus foot or neuromuscular condition. Will see "gun barrel sign" on X-ray. Curly Toe = DIP] contracture with rotation. Congenital HPK on lateral aspect of toes 2-4

I)

ARTHROPLASTY

(post Procedure)

Excise as much HPK as possible using an elliptical cut Large HPK can remain if not excised Cut PP head behind both anatomical and surgical necks. Do Kelikian push-up test. If digit is still contracted, release the following in order until resolved: I. Extensor Tendon Hood 2. MP] Capsule 3. Plantar Hood Fixation: K-wire (not always done) .045 if just into subchondral bone at PP base .062 ifthroughMPJ If no K-wire, suture proximal tendon into capsule plantarly with 2.0 or 3.0 absorbable. Post-op: WB I NWB Sx shoe 2-3 weeks Pin Removal - pins stay in the duration of post-op care, or until they come loose, or until bony healing is seen on X-ray Complications: 1) Flail Toe - Tx = syndacty1ization, implant. fusion 2) Sausage Toe - due to poor technique leading to increased bleeding and fibrosis Tx = acetate steroid and coban wrap 3) White Toe - Tx = a. check bandage b. dangle toe c. reflex heat d. bend K-wire or push proximally e. Lidocaine f. Nitro Patch g. Remove K-wire h. Call for help

II)

ARTHRODESIS

A) End-t~End
Take oITminimal smOUI1.t of cartile be or. both PP head and MP base (to avoid

shortening). Use either a power saw or rasp. Fixate: .04S or .062 B) Digital "V" - Start ofTwith narrow cut and then widen it if you need to. Fixate: .04S or .062
C) Peg-in-Hole

Most stable procedure. Mayor may not use fixation - Remove medial, lateral, and plantar condyles of PP. Keep dorsal cortex intact (plantar cut is more of a backwards scrape with the power saw. Post-op: - NWB BK cast for 6-8 weeks - Sx shoe with 112 in. piano felt to float the toes
A

NEVER II fuse the SIh digit

III)

HEWMA

MOLLE (4th interspace)

- dorsal linear incision lateral to EDL tendon - rasp lateral condyle of base of 4th PP - lateral elliptical incision to expose head of Sth PP for resection (arthroplasty) Post-op: Sx shoe WB 2-3 weeks Comps: flail toe, undercorrection

IV)

DIGITI QUINTI VARUS

- lateral elliptical incision to expose head of SthPP for resection (arthroplasty) Post-op: Sx shoe and sterile dressings about 14 days Comps: flail toe, undercorrection

iJX-'

. \~
\ I '~:.

q<D

3
V)

OVERLAPPING 5TH TOE - All have tenotomy/capsulotomy - Fixate: K-wire pm - Post-op: bandage in PF, Sx shoe 4-6 weeks A) Butler - "Double Racquet" incision - plantar incision is longer that dorsal - Underscore proximal skin in order for more rotation of toe - Release dorsal, plantar, and medial capsule to allow for rotation Comps: vascular compromise

B) Wilson - Dorsal "V - Y" incision - Make V incision over MPJ and pull toe down

TIJ-

Y0
~

A
~

0 C

J.

"

Fig. 20-41. Wilson's technique for correction of overlapping fifth toe. A, Overlapping toe. B, V-shaped incision over fifth metatarsophalangeal joint. C, Sectioning of dorsal tendon and capsule of metatarsophalangeal joint. D, Correction of deformity and suturing of skin.

C) Lapidus

- Make smaIl stab incision at mid-shaft of the Sth met And release EDL - Make lazy S dorsal incision over MPJ, fmd abductor digiti minimi - Pull extensor tendon distally, drill hole in PP base, pull tendon through hole . - attach EDL to tendon of Abd digiti minimi Comps: vascular compromise, undercorreetion

lapidus' technique for correction of overlapping fjfth toe. A, Hockeystick incision over dorsum of fifth toe. A second incision is made over the middl, the shaft of the fifth metatarsal. B, Sectioning of extensor digitorum longus tene:,' .fth toe at second incision. The distal portion is retracted. C, Threading of he.,.c. \:~(ldon through drill hole in proximal phalanx from tibial to fibular side. There it is sutured to the abductor digiti quinti tendon.

D) DuVries

!DuVries' technique for overlapping fifth toe with moderate skin contracture. (For severe skin contracture, see Fig. 20-38, A-C.) A, longitudinal incision made over fourth metatarsal interspace. Tenotomy and a capsulotomy over the fifth metatarsophalangeal joint are then performed. I, Fifth toe plantar flexed to force fibular margin of Incision distally and tibial margin proximally. This forms a fold at each end of the incision. The folds are then excised. C, Incision sutured in new position.

5
LESSER METATARSALS
I) NEUROMA

DlDx: Fx, RA, AVN (Freiburgs), Neuropathy, Bursitislcapsulitis Conservative Tx: Padding, orthoses, NSAIDS, Acetate Steroid ... Anesthesia: PT block as well as at neuromal site Incision: McKeever = dorsal, longitudinal, intermetatarsal that runs up onto either toe - Plantar incision is longitudinal or transverse in the sulcus Procedure: Dissect down to DTML, cut it, dissect out digital branches, then go proximal to good neuronal tissue. Fixate: 4.0 and suture adjacent capsules together (no always done) Post-op: WB Sx shoe 2-3 weeks. (plantar approach is NWB) Comps: Stump neuroma, white toe, hematoma, lIDS if interossei or lumbricales were cut

(
\

ll)

DORSIFLEXORY

OSTEOTOMIES

- For relief ofIPK pain - Linear incision dorsally between the EDL and EDB. Find and free up EDL and EDB in order to retract them Linear capsule incision. Post-op: WB/NWBSx~oe3~weeks Comps: transfer lesions, recurrence, non-union/delayed
A) Jacoby - Dorsiflexory "V"

-- - 0... ......-

.,._

....

- apex distal and arms going lateral and medial. - Bone cut must be proximal to plantar condyles and IPK Fixate: percutaneous .045 K-w .
B) Jimenez

- oblique wedge with cortical binge located plantar proximal Fixate: 2.0 or 2.7 C) "Tilt Up" - Vertical wedge with cortical binge located plantarly Fixate: 2.0 or 2.7 dorsal to plantar D) Straight Vertical - Through and through vertical cut Slide head up Fixate: .045 K-w proximal dorsal to distal plantar
E) Gianaestru

- S~

doW" ,.z:

-1'0 .st,~."

Ill)

TAll-ORIS BUNION

Fallat & Bucholtz

4th 1M

Pathology Lateral Deviation

6.47 2.64 8.71 8.05

BUCKHOLTZ
c

1M

Incision: lateral to EDL - Closing wedges at thebase will decrease the blood supply - Measure the following angles to assess
A) Mini

»zr

Fixate: 2.0 or 2.7 dorsal to plantar B) Chevron (reverse Austin) Fixate: Othosorb pin like Austin

C) Reverse Wilson (Hohmann)

- oblique cut lateral distal to medial proximal, slide capital fragment over Fixate: .062 K-w from proximal shaft into head

D) Wedge (reverse Reverdin)

Fixate: 2.0 or 2.7

E) Exostedomy I Resection
- partial or complete MI'H resection - resection for elderly or with poor bone stock ~: WB I NWB Sx shoe for 3-6 weeks Comps: recurrence, non-union I delayed

SPLI'ITING mE PERPENDICULAR

HA V - (DISTAL PROCEDURES)
GOALSOFHAVSURGERY I) 3)
4) S) 2)

6)

Cosmesis Restore abnonnal osseous angles Congruous III MPJ TSP of 3 or less PF and Shorten IIt ray (decompress joint) Pain free ROM

1M Angle: Less than 14

Skin Incision: Curvalinear following deformity, dorsomedial Capsular Incision: Inverted L, lenticular, ... Bumoectomy: Angled more medially at plantar aspect to avoid the sagittal sulcus (staking) Indications: Evaluate Total 1M (see metatarsus adductus) Procedure: All procedures have bumpectomy and SilverlMcBride Post~p: ROM Exercises I!!
I)

SILVER/McBRIDE
A) Silver 1. resect medial eminence

2. Lateral release a. lateral capsulotomy b. cutDTML c. adductor haIIucis tenotomy d. fibular sesamoid release or drop 3. EHB tenotomy
B) McBride

- Silver plus: a. Adductor Hallucis and Lateral head of FHB transfer to dorsolateral aspect of 1It MTH b. Fibular sesamoidectomy (modified McBride = Silver with fibular tendon release) (Hiss Procedure = Abductor haI1ucis transfer- moved more dorsal and medial on PP) Indications: Bump pain. No DID, No pain on ROM, osseous angles WNL, adjunctive Post-o.o: WB Sx shoe, 2·3 weeks Comps: hallux varus, stiff toe, undercorrection
II)

AUSTIN - corrects 1M, arms of = length, 600 angle • Apex is located at the mid-point of a line drawn that connects the proximal ends of the articular cartilage of the head and = the point of insertion of an axis guide. Axis Guide: .062 K-w (placed in relation to 2nd MT) ~: Cancellous &CreW, or K-w through dorsal shaft, plantar osteotomy, and into capital fragment aiming at the crista. ~: WB / NWB Sx shoe 3-6 weeks

A) Youngswick - will PF, correct 1M, and shorten - resect additional bone from dorsal cut Fixate: same as Austin B) Kalish (long ann Austin) - Angle is SSG Fixate: 2.7 cortical from dorsal distal

C) Gerbert-Massad

kALlS(./..

- corrects PASA and 1M - through and through wedge on the Austin cut with apex lateral Fixate: anything

Ill)

REVERDIN

- distal cut lcm from MIH - Wedge with lateral cortical hinge, corrects PASA Comps: sesamoiditis, DID Fixate: K-w, orthosorb pins, or screws (two point if no cortical binge) Post-op: same as Austin A) Green - Plantar shelf protects sesamoids B) Green-Laird - wedge with through and through cut - corrects 1M and PAS A
C) Green-Laird- Todd

l¥J

- move fragment to PF as well as correct 1M and PASA

IV)

HOHMANN - Original was a trapezoid cut that shortened

- Now it is the same as the Reverdin-Todd except without the plantar shelf Post-op: NWB Sx shoe or cast 4-6 weeks

10
V) WATERMANN
A and B. Original Watennann osteotomy involved dorsally based trapezoidal wedge osteotomy of first metatarsal head and neck

area.

..

..

A} Modified Watermann
" A and B. Modified Watermann osteotomy Integnty of plantar cortex and cartilage. maintaining

A
B) Watermann - Green

A and B. Modified Green-Watennann

procedure

involVE

removal of rectangular-shaped section of bone. Enlarging angle betwe€ dorsal and plantar cuts will result in further plantarflexion of capital fra~ ment for enhanced weight-bearing function.'

HALLUX PROCEDURES
I)

IPJFUSION Indications: *Double Sesamoidectomy (FHB has no stabilizing power and toe floats) with or without Jone's, DID, Hallux varus, Hallux hammertoe, Caws foot, NIM disease, instability Goal: correct structural deformity and restore musculotendinous balance by creating a rigid lever Incision: Elliptical over IPJ for exposure. Procedure: Resect cartilage from joint, wedge PP head pm to correct for Hl Fixate: 4.0 partially threaded or 3.0 cortical with lag teclmique ifbone is soft. us 2 crossed K-w Post-op: BIK, NWB 6-8 weeks Comps: Non/mal-union, mal-position, infection TIBIAL SESAMOIDECTOMY Indications: arthritis, hypertrophied, FHB adducting toe, A VN, Fx Incision: medial approach over MI'-sesamoid articulation Procedure: remove sesamoid, suture MHFHL, intersesamoidalligament, With 3.0 suture Post-op: WB shoe 2-3 weeks

and capsule together

1m

FIBULAR SESAMOIDECTOMY Indications: HA V, Fx, A VN, arthritis, hypertrophy Incisions: plantar or dorsal approach longitudinally lateral to the sesamoid Post-op: Dorsal- WB 2-3 weeks, Plantar - NWB 3 weeks AKIN Fixation: Incision: Post-op: Comps: absorbable pin, K-w .062 (medial dorsal- plantar lateral), screw (cylindrical), wire medial to EHL WB I NWB (cylindrical only) Sx shoe 3-6 weeks Hinge Fx, IPJ stiffness (distal), MPJ stiffness (proximal), cut EHL - corrects DASA - Proximal cut.5 - lern distal to MPJ and parallel to cartilage on base - Distal cut perpendicular to PP shaft
C)DistaI

IV)

A) Proximal

-corrects Hl

D) Cylindrical

1. Type "A" - for a long phalanx - oblique parallel cuts 2. Type "B" -form closing, oblique wedge
V)

KESSELL - BONNEY

Il.

HA V (BASE AND SHAFT PROCEDURES)

SHAFT PROCEDURES A) SCARF ("Z") Procedure: longitudinal incision first. dorsal is 213 the width, Icm from cartilage at both the head and base, dorsal cut is distal and plantar cut is proximal, Angles 45, 60, 70, 80°, can use axis guide for multiplanar correction Modifications: Make a shorter arm, angle can range from 70-90° Fixate: Two 2.7, Two 2.4 Osteomed, Two threaded .062 Comps: Troughing, Stress riser Post op: WB or NWB 3-6w ROM exercises IIII

B) VOGLER OFFSET "V" Procedure: Axis at metaphyseal diaphyseal junction, can use axis guides, dorsal cut first to exit at the basal epicondyle, angle is 40° Fixate: Two 2.7, 3.5, .062, or 5/64 Post op: WB or NWB 6-8w !

C) MAU and LUDLOFF

Fixate: Two 2.7,3.5, K-w Comps: NWB 3-6w Post-op: Troughing, Dorsal displacement

.,A'fAU

ll}

BASE PROCEDURES Comps: Always IIII get 111 MTH elevatus Post op: NWB, BK cast., 6w A) LOISON-BALACESCU Procedure: transverse base wedge with a medial hinge. Cut lcm from MTB cartilage and parallel to MTB cartilage surface Fixate: a) .062 longitudinally through MT shaft and lit cuneiform b) 5/64 medial-distal to lateral-proximal through cut and into 3rd cuneiform

13
B) JUVARA Subtypes A = hinge intact BI = through and through, Bl = through and through, CI = through and through, Cl = through and through,

wedge - correct TP and SP wedge - TP, SP, and lengthen no wedge - SP no wedge - SP and lengthen

Procedure: oblique wedge with hinge medial-proximal and 0.5cm from Mm. Base of wedge is lateral-distal. Proximal cut is 4O-4sO from longitudinal axis for fixation purposes. Distance of cut should be 2X the width of the bone Fixate: a) Proximal Anchor Screw (2.7) - goes in I"', medial to lateral perpendicular to shaft b) Distal Compression Screw (2.7) - perpendicular to cut or split the perpendiculars .

PROXIMAL ANCHOR

DISTAL COMPRESSION

C) LAPIDUS

Indications: hypermobile I"' ray, 1M correction (angulated) - stabilizes medial column to restore the fulcrum for better functioning of the peroneus longus Procedure: fusion of the I"' Mf and I"' cuneiform. If correcting 1M, angulate the cuneiform. Use bone graft pm to lengthen Comps: malposition, bone graft failure, plate open Fixate: Two 4.0 cannulated PT screws, side by side or crossed; Two 5/64 pins crossed; 1/3 or 114tubular plate medially and one 4.0 PT cannulated screw from dorsal-proximal to plantardistal Post on: NWB, BK cast up to 12w or until X-ray healing

D) CRESCENTIC

E) LAMBRINUDI

14

CALCANEAL HYPEROSTOSES

Conservative

Tx

Duration: always attempt for at least 3 months Tx Options: NSAIDS, Orthoses, Injections, Ice, Stretching, Night Splints, ...

I)

"OPEN"

HEEL SPUR (plantar

Spur)

Procedure: DuVries incision medially, dissect down to fascia. cut medial band (and central band T). use osteotome or bone cutters to remove spur Comps: nerve entrapment, continued heel pain, excessive fibrosis Post op: NWB cast, 3-6w

RETROCALCANEALSPUR

Incision: split the achilles tendon or Zadek lateral to the achilles Procedure: remove spur with osteotome (always plantar to dorsal) or rongeur, rasp to smooth Comps: tendonitis, rupture, stress Fx Post op: usually NWB

Ill)

HAGLUND'S

(Pump Bump)

~ 3 Way. to Assess for a Pathological

Haglund'.

1) Philip-Fowler Angle - pathological if> 7So 2) Pavlov's Parallel Pitch Lines - anythiDg above the superior line is pathological 3) Total Angle = FF Angle + CalcaneallDclination Angle - pathological if> 900

15

PAVLOV'.s

.,/'

A) HAGLUND'S

Procedure: Zadek incision on side with bump, free up around achilles, osteotome plantar to dorsal, smooth with rasp Comps: "chasing the bump", Fx, tendonitis, rupture Post op: splint or cast

B) KECK & KELLY Incision: lateral, inferior, and parallel to peroneal tendons Procedure: Dorsiflexory wedge osteotomy with a plantar binge Comps: tendonitis, binge breaks, posterior bone fragment Post op: NWB cast, 6w

I~

METATARSUSADDUCTUS
RESULT

Normal
MUd Moderate Sever

< 15 16 - 24 25 - 34 35 +

< 15 16 -20 21- 24 25 +

EOUASION

[measured] IMT = IMM + (MAA -15) [predicted] HApo = IMpo + MAA Example: 1M = 15, MAA = 25, IMro = 7

= Total M=Measured PO =Post-op

T

Results: 1) IMT = 25° therefore need closing base wedge osteotomy 2) HAro = 7+25 = 32° therefore, moderate bunion to pt (in select cases it is alright to close 1M to a small negative number)

I)

HEYMAN, HERNDON, AND STRONG

(HH&S)

Age: 3-7y/o Incision: a) 3 incision approach - medial to EIll., 2nd interspace, 4thinterspace b) 5 incision approach - difficult to close Procedure: Release all soft tissue and ligamentous structures a LisFranc's joint except 1/3 of the plantar-lateral aspects of the bases of metatarsals 1-4. The 5th metatarsal cuboid joint is left intact for stability. The procedure is designed to refashion the articulations Modification: 2ndmet. osteotomy (Harris) Comps: Pain from shoegear, dislocations, DID, residual deformity, growth plate disturbances, pes valgus defonnity fQn.Qp: NWB, AK cast, 3months - recast every 3-4w to re-abduct foot (pes valgus defonnity can be caused from casting)

BERMAN-GARTLAND

Age: 7-adult (done when growth plate is closed) Procedure: 3 or 5 incision approach. Crescentic osteotomies of all MTB's 1ern distal to articular cartilage. Can use power with curved blade, or hand gouge tool with curved blade Fixate: Originally fixated only 1 and S. Comps: Undercorrection, mal-union or non-union Post op: NWB, BK cast, 6w

III)

LEPIRD Age: 7-adult Incisions: 3 or 5 dorsal incision approach Procedure: 1) MI"s 1 and 5 - closing base wedge with base medial 2) MI"s 2 - 4 - Osteotomy from dorsal-distal to proximal-lateral, leaving lateral cortex intact, angled 45° to the perpendicular of the shaft, proximal portion of osteotomy no closer than lcrn from base. 3) MI"s 1 and 5 - binges are left intact and fixated with one screw 4) MI"s 2 - 4 - One screw in driven into osteotomy and not tightened, lateral cortex is broken and Mrs are moved laterally. Screws are tightened Fixation: 2.0, 2.4, or 2.7 Comps: same as B-G Post op: NWB, BK cast 6w

c
F1gurt: 33.24. Diagrammatic representation of Lepird procedure for correction of rnetetersus adductus. Oblique wedge osteotomies of first and fifth metatarsals are performed with through-,md-through rotational osteotomies of second, third, and fourth metatarsals. If desired, the same osteotomy !MY be employed on fifth metatarsal as well.

IV)

OTHER TYPES

Figure 33.23.

A. Diagrammatic representation of Peabody and Muro procedure. B. McCormick and Blount procedure C. Procedure of Steytler and Van Der Walt. D. Berman and Gartland procedure.

Figure 33.31. A. If medial angulation of the cuneiform is the principal abnormality (deviated LASA), open wedge cuneiform osteotomy may work well. If made at the midpoint, it may be deepened through the second cuneiform without harm to base of the second metatarsal. B. If deformity is fixed and the foot rigid, it may not be possible to gain adequate correction via cuneiform osteotomy alone. Additional correction may be gained by removing a weose of bone from the cuboid. The apex is directed toward the medial cut.

1<1

FLATFOOT SURGERY
I)

ARTHROERESIS (Joint I Lifting) Done to prevent abnonnal valgus motion at the STJ Used with either a Kidner or Y01Ulgprocedure Trephine = tool used to cut out a hole in calcaneus for implant Goals: I) prevent lateral talar process from falling into the calcaneal sulcus 2) increase arch height 3) stabilize STJ thereby stabilizing PL and the medial column as well as decreasing heel valgus Indications: positive family Hx, positive HA V, HOS, ... at an early age, orthotics don't help, night cramps, resultant decrease in activity and/or trips while playing X-ray: increase in Kite's and taIar declination, decreased calcaneal inclination and TNJ articulation < SOO/O Incision: 3 - 4cm Grice incision Procedure (axis altering and direct impact): Cut out deep sinus tarsi plug (Hoke tonsil) and leave attached anteriorly, visualize STJ, square off posterior wall and floor of the anterior calcaneal process, drill hole with trephine. Comps: sinus tarsitis, overcorrection, implant problems (cement), iatrogenic coalition, tendonitis, calcaneal Fx, infection Post op: WB in Sx shoe, 3w; or can cast in a Maxwell cast for 3w TYPES A) SELF-LOCKING WEDGE I) VALENTI (polypropylene) 2) MBA (Maxwell-Brochnau - titanium) Any age Elevates the STJ axis Do not remove Screws into sinus tarsi A) AXIS ALTERING (Sta-Peg) I) SMITH (straight top) 2) LUNDEEN (concave top) Age3-13 May be removed Drilled into calcaneus B) DIRECT IMPACT I) SCARLATO (mushroom) Any age Do not remove

II)

SOFT TISSUE PROCEDURES A) KIDNER *Adj1Ulctive procedure Procedure: resect hypertrophic navicular or remove Os Tibiale Externum. Reposition TP distal and plantar. Can leave TP intact at its insertion and advance a proximal portion. Cmnm: improper procedure (used alone), TP problems f2rum: usually casted depending upon other procedures

B) YOUNG -- Adjunctive procedure Principle: 1) redirect TA insertion so it functionally works at the navicular 2) reinforce plantar arch 3) Stabilize fulcrum for PL by increasing stability at lit ray Incision: from lit met-cuneiform to medial malleolus Procedure: Make keyhole in navicular, leave TA insertion intact and pass through the keyhole. Modification: Split TA and pass only half through keyhole ~: Navicular Fx, tendon problems, subluxation Post QP: NWB, BK cast 6w

un

OSSEOUS PROCEDURES A) MEDIAL COLUMN STABaIZATIONS Age: late teen to adult Indications: long standing flatfoot, faults and DID on X-ray, RF rigid and in valgus, symptoms of TP dysfunction/tendooitis, and sinus "tarsitis. Usually combined with TAL and desmoplasty. Bone graft used pm to prevent shortening Fixate: 6.5, 7.0, 7.3 screws, or staples Comps: mal-union, bone graft failure. Post op: NWB, BK cast up to 12w or until X-ray healing LOWMAN TN fusion 2) HOKE Navicular, lit and 2ndcuneiform fusion 3) MaLER Navicular, lit cuneiform, and lit MTB fusion
1)

B) CALCANEAL OSTEOTOMIES 1) EVANS Indications: ·00 Nor use with flatfoot caused by neurological disorders, Used with unstable WJ which fails to lock up when STJ is in neutral position and FF will be abducted (I'P deformity). Procedure: Lengthens lateral column. Through and through cut I.Scm proximal to CC joint. Insert bone graft wedge. Put STJ in neutral and open wedge until FF locks up. Fixation: optional ~: graft failure, DID, sinus tarsitis, union problems, over/undercorrection Post op: BIL, NWB, BK cast up to 12w SaVER - posterior opening wedge medially J) DWYER - posterior closing wedge medially 4) KOUTSUGIANNIS - arcuarc through aod through posterior with medial transposition
2)

Figure 31.36. Original LO'NrT1an rocedure included Achilles tendon p lengthening, talonavicular arthrodesis, rerouting the tibialis anterior tendon under the navicular and suture to the spring ligament, tenodesis of the medial arch with a slip of the Achilles tendon, which is left attached to calcaneus and folded forward along medial arch, and desmoplasty of the talonavicular ligaments.

Figure 31.37. Original Young procedure included lengthening of the Achilles tendon, rerouting tibialis anterior tendon through a slot in the navicular, and advancement of the tibialis posterior tendon beneath the navicular.

Figure 31.38. Miller procedure involves detachment of a medial 05teoperiosteal flap along the medial arch that is left attached proximally and includes the spring ligament and tibialis posterior tendon insertion. Navicular -first cuneiform and cuneiform-first metatarsal joints are arthrodesed. Osteoperiosteal flap is replaced in an advanced position to tighten the spring ligament and tibialis posterior tendon.

Figure 31.59. Diagram illustrating the effect of the Silver calcaneal osteotomy on weight-bearing forces. Weight-bearing forces in pes valgus deformity pass medial to the foot, reinforcing the valgus attitude of foot. Posterior view of the rearfoot complex demonstrating the effect of a varusproducing calcaneal osteotomy on weight-bearing forces. Note that this only indirectly affects the subtalar joint by redirecting the available range of motion in a direction of inversion.

Figure 31.60.

Calcaneal osteotomy

as described

by Koutsogiannis.

Figure 31.44.

J;..

Hoke fusion

lIS

originelly

figure 31.51. Dwyer calcaneal osteotomy performed lIS ~ medial dosing wedge in ~ large heel. The procedure is ~ commonly performed IS II IaterIII openi~ wedge with bone gRIft

CAVUSFOOTSURGERY

I RUCH

CLASSIFICA nON OF CA VUS FOOT DEFORMlT\'

RUCD I = Flexible cavus Tx: Rigid fusions, MPJ release, Hibbs, Jones, Orthoses RUCD

n = Cavus

becoming rigid - PF lit ray and RF varus

RUCD ill = Rigid (Global) Cavus 67% due to NIM Dz with C-M-T being the most common

I) .

STEINDLER STRIPPING Incision: Du Vries medially Procedure: Adjunctive with a Dwyer and/or FF osteotomies Release plantar fascia, 1It muscle layer, quadratus plantae, and long plantar ligament If pt is young, can do a Dwyer and just cut the plantar fascia Comps: excessive fibrosis, nerve entrapment, myositis, fasciculitis, neuritis Post op: Procedure dependent if adjunctive, usually NWB, BK cast, 6w If done alone, cast FF in OF DWYER Age: usually 10-12 y/o (beware of apophysitis) Indication: RUCH II - Do Coleman Block Test Incision: parallel and inferior to peroneal tendons Procedure: Straight or oblique wedge with base lateral, between the TA and post. facet. The closer the osteotomy is to the STJ, the greater the amount of correction per amount of wedge removed. This will decrease the supinatory forces of the TA on the calcaneus. Fixate: Two staples Comps: non-union, tendonitis, wedge into STJ, DID Post op: NWB, BK or AK, 6w

llI)

JONES

Indication: RUCH I, hallux hammertoe, hallux varus, double sesamoidectomy Procedure: I) EHL cut at insertion and tagged with suture 2) Drill hole through MTH, feed EHL tendon through 3) Reattach tendon to itself with 2.0 or 3.0 non-absorbable 4) Fuse hallux IP] Comps: wrong procedure, rigid PF lit ray, tendon dislocation, not enough tension on EHL
cast,

Post 00: NWB. BK

6w

G~,,~
3,.0
;>'1_."_~o'"b.
1<0

IV)

Indication: RUCH I or II Will decrease the effects of the PL on the lit ray putting the force through the PB to abduct and evert the foot Procedure: 1) PL is left intact and sutured to the PB with 3.0 non-absorbable while the foot is abducted and everted 2) PL is cut, stab incisions are made along the length of the PB and the PL is weaved through. Suture stab ends so they won't tear Comps: Tendon problems, rigid PF lit ray Post op: NWB, BK cast, 4-6w
V)

PERONEAL STOP

STATT (Split Tibialis Anterior Tendon Transposition) Indication: RUCH II, equinovarus, swing phase supinatus, inverters overpowering dorsiflexers Incisions: 1) linear over cuboid and 5th Mf base 2) linear over lit cuneiform and lit MT base 3) linear or transverse incision over dorsum of tibia, 5-7cm proximal to ankle joint Procedure: make a stab incision and divide the TA into medial and lateral halves over tibia Pass and instrument under the skin from the medial incision to the tibia. Place abdominal tape through the stab incision in the T A Grab the tape with the instrument and pull out through the medial incision. This will split the tendon down to the insertion. Detach the lateral half of the tendon from the insertion and pass up and out of the tibial incision. Pass and instrument from the lateral incision to the tibia, grab medial T A and pull back through. Attach to the cuboid or peroneus tertius if present Camps: not enough tension on tendon, cavus too rigid, tendon dislocation Post 00: NWB, BK cast, 6w
1. Suitable Case 5. Proper nming

. 10. AtrBumatic technique

12.

Adequate tension upon fixation

VI)

JAPAS

Indication: RUCH III = end stage cavus, sever NIM Dz Incisions: I) lotcuneiform-navicular 2) 2nd and 3rd cuneiforms-navicular 3) 4th and 5th MTB-cuboid Procedure: through and through "V" cut with apex in navicular, medial ann through lit cuneiform, lateral arm through the cuboid. Plantarflex the distal portion Fixate: Two 7/64 pins Comps: DID Post op: NWB, BK cast, 6w at least
VII)

COLE Indication: RUCH III, sever anterior cavus Incision: three incisions like HH&S Procedure: Dorsiflexory wedge of midtarsus with through and through cut extending from cuboid through all cuneiform-navicular joints. , Fixate: Staples or Steinman pins \ Comps: short, wide, thick foot, DID Post op: NWB, BK cast, 6w at least
" \

c
~
Japas procedure.

Cole procedure for midtarsal osteotomy.

Cole, 19'"'0

Japal,1968

OTBERPROCEDURES
This site can be selected any.vhere on dorsal structures to balance foe (From McGlllmry ED, Kitting, RW:Surgery of the equinus foot. In McGlamry ED ledl. Reconstructive Surgery of the Foot and Leg. Miami, Symposia Specialists, 1974, p 347.)

Tibialis anterior tendon transfer technique. A. Detachment of tibialis anterial tendon. B. Retrieval of tendon through proximal incision. C. Passing of tendon through extensor compartment using retrograde tendon passer. D. Attachment of transferred tendon into third cuneiform.

.'

.,
D

C
Flsurc 30.30.
Dorsiflcxory truncated Nthrodesis of Usfr!Inc's joint.

~7
FI~ 50.36. TIbialis posterior tendon transfer ttvough interosseous membrane (technique 1). A. Detachment of tibialis posterior tendon at medial navicular bone. B. Exposing interosseous membrane and locating SUrrounding structures. C. Retrieving posterior tibial muscle and tendon. Tibialis posterior muscle belly lies immediately beneath interosseous mernbrc!ne. Note location of neurovascular structures. Care must be taken not to detach muscle from its nerve and blood supply. D. Passingposterior tibial tendon distally through extensor compartment beneath retinacula. E. Attachment of tendon into dorsal bony structures.

·Interosseous . membrane

Window through interosseous membrane

Fibula

"

Neurovascular bundle

:/

, ,
\ \

~ ~ ~ ~

\ \

\ \ \

1
0\

FIgure 50.37. Tibialis posterior tendon transfer through interosseous membrane (technique 2). A. ~on of medial foot and leg incisions. I. Dmchmcnt of posterior tibial tendon at Its insertion. Preservation of maxilTUTl 1ef\'3this important. C. Retrievel of posterior tibial muscle and tendon into proximal 'M:XXld using two-hand sponge technique. D. L0cation of incisions on the enterior leg end dorsal foot. E. Tendon is de-

livered ttvough interosseous membrane and passed down extensor cornpartment beneath retinacula. F. A~ of tendon into dorsal osseo structures. Posterior tibial tendon can be split and attached to tibi,: enterior end peroneus tertius tendons, respectively, for more balanced suspension.

Interphalangeal joint arthrodesis Pan metatarsal osteotomies Rigid (Ident deformity) Lisfranc's joint arthrodesis Lesser tarsal Osteotomies Chopart's joint arthrodesis Lesser digital deformity Ha"ux deformity Flexible -----. Double ertbrooess Triple erthrocesis arthrodesis Hibbs suspension

--C

L Interphalangeal

Jones suspension Peroneus longus and tibialis posterior transfer to calcaneus

---+-

Triceps surae weak -----

Anterior group weak

----+--

Ankle equinus (caution) Pan metatarsal osteotomies R'd Igl -{ 1-5 -[ Valgus Anterior cavus Rigid { Flexible ---Jones suspension Pan metatarsal osteotomies Ri id ·bl --[ FIexl e

E -f
--C

STAn PLTI TPn

TAL Gastrocnemius recession Murphy advancement triceps

Iisfrenc's joint

arthrodesis Lesser tarsal osteomies Chopart's joint arthrodesis Peroneal anastomosis PLn DFWO 1 st metatarsal DFWO 1 st cuneiform

~1~1:~~=iS

Frontal plane

Plantarflexed 1st ray

----j

Lisfrenc's joint arthrodesis

-{ Lesser tarsal osteotomies ,.. . Chopart s JOint arthrodesis STAn . Posteromedial [

1-5 Varus

-{
ibl FIeXI e --[

---c

Double arthrodesis Triple arthrodesis

release (see clubfoot)

Cavus foot Transverse plane -{

Rigid

Pan metatarsal osteotomies Triple arthrodeSIS STAn

Flexible

__f

Metatarsocuneiform Abductor

joint release

hallucis release (see metadductus)

Tibialis posterior lengthening Posteromedial release (see clubfoot) Dorsoflexory calcaneal osteotomy .I h ode . Trip e art r SIS (caution)

.II -[ Sagitta p ane

Posterior
ClMJS

T -[ ~Iansverse pane Flexible-------

Posteromedial release (see clubfoot) Triple arthrodesis

(Perspective, ectually anterior ClMJS. See above and foUOIN anterior ClMJS for

management.) Note: Steindler stripping may be a useful adjlXlCtive procedlKe. PlTT, peroneus longus tendon transfer; TPTT,tibialis posterior tendon transFIsurc 10.17. This scheme represents the logic of thousht in the SlM'9ical epproech to idiopathic caws foot SIJIgeIY by plane and level of deformity fer; TAL, tendoAchiliis lengthening; DFWO, dorsiflexorywedge osteotomy. in skeletally mature patient. STATT, Split tibialis anterior tendon transfer;

REARFOOT ARTHRODESIS

Indications;

Comps: Post op:

Stability, DID, pain, trauma, failed implant, end stage flatfoot or caws, SIP infection, RA, AVN Non or mal-union, varus, fuse wrong joint (do diagnostic injection) 1) 2) 3) 4) Drain for 24 - 48 hours, then Posterior splint for up to 2 weeks, then NWB, BK cast for 6 weeks, then WB, BK cast for 6 weeks

I)

ANKLE FUSION

Incision: Kocher, or from behind fibula to the 4th MfB Procedure: Remove at least 2cm of the fibula and retain for bone chips. Take the top off of the talus and tibial plafond Resect medial malleolus pm taking approximately lcm off. Pack all voids with bone chips.
Position Foot At

TP = 5 - 10° externally rotated, or match other limb FP = 5 - 10° of valgus SP = 0° therefore no DP or PF Talus = IOmm post. to tibia - will increase the lever arm and decrease the stress distally Crossed heading down or put both in from talus on lateral side

Fixate: 6.5, 7.0, 7.3 cannulated and up into the tibia

II)

STJ FUSION

Incision: Ollier, or lateral linear (reflect EHB for exposure) Procedure: Resect cartilage from talus and calcaneus using an osteotome, power, or curette. Some only do the posterior facet others take as much cartilage as possible. Pack with bone chips to increase healing and to maintain height Position at SO of valgus Fixate: 6.S, 7.0, 7.3 from dorsal to plantar through the posterior facet, or use staples

Ill)

TRIPLE ARTHRODESIS

Incision: A) Kocker B) Two incision approach I) Curvalinear for STJ and CCJ 2) Dorsomedial for lNJ Procedure: Some do STJ first, others do it last
Fusion Rates = CCJ> ST] > TN]

Fixate: 6.5, 7.0, 7.3, or use staples making sure they don't enter other joints

/-.! . _-

. .:

.'

,",

'\

F
Figure 30.37. Thret-dimensionel visueliZ8tion of triple arthroclesis. A and 8. Anticipeted wedges on laterel view. C and D. Antici~ted wedges on enteroposterior view. E end F. Anticipeted wedges on frontel view.

31

figure 4i.1.

A and B. Triple arthrodesis as described by Ryerson, 1923.

Figure 42.i.

A and B. In the Hoke triple arthrodesis the head and neck of the talus are used as a bone graft.

FJsurc 41.3. A. end B. The lambrinudi stabilization is most effectNe in dealing with a drop foot provided edequate muscles ere aveileble for concooent trilnsrer. When the foot ettempts to p1enterf1ex, the posterior

process of the Ullus serves es e stop ageinst the posterior melleolus of the tibia.

1041

Section 6: Major Arthodesis Procedures

Figure 42.4.

A and B. Brewster countersinking operation.

Figure 42.5.

A and B. Dunn modification.

Figure 41.6.

A iIOd •• Seiffert,

Q(

beak, triple Clrthrodesis.

33

TENSION

BANDING

~: For lateral and medial malleolus, calcaneal Fx, lit MPJ fusion, Sib MI'B Fx Procedure: (not always 28 gage wire) 1) Make hole for wire with K-wire from dorsal to plantar 2) Insert two .062 wires into Fx is a parallel manner leaving Ian ofwire out 3) Twist wire together then thread through hole. Make a figure 8 around the wires with them crossing over the Fx site 4) Twist wire dorsally and sink into hole 5) Bend the K-w down and hammer into the bone

LATERAL

ANKLE STABll.JZATION

PROCEDURES

I) 2)

Watson - Jones
Lee

3) Nilsonne 4) Evans
5)

6) 7) 8)

Christman & Shook Elmslie Hambly Whinfield 9) Kelikian 10) Seeburger 11) Split Peroneus Brevis

1018

Section 5: Compound Deformities

FIgure 40.43. A. Skin incision for delayed primary repair of the lateral collateral ligaments of the ankle. Note the location. of the intermediate dorsal cutaneous and sural nerves at each end of the incision. B. The

calcaneofibular tendons.

ligament can be seen undemeath the retracted peroneal

Figure 40.44.

Diagram of a Watson-Jones lateral ankle ligament repair.

Figure 40.45.

Diagram of a Lee lateral ankle stabilization.

FIsurc 40.46.

Diagramof a Nilsome lateralankle ligament repair.

Figure 40.47.

Diagramof an Evanslateral ankle st&>i1ization.

I
!

Chapter 40: Chronic Ankle Conditions

1019

posterior to anterior through the fibula and sutured to the peroneus brevis and longus tendons distally. A periostealcapsular flap is folded down from the lower fibula to reinforce the reconstruction site (Fig. 40.45). Nilsonne (223) detached the peroneus brevis at the musculotendinous junction, sutured the muscle to peroneus longus, and created a subperiosteal groove in the lateral aspect of the lateral malleolus from posterosuperior to anteroinferior. The calcaneofibular ligament was repaired, and the peroneus brevis tendon was placed within the groove and sutured in place (Fig. 40.46). Evans (246) detached the peroneus brevis tendon from the musculotendinous junction, sutured the muscle belly to peroneus longus, then created a hole in the fibula from the tip of the malleolus exiting posterosuperiorly, The tendon was passed through the tunnel from anterior to posterior and sutured in place. Neither the Evans nor Nilsonne procedures recreate a normal anatomical orientation of the anterior talofibular ligament, but each does supply some stability against inversion (Fig. 40.47). Other procedures have also been reported to recreate the anterior talofibular ligament. These are effective for single ligamentous chronic sprains (247-251). However, in most instances double ligament repairs are required (226). Elmslie (252)· performed his double-ligament repair through a 12-cm incision centered over the peroneus brevis tendon, beginning 5 em proximal to the tip of the lateral malleolus and ending midway between the base of the fifth metatarsal and the malleolar tip. The peroneal tendons were retracted inferiorly, and the lateral surfaces of the talus, calcaneus, and lateral malleolus were exposed. A strip of fascia lata was used and placed through an osseous canal in the talar neck from superior to inferior, then through a canal in the fibula from superoanterior to posteroinferior, then through the calcaneus from posterosuperior to anteroinferior. The ends were then sutured on themselves (Fig. 40.48).

Christman and Snook (253) modified Elmslie's procedure by using half of the peroneus brevis tendon. The tendon was left intact at its insertion, passed through the talar neck to the lateral malleolus from anterior to posterior, then sutured to a periosteal flap at the insertion of the calcaneofibular ligament. The remaining tendon end was directed anteriorly and sutured to the peroneus brevis near its insertion (Fig. 40.49). Hambly (254) split the peroneus longus and sutured it to the lateral talar neck, passed the tendon from anterior to posterior through the fibula, and fixated it to the calcaneofibular ligament insertion. Winfield (255) devised a similar procedure but used peroneus brevis (Figs.40.50 and 40.51).

Figure 40.49. zation.

Diagram of a Christman and Shook lateral ankle stabili-

FJsurc
F1S'ft 40.41.
Diagram of an Elmslie double-ligament reconstruction.
CedlXe.

40.50.

Di~ram

of Hambly's lateral ligament reconstructive

pro-

1010

Section 5: Compound Deformities

Kelikian and Kelikian (256) used plantaris tendon to recreate the lateral ligaments. The plantaris insertion is left intact. The tendon is stripped to the proximal calf area and is transected through a small incision. A drill hole is made from the calcaneofibular ligament insertion toward the plantaris, and the tendon is passed from posterior to anterolateral through the calcaneus. The tendon is placed through the fibula from posterior to anterior and then threaded through a drill hole in the talar neck. The remaining tendon is passed through the original hole in the fibula from an-

Figure 40.51. bilization.

Diagram of a Whinfield double-ligament

lateral ankle sta-

terior to posterior and sutured on itself as it exits the calcaneal drill hole (Fig. 40.52). Seeburger (personal communication) used a hemisection of the peroneus longus as free graft to accurately reconstruct the anatomical orientation of the anterior talofibular and calcaneofibular ligaments. The incision begins 12 em proximal to the tip of the lateral malleolus, extends distally just posterior to the malleolus, then anteriorly toward the base of the fifth metatarsal. Occasionally, an ancillary incision is needed just anterior to the lateral malleolus and courses toward the talar head. The incision is deepened to the level of the peroneal tendons and the peroneal retinaculum. Care must be taken to retract the sural nerve and to keep the retinaculum intact. The peroneus longus tendon is identified and the peritenon is incised. The tendon is separated into two halves. Umbilical tape is placed around one half and is used to separate the tendon the length of the incision. The surgeon should measure the length of the tendon needed before obtaining the graft. The tendon is incised at each end to obtain the hemisection graft. The peroneal tendons are retracted inferiorly to expose the insertion of the calcaneofibular ligament into the calcaneus. A trephine hole is made through the cortex that has the same diameter as a small serrated washer. This willallow for countersinking so there willbe no prominence and possible irritation. A trephine hole is then created in the fibula from posteroinferior to anterosuperior, and the plug of bone is saved. A trephine hole is made through the cortex of the lateral talar neck the sizeof the washer at the insertion of the anterior talofibular ligament. The free tendon graft is fixated to the calcaneus with a 4.0-mm cancellous screw and washer. The tendon is then placed through the osseous canal in the fibula from posterior to anterior. The foot is held in dorsiflexion and eversion, and the slack is removed from the tendon. The plug of bone from the fibula is im-

Flsurc 40.51.

A. IIIld B. DiagRImof a Kelildml ankle stabilization.

37
Chapter 40: Chronic Ankle Conditions
1021

planted into the fibular hole. The tendon is then fixated into the lateral talar neck with a screw and washer. Care is taken not to enter the subtalar joint with the screws. The paratenon is repaired and the surgical site is closed in layers. A below-knee cast is applied for 6 to 8 weeks. Weight bearing is allowed 3 to 4 weeks after surgery. Physical therapy is then instituted (Fig. 40.53). A split peroneus brevis lateral ankle stabilization procedure has also been popularized. The tendon is identified and severed from the muscle belly at the proximal aspect

of the incision and freed distally. Approximately one half to two thirds of the peroneus brevis tendon will be used. A subperiosteal channel is created at the talar neck, and the end of the tendon is passed through. The tendon is then passed through a trephine hole from anterior to posterior, and the plug of bone is then replaced in the fibula. The tendon is then passed through a subperiosteal channel into a trephine hole at the calcaneofibular ligament insertion of the calcaneus. The trephine plug isreplaced, and the tendon can be reinforced with sutures (Fig. 40.54).

'-

,
1

i:.:,i

Figure 40.54. Figure 40.53.

The Seeburger lateral ankle stabilization. cedure.

The split peroneus brevis lateral ankle stabilizing pro-

FIgure 40.55.

TII"'r dome frIIc:tures. It.. lIIterlll lesion demonstrIIted on this

stress

inversion radiogrllph. 8. Tomogrem of II ~erallesion.

SYNTHES SCREWS
CORTICAL
SIZE
(mm)
PITCH

SCREWS
CORE SHAFT THREAD HEAD

1.5 2.0 2.7 3.5 SIZE 1.5 2.0 2.7 3.5

0.5 .6 1 1.25
OVERDRILL

1
1.3

1.5

1.9 2.4
UNDERDRILL

2 2.7 3.5
COUNTERSINK

3 4 5 6
TAP

1.5

2 2.7 3.5

1.1 1.5

1.1 1.1

1.5 1.5

2 2.5

2 2

2.7 3.5

CANCELLOUS
SIZE
4.0
(partially

SCREWS
PITCH CORE SHAFf THREAD HEAD

threaded)

4.0
(BUNION)

6.5 SIZE
4.0 4.0 _(BUNION)
THREAD

1.75 1.75 2.75

1.9 1.9 3

2.3 2.3 4.5

4 4 6.5

6 5
8

HOLE

COUNTERSINK

TAP

6.5

2.0/2.5 2.0 3.2

2 2 3.2

3.5/4.0 3.5 6.5

-- HEAD LAND
/

Undersurface of (he head of the screw which comes ill contact with bone

Usually hexagonal which .!Iows for men efficient translation of torque and reduce CAM·QlTT:lifting out of the screw driver rrom the screw bead

only present in cancellous

SHANK
screws

RUNOUT--weakest point in screw

distance

threads, conic.alscrcwi have I IIDIller pilCh than c:oncxlloua ICreWI

!.E!,CH r-

-RAKEANGLE
Thread to lXi~ angle

volue II ..... 10 cIeocribe die ICRW Iizo (I.e. I 2.7mm oc:rcw Iw I 2.7 mim_w IIvud dia_.)

nil

THREAD DIAMETER

~-.....;.o.;

Di.-w
between

of the IC<tN !he thrcadJ

,.. TIP ANGLE

Tip
&0 ..

La

.nate

INCISIONS
DIGITAL INCISIONS

Longitudinal - across creases only when contraction is needed

Curvilinear - gives good exposure at l" and 5 digits and

Lateral, Medial, Transverse,

Longitudinal

- heal nicely

• careful not to cut both dorsal or plantar neurovascular bundles in one digit

DORSAL INCISIONS McKeever - A longitudinal incision used

mainly for neurectomies. Multiple longitudinal incisions must be at least lcm apart to preserve blood supply
Clavton - transverse curvilinear incision across MTH's. Do not use if evidence of

vascularDz

PLANTAR

INCISIONS

HotTman - transverse, curvilinear just distal to

the MTH's. Used for neurectomies. Post op: NWB, 3 weeks

MEDIAL FOOT INCISIONS

Obcr - curvilinear at posterior foot for total

MF and RF exposure.

* Watch For:
medial marginal vein. dorsalis pedis, posterior tibial NV bundle, venous network, inferior band of inferior extensor retinaculum, anterior and posterior tibial tendons. DuVries - oblique at posterior calcaneus. Used for plantar heel spurs

POSTERIOR HEEL INCISION Zadek - curved longitudinal close to posterior heel either lateral or medial to achilles. Central incisions can lead to shoe irritation

TOTAL ANKLE EXPOSURE Cincinnati

1./1

LATERAL FOOT INCISIONS

Kocher - "]" with a loop at the ST] level.

*WatchFor: intermediate and lateral (sural) dorsal cutaneous nerves, lateral marginal vein, lateral tarsal artery, perforating peroneal artery, EDL tendons, peroneal tendons, venous plexus.

Grice - oblique, cwvilinear at level of STJ for exposure of sinus tarsi

Oilier - curvilinear from dorsal ankle crease laterally to posterior STJ facet.