Easley_CH066.indd

632

Operative Techniques in Foot and Ankle Surgery

T E C H N I Q U E S

B

C

D

TECH FIG 3 ● A. Placement of the K-wires for guidance of the osteotomy. B. Intraoperative ra- diograph showing the guidewires for the tibial osteotomy after the Z-shaped fibula osteotomy. Distal tibia/fibula before ( C ) and after ( D ) closure of the osteotomy. Note the shortening of the fibula.

A

■ Prior to locking the plate both proximal and distal to the oste- otomy, we use a tensioning device to optimally compress the osteotomy. ■ We routinely close the periosteum over the osteotomy with 2-0 absorbable sutures. Optimizing Joint Congruity and Securing the Fibula ■ Fluoroscopically, optimal tibiotalar joint congruity and fibular os- teotomy reduction are determined. ■ Once the joint is congruent, the fibula is secured with screws (in the longitudinal limb of the Z-osteotomy) or a one-third tu- bular plate ( TECH FIG 4 ). ■ The subcutaneous tissues and the skin are closed with inter- rupted sutures. ■ Medial Open Wedge Osteotomy for Correction of Varus Deformity Exposure ■ The limb is exsanguinated and the thigh tourniquet is inflated. ■ The anterior incision is made anteriorly over the distal tibia and ankle, immediately lateral to the tibial crest. The superficial peroneal nerve crosses the distal aspect of the incision and must be protected.

TECH FIG 4 ● Fixation of the fibula with a plate.

■ The extensor retinaculum is then divided longitudinally to ex- pose the extensor tendons. The approach uses the interval be- tween the tibialis anterior and extensor hallucis longus tendons. ■ A longitudinal incision in the extensor retinaculum is made be- tween the anterior tibial tendon and the extensor hallucis longus tendon, starting 10 cm proximal to the joint, about midway be- tween the malleoli ( TECH FIG 5 ). ■ The anterior tibial tendon is retracted medially and the ten- don of the extensor hallucis longus is retracted laterally, if possible, without opening the tendon sheaths.