Principles and Management of Pediatric Foot and Ankle Deformities and Malformations by Mosca Vincent S

Author:Mosca, Vincent S.
Language: eng
Format: epub
Publisher: LWW
Published: 2014-05-06T04:00:00+00:00

c. Open Double Cut Slide TAL (Figure 7-14)

i. The advantage of this technique is that there is little risk for overlengthening or complete tenotomy

ii. The disadvantages/risks with this technique are:

• With extensive lengthenings, it may be hard to identify the opposite fibers. Release of additional fibers, even under direct vision, could inadvertently result in complete tenotomy.

• This technique requires an incision that is larger and, therefore, less cosmetic than the incisions used for the mini-open double cut slide TAL and the percutaneous triple-cut technique.

iii. This technique considers and takes advantage of the 90° of internal rotation of the tendon fibers that takes place as they approach their insertion on the calcaneus (Figures 7-15 and 7-16).

iv. Use a standard lower limb prep and drape with the patient in the supine position

v. Make a 5- to 7-cm longitudinal incision anteromedial to the tendo-Achilles in the concavity between the tendo-Achilles and the posterior edge of the tibia. Never make the incision directly posterior where the shoe counter will later rub and cause irritation. Directly posterior incisions also tend to be uncosmetic, as they often heal thick and wide (Figure 7-17).

vi. Incise the anteromedial aspect of the tendon sheath from proximal to distal

vii. Avoid disruption of the posterior tendon sheath and subcutaneous fat. By so doing, there will be less adherence of the tendon to the skin.

viii. Divide the plantaris tendon distally—if an inadvertent tenotomy occurs, the plantaris can be used as an intercalary graft

ix. Insert a #15 scalpel into the tendon from posterior to anterior with the face of the blade in line with the direction of the tendon fibers and in the sagittal midline of the tendon immediately proximal to the insertion on the calcaneus

x. Insert the scalpel through the tendon to the presumed thickness of the tendon (at least 1 cm), turn it 90° medially, and cut the medial half of the fibers by translating the blade in that direction

xi. Insert a #15 scalpel into the tendon from medial to lateral with the face of the blade in line with the direction of the tendon fibers and in the midcoronal plane of the tendon approximately 4 to 6 cm more proximal than the first cut

xii. Insert the scalpel through the tendon, turn it 90° posteriorly, and cut the posterior half of the fibers by translating the blade in that direction

xiii. With the knee extended and the subtalar joint in neutral alignment, dorsiflex the ankle to approximately 10°. There should be a sudden release of tension to allow the ankle to dorsiflex, and also a sense of resistance to excessive dorsiflexion. The overlapping halves of the tendon should maintain side-to-side contact even with lengthenings of 3 to 4 cm or more. Reinforcing sutures are rarely required.

• Perform the Thompson test, by squeezing the calf musculature and watching the ankle plantar flex, to confirm maintenance of musculotendinous continuity

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