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nnDATE OF PROCEDURE: 04/17/20XXnnPREOPERATIVE DIAGNOSIS: Left degenerative peritalar subluxation and deformity with contracted peroneal tendons and attenuated and tom tibialis posterior tendon, gastrocnemius contracture. nnPOSTOPERATIVE DIAGNOSIS: Same.nnPROCEDURE: Left Strayer gastrocnemius resection, subtalar and talonavicular joint arthrodesis, peroneal tendon lengthening, tibialis posterior tendon repair, cotton cuneiform osteotomy.nnSURGEON: K., MD.nnASSISTANT FOR THE CASE: M. nnANESTHESIA: General.nnBLOOD LOSS: Minimal.nnBRIEF HISTORY: The patient had chronic pain secondary to above. This was refractory conservative treatment. This was causing her severe difficulty and pain with her knee. Risks and benefits of the above procedure were explained to the patient at length which included pain, bleeding, infection, stiffness, swelling, nerve injury, nonunion, painful hardware, recurrence of deformity, blood clots, a possible need for further surgery, and complications. Informed consent was obtained.nnDESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the table in supine position. After a popliteal block was performed, general anesthesia was induced. A well-padded thigh tourniquet was applied. She was prepped and draped in the usual sterile fashion.nnEsmarch bandage and tourniquet elevated to 300 mmHg. An incision was made centered over the gastrocnemius aponeurosis posteriorly. Sharp dissection was carried out down to the distal aponeurosis. A linear incision was made. Care was taken to avoid injury to the sural nerve or the small saphenous vein. Excellent correction of the contracture was achieved with dorsiflexion well past neutral with the knee extended. Thorough irrigation was carried out using saline. Subcutaneous was closed using inverted 2-0 Vicryl stitches followed by staples for the skin.nnAttention was then turned to the subtalar joint. An incision was made over the sinus tarsi. Sharp dissection was carried out down to the subtalar joint. The peroneal tendons were identified. Z lengthening of the peroneus longus and brevis tendons were then carried out using a 15 blade. This allowed easier correction of the hindfoot valgus. The subtalar joint was entered. This was held open using a lamina spreader. Joint was prepped by removal of cartilage along with perforation of the subchondral bone, surfaced multiple times using a drill bit and chisel. In a similar manner, an incision was made over the talonavicular joint between the tibialis anterior and tibialis posterior tendon. This joint was exposed using a laminar spreader and the joint was prepped in a similar fashion Severe deformity of this joint was seen in a large bone fragment that was non-united from the navicular was present which was excised. The tibialis posterior tendon was obviously lengthened and attenuated. 3 mL of Trinity Elite graft was then thawed and prepped in the standard fashion. A Wright Medical augment was prepped in the standard fashion as well. The augment was first placed on the bone surfaces of both joints with the joint space then filled with the Trinity Elite graft. The talonavicular joint was then first reduced with con-ection of the forefoot abduction. Good co1Tection of the deformity was achievable. This was provisionally held using a K-wire. Once C-mm confirmed a reasonable reduction of the joint and reasonable clinical foot alignment was felt to be present, a single Paragon 28 4.5 mm partially threaded cannulated screw was then placed over the wire with good reduction and fixation.nnNext, attention was then turned to the subtalar joint. Subtalar joint was reduced with correction of the valgus deformity and held in a reduced position with the assistance of the surgical assistant. Through a small posterior incision, a single Paragon 28 7.0 mm partially threaded headless cannulated screw of appropriate size was then placed with good compression and fixation across the joint achieved and good screw placement confirmed bynnC-a1m.nnNext, a 2-hole compression plate was then applied to further supplement fixation on the talonavicular joint with good fixation achieved. Next, the forefoot varus was assessed. There was a significant forefoot varus still present and therefore the Cotton osteotomy was performed. A separate incision was made with sharp dissection down to the cuneiform bone dorsally. A TPS saw was then utilized to perform the Cotton osteotomy in the mid-portion of the cuneiform bone. An osteotome was then used to complete the osteotomy plantarly. Paragon bone wedge trials were then utilized to determine the appropriate size of the bone wedge to be used. A 5mm bone wedge was felt to be appropriate. This was then placed in saline for 5 minutes. The graft was then inserted with the deformity corrected with the aid of the surgical assistant. The correction of deformity was felt to have been achieved.nnNext, attention was then turned to the tibialis posterior tendon. The tendon was advanced and repaired onto the navicular bone using 2 Arthrex corkscrew anchors. Good fixation was achieved. Good stability of the ankle was present. Good correction of deformity was present. Irrigation of all wounds was carried out using saline. Subcutaneous was closed using inverted 2-0 Vicryl stitches followed by staples for the skin. Wounds were dressed using Xerofo1m, 4 x 4s, cast padding followed by a well-padded plaster splint followed by an Ace wrap.nnThe patient tolerated the procedure well. There were no complications. She was transferred to the recovery room in good condition. M was used for assistance for the case. Their service was essential for safe time for this case as were proper maintenance of alignment of all articulations while arthrodesis and fixation were performed.nn
