Treating An Active Hiker With A Gastroc Recession And A Midfoot Osteotomy

This blog is a follow-up to my last blog on the active hiker with left forefoot pain under the metatarsal heads.¹

As I previously described, the patient had forefoot pain even after multiple attempts at a cavus foot reconstruction.¹ We had exhausted previous non-operative treatments including custom-molded orthoses with a metatarsal pad. Operative management included a calcaneal osteotomy and a midfoot osteotomy. The patient still had exquisite pain under all five metatarsal heads despite these treatments.

The discussion regarding a reduction in forefoot pain centered around the posterior muscle group and “rigid” midfoot. The patient gave consent for a gastrocnemius recession and midfoot osteotomy, or Cole osteotomy.

Typically, I will start proximally with most deformity corrections and release the appropriate muscle groups as necessary. In this case, I lengthened just the gastrocnemius muscle group at the aponeurosis. We then focused on the midfoot.    

When mixed or global cavus is present with the apex of the deformity at the midfoot and the foot is rigid, a midfoot corrective osteotomy is best for acute correction.  

Below is a description of the technique. I urge those residents, fellows and first-timers to perform the dissection on a cadaver prior to performing it on your patient, and get comfortable with the approach.

Make a central midfoot incision centered over the naviculocuneiform joint, just lateral to the neurovascular bundle (see photo 1). Make this 5 cm incision over the extensor digitorum longus and carry dissection down through the extensor hallucis brevis. After subcutaneous dissection, the surgeon should be able to easily visualize the entire naviculocuneiform joint and dorsal cuboid (see photo 2).

Proceed to drive two Steinmann pins from the dorsal navicular and the intermediate cuneiform to the plantar aspect of this joint (see photos 3 and 4). Confirm pin placement on fluoroscopy and adjust as needed. Then use a large sagittal saw to resect a dorsal-based wedge following the pin placement. Take care to excise the appropriate amount from the mid-cuboid. Otherwise, the surgeon will inadvertently create a varus foot type by elongating the lateral column. After removing the wedge, remove the Steinmann pins and close the osteotomy (see photo 5).

Fixation is important with this osteotomy. There is a fair amount of healthy cancellous bone apposition and bone grafting is rarely necessary. We prefer multiple large cannulated screws for fixation. One would typically leave the lateral column unfixed. Reduce the central and medial columns, and insert guide wires from the proximal medial pole of the navicular into the cuneiforms. From distal to proximal, insert two screws from the medial and lateral cuneiform into the navicular. I have found that 5.0 mm headed screws with washers are adequate for rigid fixation. After confirming reduction on fluoroscopy, close the incision in layers with absorbable sutures and your preference for skin closure. 

Again, there are multiple ways to fixate this osteotomy. Other fixation options include staples, external fixation, Steinmann pins and plates.

The patient was non-weightbearing for six weeks and progressed with weightbearing in a controlled ankle motion (CAM) boot until he achieved radiographic and clinical healing (see photos 6, 7 and 8). His forefoot pain significantly reduced and he did not require any custom or non-custom molded foot devices. He returned to his active lifestyle without complications.

Please contact me with questions or concerns.

Reference

1. McAlister JE. How would you treat an active hiker with bilateral foot pain? Podiatry Today DPM Blog. Available at https://www.podiatrytoday.com/blogged/how-would-you-treat-active-hiker-bilateral-foot-pain . Published Jan. 16, 2018.