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"Obvious tip is to make sure you get the distractor down to the bone, so there is little lever arm as possible to prevent distortion of the k-wires/pins."
Dr. Greg Graglia
Rock River Foot & Ankle Clinics
Watertown, WI
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"The biggest pins [2.0mm Steinman pins ]seem to work best [for the Evans procedure] and to keep the distractor near the site to avoid bending the pins."
Dr. Randy Rhodes
Intermountain Salt Lake Clinic
Salt Lake City, UT
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"Apply the device during a calcaneal slide procedure and have it secure with no risk of popping off."
Dr. Benjamin Marble
Pueblo Ankle and Foot Care, PLLC
Pueblo, CO
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Surgical Pearls to Decrease Non-Union in the Lapidus Procedure for the Correction of Large Unstable Bunion Deformity
The Lapidus Procedure has certainly undergone a resurgence in popularity in recent years for the correction of severe and unstable bunion deformities. Although fusion of the first met cuneiform joint can afford the surgeon the ability to easily correct a large bunion deformity or one with a component of first ray instability, it is critical that adequate joint preparation is performed in order to achieve a successful result.
The most difficult part about this procedure is gaining access to the plantar aspect of the joint. Because of the depth and kidney bean-shaped curvature of the first metatarsocuneiform joint, it can be very challenging to reach the plantar-most section of the articular surface.
The easiest way to open the fully joint the open and access the plantarlateral corner of the first met cuneiform joint is to use two k-wires applied on either side of the joint. Simply place one k-wire in the body of the medial cuneiform and one in the base of the first metatarsal.
The Tarsal Joint Distractor can then be placed over these k-wires and used to retract the first metatarsocuneiform joint. Now by simply cranking the Tarsal Joint Distractor open, you have clear stable access the the articular surfaces.
With the first met-cuneiform joint held open in this retracted position, you may then perform your joint preparation. If you prefer the curettage technique, you can of course curette all of the cartilage away. You may also use a burr, osteotome or powered sagital saw in order to remove the cartilage from the joint.
Additional subchondral drilling, fenestration or fish-scaling of the joint may alsoe be performed while the joint is held in this retracted position.
The key here is take make certain that the plantar-lateral corner of the first metcuneiform joint has been adequately prepared for fusion. By using the Tarsal Distractor it will be much easier for you to see all the way to the plantar aspect of the joint and assess your fusion site for complete preparation.
Now that you have fully denuded the cartilage and prepared the joint for fusion, you can use the Tarsal Joint Distractor to close down the joint. As you close the joint, you can also rotate the distractor to fin-tune the alignment of your fusion site and ensure that you maintain the ideal positioning to reduce the first intermetatarsal angle and correct the bunion.
Having achieved the desired alignment, you can further compress the fusion site with the Tarsal Joint Distractor. By doing so, you can use the distractor as a form of temporary fixation. This allows you to place your internal fixation without any loss of correction or compression of the joint.
By making sure that all of the cartilage is removed (especially that plantarlateral corner of the first metatarsal-cuneiform joint) you will help increase your chances for successful fusion and a desirable surgical result for your bunion patient.
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Subtalar Joint Arthrodesis Surgical Tips and Technique (video transcript)
Subtalar arthrodesis can be challenging simply because the joint is difficult to expose. This video highlights the surgical technique and pearls that will help you gain surgical access to the posterior facet in order to perform you joint preparation for hindfoot fusion. The Tarsal Joint Distractor offers superior joint space exposure by distracting the subtalar joint without inserting blades into the joint or blocking surgical access from above.
Whether as treatment for hindfoot arthritis or simply as a component of an adult flatfoot reconstructive surgery, access to the posterior facet is critical. This short video will help you understand how to get the best exposure of the posterior facet of the subtalar joint in order to facilitate fusion. Before we begin, we will discuss three key points.
First you will notice that there are two different sized holes in the arms of the Tarsal Joint Distractor. When distracting the subtalar joint, it is important to use the larger proximal holes with 5/64 (2.0mm) Steinman pins. Using these larger pins will help to facilitate exposure of the joint without risk of damage to the sometimes questionable bone stock of the calcaneus.
The second point relates to pin placement. It is important that you place the distractor all the way down against the bone and then drive the pins through the arms of the distractor and into the lateral process of the talus and then the anterior process of the calcaneus. Many surgeons are tempted to place the pins first, and slide the distractor down onto the pins. However, you will get much better positioning of the distractor if you drive the pins through the distractor (much as you would use a soft tissue guide when drilling).
The third point is that you should bend the k-wires at 90 degrees to keep them out of your way and secure the distractor in position. This will prevent the instrument from migrating up the pins and away from the bones as you expose the joint.
Now we will go through some surgical technique illustrations to demonstrate use.
The next image in the video is anatomic model demonstrating the appropriate position of the Tarsal Joint Distractor in relation to the posterior facet of the subtalar joint. The pins are driven into the anterior process of the calcaneus as well as the lateral process of the talus.
Once you have performed your initial dissection and capsulotomy, place the arms of the distractor flush against the periosteum of the bones on either side of the joint. As we discussed earlier, it is important that the distractor is flush against the bones.
With the instrument held in place, drive a 2.0mm Steinman pin through the hole in the arm of the distractor and into the lateral process of the talus. Use the arms of the distractor as a guide to drive the k-wire into the talus.
Once you have the first pin placed in the lateral process of the talus, the distractor can be open or closed in order to move the second arm into position just inferior to the middle facet of the subtalar joint. You can then drive the second pin into the calcaneus.
The video clip then shows the second pin being driven through the distractor and into the calcaneus on the opposite side of the subtalar joint.
Once the pins have been driven on either side of the subtalar joint, the handle of the Tarsal Joint Distractor is simply rotated to distract and open the joint. Now your joint preparation can be performed. With the joint fully opened, it is easy to access the posterior facet of the subtalar joint in order to denude the cartilage, perform subchondral drilling, or perform joint resection with power instrumentation.
The video then shows multiple angles of posterior facet of the subtalar joint visualization with the Tarsal Joint Distractor in place. You will note the amount of distraction needed to provide sufficient exposure of the posterior facet articular surfaces and prepare them for fusion.
When applied to an anatomic foot model as illustrated in the video, it is easy to appreciate the ideal placement of the superior pin in the lateral process of the talus and the inferior pin in the anterior process of the calcaneus. In addition, you can see the amount of distraction that is afforded with the subtalar joint.
By following these guidelines on use of the Tarsal Joint Distractor, you can certainly expect to have all of the exposure you need to facilitate your next subtalar joint arthrodesis.
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Surgical Tips for Cuboid Articular Exposure (Calcaneocuboid Joint)
Of the many joints in foot surgery, the joints involving the cuboid can be difficult to access. Because of the curved shape of the joint as well as the strong joint supporting structure, the calcaneocuboid joint (CCJ) can be very difficult to retract.
Yet, when a patient is suffering from chronic foot pain or adult flatfoot deformity, the foot and ankle surgeon may need direct visualization of the CCJ. Whether the CC-joint is explored to search for cartilage damage, or for anticipated fusion of an arthritic calcaneo-cuboid joint, or simply as a component of a triple arthrodesis for pes planus correction, the podiatric surgeon must be able to open the joint.
To access the joint, place your incision while carefully avoiding the vulnerable structures than can lead to complication. These include the peroneal tendons, sural nerve, intermediate dorsal cutaneous nerve and communicating branch.
The most difficult part about CCJ exploration is gaining access to the plantar medial aspect of the CC joint. Because of the tight nature and curvature of the first calcaneocuboid joint, it can be very challenging to access the articular surfaces and work within the joint.
The easiest way to open the joint and access the cartilage of the calcaneocuboid joint is to use two k-wires applied on either side of the joint. Simply place one k-wire in the body of the cuboid and one in the anterior process of the calcaneus. The Tarsal Joint Distractor can then be placed over these k-wires and used to retract the calcaneo-cuboid joint. Now, by simply cranking the Tarsal Joint Distractor open, you have clear stable hands-free access the the articular surfaces.
One surgical tip is to hold the distractor against the bone and drive the k-wires through the distractor (using the arms of the instrument as a guide) and into the bone. This will give you better positioning and hence, better exposure of the CC joint.
Depending on the bone quality, you may use either 2.0mm Steinman (in the proximal holes) or 0.062 K-wires (in the distal holes). If the patient’s bone stock appears soft, osteopenic or osteoporotic, you may want to choose the larger pins.
Another surgical pearl is that after the K-wires are driven through the distractor and into the bone, they should been bent at 90 degrees, so that they are parallel with the arms of the Tarsal Joint Distractor. This secures the distractor in position and prevents and migration away from the bone as the joint is retracted.
Now you may simply rotate the handle on the Tarsal Joint Distractor and open the joint.
With the calcaneocuboid joint exposed in this retracted position, you can easily inspect the articular surfaces and begin your joint preparation for arthrodesis. Curettage or power removal the cartilage will be easy with the joint distracted. Subchondral drilling, fenestration and fish scaling of the joint surface can also be performed.
Once you’ve completed your preparation for fusion, you can use the Tarsal Joint Distractor to close and compress the joint. As you close the joint, you can also rotate the distractor to fine-tune the alignment of your fusion site and ensure that you maintain the ideal positioning to reduce the calcaneocuboid joint. With the site compressed, you can use the distractor as temporary fixation. This allows you to place your internal fixation without any loss of correction or compression of the joint.
By getting the exposure you need and ensuring that all articular cartilage is removed you will increase your chances for successful arthrodesis and a desirable result.
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more coming soon...
