Stage II – Lateral Column Lengthening: Who? What? When? Where? Why? AOFAS OLC Advanced Surgical Technique Course San Diego, CA March, 2017 Scott Ellis Hospital for Special Surgery

Goals and Overview The Who? What? When? Where? Why? Questions we should probably ask ourselves for every surgery. Describe surgical technique (briefly): How? Indicate when to perform surgery How to avoid complications Lateral foot overload (overcorrection) Nounion

Who? Who described it? Who does it? Evans: anterior calcaneal calcaneal osteotomy 1975 Calcaneovalgus feet Who does it? 41% of AOFAS in 2003 (Pinney) Perhaps more today? Pediatric Orthopaedic Surgeons more commonly in isolation without heel slide

What? Elongation of lateral side of foot, usually at anterior calcaneus or CC joint. Evans, stepcut, or through CC joint A way to correct forefoot abduction in flatfoot May correct slightly arch or heel valgus

Evans: Where? Opening wedge osteotomy, anterior calcaneus 12 to 15 proximal to cc joint Leave medial cortex?

When? Stage II b deformity Flexible deformity Significant forefoot abduction (>30% uncoverage) Spring ligament compromise (superiomedial) Good eversion potential after medial heel slide

How to Judge the Amount of Lengthening ? ASSESSMENT in OR CRITICAL: avoid stiffness Reduce TN abduction Simulated Fluoro Test passive eversion and stop before feels too tight Trial wedges

Graft Size Between 4 and 8mm Less than 4mm More than 8mm Probably don’t need LCL More than 8mm Risking lateral overload Possible increase in nonunion

Why LCL? Corrects forefoot abduction Takes tension of spring ligament Not solved by heel slide Takes tension of spring ligament

Why not LCL? Nonunion Lateral overload Subtalar subluxation

Other Pearls Use equations to guide amount of correction Slightly overcorrect radiographically heel valgus Slightly undercorrect forefoot abudction radiographically Obsess yourself with eversion potential

Conclusions Important component of stage IIb reconstruction Probably less important than heel alignment Put in appropriate size graft, not too much 4 to 8mm Correction Assess intraop eversion potential Simulated AP fluro correction Preop incongruency angle