1. Minimally Invasive Soft Tissue Release of Foot and Ankle Contracture Secondary to Stroke 
Troy J. Boffeli, DPM, FACFAS, Rachel C. Collier, DPM, AACFAS 
The Journal of Foot and Ankle Surgery 
Volume 53, Issue 3, Pages (May 2014)
DOI: /j.jfas
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions

2. Fig. 1
Preoperative planning. Biomechanical examination of stroke-related contracture and deformity. A biomechanical examination is helpful to determine the extent of spasticity and the reducibility of the equinovarus deformity. Several patients are shown to demonstrate the typical preoperative findings. (A) Inverted varus foot position associated with posterior tibial tendon contracture. Note, how this causes prominence of the lateral border of the foot. (B) Rigid plantarflexion deformity due to contracture of the posterior muscle group. (C) Claw toe deformity that is accentuated when standing. This toe position commonly results in pressure sores and pain at the tips of the toes.
The Journal of Foot and Ankle Surgery  , DOI: ( /j.jfas )
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions

3. Fig. 2
Preoperative planning. Soft tissue examination. A soft tissue examination for pressure irritation or sores is an important aspect of the preoperative examination. The presence of open wounds can further heighten the desire for surgical intervention or can delay surgery because of concerns for infection. Common locations for pressure sores include the lateral malleolus, lateral head of the talus (A, arrow), fifth metatarsal head or base, and the distal tip of the toes (B, arrow).
The Journal of Foot and Ankle Surgery  , DOI: ( /j.jfas )
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions

4. Fig. 3
Triple hemisection tendoachilles lengthening. (A) Incision planning follows the standard minimal incision technique, with the distal and proximal incisions located medially. The patient is placed supine with the leg elevated. (B) The foot is held in dorsiflexion during the procedure. (C) Note, improved ankle dorsiflexion after triple hemisection tendoachilles lengthening.
The Journal of Foot and Ankle Surgery  , DOI: ( /j.jfas )
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions

5. Fig. 4
Z Lengthening of the posterior tibial tendon. (A) Open posterior tibial tendon Z lengthening performed through an incision centered over the posterior tibial tendon from the tip of the medial malleolus to the navicular tuberosity. This location allows safe and easy acess to the tendon and provides adequate exposure for slide lengthening. A malleable retractor is placed under the tendon to provide a stable surface to incise the tendon. (B) Fifty percent of the tendon width is cut both distally and proximally to create a Z as the tendon is gradually stretched with eversion or pronation of the foot. The tendon is then sutured with a side to side or an end to end anastamosis.
The Journal of Foot and Ankle Surgery  , DOI: ( /j.jfas )
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions

6. Fig. 5
Digital flexor tenotomy of toes 1 to 5. The toe is held in extension to provide tension on the flexor tendons. A transverse “stab” incision is made beneath the proximal interphalangeal joint (blue lines) on toes 2 to 5. The incision on the hallux is located at the mid-proximal phalanx where the long flexor tendon is narrow and easily accessable. Transection of the long and short flexors and proximal interphalangeal joint capsulotomy are performed on the lesser digits. Each toe is then hyperextended to ensure complete release and manually stretch the contracted tissue and adhesions. These small transverse incisions should be the width of a no. 62 blade and are not typically sutured.
The Journal of Foot and Ankle Surgery  , DOI: ( /j.jfas )
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions

7. Fig. 6
Temporary postoperative ankle-foot orthosis modification. A temporary strap can be added to hinged ankle-foot orthoses to provide a dorsiflexion stop to protect the Achilles tendon from overlengthening during the early postoperative healing process. This modified brace can be worn starting 2 weeks postoperatively once the incisions have healed and the sutures have been removed.
The Journal of Foot and Ankle Surgery  , DOI: ( /j.jfas )
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions

8. Fig. 7
Preoperative, 2-week postoperative, and 6-week postoperative clinical photographs contrasting the preoperative and postoperative appearance of the foot position. (A and B) Preoperative photographs showing nonreducible equinovarus deformity and contracture of the foot and ankle. (C and D) Two-week postoperative photographs showing dramatic improvement with surprisingly normal foot appearance and active dorsiflexion at the ankle. (E and F) Six-week postoperative photographs demonstrating maintenance of the corrected position. (F) Maintained active dorsiflexion. Note, tenting of tibialis anterior and extensor tendons under the skin, indicating active dorsiflexion despite no attempt at tendon transfer (arrow).
The Journal of Foot and Ankle Surgery  , DOI: ( /j.jfas )
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions

9. Fig. 8
Preoperative and 6-week postoperative lateral radiographs. (A) Preoperative weightbearing radiographs demonstrating lack of heel purchase (arrow) and increased pressure on fifth metatarsal owing to uncompensated spastic equinovarus deformity. The talus is plantarflexed within the ankle mortise, and the tibia is tilted posteriorly. This foot position causes an unstable gait that led to a fall-related fracture at the neck of the fifth metatarsal. (B) Six-week postoperative weightbearing lateral radiograph demonstrating overall improved foot position with lack of a prominent lateral column. The heel now purchases the ground on stance position, the tibial is in alignment with the weightbearing surface, and the talus position is improved.
The Journal of Foot and Ankle Surgery  , DOI: ( /j.jfas )
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions

10. Fig. 9
Active dorsiflexion and long-term weightbearing photograph. (A) The patient was able to reach neutral position of the ankle with active dorsiflexion. Active dorsiflexion is a common postoperative finding for this patient population, because the condition primarily involves posterior contracture rather than weak anterior muscles. The patient continued to maintain this active dorsiflexion at long-term follow-up. She was able to return to independent living 2 weeks after surgery. (B) Weightbearing photograph at long-term follow-up demonstrating maintenance of active dorsiflexion. She was able to ambulate in her home comfortably without the use of an ankle-foot orthosis. The patient continued to use the ankle-foot orthosis for community ambulation because it provided greater stability. Her foot remained in a supple rectus position at long-term follow-up. The gait examination continued to demonstrate hip circumduction.
The Journal of Foot and Ankle Surgery  , DOI: ( /j.jfas )
Copyright © 2014 American College of Foot and Ankle Surgeons Terms and Conditions