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Circumferential Release: “Cincinati Incision”

- Discussion:
     - circumferential soft-tissue release involving posterior, medial, lateral, and plantar aspects of the foot;
     - its designed particularly to correct the horizontal subtalar rotation of the calcaneus that is associated with congenital club foot;
     - because of this, the posterior aspect of the calcaneus not only is in position of equinus but also is rotated and displaced laterally toward 
          the fibular malleolus;
     - this can be corrected only by freeing it completely, thus correcting abnormal rotation;
     - complete subtalar soft-tissue release must be done as single procedure because postop scarring makes subsequent procedures more difficult;
     - consider release of interosseous talocalcaneal ligament as well as of posterior talofibular ligament in all feet;
     - this incision provides exposure of the subtalar joint and is useful in patients with severe internal rotation deformity of the calcaneus;
     - potential problem with this incision is the tension on the suture line when attmepting to dorsiflex foot to apply the postoperative cast;
     - to avoid this the foot must be placed in mild plantar flexion in immediate post operative cast.
     - make a medial incision 8 to 9 cm long extending from the base of 1st metatarsal to the tendo calcaneus, curving it slightly just inferior to 
         the medial malleolus.
     - expose the and mobilize by careful disection the tendons of tibialis posterior, FDL, and FHL & posterior tibial artery, vein, and nerve;
     - expose the tendo calcaneus;
     - incise the sheaths of the tendons as they are exposed;
     - free posterior tibial neurovascular bundle and retract it posteriorly
     - by continuing incision in sheaths of FDL & FHL, divide master knot of Henry bundle beneath the Navicular;
     - divide calcaneonavicular (spring) ligament and the abnormal origin of the Abductor Hallucis.
     - of the remaining contractures, release the posterior ones first;
     - lengthen tendo calcaneus by Z plasty - detaching medial half of its tendinous insertion on the calcaneus;
     - retract neurovascular bundle and FHL anteriorly & expose posterior aspect of the ankle and subtalar joints;
     - incise the posterior capsule of the ankle joint under direct vision
     - if necessary divide the posterior talofibular ligament.
     - identify the posterior capsule of the subtalar joint and divide this along with the calcaneofibular ligament.
     - retract the neurovascular bundle posteriorly & divide tibiocalcaneal part of deltoid ligament;
     - do this by extending the incision in the posterior capsule of the subtalar joint medially and anteriorly;
          - realease the deep medial structures:
     - retract neurovascular bundle & lengthen by Z plasty tibialis posterior tendon just proximal to the medial malleolus;
     - use its distal end as a retractor of the navicular.
     - mobilize the navicular by opening the talonavicular joint & excising that part of the deltoid ligament that inserts on this bone;
     - incise talonavicular capsule but avoid damaging articular surface;
     - free navicular from tendon attachment to sustenaculum tali & spring ligament & detach spring ligament from sustenaculum tali;
     - evert the foot:
     - release posterior part of the incision and evert the foot;
     - release superficial layer of deltoid ligament from calcaneus posteriorly - under direct vision;
     - do not incise the deep layer of this liagment that extends from body of talus to the medial malleolus because this would cause
          flat foot deformity;
     - only remaining structures to be released are the subtalar ligaments
     - evert the foot and expose the talocalcaneal interosseous ligament, and cut the ligament under direct vision.
     - divide bifurcated (Y) ligament that extends from the calcaneus to lateral border of the navicular and to medial border of cuboid

The cincinnati incision for the split posterior tibial tendon transfer: a technical note.

Complete subtalar release in club feet. Part I--A preliminary report.

Complete subtalar release in club feet. Part II--Comparison with less extensive procedures.

New Concept of and Approach to Clubfoot Treatment. Section I. Principles and Morbid Anatomy

New Concept of and Approach to Clubfoot Treatment. Section II. Correction of the Clubfoot

New Concept of and Approach to Clubfoot Treatment. Section III. Evaluation and Results.