Circumferential Release: "Cincinati Incision" : Wheeless' Textbook of Orthopaedics

- 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