Modified Mckay procedure

Modified Mckay surgery for the surgical treatment of congenital clubfoot. In 1982, Mckay proposed the concept of rotation of the ankle joint in three planes according to the pathological anatomy of the 102 foot surgery, and reported that he designed the posterior, medial and lateral lysis, and obtained Good efficacy. He observed that the congenital clubfoot and the joints were deformed in three planes, namely the sagittal foot drop, the coronal varus in the coronal plane, and the internal rotation of the joint plane. Due to the internal rotation in the horizontal direction, the anterior portion of the calcaneus slides downward to the talus and the neck, while the posterior calcaneus nodules move outward to the iliac crest, and the calcaneus is simultaneously inverted in the coronal plane. The moving contact of the posterior part of the calcaneus to the tibia is caused by the internal rotation of the talus in the horizontal direction. It is not caused by the ptosis of the foot or the varus varus, the internal rotation of the humerus, etc. . The traditional posteromedial lysis only pays attention to the correction of the foot drop, varus and forefoot adduction malformation, while ignoring the internal rotation of the heel joint and the whole foot on the horizontal plane. Therefore, the deformity often remains after surgery. Mckay surgery pays attention to correcting the internal rotation deformity of the horizontal plane of the joint, completely dissociating the joint and its related tissues, and using the interosseous ligament as the axis, the external rotation of the heel joint in the horizontal direction, so that the longitudinal axis of the sole The longitudinal axis of the thigh (prone position, 90° knee flexion) is +10°, and the angle between the inner and outer collaterals and the longitudinal axis of the sole is 85°-90°. The advantage of the modified Mckay procedure is that it not only corrects the sagging, varus, and forefoot deformity of the foot, but also corrects the internal rotation deformity of the lateral plane of the heel. Postoperative appearance, gait is good, no internal "eight" foot deformity. Mckay reported 102 feet with an excellent and good rate of 80%. Treatment of diseases: congenital clubfoot Indication Improved Mckay surgery is available for: 1. The stiff horseshoe is turned over and the deformity is large. 2. When walking, the back of the foot is on the ground, and the heel is turned inward. 3. The tibia is displaced backwards, that is, the angle between the inner and outer sacral line and the second toe of the sole to the tip of the heel is <76° (normally 85° to 90°). 4. After the deformity is corrected, the gait is in the shape of an "eight". 5. The age of surgery is 1 to 4 years old, and the highest is 8 years old. Contraindications 1. "flat-top talus" or long-term cast immobilization caused by joint capsule contracture in front of the ankle joint caused by severe ankle joint flexion. 2. "rocker-bottom deformity" and severe flat feet. 3. The horseshoe is more light and soft. Preoperative preparation Prepare routinely before surgery. Surgical procedure Incision Make a U-shaped transverse incision (cineinnati incision) inside and outside the foot. Starting from the bottom of the first metatarsal, under the tip of the medial malleolus, around the posterior aspect of the calcaneus, and then under the outer malleolus tip, forward to the achilles tendon joint on the lateral side of the foot. Due to the patient's prone position, this transverse incision makes the posterior and medial and lateral release easier, and the entire field is clear. 2. Back side release The small saphenous vein and the sural nerve were preserved slightly outside the incision. After the subcutaneous tissue was cut, the Achilles tendon was separated from the upper and lower axilla, and the Achilles tendon was Z-shaped in the coronal plane, and the posterior and posterior joints were revealed. The joint capsule is cut transversely and the ligament is cut. 3. Lateral release On the lateral side, the thickened humerus supports the ligament, the Achilles tendon ligament and the posterior talus ligament, and the tibiofibular tendon sheath is loosened (the ligaments and tissues tightly pull the calcaneus outward), and the tendon sheath is lifted and exposed. The lateral talus and the lateral ligament and the joint capsule are cut open. For the stiff horseshoe varus, it is also necessary to separate the short extensor tendon tendon, the dorsal ligament ligament and the scapular ligament at the same time, so that the anterior portion of the calcaneus can move outward. 4. Inside release The cleavage ligament was incised, and the posterior tibial neurovascular bundle was exposed and carefully separated, and the neurovascular bundle was separated down to the lateral aspect of the ankle, and the starting point of the short flexor of the toe was cut at the calcaneus nodule. Because the posterior muscle contracture, the tendon is tense, hindering the scaphoid to move forward and outward, so the posterior tibial tendon sheath is cut open in the upper part of the medial malleolus. The Z-shaped extension of the posterior tendon is guided by the distal end of the posterior tibial tendon, which continues to descend downward to the scaphoid and around the scaphoid. Cut the triangular ligament, the dorsal lateral ligament and the sacral ligament (spring ligament), cut the inner, lower, upper and outer sides of the scaphoid sac, and cut the fork ligament at the inner side of the anterior calcaneus. This ligament is often thickened. The calcaneus, the scaphoid and the tibia are tightly pulled together, and the internal rotation of the calcaneus can be corrected by cutting the ligament and cutting the medial talus. 5. Correct the rotational deformity of the affected foot in 3 planes and fix the needle After the incision of the posterior joint capsule, there are still posterior lateral ligament ligament, posterior iliac ligament, deep triangular ligament, contracture flexor longus and flexor longus tendon. When the foot can not be corrected, the posterior ligament can be cut open, but do not cut all the above ligaments to avoid instability of the ankle joint. The flexor longus tendon and the long flexor tendon tend to also need to be prolonged. When correcting the varus of the calcaneus, it can be seen that the inside of the joint is open to the book. Correction of the forefoot adduction requires pushing the scapula back to the front of the talus and returning the talar neck and wedge bone to their normal position. At this time, a Kirschner wire is placed at the back of the talus, and the skin is worn forward through the middle of the talus to the scaphoid joint and the wedge bone, and between the first and second toes of the medial aspect of the forefoot. When placing the needle, the forefoot should be maintained at the correct position, and the needle that pierces the skin should be slowly withdrawn slightly until the tail end is buried in the talar body. At this point, the sagging of the foot, the varus varus, and the adduction of the forefoot can be corrected, but it is necessary to correct the critical inferiority of the lateral plane of the joint. The calcaneus is rotated outward in the horizontal direction. During the rotation, sometimes from the posterior aspect of the heel joint, the posterior medial aspect of the talus protrudes toward the temporal side, hindering the rotation of the calcaneus, and the protruding portion can be removed at this time. Then check the angle between the inner and outer splicing lines and the longitudinal axis of the sole. If it is between 85° and 90°, the horizontal internal rotation can be considered corrected. For children over 1 year old, some of the ligaments from the calcaneus are widened and thickened to hinder the correction of the internal plane rotation of the joint and the joint. If necessary, the interosseous ligament should be cut off to correct the horizontal rotation of the internal rotation. After confirming that the horizontal rotation is corrected, wear two Kirschner wires under the calcaneus to fix the talus (do not penetrate the ankle joint) to maintain the horizontal correction position. 6. Stitching Rinse the wound, completely stop bleeding, suture and cut the extended Achilles tendon, the posterior tibial muscle (or long flexor, long toe flexor), and suture the wound in layers. complication Skin necrosis Occurred in the correction of more severe horseshoe varus deformity, due to skin tension and reluctance to suture the skin. Precautionary measures have been described in the surgical attention points. 2. Joint rigidity The causes are: 1 rough operation, damage to the articular cartilage surface; 2 hemostasis does not occur completely; 3 trauma, scar formation; 4 wound infection; 5 functional exercise is not enough, plaster fixation time is too long. If you can operate carefully, protect articular cartilage, completely stop bleeding, prevent infection, and perform functional exercise early, you can prevent joint rigidity and restore joint function. 3. talus sterile necrosis It is related to excessive peeling of the operation and severe damage to the blood supply to the talus. If the soft tissue attached to the talus is cut off, it will inevitably cause aseptic necrosis of the talus. Intraoperative care should be taken to protect the nutrient vessels from the joint capsule into the talar neck. 4. Malformation is not enough or overcorrected If the intraoperative loosening is not enough or there is a bone fixation deformity, the deformity may be insufficiently corrected and residual deformity. If the surgery is too loose, the position is not well mastered, which can cause excessive correction. Surgical correction or bone surgery should be corrected according to the situation. 5. Ankle instability If the deep ligament of the triangle and the posterior iliac ligament are severed during surgery, ankle instability may occur. Attention should be paid to the protection of the above ligaments. If the instability of the ankle joint seriously affects the function, surgery or joint fixation should be performed again. 6. radial nerve injury During surgery, attention should be paid to protecting and freeing the phrenic nerve to prevent traction injury caused by accidental injury or deformity correction.