Tibia

As determined by the individual situation, an autogenous tricortical bone graft of appropriate size was harvested from the ipsilateral iliac crest. Cancellous bone was harvested with the smallest osteotome possible. A longitudinal dorsal incision was made lateral to the extensor hallucis longus tendon with an interface between the extensor hallucis longus tendon and the dorsalis pedis artery, both of which were retracted correspondingly. The soft tissue was distracted by a lamina spreader to expose the talonavicular and navicular-cuneiform joints. The talonavicular and navicular-cuneiform joints were distracted using a Hintermann distractor over separate K-wires. The articular surfaces were debrided in situ with cartilage shovels to the subchondral bone. A K-wire was used to drill the subchondral sclerotic bone plate into a favaginous condition for fusion. Then bite off the excess osteophyte from the lateral 4-corners. The plantar ligament and plantar soft tissue of the navicular are loosened with a sharp knife, leaving only the insertion point of the posterior tibial tendon. The whole debridement process created a relative space around the navicular bone. Subsequently, a periosteal detacher was pressed against the lateral bony protrusion of the navicular bone to rotate the bone outwards to the original top location. Once the reduction was deemed satisfactory by direct visualization, two to three crossing K-wires were used for temporary fixation. After the demonstration of the corrected medial longitudinal arch on the C-arm, the lateral half of the navicular bone (including the talonavicular and navicular-cuneiform joints involved in the necrotic lesion) was excised using an osteotome to form a broad dorsal trapezoid laterally and a rectangular longitudinal bone bed. And the modified tricortical iliac bone block was inserted into the space between the talus and the cuneiforms. Finally, two hollow lag screws and a dorsal LCP were used to arthrodese the talonavicular-cuneiform joints. A transverse Herbert screw was used (where needed) to fix the bone block and medial navicular bone. The wound was closed after packing the previously acquired cancellous bone to smooth the defect gaps.
Postoperatively, a protective non-weight bearing short-leg plaster cast was applied for 6 weeks, after which weight-bearing was gradually allowed as tolerated.