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Cincinnati Incision Approach for Posterior Ankle and Calcaneal Pathology:

Technique Tip

Article in Foot & Ankle International · January 2011

DOI: 10.3113/FAI.2011.0092 · Source: PubMed

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FOOT & ANKLE INTERNATIONAL
Copyright © 2011 by the American Orthopaedic Foot & Ankle Society
DOI: 10.3113/FAI.2011.0092

Cincinnati Incision Approach for Posterior Ankle and Calcaneal Pathology:

Technique Tip

Zeev Feldbrin, MD1 and Lipkin Alexander, MD1

Ramat Aviv, Israel

Level of Evidence: V, Expert Opinion Beginning in 2000, we have used this incision mainly
for the correction of Haglund’s disease and were very
Key Words: Haglund’s Disease; Achilles; Cincinnati;
satisfied with the operative technique and outcome. As
Transverse
Crawford et al.3 had stated, the transverse incision was based
on a thorough study of the anatomy of the foot, including its
INTRODUCTION neurovascular and lymphatic supply. Furthermore, we used
only a small part of the possible length of this incision so
Haglund’s disease can be approached by various incisions. that only the necessary section of the Achilles tendon and
A review of the literature revealed that the traditional the retrocalcaneal area were exposed. The full incision such
approach recommended currently by most authors2,6,9 used as one required in clubfoot surgery was not needed. This
a longitudinal incision. For years we used the longitudinal transverse incision provided excellent exposure of Haglund’s
incision either laterally or medially or combined, according disease, even the cases in which release and reattachment of
to the primary affected area, which had been determined part of the Achilles was needed were done easily through
by clinical examination. However, we experienced many this approach.
problems with this longitudinal incision as described by
others (Figure 1) including wound breakdown, iatrogenic
SURGICAL TECHNIQUE
nerve injury, hypertrophic scarring and keloid formation. The
heel scars, which form after this incision, were especially The full extent of the incision, described by Crawford
problematic as they often interfered with patient’s ability to et al.3 is not necessary. We use only part of the length
wear shoes. according to the needs of a specific case with the length
There have been sporadic reports of transverse plantar as long as necessary. Crawford et al.3 began the incision
incision used for a calcaneal spur. Carmont and Maffulli1 on the medial aspect of the foot in the region of navicu-
use the Cincinnati incision for treating insertional Achilles locuneiform joint and carried it posteriorly, gently curving
tendinopathy with detachment of the Achilles. Crawford beneath the distal end of the medial malleolus, and then
et al.3 ’s classic article, which popularized the use of the ascending slightly, passed transversely over the Achilles
Cincinnati incision for correction of clubfoot in children, was tendon, approximately at the level of the tibiotalar joint.
the inspiration for the use of this transverse incision for the From here, the incision continued over the lateral malle-
posterior aspect of the ankle (Figure 2). olus until the sinus tarsi. Over the heel, there were three
1
to four transverse skin crests; the incision was made in one
Department of Orthopedics, Wolfson Medical Center, Holon, affiliated with Sackler
Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel. of those skin crests, usually in the first or second-most prox-
No benefits in any form have been received or will be received from a commercial imal one. The skin crests are parallel with the Langer lines
party related directly or indirectly to the subject of this article.
so the incision was hidden in those skin crests. Once they
Corresponding Author: mature they are difficult to identify and avoid the formation
Zeev Feldbrin, MD of unsightly scars. The longitudinal incisions, which cross
Wolfson Medical Center
Orthopaedic Department the Langer lines, may result in formation of wide, ugly scars
6 Arie Sharon (Figure 1B).5
Tel Aviv, 69553 After making the transverse skin incision, we perform a
Israel
E-mail: feldbrin@netvision.net.il longitudinal incision along the border of the Achilles, either
For information on pricings and availability of reprints, call 410-494-4994, x232. laterally or medially or on both sides as needed.

92
Foot & Ankle International/Vol. 32, No. 1/January 2011 CINCINNATI INCISION FOR HAGLUND’S DISEASE 93

Fig. 1: A, Longitudinal incision. B, Longitudinal incision, which sometimes creates ugly scar.

Fig. 2: Transverse incision.

DISCUSSION Fig. 3: Exposure of the Haglund’s tuberosity and bursa.

Exposure of the Achilles for treating Achilles and posterior peroneal artery which supplies this area so there is
retro-Achilles pathology, such as Haglund’s disease, has minimal danger of injuring the artery.4
been traditionally performed using a longitudinal incision From 2000 to 2008, we performed over 40 opera-
(Figure 3).2,6−8 There are some surgeons who use the “L” tions through a transverse Cincinnati incision. Carmont
shaped incision, which is a combination of transverse and and Maffulli,1 who use this transverse incision, detach the
longitudinal incisions. From the cosmetic point of view, the Achilles tendon and then debride the damaged tendon tissue,
vertical, longitudinal incisions are 90 degrees to the skin reattaching the tendon using drill holes in the calcaneus or
crest, and therefore, will likely form unsightly scars.5 Also, with suture anchors. We did not detach the Achilles and
one cannot always get adequate exposure around the Achilles approached the Haglund’s tuberosity and the insertion of the
through a unilateral longitudinal incision, and then, one has tendon from both sides. Using the transverse incision we
to be made on the other side. These longitudinal incisions encountered four superficial wound infections which resolved
can at times cause problematic scars which interfere with with oral antibiotics.
the ability to wear normal shoes. With the longitudinal inci- The transverse incision was described initially for the
sion iatrogenic sural nerve injury is relatively frequent.7 The correction of clubfeet, but it can be used for severe trauma
transverse incision is distal to the perforation zone of the to the posterior aspect of the foot and ankle, tarsal coalition
Copyright © 2011 by the American Orthopaedic Foot & Ankle Society
 94 FELDBRIN AND LIPKIN Foot & Ankle International/Vol. 32, No. 1/January 2011

Fig. 5: Good visualization around the Achilles tendon.

2. Coughlin, MJ; Mann, RA: Surgery of the Foot and Ankle, Mosby, St.
Fig. 4: Hair-line scar after transverse incision. Louis, 1999.
3. Crawford, AH; Marxen, JL; Osterfeld, DL: The Cincinnati incision:
a comprehensive approach for surgical procedures of the foot and ankle
and resection of tumors.3 Crawford et al.3 gives the credit for
in childhood. J Bone Joint Surg Am. 64(9):1355 – 1358, 1982.
this transverse incision to Dr. Nicholas J. Giannestras who 4. Freeman, BJC; Duff, S; Allen, PE; Nickolson, HD; Atkin, RM: The
performed a correction of congenital vertical talus using this extended lateral approach to the hindfoot. Anatomic basis and surgical
incision. implications. J Bone Joint Surg Br. 80(1):139 – 42, 1998. http://dx.doi.
There are several advantages to this incision over the org/10.1302/0301-620X.80B1.7987
5. Gangopadhyay, SG; Packer, G: A comparative study between longi-
longitudinal one. First, from the cosmetic point of view, the
tudinal and T incision for dorsal plating of the distal radius. J of Hand
transverse incision is made parallel to the skin crests. This Surgery. (British and European) 28B(6):568 – 70, 2003. http://dx.doi.
type of incision often generates hair-like scars (Figure 4) org/10.1016/S0266-7681(03)00171-2
which are almost invisible after several months, as compared 6. Kitaoka, HB: The Foot and Ankle, Lippincott Williams & Wilkins,
to much thicker and sometimes ugly, wide scars which Philadelphia, 2002.
7. Johnson, KW; Zalavras, C; Thordarson, DB: Surgical management
remain after a longitudinal one. This transverse incision
of insertional calcific achilles tendinosis with a central tendon splitting
allows the ideal straightforward approach to both sides of the approach. Foot and ankle int. 27(4):245 – 50, 2006.
Achilles tendon (Figure 5), as compared to the longitudinal 8. McGarvey, WC; Palumbo, RC; Baxter, DE; Leibman, BE:
one, which provides good visualization of one side only. Insertional Achilles tendonosis: surgical treatment through a central
Even when doing two longitudinal incisions simultaneously, tendon splitting approach. Foot Ankle Int., 23(1):19 – 25, 2002.
9. Myerson, MS: Foot and Ankle Disorders, Saunders, Philadelphia, 2000.
one cannot approach the tendon itself easily. The sural nerve
10. Self, TC; Kunz, RE; Young, G: Transverse plantar incision for heel
is out of danger with this transverse incision. Using this spur surgery. Four-year follow-up survey of 35 patients. J Am Podiatric
incision we encountered only minor complications. Med Assoc. 83(5):259 – 62, 1993.

REFERENCES

1. Carmont, MR; Maffulli, N: Management of insertional Achilles

tendinopathy through a Cincinnati incision. BMC Musculoskeletal
Disorders, 15(8)82, 2007. http://dx.doi.org/10.1186/1471-2474-8-82

Copyright © 2011 by the American Orthopaedic Foot & Ankle Society

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