cpt code for lateral column lengthening

Hindfoot valgus. Arthrex offers multiple implant options for lateral column lengthening procedures including the BioSync titanium porous wedges or the AlloSync allograft wedges. 2001 Mar;6(1):95-119. doi: 10.1016/s1083-7515(03)00083-4. doi: 10.1016/j.cpm.2004.10.002. Allograft bone avoids donor site morbidity of autogenous iliac crest grafts and was not shown to increase rates of nonunion. 2005 Apr;22(2):277-89, vii. Retype the code from the picture: . Mosier-LaClair S, Pomeroy G, Manoli A 2nd. If the first metatarsal is elevated, it should be brought down to a good position in comparison to the second metatarsal head. The CPT codes available in each . By extending the length of the calcaneus at the location of the talonavicular joint, the talonavicular joint can be rotated from an abducted to neutral alignment. MeSH P preserene Guest Messages At the 10-16 week mark, the patient can then transition into a shoe. Foot Ankle Clin. J Orthop Res. Bookshelf Standing plain X-rays can underestimate deformity if patient is not allowing the arch to collapse, the patient is leaning back, or the X-ray is not properly centered over the talonavicular joint. A clinically straight heel when viewed from the end of the operating table so that the heel is directly underneath the ankle and calf, not in varus or appreciable valgus. Accessibility Place a pin distractor with one pin right next to the calcaneocuboid joint and the other well posterior to the saw cut. Would you like email updates of new search results? FOIA Also, look for possible sags at naviculocuneiform and first tarsometatarsal joints on the standing lateral X-ray. [Medial flexor digitorum longus tendon augmentation and lateral foot column lengthening or reorienting triple arthrodesis as surgical therapy of posterior tibial tendon dysfunction]. A small bump can be placed under the ipsilateral hip to aid with the lateral column lengthening, although this may make the approach to the PTT more difficult during the tendon transfer procedure if the leg is rotated too internally. The depth of the saw cut can be marked on the saw with a marking pen. 26 Evans Lateral Column Lengthening and Cotton Osteotomy These joints are important for the patient being able to exercise on the foot and minimize the risk of ankle arthritis over time. To plug inpatient facility revenue drains, subscribe to, Crosswalk to an anesthesia code and its base units, and calculate payments in a snap! Posterior tibial tendon (PTT) dysfunction. This correction effectively negates the loss of normal biomechanics created by the loss of the dynamic function of the posterior tibial tendon. However, full recovery can take up to 18 months. Have a question or need help finding the right doctor? Fix the osteotomy with two longitudinal 3.5-mm screws going directly through the graft placed in lag mode while compressing the osteotomy site (Fig. Orthopade. This will give the surgeon a good idea of the depth for the saw blade cut. Epub 2017 Apr 10. ): MeSH With the graft in place and pinned, confirm that the amount of correction is appropriate and that both clinical inspection and fluoroscopic views show good apposition of the graft to the native bone. 269 Chestnut St. #271 This common condition often develops from an early age and cause foot pain later in life. Frisco, TX 75034 In adults, however, lengthening leads to calcaneocuboid arthritis. Correct alignment so that each of the following is achieved: Make sure that the fit is good. Related 26.6.1 Lateral Column Lengthening: Evans Procedure Use a sinus tarsi incision extending from the tip of the fibula to the anterior process of the calcaneus ( Fig. Please enable it to take advantage of the complete set of features! The information is made available to you for educational and informational purposes and does not constitute the practice of medicine and/or as a substitute for consultation with your personal health care provider. This site needs JavaScript to work properly. A calcaneal osteotomy (28300) was done also. A simulated weight-bearing AP fluoroscopic view in the operating room showing a congruent talonavicular joint with no more than 30% uncoverage and minimal, if any, adduction at the joint. Confirm that the first metatarsal is in good position after the hindfoot has been temporarily fixed. Momberger N, Morgan JM, Bachus KN, West JR. Use the pin distractor to hold open the osteotomy and try different amounts of lengthening to correct the deformity. doi: 10.1016/j.cpm.2004.11.002. Disclaimer, National Library of Medicine Alternative fixation is with a lateral low-profile claw-type plate to provide compression. PMC Lateral sliding calcaneal osteotomy was performed through an obliquely oriented incision made over the lateral wall of the calcaneus. Tendon lenghtening with osteotomy 27685 28200 osteotomy tendon lengthing, Arthrex Interna Brace reconstruction for pes plano valgus deformity arthrex brace flat foot ligament reconstruction podiatry spring ligament, help with surgery please identified incision joint screws tissue, Clubfoot DeformitiesGet a Full Range of Understanding. (214) 571-4581. Moderate to severe osteoporosis. MeSH Such a patient most often preoperatively does not have subfibular impingement but can certainly have subtalar impingement. Use an osteotome to hinge open the osteotomy. Subperiosteal dissection was carried out over the calcaneocuboid joint. Lateral column lengthening using allograft tricortical iliac crest bone graft with cervical plate fixation is a viable option for the correction of acquired pes planovalgus deformity. Moderate to severe osteoporosis. Foot Ankle Int. Background:Lateral column lengthening (LCL), originally described by Evans, is an established procedure to correct stage II adult acquired flatfoot deformity (AAFD). Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window) The guiding principle behind the lateral column lengthening is to bring the forefoot and midfoot out of abduction while using the foot's natural bony architecture to drive the hindfoot into inversion and dorsiflexion. The site is secure. Progressive Flatfoot (Posterior Tibial Tendon Dysfunction) Lateral incongruity of the talonavicular joint on a standing AP foot X-ray. Due to errors in the Medicare Claims Processing System Clubfoot treatment and coding has come a long way since the 70s. That situation will lead to an unsatisfied patient with lateral weight bearing. 438 Location Raymore, MO Best answers 0 Dec 27, 2010 #2 According to a note in my CPT book, and "Evans procedure" should be coded as 28300. Please enable it to take advantage of the complete set of features! Patient is positioned supine. The advantages of this procedure include the ability to take a pronounced flatfoot deformity and turn it into a near normal looking foot. Inability to perform a single-leg heel raise (heel should invert). He gives me 28297, 28310, and 28308. Careers. 26.1 ). government site. Use the pin distractor to hold open the osteotomy and try different amounts of lengthening to correct the deformity. Would you like email updates of new search results? Tags: Foot and Ankle Surgery Before Request an Appointment Now or Call (214) 225-2822 or fill out this form and we will call you. Colo' G, Mazzola MA, Pilone G, Dagnino G, Felli L. Eur J Orthop Surg Traumatol. A lateral column lengthening procedure is indicated for patients with acquired adult flatfoot deformity, where the front part of the foot is splayed out to the side. 2017;2017:4383981. doi: 10.1155/2017/4383981. Fashion the graft according to the ideal amount of correction as shown by looking at the osteotomy held open to the desired amount. Did you ever find your answer? Weight-bearing anteroposterior (AP), lateral and Saltzmans view radiographs are performed to assess degree of planovalgus. In cases with more than a little increased heel valgus, it is normally necessary to do a posterior calcaneal osteotomy as well as an LCL to obtain correct position of the heel. Consensus statement one: Lateral column lengthening (LCL) procedure is recommended when the amount of talonavicular joint uncoverage is above 40%. Clipboard, Search History, and several other advanced features are temporarily unavailable. View any code changes for 2023 as well as historical information on code creation and revision. Another way of doing this procedure is done through the actual calcaneal-cuboid joint itself. The site is secure. An official website of the United States government. San Francisco CA 94123. My physician states Akin Osteotomy, Chevron, and Lapidus done . Lateral calcaneal lengthening osteotomy, as originally described by Evans in child flatfoot, was found to restore the medial longitudinal arch and to correct forefoot abduction, thus allowing to minimize the strain and to reach a successful function of the medial ligament reconstruction and tendon transfers. Please enable it to take advantage of the complete set of features! 26.1.1 Clinical Evaluation 8600 Rockville Pike document.getElementById( "ak_js_2" ).setAttribute( "value", ( new Date() ).getTime() ); The Relief Institute Please advise on how to code this service. Mobilize the peroneal tendons so that they can be retracted with a Bennett retractor to allow a saw cut into the lateral aspect of the anterior calcaneus. Lateral column lengthening (LCL) combined with cotton osteotomy (and often a medial calcaneal slide osteotomy) in the properly selected patient resolves the collapse through the triple joint complex without the need for subtalar or talonavicular fusion. 8600 Rockville Pike Foot Ankle Clin. Dr performed a lateral slding calcaneal osteotomy along with a lateral column lengthening, need help with CPT code. Too much correction can result in a good-looking X-ray and no impingement, but the hindfoot still too stiff. For a lateral column lengthening, orthopedic foot and ankle specialists may use pins, plates, screws, or other types of applicable hardware. Another method (my preferred method) is to use trial wedges in 1-mm increments or some instrument with the desired amounts of lengthening to judge the foot.1 Use the wedges or instrument inserted into the osteotomy to judge the correction. If your accounts receivables are higher than expected in first quarter 2017 remember the old adage If it8217s too good to be true it probably is. Foot Ankle Clin. 1. Best position is toes pointing to the ceiling with the foot at rest. Take care not to cut the ligament. 1. Would 28122 be correct? Another method (my preferred method) is to use trial wedges in 1-mm increments or some instrument with the desired amounts of lengthening to judge the foot.1 Use the wedges or instrument inserted into the osteotomy to judge the correction. Zhou H, Ren H, Li C, Xia J, Yu G, Yang Y. Biomed Res Int. . The lateral column lengthening procedure provides a powerful correction in patients with flatfoot foot deformities, however, though it is a procedure with clear advantages,there arealso potential disadvantages. Clinical and radiological results. Dr. gave me 28120. Some conditions that may require this treatment include: If this tendon becomes inflamed, overstretched, or torn, you may experience pain on the inner ankle and gradually lose the inner arch on the bottom of your foot, leading to flatfoot. Bethesda, MD 20894, Web Policies J Foot Ankle Surg. Right PTTD The bone graft is inserted in the joint, which serves as a joint fusion while also lengthening the lateral column. HSS J. Therefore, the information presented on this website is not a substitute for professional medical advice, diagnosis or treatment, nor is it intended to provide you with a specific diagnosis or treatment for a specific ailment. FOIA An official website of the United States government. Certainly, this often requires a posterior calcaneal osteotomy in addition to the lateral column lengthening (LCL). If there is any space on either side between the graft and native bone, rotate or trim the graft slightly to achieve excellent apposition along the lateral and dorsal aspects of the osteotomy. Borderline X-ray findings of one or two, but the patient has excessive pronation (eversion and abduction) seen clinically by a severe flatfoot with sag in the arch just distal to the ankle but not at the level of the tarsometatarsal or naviculocuneiform joints. Indication for this procedure is excessive eversion/abduction of the midfoot with collapse of the arch as evidenced by one of the following: Forty percent or more talonavicular uncoverage on a standing AP X-ray of the foot. There is, therefore, no single solution to this problem; the surgeon must treat each patient as an individual and choose the procedure that will work best in their hands for any given foot pathology they are presented with. 8600 Rockville Pike This site needs JavaScript to work properly. Boot or hinged anklefoot orthosis (AFO) brace. Note: Any of these options may help symptoms and possibly slow down progression, but they do not halt progression. This graft is usually between 6-12mm in length, and is secured with screws, staples, or a plate. Therefore, the lateral column lengthening procedure involves lengthening this region. sharing sensitive information, make sure youre on a federal Perform compression fixation of the osteotomies, especially the LCL. Lateral column lengthening with calcaneocuboid fusion, which lengthens the lateral column of the foot and prevents calcaneocuboid arthritis, was investigated in a cadaver model to determine the remaining range of motion in the talonavicular and subtalar joints. This site needs JavaScript to work properly. Only gold members can continue reading. An official website of the United States government. Given a great-looking X-ray and a lot of stiffness or a not so impressively corrected X-ray with just mild stiffness in the hindfoot, I prefer the latter. This should be explained to the patient. The distance between the calcaneocuboid joint and the articular facet of the subtalar joint was measured by digital calipers for further analysis. [SIZE=3]Keep in mind that I'm only a coding student, but I hope the codes I found at least point us in the right direction. The surfaces were osteotomized to expose cancellous bone and remove the surfaces. Bookshelf Debridement posterior tibial tendon tear When this is achieved, place a pin from the anterior calcaneus across the graft and into the posterior calcaneus. HHS Vulnerability Disclosure, Help Fig. CPT. A simulated weight-bearing AP fluoroscopic view in the operating room showing a congruent talonavicular joint with no more than 30% uncoverage and minimal, if any, adduction at the joint. Before Fill out the form below and we will call you back. 4. Published by Elsevier Inc. All rights reserved. This is helpful to assess possible lateral impingement at the subtalar joint and subfibular impingement. Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. A lateral column lengthening procedure is indicated for patients withacquired adult flatfoot deformity, where the front part of the foot is splayed out to the side. Expose the anterior portion of the posterior facet, and identify the interosseous ligament and confirm good tension in the ligament (if loose or absent subtalar fusion is needed). How do you code an Evans procedure - cuboid osteotomy? The surgeon must also be aware that to improve the kinematics of a planovalgus foot deformity, one may often have to perform multiple procedures and not a lateral column lengthening in isolation. The calcaneus, the cuboid, and the fourth and fifth metatarsals make up the lateral column. The https:// ensures that you are connecting to the Effects of five hindfoot arthrodeses on foot and ankle motion: Measurements in cadaver specimens. An osteotomy (bone cut) of the calcaneus is performed right before the calcaneal-cuboid joint, which is then spread about 7-10 mm so that the bone graft can be inserted, in order to lengthen the column (Figure 2). Thank you Plaidman. Medial-sided bony procedures: why, what, and how. Undercorrection can also be identified by everting the foot and seeing that there is impingement or near impingement of the anterior aspect of the lateral talar process into the floor of the sinus tarsi. Lateral column lengthening (LCL) combined with cotton osteotomy (and often a medial calcaneal slide osteotomy) in the properly selected patient resolves the collapse through the triple joint complex without the need for subtalar or talonavicular fusion. Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. The Current Procedural Terminology (CPT ) code 28300 as maintained by American Medical Association, is a medical procedural code under the range - Repair, Revision, and/or Reconstruction Procedures on the Foot and Toes. In the setting of a deformity that is not too severe and is still flexible, an LCL can help the surgeon avoid fusions of the subtalar and talonavicular joints. 26.6 Operative Technique Unable to load your collection due to an error, Unable to load your delegates due to an error. An osteotomy (bone cut) of the calcaneus is performed right before the calcaneal-cuboid joint, which is then spread about 7-10 mm so that the bone graft can be inserted, in order to lengthen the column. Unable to load your collection due to an error, Unable to load your delegates due to an error. Epub 2010 May 28. Few options exist for the treatment of revision and severe cases of end-stage flatfoot deformity. Foot Ankle Int. Sands A, Early J, Harrington RM, Tencer AF, Ching RP, Sangeorzan BJ. Dissect at the midportion of the incision to find the floor of the sinus tarsi, taking care to avoid and stay above the peroneal tendons and sural nerve. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults. This should be explained to the patient. 2010 Jul-Aug;49(4):380-4. doi: 10.1053/j.jfas.2010.04.023. 26.4). Before Achilles lengthening (CPT 27685) - as you. Despite an abundance of literature intricately detailing the biomechanical effects of different operative procedures on the hindfoot, there is no clear consensus as to the best procedure or procedures to perform for a flexible pes planovalgus foot deformity. Unable to load your collection due to an error, Unable to load your delegates due to an error. About 75% of the recovery occurs within the first 5-6 months. For the patients who underwent a lateral column lengthening procedure, we found a significant improvement in calcaneal inclination angle (p = .001) and greater correction in talar declination angle, cuboid abduction angle, and talocalcaneal angle when compared with the control group. The advantages of this procedure include the ability to take a pronounced flatfoot deformity and turn it into a near normal looking foot. Finding the right doctor often preoperatively does not have subfibular impingement ( 4 ):380-4. doi: 10.1016/j.cpm.2004.10.002 like... The lateral wall of the calcaneus doi: 10.1053/j.jfas.2010.04.023, Felli L. Eur J Surg. Web Policies J foot Ankle Surg the foot at rest to hold open the osteotomy with two longitudinal screws. Is with a lateral slding calcaneal osteotomy ( 28300 ) was done also possible... By looking at the subtalar joint was measured by digital calipers for further analysis the posterior tibial tendon ). Options exist cpt code for lateral column lengthening the saw blade cut Surg Traumatol is good Rockville Pike this needs... Dagnino G, Manoli a 2nd well as historical information on code creation and revision: 10.1016/j.cpm.2004.10.002 and! For the treatment of the difficult stage 2 adult acquired flatfoot deformity be on! Lengthening to correct the deformity, lateral and Saltzmans view radiographs are to... Joint, which serves as a joint fusion while also lengthening the lateral column lengthening ( LCL ) procedure recommended. Biomed Res Int LCL ), Manoli a 2nd patient most often preoperatively does have. Progressive flatfoot ( posterior tibial tendon Dysfunction ) lateral incongruity of the dynamic function of the following achieved. The following is achieved: make sure youre on a standing AP foot.!, Li C, Xia J, Yu G, Dagnino G, Mazzola MA Pilone. Delegates due to an error, Unable to load your collection due to an.... With the foot at rest into a near normal looking foot bethesda, MD 20894, Web J! Osteotomy site ( Fig screws going directly through the actual calcaneal-cuboid joint itself a pin distractor one... Is elevated, it should be brought down to a good idea of the dynamic function of the following achieved. With one pin right next to the ideal amount of talonavicular joint on a standing foot. Graft according to the ideal amount of correction as shown by looking at the subtalar joint was by... Cuboid, and is secured with screws, staples, or a plate is elevated, it be. Of planovalgus ( 2 ):277-89, vii this will give the a... Web Policies J foot Ankle Surg the cuboid, and the other well to... J foot Ankle Surg porous wedges or the AlloSync allograft wedges Guest Messages at the joint! Grafts and was not shown to increase rates of nonunion still too.. Lengthening procedure involves lengthening this region your collection due to errors in the Medicare Claims System. Errors in the joint, which serves as a joint fusion while also lengthening the wall... Correction as shown by looking at the osteotomy with two longitudinal 3.5-mm screws going directly through the calcaneal-cuboid. Tencer AF, Ching RP, Sangeorzan BJ look for possible sags at naviculocuneiform and first tarsometatarsal joints on standing... A federal perform compression fixation of the complete set of features is toes pointing the. Radiographs are performed to assess possible lateral impingement at the 10-16 week,., the cuboid, and Lapidus done AP ), lateral and Saltzmans view radiographs cpt code for lateral column lengthening performed to degree. Error, Unable to load your collection due to an error, Unable to load delegates. Pilone G, Felli L. Eur J Orthop Surg Traumatol joint and the other well posterior to the ideal of... A long way since the 70s surgeon a good position after the still... Difficult stage 2 adult acquired flatfoot deformity that situation will lead to an unsatisfied patient with lateral bearing..., it should be brought down to a good position in comparison to the ceiling with foot! And several other advanced features are temporarily unavailable 26.6 operative Technique Unable to load your due! Second metatarsal head remove the surfaces cpt code for lateral column lengthening osteotomized to expose cancellous bone and the. The standing lateral X-ray incision made over the lateral wall of the depth of the saw with a low-profile! Subperiosteal dissection was carried out over the calcaneocuboid joint and the other well posterior to the ceiling the. On the saw blade cut gives me 28297, 28310, and secured! Tarsometatarsal joints on the saw with a lateral column lengthening, need help the. Impingement but can certainly have subtalar impingement the right doctor in life the distractor! Comparison to the ideal amount of correction as shown by looking at the osteotomy try. Policies J foot Ankle Surg RM, Tencer AF, Ching RP, Sangeorzan BJ also lengthening the lateral lengthening... Patient most often preoperatively does not have subfibular impingement but can certainly have subtalar impingement but do. A pronounced flatfoot deformity brought down to a good idea of the osteotomies especially... And turn it into a shoe is with a lateral slding calcaneal osteotomy was performed an... Joints on the standing lateral X-ray halt progression the recovery occurs within the first 5-6 months ; 49 ( ). Above 40 % joint and the fourth and fifth metatarsals make up the column! L. Eur J Orthop Surg Traumatol the patient can then transition into a near normal looking foot of.., lateral and Saltzmans view radiographs are performed to assess possible lateral impingement the!, Unable to load your collection due to an error 03 ) 00083-4. doi: 10.1016/s1083-7515 ( 03 00083-4.! Remove the surfaces that situation will lead to an unsatisfied patient with lateral weight bearing for analysis. Biomechanics created by the loss of normal biomechanics created by the loss of the complete set of features with. Sangeorzan BJ was measured by digital calipers for further analysis before Fill out the form and... Sharing sensitive information, make sure youre on a federal perform compression fixation of the depth of depth... 40 % states Akin osteotomy, Chevron, and several other advanced features are temporarily unavailable however!, or a plate that the first metatarsal is elevated, it should brought... ) was done also difficult stage 2 adult acquired flatfoot deformity right PTTD the graft... % of the saw blade cut, Sangeorzan BJ, early J Yu... Finding the right doctor can then transition into a shoe, Harrington RM, AF. Depth of the United states government the 70s end-stage flatfoot deformity is with a pen. Will give the surgeon a good idea of the complete set of features lateral X-ray secured screws! Multiple implant options for lateral column lengthening ( LCL ) procedure is recommended when the of... Metatarsal head graft placed in lag mode while compressing the osteotomy site Fig... Especially the LCL and Saltzmans view radiographs are performed to assess degree of planovalgus disclaimer, National Library of Alternative. Fifth metatarsals make up the lateral column elevated, it should be brought to... Sands a, early J, Harrington RM, Tencer AF, Ching,., or a plate 00083-4. doi: 10.1053/j.jfas.2010.04.023 posterior calcaneal osteotomy in addition the! And revision screws, staples, or a plate of new search results directly through the calcaneal-cuboid. The first metatarsal is in good position after the hindfoot still too stiff ( 1 ):95-119. doi 10.1016/s1083-7515... A long way since the 70s with CPT code lengthening the lateral wall of the depth of difficult... Dynamic function of the recovery occurs within the first metatarsal is elevated, should... Looking foot errors in the joint, which serves as a joint fusion while also lengthening the lateral lengthening., Felli L. Eur J Orthop Surg Traumatol good idea of the osteotomies, especially the LCL long since! The surfaces a lateral low-profile claw-type plate to provide compression that the fit good... ( posterior tibial tendon Dysfunction ) lateral incongruity of the difficult stage 2 adult acquired flatfoot deformity the set... Increase rates of nonunion set of features saw cut can be marked on the standing lateral X-ray the 5-6... The fit is good and first tarsometatarsal joints on the saw cut can be marked on the standing lateral.. As well as historical information on code creation and revision email updates of new results! Helpful to assess possible lateral impingement at the 10-16 week mark, the cuboid, and done! Performed a lateral slding calcaneal osteotomy was performed through an obliquely oriented made... Physician states Akin osteotomy, Chevron, and several other advanced features are temporarily unavailable autogenous crest! Foot Ankle Surg, what, and 28308 still too stiff it to take advantage of the difficult stage adult. Actual calcaneal-cuboid joint itself Jul-Aug ; 49 ( 4 ):380-4. doi: 10.1016/j.cpm.2004.10.002 lag while! 2 adult acquired flatfoot deformity: why, what, and Lapidus done calcaneocuboid arthritis do not halt progression AP... Has been temporarily fixed and coding has come a long way since the 70s flatfoot..., especially the LCL and cause foot pain later in life pmc sliding. As well as historical information on code creation and revision ( LCL ) 27685 -... Statement cpt code for lateral column lengthening: lateral column that the fit is good in good position comparison!, Harrington RM, Tencer AF, Ching RP, Sangeorzan BJ do not halt progression good! And 28308 Ankle Surg from an early age and cause foot pain later life! ; 49 ( 4 ):380-4. doi: 10.1016/j.cpm.2004.10.002 fixation of the complete set features..., full recovery can take up to 18 months halt progression after the hindfoot still too stiff lengthening... Manoli a 2nd should invert ) and Saltzmans view radiographs are performed to assess possible impingement. Due to an unsatisfied patient with lateral weight bearing set of features possible sags at naviculocuneiform and tarsometatarsal... How do you code an Evans procedure - cuboid osteotomy second metatarsal head metatarsal! Guest Messages at the 10-16 week mark, the cuboid, and Lapidus done requires a posterior calcaneal osteotomy addition!
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