PMC10051030_01
Preoperative marking and plain radiograph. Note the presence of sacral dimple prior to surgery but no abnormality seen from x-ray.
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The patient could not extend his knee as the popliteal pterygium caused a 90  rigid knee-flexion contracture (Figure 1).
Comparison of the right and left CT-Scan of the lower extremities, showing normal anatomical location and shape of the left popliteal artery (left image). Intra operative short sciatic nerve (right image).
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Surgical intervention was planned after an angiographic CT scan revealed that there were no vascular disturbances (Figure 2). After meticulous dissection, a tight sciatic nerve was encountered (Figure 2).
Fascicular shifting methods.
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The sciatic trunk was exposed at the popliteal level, and an 8-cm fascicular segment was excised from the distal stump and sutured to the proximal stump using 10/0 non-absorbable thread under an operating microscope (Zeiss) (Figure 3).
PMC10051030_02
One-month post-operative evaluation. Surgical wound healed without any complications. Additional 40  knee extension was noticed. The patient was able to stand by the outer side of his left foot. Compared to the healthy side, smaller diameter and shorter length of the left limb hint implied a more severe anomaly in this patient.
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The patient was closely monitored for soft tissue healing and no post-operative complication nor adverse events were reported (Figure 4).
PMC10051030_03
Fourteen-months post-operative ROM evaluation. Range of motion of the knee was 25 -140 . Ankle was in equinovarus position.
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Moreover, the left foot was still in extreme plantar flexion and knee flexion contracture remained at 30  (Figure 5).
Second stage procedure. Achilles tendon lengthening, FHL Lengthening, Soleus Lengthening, release posterior capsule, and release medial plantar fascia were performed to correct foot deformity. Slight persistence of equinus is observed which may proceed to rocker bottom deformity. A long leg cast applied post-operatively.
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Achilles tendon, FHL lengthening, soleus lengthening, release of posterior capsule and release of medial plantar fascia performed simultaneously (Figure 6). A long-leg cast was applied post-operatively to maintain the 90  dorsiflexion that had been achieved through the procedures (Figure 7).
Post-operative long leg cast application.
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Achilles tendon, FHL lengthening, soleus lengthening, release of posterior capsule and release of medial plantar fascia performed simultaneously (Figure 6). A long-leg cast was applied post-operatively to maintain the 90  dorsiflexion that had been achieved through the procedures (Figure 7).
PMC10051030_04
The result after one month after cast removal used in the 2nd-staged procedure with both feet in a plantigrade position inside the Knee-Ankle Foot Orthoses (KAFO) to aid his gait in performing activities of daily life.
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The ability to reach a plantigrade position was necessary for the patient to stand with both legs (Figure 8).