The calcaneal scarf osteotomy: operative technique

Examination of Safe Zone to Avoid Injury of the Lateral Plantar Artery During Calcaneal Osteotomy: A Fresh Cadaveric Study

BACKGROUND

Calcaneal osteotomy are used to treat various pathologies in the correction of hindfoot deformities. But lateral plantar artery (LPA) pseudoaneurysms have been reported following calcaneal osteotomy, and LPA pseudoaneurysms may be at risk for rupture. Although the vascular structures in close proximity to calcaneal osteotomies have variable courses and branching patterns, there is little information on safe zone for LPA during calcaneal osteotomy. The aims of this study were to identify the safety zone to avoid the LPA injury during calcaneal osteotomy.

METHODS

Enhanced computed tomography scans of 25 fresh cadaveric feet (male, n = 13; female, n = 12; mean age 79.0 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery. Line A is the landmark line and extends from the posterosuperior aspect of the calcaneal tuberosity to the plantar fascia origin, and the perpendicular distance between the LPA and line A at its closest point was measured on sagittal images.

RESULTS

The average perpendicular distance between the LPA and line A at its closest point was 15.2 ± 2.9 mm. In 2 cases (8.0 %), the perpendicular distance between the LPA and line A at its closest point was very close, approximately 9 mm. In 18 of 25 feet (72.0%), the point where perpendicular distance from the line A to LPA is the closest was the bifurcation of one of the medial calcaneal branches from LPA, and in 7 feet in 25 feet (28.0%) feet the point where perpendicular distance from the line A to LPA is the closest was the trifurcation of LPA, medial plantar artery, and one of the medial calcaneal branches.

CONCLUSIONS

Calcaneal osteotomy approximately more than 9 mm from the line A could injure the LPA in overpenetration into the medial aspect of tcalcaneal osteotomy. Completion of the osteotomy on the medial side should be performed with caution to avoid iatrogenic injury of the LPA.

LEVELS OF EVIDENCE:

Level IV, Cadaveric study.

A Modified Extra-articular Lateral Column Lengthening Procedure for Adult Acquired Flatfoot Deformity

BACKGROUND

Lateral column lengthening (LCL), originally described by Evans, is an established procedure to correct stage II adult acquired flatfoot deformity (AAFD). However, the relative position between the facets is violated, and other problems may include nonunion, malunion, and calcaneocuboid (CC) joint subluxation. Herein, we report a modified extra-articular technique of LCL with hockey-stick osteotomy, which preserves the subtalar joint as a whole, increases bony apposition to enhance healing ability, and preserves the insertion of the calcaneofibular ligament to stabilize the posterior fragment to promote adduction of the forefoot.

METHODS

We retrospectively recruited 24 patients (26 feet) with stage II AAFD who underwent extra-articular LCL. The mean age was 55.7 ± 15.7 years, and the mean follow-up period was 33.4 ± 12.1 months. Associated procedures of spring ligament repair/reconstruction and posterior tibial tendon plication or flexor digitorum longus transfer were routinely performed and may also include a Cotton osteotomy, heel cord lengthening, or hallux valgus correction. Clinical and radiographic outcomes at the final follow-up were compared with the preoperative assessments.

RESULTS

All patients achieved calcaneus union within 3 months of operation. The VAS pain score improved from 5.3 ± 0.75 preoperatively to 1.2 ± 0.79 at the final follow-up (P < .001), and the AOFAS Ankle-Hindfoot Scale from 63.5 ± 8.5 to 85.8 ± 4.8 points (P < .001). The radiographic measurements significantly improved in terms of the preoperative vs final angles of 8.9 ± 5.3 vs 15.2 ± 3.6 degrees for calcaneal pitch (P < .001), 20.5 ± 9.2 vs 4.9 ± 4.8 degrees for Meary angle (P < .001), 46.5 ± 5.2 vs 41.9 ± 3.2 degrees for lateral talocalcaneal angle (P < .001), 23.9 ± 8.5 vs 3.9 ± 3.1 degrees for talonavicular coverage angle (P < .001), and 18.2 ± 9.2 vs 7.3 ± 5.0 degrees for talus-first metatarsal angle (P = .002). The CC joint subluxation percentage was 7.0% ± 5.4% preoperatively compared with 8.5% ± 2.4% at the final follow-up (P = .101). No case showed progression of CC joint arthritis or CC joint subluxation (>15% CC joint subluxation percentage). One case showed transient sural nerve territory paresthesia, and 1 had pin tract infection. Three cases had lateral foot pain, which could be relieved by custom insoles.

CONCLUSION

Modified extra-articular LCL as part of AAFD correction is a feasible alternative technique without subtalar joint invasion and may be associated with less CC joint subluxation compared with the Evans osteotomy.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Comparison between Malerba osteotomy and combined Evans/medial displacement calcaneal osteotomies for the management of flexible pes planus in young adults: a prospective randomised control trial, three years follow-up

PURPOSE

The aim of the current study is to evaluate the functional and radiological outcomes of Malerba osteotomy in comparison to the standardized combined Evans/Medial Displacement Calcaneal Osteotomy (MDCO) in the management of symptomatic flexible pes planus in young adults.

METHODS

Prospective randomized control trial included 34 feet (33 patients), 17 cases in each group. Functionally, patients were assessed by AOFAS and FADI scores. Radiographic evaluation included calcaneal pitch, lateral talo-1st metatarsal, AP talo-first metatarsal, AP talo-calcaneal angles, and the talar coverage percentage.

RESULTS

Pre-operative and three years follow-up scores and angles were compared between both groups. No statistically significant difference could be detected between both groups (P value 0.87). However, the data showed statistically significant difference in each group when comparing (pre-operative and third year follow-up scores and angles) (P value < 0.001). The mean union rate was eight weeks in Malerba group and nine weeks in Evans/MDCO group. No incidence of nonunion. Complications like calcaneocuboid subluxation, calcaneal anterior process fracture, and lateral column pain were exclusively reported in Evans/MDCO group.

CONCLUSION

Malerba osteotomy is a strong valid option for the operative management of flexible pes planus in young adults. Authors recommend Malerba osteotomy in all mild and moderate deformities due to lower complication rate while the combined Evans/MDCO is preferred in severe deformity due to relatively higher corrective power with consideration of possible complications.

Effects of Medial Displacement Calcaneal Osteotomy and Calcaneal Z Osteotomy on Subtalar Joint Pressures: A Cadaveric Flatfoot Model

Medial displacement calcaneal osteotomies have been shown to be successful in the surgical management of adult acquired flatfoot, in particular, stage 2 deformity. Classically, the medial displacement calcaneal osteotomy technique has been performed. However, a calcaneal Z osteotomy has been more recently described and applied in the surgical management of flatfoot deformity. Although the potential advantages of the calcaneal Z technique have been reported, data on its effect on the subtalar joint are lacking. A validated flatfoot model was induced in 8 cadaveric feet that had been randomly assigned to either medial displacement calcaneal osteotomy (n = 4) or calcaneal Z osteotomy (n = 4). The feet were loaded through the tibia with a constant ground reaction force of 400 N, with a simultaneous increase in the Achilles tendon force to 300 or 500 N. The subtalar joint pressures were recorded before and after osteotomy. We did not detect any statistically significant differences between the 2 techniques in terms of their effects on subtalar joint pressure.

Minimally Invasive Calcaneal Displacement Osteotomy Site Using a Reference Kirschner Wire: A Technique Tip

As a standard open approach, the lateral oblique incision has been widely used for calcaneal displacement osteotomy. However, just as with other orthopedic procedures that use an open approach, complications, including wound healing problems and neurovascular injury in the heel, have been reported. To help avoid these limitations, a percutaneous technique using a Shannon burr for calcaneal displacement osteotomy was introduced. However, relying on a free-hand technique without direct visualization at the osteotomy site has been a major obstacle for this technique. To address this problem, we developed a technical tip using a reference Kirschner wire. A reference Kirschner wire technique provides a reliable and accurate guide for minimally invasive calcaneal displacement osteotomy. Also, the technique should be easy to learn for surgeons new to the procedure.

Corrective Osteotomies Used in Cavus Reconstruction

The authors dedicate this article to describing the clinical work-up and etiology for a cavus foot deformity as well as the surgical decision making for correction. Understanding and proper utilization of osteotomies is paramount in the improvement of cavus foot deformities. Also, the authors share their own experiences with preferred techniques for optimal outcomes.

Osteotomies for the Flexible Adult Acquired Flatfoot Disorder

Flexible adult acquired flatfoot disorder is commonly treated with the use of osteotomies in the calcaneus and medial column. The combination of these joint-preserving osteotomies with additional soft-tissue procedures allows realignment of the hindfoot with the goal of preventing further deformity or degenerative joint disease. A thorough understanding of each patient's condition allows the surgeon to match the correct osteotomy to the clinical indication, while also successfully executing the planned surgery.

Hindfoot deformity and calcaneal tuberosity osteotomies

Calcaneal tuberosity osteotomies are commonly used to treat coronal plane deformities of the hindfoot. Assessing hindfoot alignment can be difficult and there is little evidence to guide the physician when considering the surgical treatment of these deformities. The indications for a calcaneal osteotomy are unclear in the literature because most of the published studies supporting their use are confounded by concurrent procedures such as in adult-acquired flatfoot correction or cavovarus reconstruction. For the same reason, the biomechanical consequences, long-term effects, and performance in vivo are largely unknown.

LEVEL OF EVIDENCE

Expert opinion, Level V.

Adult flatfoot

Adult flatfoot is defined as a flattening of the medial arch of the foot in weight-bearing and lack of a propulsive gait. The 3 lesion levels are the talonavicular, tibiotarsal and midfoot joints. The subtalar joint is damaged by the consequent rotational defects. Clinical examination determines deformity and reducibility, and assesses any posterior tibialis muscle deficit, the posterior tibialis tendon and spring ligament being frequently subject to degenerative lesions. Radiographic examination in 3 incidences in weight-bearing is essential, to determine the principal level of deformity. Tendon (posterior tibialis tendon) and ligamentous lesions (spring ligament and interosseous ligament) are analyzed on MRI or ultrasound. In fixed deformities, CT explores for arthritic evolution or specific etiologies. 3D CT reconstruction can analyze bone and joint morphology and contribute to the planning of any osteotomy. Medical management associates insoles and physiotherapy. Acute painful flatfoot requires strict cast immobilization. Surgical treatment associates numerous combinations of procedures, currently under assessment for supple flatfoot: for the hindfoot: medial slide calcaneal osteotomy, calcaneal lengthening osteotomy, or arthroereisis; for the midfoot: arthrodesis on one or several rays, or first cuneiform or first metatarsal osteotomy; for the ankle: medial collateral ligament repair with tendon transfer. Fixed deformities require arthrodesis of one or several joint-lines in the hindfoot; for the ankle, total replacement after realignment of the foot, or tibiotalocalcaneal fusion or ankle and hindfoot fusion; and, for the midfoot, cuneonavicular or cuneometatarsal fusion. Tendinous procedures are often associated. Specific etiologies may need individualized procedures. In conclusion, adult flatfoot tends to be diagnosed and managed too late, with consequent impact on the ankle, the management of which is complex and poorly codified.

The calcaneal scarf osteotomy: surgical correction of the adult acquired flatfoot deformity and radiographic results

PURPOSE

Surgical correction of the adult acquired flatfoot deformity (AAFD) is continually evolving. This technique article presents the technique of the calcaneal scarf osteotomy (CSO) and radiographic evidence supporting the ability of this procedure to correct an AAFD.

METHOD

The technique described here is a single osteotomy that corrects flatfoot deformity in all 3 planes. Retrospectively, medical records were reviewed to identify patients who underwent a CSO for surgical correction of AAFD. Pre- and postoperative radiographs were reviewed.

RESULTS

Thirty patients (32 feet) had an average age of 49.0 ± 17.2 years (range = 35-73 years) with an average of 5.7 ± 2.0 years (range = 1-11 years) of follow-up. Anteroposterior and lateral radiographic parameters were significantly altered with this procedure (P < .001). CSO-induced calcaneal-cuboid joint arthritis did not occur.

DISCUSSION AND CONCLUSIONS

The results of the current study demonstrate that the CSO significantly changes radiographic exam parameters in patients who suffer from AAFD. Therefore, the CSO provides triplanar correction through one osteotomy with early return to weight bearing and lacks the complications such as lateral column pain associated with other calcaneal osteotomies.

LEVELS OF EVIDENCE

Level IV, Retrospective cohort study.

Relationship of the Scarf valgus-inducing osteotomy of the calcaneus to the medial neurovascular structures

BACKGROUND

The Scarf valgus inducing osteotomy of the calcaneus is an operative technique to correct varus deformity of the hindfoot. It is versatile with significant corrective power; however, the neurovascular structures are in close proximity on the medial side and thus may be harmed during the osteotomy. Moreover, because this type of osteotomy can cause a great lateral translation, traction of the medial neurovascular structures is possible. We performed an anatomic study to evaluate the medial soft tissues after a lateralizing Scarf-type calcaneal osteotomy.

MATERIALS AND METHODS

The osteotomies were carried out on ten fresh-frozen cadaver specimens. We performed the osteotomy and induced valgus. Then we performed a medial dissection to identify the important medial structures: the medial and lateral plantar nerve (MPN , LPN) and the posterior tibial artery (PTA). We noted their relation to the osteotomy and their integrity.

RESULTS

In several cases, one or more of the structures were sectioned. In five cases, all the structures crossed the osteotomy, four of which even a transection of one or both of the plantar nerves occurred. Although the PTA crossed the osteotomy in eight specimens, there was no transection of this structure.

CONCLUSION

Scarf osteotomy of the calcaneus is a highly corrective osteotomy. However, caution must be exercised when performing as the medial neurovascular structures cross the osteotomy lines and transection can occur.

CLINICAL RELEVANCE

When performing the osteotomy one should keep in mind that vigorous sawing and large displacement can cause damage to the medial neurovascular structures.

Flexible pediatric and adolescent pes planovalgus: conservative and surgical treatment options

Pediatric and adolescent flexible flatfoot is a pathomechanically complex deformity. Conservative and surgical treatment is directed at realigning the foot and alleviating symptoms. When surgical intervention is considered, there are various methods and techniques that may be performed to realign the foot. The treatment goals are directed first at resolution of pain, and second at the realignment of the foot. A specific treatment algorithm does not exist, although planal dominance influences direct the surgeons when considering surgical intervention. Open physis often dictates the direction of the reconstruction. Attempts at essential joint preservation should be strongly considered in this young patient population. This article provides an overview of the common treatment pathways that highlight methods to structurally realign the pediatric and adolescent flatfoot.

Full-scale 3D preoperative planning system for calcaneal osteotomy with a multimedia system

This study presents a new computer-assisted surgical planning and simulating system that employs a multimedia environment for calcaneal osteotomy surgery. The system uses a full-scale computer-assisted engineering technique for designing and developing preoperative planning modules. The planning system not only presents a real-sized 3-dimensional (3D) image of the calcaneus, but also provides detailed interior measurements of the calcaneus from various cutting planes. The multimedia user interface integrates the function of different software programs in order to plan and simulate the operation. These functions include 3D image model capturing, sectioning, translocation, rotating, and measuring relevant foot anatomy, all of which can be integrated and used for surgical planning, as well as for future study and discussion. Furthermore, because the system is computer based with a multimedia user interface, surgeons can use it to explore the optimal operative procedure. The system also has a databank that can be updated and expanded, and can be used to provide clinical cases to different users for education and training.

LEVEL OF CLINICAL EVIDENCE

5.

Posterior calcaneal displacement osteotomy for the adult acquired flatfoot

The posterior calcaneal displacement osteotomy with flexor digitorum longus tendon transfer is an accepted approach to the stage II posterior tibial tendon dysfunction flatfoot. This reconstructive osteotomy provides a viable alternative to isolated hindfoot arthrodesis procedures. Proper patient selection and sound surgical technique ensure favorable postoperative results. Complications, though limited, may include sural neuritis, peroneal tendonitis, undercorrection, and peritalar arthrosis.