A Novel Technique of Medial Displacement Calcaneal Osteotomy Using the Intramedullary Fixation of a Conventional Low-Profile Locking Wedge Plate

BACKGROUND

Postoperative heel pain arising from prominent screw heads is a common complication following medial displacement calcaneal osteotomy (MDCO). This study aims to present the clinicoradiographic outcomes of a novel MDCO technique, wherein intramedullary fixation of a conventional low-profile locking wedge plate is employed.

METHODS

A retrospective analysis, involving a comparison of clinical and radiographic parameters among consecutive patients who underwent MDCO was conducted. The patients were subjected to either intramedullary wedge plate fixation through the osteotomy site (IWPF group, n = 45 cases) or conventional cannulated screw fixation from the heel (CCSF group, n = 51 cases). Radiographic evaluation included measurement of hindfoot alignment angle, alignment ratio, and moment arm. Clinical outcomes were measured with the American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and the Foot and Ankle Ability Measure (FAAM) activities of daily living and sports subscales, before and at 6, 12, and ≥24 months postoperatively. The presence of heel pain was evaluated at the postoperative 6 and 12 months in both groups.

RESULTS

For both groups, a marked enhancement in all 3 radiographic parameters was observed. The extent of correction for all clinicoradiographic parameters demonstrated no statistically significant divergence between the 2 groups. However, the FAAM-Sports scores at the 6-month postoperative juncture exhibited a significant elevation in the IWPF group relative to the CCSF group. Importantly, no patient reported heel pain at postoperative 6 and 12 months in the IWPF group whereas the rates of patients having heel pain at postoperative 6 and 12 months were 56.8% (29 cases) and 33.3% (17 cases), respectively, in the CCSF group.

CONCLUSIONS

Both techniques yield analogous postoperative clinical and radiographic enhancements. However, the utilization of IWPF promotes a swifter clinical improvement with respect to sports activities when juxtaposed with the CCSF from the calcaneal tuberosity.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The Zadek Osteotomy for Surgical Management of Insertional Achilles Tendinopathy: A Systematic Review

BACKGROUND

The calcaneal dorsal closing wedge osteotomy, otherwise known as the Zadek or Keck and Kelly osteotomy, is used to treat insertional Achilles tendinopathy. The purpose of this study is to investigate the clinical outcomes affiliated with the Zadek technique for insertional Achilles tendinopathy (IAT) as reported in the literature.

METHODS

An English literature search on PubMed was performed yielding 8 level IV retrospective case series.

RESULTS

The weighted mean of preoperative and postoperative Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A) scores was 52.7 and 87.8, respectively. The weighted mean of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores was 56.3 and 92.9, respectively. Majority of the reported complications were minor events, including symptomatic hardware (2.8%; n = 7/247), sural nerve paresthesia (2%; n = 5/247), and superficial infection (3.2%; n = 8/247). There was 1 reported event of hardware failure resulting in re-operation. Deep vein thrombosis occurred at a rate of 0.8% (n = 2/247), complex regional pain syndrome at 0.4% (n = 1/247) and nonunion at a rate of 1.2% (n = 3/247).

CONCLUSION

The Zadek osteotomy is a viable option for insertional Achilles tendinopathy based on significantly improved outcome measures and minor complication rates.

LEVEL OF EVIDENCE

4.

Lateralizing Calcaneal Osteotomy and First Metatarsal Dorsiflexion Osteotomy for Cavovarus Foot and Peroneal Sheath Release with Peroneus Brevis Repair for Peroneal Tendinopathy in Chronic Ankle Instability and Sprain

A 47-year-old male presented with an eight-year history of pain in the posterior inferior part of the lateral malleolus, ankle instability, and repeated right-sided ankle sprains. He had pes cavus and hind-foot varus in his right foot, which is an unknown congenital entity or acquired with tenderness in the inferior peroneal retinaculum. There is no deformity in his left foot. The pain was elicited by the movement of the subtalar joint. Imaging revealed a high medial longitudinal arch, an enlarged peroneal tubercle, thinning of the peroneus brevis tendon, and hypertrophy of the peroneus longus tendon. We diagnosed peroneal tendinopathy with cavovarus foot in a chronic ankle sprain. The supination generated by pes cavus was thought to be aggravating the peroneal tendinopathy and causing the ankle sprains. Incision of the peroneal tendon sheath, repair of the peroneus brevis tendon, lateralizing calcaneal osteotomy, and first metatarsal dorsiflexion osteotomy were performed. At the one-year follow-up, Meary's angle was corrected to 0°, the calcaneal pitch was corrected to 20°, and the hindfoot varus was improved. He was pain-free and reported no further instability when walking. His Japanese Society of Surgery of the Foot ankle-hindfoot scale score improved from 59 preoperatively to a maximum of 100 and the Self-Administered Foot Evaluation Questionnaire gave an almost perfect score for non-sports-related items and a score of 83.3 for sports-related items. We believe that the addition of treatment of the pes cavus, which was the center of the pathology, as well as treatment of the peroneal tendon, resulted in a good outcome.

Calcaneal osteotomy due to insertional calcaneal tendinopathy: preoperative planning

Purpose

Dorsal closing wedge calcaneal osteotomy (DCWCO) is indicated in patients with insertional tendinopathy of the calcaneal (Achilles) tendon. The Chauveaus-Liet’s (CL) angle is represented by the difference between the angle of verticalization (α) and morphological angle (β) of the calcaneus (CL angle = α − β). The purpose of the study was to assess whether the DCWCO affects the Chauveaus-Liet’s angle.

Methods

The study included 12 patients indicated to DCWCO. Three directions of close wedge osteotomy were designed for each patient—horizontal, vertical and in the middle type of osteotomy and a virtual osteotomy was created in each of them in the ABAQUS system in cooperation with Czech Technical University. The most used directions of osteotomy according to the available literature were used. We evaluated α and β angles before and after osteotomy, changes of the length plantar aponeurosis and the elevation of distal insertional point of the calcaneal tendon. The changes of grades, median and standard deviation were observed.

Results

The change of the alfa angle was dependent on the direction of the osteotomy and the change of the beta angle was affected by the size of the osteotomy. The greatest elevation of the distal insertional point of the calcaneal tendon occurred in the horizontal type of the osteotomy.

Conclusion

Our study shows that the more we want to reduce the tension in the calcaneal tendon, the more we have to perform an osteotomy horizontally. This study could serve as a preoperative guide for osteotomy planning.

Incidence of Lateral Prominence Pain Following Open Medial Displacement Calcaneal Osteotomy and the Efficacy of Crushplasty as a Preventive Technique

BACKGROUND

There has been concern about lateral prominence pain at the osteotomy site following medial displacement calcaneal osteotomy (MDCO). However, no study has investigated this complication. This study aimed to investigate the incidence of lateral prominence pain following MDCO and examine the efficacy of crushplasty as a surgical technique to minimize this complication.

METHODS

This was a retrospective cohort study in which 137 patients (148 feet) who underwent MDCO were divided into 2 groups by whether they had concurrent crushplasty at the time of MDCO (crushplasty [n = 81] vs noncrushplasty group [n = 67]). Crushplasty was performed by flattening the bony step-off using a rongeur and bone impactor. Lateral prominence pain was defined as pain or irritating symptoms over the osteotomy site that persisted over 12 months after MDCO. The overall incidence of lateral prominence pain after MDCO and within each group was investigated. Multiple logistic regression analysis was used to determine the influence of possible risk factors on the development of postoperative lateral prominence pain.

RESULTS

The overall incidence of lateral prominence pain was 9.5% (14 of 148): 3.4% (3 of 87) in the crushplasty group, and 18% (11 of 61) in the noncrushplasty group, and χ² analysis showed a statistically significant relationship between crushplasty and lateral prominence pain (P < .05). A relationship between the amount of medial displacement and the development of lateral prominence pain was observed in the noncrushplasty group (OR = 5.31, 95% CI 2.35-16.4, P < .05), but this was not observed in the crushplasty group (P = .641). The amount of medial displacement was an independent risk factor for the development of lateral prominence pain (OR = 2.72, 95% CI 1.54-4.79, P < .05), and concurrent crushplasty had a negative relationship with lateral prominence pain development (OR = 0.12, 95% CI 0.03-0.57, P < .05).

CONCLUSION

This study revealed that lateral prominence pain is a significant complication of MDCO, especially in the setting of a larger displacement. The crushplasty following MDCO may minimize this complication, particularly when a greater degree of hindfoot correction is attempted.

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.

The Effect of Chilled vs Room-Temperature Irrigation on Thermal Energy Dissipation During Minimally Invasive Calcaneal Osteotomy of Cadaver Specimens

BACKGROUND

Minimally invasive (MIS) calcaneal osteotomy has grown in popularity in recent years to address hindfoot deformity. A potential complication is thermal bone necrosis secondary to heat generation from the burr that may lead to osteotomy nonunion. Irrigation is commonly employed to reduce this risk. The effect of irrigation on reducing heat accumulation remains an understudied area. The purpose of this study was to evaluate the effect of cooled vs room-temperature irrigation on thermal energy dissipation during calcaneal osteotomy using a Shannon burr.

METHODS

Fourteen cadaveric limbs at room temperature (68 °F) were randomized to receive either cooled saline (7 limbs) or room-temperature (7 limbs) irrigation during MIS calcaneal osteotomy. Two thermocouple probes were inserted 5 mm away from the plane of the osteotomy, on the proximal and distal sides, respectively. A 3 × 30-mm Shannon burr was used to perform the osteotomy. The burr was run continuously with continuous irrigation using either room-temperature (68 °F) or chilled (37 °F) irrigation, until the osteotomy was completed. Temperature was recorded at 0, 15, 30, 45, and 60 seconds for the 2 groups and used as a measure of thermal energy accumulation.

RESULTS

Both room-temperature and chilled irrigation were effective in minimizing temperature change. On the proximal side, an overall mean increase of 2.5 °F with room-temperature irrigation and a mean decrease of 1.0 °F with chilled irrigation were observed at the 60-second interval (P = .004). On the distal side, there was a mean increase of 1.3 °F with room-temperature irrigation and a mean increase of 0.5 °F with chilled irrigation (P = .05).

CONCLUSION

For the duration of an MIS calcaneal osteotomy, both continuous room-temperature and chilled irrigation can minimize temperature increases and potentially reduce the risk of an osteotomy nonunion.

CLINICAL RELEVANCE

Both room-temperature and chilled irrigation can minimize bone temperature increases during MIS calcaneal osteotomy.

Haglund's Deformity as a Cause of Acute Achilles Tendon Rupture: A Case Report

Achilles tendon rupture is a common problem affecting both high level and casual athletes. Haglund´s deformity is an abnormality of the postero-superior part of the calcaneus, which often leads to retro-calcaneal bursitis as well as thickening and inflammation of the calcaneal tendon, a combination of pathologies known as Haglund's syndrome. We report a rare case of a relapse Achilles tendon rupture in a 39-year-old professional handball player with a pronounced painful Haglund´s deformity treated with tendon debridement and reattachment using the Arthrex Speedbridge® system. This case report illustrates a rarely described operative and post-operative management of this unusual combination of Achilles tendon rupture and Haglund´s deformity.

Is There a Borderline Value in the Radiological Findings of Patients With Calcaneal Malunion That May Help to Select an Appropriate Treatment Option?

BACKGROUND

Despite the constant evolution of technological support, operative techniques, and rehabilitation techniques after conservative treatment and operative treatment, a considerable number of patients with calcaneal fractures have constant pain, frequently resulting in loss of occupation. There are numerous options for the operative treatment of painful calcaneal malunion; however, very few publications suggest specific radiological measurements for pre- and postoperative planning-even fewer have statistically analyzed how these radiological measurements affect clinical outcomes.

METHODS

We performed a retrospective study of 100 patients after operative treatment of calcaneal malunion to determine the correlation between radiological measurements and clinical outcomes. Data were used to create an algorithm that would help to choose between in situ subtalar arthrodesis and complex reconstructive operations. The algorithm was then used to treat 27 prospective patients. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) were used for clinical assessment, whereas standard weightbearing anteroposterior (AP), lateral (LAT) ankle x-rays, and long axial hindfoot view were used for radiological assessment.

RESULTS

The talar declination angle was positively correlated with clinical outcome. Patients with talar declination angles less than 6.5 degrees showed worse results in AOFAS score than patients with a greater angle did (57.3 ± 15.3 and 81 ± 15.6, respectively).

CONCLUSION

The combination of subtalar arthrodesis with distraction bone block or calcaneal osteotomy in patients with calcaneal malunion and a talar declination angle less than 6.5 degrees showed better results than isolated in situ arthrodesis.

LEVEL OF EVIDENCE

Level III, retrospective cohort study, case series.

Neurological Injuries after Calcaneal Osteotomies Are Underdiagnosed

The incidence of peripheral neurological injuries related to calcaneal osteotomies reported in the literature is low and often described as occasional. The main objective of this study is to determine the incidence of neurological injuries after calcaneal osteotomies and identify which nerve structures are most affected. This retrospective work included 69 patients. Medical records, surgical protocols, and radiographs were analyzed. All patients were summoned to perform current functional tests (EFAS score and SF-12), and a thorough physical examination was performed systematically and bilaterally. The total incidence of neurological injuries was 43.5% (30/69). The percentage of neurapraxias (transient injuries) was 8.7%, while 34.8% of patients presented neurological sequelae (permanent injuries). The most injured nerve or branch was, in decreasing order: sural nerve, medial plantar branch, lateral plantar branch and medial calcaneal branch. Following the so-called "safe zone" clearly decreases the incidence of sural nerve injury (p = 0.035). No significant differences were found between osteotomy site, number of screws, and type of closure and increased neurological injuries. No significant differences were found in the functional tests between the different techniques, nor between patients who presented neurological injuries and those who did not. Neurological injuries after calcaneal osteotomies are underdiagnosed and the incidence is higher than previously reported (43.5%). Such injuries mostly go unnoticed and have no implications in the functional results and patients' satisfaction.

Medial Displacement Calcaneal Osteotomy for Unilateral Adult Acquired Flatfoot: Effects of Minimally Invasive Surgery on Pain, Alignment, Functioning, and Quality of Life

We aimed to assess the effects of medial displacement calcaneal osteotomy (MDCO) through a minimal skin incision in terms of pain, function, and alignment in patients with unilateral adult acquired flatfoot. American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scale and Numeric Pain Rating Scale (NPRS) were assessed as outcomes at the baseline (T0), at 6 months (T1), and at 1 year (T2) from surgery. We analyzed data of 20 patients (7 male and 13 female), mean aged 46.6 ± 5.34 years, showed significant differences after 6 months in terms of AOFAS total score (44.30 ± 7.39 vs 96.50 ± 4.89; p = .0001), AOFAS subitems (p < .001), and pain (NPRS: 7.95 ± 1.36 vs 1.05 ± 1.05; p = .0001). At 1 year after surgery (T2), all outcome measures still significantly differ from baseline (p < 01). Therefore, percutaneous MDCO through a minimal skin incision seemed to be safe and effective in the middle and long term in reducing pain and improving function and alignment in patients with unilateral adult acquired flatfoot.

Effect of Lateral Column Lengthening on Subtalar Motion in a Cadaveric Model

BACKGROUND

Although lengthening of the lateral column through a calcaneal neck osteotomy is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, concern exists as to the effect of this intra-articular osteotomy on subtalar motion. The purpose of this study was to quantify the alterations in subtalar motion following lateral column lengthening (LCL).

METHODS

The subtalar motion of 14 fresh-frozen cadaveric feet was assessed using a 3-dimensional motion capture system and materials testing system (MTS). Following potting of the tibia and calcaneus, optic markers were placed into the tibia, calcaneus, and talus. The MTS was used to apply a rotational force across the subtalar joint to a torque of 5 Nm. Abduction/adduction, supination/pronation, and plantarflexion/dorsiflexion about the talus were recorded. Specimens then underwent LCL via a calcaneal neck osteotomy, which was maintained with a 12-mm porous titanium wedge. Repeat subtalar motion analysis was performed and compared to pre-LCL motion using a paired t test.

RESULTS

No statistically significant differences in subtalar abduction/adduction (10.9 vs 11.8 degrees, P = .48), supination/pronation (3.5 vs 2.7 degrees, P = .31), or plantarflexion/dorsiflexion (1.6 vs 1.0 degrees, P = .10) were identified following LCL.

CONCLUSION

No significant changes in subtalar motion were observed following lateral column lengthening in this biomechanical cadaveric study.

CLINICAL RELEVANCE

Although these findings do not obviate concerns of clinical subtalar stiffness following lateral column lengthening for planovalgus deformity correction, they suggest that diminished postoperative subtalar motion, when it occurs, may be due to soft tissue scarring rather than alterations of joint anatomy.

Effects of variations in Dwyer calcaneal osteotomy determined by three-dimensional printed patient-specific modeling

Dwyer (lateral calcaneal closing wedge) osteotomy is commonly used in surgical correction of heel varus deformity. The purpose of this study was to determine the effect of wedge size and angle of osteotomy on deformity correction using preoperative imaging analysis with three-dimensional (3D) printed modeling. Seven patients diagnosed with pes cavovarus deformity who underwent Dwyer calcaneal osteotomy were identified retrospectively. Preoperative computed tomogrphy scans were used to create 3D printed models of the foot. After18 variations of osteotomy and fixation performed for each foot, Harris heel and Saltzman images were obtained. The angle between the tibia-talus axis and calcaneal-tuber axis was measured and compared to pre-osteotomy state. Change in the calcaneal lengths was also analyzed. The average degree correction of deformity per mm of bone resected was 3.8 ± 0.2 degrees in the Harris Heel view and 2.7 ± 0.8 degrees in the Saltzman view. A significant increase in correction was obtained with 10 mm compared with 5 mm wide wedges (P < .001). The difference in correction was not statistically significant between 30 and 45 degree cuts or osteotomy distance from the posterior calcaneal tuberosity, but a 45 degree sagittal angle resulted in less calcaneal shortening compared to 30 degrees (P = .02). A clinically driven method using patient-specific 3D models for determining effects of calcaneal osteotomy variables in correcting hindfoot alignment was developed. In summary, the amount of wedge resected impacts hindfoot alignment more than location and sagittal angle of the cut. Calcaneal shortening depends on sagittal angle of the cut.

Outcomes Following Revision Surgery After Failed Kidner Procedure for Painful Accessory Navicular

BACKGROUND

The Kidner procedure is performed to treat painful accessory navicular syndrome, with varying results. Recurrent pain remains a complication, and to date, there is a paucity of literature regarding the causes of recurrent pain and surgical outcomes of revision.

METHODS

Twenty-one patients who underwent revision surgery for recurrent pain after the Kidner procedure were identified. All patients had their tendon inspected and treated, and all had a medial displacement calcaneal osteotomy. Revision was indicated after 6 months of failed conservative therapy. Pre- and postrevision radiographic measurements included lateral talo-first metatarsal angle (Meary's angle), talonavicular coverage angle, calcaneal pitch, and hindfoot moment arm (HMA). Meary's angle >4 degrees was considered a planus deformity and HMA >9.1 mm was considered a hindfoot valgus deformity; patients fulfilling both criteria were categorized as having planovalgus deformity. Measurements in the contralateral foot were performed to determine whether alignment of the involved side was attributed to failed treatment or a preexisting deformity. Visual analog scale and Foot and Ankle Outcome Scores were compared and average follow-up was 20.1 months (range, 14-26).

RESULTS

Preoperatively, 20 of 21 (95%) patients had a form of valgus heel alignment (planovalgus, n = 11; hindfoot valgus only, n = 9), and 1 had an isolated planus deformity. The contralateral side revealed similar deformity, with 17 of 21 (81%) patients having a form of valgus heel alignment (planovalgus, n = 13; hindfoot valgus only, n = 4) and 4 patients with an isolated planus deformity. All patients underwent realignment surgery with medial displacement calcaneal osteotomy. All radiographic parameters except Meary's angle (P = .885) significantly improved postoperatively along with significantly improved clinical outcomes.

CONCLUSION

Recurrent pain following the Kidner procedure was associated with valgus heel alignment. Revision surgery including realignment procedure alleviated pain and improved functional outcomes with minimal complications. Therefore, we recommend assessing heel alignment in patients presenting with recurrent pain following the Kidner procedure.

LEVEL OF EVIDENCE

Level IV, case series.

Consensus for the Indication of a Medializing Displacement Calcaneal Osteotomy in the Treatment of Progressive Collapsing Foot Deformity

RECOMMENDATION

There is evidence that the medial displacement calcaneal osteotomy (MDCO) can be effective in treating the progressive collapsing foot deformity (PCFD). This juxta-articular osteotomy of the tuberosity shifts the mechanical axis of the calcaneus from a more lateral position to a more medial position, which provides mechanical advantage in the reconstruction for this condition. This also shifts the action of the Achilles tendon medially, which minimizes the everting deforming effect and improves the inversion forces. When isolated hindfoot valgus exists with adequate talonavicular joint coverage (less than 35%-40% uncoverage) and a lack of significant forefoot supination, varus, or abduction, we recommend performing this osteotomy as an isolated bony procedure, with or without additional soft tissue procedures. The clinical goal of the hindfoot valgus correction is to achieve a clinically neutral heel, as defined by a vertical axis from the heel up the longitudinal axis of the Achilles tendon and distal aspect of the leg. The typical range when performing a MDCO, while considering the location and rotation of the osteotomy, is 7 to 15 mm of correction.

LEVEL OF EVIDENCE

Level V, consensus, expert opinion.

Dorsally Based Closing Wedge Osteotomy of the Calcaneus for Insertional Achilles Tendinopathy

Background

Surgical management may be indicated for patients with insertional Achilles tendinopathy (IAT) after failure of nonoperative management, and various surgical techniques have been described.

Hypothesis

We present the technique and results of modified dorsal closing wedge calcaneal osteotomy, performed in a cohort of 28 consecutive patients. We hypothesized that this will be a safe procedure that can improve hindfoot pain and function for most patients who will return to preoperative daily life and sports activities.

Study Design

Case series; Level of evidence, 4.

Methods

A modified dorsal closing wedge osteotomy was performed in 28 patients (mean age, 54.7 years) from November 2015 to December 2016. All patients were followed for at least 2 years postoperatively.

Results

All osteotomies united at a mean of 5 weeks. The mean anatomic change in calcaneal length was 4 mm (range, 3-6 mm). The overall complication rate was 10.7%. There were 2 superficial wound infections (7.1%) and 1 instance of sural nerve-related paresthesia (3.5%) reported. All patients returned to their presurgical level of activities at a mean of 23 ± 8.0 weeks. Further, 3 of 4 patients who participated in recreational sports activities returned to their preinjury level. Visual analog scale and Victorian Institute of Sports of Australia-Achilles scores significantly improved postoperatively (P < .001) and continued to improve for 24 months.

Conclusion

The modified dorsal closing wedge calcaneal osteotomy is a safe procedure and significantly improved pain and function in patients with IAT at 2 years after surgery.

Review of Calcaneal Osteotomies Fixed With a Calcaneal Slide Plate

BACKGROUND

The calcaneal slide osteotomy is a common procedure used for the surgical correction of heel varus and valgus deformities. A variety of fixation methods exist including screws and plates. The literature shows a high rate of hardware prominence with screws leading to subsequent removal of hardware. Few studies have examined the use of plates for fixation of a calcaneal osteotomy. The purpose of this study was to assess outcomes following fixation of a calcaneal osteotomy with a calcaneal slide plate.

METHODS

This is a retrospective consecutive case series of all patients who underwent either a medial or lateral calcaneal slide osteotomy using the specialized calcaneal slide plate between September 2013 and December 2018 by a single surgeon. The primary outcome measures were the rate of hardware removal, healing of the calcaneal osteotomy, and any associated complications such as infection or incision healing delays. Patient baseline demographics and procedure-related data were recorded. The minimum follow-up was 4 months. A total of 81 procedures were performed using this calcaneal slide plate.

RESULTS

All of the patients had one or more additional procedures at the same time as the calcaneal osteotomy. All of the calcaneal osteotomies healed without displacement. Only 1 patient (1.2%) returned to the operating room and had removal of the calcaneal slide plate, which was after osteotomy union for an infected wound. There were no cases of hardware failure or removal due to it being symptomatic.

CONCLUSION

A specialized calcaneal slide plate was an effective fixation device for both medial and lateral calcaneal slide osteotomies for a variety of foot and ankle conditions. The union rate was 100% and none of the patients had hardware symptoms, which is an improvement on published reports of symptomatic hardware after calcaneal slide osteotomy.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Tibial Nerve Palsy After Lateralizing Calcaneal Osteotomy

Background: Lateralizing calcaneal osteotomy (LCO) is a common procedure used to correct hindfoot varus. Several complications have been described in the literature, but only a few articles describe tibial nerve palsy after this procedure. Our hypothesis was that tibial nerve palsy is a common complication after LCO. Methods: A retrospective study of patients undergoing LCO for hindfoot varus between 2007 and 2013 was performed. A total of 15 patients (18 feet) were included in the study. The patients were examined for tibial nerve deficit, and all the patients were examined with a computed tomography (CT) scan of both feet. Patients with a preexisting neurological disease were excluded. The primary outcome was tibial nerve palsy, and the secondary outcomes were reduction of the tarsal tunnel volume, the distance from subtalar joint to the osteotomy, and the lateral step at the osteotomy evaluated by CT scans. Results: Three of the 18 feet examined had tibial nerve palsy at a mean follow-up of 51 months. The mean reduction in tarsal tunnel volume when comparing the contralateral nonoperated foot to the foot operated with LCO was 2732 mm³ in the group without neurological deficit and 2152 mm³ in the group with neurological deficit (P = .60). Conclusion: 3 of 18 feet had tibial palsy as a complication to LCO. We were not able to show that a larger decrease in the tarsal tunnel volume, a more anterior calcaneal osteotomy, or a larger lateral shift of the osteotomy is associated with tibial nerve palsy. Levels of Evidence: Level IV: Retrospective case series.

Outcomes of the Extended Z-Cut Osteotomy for Correction of Adult Acquired Flatfoot Deformity

BACKGROUND

Medial displacement calcaneus tuberosity osteotomy and anterior process lengthening calcaneus osteotomy are traditional single-plane osteotomy techniques used in adult acquired flatfoot deformity reconstruction. More recently, 3-plane step-cut osteotomies were described for each of these and shown to offer improved rotational stability via the horizontal limb. However, a major technical challenge is achieving a sufficiently long horizontal limb to correct deformity through lengthening without losing bony apposition. Combining the anterior process and tuberosity step-cuts using an elongated horizontal limb alleviates this technical challenge, creates a very large surface area for bony healing, and utilizes a single incision. We hypothesized that the Z-cut osteotomy would achieve clinical and radiographic flatfoot deformity correction with a high union rate.

METHODS

This was an institutional review board-approved retrospective study of 16 patients who underwent Z-cut osteotomy for the treatment of moderate to severe symptomatic adult acquired flatfoot deformity, stage IIA/B. The mean radiographic follow-up was 8.8 months, while the mean clinical follow-up was 2.36 years. Radiographic correction was assessed via weightbearing radiographs taken preoperatively and at a mean of 26 ± 2 weeks postoperatively. Measurements included Meary's angle (talo-first metatarsal angle), talonavicular (TN) joint uncoverage percentage, TN incongruency angle, medial cuneiform to fifth metatarsal height, and calcaneal pitch. Union rates and clinical outcomes via the Foot Function Index (FFI) score were assessed preoperatively and at a mean of 29 months following surgery. Paired t test was used to compare both clinical and radiographic outcomes with statistical significance set at P < .05.

RESULTS

Fifteen of 16 patients returned an FFI questionnaire with a mean improvement of 52.1 to 10.3 (P = .002). The calcaneal pitch improved from 12.7 to 15.2 degrees (P = .002), the medial cuneiform-fifth metatarsal distance improved from 12.8 to 18.5 mm (P = .002), the TN coverage angle improved from 21.3 to 9.1 degrees (P < .001), the TN uncoverage percentage improved from 32.9% to 20.3% (P < .001), and the TN incongruency angle improved from 41.4 to 19.9 degrees (P < .001). Deformity correction was well maintained in 13 of 16 patients at final follow-up. The union rate of the osteotomy was 100%. Three patients had symptomatic hardware initially; 1 patient required removal of hardware. One patient developed a superficial infection that cleared. Another patient developed peroneal tendonitis, which resolved with corticosteroid injection.

CONCLUSION

The Z-cut osteotomy is a novel, technically simplified, single-incision, single-osteotomy alternative to the previously described double calcaneus osteotomy techniques for reconstructing flexible moderate to severe adult acquired flatfoot deformity that offers comparable short-term clinical and radiographic outcomes with acceptably low complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Outcomes of Evans Versus Hintermann Calcaneal Lengthening Osteotomy for Flexible Flatfoot

BACKGROUND

Evans (E) and Hintermann (H) lateral lengthening calcaneal osteotomies (LLCOTs) are commonly used to correct flexible flatfoot deformities. Both methods are well accepted and produce good clinical results. The aim of this study was to compare the postoperative outcomes of both osteotomies.

METHODS

We retrospectively examined 53 patients with flatfoot deformities, who received surgery between October 2008 and March 2014. Seventeen E-LLCOT and 36 H-LLCOT procedures were performed during this time period, with a mean follow-up of 67.7 ± 20.6 and 40 ± 12.9 months, respectively. Data were collected using clinical and radiological examination, as well as clinical scores (Foot and Ankle Outcome Score [FAOS], University of California at Los Angeles [UCLA] activity score, numerical rating scale [NRS], and the Short-Form 36-item Health Survey [SF-36]) during regular follow-up.

RESULTS

For both groups of patients, the FAOS score, pain-NRS, and SF-36 improved significantly following surgery ( P < .05). The talus-second metatarsal angle, talonavicular coverage, and naviculocuneiform overlap showed significant correction ( P < .05). Postoperatively, radiographic degenerative changes were detected in the calcaneocuboid (CC) and subtalar joint in both groups of patients: 41% and 18% after E-LLCOT compared with 25% and 14% after H-LLCOT, although these changes did not have any clinical relevance ( P < .05). No secondary arthrodesis was necessary. There were no significant differences in the clinical or radiological outcome parameters when compared between the 2 groups.

CONCLUSION

Both surgical techniques resulted in a significant improvement of clinical outcome scores and led to good radiological correction of flatfoot deformities. It appears that the CC joint develops less degenerative changes following the H-LLCOT procedure.

LEVEL OF EVIDENCE

Level III, comparative series.

Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

BACKGROUND:

Calcaneal osteotomies are often required in the correction of hindfoot deformities. The traditional open techniques, which include a lateral or oblique incision, are occasionally associated with wound healing problems and neurovascular injury.

METHODS:

A total of 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. Fifty-eight patients were operated using an open incision technique and 64 patients (66 feet) using a percutaneous technique. Clinical and radiologic assessments were performed preoperatively, at 6 weeks, and 1 year postoperatively.

RESULTS:

The American Orthopaedic Foot & Ankle Society scale scores and visual analog scale pain scores improved in both groups postoperatively. The difference between the groups was not significant. The results of the radiologic measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in either group. The comparison of both groups showed a significantly lower risk for wound healing problems in the percutaneous group. The hospitalization time was significantly shorter in the percutaneous group.

CONCLUSION:

Because of the excellent results with the percutaneous calcaneal osteotomy, the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy, especially patients at high risk for wound healing problems.

LEVEL OF EVIDENCE:

Level III, comparative series.

Calcaneal Osteotomy Safe Zone to Prevent Neurological Damage: Fact or Fiction?

BACKGROUND

Calcaneal osteotomy is a commonly used surgical option for the correction of hindfoot malalignment. A previous cadaveric study described a neurological "safe zone" for calcaneal osteotomy. We performed a retrospective chart review to evaluate the presence of neurological injuries following calcaneal osteotomies and the location of the osteotomy in relation to the reported safe zone.

METHODS

In this retrospective study, we reviewed charts of patients who underwent calcaneal osteotomy at our institution from 2011 to 2015. All immediate postoperative radiographs were examined and the shortest distance between the calcaneal osteotomy line and a reference line connecting the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia was measured. If the osteotomy line was positioned within an area 11.2 mm anterior to the reference line, it was considered to be inside the neurological safe zone. We correlated the positioning of the osteotomy with the presence of postoperative neurological complications.

RESULTS

We identified 179 calcaneal osteotomy cases. Of the 174 (97.2%) nerve injury-free cases, 62.6% (109/174) were performed inside the defined "safe zone" while 37.4% (65/174) outside. A total of 5 (2.8%) nerve complications were identified: 3 (60%) were inside the safe zone and 2 (40%) outside the safe zone. Osteotomies outside the safe zone had a 1.114 relative risk of nerve injury with a 95% CI of 0.191 to 6.500 and showed no statistically significant difference ( P = .9042).

CONCLUSION

Our findings suggest that the clinical "safe zone" in calcaneal osteotomies may not actually exist, likely because of wide anatomical variation of the implicated nerves, as described in prior studies. Patients should be properly counseled preoperatively on the low, but seemingly fixed, risk of nerve injury before undergoing calcaneal osteotomy.

LEVELS OF EVIDENCE

Level III: Retrospective comparative study.

Plantar Fascia Release Through a Single Lateral Incision in the Operative Management of a Cavovarus Foot: A Cadaver Model Analysis of the Operative Technique

Plantar fascia release and calcaneal slide osteotomy are often components of the surgical management for cavovarus deformities of the foot. In this setting, plantar fascia release has traditionally been performed through an incision over the medial calcaneal tuberosity, and the calcaneal osteotomy through a lateral incision. Two separate incisions can potentially increase the operative time and morbidity. The purpose of the present study was threefold: to describe the operative technique, use cadaveric dissection to analyze whether a full release of the plantar fascia was possible through the lateral incision, and examine the proximity of the medial neurovascular structures to both the plantar fascia release and calcaneal slide osteotomy when performed together. In our cadaveric dissections, we found that full release of the plantar fascia is possible through the lateral incision with no obvious damage to the medial neurovascular structures. We also found that the calcaneal branch of the tibial nerve reliably crossed the osteotomy in all specimens. We have concluded that both the plantar fascia release and the calcaneal osteotomy can be safely performed through a lateral incision, if care is taken when completing the calcaneal osteotomy to ensure that the medial neurovascular structures remain uninjured.

Comparison of Anatomic Structures at Risk With 2 Lateral Lengthening Calcaneal Osteotomies

BACKGROUND:

Lateral lengthening calcaneal osteotomies (LLCOT) are commonly used to treat flexible pes planovalgus deformity. Different operative techniques have been described. The aim of this study was to examine which anatomic structures were affected by 2 different osteotomy techniques.

METHODS:

Two experienced foot and ankle surgeons each performed an Evans (E)- or Hintermann (H) osteotomy on 7 cadaver feet. The mean age of the donors was 80.4 ± 4.4 years. Eight left and 6 right feet were prepared. Previously identified structures at risk were prepared and evaluated.

RESULTS:

After H-LLCOT, there was no damage of the peroneus longus tendon, whereas after E-LLCOT, damage was noted in 1 case (14.3%). The peroneus brevis tendon was once cut after H-LLCOT and eroded after E-LLCOT. In one cadaver, the sural nerve was partially damaged after H-LLCOT but in no case after E-LLOCT. The calcaneal anterior and medial articular facets were intact after H-LLCOT in 100% and 85.7% and after E-LLCOT in 42.9% and 71.4%, respectively. The posterior articular surface was not affected in any cadaver.

CONCLUSION:

Anatomic structures can be damaged after both osteotomies. With the Hintermann osteotomy, the calcaneal anterior and medial articular surface can be protected to a larger extent than with the Evans osteotomy.

CLINICAL RELEVANCE:

The Hintermann osteotomy seems to be superior, regarding damage of the articular surfaces of the subtalar joint. These findings have to be correlated with biomechanical and clinical studies before a final recommendation can be given, which osteotomy is superior.

Lateralizing Calcaneal Osteotomies and Their Effect on Calcaneal Alignment: A Three-Dimensional Digital Model Analysis

BACKGROUND

Few authors have directly compared multiple types of lateralizing calcaneal osteotomies (LCOs) in terms of their ability to achieve deformity correction. The aim of this research was to use a digital model of a varus hindfoot to compare 4 different LCOs in terms of deformity correction and amount of tuberosity lateralization required. The authors hypothesis was that osteotomies involving a wedge resection would achieve greater correction with less lateralization.

METHODS

A weightbearing computed tomographic scan of a patient with a varus hindfoot deformity was used to construct a 3-dimensional digital model of the hindfoot, preserving weightbearing alignment. Four different LCOs were modeled: a standard oblique osteotomy, a Dwyer osteotomy, a modified Dwyer osteotomy involving lateralization in addition to wedge resection, and a Malerba Z-type osteotomy with wedge resection and lateralization. Incremental corrections were performed with each osteotomy type, and amount of correction was assessed with a vertical hindfoot angle and measurement of the lateral translation of the most inferior aspect of the calcaneus. Calcaneal length and osteotomy contact surface area were also measured.

RESULTS

The modified Dwyer osteotomy led to the greatest improvements in the vertical hindfoot angle and lateral translation, followed by the Malerba osteotomy. The standard and Malerba osteotomies allowed the most preservation of calcaneal length; the Malerba and Dwyer osteotomies had the greatest contact surface area.

CONCLUSION

LCOs that involve wedge resection as well as lateralization were able to achieve the greatest correction of hindfoot varus.

CLINICAL RELEVANCE

For the surgical treatment of cavovarus foot deformities, osteotomies with wedge resection in addition to lateralization enable more powerful correction.

Rate of Neurologic Injury Following Lateralizing Calcaneal Osteotomy Performed Through a Medial Approach

BACKGROUND

Calcaneal osteotomies are commonly used to correct varus hindfoot alignment in patients with symptomatic cavovarus deformity. Translational, closing wedge, and Malerba-type osteotomies have been implicated in the development of tarsal tunnel syndrome and neurologic injury to branches of the tibial nerve. The authors hypothesized that there would be minimal clinically important injury to the tibial nerve by performing a translational calcaneal osteotomy from a medial approach.

METHODS

All patients undergoing a cavovarus reconstruction by a single surgeon were identified. Patients were included if they underwent a lateralizing calcaneal osteotomy via medial approach. Demographics, operative reports, and clinic notes were reviewed to identify concomitant procedures performed, incidence of postoperative tarsal tunnel syndrome, complications, and preoperative and postoperative nerve examinations. Postoperative radiographs were reviewed for location of the osteotomy relative to the posterior tubercle.

RESULTS

Twenty-four patients underwent lateralizing calcaneal osteotomy via a medial approach. Of the osteotomies, 83.3% (20/24) were in the middle third of the calcaneus, with a mean of 11.6-mm translation. No patients developed postoperative tarsal tunnel syndrome or tibial nerve palsy.

CONCLUSION

Lateralizing calcaneal osteotomy performed via a medial approach had a clinically negligible incidence of neurologic injury. Adequate translation was achieved to obtain correction of varus hindfoot deformity. The authors believe that there is less direct and less percussive injury to branches of the tibial nerve when performing the osteotomy from medial to lateral. This technique may represent an operative strategy to minimize risk to the tibial nerve and reduce neurologic deficit following cavovarus reconstruction.

LEVEL OF EVIDENCE

Level IV, case series.

Ankle Fusion Combined With Calcaneal Sliding Osteotomy for Severe Arthritic Ball and Socket Ankle Deformity

BACKGROUND

Although a ball and socket ankle deformity is usually congenital and asymptomatic, abnormal inversion and eversion mobility can result in recurrent ankle sprain and osteoarthritis. This retrospective study was performed to evaluate the clinical and radiologic outcomes of ankle fusion combined with calcaneal sliding osteotomy for severe arthritic ball and socket ankle deformity.

METHODS

Fourteen patients with severe arthritic ball and socket ankle deformity were followed for more than 3 years after operation. The clinical evaluation consisted of American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS) for pain, and subjective satisfaction score. The period to fusion and union of osteotomy, the change of hindfoot alignment angle, and complications were evaluated radiologically.

RESULTS

AOFAS and FAAM scores were significantly improved from an average of 37.4 and 34.5 points to 74.6 and 78.5 points, respectively. VAS for pain with walking over 20 minutes was significantly improved from an average of 8.4 points to 1.9 points. The average satisfaction score of patients was 88.9 points. The difference in heel alignment angle (compared to contralateral side) was significantly improved from an average of 34.8 to 5.4 degrees. There were 2 cases of progressive arthritis in an adjacent joint and 1 case of failed fusion.

CONCLUSIONS

Ankle fusion combined with calcaneal sliding osteotomy can be an effective operative option for ball and socket ankle deformity with advanced arthritis. In spite of increased complication rate, reliable pain relief, and restoration of gait ability through correcting hindfoot malalignment could improve the quality of life.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Effects on the Tarsal Tunnel Following Malerba Z-type Osteotomy Compared to Standard Lateralizing Calcaneal Osteotomy

BACKGROUND

Tarsal tunnel syndrome is a known complication of lateralizing calcaneal osteotomy. A Malerba Z-type osteotomy may preserve more tarsal tunnel volume (TTV) and decrease risk of neurovascular injury. We investigated 2 effects on the tarsal tunnel of the Malerba osteotomy compared to a standard lateralizing osteotomy using a cadaveric model: (1) the effect on TTV as measured by magnetic resonance imaging (MRI) and (2) the proximity of the osteotomy saw cuts to the tibial nerve.

METHODS

Ten above-knee paired cadaveric specimens underwent MRI of the ankle to obtain a baseline measurement of TTV. One foot in each pair received a standard lateralizing calcaneal osteotomy, with the other foot receiving a Malerba osteotomy. MRIs were performed after each of 3 increasing amounts of lateral displacement, which were accompanied by increasing amounts of wedge resection in the Malerba osteotomy group. TTV was measured on MRI using previously described and validated parameters. Differences in TTV with osteotomy type, displacement, and their interaction were assessed with generalized estimating equations. After all MRIs were completed, each specimen was dissected and the nearest distance of tibial nerve branches to the osteotomy site was measured.

RESULTS

Baseline TTV averaged 13 229 ± 2354 mm(3) and did not differ between groups (P = .386). TTV decreased on average by 7% after the first translation, 14% after the second, and 27% after the third (P < .005 for each). The magnitude of the decrease in TTV did not differ between those specimens with standard osteotomies versus those with Malerba osteotomies (P = .578). At least one of the major branches of the tibial nerve crossed the osteotomy site in 5 of 5 specimens that received the Malerba osteotomy versus 2 of 5 that received a standard osteotomy.

CONCLUSION

Regardless of osteotomy type, lateralizing calcaneal osteotomy decreased TTV. In all specimens, the osteotomy was at the level of branches of the tibial nerve.

CLINICAL RELEVANCE

Our results demonstrate that lateralizing calcaneal osteotomies must be performed with care to avoid excessive lateral translation as well as direct nerve injury on the nonvisualized medial side of the calcaneus.

Safe Zone for Neural Structures in Medial Displacement Calcaneal Osteotomy: A Cadaveric and Radiographic Investigation

BACKGROUND

We aimed to define reference lines on standard lateral ankle radiographs that could be used intraoperatively to minimize iatrogenic nerve injury risk in medial displacement calcaneal osteotomy.

METHODS

Forty cadaveric specimens were used. In 20 specimens, the sural, medial plantar (MP), and lateral plantar (LP) nerves were sutured to radiopaque wire, and a lateral ankle radiograph was obtained. On the radiograph, a line was drawn from the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia and labeled as the "landmark line." A parallel line was drawn 2 mm posterior to the most posterior nerve, and the area between these lines was defined as the safe zone. In 20 additional specimens, an osteotomy was performed 1 cm anterior to the landmark line using a percutaneous or open technique. Dissection was performed to assess for laceration of the sural, MP, LP, medial calcaneal (MC), or lateral calcaneal (LC) nerves.

RESULTS

The safe zone was determined to be within the area 11.2 ± 2.7 mm anterior to the landmark line. After open osteotomy, lacerations were found in 3 of 10 MC nerves and 3 of 10 LC nerves. After percutaneous osteotomy, lacerations were found in 2 of 10 MC nerves and 1 of 10 LC nerves. No lacerations of the sural, MP, or LP nerves were found with either osteotomy.

CONCLUSIONS

The safe zone extended 11.2 ± 2.7 mm anterior to the described landmark line. The MC and LC nerves were always at risk during medial displacement calcaneal osteotomy.

CLINICAL RELEVANCE

Nerve injury to both major and minor sensory nerves is likely underrecognized as a source of morbidity after calcaneal osteotomy. The current study provides a ready intraoperative guideline for minimizing this risk.

Midterm Follow-Up of Talectomy for Severe Rigid Equinovarus Feet

Rigid equinovarus foot is a challenging problem. Talectomy has been advocated as a salvage procedure to achieve a plantigrade painless foot in the treatment of rigid equinovarus deformity. The present prospective observational study evaluated the effectiveness of talectomy in the treatment of Dimeglio grade IV rigid equinovarus feet. Nineteen feet in 13 patients were treated by talectomy from September 2001 through January 2012 (10-year, 2-month period). Of the 13 patients, 9 (69.23%) had a foot deformity due to arthrogryposis multiplex congenita and 1 (7.69%) each due to sacral agenesis, spastic cerebral palsy, neglected congenital talipes equinovarus, and post-traumatic contracture. Of the 13 patients, 9 (69.23%) were male and 4 (30.77%) were female. Their mean age was 7.7 (range 3 to 26) years. The mean follow-up duration was 6.4 (range 2 to 11) years. Along with talectomy, excision of the navicular was performed in 8 feet (42.11%), calcaneal osteotomy with a laterally based wedge in 8 (42.11%), and calcaneocuboid fusion in 3 feet (15.79%). Postoperatively, all the feet improved to Dimeglio grade II and were painless, and 16 feet (84.22%) were plantigrade; 1 foot (5.26%) had residual equinus resulting from incomplete removal of the talus and 2 (10.53%) had residual varus. Also, 3 feet (15.79%) had forefoot adduction (2 residual and 1 recurrent) that required a second surgery to correct the deformity. From our experience, talectomy is an effective procedure for correction of severe rigid equinovarus feet, provided that the talus is completely removed and the calcaneus is positioned correctly in the ankle mortise.

Optimal Position of the Heel Following Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity

BACKGROUND

While previous work has demonstrated a linear relationship between the amount of medializing calcaneal osteotomy (MCO) and the change in radiographic hindfoot alignment following reconstruction, an ideal postoperative hindfoot alignment has yet to be reported. The aim of this study was to identify an optimal postoperative hindfoot alignment by correlating radiographic alignment with patient outcomes.

METHODS

Fifty-five feet in 55 patients underwent flatfoot reconstruction for stage II adult-acquired flatfoot deformity (AAFD) by 2 fellowship-trained foot and ankle orthopedic surgeons. Hindfoot alignment was determined as previously described by Saltzman and el-Khoury.(23) Changes in pre- and postoperative scores in each Foot and Ankle Outcome Score (FAOS) subscale were calculated for patients in postoperative hindfoot valgus (≥0 mm valgus, n = 18), mild varus (>0 to 5 mm varus, n = 17), and moderate varus (>5 mm varus, n = 20). Analysis of variance and post hoc Tukey's tests were used to compare the change in FAOS results between these 3 groups.

RESULTS

At 22 months or more postoperatively, patients corrected to mild hindfoot varus showed a significantly greater improvement in the FAOS Pain subscale compared with patients in valgus (P = .04) and the Symptoms subscale compared with patients in moderate varus (P = .03). Although mild hindfoot varus did not differ significantly from moderate varus or valgus in the other subscales, mild hindfoot varus did not perform worse than these alignments in any FAOS subscale. No statistically significant correlations between intraoperative MCO slide distances and FAOS subscales were found.

CONCLUSIONS

Our study indicates that correction of hindfoot alignment to between 0 and 5 mm of varus on the hindfoot alignment view (clinically a straight heel) following stage II flatfoot reconstruction was associated with the greatest improvement in clinical outcomes following hindfoot reconstruction in stage II AAFD.

LEVEL OF EVIDENCE

Level III, comparative series.

Complications of minimally invasive calcaneal osteotomy versus open osteotomy

BACKGROUND

Calcaneal osteotomy is an established technique for correcting hindfoot deformity. Patients traditionally receive an osteotomy through the open lateral approach to the calcaneus. To reduce the rate of wound complications associated with a direct open lateral approach, a minimally invasive surgical (MIS) technique has been adopted. This uses a low-speed, high-torque burr to perform the same osteotomy under radiographic guidance. We hypothesized that the new MIS calcaneal osteotomy would be a safe alternative to open calcaneal osteotomy while obtaining the same displacement.

METHODS

The safety of the new MIS technique was investigated with a case controlled study on all patients who underwent displacement calcaneal osteotomy at the Nuffield Orthopaedic Centre from 2008 to 2014. The primary outcome measure was 30 day postoperative complication rate. Secondary outcome measures included operating time, duration of stay, fusion rates, and calcaneal displacement. Eighty-one patients underwent calcaneal osteotomy as part of their corrective surgery, 50 in the Open approach group and 31 in MIS group. The average age was 47.7 years (range 16-77) for the Open group and 50.1 (range 21-77) in the MIS group.

RESULTS

A mean calcaneal displacement of 9.4 mm (SD = 1.16, 8 to 11 mm) and 10.2 mm (SD = 1.06, 8 to 13 mm) was achieved through the MIS and Open approaches, respectively. There were significantly fewer wound complications in the MIS group (6.45%) compared to the Open group (28%, P = .022). The MIS group was associated with significantly lower rate of wound infection (3% versus 20%, P = .044). Three patients in the Open group experienced sural peripheral neuropathy. The average length of stay was 3.8 days following MIS and 4.3 days following open calcaneal osteotomy. Nonunion occurred in only 1 patient in the MIS group and none in the open group.

CONCLUSIONS

MIS calcaneal osteotomy was found to be a safe technique. It was technically as effective as calcaneal osteotomy performed through an open lateral approach but was associated with significantly fewer wound complications and fewer nerve complications.

LEVEL OF EVIDENCE

Level III, comparative study.

Long-term follow-up of flexor digitorum longus transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (sd 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Screw size and insertion technique compared with removal rates for calcaneal displacement osteotomies

BACKGROUND

The calcaneal displacement osteotomy is frequently used by foot and ankle surgeons to correct hindfoot angular deformity. Headed compression screws are often used for this purpose, but a common complication is postoperative plantar heel pain from prominent hardware. We evaluated hardware removal rates after calcaneal displacement osteotomies and analyzed technical factors including screw size, position, and angle. We hypothesized that larger screws placed more plantarly would have been removed more frequently. We also believed that although 2 smaller screws cost more initially, when removal rates and cost are accounted for, savings would be demonstrated with this technique.

METHODS

We retrospectively collected data on type of fixation, cost of fixation, and frequency of removal. After exclusions we had 30 patients in our screw removal cohort and 119 in our screws retained cohort. A basic cost analysis and statistical analysis was performed.

RESULTS

The small screw group had a hardware removal rate of 9% (4/43) compared to 25% (26/104) of the larger screw group (P = .032). While the cost of 2 smaller screws is more than that of 1 larger screw, when the cost of removal and the rates of doing so are considered, the smaller screws resulted in substantial cost savings.

CONCLUSION

Technical considerations for the medial displacement calcaneal osteotomy, including the use of multiple smaller screws, provided for a lower rate of hardware removal and likely decreased long-term costs.

LEVEL OF EVIDENCE

Level III, comparative series.

Medial displacement calcaneal osteotomy using minimally invasive technique

BACKGROUND

Medial displacement calcaneal osteotomy is a common procedure often used as part of pes planovalgus deformity correction. Traditionally the osteotomy is performed using a direct lateral or extended lateral approach, which may carry the risk of wound problems, infection and neurovascular injury. The authors describe a minimally invasive technique to perform the osteotomy and achieve the desired correction. The article illustrates our experience and learning curve with the use of this technique as an option for calcaneal osteotomy.

METHODS

We retrospectively reviewed the records of a sequential series of patients since 2011 whose calcaneal osteotomies were performed by 2 surgeons, after cadaveric training using a minimally invasive operative approach. Prior to 2011, similar surgeries, performed by the senior authors, were undertaken using a direct lateral approach. Thirty cases were identified; 29 had tibialis posterior reconstruction coupled with calcaneal osteotomy for acquired flexible planovalgus deformity and 1 patient had surgery for a malunited calcaneal fracture.

RESULTS

Radiological and clinical union occurred in all 30 cases (100%). The radiographs of all cases were reviewed by a specialist musculoskeletal radiologist. There were no neurovascular or wound complications. All patients had restoration of neutral hindfoot alignment. One patient required screw removal after union, resolving all symptoms.

CONCLUSION

This series suggests that minimally invasive calcaneal osteotomy surgery can achieve excellent union rates aiding correction of deformity with no observed neurovascular or soft tissue complications. For surgeons experienced in open surgery, there is a short learning curve after appropriate training.

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.

The effect of medial and lateral calcaneal osteotomies on the tarsal tunnel

BACKGROUND

As an entrapment phenomenon, tarsal tunnel syndrome has been described after calcaneal osteotomy, and since the tibial nerve has also been shown to be very sensitive to ankle position, position of the calcaneus after osteotomy and displacement was thought to likely influence the environment of the tibial nerve within the tarsal canal. The respective volume of the tarsal canal was therefore hypothesized to decrease with medial or lateral displacement osteotomies of the calcaneus.

METHODS

Anterior and posterior calcaneal osteotomies were made in cadaveric matched pairs and brought through sequential medial and lateral displacements. Magnetic resonance imaging was used to estimate the comparative resultant volume of the tarsal canal after each of these new positions were assumed, as compared with baseline. The proximity of the osteotomy cut to the nerve's location was also measured.

RESULTS

The tarsal tunnel volume was calculated for all 5 displacement states and were as follows: far-lateral (9506 mm(3)), near-lateral (10 073 mm(3)), normal (11 839 mm(3)), near-medial (11 489 mm(3)), and far-medial (11 760 mm(3)). No significant difference in tarsal tunnel volume was identified between the normal, nondisplaced specimens in the anterior or posterior groups (11 954 mm(3) vs 11 809 mm(3)). No difference in tarsal tunnel volume was identified between the anterior and posterior osteotomies at any of the 4 displacements. The distance from tibial nerve to the medial exit site of the osteotomy was found to be significantly less in the anterior group compared to the posterior group (4 mm vs 14.2 mm, P < .0001).

CONCLUSION

Lateral, but not medial, osteotomy fragment displacement results in significant reduction of tarsal tunnel volume. The location of the cut does not seem to affect any substantive change in volume. Anteriorly placed osteotomies appear to jeopardize the neurovascular structures more than posteriorly placed osteotomies.

CLINICAL RELEVANCE

These findings provide surgeons with clinical evidence in support of performing a prophylactic tarsal tunnel release for patients undergoing lateralizing calcaneal osteotomies.

Geometry of the lateral sliding, closing wedge calcaneal osteotomy: review of the two methods and technical tip to minimize shortening

BACKGROUND

A lateral closing wedge osteotomy is used for correction of varus hindfoot deformities. Since its original description, different techniques and geometries of the calcaneal bone wedge resection have been described. Even though the techniques seem similar, very different final bone architectures result from each technique, the effects of which are not known. This paper explores several of these techniques and the implications in deformity correction as well as the secondary effects of calcaneal shortening.

METHODS

Mathematical and geometric analysis is performed in 2-dimensions for several hypothetical calcaneal osteotomies as described by the original authors. The resulting changes are calculated and compared.

RESULTS

The shape of the bone resection for the lateral closing wedge osteotomy does not result in significantly different final calcaneal architectures. Both techniques studied result in the same amount of calcaneal shortening and deformity correction. However, when lateral calcaneal wedge resection is combined with lateral translation of the tuberosity for additional deformity correction, more calcaneal shortening is seen with posteriorly directed osteotomies than those that are transverse.

CONCLUSION

The lateral closing wedge osteotomy of the calcaneus results in correction of varus hindfoot deformity at the expense of some calcaneal shortening. Lateral translation of the tuberosity may result in additional calcaneal. The clinical effects of calcaneal shortening or medial soft tissue or nerve tethering from these different techniques are unknown and deserve further investigation.

LEVEL OF EVIDENCE

Level V, expert opinion.

A comparative study of incorporation rates between non-xenograft and bovine-based structural bone graft in foot and ankle surgery

Several types of structural bone grafts are available, each with different characteristics. Our previous study showed poor performance with the bovine-based xenograft in foot and ankle applications. In the present study, we compared the incorporation rates of non-xenografts, including allografts and autografts, with the bovine-based xenograft to determine whether the poor result was unique to the graft type and not institutional. The proportion of incorporated grafts at 12, 24, 36, and 48 weeks was compared between the nonxenograft and xenograft groups. Furthermore, Cox regression analysis was used to evaluate the factors associated with nonunion. A total of 61 patients (23 women and 38 men) with a median age of 24.0 years were enrolled. The factors associated with slower incorporation included side of operation (p = .033), tobacco use (p = .010), and graft type (p = .001). At 48 weeks, 5% of the nonxenografts and 58% of the xenografts were not incorporated. The median incorporation time for the non-xenograft and xenograft group was 16 and 57 weeks, respectively. We have concluded that it is not advisable to use a bovine-based bone xenograft in foot and ankle surgery.

Ankle joint pressure changes in a pes cavovarus model: supramalleolar valgus osteotomy versus lateralizing calcaneal osteotomy

BACKGROUND

A fixed cavovarus foot deformity can be associated with anteromedial ankle arthrosis due to elevated medial joint contact stresses. Supramalleolar valgus osteotomies (SMOT) and lateralizing calcaneal osteotomies (LCOT) are commonly used to treat symptoms by redistributing joint contact forces. In a cavovarus model, the effects of SMOT and LCOT on the lateralization of the center of force (COF) and reduction of the peak pressure in the ankle joint were compared.

METHODS

A previously published cavovarus model with fixed hindfoot varus was simulated in 10 cadaver specimens. Closing wedge supramalleolar valgus osteotomies 3 cm above the ankle joint level (6 and 11 degrees) and lateral sliding calcaneal osteotomies (5 and 10 mm displacement) were analyzed at 300 N axial static load (half body weight). The COF migration and peak pressure decrease in the ankle were recorded using high-resolution TekScan pressure sensors.

RESULTS

A significant lateral COF shift was observed for each osteotomy: 2.1 mm for the 6 degrees (P = .014) and 2.3 mm for the 11 degrees SMOT (P = .010). The 5 mm LCOT led to a lateral shift of 2.0 mm (P = .042) and the 10 mm LCOT to a shift of 3.0 mm (P = .006). Comparing the different osteotomies among themselves no significant differences were recorded. No significant anteroposterior COF shift was seen. A significant peak pressure reduction was recorded for each osteotomy: The SMOT led to a reduction of 29% (P = .033) for the 6 degrees and 47% (P = .003) for the 11 degrees osteotomy, and the LCOT to a reduction of 41% (P = .003) for the 5 mm and 49% (P = .002) for the 10 mm osteotomy. Similar to the COF lateralization no significant differences between the osteotomies were seen.

CONCLUSION

LCOT and SMOT significantly reduced anteromedial ankle joint contact stresses in this cavovarus model. The unloading effects of both osteotomies were equivalent. More correction did not lead to significantly more lateralization of the COF or more reduction of peak pressure but a trend was seen.

CLINICAL RELEVANCE

In patients with fixed cavovarus feet, both SMOT and LCOT provided equally good redistribution of elevated ankle joint contact forces. Increasing the amount of displacement did not seem to equally improve the joint pressures. The site of osteotomy could therefore be chosen on the basis of surgeon's preference, simplicity, or local factors in case of more complex reconstructions.

Chronic insertional Achilles tendinopathy: surgical outcomes

BACKGROUND AND OBJECTIVE

insertional Achilles tendinopathy is a common condition among athletes and joggers. One fifth of the injuries involves the insertion of the tendon. The etiology is either due to mechanical overuse related to sports activity, or a systemic inflammatory disease. The clinical appearance includes pain and movement restriction. The primary treatment is conservative. The surgery referred to in this study (Calcaneal Osteotomy) is performed by decompression of the posterior margin of the calcaneus. If the tendon is degenerative, debridement is needed. There is controversy on the surgical outcome and the surgical approach. A retrospective analytic observational study.

METHODS

20 patients who were diagnosed with IAT (21 feet) and were operated on between the years 2000-2007 by calcaneal osteotomy.

MAIN OUTCOME MEASURES

the primary measure of success was diminished pain. It was demonstrated in the AOFAS score and in the VAS scale of pain.

RESULTS

the average grade in the AOFAS questionnaire improved by 20 points, and the average grading of pain in the VAS scale was decreased by 4.21. The median satisfaction rate was 8, the average was 5.81. 62% of the patients would repeat the surgery/recommend it. We found a significant relationship (p=0.022) between patients who avoided sports activity while suffering from insertional Achilles tendinopathy and the satisfaction rate from the surgery.

CONCLUSIONS

using the calcaneal osteotomy technique as a surgical treatment for IAT is successful, and improves measures of pain and function. Low compliance with avoiding sports activity while suffering from an IAT might lead to a need for surgery.

The influence of foot geometry on the calcaneal osteotomy angle based on two-dimensional static force analyses

BACKGROUND

Malalignment of the hindfoot can be corrected with a calcaneal osteotomy (CO). A well-selected osteotomy angle in the sagittal plane will reduce the shear force in the osteotomy plane while walking. The purpose was to determine the presence of a relationship between the foot geometry and loading of the calcaneus, which influences the choice of the preferred CO angle.

METHODS

A static free body force analysis was made of the posterior calcaneal fragment in the second half of the stance phase to determine the main loads: the plantar apeunorosis (PA) and Achilles tendon (AT). The third load is on the osteotomy surface which should be oriented such that the shear component of the force is zero. The force direction of the PA and AT was measured on 58 MRIs of the foot, and the force ratio between both structures was taken from the literature. In addition the PA-to-AT force ratio was estimated for different foot geometries to identify the relationship.

RESULTS

Based on the wish to minimize the shear force during walking, a mean CO angle was determined to be 33° (SD8) relative to the foot sole. In pes planus foot geometry, the angle should be higher than the mean. In pes cavus foot geometry, the angle should be smaller.

CONCLUSION

Foot geometry, in particular the relative foot heights is a determinant for the individual angle in performing the sliding calcaneal osteotomy. It is recommended to take into account the foot geometry (arch) when deciding on the CO angle for hindfoot correction.