Calcaneal Osteotomy - Indications, Contraindications, Techniques, and Complications

Introduction:

The calcaneus is the large heel bone that is articulated with the talus bone of the ankle and the cuboid bone of the feet. It plays an important role in walking. The position of the calcaneus also has great significance for foot alignment during weight bearing. Calcaneus osteotomy (surgical cutting of bone for realignment or reshaping) plays an important role in restoring hindfoot biomechanics. Calceneus osteotomy realigns the tuberosity and redirects the pull of the achilles tendon, thus producing a corrective force. The Calceneus osteotomy procedure was popularized by Dwyer in the 1950s.

What Are the Indications and Contraindications for the Calcaneal Osteotomy?

• Calcaneal osteotomy is a joint-sparing extra-articular procedure for correcting planovalgus (flattening of the medial longitudinal arch of the foot) and cavovarus (a foot deformity characterized by a high arch) foot deformities.

• At first, conservative or non-surgical treatment options are used for correction. These include foot and ankle orthoses. Surgical management is considered in cases where conservative treatment options like orthotics, analgesic medications, physical therapy, fail to reduce the patient’s symptoms.

• Calcaneal osteotomy is contraindicated in the case of pre-existing subtalar arthritis (arthritis that affects the joint below the ankle joint in the hindfoot).

• Other relative contraindications include:

• Diabetes.

• Obesity.

• Smoking.

• Peripheral edema (fluid accumulation leading to swelling, usually in the lower limbs).

• Skin conditions.

• Peripheral vascular disease (a progressive blood circulation disorder that restricts blood flow to legs, arms, and other body parts).

What Are the Different Calcaneal Osteotomy Techniques?

• The patient is supine (lying flat on one’s back) or in a lateral position.

• A sandbag is placed under the hip (on the same side) and under the feet to improve access.

• An oblique incision at a 45 degree angle to the sole is placed for proximal osteotomy procedures to minimize sural nerve injury.

• For distal calcaneal osteotomy procedures, a 5-centimeter-long longitudinal incision is placed.

1. Lateral Column Lengthening Osteotomy: Evans described a lateral column lengthening osteotomy. In this procedure, an overcorrected clubfoot deformity was corrected. The foot arch is corrected by lengthening the lateral column and medially rotating the hindfoot and forefoot. The lateral column lengthening osteotomy is combined with a medial translational osteotomy in patients with severe flat foot defects.

2. Single-Plane Translational Osteotomy: Single-plane translational osteotomy is used for realigning the posterior part of the foot tripod. Depending on the type of deformity, the tuberosity can be translated proximally, medially, laterally, distally, or combined. Mostly, lateral translation is used for correcting cavovarus deformity, and medial translation is used for correcting planovalgus deformity. The procedure is done using a power saw. It is carried out with the utmost care to prevent overpenetration of the blade into the medial neurovascular structures. A translational single planar osteotomy is also done using a percutaneous technique. In this procedure, the Gilgi saw is tunneled deep into the neurovascular structures near the medial wall of the calcaneus. Both sides of the Gilgi saw are inferior and superior to the calcaneus. The sawing technique should be done carefully to prevent damage from the lateral stab incision.

3. Closing Wedge Osteotomy: Dwyer, in 1959, first described the lateral closing wedge osteotomy. The approach used is the same as that of translational osteotomy. Before bone stabilization, an 8 to 12 millimeter lateral bone wedge is removed. In this technique, the weight-bearing portion of the heel is displaced laterally. This technique is beneficial in cases where there is overloading on the lateral heel edge. The risk of an injury to neurovascular structures is minimal with this technique.

4. Complex Osteotomy: Complex Osteotomy is a Z osteotomy procedure, with oblique superior and inferior incisions. A wedge is sometimes placed on the distal inferior cut, as in Evans osteotomy.

What Are the Complications of Calcaneal Osteotomy?

The complications associated with calcaneal osteotomy are:

• Painful hardware is a common complication of calcaneal osteotomy.

• Overcorrection (uncommon complication).

• Under correction.

• Nerve injury (injury to the sural nerve).

• Heel cord tightness.

• Local skin complications.

• Painful scars with or without nerve injury.

• Neuroma (a localized nerve tissue tumor) formation.

• Lateralizing calcaneal osteotomy is associated with Tarsal tunnel syndrome. Irritation to the nerve passing through the sinus tarsi and tarsal tunnel results in this condition. These can occur due to screw heads placed on the lateral plate or posteroinferior tuberosity for the Evans osteotomy technique.

• Infections.

• Tendon injury.

• Unhealing bone fragments.

• Bleeding.

• Blood clot formation.

• Anesthesia complications.

How Long Is the Recovery Period for the Calcaneal Osteotomy?

After the calcaneal osteotomy procedure, the incision is closed and sutured, and post-operative instructions will be given. The bone heals in about six weeks in most cases. Till then, the patient will be in a cast or boot. There is a restriction on weight-bearing during this period. After six weeks post-surgery, radiographs are taken to evaluate bone healing. If bone healing is proper, the patient is asked to start weight-bearing in cast boots. 12 weeks into the surgery, with proper bone healing, the patient can start using regular shoes.

What Are the Newer Innovations Related to the Calcaneal Osteotomy?

Some recent advances have been made in calcaneal osteotomy procedures, both in technique and implant development.

• A percutaneous technique that uses endoscopic assistance has been used for translational calcaneal osteotomy.

• A trabecular metal wedge has been used instead of lateral plate fixation and bone grafts in Evans osteotomy.

• But this newer approach requires more long-term follow-up and clinical comparative evidence.

• The cost of the newer approach should also be considered.

Conclusion:

Calcaneal osteotomy is a joint-sparing extra-articular procedure mainly used to correct planovalgus (flat foot) and cavovarus (high-arched foot) deformities. It is considered a reliable, powerful, and joint-preserving procedure. Even though the procedure started in the late nineteenth century, it still evolves with newer surgical approaches and implant developments. It is mostly done in cases where conservative treatment options fail. The surgical complications include anesthesia, nerve injuries, over/under correction, painful hardware. The recovery time period is around six to eight weeks.