Displacement Calcaneal Osteotomy Research Articles

MODIFIED MUBARAK TECHNIQUE FOR FLEXIBLE FLATFOOT CORRECTION IN CHILDREN AND ADOLESCENTS.

To describe the technique, analyze possible radiographic correction and evaluate the clinical result of medial and plantar calcaneal displacement osteotomy associated with opening wedge cuboid osteotomy for flexible flatfoot correction. 23 patients (30 feet) diagnosed with flexible flat foot treated with plantar and medial calcaneal displacement osteotomy associated with opening wedge cuboid osteotomy were evaluated retrospectively. In the lateral radiographs calcaneal pitch and Meary's angle were the radiographic parameters evaluated; while the talonavicular coverage angle was evaluated in the anteroposterior radiographs. To assess the clinical outcome of the surgical procedure, the American Orthopedic Foot and Ankle Society Score (AOFAS) for the ankle and hindfoot was adopted. The mean values of the evaluated angles and AOFAS score for ankle and hindfoot significantly improved when comparing pre- and postoperative values. Plantar and medial calcaneal displacement osteotomy associated with an opening wedge cuboid osteotomy is able to improve radiological and clinical parameters of child patients with flexible flatfoot. Level of Evidence III, Retrospective Comparative Study.

Adult-Acquired Flatfoot Deformity: Combined Talonavicular Arthrodesis and Calcaneal Displacement Osteotomy versus Double Arthrodesis.

Background: Adult-acquired flatfoot deformity due to posterior tibial tendon dysfunction (PTTD) is one of the most common foot deformities among adults. Hypothesis: Our study aimed to confirm that the combined procedures of calcaneal displacement osteotomy and talonavicular arthrodesis are equivalent to double arthrodesis. Methods: Between 2016 and 2020, 41 patients (13 male and 28 females, mean age of 63 years) were retrospectively enrolled in the comparative study. All deformities were classified into Stages II and III of PTTD, according to Johnson and Strom. All patients underwent isolated bony realignment of the deformity: group A (n = 19) underwent calcaneal displacement osteotomy and talonavicular arthrodesis, and group B (n = 23) underwent double arthrodesis. Measurements from the Foot Function Index-D (FFI-D) and the SF-12 questionnaire were collected, with a comparison of pre- and post-operative radiographs conducted. The mean follow-up period for patients was 3.4 years. Results: The mean FFI-D was 33.9 (group A: 34.5; group B: 33.5), the mean SF-12 physical component summary was 43.13 (group A: 40.9; group B: 44.9), and the mean SF-12 mental component summary was 43.13 (group A: 40.9; group B: 44.9). The clinical data and corrected angles showed no significant intergroup differences. Conclusion: Based on the available data, our study confirmed that the combined procedures of talonavicular arthrodesis and calcaneal shift, with preservation of the subtalar joint, can be considered equivalent to the established double arthrodesis, with no significant differences in terms of clinical and radiological outcomes.

Short-Term Outcomes of the Lapicotton Technique in the Treatment of Progressive Collapsing Foot Deformity

Category:Midfoot/ForefootIntroduction/Purpose:Medial column instability (MCI) in Progressive Collapsing Foot Deformity (PCFD) is not solely determined by forefoot varus (FV). First ray hypermobility, hallux valgus, midfoot arthritis, gapping at the tarsometatarsal joint and dorsal metatarsal migration are findings associated with MCI. Acknowledgement of this instability requires inclusion of a procedure to the medial column in order to correct the forefoot varus, stabilize the ray and bring the foot to a plantigrade tripod position. Cotton opening wedge medial cuneiform osteotomy and Lapidus tarsometatarsal arthrodesis are procedures of choice in these scenarios. We have combined these 2 procedures into one called Lapicotton. The purpose of this study was to present the short-term outcomes of this technique.We hypothesized that Lapicotton will improve both clinical and radiological outcomes.Methods:We performed an IRB-approved retrospective study comprising 3 PCFDs having benefited from a Lapicotton procedure. Clinical outcomes were assessed with the European Foot and Ankle Society Score (EFAS), the Foot Function Index Score (FFI) and the Pain Catastrophizing Scale (PCS). Radiographic outcomes were assessed using weight-bearing computed tomography (WBCT) assessments. Middle Cuneiform Floor distance, Forefoot Arch Angle, Middle Facet uncoverage percentage, Talonavicular Coverage angle and the Foot and Ankle Offset (FAO) were measured. All these data were both preoperatively and postoperatively collected. Comparison between preoperative and postoperative results were done as described below. The Kruskal-Wallis H-test for independent groups was used to compare median values of the EFAS. The Wilcoxon signed-rank test for paired samples was used to compare preoperative and postoperative variables of FFI and PCS. For the radiographic measurements, normality was assessed using Shapiro-Wilk test. Comparisons were made using Student tests for normal variables and Mann-Whitney for non-normals.Results:This small series included 2 female and 1 male, with a mean age of 56 and a mean BMI of 31.8 kg/m2. Mean follow up was 2.9+/-0.2 (range from 2.7 to 3.1) months. 2 out of 3 patients simultaneously benefited of a Medial Calcaneal Displacement Osteotomy (MDCO 10mm) and a Lateral Column Lengthening (LCL 8mm). The wedge sizes used for the Lapicotton were 8 mm in all cases. Regarding clinical outcomes, EFAS (p=0.79) and FFI (p=0.99) did not showed any significant improvement whereas PCS were significantly improved (Δ=-5.67[-9.2–2.2];p=0.03). Regarding radiological outcomes, fusion was present in all the cases at the maximal follow-up. Middle cuneiform floor distance and Forefoot Arch Angle were significantly increase (respectively Δ=6.9;CI95%=[6.4;7.4];p< 0.01 and Δ=7.5;CI95%=[4.3;10.8]p<0.05). Middle Facet uncoverage was significantly improved (Δ=- 28.8;CI95%=[-33.1;-24.5]p< 0.01). Statistical power of the serie did not allowed comparison regarding the Talonavicular Coverage Angle (Δ=-14;CI95%=[-24;-3.9]) and the FAO (Δ=-3.9;CI95%=[-10.7;2.9]).Conclusion:The Lapicotton procedure showed encouraging outcomes with fusion in all cases at 3 months postoperatively, improvement in pain, correction of forefoot varus and of the of the Peritalar subluxation represented by the Middle Facet Uncoverage. These results should be moderate because other procedures (MDCO and LCL) were performed in 2/3 of the patients, and the outcomes were issued from a small cohort with short-term follow-up. Longer follow-up and a larger cohort are needed to confirm these results.

Novel Minimally Invasive Sliding Calcaneal Osteotomy: A Case Series

Category:Hindfoot; AnkleIntroduction/Purpose:Sliding calcaneal displacement osteotomy is a mainstay in the treatment of hindfoot deformity. A lateral oblique or L shaped incision and direct visualization of the calcaneus is the traditional open approach to this osteotomy.Complications of this approach are not common and include wound dehiscence, delayed union, neurovascular damage, tarsal tunnel syndrome, symptomatic bony overhang and peroneal fibrosis. Several techniques have been developed to address the limitations of the open approach including osteotomy with a Gigli saw, percutaneous endoscopic assisted osteotomy, and most recently minimally invasive osteotomy (MICO) with a low speed, high torque burr. Each of these techniques has limitations. This report presents a simple minimally invasive technique that may help mitigate wound issues without the technical hurdles of a steep learning curve.Methods:Patients undergoing MICO procedures with the senior author from February 2019 - June 2020 who had not undergone previous foot/ankle surgery were retrospectively enrolled. Patients underwent clinical and radiographic assessment preoperatively as well as at 2, 6, 12, and 24 weeks postoperatively. The technique utilizes a 1.5cm incision along the plane of osteotomy, centered about a K-wire placed through both cortices of the calcaneus at the midpoint of the osteotomy plane. The plane and K-wire placement are determined under radiographic guidance. A micro-sagittal saw is rested on the K-wire and used as a cutting block in the coronal plane. After the osteotomy is created and mobility of the calcaneus confirmed, the K-wire is removed. The mobile segment is adjusted as needed, held in placed by dorsiflexing the ankle, and fixed using two posterior-to-anterior 6.5 cannulated screws, one 1cm superior to the other. The wounds can then be irrigated and closed.Results:37 patients were treated using this technique. 24 (65%) patients were female, with average age 56.9 years. Osteotomies were performed concomitantly with procedures including flexor digitorum longus transfer, subtalar fusion, triple arthrodesis, talonavicular fusion, hallux valgus corrective osteotomy, and Strayer gastrocnemius recession. Thirty-five (95%) patients achieved radiographic fusion within 1 year postoperatively with 28 (76%) fusing by 3-month follow up. Two (5%) patients developed a radiographic non-union without instability and opted to be managed expectantly. Of note, one patient is a diabetic current smoker with Rheumatoid Arthritis, while the other is a non-diabetic former smoker. A single patient was readmitted within 90 days for incision and debridement of a dehisced wound from subtalar fusion performed concomitantly. One patient underwent eventual removal of the screw compressing the calcaneal osteotomy site due to hardware prominence. No patients reported peroneal symptoms postoperatively. No patients reported any other complications related to the osteotomy.Conclusion:Sliding calcaneal displacement osteotomy is a well-established component in the treatment of hindfoot deformity. Although larger lateral oblique and L shaped incisions allow direct visualization of the osteotomy, more minimally invasive approaches have been used. The proposed technique in the current report offers a low non-union rate, minimal surgical footprint, easily available surgical instruments, reliable osteotomy plane, and short surgical time.

Headless vs. Headed Screws Fixation for Calcaneal Osteotomy and Subtalar Arthrodesis: What’s the Cost?

Category:Hindfoot; Ankle ArthritisIntroduction/Purpose:Screw prominence in the heel following calcaneal fixation has resulted in unacceptably high rates of symptomatic hardware and subsequent screw removal. The hardware removal rate following calcaneal screw fixation ranges from 11-50%. We are unaware of any cost analysis comparing headed screw fixation vs. headless screw fixation in the foot and ankle literature. Furthermore, there is no literature comparing the rate of subtalar arthrodesis following headed screw fixation vs. headless screw fixation.Methods:CPT codes were used to identify all patients that had a subtalar arthrodesis or displacement calcaneal osteotomy (with screw fixation) performed by a single orthopedic foot and ankle surgeon between 2010 and 2016. The cohort was divided into two groups by the type of screw fixation, 7.0 mm headless screw or 6.7 mm headed screw. Exclusion criteria included <2 years from the index surgery and AVN of the calcaneus or talus. Retrospective chart review was performed to collect demographic data, complications, and cause for screw removal. The primary outcome measure was the rate of symptomatic screw removal.Secondary outcome measure included subtalar arthrodesis as determined by CT or radiographic review. The expense associated with symptomatic hardware removal was determined and cost analysis was performed for the two groups.Results:Seventy-six patients underwent headless screw fixation for calcaneal osteotomy or subtalar arthrodesis, and only two patients (2.6%) required symptomatic screw removal. Fifty-four patients underwent headed calcaneal screw fixation, and twelve patients (22.2%) required symptomatic screw removal. Symptomatic hardware removal was performed more frequently in the headed screw group (p< 0.001). There was no difference in the rate of nonunion after subtalar arthrodesis between the two groups (p = 0.363). The calcaneal osteotomy healed in 100% of patients in both groups. The cost associated with isolated screw removal was compared for private insurance and Medicare at an outpatient surgery center. There was a $51,755 cost savings per 100 cases using headless screw fixation compared to headed screw fixation.Conclusion:The rate of symptomatic screw removal following calcaneal osteotomy or subtalar arthrodesis is lower with headless screw fixation compared to headed screw fixation. There was no difference in the rate of subtalar union between the two groups as a secondary outcome, but the study was underpowered. Although the headless screw implant is more expensive, cost analysis demonstrates a significant benefit when the expense of hardware removal is considered.

Medial Displacement Calcaneal Osteotomy: Loss of Correction with Varying Drilling Techniques

Category:HindfootIntroduction/Purpose:Surgical correction of Stage 2 posterior tibial tendon dysfunction typically involves a combination of soft tissue and bony corrections, often including a medial displacement calcaneal osteotomy (MDCO). This osteotomy is often fixated utilizing two parallel screws; however, it remains unknown how much correction is lost based on various accepted drilling techniques for common fixation of this osteotomy. Our cadaveric study compares three different surgical drilling techniques, using two parallel cannulated screws for fixation, to best maintain desired translation of the MDCO.Methods:Fifteen above knee, fresh-frozen, matched pair cadaveric specimens (30 limbs) were randomized equally into three groups. Calcanealosteotomies were performed, followed by manual 10 mm medial translation of the tuberosity. Two parallel 2.5mm guide wires were advanced across the osteotomy site under fluoroscopy. The first group involved a ‘staggered’ drilling technique in which one guide wire was over drilled to the osteotomy site with a 4.5mm cannulated drill and then a 7.0 mm cannulated screw was placed across the osteotomy, followed by a second screw in similar fashion. The second, ‘simultaneous’ group consisted of over drilling both guide wires sequentially followed by placement of both screws. The third control group involved simultaneously over drilling only the near cortex, followed by placement of the 2 screws. Following screw fixation, the calcaneal tuberosity was manually translated in a lateral direction. The loss of correction was then marked and measured in millimeters.Results:All thirty cadaveric specimens underwent standard medializing calcaneal displacement osteotomy without significant variation, or complication. Loss of medialization was measured in millimeters following a manual lateral displacing force after the screw fixation of the osteotomy. The ‘simultaneous’ drilling group experienced the greatest loss of medial displacement with the mean loss of correction being 2.6 mm (range 1.37 - 3.48 mm) following manual lateral translation. The ‘staggered’ group showed an average loss of 1.16 mm (range 0.36 - 2.67 mm). The control group, that simply involved drilling of the near cortex, demonstrated the greatest maintenance of medial displacement with a mean loss of only 0.036 mm (range 0.01 - 0.06 mm).Conclusion:Our cadaveric study comparing three different drilling techniques for maintaining the intended correction following MDCO demonstrates that simultaneous over drilling of only the tuberosity near cortex prior to screw fixation was the most resistant to loss of medial displacement; whereas mean loss of correction with simultaneous drilling of both wires to the osteotomy resulted in the greatest loss of correction at an average of 26%.

Analysis of Micromotion in a Talonavicular Arthrodesis With and Without a Calcaneal Displacement Osteotomy in a Cadaver Model

The isolated talonavicular joint arthrodesis can be beneficial to correct midfoot deformities involving the talonavicular joint, including collapsing pes planovalgus. Studies show that isolated talonavicular arthrodesis has a higher nonunion rate because of micromotion; thus, other procedures should be used in conjunction with it. We sought to determine if adding an adjunctive medial calcaneal displacement osteotomy helps to reduce the ground reactive force and, therefore, the micromotion on the talonavicular joint. We used 4 below-knee limbs to study the force placed on the joint in an isolated talonavicular arthrodesis compared with the same procedure with an adjunctive calcaneal osteotomy under weightbearing simulation. A 0.5-inch circular force sensing resistor was placed within the talonavicular and used to check the force on the joint after a 5-lb force was added to the proximal limb. The resistance was quantified with force measured as a direct inverse. This procedure was performed 3 times for each limb. The mean resistance before and after calcaneal osteotomy was analyzed with use of the paired t test. In the pre–calcaneal osteotomy sites, the mean resistance given in 200 kΩ was 388.2 ± 565.9 compared with 1016.6 ± 482.7 in the post–calcaneal osteotomy sites (p = .02). Findings from this cadaver study indicate reduction in forces to the talonavicular joint with an adjunctive calcaneal osteotomy. We conclude that it can be a beneficial adjunctive procedure for patients at a high risk of nonunion, such as those with obesity or diabetes or those who smoke. These patients could benefit from the decreased micromotion that the adjunctive procedure allows.

Percutaneous Calcaneal Displacement Osteotomy in the Pediatric Population

Calcaneal displacement osteotomy is a well- established surgery for correction of rigid heel varus or valgus deformity in young patients. We describe a percutaneous technique of doing this surgery which can help avoid possible complications of open surgery.

A Comparative Study of Two Different Techniques for Calcaneal Displacement Osteotomy

Category: Hindfoot Introduction/Purpose: The lateral oblique incision is widely used for calcaneal displacement osteotomy in correction of hindfoot deformities. Wound healing problems and neurovascular injury are limitations of this procedure. A technique using a Shannon burr for calcaneal displacement osteotomy was introduced to avoid these complications. The advantages of the percutaneos calcaneus osteotomy have been evaluated in a comperative study. Methods: Lateral oblique incision for calcaneus osteotomy was performed in 58 patients. The senior author changed the osteotomy technique 2014. Further 64 calcaneus osteotomies were performed percutaneously. The main indication for the calcaneus osteotomy was correction of hindfoot deformities. Complementary the number of screws used for the fixation have been axamined in the study. Results: The mean age of the patients was 51,6 (14-72) years. The patients were folled up for 12 months. All cases achieved radiographic union. Wound healing problems have been registrated in the open technique group in 16 patients (27,6%). Six of them (10,3%) required a surgical revision. No wound healing problems appeared in the percutaneous group. N. suralis was affected in the open technique group in 12 patients (20,6%) and in 4 patients (6,2%) in the percutaneous osteotomy group (p 0,02). The operating time was significantly shorter in the percutaneus osteotomy group. The correction of the hindfoot axis succeed in all patients. Risk of complication did not differ significantly between single and double screw in the percutaneous osteotomy group. Conclusion: The clinical and radiological examinations showed outstanding results. There is no evident difference between the two techniques in the radiological results. Use of a single screw in percutaneous osteotomy of the calcaneus did not increased the complication rate. The percutaneous calcaneal osteotomy had a lower complication rate in our study and is probably a useful technique in patients with diabetes and affected perfusion. Further randomised studies should consider this results.

Assessment of Medial and Lateral Neurovascular Structures after Percutaneous Posterior Calcaneal Displacement Osteotomy: A Cadaver Study

A prospective investigation of the effects on the medial and lateral neurovascular structures of the rearfoot after percutaneous posterior calcaneal displacement osteotomy was performed using 20 below the knee fresh frozen cadaver specimens. This anatomic study aimed to examine the medial and lateral neurovascular structures to determine whether they were jeopardized during execution of the osteotomy. After completion of the osteotomy, the medial plantar, lateral plantar, medial calcaneal, sural, and posterior tibial neurovascular structures, along with their respective branches, were inspected for iatrogenic injury. Our findings demonstrated that the percutaneous, subperiosteal osteotomy minimized trauma to the local soft tissue envelope and protected the adjacent neurovascular structures. Because no iatrogenic injury was observed in the cadaveric specimens, we postulated that percutaneous calcaneal displacement osteotomy is a safe, predictable, and advantageous alternative compared with open techniques for osteotomy and could result in reduced postoperative complications. The results of this investigation remain to be confirmed in the clinical setting.

Treatment of Posterior Tibial Tendon Dysfunction without Flexor Digitorum Tendon Transfer: A Retrospective Study of 34 Patients

A retrospective study of patients who underwent gastrocnemius recession, double calcaneal osteotomy (Evans osteotomy and percutaneous calcaneal displacement osteotomy), and medial column fusion for the treatment of posterior tibial tendon dysfunction was conducted. The senior author performed the procedures between November 2002 and January 2009 on 34 patients who displayed at least Johnson and Strom stage II deformity and had undergone 12 months of failed conservative treatment. The coauthors evaluated the patients’ radiographs before and after the operation. At a mean of 14 (range 3 to 44) months after surgery, radiographic measurements demonstrated statistically significant changes in the structural alignment of the feet. Based on our experience with these patients, we believe that a double calcaneal osteotomy combined with a gastrocnemius recession and stabilization of the medial column for the treatment of posterior tibial tendon dysfunction provides satisfactory correction, stability, and realignment of the foot. Furthermore, we feel that the use of flexor digitorum longus transfer, as well as triple arthrodesis, can be avoided without compromising the outcome when surgically treating posterior tibial tendon dysfunction.

Double calcaneal osteotomy and percutaneous tenoplasty for adequate arch restoration in adult flexible flat foot

Treatment of adult acquired flexible flat foot deformity can be problematic. Triple arthrodesis for structural correction has been the standard of care, thus sacrificing hind foot motion. The objective of this study was to assess the value of double calcaneal osteotomies in improving structural alignment while maintaining hind foot motion, which may further protect the function of adjacent motion segments. Double calcaneal osteotomies (Evans osteotomy and posterior calcaneal displacement osteotomy) were performed on 17 feet of 14 patients. Postoperative follow-up showed significant improvement in clinical foot and ankle scores.

Double-Calcaneal Osteotomy With a Unilateral Rail External Fixator for Correction of Pes Planus

A combination of the medial displacement calcaneal osteotomy with the Evans lateral column-lengthening osteotomy has been suggested when hindfoot valgus, forefoot abduction, and midtarsal joint instability are significant. However, the deforming forces must be flexible. The goal of this procedure is to restore alignment, stabilize the foot, and improve overall function. This double-calcaneal osteotomy addresses all components of the pes planus deformity. This article reports the use of a unilateral external fixator to callus distract the Evans calcaneal osteotomy while compressing the posterior medial calcaneal displacement osteotomy, which to the authors' knowledge has not been performed or reported in the literature. At the final post-operative visit of this clinical patient, the foot was rectus, and X-rays demonstrated an increased calcaneal inclination angle from 10 degrees preoperatively to 15 degrees postoperatively, a decreased talar declination angle from 39 degrees preoperatively to 26 degrees postoperatively, and the cuboid abduction angle decreased from 32 degrees preoperatively to 9 degrees postoperatively. The patient was pain free and extremely satisfied with the surgery, especially with the use of the external fixator.

Functional Outcome after Surgical Reconstruction of Posterior Tibial Tendon Insufficiency in Patients under 50 Years

Procedures utilized to address the flatfoot in this study included medializing calcaneal osteotomy, posterior tibial tendon reconstruction with flexor digitorum longus tendon transfer, and in patients with more severe deformity, lateral column lengthening. We evaluated patients age 50 and less at the time of surgery, who underwent surgical reconstruction for Stage 2 posterior tibial tendon dysfunction. Pre- and postoperative activity levels were evaluated to assess the effect of surgical reconstruction in the younger patient. Thirty-four feet in 30 patients (11 male, 19 female) with an average age of 41.2 (range, 17 to 50) years had surgery between 1997 and 2004. All feet were examined at an average followup of 44.5 (range, 24 to 65) months and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score and SF-36 score. The average preoperative AOFAS-Score was 53.1 +/- 14.5 points and 83.2 +/- 12.2 points at final postoperative followup. The mean improvement was 29.5. The difference between the preoperative and postoperative AOFAS score was significant (p < 0.0001) using a two-tailed t-test. The difference in the AOFAS pain and alignment subscales was also significant (p < 0.0001). The function subscale improvement was also significant (p = 0.018). The mean physical function component of the postoperative SF-36 score was 79.2. A correlation was found between the SF-36 physical component score and the post operative AOFAS score (r(2) = 0.754). While some lateral discomfort or pain occurred in patients with or without a lateral column lengthening, the posterior tibial tendon reconstruction utilizing medial calcaneal displacement osteotomy with flexor digitorum longus transfer and a lateral column lengthening with more deformity was successful in the higher-functioning, younger patients.

Der erworbene Plattfuß: mittelfristige Ergebnisse der medialisierenden Kalkaneusosteotomie mit Flexor digitorum longus-Sehnentransfer

The present retrospective study investigates the mid-term results after medial displacement calcaneal osteotomy combined with flexor digitorum longus transfer for the treatment of acquired flatfoot deformity due to posterior tibial tendon insufficiency at stage II (Johnson and Strom Classification). 30 feet in 29 patients (6 male, 23 female) with an average age of 58 years (from 43 to 68 years) had surgery between 1995 and 2001. All feet were examined at an average follow-up of 58.5 months (range 35-97 months) and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score. The average AOFAS-Score was 88.8+/-10.7 points (range 48 to 100) at final follow-up. The AOFAS-pain-subscale score was 34+/-6.2 points. At the latest follow-up were 14 feet (47%) painfree, 14 feet (47%) noted mild pain and 2 feet (6%) had daily pain. One foot (3%) had pain due to subluxation of the musculus flexor digitorum longus tendon, in another one pain was caused by a contract Chopart joint (3%). Further complications were painful prominent hardware (17%) and neuralgia of the sural nerve (7%). The authors conclude that the combination of the medial calcaneal displacement osteotomy with flexor digitorum longus transfer may provide optimal results in patients with adult acquired flatfoot deformity and posterior tibialis tendon dysfunction.

Double Calcaneal Osteotomy

Posterior calcaneal displacement and anterior calcaneal distraction osteotomies have been recommended for surgical management of flexible flatfoot deformity. We combined these procedures for surgical management of adolescent flatfoot and late stage II posterior tibial tendon dysfunction in the adult. Lateral column distraction has been shown to reduce rearfoot valgus and forefoot abduction by stabilizing the midtarsal joint. Posterior calcaneal displacement osteotomy, which results in medial translation of the tuberosity, converts the posterior muscle group from an everter to an inverter. A supinatory moment, therefore, is created about the subtalar joint axis, which results in supination during the midstance phase of gait. These procedures may be considered when calcaneal valgus, forefoot abduction, and midtarsal joint instability are clinically significant. We also include rearfoot alignment radiographs, long leg calcaneal axial radiographs, and malleolar valgus indices to further evaluate alignment of the foot, ankle, and leg. Ideal realignment is achieved when the heel is vertical in resting calcaneal stance position, the forefoot is parallel to the rearfoot in the frontal plane, and the medial column is stabilized, with elimination of forefoot abduction.

The Kirby view: A radiographic view for flatfoot evaluation

The authors reintroduce the anterior axial projection of the foot as described by Kirby et al (1) and how it can be used to better evaluate a flatfoot deformity when a medial calcaneal displacement osteotomy is contemplated. Over the years, although flatfoot surgery has become more sophisticated in both procedures and the selection of these procedures, many decisions are being made by the surgeon based on clinical examination and previous experiences without relying on a specific test to definitively determine the need for a specific surgical procedure. The use of the Kirby view when evaluating a flatfoot deformity will provide the surgeon with specific knowledge about location of the calcaneus relative to the tibiotalar joint (2–4). If a calcaneal osteotomy is needed, this radiographic view will allow the surgeon to determine, by the use of a preoperative template, how much medial displacement should be performed at the time of surgery.

Percutaneous displacement calcaneal osteotomy

Gleich (1) first described in 1893 the calcaneal osteotomy as a plantar-medial wedge resection to increase the calcaneal inclination angle. Later, Dwyer (2) and Silver (3) each described closingand opening-wedge osteotomies for calcaneal realignment with promising results. Koutsogiannis (4) popularized the medial displacement osteotomy in 1971. It has been shown that the medial displacement osteotomy addresses the flatfoot deformity in all 3 planes (5). The calcaneal displacement osteotomy (CDO) can also be used to reposition the heel in all 3 cardinal body planes. The tuberosity can be rotated to accommodate a frontal-plane deformity. It can be translocated medially and laterally or in the sagittal plane (6). Several authors suggest that the complication rate for medial displacement osteotomies is low (7, 8). Wound complications, especially in immunocompromised individuals, may pose a threat to the outcome of the procedure. Furthermore, the relationships of the soft tissues on the medial side of the calcaneus must be understood to minimize trauma to this area. A recent study by Greene et al (9) analyzed the topography of the medial neuro vascular supply and its relationship to the site of the open CDO. They surveyed the medial plantar nerve, lateral plantar nerve, posterior tibial artery, and their branches. Neither the medial plantar nerve nor its branches crossed the osteotomy site in any of the 22 specimens. The lateral plantar nerve crossed the site in only 1 specimen; however, its calcaneal branch crossed the site 86% of the time. This intersection occurred at approximately 20% of the distance from the proximal portion of the calcaneus. Additionally, the second lateral plantar nerve branch crossed in 95% of the specimens at two-thirds from the proximal point. The posterior tibial artery crossed the osteotomy site in 2 specimens. Branches crossed in 77% of the cases at the midsection of the osteotomy. They concluded that, when performing the CDO, the

Posterior calcaneal displacement osteotomy: A new percutaneous technique

The posterior calcaneal displacement osteotomy (PCDO) was originally described by Koutsogiannis (1) in 1971. This procedure is indicated for both adolescents and adults with a symptomatic calcaneal valgus that is unresponsive to conventional conservative care. More recently, it has become a common procedure in managing late stage I and early stage II posterior tibial tendon dysfunction with a reducible calcaneal valgus (2–4) and the absence of a fixed forefoot supinatus. Additionally, it may be combined with an anterior calcaneal osteotomy (5–7).

The contribution of the medial calcaneal osteotomy to the correction of flatfoot deformities.

The success of the medial displacement calcaneal osteotomy in correcting flatfoot deformities is likely to be the result of a shift of the Achilles tendon forces on the hindfoot. The purpose of this study was twofold: 1) to define the contribution of the Achilles tendon to the flatfoot deformity, and 2) to define the effect of a calcaneal medial displacement osteotomy. We used six different experimental dynamic stages: 1) intact foot without Achilles loading; 2) intact foot with Achilles loading; 3) flatfoot without medial calcaneal displacement osteotomy and without Achilles loading; 4) flatfoot without medial calcaneal displacement osteotomy but with Achilles loading; 5) flatfoot with medial calcaneal displacement osteotomy but without Achilles loading; and 6) flatfoot with medial calcaneal displacement osteotomy and with Achilles loading. The experimental flaffoot was developed by releasing the posterior tibial tendon, spring ligament, and plantar fascia and applying 7,000 cycles of axial fatigue load (range, 700 to 1,400 N; 1-Hz frequency). To simulate the phase of midstance, the peroneus longus, peroneus brevis, flexor digitorum longus, and flexor hallucis longus tendons were grasped by clamps, connected to pneumatic actuators, and loaded with precalculated forces. Anteroposterior and lateral radiographs were obtained for each stage on which the following measurements were made: talonavicular coverage angle, talar-first metatarsal angle, talocalcaneal angle, and height of the medial cuneiform. These measurements were compared with a one-way ANOVA. Between stages 1 and 2, all measurements were statistically insignificant. Between stages 3 and 4, for all measurements, Achilles tendon loading aggravated the flatfoot deformity (p < 0.05). After medial calcaneal osteotomy (stages 5 and 6), the Achilles tendon contributed less to the arch-flattening. We found that the medial displacement osteotomy plays an important role in reducing and/or delaying the progress of flatfoot deformity. In the flatfoot, loading of the Achilles tendon increases the deformity. Medial calcaneal osteotomy significantly decreases the arch-flattening effect of this tendon and therefore limits the potential increase of the deformity.