Double Calcaneal Osteotomy Research Articles

Clinical and radiological outcomes of flexible flatfoot correction with double calcaneal osteotomy

BackgroundAlthough double calcaneal osteotomy (medial displacement calcaneal osteotomy with lateral column lengthening) is widely regarded as an effective treatment option for flexible flatfoot, limited studies have extensively analyzed the degree of deformity correction in three dimensions following double calcaneal osteotomy. This study was performed to evaluate the radiographic and clinical effectiveness of double calcaneal osteotomy to correct flexible flatfoot deformities.MethodsThirty-one patients who had 44 symptomatic flexible flatfeet and underwent double calcaneal osteotomy were examined retrospectively with a mean follow-up of 50 months. Visual analog scale, foot and ankle activity measure, and other clinical data were obtained from medical records. Various radiographic variables for assessing flatfoot and osteoarthritic change in tarsal joints were analyzed from weightbearing radiographs.ResultsClinical scores and radiographic variables were significantly improved postoperatively. The mean values of medial sliding and lateral lengthening were 7.6 and 8.7 mm, respectively. No osteoarthritic changes were observed.ConclusionsDouble calcaneal osteotomy could be used to correct flatfoot deformities effectively and sustainably and provide symptomatic relief and patient satisfaction.Level of evidenceLevel 4, retrospective case series.

Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit.

We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents. A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test. The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal. Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

The Double Calcaneal Osteotomy for Pediatric Flatfoot

Category: Hindfoot Introduction/Purpose: The double calcaneal osteotomy combines a medial calcaneal sliding osteotomy and lateral column lengthening. Corrective osteotomies, as opposed to arthrodesis and arthroereises, are preferred for foot deformity correction in children and adolescents because they preserve joint mobility, shock absorption, and avoid concerns about adjacent joint degeneration. Individually, both types of osteotomies have demonstrated efficacy in achieving deformity correction and improved functional outcomes for patients. The literature regarding outcomes of this procedure in children is sparse. This retrospective study objectively analyzes outcomes of children who underwent double calcaneal osteotomies at our institution by comparing pre and postoperative radiographs and reporting postoperative complications. To our knowledge, this study contains the largest sample size of symptomatic flatfeet analyzed with regards to double calcaneal osteotomies in children. Methods: Patients who underwent a double calcaneal osteotomy over the past 5 years at our institution were analyzed. Pre and postoperative weightbearing radiographs of the foot were measured (Figure 1). Paired t tests were used to compare pre and postoperative measurements. Statistical significance was set at α &lt; 0.05. Additional factors analyzed for each procedure include total operative time, torniquet time, hardware used for fixation, type of graft, concomitant procedures, and post-operative complications such as infection, nerve injury, nonunion, and reoperation. Results: A total of 20 patients and 26 feet were studied. Significant correction from pre to postoperative radiographic measurement was noted for the talo-first metatarsal angle, talonavicular coverage angle, calcaneal pitch, and tibiocalcaneal angle (p &lt; 0.001). Complications were noted in 3 of the 20 patients, or 3 of 26 feet, and included infection, painful hardware, and hardware failure. Conclusion: The double calcaneal osteotomy was found to be effective in correcting the radiographic parameters associated with flatfoot deformity in children and adolescents with symptomatic flatfeet. The average postoperative radiographic measurements for the 26 feet analyzed were significantly improved from preoperative measurements. Pediatric orthopedists should strongly consider the double calcaneal osteotomy for appropriate surgical candidates.

Surgical management of pes planus in children with cerebral palsy: A systematic review.

Purpose:Pes planus (or flatfoot) is the most common deformity in children with cerebral palsy. There are several surgical interventions used to treat it: single calcaneal osteotomies, extra-articular arthrodesis, double calcaneal osteotomy, calcaneo-cuboid-cuneiform osteotomy, intra-articular arthrodesis, and arthroereisis. There is currently no evidence on optimal treatment for flatfoot in children with cerebral palsy. Our purpose is to systematically review studies reporting complications, recurrence rates, and radiological outcomes of the surgical management of flatfoot in children with cerebral palsy.Methods:Five databases were searched to identify studies published from inception until July 2021, with keywords relating to flatfoot, cerebral palsy, and surgical interventions. We included prospective, retrospective, and comparative study designs in the English language. Data was extracted and tabulated in duplicate into Excel, and analysis was conducted using Python SciPy.Results:In total, 1220 studies were identified of which 44 met the inclusion criteria, comprising 2234 feet in 1364 patients with a mean age of 10.3 years and mean follow-up of 55.9 months. Radiographic outcomes showed improvement with all procedures; complications and recurrence rates were too poorly reported to compare. Only 6 (14%) studies were assessed as a low risk of bias. There was substantial heterogeneity of outcome measures.Conclusion:There is a lack of high-quality, comparative studies assessing the radiological outcomes, complications, and recurrence rates of surgical alternatives to treat flatfoot in children with cerebral palsy. There is currently no clear evidence on optimal surgical treatment.Level of evidence:IIa based on Oxford Centre for Evidence-based Medicine.

Double Calcaneal Osteotomy in Treatment of Flexible FlatFoot

Double Calcaneal Osteotomy in Treatment of Flexible FlatFoot

Radiographic Union of Evans Osteotomy Without Fixation

Category:Hindfoot; OtherIntroduction/Purpose:The Evans osteotomy is a lateral column lengthening procedure of the calcaneus that is commonly used to correct flexible flatfoot deformities. There is no consensus on whether fixation is needed to avoid nonunion and calcaneocuboid subluxation when performing this osteotomy. We assessed the nonunion rate and correlated extent of subluxation with graft size in an unfixed Evans osteotomy with an allograft wedge and no pinning of the calcaneocuboid joint at any point in the largest series of the procedure to date. Surgeries were performed in patients undergoing flexible flatfoot reconstruction.Methods:We retrospectively reviewed 120 consecutive patients who had undergone 145 unfixed Evans osteotomies by a single surgeon with allogenic bone graft for flatfoot reconstruction between January 2013 and October 2017, with a mean follow-up of 62.5 (range 9.4-266.7) weeks. The calcaneocuboid joint was not pinned during the procedure. Data were collected using clinical and radiographical examination during regular follow-up.Results:A total of 137 feet (94.5%) underwent a double calcaneal osteotomy with an associated medial displacement calcaneal osteotomy (MDCO). There was one nonunion (0.69%). The mean time to union was 10.8 (range, 6.7-17.9) weeks. There was significant improvement in all radiographic parameters postoperatively, including calcaneal pitch, talonavicular uncoverage, anteroposterior and lateral talo-first metatarsal angle, lateral column length, and naviculocuboid overlap (p<0.05). Minor postoperative calcaneocuboid joint subluxation (1.51 +- 2.3 mm) occurred in 72 of 118 feet (61.0%) and had no correlation with wedge size (r=0.06; 95% CI, -0.13, 0.24; p=0.6).Conclusion:An unfixed Evans osteotomy for symptomatic flatfoot deformity resulted in a significant improvement in the radiographic alignment of the foot with an exceptionally rare nonunion rate. Detectable calcaneocuboid subluxation was common but minimal in extent and was not correlated with wedge size in this series in which wedges were less than 12 mm in the maximum dimension. This report represents the largest series of the Evans procedure to date.

Double calcaneal osteotomy in treatment of flexible planovalgus foot deformity in ambulatory cerebral palsy. A case series study

BackgroundThe aim of this prospective non randomized case series study was to assess the intermediate-term outcomes of double calcaneal osteotomy (lateral column lengthening and medial slide calcaneal osteotomy) use in ambulatory cerebral palsy with flexible planovalgus feet. Methods16 cases with planovalgus feet were surgically treated by double calcaneal osteotomy and observed over an average of 33.5months. The mean age at the time of surgery was 10.74years. The functional outcomes were assessed clinically and radiologically. ResultsThere were a statistical improvement of clinical heel valgus and all radiological parameters as regard talar head uncoverage, calcaneal pitch, talo-calcaneal angle, and talus 1st metatarsal angle at the end of follow up period. ConclusionDouble calcaneal osteotomy is a good option in the treatment of flexible planovalgus feet in ambulatory cerebral palsy patients.

Double calcaneal osteotomy with minimally invasive surgery for the treatment of severe flexible flatfeet.

Severe flexible flatfoot deformity in children and adolescents is a complex problem. Calcaneal lengthening remains the gold standard for surgical correction at this institution. However, in a minority of patients, inadequate correction of valgus is noted at surgery and a further calcaneal shift osteotomy is done. We have conducted a retrospective review of ten patients who received 15 combined minimally invasive calcaneal shift and calcaneal lengthening osteotomies, which were all performed by the senior author. All patients had failed conservative treatment. We describe our technique for double calcaneal osteotomy combining minimally invasive surgery (MIS) for the medial calcaneal shift with traditional open calcaneal lengthening osteotomy for treating children and adolescents with severe flexible flatfoot deformity. The average shift achieved was 8.07mm. The average improvement in Meary's angle was 14.99°. All of them had radiological and clinical union at 12weeks. None of the patients developed sural nerve injury, wound breakdown, or infection of the MIS incision. In double calcaneal osteotomies, the MIS calcaneal medial shift technique can be used safely with potentially lower risks of wound complications and sufficient medial shift, compared to conventional open extensive surgery. MIS calcaneal shift osteotomy has an advantage over open conventional open technique in cases where the skin is under tension like in combined calcaneal lengthening osteotomy. With experience, the procedure can be faster than an open procedure.

Double calcaneal osteotomy for severe adolescent flexible flatfoot reconstruction

BackgroundThe timing and strategy of treatment for flatfoot still remain controversial. It is a difficult problem when facing severe adolescent flexible flatfoot because a single procedure cannot realign flatfoot deformity effectively.MethodsWe reviewed 13 adolescent flexible flatfoot patients who underwent double calcaneal osteotomy during May 2012 to June 2015. The mean age of patients was 15.2 ± 1.8 (range, 10–18) years. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS-AH) scores and SF-36 score were adopted to evaluate the preoperative and postoperative functions of the foot. Changes of hindfoot valgus angles, talonavicular uncoverage angles on AP view and talo-first metatarsal angles, and talar pitch angles and calcaneal pitch angles on the lateral film before and after surgery were measured.ResultsAll 13 patients (15 ft) were followed. The mean duration of follow-up was 34.5 ± 15.7 (range, 21–60) months. The hindfoot valgus angle improved from 16.5 ± 4.1 to 2.9 ± 1.6. On the foot AP view, the mean preoperative and postoperative talonavicular coverage angles were 24.9 ± 8.5 and 6.5 ± 3.6. On the lateral view of the foot, the average preoperative and postoperative talo-first metatarsal angles were 18.1 ± 5.5 and 4.9 ± 4.4. The mean preoperative and postoperative talar pitch angles were 36.4 ± 4.7 and 24.0 ± 5.6. The AOFAS-AH score improved from 68.9 ± 12.3 preoperatively to 94.6 ± 3.9 postoperatively.ConclusionWith additional procedures, double calcaneal osteotomy was an effective method for severe adolescent flexible flatfoot.

Remodeling of the Calcaneocuboid Joint in the Flatfoot

Category: Hindfoot Introduction/Purpose: Although the flatfoot has been successfully treated with a lateral column lengthening (LCL) for over half of a century, there has been controversy recently about whether the lateral column is actually short in a flatfoot, especially the acquired type. Some ask, “How can the normal, hard bones actually change and shorten?” And, if it is not short, perhaps the lengthening procedure is producing a non-physiologic state with abnormal anatomy. Would the flatfoot patient be better served with other procedures that don’t include a lateral column lengthening? Level of Evidence: Therapeutic Level IV. Methods: After observing a very dramatically changed calcaneocuboid (CC) joint when performing a double calcaneal osteotomy with a medial soft tissue reconstruction for a Johnson-Strom Stage II posterior tibial tendon insufficiency, it was decided to carefully observe, photograph, and record any changes in the CC joint at surgery in a consecutive series of 21 patients who were operated on who had this disorder(Figure 1). In total, there were fourteen double heel osteotomies, with medial soft tissue reconstructions for Johnson-Strom Stage II deformities, five triple arthrodeses for Stage III deformities, and two lateral column lengthenings with an ankle arthrodesis for a Stage IV deformity. All of the patients had a triple hemisection heel cord lengthening for hindfoot equinus. Results: Every patient studied had some changes to the CC joint which were generally related to the amount of deformity present. At a minimum, the calcaneal side of the joint drifted proximally, laterally and dorsally, with bone being laid down on the outside of the calcaneus, resulting in the joint being larger. There was drifting and abduction of the lateral portion of the articular surface of the joint. In some joints the lateral portion looked like a distinct but confluent facet. Often times, a marginal osteophyte was present laterally and dorsally in the widened area of the calcaneus and “kissing” osteophytes were seen on the cuboid. All of these remodeling changes resulted in the calcaneal side of the joint being short, and facing laterally and dorsally. Conclusion: These findings give evidence to the rationale for performing of a LCL proximal to the calcaneocuboid joint to treat the acquired flatfoot. When performing a LCL one should attempt to restore length to the calcaneal side of the joint, and to redirect it medially and plantarward. We do not remove the marginal spurs, rather they are maintained to provide an area to insert a retrograde fixation screw. If the patient has lateral column pain after the bone graft has incorporated, the screw and spurs are removed.

The Application of Calcaneal Z Osteotomy in Treating Type ⅡB Adult Acquired Flatfoot Deformity

Category: Hindfoot Introduction/Purpose: A retrospective control study to evaluate the application of calcaneal Z osteotomy in treating type ⅡB adult acquired flatfoot deformity. Methods: From September 2011 to March 2013, 20 cases of typeⅡB adult acquired flatfoot (according to Myerson’s classification) were treated by calcaneal Z osteotomy combined with medial soft tissue reconstructing. There were 4 males and 16 females with a mean age of 52.6 years (range 49 to 72 years). A Z osteotomy of the calcaneus was performed instead of a lateral column lengthening or a double calcaneal osteotomy for purpose of correct the forefoot abduction and hind foot valgus deformity. The medial soft tissue procedure included posterior tibial tendon resection and Flexor digitorum longus tendon transfer. American Orthopaedic Foot and Ankle Society (AOFAS) score and radiological assessments were used to evaluate the conditions before and after operation. Results: Eventually, 19 patients were followed up with an average duration of 26.5 months (range, 18-56 months). AOFAS scores were 80-90 points in 11 patients, 90-100 points in 6 patients and the excellent and good rate was 89% (17/19). The specific indexes of X-ray improved obviously (P &lt; 0.01). The anteroposterior talocalcaneal angle decreased by 12°, lateral talar first metatarsal angle decreased by 15°, and talonavicular coverage angle decreased by 7°. There was no calcaneal-cuboid joint symptom in this group of patients. All these cases got good bone healing. Conclusion: The calcaneal Z osteotomy can correct the hind-foot deformity in three dimensions and can act as a lateral column lengthening in treating type ⅡB adult acquired flatfoot. The complication of this procedure is minimal.

Doble osteotomía de calcáneo

In the past 30 years the surgical treatment of acquired adult flat foot has changed. Nowadays joint preservation techniques to restore the bone alignment are more common than arthrodesis surgery, which is restricted to cases of joint arthritis. Double calcaneal osteotomy is a good option in cases of flexible flat foot type IIB with hindfoot valgus and forefoot abduction.

Functional Results of Posterior Tibial Tendon Reconstruction, Calcaneal Ostetomy, and Gastrocnemius Recession

This study aimed to assess and provide prospective outcome data following reconstruction of Stage II posterior tibial tendon insufficiency, as well as evaluate the effect of reconstruction with gastrocnemius recession on plantarflexion strength. A prospective evaluation of 24 patients undergoing reconstruction for Stage II posterior tibial tendon insufficiency was granted IRB approval. The reconstructive procedures consisted of a flexor digitorum longus transfer, medial displacement calcaneal osteotomy, lateral column lengthening, and gastrocnemius recession. Patients were asked to complete multiple outcome measures preoperatively, 6 months, 1 year, and 2 years postoperatively. A dynamometer was utilized to evaluate peak torque plantarflexion preoperatively, 6 months, and 1 year postoperatively. In the study, 14 patients completed preoperative surveys, and 23 patients had 2-year followup. Patients were highly satisfied with the results of their surgery. All outcome measures showed statistically significant improvement. Improvement was seen at 6 months, but results continued to improve at the 1-year mark. By the second year, improvement largely reached a plateau. Biodex testing showed no loss of plantarflexion strength after reconstruction and gastrocnemius recession. Reconstruction of the flexible adult acquired flatfoot with FDL transfer, double calcaneal osteotomy, and gastrocnemius recession yielded excellent functional results for the treatment of Stage II posterior tibial tendon insufficiency. Plantarflexion weakness was not found to be a concern. A good functional outcome can be anticipated after the early postoperative period. However, it should be expected to take at least 1 year for maximal benefit.

Double Calcaneal Osteotomy Using Single, Dual-function Screw Fixation Technique

Historically, a variety of fixation techniques for calcaneal osteotomies have been used. The prevention of postoperative sequelae, including delayed or nonunion of the osteotomy sites and minimization of soft tissue damage, is always a primary consideration for foot and ankle surgeons. The present report describes a fixation technique for a double calcaneal osteotomy that entails use of a single screw that functions as both a positional tool, as well as a compressive fixation device. This technique provides compressive and positional qualities and decreases the amount of soft tissue disruption to the surgical site.

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 in the treatment of posterior tibial tendon dysfunction

This article presents an alternative treatment for tibialis posterior tendon rupture in a select group of patients with recent rupture and planovalgus foot structure. Double calcaneal osteotomy is used to realign weightbearing forces in situations where soft-tissue repair alone is not sufficient, and arthrodesis is premature. A single case is presented followed by a discussion, with encouraging results.