How To Perform The Double Calcaneal Osteotomy

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Continuing Education Course #126 December 2004

I am very pleased to introduce the latest article, “How To Perform The Double Calcaneal Osteotomy,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Within the array of possible treatments for symptomatic flexible flatfoot, Alan R. Catanzariti, DPM, Robert W. Mendicino, DPM, and Brian D. Neerings, DPM, take a closer look at the double calcaneal osteotomy, a procedure that combines the posterior calcaneal displacement osteotomy (PCDO) and the Evans anterior calcaneal osteotomy. In the article, they discuss key diagnostic essentials and surgical treatment considerations for ensuring a successful outcome.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Editor-In-Chief
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 53 and successfully answering the questions on pg. 58. Use the enclosed card provided to submit your answers or fax the form to the NACCME at (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by the NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Catanzariti, Mendicino and Neerings have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by the NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: December 2004.
EXPIRATION DATE: December 31, 2005.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• recognize the indications for performing the double calcaneal osteotomy;
• discuss key aspects of the clinical exam when evaluating patients with symptomatic flexible flatfoot deformity;
• explain the role of diagnostic imaging in assessing patients with symptomatic flexible flatfoot;
• describe the posterior calcaneal displacement osteotomy; and
• discuss key aspects of the Evans anterior calcaneal osteotomy.

Sponsored by the North American Center for Continuing Medical Education.

When considering a double calcaneal osteotomy, one should assess standard weightbearing views (AP, lateral and oblique views of the foot and ankle) for degenerative changes and angular deformity.
Obtaining a hindfoot alignment view   can help in determining the level of valgus deformity.
Obtaining a long leg calcaneal axial view can help in determining the level of valgus deformity.
Surgeons should check the cortical shelf on the calcaneal axial view to ensure adequate medial displacement.
One can achieve final fixation for the posterior calcaneal displacement osteotomy (PCDO) with one or two large diameter compression screws. Do not violate the subtalar joint. Surgeons can perform fixation percutaneously under image intensification.
The incision for the Evans osteotomy should be made in an oblique or longitudinal fashion just distal to the sinus tarsi and 1 to 1.5 cm proximal to the calcaneocuboid joint.
Surgeons must ensure careful dissection and preservation of the peroneal tendons and the sural nerve.
58
Author(s): 
By Alan R. Catanzariti, DPM, Robert W. Mendicino, DPM, and Brian D. Neerings, DPM

   The double calcaneal osteotomy includes a combination of the posterior calcaneal displacement osteotomy (PCDO) and the Evans anterior opening wedge calcaneal osteotomy. One would consider this combination for symptomatic flexible flatfoot deformity in both the adolescent flexible flatfoot and the adult with late stage II (Johnson and Strom’s classification) posterior tibial tendon dysfunction (PTTD).

   The PCDO consists of a transcortical osteotomy through the posterior tuber of the calcaneus with medial transposition of the tuberosity. The PCDO displaces the insertion of the Achilles tendon medially in relation to the subtalar joint axis, increasing the supinatory action during the midstance phase of gait. In addition, this procedure displaces the ground reactive forces medially in relation to the subtalar joint axis with medial translation of the plantar tubercle resulting in a supinatory moment at heel strike.

   The Evans anterior calcaneal osteotomy is placed approximately 1.0 cm proximal to the calcaneocuboid joint. The surgeon would subsequently place a laterally based wedge of bone into the osteotomy site, effectively lengthening the lateral column and stabilizing the midtarsal joint. The prevailing theory is that lengthening the lateral column creates a “bowstringing” effect that may be responsible for clinical restoration of the longitudinal arch. Lateral column lengthening will reduce inversion demand on the posterior tibial tendon and reduce the posterior muscle group force required to achieve the heel rise position.

   Surgeons may employ the double calcaneal osteotomy when significant calcaneal valgus, forefoot abduction and midtarsal joint instability coexist. The deformity must be flexible with no radiographic signs of tritarsal joint degeneration. The double calcaneal osteotomy is a joint sparing procedure that maintains a supple foot while restoring anatomic alignment, stabilizing the midtarsal joint and improving function.

What You Should Look For During The Physical Examination

   Clinicians should evaluate the foot and ankle with both non-weightbearing and weightbearing exams. The examination should answer several key questions. Is the deformity flexible? What are the primary components of deformity (i.e., soft tissue contractures or muscle/tendon weakness)? What is the function of the tibialis posterior tendon? Does the ankle joint contribute to the valgus deformity?

   During the non-weightbearing exam, one should evaluate the ankle joint for the presence of instability, equinus, deformity or pain. Assess the tritarsal complex for flexibility and instability. Check for midtarsal joint instability by placing the subtalar joint in neutral and maximally loading the lateral column. When evaluating adult patients, one should check the course of the tibialis posterior tendon for tenderness, edema, nodularity or gross attenuation. Keep in mind that the tibialis posterior tendon is often unable to support the medial arch adequately in mid- to late-stage II PTTD and one may need to address this following osseous realignment.

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