A Closer Look At The Percutaneous Calcaneal Displacement Osteotomy

Author(s): 
By Lawrence DiDomenico, DPM

Podiatric surgeons commonly perform an extraarticular calcaneal osteotomy on hindfoot deformities of the foot and ankle.1 One would typically perform this powerful osteotomy in conjunction with other procedures. Complications with the percutaneous calcaneal displacement osteotomy are rare.2-4 This is in contrast to the customary lateral approach of a calcaneal osteotomy as the surgeon may see complications that include wound dehiscence, sural nerve damage, sural neuritis, delayed union, non-union, infection and invasion of the medial neurovascular structures.2-6 Due to the thin soft tissue layer on the lateral aspect of the calcaneus, wound dehiscence is a common problem one encounters when performing the traditional lateral approach to the calcaneal osteotomy. Large incisions on the lateral aspect of the calcaneus can cause fibrosis in this area, leading to nerve symptoms. When performing this osteotomy open, the surgeon must be cautious about exiting the medial aspect of the calcaneus due to the neurovascular structures.6-7 When it comes to the percutaneous calcaneal displacement osteotomy technique, one would perform this procedure through four small stab incisions. The technique avoids major neurovascular structures. I have successfully completed more than 100 percutaneous calcaneal displacement osteotomies since the year 2000. With this procedure, I have been able to achieve radiographic evidence of osseous healing, minimize wound problems, avoid invading the neurovascular structures and provide pleasing cosmetic results to the surgical site. What Does The Research Reveal? Numerous authors have described the medial displacement osteotomy for the treatment of conditions such as calcaneal valgus deformities, posterior tibial tendon dysfunction and flexible flatfoot deformities with good results reported for adults and children.1-4,8-20 Posterior tibial tendon dysfunction occurs when the adult-acquired flatfoot becomes evident with the heel in a valgus position, the flattening of the medial longitudinal arch and forefoot abduction.14,16,21 Surgeons are currently using calcaneal osteotomies in combination with various ancillary procedures to treat posterior tibial tendon dysfunction.2,3,8-10,12-17,21-31 Flexible flatfoot is one of the most common orthopedic problems among children.17,18 Torosian, et. al., found that the medial slide calcaneal osteotomy is a simple and effective treatment for hindfoot valgus.19 When one detects valgus malalignment, medializing the calcaneus provides satisfactory outcomes.22 In advanced stages of the deformity, the medial column may be affected. Accordingly, there is a need for tendon transfers or joint fusions (in adults), and these are effective treatments when one combines them with the medial calcaneal displacement osteotomy.22 Mann and Myerson both describe a posterior calcaneal osteotomy in which one moves the posterior aspect of the calcaneus medially.3,9,26-28 Surgeons would frequently perform this type of osteotomy in conjunction with other bony or soft tissue procedures. Mann describes the foot as a tripod.3,9 The three legs consist of the first metatarsal head, the fifth metatarsal head and the calcaneus. If too much heel valgus is present, the tripod does not function properly and the medial aspect of the foot sags. Performing the posterior medial calcaneal displacement osteotomy places the calcaneus back into its correct position.3,9 One may often see a loss of hindfoot height after a calcaneal fracture.22 Performing the posterior calcaneal osteotomy enables the surgeon to shift the posterior aspect of the calcaneus plantarly to restore the height of the hindfoot.22 Authors have also reported that the posterior calcaneal slide osteotomy can correct abnormal heel alignment that is in varus.22,32 The objective of the osteotomy is to reposition the Achilles tendon, plantar fascia and the bone more laterally. The aforementioned deformities are indications for the open posterior calcaneal displacement osteotomy. These are the same indications for the percutaneous calcaneal displacement osteotomy. One may perform the percutaneous calcaneal displacement osteotomy on any patient who would experience a benefit from the traditional open calcaneal displacement osteotomy.

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