Maximizing The Effectiveness Of The Evans Calcaneal Osteotomy

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Seven Pearls For The Evans Calcaneal Osteotomy

• Make an oblique incision. Avoid peroneal tendons and the sural nerve.
• Avoid aggressive dissection at the calcaneocuboid joint.
• Place the osteotomy 11 to 15 mm proximal to the calcaneocuboid joint.
• Execute the osteotomy perpendicular to the weightbearing surface and parallel to the calcaneocuboid joint.
• Use allogeneic, tricortical iliac crest bone graft fashioned individually.
• No fixation is needed if the osteotomy is stable.
• Perform additional procedures as warranted.

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Author(s): 
Michelle Butterworth, DPM, FACFAS

   After placing the graft, assess its stability. Since the bone graft is under significant compression, it is usually very stable within the osteotomy and fixation is not routine. If the anterior fragment of the calcaneus appears to be unstable or dorsally dislocated, one can obtain fixation with a percutaneous Kirschner wire or Steinman pin. The two main reasons for displacement of the anterior fragment are aggressive dissection of the calcaneocuboid ligaments creating instability or placement of too large of a graft. The surgeon may want to reassess the graft size if dorsal displacement of the anterior process is present.

A Few Considerations On Closure And Post-Op Protocol

Perform standard tissue and skin closure. Then assess the foot for remaining deformities. Typically, a forefoot supinatus is present, warranting additional procedures such as a Cotton medial cuneiform osteotomy. Also, one needs to address any equinus deformity and treat it to gain full correction.

   Postoperatively, the patient is non-weightbearing in a cast for about six weeks or until he or she achieves osseous consolidation radiographically. The patient then transitions to a controlled ankle motion (CAM) walker and begins weightbearing and range of motion exercises over the next three weeks. Continuation to full weightbearing and normal shoegear then ensues as pain and swelling permit. Obviously, one can modify this post-op course as needed depending on the other procedures performed.

In Conclusion

I have found the Evans calcaneal osteotomy to be a powerful procedure resulting in triplanal correction for flexible pes planovalgus deformities. I have found that this surgical technique is reliable and consistently renders successful results. It is the workhorse for this deformity but it cannot stand alone. Additional procedures such as a Cotton osteotomy and gastrocnemius recession or Achilles tendon lengthening are typically necessary to gain full correction.

   Dr. Butterworth is a Fellow and the Immediate Past President of the American College of Foot and Ankle Surgeons. She is in private practice in Kingstree, S.C.

References
1. Evans D. Calcaneo-valgus deformity. J Bone Joint Surg. 1975; 57(3):270-8.
2. Mahan KT, McGlamry ED. Evans calcaneal osteotomy for flexible pes valgus deformity. Clin Podiatr Med Surg. 1987; 4(1):137-51.
3. Roye DP, Raimondo RA. Surgical treatment of the child’s and adolescent’s flexible flatfoot. Clin Podiatr Med Surg. 2000; 17(3):515-30.
4. Mosier-LaClair S, Pomeroy G, Manoli A. Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. Foot Ankle Int. 2001; 6(1):95-119.
5. Viegas GV. Reconstruction of the pediatric flexible planovalgus foot by using an Evans calcaneal osteotomy and augmentative medial split tibialis anterior tendon transfer. J Foot Ankle Surg. 2003; 42(4):199-207.
6. Zwipp H, Rammelt S. Modified Evans osteotomy for the operative treatment of acquired pes planovalgus. Oper Orthop Traumatol. 2006; 18(2):182-97.
7. Hix J, Kim C, Mendicino RW, Saltrick K, Catanzariti AR. Calcaneal osteotomies for the treatment of adult-acquired flatfoot. Clin Podiatr Med Surg. 2007; 24(4):699-719.
8. Hyer CF, Lee T, Block AJ et al. Evaluation of the anterior and middle talocalcaneal articular facets and the Evans osteotomy. J Foot Ankle Surg. 2002; 41(6):389-393.
9. Mahan KT, Hillstrom H. Bone grafting in foot and ankle surgery: A review of 300 cases. J Am Podiatr Med Assoc. 1998; 88(3):109-18.
10. John S, Child BJ, Hix J, et al. A retrospective analysis of anterior calcaneal osteotomy with allogeneic bone graft. J Foot Ankle Surg. 2010; 49(4):375-79.
11. Grier KM, Walling AK. The use of tricortical autograft versus allograft in lateral column lengthening for adult acquired flatfoot deformity: An analysis of union rates and complications. Foot Ankle Int. 2010; 31(9):760-69.

   For further reading, see “Essential Insights On The Evans Calcaneal Osteotomy” in the June 2009 issue of Podiatry Today.

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