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Benjamin Overley, Jr, DPM
Surgical Skills Committee
Section Editor for Trauma-Journal of Foot and Ankle Surgery
Foot and Ankle Specialist/PMSI Orthopedics
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Male Speaker: I had a little reload there. Okay. Calcaneal osteotomy. In terms of procedures that I perform on a routine basis, this probably is at the top or close to the top of the list. The reason why is because it’s, in my hands, relatively easy to do. It’s very powerful. I can achieve a lot of things with it and I think they’re pretty easy to fix. The heel bone, in general, is pretty accommodating in terms of actually healing, with an A, after working on it. These are your objectives. Just understanding the different types in fixation techniques and we don’t need to go through the beat down on history. Just understanding the types and understanding that we’ve adapted to heel to just almost fix just about every condition we can think of. Whether it’s a transverse plane, flat deformity sagittal plane, old calcaneal fracture with loss of height, flatfoot deformity, cavus foot deformity, you name it, we’ve developed an osteotomy or way to abuse surgically the heel bone to realize our dreams of getting this patient better, at least into better mechanical alignment. Here are all the different approaches and you can see this is what we’ve done over the years. You have your standard Kouts, your Evans. You’ve got modifications of that into the SCARF, which you’re going to see a lot of today. Or the Malerba, we can do opening wedges, closing wedges. Laterally based things, we can swing it right, swing it left, bring it up, bring it down. We can pretty much do anything with this thing. It’s very much like a first metatarsal in that way that we’ve seemed to cut up this thing in 50 different fashions to achieve our end goal. We’ve been pretty successful with doing it, I don’t really see that changing. How do we get this right the first time? For those of you that don’t do this, I think this is a good way to address this. A tip is just to use a metallic straight edge in the operative room and just plant that out with a skin marker. You just mark your area where you’re going to be and there’s that, and you through skin down the bone and you do your procedure. This does not require a ton of dissection. In fact, the more layers that you create, the more swelling you’re going to have. You’re probably going to incarcerate some things that you don’t want to get into. It’s best just to go straight down almost like an Achilles repair. Flatfoot deformities. Well, clearly, we’re going to use them for these types of deformities. They tend to work best for the flatfoot deformity. Though I’ve really adapted them for varus feet as well over the years and I also had them working very well for them, but there’s also a level of competence that needs to go with it. That looks like a lady, it’s not too bad till you flip her around and you take a look at that right ankle of hers and you see how much she is in, how much the heel is out, and we see the difference there. Taking a look at this multiplane or transverse sagittal plane, we’ve got everything going on, lot of different interactions in terms of the flatfoot deformity itself as a transverse plane. Is it sagittal? Is it a combined deformity? All these different things. We have a short lateral column. Is the lateral column long enough? Understanding that when these patients you first see and this is still probably the best diagnostic test for PTTD and flatfoot. You see right there on the left, you actually see the PT10 in trying to fire as this patient is trying to lift herself up. When she gets to the single leg exam on her nonaffected side, she can get up there very easily. When we switched over to the affected side and we lift up that right heel of hers and try to get her to go left, you’ll actually see her do little maneuver, it’s called the step jump. You’ll actually see her try to use her upper body just to give her the momentum to get that heel off the ground. Just watch the right as she tries to use that weight to lift herself up. I don’t even know if she does it on that video but I think she actually did it from the side view. The understanding that with all these, you’re dealing with the calcaneal osteotomy allows you all these different options and how you can fix these different things. You can see the associated HAV, lateral peritalar subluxation. You can see this typical on medial on coverage that we see with these patients and these are things that are easily addressed with calcaneal osteotomies. We can do wedge osteotomies that are based from a medial or lateral standpoint. We always worry about going medially because clearly there are some things, just like going through the front of the neck that we don’t want to get into around, it doesn’t mean we can’t do it. You can do medializing, lateralizing osteotomies of the os calcis. We know this, Kouts again is described these years ago and I’ll show you why I’ve gravitated away from this particular type of procedure. Though it’s been used and I still use it in occasion today for different things, it’s still very unstable osteotomy of that area. We could do an Evans where we’re lengthening that lateral column, for short and lateral column but understanding when we’re doing this type of a procedure that we’re affecting a lot of things. The Evans osteotomy is a very strong and powerful osteotomy because it not only swings that foot back around or that brings that foot back around that talar head, for those of you that saw Harold’s talk yesterday, which was a fantastic one, path mechanics.
Not only we’re bringing the foot back around but we’re also lifting up the anterior axis of the calcaneus simultaneously. It’s really a three-plane correction with one bone cut. If we violate that calcaneal cuboid joint in an effort to get this osteotomy done and we blow those ligaments on top of that joint, what you’ll see is you actually see that anterior calcaneus begin to escape. A lot of patients will come back complaining of pain in that area which is CCJ impingement because we’ve basically created an arthritic situation at their calcaneocuboid joint. Here is the typical fixation technique for Koutsogiannis and we’ll see this a lot. This is very easy to perform. They take me no more than about eight or nine minutes to do and probably about another two minutes to throw a single screw in. They’re very time efficient as well. You can see there, we got a very flatfoot, forefoot varus, medial in coverage. We can do the osteotomy and even drop it down a little bit to recreate some of that arch. Naviculocuneiform arthrodesis at the same time, and you noticed the talar head is now captured in that area and that first met angle has also been corrected out at the same time. Here some other fixation constructs and techniques that I’ve used over the years. Nothing that exciting, just to show you different techniques. The Kouts, yeah, you can correct it and you can push it laterally, you can push it medially. You can pull it down. You can bring it up if you’ve got a cavus foot. You want to really take a lot of that out. You can actually displace it vertically as well and it is very versatile. From my standpoint, it’s also very unstable and a lot of its versatility and its instability are sort of inexorably linked. You can see there is an example of ankle replacement I did in conjunction with its standard Koutsogiannis. As I said, I still use those. I just don’t use them that often. You can combine with fusions like I did here with an ankle replacement as well. You can see here, if we’re going to get to the posterior facet and we’re going to do a calcaneal osteotomy at the same time, we’re want to make sure our incisions are not, you know, kind of getting into each other. There, you can see a calcaneal osteotomy, posterior facet arthrodesis and an ankle replacement. We have all different types of step plates that we can use. You can use single screws. You can use these plates to push away that bone and also do capture it in that locking plate formation. We’ve got intramedullary plates that actually go inside the heel bone although I’ve never really truly trusted them any of themselves. I always threw an additional screw just for rotational component and we’ll talk about that right now. The Koutsogiannis inherently, is very unstable. It’s very unstable because it’s very similar to basicervical fracture of the femoral neck. If you think about the head of the femur which is a ball and you think about the neck as it comes down to the lesser and greater trochanters in the calcar process. If you’ve got a fracture there what the orthopedist found over time and when they would fix this and they would just put two screws or three screws across is that – sorry, just a single screw across with the plate is that that single screw over time there is sort of force to takes place with the head begins to move on it. It sort of like the top of an ice cream moving on the cone and as it takes place there’s a cut out that occurs. That cut out would always happen in the bottom of the femoral neck and they would have all these basicervical hip fracture failures. The same thing is inherent with the Koutsogiannis because we’ve got an Achilles attached on one side, we’re cutting it basically straight up and down or maybe put a little obliquity to it to give the greater bone surface. But we still haven’t changed one thing, the Achilles is still attached. The potential for that thing to spin around a single screw is very, very possible. What you’ll often see with the single fixation technique is that what you see in the operating room and what you see when the patient begins to bear weight. When you think on x-ray that that patient is healed, then, you say okay, get down on this thing and you take a look at it and you start to see their heel kind of drifting back to where it was. Do you know why? Because this is a soft bone and you basically just got a piece of metal sitting inside the soft spongy bone. Well, guess what happens when they go and they start to walk on this thing the way they always walk with their flatfoot deformity, it spins. That little spinning, I’m not saying it’s going to go on to a nonunion as you see in this picture but understand that you will lose correction with these. Sometimes, you have to push them so far over to get your correction that the only thing it’s holding that heel bone together is your screw. In those patients, they’re strict nonweightbearing minimum of eight to 10 weeks which patients are not crazy about and I’m not either. I get my patients going as soon as possible. Here you see a perfect example of one healed but you see the screw heads don’t even purchasing the posterior calcaneus. Had this been a single screw fixation technique, that would’ve going to much like the x-ray you just saw.
There is also the potential with Koutsogiannis because that Achilles is attached and if this is a very unwanted thing that can take place but that calcaneus can actually ride up. You have to really fixate that thing and hold it in place until your screws are placed and then you can take out that provisional fixation. But as long as that Achilles is intact, it’s going to want to pull that posterior tuber that you’ve just created of that posterior osteotomy vertically. If it does do that then you’re going to get this inadvertent elevation where the Achilles, where you now created sort of a step off and you’ve shortened that side of that extremity as a result of it. There’s one of mine done with a mobile bearing ankle replacement. However, in this instance, this patient actually had a cavovarus foot. I was actually trying to flatten her out. That was inadvertent on my part but I have plenty that were inadvertent where I look that in postop is like that looks good in the operating room but look at this now and did it move a little bit? Sure, it certainly could have. When we’re doing this in the operation room, you see me there and you see the way I’m standing there. This is the view you want to get. People think the calcaneal axial views can’t be done in the operating room, they certainly can. You just basically place our patient on a radiolucent triangle which you see there and you just basically aim down at the heel. You can see how much shift he got if your fixation has missed or hit the spot or if you’re exactly where you thought you’re going to be. This is what gives you a good approximation of where you’re at and you can see the severity of step. If you hit that spot, you’re going to get it every time. Evans, again, we touch in this earlier and this is really isolated for sagittal and transverse plane deformity, short and lateral columns and this is the way you do it. You’re just using a needle to sort of isolate where that CCJ is and we want to go roughly 1 to 1-1/2 centimeters proximal to that, isolate it, cut it and measure it out. At this point, while we’re doing that expansion with those retractors we’re looking at an AP view of the foot or dorsal plantar view. We’re making sure that talar head is completely captured within the body, the navicular by placing them on an instrument tray and we want to hold them in that position to make sure that they are in the correct spot until we can get our graft fashion and then, we can just place it back in. You can do trabecular metal, you can do bone, you can do autograft, allograft, you name it, you can pretty much have just about anything in there and it probably would do pretty good. The things that I would be concerned about it is as we move backwards into the heel using anything but bone substitute is really, really not a good idea. You really want to avoid using trabecular metal such as this. This is really restrictive for Cotton’s and Evans procedures only and you can actually drop graft right in the middle of that donut and it will actually integrate very nicely across that area. Here is a typical example of what you do, how you cut it, how you wedge it and how you place it. Jeff Christensen did a great study of Evans osteotomies and fixation techniques. He found that there was no difference between a single K-wire across that osteotomy with that graft versus a $4000 plate and screw construct. Basically, he had the exact same results and they all agree and the graft incorporated in all those cases. It does go to show that a single screw, a single K-wire can certainly fix this. But making sure that you do not violate that dorsal joint and you’re not bugging the sural nerve which is going to be right in play is going to be the issue. Again, these are the things that we worry about with Evans is that we are lifting that joint line axis. We are taking the anterior calcaneus and propping it up on top of the cuboid and our really only thing or protection against that is that dorsal joint capsule which just going to hold that sleeve intact. [Indecipherable] [13:59] wire, we really still using as well. Clearly, I don’t use this procedure anymore. I never knew how much bone to take. It never seem like it really corrected anything. I took out a wedge bone and I was like yeah, I think that work, I’m not really sure. Still look like they embarrassed to me, the whole thing to me just in its inception and has had an exceptional amount of heel bone like some, you know, abnormally long heel bone where I could take a wedge. I always felt like I left one, the very, very shortened heel bone that really didn’t get a lot of correction when it was all set and done. You see the aggressiveness of that cut and how it takes how much heel bone out to correct it. There’s clearly going to be other issues that take place as a result of doing that, this is why I use this Malerba or the Z-cut and I do this for my medial and lateralizing osteotomies then you can see what that looks like intraoperatively. It’s a typical approach like I was doing a calcaneal fracture then K wires, no retraction on the skin. Again, I can do this in about eight or nine minutes and they work very well and I don’t have to do anything more than these guys. I can open them up.
I can drop graft in top. I can drop a graft in that bottom arm of it and create an Evans and slide at the same time. I think I have a little video showing that but you see the approach there and that’s what it looks like and you can see what it’ll be look like when we’re done. Very, very easy to do, not that complicated. This was a patient that actually had an old calcaneal fracture that heeled and varus and can see that from that calcaneal axial projection and you can see how shortened he looks and you can’t see any of the tubercles. This is after the osteotomy and clearly, it is already progress subtalar joint arthritis but you see the difference in the posterior calcaneus same view in how you can swing them over with just one osteotomy. That’s a lateralizing medial shift Malerba, there’s your incisional approach but it looks like intraoperatively pins holding it, that’s what it looks like when we do the cut. I think this is video, yes? Don’t tell me this isn’t playing. It isn’t playing. That’s a shame. This is a really good video. You can see just using a fixed locking plate to do it, okay. Here’s also a video that shows you how powerful this osteotomy. You see that gap in the bottom, I can actually drop a graft in there which I’m doing. I’m creating almost an Evans-Koutsogiannis construct at the same. I’m correcting out lateral plane without worrying about the calcaneocuboid joint and I’m close enough to the mid axis of the subtalar joint. It actually has some sort of function in lengthening the lateral column. This allows me to do that. Again, that hands-off approach we talked about, not very complicated. Very easy to do and once it’s in you see that opening area, this is going to be a combined osteotomy graft goes in there. You see we’re trimming it up, thumping it flush and what it looks like once it’s in. You can feel that top part of the arm with particular graft and you just simply put two screws. Great thing about the Malerba is I actually walks these patients at about three and half to four weeks and they do great with it. Here is a lady that was very old gal, come to the end of my talk here, so you guys can all rest easy. This is a gal. This is one of those cases where I had stage IV flatfoot, ankle valgus and I’m trying to stage her. I’m going to do all the hindfoot work. For those of you who were at my talk last night, I talked about not doing valgus ankle replacements all in one sitting, splitting them up, doing the valgus and hindfoot work first, seeing where the foot balance is out then coming back and doing the replacement and this is one of the unfortunate instances where we’re fortunate as you look at it that I did too good of the job balancing her out and she never came back for the replacement. I still see her every year just as a followup but she’s doing great. A lot times of this stage IV flatfeet, if you correct the flatfeet and the valgus deformity they really don’t need anything further and even other joint looks horrible, they tend to do very well. As you can see the significance of this patient or the significance of her deformity, I mean the talar heads are basically out of her foot. Look at that angle, I mean, we’re really approaching 45 degrees out, hyperdeclanated. The interior dome or central dome that the talus is actually rotated anteriorly and it’s escaping the ankle joint. It’s just got a diving talus we see here, mechanical axis of tibia and my mission as I accepted it was to get that talus back up and over. We’ve got the added fund of an old fibular fracture from her valgus deformity and the calcaneal fibular impingement. I’ve got two things I’ve got to fix here. I’ve got to fix that and also the fact that she’s pinching into the lateral wall of her heel. She escaped so far laterally that actually broke her fibula and she’s incongruent. I know none of the soft tissues structures on the medial side are worth anything. It’s really only one thing you can do which is a triple and it’s actually a double medial with a calcaneal osteotomy. You can see me preparing, that’s a large curette in there, I’m rotating her foot back in, medial approach only. This is only done through medial incision. In fact, everything you see here is only done through one incision on the medial side. Once this is done, her TMJ is reduced, okay. I got that fixed and I’m pretty happy with that. You see the talus is beginning to sit back up again. You can actually see her ankle joint again but that’s not going to be enough. We’ve got a Z here, okay, single screw to fix the osteotomy and the fusion site. But now, I’m left with this issue with this fibula, what I’m going to do? Now her distal lateral malleolus is blues but I still have a malaligned malunited old fibular fracture. If your percutaneous incision prying a lot but let you see me pricing the lateral malleolus away from the calcaneus to loosen it up, throwing a guide wire up here percutaneously, grafting it percutaneously, applying varus stress to the ankle joint and then rodding it.
What you’ll notice on that picture that is on your left is her completing congruent ankle valgus is completely resolved. That’s her preop, postop. We have some other in here like a Cotton osteotomy, the first cuneiform to bring that first met down and we’ve completely reduced that longitudinal issue, Mary’s ankles are completely corrected and her talar dome is sitting right where it should be. That was her views six weeks postop. Preop, postop. You can see just the remainder in the followup views. Here’s your take home points, with all these you noticed that have C-arm in the room. They always want to use C-arm. I don’t know why guys insist on not using C-arm but for some reason avoid it. Careful with the overcorrection with these things, with any of the osteotomies that I just showed you especially the Evans and the Malerba. You don’t need to shift to Malerba the way you do Koutsogiannis. In fact, a little bit goes a long way, in fact, if you use the two by one ratio for every two millimeters you would shift the Koots, you only need to do a Malerba by one. It’s a very stable osteotomy as we know, the Z of the first metatarsal is also very stable osteotomy. We also have a lot of room to plate and screw fixation and it heals very well with early weightbearing, actually encouraged not discourage as you would with the Koutsogiannis. Thanks for patience guys. Thanks for being super bones and hang me down here. Have a very safe trip home wherever you’re going. Thank you.