Lateralizing calcaneal osteotomy via medial approach corrects hindfoot deformity

Cavovarus reconstruction with a lateralizing calcaneal osteotomy done though a medial approach posed low risk of neurologic injury and offered “powerful” translational correction for patients with hindfoot varus deformity, according to results presented at a meeting and published in Foot & Ankle International.

Perspective from Nelson F. SooHoo, MD

“The medial approach is safe. It has its benefits [and] you can get adequate lateral translation over 1 cm,” David E. Jaffe, MD, said. “You can perform a simultaneous plantar fascia release, which can aid in your cavovarus reconstruction. This can also eliminate small skin bridges if lateral access is needed, which is often the case in cavovarus reconstruction, and you are completely avoiding the sural nerve branches.”

He added, “Acute tarsal syndrome did not occur in our case series. We had a low rate of neurologic injury detection. You will encounter a branch of calcaneal nerve which can be protected and we did not find this to be a functional limitation in our cohort. Ultimately, we do not believe a tarsal tunnel release is necessary after lateralizing osteotomy.”

Low rate of neurologic injury

Jaffe and his colleagues retrospectively reviewed 24 consecutive patients who underwent cavovarus reconstruction with a lateralizing calcaneus osteotomy via medial approach by a single fellowship-trained surgeon. Investigators collected patient demographics, operative reports and postoperative clinical notes and reviewed them for the presence of immediate tarsal tunnel syndrome, concomitant procedures performed, perioperative complications, preoperative neurologic examinations and postoperative neurologic complications.

Investigators collected postoperative radiographs to determine the osteotomy location in relation to the posterior tubercle.

Most of the osteotomies were performed in the middle-third of the calcaneus.

No patient developed acute tarsal tunnel syndrome in the immediate postoperative period. Furthermore, permanent postoperative tibial nerve palsy was not seen in any patient. One patient each had late onset of lateral foot numbness that resolved 12 months postoperatively and diffuse numbness of the entire foot in no specific distribution.

Irrigation and debridement, antibiotics and plastic surgery closure were needed for two incision-related complications. Three patients underwent removal of symptomatic calcaneal hardware and one patient had a delayed union of the osteotomy and had a broken calcaneus screw.

Study limitations

One study limitation was patients with a preoperative neuropathy, which can lead to unreliable exams, were not included. However, this does not accurately represent the cavovarus patient population, Jaffe said.

Another limitation was that preoperative regional anesthesia was used, which could mask acute tarsal tunnel syndrome. These patients are usually sent home, but Jaffe and colleagues did not see persistent deficits during the patients’ first preoperative visit. As a result, investigators may have not have detected all neurologic deficits, he noted.

“Also, clinicians were not necessarily seeking out such deficits at the time of these clinical encounters and patients were not actively complaining about these deficits either,” he said. – by Monica Jaramillo

Reference:

Jaffe DE, et al. Foot Ankle Int. 2017;doi:10.1177/1071100717728678.

For more information:

David E. Jaffe, MD, can be reached at OrthoArizona, Arizona Bone & Joint Specialists, 13640 N. 7th St., Phoenix, AZ 85022; email: jaffed28@gmail.com.

Disclosure: Jaffe reports no relevant financial disclosures.

Perspective

Nelson F. SooHoo, MD

Jaffe and his colleagues report on the safety and efficacy of using a medial approach to perform a lateralizing calcaneal osteotomy. This is a promising alternative to traditional closing wedge osteotomies performed from a lateral approach to correct hindfoot varus. Specifically, the authors note the medial approach for the osteotomy can be used for concurrent plantar fascia release, which is often required for correction of severe cavovarus deformities. This would decrease the need for separate medial and lateral incisions.
The authors did note two wound complications requiring reoperation were seen in the 24 patients reviewed. This bears further clinical investigation as wound complications for the smaller incisions used in medial plantar fascia release are uncommon. A lateralizing osteotomy would theoretically place tension on the larger medial incision after lateral displacement of the os calcis. Larger case series will be helpful in determining the relative risks and benefits of wound complications from more extensile medial approaches for lateralizing osteotomies compared to traditional lateral approaches.

Nelson F. SooHoo, MD

Orthopedics Today Editorial Board Member

Disclosures: SooHoo reports no relevant financial disclosures.