Calcaneal Osteotomy

Indications

A calcaneal osteotomy comprises cutting the heel bone and shifting it toward the inside (medial) or outside (lateral). A calcaneal osteotomy is indicated for patients whose hindfoot alignment is significantly offset and for whom non-operative management has failed. Depending which way the hindfoot is offset, the heel (calcaneus) may be shifted towards the midline of the body (medializing calcaneal osteotomy), or away from the midline of the body (lateralizing calcaneal osteotomy). For example, a patient with acquired adult flatfoot deformity will often have the heel offset to the outside and may benefit from a medializing calcaneal osteotomy to shift the hindfoot to the inside and change the way load is distributed through the heel (Figure 1). On the other hand, a patient with a high arched foot (cavus foot pattern) often has a heel that is offset to the inside (Figure 2). Individuals with a high arched foot are predisposed to sprain their ankle and may develop ankle instability. In severe forms of ankle instability, a lateralizing calcaneal osteotomy to shift the heel to the outside and re-establish a more normal hindfoot alignment may be beneficial.

Figure 1: Heel shifted to the outside in Flatfoot Deformity

Calcaneal Osteotomy

 

Figure 2: Both heels shifted to the inside in high arched foot

High Arched Foot

 

Procedure

An oblique incision is made on the outside region of the heel and is dissected down to the bone, which is about 5-10mm under the skin. One precaution while exposing the bone is to avoid cutting or injuring the sural nerve which provides sensation to the outside part of the foot. Once exposed, the back part of the heel bone is cut (osteotomy) into two pieces. The back part of the bone is then either shifted towards (medially) or away from (laterally) the midline. The bone is shifted between 5-12mm (1/4-1/2″). After the bone is shifted it is fixed in place usually with 1-2 large screws to stabilize the heel in its new position (see Figure 3). When the bone is shifted, a sharp edge is created, which is smoothed out prior to closing the wound.

Figure 3: Calcaneal Osteotomy (Side and Bottom View)

Calcaneal OsteotomyCalcaneal Osteotomy

 

Recovery

0-6 weeks Post-Surgery
Patients undergoing this type of surgery will typically need about 6 weeks for the bone to heal. During this period, the patient is either in a cast or a cast boot and remains non-weight bearing or touch weight-bearing.

6-12 weeks Post-Surgery
After the 6 week period of non-weight bearing x-rays will usually be taken. If healing is documented, the patient can begin weight-bearing in a cast boot (Cam Walker or equivalent) as tolerated. During the next 4-6 weeks patients can gradually increase the amount of walking (number of steps per day) that they doing. They can eventually start to transition to a stiff-soled “comfort shoe.” Initially a shoe would be worn for short distances within the house (often at 9-10 weeks post surgery). However, over time the patient will be able to increase the amount of time that he or she is in a shoe (and out of the CAM Walker). It is often 12-16 weeks post-op before the patient is in a shoe 100% of the day.
Calcaneal osteotomies are often combined with other procedures such as tendon transfers so the actual recovery time may vary depending on the procedures that are performed. In general during the first 5-6 months, patients generally get about 75-80% of their recovery. However, it commonly takes a year or more for full recovery since it takes a long time for all of the swelling to settle and the bones to remodel.

Potential Complications

Wound Healing Problems

Wound Infection

Deep Vein Thrombosis (DVT)

Pulmonary embolism (PE)

Complex regional Pain Syndrome (CRPS)

Asymmetric Gait

Specific potential complications

Complications specific to this surgery include:

    • Sural nerve and medial calcaneal nerve injury: Injury to the sural nerve on the outside of the heel can occur during the procedure either due to retraction, or direct injury; or from scarring during the recovery period. Injuries to one or more branches of the medial calcaneal nerve on the inside of the heel may occur when the heel bone is cut. If these nerves are injured or cut, the patient could end up with numbness or pain along the path of the nerve.
    • Painful Hardware: Another potential complication with this procedure is having pain associated with the screws that are used to secure the heel. About 10-20% of people will need to undergo removal of the screws due to discomfort, once the bones have healed.

 

edited July 3rd, 2014