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Calcaneal osteotomy (open technique using Atkins approach)

    Overview

    Learn the Calcaneal osteotomy (open technique using Atkins approach) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Calcaneal osteotomy (open technique using Atkins approach) surgical procedure.
    A Calcaneal osteotomy is a key component of the correction in many plano-valgus and cavo-varus deformities .
    Most common for both indications is to perform the osteotomy through a lateral approach ,of which there are several varieties.
    There are also various osteotomy designs to be considered for various specific indications. The most utilitarian is simply the oblique Calcaneal osteotomy detailed here , exposed through an Extended Lateral (Roger Atkins) approach.

    Indications

    There are various indications for a Calcaneal osteotomy. Most commonly it is used as part of a plano-valgus correction or Cavo-varus correction.
    There are a number of different Calcaneal osteotomy designs that are described. The most versatile is the oblique version detailed here. This can also be modified simply by the use of an opening or closing wedge technique (adding or removing a wedge respectively).
    The Evans osteotomy lengthens just through the anterior Calcaneus with the insertion of an opening wedge structural graft. The Rose osteotomy is designed to allow both rotational correction and medial displacement. A Z-shaped Scarf osteotomy utilising most of the Calcaneus and Cresentic osteotomy of the posterior aspect are also described.
    The minimally invasive technique for producing an oblique Calcaneal osteotomy under Image intensification has worthwhile advantages and is detailed elsewhere in the atlas by Paul Cooke.
    Different approaches can be used though the extended lateral approach (demonstrated here) is quick and with low rates of soft tissue complications once it is learned and performed correctly.

    Setup

    Laminar flow theatre used.
    GA or Spinal anesthesia
    Thigh Tourniquet
    Supine patient position
    Well padded bolster behind calf to raise heel off couch , slight internal tilt to table and bolster under buttock if required to allow neutral position of foot and counter-act lower limbs tendency to external roatation.
    Peri-operative antibiotics & LMW Heparin until patient adequately mobile (4-6 weeks).

    Operation

    An Extended lateral (Atkins) type approach is used to access the Calcaneum for the osteotomy. It is important to raise full thickness fascio-cutaneous skin flaps.
    The skin incision is created by commencing at/just anterior to the Achilles and approximately 5cm above the Fibula tip. This then continues inferiorly to the level of the junction of plantar and dorsal skin where the direction changes acutely in anteriorly and towards the base of the 5th metatarsal (though of course not this far anterior).
    The bone is first identified by deep , sharp direct dissection onto the calcaneus at the apex of the incision (where direction of the incision changes acutely). Once the Calcaneus itself is identified a sub-periosteal dissection can proceed initially in an anterior direction.
    To assist this early stage of the exposure Wests’ retractors are placed placed progressively more and more deeply at each end of the wound . These put the deeper soft tissues on maximum stretch and this assists the dissection.

    This is an adequate exposure for a Calcaneal osteotomy.
    The lateral wall of the Calcaneum has been sub-periosteally dissected with a combination of sharp dissection and also using a large round nosed periosteal elevator.
    The Achilles insertion posteriorly(1) ,the posterior facet of the subtalar joint (sitting beneath the elevated peroneal tendons) (2) and the superior border of the calcaneum(3) are the landmarks to be identified. The anterior extent of the weight-bearing plantar surface of the heel also needs to be identified as the osteotomy should exit inferiorly in front of this.
    The osteotomy cut should be made obliquely in the sagittal plane with usually a smaller amount of Calcaneus cut in the A-P plane superiorly than inferiorly.

    The osteotomy is performed using a large one sided reciprocating saw blade (1). The osteotomy cut starts between the Achilles insertion (2) and posterior facet of the subtalar joint superiorly and exits inferiorly anterior to the weight bearing surface of the Calcaneus (3).
    At this level the neuro-vascular bundle usually sits anteriorly and so is away from the blade.
    Two large Trethowans retractors (or similar) are placed superiorly and inferiorly (2,3) at the location of the saw cut , their tips angle towards the medial aspect of the Calcaneum.

    The calf is rested on a sterile well padded bowl and the foot left free. Careful probing cuts should be made, ensuring not to overshoot the medial wall of the calcaneum.
    The medial cortex breach should be very well controlled. This can be completed with a few controlled blows using a suitably sized Hibs osteotome.

    Once the osteotomy is completed there are several tricks which will assist in mobilising the heel.
    Initially placing a laminar spreader(with smooth tips) into the osteotomy cut and “jacking it out” by moving it carefully up and down the length of the osteotomy will help.
    If this does not allow adequate mobilisation then inspect the medial aspect of the osteotomy using the laminar spreader placed in the mid-point of the osteotomy and look medially for any obvious incompletely cut bone or spikes of bone that may be impeding mobility.
    Also try using a McDonalds as shown here (2) and carefully probe/strip soft tissue attachments and periosteum medially on both sides of the osteotomy.

    The posterior fragment should be moved as far ( medially or laterally) as it can be. One may wish to inferiorly translate the distal fragment if treating a plano-valgus deformity to increase the Calcaneal pitch (though this is often difficult to achieve as it involves distracting the Achilles ).
    A second pair of hands (attached to an assistant) are very useful for this stage. The reduction should be keenly maintained by the Surgeon whilst two guide wires are introduced (2) ,under careful instruction, by the assistant.
    Care should be taken not to allow guide wire (and therefore subsequent screw) to exit the bone and enter the medial Calcaneal soft tissue.
    This is a risk in particular when the posterior aspect of the calcaneus(and point of entry for fixation) is being moved medially.
    To this end the guide wire should enter the posterior heel (2) not in the midline medio-laterally but more towards the lateral edge of the Calcaneum. It should then also be angled laterally from this point of bony insertion.

    Two guide wires should be inserted parallel to the osteotomy and their position checked on lateral X Ray (and axial view also if there is uncertainty about their medial position).
    A second guide wire prevents the slight superior translation which can occur after drilling for the first screw(due to the pull of the Achilles). The ideal screw is placed towards the anterior process and has long partial threads. Generally no washer is needed and the screw head should be adequately seated. The inferior screw here in particular needs to be driven home by a few more turns.
    Using 2 screws reduces the chance of displacement occurring post-operatively.

    Post Operative

    Remove drain at 24 hours if used
    Non-weight bear 5 weeks
    Back-slab post op till 2 weeks , dressing changes at 1& 2 weeks (and as required if soft tissue healing issues).
    Full cast then till 5 weeks & check X-ray
    Long Aircast boot with crutches & increase weight bear as tolerated after 5 weeks.
    Physiotherapy is most meaningfully started once weight bearing is comfortable.
    Initially non-weight bearing program of range of movement & strengthening , progressing to balance as full weight is tolerated.
    Once able to full weight bear comfortably out of Aircast consider transition into stiff-soled hiking boot and subsequently normal shoe-wear once balance & swelling permit.

    Recommended Reading

    Calcaneus Osteotomy
    Curr Rev Musculoskelet Med. 2014. 7(4): 271-276
    Tennant JN, Carmont M, Phisitkul P
    Good overview of the published techniques and indications
    Full text article on :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596212/
    The distal course of the Sural nerve and its significance for incisions around the lateral hindfoot
    Foot & Ankle 1992 .13(4): 199-202
    Cadaveric study of 2o limbs plotting the course of the Sural nerve and its branches related to the Fibula and 5th metatarsal base .
    With the foot in full equinus it is suggested that an incision more than 7mm inferior to the Fibula tip risks direct injury to the nerve. (incisions far inferior to this point as with the Extended lateral approach can therefore be expected to avoid the main trunk).
    Intra-articular fractures of the Calcaneum: Open reduction and internal fixation by the extended lateral trans-calcaneal approach.
    J Bone Joint Surg 1993. 75-B (2):189-195
    Eastwood D, Langkamer VG, Atkins RM.
    The extended lateral approach is described in detail and this is a paper worth owning.
    Comparison of three different fixation methods of calcaneal osteotomy.
    Foot Ankle Int 2013. 34(3):420-5
    Abbasian A, Zaidi R, Guha A, Goldberg A, Cullen N, Singh D.
    Laterally applied locking plate fixation is compared with both headed and headless screws used via a plantar-posterior insertion.
    67 osteotomies in all reported of which 2 underwent delayed union (both lateral plate fixations in which group wound complications were also higher) .
    Implants that required removal were 47% of the headed screws ,11 of the headless screws (used in 18 osteotomies) and 6 of the lateral plates (32 osteotomies).

    Reference

    • orthoracle.com

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