The Journal of Foot & Ankle Surgery xxx (2014) 1–5
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Double Calcaneal Osteotomy with Percutaneous Steinmann Pin Fixation as Part of Treatment for Flexible Flatfoot Deformity: A Review of Consecutive Cases Highlighting Our Experience with Pin Fixation Troy J. Boffeli, DPM, FACFAS 1, Kyle W. Abben, DPM 2 1 2
Director, Foot and Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education and Research, St Paul, MN Chief Resident, Department of Foot and Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, St Paul, MN
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Surgical correction of flexible flatfoot deformity and posterior tibial tendon dysfunction has been extensively reported in published studies. When appropriate, calcaneal osteotomies for flatfoot correction have been a favorite of foot and ankle surgeons because of the corrective power achieved without the need to fuse any rearfoot joints. The medial displacement calcaneal osteotomy and Evans calcaneal osteotomy, together termed the double calcaneal osteotomy, have been reported several times by various investigators with a wide variety of fixation options. We undertook an institutional review board-approved retrospective review of 9 consecutive patients (11 feet), who had undergone double calcaneal osteotomy with 2 percutaneous Steinmann pin fixation for the correction of flexible flatfoot deformity, with or without posterior tibial tendon dysfunction. All patients had radiographic evidence of bone healing of the posterior calcaneal osteotomy and incorporation of the Evans osteotomy bone graft at 6 weeks and demonstrated clinical healing at 6 weeks. All patients had 2 percutaneous Steinmann pins placed through both osteotomies, and these were removed an average of 6 weeks postoperatively. No patient developed pin site complications. The only complication noted was sural neuritis, which was likely incision related. No patients had delayed union or nonunion, and we did not identify any graft shifting postoperatively. The present retrospective series highlights our experience with 2 percutaneous Steinmann pin fixation, demonstrating equal or better results than many previous published fixation methods for double calcaneal osteotomy. It is cost-effective and minimizes the potential risk of iatrogenic Achilles pathologic features associated with screw fixation. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: Achilles tendon calcaneus Evans osteotomy posterior tibial tendon dysfunction sural nerve
Surgical correction of flexible flatfoot deformity and posterior tibial tendon dysfunction has been extensively reported in published studies. When appropriate, calcaneal osteotomies for flatfoot correction have long been a favorite of foot and ankle surgeons owing to the corrective power achieved without the need for midfoot or hindfoot joint fusion. Koutsogiannis (1) described a medial displacement posterior calcaneal osteotomy that was intended to bring the weightbearing portion of the heel back under the leg and medialize the ground reactive forces. A wide variety of fixation options have been described for this osteotomy, all of which have had relatively good results (1,3–7). Evans also described a calcaneal osteotomy, but
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Kyle W. Abben, DPM, Department of Foot and Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, 640 Jackson Street, St Paul, MN 55101. E-mail address: [email protected] (K.W. Abben).
this time in the anterior process of the calcaneus using a bone graft to achieve lateral column lengthening (2). Koutsogiannis (1) did not fixate the grafted osteotomy, which has remained common practice. The combination of the anterior and posterior heel osteotomies is widely known as the double calcaneal osteotomy. Several investigators have advocated for some form of fixation of the Evans anterior calcaneal osteotomy to prevent graft displacement (3,7–11). Before 2008, we did not routinely use fixation of the Evans anterior calcaneal osteotomy and have traditionally used percutaneous Steinmann pins for the posterior heel osteotomy. As trends have moved toward fixation of the Evans osteotomy, it was a natural progression to simply advance the pins into the anterior calcaneus to achieve stabilization of both osteotomies with 2 pins, thereby preventing rotation of either osteotomy. Pins have been used for decades for fixating the posterior heel osteotomy and advancing these pins across the Evans anterior calcaneal osteotomy serves as insurance against graft displacement and elevation of the anterior calcaneal fragment. Cannulated screw systems offer a variety of options for the
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.04.017
2
T.J. Boffeli, K.W. Abben / The Journal of Foot & Ankle Surgery xxx (2014) 1–5
Fig. 1. Incision placement. (A) Separate incisions are used for the medial displacement posterior calcaneal osteotomy and Evans anterior calcaneal osteotomy. The sural nerve is typically anterior to the posterior calcaneal incision and inferior to the anterior calcaneal incision. The dashed lines serve as approximations of the typical nerve location of the sural and intermediate dorsal cutaneous nerves. (B) We typically lay a Kirschner wire over the skin using imaging guidance to ensure our posterior incision is in the ideal location. Proper placement of the incision allows minimal dissection.
size and length of the screw; however, placement of the drill and large-diameter screw through the Achilles tendon insertion in the posterior calcaneus is less than optimal. Furthermore, a large screw through the center of the graft is less than desirable. In contrast, we are able to space the 2 pins apart from each other within the graft. Plate fixation requires more extensive dissection, adds cost, and can require a second operation for removal. We present a retrospective study of 9 consecutive patients (11 feet) who had undergone a double calcaneal osteotomy as part of treatment of flexible flatfoot deformity, with or without posterior tibial tendon dysfunction. Our typical surgical plan for patients with flexible flatfoot deformity has consisted of gastrocnemius recession, double calcaneal osteotomy, and Cotton midfoot osteotomy. However, the focus of the present study was to highlight our results with modified 2 Steinmann pin fixation of the double calcaneal osteotomy.
Patients and Methods After institutional review board approval, we performed a retrospective analysis of consecutive patients who had undergone double calcaneal osteotomies that were fixated with 2 percutaneous Steinmann pins from June 2008 to July 2013. The inclusion criteria for the present study were 2 percutaneous Steinmann pin fixation and follow-up of at least 10 weeks with appropriate interval postoperative radiographs. Patients with any other form of double calcaneal osteotomy fixation were excluded. The senior author (T.J.B.) performed all procedures. Both investigators evaluated the radiographs to determine the interval to radiographic healing, which was defined as radiographic evidence of bone formation across the
osteotomies. Clinical healing was determined by an absence of pain at the surgical sites. The other data collected included age, gender, tobacco use at the time of procedure, chronic medical comorbidities, postoperative complications, and follow-up period (in months).
Surgical Technique The procedures are performed with the patient in the supine position under general anesthesia with a popliteal block. Separate incisions are used for the medial displacement posterior calcaneal osteotomy and the Evans anterior calcaneal osteotomy (Fig. 1A). The sural nerve is typically anterior to the posterior calcaneal incision and inferior to the anterior calcaneal incision. We typically lay a Kirschner wire over the skin under imaging to ensure our posterior incision is in the ideal location (Fig. 1B). The posterior incision is then carried down to the bone as we are posterior to the sural nerve. We try to minimize the periosteal dissection and only dissect where the osteotomy will be made. A Crego elevator is then used to free up the dorsal and plantar regions of the osteotomy of the calcaneus. The osteotomy is made with a standard sagittal saw, with the saw blade marked at 3 cm with a strip of tape to help improve depth perception and ensure the medial neurovascular structures are not violated. A long osteotomy guide is typically used to ensure the osteotomy is created in the same plane all the way through (Fig. 2). Next, a lamina spreader without teeth is introduced to the osteotomy to stretch the soft tissues to ease medial displacement of the posterior calcaneal tuber. The calcaneus is marked to ensure no dorsal or plantar displacement on translation of the posterior calcaneal tuber, because the pull of the Achilles tendon tends to displace the posterior tuber superiorly (Fig. 3).
Fig. 2. Osteotomy guide technique. (A) A long osteotomy guide and guide pin are typically used to ensure that the osteotomy is created in the same plane all the way through. (B and C) Imaging can ensure that the osteotomy guide is at the proper angle and anterior to the Achilles insertion and plantar fascia origin.
T.J. Boffeli, K.W. Abben / The Journal of Foot & Ankle Surgery xxx (2014) 1–5
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Fig. 3. (A) The calcaneus should be marked to ensure no dorsal or plantar displacement on translation of the posterior calcaneal tuber. (B) The pull of the Achilles tendon will tend to displace the posterior tuber superiorly during medial displacement. Marking a line across the osteotomy will ensure that no dorsal or plantar displacement occurs before advancement of fixation.
Then, the anterior calcaneal incision is made at the inferior border of the sinus tarsi in preparation for the Evans osteotomy. The trapezoidal-shaped allogenic iliac crest bone graft is fashioned on the back table. A Crego elevator is used to free the plantar soft tissue structures. Care is taken during deep dissection not to disrupt the calcaneocuboid joint ligaments, because these help stabilize the anterior process of the calcaneus once the Evans osteotomy has been completed. The peroneal tendons are also retracted. Next, a guide pin is inserted almost parallel with the calcaneocuboid joint and approximately 1.5 cm proximal to the joint (Fig. 4). The osteotomy is made using a sagittal saw, and the medial cortex is not left intact. After creation of the Evans osteotomy, a 2.0 Steinmann pin is placed from the posterior aspect of the calcaneus and advanced into the posterior calcaneal osteotomy. We watch the pin advance into the osteotomy and then back it up slightly. This pin then serves as a “joystick” to aid in medial displacement of the posterior calcaneal tuber (Fig. 5). Next, with the forefoot plantar flexed and distracting the
posterior tuber with the joystick, the posterior tuber is displaced medially approximately 1 cm and the 2 lines on the lateral aspect of the calcaneus that we drew are lined up. The Steinmann pin is advanced across the posterior osteotomy and advanced until it is seen coming through the Evans osteotomy site. We aim to have the pin enter near the midportion of the osteotomy. We confirm placement under imaging, and, once we are satisfied, a second Steinmann pin is placed superior to the first pin, which is visualized as it enters the Evans anterior osteotomy site. Once both pins are visualized and we are happy with their placement across the future graft site, the pins are retracted a couple millimeters below the bone surface, and the allogenic bone graft wedge is inserted. Once proper graft placement and deformity reduction is confirmed with imaging and clinical examination, the 2 Steinmann pins are advanced distally into the subchondral bone of the anterior calcaneus. This is typically done under imaging to ensure no violation of the calcaneocuboid joint has occurred (Fig. 6). The pins are then bent, cut, and rotated with the ends toward each other and overlapping (Fig. 7A and 7B). Steri-Strips (NexCareÔ, 3M, St Paul, MN) are then wrapped around the bent portions of the pins, holding them together to prevent rotation or loosening. This technique prevents the pins from working loose before removal at 6 weeks postoperatively. Standard closure is then performed, and the patient is placed in a well-padded posterior splint. They are kept nonweight bearing for 6 weeks. No pin care is done postoperatively. Results Nine patients (11 feet) were included in the present study (4 males and 5 females). The average age was 37.55 (range 12 to 70) years. All 11 feet demonstrated clinical and radiographic healing at the 6-week postoperative visit. Good incorporation of the bone graft was seen, with no evidence of displacement in all 11 feet. All patients had both pins removed 6 weeks after surgery, and none had to be removed prematurely because of loosening. One patient had a history of pulmonary embolism; otherwise, all were free of chronic medical conditions. No patients were active tobacco users at the time of surgery. The only postoperative complication identified was sural neuritis in 1 patient, but it did not require any intervention and had resolved by the final follow-up visit. This was most likely incision related. The average follow-up for this group of patients was 11.14 (range 2.5 to 32) months.
Fig. 4. Osteotomy guide pins for the Evans calcaneal osteotomy. Osteotomy guide pins are placed from both the lateral-to-medial and dorsal-to-plantar directions approximately 1.5 cm proximal to the calcaneocuboid joint. The pins are placed close to parallel to the calcaneocuboid joint in both planes. The osteotomy is created using a standard sagittal saw following the lateral-to-medial guide pin to the medial cortex, which is approximately 3 cm.
Discussion The double calcaneal osteotomy is a powerful and well-accepted procedure for correction of flexible flatfoot deformity with or without posterior tibial tendon dysfunction. Several fixation options
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T.J. Boffeli, K.W. Abben / The Journal of Foot & Ankle Surgery xxx (2014) 1–5
Fig. 5. Joystick placement for medial translation of the posterior calcaneal tuber. (A) Lateral radiograph of intraoperative placement of the Steinmann pin joystick. (B and C) A 2.0-mm Steinmann pin is placed in the posterior aspect of the calcaneus and used as a joystick to aid in medial translation of the posterior tuber. We watch the pin advance into the osteotomy and then back it up slightly. A second Kirschner wire can be placed through the posterior incision as a temporary stop once the posterior tuber has been displaced (optional).
have been previously reported for double calcaneal osteotomy (3–6). In 2011, DiDomenico et al (3) reported a case study of using 2 cannulated screws, 1 fixating only the calcaneal slide osteotomy. The second cannulated screw had a long thread pattern to obtain compression across the posterior osteotomy, and the threads proximal and distal to the anterior osteotomy prevented graft displacement and unwanted compression across the graft (3). Frankel et al (4) published a case report of using 2 Steinmann pins for the posterior osteotomy and no fixation for the Evans osteotomy. The 2 pins were removed at 7 weeks postoperatively, and the patient had returned to regular shoe wear at 16 weeks postoperatively (4). Other published fixation techniques have included Kirschner wires and external fixation (5,6). There is debate regarding whether fixation is needed for the Evans osteotomy. A wide range of fixation options for the Evans calcaneal
osteotomy has been previously published, including no fixation, plate fixation, and absorbable bone pins (8–10). In their 2012 systematic review, Prissel and Roukis (12) found the nonunion rate to be 1.4% with the unfixated, isolated Evans calcaneal osteotomy. However, we have typically not performed this as an isolated procedure, and previous published reports have demonstrated the ability of the bone graft or anterior calcaneal process to migrate postoperatively. In their 2011 study, Dunn and Meyer (11) concluded in their retrospective radiographic analysis of the Evans calcaneal osteotomy that the anterior process of the calcaneus does displace dorsally in the immediate postoperative period, although this was noted to largely resolve to statistically insignificant levels at the final long-term follow-up examination. They recommended a future study correlating the radiographic findings such as theirs with the clinical outcomes (11). Dayton et al (10) recommended using a locking plate for
Fig. 6. (A–C) Advancement of the Steinmann pins for fixation of the medial displacement and Evans calcaneal osteotomies using imaging guidance. Both Steinmann pins cross each calcaneal osteotomy. The pins should be visualized entering the posterior osteotomy before advancement to the anterior osteotomy to ensure proper positioning.
T.J. Boffeli, K.W. Abben / The Journal of Foot & Ankle Surgery xxx (2014) 1–5
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Fig. 7. External pin management. (A and B) Once the pins have been advanced into the subchondral bone of the anterior calcaneus, they are bent, cut, and rotated, with the ends overlapping. Two Steri-Strips are then wrapped around the pins, holding them together to prevent rotation. This prevents the pins from working loose during the 6 weeks they are in place. (C) Typical clinical appearance of pin sites 6 weeks postoperatively. Patients do not require pin site care postoperatively, because the pins are not allowed to rotate and have been placed in safe zones minimally affected by edema fluctuation, resulting in less soft tissue irritation.
fixation of the Evans calcaneal osteotomy to maintain correction and reduce the incidence of anterior fragment displacement in the early postoperative period. Few studies have been reported on the complications associated with various fixation methods for the double calcaneal osteotomy, especially regarding any Achilles tendon pathologic entities associated with posterior heel screw placement. This has been more related to the dorsal point of posterior fixation, because it would be ideal to have a point of fixation through the upper half of the osteotomy, which would require placement through the distal Achilles tendon. Although not widely reported, it seems that disrupting the insertional fibers of the Achilles tendon with the large drill, countersink, and screw threads required for cannulated screw placement would be less than ideal and could potentially have postoperative implications. Monseir-LaClair et al (7) previously reported that 10 of 28 feet (35%) in their study required removal of the calcaneal screw fixation secondary to pain. Although speculative, it is intuitive that a smooth Steinmann pin placed through the Achilles tendon insertion would likely cause minimal damage to the tendon itself. Another added benefit of using 2 percutaneous Steinmann pins is the cost-effectiveness compared with any other reported fixation method. They are significantly less expensive than any available cannulated or solid core screw. They also can be removed at an office visit; thus, the concerns regarding long-term hardware complications are negated. We had no major complications in our study. One patient did develop sural neuritis; however, this had resolved before the final follow-up visit. No patient had any loosening of the Steinmann pins or infection postoperatively. We largely credit the lack of pins loosening to advancing them into the subchondral bone of the anterior calcaneus and to attaching the pins together with Steri-Strips (NexcareÔ, 3M) to prevent rotation. We consider the tips of the toes and the posterior heel be safe zones for percutaneous pin placement, because these areas will generally not be affected by swelling. Other regions of the foot and ankle are prone to fluctuating edema, which can cause soft tissue irritation around the pin, leading to pin loosening and/or infection, which could require premature removal. By rotating the pins and taping them together, we created stable pins, preventing pin loosening and resulting in less soft tissue irritation. Furthermore, we do not perform pin care, because it is not needed with stable pins placed through soft tissue that is not prone to fluctuating edema. All pins were removed in the office an average of 6 weeks postoperatively. Fig. 7C demonstrates the typical appearance of the pin sites 6 weeks after surgery. All patients healed of their double
calcaneal osteotomies uneventfully and had returned to regular shoes at 10 weeks postoperatively. The limitations of our study included the relatively small number of patients in the study, although all were consecutive, decreasing exclusion bias. Also, all procedures were performed by a single surgeon, which could also be seen as a benefit, because this removes the intersurgeon variability with procedure technique. We also had a relatively short follow-up period, with an average of 11.14 months; however, this was sufficient to determine the incidence of postoperative pin complications or osseous healing issues that have been suggested to occur with the absence of fixation past 6 weeks postoperatively. In conclusion, the present retrospective study of consecutive patients has demonstrated that 2 percutaneous Steinmann pins for fixation of the double calcaneal osteotomy is safe, reliable, and costeffective. Furthermore, no patient identified any insertional Achilles tendon issues associated with pin placement with just longer than 11 months of follow-up. A prospective comparative study contrasting the various fixation techniques would be beneficial and worth future efforts. References 1. Koutsogiannis E. Treatment of mobile flat foot by displacement osteotomy of the calcaneus. J Bone Joint Surg Br 53B:96–100, 1971. 2. Evans D. Calcaneo-valgus deformity. J Bone Joint Surg Br 57B:270–278, 1975. 3. DiDomenico LA, Haro AA, Cross DJ. Double calcaneal osteotomy using single, dualfunction screw fixation technique. J Foot Ankle Surg 50:773–775, 2011. 4. Frankel JP, Turf RM, Kuzmicki LM. Double calcaneal osteotomy in the treatment of posterior tibial tendon dysfunction. J Foot Ankle Surg 34:254–261, 1995. 5. Basioni Y, El-Ganainy AR, El-Hawary A. Double calcaneal osteotomy and percutaneous tenoplasty of adequate arch restoration in adult flexible flat foot. Int Orthop 35:47–51, 2011. 6. Penny NT, Viselli SJ, Holmes TR, Weiner RD. Double calcaneal osteotomy with a unilateral rail fixator for correction of pes planus. Foot Ankle Spec 2:194–199, 2009. 7. Monseir-LaClair S, Pomeroy G, Manoli A. Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency. Foot Ankle Int 22:283–291, 2001. 8. Weinraub GM, Daulat R. The Evans osteotomy: technique and fixation with cortical bone pin. J Foot Ankle Surg 40:54–57, 2001. 9. Saxena A. Evans calcaneal osteotomy. J Foot Ankle Surg 39:136–137, 2000. 10. Dayton P, Prins DB, Smith DE, Feilmeier MJ. Effectiveness of a locking plate in preserving midcalcaneal length and positional outcome after Evans calcaneal osteotomy: a retrospective pilot study. J Foot Ankle Surg 52:710–713, 2013. 11. Dunn SP, Meyer J. Displacement of the anterior process of the calcaneus after Evans calcaneal osteotomy. J Foot Ankle Surg 50:402–406, 2011. 12. Prissel MA, Roukis TS. Incidence of nonunion of the unfixated, isolated Evans calcaneal osteotomy: a systematic review. J Foot Ankle Surg 51:323–325, 2012.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Double Calcaneal Osteotomy with Percutaneous Steinmann Pin Fixation as Part of Treatment for Flexible Flatfoot Deformity: A Review of Consecutive Cases Highlighting Our Experience with Pin Fixation Troy J. Boffeli, DPM, FACFAS 1, Kyle W. Abben, DPM 2 1 2
Director, Foot and Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education and Research, St Paul, MN Chief Resident, Department of Foot and Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, St Paul, MN
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Surgical correction of flexible flatfoot deformity and posterior tibial tendon dysfunction has been extensively reported in published studies. When appropriate, calcaneal osteotomies for flatfoot correction have been a favorite of foot and ankle surgeons because of the corrective power achieved without the need to fuse any rearfoot joints. The medial displacement calcaneal osteotomy and Evans calcaneal osteotomy, together termed the double calcaneal osteotomy, have been reported several times by various investigators with a wide variety of fixation options. We undertook an institutional review board-approved retrospective review of 9 consecutive patients (11 feet), who had undergone double calcaneal osteotomy with 2 percutaneous Steinmann pin fixation for the correction of flexible flatfoot deformity, with or without posterior tibial tendon dysfunction. All patients had radiographic evidence of bone healing of the posterior calcaneal osteotomy and incorporation of the Evans osteotomy bone graft at 6 weeks and demonstrated clinical healing at 6 weeks. All patients had 2 percutaneous Steinmann pins placed through both osteotomies, and these were removed an average of 6 weeks postoperatively. No patient developed pin site complications. The only complication noted was sural neuritis, which was likely incision related. No patients had delayed union or nonunion, and we did not identify any graft shifting postoperatively. The present retrospective series highlights our experience with 2 percutaneous Steinmann pin fixation, demonstrating equal or better results than many previous published fixation methods for double calcaneal osteotomy. It is cost-effective and minimizes the potential risk of iatrogenic Achilles pathologic features associated with screw fixation. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: Achilles tendon calcaneus Evans osteotomy posterior tibial tendon dysfunction sural nerve
Surgical correction of flexible flatfoot deformity and posterior tibial tendon dysfunction has been extensively reported in published studies. When appropriate, calcaneal osteotomies for flatfoot correction have long been a favorite of foot and ankle surgeons owing to the corrective power achieved without the need for midfoot or hindfoot joint fusion. Koutsogiannis (1) described a medial displacement posterior calcaneal osteotomy that was intended to bring the weightbearing portion of the heel back under the leg and medialize the ground reactive forces. A wide variety of fixation options have been described for this osteotomy, all of which have had relatively good results (1,3–7). Evans also described a calcaneal osteotomy, but
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Kyle W. Abben, DPM, Department of Foot and Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, 640 Jackson Street, St Paul, MN 55101. E-mail address: [email protected] (K.W. Abben).
this time in the anterior process of the calcaneus using a bone graft to achieve lateral column lengthening (2). Koutsogiannis (1) did not fixate the grafted osteotomy, which has remained common practice. The combination of the anterior and posterior heel osteotomies is widely known as the double calcaneal osteotomy. Several investigators have advocated for some form of fixation of the Evans anterior calcaneal osteotomy to prevent graft displacement (3,7–11). Before 2008, we did not routinely use fixation of the Evans anterior calcaneal osteotomy and have traditionally used percutaneous Steinmann pins for the posterior heel osteotomy. As trends have moved toward fixation of the Evans osteotomy, it was a natural progression to simply advance the pins into the anterior calcaneus to achieve stabilization of both osteotomies with 2 pins, thereby preventing rotation of either osteotomy. Pins have been used for decades for fixating the posterior heel osteotomy and advancing these pins across the Evans anterior calcaneal osteotomy serves as insurance against graft displacement and elevation of the anterior calcaneal fragment. Cannulated screw systems offer a variety of options for the
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.04.017
2
T.J. Boffeli, K.W. Abben / The Journal of Foot & Ankle Surgery xxx (2014) 1–5
Fig. 1. Incision placement. (A) Separate incisions are used for the medial displacement posterior calcaneal osteotomy and Evans anterior calcaneal osteotomy. The sural nerve is typically anterior to the posterior calcaneal incision and inferior to the anterior calcaneal incision. The dashed lines serve as approximations of the typical nerve location of the sural and intermediate dorsal cutaneous nerves. (B) We typically lay a Kirschner wire over the skin using imaging guidance to ensure our posterior incision is in the ideal location. Proper placement of the incision allows minimal dissection.
size and length of the screw; however, placement of the drill and large-diameter screw through the Achilles tendon insertion in the posterior calcaneus is less than optimal. Furthermore, a large screw through the center of the graft is less than desirable. In contrast, we are able to space the 2 pins apart from each other within the graft. Plate fixation requires more extensive dissection, adds cost, and can require a second operation for removal. We present a retrospective study of 9 consecutive patients (11 feet) who had undergone a double calcaneal osteotomy as part of treatment of flexible flatfoot deformity, with or without posterior tibial tendon dysfunction. Our typical surgical plan for patients with flexible flatfoot deformity has consisted of gastrocnemius recession, double calcaneal osteotomy, and Cotton midfoot osteotomy. However, the focus of the present study was to highlight our results with modified 2 Steinmann pin fixation of the double calcaneal osteotomy.
Patients and Methods After institutional review board approval, we performed a retrospective analysis of consecutive patients who had undergone double calcaneal osteotomies that were fixated with 2 percutaneous Steinmann pins from June 2008 to July 2013. The inclusion criteria for the present study were 2 percutaneous Steinmann pin fixation and follow-up of at least 10 weeks with appropriate interval postoperative radiographs. Patients with any other form of double calcaneal osteotomy fixation were excluded. The senior author (T.J.B.) performed all procedures. Both investigators evaluated the radiographs to determine the interval to radiographic healing, which was defined as radiographic evidence of bone formation across the
osteotomies. Clinical healing was determined by an absence of pain at the surgical sites. The other data collected included age, gender, tobacco use at the time of procedure, chronic medical comorbidities, postoperative complications, and follow-up period (in months).
Surgical Technique The procedures are performed with the patient in the supine position under general anesthesia with a popliteal block. Separate incisions are used for the medial displacement posterior calcaneal osteotomy and the Evans anterior calcaneal osteotomy (Fig. 1A). The sural nerve is typically anterior to the posterior calcaneal incision and inferior to the anterior calcaneal incision. We typically lay a Kirschner wire over the skin under imaging to ensure our posterior incision is in the ideal location (Fig. 1B). The posterior incision is then carried down to the bone as we are posterior to the sural nerve. We try to minimize the periosteal dissection and only dissect where the osteotomy will be made. A Crego elevator is then used to free up the dorsal and plantar regions of the osteotomy of the calcaneus. The osteotomy is made with a standard sagittal saw, with the saw blade marked at 3 cm with a strip of tape to help improve depth perception and ensure the medial neurovascular structures are not violated. A long osteotomy guide is typically used to ensure the osteotomy is created in the same plane all the way through (Fig. 2). Next, a lamina spreader without teeth is introduced to the osteotomy to stretch the soft tissues to ease medial displacement of the posterior calcaneal tuber. The calcaneus is marked to ensure no dorsal or plantar displacement on translation of the posterior calcaneal tuber, because the pull of the Achilles tendon tends to displace the posterior tuber superiorly (Fig. 3).
Fig. 2. Osteotomy guide technique. (A) A long osteotomy guide and guide pin are typically used to ensure that the osteotomy is created in the same plane all the way through. (B and C) Imaging can ensure that the osteotomy guide is at the proper angle and anterior to the Achilles insertion and plantar fascia origin.
T.J. Boffeli, K.W. Abben / The Journal of Foot & Ankle Surgery xxx (2014) 1–5
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Fig. 3. (A) The calcaneus should be marked to ensure no dorsal or plantar displacement on translation of the posterior calcaneal tuber. (B) The pull of the Achilles tendon will tend to displace the posterior tuber superiorly during medial displacement. Marking a line across the osteotomy will ensure that no dorsal or plantar displacement occurs before advancement of fixation.
Then, the anterior calcaneal incision is made at the inferior border of the sinus tarsi in preparation for the Evans osteotomy. The trapezoidal-shaped allogenic iliac crest bone graft is fashioned on the back table. A Crego elevator is used to free the plantar soft tissue structures. Care is taken during deep dissection not to disrupt the calcaneocuboid joint ligaments, because these help stabilize the anterior process of the calcaneus once the Evans osteotomy has been completed. The peroneal tendons are also retracted. Next, a guide pin is inserted almost parallel with the calcaneocuboid joint and approximately 1.5 cm proximal to the joint (Fig. 4). The osteotomy is made using a sagittal saw, and the medial cortex is not left intact. After creation of the Evans osteotomy, a 2.0 Steinmann pin is placed from the posterior aspect of the calcaneus and advanced into the posterior calcaneal osteotomy. We watch the pin advance into the osteotomy and then back it up slightly. This pin then serves as a “joystick” to aid in medial displacement of the posterior calcaneal tuber (Fig. 5). Next, with the forefoot plantar flexed and distracting the
posterior tuber with the joystick, the posterior tuber is displaced medially approximately 1 cm and the 2 lines on the lateral aspect of the calcaneus that we drew are lined up. The Steinmann pin is advanced across the posterior osteotomy and advanced until it is seen coming through the Evans osteotomy site. We aim to have the pin enter near the midportion of the osteotomy. We confirm placement under imaging, and, once we are satisfied, a second Steinmann pin is placed superior to the first pin, which is visualized as it enters the Evans anterior osteotomy site. Once both pins are visualized and we are happy with their placement across the future graft site, the pins are retracted a couple millimeters below the bone surface, and the allogenic bone graft wedge is inserted. Once proper graft placement and deformity reduction is confirmed with imaging and clinical examination, the 2 Steinmann pins are advanced distally into the subchondral bone of the anterior calcaneus. This is typically done under imaging to ensure no violation of the calcaneocuboid joint has occurred (Fig. 6). The pins are then bent, cut, and rotated with the ends toward each other and overlapping (Fig. 7A and 7B). Steri-Strips (NexCareÔ, 3M, St Paul, MN) are then wrapped around the bent portions of the pins, holding them together to prevent rotation or loosening. This technique prevents the pins from working loose before removal at 6 weeks postoperatively. Standard closure is then performed, and the patient is placed in a well-padded posterior splint. They are kept nonweight bearing for 6 weeks. No pin care is done postoperatively. Results Nine patients (11 feet) were included in the present study (4 males and 5 females). The average age was 37.55 (range 12 to 70) years. All 11 feet demonstrated clinical and radiographic healing at the 6-week postoperative visit. Good incorporation of the bone graft was seen, with no evidence of displacement in all 11 feet. All patients had both pins removed 6 weeks after surgery, and none had to be removed prematurely because of loosening. One patient had a history of pulmonary embolism; otherwise, all were free of chronic medical conditions. No patients were active tobacco users at the time of surgery. The only postoperative complication identified was sural neuritis in 1 patient, but it did not require any intervention and had resolved by the final follow-up visit. This was most likely incision related. The average follow-up for this group of patients was 11.14 (range 2.5 to 32) months.
Fig. 4. Osteotomy guide pins for the Evans calcaneal osteotomy. Osteotomy guide pins are placed from both the lateral-to-medial and dorsal-to-plantar directions approximately 1.5 cm proximal to the calcaneocuboid joint. The pins are placed close to parallel to the calcaneocuboid joint in both planes. The osteotomy is created using a standard sagittal saw following the lateral-to-medial guide pin to the medial cortex, which is approximately 3 cm.
Discussion The double calcaneal osteotomy is a powerful and well-accepted procedure for correction of flexible flatfoot deformity with or without posterior tibial tendon dysfunction. Several fixation options
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Fig. 5. Joystick placement for medial translation of the posterior calcaneal tuber. (A) Lateral radiograph of intraoperative placement of the Steinmann pin joystick. (B and C) A 2.0-mm Steinmann pin is placed in the posterior aspect of the calcaneus and used as a joystick to aid in medial translation of the posterior tuber. We watch the pin advance into the osteotomy and then back it up slightly. A second Kirschner wire can be placed through the posterior incision as a temporary stop once the posterior tuber has been displaced (optional).
have been previously reported for double calcaneal osteotomy (3–6). In 2011, DiDomenico et al (3) reported a case study of using 2 cannulated screws, 1 fixating only the calcaneal slide osteotomy. The second cannulated screw had a long thread pattern to obtain compression across the posterior osteotomy, and the threads proximal and distal to the anterior osteotomy prevented graft displacement and unwanted compression across the graft (3). Frankel et al (4) published a case report of using 2 Steinmann pins for the posterior osteotomy and no fixation for the Evans osteotomy. The 2 pins were removed at 7 weeks postoperatively, and the patient had returned to regular shoe wear at 16 weeks postoperatively (4). Other published fixation techniques have included Kirschner wires and external fixation (5,6). There is debate regarding whether fixation is needed for the Evans osteotomy. A wide range of fixation options for the Evans calcaneal
osteotomy has been previously published, including no fixation, plate fixation, and absorbable bone pins (8–10). In their 2012 systematic review, Prissel and Roukis (12) found the nonunion rate to be 1.4% with the unfixated, isolated Evans calcaneal osteotomy. However, we have typically not performed this as an isolated procedure, and previous published reports have demonstrated the ability of the bone graft or anterior calcaneal process to migrate postoperatively. In their 2011 study, Dunn and Meyer (11) concluded in their retrospective radiographic analysis of the Evans calcaneal osteotomy that the anterior process of the calcaneus does displace dorsally in the immediate postoperative period, although this was noted to largely resolve to statistically insignificant levels at the final long-term follow-up examination. They recommended a future study correlating the radiographic findings such as theirs with the clinical outcomes (11). Dayton et al (10) recommended using a locking plate for
Fig. 6. (A–C) Advancement of the Steinmann pins for fixation of the medial displacement and Evans calcaneal osteotomies using imaging guidance. Both Steinmann pins cross each calcaneal osteotomy. The pins should be visualized entering the posterior osteotomy before advancement to the anterior osteotomy to ensure proper positioning.
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Fig. 7. External pin management. (A and B) Once the pins have been advanced into the subchondral bone of the anterior calcaneus, they are bent, cut, and rotated, with the ends overlapping. Two Steri-Strips are then wrapped around the pins, holding them together to prevent rotation. This prevents the pins from working loose during the 6 weeks they are in place. (C) Typical clinical appearance of pin sites 6 weeks postoperatively. Patients do not require pin site care postoperatively, because the pins are not allowed to rotate and have been placed in safe zones minimally affected by edema fluctuation, resulting in less soft tissue irritation.
fixation of the Evans calcaneal osteotomy to maintain correction and reduce the incidence of anterior fragment displacement in the early postoperative period. Few studies have been reported on the complications associated with various fixation methods for the double calcaneal osteotomy, especially regarding any Achilles tendon pathologic entities associated with posterior heel screw placement. This has been more related to the dorsal point of posterior fixation, because it would be ideal to have a point of fixation through the upper half of the osteotomy, which would require placement through the distal Achilles tendon. Although not widely reported, it seems that disrupting the insertional fibers of the Achilles tendon with the large drill, countersink, and screw threads required for cannulated screw placement would be less than ideal and could potentially have postoperative implications. Monseir-LaClair et al (7) previously reported that 10 of 28 feet (35%) in their study required removal of the calcaneal screw fixation secondary to pain. Although speculative, it is intuitive that a smooth Steinmann pin placed through the Achilles tendon insertion would likely cause minimal damage to the tendon itself. Another added benefit of using 2 percutaneous Steinmann pins is the cost-effectiveness compared with any other reported fixation method. They are significantly less expensive than any available cannulated or solid core screw. They also can be removed at an office visit; thus, the concerns regarding long-term hardware complications are negated. We had no major complications in our study. One patient did develop sural neuritis; however, this had resolved before the final follow-up visit. No patient had any loosening of the Steinmann pins or infection postoperatively. We largely credit the lack of pins loosening to advancing them into the subchondral bone of the anterior calcaneus and to attaching the pins together with Steri-Strips (NexcareÔ, 3M) to prevent rotation. We consider the tips of the toes and the posterior heel be safe zones for percutaneous pin placement, because these areas will generally not be affected by swelling. Other regions of the foot and ankle are prone to fluctuating edema, which can cause soft tissue irritation around the pin, leading to pin loosening and/or infection, which could require premature removal. By rotating the pins and taping them together, we created stable pins, preventing pin loosening and resulting in less soft tissue irritation. Furthermore, we do not perform pin care, because it is not needed with stable pins placed through soft tissue that is not prone to fluctuating edema. All pins were removed in the office an average of 6 weeks postoperatively. Fig. 7C demonstrates the typical appearance of the pin sites 6 weeks after surgery. All patients healed of their double
calcaneal osteotomies uneventfully and had returned to regular shoes at 10 weeks postoperatively. The limitations of our study included the relatively small number of patients in the study, although all were consecutive, decreasing exclusion bias. Also, all procedures were performed by a single surgeon, which could also be seen as a benefit, because this removes the intersurgeon variability with procedure technique. We also had a relatively short follow-up period, with an average of 11.14 months; however, this was sufficient to determine the incidence of postoperative pin complications or osseous healing issues that have been suggested to occur with the absence of fixation past 6 weeks postoperatively. In conclusion, the present retrospective study of consecutive patients has demonstrated that 2 percutaneous Steinmann pins for fixation of the double calcaneal osteotomy is safe, reliable, and costeffective. Furthermore, no patient identified any insertional Achilles tendon issues associated with pin placement with just longer than 11 months of follow-up. A prospective comparative study contrasting the various fixation techniques would be beneficial and worth future efforts. References 1. Koutsogiannis E. Treatment of mobile flat foot by displacement osteotomy of the calcaneus. J Bone Joint Surg Br 53B:96–100, 1971. 2. Evans D. Calcaneo-valgus deformity. J Bone Joint Surg Br 57B:270–278, 1975. 3. DiDomenico LA, Haro AA, Cross DJ. Double calcaneal osteotomy using single, dualfunction screw fixation technique. J Foot Ankle Surg 50:773–775, 2011. 4. Frankel JP, Turf RM, Kuzmicki LM. Double calcaneal osteotomy in the treatment of posterior tibial tendon dysfunction. J Foot Ankle Surg 34:254–261, 1995. 5. Basioni Y, El-Ganainy AR, El-Hawary A. Double calcaneal osteotomy and percutaneous tenoplasty of adequate arch restoration in adult flexible flat foot. Int Orthop 35:47–51, 2011. 6. Penny NT, Viselli SJ, Holmes TR, Weiner RD. Double calcaneal osteotomy with a unilateral rail fixator for correction of pes planus. Foot Ankle Spec 2:194–199, 2009. 7. Monseir-LaClair S, Pomeroy G, Manoli A. Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency. Foot Ankle Int 22:283–291, 2001. 8. Weinraub GM, Daulat R. The Evans osteotomy: technique and fixation with cortical bone pin. J Foot Ankle Surg 40:54–57, 2001. 9. Saxena A. Evans calcaneal osteotomy. J Foot Ankle Surg 39:136–137, 2000. 10. Dayton P, Prins DB, Smith DE, Feilmeier MJ. Effectiveness of a locking plate in preserving midcalcaneal length and positional outcome after Evans calcaneal osteotomy: a retrospective pilot study. J Foot Ankle Surg 52:710–713, 2013. 11. Dunn SP, Meyer J. Displacement of the anterior process of the calcaneus after Evans calcaneal osteotomy. J Foot Ankle Surg 50:402–406, 2011. 12. Prissel MA, Roukis TS. Incidence of nonunion of the unfixated, isolated Evans calcaneal osteotomy: a systematic review. J Foot Ankle Surg 51:323–325, 2012.
