Edited by Vinod Panchbhavi MD
A calcaneal osteotomy comprises of making a cut across the heel bone and shifting it toward the inside (medial) or outside (lateral). The heel bone called the calcaneus is the main bone that lies in the heel of the hindfoot. When the heel is observed from behind, it is generally situated in line with the leg. But if there is an inward or outward tilt of the heel in relation to the leg, then the hindfoot alignment is considered offset or abnormal. A calcaneal osteotomy is indicated for patients whose hindfoot alignment is significantly offset and for whom non-operative management has failed. Alignment of the heel influences how weight-bearing stress is applied to the foot, ankle, knee and hip. Depending on 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 may have symptoms ranging from pain along the lateral or outside half of the foot, to wearing out of the inside (medial) portion of the ankle joint. With this structural alignment, individuals 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
Figure 2: Both heels shifted to the inside in high arched foot
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 the surface of the bone is exposed, a fine cut is made across the middle of the calcaneus (osteotomy). The part of the heel bone that is at the back attached to the Achilles tendon is then shifted. This part can be shifted towards (medially) or away (laterally) from 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 or 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)
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 2-6 weeks, patients can gradually increase the amount of walking (number of steps per day) that they doing. After the foot has accommodated to bearing weight in the CAM walker, weight-bearing progresses incrementally (adding 20 to 30 pounds every day or every other day) in a supportive running or walking shoe. Supervised physical therapy is an important part of the recovery process. It is often 8-12 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.
- 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.
Previously Edited by Michael Castro, DO
Edited February 20, 2018