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Calcaneal osteotomy for the treatment of plantar fasciitis

Discussion in 'Foot Surgery' started by NewsBot, Apr 23, 2009.

  1. NewsBot

    NewsBot The Admin that posts the news.

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    Calcaneal osteotomy for the treatment of plantar fasciitis.
    Miyamoto W, Takao M, Uchio Y.
    Arch Orthop Trauma Surg. 2009 Apr 21. [Epub ahead of print]
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. tsdefeet

    tsdefeet Member

    I could see a displacement calcaneal osteotomy if it were done as an adjuct procedure to other procedures addressing the structural and functional issues related to chronic unresolving plantar fasciitis.
    But if one were going to only do a single procedure for this problem lengthening the fascia endoscopically carries much less morbidity and although I have not run the statistics on it used as a single procedure I would bet it is comparable if not better.
     
  4. STEVE LEVITZ

    STEVE LEVITZ Active Member

    Remeniscent of Arthur Steindler's Rotational Calaneal Osteotomy in which his results were not beneficial to the patient so he went back to excising the spur with central band fasciectomy
     
  5. drsarbes

    drsarbes Well-Known Member

    Well, first, where is 1 cm anterior to the attachment of the plantar fascia on the os caclis?
    Two, why is this showing up in a J. of Ortho Trauma?
    Third, a diagnosis of Chronic Plantar Fasciitis is not an indication for a calcaneal "osteotomy" (meaning a realignment of the os calcis)

    Steve
     
  6. STEVE LEVITZ

    STEVE LEVITZ Active Member

    I can only assume that these surgeons had nothing to do at the time?
    It is unfortunate that this gets "pier reviewed"? and published.
    This will justify these calcaneal osteotomies for chronic Fasciitis which will pay more than a fasciectomy.
    S. Levitz
     
  7. drsarbes

    drsarbes Well-Known Member

    You may be right, is it ALWAYS about the money?
    I'm a bit more trusting, I just assumed they wanted to reinvent the wheel.

    Steve
     
  8. STEVE LEVITZ

    STEVE LEVITZ Active Member

    My opinion is that these surgeons have found a way of reducing the tension stresses within the plantar fascia by increasing the the calcaneal inclination and supinatory moment"Ala Kirby" via osteotomy. Much to do for a diagnosis which has been proven to be self limiting in 98-99% of the time irrigardless of therapy.
    S. Levitz
     
  9. Tip:

    The calcaneal osteotomy would eliminate the many problems seen with plantar fasciotomy such as medial longitudinal arch flattening, reducing medial arch stiffness, dorsal joint pain, possible development of hammertoe deformity, etc. However, the calcaneal osteotomy surgery would require an extended period of morbidity due to bone healing and could possibly lead to new problems.

    A gastrocnemius recession/lengthening surgery makes more sense to me biomechanically if the plantar fasciotomy does not seem like the proper choice surgically, when conservative treatments have all failed.

    Good to see you so active on Barry Block's PM news....always enjoy reading your posts.
     
  10. STEVE LEVITZ

    STEVE LEVITZ Active Member

    Hello Kevin
    I have no anamositie tworards your mechanical foot therapy and I am in favor of grand rounds at NYCPM
     
  11. Hi Steve:

    Never been to NYCPM. Hope the school is still doing well. Good to hear that there are some podiatrists in New York that can see the benefit of looking at the foot from a mechanically-based method that can be mathematically quantified.
     
  12. tsdefeet

    tsdefeet Member

    The point that I was trying to make without being rude or disrespectful (the main gripe that I have with this forum) was that colcaneal osteotomy "theo0retically" should work BUT BUT BUT to perform a calcaneal osteoomy for this isolated problem is a disservice to your pt. (nothing to do with $$$). How many times do you see RECALCITRANT--which I define as failed tx >1 year---plantar fasciitis without other structural deformities??? SO strictly from a surgical standpoint if you are reconstructing a foot to make it the most "normal" foot that you can one usually does multiple procedures to address mutiple structural and functional problems. The discussion of the concept of the effect of calcaneous osteotomy on plantar fasciitis , I think, is a valid and healthy discussion. I don't think that we look at calcaneal position (frontal plane) very closely and as Kevin has pointed out it is important ---may be very very very important. Think about it --- it was not long ago that thinking about what you can surgically do to the STJ axis to help your bunion results would not have entered most peoples minds.

    take care
     
  13. drsarbes

    drsarbes Well-Known Member

    IT SHOULD WORK!
    BUT.

    First, there are less involved and most likely more successful procedures for chronic fasciitis than a cal osteotomy.

    2nd: Just because it works doesn't mean it's a proper procedure. Like telling a patient with chronic gastric reflux that you're going to perform a total gastrectomy.

    Steve
     
  14. Frederick George

    Frederick George Active Member

    I agree. It seems like a 2dollar solution for a 10cent problem.

    Biomechanical aspects aside, some symptomatic relief may be from the release of the bone marrow oedema by the osteotomy.

    Cheers

    Frederick
     
  15. tsdefeet

    tsdefeet Member

    I agree with both frederick and steve about heel pain (ps-there was an old procedure that I remember reading about where a series of percut holes were drilled in the cal to "let out the bad humors" i.e.release the "congestion")--just trying to get some thoughts on revisiting posterior cal osteotomies ie dwyer/kouts for the purpose of altering the STJ axis. I use them occasionally for flat foot reconstructions when literally I have to get the heel back under the leg to have a starting place to do the rest of the reconstruction. I have honestly not been really thinking about STJ axis changes when I do them--it is more like common sense and surgical necessity to get a starting point for a reconstruction. Maybe we should look more closely at them??
    Maybe not?? I occasionally do SJT arthroeresis for bunions in conjunction with the first ray work. When you look at po xr,,, STJ arthroeresis does increase the calcaneal pitch and thus must medially move the plantar calcaneal contact point. How much?? I have not measured it. Has anyone?? Might desrve some thought??

    tip
     
  16. STEVE LEVITZ

    STEVE LEVITZ Active Member

    to all
    If some clinicians measure their calcaneal bisection ala the Root Method while holding the STJ in its Neutral position off weight bearing and determine for instance that the helel has a 5 degree "calcaneal varus deformity ala the Root Method and that the heel will pronate upon weight bearing to the perpendicular which would be pathalogical according to Root Theory and the orthotic Rx would be a 5 degree rearfoot varus posting to prevent this pronation;
    Then how come when a medial calcaneal osteotomy is performed and the tuber of the heel is translated medially the varus deformity ala Root is not corrected. I.E. rotating the tuber in a valgus frontal plane position for correction of "Calaceal Varus"?
    Excuse the run on this is how I am
    Please explain?
    S.Levitz
     
  17. drsarbes

    drsarbes Well-Known Member

    TIP:

    "I occasionally do SJT arthroeresis for bunions in conjunction with the first ray work."

    I assume you mean STJ not SJT.......
    SO, you sometimes do an arthroereisis procedure along with a bunion correction?
    That's interesting.
    Can you give us a few more details? Indications, type of implant, theory behind this decision, etc.......

    Steve
     
  18. tsdefeet

    tsdefeet Member

    I have never done a medial translational calcaneal osteotomy on a varus positioned calcaneus BUT for those heels that are in a valgus position with the STJ max pronated and in "neutral" I promise you that a medial displacement osteotomy corrects the deformity. When I do posterior medial displacement osteomies I can not ever remember intentionally rotating the fragment in the frontal plane. It is hard enough to get the exact # of mm that I want in the transverse plane translation. I guess that I am not good enough surgically. In my hands surgery is still an art with the complexities of the mutiple joint interactions I don't see how we can get it perfect. One thing I do use surgically in getting the Rearfoot position is placing force on the calaneus from plantar to find the STJ axis and trying to put the calcaneus in a position that neither pronates or supinates the joint.

    Tip
     
  19. Medial translational calcaneal osteotomies cause two very strong influences on subtalar joint (STJ) kinetics:

    1. Increases the STJ supination moment due to the plantar calcaneus now being more medial to the STJ axis so that when ground reaction force acts on the plantar calcaneus there will be a longer STJ supination moment arm.

    2. Increases the STJ supination moment due to the posterior calcaneus now being more medial to the STJ so that when tensile force is increased within the Achilles tendon there will be a longer STJ supination moment arm.

    I know of no other theory of foot biomechanics that explains the mechanical effects of these osteotomies more simply and completely than the subtalar joint axis location and rotational equilibrium theory of foot function. How could you explain this using the other major theories of foot biomechanics?? Any volunteers??
     
    Last edited: Apr 29, 2009
  20. STEVE LEVITZ

    STEVE LEVITZ Active Member

    I agree with Kevin as to why the medial translation of the calaneal tuberosity is corrective for flatfoot by decreasing foot pronation.
    But Again I Question why we bisect the heel and then measure this bisection while manipulating and holding the Subtalor Joint in its "Neutral Position" inorder to measure the deviation of this heel bisection to the lower 1/3 of the leg.
    I was taught that the measured FRONTAL plane deviation if any was a deformity IE Calaneal Varus which was Osseous and had to be Corrected to prevent the Subtalor Joint from pronating to the perpendicular assuming no other influence from the forefoot or leg above. The correction was with a rearfoot posted foot orthosis keeping the Subtalor joint in its Neutral position thus preventing the pronation to the perpendicular. I ask again if this was what I was taught then why didn't anyone surgically correct the "Calcaneal Varus" deformity as found by the Root method by osteotomy of the Calcaneal Tuberosity to realign the calcaneal bisection parallel to the lower 1/3 of the leg.
    If this measurement is SO crucial than why is it not Surgically Corrected within the plane that it is measured?
    S.Levitz
     
  21. tsdefeet

    tsdefeet Member

    When I think of what it sounds like you are discribing--structural calcaneal varus or "c" shaped calcaneus(from an axial view)--I would tell you that I never have seen a "c"shaped calcaneus in a flat foot. Perhaps it does exist? It does exist in cavus foot types and maybe exists in compensated met adductus or compensated club foot deformity--I just have not seen it in my practice. When I move the calcaneus during surgery I move it in the transverse plane I would think it would be very hard given the position of the cal to make an osteotomy that would give true frontal plane motion. If you could that would simply change the wt bearing from one tubercle to another. I would agree with your thoughts that a structural deformity should be corrected if it is significant. The debate is what is significant??? What criterion do you place on significant--my significant may be different than yours or Kevins. One patient may place significance on something that I may not. I honestly do not think we as podiatrists will ever get it pertfect because of the variabilty of our models as well as the clinical variability in our patients but certainly the sharing of ideas helps all of us. Thank you.

    Tip
     
  22. Here is an illustration I did 5 years ago for a PowerPoint lecture I currently give on surgical correction of posterior tibial tendon dysfunction (PTTD).

    The drawing demonstrates (left) how a foot with PTTD will have a medially deviated subtalar joint (STJ) axis, where the STJ axis is medially located both at the rearfoot and forefoot. A normal foot would have the STJ axis passing more laterally out of the posterior calcaneus and would have the STJ axis passing over the lateral 1st metatarsal head area anteriorly.
    Now, when a medial displacement calcaneal osteotomy is performed (right), this osteotomy will shift the plantar-posterior half of the calcaneus more medially which will, in turn, increase the STJ supination moment arm for the Achilles tendon. [Note that the STJ axis spatial location would not change relative to the dorsal-anterior half of the calcaneus or to the talus since the spatial location of the STJ axis is determined by the articular shapes of the talus and calcaneus at the talo-calcaneal joint.]

    Due to the increased STJ supination moment arm for the Achilles tendon, the medial displacement calcaneal osteotomy will cause an increase in magnitude of STJ supination moment when Achilles tendon tensile forces are at their greatest magnitude, such as during the latter half of midstance and early propulsion phases of walking. In addition, the medial displacement calcaneal osteotomy will increase the supination moment arm for ground reaction force (GRF) to cause a STJ supination moment, especially during the first half of the stance phase of walking when GRF is at its maximum. If anyone is interested, I can post the illustration of the mechanical effects of this type of osteotomy on GRF acting on the plantar rearfoot also.
     

    Attached Files:

    Last edited: Apr 30, 2009
  23. STEVE LEVITZ

    STEVE LEVITZ Active Member

    I uderstand the heel bisection as a refference to statically balance casts in the fabrication of foot orthoses but AGAIN please explain to me why the heel bisection off weight bearing while holding the Subtalor joint in its Root neutral position measured to the lower 1/3 of the leg is an indicator of deformity within the frontal plane of the heel?
    S.Levitz
     
  24. STEVE LEVITZ

    STEVE LEVITZ Active Member

    Bump Anyone?
    S. Levitz
     
  25. sneakyphil

    sneakyphil Welcome New Poster

    does this kind of surgery have any kind of negative effects on the function of post tib tendon, perroneal tendons or achielles tendon? or do they handle it pretty well?
     
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