Dwyer Calcaneal Osteotomy

NewsBot · Sep 21, 2012

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Preoperative Planning and Intraoperative Technique for Accurate Realignment of the Dwyer Calcaneal Osteotomy
Bradley M. Lamm, DPM, FACFAS, Martin G. Gesheff, BS, Heather L. Salton, DPM, Travis W. Dupuis, DPM, FACFAS, Ferras Zeni, MD
Journal of Foot and Ankle Surgery; Article in Press

The Dwyer calcaneal osteotomy is an effective procedure for the correction of calcaneal varus deformity. However, no intraoperative method has been described to determine the amount of bone resection. We describe a simple intraoperative method for assuring accurate bone resection and measure the realignment effects of the Dwyer calcaneal osteotomy. We also review radiographic outcomes associated with 20 Dwyer calcaneal osteotomies (in 17 patients) using the intraoperative realignment technique described in this report. Preoperative and postoperative radiographs at a mean of 2.5 (range 1.5 to 5) years taken after Dwyer osteotomy were measured and compared, which revealed a mean reduction in calcaneal varus of 18° (range 2° to 36°) (p < .001), a mean decrease in the calcaneal inclination angle of 5° (range –40° to 7°) (p < .05), a mean decrease in medial calcaneal translation of 10 (range 0 to 18) mm (p < .001) relative to the tibia, and a mean dorsal translation of 2 (range 0 to 7) mm (p = .002). In an effort to attempt to structurally realign the calcaneus to a more rectus alignment, by means of Dwyer osteotomy, we recommend the use of the intraoperative bone wedge resection technique described in this report. Our experience with the patients described in this report demonstrates the usefulness of the intraoperative method that we describe in order to accurately restore the axial tibial and calcaneal relationship.
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Admin2 · Sep 21, 2012

Related Thread:
Calcaneal osteotomy for the treatment of plantar fasciitis ...

NewsBot · Sep 11, 2014

Modified Dwyer Osteotomy with Rotation and Reinsertion of Autograft Bone Wedge for Residual Heel Deformity Despite Previous Delayed Subtalar Joint Arthrodesis after Calcaneal Fracture
Troy J. Boffeli, DPM, FACFAS, Kyle W. Abben, DPM, AACFAS
The Journal of Foot and Ankle Surgery; Articles in Press

Calcaneal fracture patterns vary widely, and many factors determine the type and timing of the treatment rendered. Severe calcaneus fractures involving joint damage, loss of heel height, and varus deformity of the tuberosity are ideally treated with open reduction and internal fixation to repair the joint surface and re-establish anatomic structure. This is not always possible owing to delayed presentation, soft tissue compromise, unrelated injuries, unstable medical condition, or lack of expertise by the treating physician. We present the case of a patient who had residual forefoot and rearfoot deformity despite undergoing delayed subtalar joint arthrodesis at an outside hospital 10 years before for a calcaneal fracture that was initially treated nonoperatively. At 4 years of follow-up after modified Dwyer calcaneal osteotomy with rotation and reinsertion of the autograft bone wedge and Cotton midfoot osteotomy, the postoperative gait was relatively normal, other than the expected lack of hindfoot mobility. The lateral column pain was resolved. The patient remained highly satisfied with the outcome at long-term follow-up of 48 months, with improved heel alignment, lack of a wide stance gait, a functional medial column, and a relatively normal gait. This case demonstrates the value of periarticular calcaneal osteotomies without the need to revise the subtalar joint arthrodesis for this challenging clinical situation.
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NewsBot · Jul 23, 2015

Dwyer osteotomy : Lateral sliding osteotomy of calcaneus
Barg A, Hörterer H, Jacxsens M, Wiewiorski M, Paul J, Valderrabano V.
Oper Orthop Traumatol. 2015 Jul 22

OBJECTIVE:
To correct the underlying inframalleolar varus deformity and to restore physiologic biomechanics of the hindfoot.
INDICATIONS:
Neurologic, posttraumatic, congenital, and idiopathic cavovarus deformity. In patients with end-stage ankle osteoarthritis with varus heel malposition as additional single-stage procedure complementing total ankle replacement. Severe peroneal tendinopathy with concomitant cavovarus deformity.
CONTRAINDICATIONS:
General surgical or anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy (e. g., Charcot arthropathy), end-stage osteoarthritis of the subtalar joint, severely reduced bone quality, high age, insulin-dependent diabetes mellitus, smoking.
SURGICAL TECHNIQUE:
The lateral calcaneus cortex is exposed using a lateral incision. The osteotomy is performed through an oscillating saw. The posterior osteotomy fragment is manually mobilized and shifted laterally. If needed, a laterally based wedge can be removed and/or the osteotomy fragment can be translated cranially. The osteotomy is stabilized with two cannulated screws, followed by wound closure.
POSTOPERATIVE MANAGEMENT:
A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated step by step.
RESULTS:
Between January 2009 and June 2013, a Dwyer osteotomy was performed in 31 patients with a mean age of 45.7 ± 16.3 years (range 21.5-77.4 years). All patients had a substantial inframalleolar cavovarus deformity with preoperative moment arm of the calcaneus of -17.9 ± 3.3 mm (range -22.5 to -10.5 mm), which has been improved significantly to 1.6 ± 5.9 mm (range -16.9 to 9.9 mm). Significant pain relief from 6.3 ± 1.9 (range 4-10) to 1.1 ± 1.1 (range 0-4) using the visual analogue scale was observed. The American Orthopaedic Foot and Ankle Society score significantly improved from 33.1 ± 14.2 (range 10-60) to 78.0 ± 10.5 (range 55-95).
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NewsBot · Aug 1, 2015

Safe Zone for Neural Structures in Medial Displacement Calcaneal Osteotomy
A Cadaveric and Radiographic Investigation
Paul G. Talusan et al
Foot & Ankle International July 31, 2015

Background: We aimed to define reference lines on standard lateral ankle radiographs that could be used intraoperatively to minimize iatrogenic nerve injury risk in medial displacement calcaneal osteotomy.
Methods: Forty cadaveric specimens were used. In 20 specimens, the sural, medial plantar (MP), and lateral plantar (LP) nerves were sutured to radiopaque wire, and a lateral ankle radiograph was obtained. On the radiograph, a line was drawn from the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia and labeled as the “landmark line.” A parallel line was drawn 2 mm posterior to the most posterior nerve, and the area between these lines was defined as the safe zone. In 20 additional specimens, an osteotomy was performed 1 cm anterior to the landmark line using a percutaneous or open technique. Dissection was performed to assess for laceration of the sural, MP, LP, medial calcaneal (MC), or lateral calcaneal (LC) nerves.
Results: The safe zone was determined to be within the area 11.2 ? 2.7 mm anterior to the landmark line. After open osteotomy, lacerations were found in 3 of 10 MC nerves and 3 of 10 LC nerves. After percutaneous osteotomy, lacerations were found in 2 of 10 MC nerves and 1 of 10 LC nerves. No lacerations of the sural, MP, or LP nerves were found with either osteotomy.
Conclusions: The safe zone extended 11.2 ? 2.7 mm anterior to the described landmark line. The MC and LC nerves were always at risk during medial displacement calcaneal osteotomy.
Clinical Relevance: Nerve injury to both major and minor sensory nerves is likely underrecognized as a source of morbidity after calcaneal osteotomy. The current study provides a ready intraoperative guideline for minimizing this risk.
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NewsBot · Sep 4, 2017

Rate of Neurologic Injury Following Lateralizing Calcaneal Osteotomy Performed Through a Medial Approach.
Jaffe D et al
Foot Ankle Int. 2017 Sep 1:1071100717728678. doi: 10.1177/1071100717728678.

BACKGROUND:
Calcaneal osteotomies are commonly used to correct varus hindfoot alignment in patients with symptomatic cavovarus deformity. Translational, closing wedge, and Malerba-type osteotomies have been implicated in the development of tarsal tunnel syndrome and neurologic injury to branches of the tibial nerve. The authors hypothesized that there would be minimal clinically important injury to the tibial nerve by performing a translational calcaneal osteotomy from a medial approach.
METHODS:
All patients undergoing a cavovarus reconstruction by a single surgeon were identified. Patients were included if they underwent a lateralizing calcaneal osteotomy via medial approach. Demographics, operative reports, and clinic notes were reviewed to identify concomitant procedures performed, incidence of postoperative tarsal tunnel syndrome, complications, and preoperative and postoperative nerve examinations. Postoperative radiographs were reviewed for location of the osteotomy relative to the posterior tubercle.
RESULTS:
Twenty-four patients underwent lateralizing calcaneal osteotomy via a medial approach. Of the osteotomies, 83.3% (20/24) were in the middle third of the calcaneus, with a mean of 11.6-mm translation. No patients developed postoperative tarsal tunnel syndrome or tibial nerve palsy.
CONCLUSION:
Lateralizing calcaneal osteotomy performed via a medial approach had a clinically negligible incidence of neurologic injury. Adequate translation was achieved to obtain correction of varus hindfoot deformity. The authors believe that there is less direct and less percussive injury to branches of the tibial nerve when performing the osteotomy from medial to lateral. This technique may represent an operative strategy to minimize risk to the tibial nerve and reduce neurologic deficit following cavovarus reconstruction.
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NewsBot · Sep 7, 2017

A comparison of union rates and complications between single screw and double screw fixation of sliding calcaneal osteotomy
Bahman SahraNavard et al
Foot and Ankle Surgery; 6 September 2017

Highlights
•Compared union and complications of 1 and 2 screw fixation of calcaneal osteotomy.
•No significant difference between single and double screw fixation.
•No significant difference between short and extended incisions.
•Increased complications, specifically hardware removal, with headed screws.
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Background
The number of screws used for sliding calcaneal osteotomy fixation has not been examined in the literature. The purpose of this paper is to examine this topic.

Methods
Retrospective chart review was performed on 190 patients who met selection criteria. We compared complication risk for single versus double screw, headed versus headless screw, and short versus longitudinal incision cases.

Results
The mean age was 48.4 (18-83) years and average follow up was 28 (12-150) weeks. All cases achieved radiographic union. Overall complication rate was 19.5% (37/190). Risk of complication did not differ significantly between single and double screw (RR: 1.170; 95% CI: 0.66-2.09; p = 0.594) or short and extended incision groups (RR: 0.868; 95% CI: 0.42-1.80; p = 0.704). Risk of complication differed significantly between headed and headless screw fixation (RR: 5.558; 95% CI: 2.69-11.50; p<0.0001).

Conclusions
Single screw fixation of sliding calcaneal osteotomy achieves similar outcomes as double screw fixation. Headless screws are advantageous for minimizing hardware pain and subsequent hardware removal.
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NewsBot · Jun 16, 2020

Effects of variations in Dwyer calcaneal osteotomy determined by three‐dimensional printed patient‐specific modeling
Kent Weinheimer MD Brett Campbell MD Evan P. Roush BS Gregory S. Lewis PhD Allen Kunselman MA Umur Aydogan MD
Jnl Orthop Res: 08 June 2020

Clinical Significance: : This study quantifies effects of various surgical parameters, including amount of bone resected, on amount of correction in the Dwyer osteotomy.
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Dwyer (lateral calcaneal closing wedge) osteotomy is commonly used in surgical correction of heel varus deformity. The purpose of this study was to determine the effect of wedge size and angle of osteotomy on deformity correction using preoperative imaging analysis with three‐dimensional (3D) printed modeling. Seven patients diagnosed with pes cavovarus deformity who underwent Dwyer calcaneal osteotomy were identified retrospectively. Preoperative computed tomogrphy scans were used to create 3D printed models of the foot. After18 variations of osteotomy and fixation performed for each foot, Harris heel and Saltzman images were obtained. The angle between the tibia‐talus axis and calcaneal‐tuber axis was measured and compared to pre‐osteotomy state. Change in the calcaneal lengths was also analyzed. The average degree correction of deformity per mm of bone resected was 3.8 ± 0.2 degrees in the Harris Heel view and 2.7 ± 0.8 degrees in the Saltzman view. A significant increase in correction was obtained with 10 mm compared with 5 mm wide wedges (P < .001). The difference in correction was not statistically significant between 30 and 45 degree cuts or osteotomy distance from the posterior calcaneal tuberosity, but a 45 degree sagittal angle resulted in less calcaneal shortening compared to 30 degrees (P = .02). A clinically driven method using patient‐specific 3D models for determining effects of calcaneal osteotomy variables in correcting hindfoot alignment was developed. In summary, the amount of wedge resected impacts hindfoot alignment more than location and sagittal angle of the cut. Calcaneal shortening depends on sagittal angle of the cut.
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NewsBot · Oct 17, 2021

Double Calcaneal Osteotomy in Treatment of Flexible FlatFoot
M.S.AlZahhar, E.A.Tabl, M.S.Abou Zied and M.M.Abdelmalak
Benha Journal of Applied Sciences (BJAS)

Double Calcaneal osteotomy is the gold standard surgery for treatment of flexible flatfoot in patients who have
both forefoot abduction and heel valgus. MCO (Medializing calcaneal osteotomy) corrects the heel valgus while Evan's
osteotomy corrects the forefoot abduction. Most of the cases are satisfied with the results. They returned back to their
normal activities within 2 months. The procedure has little complications the most common is wound dehiscence. Our
study was on 16 feet all of them were diagnosed as flexible flatfoot with mean age 18 years old. We used AOFAS for
follow up. Heel valgus , Mearye`s angle , TNC angle and VAS score were used for assessment .Most of the patients
were satisfied either from the improvement of the pain or the shape of the heel. There are a lot of operations used in
treatment of FFF like arthroeresis ,calcaneal stop ,evan's osteotomy but DCO is superior to those as it corrects both heel
valgus anf forefoot abduction at the same session.
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NewsBot · Oct 26, 2021

CALCANEAL OSTEOTOMY FOR HINDFOOT DEFORMITY
JeanBrihault
Orthopaedics & Traumatology: Surgery & Research 20 October 2021, 103121

Calcaneal osteotomy is an extra-articular procedure used for conservative surgical treatment of hindfoot deformity. It has static, architectural and dynamic effects, reorienting the tuberosity action point of the digastric muscle formation of the sural triceps and plantar aponeurosis.

Calcaneal osteotomies vary in location, form and displacement, but can be categorized as tuberosity osteotomy, acting on talar position, and cervical osteotomy, acting on Chopart joint-line orientation.

We here describe the 3 main calcaneal osteotomies we use for hindfoot deformity: talar varus/valgus, valgus flatfoot, and midfoot abductus/adductus. In each case, we describe our technique, resulting from our responses to the difficulties we have had to deal with:

medializing osteotomy: performed percutaneously to limit skin complications, and easily associated to cervical calcaneal osteotomy to manage valgus flatfoot;

Hintermann cervical adduction osteotomy: providing excellent angular correction, while conserving a medial cortical hinge;

lateralizing osteotomy: performed on a medial approach, to enhance translation capacity and prevent the acute tarsal tunnel syndrome with which we have been otherwise confronted.

Correcting foot deformities involves complex, multi-dimensional, multi-tissue surgery that is risky as it concerns a segment with terminal vascularization. The present three techniques need to be mastered, as they are usually associated to other tendon and/or ligament reconstruction procedures, and tourniquet time is limited.
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NewsBot · Jul 2, 2022

Incidence of Lateral Prominence Pain Following Open Medial Displacement Calcaneal Osteotomy and the Efficacy of Crushplasty as a Preventive Technique
Jaeyoung Kim et al
Foot Ankle Int. 2022 Jul 1

Background: There has been concern about lateral prominence pain at the osteotomy site following medial displacement calcaneal osteotomy (MDCO). However, no study has investigated this complication. This study aimed to investigate the incidence of lateral prominence pain following MDCO and examine the efficacy of crushplasty as a surgical technique to minimize this complication.

Methods: This was a retrospective cohort study in which 137 patients (148 feet) who underwent MDCO were divided into 2 groups by whether they had concurrent crushplasty at the time of MDCO (crushplasty [n = 81] vs noncrushplasty group [n = 67]). Crushplasty was performed by flattening the bony step-off using a rongeur and bone impactor. Lateral prominence pain was defined as pain or irritating symptoms over the osteotomy site that persisted over 12 months after MDCO. The overall incidence of lateral prominence pain after MDCO and within each group was investigated. Multiple logistic regression analysis was used to determine the influence of possible risk factors on the development of postoperative lateral prominence pain.

Results: The overall incidence of lateral prominence pain was 9.5% (14 of 148): 3.4% (3 of 87) in the crushplasty group, and 18% (11 of 61) in the noncrushplasty group, and χ2 analysis showed a statistically significant relationship between crushplasty and lateral prominence pain (P < .05). A relationship between the amount of medial displacement and the development of lateral prominence pain was observed in the noncrushplasty group (OR = 5.31, 95% CI 2.35-16.4, P < .05), but this was not observed in the crushplasty group (P = .641). The amount of medial displacement was an independent risk factor for the development of lateral prominence pain (OR = 2.72, 95% CI 1.54-4.79, P < .05), and concurrent crushplasty had a negative relationship with lateral prominence pain development (OR = 0.12, 95% CI 0.03-0.57, P < .05).

Conclusion: This study revealed that lateral prominence pain is a significant complication of MDCO, especially in the setting of a larger displacement. The crushplasty following MDCO may minimize this complication, particularly when a greater degree of hindfoot correction is attempted.
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NewsBot · Nov 28, 2023

Safety of the neurovascular bundles when performing minimally invasive calcaneal osteotomy: A cadaveric study
J Guirguis et al
Foot Ankle Surg. 2023 Nov 4

Background: Calcaneal osteotomies correct hindfoot deformities and are often performed using a minimally invasive technique. The aim was to compare the safety of three calcaneal osteotomy techniques (oblique, chevron with apex anterior and chevron with apex posterior).

Methods: Each osteotomy technique was performed on five cadavers (n = 15). These were then dissected to identify any injury to the neurovascular bundles. The distance between the burr and these structures was measured.

Results: Using the apex posterior technique, the burr was closer to the medial and lateral neurovascular structures, and in one case the sural nerve was injured. There were no neurovascular injuries using the other techniques.

Conclusions: Minimally invasive surgery using a burr is generally a safe, reliable method for performing calcaneal osteotomies. The chevron with apex posterior osteotomy should be performed with caution given the closer relationship between the burr and neurovascular bundles. The other two techniques provide safer alternatives.
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NewsBot · Apr 3, 2024

Impact of the medial displacement calcaneal osteotomy on foot biomechanics: a systematic literature review
Gunnar Mueller et al
Arch Orthop Trauma Surg. 2024 Mar 30

Introduction: Progressive collapsing foot deformity (PCFD), formally known as "adult-acquired flatfoot deformity" (AAFFD), is a complex foot deformity consisting of multiple components. If surgery is required, joint-preserving procedures, such as a medial displacement calcaneal osteotomy (MDCO), are frequently performed. The aim of this systematic review is to provide a summary of the evidence on the impact of MDCO on foot biomechanics.

Materials and methods: A systematic literature search across two major sources (PubMed and Scopus) without time limitation was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) criteria. Only original research studies reporting on biomechanical changes following a MDCO were included. Exclusion criteria consisted of review articles, case studies, and studies not written in English. 27 studies were included and the methodologic quality graded according to the QUACS scale and the modified Coleman score.

Results: The 27 included studies consisted of 18 cadaveric, 7 studies based on biomechanical models, and 2 clinical studies. The impact of MDCO on the following five major parameters were assessed: plantar fascia (n = 6), medial longitudinal arch (n = 9), hind- and midfoot joint pressures (n = 10), Achilles tendon (n = 5), and gait pattern parameters (n = 3). The quality of the studies was moderate to good with a pooled mean QUACS score of 65% (range 46-92%) for in-vitro and a pooled mean Coleman score of 58 (range 56-65) points for clinical studies.

Conclusion: A thorough knowledge of how MDCO impacts foot function is key in properly understanding the postoperative effects of this commonly performed procedure. According to the evidence, MDCO impacts the function of the plantar fascia and Achilles tendon, the integrity of the medial longitudinal arch, hind- and midfoot joint pressures, and consequently specific gait pattern parameters.
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