Professional Documents
Culture Documents
Director, Foot and Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Medical Education, Saint Paul, MN
Foot and Ankle Surgery Resident, Regions Hospital/HealthPartners Institute for Medical Education, Saint Paul, MN
a r t i c l e i n f o
a b s t r a c t
Keywords:
ankle
calcaneus
cavovarus
foot
high arch
surgery
tendon
Peroneal tendon pathology is commonly seen in patients with underlying pes cavus. The Dwyer calcaneal
osteotomy is a useful adjunctive procedure to address the heel varus component of the cavus foot deformity,
especially in the presence of concomitant peroneal tendon pathology. The lateralizing heel osteotomy using
a wedge resection can effectively reduce future stress on the repaired peroneal tendons, although technical
challenges arise when attempting to perform both tendon repair and heel osteotomy through the same
incision. Specic principles must be followed to achieve adequate exposure of the desired structures, obtain
desired correction of the deformity, and avoid complications such as sural neuritis. In the present report, the
surgical principles and technical pearls are highlighted in a pictorial demonstration of preoperative planning
for calcaneal wedge resection, incision placement, osteotomy guide pin technique, xation pearls, and
peroneal tendon repair and transfer.
2012 by the American College of Foot and Ankle Surgeons. All rights reserved.
1067-2516/$ - see front matter 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.
doi:10.1053/j.jfas.2011.10.021
136
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140
Fig. 1. Preoperative template planning. Calcaneal axial radiograph used as template for
paper cutouts to determine proper size and location of wedge to achieve desired amount
of correction. Outline of calcaneus is traced if necessary.
Fig. 2. Identication of apex of varus deformity. Long axis of anterior portion of calcaneus
and long axis of calcaneal tuberosity drawn on template. Long axis of anterior portion of
calcaneus should be 90 to posterior facet of subtalar joint. Axis lines aid in orientation of
anterior and posterior osteotomies and help determine wedge amount needed to correct
varus deformity.
(Fig. 3). Once the desired wedge has been created on the template,
a photocopy is made. The calcaneal tuberosity portion is cut from the
photocopy and placed over the template in the corrected position. This
allows the surgeon to visualize the amount of correction achieved
according to the planned wedge width and osteotomy location (Fig. 4).
Intraoperative Tips
The patient is placed laterally on the operating table with the side
operated upward and with an ipsilateral thigh tourniquet in place. A
curved incision is then made over the peroneal tendons, anterior to
the sural nerve (Fig. 5). This incision allows access for both peroneal
tendon repair and Dwyer heel osteotomy and is distinctly different
from the traditional heel osteotomy incision, which is usually made
posterior to, and below, the sural nerve (Fig. 6). The peroneal tendons
are then mobilized and retracted toward the bula to perform the
wedge osteotomy. The location and direction of the osteotomy is
conrmed with the use of lateral image intensication uoroscopy,
with the aid of a Kirschner wire laid within (collinear to the direction
of) the incision. It is important to evaluate the dorsal and plantar exit
points of the calcaneal osteotomy, with attention paid to avoiding
involvement of the posterior facet of the subtalar joint (Fig. 7). The
lateral periosteal incision and dissection is then performed on the
lateral wall of the body of the calcaneus. We prefer to achieve dorsal
and plantar periosteal elevation with the use of a curved Crego
elevator. No dissection is needed or desired on the medial aspect of
the calcaneus.
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140
137
Fig. 4. Completion of paper template. Photocopy of template from Fig. 3 allows cutout of
posterior fragment to be overlaid in corrected position, allowing surgeon to visualize
amount of correction achieved after wedge resection. This template demonstrates that an
anteriorly placed osteotomy achieves dramatic correction. This technique produces
a posterior tuberosity parallel with the tibia and positioned laterally to weight-bearing
vector. Wedge width can be adjusted if foot structure and ankle instability does not
warrant this correction amount.
location of the laterally based calcaneal wedge. The anterior guide pin
is placed roughly parallel to the posterior facet of the subtalar joint.
The posterior guide pin is placed roughly 90 to the long axis of the
calcaneal tuberosity. At this point in the procedure, we prefer to
Fig. 5. Incision placement for combined technique. Incision (dashed line) over peroneal
tendons, anterior to sural nerve (dotted line). One might need to extend the incision
proximally or distally depending on peroneal pathology location. Both Dwyer calcaneal
osteotomy and peroneal tendon repair procedures are performed through this incision.
Fig. 6. Differences in heel osteotomy incision placement. Dwyer incision (dashed line)
noted to be more anterior than traditional heel osteotomy incision (solid line), which is
posterior and inferior to sural nerve.
138
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140
Fig. 9. Screw xation. Cannulated screws or Steinmann pins used for xation. Pins used as
joystick to aid in reduction of osteotomy. Guide pins inserted to level of osteotomy.
Valgus force applied to 1 pin to close and compress osteotomy while second pin is
advanced into anterior fragment.
Fig. 8. Osteotomy guide pin placement. Two osteotomy guide pins placed from laterally to
medially. Anterior guide pin placed roughly parallel to posterior facet of subtalar joint.
Posterior guide pin placed at 90 to long axis of calcaneal tuberosity. Width of wedge on
lateral cortex can be estimated from preoperative template measurements. Osteotomy
guide pins contain saw blade to create predictable wedge with apex at medial cortex.
Fig. 10. Transfer of peroneus longus to peroneus brevis. Peroneus longus tendon (a)
anastomosed to brevis tendon (b) in side-to-side fashion. Peroneus longus tendon can be
cut distal to anastomosis, allowing elevation of rst ray, which is useful in cavus foot
reconstruction when the medial column is partly exible. The free end of the peroneus
longus tendon usually scars in place and behaves similar to a plantar ligament.
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140
saw blade is placed on the interior of the guide pins, and no other
guiding instruments are used. The osteotomies are then made from
laterally to medially. Although preservation of the medial hinge is
optional, we typically create a through-and-through osteotomy,
taking care to avoid the medial neurovascular structures, which are
intimately associated with the medial wall of the body of the calcaneus. After completion of the posterior and anterior osteotomies, the
resultant wedge of bone is removed and the posterior portion of the
calcaneus, including the weight-bearing tuberosity, are shifted into
the corrected alignment with closure of the wedge, with or without
transposition of the posterior fragment.
After reduction of the osteotomy, it is xated with 1 or 2 cannulated
interfragmental compression screws or 2 Steinmann pins (5/64-in. or
7/64-in. diameter). If necessary, the Steinmann pins or cannulated
screw guide pins can be used as joysticks to further achieve optimal
reduction of the osteotomy. We recommend inserting the pins into the
posterior fragment of the calcaneus before reduction, because this
enables the surgeon to directly visualize the location at which the
xation will traverse the osteotomy interface. The tuberosity is positioned and compressed with 1 pin while the second pin is advanced
into the anterior fragment (Fig. 9).
The peroneal tendons are repaired after the osteotomy has been
completed and the tendons have been carefully inspected. In our
experience, the peroneus longus tendon is typically more normal
in appearance than the peroneus brevis tendon. Direct repair, or
side-to-side anastomosis of the longus and brevis tendons, is then
undertaken, depending on the severity of the tendon disease. We
have also found that a side-to-side anastomosis is most appropriate in
the presence of extensive tendon degeneration that requires
substantial debridement with an attempt to preserve the best parts of
both tendons. Furthermore, it has been our experience that debulking
of abnormally thick tendons reduces the risk of recurrent or future
peroneal subluxation. Care should also be taken to use a suture
technique that buries the suture material.
For a exible cavus foot deformity with a plantarexed rst ray,
transfer of the peroneus longus to the brevis insertion at the fth
metatarsal base is recommended. This entails sectioning the peroneus
longus tendon just distally to the longus/brevis anastomosis. This
technique allows elevation of the rst ray, which can further reduce
cavus deformation while maintaining full eversion strength (Fig. 10).
The goal of peroneal tendon repair and transfer is to create 1 good
tendon out of 2 badly damaged tendons. The distal, cut end of the
peroneus longus tendon remains in the plantar aspect of the foot as it
139
traverses the peroneal tunnel en route to the plantar aspect of the rst
ray. We make no attempt to reattach or repair this segment of the
tendon. Over time, we believe that this derelict portion of the peroneus
longus tendon becomes incarcerated in the tendon sheath and eventually functions as another plantar ligament. After completion of the
peroneus longus to brevis transfer, the medial arch is inspected and
consideration given to undertaking dorsiexory base wedge osteotomy of the rst metatarsal if residual plantarexion persists (Fig. 11).
Discussion
The surgical recommendations and images we have described in
this brief report are intended to highlight the rationale for, and
execution of, our preferred methods for combined Dwyer calcaneal
140
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140