SKIN INCISION:
A linear incision is made along the lateral aspect of the calcaneus, extending from the anterior beak of the calcaneus distally, to the inferior surface of the calcaneus proximally. The incision should be parallel to the relaxed skin tension lines to minimize scar tissue formation. Care should be taken to avoid the dorsal intermediate cutaneous nerve superiorly as well as the sural nerve and peroneal tendons inferiorly
Picture A
Preparing the osteotomy site
Blunt dissection is performed with care taken to avoid all vital structures. The Extensor Digitorum Brevis muscle belly will be identified and reflected distally to expose the anterior calcaneus. The calcaneo-cuboid joint is identified. Care is taken to avoid extensive dissection of the calcaneo-cuboid joint to prevent instability of the joint. A key elevator can be used to reflect soft tissue from the proposed osteotomy site.
Picture B
Performing the Osteotomy
The proposed osteotomy will be 1-1.5cm proximal to the calcaneo-cuboid joint. The osteotomy should be made perpendicular to the weight bearing surface and lateral wall of the calcaneus and parallel to the calcaneo-cuboid joint. Using the appropriate sagittal saw, the osteotomy is made from lateral to medial. Care should be taken to avoid the medial vital neurovascular structures.
Picture C
Bone Graft Placement
The osteotomy is distracted until desired correction is attained. An appropriate thickness Corticocancellous bone wedge allograft is prepared in a trapezoidal shape. The bone graft is placed in the osteotomy and flush to the lateral wall of the calcaneus. Appropriate placement and correction is confirmed with C-Arm Fluoroscopy
Picture D
Fixation
Using the Reign Medical Clench staple operative guide for appropriate insertion, the Clench stable is then inserted perpendicular to the bone graft with care taken to avoid the calcaneo-cuboid joint. Appropriate fixation placement is confirmed with C-Arm Fluoroscopy.
Pearl: Generally, an 18mm or 20mm staple is used for appropriate fixation
Picture E
Post-operative treatment
Stitches are typically removed at 10-14 days
Patient is non-weight bearing in a cast boot for 4 weeks
Patient is transferred to a Darby shoe at 4 weeks and light weight bearing is initiated
Patient is transitioned to supportive shoe gear at 6 weeks with continued light activity
Patient can return to full activity at 3 months
Physical therapy can be initiated for gait and strength training as needed
Credit for Pics A & B:
Mosca VS. Calcaneal lengthening osteotomy for valgus deformity of the hindfoot. In: Skaggs DL and Tolo VT, editors. Master Techniques in Orthopaedic Surgery: Pediatrics. Philadelphia: Lippincott Williams & Wilkins. 2008; 263–276