The alignment of the heel bone (calcaneus) is an important consideration in conservative and surgical treatment of a high arch or low arch foot. Realignment of the heel can be accomplished with an arch support, brace or surgical change of the heel bone. The realignment goal always focuses on how we can center the heel under the weight of the leg. By doing so, we can have a powerful impact on the treatment of both high arch feet and low arch feet.
The surgical technique used to realign the heel is called a translational calcaneal osteotomy. Translational refers to the movement of the heel bone following an osteotomy (cut or break in the bone). In the high arch foot, following osteotomy, the capital fragment of bone is translated laterally (away from the other foot), correcting the position of the heel. In a flatfoot case, the opposite is performed. Following osteotomy, the capital fragment is translated medially (towards the other foot), correcting the flatfoot and centering the load bearing of the leg directly over the foot. In each case, the osteotomy is fixated by screws or plates.
Recently, minimal incision foot surgery has come back into vogue. In many cases, minimal incision surgery can benefit patients by decreasing healing time and by keeping the soft tissue envelop surrounding the osteotomy intact. Disruption of the soft tissue envelop can lead to instability of the osteotomy and to delayed healing. As a surgeon, when considering minimal versus an open technique for calcaneal osteotomy, you also have to consider how well you can accomplish the job through a small incision, what kinds of tools you’ll need for the minimal vs open technique and how reliable the outcome is for each technique.
Many foot and ankle surgeons are now using a minimal technique for translational calcaneal osteotomies. To be able to work through a small 0.5cm incision, the surgeon uses a burr as a saw. The procedure is performed under fluoroscopic guidance. Fixation is usually placed through a separate incision in the posterior heel. The open technique on the other hand is performed through a 3cm incision and a traditional saw blade is used for the osteotomy.
Minimal incision techniques were very popular in the ‘80’s be fell out of favor due to poor outcomes. I don’t see this as the case when performing translational calcaneal osteotomies with a minimal incision technique. I have found this procedure is appropriate for minimal incision techniques. Is it for me? No. I think I’ll stick to the traditional 3cm incision. A 3cm incision creates minimal violation of the soft tissue envelop encompassing the heel bone. With the 3cm incision, I can also directly see the amount of motion/correction (translation) of the heel bone prior to fixation.
Is the minimal incision technique for calcaneal translational osteotomy superior to the traditional open technique? No, but it’s perfectly acceptable as a new way to treat an old problem.
Jeffrey A. Oster, DPM