Calcaneus Osteotomies In The Flat Foot Valg

The talocrural joint (ankle) is a joint complex that allows the foot movement in all directions of space, shock absorption, and weight transmission to the support in static and locomotion. To withstand the action of high stresses, the ankle joint must be stable in both joint statics and dynamics. The stability of the ankle is mixed, resulting from the combined action of bone and ligament elements. The geometric conformation of the articular surfaces is mainly responsible for bone stability.

Pes valgus represents a deformation of the ankle and hindfoot, clinically easy to recognize, which consists of decreasing the height of the medial longitudinal arch. However, there is no clinical or radiological definition, unanimously accepted, of the average height, of the values considered normal of the medial longitudinal arch of the foot.

The height of the medial longitudinal arch is determined by the shape of the bones and the strength of the ligament structures. The muscles intervene only for balance because it has been shown that the leg muscles are inactive during orthostatism (standing).

Pes valgus occurs at the time of loading and represents a change in normal bone ratios at the ankle, so the heel is rotated externally and flexed dorsally relative to the talus, so there is a pronation movement, valgus of the foot. These changes in interosseous relationships create a collapse of the medial longitudinal arch.

Soft tissue correction or bone alignment cannot adequately correct deformation. Therefore, both procedures are used simultaneously to make a long-term correction. 

The purpose of surgery is to create a stable bone configuration with an adequate soft-tissue balance to maintain a dynamic balance in the hind legs. 

Surgical technique

The patient is lying on his side (on one side); an incision of about 5 cm retro and inframalleolar is made, the subcutaneous tissue is carefully dissected and the tendons of the peroneal muscles are highlighted, to be protected.

The relationship between the osteotomy and the posterior subtalar facet modifies the biomechanics of the posterior part in different ways: anterior osteotomies of the calcaneus correct the deformations of the transverse plane (abduction of the forefoot), while osteotomies of the posterior tuberosity determine the "varus" of the calcaneus and correct the deformation of the frontal plane.

The choice of osteotomy depends on the plane of the dominant deformity. If the subtalar axis is more horizontal than normal, the movement of the transverse plane is canceled and the eversion - the inversion of the frontal plane is predominant. The patient has marked valgus in the hind legs without significant abduction of the foot. 

If, on the contrary, the subtalar axis is more vertical than normal, the movement of the transversal plane predominates, and the patient presents an abduction of the front leg and the instability of the medial joints, although without significant posterior valgus. In this situation, we recommend a procedure to extend the lateral side and improve the height of the arch while correcting the position of the foot.

With a predominant flat frontal deformation, the medialization of the calcaneal tuberosity is used to move the load-bearing axis of the medial calcaneal weight, its alignment with the tibial axis, and the restoration of the gastro-solear function as a heel inverter. An essential condition for this is the absence of arthritis that affects the subtalar joint. The Achilles tendon may be stretched at the same time.

Postoperatively

After the operation, the patient remains hospitalized for 1 day. He will receive pain medication and antibiotics during his hospitalization. The operated limb is immobilized in a plaster splint, and the patient is advised not to make ankle movements, 60 days after the intervention. When walking, is necessary to use crutches, even if the chosen intervention was minimally invasive. 

Patients will wear a compressive bandage on the foot for 5 days. Patients can return to family and professional activities quickly, up to 3-4 weeks, if they have office work, and 12 weeks, if they have fieldwork.

At home

Although recovery after this operation is much faster than a classic intervention, it will still take a few weeks for you to fully recover the operated joint. You should expect pain and discomfort for at least a week postoperatively. You can use a special ice pack, which will reduce the pain and inflammation. You must be careful not to lean on the operated area in the first weeks because the pain and discomfort can worsen. You can take a bath, but without wetting the bandage and incisions. The threads are suppressed at 14 days postoperatively. At 6 weeks postoperatively, an MRI is necessary to see how the tendon suture heals. Driving is allowed after 8 weeks, and hard physical work after 10-12 weeks.

Physical therapy plays a very important role in the rehabilitation program, and the exercises must be followed by a physical therapist until the end of the recovery period.

It is very important to follow the recovery program strictly and seriously for the surgery to be a success. Our medical team works on average with the patient after this intervention, 12-16 weeks until complete recovery of the operated area.

Following any surgery, medical recovery plays an essential role in the social, professional, and family reintegration of the patient. Because we pursue the optimal outcome for each patient entering the clinic, recovery medicine from Centrokinetic is based on a team of experienced physicians and physical therapists and standardized medical protocols.