- Email: [email protected]
Obtaining local bone graft for Evans calcaneal osteotomy in pes planovalgus deformity correction
Accepted Manuscript Title: Technical Tip: Obtaining local bone graft for Evans Calcaneal Osteotomy in pes planovalgus deformity correction Author: Khalid MS Mohamed Christopher Fenelon John G Galbraith Lester G D’souza PII: DOI: Reference:
S1268-7731(16)30462-3 http://dx.doi.org/doi:10.1016/j.fas.2016.10.007 FAS 973
To appear in:
Foot and Ankle Surgery
Received date: Revised date: Accepted date:
16-8-2016 24-10-2016 29-10-2016
Please cite this article as: Mohamed Khalid MS, Fenelon Christopher, Galbraith John G, D’souza Lester G.Technical Tip: Obtaining local bone graft for Evans Calcaneal Osteotomy in pes planovalgus deformity correction.Foot and Ankle Surgery http://dx.doi.org/10.1016/j.fas.2016.10.007 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title Page
Title Technical Tip: Obtaining local bone graft for Evans Calcaneal Osteotomy in pes planovalgus deformity correction
Authors Khalid MS Mohameda, Christopher Fenelona, John G Galbraitha, Lester G D’Souzaa a
= Department of Orthopaedic Surgery, University Hospital Limerick,
Limerick, Ireland, IRL
Authors Addresses Khalid MS Mohamed, Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland, IRL, [email protected] Christopher Fenelon, Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland, IRL. [email protected] John G Galbraith, Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland, IRL [email protected] Lester G D’Souza, Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland, IRL. [email protected]
Corresponding Author Christopher Fenelon 18 Crescent Court, Father Griffin Road, Galway, Ireland [email protected], +353 83 3974767
1
HIGHLIGHTS -
Lateral column lengthening is a useful technique used to treat stage two of pes planovalgus deformity
-
Traditionally the iliac crest has been used as a donor site
-
The technique we describe of obtaining bone graft locally avoids the complications associated with an iliac crest graft
ABSTRACT Lateral column lengthening osteotomy is very useful surgical technique in treating stage II of pes planovalgus deformity of the foot. Either autograft from the iliac crest or allograft can be used for this purpose. In our technique we describe a novel method of obtaining bone graft locally from the calcaneus and therefore avoiding complications and morbidity associated with iliac crest graft.
KEYWORDS Pes planovalgus, Evans, Calcaneal, Osteotomy, Deformity, Correction
INTRODUCTION Evans calcaneal osteotomy is a popular corrective surgery for the flexible pes planovalgus (PPV) deformity [1]. Traditionally it has utilised a tricortical structural bone graft to correct the deformity in three dimensions i.e. Lengthening of the lateral column, adduction of the fore foot and correcting the dorsiflexion of the calcaneus. Either tricortical autograft, allograft or xenograft can be used for this. Other methods of correction have been used including wedge locking plates, screw fixation and trabecular metal wedges. 2
Evans originally in 1959 used a structural bone graft harvested from the ipsilateral tibia [2]. Mosca published a modification of the technique in 1995 where tricortical autograft obtained from iliac crest [3]. Recently Kim showed significant incidence of complications with iliac crest graft e.g. pain at harvest site 16.5%, 29.1% numbness, 3.9% scarring and 15.1% difficulty with walking and 5.9% irritation from clothing [4]. In this paper we describe a surgical technique to obtain structural graft locally avoiding the need for a separate surgical site.
Description of Technique Preoperative planning is important in determining the width of the base of the graft. Every 1 mm corrects the forefoot deformity by 1 degree with the maximum lengthening of 15 mm [5]. The patient is positioned supine with a wedge under the ipsilateral hip and the foot internally rotated to provide adequate visualization of the surgical site (Figure 1). The first incision utilises the L-shaped extended lateral approach to the calcaneus. The vertical component of the incision commences midway between the fibula and achilles tendon. The horizontal component is begun in line with the fifth metatarsal and the two lines joined (Figure 2). The incision is carried down to bone at the corner of the flap. The skin should not be undermined and a full thickness flap should be created. Two Homan’s retractors are placed at the inferior and superior aspect of the calcaneus. The periosteum is reflected from the calcaneus on either side of the incision in preparation for the calcaneal osteotomy. Prior to performing the calcaneal osteotomy, the superior surface of the calcaneus is dissected subperiosteally from the posterior aspect of the subtalar joint up to the lateral border of the Achilles tendon. The Achilles tendon is inserted usually to the calcaneal tuberosity, a point one-third from 3
the superior aspect of the calcaneus. The graft from the calcaneus can be retrieved from the superior aspect of the calcaneus. This extends from the posterior aspect of the subtalar joint anteriorly to the insertion of the Achilles tendon over the calcaneus. The sural nerve is protected and blunt dissection used to expose the superior aspect of the calcaneus with a retractor placed anterior to the Achilles tendon. The bursa tissue and the periosteum are elevated off the calcaneus and the graft measurements are marked on the bone. Sagittal saw or osteotome are used to obtain the graft from the superior non- articular surface of the calcaneus. The graft size is usually around 3cm in all dimensions (Figure 3). The same incision provides excellent visualization of the hind part of the calcaneus and allows for the medial calcaneal displacement osteotomy, which is usually required for stage II deformities in combination with the lateral column lengthening (Figure 4).
DISCUSSION This unique technique combines the traditional extended lateral exposure used for intra-articular calcaneal fractures with the exposure for excision of Haglund’s lesion. The Haglund’s excision exposure was originally described by Keck and Kelly in 1965 [6]. It provides adequate access to the superior extra-articular surface of the calcaneus, which can safely be used as local graft donor site, as well as avoiding the sural nerve [7].
Bone graft options include autograft, allograft or less commonly xenograft. Autografts
are
commonly
preferred
due
to
their
osteoinduction,
osteoconduction and osteogenicity characteristics. They also are preferred as they carry no immunogenic or disease transmission risk. Studies comparing autografts with allografts have reported similar outcomes while allografts have 4
been shown to have better rates of incorporation in comparison to xenografts in their use in foot and ankle surgery and calcaneal lengthening [8 -10].
The iliac crest has been the traditional donor site for the tricortical graft. The morbidity associated with the iliac crest graft has been well described in the literature. In the immediate postoperative period this causes significant pain and discomfort and increases the analgesic requirement. In the long-term this can cause chronic pain, numbness, decrease in activity as well as the effect of scarring on the cosmetic outcome.
This technique avoids all these inherent complications of the iliac crest graft. It potentially provides easier pain management postoperatively through one anesthetic regional block. In addition, it is more cosmetically efficient as incisions are limited to one surgical site only. However, it must be noted that this approach does require a larger incision. It is important to raise a full thickness flap and not undermine the skin edges so to avoid compromising the blood supply. Patients should be informed that they will have a longer scar and potentially more swelling post operatively. Careful observation and wound care can avoid many of the incision issues.
ACKNOWLEDGMENTS The authors are grateful to all the help received from Dr. S. Kimura for demonstrating the surgical technique and Mr. F. Khan for taking care of the photography.
CONFLICTS OF INTEREST None to Declare 5
FUNDING This research did not receive any specific grant from funding agencies in the public, commercial or non for profit sectors.
REFERENCES 1. Mosier-LaClair S, Pomeroy G, Manoli A, 2nd. Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. Foot and ankle clinics. [Review]. 2001 Mar;6(1):95-119 2. Evans D. Calcaneo-valgus deformity. The Journal of bone and joint surgery British volume. 1975 Aug;57(3):270-8 3. Mosca VS. Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skewfoot. The Journal of bone and joint surgery American volume. 1995 Apr;77(4):500-12 4. Kim DH, Rhim R, Li L, Martha J, Swaim BH, Banco RJ, et al. Prospective study of iliac crest bone graft harvest site pain and morbidity. The spine journal : official journal of the North American Spine
Society.
[Research
Support,
Non-U.S.
Gov't].
2009
Nov;9(11):886-92 5. Saxena A. Evans calcaneal osteotomy. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2000 Mar-Apr;39(2):136-7 6. Keck SW, Kelly PJ. Bursitis of the Posterior Part of the Heel; Evaluation of Surgical Treatment of Eighteen Patients. The Journal of bone and joint surgery American volume. 1965 Mar;47:267-73
6
7. Raines RA, Jr., Brage ME. Evans osteotomy in the adult foot: an anatomic study of structures at risk. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 1998 Nov;19(11):743-7 8. Muller SA, Barg A, Vavken P, Valderrabano V, Muller AM. Autograft versus sterilized allograft for lateral calcaneal lengthening osteotomies: Comparision of 50 patients. Medicine (Baltimore). 2016;95(30):e4343 9. Shibuya N, Holloway BK, Jupiter DC. A comparitive study of incorporation rates between non xenograft and bovine based structural bone graft in foot and ankle surgery.
J Foot Ankle Surg.
2014;53(2):164-7 10. Rhodes J, Mansour A, Frickman A, Pritchard B, Flynn K, Pan Z et al. Comparison of Allograft and Bovine in Calcaneal Lengthening Osteotomy for Flatfoot Deformity in Cerebral Palsy. J Pediatric Orthop. 2016. Jul 2 [Epub ahead of print]
7
FIGURE LEGENDS Figure 1 Patient Positioned on the operation table with a wedge under the ipsilateral hip to allow for internal rotation of the limb and exposure of the lateral aspect of the foot. The end of the table is radiolucent to allow imaging intraoperative.
Figure 2 Surface landmarks drawn on the foot of the patient with the two incisions marked (A). The relation between the surface landmarks and the bony anatomy is shown in (B). The proximal incision allows exposure of the extra-articular portion of the calcaneus as well as performing the medial displacement calcaneal osteotomy. The distal incision allows lateral column lengthening osteotomy.
8
Figure 3 Three-dimensional measurements and orientation of the graft. Posterolateral view of the calcaneal graft site (A). Posterior view of the calcaneus with measurement of the graft width (B). Lateral view with the graft length marked and measured (C).
Figure 4 Plain radiographs at different stages of a patient who had lateral column lengthening and medial calcaneal displacement osteotomy with tricortical graft obtained from the extra-articular part of the calcaneus. Preoperative radiograph (A). Postoperative radiographs obtained at different intervals following the surgery (B, C, D).
9
S1268-7731(16)30462-3 http://dx.doi.org/doi:10.1016/j.fas.2016.10.007 FAS 973
To appear in:
Foot and Ankle Surgery
Received date: Revised date: Accepted date:
16-8-2016 24-10-2016 29-10-2016
Please cite this article as: Mohamed Khalid MS, Fenelon Christopher, Galbraith John G, D’souza Lester G.Technical Tip: Obtaining local bone graft for Evans Calcaneal Osteotomy in pes planovalgus deformity correction.Foot and Ankle Surgery http://dx.doi.org/10.1016/j.fas.2016.10.007 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title Page
Title Technical Tip: Obtaining local bone graft for Evans Calcaneal Osteotomy in pes planovalgus deformity correction
Authors Khalid MS Mohameda, Christopher Fenelona, John G Galbraitha, Lester G D’Souzaa a
= Department of Orthopaedic Surgery, University Hospital Limerick,
Limerick, Ireland, IRL
Authors Addresses Khalid MS Mohamed, Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland, IRL, [email protected] Christopher Fenelon, Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland, IRL. [email protected] John G Galbraith, Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland, IRL [email protected] Lester G D’Souza, Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland, IRL. [email protected]
Corresponding Author Christopher Fenelon 18 Crescent Court, Father Griffin Road, Galway, Ireland [email protected], +353 83 3974767
1
HIGHLIGHTS -
Lateral column lengthening is a useful technique used to treat stage two of pes planovalgus deformity
-
Traditionally the iliac crest has been used as a donor site
-
The technique we describe of obtaining bone graft locally avoids the complications associated with an iliac crest graft
ABSTRACT Lateral column lengthening osteotomy is very useful surgical technique in treating stage II of pes planovalgus deformity of the foot. Either autograft from the iliac crest or allograft can be used for this purpose. In our technique we describe a novel method of obtaining bone graft locally from the calcaneus and therefore avoiding complications and morbidity associated with iliac crest graft.
KEYWORDS Pes planovalgus, Evans, Calcaneal, Osteotomy, Deformity, Correction
INTRODUCTION Evans calcaneal osteotomy is a popular corrective surgery for the flexible pes planovalgus (PPV) deformity [1]. Traditionally it has utilised a tricortical structural bone graft to correct the deformity in three dimensions i.e. Lengthening of the lateral column, adduction of the fore foot and correcting the dorsiflexion of the calcaneus. Either tricortical autograft, allograft or xenograft can be used for this. Other methods of correction have been used including wedge locking plates, screw fixation and trabecular metal wedges. 2
Evans originally in 1959 used a structural bone graft harvested from the ipsilateral tibia [2]. Mosca published a modification of the technique in 1995 where tricortical autograft obtained from iliac crest [3]. Recently Kim showed significant incidence of complications with iliac crest graft e.g. pain at harvest site 16.5%, 29.1% numbness, 3.9% scarring and 15.1% difficulty with walking and 5.9% irritation from clothing [4]. In this paper we describe a surgical technique to obtain structural graft locally avoiding the need for a separate surgical site.
Description of Technique Preoperative planning is important in determining the width of the base of the graft. Every 1 mm corrects the forefoot deformity by 1 degree with the maximum lengthening of 15 mm [5]. The patient is positioned supine with a wedge under the ipsilateral hip and the foot internally rotated to provide adequate visualization of the surgical site (Figure 1). The first incision utilises the L-shaped extended lateral approach to the calcaneus. The vertical component of the incision commences midway between the fibula and achilles tendon. The horizontal component is begun in line with the fifth metatarsal and the two lines joined (Figure 2). The incision is carried down to bone at the corner of the flap. The skin should not be undermined and a full thickness flap should be created. Two Homan’s retractors are placed at the inferior and superior aspect of the calcaneus. The periosteum is reflected from the calcaneus on either side of the incision in preparation for the calcaneal osteotomy. Prior to performing the calcaneal osteotomy, the superior surface of the calcaneus is dissected subperiosteally from the posterior aspect of the subtalar joint up to the lateral border of the Achilles tendon. The Achilles tendon is inserted usually to the calcaneal tuberosity, a point one-third from 3
the superior aspect of the calcaneus. The graft from the calcaneus can be retrieved from the superior aspect of the calcaneus. This extends from the posterior aspect of the subtalar joint anteriorly to the insertion of the Achilles tendon over the calcaneus. The sural nerve is protected and blunt dissection used to expose the superior aspect of the calcaneus with a retractor placed anterior to the Achilles tendon. The bursa tissue and the periosteum are elevated off the calcaneus and the graft measurements are marked on the bone. Sagittal saw or osteotome are used to obtain the graft from the superior non- articular surface of the calcaneus. The graft size is usually around 3cm in all dimensions (Figure 3). The same incision provides excellent visualization of the hind part of the calcaneus and allows for the medial calcaneal displacement osteotomy, which is usually required for stage II deformities in combination with the lateral column lengthening (Figure 4).
DISCUSSION This unique technique combines the traditional extended lateral exposure used for intra-articular calcaneal fractures with the exposure for excision of Haglund’s lesion. The Haglund’s excision exposure was originally described by Keck and Kelly in 1965 [6]. It provides adequate access to the superior extra-articular surface of the calcaneus, which can safely be used as local graft donor site, as well as avoiding the sural nerve [7].
Bone graft options include autograft, allograft or less commonly xenograft. Autografts
are
commonly
preferred
due
to
their
osteoinduction,
osteoconduction and osteogenicity characteristics. They also are preferred as they carry no immunogenic or disease transmission risk. Studies comparing autografts with allografts have reported similar outcomes while allografts have 4
been shown to have better rates of incorporation in comparison to xenografts in their use in foot and ankle surgery and calcaneal lengthening [8 -10].
The iliac crest has been the traditional donor site for the tricortical graft. The morbidity associated with the iliac crest graft has been well described in the literature. In the immediate postoperative period this causes significant pain and discomfort and increases the analgesic requirement. In the long-term this can cause chronic pain, numbness, decrease in activity as well as the effect of scarring on the cosmetic outcome.
This technique avoids all these inherent complications of the iliac crest graft. It potentially provides easier pain management postoperatively through one anesthetic regional block. In addition, it is more cosmetically efficient as incisions are limited to one surgical site only. However, it must be noted that this approach does require a larger incision. It is important to raise a full thickness flap and not undermine the skin edges so to avoid compromising the blood supply. Patients should be informed that they will have a longer scar and potentially more swelling post operatively. Careful observation and wound care can avoid many of the incision issues.
ACKNOWLEDGMENTS The authors are grateful to all the help received from Dr. S. Kimura for demonstrating the surgical technique and Mr. F. Khan for taking care of the photography.
CONFLICTS OF INTEREST None to Declare 5
FUNDING This research did not receive any specific grant from funding agencies in the public, commercial or non for profit sectors.
REFERENCES 1. Mosier-LaClair S, Pomeroy G, Manoli A, 2nd. Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. Foot and ankle clinics. [Review]. 2001 Mar;6(1):95-119 2. Evans D. Calcaneo-valgus deformity. The Journal of bone and joint surgery British volume. 1975 Aug;57(3):270-8 3. Mosca VS. Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skewfoot. The Journal of bone and joint surgery American volume. 1995 Apr;77(4):500-12 4. Kim DH, Rhim R, Li L, Martha J, Swaim BH, Banco RJ, et al. Prospective study of iliac crest bone graft harvest site pain and morbidity. The spine journal : official journal of the North American Spine
Society.
[Research
Support,
Non-U.S.
Gov't].
2009
Nov;9(11):886-92 5. Saxena A. Evans calcaneal osteotomy. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2000 Mar-Apr;39(2):136-7 6. Keck SW, Kelly PJ. Bursitis of the Posterior Part of the Heel; Evaluation of Surgical Treatment of Eighteen Patients. The Journal of bone and joint surgery American volume. 1965 Mar;47:267-73
6
7. Raines RA, Jr., Brage ME. Evans osteotomy in the adult foot: an anatomic study of structures at risk. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 1998 Nov;19(11):743-7 8. Muller SA, Barg A, Vavken P, Valderrabano V, Muller AM. Autograft versus sterilized allograft for lateral calcaneal lengthening osteotomies: Comparision of 50 patients. Medicine (Baltimore). 2016;95(30):e4343 9. Shibuya N, Holloway BK, Jupiter DC. A comparitive study of incorporation rates between non xenograft and bovine based structural bone graft in foot and ankle surgery.
J Foot Ankle Surg.
2014;53(2):164-7 10. Rhodes J, Mansour A, Frickman A, Pritchard B, Flynn K, Pan Z et al. Comparison of Allograft and Bovine in Calcaneal Lengthening Osteotomy for Flatfoot Deformity in Cerebral Palsy. J Pediatric Orthop. 2016. Jul 2 [Epub ahead of print]
7
FIGURE LEGENDS Figure 1 Patient Positioned on the operation table with a wedge under the ipsilateral hip to allow for internal rotation of the limb and exposure of the lateral aspect of the foot. The end of the table is radiolucent to allow imaging intraoperative.
Figure 2 Surface landmarks drawn on the foot of the patient with the two incisions marked (A). The relation between the surface landmarks and the bony anatomy is shown in (B). The proximal incision allows exposure of the extra-articular portion of the calcaneus as well as performing the medial displacement calcaneal osteotomy. The distal incision allows lateral column lengthening osteotomy.
8
Figure 3 Three-dimensional measurements and orientation of the graft. Posterolateral view of the calcaneal graft site (A). Posterior view of the calcaneus with measurement of the graft width (B). Lateral view with the graft length marked and measured (C).
Figure 4 Plain radiographs at different stages of a patient who had lateral column lengthening and medial calcaneal displacement osteotomy with tricortical graft obtained from the extra-articular part of the calcaneus. Preoperative radiograph (A). Postoperative radiographs obtained at different intervals following the surgery (B, C, D).
9