Effectiveness of calcaneal osteotomy in surgical treatment of foot conditions: A Prisma statement guidelines compliant systematic review.

Calcaneal osteotomy is a commonly established method used to correct various foot malalignment surgery problems that produce varus and valgus hindfoot abnormality as well as Haglund's deformity, cavovarus foot reconstruction, flatfoot deformity, plantar fasciitis, posterior tibial tendon insufficiency and planovalgus foot. After decades, several procedures in orthopaedic foot surgery have been suggested for reducing the risk of wound and neurovascular complications. The goal of this Prisma statement guidelines compliant systematic review was to establish the effectiveness and safety of calcaneal osteotomy in foot surgery. We have performed a novel systematic review of the current published literature in order to evaluate the scientific evidence now available on this association, assigning predefined exclusion and inclusion criteria. Eight investigations were selected which had 191 cases. The adult flatfoot, tibialis posterior reconstruction and cavovarus foot deformity were treated with different procedures of calcaneal osteotomy techniques. The adequate level of effectiveness of calcaneal osteotomy is associated with the kind and location of the incision, with or without screw application, in each specific foot condition. There is a limited number of scientific investigations of the effectiveness and safety of the different kinds of calcaneal osteotomy in foot surgery, and there is the need to enhance outcome knowledge on this foot surgery technique.

INTRODUCTION

Calcaneal osteotomy is a commonly established method used to correct various foot malalignment surgery problems that produce varus and valgus hindfoot abnormality as well as Haglund's deformity, cavovarus foot reconstruction, flatfoot deformity, plantar fasciitis, posterior tibial tendon insufficiency and planovalgus foot. , , , , Furthermore, this surgical technique improves the biomechanical characteristics of the calcaneal alignment, produces deformity correction in multi‐plane motion and can have a positive impact on walking dynamics in people that suffer this condition.

In the last decades, these kind of deformities and alterations of the foot are identified as an indispensable public health problem, linked with the augment of the high prevalence and discomfort of most of the foot malalignment symptoms is related with: (a) joint pain, (b) difficulties for putting on shoes, (c) variation in plantar pressures, (d) muscle weakness, (e) gait abnormalities and (f) risk of falls. , This has been confirmed by the physicians and health policymakers as a significant threat to overall public health owing to its negative influence on individual and global health. ,

Thus, many methods of fixation in the foot surgery specialty have been developed over the years, to increase safety and effectiveness, according to the orthopaedic surgeons' preferences, to reduce several complications such as: (a) infection, (b) undercorrection or overcorrection, (c) limited fixation, (d) greater postoperative oedema, (e) vascular embarrassment, (f) sural nerve loss or entrapment, (g) graft absorption, (h) subtalar or calcaneocuboid arthritis and (i) fracture in the calcaneus and so improve the outcomes of these procedures.

Based on these antecedents, studies have not been found focussing on correcting various foot malalignments related to how best to secure the calcaneal osteotomy. In this way, in our hypothesis, there is a small number of the clinical studies and trials regarding the effectiveness of calcaneal osteotomy in surgical treatment of foot conditions. Thus, our goal in this novel Prisma statement guidelines compliant systematic review was to establish the effectiveness and safety of calcaneal osteotomy in foot surgery.

MATERIALS AND METHODS

Study design

This Prisma statement guidelines compliant systematic review was conducted to improve the global overview of this important foot malalignment in order to better understand available evidence. The investigation was registered with the record number CRD42021271306 in the International Prospective Register of Systematic Reviews [PROSPERO]; this database is linked to health sciences report related outcomes.

Search strategy

An electronic systematic search was performed in the following online databases: Web of Science and MEDLINE applying relevant keywords and checked vocabulary words (ie, medical sub‐heading [MeSH] terms). The keywords incorporated global search terms such as Calcaneus, Foot, Foot diseases, and Heel and treatment‐related terms Calcaneal osteotomy, Calcaneal surgery, Calcaneal treatment, and Minimally invasive, Foot Surgery. Our completed search protocol strategy can be reviewed in Appendix.

In addition, this systematic review interval included the last 10 years. All investigations available in these two online databases until August 2021 were incorporated. We selected articles reporting finished randomised or non‐controlled clinical trials published in international peer‐reviewed journals. All references list incorporated in these articles issued in English or Spanish were evaluated and subjected to revision in both languages.

Further, special caution was used on the online search in Web of Science and MEDLINE, to make sure to include all relevant investigations, even though that ran the risk of detecting irrelevant data that would subsequently have to be erased.

Exclusion and inclusion criteria

We assigned these exclusion and inclusion criteria to analyse which studies were included in this novel systematic review related to original investigations in foot surgery conducted in experimental laboratories, podiatry clinic or orthopaedic medical centres applying any calcaneal osteotomy procedure. Only research in human and cadaveric fresh frozen specimens was included. The criteria for assignment of variables were: (a) randomised or non‐controlled clinical trials published in the previous 10 years, (b) cases of patients or cadaveric samples, (c) various foot malalignment surgery problems, (d) type of calcaneal osteotomy, (e) outcomes measurements, (f) time of follow‐up, (g) efficacy of the calcaneal osteotomy and (h) investigations written in English and Spanish.

The exclusion criteria were: (a) studies evaluating the finite element method or sawbones anatomical models, (b) commentaries or letters to the editor and (c) investigations published in languages other than English and Spanish.

Synthesis of data and management of search results

Two senior expert reviewers evaluated the search findings related with calcaneal osteotomy procedures in foot surgery (D.L.‐L. and J.B.‐L.), and if there were queries on any investigation regarding the exclusion or inclusion criteria, this was agreed with all co‐authors. All references of scientific investigations to be incorporated were manually analysed, and those original articles that might be added were also evaluated and obtained.

We retrieved identical information associated with all the original articles according to the Prisma statement guidelines, applying a standardised format that is shown in Table 1 with individual fields for each original paper. We recorded all the information from every investigation in an evidence level table with qualitative data, and an overall conclusion was drawn. The level of risk of bias evaluation in the systematic review was assessed using the Review Manager software of The Cochrane Library, version 5.3. It was not possible to conduct a meta‐analysis because of the heterogeneity of the incorporated investigations.

TABLE 1

Main characteristics of the included investigations

	Cases	Foot malalignment	Intervention	Type of the System	System insertion place	Outcomes measures	Follow Up	Level of the Fixation
Schmid et al 13	10	Cavovarus foot deformity	Calcaneal osteotomies (5‐ and 10‐mm displacement)	Two 2.0 mm Kirschner wires were driven from the first and third metatarsal into the talar head. The proximal 30 mm of the tibia and fibula were fixed in a polymethylmethacrylate (PMMA) block (Beracryl, Suter Kunststoff AG, Jegenstorf, Switzerland)	Supramalleolar valgus osteotomies and lateralising calcaneal osteotomies	High‐resolution pressure and force measurement sensors (TekScan Inc, South Boston, Massachusetts). Custom air pressure sensor calibration machine (AO Foundation, Switzerland).	None	Both osteotomies showed good results.
Charwat‐Pessler et al 14	21	Adult acquired flat foot deformity	Interference screw fixation for flexor digitorum longus transfer combined with medial displacement calcaneal osteotomy	A cannulated 6.5 Synthes cortical screw (Synthes Inc., West Chester, Pennsylvania)	Medial displacement calcaneal osteotomy Tenotomy of the flexor digitorum longus and junction with the tendon of the flexor hallucis longus.	Visual Analogue Scale American Orthopaedic Foot and Ankle Society Radiographic parameters (talo‐first metatarsal angle, talonavicular coverage angle and the hindfoot alignment)	20 months	Good results
Martinkevich et al 15	10	Pes planovalgus	Calcaneal lengthening osteotomy	Hydroxyapatite tricalcium phosphate graft (Sheffield, England). Tricortical iliac crest autograft	Osteotomy proximal and parallel to the calcaneocuboid joint was distracted by 10 mm to 12 mm until the deformity was corrected.	Radiostereometric analysis (Arco‐Ceil/Medira; Santax Medico, Aarhus, Denmark) with x‐ray tubes angled towards each other at 40° and a focus‐grid uniplanar carbon calibration box (Box 24, Medis Special, Leiden, the Netherlands)	6 months	Poor results (Hydroxyapatite tricalcium phosphate graft). Good results (Tricortical iliac crest autograft)
Chong et al 16	24	Planovalgus deformity	Subtalar arthroereisis or lateral column calcaneal lengthening	Vilex titanium implants (McMinnville, Tennessee)	A lateral incision was made over the distal calcaneus for an opening wedge osteotomy, inserting a wedge of cadaveric bone. A 1 cm lateral incision in sinus tarsi to implant the conical screw.	Fluoroscopy. 10‐camera motion capture system (Vicon, Centennial, Colorado). Force plates (AMTI, Watertown, Massachusetts). Pedobarograph mat (RSScan, Paal, Belgium). Oxford Ankle–Foot Questionnaire for Children.	12 months	Optimal (lateral column lengthening) Optimal (subtalar arthroereisis)
Usuelli et al 17	42	Adult flatfoot	Medial displacement calcaneal osteotomy and flexor digitorum longus transfer to navicular bone	2.5‐mm Kirschner wire for fixation of the calcaneal osteotomy. Bioabsorbable interference screw for fixation of the FDL tendon in navicular bone.	A 4 cm lateral incision of the calcaneal tuberosity. The tuberosity was cut from lateral to medial and displaced medially and fixed with a cannulated 7.3‐mm cancellous lag screw.	Radiographs Magnetic resonance imaging Sports Athlete Foot and Ankle Score	24 months	Good results
Chan et al 18	30 cases	Adult acquired flatfoot deformity	Medialising calcaneal osteotomy	6.5‐ or 7.3‐mm cannulated screw fixation Iliac crest autograft Two fully threaded with cortical screws	Lateral incision with cut of the calcaneus was translated medially, fixed with 6.5‐ or 7.3‐mm cannulated screws. The lateral column lengthening was performed through the anterior part of the calcaneus, filled with iliac crest autograft and two fully threaded, cortical screws.	Radiographs	24 weeks	Good results
Kheir et al 19	29 cases	Tibialis posterior reconstruction	Medial displacement of at least 10 mm	6.5 mm cannulated screw	Minimally invasive calcaneal osteotomy surgery	Fluoroscopy	20 weeks	Good results
Niki et al 20	25 cases	Adult acquired flatfoot	Medial displacement calcaneal osteotomy with flexor digitorum longus tendon transfer	Not applicable	Not applicable	Radiographs Magnetic resonance imaging Preoperative and postoperative Japanese Society for Surgery of the Foot Foot Function Index SF‐36	12 months	Poor results

RESULTS

Summary of the studies included

Figure 1 presents the flowchart of the data published in the original articles associated with calcaneal osteotomy in foot surgery retrieved.

FIGURE 1

Flowchart of the included studies describing calcaneal osteotomy in foot surgery

Eight studies recorded all the inclusion criteria. Most of the studies analysed were original articles on randomised or non‐controlled clinical trials. Eight of the original papers corresponded to outcomes of cases of patients, and one study in fresh frozen human cadavers, all information appears in Table 1.

Lastly, the risk of bias was evaluated in these eight studies. Only one investigation showed a low risk in random sequence generation, in blinding of outcome assessment and in allocation concealment. All the studies recorded displayed a low risk in incomplete outcome data, and four included a selective reporting bias. Also, the majority of the investigations appeared unclear of bias in terms of other bias. All data are shown in Figures 2 and 3.

FIGURE 2

Risk of bias graph in the studies included. (1) Green (low risk), (2) white (unclear risk) and (3) red (high risk)

FIGURE 3

Risk of bias summary in the studies. (1) green (low risk), (2) white (unclear risk) and (3) red (high risk)

DISCUSSION

To our scientific knowledge, this is the first Prisma statement guidelines compliant systematic review. This innovative investigation focussed on suitable published original literature that exclusively determines the overall knowledge available on the effectiveness and safety of calcaneal osteotomy in foot surgery.

We have discovered that calcaneal osteotomy is a standard method of choice to enhance various foot malalignment surgery problems that produce varus and valgus hindfoot abnormality. This is a main technique for reparation of functional or structural alterations such as supinatory or pronatory syndromes. This surgical method can modify the calcaneal axis, the orthopaedic correction in aligning biomechanical problems in any planes of motion.

Due to the large number of studies in the current literature describing foot malalignment surgery problems and evaluating various techniques with theoretical instructions for performing various types of calcaneal osteotomies, the reports recognise heterogeneity in the site of the calcaneal osteotomy that suggests the choice is based on the orthopaedic surgeon's preference, simplicity or other local factors in the case of more complicated reconstructions. ,

In fact, it was identified that most of these foot problems were managed through a lateral approach, applying screws, a lateral plate or transfer of muscles, which are safe techniques with good radiographic and clinical results which are satisfactory in most of the patients. , , , , , ,

The majority of these scientific studies displayed adequately performed calcaneal osteotomy in foot surgery through a lateral approach as an excellent technique for the reparation of various foot malalignments.

For deciding on calcaneal osteotomy, it is necessary to establish clinical and surgery recommendations related with to consider availability, the higher cost and the structural quality of the bone to determine the fixation model. Thus, there must be an evaluation and analysis of the joints that allow adequate biomechanical movement, using screws, different size plate systems and/or the transfer muscles for the patient to obtain the optimal outcome in the foot surgery treatment and the best fixation system in every case.

This Prisma statement guidelines compliant systematic review highlights some limitations because of the scant available scientific evidence, foot malalignment was very different in the provided studies and due to the heterogeneous methods associated with these original studies, which did not provide the opportunity to perform a meta‐analysis. Furthermore, some scientific investigations were of patients and others of cadaveric samples with variations in the types of measurements of the main features in the included reports.

Last, innovative systematic review offers helpful data to treat various related foot malalignment surgery problems for investigators and orthopaedic surgeon clinicians regarding the safety and effectiveness of calcaneal osteotomy techniques. Additionally, it manifests the value of continuous scientific investigation of this technique to get better surgical findings, overall health and quality of life for the patients with these foot problems.

CONCLUSIONS

There is a limited number of scientific investigations about the effectiveness and safety of the different kinds of calcaneal osteotomy in foot surgery, and there is a need to enhance outcome knowledge on this foot surgery technique.

CONFLICT OF INTEREST

All authors declare there is no conflict of interest with the article publication and agree with this journal copyright.

AUTHOR CONTRIBUTIONS

Conceptualisation, Daniel López‐López, Ricardo Larrainzar‐Garijo, Ricardo Becerro de Bengoa Vallejo, Marta Elena Losa‐Iglesias and Javier Bayod López, data curation, Daniel López‐López and Javier Bayod López, formal analysis, Daniel López‐López and Javier Bayod López, investigation, Daniel López‐López, Ricardo Larrainzar‐Garijo, Ricardo Becerro de Bengoa Vallejo, Marta Elena Losa‐Iglesias and Javier Bayod López, methodology, Daniel López‐López, Ricardo Larrainzar‐Garijo, Ricardo Becerro de Bengoa Vallejo, Marta Elena Losa‐Iglesias and Javier Bayod López, supervision, Daniel López‐López, Ricardo Larrainzar‐Garijo, Ricardo Becerro de Bengoa Vallejo, Marta Elena Losa‐Iglesias and Javier Bayod López, writing – original draft, Daniel López‐López, Ricardo Larrainzar‐Garijo, Ricardo Becerro de Bengoa Vallejo, Marta Elena Losa‐Iglesias and Javier Bayod López, writing – review and editing, Daniel López‐López, Ricardo Larrainzar‐Garijo, Ricardo Becerro de Bengoa Vallejo, Marta Elena Losa‐Iglesias and Javier Bayod López.

Appendix S1: Supporting Information

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