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The Journal of Foot & Ankle Surgery 51 (2012) 135140

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The Journal of Foot & Ankle Surgery


journal homepage: www.jfas.org

Surgical Technique for Combined Dwyer Calcaneal Osteotomy and Peroneal


Tendon Repair for Correction of Peroneal Tendon Pathology Associated
with Cavus Foot Deformity
Troy J. Boffeli, DPM, FACFAS 1, Rachel C. Collier, DPM 2
1
2

Director, Foot and Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Medical Education, Saint Paul, MN
Foot and Ankle Surgery Resident, Regions Hospital/HealthPartners Institute for Medical Education, Saint Paul, MN

a r t i c l e i n f o

a b s t r a c t

Keywords:
ankle
calcaneus
cavovarus
foot
high arch
surgery
tendon

Peroneal tendon pathology is commonly seen in patients with underlying pes cavus. The Dwyer calcaneal
osteotomy is a useful adjunctive procedure to address the heel varus component of the cavus foot deformity,
especially in the presence of concomitant peroneal tendon pathology. The lateralizing heel osteotomy using
a wedge resection can effectively reduce future stress on the repaired peroneal tendons, although technical
challenges arise when attempting to perform both tendon repair and heel osteotomy through the same
incision. Specic principles must be followed to achieve adequate exposure of the desired structures, obtain
desired correction of the deformity, and avoid complications such as sural neuritis. In the present report, the
surgical principles and technical pearls are highlighted in a pictorial demonstration of preoperative planning
for calcaneal wedge resection, incision placement, osteotomy guide pin technique, xation pearls, and
peroneal tendon repair and transfer.
2012 by the American College of Foot and Ankle Surgeons. All rights reserved.

Chronic lateral ankle instability, peroneal tendon pathology, and


cavovarus foot structure often contribute to the development of
chronic lateral ankle pain (13). The published data support correction of the pes cavus using calcaneal osteotomy, including the Dwyer
osteotomy, in patients with recurrent lateral ankle sprains (2). Our
review of the published data led us to conclude that relatively little
attention has been given to correcting cavus deformity in patients
with peroneal tendon pathology. More recently, the management of
concomitant tears of the peroneal tendons associated with pes cavus
has been examined, and the need to correct the cavus deformity of the
hindfoot, as well as the tendon pathology, has been appreciated (3).
Lateralizing heel osteotomy using a wedge resection can be
effective at reducing future stress on the repaired peroneal tendons;
however, technical challenges arise when attempting to perform the
tendon repair and heel osteotomy through the same incision. Specic
principles must be followed to achieve adequate exposure of the
desired structures, obtain the desired amount of deformity correction,
and avoid complications such as sural neuritis. The technique we
describe in the present report demonstrates the surgical principles

Financial Disclosure: None reported.


Conict of Interest: None reported.
Address correspondence to: Rachel C. Collier, DPM, Foot and Ankle Surgery
Resident, Regions Hospital, 640 Jackson Street, MS 11051G, St. Paul MN 55101.
E-mail address: rachel.c.collier@healthpartners.com (R.C. Collier).

and technical pearls we have found useful in the execution of a Dwyer


calcaneal osteotomy combined with peroneal tendon repair for cavus
foot deformity. The tips and pearls we believe to be helpful are
supported by a pictorial demonstration of preoperative planning for
wedge resection, incision placement, osteotomy guide pin technique,
xation options, and peroneal tendon repair technique.
Surgical Technique
Preoperative Planning Tips
Preoperative planning for correction of a cavus foot deformity is
essential. In addition to standard weight-bearing radiographs of the
foot, we have come to appreciate the value of a long leg calcaneal axial
view and ankle radiographs to evaluate the extent of heel varus
deformity and to rule out deformity elsewhere in the lower extremity.
An early report by Krackow et al (4) described the use of a template for
the Dwyer calcaneal osteotomy. We believe this could be useful in
many cases. The heel axial portion of the long leg calcaneal axial view
can be used as a template for paper cutouts to determine the amount
of wedge resection needed to correct a heel varus deformity (Fig. 1).
The use of digital radiography enables creation of a life-size
(1:1 aspect ratio) heel axial printed image. The rst step in determining the alignment of the heel is to draw the long axis of the
anterior portion of the calcaneus and the long axis of the calcaneal

1067-2516/$ - see front matter 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.
doi:10.1053/j.jfas.2011.10.021

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T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140

Fig. 1. Preoperative template planning. Calcaneal axial radiograph used as template for
paper cutouts to determine proper size and location of wedge to achieve desired amount
of correction. Outline of calcaneus is traced if necessary.

tuberosity, because these frontal plane lines demonstrate the inherent


curvature of the calcaneus and aid in placement of the osteotomies
(Fig. 2). It is also useful to make a few copies of the template before
going to the operating room to assist in the trial and error, cut and
paste process.
The combined peroneal tendon repair and Dwyer calcaneal
osteotomy approach through 1 lateral incision requires that the
osteotomy be placed deep to the tendons, which differs from the more
traditional location of the posterior heel osteotomy. This location has
the advantage of a longer lever arm, which can be advantageous in
regard to providing greater correction of the deformity, although this
does not always correlate with the apex of the deformity within the
calcaneus. Therefore, a smaller size wedge is needed to create the
desired amount of heel correction compared with an osteotomy
positioned more posteriorly. This is similar to what is seen with a rst
metatarsal base wedge osteotomy for bunion correction. For example,
the more proximal one makes the wedge osteotomy in the base of the
metatarsal, the smaller the wedge needs to be to create the desired
amount of correction due to the lever arm effect. As such, it is helpful
to minimize the amount of bone resection to maintain the calcaneal
length and height and the gross appearance of the heel. In our
experience, some heels look short and/or stumpy after wedge
osteotomies that did not take advantage of this lever arm principle.
When creating the template, the anterior osteotomy is drawn rst
and is oriented perpendicular to the long axis of the anterior portion of
the calcaneus. The anterior osteotomy is best situated beneath and
roughly parallel to the posterior facet of the subtalar joint. The
posterior osteotomy is then drawn perpendicular to the long axis of
the calcaneal tuberosity, thereby creating an apex on the medial cortex

Fig. 2. Identication of apex of varus deformity. Long axis of anterior portion of calcaneus
and long axis of calcaneal tuberosity drawn on template. Long axis of anterior portion of
calcaneus should be 90 to posterior facet of subtalar joint. Axis lines aid in orientation of
anterior and posterior osteotomies and help determine wedge amount needed to correct
varus deformity.

(Fig. 3). Once the desired wedge has been created on the template,
a photocopy is made. The calcaneal tuberosity portion is cut from the
photocopy and placed over the template in the corrected position. This
allows the surgeon to visualize the amount of correction achieved
according to the planned wedge width and osteotomy location (Fig. 4).
Intraoperative Tips
The patient is placed laterally on the operating table with the side
operated upward and with an ipsilateral thigh tourniquet in place. A
curved incision is then made over the peroneal tendons, anterior to
the sural nerve (Fig. 5). This incision allows access for both peroneal
tendon repair and Dwyer heel osteotomy and is distinctly different
from the traditional heel osteotomy incision, which is usually made
posterior to, and below, the sural nerve (Fig. 6). The peroneal tendons
are then mobilized and retracted toward the bula to perform the
wedge osteotomy. The location and direction of the osteotomy is
conrmed with the use of lateral image intensication uoroscopy,
with the aid of a Kirschner wire laid within (collinear to the direction
of) the incision. It is important to evaluate the dorsal and plantar exit
points of the calcaneal osteotomy, with attention paid to avoiding
involvement of the posterior facet of the subtalar joint (Fig. 7). The
lateral periosteal incision and dissection is then performed on the
lateral wall of the body of the calcaneus. We prefer to achieve dorsal
and plantar periosteal elevation with the use of a curved Crego
elevator. No dissection is needed or desired on the medial aspect of
the calcaneus.

T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140

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Fig. 3. Drawing arms (cuts) of osteotomy. Anterior osteotomy drawn perpendicularly to


long axis of anterior portion of calcaneus. Posterior osteotomy drawn perpendicular to long
axis of calcaneal tuberosity, creating apex at medial cortex. Note, osteotomy purposely
placed anterior to apex of varus deformity, allowing easy access through incision placed
over peroneal tendons and anterior to sural nerve. More traditional heel osteotomy incision
would be behind the sural nerve and would not provide access to peroneal tendons.
Proposed osteotomy also takes advantage of longer lever arm, which provides greater
correction of varus deformity with a smaller wedge.

Fig. 4. Completion of paper template. Photocopy of template from Fig. 3 allows cutout of
posterior fragment to be overlaid in corrected position, allowing surgeon to visualize
amount of correction achieved after wedge resection. This template demonstrates that an
anteriorly placed osteotomy achieves dramatic correction. This technique produces
a posterior tuberosity parallel with the tibia and positioned laterally to weight-bearing
vector. Wedge width can be adjusted if foot structure and ankle instability does not
warrant this correction amount.

After preparation of the calcaneus for osteotomy, 2 guide pins (we


prefer to use 0.45-in. Kirschner wires) are inserted to achieve
a controlled and predictable wedge. The guide pins are placed laterally to medially in an effort to recreate the predetermined width and

location of the laterally based calcaneal wedge. The anterior guide pin
is placed roughly parallel to the posterior facet of the subtalar joint.
The posterior guide pin is placed roughly 90 to the long axis of the
calcaneal tuberosity. At this point in the procedure, we prefer to

Fig. 5. Incision placement for combined technique. Incision (dashed line) over peroneal
tendons, anterior to sural nerve (dotted line). One might need to extend the incision
proximally or distally depending on peroneal pathology location. Both Dwyer calcaneal
osteotomy and peroneal tendon repair procedures are performed through this incision.

Fig. 6. Differences in heel osteotomy incision placement. Dwyer incision (dashed line)
noted to be more anterior than traditional heel osteotomy incision (solid line), which is
posterior and inferior to sural nerve.

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T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140

Fig. 7. Location of Dwyer osteotomy. Location and direction of osteotomy conrmed by


imaging a pin laid within the incision. It is important to avoid the posterior facet of the
subtalar joint. Note, Dwyer osteotomy location is more anterior than that of a Koutsogiannis osteotomy. An anteriorly placed osteotomy creates a longer lever arm; thus, less
bone resection is required to achieve adequate correction of varus deformity.

conrm the appropriate position of the osteotomy guide pins using


axial heel uoroscopy. The guide pins should converge at the medial
cortex of the calcaneus and indicate the orientation of the planned
osteotomy (Fig. 8).

Fig. 9. Screw xation. Cannulated screws or Steinmann pins used for xation. Pins used as
joystick to aid in reduction of osteotomy. Guide pins inserted to level of osteotomy.
Valgus force applied to 1 pin to close and compress osteotomy while second pin is
advanced into anterior fragment.

After conrmation of the orientation of the osteotomy, the long,


tapered saw blade is marked at a depth of 3 cm before performing the
osteotomy to control and monitor the depth of the cut. The posterior
cut is performed rst, and we recommend cutting the guide pins such
that only about 2 cm of each pin protrudes laterally from the surface of
the skin to contain and guide the saw blade to the medial apex. The

Fig. 8. Osteotomy guide pin placement. Two osteotomy guide pins placed from laterally to
medially. Anterior guide pin placed roughly parallel to posterior facet of subtalar joint.
Posterior guide pin placed at 90 to long axis of calcaneal tuberosity. Width of wedge on
lateral cortex can be estimated from preoperative template measurements. Osteotomy
guide pins contain saw blade to create predictable wedge with apex at medial cortex.

Fig. 10. Transfer of peroneus longus to peroneus brevis. Peroneus longus tendon (a)
anastomosed to brevis tendon (b) in side-to-side fashion. Peroneus longus tendon can be
cut distal to anastomosis, allowing elevation of rst ray, which is useful in cavus foot
reconstruction when the medial column is partly exible. The free end of the peroneus
longus tendon usually scars in place and behaves similar to a plantar ligament.

T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140

Fig. 11. Dorsiexory metatarsal osteotomy. Dorsiexory osteotomy of rst metatarsal


performed if rst metatarsal remains plantarexed to a point at which it will affect rearfoot
alignment. Similar osteotomy guide pin technique is used to obtain a predictable result.

saw blade is placed on the interior of the guide pins, and no other
guiding instruments are used. The osteotomies are then made from
laterally to medially. Although preservation of the medial hinge is
optional, we typically create a through-and-through osteotomy,
taking care to avoid the medial neurovascular structures, which are
intimately associated with the medial wall of the body of the calcaneus. After completion of the posterior and anterior osteotomies, the
resultant wedge of bone is removed and the posterior portion of the
calcaneus, including the weight-bearing tuberosity, are shifted into
the corrected alignment with closure of the wedge, with or without
transposition of the posterior fragment.
After reduction of the osteotomy, it is xated with 1 or 2 cannulated
interfragmental compression screws or 2 Steinmann pins (5/64-in. or
7/64-in. diameter). If necessary, the Steinmann pins or cannulated
screw guide pins can be used as joysticks to further achieve optimal
reduction of the osteotomy. We recommend inserting the pins into the
posterior fragment of the calcaneus before reduction, because this
enables the surgeon to directly visualize the location at which the
xation will traverse the osteotomy interface. The tuberosity is positioned and compressed with 1 pin while the second pin is advanced
into the anterior fragment (Fig. 9).
The peroneal tendons are repaired after the osteotomy has been
completed and the tendons have been carefully inspected. In our
experience, the peroneus longus tendon is typically more normal
in appearance than the peroneus brevis tendon. Direct repair, or
side-to-side anastomosis of the longus and brevis tendons, is then
undertaken, depending on the severity of the tendon disease. We
have also found that a side-to-side anastomosis is most appropriate in
the presence of extensive tendon degeneration that requires
substantial debridement with an attempt to preserve the best parts of
both tendons. Furthermore, it has been our experience that debulking
of abnormally thick tendons reduces the risk of recurrent or future
peroneal subluxation. Care should also be taken to use a suture
technique that buries the suture material.
For a exible cavus foot deformity with a plantarexed rst ray,
transfer of the peroneus longus to the brevis insertion at the fth
metatarsal base is recommended. This entails sectioning the peroneus
longus tendon just distally to the longus/brevis anastomosis. This
technique allows elevation of the rst ray, which can further reduce
cavus deformation while maintaining full eversion strength (Fig. 10).
The goal of peroneal tendon repair and transfer is to create 1 good
tendon out of 2 badly damaged tendons. The distal, cut end of the
peroneus longus tendon remains in the plantar aspect of the foot as it

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Fig. 12. Radiographic examination. Preoperative and postoperative lateral radiographs


demonstrating results of Dwyer heel osteotomy, peroneal tendon repair with peroneal
longus to brevis tendon transfer, and, in this patient, dorsiexory metatarsal osteotomy.
Note, improvement of Mearys line and maintenance of normal-looking calcaneus despite
wedge osteotomy.

traverses the peroneal tunnel en route to the plantar aspect of the rst
ray. We make no attempt to reattach or repair this segment of the
tendon. Over time, we believe that this derelict portion of the peroneus
longus tendon becomes incarcerated in the tendon sheath and eventually functions as another plantar ligament. After completion of the
peroneus longus to brevis transfer, the medial arch is inspected and
consideration given to undertaking dorsiexory base wedge osteotomy of the rst metatarsal if residual plantarexion persists (Fig. 11).
Discussion
The surgical recommendations and images we have described in
this brief report are intended to highlight the rationale for, and
execution of, our preferred methods for combined Dwyer calcaneal

Fig. 13. Postoperative clinical appearance showing typical postoperative result at 10


weeks. Right foot was the operated foot. Note, improved resting calcaneal stance position
compared with untreated left foot.

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T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery 51 (2012) 135140

osteotomy and peroneal tendon repair in patients with peroneal


pathology complicated by pes cavovarus deformity. Our report is not
meant to provide the results of a cohort study. We have found this
combination of procedures to be useful, and a comparison of the
preoperative and postoperative foot radiographs typically reveals
substantial improvement in the structure of the foot (Fig. 12). Similarly, inspection of the postoperative clinical appearance of the
operated foot typically reveals an improved calcaneal stance position
(Fig. 13). Although we fully appreciate that radiographic and visual
changes in the appearance of the structure of the foot do not always
correlate with clinical satisfaction, we believe such changes are
associated with subjective clinical improvement in foot-related
quality of life. Furthermore, we believe that correction of cavus foot
deformity in patients with peroneal tendon pathology reinforces the
tendon repair and decreases the likelihood of recurrent tendon
pathology.
It is interesting to note that this same topic was recently discussed by Maskill et al (5), who described a treatment algorithm to
correct the subtle cavovarus foot. The algorithm included the use of
a lateral displacement calcaneal osteotomy, peroneus longus to
brevis tendon transfer, dorsiexory rst metatarsal osteotomy, and
Achilles tendon lengthening. In addition, Maskill et al (5) emphasized that treatment algorithms for the subtle cavovarus foot have
been described in the published data less often than data related to
planovalgus deformity. They believed that more attention should
be given to this pathology (5). The surgical treatment algorithm
proposed by Maskill et al (5) parallels the protocol we have used for
years to treat this complex disorder. Transfer of the peroneus longus to brevis tendon is commonly performed at our institution for
pes cavus deformities with concomitant peroneal tendon

pathology. In our experience, moreover, we have not seen


complications from the release of the peroneus longus tendon
distal to the anastomosis because the procedure is used in patients
with plantarexed rst metatarsals and cavus foot deformity,
which is not associated with rst ray hypermobility. Mild correction is noted at the time of the tendon release without progressive
drift or elevation over time. We believe the distal cut end of the
peroneus longus tendon scars into the tissue and eventually acts as
another plantar ligament.
In conclusion, it was our goal to describe a surgical technique that
produces consistent results when adding a Dwyer calcaneal osteotomy to the repair of peroneal tendon pathology. Furthermore, it is our
hope that this combined technique will improve the outcomes and
reduce complications when repairing this common but complex foot
deformity. A need remains for meaningful prospective cohort studies
and randomized controlled trials focusing on the use of these
procedures for the surgical treatment of the combination of pes cavovarus and peroneal tendon pathology.
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