Calcaneal Osteotomy Safe Zone to Prevent Neurological Damage: Fact or Fiction?

Wills, Bradley W.; Lee, Sung Ro; Hudson, Parke; Sahranavard, Bahman; Naranje, Sameer; Shah, Ashish

doi:10.1177/1938640018762556

Cited by 10 publications

(12 citation statements)

References 28 publications

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“…12 Respecting the anatomic landmarks, injury of the sural, medial plantar, and lateral plantar nerves was avoided. 12 In contrast, Wills et al found no significant difference in nerve injury between osteotomies performed inside or outside the “safe zone.” 18 However, in the present study, the injury rate of the sural nerve was significantly lower in the percutaneous group. The authors suggest that the “safe zone” only refers to the percutaneous technique of calcaneus osteotomy.…”

Section: Discussioncontrasting

confidence: 67%

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Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

et al. 2018

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Background: Calcaneal osteotomies are often required in the correction of hindfoot deformities. The traditional open techniques, which include a lateral or oblique incision, are occasionally associated with wound healing problems and neurovascular injury. Methods: A total of 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. Fifty-eight patients were operated using an open incision technique and 64 patients (66 feet) using a percutaneous technique. Clinical and radiologic assessments were performed preoperatively, at 6 weeks, and 1 year postoperatively. Results: The American Orthopaedic Foot & Ankle Society scale scores and visual analog scale pain scores improved in both groups postoperatively. The difference between the groups was not significant. The results of the radiologic measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in either group. The comparison of both groups showed a significantly lower risk for wound healing problems in the percutaneous group. The hospitalization time was significantly shorter in the percutaneous group. Conclusion: Because of the excellent results with the percutaneous calcaneal osteotomy, the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy, especially patients at high risk for wound healing problems. Level of Evidence: Level III, comparative series.

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Section: Discussioncontrasting

confidence: 67%

“…Wills et al presented results regardless of the osteotomy technique. 18 Wound healing problems after calcaneal osteotomy via the open approach are common, up to 28% in the literature. 1,6,7 In our study, 9 patients (15.5%) with open calcaneus osteotomy had wound healing problems and 6 (10.3%) of them had to be revised.…”

Section: Discussionmentioning

confidence: 99%

Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

et al. 2018

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“…These authors concluded that the safety zone comprises the area formed on a lateral ankle x-ray by a line connecting the posterosuperior apex of the calcaneal tuberosity and the origin of the plantar fascia, and a line 11.2 mm anterior and parallel to it [7]. In contrast to that study, Wills et al found identical neurological injury rates between osteotomies performed inside and outside the "safety zone" [1]. As with Wills et al, we also found no significant difference between the occurrence of neurological injuries and the performance of the osteotomy inside or outside the "safety zone" (p = 0.163).…”

Section: Discussionmentioning

confidence: 94%

“…Calcaneal osteotomy is a procedure performed in routine clinical practice, its main objective is to re-establish the mechanical and load-bearing axis of the foot and ankle, demonstrating good and excellent results in the medium and long term [ 1 , 2 ]. Historically, potential complications associated with this surgery include surgical wound healing problems, infection, discomfort from the osteosynthesis material, over-/under-correction of the deformity, subtalar osteoarthritis, and iatrogenic fractures [ 1 , 3 , 4 ].…”

Section: Introductionmentioning

confidence: 99%

“…The incidence of peripheral neurological injury after calcaneal osteotomy reported in the literature is low and often described as occasional [ 5 , 6 ]. Lateral nerve structures, such as the sural nerve and lateral calcaneal nerve, are at risk in the lateral approach, while medial structures, such as the posterior tibial nerve and its branches, may be at risk when completing the osteotomy on the medial wall, or when performing the mobile segment displacement to correct the deformity [ 1 , 7 ].…”

Section: Introductionmentioning

confidence: 99%

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Neurological Injuries after Calcaneal Osteotomies Are Underdiagnosed

González-Martín

Herrera-Pérez

Ojeda-Jiménez

et al. 2021

JCM

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The incidence of peripheral neurological injuries related to calcaneal osteotomies reported in the literature is low and often described as occasional. The main objective of this study is to determine the incidence of neurological injuries after calcaneal osteotomies and identify which nerve structures are most affected. This retrospective work included 69 patients. Medical records, surgical protocols, and radiographs were analyzed. All patients were summoned to perform current functional tests (EFAS score and SF-12), and a thorough physical examination was performed systematically and bilaterally. The total incidence of neurological injuries was 43.5% (30/69). The percentage of neurapraxias (transient injuries) was 8.7%, while 34.8% of patients presented neurological sequelae (permanent injuries). The most injured nerve or branch was, in decreasing order: sural nerve, medial plantar branch, lateral plantar branch and medial calcaneal branch. Following the so-called “safe zone” clearly decreases the incidence of sural nerve injury (p = 0.035). No significant differences were found between osteotomy site, number of screws, and type of closure and increased neurological injuries. No significant differences were found in the functional tests between the different techniques, nor between patients who presented neurological injuries and those who did not. Neurological injuries after calcaneal osteotomies are underdiagnosed and the incidence is higher than previously reported (43.5%). Such injuries mostly go unnoticed and have no implications in the functional results and patients’ satisfaction.

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“Safe incision” in calcaneal sliding osteotomies reduces the incidence of sural nerve injury

González-Martín

Herrera-Pérez

Ojeda-Jiménez

et al. 2021

International Orthopaedics (SICOT)

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Purpose The purpose of this study was to demonstrate whether application of the so-called safe incision when performing calcaneal sliding osteotomies reduces the risk of sural nerve injury. Methods Patients who underwent either medial or lateral sliding calcaneal osteotomies between 2010 and 2018 were analysed retrospectively. A thorough neurological examination was performed, and the location of the surgical wound and the type of wound closure were recorded. The European Foot and Ankle Surgery (EFAS) score and 12-item Short Form Survey (SF-12) were also documented. Results A total of 57 patients were included, of which 20 (35.1%) had a sural nerve injury. Five patients had a neurapraxia (8.8%), while 15 patients had a permanent injury (26.3%). Respecting the "safe incision" decreased sural nerve injury (p = 0.02). The type of osteotomy and closure was not significant. No significant differences were found in the functional tests between the different techniques, or between patients who presented sural nerve injury and those who did not. Conclusion Sural nerve injury after calcaneal sliding osteotomies is higher than previously reported in the scientific literature, with an incidence of 35.1% (20/57 patients). Respecting the so-called safe zone (oblique incision that runs through the point that is > 1/3 of the distance from the tip of the lateral malleolus to the posteroinferior margin of the calcaneus) clearly decreases the incidence of sural nerve injury. Finally, the majority of patients remained asymptomatic despite the neurological injury.

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Calcaneal Osteotomy Safe Zone to Prevent Neurological Damage: Fact or Fiction?

Abstract: Level III: Retrospective comparative study.

Cited by 10 publications

References 28 publications

Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

Neurological Injuries after Calcaneal Osteotomies Are Underdiagnosed

“Safe incision” in calcaneal sliding osteotomies reduces the incidence of sural nerve injury

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