Z-Osteotomy for Varus Heel

Indications

Indications Pitfalls

If an underlying neurologic disease is suspected, a neurologic assessment should be considered before surgery is performed.

Indications Controversies

Consider a dorsiflexion osteotomy of the metatarsal if the hindfoot varus is due to the plantar flexed first ray.
Consider peroneus longus to brevis transfer in case of an excessively pronated forefoot.

Analyze the patient’s gait and assess the entire alignment of the lower extremity ( Fig. 35.1 ).
Perform a lateral Coleman block test to differentiate between a forefoot induced (flexible) and a true (rigid) hindfoot varus deformity.
Ask the patient for lateral giving way or instability when walking.
While the patient is sitting with free-hanging feet, perform the anterior drawer test and talar tilt test to assess ankle joint stability. Furthermore, assess the inversion/eversion force (function of posterior tibial and peroneal muscles) and subtalar range of motion.
Weight-bearing plane radiographs (anteroposterior, lateral, dorsoplantar, and Saltzman views) should be obtained ( Fig. 35.2 ).
To analyze the deformity, (weight-bearing) computed tomography (CT) scans can also be performed.

Treatment Options

Conservative treatment (i.e., pain medication, shoe modification, orthoses) should always be considered before surgery is performed.
If brace management is chosen, a short-leg ankle foot orthosis with an outside (varus correcting) T-strap is recommended. Stretching of the heel cord and the plantar fascia has also shown to be useful.

The lateral dorsal cutaneous branch of the sural nerve proceeds on the lateral aspect of the calcaneus. The peroneal tendons lie retromalleolar and can be damaged during the skin incision.
Care should be taken not to compromise the medial soft-tissue structures. The medial neurovascular bundle lies next to the posteromedial corner.

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

If you are a member. Log in here