The Journal of Foot & Ankle Surgery 54 (2015) 478482

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Case Reports and Series

Double Calcaneal Osteotomy With Percutaneous Steinmann Pin

Fixation as Part of Treatment for Flexible Flatfoot Deformity:
A Review of Consecutive Cases Highlighting Our Experience
With Pin Fixation
Troy J. Boffeli, DPM, FACFAS 1, Kyle W. Abben, DPM, AACFAS 2
1
2

Director, Foot and Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education and Research, St Paul, MN
Chief Resident, Department of Foot and Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research, St Paul, MN

a r t i c l e i n f o

a b s t r a c t

Level of Clinical Evidence: 4

Surgical correction of exible atfoot deformity and posterior tibial tendon dysfunction has been extensively
reported in published studies. When appropriate, calcaneal osteotomies for atfoot correction have been a
favorite of foot and ankle surgeons because of the corrective power achieved without the need to fuse any
rearfoot joints. The medial displacement calcaneal osteotomy and Evans calcaneal osteotomy, together termed
the double calcaneal osteotomy, have been reported several times by various investigators with a wide variety
of xation options. We undertook an institutional review board-approved retrospective review of 9 consecutive patients (11 feet), who had undergone double calcaneal osteotomy with 2 percutaneous Steinmann pin
xation for the correction of exible atfoot deformity, with or without posterior tibial tendon dysfunction. All
patients had radiographic evidence of bone healing of the posterior calcaneal osteotomy and incorporation of
the Evans osteotomy bone graft at 6 weeks and demonstrated clinical healing at 6 weeks. All patients had 2
percutaneous Steinmann pins placed through both osteotomies, and these were removed an average of 6
weeks postoperatively. No patient developed pin site complications. The only complication noted was sural
neuritis, which was likely incision related. No patients had delayed union or nonunion, and we did not identify
any graft shifting postoperatively. The present retrospective series highlights our experience with 2 percutaneous Steinmann pin xation, demonstrating equal or better results than many previous published xation
methods for double calcaneal osteotomy. It is cost-effective and minimizes the potential risk of iatrogenic
Achilles pathologic features associated with screw xation.
2015 by the American College of Foot and Ankle Surgeons. All rights reserved.

Keywords:
Achilles tendon
calcaneus
Evans osteotomy
posterior tibial tendon dysfunction
sural nerve

Surgical correction of exible atfoot deformity and posterior

tibial tendon dysfunction has been extensively reported in published
studies. When appropriate, calcaneal osteotomies for atfoot correction have long been a favorite of foot and ankle surgeons owing to the
corrective power achieved without the need for midfoot or hindfoot
joint fusion. Koutsogiannis (1) described a medial displacement
posterior calcaneal osteotomy that was intended to bring the
weightbearing portion of the heel back under the leg and medialize
the ground reactive forces. A wide variety of xation options have
been described for this osteotomy, all of which have had relatively
good results (1,37). Evans also described a calcaneal osteotomy, but

Financial Disclosure: None reported.

Conict of Interest: None reported.
Address correspondence to: Kyle W. Abben, DPM, AACFAS, Department of Foot and
Ankle Surgery, Regions Hospital/HealthPartners Institute for Education and Research,
640 Jackson Street, St Paul, MN 55101.
E-mail address: kyle.w.abben@healthpartners.com (K.W. Abben).

this time in the anterior process of the calcaneus using a bone graft to
achieve lateral column lengthening (2). Koutsogiannis (1) did not
xate the grafted osteotomy, which has remained common practice.
The combination of the anterior and posterior heel osteotomies is
widely known as the double calcaneal osteotomy.
Several investigators have advocated for some form of xation of
the Evans anterior calcaneal osteotomy to prevent graft displacement
(3,711). Before 2008, we did not routinely use xation of the Evans
anterior calcaneal osteotomy and have traditionally used percutaneous Steinmann pins for the posterior heel osteotomy. As trends
have moved toward xation of the Evans osteotomy, it was a natural
progression to simply advance the pins into the anterior calcaneus to
achieve stabilization of both osteotomies with 2 pins, thereby preventing rotation of either osteotomy. Pins have been used for decades
for xating the posterior heel osteotomy and advancing these pins
across the Evans anterior calcaneal osteotomy serves as insurance
against graft displacement and elevation of the anterior calcaneal
fragment. Cannulated screw systems offer a variety of options for the

1067-2516/$ - see front matter 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2014.04.017

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479

Fig. 1. Incision placement. (A) Separate incisions are used for the medial displacement posterior calcaneal osteotomy and Evans anterior calcaneal osteotomy. The sural nerve is typically
anterior to the posterior calcaneal incision and inferior to the anterior calcaneal incision. The dashed lines serve as approximations of the typical nerve location of the sural and intermediate dorsal cutaneous nerves. (B) We typically lay a Kirschner wire over the skin using imaging guidance to ensure our posterior incision is in the ideal location. Proper placement of
the incision allows minimal dissection.

size and length of the screw; however, placement of the drill and
large-diameter screw through the Achilles tendon insertion in the
posterior calcaneus is less than optimal. Furthermore, a large screw
through the center of the graft is less than desirable. In contrast, we
are able to space the 2 pins apart from each other within the graft.
Plate xation requires more extensive dissection, adds cost, and can
require a second operation for removal.
We present a retrospective study of 9 consecutive patients (11 feet)
who had undergone a double calcaneal osteotomy as part of treatment of exible atfoot deformity, with or without posterior tibial
tendon dysfunction. Our typical surgical plan for patients with exible
atfoot deformity has consisted of gastrocnemius recession, double
calcaneal osteotomy, and Cotton midfoot osteotomy. However, the
focus of the present study was to highlight our results with modied 2
Steinmann pin xation of the double calcaneal osteotomy.

Patients and Methods

After institutional review board approval, we performed a retrospective analysis of consecutive patients who had undergone double
calcaneal osteotomies that were xated with 2 percutaneous Steinmann pins from June 2008 to July 2013. The inclusion criteria for the
present study were 2 percutaneous Steinmann pin xation and
follow-up of at least 10 weeks with appropriate interval postoperative radiographs. Patients with any other form of double
calcaneal osteotomy xation were excluded. The senior author (T.J.B.)
performed all procedures. Both investigators evaluated the radiographs to determine the interval to radiographic healing, which was
dened as radiographic evidence of bone formation across the

osteotomies. Clinical healing was determined by an absence of pain

at the surgical sites. The other data collected included age, gender,
tobacco use at the time of procedure, chronic medical comorbidities,
postoperative complications, and follow-up period (in months).

Surgical Technique
The procedures are performed with the patient in the supine position under general anesthesia with a popliteal block. Separate incisions are used for the medial displacement posterior calcaneal
osteotomy and the Evans anterior calcaneal osteotomy (Fig. 1A). The
sural nerve is typically anterior to the posterior calcaneal incision and
inferior to the anterior calcaneal incision. We typically lay a Kirschner
wire over the skin under imaging to ensure our posterior incision is in
the ideal location (Fig. 1B). The posterior incision is then carried down
to the bone as we are posterior to the sural nerve. We try to minimize
the periosteal dissection and only dissect where the osteotomy will be
made. A Crego elevator is then used to free up the dorsal and plantar
regions of the osteotomy of the calcaneus. The osteotomy is made
with a standard sagittal saw, with the saw blade marked at 3 cm with
a strip of tape to help improve depth perception and ensure the
medial neurovascular structures are not violated. A long osteotomy
guide is typically used to ensure the osteotomy is created in the same
plane all the way through (Fig. 2). Next, a lamina spreader without
teeth is introduced to the osteotomy to stretch the soft tissues to ease
medial displacement of the posterior calcaneal tuber. The calcaneus is
marked to ensure no dorsal or plantar displacement on translation of
the posterior calcaneal tuber, because the pull of the Achilles tendon
tends to displace the posterior tuber superiorly (Fig. 3).

Fig. 2. Osteotomy guide technique. (A) A long osteotomy guide and guide pin are typically used to ensure that the osteotomy is created in the same plane all the way through. (B and C)
Imaging can ensure that the osteotomy guide is at the proper angle and anterior to the Achilles insertion and plantar fascia origin.

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Fig. 3. (A) The calcaneus should be marked to ensure no dorsal or plantar displacement on translation of the posterior calcaneal tuber. (B) The pull of the Achilles tendon will tend to displace
the posterior tuber superiorly during medial displacement. Marking a line across the osteotomy will ensure that no dorsal or plantar displacement occurs before advancement of xation.

Then, the anterior calcaneal incision is made at the inferior border

of the sinus tarsi in preparation for the Evans osteotomy. The
trapezoidal-shaped allogenic iliac crest bone graft is fashioned on the
back table. A Crego elevator is used to free the plantar soft tissue
structures. Care is taken during deep dissection not to disrupt the
calcaneocuboid joint ligaments, because these help stabilize the
anterior process of the calcaneus once the Evans osteotomy has been
completed. The peroneal tendons are also retracted. Next, a guide pin
is inserted almost parallel with the calcaneocuboid joint and
approximately 1.5 cm proximal to the joint (Fig. 4). The osteotomy is
made using a sagittal saw, and the medial cortex is not left intact.
After creation of the Evans osteotomy, a 2.0 Steinmann pin is placed
from the posterior aspect of the calcaneus and advanced into the
posterior calcaneal osteotomy. We watch the pin advance into the
osteotomy and then back it up slightly. This pin then serves as a
joystick to aid in medial displacement of the posterior calcaneal
tuber (Fig. 5). Next, with the forefoot plantar exed and distracting the

posterior tuber with the joystick, the posterior tuber is displaced

medially approximately 1 cm and the 2 lines on the lateral aspect of
the calcaneus that we drew are lined up. The Steinmann pin is
advanced across the posterior osteotomy and advanced until it is seen
coming through the Evans osteotomy site. We aim to have the pin
enter near the midportion of the osteotomy. We conrm placement
under imaging, and, once we are satised, a second Steinmann pin is
placed superior to the rst pin, which is visualized as it enters the
Evans anterior osteotomy site. Once both pins are visualized and we
are happy with their placement across the future graft site, the pins
are retracted a couple millimeters below the bone surface, and the
allogenic bone graft wedge is inserted. Once proper graft placement
and deformity reduction is conrmed with imaging and clinical examination, the 2 Steinmann pins are advanced distally into the subchondral bone of the anterior calcaneus. This is typically done under
imaging to ensure no violation of the calcaneocuboid joint has
occurred (Fig. 6). The pins are then bent, cut, and rotated with the
ends toward each other and overlapping (Fig. 7A and 7B). Steri-Strips
(NexCare, 3M, St Paul, MN) are then wrapped around the bent
portions of the pins, holding them together to prevent rotation or
loosening. This technique prevents the pins from working loose
before removal at 6 weeks postoperatively. Standard closure is then
performed, and the patient is placed in a well-padded posterior splint.
They are kept nonweight bearing for 6 weeks. No pin care is done
postoperatively.
Results
Nine patients (11 feet) were included in the present study (4
males and 5 females). The average age was 37.55 (range 12 to 70)
years. All 11 feet demonstrated clinical and radiographic healing at
the 6-week postoperative visit. Good incorporation of the bone graft
was seen, with no evidence of displacement in all 11 feet. All patients
had both pins removed 6 weeks after surgery, and none had to be
removed prematurely because of loosening. One patient had a history of pulmonary embolism; otherwise, all were free of chronic
medical conditions. No patients were active tobacco users at the
time of surgery. The only postoperative complication identied was
sural neuritis in 1 patient, but it did not require any intervention and
had resolved by the nal follow-up visit. This was most likely incision related. The average follow-up for this group of patients was
11.14 (range 2.5 to 32) months.

Fig. 4. Osteotomy guide pins for the Evans calcaneal osteotomy. Osteotomy guide pins are
placed from both the lateral-to-medial and dorsal-to-plantar directions approximately
1.5 cm proximal to the calcaneocuboid joint. The pins are placed close to parallel to the
calcaneocuboid joint in both planes. The osteotomy is created using a standard sagittal
saw following the lateral-to-medial guide pin to the medial cortex, which is approximately 3 cm.

Discussion
The double calcaneal osteotomy is a powerful and well-accepted
procedure for correction of exible atfoot deformity with or
without posterior tibial tendon dysfunction. Several xation options

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481

Fig. 5. Joystick placement for medial translation of the posterior calcaneal tuber. (A) Lateral radiograph of intraoperative placement of the Steinmann pin joystick. (B and C) A 2.0-mm
Steinmann pin is placed in the posterior aspect of the calcaneus and used as a joystick to aid in medial translation of the posterior tuber. We watch the pin advance into the osteotomy and
then back it up slightly. A second Kirschner wire can be placed through the posterior incision as a temporary stop once the posterior tuber has been displaced (optional).

have been previously reported for double calcaneal osteotomy (36).

In 2011, DiDomenico et al (3) reported a case study of using 2 cannulated screws, 1 xating only the calcaneal slide osteotomy. The
second cannulated screw had a long thread pattern to obtain
compression across the posterior osteotomy, and the threads proximal and distal to the anterior osteotomy prevented graft displacement and unwanted compression across the graft (3). Frankel et al (4)
published a case report of using 2 Steinmann pins for the posterior
osteotomy and no xation for the Evans osteotomy. The 2 pins were
removed at 7 weeks postoperatively, and the patient had returned to
regular shoe wear at 16 weeks postoperatively (4). Other published
xation techniques have included Kirschner wires and external xation (5,6).
There is debate regarding whether xation is needed for the Evans
osteotomy. A wide range of xation options for the Evans calcaneal

osteotomy has been previously published, including no xation, plate

xation, and absorbable bone pins (810). In their 2012 systematic
review, Prissel and Roukis (12) found the nonunion rate to be 1.4%
with the unxated, isolated Evans calcaneal osteotomy. However, we
have typically not performed this as an isolated procedure, and previous published reports have demonstrated the ability of the bone
graft or anterior calcaneal process to migrate postoperatively. In their
2011 study, Dunn and Meyer (11) concluded in their retrospective
radiographic analysis of the Evans calcaneal osteotomy that the
anterior process of the calcaneus does displace dorsally in the immediate postoperative period, although this was noted to largely
resolve to statistically insignicant levels at the nal long-term
follow-up examination. They recommended a future study correlating the radiographic ndings such as theirs with the clinical outcomes (11). Dayton et al (10) recommended using a locking plate for

Fig. 6. (AC) Advancement of the Steinmann pins for xation of the medial displacement and Evans calcaneal osteotomies using imaging guidance. Both Steinmann pins cross each
calcaneal osteotomy. The pins should be visualized entering the posterior osteotomy before advancement to the anterior osteotomy to ensure proper positioning.

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Fig. 7. External pin management. (A and B) Once the pins have been advanced into the subchondral bone of the anterior calcaneus, they are bent, cut, and rotated, with the ends
overlapping. Two Steri-Strips are then wrapped around the pins, holding them together to prevent rotation. This prevents the pins from working loose during the 6 weeks they are in
place. (C) Typical clinical appearance of pin sites 6 weeks postoperatively. Patients do not require pin site care postoperatively, because the pins are not allowed to rotate and have been
placed in safe zones minimally affected by edema uctuation, resulting in less soft tissue irritation.

xation of the Evans calcaneal osteotomy to maintain correction and

reduce the incidence of anterior fragment displacement in the early
postoperative period.
Few studies have been reported on the complications associated
with various xation methods for the double calcaneal osteotomy,
especially regarding any Achilles tendon pathologic entities associated with posterior heel screw placement. This has been more related
to the dorsal point of posterior xation, because it would be ideal to
have a point of xation through the upper half of the osteotomy,
which would require placement through the distal Achilles tendon.
Although not widely reported, it seems that disrupting the insertional
bers of the Achilles tendon with the large drill, countersink, and
screw threads required for cannulated screw placement would be less
than ideal and could potentially have postoperative implications.
Monseir-LaClair et al (7) previously reported that 10 of 28 feet (35%) in
their study required removal of the calcaneal screw xation secondary to pain. Although speculative, it is intuitive that a smooth Steinmann pin placed through the Achilles tendon insertion would likely
cause minimal damage to the tendon itself. Another added benet of
using 2 percutaneous Steinmann pins is the cost-effectiveness
compared with any other reported xation method. They are significantly less expensive than any available cannulated or solid core
screw. They also can be removed at an ofce visit; thus, the concerns
regarding long-term hardware complications are negated. We had no
major complications in our study. One patient did develop sural
neuritis; however, this had resolved before the nal follow-up visit.
No patient had any loosening of the Steinmann pins or infection
postoperatively. We largely credit the lack of pins loosening to
advancing them into the subchondral bone of the anterior calcaneus
and to attaching the pins together with Steri-Strips (Nexcare, 3M) to
prevent rotation. We consider the tips of the toes and the posterior
heel be safe zones for percutaneous pin placement, because these
areas will generally not be affected by swelling. Other regions of the
foot and ankle are prone to uctuating edema, which can cause soft
tissue irritation around the pin, leading to pin loosening and/or
infection, which could require premature removal. By rotating the
pins and taping them together, we created stable pins, preventing pin
loosening and resulting in less soft tissue irritation. Furthermore, we
do not perform pin care, because it is not needed with stable pins
placed through soft tissue that is not prone to uctuating edema. All
pins were removed in the ofce an average of 6 weeks postoperatively. Fig. 7C demonstrates the typical appearance of the pin
sites 6 weeks after surgery. All patients healed of their double

calcaneal osteotomies uneventfully and had returned to regular shoes

at 10 weeks postoperatively.
The limitations of our study included the relatively small number
of patients in the study, although all were consecutive, decreasing
exclusion bias. Also, all procedures were performed by a single surgeon, which could also be seen as a benet, because this removes the
intersurgeon variability with procedure technique. We also had a
relatively short follow-up period, with an average of 11.14 months;
however, this was sufcient to determine the incidence of postoperative pin complications or osseous healing issues that have been
suggested to occur with the absence of xation past 6 weeks
postoperatively.
In conclusion, the present retrospective study of consecutive patients has demonstrated that 2 percutaneous Steinmann pins for
xation of the double calcaneal osteotomy is safe, reliable, and costeffective. Furthermore, no patient identied any insertional Achilles
tendon issues associated with pin placement with just longer than 11
months of follow-up. A prospective comparative study contrasting the
various xation techniques would be benecial and worth future
efforts.
References
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calcaneus. J Bone Joint Surg Br 53B:96100, 1971.
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4. Frankel JP, Turf RM, Kuzmicki LM. Double calcaneal osteotomy in the treatment of
posterior tibial tendon dysfunction. J Foot Ankle Surg 34:254261, 1995.
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