Medically Reviewed | Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle, Michigan
Quick Answer:
Quick Answer: Calcaneal osteotomies are bone-cutting procedures that realign the hindfoot to correct the valgus (outward tilting) and forefoot abduction of adult flatfoot deformity — most commonly performed as part of the Stage II PTTD / adult acquired flatfoot reconstruction. Two primary osteotomy types are used: the medializing calcaneal osteotomy (MCO) translates the calcaneal tuberosity medially to shift the weight-bearing axis under the hindfoot, effectively reducing hindfoot valgus and medial column overload; the Evans procedure (lateral column lengthening calcaneal osteotomy) opens a wedge at the calcaneal anterior process to lengthen the lateral column and correct the forefoot abduction (‘too many toes sign’). Most flatfoot reconstructions use the MCO; Evans osteotomy is added when forefoot abduction exceeds 30% on radiographic talonavicular coverage angle. Both procedures are combined with tendon and ligament procedures (FDL transfer, spring ligament repair) for comprehensive reconstruction. Recovery requires 6–8 weeks non-weight-bearing followed by 3–4 months of rehabilitation.
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Calcaneal osteotomies — surgical realignment of the heel bone — are the cornerstone bony correction procedure in adult flatfoot reconstruction. Without addressing the hindfoot valgus deformity that drives every aspect of the flatfoot posture, soft tissue procedures (FDL tendon transfer, spring ligament repair) will fail over time because they are mechanically overloaded by an uncorrected bony deformity. Dr. Biernacki at Balance Foot & Ankle integrates calcaneal osteotomy into a comprehensive flatfoot reconstruction strategy.
The Medializing Calcaneal Osteotomy (MCO)
The medializing calcaneal osteotomy — also called the Koutsogiannis procedure — is the most commonly performed calcaneal osteotomy in adult flatfoot reconstruction. A transverse osteotomy through the calcaneal tuberosity, approximately 1.5 cm proximal to the posterior tuber, allows the tuberosity fragment to be translated medially 8–10mm, placing the Achilles tendon’s line of action directly under the tibial mechanical axis. This effectively converts a hindfoot-valgus moment into a more neutral or slight varus position, reducing stress on the medial column and on the posterior tibial tendon/spring ligament repair. Fixation: one or two large cancellous screws driven from posterior to anterior in the heel. The patient is non-weight-bearing for 6–8 weeks until radiographic healing is confirmed.
Evans Lateral Column Lengthening
When the flatfoot deformity has significant forefoot abduction — the ‘too many toes’ sign with forefoot abducted beyond the heel by >3 toes, talonavicular coverage angle >30° — an Evans osteotomy (lateral column lengthening) is added to the reconstruction. The calcaneocuboid joint is identified; an opening wedge osteotomy is made at the anterior process of the calcaneus, and a tricortical iliac crest or allograft bone wedge is inserted to lengthen the lateral column by 8–12mm. This lengthening pushes the forefoot into adduction, correcting the ‘too many toes’ posture and improving talonavicular coverage. Evans osteotomy requires careful planning — overlengthening creates lateral column overload, causing calcaneocuboid joint pain and lateral column stress fractures.
Surgical Planning and Radiographic Assessment
Dr. Biernacki performs comprehensive weight-bearing radiographic assessment before planning any flatfoot reconstruction: AP foot: talonavicular coverage angle (normal <7°; >30° indicates Evans osteotomy); 1st/2nd metatarsal base angle; lateral foot: Meary’s angle (talo-first metatarsal angle; normal 0°; >4° indicates medial column sag requiring correction); calcaneal pitch angle (normal >18°); AP ankle: tibiotalar angle (Stage IV valgus ankle detection); hindfoot alignment view: Saltzman view for true hindfoot valgus measurement. Simulated correction on radiograph allows determination of MCO translation magnitude and Evans wedge size needed. CT scanning is added for complex or revision cases and for patients with subtalar or midfoot arthrosis requiring concurrent or alternative procedures.
Recovery and Rehabilitation
After calcaneal osteotomy (with concurrent soft tissue procedures), recovery follows a structured protocol: 0–6 weeks: non-weight-bearing cast; 6–8 weeks: X-ray confirmation of healing, transition to CAM boot, progressive protected weight-bearing; 3–4 months: transition to supportive shoes with custom orthotics; 6–12 months: progressive return to full activity. Physical therapy focuses on calf flexibility, peroneal and posterior tibial tendon strengthening, proprioception, and gait retraining. Patients require custom orthotics long-term — the reconstruction corrects deformity but the underlying ligamentous laxity and arch collapse tendency remains, requiring orthotic maintenance support.
Dr. Tom's Product Recommendations
Powerstep ProTech Control Orthotics — Post-Flatfoot Reconstruction
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Post-flatfoot reconstruction patients needing secondary arch support in casual or work shoes
Active Stage II-III PTTD pre-operatively — custom UCBL required for adequate control
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Maximum stability motion-control running shoe for post-flatfoot reconstruction patients returning to walking and running. Aggressive medial post reduces valgus loading on the reconstructed hindfoot.
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Post-calcaneal osteotomy patients returning to walking and running with corrected hindfoot alignment
Patients requiring custom therapeutic footwear for residual deformity accommodation
Disclosure: We earn a commission at no extra cost to you.
✅ Pros / Benefits
- MCO directly corrects hindfoot valgus — the mechanical precondition for durable soft tissue repair
- Evans osteotomy simultaneously corrects forefoot abduction for comprehensive reconstruction
- Well-validated procedure with 10+ year follow-up studies demonstrating maintained correction
❌ Cons / Risks
- 6–8 weeks non-weight-bearing required post-operatively
- Evans osteotomy carries risk of lateral column overload if overcorrected
- Long-term custom orthotic use required to maintain correction in ligamentously lax patients
Dr. Tom Biernacki’s Recommendation
Calcaneal osteotomy is the foundational procedure in my flatfoot reconstruction practice. I tell patients: the tendon transfer and ligament repair are the ‘building,’ but the osteotomy is the ‘foundation.’ Without the bony realignment, the soft tissue repairs are fighting against a deforming force with every step. The technical challenge is getting the right amount of translation — enough to correct the valgus, not so much that you overcorrect or create lateral overload. Careful preoperative planning with simulated radiographic correction is essential before entering the OR.
— Dr. Tom Biernacki, DPM | Board-Certified Podiatric Surgeon | Balance Foot & Ankle
Frequently Asked Questions
What is a calcaneal osteotomy and why is it needed for flatfoot?
A calcaneal osteotomy cuts through the heel bone to reposition it — correcting the hindfoot valgus (outward tipping) that drives the collapse of the medial arch. Without this bony correction, the soft tissue procedures (tendon transfers, ligament repairs) are mechanically overloaded and fail earlier. The osteotomy creates the mechanical environment in which the soft tissue repairs can work effectively.
Will I have screws in my heel after a calcaneal osteotomy?
Yes — one or two large screws are used to hold the cut calcaneal tuberosity in its new medial position until the bone heals (approximately 6–8 weeks). Most patients leave the hardware in permanently — screws are generally only removed if they cause symptoms (prominent screw head pain) after healing.
Can I walk after calcaneal osteotomy?
Not immediately — 6–8 weeks of non-weight-bearing (crutches, knee scooter, or wheelchair) are required for the osteotomy to heal before weight can be applied. Progressive weight-bearing in a boot begins after radiographic evidence of healing. Full return to walking and daily activity: typically 4–6 months after surgery.
Is flatfoot surgery the same as bunion surgery?
No — they are completely different procedures addressing different deformities. Bunion surgery corrects the first metatarsal deviation. Flatfoot reconstruction addresses posterior tibial tendon dysfunction, spring ligament failure, and hindfoot valgus with osteotomies and tendon/ligament procedures. They can be combined in carefully selected patients, but are typically addressed separately due to rehabilitation complexity.
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Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)
- Hallux Valgus (Bunions): Evaluation and Management (PubMed)
- Bunions (Mayo Clinic)