Calcaneal Lengthening Osteotomy Research Articles

Corrective Efficacy of Calcaneal Lengthening Osteotomy for Planovalgus Deformity in Cerebral Palsy Patients.

Introduction Planovalgus deformity is common in children with spastic cerebral palsy (CP), particularly spastic diplegia and spastic quadriplegia. It results from muscle imbalance over the immature foot skeleton, leading to hindfoot valgus, forefoot abduction, and joint subluxation. Surgical interventions, like calcaneal lengthening osteotomy (CLO), are frequently employed to correct this deformity, but objective guidelines for its use in CP patients are lacking. Material and methods This retrospective cohort study examined the efficacy of CLO in correcting plano valgus deformity in pediatric CP patients at the Pediatric Orthopedic Unit of Christian Medical College (CMC) in Vellore, India. Data from patient records and radiographs were collected, including demographics, pre- and postoperative angles, and surgical details. Statistical analysis was performed to assess changes in angles and associations with various factors. Results After the surgery, there was a notable enhancement in the calcaneal pitch, lateral talo-first metatarsal angle, and naviculocuboid overlap, as shown by the CLO results. However, tibiocalcaneal angles did not show significant changes. Associations were observed between age, Gross Motor Function Classification System (GMFCS) level, additional surgeries, and postoperative angle corrections. Conclusion CLO shows promise in correcting plano valgus deformity, with age, GMFCS level, and comorbidities influencing outcomes. Long-term follow-up is crucial to monitor correction durability. Specific radiographic angles provide insights into CLO's biomechanical effects, but study limitations warrant caution in interpretation. CLO effectively corrects plano valgus deformity in pediatric CP patients, with age, GMFCS level, and comorbidities influencing outcomes. Long-term follow-up and further research are needed to optimize management strategies and enhance understanding of surgical outcomes.

ALTERNATION OF THE 3D SUBTALAR JOINT ALIGNMENT AFTER INFRAMALLEOLAR OSTEOTOMY IN PROGRESSIVE COLLAPSING FLATFOOT DEFORMITY

A medializing calcaneal osteotomy (MCO) is one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the hind- and midfoot alignment after PCFD correction, the subtalar joint remained obscured by superposition on plain radiography. Therefore, we aimed to perform a 3D measurement assessment of the hind- and subtalar joint alignment pre- compared to post-operatively using weightbearing CT (WBCT) imaging.Fifteen patients with a mean age of 44,3 years (range 17-65yrs) were retrospectively analyzed in a pre-post study design. Inclusion criteria consisted of PCFD deformity correct by MCO and imaged by WBCT. Exclusion criteria were patients who had concomitant midfoot fusions or hindfoot coalitions. Image data were used to generate 3D models and compute the hindfoot - and talocalcaneal angle as well as distance maps.Pre-operative radiographic parameters of the hindfoot and subtalar joint alignment improved significantly relative to the post-operative position (HA, MASa, and MACo). The post-operative talus showed significant inversion, abduction, and dorsiflexion of the talus (2.79° ±1.72, 1.32° ±1.98, 2.11°±1.47) compared to the pre-operative position. The talus shifted significantly different from 0 in the posterior and superior direction (0.62mm ±0.52 and 0.35mm ±0.32). The distance between the talus and calcaneum at the sinus tarsi increased significantly (0.64mm ±0.44).This study found pre-dominantly changes in the sagittal, axial and coronal plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings demonstrate the amount of alternation in the subtalar joint alignment that can be expected after MCO. However, further studies are needed to determine at what stage a calcaneal lengthening osteotomy or corrective arthrodesis is indicated to obtain a higher degree of subtalar joint alignment correction.

Is There a Benefit to Rigid Fixation in Calcaneal Lengthening Osteotomy in Painful Pediatric Idiopathic Flatfoot Deformity? Comparing Results of Kirschner Wire Versus Plate Fixation.

Flexible flatfoot (FF) is a common pediatric condition that is mostly asymptomatic, and surgical intervention is only considered when painful FF is refractory to conservative treatment. Calcaneal lengthening osteotomy (CLO) is one of the most commonly used procedures to address painful FF. Traditionally, Kirschner wires (K-wires) were used for fixation, but there has been a recent increase in the use of plates. We compared the clinical and radiographic outcomes of these 2 fixation methods. This single-center retrospective study included children aged 8 to 18 years with symptomatic FF that received CLO using K-wire or plate fixation. Primary outcomes include weight-bearing radiographic measurements and complications after surgery. Secondary outcomes included patient-reported outcomes. Statistical significance was held at 0.05. Among 102 feet (65 patients), 42 feet (41.2%) underwent K-wire and 60 feet (58.8%) underwent plate fixation. No differences in casting duration ( P =0.525) and time-to-radiographic healing ( P =0.17) were noted. Total complications were higher in the plate cohort (12 vs. 2, P =0.04) due to a higher rate of reoperations (16.7%) for hardware-related pain [10 vs. 0; odds ratio 17.74, 95% CI (1.01, 310.54), P <0.05], and infection rates were similar. Both interventions significantly improved ( P ≤ 0.001) aneteroposterior (AP) Talo-first metatarsal and calcaneal pitch angles. Irrespective of intervention, CLO significantly improved pain at 6 months and mobility scores at 12 months. Neither modality demonstrated superior pain or mobility scores at final follow-up. Both K-wire and plate fixations lead to similar radiographic and functional outcomes after CLO in painful, pediatric flatfeet. Compared with K-wire fixation, plates cause a 17.7-fold increased risk of reoperations for painful hardware, with 16.7% of plated cases requiring reoperation. Noting this, along with the higher costs associated with using plates, our study advocates for K-wire fixation for children undergoing CLO. Level III.

Risk Factors for Failure of Calcaneal Lengthening Osteotomy in Children and Adolescents With Planovalgus Foot Deformity: A Retrospective Study.

The calcaneal lengthening procedure (CLP) is a well-known surgical technique used for the correction of symptomatic planovalgus foot deformities. Literature shows a significant rate of relapse and undercorrection of the foot post-operatively. Factors determining the failure or success of CLP are still not well understood. The purpose of this retrospective study was to assess the most significant factors related to the failure of this procedure. A case-control retrospective study was conducted on 50 patients (80 feet) aged 12.4±2.5 years who underwent CLP. A clinical (demographic parameters, etiology, Gross Motor Function Classification System (GMFCS) level) and radiological evaluation were assessed preoperatively and repeated postoperatively at 56.5±32.5 months. Two methods of osteotomy bone fixation were studied: K-wires vs. eight-plate. Standing anteroposterior (AP) and lateral (L) radiographs were done, and the following radiographic parameters were measured: calcaneocuboid (CC) joint subluxation classified into normal, moderate, and severe (L); AP and L talo-first metatarsal (T1MT) angle; AP talonavicular (TN) coverage angle; AP and L talocalcaneal (TC) angle; calcaneal pitch (CP) angle; and L talo-horizontal (TH) angle. Mosca's criteria were used for clinical and radiological assessments. The association between demographic data, clinical and radiological results, and the variation between preoperative and postoperative angles were studied. The main risk factors affecting clinical results and CC joint subluxation were investigated (logistic regression and analysis of covariance (ANCOVA)). Satisfactory clinical results were associated with satisfactory radiological ones on Mosca's criteria (p<0.001). The use of an eight-platefor osteotomy fixation gave better results than K-wires (79% vs. 59%). Radiological angles were improved in both techniques postoperatively (increase of CP and L-TC and decrease of AP-T1MT, AP-TC, AP-TN, and L-T1MT, all p<0.05). Non-satisfactory clinical results were associated with a high GMFCS level, a low preoperative AP-TN coverage angle, and a low preoperative CP angle (R2=0.45). Both a young age and a low CP angle preoperatively were associated with CC subluxation (R2=0.31). The neurological status and the severity of the planovalgus foot deformity preoperatively were the main risk factors affecting clinical outcomes after CLP. However, young age and the severity of the deformity preoperatively were the main risk factors behind CC joint subluxation affecting CLP outcomes.

Tibialis anterior rerouting combined with calcaneal lengthening osteotomy as a single-stage reconstruction of symptomatic flexible flatfoot in children and adolescents

BackgroundSymptomatic flexible flatfoot in children and adolescents should be surgically managed only if conservative measures have failed. The aim of this study was to assess functional and radiological results of tibialis anterior rerouting combined with calcaneal lengthening osteotomy as s single-stage reconstruction of symptomatic flexible flatfoot.MethodsThe current study was a prospective study of patients with symptomatic flexible flatfoot treated by single-stage reconstruction in the form of tibialis anterior tendon rerouting combined with calcaneal lengthening osteotomy. The American Orthopaedic Foot and Ankle Society score (AOFAS) was utilized to evaluate the functional outcomes. The evaluated radiological parameters included the standing anteroposterior (AP) and lateral talo-first metatarsal angle, talar head coverage angle, and calcaneal pitch angle.Results The current study included 16 patients (28 feet) with a mean age of 11.6 ± 2.1 years. There was a statistically significant improvement in the mean AOFAS score from 51.6 ± 5.5 preoperatively to 85.3 ± 10.2 at final follow-up. Postoperatively, there was a statistically significant reduction in the mean AP talar head coverage angle from 13.6 ± 4.4° to 3.9 ± 3°, the mean AP talo-first metatarsal angle from 16.9 ± 4.4° to 4.5 ± 3.6°, and the mean lateral talo-first metatarsal angle from 19.2 ± 4.9° to 4.6 ± 3.2°, P < 0.001. Additionally, the mean calcaneal pitch angle increased significantly from 9.6 ± 1.9° to 23.8 ± 4.8°, P < 0.001. Superficial wound infection occurred in three feet and was treated adequately by dressing and antibiotics.Conclusion Symptomatic flexible flatfoot in children and adolescents can be treated with combined lateral column lengthening and tibialis anterior rerouting with satisfactory radiological and clinical outcomes.Level of evidence Level IV.

Efficacy of Hintermann calcaneal lengthening osteotomy for flexible flatfoot

Objective: To investigate the clinical efficacy of Hintermann osteotomy (H-LCL) for flexible flatfoot. Methods: A follow-up study. Clinical data of 30 patients with flexible flatfoot treated with H-LCL operation from January 2020 to December 2021 in Sports Medical Center of the First Affiliated Hospital of Army Medical University were retrospectively analyzed. There were 8 males and 22 females, with a mean age of (39.0±15.2) years. The mean time from symptom onset to the diagnosis［M（Q1，Q3）］was 24.0 (5.5, 102.0) months. The functional and imaging scores of the patients before and after the last follow-up were compared to evaluate the clinical efficacy of the operation. The functional scores included American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) of pain, pain interference (PI) and physical function (PF) index in Patient-Reported Outcomes Measurement Information System (PROMIS). And the imaging scores included Meary's angle, calcaneal pitch angle, calcaneal valgus angle and talonavicular coverage angle. Results: The mean operation time was (82.3±24.4) min, and the follow-up periods was (17.9±6.9) months. At the last follow-up, VAS of pain [M(Q1, Q3)] decreased from 5 (4, 6) to 2 (1, 2); PI decreased from 59.8±5.0 to 44.6±5.7; AOFAS increased from 65.2±10.0 to 85.8±3.3; PF increased from 50 (48.5,51.0) to 58.5 (54.0, 66.0); Meary's angle (antero-posterior image) decreased from 15.7° (10.1°, 29.2°) to 3.9° (2.6°, 5.3°); Meary's angle (lateral image) decreased from 13.5°±6.8° to 4.4°±2.6°; calcaneal pitch angle increased from 14.0°±3.3° to 18.6°±4.2°; calcaneal valgus angle decreased from 12.6°±7.3° to 4.3°±2.5°; and talonavicular coverage angle decreased from 20.9°±10.7° to 7.7°±5.2°. The up-mentioned parameters were all improved statistically significant at the last follow-up when compared with those before the operation (all P<0.05). Conclusion: H-LCL brings a significant improvement of clinical outcome scores and good radiological correction of flatfoot deformities in correcting flexible flatfoot, it conforms to the anatomical characteristics of the subtalar joint.

Changes in gait pattern and quality of life of adolescents with flexible flat foot after Calcaneal Lengthening Osteotomy

BackgroundCalcaneal Lengthening Osteotomy is a surgical technique to correct flexible flat foot deformities in patients who did not show any change in their symptoms after conservative treatment. In this study, the effects of CLO on the kinematic and kinetic changes of gait was analyzed and the clinical and quality of life improvements in children treated by CLO for moderate to severe symptomatic flexible flat foot deformities were assessed. MethodsParticipants were seven adolescents (13 feet) with symptomatic FFF who underwent during 2019–2022 and seven (10 feet) healthy children as control group. Three items were evaluated in each foot before and after surgery including: 1. Clinical examination 2.quality of life (using Pediatric Quality of Life Inventory version 4 questionnaire) 3. Gait analysis (Vicon motion systems, Oxford metrics Inc., UK). Also, the kinetic and kinematic analysis between patients and healthy groups were compared. ResultsKinematic results of control was significantly better than FFF group. Ankle range of motion(32.94 ± 13.39 compared to 32.94 ± 13.39,P-Value:0.01),foot progression angle (−9.26 ± 7.67 compared to −16.07 ± 9.00,P-Value:0.01),and internal rotation of ankle was higher in control group compared to FFF. FFF patients demonstrated improvement in kinematic results after CLO surgery. Foot progression angle was improved after surgery (−11.31 ± 6.07 compared to −16.19 ± 7.06, P-value:0.00), maximum plantar flexion decreased after CLO surgery due to achil tendon procedure during CLO surgery. Kinetic results of FFF patients showed significant increase in ankle Power in coronal and transverse plane, Also knee and hip power showed similar results.Quality of life parameters showed significant improve in all parameters (Physical,Social, emotional and school function), Also ADKE and ADKF improved after surgery. ConclusionCLO surgery significantly improved patients' quality of life of patients with symptomatic FFF. Also, kinetic results showed improvement in some parameters of gait results after CLO surgery. Thus, our study suggested CLO surgery as an excellent surgical option for symptomatic FFF.

Lateral calcaneal lengthening osteotomy versus subtalar arthroereisis in symptomatic flexible flat foot in children

Abstract Background Pediatric Flexible flat foot is the prevalent type of flat foot. Conservative measures are the first line of treatment. However, surgery may be required in some cases. Objective To compare outcomes of lateral calcaneal lengthening osteotomy versus subtalar arthroereisis for the pediatric flexible flat foot. Methods Calcaneal lengthening osteotomy was operated on 25 feet and subtalar arthroereisis was operated on 19 feet. Patients were evaluated preoperative and postoperative according to the American orthopedic foot and ankle society (AOFAS) ankle-hindfoot score, Meary’s angle and Talonavicular coverage angle. The follow-up duration was 18 months. Results Lateral calcaneal lengthening osteotomy showed better clinical and radiological outcome versus subtalar arthroereisis. In LCL group,American orthopedic foot and ankle society (AOFAS) ankle-hindfoot score (68.2 ± 1.45 preoperative to 98 ± 5 postoperative) and Talonavicular coverage angle (18.8 ± 5.6 preoperative to 3.96 ± 2.46 postoperative) improved versus SA group, the AFOAS (68.62 ± 2.93 preoperative to 96.55 ± 3.48 postoperative) and Talonavicular coverage angle (23.98 ± 5.88 preoperative to 5.94 ± 4.59 postoperative) respectively. Significant difference was found postoperative between the two groups regarding Meary’s angle, in LCL group improved from 17 ± 5.04 preoperative to 4.44 ± 1.66 postoperative while in SA group the angle improved from 23.62 ± 7.74 preoperative to 2.98 ± 1.27 postoperative. Conclusion Calcaneal lengthening osteotomy achieved more improvement in AOFAS score than subtalar arthroereisis group with better clinical and radiological outcomes but subtalar arthroereisis is less invasive procedure with early weight bearing and mobilization.

Bilateral talocalcaneal tarsal coalition with flatfeet treated with single-stage coalition resection and calcaneal lengthening osteotomy: A case report

A coalition is a bridge connecting osseous structures. Tarsal coalitions typically involve talocalcaneal and calcaneonavicular joints. As a result, patients might present with pain and/or rigid flatfoot deformity. We outline a case of bilateral middle facets talocalcaneal tarsal coalition with rigid flatfeet who was treated with resection combined with flatfoot reconstruction. the patient was an 11-year-old Saudi girl who had progressive bilateral flatfoot for which non-operative treatment failed. A single-stage middle facet talocalcaneal coalition resection with concomitant Evans calcaneal lengthening osteotomy and gastrocnemius recession was performed. Postoperatively, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle midfoot score was measured, and the patient had a score of 90/100. The outcome was satisfactory, and the other foot was operated on 6 months later, with the same procedure and outcome (AOFAS: 90/100). Six years of follow-up showed no recurrence and a satisfactory lifestyle with no activity limitation. We aimed to highlight the AOFAS score 6 years after resecting the coalitions while reconstructing the foot in a single-staged procedure.

Calcaneal lengthening osteotomy in the management of idiopathic flatfoot in children: cCase series of twenty-one feet.

IntroductionFlatfoot is a frequent reason for consultation in pediatric orthopedics. The calcaneal lengthening osteotomy according to the EVANS technique is a therapeutic alternative. The objective of this work was to evaluate the short and medium term clinical and radiological results of calcaneal lengthening osteotomy in children with idiopathic flat foot valgus.MethodsThis study concerned 12 children and 15 ft treated surgically by calcaneal lengthening osteotomy by an orthopedic surgeon in a pediatric orthopedic surgery center. The evaluation of the results was clinical according AOFAS score and radiological.ResultsThe deformity was reducible in all of our patients. The mean preoperative AOFAS score was 61, postoperatively 90. The overall result was excellent in 11 cases (11 ft) and good in 4 cases. The postoperative radiological result was close to normal values.ConclusionCalcaneal lengthening osteotomy is a reliable and recommended technique for the correction of symptomatic idiopathic flatfoot.Level of evidence: IV, Case series.

Rare, But Existing Complications after Calcaneal lengthening osteotomy for the treatment of symptomatic planovalgus deformity in children and Adolescent

Purpose: Description and analysis of the rare, but existing complications from the application of calcaneal lengthening osteotomy for treatment of the symptomatic flatfoot deformity in children and adolescents.&#x0D; Materials and methods: The procedure of calcaneal lengthening osteotomy has been introduced at the University Orthopaedics Hospital „Prof. B. Boichev“in 1999. The study included 64 children or 92 cases, the average age being 11.61±1.90, and the youngest child being 7 years of age. The deformity is more often found in males, making up 44 or 68.75% of the cases. The females make up 20 of the cases, or more precisely 31.25%. We used angle X-ray measurements of the feet in AP and profile positioning, with a mandatory upright position of the pateints, to figure out the severity of the flatfoot deformity. When grading based on the subjective criteria, we used an instrument called Visual-Analogue-Scale Foot and Ankle (VAS FA). To grade the complications, we applied the clinically based Dindo-Clavien classification, used in orthopaedic surgery.&#x0D; Results: The average timing for an overall follow-up for all cases is 18.65± 8.29 months. A correction of the CIA appears in all cases that were operated. The average value of the angles at the time of diagnosis of the deformity, the average value was 13.07°, which has risen to 23.25° by the last follow-up session. When analyzing the changes in the MA (angle of Meary), we observed that the angle has decreased to 7.87° in the last follow-up session. The TNCA has decreased with an average of -8.272±5.27°, taking into consideration the high statistical reliability (p≤0.00). Even though we mark five cases of dorsal subluxation of the distal fragment, we have observed a complication from a degenerative process of the CC (calcaneo-cuboid) joint.

Risk Factors for Nonunion in Pediatric Lateral Column Lengthening (Mosca) Procedures

Category:HindfootIntroduction/Purpose:The Evans/Mosca procedure remains the most utilized extra-articular osteotomies for correction of pes planus. This desired lengthening is created by inserting a graft in the anterior aspect of the calcaneus through a complete transverse osteotomy. Failure of conservative methods, particularly for rigid pes planus, is a primary consideration for surgical management. Complications of the Evans procedure include delayed union, nonunion, malunion, subluxation of the calcaneocuboid joint, and persistent lateral column pain. Our study analyzes risk factors for development of non-union.Methods:After IRB approval 120 patients charts and 157 feet were analyzed for incidence of non-union which was defined by clinical and radiographic evidence of absence of union >6 months. Delayed union was diagnosed if there was clinical evidence of healing without complete union at >6 months. Exclusion criteria included age >18 and revision lateral column lengthening. Patients' medical records were reviewed for basic demographics, complications, and surgical technique.Results:The cohort consisted of 75 females (47.8%) and 82 males (52.2%). The median age was 12 with an interquartile range (IQR) of 3. A total of 6 patients (3.7%) had wound complications or nerve injury. Nonunion occurred in 7 of 157 feet (4.5%) with 2 of 157 feet (1.3%) experiencing delayed union. The median age for patients with nonunion was significantly higher than those who achieved union (13.2 (IQR 2.75) vs. 11.2 (IQR 3) respectively). The fixation construct used was associated with increased risk of nonunion. Patients with screw fixation had the highest rate of nonunion at 50% (2/2) compared to pin and/or staple fixation at 6.8% (5/73), no fixation at 4% (3/75), and plate fixation at 0% (0/2). Both delayed union patients were treated with ultrasound bone stimulation, both patients were able to achieve complete union. Revision was attempted in 5/7 nonunions with all operative patients achieving union.Conclusion:Our study analyzed risk factors for developing non-union in patients undergoing calcaneal lengthening osteotomy for pediatric pes planus. We found age at time of surgery and graft fixation method to be significant risk factors for development of non-union. Our study highlighted that those patients who had non-union was on average >2yrs older at time of surgery. Overall, lateral column lengthening is a well-tolerated procedure with a complication rate, including non-and delayed union, of 10.8%. Surgeons should be aware, in the largest cohort of pediatric Evans/Mosca procedures to date, patient age and type of fixation were associated with nonunion.

Evaluation of lateral column lengthening using autogenous fibular graft in the treatment of supple flat foot

Background: Treatment options of flat foot vary from using orthosis to arthrodesis and the surgical procedure varies from soft-tissue operations till bony osteotomies. We hypothesized that the clinical, functional, and radiological outcomes of lateral calcaneal lengthening osteotomy using fibular graft in the treatment of symptomatic flatfoot are satisfactory. Materials and Methods: A prospective study was conducted involving 25 feet of 25 patients who underwent lateral calcaneal lengthening due to symptomatic flexible flat foot. All patients underwent clinical and radiological evaluation preoperatively and postoperatively, American Orthopedic Foot and Ankle Society (AOFAS) hindfoot/ankle scoring preoperatively and postoperatively. All patients underwent osteotomy of the calcaneus using a saw, after a satisfactory correction of the deformity obtained, autogenous fibular graft was inserted in the osteotomy site, and tendon Achilles lengthening was performed. Results: In our study, we had 25 patients, the average age was 11.48 years. There were 15 girls and 10 boys. The average AOFAS preoperative score was 68.56 ± 5. A 3-month postoperative. The average score was 86.40 ± 3.65. A final AOFAS hindfoot/ankle score at the time of maximal follow-up (average 21 months; range, 6–36 months) had an average score of 95.19 ± 1. A final AOFAS hindfoot/ankle score at the time of maximal follow-up (average 21 months; range, 6–36 months). Conclusion: Isolated lateral column lengthening using autogenous fibular graft was found to provide significant correction of all components of the supple pes planovalgus and forefoot abduction deformity. Level of Evidence: Level IV.

Clinico-radiological factors predicting the failure risk of conservative management in moderate to severe pediatric idiopathic flexible flatfoot.

This study aimed to investigate the clinico-radiological factors of related future surgical treatment in patients with pediatric flexible flatfoot (FFF) who first visited the orthopedic clinic before the age of 10 years. Sixty-five patients diagnosed with moderate/severe idiopathic FFF deformity between the ages of 2-10 years were included. We developed prognostic models for the risk of the surgery during the follow-up period. Twenty (30.8%) patients required surgical treatment, and all of them underwent calcaneal lengthening osteotomy. Among them, 7 (10.8%) patients required concomitant Achilles-lengthening surgery. Unilateral involvement, older age, smaller calcaneal pitch angle, and higher talo-first metatarsal malalignment were considered high-risk factors for pediatric FFF surgery. Prognostic models identified three prognostic risk groups based on those factors, and survival curves revealed significant differences among the groups. Our prognostic models help predict the failure risk of conservative management of pediatric idiopathic FFF. Level of Evidence: Level III, prognostic study.

Calcaneal lengthening using ipsilateral fibula autograft in the treatment of symptomatic pes valgus in adolescents

BackgroundEvans calcaneal lengthening osteotomy is used to treat symptomatic flexible flatfoot when conservative treatment fails. Grafts such as autologous iliac bone grafts, allografts, and xenografts are implanted at the osteotomy site to lengthen the lateral column of the hindfoot. This study aimed to present the outcomes of an autologous mid-fibula bone graft used for calcaneal lengthening in symptomatic pes valgus in adolescents.MethodsWe retrospectively examined 23 ft of 13 adolescents who underwent surgery between July 2014 and January 2018. The radiological and clinical outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores) were assessed during a mean follow-up of 49.7 (range, 30.9–73.4) months. The mean distance of the lengthening site was measured to evaluate graft sinking or collapse. The Goldberg scoring system was used to determine the degree of union at the donor and recipient sites.ResultsThe calcaneal pitch and the anteroposterior and lateral talo-first metatarsal (Meary) angles showed significant correction, from 14.4 to 19.6 (p < 0.001), and from 14.5 to 4.6 (p < 0.001) and 13.5 to 8.5 (p < 0.001), respectively. The mean distance of the lengthening site showed no significant change (p = 0.203), suggesting no graft sinking or postoperative collapse. The lateral distal tibial angle showed no significant difference (p = 0.398), suggesting no postoperative ankle valgus changes. Healing of the recipient and donor sites occurred in 23 and 21 ft, respectively. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scores improved significantly, from 68.0 to 98.5 (p < 0.001).ConclusionsEvans calcaneal lengthening using an ipsilateral mid-fibula bone autograft resulted in significant improvement in clinical and radiological outcomes without ankle valgus deformity. Hence, it could be a treatment option for lateral column calcaneal lengthening in adolescents.

Calcaneal Lateral Column Lengthening Osteotomy for Symptomatic Flexible Flatfoot

Background: Existing methods of foot type classification based on foot morphology could be put into one of the 4 categories, including visual non-quantitative inspection, anthropometric values, footprint parameters and radiographic evaluation. Objective: The aim of the present study was to evaluate the clinical and functional outcome after calcaneal lateral column lengthening osteotomy in patients with symptomatic flexible flatfoot. Patient and Methods: This is clinical trial (pre-post intervention) included 18 patient with symptomatic flexible flatfoot who were admitted to Zagazig Orthopedic Department, with mean follow up period of 13.6±2.7 months. Results: Age was 9.05±1.89 with minimum 6 and maximum 13 years, and as regard sex distribution male were majority with 66.7%. There was significant improvement regarding talocalcaneal angle at anterior view from pre to 3, 6 and 12 months as it decreased from 46.94±5.19 to 29.66±2.86 at 3 months to 26.55±3.45 at 6 months and to 24.55±3.97 at 12 months. There was significant improvement regarding talocalcaneal angle at lateral view from pre to 3 months and also to 6 and 12 months. Conclusion: The advantages of calcaneal lengthening osteotomy are as follows: it is technically easy to be applied, has a low risk of neurovascular injury and low loss of blood. In addition, it allows other procedures to be applied in the future contrary to arthrodesis. If arthrodesis is required later in these feet, it will be far easier to do because of the corrected alignment of the foot.

Biomechanical Effects of Graft Shape for the Evans Lateral Column Lengthening Procedure: A Patient-Specific Finite Element Investigation.

The Evans calcaneal lengthening osteotomy procedure is widely used for correcting progressive collapsing foot deformity. However, it can result in overcorrection and degenerations of the calcaneocuboid joint. Different shapes of graft have been used in the Evans calcaneal osteotomy, but potential differences in their biomechanical effects is still unclear. The present study was designed to explore the biomechanical effects of graft shape and improve the Evans procedure to avoid or minimize detrimental effects. Twelve patient-specific finite element models were established and validated. A triangular or rectangular wedge of varying size was inserted at the lateral edge of calcaneus, and the degree of correction was quantified. The stress in spring ligaments and plantar fascia and the contact characteristics of the talonavicular and calcaneocuboid joints were calculated and compared accordingly. The rectangular graft provided a much higher degree of correction than triangular grafts did. However, the contact characteristics of the calcaneocuboid joint and talonavicular joint were abnormal, with clear sensitivity to increased graft size, and the modeled strain of the spring ligament increased. The finite element analysis predicts that the rectangular grafts provide a higher degree of correction, but risks overcorrection compared with triangular grafts. The triangular graft may have a lower degree of disturbance to the biomechanical behaviors of the midtarsal joint. The model shows that both the shape and size of an Evans osteotomy bone wedge can have effects on the contiguous joints and ligamentous structures. Those effects should be considered when selecting a bone wedge for an Evans calcaneal osteotomy. Level III, case-control study.

Anatomical Study of Sinus Tarsi-Based Lateral Lengthening Calcaneal Osteotomy.

Lateral lengthening calcaneal osteotomy (LL-CO) is commonly performed as a treatment for an abducted midfoot in pes planovalgus deformity. The purpose of this study is to investigate potential damage to medial structures with a sinus tarsi LL-CO. Sixteen cadaver feet were used. Eight feet had an extended lateral approach, and 8 had a limited lateral (sinus tarsi) approach. All underwent a sinus tarsi LL-CO. Specimens were then dissected to identify inadvertent injury to medial structures. Sinus tarsi LL-CO was associated with damage to the sustentaculum tali and medial articular facets in 56% and 62.5% of specimens, respectively. No anterior or posterior facet injuries were found, although 56% of specimens had a confluent medial and anterior facet. Damage to the medial articular facet and sustentaculum is possible with a flat cut sinus tarsi LL-CO due to the curved nature of the relevant sinus tarsi and canal anatomy. Sinus tarsi LL-CO needs to be performed with caution since damage to the subtalar joint is possible. Level II, prospective cohort study.

Talus morphology differs between flatfeet and controls, but its variety has no influence on extent of surgical deformity correction

BackgroundProgressive collapsing foot deformity (PCFD) is a complex 3-dimensional (3-D) deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus. The first aim of this study was to perform a 3-D analysis of the talus morphology between symptomatic PCFD patients that underwent operative flatfoot correction and controls. The second aim was to investigate if there is an impact of individual talus morphology on the success of operative flatfoot correction.MethodsWe reviewed all patients that underwent lateral calcaneal lengthening for correction of PCFD between 2008 and 2018 at our clinic. Radiographic flatfoot parameters on preoperative and postoperative radiographs were assessed. Additionally, 3-D surface models of the tali were generated using computed tomography (CT) data. The talus morphology of 44 flatfeet was compared to 3-D models of 50 controls without foot or ankle pain of any kind.ResultsGroups were comparable regarding demographics. Talus morphology differed significantly between PCFD and controls in multiple aspects. There was a 2.6° increased plantar flexion (22.3° versus 26°; p = 0.02) and medial deviation (31.7° and 33.5°; p = 0.04) of the talar head in relation to the body in PCFD patients compared to controls. Moreover, PCFD were characterized by an increased valgus (difference of 4.6°; p = 0.01) alignment of the subtalar joint. Satisfactory correction was achieved in all cases, with an improvement of the talometatarsal-angle and the talonavicular uncoverage angle of 5.6° ± 9.7 (p = 0.02) and 9.9° ± 16.3 (p = 0.001), respectively. No statistically significant correlation was found between talus morphology and the correction achieved or loss of correction one year postoperatively.ConclusionThe different morphological features mentioned above might be contributing or risk factors for progression to PCFD. However, despite the variety of talar morphology, which is different compared to controls, the surgical outcome of calcaneal lengthening osteotomy was not affected.Level of evidenceIII.

Calcaneal cuboid joint motion and osteotomy stability in children one year after calcaneal lengthening osteotomy

IntroductionFlexible pes planovalgus in children may be corrected with a calcaneal lengthening osteotomy (CLO).However, CLO surgery may displace the distal calcaneal fragment dorsally and affect the motion in the calcaneal-cuboid joint (CCJ). We used radiostereometric analysis (RSA) to evaluate CCJ motion and CLO stability in children one year after CLO. MethodsTen patients (10 feet) with symptomatic flexible pes planovalgus were investigated one year after CLO. Mean age was 11.5 years (range 8.2–14.2). Standardised RSA measurements of the foot were obtained one year after surgery without and with weight-bearing (single leg stance). Tantalum markers inserted during surgery, were used to described the CCJ motion as cuboid bone motion with respect to the distal calcaneus, and the CLO stability as distal calcaneal migration with respect to the proximal calcaneus. ResultsOne year after surgery the CLO was stable. The motion in the CCJ upon full weight-bearing was mean −1.04 mm (CI95% −1.40; −0.67) joint distraction, mean 2.27 mm (CI95% 1.57; 2.96) cuboid dorsal translation, mean −1.94 mm (CI 95% −2.68; −1.20) cuboid medial translation, and mean 7.43° (CI 95% 3.97; 10.88) adduction. ConclusionThe motion in the CCJ of children with CLO corrections for pes planovalgus is similar to that of adults during stance load with a normal foot posture and the patients were asymptomatic. Marker-based RSA may be used to evaluate causalities of foot symptoms after CLO surgery.