Lateral column lengthening augmented by medial split tibialis posterior tendon advancement for the treatment of symptomatic flexible flatfeet
Keywords:Flat foot, Evans osteotomy, Calcaneal lengthening, Tibialis posterior, Advancement
Background: Management of Idiopathic flexible pes planus (IFPP) is debatable. Surgery is rarely indicated for flexible flatfoot. The goal of the surgery should be always to treat symptomatic patients and not to alter the shape of the foot. There are numerous options for surgical treatment in children and adolescents including subtalar arthroereisis or osteotomy with or without soft tissue procedures.
Methods: Between June 2013 to December 2017, twenty eight feet in sixteen patients (9 boys, 7 girls) were included in this study. Twelve cases were operated bilaterally, three in the right foot and one in the left side. The mean age of the patients was 8.36±1.704 years (6-12 years). Calcaneal lengthening osteotomy was done with an oscillating saw about 1.5 cm proximal to the calcaneocuboid joint. Usually, 8-10 mm autologous bone graft from iliac crest was sufficient and fixed by K wires. Half of the tibialis posterior tendon after splitting with a periosteal flap from the navicular was then advanced distally until clinical restoration of the medial arch was then performed.
Results: Radiographic analysis revealed significant improvements in talo-first metatarsal, calcaneal pitch, talocalcaneal angles in lateral radiographs, and talo-first metatarsal and talonavicular coverage angles in AP radiographs. All patients were evaluated at final follow-up visits. Preoperative mean AOFAS score increased significantly from 64.04±8.867 (range: 50 to75) to 94.11±3.765 (90-100).
Conclusions: It is concluded that Evans calcaneal lengthening osteotomy augmented by spilt tibialis posterior tendon advancement is an excellent procedure in the management of IFPP.
Blitz NM, Stabile RJ, Giorgini RJ, DiDomenico LA. Flexible pediatric and adolescent pes planovalgus: conservative and surgical treatment options. Clin Podiatr Med Surg, 2010;27:59-77.
Mosca VS. Flexible flatfoot in children and adolescents. J Child Orthop. 2010;4:107-21.
Yeagerman SE, Cross MB, Positano R, Doyle SM. Evaluation and treatment of symptomatic flatfoot. Curr Opin Pediatr. 2011;2:60-7.
Roth S, Sestan B, Tudor A, Ostojic Z, Sasso A, Durbesic A. Minimally invasive calcaneo-stop method for idiopathic, flexible pes planovalgus in children. Foot Ankle Int. 2007;28:991-5.
Jay RM, Din N. Correcting pediatric flatfoot with subtalar arthroereisis and gastrocnemius recession:a retrospective study. Foot Ankle Spec. 2013;6:101-7.
Oh I, Williams BR, Ellis SJ, Kwon DJ, Deland JT. Reconstruction of the symptomatic idiopathic flatfoot in adolescents and young adults. Foot Ankle Int, 2011;32:225-32.
Akimau P, Flowers M. Medium term outcomes of planovalgus foot correction in children using a lateral column lengthening approach with additional procedures ‘a la carte’. Foot Ankle Surg, 2014;20:26-9.
Moraleda L, Salcedo M, Bastrom TP, Wenger DR, Albinana J, Mubarak SJ. Comparison of the calcaneo-cuboid-cuneiform osteotomies and the calcaneal lengthening osteotomy in the surgical treatment of symptomatic flexible flatfoot. J Pediatr Orthop. 2012;32:821-9.
Necip S, Tahir O, Mehmet FG, Huseyin B, Gokhan K, Ata Can. Surgical treatment results for flexible flatfoot in adolescents. Acta Orthopaedica et Traumatologica Turcica 2016;50:655-9.
Verheyden F, Vanlommel E, Van Der Bauwhede J, Fabry G, Molenaers G. The sinus tarsi spacer in the operative treatment of flexible flat feet. Acta. Orthop. Belg. 1997;63:305-9.
Oh I, Williams BR, Ellis SJ, Kwon DJ, Deland JT. Reconstruction of the symptomatic idiopathic flat foot in adolescents and young adults. Foot Ankle Int. 2011;32:225-32.
Akimau P, Flowers M. Medium term outcomes of planovalgus foot correction in children using a lateral column lengthening approach with additional procedures ‘a la carte’. Foot Ankle Surg. 2014;20:26-9.
Mosca VS. Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skew foot. J Bone Joint Surg Am 1995;77:500-12.
Cooper P, Nowak MD, Shaer J. Calcaneocuboid joint pressures with lateral column lengthening (Evans) Procedure. Foot and Ankle Int. 1997;18(4):199-205.
Momberger N, Morgan JM, Bachus KN, West JR. Calcaneocuboid joint pressure after lateral column lengthening in a cadaveric planovalgus deformity model. Foot Ankle Int. 2000;21(9):730-5.
Adams SB Jr, Simpson AW, Pugh LI, Stasikelis PJ. Calcaneocuboid joint subluxation after calcaneal lengthening for planovalgus foot deformity in children with cerebral palsy. J Pediatr Orthop. 2009;29(2):170-4.
Ahn JY, Lee HS, Kim CH, Yang JP, Park SS. Calcaneocuboid Joint Subluxation After the Calcaneal Lengthening Procedure in Children. Foot Ankle Int, 2014;35(7):677-82.
Hintermann B, Valderrabano V, Kundert HP. Lengthening of the lateral column and reconstruction of the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the posterior tibial tendon. Foot Ankle Int. 1999;20(10):622-9.
Sands A, Early J, Harrington RM, Tencer AF, Ching RP, Sangeorzan BJ. Effect of variations in calcaneocuboid fusion technique on kinematics of the normal hindfoot. Foot Ankle Int. 1998;19(1):19-25.
Xia J, Zhang P, Yang YF, Zhou JQ, Li QM, Yu GR. Biomechanical analysis of the calcaneocuboid joint pressure after sequential lengthening of the lateral column. Foot Ankle Int. 2013;34(2):261-6.
Yarmel D, Mote G, Treaster A. The Cotton osteotomy:a technical guide. J Foot Ankle Surg. 2009;48:506-12.