Calcaneal lengthening for the planovalgus foot deformity in children with cerebral palsy

Preliminary Results of Calcaneal Lengthening Osteotomy Combined With Extra-articular Subtalar Arthrodesis for Severe Pes Planovalgus Deformity in Children With Cerebral Palsy: A New Surgical Technique

OBJECTIVE

Pes planovalgus is the most common foot deformity seen in patients with cerebral palsy (CP). There are several different treatment modalities to treat this condition. Single or double calcaneal osteotomies, extra-articular arthrodesis, calcaneo-cuboido-cuneiform osteotomy, intraarticular arthrodesis, and arthroereisis are some of these modalities. Currently, there is insufficient information to determine the most effective treatment approach for pes planovalgus in children with CP. The aim of this study is to show the short to mid-term results of the new technique which combines calcaneus lengthening osteotomy, extra-articular subtalar arthrodesis, and soft tissue reconstruction that aims to decrease recurrence and complication rates of pes planovalgus surgery for patients with ambulatory CP.

METHODS

Patients with CP who were treated with calcaneal lengthening surgery and extra-articular subtalar arthrodesis between 2018 and 2021 were investigated retrospectively. All patients were ambulatory and Gross Motor Function Classification System I-II-III. Functional levels of the patients were assessed with the American Orthopaedic Foot and Ankle Society, Ankle-Hindfoot Score, and the Foot and Ankle Ability Score (Foot and Ankle Ability Measure) in preoperative and postoperative periods. On anteroposterior x-rays, talus-first metatarsal, talocalcaneal, talonavicular coverage angle and on lateral x-rays talus-first metatarsal, talocalcaneal, calcaneal inclination angle and talar tilt angle were evaluated.

RESULTS

The mean follow-up was 46 (range: 36 to 60) months. The mean American Orthopaedic Foot and Ankle Society increased from 41 (20 to 79) to 74 (38 to 93; P < 0.001). The mean Foot and Ankle Ability Measure increased significantly from 35 (7 to 73) to 54 (29 to 96; P<0.001). Clinical results were "satisfactory" for 32 feet, while they were "unsatisfactory" for 2 feet. Significant deformity correction was observed in all radiologic parameters.

CONCLUSION

Our technique is found to be efficient for patients with Gross Motor Function Classification System I-II-III CP with pes planovalgus deformity. In short to mid-term follow-up, the technique achieved successful clinical and radiologic results with low complication rates. Superiority of this technique compared with the traditional ones can only be shown with randomized prospective studies.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

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

BACKGROUND

Calcaneal 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.

METHODS

Participants 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.

RESULTS

Kinematic 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.

CONCLUSION

CLO 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.

Radiographic Measurements Associated With Ankle Power Generation During Gait in Patients With Cerebral Palsy

BACKGROUND

Pes planovalgus (PV) deformity accounts for lever arm dysfunction and compromises gait in patients with cerebral palsy (CP). However, the association between ankle power generation and radiographic indices is not yet understood. We aimed to investigate the association between ankle power and radiographic indices during gait in patients with CP concomitant with PV deformity.

METHODS

Patients older than 14 years with ambulatory CP and PV deformity were included. All the patients underwent 3-dimensional gait analysis and weight-bearing foot radiography. Gait data were collected, including foot progression angle, tibial rotation, hip rotation, and ankle power generation. Radiographic measurements included anteroposterior (AP) talo-first metatarsal angle, lateral talo-first metatarsal angle, and hindfoot angle. A linear mixed-effects model was performed to identify significant radiographic indices associated with ankle power generation.

RESULTS

Thirty-one limbs from 15 patients with spastic diplegia and 6 with spastic hemiplegia were included. Statistical analysis demonstrated that ankle power generation was significantly correlated with the CP type ( P =0.0068) and AP talo-1 st metatarsal angle ( P =0.0230).

CONCLUSION

Ankle power generation was significantly associated with the AP talo-first metatarsal angle. Surgeons might need to pay attention to correcting forefoot abduction to restore ankle power when planning surgeries for pes PV deformities in patients with CP.

LEVEL OF EVIDENCE

Prognostic Level III.

Clinical and Radiological Outcomes of Subtalar Arthroereisis for Management of Planovalgus Foot in Children With Cerebral Palsy: 3-Year Follow-up

BACKGROUND

Planovalgus deformity of the foot is common among cerebral palsy (CP) patients. It is an upcoming topic with debate and controversy that require further studies. Many clinical studies involving arthroereisis have shown acceptable results in short- and mid-term follow-up. The aim of this work was to evaluate the outcome of arthroereisis using a conventional screw placed percutaneously across the talocalcaneal articulation for the treatment of moderate planovalgus deformity in children with CP.

METHODS

Between 2015 and 2018, a prospective study was conducted including 23 CP patients with bilateral flexible planovalgus deformity with follow-up period ranging from 24 to 40 months (mean of 36.7 months). The radiological and clinical outcomes were assessed. The patient/parent outcome was evaluated using the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C).

RESULTS

The results showed statistically significant improvement in both radiological and clinical data as well as patient's symptoms and parent's satisfaction.

CONCLUSION

Results obtained from literature from the past decades after arthroereisis for the correction of moderate planovalgus deformity in CP patients are promising. The few studies reported on that procedure shared the same harmony with our study giving a chance to be a good alternative to joint destructive procedures. Our technique is simple, effective, economical, and minimally invasive if used in selected pediatric CP patients.

LEVELS OF EVIDENCE

Therapeutic, Level IV.

Prospective Comparison of Subtalar Arthroereisis With Calcaneal Lengthening in the Management of Planovalgus Feet of Ambulatory Children With Spastic Cerebral Palsy?

BACKGROUND

Pes planovalgus (PPV) deformity is common among cerebral palsy (CP) patients. There is no true consensus about the best way of treating this common deformity, especially when surgical interference is required. Treatment options range from orthotics to complex surgical procedures. The purpose of this prospective study was to evaluate and compare the effectiveness of 2 different procedures in the correction of symptomatic flexible PPV in ambulatory CP patients.

METHODS

A total of 57 feet in 35 patients were divided into 2 groups: group 1, subtalar arthroereisis group, using the calcaneostop technique; group 2, lateral column lengthening group, using Evans osteotomy. Patients were assessed clinically by the clinical score proposed by Yoo et al and radiologically by measuring 7 weight-bearing angles, both preoperatively and 12 months postoperatively. Patients' (or parents') satisfaction and their tolerance to braces or shoes were assessed 12 months after surgery as secondary outcome parameters.

RESULTS

There was a statistically significant improvement in both primary and secondary outcome parameters after both procedures in comparison to the preoperative parameters. No statistically significant differences were observed between the 2 groups regarding the outcomes of both procedures except for the greater power of arthroereisis in the correction of hindfoot valgus, which was statistically significant both clinically and radiographically.

CONCLUSION

Both procedures are valid options for the surgical management of PPV in ambulatory children with spastic CP. The less-invasive nature and lower potential morbidity suggest that judicious use of arthroereisis is appropriate for some patients, especially in the context of single-event multilevel surgery.

LEVELS OF EVIDENCE

Level II: Prospective, comparative study.

Surgical management of pes planus in children with cerebral palsy: A systematic review

PURPOSE

Pes planus (or flatfoot) is the most common deformity in children with cerebral palsy. There are several surgical interventions used to treat it: single calcaneal osteotomies, extra-articular arthrodesis, double calcaneal osteotomy, calcaneo-cuboid-cuneiform osteotomy, intra-articular arthrodesis, and arthroereisis. There is currently no evidence on optimal treatment for flatfoot in children with cerebral palsy. Our purpose is to systematically review studies reporting complications, recurrence rates, and radiological outcomes of the surgical management of flatfoot in children with cerebral palsy.

METHODS

Five databases were searched to identify studies published from inception until July 2021, with keywords relating to flatfoot, cerebral palsy, and surgical interventions. We included prospective, retrospective, and comparative study designs in the English language. Data was extracted and tabulated in duplicate into Excel, and analysis was conducted using Python SciPy.

RESULTS

In total, 1220 studies were identified of which 44 met the inclusion criteria, comprising 2234 feet in 1364 patients with a mean age of 10.3 years and mean follow-up of 55.9 months. Radiographic outcomes showed improvement with all procedures; complications and recurrence rates were too poorly reported to compare. Only 6 (14%) studies were assessed as a low risk of bias. There was substantial heterogeneity of outcome measures.

CONCLUSION

There is a lack of high-quality, comparative studies assessing the radiological outcomes, complications, and recurrence rates of surgical alternatives to treat flatfoot in children with cerebral palsy. There is currently no clear evidence on optimal surgical treatment.

LEVEL OF EVIDENCE

IIa based on Oxford Centre for Evidence-based Medicine.

Long-term Outcomes of Talonavicular Arthrodesis for the Treatment of Planovalgus Foot in Children With Cerebral Palsy

BACKGROUND

Planovalgus foot (PVF) in cerebral palsy (CP) tends toward progression and rigidity in adolescence, especially in patients with greater functional impairment. Deformity at the talonavicular joint justifies the use of talonavicular arthrodesis as a corrective surgical technique. This study aims to assess patient or caregiver functional satisfaction and radiographic outcomes of talonavicular arthrodesis for PVF in CP patients with assisted ambulation in the long-term.

METHODS

Retrospective comparative study of level III and level IV pediatric CP patients who underwent talonavicular arthrodesis for PVF between 1999 and 2010 as part of multilevel surgery and with a minimum follow-up of 10 years. Radiologic correction at 10 years was compared with preintervention values, and functional impact at 10 years was measured by the foot function index (FFI); correlation between radiologic measurements and FFI were obtained, and complications were recorded.

RESULTS

Forty-nine PVFs in 25 patients with CP (72% level III and 28% level IV) were included; 52% were male. The patients had a median age of 12 years at the time of surgery (range: 11 to 15) and 23 years at the time of the study (21 to 26). Significant (P<0.01) pre-post radiologic improvements were obtained in Meary angle (37.86±10.7/8.37±5.5 degrees), calcaneal pitch (3.20±8.1/13.22±5.6 degrees), lateral talocalcaneus angle (42.18±12.1/25.29±2.9 degrees), Moreau-Costa-Bartani angle (167.04±8/146.12±7.1 degrees), talus-first metatarsal angle (27.92±13.9/9.69±4.4 degrees), anteroposterior talocalcaneal angle (37.61±7.4/22.61±2.4 degrees), and talus coverage angle (37.04±11.11/2.45±2.5 degrees). At 10 years postoperatively, functional outcome measured with the FFI was satisfactory (33.9±15.2%) and the mean maximum pain was 3.04; 56% of cases had mild pain. All patients were able to wear an ankle-foot orthosis and 8 no longer needed the device. A significant correlation was found between the talofirst metatarsal angle and the FFI (P=0.024). There were 8% of cases with screw protrusion and 14% presented pseudarthrosis, most of them asymptomatic.

CONCLUSIONS

The adequate functional outcome, as well as the persistence of long-term radiologic correction and acceptable number of complications, enables us to recommend talonavicular arthrodesis as an alternative treatment to consider in level III and level IV CP patients with PVF.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

The Pediatric Foot in Neurologic Disorders

Every child with a neuromotor disorder is at risk for the development or a deterioration of foot deformities. This relates to central and peripheral diseases. Almost any kind of deformity may occur. As the basic problems mostly remain, a multidisciplinary team care program is necessary in addition to surgical management of the feet. Surgery must respect any muscle imbalance as well as joint deformities and instabilities. Postoperative orthotic support supplements most treatments. Long-term follow-ups are strongly advised to detect any recurrences or overcorrections.

What are the long-term outcomes of lateral column lengthening for pes planovalgus in cerebral palsy?

BACKGROUND

Lateral column lengthening (LCL) is commonly performed on children and adolescents with cerebral palsy (CP) for correction of pes planovalgus (PPV). There are limited reports of the long-term outcomes of this procedure. The purpose of this study was to examine the long-term results of LCL for correction of PPV in individuals with CP by evaluating subjects when they had transitioned to adulthood and were entering the workforce.

METHODS

Clinical assessments, quantitative gait analysis including the Milwaukee Foot Model (MFM) for segmental foot kinematics, and patient reported outcomes were collected from 13 participants with CP treated with LCL for PPV in childhood (average age 24.4 ± 5.7 years, average 15.3 ± 8.5 years since LCL). Additionally, 27 healthy adults average age 24.5 ± 3.6 years functioned as controls.

RESULTS

Strength and joint range of motion were reduced in the PPV group (p < 0.05). Sixty nine percent showed operative correction of PPV based on radiologic criteria. Gait analysis showed reduced walking speed and stride length, as well as midfoot break and residual forefoot abduction. Patient reported outcomes indicated that foot pain was not the only factor that caused limited activity and participation. LCL surgery for PPV in childhood resulted in long-term operative correction. Decreased ankle passive range of motion and strength, subtalar joint arthritic changes, inefficient and less stable ambulation, and problems with participation (difficulties in physical function, education, and employment) were observed in the long-term.

CONCLUSION

This study identified postoperative impairments and limitations to guide future clinical decision-making. These results provide clinicians and researchers the common residual and recurrent issues for these individuals as they age. The inclusion of contextual factors that influence the disease and impairments can equip these individuals with enhanced skills they need as they transition into adulthood.

Calcaneal Sliding Osteotomy Versus Calcaneal Lengthening Osteotomy for Valgus Foot Deformity Correction in Children With Cerebral Palsy

BACKGROUND

Medial calcaneal sliding (CS) osteotomy and lateral column lengthening (LCL) are often performed to relieve pain and improve transverse plane alignment and gait stability for children with cerebral palsy (CP) and valgus foot deformities. The purpose of this study was to examine the effectiveness of these procedures in this population.

METHODS

Retrospective medical record review (including 3D gait analysis data) of patients with CP who underwent LCL (26 subjects, 46 limbs) or CS (46 subjects, 73 limbs). Data extraction included complications (modified Clavien-Dindo system), change in standing foot position (modified Yoo system), and change in gait kinematics and kinetics preoperatively to postoperatively. Groups were compared using paired t tests, Fisher exact test, and survivorship analysis using Cox proportional hazard models.

RESULTS

Subjects were 57% male, average age at surgery 11.1 (SD 2.5) years. Average length of follow-up was 3.2 (SD 2.8) years, and was longer in the LCL group (P=0.0004). Complications were minor with similar rates between groups (P=0.14). Prolonged pain and plantar hypersensitivity occurred only in the CS group. Successful maintenance of deformity correction was achieved in 52/73 limbs (71%) in the CS group and 16/44 limbs (36%) in the LCL group (P<0.001). Recurrent pes valgus and need for repeat foot surgery were more common after LCL (P=0.003 and 0.001, respectively). Recurrent pes valgus never occurred when talonavicular fusion was done concomitantly with CS. After accounting for the between group difference in length of follow-up, there was no difference in the rates of recurrent valgus or repeat foot surgery between LCL and CS. None of the variables predicted development of pes varus (P>0.20). Ankle kinematics and kinetics during gait were unchanged in both groups.

CONCLUSIONS

CS and LCL have similar effectiveness in providing long-lasting correction of valgus foot deformities. Concomitant talonavicular fusion is key to success of CS for lower functioning patients with severe deformities, and obligate brace wearers.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Functional and radiographic comparison of subtalar arthroereisis and lateral calcaneal lengthening in the surgical treatment of flexible flatfoot in children

PURPOSE

One of the most widespread diseases of children's orthopaedic problems is flatfoot. If conservative therapy failed, surgical treatment would be indicated. Lateral calcaneal lengthening (LCL) and subtalar arthroereisis (SA) are two types of operations used to correct symptomatic flexible flatfoot (FFF). The purpose of this study is to compare the functional and radiographic features of these two surgical procedures.

PATIENTS AND METHODS

In this prospective randomized clinical trial study, we recruited 66 patients between 2018 and 2019. For clinical assessment, American Orthopedics Foot and Ankle Society (AOFAS), visual analog scale (VAS), subtalar motion, presence of medial longitudinal arch, and family satisfaction were measured. Evaluation of radiographic angles was based on AP (AP Tal-1Met) and Lat (Lat Tal-1Met) view of Talus-1st metatarsal angle (Meary's angle) and calcaneal pitch.

RESULT

There was no significant difference between the two types of surgery regarding Lat Tal-1Met and AP Tal-1Met. The significantly larger angle in the LCL group was calcaneal pitch (P value < 0.001). AOFAS significantly increased from 68.71 ± 5.70 to 87.87 ± 7.14 (P value < 0.001) and from 67.28 ± 6.01 to 86.14 ± 7.56 (P value < 0.001) in LCL and SA respectively. Family satisfaction was significantly higher in the SA (8.14 ± 0.97) comparing to LCL (7.29 ± 0.86) at the latest follow-up (P value < 0.001).

CONCLUSION

While both groups have substantial improvement in clinical and radiographic aspects, the SA technique is less-invasive, rapid symptom relief, and has early weight-bearing capacity.

TRIAL REGISTRATION

IRCT20180823040853N1.

Do We Really Need to Worry About Calcaneocuboid Subluxation During Lateral Column Lengthening for Planovalgus Foot Deformity?

BACKGROUND

Although lengthening of the lateral column through an osteotomy of the anterior calcaneus is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, the procedure has been implicated in iatrogenic calcaneocuboid (CC) subluxation and subsequent degenerative changes at the CC articulation. The purpose of this study is to characterize alterations at the CC joint after lateral column lengthening (LCL) and determine if Steinmann pin stabilization of the CC joint before distraction maintains a normal relationship.

METHODS

Seven matched pairs of fresh-frozen cadaveric feet underwent preprocedure plain radiography and cross-sectional computed tomography (CT) imaging. LCL by osteotomy through the anterior calcaneus was then performed. One foot of each matched pair had a single smooth Steinmann pin placed centrally across the CC joint before osteotomy distraction. Distraction across each osteotomy was then performed and maintained with a 12-mm porous titanium wedge. Repeat imaging was obtained and compared with preprocedure studies to quantify sagittal and rotational differences at the CC articulation.

RESULTS

Following LCL, plain radiography demonstrated statistically significant increases in the percentage of the calcaneal articular surface dorsal to the superior aspect of the cuboid in both the pinned (8.2% vs. 17.6%, P=0.02) and unpinned (12.5% vs. 16.3%, P=0.04) specimens. No difference in the percentage of subluxation was found between the 2 groups after LCL. CT imaging demonstrated statistically significant increases in rotation between the calcaneus and cuboid after LCL in both the pinned (7.6±5.6 degrees, P=0.01) and unpinned (17±12.3 degrees, P=0.01) specimens. The degree of rotation was greater in unpinned specimens after LCL (P=0.043).

CONCLUSIONS

Both sagittal and rotatory subluxation seem to occur at the CC joint after LCL regardless of pin stabilization. As a single pin would be expected to limit pure translation while having little effect on rotation, it is possible that the rotational changes identified on 3-dimensional imaging are interpreted as dorsal translation when viewed 2 dimensionally using plain radiography. Consideration should therefore be given to CC stabilization with 2 pins during LCL to prevent this rotatory subluxation.

LEVEL OF EVIDENCE

Level V-cadaver study.

Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans-Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.'s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary's angle and Costa–Bertani's angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.'s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary's angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani's angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Relevance of SPECT-CT in Complex Cases of Foot and Ankle Surgery: A Comparison With MRI

BACKGROUND

Finding the right diagnoses in patients with complex foot and ankle disorders can be challenging. Single-photon emission computed tomography and computed tomography (SPECT-CT) has shown to be feasible in foot and ankle surgery. The aim of this study was to evaluate the reliability and accuracy of SPECT-CT and thereby its impact on final treatment decision compared with magnetic resonance imaging (MRI).

METHODS

A retrospective study was performed on 49 patients treated at our institution. Experienced foot and ankle surgeons independently, and blinded, analyzed clinical data and radiographs together with MRI, SPECT-CT, or a combination of both. Based on the determined final treatment decision Cohen's kappa values were calculated to illustrate interrater and intrarater reliability.

RESULTS

The kappa values for interrater reliability were higher for SPECT-CT at .68 and MRI + SPECT-CT at .71 compared to 0.38 for MRI alone (P < .05). The kappa values for intrarater reliability of MRI + SPECT-CT were higher at .75 compared with SPECT-CT alone at .67 (P < .05) and MRI at .35 (P < .01).

CONCLUSION

We found a higher interrater and intrarater reliability for SPECT-CT compared with MRI alone for diagnosing complex foot and ankle pathologies. SPECT-CT has a high impact on final treatment decision. The main indications are bony pathologies with diagnostic uncertainty especially in closely adjacent structures as the joints of the midfoot, occult coalitio, stress fractures, verification or exclusion of nonfusion, periprosthetic disorders after total ankle replacement and osteochondral lesion in cases of combined pathologies.Levels of Evidence: Level IV: Retrospective study.

Changes in Gait and Radiographic and Clinical Results of Calcaneal Lengthening Osteotomy in Children with Idiopathic Flexible Flatfoot

Backgroud

In this study, we aimed to analyze kinematic and kinetic changes in gait and to assess radiographic and clinical improvement after calcaneal lengthening osteotomy (CLO) in children with idiopathic symptomatic flexible flatfoot deformities.

Methods

The study group consisted of 22 children (28 feet) with idiopathic symptomatic flexible flatfoot, which was treated by CLO as an index operation. We excluded patients with flatfoot that developed secondary to neuromuscular diseases. There were 18 boys (22 feet) and 4 girls (6 feet). The average age of the patients was 10.8 ± 1.51 years. Surgical results were assessed by radiologic imaging, clinical evaluation, and gait analysis, which were performed before surgery and 1 year after surgery. Medical records were reviewed to check postoperative complications.

Results

Talonavicular coverage was recovered to 16.7° from 32.7° (p < 0.01). Lateral talo-first metatarsal angle and calcaneal pitch angle increased by 20.1° and 9.9°, respectively (p < 0.01). Weight-bearing radiographs demonstrated a decrease in the anteroposterior angle and lateral talocalcaneal angle by 6.9° and 10°, respectively (p < 0.01). Hindfoot valgus was corrected to near neutral position after CLO. Kinematic results showed that the ankle valgus angle in the coronal plane was reduced from 35.48° preoperatively to 16.64° postoperatively during gait (p < 0.05). The preoperative out-toeing gait (preoperative foot progression angle, 20.31°) was also normalized to 14.21° postoperatively. The kinetics results showed that the push-off moment (maximum ankle plantar flexion) on the sagittal plane increased from 0.66 Nm/kg preoperatively to 0.83 Nm/kg postoperatively (p < 0.01). The mean Yoo score was 9.2 ± 1.05 postoperatively: satisfactory in 24 cases (86%) and unsatisfactory in 4 cases. Of the 4 unsatisfactory cases, 2 cases were overcorrection and 2 cases were undercorrection, and 3 of them were well managed by wedge foot insoles.

Conclusions

The 3-dimensional deformities of the flexible flatfoot were effectively corrected by CLO, based on the morphological assessment using radiologic imaging. The correction was well maintained during gait at 1 year after the operation.

Foot and Ankle Musculoskeletal Imaging of Pediatric Patients With Cerebral Palsy

OBJECTIVE. Any combination of abnormal positioning of the ankle, hindfoot, midfoot, and forefoot is possible in the context of cerebral palsy, but some patterns are more common than others. The purpose of this article is to discuss the radiographic manifestations and surgical management of the following common conditions: equinus, equinoplanovalgus, equinocavovarus, vertical talus, oblique talus, hallux valgus, and ankle valgus. CONCLUSION. CP is defined by abnormalities of the developing fetal or infant brain that result in permanent central motor dysfunction. Foot and ankle deformities are very common in the patients with CP, occurring in up to 93% of such patients as a result of underlying abnormal muscle tone, impaired motor control, and dynamic muscle imbalance. Radiologists must develop knowledge of the most common changes in alignment and basic techniques for correction to better recognize abnormalities and improve communication with orthopedic colleagues.

Surgical treatment of pes planovalgus in ambulatory children with cerebral palsy: Static and dynamic changes as characterized by multi-segment foot modeling, physical examination and radiographs

BACKGROUND

This study employs multi-segment foot modeling (MSFM) to examine flatfoot reconstruction among ambulatory children with cerebral palsy (CP).

RESEARCH QUESTION

Does flatfoot reconstruction improve MSFM measures, physical examination and radiographic variables for forefoot varus and midfoot collapse and associated multi-planar compensatory features?

METHODS

MSFM was performed preoperatively and postoperatively in a cohort of ambulatory CP patients undergoing flatfoot reconstruction (surgical group, n = 24). A comparison group of non-surgical group of ambulatory CP patients with pes planovalgus (flatfoot) who did not undergo flatfoot reconstruction was also identified (n = 17). All patients in this comparison group underwent MSFM at two separate time points. Physical examination was performed and standing AP and lateral foot radiographs were obtained during each gait analysis session.

RESULTS

Patients in the surgical group had improvement in their forefoot varus deformity, as documented on physical examination and kinematics in the STJN position of the foot and ankle, as well as in the compensatory hindfoot eversion and midfoot abduction during stance phase of gait. Furthermore, patients in the surgical group had improvement in midfoot collapse as identified kinematically by midfoot dorsiflexion, physical examination descriptors of midfoot position, and radiographic measures of calcaneal pitch and AP and lateral talar-first metatarsal angle. Patients in the non-surgical comparison group did not demonstrate these changes.

SIGNIFICANCE

Improvements in foot motion after flatfoot reconstruction in ambulatory CP patients were identified by MSFM, physical examination measures, and radiographs. Patients in the surgical and non-surgical groups had similar pre-operative radiographic findings, suggesting that physical examination and MSFM data were important in the surgical decision making process. Finally, surgical intervention did not fully restore normal foot kinematic, physical examination, and radiographic parameters, which suggests that a different, perhaps more aggressive, surgical approach for flatfoot reconstruction is needed.

Calcaneal lengthening for the pes planovalgus foot deformity in children with cerebral palsy

PURPOSE

The objective of this study was to evaluate the operative management of pes planovalgus deformity in ambulatory cerebral palsy (CP) children by calcaneal lengthening osteotomy described by Evans.

METHOD

Fifteen children (10 girls and 5 boys) with average age 11 years 6 months (range, 8 years 4 months-14 years 6 months) with 22 feet with pes planovalgus (PPV) deformity were included in this study. Clinical evaluation was made according to Dogan's scale and graded as perfect, good, fair and poor. Preoperative and postoperative radiological assessment of anteroposterior talo-first metatarsal angle (AP-T1MT), anteroposterior talo-calcaneal angle (AP-TC), laterl Talo-first metatarsal angle (Lat. T1MT), lateral Talo-calcaneal angle (Lat. TC), and lateral Calcaneal pitch angle (Lat. CP) had been done for all feet. All feet were corrected with the modification of the calcaneal lengthening osteotomy described by Mosca.

RESULT

Clinical results were perfect in 18 feet (82%), good in 2 feet (9%) and fair in 2 feet (9%). Radiological results showed improvement in 20 feet, while 2 feet showed no improvement. The improvement was significant in Lat. T1MT (P ‹ 0.001), AP-T1MT (P < 0.05)., AP-TC and Lat. CP (P < 0.001, <0.001 respectively) whereas it was insignificant in Lat. TC (P > 0.05).

CONCLUSION

The results of the present study showed that the procedure reliably relieves pain in PPV foot in CP children and proved effective in addressing all components of the deformity in both hindfoot and forefoot clinically and Radiologically.

Can polyaryletherketone cage be used to achieve union and maintain correction in anterior calcaneal lengthening osteotomy for treatment of flexible flatfoot?

A structural graft is often used to maintain correction and achieve union after anterior calcaneal lengthening osteotomy for treatment of flexible flatfoot. Autograft, the current gold standard, is limited in availability and configuration and is associated with donor site morbidity in as much as 48%, whereas the alternative allograft carries risks of disease transmission and collapse. Polyaryletherketone cage, with a healing rate similar to that of autograft, high stability, and no donor-site morbidity, has been used in spine surgery. However, its use has not been documented in foot and ankle surgery. We reviewed 15 patients with painful flatfeet after failure of conservative treatment who were treated by anterior calcaneal lengthening osteotomy using polyaryletherketone cage instead of bone graft. Minimum follow-up was 1 year (average, 1.27 years; range, 1-1.5 years). The male-female ratio was 1:1.5 (six males, nine females). Mean age at time of surgery was 10.8 ± 1.7 years (range, 8-13.5 years). Minimum follow-up was 1 year (average, 1.27 years; range, 1-1.5 years). Nine patients had a unilateral procedure and three had a simultaneous bilateral procedure, for a total of 15 operated feet (seven right and eight left). The paired t-test result was statistically significant in comparison of radiographic measurements at presurgery and postsurgery with P value <0.001. All cases showed full union clinically and radiographically at last follow-ups and no complications occurred. Our data suggest that polyaryletherketone cage may be used as a structural graft option for anterior calcaneal lengthening osteotomy.

Double calcaneal osteotomy in treatment of flexible planovalgus foot deformity in ambulatory cerebral palsy. A case series study

BACKGROUND

The aim of this prospective non randomized case series study was to assess the intermediate-term outcomes of double calcaneal osteotomy (lateral column lengthening and medial slide calcaneal osteotomy) use in ambulatory cerebral palsy with flexible planovalgus feet.

METHODS

16 cases with planovalgus feet were surgically treated by double calcaneal osteotomy and observed over an average of 33.5months. The mean age at the time of surgery was 10.74years. The functional outcomes were assessed clinically and radiologically.

RESULTS

There were a statistical improvement of clinical heel valgus and all radiological parameters as regard talar head uncoverage, calcaneal pitch, talo-calcaneal angle, and talus 1st metatarsal angle at the end of follow up period.

CONCLUSION

Double calcaneal osteotomy is a good option in the treatment of flexible planovalgus feet in ambulatory cerebral palsy patients.

Understanding the foot's functional anatomy in physiological and pathological conditions: the calcaneopedal unit concept

BACKGROUND

A thorough review of the available orthopaedic literature shows significant controversies, inconsistencies and sparse data regarding the terminology used to describe foot deformities. This lack of consensus on terminology creates confusion in professional discussions of foot anatomy, pathoanatomy and treatment of deformities. The controversies apply to joint movements as well as static relationships between the bones.

DESCRIPTION

The calcaneopedal unit (CPU) is a specific anatomical and physiological entity, represented by the entire foot excepted the talus. The calcaneus, midfoot and forefoot are solidly bound by three strong ligaments that create a unit that articulates with the talus. The movement of the CPU is complex, as it rotates under the talus, around the axis of Henke that coincides with the talo-calcaneal ligament of Farabeuf.This calcaneopedal unit is deformable. It is compared with a twisted plate, able to adapt to many physiological situations in standing position, in order to acheive a plantigrade position.Moreover, the calcaneopedal unit and the talo-tibiofibular complex are interdependent; rotation of the latter produces morphologic modifications inside the former and vice versa.

PURPOSE

This paper is a review article of this concept and of its physiopathological applications.

Lateral column lengthening versus subtalar arthroereisis for paediatric flatfeet: a systematic review

PURPOSE

This systematic review aimed to compare radiographic correction, clinical outcomes, complications, and re-operations between lateral column lengthening (LCL) and arthroereisis (AR) for treating symptomatic flatfoot in children.

METHODS

We conducted a comprehensive search on MEDLINE, EMBASE, and Cochrane Library databases. Literature search, data extraction, and quality assessment were conducted by two independent reviewers. The outcomes analyzed included radiographic parameters, clinical scores, satisfaction, complications, and re-operations.

RESULTS

Twenty-one and 13 studies were included in the LCL and AR groups, respectively. The change in anteroposterior talo-first metatarsal angle was greater in the LCL (9.5° to 21.7°) than in the AR group (10.6° to 12.8°). The change in calcaneal pitch was greater in the LCL (2.1° to 26.53°) than in the AR group (- 1.3° to 3.23°). Improvements in the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were greater in the LCL (27.7 to 39.1) than in the AR group (17 to 22). The percentage of satisfaction was similar between the LCL (68% to 89%) and AR (78.5% to 96.4%) groups. The complication rate was higher in the LCL (0% to 86.9%) than in the AR group (3.5% to 45%). The most common complications were calcaneocuboid subluxation and persistent pain in the LCL and AR groups, respectively. The re-operation rate was similar between the LCL (0% to 27.3%) and AR (0% to 36.4%) groups.

CONCLUSIONS

The LCL group has achieved more radiographic corrections and more improvements in the AOFAS score than the AR group. Complications were more common in the LCL group than in the AR group, and the re-operation rates were similar between the two groups.

Outcomes of the calcaneo-stop procedure for the treatment of juvenile flatfoot in young athletes

PURPOSE

Flexible flatfoot (FFF) is a widespread condition in juvenile patients. If symptomatic, FFF can require surgical treatment. The calcaneo-stop procedure has shown excellent clinical and radiographic outcomes and low rates of complications. The aim of the present study was to assess the sport practice of young athletes affected by FFF having undergone the calcaneo-stop procedure.

METHODS

Between 2008 and 2016, 68 sport practitioners were bilaterally treated by the calcaneo-stop procedure, for a total of 136 FFF cases. Clinical evaluation, including the American Orthopedic Foot and Ankle Score (AOFAS), the Yoo et al score and The Foot & Ankle Disability Index (FADI) and FADI Sport scores were assessed. Radiographic evaluation was based on measurement of talar declination, Costa-Bertani's angle and calcaneal pitch.

RESULTS

Mean follow-up was 57.6 months (sd 16.8). The AOFAS score mean increased from 79.3 (sd 5.7) to 97.3 (sd 4.5) three years after surgery. The Yoo score improved from 3.1 (sd 1.0) preoperatively to 11.7 (sd 0.6) three years after surgery. The FADI Sport subscale mean improved from 74.1 (sd 10.4) preoperatively to 95.9 (sd 4.9) three years after surgery.Costa-Bertani's angle decreased from 156.1° (sd 4.2°) to 135.8° (sd 7.3°) at three years postoperatively; mean talar declination angle decreased from 44.2° (sd 6.3°) to 30.6° (sd 3.2°) at three years postoperatively and mean calcaneal pitch increased from 12.6° (sd 2.3°) to 16.3° (sd 1.3°) at three years postoperatively.

CONCLUSION

Adolescent patients who underwent the calcaneo-stop procedure reported satisfactory outcomes in terms of clinical and radiological evaluations. Moreover, our results showed an improvement of sport activity levels, with patients recovering sports activity within three months of surgery and without limitation in the execution of preferred activities.

LEVEL OF EVIDENCE

IV.

Postoperative CT-scan 3D reconstruction of the calcaneus following lateral calcaneal lengthening osteotomy for flatfoot deformity in children. Is the surgical procedure potentially associated with subtalar joint damage?

BACKGROUND

Several anatomical studies have shown that the articular facets of the calcaneus can present with different anatomy. This study assessed the 3D anatomy of lateral calcaneal lengthening (LCL) osteotomy in relation to the anterior and middle facet of the calcaneus in a group of skeletally immature patients treated for symptomatic flatfoot deformity.

METHODS

During the study period, 14 consecutive patients (10 males, 4 females) presenting symptomatic flatfoot (20 feet) with different aetiologies underwent LCL osteotomy and CT scan with 3D reconstruction of the operated feet. Anatomy of articular factes of the calcaneus were graded according to Bunning & Barnett's classification. In order to assess clinical and functional outcome, all patients were evaluated according to Yoo et al.'s, Mosca's and AOFAS clinical criteria before surgery and at last follow-up visit.

RESULTS

Despite proving difficult to assess (10 out of 20 feet), dimensions of bone and joint structures revealed significant anatomical variations. In particular, working to Bunning & Barnett's classification, anatomy of the articular facet varied significantly among patients, and in Bunning & Barnett type-B1 or B2 the LCL osteotomy necessarily violates the articular surface of the anterior and middle facet of the calcaneus due to the fact that the two facets are fused together (single articular surface).

CONCLUSIONS

These biometric notions allow a better understanding of the impact on articular facets of the calcaneus of the osteotomy procedure suggested by Evans and Mosca. We anticipate that the findings reported here should lead to improved techniques for assessing all bone structures of the hindfoot, support logical classifications of the different pathological situations, and ultimately lead to improved treatment strategies.

Undercorrection of planovalgus deformity after calcaneal lengthening in patients with cerebral palsy

Calcaneal lengthening (CL) is one of the treatment options for planovalgus deformity in patients with cerebral palsy (CP). However, its indication still needs to be clarified according to the functional status of CP. The aim of this study was to investigate the radiographic outcome after CL in patients with CP and to evaluate the risk factors causing undercorrection of planovalgus deformities. We included consecutive patients with CP who underwent CL for planovalgus deformity, were followed for more than 2 years, and had preoperative and postoperative weight-bearing anteroposterior (AP) and lateral foot radiographs. Six radiographic indices were used to assess the radiographic outcome. The patient age, sex, and Gross Motor Function Classification System (GMFCS) level were evaluated as possible risk factors, and we controlled for the interaction of potentially confounding variables using multivariate analysis. A total of 44 (77 feet) patients were included in this study. The mean age of the patients at the time of surgery was 10.5±4.0 years and the mean follow-up was 5.1±2.2 years. Patients with GMFCS III/IV achieved less correction than those with GMFCS I/II in the AP talus-first metatarsal angle (P=0.001), lateral talocalcaneal angle (P=0.028), and the lateral talus-first metatarsal angle (P<0.001). The rate of undercorrection in the GMFCS III/IV group was 1.6 times higher than that in the GMFCS I/II group in the AP talus-first metatarsal angle (odds ratios: 1.6; 95% confidence interval: 1.2-2.0; P<0.001) and 1.6 times higher in the lateral talus-first metatarsal angle (odds ratios: 1.6; 95% confidence interval: 1.3-1.9; P<0.001). In GMFCS I/II patients with CP, we found CL to be an effective procedure for the correction of planovalgus foot deformities. However, in GMFCS III/IV patients with planovalgus deformities, CL appears to be insufficient on the basis of the high rate of undercorrection in these patients. For patients with GMFCS level III/IV, additional or alternative procedures should be considered to correct the deformity and maintain the correction achieved.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Long-term development of overcorrection after femoral derotation osteotomy in children with cerebral palsy

BACKGROUND

Recent studies showed rates of recurrence of internal rotation gait (IRG) after femoral derotation osteotomy (FDO) up to 40%. Some surgeons even advice overcorrection during FDO to avoid a later recurrence.

RESEARCH QUESTION

Evaluation of the long-term development of limbs with initial overcorrection after FDO.

METHODS

29 limbs of 20 children (9.9 ± 3.2 years at surgery) with IRG, cerebral palsy (CP) and more than 5° external hip rotation postoperatively were included retrospectively. A gait analysis and clinical examination were performed preoperatively (less than one year, E0), postoperatively (9-23 months, E1) and at the long-term follow-up (at least five years postoperatively, E2). Differences between those children that remained overcorrected at E2 and those with a hip rotation within normal range at E2 were evaluated.

RESULTS

At E2 41% of these limbs remained overcorrected, 52% showed a hip rotation within normal range and 7% showed recurrence of IRG. A comparison of those limbs that remained overcorrected and those ending within normal range revealed neither a difference in age at surgery nor in static and dynamic torsional parameters at E0 and E1 except for pelvic rotation. A significantly larger pelvic internal rotation at E1 for those with remaining overcorrection could be identified.

SIGNIFICANCE

A general overcorrection during FDO in children with CP to avoid recurrence of IRG cannot be recommended, as 41% remain overcorrected. Preoperative predictors for long-term development couldn't be identified. If pelvic mal-rotation is corrected, hip rotation may change into normal range over the time in combination with the development of a flexed knee gait.

Limits of Calcaneal Lengthening for Treating Planovalgus Foot Deformity in Children With Cerebral Palsy

BACKGROUND

Calcaneal lengthening is used to correct symptomatic planovalgus foot deformity, but outcomes have been less satisfactory in children with cerebral palsy. This study aimed to define limits of calcaneal lengthening by analyzing the risk factors for undercorrection of deformity.

METHODS

We retrospectively reviewed 20 cases of children with cerebral palsy who underwent calcaneal lengthening of 30 planovalgus feet at a mean age of 11.9 years. Foot deformities were evaluated by the anteroposterior talo-first metatarsal angle (normal, 10 ± 7.0 degrees), lateral talo-first metatarsal angle (normal, 13 ± 7.5 degrees), and lateral calcaneal pitch angle (normal, 17 ± 6.0 degrees) on standing foot radiographs. Among these parameters, a corrected foot was defined as 2 or 3 parameters being corrected to within a normal range, and an undercorrected foot was only 1 or no parameter being corrected to within a normal range. Factors were compared between the corrected group and undercorrected group for significant predictors, and cutoff values of predictors were calculated for use as a clinical guideline.

RESULTS

Seventeen planovalgus feet were corrected satisfactorily by calcaneal lengthening, while the other 13 feet were undercorrected. Undercorrected feet had a greater preoperative anteroposterior talonavicular angle (33.7 vs 22.8 degrees, P = .001) and a smaller lateral calcaneal pitch (-1.7 vs 5.6 degrees, P = .03). A talonavicular angle of more than 24 degrees and calcaneal pitch less than -5 degrees were identified as cutoff values using a receiver operating characteristic curve. The predicted probability of undercorrection was 100% (9/9 feet) for 2 positive predictors, 50% (8/16 feet) for 1 positive predictor, and 0 (0/5 feet) for zero predictors.

CONCLUSION

A talonavicular lateral subluxation of more than 24 degrees on the anteroposterior radiograph and a calcaneal pitch angle less than -5 degrees on the lateral radiograph were 2 independent predictors that could be used to identify a planovalgus deformity that would be beyond the corrective capacity of calcaneal lengthening to restore normal alignment. Level of Evidence Retrospective case control study, level III.

Clinical and radiological outcome of calcaneal lengthening osteotomy for flatfoot deformity in skeletally immature patients

BACKGROUND

The purpose of this study was to evaluate the clinical, functional and radiological outcome of calcaneal lengthening osteotomy for the treatment of symptomatic flatfoot deformity in skeletally immature patients.

METHODS

A retrospective review was led on 31 prospectively enrolled patients with symptomatic flatfoot. Twenty-seven out of 31 patients met the inclusion criteria, for a total of 38 operated feet. Mean age at time of surgery was 13.3 ± 2.2 years (range 7.8-17). Mean BMI at time of surgery was 19.3 ± 4.9 (range 12.3-32). In order to assess clinical and functional outcome, all patients were evaluated according to Yoo et al., Mosca and AOFAS clinical criteria before surgery and at last follow-up visit. Moreover, all patients underwent anteroposterior and lateral weight-bearing foot radiographs preoperatively, at 3-4-month post-surgery and at last follow-up visit.

RESULTS

Average Yoo et al. score was 3.3 ± 1 (range 0-4) preoperatively and improved to 9.8 ± 2.1 (range 3-12) at last follow-up (p < 0.001). Clinical outcome was satisfactory in 34 feet (89%) and unsatisfactory in 4 feet (11%). The same results were observed when Mosca clinical criteria were applied. AOFAS score improved significantly from a preoperative mean value of 49.9 ± 16 (range 23-75) to a postoperative value of 89 ± 15.9 (range 34-100) (p < 0.001). All radiographic parameters improved significantly from mean preoperative to mean 3-4-month postoperative value. Correction was maintained at last follow-up visit. Postoperative radiographs showed calcaneocuboid (C-C) joint subluxation in 29 (76%) feet. Final AP and lateral foot radiographs showed complete bone union and good bone graft remodeling. Furthermore, correct joint alignment was restored in all but two patients (93%).

CONCLUSIONS

Calcaneal lengthening osteotomy is not contraindicated in symptomatic flatfoot of different etiologies, except neuromuscular disease-related flatfoot that can affect bone quality and reduce foot flexibility. C-C joint subluxation is frequently observed but has little functional impact as it tends to remodel over time.

Prospective comparison of subtalar arthroereisis with lateral column lengthening for painful flatfeet

We prospectively compared subtalar arthroereisis with lateral column calcaneal lengthening for the treatment of painful flatfeet. Twenty-four feet (mean age of patients 12.8 years) were treated. Kinematic motion analysis, pedobarometry, and radiography were performed, and the Oxford Ankle-Foot Questionnaire for Children was administered for each patient before surgery and at the 1-year follow-up. We found statistically significant improvements in both groups, with no difference in their outcomes. Both groups showed significantly improved hindfoot and midfoot motion and positioning. Hindfoot range of motion was preserved. Radiography and pedobarometry also revealed significant improvements. Subtalar arthroereisis is a valid and potentially less-invasive alternative to lateral column lengthening that merits further investigation.

Incidence and risk factors of allograft bone failure after calcaneal lengthening

BACKGROUND

Calcaneal lengthening with allograft is frequently used for the treatment of patients with symptomatic planovalgus deformity; however, the behavior of allograft bone after calcaneal lengthening and the risk factors for graft failure are not well documented.

QUESTIONS/PURPOSES

(1) What proportion of the patients treated with allograft bone had radiographic evidence of graft failure and what further procedures were performed? (2) What are the risk factors for radiographic graft failure after calcaneal lengthening? (3) What patient factors are associated with the magnitude of correction achieved after calcaneal lengthening?

METHODS

Between May 2003 and January 2014, we performed 341 calcaneal lengthenings on 202 patients for planovalgus deformity, the etiology of which included idiopathic, cerebral palsy, and other neuromuscular disease. Of these, 176 patients (87%) had adequate followup for graft evaluation, defined as lateral radiographs taken before and at least 6 months after the index procedure (mean, 18 months; range, 6-100 months) and 117 patients (58%) had adequate followup for the assessment of the extent of correction, defined as weightbearing anteroposterior and lateral radiographs taken before and at least 1 year after the index procedure (mean, 24 months; range, 12-96 months). These patients' results were evaluated retrospectively. The Goldberg scoring system was chosen for demonstration of allograft behavior. A score lower than 6 at 6 months after surgery was defined as radiographic graft failure; the highest possible score was 7 points, and this represented graft incorporation with excellent reorganization of the graft and no loss of height. The patient age, sex, diagnosis, graft material, ambulatory status, and use of antiseizure medication were evaluated as possible risk factors, and we controlled for the interaction of potentially confounding variables using multivariate analysis. Additionally, six radiographic indices were analyzed for their effects on the extent of correction.

RESULTS

The mean estimated Goldberg score was 6 (SD, 1.14) at 6 months after calcaneal lengthening with 11 feet (4%) classified as radiographic graft failure (Goldberg score < 6). Of these, four feet (1%) underwent reoperation using an iliac autograft bone resulting from pain and loss of correction. Multivariate analysis showed that the tricortical iliac crest allograft was superior to the patellar allograft (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.1-9.8; p = 0.038) and the possibility of radiographic graft failure was found to increase along with age (OR, 1.2; 95% CI, 1.0-1.3; p = 0.006). Radiographically, the extent of correction was found to decrease with patient age, as observed at the anteroposterior talus-first metatarsal angle (p < 0.001), lateral talocalcaneal angle (p < 0.001), lateral talus-first metatarsal angle (p < 0.001), and relative calcaneal length (p = 0.041).

CONCLUSIONS

Graft failure can occur after calcaneal lengthening using allograft. Our study showed that the tricortical iliac allograft was superior to the patellar allograft, and further studies are warranted to further elucidate the effects of age on radiographic graft failure.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Concomitant calcaneo-cuboid-cuneiform osteotomies and the modified Kidner procedure for severe flatfoot associated with symptomatic accessory navicular in children and adolescents

BACKGROUND

Accessory navicular can become symptomatic in childhood, and in some cases, the condition is associated with progressive flattening of the longitudinal arch. Moreover, some severe, rigid flatfoot deformities are associated with an accessory navicular. We investigated the results of concomitant calcaneo-cuboid-cuneiform osteotomies (triple C) and the modified Kidner procedure for severe flatfoot associated with a symptomatic accessory navicular in children and adolescents.

METHODS

Twenty-one feet of 13 patients (nine boys, four girls; mean age 12.7 years) with severe flatfoot associated with a symptomatic accessory navicular who were treated with concomitant triple C and the modified Kidner procedure were evaluated based on clinical and radiographic examinations preoperatively and at a mean follow-up of 22.4 months (range, 12-36 months). We measured 12 variables on the anteroposterior (AP) and lateral weight-bearing radiographs, and we used the American College of Foot and Ankle Surgeons (ACFAS) score for clinical assessment.

RESULTS

We found significant improvements (p < 0.001) in eight of the 12 radiographic measurements: the AP talo-first metatarsal (MTT) angle, AP talo-navicular coverage angle, AP talo-calcaneal angle, lateral talo-first MTT angle, calcaneal pitch, lateral talo-calcaneal angle, lateral talo-horizontal angle, and naviculo-cuboid overlap. Average ACFAS scores were significantly improved at the time of the last follow-up (p < 0.001). The only complication was overcorrection of the hindfoot in one patient.

CONCLUSIONS

Concomitant triple C and the modified Kidner procedure result in favorable radiographic and clinical outcomes in the treatment of severe flatfoot associated with a symptomatic accessory navicular in children and adolescents.

Pes planovalgus deformity in children with cerebral palsy: review article

Pes planovalgus deformity is common in children with cerebral palsy. In planovalgus foot, the talus subluxates medially, the calcaneus is in valgus, and the forefoot is in supination and external rotation related to the midfoot. In young children, mild planovalgus feet can be managed with orthotics. Surgery is indicated if the deformity is not reducible or if the patient cannot tolerate orthotics during functional activities. The surgery can be calcaneal lengthening or subtalar fusion to restore a stable plantigrade foot and achieve hindfoot correction. Medial column fusion is important to reconstruct the medial arch in severe planovalgus feet.

Radiologic morphology of the calcaneus: a study of radiologic angles in a pediatric population

BACKGROUND

The Fowler-Philip, calcaneal pitch, and total calcaneal angles define the radiologic morphology of the rearfoot. We studied these angles in healthy adolescents.

METHODS

We studied 141 feet. Patients with inflammatory or traumatic injuries were excluded. The mean participant age was 11.5 years. The Fowler-Philip, calcaneal pitch, and total calcaneal angles were measured on lateral weightbearing radiographs. The statistics included descriptive, sample size (α=0.05 and β=0.20), the Student t test, and analysis of variance; P < .05 was considered significant.

RESULTS

The samples were 141 and 35 radiographs for the Fowler-Philip and calcaneal pitch angles, respectively. Ninety percent, 25.1%, and 97.4% of the adolescents had normal Fowler-Philip, calcaneal pitch, and total calcaneal angles, respectively. In addition, 9.9%, 74.9%, and 2.6% of the values were outside the reference ranges, respectively. The Fowler-Philip angle decreased and the calcaneal pitch angle increased significantly with age (P = .0005). The total calcaneal angle did not change with age (P = .65).

CONCLUSIONS

The mean angle values in a pediatric population did not differ from those in adults. We found a high percentage of calcaneal pitch angles outside the reference range. Age influenced the Fowler-Philip and calcaneal pitch angles but not the total calcaneal angle.

Long-term outcome of planovalgus foot surgical correction in children with cerebral palsy

Pes planovalgus deformity results from changes in the anatomic relations among tarsal bones. Foot deformity and pain can affect the patient's ability to ambulate and are common indications for surgery. The present study was a retrospective study aimed at assessing the effectiveness and complications of subtalar fusion and calcaneal lengthening during long-term follow-up in ambulatory children with cerebral palsy. Pedobarographic measurements, ankle range of motion, and radiographic indexes were used to assess the outcome of surgery. The functional abilities of the patients were assessed using the gross motor functional classification system. Pain complaints were reported to evaluate potential risk factors. A total of 24 patients (43 feet) were included, with mean age at surgery of 11 ± 3.2 (range 4.7 to 18.3) years and mean follow-up duration of 10.9 ± 2.7 (range 6.3 to 15.4) years. Of the 43 feet, 15 were treated with calcaneal lengthening (mostly gross motor functional classification system level I and II) and 28 with subtalar fusion (mostly gross motor functional classification system level III and IV). Improvement was observed in both surgery groups during long-term follow-up. The need for additional surgery was observed more among patients with poor ambulation who were treated with subtalar fusion. Young patients who underwent surgery were more likely to develop foot pain. Foot pain was less common among children with poor functional abilities and patients who underwent subtalar fusion. Surgical correction of planovalgus deformity has good outcomes after both subtalar fusion and calcaneal lengthening, with maintenance of the deformity correction during long-term follow-up.

The operative correction of symptomatic flat foot deformities in children: the relationship between static alignment and dynamic loading

At our institution surgical correction of symptomatic flat foot deformities in children has been guided by a paradigm in which radiographs and pedobarography are used in the assessment of outcome following treatment. Retrospective review of children with symptomatic flat feet who had undergone surgical correction was performed to assess the outcome and establish the relationship between the static alignment and the dynamic loading of the foot. A total of 17 children (21 feet) were assessed before and after correction of soft-tissue contractures and lateral column lengthening, using standardised radiological and pedobarographic techniques for which normative data were available. We found significantly improved static segmental alignment of the foot, significantly improved mediolateral dimension foot loading, and worsened fore-aft foot loading, following surgical treatment. Only four significant associations were found between radiological measures of static segmental alignment and dynamic loading of the foot. Weakness of the plantar flexors of the ankle was a common post-operative finding. Surgeons should be judicious in the magnitude of lengthening of the plantar flexors that is undertaken and use techniques that minimise subsequent weakening of this muscle group.

Subtalar fusion for pes valgus in cerebral palsy: results of a modified technique in the setting of single event multilevel surgery

BACKGROUND

We studied the use of cortico-cancellous circular allograft combined with cannulated screw fixation for the correction of dorsolateral peritalar subluxation in a series of children with bilateral spastic cerebral palsy undergoing single event multilevel surgery.

METHODS

Forty-six children who underwent bilateral subtalar fusion between January 1999 and December 2004 were retrospectively reviewed. Gait laboratory records, Gross Motor Function Classification System (GMFCS) levels, Functional Mobility Scale (FMS) scores, and radiographs were reviewed. The surgical technique used an Ollier type incision with a precut cortico-cancellous allograft press-fit into the prepared sinus tarsi. One or two 7.3 mm fully threaded cancellous screws were used to fix the subtalar joint. Radiographic analysis included preoperative and postoperative standing lateral radiographs measuring the lateral talocalcaneal angle, lateral talo-first metatarsal angle, and navicular cuboid overlap. Fusion rate was assessed with radiographs >12 months after surgery.

RESULTS

The mean patient age was 12.9 years (range, 7.8 to 18.4 y) with an average follow-up of 55 months. Statistically significant improvement postoperatively was found for all 3 radiographic indices: lateral talocalcaneal angle, mean improvement 20 degrees (95% CI, 17.5-22.1; P<0.001); lateral talo-first metatarsal angle, mean improvement 21 degrees (95% CI, 19.2-23.4; P<0.001); and navicular cuboid overlap, mean improvement 29% (95% CI, 25.7%-32.6%; P<0.001). FMS improved across all patients, with Gross Motor Function Classification System III children experiencing a 70% improvement across all 3 FMS distances (5, 50, and 500 m). All 3 radiographic measures improved significantly (P<0.001). Fusion was achieved in 45 patients and there were no wound complications.

CONCLUSIONS

With this study, we demonstrate significant improvement in radiographic segmental alignment and overall function outcome with this modified subtalar fusion technique. We conclude that this technique is an effective complement for children with dorsolateral peritalar subluxation undergoing single event multilevel surgery.

LEVEL OF EVIDENCE

Level IV.

Calcaneal lengthening for planovalgus foot deformity in patients with cerebral palsy

BACKGROUND

Calcaneal lengthening has been used to correct planovalgus foot deformities in patients with cerebral palsy (CP).

QUESTIONS/PURPOSES

This study was performed to investigate the amount of correction that can be achieved after calcaneal lengthening for the treatment of a planovalgus deformity in patients with CP and to provide cutoff values based on the preoperative radiographic measurements that suggest additional procedures to achieve satisfactory correction.

METHODS

Seventy-five consecutive patients with CP who underwent calcaneal lengthening for planovalgus deformity were included. Radiographic indices were measured on preoperative and latest followup weightbearing foot radiographs. The cutoff values of the preoperative radiographic measurements between the corrected and undercorrected groups were analyzed. The cutoff values are the reference values that can judge the possibilities of sufficient correction of a planovalgus deformity by calcaneal lengthening.

RESULTS

The mean age of the patients at the time of surgery was 11.0 ± 5.2 years and the minimum followup was 1.0 years (mean, 3.1 ± 2.2 years; range, 1.0-8.4 years). AP talus-first metatarsal angle, calcaneal pitch angle, talocalcaneal angle, lateral talus-first metatarsal angle, and naviculocuboid overlap showed major improvements after calcaneal lengthening. The cutoff values of preoperative measurements between the corrected and undercorrected groups were 23° AP talus-first metatarsal angle, 36° lateral talus-first metatarsal angle, and 72% naviculocuboid overlap.

CONCLUSIONS

Calcaneal lengthening with concomitant peroneus brevis lengthening is an effective procedure for correcting a planovalgus foot deformity in patients with CP. However, for patients with greater than 23° AP talus-first metatarsal angle, 36° lateral talus-first metatarsal angle, and 72% naviculocuboid overlap, additional procedures for medial stabilization, such as tibialis posterior tendon reefing and talonavicular arthrodesis, should be considered as a result of the possibility of undercorrection with calcaneal lengthening alone.

Medial column stabilization improves the early result of calcaneal lengthening in children with cerebral palsy

Calcaneal lengthening is a popular surgical treatment for pronated foot deformity. The aim of this study is to assess the effectiveness of medial column stabilization in improving the results of calcaneal lengthening for pronated foot deformity in ambulatory children with cerebral palsy. Twenty-one consecutive (37 feet) children with cerebral palsy with pronated foot deformity who received calcaneal lengthening from 2004 to 2009 were reviewed. Talonavicular stabilizations were performed by either stapling alone or fusion depending on the children's age and correctability of midfoot deformity. Satisfaction rates were assessed using Mosca's radiographic, Mosca's clinical, and Yoo's clinical criteria. Talonavicular coverage angle was also measured. Results between groups with and without stabilization of the talonavicular joint were compared. Group 1 included 11 children (19 feet) who had no talonavicular stabilization. Group 2 included 10 children (18 feet) who had talonavicular fixation. Groups were further divided into subgroups A [Gross Motor Function Classification System (GMFCS)≤II] and B (GMFCS≥III). Factors including demography, geographical classification, functional status, and preoperative degree of deformity were similar between the two groups. After the operation, all four radiographic parameters improved significantly. The talonavicular coverage angle was better in group 2 than in group 1. Mosca's radiographic results were satisfactory in 73.68% of cases in group 1 and 100% in group 2; the difference was statistically significant (P=0.027). As for Mosca's clinical results, 63.16% in group 1 and 83.33% in group 2 achieved satisfactory results (P=0.156). On the basis of Yoo's criteria, the results were satisfactory in 57.89% of cases in group 1 and in 94.44% of cases in group 2 (P=0.012). Further analysis on the satisfaction rates between the subgroups showed similar results between the patients in subgroup 1A and 2A, and significantly better results in subgroup 2B than in subgroup 1B. Concurrent stabilization of the talonavicular joint is an effective method to improve clinical and radiographic results of calcaneal lengthening in children with cerebral palsy with pronated feet, and the effect is more significant in children with worse GMFCS levels.

Comparison of lateral opening wedge calcaneal osteotomy and medial calcaneal sliding-opening wedge cuboid-closing wedge cuneiform osteotomy for correction of planovalgus foot deformity in children

The purpose of the present study was to compare the clinical and radiographic results between 2 procedures, lateral opening wedge calcaneal osteotomy (LCL) and medial calcaneal sliding-opening wedge cuboid-closing wedge cuneiform osteotomy (3C) in patients with planovalgus foot deformity. A total of 38 patients who underwent either LCL (18 patients, 28 feet) or 3C (20 patients, 32 feet) were included in the present study. The etiology of the planovalgus foot deformity was idiopathic in 16 feet and cerebral palsy in 44 feet. The 2 procedures used in the present study were indicated in symptomatic (pain or callus) children in whom conservative treatment, such as shoe modifications or orthotics, had been applied for more than 1 year but had failed. The patients were evaluated preoperatively, postoperatively, and at the last follow-up visit, both clinically and radiologically, and the interval to union and postoperative courses were compared between the 2 groups. In the LCL group, 19 of the 28 feet (68%) showed a satisfactory outcome and 9 (32%) an unsatisfactory outcome. In the 3C group, 28 of the 32 feet (88%) showed a satisfactory outcome and 4 (12%) an unsatisfactory outcome. The clinical results were not significantly different between the 2 groups, with mild to moderate pes planovalgus deformity. However, the clinical results were better in the 3C group with severe pes planovalgus deformity than in the LCL group with severe pes planovalgus deformity. All 4 radiographic parameters were improved at the last follow-up visit in both groups. In particular, the talar-first metatarsal angle and the calcaneal pitch angle on the weightbearing lateral radiographs were significantly improved in the 3C group with mild to moderate planovalgus foot deformity. All 4 parameters were significantly improved in the 3C group with severe planovalgus foot deformity. No significant differences were observed between the 2 groups in terms of the interval to union and postoperative care. No case of postoperative deep infection or nonunion was encountered in either group. 3C is a more effective procedure than LCL for the correction of pes planovalgus deformity in children, especially severe pes planovalgus deformities.

Incidence of nonunion of the unfixated, isolated evans calcaneal osteotomy: a systematic review

The Evans calcaneal osteotomy is frequently implemented in flatfoot reconstructive surgery for correction of planar deformity. Rigid fixation across an osteotomy is a documented, accepted technique to gain stability. However, since the original description of this osteotomy, which involved no internal fixation, debate has existed regarding the necessity of fixation. Conventional wisdom suggests that the nonunion rate would increase with an unfixated osteotomy. Thus, in an effort to determine the incidence of nonunion of the unfixated, isolated Evans calcaneal osteotomy, we conducted a systematic review. Studies were eligible for inclusion only if they included the following: the nonunion rate for unfixated, isolated Evans calcaneal osteotomy, follow-up of at least 1 year and a sample size of at least 5 feet. After considering all potentially eligible studies, 2 evidence-based medicine level 2 and 3 evidence-based medicine level 3 studies met our inclusion criteria. A total of 73 feet, with a weighted mean age of 22.6 years, were included. The weighted mean follow-up of the included studies was 3.6 years. A total of 1 nonunion (1.4%) was reported. The results of our systematic review revealed an acceptably low rate of nonunion for the unfixated, isolated Evans calcaneal osteotomy. However, considering the limited data available, additional prospective investigations are warranted to further validate the nonunion rate with this technique.

The foot and ankle in cerebral palsy

Clinical decision making for the management of foot deformities in children with cerebral palsy is based on the collection and integration of data from 5 sources: the clinical history, physical examination, plain radiographs, observational gait analysis, and quantitative gait analysis (which includes kinematic/kinetic analyses, dynamic electromyography, and dynamic pedobarography). The 3 most common foot segmental malalignments in children with CP are equinus, equinoplanovalgus, and equinocavovarus. The 2 most common associated deformities are ankle valgus and hallux valgus. Foot and ankle deformities caused by dynamic overactivity and imbalance of muscles are best treated with pharmacologic or neurosurgical interventions designed to manage muscle tone and spasticity, or muscle tendon unit transfers. Deformities caused by fixed or myostatic soft tissue imbalance without fixed skeletal malalignment are best treated with muscle tendon unit lengthening surgery. Deformities characterized by structural skeletal malalignment associated with fixed or myostatic soft tissue imbalance are best treated with a combination of soft tissue and skeletal surgeries.

Flexible flatfoot in children and adolescents

Flexible flatfoot is a normal foot shape that is present in most infants and many adults. The arch elevates spontaneously in most children during the first decade of life. There is no evidence that a longitudinal arch can be created in a child's foot by any external forces or devices. Flexible flatfoot with a short Achilles tendon, in contrast to simple flexible flatfoot, is known to cause pain and disability in some adolescents and adults. Joint-preserving, deformity-correcting surgery is indicated in flexible flatfeet with short Achilles tendons when conservative measurements fail to relieve pain under the head of the plantar flexed talus or in the sinus tarsi area. Osteotomy is the fundamental and central procedure of choice. In almost all cases, Achilles tendon lengthening is required. In some cases, rigid supination deformity of the forefoot is present, requiring identification and concurrent treatment.

Neuromuscular deformity: treatment with external fixation

A multiplanar foot deformity is defined by the presence of more than one deformity affecting the foot. These deformities may develop in any plane, including the frontal, sagittal, or transverse planes. This article focuses on the treatment of multiplanar neuromuscular foot deformities with external fixation, reviewing the indications, preoperative planning, techniques, and complications.

A comparison of two different techniques in the surgical treatment of flexible pes planovalgus: calcaneal lengthening and extra-articular subtalar arthrodesis

The objective of this study was to compare the results of calcaneal lengthening and Dennyson-Fulford extra-articular subtalar arthrodesis operations performed in patients with flexible pes planovalgus owing to various etiologies and to compare their effectiveness in realigning the foot. Two patient groups were retrospectively formed out of the patients in whom calcaneal lengthening (25 feet of 13 patients) and subtalar extra-articular arthrodesis (27 feet of 15 patients) operations were performed. The modified Evans technique for the calcaneal lengthening operation and the Dennyson-Fulford technique for the subtalar extra-articular arthrodesis operation were applied. Any special criterion to choose the indication was not considered. The main indication for the surgery was pain during daily routine activities in both groups. The patients were evaluated preoperatively and during the last visit, both clinically and radiographically. The groups were homogenous for sex and mean age for the process, but in the subtalar extra-articular arthrodesis group, the deformity was more severe in some parameters, mean follow-up period was significantly longer and neurologic etiologies were more dominant. Anteroposterior talocalcaneal and talonavicular angles were worse in the subtalar extra-articular arthrodesis group preoperatively (P<0.05). Both groups showed significant correction (P<0.05) in all parameters postoperatively. In the last visit, lateral talocalcaneal, anteroposterior, and lateral talonavicular angles were worse in the calcaneal lengthening group (P<0.05) and calcaneal pitch angle was worse in the subtalar extra-articular arthrodesis group (P<0.05). Both groups showed significant clinical correction (P<0.05) in all parameters postoperatively, but there was no significant difference between the groups during the last visit in terms of total clinical scores (P>0.05). Pain, the parameter that was the main indication for surgery, was eliminated in all patients except for one in the calcaneal lengthening group. The evaluation of the effectiveness of the surgical technique on the results made by performing repeated measures from general linear models showed significantly better correction in anteroposterior and lateral talocalcaneal angles, anteroposterior and lateral talonavicular angles, and medial longitudinal arc angle in the subtalar extra-articular arthrodesis group (P<0.05). In conclusion, in this study group, the subtalar extra-articular arthrodesis technique was superior in talocalcaneonavicular joint complex reduction and medial longitudinal arc reconstruction in the surgical treatment of flexible pes planovalgus, and calcaneal lengthening provided better correction of calcaneal equinus. Therefore, it is better to use the calcaneal lengthening technique in mild or moderate deformities because of its physiological advantages, and subtalar extra-articular arthrodesis technique in severe and/or rigid deformities because of its superior potential to correct the deformity and stabilize the foot in the corrected position.

Calcaneal lengthening for planovalgus deformity in children with cerebral palsy

BACKGROUND

In children with cerebral palsy, planovalgus deformity of the foot is common. The aim of this study was to evaluate the outcome of calcaneal lengthening for the treatment of planovalgus foot deformity in children with cerebral palsy.

MATERIALS AND METHODS

We reviewed 19 children (28 feet) treated between 1996 and 2004 in our institution. There were 14 ambulating (19 feet) and 5 nonambulating children (9 feet). The average age of the children at time of surgery was 8.6 years. Followup averaged 4.3 years.

RESULTS

We found satisfactory results in 75% of the feet clinically and in 79% radiologically according to Mosca's criteria. We saw no overcorrection but a relapse of the deformity in seven cases. There were six unsatisfactory radiological results, two (out of 19) in the ambulating and four (out of nine) in the nonambulating group. Ambulating children had a significantly better clinical and radiological outcome than nonambulating children (p = 0.042). A significant correlation was found between Ankle-hindfoot Score and clinical result according to Mosca's criteria (p = 0.001).

CONCLUSION

In ambulatory children with cerebral palsy calcaneal lengthening is an effective procedure for the correction of mild to moderate planovalgus foot deformities. In nonambulatory children with severe plano-valgus deformities of the foot, calcaneal lengthening cannot be recommended because of the high relapse rate in these patients.

Calcaneocuboid joint subluxation after calcaneal lengthening for planovalgus foot deformity in children with cerebral palsy

BACKGROUND

Calcaneal lengthening is a common procedure for the treatment of symptomatic planovalgus deformity in children with cerebral palsy. Stabilization of the calcaneocuboid joint to prevent subluxation at the time of lengthening has been described. The purpose of this study was to evaluate the magnitude of calcaneocuboid joint subluxation and associated degenerative changes in patients with cerebral palsy who underwent calcaneal lengthening for planovalgus foot deformity with and without stabilization of the calcaneocuboid joint.

METHODS

We conducted a retrospective review of children with cerebral palsy who underwent lateral column lengthening through the calcaneus. For the purposes of statistical analysis, the feet were divided into 2 groups: stabilized (those that received Steinmann pin stabilization at the time of lengthening) and nonstabilized (those feet that did not receive Steinmann pin stabilization). Initial, intraoperative, and most recent follow-up radiographs were reviewed for segmental foot analysis of planovalgus deformity, calcaneocuboid joint subluxation, and osteoarthritic changes. A minimum of 3-year follow-up was required.

RESULTS

Sixty-one feet were included in this study; 28 feet in the stabilized group and 33 in the nonstabilized group. Radiographic assessment of segmental foot analysis demonstrated significant improvement with regard to planovalgus deformity (P<0.05, 5 measurements). Calcaneocuboid joint subluxation occurred in 24 feet in the stabilized group and 29 feet in the nonstabilized group (P=0.5269). At final follow-up, the magnitude of subluxation was not significantly different between the groups (P=0.076). There was no difference in the incidence of osteoarthritic changes at the calcaneocuboid joint between the groups (P=0.2856).

CONCLUSIONS

Lateral column lengthening through the calcaneus, for planovalgus foot deformity, significantly improved the segmental alignment of the foot with respect to radiographic assessment. Stabilization of the calcaneocuboid joint at the time of lateral column lengthening through the calcaneus did not significantly reduce the incidence or magnitude of subluxation when compared with nonstabilized lengthening. In addition, stabilization did not have an effect on the development of radiographic osteoarthritic changes at the calcaneocuboid joint.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.