Effects of lateral column lengthening for flat foot

NewsBot · Sep 29, 2022

Calcaneal lengthening osteotomy in the management of idiopathic flatfoot in children: cCase series of twenty-one feet
Mohamed Zairi et al
Int J Surg Case Rep. 2022 Sep 9

Introduction: Flatfoot is a frequent reason for consultation in pediatric orthopedics. The calcaneal lengthening osteotomy according to the EVANS technique is a therapeutic alternative. The objective of this work was to evaluate the short and medium term clinical and radiological results of calcaneal lengthening osteotomy in children with idiopathic flat foot valgus.

Methods: This study concerned 12 children and 15 ft treated surgically by calcaneal lengthening osteotomy by an orthopedic surgeon in a pediatric orthopedic surgery center. The evaluation of the results was clinical according AOFAS score and radiological.

Results: The deformity was reducible in all of our patients. The mean preoperative AOFAS score was 61, postoperatively 90. The overall result was excellent in 11 cases (11 ft) and good in 4 cases. The postoperative radiological result was close to normal values.

Conclusion: Calcaneal lengthening osteotomy is a reliable and recommended technique for the correction of symptomatic idiopathic flatfoot.
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NewsBot · Nov 5, 2022

Pitfalls of Calcaneal Lengthening Osteotomies

NewsBot · Nov 17, 2022

Analysis of risk factors for nonunion in pediatric lateral column lengthening
Torrez, Timothy W.a,b; Kothari, Ezan A.a; Andrews, Nicholasa; Seidenstein, Alexandra Ha; Strom, Shanea; McGwin, Gerald Jr.a; Gilbert, Shawn R.a; Shah, Ashisha; Doyle, John S.a; Conklin, Michael Ja
Journal of Pediatric Orthopaedics B: November 14, 2022 - Volume - Issue - 10.1097/BPB.0000000000001026

The lateral column lengthening procedure is a commonly used osteotomy for correction of pes planus performed by inserting a graft in the anterior aspect of the calcaneus through a transverse osteotomy. Though nonunion and calcaneo-cuboid subluxation have been previously reported, these complications have not been extensively studied in pediatric patients. After IRB approval, 111 patients (151 feet) who underwent lateral column lengthening at a single institution were identified. Fifty-three females (70 feet) and 58 males (81 feet) with an average age of 11.4 years (2.6 SD; range 5–17) were analyzed. The primary outcome was nonunion defined as a lack of radiographic evidence of osteotomy healing by 9 months. Underlying diagnosis, pre and postoperative radiographic measurements, age, operative technique, fixation, calcaneo-cuboid subluxation, graft material and concomitant procedures were analyzed for their relationship to nonunion. Nonunion occurred in 7 of 151 feet (4.6%). Patient age at the time of surgery and calcaneo-cuboid subluxation trended toward a significant association with nonunion (P = 0.053, 0.054, respectively). The degree of surgical correction, as determined by radiographic analysis, and the use of calcaneo-cuboid fixation were not significantly associated with nonunion. None of the other factors evaluated were significantly associated with nonunion. There were three cases of postoperative infections (2.0%), two were superficial and 1 (0.7%) was deep. Thirty-five of 151 feet disclosed radiographic evidence of subluxation. Excluding subluxation, the overall complication rate was 8.6%. Nonunion occurred in 4.6% of pediatric feet undergoing lateral column lengthening. Fixation type was not significantly associated with nonunion. Older age at the time of surgery and calcaneocuboid subluxation trended towards significance. The placement of a calcaneo-cuboid pin was not found to be a significant factor in preventing calcaneo-cuboid subluxation or nonunion.
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NewsBot · Nov 21, 2022

Talar Head Coverage Correction in the Absence of Lateral Column Lengthening: A Prospective Study with Calcaneal Osteotomy and First Ray Procedures
Nacime SB Mansur, MD, Kepler Carvalho, MD, […], Eli Schmidt, Ki Chun Kim, MD, Edward O. Rojas, MD, Vineel Mallavarapu, BS, Kevin N. Dibbern, PhD, Jonathan T. Deland, MD, Matthieu Lalevée, MD, and Cesar de Cesar Netto, MD, PhD
Source

Introduction/Purpose:
Peritalar subluxation (PTS) is a crucial feature of Progressive Collapsing Foot Deformity (PCFD). Surrounding structures assume distinct behaviors, contributing to different disease deformities (classes). One of its most traditional aspects is the midfoot abduction (class B), usually noted by a lateral deviation of distal structures at the talonavicular joint. This finding commonly leads surgeons to perform a lateral column lengthening osteotomy for abduction correction, a complex surgery with potential complications. The first ray's ability to reestablish the tripod and restore the hindfoot by derotating structures under the talus was previously theorized. This study aimed to test the capability of the Lapidus and the Cotton procedures in conjunction with a calcaneus displacement osteotomy (MDCO) to improve midfoot abduction in the setting of a collapsed foot.
Methods:
In this IRB-approved, prospective cohort study, we analyzed patients undergoing medial column instability surgery and evaluated preoperatively with a weight-bearing CT (WBCT). We included individuals receiving a Lapidus bone block procedure or a Cotton for PCFD or Hallux Valgus (HV). Patients having a lateral column lengthening procedure of any type were excluded. Talonavicular coverage angle (TNCA) was measured as a marker of midfoot abduction. Medial arch collapse and forefoot varus were evaluated by the sagittal talus-first metatarsal angle (TFMA), and the forefoot arch angle (FFA) was measured. Associated procedures and the correction amount (displacement or wedge size) were recorded. Normality was estimated by the Shapiro- Wilk test and comparison among timelines by the one-way ANOVA. A multivariate regression analysis was executed to evaluate which of the measurements influenced abduction improvement. Statistical significance was considered for p-values of less than 0.05.
Results:
A total of 20 patients (age: 43.85 [19-72], BMI 30.98 [SD: 5.95]) were included, 11 PCFD (55%) and 9 HV (45%) with a mean follow-up of 7.5 months (3-12). Bone block Lapidus was performed in most subjects (90%), and the median wedge used was 9mm (5-12mm). MDCO occurred in 55% of patients. All measured variables had improvement with surgery (TNCA: 23.74 to 10.66, p<0.0001; FFA: 6.27 to 12.67, p<0.0001; TFMA: 11.73 to 4.22, p=0.0003). A correlation was found between TNCA improvement and FFA improvement (rs=0.46, p=0.0407), but not among TNCA improvement and TFMA improvement (rs=0.43, p=0.06). The size of the wedge did not strongly influence the TNCA correction (R2=0.016, p=0.0036), an improvement moderately explained by the MDCO amount (R2=0.186, p<0.0001).
Conclusion:
This study demonstrated correction of midfoot abduction, translated by the TNCA, in the absence of lateral column lengthening procedures. When evaluating patients submitted to first ray procedures (bone block Lapidus and Cotton) in conjunction with MDCO, an enhancement on the talar head coverage was noted. Variables associated with arch height and forefoot varus (FFA and TFMA) were correlated with the TNCA improvement. Nevertheless, only the MDCO displacement amount and not the size of the used allograft wedge could explain changes in TNCA. The provided data might support surgeons when planning treatment in the PCFD scenario.
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NewsBot · Nov 21, 2022

How Does Lateral Column Lengthening Improve the Medial Longitudinal Arch? Now I Started to Understand!
Mohamed M. Abd-Ella, MDView all authors and affiliations
Source

Introduction/Purpose:
Since its description by Evan for correction of overcorrected clubfoot cases, lateral column lengthening (LCL) has been widely used for correction of pes planovalgus deformity of any etiology, including flexible flat foot deformity in adolescents and adults, either as a solitary procedure or in combination with other bony or soft tissue procedures. The main indication is correction of forefoot abduction manifested radiologically as talonavicular uncoverage. Different techniques were described including Evan and Hintermann techniques. It was reported by many authors that LCL improved forefoot abduction and talonavicular uncoverage, but it was also noticed that LCL corrects the flattening of medial longitudinal arch. The mechanism by which LCL corrects the medial longitudinal arch is still not clearly understood. It was also reported that LCL is associated with forefoot supination, but the exact mechanism of supination is not understood. This study aimed to try to understand the mechanism by which LCL changes the shape of the foot.
Methods:
LCL osteotomy using Hintermann technique was performed in ten fresh frozen below knee cadaveric specimens. After completion of the osteotomy, the talus and leg were removed to monitor how the foot moves under the talus with opening of the osteotomy to change the shape of the foot. After that, the whole plantar skin was removed and plantar ligaments were dissected to study the influence of plantar ligaments on the plane of motion of the osteotomy and the effect of the osteotomy on plantar ligaments.
Results:
With opening of the osteotomy, the distal portion of the foot did not move in pure adduction as might be expected. Instead, it moved medial and plantar, and the osteotomy worked as a dorsolateral opening wedge osteotomy meaning that the osteotomy opened laterally but not medially, and dorsally but not inferiorly. The result was that the distal portion was adducted and plantar flexed, so it can correct the forefoot abduction and the flat arch. Because the osteotomy opens dorsally and laterally only, with no opening medially or inferiorly, the lateral part of the distal portion was plantar flexed more than the medial part, and this is the cause of forefoot supination. After dissection of the plantar ligaments to understand their influence on the osteotomy, it was found that the long and short plantar ligaments prevent the osteotomy from opening inferiorly and force it to work as a dorsolateral opening wedge. It was possible to move the distal portion in pure adduction only after cutting the long and short plantar ligaments. As the osteotomy worked as a dorsolateral opening wedge, the plantar fascia which is plantar and medial was relaxed after opening of the osteotomy.
Conclusion:
May be this can explain how the LCL osteotomy corrects the flat medial longitudinal arch and how it causes supination and lateral side overload. Based on this study, Cotton osteotomy may be needed to be added to LCL to correct the supination. Also, plantar fascia tightening cannot be the cause of medial longitudinal arch correction as it actually becomes more lax after opening of the osteotomy
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NewsBot · Nov 26, 2022

Treatment of Symptomatic Flexible Flat Foot in Pediatrics with A Modified Mosca's Lateral Column Lengthening
Alireza Ghaznavi et al
Med J Islam Repub Iran. 2022 Aug 17

Background: The optimal treatment of flat foot is still controversial. In this study, we evaluated the outcome the Mosca's lateral column lengthening with the advancement of the tibialis posterior. Methods: In a retrospective study . fifty symptomatic pediatric flexible flat feet with or without hindfoot valgus were ‎included in this study. Lateral column lengthening was done as described by Mosca. ‎The tibialis posterior advancement was made on the navicular bone instead of the medial cuneiform. Radiographic measures of outcome were evaluated before the surgery and immediately ‎after the surgery and included Calcaneal Inclination (Pitch) Angle, Talonavicular Coverage ‎Angle, Talo-1st metatarsal Angle (Meary's Angle), Lateral Talocalcaneal Angle, Anteroposterior ‎Talocalcaneal Angle (kite's angle), and Talar Declination Angle (Talo-Horizontal Angle).‎ A paired t-test or its nonparametric counterpart (Wilcoxon T-test) was used to compare the mean value of preoperative and postoperative measures. A chi-square test was used to compare qualitative variables Results: The mean age of the patients was ‎9.2±2.2‎‏ years‎. ‎The mean follow‎-‎up of the patients was ‏‎2.6±1.1‎‏ ‏years‎. All radiographic measures were significantly improved after the surgery. According to the radiographic measures, under-correction was seen in seven feet. Overcorrection was seen in one of the patients. Union of the osteotomy site was observed in all feet. No patients had postoperative pain or limited ankle range of motion. One superficial infection occurred that was managed with oral antibiotics. Conclusion: Lateral column lengthening and advancement of tibials posterior on navicular bone is a safe and effective procedure in the treatment of the symptomatic pediatric flexible flat foot.
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NewsBot · Jan 23, 2023

Changes in Gait Pattern and Quality of Life of Adolescents with Flexible Flat Foot after Calcaneal Lengthening Osteotomy
FarzadPourghazi et al
The Foot

Highlights
•Flat foot is categorized into two types: Flexible Flat Foot (FFF) and Rigid Flat Foot.
•Many articles have been published on the clinic radiological aspect of conservative and surgical treatment of FFF; on the other hand, there are few quantitative studies on mechanical analysis or pre and postoperative kinematic changes in FFF.
•CLO is the most physiologic procedure for treating FFF.
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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, We aimed to analyze the effects of CLO on the kinematic and kinetic changes of gait and assess the clinical and quality of life improvements in children treated by CLO for moderate to severe symptomatic flexible flat foot deformities.

Methods
Participants were seven adolescents (13 feet) with symptomatic FFF who underwent during 2019 to 2022 and seven (10 feet) healthy children as control group. We evaluated three items 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, we compared the kinetic and kinematic analysis between patients and healthy groups.

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 transeverse 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
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NewsBot · Jan 23, 2023

Individual Concepts in Foot Surgery: A Comparison of Xenogeneic and Autologous Bone Grafts Used in Adults for Lateral Calcaneus-Lengthening Osteotomy According to Evans
Markus Siegel et al
J Pers Med. 2022 Dec 30;13(1):95

Background: Xenogeneic bone grafts, when compared to autologous grafts, are supposed to provide structural benefits without donor site morbidity. To date, there have been divergent results in the use of xenogeneic grafts in foot surgery, primarily in pediatric patient cohorts. The present study examines the incorporation and maintenance of the achieved correction using autologous and xenogeneic bone grafts in adult patients with a six-month follow-up period.

Material/methods: In this retrospective study, 31 adult patients (43 feet in total) treated in our clinic by a lateral calcaneus-lengthening osteotomy, according to Evans, between 01/2006 and 12/2020 were included. The patients were assigned to study groups according to the use of xenogeneic or autologous bone grafts. The osseous incorporation following the criteria of Worth et al., correction maintenance by measuring the talo-navicular coverage angle (TNCA), the talo-first metatarsal angle (TFMA), the calcaneal pitch angle (PCA) and necessary revisions six months after surgery were extracted from the medical files retrospectively. Furthermore, the medical files were screened for the relevant comorbidities, nicotine abuse, BMI, sex and age.

Results: In total, 27 autogenous (iliac crest) and 16 xenogeneic bone grafts of bovine origin were used. The evaluation of the radiographs at follow-up demonstrated that there was a mean incorporation rate of 96.3% for the autologous grafts and 57% for the patients treated with xenogeneic grafts (p = 0.002). Compared to the autologous group, xenogeneic grafts did not increase the loss of hindfoot alignment in the postoperative course, regardless of being incorporated or not. ΔTNCA, ΔTFMA and ΔPCA displayed no significant differences in both groups (p = 0.45, p = 0.42 and p = 0.10).

Conclusion: Despite a significantly lower incorporation rate, the use of xenogeneic grafts was not accompanied with a greater risk of hindfoot alignment loss in the first six months after surgery. Early revision after a postoperative course of six months should not be motivated solely by the radiographic picture of incomplete osseous integration.
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NewsBot · Apr 4, 2023

Lateral column lengthening (LCL) using a rectangular shape graft for managing symptomatic flexible flatfoot showed acceptable early functional and radiological outcomes
Gamal Ahmed Hosny et al
Foot (Edinb). 2023 May

Purpose: We aimed to report the results of performing lateral column lengthening (LCL) using a rectangular-shaped graft to correct the flat foot deformity.

Methods: A total of 28 feet of 19 patients (10 males, 9 females) having an average age of 10 ± 3.2 years who were unresponsive to conservative management underwent flat foot deformity correction through LCL procedure supplemented with rectangular-shaped graft harvested from the fibula. Functional assessment was performed according to the American Orthopedic Foot and Ankle Society (AOFAS) scale. The radiographic assessment consisted of four parameters, Meary's angle in both anteroposterior (AP) and lateral (Lat.) views, calcaneal inclination angle (CIA), and calcaneocuboid angle (CCA).

Results: After an average of 30.2 ± 8.1 months, the AOFAS improved significantly from 46.7 ± 10.2 preoperatively to 86.7 ± 9.5 at the last follow up (P < 0.05). All the osteotomies showed healing at an average of 10.3 ± 2.7 weeks. All the radiological parameters showed significant improvement at the last follow up compared to the preoperative measurements, CIA from 6.3 ± 2.8-19.3 ± 3.5, Lat. Meary's angle from 19.3 ± 4.9-5.8 ± 2.5, AP Meary's Angle from 19.3 ± 5.8-6.1 ± 3.1, and CCA from 23.9 ± 8.2-6.8 ± 4.5, (P < 0.05). No pain at the site of the fibular osteotomy was reported in any of the patients.

Conclusion: Lateral column lengthening using a rectangular graft effectively restores bony alignment with good radiological and clinical results, high patient satisfaction, and acceptable complications.
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NewsBot · Aug 1, 2023

Analysis of risk factors for nonunion in pediatric lateral column lengthening
Torrez, Timothy W et al
Journal of Pediatric Orthopaedics B 32(5) 422-427, September 2023. | DOI: 10.1097/BPB.0000000000001026

The lateral column lengthening procedure is a commonly used osteotomy for correction of pes planus performed by inserting a graft in the anterior aspect of the calcaneus through a transverse osteotomy. Though nonunion and calcaneo-cuboid subluxation have been previously reported, these complications have not been extensively studied in pediatric patients. After IRB approval, 111 patients (151 feet) who underwent lateral column lengthening at a single institution were identified. Fifty-three females (70 feet) and 58 males (81 feet) with an average age of 11.4 years (2.6 SD; range 5–17) were analyzed. The primary outcome was nonunion defined as a lack of radiographic evidence of osteotomy healing by 9 months. Underlying diagnosis, pre and postoperative radiographic measurements, age, operative technique, fixation, calcaneo-cuboid subluxation, graft material and concomitant procedures were analyzed for their relationship to nonunion. Nonunion occurred in 7 of 151 feet (4.6%). Patient age at the time of surgery and calcaneo-cuboid subluxation trended toward a significant association with nonunion (P = 0.053, 0.054, respectively). The degree of surgical correction, as determined by radiographic analysis, and the use of calcaneo-cuboid fixation were not significantly associated with nonunion. None of the other factors evaluated were significantly associated with nonunion. There were three cases of postoperative infections (2.0%), two were superficial and 1 (0.7%) was deep. Thirty-five of 151 feet disclosed radiographic evidence of subluxation. Excluding subluxation, the overall complication rate was 8.6%. Nonunion occurred in 4.6% of pediatric feet undergoing lateral column lengthening. Fixation type was not significantly associated with nonunion. Older age at the time of surgery and calcaneocuboid subluxation trended towards significance. The placement of a calcaneo-cuboid pin was not found to be a significant factor in preventing calcaneo-cuboid subluxation or nonunion.
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NewsBot · Aug 8, 2023

Three-Dimensional Distance Mapping to Identify Safe Zones for Lateral Column Lengthening
Ben Efrima, MD et al
Source

Background:
Evans (E-LCL) and Hintermann LCL (H-LCL) lateral column lengthening osteotomies are standard surgical solutions for flexible, progressive collapsing feet. E-LCL is performed between the anterior and middle facets and endangers specific os calcis subtalar joint (OCST) subtypes without distinct facets. H-LCL is oriented between the posterior and middle facets and should be suitable for all OCSTs. Both osteotomies are associated with increased subtalar osteoarthritis, indicating iatrogenic damage. Distance mapping (DM) enables visualization of the relative distance between 2 articular surfaces represented by color patterns. This study aims to measure the safe zones for LCL using 3-dimensional (3D) models and DM; we hypothesize that it could be measured with high reproducibility.
Methods:
Two raters categorized 200 feet across 134 patients into OCSTs based on the Bruckner classification. Four angles were measured independently. The proximal and distal extents of the posterior safe zone (PSZ) angles were determined for H-LCL osteotomies; similarly, the proximal and distal extents of the anterior safe zone (ASZ) angles were identified for E-LCL osteotomies. Consequently, the surface available for safe osteotomies were calculated. An interclass correlation was used to assess the agreement between the 2 raters. Additionally, analysis of variance and Mann-Whitney U test were used to compare the safe zones between OCSTs.
Results:
The mean proximal and distal extents of the PSZ angles were 68 ± 7 and 75 ± 5 degrees from a line parallel to the lateral border of the calcaneus, respectively, and the proximal and distal extent of the ASZ angles were 89 ± 6 and 95 ± 5 degrees, respectively. There were no statistically significant differences between the OCSTs. Two raters measured the angles with good to excellent interrater and intrarater agreement. In 18 cases, we were unable to plan for H-LCL or E-LCL osteotomies.
Conclusion:
Distance mapping could be used to measure the safe zone, tailor a preoperative plan, and potentially reduce the risk for iatrogenic damage in LCL. 3D models and DM can increase the reliability of preoperative plans in bones with complex 3D structures.
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NewsBot · Sep 14, 2023

Risk Factors for Failure of Calcaneal Lengthening Osteotomy in Children and Adolescents With Planovalgus Foot Deformity: A Retrospective Study
Joe Mehanna et al
Cureus. 2023 Aug 8;15(8):e43157.

Introduction: The calcaneal lengthening procedure (CLP) is a well-known surgical technique used for the correction of symptomatic planovalgus foot deformities. Literature shows a significant rate of relapse and undercorrection of the foot post-operatively. Factors determining the failure or success of CLP are still not well understood. The purpose of this retrospective study was to assess the most significant factors related to the failure of this procedure.

Methods: A case-control retrospective study was conducted on 50 patients (80 feet) aged 12.4±2.5 years who underwent CLP. A clinical (demographic parameters, etiology, Gross Motor Function Classification System (GMFCS) level) and radiological evaluation were assessed preoperatively and repeated postoperatively at 56.5±32.5 months. Two methods of osteotomy bone fixation were studied: K-wires vs. eight-plate. Standing anteroposterior (AP) and lateral (L) radiographs were done, and the following radiographic parameters were measured: calcaneocuboid (CC) joint subluxation classified into normal, moderate, and severe (L); AP and L talo-first metatarsal (T1MT) angle; AP talonavicular (TN) coverage angle; AP and L talocalcaneal (TC) angle; calcaneal pitch (CP) angle; and L talo-horizontal (TH) angle. Mosca's criteria were used for clinical and radiological assessments. The association between demographic data, clinical and radiological results, and the variation between preoperative and postoperative angles were studied. The main risk factors affecting clinical results and CC joint subluxation were investigated (logistic regression and analysis of covariance (ANCOVA)).

Results: Satisfactory clinical results were associated with satisfactory radiological ones on Mosca's criteria (p<0.001). The use of an eight-plate for osteotomy fixation gave better results than K-wires (79% vs. 59%). Radiological angles were improved in both techniques postoperatively (increase of CP and L-TC and decrease of AP-T1MT, AP-TC, AP-TN, and L-T1MT, all p<0.05). Non-satisfactory clinical results were associated with a high GMFCS level, a low preoperative AP-TN coverage angle, and a low preoperative CP angle (R2=0.45). Both a young age and a low CP angle preoperatively were associated with CC subluxation (R2=0.31).

Conclusion: The neurological status and the severity of the planovalgus foot deformity preoperatively were the main risk factors affecting clinical outcomes after CLP. However, young age and the severity of the deformity preoperatively were the main risk factors behind CC joint subluxation affecting CLP outcomes.
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NewsBot · Oct 13, 2023

Is There a Benefit to Rigid Fixation in Calcaneal Lengthening Osteotomy in Painful Pediatric Idiopathic Flatfoot Deformity? Comparing Results of Kirschner Wire Versus Plate Fixation
Tippabhatla, Abhishek BS; Torres-Izquierdo, Beltran MD; William, Matthew BA; Pereira, Daniel MD; Meyer, Zachary MD; Hosseinzadeh, Pooya MD
Journal of Pediatric Orthopaedics 43(10) e823-e827, November/December 2023.

Introduction:
Flexible flatfoot (FF) is a common pediatric condition that is mostly asymptomatic, and surgical intervention is only considered when painful FF is refractory to conservative treatment. Calcaneal lengthening osteotomy (CLO) is one of the most commonly used procedures to address painful FF. Traditionally, Kirschner wires (K-wires) were used for fixation, but there has been a recent increase in the use of plates. We compared the clinical and radiographic outcomes of these 2 fixation methods.

Methods:
This single-center retrospective study included children aged 8 to 18 years with symptomatic FF that received CLO using K-wire or plate fixation. Primary outcomes include weight-bearing radiographic measurements and complications after surgery. Secondary outcomes included patient-reported outcomes. Statistical significance was held at 0.05.

Results:
Among 102 feet (65 patients), 42 feet (41.2%) underwent K-wire and 60 feet (58.8%) underwent plate fixation. No differences in casting duration (P=0.525) and time-to-radiographic healing (P=0.17) were noted. Total complications were higher in the plate cohort (12 vs. 2, P=0.04) due to a higher rate of reoperations (16.7%) for hardware-related pain [10 vs. 0; odds ratio 17.74, 95% CI (1.01, 310.54), P<0.05], and infection rates were similar. Both interventions significantly improved (P ≤ 0.001) aneteroposterior (AP) Talo-first metatarsal and calcaneal pitch angles. Irrespective of intervention, CLO significantly improved pain at 6 months and mobility scores at 12 months. Neither modality demonstrated superior pain or mobility scores at final follow-up.

Conclusion:
Both K-wire and plate fixations lead to similar radiographic and functional outcomes after CLO in painful, pediatric flatfeet. Compared with K-wire fixation, plates cause a 17.7-fold increased risk of reoperations for painful hardware, with 16.7% of plated cases requiring reoperation. Noting this, along with the higher costs associated with using plates, our study advocates for K-wire fixation for children undergoing CLO.
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NewsBot · Nov 9, 2023

Effect of flatfoot correction on the ankle joint following lateral column lengthening: A radiographic evaluation
Ji Hye Choi et al
PLoS One. 2023 Nov 2;18(11):e0286013

Objectives: The effects of foot deformities and corrections on the ankle joint without osteoarthritis has received little attention. This study aimed to investigate the effect of flatfoot correction on the ankle joint of patients without osteoarthritis.

Methods: Thirty-five patients (24 men and 11 women; mean age 17.5 years) who underwent lateral column lengthening for flatfoot deformities were included. The mean postoperative follow-up period was 20.5 months (standard deviation [SD]: 15.7 months). Radiographic indices were measured pre- and postoperatively, including anteroposterior (AP) and lateral talo-first metatarsal angles, naviculocuboid overlap, position of the articulating talar surface, and lateral talar center migration. Postoperative changes in the radiographic indices were statistically analyzed.

Results: There was significant postoperative improvement in flatfoot deformity in terms of AP and lateral talo-first metatarsal angles (p<0.001 and p<0.001, respectively) and naviculocuboid overlap (p<0.001). On lateral radiographs, the talar articulating surface dorsiflexed by 7.3% (p<0.001), and the center of the talar body shifted anteriorly by 0.85 mm (p<0.001) postoperatively.

Conclusions: Flatfoot correction using lateral column and Achilles tendon lengthening caused dorsiflexion and an anterior shift of the articular talar body in patients without osteoarthritis. Correction of flatfoot deformity might affect the articular contact area at the ankle joint. The biomechanical effects of this change need to be investigated further.
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NewsBot · Jan 1, 2024

Flatfoot Reconstruction for Painful Pediatric Idiopathic Flexible Flatfoot: Prospective Study Demonstrates Improved Alignment, Function, and Patient-reported Outcomes
Christopher J DeFrancesco et al
Pediatr Orthop. 2023 Dec 25.

Background: This prospective study was undertaken to report outcomes following reconstructive surgery for patients with painful pediatric idiopathic flexible flatfoot.

Methods: Twenty-five patients with pediatric idiopathic flexible flatfoot were evaluated pre- and post- flatfoot reconstruction with lateral column lengthening (LCL). All patients had lengthening of the Achilles or gastrocnemius, while 13 patients had medial side soft tissue (MSST) procedures, 7 underwent medial cuneiform plantarflexion osteotomy (MCPO), and 5 had medializing calcaneal osteotomy. Measures of static foot alignment-both radiographic parameters and clinical arch height indices-were compared, as were measures of dynamic foot alignment and loading, including arch height flexibility and pedobarography. Preoperative and postoperative patient-reported outcome (PRO) scores were compared between those treated with or without MSST procedures.

Results: The median subject age was 13.8 years (range: 10.3 to 16.5) at the time of surgery. All radiographic parameters improved with surgery (P<0.001). The mean sitting arch height index showed a modest increase after surgery (P=0.023). Arch height flexibility was similar after surgery. The mean center-of-pressure excursion index increased from 14.1% to 24.0% (P<0.001), and the mean first metatarsal head (MH) peak pressure dropped (P<0.001), while the mean fifth MH peak pressure increased (P=0.018). The ratio of peak pressure in the fifth MH to peak pressure in the second MH increased (P=0.010). The ratio of peak pressure in the first MH to peak pressure in the second MH decreased when an MCPO was not used (P<0.002), but it remained stable when an MCPO was included. Mean scores in all PRO domains improved (P<0.001). Patients treated without MSST procedures showed no difference in PROMIS Pain Interference scores compared to those without MSST procedures.

Conclusions: Flatfoot reconstruction surgery using an LCL with plantarflexor lengthening results in improved PROs. LCL changes but does not normalize the distribution of MH pressure loading. The addition of an MCPO can prevent a significant reduction in load-sharing by the first MH.
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NewsBot · Apr 17, 2024 at 2:16 AM

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
Fuat Bilgili, Mehmet Demirel, Dağhan Koyuncu
J Pediatr Orthop. 2024 Apr 16

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
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Effects of lateral column lengthening for flat foot

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Effects of reinforcing the lateral longitudinal arch on foot orthotics

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