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The Results of Calcaneal Lengthening Osteotomy for the Treatment of Flexible Pes Planovalgus and Evaluation of Alignment Of ACTA ORTHOPAEDICA et Author’ s tr anslation TRAUMATOLOGICA Acta Orthop Traumatol Turc 2006;40(5):356-366 TURCICA The results of calcaneal lengthening osteotomy for the treatment of flexible pes planovalgus and evaluation of alignment of the foot Fleksibl pes planovalgusta kalkaneal uzatma osteotomisinin sonuçlar› ve ayak diziliminin de¤erlendirilmesi Ahmet DOGAN,1 Mehmet ALBAYRAK,1 Y. Emre AKMAN,1 Gazi ZORER2 1Istanbul Education and Research Hospital, 1. Orthopaedy and Traumatology Department; 2Bezm-i Alem Valide Sultan Vakif Gureba Education and Research Hospital, 2. Orthopaedy and Traumatology Department A m a ç : Fleksibl pes planovalgus (PPV) deformitesi olan has- Objectives: We evaluated the results of calcaneal lengthening talarda modifiye Evans osteotomisi tekni¤iyle uygulanan kal- using the modified Evans osteotomy technique in patients with kaneal uzatma ameliyat›n›n sonuçlar› ve bu tekni¤in ayak di- flexible pes planovalgus and the effectiveness of this technique zilimini sa¤lamadaki baflar›s› de¤erlendirildi. in restoring the alignment of the foot. Çal›flma plan›: Fleksibl PPV deformitesi olan 11 hastan›n (6 Meth o d s : Calcaneal lengthening osteotomy was performed erkek, 5 k›z; takip sonu ort. yafl 10 y›l 10 ay; da¤›l›m 5 y›l 6 ay- using the modified Evans technique in 22 feet of 11 patients (6 14 y›l 8 ay) 22 aya¤›na modifiye Evans osteotomisi tekni¤iyle males, 5 females; mean age at the end of follow-up, 10 years 10 kalkaneal uzatma ameliyat› yap›ld›. Etyoloji, befl olguda sereb- months; range 5 years 6 months to 14 years 8 months) with flex- ral felç, bir olguda miyelomeningosel sekeli, bir olguda heredi- ible pes planovalgus deformity. Etiologies were cerebral palsy ter sensorimotor polinöropati iken, dört olgu idiyopatik olarak (n=5), sequela of myelomeningocele (n=1), and sensorimotor de¤erlendirildi. Olgular›n tümü ameliyat öncesinde uzun süre- polyneuropathy (n=1); four patients were evaluated as idiopath- li konservatif tedavi görmüfl, bir hasta d›fl›nda hiçbir olgu de- ic. All the patients received long-term conservative therapy pre- formite nedeniyle ameliyat geçirmemiflti. ‹ki tarafl› deformite- o p e r a t i v e l y, and, except one patient, none had underg o n e l e r, bir hasta hariç tüm hastalarda ayn› seansta ameliyat edildi. s u rgery for the deformity. All patients but one were operated on Klinik de¤erlendirmede 10 parametre; standart ön-arka ve yan bilaterally at a single session. Clinical assessment was based on radyografiler üzerinden yap›lan radyografik de¤erlendirmede 10 parameters, and radiographic assessment was based on seven yedi parametre göz önüne al›nd›. Ameliyat sonras› takip süresi parameters on standard anteroposterior and lateral radiographs. ortalama 18 ay (da¤›l›m 13-75 ay) idi. The mean follow-up was 18 months (range 13 to 75 months). Sonuçlar: Tüm olgularda ortalama 7 hafta (da¤›l›m 6-8 hafta) Re s u l t s : R a d i o g r a p h i c a l l y, union was achieved in all the patients içinde radyografik olarak kaynama sa¤land›. Klinik de¤erlen- after a mean of 7 weeks (range 6 to 8 weeks). Clinical results dirmede 17 ayakta (%77.3) mükemmel, üçünde (%13.6) iyi, bi- were perfect in 17 feet (77.3%), good in three feet (13.6%), fair rinde (%4.6) orta, birinde kötü sonuç elde edildi. Radyografik in one foot (4.6%), and poor in one foot. Radiographically, five de¤erlendirmede befl ayakta (%22.7) mükemmel, 13’ünde feet (22.7%), 13 feet (59.1%), and four feet (18.2%) were (%59.1) iyi, dördünde (%18.2) orta sonuç elde edildi. Kalkane- assessed as perfect, good, and fair, respectively. An average of usta ortalama 7.3 mm (da¤›l›m 4-9 mm) uzama sa¤land› 7.3 mm (range 4 to 9 mm) of calcaneal lengthening was obtained (p<0.05). Hiçbir ayakta greftte pozisyon kayb› veya afl›r› düzelt- (p<0.05). Malpositioning of the graft or overcorrection did not me gözlenmedi. Ameliyattan önce iki olgu desteksiz, üçü des- o c c u r. Before surg e r y, five patients could walk on the heel with tekli olarak topukta yürüyebiliyorken, ameliyattan sonra, bir ol- (n=3) or without (n=2) support; postoperatively, all the patients gu hariç tüm olgular desteksiz olarak topukta yürüyebiliyordu. but one could perform this without support. Ç›kar›mlar: Kalkaneal uzatma osteotomisi semptomatik Conclusion: Calcaneal lengthening osteotomy for sympto- PPV’de a¤r›y› ortadan kald›rmakta, klinik ve radyografik ola- matic pes planovalgus provides pain relief and significant clin- rak arka ve ön ayakta anlaml› düzelme sa¤lamaktad›r. ical and radiographic correction in the hind foot and forefoot. Anahtar sözcükler: Kemik uzatma/yöntem; kalkaneus/cerrahi/ Key words: Bone lengthening/methods; calcaneus/surgery/radi- radyografi; düz ayak; ayak deformiteleri/cerrahi; osteotomi/yöntem. ography; flatfoot; foot deformities/surgery; osteotomy/methods. Correspondence to: Dr. Ahmet Dogan. Tesvikiye Mah., Hasan Cevdet Pasa Sok., Ihlamur Sitesi, A Blok D: 2, 34365 Sisli, Istanbul-Turkey. Phone: +90212 - 588 44 00 / 1532 Fax: +90212 - 230 54 56 e-mail: [email protected] Received: 05.06.2006 Accepted: 29.10.2006 Dogan et al. The results of calcaneal lengthening osteotomy for the treatment of flexible pes planovalgus 357 Pes planus is a term implying that longitudinal tions performed using modified Evans osteotomy arc of the foot is fallen or doesn’t exist.If valgus of technique in patients with flexible PPV and inspect- the heel is also present then it’s called pes planoval- ed how foot alignment was effected when hindfoot gus (PPV).In these patients deformity is character- was corrected by this technique. ized by plantar flexion and medially deviation of Patients and method talus, dorsiflexion and external rotation of calcaneus according to talus, severe subtalar evertion, navicu- Calcaneal lengthening operation was performed laris’ laterally and dorsally shifting and supination using modified Evans osteotomy technique in 22 of forefoot upon hindfoot.[1-7] In a patient with pes feet of 11 patients (6 boys, 5 girls,mean age at the planovalgus normal dorsiflexion of the ankle is lim- end of follow-up 10 years 10 months, range 5 years ited in the midstance phase of walking by the effect 6 months to 14 years 8 months) with flexible PPV. of contracted achilles tendon and dorsiflexor forces All of the bilateral deformities were operated at the shift upon talonavicular joint. Therefore axial load- same time except for one in which the second oper- ing and shearing forces center directly under the ation was performed 7 months later the first head of plantar flexed talus.[1,2,4,8] one.Mean age during the time of the surgery was 9 years 4 months (range 4 years 4 months- 13 years 3 Patients with pes planovalgus differ by means of months)Post-operative follow-up period was 18 etiology, patology, severity of the deformity, prog- months (range 13 months-75 months)Etiology was nosis and treatment.Pes planovalgus is an often cerebral palsy in 5, myelomeningocele sequel in 1, deformity in the patients with neuromuscular disor- hereditary sensorymotor polineuropathy in 1 and ders such as cerebral palsy, poliomyelitis, idiopatic in 4 cases.All of the patients were treated myelomeningocele and muscular dystrophy. conservatively for a long time before surgery.The Muscular spasticity or imbalance causes planoval- patient with hereditary sensorymotor polineuropa- gus deformity in these patients, but rarely deformity thy was underwent an operation for tendon transfers may also be seen in normal children.[1,3,4,9] in both feet and except for this one none of the Flexible PPV is usually asymptomatic in chil- patients were operated for their deformities. dren.Disorder is usually identified when parents are Operation technique disturbed of the shape of child’s foot and notice the Patients are positioned supine under general problems in wearing shoes.In untreated patients, by anesthesia and a pneumatic tourniquet is applied on the beginning of puberty, ulcerations on skin, diffi- thigh.A modified lateral longitudinal Ollier incision culties in wearing shoes or braces and serious walk- of 3 cm that extends 1 cm proximal of anterior cal- ing problems and as the most important severe pains caneal process is made over sinus tarsi.[8]Sural and occur.The aim of the treatment is to relieve the skin superficial branches of peroneal nerve are preserved and pain, overcome difficulties in shoe and brace and inferior extansor retinaculum is released from wearing and restore the normal alignment of the calcaneus’ superolateral border. Extensor digitorum f o o t . [ 2 , 1 0 , 1 3 ] First conservative methods should be brevis and other soft tissue contents of the sinus tarsi applied and when these methods are insufficient is elevated from the dorsal surface of the anterior then surgical procedures should be tried.Surgical aspect of the calcaneus. Peroneus longus and brevis options vary from simple soft tissue procedures to tendons are released from their tendon sheaths suffi- calcaneal osteotomy, subtalar extra-articular ciently for them to be retracted dorsally and plantar- arthrodesis and triple arthrodesis.[1,8,9,14] Because of ward. Calcaneocuboid joint was identified but the the problems associated with limited arthrodesises, the capsule was not damaged. The interval between common opinion is to correct children’s foot defor- medial and anterior fascets of calcaneus was identi- mities without arthrodesis.[3,11,14,15] fied and through this interval 2 Hohmann retractors Calcaneal lengthening osteotomy was described are placed around medial and lateral aspects of cal- for the first time by Evans in 1975 and then modified caneus extraperiosteally.Periosteum is incised in line and introduced by Mosca.[2] In our study we evaluat- with the planned osteotomy starting laterally ed mid-term results of calcaneal lengthening opera- approximatelly 1.5 cm proximal to the calca- 358 Acta Orthop Traumatol Turc neocuboid joint.
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