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RESEARCH ARTICLE

Evaluation of Clinical and Radiological Results of Calcaneal Lengthening in Pediatric Idiopathic Flexible Flatfoot

Taghi Baghdadi, MD; Hamed Mazoochy, MD; Mohammadreza Guity, MD; Nima Heidari khabbaz, MD

Research performed at Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran

Received: 20 January 2018 Accepted: 21 April 2018

Abstract

Background: Flexible idiopathic flatfoot is the most common form of flatfoot. First line treatments are parental reassurance and conservative measures; however, surgical treatment may be needed in some cases. A number of surgical techniques with varying results have been described in the literature. Here, we present our clinical and radiological outcomes of calcaneal lengthening osteotomy for pediatric idiopathic flexible flatfoot.

Methods: Calcaneal lengthening osteotomy was performed in 20 patients, 30 feet, with idiopathic flexible flatfoot that were resistant to conservative treatment between 2007 and 2011. Patients were evaluated according to ACFAS universal evaluation scoring scale and radiographic indexes. The mean follow up duration was 23.1 ± 9.9 months.

Results: The average age was 10.4 ± 0.9 years. Achilles tendon lengthening was performed in 28 feet. ACFAS score at the final follow up had improved significantly compared to pre-operative score (37 to 88, P<0.0001). Radiographic parameters also showed significant improvement after surgery ((P<0.0001)). Distal segment displacement and hardware irritation as postop complications were observed in 2 and 3 cases, respectively, with no long-term clinical impact.

Conclusion: Calcaneal lengthening osteotomy is an appropriate and safe operation in symptomatic idiopathic flexible flat foot that is resistant to conservative treatment.

Level of evidence: IV

Keywords: Flat foot, Idiopathic, Pediatric, Radiograph, Surgery

Introduction lat foot or pes planus is a term implying that normal tendon insufficiency. Flatfoot may be flexible or rigid, medial longitudinal arch of the foot has become depending on whether the appearance of the medial Fflat. It is one of the most common deformities longitudinal arch changes upon weight bearing (1, 2). referred to orthopedic surgeons and pediatricians. It Idiopathic flexible pes planus (IFPP) is the most can be either idiopathic or associated with generalized common form, which can vary in magnitude between pathological conditions including connective tissue individuals. The initial and most often main treatment disorders, neuromuscular abnormalities or foot is parental reassurance along with conservative pathologies such as tarsal coalition or posterior tibial measures including shoe modifications and stretching

Corresponding Author: Hamed Mazoochy, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Email: [email protected] the online version of this article abjs.mums.ac.ir Arch Bone Jt Surg. 2018; 6(5): 402-411. http://abjs.mums.ac.ir )403(

THE ARCHIVES OF BONE AND JOINT SURGERY. ABJS.MUMS.AC.IR CALCANEAL LENGTHENING OSTEOTOMY IN FLEXIBLE FLATFOOT VOLUME 6. NUMBER 5. SEPTEMBER 2018 exercises. However, surgical treatment may be needed proximal tibia. A k-wire could be enough to stabilize the in some cases (3-6). osteotomy; but we occasionally used a supplementary A number of surgical techniques including soft staple to mitigate the collapse of the osteotomy. In cases tissue and bone modifications have been described for the correction of flat foot deformities. Each Achilles tendon lengthening was undertaken to achieve procedure comes with its own set of advantages wherea plantigrade foot. dorsiflexion was less than 10 degrees, and disadvantages and have yielded varying results. A longleg non-weight-bearing cast was applied. At 6 “Calcaneal lengthening osteotomy” is one of these weeks post-op the K-wire was removed in the clinic procedures (2, 7, 8). and a short-leg cast was applied. Full weight bearing was allowed after detecting radiographic union, usually described decades ago, there are still controversies regarding Although patient “calcaneal selection lengthening and the osteotomy” surgical technique; was first increased to full weight bearing according to the imaging. including the site of osteotomy, amount of lengthening, betweenAll patients weeks were 10revisited to 12 in post clinic surgery in the third, and graduallysixth and twelfth week post-surgery and every 6 months thereafter. additional soft tissue procedures. Clinical studies on type of graft, the fixation device and whether to perform Scoring and Follow-up correction have various etiologies including cerebral Patients were evaluated according to ACFAS Universal thispalsy, subject myelomeningocele, are sparse and and patients connective requiring tissue disorders. operative Evaluation Scoring Scale, Module 3, which is designed to The idiopathic group is small and rarely requires surgery. Herein we report the clinical and radiological outcomes of calcaneal lengthening osteotomy in IFPP (9-24). evaluateincluding rear pain, foot appearance including flat and foot. functional This system capacities. consists of two parts. The first part is subjective parameters Materials and Methods The second part is about objective parameters including undergoing calcaneal lengthening osteotomy for idiopathic radiologicStandard evaluationanteroposterior and function, (AP), withtrue 50 lateral, points eachand During January 2007 to March 2011 all patients addinglong axial up toview a total radiographs of 100 points. were taken pre and post flexibleconsidering flatfoot surgical in our corrections center were all patientsincluded wentin this through study. Allat least operations six months were of performedconservative by treatment the first author. such as Prior weight to physiotherapy, stretching exercises and short courses of loss,NSAIDs. shoe Those modification, who failed orthosis, conservative activity treatment modification, with consistent fatigue and functional disturbance were then considered for surgery. All patients with a rigid or non- ambulators were excluded from the study. idiopathic flatfoot, vascular or sensory pathology and non- Surgical technique The patient was positioned supine. Tourniquet could be used for hemostasis. A longitudinal incision was placed from 1 centimeter proximal to the Ollier). The sural and superficial branches of peroneal calcaneocuboidnerve were protected. joint to The sinus plane tarsi of (modified dissection lateral was between extensor digitorum brevis dorsally and the peroneiEither a onFreer the orplantar periosteal side. Theelevator calcaneocuboid was inserted joint in wassinus identifiedtarsi to locate without the openingmiddle facet. the jointAn osteotomy capsule. was then created in between middle and anterior facet oflongitudinally subtalar joint in aapproximately posterior to anterior 1 to 1.5 direction cm proximal from tothe calcaneocuboidcalcaneal tuberosity, joint. passing A k-wire through was osteotomy inserted segment and avoid it’s dorsal displacement. siteTwo and Schanz calcaneocuboid pins, one in jointthe proximal to stabilize and one the in distal the distal fragments, were used to distract the osteotomy. The size of the graft was estimated according to the amount of distraction required to gain clinical correction [Figure 1]. Figure 1. Amount of distraction estimated according to clinical Autogenous graft could be harvested from the ipsilateral correction. A longitudinal k-wire used before distraction. )404(

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Table 1. Measurement method of radiologic parameters Radiologic parameter Definition Talocalcaneal Angle in Antero-Poste- Angle between axis of the talus (line midway between the medial and lateral edges) and axis of the calcaneus rior view (line tangent to the lateral edge)

Angle between longitudinal axis of the talus (line bisecting the dorsal and plantar edges) and calcaneal Talocalcaneal Angle in Lateral view inclination axis (line from most inferior portion of the calcaneal tuberosity to the most distal and inferior

Talus-First Metatarsal Angle in point of the calcaneus at the calcaneocuboid joint) Antero-Posterior view and lateral edges) Angle between axis of the talus and longitudinal axis of the first metatarsal (line midway between the medial Talus-First Metatarsal Angle in Lateral view between the dorsal and plantar edges) Angle between longitudinal axis of the talus and longitudinal axis of the first metatarsal (line midway Calcaneal Inclination Angle in Lateral Angle between calcaneal inclination axis and horizontal axis (supporting surface) view

Medial Longitudinal Arch Angle in Lateral view Talo-Horizontal Angle in Lateral view Angle between longitudinalcalcaneal inclination axis of the axis talus and and longitudinal horizontal axis axis of the first metatarsal

Talonavicular Angle in Antero-Poste- rior view Angle between talar joint inclination (line connecting medial and lateral edges of talar head articular surface) and navicular joint inclination (line connecting medial and lateral edges of navicular articular surface at the Angle between longitudinal axis of the talus and longitudinal axis of the navicular (line midway between the Talonavicular Angle in Lateral view level of talonavicular joint) dorsal and plantar edges)

Navicular-First Cuneiform Angle in Lateral view between the dorsal and plantar edges) Angle between longitudinal axis of the navicular and longitudinal axis of the first cuneiform (line midway Distance between the midpoint of a vertical line through the anterior calcaneus, parallel to the calcaneocuboid Calcaneal Length in Lateral view

Calcaneus-Fifth Metatarsal Angle in joint to the most posterior aspect of the calcaneus Antero-Posterior view metatarsal (line midway between the medial and lateral edges) Angle between axis of the calcaneus (line tangent to the lateral edge) and longitudinal axis of the fifth Calcaneal-Tibial Angle Angle between mid-diaphyseal line of the tibia to the mid-diaphyseal line of the calcaneus In Long Axial view

Calcaneal Translational Displacement Distance between mid-diaphyseal line of the tibia to the mid-diaphyseal line of the calcaneus at level of the in Long Axial view most distal part of the calcaneus

operatively. AP radiographs were used to measure Results whom 12 were boys and 8 were girls. Six boys and four talo-first metatarsal, talo-calcaneal, talonavicular, and girlsData had for bilateral20 patients, surgery. 30 feet, The is meanreported age inat our the study time of calcaneus-fifthmetatarsal, calcaneal metatarsal inclination, angles [Tabletalocalcaneal, 1]. medial longitudinalLateral radiographies arch, talo-horizontal, were used to talonavicular,measure talo-first and We used a staple along with a k-wire in 24 cases. Achilles surgicaltendon was intervention lengthened was in 10.4 28 ±feet. 0.9 (range:The mean 8-12.5 follow years). up length in millimeter [Table 1]. naviculo-first Long axial view cuneiform was used angles to measure as well calcaneal-tibial as calcaneal At final follow up, ACFAS scoring scale showed angle and calcaneal translational displacement in time was 23.1 ± 9.9 months (range: 9-50 months). millimeter [Table 1]. Statistical analysis was performed using SPSS 13, significantmean ACFAS improvement score was 37 pre-operatively in both subjective and 88 and at using chi-square test; independent-samples T-test; and objectivefinal follow parameters up (P<0.0001 in) each[Figure individual 2]. case. The paired-samples T-test. A P-value improvement after surgery (P<0.0001) [Table 2] [Figure 3]. of less than 0.05 was All radiographic parameters also showed significant considered as statistically significant. )405(

THE ARCHIVES OF BONE AND JOINT SURGERY. ABJS.MUMS.AC.IR CALCANEAL LENGTHENING OSTEOTOMY IN FLEXIBLE FLATFOOT VOLUME 6. NUMBER 5. SEPTEMBER 2018

(A) (B)

(C) (D)

Figure 2. A 10 year-old-boy with idiopathic flexible flat foot before (A,B) and two years after (C,D) calcaneal lengthening osteotomy. )406(

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Table 2. Radiographic parameters before and after surgery

Pre Operation Post Operation Correction Parameter P. Value Average (SD) Average (SD) Average

Talocalcaneal Angle in Anteroposterior view 34.9 )3.7( 25.1 )3.9( 9.8

Talocalcaneal Angle in Lateral view 48.9 )3.8( 41.6 )4( 7.3 < 0.0001

Talus-First Metatarsal Angle in Anteroposterior view 29.9 )3.6( 9.5 )1.5( < 0.0001

Talus-First Metatarsal Angle in Lateral view 28.1 )3.4( 4.6 )2.3( 20.423.5 < 0.0001

Calcaneal Inclination Angle in Lateral view 7.5 )2( 21 )1.9( 13.5 < 0.0001

Medial Longitudinal Arch Angle in Lateral view 154.2 )4.1( )19.9( 24.2 < 0.0001

Talo-Horizontal Angle in Lateral view 41.4 )4.7( 130 )4.1( < 0.0001

Talonavicular Angle in Anteroposterior view )2.8( 20.613.5 )2.7( 20.816.6 < 0.0001

Talonavicular Angle in Lateral view 30.1 4 )1.4( 1.7 )1.3( 2.3 < 0.0001

Navicular-First Cuneiform Angle in Lateral view 24.9 )3.1( 2.6 )1.6( 22.3 < 0.0001

Calcaneal Length in Lateral view 54 )6.2( 62.4 )6.1( 8.4 < 0.0001

Calcaneus-Fifth Metatarsal Angle in Anteroposterior view 23.2 )4.2( 3 )1.9( < 0.0001

Calcaneal-Tibial Angle In Long Axial view 12.1 )2.1( 3.8 )1.8( 20.28.3 < 0.0001

Calcaneal Translational Displacement in Long Axial view )1.7( 5.6 )1.9( 4.8 < 0.0001

10.4 < 0.0001

A mean of 8.4 mm calcaneal lengthening was achieved. There were no overcorrections. Two patients evaluated patients who underwent “Evans” technique. had symptom free distal segment displacement on forHe reported the treatment satisfactory of flat results foot (25).at long In term 1983, follow Phillips up radiographs. In 3 out of 24 cases where a staple was used, removal was required to alleviate symptoms of addition of medial cuneiform osteotomy to achieve a irritation., the irritated skin and peroneal tendons (26).more balanced In 1995 correction Mosca modfied (9). Evans’ technique with were seen in two and one cases, respectively. No Unlike most other previous studies, we reported the outcomes of surgical intervention on idiopathic calcaneocuboid, and no donor site complications were degenerativeseen. Clinical and changes radiographic in adjacent union , was suchachieved as the in feet were due to neuromuscular disorders (9). Dogan all the patients. The graft did not collapse or resorb in flexible flat foot. In Mosca’s cohort, 26 out of 31 flat any of the cases. 13 patients who underwent the calcaneal lengthening et al. reported only 4 idiopathic flat feet in a total of Discussion osteotomygroup is yet (27). to be Although robustly idiopathicreported. flexible flat foot is patients. Although asymptomatic in most, the severity of the Our most study common indicates type, the that efficacy calcaneal of surgery lengthening on this symptomsIdiopathic and flat functional foot can disturbance vary in magnitude is severe amongst in a few osteotomy is an appropriate technique for the cases and may not respond to conservative measures. These patients enter a vicious cycle of physical limitation soft tissue procedures alone on these patients resulted due to foot pain, calf muscles strain, callosity, and ankle correctionin considerable of the failure.idiopathic (2) flexible Although flat there foot. Performingare lots of sprain as well as limitations in choosing a shoe. This restricted mobility results in obesity, which in turn reconstruction and in recent studies there is a trend exacerbates their symptoms (1, 2). techniquestoward more and anatomic modifications spring availableligament forand soft posterior tissue A number of reports demonstrate that conservative tibialis tendon reconstructions (28). measures control the symptoms in most patients; restricts range of motion leading to early degenerative however, surgery has to be considered where a non- operative approach fails and the symptoms have an effect on the quality of life (2-8). changesbody reactions, in adjacent infection, joints. pain, (2) incomplete Arthroereisis deformity of the subtalarcorrection, joint and with need synthetic for another implant surgery may (2). cause foreign by Evans in 1975 is one of the surgical techniques Our experience has shown that the most appropriate Calcaneal lengthening osteotomy, first described )407(

THE ARCHIVES OF BONE AND JOINT SURGERY. ABJS.MUMS.AC.IR CALCANEAL LENGTHENING OSTEOTOMY IN FLEXIBLE FLATFOOT VOLUME 6. NUMBER 5. SEPTEMBER 2018

(B)

(A)

(C) Figure 3. Postoperative radiograph. A,B) AP and lateral standing radiograph shows improvement of radiologic parameters. C) Radiologic union and normal calcaneocuboid joint in oblique radiograph.

age for calcaneal lengthening osteotomy is between 8 to complications at the osteotomy or the donor site. A reported complication of calcaneal lengthening studies. osteotomy is displacement of distal segment and 10While years Evans old mirroring used tibial findings autograft, from other a number studies of other have advocated the use of iliac crest autografts as well as inserted a k-wire before distraction passing through subluxation of the calcaneocuboid joint (31, 32). We as described by Evans, but, did not observe any can help. allografts (19, 20, 25, 29, 30). We used tibial autograft, proximal and distal segment and calcaneocuboid joint )408(

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Another reported complication of calcaneal the correction following the osteotomy. It is more lengthening osteotomy is degenerative changes in induced by lengthening. Our cohort did not develop usefuldemonstrates than talofirst forefoot metatarsal abduction angle and on shorteningthe same pro- of calcaneocuboiddegenerative changes joint as or a painresult in of the excessive calcaneocuboid pressure jection.lateral column A negative associated calcaneus-fifth with the midtarsal metatarsal type. angleAfter performing calcane-al lengthening osteotomy this the distraction of the osteotomy to less than 1 cm and angle becomes closer to zero. A positive angle becomes joint (17). This, we believe, was achieved by limiting pos-itive can indicate overcorrection. A number of methods are reported for stabilization The AP talocalcaneal angle is a radiolographic index avoidingof the osteotomy injury to includingcalcaneocuboid simple joint use capsule.of a plaster for locking the plates (22). Hardware irritation due to the staple was one of our complications. Further studies for hind foot valgus. This angle in-creases significantly indoes flat not foot correlate patients withwith subtalarthe magnitude pathology. of Ourcalcaneal study increasing the stability, reduction in the length of cast mirrors find-ings in other reports where this angle areimmobilization, needed to define and minimizing the optimal the fixationhardware method irritation. for in midtarsal, may show substantial clinical valgus with However, the expenses of this new method must also be valgus.only slightly Patients increased with flat talocalcanealfoot, whose main angle. pathology It should is considered. be noted that this angle decreases normally during aging. Calcaneal tibial angle and calcaneal translational according to radiographic parameters. In this study, displacement, which can be measured on the long axial calcanealBourdet etlengthening al. divided osteotomy flat feet intois recommended 4 categorize view, are better indexes for radio-logic evaluation of for midtarsal and to some extent, mix category. On valgus (34). the other hand, calcaneal lengthening osteotomy is Radiographic indications we use for choosing a not recommended in the subtalar category and is calcaneal lengthening osteotomy for the correction contraindicated in pes plano cavus (33). We believe a satisfactory result in this surgery relies on cuneiform angle in lateral view and negative calcaneus- two factors: appropriate patient selection and surgical of flexible flat foot include sagging of naviculo-first technique. Attention to details throughout the treatment process We recommend this surgery for patients with fifthform metatarsal the cornerstone angle infor AP achieving view. satisfactory results. considerable symptoms resulting in functional Appropriate patient selection as well as technical (pre- disturbance, who have failed to respond to conservative , intra- and post-operative) considerations is crucial treatments for 6 months. We don’t recommend factors. this surgery for cosmetic indications. The need for Pre operative preparation tips - Placing a Povidone-iodine pad emphasized. - Appropriate standing radiographies theCalcaneal confirmation lengthening of the osteotomy diagnosis cannotis indicated be over in - Full explanation of the surgical process and post operative care to patient and parents subtalar type by physical examination. The lateral Intra-operative tips midtarsal flat foot which is distinguishable from incision columnis positive. in midtarsalFurthermore, flat subtalar foot is short motion and is thererelatively is a - FullMeticulous thickness protection flaps avoiding of surrounding undermining soft of thetissues. skin significantwell preserved abduction and hind in forefoot foot valgus and “too is not many prominent. toe sign” Medial plantar nerve and artery whilst performing the osteotomy, sural nerve and peroneal sheath and clinical diagnosis. Radiographs also help to rule out tendons during the sur-gical dissection and exposure Standardized standing radiographies confirm the talometatarsal angle reveals loss of the medial arch. other pathologies. In the lateral radiograph, the first and- Release avoiding of injuries plantar to periosteumthe capsule ofif calcaneocuboidthe calcaneum where the medial arch sags. In the midtarsal type the joint.completely to allow a medial hinge upon opening of Talonavicular and naviculocuneiform angles define the lateral cortex. This action minimizes the risk of by the angle, whereas in the subtalar type the main deformity is in the naviculocuneiform joint as denoted inclination angle is measured on the lateral radiograph. subluxationpain. and dispropor-tionate pressure to adjacent deformityAs a measure is from of thehind talonavicular equinus this joint. index The hascalcaneal been joints- Insertion particularly of athe longitudinal calcaneocuboid k-wire and subsequentacross the evaluated by the lateral tibiotalar angle. If a normal or increased calcaneal inclination angle is seen in a patient risk of subluxation [Figure 1]. calcaneocuboid- Distraction byjoint shanz before pin distraction or a Hintermann to mitigate type the cavus should be suspected. This is important to note as distractor, mitigates a degree of crushing that can occur withcalcaneal flat foot, lengthening pes plano osteotomy valgus is unlikely is contraindicated and pes plano in at the osteotomy edge with the use of a lamina spreader. this type. This allows for a more accurate measurement of the osteotomy gap and graft insertion [Figure 1]. measured in the AP view. This angle helps us to choose - Technical precautions while harvesting a graft from theStanding appropriate calcaneus-fifth surgical technique metatarsal and anglein measuring can be proximal of the tibia and periosteal repair [Figure 4]. )409(

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Figure 4. Harvesting graft from ipsilateral proximal tibia and periosteal repair.

- Correctly inserting the graft to avoid collapsing [Figure 5]. H-plates to supplement k-wires if the stability of the osteotomy- We advocate is in doubt. additional fixation with staples or Achilles tendon tightness. After placement of the graft - Most patients with flat foot have an associated length is assessed and lengthening performed if there and fixation of the osteotomy, the Achilles tendon isplano limitation cavus). of dorsiflexion. (This is required in the vast majority- We estimated of cases, theif not graft then size the clinically diagnosis according may be pes to the amount of distraction that gained clinical correction [Figure 1]. Although some studies suggested intra operative radiography after distraction, we relied more on the clinical criteria as the numerous radiographic measurements and criteria may be counterproductive. Larger gaps may cause overload of the calcaneocuboid The maximum graft size should be limited to 10 mm. - Technical precaution of calcaneal surgery for suturing joint,and wound displacement, closure pain and early degenerative changes. Postoperative tips - Foot elevation and splint for 48 to 72 hours and controlling compartment syndrome or wound problems - To take radiographies in periods mentioned above - Non-weight bearing long leg cast for 6 weeks. The K-wire is removed and non-weight bearing cast reapplied. Figure 5. Orientation of grafts superiorly and inferiorly o preserve - Gradually increasing weight bearing after radiologic cortical buttress and avoiding collapse.

union, around 10 to 12 weeks post-surgery. )410(

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- Post cast removal physical therapy to restore ankle Taghi Baghdadi MD range of motion and regain the strength lost during cast Hamed Mazoochy MD immobilization. Mohammadreza Guity MD In conclusion, calcaneallengthening osteotomy in Tehran University of Medical Science, Tehran, Iran Nima Heidari khabbaz MD juvenilepatient selectionand adolescent and meticulous patients with attention idiopathic to detail flexible in The Royal London Limb Reconstruction Service St flatregard foot to is athe safe technical and effective aspects procedure, of the butprocedure appropriate can Bartholomew’s and Royal London Hospital Barts Health result in an excellent outcome. NHS Trust, London, UK

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flat foot deformity associated with insufficiency )411(

THE ARCHIVES OF BONE AND JOINT SURGERY. ABJS.MUMS.AC.IR CALCANEAL LENGTHENING OSTEOTOMY IN FLEXIBLE FLATFOOT VOLUME 6. NUMBER 5. SEPTEMBER 2018

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