)402( COPYRIGHT 2018 © BY THE ARCHIVES OF BONE AND JOINT SURGERY RESEARCH ARTICLE Evaluation of Clinical and Radiological Results of Calcaneal Lengthening Osteotomy 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 ankle 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 inpost 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 Thesinus 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 onethe indistal 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( THE ARCHIVES OF BONE AND JOINT SURGERY. ABJS.MUMS.AC.IR CALCANEAL LENGTHENING OSTEOTOMY IN FLEXIBLE FLATFOOT VOLUME 6. NUMBER 5. SEPTEMBER 2018 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