International Journal of Research in Orthopaedics Soudy SE-E. Int J Res Orthop. 2016 Dec;2(4):340-345 http://www.ijoro.org DOI: http://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20164165 Original Research Article Calcaneal lengthening osteotomy for treatment of idiopathic flexible flat foot in children Sayed El-Etewy Soudy* Department of orthopedic surgery, Faculty of human Medicine, Zagazig University, Egypt Received: 27 September 2016 Accepted: 04 November 2016 *Correspondence: Dr. Sayed El-Etewy Soudy, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: The modified Evans osteotomy technique of calcaneal osteotomy was reported to be effective in correction of flexible flat foot in restoring foot alignment. Methods: The modified Evans technique of calcaneal lengthening osteotomy was used in treatment of 18 feet of 12 patients. The mean follow-up period was 24 months (18-42). The etiology was idiopathic flexible flat foot deformity in all patients. Preoperative conservative therapy was tried in all patients. For clinical evaluation a modified point scoring system containing 32 points for patients' assessment with added 4 points for radiological evaluation the total of score became 36 points. Results: According to the modified points scoring system the results were satisfactory in 16 feet (88.9%) and unsatisfactory in two feet (11.1%) at the final follow up All osteotomies were united within a mean time of 11 months (range 9-14 months). All 6 angles were measured at the end of the follow up and assessed as points added to the 32 points score. The score in 14 feet (77.7%) were (4) having the 6 angels within normal values. The values from 4 angles were within normal values and take score 3 in 3 feet (16.5%). In one foot (5.5%), 3 angles felt in normal range with score 2. Conclusions: Calcaneal lengthening osteotomy for symptomatic flexible flat foot is effective in correction of the deformity and pain relief. Keywords: Flexible, Flat foot, Calcaneal, Lengthening, Osteotomy INTRODUCTION of ‎conservative methods to solve the problem, surgical ‎methods are indicated. The term flat foot defined as a deformity composed of flattening of ‎the medial ‎arch of the foot with heel valgus The ‎advantages of surgical procedures are ‎restoring the either in pediatric, adolescent ‎or adults. The ‎deformity foot alignment, relieving pain and ‎skin. Surgical may be rigid, which commonly congenital, or ‎flexible procedures ‎in flexible flat foot vary from soft tissue to which is usually ‎acquired.1 The pathology of flatfoot may bony ‎osteotomies, ‎extra-‎articular arthrodesis of the 2,3,6,7 be ‎an isolated pathology or a part from a ‎disorder like subtalar joint, and triple arthrodesis. Arthrodesis is neurologic and ‎muscular diseases (as poliomyelitis, largely discouraged in children because 6-9 cerebral ‎palsy, ‎myelomeningocele), ‎generalized of ‎the ‎problems ‎associated with these techniques. One ligamentous laxity, genetic or collagen ‎disorders.2 of the effective ‎techniques is ‎the calcaneal lengthening The ‎mean complaints of the patients are pain osteotomy. Evans in 1975 is ‎the first to 6,10 accompanied by ‎skin ‎ulcerations, ‎difficult shoe wear and describe ‎and ‎modified by Mosca in 1995.‎ In this serious problems in walking. The ‎galls of ‎treatment was prospective the clinical and radiological results of utilized to solve this previous problems.3-5 After failure eighteen ‎patients with ‎flexible flat foot (FFF) treated International Journal of Research in Orthopaedics | October-December 2016 | Vol 2 | Issue 4 Page 340 Soudy SE-E. Int J Res Orthop. 2016 Dec;2(4):340-345 using modified Evans ‎calcaneal osteotomy Under image intensifier the ‎calcaneocuboid joint was technique ‎were evaluated in a mean follow up of identified ‎and the site of osteotomy was 24 ‎months (range 18-36).‎ determined ‎between the medial and ‎anterior facets of the calcaneus was ‎identified. After release ‎of the ‎periosteum METHODS over the calcaneus the osteotomy began from about 1.5 cm ‎proximal ‎to the ‎calcaneocuboid joint and directed Through the period from June 2010 to June 2013, obliquely ‎from ‎proximal laterally to distal ‎medially. This eighteen feet in 12 ‎patients ‎were presented by FFF. Six obliquity was done to ‎correct the valgus and distraction patients were operated on for both ‎sides, the right for lengthening ‎of the lateral column. ‎While using a side ‎was operated in 4 patients and left in 2 laminar spreader to open the osteotomy site, the ‎size patients. ‎There were 8 males, and 4 females. ‎Calcaneal of ‎the graft was measured and the trapezoidal tricortical lengthening operation was ‎performed using modified graft was ‎harvested from ‎the iliac crest through a separate Evans ‎osteotomy ‎technique in all feet. The ‎mean age at incision. The reduction ‎of the ‎talo-navicular and ‎subtalar time of operation was 8.5 years (range 4 .5-11 years). ‎The joints was evaluated clinically and ‎radiologically before mean ‎duration of follow-up was 24 months (range ‎‎18-42 any fixation. months). The mean ‎age ‎at the end of ‎follow-up was 12.5 years (range 7.5-14.5 years). In ‎bilateral cases The ‎graft is impacted from lateral to ‎medial while the ‎operation was done in two stages with 6 distracting to open the osteotomy site. ‎Two K- wires months ‎interval. All cases were idiopatic in ‎etiology. were ‎used, one to fix lateral column through All ‎patients received ‎conservative treatment as orthosis calcaneocuboid, and the ‎other ‎through the talo-navicular and before the ‎operation.‎ to fix the medial column. The K- wires were ‎bended ‎long outside the skin for ‎easy removal after healing. A Surgical technique long ‎leg ‎cast was applied after ‎skin closure for 2 weeks postoperative. After ‎removal of stitches by 2 weeks the All operations were done under general anesthesia in cast ‎was changed for another 4 ‎weeks. The K- wires supine ‎position and under ‎pneumatic ‎tourniquet. Over the were ‎removed after 6 weeks ‎postoperative in ‎outpatient sinus ‎tarsi, a lateral ‎longitudinal incision from 3-4 clinic and a walking cast was applied for 4 weeks. cm. ‎With careful dissection the ‎inferior ‎extensor For ‎clinical ‎evaluation a modified point scoring system retinaculum was incised from the ‎superolateral ‎calcaneal containing 32 points for patients' ‎assessment. ‎When border. Special care was carried out to preserve the added 4 points for radiological evaluation the total of sural ‎nerve ‎and peroneal nerve superficial branches. Next score became ‎‎36 points ‎‎as given in Table 1. step was elevation of ‎fleshy fibers ‎of extensor ‎digitorum brevis and the contents of sinus tarsi. ‎The tendons of The patients have 30-36 points are of excellent results, peroneus ‎longus and brevis were released to be 25-29 ‎points for good, ‎‎20-24 for fair, and less than 20 easily ‎retracted. points for poor results. Collectively, ‎the excellent and ‎good results were classified as satisfactory and fair and poor results ‎were classified as ‎unsatisfactory.‎ For radiological evaluation, the postoperative films (anteroposterior and lateral weight-‎‎bearing radiographs of the foot) were compared to the preoperative films for each ‎patient ‎measuring the angles used for assessment of the deformity and correction ‎which are: the ‎talohorizontal (TH), talometatarsal (TMT), calcaneal pich (CP) and ‎talocalcaneal (TC) ‎angles in lateral view and TMT and TC angles in anterioposterior ‎view as in Table 2. RESULTS Clinically as given in Table 2 the modified points scoring system the results were ‎satisfactory in 16 feet (88.9%) and unsatisfactory in two feet (11.1%) at the final ‎follow Figure 1: The operative technique A) preoperative up. As regards the pain, 14 feet (77.7%) were photo of the foot clinically; B) intraoperative photo asymptomatic and 4 feet (22.3 %) had occasional pain after doing the calcaneal osteotomy; C) intraoperative during activity. There was collapse of the medial arch photo after impacting the graft into the osteotomy in ‎‎2 feet (11.1%). Heel posture was mild varus in 3 feet site; D) intraoperative photo of the foot after (16.6%), moderate valgus in one ‎foot (5.5%). Talar head correction and K- wire fixation; E) X-ray 4months prominence was mild in 3 feet (16.5%). The range of postoperative after removal of K- wires and bony motion ‎of ankle joint was (93%) of normal in 15 feet union of the osteotomy with incorporation of the (83.5%), and 88% of normal in three ‎feet (16.5%). Range graft; F) the foot clinically after correction. of motion of subtalar joints was limited by 30% of International Journal of Research in Orthopaedics | October-December 2016 | Vol 2 | Issue 4 Page 341 Soudy SE-E. Int J Res Orthop. 2016 Dec;2(4):340-345 normal in 6 ‎feet (33.3%), and in 12 feet the limitation within a mean time of 11 months (range 9-14 ‎months). was less than 15% from normal (23%). ‎ Radiologically as All 6 angles were measured at the end of the follow up shown in Table 2 and 3 all osteotomies were united and assessed as ‎points added to the 32 points score. Table 1: The point scoring system. Parameters 4 points 3 points 2 points 1 points Clinical A. Subjectively Pain with stren- 1. Pain No pain Occasional pain Pain uous activity Unable to do Difficulty of 2. Activity Normal Mild reduction heavy work walking B. Objectively 1. Medial arch Normal Decreased absent convex Mild valgus or Moderate valgus Severe valgus 2. Heal posture Normal varus or varus or varus Moderate Severe Mild abduction or 3. Forefoot Normal abduction or abduction or adduction adduction adduction 4.