Lateral column lengthening for adolescent idiopathic pes planovalgus deformity - Systematic review

Outcomes of the "Calcaneo-stop" procedure for treating symptomatic flexible flatfoot in children: A systematic review and meta-analysis of 2394 feet

BACKGROUND

This study evaluates the efficacy of the calcaneo-stop (C-Stop) procedure's effectiveness in treating symptomatic flexible flatfoot (FFF) in children.

METHODS

A systematic review and meta-analysis were conducted using PubMed, Embase, and Cochrane databases to identify studies until 2023 on the outcomes of the C-Stop procedure in children with FFF. The risk of bias was assessed using MINORS criteria.

RESULTS

Of 85 studies screened, 20 involving 2394 feet from 1415 patients (mean age 11.2 ± 1.3 years) were included. Post-procedure, significant improvements were noted in pain reduction (93.5%), heel alignment (95.21%), and radiological measures, including reductions in Kite (7.32º), Meary (11.65º), Costa-Bartani angles (17.11º), talar declination (12.63º) and increase in Calcaneal Pitch Angle (5.92º). AOFAS scores increased by 22.32 points on average, with 94.83% reporting high satisfaction. Complication rate was low (7.8%).

CONCLUSIONS

The C-Stop procedure is effective for treating FFF in children, offering significant clinical, radiological, and functional improvements with high patient satisfaction and a low complication rate.

LEVEL OF EVIDENCE

Level IV, Systematic review of Level-IV studies.

Pedobarography and ankle-foot kinematics in children with symptomatic flexible flatfoot after medialising calcaneal osteotomy and controls: a comparative study

PURPOSE

Flexible flatfoot (FF) can interrupt children's activity through uneven pressure distribution to the medial column of the foot and may require surgery. Medialising calcaneal osteotomy (MCO) helps restore the foot‒tripod complex. The objective was to compare pedobarography and ankle‒foot kinematics in children with symptomatic FF after MCO to those in controls.

METHODS

Gait analysis was performed on 21 children with FF (37 feet, age 13.7 ± 4.9 years) 4.5 ± 3.4 years after MCO and on 21 controls (42 feet, age 12.1 ± 1.1 years). Ankle‒foot kinematics and pedobarography parameters (maximum pressure, impulse, contact area, and percentage of contact time in the stance phase) of ten anatomic foot regions from an average of five gait trials were compared. The functional outcome was determined by the AOFAS-AHFS score in the FF group.

RESULTS

The average AOFAS-AHFS score was 96. The FF group had a larger contact area and expressed more force on the medial column of the foot. The maximum pressure, impulse, contact area, and percentage of contact time in the stance phase in the midfoot region for the FF and control groups were 0.66 ± 0.5 vs. 0.24 ± 0.4 N/cm2 (p = 0.005), 0.12 ± 0.1 vs. 0.03 ± 0.1 Ns/cm2 (p = 0.02), 47.1 ± 13.4 vs. 30.1 ± 7.1 cm2 (p < 0.001), and 53.7 ± 17.4 vs. 68.2 ± 15.7% (p = 0.007), respectively. The kinematics of the FF exhibited a greater range of abduction and eversion during the mid- and terminal-stance phases of the gait cycle.

CONCLUSIONS

The MCO procedure did not normalise the pressure on the midfoot in FF to the level of that in the controls, and the deformity persisted in the forefoot.

Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit

PURPOSE

We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents.

METHODS

A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test.

RESULTS

The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal.

CONCLUSION

Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

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

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.

LEVEL OF EVIDENCE

Level III.

Tibialis anterior rerouting combined with calcaneal lengthening osteotomy as a single-stage reconstruction of symptomatic flexible flatfoot in children and adolescents

BACKGROUND

Symptomatic flexible flatfoot in children and adolescents should be surgically managed only if conservative measures have failed. The aim of this study was to assess functional and radiological results of tibialis anterior rerouting combined with calcaneal lengthening osteotomy as s single-stage reconstruction of symptomatic flexible flatfoot.

METHODS

The current study was a prospective study of patients with symptomatic flexible flatfoot treated by single-stage reconstruction in the form of tibialis anterior tendon rerouting combined with calcaneal lengthening osteotomy. The American Orthopaedic Foot and Ankle Society score (AOFAS) was utilized to evaluate the functional outcomes. The evaluated radiological parameters included the standing anteroposterior (AP) and lateral talo-first metatarsal angle, talar head coverage angle, and calcaneal pitch angle.

RESULTS

 The current study included 16 patients (28 feet) with a mean age of 11.6 ± 2.1 years. There was a statistically significant improvement in the mean AOFAS score from 51.6 ± 5.5 preoperatively to 85.3 ± 10.2 at final follow-up. Postoperatively, there was a statistically significant reduction in the mean AP talar head coverage angle from 13.6 ± 4.4° to 3.9 ± 3°, the mean AP talo-first metatarsal angle from 16.9 ± 4.4° to 4.5 ± 3.6°, and the mean lateral talo-first metatarsal angle from 19.2 ± 4.9° to 4.6 ± 3.2°, P < 0.001. Additionally, the mean calcaneal pitch angle increased significantly from 9.6 ± 1.9° to 23.8 ± 4.8°, P < 0.001. Superficial wound infection occurred in three feet and was treated adequately by dressing and antibiotics.

CONCLUSION

 Symptomatic flexible flatfoot in children and adolescents can be treated with combined lateral column lengthening and tibialis anterior rerouting with satisfactory radiological and clinical outcomes. Level of evidence Level IV.

Lateral column lengthening (LCL) using a rectangular shape graft for managing symptomatic flexible flatfoot showed acceptable early functional and radiological outcomes

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.

Analysis of risk factors for nonunion in pediatric lateral column lengthening

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.

Calcaneal lengthening using ipsilateral fibula autograft in the treatment of symptomatic pes valgus in adolescents

Background

Evans calcaneal lengthening osteotomy is used to treat symptomatic flexible flatfoot when conservative treatment fails. Grafts such as autologous iliac bone grafts, allografts, and xenografts are implanted at the osteotomy site to lengthen the lateral column of the hindfoot. This study aimed to present the outcomes of an autologous mid-fibula bone graft used for calcaneal lengthening in symptomatic pes valgus in adolescents.

Methods

We retrospectively examined 23 ft of 13 adolescents who underwent surgery between July 2014 and January 2018. The radiological and clinical outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores) were assessed during a mean follow-up of 49.7 (range, 30.9–73.4) months. The mean distance of the lengthening site was measured to evaluate graft sinking or collapse. The Goldberg scoring system was used to determine the degree of union at the donor and recipient sites.

Results

The calcaneal pitch and the anteroposterior and lateral talo-first metatarsal (Meary) angles showed significant correction, from 14.4 to 19.6 (p < 0.001), and from 14.5 to 4.6 (p < 0.001) and 13.5 to 8.5 (p < 0.001), respectively. The mean distance of the lengthening site showed no significant change (p = 0.203), suggesting no graft sinking or postoperative collapse. The lateral distal tibial angle showed no significant difference (p = 0.398), suggesting no postoperative ankle valgus changes. Healing of the recipient and donor sites occurred in 23 and 21 ft, respectively. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scores improved significantly, from 68.0 to 98.5 (p < 0.001).

Conclusions

Evans calcaneal lengthening using an ipsilateral mid-fibula bone autograft resulted in significant improvement in clinical and radiological outcomes without ankle valgus deformity. Hence, it could be a treatment option for lateral column calcaneal lengthening in adolescents.

Medial displacement calcaneal osteotomy versus lateral column lengthening to treat stage II tibialis posterior tendon dysfunction, a prospective randomized controlled study

PURPOSE

Adult-acquired flatfoot deformity (AAFD) requires optimum planning that often requires several procedures for deformity correction. The objective of this study was to detect the difference between MDCO versus LCL in the management of AAFD with stage II tibialis posterior tendon dysfunction regarding functional, radiographic outcomes, efficacy in correction maintenance, and the incidence of complications.

PATIENT AND METHODS

42 Patients (21 males and 21 females) with a mean age of 49.6 years (range 43-55), 22 patients had MDCO while 20 had LCL. Strayer procedure, spring ligament plication, and FDL transfer were done in all patients. Pre- and Postoperative (at 3 and 12 months) clinical assessment was done using AOFAS and FFI questionnaire. Six radiographic parameters were analyzed, Talo-navicular coverage and Talo-calcaneal angle in the AP view, Talo- first metatarsus angle, Talo-calcaneal angle and calcaneal inclination angle in lateral view and tibio-calcaneal angle in the axial view, complications were reported.

RESULTS

At 12 months, significant improvement in AOFAS and FFI scores from preoperative values with no significant difference between both groups. Postoperative significant improvements in all radiographic measurements in both groups were maintained at 12 months. However, the calcaneal pitch angle and the TNCA were better in the LCL at 12 months than MDCO, 17̊±2.8 versus 13.95̊±2.2 (p=0.001) and 13.70̊±2.2 versus 19.05̊±3.2 (p<0.001) respectively. 11 patients (26.2%) had metal removal, seven (16.6%) in the MDCO, and four (9.6%) in the LCL. Three (7.1%) in the LCL group had subtalar arthritis, only one required subtalar fusion.

CONCLUSION

LCL produced a greater change in the realignment of AAFD, maintained more of their initial correction, and were associated with a lower incidence of additional surgery than MDCO, however, a higher incidence of degenerative change in the hindfoot was observed with LCL.

Changes in the bony alignment of the foot after tendo-Achilles lengthening in patients with planovalgus deformity

Background

This study was performed to investigate the change in the bony alignment of the foot after tendo-Achilles lengthening (TAL) and the factors that affect these changes in patients with planovalgus foot deformity.

Methods

Consecutive 97 patients (150 feet; mean age 10 years; range 5.1–35.7) with Achilles tendon contracture (ATC) and planovalgus foot deformity who underwent TAL were included. All patients underwent preoperative and postoperative weight-bearing anteroposterior (AP) or lateral (LAT) foot radiographics. Changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, LAT talo-1st metatarsal angle, and calcaneal pitch angle and the factors affecting such changes after TAL were analyzed using lineal mixed model.

Results

There were no significant change in AP talo-1st metatarsal angle and AP talo-2nd metatarsal angle after TAL in patients with cerebral palsy (CP) (p = 0.236 and 0.212). However, LAT talo-1st metatarsal angle and calcaneal pitch angle were significantly improved after TAL (13.0°, p < 0.001 and 4.5°, p < 0.001). Age was significantly associated with the change in LAT talo-1st metatarsal angle after TAL (p = 0.028). The changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, and calcaneal pitch angle after TAL were not significantly associated with the diagnosis (p = 0.879, 0.903, and 0.056). However, patients with CP showed more improvement in LAT talo-1st metatarsal angle (− 5.0°, p = 0.034) than those with idiopathic cause.

Conclusion

This study showed that TAL can improve the bony alignment of the foot in patients with planovalgus and ATC. We recommend that physicians should consider this study’s findings when planning operative treatment for such patients.

Subtalar arthroereisis for the treatment of the symptomatic paediatric flexible pes planus: a systematic review

Subtalar arthroereisis has a controversial history and has previously been associated with high failure rates and excessive complications.A database search for outcomes of arthroereisis for the treatment of symptomatic paediatric flexible pes planus provided 24 articles which were included in this review, with a total of 2550 feet operated on.Post-operative patient-reported outcome measures recorded marked improvement. Patient satisfaction was reported as excellent in 79.9%, and poor in 5.3%. All radiological measurements demonstrated improvement towards the normal range following arthroereisis, as did hindfoot valgus, supination, dorsiflexion and Viladot grade.Complications were reported in 7.1% of cases, with a reoperation rate of 3.1%.Arthroereisis as a treatment for symptomatic paediatric flexible pes planus produces favourable outcomes and high patient satisfaction rates with a reasonable risk profile. There is still a great deal of negativity and literature highlighting the complications and failures of arthroereisis, especially for older implants.The biggest flaws in the collective literature are the lack of high-quality prospective studies, a paucity of long-term data and the heterogeneity of utilized outcome measures between studies. Cite this article: EFORT Open Rev 2021;6:118-129. DOI: 10.1302/2058-5241.6.200076.

Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans-Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.'s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary's angle and Costa–Bertani's angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.'s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary's angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani's angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Treatment for Flexible Flatfoot in Children With Subtalar Arthroereisis and Soft Tissue Procedures

Background: Children with flexible flatfoot is common in clinics and there is no unified conclusion on surgical treatment. And for some patients with severe deformities, the correction of the subtalar joint arthroereisis combine the release of the Achilles tendon or gastrocnemius muscle release is still not satisfactory. The main aim of the present study was to investigate the therapeutic outcomes of subtalar arthroereisis combined with Achilles tendon or gastrocnemius recession and medial soft tissue (spring ligament, talonavicular joint capsule, tibionavicular ligaments and tibiospring ligaments) tightening for treating flexible flatfoot with severe deformities. Methods: Thirty patients (32 feet) with pediatric flexible flatfoot who underwent subtalar arthroereisis and soft tissue procedures during January 2016 to January 2018. There were 18 males (20 feet) and 12 females (12 feet) with an average age of 9.5 years (range, 8-12 years). We used the AOFAS scores and VAS scores combined with angles measure to evaluate the pre-operative and post-operative status. Results: Thirty patients (32 feet) were followed up for 25.3 months on average (range, 18-36 months). There was no infection. Post-operative foot pain, arch collapse, and other symptoms improved. At last follow-up, the Meary angle was decreased from 17.5° ± 4.4° to 4.1° ± 1.2° (P < 0.05), the talar-first metatarsal (AP) was decreased from 15.3° ± 3.1° to 4.8° ± 1.3°(P < 0.05), The mean AOFAS score was rose from 66.6 ± 5.8 to 88.6 ± 7.9 (P < 0.05), the mean VAS score was decreased from 6.6 ± 0.6 to 1.7 ± 0.3 (P < 0.05). Conclusion: The subtalar arthroereisis combined with soft tissue procedures can effectively correct flexible flatfoot in children and it is a significant method for severe forefoot abduction reconstruction. Level of Evidence: IV.