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Combined technique for surgical correction of pediatric severe flexible flatfoot
Combined Technique for Surgical Correction of Pediatric Severe Flexible Flatfoot Ten patients with 12 symptomatic severe flatfeet were treated with a combined surgical technique. Patients 10 years or older were treated with Evan's calcaneal osteotomy, Young tenosuspension, and tendo achillis lengthening. Patients under age 10 were treated with modified Young tenosuspension, talonavicular desmoplasty and subtalar arthroereisis. Eight of the 10 patients had marked relief in pain and fatigue and were able to perform a/l physical activities. Radiographic criteria showed improvement for a/l patients in a/l categories.
Ellen Cohen-Sobel, DPM, PhD 1 Renata Giorgini, DPM, FACFAS2 Zunilda Velez, DPM 3 Pes planovalgus is a common problem with diverse clinical findings and a wide variety of etiology. Most of the time the symptoms are mild and respond to conservative treatment (1-3). However, occasionally the condition is severe and recalcitrant to long periods of conservative therapy and surgical treatment should be considered (4, 5). In children, untreated flatfoot deformity may deteriorate with age and progress to painful arthritic conditions in the adult (3, 6, 7). Although pain is the major reason for surgical correction (5, 8, 9) in the severe flatfoot, reduced activity level with fatigue and inability to walk and perform daily activities may be indications for surgical treatment (4, 6, 7, 10-12). The clinical appearance of the severe symptomatic flatfoot consists of a collapsed medial longitudinal arch (Fig. 1), heel valgus (Fig. 2), forefoot abduction (Fig. 3), heel cord tightness, and forefoot supinatus or varus. An adequate surgical approach must correct all of these deformities (10). There are many surgical procedures to correct the symptomatic flatfoot; however, no surgical technique is universally accepted (6, 13) and no single flatfoot procedure corrects the entire foot (14). Surgical procedures for the flatfoot fall into three general cate-
From the New York College of Podiatric Medicine, and North General Hospital, New York, New York. 1 Associate Professor, Division of Orthopedics; Diplomate, American Board of Podiatric Orthopedics. Address correspondence to: 54 East 124th Street, New York, NY 10035. 2 Professor, Division of Surgery; Chief, Podiatric Surgery and Residency Director, North General Hospital. 3 Surgical Fellow, North General Hospital. 1067-2516/95/3402-0183$3.00/0 Copyright © 1995 by the American College of Foot and Ankle Surgeons
gories: 1) tendon transfer or lengthening; 2) osteotomy; and 3) arthrodesis. Although arthrodesis procedures are the most common (5), the results of surgery have been poor over time. Seymour (15) reported 50% poor results of naviculocuneiform fusions after 15 years. Butte (16) also reported 50% poor results after naviculocuneiform fusion in 76 feet. Crego and Ford (9) reported poor results in five of seven naviculocuneiform fusions. Arthrodesing procedures result in significant loss of inversion and eversion (9, 17). LeLievre (18) considered any surgical procedure which required loss of joint function to produce correction of the pronated foot to be physiologically unsound. In contrast, calcaneal osteotomy does not result in an iatrogenic coalition (19) and retains joint motion. Phillips (13) reported 90% good and excellent results in patients having Evan's opening lateral wedge osteotomy with a follow-up time of 13 years. Anderson and Fowler (8) reported good results in nine feet treated with the Evan's procedure after a follow-up of 6.5 years. Most recently Sangeorzan (20) observed dramatic radiographic improvements in seven symptomatic flatfeet operated on by the Evans technique. In summary, a surgical procedure for correction of symptomatic flatfoot in a growing child should not rely on soft tissue tightening alone and should not fuse joints (17). The Evans procedure (21), which involves a lateral opening wedge osteotomy of the calcaneus, is most effective in lengthening the lateral column, which will correct forefoot abduction and heel valgus. However, the Evans procedure does not address problems of the medial column including forefoot supinatus (4, 22). Therefore, medial column procedures are commonly combined with the Evan's osteotomy (23, 24). VOLUME 34, NUMBER 2, 1995
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Figure 1. Valgus foot with collapsed medial arch.
the muscle force of the posterior tibial tendon at the navicular (26). Ankle equinus is not corrected by the procedures above. The Evans procedure may actually unmask a pre-existing equinus (27). The Young tenosuspension was originally performed with an Achilles tendon lengthening (25), which will correct the equinus component of the flat foot. The Evan's procedure is not recommended for children under the age of 10 (5). For children younger than 10 years, a combination of soft tissue procedures including modified Young tenosuspension and talonavicular desmoplasty may be sufficient to correct the symptomatic flatfoot. A SILASTIC®4 implant arthroereisis may be added to the above in the severe flatfoot in the younger child (28). The purpose of this paper is to present the authors' experience with a combined surgical technique (Evan's calcaneal osteotomy, Young tenosuspension, and tendo achillis lengthening in patients 10 years or older and modified Young tenosuspension, talonavicular desmoplasty, and subtalar arthroereisis in patients under age 10) in the treatment of the severe flatfoot. Methods and Evaluation
Figure 2. Heel valgus on the left foot.
Figure 3. Left foot, forefoot is abducted.
The Young tenosuspension (25) is frequently combined with Evan's osteotomy to correct forefoot supinatus (11, 14). The Young tenosuspension supports the medial longitudinal arch by rerouting the tibialis anterior tendon through a key-hole slot into the navicular. The Young procedure holds the subtalar joint in the neutral position by adding the anterior tibial tendon to 184
From 1990 to 1993, 10 patients (6 males and 4 females) with 12 severe symptomatic flatfeet were treated with combined surgical techniques. Patients 10 years or older (including two adults) were treated with Evans calcaneal osteotomy, Young tenosuspension and percutaneous tendo achillis lengthening. Children under age 10 were treated with modified Young tenosuspension, talonavicular desmoplasty, and SILASTIC® implant arthroereisis. All surgeries were performed by one of the authors (RG). Nine patients had severe idiopathic flatfoot and one patient had flatfoot secondary to cerebral palsy. The average age of patients at the time of surgery was 17 years, ranging from age 6 to age 41. The follow-up time was an average of 1 year, ranging from 4 to 18 months. All patients initially presented with severe pain, which drastically limited physical activity and was recalcitrant to conservative treatment. Conservative treatment consisting of stretching exercises, custom made orthotic devices, and shoe therapy was always attempted for at least 1 year prior to surgery and in most cases was tried for many years without success. Because pain, fatigue, and inability to perform daily activities were the major reasons for surgery, patients were evaluated primarily on whether they had relief or reduction in pain, fatigue, and their ability to participate
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4
Dow Coming Wright, Midland, TN.
Figure 4. Evan's calcaneal osteotomy. With permission from McCrea, JD: The Evans Procedure for Treatment of Severe Pes Planovalgus. J. A. P. M. A. 77:35-38, 1987.
Figure 5. Stab incision to release anterior 2f3 of Achilles tendon.
in physical activities after the surgery. The patient or parent was also asked to rate the surgery on a scale from "I" to "10," with "10" being the highest and to state whether they were "better," "worse," or the "same" after surgery. Eight radiographic criteria were also reviewed before and after surgery for each patient to measure reduction of heel valgus, forefoot abduction, and improvement in arch height. Surgical Procedures Evans Lateral Opening Wedge Osteotomy (Fig. 4)
A vertical incision is made over the calcaneal cuboid joint. An osteotomy is made at the lateral aspect of the calcaneus 1 em. proximal to the calcaneal cuboid joint utilizing a baby lamina spreader. A graft of cortical bone taken from the contralateral iliac crest is inserted to create an opening wedge osteotomy of the calcaneus to correct forefoot abduction and heel valgus. The iliac crest graft provides the best strength, rapid incorporation, and low morbidity (5). Once the graft is in place, it is impacted and a stainless steel staple is used to secure the osteotomy. The foot is immobilized in a short leg plaster of Paris cast in a neutral position for a period of 6 weeks.
Figure 6. Second stab incision on the midline of the Achilles tendon.
Percutaneous Tendo Achillis Lengthening
A stab incision is made 1 em. proximal to the insertion of the Achilles tendon from a lateral to medial direction, freeing up the anterior 2/3 of the Achilles tendon (Fig. 5). Approximately 3 em. proximal to the first incision, on the midline of the tendo achillis, the medial half of the tendon is dissected through a small stab incision (Fig. 6). The foot is then placed into dorsiflexion (Fig. 7) and a tendon slide "Z" plasty tendo achillis lengthening is accomplished. The skin is closed with three 4-0 nylon sutures.
Figure 7. The foot is placed into dorsiflexion.
Young Tenosuspension
A IS-em. incision is made over the medial aspect of the foot extending from the first metatarsocuneiform joint to the navicular (Fig. 8). A drill hole is placed in the navicular (Fig. 9) from anterior-dorsal to posteriorplantar, and then a wedge of bone from the navicular is removed. The tibialis anterior tendon is identified
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Figure 8. Shows medial incision in preparation tor young tenosuspension.
Figure 10. Identifying the tibialis anterior tendon.
Figure 11. The tibialis anterior tendon has been translocated through the navicular.
Figure 9. Anteroposterior radiograph. Shows keyhole slot made in the navicular for the tibialis anterior tendon.
(Fig. 10) and freed up along its route, and rerouted underneath the navicular through a key-hole slot (Fig. II). Once the tendon is found to support translocation, the keyhole wedge of bone is then placed back into the slot and fixated with 2-0 dexon sutures or staples. Modified Young Tenosuspension/talonavicular desmoplasty
A IS-em. incision is made on the medial border on the longitudinal arch of the foot (Fig. 12). The incision is deepened and the tibialis anterior tendon is divided and 186
Figure 12. Medial incision Young tenosuspension.
in preparation for modified
tagged. The posterior tibial tendon is then tagged (Fig. 13). A "U"-shaped flap is made from the capsule overlying the talonavicular joint. The talonavicular joint is then exposed and a small groove is wedged into the inferior surface of the navicular. The tibialis anterior
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Figure 13. Shows tagging of tibialis anterior tendon (attached to left sided string) and posterior tibial tendon (attached to right sided string).
Figure 14. The anterior tibial tendon and the posterior tibial
Figure 15. Shows capsular "U" flap overlying the talonavic-
ular joint.
Figure 16. Shows SILASTIC® Spherical Implant about to be placed into the sinus tarsi.
tendon are being sutured together.
tendon is reflected inferiorly and freed up and translocated by Young tenosuspension underneath the navicular and through the talonavicular joint to suspend the longitudinal arch and to raise the navicular. The tibialis anterior and tibialis posterior tendon are sutured to further reinforce the longitudinal arch utilizing 2-0 absorbable suture in a continuous locked fashion (Fig. 14). A "U" -shaped flap is sutured over the tibialis anterior tendon and sutured inferiorly to maintain the correction and prevent the tendon from dislocating out of the groove (Fig. 15). The opening overlying the talonavicular joint is then closed. The foot is placed in an adducted position and desmoplasty is accomplished closing the capsule using 2-0 absorbable simple interrupted sutures. Subtalar Arthroereisis
A 4-cm. curvilinear incision is made overlying the lateral sinus tarsi. The incision is deepened to the sinus tarsi. The fatty plug in the sinus tarsi is enucleated with a curette. The interosseous talocalcaneal ligament is not
severed. A SILASTIC® interpositional sphere is placed within the sinus tarsi (Fig. 16). Once the implant is properly seated, the capsule is closed with retention sutures and reinforced. Case Reports Case 1
DT, a black female, was 14 years old when first seen with a painful right flatfoot which had become symptomatic for the past 2 years. She frequently became fatigued after only short periods of walking. She was treated with arch supports, paddings, and strappings, but continued to complain of constant pain. At age 15 she underwent a tendo achillis lengthening, Young tenosuspension, and an Evan's calcaneal osteotomy on the right foot with a bone graft from the left hip. She was placed in a short leg cast for approximately 6 weeks postoperatively, and wore an ankle foot orthosis for the subsequent 3 months. At 1 year follow-up, she denies any pain and is able to perform physical activities without fatigue. Satisfaction with the results of the operation was rated by the patient's mother with a 9 out of a possible 10. VOLUME 34, NUMBER 2, 1995
187
fatigue, pain on the bottom of both feet and falling. She had been having these problems for many years. She was treated with orthotics, heel lifts, and stretching exercises without relief. At age 10, she underwent left Achilles tendon lengthening, Young tenosuspension, and Evan's calcaneal osteotomy with bone graft from the right hip. She was placed in a below-the-knee cast for 8 weeks and wore an ankle foot orthosis for the subsequent 3 months. Two years later, at the time of follow-up at age 12, she has only mild pain, infrequently. Her left heel is able to touch the ground, and she is able to perform all physical activities without limitation. The mother rates the results of the surgery as a 10 out of a possible 10. Figure 17. Preoperative radiograph of KC shows flattened calcaneal pitch angle, navicular cuneiform sag, and plantarflexed talus.
Figure 18. Postoperative radiograph of KC at the time of 1.5-year follow-up. Notice improvement in calcaneal pitch angle and improved alignment of the medial column.
Case 2
KC, a IS-year-old hispanic male, was initially seen in 1990 at age 11 with the chief complaint of frequent pain in both feet, and fatigue especially after playing sports (Fig. 17). He was treated with orthotic devices, and stretching exercises without relief. At age 13 he underwent bilateral Achilles tendon lengthening, Evan's calcaneal osteotomy, and Young tenosuspension (Fig. 18). He was placed in a short leg cast for 6 weeks postoperatively and was prescribed hinged ankle foot orthoses for 3 more months after removal of the cast. After 1.5 years follow-up he has no pain in the right foot and mild pain in the left foot only after intensive physical activity. Satisfaction with the results of the operation was rated by the patient's mother with a 7 out of a possible 10. Case 3
AD, a black female with a history of cerebral palsy, was 9 years old when initially seen with the chief complaint of the left heel not touching the ground, 188
Case 4
AB, a black male, was 9 years old when initially seen with a history of fatigue and pain in the right foot, which had been present for 2 years. Orthotic devices were prescribed but did not alleviate his symptoms. At age 10 he was treated with a right tendo achillis lengthening, Young's tenosuspension, and Evan's calcaneal osteotomy with bone graft from the left hip. He was placed in a below-the-knee cast for 8 weeks postoperatively and wore an ankle foot orthosis for the subsequent 3 months. At follow-up he denied pain and was able to perform all physical activities without any limitation. The child's mother rated the results of surgery with an 8 out of a possible 10. Case 5
JV was S years old when he initially presented with the chief complaint of frequent falls and "collapsed arches." He was treated with orthotic devices for approximately 1 year without success. He continued to fall frequently, especially when running. At age 6 he underwent a modified Young tenosuspension with talonavicular desmoplasty on both feet. He was placed in a short leg cast for 6 weeks postoperatively and wore a hinged ankle foot orthosis for approximately 3 months after surgery. At the time of a 2-year follow-up at the age of 8, he denies any pain, fatigue and experiences less falling during physical activities. The appearance of his foot is more normal looking. In general the mother states that he is much better after having the surgery and rates the results of surgery as a 10 out of a possible 10. Case 6
VW, a 7-year-old black female, initially presented at age S with aching pain in the medial arch of the right foot, which had been present for 2 years. She also complained of fatigue after only brief periods of walking which greatly limited physical activities. She was treated
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Figure 21. Preoperative radiograph (weightbearing) of patient from Figs. 19 and 20 0JW). Figure 19. Frontal view of VW with surgically corrected right foot. Modified Young tenosuspension, percutaneous tendo achillis lengthening, desmoplasty, and arthroereisis was performed.
Figure 20. Side view of same patient 0JW) from Fig. 19 with right foot surgically corrected.
Figure 22. Postoperative radiograph (nonweightbearing) of patient from Figs. 19-21 0JW) shows spherical implant in sinus tarsi, normal calcaneal pitch angle and good general osseous alignment.
with arch supports with no relief. At age 6 she underwent a modified Young tenosuspension with talonavicular desmoplasty, Achilles tendon lengthening, and subtalar joint arthroereisis on the right foot (Figs. 19-22). She was placed in a below-the-knee cast for 6 weeks postoperatively and was prescribed an ankle foot orthosis for the subsequent 3 months. At the time of follow-up 1 year later, she occasionally experiences mild pain in bad weather, but much less than before the surgery. She does not fatigue easily and is able to perform all physical activities. The patient's mother rates the results of the operation with a 10 out of a possible 10.
For the flatfoot deformity he was treated with orthotic devices which did not alleviate the condition. The patient underwent a right tendo achillis lengthening, Young tenosuspension, and Evan's calcaneal osteotomy (Figs. 25, 26) with bone graft obtained from the left hip. He was placed in a short leg cast for approximately 8 weeks postoperatively. At the time of follow-up 1 year later, he is pain free and the shoe wear is more normal. Satisfaction with the results of the operation was rated by the patient's mother with an 8 out of a possible 10.
Case 7
Case 8
GN, a 9-year-old boy, initially presented with right foot pain and abnormal shoe wear which had been present for the past 5 years. He had a clubfoot which was surgically treated on the left foot (Figs. 23, 24).
AS, a white male, was seen in 1988 at the age of 26, with the chief complaint of painful flat feet when walking. He was treated with orthoses, orthopedic shoes, paddings, and strappings for the past 5 years with no VOLUME 34, NUMBER 2, 1995
189
Figure 26. Postoperative radiograph of patient from Figs. 23-25 (GN) shows good bony alignment.
Figure 23. Untreated flatfoot on the right side. Clubfoot on the left surgically corrected 8 years ago by RG.
less difficulty than prior to surgery. The patient rates the results of the surgery as 8 out of a possible 10. Case 9
Figure 24. Patient from Fig. 23. Posterior view. Notice marked heel valgus on the right side.
JG is an obese hispanic male, who was 14 years old when initially seen with complaints of aching in both feet and fatigue upon ambulation and physical activities. The problem had been present for the past 4 years. Previous tendo achillis lengthening had been performed elsewhere 2 years ago on the right foot. He was treated with orthotic devices and stretching exercises without relief. At age 15 he underwent tendo achillis lengthening, Young tenosuspension, and Evan's calcaneal osteotomy in the left foot with a bone graft from the right hip. At 2 years follow-up at the age of 17, he presents with pain in the left foot, limping, and inability to perform physical activities. The mother claims that he is worse since the surgery and rates the results of surgery as a 5 out of a possible 10. There are two possible confounding factors here including the fact that the child has always been a school truent and may be using his feet as an excuse to avoid school. He also complains frequently about the first surgery. Case 10
Figure 25. Preoperative radiograph of patient from Figs. 23 and 24 (GN).
improvement. At age 30 he underwent a right Young tenosuspension, tendo achillis lengthening and Evan's calcaneal osteotomy. He was placed in a below-the-knee cast for approximately 8 weeks and was prescribed a hinged ankle foot orthosis for the subsequent 3 months. At 1 year follow-up he denies any pain and is able to perform physical activities including running with much 190
FJ is a 40-year-old female who presented with the chief complaint of left ankle swelling and medial arch pain upon ambulation present for 1 year. The patient was treated with orthotic devices for the subsequent year without improvement. At age 41, she underwent tendo achillis lengthening, Young tenosuspension, and Evan's calcaneal osteotomy in the left foot with a bone graft from the right hip. At follow-up 1 year after the operation, she complained of mild pain at the area where the staple was placed on the lateral aspect of the left foot, especially upon ambulation and when the weather is bad. Swelling at the ankle has reduced since the surgery. The patient rates the results of surgery as a 5 out of a possible 10. Although this patient was not happy with the
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TABLE 1. Clinical profile and rating Current Age
VW
7 8
JV GN AS AD KG DT JG
10 11 12 14 16 16
AS JF
31 42
Sex
Foot
Surgical Procedures"
F
right both right right left both right left
YmTAD YmD YTE YTE YTE YTE YTE YTE
right left
vrs
M M M F
M F
M M F
YTE
Age at Time of Surgery
6 6
9 10 10 13 15 15 30 41
Length of Symptoms (years)
Pain (After Surgery)
Physical Activity
4 5 5 2 many 3 2 4
mild none none none mild mild none +pain
6
none mild
all all all all all all all unable to perform all all
1
Rating Better, Worse, Same
better better better better better better better worse better same
Rating (1-10)
10 10
8 8 10
7 9 5
8 5
• Y ms Young tenosuspension modified; T, percutaneous tendo achillis lengthening; Y, Young tenosuspension; A, subtalar arthroereisis; D, desmoplasty; E, Evan's calcaneal osteotomy.
surgery, she was originally unable to work, and since the surgery she has been able to return to working a full 8-hr day as a home attendant. Results
Nine of 10 patients reported complete relief of pain or markedly reduced or infrequent pain after surgery (Table 1). All but one patient was able to perform all physical activities. Eighty percent rated themselves better after the surgery and 80% rated the surgery as a 7 or higher out of a possible 10, with three patients rating the surgery with the highest rating of 10. In general, the radiographic evaluation indicated improvement in all angles (Table 2). All but one patient had abnormally low calcaneal pitch angles preoperatively. The average increase in the calcaneal pitch angle was 10.7 degrees with all patients falling into the normal range postoperatively. The lateral talocalcaneal angle is a reflection of hindfoot valgus. The average improvement in the lateral talocalcaneal angle was 9.4 degrees with all patients falling into the normal range postoperatively.The lateral talar-first metatarsal angle decreased an average of 8 degrees after surgery. The calcaneusnaviculo-metatarsal angle measures the height of the arch (3). Seventy-five percent had grossly abnormal values prior to surgery. All patients showed improvement in arch height with an average correction of 16 degrees. There was an average improvement of 8.6 degrees in the talar declination angle however only 33% of patients had a plantarflexed attitude of the talus initially. The talocalcaneal angle (TCA) in the anteroposterior view is a reflection of heel valgus. The average reduction in the TCA was 9.8 degrees. The talar first metatarsal angle in the anteroposterior view is a measure of forefoot abduction or adduction. All patients demonstrated
grossly abnormal angles preoperatively. There was an average correction of 7.5 degrees. The Lang Index, as described by Mahan and MeGlamry (29), is the ratio of the arch height to arch length. This measurement did not correlate with the clinical severity of the foot. Only 50% showed abnormally low values initially. However, all patients demonstrated improvement with an average of 5.6% correction in arch height to length ratio. Discussion
When surgery is required to correct the severe symptomatic flatfoot, more than one surgical procedure is usually necessary (4, 7, 8, 11, 18,22,27,28,30-32). The authors have found the combined technique of Evan's calcaneal osteotomy, Young tenosuspension, and tendo achillis lengthening in patients 10 years or older and modified Young tenosuspension, talonavicular desmoplasty, and subtalar arthroereisis in patients under age 10 to be successful in correcting the severe symptomatic flexible flatfoot. The combination of procedures addresses both the lateral and medial column and equinus component of the flatfoot, and works better than any individual technique. The flatfoot is more easily corrected in the younger child. When the patient is older, the results are less predictable. Although the subtalar joint arthroereisis has been performed on patients as old as 69 years (18), most authors recommend the procedure for those not having reached skeletal maturity (6, 7, 12, 33-36). Similarly although the Evan's procedure is done on older patients (37), the authors believe that it works best with ancillary procedures in the younger patient. In general, the radiographic values improved in the expected direction in all cases. It is notable that even the VOLUME 34, NUMBER 2, 1995
191
....
IS -l I
m C-
O
c
::0
TABLE 2. Preoperative and postoperative radiographic findings
Z
~
r
0
"Tl
Calcaneal Pitch Angle (15°_25 o)a
"Tl
0 0
Lateral Talocalcaneal Angle (15°_35 )b O
~
Z
~
r m
(J)
c
::0 G)
m
::0
-<
0-1300
Talar Declination Angle 21° = Normal' >25° = Flatfoot?
Talocalcaneal Angle Dorsoplantar View (15°_30 )b 0
Talar-1st Metatarsal Angle Anteroposterior (-20° to +15 )h O
Lateral Index (18-22%);
Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postopertive ative tive ative ative tive tive ative tive ative tive ative tive ative tive ative
0
Z
Flatfoot"
Calcaneus-NaviculoMetatarsal Angle (120 )e
>15° = Severe Flatfootd
-l
;;:0:;;
Talar-1 st Metatarsal Angle (Lateral) 0° = Normal 1°_15° = Mild
VW JV (right) (left) GN AB AD KC (right) (left) DT JG AS JF
15° 8° 8° 2° 10° 12° 0° 5° 5° 10° 11° 10°
23° 18° 20° 15° 18° 20° 15° 15° 20° 20° 20° 20°
35° 38° 35° 35° 40° 35° 42° 41° 35° 38° 40° 40°
30° 28° 25° 25° 30° 25° 35° 33° 20° 28° 30° 32°
10° 10° 8° 15° 8° 10° 25° 28° 8° 10° 10° 10°
3° 0° 0° 8° 2° 5° 15° 13° 3° 2° 0° 3°
130° 135° 135° 155° 130° 130° 155° 150° 132° 132° 135° 140°
120° 120° 122° 135° 120° 115° 125° 135° 120° 110° 124° 120°
20° 20° 20° 30° 30° 22° 35° 38° 20° 18° 25° 25°
14° 16° 16° 23° 20° 15° 15° 18° 15° 12° 20° 15°
30° 28° 25° 30° 35° 30° 33° 30° 35° 28° 30° 38°
25° 20° 18° 20° 25° 20° 25° 22° 20° 20° 20° 25°
15° 18° 15° 17° 20° 15° 18° 15° 16° 15° 18° 18°
10° 15° 4° 13° 10° 2° 7° 10° 12°
r 12° 8°
17% 19% 19% 14% 18% 15% 11% 10% 17% 19% 18% 18%
Gamble, F. 0., Yale, I. Clinical Foot Roentgenology. Williams & Wilkins, Baltimore, 1966. McCrae, J. D. Pediatric Orthopedics of the Lower Extremity. Futura Publishing Company, Inc., Mount Kisco, NY, 1985. C Meary, R. On the measurement of the angle between the talus and the first metatarsal. Symposium: Le Pied Creux Essential. Rev. Chir. Orthop. 53:389, 1967. d Bordelon, R. L. Correction of hypermobile flatfoot in children by molded inserts. Foot Ankle 1:143-150,1980. e Viladot, A. Surgical treatment of the child's flatfoot. Clin. Orthop. ReI. Res. 283:34-38, 1992. 'Weissman, S. D. Radiology of the Foot. Williams & Wilkins, Baltimore, 1983. 9 Borrelli, A. H., Smith, S. D. Surgical considerations in the treatment of pes planus. J. A. P. M. A. 78:305-309, 1988. h Vanderwilde, R., Staheli, L. T., Chew, D. E., et al. Measurements on radiographs of the foot in normal infants and children. J. Bone Joint Surg. 70(A):407-421, 1988. i Mahan, K. T., McGlamry, E. D. Evan's calcaneal osteotomy for flexible pes valgus deformity. Clin. Podiatr. Med. Surg. 4:137-151,1987. a
b
22% 22% 22% 21% 21% 27% 17% 13% 26% 29% 21% 21%
two patients that found the surgery unsatisfactory (JG and FJ) demonstrated excellent radiographic improvement (Table 2). Recently, it has been shown that the metatarsus adductus (MA) angle remains virtually unchanged after the Evan's osteotomy (1.5-degree increase) (37). Previously Mahan and McGlamry (29) found the MA angle to increase an average of 3 degrees after the Evan's osteotomy. Of the nine feet having surgery that included the Evan's procedure in the present study, there was an average increase of 3.4 degrees in five feet and an average decrease of 6 degrees in four feet. Two feet which exhibited decreases in the MA angle had the highest MA angles preoperatively (23 and 24 degrees). Brim and Hecker (37) also found that one patient in their series had an improvement in the MA angle and considered the metatarsus adductus a compensatory mechanism secondary to the flatfoot deformity. Once the flatfoot is corrected, the apparent metatarsus adductus resolves. Summary
Ten patients with 12 severe symptomatic flatfeet were treated with a combined surgical technique. Patients aged 10 years or older were treated with Evan's osteotomy, Young tenosuspension, and tendo achillis lengthening. Patients under age 10 were treated with modified Young tenosuspension, talonavicular desmoplasty and subtalar arthroereisis. Most patients showed marked improvement clinically, including absence of or marked reduction in pain, improvement in ability to perform physical activities, and reduction in fatigue. All radiographic criteria revealed improvement. On the lateral view, average improvements were 10.7 degrees for the calcaneal pitch angle, 9.4 degrees for the lateral talocalcaneal angle, 8 degrees for the talar-first metatarsal angle, 4.2 degrees for the talar declination angle, 16 degrees for the calcaneo-navicular-metatarsal angle and 6 degrees for the Lange Index. On the dorsoplantar view, the average improvements were 9.8 degrees for the talocalcaneal angle, and 7.5 degrees for the talar-first metatarsal angle. It is concluded that a combined surgical technique involving osteotomy and soft tissue procedures is effective in treating the severe symptomatic flexible flatfoot, which is refractory to conservative treatment.
References 1. Bordelon, R. L. Correction of hypermobile flatfoot in children by molded insert. Foot Ankle 1:143-150, 1980. 2. Scranton, P. E. Management of hypermobile flatfoot in the child. Contemp. Orthop. 3:645-672, 1981.
3. Viladot, A. Surgical treatment of the child's flatfoot. Clin. Orthop. ReI. Res. 283:34-38, 1992. 4. Dockery, G. L. Surgical treatment of the symptomatic juvenile flexible flatfoot condition. Clin. Pod. Med. Surg. 4:99-117, 1987. 5. Mosca, V. S. Flexible flatfoot and skewfoot, ch. 17. In The Child's Foot and Ankle, pp. 355-376, edited by J. C. Drennan, Raven Press, Ltd., New York, 1992. 6. Smith, S. D., Millar, E. A. Arthrorisis by means of a subtalar polyethylene peg implant for correction of hindfoot pronation in children. Clin. Orthop. ReI. Res. 181:15-23, 1983. 7. Subotnick, S. I. The subtalar joint lateral extra-articular arthroereisis: A preliminary report. J. A. P. A. 64:701-711, 1974. 8. Anderson, A. F., Fowler, S. B. Anterior calcaneal osteotomy for symptomatic juvenile pes planus. Foot Ankle 4:274-283, 1984. 9. Crego, C. H., Ford, L. T. An end-result study of various operative procedures for correcting flat feet in children. 1. Bone Joint Surg. 34A:183-195, 1952. 10. Bordelon, R. L. Flatfoot Deformity. In Current Therapy in Foot and Ankle Surgery, pp. 188-194, edited by M. Myerson, MosbyYear Book, Inc., Chicago, 1993. 11. Mahan, K. T., McGlamry, E. D., Green, D. R. Pes Planovalgus Deformity, ch. 31. In Surgery of the Foot and Ankle, 2nd ed., pp. 769-817, edited by E. D. McGlamry, Williams & Wilkins, Baltimore, 1992. 12. Yu, G. V., Boberg, J. Subtalar Arthroereisis, ch. 32. In Surgeryof the Foot and Ankle, 2nd ed., pp. 818-828, edited by E. D. McGlamry, Williams & Wilkins, Baltimore, 1992. 13. Phillips, G. E. A review of elongation of os calcis for flat feet. J. Bone Joint Surg. 65B:15-18, 1983. 14. Sgarlato, T. Pediatric foot surgery. Clin. Pod. Med. Surg. 1:709723,1984. 15. Seymour, N. The late results of naviculo-cuneiform fusion. J. Bone Joint Surg. 49B:558-559, 1967. 16. Butte, F. L. Naviculo-cuneiform arthrodesis for flatfoot: an end result study. J. Bone Joint Surg. 19:496-502, 1937. 17. Wenger, D. R. Flatfoot and Children's Shoes, ch. 3. In The Art and Practice of Children's Orthopaedics, pp. 77-102, edited by D. R. Wenger and M. Rang, Raven Press, New York, 1993. 18. Lel.ievre, J. Current concepts and correction in the valgus foot. Clin. Orthop. ReI. Res. 70:43-55, 1970. 19. Barry, R. J., Scranton, P. E. Flat feet in children. Clin. Orthop. ReI. Res. 181:68-75, 1983. 20. Sangeorzan, B. J., Mosca, V., Hansen, S. T. Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot Ankle 14:136-141, 1993. 21. Evans, D. Calcaneo-valgus deformity. J. Bone Joint Surg. 57B: 270-278, 1975. 22. Jacobs, A. M., Oloff, L. M. Surgical management of forefoot supinatus in flexible flatfoot deformity. J. Foot Surg. 23:410-419, 1984. 23. Banks, A. S., Smith, T. F. Operative treatment of non-neurogenic pes valgus feet, ch. 14. In Foot and Ankle Disorders in Children, edited by S. DeValentine, pp. 329-367, Churchill Livingstone, New York, 1992. 24. Subotnick, S. I. New and investigative procedures for flatfoot surgery. Clin. Pod. Med. Surg. 6:605-611, 1989. 25. Young, C. S. Operative treatment of Pes Planus. Surg. Gynecol. Obstet. 68:1099-1101, 1939. 26. Beck, E. L., McGlamry, E. D. Modified Young tendosuspension technique for flexible flatfoot. J. A. P. A. 63:582-604, 1973. 27. Spinner, S. M., Chussid, F., Long, D. H. Criteria for combined procedure selection in the surgical correction of the acquired flatfoot. Clin. Pod. Med. Surg. 6:561-575, 1989.
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28. Giorgini, R. J., Schiraldi, F. G., Hernandez, P. A. Subtalar arthroere isis: A combined technique. J. Foot Surg. 27:157-160, 1988. 29. Mahan, K. T., McGlamry, E. D. Evans calcaneal osteotomy for flexible pes valgus deformity: a preliminary study. Clin. Pod. Med. Surg. 4:137-151, 1987. 30. Catanzariti, A. R. Medial column stabilization. Clin. Pod. Med. Surg. 8:667-692, 1991. 31. Dollard, M. D., Marcinko, D. E., Lazerson, A., Elleby, D. H. The Evans calcaneal osteotomy for correction of flexible flatfoot syndrome. J. Foot Surg. 23:291-301, 1984. 32. Schwartz, N. H., Tursi, F. J. A new surgical technique for the treatment of pes planus deformity: A preliminary report. J. Foot Surg. 26:149-152, 1987.
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33. Addante, J. B., Chin, M. W., Loomis, J. c, Burleigh, W., Lucarelli, J. E. Subtalar joint arthroereisis with SILASTIC® silicone sphere: A retrospective study. J. Foot Surg. 31:47-51, 1992. 34. Lanham, R. H. Indications and complications of arthroereisis in hypermobile flatfoot. J. A. P. A. 69:178-185, 1979. 35. Lundeen, R. O. The Smith STA-peg operation for hypermobile pes planovalgus in children. J. A. P. M. A. 4:177-183, 1985. 36. Smith, S. D., Wagreich, C. R. Review of postoperative results of the subtalar arthrorisis operation: A preliminary study. J. Foot Surg. 23:253-260, 1984. 37. Brim, S. P., Hecker, R. The Evans calcaneal osteotomy: Postoperative care and an evaluation of the metatarsus adductus angle. J. Foot Ankle Surg. 33:2-5, 1994.
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Ellen Cohen-Sobel, DPM, PhD 1 Renata Giorgini, DPM, FACFAS2 Zunilda Velez, DPM 3 Pes planovalgus is a common problem with diverse clinical findings and a wide variety of etiology. Most of the time the symptoms are mild and respond to conservative treatment (1-3). However, occasionally the condition is severe and recalcitrant to long periods of conservative therapy and surgical treatment should be considered (4, 5). In children, untreated flatfoot deformity may deteriorate with age and progress to painful arthritic conditions in the adult (3, 6, 7). Although pain is the major reason for surgical correction (5, 8, 9) in the severe flatfoot, reduced activity level with fatigue and inability to walk and perform daily activities may be indications for surgical treatment (4, 6, 7, 10-12). The clinical appearance of the severe symptomatic flatfoot consists of a collapsed medial longitudinal arch (Fig. 1), heel valgus (Fig. 2), forefoot abduction (Fig. 3), heel cord tightness, and forefoot supinatus or varus. An adequate surgical approach must correct all of these deformities (10). There are many surgical procedures to correct the symptomatic flatfoot; however, no surgical technique is universally accepted (6, 13) and no single flatfoot procedure corrects the entire foot (14). Surgical procedures for the flatfoot fall into three general cate-
From the New York College of Podiatric Medicine, and North General Hospital, New York, New York. 1 Associate Professor, Division of Orthopedics; Diplomate, American Board of Podiatric Orthopedics. Address correspondence to: 54 East 124th Street, New York, NY 10035. 2 Professor, Division of Surgery; Chief, Podiatric Surgery and Residency Director, North General Hospital. 3 Surgical Fellow, North General Hospital. 1067-2516/95/3402-0183$3.00/0 Copyright © 1995 by the American College of Foot and Ankle Surgeons
gories: 1) tendon transfer or lengthening; 2) osteotomy; and 3) arthrodesis. Although arthrodesis procedures are the most common (5), the results of surgery have been poor over time. Seymour (15) reported 50% poor results of naviculocuneiform fusions after 15 years. Butte (16) also reported 50% poor results after naviculocuneiform fusion in 76 feet. Crego and Ford (9) reported poor results in five of seven naviculocuneiform fusions. Arthrodesing procedures result in significant loss of inversion and eversion (9, 17). LeLievre (18) considered any surgical procedure which required loss of joint function to produce correction of the pronated foot to be physiologically unsound. In contrast, calcaneal osteotomy does not result in an iatrogenic coalition (19) and retains joint motion. Phillips (13) reported 90% good and excellent results in patients having Evan's opening lateral wedge osteotomy with a follow-up time of 13 years. Anderson and Fowler (8) reported good results in nine feet treated with the Evan's procedure after a follow-up of 6.5 years. Most recently Sangeorzan (20) observed dramatic radiographic improvements in seven symptomatic flatfeet operated on by the Evans technique. In summary, a surgical procedure for correction of symptomatic flatfoot in a growing child should not rely on soft tissue tightening alone and should not fuse joints (17). The Evans procedure (21), which involves a lateral opening wedge osteotomy of the calcaneus, is most effective in lengthening the lateral column, which will correct forefoot abduction and heel valgus. However, the Evans procedure does not address problems of the medial column including forefoot supinatus (4, 22). Therefore, medial column procedures are commonly combined with the Evan's osteotomy (23, 24). VOLUME 34, NUMBER 2, 1995
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Figure 1. Valgus foot with collapsed medial arch.
the muscle force of the posterior tibial tendon at the navicular (26). Ankle equinus is not corrected by the procedures above. The Evans procedure may actually unmask a pre-existing equinus (27). The Young tenosuspension was originally performed with an Achilles tendon lengthening (25), which will correct the equinus component of the flat foot. The Evan's procedure is not recommended for children under the age of 10 (5). For children younger than 10 years, a combination of soft tissue procedures including modified Young tenosuspension and talonavicular desmoplasty may be sufficient to correct the symptomatic flatfoot. A SILASTIC®4 implant arthroereisis may be added to the above in the severe flatfoot in the younger child (28). The purpose of this paper is to present the authors' experience with a combined surgical technique (Evan's calcaneal osteotomy, Young tenosuspension, and tendo achillis lengthening in patients 10 years or older and modified Young tenosuspension, talonavicular desmoplasty, and subtalar arthroereisis in patients under age 10) in the treatment of the severe flatfoot. Methods and Evaluation
Figure 2. Heel valgus on the left foot.
Figure 3. Left foot, forefoot is abducted.
The Young tenosuspension (25) is frequently combined with Evan's osteotomy to correct forefoot supinatus (11, 14). The Young tenosuspension supports the medial longitudinal arch by rerouting the tibialis anterior tendon through a key-hole slot into the navicular. The Young procedure holds the subtalar joint in the neutral position by adding the anterior tibial tendon to 184
From 1990 to 1993, 10 patients (6 males and 4 females) with 12 severe symptomatic flatfeet were treated with combined surgical techniques. Patients 10 years or older (including two adults) were treated with Evans calcaneal osteotomy, Young tenosuspension and percutaneous tendo achillis lengthening. Children under age 10 were treated with modified Young tenosuspension, talonavicular desmoplasty, and SILASTIC® implant arthroereisis. All surgeries were performed by one of the authors (RG). Nine patients had severe idiopathic flatfoot and one patient had flatfoot secondary to cerebral palsy. The average age of patients at the time of surgery was 17 years, ranging from age 6 to age 41. The follow-up time was an average of 1 year, ranging from 4 to 18 months. All patients initially presented with severe pain, which drastically limited physical activity and was recalcitrant to conservative treatment. Conservative treatment consisting of stretching exercises, custom made orthotic devices, and shoe therapy was always attempted for at least 1 year prior to surgery and in most cases was tried for many years without success. Because pain, fatigue, and inability to perform daily activities were the major reasons for surgery, patients were evaluated primarily on whether they had relief or reduction in pain, fatigue, and their ability to participate
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4
Dow Coming Wright, Midland, TN.
Figure 4. Evan's calcaneal osteotomy. With permission from McCrea, JD: The Evans Procedure for Treatment of Severe Pes Planovalgus. J. A. P. M. A. 77:35-38, 1987.
Figure 5. Stab incision to release anterior 2f3 of Achilles tendon.
in physical activities after the surgery. The patient or parent was also asked to rate the surgery on a scale from "I" to "10," with "10" being the highest and to state whether they were "better," "worse," or the "same" after surgery. Eight radiographic criteria were also reviewed before and after surgery for each patient to measure reduction of heel valgus, forefoot abduction, and improvement in arch height. Surgical Procedures Evans Lateral Opening Wedge Osteotomy (Fig. 4)
A vertical incision is made over the calcaneal cuboid joint. An osteotomy is made at the lateral aspect of the calcaneus 1 em. proximal to the calcaneal cuboid joint utilizing a baby lamina spreader. A graft of cortical bone taken from the contralateral iliac crest is inserted to create an opening wedge osteotomy of the calcaneus to correct forefoot abduction and heel valgus. The iliac crest graft provides the best strength, rapid incorporation, and low morbidity (5). Once the graft is in place, it is impacted and a stainless steel staple is used to secure the osteotomy. The foot is immobilized in a short leg plaster of Paris cast in a neutral position for a period of 6 weeks.
Figure 6. Second stab incision on the midline of the Achilles tendon.
Percutaneous Tendo Achillis Lengthening
A stab incision is made 1 em. proximal to the insertion of the Achilles tendon from a lateral to medial direction, freeing up the anterior 2/3 of the Achilles tendon (Fig. 5). Approximately 3 em. proximal to the first incision, on the midline of the tendo achillis, the medial half of the tendon is dissected through a small stab incision (Fig. 6). The foot is then placed into dorsiflexion (Fig. 7) and a tendon slide "Z" plasty tendo achillis lengthening is accomplished. The skin is closed with three 4-0 nylon sutures.
Figure 7. The foot is placed into dorsiflexion.
Young Tenosuspension
A IS-em. incision is made over the medial aspect of the foot extending from the first metatarsocuneiform joint to the navicular (Fig. 8). A drill hole is placed in the navicular (Fig. 9) from anterior-dorsal to posteriorplantar, and then a wedge of bone from the navicular is removed. The tibialis anterior tendon is identified
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Figure 8. Shows medial incision in preparation tor young tenosuspension.
Figure 10. Identifying the tibialis anterior tendon.
Figure 11. The tibialis anterior tendon has been translocated through the navicular.
Figure 9. Anteroposterior radiograph. Shows keyhole slot made in the navicular for the tibialis anterior tendon.
(Fig. 10) and freed up along its route, and rerouted underneath the navicular through a key-hole slot (Fig. II). Once the tendon is found to support translocation, the keyhole wedge of bone is then placed back into the slot and fixated with 2-0 dexon sutures or staples. Modified Young Tenosuspension/talonavicular desmoplasty
A IS-em. incision is made on the medial border on the longitudinal arch of the foot (Fig. 12). The incision is deepened and the tibialis anterior tendon is divided and 186
Figure 12. Medial incision Young tenosuspension.
in preparation for modified
tagged. The posterior tibial tendon is then tagged (Fig. 13). A "U"-shaped flap is made from the capsule overlying the talonavicular joint. The talonavicular joint is then exposed and a small groove is wedged into the inferior surface of the navicular. The tibialis anterior
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Figure 13. Shows tagging of tibialis anterior tendon (attached to left sided string) and posterior tibial tendon (attached to right sided string).
Figure 14. The anterior tibial tendon and the posterior tibial
Figure 15. Shows capsular "U" flap overlying the talonavic-
ular joint.
Figure 16. Shows SILASTIC® Spherical Implant about to be placed into the sinus tarsi.
tendon are being sutured together.
tendon is reflected inferiorly and freed up and translocated by Young tenosuspension underneath the navicular and through the talonavicular joint to suspend the longitudinal arch and to raise the navicular. The tibialis anterior and tibialis posterior tendon are sutured to further reinforce the longitudinal arch utilizing 2-0 absorbable suture in a continuous locked fashion (Fig. 14). A "U" -shaped flap is sutured over the tibialis anterior tendon and sutured inferiorly to maintain the correction and prevent the tendon from dislocating out of the groove (Fig. 15). The opening overlying the talonavicular joint is then closed. The foot is placed in an adducted position and desmoplasty is accomplished closing the capsule using 2-0 absorbable simple interrupted sutures. Subtalar Arthroereisis
A 4-cm. curvilinear incision is made overlying the lateral sinus tarsi. The incision is deepened to the sinus tarsi. The fatty plug in the sinus tarsi is enucleated with a curette. The interosseous talocalcaneal ligament is not
severed. A SILASTIC® interpositional sphere is placed within the sinus tarsi (Fig. 16). Once the implant is properly seated, the capsule is closed with retention sutures and reinforced. Case Reports Case 1
DT, a black female, was 14 years old when first seen with a painful right flatfoot which had become symptomatic for the past 2 years. She frequently became fatigued after only short periods of walking. She was treated with arch supports, paddings, and strappings, but continued to complain of constant pain. At age 15 she underwent a tendo achillis lengthening, Young tenosuspension, and an Evan's calcaneal osteotomy on the right foot with a bone graft from the left hip. She was placed in a short leg cast for approximately 6 weeks postoperatively, and wore an ankle foot orthosis for the subsequent 3 months. At 1 year follow-up, she denies any pain and is able to perform physical activities without fatigue. Satisfaction with the results of the operation was rated by the patient's mother with a 9 out of a possible 10. VOLUME 34, NUMBER 2, 1995
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fatigue, pain on the bottom of both feet and falling. She had been having these problems for many years. She was treated with orthotics, heel lifts, and stretching exercises without relief. At age 10, she underwent left Achilles tendon lengthening, Young tenosuspension, and Evan's calcaneal osteotomy with bone graft from the right hip. She was placed in a below-the-knee cast for 8 weeks and wore an ankle foot orthosis for the subsequent 3 months. Two years later, at the time of follow-up at age 12, she has only mild pain, infrequently. Her left heel is able to touch the ground, and she is able to perform all physical activities without limitation. The mother rates the results of the surgery as a 10 out of a possible 10. Figure 17. Preoperative radiograph of KC shows flattened calcaneal pitch angle, navicular cuneiform sag, and plantarflexed talus.
Figure 18. Postoperative radiograph of KC at the time of 1.5-year follow-up. Notice improvement in calcaneal pitch angle and improved alignment of the medial column.
Case 2
KC, a IS-year-old hispanic male, was initially seen in 1990 at age 11 with the chief complaint of frequent pain in both feet, and fatigue especially after playing sports (Fig. 17). He was treated with orthotic devices, and stretching exercises without relief. At age 13 he underwent bilateral Achilles tendon lengthening, Evan's calcaneal osteotomy, and Young tenosuspension (Fig. 18). He was placed in a short leg cast for 6 weeks postoperatively and was prescribed hinged ankle foot orthoses for 3 more months after removal of the cast. After 1.5 years follow-up he has no pain in the right foot and mild pain in the left foot only after intensive physical activity. Satisfaction with the results of the operation was rated by the patient's mother with a 7 out of a possible 10. Case 3
AD, a black female with a history of cerebral palsy, was 9 years old when initially seen with the chief complaint of the left heel not touching the ground, 188
Case 4
AB, a black male, was 9 years old when initially seen with a history of fatigue and pain in the right foot, which had been present for 2 years. Orthotic devices were prescribed but did not alleviate his symptoms. At age 10 he was treated with a right tendo achillis lengthening, Young's tenosuspension, and Evan's calcaneal osteotomy with bone graft from the left hip. He was placed in a below-the-knee cast for 8 weeks postoperatively and wore an ankle foot orthosis for the subsequent 3 months. At follow-up he denied pain and was able to perform all physical activities without any limitation. The child's mother rated the results of surgery with an 8 out of a possible 10. Case 5
JV was S years old when he initially presented with the chief complaint of frequent falls and "collapsed arches." He was treated with orthotic devices for approximately 1 year without success. He continued to fall frequently, especially when running. At age 6 he underwent a modified Young tenosuspension with talonavicular desmoplasty on both feet. He was placed in a short leg cast for 6 weeks postoperatively and wore a hinged ankle foot orthosis for approximately 3 months after surgery. At the time of a 2-year follow-up at the age of 8, he denies any pain, fatigue and experiences less falling during physical activities. The appearance of his foot is more normal looking. In general the mother states that he is much better after having the surgery and rates the results of surgery as a 10 out of a possible 10. Case 6
VW, a 7-year-old black female, initially presented at age S with aching pain in the medial arch of the right foot, which had been present for 2 years. She also complained of fatigue after only brief periods of walking which greatly limited physical activities. She was treated
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Figure 21. Preoperative radiograph (weightbearing) of patient from Figs. 19 and 20 0JW). Figure 19. Frontal view of VW with surgically corrected right foot. Modified Young tenosuspension, percutaneous tendo achillis lengthening, desmoplasty, and arthroereisis was performed.
Figure 20. Side view of same patient 0JW) from Fig. 19 with right foot surgically corrected.
Figure 22. Postoperative radiograph (nonweightbearing) of patient from Figs. 19-21 0JW) shows spherical implant in sinus tarsi, normal calcaneal pitch angle and good general osseous alignment.
with arch supports with no relief. At age 6 she underwent a modified Young tenosuspension with talonavicular desmoplasty, Achilles tendon lengthening, and subtalar joint arthroereisis on the right foot (Figs. 19-22). She was placed in a below-the-knee cast for 6 weeks postoperatively and was prescribed an ankle foot orthosis for the subsequent 3 months. At the time of follow-up 1 year later, she occasionally experiences mild pain in bad weather, but much less than before the surgery. She does not fatigue easily and is able to perform all physical activities. The patient's mother rates the results of the operation with a 10 out of a possible 10.
For the flatfoot deformity he was treated with orthotic devices which did not alleviate the condition. The patient underwent a right tendo achillis lengthening, Young tenosuspension, and Evan's calcaneal osteotomy (Figs. 25, 26) with bone graft obtained from the left hip. He was placed in a short leg cast for approximately 8 weeks postoperatively. At the time of follow-up 1 year later, he is pain free and the shoe wear is more normal. Satisfaction with the results of the operation was rated by the patient's mother with an 8 out of a possible 10.
Case 7
Case 8
GN, a 9-year-old boy, initially presented with right foot pain and abnormal shoe wear which had been present for the past 5 years. He had a clubfoot which was surgically treated on the left foot (Figs. 23, 24).
AS, a white male, was seen in 1988 at the age of 26, with the chief complaint of painful flat feet when walking. He was treated with orthoses, orthopedic shoes, paddings, and strappings for the past 5 years with no VOLUME 34, NUMBER 2, 1995
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Figure 26. Postoperative radiograph of patient from Figs. 23-25 (GN) shows good bony alignment.
Figure 23. Untreated flatfoot on the right side. Clubfoot on the left surgically corrected 8 years ago by RG.
less difficulty than prior to surgery. The patient rates the results of the surgery as 8 out of a possible 10. Case 9
Figure 24. Patient from Fig. 23. Posterior view. Notice marked heel valgus on the right side.
JG is an obese hispanic male, who was 14 years old when initially seen with complaints of aching in both feet and fatigue upon ambulation and physical activities. The problem had been present for the past 4 years. Previous tendo achillis lengthening had been performed elsewhere 2 years ago on the right foot. He was treated with orthotic devices and stretching exercises without relief. At age 15 he underwent tendo achillis lengthening, Young tenosuspension, and Evan's calcaneal osteotomy in the left foot with a bone graft from the right hip. At 2 years follow-up at the age of 17, he presents with pain in the left foot, limping, and inability to perform physical activities. The mother claims that he is worse since the surgery and rates the results of surgery as a 5 out of a possible 10. There are two possible confounding factors here including the fact that the child has always been a school truent and may be using his feet as an excuse to avoid school. He also complains frequently about the first surgery. Case 10
Figure 25. Preoperative radiograph of patient from Figs. 23 and 24 (GN).
improvement. At age 30 he underwent a right Young tenosuspension, tendo achillis lengthening and Evan's calcaneal osteotomy. He was placed in a below-the-knee cast for approximately 8 weeks and was prescribed a hinged ankle foot orthosis for the subsequent 3 months. At 1 year follow-up he denies any pain and is able to perform physical activities including running with much 190
FJ is a 40-year-old female who presented with the chief complaint of left ankle swelling and medial arch pain upon ambulation present for 1 year. The patient was treated with orthotic devices for the subsequent year without improvement. At age 41, she underwent tendo achillis lengthening, Young tenosuspension, and Evan's calcaneal osteotomy in the left foot with a bone graft from the right hip. At follow-up 1 year after the operation, she complained of mild pain at the area where the staple was placed on the lateral aspect of the left foot, especially upon ambulation and when the weather is bad. Swelling at the ankle has reduced since the surgery. The patient rates the results of surgery as a 5 out of a possible 10. Although this patient was not happy with the
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TABLE 1. Clinical profile and rating Current Age
VW
7 8
JV GN AS AD KG DT JG
10 11 12 14 16 16
AS JF
31 42
Sex
Foot
Surgical Procedures"
F
right both right right left both right left
YmTAD YmD YTE YTE YTE YTE YTE YTE
right left
vrs
M M M F
M F
M M F
YTE
Age at Time of Surgery
6 6
9 10 10 13 15 15 30 41
Length of Symptoms (years)
Pain (After Surgery)
Physical Activity
4 5 5 2 many 3 2 4
mild none none none mild mild none +pain
6
none mild
all all all all all all all unable to perform all all
1
Rating Better, Worse, Same
better better better better better better better worse better same
Rating (1-10)
10 10
8 8 10
7 9 5
8 5
• Y ms Young tenosuspension modified; T, percutaneous tendo achillis lengthening; Y, Young tenosuspension; A, subtalar arthroereisis; D, desmoplasty; E, Evan's calcaneal osteotomy.
surgery, she was originally unable to work, and since the surgery she has been able to return to working a full 8-hr day as a home attendant. Results
Nine of 10 patients reported complete relief of pain or markedly reduced or infrequent pain after surgery (Table 1). All but one patient was able to perform all physical activities. Eighty percent rated themselves better after the surgery and 80% rated the surgery as a 7 or higher out of a possible 10, with three patients rating the surgery with the highest rating of 10. In general, the radiographic evaluation indicated improvement in all angles (Table 2). All but one patient had abnormally low calcaneal pitch angles preoperatively. The average increase in the calcaneal pitch angle was 10.7 degrees with all patients falling into the normal range postoperatively. The lateral talocalcaneal angle is a reflection of hindfoot valgus. The average improvement in the lateral talocalcaneal angle was 9.4 degrees with all patients falling into the normal range postoperatively.The lateral talar-first metatarsal angle decreased an average of 8 degrees after surgery. The calcaneusnaviculo-metatarsal angle measures the height of the arch (3). Seventy-five percent had grossly abnormal values prior to surgery. All patients showed improvement in arch height with an average correction of 16 degrees. There was an average improvement of 8.6 degrees in the talar declination angle however only 33% of patients had a plantarflexed attitude of the talus initially. The talocalcaneal angle (TCA) in the anteroposterior view is a reflection of heel valgus. The average reduction in the TCA was 9.8 degrees. The talar first metatarsal angle in the anteroposterior view is a measure of forefoot abduction or adduction. All patients demonstrated
grossly abnormal angles preoperatively. There was an average correction of 7.5 degrees. The Lang Index, as described by Mahan and MeGlamry (29), is the ratio of the arch height to arch length. This measurement did not correlate with the clinical severity of the foot. Only 50% showed abnormally low values initially. However, all patients demonstrated improvement with an average of 5.6% correction in arch height to length ratio. Discussion
When surgery is required to correct the severe symptomatic flatfoot, more than one surgical procedure is usually necessary (4, 7, 8, 11, 18,22,27,28,30-32). The authors have found the combined technique of Evan's calcaneal osteotomy, Young tenosuspension, and tendo achillis lengthening in patients 10 years or older and modified Young tenosuspension, talonavicular desmoplasty, and subtalar arthroereisis in patients under age 10 to be successful in correcting the severe symptomatic flexible flatfoot. The combination of procedures addresses both the lateral and medial column and equinus component of the flatfoot, and works better than any individual technique. The flatfoot is more easily corrected in the younger child. When the patient is older, the results are less predictable. Although the subtalar joint arthroereisis has been performed on patients as old as 69 years (18), most authors recommend the procedure for those not having reached skeletal maturity (6, 7, 12, 33-36). Similarly although the Evan's procedure is done on older patients (37), the authors believe that it works best with ancillary procedures in the younger patient. In general, the radiographic values improved in the expected direction in all cases. It is notable that even the VOLUME 34, NUMBER 2, 1995
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....
IS -l I
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c
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TABLE 2. Preoperative and postoperative radiographic findings
Z
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r
0
"Tl
Calcaneal Pitch Angle (15°_25 o)a
"Tl
0 0
Lateral Talocalcaneal Angle (15°_35 )b O
~
Z
~
r m
(J)
c
::0 G)
m
::0
-<
0-1300
Talar Declination Angle 21° = Normal' >25° = Flatfoot?
Talocalcaneal Angle Dorsoplantar View (15°_30 )b 0
Talar-1st Metatarsal Angle Anteroposterior (-20° to +15 )h O
Lateral Index (18-22%);
Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postoper- Preopera- Postopertive ative tive ative ative tive tive ative tive ative tive ative tive ative tive ative
0
Z
Flatfoot"
Calcaneus-NaviculoMetatarsal Angle (120 )e
>15° = Severe Flatfootd
-l
;;:0:;;
Talar-1 st Metatarsal Angle (Lateral) 0° = Normal 1°_15° = Mild
VW JV (right) (left) GN AB AD KC (right) (left) DT JG AS JF
15° 8° 8° 2° 10° 12° 0° 5° 5° 10° 11° 10°
23° 18° 20° 15° 18° 20° 15° 15° 20° 20° 20° 20°
35° 38° 35° 35° 40° 35° 42° 41° 35° 38° 40° 40°
30° 28° 25° 25° 30° 25° 35° 33° 20° 28° 30° 32°
10° 10° 8° 15° 8° 10° 25° 28° 8° 10° 10° 10°
3° 0° 0° 8° 2° 5° 15° 13° 3° 2° 0° 3°
130° 135° 135° 155° 130° 130° 155° 150° 132° 132° 135° 140°
120° 120° 122° 135° 120° 115° 125° 135° 120° 110° 124° 120°
20° 20° 20° 30° 30° 22° 35° 38° 20° 18° 25° 25°
14° 16° 16° 23° 20° 15° 15° 18° 15° 12° 20° 15°
30° 28° 25° 30° 35° 30° 33° 30° 35° 28° 30° 38°
25° 20° 18° 20° 25° 20° 25° 22° 20° 20° 20° 25°
15° 18° 15° 17° 20° 15° 18° 15° 16° 15° 18° 18°
10° 15° 4° 13° 10° 2° 7° 10° 12°
r 12° 8°
17% 19% 19% 14% 18% 15% 11% 10% 17% 19% 18% 18%
Gamble, F. 0., Yale, I. Clinical Foot Roentgenology. Williams & Wilkins, Baltimore, 1966. McCrae, J. D. Pediatric Orthopedics of the Lower Extremity. Futura Publishing Company, Inc., Mount Kisco, NY, 1985. C Meary, R. On the measurement of the angle between the talus and the first metatarsal. Symposium: Le Pied Creux Essential. Rev. Chir. Orthop. 53:389, 1967. d Bordelon, R. L. Correction of hypermobile flatfoot in children by molded inserts. Foot Ankle 1:143-150,1980. e Viladot, A. Surgical treatment of the child's flatfoot. Clin. Orthop. ReI. Res. 283:34-38, 1992. 'Weissman, S. D. Radiology of the Foot. Williams & Wilkins, Baltimore, 1983. 9 Borrelli, A. H., Smith, S. D. Surgical considerations in the treatment of pes planus. J. A. P. M. A. 78:305-309, 1988. h Vanderwilde, R., Staheli, L. T., Chew, D. E., et al. Measurements on radiographs of the foot in normal infants and children. J. Bone Joint Surg. 70(A):407-421, 1988. i Mahan, K. T., McGlamry, E. D. Evan's calcaneal osteotomy for flexible pes valgus deformity. Clin. Podiatr. Med. Surg. 4:137-151,1987. a
b
22% 22% 22% 21% 21% 27% 17% 13% 26% 29% 21% 21%
two patients that found the surgery unsatisfactory (JG and FJ) demonstrated excellent radiographic improvement (Table 2). Recently, it has been shown that the metatarsus adductus (MA) angle remains virtually unchanged after the Evan's osteotomy (1.5-degree increase) (37). Previously Mahan and McGlamry (29) found the MA angle to increase an average of 3 degrees after the Evan's osteotomy. Of the nine feet having surgery that included the Evan's procedure in the present study, there was an average increase of 3.4 degrees in five feet and an average decrease of 6 degrees in four feet. Two feet which exhibited decreases in the MA angle had the highest MA angles preoperatively (23 and 24 degrees). Brim and Hecker (37) also found that one patient in their series had an improvement in the MA angle and considered the metatarsus adductus a compensatory mechanism secondary to the flatfoot deformity. Once the flatfoot is corrected, the apparent metatarsus adductus resolves. Summary
Ten patients with 12 severe symptomatic flatfeet were treated with a combined surgical technique. Patients aged 10 years or older were treated with Evan's osteotomy, Young tenosuspension, and tendo achillis lengthening. Patients under age 10 were treated with modified Young tenosuspension, talonavicular desmoplasty and subtalar arthroereisis. Most patients showed marked improvement clinically, including absence of or marked reduction in pain, improvement in ability to perform physical activities, and reduction in fatigue. All radiographic criteria revealed improvement. On the lateral view, average improvements were 10.7 degrees for the calcaneal pitch angle, 9.4 degrees for the lateral talocalcaneal angle, 8 degrees for the talar-first metatarsal angle, 4.2 degrees for the talar declination angle, 16 degrees for the calcaneo-navicular-metatarsal angle and 6 degrees for the Lange Index. On the dorsoplantar view, the average improvements were 9.8 degrees for the talocalcaneal angle, and 7.5 degrees for the talar-first metatarsal angle. It is concluded that a combined surgical technique involving osteotomy and soft tissue procedures is effective in treating the severe symptomatic flexible flatfoot, which is refractory to conservative treatment.
References 1. Bordelon, R. L. Correction of hypermobile flatfoot in children by molded insert. Foot Ankle 1:143-150, 1980. 2. Scranton, P. E. Management of hypermobile flatfoot in the child. Contemp. Orthop. 3:645-672, 1981.
3. Viladot, A. Surgical treatment of the child's flatfoot. Clin. Orthop. ReI. Res. 283:34-38, 1992. 4. Dockery, G. L. Surgical treatment of the symptomatic juvenile flexible flatfoot condition. Clin. Pod. Med. Surg. 4:99-117, 1987. 5. Mosca, V. S. Flexible flatfoot and skewfoot, ch. 17. In The Child's Foot and Ankle, pp. 355-376, edited by J. C. Drennan, Raven Press, Ltd., New York, 1992. 6. Smith, S. D., Millar, E. A. Arthrorisis by means of a subtalar polyethylene peg implant for correction of hindfoot pronation in children. Clin. Orthop. ReI. Res. 181:15-23, 1983. 7. Subotnick, S. I. The subtalar joint lateral extra-articular arthroereisis: A preliminary report. J. A. P. A. 64:701-711, 1974. 8. Anderson, A. F., Fowler, S. B. Anterior calcaneal osteotomy for symptomatic juvenile pes planus. Foot Ankle 4:274-283, 1984. 9. Crego, C. H., Ford, L. T. An end-result study of various operative procedures for correcting flat feet in children. 1. Bone Joint Surg. 34A:183-195, 1952. 10. Bordelon, R. L. Flatfoot Deformity. In Current Therapy in Foot and Ankle Surgery, pp. 188-194, edited by M. Myerson, MosbyYear Book, Inc., Chicago, 1993. 11. Mahan, K. T., McGlamry, E. D., Green, D. R. Pes Planovalgus Deformity, ch. 31. In Surgery of the Foot and Ankle, 2nd ed., pp. 769-817, edited by E. D. McGlamry, Williams & Wilkins, Baltimore, 1992. 12. Yu, G. V., Boberg, J. Subtalar Arthroereisis, ch. 32. In Surgeryof the Foot and Ankle, 2nd ed., pp. 818-828, edited by E. D. McGlamry, Williams & Wilkins, Baltimore, 1992. 13. Phillips, G. E. A review of elongation of os calcis for flat feet. J. Bone Joint Surg. 65B:15-18, 1983. 14. Sgarlato, T. Pediatric foot surgery. Clin. Pod. Med. Surg. 1:709723,1984. 15. Seymour, N. The late results of naviculo-cuneiform fusion. J. Bone Joint Surg. 49B:558-559, 1967. 16. Butte, F. L. Naviculo-cuneiform arthrodesis for flatfoot: an end result study. J. Bone Joint Surg. 19:496-502, 1937. 17. Wenger, D. R. Flatfoot and Children's Shoes, ch. 3. In The Art and Practice of Children's Orthopaedics, pp. 77-102, edited by D. R. Wenger and M. Rang, Raven Press, New York, 1993. 18. Lel.ievre, J. Current concepts and correction in the valgus foot. Clin. Orthop. ReI. Res. 70:43-55, 1970. 19. Barry, R. J., Scranton, P. E. Flat feet in children. Clin. Orthop. ReI. Res. 181:68-75, 1983. 20. Sangeorzan, B. J., Mosca, V., Hansen, S. T. Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot Ankle 14:136-141, 1993. 21. Evans, D. Calcaneo-valgus deformity. J. Bone Joint Surg. 57B: 270-278, 1975. 22. Jacobs, A. M., Oloff, L. M. Surgical management of forefoot supinatus in flexible flatfoot deformity. J. Foot Surg. 23:410-419, 1984. 23. Banks, A. S., Smith, T. F. Operative treatment of non-neurogenic pes valgus feet, ch. 14. In Foot and Ankle Disorders in Children, edited by S. DeValentine, pp. 329-367, Churchill Livingstone, New York, 1992. 24. Subotnick, S. I. New and investigative procedures for flatfoot surgery. Clin. Pod. Med. Surg. 6:605-611, 1989. 25. Young, C. S. Operative treatment of Pes Planus. Surg. Gynecol. Obstet. 68:1099-1101, 1939. 26. Beck, E. L., McGlamry, E. D. Modified Young tendosuspension technique for flexible flatfoot. J. A. P. A. 63:582-604, 1973. 27. Spinner, S. M., Chussid, F., Long, D. H. Criteria for combined procedure selection in the surgical correction of the acquired flatfoot. Clin. Pod. Med. Surg. 6:561-575, 1989.
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28. Giorgini, R. J., Schiraldi, F. G., Hernandez, P. A. Subtalar arthroere isis: A combined technique. J. Foot Surg. 27:157-160, 1988. 29. Mahan, K. T., McGlamry, E. D. Evans calcaneal osteotomy for flexible pes valgus deformity: a preliminary study. Clin. Pod. Med. Surg. 4:137-151, 1987. 30. Catanzariti, A. R. Medial column stabilization. Clin. Pod. Med. Surg. 8:667-692, 1991. 31. Dollard, M. D., Marcinko, D. E., Lazerson, A., Elleby, D. H. The Evans calcaneal osteotomy for correction of flexible flatfoot syndrome. J. Foot Surg. 23:291-301, 1984. 32. Schwartz, N. H., Tursi, F. J. A new surgical technique for the treatment of pes planus deformity: A preliminary report. J. Foot Surg. 26:149-152, 1987.
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33. Addante, J. B., Chin, M. W., Loomis, J. c, Burleigh, W., Lucarelli, J. E. Subtalar joint arthroereisis with SILASTIC® silicone sphere: A retrospective study. J. Foot Surg. 31:47-51, 1992. 34. Lanham, R. H. Indications and complications of arthroereisis in hypermobile flatfoot. J. A. P. A. 69:178-185, 1979. 35. Lundeen, R. O. The Smith STA-peg operation for hypermobile pes planovalgus in children. J. A. P. M. A. 4:177-183, 1985. 36. Smith, S. D., Wagreich, C. R. Review of postoperative results of the subtalar arthrorisis operation: A preliminary study. J. Foot Surg. 23:253-260, 1984. 37. Brim, S. P., Hecker, R. The Evans calcaneal osteotomy: Postoperative care and an evaluation of the metatarsus adductus angle. J. Foot Ankle Surg. 33:2-5, 1994.
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