Pes planovalgus – from Infancy to Adolescence

AAOS Annual Meeting ICL# 223, March 20, 2013

Vincent S. Mosca, M.D.
Professor of Orthopedics, University of Washington School of Medicine,
Pediatric Orthopedic Surgeon, Seattle Children's Hospital, Seattle, WA

I. FLATFOOT
A. No universally accepted clinical or radiographic definitions of the average height,
or the normal range of heights, of the longitudinal arch

B. Flexible flatfoot (FFF) is the "normal contour of a strong and stable foot…of little
consequence as a cause of disability" - Harris and Beath: JBJS 30A:116, 1948

C. Flatfoot is present in 23% of adults - Harris and Beath: Army Foot Survey, 1947
1. FFF - 64% of total - rarely causes pain or disability
2. FFF with short tendo-Achilles (FFF-STA) - 27% of total -
often causes disability
3. rigid flatfoot (peroneal spastic flatfoot ) - 9% of total -
causes disability 20-24% of the time – Leonard: JBJS 56B:520, 1974

D. Most babies are flatfooted

1. the average arch height is lower in the child than in the adult
2. the height of the longitudinal arch increases spontaneously during the first
decade of life in most children
3. there is a wide range of normal arch heights at all ages
4. "corrective shoes" and orthotics do not alter the natural history of spontaneous
development of the arch

E. Flatfoot is determined by the shapes of the bones and the laxity of the ligaments,
not the muscles

II. TREATMENT
A. ASYMPTOMATIC FLEXIBLE FLATFOOT
1. Education
NOTES:

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 B. SYMPTOMATIC FLEXIBLE FLATFOOT
1. Confirm the diagnosis
2. Orthoses (FO, UCBL) will frequently relieve symptoms and extend the useful
life of shoes

C. SYMPTOMATIC FLEXIBLE FLATFOOT w SHORT TENDO-ACHILLES

1. Heelcord stretching by exercise or serial casting
2. There is little role for orthoses – may increase symptoms
3. Many operative procedures have been proposed during the past century with
undefined indications, often good short-term results, and poor long-term
results.
a. Soft tissue plications/procedures
 fail
b. Tendon transfers
 fail
c. Bone excisions
 destructive
d. Arthrodesis of 1, 2, or all 3 joints of the subtalar complex
 loss of shock absorber of foot
 DJD at adjacent joints
e. Arthroereisis of the subtalar joint with bone block
 fail
f. Arthroereisis of the subtalar joint with synthetic implant
 foreign body reaction
 infection
 pain
 incomplete deformity correction when severe
 damage to articular cartilage of subtalar joint
g. Limited medial midtarsal fusions (Hoke, Miller, Durham, Giannestrus,
others)
 WRONG JOINT!
 incomplete deformity correction when severe
 recurrence of pain and deformity
 DJD at adjacent joints
h. Posterior calcaneal wedge osteotomy (Dwyer)
 does not correct external rotational or translational deformity
i. Posterior calcaneal displacement osteotomy (Koutsogiannis)
 “Chiari osteotomy” of the acetabulum pedis
 compensatory osteotomy to “correct” hindfoot valgus
 does not correct external rotation deformity in the subtalar complex
 does not correct malalignment at talonavicular joint
 non-arthrodesing
NOTES:

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 j. Calcaneal lengthening osteotomy (Evans/Mosca)
 “Salter osteotomy” of the acetabulum pedis
 corrects all components of even severe valgus deformity of the
hindfoot at the site of deformity
 restores function of the subtalar complex
 relieves symptoms
 theoretically, protects the ankle and midtarsal joints from early DJD by
avoiding arthrodesis
 best intermediate-long term results of any procedure used to correct
flatfoot – Phillips: JBJS 65B:15, 1983

4. Arthrodesis of any joint in the foot of a child leads to early degenerative

changes at adjacent joints

5. THE FOOT IS NOT A JOINT!

A flatfoot has 2 deformities in opposite directions – as if the foot was wrung
out. And a symptomatic flatfoot has a 3rd deformity – equinus. Each needs to
be addressed individually.
a. Valgus deformity (eversion, pronation) of the hindfoot

b. Supination deformity of the forefoot in relation to the hindfoot

c. Equinus deformity of the ankle due to contracture of the Achilles tendon,

or the gastrocnemius

6. INDICATION FOR SURGERY: when prolonged attempts at non-operative

treatment have failed to relieve the pain and the excessive callus under the
head of the plantar flexed talus.

III.CALCANEAL LENGTHENING OSTEOTOMY

A. ADVANTAGES
1. corrects all components of even severe valgus deformity of the hindfoot at
the site of deformity
2. relieves symptoms
3. restores function of the subtalar complex
4. avoids arthrodesis
5. preserves calcaneal growth
NOTES:

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 B. INDICATIONS
1. extreme valgus deformity of the hindfoot with plantar flexion of the talus
with
2. failure of prolonged non-operative treatment to relieve: pain , callus, or
ulceration under the head of the talus
3. age range not known

C. CONTRAINDICATIONS
1. incompetent plantar fascia
2. subfibular impingement secondary to lateral translation of the calcaneus –
usually seen in overcorrected clubfeet

D. TECHNIQUE
Ref: 1. MOSCA VS: Calcaneal lengthening for valgus deformity of the hindfoot: Results in
children who had severe, symptomatic flatfoot and skewfoot. J Bone Joint Surg
1995;77A:500-512.

2. MOSCA VS: Calcaneal lengthening osteotomy for valgus deformity of the hindfoot.
In: Skaggs DL and Tolo VT, editors. Master Techniques in Orthopaedic Surgery:
Pediatrics. Lippincott Williams & Wilkins, 2008;263-276.

3. MOSCA VS. Calcaneal lengthening osteotomy for the treatment of hindfoot valgus
deformity. In: Wiesel S, editor. Operative Techniques in Orthopaedic Surgery.
Philadelphia: Lippincott Williams & Wilkins, 2010:1608-1618.

1. Mosca’s modifications from Evans

a. strict indications for surgery
b. skin incision
c. location and direction of the osteotomy
d. shape of the graft
e. management of the soft tissues, laterally and medially
f. use of internal fixation to stabilize calcaneocuboid joint
g. importance of Achilles or gastrocnemius contracture and need for
lengthening
h. management of the forefoot supination deformity
2. patient is supine with folded towel under ipsilateral buttock
3. modified Ollier incision in Langer skin line
4. protect superficial peroneal and sural nerves
5. elevate soft tissues in sinus tarsi
6. release peroneal tendon sheaths
7. z-lengthen peroneus brevis, NOT peroneus longus
8. divide aponeurosis of abductor digiti minimi
9. avoid injury to capsule of calcaneocuboid jt.

NOTES:

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 10. place curved Joker elevator/retractors in interval between anterior and
middle facets of subtalar jt.
11. oblique osteotomy of calcaneus using osteotome or sagittal saw
a. from proximal-lateral to distal-medial
b. start approx 2 cm prox to calcaneocuboid joint (at lowest point of
calcaneus proximal to beak)
c. exit between anterior and middle facets – complete through the medial
cortex
12. cut plantar periosteum and long plantar ligament if necessary – NOT
plantar fascia
13. Steinmann pins as joy sticks
a. insert lateral to medial both proximal and distal to the osteotomy
14. retrograde longitudinal Steinmann pin across calcaneocuboid jt. before
osteotomy is distracted/graft inserted – stop at osteotomy
15. trapezoid-shaped graft
a. lengthening distraction-wedge osteotomy
b. use the largest graft that will fit, determined by distracting the
osteotomy with a laminar spreader
c. usually 10-14 mm laterally and 4 mm medially
d. tricortical or bicortical iliac crest graft
e. allograft or autograft
16. distract osteotomy with Steinmann pin joy sticks
a. distal pin moves distal/plantar and supinates pes acetabulum and
forefoot
17. impact graft with bone tamp
18. advance longitudinal Steinmann pin retrograde through graft and into
proximal calcaneal fragment
19. bend pin at dorsal insertion site and cut long for retrieval in clinic
20. repair lengthened peroneus brevis
21. plicate talonavicular jt. capsule and tibialis posterior tendon through
medial longitudinal incision

22. lengthen Achilles tendon through posteromedial ankle incision or

gastrocnemius through postero-medial mid-calf incision - based on
Silverskiold test

NOTES:

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 23. correct forefoot supination deformity, if present, after hindfoot is corrected
a. flexible, mild deformity may correct spontaneously due to effective
shortening of peroneus longus created by lateral column lengthening
b. osteotomy of medial cuneiform for rigid deformity
 plantar-based closing wedge if forefoot is also slightly abducted or
neutral – fix with plantar-to-dorsal staple
 dorsal opening wedge if forefoot is also adducted
 osteotomy starts half way between the proximal and distal ends of
the medial cuneiform and exits at level of middle cuneiform-2nd
MT joint

24. postoperative management

a. non-weightbearing in short leg cast for 8 wks.
b. cast change with pin removal at 6 wks.
c. simulated standing AP and lateral radiographs at 6 and 8 weeks
d. over-the-counter arch support indefinitely
NOTES:

REFERENCES:

1. Adelaar RS, Dannelly EA, Meunier PA, Stelling FH, Goldner JL, Colvard DF: A
long term study of triple arthrodesis in children. Ortho Clin North Am 1976;7:895-
908.
2. Anderson AF, Fowler SB: Anterior calcaneal osteotomy for symptomatic juvenile
pes planus. Foot Ankle 1984;4:274-283.
3. Angus PD, Cowell HR: Triple arthrodesis. A critical long-term review. J Bone Joint
Surg 1986;68B:260-265.
4. Armstrong G, Carruthers CC: Evans elongation of lateral column of the foot for
valgus deformity. J Bone Joint Surg 1975;57B:530.
5. Butte FL: Navicular-cuneiform arthrodesis for flatfoot: an end-result study. J Bone
Joint Surg 1937;19:496-502.
6. Caldwell GD: Surgical correction of relaxed flat foot by the Durham flat foot plasty.
Clin Orthop 1953;2:221-226.
7. Crego CH, Ford LT: An end-result study of various operative procedures for
correcting flat feet in children. J Bone Joint Surg 1952;34A:183-195.
8. Drew AJ: The late results of arthrodesis of the foot. J Bone Joint Surg 1951;33B:496-
502.
9. Duncan JW, Lovell WW: Modified Hoke-Miller flatfoot procedure. Clin Orthop
1983;181:24-27.

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10. Dwyer FC: Osteotomy of the calcaneum for pes cavus. J Bone Joint Surg
1959;41B:80-86.
11. Evans D: Calcaneo-valgus deformity. J Bone Joint Surg 1975;57B:270-278.
12. Giannestrus NJ: Flexible valgus flatfoot resulting from naviculocuneiform and
talonavicular sag. Surgical correction in the adolescent, in Bateman JE (ed): Foot
Science. Philadelphia, WB Saunders Co, 1976, pp 67-105.
13. Gould N, Moreland M, Alvarez R, Trevino S, Fenwick J: Development of the
child's arch. Foot Ankle 1989;9:241-245.
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Surg 1948;30A:116-138.
16. Hoke M: An operation for the correction of extremely relaxed flatfeet. J Bone Joint
Surg 1931;13:773-783.
17. Jack EA: Naviculo-cuneiform fusion in the treatment of flat foot. J Bone Joint Surg
1953;35B:75-82.
18. Koutsogiannis E: Treatment of mobile flat foot by displacement osteotomy of the
calcaneus. J Bone Joint Surg 1971;53B:96-100.
19. Miller OL: A plastic flat foot operation. J Bone Joint Surg 1927;9:84-91.
20. Mosca VS: Flexible flatfoot and skewfoot, in Drennan JC (ed): The Child's Foot and
Ankle. New York, Raven Press, 1992, pp 355-376.
21. Mosca VS: Calcaneal lengthening for valgus deformity of the hindfoot. Results in
children who had severe, symptomatic flatfoot and skewfoot. J Bone Joint Surg
1995;77A:500-512.
22. Mosca VS: Calcaneal lengthening osteotomy for valgus deformity of the hindfoot.
In: Skaggs DL and Tolo VT, editors. Master Techniques in Orthopaedic Surgery:
Pediatrics. Lippincott Williams & Wilkins, 2008;263-276.
23. Mosca VS: Calcaneal lengthening osteotomy for the treatment of hindfoot valgus
deformity. In: Wiesel S, editor. Operative Techniques in Orthopaedic Surgery.
Philadelphia: Lippincott Williams & Wilkins, 2010:1608-1618.
24. Phillips GE: A review of elongation of os calcis for flat feet. J Bone Joint Surg
1983;65B:15-18.
25. Rathjen KE, Mubarak SJ: Calcaneal-cuboid-cuneiform osteotomy for the
correction of valgus foot deformities in children. J Pediatr Orthop 1998;18:775-782.
26. Ross PM, Lyne ED: The Grice procedure: indications and evaluation of long-term
results. Clin Orthop 1980;153:194-200.
27. Scott SM, Janes PC, Stevens PM: Grice subtalar arthrodesis followed to skeletal
maturity. J Pediatr Orthop 1988;8:176-183.
28. Seymour N: The late results of naviculo-cuneiform fusion. J Bone Joint Surg
1967;49B:558-559.
29. Smith SD, Millar EA: Arthrorisis by means of a subtalar polyethylene peg implant
for correction of hindfoot pronation in children. Clin Orthop 1983;181:15-23.
30. Southwell RB, Sherman FC: Triple arthrodesis: a long-term study with force plate
analysis. Foot Ankle 1981;2:15-24.

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