Calcaneal lengthening for valgus deformity of the hindfoot

Thirty-one severe, symptomatic valgus deformities of the hindfoot in twenty children who had flatfoot (twenty-five feet) or skewfoot (six feet) were corrected with a modification of the calcaneal lengthening osteotomy described by Evans. Despite prolonged non-operative treatment, all patients had pain, a callus, ulceration, or a combination of these signs and symptoms under the head of the plantar flexed talus; they could not tolerate a brace, and shoe wear was excessive. Twenty-six of the deformities were secondary to an underlying neuromuscular disorder. The calcaneal lengthening was combined with an openingwedge osteotomy of the medial cuneiform to correct the deformities of both the hindfoot and the forefoot in the patients who had a skewfoot. Other concurrent osseous and soft-tissue procedures were frequently performed in the flatfeet and skewfeet to correct adjacent deformities or to balance the muscle forces. Allograft bone was used in twenty-four feet and autogenous bone, in seven. The patients ranged in age from four years and seven months to sixteen years at the time of the operation. The duration of follow-up ranged from two years to three years and seven months after the operation. Satisfactory clinical and radiographic correction of all components of the deformity of the hindfoot was achieved in all but the two most severely deformed feet. These two feet had sufficient correction to eliminate the symptoms despite a small persistent callus under the head of the talus. The pain and callus were eliminated in all of the other feet, the patients were able to tolerate a brace, and shoe wear was improved. Subtalar motion was preserved in all feet except for the four that had had a limited joint arthrodesis performed previously or simultaneously for pre-existing degenerative osteoarthrosis. Calcaneal lengthening is effective for the correction of severe, intractably symptomatic valgus deformities of the hindfoot in children. My patients had resolu*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. tDepartment of Orthopedics. Children s Hospital and Medical Center. P.O. Box C537l. 48(5) Sand Point Way N.E.. Seattle. Washington 98105. tion of the signs and symptoms associated with the deformity while avoiding the need for an arthrodesis and the many short and long-term complications associated with it. Valgus deformity of the hindfoot is a clinical description of the complex three-dimensional malalignment of the subtalar complex that occurs in flatfoot and skewfoot deformities. The alignment of the forefoot may be used to differentiate these two entities5. A flatfoot (Figs. 1-A. 1-B. 2-A. and 2-B) is characterized by plantar flexion of the talus and calcaneus along with excessive eversion of the subtalar complex during weight-bearing. There is valgus deformity. external rotation, and dorsiflexion of the calcaneus in relation to the talus. The navicular is abducted and dorsiflexed on the head of the plantar flexed talus. These combined relationships create a sag in the middle of the foot with lowering of the longitudinal arch. The lateral column (or border) of the foot is short relative to the medial column: this may be a true length discrepancy or it may be related to the lateral alignment at the talonavicular joint. The forefoot is supinated in relation to the hindfoot. In a skewfoot (Figs. 3-A and 3-B). the same eversion of the subtalar complex with valgus deformity of the hindfoot is combined with adduction and plantar flexion of the forefoot on the midfoot. It is not known how much adduction and plantar flexion of the forefoot are necessary to differentiate a flatfoot from a skewfoot or. for that matter, how much valgus deformity of the hindfoot is required to differentiate a metatarsus adductus deformity from a skewfoot. There is. in fact. no consensus regarding the clinical or radiographic criteria (including age-related interosseous measurements) to define the forefoot and hindfoot relationships in flatfoot. skewfoot. and metatarsus adductus deformities. Despite the absence of specific criteria. treatment of these deformities can be reasonably undertaken on the basis of symptoms that correspond to clinical deformity and to abnormal findings on radiographs. Only a small percentage of any of these deformities of the foot cause disability. Disability from flat and skewfeet is usually manifested by pain with weight-bearing. a callus, ulceration, or a combination of these signs and symptoms under