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Lateral Calcaneal Lengthening Osteotomy for Supple Adult Flatfoot


Indications

  • Posterior tibial tendon insufficiency (PTTI), stage II to stage II–III

  • Medial ankle instability

  • Both must be accompanied by supple pes planovalgus et abductus deformity with forefoot supination and subfibular impingement, and preserved subtalar and talonavicular joints

Indications Pitfalls

  • Calcaneal lengthening osteotomy is not indicated in cases of:

    • Rigid pes planovalgus et abductus deformity (PTTI stage III or IV)

    • Osteoarthritis of the subtalar and/or Chopart joints

    • Isolated valgus deformities without abductus component

Indications Controversies

  • It has been postulated that lateral column lengthening osteotomy will cause overload in the calcaneocuboid joint and thus lead to degenerative disease (Phillips, 1983). More recent work, however, did not prove increased joint pressure (Benthien et al., 2007). We also did not see any degenerative disease over time in our patients with a follow-up of up to 12 years.

Examination/Imaging

  • The standard clinical examination of a patient requiring a lateral calcaneal lengthening osteotomy includes:

    • History for differential diagnosis between PTTI (female, >40 years of age, continuous deformity with posterior tibial [PT] tendon inflammation, etc.) and medial ankle instability (trauma history, such as accompanied with lateral ankle instability/rotational ankle instability, etc.)

    • Quantification of pain (visual analog scale score, 0–10)

    • Flattening of arch

    • Swelling over PT tendon ( Fig. 33.1 )

      FIG. 33.1

    • Pes planovalgus et abductus deformity ( Fig. 33.2A )

      FIG. 33.2

    • Too-many-toes sign (abductus deformity)

    • Documentation of tender points

    • PT tendon strength test (weakness)

  • Functional tests

    • Single heel-rise test: hindfoot remains in valgus while on tiptoes as evidence for PTTI

    • Double heel-rise test: hindfoot valgization while on tiptoes position as evidence for PTTI (see Fig. 33.2B )

  • Ankle instability tests (lateral [inversion stress test and drawer test] and medial [eversion stress test])

  • Radiologic assessment includes:

    • Weight-bearing radiographs

    • Anteroposterior (AP) view of the foot: abductus deformity, subluxation of the talonavicular joint, pathologic AP talus–first metatarsal angle, bunion deformity ( Fig. 33.3A )

      FIG. 33.3

    • Lateral view of the foot: flatfoot deformity, plantar subluxation of the talonavicular joint, pathologic lateral talus–first metatarsal angle (see Fig. 33.3B )

    • AP view of the ankle joint: ev. talar valgus tilt, involvement of the ankle joint with medial joint laxity, lateral fibular impingement (see Fig. 33.3C )

  • Saltzman hindfoot view: quantification of hindfoot alignment angle

  • Magnetic resonance imaging: detection of tendon degeneration and ligament involvement (spring ligament, deltoid ligament); to rule out possible chondral, osteochondral, or osteoarthritic hindfoot changes

  • Computed tomography scan: assessment of possible osseous defects, impingements (sinus tarsi, calcaneofibular), and osteoarthritis

Treatment Options

  • Myerson calcaneal medial sliding osteotomy: indicated for correction of isolated hindfoot valgus deformity

  • Hintermann lateral calcaneal lengthening osteotomy: osteotomy along and parallel to the posterior subtalar joint facet

  • Evans osteotomy: 10 mm proximal to the calcaneocuboid joint between the middle and anterior subtalar joint facets; commonly done in children for congenital flatfoot

  • Hansen calcaneocuboid interposition arthrodesis: arthrodesis with lateral column lengthening effect

Surgical Anatomy

  • Lateral hindfoot anatomy ( Fig. 33.4A ):

    • Sinus tarsi

    • Peroneal tendons

    • Sural nerve

    • Posterior subtalar joint facet

    • Anterior process of the calcaneus

    FIG. 33.4

  • Medial midfoot anatomy (see Fig. 33.4B ):

    • Spring ligament

    • Posterior tibial tendon

    • Flexor tendons

    • Neurovascular structures

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