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The Evans lateral calcaneal lengthening osteotomy is the surgical procedure most appropriate for which pediatric foot deformity?
Flexible pes planovalgus
Juvenile hallux valgus
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Symptomatic flexible pes planovalgus that has failed extensive conservative management can be surgically treated with a calcaneal lengthening osteotomy as described by Evans.
While surgical correction of this condition is rarely necessary, Mosca concludes that calcaneal lengthening, via a modification of the Evans procedure, is effective for the correction of severe, intractably symptomatic valgus deformities of the hindfoot in children (Illustration A). In his series, additional osteotomies and soft tissue balancing procedures were done to address coexisting skewfoot. All but two of the patients in his series had relief of the pain as well as resolution of callosities over the talar head following this procedure.
J Bone Joint Surg Am. 1995 Apr;77(4):500-12. PMID: 7713966 (Link to Abstract)
Mosca, JBJS 1995
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A 12-year-old boy has 2 years of right foot pain that prevent participation in athletic activities and is symptomatic with walking. He has attempted UCBL and custom made orthoses for 1 year with no relief of symptoms. His hindfoot is supple and he has full dorsiflexion. Clinical images of the foot are shown in Figures A and B. A lateral radiograph is shown in Figure C. A surgical plan to address the deformity would most appropriately include which of the following?
Lateral calcaneal slide osteotomy
Transfer of the peroneus longus to the peroneus brevis
1st metatarsal dorsiflexion osteotomy
Calcaneal neck lengthening osteotomy
Posterior tibial tendon transfer to dorsum of the foot
The clinical presentation is consistent with pediatric flexible pes planovalgus, or flatfoot. The vast majority of these cases are asymptomatic and do not require treatment, and Level 1 evidence shows no benefit with corrective orthotics. In rare situations when nonoperative treatments fail to relieve pain under the head of the talus or in the sinus tarsi, surgery is indicated. A calcaneal lateral column lengthening osteotomy (Evans procedure) is the procedure of choice. Illustration A shows a line depicting the long axis of the talus and a line following the long axis of the 1st metatarsal. The angle between the 2 lines is referred to as Meary's angle and a plantar apex angle of greater than 4 degrees indicates collapse of the longitudinal arch. Illustration B shows an example of a normal Meary's angle and pes planus foot with a Meary's angle of 12 degrees. All of the other options are used in the treatment of pes cavus deformities.
The Level 1 investigation by Wenger et al concludes that wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children. They recommend observation as the best conservative management option.
Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL
J Bone Joint Surg Am. 1989 Jul;71(6):800-10. PMID: 2663868 (Link to Abstract)
Wenger, JBJS 1989
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Midfoot Driven Atypical Flatfoot: Michael Clare, MD (CSFA #20, 2017)
Flatfoot with Deltiod Insufficiency: Bruce Cohen, MD(CSFA #19, 2017)