FOOT & ANKLE INTERNATIONAL Copyright 2007 by the American Orthopaedic Foot & Ankle Society, Inc.

. DOI: 10.3113/FAI.2007.0991

Minimally Invasive Calcaneo-Stop Method for Idiopathic, Flexible Pes Planovalgus in Children
Sandor Roth, M.D.; Branko Sestan, Ph.D., F.R.C.S.; Anton Tudor, Ph.D.; Zdenko Ostojic, Ph.D., F.R.C.S.; Anton Sasso, Ph.D., F.R.C.S.; Artur Durbesic, M.D.
Rijeka, Croatia

ABSTRACT Background: The aim of this study was to correct heel valgus in children and to lift the longitudinal arch of the foot using a temporary cancellous screw placed percutaneously across the talocalcaneal articulation. Methods: From April, 1997, to June, 2003, 94 procedures were done on 48 children between the ages of 8 and 14 years. The Meary angle to determine the degree of collapse of the medial longitudinal arch was 170 degrees or less, and the weightbearing hindfoot was in valgus. Presumably, the screw achieves correction by stimulating the proprioceptive foot receptors allowing active inversion of the foot. Results: At 5 years followup, no serious complications occurred. The correction of the Meary angle on average was 17.10 5.51 degrees. In every foot, heel valgus and the longitudinal arch of the foot were improved radiographically and clinically without the loss of function. We removed the screws in all patients. In 91 feet, the arch of the foot and heel valgus remained in the corrected position. Conclusions: The calcaneo-stop method is a simple, effective, minimally invasive technique for the treatment of idiopathic, exible pes planus in carefully selected pediatric patients. Key Words: Arthroreisis; Pes Planovalgus; Subtalar Joint INTRODUCTION

The main cause of pes planovalgus is the valgus position of the heel which leads to plantar and medial deviation of the talus.1,2,3,6,12 In pes planovalgus, operative correction of the heel valgus by implanting different elements in the sinus tarsi has been used for this mulitplanar deformity. In
Corresponding Author: Sandor Roth, M.D. KBC Rijeka Children Orthopedics F.la Guardia 14 Rijeka 51000 Croatia E-mail: rothmed@ri.htnet.hr For informationon prices and availability of reprints, call 410-494-4994 X226.

1946, Chambers reported lling the sinus tarsi with bone mass to prevent eversion of the calcaneus.3,4,8 In 1970, LeLievre4 who introduced the term of lateral arthroreisis, achieved good results by placing free bone graft into the sinus tarsi. Smith and Millar9 used a polyethylene screw in the sinus tarsi (STA peg) and reported 96% successful results. Using the same method, other authors reported the same success in treating secondary pes planovalgus.10 In 1997, Verheyden11 rst reported the use of a spacer in the sinus tarsi. Viladot12 used a silicon implant to treat idiopathic pes planovalgus and reported 99% success in 234 patients. Gianini2 reported 94% good results in 50 cases using nonresorbable and 20 cases with bioabsorbable expanding implant material. Magnan et al.6 had 83% good results using the calcaneo-stop method in 475 patients with an average followup of 20 (range 12 to 112) months. In treating idiopathic pes planovalgus in children, we used the calcaneo-stop method with an anterograde cancellous screw for subtalar arthroreisis.7 Placement of the screw maintains correction of heel valgus by stimulating the proprioceptive receptors around the sinus tarsi and forces the hindfoot into a reduced position. De Pellegrin,2 Kranicz and Czipri,3 and Nogarin et al.7 emphasized the importance of this mechanism in their work. The screw makes heel valgus impossible and reduces the divergence of the talus and calcaneus. The active self-correction is proved by weak screw penetration into the calcaneus as well as the relatively small percentage of screw breakage. If the correction were simply mechanical (passive mechanism), a higher percentage of screw breakage would be expected.8 With the idea of further improving and optimizing the procedures, we began to implant the screw percutaneously and assumed that it would shorten the operating time and lead to less damage around the subtalar joint. We also expected rapid medical rehabilitation of a child without immobilization. The aim of our method was to simplify the operative procedure as much as possible. We tried to correct pes
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planovalgus with one simple percutaneous and temporarily implanted cancellous screw.
MATERIALS AND METHODS

From April, 1997, to June, 2003, we operated on 48 children (94 feet) between the ages of 8 and 14 years. In two patients, we performed this surgery on just one foot. In all other patients, the surgery was performed on both feet. The data were analyzed with the statistical software package by Stat Soft, Inc. version 7.1. (Tulsa, OK) The level of p < 0.05 was considered statistically signicant. Data are expressed as mean standard deviation (SD). Statistical analyses were performed using the descriptive statistic and nonparametric method. The values of preoperative and postoperative talo-rst metatarsal angles were expressed as median and ranges because of the variability and the distribution of the results previously tested according to Lilliefors and KolmogorovSmirnov. The differences between the preoperative and postoperative angles were analyzed using the Wilcoxon matched pairs test. The mean age was 11.4 1.5 years. There were 17 girls (mean SD age: 11.9 1.5 years) and 31 boys (mean SD age: 11.5 1.6 years). The mean time the screw was implanted was 31.8 7.4 (mean SD) months.
Indications

Indications for surgery included pes planovalgus with medial protrusion of the talar head and complete absence of the longitudinal arch (Figure 1, A); a talo-rst metatarsal angle (by Meary) of 170 degrees or less (measured on weightbearing lateral radiograph of the foot) (Figure 2); and valgus position of the heel (Figure 1, B). We measured all operated patients, those with and without pain. Before surgery conservative treatment (physical exercises and orthosis) was attempted and only in the unsuccessful cases was surgery suggested. We did not perform this surgery on children under 8 years of age because solid bone tissue should be present, and we wanted to be sure that the condition of the foot would not improve with conservative treatment. Children over 14 years of age also were excluded because foot growth would have been almost complete and not enough correction could be obtained with the growth remaining. In skeletally mature feet, the correction may be lost after the screw is removed. Children with neuromuscular disorders, or those who had post-traumatic or congenital atfoot also were excluded. Followup averaged 5 years (60 months 22.2 months; range 38 to 112 months).
Operative Technique

Fig. 1: Preoperative standing photographs (anterior and posterior). Surgery was performed in symptomatic children with pesplanovalgus feet when medial protrusion of the talar head and the complete absence of the longitudinal arch were observed.

Fig. 2: Preoperative lateral standing radiograph. An abnormal talo-rst metatarsal angle (Meary) of 170 degrees present in each foot.

The basic materials were a 6.5-mm cancellous screw, screw driver, trocar, and metal clip used as a radiographic marker. With a small (8-mm) longitudinal skin incision in front of the lateral malleolus at the level of the sinus tarsi

(Figure 3), the skin and underlying ligament were incised, and the lateral process of the talus was located with the metal clip. An entry hole was made into the talus with a

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Fig. 3: A small (8-mm) longitudinal skin incision was placed over the lateral process of the talus after radiographic conrmation.

Fig. 5: A cancellous (6.5-mm) approximately 30-mm in length screw, depending on the childs age, was inserted obliquely into the talus.

Fig. 6: Illustration of the screw inserted into the talus at an angle of 35 degrees in the sagittal plane and 45 degrees in the coronal plane.

Fig. 4: An entry hole was made into the talus with a trocar for screw placement.

trocar (Figure 4). A cancellous screw of approximately 30mm in length, depending on the childs age, was inserted into the talus (Figure 5). The direction of the screw implantation into the body of the talus was 35 degrees in the sagittal and 45 degrees in the coronal plains (Figure 6). During the implantation, the foot was held in inversion, and the screw was inserted into the talus until the correct position of the calcaneus was obtained. At this time, the longitudinal arch of the foot spontaneously reconstituted (Figure 7), and the nonthreaded portion of the screw was not seated in the talus allowing a calcaneo-stop abutment to maintain the corrected hindfoot position (Figure 8).
Postoperative Care

Fig. 7: The foot was held in inversion, and the screw was inserted into the talus. Correct position of the calcaneus was obtained, and at the same time the longitudinal arch of the foot was automatically lifted.

No cast immobilization was necessary, and on the second postoperative day complete weightbearing was possible if there was no pain. If the patient complained of a painful foot, we suggested gradual weightbearing. Molded arch supports

were prescribed when necessary. Orthopaedic shoes as well as special physical therapy were not necessary, and sports were allowed when perioperative pain ended. The screws

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inammation from local reaction to a foreign body. The median preoperative talo-rst metatarsal angle (by Meary) was 162 degrees (minimum 149 degrees and maximum 172 degrees) and the median postoperative talo-rst metatarsal angle was 180 degrees (minimum 163 degrees and maximum 185 degrees). Statistically signicant differences were found between preoperative talo-rst metatarsal angles and postoperative talo-rst metatarsal angles (Z = 5.905; p < 0.0001). The correction of the Meary angle on average was 17.10 5.51 degrees. Postoperative improvement of all angular measurements was statistically signicant at 95% condence level (p = 0.05). The valgus position of the heel was corrected, and the longitudinal arch of the foot was lifted in 86 feet; 91.48% had excellent and good results. After the surgery, all feet were functional. Screw breakage occurred in nine feet (9.57%); seven were asymptomatic and two were painful and had to be removed 3 weeks and 6 months after surgery. In seven feet (7%), incorrect screw positioning occurred, so we had

Fig. 8: Anteroposterior (A) and lateral (B) postoperative view of the correct screw position. Meary angle is improved to 185 degrees and the arch of the foot lifted. The average postoperative angle was 177 degrees (average correction 19 degrees).

were left in place for approximately 30 months to maintain correction. For younger children the time was shorter and for older children the time was longer. To arrive at the correct timing, we devised the following formula: (childs age in years) 2 + 6 = numbers of months that the screw needed to be implanted before removal.
RESULTS

The results were evaluated based on the correction of the foot arch; position of heel valgus (Figures 9); pain after longer weightbearing; improvement in the footprint and function; changes in radiographic measurements taken preoperatively, at 6 months after surgery, and after screw removal (improving the Meary angle, Figure 10); ability to do sports activities; and the patients personal satisfaction. A scale from 1 to 10 was used. The results were divided into excellent, good, and poor. One to 5 points were considered poor results; 6 to 8 points were good; and 9 to 10 points were excellent. Eighty-six (91.49%) had excellent and good results, and eight (9%) had poor results. The screws were removed in all feet (94), and there were no signs of

Fig. 9: A, Two years after the screw extraction the correction was maintained and the patient was satised. B, The results were evaluated considering the correction of the foot arch and the valgus position of the heel.

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a minimally invasive procedure. The surgery is reasonably straightforward without expensive instrumentation. Neither gastrocsoleus lengthening nor calcaneal osteotomy was necessary.3,5,13 Less morbidity, therefore, can be expected as well as a shorter postoperative course.5,14 Our results are similar to the results of De Pellegrin.1,10 We had a higher percentage of broken screws at followup (5 years), which raised the percentage of complications as well. Considering these results, we assumed that if we had a screw of greater strength, the percentage of failed hardware might have been less. In our opinion, the described calcaneo-stop method is a fast, minimally invasive, effective, and economical method for operative treatment of idiopathic exible pes planovalgus in children.
Fig. 10: Statistically signicant differences were found between the preoperative talo-rst metatarsal angle and postoperative talo-rst metatarsal angle.

REFERENCES
1. De Pellegrin, M: Die subtalare Schrauben-Arthrorise beim kindlichen Plattfuss. Der Orthopade. 34:941 954; 2005. 2. Giannini, S: Operative treatment of the atfoot: why and how. Foot Ankle Int. 19:52 58;1998. 3. Kranicz, J; Czipri, M: Korai tapasztalatok a Calcaneo-stop modszer alkalmazasaval a gyermekkori ludtalp muteti kezeleseben. Magyar Traumat. es Orthop. Sebeszet. 43:177 178, 2000. 4. LeLievre, J: Current concepts and correction of the valgus foot. Clin. Orthop. 70:43 55, 1970. 5. Magnan, B; Baldrighi, C; Montanari, M; Bartolozzi, P: Tenosuspension of the scaphoid after young as an accessory technique in calcaneus-stop. Ital. J. Pediatr. Orthop. 13:40 46, 1997. 6. Magnan, B; Baldrighi, C; Papadia, D; et al.: Flatfeet: comparison of surgical techniques. Result of study group into retrograde endorthesis with calcaneus-stop. Ital. J. Pediatr. Orthop. 13:28 33, 1997. 7. Nogarin, L: Retrograde endorthesis. Ital. J. Pediatr. Orthop. 13:34 39, 1997. 8. Peters, PA; Sammarco, J: Arthroereisis of the subtalar joint. Foot Ankle 10:48 50, 1989. 9. Smith, SD; Millar, E.A: Arthroereisis by means of the subtalar poly ethylene peg implant for correction of hindfoot pronation in children. Clin. Orthop. 181:15 25, 1983. 10. Vedantam, R; Capelli, AM; Schoenecker, PL: Subtalar arthroereisis for the correction of the planovalgus foot in children with neuromuscular disorders. J. Pediatr. Orthop. 18:294 298, 1998. 11. Verheyden, F; Vanlommel, E; Van der Bauwhelde, J; Fabry, G; Molenaers, G: The sinus tarsi spacer in the operative treatment of exibile at feet. Acta Orthop. Belg. 63:305 309, 1997. 12. Viladot, A: Surgical treatment of the childs atfoot. Clin. Orthop. 283:34 38, 1992. 13. Viladot, R; Pons, M; Alvarez, F; Omana, J: Subtalar arthroereisis for posterior tibial tendon dysfunction: a preliminary report. Foot Ankle Int. 24:600 606, 2003. 14. Zaret, DI; Myerson, MS: Arthroerisis of the subtalar joint. Foot Ankle Clin. 8:605 617, 2003,

to repeat the surgery in two feet (2%). We had to change the position of two screws because they were positioned incorrectly (in the subtalar joint or too vertically). In all feet (94) the screws were removed, and the longiduinal arch of the foot as well as the heel valgus remained corrected in 86 feet (91%) at a mean followup of 60.75 months. Complications occurred in 11 feet (9 screw breakages and 2 incorrectly positioned screws; 12%). Nevertheless, we had 91% excellent or good results because in seven of nine feet in which screw breakage occurred, the correction remained, and the patients were pleased. In ve feet, although the screw was incorrectly positioned, correction of the deformity remained. There was no loosening of the screw or inammation. Of the 11 complications, the screw penetrated into the calcaneus in two feet (2%). After the screws were removed in six feet (6%), the children complained of pain after long periods of weightbearing but with less intensity than preoperatively (preoperatively, 74 feet were painful after long periods of weightbearing). Preoperatively, the footprint was abnormal in all feet; postoperatively, normal footprints were present in 71 (75%) feet with mild atfoot in 15 (16%) feet, and in eight (9%) feet the footprint was the same as before surgery.
DISCUSSION

In operative treatment of idiopathic pes planovalgus in symptomatic children using a block to calcaneal eversion is