REVIEW ARTICLE |
https://doi.org/10.5005/jp-journals-10040-1296 |
Effectiveness of Lateral Column lengthening in Symptomatic Flexible Flatfoot of the Pediatric and Adolescent Population: An updated Systematic Review
1-5Department of Orthopaedics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Corresponding Author: Nirmal R Gopinathan, Department of Orthopaedics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, Phone: +91 7087009740, e-mail: dr.nirmalraj78@gmail.com
Received on: 18 January 2023; Accepted on: 22 February 2023; Published on: 11 April 2023
ABSTRACT
Background: Pes planovalgus is one of the most common pediatric foot deformities; one can manage it most conservatively. Surgery is only indicated for symptomatic flexible flatfoot with failed conservative treatment. In children, lateral column lengthening surgery is advantageous as it preserves the growth and development of the foot without fusing the joints.
Research question: Is lateral column lengthening effective in managing pediatric and adolescent symptomatic idiopathic flexible flatfeet?
Materials and methods: Four electronic databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and Google Scholar] were searched for relevant articles reporting the outcomes of lateral column lengthening surgery in idiopathic flexible flatfeet of children with a minimum 1-year follow-up. Pre and postoperative radiological outcomes were recorded using talometatarsal angles, talonavicular coverage, calcaneal pitch, and talocalcaneal angle. The functional results were recorded as pre and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores. Rehabilitation protocol and complications were noted.
Results: A total of 16 studies were included for the final review, with a total of 336 patients (468 feet) with a mean age of 11.65 years. An autologous tricortical iliac crest was the most commonly used graft during lateral column lengthening. There was a statistically significant improvement in the postoperative radiological parameters like anteroposterior (AP) talocalcaneal angle, AP talometatarsal angle, AP talonavicular angle, and in lateral views talocalcaneal angle, talometatarsal angle, and calcaneal pitch in comparison to preoperative values (p < 0.00001). The mean postoperative AOFAS scores had a standard mean difference of −5.24 [95% confidence interval (CI); −6.39, −4.09] from the mean preoperative AOFAS scores, and this difference is statistically significant (p < 0.00001). Complications like pain in the foot, infection, under-correction, graft displacement, and calcaneocuboid or talonavicular joint subluxation were noted.
Conclusion: Lateral column lengthening surgery is promising with good midterm clinical and radiological outcomes with acceptable complications for treating symptomatic flexible flatfeet in pediatric and adolescent populations.
How to cite this article: Rangasamy K, Ghosh AK, Ksheerasagar VP, et al. Effectiveness of Lateral Column lengthening in Symptomatic Flexible Flatfoot of the Pediatric and Adolescent Population: An updated Systematic Review. J Foot Ankle Surg (Asia-Pacific) 2023;10(2):66-75.
Source of support: Nil
Conflict of interest: None
Keywords: Adolescent, Calcaneal osteotomy, Flatfoot, Lateral column lengthening, Pediatric, Pes planovalgus.
INTRODUCTION
Pes planovalgus (flatfoot) is one of the most common presenting foot deformities in the pediatric orthopedic outpatient department. Physiologically, most children are born with flatfoot, and the longitudinal arch forms over the first decade of life. The prevalence of flatfeet decreases as the age progresses; it is 54% at 3 years and decreases to 24% at 6 years of age.1 The types of flatfeet seen in children and adolescents are either flexible flatfeet with or without Achilles tendon tightness or rigid flatfeet as seen in the tarsal coalition, congenital vertical talus, or skew foot. The prevalence of pathological flatfeet is <1%.1
Flexible flatfoot is most common, and they are mostly asymptomatic. Flexible flatfoot is a complex, variable three-dimensional deformity that mostly requires nonoperative management.1,2 Surgery is rarely indicated and reserved for symptomatic flatfeet despite conservative management.3 There are various surgical approaches described for flatfoot deformity correction, but in the pediatric population with open physis, one should keep in mind that the growth, development, and joint movements of the foot should be preserved.
Evans, in the year 1975,4 published a lateral column lengthening technique for correcting flexible flatfoot on 56 patients. He believed that the relative length difference between lateral and medial columns results in heel valgus deformity. He aims to equalize the length of both columns by calcaneal lengthening, which leads to simultaneous forefoot adduction and restoration of talonavicular subluxation. In 1995, Mosca2 modified Evans’ technique by placing more obliquely placed calcaneal osteotomy with or without medial cuneiform closing wedge plantarflexion osteotomy. He also advised additional soft tissue releases like the lateral origin of the plantar fascia and abductor digiti minimi aponeurosis. Later, some publications related to lateral column lengthening for flexible flatfeet were published with modifications like using different autologous and allogenic bone grafts.5,6
We conducted this systematic review to condense all the available data published to date to evaluate the clinical and radiological outcomes and complication rates following lateral column lengthening surgery in symptomatic pediatric flatfeet.
MATERIALS AND METHODS
The systematic review was conducted in concordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement.7 PubMed, CINAHL, Embase, and Google Scholar databases were searched using keywords for relevant studies (Table 1). Bibliographies of included studies were further assessed for relevant articles meeting the inclusion criteria. The articles eligible for inclusion were original articles, randomized controlled trial (RCT), cohort studies, and prospective or retrospective case series on lateral column lengthening in idiopathic and flexible pes planovalgus in the pediatric or adolescent age group (<18 years), with a minimum follow-up of 1 year. Studies on rigid flatfoot, neurologic etiology like cerebral palsy, hemiparesis, and other modalities of treatment like arthroereisis, arthrodesis, and medial column shortening were excluded. Studies in languages other than English, case reports, and animal studies were also excluded.
| Database (results) | Search strategy |
|---|---|
| PubMed (145) | Search: (((adolescent) OR (pediatric)) AND ((pes planus) OR (flat foot))) AND (lateral column lengthening) (“adolescences”[All Fields] OR “adolescency”[All Fields] OR “adolescent”[MeSH Terms] OR “adolescent”[All Fields] OR “adolescence”[All Fields] OR “adolescents”[All Fields] OR “adolescent s”[All Fields] OR (“pediatrics”[All Fields] OR “pediatrics”[MeSH Terms] OR “pediatrics”[All Fields] OR “paediatric”[All Fields] OR “pediatric”[All Fields])) AND (“flatfoot”[MeSH Terms] OR “flatfoot”[All Fields] OR (“pes”[All Fields] AND “planus”[All Fields]) OR “pes planus”[All Fields] OR (“flatfoot”[MeSH Terms] OR “flatfoot”[All Fields] OR (“flat”[All Fields] AND “foot”[All Fields]) OR “flat foot”[All Fields])) AND ((“functional laterality”[MeSH Terms] OR (“functional”[All Fields] AND “laterality”[All Fields]) OR “functional laterality”[All Fields] OR “laterality”[All Fields] OR “lateral”[All Fields] OR “lateralisation”[All Fields] OR “lateralisations”[All Fields] OR “lateralise”[All Fields] OR “lateralised”[All Fields] OR “lateralises”[All Fields] OR “lateralising”[All Fields] OR “lateralities”[All Fields] OR “lateralization”[All Fields] OR “lateralizations”[All Fields] OR “lateralize”[All Fields] OR “lateralized”[All Fields] OR “lateralizes”[All Fields] OR “lateralizing”[All Fields] OR “laterally”[All Fields] OR “laterals”[All Fields]) AND (“column”[All Fields] OR “column s”[All Fields] OR “columns”[All Fields]) AND (“lengthen”[All Fields] OR “lengthened”[All Fields] OR “lengthener”[All Fields] OR “lengthening”[All Fields] OR “lengthenings”[All Fields] OR “lengthens”[All Fields])) |
| Embase (1139) | (’flatfoot’/exp OR flatfoot OR’ pes planovalgus’/exp OR’ pes planovalgus’) AND (’pediatrics’/exp OR pediatrics OR ’adolescent’/exp OR adolescent) |
| CINAHL (253) | (Flatfoot OR planovalgus) AND (paediatric OR adolescent) |
| Google Scholar (2253) | Pediatric or adolescent flatfoot or pes planovalgus and lateral column lengthening |
Patient demographics, number of feet operated, type of graft and implant, and mean follow-up period were recorded. Pre and postoperative radiological outcomes in the form of talometatarsal angles, talonavicular coverage, calcaneal pitch, and talocalcaneal angle were recorded. The functional outcomes were recorded in the form of pre and postoperative AOFAS. The mean difference in radiological measures and AOFAS scores was calculated to assess the effect of lateral column lengthening on clinic-radiological outcomes. Complications and rehabilitation protocols suggested by different authors in the included articles were also noted.
Two independent reviewers (AG and KR) conducted a database search and independently tabulated and compared the data. In case of any disagreement, the third reviewer’s opinion was sought. The risk of bias (ROB) was assessed using the ROB in nonrandomized studies—of interventions (ROBINS-I) tool,8 and the plots were created using the robvis package.9
Statistical Analysis
Microsoft Excel was used to tabulate all the data. Our data were analyzed using Review Manager Software (Rev-Man 5.4). Calculation of standard mean difference and 95% CI were done for continuous data. We used random-effects as well as a fixed-effects model in estimating overall effect sizes, as necessary. Statistical heterogeneity was assessed using the I2 value and Chi-squared test. An I2 value of >50% was considered statistical heterogeneity, and they were analyzed using the random-effects model.
RESULTS
An initial search was conducted over four databases, as specified in the PRISMA flow diagram (Fig. 1). A total of 44 articles were shortlisted based on title, 17 studies were further excluded from reviewing the abstracts, and 27 were selected for full-text review. Out of 27, one study was excluded as all patients underwent both subtalar arthroereisis and calcaneal lengthening osteotomy.10 Six studies were excluded as they also evaluated patients with pes planovalgus due to other neurological causes like cerebral palsy and myelomeningocele.11-15 One study was excluded because the primary outcome was graft union and not the amount of correction.16 One study did not meet the age criteria despite mentioning adolescents in the title.17 Two studies were excluded due to duplication of results, and one remaining was excluded as all patients underwent medial column shortening along with lateral column lengthening.18-21 A total of 16 studies were included in the final review.
Fig. 1: Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram
A total of 10 studies5,21,22-30 were retrospective, and six19-21,24,25,32 were prospective (Table 2). In 336 patients, 468 feet underwent lateral column lengthening osteotomies in these 16 studies. There were 195 males and 126 females in the 15 studies where gender was specified. The mean age was 11.65 years (range—8.3–15.2 years). The mean follow-up period was 32.8 (range—12–100) months. The resulting bone defect from the osteotomy and lengthening was commonly filled with autologous iliac crest graft. However, Lai et al.5 and Zairi et al.26 reported using an autologous fibula graft. In contrast, Baghdadi et al.24 used an autologous tibia, and Xu et al.29 used a patella allograft. None of the authors reported any nonunion or delayed union with different types of grafts. The osteotomies were frequently fixed with Kirschner wires (K-wires), and few authors reported using plates and screws.5,29,31 The rehabilitation protocol varied amongst different authors, as depicted in Table 3. The general trend was found to be 6 weeks of non-weight-bearing in a below-knee cast followed by K-wire removal and further protected weight-bearing till radiological union (Table 3). Additional procedures like tendoAchilles (TA) lengthening, peroneus brevis lengthening, tibialis posterior augmentation, talonavicular capsular imbrication, split tibialis anterior tendon transfer, and medial cuneiform cotton osteotomy were performed in an ’à la carte’ manner by the authors.
| Author | Country | Type of study | No. of patients | Male | Female | No. of feet | Right | Left | Mean Age (years) (Mean ± SD) | Mean follow-up (months) | Graft used | Fixation |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mohsen et al. (2022)19 | Egypt | Prospective | 16 | 8 | 8 | 16 | 11 | 5 | 10.4 ± 2.5 | 12 ± 3 | Autologous Iliac | K- wires |
| Tarraf et al. (2017)20 | Egypt | Prospective | 22 | 10 | 12 | 36 | – | – | 10.3 ± 3.3 | 18.7 ± 80.5 | Autologous Iliac | K- wires |
| Ahmed et al. (2019)21 | Egypt | Prospective | 16 | 9 | 7 | 28 | 15 | 13 | 8.36 ± 1.70 | 22.57 ± 7.87 | Autologous Iliac | K- wires |
| Kehayov et al. (2022)22 | Bulgaria | Retrospective | 64 | 44 | 20 | 92 | 51 | 41 | 11.61 ± 1.90 | 18.56 ± 8.29 | Autologous Iliac | K- wires |
| Lai et al. (2021)5 | Taiwan | Retrospective | 13 | 9 | 4 | 23 | – | – | 12.3 ± 1.2 | 49.7 | Autologous fibula | K-wires, Locking plate |
| Nejib et al. (2020)23 | France | Retrospective | 15 | – | – | 20 | – | – | 13.9 ± 1.7 | 100 ± 20 | Autologous Iliac | K- wires |
| Baghdadi et al. (2018)24 | Iran | Prospective | 20 | 12 | 8 | 30 | – | – | 10.4 ± 0.9 | 23.1 ± 9.9 | Autologous tibia | K- wire, staples |
| Viegas et al. (2003)25 | USA | Prospective | 17 | 9 | 8 | 34 | 17 | 17 | 12.1 ± 2.5 | 24.9 ± 10 | Autologous Iliac- | |
| Zairi et al. (2022)26 | Tunisia | Retrospective | 12 | 7 | 5 | 15 | 7 | 8 | 12 ± 1.5 | – | Autologous fibula | K- wires |
| Luna et al. (2022)27 | Italy | Retrospective | 14 | 8 | 6 | 26 | 12.8 ± 0.9 | – | Autologous Iliac | K- wires | ||
| Westberry et al. (2013)28 | USA | Retrospective | 17 | 9 | 8 | 21 | 7 | 14 | 13.6 ± 2.9 | 28.8 | – | – |
| Xu et al. (2017)29 | China | Retrospective | 13 | 9 | 4 | 15 | – | – | 15.2 ± 1.8 | 34.5 ± 15.7 | Patella allograft | Plate and |
| Akimau et al. (2014)30 | UK | Retrospective | 15 | 12 | 3 | 25 | 13 | 12 | – | 54 ± 10.7 | Autologous Iliac | -screws |
| Ghaznavi et al. (2022)31 | Iran | Retrospective | 50 | 27 | 23 | 50 | 29 | 21 | 9.2 ± 2.2 | 31 ± 13 | Autologous Iliac | Plate and screws |
| Salam et al. (2016)21 | Egypt | Retrospective | 14 | 10 | 4 | 19 | 12 | 7 | 13.53 ± 1.38 | 27.89 ± 8.67 | Autologous Iliac | K- wires |
| Abdelhadi et al. (2021)32 | Egypt | Prospective | 18 | 12 | 6 | 18 | – | – | 9.05 ± 1.89 | 13.6 ± 2.7 | Autologous Iliac | K- wires |
| Total | 336 | 195 | 126 | 468 | 162 | 138 | Mean = 11.65 | Mean = 32.8 | ||||
| Author | Rehabilitation protocol |
|---|---|
| Mohsen et al. (2022)19 | Slab ×2 weeks, below-knee (BK) cast 4 weeks |
| Tarraf et al. (2017)20 | Cast ×2 weeks, suture removed, then again cast for 4 weeks, K- wire removed, then walking cast for 4–6 weeks |
| Ahmed et al. (2019)21 | BK cast ×6 weeks |
| Lai et al. (2021)5 | BK cast 2 weeks non-weight-bearing, full weight-bearing on BK cast for 4 weeks, cast removal at 6 weeks |
| Nejib et al. (2020)23 | Non-weight-bearing BK cast ×5 weeks, pin removal, then weight-bearing BK casts for 5 weeks |
| Baghdadi et al. (2018)24 | Non-weight-bearing AK cast ×6 weeks, K-wire removed, and BK cast till radiological union, full weight-bearing at 10–12 weeks |
| Viegas et al. (2003)25 | Non-weight-bearing BK cast for 6 weeks, K-wire removal, partial weight-bearing BK cast for 6 weeks, Full weight-bearing at 12 weeks |
| Luna et al. (2022)27 | BK cast non-weight-bearing for 6–8 weeks, weight-bearing only after the radiological union |
| Westberry et al. (2013)28 | BK cast with knee immobilizer for 6 weeks, protected weight-bearing in a cam boot for 4 weeks |
| Xu et al. (2017)29 | Non-weight-bearing cam boot for 6 weeks, walking at 8 weeks |
| Ghaznavi et al. (2022)31 | BK cast, non-weight-bearing for 6 weeks, weight-bearing at 6 weeks |
| Salam et al. (2016)21 | BK cast, 6 weeks, and then K-wire removed, weight-bearing only on union |
| Abdelhadi et al. (2021)32 | BK cast for 6 weeks |
Radiological Outcomes
Overall, nine different radiological parameters were studied in 14 articles that mentioned radiological outcomes. Four different angles (talocalcaneal angle, talometatarsal angle, talonavicular angle, and calcaneus fifth metatarsal [C-M5] angle) were measured on the AP or dorsoplantar foot radiograph, and five different angles (lateral talometatarsal angle, lateral talocalcaneal angle, calcaneal pitch, talo-horizontal angle, and Costa Bertani angle) were measured on lateral weight-bearing foot radiograph.
The AP talocalcaneal angle (Kite’s angle) was measured pre and postoperatively in seven studies, out of which six were included for statistical synthesis.14,23-26,31 The postoperative AP talocalcaneal angle had a standard mean difference of 2.82° (95% CI—1.75, 3.89) from preoperative values, and the difference was found to be statistically significant (p < 0.00001) in a random effects model (Fig. 2). The AP tarsometatarsal angle measured between the axes of the talus and 1st metatarsal was reported in seven studies.5,21,23-25,28,31 The standard mean difference between pre and postoperative values was 4.26° (95% CI—2.53, 5.99), which was statistically significant (p < 0.00001) (Fig. 3). The AP talonavicular angle, an indicator of talar head coverage, was reported in 11 studies,19,21-26,28,29,31 out of which eight studies that mentioned complete data with standard deviations were included. The standard mean difference between pre and postoperative values was 4.45 (95% CI—3.13, 5.76) (p < 0.00001), which was a statistically significant difference, using the inverse variance in a random effects mode (Fig. 4). The AP calcaneus-5th metatarsal angle was mentioned only in three studies,23,24,26 and it reduced from 21.4° (range 11–30) to 3.67° (range 2–6). The AP parameters indicate that calcaneal lengthening osteotomy effectively addressed the forefoot abduction in flatfeet.
Fig. 2: Forest plot for AP talocalcaneal angle
Fig. 3: Forest plot for AP talometatarsal angle
Fig. 4: Forest plot for AP talonavicular angle
Five different parameters were assessed on the lateral view. All five parameters showed improvement. The lateral talometatarsal angle, or Meary’s angle, was reported in 11 studies,5,19,21,22-29 and eight studies were considered for statistical synthesis. The standard mean difference between pre and postoperative values was 4.34° (95% CI—2.79, 5.89) (p < 0.00001), which was statistically significant (Fig. 5). The standard mean difference between pre and postoperative lateral talocalcaneal angle was 2.11° (95% CI—1.41, 2.80) across eight studies (p < 0.00001), using a random effects model (Fig. 6).21,23-25,28,31,32 Calcaneal pitch, the angle between the horizontal and inferior surface of calcaneum, the postoperative angle improved from a preoperative angle by a statistically significant standard mean difference of −3.88° (95% CI—−5.20, −2.56) (p < 0.00001) (Fig. 7).5,19,21-26,28,31 The talar pitch or talo-horizontal angle was measured in four studies23,24,29,31 and reduced from a mean preoperative angle of 36.8°(range: 27.6–42) to a mean postoperative angle of 22.3°(range—16.9–28). The Costa Bertani angle, the angle on a lateral radiograph between the inferior surface of the calcaneum and the axis of the fifth metatarsal, was reported only in two studies,21,27 and the mean postoperative angle reduced to 129.3°from a mean preoperative angle of 153.2°.
Fig. 5: Forest plot for lateral talometatarsal angle
Fig. 6: Forest plot for lateral talocalcaneal angle
Fig. 7: Forest plot for calcaneal pitch
Clinical Outcomes
A total of 13 out of 16 studies reported the clinical outcomes with the American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH); however, only nine studies20,21,23,25,26,27,29,32 with complete data were included for statistical synthesis. AOFAS is a 100-point score with 40 points for pain, 50 for function, and 10 for clinical alignment. The AOFAS scores showed a standard mean difference of −5.24 (95% CI; −6.39, −4.09) between preoperative and postoperative values, which was statistically significant (p < 0.00001) (Fig. 8). Kehayov et al.22 reported their outcome using the visual analog scale-foot and ankle (VAS-FA) and reported an increase in mean values from 58.9 to 88.6. This shows lateral column lengthening osteotomy had a statistically significant clinical outcome in the form of AOFAS or VAS-FA scores.
Fig. 8: Forest plot for AOFAS scores
Complications
A total of 13 studies reported a total of 71 complications (Table 4). There was a pain in 27 feet, mentioned across seven studies. Viegas et al. and Akimau et al. reported that the pain was due to sural neuropathy in five patients.25,30 There was skin irritation in nine feet across four studies. There were eight instances of under-correction and two instances of overcorrection reported in two studies. Infection was the second most common complication, reported in 10 feet over seven studies. All of them were cases of superficial infection and were resolved with antibiotics alone. Four instances of calcaneocuboid subluxation were mentioned in two studies. There was graft displacement in nine feet in three studies and one case of talonavicular subluxation (Table 4).
| Author | Pain | Skin irritation | Under-correction | Overcorrection | Infection | Calcaneocuboid subluxation | Wound dehiscence | Graft displacement | Talonavicular subluxation |
|---|---|---|---|---|---|---|---|---|---|
| Mohsen et al. (2022)19 | 7 | – | – | – | – | – | – | – | – |
| Tarraf et al. (2017)20 | 1 | – | – | – | – | – | 1 | 2 | 1 |
| Kehayov et al. (2022)22 | – | – | – | – | 3 | – | – | 5 | – |
| Lai et al. (2021)5 | – | – | – | – | 1 | – | – | – | – |
| Nejib et al. (2020)23 | 7 | – | 6 | – | 1 | 1 | – | – | – |
| Baghdadi et al. (2018)24 | – | 3 | – | – | – | – | – | 2 | – |
| Viegas et al. (2003)25 | 3* | – | – | 1 | – | – | – | – | – |
| Zairi et al. (2022)26 | 3 | 3 | – | – | 2 | – | – | – | – |
| Luna et al. (2022)27 | – | – | – | – | – | 3 | – | – | – |
| Xu et al. (2017)29 | – | 2 | – | – | 1 | – | – | – | – |
| Akimau et al. (2014)30 | 2* | 1 | 2 | 1 | – | – | – | – | – |
| Ghaznavi et al. (2022)31 | – | – | – | – | 1 | – | – | – | – |
| Salam et al. (2016)21 | 4 | – | – | – | 1 | – | – | – | – |
| Total | 27 | 9 | 8 | 2 | 10 | 4 | 1 | 9 | 1 |
*Sural neuropathy
Risk of Bias (ROB)
Three studies had a low ROB, six studies had a moderate ROB, and seven had a severe ROB measured using the ROBINS-I tool (Figs 9 and 10).
Fig. 9: Risk of bias (ROB) graph
Fig. 10: Risk of bias (ROB) summary of included studies
DISCUSSION
It is agreed upon that the management of idiopathic flexible pes planovalgus in pediatric and adolescent populations is usually conservative. The same condition warrants treatment in case the feet become painful. Nonsurgical options like shoe wear modification, weight reduction, and customized orthoses remain the first line of treatment for painful flexible flatfeet.33 Those patients who do not improve after a trial of conservative therapy for 6–12 months are usually considered candidates for surgical treatment. Most studies in our review included patients only after the failed conservative therapy ranging from 6 to 15 months.
The surgical options available for pes planovalgus are broadly arthroereisis, arthrodesis, and lateral column lengthening, along with an array of other soft tissue procedures like Kidner tibialis posterior augmentation, Young’s tenosuspension, TA lengthening.34 Arthrodesis is usually not preferred in children as it hampers normal growth of the feet and leads to secondary osteoarthritis in the long term. Arthroereisis is a good and technically easy surgery to perform in the pediatric population with rapid results. However, it comes with shortcomings like under-correction, pain, implant-related complaints, and later need for implant removal.35 Our study aimed to evaluate the efficacy of lateral column lengthening with or without additional soft tissue/bony procedures in the treatment of flexible painful pediatric flatfeet. These osteotomy procedures are difficult to perform and require meticulous planning, but they can provide good correction when combined with other soft tissue procedures on a case-to-case basis.30 A systematic review conducted by Suh et al. showed that lateral column lengthening achieved better radiological correction and AOFAS scores when compared to subtalar arthroereisis, albeit with more complications and similar reoperation rates.36
Most authors initially did a TA lengthening or a gastrocnemius recession based on an intraoperative Silfverskiöld test. The Achilles tendon must be carefully assessed and addressed in all flexible pes planovalgus.37 Most authors made an oblique osteotomy through the lateral cortex of the calcaneum between the anterior and posterior facet and kept the medial periosteum intact. Before distracting the osteotomy, a calcaneocuboid wire was placed to prevent calcaneocuboid subluxation. The choice of graft varied amongst studies, like an autologous iliac crest or fibula graft, with one study reporting the use of patellar allograft. None of the studies reported any case of nonunion or delayed union. John et al.6 used allogenic bone graft and anterior calcaneal osteotomy for supple flat foot and documented a 100% union rate with a mean graft incorporation time of 9.10 ± 1.54 weeks in adolescents. Vosseller et al.38 concluded that the rate of nonunion or loss of correction did not differ significantly based on the use of allograft or autograft in adult flatfeet. In bilateral cases, usually, a 12–15 months gap was given in between both surgeries.
Kumar et al.39 had previously conducted a systematic review on lateral column lengthening for adolescent idiopathic pes planovalgus in seven studies, including 156 feet. However, they included few studies which reported outcomes on patients with cerebral palsy and neurologic disorders. We feel that flatfeet in cerebral palsy should be treated as a separate entity when comparing outcomes due to different underlying pathology and poorer bone quality. The seven retrospective studies in their review showed that lateral column lengthening improved the radiological parameters of planovalgus feet, with only four included studies reporting these parameters.39 Our updated review with six prospective and 10 retrospective studies also showed similar results, with 14 studies reporting radiological outcomes. Lateral column lengthening surgery significantly improved the various AP and lateral postoperative radiological parameters in pediatric pes planovalgus.
Previous reviews by Suh et al. and Kumar et al. included three and four studies reporting AOFAS scores, which showed significant improvement in AOFAS scores.36,39 Similarly, this review included nine studies that reported a statistically significant improvement in AOFAS scores after lateral column lengthening.
Complications were reported in 71 of 438 feet (16.2%), which was similar to 17.5% in the review by Kumar et al.39 The pain was by far the most common complication in our study, similar to the findings of Suh et al., the instances of calcaneocuboid subluxation were fewer.36 There was no mention of calcaneocuboid pain specifically in any of the studies. This is contrary to the findings of a few cadaveric studies, which concluded that lateral column lengthening increases the calcaneocuboid joint pressures.40
This review builds on existing evidence and adds to the evidence showing the efficacy of lateral column lengthening in the treatment of flexible pediatric and adolescent pes planovalgus. To the best of our knowledge, this is the largest review by the number of patients and studies included. The systematic review exclusively included idiopathic pes planovalgus in pediatric and adolescent populations.
This review has a few limitations, firstly, the lack of higher evidence studies like RCT is evident, and there is no control group. Secondly, due to variability in the published studies on additional soft tissue/bony procedures, the indications and effectiveness of additional procedures performed along with lateral column lengthening were not studied separately. Thirdly, most studies did not report time to graft union; thus, it was not studied. The rate of revision surgery was also not commented upon due to a lack of published data. Lastly, the use of meta-analysis for analyzing effect size based on study designs using pre and post scores suffers from inherent limitations. The effect sizes (the standardized mean differences) of pre and postintervention are not independent of each other; hence there could be some sort of intrinsic correlations between these two scores.41 Ordinarily, the correlation values pre and post time points should be used in the calculation of the standardized mean differences. However, these values are not known and typically not reported by the studies. Despite this limitation, a meta-analysis based on pre and poststudy designs can still be helpful in some cases, especially in those study designs where when no control group is available. The results of such meta-analyses can still be highly informative, despite the limitation above. We recommend future higher evidence studies like RCT with a control group to evaluate the effectiveness of lateral column lengthening in symptomatic, flexible pediatric pes planovalgus with standardization of additional procedures.
CONCLUSION
Lateral column lengthening is a safe and effective option for surgical treatment of painful flexible pediatric pes planovalgus with satisfactory mid-term clinical and radiological outcomes and acceptable complication rates.
ETHICAL CLEARANCE
Since it is a systematic review, there is no need for ethical clearance.
ACKNOWLEDGMENTS
We duly acknowledge Dr Tanvi Kiran, Assistant professor, School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India, for timely assistance in the meta-analysis.
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