1 Tehran University of Medical Science, Tehran, Iran

2 The Royal London Limb Reconstruction Service St Bartholomew’s and Royal London Hospital Barts Health NHS Trust, London, UK


Background: Flexible idiopathic flatfoot is the most common form of flatfoot. First line treatments are parental
reassurance and conservative measures; however, surgical treatment may be needed in some cases. A number
of surgical techniques with varying results have been described in the literature. Here, we present our clinical and
radiological outcomes of calcaneal lengthening osteotomy for pediatric idiopathic flexible flatfoot.
Methods: Calcaneal lengthening osteotomy was performed in 20 patients, 30 feet, with idiopathic flexible flatfoot
that were resistant to conservative treatment between 2007 and 2011. Patients were evaluated according to ACFAS
universal evaluation scoring scale and radiographic indexes. The mean follow up duration was 23.1 ± 9.9 months.
Results: The average age was 10.4 ± 0.9 years. Achilles tendon lengthening was performed in 28 feet. ACFAS score
at the final follow up had improved significantly compared to pre-operative score (37 to 88, P<0.0001). Radiographic
parameters also showed significant improvement after surgery ((P<0.0001)). Distal segment displacement and hardware
irritation as postop complications were observed in 2 and 3 cases, respectively, with no long-term clinical impact.
Conclusion: Calcaneal lengthening osteotomy is an appropriate and safe operation in symptomatic idiopathic
flexible flat foot that is resistant to conservative treatment.
Level of evidence: IV


Main Subjects

1. Pfeiffer M, Kotz R, Ledi T, Hauser G, Sluga M. Prevalence
of flat foot in preschool aged children. Pediatrics.
2006; 118(2):634-9.
2. Mosca VS. Flexible flatfoot in children and adolescents.
J Child Orthop. 2010; 4(2):107-21.
3. Harris EJ, Vanore JV, Thomas JL, Kravitz SR, Mendelson
SA, Mendicino RW, et al. Clinical practice guideline:
diagnosis and treatment of pediatric flatfoot. J Foot
An-kle Surg. 2004; 43(6):341-73.
4. Blitz NM, Stabile RJ, Giorgini RJ, DiDomenico LA.
Flexible pediatric and adoles-cent pes planovalgus:
conservative and surgical treatment options. Clin
Podiatr Med Surg. 2010; 27(1):59-77.
5. Evans AM. The flat-footed child -- to treat or not to
treat: what is the clinician to do? J Am Podiatr Med
Assoc. 2008; 98(5):386-93.
6. Yeagerman SE, Cross MB, Positano R, Doyle SM.
Evaluation and treatment of sympromatic pes planus.
Curr Opin Pediatr. 2011; 23(1):262-7.
7. Kwon JY, Myerson MS. Management of the fexible flat
foot in the child: a focus on the use of osteotomies for
correction. Foot Ankle Clin. 2010; 15(2):309-22.
8. Giannini S, Ceccarelli F, Benedetti MG, Catani F, Faldini
C. Surgical treatment of flexible flatfoot in children. J
Bone Joint Surg. 2001; 83(2):73-9.
9. Mosca VS. Calcaneal lengthening for valgus deformity
of the hindfoot. Results in children who had severe,
symptomatic flatfoot and skewfoot. J Bone Joint Surg
Am. 1995; 77(4):500-12.
10. Zeifang F, Breusch SJ, Doderlein L. Evans calcaneal
lengthening procedure for spastic flexible flat foot in
32 patients (46 feet) with a follow up of 3 to 9 years.
Foot Ankle Int. 2006; 27(7):500-7.
11. Andreacchio A, Orellana C, Miller R, Bowen TR. Lateral
column lengthening as treatment for planovalgus foot
deformity in ambulatory children with spastic cerebral
palsy. J Pediatr Orthop. 2000; 20(4):501-5.
12. Yoo WJ, Chung CY, Choi IH, Cho TJ, Kim DH. Calcaneal
lengthening for the pesplanovalgus foot deformity in
children with cerebral palsy. J Pediatr Orthop. 2005;
13. Ragab A, Stewart SL, Cooperman DR. Implications

of subtalar joint anatomic variation in calcaneal
lengthening osteotomy. J Pediatr Orthop. 2003;
14. Thomas RL, Wells BC, Garriosr RL, Prada SA.
Preliminary results comparing two methods of lateral
column lengthening. Foot Ankle Int. 2001; 22(2):107-
15. Hyer C, Lee T, Block A, VanCourt R. Evaluation of
anterior and middle talocal-caneal articular facets
and the Evans osteotomy. J Foot Ankle Surg. 2002;
16. Bussewitz BW, DeVries JG, Hyer CF. Evans osteotomy
and risk to subtalar joint articular facets and
sustentaculum tali: a cadaver study. J Foot Ankle Surg.
2013; 52(5):594-7.
17. Cooper PS, Nowak MD, Shaer J. Calcaneocuboid joint
pressures with lateral column lengthening (Evans)
procedure. Foot Ankle Int. 1997; 18(4):199-205.
18. Shibuya N, Agarwal MR. Evans calcaneal osteotomy
using an anterior lumbar distractor-inserter. J Foot
Ankle Surg. 2010; 49(4):401-3.
19. Grier KM, Walling AK. The use of tricotical autograft
versus allograft in lateral lengthening for adult
acquired flat foot deformity and analysis of union rates
and complications. Foot Ankle Int. 2010; 31(9):760-9.
20. John S, Child B, Hix G, Maskill M, Bowers C, Catanzariti
AR, et al. A retrospec-tive analysis of anterior calcaneal
osteotomy with allogenic bone graft. J Foot Ankle
Surg. 2010; 49(4):375-9.
21. Bruyn J, Cerniglia M, Chaney M. Combination of Evans
calcaneal osteotomy and STA-Peg arthroreisis for
correction of the severe pes valgo planus deformity. J
Foot Ankle Surg. 1999; 38(5):339-46.
22. Dayton P, Prins DB, Smith DE, Feilmeier MJ.
Effectiveness of a locking plate in preserving
midcalcaneal length and positional outcome after
Evans calcaneal oste-otomy: a retrospective pilot
study. J Foot Ankle Surg. 2013; 52(6):710-3.
23. Hintermann B, Valderrabano V, Kundert HP.
Lengthening of the lateral col-umn and reconstruction
of the medial soft tissue for treatment of acquired
flat foot deformity associated with insufficiency

of posterior tibial tendon. Foot Ankle Int. 1999;
24. Viegas GV. Reconstruction of pediatric flexible
planovalgus foot by using an Evans calcaneal
osteotomy and augmentative medial split tibialis
anterior tendon transfer. J Foot Ankle Surg. 2003;
25. Evans D. Calcaneo-valgus deformity. J Bone Joint Surg
Br. 1975; 57(3):270-8.
26. Phillips GE. A review of elongation of os calcis for flat
feet. J Bone Joint Surg Br. 1983; 65(1):15-8.
27. Dogan A, Albayrak M, Akman E, Zorer G. The result of
calcaneal lengthening ostetomy for the treatment of
flexible pes planovalgus and evaluation of alignment
of the foot. Acta Orthop Traumatol Turc. 2006;
28. Mousavian A, Orapin J, Chinanuvathana A, Schon LC.
Anatomic spring ligament and posterior tibial tendon
reconstruction: new concept of double bundle PTT
and a novel technique for spring ligament. Arch Bone
Jt Surg. 2017; 5(3):201-5.
29. Weinraub GM, Dault R. The Evans osteotomy:
technique and fixation with cor-tical bone pin. J Foot
Ankle Surg. 2001; 40(1):54-7.
30. Templin D, Jones K, Weiner DS. The incorporation of
allogeneic and autoge-nous bone graft in healing of
lateral column lengthening of the calcaneus. J Foot
Ankle Surg. 2008; 47(4):283-7.
31. Adams SB Jr, Simpson AW, Pugh LI, Stasikelis PJ.
Calcaneocubiod joint sublux-ation after calcaneal
lengthening for planovalgus foot deformity in
children with cerebral palsy. J Pediatr Orthop. 2009;
32. Dunn SP, Meyer J. Displacement of the anterior process
of the calcaneus after Evans calcaneal osteotomy. J
Foot Ankle Surg. 2011; 50(4):402-6.
33. Bourdet C, Seringe R, Adamsbaum C, Glorion C, Wicart
P. Flatfoot in children and adolescents. Analysis
of imaging findings and therapeutic implications.
Orthop Traumatol Surg Res. 2013; 99(1):80-7.
34. Reilingh ML, Beimers L, Tuijthof GJ, Stufkens SA,
Maas M, van Dijk CN. Measur-ing hindfoot alignment
radiographically: the long axial view is more reliable
than the hindfoot alignment view. Skeletal Radiol.
2010; 39(11):1103-8.