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Early Treatment of Severe Flatfeet with Gastrocnemius Shortening by

Percutaneous Lengthening of the Heel Cord

Poster · April 2020

DOI: 10.13140/RG.2.2.19805.64481

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Stefan Blümel Anika Stephan

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Early Treatment of Severe Flatfeet with Gastrocnemius Shortening
by Percutaneous Lengthening of the Heel Cord
Stefan Blümel1,2, MD; Anika Stephan, M.A.3; Vincent Stadelmann3, PhD; Rafael Velasco1*, MD
1Department
of Pediatric Orthopedics; 2 Department of Lower Extremities;
3Department of Research and Development, Schulthess Klinik, Zürich, Switzerland

INTRODUCTION
Severe flexible flatfeet with short Triceps surae (a) (b) (c) (d) (e)
can be detected early by careful clinical
examination (Figure 1). Shortening of the Achilles
tendon leads to midfoot break, compromising
normal foot development and may result in pain.
Percutaneous Achilles tendon lengthening is an
option to change this unfavorable natural history
Figure 1: Typical clinical presentation with severe flexible flatfeet. (a) Complete collapse of the
in early childhood. Here we report radiographic
medial arch, (b) severe hindfoot valgus, (c) limited dorsiflexion in the upper ankle joint, (d) tense
follow-up results after minimal invasive Achilles achilles tendon in shortend Triceps surae complex, (e) test under talo-navicular reposition and knee
tendon lengthening followed by orthotic therapy. extension showing equinus of 20°

(a) (b) (c) (d)

MATERIALS AND METHODS
Patients: 20 children 1-6years old (38 feet) with
severe flexible flatfeet and Gastrocnemius
shortening, treated between 2006 and 2017.
Intervention: Lengthening of heel cord performed
percutaneously with 1-3 minimal incisions.
Postoperatively, feet fixed under talo-navicular Figure 2: Surgery (a, b) Percutaneous incision of the Heel cord, (c, d) Application of the Soft-cast
reposition in below-knee Soft-Casts for 4 weeks, under talo-navicular reposition
followed by custom-made corrective foot orthoses Pre-op FUP Pre-op Figure 3: Radiographical
for at least one year (Fig. 2). DP DP LAT outcomes were evaluated in
b b dorsoplantar (DP) and lateral
Outcomes: Gastrocnemius length was visually a' (LAT) standing x-rays pre-op
classified (short/normal). Five angles were b' and at follow-up. In DP x-rays,
quantified at pre-operative and follow-up g*
Talo-MT1 angle (a-b), and in
timepoints (Fig. 3). FUP LAT calcaneus pitch (g’= g*-90°),
a LAT talo-horizontal (a’), talo-MT1
Statistics: Changes between timepoints, sig- a
nificance and effect sizes of change (Cohen’s d) a' (Meary’s, a’-b’), and talo-
were computed. Measured angles were compared calcaneal (a’+ g’) angles were
b' evaluated by three independent
to normative data1, using proportions tests.
g* raters.

RESULTS Meary's angle (lat tal mt1) lateral talo calcaneal angle
60

90

Mean age at surgery was 3.5 years (1.3 - 5.9y).

p = 0.007135 p = 0.01193
Pre−op Pre−op
FUP FUP

Mean follow-up time was 4.3 years (1.1 to 8.9y).

80

Within CI 17/36 within range Within CI

50

13/36 within range

Outside CI Outside CI
29/37 within range
No complications occurred. Calcaneus pitch
70
40

26/37 within range

Angle [degrees]

Angle [degrees]

increased from 9±6 to 13±5° (p<0.001, d=0.7).

60
30

Meary’s angle decreased from 28±9 to 13±10°

50

(p<0.001, d=1.6), talo-first metatarsal angle (dp)

20

40

from 23±9 to 14±7° (p<0.001, d=0.9), talus pitch

10

30

from 47±7 to 34±8°, d=1.8, p<0.001 and lat talo-

0

calcaneal angle from 39±10 to 21±10°, d=1.7,

20

p<0.001. For Meary’s, lat tal-calcaneal and lat 0 2 4 6 8 10 12 0 2 4 6 8 10 12

talo-horizontal angles, the ratio of normal values Age [years] Age [years]

increased significantly (+34%, +31% and +37%, lateral talo horizontal angle dp tal mt1 angle
Figure 4). The ratio of short Gastrocnemius p = 0.001997
80

60

dropped from 100% to 40% (p<0.001). Pre−op

FUP
Pre−op
FUP
6/36 within range Within CI 23/36 within range Within CI
Outside CI Outside CI
60

20/37 within range

40

28/37 within range

Angle [degrees]

Angle [degrees]

CONCLUSION
40

20

With significant changes in clinical and

radiographical outcomes at follow-up visits,
20

percutaneous Achilles tendon lengthening

0

followed by orthotic therapy seems to be a

0

valuable treatment option in selected younger

0 2 4 6 8 10 12 0 2 4 6 8 10 12
children with severe, flexible flat feet.
Age [years] Age [years]

*Corresponding author:
Dr. Rafael Velasco, Head Department of Pediatric Orthopedics
rafael.velasco@kws.ch
1. Vanderwilde R, Staheli LT, Chew DE, Malagon V. Measurements on
radiographs of the foot in normal infants and children. J Bone Joint Surg
Am. 1988;70(3):407-415.
Figure 4: Comparison with normative data1. Angles were categorized as within (circles) or outside (solid
dots) the reported normal range (Mean±2SDs, gray shade). More feet were within range at FUP than at pre-op.
The increase was significant for Meary’s angle (Pre: 13/36, FUP: 26/37, +34%, p<0.001), LAT talo-calcaneal
angle (17/36, 29/37, +31%, p<0.05) and LAT talus pitch (6/36, 20/37, +37%, p<0.001), but the increase was not
significant for DP tal-MT1 (23/36, 28/37, +11%).

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