FOOT & ANKLE INTERNATIONAL

Copyright © 2000 by the American Orthopaedic Foot & Ankle Society, Inc.

Calcaneocuboid Joint Pressure after Lateral Column Lengthening in a

Cadaveric Planovalgus Deformity Model

Nathan Momberger, MD., James M. Morgan, MD., Kent N. Bachus, Ph.D., John R. West, B.S.
Salt Lake City, UT

ABSTRACT INTRODUCTION

The purpose of this study is twofold: first, to measure the
joint contact pressure across the calcaneocuboid joint in
a planovalgus deformity and compare the results to pres-
sures measured in a normal foot; and second, to deter-
mine the change in pressure across the calcaneocuboid
joint after an Evan's-type calcaneal lengthening osteoto-
my. The effect of this procedure on the calcaneocuboid
joint was evaluated using seven cadaver feet to measure
peak pressure across the calcaneocuboid joint under a
constant load. Each foot was sectioned medially to repro-
duce a deformity consistent with an adult, acquired flat-
foot. Each flatfoot deformity was then corrected using a
ten-millimeter lateral column lengthening osteotomy.
Joint pressures were measured in the normal foot, the
created flatfoot and then in the corrected flatfoot. Peak
pressures across the joint increased significantly from
baseline in the flatfoot (p <0.05). However, the change in
pressure from the flatfoot to the corrected foot was not
significant, and in some cases peak pressures in the cor-
rected foot were actually lower than in the flatfoot. These
findings indicate that calcaneal lengthening through an
Evan's osteotomy does not increase pressure across the
calcaneocuboid joint beyond physiologic loads in the
flatfoot.
Key words: flatfoot, calcaneocuboid, osteotomy.
Planovalgus deformity (flatfoot) is a common disorder
in the adult population. An extensive epidemiological
survey in the United States estimated that one in six
caucasian adults, and one in three African-American
adults, suffers from symptomatic flatfoot deformities in
varying degrees of severity." Without question, the vast
majority of these patients can be treated non-operative-
ly with orthoses, activity modification and anti-inflam-
matory medication. A small percentage of this popula-
tion will have sufficient pain and disability to warrant sur-
gical intervention. The adult, acquired flatfoot from pos-
terior tibial tendon insufficiency represents one subset
of the planovalgus deformity that frequently requires
operative intervention.
The ideal surgical intervention for symptomatic adult,
acquired flatfoot remains in question. Traditionally, hind-
foot arthrodesis or tendon transfers have been the
mainstay of operative procedures, depending of the
severity of the deformity. In recent years, lateral col-
umn lengthening by means of an Evan's osteotomy
(Figure 1) has become popular as a means to correct
deformity without compromising hindfoot motion
However, there is concern expressed in the literature
that this procedure may lead to degenerative arthrosis

Nathan Momberger, M.D.

25 North Winfield Road
Winfield, IL 60190
Voice: 630-682-5653
Fax: 630-682-8946
E-mail: nathanmomberger@netscape.net

James M. Morgan, M.D.

Utah Orthopedic Specialists
440 D. Street
Salt Lake City, UT 84103

Kent N. Bachus, Ph.D.

University of Utah (190 BPR)
Salt Lake City, UT 84112

John R. West, B.S.

Figure 1
University of Utah (190 BPR) Fig. 1: Diagramatic representation of the described Evan's cal-
Salt Lake City, UT 84112
caneal lengthening osteotomy site.
730

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Foot & Ankle InternationalNol. 21, No. 9/September 2000
in the calcaneocuboid joint5.7. 24.
The goal of this study was to evaluate how lateral col-
umn lengthening affects the calcaneocuboid joint in the
adult flatfoot. An in vitro model of planovalgus defor-
mity was used in which medial sectioning of the soft tis-
sues in cadaver flatfeet was used to mimic the adult
acquired flatfoot detorrnity". Because there is no pUb~
lished data regarding pressure across the calca-
neocuboid joint in the planovalgus foot, we measured
the change in pressure across the calcaneocuboid joint
in a flatfoot and compared it to normal. Second, we
measured the change in pressure across the calca-
neocuboid joint after calcaneal lengthening for a flatfoot
deformity.
MATERIALS AND METHODS
Seven fresh-frozen, human cadaver foot specimens
were obtained for analysis. Each specimen had been
sectioned approximately 8 inches above the ankle and
had been screened visually for observable pathology.
Antero-posterior and lateral radiographs screened out
pre-existing deformity and were used for comparison
measurements in each specimen. The proximal five
centimeters of soft tissue was stripped from the tibia
and fibula before potting the specimens vertically in a
low melting alloy (Low-melt, Cerro Bend Alloy 158F,
Cerro Alloys, Co. Pittsburgh, PA) for controlled loading.
The calcaneocuboid joint was exposed through a
small lateral incision and the joint capsule was incised
to allow placement of a Tekscan 6900 sensor (Tekscan
Inc. So. Boston, MA) (Figure 2a). Because the Tekscan
transducers are sensitive to temperature, the tempera-
ture of each specimen was recorded during testing to
ensure consistency in pressure transducer readings.
Unicortical screws were placed on either side of the
joint to facilitate joint distraction without affecting the
joint surface. Once the sensor's position was centered
in the joint, the foot was loaded from a dangling position
Fig. 28: Photograph of the Tekscan sensor used for testing.
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CALCANEOCUBOID JOINT PRESSURE 731
Fig. 2b: Photograph of unicortical screws used for placement of
sensor without affecting the surface of the joint.
above the loading platform onto a lubricated platform
(Figure 2b). The foot was allowed to find its own posi-
tion on the platform without restriction of the hindfoot or
forefoot. Peak pressures were measured in real time
while a constant load of 736N was maintained on the
specimen in load control using a compression load
transducer (Instron Model 2518-103, Instron Corp.,
Canton, MA).
Each foot was then sectioned medially through a five-
centimeter incision extending from the medial malleolus
along the talonavicular joint. The posterior tibial tendon,
the spring ligament, the talonavicular capsule, the medi-
al subtalar capsule and plantar fascia were sectioned to
simulate an acquired flatfoot. Radiographs were
repeated to document the deformity in each specimen.
The pressure sensor was again inserted into the calca-
neocuboid joint. Real time peak pressures were again
measured in the loaded specimen at 736-N.
In the last phase of testing, each specimen received
an Evan's-type calcaneal lengthening osteotomy. The
osteotomy was performed fifteen millimeters proximal to
and parallel with, the calcaneocuboid joint using a small
oscillating saw. A ten-millimeter wooden wedge was
inserted into the site of the osteotomy. Radiographs
were obtained for each foot to verify correction of the
flatfoot deformity. The foot was then loaded to 736N
and joint pressures were recorded. A third set of radi-
ographs was performed. Talocalcaneal and talo-first
metatarsal angles on the anteroposterior and lateral
projections were also measured in each foot for com-
parison. The talonavicular coverage angle was meas-
ured on the anteroposterior view. Using the same
measurements, radiographic analysis then confirmed
the correction of the deformity after lateral column
lengthening.
Reproducibility of the loading procedure was tested
732 MOMBERGER, MORGAN, BACHUS AND WEST Foot & Ankle InternationalNol. 21, No. 9/September 2000
by sequentially loading the same Table 1: Mean (Standard Deviation resUlts-of pressure and radiographic l
foot onto a platform three con- measurements.
secutive times maintaining all Normal Flat Foot Corrected
other parameters constant. Each Peak Pressure (kg/ern") 8.9 ± 3.6 18.5 ± 2.9 15.0 ± 2.9
time the foot was loaded from a
AlP TaloCalcaneal
suspended position and allowed
Angle (deg) 24.3 ± 6.1 26.0 ± 6.5 21.4±7.1
to find its own stance on a lubri-
cated platform in the same man- Second Talo Metatarsal (deg) 12.9 ± 8.1 23.9 ± 8.8 13.1±6.7
ner as the rest of the testing. Lateral TaloCalcaneal (deg) 39.0 ± 6.2 45.3 ± 10.8 39.9 ± 4.8
Standard error of measurement Lateral Talo 1st Metatarsal (deg) -2.1± 3.3 11.4 ± 4.9 3.3. ± 6.3
of these trials was within TaloNavicular
0.6kg/cm 2 • Coverage Angle (deg) 17.9 ± 6.3 38.0 ± 6.5 20.6 ± 7.0
Reproducibility of sensor place-
ment was performed by inserting
the sensor into the joint, loading it
for measurement and removing it
three consecutive times to Table 2: Statistical evaluation of pressure and radiographic measure-
exclude sensor placement error. ments.
Again, each time the foot was
loaded from a suspended posi- p value p value
tion and allowed to find its own Normal vs. Flat Flat vs. Corrected
stance on a lubricated platform in Peak pressure 0.0064 0.1590
the same manner as the rest of AlP TaloCalcaneal Angle 0.0002 0.0052
the testing. Standard error of Second Talo Metatarsal 0.0019 0.0000
measurement from this trial was Lateral TaloCalcaneal 0.0248 0.0718
within 0.75 kg/cm 2 • Lateral Talo 1st Metatarsal 0.0004 0.0002
Statistical evaluation of the ~
TaloNavicular Coverage Angle --'~
0.0023 ~
0.0009 ---1
radiographic indices were ana- RESULTS
lyzed using a paired, student t-test, A p value is report-
ed for each radiographic measurement to verify a sig- Joint contact pressure in the normal, flatfoot and cor-
nificant change from the normal to the flatfoot as well as rected foot after osteotomy were successfully recorded
from the flatfoot to the corrected foot. Peak pressures in all seven specimens. Because the Tekscan sensor
changes were also compared using paired t-tests in the approximated, but did not entirely cover the entire joint
normal to flatfoot as well as in the flatfoot to corrected surface, we were unable to comment on total force
foot. A p value of <0.05 was considered significant in across the joint. Tekscan software ''footprints'' in Figure
accordance with literature standards. 3 correlate the pressure distribution in the normal, flat-
foot, and corrected deformity. Note that the extremes of
the pressure curves are cut off by the Tekscan sensor
25,..-----------------, that prevented measurement of total force across joint.
This precluded accurate measurement of mean pres-
sure across the joint.
20
We were, however, easily able to find the peak of
maximal pressure and record this as the peak pressure.
Peak pressure across the calcaneocuboid joint
increased dramatically from 8.9kg/cm 2 in the normal
foot to 18.5kg/crn2 in the loaded specimen after medial-
ly sectioning (p= 0.006). The mean peak pressure actu-
ally decreased to 15.0 kg/cm 2 in the corrected foot after
5 lateral column lengthening (Figure 4). This decrease
was not statistically significant however (p=0.1590).
o ~--1,.-----J-- Paired Student t-Tests were used to analyze the results
Normal Flat Fool Corrected of this study through the three phases of testing and
reported below in Table 2.
Fig. 3: Tekscan graphsin the normal, flatfoot and corrected deformity. Radiographic results from this study are shown in

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Foot & Ankle InternationalNol. 21, No. 91September 2000 CALCANEOCUBOID JOINT PRESSURE 733
Table 1. All specimens showed appropriate changes in Fi ure 4: Pressure Distributions Recorded.
radiographic parameters consistent with planovalgus
deformity after medial sectioning. These parameters
also corrected as expected after calcaneal osteotomy.
The radiographic parameters that showed the most
change throughout testing were talonavicular coverage
angle and the lateral talo-first-metatarsal angle. 30.00
25.00
DISCUSSION
e
:::I
20.00

Between 1959 and 1974, Dillwyn Evans treated g: 15.00

severe, symptomatic flatfeet by elongating the calca- £ 10.00
neus. Evans reported excellent short-term results using 5.00 Position
an opening wedge osteotomy to lengthen the lateral 0.00
calcaneus'. Phillips followed up on 20 of these patients
at seven to twenty years, and reported 17 of 23 cor- Position
rected feet showing very good or good results", Phillips
reported degenerative changes at the calcaneocuboid
joint in six of the twenty-three feet in the study. Three of
these six patients, however, showed global degenera-
tive changes that accounted for the three outright fail-
ures at follow-up. Phillips concluded that ''this is a use-
ful procedure for severe flatfoot which appears to stand
30.00
the test of time".
However, the potential for creating degenerative 25.00
changes at the calcaneocuboid joint with an Evan's e
:::I
20.00
osteotomy continues to be a concern. Several authors g: 15.00
have recommended abandoning the procedure £ 10.00
because of concern over subsequent development of 5.00 Position
arthrosis'>. Cooper et a1 5 • showed that elongating the 0.00
lateral column of the foot of normal feet increased the
pressure across the calcaneocuboid joint. These co OJ
co l'-

authors concluded that this increase in pressure was Position

arbitrarily too much and recommended alternative pro-
cedures.
Unfortunately, to the best of our knowledge, there is
no accepted limit for contact forces above which cause
degenerative change in a joint like the calcaneocuboid
joint. If we extrapolate data from the tibiotalar joint
under physiologic loads, the pressures seen in our 30.00/
study are well within physiologic llmlts". While we 25.00
acknowledge the increase in peak pressures after later-
al column lengthening from the normal foot, the pres-
e
:::I
20.00
CIl 15.00
sure recorded is not statistically different from the pres-
sure in the pre-existing deformity. Because calca-
!
a. 10.00
neocuboid arthrosis has not been a common finding in 5.00 Position
the untreated planovalgus foot, we would conclude that 0.00
the pressures recorded in the planovalgus foot and also
after lateral column lengthening, are within physiologic
Position
limits of cartilage viability.
The most dramatic finding of this in vitro model was
the significant increase in pressure from the normal foot
to the flatfoot where the pressures increased from 8.9 ±
3.6 kg/cm2 to 18.5 ± 2.9 kg/cm2 (p=0.0064). This has Fig. 4: Graph of mean peak pressure recorded at the calcneocuboid
joint throughout testing.

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734 MOMBERGER, MORGAN, BACHUS AND WEST
not been documented to date. Peak pressure from the
flatfoot dropped after lateral column lengthening from
18.5 ± 2.9 kq/crn" to 15.0 ± 2.9 kg/cm2 (Figure 4). This
change was not statistically significant (p=0.1590).
Radiographic measurements demonstrated successful
creation of planovalgus deformity in all cases.
Likewise, calcaneal lengthening reduced the radi-
ographic indices of flatfoot deformity significantly
(p<0.05).
Thordarson et aI., recently published data on the flat-
foot model used above to compare different tenodesis
procedures", While this study employed a sonic digi-
tizer to verify creation of the deformity, we were able to
document the deformity with statistical significance
using common radiographic indices used to evaluate
the planovalgus foot. The greatest correction that the
lateral column lengthening produced was in the talo-
navicular coverage angle on the anteroposterior projec-
tion as described by Sangeorzan, Hansen et a1 22 • This
coincides well with their radiographic measurements
from patients that had undergone lateral column length-
ening.
Pressure recording across small joint surfaces has
historically been inconsistent and inaccurate. Pressure
sensitive film remains the most commonly used medium
to quantify pressure across a joint and the recent
advent of the Tekscan system has revolutionized this
type of pressure measurement. Although the pressure
sensor pad is comparable to the surface area of the cal-
caneocuboid joint (1.5 X 1.5 ern), the pressure sensor
does not completely cover the joint surface. This pre-
cluded us from measuring cumulative pressure
changes across the joint. Peak pressures, however,
were easily identified and recorded by simply centering
the peak near the center of the pad. Figure 4 demon-
strates representative pressure distributions in the nor-
mal, flatfoot, and corrected foot.
We recognize that several aspects of this in vitro
model limit our ability to directly extrapolate our findings
to clinical application. Clearly, sectioning static
restraints in an otherwise normal foot may not accu-
rately represent the pathophysiology involved in the
adult, acquired flatfoot. An ideal model would require
specimens with an acquired flatfoot deformity, but
cadaveric specimens with this kind of deformity are not
readily available for study. In addition, the static stance
of testing provides only a limited view of the actual loads
transmitted during normal gait. We are also unable to
evaluate the effect of opening the capsule of calca-
neocuboid joint for placement of our sensor changes
the recorded data. As a result, we can only report peak
loads in a limited area of the calcaneocuboid joint.
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Foot & Ankle InternationalNol. 21, No. 91September 2000
SUMMARY
The results of this study are first, pressure across the
calcaneocuboid joint in the planovalgus foot is signifi-
cantly increased compared to normal; and second, the
pressure in the calcaneocuboid joint after lateral column
lengthening was not different from the planovalgus
deformity. Ultimately, more long term clinical investiga-
tions will define the role in calcaneal lengthening
osteotomies in the correction of planovalgus deformity.
Our results do not support the argument that lateral col-
umn lengthening leads to overloading of the calca-
neocuboid joint.
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