Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans–Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study

Abstract

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.’s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary’s angle and Costa–Bertani’s angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.’s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary’s angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani’s angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Calcaneal lengthening osteotomy in the management of idiopathic flatfoot in children: cCase series of twenty-one feet

“…On the x-ray of the front ankle standing with heel strapping, we assess the valgus of the hindfoot in load and the orientation of the tibial-talar space because sometimes the valgus is not sub-talar but tibial epiphyseal with ascension of the fibular malleolus. In De Luna's series [7] as well as ours, the angles measured were within the range of normal values after surgery. In the different series studied, the satisfaction and the quality of the postoperative result were judged according to the AOFAS score.…”

“…In the different series studied, the satisfaction and the quality of the postoperative result were judged according to the AOFAS score. In De Luna's series [7] , the AOFAS score went from 69.03 (59–79) preoperative to 95.26 (88–100) postoperatively. Our results were similar to those in the literature with a postoperative AOFOS score between 79 and 93.…”

Analysis of risk factors for nonunion in pediatric lateral column lengthening

“…Historically, surgical management of Pes planus included hindfoot arthrodesis, osteotomies and soft tissue procedures [5,[10][11][12]. One surgical technique that produces desirable correction is the lateral column lengthening osteotomy first described by Evans and further refined by Mosca [6,7].…”

“…Pes planus is one of the most common foot abnormalities in the general population, affecting 37-59.7% of children between the age of 2-6 years and 4-19.1% of those between ages 8-13 years [1,2]. Flexible pes planus is characterized by a depression of the medial arch, often associated with hindfoot valgus, forefoot abduction and tightness of the triceps surae [2][3][4][5]. Pes planus is more common in neuromuscular conditions, such as cerebral palsy and can lead to pain, brace intolerance and lever arm dysfunction.…”

The Role of Arthroereisis in Improving Sports Performance, Foot Aesthetics and Quality of Life in Children and Adolescents with Flexible Flatfoot

“…Others mentioned that they may not be recommended due to the lack of evidence of structural improvements for pediatric flexible flatfoot; insoles seem to have a beneficial role for patients under 13, but additional studies may be required in order to confirm their therapeutic effect, and orthopedic footwear did not correct the deficient arch development [ 23 , 24 , 25 ]. Surgical procedures for flatfoot are continuously updated and some are still used nowadays, such as lateral column calcaneal lengthening described by Evans and modified by Mosca, Grice’s extraarticular arthrodesis and pseudoarthrodesis, better known as arthroereisis [ 26 , 27 , 28 , 29 , 30 ]. Arthroereisis has experienced multiple changes since its introduction, being initially based on the insertion of a bone block inside the sinus tarsi which restricts excessive subtalar joint eversion [ 28 , 29 , 30 ].…”