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Comparison of the Calcaneo-Cuboid-Cuneiform Osteotomies and the Calcaneal Lengthening Osteotomy in the Surgical Treatment of Symptomatic Flexible Flatfoot

Moraleda, Luis MD*; Salcedo, Maria MD*; Bastrom, Tracey P. MA; Wenger, Dennis R. MD; Albiñana, Javier MD, PhD*; Mubarak, Scott J. MD

Journal of Pediatric Orthopaedics: December 2012 - Volume 32 - Issue 8 - p 821–829
doi: 10.1097/BPO.0b013e3182648c74

Background: Surgery is indicated in symptomatic flatfoot when conservative treatment fails to relieve the symptoms. Osteotomies appear to be the best choice for these painful feet. The purpose of this study was to compare the clinical and radiographic outcome of the calcaneo-cuboid-cuneiform osteotomies (triple C) and the calcaneal-lengthening osteotomy in the treatment of children with symptomatic flexible flatfoot.

Methods: The surgeries were performed by senior surgeons who preferred either triple C or calcaneal lengthening. The results were graded by an orthopaedic surgeon uninvolved with the cases. The clinical and radiographic outcome was evaluated in 30 feet (21 patients) with a triple C osteotomy and 33 feet (21 patients) with a calcaneal-lengthening osteotomy. We used the American College of Foot and Ankle Surgeons (ACFAS) score (flatfoot module) for clinical assessment, which contains a subjective and objective test. We measured and compared 12 parameters on the anteroposterior and lateral weight-bearing radiographs. The effect of additional procedures (Kidner procedure, medial reefing of the talonavicular capsule, tendo-Achilles lengthening, peroneous brevis lengthening and, in the calcaneal-lengthening group, a medial cuneiform osteotomy) on the clinical and radiographic result was also evaluated.

Results: Average age at the time of surgery was similar (triple C: 11.2±3 y, calcaneal lengthening: 11.6±2.5 y, P=0.51). Average follow-up was 2.7±2.2 years in the triple C group and 5.3±4 years in the calcaneal-lengthening group. There were no significant differences in the clinical outcome measured by the ACFAS subjective test in the calcaneal-lengthening group (P=0.003). There were no significant differences in the ACFAS score, both the subjective test (triple C: 43.3±6.1, calcaneal lengthening: 44.7±7.6, P=0.52) and the ACFAS objective test (triple C: 28.6±2, calcaneal lengthening: 25.9±7, P=0.13). We found significant differences in 2 of the 12 radiographic measurements: anteroposterior talo-first metatarsal angle (triple C: 15.5±11.1, calcaneal lengthening: 7.4±7.3, P=0.001) and talonavicular coverage (triple C: 28±14.7, calcaneal lengthening: 13.7±12.4, P<0.001). None of the additional procedures improved the clinical outcome. There were 3 (10%) complications in the triple C group and 6 (18%) complications in the calcaneal-lengthening group. Also, calcaneocuboid subluxation was present in 17 (51.5%) feet of the calcaneal-lengthening group.

Conclusions: Both techniques obtain good clinical and radiographic results in the treatment of symptomatic idiopathic flexible flatfoot in a pediatric population. The calcaneal-lengthening osteotomy achieves better improvement of the relationship of the navicular to the head of the talus but it is associated with more frequent and more severe complications. Additional soft-tissue procedures have not proven to improve clinical or radiographic results.

Level of Evidence: Level III, retrospective comparative study.

*Hospital Universitario La Paz, Madrid, Spain

Rady Children’s Hospital and Health Center, San Diego, CA

None of the authors received financial support for this study.

The authors declare no conflict of interest.

Reprints: Scott J. Mubarak, MD, 3030 Children’s Way, MC 5062, San Diego, CA 92123. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.