Cath Lab Digest

The Evans calcaneal osteotomy has become a primary surgical treatment for both adults and children with pes plano valgus as it offers fewer complication rates in comparison to other procedures. These authors provide step-by-step surgical pearls as well as a guide to managing patients postoperatively.

   The flexible pes plano valgus deformity is a difficult problem to evaluate, classify and treat. There are a number of different approaches to the surgical evaluation of the pes valgus foot. One of the most straightforward approaches is to view the foot as two columns.

   Evans first introduced the idea of medial and lateral column imbalance, as it applied to talipes equinovarus, in 1961. In this case, he described the lateral column as long in comparison to the medial column. Evans popularized the shortening of the lateral column to compensate for this imbalance with a calcaneocuboid fusion.

   The advent of the Evans calcaneal osteotomy is rather similar to the discovery of penicillin as both were a result of some lab or medical misadventure. After performing a lateral subtraction osteotomy in a residual clubfoot that resulted in a post-op complication of pes plano valgus deformity, Evans performed calcaneal lengthening to correct the complication. He reported the procedure in the orthopedic literature in 1975 but Ganley popularized it in the podiatric field a few years later.¹

   The Evans osteotomy is an anterior beak osteotomy of the calcaneus with bone graft lengthening. It offers triplanar correction of symptomatic flexible flatfoot by adducting and plantarflexing the forefoot, and supinating the subtalar joint.²

   The procedure has evolved over the decades and become one of the primary surgical treatments of pediatric and adult flatfoot deformities. When the surgeon uses it appropriately, the Evans offers triplanar correction of pes plano valgus deformity with a lower rate of complications than some other procedures. Interestingly, Evans first described the osteotomy for a rigid flatfoot. Today surgeons use it much more commonly for flexible flatfoot with rigidity actually being a relative contraindication.

What You Should Know About Clinical Presentation And Evaluation

   A symptomatic pes plano valgus deformity often includes complaints of medial arch pain, medial ankle pain, radiating leg pain, generalized leg fatigue and even lateral impingement pain as the deformity progresses. Activity may aggravate pain, which usually prevents the patient from participating in athletic sports or recreation.

   In some cases, adolescent or adult patients have developed a sedentary lifestyle and activity brings on foot pain. Patients who become sedentary due to foot pain may have an associated weight gain, which exacerbates the symptoms. An adult patient may complain more of a progressive deformity while the pediatric patient cannot recall a time when the foot looked “normal.”

   Clinical examination should include both static and gait evaluations. On static stance, the patient may have the “too many toes” sign, loss of the medial arch, prominence of the talar head and eversion of the calcaneus. The arch should return with the Hubscher maneuver if the deformity is flexible. All or most of these findings may disappear in the unloaded foot due to the flexibility of the deformity. In the unloaded foot, one should evaluate the tightness of the gastrocsoleal complex with the knee flexed and extended.