Yonsei Med J 49(1):79 - 83, 2008

DOI 10.3349/ymj.2008.49.1.79

Use of Allograft in Skeletally Immature Patients for Calcaneal

Neck Lengthening Osteotomy
Yoon Hae Kwak,1 Kun Bo Park,2 Hui Wan Park,1 and Hyun Woo Kim1

1
Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul; 2Department of Orthopaedic Surgery, Hallym
University College of Medicine, Anyang, Korea.

Purpose: To date, there have been no studies evaluating when a child stands, and foot position shows
the usefulness of allograft as a substitute for autograft in hindfoot valgus, forefoot supination and relatively
calcaneal neck lengthening osteotomy. This retrospective shorter lateral column than the medial column.
study examined the results of calcaneal neck lengthening
However, in various neuromuscular diseases, this
osteotomy using allograft for pathologic flatfoot deformity in
children and adolescents with various neuromuscular deformity frequently leads to pain, callus formation
diseases. Materials and Methods: 118 feet in 79 children or ulcerative lesion in weight bearing and gait
treated surgically between Mar 2000 and July 2005 were disturbances due to non-reducible talonavicular
reviewed. The mean age at the time of the operation was 9 joint subluxation.1-3 Many surgical treatments have
+ 3 years (range, 3 - 17 years) and follow-up averaged 15.4 been suggested,2-6 and the most commonly used in
months (range, 13 - 21 months) postoperatively. Talo-1st
theses days would be calcaneal neck lengthening
metatarsal angle, talo-calcaneal angle, calcaneal pitch were
measured before and after operation and bony union was
osteotomy (CNLO). The osteotomy is performed
estimated. Results: Bony union was noted at the latest between anterior and middle facets of the subtalar
follow-up and there were no postoperative complications joint and tri-cortical bone wedge is inserted into
such as reduction loss, infection, nonunion, delayed union or osteotomy site in order to "indirectly" reduce the
graft loss during the follow-up period in all but one foot. All talonavicular joint. However, in pediatric and
radiographic indices were improved postoperatively in all adolescent populations, obtaining a sufficient
cases. Conclusion: Our results indicate that use of allograft
amount of autobone from the iliac crest frequently
in calcaneal neck lengthening osteotomy is a useful option
for correction of the planovalgus deformity in skeletally is impossible. Incision in the apophysis of iliac
immature patients whose enough autobone can not be crest may bring about growth arrest, and
obtained. excessive length of bone graft extracted can make
3,7
Key Words: Calcaneal neck lengthening osteotomy, pathologic
iliac wing deformities. The purpose of this
flatfoot, allograft retrospective study was to evaluate the usefulness
of allograft as a substitute for autograft in CNLO
for pathologic planovalgus deformity complicated
INTRODUCTION by various neuromuscular diseases.

Pes planovalgus or flatfoot is a common

physiologic condition in normal children. The MATERIALS AND METHODS
longitudinal arch of the foot shrinks or disappears
Consecutive patients from March 2000 to July
Received February 6, 2007 2005 treated with CNLO in authors institution
Accepted August 28, 2007 were reviewed. Inclusion criteria for this study
Reprint address: requests to Dr. Hyun Woo Kim, Department were as follows; the patient should be an
of Orthopaedic Surgery, Severance Childrens Hospital, Yonsei independent community-ambulator preoperatively
University College of Medicine, 250 Seongsanno, Seodaemun-gu,
Seoul 120-752, Korea. Tel: 82-2-2228-2187, Fax: 82-2-363-1139,
and the complete radiographic files were available
E-mail: [email protected] before and after operation, and the minimum

Yonsei Med J Vol. 49, No. 1, 2008

 Yoon Hae Kwak, et al.

follow-up period was 12 months. 118 feet in radiographic findings (Fig. 1). All patients followed
seventy-nine patients met the inclusion criteria. 39 radiological evaluation with standard antero-
patients were affected bilaterally and 40 were posterior and lateral views of the foot in standing
affected unilaterally. position.8 The talo-1st metatarsal angle, talo-cal-
54 patients (80 feet) were cerebral palsied and caneal angle, and calcaneal pitch were measured,
12 patients (19 feet) were affected with myelo- and the bony union was evaluated. Windows
dysplasia. Of cerebral palsy patients, 47 patients SPSS 12.0 and paired t-tests were used for the
(69 feet) were diplegics, 3 patients (4 feet) hemi- statistical analysis and significance was set at p <
plegics, and 4 patients (7 feet) triplegics. Other 0.05.
conditions included static encephalopathy (11 feet
in 7 patients), hypermobile flatfoot with tight
tendo-Achilles (2 feet in 2 patients), familial
spastic paraplegia (1 feet in 1 patient), Seckel
syndrome (2 feet in 1 patient), neurofibromatosis
(1 feet in 1 patient), and congenital vertical talus
(2 feet in 1 patient). There were 44 males and 35
females, and the average age at the time of the
+3
operation was 9 years (range, 3 - 17 years) and
the follow-up averaged 15.4 months (range, 13 - 21
months) postoperatively.
All operations were done by the last author,
and the procedures performed were based on
Moscas technique.3 Briefly, the middle facet was
identified with a freer elevator and calcaneal A
osteotomy was done at the exact site between
anterior and middle facets of the subtalar joint.
Under the image intensifier, a transverse saw cut
was made through both cortices, and a laminar
spreader was used to open the osteotomy and
simultaneously to ensure correct coverage of the
talonavicular joint. After determining appropriate
length and size of the graft to be inserted into
osteotomy site, autograft from the iliac crest was
obtained or commercially used human iliac crest B
bone wedge (Tutoplast Iliac Wedge, Alachua, FL,
USA) was trimmed in a trapezoidal shape by
matched in size to fit the calcaneal osteotomy site.
This allograft is solvent-dehydrated and gamma-
irradiated preserved, and was re-hydrated prior to
use by soaking in 0.9% saline solution for a
minimum of 15 minutes. 9 patients (10 feet) used
autograft and 70 patients (108 feet) used allograft.
Graft was fixed with Kirschner wires, and
shortened tendo-Achilles (75 feet) or gastroc- C
nemius (27 feet) was lengthened accordingly. Long
Fig. 1. Anteroposterior and lateral radiographs of both feet
leg cast was applied for 3 weeks, and then short of 9-year-old boy (A) Preoperative radiographs (B)
leg cast for additional 3 weeks after the operation. Immediate postoperative radiographs (C) Bony union was
Bony union was defined as the evidence of confirmed at the postoperative 1 year, and corrected
talonavicular subluxation was noted in standing position.
obliteration of the osteotomy lines based on

Yonsei Med J Vol. 49, No. 1, 2008

 Use of Allograft in Skeletally Immature Patients for Calcaneal Neck Lengthening Osteotomy

RESULTS allograft, there were no significant differences

before and after operation in terms of radiographic
At the latest follow-up, bony union was measurements. In autograft group, there were
confirmed and a recurrence in which the graft significant differences between the preoperative
slipped out of the osteotomy site was not noted and postoperative values (p < 0.05). Talo-1st
in all but one foot. In addition, there was no metatarsal angle was improved from 20.2 4.8
exacerbation compared with the preoperative preoperatively to 8.7 4.4 postoperatively, talo-
status in terms of talonavicular coverage. None of calcaneal angle from 35.9 3.9 to 24.1 3.3, and
the cases developed other types of foot deformity, calcaneal pitch from 1.8 6.1 to 14.0 6.2. In
and the restriction of ankle or subtalar joint allograft group, there were significant differences
motion or pain was not observed in all patients. between the preoperative and postoperative
One patient had persistent pain and recurrence of values (p < 0.05). Talo-1st metatarsal angle was
the deformity postoperatively, and plain radio- improved from 26.5 11.4 preoperatively to 11.2
graph showed subluxation of calcaneocuboidal 8.6 postoperatively, talo-calcaneal angle from
joint and resorption of the allograft, which was 41.5 8.2 to 27.9 8.1, and calcaneal pitch from
treated eventually with curettage and arthrodesis -1.3 7.6 to 10.9 8.0 (Table 2).
of the calcaneocuboidal joint.
In comparisons of preoperative and posto-
perative anteroposterior radiograph, talo-1st DISCUSSION
metatarsal angle and talocalcaneal angle were
decreased postoperatively (p < 0.05); talo-1st In planovalgus deformity observed in many
metatarsal angle from 25.6 10.9 to 10.9 8.2, neuromuscular diseases, the length of lever arm
and talo-calcaneal angle from 40.7 7.8 to 27.3 acting on the triceps surae is short due to
7.7, respectively. On the lateral radiograph, subluxated talonavicular joint and forefoot
calcaneal pitch also was improved postoperatively abduction. This results in inappropriate ankle
(p < 0.05), from - 0.8 7.4 to 11.3 7.8 (Table 1). plantarflexion-knee extension coupling. Hence,
In comparisons of the use of autograft and the surgical treatment should be directed to

Table 1. Preoperative and Postoperative Radiological Indices

Preoperative Postoperative p value

Talo-1st metatarsal 25.6 10.9 10.9 8.2 < 0.05
Talo-calcaneal 40.7 7.8 27.3 7.7 < 0.05
Calcaneal pitch - 0.8 7.4 11.3 7.8 < 0.05

Table 2. Preoperative and Postoperative Radiological Indices According to Bone Graft Materials

Autobone (n = 10) Allobone (n = 108) p value

preop Talo-1st metatarsal 20.2 4.8 26.5 11.4 0.09
Talo-calcaneal 35.9 3.9 41.5 8.2 0.06
Calcaneal pitch 1.8 6.1 -1.3 7.6 0.18
postop Talo-1st metatarsal 8.7 4.4 11.2 8.6 0.24
Talo-calcaneal 24.1 3.3 27.9 8.1 0.13
Calcaneal pitch 14.0 6.2 10.9 8.0 0.18
p value* < 0.05 < 0.05
*p value: preoperative versus postoperative.

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 Yoon Hae Kwak, et al.

correct foot malalignment, secure the stability of needed is prepared before operation and the
foot during stance, and for achieving sufficient choice of proper size and shape for grafting or
ankle plantarflexion at push-off and foot clearance replacement is possible.13 However, material
during swing. Although there have been many characteristics of allograft should be considered in
surgical methods for flatfoot deformity, the terms of source of derivation, storage, and sterili-
indication of each procedure is not clearly zation that can change biomechanical stiffness of
established yet. One of the most commonly used the graft.13-16 Major complications after allobone
method, extra-articular subtalar arthrodesis,5,9 has graft are infection, fracture, bony absorption and
the advantage of preventing secondary deformity nonunion. The fracture rate has been reported
and maintaining the growth of the foot. However, ranged from 12 to 20%, and infection is one of the
there might be a limitation of motion at the most serious complications resulting in graft
17
subtalar joint postoperatively and a possibility of failure. In this study, calcaneal neck lengthening
subsequent arthritis.3,10,11 osteotomy showed improved radiological indices
In os calcis lengthening for correction of the and all the cases had bony union and satisfactory
planovalgus deformity, insertion of a structural results at the final follow-up. However, further
2,3
graft is an essential part of the procedure. There evaluation of calcaneal lengthening osteotomy
are many kinds of graft materials such as with and without reconstruction of medial column
autobone, allobone, xenobone and artificial bone of the foot is necessary. Although cases treated
which have different characteristics in terms of with autograft were small in number, there were
osteoinduction, osteoconduction and resorption of significant improvement between preoperative
host bone. Considering all the characteristics, and postoperative radiological indices in both
autograft is generally proposed in preference to autograft and allograft groups. This suggests that
allograft. However, harvesting bone with suffi- when skeletally immature patients are not able to
cient mass and size have been limited in the extract sufficient bone mass of their own, allograft
skeletally immature patients and apophyseal would be used appropriately without major
injury to the iliac crest can result in permanent complications. In conclusion, use of allograft in
defects and deformities.12-16 skeletally immature patients for calcaneal neck
Mosca13 introduced the modified technique of lengthening osteotomy is a useful alternative for
calcaneal lengthening osteotomy with which cases where autograft is not a viable option, or
hindfoot deformity could be corrected without allobone can be applied as an initial graft of
hindering the motion of talocalcaneal joint. Many choice.
of his series were treated with autograft, probably
due to the fact that most patients were older
+10
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