Pes planovalgus, commonly referred to as flatfoot, is a deformity where the foot’s arch collapses, leading to valgus (outward angulation) of the heel. Reconstruction of this condition is often necessary in adolescents and adults when conservative measures fail. Surgical approaches, particularly osteotomies combined with soft tissue procedures, are essential in correcting severe deformities. This comprehensive overview explores the clinical findings, surgical interventions, and outcomes associated with pes planovalgus reconstruction, drawing on findings from recent studies.
Understanding Pes Planovalgus
Pes planovalgus is categorized as idiopathic (occurring without a known cause) or acquired. Idiopathic flexible pes planovalgus (IFPP) is common in adolescents and is characterized by symptoms such as foot pain, early shoe deformation, and difficulty walking. In adults, acquired pes planovalgus typically arises from posterior tibial tendon dysfunction, trauma, or other systemic conditions. The deformity can significantly impair quality of life if left untreated.
Conservative management, including orthotic devices, stretching exercises, and activity modifications, is often the first line of treatment. However, surgery becomes inevitable for symptomatic patients who do not respond to these interventions. Indications for surgery include persistent pain, progressive deformity, and failure of conservative measures.
Surgical Procedures in Pes Planovalgus Reconstruction
The reconstruction process aims to restore the alignment of the talus, calcaneus, and navicular bones. Various surgical techniques are employed based on the severity and nature of the deformity:
- Lateral Column Calcaneal Lengthening (LCL) Osteotomy:
- Performed in nearly all cases of IFPP, LCL involves lengthening the lateral side of the calcaneus to correct forefoot abduction and improve talonavicular coverage.
- Autografts or allografts are used to bridge the osteotomy site, with graft sizes typically ranging from 8 to 11 mm depending on deformity severity.
- Medializing Calcaneal Osteotomy:
- Indicated for correcting hindfoot valgus, this procedure repositions the posterior calcaneus medially. Displacement of 8–10 mm is generally achieved to restore alignment.
- Flexor Digitorum Longus (FDL) Tendon Transfer:
- The FDL tendon is rerouted to provide medial support and substitute for the weakened posterior tibial tendon. This transfer enhances the stability of the medial arch.
- Spring Ligament Plication:
- The spring ligament, which supports the arch, is plicated (tightened) in cases of ligamentous laxity.
- Medial Cuneiform (Cotton) Osteotomy:
- This procedure corrects residual forefoot supination by placing a bone graft at the medial cuneiform.
- Accessory Navicular Bone Excision:
- In patients with an accessory navicular bone contributing to flatfoot symptoms, excision of the bone is performed, followed by reattachment of the posterior tibial tendon.
- Gastrocnemius Recession or Percutaneous Achilles Lengthening:
- These soft tissue procedures address calf muscle tightness, which often exacerbates flatfoot deformity.
Postoperative Care and Outcomes
Postoperative management is crucial to ensure successful outcomes:
- Patients are non-weight-bearing for six weeks, followed by partial weight-bearing with a walking boot for four weeks.
- Rehabilitation includes gradual resumption of activities and strengthening exercises.
Radiographic and clinical evaluations reveal significant improvements in alignment and function. Parameters such as the talonavicular coverage angle, talocalcaneal angle, and calcaneal inclination angle demonstrate marked correction. The American Orthopaedic Foot and Ankle Society (AOFAS) scores in treated patients improved from an average of 56.76 preoperatively to 95.29 postoperatively, indicating substantial functional recovery.
Complications and Considerations
Although surgical reconstruction is highly effective, complications can occur:
- Non-union of grafts, often seen with allografts, requires careful postoperative monitoring.
- Pain at osteotomy sites may necessitate hardware removal.
- Recurrent deformities may require revision surgeries, particularly in cases with underlying systemic conditions.
How Medicare Covers
Your healthcare provider may bill for:
CPT Code 28304 (LCL Osteotomy) — this refers to a surgical procedure where the heel bone (calcaneus) is cut and lengthened with a bone graft to correct flatfoot or other deformities.
CPT Code 28300 (Medializing Calcaneal Osteotomy) — this refers to a surgical procedure where the heel bone (calcaneus) is cut and shifted inward (toward the midline of the foot) to correct flatfoot deformity or realign the foot.
CPT Code 27691 (FDL Tendon Transfer) — this refers to a procedure where the flexor digitorum longus tendon (a tendon that normally bends the toes) is detached and reattached to the foot or ankle bones to support the arch and replace a damaged tendon, often used in flatfoot reconstruction.
CPT Code 28200 (Spring Ligament Plication) — this refers to surgery to tighten or repair the spring ligament in the foot, which helps support the arch. It may be done when the ligament is stretched or torn, often as part of flatfoot reconstruction.
CPT Code 28306 (Medial Cuneiform (Cotton) Osteotomy) — this refers to a surgical procedure where the medial cuneiform bone in the midfoot is cut and a bone graft is inserted to raise the arch. It is often performed for flatfoot correction in combination with other procedures.
CPT Code 28238 (Accessory Navicular Excision) — this refers to surgery where an extra bone on the inside of the foot (the accessory navicular) is removed. This procedure is often done when the extra bone causes pain, irritation, or problems with the posterior tibial tendon.
CPT Code 27687 (Gastrocnemius Recession) — this refers to a surgical procedure where the gastrocnemius muscle in the calf is lengthened to relieve tightness. It is often done to improve ankle flexibility and reduce strain on the foot, commonly in flatfoot reconstruction or Achilles-related problems.
CPT Code 27606 (Achilles Lengthening) — this refers to surgery where the Achilles tendon is surgically lengthened to relieve tightness in the calf and improve ankle motion. It is often performed for flatfoot reconstruction, cerebral palsy, or contracture-related walking problems..
“What Will It Cost You?”
If you don’t have secondary insurance, here’s what you can expect:
Estimated Out-of-Pocket Cost for Lateral Column Calcaneal Lengthening (28304): $191.57
Estimated Out-of-Pocket Cost for Medializing Calcaneal Osteotomy (28300): $153.01
Estimated Out-of-Pocket Cost for Flexor Digitorum Longus Tendon Transfer (27691): $175.25
Estimated Out-of-Pocket Cost for Spring Ligament Plication (28200): $113.23
Estimated Out-of-Pocket Cost for Medial Cuneiform (Cotton) Osteotomy (28306): $139.80
Estimated Out-of-Pocket Cost for Accessory Navicular Excision (28238): $151.78
Estimated Out-of-Pocket Cost for Gastrocnemius Recession (27687): $106.77
Estimated Out-of-Pocket Cost for Achilles Lengthening (27606): $63.37
“For example, Joy needed a lateral column calcaneal lengthening after an injury. Her surgery included 1 procedure: lengthening of the heel bone (28304). Thanks to Medicare, her total out-of-pocket cost was about $191.57. Her secondary insurance then covered it completely!”
Conclusion
Pes planovalgus reconstruction is a transformative procedure for patients with severe deformity and persistent symptoms. By addressing both the bony and soft tissue components of the deformity, surgical interventions restore function and improve quality of life. A multidisciplinary approach, involving careful preoperative planning and tailored postoperative rehabilitation, ensures optimal outcomes. As research advances, newer techniques and graft materials may further enhance the efficacy and safety of these procedures.
Dr. Mo Athar
