Radiographic changes of the mid-foot joints after calcaneo-cuboid-cuneiform osteotomy for symptomatic flatfoot deformity in children: A retrospective observational study

In planovalgus foot deformity, many surgical techniques have been proposed. Among them, calcaneo-cuboid-cuneiform (Triple C) osteotomy serves as an effective intervention for children with this condition. This study evaluates the radiographic changes in the midfoot joint following Triple C osteotomy for planovalgus foot deformity in children and identifies associated risk factors. This study involved 22 patients (33 feet) who underwent Triple C osteotomy for idiopathic symptomatic flatfeet between July 2006 and April 2015. The mean age at assessment was 20.2 years, and at surgery was 11.6 years. The average follow-up period was 8.8 years. Radiographic evaluations at preoperative, 1-year postoperative, and final follow-up at skeletal maturity were conducted using weight-bearing anteroposterior (AP) and lateral foot radiographs. The modified Kellgren-Lawrence (K-L) grade was used to assess mid-foot joints based on osteophyte formation and joint space narrowing, with a grade of ≥1 defining radiographic osteoarthritic changes. The majority of radiographic measurements except for the calcaneocuboid (CC) subluxation ratio showed significant improvements at 1 year postoperatively and at the last follow-up (P < .001). The CC subluxation ratio remained statistically consistent across the 3 time points: 7.30 ± 5.3% preoperatively, 8.06 ± 4.5% 1year postoperatively, and 8.97 ± 5.3% at the last follow-up (P = .091). Radiographic osteoarthritic changes were observed at the 1st metatarso-cuneiform (MTTC) joint in 6 feet (18.1%), naviculo-cuboid joint in 16 feet (48.4%), talonavicular (TN) joint in 10 feet (30.3%), CC joint in 8 feet (24.2%), and 5th metatarso-cuboid joint in 6 feet (18.2%). The risk of radiographic osteoarthritic changes at the 1st MTTC joint was linked to the fixation method of the cuneiform during surgery (odd ratio (OR) = 2.2; 95% confidence interval (CI): 0.9-3.8; P = .048). The TN joint's risk was significantly associated with the follow-up duration (OR = 2.5; 95% CI = 0.6-1.9; P = .033), changes in the AP TN coverage (OR = 1.9; 95% CI = 0.9-3.2; P = .045), and the preoperative lateral calcaneal pitch angle (OR = 1.7; 95% CI = 1.0-2.4; P = .041). We believe that correcting pediatric flatfoot deformity with Triple C osteotomy provides the optimal approach for achieving excellent foot alignment. However, surgeons should consider the associated risk factors in surgical correction of planovalgus deformity to prevent mid-tarsal arthritis.