Graft Collapse and Loss of Fixation in Lateral Column Lengthening

CATEGORY: Ankle INTRODUCTION/PURPOSE: Lateral Column lengthening through an osteotomy of the anterior process of the calcaneus is one of the most effective procedures for restoring arch alignment in the adult acquired flatfoot, without fusing essential joints. Despite remarkable radiographic corrections, previous studies have found persistent lateral hindfoot pain remains a challenge. In this study, we reviewed a large series of patients who underwent lateral column lengthening as part of flat foot reconstructive surgery, using either autograft or allograft. Rates of graft collapse and loss of fixation were determined with two different graft sources. METHODS: After Institutional Review Board approval, all patients who underwent lateral column lengthening between 2002 and 2018 were reviewed for clinical and radiographic outcomes. Variables such as age, gender, diagnosis, type of bone graft, subsequent surgery, screw/hardware breakage, length of follow-up, time until weight bearing, and length of radiographic follow-up were recorded. Approximately half the patients had iliac crest allograft for the distraction, and the others had proximal tibial structural autograft. RESULTS: 52 patients met inclusion criteria. The average age was 47±14 years (range 18-86), with 32 women (62%) and 20 men (38%). 25 (48%) patients had a second surgery, most often for hardware removal. Two patients had repair of a nonunion. Twenty- five percent of patients who had proximal tibial autograft had hardware breakage and some degree of graft collapse, whereas none had hardware breakage in the iliac crest allograft group (p<0.05). Twenty-one of the 36 patients in the proximal tibia autograft group underwent a second surgery for persistent lateral column pain, with removal of hardware and bone debridement, compared to only 4 in the allograft group (p<0.05). CONCLUSION: Proximal tibia autograft performed relatively poorly in this case series, with a higher rate of graft collapse and lateral column pain. The allograft group had less complications, but even in this group, the rate of revision surgery is higher than might be expected for foot surgery in general. Lateral column lengthening is a powerful procedure for restoring hindfoot alignment without sacrificing essential joints, but suffers from a relatively high rate of persistent lateral column pain (which usually is not present prior to surgery) and reoperation.