Surrogate optimization of a lattice foot orthotic.
Computers in biology and medicine
BACKGROUND:Additive manufacturing enables to print patient-specific Foot Orthotics (FOs). In FOs featuring lattice structures, the variation of the cell's dimensions provides a locally variable stiffness to meet the therapeutic needs of each patient. In an optimization problem, however, using explicit Finite Element (FE) simulation of lattice FOs with converged 3D elements is computationally prohibitive. This paper presents a framework to efficiently optimize the cell's dimensions of a honeycomb lattice FO for flat foot condition. METHODS:We built a surrogate based on shell elements whose mechanical properties were computed by the numerical homogenization technique. The model was submitted to a static pressure distribution of a flat foot and it predicted the displacement field for a given set of geometrical parameters of the honeycomb FO. This FE simulation was considered as a black-box and a derivative-free optimization solver was employed. The cost function was defined based on the difference between the predicted displacement by the model against a therapeutic target displacement. RESULTS:Using the homogenized model as a surrogate significantly accelerated the stiffness optimization of the lattice FO. The homogenized model could predict the displacement field 78 times faster than the explicit model. When 2000 evaluations were required in an optimization problem, the computational time was reduced from 34 days to 10 hours using the homogenized model rather than explicit model. Moreover, in the homogenized model, there was no need to re-create and re-mesh the insole's geometry in each iteration of the optimization. It was only required to update the effective properties. CONCLUSION:The presented homogenized model can be used as a surrogate within an optimization framework to customize cell's dimensions of honeycomb lattice FO in a computationally efficient manner.
10.1016/j.compbiomed.2022.106376
Functional outcome after percutaneous tendo-Achilles lengthening.
Stauff Michael P,Kilgore William B,Joyner Patrick W,Juliano Paul J
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:Percutaneous tendo-Achilles lengthening (PTAL) is a common procedure performed as an adjunct to other procedures that are used to treat a variety of foot and ankle disorders. Despite the widespread use of PTAL, the only literature to substantiate its efficacy comes from the treatment of forefoot ulceration in diabetics. The complications of the procedure include pain along the Achilles tendon, difficulty using stairs, weakness with toe-off, inadvertent complete tenotomy, and cosmetic appearance. We sought to investigate the functional outcomes specific to PTAL when performed in tandem with triple arthrodesis and subtalar fusion. MATERIALS AND METHODS:A retrospective review of 107 patients who underwent 117 procedures was performed. Outcomes were assessed by telephone interview using a standard questionnaire. The most common procedure in the study population was triple arthrodesis (91%). RESULTS:Fifty-eight percent of the patients reported moderate improvement in motion postoperatively, but 80% reported some degree of persistent stiffness. Despite 38% of patients reporting postoperative weakness, 66% and 61% stated that ascending and descending stairs, respectively, was easier. CONCLUSION:Overall, 81% of the study population had a positive opinion regarding their surgery. In this heterogeneous population, we showed modest improvement in Achilles tendon-related outcomes when PTAL was performed in tandem with other surgeries.
10.1016/j.fas.2009.12.003
Risk Factors for Complications Associated With Minimally Invasive Medial Displacement Calcaneal Osteotomy.
Coleman Michelle M,Abousayed Mostafa M,Thompson John M,Bean Bryan A,Guyton Gregory P
Foot & ankle international
BACKGROUND:Few studies have reported the outcomes following minimally invasive medial displacement calcaneal osteotomy (MDCO) for correction of pes planovalgus deformities. METHODS:Charts were retrospectively reviewed for consecutive patients who underwent minimally invasive MDCO procedures by a single surgeon from 2013 to 2019 with more than 3 months of follow-up. A total of 160 consecutive patients who underwent 189 minimally invasive MDCO procedures were included in the study. Median follow-up was 12 months (interquartile range, 7-25 months). RESULTS:Osteotomy healing complications were present in 7% of cases during the 6-year study period. A 12-month case cluster of osteotomy healing complications was observed. Healing complication rates were 28% during the cluster and 0.7% outside of the cluster. No definitive cause was found for the case cluster, although heat osteonecrosis from the burr was suspected to be involved. Osteotomy healing complications were significantly associated with higher American Society of Anesthesiologists (ASA) classification, female sex, current tobacco use, and higher body mass index (BMI). Healing complications were not associated with osteotomy technique or fixation type. Other complications included wound dehiscence (3%), surgical site infection (2%), transient nerve symptoms (6%), and persistent nerve symptoms (2%). Nerve symptoms were significantly associated with an increased number of concomitant procedures. CONCLUSION:Patients with higher ASA classification, current tobacco use, and higher BMI were at higher risk for osteotomy healing complications after minimally invasive MDCO procedures. Patients were also more likely to develop nerve complications with more extensive surgical procedures. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/1071100720961094
Extra-articular subtalar arthrodesis with cancellous bone graft and internal fixation for children with myelomeningocele.
Aronson D D,Middleton D L
Developmental medicine and child neurology
Extra-articular subtalar arthrodesis with cancellous bone graft and internal fixation was performed on 20 feet of 12 children with myelomeningocele, whose average age at operation was 7.4 years. Indication for surgery was progressive hindfoot valgus deformity causing difficulty in fitting orthoses. At average follow-up of 4.1 years, results were satisfactory in 18 of the 20 feet. Unsatisfactory results were a result of undercorrection at time of surgery. Extra-articular subtalar arthrodesis will correct hindfoot valgus deformity in children with myelomeningocele, and the use of internal fixation and iliac crest bone grafting contributed to the improved success rate in this series.
Simple excision vs the Kidner procedure for type 2 accessory navicular associated with flatfoot in pediatric population.
Cha Soo-Min,Shin Hyun-Dae,Kim Kyung-Cheon,Lee Jeong-Kil
Foot & ankle international
BACKGROUND:Recently, many studies have argued against the Kidner procedure and its several modifications, with the accessory navicular considered an irritant rather than a hindrance to foot function, and simple excision has been advocated. We designed this prospective, comparative study of simple excision and the Kidner procedure in children and adolescents with flatfoot and evaluated functional and radiographic outcomes. METHODS:From February 2004 to March 2009, we followed 50 consecutive feet of symptomatic type 2 accessory navicular. Simple excision and the Kidner procedure were performed in 25 feet each, respectively. The American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, the visual analogue scale (VAS), and the talo-first metatarsal, talocalcaneal, and calcaneal pitch angles were evaluated preoperatively and postoperatively for a minimum of 3 years. Patient satisfaction was assessed. RESULTS:The preoperative AOFAS midfoot scale and VAS of each group were improved at final follow-up. The talo-first metatarsal and talocalcaneal angles were not significantly different pre- and postoperatively. However, the calcaneal pitch angle of both groups was improved at the final follow-up. At the final follow-up, we observed no significant differences between the 2 groups in the AOFAS midfoot scale, the VAS, and the talo-first metatarsal, talocalcaneal, and calcaneal pitch angles. The satisfaction frequencies were 86% and 82% in groups 1 and 2, respectively. CONCLUSIONS:We found that in children and adolescents with accessory navicular and flatfoot, simple excision and the Kidner procedure both gave satisfactory results and both minimally restored the medial longitudinal arch similarly. LEVEL OF EVIDENCE:Level II, prospective therapeutic study.
10.1177/1071100712467616
Minimally invasive calcaneo-stop method for idiopathic, flexible pes planovalgus in children.
Roth Sandor,Sestan Branko,Tudor Anton,Ostojic Zdenko,Sasso Anton,Durbesic Artur
Foot & ankle international
BACKGROUND:The aim of this study was to correct heel valgus in children and to lift the longitudinal arch of the foot using a temporary cancellous screw placed percutaneously across the talocalcaneal articulation. METHODS:From April, 1997, to June, 2003, 94 procedures were done on 48 children between the ages of 8 and 14 years. The Meary angle to determine the degree of collapse of the medial longitudinal arch was 170 degrees or less, and the weightbearing hindfoot was in valgus. Presumably, the screw achieves correction by stimulating the proprioceptive foot receptors allowing active inversion of the foot. RESULTS:At 5 years followup, no serious complications occurred. The correction of the Meary angle on average was 17.10 +/- 5.51 degrees. In every foot, heel valgus and the longitudinal arch of the foot were improved radiographically and clinically without the loss of function. We removed the screws in all patients. In 91 feet, the arch of the foot and heel valgus remained in the corrected position. CONCLUSIONS:The 'calcaneo-stop' method is a simple, effective, minimally invasive technique for the treatment of idiopathic, flexible pes planus in carefully selected pediatric patients.
10.3113/FAI.2007.0991
Reconstruction with tenodesis in an adult flatfoot model. A biomechanical evaluation of four methods.
Thordarson D B,Schmotzer H,Chon J
The Journal of bone and joint surgery. American volume
Six fresh-frozen adult cadaveric specimens were mounted in an Instron materials testing machine with use of a cemented intramedullary rod. Angular relationships between the first metatarsal and the talus were recorded with a sonic digitizer. A flatfoot deformity was created by dividing the talonavicular joint capsule (superiorly, medially, and inferiorly), the spring ligament, the anteromedial aspect of the subtalar joint capsule, and the plantar fascia. Angular displacement in the sagittal and transverse planes was recorded at no load and at 100, 350, and 700-newton plantar loads. Each specimen was subjected to four different reconstructions with tenodesis, and the angular relationship between the first metatarsal and the talus was measured at the four levels of load. A reconstruction with use of the peroneus longus tendon was performed by preserving its insertion into the first metatarsal, rerouting the tendon and passing it from medial to lateral through a calcaneal bone tunnel, and anchoring it to the lateral aspect of the calcaneus. A reconstruction with the tibialis tendon was performed by passing the medial third of the tendon from dorsal to plantar through the navicular and from medial to lateral through the calcaneal bone tunnel and securing it to the lateral aspect of the calcaneus. The reconstruction with the tibialis anterior tendon was repeated with the tendon graft routed along the medial aspect of the navicular, directly through the calcaneal bone tunnel. The fourth reconstruction was done with use of an Achilles tendon allograft.(ABSTRACT TRUNCATED AT 250 WORDS)
10.2106/00004623-199510000-00011
Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for posterior tibial tendon dysfunction: a middle-term clinical follow-up.
Guyton G P,Jeng C,Krieger L E,Mann R A
Foot & ankle international
HYPOTHESES/PURPOSE:The medial displacement calcaneal osteotomy has recently become a popular addition to flexor digitorum longus transfer for stage II posterior tibial tendon dysfunction. We reviewed the results of 26 patients who had undergone the procedure at an average of 32 months prior to follow-up (range 12 to 70 months) with particular attention to objective functional parameters. CONCLUSIONS/SIGNIFICANCE:FDL transfer and medial displacement calcaneal osteotomy provides good functional and symptomatic results in the middle-term. The operation preserves the majority of subtalar motion and is objectively durable as assessed by the continued ability to perform a single-leg toe rise. Although moderate radiographic improvement in the arch is frequent, often patients fail to notice this clinically. A prolonged period of steady improvement in symptoms after surgery is common. SUMMARY OF METHODS/RESULTS:Between 1993 and 1998, 26 patients underwent flexor digitorum longus transfer and medial displacement calcaneal osteotomy performed by the senior author. Sixteen returned for the study and were seen for physical exams. Three were included on the basis of chart review including one who was deceased and two who could not be contacted. Five further patients included on the basis of chart review were also contacted for telephone interviews. For the survival analysis, however, their last physical examination was used as the follow-up date. Two patients who had early technical failures were not interviewed but were counted as early failures of the procedure in the survival analysis. Functionally, all patients except three could perform a single-leg toe rise at follow-up, a maneuver none could perform preoperatively. Of these three, two cases were technical failures with loss of fixation of the FDL transfer early in the postoperative course, ultimately requiring revision procedures including one subtalar fusion. Another patient was a late failure after developing increasing pain and weakness during a pregnancy 69 months after the procedure. Clinically assessed subtalar motion remained 81 +/- 15% of the contralateral side in those patients with unilateral disease. Although improvement in the radiographic alignment of the foot was commonly noted, only 50% of patients felt the conformation of their foot had noticeably changed, and only one (4%) felt the improvement to be significant. Pain relief was rated excellent by 75% and good by 16%; the average AOFAS Hindfoot pain subscale score was 35.2 (out of 40 possible). Function was felt to be markedly improved by all patients except the three who were unable to perform a single-leg toe rise. The average score for the four functional symptom categories of the AOFAS score was 26.8 (out of 28 possible). Most patients noted that although they were able to perform daily activities after their postoperative immobilization was liberalized, there was a prolonged period of steady improvement in symptoms and function after surgery. The median length of time to self-rated maximal medical improvement was 10 months.
10.1177/107110070102200802
Decision Tree-Based Foot Orthosis Prescription for Patients with Pes Planus.
International journal of environmental research and public health
Pes planus, one of the most common foot deformities, includes the loss of the medial arch, misalignment of the rearfoot, and abduction of the forefoot, which negatively affects posture and gait. Foot orthosis, which is effective in normalizing the arch and providing stability during walking, is prescribed for the purpose of treatment and correction. Currently, machine learning technology for classifying and diagnosing foot types is being developed, but it has not yet been applied to the prescription of foot orthosis for the treatment and management of pes planus. Thus, the aim of this study is to propose a model that can prescribe a customized foot orthosis to patients with pes planus by learning from and analyzing various clinical data based on a decision tree algorithm called classification and regressing tree (CART). A total of 8 parameters were selected based on the feature importance, and 15 rules for the prescription of foot orthosis were generated. The proposed model based on the CART algorithm achieved an accuracy of 80.16%. This result suggests that the CART model developed in this study can provide adequate help to clinicians in prescribing foot orthosis easily and accurately for patients with pes planus. In the future, we plan to acquire more clinical data and develop a model that can prescribe more accurate and stable foot orthosis using various machine learning technologies.
10.3390/ijerph191912484
Deltoid ligament strain after correction of acquired flatfoot deformity by triple arthrodesis.
Song S J,Lee S,O'Malley M J,Otis J C,Sung I H,Deland J T
Foot & ankle international
Deltoid insufficiency represents a difficult surgical challenge. We have witnessed patients who have developed a valgus tibiotalar deformity following a properly positioned triple arthrodesis. To investigate whether the triple arthrodesis itself, by creating a rigid triple joint complex below the ankle, leads to increased strain of the deltoid complex, a flatfoot model was created in 8 fresh-frozen below-knee amputation specimens. Each specimen was loaded in three gait cycle (GC) positions: Heel strike (0% GC), midstance (10% GC), and heel rise (40% GC). The three components of the ground reaction force (GRF) and the tendon forces consistent with those respective positions were applied. To simulate a posterior tibial tendon insufficient state the posterior tibial tendon was not loaded. Strain at the tibiocalcaneal fibers of the superficial deltoid ligament complex was determined at each of the three foot positions. A triple arthrodesis was performed and the deltoid strains were again recorded for each position. A significant increase in the strain of the deltoid ligament was observed for only the heel rise position (p=0.007) in our cadaver model following triple arthrodesis. The results favor medializing the calcaneus following arthrodesis to protect the deltoid complex.
10.1177/107110070002100708
Is structural hydroxyapatite tricalcium-phosphate graft or tricortical iliac crest autograft better for calcaneal lengthening osteotomy in childhood? interim results from a randomised, controlled non-inferiority study.
Martinkevich P,Rahbek O,Stilling M,Pedersen L K,Gottliebsen M,Søballe K,Møller-Madsen B
The bone & joint journal
AIMS:To compare the structural durability of hydroxyapatite-tricalcium phosphate (HATCP) to autologous iliac crest bone graft in calcaneal lengthening osteotomy (CLO) for pes planovalgus in childhood. PATIENTS AND METHODS:We present the interim results of ten patients (HATCP, n = 6 and autograft, n = 5) with a mean age of 11.5 years (8.2 to 14.2) from a randomised controlled non-inferiority trial with six months follow-up. The primary outcome was the stability of the osteotomy as measured by radiostereometric analysis. A non-inferiority margin of ≤ 2 mm osteotomy compression was set. RESULTS:At six months the data showed that the osteotomy had been compressed by a mean 1.97 mm (99.8% confidence interval -1.65 to 5.60) more in the HATCP group than in the autograft group. Migration of the CLO grafted with HATCP stabilised at six months rather than at six weeks with autograft. CONCLUSION:This is the first randomised trial to compare the efficacy of HATCP graft with autograft in terms of stability of CLO in children. Because of problems with the HATCP the trial was stopped. We do not recommend HATCP graft in its current structure for use in unfixed CLOs. Cite this article: Bone Joint J 2016;98-B:1554-62.
10.1302/0301-620X.98B11.BJJ-2016-0095.R1
Comparison of Anatomic Structures at Risk With 2 Lateral Lengthening Calcaneal Osteotomies.
Ettinger Sarah,Sibai Kariem,Stukenborg-Colsman Christina,Yao Daiwei,Claassen Leif,Daniilidis Kiriakos,Plaass Christian
Foot & ankle international
BACKGROUND::Lateral lengthening calcaneal osteotomies (LLCOT) are commonly used to treat flexible pes planovalgus deformity. Different operative techniques have been described. The aim of this study was to examine which anatomic structures were affected by 2 different osteotomy techniques. METHODS::Two experienced foot and ankle surgeons each performed an Evans (E)- or Hintermann (H) osteotomy on 7 cadaver feet. The mean age of the donors was 80.4 ± 4.4 years. Eight left and 6 right feet were prepared. Previously identified structures at risk were prepared and evaluated. RESULTS::After H-LLCOT, there was no damage of the peroneus longus tendon, whereas after E-LLCOT, damage was noted in 1 case (14.3%). The peroneus brevis tendon was once cut after H-LLCOT and eroded after E-LLCOT. In one cadaver, the sural nerve was partially damaged after H-LLCOT but in no case after E-LLOCT. The calcaneal anterior and medial articular facets were intact after H-LLCOT in 100% and 85.7% and after E-LLCOT in 42.9% and 71.4%, respectively. The posterior articular surface was not affected in any cadaver. CONCLUSION::Anatomic structures can be damaged after both osteotomies. With the Hintermann osteotomy, the calcaneal anterior and medial articular surface can be protected to a larger extent than with the Evans osteotomy. CLINICAL RELEVANCE::The Hintermann osteotomy seems to be superior, regarding damage of the articular surfaces of the subtalar joint. These findings have to be correlated with biomechanical and clinical studies before a final recommendation can be given, which osteotomy is superior.
10.1177/1071100718789435
Early results and complication rate of the LapiCotton procedure in the treatment of medial longitudinal arch collapse: a prospective cohort study.
Archives of orthopaedic and trauma surgery
INTRODUCTION:Instability/collapse of the medial column has been associated with many conditions, particularly progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA). Restoration of first ray length and sagittal plane alignment to restore the foot tripod is essential when treating these deformities. This study aimed to assess early results, healing, and complication rate of a distraction dorsal opening plantarflexion wedge allograft first tarsometatarsal joint fusion (LapiCotton Procedure) in patients with collapse/instability of the medial column. METHODS:In this prospective cohort study, we included PCFD, HV, and MA patients that underwent a LapiCotton procedure. Fusion site healing was defined by > 50% bone bridging in both interfaces between allograft wedge and host bone using weight-bearing computed tomography (WBCT) after 3 months. First ray collapse radiographic correction and minor and major complications (deep dehiscence, deep infection, and reoperation) were assessed. RESULTS:A total of 22 patients (22 feet) were included (11 PCFD, 6 MA, and 5 of HV patients). Mean follow-up was 5.9 months (range 3-12) and median allograft size was 8 mm (range 5-19 mm). Bone healing was observed in 91% of cases. Two minor complications (9%, both superficial dehiscence) and one major complication (4.5%, deep infection) were observed. Statistically significant improvement of the sagittal plane talus-first metatarsal angle was observed, with mean improvement of 9.4° (95% CI 6.7-12.1°; p < 0.0001). CONCLUSION:In this prospective cohort study of 22 patients treated with the LapiCotton procedure for medial longitudinal arch collapse/instability, we observed a low complication rate (9% minor, 4.5% major), high healing rate after 3 months (91%), one clinically stable radiographic non-union (4.5%) and one unstable non-union (4.5%) needing reoperation. Our results demonstrate promising initial results for LapiCotton technique in treating collapse of the medial longitudinal arch in patients with PCFD, MA and HV deformities. Long-term results are needed to confirm these promising results. LEVEL OF EVIDENCE:Level II, prospective cohort study.
10.1007/s00402-022-04399-0
Corrective bandages and daily manipulations for treatment of congenital vertical talus: a thirteen year follow-up.
International orthopaedics
PURPOSE:To analyze the results of a conservative method for treating congenital vertical talus in children with early start and to know in which cases surgical treatment was needed. METHODS:A retrospective analysis of all children diagnosed with idiopathic vertical talus was carried out during the years 2008-2021. Thirty-two children (46 feet) were finally included. Children were treated with serial manipulations, muscle stimulation, and corrective bandages. Age at the time of initiation of treatment, duration of treatment, and correction or not of the deformity without surgical intervention were recorded as variables of interest. The talocalcaneal angle, TAMBA, and ankle range of motion were measured before treatment, after treatment, and at the end of the follow-up period. Statistics decision tree was used to determine which variable best discriminated whether the patient needed surgery. To complement the tree diagram, a two-step cluster analysis was carried out. RESULTS:After treatment, TAMBA and talocalcaneal angle changed from "vertical" to "oblique" category in 45 and 37 feet, respectively. The pathological dorsal flexion of the ankle changed to normal in 37 feet and ankle plantar flexion was normal in 46 feet. These variables showed significant changes between the three measurement moments. The results of the statistics decision tree and cluster analysis indicate that "No surgery" was associated with an age equal to or lower than one week when treatment was started, and with an ankle plantar flexion range of motion lower than 36°. CONCLUSIONS:The beginning of this conservative treatment in the first week of life and having a plantar flexion of the ankle lower than 36° were related to the success of the treatment without surgery.
10.1007/s00264-022-05685-7
Talo-navicular and calcaneo-cuboid fusion with PEEK H-pode™ vs. Titanium Maxlock™ locking plates: Comparison of functional and radiographic outcomes.
Orthopaedics & traumatology, surgery & research : OTSR
BACKGROUND:Locking plates are increasingly used to achieve hindfoot fusion. The objective of this study was to compare hindfoot fusion outcomes with the PEEK H-pode™ (Biotech™) locking plate and the titanium Maxlock™ (Tornier-Wright™) locking plate. HYPOTHESIS:A polyetheretherketone (PEEK) H-pode™ locking plate provides similar fusion rates to a titanium Maxlock™ locking plate for talo-navicular and calcaneo-cuboid arthrodesis. METHODS:We conducted a retrospective comparative study in 39 patients (including 21 [54%] with pes planovalgus and 11 [28%] with neurological equinovarus deformities) who underwent talo-navicular and/or calcaneo-cuboid fusion, usually combined with subtalar fusion. The first 17 patients (January 2014-February 2016) were managed with Maxlock™ locking plates and the next 22 patients (March 2016-August 2018) with H-pode™ locking plates. These two cohorts of consecutive patients were comparable regarding age, sex distribution, body mass index, and comorbidities. At last follow-up more than 1year after surgery, we compared functional scores, pain intensity, and fusion assessed by radiographs and computed tomography (CT) (threshold set at 33%). RESULTS:Mean follow-up was 42months (range: 34-63months) in the Maxlock™ group and 25months (range: 12-36months) in the H-pode™ group. At last follow-up, the two groups were not significantly different for the mean values of the American Orthopedic Foot & Ankle Society score, European Foot & Ankle Society score, and visual analogue scale pain score. Neither were the two groups significantly different for talo-navicular and calcaneo-cuboid fusion by CT. In the Maxlock™ group, we found non-significant trends towards a higher proportion of patients with talo-navicular nonunion (18% vs. 5% in the H-pode™ group) and weaker talo-navicular fusion in patients with pes planovalgus (60.8% vs. 82.0%, respectively). Radiographic results overestimated the fusion rates. DISCUSSION:Talo-navicular and calcaneo-cuboid fusion was not significantly different with H-pode™ and Maxlock™ locking plates. CT was more accurate than standard radiography to assess fusion. These results underline the usefulness of PEEK locking plates for talo-navicular and calcaneo-cuboid fusion; moreover, the radiolucency of PEEK facilitates the interpretation of radiographs. LEVEL OF EVIDENCE:IV.
10.1016/j.otsr.2022.103343
Stress fracture of the fifth metatarsal after Evans' calcaneal osteotomy: a report of two cases.
Davitt J S,Morgan J M
Foot & ankle international
The Evans calcaneal lengthening osteotomy has gained popularity in recent years for the treatment of symptomatic flexible pes planus deformity. To our knowledge, the occurrence of a stress fracture of the fifth metatarsal has not been reported after this procedure. We report two such cases and discuss the probable mechanism of this problem, a relative overloading of the lateral aspect of the foot. Both cases were treated successfully with immobilization. Clinicians should be aware of this possible problem and treat it appropriately.
10.1177/107110079801901011
Clinical and radiological outcomes of corrective exercises and neuromuscular electrical stimulation in children with flexible flatfeet: A randomized controlled trial.
Abd-Elmonem Amira M,El-Negamy Emam H,Mahran Mahmoud A,Ramadan Asmaa T
Gait & posture
BACKGROUND:Flexible flatfeet are common among children being scarcely symptomatic requires no specific treatment and resolves spontaneously. However, flexible flatfoot tends to advance and deteriorate overtime and eventually resulting in significant impairments such as plantar fasciitis and patellofemoral pain syndrome. RESEARCH QUESTION:What is the effect of corrective exercises and neuromuscular electrical stimulation in children with flexible flatfeet? METHOD:This is a randomized controlled trial with 72 children, seven to twelve yearsold, randomly assigned to either intervention or control group (36 children for each group) and engaged in a four months (3 sessions/week) of corrective exercise and neuromuscular electrical stimulation or corrective exercise and sham neuromuscular electrical stimulation respectively. Assessments of Staheli's arch index (through foot print), navicular drop (through navicular drop test) and radiographic indexes (through anterior-posterior and medio-lateral X-ray) of both feet were performed before and after the intervention programs. RESULTS:Study groups were comparable with respect to all outcome measures at entry (P > 0.05). Within group comparison showed significant improvements in all measured variables. Further, between groups comparison revealed significant higher improvements (P < 0.05) in right and left feet Staheli's arch index, navicular drop as well as the radiographic indexes in favor of the intervention group. SIGNIFICANCE:Integration of corrective exercises and neuromuscular electrical stimulation is more effective than exercises alone for providing clinical and radiological improvements in children with flexible flatfeet.
10.1016/j.gaitpost.2021.06.008
Selective hindfoot arthrodesis for the treatment of adult acquired flatfoot deformity: an in vitro study.
O'Malley M J,Deland J T,Lee K T
Foot & ankle international
An acquired flatfoot deformity with significant laxity at the transverse tarsal joint was created experimentally and the amount of correction that was obtained with selective hindfoot fusions was measured radiographically. Results showed that the talonavicular, double (talonavicular and calcaneocuboid), and triple arthrodeses were able to fully correct the deformity, including correction of hindfoot valgus with just a talonavicular fusion. Subtalar and calcaneocuboid fusions failed to completely correct the deformity. This study provides experimental evidence that although the triple joints are interconnected, they differ with respect to their ability to malalignment. We conclude that talonavicular or double arthrodesis will correct deformity in a flatfoot with considerable laxity through the transverse tarsal joint, but that a subtalar fusion will not provide consistent correction.
10.1177/107110079501600706
The effects of a medializing calcaneal osteotomy with and without superior translation on Achilles tendon elongation and plantar foot pressures.
Hadfield Mark,Snyder John,Liacouras Peter,Owen John,Wayne Jennifer,Adelaar Robert
Foot & ankle international
BACKGROUND:The medial calcaneal osteotomy (MCO) is a frequently used corrective procedure for posterior tibial tendon (PTT) insufficiency; however, patients often complain of lateral foot pain postoperatively. Published findings have documented the usefulness of MCO in off-loading the plantar surface of the first and second metatarsal heads but with a concomitant increase in peak pressure over the lateral forefoot and heel. Achilles tendon elongation revealed a trend toward shortening of the ventromedial aspect of the tendon. It was then hypothesized that translating the osteotomized posterior aspect of the calcaneus medially and superiorly would reduce lateral forefoot pressure and decrease the amount of lengthening of the Achilles tendon while continuing to relieve medial forefoot pressure. METHODS:Twenty-eight fresh-frozen cadaver legs were axially loaded on a load-frame device to 100 lbs to assess the effects of a 1-cm MCO in conjunction with either 0.5-cm or 1-cm superior translation on plantar foot pressures and Achilles tendon elongation. RESULTS:The 0.5-cm superior translation resulted in a greater off-loading of the first and second metatarsals than the MCO alone with a trend toward decreased pressures in the lateral forefoot. The 1-cm superior translation continued to unload the first and second metatarsals; however, lateral forefoot and midfoot pressures were increased. Achilles tendon lengthening remained unchanged in the cadaver foot model. CONCLUSIONS:Our findings suggest that the addition of a 0.5-cm superior translation to the traditional 1-cm MCO should allow some degree of off-loading of the medial forefoot without increasing lateral forefoot or heel pressures.
10.1177/107110070502600504
Reducible valgus flat-foot: assessment of posterior subtalar joint surface displacement by posterior arthroscopy during sinus tarsi expansion screwing.
Tarissi N,Vallée A,Dujardin F,Duparc F,Roussignol X
Orthopaedics & traumatology, surgery & research : OTSR
INTRODUCTION:Subtalar arthroereisis corrects childhood and adult reducible valgus flat-foot in certain indications. Inserting an expansion screw in the sinus tarsi simultaneously corrects the calcaneal valgus of the talocalcaneal divergence and first-ray pronation if these are reducible. The displacement induced in the posterior subtalar joint (decoaptation, translation, rotation) is, however, poorly known. The present study involved arthroscopic assessment of posterior subtalar joint surface displacement during insertion of a talocalcaneal arthroereisis screw, with the hypothesis that displacement varies in three dimensions according to screw size. MATERIAL AND METHOD:Eight specimens were used for the study. All ankles were supple, taken from adult subjects. A 4.5-mm arthroscope was used and measurements were taken with a graduated palpator in the posterior subtalar joint. Three sinus tarsi expansion screws of incremental diameter were assessed. Before and after insertion measurements were made of posterolateral and posteromedial talar exposure on the calcaneus, anteroposterior and lateromedial translation, and talocalcaneal joint-line opening. RESULTS:Medial rotation, varization and anterior translation of the calcaneus were comparable in all cases. Mean lateral opening of the posterior subtalar joint was 0.88 mm with 8-mm screws and 1.25 mm with 16-mm screws. Significant differences between 8 and 16 mm screws were found for lateral subtalar joint opening (P=0.028) and for lateromedial translation (P=0.004). CONCLUSION:Sinus tarsi expansion screwing corrects hindfoot valgus and talocalcaneal divergence by inducing medial translation of the calcaneus under the talus and talar medial rotation and varization, proportional to screw size (medial translation and lateral opening of the subtalar joint). LEVEL OF EVIDENCE:III.
10.1016/j.otsr.2014.09.004
Randomized prospective study comparing tri-cortical iliac crest autograft to allograft in the lateral column lengthening component for operative correction of adult acquired flatfoot deformity.
Dolan Christopher M,Henning Jeffrey A,Anderson John G,Bohay Donald R,Kornmesser Marc J,Endres Terrence J
Foot & ankle international
BACKGROUND:Operative treatment of stage II posterior tibial tendon insufficiency (PTTI) is controversial. Many soft-tissue and bony procedures and various combinations of the two have been reported for treatment of stage II PTTI. Orthopaedists recognize the lateral column lengthening component of the procedure as a successful reconstructive technique. The use of cortical allograft for lateral column lengthening in the correction of pes planus in the pediatric patient population has been routine. In the adult population, however, tricortical iliac crest autograft has been the bone graft of choice. Harvest of this autograft can precipitate significant morbidity and cost. Therefore, we undertook this randomized controlled trial to compare graft incorporation and healing of allograft and autograft in the lateral column lengthening component of adult flatfoot reconstruction. METHODS:Lateral column lengthening was done as a component of operative correction for stage II PTTI in adult patients (older than 18 years) by two surgeons using similar procedures. The patients were randomized to either the allograft or autograft procedures. The primary endpoint was graft incorporation and healing as assessed by radiographs. RESULTS:The study included 33 randomized feet in 31 patients. We followed 18 feet in the allograft group and 15 in the autograft group to the point of union. There were 21 women and 10 men. There were no delayed unions, nonunions, or hardware failures. All patients in both groups achieved bony union by the 12-week followup evaluation. Two superficial foot infections were successfully treated with oral antibiotics. Two patients in the autograft group continued to have hip donor site pain at 3 months. CONCLUSIONS:This study suggests that union rates of allograft and autograft (iliac crest bone graft) are equal. The use of allograft in the lateral column lengthening component of operative correction of adult stage II PTTI appears to be a viable alternative to the use of iliac crest autograft and eliminates the morbidity and increased cost associated with autograft harvest.
10.3113/FAI.2007.0002
Concomitant calcaneo-cuboid-cuneiform osteotomies and the modified Kidner procedure for severe flatfoot associated with symptomatic accessory navicular in children and adolescents.
Kim Jung Ryul,Park Chan Il,Moon Young Jae,Wang Sung Il,Kwon Keun Sang
Journal of orthopaedic surgery and research
BACKGROUND:Accessory navicular can become symptomatic in childhood, and in some cases, the condition is associated with progressive flattening of the longitudinal arch. Moreover, some severe, rigid flatfoot deformities are associated with an accessory navicular. We investigated the results of concomitant calcaneo-cuboid-cuneiform osteotomies (triple C) and the modified Kidner procedure for severe flatfoot associated with a symptomatic accessory navicular in children and adolescents. METHODS:Twenty-one feet of 13 patients (nine boys, four girls; mean age 12.7 years) with severe flatfoot associated with a symptomatic accessory navicular who were treated with concomitant triple C and the modified Kidner procedure were evaluated based on clinical and radiographic examinations preoperatively and at a mean follow-up of 22.4 months (range, 12-36 months). We measured 12 variables on the anteroposterior (AP) and lateral weight-bearing radiographs, and we used the American College of Foot and Ankle Surgeons (ACFAS) score for clinical assessment. RESULTS:We found significant improvements (p < 0.001) in eight of the 12 radiographic measurements: the AP talo-first metatarsal (MTT) angle, AP talo-navicular coverage angle, AP talo-calcaneal angle, lateral talo-first MTT angle, calcaneal pitch, lateral talo-calcaneal angle, lateral talo-horizontal angle, and naviculo-cuboid overlap. Average ACFAS scores were significantly improved at the time of the last follow-up (p < 0.001). The only complication was overcorrection of the hindfoot in one patient. CONCLUSIONS:Concomitant triple C and the modified Kidner procedure result in favorable radiographic and clinical outcomes in the treatment of severe flatfoot associated with a symptomatic accessory navicular in children and adolescents.
10.1186/s13018-014-0131-2
Comparison of screw fixation versus non-fixation in dorsal opening wedge medial cuneiform osteotomy of adult acquired flatfoot.
Wang Chien-Shun,Tzeng Yun-Hsuan,Lin Chun-Cheng,Chang Ming-Chau,Chiang Chao-Ching
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:The aim of this study was to compare the radiographic and functional results between fixation and non-fixation in the Cotton osteotomy for the treatment of adult acquired flatfoot. METHODS:A retrospective, case-controlled study of consecutive stage IIB posterior tibial tendon dysfunction (PTTD) patients treated with the same bony reconstructive surgery including cotton osteotomy between 2013 and 2017. Meary's angle, the medial arch sag angle (MASA), and medial cuneiform cobb angle (MCCA) were evaluated pre-operation, at first weight bearing after surgery, and 12 months post operation. RESULTS:Forty feet were included in the study. The cotton osteotomy utilized screw fixation (n = 20) or non-fixation technique (n = 20). No significant differences between groups were found in pre-operative and follow-up radiographic parameters, union rate, and functional results. CONCLUSION:The non-fixation with press fit technique is a reliable procedure for Cotton osteotomy and as effective as screw fixation. LEVEL OF EVIDENCE:Level III, case control study.
10.1016/j.fas.2019.01.011
Reconstruction of the chronically failed deltoid ligament: a new technique.
Deland Jonathan T,de Asla Richard J,Segal Ayal
Foot & ankle international
BACKGROUND:Chronic deltoid ligament insufficiency that results in valgus tilt of the talus within the ankle mortise (stage IV adult acquired flatfoot) represents a difficult and so far unsolved problem in foot and ankle surgery. If left uncorrected, the deltoid failure with malalignment predisposes to early ankle arthritis and the need for ankle arthrodesis or possibly ankle arthroplasty. METHODS:Five consecutive patients with deltoid ligament insufficiency resulting in a valgus tilt were treated with a deltoid reconstruction. Reconstruction of the deltoid ligament was done by passing a peroneus longus tendon graft through a bone tunnel in the talus from lateral to medial and then through a second tunnel from the tip of the medial malleolus to the lateral tibia. RESULTS:At a minimum 2-year followup, all patients had correction of the talar tilt. One patient had 9 degrees of valgus tilt remaining compared to 15 degrees preoperatively, and the procedure was considered a failure. The remaining four patients had correction of the valgus tilt to 4 degrees or less. CONCLUSION:Although not uniformly successful, deltoid ligament reconstruction using a tendon graft through appropriate bone tunnels can reconstruct the deltoid ligament and correct the valgus talar tilt. Successful results were achieved when combined with correction of flatfoot deformity, which is considered a necessary part of the procedure.
10.1177/107110070402501107
Medium- to Long-term Results of Nonanatomic Spring Ligament Reconstruction Using an Allograft Tendon in Progressive Collapsing Foot Deformity With Severe Abduction Deformity.
Foot & ankle international
BACKGROUND:Spring ligament reconstruction (SLR) has been suggested as an adjunct to other reconstructive procedures to potentially avoid talonavicular joint fusion in progressive collapsing foot deformity (PCFD) with severe abduction deformity. Most clinical reports present short-term follow-up data and a small number of patients. The purpose of this study was to examine the medium- to long-term outcomes of an SLR using allograft tendon augmentation as part of PCFD surgical reconstruction. This study to our knowledge represents the largest number of patients and the longest follow-up to date. METHODS:This study retrospectively reviewed 26 patients (27 feet, mean age of 61.4 years) who underwent SLR with allograft tendon as part of PCFD reconstruction. The mean follow-up of the cohort was 8 years (range, 5-13.4). Radiographic evaluation consisted of 5 parameters including talonavicular coverage angle (TNC), with the maintenance of correction being evaluated by comparing parameters from the early postoperative period (mean: 11.6 months, range, 8-17) to final follow-up. Foot and Ankle Outcome Score (FAOS) and patient satisfaction questionnaires were collected at final follow-up. Conversion to talonavicular or subtalar fusion was considered as a failure. RESULTS:Final radiographs demonstrated successful abduction correction, with the mean TNC improving from 43.7 degrees preoperatively to 14.1 degrees postoperatively (P < .0001). All other radiographic parameters improved significantly and exhibited maintenance of the correction. All FAOS subscales showed significant improvement. Responses to the satisfaction questionnaire were received from all except 1 patient, of whom 88.5% (23/26) were satisfied with the results, 96.2% (25/26) would undergo the surgery again, and 88.5% (23/26) would recommend the surgery. Eight feet (29.6%) required painful hardware removal and 1 (3.7%) developed nonunion of the lateral column lengthening osteotomy. No patient required conversion to talonavicular or subtalar fusion. CONCLUSION:This study demonstrates favorable medium- to long-term outcomes following PCFD reconstruction including an SLR with allograft tendon augmentation. LEVEL OF EVIDENCE:Level IV, case series.
10.1177/10711007231157657
Incidence of Lateral Prominence Pain Following Open Medial Displacement Calcaneal Osteotomy and the Efficacy of Crushplasty as a Preventive Technique.
Foot & ankle international
BACKGROUND:There has been concern about lateral prominence pain at the osteotomy site following medial displacement calcaneal osteotomy (MDCO). However, no study has investigated this complication. This study aimed to investigate the incidence of lateral prominence pain following MDCO and examine the efficacy of crushplasty as a surgical technique to minimize this complication. METHODS:This was a retrospective cohort study in which 137 patients (148 feet) who underwent MDCO were divided into 2 groups by whether they had concurrent crushplasty at the time of MDCO (crushplasty [n = 81] vs noncrushplasty group [n = 67]). Crushplasty was performed by flattening the bony step-off using a rongeur and bone impactor. Lateral prominence pain was defined as pain or irritating symptoms over the osteotomy site that persisted over 12 months after MDCO. The overall incidence of lateral prominence pain after MDCO and within each group was investigated. Multiple logistic regression analysis was used to determine the influence of possible risk factors on the development of postoperative lateral prominence pain. RESULTS:The overall incidence of lateral prominence pain was 9.5% (14 of 148): 3.4% (3 of 87) in the crushplasty group, and 18% (11 of 61) in the noncrushplasty group, and χ analysis showed a statistically significant relationship between crushplasty and lateral prominence pain ( < .05). A relationship between the amount of medial displacement and the development of lateral prominence pain was observed in the noncrushplasty group (OR = 5.31, 95% CI 2.35-16.4, < .05), but this was not observed in the crushplasty group ( = .641). The amount of medial displacement was an independent risk factor for the development of lateral prominence pain (OR = 2.72, 95% CI 1.54-4.79, < .05), and concurrent crushplasty had a negative relationship with lateral prominence pain development (OR = 0.12, 95% CI 0.03-0.57, < .05). CONCLUSION:This study revealed that lateral prominence pain is a significant complication of MDCO, especially in the setting of a larger displacement. The crushplasty following MDCO may minimize this complication, particularly when a greater degree of hindfoot correction is attempted.
10.1177/10711007221108098
Biotenodesis screw for fixation of FDL transfer in the treatment of adult acquired flatfoot deformity.
Wukich Dane K,Rhim Bora,Lowery Nicholas James,Dial Dekarlos
Foot & ankle international
BACKGROUND:In stage II PTTD, flexor digitorum longus (FDL) tendon transfer with an adjunctive bony procedure is the most common method of surgical correction. This paper presents an alternative method of fixation with a biotenodesis interference screw (Arthrex Biotenodesis Screw System) that allows proper tensioning of the FDL tendon transfer. MATERIALS AND METHODS:We retrospectively reviewed 25 consecutive patients who underwent FDL tendon transfer utilizing a biotenodesis interference screw. Intraoperative stability was noted and any loss of correction was assessed postoperatively. RESULTS:Stable fixation was achieved in 24 of the 25 patients who underwent FDL tendon transfer for PTTD. We were not able to achieve stable fixation in one patient due to improper placement of the bone tunnel. This was recognized intraoperatively and did not affect the final outcome. CONCLUSION:This method is technically easier to perform than the recommended technique by the manufacturer. It can be performed through a slightly smaller incision without disrupting the normal interconnections between flexor hallucis long (FHL) and FDL tendon at the Knot of Henry.
10.3113/FAI.2008.0730
Plantar pressures in patients with and without lateral foot pain after lateral column lengthening.
Ellis Scott Jacob,Yu Joseph C,Johnson A Holly,Elliott Andrew,O'Malley Martin,Deland Jonathan
The Journal of bone and joint surgery. American volume
BACKGROUND:Lateral column lengthening, a commonly used adjuvant for the reconstruction of adult flatfoot deformity, can lead to postoperative complaints of lateral plantar pain or discomfort. We hypothesized that patients with such symptoms would have increased lateral plantar pressures when compared with matched controls without these symptoms. METHODS:Ten subjects who had undergone lateral column lengthening and were experiencing pain or discomfort in the plantar-lateral aspect of the foot were selected. Controls who had undergone lateral column lengthening but who were not experiencing such symptoms were matched for age, sex, accessory reconstructive procedures, and time from surgery. At the time of the present study, the patients had been followed for at least two years after the reconstruction and had had removal of hardware. Radiographs of each foot were assessed before and after surgery. The patients completed the Short Form-36 (SF-36) and Foot and Ankle Outcome Score surveys, and standing plantar pressure measurements were obtained. Average mean pressure, peak pressure, and maximum force were assessed at twelve anatomic regions and the two groups were compared. RESULTS:There were no significant preoperative differences between the two groups in terms of radiographic parameters. Patients with pain had significantly lower SF-36 Physical Health Summary scores (p < 0.05), SF-36 Physical Function Subscale scores (p < 0.05), and average Foot and Ankle Outcome Scores (p < 0.05). Patients with pain had significantly higher lateral midfoot average mean pressure (p < 0.05), peak pressure (p < 0.05), and maximum force (p < 0.05). No differences were found in the hindfoot or forefoot regions. CONCLUSIONS:Patients who have undergone lateral column lengthening and who experience lateral plantar pain have increased plantar pressure values in the lateral aspect of the midfoot. The increased pressures in this area cannot be accounted for solely by radiographic or demographic factors.
10.2106/JBJS.H.01057
Effects of medializing calcaneal osteotomy on Achilles tendon lengthening and plantar foot pressures.
Hadfield Mark H,Snyder John W,Liacouras Peter C,Owen Johnny R,Wayne Jennifer S,Adelaar Robert S
Foot & ankle international
Posterior tibial tendon insufficiency, or adult acquired flatfoot deformity, involves collapse of the longitudinal arch of the foot with ensuing changes in the bony architecture of the foot as well. While it is generally accepted that a medializing calcaneal osteotomy (MCO) is a very useful treatment for restoring the fallen arch, questions regarding the effects of this procedure upon plantar foot pressures and Achilles tendon length changes need to be answered. This study focuses on changes in plantar foot pressures and Achilles tendon length as the result of performing a MCO. Fourteen fresh-frozen cadaver legs were used to test the effects of MCO on Achilles tendon length changes 2 cm proximal to the Achilles tendon insertion on the calcaneus. Differential variable reluctance transducers were anchored in ventromedial, dorsomedial, dorsolateral, and ventrolateral positions of the Achilles tendon at the aforementioned level. The effects of the MCO on plantar foot pressures were assessed simultaneously using the Tekscan HR Mat. Axial loading (100 lbs) of each specimen was performed in neutral and dorsiflexion (15 degrees). Data were gathered for Achilles tendon length changes and plantar foot pressures for three trials in both the neutral and dorsiflexed positions. A medializing calcaneal osteotomy (1 cm medial translation) was then performed and testing was repeated in the fashion outlined heretofore. Analysis of the data revealed that there was no significant increase in Achilles tendon length as a result of the MCO. The data also showed that average pressure over the first and second metatarsal regions of the forefoot decreased significantly after MCO. At the same time there was a significant increase in average pressure over the medial and lateral aspect of the heel. These findings suggest that the Achilles tendon aids in inversion of the forefoot without undergoing a significant increase in length change of Achilles tendon fibers in any of the regions tested.
10.1177/107110070302400703
Mechanical stability of a locked step-plate versus single compression screw fixation for medial displacement calcaneal osteotomy.
Konan Sujith,Meswania Jay,Blunn Gordon W,Madhav Rohit T,Oddy Michael J
Foot & ankle international
BACKGROUND:Reconstruction of a flatfoot commonly involves a calcaneal Medial Displacement Osteotomy (MDO) to correct hindfoot valgus in combination with soft tissue procedures. We compared fixation of an MDO using either a single, large cannulated screw versus a locking step-plate in load to failure in a cadaveric model. METHODS:Eight matched pairs of cadaveric limbs were loaded using a mechanical testing rig. Two pairs served as non-operated controls. The remaining paired limbs underwent a 10-mm MDO stabilized either with a single 7-mm screw or a step-plate with four locking screws. One pair was used as a pilot study and the remaining five pairs were loaded up to 4500 N to failure. RESULTS:In the five pairs loaded to failure, the median (with 95% CI) maximum force were 1779 N (1099-2312) and 826 N (288-1607) for the plate and screw, respectively (p = 0.043). With single screw fixation, the tuberosity fragment consistently failed by rotation and angulation into varus. With plate fixation, failure occurred as the screws cut through the internal surfaces of the tuberosity and body with no failure at the screw-plate interface. CONCLUSION:In this cadaveric model, a locked step-plate supported a significantly higher maximum force than a single large cannulated screw. CLINICAL RELEVANCE:The magnitude of the load supported by the locking step-plate suggests that allowing early weightbearing post-operation may be safe in clinical practice before union of the osteotomy.
10.3113/FAI.2012.0669
Intermediate term follow-up of calcaneal osteotomy and flexor digitorum longus transfer for treatment of posterior tibial tendon dysfunction.
Fayazi Amir H,Nguyen Hoan-Vu,Juliano Paul J
Foot & ankle international
Twenty-three patients with stage II posterior tibial tendon dysfunction who had failed non-surgical therapy were treated with flexor digitorum longus transfer and calcaneal osteotomy. At latest follow-up averaging 35 +/- 7 months (range, 24 to 51 months), 22 patients (96%) were subjectively "better" or "much better." No patient had difficulty with shoe wear; however, four patients (17%) required routine orthotic use consisting of a molded shoe insert. AOFAS scores were available on 21 patients and improved from a preoperative mean of 50 +/- 14 (range, 27 to 85) to a postoperative mean of 89 +/- 10 (range, 70 to 100). Our experience, at an intermediate date follow-up is that calcaneal osteotomy and flexor digitorum longus transfer is a safe and effective form of treatment for stage II posterior tibial tendon dysfunction.
10.1177/107110070202301205
The interposition of extensor digitorum brevis in the resection of calcaneonavicular bars.
Moyes S T,Crawfurd E J,Aichroth P M
Journal of pediatric orthopedics
In this series of 19 resected calcaneonavicular bars for peroneal spastic flatfoot (mean follow-up 3.4 years), we demonstrate that interposition of extensor digitorum brevis led to asymptomatic mobile feet without evidence of recurrence of the bar in 90% of the patients; this compares well with 43% recurrence rates of bars with associated pain and stiffness when extensor digitorum brevis is not interposed. We therefore recommend this method for prevention of the bar and their symptoms.
Calcaneo-stop procedure for paediatric flexible flatfoot.
Kellermann Péter,Roth Sandor,Gion Katalin,Boda Krisztina,Tóth Kálmán
Archives of orthopaedic and trauma surgery
BACKGROUND:Flexible flatfoot is a frequent deformity found in children. The aim of this study is to evaluate the pedographic outcome of the percutaneous arthroereisis with the use of a screw through the sinus tarsi into the talus. MATERIALS AND METHODS:43 calcaneo-stop procedures of 25 patients (18 bilateral, seven unilateral) were evaluated. Mean age at surgery was 10 years (7-14, SD 2.2) (SD: standard deviation), mean follow-up time was 9.7 months (3-19, SD 5.5). Patient satisfaction rate was recorded, the Meary's talus-first metatarsal angle was measured with lateral radiograms, and a dynamic pedographic assessment was also performed. RESULTS:Patient satisfaction rate was excellent for 33 feet of 19 children, good for eight feet of five children, and poor for either feet of one child. We did not observe any complications during or following the surgery.The mean rest heel valgus decreased from 13.4° (10°-17°, SD 1.5) to 2.8° (0°-6°, SD 1.7) post op. The Meary's angle improved from 160.2° (148°-177°, SD 6.8) to 175.9° (167°-179°, SD 3.5). By pedographic analysis, the area and the pressure-time integral (load amount, PTI) values increased on the lateral regions of the sole (except for the lesser toes) and decreased on the medial areas (except for the hallux). The relative contact time in the lateral midfoot increased from 63.8% (39.6-78.4%, SD 10.6) to 75.1% (50-86.1%, SD 9.4), and that in the lateral forefoot region from 81.2% (60.4-89.2%, SD 6.6) to 86.8% (78.1-97.1%, SD 4.8). CONCLUSION:The calcaneo-stop procedure is a simple and reliable method for the correction of severe flexible paediatric flatfoot. Our prospective, short-term results following the anterograde screw implantation into the talus correlate well with the results of similar or different arthroereisis methods. Further investigations are required to evaluate the long-term outcome of the screw calcaneo-stop method, including the conditions following implant removal.
10.1007/s00402-011-1316-3
Subtalar arthrodesis for posterior tibial tendon dysfunction and pes planus.
Kitaoka H B,Patzer G L
Clinical orthopaedics and related research
Twenty-one patients (21 feet in 18 women and three men) who were treated with subtalar arthrodesis for posterior tibial tendon dysfunction and pes planus at an average age of 60 years (range, 44-75 years) were studied. Mean duration of symptoms was 3 years. All had realignment of the calcaneus in relation to the talus, and all had screw fixation without supplemental bone graft. Average followup was 3 years (range, 2-5 years). All patients had successful union. The tibiocalcaneal angle averaged 13 degrees +/- 3.1 degrees before operation and 6 degrees +/- 1.9 degrees after operation. The lateral talometatarsal, lateral talocalcaneal, and lateral tibiotalar angles all improved significantly. Arch height (navicular height) increase averaged 5 +/- 2.7 mm. Arch length (calcaneal-metatarsal) decrease averaged 4 +/- 3.2 mm. One complication occurred: delayed wound healing (excellent result). Clinical results were excellent in eight feet, good in eight, fair in four, and poor in one. Patients were satisfied with the operative result in 16 feet, satisfied with reservations in four, and dissatisfied with the operative results in one. Subtalar arthrodesis effectively corrects deformity, does not require bone graft, has a high union rate, and is associated with a low complication rate. However, 11 of the 21 patients continued to have some pain, and in patients with preexisting arthrosis of adjacent joints, symptoms may persist.
Lengthening osteotomy of the calcaneus and flexor digitorum longus tendon transfer in flexible flatfoot deformity improves talo-1st metatarsal-Index, clinical outcome and pedographic parameter.
Richter Martinus,Zech Stefan
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
Lengthening osteotomy of the calcaneus (LO) and flexor digitorum longus tendon (FDL) transfer to the navicular is one option for the treatment of flexible flatfoot deformity (FD). The aim of the study was to analyse the amount of correction and clinical outcome including pedographic assessment. In a prospective consecutive non-controlled clinical followup study, all patients with FD that were treated with LO and FDL from September 1st 2006 to August 31st, 2009 were included. Assessment was performed before surgery and at 2-year-followup including clinical examination (with staging of posterior tibialis insufficiency) weight bearing radiographs (Talo-1st metatarsal angles (TMT)), pedography (increased midfoot contact area and force) and Visual Analogue Scale Foot and Ankle (VAS FA). 112 feet in 102 patients were analysed (age, 57.6 (13-82), 42% male). In 12 feet (9%) wound healing delay without further surgical measures was registered. All patients achieved full weight bearing during the 7th postoperative week. Until followup, revision surgery was done in 3 patients (fusion calcaneocuboid joint (n=2), correction triple arthrodesis (n=1)). 101 feet (90%) completed 2-year-followup. TMT dorsoplantar/lateral/Index and VAS FA scores were increased, and posterior tibialis insufficiency stage, pedographic midfoot contact area and force percentage were decreased (each p<.05). All relevant parameters (stage of posterior tibialis insufficiency, TMT angles and Index, pedographic midfoot contact area and force percentage, VAS FA) were improved 2 years after LO and FDL transfer to the navicular in FD. The complication rate was low. This method allows safe and predictable correction.
10.1016/j.fas.2012.10.006
Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults.
Toolan B C,Sangeorzan B J,Hansen S T
The Journal of bone and joint surgery. American volume
BACKGROUND:The successful correction of flatfoot in children through lengthening of the lateral column, osteotomy of the medial cuneiform, and advancement of the posterior tibial tendon led to the introduction of similar procedures to treat acquired pes planovalgus secondary to attrition or rupture of the posterior tibial tendon in adults. However, to our knowledge, no study has been published documenting whether these procedures are effective treatment for acquired flatfoot in adults. METHODS:The functional and radiographic results of complex reconstruction of a painful, flexible flatfoot associated with attrition or rupture of the posterior tibial tendon were evaluated in thirty-six patients (forty-one feet) with use of a detailed questionnaire, a comprehensive physical examination, and a review of the radiographs and the medical record. RESULTS:At a mean of thirty-four months (range, twenty-four to fifty months) postoperatively, thirty-six feet (88 percent) were less painful compared with the preoperative status or were pain-free and five of the six parameters that had been used to assess correction of the deformity radiographically had improved significantly (p<0.0001). Eight feet (20 percent) had a non-union at the calcaneocuboid joint, and thirteen feet (32 percent) had anesthesia or paresthesia of the sural nerve. Twenty-nine feet (71 percent) had had additional operations, including removal of hardware from twenty feet; bone-grafting to treat a nonunion at the site of the calcaneocuboid arthrodesis and revision of the internal fixation in four feet; a medial displacement calcaneal osteotomy because of recurrent valgus angulation of the hindfoot in two feet; and a Lapidus procedure because of a hypermobile tarsometatarsal joint with hallux valgus, a triple arthrodesis because of a nonunion at the site of the calcaneocuboid arthrodesis associated with loss of correction, and a dorsiflexion-abduction wedge osteotomy through the site of the calcaneocuboid arthrodesis (which had healed) for alignment of an overcorrected foot in one foot each. The outcomes of the procedures in thirty-five feet (85 percent) were rated by the patients as satisfactory, and thirty-three (92 percent) of the thirty-six patients (thirty-eight [93 percent] of the forty-one feet) stated that they would have the procedure again if the circumstances were similar. CONCLUSIONS:Despite the high prevalence of postoperative complications, most of our patients were satisfied with the result of the procedure after the short duration of follow-up. We believe that the relief of pain and the restoration of function achieved through effective correction of the severe pes planovalgus deformity account for the satisfactory outcomes in our patients.
10.2106/00004623-199911000-00006
Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skewfoot.
Mosca V S
The Journal of bone and joint surgery. American volume
Thirty-one severe, symptomatic valgus deformities of the hindfoot in twenty children who had flatfoot (twenty-five feet) or skewfoot (six feet) were corrected with a modification of the calcaneal lengthening osteotomy described by Evans. Despite prolonged non-operative treatment, all patients had pain, a callus, ulceration, or a combination of these signs and symptoms under the head of the plantar flexed talus; they could not tolerate a brace, and shoe wear was excessive. Twenty-six of the deformities were secondary to an underlying neuromuscular disorder. The calcaneal lengthening was combined with an opening-wedge osteotomy of the medial cuneiform to correct the deformities of both the hindfoot and the forefoot in the patients who had a skewfoot. Other concurrent osseous and soft-tissue procedures were frequently performed in the flatfeet and skewfeet to correct adjacent deformities or to balance the muscle forces. Allograft bone was used in twenty-four feet and autogenous bone, in seven. The patients ranged in age from four years and seven months to sixteen years at the time of the operation. The duration of follow-up ranged from two years to three years and seven months after the operation. Satisfactory clinical and radiographic correction of all components of the deformity of the hindfoot was achieved in all but the two most severely deformed feet. These two feet had sufficient correction to eliminate the symptoms despite a small persistent callus under the head of the talus. The pain and callus were eliminated in all of the other feet, the patients were able to tolerate a brace, and shoe wear was improved. Subtalar motion was preserved in all feet except for the four that had had a limited joint arthrodesis performed previously or simultaneously for pre-existing degenerative osteoarthrosis. Calcaneal lengthening is effective for the correction of severe, intractably symptomatic valgus deformities of the hindfoot in children. My patients had resolution of the signs and symptoms associated with the deformity while avoiding the need for an arthrodesis and the many short and long-term complications associated with it.
10.2106/00004623-199504000-00002
A biomechanical analysis of the effect of lateral column lengthening calcaneal osteotomy on the flat foot.
Arangio George A,Chopra Vikram,Voloshin Arkady,Salathe Eric P
Clinical biomechanics (Bristol, Avon)
BACKGROUND:Biomechanical models have been used to study the plantar aponeurosis, medial arch height, subtalar motion, medial displacement calcaneal osteotomy, subtalar arthroereisis and the distribution of forces in the normal and flat foot. The objective was to examine the hypothesis that increased load on the medial arch in the adult flat foot can be reduced through a 10mm lateral column lengthening calcaneal osteotomy 10 mm proximal from the calcaneal cuboid joint. METHODS:A three dimensional multisegment biomechanical model was used with anatomical data from a normal foot, a flat foot and a foot corrected with a 10mm lateral column lengthening calcaneal osteotomy. The response of a normal foot, a flat foot and a flat foot with a 10mm lateral column lengthening calcaneal osteotomy to an applied load of 683 N was analyzed using the biomechanical model. Data for the biomechanical model was obtained from a cadaver foot using the direct linear transformation method. Direct linear transformation uses multiple cameras to determine the spatial location of anatomical landmarks. FINDINGS:Load on the first metatarsal increases to 37% body weight in the flat foot compared to 12% for the normal foot and the moment about the talo-navicular joint increases from 5.6 N m to 21.6 N m. Lateral column lengthening shifts the load toward the lateral column, decreasing load on the first metatarsal to 10% and decreasing the moment about the talo-navicular joint to 8.1 N m. INTERPRETATION:The analysis shows that a 10mm lateral column lengthening calcaneal osteotomy reduces the excess force on the medial arch in an adult flat foot and adds biomechanical rationale to this clinical procedure.
10.1016/j.clinbiomech.2006.11.004
A surgical approach for flexible flatfeet in adults including a subtalar arthroereisis with the MBA sinus tarsi implant.
Needleman Richard L
Foot & ankle international
BACKGROUND:The purpose of this study was to determine the functional outcomes and radiographic results of adult patients who had an operation for flexible flatfeet without any hindfoot osteotomies or fusions. METHODS:Twenty-eight feet in 23 patients with problems caused by their flexible flatfoot deformities had reconstructive foot and ankle surgery that included a subtalar arthroereisis (the restriction of the range of motion of a joint) with the Maxwell-Brancheau Arthroereisis (MBA) sinus tarsi implant. The American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot Scale and a patient assessment questionnaire were obtained from all patients before surgery and at final follow-up. Preoperative and postoperative standing radiographs were analyzed to determine radiographic correction of the deformities. The average followup was 44 months. The MBA implant was surgically removed in 11 of 28 feet (39%) because of sinus tarsi pain. RESULTS:The average preoperative AOFAS score was 52 and had improved to 87 (p<0.00001) at final followup. The average response to four of five questions in the patient assessment had significantly improved (p<0.05). On a 10-point scale, average patient satisfaction was 8.3 points; 78% said that they would have the surgery again. Correction after surgery was significant (p<0.0001) in each of the three radiographic parameters evaluated for 'correction with MBA' and 'final correction.' With the numbers available, no significant differences could be detected after the MBA was removed. Complications included sinus tarsi pain in 46% (13) of the 28 feet in this study; after implant removal, 73% (8) of 11 feet had less discomfort than before surgery with AOFAS scores 80 or better. CONCLUSIONS:Reconstructive foot and ankle surgery that included a subtalar arthroereisis with the MBA sinus tarsi implant resulted in favorable clinical outcomes and patient satisfaction in 78% (18) of 23 patients. In spite of the high incidence of temporary sinus tarsi pain until the implant was removed, this operative approach compares favorably with other operations for flexible flatfoot deformities in adults.
10.1177/107110070602700103
Photocurable and elastic polyurethane based on polyether glycol with adjustable hardness for 3D printing customized flatfoot orthosis.
Biomaterials science
Orthopedic insoles is the most commonly used nonsurgical treatment method for the flatfoot. Polyurethane (PU) plays a crucial role in the manufacturing of orthopedic insoles due to its high wear resistance and elastic recovery. However, preparing orthopedic insoles with adjustable hardness, high-accuracy, and matches the plantar morphology is challenging. Herein, a liquid crystal display (LCD) three-dimensional (3D) printer was used to prepare the customized arch-support insoles based on photo-curable and elastic polyurethane acrylate (PUA) composite resins. Two kinds of photo-curable polyurethanes (DL1000-PUA and DL2000-PUA) were successfully synthesized, and a series of fast-photocuring polyurethane acrylate (PUA) composite resins for photo-polymerization 3D printing were developed. The effects of different acrylate monomers on the Shore hardness, viscosity, and mechanical properties of the PUA composite resins were evaluated. The PUA-3-1 composite resin exhibited low viscosity, optimal hardness, and mechanical properties. A deviation analysis was conducted to assess the accuracy of printed insole. Furthermore, the stress conditions of the PUA composite resin and ethylene vinyl acetate (EVA) under the weight load of healthy adults were compared by finite element analysis (FEA) simulation. The results demonstrated that the stress of the PUA composite resin and EVA were 0.152 MPa and 0.285 MPa, and displacement were 0.051 mm and 3.449 mm, respectively. These results indicate that 3D-printed arch-support insole based on photocurable PUA composite resin are high-accuracy, and can reduce plantar pressure and prevent insoles premature deformation, which show great potential in the physiotherapeutic intervention for foot disorders.
10.1039/d2bm01538b
Combined Medial Cuneiform Osteotomy and Multiple Metatarsal Osteotomies For Correction of Persistent Metatarsus Adductus in Children.
Feng Lin,Sussman Michael
Journal of pediatric orthopedics
BACKGROUND:Metatarsus adductus may occur in children after otherwise successful clubfoot treatment or may be an isolated deformity. There are various bony procedures currently in use for treatment of this problem. The purpose of this study was to review our experience with medial cuneiform opening-wedge osteotomy along with transmetatarsal osteotomy through the base of the second to fifth for treatment of the forefoot adductus in children. METHODS:From 1992 to 2008, we found 16 patients, 25 feet who underwent the procedure by a single surgeon (MDS) at the Shriners Hospitals for Children in Portland. All preoperative and postoperative radiographs were measured and analyzed and all clinic notes were reviewed. RESULTS:Major improvements were seen in the configuration of the foot. Significant differences were found between preoperative and postoperative anteroposterior standing radiographs by measuring the talo-first metatarsal angle, the talo-calcaneal angle, the calcaneal-second metatarsal angle, and the calcaneal-fifth metatarsal angle (P<0.005). On the lateral view the talo-first metatarsal, the talo-calcaneal, the tibio-talar, the tibio-calcaneal, and the pitch angle did not show any change. An unexpected finding was that after the surgery, the lateral subluxation of talo-navicular joint was partially corrected. CONCLUSIONS:This retrospective study suggests that combined medial cuneiform opening-wedge osteotomy with transmetatarsal osteotomy through the base of second to fifth can effectively correct this deformity regardless of the underlying cause. In our cases, we achieved good clinical and radiographic results. We have used this procedure for patients 6 years and older who have moderate to severe forefoot adductus. LEVEL OF EVIDENCE:Level IV-therapeutic studies.
10.1097/BPO.0000000000000559
Surgically treated adult acquired flatfoot deformity: Register-based study of patient characteristics, health-related quality of life and type of surgery according to severity.
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:Population-level data describing patient characteristics and interventions used in surgical treatment of adult acquired flatfoot deformity (AAFD) is lacking. METHODS:We analyzed baseline patient-reported data including PROMs and surgical interventions for patients with AAFD reported to the Swedish Quality Register for Foot and Ankle Surgery (Swefoot) 2014-2021. RESULTS:625 feet with primary AAFD surgery were registered. Median age was 60 (range 16-83) years and 64% were women. Mean preoperative EQ-5D index and Self-Reported Foot and Ankle Score (SEFAS) were low. In stage IIa (n = 319) 78% had medial displacement calcaneal osteotomy and 59% had flexor digitorium longus transfer, with some regional variations. Spring ligament reconstruction was less common. In stage IIb (n = 225), 52% had lateral column lengthening, and in stage III (n = 66), 83% had hind-foot arthrodesis. CONCLUSIONS:Patients with AAFD have low health-related quality of life before surgery. Treatment in Sweden follows best-available evidence but regional variations exist. LEVEL OF EVIDENCE:III.
10.1016/j.fas.2023.03.003
Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity.
Jeng Clifford L,Bluman Eric M,Myerson Mark S
Foot & ankle international
BACKGROUND:Stage IV is the most advanced form of acquired adult flatfoot deformity (AAFD). It is present when valgus tibiotalar angulation occurs with foot deformities associated with AAFD. Tibiotalocalcaneal or pantalar fusion has been the gold standard for treatment of Stage IV AAFD. However, in some of these patients the tibiotalar deformity is correctable. We sought to determine whether minimally invasive deltoid ligament reconstruction in conjunction with triple arthrodesis (MIDLR/Triple) allows tibiotalar joint sparing surgical therapy in Stage IV-A AAFD patients. MATERIALS AND METHODS:Patients diagnosed with Stage IV-A AAFD were given the option of undergoing ankle joint sparing surgery with the MIDLR/Triple technique. Those that chose this option were followed longitudinally. Eight patients underwent the ankle joint sparing procedure. Average followup was 36 months. Radiographic and functional outcome measures were obtained. Success was defined as maintenance of 3 degrees or less of valgus tibiotalar angulation and greater than 2 mm of lateral joint space remaining at final followup. RESULTS:At final followup, five were judged to have a successful outcome. In those, tibiotalar valgus angulation was reduced from 6.4±2.9 degrees to 2.0±2.0 degrees, lateral ankle joint space was maintained at preoperative levels and SF-12 functional scores were equal to age matched normative scores. The only parameter found to be predictive of successful outcome was the magnitude of preoperative tibiotalar tilt. CONCLUSIONS:MIDLR/triple is a new treatment option that requires significant care in patient selection and surgical execution. It is a choice that allows for preservation of ankle motion in patients diagnosed with Stage IV-A AAFD who have less than 10 degrees of valgus tibiotalar tilt on preoperative standing ankle radiographs.
10.3113/FAI.2011.0021
Long-term Outcomes of Talonavicular Arthrodesis for the Treatment of Planovalgus Foot in Children With Cerebral Palsy.
Journal of pediatric orthopedics
BACKGROUND:Planovalgus foot (PVF) in cerebral palsy (CP) tends toward progression and rigidity in adolescence, especially in patients with greater functional impairment. Deformity at the talonavicular joint justifies the use of talonavicular arthrodesis as a corrective surgical technique. This study aims to assess patient or caregiver functional satisfaction and radiographic outcomes of talonavicular arthrodesis for PVF in CP patients with assisted ambulation in the long-term. METHODS:Retrospective comparative study of level III and level IV pediatric CP patients who underwent talonavicular arthrodesis for PVF between 1999 and 2010 as part of multilevel surgery and with a minimum follow-up of 10 years. Radiologic correction at 10 years was compared with preintervention values, and functional impact at 10 years was measured by the foot function index (FFI); correlation between radiologic measurements and FFI were obtained, and complications were recorded. RESULTS:Forty-nine PVFs in 25 patients with CP (72% level III and 28% level IV) were included; 52% were male. The patients had a median age of 12 years at the time of surgery (range: 11 to 15) and 23 years at the time of the study (21 to 26). Significant (P<0.01) pre-post radiologic improvements were obtained in Meary angle (37.86±10.7/8.37±5.5 degrees), calcaneal pitch (3.20±8.1/13.22±5.6 degrees), lateral talocalcaneus angle (42.18±12.1/25.29±2.9 degrees), Moreau-Costa-Bartani angle (167.04±8/146.12±7.1 degrees), talus-first metatarsal angle (27.92±13.9/9.69±4.4 degrees), anteroposterior talocalcaneal angle (37.61±7.4/22.61±2.4 degrees), and talus coverage angle (37.04±11.11/2.45±2.5 degrees). At 10 years postoperatively, functional outcome measured with the FFI was satisfactory (33.9±15.2%) and the mean maximum pain was 3.04; 56% of cases had mild pain. All patients were able to wear an ankle-foot orthosis and 8 no longer needed the device. A significant correlation was found between the talofirst metatarsal angle and the FFI (P=0.024). There were 8% of cases with screw protrusion and 14% presented pseudarthrosis, most of them asymptomatic. CONCLUSIONS:The adequate functional outcome, as well as the persistence of long-term radiologic correction and acceptable number of complications, enables us to recommend talonavicular arthrodesis as an alternative treatment to consider in level III and level IV CP patients with PVF. LEVEL OF EVIDENCE:Level III-retrospective comparative study.
10.1097/BPO.0000000000002081
Fusion rate of first tarsometatarsal arthrodesis in the modified Lapidus procedure and flatfoot reconstruction.
Thompson Ian M,Bohay Donald R,Anderson John G
Foot & ankle international
BACKGROUND:The purpose of this study was to determine the overall first tarsometatarsal joint (TMTJ) union rate in patients after they had a modified Lapidus procedure or a TMTJ arthrodesis as part of a flatfoot reconstruction. METHODS:We retrospectively reviewed the charts of 182 patients (201 feet) who had a modified Lapidus procedure or a TMTJ arthrodesis as part of a flatfoot reconstruction between May, 1997, and May, 2001; all had at least a 6-month followup. The data collected included age, gender, tobacco use, diabetic status, complications, and radiographic evidence of union. There were 167 women and 15 men. The right foot was operated on in 106 patients and the left foot in 95. The average age was 53 (range 11 to 87) years. RESULTS:First TMTJ arthrodesis healed uneventfully in 193 (96%), and eight (4%) had nonunions. Of those eight patients with nonunions, five had previous bunion surgeries, two were smokers, and one had diabetes. There were 25 (12%) patients with previous bunion surgeries and five of these (20%) had nonunions. Four patients (2%) had symptomatic nonunions resulting in revision. Of the 21 patients undergoing flatfoot reconstruction, none had a nonunion. CONCLUSION:One criticism of the modified Lapidus procedure is the unacceptable nonunion rate (10 to 12%). Out of the 201 feet, we had a 4% nonunion rate and a 2% revision rate, which is well below the reported nonunion rates. We also have found that patients with previous bunion surgery and recurrent deformity were at a higher risk for a nonunion. CLINICAL RELEVANCE:We believe that the modified Lapidus procedure and first TMTJ arthrodesis can achieve acceptable union rates and be successful for correcting hallux valgus with a hypermobile first ray and can also be applied to certain patients undergoing flatfoot reconstruction.
10.1177/107110070502600906
Preoperative Patient-Reported Outcome Measures Relationship With Postoperative Outcomes in Flexible Adult-Acquired Flatfoot Deformity.
Conti Matthew S,Caolo Kristin C,Nguyen Joseph T,Deland Jonathan T,Ellis Scott J
Foot & ankle international
BACKGROUND:Previous studies have demonstrated that procedure-specific thresholds using preoperative patient-reported outcome scores may be used to predict postoperative outcomes. The primary purpose of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) thresholds could be used to predict which patients would clinically improve at 2 years postoperatively following reconstruction of their flexible adult-acquired flatfoot deformity (AAFD). METHODS:PROMIS physical function, pain interference, and depression scores were prospectively collected preoperatively and at a minimum of 2 years postoperatively for 75 feet with flexible AAFD. Minimal clinically important differences (MCIDs) were calculated to establish significant postoperative improvement. Receiver operating characteristic curves and area under the curve analyses were employed to determine whether preoperative PROMIS scores could be used to predict postoperative outcomes. RESULTS:The PROMIS physical function receiver operating characteristic curve analysis (area under the curve = 0.913, < .001) found that a preoperative PROMIS physical function score greater than 45.7 resulted in a 14.3% probability of achieving the MCID, whereas a preoperative score of less than 40.8 had a 97.7% probability of achieving the MCID. A preoperative PROMIS pain interference score (area under the curve = 0.799, < .001) less than 54.1 had only a 23.1% probability of achieving the MCID at 2 years postoperatively. CONCLUSIONS:Preoperative PROMIS physical function and pain interference scores could be used to predict postoperative improvement in patients with flexible AAFD. These results may help surgeons counsel patients regarding the anticipated benefit of surgery. LEVEL OF EVIDENCE:Level III, retrospective comparative series.
10.1177/1071100720963077
Isolated talonavicular arthrodesis in patients with rheumatoid arthritis of the foot and tibialis posterior tendon dysfunction.
Popelka Stanislav,Hromádka Rastislav,Vavrík Pavel,Stursa Pavel,Pokorný David,Jahoda David,Sosna Antonín
BMC musculoskeletal disorders
BACKGROUND:The foot is often affected in patients with rheumatoid arthritis. Subtalar joints are involved more frequently than ankle joints. Deformities of subtalar joints often lead to painful flatfoot and valgus deformity of the heel. Major contributors to the early development of foot deformities include talonavicular joint destruction and tibialis posterior tendon dysfunction, mainly due to its rupture. METHODS:Between 2002 and 2005 we performed isolated talonavicular arthrodesis in 26 patients; twenty women and six men. Tibialis posterior tendon dysfunction was diagnosed preoperatively by physical examination and by MRI. Talonavicular fusion was achieved via screws in eight patients, memory staples in twelve patients and a combination of screws and memory staples in six cases. The average duration of immobilization after the surgery was four weeks, followed by rehabilitation. Full weight bearing was allowed two to three months after surgery. RESULTS:The mean age of the group at the time of the surgery was 43.6 years. MRI examination revealed a torn tendon in nine cases with no significant destruction of the talonavicular joint seen on X-rays. Mean of postoperative followup was 4.5 years (3 to 7 years). The mean of AOFAS Hindfoot score improved from 48.2 preoperatively to 88.6 points at the last postoperative followup. Eighteen patients had excellent results (none, mild occasional pain), six patients had moderate pain of the foot and two patients had severe pain in evaluation with the score. Complications included superficial wound infections in two patients and a nonunion developed in one case. CONCLUSIONS:Early isolated talonavicular arthrodesis provides excellent pain relief and prevents further progression of the foot deformities in patients with rheumatoid arthritis and tibialis posterior tendon dysfunction.
10.1186/1471-2474-11-38
Immediate Effects of Medially Posted Insoles on Lower Limb Joint Contact Forces in Adult Acquired Flatfoot: A Pilot Study.
Peng Yinghu,Wong Duo Wai-Chi,Wang Yan,Chen Tony Lin-Wei,Tan Qitao,Chen Zhenxian,Jin Zhongmin,Zhang Ming
International journal of environmental research and public health
Flatfoot is linked to secondary lower limb joint problems, such as patellofemoral pain. This study aimed to investigate the influence of medial posting insoles on the joint mechanics of the lower extremity in adults with flatfoot. Gait analysis was performed on fifteen young adults with flatfoot under two conditions: walking with shoes and foot orthoses (WSFO), and walking with shoes (WS) in random order. The data collected by a vicon system were used to drive the musculoskeletal model to estimate the hip, patellofemoral, ankle, medial and lateral tibiofemoral joint contact forces. The joint contact forces in WSFO and WS conditions were compared. Compared to the WS group, the second peak patellofemoral contact force ( < 0.05) and the peak ankle contact force ( < 0.05) were significantly lower in the WSFO group by 10.2% and 6.8%, respectively. The foot orthosis significantly reduced the peak ankle eversion angle ( < 0.05) and ankle eversion moment ( < 0.05); however, the peak knee adduction moment increased ( < 0.05). The reduction in the patellofemoral joint force and ankle contact force could potentially inhibit flatfoot-induced lower limb joint problems, despite a greater knee adduction moment.
10.3390/ijerph17072226
Limited plantar incision for flexor digitorum longus tendon harvest in surgical treatment of tibialis posterior tendon insufficiency.
Robberecht Joris,Oddy Michael J
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:Surgical correction of stage II tibialis posterior tendon dysfunction (TPTD) commonly utilises the Flexor Digitorum Longus (FDL) tendon to augment the tibialis posterior tendon. The aim of this study is to present our experience and clinical outcomes harvesting the FDL via a limited plantar incision technique. METHODS:25 flat foot operations for stage II TPTD were performed harvesting the FDL via a limited plantar incision centred half-way between the base of the heel to the base of the 2nd toe and two-thirds from the lateral border of the foot. RESULTS:The FDL was isolated with no inter-tendonous connections requiring surgical division. There were no recorded cases of plantar nerve injury nor any technique-related complications observed. CONCLUSIONS:The plantar harvest technique for FDL is safe, provides a long tendon graft for transfer and limits the need for an extensive medial midfoot dissection.
10.1016/j.fas.2020.01.003
Surgical Reconstruction for Talocalcaneal Coalitions With Severe Hindfoot Valgus Deformity.
Javier Masquijo Julio,Vazquez Ignacio,Allende Victoria,Lanfranchi Lucas,Torres-Gomez Armando,Dobbs Matthew B
Journal of pediatric orthopedics
INTRODUCTION:Coalition resection can restore motion, and improve pain in patients with talocalcaneal coalitions (TCCs) and an aligned foot. However, there is some debate regarding appropriate treatment of patients with associated valgus deformity. The purpose of this study was to present the outcomes and complications following surgical reconstruction, with or without coalition resection, in a series of patients with TCC and severe hindfoot valgus. METHODS:Thirteen consecutive patients (14 feet) were evaluated. Eleven patients were male. Mean age was 14 years. Mean follow-up was 43.8 months. Seven patients (8 feet) underwent simultaneous resection of the coalition and reconstruction, and 6 patients (6 feet) isolated reconstruction. The talar-first metatarsal angle, the talar-horizontal angle, and calcaneal pitch were measured preoperatively and postoperatively. Clinical evaluation was made according to the American Orthopaedic Foot and Ankle Society ankle-hindfoot score. RESULTS:All radiographic values improved significantly and were within the normal ranges postoperatively. The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score had improved from 45 to 98 points (P<0.001) in the group of simultaneous resection and reconstruction, and from 60 to 92.3 points (P=0.002) in the group of isolated reconstruction. All patients were asymptomatic at the last follow-up and were satisfied with the procedure. DISCUSSION:Surgical reconstruction with or without coalition resection can achieve significant functional and radiographic improvements, and symptoms relief in selected patients with TCCs and severe valgus deformity. LEVEL OF EVIDENCE:Level IV-therapeutic study.
10.1097/BPO.0000000000000642
Indications for Deltoid and Spring Ligament Reconstruction in Progressive Collapsing Foot Deformity.
Foot & ankle international
RECOMMENDATION:There is evidence supporting medial soft tissue reconstruction, such as spring and deltoid ligament reconstructions, in the treatment of severe progressive collapsing foot deformity (PCFD). We recommend spring ligament reconstruction to be considered in addition to lateral column lengthening or subtalar fusion at the initial operation when those procedures have given at least 50% correction but inadequate correction of the severe flexible subluxation of the talonavicular and subtalar joints. We also recommend combined flatfoot reconstruction and deltoid reconstruction be considered as a joint sparing alternative in the presence of PCFD with valgus deformity of the ankle joint if there is 50% or more of the lateral joint space remaining. LEVEL OF EVIDENCE:Level V, expert opinion.
10.1177/1071100720950742
Posterior tibial tendon transfer in the spastic brain-damaged adult does not lead to valgus flatfoot.
Gasq D,Molinier F,Reina N,Dupui P,Chiron P,Marque P
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:We studied the possible development of valgus flat foot after transfer of the posterior tibial tendon to the lateral cuneiform, used for surgical restoration of dorsiflexion in brain-damaged adult patients with spastic equinovarus foot. METHODS:Twenty hemiplegic patients were reviewed with a mean postoperative follow-up of 57.9 months. Weightbearing radiographs, static baropodometry analysis and functional evaluation were used to assess postoperatively outcomes. RESULTS:On the operated side, weightbearing radiographs showed an absence of medial arch collapse and a symmetrical and physiological hindfoot valgus; static baropodometric analysis showed a reduced plantar contact surface with a pes cavus appearance. The surgical procedure yielded good functional results. Nineteen patients were satisfied with the outcome of their surgery. CONCLUSIONS:Our findings support that transfer of the posterior tibial tendon does not lead to valgus flat foot in the spastic brain-damaged adult, and is still a current surgical alternative for management of spastic equinovarus foot.
10.1016/j.fas.2013.04.001
Surgical technique: Medial column arthrodesis in rigid spastic planovalgus feet.
de Moraes Barros Fucs Patricia Maria,Svartman Celso,de Assumpção Rodrigo Montezuma Cezar,Yamada Helder Henzo,Simis Simone Dota
Clinical orthopaedics and related research
BACKGROUND:Treatment of spastic planovalgus feet is challenging, especially in patients with severe and rigid deformities. The available techniques do provide some correction but not at the site of the deformity and sometimes the correction is lost over time. We describe a new surgical approach at the site of the deformity. TECHNIQUE:Indications for the surgery included adolescents or young adults with severe and rigid planovalgus deformities of the feet resulting from cerebral palsy. Through a medial approach, arthrodesis of the talonavicular, navicular-medial cuneiform, and medial cuneiform first metatarsal joints was internally fixed using a single-molded plate over the plantar surface of the foot, recreating the longitudinal arch. METHODS:We retrospectively reviewed 21 patients (35 feet) with spastic cerebral palsy in whom the new technique was indicated for severe and rigid deformity, gait dysfunction, and pain (mean age, 190 months; range, 96-345 months). The mean age of the patients was 16 years (range, 8-29 years). We analyzed the patients clinically and radiographically. The minimum followup was 2.5 years (mean, 58 months; range, 2.5-7.5 years). RESULTS:At last followup, 34 of the 35 feet (97%) had radiographic improvement of the deformity with no difficulties wearing shoes; one patient had persistent pain despite bone union. Union was achieved initially in eight patients (17 feet) and in another eight (10 feet) after revision surgery, of 27 of the 35 feet. The radiographic calcaneal inclination angle improved an average of 13°. The lateral talocalcaneal angle decreased from a mean of 43° to 26° after surgery. Four patients (five feet) had revision surgery for pseudoarthrosis, and another four patients (five feet) had revision surgery for other problems. CONCLUSIONS:Based on our preliminary observations, we believe stabilization of the medial column is a reasonable option for treating selected patients with severe and rigid planovalgus feet by providing a stable and pain-free foot, recreating the anatomy, and allowing the use of braces or regular shoes. Further studies with longer followup periods will be required to confirm these initial results and to verify if these findings persist over time. LEVEL OF EVIDENCE:Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.
10.1007/s11999-011-2185-3
The Potential of Endoscopic Spring Ligament Repair in Flatfoot Reconstruction.
Foot & ankle international
BACKGROUND:Spring ligament fulfills 2 main important functions: one, supporting the head of the talus and stabilizing the talonavicular joint, and the other, maintaining the longitudinal arch by acting as a static support. In this preliminary report, we describe an endoscopic repair for spring ligament injuries with modified portals. METHODS:We performed a retrospective case series study from February 2019 to January 2022. Posterior tibial tendon and/or associated bone deformities were assessed at the same surgical procedure. All patients were ≥18 years old and they had more than 6 months of follow-up. The procedure was performed in 11 patients. Mean age was 46 years (range 18-63). Ten had concomitant bony realignment surgery, and 8 had posterior tibial tendon surgery. RESULTS:In all patients, endoscopic spring ligament repair could be technically done. The modified portals were used in all procedures as described in the surgical technique. Three patients had a superficial lesion, 1 had a rupture <5 mm, 7 had a rupture >5 mm but not a complete rupture through the entire spring ligament. Most of the patients had good clinical results from the surgery that included endoscopic spring ligament debridement and/or repair at 2 years follow up. CONCLUSION:In this small series we found that endoscopy may be an effective technique to diagnose and treat incomplete spring ligament injuries. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/10711007231152874
Effectiveness of calcaneal osteotomy in surgical treatment of foot conditions: A Prisma statement guidelines compliant systematic review.
International wound journal
Calcaneal osteotomy is a commonly established method used to correct various foot malalignment surgery problems that produce varus and valgus hindfoot abnormality as well as Haglund's deformity, cavovarus foot reconstruction, flatfoot deformity, plantar fasciitis, posterior tibial tendon insufficiency and planovalgus foot. After decades, several procedures in orthopaedic foot surgery have been suggested for reducing the risk of wound and neurovascular complications. The goal of this Prisma statement guidelines compliant systematic review was to establish the effectiveness and safety of calcaneal osteotomy in foot surgery. We have performed a novel systematic review of the current published literature in order to evaluate the scientific evidence now available on this association, assigning predefined exclusion and inclusion criteria. Eight investigations were selected which had 191 cases. The adult flatfoot, tibialis posterior reconstruction and cavovarus foot deformity were treated with different procedures of calcaneal osteotomy techniques. The adequate level of effectiveness of calcaneal osteotomy is associated with the kind and location of the incision, with or without screw application, in each specific foot condition. There is a limited number of scientific investigations of the effectiveness and safety of the different kinds of calcaneal osteotomy in foot surgery, and there is the need to enhance outcome knowledge on this foot surgery technique.
10.1111/iwj.13745
Kinematic changes in patients with double arthrodesis of the hindfoot for realignment of planovalgus deformity.
Schuh Reinhard,Salzberger Florian,Wanivenhaus Axel H,Funovics Philipp T,Windhager Reinhard,Trnka Hans-Joerg
Journal of orthopaedic research : official publication of the Orthopaedic Research Society
Double fusion (i.e., fusion of the subtalar and talonavicular joint) represents a modification of triple arthrodesis preserving integrity of the calcaneocuboidal joint. Our aims were (1) to evaluate dynamic plantar pressure distribution in patients undergoing double arthrodesis, (2) to obtain a comparison of kinematic changes to healthy feet, (3) to evaluate the influence of radiographic alignment, and (4) to assess functional outcome. Sixteen feet (14 patients) treated by double fusion due to fixed planovalgus deformity were included. Dynamic plantar pressure distribution was assessed using a capacitive pressure platform. Results were compared with a demographically matched control group. Clinical assessment included the American Orthopaedic Foot and Ankle Society (AOFAS) score and radiographic assessment included measurement of talometatarsal, calcaneal pitch, and talocalcaneal (TC) angle on lateral radiographs. Significant differences in plantar pressure distribution were found for maximum force of the hindfoot, midfoot, and big toe region: While the hindfoot and hallux represented decreased load in the double arthrodesis patients, load increased in the midfoot region compared with healthy controls. The lateral talus-first metatarsal-angle increased from -16.3° to -8.2°, and the TC angle decreased from 41.3° to 35.8° (p < 0.05). The pre- and post-operative AOFAS score increased from 37 points (SD, 16.3) to 70 points (SD, 16.7). These results revealed that double arthrodesis represents a reliable method for correction of planovalgus deformity. Compared with healthy feet, force transmission of the midfoot is increased whereas push-off force decreases.
10.1002/jor.22269
Functional evaluation of bilateral subtalar arthroereisis for the correction of flexible flatfoot in children: 1-year follow-up.
Caravaggi Paolo,Lullini Giada,Berti Lisa,Giannini Sandro,Leardini Alberto
Gait & posture
BACKGROUND:Flexible flatfoot (FFF) is a common alteration of the foot diagnosed in the pediatric population causing pain and decreased quality of life. Surgical treatment via arthroereisis of the subtalar joint can be recommended when non-invasive options do not result in sufficient pain relief. While clinical outcome of subtalar joint arthroereisis is generally positive, no functional evaluation has thus far been reported following surgery. RESEARCH QUESTION:The aim of this study was to assess the effects of two arthroereisis implants for the correction of bilateral FFF on foot and lower limb biomechanics during gait. METHODS:This is a prospective study following 13 children affected by bilateral symptomatic FFF. The patients underwent bilateral subtalar arthroereisis during the same surgery using two types of poly-L-lactide bioabsorbable implants: an expanding endo-orthotic implant, and a calcaneo-stop screw. Radiological parameters and gait analysis were performed preoperatively and at 1 year follow-up and compared to those from an age-matched normal-arched control population. Lower limb and multisegment foot kinematic analysis, along with EMG of the main ankle flexor/extensor muscles, were performed during level walking at comfortable speed. Paired non-parametric Wilcoxon signed-rank test was used to assess differences in radiological and kinematic parameters between pre-op and post-op assessments. RESULTS:All radiological parameters, and frontal-plane orientation of the rearfoot in double-leg standing were improved at 1-year follow-up in both implant groups (e.g calcaneo-stop: pre-op = 15 ± 7 deg; post-op = 6 ± 9 deg; p < 0.01). The endo-orthotic implant group showed significantly lower pronation/supination at the ankle and midtarsal joint. Activation of the tibialis anterior muscle was more physiological after surgery in both groups. SIGNIFICANCE:According to the present analysis, both implants appear effective in restoring physiological alignment of the rearfoot, however the endo-orthotic implant appeared more effective in restoring a more correct frontal-plane mobility of foot joints.
10.1016/j.gaitpost.2018.06.023
Adult acquired flexible flatfoot, treated by calcaneocuboid distraction arthrodesis, posterior tibial tendon augmentation, and percutaneous Achilles tendon lengthening: a prospective outcome study of 20 patients.
van der Krans Arie,Louwerens Jan Willem K,Anderson Patricia
Acta orthopaedica
BACKGROUND:Several methods for the treatment of acquired flexible flatfoot have been described. PATIENTS AND METHODS:We followed the outcome of calcaneocuboid distraction arthrodesis with lengthening of the lateral column prospectively in 20 patients (20 feet). The mean age of the patients was 55 (30-66) years and 16 were women. The lateral column lengthening was combined with percutaneous lengthening of the Achilles tendon and augmentation of the posterior tibial tendon in all patients. Fixed forefoot supination, hallux valgus, and/or symptomatic arthrosis, were corrected with arthrodesis of the first cuneiform-metatarsal joint (n = 8) and arthrodesis of the naviculocuneiform joint (n = 2). The Foot Function Index (FFI) and American Orthopedic Foot and Ankle Society (AOFAS) Clinical Rating Index hindfoot score (CRI) were completed preoperatively and at follow-up. Follow-up time was 25 (13-39) months. All patients were physically examined at follow-up at the outpatient clinic, and the overall satisfaction rate was registered. Standardized weight-bearing radiographs were taken preoperatively and at follow-up. The lateral and dorsoplantar talometatarsal angle was measured, together with the ground-navicular distance. RESULTS:At follow-up, 17/20 feet had complete relief of pain or only minor symptoms. The overall patient satisfaction rate was excellent or good in 15 patients and 17 patients reported an increase in daily and/or recreational activities. 3 patients complained of pain at the distraction site and/or cuboid-MT5 joint, without signs of arthrosis. All but 1 patient would have chosen to undergo the same procedure given the same circumstances. The improvement in both the FFI and CRI was statistically significant. On radiographic examination, the lateral and dorsoplantar talometatarsal angle and the ground-navicular distance improved significantly. Nonunion developed in 2 patients and united after bone grafting. 3 patients had either paresthesia or anesthesia in the distribution area of the sural nerve. INTERPRETATION:We found good short-term results after calcaneocuboid distraction arthrodesis, percutaneous tendon Achilles lengthening, and medial soft tissue augmentation for the treatment of degenerative/acquired flexible flatfoot. Pain or discomfort along the lateral aspect of the foot is the most common and worrying postoperative complaint.
10.1080/17453670610045858
Novel reconstruction of a static medial ligamentous complex in a flatfoot model.
Tan Giselle J,Kadakia Anish R,Ruberte Thiele Ramon A,Hughes Richard E
Foot & ankle international
BACKGROUND:Little progress has been made addressing reconstruction of the static medial ligamentous structures of the foot. The purpose of this investigation was to reconstruct a flatfoot deformity with a novel static medial ligamentous complex (MLC) and evaluate its ability to correct talar head subluxation and radiographic deformity in a cadaveric model. MATERIALS AND METHODS:Eight fresh frozen cadaveric specimens underwent cyclic preconditioning and static axial loading. Loading was applied to the intact foot, the severe flatfoot, and the reconstructed MLC foot. Anteroposterior (AP) and lateral radiographs were taken at each stage. The talo-first metatarsal angle, medial cuneiform height, talocalcaneal angle, and the calcaneal pitch angle were measured on the lateral views and the talo-first metatarsal angle was measured on the anteroposterior views. RESULTS:Compared with the intact foot, the flatfoot showed significant change in the AP talo-first metatarsal angle (p = 0.001), the lateral talo-first metatarsal angle (p = 0.002), the medial cuneiform height (p = 0.007), the talocalcaneal angle (p = 0.03), and the calcaneal pitch angle (p = 0.018). After MLC reconstruction, there was a significant change in the AP talo-first metatarsal angle (p = 0.001), the lateral talo-first metatarsal angle (p = 0.002), and the medial cuneiform height (p = 0.007) and these values were not significantly different than the intact foot. The talocalcaneal angle and the calcaneal pitch angle remained significantly undercorrected after static MLC reconstruction. CONCLUSION:Static MLC reconstruction was effective in correcting several key radiographic parameters in a cadaveric flatfoot model. CLINICAL RELEVANCE:The surgical technique evaluated here may be useful as a new soft tissue reconstructive procedure for treating adult flatfoot.
10.3113/FAI.2010.0695
Comparative Outcomes Between Step-Cut Lengthening Calcaneal Osteotomy vs Traditional Evans Osteotomy for Stage IIB Adult-Acquired Flatfoot Deformity.
Saunders Stuart M,Ellis Scott J,Demetracopoulos Constantine A,Marinescu Anca,Burkett Jayme,Deland Jonathan T
Foot & ankle international
BACKGROUND:The forefoot abduction component of the flexible adult-acquired flatfoot can be addressed with lengthening of the anterior process of the calcaneus. We hypothesized that the step-cut lengthening calcaneal osteotomy (SLCO) would decrease the incidence of nonunion, lead to improvement in clinical outcome scores, and have a faster time to healing compared with the traditional Evans osteotomy. METHODS:We retrospectively reviewed 111 patients (143 total feet: 65 Evans, 78 SLCO) undergoing stage IIB reconstruction followed clinically for at least 2 years. Preoperative and postoperative radiographs were analyzed for the amount of deformity correction. Computed tomography (CT) was used to analyze osteotomy healing. The Foot and Ankle Outcome Scores (FAOS) and lateral pain surveys were used to assess clinical outcomes. Mann-Whitney U tests were used to assess nonnormally distributed data while χ and Fisher exact tests were used to analyze categorical variables (α = 0.05 significant). RESULTS:The Evans group used a larger graft size ( P < .001) and returned more often for hardware removal ( P = .038) than the SLCO group. SLCO union occurred at a mean of 8.77 weeks ( P < .001), which was significantly lower compared with the Evans group ( P = .02). The SLCO group also had fewer nonunions ( P = .016). FAOS scores improved equivalently between the 2 groups. Lateral column pain, ability to exercise, and ambulation distance were similar between groups. CONCLUSION:Following SLCO, patients had faster healing times and fewer nonunions, similar outcomes scores, and equivalent correction of deformity. SLCO is a viable technique for lateral column lengthening. LEVEL OF EVIDENCE:Level III, retrospective cohort study.
10.1177/1071100717732723
Satisfactory outcomes of post-operative subtalar extra-articular arthroereisis in juvenile flexible flat foot.
Saudi medical journal
OBJECTIVES:To analyze the surgical outcomes of subtalar extra-articular arthroereisis and the patient/parent satisfaction regarding the foot's shape, foot pain, ability to walk, ability to jump, and shoe wear. METHODS:Our retrospective cross-sectional study was carried out through an online-based questionnaire to assess patient satisfaction postoperatively at 3 hospitals (King Khalid University Hospital, Sultan bin Abdulaziz Humanitarian City, and Dallah Hospital, Riyadh, Saudi Arabia) between the years 2014-2021. RESULTS:A total of 65 patients participated in our study. Approximately 86.1% of them had the operation bilaterally. The most important aspects where patients noticed the most improvement were the foot's shape (90.8%), pain (81.5%), and ability to walk (76.9%). CONCLUSION:Several studies have been carried out highlighting the surgical technique and complications of the procedure. However, a limited number of studies have been carried out to assess patient satisfaction with the procedure, especially in Saudi Arabia, as the procedure is considered relatively new in the region with insufficient data regarding it. Therefore, this study is considered one of the few articles regarding subtalar extra-articular arthroereisis in the region.
10.15537/smj.2023.44.1.20220607
Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency.
Moseir-LaClair S,Pomeroy G,Manoli A
Foot & ankle international
26 patients with 28 pes planovalgus feet secondary to Johnson stage 2 posterior tibial tendon insufficiency were treated with flexor digitorum longus tendon transfer, lateral column lengthening, medial displacement calcaneal osteotomy, and heel cord lengthening. The mean patient age at surgery was 48.5 years. The AOFAS ankle-hindfoot scale was applied postoperatively to assess clinical outcome. Preoperative and postoperative standing radiographs of the foot and ankle were analyzed to determine radiographic correction of the pes planovalgus deformities. The mean follow-up to date is 5 years. The mean ankle-hindfoot score was 90 postoperatively. The medial cuneiform to fifth metatarsal distance improved from -0.2 mm preoperatively to 7.6 mm postoperatively. Similarly, the talonavicular distance improved from 19.4 mm preoperatively to 10.9 postoperatively. There were no nonunions. Four feet (14%) displayed radiographic signs of calcaneocuboid arthritis at follow-up. Only one was symptomatic requiring calcaneocuboid joint fusion. The double osteotomy technique provides symptomatic relief and lasting correction of the pes planovalgus deformity associated with stage 2 posterior tibial tendon insufficiency at intermediate follow-up. It has a high patient satisfaction based on the AOFAS ankle-hindfoot scale and radiographic measurements demonstrate maintenance of correction of the adult acquired flatfoot.
10.1177/107110070102200403
Calcaneocuboid distraction arthrodesis for posterior tibial tendon dysfunction and flatfoot: a cadaveric study.
Kitaoka H B,Kura H,Luo Z P,An K N
Clinical orthopaedics and related research
Nine fresh-frozen foot specimens were studied to determine the mechanical behavior of the foot using calcaneocuboid distraction arthrodesis, an operation designed for treatment of posterior tibial tendon dysfunction with flatfoot deformity. Flatfoot deformity was created in cadaveric specimens, and to simulate toe-off phase of gait, loads were applied to the plantar surface of the foot and six tendons. Three-dimensional tarsal bone positions were determined with a magnetic tracking system. With ligament sectioning, flatfoot deformity was observed and average arch height decreased 53 +/- 3.5 mm. Height arch increased after calcaneocuboid distraction arthrodesis an average of 3.2 +/- 3.6 mm and was less than normal arch at an average of 2.1 +/- 2.4 mm. Metatarsotalar alignment compared with flatfoot improved after calcaneocuboid distraction arthrodesis in adduction and inversion to the extent that these were not significantly different from intact foot positions. Calcaneotalar position improved after calcaneocuboid distraction arthrodesis in adduction and inversion. Calcaneocuboid alignment compared with flatfoot improved after calcaneocuboid distraction arthrodesis in adduction, plantar flexion, and eversion, but compared with an intact foot was overcorrected in all three planes of motion. Arch alignment in simulated toe-off phase of gait in cadaveric feet was improved significantly with calcaneocuboid distraction arthrodesis but was not reduced anatomically.
10.1097/00003086-200012000-00028
Return to sport activities after medial displacement calcaneal osteotomy and flexor digitorum longus transfer.
Usuelli F G,Di Silvestri C A,D'Ambrosi R,Maccario C,Tan E W
Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA
PURPOSE:Medial displacement calcaneal osteotomy with flexor digitorum longus transfer is a common treatment for the management of the adult flatfoot associated with posterior tibial tendon dysfunction. In the literature, there is a paucity of information regarding the ability of patients to return to sport and recreational activities after this surgical procedure. The purpose of this retrospective clinical study was to assess the rate and type of athletic activities that patients participated in before and after medial displacement calcaneal osteotomy with flexor digitorum longus transfer. METHODS:A consecutive series of 42 patients with a mean age at surgery of 41 years (range 19-74 years) was evaluated with a minimum follow-up of 24 months (range 18-31 months). Pre- and post-operative sporting activities were assessed. At final follow-up, patients were asked to complete a Sports Athlete Foot and Ankle Score (SAFAS). Each patient was also evaluated with weight-bearing radiographs of the foot before surgery and at final follow-up. RESULTS:Preoperatively, 27 of 42 (64.3 %) patients were engaged in athletic activities, participating in an average of 1.4 h/week (range 0-6 h/week); post-operatively, 36/42 (85.7 %) participated in sport and recreational activities for an average of 3.5 h/week (range 0-15 h/week). Meary's angle improved significantly from 11.5 ± 6.2 degrees preoperatively to 7.0 ± 5.7 degrees at final follow-up (p < 0.01); calcaneal pitch improved significantly from 16.5 ± 4.6 degrees to 19.0 ± 5.0 degrees (p < 0.01). At final follow-up, patients demonstrated good SAFASs in symptom tolerance (86.4 %), pain tolerance (89.0 %), daily living performance (96.1 %), and sports performance (86.7 %). CONCLUSION:The majority of patients returned to sports and recreational activity after medial displacement calcaneal osteotomy and flexor digitorum longus for the treatment of adult flatfoot associated with posterior tibial tendon dysfunction. LEVEL OF EVIDENCE:III.
10.1007/s00167-016-4360-2
Mid-term Results of Subtalar Arthroereisis with Talar-Fit Implant in Pediatric Flexible Flatfoot and Identifying the Effects of Adjunctive Procedures and Risk Factors for Sinus Tarsi Pain.
Wang Sen,Chen Li,Yu Jian,Zhang Chao,Huang Jia-Zhang,Wang Xu,Ma Xin
Orthopaedic surgery
OBJECTIVES:To (i) report the mid-term outcomes of subtalar arthroereisis using Talar-Fit implant for the treatment of flexible flatfoot patients; (ii) compare clinical and radiographic outcomes between arthroereisis with and without adjunctive operative procedures to investigate the effects of adjuncts on the outcomes; and (iii) analyze the risk factors associated with sinus tarsi pain, which is the most common postoperative complication of arthroereisis. METHODS:Thirty-one flexible flatfoot children and adolescents (46 feet) treated with subtalar arthroereisis using Talar-Fit implant from June 2014 to May 2019 were retrospectively analyzed. The feet were divided into four treatment groups: (i) arthroereisis alone, (ii) arthroereisis with gastrocnemius recession, (iii) arthroereisis with Kidner procedure, and (iv) arthroereisis with gastrocnemius recession and Kidner procedure. Clinical function was evaluated based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score. The following angles were measured for radiographic evaluation: talar-first metatarsal angle, calcaneal pitch angle, and talar declination angle on the lateral view; and talar-first metatarsal angle, talocalcaneal angle, and anteroposterior talonavicular coverage angle on the anteroposterior (AP) view. The paired Student's t-test was used to compare the pre- and postoperative angular measurements and AOFAS scores. The Wilcoxon rank-sum test was undertaken to determine the outcome differences among four treatment groups. Multivariate logistic regression analysis was used to analyze risk factors for sinus tarsi pain. P value <0.05 is considered statistically significant. RESULTS:The mean follow-up of the feet was 32.8 months (range, 10-71 months). The mean AOFAS score significantly improved from 55.5 ± 14.5 preoperatively to 86.3 ± 9.9 (P < 0.001). Comparison of radiographic outcomes showed that the lateral talar-first metatarsal angle decreased by a mean of 19.1° ± 11.9° (P < 0.001), the calcaneal pitch angle increased by a mean of 5.4° ± 3.4° (P < 0.001), the talar declination angle decreased by a mean of 14.8° ± 9.9° (P < 0.001), the AP talar-first metatarsal angle decreased by a mean of 15.6° ± 10.3° (P < 0.001), the AP talocalcaneal angle decreased by a mean of 7.2° ± 8.3° (P = 0.001), and the AP talonavicular coverage angle decreased by a mean of 20.4° ± 9.0° (P < 0.001). There were no statistically significant differences with regard to AOFAS score and all angle measurements on both the AP and lateral views among the four treatment groups. There was one dislocation case caused by a fall 6 weeks after surgery, which was treated nonoperatively. The incidence of sinus tarsi pain was 13% and logistic regression analysis indicated that patients with a longer distance from the tail end of the implant to the lateral calcaneal wall had 38.8% greater odds of developing sinus tarsi pain. CONCLUSIONS:The mid-term clinical and radiographic results were satisfactory in patients who underwent the subtalar arthroereisis procedure using Talar-Fit implant, alone or in combination with other adjuncts, for the treatment of flexible flatfoot.
10.1111/os.12864
Comparison of Allograft and Bovine Xenograft in Calcaneal Lengthening Osteotomy for Flatfoot Deformity in Cerebral Palsy.
Rhodes Jason,Mansour Alfred,Frickman Allison,Pritchard Breanna,Flynn Katherine,Pan Zhaoxing,Chang Frank,Miller Nancy
Journal of pediatric orthopedics
BACKGROUND:The Evan's calcaneal lengthening osteotomy is a treatment method for spastic flatfoot deformity in patients with cerebral palsy that fail nonoperative measures. Autograft and allograft have been reported as potential graft choices. Bovine xenograft has been introduced as an alternative, but limited human data exists supporting its efficacy. This study compares the long-term results of allograft versus xenograft in isolated Evan's procedure performed for correction of flexible spastic flatfoot deformity. METHODS:This retrospective study accessed charts of 4- to 18-year-olds diagnosed with cerebral palsy who received an Evan's procedure. Preoperative and postoperative radiographic measurements (lateral calcaneal pitch, lateral talocalcaneal, lateral talo-first metatarsal, anteroposterior talonavicular coverage, anteroposterior talo-first metatarsal), graft incorporation, recurrence, secondary procedures, and complications were recorded and analyzed between graft types. RESULTS:Sixty-three feet (34 allograft and 29 xenograft) in 36 patients (mean age 9.3 y) were included. Gross Motor Function Classification System between groups was significant (P=0.001). Mean time for preoperative x-rays was 5.3 months before day of surgery (DOS) for allograft and 3.6 months for xenograft. Mean time of first and last postoperative x-ray for allograft was 3.6 and 39.5 months, respectively; for xenograft, 1.8 and 35.1 months, respectively. There was a significant difference in timing of preoperative x-ray to DOS and DOS to first postoperative x-ray (P=0.012, 0.006, respectively). Radiographically, xenograft retained postoperative improvement better than allograft, yet allograft had a higher grade 4 incorporation rate (P=0.036). The allograft group experienced significantly more cast pressure ulcers (P=0.006), but no other differences in complications between groups, and no infections were reported in either group. CONCLUSIONS:Allograft incorporated better than xenograft, likely with a greater potential to reach grade 5 incorporation, yet both groups retained postoperative improvement. Results indicate both grafts are appropriate; yet incorporation rate could affect correction maintenance, and should be considered during graft selection for Evan's procedure. LEVEL OF EVIDENCE:This study presents clinical results using a novel bone graft material. Level III-retrospective comparative study.
10.1097/BPO.0000000000000822
Results of treatment of congenital vertical talus by the Dobbs method.
Journal of orthopaedic surgery and research
Congenital vertical talus is a rare foot deformity. The hindfoot is valgus and equinus, the midfoot is dorsiflexed and forefoot is abducted due to a fixed dorsal dislocation of the navicular on the head of the talus and the cuboid on the anterior part of the calcaneus. The epidemiology and etiology of vertical talus is unknown. Dobbs et al. (J Bone Joint Surg Am 88(6):1192-200, 2006) described a minimally invasive alternative which allowed to avoid the need for extensive soft tissue release procedures in treatment of congenital vertical talus. Eleven congenital vertical talus feet (group 5 according to Hamanishi) in eight children (four boys and four girls) constituted the study material. Upon the diagnosis, the patients' age ranged from 5 to 26 months old (the mean - 14.6). The treatment involved serial manipulation and casting according to the reverse Ponseti method (from 4 to 7 casts) followed by a minimally invasive approach consisting in temporary stabilization of the talonavicular joint with the use of K-wire and Achilles tenotomy according to the Dobbs technique. Then patients continued the shoe and bar program for 2 years. The X-ray measurements on lateral radiographic included the talocalcaneal angle, tibiotalar angle and talar axis-first metatarsal base angle whereas AP radiographic images-the talocalcaneal angle and talar axis-first metatarsal angle. The Wilcoxon test was used to compare dependent variables. The final clinical assessment made during the last follow-up (the mean: 35.8 months, the range: 25-52) revealed that neutral position of the foot and normal range of motion were observed in ten cases and recurrence of foot deformity in one case. The last X-ray examination showed normalization all of radiological parameters, except for one case, and examined parameters were statistically significant. The minimally invasive technique described by Dobbs should be the first option in treatment of congenital vertical talus. It allows to reduce the talonavicular joint, brings good results and preserves foot mobility. The attention should be put on early diagnosis.
10.1186/s13018-023-03708-6
Outcomes of Evans Versus Hintermann Calcaneal Lengthening Osteotomy for Flexible Flatfoot.
Foot & ankle international
BACKGROUND:Evans (E) and Hintermann (H) lateral lengthening calcaneal osteotomies (LLCOTs) are commonly used to correct flexible flatfoot deformities. Both methods are well accepted and produce good clinical results. The aim of this study was to compare the postoperative outcomes of both osteotomies. METHODS:We retrospectively examined 53 patients with flatfoot deformities, who received surgery between October 2008 and March 2014. Seventeen E-LLCOT and 36 H-LLCOT procedures were performed during this time period, with a mean follow-up of 67.7 ± 20.6 and 40 ± 12.9 months, respectively. Data were collected using clinical and radiological examination, as well as clinical scores (Foot and Ankle Outcome Score [FAOS], University of California at Los Angeles [UCLA] activity score, numerical rating scale [NRS], and the Short-Form 36-item Health Survey [SF-36]) during regular follow-up. RESULTS:For both groups of patients, the FAOS score, pain-NRS, and SF-36 improved significantly following surgery ( P < .05). The talus-second metatarsal angle, talonavicular coverage, and naviculocuneiform overlap showed significant correction ( P < .05). Postoperatively, radiographic degenerative changes were detected in the calcaneocuboid (CC) and subtalar joint in both groups of patients: 41% and 18% after E-LLCOT compared with 25% and 14% after H-LLCOT, although these changes did not have any clinical relevance ( P < .05). No secondary arthrodesis was necessary. There were no significant differences in the clinical or radiological outcome parameters when compared between the 2 groups. CONCLUSION:Both surgical techniques resulted in a significant improvement of clinical outcome scores and led to good radiological correction of flatfoot deformities. It appears that the CC joint develops less degenerative changes following the H-LLCOT procedure. LEVEL OF EVIDENCE:Level III, comparative series.
10.1177/1071100719835464
Correction of moderate and severe acquired flexible flatfoot with medializing calcaneal osteotomy and flexor digitorum longus transfer.
Vora Anand M,Tien Tudor R,Parks Brent G,Schon Lew C
The Journal of bone and joint surgery. American volume
BACKGROUND:Acquired flexible flatfoot encompasses a wide spectrum of disease, and there is no validated treatment protocol. We hypothesized that a medializing calcaneal osteotomy with a flexor digitorum longus transfer is adequate to correct a less severe acquired flexible flatfoot but not a more severe flatfoot. We also hypothesized that use of an additional procedure would further correct the flatfoot. METHODS:The study included seven pairs of cadaver specimens, with one side randomly selected for the creation of a mild flatfoot deformity and the other, for the creation of a severe flatfoot deformity. Cyclic axial load was applied to the intact foot, to the flatfoot, after correction with a medializing calcaneal osteotomy and a flexor digitorum longus transfer, and after the addition of a subtalar arthroereisis. Radiographic and pedobarographic data were obtained at each stage. A repeated-measures analysis of variance with post hoc analysis was used to compare all parameters in the intact foot with those in the flatfoot and corrected specimens. A Student t test was used to compare flatfoot severity between the mild and severe models. RESULTS:Compared with the intact foot, the mild and severe flatfoot models showed a significant change in the talar-first metatarsal angle (p = 0.01 and 0.03, respectively), talonavicular angle (p = 0.04 and 0.04), and medial cuneiform height (p = 0.03 and 0.05). The mild and severe models were significantly different from each other with regard to the talar-first metatarsal angle (p = 0.003) and talonavicular angle (p = 0.002). After the osteotomy and tendon transfer in the mild-flatfoot model, the talar-first metatarsal angle and talonavicular angle were not significantly different from those in the intact state. In the severe-flatfoot model, the talar-first metatarsal angle, talonavicular angle, and medial cuneiform height remained significantly undercorrected after the osteotomy and tendon transfer. After the arthroereisis, the talonavicular angle and medial cuneiform height were not significantly different from the values for the intact foot. CONCLUSIONS:In a cadaver model, the effectiveness of different procedures on radiographic and pedobarographic parameters varies with the severity of an acquired flatfoot deformity.
10.2106/JBJS.E.00045
Correction and prevention of deformity in type II tibialis posterior dysfunction.
Parsons Stephen,Naim Soulat,Richards Paula J,McBride Donald
Clinical orthopaedics and related research
UNLABELLED:Cobb described a method of reconstruction in Johnson and Strom Type II tibialis posterior dysfunction (TPD) using a split tibialis anterior musculotendinous graft. We assessed patient function and satisfaction after a modified Cobb reconstruction in a group of patients with a narrow spectrum of dysfunction, examined a modification of the Johnson and Strom classification to emphasize severity of deformity, and assessed the ability of the technique to prevent subsequent fixed deformity. We prospectively followed 32 patients managed by this technique and a translational os calcis osteotomy with early flexible deformity after failed conservative treatment. There were 28 women and four men with unilateral disease. The average followup was 5.1 years. Staging was confirmed clinically and with imaging. The modified surgery involved a bone tunnel in the navicular rather than the medial cuneiform with plaster for 8 weeks followed by orthotics and physiotherapy. All of the osteotomies healed and 29 of the 32 patients could perform a single heel rise test at 12 months. The mean postoperative American Orthopaedic Foot and Ankle Society hindfoot score was 89. One patient had a superficial wound infection and one a temporary dysesthesia of the medial plantar nerve; both resolved. The observations suggest the technique is a comparable method of treating early Johnson and Strom Type II TPD. LEVEL OF EVIDENCE:Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
10.1007/s11999-009-1122-1
Effect of subtalar arthroereisis on the tibiotalar contact characteristics in a cadaveric flatfoot model.
Martinelli N,Marinozzi A,Schulze M,Denaro V,Evers J,Bianchi A,Rosenbaum D
Journal of biomechanics
Previous studies reported the effect of flatfoot deformity on tibiotalar joint contact characteristics. The lateral shift of the load which occurred in flatfeet may be responsible for degenerative changes in the ankle joint. The purpose was to assess the pattern of joint contact stress of the tibiotalar joint in intact, flat, and corrected specimens with subtalar arthroereisis. Seven fresh-frozen cadaver specimens were studied in the intact and flat-footed condition after transection of ligaments which support the medial arch. Ankle joint contact stress and plantar pressure patterns were determined from a capacitive pressure sensor inserted in the tibiotalar joint and a pressure distribution platform when the specimens were axially loaded in simulated mid-stance. Contact pressure was also assessed after subtalar arthroereisis with a 12 mm Kalix implant for correction of the flatfoot deformity. A maximum contact pressure of 1414.2±319.2 kPa was recorded in the middle-medial region in intact specimens. Flatfoot caused a lateral shift in the pressure distribution (p<0.05). In the flat specimens, the maximum contact pressure of 1394.7 8±470.5 kPa was in the anterior-central region. After subtalar arthroereisis with the Kalix implant for correction of the flatfoot deformity a maximum contact pressure of 1323.3±497.5 kPa was observed in the middle-lateral region. In a cadaver model, subtalar arthroereisis with Kalix implant failed to restore a normal intraarticular ankle joint pressure pattern. Further interventions should be considered to restore a normal pressure pattern.
10.1016/j.jbiomech.2011.11.009
A Novel Anatomic Reconstruction for Posterior Tibialis Tendon in Treatment of Flexible Adult-Acquired Flatfoot Deformity.
Orthopaedic surgery
OBJECTIVE:To present a novel approach for the anatomic reconstruction of the posterior tibialis tendon (PTT) in restoring plantar insertions and evaluate its efficiency in treating flexible adult-acquired flatfoot deformity (AAFD) caused by PTT dysfunction. METHODS:For AAFD treatment, a novel PTT reconstruction method was presented. The current study involved 16 patients, including three men, and 13 women, from August 2017 to July 2019. The mean age was 43.2 ± 15.1 years (21-64 years). The innovative PTT repair method was used on all patients. The treatment involved performing a traditional Flexor Digitorum Longus (FDL) transfer in the navicular tuberosity and suturing the plantar insertions to FDL as tension was applied to tighten the plantar structures of the foot. The results were retrospectively analyzed. The clinical outcome was assessed using the pain visual analogue scale (VAS), the satisfaction VAS, and the American Orthopedic Foot and Ankle Society ankle-hindfoot scale (AOFAS-AH). Isokinetic testing was performed using a dynamometer at 60°/s and 120°/s for inversion/eversion and plantarflexion/dorsiflexion, respectively, to determine the mean peak torque. Radiographic measurements were employed to assess the outcomes. RESULTS:Bone surgeries combined with the modified anatomic PTT reconstruction were performed on patients with medializing calcaneal osteotomy in 12 (75%) patients and subtalar joint fusion in four (25%) patients. The branch linking to the plantar insertions was detected in every case, with an average width of 3.5 ± 0.8 mm (3.1-4.3 mm). All patients were followed up for the mean of 16.8 ± 1.8 months (range, 15-20 months). The average postoperative functional scores, including pain VAS, satisfaction VAS, total AOFAS-AH, and all AOFAS-AH sub-scales, steadily improved during the follow-up. In the last follow-up, isokinetic testing revealed no loss of plantarflexion strength (p = 0.350 and 0.098) and significant improvement in the inversion strength (p = 0.007 and 0.008) in the operated ankles at 60°/s and 120°/s. Radiographic outcomes, particularly the talar head uncovering, improved significantly after more than a year (p < 0.001 for all). CONCLUSIONS:The novel technique for PTT reconstruction in restoring the plantar insertions serves as an effective procedure in treating AAFD caused by PTT dysfunction in terms of delivering a consistent improvement in ankle inversion strength, medial longitudinal arch restoring, and satisfactory clinical outcomes.
10.1111/os.13329
Endosinotarsal device exerts a better postoperative correction in Meary's angle than exosinotarsal screw from a meta-analysis in pediatric flatfoot.
Hsieh Chiun-Hua,Lee Chia-Che,Tseng Tzu-Hao,Wu Kuan-Wen,Chang Jia-Feng,Wang Ting-Ming
Scientific reports
For pediatric flexible flatfoot, the subtalar extra-articular screw arthroereisis (SESA) and endosinotarsal device are the most popular techniques in current practice. Nevertheless, scarce literature is available comparing the outcomes between these two techniques. Thus, we aimed to provide a meta-analysis for the radiographic and clinical outcomes, respectively. A systemic search for correction of pediatric flexible flatfoot using subtalar arthroereisis was conducted mainly in Pubmed and Scopus, and the search was completed on 31 Dec., 2019. The standardized mean differences (SMD) of postoperative versus preoperative calcaneal pitch and Meary's angle were defined as the primary outcomes, whereas the preoperative versus posteoperative AOFAS (American Orthopaedic Foot and Ankle Society) as the secondary outcome. The meta-analysis included 12 comparative studies comprising 2063 feet in total. The quantitative analysis showed a marked improvement in Meary's angle of endosinotarsal cone implant group (SMD: 4.298; 95% CI 2.706-5.889) than exosinotarsal screw group (SMD: 1.264; 95% CI 0.650-1.877). But no significant difference was noted between both groups in calcaneal pitch and AOFAS. The exosinotarsal screw and endosinotarsal device are both effective arthroereisis implant for pediatric flexible flatfoot. While considering the correction of Meary's angle, the endosinotarsal device is better than exosinotarsal screw.
10.1038/s41598-020-70545-6
Minimally Invasive Method in Treatment of Idiopathic Congenital Vertical Talus: Recurrence is Uncommon.
Journal of pediatric orthopedics
BACKGROUND:Historically, treatment for congenital vertical talus (CVT) has included open reduction of the talonavicular joint and extensive soft tissue release. In 2006, a new minimally invasive method consisting of serial manipulation and casting followed by percutaneous fixation of the talonavicular joint and percutaneous Achilles tenotomy was introduced. Although the early results of this new technique are promising, more research is needed to verify that the talonavicular correction is maintained with time. METHODS:We conducted a retrospective chart review of all patients with idiopathic CVT who underwent minimally invasive correction by a single surgeon at a tertiary care institution. Radiographic evaluation of the preoperative, immediate postoperative, 1 year postoperative and latest follow-up appointments were performed. Complications and clinical outcomes were recorded. Radiographic recurrence of the deformity was defined as lateral talar axis-first metatarsal base angle >30 degrees. Statistical analysis was performed on the maintenance of radiographic correction and factors associated with recurrence. RESULTS:Forty seven feet in 35 patients were included in the study with average follow-up of 45 months. The average preoperative lateral talar axis-first metatarsal base angle was 74±18 compared with 12±8 after initial surgical intervention. In addition, radiographic correction of all other measured angles was achieved in every child following the initial surgery. Radiographic recurrence of talonavicular deformity was seen in 4 feet (9%). No cases of recurrence required a second corrective surgery during the follow-up period. There was a significant association between patient age at the time of treatment and recurrence of talonavicular deformity with patients older than 12 months being more likely to experience recurrence ( P =0.041). CONCLUSIONS:In this large series, we found that correction of talonavicular deformity can be achieved and maintained in a large majority of children with idiopathic CVT who undergo treatment with this minimally invasive technique and recurrences are uncommon. Treatment with this technique should be initiated as soon as a diagnosis of CVT is confirmed and the patient is medically stable to decrease the likelihood of experiencing recurrence of talonavicular deformity. LEVEL OF EVIDENCE:Level III.
10.1097/BPO.0000000000002235
Flexor digitorum longus tendon exposure for flatfoot reconstruction: A comparison of two methods in a cadaveric model.
Oddy Michael J,Flowers Mark J,Davies Mark B
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:A novel method for harvesting the flexor digitorum longus (FDL) tendon has been described via a plantar approach based on a surface coordinate. The aim of this investigation is to provide a comparison with the traditional medial midfoot dissection for tendon harvest. METHODS:The FDL tendon was exposed in 10 cadaveric feet via a limited plantar approach and also medially as far as could be accessed via the knot of Henry. The FDL was marked with a metal clip in each approach. The lengths of the skin incisions were recorded and the distance between the two markers was measured. RESULTS:The mean additional length of tendon accessed via the plantar approach was 22.9 mm with a mean reduction in skin incision length of 15.6 mm. CONCLUSION:Using the plantar exposure, a longer length of tendon can be obtained through a smaller skin incision which has been quantified here.
10.1016/j.fas.2009.06.003
Use of the arthroereisis screw with tendoscopic delivered platelet-rich plasma for early stage adult acquired flatfoot deformity.
Yasui Youichi,Tonogai Ichiro,Rosenbaum Andrew J,Moore David M,Takao Masato,Kawano Hirotaka,Kennedy John G
International orthopaedics
PURPOSE:Early stage adult acquired flatfoot deformity (AAFD) is traditionally treated with osteotomy and tendon transfer. Despite a high success rate, the long recovery time and associated morbidity are not sufficient. This study aims to evaluate the functional and radiological outcomes following the use of the arthroereisis screw with tendoscopic delivered PRP for early stage AAFD. METHODS:Patients with stage IIa AAFD who underwent the use of the arthroereisis screw with tendoscopic delivered PRP with a minimum follow-up time of 24 months were retrospectively evaluated. Clinical outcomes for pain were evaluated with the Foot and Ankle Outcomes Score (FAOS) and Visual Analog Score (VAS). Radiographic deformity correction was assessed using weight-bearing imaging. RESULTS:Thirteen patients (13 feet) with mean follow-up of 29.5 months were included. The mean age was 37.3 years (range, 28-65 years). FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life significantly improved from 52.1, 42.6, 57.6, 35.7, and 15.4 pre-operatively to 78.5, 68.2, 83.3, 65.0, and 49.6 post-operatively, respectively (p < 0.05). Statistically significant radiographic improvements (lateral talus first metatarsal angle, calcaneal pitch, and cuneiform to ground distance) were also observed between the pre- and post-operative images. CONCLUSIONS:This study elucidates the successful implementation of a less invasive approach to stage IIa AAFD. Through the use of a subtalar arthroereisis screw, PTT tendoscopy, and PRP injection, clinical and radiographic outcomes were improved.
10.1007/s00264-016-3349-2
Surgical management of symptomatic talocalcaneal coalitions by resection of the sustentaculum tali.
Westberry David E,Davids Jon R,Oros William
Journal of pediatric orthopedics
Previously described techniques for surgical resection of the subtalar coalitions are technically demanding, with poor outcomes related to incomplete resection and recurrence of the coalition. A new technique, involving complete excision of the involved portion of the sustentaculum tali, has been developed at the authors' institution. A retrospective review of 10 patients with 12 coalitions was performed. The index procedure was performed at an average age of 12.7 years, with a mean follow-up of 5.1 years. Preoperative CT scans obtained to assess the extent of the coalition were analyzed. The AOFAS Hindfoot Questionnaire was used postoperatively to assess the patients' overall outcome and satisfaction with the procedure. Overall, there were eight excellent results and three good results. The postoperative mean AOFAS score was 90 compared with a preoperative score of 46. There have been no recurrences of the coalition or progressive foot malalignment in this series of patients.
Mid- to long-term outcome of 96 corrective hindfoot fusions in 84 patients with rigid flatfoot deformity.
Röhm J,Zwicky L,Horn Lang T,Salentiny Y,Hintermann B,Knupp M
The bone & joint journal
Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction. The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus. A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively. In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10). In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique.
10.1302/0301-620X.97B5.35063
Interposition of the split flexor hallucis longus tendon after resection of a coalition of the middle facet of the talocalcaneal joint.
Raikin S,Cooperman D R,Thompson G H
The Journal of bone and joint surgery. American volume
Ten consecutive patients (fourteen feet) who had a painful coalition of the middle facet of the talocalcaneal joint with restricted motion of that joint were managed with a resection of the coalition and interposition of a split flexor hallucis longus tendon in 1992, 1993, or 1994. Initial nonoperative treatment of all of the feet had failed. According to the ankle-hindfoot clinical rating system of the American Orthopaedic Foot and Ankle Society, there were eleven excellent results and one good, one fair, and one poor result at a mean of fifty-one months (range, thirty-two to sixty months) after the procedure. Thirteen of the fourteen procedures resulted in considerable relief of pain, an improved range of motion of the talocalcaneal joint, and improved function of the foot. No patient had symptoms or functional impairment of the great toe secondary to the interposition of the split flexor hallucis longus tendon. On the basis of these early results, tendon interposition appears to be an excellent procedure for the treatment of a symptomatic coalition of the middle facet of the talocalcaneal joint after initial nonoperative treatment has failed. The presence of degenerative osteoarthritis in the other facets of the talocalcaneal joint is a contraindication to this procedure. The long-term results have yet to be determined. However, the standardized rating system used in the present study will allow accurate comparison of our results with those of subsequent studies.
10.2106/00004623-199901000-00003
Effect of Lateral Column Lengthening on Subtalar Motion in a Cadaveric Model.
Harris Mitchell C,Hedrick Brittany N,Zide Jacob R,Thomas Danielle M,Shivers Claire,Siebert Matthew J,Pierce William A,Kanaan Yassine,Riccio Anthony I
Foot & ankle international
BACKGROUND:Although lengthening of the lateral column through a calcaneal neck osteotomy is an integral component of flatfoot reconstruction in younger patients with flexible planovalgus deformities, concern exists as to the effect of this intra-articular osteotomy on subtalar motion. The purpose of this study was to quantify the alterations in subtalar motion following lateral column lengthening (LCL). METHODS:The subtalar motion of 14 fresh-frozen cadaveric feet was assessed using a 3-dimensional motion capture system and materials testing system (MTS). Following potting of the tibia and calcaneus, optic markers were placed into the tibia, calcaneus, and talus. The MTS was used to apply a rotational force across the subtalar joint to a torque of 5 Nm. Abduction/adduction, supination/pronation, and plantarflexion/dorsiflexion about the talus were recorded. Specimens then underwent LCL via a calcaneal neck osteotomy, which was maintained with a 12-mm porous titanium wedge. Repeat subtalar motion analysis was performed and compared to pre-LCL motion using a paired test. RESULTS:No statistically significant differences in subtalar abduction/adduction (10.9 vs 11.8 degrees, = .48), supination/pronation (3.5 vs 2.7 degrees, = .31), or plantarflexion/dorsiflexion (1.6 vs 1.0 degrees, = .10) were identified following LCL. CONCLUSION:No significant changes in subtalar motion were observed following lateral column lengthening in this biomechanical cadaveric study. CLINICAL RELEVANCE:Although these findings do not obviate concerns of clinical subtalar stiffness following lateral column lengthening for planovalgus deformity correction, they suggest that diminished postoperative subtalar motion, when it occurs, may be due to soft tissue scarring rather than alterations of joint anatomy.
10.1177/1071100720970189
Outcome After Modified Grice-Green Procedure (SAMBB) for Arthritic Acquired Adult Flatfoot.
Mosca Massimiliano,Caravelli Silvio,Vocale Emanuele,Massimi Simone,Fuiano Mario,Grassi Alberto,Ceccarelli Francesco,Zaffagnini Stefano
Foot & ankle international
BACKGROUND:Adult acquired flatfoot deformity is a well-known and recognized cause of pain and disability. The purpose of this retrospective study was to describe radiographic and clinical outcomes of the modified mini bone block distraction subtalar arthrodesis (SAMBB) in adult patients affected by adult flatfoot with subtalar joint osteoarthritis at a midterm mean follow-up. METHODS:A retrospective review of our database identified patients. Radiological imaging was used to evaluate angular corrections (Meary's angle [MA], talar coverage angle [TC], and calcaneal pitch angle [CP]) to assess the rate of union and highlight the possible progression of arthritis in nearby joints. Clinical evaluation was performed at the time of surgery and at the final follow-up using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. Sixty-two feet were evaluated at a mean follow-up of 6.2 ± 4.2 years. RESULTS:The AOFAS score improved from a mean value of 48.1 ± 6.1 to a postoperative average score of 87.7 ± 5. CP, TC, and MA showed a postoperative improvement to 17.7 ± 2.1, 2.9 ± 0.7, and 0.6 ± 0.6 degrees, respectively, at the final follow-up, and all deformities were corrected. Five complications (8%) were reported: 1 major and 4 minor. No graft reabsorption, sural nerve neuralgia, or donor site morbidity was recorded. CONCLUSION:To our knowledge, this study is the first report of a modified Grice-Green technique (SAMBB) that is a safe and effective treatment of flatfoot in the adult with subtalar arthritis. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/1071100720938665
Effect of graft shape in lateral column lengthening on tarsal bone position and subtalar and talonavicular contact pressure in a cadaveric flatfoot model.
Campbell Sean T,Reese Keri A,Ross Steven D,McGarry Michelle H,Leba Thu-Ba,Lee Thay Q
Foot & ankle international
BACKGROUND:Lateral column lengthening (LCL) has been used for correction of flatfoot deformity. The purpose of this study was to determine the effect of LCL graft shape on tarsal bone position and talonavicular and subtalar joint pressure. METHODS:A flatfoot model was created in 6 cadaveric specimens. Corrective LCL was performed using a rectangular graft or a trapezoidal graft with the broad surface oriented dorsally, laterally, or plantarly. Bony surface markers were digitized to calculate angular parameters used in the evaluation of flatfoot deformity. Contact pressure and area in the subtalar and talonavicular joints were also recorded. All measurements were carried out under multiple axial loads in the intact and flatfoot conditions, and following LCL with each graft shape. RESULTS:Flatfoot creation resulted in significant changes in arch collapse and forefoot abduction. LCL with a rectangular graft best corrected these parameters, while a laterally oriented trapezoidal graft provided some correction. Talonavicular contact pressure was unchanged after flatfoot creation, and was significantly less than intact after LCL. Subtalar contact pressure decreased in some conditions after flatfoot creation, and decreased further after LCL. CONCLUSION:LCL with a rectangular graft best restored tarsal bone orientation in a cadaveric flatfoot model. The decreases in talonavicular pressure likely represent redistribution of force from the medial to lateral foot. CLINICAL RELEVANCE:When performing LCL for flatfoot deformity, increased bone graft volume medially better restores tarsal bone position. One way of achieving this is through the use of a rectangular graft as opposed to a trapezoidal graft.
10.1177/1071100714549044
Double calcaneal osteotomy in treatment of flexible planovalgus foot deformity in ambulatory cerebral palsy. A case series study.
Aly Ahmad Saeed,Abdel Rahman Amr Farouk,Mahmoud Shady
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:The aim of this prospective non randomized case series study was to assess the intermediate-term outcomes of double calcaneal osteotomy (lateral column lengthening and medial slide calcaneal osteotomy) use in ambulatory cerebral palsy with flexible planovalgus feet. METHODS:16 cases with planovalgus feet were surgically treated by double calcaneal osteotomy and observed over an average of 33.5months. The mean age at the time of surgery was 10.74years. The functional outcomes were assessed clinically and radiologically. RESULTS:There were a statistical improvement of clinical heel valgus and all radiological parameters as regard talar head uncoverage, calcaneal pitch, talo-calcaneal angle, and talus 1st metatarsal angle at the end of follow up period. CONCLUSION:Double calcaneal osteotomy is a good option in the treatment of flexible planovalgus feet in ambulatory cerebral palsy patients.
10.1016/j.fas.2018.07.003
Outcomes of a Minimally Invasive Approach for Congenital Vertical Talus With a Comparison Between the Idiopathic and Syndromic Feet.
Hafez Mohamed,Davis Naomi
Journal of pediatric orthopedics
BACKGROUND:Congenital vertical talus (CVT) is a rare congenital foot disorder. Approximately half of the affected children have associated neuromuscular syndromes which may further complicate the treatment. The traditional treatment involved extensive soft tissue and bony reconstructions. The minimally invasive method (Dobbs method/reverse Ponseti) has changed the treatment of CVT. There is significant variation of the reported outcome of this method in the current literature. In this study we report the outcome of this minimally invasive technique for treatment of CVT and compare the results of treatment in syndromic and idiopathic patients. METHODS:Idiopathic and syndromic patients treated from CVT with minimally invasive method from 2006 till 2016 were included in this retrospective study. We reviewed the patients' notes, radiographs and collected parents reported outcome questionnaire (Roye score) in addition to clinical examination to comprehensively report the treatment outcome. RESULTS:A total of 21 patients 30 feet were included in this study. The average age of commencing treatment was 6 months (1 to 17 mo). The mean follow-up was 6.5 years (1 to 11 y). Correction of the deformities and abnormal angles were achieved in all feet. Five of the 17 syndromic feet had recurrence while no recurrence was reported in any if the 13 idiopathic feet. At the time of the index procedure no supplementary procedures were required. The average arc of motion for foot ankle dorsiflexion and plantar flexion was 30 degrees. Patients with idiopathic CVT had a mean the Roye score of 11 while syndromic patients had a mean score of 22. CONCLUSION:The minimally invasive method is a valuable option for treatment of CVT. Idiopathic patients had no recurrence and better functional scores compared syndromic patients. There was no requirement for supplementary procedures such as tibialis anterior transfer or anterolateral release at the time of the initial surgery. LEVEL OF EVIDENCE:Level IV-case series.
10.1097/BPO.0000000000001769
Deltoid-Spring Ligament Reconstruction in Adult Acquired Flatfoot Deformity With Medial Peritalar Instability.
Foot & ankle international
BACKGROUND:A spring ligament tear is commonly present in advanced stages of adult acquired flatfoot deformity (AAFD). Previous anatomic studies have demonstrated that the superficial deltoid ligament blends with the superomedial spring ligament, forming the tibiocalcaneonavicular ligament (TCNL). Adding allograft TCNL reconstruction to osseous correction has been suggested to augment medial peritalar stability in advanced AAFD with large spring ligament tears. We aimed to investigate the clinical and radiographic outcomes of TCNL reconstruction for flexible AAFD with medial peritalar instability. METHODS:Fourteen feet in 12 patients who underwent osseous and TCNL reconstructions for advanced AAFD (stage IIB with large spring ligament tears or stage IV) were recruited for the study. The mean postoperative follow-up was 24 (range, 12-33) months. Pre- and postoperative clinical outcomes were assessed by the Foot and Ankle Ability Measure (FAAM), SF-36, and Patient-Reported Outcomes Measurement Information System (PROMIS). Correction of forefoot abduction and the sagittal arch were measured from pre- and postoperative weightbearing radiographs. RESULTS:The FAAM Activities of Daily Living improved from 69.3 to 90.1 ( = .001). The SF-36 Physical Function (PF) and Pain subscales both improved significantly (39.4 to 87.8 and 44.6 to 93.1, respectively, < .001 for each). The PROMIS PF improved from 38.2 to 46.8 ( = .002) and the PROMIS Pain Interference (PI) from 62.6 to 50.1 ( = .003). Radiographic measures showed an improved anterior-posterior (AP) talo-first metatarsal angle of 24.7 to 11.8 degrees ( < .001) and talonavicular coverage angle of 47.4 to 23.1 degrees ( < .01). An improved Meary's angle of 29.7 to 12.5 degrees ( < .001) and a calcaneal pitch angle of 11.7 to 16.9 degrees ( = .14) were noted in the lateral view. CONCLUSION:Considering the anatomic characteristics of the deltoid-spring ligament complex, TCNL reconstruction may play a significant role in maintaining peritalar stability when performed with osseous correction. Deltoid-spring ligament (TCNL) reconstruction is a viable surgical option for those with advanced stage AAFD with medial peritalar instability that leads to improved functional and radiographic outcomes. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/1071100719839176
Postoperative CT-scan 3D reconstruction of the calcaneus following lateral calcaneal lengthening osteotomy for flatfoot deformity in children. Is the surgical procedure potentially associated with subtalar joint damage?
Canavese Federico,Dimeglio Alain,Bonnel François
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:Several anatomical studies have shown that the articular facets of the calcaneus can present with different anatomy. This study assessed the 3D anatomy of lateral calcaneal lengthening (LCL) osteotomy in relation to the anterior and middle facet of the calcaneus in a group of skeletally immature patients treated for symptomatic flatfoot deformity. METHODS:During the study period, 14 consecutive patients (10 males, 4 females) presenting symptomatic flatfoot (20 feet) with different aetiologies underwent LCL osteotomy and CT scan with 3D reconstruction of the operated feet. Anatomy of articular factes of the calcaneus were graded according to Bunning & Barnett's classification. In order to assess clinical and functional outcome, all patients were evaluated according to Yoo et al.'s, Mosca's and AOFAS clinical criteria before surgery and at last follow-up visit. RESULTS:Despite proving difficult to assess (10 out of 20 feet), dimensions of bone and joint structures revealed significant anatomical variations. In particular, working to Bunning & Barnett's classification, anatomy of the articular facet varied significantly among patients, and in Bunning & Barnett type-B1 or B2 the LCL osteotomy necessarily violates the articular surface of the anterior and middle facet of the calcaneus due to the fact that the two facets are fused together (single articular surface). CONCLUSIONS:These biometric notions allow a better understanding of the impact on articular facets of the calcaneus of the osteotomy procedure suggested by Evans and Mosca. We anticipate that the findings reported here should lead to improved techniques for assessing all bone structures of the hindfoot, support logical classifications of the different pathological situations, and ultimately lead to improved treatment strategies.
10.1016/j.fas.2017.05.005
A plantar closing wedge osteotomy of the medial cuneiform for residual forefoot supination in flatfoot reconstruction.
Ling Jeffrey S,Ross Keir A,Hannon Charlie P,Egan Chris,Smyth Niall A,Hogan Macalus V,Kennedy John G
Foot & ankle international
BACKGROUND:Residual forefoot supination is commonly encountered during a flatfoot reconstruction, and a new technique for its treatment is described. Contrary to the standard Cotton osteotomy, a plantar closing wedge osteotomy of the medial cuneiform (PCWOMC) was performed, which has a number of advantages. METHODS:We followed 10 feet in 9 patients who had a PCWOMC performed as the last step of a standard flatfoot reconstruction for the correction of residual forefoot supination. These patients were evaluated pre- and postoperatively by standardized radiographic parameters, Short Form-12 (SF-12), and Foot and Ankle Outcome Score (FAOS). RESULTS:Patients were followed for an average of 25.8 months with final radiographic analysis performed at an average of 9.9 months. A significant difference (P < .001) between pre- and postoperative parameters was demonstrated for both lateral talus-first metatarsal angle and medial-cuneiform-to-ground distance. Likewise, there was a statistically significant improvement in the SF-12 score and 4 out of 5 components of the FAOS. One patient developed internal hardware-related symptoms, which were relieved following implant removal. All osteotomies healed uneventfully. CONCLUSION:A PCWOMC can be considered an alternative to the Cotton osteotomy for the treatment of forefoot supination deformity in adult flatfoot reconstruction. The main advantage of this technique over the Cotton osteotomy was simplicity, as an additional dorsal incision and bone graft were not required. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/1071100713487726
The effect of different foot orthoses on pain and health related quality of life in painful flexible flat foot: a randomized controlled trial.
Yurt Yasin,Şener Gül,Yakut Yavuz
European journal of physical and rehabilitation medicine
BACKGROUND:Foot orthoses are widely used in conservative treatment of painful flexible flatfoot (PFFF) however research is limited to choose the best option in orthotic treatment. AIM:We aimed to compare the effects of computer-aided design/computer-aided manufacturing (CAD-CAM) and conventional insole types in comparison with sham insole, on pain and health related quality of life in patients with PFFF. DESIGN:Randomized controlled trial. SETTING:Outpatient rehabilitation clinic. POPULATION:Sixty-seven people with PFFF, aged between 18 and 45 years, were assigned to CAD-CAM (N.=22), conventional (N.=22) or sham (N.=23) groups. METHODS:In addition to insoles, a home-based exercise program was followed by all participants for eight weeks. Foot pain intensity and quality of life were assessed at the initial evaluation and at the end of two-month follow-up. RESULTS:Pain intensity (Mean±SD, mm on VAS) was significantly lower in CAD-CAM (27.84±18.41) and conventional (27.05±16.82) insole groups than sham group (46.39±20.18) after two months (P<0.05), but there was no difference between conventional and CAD-CAM (P>0.05). All groups had significantly higher physical health scores at the second assessment (P<0.05), but there was no intergroup difference (P>0.05). CONCLUSIONS:CAD-CAM and conventionally designed insoles are both more effective than having sham insole in alleviating pain in PFFF. CLINICAL REHABILITATION IMPACT:CAD-CAM and conventionally designed semicustom insoles in conjunction with a home-based exercise program are both effective in controlling pain compared with sham insole and exercise in PFFF. Clinicians can prescribe both types of semicustom insoles as a part of conservative treatment instead of each other.
10.23736/S1973-9087.18.05108-0
Extraarticular subtalar arthrodesis for pes planovalgus: an interim result of 50 feet in patients with spastic diplegia.
Yoon Hong Ki,Park Kun Bo,Roh Jae Young,Park Hui Wan,Chi Hye Jin,Kim Hyun Woo
Clinics in orthopedic surgery
BACKGROUND:There are no reports of the pressure changes across the foot after extraarticular subtalar arthrodesis for a planovalgus foot deformity in cerebral palsy. This paper reviews our results of extraarticular subtalar arthrodesis using a cannulated screw and cancellous bone graft. METHODS:Fifty planovalgus feet in 30 patients with spastic diplegia were included. The mean age at the time of surgery was 9 years, and the mean follow-up period was 3 years. The radiographic, gait, and dynamic foot pressure changes after surgery were investigated. RESULTS:All patients showed union and no recurrence of the deformity. Correction of the abduction of the forefoot, subluxation of the talonavicular joint, and the hindfoot valgus was confirmed radiographically. However, the calcaneal pitch was not improved significantly after surgery. Peak dorsiflexion of the ankle during the stance phase was increased after surgery, and the peak plantarflexion at push off was decreased. The peak ankle plantar flexion moment and power were also decreased. Postoperative elevation of the medial longitudinal arch was expressed as a decreased relative vertical impulse of the medial midfoot and an increased relative vertical impulse (RVI) of the lateral midfoot. However, the lower than normal RVI of the 1st and 2nd metatarsal head after surgery suggested uncorrected forefoot supination. The anteroposterior and lateral paths of the center of pressure were improved postoperatively. CONCLUSIONS:Our experience suggests that the index operation reliably corrects the hindfoot valgus in patients with spastic diplegia. Although the operation corrects the plantar flexion of the talus, it does not necessarily correct the plantarflexed calcaneus and forefoot supination. However, these findings are short-term and longer term observations will be needed.
10.4055/cios.2010.2.1.13
Preliminary Results of Subtalar Arthroereisis with Vulpius Procedure for Symptomatic Flatfoot in Patients with Type I Osteogenesis Imperfecta.
Hsu Cheng-Min,Lin Sheng-Chieh,Wu Kuan-Wen,Wang Ting-Ming,Chang Jia-Feng,Lee Chia-Che
International journal of environmental research and public health
In this retrospective study, we aim to assess the safety and feasibility of adapting subtalar arthroereisis (SA) for type I osteogenesis imperfecta (OI) patients with symptomatic flatfoot. From December 2013 to January 2018, six type I OI patients (five girls and one boy, 12 feet) with symptomatic flexible flatfoot were treated with SA and the Vulpius procedure. All the patients were ambulatory and skeletally immature with failed conservative treatment and unsatisfactory life quality. The median age at the time of surgery was 10 years (range 5-11), and the median follow-up period was 55 months (range 33-83). All functional and radiographic parameters improved ( < 0.05) after the procedure at the latest follow-up. The median American Orthopaedic Foot and Ankle Society ankle-hindfoot scale improved from 68 (range 38-80) to 95 (range 71-97). All of the patients ambulated well without significant complications. The weight-bearing radiographs showed maintained correction of the tarsal bone alignment with intact bony surfaces adjacent to implants during the post-operative follow-up period. This is the very first study on symptomatic flatfoot in pediatric patients with type I OI. Our data suggest that SA is a potentially viable approach, as functional improvements and maintained radiographic correction without significant complication were observed.
10.3390/ijerph18010067
Comparison between Malerba osteotomy and combined Evans/medial displacement calcaneal osteotomies for the management of flexible pes planus in young adults: a prospective randomised control trial, three years follow-up.
Nagy Mohamed,Kholeif Ahmed,Mansour Ali M Reda,Abdelhameed Samar,Radwan Yasser A,Khedr Ahmed,Elhalawany Ahmed S,Samir Ahmed,Sarhan Islam,Zein Abo Bakr
International orthopaedics
PURPOSE:The aim of the current study is to evaluate the functional and radiological outcomes of Malerba osteotomy in comparison to the standardized combined Evans/Medial Displacement Calcaneal Osteotomy (MDCO) in the management of symptomatic flexible pes planus in young adults. METHODS:Prospective randomized control trial included 34 feet (33 patients), 17 cases in each group. Functionally, patients were assessed by AOFAS and FADI scores. Radiographic evaluation included calcaneal pitch, lateral talo-1st metatarsal, AP talo-first metatarsal, AP talo-calcaneal angles, and the talar coverage percentage. RESULTS:Pre-operative and three years follow-up scores and angles were compared between both groups. No statistically significant difference could be detected between both groups (P value 0.87). However, the data showed statistically significant difference in each group when comparing (pre-operative and third year follow-up scores and angles) (P value < 0.001). The mean union rate was eight weeks in Malerba group and nine weeks in Evans/MDCO group. No incidence of nonunion. Complications like calcaneocuboid subluxation, calcaneal anterior process fracture, and lateral column pain were exclusively reported in Evans/MDCO group. CONCLUSION:Malerba osteotomy is a strong valid option for the operative management of flexible pes planus in young adults. Authors recommend Malerba osteotomy in all mild and moderate deformities due to lower complication rate while the combined Evans/MDCO is preferred in severe deformity due to relatively higher corrective power with consideration of possible complications.
10.1007/s00264-021-05172-5
Return to Physical Activity Following Flatfoot Reconstruction.
Foot & ankle international
BACKGROUND:Progressive collapsing foot deformity (PCFD) is a debilitating condition encompassing several interrelated, progressive deformities requiring a combination of reconstructive procedures. Few studies investigate returns to activity following flatfoot reconstruction, and existing studies only examine 1 or 2 of the numerous procedures employed. This study aims to provide the first generalizable assessment of returns to sports and physical activity following reconstruction surgery in patients with flexible flatfoot deformity. METHODS:Patients aged 18-60 years who underwent reconstructive surgery between February 16 and May 19 for symptomatic flexible-stage flatfoot deformity were identified by registry review. Eighty-two of 113 eligible patients (73%) were reached at a mean 2.9 years (range, 2.0-5.4) of follow-up with mean age at surgery of 48.9 years (range, 18-59). Returns to physical activity were evaluated with a sports-specific survey. Clinical outcomes were evaluated with Patient-Reported Outcomes Measurement Information System (PROMIS) scores. RESULTS:Patients reported participation in 21 specific sports and activities. One-fourth (25.6%) of patients (21/82) reported increased difficulty with physical activities postoperatively, 15.9% reported equal difficulty, and 58.5% (48/82) reported decreased difficulty. Median return times were 9-12 months for participation and 12-18 months to reach maximum preoperative participation levels. Improvements in Physical Function (= .001), Pain Interference ( < .001), Pain Intensity ( <.001), and Global Physical Health ( = .004) were associated with increased satisfaction with respect to sports and physical activities. DISCUSSION:This study investigated participation in specific sports and physical activities following flatfoot reconstruction. Our findings suggest mixed outcomes, where many patients reported life-changing improvements but many also experienced prolonged pain and difficulty after surgery. Some patients reported increased difficulty or inability to return to their preoperative maximum level of participation, indicating that flatfoot reconstructions can lead to athletic limitations. CONCLUSION:Although flatfoot reconstruction can be a powerful tool to increase patients' capacity to engage in physical activity, in our cohort many patients had reduced physical activity outcomes. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/10711007221077098
Outcomes of the Extended Z-Cut Osteotomy for Correction of Adult Acquired Flatfoot Deformity.
Foot & ankle international
BACKGROUND:Medial displacement calcaneus tuberosity osteotomy and anterior process lengthening calcaneus osteotomy are traditional single-plane osteotomy techniques used in adult acquired flatfoot deformity reconstruction. More recently, 3-plane step-cut osteotomies were described for each of these and shown to offer improved rotational stability via the horizontal limb. However, a major technical challenge is achieving a sufficiently long horizontal limb to correct deformity through lengthening without losing bony apposition. Combining the anterior process and tuberosity step-cuts using an elongated horizontal limb alleviates this technical challenge, creates a very large surface area for bony healing, and utilizes a single incision. We hypothesized that the Z-cut osteotomy would achieve clinical and radiographic flatfoot deformity correction with a high union rate. METHODS:This was an institutional review board-approved retrospective study of 16 patients who underwent Z-cut osteotomy for the treatment of moderate to severe symptomatic adult acquired flatfoot deformity, stage IIA/B. The mean radiographic follow-up was 8.8 months, while the mean clinical follow-up was 2.36 years. Radiographic correction was assessed via weightbearing radiographs taken preoperatively and at a mean of 26 ± 2 weeks postoperatively. Measurements included Meary's angle (talo-first metatarsal angle), talonavicular (TN) joint uncoverage percentage, TN incongruency angle, medial cuneiform to fifth metatarsal height, and calcaneal pitch. Union rates and clinical outcomes via the Foot Function Index (FFI) score were assessed preoperatively and at a mean of 29 months following surgery. Paired test was used to compare both clinical and radiographic outcomes with statistical significance set at < .05. RESULTS:Fifteen of 16 patients returned an FFI questionnaire with a mean improvement of 52.1 to 10.3 ( = .002). The calcaneal pitch improved from 12.7 to 15.2 degrees ( = .002), the medial cuneiform-fifth metatarsal distance improved from 12.8 to 18.5 mm ( = .002), the TN coverage angle improved from 21.3 to 9.1 degrees ( < .001), the TN uncoverage percentage improved from 32.9% to 20.3% ( < .001), and the TN incongruency angle improved from 41.4 to 19.9 degrees ( < .001). Deformity correction was well maintained in 13 of 16 patients at final follow-up. The union rate of the osteotomy was 100%. Three patients had symptomatic hardware initially; 1 patient required removal of hardware. One patient developed a superficial infection that cleared. Another patient developed peroneal tendonitis, which resolved with corticosteroid injection. CONCLUSION:The Z-cut osteotomy is a novel, technically simplified, single-incision, single-osteotomy alternative to the previously described double calcaneus osteotomy techniques for reconstructing flexible moderate to severe adult acquired flatfoot deformity that offers comparable short-term clinical and radiographic outcomes with acceptably low complications. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/1071100719847662
Graft shape affects midfoot correction and forefoot loading mechanics in lateral column lengthening osteotomies.
Baxter Josh R,Demetracopoulos Constantine A,Prado Marcelo Pires,Gilbert Susannah L,Tharmviboonsri Theerawoot,Deland Jonathan T
Foot & ankle international
BACKGROUND:Adult acquired flatfoot deformity is characterized by midfoot abduction and collapse of the medial longitudinal arch. Lateral column lengthening osteotomies primarily correct the abduction deformity, but the effects of graft shape on deformity correction and forefoot loading are unclear. Therefore, the purpose of this study was to demonstrate the effect of graft shape and taper on deformity correction and forefoot loading mechanics in a cadaveric flatfoot model. METHODS:Flatfoot deformity was simulated in 18 cadaveric specimens. A lateral column lengthening osteotomy was performed using a triangular, trapezoidal, and rectangular graft for each specimen. During each testing condition, talonavicular joint angles and forefoot plantar pressures were measured. RESULTS:Each graft shape corrected abduction and dorsiflexion deformity at the talonavicular joint. Coronal plane correction was affected by graft shape, and the less tapered trapezoidal and rectangular grafts overloaded the lateral forefoot compared to the intact condition. The more tapered triangular graft did not cause a lateral shift in forefoot pressures. Forefoot plantar pressures were strongly correlated with talonavicular abduction correction (R (2) = .473, P < .001). CONCLUSION:Graft shape had no effect on the correction of talonavicular abduction or dorsiflexion but did influence coronal plane motion and forefoot loading mechanics. Also, overcorrecting the abduction deformity was predictive of increased lateral plantar pressures. CLINICAL RELEVANCE:Although overcorrection of the abduction deformity at the midfoot remains the primary determinant of lateral forefoot overload, utilizing a graft with a larger taper may lower the incidence of lateralized forefoot pressure following correction.
10.1177/1071100714545628
Effects of Short-Foot Exercises on Foot Posture, Pain, Disability, and Plantar Pressure in Pes Planus.
Unver Banu,Erdem Emin Ulas,Akbas Eda
Journal of sport rehabilitation
CONTEXT:Pes planus is a prevalent chronic condition that causes foot pain, disability, and impaired plantar load distribution. Short-foot exercises are often recommended to strengthen intrinsic foot muscles and to prevent excessive decrease of medial longitudinal arch height. OBJECTIVE:To investigate the effects of short-foot exercises on navicular drop, foot posture, pain, disability, and plantar pressures in pes planus. DESIGN:Quasi-experimental study. SETTING:Biomechanics laboratory. PARTICIPANTS:A total of 41 participants with pes planus were assigned to the short-foot exercises group (n = 21) or the control group (n = 20). INTERVENTION:Both groups were informed about pes planus, usual foot care, and appropriate footwear. Short-foot exercises group performed the exercises daily for 6 weeks. MAIN OUTCOME MEASURES:Navicular drop, Foot Posture Index, foot pain, disability, and plantar pressures were assessed at the baseline and at the end of 6 weeks. RESULTS:Navicular drop, Foot Posture Index, pain, and disability scores were significantly decreased; maximum plantar force of midfoot was significantly increased in short-foot exercises group over 6 weeks (P < .05). No significant differences were determined between the baseline and the sixth week outcomes in control group (P > .05). CONCLUSIONS:Six-week short-foot exercises provided a reduction in navicular drop, foot pronation, foot pain, and disability and increment in plantar force of medial midfoot in pes planus.
10.1123/jsr.2018-0363
Triple arthrodesis with lateral column lengthening for the treatment of planovalgus deformity.
Frost Nathan L,Grassbaugh Jason A,Baird Glen,Caskey Paul
Journal of pediatric orthopedics
BACKGROUND:The rigid planovalgus foot has historically been difficult to correct and maintain in a corrected position with triple arthrodesis (TA). The lateral column lengthening (LCL) is a procedure that corrects the position of the planovalgus foot. Combining the TA with LCL at the calcaneocuboid joint may improve ultimate position after fusion for patients with rigid planovalgus foot deformities. METHODS:A retrospective review of all patients who underwent TA with LCL through the calcaneocuboid joint for rigid planovalgus foot deformity was performed. Preoperative and postoperative radiographs were compared for foot alignment by measuring the talo-first metatarsal angle in the anterior-posterior and lateral planes, calcaneal pitch, talo-horizontal angle, metatarsal stacking angle, and medial/lateral column ratio. Clinical outcomes were evaluated for correlation with preoperative and postoperative deformity and surgical indications. RESULTS:were evaluated using radiographic and clinic outcome measures developed for TA and LCL. RESULTS:: Twenty-nine surgeries were identified with solid fusions occurring in 27 patients by 12 weeks postoperatively. Two patients with cerebral palsy had persistent hindfoot valgus. At an average follow-up of 32 months after surgical intervention, correction of the talo-first metatarsal angle in the AP and lateral planes, calcaneal pitch, and talo-horizontal angles were statistically significant. There were 25 good clinical results with minimal or no pain with activity (86.2%) and 4 poor or fair results with moderate or severe pain (13.8%). There were 26 radiographic successes (89.7%) and 3 radiographic failures (10.3%). Cerebral palsy was associated with a higher rate of radiographic failures (P=0.01). There were 15 total complications in 11 feet (37.9%). These included 4 related to hardware, 3 involving neurological symptoms, 2 related to soft tissues, development of a symptomatic bony prominence in 2 patients, 1 forefoot deformity, 2 nonunions, and 1 case of Achilles tendonitis. CONCLUSION:Good correction can be obtained and maintained with LCL and TA for rigid planovalgus foot deformity. The procedure is associated with good short-term clinical and radiographic outcomes and improves the position of the foot with diminished risk of recurrent or continued deformity as compared with historical controls. LEVEL OF EVIDENCE:Level IV (case series).
10.1097/BPO.0b013e31822d3882
The combined effect of short foot exercises and orthosis in symptomatic flexible flatfoot: a randomized controlled trial.
European journal of physical and rehabilitation medicine
BACKGROUND:Flatfoot is a musculoskeletal problem associated with dysfunctional active and passive supporting structures of the normal foot curvature. Strengthening of the intrinsic foot muscles or using shoe orthosis are recommend treatment approaches. However, investigating the effect of combining both approaches is still warranted. AIM:To examine the effect of applying short foot exercises (SFE) combined with shoe insole versus shoe insole alone on foot pressure measures, pain, function and navicular drop in individuals with symptomatic flexible flatfoot. DESIGN:Prospective, active control, parallel-group, assessor-blinded, randomized controlled trial and intention-to-treat analysis. SETTING:Outpatient physical therapy clinic of a university teaching hospital. POPULATION:Forty participants with symptomatic flexible flatfoot. METHODS:A six-week treatment protocol of SFE (three sets of 10 repetitions a day) in addition to shoe insole (eight hours a day) (experimental group, N.=20) or shoe insole only (eight hours a day) (control group, N.=20). Clinic visits were made at baseline and every two weeks for monitoring and follow-up. The static and dynamic foot area, force and pressure measures, pain, lower extremity function, and navicular drop were assessed at baseline and postintervention. RESULTS:Forty participants joined the study and 37 (92.5%) completed the six-week intervention period. Foot pressure, pain and function showed a significant interaction (P=0.02 - <0.001) and time (P<0.001) effects with a non-significant group effect in favor of the experimental group. Post-hoc analysis revealed that the experimental group had lesser pain (P=0.002) and better function (P=0.03) than the control group at six weeks. Navicular drop decreased equally in both groups. CONCLUSIONS:Implementation of shoe insole and SFE for six weeks improved pain and function and altered foot pressure distribution greater than shoe insole alone in patients with symptomatic flatfoot. CLINICAL REHABILITATION IMPACT:Wearing shoe insole is an easy, but passive, treatment approach for a flatfoot problem. This study provided evidence regarding the added benefit of SFE. It is recommended that rehabilitation practitioners implement a comprehensive treatment protocol including both shoe insole and SFE for at least six weeks to achieve better results for their flatfoot patients.
10.23736/S1973-9087.23.07846-2
A novel implantable mechanism-based tendon transfer surgery for adult acquired flatfoot deformity: Evaluating feasibility in biomechanical simulation.
PloS one
Adult acquired flatfoot deformity becomes permanent with stage III posterior tibialis tendon dysfunction and results in foot pain and difficulty walking and balancing. To prevent progression to stage III posterior tibialis tendon dysfunction when conservative treatment fails, a flexor digitorum longus to posterior tibialis tendon transfer is often conducted. However, since the flexor digitorum longus only has one-third the force-capability of the posterior tibialis, an osteotomy is typically also required. We propose the use of a novel implantable mechanism to replace the direct attachment of the tendon transfer with a sliding pulley to amplify the force transferred from the donor flexor digitorum longus to the foot arch. In this work, we created four OpenSim models of an arched foot, a flatfoot, a flatfoot with traditional tendon transfer, and a flatfoot with implant-modified tendon transfer. Paired with these models, we developed a forward dynamic simulation of the stance phase of gait that reproduces the medial/lateral distribution of vertical ground reaction forces. The simulation couples the use of a fixed tibia, moving ground plane methodology with simultaneous activation of nine extrinsic lower limb muscles. The arched foot and flatfoot models produced vertical ground reaction forces with the characteristic double-peak profile of gait, and the medial/lateral distribution of these forces compared well with the literature. The flatfoot model with implant-modified tendon transfer produced a 94.2% restoration of the medial/lateral distribution of vertical ground reaction forces generated by our arched foot model, which also represents a 2.1X improvement upon our tendon transfer model. This result demonstrates the feasibility of a pulley-like implant to improve functional outcomes for surgical treatment of adult acquired flatfoot deformity with ideal biomechanics in simulation. The real-world efficacy and feasibility of such a device will require further exploration of factors such as surgical variability, soft tissue interactions and healing response.
10.1371/journal.pone.0270638
Lateral column osteotomy versus subtalar arthroereisis in the correction of Grade IIB adult acquired flatfoot deformity: A clinical and radiological follow-up at 24 months.
Silva M G A N,Koh Don T S,Tay Kae Sian,Koo Kevin O T,Singh Inderjeet R
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:Adult acquired flat foot deformity (AAFD) is a spectrum of conditions which can be progressive if untreated. Surgical correction and restoration of anatomical relationship are often required in the treatment of symptomatic Grade II AAFD after a failed course of conservative treatment. There is a paucity of literature recommending best practice-especially in the adult population. The authors aim to compare radiological and clinical outcomes of two widely employed surgical techniques in the treatment of symptomatic AAFD. METHODS:A retrospective study of 76 patients with Grade IIB AAFD and had undergone either lateral column lengthening (LCL) or subtalar arthroereisis (STA) surgical correction of their symptomatic AAFD. Each technique was augmented with both bony osteotomy and soft tissue transfer as determined by on table assessment. Clinical and radiological outcomes were reviewed 24 months after surgery. RESULTS:LCL and STA groups had comparable radiological outcomes at 24 months after surgery. However, LCL group demonstrated superior American Orthopaedic Foot and Ankle Society (AOFAS) midfoot (90.3 ± 12.6 vs 81.1 ± 20.6, p < 0.001) as well as Visual Analogue Scale (VAS) midfoot scores (0.5 ± 1.6 vs 1.3 ± 2.4, p < 0.001) at 24 months compared to the STA group. STA had a higher complication rate (20.6% vs 4.4%), with all cases complaining of sinus tarsi pain requiring subsequent removal of implant. CONCLUSION:There is a role for either techniques in the treatment of symptomatic AAFD. LCL whilst more invasive has demonstrated superior outcome scores and lower complication rates at 24 months compared to STA. Patients need to be counselled appropriately to appreciate the benefits of each technique.
10.1016/j.fas.2020.07.010
Passive engineering mechanism enhancement of a flexor digitorum longus tendon transfer procedure.
Pihl Connor M,Stender Christina J,Balasubramanian Ravi,Edinger Kylie M,Sangeorzan Bruce J,Ledoux William R
Journal of orthopaedic research : official publication of the Orthopaedic Research Society
Standard treatments of adult acquired flatfoot deformity (AAFD) fail to correct associated dysfunction of the posterior tibial tendon (PTT). This study aimed to determine if a novel passive engineering mechanism (PEM) enhanced flexor digitorum longus (FDL) tendon transfer procedure would better restore physiologic PTT function to improve AAFD gait parameters compared to standard treatment. We evaluated the kinetic, pedobarographic, and kinematic effects of a pulley-based PEM-enhancement system utilizing a cadaveric flatfoot model and robotic gait simulator. FDL tendon force, FDL tendon excursion, regional peak plantar pressures, center of pressure, and foot bone/joint motions were quantified. Throughout the stance phase of gait, PEM-enhancement significantly increased FDL tendon forces, resulting in gait cycle medial column unloading, lateral column loading, forefoot adduction, hindfoot inversion, and increased plantar flexion (p < 0.05). This proof-of-concept study demonstrated that an innovative PEM-enhanced FDL tendon transfer procedure better restored physiologic PTT function, resulting in improved correction of the distinctive AAFD gait characteristics-medial column collapse, hindfoot eversion, and forefoot abduction. Clinical significance: Novel PEM-enhancement of a FDL tendon transfer procedure holds promise as a method for improved treatment of AAFD. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3033-3042, 2018.
10.1002/jor.24051
Postoperative Medial Cuneiform Position Correlation With Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity.
Foot & ankle international
BACKGROUND:Residual supination of the midfoot during reconstruction of the stage II adult-acquired flatfoot deformity (AAFD) is often addressed with a medial cuneiform (Cotton) osteotomy after adequate correction of the hindfoot valgus deformity. The purpose of this study was to determine if there was a correlation between postoperative alignment of the medial cuneiform and patient-reported outcomes. METHODS:Sixty-three feet in 61 patients with stage II AAFD who underwent a Cotton osteotomy as part of a flatfoot reconstruction were included in the study. Radiographic angles were measured on weightbearing lateral radiographs at a minimum of 40 weeks postoperatively. Pearson's correlation analysis was used to determine if there was an association between postoperative radiographic angles and Foot and Ankle Outcome Score (FAOS) at a minimum of 24 months postoperatively. Patients were also divided into mild plantarflexion (cuneiform articular angle [CAA] ≥-2 degrees) and moderate plantarflexion (CAA <-2 degrees) groups to evaluate for differences in clinical outcomes. RESULTS:Postoperative CAA was significantly positively correlated with the postoperative FAOS symptoms ( r = .27, P = .03), daily activities ( r = .29, P = .02), sports activities ( r = .26, P = .048), and quality of life ( r = .28, P = .02) subscales. Patients in the mild plantarflexion group had statistically and clinically better outcomes compared with the moderate plantarflexion group in the FAOS symptoms ( P = .04), daily activities ( P = .04), and sports activities ( P = .01) subscales. CONCLUSIONS:Our study suggests that the surgeon should avoid excessive plantarflexion of the medial cuneiform and use the Cotton osteotomy judiciously as part of a flatfoot reconstruction for stage II AAFD. LEVEL OF EVIDENCE:Level III, comparative series.
10.1177/1071100718822839
The use of tricortical autograft versus allograft in lateral column lengthening for adult acquired flatfoot deformity: an analysis of union rates and complications.
Grier Kathleen M,Walling Arthur K
Foot & ankle international
BACKGROUND:The management of adult acquired flatfoot is an evolving practice with the optimal lateral column lengthening procedure still left to considerable debate. The usual choices include lengthening with the use of autograft or allograft through a calcaneocuboid lengthening arthrodesis or Evans' calcaneal lengthening osteotomy. To our knowledge there is only one other study comparing autograft to allograft in adult lateral column lengthening procedures.(9) The purpose of this study was to evaluate differences with regard to union rates and complications when comparing the use of iliac tricortical autograft versus iliac tricortical allograft supplemented with platelet rich plasma (PRP) in adult acquired flatfoot lateral column lengthening procedures. MATERIALS AND METHODS:The charts and radiographs of 49 patients (51 feet) were evaluated. Twenty total procedures were performed using iliac tricortical autograft and 31 procedures were performed using iliac tricortical allograft with PRP. RESULTS:Successful union was achieved in 14 of 20 (70%) autograft procedures and 29 of 31 (94%) allograft procedures. Thirteen of 20 (65%) of the autograft group and 11 of 31 (35%) of the allograft group had a documented complication other than nonunion. Average length of hospital stay for patients who had procedures using autograft was 3.6 days and those who had allograft was 2.5 days. The average charge for those receiving allograft with PRP, including hospital stay, was roughly $2,500 more than those receiving an autograft procedure. CONCLUSION:Although the numbers were small, we believe that equivalent if not better healing and complication rates are possible with the use of allograft with PRP versus autograft for lateral column lengthening procedures while allowing for similar correction of deformity.
10.3113/FAI.2010.0760
Obtaining local bone graft for Evans calcaneal osteotomy in pes planovalgus deformity correction.
Mohamed Khalid M S,Fenelon Christopher,Galbraith John G,D'Souza Lester G
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
Lateral column lengthening osteotomy is very useful surgical technique in treating stage II of pes planovalgus deformity of the foot. Either autograft from the iliac crest or allograft can be used for this purpose. In our technique we describe a novel method of obtaining bone graft locally from the calcaneus and therefore avoiding complications and morbidity associated with iliac crest graft.
10.1016/j.fas.2016.10.007
Combined Spring and Deltoid Ligament Repair in Adult-Acquired Flatfoot.
Nery Caio,Lemos André Vitor Kerber C,Raduan Fernando,Mansur Nacime Salomão B,Baumfeld Daniel
Foot & ankle international
BACKGROUND:Adult-acquired flatfoot deformity (AAFD) is usually due to a combination of mechanical failure of the osteoligamentous complex that maintains the medial longitudinal arch of the foot and attenuation or complete tear of the posterior tibial tendon. Magnetic resonance imaging studies in patients with flatfoot deformities have reported the posterior tibial tendon to be pathologic in up to 100% of patients, the spring ligament in up to 87%, and the deltoid ligament in 33%. Many studies in the literature describe reconstruction of the spring ligament or the deltoid ligament associated with AAFD, but there is no study in which both (spring and deltoid) ligaments are reconstructed at the same time. We describe a novel technique to reconstruct the deltoid ligament and the spring ligament at the same time. METHODS:We described the technique and evaluated 10 consecutive patients with AAFD and insufficient ankle and midfoot ligaments. RESULTS:We found no postoperative complications, stiffness, or loss of correction. CONCLUSION:We present a novel technique to reconstruct the failed deltoid and spring ligament during flatfoot correction. It is unique in that it uses internal brace augmentation with FiberTape to help and protect the soft tissue healing. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/1071100718770132
The effect of 3 foot pads on plantar pressure of pes planus foot type.
Nordsiden Lacey,Van Lunen Bonnie L,Walker Martha L,Cortes Nelson,Pasquale Maria,Onate James A
Journal of sport rehabilitation
CONTEXT:Many styles of foot pads are commonly applied to reduce immediate pain and pressure under the foot. OBJECTIVE:To examine the effect of 3 different foot pads on peak plantar pressure (PPP) and mean plantar pressure (MPP) under the first metatarsophalangeal joint (MTPJ) during slow running. DESIGN:A 4 (pad) x 4 (mask) repeated-measures design. SETTING:University athletic training clinic and fitness facility. PARTICIPANTS:20 physically active participants, 12 men (19.7 +/- 1.3 y, 181.5 +/- 6.3 cm, 83.6 +/- 12.3 kg) and 8 women (20.8 +/- 1.5 y, 172.7 +/- 11.2 cm, 69.9 +/- 14.2 kg) with navicular drop greater than or equal to 10 mm, no history of surgery to the lower extremity, and no history of pain or injury to the first MTPJ in the past 6 months. INTERVENTIONS:PPP and MPP were evaluated under 4 areas of the foot: the rear foot, lateral forefoot, medial forefoot, and first MTPJ. Four pad conditions (no pad, metatarsal dome, U-shaped pad, and donut-shaped pad) were evaluated during slow running. All measurements were taken on a standardized treadmill using the Pedar in-shoe pressure-measurement system. MAIN OUTCOME MEASURES:PPP and MPP in 4 designated foot masks during slow running. RESULTS:The metatarsal dome produced significant decreases in MPP (163.07 +/- 49.46) and PPP (228.73 +/- 63.41) when compared with no pad (P < .001). The U-shaped pad significantly decreased MPP (168.68 +/- 50.26) when compared with no pad (P < .001). The donut-shaped pad increased PPP compared with no pad (P < .001). CONCLUSIONS:The metatarsal dome was most effective in reducing both peak and mean plantar pressure. Other factors such as pad comfort, type of activity, and material availability must also be considered. Further research should be conducted on the applicability to other foot types and symptomatic subjects.
10.1123/jsr.19.1.71
Lateral column lengthening corrects hindfoot valgus in a cadaveric flatfoot model.
Baxter Josh R,Demetracopoulos Constantine A,Prado Marcelo Pires,Tharmviboonsri Theerawoot,Deland Jonathan T
Foot & ankle international
BACKGROUND:Adult-acquired flatfoot deformity requires a complex operative plan that often utilizes a number of procedures to correct deformity, at both the hindfoot and midfoot. A lateral column lengthening procedure is typically performed to correct abduction deformity across the talonavicular joint; however its effect on hindfoot alignment is not well understood, and overcorrecting the hindfoot deformity can lead to pain and revision surgeries. Therefore, understanding the effect of lateral column lengthening on hindfoot alignment is important for operative planning. The aim of this study was to demonstrate the effect of a lateral column lengthening osteotomy on hindfoot valgus in a simulated flatfoot model. METHODS:A flatfoot deformity was created in 12 lower limb cadaveric specimens. A step-cut lateral column lengthening osteotomy was performed and changes in hindfoot and midfoot alignment were measured using a motion capture system. RESULTS:The lateral column lengthening procedure corrected 60% of the hindfoot valgus deformity (P < .001). In addition, the abduction deformity at the midfoot was completely corrected with the procedure (P < .001). CONCLUSION:Our findings suggest that the lateral column lengthening procedure corrects hindfoot valgus, in addition to midfoot abduction, in a flatfoot deformity. CLINICAL RELEVANCE:Understanding the relative contribution of each operative procedure to the overall deformity correction in flatfoot reconstruction will allow surgeons to accurately correct the foot into a plantigrade position while minimizing the risk of overcorrection.
10.1177/1071100715571439
Severe Flexible Pes Planovalgus Deformity Correction Using Trabecular Metallic Wedges.
Tsai Justin,McDonald Elizabeth,Sutton Ryan,Raikin Steven M
Foot & ankle international
BACKGROUND::Lateral column lengthening and plantarflexion dorsal opening wedge osteotomy of the medial cuneiform are 2 commonly used procedures to address the deformity seen in severe flexible pes planovalgus deformity. Traditionally, iliac crest allograft or autograft has been used to fill the osteotomy sites. Porous metallic wedges can be used as an alternative to avoid the concerns associated with both autograft and allograft. METHODS::We performed a retrospective review of patients who had corrective osteotomies utilizing metallic wedges to address flexible pes planovalgus with at least 2 years of follow-up data. Preoperative radiographic measurements (anteroposterior [AP] and talo-first metatarsal angle, calcaneal pitch, talocalcaneal angle, and talonavicular uncoverage angle) and functional scores (visual analog scale [VAS] pain, Foot and Ankle Ability Measure [FAAM] Activities of Daily Living [ADL], FAAM Sports) were compared to postoperative radiographic measurements and functional scores. RESULTS::There were statistically significant improvements in all radiographic parameters and functional scores. Two nonunions were seen, one of which healed with revision surgery while the other was asymptomatic. At the time of last radiographic follow-up, there were no recurrences of deformity or collapse. CONCLUSION::Porous metallic wedges offer an attractive alternative to autograft and/or allograft in the setting of corrective osteotomies for severe flexible pes planovalgus. Patients who underwent corrective osteotomies using these wedges demonstrated reliable, effective, and stable radiographic correction as well as significant improvements in function and pain. LEVEL OF EVIDENCE::Level IV, case series.
10.1177/1071100718816054
Reconstruction of the symptomatic idiopathic flatfoot in adolescents and young adults.
Oh Irvin,Williams Benjamin R,Ellis Scott J,Kwon Duck Joo,Deland Jonathan T
Foot & ankle international
BACKGROUND:The surgical indications, timing, and procedure for flexible flatfoot reconstruction in young patients remains controversial. This retrospective study reports the clinical results of reconstruction of flexible, idiopathic, symptomatic flatfoot in adolescent and young adults indicated for surgery by persistent pain and functional limitations. The hypothesis was that the results of these procedures allow patients to return to sports activities with minimal discomfort or pain. MATERIALS AND METHODS:Sixteen consecutive idiopathic flatfeet in ten patients with a mean age of 15.6 years at the time of surgery (range, 10 to 22) were assessed at a final followup visit at average of 5.2 (range, 2 to 10) years. Reconstruction included combined medializing calcaneal osteotomy and lateral column lengthening in all 16 patients. Flexor digitorum longus transfer (nine), medial column stabilization (eight), and gastroncnemius recession (eight) were carried out as needed. The AOFAS, SF-36, and FAOS questionnaires were completed. Sports activity and patient satisfaction were also assessed. Standard preoperative and postoperative radiographic parameters were measured. RESULTS:The mean AOFAS score increased on average from 49.1 to 93.4. Only one patient reported a postoperative restriction in sports. The satisfaction level was excellent in 15 feet and good in one foot. Significant improvement in radiographic parameters was noted for the AP talonavicular coverage angle (p < 0.001) and lateral talar-first metatarsal angle (p < 0.001). CONCLUSION:Flexible flatfoot reconstruction in a cohort of symptomatic adolescent and young adult patients achieved a reduction of pain and improved functional outcome including the ability to participate in sporting activities.
10.3113/FAI.2011.0225
Treatment of severe, painful pes planovalgus deformity with hindfoot arthrodesis and wedge-shaped tricortical allograft.
Chou Loretta B,Halligan Benjamin W
Foot & ankle international
BACKGROUND:This study tested the hypothesis that modification of the standard technique of hindfoot arthrodesis with the use of a wedge-shaped tricortical allograft would improve the amount of correction of pes planovalgus deformity. The results were compared to previous reports. METHODS:Between 1998 and 2005, the senior author (LBC) performed 13 hindfoot arthrodeses on 12 patients using an allograft to improve correction of the deformity for severe, painful pes planovalgus deformity. The average patient age was 55 (range 27 to 77) years. There were seven women and five men. The indications were posterior tibial tendon dysfunction (seven feet), rheumatoid arthritis (three feet), post-traumatic arthritis and deformity (one foot), congenital pes planovalgus (one foot), and tarsal coalition (one foot). RESULTS:Twelve of 13 feet achieved union by 12 weeks postoperatively. There was one nonunion. The average time to fusion was 12 weeks. All 12 patients were satisfied with the results of the operation. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score was 87 points, and the AOFAS Midfoot score was 85 points. Preoperative and postoperative radiographs were compared to evaluate correction of deformity. On lateral weightbearing views, the talo-first metatarsal angle improved from 15 to 6 degrees, and the lateral talocalcaneal angle improved from 48 to 35 degrees. On anteroposterior views, the talo-first metatarsal angle improved from 17 to 7 degrees, the talonavicular coverage decreased from 28 to 13 degrees, and the talocalcaneal angle improved from 23 to 13 degrees. CONCLUSIONS:A simple modification of the addition of allograft to a common procedure of hindfoot arthrodesis to treat severe, painful pes planovalgus results is reliable and offers satisfactory correction.
10.3113/FAI.2007.0569
PTT functional recovery in early stage II PTTD after tendon balancing and calcaneal lengthening osteotomy.
Brilhault Jean,Noël Vincent
Foot & ankle international
BACKGROUND:The decision to offer surgery for Stage II posterior tibial tendon deficiency (PTTD) is a difficult one since orthotic treatment has been documented to be a viable alternative to surgery at this stage. Taking this into consideration we limited our treatment to bony realignment by a lengthening calcaneus Evans osteotomy and tendon balancing. The goal of the study was to clinically evaluate PTT functional recovery with this procedure. METHOD:The patient population included 17 feet in 13 patients. Inclusion was limited to early Stage II PTTD flatfeet with grossly intact but deficient PTT. Deficiency was assessed by the lack of hindfoot inversion during single heel rise test. The surgical procedure included an Evans calcaneal opening wedge osteotomy with triceps surae and peroneus brevis tendon lengthening. PTT function at follow up was evaluated by an independent examiner. Evaluation was performed at an average of 4 (range, 2 to 6.3) years. RESULTS:One case presented postoperative subtalar pain that required subtalar fusion. Every foot could perform a single heel rise with 13 feet having active inversion of the hindfoot during elevation. CONCLUSIONS:The results of this study provide evidence of PTT functional recovery without augmentation in early Stage II. It challenges our understanding of early Stage II PTTD as well as the surgical guidelines recommending PTT augmentation at this specific stage.
DOI: 10.3113/FAI.2012.0813
Anti-pronator components are essential to effectively alter lower-limb kinematics and kinetics in individuals with flexible flatfeet.
Desmyttere Gauthier,Hajizadeh Maryam,Bleau Jacinte,Leteneur Sébastien,Begon Mickael
Clinical biomechanics (Bristol, Avon)
BACKGROUND:Foot orthoses are commonly used to correct for foot alterations and especially address excessive foot pronation in individuals with flatfeet. In recent years, 3D printing has taken a key place in orthotic manufacturing processes as it offers more options and can be patient specific. Hence, the purpose of this study was to evaluate whether stiffness of 3D printed foot orthoses and a newly designed rearfoot posting have an effect on lower limb kinematics and kinetics in individuals with flatfeet. METHODS:Nineteen patients with flexible flatfeet were provided two pairs of customized 3D printed ¾ length orthotics. Foot orthoses were of different stiffness and could feature a rearfoot posting, consisting of 2-mm carbon fiber plate. Lower limb kinematics and kinetics were computed using a multi-segment foot model. One-way ANOVAs using statistical non-parametric mapping, refined by effect sizes, were performed to determine the magnitude of the effect between conditions. FINDINGS:Foot orthoses stiffness had little effect on midfoot and forefoot biomechanics. Reductions in midfoot eversion and forefoot abduction were observed during short periods of stance with rigid foot orthoses. Adding the posting had notable effects on rearfoot kinematics and on the ankle and knee kinetics in the frontal plane; it significantly reduced the eversion angle and inversion moment at the ankle, and increased the knee abduction moment. INTERPRETATION:Using an anti-pronator component is more effective than increasing foot orthoses stiffness to observe a beneficial impact of foot orthoses on the control of excessive foot pronation in individuals with flatfeet.
10.1016/j.clinbiomech.2021.105390
Mid-term Results of Intramuscular Lengthening of Gastrocnemius and/or Soleus to Correct Equinus Deformity in Flatfoot.
Rong Kai,Ge Wen-tao,Li Xing-chen,Xu Xiang-yang
Foot & ankle international
BACKGROUND:Intramuscular lengthening of the gastrocnemius and/or soleus (Baumann procedure) is widely used in patients who have cerebral palsy, with several advantages over other lengthening techniques. Tightness of the gastrocnemius or gastrocnemius-soleus complex has been confirmed to be related to flatfoot deformity. The purpose of this study was to evaluate the mid-term results of the Baumann procedure as a part of the treatment of flatfoot with equinus deformity. METHODS:We reviewed 35 pediatric and adult patients (43 feet) with flatfoot who underwent the Baumann procedure for the concomitant equinus deformity. The mean duration of follow-up was 39.4 months. Preoperative and follow-up evaluations included the maximal angle of dorsiflexion of the ankle with the knee fully extended and with the knee flexed to 90 degrees, the American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS-AH) scores, and postoperative complications. RESULTS:Preoperatively, the mean angle of passive ankle dorsiflexion with the knee extended was -4.7 ± 2.7 degrees and that with the knee flexed was 2.3 ± 2.5 degrees. At the final follow-up, both values improved significantly by a mean of 13.6 degrees (P < .001) and 9.7 degrees (P < .001), respectively. The average AOFAS-AH scores improved from 56.8 points preoperatively to 72.1 at the final follow-up. Recurrence of equinus was observed in 3 patients (4 feet). There were no cases of overcorrection, neurovascular injury, or healing problems. CONCLUSIONS:Our results indicate that the Baumann procedure can effectively and sequentially correct the tightness of the gastrocnemius or the gastrocnemius-soleus complex in patients with flatfoot deformity, without obvious postoperative complications. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/1071100715588994
Lengthening of the lateral column and reconstruction of the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the posterior tibial tendon.
Hintermann B,Valderrabano V,Kundert H P
Foot & ankle international
We analyzed our results of surgery for acquired flatfoot deformity after dysfunction of the posterior tibial tendon. This included lengthening the proximal lateral column by calcaneal osteotomy and reconstructing the medial soft tissue. Nineteen patients (9 women and 10 men; average age, 52.9 years [range, 24-72 years]) were treated for stage II and stage II-III insufficiency of the posterior tibial tendon. The medial soft tissue surgery included 18 reconstructions of the tendon, 11 transfers of the flexor digitorum longus tendon, 13 repairs of the deltoid ligament, and 3 repairs of the spring ligament. At follow-up (mean, 23.4 months), all patients had satisfactory restoration of their medial longitudinal arch, reduction of abduction in the forefoot, and restored height in the arch. All patients were able to bear weight fully on the foot that underwent surgery, and all but one were satisfied with the result achieved. The clinical result was rated as excellent in 6, good in 11, and fair in 2 cases. In all but one case, no loss of achieved correction in the foot was found. In one case, the calcaneocuboid joint had to undergo arthrodesis after 5 months because of painful degenerative joint disease. In the pes planovalgus and abductus deformities occurring in stage II disease, calcaneal osteotomy and reconstruction of the medial tendon and ligament seem to play a significant role in operative management. This was the case only when degenerative joint disease and significant subluxation of the subtalar or talonavicular joint or both had not already occurred. They seem to function by restoring more normal biomechanics, which allows reconstructed or transferred tendon to function successfully.
10.1177/107110079902001002
Results of calcaneocuboid distraction arthrodesis.
Grunander Todd R,Thordarson David B
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:One powerful method of reconstructing an adult acquired flatfoot deformity is a calcaneocuboid distraction arthrodesis. We performed a retrospective review of a small series of patients who underwent a calcaneocuboid distraction arthrodesis with a femoral head allograft. MATERIALS AND METHODS:Sixteen feet (14 patients) were identified with an average follow up of 23 months (8-39 months) and an average age of 43 years (16-60 years). A calcaneocuboid distraction arthrodesis was performed with a femoral head allograft, secured with a 3 hole 1/3 tubular plate with 7 of the grafts being supplemented with platelet rich plasma (PRP). Patients were kept non-weight bearing for 6 weeks with an additional 6 weeks in a walking cast or boot. Plain radiographs and if necessary a CT or MRI were used to evaluate for union. RESULTS:Seven of the 16 feet developed a nonunion. Five of 9 patients without PRP developed a nonunion vs 2 of 7 patients where PRP was used. CONCLUSION:Due to the unacceptably high complication rate with this procedure, the authors have abandoned this procedure. If an allograft is to be used for a calcaneocuboid arthrodesis, the authors strongly recommend using rigid locking fixation with a longer period of protected immobilization.
10.1016/j.fas.2011.01.004
Surgical treatment of idiopathic pes planovalgus in paediatric patients.
Thévenin-Lemoine Camille,Khouri Néjib
Orthopaedics & traumatology, surgery & research : OTSR
Idiopathic pes planus is common and usually physiologic. Decompensation, when it occurs, may be obvious or on the contrary difficult to identify, raising challenges in patient selection for surgical treatment. The physical examination of a child with pes planus must include an evaluation in the supine position, which helps to adjust the amount of correction during surgery. The many reported surgical procedures include repositioning (talus-reseating, subtalar implants and calcaneo-stop screw), osteotomies and joint fusions. The primary treatment goal is to achieve full architectural correction of the deformity. Selection of the procedure depends on patient age and reducibility of the deformity. The joint lines should be preserved whenever possible. Triceps surae contracture should be sought and corrected if found.
10.1016/j.otsr.2018.03.010
Clinical and multi-segment kinematic analysis of a modified Grice arthrodesis to correct type II adult-acquired flat-foot.
Gait & posture
BACKGROUND:Adult acquired flat foot (AAFF) is a symptomatic postural alteration of the foot due to modifications in bony structures and/or soft tissues supporting the medial longitudinal arch. For the most severe cases, when orthotic solutions do not provide enough pain relief, surgery may be necessary. RESEARCH QUESTION:Is it possible to restore a normal medial longitudinal arch and to correct the static and dynamic frontal plane alignment of the rearfoot via a modified Grice surgical procedure in AAFF patients? METHODS:Eleven patients with stage II AAFF were recruited in the study and underwent the Grice procedure. Patients were assessed via gait analysis using a validated multi-segment foot protocol. Double-leg standing static posture and foot joint kinematics during barefoot walking were measured before surgery and at a mean follow-up of 15 ± 8 months. Twenty-seven age-matched healthy subjects without foot morphological alterations were used as control. Patients' feet were clinically assessed via the Foot Function Index and the Foot Posture Index. Wilcoxon signed rank test was used to assess differences in kinematic and spatio-temporal parameters between pre-op and follow-up evaluations. 1D statistical parametric mapping was used to assess differences in temporal profiles of foot joint rotations. RESULTS:The clinical indexes significantly improved at post-op (p < 0.05). No differences in sagittal plane static and dynamic joint rotations were observed between pre-op and post-op. In the frontal plane, metatarsus to calcaneus and midfoot to calcaneus rotation angles significantly improved from pre-op to post-op, with the latter resulting consistent with control data. Range of motion and maximum value of the medial longitudinal arch angle were reduced following surgery. SIGNIFICANCE:The modified Grice procedure restored a good frontal-plane alignment of rearfoot and midfoot, and the clinical scores provided evidence of its effectiveness in significantly reducing pain and improving the quality of daily activities.
10.1016/j.gaitpost.2023.01.006
The inter- and intraobserver reliability for the radiological parameters of flatfoot, before and after surgery.
Bock P,Pittermann M,Chraim M,Rois S
The bone & joint journal
Aims:Various radiological parameters are used to evaluate a flatfoot deformity and their measurements may differ. The aims of this study were to answer the following questions: 1) Which of the 11 parameters have the best inter- and intraobserver reliability in a standardized radiological setting? 2) Are pre- and postoperative assessments equally reliable? 3) What are the identifiable sources of variation? Patients and Methods:Measurements of the 11 parameters were recorded on anteroposterior and lateral weight-bearing radiographs of 38 feet before and after surgery for flatfoot, by three observers with different experience in foot surgery (A, ten years; B, three years; C, third-year orthopaedic resident). The inter- and intraobserver reliability was calculated. Results:Preoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Postoperative interobserver reliability was high for four, moderate for five, and low for two parameters. Intraobserver reliability was excellent for all parameters preoperatively as recorded by observer A (PB) and B (MP), and for eight parameters as recorded by observer C (SR). Intraobserver reliability was excellent for ten parameters postoperatively as recorded by observer A and B, and for eight parameters as recorded by observer C. Conclusion:The following parameters can be recommended. For preoperative and postoperative evaluation of flatfoot: anteroposterior, talonavicular coverage angle; lateral, talometatarsal I angle, calcaneal pitch angle, and cuneiform-medial height (high interobserver reliability); and anteroposterior, talometatarsal II angle; lateral, talocalcaneal angle,tibiocalcaneal angle (moderate interobserver reliability). For more experienced observers, we also recommend the anteroposterior talometatarsal I angle (moderate reliability). The inter- and intraobserver reliability for most parameters were similar pre- and postoperatively. The experience of the observer and the definition and ability to measure the parameters themselves were sources of variation. Cite this article: Bone Joint J 2018;100-B:596-602.
10.1302/0301-620X.100B5.BJJ-2017-1279
Preliminary results comparing two methods of lateral column lengthening.
Thomas R L,Wells B C,Garrison R L,Prada S A
Foot & ankle international
Forty-five patients (49 feet) underwent lateral column lengthening as treatment for painful pes planus. Twenty-five patients (27 feet) were available for both radiographic and clinical evaluation at least one year postoperatively. Of these 25 patients, 10 feet underwent Evans opening wedge osteotomy with tricortical iliac crest bone graft; 17 feet underwent calcaneocuboid distraction arthrodesis utilizing iliac crest bone graft. In addition, both groups underwent debridement of the posterior tibial tendon combined with transfer of the flexor digitorum longus into the navicular for reinforcement. Radiographic results documented marked improvement in all parameters. There was more improvement in the calcaneocuboid fusion group than the osteotomy group, but the difference was not statistically significant. Postoperative AOFAS rating scores averaged 87.9 for the osteotomy group and 80.9 for the distraction arthrodesis group. The difference was not statistically significant. Twenty of 25 patients (83.5%) in both groups were very satisfied. Twenty-four of 25 patients (96%) stated that knowing the final result they would have the same surgery again. Complications were reported for 32 patients (34 feet). Both the Evans opening wedge calcaneal osteotomy and calcaneocuboid distraction arthrodesis offer significant improvement in the radiographic parameters and AOFAS clinical scores for patients with painful, flexible flatfoot deformity. However, the complication rate remains high with both methods, and the rate of nonunion and delayed union with the calcaneocuboid distraction arthrodesis method remains a significant problem with this technique.
10.1177/107110070102200205
Clinical outcomes and static and dynamic assessment of foot posture after lateral column lengthening procedure.
Barske Heather,Chimenti Ruth,Tome Josh,Martin Elizabeth,Flemister Adolph S,Houck Jeff
Foot & ankle international
BACKGROUND:Lateral column lengthening (LCL) has been shown to radiographically restore the medial longitudinal arch. However, the impact of LCL on foot function during gait has not been reported using validated clinical outcomes and gait analysis. METHODS:Thirteen patients with a stage II flatfoot who had undergone unilateral LCL surgery and 13 matched control subjects completed self-reported pain and functional scales as well as a clinical examination. A custom force transducer was used to establish the maximum passive range of motion of first metatarsal dorsiflexion at 40 N of force. Foot kinematic data were collected during gait using 3-dimensional motion analysis techniques. RESULTS:Radiographic correction of the flatfoot was achieved in all cases. Despite this, most patients continued to report pain and dysfunction postoperatively. Participants post LCL demonstrated similar passive and active movement of the medial column when we compared the operated and the nonoperated sides. However, participants post LCL demonstrated significantly greater first metatarsal passive range of motion and first metatarsal dorsiflexion during gait than did controls (P < .01 for all pairwise comparisons). CONCLUSION:Patients undergoing LCL for correction of stage II adult-acquired flatfoot deformity experience mixed outcomes and similar foot kinematics as the uninvolved limb despite radiographic correction of deformity. These patients maintain a low arch posture similar to their uninvolved limb. The consequence is that first metatarsal movement operates at the end range of dorsiflexion and patients do not obtain full hindfoot inversion at push-off. Longitudinal data are necessary to make a more valid comparison of the effects of surgical correction measured using radiographs and dynamic foot posture during gait. LEVEL OF EVIDENCE:Level III, comparative series.
10.1177/1071100712471662
Therapeutic Outcomes of Kalix II in Treating Juvenile Flexible Flatfoot.
Cao Le,Miao Xu-Dong,Wu Yong-Ping,Zhang Xiang-Feng,Zhang Qiang
Orthopaedic surgery
OBJECTIVES:To evaluate the therapeutic outcomes with Kalix II subtalar arthroereisis in sinus tarsi for juvenile flexible flatfoot. METHODS:A retrospective analysis of the data of 20 juveniles with symptomatic flexible flatfoot (27 feet) who underwent the Kalix II implant procedure from January 2008 to September 2012 was performed. The pain during daily activities was assessed and followed up by use of a standard 10-point visual analog scale (VAS), and function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system, and anteroposterior talar-first metatarsal angle, lateral talar-first metatarsal angle, calcaneal pitch angle, and talar declination angle at X-ray film were measured to assess the therapeutic outcomes. Patients were asked to grade the result of the procedure as excellent, good, fair, or poor at latest follow-up. The data was expressed as mean ± standard deviation (SD). A paired Student's t -test was used for comparisons of the preoperative and postoperative angular measurements for each foot, VAS scores, and AOFAS scores. In all tests, P < 0.05 was considered statistically significant. RESULTS:The mean age of the patients was 12.1 years (range, 7-16 years), and 16 left feet and 11 right feet were involved. All patients finished the follow-up with a mean period of 28.1 months (range, 23-60 months). Eleven feet were treated with subtalar arthroereisis combined with reconstruction of the end point of the posterior tibialis tendon after dissection of the accessory scaphoid. The subtalar arthroereisis device displaced in 1 foot due to a fall from the inversion position 3 months after surgery, and was replaced by a new device after the failure of conservative treatment. The mean VAS score decreased from 5.6 ± 0.5 preoperatively to 1.2 ± 0.2 (P < 0.001), and the mean AOFAS hindfoot and ankle score improved from 71.1 ± 6.1 preoperatively to 88.1 ± 6.3 (P < 0.001). Differences between preoperative and postoperative measurements for each radiographic variable were statistically significant (P < 0.001). Comparison of radiographic measurements showed that the anteroposterior talar-first metatarsal (Meary) angle decreased by a mean of 12.8° ± 1.5°, the lateral talar-first metatarsal (Meary) angle decreased by a mean of 15.4° ± 1.3°, the calcaneal pitch angle increased by a mean of -2.1° ± 0.7°, and the talar declination angle decreased by a mean of 17.9° ± 2.8°. Overall, 12 patients rated the result as excellent, 6 as good, and 2 as fair. CONCLUSION:The application of Kalix II in subtalar arthroereisis combined with dissection of accessory scaphoid and reconstruction of posterior tibialis tendon is an effective therapy for flexible juvenile flatfoot.
10.1111/os.12309
Results of Arthroscopic Subtalar Arthrodesis for Adult-Acquired Flatfoot Deformity vs Posttraumatic Arthritis.
Vilá y Rico Jesús,Jiménez Díaz Verónica,Bravo Giménez Beatriz,Mellado Romero María Ángeles,Ojeda Thies Cristina
Foot & ankle international
BACKGROUND:The goal of this study was to compare results with arthroscopic posterior subtalar arthrodesis between patients treated for adult-acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction and patients with posttraumatic subtalar arthritis. METHODS:Retrospective case series of 61 consecutive patients (group 1: posttraumatic arthritis, n = 37; group 2: AAFD, n = 24) averaging 49 years of age (range, 21-72 years) undergoing posterior arthroscopic subtalar arthrodesis via 1 or 2 percutaneous 6.5- to 7.3-mm screws, with a mean follow-up of 57.5 months (range, 24-105 months). Fusion was defined as the appearance of bony trabeculae across the subtalar joint on standard x-rays, along with clinical signs of union. RESULTS:Patients with posttraumatic arthritis (group 1) were more predominantly male and younger than patients treated for AAFD (group 2). Overall, we achieved a 95.1% radiologic union rate after an average of 11.7 weeks. Complications appeared in 14.8% of patients. Union rate and complications did not differ significantly between groups. American Orthopaedic Foot & Ankle Society (AOFAS) scores improved significantly for both patient groups, although patients with AAFD showed significantly larger improvement and higher postoperative AOFAS scores, even after adjusting for age and sex (mean improvement in AOFAS scores: 27.0 ± 9.1 points for the posttraumatic arthritis group vs 34.9 ± 7.4 points for the AAFD group; P < .001). CONCLUSIONS:Arthroscopic subtalar arthrodesis was a safe and reliable technique, with consistent improvement in AOFAS scores throughout different patient subgroups, as well as comparable time to union and complication rates. Improvements were larger for patients treated for AAFD, even after adjusting for age and sex. LEVEL OF EVIDENCE:Level III, retrospective case series.
10.1177/1071100715604237
Changes in the bony alignment of the foot after tendo-Achilles lengthening in patients with planovalgus deformity.
Kim Nak Tscheol,Lee Young Tae,Park Moon Seok,Lee Kyoung Min,Kwon Oh Sang,Sung Ki Hyuk
Journal of orthopaedic surgery and research
BACKGROUND:This study was performed to investigate the change in the bony alignment of the foot after tendo-Achilles lengthening (TAL) and the factors that affect these changes in patients with planovalgus foot deformity. METHODS:Consecutive 97 patients (150 feet; mean age 10 years; range 5.1-35.7) with Achilles tendon contracture (ATC) and planovalgus foot deformity who underwent TAL were included. All patients underwent preoperative and postoperative weight-bearing anteroposterior (AP) or lateral (LAT) foot radiographics. Changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, LAT talo-1st metatarsal angle, and calcaneal pitch angle and the factors affecting such changes after TAL were analyzed using lineal mixed model. RESULTS:There were no significant change in AP talo-1st metatarsal angle and AP talo-2nd metatarsal angle after TAL in patients with cerebral palsy (CP) (p = 0.236 and 0.212). However, LAT talo-1st metatarsal angle and calcaneal pitch angle were significantly improved after TAL (13.0°, p < 0.001 and 4.5°, p < 0.001). Age was significantly associated with the change in LAT talo-1st metatarsal angle after TAL (p = 0.028). The changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, and calcaneal pitch angle after TAL were not significantly associated with the diagnosis (p = 0.879, 0.903, and 0.056). However, patients with CP showed more improvement in LAT talo-1st metatarsal angle (- 5.0°, p = 0.034) than those with idiopathic cause. CONCLUSION:This study showed that TAL can improve the bony alignment of the foot in patients with planovalgus and ATC. We recommend that physicians should consider this study's findings when planning operative treatment for such patients.
10.1186/s13018-021-02272-1
Tarsal coalition and painful flatfoot.
Vincent K A
The Journal of the American Academy of Orthopaedic Surgeons
The prevalence of tarsal coalition is probably 1% or less. The two sites most commonly affected are the calcaneonavicular joint and the middle facet of the talocalcaneal joint. Diagnosis should be suspected in the preteen or teenage patient with insidious or sudden onset of pain in the midfoot to hindfoot associated with a lack of motion in the subtalar joint. Initial treatment with immobilization or an orthosis may relieve symptoms, but most patients will have persistent symptoms that warrant surgical correction. Long-term results indicate that excision of the coalition is moderately successful in relieving symptoms in the calcaneonavicular bar. Long-term success with excision of subtalar bars is less clear, although early relief of symptoms is usually possible.
10.5435/00124635-199809000-00002
Subtalar arthroereisis for posterior tibial tendon dysfunction: a preliminary report.
Viladot Ramón,Pons Miquel,Alvarez Fernando,Omaña Jorge
Foot & ankle international
BACKGROUND:The purpose of this study was to evaluate preliminary results with Kalix subtalar arthroereisis in sinus tarsi for stage II posterior tibial tendon dysfunction. METHODS:Twenty-one patients with stage II posterior tibial dysfunction, according to Johnson and Storm, underwent surgical treatment between July 1999 and December 2000. All patients were evaluated clinically using the America Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle score. We performed a tendon repair depending on the type and location of the injury and implanted a Kalix endorthesis in the sinus tarsi. RESULTS:Nineteen patients attended for clinical review with an average follow-up of 27.31 months (range, 19-36). AOFAS scale improved from a preoperative average of 47.2 to an average of 81.6 at revision. The most important improvement was observed in pain (16.3 preoperative to 31.6 postoperative). Two cases required removal of the endorthesis for pain, probably because the endorthesis was too big, without any loss of correction. Patient satisfaction was "satisfied" or "very satisfied" in 17/19. All except three patients would have elected to undergo the same procedure. CONCLUSIONS:Subtalar arthroereisis by means of implantation of a Kalix endorthesis in the sinus tarsi, with prior correction of the deformity and tendon repair, offers an alternative to bone operations such as calcaneal osteotomies, lengthening the external column, or arthodesis in patients with stage II posterior tibial dysfunction.
10.1177/107110070302400806
Pedobarographic outcome after subtalar screw arthroereisis in flexible juvenile flatfoot.
Franz Andrea,Herz Daniel,Raabe Jens,Seeberger Ulrike,Bollmann Christine
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:Flatfoot is a frequent skeletal deformity in childhood that can be minimally invasively treated by arthroereisis. QUESTION:Does the motion of juvenile flexible flatfoot normalize after arthroereisis? METHOD:Pedographic measurements were obtained from 39 patients preoperatively, six months postoperatively and compared to a healthy group. The footprints were divided into 8 areas. The selected parameters were: contact area and force-time-integral. RESULTS:After surgery, a load shift from the medial to the lateral areas was detected under the midfoot and forefoot. The force-time-integral under the hallux normalized. However, under the lateral midfoot, the postoperative force-time-integral was significantly higher than in the control group. SIGNIFICANCE:The study shows that arthroereisis is able to correct the medially displaced load distribution of juvenile flexible flatfoot. However, further investigations are required to find out if the higher punctual loading under the lateral midfoot may cause problems in the long term.
10.1016/j.fas.2020.05.003
Biodegradable device applied in flatfoot surgery: comparative studies between clinical and technological aspects of removed screws.
Ruozi Barbara,Belletti Daniela,Manfredini Giuseppe,Tonelli Massimo,Sena Paola,Vandelli Maria Angela,Forni Flavio,Tosi Giovanni
Materials science & engineering. C, Materials for biological applications
Poly-L-lactide (PLLA) is one of the most used polymers for biomedical application; its use in sutures and other implants has been widely investigated. Although the knowledge of PLLA biodegradation and biocompatibility features is deep, PLLA screws used to correct the flat foot deformity have deserved attention since they are not degraded in most of cases after a long period of years (3-7) from the implantation. In this article, a clinical and radiological evaluation (NMR, histological and clinical outcomes) on patients was correlated with physico-chemical characterization (by SEM, DSC, GPC and XRD analysis at different temperatures) on both native and patient-recovered screws together with the theoretical degradation processes of PLLA-based implants. The data demonstrated the need for crossing the biodegradation and bioabsorption of the polymer with the characteristics of both the device (geometry, structure and fabrication process) and the implantation site.
10.1016/j.msec.2012.12.093
Grice extra-articular subtalar fusion for spastic pes planovalgus.
International orthopaedics
INTRODUCTION:A pes planovalgus deformity, an unstable foot deformity, affects the gait of children with cerebral palsy (CP). Treatments, including subtalar fusion, were proposed. The Grice procedure maintains foot stability, but bone graft non-union poses a challenge. This study aimed to identify the rate and factors related to post-operative bone graft non-union. METHODS:Thirty-one paediatric CP patients (age, 8.9 ± 1.8 years) who underwent the Grice procedure (53 feet) using ipsilateral tibial bone grafts were reviewed. Pre-operative gross motor function classification system (GMFCS) classes were class 1 in five, 2 in five, 3 in 14, and 4 in seven patients. Standing foot radiographs were assessed for signs of non-union, and parameters (talocalcaneal and talar declination angles and talar head uncovering index) measured pre-operatively, post-operatively, and at the most recent evaluation were compared. Factors associated with bone graft non-union were analysed by regression analysis. P < 0.05 was considered statistically significant. Degenerative changes in hindfoot joints were evaluated by Bargon's criteria. RESULTS:At the average follow-up evaluation at 5.4 ± 4.3 years, the GMFCS class was improved or was maintained in 29/31 patients. Post-operative radiographic measurements were restored and were maintained over the follow-up period (P < 0.001). A total of 14/53 feet (26%) had non-union. The pre-operative lateral talocalcaneal angle (OR 1.08, p = 0.04) and follow-up duration (OR 1.18, p = 0.03) were identified in univariate analysis as potential factors related to non-union but were not confirmed in a multivariate model. Hindfoot joints in most feet showed mild degenerative changes. CONCLUSION:Grice subtalar fusion in patients with a higher pre-operative lateral talocalcaneal angle might lead to bone graft non-union.
10.1007/s00264-022-05455-5
Effect of corrective rearfoot orthotic devices on ground reaction forces during ambulation.
Miller C D,Laskowski E R,Suman V J
Mayo Clinic proceedings
OBJECTIVE:To determine the quantitative effects of a corrective rearfoot orthotic device on the vertical, anteroposterior, and mediolateral ground reaction forces (GRFs) during ambulation. DESIGN:We conducted a prospective, randomized, single-blinded study of 25 subjects during ambulation with and without a rearfoot orthotic device. MATERIAL AND METHODS:Thirteen men and 12 women were enrolled in the study; the inclusion criteria included asymptomatic pes planus (5 to 10 degrees of calcaneal eversion). Each subject walked across a standard force plate in 10 trials without an orthotic device. The force plate was used to quantify the effect of a semirigid functional rearfoot orthotic device on GRFs and the center of pressure versus a standard shoe with no device. The observer was blinded, trials were completed in random order, and the paired t test was used for statistical analysis. RESULTS:No evidence suggested the presence of a significant difference in mediolateral GRFs and in the center of pressure exerted at 10%, 20%, 50%, and 80% of stance phase with and without the orthotic device. Significant reductions were noted in vertical GRFs per newton of body weight exerted at 10% (P = 0.0009) and 20% (P = 0.0383) of stance phase and in anteroposterior GRFs exerted at 10% (P = 0.0009) and 50% (P = 0.0033) of stance phase when ambulation was compared with and without the orthotic device. CONCLUSION:These results indicate that a rearfoot orthotic device reduces vertical and anteroposterior GRFs in the early stages of the stance phase during the gait cycle. We found no evidence to suggest a significant difference at any of the percent stance phases when comparisons were made of mediolateral GRFs exerted with and without the orthotic device. These data are contrary to current hypotheses about use of orthotic devices, and further studies would be helpful to reproduce these findings and to determine whether these changes are related to clinical improvement in symptomatic pes planus.
10.1016/S0025-6196(11)64840-4
Operative treatment of flatfoot with talocalcaneal coalition.
Giannini Sandro,Ceccarelli Francesco,Vannini Francesca,Baldi Elena
Clinical orthopaedics and related research
Rigid flatfoot or peroneal spastic flatfoot often is associated with a congenital fibrous, cartilaginous, or osseous union of two tarsal bones or more, potentially causing great difficulties in its treatment. Since 1996, 12 patients (14 feet) with painful flatfoot and restricted motion of the hindfoot attributable to talocalcaneal coalition, were treated by resection of the coalition and subtalar arthroereisis by a bioreabsorbable implant. The results were evaluated by the ankle hindfoot clinical rating system of the American Orthopaedic Foot and Ankle Society. These clinical results also were evaluated statistically. Radiographs and computed tomography scans were taken preoperatively and postoperatively. Eight (57.1% of patients) had excellent results, three (21.4% of patients) had good results, and three (21.4% of patients) had fair results. No poor results, or subjective or objective complications were reported. On the basis of these early results, arthroereisis by implanting a bioreabsorbable device after removal of the tarsal coalition, seems to be an effective procedure for the treatment of symptomatic flatfoot associated with talocalcaneal coalitions: correcting the relationship between talus and calcaneus, restoring the alignment of the hindfoot, and reducing pain.
10.1097/01.blo.0000069897.31220.7a
Treatment Outcomes at Skeletal Maturity after Calcaneo-Cuboid-Cuneiform Osteotomy for Symptomatic Flatfoot Deformity in Children.
Clinics in orthopedic surgery
BACKGROUND:The purpose of this study was to evaluate clinical and radiological outcomes at skeletal maturity after a calcaneo-cuboid-cuneiform osteotomy (triple C osteotomy) for symptomatic flatfoot deformity compared with healthy young adult controls. METHODS:Nineteen patients (30 feet) who undergone a triple C osteotomy for idiopathic symptomatic flatfeet from July 2006 to April 2013 were compared with 19 controls (38 feet). Radiographic measurements at preoperative examination, 1-year postoperative follow-up, and follow-up at skeletal maturity were evaluated. Functional outcomes were assessed by using the validated visual analog scale foot and ankle (VAS-FA) and the modified American Orthopaedic Foot and Ankle Surgery (AOFAS) score. RESULTS:In the triple C osteotomy group, 11 of 12 radiographic measurements were significantly improved at 1 year postoperatively and the last follow-up ( < 0.001). There was no recurrence at skeletal maturity ( > 0.05). There were no significant differences in nine of 12 radiographic measurements between the triple C osteotomy group at maturity and the control group ( > 0.05). Average VAS-FA and AOFAS scores were significantly improved at the time of skeletal maturity ( < 0.001). CONCLUSIONS:Surgical correction of symptomatic flatfoot deformity in childhood resulted in favorable outcomes after the triple C osteotomy. Deformity correction was also maintained during follow-up at skeletal maturity.
10.4055/cios19062
Double calcaneal osteotomy with minimally invasive surgery for the treatment of severe flexible flatfeet.
Mourkus Hany,Prem Hari
International orthopaedics
BACKGROUND:Severe flexible flatfoot deformity in children and adolescents is a complex problem. Calcaneal lengthening remains the gold standard for surgical correction at this institution. However, in a minority of patients, inadequate correction of valgus is noted at surgery and a further calcaneal shift osteotomy is done. METHODS:We have conducted a retrospective review of ten patients who received 15 combined minimally invasive calcaneal shift and calcaneal lengthening osteotomies, which were all performed by the senior author. All patients had failed conservative treatment. We describe our technique for double calcaneal osteotomy combining minimally invasive surgery (MIS) for the medial calcaneal shift with traditional open calcaneal lengthening osteotomy for treating children and adolescents with severe flexible flatfoot deformity. RESULTS:The average shift achieved was 8.07 mm. The average improvement in Meary's angle was 14.99°. All of them had radiological and clinical union at 12 weeks. None of the patients developed sural nerve injury, wound breakdown, or infection of the MIS incision. CONCLUSION:In double calcaneal osteotomies, the MIS calcaneal medial shift technique can be used safely with potentially lower risks of wound complications and sufficient medial shift, compared to conventional open extensive surgery. IMPLICATIONS:MIS calcaneal shift osteotomy has an advantage over open conventional open technique in cases where the skin is under tension like in combined calcaneal lengthening osteotomy. With experience, the procedure can be faster than an open procedure.
10.1007/s00264-018-3910-2
Preliminary Outcomes of Calcaneal Lengthening in Adolescent Flatfoot in Müller-Weiss Disease.
Foot & ankle international
BACKGROUND:Müller-Weiss disease (MWD) remains a controversial painful foot condition without consensus on its pathogenesis or a gold standard treatment modality. The aim of the study was to evaluate the outcomes of calcaneal lengthening in adolescent patients with symptomatic MWD with flatfoot. METHODS:The study included 13 feet of 7 patients including 5 females and 2 males who were treated from March 2012 until June 2015 by calcaneal lengthening. The mean age was 15.6 years. The mean duration of symptoms was 13.5 months. The body mass index (BMI) averaged 28.9 kg/m at presentation. The patients were followed up for a mean of 37.8 months. RESULTS:The osteotomy healed in all cases after a mean of 7.2 weeks. The second foot was operated on after an average of 11.5 months. The mean talometatarsal-1 angle improved from 39.8 degrees preoperatively to 5.9 degrees. The mean preoperative calcaneal pitch angle of 7.5 degrees increased to an average of 17.8 degrees postoperatively. The mean American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score was improved from 61.9 preoperatively to 94.2 postoperatively. Four patients had occasional exertional pain. Four feet had mild residual forefoot abduction. Arthrodesis was not needed in any case by the last follow-up. CONCLUSION:Early diagnosis of MWD with flatfoot was important and allowed for nonfusion treatment options. Calcaneal lengthening osteotomy in selected MWD cases achieved satisfactory outcomes with pain control, deformity correction, and improvement of the functional results. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/1071100719833928
Double calcaneal osteotomy for severe adolescent flexible flatfoot reconstruction.
Xu Yang,Cao Yong-Xing,Li Xing-Chen,Zhu Yuan,Xu Xiang-Yang
Journal of orthopaedic surgery and research
BACKGROUND:The timing and strategy of treatment for flatfoot still remain controversial. It is a difficult problem when facing severe adolescent flexible flatfoot because a single procedure cannot realign flatfoot deformity effectively. METHODS:We reviewed 13 adolescent flexible flatfoot patients who underwent double calcaneal osteotomy during May 2012 to June 2015. The mean age of patients was 15.2 ± 1.8 (range, 10-18) years. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS-AH) scores and SF-36 score were adopted to evaluate the preoperative and postoperative functions of the foot. Changes of hindfoot valgus angles, talonavicular uncoverage angles on AP view and talo-first metatarsal angles, and talar pitch angles and calcaneal pitch angles on the lateral film before and after surgery were measured. RESULTS:All 13 patients (15 ft) were followed. The mean duration of follow-up was 34.5 ± 15.7 (range, 21-60) months. The hindfoot valgus angle improved from 16.5 ± 4.1 to 2.9 ± 1.6. On the foot AP view, the mean preoperative and postoperative talonavicular coverage angles were 24.9 ± 8.5 and 6.5 ± 3.6. On the lateral view of the foot, the average preoperative and postoperative talo-first metatarsal angles were 18.1 ± 5.5 and 4.9 ± 4.4. The mean preoperative and postoperative talar pitch angles were 36.4 ± 4.7 and 24.0 ± 5.6. The AOFAS-AH score improved from 68.9 ± 12.3 preoperatively to 94.6 ± 3.9 postoperatively. CONCLUSION:With additional procedures, double calcaneal osteotomy was an effective method for severe adolescent flexible flatfoot.
10.1186/s13018-017-0655-3
Double versus triple arthrodesis for adult-acquired flatfoot deformity due to stage III posterior tibial tendon insufficiency: a prospective comparative study of two cohorts.
Fadle Amr A,El-Adly Wael,Attia Ahmed Khalil,Mohamed Mo'men M,Mohamadean Aly,Osman Ahmed E
International orthopaedics
PURPOSE:The study aims to prospectively compare double and triple arthrodesis in terms of functional outcomes and deformity correction. To the best of our knowledge, this is the first prospective comparative study in the literature to date. METHODS:This is a prospective comparative cohort study carried out between May 2017 and May 2019. The study was approved by the IRB at Assiut University and done according to the Helsinki declaration. Patients with AAFD stage III aged between 15 and 40 years old were assigned to double arthrodesis or triple arthrodesis. The groups were prospectively followed for one year. Primary outcomes were union rates, AOFAS scores, and radiological parameters of deformity correction on AP and lateral plain radiographs. Secondary outcomes were operative time, time to union, and complications. The double arthrodesis was done through the medial approach, while the triple arthrodesis was done through dual medial and lateral approaches. The post-operative protocol was standardized for both groups. RESULTS:A total of twenty-three patients matched the inclusion criteria and provided their consent to participate in the study. Thirteen (all males) patients underwent double arthrodesis, while ten (nine males and one female) patients underwent triple arthrodesis. The mean age for double and triple arthrodesis was 20.15 ± 5.63 and 25.10 ± 8.36 years, respectively, and the mean follow-up lengths were 12.46 and 12.9 months, respectively. There were no statistically significant differences between both groups in age, gender, laterality, or duration of follow-up. There were no statistically significant differences between both groups in AOFAS hindfoot scores or radiographic parameters. All patients were available for the final follow-up evaluation. All patients in both groups achieved union by four months post-operatively. The mean time to union in the double and triple arthrodesis groups was 3.39 ± 0.65 vs. 3.31 ± 0.6 months, respectively, with no statistically significant differences (p = 0.77). The mean operative time was significantly shorter in the double arthrodesis group than the triple arthrodesis group, 55.77 ± 15.18 vs. 91.6 ± 24.14 min (p < 0.001), respectively. Both double and triple arthrodesis groups had a statistically significant improvement of the mean AOFAS hindfoot score post-operatively (71.46 ± 7.77 vs. 88.38 ± 3.66, p < 0.001) and (66.9 ± 7.69 vs. 85 ± 5.83, p < 0.001), respectively. In the double arthrodesis group, the mean calcaneal pitch angle increased from 11.46° pre-operatively to 19.34° (MD = 8.45°, p < 0.001). The mean Meary's angle improved from - 4.19 to 2.9° (MD = 7.32°, p < 0.001). Hibbs angle had a mean reduction of 6.45° post-operatively (p = 0.069). In the triple arthrodesis group, the mean calcaneal pitch angle improved from 10.06° pre-operatively to 17.49° post-operatively (MD = 7.12°, p < 0.001). The mean Meary's angle improved from - 4.72 to 2.29° (MD = 7.09°, p < 0.001). The mean Hibbs angle decreased from 153.07 to 142.32° (MD = 10.54°, p < 0.001). The double vs. triple arthrodesis groups had no statistically significant differences in AOFAS hindfoot score improvement (16.92 vs. 19.1, p = 0.44), respectively. The two groups had no statistically significant differences in the magnitude of correction of all the radiographic parameters. CONCLUSION:Double arthrodesis is an equally reliable surgical option for AAFD stage III for achieving union, improving the functional outcomes, and deformity correction as triple arthrodesis with a significantly shorter operative time in the former. The authors recommend double arthrodesis if the calcaneocuboid joint is unaffected.
10.1007/s00264-021-05041-1
A new operative approach for flatfoot secondary to posterior tibial tendon insufficiency: a preliminary report.
Pomeroy G C,Manoli A
Foot & ankle international
The treatment of Johnson stage 2 posterior tibial tendon insufficiency remains controversial. Because the deformities remain flexible in stage 2, bony osteotomies are preferable over fusion operations. It is our contention that operative intervention should address all of the components of the pes planovalgus deformity that exists in stage 2 disease. Seventeen patients with 20 cases of stage 2 posterior tibial tendon insufficiency were treated with heel cord lengthening, flexor digitorum longus to medial cuneiform tendon transfer, lateral column lengthening, and medial displacement calcaneal osteotomy. Preoperative, postoperative, and final radiographs while standing were analyzed to determine radiographic correction of the deformities. In addition, the American Orthopaedic Foot and Ankle Society's ankle/hindfoot rating scale was applied to all patients before surgery and at 6-month intervals after surgery. Currently, the average follow-up is 17.5 months. The average foot rating score preoperatively was 51.4 and has improved to 82.8. Radiograph measurements have demonstrated statistically significant correction of the pes planovalgus deformity, as well as maintenance of the correction to date. It is our conclusion that this combination of surgical procedures provides correction of the symptomatology and deformity associated with stage 2 posterior tibial tendon insufficiency. The long-term result of the procedure is unknown.
10.1177/107110079701800404
Calcaneal Osteotomies: Pearls and Pitfalls.
Greenfield Stephen,Cohen Bruce
Foot and ankle clinics
Adult acquired flatfoot deformity is a debilitating condition typically affecting middle-aged patients. The multiple components include hindfoot valgus, first ray elevation, medial soft tissue compromise, and forefoot abduction. As the foot becomes unbalanced, the deformity progresses with repetitive loading and time. Untreated patients often need significant reconstructions or extensive arthrodesis after arthritis and joint contractures present. Medializing calcaneal osteotomy is the workhorse operation for correction of hindfoot valgus, reliably correcting deformity with a relatively low complication risk. This article reviews indications, techniques, complications, and outcomes for the medializing calcaneal osteotomy.
10.1016/j.fcl.2017.04.011
Incidence of plantar lateral foot pain before and after the use of trial metal wedges in lateral column lengthening.
Ellis Scott J,Williams Benjamin R,Garg Rohit,Campbell Graham,Pavlov Helene,Deland Jonathan T
Foot & ankle international
BACKGROUND:One of the major concerns with lateral column lengthening (LCL) in symptomatic flatfoot deformity treatment is the risk of postoperative plantar lateral foot discomfort. We evaluated whether this risk can be minimized by using trial metal wedges. Using our study's evaluation tools, the incidence of postoperative plantar lateral foot discomfort before and after using trial metal wedges was determined. MATERIALS AND METHODS:The incidence of planter lateral foot pain after LCL was retrospectively assessed in 122 consecutive patients (132 feet) after they had undergone flatfoot reconstruction with LCL between 2001 and 2007. To determine if the incidence could be reduced, levels of pain or revision were compared before and after the use of trial metal wedges. The ratio of wedge size to preoperative radiographic calcaneal length was also determined. RESULTS:The overall incidence of plantar lateral discomfort was 11.2%. The incidence of pain or revision was lower after the introduction of trial metal wedges (6.3% compared to 14.7%), but did not reach significance (p = 0.084). There was no significant difference found in the ratio of the size of bone graft wedge to calcaneal length between the two groups (p = 0.805). CONCLUSION:The incidence of plantar lateral foot discomfort overall was 11.2% after LCL. We believe this risk may be reduced using trial metal wedges, properly judging eversion stiffness and carefully assessing the position of the foot intraoperatively.
10.3113/FAI.2011.0665
Effect of calcaneal osteotomy and lateral column lengthening on the plantar fascia: a biomechanical investigation.
Horton G A,Myerson M S,Parks B G,Park Y W
Foot & ankle international
Medial calcaneal displacement osteotomy or lateral column lengthening fusion has been advocated to augment tendon transfer in planovalgus foot deformity associated with chronic posterior tibial tendon insufficiency. It is hypothesized that plantar fascia tightening occurs with these procedures, helping to restore a more normal longitudinal arch. To investigate this further, nine fresh-frozen cadaver below-knee specimens were used. A flatfoot model was created by sectioning of the posterior tibial tendon, spring ligament, talonavicular capsule, and deltoid ligament. A liquid-metal strain gauge, calibrated to measure fractional changes in length, was sutured proximally to the origin and distally into the thickest portion of the medial band of the plantar fascia. Specimens were axially loaded to 400 N and plantar fascia strain was measured. Fractional length changes in the plantar fascia were then measured after a medial displacement calcaneal osteotomy and after a lateral column lengthening through the calcaneocuboid joint. Tightening of the plantar fascia did not occur with either medial calcaneal displacement or lateral column lengthening. The plantar fascia became significantly less taut with both medial displacement and lateral column lengthening. We found that lateral column lengthening produced significantly looser plantar fascia than did medial displacement of the calcaneal tuberosity.
10.1177/107110079801900605
Long-term results of subtalar arthroereisis for the treatment of symptomatic flexible flatfoot in children: an average fifteen year follow-up study.
Mazzotti Antonio,Di Martino Alberto,Geraci Giuseppe,Casadei Cinzia,Panciera Alessandro,Giannini Sandro,Faldini Cesare
International orthopaedics
AIM OF THE STUDY:The aim of this study is to report the long-term outcomes of a homogenous series of patients who underwent subtalar arthroereisis (STA) for the treatment of symptomatic flexible flatfoot (FFF). METHODS:Thirty-four pediatric patients who underwent STA with a bioabsorbable implant were enrolled and radiographic measurements, clinical outcomes, and patients' satisfaction were evaluated. RESULTS:At a mean 180 months follow-up, radiographic measurements showed significant improvement. A physiological footprint and a proper hindfoot alignment were shown in more than 70% of patients. Mean AOFAS score was 90.4 ± 9.2 (72-100), mean SF-12 was 44.7 with 30 out of 34 patients (88.2%) satisfied with the procedure. CONCLUSION:STA with a bioabsorbable implant showed satisfactory long-term results. Based on the data subgroup analysis, nine to 11.5 years for female and nine to 13.5 years for male appeared to be the most appropriate age for surgery.
10.1007/s00264-020-04911-4
Association of Fusion of the First Metatarsophalangeal Joint and Pes Planus Deformity Correction.
Foot & ankle international
BACKGROUND:There has been scant investigation on the relationship between the distal aspect of the medial longitudinal arch and pes planus deformity. The aim of this study was to investigate whether the reduction and stabilization of the distal aspect of the medial longitudinal arch through fusion of the first metatarsophalangeal joint (MTPJ) can subsequently improve pes planus deformity parameters. This could be useful in both further understanding the role of the distal medial longitudinal arch in patients with pes planus and planning operative intervention in patients with multifactorial medial longitudinal arch problems. METHODS:A retrospective cohort study was undertaken between January 2011 and October 2021, including patients undergoing first MTPJ fusion with a pes planus deformity on weightbearing preoperative radiographs. These were compared to postoperative images, and multiple pes planus measurements were taken for comparison. RESULTS:A total of 511 operations were identified for further analysis, with 48 feet meeting the inclusion criteria. There was a statistically significant reduction identified between the pre- and postoperative measurements of Meary angle (3.75 degrees, 95% CI 2.9-6.47 degrees) and talonavicular coverage angle (1.48 degrees, 95% CI 1.09-3.44 degrees). There was a statistically significant increase between the pre- and postoperative measurements of calcaneal pitch angle (2.32 degrees, 95% CI 0.24-4.41 degrees) and medial cuneiform height (1.25 mm, 95% CI 0.6-1.92 mm). Reduced intermetatarsal angle was significantly associated with an increase in first MTPJ angle postfusion. Many of the measurements made were found "almost perfectly" reproducible by the Landis and Koch description. CONCLUSION:Our results demonstrate that fusion of the first MTPJ is associated with improvement of medial longitudinal arch parameters of a pes planus deformity but not to levels considered to be clinically normal. Therefore, the distal aspect of the medial longitudinal arch could, to some degree, be a feature in the pes planus deformity etiology. LEVEL OF EVIDENCE:Level III, retrospective case control study.
10.1177/10711007231159098
Rupture of the posterior tibial tendon causing flat foot. Surgical treatment.
Mann R A,Thompson F M
The Journal of bone and joint surgery. American volume
Rupture of the posterior tibial tendon results in a progressive, painful flat-foot deformity. Other physical findings are an inability to invert the heel on tip-toe standing and loss of inversion power. In this study we report on seventeen patients with this condition who were surgically treated with a transfer of the flexor digitorum longus tendon into the navicular or an advancement of the posterior tibial tendon. Follow-up results were excellent in twelve, good in one, fair in three, and poor in one patient. Arthrodesis of the talonavicular and calcaneocuboid joints was subsequently done for the patient with the poor result.
Calcaneal lengthening using ipsilateral fibula autograft in the treatment of symptomatic pes valgus in adolescents.
Lai Chien-Cheng,Wang Ting-Ming,Chang Chih-Hung,Pao Jwo-Luen,Fang Hsu-Wei,Chang Chun-Chien,Lin Shang-Ming,Lan Tsung-Yu
BMC musculoskeletal disorders
BACKGROUND:Evans calcaneal lengthening osteotomy is used to treat symptomatic flexible flatfoot when conservative treatment fails. Grafts such as autologous iliac bone grafts, allografts, and xenografts are implanted at the osteotomy site to lengthen the lateral column of the hindfoot. This study aimed to present the outcomes of an autologous mid-fibula bone graft used for calcaneal lengthening in symptomatic pes valgus in adolescents. METHODS:We retrospectively examined 23 ft of 13 adolescents who underwent surgery between July 2014 and January 2018. The radiological and clinical outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores) were assessed during a mean follow-up of 49.7 (range, 30.9-73.4) months. The mean distance of the lengthening site was measured to evaluate graft sinking or collapse. The Goldberg scoring system was used to determine the degree of union at the donor and recipient sites. RESULTS:The calcaneal pitch and the anteroposterior and lateral talo-first metatarsal (Meary) angles showed significant correction, from 14.4 to 19.6 (p < 0.001), and from 14.5 to 4.6 (p < 0.001) and 13.5 to 8.5 (p < 0.001), respectively. The mean distance of the lengthening site showed no significant change (p = 0.203), suggesting no graft sinking or postoperative collapse. The lateral distal tibial angle showed no significant difference (p = 0.398), suggesting no postoperative ankle valgus changes. Healing of the recipient and donor sites occurred in 23 and 21 ft, respectively. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scores improved significantly, from 68.0 to 98.5 (p < 0.001). CONCLUSIONS:Evans calcaneal lengthening using an ipsilateral mid-fibula bone autograft resulted in significant improvement in clinical and radiological outcomes without ankle valgus deformity. Hence, it could be a treatment option for lateral column calcaneal lengthening in adolescents.
10.1186/s12891-021-04855-9
Arthrorisis with calcaneostop screw in children corrects Talo-1st Metatarsal-Index (TMT-Index).
Richter Martinus,Zech Stefan
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:Arthrorisis (other terms: Arthrorhisis or Arthroreisis) with calcaneostop screw is one option for the treatment of flatfoot (Pes abductoplanovalgus) in children. The aim of the study was to analyze the amount of correction (for example Talo-1st Metatarsal-Index (TMT-Index)) and clinical outcome including pedographic assessment. METHODS:In a prospective consecutive non-controlled clinical follow-up study, all patients that were treated with arthrorisis with calcaneostop screw from September 1st 2006 to August 31st, 2009 were included. One foot was operated at a time, and the contralateral foot was operated 3 months later if indicated. Postoperatively, 15 kg partial weight-bearing was performed for 6 weeks. The screws were removed after 2-year-followup. Assessment was performed before surgery, at two-year-followup, and at 2.5-year-followup. The assessment staging of posterior tibialis insufficiency, radiographs with full weight bearing (TMT-Index), pedography, and Visual-Analogue-Scale Foot and Ankle (VAS FA). RESULTS:18 patients/31 feet were included in the study (age, 10.6 [8-12], 45% male). No complications were observed. In comparison with the preoperative parameters, the parameters posterior tibialis insufficiency stage, percentage of increased pedographic midfoot contact area and force were decreased, and TMT dorsoplantar/lateral/Index and VAS FA scores were increased at both followups (each p<.05). The parameters did not differ between followups (each p ≥.4). CONCLUSIONS:All relevant parameters (stage of posterior tibialis insufficiency, TMT dorsoplantar/lateral/Index, pedographic midfoot contact area and force, VAS FA) improved after arthrorisis with calcaneostop screw (before and after screw removal) in pes abductoplanovalgus in children. Since the complication rate is very low, this method allows safe and predictable correction.
10.1016/j.fas.2012.11.008
Operative versus nonoperative treatment in children with painful rigid flatfoot and talocalcaneal coalition.
Di Gennaro Giovanni Luigi,Stallone Stefano,Olivotto Eleonora,Zarantonello Paola,Magnani Marina,Tavernini Tullia,Stilli Stefano,Trisolino Giovanni
BMC musculoskeletal disorders
BACKGROUND:The management of painful rigid flatfoot (RFF) with talocalcaneal coalition (TCC) is controversial. We aimed to compare operative and nonoperative treatment in children with RFF and TCC. METHODS:We retrospectively reviewed medical records and radiographs of children with RFF and TTC treated between 2005 and 2015. The nonoperative treatment consisted of manipulation under anesthesia, cast immobilization and shoe insert after cast removal. The operative treatment consisted of combined TCC resection, graft interposition and subtalar arthroereisis. RESULTS:Thirty-four children (47 ft) in the nonoperative group and twenty-one children (34 ft) in the operative group were included. No differences were found between groups, concerning baseline characteristics. The mean age at treatment was 11.8 years (9-17): 11.6 (9-17) for the nonoperative group, 12.2 (10-15) for the operative group. The mean follow-up averaged 6.6 (3-12) years and was significantly longer in the nonoperative group (7.8 versus 4.7 years; p < 0.0005), since the operative procedure was increasingly practiced in the latest years. There were no complications in either groups, but 6 patients (7 ft) in the nonoperative group were unsatisfied and required surgery. At the latest follow-up, the AOFAS-AHS improved in both groups, although the operative group showed significantly better improvement. The operative group reported also significantly better FADI score, after adjustment for follow-up and baseline variables. CONCLUSION:The operative treatment showed better results compared to the nonoperative treatment. Symptomatic RFF with TCC in children can be effectively treated in one step with resection, graft interposition and subtalar arthroereisis. Further prospective randomized studies are needed to confirm our findings and to identify the best operative strategy in this condition.
10.1186/s12891-020-03213-5
Functional and radiographic comparison of subtalar arthroereisis and lateral calcaneal lengthening in the surgical treatment of flexible flatfoot in children.
Tahririan Mohammad Ali,Ramtin Sina,Taheri Pegah
International orthopaedics
PURPOSE:One of the most widespread diseases of children's orthopaedic problems is flatfoot. If conservative therapy failed, surgical treatment would be indicated. Lateral calcaneal lengthening (LCL) and subtalar arthroereisis (SA) are two types of operations used to correct symptomatic flexible flatfoot (FFF). The purpose of this study is to compare the functional and radiographic features of these two surgical procedures. PATIENTS AND METHODS:In this prospective randomized clinical trial study, we recruited 66 patients between 2018 and 2019. For clinical assessment, American Orthopedics Foot and Ankle Society (AOFAS), visual analog scale (VAS), subtalar motion, presence of medial longitudinal arch, and family satisfaction were measured. Evaluation of radiographic angles was based on AP (AP Tal-1Met) and Lat (Lat Tal-1Met) view of Talus-1st metatarsal angle (Meary's angle) and calcaneal pitch. RESULT:There was no significant difference between the two types of surgery regarding Lat Tal-1Met and AP Tal-1Met. The significantly larger angle in the LCL group was calcaneal pitch (P value < 0.001). AOFAS significantly increased from 68.71 ± 5.70 to 87.87 ± 7.14 (P value < 0.001) and from 67.28 ± 6.01 to 86.14 ± 7.56 (P value < 0.001) in LCL and SA respectively. Family satisfaction was significantly higher in the SA (8.14 ± 0.97) comparing to LCL (7.29 ± 0.86) at the latest follow-up (P value < 0.001). CONCLUSION:While both groups have substantial improvement in clinical and radiographic aspects, the SA technique is less-invasive, rapid symptom relief, and has early weight-bearing capacity. TRIAL REGISTRATION:IRCT20180823040853N1.
10.1007/s00264-020-04899-x
Evidence for foot orthoses for adults with flatfoot: a systematic review.
Journal of foot and ankle research
BACKGROUND:Flatfoot is characterised by the falling of the medial longitudinal arch, eversion of the hindfoot and abduction of the loaded forefoot. Furthermore, flatfoot leads to a variety of musculoskeletal symptoms in the lower extremity, such as knee or hip pain. The standard conservative treatment for flatfoot deformity is exercise therapy or treatment with foot orthoses. Foot orthoses are prescribed for various foot complaints. However, the evidence for the provision of foot orthoses is inconsistent. The aim of this systematic review is to synthesize the evidence of foot orthoses for adults with flatfoot. METHODS:A computerized search was conducted in August 2021, using the databases PubMed, Scopus, Pedro, Cochrane Library, and the Cochrane Central Register of Controlled Trials. Intervention studies of any design investigating the effects of foot orthoses were included, apart from case studies. Two independent reviewers assessed all search results to identify eligible studies and to assess their methodological quality. RESULTS:A total of 110 studies were identified through the database search. 12 studies met the inclusion criteria and were included in the review. These studies investigated prefabricated and custom-made foot orthoses, evaluating stance and plantar pressure during gait. The sample sizes of the identified studies ranged from 8 to 80. In most of the studies, the methodological quality was low and a lack of information was frequently detected. CONCLUSION:There is a lack of evidence on the effect of foot orthoses for flatfoot in adults. This review illustrates the importance of conducting randomized controlled trials and the comprehensive development of guidelines for the prescription of foot orthoses. Given the weak evidence available, the common prescription of foot orthoses is somewhat surprising.
10.1186/s13047-021-00499-z
A Modified Extra-articular Lateral Column Lengthening Procedure for Adult Acquired Flatfoot Deformity.
Foot & ankle international
BACKGROUND:Lateral column lengthening (LCL), originally described by Evans, is an established procedure to correct stage II adult acquired flatfoot deformity (AAFD). However, the relative position between the facets is violated, and other problems may include nonunion, malunion, and calcaneocuboid (CC) joint subluxation. Herein, we report a modified extra-articular technique of LCL with hockey-stick osteotomy, which preserves the subtalar joint as a whole, increases bony apposition to enhance healing ability, and preserves the insertion of the calcaneofibular ligament to stabilize the posterior fragment to promote adduction of the forefoot. METHODS:We retrospectively recruited 24 patients (26 feet) with stage II AAFD who underwent extra-articular LCL. The mean age was 55.7 ± 15.7 years, and the mean follow-up period was 33.4 ± 12.1 months. Associated procedures of spring ligament repair/reconstruction and posterior tibial tendon plication or flexor digitorum longus transfer were routinely performed and may also include a Cotton osteotomy, heel cord lengthening, or hallux valgus correction. Clinical and radiographic outcomes at the final follow-up were compared with the preoperative assessments. RESULTS:All patients achieved calcaneus union within 3 months of operation. The VAS pain score improved from 5.3 ± 0.75 preoperatively to 1.2 ± 0.79 at the final follow-up ( < .001), and the AOFAS Ankle-Hindfoot Scale from 63.5 ± 8.5 to 85.8 ± 4.8 points ( < .001). The radiographic measurements significantly improved in terms of the preoperative vs final angles of 8.9 ± 5.3 vs 15.2 ± 3.6 degrees for calcaneal pitch ( < .001), 20.5 ± 9.2 vs 4.9 ± 4.8 degrees for Meary angle ( < .001), 46.5 ± 5.2 vs 41.9 ± 3.2 degrees for lateral talocalcaneal angle ( < .001), 23.9 ± 8.5 vs 3.9 ± 3.1 degrees for talonavicular coverage angle ( < .001), and 18.2 ± 9.2 vs 7.3 ± 5.0 degrees for talus-first metatarsal angle ( = .002). The CC joint subluxation percentage was 7.0% ± 5.4% preoperatively compared with 8.5% ± 2.4% at the final follow-up ( = .101). No case showed progression of CC joint arthritis or CC joint subluxation (>15% CC joint subluxation percentage). One case showed transient sural nerve territory paresthesia, and 1 had pin tract infection. Three cases had lateral foot pain, which could be relieved by custom insoles. CONCLUSION:Modified extra-articular LCL as part of AAFD correction is a feasible alternative technique without subtalar joint invasion and may be associated with less CC joint subluxation compared with the Evans osteotomy. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/10711007211051359
Plantar forces in flexor hallucis longus versus flexor digitorum longus transfer in adult acquired flatfoot deformity.
Spratley E Meade,Arnold John M,Owen John R,Glezos Christopher D,Adelaar Robert S,Wayne Jennifer S
Foot & ankle international
BACKGROUND:Flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon transfers are frequently used to restore the function of a deficient tibialis posterior tendon in stage II adult acquired flatfoot deformity (AAFD). Either transfer causes some loss in toe flexion force, although the decision to tenodese the cut tendon to restore associated function remains controversial. This study quantified changes in plantar force before and after tendon transfer and with or without distal tenodesis in a cadaveric model. METHODS:The plantar force distribution of 10 matched pairs of statically loaded cadaveric lower extremities was investigated. Each foot was tested when it was intact, after FDL/FHL tendon transfer, and after tendon transfer + tenodesis. RESULTS:Transfer of either FHL or FDL showed a statistically significant decrease in flexion force of the great toe (P < .01) and lesser toes (P < .001), respectively. Subsequent tenodesis in either tendon demonstrated an ability to restore flexion force in the great (P < .05) and lesser (P < .01) toes, respectively, with the FHL transfer + tenodesis restoring great toe loading to near pretransfer levels. Following either transfer, plantar force increased in the medial forefoot; this was sustained with FDL transfer + tenodesis but reduced under FHL transfer + tenodesis. Lateral forefoot force increased modestly (8%) with FHL transfer (P < .05) but returned to near intact levels with tenodesis. FDL transfer + tenodesis resulted in increased medial midfoot and heel loading. DISCUSSION:FHL or FDL transfer notably reduces associated toe flexion force. This loss can be restored to near normal levels with tenodesis for FHL transfer. As increased lateral forefoot loading is commonly associated with AAFD corrective procedures, FHL tenodesis may mitigate the unintended increases caused by the tendon transfer. The medial midfoot and heel loading with FDL transfer + tenodesis underscores that tendon transfers alone do not reestablish the passive architecture of the foot but augment deficient subtalar inversion force. CLINICAL RELEVANCE:This cadaveric study shows that the FHL is more biomechanically suitable for tibialis posterior tendon insufficiency than the FDL, which may be a basis for a study to investigate whether it is superior in a clinical situation.
10.1177/1071100713487724
Outcomes of a Stepcut Lengthening Calcaneal Osteotomy for Adult-Acquired Flatfoot Deformity.
Demetracopoulos Constantine A,Nair Pallavi,Malzberg Andrew,Deland Jonathan T
Foot & ankle international
BACKGROUND:Lateral column lengthening is used to correct abduction deformity at the midfoot and improve talar head coverage in patients with flatfoot deformity. It was our hypothesis that following a stepcut lengthening calcaneal osteotomy (SLCO), patients would have adequate correction of the deformity, a high union rate of the osteotomy, and improvement in clinical outcome scores. METHODS:We retrospectively reviewed 37 consecutive patients who underwent SLCO for the treatment of stage IIB flatfoot deformity with a minimum 2-year follow-up. Deformity correction was assessed using preoperative and postoperative weight-bearing radiographs. Healing of the osteotomy was assessed by computed tomography. Clinical outcomes included the FAOS and SF-36 questionnaires. The Wilcoxon signed-rank test was used to compare clinical outcome scores. An alpha level of .05 was deemed statistically significant. RESULTS:Healing of the osteotomy occurred at a mean of 7.7 weeks postoperatively. The talonavicular (TN) coverage angle improved from 34.0 to 8.8 (P < .001), the percentage of TN uncoverage improved from 40.9% to 17.7% (P < .001), and the TN incongruency angle improved from 68.1 to 8.7 (P < .001). In addition, there was an improvement in FAOS pain (P < .001), daily activities (P < .001), sport activities (P = .006), and quality of life scores (P < .001). Overall SF-36 scores also showed improvement postoperatively (P < .001). There was no incidence of delayed union, nonunion, or graft collapse. CONCLUSION:Following SLCO, patients demonstrated excellent healing, good correction of the deformity, and improvement in clinical outcomes scores. The SLCO is an alternative to the Evans osteotomy for lateral column lengthening. LEVEL OF EVIDENCE:Level IV, retrospective case review.
10.1177/1071100715574933
Lateral column lengthening versus subtalar arthroereisis for paediatric flatfeet: a systematic review.
Suh Dong Hun,Park Jung Ho,Lee Soon Hyuck,Kim Hak Jun,Park Young Hwan,Jang Woo Young,Baek Jung Heum,Sung Hyun Jae,Choi Gi Won
International orthopaedics
PURPOSE:This systematic review aimed to compare radiographic correction, clinical outcomes, complications, and re-operations between lateral column lengthening (LCL) and arthroereisis (AR) for treating symptomatic flatfoot in children. METHODS:We conducted a comprehensive search on MEDLINE, EMBASE, and Cochrane Library databases. Literature search, data extraction, and quality assessment were conducted by two independent reviewers. The outcomes analyzed included radiographic parameters, clinical scores, satisfaction, complications, and re-operations. RESULTS:Twenty-one and 13 studies were included in the LCL and AR groups, respectively. The change in anteroposterior talo-first metatarsal angle was greater in the LCL (9.5° to 21.7°) than in the AR group (10.6° to 12.8°). The change in calcaneal pitch was greater in the LCL (2.1° to 26.53°) than in the AR group (- 1.3° to 3.23°). Improvements in the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were greater in the LCL (27.7 to 39.1) than in the AR group (17 to 22). The percentage of satisfaction was similar between the LCL (68% to 89%) and AR (78.5% to 96.4%) groups. The complication rate was higher in the LCL (0% to 86.9%) than in the AR group (3.5% to 45%). The most common complications were calcaneocuboid subluxation and persistent pain in the LCL and AR groups, respectively. The re-operation rate was similar between the LCL (0% to 27.3%) and AR (0% to 36.4%) groups. CONCLUSIONS:The LCL group has achieved more radiographic corrections and more improvements in the AOFAS score than the AR group. Complications were more common in the LCL group than in the AR group, and the re-operation rates were similar between the two groups.
10.1007/s00264-019-04303-3
Subtalar repositional arthrodesis for adult acquired flatfoot.
Stephens H M,Walling A K,Solmen J D,Tankson C J
Clinical orthopaedics and related research
Arthrodesis of the subtalar joint is well recognized treatment option for moderate or severe flatfoot associated with adult acquired flatfoot secondary to posterior tibial tendon dysfunction. The success of the subtalar arthrodesis is dependent on restoration of normal bony relationships in the hindfoot and midfoot. For this reason, a distinction is made between a repositional arthrodesis and the traditional in situ type of arthrodesis. An in vitro study of the adult acquired flatfoot identifies an anteroposterior subluxation of the subtalar articulation that can be corrected durably and reliably through a repositional talocalcaneal arthrodesis. Intraoperative reduction techniques are useful in obtaining reduction of the peritalar subluxation. There are certain clinical features that help identify patients with flatfoot deformities who are good candidates for subtalar fusion. As the pathoanatomy of the flatfoot deformity is better elucidated, treatment techniques are modified to better address the key elements of the deformity. A repositional subtalar arthrodesis was shown to produce excellent correction in a moderate to severe in vitro flatfoot example in the authors' clinical series.
10.1097/00003086-199908000-00009
Changes in Gait and Radiographic and Clinical Results of Calcaneal Lengthening Osteotomy in Children with Idiopathic Flexible Flatfoot.
Clinics in orthopedic surgery
BACKGROUD:In this study, we aimed to analyze kinematic and kinetic changes in gait and to assess radiographic and clinical improvement after calcaneal lengthening osteotomy (CLO) in children with idiopathic symptomatic flexible flatfoot deformities. METHODS:The study group consisted of 22 children (28 feet) with idiopathic symptomatic flexible flatfoot, which was treated by CLO as an index operation. We excluded patients with flatfoot that developed secondary to neuromuscular diseases. There were 18 boys (22 feet) and 4 girls (6 feet). The average age of the patients was 10.8 ± 1.51 years. Surgical results were assessed by radiologic imaging, clinical evaluation, and gait analysis, which were performed before surgery and 1 year after surgery. Medical records were reviewed to check postoperative complications. RESULTS:Talonavicular coverage was recovered to 16.7° from 32.7° ( < 0.01). Lateral talo-first metatarsal angle and calcaneal pitch angle increased by 20.1° and 9.9°, respectively ( < 0.01). Weight-bearing radiographs demonstrated a decrease in the anteroposterior angle and lateral talocalcaneal angle by 6.9° and 10°, respectively ( < 0.01). Hindfoot valgus was corrected to near neutral position after CLO. Kinematic results showed that the ankle valgus angle in the coronal plane was reduced from 35.48° preoperatively to 16.64° postoperatively during gait ( < 0.05). The preoperative out-toeing gait (preoperative foot progression angle, 20.31°) was also normalized to 14.21° postoperatively. The kinetics results showed that the push-off moment (maximum ankle plantar flexion) on the sagittal plane increased from 0.66 Nm/kg preoperatively to 0.83 Nm/kg postoperatively ( < 0.01). The mean Yoo score was 9.2 ± 1.05 postoperatively: satisfactory in 24 cases (86%) and unsatisfactory in 4 cases. Of the 4 unsatisfactory cases, 2 cases were overcorrection and 2 cases were undercorrection, and 3 of them were well managed by wedge foot insoles. CONCLUSIONS:The 3-dimensional deformities of the flexible flatfoot were effectively corrected by CLO, based on the morphological assessment using radiologic imaging. The correction was well maintained during gait at 1 year after the operation.
10.4055/cios19150
Interference screw for fixation of FDL transfer in the treatment of adult acquired flat foot deformity stage II.
Charwat-Pessler Christoph Georg,Hofstaetter Stefan Gerhard,Jakubek Doris Elvira,Trieb Klemens
Archives of orthopaedic and trauma surgery
INTRODUCTION:Flexor digitorum longus transfer and medial displacement calcaneal osteotomy have shown favourable results in the treatment of adult acquired flat foot deformity stage 2. Little is known about the resorbable interference screw for tendon fixation and postoperative patient satisfaction though. Moreover possible changes of radiographic parameters at final follow-up, possible implant-associated complications and differences concerning clinical results at final follow-up to other studies using bone tunnel techniques for fixation of the FDL tendon were investigated. MATERIALS AND METHODS:21 feet in 21 patients with a mean age of 51 years were evaluated pre- and postoperatively after a standardised operative procedure using MDCO and FDL transfer with interference screw fixation. Patients were evaluated with the American Orthopaedic Foot and Ankle Society Hindfoot Score and the Visual Analogue Scale at an average follow-up of 20 months. Hindfoot radiographic parameters were evaluated according to AOFAS guidelines. For statistical analysis SPSS v.15.0.1 was used. RESULTS:The average AOFAS Score (from 42 to 95 points) and VAS (from 0.5 to 8 points) both increased significantly (p < 0.001 each) from preoperative to final follow-up as well as the hindfoot valgus (from 10 to 4 degrees (p = 0.005)) and the lateral talo-first metatarsal angle (from 13.6 preoperative to 5.2° at follow-up). 88 percent of patients evaluated the postoperative result with "very good" or "good". Implant-associated complications could not be detected. CONCLUSION:We conclude that interference screw fixation for FDL transfer is a safe and promising operative technique, allowing a smaller skin incision without disrupting the normal interconnections at the knot of Henry, while achieving very high patient satisfaction and improving postoperative function as well as relieving pain. This method is technically easy to perform, has a low complication risk and we, therefore, recommend this fixation technique in patients with adult acquired flatfoot deformity stage 2.
10.1007/s00402-015-2295-6
Anatomical reconstruction of the spring ligament using peroneus longus tendon graft.
Choi Kyungjin,Lee Samuel,Otis James C,Deland Jonathan T
Foot & ankle international
Posterior tibial tendon insufficiency is often associated with failure of the spring ligament and flatfoot deformity. Arch correction procedures involving bony realignment, such as lateral column lengthening or joint fusions, can predispose to arthritis. Soft tissue reconstruction may provide a more anatomical correction without these complications. The purpose of this investigation was to compare the ability of three different spring ligament reconstruction procedures to correct flatfoot deformity. A deformity model of 5 degrees - 15 degrees talonavicular abduction was created in 10 cadaver foot-ankle specimens. Three reconstructions utilizing the peroneus longus tendon were evaluated for their ability to correct talonavicular abduction and subtalar eversion under 357 N vertical GRF load. A superomedial/plantar passage of the tendon through the calcaneus and navicular was shown to be more effective than either of the other two approaches, correcting the talonavicular joint from 9.1 degrees +/- 8.1 degrees abducted to 1.0 degree +/- 6.8 degrees adducted, and the subtalar joint from 3.1 degrees +/- 3.3 degrees everted to 0.4 degrees +/- 4.2 degrees inverted. Thus, an anatomical reconstruction of a model of a failed spring ligament was demonstrated to be effective in the correction of a flatfoot deformity produced in cadaver foot-ankle specimens.
10.1177/107110070302400510
Peritalar instability after tibiotalar fusion for valgus unstable ankle in stage IV adult acquired flatfoot deformity: case series.
Colin Fabrice,Zwicky Lukas,Barg Alexej,Hintermann Beat
Foot & ankle international
BACKGROUND:An unstable valgus ankle with an incompetent medial ligament complex is still treated by many surgeons with isolated tibiotalar (TT) arthrodesis. To date, it is unknown whether rigid fixation of the talus within the ankle mortise sufficiently corrects and stabilizes the hindfoot complex. The purpose of this study was to critically analyze patients with this problem and to assess the underlying causes for their acquired peritalar instability. METHODS:This series included 4 male patients (ages 55, 70, 72, and 79 years). Preoperatively, all patients presented with an unstable valgus ankle associated with stage IV adult acquired flatfoot deformity (AAFD), with a valgus talar tilt averaging 12 degrees (ranging from 9 to 14 degrees). All patients had a successful TT fusion, with screws and plates used for fixation. The position of the TT fusion was estimated at the intersection of a line drawn defining the talar shoulders and the longitudinal tibial axis on the anteroposterior weight-bearing radiograph. The hindfoot deformity was measured via the calcaneal offset on the Saltzman view. RESULTS:All patients had a healed TT fusion with the talus remaining in valgus averaging 4.8 degrees (ranging from 4 to 6 degrees). At the latest follow-up (1.2-18 years), all patients showed a progressive destabilization of the hindfoot complex that resulted in a valgus pronation deformity with flattening of the arch and a highly unstable foot that was not manageable with corrective shoes and braces. Key findings were a floppy hindfoot that turned into extreme valgus misalignment while loading. Radiographically, the calcaneal offset was in valgus misalignment of 16 to 54 mm related to the tibial axis on the Saltzman alignment view. In 2 cases, there was a complete medial dislocation of the talus. CONCLUSIONS:Even with rigid stabilization of the talus in the ankle mortise, peritalar instability may persist and allow calcaneus and navicular subluxation around the talus, which can result in progressive destabilization of the hindfoot complex. In stage IV AAFD, incompetent peritalar ligaments may not be able to withstand the increased mechanical load after TT fusion. Persistent valgus talar tilt after fusion may promote this unfavorable process. Therefore, isolated TT fusion should be performed with caution for treatment of valgus tilted ankles in stage IV AAFD. If this is considered, we recommend that fusion in neutral or even slightly varus talar positions be attempted. LEVEL OF EVIDENCE:Level IV, retrospective case series.
10.1177/1071100713505753
Dynamic correction for forefoot varus in stage II-A adult flatfoot: Technique tip.
Sanhudo Jose Antonio Veiga
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
Posterior tibial tendon dysfunction (PTTD) is a progressive disorder and a common cause of adult acquired flatfoot deformity, and forefoot varus is a frequent component in advanced cases. The author proposes peroneus brevis-to-longus transfer as an additional step to correct the forefoot varus component of stage II-A posterior tibial tendon dysfunction. We have performed this dynamic correction of forefoot varus in 12 patients at our institution, and observed promising clinical and radiographic improvement. It is a soft tissue procedure that avoids additional incisions and represents a favorable alternative to more demanding techniques, such as osteotomy or arthrodesis.
10.1016/j.fas.2018.05.007
Associated correction of forefoot alignment with hindfoot fusion for pes planovalgus deformity.
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:The present study aimed to investigate changes in hallux alignment after corrective surgery for adult-acquired flatfoot deformity (AAFD). PATIENTS AND METHODS:The present study retrospectively investigated the changes of hallux alignment in 37 feet (33 patients) which were treated with double or triple arthrodesis of the hindfoot for AAFD between 2015 and 2021 and could be followed up to one year postoperatively. RESULTS:Hallux valgus (HV) angle significantly decreased by a mean 4.1° among the whole 37 subjects and by a mean 6.6° among the 24 subjects who had a preoperative HV angle of 15° or more. Those who had HV correction (HV angle correction ≥ 5°) demonstrated more near-normal postoperative alignment of the medial longitudinal arch and hindfoot than those without HV correction. CONCLUSIONS:Hindfoot fusion for AAFD could improve preoperative HV deformity to some degree. HV correction was associated with proper realignment of the midfoot and hindfoot. LEVEL OF EVIDENCE:Level IV; retrospective case series.
10.1016/j.fas.2023.02.012
Calcaneal lengthening: investigation of deformity correction in a cadaver flatfoot model.
Dumontier Timothy A,Falicov Alexis,Mosca Vincent,Sangeorzan Bruce
Foot & ankle international
BACKGROUND:Evans showed that lengthening the lateral column by inserting structural bone graft into the anterior calcaneus could correct abduction and valgus deformity in flatfoot. To better understand the mechanism of correction and the three-dimensional effect of this procedure a cadaver study was done. METHODS:Three cadaver flatfoot models were used. Computed tomographic (CT) scans were made of each specimen before and after lengthening. Data from these scans were used to determine the center of volume of the talus, navicular, cuboid, and calcaneus. The angular and translational motions for each bone were determined. RESULTS:On average, relative to the talus, the navicular moved 18.6 degrees of rotation in adduction, 2.6 degrees of rotation in pronation, and 3.4 degrees in plantarflexion. The average translation was 5.6 mm medial, 0.4 mm posterior, and 1.8 mm plantar. The cuboid moved an average of 24.2 degrees of rotation in adduction and lengthening, 13.9 degrees in pronation, and 1.9 degrees in plantarflexion. The average translation was 9.4 mm medial, 2.6 mm distal, and 1.5 mm plantar. The calcaneus moved an average of 4.4 degrees of rotation in adduction, 0.1 degrees of rotation in eversion, and 1.3 degrees of plantarflexion. The average translation was 3 mm medial and 0.7 mm posterior with no plantar translation. CONCLUSIONS:The mechanism of Evans calcaneal lengthening involves adduction and plantarflexion of the midfoot relative to the hindfoot. The cuboid and navicular appear to move as a unit. The shape of the talar head, axis of the subtalar joint, degree of initial deformity, competence of plantar soft tissues, such as the long plantar ligament, and adequate length of the Achilles tendon are important. Knowing what qualitative three-dimensional changes take place allows a better understanding of the mechanics of the procedure and its possible applications.
10.1177/107110070502600209
Biomechanical analysis of the calcaneocuboid joint pressure after sequential lengthening of the lateral column.
Xia Jiang,Zhang Peng,Yang Yun-Feng,Zhou Jia-Qian,Li Qian-Ming,Yu Guang-Rong
Foot & ankle international
BACKGROUND:Lengthening of the lateral column by means of the Evans osteotomy is commonly used for reconstruction of adult and pediatric flatfoot. However, some reports have shown that the Evans osteotomy is linked with increased calcaneocuboid joint pressures and an increased risk of arthritis in the joint. The purpose of this study was to measure the pressure across the calcaneocuboid joint and demonstrate the changing trends of the pressure within the calcaneocuboid joint after sequential lengthening of the lateral column. METHODS:Six cadaver specimens were physiologically loaded and the peak pressure of the calcaneocuboid joint was measured under the following conditions: (1) normal foot, (2) flatfoot, and (3) sequential lengthening of the lateral column by means of the Evans procedure (from 4 mm to 12 mm, in 2 mm increments). RESULTS:Peak pressures across the joint increased significantly from baseline in the flatfoot (P < .05). In the corrected foot, with the increment of the graft, the peak pressure decreased initially and then increased. The pressure reached its minimum value (11.04 ± 1.15 kg/cm(2)) with 8 mm lengthening of the lateral column. The differences were significant compared to the flatfoot (P < .05) and corrected foot with the other sizes of grafts (P < .05), but differences were not significant compared to the intact foot (P = .143). CONCLUSIONS:Lateral column lengthening within a certain extent will decrease the pressure in calcaneocuboid joint with a flatfoot deformity. CLINICAL RELEVANCE:Performing the procedure with an 8 mm lengthening may reduce the risk of the secondary calcaneocuboid osteoarthritis.
10.1177/1071100712464211
The Cobb procedure for treatment of acquired flatfoot deformity associated with stage II insufficiency of the posterior tibial tendon.
Knupp Markus,Hintermann Beat
Foot & ankle international
BACKGROUND:A supple flatfoot deformity caused by posterior tibial tendon (PTT) dysfunction may include a supination deformity of the forefoot that usually is not sufficiently corrected by the commonly suggested treatment options. The use of a partial anterior tibial tendon (ATT) graft that is rerouted through the first cuneiform to the proximal stump of the PTT may restore plantarflexion power of the first ray (Cobb procedure). METHODS:Twenty-two consecutive patients with stage II PTT dysfunction and a supple supination deformity of the forefoot were included. A clinical examination, a subjective score, and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale were evaluated. RESULTS:The mean AOFAS score increased from preoperatively 53.2 (range 40 to 68) to 88.5 (range 78 to 94) at a followup of 24 (range 12 to 46) months. The overall clinical results were excellent in nine patients (41.0%), good in 12 (54.5%), fair in one (4.5%), and poor in none. None of the patients had decreased power of the anterior tibial tendon compared to the contralateral foot. Nineteen patients (86%) were able to wear shoes without shoe modifications. CONCLUSIONS:The Cobb procedure provided satisfactory correction of associated forefoot supination deformity in stage II PTT dysfunction. All patients had improved function because of the increased stability of the first ray. There was no evidence of loss of ATT power. The Cobb procedure may be considered an appropriate alternative to arthrodeses in selected patients with supple supination deformity in flatfeet.
10.3113/FAI.2007.0416
The optimal procedure for lateral column lengthening calcaneal osteotomy according to anatomical patterns of the subtalar joint: an anatomical study in the Chinese population.
BMC musculoskeletal disorders
BACKGROUND:Lateral column lengthening calcaneal osteotomy is a powerful procedure for correcting forefoot abduction in flatfoot deformity. However, it involves the risk of damaging articular facets of the subtalar joint. The optimal method to avoid violating the subtalar joint during lateral column lengthening remained controversial in published reports, implying that the subtalar joint might present anatomical variations among different nationalities. Therefore, the objective of this study was to perform an anatomical study by targeting the healthy Chinese population for the purpose of identifying the optimal procedure for lateral column lengthening calcaneal osteotomy according to anatomical patterns of the subtalar joint. METHODS:A total of 72 ft from 70 fresh frozen cadavers were obtained from the Department of Anatomy of Central South University. For each foot, soft tissues were surgically removed from the bones, and the calcaneus was completely separated from other bones to recognize the anatomical features of the calcaneus. The distance between the calcaneocuboid joint and the articular facet of the subtalar joint was measured by digital calipers for further analysis. RESULTS:Out of the 72 ft, 36.1% had separated anterior and middle facets in the calcaneus, and 63.8% had partly or completely fused anterior and middle facets. In the calcanei with discrete facets, the mean distance from the calcaneocuboid joint to the proximal margin of the anterior facet was 12.75 ± 2.10 mm, and the mean width of the separation between the anterior and middle facets was 2.43 ± 1.41 mm. In the calcanei with partly or completely fused anterior and middle facets, the mean width of the narrowest part of the tarsal sinus was 5.81 ± 0.62 mm and 6.25 ± 0.35 mm, respectively. CONCLUSIONS:The anatomy of the subtalar joint presents significant individual variations in the Chinese population. Calcanei with partly or completely fused anterior and middle facets were observed in nearly two thirds of individuals. Since the modified Evans procedure might potentially incur damage to the subtalar joint facets, the Hintermann procedure or other modified extra-articular lateral column lengthening procedures may be more applicable to the Chinese population.
10.1186/s12891-022-05715-w
How does the postoperative medial arch height influence the patient reported outcomes of stage Ⅱ acquired adult flatfoot deformity?
Yoshimoto Kensei,Noguchi Masahiko,Maruki Hideyuki,Nasu Yuki,Ishibashi Mina,Okazaki Ken
Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association
BACKGROUND:This study aimed to assess how the postoperative medial arch height influenced postoperative patient-reported clinical outcomes after surgery for stage Ⅱ acquired adult flatfoot deformity. METHODS:A total of 30 feet of 30 patients (7 males, 23 females) who underwent surgery for stage Ⅱ acquired adult flatfoot deformity and could be followed up for at least 2 years were included. The average age at surgery was 60.0 (standard deviation, 13.0) years, and the average follow-up period was 40 (standard deviation, 15.4) months. Among them, 16 patients underwent lateral column lengthening and 14 patients did not. Patient-reported clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire. Radiographic alignment was evaluated by the talonavicular coverage angle, lateral talo-1st metatarsal angle, medial cuneiform height, medial cuneiform to 5th metatarsal height, and calcaneal pitch. The correlation between postoperative Self-Administered Foot Evaluation Questionnaire and radiographic alignment was assessed with Pearson's correlation analysis. RESULTS:Self-Administered Foot Evaluation Questionnaire and radiographic alignment significantly improved postoperatively in all patients (P < 0.0001). In patients with severe deformity who needed lateral column lengthening, lateral talo-1st metatarsal angle was negatively and medial cuneiform to 5th metatarsal height was positively correlated with physical functioning Self-Administered Foot Evaluation Questionnaire subscales (r = -0.56 and 0.55), and medial cuneiform height was positively correlated with physical functioning, social functioning and general health Self-Administered Foot Evaluation Questionnaire subscales (r = 0.70, 0.55 and 0.73, respectively). CONCLUSION:Postoperative medial arch height could influence physical functioning, social functioning, and general health in patients with severe stage II adult-acquired flatfoot deformity.
10.1016/j.jos.2020.12.018
Pedobarographic changes during first month after subtalar extra-articular screw arthroereisis (SESA) operation of juvenile flexible flatfoot.
Hagen Lasse,Pape Jonas Paul,Kostakev Mark,Peterlein Christian-Dominik
Archives of orthopaedic and trauma surgery
BACKGROUND:Juvenile flexible flatfoot deformity is a common problem in childhood. In severe cases, the subtalar extra-articular screw arthroereisis (SESA) according to De Pellegrin is a viable and effective option. There are just a few retrospective studies showing long-term outcomes, but the interval right after the surgery has not been described so far, even though the short time of healing is one of the great benefits of this technique. In this study, we examined if the pedobarographic measurements are able to demonstrate functional changes in the month after surgery. METHODS:Data were analyzed for seven patients (13 feet). Measurements were performed before surgery, as well as 3, 14 and 28 days after. For analysis, the foot was comparted in six areas-fore-, mid- and hindfoot, each split in their lateral and medial parts. Plantar forces and contact area were measured under static and dynamic conditions. Time-dependent changes of plantar acting forces and the contact area were compared. RESULTS:During bipedal stance, the ground force increased significantly in lateral foot areas (p < 0.001) and decreased in medial areas (p < 0.001). While the force in the medial midfoot remained reduced, in the medial forefoot, the force increased 14 days after surgery (p < 0.05) CONCLUSION: The functional changes after SESA can be accurately assessed using pedobarography. The results indicate morphologic changes of the foot, in particular the development of a longitudinal arch. Post-surgical progression can be monitored and success of the surgery can be verified.
10.1007/s00402-019-03230-7
Outcomes of Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity in Older Patients.
Conti Matthew S,Jones Mackenzie T,Savenkov Oleksandr,Deland Jonathan T,Ellis Scott J
Foot & ankle international
BACKGROUND:Reconstruction of the stage II adult-acquired flatfoot deformity (AAFD) often requires the use of multiple osteotomies and soft tissue procedures that may not heal well in older patients. The purpose of our study was to determine whether patients older than 65 years with stage II AAFD had inferior clinical outcomes or an increased number of subsequent surgical procedures after flatfoot reconstruction when compared with younger patients. METHODS:One-hundred forty consecutive feet (70 right, 70 left) with stage II AAFD in 137 patients were divided into 3 groups based on age: younger than 45 years (young; n = 21), 45 to 65 years (middle-aged; n = 87), and 65 years and older (older; n = 32). Preoperative and postoperative Foot and Ankle Outcome Scores (FAOSs) at a minimum of 2 years were compared. Hospital records were reviewed to determine if patients underwent a subsequent procedure postoperatively. RESULTS:Patients in the older group did not demonstrate any differences in changes in FAOS subscales compared with patients in the young and middle-aged groups (all P > .15). The older group had significant preoperative to postoperative improvements in all the FAOS subgroups ( P < .01). In addition, patients in the older group were not more likely to undergo a subsequent surgery than were the younger patients (all P > .10). CONCLUSIONS:Our study found that patients older than 65 years with stage II AAFD have improvements in patient-reported outcomes and rates of revision surgery after surgical reconstruction that were not significantly different than those of younger patients. LEVEL OF EVIDENCE:Therapeutic Level III, comparative series.
10.1177/1071100718777459
First-Ray Radiographic Changes After Flexible Adult Acquired Flatfoot Deformity Correction.
Foot & ankle international
BACKGROUND:Adult acquired flatfoot deformity (AAFD) and hallux valgus (HV) are common foot and ankle deformities. Few studies have reported the changes in radiographic parameters of HV after reconstructive surgery for AAFD. This study aimed to evaluate the changes in radiographic parameters of HV and analyze the risk factors for increased HV after correction of AAFD. METHODS:Adult patients with flexible AAFD who underwent similar bony procedures including medializing calcaneal osteotomy and Cotton osteotomy were included. Radiographic parameters were measured on weightbearing radiographs preoperatively, postoperatively, and at the final follow-up. Patients were divided into hallux valgus angle (HVA) increased and HVA nonincreased groups; logistic regression analysis was performed to identify risk factors affecting increased HV. RESULTS:Forty-six feet of 43 patients were included. After AAFD reconstructive surgery, the tibial sesamoid position improved by 1 grade, but the HVA increased 4 degrees in average. Further, 21 of 46 feet (46%) showed an HVA increase ≥5 degrees immediately after AAFD correction surgery. Preoperative talonavicular coverage angle <21.6 degrees was a risk factor associated with HV increase immediately after the surgery. CONCLUSION:In this case series, using plain radiographs to measure standard parameters of foot alignment, we found the association between AAFD correction and HV deformity measures somewhat paradoxical. Correction of overpronation of the hindfoot and midfoot appears to improve the first metatarsal rotational deformity but may also increase HVA. A lower preoperative talonavicular coverage angle was associated with an increase of the HVA after surgery. LEVEL OF EVIDENCE:Level IV, case series study.
10.1177/10711007211034516
Reconstruction of the spring ligament using a peroneus longus autograft tendon transfer.
Williams Benjamin R,Ellis Scott J,Deyer Timothy W,Pavlov Helene,Deland Jonathan T
Foot & ankle international
BACKGROUND:The spring (calcaneonavicular) ligament provides one of the main static supports of the medial arch of the foot. The purpose of this study was to retrospectively assess the results of patients having undergone reconstruction of the spring ligament using a peroneus longus tendon autograft left at its distal attachment and passed through the navicular followed by either a calcaneal or tibial drill hole, a technique not previously reported. MATERIALS AND METHODS:Thirteen consecutive patients (14 feet) (mean age, 63.5 +/- 12.3 years) undergoing flatfoot surgery with spring ligament reconstruction for cases in which lateral column lengthening failed to correct talonvavicular deformity were reviewed. The AOFAS, FAOS, and SF-36 were assessed along with standard weightbearing radiographs at a followup visit at a mean of 8.9 +/- 1.8 years after surgery. Hindfoot alignment and eversion strength were measured. RESULTS:The AOFAS ankle-hindfoot score increased from 43.1 to 90.3 (\hbox{p}\leq 0.001). The postoperative FAOS pain subscale and overall SF-36 were 83.7 (range, 67.9 to 100), and 77.3 (range 37.8 to 95.6) respectively. The AP first tarsometatarsal angle (p = 0.015), talonavicular coverage angle (p = 0.003), lateral calcaneal pitch (p = 0.002), and lateral talonavicular angle (p = 0.017) improved significantly and were within normal ranges postoperatively. The mean hindfoot alignment measured 2.7 degrees of valgus. All but one patient had normal (5/5) eversion strength. CONCLUSION:Reconstruction of the spring ligament resulted in few complications and might be considered as an alternative to arthrodesis in patients with ruptures of the spring ligament and deformity that does not correct fully with bony procedures alone.
10.3113/FAI.2010.0567
Bilateral Foot Orthoses Elicit Changes in Gait Kinematics of Adolescents with Down Syndrome with Flatfoot.
Galafate Daniele,Pournajaf Sanaz,Condoluci Claudia,Goffredo Michela,Di Girolamo Gabriella,Manzia Carlotta Maria,Pellicciari Leonardo,Franceschini Marco,Galli Manuela
International journal of environmental research and public health
Subjects with Down Syndrome (DS) are characterized by specific physiological alterations, including musculoskeletal abnormalities. Flat Foot (FF), caused by hypotonia and ligament laxity, represents one of the most common disabling disorders in this population. Conservative treatments promote the use of orthopaedic insoles and plantar supports. The aim of this study was to evaluate the impact of Foot Orthoses (FOs) on the gait pattern of subjects with DS, assessing the biomechanical effects associated with their use. Twenty-nine subjects were screened under two conditions-walking barefoot (WB); with shoes and insoles (WSI), during three trials for each. Assessments were performed through the 3D gait analysis, using an optoelectronic system, force platforms, and video recording. Specifically, synthetic indices of gait kinematics, i.e., gait profile score (GPS) and gait variable score (GVS) were calculated and compared with Wilcoxon signed-rank test, to evaluate between-conditions. Significant variations were found in GVS foot progression index, representative of foot rotation during walking, in adolescents only. Bilateral FOs has a positive immediate impact on gait quality in adolescents with DS, as confirmed by quantitative analysis. FOs prescription is an evidence-based early approach to slow down biomechanical abnormalities and prevent relative symptoms.
10.3390/ijerph17144994
Lateral column calcaneal lengthening, flexor digitorum longus transfer, and opening wedge medial cuneiform osteotomy for flexible flatfoot: a biomechanical study.
Benthien Ross A,Parks Brent G,Guyton Gregory P,Schon Lew C
Foot & ankle international
BACKGROUND:Lengthening of the lateral column is commonly used for reconstruction of the adult and pediatric flatfoot, but can result in supination of the foot and symptomatic lateral column overload. The addition of a medial cuneiform osteotomy has been used to redistribute forces to the medial column. The combined use of a lateral column lengthening and medial cuneiform osteotomy in a reproducible cadaver flatfoot model was evaluated. METHODS:Twelve cadaver specimens were physiologically loaded and each was evaluated radiographically and pedobarographically in the following conditions: 1) intact, 2) severe flatfoot, 3) lateral column lengthening with simulated flexor digitorum longus transfer, and 4) lateral column lengthening and flexor digitorum longus (FDL) transfer with added medial cuneiform osteotomy. The lateral column lengthening was performed with a 10-mm foam bone wedge through the anterior process of the calcaneus, and the medial cuneiform osteotomy was performed with a dorsally placed 6-mm wedge. RESULTS:Lateral column lengthening with simulated FDL transfer on a severe flatfoot model resulted in a significant change as compared with the flatfoot deformity in three measurements: in lateral talus-first metatarsal angle (-17 to -7 degrees; p<0.001), talonavicular angle (46 to 24 degrees; p<0.001), and medial cuneiform height (16 to 20 mm; p<0.001). Lateral forefoot pressure increased from 24.6 to 33.9 kPa (p<0.001) after these corrections as compared with the flatfoot. Adding a medial cuneiform osteotomy decreased the lateral talar-first metatarsal angle from -7 to -4 degrees, decreased the talonavicular coverage angle from 24 to 20 degrees, and increased the medial cuneiform height from 20 to 25 mm. After added medial cuneiform osteotomy, lateral pressure was significantly different from that of the flatfoot (p=0.01) and was not significantly different from that of the intact foot (p=0.14). Medial forefoot pressure was overcorrected as compared with the intact foot with added medial cuneiform osteotomy. CONCLUSIONS:Lateral column lengthening increased lateral forefoot pressures in a severe flatfoot model. An added medial cuneiform osteotomy provided increased deformity correction and decreased pressure under the lateral forefoot.
10.3113/FAI.2007.0013
Biomechanical Analysis of Cuboid Osteotomy Lateral Column Lengthening for Stage II B Adult-Acquired Flatfoot Deformity: A Cadaveric Study.
Zhou Haichao,Ren Haoyang,Li Chunguang,Xia Jiang,Yu Guangrong,Yang Yunfeng
BioMed research international
. To investigate the effect of cuboid osteotomy lateral column lengthening (LCL) for the correction of stage II B adult-acquired flatfoot deformity in cadaver. . Six cadaver specimens were loaded to 350 N. Flatfoot models were established and each was evaluated radiographically and pedobarographically in the following conditions: (1) intact foot, (2) flatfoot, and (3) cuboid osteotomy LCL (2, 3, 4, and 5 mm). . Compared with the flatfoot model, the LCLs showed significant correction of talonavicular coverage on anteroposterior radiographs and talus-first metatarsal angle on both anteroposterior and lateral radiographs ( < .05). Compared with the intact foot, the above angles of the LCLs showed no significant difference except the 2 mm LCL. In terms of forefoot pressure, medial pressure of the 2 mm LCL ( = .044) and lateral pressure of the 3, 4, and 5 mm LCLs showed statistical differences ( < .05), but lateral pressure of the 3 mm LCL was not more than the intact foot as compared to the 4 and 5 mm LCLs, which was less than medial pressure. . Cuboid osteotomy LCL procedure avoids damage to subtalar joint and has a good effect on correction of stage II B adult-acquired flatfoot deformity with a 3 mm lengthening in cadavers.
10.1155/2017/4383981
Is subtalar arthroereisis a good procedure in adult-acquired flatfoot? A systematic review of the literature.
Mattesi Lucas,Ancelin David,Severyns Mathieu Pierre
Orthopaedics & traumatology, surgery & research : OTSR
INTRODUCTION:The aim of the present systematic literature review was to determine results and complications in subtalar arthroereisis for stage-2 adult-acquired flatfoot. METHOD:A search of the PubMed, Medline, CINAHL, Cochrane and Embase databases used MeSH terms "arthroereisis" AND "flatfoot" OR "adult-acquired flatfoot" OR "pes planovalgus" OR "pes planus". Two of the authors analyzed 125 articles. After reading titles and Abstracts, 105 articles were read in full text and their references were analyzed. Finally, 12 articles were selected and divided into 2 groups: isolated and associated arthroereisis. RESULTS:Improvement in functional scores was greater in associated arthroereisis. Whether isolated or associated, arthroereisis achieved radiologic correction. However, the rate of complications was high, mainly concerning tarsal sinus pain. CONCLUSION:Subtalar arthroereisis for stage-2 adult-acquired flatfoot is rarely performed in isolation. When it is associated to other procedures, good radiologic and clinical results can be expected. LEVEL OF EVIDENCE:IV.
10.1016/j.otsr.2021.103002
The Effect of Different Foot Orthosis Inverted Angles on Plantar Pressure in Children with Flexible Flatfeet.
Bok Soo-Kyung,Lee Hyunkeun,Kim Bong-Ok,Ahn Soyoung,Song Youngshin,Park Insik
PloS one
Although orthotic modification using the inverted technique is available for the treatment of flatfoot, empirical evidence for the biomechanical effects of inverted-angle foot orthoses (FOs) is lacking. The aim of this study was to evaluate the effects of different FO inversion angles on plantar pressure during gait in children with flatfoot. Twenty-one children with flexible flatfeet (mean age 9.9 years) were enrolled in this study. The plantar pressures were measured for the rearfoot; medial and lateral midfoot; and medial, central, and lateral forefoot as participants walked on a treadmill while wearing shoes only and shoes with the following 3 orthotic conditions: (i) orthosis with no inverted angle, (ii) orthosis with a 15° inverted angle, and (iii) orthosis with a 30° inverted angle. A one-way repeated measures analysis of variance (ANOVA) with the Bonferroni-adjusted post-hoc test was used to compare the mean values of each orthotic condition. Compared with the shoe only condition, the peak pressure decreased significantly under the medial forefoot and rearfoot with all FOs (p <0.05). However, no significant differences in the peak pressure under the medial forefoot and rearfoot were observed between the FOs. The peak pressure under the medial midfoot increased significantly with all FOs, and a maximal increase in the peak pressure was obtained with a 30° inverted angle orthosis. Furthermore, the contact area under the medial midfoot and rearfoot increased significantly with all FOs, compared with the shoe only condition (p <0.05). Again, no significant differences were observed between the FOs. For plantar pressure redistribution, a FO with a low inverted angle could be effective, accommodative, and convenient for children with flatfoot.
10.1371/journal.pone.0159831
Outcomes of 2B Adult Acquired Flatfoot Deformity Correction in Patients With and Without Spring Ligament Tear.
Foot & ankle international
BACKGROUND:It is currently unclear how injury to the spring ligament (SL) affects the preoperative presentation of adult acquired flatfoot deformity (AAFD) or the outcome of operative reconstruction. The purposes of this study were to assess the preoperative features and pre- or postoperative function of patients who underwent direct operative repair of an SL tear compared to those without a tear. METHODS:86 patients undergoing operative correction of grade 2B AAFD by a single fellowship-trained foot and ankle orthopaedic surgeon were reviewed at an average follow-up of 45.9 months. There were 35 feet found to have an SL tear that underwent concomitant debridement and direct repair of the SL. Patient charts were reviewed for demographic information, preoperative visual analog scale (VAS) pain level, and their Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and sports subscales. Preoperative radiographic parameters were assessed. Patient outcomes of VAS pain, FAAM-ADL, and FAAM-Sports were collected and compared between groups. RESULTS:Those with an SL tear had significantly lower FAAM-ADL and sports scores, with higher VAS pain scores preoperatively. Patient age, talonavicular uncoverage percentage, and talonavicular angle were found to be associated with spring ligament degeneration. At final follow-up, patients demonstrated a significant improvement in all outcome parameters, with no statistical difference found with patient satisfaction, final postoperative VAS pain, FAAM-ADL, or FAAM-Sports in those requiring a repair of their SL as compared to the control group. CONCLUSION:Increasing patient age, increasing talonavicular uncoverage percentage, and decreasing talonavicular angle are all independently associated with increased likelihood of patients with AAFD having an SL tear. At follow-up for operative treatment of grade 2B AAFD flatfoot with our approach, we found no clinical outcomes difference between those without SL tears and those with SL tears treated with concomitant SL debridement and repair. LEVEL OF EVIDENCE:Level III, retrospective cohort study.
10.1177/10711007211027270
Subtalar arthroereisis combined with medial soft tissue reconstruction in treating pediatric flexible flatfoot with accessory navicular.
Journal of orthopaedic surgery and research
PURPOSE:Accessory navicular is accompanied by the deformity of valgus flexible flatfoot. The surgical treatment includes reconstruction of insertion of posterior tibial tendon following resection of the accessory navicular. However, this treatment could not correct completely the deformity of valgus flexible flatfoot. This study aimed to evaluate the efficacy of subtalar arthroereisis combined with medial soft tissue reconstruction in treating 8-14-year-old flexible flatfoot patients with accessory navicular. METHODS:Clinical data of 35 pediatric flatfoot patients (with 50 feet) with accessory navicular who underwent subtalar arthroereisis and medial soft tissue reconstruction between April 2013 and September 2018 were analyzed retrospectively. Anteroposterior, lateral, and hindfoot alignment radiological images were measured in the weight-bearing position, and visual analog scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and satisfaction degree were evaluated. Also, surgical complications were recorded. RESULTS:The average follow-up time of the patients was 30 ± 9.3 months. None of the patients presented wound complications, and no implant loosening was detected. The AOFAS and VAS scores improved significantly (P < 0.001). Radiological parameters, such as the talar first metatarsal angle and talonavicular coverage angle on anteroposterior foot view, Meary's angle and calcaneal pitch angle on the lateral view, and calcaneus valgus angle on hindfoot alignment view improved significantly (P < 0.001). Postoperative complications were observed in three patients. CONCLUSION:Subtalar arthroereisis combined with medial soft tissue reconstruction significantly alleviated pain and improved the functions in pediatric and adolescent flexible flatfoot patients with accessory navicular; also, the radiological manifestations and functions improved.
10.1186/s13018-023-03542-w
Radiographic Outcomes of Cotton Osteotomy in Treatment of Adult-Acquired Flatfoot Deformity.
Abousayed Mostafa M,Coleman Michelle M,Wei Lawrence,de Cesar Netto Cesar,Schon Lew C,Guyton Gregory P
Foot & ankle international
BACKGROUND:We investigated the long-term radiographic outcomes of the Cotton osteotomy performed at our institution by the 2 senior authors in conjunction with other reconstruction procedures to correct adult-acquired flatfoot deformity (AAFD). METHODS:We retrospectively studied patients who underwent Cotton osteotomy between 2005 and 2010 with minimum 4-year follow-up. Radiographic assessment was made on weightbearing radiographs taken at 4 different time intervals: preoperative, early (first postoperative full weightbearing), intermediate (between 1 and 4 years postoperatively), and final (over 4 years postoperatively). RESULTS:Nineteen patients were included. Final follow-up was 8.6 ± 2.6 years. The lateral talus-first metatarsal angle improved significantly from preoperative to early radiographs (n = 15; mean change: 30 degrees, 95% CI, 21.6-38.7; < .0001). A significant loss of correction was observed between intermediate and final radiographs (n = 11; mean change: 17 degrees, 95% CI, 8.1-26.4; < .0001). Of 14 patients with early radiographs, 8 lost >50% of the correction initially achieved. Medial column height decreased by 3.0 mm (95% CI, 1.80-7.90; = .35) between early radiographs and final follow-up. DISCUSSION:This is the longest reported radiographic follow-up of the Cotton osteotomy performed to address forefoot varus deformity as part of AAFD. The Cotton osteotomy achieved radiographic correction of the medial longitudinal arch at early follow-up, but approximately half of the patients had lost over 50% of that correction at final follow-up. The lengthened angular shape of the cuneiform did not collapse, implying that further collapse occurred through the medial column joints. LEVEL OF EVIDENCE:Level IV, case series.
10.1177/10711007211015175
Calcaneocuboid distraction arthrodesis and first metatarsocuneiform arthrodesis for correction of acquired flatfoot deformity in a cadaver model.
Logel Kevin J,Parks Brent G,Schon Lew C
Foot & ankle international
BACKGROUND:Lateral column lengthening has been associated with residual forefoot supination and symptomatic lateral overload in treatment of acquired flatfoot. A medial column procedure may be useful to redistribute load to the medial column. We evaluated radiographic and pressure changes in a severe flatfoot model with lateral column lengthening and investigated the effect of an added first metatarsocuneiform arthrodesis. METHODS:Ten cadaver specimens were loaded in simulated double-legged stance, and radiographic and pressure data were collected for all tested states. Calcaneocuboid arthrodesis was done with a 10-mm foam wedge. Residual forefoot varus was corrected through the first metatarsocuneiform joint. RESULTS:Differences in the mean lateral talar-first metatarsal angle, talonavicular angle, talocalcaneal angle, and calcaneal pitch were significant between the intact foot and the flatfoot. After calcaneocuboid distraction arthrodesis and tendon transfer, the lateral talar-first metatarsal angle, talonavicular angle, and calcaneal pitch were significantly different from the flatfoot. After added first metatarsocuneiform arthrodesis, the talonavicular angle was not significantly different from the intact foot. Lateral forefoot pressure increased in the flatfoot after lateral column lengthening but was not significantly different from the intact foot after first metarsocuneiform arthrodesis was added. CONCLUSIONS:Adding first metatarsocuneiform arthrodesis to calcaneocuboid distraction arthrodesis for treatment of flatfoot deformity provided improvement in radiographic and pedobarographic parameters of a severe model of stage II posterior tibial tendon dysfunction.
10.3113/FAI.2007.0435
Minimally invasive technique for stage III adult-acquired flatfoot deformity: a mid- to long-term retrospective study.
Tejero Sergio,Carranza-Pérez-Tinao Andres,Zambrano-Jiménez Maria Dolores,Prada-Chamorro Estefanía,Fernández-Torres Jose Juan,Carranza-Bencano Andrés
International orthopaedics
PURPOSE:The purpose of this study was to present the functional, radiological, and quality of life outcomes of a series of stage III adult-acquired flatfoot deformity corrections using an original operative approach based on minimal incision surgery (MIS). METHODS:Sixty-two patients (67 feet) with a symptomatic stage III flatfoot deformity were treated using a modified double arthrodesis by MIS. The mean age was 63 years (range, 50 to 81) and the mean follow-up was 6.6 years (range, 3.2 to 11.5). Clinical, radiological, American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score), quality of life (SF-36), and satisfaction scores were collected retrospectively. RESULTS:The mean AOFAS score improved by 54.27 (95% [CI], 57.27-51.3; P < 0.0001), and the SF-36 improved by a mean of 17.5 points (95% CI, 1.4-20.9) in the physical component summary (PCS). Deformity correction was confirmed by a significant improvement in the x-ray measurements (six angles). Bony union was observed in 89.5% of cases (60/67). In all, nine patients (13.4%) needed a secondary surgery: three for talonavicular nonunion, four for progression of the flatfoot deformity, and two for screw protrusion. No cases of superficial infection, wound dehiscence, or avascular necrosis of the talus were observed. CONCLUSION:The present series represents the largest study of stage III flatfoot correction using MIS with a mid- to long-term follow-up. Because the data showed clinical and functional improvement after surgery with fewer complications, this technique may be ideal for patients at risk of complications. Graphical abstract.
10.1007/s00264-020-04724-5
Deltoid ligament reconstruction with peroneus longus autograft in flatfoot deformity.
Ellis Scott J,Williams Benjamin R,Wagshul Adam D,Pavlov Helene,Deland Jonathan T
Foot & ankle international
BACKGROUND:Stage IV posterior tibial tendon insufficiency is characterized by the presence of valgus talar tilt in the setting of a flatfoot deformity which results from attenuation of the deltoid ligament. Correcting valgus tilt at the time of flatfoot reconstruction may prevent future collapse and the need for joint sacrificing procedures. The purpose of this study was to report the intermediate-term results of patients who underwent deltoid ligament reconstruction using a peroneus longus tendon transfer. MATERIALS AND METHODS:Five patients (mean age, 67 years ± 5.3 years) who underwent flatfoot reconstruction along with deltoid ligament reconstruction using a peroneus longus autograft were evaluated at a mean of 8.9 ± 1.7 years after surgery. The FAOS, SF-36v2, and VAS surveys were administered. The correction of valgus talar tilt was determined with weightbearing radiographs of the ankle. Ankle range of motion along with standing hindfoot alignment was assessed. RESULTS:The postoperative average FAOS and SF-36v2 were 68.3 (range, 55.2 to 85.0) and 75.7 (range, 40 to 92), respectively. The valgus talar tilt improved from 7.7 degrees preoperatively to 2.1 degrees postoperatively. Mean ankle range of motion was 47 degrees (range, 40 degrees to 55 degrees). Mean hindfoot alignment was 4 degrees valgus (range, 1 degree varus to 8 degrees valgus). CONCLUSION:Deltoid ligament reconstruction using a peroneus longus tendon transfer was a useful technique for reducing tibiotalar tilt in the setting of stage IV flatfoot deformity. Correction and function were maintained at intermediate-term followup.
10.3113/FAI.2010.0781
The Viladot implant in flatfooted children.
Black P R,Betts R P,Duckworth T,Smith T W
Foot & ankle international
In 1991, Viladot described an implant for the treatment of painless flatfeet in children. This was inserted through a double approach to allow the talus to function while limiting its ability to slide off the calcaneus. The wineglass shaped prosthesis was inserted into the sinus tarsi with a tibialis posterior advancement and soft tissue correction to allow the foot to adopt a neutral position. This is in keeping with other procedures described for the correction of flatfoot. Viladot reported excellent results in 234 feet operated on in such a manner using clinical, radiological and photopodographic parameters. In Sheffield, over three years, 22 implants were inserted for similar painless flatfeet in children. The results were assessed using clinical, radiological and pedobarographic parameters. Viladot was able to demonstrate an improvement in all cases, clinically, radiologically and photopodographically with little or no discomfort and a return to preoperative levels of activity including sport. We found that in all cases, postoperative pain was a major feature which limited activity in all but 2 feet and which reduced the ability to take part in sport and other preoperative pastimes. Unlike Viladot, we were unable to demonstrate consistent improvements radiologically. Pedobarographically, the loading of the first metatarsal head remained unchanged and the centre of pressure was corrected in only 14%.
10.1177/107110070002100605
Posterior Tibial Tendon Allograft Reconstruction for Stage II Adult Acquired Flatfoot: A Case Series.
Dominick Darrick R,Catanzariti Alan R
The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons
Surgical treatment for a stage II adult acquired flatfoot has consisted of reconstruction of the diseased posterior tibial tendon with flexor digitorum longus tendon transfer, combined with osteotomies to address the underlying deformity. This case series presents an alternative to tendon transfer using allograft tendon for posterior tibial tendon reconstruction. Four patients who underwent stage II flatfoot reconstruction with posterior tibial tendon allograft transplantation were included. All patients had preoperative radiographs demonstrating flatfoot deformity and magnetic resonance imaging showing advanced tendinopathy of the posterior tibial tendon. Allograft tendon transplant was considered in patients demonstrating adequate posterior tibial tendon excursion during intraoperative assessment. Additional procedures were performed as necessary depending on patient pathology. Postoperatively, all patients remained non-weightbearing in a short leg cast for 6 weeks. Radiographs performed during the postoperative course demonstrated well-maintained and improved alignment. No complications were encountered. Each patient demonstrated grade 5 muscle strength and were able to perform a single-limb heel rise at the time of final follow-up. The average follow-up duration was 19.0 months. Flexor digitorum longus transfer has been studied extensively for stage II adult acquired flatfoot. However, the flexor digitorum longus has been shown to be much weaker relative to the posterior tibial tendon, and concern remains regarding its ability to recreate the force of the posterior tibial tendon. Our results demonstrate that posterior tibial tendon allograft reconstruction combined with flatfoot reconstruction is a reasonable option. This alternative has the advantage of preserving the stronger muscle without disturbing regional anatomy.
10.1053/j.jfas.2019.12.005
Impact of pes planus on clinical outcomes of hallux valgus surgery.
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons
BACKGROUND:Pes planus is associated with hallux valgus development. This study evaluated the impact of pes planus on clinical outcomes following hallux valgus surgery. METHODS:191 patients underwent Scarf osteotomy for hallux valgus. Pes planus angles including talonavicular coverage angle, lateral talus-first metatarsal angle (Meary's angle) and lateral talocalcaneal angle were measured. The cohort was stratified into control (0°-4.0°), mild (4.1°-14.9°), moderate (15.0°-30.0°) and severe (> 30.0°) pes planus groups according to Meary's angle. Clinical outcomes were compared at baseline, 6 months and 24 months. RESULTS:There were 78 controls, 95 mild and 18 moderate cases of pes planus. Meary's angle was independently associated with preoperative hallux valgus angle. Pes planus angles were not associated with pain, AOFAS, SF-36 physical or mental scores. All three groups had similar clinical outcomes and patient satisfaction. CONCLUSION:Compared to patients with neutral foot arches, those with pes planus presented with more severe hallux valgus deformity but had similar clinical outcomes following surgical correction.
10.1016/j.fas.2021.04.004
Contribution of Lateral Column Lengthening to Correction of Forefoot Abduction in Stage IIb Adult Acquired Flatfoot Deformity Reconstruction.
Chan Jeremy Y,Greenfield Stephen T,Soukup Dylan S,Do Huong T,Deland Jonathan T,Ellis Scott J
Foot & ankle international
BACKGROUND:Correction of forefoot abduction in stage IIb adult acquired flatfoot likely depends on the amount of lateral column lengthening (LCL) performed, although this represents only one aspect of a successful reconstruction. The purpose of this study was to evaluate the correlation between common reconstructive variables and the observed change in forefoot abduction. METHODS:Forty-one patients who underwent flatfoot reconstruction involving an Evans-type LCL were assessed retrospectively. Preoperative and postoperative anteroposterior (AP) radiographs of the foot at a minimum of 40 weeks (mean, 2 years) after surgery were reviewed to determine correction in forefoot abduction as measured by talonavicular coverage (TNC) angle, talonavicular uncoverage percent, talus-first metatarsal (T-1MT) angle, and lateral incongruency angle. Fourteen demographic and intraoperative variables were evaluated for association with change in forefoot abduction including age, gender, height, weight, body mass index, as well as the amount of LCL and medializing calcaneal osteotomy performed, LCL graft type, Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament repair, gastrocnemius recession and any one of the modified McBride/Akin/Silver procedures. RESULTS:Two variables significantly affected the change in lateral incongruency angle. These were weight (P = .04) and the amount of LCL performed (P < .001). No variables were associated with the change in TNC angle, talonavicular uncoverage percent, or T-1MT angle. Multivariate regression analysis revealed that LCL was the only significant predictor of the change in lateral incongruency angle. The final regression model for LCL showed a good fit (R2 = 0.70, P < .001). Each millimeter of LCL corresponded to a 6.8-degree change in lateral incongruency angle. CONCLUSION:Correction of forefoot abduction in flatfoot reconstruction was primarily determined by the LCL procedure and could be modeled linearly. We believe that the lateral incongruency angle can serve as a valuable preoperative measurement to help surgeons titrate the proper amount of correction performed intraoperatively.
10.1177/1071100715596607
Effect of calcaneal osteotomy and plantar fasciotomy on arch configuration in a flatfoot model.
Thordarson D B,Hedman T,Lundquist D,Reisch R
Foot & ankle international
Seven fresh-frozen cadaver specimens had a calcaneal osteotomy performed obliquely through the posterior portion of the calcaneus. Angular relationships between the first metatarsal and talus were recorded with the use of a motion-analysis system in the transverse, sagittal, and coronal planes. The specimen was mounted in a testing machine and loaded via an intramedullary rod to 150, 350, and 550 N. A flatfoot model was created, and repeat measurements were obtained. The calcaneal osteotomy was then displaced 1 cm medially, and repeat measurements were made at each of the three load levels. The calcaneal osteotomy was then returned to its original position, the plantar fascia was divided, and the new angular measurements were obtained. The calcaneal osteotomy was again displaced 1 cm, and repeat angular measurements were obtained. A mild consistent flatfoot deformity was created in all three axes before the plantar fascia was cut. A statistically significant increase in deformity was noted after cutting the plantar fascia. A correction of the flatfoot deformity in all three planes occurred with the medial displacement of the calcaneal osteotomy, which was greater at the lower load levels. We noted that a medial displacement calcaneal osteotomy partially corrected a flatfoot deformity in all three planes. The correction occurred with or without an intact plantar fascia and, therefore, is independent of the structure. We also noted an increased deformity after dividing the plantar fascia. This study provides some biomechanical insight as to the corrective effect of a medial displacement calcaneal osteotomy in correcting a flatfoot deformity.
10.1177/107110079801900606
Comparison of the calcaneo-cuboid-cuneiform osteotomies and the calcaneal lengthening osteotomy in the surgical treatment of symptomatic flexible flatfoot.
Moraleda Luis,Salcedo Maria,Bastrom Tracey P,Wenger Dennis R,Albiñana Javier,Mubarak Scott J
Journal of pediatric orthopedics
BACKGROUND:Surgery is indicated in symptomatic flatfoot when conservative treatment fails to relieve the symptoms. Osteotomies appear to be the best choice for these painful feet. The purpose of this study was to compare the clinical and radiographic outcome of the calcaneo-cuboid-cuneiform osteotomies (triple C) and the calcaneal-lengthening osteotomy in the treatment of children with symptomatic flexible flatfoot. METHODS:The surgeries were performed by senior surgeons who preferred either triple C or calcaneal lengthening. The results were graded by an orthopaedic surgeon uninvolved with the cases. The clinical and radiographic outcome was evaluated in 30 feet (21 patients) with a triple C osteotomy and 33 feet (21 patients) with a calcaneal-lengthening osteotomy. We used the American College of Foot and Ankle Surgeons (ACFAS) score (flatfoot module) for clinical assessment, which contains a subjective and objective test. We measured and compared 12 parameters on the anteroposterior and lateral weight-bearing radiographs. The effect of additional procedures (Kidner procedure, medial reefing of the talonavicular capsule, tendo-Achilles lengthening, peroneous brevis lengthening and, in the calcaneal-lengthening group, a medial cuneiform osteotomy) on the clinical and radiographic result was also evaluated. RESULTS:Average age at the time of surgery was similar (triple C: 11.2 ± 3 y, calcaneal lengthening: 11.6 ± 2.5 y, P = 0.51). Average follow-up was 2.7 ± 2.2 years in the triple C group and 5.3 ± 4 years in the calcaneal-lengthening group. There were no significant differences in the clinical outcome measured by the ACFAS subjective test in the calcaneal-lengthening group (P = 0.003). There were no significant differences in the ACFAS score, both the subjective test (triple C: 43.3 ± 6.1, calcaneal lengthening: 44.7 ± 7.6, P = 0.52) and the ACFAS objective test (triple C: 28.6 ± 2, calcaneal lengthening: 25.9 ± 7, P = 0.13). We found significant differences in 2 of the 12 radiographic measurements: anteroposterior talo-first metatarsal angle (triple C: 15.5 ± 11.1, calcaneal lengthening: 7.4 ± 7.3, P = 0.001) and talonavicular coverage (triple C: 28 ± 14.7, calcaneal lengthening: 13.7 ± 12.4, P<0.001). None of the additional procedures improved the clinical outcome. There were 3 (10%) complications in the triple C group and 6 (18%) complications in the calcaneal-lengthening group. Also, calcaneocuboid subluxation was present in 17 (51.5%) feet of the calcaneal-lengthening group. CONCLUSIONS:Both techniques obtain good clinical and radiographic results in the treatment of symptomatic idiopathic flexible flatfoot in a pediatric population. The calcaneal-lengthening osteotomy achieves better improvement of the relationship of the navicular to the head of the talus but it is associated with more frequent and more severe complications. Additional soft-tissue procedures have not proven to improve clinical or radiographic results. LEVEL OF EVIDENCE:Level III, retrospective comparative study.
10.1097/BPO.0b013e3182648c74
Outcome of medial displacement calcaneal osteotomy for correction of adult-acquired flatfoot.
Niki Hisateru,Hirano Takaaki,Okada Hirokazu,Beppu Moroe
Foot & ankle international
BACKGROUND:The results of medial displacement calcaneal osteotomy (MDCO) with flexor digitorum longus (FDL) tendon transfer were reviewed, as well as postoperative radiographic changes, to determine quantitative x-ray-based indications for MDCO with FDL tendon transfer in cases of adult-acquired flatfoot. MATERIALS AND METHODS:Twenty-five patients, ages 42 to 71 years, underwent MDCO with FDL tendon transfer for stage II posterior tibial tendon dysfunction. Follow-up was 2.6 to 10.2 years. Preoperative and postoperative Japanese Society for Surgery of the Foot (JSSF), Foot Function Index, and SF-36 scores and physical and radiographic findings were compared. Eight measures of foot alignment were obtained from weight-bearing radiographs at 3, 6, 9, and 12 months after surgery and every 6 months thereafter. Differences in scores and values over time were analyzed statistically. RESULTS:Average JSSF scores improved from 59 preoperatively to 91.3 postoperatively (p < .001). The only x-ray parameters that improved significantly and showed maintenance of the surgical correction were the lateral talometatarsal (LTMT) and tibiocalcaneal (TBC) angles. With preoperative LTMT and TBC angles of >25° and >15°, respectively, correction was inadequate. CONCLUSIONS:It was concluded that indications for MDCO with FDL tendon transfer in cases of adult-acquired flatfoot are a preoperative LTMT angle of <25° and hindfoot coronal alignment (TBC angle) of <15°.
DOI: 10.3113/FAI.2012.0940