Adult Flatfoot Research Articles

Matrix metalloproteinase-1 (MMP-1) and (MMP-8) gene polymorphisms promote increase and remodeling of the collagen III and V in posterior tibial tendinopathy.

Posterior tibial tendinopathy (PTT) can lead to acquired flatfoot in adults. Many patients develop PTT without any identifiable risk factors. Molecular changes in extracellular matrix (ECM) and matrix metalloproteinase (MMP) polymorphism may influence the risk of developing PTT. We aim to investigate the association between matrix metalloproteinase-1 (MMP-1) and (MMP-8) gene polymorphisms with changes in collagen I, III and V in PTT. A case-control study with 22 patients and 5 controls was performed. The MMP-1 (2G/2G) and MMP-8 (T/T) genotypes were determined by PCR-restriction fragment length polymorphism. Tendon specimens were evaluated by a histologic semiquantitative score, immunofluorescence and histomorphometry for collagen I, III and V. Tendon specimens from PTT demonstrated marked distortion of the architecture with necrosis, large basophilic areas with disruption of the normal linear orientation of collagen bundles, infiltration of inflammatory cells, dystrophic calcification and ossification. Under immunofluorescence, PTT tendon specimens showed weak green fluorescence and diffuse distribution of collagen I fibers, but strong fluorescence of collagen III and V. The collagen I fibers were significantly decreased whereas an increase of collagen III and V were found in PTT compared to control groups. In addition, PTT group presented a significant association with MMP-1 and MMP-8 gene polymorphisms. Patients with PTT matrix metalloproteinase-1 (MMP-1) and (MMP-8) gene polymorphisms presented an increase of the collagen III and V ratio, suggesting that the higher proportion in degenerated tendons could contribute to a decrease in the mechanical resistance of the tissue. Still, functional and association studies are needed to elucidate evident roles of MMPs in PTT.

Posterior tibial tendon dysfunction: Clinical and magnetic resonance imaging findings having histology as reference standard

ObjectiveTo investigate the correlation between MRI, clinical tests, histopathologic features of posterior tibial tendon (PTT) dysfunction in patients with acquired adult flatfoot deformity surgically treated with medializing calcaneal osteotomy and flexor digitorum longus tendon transposition. Materials and methodsNineteen patients (11 females; age: 46 ± 15 year, range 18–75) were pre-operatively evaluated using the single heel rise (HR) and the first metatarsal rise (FMR) sign tests. Two reviewers graded the PTT tears on a I–III scale and measured the hindfoot valgus angle on the pre-operative MRI of the ankle. The specimens of the removed portion of PTT were histologically analysed by two pathologists using the Bonar and Movin score. Linear regression, Spearman’s rank-order, and intraclass correlation coefficient (ICC) statistics were used. ResultsICC for MRI was excellent (0.952). Correlation between FMR and HR tests was at limit of significance (r = 0.454; P = 0.051). The HR and FMR tests were significantly correlated to the Movin score (r = 0.581; P = 0.009 and r = 0.538; P = 0.018, respectively) and were not significantly correlated to the Bonar score (both with a r = 0.424; P = 0.070). PTT tendinopathy grading at MRI was significantly correlated to the FMR test (p = 0.041) but not to the hindfoot valgus angle (p = 0.496), the HR test (p = 0.943), the Bonar score (p = 0.937), and the Movin score (p = 0.436). The hindfoot angle was not correlated to any of the other variables (p > 0.264). ConclusionFor PTT dysfunction, there is high correlation between HR and FMR test and histology evaluated using the Movin score, while no correlation was seen for the Bonar score. Semiquantitative grading of PTT dysfunction at MRI only correlates to the FMR and not to histology. The hindfoot valgus angle is not correlated to any of the considered variables.

The role of arthroereisis of the subtalar joint for flatfoot in children and adults.

Subtalar arthroereisis has been reported as a minimally-invasive, effective and low-risk procedure in the treatment of flatfoot mainly in children but also in adults.It has been described as a standalone or adjunctive procedure, and is indicated in the treatment of flexible flatfoot, tibialis posterior tendon dysfunction, tarsal coalition and accessory navicular syndrome.Different devices for subtalar arthroereisis are currently used throughout the world associated with soft-tissue and bone procedures, depending on the surgeon rather than on standardised or validated protocols.Sinus tarsi pain is the most frequent complication, often requiring removal of the implant.To date, poor-quality evidence is available in the literature (Level IV and V), with only one comparative non-randomised study (Level II) not providing strong recommendations. Long-term outcome and complication rates (especially the onset of osteoarthritis) are still unclear.Cite this article: EFORT Open Rev 2017;2:438–446. DOI: 10.1302/2058-5241.2.170009

Occupational Outcomes of Reconstructive Surgery for Adult Acquired Flatfoot Deformity.

Reconstruction of a symptomatic adult flatfoot is an involved operation with a long recovery period. No previous studies have looked at the occupational or functional results of athletically active patients who have undergone this surgery. In the U.S. Military, the rates of return to unrestricted active duty are unknown. A retrospective review of all active duty military patients who underwent a reconstructive surgery for adult acquired flatfoot surgery at a single institution from January 2001 to 2015 was performed. 50 patients met inclusion criteria. 28 of 50 patients (56%) remained on active duty with permanent duty restrictions, and only 2 of 50 patients (4%) returned to full duty without restrictions. 20 of 50 (40%) patients underwent a Medical Evaluation Board to separate from the military. A difference was noted in terms of the hindfoot realignment procedure performed: the probability of a Medical Evaluation Board is higher for those patients who had a lateral column lengthening procedure as compared to those who were treated with a medializing calcaneal osteotomy. The sample size is the largest study to date of young active patients who underwent surgical correction for symptomatic pes planus. The results demonstrate that a service member with symptomatic pes planus requiring surgery faces a 96% chance of failure to return to his or her preinjury level of function. Although some patients (56%) were able to remain on active duty with restrictions, there is a 40% chance that service members will face separation from the military because their foot pain despite a year of surgery and recovery. Furthermore, patients treated with a lateral column lengthening had a higher probability of being medically discharged than those who had a medializing calcaneal osteotomy.

Can patients affected by stage II Posterior Tibial Tendon Dysfunction return to sport activities after surgical treatment?

Category: Hindfoot, Sports Introduction/Purpose: Medial displacement calcaneal osteotomy with flexor digitorum longus transfer is considered the gold standard in treatment of adult flatfoot associated with posterior tibial tendon dysfunction (stage II in Myerson classification). The aim of this study was to estimate if patients underwent medial displacement calcaneal osteotomy with flexor digitorum longus transfer can participate to sport activities. Methods: 48 patients (21 men, 43,75%; 27 women, 56,25%) with a mean age at time of surgery of 42,3 years (range 19-74 years) were evaluated with a medium follow-up of 30 months (range, 27-34 months). All patients were evaluated clinically and by imaging before and after surgery. The clinical evaluation included for each patient the self-filling of Sports Athlete Foot and Ankle Score (SAFAS). and Pre- and postoperative sporting activities were recorded. The imaging evaluation included a pre-operative foot and ankle MRI and weight-bearing radiographs (antero-posterior, lateral and Saltzman 20° views) of the foot and ankle before surgery and at final follow-up. Moreover, each patients’ pre- and post-operative sport activities were recorded. Results: Preoperatively, 29 of 48 (60,4%) patients were engaged in athletic activities, participating in an average of 1.4 hours/week (range, 0-6 hours/week); postoperatively, 40/48 (83.3%) participated in sport and recreational activities for an average of 3.5 hours/week (range, 0-15 hours/week). Meary’s angle improved significantly from 11.3±6.3 degrees preoperatively to 7.2±5.5 degrees at final-follow-up (p<0.01); calcaneal pitch improved significantly from 16.1±4.3 degrees to 19.4±4.8 degrees (p<0.01). At final follow-up, patients demonstrated good SAFAS scores in symptom tolerance (85.90%), pain tolerance (88.30%), daily living performance (96.2%) and sports performance (86.45%). Conclusion: Most of patients returned or resumed to participate to sport activities after medial displacement calcaneal osteotomy and flexor digitorum longus transfer for the treatment of adult flatfoot associated with posterior tibial tendon dysfunction and the increase of the average number of activities for patient and of the mid time spent was observed.

Outcome of operative treatment of acquired adult flatfoot deformity in stage 2 patients

Outcome of operative treatment of acquired adult flatfoot deformity in stage 2 patients

Occupational Outcomes Of Reconstructive Surgery For Adult Acquired Flatfoot Deformity

Category: Hindfoot Introduction/Purpose: Reconstruction of a symptomatic adult flatfoot is an involved operation with a long recovery period. No previous studies have looked at the occupational or functional results of athletically active patients who have undergone this surgery. In the United States military, the rates of return to unrestricted active duty are unknown. Methods: A retrospective review of all active duty military patients who underwent a reconstructive surgery for adult acquired flatfoot surgery at a single institution from January 2001-2015 was performed. Surgical, inpatient, and outpatient databases were searched via CPT and ICD9 codes. Approximately 1300 cases with potential flatfoot reconstructive surgery were identified. Only those patients with the diagnosis of flatfoot treated with both a boney procedure and a soft tissue procedure were included. Patients had to have at least one year follow-up or follow-up to the point of maximum medical benefit as defined by the operative provider. Final disposition of the patients had to have been recorded in the medical record. Three possible outcomes were utilized in the review of this cohort: patient returned to duty without restrictions, patient returned to active duty with restrictions, or patient separated from active duty due all or in part to this medical condition. Results: Fifty patients met inclusion criteria. 30/50 patients (60%) remained on active duty with permanent duty restrictions, and only two of 50 patients (4%) returned to full duty without restrictions. 20/50 (40%) underwent a Medical Evaluation Board (MEB) to separate from the military. A difference was noted in terms of the hindfoot realignment procedure performed: the probability of an MEB is higher for those patients who had a lateral column lengthening procedure than those who were treated with a medializing calcaneal osteotomy. Conclusion: The sample size is the largest study to date of patients with surgical correction for symptomatic pes planus. The results demonstrate that a service member with symptomatic pes planus requiring surgery faces a 96% chance of failure to return to pre-injury level of function. While some (60%) were able to remain on active duty with restrictions, there is a 40% chance that service members will face separation from the military due to their foot pain. Furthermore, patients treated with a lateral column lengthening had a higher probability of being medically discharged than those who had a medializing calcaneal osteotomy.

Medializing calcaneal osteotomy (MCO) for acquired adult flatfoot

The number of screws used for sliding calcaneal osteotomy fixation has not been examined in the literature. The purpose of this paper is to examine this topic.Retrospective chart review was performed on 190 patients who met selection criteria. We compared complication risk for single versus double screw, headed versus headless screw, and short versus longitudinal incision cases.The mean age was 48.4 (18–83) years and average follow up was 28 (12–150) weeks. All cases achieved radiographic union. Overall complication rate was 19.5% (37/190). Risk of complication did not differ significantly between single and double screw (RR: 1.170; 95% CI: 0.66–2.09; p = 0.594) or short and extended incision groups (RR: 0.868; 95% CI: 0.42–1.80; p = 0.704). Risk of complication differed significantly between headed and headless screw fixation (RR: 5.558; 95% CI: 2.69–11.50; p < 0.0001).Single screw fixation of sliding calcaneal osteotomy achieves similar outcomes as double screw fixation. Headless screws are advantageous for minimizing hardware pain and subsequent hardware removal.

Comparison of Extraosseous Talotarsal Stabilization Implants in a Stage II Adult-Acquired Flatfoot Model: A Finite Element Analysis

Subtalar arthroereisis has been proved to be an efficient method for correcting flexible adult flatfoot. However, the optimal sinus tarsi implant is still debated and yet to be determined. In the present study, we compared the biomechanical effects of type I and II sinus tarsi implants in stage II adult-acquired flatfoot deformity (AAFD). First, a finite element model of stage II AAFD was established in which virtual surgery of subtalar arthroereisis was simulated. The indexes of plantar stress distribution, peak von Mises of the medial and lateral columns, strain of the medial ligaments and plantar fascia, arch height, talo-first metatarsal angle, calcaneus pitch angle, talonavicular coverage angle, and hindfoot valgus angle were all compared and analyzed. The results of the present study have validated the stage II AAFD finite element model by comparing the simulation results with the same parameters measured from weightbearing radiographs in the midstance phase. All the indexes showed that both types of arthroereisis can lower the plantar pressure and the strain of the medial ligaments that support the medial longitudinal arch and can shift the load of the medial column to the lateral column. They can also help to correct the deformity and restore the arch. However, the type II sinus tarsi implant design exhibited a more obvious effect than that of type I.

The resistance to failure of spring ligament reconstruction

IntroductionThe spring ligament (SL) is increasingly recognised as the major structure that fails in acquired adult flatfoot deformity (AAFD). This is the first study that demonstrates integrity of repair of the SL. Patients and methodsSix pairs of fresh frozen cadavers were setup in a standardised fashion with ankle in plantargrade (mean age 59 years, BMI 25).A 25N lateral force was applied to the medial metatarsal head using an algometer. Lateral displacement of the foot was measured with SL intact, sectioned, following FibreWire® repair, then Arthrex InternalBrace (IB) reconstruction, then with selective sectioning of each limb of the IB reconstruction. ResultsIn 12 specimens, overall lateral translation with SL intact was 21mm±4.9. This increased to 39.2mm±10.9 (p<0.05) with SL sectioning, no significant improvement to 34.2mm±9.5 with repair (p=0.159), before significantly returning to baseline 16.55mm±5.1 (p<0.001) with the IB. Augmenting with FDL did not influence lateral translation (p=0.586). ConclusionRestoration of SL integrity is fundamental to prevent flatfoot. This study shows traditional repair models fail to provide sufficient resistance to planovalgus. Using an augmented device such as the IB provides optimal resistance to lateral translation and hence planovalgus, particularly the plantar limb of the augmentation.

The arthroereisis procedure in adult flexible flatfoot grade IIA due to insufficiency of posterior tibial tendon

BackgroundTo report on the functional, biomechanical, and radiographic results of patients who had undergone arthroereisis plus tensioning of the posterior tibial tendon for flexible flatfoot. The hypothesis is that arthroereisis associated to a tensioning of the posterior tibial tendon give a good correction with great satisfaction in patients with flexible flatfoot in grade IIA. MethodsWe evaluated 29 patients (31 feet), mean age of 46.4 years, who had been surgically treated for adult flatfoot grade IIA according to Myerson. Mean follow-up was 34.15 months. For clinical evaluation, the AOFAS hindfoot and VAS-FA scores were used. ResultsPostoperative results showed significant increases in both AOFAS and VAS-FA scores: 54.2–81.9 and 61.5–83.2 points, respectively. For the X-ray parameters, we observed a significant variation in the talo-first metatarsal angle, from 13.8° in pre-op to 7.4° in post-op. In lateral view, Djian Annonier angle was improved from 146.6° to 134.1°. The Meary’s angle, compared to an average of 8.8° in pre-operative stage improved to 4.3° in the post-operative stage. Postoperative satisfaction was excellent-good according to 23 patients (79.4%). Pain in the tarsal sinus was reported in 5 out of 31 feet (16.1%) for the first three months after surgery. ConclusionsArthroereisis and tensioning of the posterior tibial tendon provided good functional outcomes for patients under 60 years of age having stage IIA flexible flatfoot without arthritic manifestations.

Fat grafting for chronic heel pain following surgery for adult flatfoot deformity: Pilot study

IntroductionAutologous fat grafting is now a highly popular technique in plastic and reconstructive surgery, with broad applicability for various surgical procedures. Fat grafting can impart contours and augmentation, nourish tissue, modulate scar tissue, and produce regeneration at the recipient site. In this pilot study, the authors suggest that fat grafting may be useful therapeutic adjunct for cases of chronic heel pain following surgery for adult flatfoot deformity. Materials and methodsEight patients with chronic heel pain following surgery for adult flatfoot deformity underwent autologous subcutaneous heel fat grafting and recorded their levels of pain relief for 6 months postoperatively. ResultsThe authors recorded a statistically significant difference (p<0.001) between pain scale values recorded before (t0) and six months postoperatively (t6). From t0 to t6, mean pain scale values changed from 8.125 to 2.413. ConclusionsVolumetric enhancement of the subcutaneous heel fat pad significantly ameliorated weight-bearing pain in these patients.

Prevalence of Flexible Flat Foot in Adults: A Cross-sectional Study.

Flat foot (pes planus) is a commonly observed disorder in clinical practice. The height of Medial Longitudinal Arch (MLA) determines the degree of pes planus. Majority of the previous studies on prevalence of flexible flat foot were done among children. The present study was undertaken to determine the prevalence of flexible flat foot among 18-21-year-old Indian adults using Navicular Drop Test (NDT) which is regarded as reliable and valid method to characterise MLA. The present study was a cross-sectional study in which Brody's Navicular Drop Test was performed in five hundred healthy subjects (250 males and 250 females) aged 18-21-year-old. Navicular Drop (ND) of ≥ 10 mm was regarded as flexible flat foot. Statistical analysis was done using SPSS version 23.0. The prevalence of flexible flat foot was 13.6% (for males-12.8%; for females-14.4%). The median with Inter Quartile Range (IQR) for ND among males was 6 mm (4-8) and 6 mm (4-9) for right and left foot respectively. The median with IQR for ND among females was 6mm (4-10) and 7mm (3-8) for right & left respectively. The correlation of Right Side Navicular Drop (RND) with height and weight was significant, but insignificant correlation was found between RND and BMI. The correlation of Left Side Navicular Drop (LND) with height, weight and BMI of individuals was statistically not significant. The difference between the ND of males and female group was statistically not significant. The present study quantified the prevalence of flexible flat foot and gender wise normative values of ND among 18-21-year-old Indian adults. The information obtained by this study will be useful in the field of orthopaedics.

Modern Theory of the Development of Adult Acquired Flat Foot and an Updated Spring Ligament Classification System

Traditionally tibialis Posterior Insufficiency is still considered the commonest cause of acquired adult flat foot. This is still considered as the primary cause and has influenced both treatment and the diagnosis of the condition. Foot surgeons are now questioning the whole classification and the fundamental errors within this that have not been challenge for over 30 years. In this review article we examine the emerging evidence that suggests a new and alternative pathogenesis to this disease process centred on failure of the spring ligament.

MODERN X-RAY DIAGNOSIS OF ADULT ACQUIRED FLATFOOT DEFORMITY

This scientific review is devoted to the modern diagnostics of adult flatfoot using radiographic method. Describes the main radiographic projections and basic morpho-functional parameters that determine the degree of deformation and the further tactics of patients’ treatment.

Return to sport activities after medial displacement calcaneal osteotomy and flexor digitorum longus transfer.

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. A consecutive series of 42 patients with a mean age at surgery of 41years (range 19-74years) was evaluated with a minimum follow-up of 24months (range 18-31months). 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. Preoperatively, 27 of 42 (64.3%) patients were engaged in athletic activities, participating in an average of 1.4h/week (range 0-6h/week); post-operatively, 36/42 (85.7%) participated in sport and recreational activities for an average of 3.5h/week (range 0-15h/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%). 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. III.

The Application of Calcaneal Z Osteotomy in Treating Type ⅡB Adult Acquired Flatfoot Deformity

Category: Hindfoot Introduction/Purpose: A retrospective control study to evaluate the application of calcaneal Z osteotomy in treating type ⅡB adult acquired flatfoot deformity. Methods: From September 2011 to March 2013, 20 cases of typeⅡB adult acquired flatfoot (according to Myerson’s classification) were treated by calcaneal Z osteotomy combined with medial soft tissue reconstructing. There were 4 males and 16 females with a mean age of 52.6 years (range 49 to 72 years). A Z osteotomy of the calcaneus was performed instead of a lateral column lengthening or a double calcaneal osteotomy for purpose of correct the forefoot abduction and hind foot valgus deformity. The medial soft tissue procedure included posterior tibial tendon resection and Flexor digitorum longus tendon transfer. American Orthopaedic Foot and Ankle Society (AOFAS) score and radiological assessments were used to evaluate the conditions before and after operation. Results: Eventually, 19 patients were followed up with an average duration of 26.5 months (range, 18-56 months). AOFAS scores were 80-90 points in 11 patients, 90-100 points in 6 patients and the excellent and good rate was 89% (17/19). The specific indexes of X-ray improved obviously (P &lt; 0.01). The anteroposterior talocalcaneal angle decreased by 12°, lateral talar first metatarsal angle decreased by 15°, and talonavicular coverage angle decreased by 7°. There was no calcaneal-cuboid joint symptom in this group of patients. All these cases got good bone healing. Conclusion: The calcaneal Z osteotomy can correct the hind-foot deformity in three dimensions and can act as a lateral column lengthening in treating type ⅡB adult acquired flatfoot. The complication of this procedure is minimal.

Adult Flexible Flatfoot Due to Insufficiency of Posterior Tibial Tendon

Category: Hindfoot Introduction/Purpose: We postulated that in a flexible adult flatfoot, calcaneo-stop procedure combined with medial tensioning of posterior tibial tendon allowed the resolution of symptoms by correcting the pattern of the gait and avoiding the evolution to a subsequent stage. The purpose of this study was to determine functional, biomechanic, and radiographic results in patients who underwent surgery for flexible flatfoot without osteotomies or arthrodesis. Methods: We evaluated clinically and radiographically 29 patients surgically treated for adult flatfoot grade IIa according to Myerson, with a mean age of 46.4 years. Mean follow-up was 34.15 months. For clinical evaluation the AOFAS hindfoot and VAS- FA scores were used. In 10 patients, pre and post-operatively gait analisys was performed. Results: Postoperative results showed a significant increase of AOFAS and VAS-FA scores, from 54.7 (range 34 to 78) to 83.1 (range 66-100) and 60.5 (range 35-86) 85 (range 64-100) points, respectively. For the X-ray parameters, in the AP projection, we observed a significant variation of Kite's angle, from 24.2° in the pre-op to 19.2° in the post-op. In lateral view Costa-Bertani angle showed changes from 146.8° to 140.5°. The Meary's angle, showed an average at the post-op of 4.3°. Postoperative satisfaction was excellent-good for 25 patients (86.2%). Postoperative gait analysis showed an improved pattern of the gait. Conclusion: The technique of arthroereisis with medial tensioning of PTT is a valid technique for the young adult, up to 50 years and with no signs of osteoarthritis of the midfoot and hindfoot.

Influence of tibialis posterior muscle activation on foot anatomy under axial loading: A biomechanical CT human cadaveric study.

Collapse of the medial longitudinal arch and subluxation of the subtalar joint are common occurrences in adult flatfoot deformity. Controversy exists about the role of the tibialis posterior (TP) tendon as first and/or essential lesion. Subtle changes in the foot configuration can occur under weight bearing. This human cadaveric study is designed to investigate the effect that isolated actuation of the TP tendon has on the medial longitudinal arch and the hindfoot configuration under simulated weight bearing. A radiolucent frame was developed to apply axial loading on cadaveric lower legs during computer tomography (CT) examinations. Eight pairs of fresh-frozen specimens were imaged in neutral position under foot-flat loading (75N) and under single-leg stance weight bearing (700N) without and with addition of 150N pulling force on the TP tendon. Measurements of subtalar joint subluxation, forefoot arch angle and talo-first metatarsal angle were conducted on each set of CT scans. Subtalar subluxation, talo-first metatarsal angle and talo-navicular coverage angle significantly increased under single-leg stance weight bearing, whereas forefoot arch angle significantly decreased. Actuation of the TP tendon under weight bearing did not restore the forefoot arch angle or correct subtalar subluxation and talo-metatarsal angle. Significant effect that weight bearing has on the medial longitudinal arch and the subtalar joint configuration is demonstrated in an ex-vivo model. In absence of other medial column derangement, actuation of the TP tendon alone does not seem to reconstitute the integrity of the medial longitudinal arch or correct the hindfoot subluxation under weight bearing. The findings of this study together with the developed model for ex-vivo investigation provide a further insight in foot anatomy.

MCO and FDL transfer as therapy for adult flat foot: Comparison of 1-year and intermediate results

The supracondylar process is a congenital bone projection on the distal anteromedial humerus often associated with a ligament of Struthers, a fibrous connection between the process and medial epicondyle. It is largely asymptomatic and only on rare occasions presents with neurovascular compression resulting in a supracondylar process syndrome. This case report describes a 28-year-old woman with supracondylar process syndrome, and our management. The topic is further explored with a literature review of 43 reported cases. Analysis of the case reports indicates that isolated median nerve injuries are the most common. Other presentations such as fractures, vascular compromise, and ulnar nerve involvement are less frequent.