Ankle Valgus Research Articles

Clinical study of Cross-Union surgery for treatment of pseudarthrosis of tibia with neurofibromatosis type 1 in children

To evaluate the effectiveness of Cross-Union surgery for the treatment of pseudarthrosis of the tibia (PT) with neurofibromatosis type 1 (NF1). The clinical data of 8 children of PT with NF1 who met the selection criteria between January 2018 and December 2023 was retrospectively analyzed. There were 5 boys and 3 girls, and the operative age ranged from 1.8 to 13.3 years with a median age of 3.5 years. According to Paley classification, there were 2 cases of type 2a, 2 cases of type 3, 2 cases of type 4a, and 2 cases of type 4c. There were 5 cases of first operation and 3 cases of re-fracture after previous operation. Six cases had leg length discrepancy before operation, and 2 of them had shortening over 2.0 cm. Except for 1 case of ankle fusion, the other 7 cases had ankle valgus. Preoperative coronal/sagittal angulation was recorded. Postoperative pseudarthrosis healing and refracture were observed. Leg length discrepancy and tibiotalar angle were measured and recorded before operation and at last follow-up. Inan imaging evaluation criteria was used to evaluate the imaging effect. All patients were followed up 12-37 months (mean, 23.5 months). One pseudarthrosis failed to heal at 12 months after operation and healed at 3 months after reoperation, while the other pseudarthrosis healed with a healing rate of 87.5% and a healing time of 4-8 months (mean, 5.3 months). No refracture occurred during the follow-up. At last follow-up, there were 2 new cases with leg length discrepancy, which were 0.7 cm and 1.3 cm, respectively. In 2 cases with the leg length discrepancy more than 2.0 cm before operation, the improvement was from 4.1 cm and 12.6 cm to 2.1 cm and 9.0 cm, respectively. There was no significant difference in leg length discrepancy between pre- and post-operation in 8 cases ( P>0.05). At last follow-up, 6 patients still had ankle valgus, and there was no significant difference in the tibiotalar angle between pre- and post-operation ( P>0.05); the tibial coronal/sagittal angulation significantly improved when compared with that before operation ( P<0.05). According to Inan imaging evaluation criteria, 1 case was good, 6 cases were fair, and 1 case was poor. Cross-Union surgery is an effective method for the treatment of PT with NF1 in children, can achieve good bone healing results with a low risk of re-fracture. The surgery may not have significant effects on leg length discrepancy and ankle valgus, and further treatment may be required.

The clinical characteristics of 497 children with congenital pseudarthrosis of the tibia

Objective: To investigate the clinical and radiologic characteristics of children with congenital pseudarthrosis of the tibia (CPT) in a single center. Methods: This is a retrospective case series study. According to inclusion and exclusion criteria, clinical data of 497 children(507 limbs) with CPT who were treated at Department of Orthopedics, the Children's Hospital Affiliated to Xiangya School of Medicine, Central South University from January 2011 to December 2020 were collected. Baseline data included gender, age at initial visit, age at onset of symptoms, accompanying symptoms, domicile, whether first treated at our hospital, and treatment-related information such as surgical or conservative treatment, surgical complications, etc., were extracted and analyzed using the health information system. Imaging data of the children, including Crawford classification, bilateral leg lengths, presence of fibular pseudarthrosis, and location of pseudarthrosis along the tibia segment, were analyzed using the Picture Archiving and Communication System. Data were compared using independent sample t test or χ2 tests. Results: Among 497 children with CPT, there were 305 males (61.4%) and 192 females (38.6%). The age at initial visit was (3.6±3.2) years (range: 0.1 to 16.2 years). Neurofibromatosis type 1 (NF1) symptoms were positive in 340 children (68.4%), and negative in 157 children (31.6%). Among NF1-positive children, those with symptoms onset before 1 year of age were significantly more than NF1-negative children (74.1%(252/340) vs. 66.2%(104/157);χ2=9.24, P=0.001), and the proportion of fractures (92.9%,316/340) was significantly higher than that in the NF1-negative group (84.7%,133/157) (χ2=8.33, P=0.004). According to imaging data, Crawford type Ⅳ was the most common type, with 321 limbs (63.3%), followed by type Ⅱ in 100 limbs (19.7%), type Ⅲ in 54 limbs (10.7%) and type Ⅰ in 32 limbs (6.3%). Pseudarthrosis occurred in the proximal third of the tibia in 14 limbs (2.8%), in the middle third in 185 limbs (36.5%), and in the distal third in 308 limbs (60.8%). Seventy-four children (14.9 %) had associated fibular pseudarthrosis. The lateral proximal tibial angle was 86.91°±5.21°(range: 72.17° to 102.08°), and the lateral distal tibial angle was 87.27°±10.73°(range: 51.07° to 128.17°). A total of 421 children (84.7%) underwent surgical treatment with (3.1±2.4) surgeries performed per child (range:0 to 12 surgeries); 76 children (15.3%) received conservative treatment. Postoperative complications mainly included ankle valgus (77 cases), leg length discrepancy (71 cases),refracture (48 cases), osteomyelitis (11 cases), and hardware failure (10 cases). NF1-positive children underwent more surgeries than NF1-negative children ((5.1±2.2)times vs.(2.1±1.8)times;t=14.93,P<0.01). Conclusions: Crawford type Ⅳ is the most common type of CPT in children in this study. CPT predominantly occurs in the middle or distal third of the tibia. The majority of children with CPT experienced symptoms and were seen at outpatient clinics before the age of 3 years. The main surgical complications currently associated with CPT treatment are ankle valgus and leg length discrepancy. Compared with CPT without NF1, children with NF1-positive CPT tend to have earlier symptom onset and may require more frequent treatments.

Total ankle arthroplasty in valgus ankle osteoarthritis

The valgus total ankle replacement (TAR) presents a considerable challenge and tests the skill and ingenuity of even the most accomplished foot and ankle surgeon. Coronal plane deformity used to be considered a relative contra-indication for TAR, however with implant innovation and greater surgical understanding, the indications for TAR in deformity continue to expand. Success requires a bespoke approach to each patient to ensure that intra- and extraarticular deformities and imbalance are adequately addressed to avoid TAR failure. The overall goal in TAR surgery is achieving a well aligned and stable ankle with a well aligned and stable foot below. This article presents some of our strategies to achieve this when considering TAR in the valgus ankle.10.1016/j.fuspru.2024.08.002

Gradual Transverse Transport of Naturally Tibialized Fibula Using Hexapod Frames to Treat Neglected Type V Tibial Segmental Defects.

Although several reconstructive methods have been developed to manage large segmental tibial bone defects including bone transport (distraction osteogenesis), contralateral fibular graft, allograft, tibiofibular synostosis, Masquelet technique, and 3D printed scaffold, neglected large tibial defects in adults remain challenging problems. This study describes gradual transverse transport of naturally tibialized fibula using hexapod frames in management of adult patients with neglected large tibial defects. We retrospectively reviewed four cases of transverse transport of naturally tibialized fibula from November 2018 to February 2022. We measured the length of the tibial defect and the transported fibular segment, the mid-diaphyseal diameter and cortical thickness of the affected fibula, contralateral fibula, and tibia. The parameters measured both preoperatively and postoperatively were leg length discrepancy, hip-knee-ankle angle, medial proximal tibial angle, posterior proximal tibial angle, lateral distal tibial angle, range of motion of the knee and ankle joints, and Lower Extremity Functional Scores (LEFS). Patients' satisfaction rates using Likert scale were also recorded. Among four female patients, three suffered from tibial osteomyelitis, and one was due to congenital pseudarthrosis of the tibia. The average follow-up time was 2.7 ± 1.4 years. The average length of tibial defect was 14.0 ± 0.8 cm. The average preoperative shortening of the affected leg was 9.0 ± 2.5 cm, which changed to 0.6 ± 0.8 cm postoperatively. The median length of the transported fibular segment was 15.2 cm. Two patients had varus deformity, two had recurvatum, and one had procurvatum preoperatively. Postoperative radiological measurement showed all deformities corrected and no ankle valgus deformity developed during follow-up. All patients achieved union and can fully weight bear on the affected extremity. The average fixator time was 12.9 ± 2.9 months. The average preoperative and postoperative LEFS, respectively, were 53.5 ± 5.0, 70.5 ± 1.3, with a significant difference (p = 0.003). Three patients reported very satisfied with the outcome, and one patient reported satisfied. Three patients had pin tract infections, and one patient had skin necrosis which healed after additional surgery. One patient had surgical release of the hamstring tendons due to flexion contracture of the knee. Two patients had 15° of reduction in ankle range of motion. One patient had transient common peroneal nerve palsy which spontaneously recovered within 6 weeks. The transverse transport of naturally tibialized fibula was both a safe and effective method to treat the long-standing type V tibial segmental defect.

Comparative study of different extendable intramedullary rods combined with surgery in the treatment of congenital pseudarthrosis of the tibia

BackgroundWhen using traditional extensible intramedullary rods to treat congenital pseudarthrosis of the tibia (CPT), there were cases of re-fracture and internal fixation fracture. Therefore, the authors propose a research hypothesis that a thicker distal extensible intramedullary rod can better protect the tibia and reduce the incidence of refracturePurposeTo investigate the clinical efficacy of new and traditional extensible intramedullary rods in the treatment of CPT in childrenMethodsFrom January 2017 to December 2021, the clinical data of 49 children with CPT who were treated with traditional extensible intramedullary rod combined surgery (group A) and new extensible intramedullary rod combined surgery (group B) in our hospital were collected. Inclusive criteria: ① Crawford type IV CPT children; ② The operation was performed by the same team. Exclusion criteria: patients with multiple tibial angulation. During follow-up, the initial healing, proximal tibial valgus, tibial length, ankle valgus, refracture and intramedullary rod displacement of CPT children in the two groups were evaluatedResultsIt was a retrospective investigation. In group A, 26 cases met the inclusion criteria, 24 cases achieved primary healing, with an primary healing rate of 92%, including 1 case of nonunion due to osteomyelitis complications after surgery, and 1 case of delayed healing, with an average healing time of 4.7 ± 0.8 months. 17 cases (68%) had unequal tibia length, with an average difference of 1.6 ± 0.8 cm. Ankle valgus occurred in 10 cases (40%) with an average of 14.4°±4.8°; Proximal tibial valgus occurred in 6 cases (24%) with an average of 7 °± 1.8 °. 20 cases (80%) had tip of the rod migration.10 cases (40%) had re-fracture; The average follow-up time was 2.4 ± 0.4 years. In group B, 22 patients achieved primary healing, and the primary healing rate was 95%, including 1 case with delayed healing. The average healing time was 4.7 ± 1.7months. 14 cases (61%) had unequal tibia length, with an average difference of 1 ± 0.5 cm. Ankle valgus occurred in 4 cases (17%) with an average of 12.3 °±4.9°; The proximal tibia valgus occurred in 9 cases (39%), with an average of 7.7 °±2.5 °. 14 cases (61%) had new type of intramedullary rod displacement. 3 cases (13%) had re-fracture; The average follow-up time was 2.3 ± 0.6yearsConclusionCompared with the traditional extended intramedullary rod combined operation, the new type of extended intramedullary rod combined operation has a lower incidence of re-fracture after CPT, but it still needs to be verified by large sample and multi-center research

Cueing Dancers to "Externally Rotate From the Hips" Improves Potentially Injurious Ankle Joint Angles and Contact Forces During a Demipointe Ballet Position.

Introduction: The demipointe dance position puts the ankle at high risk of overuse injury and posteromedial ankle pain due to increased ankle valgus forces. Previous work has shown that creating lower limb external rotation intrinsic to demipointe with hip external rotation reduces foot pronation that causes ankle valgus stress. Therefore, the purpose of this work was to examine long axis rotation kinematics of the hip, knee, and ankle as well as the ankle joint contact forces in demipointe to better understand the biomechanical impact(s) of the specific cue to increase hip external rotation in this position. Methods: Three-dimensional motion capture and force plate data were collected from 23 contemporary or ballet pre-professional dancers (age: 19.94 ± 1.34 years) who each performed 3 dancer-selected (DS) demipointe positions and 3 demipointes with the cue to "externally rotate from the hips." Results: The cue to increase hip external rotation resulted in significantly increased hip external rotation angle [DS: 37.5; 9.42° (median; interquartile range), Cued: 39.9; 10.8°, P < .0001)] and significantly reduced ankle eversion angle (DS: 8.13; 11.4°, Cued: 7.77; 10.3°, P = .023). However, total turnout angle was also significantly decreased (DS: 75.8; 7.91°, Cued: 75.4; 7.73°, P < .0001), which is undesirable for proper esthetic performance of demipointe. Total ankle joint force remained unchanged, but ankle eversion force was significantly reduced (DS: 15.3; 4.18 %bodyweight (BW), Cued: 14.7; 4.99 %BW, P < .0001) with use of the cue. Discussion/Conclusion: Utilization of a cue to increase hip external rotation was successful in increasing hip contribution to turnout angle and reducing injurious ankle eversion force. Further coaching using this cue may allow dancers to produce these advantageous mechanics while maintaining turnout angle.

Is Using a Ring External Fixator in the Treatment of Congenital Pseudarthrosis of the Tibia Associated With Better Results or Using a Locking Plate?

Congenital pseudarthrosis of the tibia (CPT) is a rare disease. CPT is often unilateral and occurs between the middle and distal third of the tibia. Concurrent involvement of the fibula is present in more than half of cases. histologic studies indicate the presence of fibrous hamartoma tissue and a sick periosteum, which leads to recalcitrant bone fracture and, eventually, pseudoarthrosis. Although there are various surgical techniques, we intend to compare the 2 methods of external fixation versus internal plating. Demographic data were collected from 26 patients with frank pseudoarthrosis. After exclusion criteria, patients were compared in groups A (12 patients) and B (11 patients). Resection of hamartoma and sclerotic bone, intramedullary rodding and autologous bone, and periosteal grafting were performed for all patients. In group A, we used a ring external fixator for compression and rotational stability, but in group B, a locking plate was used for these purposes. Plating takes less time to use during surgery. In group A, the primary bony union was obtained in 67% of patients, while in group B, 82% of patients had a primary union. Meanwhile, the average time till the final union in group A was 6 months, while in group B, this time was 3.5 months. Positive union mass was obtained in 58% of the patients in group A and 82% of group B. In addition, plating prevented ankle valgus deformity in group B. Permanent intramedullary rodding is a surgical requirement for correction of deformity and refracture prevention, but additional stability can be achieved with the use of a ring external fixator or internal plate. Cross union and positive union mass are 2 important factors in the treatment of pseudoarthrosis; these results are achieved to a greater extent and in a shorter period of time using the plate. level IV - case series.

Multi-segment foot kinematics during gait in children with spastic cerebral palsy

BackgroundFoot deformities (e.g. planovalgus and cavovarus) are very common in children with spastic cerebral palsy (CP), with the midfoot often being involved. Dynamic foot function can be assessed with 3D gait analysis including a multi-segment foot model. Incorporating a midfoot segment in such a model, allows quantification of separate Chopart and Lisfranc joint kinematics. Yet, midfoot kinematics have not previously been reported in CP. Research questionsWhat is the difference in multi-segment kinematics including midfoot joints between common foot deformities in CP and typically-developing feet? Methods103 feet of 57 children with spastic CP and related conditions were retrospectively included and compared with 15 typically-developing children. All children underwent clinical gait analysis with the Amsterdam Foot Model marker set. Multi-segment foot kinematics were calculated for three strides per foot and averaged. A k-means cluster analysis was performed to identify foot deformity groups that were present within CP data. The deformity type represented by each cluster was based on the foot posture index. Kinematic output of the clusters was compared to typically-developing data for a static standing trial and for the range of motion and kinematic waveforms during walking, using regular and SPM independent t-tests respectively. ResultsA neutral, planovalgus and varus cluster were identified. Neutral feet showed mostly similar kinematics as typically-developing data. Planovalgus feet showed increased ankle valgus and Chopart dorsiflexion, eversion and abduction. Varus feet showed increased ankle varus and Chopart inversion and adduction. SignificanceThis study is the first to describe Chopart and Lisfranc joint kinematics in different foot deformities of children with CP. It shows that adding a midfoot segment can provide additional clinical and kinematic information. It highlights joint angles that are more distinctive between deformities, which could be helpful to optimize the use of multi-segment foot kinematics in the clinical decision making process.

Effect of non-vascularized fibular harvest on the donor limb: radiological evaluation at a mean follow-up of twelve point eightyears.

The study is aimed at evaluating the long-term (at a minimum follow-up of 10years) impact of non-vascularized fibular harvest on the donor limbs. There were 27 donor limbs (n = 19 children) available for retrospective radiological review. The graft was obtained bilaterally in eight patients. The following parameters were evaluated in the follow-up radiographs: continuity/non-continuity of fibular regenerate, width of the regenerated fibula, distal fibular station, medial proximal tibial angle, posterior proximal tibial angle, lateral distal tibial angle (LDTA), anterior distal tibial angle, and tibia diaphyseal angulation (interphyseal angles). For analysis and comparisons, the donor limbs were compared to the healthy limbs (controls) of the children with unilateral harvest. Additionally, the impact of continuous and non-continuous fibular regeneration was separately analyzed. The mean child's age at the time of fibular harvest was fouryears. The mean follow-up was 12.8years. The fibula was found regenerated in continuity in 22 limbs of 15 children (81.5%). When analyzed as a combined group (both continuous and non-continuous fibular regenerations), all the donor limb radiological parameters matched those of healthy limbs except LDTA (p = 0.04). In the subgroup analysis between non-continuous and continuous fibulae, significant abnormalities were again obvious in LDTA (p = 0.0001). The non-continuous fibulae were significantly lesser in width. All limbs with non-continuous fibular regeneration manifested ankle valgus. The non-vascularized fibula emerged as a relatively safe procedure in the long term with minimal affections of the knee, ankle, or tibial anatomy when longitudinal integrity of fibula was restored. The non-regenerations of the fibula may be prone to developing ankle valgus.

Radiographic Analysis of Valgus Ankle Deformity With or Without Medial Longitudinal Arch Collapse.

Establishing a surgical plan for ankle deformities necessitates a comprehensive understanding of the deforming forces involved, and the morphology of the ankle deformity plays an important role as well. Valgus tibiotalar tilt development has mostly been described in patients with a low medial longitudinal arch, as seen in progressive collapsing foot deformity (PCFD). However, some valgus ankles demonstrate no radiographic evidence of a collapsed medial arch. This study aims to investigate whether there are differences in the radiographic morphology of valgus ankle deformities between patients with and without a low medial longitudinal arch to explore if they have different etiologies. We retrospectively reviewed patients who underwent surgical treatment for asymmetric valgus ankle deformity at our institution between 2017 and 2021. Patients with a valgus tibiotalar tilt (TT) greater than 4 degrees and Meary angle greater than 30 degrees (mean: 38.9) were included in the PCFD group (n = 29). The non-PCFD group (n = 24) with TT greater than 4 degrees and Meary angle less than 4 degrees (mean: 0.3) was also established. In the weightbearing ankle anteroposterior view, the TT and medial distal tibial angle were measured. Additionally, to assess the mediolateral position of the talus, the talar center migration (TCM) and lateral talar dome-plafond distance (LTD-P) ratio in the coronal plane were measured. In weightbearing computed tomography (WBCT), the degree of axial plane talocalcaneal subluxation and the prevalence of sinus tarsi bony impingement were assessed. Intergroup comparison was conducted. Both groups demonstrated a similar degree of TT, with a mean of 11.6 degrees in the PCFD group and 13.7 degrees in the non-PCFD group (P = .2330). However, the PCFD group showed a significantly greater TCM and LTD-P ratio compared with those of the non-PCFD group (P < .0001), indicating that PCFD patients have a more medially translated talus in ankle anteroposterior radiographs. WBCT showed that the PCFD group on average had 18 degrees greater axial plane talocalcaneal subluxation (P < .0001) and 52% higher prevalence of sinus tarsi bony impingement (P = .0002) compared with the non-PCFD group. This study suggests that valgus ankles may exhibit different radiographic morphologies depending on the status of the longitudinal arch. Valgus ankles in PCFD patients tend to have a more medially translated talus. This finding may suggest the presence of different deforming forces between the 2 groups and may indicate the need for different treatment strategies to address talar tilt. Level III, case-control.

Free Fibula Flap for Congenital Pseudarthrosis of the Tibia: Indications and Challenges

BackgroundCongenital pseudoarthrosis of the tibia (CPT) is a rare pathological disease associated with neurofibromatosis type 1 (NF1). It presents with tibial bowing and can progress into a nonhealing fracture. Treatment options include conservative approaches such as serial bracing or various surgical options.Surgically, the aims are to achieve long-term bone union, prevent limb length discrepancies (LLDs), and avoid mechanical axis deviation, soft tissue lesions, nearby joint stiffness, and pathological fracture.The purpose of our study is to highlight our experience with both the conservative approach and the use of vascularized free fibula reconstruction of these deformities, including the challenges encountered with a long-term follow-up until skeletal maturity. MethodsWe present a retrospective analysis of a total of nine (9) patients consisting of three (3) girls and six (6) boys. Six (6) children were treated with a vascularized fibula flap, and the other three (3) were treated conservatively. Outcomes measured included fractures, LLD, ankle valgus deformity, donor site morbidity, and number of surgical corrections. ResultsAll patients had flap survival. Three (3) of six children had a previous failed surgery with intramedullary nail and bone graft prior to performing a vascularized free fibula reconstruction. The follow-up period ranged from 8 months to 200 months. The complications included stress fractures (50%), LLD (66.6%), and ankle valgus (33.3%). During growth phases, these children required multiple corrective surgeries. ConclusionsFibula free flap is a good treatment option for CPT even in patients with prior surgical failures with variable results.Level of Evidence - Level 4 - Case series Therapeutic Studies—Investigating the Results of Treatment.

Selective Strength Training Changes the Morphology and Ankle Strength of the Peroneus Longus and the Peroneus Brevis.

This study aimed to investigate the 8-week selective training effect of the peroneus longus (PL) and the peroneus brevis (PB) on muscle morphology, echogenicity, and ankle strength and to examine post-intervention detraining effects. Twenty healthy participants without orthopedic disease in the lower extremities were assigned to either the PL intervention group (training consisted of pushing the Thera-Band® out from the ball of the foot to emphasize ankle eversion) or the PB intervention group (training consisted of pulling the Thera-Band® from the base of the fifth metatarsal to enhance ankle valgus and external rotation). Each intervention was performed three times per week for 8 weeks. The cross-sectional area (CSA), thickness, echogenicity, and ankle strength of the PL and the PB were measured before week 1 and after each training session. Detraining effects were evaluated after the 8-week intervention. The results revealed a significant interaction between within-group (week) and between-group (type of intervention) variables on CSA and ankle strength of both the PL and the PB. Over the 8-week training period, the CSA and ankle strength of the PL significantly increased in the PL intervention group, as did the CSA and ankle strength of the PB in the PB intervention group (p < 0.05). The residual effect of muscle hypertrophy was observed during the detraining period. In conclusion, 8-week selective PL and PB training interventions can increase the CSA and ankle strength of these muscles over time. Long-term selective intervention is required to improve peroneus muscle morphology and function, with separate assessments of the CSA and ankle strength of the PL and the PB.

Assessment of foot impairment in systemic sclerosis: a cross-sectional study.

To assess foot function in Systemic Sclerosis (SSc) and its association with sociodemographic and clinical factors. To evaluate mobility, foot alterations, foot pain, and foot care in these patients. Consecutive SSc patients underwent structured interviews and physical examinations. Disability was assessed using Health Assessment Questionnaire (HAQ) and Scleroderma Health Assessment Questionnaire. (SHAQ). Foot function was measured using Foot Function Index (FFI), foot pain using a numeric pain scale (NPS), and mobility using Timed-UP-Go test (TUG). 101 patients were included. Forefoot pain was observed in 50.5%, hindfoot pain in 31.7%, foot ulcers in 6.9%, foot plantar callosities in 38.6%, foot arthritis in 2.97%, hallux valgus in 9.9%, claw toes in 5%, and valgus ankle in 3% of patients. The mean FFI was 3.54 (±2.6), NPS was 6.08 (±3.58), and TUG test was 10.52 (±6.5) seconds. Higher FFI scores, increased NPS, and prolonged TUG were associated with Raynaud's phenomenon severity, SHAQ, and HAQ. 36.6% of patients reported never having their feet examined, and only 32.7% had their feet examined within the past year. Foot dysfunction and pain are common in SSc. Higher FFI scores, increased pain, and prolonged TUG duration were linked to disability (HAQ and SHAQ). These analyses should be considered exploratory and require confirmation in external cohorts. Routine foot examinations were lacking in clinical practice. Improved attention for evaluating and caring for the feet in SSc patients is needed.

The Effect of Different Degrees of Ankle Dorsiflexion Restriction on the Biomechanics of the Lower Extremity in Stop‐Jumping

Purpose. The functional status of the ankle joint is critical during dynamic movements in high‐intensity sports like basketball and volleyball, particularly when performing actions such as stopping jumps. Limited ankle dorsiflexion is associated with increased injury risk and biomechanical changes during stop‐jump tasks. Therefore, this study aims to investigate how restricting ankle dorsiflexion affects lower extremity biomechanics during the stop‐jump phase, with a focus on the adaptive changes that occur in response to this restriction. Initially, 18 participants during stop‐jumping with no wedge plate (NW), 10° wedge plate (10 W), and 20° wedge plate (20 W) using dominant leg data were collected to explore the relationship between limiting ankle mobility and lower extremity biomechanics. Following this, a musculoskeletal model was developed to simulate and calculate biomechanical data. Finally, one‐dimensional parametric statistical mapping (SPM1D) was utilized to evaluate between‐group variation in outcome variables using a one‐way repeated measures analysis of variance (ANOVA). Results. As the ankle restriction angle increased, knee external rotation angles, knee extension angular velocities, hip extension angle, and angular velocity increased and were significantly different at different ankle restriction angles (p &lt; 0.001 and p = 0.001), coactivation of the peripatellar muscles (BF/RF and BF/VM) increased progressively, and patellofemoral joint contact force (PTF) increased progressively during the 3%–8% phase (p = 0.015). These results highlight the influence of ankle joint restriction on lower limb kinematics and patellofemoral joint loading during the stop‐jump maneuver. Conclusion. As the angle of ankle restriction increased, there was an increase in coactivation of the peripatellar muscles and an increase in PTF, possibly because a person is unable to adequately adjust their body for balance when the ankle valgus angle is restricted. The increased coactivation of the peripatellar muscles and increased patellofemoral contact force may be a compensatory response to the body’s adaptation to balance adjustments.

Blood flow restriction training improves the efficacy of routine intervention in patients with chronic ankle instability

As a new means of rehabilitation, blood flow restriction training (BFRT) is widely used in the field of musculoskeletal rehabilitation. To observe whether BFRT can improve the efficacy of routine rehabilitation intervention in patients with chronic ankle instability (CAI). Twenty-three patients with CAI were randomly divided into a routine rehabilitation group (RR Group) and a routine rehabilitation ​+ ​blood flow restriction training group (RR ​+ ​BFRT Group) according to the Cumberland Ankle Instability Tool (CAIT) score. The RR Group was treated with routine rehabilitation means for intervention, and the RR ​+ ​BFRT Group was treated with a tourniquet to restrict lower limb blood flow for rehabilitation training based on routine training. Before and after the intervention, the CAIT score on the affected side, standing time on one leg with eyes closed, comprehensive scores of the Y-balance test, and surface electromyography data of tibialis anterior (TA) and peroneus longus (PL) were collected to evaluate the recovery of the subjects. Patients were followed up 1 year after the intervention. After 4 weeks of intervention, the RR ​+ ​BFRT Group CAIT score was significantly higher than the RR Group (19.33 VS 16.73, p ​< ​0.05), the time of standing on one leg with eyes closed and the comprehensive score of Y-balance were improved, but there was no statistical difference between groups (p ​> ​0.05). RR ​+ ​BFRT Group increased the muscle activation of the TA with maximum exertion of the ankle dorsal extensor (p ​< ​0.05) and had no significant change in the muscle activation of the PL with maximum exertion of the ankle valgus (p ​> ​0.05). There was no significant difference in the incidence of resprains within 1 year between the groups (36.36% VS 16.67%, p ​> ​0.05). The incidence of ankle pain in the RR ​+ ​BFRT Group was lower than that in the RR Group (63.64% VS 9.09%, p ​< ​0.01). Therefore, four-weeks BFRT improves the effect of the routine intervention, and BFRT-related interventions are recommended for CAI patients with severe ankle muscle mass impairment or severe pain.

Effect of Custom Design Insole Applications with 3D Modelling on Baropodometric Parameters in Individuals with Pes Planus

It was aimed to investigate the effect of custom made insoles on baropodometric analysis parameters in individuals with pes planus, using objective measurement and production methods. 100 individuals with pes planus, aged between 4-18 years in the study. Individuals who met the inclusion criteria and the medial longitudinal arch index were included in the study. Valgus angles of individuals, plantar measurements of the feet before the use of insoles and after 6 months of the use of insoles were evaluated with the Sensor Medica®️ device. When the measurement results of the ankle valgus angles of the individuals before and after the insoles were examined, it was observed that there was a statistical decrease in the mean results in both feet (p&amp;lt;0,05). When the plantar pressure results were examined, the load on the medial side of the right foot was reduced significantly (p=0,012). Although there was a decrease in medial longitudinal arch of the right foot, it was not significant. There were no change in the lateral side of the right foot and the medial side of the right rearfoot. The load on the medial left rearfoot and the left medial longitudinal arch were reduced significantly (p=0,004, p=0.021). In study in individuals with pes planus, it was concluded that the foot should be well evaluated before and after technological based applications. Whether the insoles used provide benefits in foot development should be followed up with controls and their suitability should be checked, and changes in their physical capacities should be observed.

Conservative Treatment with Arch Support Inflatable Ankle-Foot Orthosis Does Not Correct Progressive Collapsing Foot Deformity: A Prospective Comparative and Controlled Study

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Progressive Collapsing Foot Deformity (PCFD) can present with independent deformities, characterized by five classes: hindfoot valgus (Class A), midfoot abduction (Class B), forefoot varus (Class C), Peritalar Subluxation (PTS) (Class D) and ankle valgus (Class E). Conservative treatment includes the use of corrective insoles and orthotics. Arch support inflatable Ankle-Foot orthoses (IAFO) can help control symptoms in PCFD patients. However, the ability of IAFOs to correct deformities in PCFD is unknown. The aim of this prospective comparative and controlled study was to assess the ability of arch support IAFOs to correct 3D overall PCFD alignment as well as the five different PCFD classes independently. We hypothesized that IAFOs would correct PCFD 3D overall alignment as well as the five independent classes of deformity. Methods: After IRB approval, we enrolled 24 symptomatic PCFD and 24 controls matched on age, sex, and BMI. Flexible PCFD patients and controls were scanned using Weight-Bearing CT (WBCT) with and without an arch support IAFO. The Foot and Ankle Offset (FAO) was used to assess the 3D foot overall alignment. We measured the Hindfoot moment arm (HMA, Class A), the Talonavicular coverage angle (TNCA, Class B), the Meary’s angle and medial cuneiform-to-floor distance (C1-floor) for the Class C and the middle facet uncoverage (MFunco, Class D). No Class E patients were included. Measurements were performed by two fellowship-trained surgeons. A power-analysis hypothesizing that IAFOs would be two times less efficient than the PCFD surgery in correcting the FAO, the requisite number of subjects was 24 per group. Data normality was assessed by Shapiro-Wilk test. Comparisons used normality based paired T-tests or paired-Wilcoxon tests. P-values &lt; 0.05 were considered significant. Results: PCFD measurements performed in controls were all significantly less pronounced than unbraced PCFD patients, confirming the presence of collapse (ps &lt; 0.0001). Comparing PCFD without and with IAFO, the FAO did not show significant improvement (respectively 6.6+/-3.7% vs 5.5+/-4.2%, p=0.101). The HMA (8.8+/-5.8 vs 8.1+/-5.8, p=0.66), the TNCA (24.2+/-10.6 vs 21.9+/-9.7, p=0.44) and the MFunco (37+/-12% vs 31+/-18%, p=0.17) also did not portray significant improvements when applying the IAFOs. The Meary’s angle (17.6+/-7.2 vs 10.8+/-7.3, p=0.002) and C1-floor (17.2+/-3.3mm vs 24.1+/-5.3mm, p&lt; 0.001) were the only to improve significantly with use of IAFOs. When comparing braced PCFD and controls, the only measurement that improved to normal values, similar to controls, in braced PCFD was the C1-floor (24.1+/-5.3mm in PCFD with IAFO vs 25.7+/- 5.4mm in controls, p=0.31). Conclusion: In this prospective comparative and controlled study, we found that arch support IAFOs was not able to correct overall 3D deformity and most of the specific classes in PCFD. The orthosis did not improve hindfoot valgus (Class A), midfoot abduction (Class B) or peritalar subluxation (Class D) in PCFD. The only deformity pattern to improve with the use of IAFOs was the medial longitudinal arch height (Class C). These improvements were expected by the presence of the inflatable bladder of the IAFO on the plantar aspect of the foot, pushing the longitunal arch up but not correcting the entire PCFD.

Deformities Influencing Different Classes in Progressive Collapsing Foot

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 possible classes. PCFD is understood to be a complex, three-dimensional deformity occurring in many regions along the foot and ankle. The question remains whether a deformity in one area impacts other areas. The objective of this study is to assess how each one of the classes is influenced by other classes by evaluating each associated angular measurement. We hypothesized that positive and linear correlations would occur for each class with at least one other class and that this influence would be high. Methods: We retrospectively assessed weight-bearing computed tomography (WBCT) measurements of 32 feet with PCFD diagnosis. The classes and their associated radiographic measurements were defined as follows: class A (hindfoot valgus) measured by the hindfoot moment arm (HMA), class B (midfoot abduction) measured by the talonavicular coverage angle (TNCA), class C (medial column instability) measured by Meary’s angle, class D (peritalar subluxation) measured by the medial facet uncoverage (MFU), and class E (ankle valgus) measured using the talar tilt angle (TTA). Multivariate analyses were completed comparing each class measurement to the other classes. A p-value &lt; 0.05 was considered significant. Results: Class A showed a substantial positive correlation with class C (ρ=0.71; R2=0.576; p 0.001). Class B was substantially correlated with class D (ρ=0.74; R2=0.613; p 0.001). Class C showed a substantial positive correlation with class A (ρ=0.71; R2=0.576; p 0.001) and class D (ρ=0.75; R2=0.559; p 0.001). Class D showed a substantial positive correlation with class B and class C (ρ=0.74; R2=0.613; p 0.001), (ρ=0.75; R2=0.559; p 0.001) respectively. Class E did not show correlation with class B, C, or D (ρ=0.24; R2=0.074; p=0.059), (ρ=0.17; R2=0.071; p=0.179), and (ρ=0.22; R2=0.022; p=0.082) respectively. The average values of each class radiographic markers are listed in Figure 1. Conclusion: This study was able to find relations between components of PCFD deformity with exception of ankle valgus deformity (Class E). Measurements associated with each class were influenced by others, and in some instances, with pronounced strength such as between class A and C as well as between Class B and D. Surgical procedures to address certain class deformities could indirectly address other classes as well, which ultimately decreases surgical procedures numbers or complexity. The presented data may support the notion that PCFD is a three-dimensional complex deformity and suggests a possible relation among its ostensibly independent features.

Outcomes of Hindfoot Joint-Sparing Reconstructive Procedures for Flexible Progressive Collapsing Foot Deformity: A Prospective Cohort Study

Category: Hindfoot; Other Introduction/Purpose: Treatment of Progressive Collapsing Foot Deformity (PCFD) is controversial and surgical procedures utilized usually depend on the type and rigidity of deformities present (PCFD classes and stages), degree of soft tissue involvement, and surgeon’s preference. Multiple surgical procedures are usually performed concomitantly to achieve adequate correction. Prospective data regarding the utilization of hindfoot joint-sparing reconstructive procedures in the treatment of flexible PCFD is scarce, and little is known about the influence of the different procedures utilized to treat PCFD in deformity correction and patient-reported outcomes (PROs). The objective of this prospective study was to evaluate the most used hindfoot joint-sparing procedures utilized by a single-surgeon to treat flexible PCFD, and the influence of the utilized procedures in deformity pattern corrections, and PROs. Methods: IRB-approved, prospective, and comparative cohort study. Adult PCFD patients with flexible deformity (stage 1), no history of surgical treatment, and that failed conservative treatment for &gt;3-months were enrolled. Patients underwent surgical treatment by a single-surgeon. Patients were excluded if a hindfoot fusion procedure was needed intra-operatively to achieve correction. Types, numbers, and sizes of surgical procedures utilized were recorded. Weight-bearing CT (WBCT) measurements of overall 3D deformity, Classes A (hindfoot valgus), B (abduction), C (medial column instability), D (peritalar subluxation), and E (ankle valgus tilt) were assessed preoperatively, and at first 3-months WBCT. PROs were recorded preoperatively and at the most recent follow-up. Descriptive statistics were used to report the frequency of deformity and procedures utilized. Pre and postoperative measurements and PROs were compared with paired T-tests/Wilcoxon. Multivariate regression analysis was used to correlate procedures utilized with deformity correction and PROs. P-values of &gt;0.05 were considered significant. Results: A total of 29 patients included (28 feet, 79%F, 21%M), mean age and BMI of respectively 47.6-years and 34kg/m2. Average number of procedures performed was five and mean follow-up was 19.1 months (range, 3 to 40). Frequency and sizes of medial displacement calcaneal osteotomy (MDCO), first ray plantarflexion procedure (Cotton/LapiCoton), and lateral column lengthening (LCL) procedures were, respectively: 100% (8.9mm displacement), 100% (66% Lapicotton/34% Cotton, 8.3mm wedge-opening) and 39% (6.8mm wedge-opening). Soft-tissue procedures performed: 83% Posterior tibial tendon (re-tensioning/FDL transfer/allograft reconstruction), 34% peroneal tendon (brevis-to-longus and brevis lengthening), 76% gastrocnemius-recession, 38% spring ligament (re-tensioning/reconstruction/augmentation) and 31% deltoid ligament (re- tensioning/reconstruction/augmentation). Significant improvement postoperatively was observed in all PCFD measurements performed and PROs (Figure). However, no direct correlation was found between procedures performed/measurement improvements and PROs. Conclusion: In this prospective comparative cohort study of flexible PCFD patients undergoing surgical treatment with hindfoot joint sparing surgical procedures, we observed significant postoperative improvement in all deformity patterns assessed (Classes A, B, C, and D) as well as PROs. MDCO and first ray plantarflexion procedures (Cotton or LapiCotton) were the most commonly utilized procedures and were performed in all cases. Even though deformity correction and PRO improvements were observed postoperatively, no direct correlation was observed between PROs and specific surgical procedures performed or deformity pattern corrections (PCFD classes).

Ankle Radiographic Characteristics of Two Different Types of Valgus Ankle Arthritis: With or Without Progressive Collapsing Foot Deformity

Category: Ankle Arthritis; Ankle Introduction/Purpose: Establishing a surgical plan for ankle arthritis requires a thorough understanding of the deforming forces involved. While ankle morphology-based classification and application are common in the surgical treatment of varus ankle arthritis (i.e., Takakura stage), such an approach has not been described for valgus ankle arthritis. Progressive collapsing foot deformity (PCFD) has been identified as the major cause of non-traumatic valgus ankle arthritis. However, mounting evidence suggests that it can also develop without PCFD, which may mean that the etiology and possibly the outcomes of treatment are different when comparing the two groups. Therefore, this study aimed to investigate whether weightbearing ankle radiographs can be used to differentiate PCFD origin from non-PCFD origin in valgus ankle arthritis. Methods: This study retrospectively reviewed patients who were surgically treated for asymmetric valgus ankle arthritis at our institution between 2017 and 2021. Patients with valgus tibiotalar tilt (TT &gt;4 degrees and Meary’s angle&gt;30 degrees) were included in the PCFD group (n=24). A control group (non-PCFD group [n=24]) with valgus tibiotalar tilt&gt;4 degrees and Meary’s angle &lt; 4 degrees was also established. In the weightbearing ankle anteroposterior (AP) view, the TT and medial distal tibial angle (MDTA) were measured. Additionally, to assess mediolateral position of the talus, the talar center migration (TCM) and lateral talar dome-plafond distance (LTD-P) ratio was measured (Figure 1A). Other PCFD radiographic parameters were also measured. In weightbearing computed tomography (WBCT), the degree of axial plane talocalcaneal subluxation was assessed using transmalleolar axis method as previously described, and the prevalence of sinus tarsi bony impingement was assessed. All parameters were compared between groups using Student t- or chi-square tests. Results: Both groups demonstrated a similar degree of TT, with a mean and standard deviation of 11.1±7.8 degrees in the PCFD group and 12.7±5.9 degrees in the non-PCFD group (p=0.2013, Table 1). However, the PCFD group showed a significantly greater TCM and LTD-P ratio compared to those of the non-PCFD group (p &lt; 0.0001), indicating that PCFD patients have a more medially translated talus in ankle AP radiographs (Figure 1A). WBCT showed that the PCFD group had a greater axial plane talocalcaneal subluxation (p &lt; 0.0001) and a higher prevalence of sinus tarsi bony impingement (p=0.0077) compared to the non- PCFD group, indicating a different degree of subtalar joint subluxation between the two groups. Conclusion: This study demonstrates that weightbearing ankle radiographs reveal different morphologies based on the etiology of valgus ankle arthritis. While both groups exhibited similar degrees of valgus tibiotalar tilt, PCFD patients demonstrated medial translation of the talus compared to non-PCFD patients. We propose a morphology-based classification (Figure 1B) that may assist in differentiating between the PCFD and non-PCFD origins of valgus ankle arthritis. Also, the different morphology of the valgus tibiotalar tilt in the each group may mean that they may require different treatments, as well as potentially different outcomes of treatment for the valgus tibiotalar tilt.