Arch Collapse Research Articles

Pre-Operative Radiographic Parameters of Arch Collapse Do Not Predict Future Treatment Failure in Patients with Stage IIb Pes Planus

Category:Ankle; Hindfoot; Midfoot/ForefootIntroduction/Purpose:Adult-acquired flatfoot deformity (AAFD) is a complex pathology of the foot that often results from dysfunction of the posterior tibial tendon (PTTD) and encompasses a wide spectrum of deformity. A high-degree of continued morbidity following flatfoot reconstruction exists for which prognostic indicators of future poor outcomes are uncertain. AP and lateral weight-bearing radiographs are commonly utilized to assess the severity of deformity including forefoot abduction, medial arch collapse, and hindfoot valgus. However, the relationship between pre-operative radiographic severity of deformity and predilection for future surgical treatment failure remains uncertain. The purpose of this study was to perform pre-operative radiographic measurements of patients with stage IIb PTTD and determine which preoperative radiographic parameters, if any, predict future surgical treatment failure.Methods:Following IRB approval, an institutional electronic medical record database was queried from January 2000-2014 to identify all patients undergoing surgical correction for stage IIb PTTD. 256 patients with stage IIb PTTD underwent medial displacement calcaneal osteotomy and flexor digitorum longus transfer, with possible spring ligament repair and/or Achilles lengthening. Patients undergoing concomitant lateral column lengthening or midfoot fusion, patients with previous hardware, and patients with incomplete medical records were excluded. Preoperative radiographs were retrospectively analyzed to assess preoperative deformity. Talonavicular coverage angle was measured using AP radiographs. Lateral radiographs were used to measure talar-1st metatarsal angle (Meary’s) angle, calcaneal pitch and medial cuneiform-floor height. Patient charts were also reviewed to determine whether patients experienced treatment failure, defined as return to the operating room for unplanned revision surgery (e.g. broken/painful hardware, nonunion, residual deformity, infection, nerve damage, blood clot/DVT). The degree of pre-operative deformity was compared between treatment failure and non-failure groups.Results:Out of the 256 patient cohort, a total of 58 patients (22.7%) experienced treatment failure indicated by the need for an unplanned revision surgery, while 198 patients (77.3%) did not experience failure. There were no significant differences in the severity of pre-operative radiographic deformity between the treatment failure and non-failure groups including Meary’s angle (p = 0.93), calcaneal pitch (p = 0.70), talonavicular coverage angle (p = 0.99), and medial cuneiform height (p = 0.52, Table 1).Conclusion:The results of this study show that there is no significant difference in pre-operative radiographic deformity between patients who experienced failure versus non-failure following surgical flatfoot correction suggesting that the degree of pre- operative deformity is not significantly associated with an increased risk for future surgical failure. The analysis of these results, may underscore the relative importance of the physical exam in the evaluation of patients with symptomatic stage IIb PTTD and a relative lack of prognostic value in radiographic parameters commonly used to describe patients’ deformity.

Adult acquired flatfoot deformity-operative management for the early stages of flexible deformities

Flexible adult acquired flatfoot deformity includes awide spectrum of fore- and hindfoot pathologies and remains acomplex clinical challenge. Clinical history, inspection and accurate physical examination are paramount for diagnosis. Early stages of flexible adult acquired flatfoot deformity present with increased hindfoot valgus and medial arch collapse. Operative management typically consists of an open medializing calcaneal osteotomy and an augmentation of the insufficient posterior tibial muscle using aflexor digitorum longus tendon transfer. New surgical techniques and adeeper understanding of pathophysiology may change traditional treatment pathways.

Subtalar Fusion for Correction of Forefoot Abduction in Stage II Adult-Acquired Flatfoot Deformity.

Correction of talonavicular uncoverage (TNU) in adult-acquired flatfoot deformities (AAFD) can be a challenge. Lateral column lengthening (LCL) traditionally is utilized to address this. The primary study objective is examining stage II AAFD patients and determining if correction can be achieved with subtalar fusion (STF) comparable to LCL. Following institutional review board approval, retrospective chart review performed identifying patients meeting criteria for stage IIB AAFD who underwent either STF with concomitant flatfoot procedures (but not LCL) to correct TNU, or who underwent LCL as part of their flatfoot reconstruction. Patients indicated for STF had one or more of the following: higher body mass index (BMI), were older, had greater deformity, lateral impingement pain, intraoperative spring ligament hyperlaxity. Patients without 1-year follow-up or compete records were excluded. All other patients were included. A total of 27 isolated STFs identified, along with 143 who underwent LCL. Pre-/postoperative radiographic parameters obtained as well as PROMIS (Patient-Reported Outcomes Measurement Information System) and FAOS (Foot and Ankle Outcome Score) scores. Radiographic and patient reported outcomes both preoperatively and at 1-year follow-up evaluated for both groups. STF patients were older (P < .05), with higher BMIs (P < .004). STF had significantly worse TNU (P < .001) than LCL patients, and average change in STF TNU was larger than LCL change postoperatively (P = .006), after adjusting for age, BMI, gender. PROMIS STF improvement reached statistical significance in Physical Function (P 0.011), for FAOS Pain (P 0.025) and Function (P = 0.04). STF can be used in appropriately indicated patients to correct flatfoot deformity without compromising radiographic or clinical, correcting not only hindfoot valgus, but also talonavicular uncoverage (TNU) and corresponding medial arch collapse. Level III: Retrospective chart review comparison study (case control).

Expeditious damage index for arched structures based on dynamic identification testing

This paper presents a new damage detection index for arched structures, which can easily and quickly provide an estimate of their integrity. The results from eight laboratory tests performed on both reinforced and unreinforced adobe arches are used to define the index. The arches are damaged up to collapse using pseudo-static test cycles carried out by applying progressive controlled displacements at third span. The test records allow to follow the stiffness degradation of each arch by plotting the relative force–displacement curves, as well as to track their frequencies variation during the damage evolution by means of dynamic identification tests performed at the end of each cycle. The new index considers the bending moment as the main cause of damage for the analysed arches; therefore, starting from the bending stiffness, a damage indicator was developed and experimentally validated, as function of the frequency reduction, respect to the undamaged scenario. Finally, the index is also validated for different types of arch collapse mechanisms through Finite Element Modelling.

Effect of dynamic guidance-tubing short foot gait exercise on muscle activity and navicular movement in people with flexible flatfeet.

Navicular drop is a common plantar deformity which makes the plantar medial longitudinal arch (MLA) collapse and leads to other deformities in lower extremities. Active structures are from intrinsic and extrinsic foot muscle activities such as abductor hallucis (AbdH), tibialis anterior (TA), tibialis posterior, flexor hallucis brevis, flexor digitorum brevis during dynamic situations. As AbdH plays a role as a dynamic elevator of MLA, the importance of AbdH has been emphasized and the proper recruitment of both intrinsic and extrinsic muscle is crucial for stabilization of MLA during dynamic weight bearing condition. Because the short foot (SF) exercise is difficult to perform and tends to activate the intrinsic muscles concentrically rather than a natural coordination of concentric-isometric-eccentric activation, we have developed the guidance-tubing SF gait (GFG) exercise. We investigated the effect of GFG exercise on muscle activity, AbdH:TA activity ratio, MLA angle, and foot pressure distribution during walking compared to SF gait (SFG) exercise. Thirty-two subjects with flexible flat feet were divided into two groups and performed SFG exercise with (GFG) and without guidance-tubing (SFG) for seven serial days. AbdH muscle activity significantly increased from foot flat to heel rise in the GFG group (p = 0.006). The AbdH:TA activity ratio significantly increased in both the SFG (p = 0.015) group and GFG group (p = 0.006). MLA angles significantly decreased in both the SFG group (p = 0.001) and GFG group (p = 0.000), and the decrement was significantly higher in the GFG group (p = 0.001). The foot pressure distribution did not show any statistically significant change. The result of this study provides a clinical implication for training MLA supporter muscles in individuals with flat feet. The overactive muscle must be inhibited first, then facilitation and strengthening are followed respectively.

Effects of Artificial Texture Insoles and Foot Arches on Improving Arch Collapse in Flat Feet.

The arches of the foot play a vital role in cushioning the impact and pressure generated from ground reaction forces due to body weight. Owing to a lack of normal human arch structure, people diagnosed as having flat feet often have discomfort in the soles of their feet. The results may not only cause inappropriate foot pressure distribution on the sole but also further cause foot injuries. This study heavily relies on a homemade foot pressure sensing device equipped with textured insoles of different heights and artificial arches. This was to explore the extent to which the pressure distribution of the foot in people with flat feet could be improved. A further comparison was made of the effects of using the textured insoles with different heights on two different groups of people diagnosed with flat and normal feet respectively. Sixty-five undergraduate and postgraduate volunteers were invited to receive the ink footprint test for measuring their degrees of arch index. Nine of these 65 had 2 flat feet, 3 had a left flat foot, 5 had a right flat foot, and 48 had 2 normal feet. To ensure the same number of subjects in both the control and the experimental groups, 9 of the 48 subjects who had normal feet were randomly selected. In total, 26 subjects (Male: 25, Female: 1; Age: 22 ± 1 years; height: 173.6 ± 2.5 cm; body mass: 68.3 ± 5.4 kg; BMI: 22.6 ± 1.2) were invited to participate in this foot pressure sensing insoles study. The experimental results showed that the use of textured insoles designed with different heights could not effectively improve the plantar pressure distribution and body stability in subjects with flat feet. Conversely, the use of an artificial arch effectively improved the excessive peak in pressure and poor body stability, and alleviated the problem of plantar collapse for patients with flat feet, especially in the inner part of their hallux and forefoot.

The Association of Parity with Greater Dynamic Pronation of the Feet.

Postpartum women are at increased risk for lower limb musculoskeletal disorders. Foot arch collapse following pregnancy has been reported as a mechanism for this increased risk. However, dynamic changes during gait in postpartum women have not been reported. Therefore, we assessed the association between parity and dynamic foot pronation during gait. To determine (1) if there is an association between parity and dynamic foot pronation (center of pressure excursion index, CPEI) during gait; and (2) the extent to which there is a dose-effect of parity on foot pronation. The Multicenter Osteoarthritis Study (MOST) Study is a longitudinal cohort study of adults with or at risk for knee osteoarthritis (OA). Two communities in the United States, Birmingham, Alabama and Iowa City, Iowa. Not applicable PARTICIPANTS: A population-based sample of 1177 MOST participants who were female, had complete CPEI and parity data and completed the baseline, 30- and 60-month visits. Odds of a one quintile decrease in CPEI by parity group and mean CPEI by parity group. In 1177 women, mean age was 67.7 years and mean body mass index (BMI) was 30.6 kg/m2 . As parity increased, there was significantly greater foot pronation, lower mean CPEI: 19.1 (18.2-20.1), 18.9 (18.4-19.4), 18 (17.5-18.6) to 17.5 (16.4-18.6) in the 0 to 4 and >5 children groups, respectively; (P = .002), which remained significant after adjusting for race and clinic site (P = .005). There was a positive linear trend (β = 1.08, 1.03-1.14) in odds ratios of a one quintile decrease in CPEI (greater pronation) with increasing parity level (P = .004), which remained significant after adjusting for race and clinic site (P = .01). After adjusting for age and BMI, these two associations were no longer statistically significant. This study indicates a positive correlation between parity and greater dynamic pronation of the feet.

Brostrom-Like Procedure Augmented with Swivelock Internal Brace for the Reconstruction of Chronic Medial Ankle Ligament Complex

Category:Midfoot/ForefootIntroduction/Purpose:The medial ligaments and joint capsules appear to stretch or rupture under the increasing stress following a tear of the PTT in patients with flat foot often leading to pain, swelling and dysfunctional foot. This study assesses the efficacy of a Brostrom like procedure augmented with Swivelock Internal Brace for the reconstruction of chronic medial ankle ligament complex.Methods:A retrospective study was performed reviewing 15 flat foot patients who presented with pronounced hindfoot pronation collapse of the medial longitudinal arch after injury. The procedures included exploration and direct repair of PTT, deltoid ligament and spring ligament. Our modification included Swivelock Internal Brace enhanced reconstruction of deltoid and spring ligaments, after calcaneal medializing osteotomy. Other additional procedures such as FDL transfer, subtalar arthroereisis and Cotton osteotomy were performed as needed (Fig.1). Weight bearing X-rays of the foot, AOFAS-AH and SF36 scoring were taken before and after surgery.Results:There were 8 males and 7 females among the 15 patients. The age was 29.8±10.1 years old. The follow-up time period was 32.6±11.4 months. Both the AOFAS-AH (52.8±15.2 to 90.4±7.5 and SF-36 (55.4±12.6 to 91.2±6.3 scores improved significantly (p<0.001). Comparing preoperative to postoperative standing radiographs, there was significant improvement in the AP talar first metatarsal angle (25.6±18.4 to 9.5±7.8 degrees（P<0.001), lateral talar first metatarsal angle (18.3±8.4 to +2.6±4.5 degrees（P<0.001）and moment arm on the Saltzman view (+15.2mm±10.8 to +2.5±3.6mm（P=0.003） (Fig.2). No recurrence of pronation deformity or foot arch collapse was observed after surgery.Conclusion:The medial ankle ligaments were attenuated and under the increasing stress following a tear of the PTT in patients of flat foot. Direct repair of the ligaments after rupture usually resulted in low strength and high recurrence. Simultaneous reconstruction of medial ankle ligaments with Swivelock internal brace maintained long term medial ankle stability and the longitudinal arch. This technique protects the repaired tendon and decreased the need for FDL transfer, potentially permitted earlier rehabilitation and improved function compared to traditional techniques.

Weightbearing CT and MRI findings of Stage II Flatfoot Deformity: Can We Predict Patients at High- Risk for Foot Collapse?

Category:HindfootIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) allows excellent dynamic evaluation of the relative three-dimensional positioning of the tarsal bones. MRI provides accurate evaluation of soft tissue integrity in the unloaded foot. Study’s objective was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of soft tissue involvement.Methods:This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant.Results:We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p<0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p<0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04).Conclusion:This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

Intermediate to Long-Term Clinical and Radiographic Results of Deltoid Ligament Reconstruction with Tendon Graft

Category:Ankle, Hindfoot, FlatfootIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is a complex deformity characterized by hindfoot valgus, medial longitudinal arch collapse, midfoot abduction, and forefoot supination. In its most advanced stages (stage IV), the deltoid ligament is compromised, which leads to valgus talar tilt at the tibiotalar joint. This talar tilt puts patients at high risk of developing ankle arthritis necessitating ankle arthrodesis or arthroplasty. Tendon graft reconstruction of the deltoid ligament has previously demonstrated good clinical and radiographic outcomes at short to intermediate-term follow-up but controversy over efficacy of the procedure remains. The goal of the current study was to present the intermediate to long-term clinical and radiographic outcomes of the largest series to date of patients undergoing this procedure.Methods:Data from a prospectively collected Foot and Ankle Registry was reviewed. All consecutive patients undergoing deltoid ligament reconstruction with tendon allograft or autograft as part of their flatfoot surgery by the senior author prior to 1/1/2015 were eligible for inclusion. Patients with radiographic follow-up of <3 years were asked to return for follow-up under an IRB- approved study protocol. Patients missing preoperative radiographs or unable to complete follow-up were excluded from radiographic analysis. Measurements of talar tilt were performed on AP ankle x-rays by two observers (Figure 1). Reliability analysis was performed using intraclass correlation. Preoperative Foot and Ankle Outcome Scores (FAOS) were obtained from the registry. Patients were contacted to complete postoperative FAOS and PROMIS surveys. Paired t-tests were used to evaluate changes in talar tilt and clinical outcomes. P-values of less than 0.05 were considered significant.Results:35 feet/34 patients were eligible. Two feet/patients failed treatment (one ankle fusion, one deep infection and amputation). Three patients were deceased, two unable to follow-up due to unrelated medical problems, one missing preoperative imaging, and five unwilling to return for long-term follow-up. None of these patients failed treatment at last follow-up. 21 feet/20 patients (7/7 female) underwent radiographic analysis. Mean age at surgery was 58.4 (43.8-80.9) years. Interobserver agreement assessing change in talar tilt was excellent (ICC=.892). At mean radiographic follow-up of 10.3 (4.1-18.3) years, talar tilt improved significantly from an average of 9.71 +/- 6.22 degrees preoperatively to 3.63 +/- 3.27 degrees valgus postoperatively (p<.001). All FAOS subscores improved significantly pre to postoperatively. Postoperative PROMIS scores were comparable to or better than population means.Conclusion:Our findings demonstrate that deltoid ligament reconstruction with tendon graft enables radiographic correction, though not always complete, in patients with stage IV AAFD over the medium to long-term. Although limited by the sample size, our study demonstrates overall good clinical outcomes with few treatment failures. Though accessory procedures performed routinely at the time of flatfoot reconstruction present possible confounding variables, untreated ankle valgus likely leads to worsening deformity and ankle arthritis. Although the correction is not necessarily full, surgical reconstruction of the ligament may preclude patients from requiring joint sacrificing procedures such as ankle fusion or replacement over the long-term.

A high-profile thread with grit-blasted and acid-etched surface reduces loosening of medial column fusion bolt in instable Charcot foot

BackgroundIntramedullary fusion bolts (FB) were introduced to stabilize the medial column of the instable Charcot foot (ICF), but complications as bolt loosening or breakage are frequent. We compared the use of a standard FB and a high-profile threaded FB with a grit-blasted surface. We hypothesized that implant related complications occurred less often and osseous consolidation of fusion sites was more distinctive using the latter type of FB. MethodsConsecutive patients suffering from an ICF were stabilized with a high-profile threaded and surface-modified FB (HTFB) (n=20) or with a standard FB (n=20) which was placed into the first ray. Additional bolts and dorsal low-profile plates were applied in every patient. In a retrospective assessment osseous consolidation of the fusion sites was analyzed at 3 month and quantified by CT scan. At 3 and 12 month longitudinal foot arch collapse and rate of bolt loosening were assessed. ResultsCompared to the control group, the HTFB group reached significant higher consolidation after 3 month. No dislocation and a single bolt breakage was observed in the HTFB group after the fourth month, while the control group included 3 patients with bolt dislocation at 3±1 month and 5 patients with bolt breakage at 6±1.8 month. Compared to preoperative values, the improvement of Meary’s angle after one-year was significant higher in the HTFB group (23.4°±14) than in controls (11.7°±13). ConclusionsModification of bolt design improves the stability of the medial column: A higher rate of osseous consolidation of the medial column leads to lower rate of bolt dislocation/breakage and finally to permanently erected longitudinal foot arch. Initially disappointing results following medial column stabilization with fusion bolts can be rejected by modifications of bolt design and its technical application.

What is the Prognosis of Triple Arthrodesis in the Treatment of Adult Acquired Flatfoot Deformity (AAFD)?

Objective The present study aims to evaluate the ability of triple arthrodesis in eliminating the main complaints presented by patients with adult acquired flatfoot deformity (AAFD): 1) disabling hindfoot pain; 2) major deformities, such as medial arch collapse, valgus, abduction, and supination. Methods A total of 17 patients (20 feet) with advanced AAFD who underwent surgical correction by triple arthrodesis were evaluated after a mean follow-up period of 43 months (range: 18–84 months). The average age of the patients at surgery was 62 years old (range: 38–79 years old). The visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score were used to assess the final results. Results According to the VAS, the average residual pain was 3 points; the AOFAS hindfoot score points increased 23% after the surgery; and the correction of deformities was considered satisfactory in 10 out of 20 feet; partially satisfactory in 4 out of 20 feet; partially unsatisfactory in 5 out of 20 feet; and unsatisfactory in 1 out of 20 feet. Conclusion Despite the high index of bone fusion after triple arthrodesis, which is the gold standard treatment in advanced AAFD, the incomplete correction of major deformities and the persistence of residual pain contributed to a high disappointment rate of the patients with the surgical results.

Does the minimally invasive complete plantar fasciotomy result in deformity of the Plantar arch? A prospective study

BackgroundComplete plantar fasciotomy has been associated with changes in foot loading, leading to medial longitudinal arch collapse. The purpose of this study is to analyse our clinical experience with percutaneous complete plantar fasciotomy and quantify the possible changes in foot loading measured by the calcaneal pitch angle. MethodsA prospective case series study with patients operated between 2005–2012 was conducted, where AOFAS, Maryland Foot Score (MFS), VAS and radiological calcaneal pitch (CP) were recorded. Postoperative data were collected, where the surgeon evaluated the presence of complications, and an independent investigator performed radiological and scale evaluations follow-up: AOFAS, MFS, VAS and Benton-Weil questionnaire. ResultsA total of 60 patients, 62 feet, with a mean follow-up of 57 months (range 13–107) were studied. The MFS increased a mean of 21 points (p=.001), the AOFAS score a mean of 25 points (p=.001), and the VAS decreased a mean of 8.89 points (p=.001). A total of fifty-seven feet (91.9%) were pain-free at the end of follow-up. The mean CP dropped from 20.2° (range 11–34) preoperatively to 19.3° (range 11–34) at the end of follow-up (p=.05). In 25 feet (40.3%) there were no changes in the calcaneus pitch angle, in 21 feet dropped 1° (33.9%), in 11 dropped 2° (17.8%), 3 feet 3° (4.8%) and 2 feet (3.2%) 4°. Postoperative complications were noted in 4 feet (6.4%), with lateral column pain. The surgery meets the expectations of all patients. ConclusionsPercutaneous total fascia release is safe and does not produce a significant drop in arch height based on the radiological finding. Lack of success after surgery may be explained by other pathologies that might appear like plantar fasciitis. Further studies with gait analysis after total plantar fascia release in patients are needed.

Statistical Validation of the Grand Rapids Arch Collapse Classification.

Background:The Grand Rapids Arch Collapse Classification system was devised in 2011 to assist physicians’ and patients’ understanding of the mechanisms underlying arch collapse. Five types of arch collapse are described, based on which part of the foot or ankle is affected. The purpose of this study was to determine the inter- and intrarater reliability of this classification system when used by physicians with various levels of training.Methods:A senior author identified a stratified selection of 50 patients (10 per classification type) who presented with foot/ankle pain and suitable radiographs. A survey was designed using prediagnosis radiographs and clinical synopses of the patient’s chart. The survey consisted of a description of the classification scheme and the 50 cases in a randomized order. Eight weeks later, they repeated the test to analyze for intra-rater agreement.Results:Of the 33 physicians who received the survey, 26 completed the first round (16 attendings, 4 foot and ankle fellows, and 6 residents). Overall, there was substantial agreement among raters in all five types. Kappa scores for each type were 0.72, 0.65, 0.72, 0.70, 0.63, respectively. The combined kappa score was 0.68. After 8 weeks, 13 of the 26 participants repeated the study. A Kappa analysis was once again performed for the 13 respondents, which produced a substantial level of agreement with a value of 0.74 for intrarater reliability.Conclusion:The Grand Rapids Arch Collapse Classification system was designed to provide an accessible mechanism for physicians to consistently describe arch collapse, its effects, and the conditions associated with it. The utility of this system is wholly reliant on the repeatability among clinicians. This study has demonstrated that the classification system has substantial rates of reliability among physicians of different levels of experience and training.Level of evidence:Level IV.

An efficient local binary pattern based plantar pressure optical sensor image classification using convolutional neural networks

The objective of this study was to design and produce highly comfortable shoe products guided by a plantar pressure imaging data-set. In this research a plantar pressure optical imaging data-set based classification technology has been developed. In this paper, an improved local binary pattern (LBP) algorithm is used to retrieve texture-based features and recognize patterns from the data-set. A calculation model of plantar pressure imaging feature area is established subsequently. The data-set is classified by a neural network to guide the generation of various shoe-last surfaces. Firstly, the local binary mode is improved to adapt to the pressure imaging data-set, and the texture-based feature calculation is fully used to accurately generate the feature point set; hereafter, the plantar pressure imaging feature point set is then used to guide the design of last free surface forming. In the presented experiments of plantar imaging, multi-dimensional texture-based features and improved LBP features have been found by a convolution neural network (CNN), and compared with a 21-input-3-output two-layer perceptual neural network. Three feet types are investigated in the experiment, being flatfoot (F) referring to the lack of a normal arch, or arch collapse, Talipes Equinovarus (TE), being the front part of the foot is adduction, calcaneus varus, plantar flexion, or Achilles tendon contracture and Normal (N). This research has achieved an 82% accuracy rate with 10 hidden-layers CNN of rotation invariance LBP (RI-LBP) algorithm using 21 texture-based features by comparing other deep learning methods presented in the literature.

Flexible Juvenile Flat Foot Surgical Correction: A Comparison Between Two Techniques After Ten Years’ Experience

The aim of our study is a retrospective analysis of the 2 most common surgical treatments of symptomatic juvenile flat foot: different arthroereisis techniques. Exosinotarsal arthroereisis with metallic screw and endosinotarsal with bioabsorbable devices were compared. In total, 402 feet were examined for a median follow-up of 130 months. Only symptomatic (plantar or calcaneus pain), flexible, and idiopathic flat feet were included in our study. Congenital (fibrous/bone tarsal coalitions), neurologic, and posttraumatic flat feet were excluded. During clinical examination, the feet were categorized according to the Viladot classification, which took into consideration the plantar impression: only grades 3 and 4 were included (complete medial longitudinal arch collapse). Evaluation was determined by taking into consideration 3 parameters: clinical evaluation, pain, and variation of the radiologic angles. No statistical differences were found between the 2 techniques; the choice can be determined mostly by the surgeon's preference.

Results of Simple Conservative Treatment of Midfoot Charcot Arthropathy.

BackgroundTraditionally, conservative management with an offloading orthosis, such as total contact cast (TCC), has been the standard of care for midfoot Charcot arthropathy. Considering complications of TCC and surgery, we treated midfoot Charcot arthropathy without TCC in our patients. The purpose of this study was to report clinical and radiological outcomes of conservative management of midfoot Charcot arthropathy.MethodsA total of 34 patients (38 feet) who were diagnosed as having midfoot Charcot arthropathy between 2006 and 2014 were included. Patients started full weight bearing ambulation in a hard-soled shoe immediately after diagnosis. Outcomes such as progression of arch collapse, bony prominence, ulcer occurrence, limb amputation, and changes in Charcot stage were evaluated.ResultsOf 38 feet, arch collapse was observed in four while progression of bottom bump of the midfoot was observed in five feet. Foot ulcers related to bony bumps were found in two feet.ConclusionsConservative treatment without restriction of ambulation is recommended for midfoot Charcot arthropathy because it is rarely progressive, unlike hindfoot-ankle arthropathy. In some cases, simple bumpectomy can be required to prevent catastrophic infection.

Combined Subtalar and Naviculocuneiform Fusion for Treating Adult Acquired Flatfoot Deformity With Medial Arch Collapse at the Level of the Naviculocuneiform Joint.

A challenge in treating acquired flatfoot deformities is the collapse of the medial arch at the level of the naviculocuneiform (NC) joint. Triple fusions, being a treatment option, may lead to problems such as increased foot stiffness. We thus established a method that combines subtalar (ST) fusion with NC fusion while preserving the Chopart joint. We analyzed the radiographic correction, fusion rate, and patient satisfaction with this procedure. 34 feet in 31 patients (female, 23; male, 8; age 67 [45-81] years) were treated with a ST and NC joint fusion. In 15 cases, a medial sliding-osteotomy was additionally necessary to fully correct hindfoot valgus. The following radiographic parameters were measured on weightbearing radiographs preoperatively and at 2 years: talo-first metatarsal angle, talocalcaneal angle, calcaneal pitch, talonavicular coverage angle and calcaneal offset. Fusion was radiologically confirmed. All parameters, except the calcaneal pitch, showed a significant improvement. Fusion was observed after 1 year in all but 2 cases (94.1%). One nonunion each occurred at the ST and NC joint without needing any subsequent treatment. One patient developed avascular necrosis of the lateral talus with need for total ankle replacement after 1 year. All patients were satisfied with the obtained results. Our data suggest that a combined fusion of the ST and NC joint was effective and safe when treating adult acquired flatfoot with collapse of the medial arch at the level of the NC joint. Although the talonavicular joint was not fused, its subluxation was significantly reduced. Level IV, case series.

The transverse arch collapse correction as a path to foot toes alignment

Abstract The study presents a fragment of pilot studies showing the reconstruction of the transverse arch of the foot using a specially constructed orthosis for this purpose. It involves the mechanical reinforcement of the effect by an orthosis, which pushes down the I, IV, and V metatarsal bones while elevating or blocking the fall of the near-immobile II and III metatarsal bones according to the “three-force” rule. The correction of the transverse arch of the foot runs simultaneously with the correction of hallux valgus (HV). As a result, the significant correction of HV and associated toe deformities was achieved. In stage I foot deformity, the reduction of HV was reduced from 19.1° before to 15.1° after putting on orthosis (p = 0.024). In stage II, the reduction was from 20.1° (before) to 16.2° (after; p = 0.032). Equally satisfactory results were obtained for the remaining angles of the metatarsal bones. In the future, the method can be suitable for patients undergoing preparation for corrective HV surgery and for maintaining postoperative HV results. It can be used preventively, for example, by women who frequently wear high-heeled shoes and by those who need to remain standing for prolonged periods of time.

Combined Medial Column Arthrodesis with Open Reduction Internal Fixation of Central Column for Treatment of Lisfranc Fracture-Dislocation: A Review of Consecutive Cases

Lisfranc fracture-dislocations can be devastating injuries with significant long-term sequelae with or without surgical intervention. The main goal of treatment is to minimize the common long-term complications including pain, progressive arch collapse, degenerative joint disease, hardware failure, and reoperation. Partial primary fusion involving the first, second, and third tarsometatarsal joints has become a common approach for primarily dislocation injuries, with open reduction and internal fixation (ORIF) favored for Lisfranc injuries involving fracture. ORIF commonly requires revision surgery for hardware removal or delayed fusion. Major revision creates hardship for the patient due to the prolonged recovery required, and even “simple” hardware removal can be traumatic to local nerve, artery, and tendon structures. A common injury pattern includes the findings of primary dislocation and instability of the first tarsometatarsal joint with oftentimes comminuted fracture to the second and third tarsometatarsal joints, which does not fit the standard surgical approach. We report a review of our preferred surgical approach consisting of medial column primary arthrodesis combined with central column ORIF and lateral column temporary pinning. We undertook an institutional review board-approved review of 35 consecutive Lisfranc injuries treated with this hybrid approach. Mean follow-up time was 22.14 ± 22.39 (range 2.5 to 84) months. All but 2 (5.71%) patients had radiographic evidence of union at 10 weeks. Complications included 3 with neuritis, 1 with medial column nonunion that was treated with a bone stimulator, and 1 with revision of second metatarsal nonunion. The present retrospective series highlights our experience with isolated primary fusion of the medial column in both subtle and obvious Lisfranc injuries.