Correction Of Hindfoot Deformity Research Articles

АКТУАЛЬНЫЕ ВОПРОСЫ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ДЕФОРМАЦИЙ ЗАДНЕГО ОТДЕЛА СТОПЫ

Abstract. Introduction. The review analyzes and summarizes the results of studying the surgical treatment of traumatic and non-traumatic hindfoot deformities with subtalar joint osteoarthritis. Relevance of this issue is supported by highly frequent unsatisfactory results achieved in primary care, which often lead to post-traumatic subtalar arthrosis, high percentage of the disablement of mostly working-age patients, and economic costs associated with their further treatment and rehabilitation. Subtalar arthrodesis, in combination with bone grafting augmentation with auto-, allo- or xenograft and internal fixation, is the most common surgical technique for patients of this category. Aim. To study the advantages and disadvantages of the known surgical techniques used in treatment of posttraumatic hindfoot deformities. Materials and Methods. To perform the literature analysis, we used international databases, such as Web of Science, Scopus, and PubMed, as well as the domestic library system, eLibrary. Results and Discussion. Despite good surgical treatment outcomes presented in the publications, some failures were registered, such as insufficient deformity correction, arthrodesis nonunion due to the bone graft migration, bone graft osteolysis, metal structure instability, and infectious complications. According to the authors, the key reason for some unsatisfactory results in non-infectious cases was the lack of preoperative planning, including accurate calculations of the necessary hindfoot deformity correction and of the optimal extent of bone grafting.

Calcaneal Osteotomies in Prevention of Deformity-Driven Subtalar Joint Arthritis

Category: Hindfoot Introduction/Purpose: Calcaneal osteotomies (CO) have been described thoroughly in reduction of hindfoot and global deformities of the foot and ankle. Their ability to alter the ground reactive forces and abnormal joint motion in various deformities, realigning the mechanical axes to a more normal alignment has been well-described in the literature. Despite the high volume of studies involving calcaneal osteotomies in the correction of hindfoot deformities, few have investigated the protective nature of them in the prevention of end-stage osteoarthritis of the subtalar joint. The purpose of the present study was to identify the preventative nature of calcaneal osteotomies in the prevention of deformity-driven subtalar joint arthritis. Methods: 255 patients who underwent various calcaneal osteotomies (medial calcaneal displacement, lateral column lengthening, Dwyer) in a 2-year span were reviewed. Minimum of 3 years of follow up was required for the present study, and patient charts were reviewed to see if any went on to subtalar joint fusion secondary to deformity-driven osteoarthritis. Charts were also evaluated for hardware removal and nonunion rates, while lateral radiographs were evaluated for preoperative and long-term postoperative arthritis based on the Kellgren-Lawrence scale. Results: After inclusion criteria was applied, 44 patients were ultimately included in the study with an average follow up time of 51.8 months. In the end, 2.3% of patients underwent subtalar joint arthrodesis for treatment of deformity-driven osteoarthritis (1/44). Hardware removal and nonunion rates were 25% (11/44) and 2.3% (1/44), respectively. Kellgren-Lawrence evaluation showed there was some protective nature of CO's in prevention of subtalar joint arthritis, but the inter-observer coefficient was fair between two observers. ICC was fair for preoperative Kelgren Lawrence scores between the two presenters (ICC = 0.664), and poor for postoperative Kelgren Lawrence scores (ICC = 0.459). Conclusion: This is one of the only studies to evaluate the protective nature of calcaneal osteotomies in the prevention of deformity-driven subtalar joint arthritis. Clinical evaluation of this group suggested there is some protective nature in calcaneal osteotomies in the prevention of subtalar joint arthritis requiring arthrodesis, supporting the use of these osteotomies in the correction of hindfoot deformities. While the identified KG scores were not consistent between the two presenters, this is consistent with previous studies who investigated KG in the subtalar joint.

Foot Deformity Correction Planning in the Sagittal Plane Based on the Vitruvian Foot First Metatarsal Mechanical Axis and Calcaneus Anatomic Axis

The aim of the study was to test a novel planning method for simultaneous midfoot and hindfoot deformity correction, based on reference lines and angles (RLA) of the talus, calcaneus and first metatarsal in 64 normal radiographs from 55 patients. Talus Joint Line (TJL), from the border of the articular surface of the talus and the posterior process of talus, and mechanical axis of the first metatarsal form the mechanical Lateral Talometatarsal Angle (mLTMA)=23.6º (±3.2). The length of the first metatarsal line was measured from its intersections with the TJL and first metatarsal head and it was 4.3 (±0.94) times longer that TJL (k). For hindfoot correction planning, we used an axis of the calcaneus formed by a line starting at the middle of the back of the calcaneal tuberosity and going perpendicular to a line from the top point to the bottom point of the calcaneal tuberosity. The intersection of the calcaneal line and the anterior continuation of TJL form the lateral heel angle (LHA)=15.2º (±3.4).The following parameters were identified: the length from the intersection point of the lines and anterior point of TJL was 2.56 ± 1.1 longer than TJL (k1). The length from the intersection point and posterior border of the calcaneus was 4.59 ± 1.0 times longer than TJL (k2). Planning using the new method was demonstrated and confirmed on 3 case examples. A novel method for analysis and planning of midfoot and hindfoot sagittal plane deformity correction may be used separately or simultaneously for complex deformity correction.

Examination of Safe Zone to Avoid Injury of the Lateral Plantar Artery During Calcaneal Osteotomy: A Fresh Cadaveric Study.

Calcaneal osteotomy are used to treat various pathologies in the correction of hindfoot deformities. But lateral plantar artery (LPA) pseudoaneurysms have been reported following calcaneal osteotomy, and LPA pseudoaneurysms may be at risk for rupture. Although the vascular structures in close proximity to calcaneal osteotomies have variable courses and branching patterns, there is little information on safe zone for LPA during calcaneal osteotomy. The aims of this study were to identify the safety zone to avoid the LPA injury during calcaneal osteotomy. Enhanced computed tomography scans of 25 fresh cadaveric feet (male, n = 13; female, n = 12; mean age 79.0 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery. Line A is the landmark line and extends from the posterosuperior aspect of the calcaneal tuberosity to the plantar fascia origin, and the perpendicular distance between the LPA and line A at its closest point was measured on sagittal images. The average perpendicular distance between the LPA and line A at its closest point was 15.2 ± 2.9 mm. In 2 cases (8.0 %), the perpendicular distance between the LPA and line A at its closest point was very close, approximately 9 mm. In 18 of 25 feet (72.0%), the point where perpendicular distance from the line A to LPA is the closest was the bifurcation of one of the medial calcaneal branches from LPA, and in 7 feet in 25 feet (28.0%) feet the point where perpendicular distance from the line A to LPA is the closest was the trifurcation of LPA, medial plantar artery, and one of the medial calcaneal branches. Calcaneal osteotomy approximately more than 9 mm from the line A could injure the LPA in overpenetration into the medial aspect of tcalcaneal osteotomy. Completion of the osteotomy on the medial side should be performed with caution to avoid iatrogenic injury of the LPA. Level IV, Cadaveric study.

Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

Category:HindfootIntroduction/Purpose:Calcaneal osteotomies are often required in correction of hindfoot deformities. The traditional open techniques as lateral or oblique incision are occasionally associated with wound healing problems and neurovascular injury.Methods:In a prospective study 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. 58 patients were operated using an open incision technique and 64 patients with 66 feet using a percutaneous technique. Clinical and radiological assessments were performed preoperatively, six weeks and one year postoperatively.Results:The AOFAS score and VAS improved in both groups postoperatively. The difference was not significant. The results of the radiological measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in both groups. The comparison of both groups showed a significant lesser risk for wound healing problems in percutaneous group (B). The hospitalisation time was significantly shorter in the percutaneous group.Conclusion:Due to the excellent results with the percutaneous calcaneal osteotomy the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy at our clinic.

A Comparative Study of Two Different Techniques for Calcaneal Displacement Osteotomy

Category: Hindfoot Introduction/Purpose: The lateral oblique incision is widely used for calcaneal displacement osteotomy in correction of hindfoot deformities. Wound healing problems and neurovascular injury are limitations of this procedure. A technique using a Shannon burr for calcaneal displacement osteotomy was introduced to avoid these complications. The advantages of the percutaneos calcaneus osteotomy have been evaluated in a comperative study. Methods: Lateral oblique incision for calcaneus osteotomy was performed in 58 patients. The senior author changed the osteotomy technique 2014. Further 64 calcaneus osteotomies were performed percutaneously. The main indication for the calcaneus osteotomy was correction of hindfoot deformities. Complementary the number of screws used for the fixation have been axamined in the study. Results: The mean age of the patients was 51,6 (14-72) years. The patients were folled up for 12 months. All cases achieved radiographic union. Wound healing problems have been registrated in the open technique group in 16 patients (27,6%). Six of them (10,3%) required a surgical revision. No wound healing problems appeared in the percutaneous group. N. suralis was affected in the open technique group in 12 patients (20,6%) and in 4 patients (6,2%) in the percutaneous osteotomy group (p 0,02). The operating time was significantly shorter in the percutaneus osteotomy group. The correction of the hindfoot axis succeed in all patients. Risk of complication did not differ significantly between single and double screw in the percutaneous osteotomy group. Conclusion: The clinical and radiological examinations showed outstanding results. There is no evident difference between the two techniques in the radiological results. Use of a single screw in percutaneous osteotomy of the calcaneus did not increased the complication rate. The percutaneous calcaneal osteotomy had a lower complication rate in our study and is probably a useful technique in patients with diabetes and affected perfusion. Further randomised studies should consider this results.

Overview of subtalar arthrodesis techniques: Options, pitfalls and solutions

Subtalar arthrodesis (SA) is the preferred treatment for painful isolated subtalar disease. Although results are generally favourable, analysis of current operative techniques will help optimizing this treatment. The aim was to give an overview of SA-techniques and their pitfalls. Possible solutions were identified. A literature search was performed for papers that presented SA operative techniques. The general technique was divided into phases: surgical approach, cartilage removal, bone graft selection, hindfoot deformity correction and fixation. The published series were invariably retrospective reviews of small heterogenous groups of different hindfoot pathologies. The weighted outcome rate for SA was 85% (68-100%) performed in 766 feet and for SA requiring correction of malalignment 65% (36-96%) in 1001 feet. Non-union (weighted percentage 12%), malalignment (18%), and screw removal (17%) were the prevailing late complications. The following pitfalls were identified: 1) early complications related to the incisions made in open approaches, 2) insufficient cartilage removal, improper bone graft selection and fixation techniques, all possibly leading to non-union, 3) morbidity caused by bone graft harvesting and secondary screw removal, 4) under- or overcorrection of the hindfoot possibly due to improper intraoperative verification and 5) inadequate assessment of bony fusion. The review provides solutions to possibly overcome some pitfalls: 1) if applicable use an arthroscopic approach in combination with distraction devices and new burrs, 2) if possible use local bone graft or allografts, 3) use two screws for fixation to prevent rotational micromotion, and 4) improve assessment of operative outcome by application of appropriate assessment of bony fusion and alignment. The review provides practical suggestions to optimize SA-techniques.

Conservative management of the hindfoot in juvenile chronic arthritis

Hindfoot involvement in children with juvenile chronic arthritis has been investigated. 50 children were seen; there was bilateral involvement in 36 and one foot was affected in 14. Correction of hindfoot deformity by manipulation under anaesthesia combined with a local corticosteroid injection improved the position and pain in the majority of patients. Children with a short duration of symptoms did best.