Flatfoot Deformity Research Articles

Midfoot and Forefoot Disorders in Adolescents and Adults with X-Linked Hypophosphatemia

Objectives: X-linked hypophosphatemia (XLH, OMIM 307800) is a rare genetic disorder that affects phosphate metabolism. While lower limb deformity represents a hallmark symptom of patients with XLH, the effect on the foot has not been investigated. This study aimed to characterise foot pathologies and assess related outcome scores in adolescents and adults with XLH. Methods: Patients aged ≥ 16 years with genetically verified XLH were included in this study. Physical examination was performed, and foot scores as well as foot X-rays were assessed. Radiographic analysis included the assessment of osteoarthritis, enthesopathies, and alignment abnormalities. Results: Twenty-six participants (51 limbs) with a mean age of 33.9 ± 15.4 years were eligible for the study. Patients with XLH presented with flatfoot deformity (reduced Meary angles > −4° in 84.3%), elevated first and fifth metatarsal angles > 30° (IM 1–5, 53.5%) and hallux valgus angles > 15° (36.0%). Moderate-to-severe joint space narrowing was observed in the talonavicular (49%) and cuneonavicular joints (41.2%). The American Orthopedic Foot and Ankle Society (AOFAS) score was associated with mildly reduced midfoot function. Conclusions: A high rate of bony deformity, joint degeneration, and decreased foot scores indicated the impact of forefoot and midfoot disorders in patients with XLH.

Advancing Adult-Acquired Flatfoot Deformity Treatment: Enhanced Biomechanical Support Through Graphene Oxide-Integrated Bioengineered Grafts Tested In Silico

Adult-Acquired Flatfoot Deformity (AAFD) is a progressive orthopedic condition causing the collapse of the foot’s medial longitudinal arch, often linked with injuries to the plantar arch’s passive stabilizers, such as the spring ligament (SL) and plantar fascia. Conventional treatment typically involves replacing the SL with synthetic material grafts, which, while providing mechanical support, lack the biological compatibility of native ligaments. In response to this shortcoming, our study developed an electrospun, twisted polymeric graft made of polycaprolactone (PCL) and type B gelatin (GT), enhanced with graphene oxide (GO), a two-dimensional nanomaterial, to bolster biomechanical attributes. The addition of GO aimed to match the native ligamentous tissue’s mechanical strength, with the PCL-GT-GO 2.0% blend demonstrating an optimal Young’s modulus of 240.75 MPa. Furthermore, the graft showcased excellent biocompatibility, evidenced by non-hemolytic reactions, suitable wettability and favorable platelet aggregation—essential features for promoting cell adhesion and proliferation. An MTT assay revealed cell viability exceeding 80% after 48 h of exposure, highlighting the potential of the graft as a regenerative scaffold for affected ligaments. Computational modeling of the human foot across various AAFD stages assessed the graft’s in situ performance, with the PCL-GT-OG 2.0% graft efficiently preventing plantar arch collapse and offering hindfoot pronator support. Our study, based on in silico simulations, suggests that this bioengineered graft holds significant promise as an alternative treatment in AAFD surgery, marking a leap forward in the integration of advanced materials science for enhanced patient care.

HyProCure for Flatfoot Deformity: A Clinical Characteristics Analysis in China.

Flatfoot is a common foot disorder involving progressive foot deformity of the three-dimensional structures of the forefoot, midfoot, and hindfoot. Currently, Chinese surgeons and patients favor subtalar arthroereisis (SA) due to its minimally invasive and low-damage characteristics. HyProCure device is widely used. However, there is limited analysis of large sample sizes. This study utilized statistical evaluation with a large sample size to analyze clinical characteristics trends of SA for flatfoot, including baseline indicators, selection of HyProCure size and surgical strategy, complications, and implant removal. This study will enhance the understanding of SA in China. A retrospective analysis of 732 patients (1008 ft) who underwent SA from June 2015 to June 2023, with 509 pediatric and adolescent patients (772 ft) and 223 adult patients (236 ft). Based on the patient's age, patients aged ≤ 18 were included in the children and adolescent group, while adult acquired flatfoot deformity (AAFD) patients aged > 18 were included in the adult group. General data was collected, including patient sex, age, side, body mass index (BMI), surgery date, HyproCure size, and surgical data, and trends were analyzed. Postoperative complications and HyProCure removal were collected as outcome measures during follow-up. The age of patients treated with SA was gradually getting younger, with male patients predominating, mainly concentrated in the 11-14 age group. HyProCure 7 has the highest usage rate. In the children and adolescent group, 288 ft (37.31%) only underwent SA. In the adult group, 18 ft (7.63%) only underwent SA. Complications include sinus tarsi pain, peroneal spasms, achilles tendon tension, and muscle strength decline. The complication rate in the children and adolescent group was 5.05%, while in the adult group it was 28.81%. Overall, it was 10.62%. The removal rate of HyProCure in the children and adolescent group is 1.04%, in the adult group is 15.25%, and overall is 4.37%. The trend in flatfoot treated with SA was towards children and adolescent male patients, and sinus tarsi pain was the most common complication after SA. The complication rate and removal rate in the children and adolescent group were lower than those in the adult group. HyProCure can be removed without additional adverse effects.

Tarsal Coalition Resection in Children: Is it Effective?

Tarsal coalitions in children are a group of disorders that typically present as a rigid flatfoot deformity. Operative treatment generally consists of resecting the coalition alone or resection plus flatfoot reconstructive procedures. The purpose of this study was to evaluate the rate and risk factors for complications, including infection, recurrence, and reoperation, following the surgical management of tarsal coalitions in children. This is a retrospective cohort study on the surgical outcomes of pediatric tarsal coalitions alone or in combination with adjunctive procedures. This study was conducted between 01/01/2008 and 12/31/2019 and utilized electronic health records and chart review was performed to describe patient demographic, clinical, perioperative characteristics, and whether patients have subsequent foot and ankle procedures after the index resection surgery. The study cohort included 165 feet belonging to 144 patients. The age range at time of surgery was 12 years of age (11-14). Of the 165 feet, 18 (10.9%) experienced a postoperative complication, including six infections of which two required reoperation, six recurrences all requiring reoperation, and six reoperations not due to recurrence. Patients with a postoperative complication demonstrated increased age (13.9 years vs 12.4 years, p=0.007), obesity (33.3% vs 13.6%, p=0.026), and/ or preoperative hindfoot valgus deformity (33.3% vs 7.5%, p=0.004). The overall postoperative complication rate was 10.9%. Results of this study provided important information for providers as they discuss different treatment approaches and anticipated outcomes with patients and their families.

Tibialis Anterior Tendon Transfer for Clubfoot Deformity: Cuboid Versus Lateral Cuneiform.

Tibialis anterior tendon transfer in relapsing clubfoot deformity is a well-known treatment option for dynamic forefoot supination and adduction deformities. The tibialis anterior tendon can be anchored to the lateral cuneiform or the cuboid. A complication of this surgery is overcorrection to a flatfoot deformity or undercorrection that maintains the clubfoot deformity. We compared reoperation rates and clinical outcomes between these 2 groups. This is a retrospective study performed from 2005 to 2020. The primary outcome was repeat operation. The secondary outcome included clinical appearance scores described by Garceau and Palmer. There were 114 clubfeet (111 patients) treated in our study. Of them, 67 (58.8%) had a transfer to the lateral cuneiform, whereas 47 (41.2%) had a transfer to the cuboid. Nine patients had reoperations which included 4 (44.4%) in the lateral cuneiform group and 5 (55.6%) in the cuboid group which was not statistically significant (P=0.485). Clinical appearance scores revealed significantly better clinical appearance in the lateral cuneiform group after surgery compared with the cuboid group (P=0.0172). There were no clinically significant differences in reoperation rates between transfers to the lateral cuneiform versus the cuboid. We did find better clinical appearance in the lateral cuneiform group after surgery compared with the cuboid group. Level III retrospective comparative study.

Clinical and radiological outcomes of flexible flatfoot correction with double calcaneal osteotomy

BackgroundAlthough double calcaneal osteotomy (medial displacement calcaneal osteotomy with lateral column lengthening) is widely regarded as an effective treatment option for flexible flatfoot, limited studies have extensively analyzed the degree of deformity correction in three dimensions following double calcaneal osteotomy. This study was performed to evaluate the radiographic and clinical effectiveness of double calcaneal osteotomy to correct flexible flatfoot deformities.MethodsThirty-one patients who had 44 symptomatic flexible flatfeet and underwent double calcaneal osteotomy were examined retrospectively with a mean follow-up of 50 months. Visual analog scale, foot and ankle activity measure, and other clinical data were obtained from medical records. Various radiographic variables for assessing flatfoot and osteoarthritic change in tarsal joints were analyzed from weightbearing radiographs.ResultsClinical scores and radiographic variables were significantly improved postoperatively. The mean values of medial sliding and lateral lengthening were 7.6 and 8.7 mm, respectively. No osteoarthritic changes were observed.ConclusionsDouble calcaneal osteotomy could be used to correct flatfoot deformities effectively and sustainably and provide symptomatic relief and patient satisfaction.Level of evidenceLevel 4, retrospective case series.

Comparative study of subtalar arthroereisis, medializing calcaneal osteotomy and the combination of both techniques for the treatment of symptomatic adult flatfeet

BackgroundSymptomatic adult flatfeet are a common problem that is treated with various therapeutic approaches. In this study, three different surgical approaches, subtalar arthroereisis (SA), medializing calcaneal osteotomy (MDCO) and a combination of both techniques (SA+MDCO) were analyzed. Methods32 patients (36 feet) with pes planovalgus (mean age 49 +/- 16 years) were surgically treated with either SA (n = 8 feet), MDCO (n = 9 feet) or SA+MDCO (n = 19 feet). The American Orthopaedic Foot and Ankle Society (AOFAS) and the European Foot and Ankle Society (EFAS) questionnaires, as well as radiological parameters were compared before and after surgery within and between groups. At follow up (6 +/- 2 years) patients were additionally invited for dynamic pedobarography and static hindfoot axis examination. ResultsWithin all three groups AOFAS and EFAS questionnaire values and radiological parameters improved significantly after surgery. Questionnaires did not differ between all groups. Before surgery the SA+MDCO group displayed the most severe radiological flatfeet parameter in comparison to the other cohorts. After surgery, the SA and SA+MDCO groups were greatly improved, while the MDCO group displayed less correction, indicating poorer surgical results with MDCO only. Pedobarography of surgically treated feet revealed similar results in comparison to the contralateral side within all three groups and all feet displayed a normal gait line after surgery. ConclusionsAnalyzing questionnaires and radiographs, all three surgical techniques (SA, MDCO and SA+MDCO) significantly improved the severity of flatfoot deformity. Pedobarography revealed similar dynamic properties of treated feet in comparison to the contralateral side. While treatment with SA showed better results than treatment with MDCO alone, the combination of SA+MDCO was most effective. In this study, severe adult flatfeet benefited most from a surgical combination of SA+MDCO with respect to normalization of radiological parameter. Level of Evidence/Clinical relevanceTherapeutic Level III

Does severity of the flatfoot deformity affect pain and mobility in adolescents with symptomatic flatfoot.

Level III.

Three-Dimensional Bone Alignment from Cone-Beam Computed-Tomography Scans in Weight-Bearing and Clinical Outcomes Following the Modified Grice–Green Surgical Procedure for Adult Acquired Flatfoot

Severe adult-acquired flatfoot deformity is widely addressed surgically via the Grice–Green subtalar arthrodesis. Standard radiographic measurements have been reported, but these are limited to planar views. These complex deformities and the relevant corrections after surgery should be assessed in weight-bearing using 3D analyses now enabled by modern cone-beam CT scans. The present study is aimed at reporting these 3D radiographical foot bone alignments and the clinical results for this surgery. Ten patients were treated with the Grice–Green procedure. This implies inserting an autologous bone graft from the proximal tibial into the extra-articular sinus-tarsi to perform a subtalar arthrodesis. Before and after surgery, the patients were assessed based on the clinical range-of-motion and Foot-Function and Posture Indexes. Three-dimensional models of the tibia, calcaneus, talus, navicular, and 1st metatarsus were reconstructed from cone-beam CT scans in a single-leg up-right posture. Relevant longitudinal axes were defined to calculate ten spatial angles. Post-operatively, a significant realignment was observed for seven angles, including corrections lift-up of the talus (on average by 15°) and subtalar joint (13° in 3D), as well as the Meary’s angle (21°). Only few correlations were found between traditional clinical and novel 3D radiographical measurements, suggesting the former only limitedly represent the corresponding real skeletal status, and the latter thus offer the physician a more comprehensive evaluation. The present original analysis from modern cone-beam CT scans shows precisely the correction of foot and ankle bone alignments achieved using the Grice–Green surgical procedure, finally in 3D and in weight-bearing. For the first time, traditional clinical and score system evaluations are reported together with bone orientation and joint angles in the three anatomical planes.

Postoperative Calcaneocuboid Joint Subluxation and Midtarsal Joint Changes in Pediatric Idiopathic Flexible Flatfoot Treated With Calcaneal Lengthening Osteotomy: A Midterm Follow-up Study.

Calcaneal lengthening osteotomy (CLO) is one of the main surgical options for treatment of pediatric idiopathic flexible flatfoot (FFF). Reportedly, calcaneocuboid (CC) joint subluxation occurs after CLO; however, its effect on the midfoot remains unclear. This study aimed to investigate the radiologic midterm results after CLO treatment in pediatric idiopathic FFF. We evaluated 23 pediatric patients with idiopathic FFF aged ≥8 years, who underwent CLO from 1999 to 2017 owing to moderate to severe flatfoot deformity (assessed by visual inspection). Patients aged between 8 and 14 years were included (mean follow-up: 6.3 years; range, 3.1-11.4 years). Anteroposterior and lateral weightbearing foot radiographs were assessed for radiologic parameters preoperatively and at the 3-month, 1-year, and final follow-ups postoperatively. All patients had immediate postoperative radiologic correction of the flatfoot deformity, and these improvements were maintained until the final follow-up. The mean allograft length inserted was 9 (range, 8-10) mm. There was increased CC joint subluxation after CLO, but it improved continuously until the final follow-up. A CC joint spur was newly noted in 1 case. There were 24 cases (24/39, 61.5%) of talonavicular (TN) joint spurs at the final follow-up, but 19 of these were already present on the preoperative radiographs (19/24, 79.2%). Further, the new-onset TN joint spurs were not associated with preoperative clinicoradiologic factors. In pediatric patients with idiopathic FFF receiving CLO treatment, preoperative radiologic angles improved. CC joint subluxation increased after surgery; however, it gradually reduced without evidence of CC joint arthritic changes over the time period studied in this cohort.

The Effects of Midfoot/Hindfoot Fusions on the Behaviour of Peroneus Longus Tendon in Adult-Acquired Flatfoot Deformity: A Biomechanical and Finite Element Analysis

Adult-acquired flatfoot has been considered to arise from tibialis posterior tendon deficiency. Recent evidence shows that arch stability is mainly maintained by structures such as plantar fascia and spring ligament. The dysfunction of these ’passive’ stabilizers results in loss of arch integrity that causes forefoot pronation and reactive tendon overload, especially in the tibialis posterior tendon and peroneus longus tendon. The peroneus longus tendon (PLT) spans several midfoot joints and overloads with arch lengthening. The biomechanical stress/changes that occurs in this tendon are not well recognized. This study evaluates the biomechanical consequences that fusions have on peroneus longus tendon stresses in soft-tissue deficiencies associated with flatfoot deformity. A complete computational human foot model was used to simulate different scenarios related to the flatfoot deformity and associated common midfoot/hindfoot fusions, to quantify the biomechanical changes in the peroneus longus tendon. The results showed that the stress of the peroneus longus tendon is especially affected by the fusion of hindfoot joints and depends on the soft tissue types that fail, causal in generating the flatfoot. These results could be useful to surgeons when evaluating the causes of flatfoot and the secondary effects of surgical treatments on tissues such as the peroneus longus tendon.

Surgical treatment of mobile planovalgus deformation of feet using calcaneal osteotomy based on preoperative computer modeling in adolescent: a retrospective cohort study

Background: Evans calcaneal osteotomy is one of the recognized surgical techniques for the treatment of flat-valgus foot deformity in children over 12 years of age, which allows simultaneous multiplanar correction. Preoperative planning of the formed diastasis parameters to reduce the number of cases of hypo- and hypercorrection remains an urgent issue. AIM: To evaluate the results of Evans calcaneal osteotomy using the developed method of preoperative planning and fixation with the individual H-shaped reconstructive plate. MATERIALS AND METHODS: This study included 64 children aged 12–17 years with symptomatic planovalgus deformity, who were divided into two groups: in the main group, preoperative planning was used according to the developed method; in the control group for intraoperative control of correction was used only fluoroscopy and visual assessment. To study the effectiveness of the developed method, we used dynamic assessment of radiometric parameters and AOFAS questionnaire results before and after surgery. We also took into account the changes in the Foot Posture Index 6 and the Chippaux-Smirak and Stasheli podometric indices. RESULTS: In comparison with the control group, the main group showed a reduction in the swelling period after surgery, as well as the timing of the onset of full limb support, and a significant decrease in the incomplete correction. Similar dynamics was observed when studying the groups according to the Foot Posture Index 6 scale and podometric indices. CONCLUSION: The use of the developed method of preoperative planning during the Evans operation has shown its effectiveness for the treatment of flexible flatfoot deformity of the feet in adolescence.

An ex vivo sequential ligament transection model of flatfoot

BackgroundThe ligaments implicated in the earliest stages of developing a progressive collapsing foot deformity are poorly understood. Commonly employed cadaveric flatfoot models are created from simultaneous transection of multiple ligaments, making it difficult to assess early changes in pressure distribution from ligaments critical for maintaining load distribution. A serial transection of ligaments may provide insight into changes in pressure distribution under the foot to identify a potential combination of ligaments that may be involved in early deformities. MethodsSpecimens were loaded using a custom designed axial and tendon loading system. Plantar pressure data for the forefoot and hindfoot were recorded before and after six sequential ligament complex transections. FindingsSectioning the plantar fascia (first) and short/long plantar ligaments (second) failed to generate appreciable differences in load distribution. Dividing the spring ligament (third) led to changes in hindfoot load distribution with a shift towards the lateral column indicative of hindfoot valgus angulation. All subsequent conditions resulted in similar patterns in hindfoot plantar load distribution. An anterior shift in the center of pressure only occurred after transection of all six ligament complexes. InterpretationLoss of the plantar fascia and short/long plantar ligaments are not critical in maintaining plantar load distribution or contact area. However, the additional loss of the spring ligament caused notable changes in hindfoot load distribution, indicating the combination of these three ligament complexes is particularly critical for preventing peritalar subluxation. Minimal changes in load distribution occurred when performing additional transections to reach a complete flatfoot deformity.

Pes planus intermetatarsal angle to measure flatfoot deformity on dorsoplantar radiographic imaging

Pes planus intermetatarsal angle to measure flatfoot deformity on dorsoplantar radiographic imaging

Talocalcaneal Coalition Resection with Local Fat Grafting and Flatfoot Reconstruction.

Talocalcaneal (TC) coalitions typically present in the pediatric population with medial hindfoot and/or ankle pain and absent subtalar range of motion. Coalition resection with fat interposition is well described for isolated tarsal coalitions1,2; however, patients with concomitant rigid flatfoot may benefit from additional reconstructive procedures. To address this, we employ the surgical technique of TC resection with local fat grafting and flatfoot reconstruction. This procedure is described in 3 steps: (1) gastrocnemius recession and fat harvesting, (2) TC coalition resection with local fat interposition, and (3) peroneus brevis Z-lengthening and calcaneal lateral column lengthening osteotomy with allograft. A 3 to 4-cm posteromedial longitudinal incision is made at the distal extent of the medial head of the gastrocnemius muscle. The gastrocnemius tendon is identified, dissected free of surrounding tissue, and transected. Superficial fat is then harvested from this incision before wound closure. A 7-cm incision is made from the posterior aspect of the medial malleolus to the talonavicular joint. The neurovascular bundle and flexor tendons are dissected carefully from the surrounding tissue as a group and protected while the coalition is completely resected, and bone wax and the local fat are utilized at the resection site to prevent regrowth of the coalition. An approximately 7-cm incision is then made laterally and obliquely following the Langer lines and centered over the lateral calcaneus. The peroneal tendons are released from their sheaths, and the peroneus brevis is Z-lengthened. A calcaneal osteotomy is performed about 1.5 cm proximal to the calcaneocuboid joint and angled to avoid the anterior and middle subtalar facet joints. Two Kirschner wires are inserted retrograde across the calcaneocuboid joint, and the calcaneal osteotomy is opened. A trapezoid-shaped allograft bone wedge is impacted, and the Kirschner wires are advanced across into the calcaneus. The lengthened peroneus brevis tendon is repaired, and the wound is closed in a layered fashion. First-line treatment is nonoperative with orthotics and immobilization. Surgical options include coalition resection with or without calcaneal lengthening osteotomy, arthrodesis, or arthroereisis. Following coalition resection, various grafts can be utilized, including fat autografts, bone wax, or split flexor hallucis longus tendon3-6. This procedure addresses TC coalition with concomitant rigid flatfoot. Resection alone may increase subtalar motion but does not correct a flatfoot deformity. Historically, surgeons performed arthrodesis or arthroereisis, but these are rarely performed in young patients. In patients with coalitions involving >50% of the posterior facet or preexisting degenerative changes, arthrodesis may be indicated7. Patients can expect improvement in pain and function8-11. Previous investigators reported improved patient satisfaction, improved range of motion, clinical and radiographic hindfoot correction, and an improved American Orthopaedic Foot & Ankle Society hindfoot score at the time of final follow-up8,9. Carefully free the neurovascular bundle from the surrounding soft tissue so that it can be carefully retracted away from the area of coalition resection.Utilize the interval between the posterior tibialis and flexor digitorum longus tendons to approach the coalition.Expose the medial wall of the coalition and perform a careful resection that avoids inadvertently diverging into the body of the talus or calcaneus.Place a smooth lamina spreader into the resected area and gently open the subtalar joint to confirm complete coalition resection.Place 2 retrograde wires across the calcaneocuboid joint before performing the osteotomy. Without this step, up to 50% of cases experience calcaneocuboid subluxation and/or rotation after the lateral column lengthening12.To determine the size of the allograft, place a lamina spreader into the osteotomy site to measure the width.If present, rigid supination of the forefoot must be corrected with a medial cuneiform plantar-based closing osteotomy. AOFAS = American Orthopaedic Foot & Ankle SocietyFADI = Foot and Ankle Disability IndexMRI = magnetic resonance imagingCT = computed tomographyOR = operating roomK-wire = Kirschner wire.

Outcomes and Complications Associated with Lateral Column Lengthening Using Porous Titanium Wedges for Flexible Flatfoot Deformity Correction: A Systematic Review

Outcomes and Complications Associated with Lateral Column Lengthening Using Porous Titanium Wedges for Flexible Flatfoot Deformity Correction: A Systematic Review

Is a keystone Bone Anomaly the Main Cause of Flatfoot (Pes Planus)?

Flatfoot (pes planus) is a decrease or loss of longitudinal medial arch height. The cause of symptomatic flatfoot occurring in adolescents is still unclear. In this study, the relationship between adolescent pes planus and foot bone shape was investigated. For this purpose, the volume and superficial area data of the foot bones of adolescent individuals with flatfoot deformity and individuals without any foot deformity were compared. Between September 2022 and June 2023, 30 individuals with adolescent pes planus with a medial arch angle greater than 145 degrees and 30 individuals without any foot deformity were included in the study. Computed tomography (CT) images of the participants' feet were obtained with a General Electric brand IQ model 32 detector CT device with a section thickness of 0.625mm in accordance with the bone protocol. Using the 3D Slicer program on CT images, foot bones were segmented and the volume and surface area ratios of each foot bone were determined. Cuneiforme mediale and cuneiforme intermediale volume ratios in individuals with flatfoot deformity decreased by 14% and 24%, respectively, compared with the control group ( P <0.05). Cuneiforme mediale and cuneiforme intermediale superficial area ratios were found to be 10% and 30% lower in the flatfoot group compared with the control group, respectively ( P <0.05). There was no difference in the volume and superficial area ratios of other foot bones between the groups ( P >0.05). The study results suggest that symptomatic adolescent flatfoot deformity may be associated with developmental anomalies of the os cuneiforme mediale and os cuneiforme intermedium.

Chronic Deltoid Insufficiency in Stage IV Adult Acquired Flatfoot Deformity: Do We Have a Good Answer?

Stage IV adult acquired flatfoot deformity (AAFD) with secondary chronic deltoid ligament insufficiency is a challenging deformity to treat, with minimal consensus in the literature concerning its surgical management. Many surgical treatment options have been described, including joint-sparing techniques, fusions, osteotomies, and even arthroplasties. However, questions remain as to what, if any, treatment is optimal. This contribution reviews studies on surgical treatments for stage IV AAFD with deltoid ligament failure and provides a critical analysis regarding the quality of outcomes reported for those different treatment options. PubMed and Google Scholar databases were searched between June 1, 2022, and August15, 2022, for studies published between 1990 and 2022 that describe the treatment of stage IV AAFD with deltoid ligament insufficiency. Articles included in the study focused on subjects with stage IV AAFD and associated deltoid ligament insufficiency undergoing surgical correction. Exclusion criteria included stage I, II, and III AAFD, as well as deltoid ligament repair following acute injury/rupture. Nine studies covering five different treatment options for patients with stage IV AAFD and chronic deltoid insufficiency were included, with minimal overlap in outcome measures used to assess the efficacy of the procedure. Triple arthrodesis with deltoid ligament reconstruction resulted in a 62.5% (5/8) success rate with a residual tibiotalar (TT) angulation of 2°(success defined as <3°). Tibiotalar arthrodesis of four patients resulted in an average post-operative tibiotalar angulation of 4.8°with all patients showing progressive destabilization of the hindfoot complex at 12-18 year follow-ups. Deltoid arthroscopic laminoplasty (Brostrom) resulted in an increased American Orthopaedic Foot and Ankle Society (AOFAS) score from 49.7 pre-op to 91.9 post-op. There was no long-term follow-up of these patients. Deltoid ligament reconstruction using autografts of the peroneus longus resulted in a post-operative valgus of 2.1°in one study and <5°in another. Deltoid ligament reconstruction using an anterior tibial tendon autograft resulted in a gain of 126.4 + 40.2% in stiffness compared to an intact ligament. Twinfix suture anchors resulted in a post-operative hindfoot angle averaging 5.3°. Combined deltoid and spring ligament reconstruction resulted in a 5.1°valgus angulation. There is currently no standard of care or clinical consensus regarding surgical treatment for stage IV AAFD with deltoid insufficiency. Several studies imply that mild valgus malalignment around the tibiotalar joint can result in satisfactory outcomes. A few studies even deemed <5°of valgus tilt post-operatively successful. However, it has been described that any imbalance in tibiotalar tilt is a significant risk factor for progressive arthritis and future ligamentous failure. No treatment option was able to correct valgus tilt to an anatomical standard (i.e., to normal anatomy). These varied findings, along with the lack of consensus on post-surgical measures to assess efficacy, are worrisome and emphasize the need for better surgical options. Moreover, there is a critical need for additional research on the long-termoutcomes following stage IV AAFD and deltoid insufficiency repair, particularly, as over five million people in the United States and 10% of the geriatric population are affected by AAFD with a risk of progressing to stage IV.

Biomechanical variations in patients with flatfoot deformity: Impact of gender, age, and BMI on foot kinetics and kinematics

BackgroundFlatfoot is considered by the collapse of the foot arch, altered biomechanics and impacting functional abilities. The biomechanical gait alteration of foot kinematics and kinetics in individuals with flatfoot, based on gender, age and Body mass index (BMI) in each cohort is unclear. This study explores how gender, age, and body mass index (BMI) impact distinct foot biomechanical characteristics, including ankle joint angle (Jc°), Ground force reaction angle (GFR°), Achilles tendon force (T), Ankle joint force (Jc) and vertical ground reaction force (VGRF) during the gait stance phase, in flatfoot versus normal-foot individuals on Indian Population. MethodA foot pressure test and sagittal plane motion analysis were performed on 142 individuals with normal-foot arches and 102 with flatfoot, stratified by gender, age, and BMI. Calculations of the magnitude and direction of forces in ankle joint equilibrants relied on inverse dynamic analysis, vertical ground force reaction and mapping motion data of the gait stance phases. ResultIn the midstance phase, females with high BMI (HBMI) in the middle and older age group (p = 0.029 and p = 0.014), and males with HBMI in the older age group (p = 0.039) demonstrate significantly higher VGRF. Females and males with HBMI in middle and older age groups, along with males with normal BMI in the older age cohort, show positive and negative ranges of GFR°, indicating gait instability. In the push-off phase, females with HBMI in a middle-aged group exhibit significantly lower TandJc (p = 0.023 and p = 0.026) respectively. ConclusionThe biomechanical issues in individuals with flatfoot, while accounting for the influence of gender, age and BMI, are crucial for tailored interventions and precise solutions to biomechanical issues, thereby enhancing foot function and reducing discomfort.

Comparison of Radiological Parameters to Predict the Adult Acquired Flatfoot Deformity (AAFD) in Indian population: A Retrospective Study

Comparison of Radiological Parameters to Predict the Adult Acquired Flatfoot Deformity (AAFD) in Indian population: A Retrospective Study