Hindfoot Alignment Research Articles

Different Positions of Weightbearing CT Images Can Influence the Hindfoot Alignment Evaluation Using 2-Dimensional Methodology.

Three-dimensional weightbearing CT (WBCT) has been widely used to assess foot and ankle alignment. However, most current measurement methods are based on 2-dimensional concepts-distance, long axis, angulation, etc-and are sensitive to changes in orientation of the WBCT images. This study demonstrated how changes in positioning of the image can significantly influence the evaluation of hindfoot alignment. WBCT scans of 10 feet without deformities were used. In the horizontal view, the long axis of the foot image was aligned to a neutral position and then rotated 5, 10, 15, and 20 degrees both internally and externally to simulate malposition. The Calcaneal Moment Arm (CMA) was measured by 2 investigators independently in the above positions. An intraclass correlation coefficient (ICC) model was used to assess the intra- and interobserver reliabilities. The correlation between the CMA and the rotation angle of the foot images was analyzed using linear regression. The CMA measurements demonstrated that internal rotation of the image changed the neutral hindfoot into valgus, whereas external rotation led to varus. A 1-degree internal or external rotation of the image correlated with 0.48 (±0.03) mm increase or decrease in the modified WBCT-CMA value (P < .0001, R2 = 0.6406). This study demonstrated that although 3D WBCT provides the ability to observe the foot from different perspectives, current alignment evaluation tools are limited to 2 dimensions. Therefore, positioning the WBCT images in a consistent orientation is important to generate correct data.

Anterior or Posterior Tibial Tendon Transfer to the Peroneus Tertius for Equinovarus Deformity.

Equinovarus deformity correction was performed by soft tissue release and bone deformity correction, and tendon transfer to maintain deformity correction. Because of the high complication rate of tendon fixation methods, partial or total anterior tibial tendon or posterior tibial tendon transfer to the peroneus tertius tendon was reported. The purpose of this study was (i) to review the results of this tendon transfer technique after release and correction of talipes equinovarus, and (ii) to analyze the complication of this technique. Between February 2017 and May 2022, 176 patients (210 feet) with equinus and/or varus foot and ankle deformities underwent anterior or posterior tibial tendon transfer to the peroneus tertius in our institute. Preoperative and postoperative foot and ankle range of motion (passive and active) were checked. The postoperative radiographic assessment included antero-posterior (AP), lateral, and hindfoot alignment radiographs. Preoperative and postoperative lateral tibio-talar, talo-calcaneal, talo-first metatarsal, tibial-sole angles, hindfoot alignment, and anterior subluxation of the talus were checked. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and visual analog scale (VAS) were used to assess pain. Paired Student's t-test was used to compare the clinical scores and radiographic angles before the operation and at the last follow-up. The mean age of the patients was 23.27 ± 13.44 years (range, 3-69 years). The mean follow-up time was 25.56 ± 16.37 months (range, 12-68 months). There were significant differences between the preoperative and postoperative measurements of the lateral tibio-talar angle, lateral talo-calcaneal angle, lateral talo-first metatarsal angle, lateral tibial-sole angle, and hindfoot alignment (p < 0.001). There was significant difference between the preoperative and postoperative AOFAS and VAS scores (p < 0.001). The early complications included infection in one patient, skin necrosis in two patients, and plantar numbness in three patients. The late complications included pin infection in three patients, tibio-talar joint compression in four patients, forefoot pain in two patients, toe flexion in two patients, and plantar numbness in one patient. There were three cases of complications (1.43%) related to the transferred tendons. Tibialis anterior or posterior tendon transfer to the peroneus tertius is a safe and effective method for equinovarus deformity correction. It yielded excellent outcomes that produced high patient satisfaction and few complications.

Hindfoot Alignment in Pediatrics: The Relationship Between Hindfoot Moment Arm and Hindfoot Alignment Angle.

Various measurements are used to evaluate hindfoot alignment and determine appropriate treatment, though the best tool is not known. Few studies have examined the relationship between these measurements in pediatric patients. This study sought to compare Hindfoot Moment Arm (HMA) and Hindfoot Alignment Angle (HAA) in evaluation of pediatric hindfoot deformity. This was a retrospective cohort study of pediatric patients by age: school-aged (7 to 10 years old), preadolescents (11 to 14), and adolescents (15 to 18). A total of 10 males and 10 females were randomly selected for each cohort from patients with available hindfoot radiographs. HMA and HAA were measured by 2 independent reviewers. Pearson correlation of HMA and HAA was performed by age cohort. Multivariable linear regression was used to investigate the association of HMA and HAA adjusting for age, sex, height, and weight. Sixty participants were analyzed. Interrater reliability was found to be excellent for HMA and HAA (ICC=0.996 and 0.992, respectively). HMA was 8.7±9.4mm in school age, 5.7±6.7 mm in preadolescents, and 2.5±13.0 mm among adolescents (P=0.153). HAA was 6.3±9.7 degrees in school age, 6.7±8.6 degrees in preadolescents, and 6.0±14.5 degrees among adolescents (P=0.983). The Pearson correlation coefficient was 0.78 (CI: 0.51-0.91) for school-aged, 0.92 (CI: 0.81-0.97) for preadolescents, and 0.86 (CI: 0.67-0.94) for adolescents. Using multivariable regression, each degree increase in HAA, increased HMA by 0.77 mm. Age, height, and weight were not found to be independent predictors of HMA. HMA and HAA were both found to be reliable measurements across all age cohorts. When comparing across age cohorts, neither HMA nor HAA differed significantly (P=0.153 and 0.983, respectively). Furthermore, Pearson correlation demonstrated a linear relationship between HMA and HAA. When evaluating hindfoot deformity, surgeons may assess hindfoot alignment via either HMA or HAA regardless of patient age. The authors support the use of HMA for clinical and academic purposes as HMA is considerably simpler to measure. Level III.

Joint Preservation Surgery Using Supramalleolar Osteotomy Combined with Posterior Tibial Tendon Release and Lateral Ligament Augmentation in Advanced Varus Ankle Arthritis.

Background: Recent studies utilizing weight-bearing computed tomography have identified abnormal internal rotation of the talus in advanced varus ankle arthritis (VAA) with a large talar tilt (TT), influenced by the posterior tibial tendon (PTT). This study aimed to evaluate the clinical and radiographic results of supramalleolar osteotomy (SMO) combined with PTT release and lateral ligament augmentation for VAA with a large TT. Methods: From January 2015 to September 2018, 15 patients with VAA and a large TT (greater than 5°) underwent SMO combined with PTT release. Clinical results, including visual analog scale (VAS) for pain, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and ankle osteoarthritis scale (AOS), were assessed. Radiographic results were assessed with various parameters, including medial distal tibial angle (MDTA), anterior distal tibial angle (ADTA), talar tilt (TT), talus center migration (TCM), Meary angle, hindfoot alignment angle (HAA), and hindfoot moment arm (HMA) on foot and ankle weight-bearing radiographs. Clinical and radiographic results were evaluated preoperatively and at the last follow-up. Results: VAS, AOFAS ankle-hindfoot score, and AOS improved significantly from 7.5, 54.4, and 72.6 preoperatively to 3.1, 82.5, and 34.5 postoperatively, respectively. All radiographic parameters exhibited significant changes postoperatively, with the exception of the Meary angle, which demonstrated no significant change. Four patients exhibited improvement in radiographic stage postoperatively; however, average radiographic stage did not significantly improve postoperatively in all patients. One patient progressed to end-stage arthritis postoperatively, necessitating additional ankle arthrodesis. Conclusions: In conclusion, lengthening and lateral ligament augmentation combined with bony realignment procedures may be a reasonable option for treating VAA with a large TT greater that 5°.

Is a Plantarflexed First Ray the Primary Deformity In Children With Cavovarus Feet Secondary to Charcot-Marie-Tooth Disease? A Pedobarographic Analysis.

Charcot-Marie-Tooth disease (CMT) is a common cause of cavovarus foot deformity in children. This deformity is often quoted as being forefoot driven, with a primary deformity of first ray plantarflexion driving the hindfoot into varus by virtue of the tripod effect of the foot, which was hypothesized by Coleman and is commonly assessed clinically using his eponymous block test. The primary goal of this study was to objectively investigate this hypothesis using dynamic pedobarography. A review of the gait lab archives at a large tertiary referral center was carried out to identify children with CMT who had foot photos and dynamic pedobarographic data. Two orthopaedic surgeons then determined the weight-bearing hindfoot alignment of these children using clinical photography. The order of contact during gait of the first metatarsal relative to the fifth metatarsal was then obtained from the dynamic pedobarographic data. One hundred eighteen feet from 60 children with CMT met the study inclusion criteria. Sixty-eight varus feet were compared with 50 nonvarus feet. First ray contact occurred before fifth ray contact in only 39.7% of the varus feet compared with 34.0% of the nonvarus feet, which did not meet statistical significance (P=0.526). In this cohort, dynamic pedobarography did not consistently demonstrate the first metatarsal contact occurring before the fifth metatarsal contact in children with varus feet secondary to CMT. While nearly 40% of the feet did make initial contact on the first ray, 60% of the feet landed in varus before the first ray made contact, leading us to believe that the foot is prepositioned in varus. This may be in part due to the progressive muscle imbalance and secondary deformity that has occurred. Surgical management of these children should take this.

Influence of the transverse tarsal arch on radiological components of progressive collapsing foot deformity.

The importance of the transverse tarsal arch (TTA) has recently been extensively reevaluated and has even been considered to play a greater role in foot stability than the medial longitudinal arch (MLA). However, the relevance of this observation in the context of common clinical foot disorders, such as progressive collapsing foot deformity (PCFD), has not yet been fully clarified. In this biomechanical study, we examined ten pairs of human cadaveric feet by serial weight-bearing cone-beam computed tomography under controlled loading using a custom-designed testing machine. The MLA and TTA were transected separately, alternating the order in two study groups. A semiautomated three-dimensional evaluation of their influence on three components of PCFD, namely collapse of the longitudinal arch (sagittal Meary's angle), hindfoot alignment (sagittal talocalcaneal angle), and forefoot abduction (axial Meary's angle), was performed. Both arches had a relevant effect on collapse of the longitudinal arch, however the effect of transecting the MLA was stronger compared to the TTA (sagittal Meary's angle, 7.4° (95%CI 3.8° to 11.0°) vs. 3.2° (95%CI 0.5° to 5.9°); p = 0.021). Both arches had an equally pronounced effect on forefoot abduction (axial Meary's angle, 4.6° (95%CI 2.0° to 7.1°) vs. 3.0° (95%CI 0.6° to 5.3°); p = 0.239). Neither arch showed a consistent effect on hindfoot alignment. In conclusion, weakness of the TTA has a decisive influence on radiological components of PCFD, but not greater than that of the MLA. Our findings contribute to a deeper understanding and further development of treatment concepts for flatfoot disorders.

Hindfoot Alignment in Flexible Cavovarus Deformity Under Orthostatic and Coleman Block Test Positions: A Weightbearing Computed Tomography Study.

Flexible cavovarus deformity is prevalent and the Coleman block test is frequently used to assess the first ray plantarflexion malpositioning in the overall deformity as well as the flexibility of the hindfoot. The objective was to assess and compare the weightbearing computed tomography (WBCT) 3-dimensional (3D) changes in clinical and bone alignment in flexible cavovarus deformity patients when performing the Coleman block test when compared to normal standing position and to controls. Twenty patients (40 feet) with flexible cavovarus deformity and 20 volunteer controls (40 feet) with normal foot alignment underwent WBCT imaging of the foot and ankle. Cavovarus patients were assessed in normal orthostatic and Coleman block test positions. Foot and ankle offset (FAO), hindfoot alignment angle (HAA), talocalcaneal angle (TCA), subtalar vertical angle (SVA) and talonavicular coverage angle (TNCA) and a CT-simulated soft tissue envelope image, WBCT clinical hindfoot alignment angle (WBCT-CHAA), were evaluated by 2 readers. Measurements were compared between cavovarus nonstressed and stressed positions and to controls. P values of .05 or less were considered significant. The intra- and interobserver intraclass correlation coefficient were good or excellent for all WBCT measurements. Cavovarus patients demonstrated significant correction of WBCT-CHAA (9.7 ± 0.4 degrees), FAO (2.6 ± 0.4%), and TNCA (8.8 ± 1.8 degrees) when performing the Coleman block test (all P values <.0001). However, WBCT-CHAA and FAO measurements were still residually deformed and significantly different from controls (P values of .001 and <.0001, respectively). TNCA values corrected to values similar to healthy controls (P = .29). No differences were observed in cavovarus patients during Coleman block test for the coronal measures: HAA, TCA, and SVA measurements. In this study, we observed improvement in the overall 3D WBCT alignment (FAO), axial plane adduction deformity (TNCA), as well as CT simulated clinical hindfoot alignment (WBCT-CHAA) in flexible cavovarus deformity patients when performing a Coleman block test. However, we did not find improvement in measures of coronal alignment of the hindfoot, indicating continued varus positioning of the hindfoot in these patients.

Electromyographic Analysis of Large Muscle Activity in Progressive Collapsing Foot Deformity.

There are various deformities described in the spectrum of Progressive Collapsing Foot Deformity (PCFD) which not only have adverse effects on the foot but also on the entire lower limb. Early lower limb muscular fatigue and pain during exertion is the most common complaint of patients with PCFD. Surface electromyography (sEMG) provides an accurate assessment of muscle activity. In this study, we aim to compare the activities of quadriceps, hamstrings, and gastrosoleus muscle groups of adult patients with PCFD with normal lower limbs and correlate the radiological parameters and functional effects of PCFD with the activities. Thirty patients with bilateral PCFD and 30 controls underwent weight-bearing anteroposterior (AP), lateral, and hindfoot alignment radiographs of the foot. Radiographic parameters of PCFD were assessed. Surface electromyography was used to assess the quadriceps, hamstrings, and gastrosoleus activities, and this was compared between the 2 groups and correlated with radiological measurements of PCFD. Tegner activity questionnaire was used to assess the functional effects of collapsed arch. Electrical activities of all muscle groups were significantly higher in cases than controls. Meary's angle and hindfoot moment arm had significant correlations with hamstring activity (P = .013) and gastrosoleus activity (P = .027), respectively. Tegner scores of cases were significantly lower than those of controls (P = .041). The PCFD causes an increase in activity of large muscles of the affected lower limb which act on joints other than those in the foot. This finding may be due to several compensatory mechanisms that counteract the deforming forces. This may be a cause for the frequent complaint, early fatigue, and hence functional impairment. However, most radiological parameters did not correlate with muscle activities and larger study size may be required for further association. Diagnostic: Level 3.

Correction of progressive collapsing foot deformity classes after isolated arthroscopic subtalar arthrodesis

IntroductionSubtalar osteoarthritis in the context of flatfoot (recently renamed Progressive Collapsing Foot Deformity (PCFD)) may be treated through subtalar joint (SJ) arthrodesis with anticipated consequences on three-dimensional bony configuration. This study investigates the correction of PCFD-related deformities achieved after Anterolateral Arthroscopic Subtalar Arthrodesis (ALAPSTA). MethodsIn this retrospective study, we evaluated pre- and post-operative (at 6 months) weight bearing computed tomography (WBCT) images of patients diagnosed with PCFD with a degenerated SJ (2 A according to PCFD classification) and/or peritalar subluxation (2D) with or without associated flexible midfoot and/or forefoot deformities (1B, 1 C and 1E) which underwent ALAPSTA as a standalone procedure between 2017 and 2020. Multiple measurements were used to assess and compare pre and post-operative PCFD classes. ResultsThirtythree PCFD (33 patients, median age 62) were included in the study. Preoperative medial facet subluxation was 28.3 % (IQR, 15.1 to 49.3 %). Overall PCFD 3D deformity improved with a reduction of the foot and ankle offset from 9.3 points (IQR, 7.8 to 12) to 4 (IQR, 0.9 to 7) (p < 0.001). Class A-hindfoot valgus (median tibiocalcaneal angle and median calcaneal moment arm improved by 9.4 degrees (p < 0.001) and 11 mm (p < 0.001), respectively), class B-midfoot abduction (median talonavicular coverage angle improved by 20.5 degrees, p < 0.001) and class C-forefoot varus (median sagittal talo-first metatarsal angle improved by 10.2 degrees (p < 0.001)) were significantly corrected after surgery. Class D was difficult to assess due to the fusion procedure. No patient had a pre-operative valgus deformity at the ankle (no class E), and no significant change of the talar tilt was observed (p = 0.12). ConclusionIn this series, ALAPSTA performed as a standalone procedure to treat patients diagnosed with PCFD with a degenerated subtalar joint and/or peritalar subluxation was effective not only at correcting hindfoot alignment but also flexible midfoot abduction and flexible forefoot varus. Level of evidenceLevel IV, case series

Do First Ray-Related Angles Change following Subtalar Arthroereisis in Pediatric Patients? A Radiographic Study.

Subtalar Arthroereisis (STA) is a surgical intervention for pediatric flexible flatfoot (PFF), primarily targeting hindfoot alignment by limiting excessive subtalar eversion. However, its effects on forefoot parameters remain underexplored. This study aims to investigate radiological changes following STA in pediatric patients. A retrospective analysis was conducted on consecutive patients treated with STA for PFF. First ray-related angles, including the Hallux Valgus Angle (HVA) and the Intermetatarsal Angle (IMA), alongside hindfoot radiological parameters such as the Meary, Calcaneal Pitch, and Costa Bartani angles, were assessed. Subgroup analysis by gender was performed, and correlations between demographic and preoperative radiological parameters were examined. Forty-one patients (81 feet) with an average age of 11.6 years were included, with a mean follow-up duration of 6.4 months. No significant differences were observed in first ray-related angles pre-and postoperatively, with the mean IMA changing from 7.97° to 7.18° and the mean HV angles changing from 9.51° to 8.66°. Noteworthy improvements were seen in flat foot angles, including the Meary, Calcaneal Pitch, and Costa Bartani angles, postoperatively. The age subgroup analysis revealed similar trends in IMA and HVA changes between Group A (who underwent surgery before peak growth) and Group B (who underwent surgery after peak growth). Higher preoperative angles tended to improve, while lower preoperative IMAs and HVAs tended to worsen postoperatively, all remaining within normal ranges. STA showed positive radiological outcomes for PFF treatment, while negligible changes in first ray-related angles were observed. The age subgroup analysis indicated similar trends regardless of operation timing. Higher preoperative angles tended to improve, while lower preoperative angles tended to worsen postoperatively, despite all falling within non-pathological ranges. Further research is warranted to confirm this correlation.

The amount of femorotibial alignment correction through total knee arthroplasty may affect postoperative hindfoot alignment.

This study was performed to investigate the relationship between the amount of femorotibial alignment correction and the amount of improvement of hindfoot alignment in total knee arthroplasty (TKA). A total of 159 knees undergoing TKA in 120 patients were assessed preoperatively and at 2 weeks, 1 month, 3 monthsand 6 months postoperatively. Standing hindfoot alignment was evaluated using the leg-heel angle (LHA). The amount of change in hindfoot alignment was compared between patients with severe varus knee (Group 1) and those with moderate varus, neutralor valgus knee (Group 2). The mean values of pre- and postoperative hip-knee-ankle (HKA) angle were -14 ± 4° and -1 ± 3° in Group 1 and -7 ± 5° and -1 ± 3° in Group 2, respectively. The differences between pre- and postoperative LHA were significantly larger in Group 1 than in Group 2 at 2 weeks, 1 monthand 3 months postoperatively (p = 0.006, 0.001and 0.03, respectively). At 6 months postoperatively, no differences were observed between the two groups (p = 0.31). The amount of change in hindfoot alignment was larger in Group 1 than in Group 2 at 2 weeks, 1 monthand 3 months after TKA, but there was no significant difference between the two groups at 6 months after TKA. Prognostic Level II.

Patient-specific modelling of contact characteristics in the ankle joint following triple arthrodesis in valgus, neutral and varus hindfoot positions

The aim of the current study was to understand the importance of the joint alignment following triple arthrodesis by analysing the contact characteristics in a normal and arthritic ankle joint using a patient-specific numerical model developed using open source software. The alignment of the hindfoot with respect to tibia is calculated from CT scans and the ankle joint model was numerically analysed for neutral, valgus and varus positions in both normal and arthritic conditions. The contact area, the magnitude and distribution of the contact pressure on the articular surface of the talar dome was evaluated using a cell-centred Finite Volume Method implemented in open-source software OpenFOAM. It was found that all positions of the hindfoot predict higher lateral pressures during heel strike. The varus position predicts the maximum increase in lateral pressures. Comparing the valgus and neutral positions, although the neutral position predicts 9.1 % higher increase in lateral pressures during heel strike than valgus, it predicts 33.6 % decrease in pressures during heel-rise and the distribution is more medial during toe-off. In the case of arthritic ankle, it could be observed that the neutral and varus hindfoot fusion positions result in a concentrated increase of lateral pressures in heel strike and flat-foot. In the case of toe-off, the neutral alignment results in an increase of 62.3 % in the contact pressures compared to the arthritic pressure of the unfused foot and is 20.8 % higher than the valgus alignment. The study helps to conclude that the fusion is more beneficial at the neutral position of the hindfoot for the patient specific ankle. However, the 5° valgus position of hindfoot alignment could be more beneficial in the arthritic ankle. Patient-specific approach to the placement of the hindfoot with the help of numerical analysis could help address the issue of ankle degradation following arthrodesis.

Hindfoot Alignment Change after High Tibial Valgization Osteotomy in a Patient with an Ipsilateral Fused Ankle: A Case Report

Hindfoot Alignment Change after High Tibial Valgization Osteotomy in a Patient with an Ipsilateral Fused Ankle: A Case Report

Varus knee osteoarthritis with ankle osteoarthritis demonstrates greater hindfoot inversion and larger ankle inversion loading during gait following total knee arthroplasty compared to varus knee osteoarthritis alone.

Although patients with varus knee osteoarthritis (KOA) and concurrent ankle osteoarthritis (AOA) may experience increased ankle joint pain after total knee arthroplasty (TKA), the underlying mechanism remains unclear. This study aimed to investigate the effects of concurrent AOA on ankle and hindfoot alignment, frontal plane ankle and hindfoot biomechanics during gait following TKA and the clinical outcomes. Twenty-four patients with varus KOA who underwent TKA were included in this retrospective cohort study. Patients were categorized into two groups: with and without AOA. Radiographic evaluations of lower-limb, ankle and hindfoot alignment, and knee and ankle clinical outcomes were conducted preoperatively and 6 months postoperatively. In addition, gait analyses were performed to investigate knee, ankle and hindfoot kinematics and kinetics. Each data was compared between patients with and without AOA. Concomitant AOA was found in eight ankles. The AOA group exhibited greater postoperative hindfoot varus and increased postoperative ankle pain than the non-AOA group. Gait analysis showed no significant differences in knee varus alignment or tibial tilt after TKA between the groups. However, the AOA group demonstrated significantly greater hindfoot inversion and larger ankle inversion loading. One third of patients who underwent TKA had concurrent AOA associated with hindfoot varus. Despite achieving proper coronal knee alignment postoperatively, these patients experienced greater hindfoot and ankle joint inversion load during gait. Surgeons should consider the inability to evert the hindfoot and the possibility of increased ankle joint pain when planning and performing TKA. Level III.

MULLER-WEISS DISEASE: PROPOSED CLASSIFICATION AND TREATMENT ALGORITHM

Muller-Weiss disease is an uncommon condition with unclear etiology and no gold standard treatment. The question arises; which joints to fuse? Although no consensuses prevail, one must postulate fusion should include those affected. Consequently, to establish an algorithm for its surgical management we set out to study clinical and radiographic features with use of SPECT-CT and a literature review.57 consecutive feet presenting with Muller-Weiss disease analysed; 15 men, 25 women, age 22–84. Condition bilateral in 17, left side 16, right in 7 patients. Specific history and examination by senior author. Radiographic series and SPECT-CT obtained with surgery performed on significantly symptomatic feet. Measurements of Meary-Tomeno angles, anteroposterior thickness of navicular at the midpoint of each naviculo-cuneiform, alongside the medial extrusion distance and percentage of compression in each case performed. Poor correlation between Meary's angle and 1) degree of compression at naviculo-cuneiform joints, 2) degree of extrusion 3) compression vs extrusion using R2 coefficient of determination (invalidating Maceira et al. classification). In unilateral cases, extrusion significantly greater on affected side 94.7% (P&lt; 0.001 Fisher exact test). Degree of extrusion significantly greater in bilateral than unilateral cases (p=0.004 unpaired T test). Valgus hindfoot and Meary's negative most common pattern with no correlation between heel alignment and Meary's R2 = 0.003. SPECT-CT useful to determine subtalar involvement in ‘stage 2 disease.’Following review of cases and published literature we propose the following classification for Muller-Weiss disease with treatment algorithm. 3 Stage delineation; Stage 1 (Normal hindfoot alignment); 1A. Talonavicular disease only - Isolated Talonavicular arthrodesis 1B. Talonavicular + Subtalar; double medial or triple arthrodesis. Stage 2. Talonavicular + Naviculocuneiform; 2A. Adequate bone stock - Talo-naviculo-cuneiform arthrodesis, 2B. Inadequate bone stock +- subtalar disease; Talo-naviculo-cuneiform arthrodesis with tricortical bone graft (Mayich). Stage 3; Asymmetric ankle varus. Pantalar arthrodesis Double/triple/TNC/TAR arthrodesis with hindfoot re-alignment.

Biomechanical Effects of Hindfoot Alignment in Supination External Rotation Malleolar Fractures: A Human Cadaveric Model.

Pressure distribution in the ankle joint is known to be dependent on various factors, including hindfoot alignment. We seek to evaluate how hindfoot alignment affects contact pressures in the ankle joint in the setting of supination external rotation (SER) type ankle fractures. SER fractures were created in 10 human cadaver lower extremity specimens, simulating progressive stages of injury: without fracture (step 0), SER fracture and intact deltoid ligament (step 1), superficial deltoid ligament disruption (step 2), and deep deltoid ligament disruption (step 3). At each step, varus and valgus alignment was simulated by displacing the calcaneal tuberosity 7 mm medial or lateral. Each limb was axially loaded following each osteotomy at a static load of 350 N. The center of force (COF), contact area (CA), and peak contact pressure (PP) under load were measured, and radiographs of the ankle mortise were taken to analyze the medial clear space (MCS) and talar tilt (TT). The COF (5.3 mm, P = .030) and the CA (-188.4 mm2, P = .015) changed in step 3 in the valgus hindfoot alignment compared to baseline parameters, indicating the importance of deep deltoid ligament integrity in maintaining normal ankle joint contact stress in the valgus hindfoot. These changes were not seen in the setting of varus alignment (COF: 2.3 mm, P = .059; CA -121 mm2, P = .133). PP were found to not change significantly in either varus or valgus (varus: -4.9 N, P = .132; valgus: -4 N, P = .464).The MCS demonstrated widening in step 3 compared to step 2 (0.7 mm, P = .020) in both varus and valgus hindfoot. The TT increased significantly in step 3 in the valgus hindfoot (2.8 degrees, P = .020) compared to step 0. SER-IV fractures with valgus hindfoot alignment showed significant changes in pressure distribution and radiographic parameters when compared to SER-IV fractures with varus hindfoot alignment. Based on this cadaver modeling study, patients with SERIV fracture with varus hindfoot alignment and complete deltoid ligament lesion may not need fracture fixation, whereas those with valgus hindfoot alignment likely need fracture fixation.

Enhancing precision in osteochondral lesions of the talus measurements and improving agreement in surgical decision-making using weight-bearing computed tomography and distance mapping.

Weight-bearing computed tomography (WBCT) enables the creation of a three-dimensional (3D) model that represents the ankle morphology in a standing position. Distance mapping (DM) is a complementary feature that uses color coding to represent the relative intraarticular distance and can be used to outline intraarticular defects. Consequently, DM offers a novel approach to delineating osteochondral lesions of the talus (OLT), allowing for the quantification of its surface, volumeand depth. The reliability of DM for OLT measurements has yet to be thoroughly evaluated. This study primarily aims to determine the reliability of DM in measuring the surface, depthand volume of OLT. A secondary objective is to ascertain whether measurements obtained through DM, when integrated with a predefined treatment algorithm, can facilitate consensus among surgeons regarding the optimal surgical intervention. This cohort comprised 36 patients with 40 OLTs evaluated using WBCT and DM. Two raters used DM to determine the lesion boundary (LB) and lesion fundus (LF) and calculate the lesion depth, surfaceand volume. The raters were asked to choose between bone marrow stimulation, autologous matrix-induced chondrogenesisand osteochondral transposition based on the measurement. Inter-rater and intra-rater agreement was measured. Interclass correlation of the lesion's depth surface produced an excellent inter-rater and intra-rater agreement of 0.90-0.94 p < 0.001. Cohen's κ agreement analysis of the preferable preoperative plan produced a κ = 0.834, p < 0.001, indicating a near-perfect agreement. WBCT-based 3D modules and DM can be used to measure the lesion'ssurface, depth and volume with excellent inter-rater and inter-rater agreement; using this measurement and a predetermined treatment algorithm, a near-perfect inter-rater agreement for the preoperative planning was reached. WBCT in conjunction with AI capabilities could help determine the type of surgery needed preoperatively, evaluate the hindfoot alignmentand assess if additional surgeries are needed. Level III.

Criteria for surgical decision-making in talocalcaneal tarsal coalitions

Assessment and management of talocalcaneal middle facet tarsal coalitions present a complex orthopedic challenge. Various studies have attempted to establish guidelines for surgical intervention based on coalition size and hindfoot alignment. Our paper reviews the historical focus on coalition size, suggesting instead that posterior facet health is a more appropriate consideration for surgical decision making. Additionally, we challenge the traditional method for evaluating hindfoot alignment and propose a more accurate evaluation method. This critical review intends to highlight flaws in historical literature, aiming to trigger a reevaluation of the criteria for surgical intervention in talocalcaneal tarsal coalitions and promote future research studies driven by data and scientifically validated methodologies. Level of evidenceV

Getting the Hindfoot Alignment and Starting Point Correct: A Technique Tip for Accurate Placement of Hindfoot Fusion Nails.

Getting the Hindfoot Alignment and Starting Point Correct: A Technique Tip for Accurate Placement of Hindfoot Fusion Nails.

Reaming for Tibiotalocalcaneal Nailing Removes Only 10% of the Ankle and Subtalar Joints.

Tibiotalocalcaneal (TTC) nailing in the setting of acute ankle trauma has become increasingly popular. No consensus exists as to whether formal joint preparation is necessary, although there is some concern that residual motion at unprepared joints may lead to implant loosening and/or breakage. The objective of this study was to quantify the proportion of tibiotalar and subtalar articular surface destruction that occurs during reaming for TTC nail fixation. Twelve cadaver lower extremities were procured. The specimens were pinned into neutral ankle and hindfoot alignment. A guidewire was inserted under fluoroscopy, followed by a 12-mm opening reamer. The specimens were then dissected, exposing the tibial plafond, talar dome, posterior facet of the talus, and posterior facet of the calcaneus. Images of each joint were obtained, and ImageJ software was used to calculate the total joint surface area and the area of articular destruction. The mean proportion of articular cartilage destruction was 9.3%, 10.3%, 8.9%, and 10.3% for the tibial plafond, talar dome, posterior facets of the talus, and posterior facets of the calcaneus, respectively. No joint destruction was observed in the middle facets of the subtalar joint. Reaming for TTC nail placement violates approximately 10% of each articular surface of the tibiotalar and subtalar joints. Retention of 90% of the articular surface may allow for residual motion at the joints and therefore potentially substantial stress on the implant. Formal joint preparation for the purposes of achieving fusion during TTC nail placement may be beneficial to prevent implant loosening or breakage.