Lateral Talocalcaneal Angle Research Articles

Calcaneocuboid Distraction Arthrodesis and First Metatarsocuneiform Arthrodesis for Correction of Acquired Flatfoot Deformity in a Cadaver Model

Lateral column lengthening has been associated with residual forefoot supination and symptomatic lateral overload in treatment of acquired flatfoot. A medial column procedure may be useful to redistribute load to the medial column. We evaluated radiographic and pressure changes in a severe flatfoot model with lateral column lengthening and investigated the effect of an added first metatarsocuneiform arthrodesis. Ten cadaver specimens were loaded in simulated double-legged stance, and radiographic and pressure data were collected for all tested states. Calcaneocuboid arthrodesis was done with a 10-mm foam wedge. Residual forefoot varus was corrected through the first metatarsocuneiform joint. Differences in the mean lateral talar-first metatarsal angle, talonavicular angle, talocalcaneal angle, and calcaneal pitch were significant between the intact foot and the flatfoot. After calcaneocuboid distraction arthrodesis and tendon transfer, the lateral talar-first metatarsal angle, talonavicular angle, and calcaneal pitch were significantly different from the flatfoot. After added first metatarsocuneiform arthrodesis, the talonavicular angle was not significantly different from the intact foot. Lateral forefoot pressure increased in the flatfoot after lateral column lengthening but was not significantly different from the intact foot after first metarsocuneiform arthrodesis was added. Adding first metatarsocuneiform arthrodesis to calcaneocuboid distraction arthrodesis for treatment of flatfoot deformity provided improvement in radiographic and pedobarographic parameters of a severe model of stage II posterior tibial tendon dysfunction.

The use of Standing Lateral Tibial-Calcaneal Angle as a Quantitative Measurement of Achilles Tendon Contracture in Adult Acquired Flatfoot

To quantitate the association of Achilles tendon contracture (ATC) with adult acquired flatfoot, the authors hypothesized that the standing lateral tibial-calcaneal angle increases because of ATC. The standing lateral tibial-calcaneal angle, talo-first metatarsal angle, lateral talocalcaneal angle, lateral standing medial cuneiform, arch height, and anteroposterior talonavicular coverage angle were measured in 21 patients (25 feet) with clinical diagnoses of ATC and adult acquired flatfoot (AAF) and compared to the same measurements in a control group of 15 patients (30 feet) with no foot deformities or previous foot surgeries. The mean lateral tibial-calcaneal angle in the control group was 64.43 degrees and in the AAF group 71.24 degrees (p < 0.001). The mean lateral talo-first metatarsal angle in the control group was 11.77 degrees, and in the AAF group with ATC it was 25.80 degrees (p < 0.001). The mean arch height in the control group was 17.90 mm and in the AAF group, 8.48 mm (p < 0.001). In the ATC and AAF group an increasing standing lateral tibial-calcaneal angle was correlated with a decreasing lateral talo-calcaneal angle (p = 0.044), and a decreasing arch height was correlated to an increasing lateral talo-first metatarsal angle (p < 0.001). Adults with flatfeet and Achilles tendon contracture may have a statistically significant increase in the standing lateral tibial-calcaneal angle. This angle may be a reproducible measure of ATC. An increase in the standing lateral tibial-calcaneal angle may confirm and quantitate the clinical diagnosis of Achilles tendon contracture. Further studies with more patients are needed.

Arthrodesis of the Subtalar and Talonavicular Joints for Correction of Symptomatic Hindfoot Malalignment

Triple arthrodesis has long been used for the treatment of painful malalignment or arthritis of the hindfoot. However, the effect of fusion on adjacent joints has sparked interest in a more limited arthrodesis in patients without involvement of the calcaneocuboid joint. Results of 16 feet in 14 patients who had a modified double arthrodesis for symptomatic flatfoot, cavovarus deformity, or hindfoot arthritis were reviewed retrospectively with a minimum followup of 18 (range 18 to 93) months. The most common diagnosis contributing to the hindfoot deformity was pes planovalgus. All operations were done with a consistent technique using rigid internal fixation with screws. In 15 feet, a concomitant gastrocnemius recession for equinus contracture was done at the time of the primary surgery. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale in addition to subjective assessments of pain, function, shoewear, cosmesis, and overall satisfaction. Radiographic evaluation included measurements of the anterior-posterior talo-second metatarsal angle, lateral talocalcaneal angle, and lateral talo-first metatarsal angle, and notation of arthritic changes of the ankle, calcaneocuboid, and midfoot joints, as well as an assessment of time to union of all arthrodeses. The average AOFAS Ankle-Hindfoot Scale improved from 44.7 preoperatively to 77.0 postoperatively (p < 0.01). Subjectively, patients experienced improvements in pain, function, cosmesis, and shoewear. Overall, all patients were satisfied and would have the procedure again under similar circumstances. Radiographically, all parameters statistically improved. There was an increase in arthritic scores for six ankle, six calcaneocuboid, and five midfoot joints. One talonavicular joint nonunion occurred in a rheumatoid patient, requiring revision arthrodesis. We have concluded that simultaneous arthrodesis of the talonavicular and subtalar joints is a reasonable treatment in the subset of patients with symptomatic hindfoot malalignment whose calcaneocuboid joints are not involved in the primary disease.

Frühe Ergebnisse der Ponseti-Methode zur Behandlung des idiopathischen Klumpfußes

The Ponseti method for the treatment of congenital clubfeet has been propagated due to the sometimes disappointing functional results after surgical treatment. The aim of our study was to evaluate our early results and experiences with the Ponseti method. Between December 2002 and December 2004 a total of 87 clubfeet in 59 patients were treated using the Ponseti method at our department. Only patients in whom treatment was initiated within the first three weeks of life were included in this study. Rate of successful correction without open release surgery, radiological findings, classification according to Pirani at the time of the last follow up, recurrence rate and duration of treatment were defined as outcome measures for this prospective study. Fifty-nine cases in 37 patients met the inclusion criteria. Ninety-three percent of all cases (55 feet) were corrected without open surgery. The mean duration of active treatment was 11.4 weeks (8-20 weeks). The mean tibiocalcaneal angle 3-4 weeks after the percutaneous tenotomy of the Achilles tendon was 69 degrees, the mean a.-p.-talocalcaneal angle measured 33 degrees and the lateral talocalcaneal angle 36 degrees. A recurrence was seen in one patient with bilateral clubfeet (3.6 %). Open release surgery can be averted in most cases of idiopathic clubfoot using the Ponseti method. Scarring of the soft tissue and especially of the joint capsule can thereby be avoided.

Ergebnisse der operativen Behandlung des idiopathischen Klumpfußes unter Verwendung eines dorsomedialen Zuganges mit Weichteilpräparation „à la carte”

Several concepts have been published for therapy of idiopathic clubfoot. Actually the Cincinnati approach is the "gold-standard" in operative treatment of idiopathic clubfoot. Using this approach delayed wound healing and overcorrection are wellknown complications. During the last 30 years a dorsomedial approach is used in operative treatment of idiopathic clubfoot in our clinic. Using this approach a dorsal, medial and/or lateral release can be performed. Postoperatively a plaster cast is used. The following years a rigid therapy with orthosis and support is requested. Between June 1986 and December 2000 130 clubfoot operations with soft tissue release were performed. 119/130 (91 %) patients could be clinically and radiologically followed-up after a mean of 4.5 years (min: 2, max: 17) including 65.5 % male and 34.5 % female patients. Average age at time of operation was 7.6 months. The findings were classified according to Dimeglio. To evaluate the clinical results the score according to Laaveg and Ponseti was used. X-rays with load (a. p. and lateral view) were evaluated preoperatively and at follow-up for a. p. and lateral talocalcaneal angle, talometatarsal-I-angle, calcaneometatarsal-V-angle and the angle of the first ray. Additionally complications and recurrences were documented. 21.8 % of the feet were classified IV degrees , 39.5 % III degrees and 38.7 % II degrees according to Dimeglio. Recurrent clubfoot was found in 7.6 % of all cases. All angles showed a significant improve. At latest follow-up 95.6 +/- 9.2 points according to the score of Laaveg and Ponseti were achieved. Flat top talus was found in 37 cases. The dorsomedial approach allows an excellent correction of clubfeet with a low rate of complications and recurrences in comparison to other studies.

Reconstruction of the pediatric flexible planovalgus foot by using an Evans calcaneal osteotomy and augmentative medial split tibialis anterior tendon transfer

Seventeen consecutive pediatric patients (34 feet) underwent reconstruction of flexible pes planovalgus deformity between 1994 and 1999. The average follow-up was 24.9 months (range, 8 to 48 months). All patients underwent a medial split tibialis anterior tendon transfer/tenodesis in combination with an Evans calcaneal-lengthening osteotomy, Kidner or modified Kidner procedure, and tendo-Achilles lengthening. Various angular parameters were measured both preoperatively and postoperatively, and improvement in each was noted. The calcaneal pitch improved by an average of 26° (85.88%), the lateral talometatarsal angle improved by an average of 26.4° (96.15%), the lateral talocalcaneal angle improved by an average of 14.8° (34.26%), the anteroposterior talometatarsal angle improved by an average of 21.9° (81.92%), the anteroposterior talocalcaneal angle improved by an average of 15.9° (37.95%), the cuboid abduction angle improved by an average of 13.8° (87.34%), and the talonavicular coverage angle improved by an average of 26.7° (94.68%). Postoperative improvement of all angular measurements was statistically significant at the 95% confidence level ( P = .05). In addition, American Orthopedic Foot and Ankle Society hindfoot/ankle scoring was performed preoperatively, 3 months after the second foot surgery, and at the time of maximal follow-up. A preoperative average score of 68.59 improved to 85.76 at 3 months after the second foot surgery, and improved to 96.55 at the time of the last follow-up. All 17 patients were satisfied with their surgical result because all returned for correction of the contralateral foot. All patients indicated a uniform willingness to have these procedures performed again. (The Journal of Foot & Ankle Surgery 42(4):199-207, 2003)

Biomechanical analysis of Maxwell-Brancheau arthroereisis implants

The Maxwell-Brancheau arthroereisis (MBA) implant is currently used in treating flexible flatfoot deformities in children and adults. However, no guidelines have been established to determine the degree of correction with the five different MBA implant sizes (6-, 8-, 9-, 10-, and 12-mm diameters). A biomechanical analysis of these implants was performed in fresh-frozen cadaver limbs to quantitate the effects on subtalar joint (STJ) motion restriction and radiographic angles. This study found a restriction of subtalar joint range of motion that ranged from 32.0 +/- 5.4%, 44.8 +/- 7.7%, 59.0 +/- 7.2%, 65.5 +/- 8.7%, and 76.8 +/- 7.6% restriction with successively larger sized implants respectively (p < .001). Repeated measures analysis of variance (ANOVA) revealed alterations in the first intermetatarsal, lateral talo-first metatarsal, talar declination, calcaneal inclination, and first metatarsal declination angles with successively larger implant use. Analysis of the dorsal talo-first metatarsal, talo-second metatarsal, lateral talocalcaneal angles, and first to fifth metatarsal head splay showed no changes as implant size was altered. The study also attempted to assess the effects on the tendo Achillis when the subtalar joint was changed from a pronated to a supinated position. The observations showed a 6.33 +/- 1.40% (p = .001) increase in tendon length which suggests increased tension to the tendon. These findings can aid the surgeon in selection of the MBA implant size based on the desired amount of subtalar joint motion restriction. In turn, this may reduce errors in the correction of flexible flatfoot with the MBA implant.

Single Stage Surgical Correction of Congenital Vertical Talus by Complete Subtalar Release and Peritalar Reduction by Using the Cincinnati Incision*

Seventeen feet of 12 patients with congenital vertical talus, which were treated with a single-stage surgical correction of complete subtalar release and peritalar reduction by using the Cincinnati incision, were reviewed. Five of the feet were associated with neuromuscular disorders, four with neural tube defects, and eight were idiopathic. All patients were operated on by the same surgeon and all were available for clinical and radiographic follow-up averaging 42.9 months (range 19-81) from the time of surgery. There were no wound complications or avascular necrosis of the talus. None required subsequent reoperation. At final follow-up, results were based on clinical and radiographic outcomes and included five excellent, eight good, two fair, and two poor. All families were satisfied with the results and appearance of the feet. Radiographically, there was a significant improvement in the anteroposterior and lateral talocalcaneal and talo-first metatarsal angles, and at follow-up, the group averages for each of these angles were within the normal ranges. In the treatment of congenital vertical talus, good clinical and radiographic outcomes can be obtained, with a low incidence of complications, using this single-stage surgical correction procedure.

Talo-Calcaneal Relationship in Clubfoot

Talo-calcaneal angles were measured on anteroposterior, stress dorsiflexion, and plantarflexion lateral radiographs of 75 normal feet and 145 clubfeet. The talus and calcaneum from 15 normal fetal limbs were dissected without disturbing the subtalar capsule. Anteroposterior and lateral radiographs of these specimens were also obtained. The long axes of the ossific nuclei and the long axes of the cartilaginous anlagen of the bones were marked, and the talo-calcaneal angles were measured. The talo-calcaneal angles were lower in clubfeet than in normal feet, but there was considerable overlap in the ranges of normal and clubfeet for all the angles measured. The lateral talo-calcaneal angles in normal feet were higher in dorsiflexion than in plantarflexion, whereas the converse was true in clubfeet. The talo-calcaneal angles measured from the axes of the ossific nuclei of the fetal specimens were higher than those measured from the axes of the cartilaginous anlagen. Using logistic regression analysis, a mathematical model was made to predict the probability of correction of clubfeet. A lateral talo-calcaneal angle difference (between the stress dorsiflexion and plantarflexion angles) of 20 degrees suggests that there is a 93% probability that the hindfoot deformity of clubfoot has been adequately corrected. A talo-calcaneal angle of 30 degrees or a talo-calcaneal index of 40 degrees does not ensure correction of clubfoot. A decrease of the talo-calcaneal angle by up to 10 degrees occurs as the child grows because of the alteration of the shape of the ossific nucleus of the talus that occurs normally with growth.

Talo-calcaneal relationship in clubfoot.

Talo-calcaneal angles were measured on anteroposterior, stress dorsiflexion, and plantarflexion lateral radiographs of 75 normal feet and 145 clubfeet. The talus and calcaneum from 15 normal fetal limbs were dissected without disturbing the subtalar capsule. Anteroposterior and lateral radiographs of these specimens were also obtained. The long axes of the ossific nuclei and the long axes of the cartilaginous anlagen of the bones were marked, and the talo-calcaneal angles were measured. The talo-calcaneal angles were lower in clubfeet than in normal feet, but there was considerable overlap in the ranges of normal and clubfeet for all the angles measured. The lateral talo-calcaneal angles in normal feet were higher in dorsiflexion than in plantarflexion, whereas the converse was true in clubfeet. The talo-calcaneal angles measured from the axes of the ossific nuclei of the fetal specimens were higher than those measured from the axes of the cartilaginous anlagen. Using logistic regression analysis, a mathematical model was made to predict the probability of correction of clubfeet. A lateral talo-calcaneal angle difference (between the stress dorsiflexion and plantarflexion angles) of 20 degrees suggests that there is a 93% probability that the hindfoot deformity of clubfoot has been adequately corrected. A talo-calcaneal angle of 30 degrees or a talo-calcaneal index of 40 degrees does not ensure correction of clubfoot. A decrease of the talo-calcaneal angle by up to 10 degrees occurs as the child grows because of the alteration of the shape of the ossific nucleus of the talus that occurs normally with growth.

Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency.

The surgical treatment of flexible pes planovalgus deformities resulting from Stage 2 posterior tibial tendon insufficiency is controversial and many techniques have been proposed. We retrospectively reviewed the results of subtalar arthrodesis combined with spring ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular. There were sixteen patients (seventeen feet) with an average follow-up of 27 months (9-52). All deformities were passively correctable. The average age was 56 yrs (39-78). All patients had failed conservative management, 88% had previously been treated with orthotics, and 53% had lateral pain from subfibular impingement. Two patients were noted to have degenerative changes of the subtalar joint. Successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5-24). The average AOFAS hindfoot score and Maryland foot score postoperatively was 82 and 86 respectively. Standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6 degrees (24 degrees preoperative, 18 degrees postoperative). The talonavicular coverage angle improved an average of 17 degrees (34 degrees preoperative, 17 degrees postoperative). The lateral talo-1st metatarsal angle improved an average of 10 degrees (18 degrees preoperative, 8 degrees postoperative). The lateral talocalcaneal angle decreased an average of 21o (55 degrees preoperative, 34 degrees postoperative). The distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively (avg. improvement 6mm). The combination of the flexor digitorum longus tendon transfer and spring ligament repair with subtalar arthrodesis is an effective and reliable procedure which provides excellent correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the longitudinal arch. These results compare favorably with flexor transfer combined with either calcaneal osteotomy or lateral column lengthening.

The natural history and longitudinal study of the surgically corrected clubfoot

Surgical treatment for clubfoot has been largely directed at finding the best one-stage operation for the resistant clubfoot. Eighteen patients with 27 clubfeet (average follow-up 11 years since first surgery; range, 3.5-24 years) were reviewed. More than one clubfoot operation was required in 56% of cases. Forty-six percent were corrected after one surgery; 33% required a second surgery and 14% required a third operation. One patient with particularly severe feet required a fourth operation on each foot. The mean age at the time of surgery was 1.26 years, 5.12 years, and 8 years for the first, second, and third operations, respectively. The first operation consisted of a soft-tissue release. The second and third operations consisted of more extensive soft-tissue release and various rearfoot and forefoot procedures. Radiographic values revealed an AP talocalcaneal angle of 18 degrees, AP talo-first metatarsal angle of 6 degrees, lateral talocalcaneal angle of 29.6 degrees, lateral talo-first metatarsal angle of 15 degrees, and calcaneo-first metatarsal angle of 143 degrees. At follow-up all patients had adequate function as determined by personal interview and clinical examination. We conclude that correction of resistant congenital clubfoot often requires more than one surgery, not because of a "failed first operation," but due to dynamic muscle imbalances that may not be fully recognized in infancy and early childhood. Thus, the need for a second operation should not be perceived as a failure of the first, but as part of the natural history of congenital clubfoot.

Combination of Evans calcaneal osteotomy and STA-Peg arthroreisis for correction of the severe pes valgo planus deformity

Twenty patients with 25 symptomatic severe flexible pes valgo planus were treated with a combined surgical technique. All patients underwent an Evans calcaneal osteotomy with allogenic bone graft and subtalar joint arthroreisis (STA-Peg) procedure. Adjunctive procedures as deemed necessary included Achilles tendon lengthening, navicular-cuneiform fusion, Lapidus first metatarsal cuneiform fusion, Cotton medial cuneiform plantarflexory wedge osteotomy with allogenic bone graft, plantarflexory medial cuneiform osteotomy, and excision of os tibiale externum. A retrospective pre- and postoperative radiographic evaluation revealed the following mean changes: lateral talo-first metatarsal angle, 16.9 degrees to -0.6 degrees; calcaneal cuboid abduction angle, 24.8 degrees-2.8 degrees; anterior posterior talocalcaneal angle, 25.3 degrees-15.4 degrees; talonavicular coverage angle, 22.7 degrees-5.2 degrees; calcaneal inclination angle, 10.6 degrees-18.6 degrees; talar declination angle, 32.4 degrees-16.4 degrees; lateral talocalcaneal angle, 18.3 degrees-5.2 degrees. A subjective questionnaire revealed that 100% of the patients stated they were satisfied or very satisfied with the surgery and achieved an average score of 93 based on a 100-point scale.

Triple arthrodesis in adults using rigid internal fixation: an assessment of outcome.

The intermediate outcome of patients who underwent a triple arthrodesis for the treatment of adult foot disorders was evaluated with an outcome tool to determine if their pain and functional status were improved. We evaluated 63 feet in 57 patients who underwent a triple arthrodesis using rigid internal fixation for the treatment of hindfoot deformities associated with symptomatic arthrosis. Twenty-four men and thirty-three women, with an average age of 54 years, were evaluated. The average follow-up was 30 months. Multiple diagnoses contributed to hindfoot deformities with secondary arthrosis. Iliac crest bone graft was used in 56 of 63 cases (89%). Percutaneous heel cord lengthening was done in 53 of 63 cases (84%). Twenty-four of the thirty patients (80%) returned to work. Twenty-five patients were retired and two were unemployed before surgery. All patients except two (97%) were satisfied with the surgery and would have the surgery again. The average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot preoperative score was 28 points, and the average postoperative score was 81 points (P < 0.0001). In the radiographic measurements, there was an average improvement of 12 degrees in the lateral talometatarsal angle, 7 degrees in the lateral talocalcaneal angle, and 10 degrees in the AP talometatarsal angle (P < 0.0001). Complications experienced included two varus malunions, two valgus malunions, two nonunions, two deep vein thromboses, one distal fibula stress fracture, and one wound infection. Of the 26 feet in 22 patients with mortise views available, 10 feet (38%) had evidence of ankle arthrosis and 19 feet (73%) had some degree of talar tilt postoperatively.

Radiographic evaluation of weight-bearing orthotics and their effect on flexible pes planus

Objective: To determine whether any positive change in the alignment of the bones of the feet occur with the use of custom-made flexible orthotics, cast by weight bearing, in individuals having flexible pes planus. Methods: Anteroposterior and lateral radiographs were obtained with and without orthotics in place. The anteroposterior and lateral talocalcaneal angles and the lateral pitch of both the left and right foot were assessed. Results: The t test values and P values derived from the radiographic measurements indicated statistically significant improvements in weight-bearing foot alignment. Discussion: Biomechanical faults in the pedal foundation can adversely affect any of the joints and structures of the foot/ankle complex, lower extremities, pelvis, and spine. Conclusion: This study supports the use of a custom-made flexible orthotic for the improvement of pedal structural alignment. (J Manipulative Physiol Ther 1999;22:221–6)

Single-stage surgical correction of congenital vertical talus.

Forty-one patients (55 feet) with congenital vertical talus (CVT) were reviewed. Thirty of the feet were associated with neural tube defects, 10 with neuromuscular disorders, five with congenital malformation syndromes, and none with chromosomal aberrations. Ten of the feet were idiopathic. All were treated with a single-stage surgical correction as described, by using the Cincinnati incision, and performed by the same surgeon. Thirty-two patients (42 feet) were available for clinical and radiographic follow-up averaging 7 years (range, 2-12) from the time of surgery. There were no wound complications or avascular necrosis of the talus. In 10 feet, subsequent reoperation was necessary. At final follow-up, results were based on the clinical and radiographic outcomes and included 31 good and 11 fair. All patients and families were satisfied with the results and appearance of the feet. There were no bony prominences or skin problems. The presence of mild pain was noted in only three feet. Radiographically, there was a significant improvement in the anteroposterior (AP) and lateral talocalcaneal and talo-first metatarsal angles, and at follow-up, the group averages for each of these angles were within the normal range. In treating CVT, good clinical and radiographic results can be obtained with a low incidence of complications using this single-stage surgical correction of the hindfoot and midfoot deformities.

Local Bone-Graft Technique for Subtalar Extraarticular Arthrodesis in Cerebral Palsy

A modification of the subtalar extraarticular arthrodesis is described in which local bone graft from the calcaneus and talus is used with internal fixation to obtain fusion. Twenty-eight patients with cerebral palsy underwent 52 local bone-graft subtalar arthrodeses to correct valgus deformity of the hindfoot at an average age of 7 years 5 months. The preoperative lateral talocalcaneal angle averaged 44.5 degrees, with the intraoperative and postoperative angles being 35 and 33.5 degrees, respectively. These postoperative figures were significantly different from the preoperative films and remained stable over the average 41-month follow-up period. Six feet did not have radiographic union, yet only two lost correction requiring repeated surgery. Thus 88% of the feet had radiographic union, and 96% had a stable talocalcaneal angle at follow-up. This procedure is quick without the necessity of a distant bone graft and the inherent morbidity associated with it. It is as successful in stabilizing the subtalar joint as are other techniques reported in the literature.

Subtalar Distraction Bone Block Fusion: An Assessment of Outcome

Twenty-nine feet in 28 patients who underwent subtalar distraction bone block fusion for the treatment of subtalar deformities associated with symptomatic arthrosis were evaluated. All patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score. Eighteen men and 10 women with a mean age of 44 years were evaluated. The mean follow-up was 33 months. Subtalar arthrosis was secondary to trauma in 27 of 29 feet (93%) with os calcis fractures in 19, subtalar dislocations in 5, and talus fractures in 3. Eighteen of the 28 patients (64%) returned to either full- or part-time work. The change in the mean AOFAS Ankle-Hindfoot Scale score from 25 preoperatively to 75 postoperatively was statistically significant (P < 0.0001). The radiographic analysis of the pre- and postoperative standing lateral radiographs showed an average increase of 8 mm in hindfoot height, 9 degrees in lateral talocalcaneal angle, and 11 degrees in lateral talar declination angle that were statistically significant (P < 0.0001). All patients but one (96%) were satisfied. Complications included four nonunions, two varus malunions, one metatarsal stress fracture, and one medial plantar nerve paresthesia. Each nonunion occurred in patients who smoked.

Results of serial casting and additional posterior release in congenital talipes equinovarus

Lengthening of the achilles tendon and release of the posterior aspect of the ankle and subtalar joint after serial cast correction of midfoot and forefoot deformities has been recommended for residual equinus in congenital clubfeet. Published results depend on different treatment modalities and type of post-operative rating systems for evaluation. The aim of this study was to investigate the results of serial casting and a standardized posterior release using several functional and radiographic evaluation systems. This review includes 43 patients (62 feet). Treatment began in all patients soon after birth with manipulation and serial casting until a posterior release was performed at a mean age of 4.2 months (range 3–8). The mean follow-up after surgery was 42.3 months (range 12–93). Different rating systems were used which combined a subjective and objective clinical assessment and radiographic criteria. On standard anteroposterior and lateral radiographs the talo- and tibiocalcaneal angle, talar-first metatarsal angle, first-ray angle, and navicular position were measured. Hindfoot varus could be corrected in most feet. Radiographically, there was a mean improvement of the AP talocalcaneal angle of 12.9° (from a mean value of 21.7° pre-operatively to 34.6° post-operatively) and of the lateral talocalcaneal angle of 17.9° (from 14.0° to 31.9°), while clinically, a mild varus deformity persisted in 23 feet (37.1%). In 35 feet (56.6%) there was a residual forefoot adduction of >5°, but the talar-first metatarsal angle improved from a mean value of −22.5° pre-operatively to −1.6° post-operatively. The navicular position was considered central or satisfactorily improved in most patients after the operation (average grade +0.1, range −2 to +2). According to the functional rating system of Lehman et al. 1990 82% of the results were good and excellent, 14.5% fair and 3.2% poor. With the assessment of Magone et al. 1989 59.7% of the patients still showed good and excellent results, but due to a high rating of normal ankle motion and bimalleolar axis, the evaluation by the functional score of McKay 1983 was significantly worse. Neben einer Verlängerung der Achillessehne und der dorsalen Kapsulotomie des oberen und unteren Sprunggelenkes nach initial redressierender Gipsbehandlung werden in der Literatur viele andere Therapieverfahren und Operationstechniken zur Behandlung des angeborenen Klumpfußes angegeben. Publizierte Ergebnisse sind jedoch nicht immer eindeutig vergleichbar, da eine von allen Autoren einheitlich angewendete Erfolgsbeurteilung anhand standardisierter und reproduzierbarer Kriterien häufig unterbleibt. Ziel unserer Studie war deshalb eine retrospektive Analyse der Behandlungsergebnisse initialer Gipsbehandlung mit anschließend durchgeführtem dorsalem Release, wobei die Evaluation klinisher und röntgenologischer Parameter anhand unterschiedlicher funktioneller Scores aus der Literatur erfolgte. Damit soll sowohl ein Vergleich zu den Behandlungsergebnissen anderer Autoren erleichtert wie auch der Einfluß unterschiedlicher Evaluationssysteme auf das Resultat gezeigt werden. Bei insgesamt 43 Kindern (62 Füsse) wurde wegen eines angeborenen Klumpfußes im Durchschnittsalter von 4.2 Monaten (3–8 Monate) nach initial redressierender Gipsbehandlung die Achillessehnenverlängerung und Kapsulotomie des oberen und unteren Sprunggelenkes über einen dorsalen Zugang vorgenommen. Nach einer durchschnittlichen Beobachtungszeit von 42,3 Monaten (12–93 Monate) erfolgte bei allen Patienten die klinische Nachuntersuchung anhand der von McKay 1983, Magone et al. 1989 und Lehman et al. 1990 in den jeweiligen Funktionsscores angegebenen Kriterien. Die radiologische Auswertung von Talo- bzw. Tibiocalcanearwinkel, Talus-MT-I-Winkel, Metatarsalreihen-Winkel und Lage des Os naviculare wurde auf standardisierten seitlichen und anteroposterioren Aufnahmen der Füsse in der Technik nach Simons [1983] vorgenommen. Obwohl postoperativ eine leichte Varuskomponente des Rückfußes bei 23 Patienten (37,1%) verblieb, zeigte die radiologische Ausmessung des Talocalcanearwinkels in der AP-Aufnahme eine Verbesserung um durchschnittlich 12.9° (von präoperativ 21,7° auf postoperativ 34,6°) und in der seitlichen Ebene um 17,9° (von 14,0° auf 31,9°). Bei genauer Vermessung wiesen 35 Füsse (56,6%) klinisch noch eine Adduktion von mehr als 5° auf, was sich röntgenologisch in einem durchschnittlichen Talus-MT-I-Winkel von −1,6° (präoperativ −22,5°) bestätigte. Die Naviculare-Position normalisierte sich jedoch bei den meisten Patienten (post-operative Graduierung von −2 bis +2 mit einem Mittelwert von +0,1). Die Ermittlung des Gesamtergebnisses anhand des von Lehman et al. 1990 angegebenen Scores zeigte 82% gute und exzellente sowie 14,5% mäßige und 3, 2% schlechte Resultate. Während die Beurteilung nach den von Magone et al. 1989 publizierten Kriterien noch 59,7% gute und sehr gute Behandlungsergebnisse aufwies, lag der McKay-Score 1983 deutlich darunter, was auf eine übergproportionale Bewertung von normaler OSG-Beweglichkeit und bimalleolärer Achse zurückzuführen ist.

Reliability of Standard Foot Radiographic Measurements

Fifty standing dorsoplantar and lateral foot radiographs were obtained on a consecutive series of patients seen in an orthopaedic foot and ankle clinic. These radiographs were duplicated, and eight common foot measurements were made on each pair by six experienced examiners. Measurements were made in two ways: first by a subjective visual assessment, and second by quantitative evaluation made according to strictly defined criteria. All measurements were made under controlled, ideal conditions with similar high quality goniometers. The results demonstrated overall greater reliability in the quantitative methods than the non-quantitative methods. For each of the quantitative techniques, a cumulated frequency distribution of differences between examiners was calculated. The approximate 95% bounds for these measures were: hallux-metatarsophalangeal angle = 6 degrees, first intermetatarsal angle = 4 degrees, metatarsophalangeal-5 angle = 11 degrees, fourth intermetatarsal angle = 4 degrees, AP talocalcaneal angle = 20 degrees, lateral talocalcaneal angle = 12 degrees, sesamoid station = 2 grades, and forefoot width = 5 mm. Physicians using these parameters to make decisions regarding patient care and clinical outcomes need to keep in mind these potential errors in making foot radiographic measurements.