Lateral Talocalcaneal Angle Research Articles

Pediatric flexible flatfoot: Does obesity influence the outcomes of arthroereisis?

Childhood obesity has emerged in the last decades as an important public health problem worldwide. Although relationships between obesity and flatfoot have been shown, no studies have investigated the influence of obesity on arthroereisis outcomes. To evaluate correlations between childhood overweight/obesity and clinical and radiographic outcomes after subtalar arthroereisis with self-locking implants. This retrospective study included one hundred and sixty-nine pediatric patients (10-14 years old) who underwent subtalar arthroereisis (PEEK PitStop® device) for severe flexible flatfoot. Exclusion criteria were additional procedures, revision of previous corrective surgeries, rigid flatfoot with severe deformity, and neurological or post-traumatic flatfoot. Preoperative/postoperative European Foot and Ankle Society (EFAS) and visual analogue scale (VAS) scores were determined; radiographic assessment was conducted on weight-bearing foot X-rays: Kite angle, first metatarsal-talus angle, Meary angle, calcaneal pitch angle and lateral talo-calcaneal angle were analyzed. EFAS and VAS scores improved post-operatively in the whole population. Only seven cases with complications were reported. Radiographic assessment revealed an improvement in all angles. Statistical analysis demonstrated that the impact of obesity was significant on arthroereisis outcomes: Relationships were reported between BMI and postoperative EFAS/VAS scores, postoperative calcaneal pitch angle, Kite angle, Meary angle and talo-first metatarsal angle. Although arthroereisis represents a very effective and valid treatment for flatfoot both in normal weight and obese children, obesity significantly influences clinical and radiographic outcomes of arthroereisis, and obese children tend to perceive more pain and discomfort.

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.

Morphological changes in flatfoot: a 3D analysis using weight-bearing CT scans

BackgroundFlatfoot is a condition resulting from complex three-dimensional (3D) morphological changes. Most Previous studies have been constrained by using two-dimensional radiographs and non-weight-bearing conditions. The deformity in flatfoot is associated with the 3D morphology of the bone. These morphological changes affect the force line conduction of the hindfoot/midfoot/forefoot, leading to further morphological alterations. Given that a two-dimensional plane axis overlooks the 3D structural information, it is essential to measure the 3D model of the entire foot in conjunction with the definition under the standing position. This study aims to analyze the morphological changes in flatfoot using 3D measurements from weight-bearing CT (WBCT).MethodIn this retrospective comparative our CT database was searched between 4–2021 and 3–2022. Following inclusion criteria were used: Patients were required to exhibit clinical symptoms suggestive of flatfoot, including painful swelling of the medial plantar area or abnormal gait, corroborated by clinical examination and confirmatory radiological findings on CT or MRI. Healthy participants were required to be free of any foot diseases or conditions affecting lower limb movement. After applying the exclusion criteria (Flatfoot with other foot diseases), CT scans (mean age = 20.9375, SD = 16.1) confirmed eligible for further analysis. The distance, angle in sagittal/transverse/coronal planes, and volume of the two groups were compared on reconstructed 3D models using the t-test. Logistic regression was used to identify flatfoot risk factors, which were then analyzed using receiver operating characteristic curves and nomogram.ResultThe flatfoot group exhibited significantly lower values for calcaneofibular distance (p = 0.001), sagittal and transverse calcaneal inclination angle (p < 0.001), medial column height (p < 0.001), sagittal talonavicular coverage angle (p < 0.001), and sagittal (p < 0.001) and transverse (p = 0.015) Hibb angle. In contrast, the sagittal lateral talocalcaneal angle (p = 0.013), sagittal (p < 0.001) and transverse (p = 0.004) talocalcaneal angle, transverse talonavicular coverage angle (p < 0.001), coronal Hibb angle (p < 0.001), and sagittal (p < 0.001) and transverse (p = 0.001) Meary’s angle were significantly higher in the flatfoot group. The sagittal Hibb angle (B = − 0.379, OR = 0.684) and medial column height (B = − 0.990, OR = 0.372) were identified as significant risk factors for acquiring a flatfoot.ConclusionThe findings validate the 3D spatial position alterations in flatfoot. These include the abduction of the forefoot and prolapse of the first metatarsal proximal, the arch collapsed, subluxation of the talonavicular joint in the midfoot, adduction and valgus of the calcaneus, adduction and plantar ward movement of the talus in the hindfoot, along with the first metatarsal’s abduction and dorsiflexion in the forefoot.

Surgical management of severe planovalgus foot deformity in children with generalised joint hypermobility

BackgroundThis study aimed to evaluate the outcomes of calcaneal lengthening osteotomy (CLO) and double arthrodesis of the talonavicular and calcaneocuboid joints (DA) for correcting planovalgus foot deformity exclusively in patients with generalised joint hypermobility. MethodsWe retrospectively reviewed 29 feet in 17 consecutive patients who underwent either CLO or DA. The mean age at surgery was 11.3 ± 2.3 years, and the mean follow-up duration was 7.7 ± 3.2 years. Preoperative and final follow-up radiographs and dynamic foot-pressure measurements were analysed. ResultsBoth operations significantly improved the radiographic parameters, except for the lateral talocalcaneal angle in the CLO group. Pedobarographic study demonstrated an elevation of the medial longitudinal arch and an improved foot-pressure distribution after both surgeries. The plantar pressure in the lateral forefoot significantly increased only in the DA group, while the pressures exerted on the medial forefoot and hindfoot and the arch index improved only in the CLO group. ConclusionsBoth CLO and DA effectively improve the foot alignments of the deformity in patients with generalised joint hypermobility. However, differences were observed in the changes in the lateral talocalcaneal angle and plantar pressure distribution between the two procedures. Level of evidenceTherapeutic Level III.

Early Radiographic Characteristics of the Lateral Talocalcaneal Angle and its Predictive Significance for Relapse in Patients With Idiopathic Clubfoot Treated With the Ponseti Method

In order to evaluate the early radiographic characteristics of the lateral talocalcaneal (L-TC) angle in patients with idiopathic clubfoot (ICF) and to investigate its prognostic significance for relapse after initial treatment with the Ponseti method. We retrospectively included 151 patients (96 males and 55 females; 227 feet) with ICF treated at our Institution between January 2005 and December 2014. The age at initial treatment was less than 6 months, and radiographs were obtained within 3 months of the Achilles tenotomy (mean age: 2.3 months; range: 0.77-6.8). All patients were followed up for at least 7 years (range, 7-18). The participants' feet were classified into three groups: relapsed (Group A), not relapsed (Group B), and normal foot groups which consisted of healthy feet in patients with unilateral ICF (Group C). All angle measurements were expressed in degrees. Forty-seven ICF feet in 33 patients relapsed, while 180 feet in 118 patients did not, and the age at relapse was 5.92±1.91 years. Seventy-five normal feet were included in Group C. The average L-TC angle in Group A and B patients was 33.57°±12.05° and 39.37°±12.55°, respectively, while Group C was 49.61°±9.11°. A significant difference was found among the three groups of patients (F=31.48, P<0.001). The L-TC angle cut-off value below which a recurrence could be predicted was 36.1° (sensitivity, 74.47%). The L-TC angle of ICF patients treated using the Ponseti method were reduced compared to normal feet. An L-TC angle of <36.1° has relative value in predicting ICF relapse. LEVEL OF EVIDENCE: III.

Is medial or lateral localization of osteochondral lesions of talus related to foot angles?

This study aims to examine the relationship between foot angles and the presence and localization of osteochondral lesions of the talus (OLTs). Between January 2014 and January 2019, a total of 152 patients with a diagnosis of medial OTLs (95 males, 57 females; mean age: 28.8±6.4 years; range, 18 to 40 years), 51 patients with a diagnosis of lateral OTLs (36 males, 15 females; mean age: 27.1±6.2 years; range, 18 to 39 years), and 114 patients without known foot-ankle trauma as the control group (56 males, 58 females; mean age: 29.0±6.1 years; range, 18 to 40 years) were included. Magnetic resonance imaging and radiographs of each group were analyzed retrospectively. Lateral talocalcaneal angle (LTCA), calcaneal inclination angle (CIA), Böhler angle (BA), and Gissane angle (GA) were measured on the images and the values were compared among the groups. The CIA had a significant relationship with the localization (p<0.001). It was higher in patients with OLTs and had an effect on localization. The mean CIA was 26.6º±3.9º in the medial OLTs group, 23.0º±3.5º in the lateral OLTs group, and 18.5º±3.6º in the control group. There was a significant difference in the LTCA between the control and OLTs groups (p<0.001). The LTCA was higher in patients with OLTs, but had no effect on localization. The mean LTCA was 41.1º±4.2º for medial OLTs, 41.3º±4.2º for lateral OLTs, and 35.7º±6.8º for the controls. No significant relationship was found for BA and GA among the three groups. Factors affecting the localization of OLTs are still not fully understood. However, foot morphology seems to play a role in determining medial or lateral localization. The LTCA is not related to the localization of OLTs; however, an increased LTCA may be related to the occurrence of OLTS. Increased CIA may be related to both OLTS localization and OLTs occurrence.

Comparison Between Clinical, Radiological and Functional Outcome of Arthroereisis vs Corrective Osteotomies for Correction of Symptomatic Flexible Pes Planovalgus in Adolescents

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Flexible pes planovalgus is a common deformity in young adolescents. It can interfere with daily activities and athletic participation. If conservative treatment fails, operative intervention is justified. Operative interventions include lateral column lengthening alone, multiple osteotomies (medial translation calcaneal osteotomy, lateral column lengthening, and Cotton osteotomies), and arthroereisis. All these options can be combined with gastrocnemius recession, excision of accessory navicular, or other soft tissue procedures. Arthroereisis is a highly controversial procedure with a great debate regarding indications, safety and clinical outcome. The literature comparing corrective osteotomies to arthroereisis in young adolescents is deficient and non conclusive. This study was done to compare the clinical and radiological outcome of multiple corrective osteotomies to arthroereisis in young adolescents. Methods: This is a case control prospective study that included 40 feet (20 feet in each group) in 25 patients with flexible pes planovalgus deformity in patients aged 10 to 13 years, after failure of conservative treatment. Exclusion criteria included generalised ligamentous laxity, neurogenic disorders, and rigid deformity. Cases with severe talonavicular uncoverage (angle more than 40 degrees) were excluded as this might be a contraindication to arthroereisis. Group 1 underwent correction by multiple osteotomies (medial translation calcaneal osteotomy, lateral column lengthening, and Cotton osteotomies) and group 2 underwent arthroereisis using a conical titanium subtalar spacer. Gastrocnemius recession and resection of painful accessory navicular were done if indicated in both groups. Clinical outcome was assessed using AOFAS, FAAM scores and subjective patient satisfaction. Radiological assessment included lateral talocalcaneal angle, anteroposterior and lateral talus first metatarsal angle, talonavicular coverage angle, and calcaneal pitch angle. Results: The mean follow up in group 1 was 29 months compared to 25 months in group 2. Preoperatively, there was no statistically significant difference between the two groups regarding patient demographics, clinical scores, or radiological measurements. Clinically, 18 patients were satisfied in group 1, compared to 17 patients in group 2. The mean AOFAS score improved significantly from 73 (62-90) to 91(73-100) in group 1 and from 73 (62-90) to 89 (73-100) in group 2. FAAM score improved significantly from 76% (68-87) to 95.75% (74-100) in group 1, and from 73% (62-86) to 91% (71-98) in group 2. The difference between the two groups was not statistically significant. All radiological measurements improved significantly in both groups without a statistically significant difference between the two groups. Conclusion: Clinical and radiological outcome of arthroereisis is comparable to corrective osteotomies in young adolescents with symptomatic pes planovalgus deformity and can be a valid option in management of these cases, but long term follow up is needed. Also, consensus regarding the perfect age, implant removal, and the degree of talonavicular uncoverage that can be corrected by arthroereisis need further studies.

Union in Lateral Column Lengthening by Plate Fixation Without Bone Graft in Flexible Flatfoot: A Case Series.

This study's goal was to evaluate the outcomes of lateral column lengthening by plate fixation without bone graft in the management of symptomatic flexible flatfoot. A prospective randomized trial study included 30 feet (27 patients) and was performed from March 2017 to December 2019. Functional and radiological evaluations were done pre-operative and at the final post-operative follow-up. The functional assessment was done using the American Orthopaedic Foot and Ankle Society (AOFAS) score. The mean follow-up was 16.5 ± 3.027months. The mean age of patients was 22.6 ± 6.29years. All cases showed union ranging from 8 to 12weeks, with a mean of 10 ± 1.88weeks. The mean AOFAS score improved from 51.6 ± 6.75 to 92.2 ± 6.21. The mean anteroposterior (AP) talo-first metatarsal angle improved from 25.3° ± 8.31° to 3.4° ± 5.10°. The mean anteroposterior (AP) talo-navicular coverage improved from 22.10° ± 4.28° to 2.3° ± 3.46°. The mean Lateral talo-first metatarsal angle improved from 18.6° ± 4.79° to 3.3° ± 3.16°. The calcaneal pitch angle improved from 9.6° ± 4.14° to 15.1° ± 4.43°. The mean lateral talo-calcaneal angle improved from 45.7° ± 3.77° to 37.5° ± 3.47°. Using an interposition wedge plate for LCL without bone graft leads to a high union rate, maintains the correction, and avoids possible complications of autografts and allografts.

Radiographic Measurements of the Foot and Ankle After Ankle Arthrodesis.

Ankle arthrodesis is an established treatment for ankle arthritis. For patients with ankle arthritis, the position of the talus during ankle arthrodesis may affect the radiographic parameters of the foot. The purpose of this study is to assess the radiographic relationship between talar alignment and the longitudinal arch of the foot before and after ankle arthrodesis. We retrospectively reviewed a single-surgeon series of 30 patients who had undergone ankle arthrodesis. Measured parameters included the lateral tibiotalar angle (LTTA), lateral talometatarsal angle (LTMA), lateral talocalcaneal angle (LTCA), cuneiform height (CH), and calcaneal pitch (CP). Additional data collected included demographics, fusion construct type, and visual analog scale (VAS) measurements. LTTA was increased from 68.2 ± 7.4 degrees preoperatively to 75.0 ± 6.4 degrees postoperatively (P = .001), LTMA increased from -2.0 ± 10.7 degrees to 4.0 ± 10.1 degrees (P < .001), CH increased from 20.1 ± 7.5 mm to 26.1 ± 8.4 mm (P < .001), LTCA and CP had no statistically significant change. VAS score decreased from 5.7 ± 2.7 to 1.3 ± 1.9 (P < .001). Correcting the talar alignment in the sagittal plane during ankle arthrodesis improved the radiographic parameters of the foot, contributing to restoration of the longitudinal arch. The clinical significance of these findings is that in patients undergoing ankle arthrodesis, the surgeon should be aware that the alignment of the foot will be altered at the time of ankle arthrodesis and should be considered in preoperative planning. Further research is needed to determine the effect of ankle arthrodesis in patients determined to have pes planus preoperatively. Level III, retrospective cohort study.

Radiological Evaluation of the Relationship Between Plantar Fasciitis and Foot Arch Angles in Adults

Objective: The foot arch deformation increases plantar fasciitis (PF) and plantar calcaneal spur (PCS) for-mation. As a result, the heel fat pad becomes thinner. This study investigated the relationship between plantar fasciitis and foot arch angles. Methods: We performed a retrospective review of patients who had PF patients (n = 53) and healthy individu-als (n = 71) without PF. We have evaluated the presence of PCS and heel fat pad thickness measurements on magnetic resonance imaging (MRI), and the lateral talus-first metatarsal angle (Meary’s angle), lateral talocal-caneal angle, and calcaneal inclination angle measurements were performed on X-ray images. Results: The mean age of the PF group was significantly higher than the control group (p = 0.001). The degrees of Meary’s angle and calcaneus inclination angle were significantly higher in the PF group (p &amp;lt; 0.001 and p = 0.026, respectively) than in the control group. The incidence of PCS was significantly higher in the PF group (p = 0.028). In the binary logistic regression analysis model, high Meary’s angle and calcaneal pitch angle were found to be associated with the risk of PF. There was also a significant association between age and the pres-ence of PCS and PF. Conclusion: Changes in Meary’s angle and calcaneal pitch angle were significant risk factors for PF.

The relationship between osteochondral lesion of the talus and the foot arch angles in adults: A retrospective study

Objective: The current study aimed to compare the arch angles of the foot, Achilles tendinopathy, subcutaneous fat tissue thickness of the heel, and epin calcanei (EC) in patients with osteochondral lesion of the talus (OLT). Methods:The magnetic resonance images (MRI) of the ankle performed by the radiology clinic between March 2020 and October 2021 were examined.Based on the MRI findings, the patients diagnosed with OLT were included in the study group (n = 55) and those not diagnosed with OLT formed the control group (n = 118). All the patients included in the study were investigated for their demographic characteristics and presence of EC. Weight-bearing lateral X-ray images were used to measure the lateral talus-first metatarsal angle (Meary’s angle), lateral talocalcaneal angle (LTCA), and calcaneal inclination angle (also known as the calcaneal pitch). Results: The study and control groups had no significant difference in terms of gender distribution (P = 0.575). The patients in the study group had a significantly higher mean age than the control group (P &lt; 0.001). Evaluation of the arch angles of the foot showed the patients with OLT to have higher LTCA and calcaneal pitch angles and greater subcutaneous fat thicknesses (p &lt; 0.001, p &lt; 0.001, and p = 0.004, respectively). In addition, the study group showed higher rates of patients with EC and Achilles tendinopathy (p = 0.076 and p = 0.019, respectively).Conclusion: Our study demonstrated that sex had no effect on OLT incidence, whereas changes in the LTCA and pitch angles elevated the risk of OLT. Furthermore, increased age was found to be associated with a higher risk of OLT formation. We also showed that Achilles tendinopathy and EC were significantly higher in patients with OLT.A considerable number of future studies are needed to establish whether this significant relationship is causal.

No Association Between Cavovarus Alignment and Risk of Non-Union or Delayed Union in Jones Fractures

Category: Midfoot/Forefoot; Other Introduction/Purpose: It has been well documented in the literature that fractures of the base of the fifth metatarsal are often associated with varus hindfoot alignment. Zone two fractures at the metaphyseal-diaphyseal junction, commonly referred to as Jones fractures, have specifically been noted to have a higher incidence of delayed union and nonunion. This has historically been attributed to the tenuous blood supply in this region. Although it is known that hindfoot varus may predispose to these fractures, there is little information on whether a cavovarus alignment may also contribute to the increased risk of nonunion. The purpose of this study is to determine whether cavovarus foot alignment is associated with delayed union or nonunion in Jones fractures. Methods: We identified patients who sustained a proximal fifth metatarsal fracture between the years 2016-2021 at a single academic institution. Weightbearing foot radiographs were then reviewed to identify zone 2 fractures. Talo-first metatarsal, talonavicular coverage, and talocalcaneal angles were then measured on the AP view and calcaneal pitch, talocalcaneal, and talo- first metatarsal angles were measured on the lateral view to assess foot alignment. The primary outcome measure was the presence of a nonunion or delayed union. T-tests, Mann Whitney U tests, and ANOVA analyses were conducted to assess for differences. Results: We identified a total of 117 patients with 118 zone 2 proximal fifth metatarsal fractures. Of those fractures, there were 23 of which were considered either delayed union (n=8) or nonunion (n=15). Similar rates of nonunion and delayed union were observed between patients undergoing nonoperative and operative management of their Jones fractures (p=0.514, p=0.200, respectively). For all patients with a nonunion or delayed union, no differences in anteroposterior (AP) talo-first metatarsal angle, AP talonavicular coverage angle, AP talocalcaneal angle, lateral calcaneal pitch, lateral talo-first metatarsal angle, or lateral talocalcaneal angle from those with expected healing were observed (p = 0.773, p = 0.084, p = 0.874, p = 0.751, p = 0.471, and p = 0.386 - respectively). Conclusion: Overall, no measured foot alignment values (talo-first metatarsal angle, talonavicular coverage, talocalcaneal angle, or calcaneal pitch) were statistically associated with increased risk of delayed union or non-union among patients with Jones fractures undergoing either operative or non-operative treatment. Furthermore, there was no measured difference in these foot alignment parameters between those patients undergoing operative treatment and those undergoing non-operative treatment. In conclusion, cavovarus alignment is not associated with an increased risk of non-union or delayed union in the operative or non-operative treatment of Jones fractures.

Comparison Between Corrective Osteotomies and Arthroereisis in Management of Symptomatic Flexible Pes Planovalgus in Young Adolescents: A Prospective Randomised Controlled Study

Category: Hindfoot Introduction/Purpose: Flexible pes planovalgus is a common deformity in young adolescents. It can interfere with daily activities and athletic participation. If conservative treatment fails, operative intervention is justified. Operative interventions include lateral column lengthening alone, multiple osteotomies (medial translation calcaneal osteotomy, lateral column lengthening, and Cotton osteotomies), and arthroereisis. All these options can be combined with gastrocnemius recession, excision of accessory navicular, or other soft tissue procedures. Arthroereisis is a highly controversial procedure with a great debate regarding indications, safety and clinical outcome. The literature comparing corrective osteotomies to arthroereisis in young adolescents is deficient and non conclusive. This study was done to compare the clinical and radiological outcome of multiple corrective osteotomies to arthroereisis in young adolescents. Methods: This prospective randomized controlled study included 40 feet (20 feet in each group) in 25 patients with flexible pes planovalgus deformity in patients aged 10 to 13 years, after failure of conservative treatment. Exclusion criteria included generalised ligamentous laxity, neurogenic disorders, and rigid deformity. Cases with severe talonavicular uncoverage (angle more than 40 degrees) were excluded as this might be a contraindication to arthroereisis. Group 1 underwent correction by multiple osteotomies (medial translation calcaneal osteotomy, lateral column lengthening, and Cotton osteotomies) and group 2 underwent arthroereisis using a titanium subtalar spacer. Gastrocnemius recession and resection of painful accessory navicular were done if indicated in both groups, but no other soft tissue procedures were used. Clinical outcome was assessed using AOFAS, FAAM scores and subjective patient satisfaction. Radiological assessment included lateral talocalcaneal angle, anteroposterior and lateral talus first metatarsal angle, talonavicular coverage angle, and calcaneal pitch angle. Results: The mean follow up in group 1 was 29 months (12-43 months) compared to 25 months (12-41 months) in group 2. Preoperatively, there was no statistically significant difference between the two groups regarding patient demographics, clinical scores, or radiological measurements. Clinically, 18 patients were satisfied in group 1, compared to 17 patients in group 2. The mean AOFAS score improved significantly from 73 (62-90) to 91(73-100) in group 1 and from 73(62-90) to 89(73-100) in group 2. FAAM score improved significantly from 76%(68-87) to 95.75%(74-100) in group 1, and from 73%(62-86) to 91%(71-98) in group 2. The difference between the two groups was not statistically significant. All radiological measurements improved significantly in both groups without a statistically significant difference between the two groups. Arthroereisis implant was not removed in any patient. Conclusion: Clinical and radiological outcome of arthroereisis is comparable to corrective osteotomies in young adolescents with symptomatic pes planovalgus deformity and can be a valid option in management of these cases, but long term follow up is needed. Also, consensus regarding the perfect age, implant removal, and the degree of talonavicular uncoverage that can be corrected by arthroereisis need further studies.

The diagnostic dilemma of congenital foot deformity in pediatrics: could adding ultrasound be problem solving?

BackgroundFoot deformity is one of the most common congenital musculoskeletal anomalies in the pediatric age group. Accurate diagnosis can be sometimes impossible to be established clinically. In the assessment of foot abnormalities, radiology plays a crucial role. Lack of ossification of the tarsal bones renders plain radiographs of the foot as of little diagnostic value in this age group. MRI apart from its cost requires anesthesia and sedation. In contrast, ultrasonography allows for the imaging of cartilaginous structures. As a result, newborn foot abnormalities can be thoroughly assessed. The whole anatomy of the foot is evaluated using several scanning views. Additional planes may be needed to show the pathologic features of a specific deformity. The purpose of this study was to demonstrate the additive value of ultrasound to plain radiographs in the assessment of foot deformities in the pediatric age group.ResultsThis case–control study was performed on sixty children, 30 of which were patients admitted from the pediatric orthopedic clinic, presenting with foot deformity, after being examined clinically. Antero-posterior and lateral radiographs of foot, tibiocalcaneal, antero-posterior talocalcaneal, and lateral talocalcaneal angles were measured. Sonographic examination was done in different projections of both feet, while the patient is lying supine with dynamic sonography. The sonographic parameters measured were as follows: medial malleolar–navicular distance and medial soft tissue thickness on medial projection, calcaneocuboid distance on lateral projection, talonavicular relation on dorsal projection, and tibiocalcaneal distance on posterior projection. There was a statistically significant difference between patients and controls in the medial malleolar–navicular distance and medial soft tissue thickness measured on the medial view, the calcaneocuboid distance recorded on the lateral view, and the tibiocalcaneal distance measured on the posterior view.ConclusionsUltrasonography has a growing and useful role as a complementary imaging modality in the evaluation and follow-up of pediatric patients with foot deformity.

Evaluation of the relationship between hallux valgus and foot measurements in radiographic images of adult female.

In the present study, we aimed to determine the relationship of HV angle with angles and measurements obtained from lateral and anteroposterior (AP) radiological images of the foot in individuals with HV. The present study had a retrospective design, and the participants consisted of 66 female patients between the ages of 19 and 64 who applied to Orthopedics and Traumatology and were diagnosed with Hallux valgus. Metatarsus adductus angle, metatarsus primus adductus angle, hallux valgus angle, hallux interphalangeal angle, metatarsal break angle, first metatarsal protrusion distance, metatarsal width, talocalcaneal angle, AP Meary's angle were measured on AP view and calcaneal inclination angle, talar declination angle, lateral talocalcaneal angle, first metatarsal declination angle, fifth metatarsal declination angle, navicular height, lateral Meary's angle, tibiotalar angle were measured on a lateral radiograph. The IBM SPSS 21.0. program was used for statistical analysis, and the level of significance was taken as p < 0.05. There were statistically significant differences between the right and left feet in MPA and AMA measurements. The results showed that HV angle (HVA) had a weak relationship with MAA and MW, as well as a moderately positive relationship with MPA. However, it had a moderately negative relationship with AMA and a weak negative relationship with HIPA. We believe that in addition to the HVA angle, MPA and AMA angles should be considered in the diagnosis of HV, especially as the HVA angle is moderately positively correlated with the MPA angle and moderately negatively correlated with the AMA angle.

Treatment of Symptomatic Flexible Flat Foot in Pediatrics with A Modified Mosca's Lateral Column Lengthening.

Background: The optimal treatment of flat foot is still controversial. In this study, we evaluated the outcome the Mosca's lateral column lengthening with the advancement of the tibialis posterior. Methods: In a retrospective study . fifty symptomatic pediatric flexible flat feet with or without hindfoot valgus were ‎included in this study. Lateral column lengthening was done as described by Mosca. ‎The tibialis posterior advancement was made on the navicular bone instead of the medial cuneiform. Radiographic measures of outcome were evaluated before the surgery and immediately ‎after the surgery and included Calcaneal Inclination (Pitch) Angle, Talonavicular Coverage ‎Angle, Talo-1st metatarsal Angle (Meary's Angle), Lateral Talocalcaneal Angle, Anteroposterior ‎Talocalcaneal Angle (kite's angle), and Talar Declination Angle (Talo-Horizontal Angle).‎ A paired t-test or its nonparametric counterpart (Wilcoxon T-test) was used to compare the mean value of preoperative and postoperative measures. A chi-square test was used to compare qualitative variables Results: The mean age of the patients was ‎9.2±2.2‎‏ years‎. ‎The mean follow‎-‎up of the patients was ‏‎2.6±1.1‎‏ ‏years‎. All radiographic measures were significantly improved after the surgery. According to the radiographic measures, under-correction was seen in seven feet. Overcorrection was seen in one of the patients. Union of the osteotomy site was observed in all feet. No patients had postoperative pain or limited ankle range of motion. One superficial infection occurred that was managed with oral antibiotics. Conclusion: Lateral column lengthening and advancement of tibials posterior on navicular bone is a safe and effective procedure in the treatment of the symptomatic pediatric flexible flat foot.

The Predictive Value of Radiographs and the Pirani Score for Later Additional Surgery in Ponseti-Treated Idiopathic Clubfeet, an Observational Cohort Study.

There are few validated predictors of the need for additional surgery in idiopathic clubfeet treated according to the Ponseti method. Our aim was to examine if physical examination (Pirani score) and radiographs at the age of three months (after initial correction of the clubfeet) can predict the future need for additional surgery. In this retrospective cohort study, radiographs of idiopathic clubfeet were made at the age of three months. The Pirani score was determined at the first cast, before tenotomy, and at the age of three months. Follow-up was at least five years. The correlation between the radiograph, Pirani score, and the need for additional surgery was explored with logistic regression analysis. Parent satisfaction was measured with a disease-specific instrument. The study included 72 clubfeet (50 children) treated according to the Ponseti method. Additional surgery was needed on 27 feet (38%). A larger lateral tibiocalcaneal angle (i.e., equinus) and a smaller lateral talocalcaneal angle (i.e., hindfoot varus) at the age of three months were correlated with the need for additional surgery. Higher Pirani scores before tenotomy and at the age of three months also correlated with additional surgery. Parent satisfaction was lower in patients who needed additional surgery. Both the Pirani scores and the lateral radiographs are predictive for future additional surgery.

Grice extra-articular subtalar fusion for spastic pes planovalgus.

A pes planovalgus deformity, an unstable foot deformity, affects the gait of children with cerebral palsy (CP). Treatments, including subtalar fusion, were proposed. The Grice procedure maintains foot stability, but bone graft non-union poses a challenge. This study aimed to identify the rate and factors related to post-operative bone graft non-union. Thirty-one paediatric CP patients (age, 8.9 ± 1.8 years) who underwent the Grice procedure (53 feet) using ipsilateral tibial bone grafts were reviewed. Pre-operative gross motor function classification system (GMFCS) classes were class 1 in five, 2 in five, 3 in 14, and 4 in seven patients. Standing foot radiographs were assessed for signs of non-union, and parameters (talocalcaneal and talar declination angles and talar head uncovering index) measured pre-operatively, post-operatively, and at the most recent evaluation were compared. Factors associated with bone graft non-union were analysed by regression analysis. P < 0.05 was considered statistically significant. Degenerative changes in hindfoot joints were evaluated by Bargon's criteria. At the average follow-up evaluation at 5.4 ± 4.3 years, the GMFCS class was improved or was maintained in 29/31 patients. Post-operative radiographic measurements were restored and were maintained over the follow-up period (P < 0.001). A total of 14/53 feet (26%) had non-union. The pre-operative lateral talocalcaneal angle (OR 1.08, p = 0.04) and follow-up duration (OR 1.18, p = 0.03) were identified in univariate analysis as potential factors related to non-union but were not confirmed in a multivariate model. Hindfoot joints in most feet showed mild degenerative changes. Grice subtalar fusion in patients with a higher pre-operative lateral talocalcaneal angle might lead to bone graft non-union.

Long-term clinical and radiological outcomes following surgical treatment for symptomatic pediatric flexible flat feet: a systematic review.

Background and purposeAlbeit pediatric flexible flat foot (FFF) is a common condition, only a minority of patients become symptomatic. Long-term outcomes of surgically treated pediatric patients with symptomatic FFF are largely unknown. In this systematic review, studies providing outcomes at a mean follow-up of at least 4 years after the procedure in these patients were analyzed.Material and methodsA PubMed search was undertaken involving original articles published up to July 2021 on outcome in children aged 6 to 14 with surgically treated FFF and mean (or minimum) follow-up of at least 4 years. Radiographic and clinical outcomes were analyzed.ResultsOf initially 541 entries, 10 could be included in the systematic review (all level IV), involving 846 pediatric patients with 1,536 symptomatic FFF. Pooled mean radiological (n = 8) and clinical follow-up (n = 10) was 5.3 (range 0.5–15) and 7.0 (range 4.1–15) years, respectively. Surgical procedures included arthroereisis (n = 8), lateral column lengthening (n = 1), and Horseman procedure (n = 1). Overall relative frequency of implant-associated complications and wound-healing problems was 3.2% and 1.3%, as well as 2.8% and 1.6% following subtalar arthroereisis only. From preoperative to latest radiological assessment following subtalar arthroereisis (including 3 studies with radiological follow-up < 48 months), pooled median decrease in talonavicular coverage angle (TNCA; –9.2°), anteroposterior talocalcaneal angle (A-TCA; –6.5°), lateral talocalcaneal angle (L-TCA; –3.5°), talar declination angle (TDA; –14°), Moreau Costa Bertani angle (MCB; –13°), and talo-firstmetatarsal angle (L-T1MA; –10°) was observed, as was an increase in calcaneal pitch (4.5°).InterpretationIn symptomatic pediatric FFF patients, surgery is associated with a manageable complication profile, and results in satisfactory long-term clinical as well as radiological outcome. Yet scientific evidence is low, warranting larger scaled studies in the future.

Pes Planus Does Not Negatively Affect Clinical Outcomes after Hallux Valgus Surgery

Category:Bunion; Hindfoot; Midfoot/Forefoot; OtherIntroduction/Purpose:Pes planus is associated with hallux valgus development. Increased forefoot abduction and pressure through the hallux during the heel-rise phase of the gait in a pes planus foot is believed to contribute to hallux valgus formation. These abnormal forces through the hallux may result in poorer healing and more residual pain after surgical correction. We investigated if patients with increasing severity of pes planus presented with more severe hallux valgus deformity and whether these patients had more residual pain and poorer function following hallux valgus surgery.Methods:We evaluated 191 consecutive cases of hallux valgus surgery with Scarf osteotomy as the primary procedure. American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, visual analog scale (VAS), Short Form-36 physical component summary (SF-36 PCS), mental component summary (SF-36 MCS) and a satisfaction questionnaire were assessed at baseline, 6 months and 24 months postoperatively. Pes planus angles measured were the talonavicular coverage angle (TNCA), lateral talus-first metatarsal angle (Meary's angle) and lateral talocalcaneal angle (LTCA). The cohort was stratified into controls (0°-4.0°), mild (4.1°-14.9°), moderate (15.0°-30.0°) and severe (>30.0°) pes planus groups according to Meary's angle. Clinical outcomes were compared among the groups. Multiple regression was used to determine association between pes planus angles and outcomes.Results:There were 78 controls, 95 mild, 18 moderate and no severe cases of pes planus. Meary's angle was independently associated with preoperative HVA (beta 0.408, 95% CI 0.104-0.712, P =.009). Patients with mild and moderate pes planus had significantly greater preoperative HVA (P <.001) compared to controls. Pes planus angles were not associated with pre- or postoperative VAS, AOFAS score, SF-36 PCS or SF-36 MCS. Among controls, mild and moderate pes planus groups, there were no significant differences in pre- or postoperative clinical scores (Table 1), and satisfaction was 84.6, 80.0% and 77.8%, respectively (P =.667).Conclusion:Patients with increasing severity of pes planus presented with greater severity of hallux valgus deformity. However, patients with pes planus had similar pre- and postoperative clinical outcomes and satisfaction after hallux valgus surgery in comparison to patients with neutral foot arches.