Medial Cuneiform Height Research Articles

Association of Fusion of the First Metatarsophalangeal Joint and Pes Planus Deformity Correction.

There has been scant investigation on the relationship between the distal aspect of the medial longitudinal arch and pes planus deformity. The aim of this study was to investigate whether the reduction and stabilization of the distal aspect of the medial longitudinal arch through fusion of the first metatarsophalangeal joint (MTPJ) can subsequently improve pes planus deformity parameters. This could be useful in both further understanding the role of the distal medial longitudinal arch in patients with pes planus and planning operative intervention in patients with multifactorial medial longitudinal arch problems. A retrospective cohort study was undertaken between January 2011 and October 2021, including patients undergoing first MTPJ fusion with a pes planus deformity on weightbearing preoperative radiographs. These were compared to postoperative images, and multiple pes planus measurements were taken for comparison. A total of 511 operations were identified for further analysis, with 48 feet meeting the inclusion criteria. There was a statistically significant reduction identified between the pre- and postoperative measurements of Meary angle (3.75 degrees, 95% CI 2.9-6.47 degrees) and talonavicular coverage angle (1.48 degrees, 95% CI 1.09-3.44 degrees). There was a statistically significant increase between the pre- and postoperative measurements of calcaneal pitch angle (2.32 degrees, 95% CI 0.24-4.41 degrees) and medial cuneiform height (1.25 mm, 95% CI 0.6-1.92 mm). Reduced intermetatarsal angle was significantly associated with an increase in first MTPJ angle postfusion. Many of the measurements made were found "almost perfectly" reproducible by the Landis and Koch description. Our results demonstrate that fusion of the first MTPJ is associated with improvement of medial longitudinal arch parameters of a pes planus deformity but not to levels considered to be clinically normal. Therefore, the distal aspect of the medial longitudinal arch could, to some degree, be a feature in the pes planus deformity etiology. Level III, retrospective case control study.

Does ankle arthrodesis induce satisfactory changes in the medial longitudinal arch height of the foot for severe varus ankle arthritis?

We designed this study to determine how changes in coronal ankle alignment affect sagittal alignment of the foot. Specifically, we focused on the changes in medial longitudinal arch height, which could be reflected by the medial cuneiform height (MCH), Meary's angle, and calcaneal pitch angle (CPA). We retrospectively analyzed the radiographic findings of 37 patients who underwent open ankle arthrodesis without inframalleolar correction (such as first metatarsal dorsal closing wedge osteotomy, calcaneal osteotomies, tendon transfers, or tarsal joint arthrodesis) of severe varus ankle arthritis. The inclusion criterion was a pre-operative tibial axis to talar dome angle of 80 degrees or less. The enrolled patients were divided into two groups according to the post-operative decrease in MCH (≥ 2mm or < 2mm). A post-operative MCH decrease of ≥ 2mm was observed in 43.2% (16 patients). Although the degree of coronal ankle varus correction was similar, the decrease in the Meary's angle was significantly greater in the group with a post-operative MCH decrease of ≥ 2mm than in those with < 2mm (- 4.1 degrees vs. - 1.3 degrees, P = 0.01). The changes in CPA were not significantly different (P = 0.172). Correction of ankle varus deformity via ankle arthrodesis could lead to a decrease in the medial longitudinal arch height in less than half of the enrolled patients. In these patients, a cavus component of the foot might be an important factor in determining a successful sagittal foot alignment change, while the CPA was maintained post-operatively.

Does a 1st Metatarsophalangeal Fusion in a Patient with Pes Planus Improve the Pes Planus Deformity? A Retrospective Case Series

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: A pes planus deformity is a pathology relating to the loss of normality of the complex interaction of the bones and joints of the foot resulting in a flattening of the medial longitudinal arch with or without abduction of the midfoot. The distal aspect of the medial longitudinal arch can be a feature of the deformity. The fusion of the 1st metatarsophalangeal joint (MTPJ) is a common operation. In patients with concomitant pes planus deformity, it is unknown if reducing and stabilising the distal aspect of the medial ray through a 1st MTPJ fusion can subsequently improve the pes planus deformity. We sought to analyse the pes planus deformity pre and post 1st MTPJ fusion with the null hypothesis that there was no difference. Methods: We identified patients who had undergone 1st MTPJ fusion using our electronic database from January 2011 to October 2021. To meet the inclusion criteria, cases required pre- and post-operative weightbearing plain radiographs, with a Meary's angle of &gt;4 degrees on pre-operative imaging. Routine pes planus measurements were undertaken by 2 independent observers. Pre- and post-operative measurements were tested for significant change using Wilcoxon Signed Rank Test or Paired T-Test depending on the normality testing of the data. Routine demographic data was also collected. Data was analysed using IBM SPSS v.27. Results: Following radiographic analysis, 25 feet fitted the inclusion criteria. The mean patient age was 63 years. There was no pre-operative correlation between Meary's angle and the hallux valgus angle (Kendall's tau p=.441). Pre-operatively, Meary's line broke at the talo-navicular and navicular-cuneiform joints in 12 cases each; the remaining case broke at the tarsal-metatarsal joint. A statistically significant improvement between the pre- and post-operative measurements was identified in Meary's angle, calcaneal pitch angle, talo-navicular coverage angle, intermetatarsal angle and talo-navicular angle (see table). Significant changes were also noted in the medial cuneiform height (mean increase of 2.74mm; p=.022). A post-operative Meary's angle of &lt;4°was only achieved in 4/25 (16%) of cases. Of the remaining 21 cases, the point at which Meary's line broke moved proximally one joint in 4 and distally one joint in 3 cases; it remained at the same joint in 14 cases. Conclusion: Our results suggest that 1st MTPJ fusion improves axial alignment of the foot as well as reducing Meary's angle by a statistically significant amount, although diagnostic criteria for pes planus remained in most cases.

Interobserver Reliability of Radiographic Angles and Measurements in Flat Foot Deformity

Category: Other Introduction/Purpose: Radiographic angles and measurements are widely used in foot and ankle pathologies to define normal and abnormal skeletal alignment. In spite of this the inter-observer reliability of these parameters is debatable. The aim of this study was to determine the inter-observer reliability of various radiographic angles and measurements in flat foot deformity. Methods: Antero-posterior (AP) and lateral foot radiographs of 18 patients with flatfoot deformity were analysed by eight clinicians of various grade of experience (2 consultants, 4 fellows / registrars and 2 core training grades) with 11 different radiological parameters. A digital presentation demonstrating the method of measurement of all parameters using same software was provided to the participants. The inter-observer reliability was analysed using interclass correlation (ICC) model mixed for reliability at 95% confidence interval for individual parameters and different grade of experience. Results: The inter-observer reliability was excellent (&gt;0.9) in calcaneal pitch angle (CPA), medial cuneiform height (C1H) and lateral incongruency angle (LIA). It was good (0.75 - 0.90) in talo-navicular angle (TNA), medial cuneiform articular angle (CAA), medial arch sag angle (MASA), medial cuneiform - 1st MT angle (C1MTA), talonavicular coverage angle (TNCA)andtalar - 1st MT angle on AP radiograph (T1MTA). The inter-observer reliability was moderate (0.5 - 0.75) in Meary's angle and talo-navicular uncoverage percentage (TNUP). The reliability did not differ with the grade of surgeon on sub-group analysis. Conclusion: This is first study to analyse the interobserver reliability of radiographic measurements in a flatfoot deformity, including grade of surgeon. The results suggest that these radiological parameters can be reliably used in clinical practice if standard measurement techniques are followed by clinicians of all grades.

Non-invasive and quantitive analysis of flatfoot based on ultrasound.

Flatfoot is a common foot deformity that seriously affects the quality of life. The aim of this study is to develop an accurate and noninvasive method for the diagnosis of flatfoot based on B-mode ultrasound. In this study, 51 patients (the flatfoot group) and 43 healthy subjects (the control group) were included. The plantar fascia angle, a new measurement for use in the diagnosis of flatfoot is proposed, as determined using B-mode ultrasound. For comparison, the calcaneal pitch angle and medial cuneiform height were also measured using lateral X-radiography, based on traditional diagnostic methods. The intraclass correlation values of the plantar fascia angle, the calcaneal pitch angle, and the medial cuneiform height were all more than 0.95, and there is a moderate correlation (r = 0.51) between the medial cuneiform height and the calcaneal pitch angle, and an excellent correlation (r = 0.85) between the plantar fascia angle and the calcaneal pitch angle. The optimal cutoff value, sensitivity, and specificity for medial cuneiform height in flatfoot diagnosis were 12.8 mm, 93.0%, and 54.9%, respectively. The optimal cutoff value, sensitivity, and specificity for plantar fascia angle in flatfoot diagnosis were 9.8°, 97.7%, and 94.1%, respectively. The proposed plantar fascia angle has good sensitivity and specificity in diagnosing flatfoot, therefore supplying a new approach for the noninvasive diagnosis of flatfoot.

Assessment of Flatfoot Deformity Using Digitally Reconstructed Radiographs: Reliability and Comparison to Conventional Radiographs.

Digitally reconstructed radiographs (DRRs) generated from weightbearing computed tomography (WBCT) may potentially substitute for weightbearing plain radiographs (XRs) but have not been clinically validated. This study aims to test the reliability of 6 radiographic parameters of progressive collapsing foot deformity (PCFD) as measured on DRR, to investigate whether DRR represents comparably to XR through the same measurements, and to compare agreement of DRR and XR measurements of a standardized arch height parameter with reference measurements made on WBCT. DRR generated from preoperative WBCT of 71 patients (72 feet) treated surgically for PCFD were retrospectively compared with preoperative weight-bearing XR after exclusion criteria were applied. Six radiographic measurements were performed, including Meary angle, calcaneal pitch (CPA), medial cuneiform height (MCH), AP talar-first metatarsal angle (T-1MT), talonavicular coverage (TNCA), and talar incongruency (TIA). Arch height was measured on XR, DRR, and WBCT using a validated, standardized, navicular-based index. Intraclass correlation coefficients assessed DRR intraobserver and interobserver reliability. Paired samples t tests tested differences between XR and DRR. Bland-Altman limits of agreement analysis compared DRR and XR agreement with WBCT measurements. Measurements were within standard PCFD ranges on XR and DRR. All measurements demonstrated excellent intrarater reliability and good to excellent interrater agreement, consistent with previous literature on XR. No differences were found for Meary, CPA, or TNCA. Minor differences were observed for MCH, T-1MT, and TIA. DRR measurements demonstrated greater agreement with WBCT than XR measurements. DRR from WBCT may be a promising substitute for XR in the clinical evaluation of PCFD. Radiographic measurements made on DRR demonstrated good to excellent reliability. Although small differences were found between XR and DRR for certain measurements, DRR more accurately represented medial arch anatomy compared to gold standard WBCT data than XR. If validated as a clinical substitute, DRR could eventually obviate XR where WBCT is available. Level III, retrospective cohort study.

Subtalar Arthrodesis and Dynamic Medial Column Stabilization in the Surgical Treatment of Rigid Progressive Collapsing Foot Deformity: A Comparative Analysis with Triple Arthrodesis

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:In the surgical treatment of rigid progressive collapsing foot deformity (PCFD), triple arthrodesis has been commonly used for its ability to correct multiplanar deformities. However, complications associated with postoperative stiffness resulting from the added number of arthrodesis have led to an interest in more joint sparing options. A recent study has shown that dynamic medial column stabilization (DMCS), which transfers flexor hallucis longus tendon to the first metatarsal base, successfully restores medial longitudinal arch without the need for arthrodesis. This study aimed to evaluate the results of subtalar arthrodesis with dynamic medial column stabilization (DMCS) in treating rigid PCFD compared to the triple arthrodesis.Methods:Sixteen patients (18 feet) who underwent triple arthrodesis (TA group) and 24 patients (24 feet) who underwent subtalar arthrodesis and DMCS (SA+DMCS group) for surgical correction of rigid PCFD were reviewed. Five radiographic parameters were measured preoperatively, 3 months, 6 months postoperatively, and at the last follow-up (minimum 2 years) to compare the amount of correction and its maintenance. Clinical outcomes were assessed using a visual analogue scale (VAS) and foot function index (FFI). Complications such as non-union, development of adjacent joint arthritis were recorded.Results:TA group demonstrated a greater amount of correction in the Meary angle than the SA+DMCS group at 3 months postoperatively. However, the TA group showed a significant decrease in the medial cuneiform height, navicular-1st metatarsal angle, and Meary angle at 6 months compared to the initial reduction at 3 months. In contrast, the SA+DMCS group maintained initial correction throughout the follow-up (Figure 1). Clinical scores improved in all patients. Degenerative arthritis in the NC and TMT joints newly developed in nine and one foot, respectively, in the TA group. In contrast, there were no patients with newly developed arthritis in the SA+DMCS group. Postoperative valgus talar tilt occurred with nine ankles in the TA group, whereas only one ankle in the SA+DMCS group. One non-union of the subtalar arthrodesis occurred in the SA+DMCS group.Conclusion:SA+DMCS group demonstrated a comparable amount of correction as the TA group and maintained initial correction throughout the follow-up period. Additionally, the SA+DMCS group developed fewer complications than the TA group. The current findings suggest that SA+DMCS may be a viable option in treating rigid PCFD deformity with less concern for the complications related to the stiffness.

Hindfoot Varus Deformity: An Essential but Easily Neglected Pathological Change in Müller-Weiss Disease

Category:Hindfoot; Midfoot/Forefoot; OtherIntroduction/Purpose:The key pathology of Müller-Weiss Disease (MWD) is fragmentation of the lateral pole of the navicular which leads to lateral rotation of the talar head, inversion of the subtalar joint, and eventually collapse of the medial arch with a paradoxical flatfoot deformity since the varus heel persists. Treatment for MWD should be based on an understanding of this unusual hind and midfoot deformity in order to achieve ideal outcomes. For years however, some authors have treated MWD as a flatfoot deformity instead of correction of the varus heel. This study used weightbearing CT (WBCT) images to demonstrate the structural and alignment changes of the hindfoot and medial arch in patients with MWD compared to those of controls and patients with adult acquired flatfoot deformity (AAFD).Methods:Twelve patients with 17 feet from two medical centers with a clinical diagnosis of MWD were retrospectively reviewed. Ten feet with flexible AAFD were chosen as the flatfoot control group. Ten feet without deformity, arthritis, a history of trauma, or prior surgical history in the foot and ankle were chosen as normal controls. The hindfoot moment arm (HMA), foot and ankle offset (FAO), middle facet subluxation (MFS), talonavicular joint coverage angle (TNCA), and the percentage of calcaneocuboid joint subluxation (CCS) measured on WBCT were used to assess the alignment of the hindfoot and peritalar joints. The arch height index was used to assess the height of the medial arch. Positive was used to reflect lateral subluxations and negative was for the medial ones. ANOVA test were used to compare data among the three groups with a normal distribution, while Wilcoxon test were used for non normal distribution.Results:According to WBCT analysis, patients with MWD showed totally different hindfoot alignment and peritalar subluxation characteristics compared to the AAFD and the normal control groups. In the order of MWD, AAFD and control, the mean HMA values were -3.44 mm, 15.75 mm, and 3.19 mm, FAO values were -0.72%, 7.42%, and 2.63%. TNCA values were -7.18, 22.11, and 11.37; MFS values were 14%, 45%, and 23%; CCS values were -0.19, 0 and -0.04. The arch height index values were 0.46, 0.45, and 0.58. There was statistically significant difference among the three groups in all the above parameters except the middle facet subluxation and fifth metatarsal medial cuneiform height ratios between the MWD group and the normal controls.Conclusion:This study confirmed that hindfoot varus is a typical feature of MWD. And this is the first study to demonstrate that peritalar subluxation is an important marker. With lateral rotation of the talar head, the subtalar joint is driven into varus, with medial subluxation of both the middle facet and the calcaneocuboid joint, resulting in peritalar subluxation opposite to that of AAFD. No significant difference between the medial arch of the MWD group and the controls was present. In conclusion, structural changes of the midfoot and hindfoot totally different from the characteristics of AAFD are present in MWD.

Anatomic Description of the Distal and Intercuneiform Articulations: A Cadaveric Study

The medial, intermediate, and lateral cuneiforms play a pivotal role in foot biomechanics. When correcting deformities of this joint complex understanding the clinical anatomy remains imperative to provide both anatomic reduction and appropriately sized fixation. This study qualitatively and quantitatively describes the distal and intercuneiform articulations and their clinical implications. The cuneiform complex of 10 fresh-frozen cadavers was dissected, and the width of the complex was measured with digital calipers. Following further dissection, the distal articular surface shapes of each cuneiform were described, and the individual heights and widths were measured. The intercuneiform articular facets were described and the protrusion distances, between the medial and lateral cuneiforms with the intermediate cuneiform, were measured. The width of the joint complex was 44.74 ± 3.40 mm. The medial cuneiform height, width, dorsal anterior, and plantar protrusion distances were 32.58 ± 2.77 mm, 14.08 ± 2.26 mm, 8.51 ± 2.17 mm, and 6.66 ± 1.21 mm, respectively. The intermediate cuneiform height and width was 23.05 ± 1.92 mm and 9.59 ± 1.85 mm, respectively. The lateral cuneiform height, width, dorsal, and plantar anterior protrusion distances were 23.38 ± 2.67 mm, 10.98 ± 3.01 mm, and 6.76 ± 1.43 mm, and 4.19 ± 1.10 mm respectively. The anterior surface of the medial, intermediate, and lateral cuneiforms was described as reniform, triangular, and triangular, respectively. The majority of intermediate cuneiforms shared an inverted L-shaped articulation with the medial cuneiform, and a B-shaped articulation with the lateral cuneiform. The shapes and sizes of distal and intercuneiform articulations were described with shared anatomical features across cadavers. Understanding the dimensions of the respective surfaces allows for anatomically appropriate fixation size.

Radiographic analysis of specific morphometrics and patient-reported outcomes (PROMIS) for surgical repair of zones 2 and 3 fifth metatarsal fractures

BackgroundZones 2 and 3 fifth metatarsal fractures are often treated with intramedullary fixation due to an increased risk of nonunion. A previous 3-dimensional (3D) computerized tomography (CT) imaging study by our group determined that the screw should stop short of the bow of the metatarsal and be larger than the commonly used 4.5 millimeter (mm) screw. This study determines how these guidelines translate to operative outcomes, measured using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys. Radiographic variables measuring the height of the medial longitudinal arch and degree of metatarsus adductus were also obtained to determine if these measurements had any effect on outcomes. And lastly, this study aimed to determine if morphologic differences between males and females affected surgical outcomes.MethodsWe retrospectively identified 23 patients (14 male, 9 female) who met inclusion criteria. Eighteen patients completed PROMIS surveys. Preoperative PROMIS surveys were completed prior to surgery, rather than retroactively. Weightbearing radiographs were also obtained preoperatively to assist with surgical planning and postoperatively to assess interval healing. Correlation coefficients were calculated between PROMIS scores and repair characteristics (hardware characteristics [screw length and diameter] and radiographic measurements of specific morphometric features). T tests determined the relationship between repair characteristics, PROMIS scores, and incidence of operative complications. PROMIS scores and correlation coefficients were also stratified by gender.ResultsThe average screw length and diameter adhered to guidelines from our previous study. Preoperatively, mean PROMIS PI = 57.26±11.03 and PROMIS PF = 42.27±15.45 after injury. Postoperatively, PROMIS PI = 44.15±7.36 and PROMIS PF = 57.22±10.93. Patients with complications had significantly worse postoperative PROMIS PF scores (p=0.0151) and PROMIS PI scores (p=0.003) compared to patients without complications. Females had non-significantly worse preoperative and postoperative PROMIS scores compared to males and had a higher complication rate (33 percent versus 21 percent, respectively). Metatarsus adductus angle was shown to exhibit a significant moderate inverse relationship with postoperative PROMIS PF scores in the overall cohort (r=−0.478; p=0.045). Metatarsus adductus angle (r=−0.606; p=0.008), lateral talo-1st metatarsal angle (r=−0.592; p=0.01), and medial cuneiform height (r=−0.529; p=0.024) demonstrated significant inverse relationships with change in PROMIS PF scores for the overall cohort. Within the male subcohort, significant relationships were found between the change in PROMIS PF and metatarsus adductus angle (r=−0.7526; p=0.005), lateral talo-1st metatarsal angle (r=−0.7539; p=0.005), and medial cuneiform height (r=−0.627; p=0.029).ConclusionPatients treated according to guidelines from our prior study achieved satisfactory patient reported and radiographic outcomes. Screws larger than 4.5mm did not lead to hardware complications, including screw failure, iatrogenic fractures, or cortical blowouts. Females had non-significantly lower preoperative and postoperative PROMIS scores and were more likely to suffer complications compared to males. Patients with complications, higher arched feet, or greater metatarsus adductus angles had worse functional outcomes. Future studies should better characterize whether patients with excessive lateral column loading benefit from an off-loading cavus orthotic or plantar-lateral plating.

How does the postoperative medial arch height influence the patient reported outcomes of stage Ⅱ acquired adult flatfoot deformity?

BackgroundThis study aimed to assess how the postoperative medial arch height influenced postoperative patient-reported clinical outcomes after surgery for stage Ⅱ acquired adult flatfoot deformity. MethodsA total of 30 feet of 30 patients (7 males, 23 females) who underwent surgery for stage Ⅱ acquired adult flatfoot deformity and could be followed up for at least 2 years were included. The average age at surgery was 60.0 (standard deviation, 13.0) years, and the average follow-up period was 40 (standard deviation, 15.4) months. Among them, 16 patients underwent lateral column lengthening and 14 patients did not. Patient-reported clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire. Radiographic alignment was evaluated by the talonavicular coverage angle, lateral talo-1st metatarsal angle, medial cuneiform height, medial cuneiform to 5th metatarsal height, and calcaneal pitch. The correlation between postoperative Self-Administered Foot Evaluation Questionnaire and radiographic alignment was assessed with Pearson's correlation analysis. ResultsSelf-Administered Foot Evaluation Questionnaire and radiographic alignment significantly improved postoperatively in all patients (P < 0.0001). In patients with severe deformity who needed lateral column lengthening, lateral talo-1st metatarsal angle was negatively and medial cuneiform to 5th metatarsal height was positively correlated with physical functioning Self-Administered Foot Evaluation Questionnaire subscales (r = −0.56 and 0.55), and medial cuneiform height was positively correlated with physical functioning, social functioning and general health Self-Administered Foot Evaluation Questionnaire subscales (r = 0.70, 0.55 and 0.73, respectively). ConclusionPostoperative medial arch height could influence physical functioning, social functioning, and general health in patients with severe stage II adult-acquired flatfoot deformity.

Patient-Reported Outcomes and Radiographic Assessment in Primary and Revision Stage II, III, and IV Progressive Collapsing Foot Deformity Surgery.

Background:Progressive collapsing foot deformity (PCFD) is a progressive hindfoot and midfoot deformity causing pain and disability. Although operative treatment is stage dependent, few studies have looked at patient-reported and radiographic outcomes stratified by primary vs revision stage II, III, and IV reconstruction surgery. Our goal was to assess operative improvement using Patient-Reported Outcomes Measurement Information System (PROMIS) and to determine whether radiographic parameter improvement correlates with patient-reported outcomes.Methods:PROMIS Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent PCFD reconstruction between November 2013 and January 2019. Thirty-six patients completed pre- and postoperative PROMIS surveys, 6 patients completed only preoperative PROMIS surveys, and 4 patients completed 12-month postoperative PROMIS surveys but did not complete preoperative PROMIS surveys. Minimum follow-up was 12 (average, 23) months. Radiographic correction was measured with pre- and postoperative weightbearing radiographs and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percentage, anteroposterior talo–first metatarsal angle, Meary angle, medial cuneiform height (MCH), and medial cuneiform–fifth metatarsal height.Results:For the overall cohort, PROMIS PF increased significantly from 37.5±5.6 to 42.3±7.1 (P = .0014). PROMIS PI improved significantly from 64.5±6.0 to 55.1±9.8 (P < .0001). Preoperative, postoperative, and change in PROMIS scores were not statistically different between PCFD stages. Change in PROMIS PI was significantly greater in primary (–12.3) vs revision (–3.7) surgery (P = .0157). Change in PROMIS PF was greater in primary (+6.0) vs revision surgery (+2.3) but did not reach statistical significance. All radiographic measurements improved significantly (P < .05). In primary stage II PCFD, postoperative PROMIS scores correlated with postoperative MCH (PF: r = 0.7725, P = .0020; PI: r = –0.5692, P = .0446).Conclusion:Patient-reported and radiographic outcomes improved significantly after PCFD reconstruction. We found no significant difference in preoperative, postoperative, or change in PROMIS scores between PCFD stages. However, stage III patients had smaller improvements in PROMIS PF, which we feel may be secondary to change in function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II PCFD, reconstructing the medial arch height correlated significantly with improvement in pain and functionality.Level of Evidence:Level II, prospective cohort study.

Effect of the First Tarsometatarsal (Modified Lapidus) Arthrodesis on Hindfoot Alignment

The purpose of this study is to demonstrate the effect of first tarsometatarsal (modified Lapidus) arthrodesis on hindfoot alignment. We reviewed the radiographs of 39 patients, 40 feet (16 right feet and 24 left feet in 6 males and 34 females; mean age 43 years) who underwent hallux valgus reconstruction and isolated first tarsometatarsal arthrodesis. Patients who had ancillary osseous procedures were excluded from the study, with the exception of proximal phalangeal osteotomy to address hallux interphalangeus.The mean time to follow up was 33.78 weeks (8.45 months), median 21.5 weeks. Statistically significant differences were found between preoperative and postoperative measurements for talar declination (−3.3 ± 3.5), lateral talocalcaneal angle (−3.1 ± 3.9), lateral Meary's angle (−4.2 ± 4.9), medial cuneiform height (3.5 ± 4.6), medial cuneiform to fifth metatarsal distance (4.7 ± 4.5), AP talocalcaneal angle (−2.8 ± 5.3), and percentage of talar head uncovering (−6.6 ± 7.6). Our results suggest that first tarsometatarsal arthrodesis can affect hindfoot alignment on AP and lateral radiographs.

Radiographic Analysis and Patient Reported Outcomes (PROMIS) in Zone 2 and 3 Fifth Metatarsal Fracture Surgery

Category:Midfoot/Forefoot; TraumaIntroduction/Purpose:Proximal (zone 2 and 3) fifth metatarsal fractures are common fractures. Due to poor blood supply, these fractures are generally treated operatively due to an increased risk of nonunion. A recent study by this group used 3D CT imaging to determine guidelines for choosing the optimal screw. The study found that the screw length should stop short of the bow of the metatarsal and the screw diameter should be larger than the commonly used 4.5 mm screw to ensure endosteal fixation. The purpose of this study is to determine how well these guidelines translate to surgical outcomes, measured using Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys.Methods:A retrospective review yielded 24 patients with zone 2 or 3 fractures between 2013 and 2016. Twenty-three patients met inclusion criteria and 18 patients completed preoperative and postoperative PROMIS PF and PI surveys. Radiographic measurements included pitch angle, metatarsus adductus angle, AP talo-1st metatarsal angle, Meary’s angle, and medial cuneiform height. Length of the fifth metatarsal, width of the medullary canal at the bow, and distance of fracture from the proximal tip of the fifth metatarsal were also measured. Correlation coefficients were calculated between postoperative PROMIS scores and repair characteristics (radiographic measurements, screw length, and screw diameter). Correlation coefficients were also calculated comparing change in PROMIS scores from preoperative baseline and repair characteristics. T-tests were used to determine the relationship between repair characteristics, PROMIS scores, and incidence of surgical complications - re-fractures (n=3) and non- unions (n=3).Results:The average screw parameters adhered to the guidelines established by our previous study. Average screw length was 42.17+-4.96mm and screw diameter was 5.38+-0.28mm. Preoperatively, PROMIS PI = 57.26+-11.03 and PROMIS PF = 42.27+- 15.45 after injury. Postoperatively, PROMIS PI = 44.15+-7.36 and PROMIS PF = 57.22+-10.93. Patients who had complications had significantly lower postoperative PROMIS PF scores (p=0.0432) compared to patients without complications. There was no significant difference (p>0.05) in other repair characteristics between those with and without complications. Metatarsus adductus angle (MAA) correlated inversely with postoperative PROMIS PF scores (r=-0.478; p=0.045). AP talo--1st metatarsal angle (r=- 0.611; p=0.007), medial cuneiform height (r=-0.59; p=0.01), and screw diameter (r=-0.525; p=0.025) had significant inverse relationships with change in PROMIS PF scores from baseline.Conclusion:Patients treated according to guidelines from our prior study achieved excellent outcomes as measured by PROMIS PI and PF scores. Patients with complications or excessive lateral column loading on radiograph had worse functional outcomes. Larger diameter screws may not be as important clinically as thought in radiographic/cadaveric studies, perhaps because slightly smaller diameter screws allow sufficient endosteal fixation while allowing more functionality through the metatarsal. Future studies should better characterize how screw diameter affects outcomes and whether patients with excessive lateral column loading benefit from an off-loading cavus orthotic or plantar-lateral plating.

Outcomes after Tibiocalcaneonavicular Ligament Reconstruction in Stage IIB and Stage IV Adult Acquired Flatfoot Deformity

Category:Hindfoot; Ankle; Midfoot/ForefootIntroduction/Purpose:The tibiocalcaneonavicular ligament (TCNL) is formed from the confluence of the superficial deltoid ligament and the superomedial spring ligament. In advanced flexible adult acquired flatfoot deformity (AAFD), progressive strain on the TCNL can lead to spring ligament tears, deltoid insufficiency, and eventual medial peritalar instability. Historically, medial peritalar instability was corrected using calcaneal osteotomy in conjunction with isolated spring or deltoid reconstruction. A recent study (Brodell et al.) demonstrated the efficacy of TCNL reconstruction in patients with medial peritalar instability. The purpose of this study is to add to this literature using patient-reported and radiographic outcomes in patients undergoing TCNL reconstruction. Patient-reported outcomes were collected using Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys.Methods:Sixteen patients (mean age 50.25 years; 11 female, 5 male) who underwent TCNL reconstruction were prospectively identified. TCNL reconstruction was indicated for stage IIB patients (n=13) with large spring ligament tears (>1.5cm on MRI or intraoperatively) or if osseous correction did not provide adequate talonavicular joint correction. TCNL reconstruction was indicated in stage IV patients (n=3) if deltoid reconstruction required additional medial stabilization. No patients underwent lateral column lengthening osteotomies. PROMIS scores were obtained at baseline and at minimum 12-months follow-up (average 16 months). Surgical success was determined using minimum clinically important differences (MCID), defined as improvement greater than one-half the standard deviation of each pre-operative PROMIS domain (PF: +2.9 and PI: -2.5). Pre- and post-operative radiographic parameters were measured: talonavicular uncoverage angle, talonavicular uncoverage percentage, AP talo-first metatarsal angle, Meary’s angle, and medial cuneiform height (MCH). Correlation coefficients determined the relationship between radiographic parameters and PROMIS scores.Results:PROMIS PF scores improved significantly from 38.1+-5.8 to 44.1+-7.1 (p=0.0087). PROMIS PI scores improved significantly from 62.9+-5.1 to 52.3+-8.9 (p=0.0025). Seventy-nine and 77 percent of patients had successful surgeries, as defined by MCIDs in the PROMIS PF and PI domains, respectively. Talonavicular uncoverage percentage and Meary’s angle improved significantly from 34.4+-13.4 to 26.3+-9.9 percent (p=0.0360) and 19.2+-8.8 to 15.3+-6.2 degrees (p=0.0089), respectively. Talonavicular uncoverage angle improved from 29.3+-9.6 to 23.3+-8.0 degrees (p=0.0562), AP talo-first metatarsal angle improved from 15.2+-10.2 to 10.4+-9.0 degrees (p=0.0555), and MCH improved from 13.5+-6.2 to 15.9+-4.8 millimeters (p=0.1374). Post- operative MCH correlated significantly with post-operative PROMIS PF scores (r=0.5941; p=0.0152). Change in AP talo-first metatarsal angle correlated significantly with change in PROMIS PI scores (r=0.5682; p=0.0427). No other correlations were significant.Conclusion:Patients with stage IIB and stage IV AAFD who undergo TCNL reconstructions have excellent patient-reported and radiographic outcomes. Reconstruction of the medial longitudinal arch, as measured by post-operative MCH, is associated with higher post-operative functionality. Surgical correction of midfoot abduction, as measured by change in the AP talo-first metatarsal angle after surgery, is associated with improvements in pain. In patients with medial peritalar instability, TCNL reconstruction can be a valuable technique to correct the sagittal arch, prevent excessive midfoot abduction, and improve pain and functionality.

Pre-Operative Radiographic Parameters of Arch Collapse Do Not Predict Future Treatment Failure in Patients with Stage IIb Pes Planus

Category:Ankle; Hindfoot; Midfoot/ForefootIntroduction/Purpose:Adult-acquired flatfoot deformity (AAFD) is a complex pathology of the foot that often results from dysfunction of the posterior tibial tendon (PTTD) and encompasses a wide spectrum of deformity. A high-degree of continued morbidity following flatfoot reconstruction exists for which prognostic indicators of future poor outcomes are uncertain. AP and lateral weight-bearing radiographs are commonly utilized to assess the severity of deformity including forefoot abduction, medial arch collapse, and hindfoot valgus. However, the relationship between pre-operative radiographic severity of deformity and predilection for future surgical treatment failure remains uncertain. The purpose of this study was to perform pre-operative radiographic measurements of patients with stage IIb PTTD and determine which preoperative radiographic parameters, if any, predict future surgical treatment failure.Methods:Following IRB approval, an institutional electronic medical record database was queried from January 2000-2014 to identify all patients undergoing surgical correction for stage IIb PTTD. 256 patients with stage IIb PTTD underwent medial displacement calcaneal osteotomy and flexor digitorum longus transfer, with possible spring ligament repair and/or Achilles lengthening. Patients undergoing concomitant lateral column lengthening or midfoot fusion, patients with previous hardware, and patients with incomplete medical records were excluded. Preoperative radiographs were retrospectively analyzed to assess preoperative deformity. Talonavicular coverage angle was measured using AP radiographs. Lateral radiographs were used to measure talar-1st metatarsal angle (Meary’s) angle, calcaneal pitch and medial cuneiform-floor height. Patient charts were also reviewed to determine whether patients experienced treatment failure, defined as return to the operating room for unplanned revision surgery (e.g. broken/painful hardware, nonunion, residual deformity, infection, nerve damage, blood clot/DVT). The degree of pre-operative deformity was compared between treatment failure and non-failure groups.Results:Out of the 256 patient cohort, a total of 58 patients (22.7%) experienced treatment failure indicated by the need for an unplanned revision surgery, while 198 patients (77.3%) did not experience failure. There were no significant differences in the severity of pre-operative radiographic deformity between the treatment failure and non-failure groups including Meary’s angle (p = 0.93), calcaneal pitch (p = 0.70), talonavicular coverage angle (p = 0.99), and medial cuneiform height (p = 0.52, Table 1).Conclusion:The results of this study show that there is no significant difference in pre-operative radiographic deformity between patients who experienced failure versus non-failure following surgical flatfoot correction suggesting that the degree of pre- operative deformity is not significantly associated with an increased risk for future surgical failure. The analysis of these results, may underscore the relative importance of the physical exam in the evaluation of patients with symptomatic stage IIb PTTD and a relative lack of prognostic value in radiographic parameters commonly used to describe patients’ deformity.

Patient-Reported and Radiographic Outcomes in Primary and Revision Stage II, III, and IV Adult- Acquired Flatfoot Deformity Surgery

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:Adult-Acquired Flatfoot Deformity (AAFD) is a progressive hindfoot and midfoot deformity that causes pain and disability. It presents as a plano-valgus deformity from the failure of static and dynamic medial osteoligamentous stabilizers. Stage II presents as a passively correctable, flexible deformity of the foot; stage III presents as a fixed or arthritic deformity of the foot; and stage IV presents with marked deformity of the foot caused by failure of the deltoid ligament and subsequent peritalar instability. Although operative treatment of AAFD is dependent on the stage, there is little data on patient- reported and radiographic outcomes stratified by primary versus revision stage II, III, and IV reconstruction surgery.Methods:Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent AAFD reconstruction between November 2013 and January 2019 with minimum 12-month follow-up (average 23 months). Twenty patients underwent stage II reconstruction, 5 of which were revision surgeries; 19 patients underwent stage III reconstruction, 8 of which were revision surgeries; and 7 patients underwent stage IV reconstruction, all of which were primary surgeries. Radiographic correction was measured pre- and post-operatively and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percent, AP talo-first metatarsal angle, Meary’s angle, medial cuneiform height, and medial cuneiform-fifth metatarsal height.Results:For the overall cohort, PROMIS PF increased significantly from 37.6+-5.7 to 42.4+-6.8 (p=0.0014). PROMIS PI improved significantly from 64.7+-6.3 to 54.6+-9.5 (p<0.0001). PROMIS scores were not statistically different between AAFD stages. Change in PROMIS PI was significantly greater in primary (-12.3) versus revision (-3.7) surgery (p=0.0157). Change in PROMIS PF was non- significantly greater in primary (+4.0) versus revision surgery (+2.3). All radiographic measurements improved significantly (p<0.05). In primary stage II AAFD, pre-operative PROMIS PI scores correlated with pre-operative medial cuneiform-fifth metatarsal height (r = -0.606, p = 0.0479). In addition, in primary stage II AAFD, post-operative PROMIS scores correlated with post-operative medial cuneiform height (PROMIS PF: r=0.7725, p=0.0020; PROMIS PI: r=-0.5692, p=0.0446).Conclusion:Patient-reported and radiographic outcomes improve significantly after AAFD reconstruction. There was no significant difference in PROMIS scores between AAFD stages. However, stage III patients had non-significantly lower improvements in PROMIS PF, likely due to loss of function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II AAFD, reconstructing the medial arch correlates significantly with improvement in pain and functionality. This survey of outcomes after primary and revision stage II, III, and IV reconstruction should help clinical decision making by providing data on expected surgical improvement.

Structural Effect of Long-Term Use of Medial Arch Support Insole on Children with Pediatric Flexible Flatfoot

Category:Midfoot/ForefootIntroduction/Purpose:This prospective study aimed to rule out the effect of the normal physiologic maturation in applying medial arch support insole for patients with pediatric flexible flatfoot (PFFF).Methods:From January 2005 to June 2015, 18 patients (34 feet) in group 1 (insole was continuously applied) and 16 patients (32 feet) in group 2 (untreated group) were enrolled. A medial arch support insole was applied from age 10-11 years until radiographic physeal closure.Results:In group 1, the talonavicular coverage angle, lateral talo-first metatarsal angle, calcaneal pitch angle, and medial cuneiform height were significantly changed at final follow-up, although all values were still within the abnormal range. Moreover, no significant differences were found in any of the increments of the radiographic parameters between groups 1 and 2.Conclusion:Radiographic improvements were found in both medial arch support insole-treated and untreated groups even if all radiographic values were still within the abnormal range. This means that PFFF could be somehow improved with heel stretching exercise until the physes were closed. Further, hindfoot alignment remained unchanged regardless of the medial arch support insole application.

Does the long-term use of medial arch support insole induce the radiographic structural changes for pediatric flexible flat foot? — A prospective comparative study

BackgroundSeveral conservative treatment methods, from intrinsic muscle exercises to orthoses, including insoles or specially designed shoes, have been introduced for pediatric flexible flat foot (PFFF). However, the structural effects of a long-term use of medial arch support insole remain unclear because the normal physiological maturation of the medial longitudinal arch cannot be ruled out. MethodsFrom January 2005 to June 2015, 18 patients (34 feet) in group 1 (continuously insole applied group) and 13 patients (26 feet) in group 2 (untreated group) were enrolled. Medial arch support insole was applied from the age 10–11years to radiographic physeal closure. ResultsIn group 1, talonavicular coverage angle, lateral talo-1st metatarsal angle, calcaneal pitch angle and medial cuneiform height were significantly changed at final follow-up, although all values were still within the abnormal range. Further, no significant differences were found in any of the increments of the radiographic parameters between group 1 and 2. ConclusionsRadiographic improvements were found in both of medial arch support insole treated or untreated group despite all radiographic values were still within the abnormal range. It was meaningful that the PFFF could be improved somewhat until the physes were closed. And the hindfoot alignment remained unchanged regardless of medial arch support insole application.

How the three arches of the foot intercorrelate.

The foot is composed of medial, lateral and transverse arches which, particularly the medial arch, provide it with the ability to function both as a flexible and rigid structure for proper locomotion. Arches of the foot, as well as their effect on lower extremity function, have been studied. However, quantitative data on the relationship between these arches still remain scanty. The purpose of this study was, therefore, to examine how the three arches of the foot intercorrelate. Seventy-six participants (58 males, 18 females) were recruited to participate in the study. Bilateral weight-bearing lateral radiographs of the right foot were taken from each participant. Navicular heights (NH), medial cuneiform height (MCH), calcaneal inclination angle (CIA) and calcaneal-first metatarsal angle (C1MA) were measured to represent the medial arch. The lateral arch was represented by cuboid height (CH) and calcaneal-fifth metatarsal angle (C5MA) whereas; MCH and CH represented the transverse arch. Mean difference of variables between males and females was compared using independent t-test while the correlation between the variables was determined using Pearson correlation. All the variables were not significantly related to gender. Significant moderate to excellent linear correlations were observed between the variables. CIA showed the strongest correlation with C1MA (r = -0.90) and C5MA (r = -0.84) whereas, CH had the least correlation with other variables. The moderate to excellent correlations between the variables indicate that deformation or elevation of the medial arch may consequently result in similar movements of the lateral and transverse arches and vice versa.