Pes Planovalgus Research Articles

Radiographic Measurements of Pes Planovalgus Do Not Predict Clinical Outcomes in Tarsal Coalition Excision.

Many patients who undergo tarsal coalition excision have persistent postoperative pain. Most studies have utilized cat scan (CT) scan parameters of pes planovalgus and heel valgus but have found this to be an inconsistent predictor of outcomes. Plain radiographic parameters have been less utilized in trying to predict outcomes after coalition excision. Radiographic talonavicular coverage angle correlates with pain in patients with flexible pes planovalgus (PPV) but has not been studied in tarsal coalition population. Furthermore, foot alignment is not understood to change after simple coalition excision. The purpose of this study was to compare plain radiographic parameters, including talonavicular coverage angle, with pain after tarsal coalition excision, as well as compare preoperative and postoperative weight-bearing radiographs. Seventy-seven feet that underwent excision of the tarsal coalition had clinical outcomes and radiographic data collected >1 year postoperatively. Measures of PPV on preoperative and postoperative weight-bearing radiographs and CT scans were evaluated. Patients were an average of 13 years old at excision. Of the total, 65% had calcaneonavicular (CN) coalitions, whereas the remainder had talocalcaneal coalitions. All patients had significant postoperative improvement in clinical outcomes but 34% (13/38) had continued pain at the most recent follow-up, more so in talocalcaneal than CN coalitions (55% vs 26%, P < 0.001). The subset with CN coalitions had more severe preoperative PPV but greater postoperative PPV improvement. Except for a weak correlation between radiographic weight-bearing (anterior-posterior) talus-first metatarsal angle and pain with activity (r = -0.54), there were no other correlations between preoperative radiographic parameters and clinical outcomes. Heel valgus on CT did not correlate with radiographic measurements of PPV or pain. We did not find a correlation of radiographic PPV with persistent pain after tarsal coalition excision. We did find improvement in radiographic PPV in CN coalitions after treatment with simple excision. Heel valgus on CT was not a useful metric for evaluating PPV in the setting of a tarsal coalition. Level III-prognostic study.

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

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

НАСЛЕДСТВЕННАЯ ТУБУЛОПАТИЯ: ФОСФАТ-ДИАБЕТ (Два клинических наблюдения)

Introduction. Phosphate diabetes is a representative of a group of diseases known as tubulopathies. It is more often of a hereditary nature. The disease manifests at an early age with symptoms similar to alimentary rickets, which creates problems for diagnosing and prescribing an adequate therapy. In this case, the current situation leads to the development of bone deformities and disability, delayed physical development, and the need for surgical treatment, which reduces the quality of life of the patients for a long time. Aim: To consider two clinical cases of phosphate diabetes with typical symptoms, demonstrate the diagnosing challenges, and analyze the treatment effects. Materials and Methods. Two clinical cases of phosphate diabetes are presented. The first patient: 16 years old, observed from the age of 2, and takes vitamin D and inorganic phosphates from the diagnosis date. The geneticist found the autosomal dominant of the pathology. The girl underwent two surgeries for her leg deformity. The second patient, 10 years old, was diagnosed at the age of 4 years. DNA diagnostics detected a mutation in the COL9A3 gene. They refused the complete DNA exome sequencing. From the diagnosis date, the patient is treated with the active vitamin D metabolite and inorganic phosphates. Results and Discussion. Clinician-observed: Patient 1 had leg deformities, painful legs, and disharmonious physical development caused by her growth retardation. Blood concentrations of calcium and phosphorus are within normal, there is hypocalciuria typical of phosphate diabetes in the urine, while phosphates are within normal. The patient’s kidney function is not impaired. Clinician-observed: Patient 2 is physically retarded, there are varus foot deformities and pes planovalgus feet. Kidney function is not impaired, the level of alkaline phosphatase is increased, the total blood calcium levels are decreased with phosphorus indicating normal values, and the urine phosphaturia and hypocalciuria are within normal ranges. Due to the COL9A3 mutation detected, Stickler syndrome was excluded. Orthopedic surgeon recommended surgical treatment of her leg deformities. Conclusions. The examination showed that the therapy allows keeping phosphate diabetes under control and avoiding the side effects of taking vitamin D.

Bipartitism in Tarsal Bones: A Retrospective Analysis of Clinical and Radiological Features

Background: Bipartitism in the foot, especially in the tarsal bones, is a rare anatomical variant characterised by dividing one bone into two separate ossification centers. This condition can be congenital or acquired, often remains asymptomatic, and is only discovered incidentally during radiological imaging. This study aims to present a comprehensive retrospective analysis of bipartitism in tarsal bones, assessing its prevalence, type of articulation and associated clinical features in a cohort of patients. Methods: A total of 4,645 patients were retrospectively evaluated from 6,145-foot images consisting of 4,975 computed tomography (CT) and 1,170 magnetic resonance imaging (MRI) scans obtained between 2015 and 2023. 15 patients with tarsal bipartitism were identified and contacted through the hospital system for in-person medical history and examination. Radiological exams assessed partial and complete bipartition, diastasis, and exostosis in the tarsal bones. Age, sex, side, trauma history, pain, foot deformity, gait disturbance, and other clinical findings were also recorded. Results: Bipartitism was detected in 15 patients (0.32%), predominantly affecting males (87%). The most common variant was medial cuneiform bipartitism, observed in 13 patients (0.28%). Talus and calcaneus bipartitism were each observed in one patient (0.02%). Bilateral involvement was present in 67% of the cases, with 60% of patients reporting chronic pain. Complete dissociation of bipartite bones was noted in 80% of cases. Accompanying bipartitism, two patients had pes planovalgus, and one had hallux varus deformity. Conclusion: Although bipartitism of the tarsal bones is rare, it remains a diagnostic challenge due to variability in clinical presentation and possible association with other foot deformities. Accurate diagnosis through advanced imaging techniques is essential to differentiate these variants from fractures and guide appropriate treatment. This study contributes valuable insights into the prevalence and clinical impact of bipartitism in the tarsal bones, emphasising the importance of early diagnosis and individualised treatment strategies.

Satisfaction survey toward an innovative orthosis for children with cerebral palsy with pes planovalgus.

Pes planovalgus (PPV) is common in children with cerebral palsy and can cause pain and gait alterations over time. Initial treatment of flexible PPV includes orthotics, despite a lack of consensus on the type of orthosis. We developed an innovative ankle-foot orthosis (RAFO). RAFO is a one-piece orthosis designed to correct both the valgus and the flat of the foot. Its conception situated above the malleolar enables a moderate anti equinus effect. Its precise description and fabrication's process is detailed. We wanted to assess user's satisfaction after several months of use and looked for clinical criteria of satisfaction. Retrospective. We conducted a satisfaction study through a telephonic QUEST (Quebec User Evaluation of Satisfaction with Assistive Technology) survey analysing the device and the process in children and parents. 24 parents were contacted, whose child was wearing RAFO on a daily basis for at least 4 months. 20 parents answered the questionnaire. The results were then related to clinical data to research satisfaction' criteria. Mean QUEST satisfaction was 4.25/5 (4.18/5 for device and 4.38/5 for process). Advantages reported concerned weight and dimensions (95%), although 20% reported the necessity to change to a shoe size above, ease of use (90%) and level of comfort (80%). Parent's satisfaction regarding perceived effectiveness was 80%. Children with equinus due to triceps surae spasticity were more susceptible to develop pain with our orthosis. Parents were overall very satisfied with the orthosis. Its technical characteristics allowing both to be a corrector of flat foot and valgus and at the same time to be comfortable and discreet makes it innovative. The presence of spastic equinus is a limit for its utilization.

Medial Column Soft Tissue Imbrication with Internal brace Augmentation Following Lateral Column Lengthening in the Ambulatory Pediatric CP with Pes Planovalgus Foot Deformities: A Novel Indication

Category: Midfoot/Forefoot; Other Introduction/Purpose: Pes planovalgus foot deformity is common in children with cerebral palsy (CP), and with failed bracing or painful progression, surgery is often needed. This study examines the effect of flatfoot reconstruction utilizing a novel approach to address the redundant medial soft tissue on these measures when compared to matched cohort undergoing the traditionally described soft tissue plication (STP) (Figure 1). Methods: An IRB approved, retrospective review of ambulatory pediatric CP, GMFCS I-III, patients with pes planovalgus foot deformities was conducted. Patients underwent a lateral column lengthening (LCL) along with medial column STP, with/without internal brace (IB) augmentation at a single tertiary institution by the same surgeon from 2017 to 2020. Patients were divided into two groups: without IB, and with IB augmentation. Radiographic indices on orthogonal weightbearing (WB) x-rays were measured at multiple timepoints: Preoperative, immediate postoperative and at the 3/6/12/24 months postoperative follow-up periods. Variables measured included AP and lateral talus-first metatarsal angles (TFMA), talonavicular coverage angle (TCA) and calcaneal pitch (CP). Means and standard deviation for continuous radiographic variables were calculated, followed by one-sided t-tests to compare the values between the two groups at all intervals. Results: 58 patients were identified, 31 without IB and 27 with IB augmentation. Both groups were well matched with respect to age, CP type, GMFCS level and gender. Preoperative WB radiographs showed no statistical difference between the two groups: Mean AP TFMA (26° vs. 28°, p=0.073), lateral TFMA (27° vs. 30°, p=0.067), TCA (34° vs. 30°, p=0.059) and CP (4° vs. 2°, p=0.069)(Table 1). Both cohorts maintained improved radiographic indices at the final 2-year timepoint. However, radiographs showed that the IB group had less midfoot collapse, maintaining a statistically significant difference in all radiographic parameters at final 2-year follow-up: Mean AP TFMA (13° vs. 5°, p&lt; 0.001), lateral TFMA (11° vs. 2°,p &lt; 0.001), TCA (15° vs. 6°,p &lt; 0.001) and CP (10° vs. 19°,p &lt; 0.001) Table 2). Conclusion: Internal brace augmentation is an innovative surgical technique that provides additional stability to the medial column soft tissues following LCL. This procedure will help prevent mid-foot collapse and better maintain long-term foot shape when WB. Utilizing this novel technique helps maintain proper biomechanical orientation of foot following reconstruction of pes planovalgus deformities in the ambulatory pediatric CP population.

Radiographic Measurements Associated with Ankle Power Generation During Gait in Patients with Cerebral Palsy

Category: Basic Sciences/Biologics; Ankle Introduction/Purpose: Pes planovalgus (PV) deformity accounts for lever arm dysfunction and compromises gait in patients with cerebral palsy (CP). However, the association between ankle power generation and radiographic indices is not yet understood. We aimed to investigate the association between ankle power and radiographic indices during gait in patients with CP concomitant with PV deformity. Methods: Patients older than 14 years with ambulatory CP and PV deformity were included. All the patients underwent three- dimensional gait analysis and weight-bearing foot radiography. Gait data were collected, including foot progression angle, tibial rotation, and ankle power generation. Radiographic measurements included anteroposterior (AP) talo-first metatarsal angle, lateral talo-first metatarsal angle, and hindfoot angle. A linear mixed-effects model was used for statistical analysis to identify significant radiographic indices associated with ankle power generation. Results: Thirty-one limbs from 15 patients with spastic diplegia and six with spastic hemiplegia were included. Statistical analysis demonstrated that ankle power generation was significantly correlated with the CP type (p=0.01) and AP talo-1st metatarsal angle (p=0.02). Conclusion: Ankle power generation was significantly associated with the AP talo-first metatarsal angle. Surgeons might need to pay attention to correcting forefoot abduction to restore ankle power when planning surgeries for pes PV deformities in patients with CP.

Higher revision rates in patients with preoperative contralateral pes planovalgus deformity following total knee arthroplasty.

The purpose of this study was to compare the incidence of revision in those with pes planovalgus deformity to those without using a large national database. Given the reciprocal changes in lower extremity alignment associated with planovalgus foot deformity, it has been suggested that patients with this deformity has worse outcomes following total knee arthroplasty (TKA). A retrospective cohort analysis of patients undergoing elective TKA was conducted using the PearlDiver database. Patients were stratified into three cohorts: those without pes planovalgus, patients with ipsilateral or bilateral pes planovalgus relative to the TKA, and patients with contralateral pes planovalgus. Patients with prior foot reconstructive surgery were excluded. The cohorts were each matched to those without pes planovalgus. Bivariate analysis was performed comparing 90-day medical complications and 2- and 4-year revisions following TKA. An adjusted number needed to be exposed for one additional person to be harmed (NNEH) was calculated using the adjusted odds ratio (OR) and unexposed event rate. Following matched analysis, those with contralateral pes planovalgus had similar odds (OR 3.41; 95% CI 0.93-12.54; p = n.s.) for aseptic revision within 2 years but significantly higher odds (OR 3.35; 95% CI 1.08-10.41; p = 0.03) within 4 years when compared to those without a pes planovalgus deformity. Within 4 years, there was no significant difference in the incidence of aseptic revision (p = n.s.) in patients with ipsilateral/bilateral pes planovalgus. No patients in any cohort underwent septic revision within 4 years of TKA. This study found that patients with contralateral pes planovalgus deformity had higher odds of aseptic revision within 4 years following primary TKA in a national database, suggesting that the change in gait kinematics associated with this deformity could possibly be associated with increased revision rates. Level III.

Radiographic Measurements Associated With Ankle Power Generation During Gait in Patients With Cerebral Palsy.

Pes planovalgus (PV) deformity accounts for lever arm dysfunction and compromises gait in patients with cerebral palsy (CP). However, the association between ankle power generation and radiographic indices is not yet understood. We aimed to investigate the association between ankle power and radiographic indices during gait in patients with CP concomitant with PV deformity. Patients older than 14 years with ambulatory CP and PV deformity were included. All the patients underwent 3-dimensional gait analysis and weight-bearing foot radiography. Gait data were collected, including foot progression angle, tibial rotation, hip rotation, and ankle power generation. Radiographic measurements included anteroposterior (AP) talo-first metatarsal angle, lateral talo-first metatarsal angle, and hindfoot angle. A linear mixed-effects model was performed to identify significant radiographic indices associated with ankle power generation. Thirty-one limbs from 15 patients with spastic diplegia and 6 with spastic hemiplegia were included. Statistical analysis demonstrated that ankle power generation was significantly correlated with the CP type ( P =0.0068) and AP talo-1 st metatarsal angle ( P =0.0230). Ankle power generation was significantly associated with the AP talo-first metatarsal angle. Surgeons might need to pay attention to correcting forefoot abduction to restore ankle power when planning surgeries for pes PV deformities in patients with CP. Prognostic Level III.

A Very Rare Pathogen of Osteomyelitis: Alcaligenes faecalis.

To the Editors: Alcaligenes faecalis is a Gram-negative, rod-shaped, oxidase-positive, catalase-positive, obligate aerobic, motile and nonfermenting bacteria.1 It is commonly found in the environment (soil or water) and in the human gut.2A. faecalis has been associated with various infections such as bacteremia, meningitis, endophthalmitis, endocarditis, skin and soft tissue infections, urinary tract infections, peritonitis, otitis media and pneumonia.3 Here, we present 2 patients with osteomyelitis due to A. faecalis, a rarely reported clinical condition in the literature. Patient 1: An 18-year-old female with a medical history of operated for meningomyelocele and pes cavus was admitted with worsening pain in her right lower extremity. On admission, she was afebrile with normal vital signs there was a chronic ulcerated wound with seropurulent discharge on the right foot. On the laboratory evaluation, there was no leukocytosis, C-reactive protein, and procalcitonin were negative, erythrocyte sedimentation rate was 35 mm/h. Clindamycin 30 mg/kg/d and cefotaxime 200 mg/kg/d intravenously (IV) were administered empirically. The contrast-enhanced magnetic resonance imaging showed cellulitis in soft tissue and osteomyelitis in the bone at the level of the 5th finger metatarsal base and proximal shaft (Fig. 1). Wound debridement was performed by orthopedics. She developed emesis and rash on day 4 and the antibiotic was changed to IV ciprofloxacin (30 mg/kg/d). Intraoperative wound culture grew A. faecalis which was sensitive to ampicillin, cefotaxime and gentamicin. Due to clinical improvement, treatment with ciprofloxacin continued and she was discharged after 15 days of IV therapy. The total treatment is planned to be completed in 8 weeks.FIGURE 1.: MRI (T2 weighted) showing osteomyelitis of the right foot. MRI indicates magnetic resonance imaging.Patient 2: A 15-year-old girl presented with a chronic ulcerated wound on her right foot. She had been operated twice for meningomyelocele and had pes planovalgus. She was afebrile and there was a chronic wound without any discharge on her right foot on admission. Laboratory evaluation revealed negative acute phase reactants and erythrocyte sedimentation rate was 24 mm/h. The empirical treatment was administered as IV cefotaxime and clindamycin. The contrast-enhanced magnetic resonance imaging showed findings suggestive of active osteomyelitis on the right calcaneus (Fig. 1). Orthopedics performed wound debridement and inserted vacuum-assisted closure therapy system. A. faecalis growth was detected in the tissue culture which was sensitive to ceftazidime and meropenem but resistant to amikacin. Her treatment was changed to IV ceftazidime (150 mg/kg/d). After vacuum-assisted closure treatment, it was planned to perform tissue repair by plastic surgery and to continue antibiotherapy IV due to the resistance pattern of the microorganism. Opportunistic infections and antimicrobial resistance associated with A. faecalis have been reported but osteomyelitis due to A. faecalis was documented in a few patients with diabetic foot ulcers in the literature.4 It is usually sensitive to beta-lactam antibiotics and trimethoprim/sulfamethoxazole and resistant to aminoglycosides and tetracyclines.5 Most of the previously documented cases have been successfully treated with amoxicillin/clavulanic acid but antibiotic resistance is an emerging problem. In summary, we present 2 patients with osteomyelitis due to A. faecalis, a rare cause of osteomyelitis. In addition to surgery, medical treatment should be arranged based on the antibiotic susceptibility results for successful and appropriate treatment.

The spectrum of foot deformities in Loeys-Dietz syndrome.

Loeys-Dietz syndrome (LDS) is characterized by a wide spectrum of musculoskeletal manifestations, including foot deformities. The spectrum of foot deformities in LDS has not been previously characterized. Our objective was to describe the incidence and characteristics of foot deformities in LDS. We retrospectively reviewed the demographic, clinical and imaging data for patients diagnosed with LDS who were seen at our Orthopedic surgery department from 2008 to 2021. We performed descriptive analyses and compared distributions of deformities by LDS genetic mutations. Of the 120 patients studied, most presented for evaluation of foot deformities ( N = 56, 47%) and scoliosis ( N = 45; 38%). Ninety-seven patients (81%) had at least one foot deformity, and 87% of these patients had bilateral foot deformities. The most common deformities were pes planovalgus (53%) and talipes equinovarus (34%). Of patients with foot deformities, 58% presented for evaluation of the feet. Of patients with pes planovalgus, only 17% presented for evaluation of the feet. Among patients with pes planovalgus, 2% underwent surgery and 16% used orthotics compared with 76% and 42%, respectively, for patients with talipes equinovarus. We found no association between deformities and genetic mutations. Bilateral foot deformities are highly prevalent in patients with LDS and are the most common reason for presentation to orthopedic surgeons. Although pes planovalgus is the most common deformity, it rarely prompted surgical treatment. Orthopedic surgeons treating LDS patients should be aware of the unique characteristics of foot deformities in LDS.

Analysis of selected methods of diagnostics and physiotherapy of pes plano-valgus in children

Introduction: Flat feet is one of the most common posture defects among children and it usually co-occurs with valgus of the heels, which is called pes plano-valgus. There are many diagnostic methods and physiotherapeutic activities that allow for early detection and appropriate correction of the defect. The use of non-surgical methods may allow the child to avoid surgery in the future. Aim and Methods: Review and analysis of the current scientific literature on the diagnosis and physiotherapy of plano-valgus feet in children. Conclusions: In the diagnostic process, there are many static and dynamic methods for the assessment of plano-valgus foot among children. Special devices such as plantoconturograph, podoscope, and pedobarographic mat are used in the diagnosis of feet in children and have proven to be helpful in the detailed analysis of foot defects. However, an extensive range of physiotherapeutic methods allows for comprehensive treatment using not only corrective exercises, but also physical therapy treatments in order to relieve pain and accelerate recovery. Orthopedic appliances, such as supination insoles, also play an important role in the treatment. The best results were seen in the use of comprehensive treatment and multiple terapeutic methods. Early detection and correct diagnosis of foot abnormalities allow for appropriate treatment with the use of a wide range of physiotherapy methods. This increases the chances of restoring normal foot functions among children and reducing pain with other abnormal symptoms.

The Effect of Customized and Silicon Insoles on Mid- and Hindfoot in Adult Flexible Pes Planovalgus.

BackgroundFlexible flat foot or pes planovalgus is a common foot deformity, and silicone and customized insole are commonly used as a non-operative treatment modality of flexible planovalgus. However, there are inadequate data and limited evidence available regarding the immediate effects of their use in midfoot and hindfoot of adults. The aim of this study is to quantify and compare the radiological parameters immediately on weightbearing with silicon and customized insoles and without them to assess the effect on midfoot and hindfoot of the flexible planovalgus in adults.MethodsA total number of 11 (8 females and 3 males) subjects with flexible pes planovalgus deformity without any other foot deformity were included in the study. Each patient was assessed three times in a random sequence without and with use of either silicon insoles or customized insole. The radiographic parameters without insole, with silicon insole, and with customized insole conditions were calculated using online available computer software Kinovea.ResultsOne-way ANOVA analysis was performed between groups (without insole, with silicone insole and with customized insole). The hindfoot parameters depicted that calcaneal inclination angle (CIA) was significant increased (P = 0.000) and talar declination angle (TDA) was significantly decreased (P = 0.003) only with the use of customized insole compared to without insole. The midfoot parameters depicted that the first metatarsal angle (FMA) and talonavicular coverage angle (TCA) were significantly lower with customized insole (P = 0.00) as compared to other two groups and significantly lower with silicone insole (P = 0.00) as compared to without insole group.ConclusionThe results imply that the compressibility of the insole material affects the forefoot and hindfoot biomechanics differently. This study concludes that silicone insole affects only the midfoot which bears 45% of bodyweight and customized insole affects both midfoot and more importantly the hindfoot which bears 55% of bodyweight.

Talo-navicular and calcaneo-cuboid fusion with PEEK H-pode™ vs. Titanium Maxlock™ locking plates: Comparison of functional and radiographic outcomes

BackgroundLocking plates are increasingly used to achieve hindfoot fusion. The objective of this study was to compare hindfoot fusion outcomes with the PEEK H-pode™ (Biotech™) locking plate and the titanium Maxlock™ (Tornier-Wright™) locking plate. HypothesisA polyetheretherketone (PEEK) H-pode™ locking plate provides similar fusion rates to a titanium Maxlock™ locking plate for talo-navicular and calcaneo-cuboid arthrodesis. MethodsWe conducted a retrospective comparative study in 39 patients (including 21 [54%] with pes planovalgus and 11 [28%] with neurological equinovarus deformities) who underwent talo-navicular and/or calcaneo-cuboid fusion, usually combined with subtalar fusion. The first 17 patients (January 2014–February 2016) were managed with Maxlock™ locking plates and the next 22 patients (March 2016–August 2018) with H-pode™ locking plates. These two cohorts of consecutive patients were comparable regarding age, sex distribution, body mass index, and comorbidities. At last follow-up more than 1year after surgery, we compared functional scores, pain intensity, and fusion assessed by radiographs and computed tomography (CT) (threshold set at 33%). ResultsMean follow-up was 42months (range: 34–63months) in the Maxlock™ group and 25months (range: 12–36months) in the H-pode™ group. At last follow-up, the two groups were not significantly different for the mean values of the American Orthopedic Foot & Ankle Society score, European Foot & Ankle Society score, and visual analogue scale pain score. Neither were the two groups significantly different for talo-navicular and calcaneo-cuboid fusion by CT. In the Maxlock™ group, we found non-significant trends towards a higher proportion of patients with talo-navicular nonunion (18% vs. 5% in the H-pode™ group) and weaker talo-navicular fusion in patients with pes planovalgus (60.8% vs. 82.0%, respectively). Radiographic results overestimated the fusion rates. DiscussionTalo-navicular and calcaneo-cuboid fusion was not significantly different with H-pode™ and Maxlock™ locking plates. CT was more accurate than standard radiography to assess fusion. These results underline the usefulness of PEEK locking plates for talo-navicular and calcaneo-cuboid fusion; moreover, the radiolucency of PEEK facilitates the interpretation of radiographs. Level of evidenceIV.

Idiopathic Symptomatic Planovalgus Foot- Current Concepts in Minimally Invasive Correction

This paper presents a literature review and the author’s current recommended surgical treatment for idiopathic symptomatic planovalgus foot. This condition has gained recognition as a diagnosis entity over the past several years. There have only been brief case reports prior to this paper. The authors aim to describe the anatomical and morphological features indicative of idiopathic pes planovalgus (ISP). This also includes the distinct features of the flat medial arch and how the medial rotation of the talus affects the different types of ISP.ISP, in essence, is a diagnosis of exclusion. It is distinct from conditions such as tibilias posterior failure and as such, the approach to management is different.

What is New in Pediatric Orthopaedic Foot and Ankle.

This paper aims to report on the last 5 years of relevant research on pediatric foot and ankle pathology with specific focus on clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. The Browzine platform was used to review the table of contents for all papers published in the following target journals related to the treatment of pediatric foot and ankle conditions. Search results were further refined to include clinical trials and randomized controlled trials published from March 1, 2015 to November 15, 2021. A total of 73 papers were selected for review based on new findings and significant contributions in treatment of clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. Also included were several papers that did not fit into any of these categories but provided new insight into specific foot and ankle pathologies. Treatment strategies for children with foot and ankle pathology are continually evolving. We review many of the most recent publications with the goal of improving understanding of these pathologies and highlighting current best practices. Level III.

Residual Deformity and Outcome of Ambulatory Adults With Cerebral Palsy: A Long-term Longitudinal Assessment.

Advances in pediatric orthopaedic care have improved mobility and function for children with cerebral palsy (CP) as mobility declines from adolescence into adulthood. The long-term effectiveness of modern orthopaedic care is not widely reported. This study aimed to report the pediatric orthopaedic surgical burden, residual deformities, and outcomes using objective evidence of mobility in ambulatory adults with CP. An institutional review board-approved prospective cohort study was performed in ambulatory adults with CP between 25 and 45 years, who had an adolescent gait analysis. Orthopaedic interventions were reviewed, and adolescent and adult gait analyses were compared using paired 2-tailed t tests. Adults were categorized by the presence of no, mild, or severe residual deformities in rotation, crouch, stiff knee, equinus, and foot deformity. Of 106 adults with CP, Gross Motor Function Classification System (GMFCS) distribution was grade I (22%), II (50%), III (23%), and IV (5%). Sixty-one males and 45 females were tested. The average age was 30±4 years with follow-up of 13±4 years since previous analysis; 279 surgical events (1165 procedures) were performed with a mean per patient of 2.6 events and 11 procedures. Comm on procedures were gastrocsoleus complex (88%) and hamstring lengthening (79%). The mean gait deviation index at adolescent and adult visit were 72.7±13 and 72.3±13 (P=0.78). Mean gait velocity at the adolescent visit was 85±27 and 79±31 cm/s at adult visit (P=0.02). Both gait deviation index and gait velocity change were clinically insignificant. Fifty-seven adults (81 limbs, 54%) had mild residual deformities. Residual hip internal rotation, pes planovalgus, and crouch gait were common. Severe deformities impacting function or causing pain were present in 11 participants (14 limbs, 10%). Seven of the 11 adults with severe deformities were worse compared with their adolescent evaluation; 4 were unchanged. Correcting deformities before adulthood has lasting stability with little functional loss in most ambulatory young adults with CP. Increasing deformity after adolescence can occur in young adults but is uncommon. Level III.

Weightbearing CT Assessment of Foot and Ankle Joints in Pes Planovalgus Using Distance Mapping

Category:Hindfoot; Ankle; OtherIntroduction/Purpose:The goal of this study was to describe the abnormal joint surface interaction at the ankle, hindfoot and midfoot joints in patients presenting with Pes Planovalgus (PP) using three-dimensional (3D) distance mapping on weightbearing computed tomography (WBCT) images by comparing a series of PPs to a series of normally-aligned feet. We hypothesized that in PPs joint interactions would reveal significantly increased spaces in the medial side of the ankle, hindfoot and midfoot joints.Methods:In this case-control study, ten feet (10 patients) with asymptomatic PP (cases; N=10) were compared to 10 matched- paired (by age, gender and body mass index) normally-aligned feet (10 patients) (controls; N=10). Three-dimensional models were produced from the images and distance maps representing joint surface configuration were generated for the ankle, hindfoot and midfoot joints. The distance maps for each joint were then compared between the two groups and between regions in the same group.Results:In PP patients there was a significantly increased surface-to-surface distance anteromedially at the ankle joint (+46.3%, p<0.001) along with an increased distance on the anterior halves of both the medial (+21.3%, p=0.098) and lateral malleoli (+22.7%, p=0.038). At the posterolateral corner of the posterior facet of the subtalar joint we found an increased surface-to- surface distance (by 57.1%, p< 0.001), while at the talonavicular joint there was a reduction of the distance at the superomedial corner (-20%, p=0.097) along with a significant increase in the upper central (+20%, p=0.039) and lateral (+30.7%, p=0.015) zones. A reduction of the surface-to-surface distance was also observed in three of the four zones of the calcaneocuboid joint. Finally, a statistically significant increase in the mean distance was observed at the naviculocuneiform and tarsometatarsal joints in a range between 38% and 93.4% (p<0.001 in all cases).Conclusion:We found significant differences in surface-to-surface interaction at the foot and ankle joints between Pes Planovalgus and normally-aligned controls. Distance mapping on WBCT images could be used in clinical practice as a diagnostic support to gauge the morphological changes of articular spaces occurring in Pes Planovalgus.

Long Term Patient Reported Outcomes of Tarsal Coalition Resection in Pediatric Patients

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:Tarsal Coalition has been known to be associated with pes planovalgus, unrelenting pain, recurrent sprains, and arthrosis due to an abnormal connection between two or more bones of the feet following failure of segmentation during development. Three entities of coalition exist fibrous, cartilaginous and osseous. Most commonly patients present with pain during activity. On exam range of motion is usually limited and there may be valgus or varus malalignment of the hindfoot. Patients are often offered surgical resection following failure of conservative management. Few large cohort studies exist analyzing complications and patient reported outcomes of pediatric patients undergoing operative treatment.Methods:After IRB approval, patients under the age of 18 undergoing excision of tarsal coalition at a single academic center from 2010-2019 were identified. Medical records were reviewed for variables such as demographics, surgical technique, coalition characteristics, postoperative complications, and coalition recurrence. Patients were contacted via telephone to complete a PROMIS Physical Function and Pain Interference in addition to the Foot Function Index. Contact was attempted at least 3 times before a patient was considered non-respondent. A total of 44 patients and 54 feet were included in the analysis with 17 patients (22 feet) completing patients reported outcomes.Results:The median age at the time of surgery was 12 (IQR 3). Thirty-five feet (64.8%) were from male patients, while 19 feet (35.2%) were from female patients. Pain was the presenting symptom in 49 (90.7%) of feet. Pes planovalgus was present in 25 feet (46.3%). Forty feet (74.1%) had calcaneonavicular coalition compared to 12 feet (22.2%) with talocalcaneal coalition and 2 feet (3.7%) with both. Fibrous coalition was found in 19 feet (35.2%) and the most common. Interposition material was used in 49/54 (90.7%) feet. Wound complications or temporary neuropraxias were seen in 7/54 feet (13.0%), and coalition recurrence occurred in 3/54 feet (5.6%). At a median of 6 years (6.0 IQR) postoperatively, the median postoperative outcomes scores were as follows: PROMIS Physical Function 54.7 (17.9 (IQR)), PROMIS Pain Interference 38.7 (10.0), FFI Pain 14.0 (30.0), FFI Disability 1.0 (9.0), FFI Activity Limitation 3.0 (8.0), and FFI Total 6.0 (12.0).Conclusion:Our study investigated complications and long-term patient outcomes following coalition resection. At follow-up, pediatric patients who underwent excision of tarsal coalition had higher physical function and less pain than the average U.S. population (PROMIS population mean is score of 50). Our recurrence rate of 5.6% is lower than reported in literature. Infection rate was similar to reports in literature at 3.1%. Overall, Coalition resection in pediatrics is a well-tolerated procedure that improves both physical and emotional health.

What are the long-term outcomes of lateral column lengthening for pes planovalgus in cerebral palsy?

BackgroundLateral column lengthening (LCL) is commonly performed on children and adolescents with cerebral palsy (CP) for correction of pes planovalgus (PPV). There are limited reports of the long-term outcomes of this procedure. The purpose of this study was to examine the long-term results of LCL for correction of PPV in individuals with CP by evaluating subjects when they had transitioned to adulthood and were entering the workforce. MethodsClinical assessments, quantitative gait analysis including the Milwaukee Foot Model (MFM) for segmental foot kinematics, and patient reported outcomes were collected from 13 participants with CP treated with LCL for PPV in childhood (average age 24.4 ± 5.7 years, average 15.3 ± 8.5 years since LCL). Additionally, 27 healthy adults average age 24.5 ± 3.6 years functioned as controls. ResultsStrength and joint range of motion were reduced in the PPV group (p < 0.05). Sixty nine percent showed operative correction of PPV based on radiologic criteria. Gait analysis showed reduced walking speed and stride length, as well as midfoot break and residual forefoot abduction. Patient reported outcomes indicated that foot pain was not the only factor that caused limited activity and participation. LCL surgery for PPV in childhood resulted in long-term operative correction. Decreased ankle passive range of motion and strength, subtalar joint arthritic changes, inefficient and less stable ambulation, and problems with participation (difficulties in physical function, education, and employment) were observed in the long-term. ConclusionThis study identified postoperative impairments and limitations to guide future clinical decision-making. These results provide clinicians and researchers the common residual and recurrent issues for these individuals as they age. The inclusion of contextual factors that influence the disease and impairments can equip these individuals with enhanced skills they need as they transition into adulthood.