Spring Ligament Research Articles

Outcomes of 2B Adult Acquired Flatfoot Deformity Correction in Patients With and Without Spring Ligament Tear.

It is currently unclear how injury to the spring ligament (SL) affects the preoperative presentation of adult acquired flatfoot deformity (AAFD) or the outcome of operative reconstruction. The purposes of this study were to assess the preoperative features and pre- or postoperative function of patients who underwent direct operative repair of an SL tear compared to those without a tear. 86 patients undergoing operative correction of grade 2B AAFD by a single fellowship-trained foot and ankle orthopaedic surgeon were reviewed at an average follow-up of 45.9 months. There were 35 feet found to have an SL tear that underwent concomitant debridement and direct repair of the SL. Patient charts were reviewed for demographic information, preoperative visual analog scale (VAS) pain level, and their Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and sports subscales. Preoperative radiographic parameters were assessed. Patient outcomes of VAS pain, FAAM-ADL, and FAAM-Sports were collected and compared between groups. Those with an SL tear had significantly lower FAAM-ADL and sports scores, with higher VAS pain scores preoperatively. Patient age, talonavicular uncoverage percentage, and talonavicular angle were found to be associated with spring ligament degeneration. At final follow-up, patients demonstrated a significant improvement in all outcome parameters, with no statistical difference found with patient satisfaction, final postoperative VAS pain, FAAM-ADL, or FAAM-Sports in those requiring a repair of their SL as compared to the control group. Increasing patient age, increasing talonavicular uncoverage percentage, and decreasing talonavicular angle are all independently associated with increased likelihood of patients with AAFD having an SL tear. At follow-up for operative treatment of grade 2B AAFD flatfoot with our approach, we found no clinical outcomes difference between those without SL tears and those with SL tears treated with concomitant SL debridement and repair. Level III, retrospective cohort study.

Short Term Clinico-Radiological Outcome of Extra Osseous Talo-Tarsal Stabilization (EOTTS) in Flat Foot: An Indian Perspective.

Flexible flat foot is one of the most common foot conditions found amongst any age group across the world. One very important reason for this condition is the incongruency or partial dislocation of one or more joints within the talo-tarsal mechanism. This flexible talo-tarsal malalignment is termed as recurrent talo-tarsal joint dislocation (RTTJD). Between 2016 and 2018, 32 patients were advised Extra osseous talo-tarsal stabilization (EOTTS) as a standalone procedure for RTTJD following detailed clinical examination including foot posture index (FPI) scoring and weight-bearing radiographic evaluation. Subjective assessment was done through Maryland Foot Score (MFS) questionnaire. Radiological parameters like talar declination angle, talar second metatarsal angle and tibio-calcaneal valgus angle were assessed for preoperative and postoperative comparison. 15 patients (20 feet) underwent surgery and rest 17 patients (25 feet) became our control group. A retrospective record analysis of longitudinal data was done over a period of 4years. The purpose of this study is to depict the short-term results of EOTTS procedure in terms of functional and radiological improvement and compare it with the non-surgical group. Significant improvement was seen in MFS from 67.31 ± 16.04 to 95.47 ± 4.36 over a mean follow-up period of 30.66 ± 7.09months. Total FPI improved by 96.83 ± 4.80% at final follow-up of EOTTS group. Radiologically, maximum correction achieved was in coronal plane (93.07 ± 30.05%). EOTTS, as a standalone procedure improved the foot radiological angles and restored the normal foot biomechanics significantly in presence of competent spring ligament and posterior tibial tendon. This procedure resulted in excellent patient satisfaction score as assessed by MFS questionnaire. III.

Comparison of each bundle of the spring ligament complex between the standing and supine positions: A multiposture magnetic resonance imaging study

BackgroundThe spring ligament complex (SLC) supports the medial longitudinal arch of the foot, particularly in standing. We evaluated posture-related changes in the thickness and length of the three SLC bundles and their histology. MethodsThe thickness and length of the supramedial calcaneonavicular ligament (smCNL), medioplantar oblique calcaneonavicular ligament (mpoCNL), and inferoplantar calcaneonavicular ligament (iplCNL) were measured in the supine and standing positions, using a multiposture magnetic resonance imaging system, in 72 healthy adult feet. Histological examination was performed for 10 feet from five cadavers. ResultsThe smCNL thickness decreased and its length increased from the supine to the standing position (P < 0.001); no other posture-related effects were noted. Histologically, smCNL fibers overlapped along multiple directions while mpoCNL and iplCNL, fibers were oriented horizontally along the longitudinal axis and vertically along the short axis, respectively. ConclusionThe complex, multidirectional, orientation of the smCNL allows an adaptive response to changes in loading.

Augmented Spring Ligament Repair in Pes Planovalgus Reconstruction

Patients with pes planovalgus deformity often have coexisting spring ligament pathology. A primary repair of the ligament may fail during weightbearing due to chronic degeneration of the ligamentous tissue. Augmentation with a suture tape has been suggested to strengthen the repair. Limited data exist regarding flatfoot reconstruction with augmented spring ligament repair using a suture tape. This is a review of 57 consecutive patients who had flatfoot reconstruction with concomitant spring ligament augmented repair between July 2014 and August 2017. Weightbearing radiographic parameters were obtained preoperatively and compared to radiographs at an average time of 62 ± 46.5 (range 20-220) weeks postoperative. Significant improvements were seen in the radiographic parameters evaluated. Five patients had subsequent operations including one deep infection, 2 hardware removals remote to the spring ligament augmentation, 1 ankle arthrodesis, and 1 triple arthrodesis. Concomitant spring ligament repair augmented with a suture tape was a safe procedure that contributed to radiographic correction in a consecutive series of 57 patients undergoing flatfoot deformity correction.

Ankle and syndesmosis instability: consensus and controversies.

Ankle sprains are mainly benign lesions, but if not well addressed can evolve into permanent disability. A non-treated lateral, syndesmotic or medial ankle instability can evolve into ankle osteoarthritis. For this reason, diagnosis and treatment of these entities is of extreme importance.In general, acute instabilities undergo conservative treatment, while chronic instabilities are better addressed with surgical treatment. It is important to identify which acute instabilities are better treated with early surgical treatment.Syndesmosis injuries are frequently overlooked and represent a cause for persistent pain in ankle sprains. Unstable syndesmotic lesions are always managed by surgery.Non-treated deltoid ligament ruptures can evolve into a progressive valgus deformity of the hindfoot, due to its links with the spring ligament complex. This concept would give new importance to the diagnosis and treatment of acute medial ligament lesions.Multi-ligament lesions are usually unstable and are better treated with early surgery. A high suspicion rate is required, especially for combined syndesmotic and medial lesions or lateral and medial lesions.Ankle arthroscopy is a powerful tool for both diagnostic and treatment purposes. It is becoming mandatory in the management of ankle instabilities and multiple arthroscopic lateral/syndesmotic/medial repair techniques are emerging.Cite this article: EFORT Open Rev 2021;6:420-431. DOI: 10.1302/2058-5241.6.210017

Peroneus Longus overload caused by soft tissue deficiencies associated with early adult acquired flatfoot: A finite element analysis

BackgroundPeroneus Longus tendinopathy has been related to overload from cavus and ankle instability. The etiology of isolated Peroneus Longus tendon synovitis has not been elucidated. Loss of foot arch integrity as a cause of isolated Peroneus Longus overload is difficult to establish using cadaver modeling. Our objective was to analyze Peroneus Longus stress changes in pathological scenarios related to flatfoot development. MethodsA three-dimensional finite element foot model which included the foot bones and main soft tissues that maintain the arch was used. Simulations were performed in midstance of gait. Tendon's maximum principal stress and von Mises were calculated in scenarios where the plantar fascia, spring ligament and the posterior tibial tendon were weakened. FindingsDecreasing plantar fascia stiffness thus weakening arch integrity increases Peroneus Longus stresses by over three times. Additional failure of tissues that support arch, such as the spring ligament and tibialis posterior tendon further overloads this tendon. The absence of Peroneus Longus also affects stresses in tissues that maintain the arch. Stress concentrations increase in the plantar component of the Peroneus Longus. InterpretationResults offer an explanation into isolated Peroneus Longus overload synovitis. Recognition of failing medial arch structures that occur in early acquired flatfoot as a cause of Peroneus Longus overload could help in its treatment. We caution the practice of transfer of peroneus brevis to longus in surgical treatment of flatfoot as it may further overload an overloaded tendon and focus should be on restoration of arch stability to offload stresses within it.

MRI of lateral hindfoot impingement.

Lateral hindfoot impingement (LHI) is a subtype of ankle impingement syndrome with classic MRI findings. Biomechanically, LHI is the sequela of lateral transfer of weight bearing from the central talar dome to the lateral talus and fibula. The transfer occurs due to collapse of the medial arch of the foot, most commonly from posterior tibial tendon (PTT) and spring ligament (SL) insufficiency. Clinical features include lateral hindfoot pain, deformity, and overpronation on gait analysis. MRI changes continuously reflect the altered biomechanics as the syndrome progresses over time, including typical and often sequential changes of PTT and SL failure, increasing heel valgus, talocalcaneal and subfibular impingement, and finally lateral soft tissue entrapment. In addition to diagnosis, MRI is a useful adjunct to plan surgical treatment.

Spring ligament insufficiency and hallux valgus as an independent risk factors for first ray instability

IntroductionFirst ray instability (FRI) arising from failed plantar/interosseous ligaments is strongly associated with planovalgus, leading to synovitis and deformity. Our hypothesis is that proximal spring ligament insufficiency (SLI) drives secondary FRI in the absence of hallux valgus (HV) and may be an independent risk factor. MethodsPatients with FRI, screened by Klaue’s test, were recruited. Patients’ normal contralateral feet with previous radiographs were included as controls. First ray dorsal translation was measured with a digital Klauemeter. Spring ligament integrity was assessed using lateral translation distance as an indirect measure of spring ligament strain. Intermetatarsal angle and hallux valgus angle were recorded to classify the severity of HV. ResultsSeventy feet included, 54 had symptomatic FRI and 16 were asymptomatic contralateral feet included as control. Twenty-three feet had moderate/severe HV and 47 had mild/normal HV. Moderate/severe HV was associated with FRI (OR, 10.31; p = 0.029). Forty-five feet with SLI had a strong association with FRI (OR, 100.7; p < 0.0001). SLI without moderate/severe HV was the most prevalent group (31/54), followed by SLI with moderate/severe HV, 29.63% (16/54). Moderate/severe HV without SLI was prevalent in 11.1% (6/54) and 1.85% (1/54) had no SLI or moderate/severe HV. In a multivariate logistic regression analysis model, both SLI and severe/moderate HV were independent predictors of FRI. ConclusionThis is the first study that links SLI and HV as independent risk factors to FRI. 98.15% of FRI can be attributed to SLI, HV or both. First ray instability may allude to the strong presence of spring ligament insufficiency in the absence of hallux valgus. Level of evidenceLevel III, retrospective cohort study.

Biomechanical Evaluation of a Cadaveric Flatfoot Model and Lateral Column Lengthening Technique

Patients with adult acquired flatfoot have progressive worsening of bony alignment with many being unable to perform a heel rise. Following reconstruction, pathologic skeletal alignment is corrected and the ability to perform a heel rise is often restored. The purpose of this study was to evaluate the relationship between forefoot liftoff forces and skeletal alignment in a cadaveric flatfoot model by assessing the effect of sequential lengthening of the lateral column using an Evans-type calcaneal osteotomy. Bony alignment was measured in 8 cadaveric specimens with the use of a 3-dimensional digitizing system. Transection of the spring ligament, pie-crusting of the plantar fascia, and cyclic axial loading of the foot was performed to create an anatomic and functional flatfoot model. An Evans-type calcaneal osteotomy using 6, 8, 10, and 12 mm wedges was performed. Specimens were mounted to a custom jig that applies tensile loads to the Achilles, peroneus brevis, peroneus longus, and tibialis posterior tendons. Creation of a flatfoot reduced the lateral talo-first metatarsal angle (Meary's angle) by 13° (23.6° ± 2.8° vs 10.6° ± 3.8°, p < .05) and forefoot force by 7% (199.3 N ± 7.3 N vs 185.4 N ± 9 N, p < .05). Sequential lengthening of the lateral column restored skeletal alignment and force transfer to the forefoot (12 mm wedge: Meary's angle 22.7° ± 3.9°, liftoff force 206.8 N ± 7.5 N). The cadaveric flatfoot model demonstrated decreased forefoot forces that were restored with an Evans-type calcaneal osteotomy wedge. This highlights the importance of restoring skeletal alignment when correcting advanced adult acquired flatfoot.

Validity and reproducibility of foot motion analysis using a stretch strain sensor

BackgroundMulti-segment foot analysis is traditionally challenging to perform while subjects are wearing footwear or a foot orthosis and is difficult to apply in the clinical setting. A recently developed stretch strain sensor (STR), that is thin and highly flexible, may solve this limitation because it does not require observation using a camera and is highly portable. Research questionThis study aimed to examine the reproducibility and validity of foot motion analysis using the STR during walking and running by comparing it with a conventional motion capture system. MethodsTwenty-one healthy participants were examined in this study. The STR was placed on the participant's foot in one of two locations in separate experiments (spring ligament; SL and navicular drop; ND methods). Foot kinematic data during walking and running were simultaneously recorded using the STR and a three-dimensional motion capture system. Intra-class correlation (ICC) was used to assess test-retest reproducibility of the STR method. Cross-correlation coefficient evaluated the similarity of the pattern of the signals between the two systems. Pearson and Spearman correlation analysis was used to evaluate the relationships between the STR measurement and angular excursion of the forefoot or hindfoot. ResultsThe ICCs of the SL method were 0.95 and 0.96, and those of the ND method were 0.93 and 0.71 during walking and running, respectively. In the SL method, the pattern of the signals between the STR and forefoot frontal motion was strongly correlated. The STR measurement was significantly correlated with forefoot eversion excursion (walking: r=-0.67, running: r=-0.64, p < 0.01 each). In the ND method, the STR signal was not associated with forefoot and hindfoot kinematics. SignificanceOur results showed that the STR has acceptable reproducibility and validity of foot motion analysis. This system may enable measurement of foot motion while subjects are wearing shoes and outside the laboratory.

MRI findings of spring ligament injury: association with surgical findings and flatfoot deformity.

BackgroundSpring ligament injury is an important cause for flatfoot deformity; however, reliability of magnetic resonance imaging (MRI) findings of spring ligament injury is still ambiguous.PurposeTo investigate the reliability of MRI findings for the diagnosis of spring ligament injury.Material and methodsForty-three cases with spring ligament injury proven by surgery and 29 control cases were enrolled. The spring ligament complex was demonstrated on proton density-weighted images reconstructed from 3D-isotropic MRI data. The presence of waviness, discontinuity, and abnormally high signal intensity of the spring ligament complex was evaluated by two radiologists in cooperation. Also, injury of the posterior tibial tendon (PTT) on MRI and the lateral talo-1st metatarsal angles on weight-bearing X-rays were evaluated.ResultsDiscontinuity and abnormally high signal intensity of the superomedial calcaneonavicular ligament (SmCNL) on MRI were more frequently observed in patients with spring ligament injury than in controls (p < 0.001). Discontinuity and abnormally high signal intensity of the SmCNL were found more often in the PTT injury group than in those without (p < 0.001). The talo-1st metatarsal angle was greater in patients with discontinuity and abnormally high signal intensity of the SmCNL on MRI than in patients without these findings (p < 0.001).ConclusionDiscontinuity and abnormally high signal intensity are reliable MRI findings for spring ligament injury and related disorders, such as flatfoot deformity and PTT injury.

Tendoscopy for Early-Stages (I and II) Posterior Tibial Tendon Dysfunction

Tendoscopy of tibialis posterior tendon has been proposed &gt;20 years ago for the treatment of posterior tibial tendon dysfunction. A few studies have reported satisfactory results in stages I and II posterior tibial tendon dysfunction (Johnson and Strom classification). This approach allows us to assess the posterior tibial tendon and the spring ligament status, and if needed to perform a synovectomy with soft-tissue debridement. Longitudinal split tendon tears can also be repaired. In case of failure, a traditional corrective open surgery can normally be performed. In this manuscript, we summarize the history of this technique and also reported the indications, surgical approach, results, and complications.

The Flexor Retinaculum Connects the Surrounding Structures into the Medial Ankle Complex

This study aimed to prove the hypothesis that the medial structures of the ankle are interconnected through the flexor retinaculum’s projections. We conducted a retrospective re-evaluation of 132 MRI examinations of the ankle joint from 57 females and 75 males with an age range of 18–65 and a mean age of 35 years. The correlation between the presence of connections between the flexor retinaculum and the deltoid ligament, the spring ligament, the inferior extensor retinaculum, the paratenon, the fibulotalocalcaneal ligament, the fascia covering the abductor hallucis, and the flexor fibrous sheath were studied. The most common connections of the flexor retinaculum were to the deltoid ligament (97%), the fibulotalocalcaneal ligament (84.1%), and the flexor fibrous sheath (83.3%). Interconnection between the flexor retinaculum and the deltoid ligament correlated with the presence of connections between the flexor retinaculum and the inferior extensor retinaculum, the paratenon, and the spring ligament. Side difference was noticed in connections to the flexor fibrous sheath, the deltoid ligament, the fascia on the abductor hallucis, and the paratenon (p &lt; 0.05). The flexor retinaculum formed a more complex anatomical unit with adjacent structures.

Joint-preserving surgical correction of advanced flexible planovalgus deformity of the adult foot

Adult acquired flatfoot deformity is characterized by aprogressive functional deficit of the foot that leads to an eversion of the subtalar joint complex with heel valgus, abduction of the forefoot and collapse of the medial arch. In the case of aflexible deformity, ajoint-preserving operative reconstruction is advisable, which should correct all elements of the deformity. Acalcaneal lengthening osteotomy can correct excessive abduction of the forefoot, which can be measured by the amount of talar head uncoverage visible on AP weight-bearing x‑rays of the foot. Any calcaneal lengthening osteotomy leads to an incongruence between talar and calcaneal joint surfaces of the subtalar joint, which is arisk factor for secondary degenerative changes. It is, therefore, advisable to limit the amount of lengthening to thenecessary minimum. Aresidual heel valgus can be corrected by an additional medial displacement osteotomy as adjunct to the calcaneal lengthening. Calcaneal osteotomies are usually part of acomplex reconstruction of advanced but still flexible adult flatfoot deformities. In addition to the correction of the hindfoot deformity, persistent forefoot supination needs to be corrected. In cases of midfoot instability, which is frequently located in the naviculo-cuneiforme joint line, acorrective arthrodesis is recommended. Without midfoot instability forefoot aCotton osteotomy is able to reduce forefoot supination and add to reconstruction of the medial arch of the foot. All bony corrections should be combined with soft tissue reconstruction, i.e. spring ligament repair, Flexor tendon transfer and, in cases of gastrocnemius shortening, agastroc recession.

Predictors of Spring Ligament Degeneration and Outcomes of Reconstruction during Correction of Adult Acquired Flatfoot Deformity

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:It is currently unclear how injury to the spring ligament (SL) affects the preoperative presentation of adult acquired flatfoot deformity (AAFD). The purposes of this study were to retrospectively identify shared factors that could be used to preoperatively predict SL damage in patients undergoing AAFD correction as well as compare outcomes of patients undergoing SL reconstruction to those not undergoing reconstruction during AAFD correction.Methods:All patients undergoing operative correction of grade 2B AAFD secondary to tibialis posterior tendon dysfunction by a single fellowship-trained foot and ankle orthopaedic surgeon from 2011 to 2017 were reviewed. Operative reports were reviewed for the surgeon’s evaluation of the competency of the SL and to determine whether SL reconstruction was performed. Patient charts were reviewed for demographic information, preoperative Visual Analog Scale (VAS) pain level, and their Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and -Sports subscales. Preoperative radiographic parameters were assessed by a surgeon blinded to the intraoperative findings. Patient outcomes of VAS pain, FAAM-ADL, and FAAM-Sports were collected at a minimum of 24 months postoperatively. Multiple logistic regression analysis was performed to determine significant independent predictors of spring ligament tears.Results:The study included 115 feet undergoing corrective reconstruction, with 47 feet having a spring ligament tear (40.9%). Patients with tears were significantly older (p<0.001), with higher preoperative reported pain (p=0.01), and lower preoperative FAAM-ADL (p=0.04) and -Sports (p=0.006) scores than those without SL tears. Patients with a SLT demonstrated significant differences in AP talo-1st MT angle (p=.003), talonavicular uncoverage percentage (p<0.001), talonavicular angle (p=0.017), and Meary`s talo-1st MT angle (p=0.001). Based on multiple logistical regression analysis (odds ratio [95% confidence interval]), patient age (1.10 [1.03, 1.18]; p=0.003), talonavicular uncoverage percentage (1.35 [1.13, 1.60]; p<0.001), and talonavicular angle (0.82 [0.71, 0.96]; p=0.0133) were independently predictive of ligament degeneration. Patients undergoing SL reconstruction did not differ significantly in functional score improvements compared to those without reconstruction.Conclusion:Our findings suggest that a SLT is associated with more advanced flexible pes planovalgus, measured both by radiographic parameters as well as its impact on patient function. Increasing patient age, increasing talonavicular uncoverage percentage, and decreasing talonavicular angle are all independently associated with increased likelihood of patients with AAFD having a SLT. AAFD correction with concomitant SL reconstruction does not appear to influence absolute or changes in patient pain and function.

Short-Term Complications Following Early Protected Weight Bearing after Flatfoot Reconstruction when Utilizing a Fibertape Device for Spring Ligament Reefing Augmentation

Category:AnkleIntroduction/Purpose:In an estimated 70% of cases of Adult Acquired Flatfoot Deformity (AAFD) reconstruction, the spring ligament is elongated and/or damaged. Spring ligament reefing can be performed through several techniques including augmentation with Fibertape devices. In addition, biomechanical studies have demonstrated its safety and suggest early weight bearing may be performed. The purpose of this study is to evaluate the outcomes of early weight bearing following flatfoot reconstruction with use of InternalBrace augmentation for spring ligament reefing when performed in combination with medical displacing calcaneal osteotomy (MCO) and FDL tendon transfer.Methods:From 2016-2018, 45 patients underwent flatfoot reconstruction (MCO, FDL transfer, and gastrocnemius recession) with spring ligament reefing and augmentation with the InternalBrace device. All surgeries were performed by the senior orthopaedic surgeons (PJJ & MCA). Institutional early post-operative weight bearing protocol involves weight bearing as tolerated in a splint with crutches for two weeks, transitioning at 2 weeks to a Cam boot with 1 wedge WBAT. At 4 weeks, the patient is weaned off crutches and recommended to start therapy restricting excessive eversion and concentrating on calf strengthening, gait, and ROM. At weeks 6-8 they are weaned from the Cam boot into lace up ASO and shoe with arch support. Data were recorded at 2 weeks, 6 weeks, 12 weeks, 6 months and at yearly intervals. Outcomes and complications were documented.Results:Of the 45 cases there were no complications related to early weight bearing. Radiographic bony union rate of the MCO was 100% (45/45). Moreover, there was no loss of fixation of either the FDL transfer or spring ligament reefing with InternalBrace augmentation with early weight bearing. Lastly, radiographic evaluation noted no loss of Meary’s talo-first metatarsal angle when comparing initial postoperative radiographic to their final follow up. Additional complications in our cohort included the following: removal of painful hardware (1, 2.22%), sural neuritis (2, 4.44%), superficial cellulitis (1, 4.44%), and delayed lateral wound healing(1, 2.22%).Conclusion:Preliminary data shows that early protected weight bearing after flatfoot reconstruction and augmentation of the spring ligament with the InternalBrace device is safe and demonstrates few complications and no early loss of correction.

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.

Subtalar Arthroereisis as an Adjunct Procedure Improves Forefoot Abduction in Stage IIb Adult- Acquired Flatfoot Deformity

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:Our aims were: (i) to determine whether subtalar arthroereisis (STA) as adjunct procedure improved radiographic correction of stage IIb adult acquired flexible flatfoot deformity (AAFD); (ii) to assess the STA-related complication rate.Methods:A retrospective analysis of 22 feet (21 patients) diagnosed with stage IIb AAFD treated by medialising calcaneal osteotomy (MCO), flexor digitorum longus (FDL) transfer, spring ligament (SL) repair with or without Cotton osteotomy and with or without STA in a single institution was carried out. Seven measurements were recorded on pre and postoperative (minimum 24 weeks) radiographs by two observers and repeated twice by one. Inter and intraobserver reliability was assessed. The association of demographic (gender, side, age, BMI) and surgical variables (Cotton, STA) with radiographic change was tested with univariate analysis followed by a multivariable regression model.Results:Excellent inter and intraobserver reliability was demonstrated for all measurements (ICC range, 0.75-0.99). Multivariable regression showed that STA was the only predictor of change in talo-navicular coverage angle (TNCA) (R2=0.31; p=0.03) and in calcaneo-fifth metatarsal angle (CFMA) (R2=0.40; p=0.02) on dorsoplantar view. STA was associated to a greater change in TNCA by 10.1 degrees and in CFMA by 5 degrees. Four patients out of 12 STA complained of sinus tarsi pain after STA, and removal of the implant resolved symptoms in 3 of them.Conclusion:In this series, STA as an adjunct procedure to MCO, FDL transfer, SL repair in the treatment of stage IIb AAFD led to improvement in correction of forefoot abduction. STA-related complication and removal rates were 33%.

The Efficacy of Surgical Treatment in the Correction of Adult Acquired Flatfoot Deformity: A Three- dimensional Biometric Weightbearing Computed Tomography Evaluation

Category:Hindfoot; Ankle; Midfoot/ForefootIntroduction/Purpose:Multiple surgical techniques are used in the correction of Adult Acquired Flatfoot Deformity (AAFD). Assessment of the efficacy of a surgical treatment in the correction of the deformity is usually performed by clinical evaluation and conventional radiographic imaging. Weightbearing CT (WBCT) allows a more reliable and multiplanar evaluation of AAFD. The Foot and Ankle Offset (FAO) is a WBCT biometric semi-automatic measurement that gauges the relative positioning between the foot tripod and the center of the ankle joint. This study aimed to investigate the efficacy of surgical treatment in correcting AAFD, comparing preoperative and postoperative FAO measurements. We hypothesized that surgical treatment would provide significant correction of the deformity, centering the tripod of the foot underneath the ankle joint.Methods:In this prospective comparative study, 21 adult patients (22 feet) with flexible AAFD were included, mean age 55 (range, 23-81) years, 13 females and eight males. Patients underwent preoperative and postoperative standing WBCT examination. Three-dimensional coordinates (X, Y and Z planes) of the foot tripod (weightbearing point of the first and fifth metatarsals and calcaneal tuberosity) and center of the ankle (apex of the talar dome) were harvested by two independent and blinded observers. The FAO was automatically calculated from the harvested 3D coordinates by dedicated software. Data regarding the surgical technique used was recorded. Patient Reported Outcomes (PROs) were collected preoperatively and postoperatively at a mean follow-up of 22 (range, 8-36) months. Pre and postoperative FAO measurements were compared by paired T-tests. Multivariate analysis was used to assess the influence of surgical procedures in the amount of FAO correction. P-values of less than 0.05 were considered significant.Results:We found excellent intra (0.98) and interobserver reliability (0.96) for FAO measurements. The mean preoperative FAO was 10.4 (95% CI, 8.5 to 12.1). There was a significant correction of the deformity postoperatively (p<0.0001), with a mean postoperative FAO of 1.4 (CI, -0.1 to 2.9), and mean improvement of 8.9 (95% CI, 6.6 to 11.2). Average increase in PROs was(p<0.05): physical function (8; CI, 4 to 12), pain interference (10.3; CI, 4.8 to 15.9), pain intensity (5.3; CI, -10:20.6), mental health(4.2; CI, 0.2:8.2), physical health (4.3; CI, 0.9 to 9.8), and depression (10.4; CI, -0.6 to 21.4). The mean number of surgical procedures performed was 8 (range, 2-12). Spring ligament reconstruction was the only technique that influenced the amount of FAO correction (P<0.001).Conclusion:To the author’s knowledge, this is the first study to assess the amount of surgical correction of AAFD using standing WBCT images and semiautomatic 3D measurements. We found that surgical treatment provided a significant and pronounced amount of correction in the FAO, with the foot tripod more centered underneath the ankle joint. We also found a significant improvement in the PROMIS after an average postoperative follow-up of 22 months. Among multiple different surgical procedures performed, reconstruction of the spring ligament was the only technique that significantly influenced the amount of FAO correction. Longer-term follow-up studies are needed.Figure 1.

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.