Symptomatic Flexible Flatfoot Research Articles

Symptomatic flexible flatfoot in adults: subtalar arthroereisis.

Flexible flatfoot is a common deformity in pediatric and adult populations. In this study, we aimed to evaluate the functional and radiographic results of subtalar arthroereisis in adult patients with symptomatic flexible flatfoot. We included 26 feet in 16 patients who underwent subtalar arthroereisis for symptomatic flexible flatfoot. Radiographic examination included calcaneal inclination angle, lateral talocalcaneal angle, Meary’s angle, anteroposterior talonavicular angle, and Kite’s angle. The clinical assessment was based on the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale and a visual analog scale (VAS). The mean follow-up was 15.1±4.7 months. The mean preoperative AOFAS score was 53±6.6, while the mean AOFAS score at the last follow-up visit was 75±11.2 (P<0.05). The mean visual analog scale score was 6.9±0.6 preoperatively and 4.1±1.4 at the last follow-up visit (P<0.05). The mean preoperative and postoperative values measured were 13.4°±3.3° and 14.6°±2.7° for calcaneal inclination angles (P<0.05); 35.7°±6.9° and 33.2°±5.3° for lateral talocalcaneal angles (P>0.05); 8°±5.3° and 3.3±3 for Meary’s angles (P<0.05); 5.6°±3.5° and 2.6°±1.5° for anteroposterior talonavicular angles (P<0.05); and 23.7°±6.1° and 17.7°±5° for Kite’s angles, respectively (P<0.05). Implants were removed in three feet (11.5%). Subtalar arthroereisis is a minimally invasive procedure that can be used in the surgical treatment of adults with symptomatic flexible flatfoot. This procedure provided radiological and functional recovery in our series of patients.

Más de 10 años de seguimiento de la técnica de calcáneo stop

IntroductionInfantile flexible flatfoot does not require treatment in most cases. Symptomatic flexible flat feet are treated orthopaedically and surgery is only indicated when orthosis fails. Material and methodsCases who underwent surgical treatment with the stop screw technique at the 12 de Octubre Hospital between 1995 and 2002 are reported. Patient progress is also analysed. Six angles are measured on the x-ray prior to surgery and those same x-ray angles are measured again before material extraction. They are then compared to see if the correction achieved is statistically significant. A more reduced sample is currently being assessed with the same radiological measurements and two clinical assessment scales: Lickert, and Smith and Millar. The latest x-rays are analysed by two radiologists to determine if there is subtalar arthrosis. ResultsIn the short term, statistically significant differences are observed in all angles. The comparison between the post-surgery angles and the current angles does not show differences, except for the Giannestras angle, which has statistically significantly worsened. Clinical results and patient satisfaction is good. Incipient subtalar arthrosis is present in 68.5% of current patient x-rays. ConclusionsStop screw method is a cheap, simple and effective technique to correct symptomatic flexible flatfoot that has not improved with conservative treatment. This technique provides short-term foot correction which can be maintained over time.

Effect of Custom-Molded Foot Orthoses on Foot Pain and Balance in Children With Symptomatic Flexible Flat Feet.

ObjectiveTo evaluate the effect of custom-molded foot orthoses on foot pain and balance in children with symptomatic flexible flat foot 1 month and 3 months after fitting foot orthosis.MethodA total of 24 children over 6 years old with flexible flat feet and foot pain for at least 6 months were recruited for this study. Their resting calcaneal stance position and calcaneal pitch angle were measured. Individual custom-molded rigid foot orthoses were prescribed using inverted orthotic technique to control foot overpronation. Pain questionnaire was used to obtain pain sites, degree, and frequency. Balancing ability was determined using computerized posturography. These evaluations were performed prior to custom-molded foot orthoses, 1 month, and 3 months after fitting foot orthoses.ResultOf 24 children with symptomatic flexible flat feet recruited for this study, 20 completed the study. Significant (p<0.001) improvements in pain degree and frequency were noted after 1 and 3 months of custom-molded foot orthoses. In addition, significant (p<0.05) improvement in balancing ability was found after 3 months of custom-molded foot orthoses.ConclusionShort-term use of custom-molded foot orthoses significantly improved foot pain and balancing ability in children with symptomatic flexible flat foot.

Calcaneo-stop Procedure for Management of Pediatric Symptomatic Flexible Flatfoot

Calcaneo-stop Procedure for Management of Pediatric Symptomatic Flexible Flatfoot

Isolated Spring Ligament Failure as a Cause of Adult-Acquired Flatfoot Deformity

Adult-acquired flatfoot deformity is usually secondary to failure of the tibialis posterior tendon, with secondary injury to the surrounding osseous-ligamentous complex. Rarely, patients may present with a normal tibialis posterior tendon and an isolated injury of the plantar calcaneonavicular, or spring, ligament. The current study describes the clinical presentation and operative management of 6 patients with isolated spring ligament ruptures who presented with symptomatic flexible flatfoot deformities. Six consecutive patients with unilateral flatfoot deformities secondary to spring ligament failure were operatively treated at one institution between 2003 and 2010. All patients presented with symptomatic flatfoot deformities recalcitrant to conservative management. No patients had previous flatfoot reconstructive surgery, but all had undergone some combination of orthotic use, immobilization, or activity modifications prior to operative treatment. In each case, intraoperative findings demonstrated a tear of the spring ligament complex with a normal tibialis posterior tendon. To address the deformities, spring ligament repairs and adjunctive flatfoot reconstructions were performed. A retrospective chart study was performed to document patient presentation, demographics, and outcomes. Average patient age was 42 years. All 6 patients were female. All patients presented with medial foot pain for a mean of 27 months prior to presentation. Spring ligament abnormality was demonstrated in all 5 patients who received preoperative magnetic resonance imaging. Intraoperatively, all 6 patients demonstrated spring ligament tears and no significant tibialis posterior tendon abnormality. All 6 patients underwent spring ligament repairs with or without adjunctive flatfoot reconstructions. At mean follow-up of 13 months, all but 1 patient were pain-free without orthotics, and all patients were without residual deformity. There was a single patient with delayed bone graft healing and no other minor or major complications in this series. Adult-acquired flatfoot deformity is usually secondary to tibialis posterior tendon failure but in rare cases may be secondary to isolated spring ligament injury without tibialis posterior tendon abnormality. This unique clinical entity should be considered in patients who present with flatfoot deformities. In this study, although preoperative magnetic resonance imaging was not required, it identified a suspected spring ligament tear in all cases in which it was used. Thorough intraoperative exploration can identify an injury to the spring ligament and a normal tibialis posterior tendon. Failure to recognize an isolated spring ligament injury as the primary cause of a flatfoot deformity could lead to inappropriate operative management. Level IV, retrospective study.

Correcting Pediatric Flatfoot With Subtalar Arthroereisis and Gastrocnemius Recession

Flatfoot deformities are common in children and are treated using many conservative and surgical approaches. Subtalar extra-articular arthroereisis, in particular, limits talar motion, spares the subtalar joint, and prevents excessive subtalar joint pronation. Addressing the underlying equinus deformity with gastrocnemius recession is an important factor in optimizing outcomes in patients with flatfoot deformity. This study included 20 children, 4 to 17 years old. The patients presented 34 cases of functional flexible flatfoot, and each was treated with gastrocnemius recession and a subtalar implant insertion of either a resorbable arthroereisis plug constructed of poly-L lactic acid or a threaded titanium alloy plug. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale as well as subjective assessments of pain, function, shoe wear, and overall preoperative and postoperative satisfaction. The average AOFAS Ankle-Hindfoot Scale reading improved by 21.3 points (standard deviation = 8.1; 95% confidence interval = 17.5-25.1), from an average preoperative reading of 67.7 points to an average postoperative reading of 89 points (P < .0001). Subjectively, patients experienced reduced pain and improved function, cosmesis, and shoe wear. Treating equinus deformity with gastrocnemius recession significantly improved patient outcomes when treating flatfoot deformity. Reconstructive flatfoot surgery that combined subtalar arthroereisis with a resorbable arthroereisis plug and gastrocnemius recession resulted in favorable clinical outcomes and patient satisfaction. Symptom improvement and preservation of the subtalar joint were seen with these procedures, which are reasonable and useful options in treating children with symptomatic flexible flatfoot. Therapeutic, Level IV, Retrospective case series.

Comparison of the Calcaneo-Cuboid-Cuneiform Osteotomies and the Calcaneal Lengthening Osteotomy in the Surgical Treatment of Symptomatic Flexible Flatfoot

Surgery is indicated in symptomatic flatfoot when conservative treatment fails to relieve the symptoms. Osteotomies appear to be the best choice for these painful feet. The purpose of this study was to compare the clinical and radiographic outcome of the calcaneo-cuboid-cuneiform osteotomies (triple C) and the calcaneal-lengthening osteotomy in the treatment of children with symptomatic flexible flatfoot. The surgeries were performed by senior surgeons who preferred either triple C or calcaneal lengthening. The results were graded by an orthopaedic surgeon uninvolved with the cases. The clinical and radiographic outcome was evaluated in 30 feet (21 patients) with a triple C osteotomy and 33 feet (21 patients) with a calcaneal-lengthening osteotomy. We used the American College of Foot and Ankle Surgeons (ACFAS) score (flatfoot module) for clinical assessment, which contains a subjective and objective test. We measured and compared 12 parameters on the anteroposterior and lateral weight-bearing radiographs. The effect of additional procedures (Kidner procedure, medial reefing of the talonavicular capsule, tendo-Achilles lengthening, peroneous brevis lengthening and, in the calcaneal-lengthening group, a medial cuneiform osteotomy) on the clinical and radiographic result was also evaluated. Average age at the time of surgery was similar (triple C: 11.2 ± 3 y, calcaneal lengthening: 11.6 ± 2.5 y, P = 0.51). Average follow-up was 2.7 ± 2.2 years in the triple C group and 5.3 ± 4 years in the calcaneal-lengthening group. There were no significant differences in the clinical outcome measured by the ACFAS subjective test in the calcaneal-lengthening group (P = 0.003). There were no significant differences in the ACFAS score, both the subjective test (triple C: 43.3 ± 6.1, calcaneal lengthening: 44.7 ± 7.6, P = 0.52) and the ACFAS objective test (triple C: 28.6 ± 2, calcaneal lengthening: 25.9 ± 7, P = 0.13). We found significant differences in 2 of the 12 radiographic measurements: anteroposterior talo-first metatarsal angle (triple C: 15.5 ± 11.1, calcaneal lengthening: 7.4 ± 7.3, P = 0.001) and talonavicular coverage (triple C: 28 ± 14.7, calcaneal lengthening: 13.7 ± 12.4, P<0.001). None of the additional procedures improved the clinical outcome. There were 3 (10%) complications in the triple C group and 6 (18%) complications in the calcaneal-lengthening group. Also, calcaneocuboid subluxation was present in 17 (51.5%) feet of the calcaneal-lengthening group. Both techniques obtain good clinical and radiographic results in the treatment of symptomatic idiopathic flexible flatfoot in a pediatric population. The calcaneal-lengthening osteotomy achieves better improvement of the relationship of the navicular to the head of the talus but it is associated with more frequent and more severe complications. Additional soft-tissue procedures have not proven to improve clinical or radiographic results. Level III, retrospective comparative study.

Arthroereisis of the Subtalar Joint: An Uncommon Complication and Literature Review

Arthroereisis is an operation to prevent abnormal pronation in the subtalar joint in children and adults with symptomatic flexible flatfeet. In the present report, we describe an uncommon late complication of a former variation of this procedure, namely the case of an adult male who experienced migration of a xenogeneic bone graft that had been implanted 55 years earlier. A thorough review of the existing data was also undertaken to better understand the complications of this procedure.

The Modified Kidner-Cobb Procedure for Symptomatic Flexible Pes Planovalgus and Posterior Tibial Tendon Dysfunction Stage II: Review of 50 Feet in 39 Patients

Symptomatic flatfoot is a prevalent disorder. We undertook a review of 50 feet in 39 patients with flexible flatfoot treated between August 2000 and January 2008 in order to evaluate the modified Kidner-Cobb procedure. Overall clinical results were rated as good in 48 (96%) feet and fair in 2 (4%) feet, and there were no poor results. Average follow-up was 4.6 years, and total recovery time was 5.7 months in older patients and 3.7 months in children. Manual muscle-strength testing revealed no difference in tibialis anterior strength between the operated and contralateral extremity. All patients visually demonstrated postoperative elevation of the medial longitudinal arch height. Complications included 2 feet with wound dehiscence and 1 foot with fractured hardware. The results of this review indicate that the modified Kidner-Cobb procedure is a useful treatment option for patients with symptomatic flexible flatfoot with posterior tibial tendon dysfunction stage 2.

Flat foot functional evaluation using pattern recognition of ground reaction data

Objective. Main purpose of this study was to apply quantitative gait analysis and statistical pattern recognition as clinical decision-making aids in flat foot diagnosis and post-surgery monitoring. Design. Statistical pattern recognition techniques were applied to discriminate between normal and flat foot populations through ground reaction force measurements; ground reaction forces time course was assumed as a sensible index of the foot function. Background. Gait analysis is becoming recognized as an important clinical tool in orthopaedics, in pre-surgery planning, post-surgery monitoring and in a posteriori evaluation of different treatment techniques. Statistical pattern recognition techniques have been utilized with success in this field to identify the most significant variables of selected motor functions in different pathologies, and to design classification rules and quantitative evaluation scores. Methods. Ground reaction forces were recorded during free speed barefoot walks on 28 healthy subjects, and 28 symptomatic flexible flat foot children selected for surgical intervention. A new feature selection algorithm, based on heuristic optimization, was applied to select the most discriminant ground reaction forces time samples. A two-stage pattern recognition system, composed by three linear feature extractors, one for each ground reaction force component, and a linear classifier, was designed to classify the feet of each subject using the selected features. The output of the classifier was used to define a functional score. Results. The classifier assigned the ground reaction force patterns performed by each subject into the right class with an estimated error of 15%, corresponding to an assignment error for each subject’s foot of 9%. The most discriminant ground reaction forces time samples selected are in full agreement with the pathophysiology of the symptomatic flexible flat foot. The obtained score was utilized to monitor the 1 and 2 years post-operative functional recovery of two differently treated subgroups of 32 flexible flat foot subjects. Conclusions. Statistical pattern recognition techniques are promising tools for clinical gait analysis; the obtained score provides important functional information that could be used as a further aid in the clinical evaluation of flat foot and different surgical treatment techniques. Relevance Symptomatic flexible flat foot surgical decision making is frequently difficult because of the lack of objective criteria to assess functional abnormalities of the foot/ankle complex. Gait analysis and statistical pattern recognition can give us parameters with which to characterize “functional” flat foot. Moreover, we can objectively follow up the recovery of the foot/ankle complex function after surgical treatment.

Arthroresis in flexible flatfoot treatment: comparative follow-up of two methods

The aim of this study was a retrospective analysis of the surgical treatment of symptomatic flexible flatfoot in infants and adolescents, with two different techniques of arthroresis. From 1992 to 1996 we performed arthroreses in 40 feet (25 patients); out of these, 20 were treated by an expanding endo-orthesis applied into the sinus tarsi, and the remainings by a dedicated conical cancellous talar screw applied into the lateral process of the talus. The mean patients' age and time of follow-up were 11 years and 32 months, respectively. Clinical evaluation as well as standing radiograph films and baropodometry were used pre- and postoperatively in both groups of treatment. Our study shows that both methods can give satisfying correction and good clinical results mid-term, without significant clinical, radiographic or podometric differences.