Talar Angle Research Articles

A new method for assessing tibial torsion using computerized tomography in a pediatric population.

Tibial torsion disorders may lead to abnormal gait, frequently leading to a consultation with a pediatric orthopedic surgeon. The present study evaluated an alternative method for assessing tibial torsion on computerized tomography (CT) images that considers the tibial distal axis to be equivalent to the geometric axis of the tibiotalar joint. One hundred CT scans were reviewed retrospectively, and four measurements were taken: proximal transtibial angle (PTTA), posterior margin tibial plateau angle (PMTPA), intermalleolar angle (IMA), and talar angle (TA). The tibial torsion angle was then calculated using these different angles. The patient cohort comprised 38 girls and 62 boys, with a mean age of 12 ± 4.4 years. Median PTTA and PMTPA were -8.4° ± 14.7° and -8.8° ± 14.2°, respectively, with no statistically significant difference. Mean IMA and TA were 23° ± 16.2° and 17.2° ± 16.9°, respectively, with a statistically significant difference. Mean total measurement time per patient was 6'44", with means of 2'24" for PTTA, 36" for PMTPA, 2'14" for IMA, and 1'12" for TA. Tibial torsion values may differ significantly depending on the axis chosen to define tibial orientation. At the level of the proximal tibia, the choice of PTTA or PMTPA had little influence on the calculation of the tibial torsion angle. There was a significant difference of 5.8° when measuring the distal tibia. Measuring the PMTPA and TA is probably more suited for use in clinical practice because their tracing is simple and faster.

High-Heel Wearing Does Not Change The Forefoot Alignment In Non-Frequent Users Without Hallux Valgus: 3D Weight-Bearing Scan Study

Category: Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Women wearing high heels for 20 years without Hallux valgus angle alterations make it debatable that causes Hallux valgus deformation. A recent systematic review determined that 4.13 ± 0.34 cm of heel height would improve foot weight-bearing . Wearing high heels would realign the foot, causing an inversion of the foot, which locked the navicular-cuneiform and cuneo-metatarsal joints rather than primarily rotate the metatarsophalangeal joint. Nowadays, weight-bearing scans could favor understanding the alignment mechanism involved in the foot and ankle with different shoe heights. Therefore, we aimed to determine the acute foot alignment in non-frequent HH users without Hallux valgus during stand posture. Here, we hypothesize that high heels studied by weight-bearing scans shows radiology changes linked to hindfoot alignment rather than primary forefoot rotation. Methods: This comparative cross-sectional study, participants were randomly submitted to a tridimensional weight-bearing CT. Foot alignment for barefoot and wearing custom high heels of 3, 6, and 9 cm. Forty-one feet from twenty-one participants (11 males and 10 females, aged 30.8 ± 8.9 years, and Body Mass Index 25.5 ± 2.0 m kg-2) were submitted to a tridimensional weight- bearing scan in barefoot and wearing high heels of 3, 6, and 9 cm. The inclusion criteria were: Aged between 20 and 50 years, and no regular wearing of heels.Participants were instructed to bear weight in their regular standing upright posture, dispensing the body weight uniformly between the lower limbs with the feet set at shoulder width. Declination talar, forefoot arch, foot ankle offset, 1st, 2nd, and 3rd metatarsophalangeal dorsiflexion, and metatarsal rotation and sesamoid rotation angles were compared with repeated measurement analysis and multiple comparisons as well as the raters intraclass coefficient. Results: When height increases, the declination talar angle decrease (p < 0.001), the foot ankle offset decreases (p < 0.001), the 1st, 2nd, and 3rd dorsiflexion angle increases (p < 0.001), and metatarsal rotation angle (p=0.696) and sesamoid rotation angles (p=0.649) did not change. The forefoot arch for 6 cm was higher than 3 cm (p < 0.001) and then 9 cm (p=0.001), and the forefoot arch for 9 cm was higher than 3 cm (p=0.049). Conclusion: The main finding was that increased forefoot arch, lower ankle offset, no metatarsal rotation angle, and no sesamoid rotation angle strongly suggest an acute primary hindfoot alignment adaptation mechanism rather than forefoot rotation with increase of heel heigth. The most critical mechanism combines the activation of the windlass mechanism together with a stiffer alignment of Hindfoot. Our interpretation here is supported by the lower FAO, and increased forefoot arch and metatarsophalangeal joints, giving insight into pathology foot deformation like Hallux valgus. Thus, our findings suggest that it is debatable that wearing high heels can trigger forefoot deformity,

Diagnostic Accuracy of Various Radiological Measurements in the Evaluation and Differentiation of Flatfoot: A Cross-Sectional Study.

Arch angle is used to indicate flatfoot, but in some cases, it is not easily defined. The presence of flatfoot deformity remains difficult to diagnose due to a lack of reliable radiographic assessment tools. Although various assessment methods for flatfoot have been proposed, there is insufficient evidence to prove the diagnostic accuracy of the various tools. The main purpose of the study was to determine the best radiographic measures for flatfoot concerning the arch angle. Fifty-two feet radiographs from thirty-two healthy young females were obtained. Five angles and one index were measured using weight-bearing lateral radiographs; including arch angle, calcaneal pitch (CP), talar-first metatarsal angle (TFM), lateral talar angle (LTA), talar inclination angle (TIA) and navicular index (NI). Receiver-operating characteristics were generated to evaluate the flatfoot diagnostic accuracy for all radiographic indicators and Matthews correlation coefficient was calculated to determine the cutoff value for each measure. The strongest correlation was between arch angle and CP angle [r = −0.91, p ≤ 0.0001, 95% confidence interval (CI) (from −0.94 to −0.84)]. Also, significant correlations were found between arch angle and NI [r = 0.62, p ≤ 0.0001, 95% CI (0.42 to 0.76)], and TFM [r = 0.50, p ≤ 0.0001, 95% CI (from 0.266 to 0.68)]. Furthermore, CP (cutoff, 12.40) had the highest accuracy level with value of 100% sensitivity and specificity followed by NI, having 82% sensitivity and 89% specificity for the cutoff value of 9.90. In conclusion, CP angle is inversely correlated with arch angle and considered a significant indicator of flatfoot. Also, the NI is easy to define radiographically and could be used to differentiate flat from normal arched foot among young adults.

Medial malleolar osteotomy for the correction of tibiotalar varus deformity during total ankle arthroplasty: Results in 95 ankles

BackgroundThe importance of deformity correction before or during total ankle replacement (TAR) has been recognized for a long time. Our results of TAR, combined with medial malleolar lengthening osteotomy, for the reconstruction of osteoarthritic ankles with varus deformity are hereby reported. MethodsAll ankles in which a medial malleolar osteotomy was performed during implantation of an ankle prosthesis during the period 1998–2018 were filtered out of our database. Preoperative coronal talar alignment was evaluated by measuring the angle between the tibial shaft and talar dome on the weightbearing mortise ankle radiograph. Patient-reported outcomes were measured with the Foot and Ankle Outcome Score (FAOS) and the Foot and Ankle Ability Measure (FAAM). A Kaplan-Meier survival curve was constructed and the number of revisions per 100 observed component years was calculated for interprosthetic comparison. ResultsA total of 95 TARs were included, consisting of the Alpha Ankle Arthroplasty (n = 22); Buechel-Pappas (n = 14) and the Ceramic Coated Implant Evolution (n = 59) prostheses. The preoperative average talar angle in these ankles was 12.4 degrees varus. In 33% (31/95) corrective procedures, in addition to the medial malleolar osteotomy, were performed. A reoperation rate of 44% (42/95) was found, including 28 revisions (revision rate 29% (4% septic; 25% aseptic) at an average follow-up of 5.9 years, resulting in a survival of 0.69 for the total cohort at 10 years of follow-up.At an average follow-up of 6.6 years the average FAOS scores were: FAOSsymptoms 66, FAOSpain 73, FAOSfunction 78, FAOSsport 45 and FAOSquality of life 56 respectively. The FAAMadl score averaged 64. ConclusionThis is the largest cohort of TAR combined with medial malleolar osteotomy to date. A 29% revision rate at 5.9 years of average follow-up compares unfavorably with regular cohort studies and with most other results in varus-deformed ankles. Scores on the FAOS and FAAM are comparable to those obtained in regular cohorts with similar length of follow-up. TAR in varus-deformed ankles necessitating medial malleolar osteotomy has an even higher failure rate than regular TAR. Obtaining a stable prosthesis with a neutrally-aligned hindfoot at the end of the procedure is of paramount importance. Level of evidenceIV.

Clinical evaluation of arthrodesis with Ilizarov external fixator for the treatment of end-stage ankle osteoarthritis: A retrospective study.

To analyze the efficacy of arthrodesis with Ilizarov external fixator for the treatment of end-stage ankle osteoarthritis.This retrospective study included 88 patients with end-stage (stage-3) ankle osteoarthritis according to Morrey–Wiedeman classification who underwent arthrodesis with Ilizarov external fixator from January 2016 to January 2019. There were 47 males and 41 females with a mean age of (57.21 ± 7.12) years old (range 49–76). Outcomes were measured by the American Orthopaedic Foot and Ankle society (AOFAS) Ankle Hindfoot Scale, Visual Analog Scale (VAS) pain scores, complications, subjective satisfaction, ankle function, correction of deformity, and complications.With an average follow-up of (13.50 ± 5.41) months (range 10–21), all 88 patients returned for final follow-up. All patients achieved bony healing with a success rate of 100%. Mean postoperative healing time (3.56 ± 1.04) months (range 3–6). Two patients developed sinus tract infection, delayed healing in 1 patient, and 2 patients had pain and swelling again in the ankle joint. No serious complications occurred in other patients. All the patients evaluated with the VAS scores and AOFAS scores at final follow-up showed significant improvement (P < .05). Through imaging analysis, medical tibial talar angle (MTTA) improved from (85.76 ± 6.01) degrees to (88.98 ± 1.35) degrees postoperative. Lateral talar station (LTS) decreased from (5.32 ± 3.81) mm to (2.71 ± 2.62) mm after operation (P < .05). The overall satisfaction of patients is 88.64%.In the treatment of end-stage ankle osteoarthritis, arthrodesis with Ilizarov external fixator can achieve good radiological and clinical outcomes with low prevalence of ankle joint malalignment and high fusion rates and satisfaction.

Tibial Torsion May Predict Morphology of the Talus

Category:Ankle Arthritis; Ankle; HindfootIntroduction/Purpose:The role of implant positioning in total ankle arthroplasty (TAA) has garnered increasing attention, particularly in defining coronal and sagittal plane alignment. With the ongoing developments in patient specific instrumentation, advanced imaging is becoming a more common tool in preoperative planning. Despite this, there is limited information available on axial rotation of the ankle or variations in anatomy of the talus and foot. We aim to evaluate the rotational profile of the distal tibia and its relationship to morphology of the talus, as well as assess tibiotalar tilt, in a cohort of end-stage arthritic ankles.Methods:Computed tomography (CT) scans and plain radiographs were reviewed in 59 patients with end-stage ankle arthritis. Patients with previous tibial or ankle trauma were excluded. Scans were obtained prior to total ankle arthroplasty surgery as part of standard preoperative planning protocol. Demographic data was recorded. Measurements were obtained at the posterior condyles of the tibial plateau and transmalleolar axis to calculate tibial torsion, as well as along the talar neck and body to evaluate talar angle. Tibiotalar tilt angle was measured on weightbearing mortise view radiographs. Linear regression was performed to evaluate statistical associations between tibial torsion and other measured parameters.Results:The mean tibial torsion was 29.5±9.2 degrees external (range 13.6-50.8 degrees), no internal torsion was found. Mean talar neck-body angle was 38.2±8.8 degrees medial (range 24.1-59.5 degrees). Tibiotalar angle ranged from 26.5 degrees varus to 23.5 degree valgus. There was a statistically significant relationship between increasing tibial torsion and decreasing talar neck-body angle (r=-0.49, p<0.001), demonstrating more angulation of the talar neck corresponding to the least tibial torsion as seen in Figure 1. No relationship was found between tibial rotation and tibiotalar angle when assessing varus/valgus tilt on a spectrum (p=.89) or when evaluating absolute angulation from neutral (p=.43). Our cohort had a mean age of 63.1±8.2 years, and 54% were male.Conclusion:Our cohort displayed wide variation in axial anatomy of the ankle. Our analysis identifies a statistically significant correlation between tibial torsion and morphology of the talus. This is a previously unreported association that could help understand development of foot and ankle deformity and pathology. While there was no clear correlation to degree of tibiotalar angulation, these axial deformities surely play a role in altered foot and ankle mechanics and the development of end-stage ankle arthrosis. In patients undergoing ankle arthroplasty, these are important parameters for the surgeon to consider in conjunction with other aspects of the hindfoot deformity.

The Influence of Preoperative Deformity Severity in Postoperative Patient Reported Outcomes in Adult Acquired Flatfoot

Category:Ankle; Hindfoot; OtherIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is a complex deformity. Previous work has demonstrated correlation between postoperative foot alignment and patient-reported outcomes. While this work has provided essential targets for surgeons performing flatfoot reconstruction, there is an absence of data that would enable surgeons to predict which patients are likely to have greater or less improvement after surgery based on their preoperative deformity. Conventional radiographs alone may not provide enough detail to isolate individual elements of the deformity. Weightbearing CT (WBCT) allows for far more precise analysis in this regard. We hypothesized that there would be a set of parameters defining preoperative alignment on WBCT that would predict which patients are at risk for a lower magnitude of postoperative improvement in patient-reported outcomes (PROs).Methods:In this retrospective IRB-approved study, patients that underwent surgical flatfoot reconstruction after having a preoperative standing WBCT were identified. Preoperative WBCT images were evaluated by two independent/blinded observers. Multiple parameters related to preoperative alignment and AAFD severity were measured in the sagittal, coronal and transverse planes. Parameters measured included talus-first metatarsal angle; distances between the floor and the navicular, medial cuneiform and cuboid; subtalar joint horizontal angle; superior talar - inferior talar angle; subtalar joint subluxation; talonavicular uncoverage angle; hindfoot moment arm (HMA); and foot and ankle offset (FAO). Prospectively collected data regarding preoperative and postoperative PROs was evaluated. Six PROs components were assessed: physical function; pain interference, pain intensity, global mental health, global physical health and depression. Multivariate regression analysis and a partition prediction model were used to assess the correlation between preoperative alignment and improvement in PROs. P-values of less than 0.05 were considered significant.Results:A total of 51 patients with a preoperative WBCT and postoperative PROs scores were identified and included. Demographic data is shown in Table 1. Multivariate regression analysis demonstrated that preoperative alignment significantly correlated with improvement in three out six components of PROs: pain interference, pain intensity and global mental health. The strongest predictor of improvement in PROMIS physical function t-score was medial cuneiform to floor distance, for pain interference t-score: cuboid to floor distance, for pain intensity: subtalar joint subluxation, for depression t-score: superior talar - inferior talar angle, and for global physical and mental health t-scores: sagittal talus-first metatarsal angle.Conclusion:Our analysis yielded readily identifiable cutoffs for WBCT measurements, where values above or below were correlated with significant differences in the magnitude of PRO score change. Interestingly, measures of sagittal plane collapse and hindfoot valgus were the most predictive of score changes. This data provides useful information for surgeons counseling patients prior to flatfoot reconstruction. Future work using this data to develop prediction models for postoperative outcomes would be valuable, as would studies using WBCT to evaluate the relationship between postoperative corrected alignment and PROs.Complete results are shown in the attached Table.

Talus Arthritis Pattern in Juvenile Idiopathic Arthritis (JIA)

Category:Ankle ArthritisIntroduction/Purpose:Juvenile idiopathic arthritis is a broad term that describes a clinically heterogeneous group of arthritides of unknown cause, which begin before 16 years of age persist for more than 6 weeks.It is one of the main diseases affecting Paediatric age group Joints in a form of a chronic, long standing and debilitating disease. It is estimated that 1 in 1000 children present with JIA in the UK alone.Radiographic progression of the disease occurs early, and if not addressed may result in permanent joint destruction and poor functional outcomes.The ankle is frequently involved, but it is unclear whether this is due to synovitis, tenosynovitis.To date, no evidence of combined therapies or integrated care for juvenile idiopathic arthritis patients with F&A problems exists.Methods:JIA patients with ankle involvement presented to orthopedic foot and ankle services between 2012-2017 were include. All patients had weight bearing x-rays ankle measuring Tibio talar angle, also underwent Ankle MRI following standard hospital MRI protocols.The MRI scans were used to measure the affected areas in talus. Talus was divided into 4 anatomical regions (Anterio-medial, Anterio-lateral, posterior-medial, posterolateral). lesion involving wider areas were recorded as two or more regions accordingly, i.e.: AM and PM involvement at the same time were given yes for area of involvement in both region and recorded separately.Bilateral Ankles involvement were also recorded. Tibial growth plate involvement in these patients on the MRI scan was recorded. Demographic data was collected along with side, disease pattern, age at diagnosis and age at presentation to F&A speciality and patients requiring surgical intervention. Measurements were carried out by two in dependent orthopaedics F&A surgeons.Results:14 patients were included in this study with a total of 17 ankles. 12 were females (N=12, 85.7%). Mean age was between 8-21 years (15.0 ± 4.08, M±SD). Time to presentation was 2.9 to 8.4 years (5.1 ± 1.4 years). 5 had Oligo-articular involvement (37.5%),9 patients had polyA (64.2%).11/17 Right Ankles (64.7%), 3 left (21.4%). 3 bilateral (21.4%). 11/17 Ankles in Varus (64.7%), 1/17 valgus (5.8%), 5/17 neutral (29.4%).Mean Tibiotalar angle was 80° ± 13.5° (Range 49° - 100°).12/17(70.5%) had involvement of the antero-medial part of the talus,1/17(5.8%)antero-lateral, 8/17 postero-medial(47.06%), 3/17(17.6%) postero-lateral .All the patients with postero-lateral involvement, they also had postero-medial involvement. (p=0.043). 13/17 ankles (76.4%) had tibial growth plate involvement.5 patients (35.7%) had subsequent operations.Conclusion:This study shows a pattern of involvement in the talus and the effect this disease has on Tibiotalar alignment. This needs to be confirmed on a larger number of patients. And highlights the need for an earlier presentation of these patients to F&A surgeon to prevent the disease sequela. Further research is required to study the tibial growth plate involvement for its contribution to the varus / valgus deformity in a chronological method. Further research is also required to quantify the time frame for disease and deformity progression in the Tibiotalar Joint.

Early Outcomes of Pes Planus Reconstruction Using Either Hamstring Allograft or Synthetic Ligament

Category:Hindfoot, Midfoot/ForefootIntroduction/Purpose:Maintenance of the medial longitudinal arch is crucial to efficient kinematics in gait. It is supported by as complex interplay of osseous structures, ligaments, extrinsic tendons and plantar fascia.Two ligaments critical to stabilising the medial longitudinal arch are the Spring (Calcaneofibular) and Naviculocuneiform ligaments. The Spring Ligament serves as a sling within the “Acetabulum Pedis” to orientate the Talus relative to the Calcaneus and Navicular. The Naviculocuneiform ligament is an important plantar tension band and a separate entity to the Posterior Tibial Tendon (PTT) insertion. Attenuation of these ligaments leads to Pes Planus deformity and subsequent defunctioning of the PTT. This study evaluates the functional and radiological outcomes of Spring and Naviculocuneiform ligament reconstruction using Hamstring (Semitendinosis) Allograft and Synthetic ligament (Internal BraceTM, Arthrex).Methods:33 consecutive Pes Planus reconstructions were performed between 11/11/2013 and 06/03/2018. All patients were followed up prospectively with serial radiographs and functional scores including; MOXFQ, EQF5D and VAS. Minimum follow up was six months.At the midpoint during the study there was transition to using Synthetic Ligament instead of allograft. This was due to availability and ease of use.Surgical technique for both reconstructions included a proximal medial gastrocnemius recession and medialising calcaneal osteotomy. For allograft reconstructions, a pre-tensioned Semitendinosis allograft was fixed proximally to Talar neck using a tenodesis screw and passed plantar to PTT and through a bone tunnel in the medial cuneiform. Synthetic ligaments were inserted from the Sustentaculum Tali to the medial cuneiform in a hammock fashion. In both reconstructions tendinopathic PTTs were excised and a Flexor Digitorum Longus transfer used.Results:There were 17 synthetic ligament reconstructions (6 male, 11 female) and 16 allograft reconstructions (6 male, 10 female). Groups were matched pre-operatively for age, functional scores and radiological markers (T test P values >0.05).At six months significantly better improvements were observed in the synthetic ligament group compared to allograft group with regards to VAS, MOXFQ pain score, Meary’s line, 1st metatarsal Talus angle, Talonavicular uncoverage angle and Hindfoot alignment (T test P < 0.05).Statistical significance was maintained at 12 months with the synthetic ligament providing a significantly better reduction of Meary’s line 1st Metatarsal Talar angle, Talonavicular uncoverage and hindfoot alignment. 2 patients were revised to double fusions in the allograft group and 1 patient revised in the synthetic ligament group.Conclusion:Statistically significant improved functional scores and radiological appearance can be found up to 1 year following Synthetic ligament reconstruction of the Spring and Naviculocuneiform ligaments when compared to Hamstring allograft.

Foot Alignment Profile in Injured Professional Basketball and Football Athletes

Category: Sports Introduction/Purpose: Adequate evaluation of foot and ankle problems in elite athletes is paramount for planning the correct treatment, predicting clinical prognosis and supporting decision making. A complete physical examination that includes the assessment of foot alignment during weightbearing is mandatory. The three-dimensional evaluation provided by weightbearing CT imaging (WBCT) represent an important diagnostic tool for foot and ankle surgeons when dealing with these extremely physically active patients. The purpose of this study was to assess different WBCT measurements of hindfoot and forefoot alignment in injured high-level football and basketball players. We hypothesized that specific patterns of hindfoot alignment and height of the longitudinal arch of the foot could be identified. Methods: In this single center retrospective comparative study, 80 professional male athletes - 47 basketball and 33 American football players from College, NBA and NFL leagues - that underwent WBCT as part of the clinical investigation for different injuries of the foot and ankle were included in the study. WBCTs images were evaluated by a blinded board-certified foot and ankle orthopedic surgeon. Multiple measurements used for assessment of hindfoot valgus and longitudinal arch height were assessed and included: foot and ankle offset (%), calcaneal offset (mm), hindfoot alignment angle (°), navicular-floor distance (mm), medial cuneiform-floor distance (mm), forefoot arch angle (°), inferior talar-superior talar angle (°), and subtalar horizontal angle (°). An unpaired Student’s t test was performed to evaluate any differences in the measurements when comparing professional basketball and football patients. P-values less than 0.05 were considered significant. Results: A summary of demographic characteristics and each measurement’s distributions and standard deviations, as well as p-values for the analysis between groups, is given in table 1. No significant differences were found between basketball and American football elite athletes when comparing the mean values of measurements evaluated (mean differences): foot and ankle offset (0.26%), calcaneal offset (0.58 mm), hindfoot alignment angle (0.73°), navicular-floor (0.35 mm) and medical cuneiform-floor distances (0.38 mm), forefoot arch angle (0.74°), inferior talar–superior talar angle (0.83°) and subtalar horizontal angle (0.1°). Conclusion: Although we did not find significant differences in foot alignment when comparing basketball and American football professional athletes, the results of our study highlight some of the important foot alignment parameters and establish distributions in an extreme but important population. Further studies correlating foot alignment with the incidence of some of the most common pathologies diagnosed in elite athletes, such as the ones reported in our study, can help in the understanding and prevention of those injuries.

Outcomes of spring ligament reconstruction for idiopathic flexible flatfoot deformity

Category: Hindfoot Introduction/Purpose: Idiopathic flatfeet are usually caused by attenuation of the medial soft tissues rather than a lateral osseous deficiency. Our prospective study aimed to quantify the functional and radiological outcome of a new technique for spring ligament reconstruction using a hamstring graft for idiopathic flat feet Methods: Our prospective study included 17 feet in 14 patients, from 05/14 to 05/17, on which a spring ligament reconstruction was performed. This pre-tensioned allograft reconstruction was performed using a blind talar tunnel, with the graft being passed deep to the navicular tuberosity, through a tunnel in the medial cuneiform and then sutured back onto its proximal limb to control abduction. Additional procedures included medial head of gastrocnemius recession (17), calcaneal osteotomy (16), FDL transfer (3), tibialis posterior synovectomy (2), peroneus longus to brevis transfer (2). There was a minimum of 6 months follow-up. Radiographic analysis was performed for standardised parameters. Paired t-test was used for analysis Results: The average age was 41 (range 23 -65). The mean BMI was 31.1 (range 24.6 – 37.3). Mearys line improved from a mean of 24.1 (9 – 36.4) to a mean of 13.8 (-3.1 – 26.7). This was statistically significant (p&lt;0.001). Talar uncoverage angle improved from a mean of 39.5 (27.7 – 55.8) to 23.9 (3.5 – 39.7). First metatarsal talar angle improved from a mean of 18.9 (8.4 – 33.9) to 10.3 (-6.1 – 21.5). There were no wound infections. There was one revision (5.9%) to a triple arthrodesis; at revision it was found that the allograft had attenuated to incompetency. Of the patients that improved the least, 80% (4/5) were over the age of 49. Our numbers are insufficient to statistically analyse this Conclusion: This new method of spring ligament reconstruction provides a predictable solution for more anatomical reconstruction of idiopathic flatfoot deformity, with statistically significant improvements in all radiographic parameters. Further numbers will be needed but we would exercise caution in using this technique in older patients.

Angular dimensions and squatting facets in human dry tali of South Indian origin

The angular dimensions of the talus are indicative of its biomechanical role in load transmission. Squatting facets on the neck of the talus are indicative of habitual squatting. The primary objective of this study was to estimate the strength of association between the talar angles and the presence of squatting facets. The secondary objectives were to estimate the side differences in the angular dimensions and to assess the reliability of the method. One hundred and sixty dry tali of unknown sex were studied. The neck angle, vertical angle, torsion angle, trochlear surface angle and depth angle were measured using a photographic method. The presence of squatting facets was noted. The mean and standard deviation of those angles were 108.3 ± 5.23, 89.87 ± 3.97, 37.57 ± 5.62, 9.7 ± 3.3 and 156 ± 5.1 degrees respectively. The neck, vertical and depth angles were significantly higher on the left side. There were significant positive correlations between the neck and vertical angles, the neck and depth angles and the torsion and depth angles. Squatting facets were noted in 90 of the 160 (56%) of the tali. The torsion angle was significantly higher in tali with squatting facets. Intraobserver and inter-observer reliability of the methods were found to be good to excellent. The findings of this study indicate the factors that can possibly influence the magnitude of the talar angles. This data can be useful for designing talar prostheses and analyzing the biomechanical interface of the hind foot bones.

Short-term Clinical and Radiographic Results of the Salto Mobile Total Ankle Prosthesis.

The mobile-bearing Salto total ankle prosthesis has been reported to have promising outcomes. However, clinical reports on this prosthesis are few, and most have been published by the inventors and disclosed consultants. We retrospectively reviewed 59 patients who received Salto prosthesis unilaterally. The average follow-up was 35.9 (range, 6-56) months. Clinical and radiologic results were evaluated. Clinical results were evaluated according to visual analog scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Scale (AOS) pain and disability score, and ankle range of motion (ROM) in dorsiflexion/plantarflexion. In the radiographic evaluation, we measured the tibial angle (TA), talar angle (TAL), tibial slope, and talocalcaneal angle (TCA) on weightbearing radiographs. By the last follow-up, 7 of 59 patients (11.9%) had undergone reoperation, and 3 of 59 implants (5.1%) had been removed. The prosthesis survival was 94.9% (95% CI, 89.1%-100%). With any reoperation as the endpoint of follow-up, the clinical success rate was 88.1% (95% CI, 79.4%-96.9%). The mean postoperative visual analog scale score, AOFAS ankle-hindfoot score, and Ankle Osteoarthritis Scale pain and disability score improved significantly ( P < .001). The ankle range of motion also improved from preoperative 33.4 ± 16.6 to 40.3 ± 15.5 postoperatively ( P < .001); however, there was no statistically significant change in plantarflexion ( P = .243). Radiolucent areas and osteolysis were found in 28 (47.5%) and 27 (45.8%) patients, respectively. Heterotopic ossification was observed in 13 patients (22.0%). In this series, early clinical and radiographic outcomes of this prosthesis were promising. We believe the early radiolucent lines were probably due to the gap at the implant and bone interface, and they disappeared at the time of osseous integration. However, longer follow-up is necessary to determine the long-term durability and survivorship of this implant, particularly given the high incidence of postoperative osteolysis. Level IV, case series.

Short Term Clinical and Radiographic Results of the Salto Mobile Version Ankle Prosthesis

Category: Ankle, Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) has become an increasingly attractive option for advanced tibiotalar arthritis treatment. The Salto prosthesis (Tornier SA, Saint Ismier, France) was reported to have midterm and long term promising outcomes. However, to date, the clinical reports of this prosthesis are few and most of the papers were published by the inventors and disclosed consultants. The published areas are also limited to Europe, and no results were documented from other region. Methods: We retrospectively reviewed 62 patients in total. All of underwent unilateral Salto TAA. The average clinical follow-up was 34.3 months. Clinical and radiologic results were evaluated and enrolled. Clinical follow-up included medical records review, visual analogue scale (VAS) pain score, American Orthopeadic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Scale (AOS) pain and disability score and range of motion (ROM). Apart from these, subsequent surgeries and perioperative events that occurred at the first 3 months after the operation were recorded simultaneously. In the radiographic evaluation, we measured the tibial angle (TA), talar angle (TAL), tibial slope, and talocalcaneal angle (TCA) described by Bonnin. Distributive regions of osteolysis and radiolucency were reviewed. In addition, heterotopic ossification also be observed and graded. Endpoint of the follow-up was either any component removal or reoperation for any reason. Results: Date to last follow-up, the survival rate with any reoperation as the endpoint was 88.7% (7/62). Using any component removal as the endpoint of followup, the survival rate was 95.2% (3/62). The mean VAS score, AOFAS ankle-hindfoot score, and AOS pain and disability score were improved postoperatively (p &lt; 0.001). Postoperative ROM of ankle was also improved (p = 0.003). Within 6 weeks of postoperation, radiolucent line arose around tibial implant in 39 cases and disappeared at mean 5.5 ± 2.6 months. 28 patients with postoperative mean 8.5 ± 4.5 months appeared radiolucent area. Osteolysis was found in 28 patients with mean 18.1 ± 8.2 months postoperatively. 13 patients suffered heterotopic ossification which appeared 9.4 ± 4.3 months after operation. Conclusion: At the last followup, obvious pain relief and satisfactory results were achieved in most of the patients. Different from previous studies on Salto prosthesis, we considered that the early radiolucent line around the tibial implant is likely due to the tiny gap between the implant and bone contacted interface, and it would disappear at the time of osseous integration. The lucent area and osteolysis occurred frequently around the tibial keel and tray due to the stress shielding of the tibial component. However, longer follow-up is necessary to determine the durability of this implant.

Calcaneocuboid Distraction Arthrodesis With Synthetic Bone Grafts: Preliminary Results of an Innovative Bone Grafting Procedure in 13 Patients

Calcaneocuboid distraction arthrodesis (CCDA) is regarded as an effective method for reconstructing adult-acquired flatfoot deformity. In the present study, we present our experience with newly developed rigid β-tricalcium phosphate wedges to treat CCDA to better understand the outcomes of this synthetic bone grafting procedure. A total of 13 feet in 13 patients underwent CCDA with synthetic bone grafts. One male (7.69%) and 12 females (92.31%), with a mean age of 65.07 ± 11.83 (range 36 to 77) years, were followed up for a mean duration of 32.76 ± 12.81 (range 18 to 55) months. Successful graft union was postoperatively obtained in 12 of the 13 feet (92.31%). The mean preoperative visual analog scale and American Orthopaedic Foot and Ankle Society scale score were 7.97 ± 1.52 (range 5.4 to 10) and 54.46 ± 14.72 (range 18 to 75), respectively. These scores improved to 1.52 ± 1.78 (range 0 to 6.2) and 85.46 ± 13.38 (range 50 to 97) postoperatively (p = .001 for both comparisons). On radiographic analysis, the talonavicular coverage angle, first metatarsal talar angle, calcaneal pitch, and heel alignment angle had significantly improved (p = .001, p = .028, p = .006, and p = .001, respectively). The use of bone graft substitutes in CCDA is a viable treatment option for reconstructing flexible flatfoot deformity. Although good clinical and radiographic outcomes were obtained, our method is even more challenging than conventional methods and should be used with caution. Rigid locking fixation with a long period of protected weightbearing is highly recommended to attain uneventful bone healing.

Tratamiento quirúrgico de las dismetrías y deformidades angulares de miembros inferiores mediante epifisiodesis con tornillos transfisarios (técnica de Metaizeau)

We evaluated children with lower limb length discrepancy and angular deformity operated by the Metaizeau technique in the 2010-2014 period through a retrospective study of 11 patients analyzed in 2 groups. Group 1 (Lower limb length discrepancy), consisted of 5 patients, among whom 3 were operated only by Metaizeau technique, whereas the other 2 additionally required procedures for femoral elongation. We evaluated initial discrepancy, predicted discrepancy for ultimate control and at maturity, and final discrepancy. Group 2 (Angular deformity), consisted of 6 patients, among whom 1 had genu varum, 4 genu valgum and, 1 ankle valgus. We evaluated anatomic femorotibial angle, anatomic lateral distal femoral angle, medial proximal tibial angle, and tibio talar angle. In both groups the complications were assessed. The average follow-up was 2 years and 5 months. In Group 1 we obtained the following values: average initial discrepancy, 7.64 cm; average discrepancy predicted for ultimate control, 8.54 cm; average final discrepancy, 7.62 cm and average correction achieved, 0.91 cm. In Group 2 the values were: average correction anatomic femorotibial angle, 16.85˚; average correction anatomic lateral distal femoral angle, 16.85˚ and average correction medial proximal tibial angle, 7.62˚. We found no complications in any patient. In 8 patients (72.72%) the technique was effective, while in 3 (27.27%) the results were poor due to technical errors or prediction errors . Metaizeau Technique, respecting the surgical details and making an accurate prediction is an effective, simple and uncomplicated procedure.

Comparison of Radiographic Outcomes Between Dynamic Medial Column Stabilization and Lateral Column Lengthening

Category: Midfoot/Forefoot Introduction/Purpose: Lateral column lengthening (LCL) has been recognized as a most effective surgical treatment for flexible flatfoot. But the LCL is known to be associated with many complications, which are lateral foot pain or calcaneocuboid arthrosis. In order to correct flexible flatfoot without these complications, we have developed a novel technique-dynamic medial column stabilization (dynamic-MCS). The dynamic-MCS consists of flexor hallucis longus transfer to the medial cuneiform, arthrodesis of first tarsometatarsal joint and medial displacement calcaneal osteotomy. The dynamic-MCS had different mechanism from the LCL. The dynamic-MCS directly restores longitudinal arch of flexible flatfoot, while the LCL indirectly restores the longitudinal arch. The purpose of this study is to investigate difference of radiographic outcomes between the dynamic-MCS and the LCL. Methods: Dynamic-MCS group included 16 flexible flatfeet of 16 patients which were treated with the dynamic-MCS from January 2014 to February 2015. The LCL group included 23 flexible flatfeet of 21 patients which were treated with the LCL from January 2011 to January 2014. A single surgeon performed the dynamic-MCS and the LCL in our clinic. We retrospectively evaluated radiological outcomes of the dynamic-MCS group and the LCL group. The preoperative and postoperative radiographic parameters were measured. Talonavicular coverage angle was measured on plain weight-bearing anteroposterior radiograph. Calcaneal pitch, talocalcaneal angle, talar angle, meary angle and 1st metatarsal declination angle were measured on plain weight- bearing lateral radiograph. Hindfoot alignment angle was measured on hindfoot alignment view. We compared postoperative improvements of the dynamic-MCS group with those of the LCL group in each radiographic parameters. All the postoperative values were obtained at the last follow-up. Results: The average age in the dynamic-MCS group was 41 years (95% CI: 33.5-47.9) and mean follow-up period was 12.9 months (minimum 10months). The average age in the LCL group was 36 years (95% CI: 27.9-43.1) and mean follow-up period was 22.2 months (minimum 12 months). The talonavicular coverage angle (P=0.002) and calcaneal pitch (P=0.002) of the LCL group showed significant higher improvement than that of the dynamic-MCS group. The talocalcaneal angle (P=0.030) and hindfoot alignment angle (P=0.005) of the dynamic-MCS group showed significant higher improvement than that of the LCL group. The improvement of the other radiographic parameters showed no significant difference between the dynamic-MCS group and the LCL group (Fig 1-B). Conclusion: Radiographic outcomes between the dynamic-MCS and the LCL were different for flatfoot correction in this study. The LCL showed higher correction of forefoot abduction than the dynamic-MCS. The dynamic-MCS showed higher correction of heel valgus than the LCL. Correction of flat longitudinal arch was not different between the dynamic-MCS and the LCL. To restore the flat longitudinal arch,the dynamic-MCS corrected the plantar-flexed talus and the LCL corrected the low calcaneal pitch. Lateral plantar pain and calcaneocuboid arthrosis did not occurred after the dynamic-MCS in our experience. We concluded that the dynamic-MCS could be a good treatment option for flexible flatfoot.

Radiographic evaluation of INBONE total ankle arthroplasty: a retrospective analysis of 30 cases

The objectives of this work were to retrospectively describe the radiographic assessment of INBONE total ankle arthroplasty in 30 patients using validated linear and angular measurements and to correlate these findings with the final surgical outcome over a 2-year follow-up period. Thirty consecutive patients (21 females, nine males; mean age, 64.8 years) underwent INBONE total ankle arthroplasty during 2007-2011. After IRB approval, a retrospective pre- and post-operative radiographic analysis was performed using validated linear and angular measurements. The pre- and post-operative assessment included the tibial angle, talar angle, tibial slope, and coronal deformity. Post-operative measurements also included the talocalcaneal angle, joint space height, talar height, lateral tibial component angle, lateral talar component angle, and anteroposterior tibial component angle. The post-operative bone loss, subluxation, positioning, and subsidence were also assessed. Statistical analysis was performed using two-sample t test and Fisher's exact test. Out of 30 patients, 23 had a successful clinical outcome with intact prosthesis at a 2-year follow-up. The only variables with significant correlation (p < 0.05) to the post-surgical outcome were the lateral talar component angle (p = 0.002) and the mean difference between pre- and post-operative tibial slope (p = 0.001). The coronal deformity had significant mean difference between pre- and post-operative values (p < 0.001); however, it lacked a significant correlation to the final surgical outcome. None of the categorical variables had a significant correlation with post-surgical outcome. In our retrospective study, only the lateral talar component angle and the mean difference between the pre- and post-operative tibial slope had significant correlation with post-surgical outcome in INBONE ankle arthroplasty. These measurements may be helpful in radiographic assessment of the INBONE ankle arthroplasty.

Radiological study of joint destruction patterns in rheumatoid flatfoot

The purpose of this study was to clarify variations in patterns of flattening in rheumatoid hindfoot. Out of 232 outpatients with rheumatoid arthritis treated at our hospital from 2001 to 2003, we studied lateral radiographs of feet of 216 patients (423 weight-bearing views). We measured the medial arch angle (MAA) and talar angle (TA) and compared the alignment of the talonavicular joint-sagittal plane of each foot. We also evaluated the relationship between the severity of flattening and inclination of the talus and performed cluster analysis. Three groups were clustered by MAA and TA. In group I, joints were normal or close to normal. In group II, both talonavicular and subtalar joints were affected. In group III, talonavicular joints were minimally affected, and the subtalar joints were primarily affected. Groups II and III were thought to be a different pattern of flattening. The present results suggest that there are at least two patterns of flattening in rheumatoid hindfoot.

Giannini Prosthesis for Flatfoot

To determine the clinical and radiographic results of arthroereisis using the Giannini endo-orthotic implant for the treatment of pediatric flatfoot deformity, we retrospectively evaluated 37 patients (65 feet). Twenty-two boys and 15 girls were followed for an average of 26.5 months. Their overall average age was 9.4 (range 5 to 14) years. Pain, function, participation in sports activity, and the changes in radiographic measurements taken at 3, 6, and 12 months and then at 1-year intervals were evaluated. Pain or discomfort decreased from 60% (22 patients) preoperatively to 6% (2 patients) postoperatively. The percentage of normal postoperative footprints was 59% (38 feet) with first-degree flatfoot present in 27 feet (41%). Sports activities were taken up by 19 patients (51%) after surgery. An 8-mm endo-orthotic implant was used in 43 (66%) feet and an Achilles tenotomy was done in 38 feet (59%). The radiographic angles with the greatest degree of correction when compared to preoperative angles were the talar-first metatarsal angle (99%) and the calcaneal-pitch (36%). After placement of the endo-orthotic implant, the talar angle influenced the rest of the radiographic measurements. There was no postoperative deterioration in any of the radiographic angles measured during the monitoring period. Complications occurred in 10.7% of the patients, with postoperative pain being the most frequently reported (6% of patients). There was no infection or local reaction to a foreign body. Removal of the endo-orthotic implant was not done on a routine basis. This operative technique respects the anatomical structure of the foot and produces good clinical and radiographic results.