Talar Head Research Articles

Radiographic analysis of Müller-Weiss disease

BackgroundThe only classification of Müller-Weiss disease (MWD) is based primarily on Méary’s talo-first metatarsal angle. It describes increasing sag of the medial longitudinal arch with greater degrees of compression and fragmentation of the navicular. Purportedly, the talar head pushes the subtalar joint into varus and drives the medial pole of the navicular medially, as it protrudes inferiorly and laterally. Its authors stipulated heel varus as a pre-requisite, coining the term ‘paradoxical pes planus varus’ to define heel varus and flatfoot as hallmark deformities of the condition. MethodsWe measured Méary’s and Kite’s talocalcaneal angles, heel offset, anteroposterior thickness of the navicular at each naviculocuneiform (NC) joint, medial extrusion of the navicular and calculated percentage compression at each NC joint in 68 consecutive feet presenting with MWD. Morphology and activity at the various peri-navicular joints were studied using SPECT-CT in 45 feet. ResultsInverse relationships between Méary’s angle and degree of navicular compression reach statistical significance at NC2 but not at NC3. Strong correlation exists between medial extrusion and percentage compression at NC2 and NC3. Medial extrusion is significantly greater on the affected side in unilateral cases and on the more compressed side in bilateral cases. Significant inverse relationships exist between Kite’s angle and percentage compression at both NC2 and NC3 and degree of medial extrusion of the navicular. No correlation was detected between Kite’s angle and either heel offset or Méary’s angle. Varus heel offset was present in only 33% of cases. The combination of heel varus and negative Méary’s angle was present in just 26% of cases, the commonest combination being heel valgus with sagging at 56%. ConclusionOur findings confirm part of Maceira’s hypothesized pathomechanism of MWD. Reductions in Kite’s talocalcaneal angle confirm that lateral and inferior protrusion of the talar head causes increasing compression and medial extrusion of the navicular. However, such shift of the talar head does not always lead to heel varus. As such, we caution against universal advocacy of lateral displacement calcaneal osteotomy, as the heel is not always in varus in MWD.

Effect of Achilles tendon on kinematic coupling relationship between tarsal bones: a pilot finite element study

BackgroundThe procedure of percutaneous Achilles tenotomy (PAT) is an important component of the Ponseti method. However, few studies reported the influence of Achilles tendon on kinematic coupling relationship between tarsal bones. The purpose of present study was to demonstrate the effect of Achilles tendon on the kinematic coupling relationship between tarsal bones, and to illustrate how kinematic coupling relationship between tarsal bones works in term of finite element analysis.MethodsA three-dimensional finite element model of foot and ankle was constructed based on the Chinese digital human girl No.1 (CDH-G1) image database using the software of mimics, Geomagic studio, HyperMesh, and Abaqus. The last manipulation of the Ponseti method before the procedure of PAT was simulated. The talus head and the proximal tibia and fibula bone were fixed in all six degrees of freedom, and the outward pressure was added on the first metatarsal head to investigate the kinematic coupling relationship between tarsal bones.ResultsThe least relationship of kinematic coupling between tarsal bones was found in calcaneus. Stress concentration was mainly observed at the navicular, talus and the medial malleolus. The difference in displacement of the navicular was only found with the Achilles tendon stiffness of 0 N/mm and others. No difference in the navicular displacement was found in the stiffness of Achilles tendon between 40, 80, 200, 400, and 1000 N/mm. The maximum displacement of navicular was observed at the ankle position of PF-20° (plantar flexion-20°). The difference in displacement of the navicular was greater at the ankle position of PF-20° with the Achilles tendon stiffness of 0 N/mm than that at the ankle position of PF-40° with the Achilles tendon stiffness of 40 N/mm.ConclusionsBased on the findings from this study, it was demonstrated that the Achilles tendon existence or not and ankle position had great influence, while increased stiffness of Achilles tendon had no influence on kinematic coupling relationship between tarsal bones. For the cases with severe equinus, earlier implementation of PAT procedure (with the purpose of release the Achilles tendon and reduce the degree of ankle plantar flexion) may be beneficial to the deformity correction.

An observational study on congenital talipes equinovarus.

Introduction: Clubfoot or Congenital Talipes Equinovarus (CTEV) is a congenital ab-normality characterized by the permanent foot morphological alteration, conse-quently individual is unable to lean the foot properly on the floor in an appropriate physiological manner.Objective: To execute an observational study on Congenital Talipes Equinovarus (CTEV) in the Orthopedic Department of Indus Medical College Hospital, Tando Mu-hammad Khan.Methodology: Study conducted from Jan 2018 to Jan 2019 at Orthopedic Depart-ment of Indus Medical College Hospital, Tando Muhamad Khan. Medial Crease (MC), Curved Lateral Border (CLB), and Lateral Head of Talus (LHT) assessed based on the Mid Foot Contracture Score (MFCS). Also, an assessment of the Posterior Crease (PC), Empty Heel (EH) and Right Equinus (RE) made as part of the Hind-foot Contracture Score (HFCS). Data collected from 100 participants through conven-ience sampling technique and quantitative analysis performed.Results: Of all participants, Pirani score was calculated from 0 to 1. Scoring is based on the average values. It has been found that the incidence of curved lateral border was 30%, medial crease as 55% and lateral head of talus as 15%. Additionally, it has been found that the empty heel incidence is 35%, posterior crease is 60% and rigid Equinus as 15%. These results reveal that there is a high incidence of CTAV in the given sample.Conclusion: The study revealed that the exact cause (s) of CTEV are still unknown.
 Keywords: Congenital Talipes Equinovarus (CTEV), Pirani score, Pediatric Orthope-dic

Prevalence of Functional Foot Deformities in Obese School Going Children

Background and Objectives: Obesity is a leading factor resulting in many health problem of which childhood obesity due to unhealthy diet and lifestyle is not uncommon. Obesity and foot deformities are closely linked to each other as the foot is the main support of body weight and the body weight need to be evenly distributed around the body. Increase in the body weight may increase the loading forces on the foot this in turn may alter the foot posture. This repetitive loading forces on the foot may give rise to the foot deformities. This study was conducted to find out functional foot deformities in obese school going children. Method: A total of 75 subjects in between age group of 12-15 years were allocated in obese group according to their BMI to assess the presence of functional foot deformities respectively. Each subject was assessed using foot posture index and scored according to the components. The outcome measure included six components and each was assessed and scored according to appropriate values. The score was taken for both right and left foot. Result: The results showed that all the components of foot posture index that is Talar head palpation, curves above and below the malleolus, inversion/eversion of calcaneus, prominence in the region of TNJ,congruence of medial longitudinal arch and abduction/adduction of forefoot on rearfoot are significant in obese children. Conclusion: It was concluded that there is presence of functional foot deformities in obese school going children both in right and left foot.

Temporal Variation of Scores Along the Course of the Ponseti Treatment in Older Children: A Ready Guide to Progress of Treatment.

We aimed to graphically study the correction trend along the course of Ponseti treatment in older children with idiopathic clubfeet. The temporal variation of total Pirani and Dimeglio scores and their individual components at each casting session was represented graphically. Tenotomy correction was accounted for separately. We classified 0 to 4 as early, 4 to 8 as midlevel, and beyond 8 as late casts to describe the sequence of treatment. A total of 27 patients (39 feet; bilateral in 12) were studied. The average patient age was 4.78±2.36 years. Rigid equinus was the more severe pretreatment deformity in Pirani system and also the most difficult to treat component. Posterior crease and medial crease were least severe and were treated in early casts. Reducibility of lateral head of talus, curved lateral border of foot, and empty heel were moderately severe and showed a gradual improvement pattern over subsequent casting sessions. For Dimeglio components, equinus was the most resistant deformity, and it persisted until late casts. Adduction, rotation, and varus were moderately severe, and they followed a gradual improvement slope. Several components/scores did not turn 0 after correction for older clubfoot children. The treatment graphs for older clubfoot children adequately illustrated the initial severity, number of Ponseti casts used, correction of total scores and their individual components over sequential casting sessions, tenotomy influence, and the residual deformities.

Morphological variations of the human talus investigated using three-dimensional geometric morphometrics.

The shape of the talus determines the positional and kinematic features of the subtalar, talonavicular, and talocrural joints during walking. Thus, detailed knowledge of the pattern of sexual dimorphism of the human talus may be useful for revealing the pathogenetic mechanism of foot and knee disorders, which are more prevalent in females. The aim of this study was to characterize and visualize the three-dimensional shape variations of the talus in relation to sex and age using geometric morphometrics. Computed tomography images of 56 feet without talar injuries or disorders were used in this study. Thirty-seven anatomical landmarks were identified on a bone model of the talus to calculate principal components (PCs) of shape variations among specimens. PC scores were compared between sexes, and their correlations with age were also investigated. The female talus had a longer neck and narrower head width than the male talus. The superior trochlea was tilted more laterally in the frontal plane in females. Furthermore, the female talar head was more twisted and was more elongated in the dorsoplantar direction. Morphological features of the talus in females could alter the subtalar and talonavicular joint kinematics during walking and could be a structural factor in the pathogenetic mechanism underlying foot and knee disorders. This study contributes to the comprehensive understanding of shape variations in the human talus.

A study on perforating peroneal artery

Aims. Peroneal flap with vascular pedicles is considered as a good substitute for limb reconstructions or any other soft tissue defects because of the number of perforating branches given from the PA. Purpose of this study is to evaluate the branching and communicating pattern of distal most perforating peroneal artery (PP). Methods. Dissected lower limbs of 48 cadavers were studied for the course and communications of PP. Results. The study encountered usual as well as variant communications of PP. In about 12% of the study sample PP continued as DPA and in about 6% of the cases it was communicated with DPA dorsal to the talar head region. The most frequent finding in the present study is PP piercing the interosseous membrane between tibia and fibula at about 6 to 6.5cm proximal to the tip of lateral malleolus. In one of the specimens it was piercing the LM at the base of LM. Conclusions. The results of present study imply a cautious dissection to locate an appropriate vascular pedicle for the flap surgery as there are small communications of PP with ATA as well as DPA and PP can also take variant course. Because failure to do so may lead to accidental and serious vascular injuries.

Assessment of the talar deformity and alignment in congenital clubfoot using three-dimensional MRI after Ponseti method

BackgroundPonseti method have been widely accepted as the initial treatment of congenital idiopathic clubfoot because its excellent primary result. On the other hand, relapses after Ponseti method are not uncommon and the cause of relapses have not been fully elucidated. We investigated detailed morphology and alignment of tarsal bones in clubfoot after Ponseti method using three-dimensional MRI analysis. MethodsWe performed MRI with 10 patients of unilateral clubfoot at three months after Achilles tenotomy. Based on the MRI volume data, we reconstructed three-dimensional bone surface model using the marching cubes method. We evaluated the volume of the talus and navicular bone, medial and planter deviation of the talar head and neck, medial deviation of the navicular bone, and internal rotation angle of the distal tibiofibular joint. ResultsIn clubfoot, the volume of talus and navicular bone were significantly smaller compared with the contralateral side. Deviation of the talar head and neck varied from medially to almost the same as that on the contralateral side. The degree of deformity of the talus and alignment of the navicular bone and distal tibiofibular joint showed correlations. ConclusionsPatients with the medial deviated talar neck might have the alignment change of navicular bone and distal tibiofibular joint. Deformity of talar neck might to be compensated by talonavicular joint and distal tibiofibular joint through the manipulation of Ponseti method.

High Burden of Associated Injuries Occurring With Major Fractures of the Talus.

Talus fractures are severe injuries typically occurring after high-energy trauma. As a result, associated injuries to different anatomic sites and organ systems occur with high frequency. The objective of this study was to determine what injuries occur with high incidence in patients presenting with major fractures of the talus and to identify clinical injury patterns that may warrant special attention in these patients. We performed a retrospective review of patients presenting to 3 level 1 trauma centers with fractures of the talar neck, body, or head over a 14-year period. Patient charts were reviewed for associated orthopedic and nonorthopedic injuries identified during the initial patient encounter and hospitalization. In total, 262 fractures in 258 unique patients met criteria for inclusion. Overall, 33.3% of talus fractures occurred in isolation. One or more associated injuries were identified in the remainder of cases (66.7%). The incidence of associated injuries was similar across fracture patterns. Mean total number of injuries per patient was 2.2 (range, 0-15). The ipsilateral foot was the most frequent site of associated orthopedic injury. Noncontiguous injuries occurred in 36% of cases. Lumbar spine injury occurred in 10.5% of cases. Lower extremity vascular injury was uncommon but bore significant association with open talus fractures. Talus fractures are commonly associated with injuries to different anatomic sites and organ systems. A similar rate of lumbar spine trauma may occur with major talus fractures as has been historically associated with calcaneal fractures. Thorough evaluation and a high index of suspicion are necessary when evaluating patients with major fractures of the talus to avoid missing concomitant injuries. Level IV, retrospective case series.

Biomechanical effect of anterior talofibular ligament injury in Weber B lateral malleolus fractures after lateral plate fixation: A finite element analysis

ObjectiveTo determine the biomechanical effect of anterior talofibular ligament injury in Weber B lateral malleolus fractures after lateral plate fixation. MethodA three-dimensional model was established based on CT images from a healthy volunteer. The simulation of lateral malleolus fracture, and the modeling and assembly of plate were completed by referring to characteristics of Weber B lateral malleolus fractures, as well as the technical characteristics of open reduction and internal fixation of lateral plate. Operating conditions were set up for groups A−D. The proximal end of the model was restrained in all four groups, 200N of upward force and 100N of backward force were applied at anterior of talus head in order to simulate the dorsiflexion of ankle joint. Biomechanical differences of the lateral plate were observed under various conditions of different ligament ruptures. ResultsThe maximum stress value of group A was the smallest, approximately 78.47N, while that of group C was the largest, approximately 238.83N. The maximum stress value of group B was about 91.69N; and that of group D was about 184.08N. Importantly, location of the maximum stress in group D (CUT ATaF) was displaced from the posterior edge to the anterior edge of the plate, which was different from those of the other three groups. ConclusionsThe anterior talofibular ligament injury may be a major contributing factor to the stress of lateral plate fixation following Weber B lateral malleolus fracture. It should be considered as an essential risk factor for evaluation of the stability in these fractures.

Sex determination from talus in Chinese population by three-dimensional measurement approach.

The determination of sex is an essential part of building the biological profile for unknown human remains. Sex determination from talus in Chinese population has been rarely reported. The aim of this study was to determine sex by discriminant function analysis through talus measurement in Chinese population. 48 male and 47 female Chinese northeast subjects were taken in this research. The ankle joints of these subjects were scanned by CT. In total, thirteen indexes were measured through Mimics and Magics software. Length and breadth indexes of total talus, trochlea, talar head, medial and lateral malleolus articular surface were mainly selected. Nine of them were measured through Mimics software. The other four indexes were measured through Magics software. All data were analyzed by independent-samples t-test in SPSS and Stata software. Discriminant function equations were generated for sex determination. All the indexes were normally distributed. No significant difference between left and right talus in either males or females was identified (P > 0.05). All results showed significant sexual difference (P < 0.05) except posterior breadth of trochlea. The average accuracy of sex determination ranged from 95.85% to 98.45% in the direct method and 98.95% in the stepwise method. Length indexes showed higher accuracy rate than breadth ones. Length of lateral malleolus articular surface was the best discriminator of sexual dimorphism. Talus was proved effective for sex determination in Chinese population. This study provided a remarkable reference for sex determination in forensic science.

The Navicular Prosthesis Template: A Cadaveric Study of the Talonavicular Morphometric Profiles and Side-to-side Differences

Category:Hindfoot, Midfoot/Forefoot, TraumaIntroduction/Purpose:The navicular bone destruction is a challenging condition in the foot surgery. This can be occurred from severe comminuted fracture, avascular necrosis from steroid used or Mueller-Weiss Syndrome, etc. However, little is known about the treatment option which can spare the talonavicular or naviculocuneiform joint regarding this condition. The navicular prosthesis replacement may be the promising option in the future. This study is to present the talonavicular (TN) ratio, other morphometric profiles, and side-to-side differences for the template of customized navicular prosthesis manufacturing.Methods:A total of eight matched pairs of the ankle (16 ankles) were collected in this study. The measurements were performed regarding the morphometric profiles of navicular and talar head. All data were recorded and analyzed to determine the TN ratio to be the template of navicular prosthesis manufacturing. The TN width ratio was calculated as talar head width was divided by navicular width in axial view. The TN height ratios were calculated as talar head height was divided by navicular height at the central arc in sagittal view. Medial and lateral navicular heights were also recorded in sagittal view. The medial, lateral, and central arc lengths of navicular were recorded from the cadaveric specimens.Results:The average talar head width was 28.5 +/- 3.2 mm. The average talar head height at central arc was 26.6 +/- 2.2 mm. The average navicular heights at medial, lateral rims, and central arc were 16.8, 21.4, and 24.5 mm respectively. The average navicular lengths at medial, lateral rims, and central arc were 18.6, 15.3, and 18.4 mm respectively. The average navicular width was 40.4 +/-2.7 mm. The average TN width ratio was 0.7 +/- 0.1. The average TN height ratio at central arc was 1.2 +/- 0.2. The side-to-side differences were insignificantly found on all talonavicular morphometric profiles (P>0.05).Conclusion:Based on this study, the talonavicular ratios and the morphometric profiles were demonstrated in the cadaveric specimens. The contralateral side of navicular can be the template for the manufacturing of the customized navicular prosthesis for the pathologic side due to the insignificant differences of side-to-side morphometric profiles. These data may help develop the customized navicular prosthesis to replace in the challenging pathologic condition of navicular.

Operative Treatment of Talar Head Fractures: Surgical Technique: Erratum

Operative Treatment of Talar Head Fractures: Surgical Technique: Erratum

Investigation of Lateral Column Lengthening Osteotomy on the Movement of the Calcaneus: A Cadaveric Study

Category:HindfootIntroduction/Purpose:Lateral column lengthening calcaneus osteotomy has been used widely in treating Stage IIB flexible flatfoot deformity in order to shift the anterior segment of the calcaneus forwards, which improves the coverage of the talonavicular joint by forefoot adduction. The premise of this investigation is that in addition to shifting the forefoot anteriorly around the axis of the talar head, there is also a posterior translation of the tuberosity of the calcaneus which is detrimental in that the angle of Gissane then impinges upon the posterior facet of the subtalar joint causing pain. Our hypothesis is that in addition to anterior translation of the calcaneus, posterior shift of the calcaneal tuberosity occurs with lengthening osteotomy of the calcaneus.Methods:An acute cadaveric flatfoot model was created on 5 fresh frozen cadaver feet with no previous foot and ankle deformity. In order to simulate the surgical scenario, the study was performed with no external load on the limb. A vertical osteotomy was performed 1 cm posterior of the calcaneocuboid joint. Commercially available precut wedges of 6 mm, 8 mm, 10 mm, and 12 mm were used for lateral column lengthening. After the insertion of the bone grafts, positional changes in sagittal plane of both the anterior and posterior calcaneus segments were monitored on lateral views under both fluoroscopy and a 3D digital high-resolution motion capture system. Results were calculated in percentage change from the base line horizontal distance between the talar and both anterior and posterior calcaneus markers before insertion of the wedges.Results:According to fluoroscopic measurements, the anterior translation of the anterior calcaneus segment was 7.27%+/-0.06 for 6 mm wedge, 16.11%+/-0.06 for 8 mm wedge, 20.81%+/- 0.08 for 10 mm wedge and 18.16%+/-0.07 for 12 mm wedge. The posterior translation of the posterior calcaneus segment was 9.85%+/-0.09 for 6 mm wedge, 13.15%+/-0.09 for 8 mm wedge, 12.04+/-0.09 for 10 mm wedge, and 14.06%+/-0.10 for 12 mm wedge. Statistical analysis showed that: 6 mm wedges did not cause significant changes in the translation of both anterior and posterior calcaneus segments with respect to the talus. 8 mm, 10 mm and 12 mm wedges caused significant translations both anteriorly and posteriorly. There was no statistically significant difference in the amount of either anterior or posterior translation caused by 8 mm, 10 mm or 12 mm wedges. These results were corroborated by 3D measurements.Conclusion:Of interest is that a 6 mm graft did not cause any significant anterior or posterior shift of the calcaneus. Lateral column lengthening with the 8,10, and 12 mm grafts however caused forward shifting of the anterior calcaneus, but also statistically significant posterior translation of the tuberosity, causing impingement of the posterior facet which was visible in each cadaver tested. There was no statistical difference between the sizes of the wedge above 6 mm and the translations they caused either anteriorly or posteriorly. Surgeons should be aware of the potential for painful impingement with the lateral column lengthening osteotomy.

Arthroscopic Debridement and Microfracture of Osteochondral Lesion of the Talar Head

Osteochondral lesions of the talar head can be classified into 4 types according to their location. A type 1 lesion is located at the anterior part of the talar head. Surgical debridement and microfracture are indicated for symptomatic type 1 lesions if conservative treatment fails to relieve the pain. The purpose of this technical note was to describe the details of arthroscopic debridement and microfracture of the symptomatic type 1 osteochondral lesion of the talar head and the kissing lesion at the navicular bone. The procedure is performed through the standard portals of talonavicular arthroscopy and has the advantages of minimally invasive surgery of better cosmetic results and less surgical trauma.

Fluoroscopy and Dynamic Pressure-Based Foot Orthoses for Children With Flatfoot

ABSTRACT Introduction The current nonsurgical treatment for pediatric flatfoot includes shoe modification, inserts, and foot orthoses (FOs). However, these methods do not affect the course of flatfoot in children and have only limited evidence of correction of foot pronation. The goals of this study are 1) to describe how to design novel customized FOs using plantar pressure and fluoroscopic measurements; and 2) to assess kinematics and kinetics of the foot and ankle joint and functional outcomes at baseline and 12-month follow-up. Materials and Methods One child with bilateral flatfeet received trio-pressure measurements, including dynamic plantar pressure, single sensor pressures on the lateral calcaneus, and medial talar head. The two-dimensional (2D) foot motion in the sagittal plane during the stance phase using single gantry fluoroscopy was recorded. Three-dimensional (3D) surface images of the entire foot and distal lower limb were registered. Results A total of 14 pressure metrics and three-dimensional (3D) foot and ankle topography were used to design the new orthoses and generate a computer-aided design model. Data from the fluoroscopic images were used to evaluate the orthotic design. Finally, two orthoses were designed and manufactured with a rapid prototype system (SLS). Discussion The gait-based software was successfully developed to design the new orthoses. Features included use of navicular height, talar and calcaneal alignment, pressure metrics, and foot geometry. This case study had 12-month follow-up and showed that the new FOs reduced pain and improved functional outcomes. Conclusions Use of gait-based software allows a further approach directly into the rapid prototype systems for orthoses designed to address pes valgus deformity.

Neandertal foot remains from Regourdou 1 (Montignac-sur-Vézère, Dordogne, France)

Regourdou is a well-known Middle Paleolithic site which has yielded the fossil remains of a minimum of two Neandertal individuals. The first individual (Regourdou 1) is represented by a partial skeleton while the second one is represented by a calcaneus. The foot remains of Regourdou 1 have been used in a number of comparative studies, but to date a full description and comparison of all the foot remains from the Regourdou 1 Neandertal, coming from the old excavations and from the recent reanalysis of the faunal remains, does not exist. Here, we describe and comparatively assess the Regourdou 1 tarsals, metatarsals and phalanges. They display traits observed in other Neandertal feet, which are different from some traits of the Sima de los Huesos (Atapuerca) hominins and of Middle Paleolithic, Upper Paleolithic and recent modern humans. These Neandertal features are: a rectangular talar trochlea with a large lateral malleolar facet, a broad talar head, a broad calcaneus with a projecting sustentaculum tali, a wide and wedged navicular with a projecting medial tubercle, large and wide bases of the lateral metatarsals, and mediolaterally expanded and robust phalanges that also show hallux valgus in a strongly built hallux.

Arthroscopic Management of Osteochondral Lesion of Plantar Medial Talar Head

Osteochondral lesions of the talar head can be classified into 4 types: type 1 is located at the anterior part of the talar head, type 2 is at the plantar side of the talar head, type 3 is at the plantar lateral side of the talar head, and type 4 is at the plantar medial aspect of the talar head. The purpose of this Technical Note is to describe the details of arthroscopic management of an osteochondral lesion of the plantar medial talar head. It includes arthroscopic synovectomy of the medial recess of the anterior subtalar joint, debridement, and microfracture of the osteochondral lesion.

Development and validation of a delayed presenting clubfoot score to predict the response to Ponseti casting for children aged 2\u201310

The aim of the study was to develop a simple and reliable clinical scoring system for delayed presenting clubfeet and assess how this score predicts the response to Ponseti casting. We measured all elements of the Diméglio and the Pirani scoring systems. To determine which aspects were useful in assessing children with delayed presenting clubfeet, 4 assessors examined 42 feet (28 patients) between the ages of 2–10 years. Selected variables demonstrating good agreement were combined to make a novel score and were assessed prospectively on a separate consecutive cohort of children with clubfeet aged 2–10, comprising 100 clubfeet (64 patients). Inter-observer and intra-observer agreement was found to be greatest using the following clinically measured angles of the deformities. These were plantaris, adductus, varus, equinus of the ankle and rotation around the talar head in the frontal plane (PAVER). Measured angles of 1–20, 21–45 and > 45 degrees scored 1, 2 and 3 points, respectively. The PAVER score was derived from both the sum of points derived from measured angles and a multiplier according to age. The sum of the points was multiplied with 1, 1.5 or 2 for ages 2–4, 5–7 and 8–10, respectively. This demonstrated a good association with the total number of casts to achieve a full correction (tau = 0.71). A score greater than 18 out of 30 indicated a cast-resistant clubfoot. The score could be used clinically for prognosis and treatment, and for research purposes to compare the severity of clubfoot deformities.

Radiographic Analysis of National Football League Players' Fifth Metatarsal Morphology Relationship to Proximal Fifth Metatarsal Fracture Risk.

Fractures of the proximal fifth metatarsal are one of the most common foot injuries in athletes. Repetitive stresses endured by the fifth metatarsal can lead to stress fracture, delayed union, and refracture, making optimal treatment challenging. A radiographic analysis of fifth metatarsal morphology and foot type in National Football League (NFL) players was performed to investigate morphologic risk factors for these injuries. This was a case-control study that looked at NFL players treated between 1992 and 2012, as well as participants at the NFL Combine. Ninety-six feet (51 athletes) were included. Fractures were present in 15 feet. Two reviewers assessed fifth metatarsal morphology and foot type on anteroposterior, lateral, and oblique radiographs. Differences in foot type and metatarsal morphology between athletes with and without fractures were determined. On anteroposterior radiographs, significant differences in apex medullary canal width, 4-5 intermetatarsal angle, fifth metatarsal angle, and talar head uncovering were observed between fractured and non-fractured feet ( P = .001, .003, .004, .008, respectively). On lateral radiographs, significant differences in the fifth metatarsal length, distance to apex, apex height, fifth metatarsal angle, and talocalcaneal angle were observed between fractured and nonfractured feet ( P = .04, .01, .02, .01, .01, respectively). On oblique radiographs, a significant difference was observed in apex height between fractured and nonfractured feet ( P = .002). Individuals with long, narrow, and straight fifth metatarsals with an adducted forefoot were most at risk for fifth metatarsal fractures. With this insight, attempts at fracture prevention can be implemented via footwear modifications, orthoses, and off-loading braces that account for those aforementioned morphologic attributes that place athletes at risk. Level III, retrospective comparative study.