Talo-1st Metatarsal Angle Research Articles

Results of JESS (Joshi's External Stabilizing System) in Relapsed, Neglected and Neurogenic Clubfoot in an Age Group of 2-10 Years.

Joshi's External Stabilization System (JESS) is an external fixator based methodology to correct different deformities of club foot using differential distraction. 31 difficult clubfeet feet in 24 patients who were neglected, neurogenic or relapsed were treated using JESS between July 2013 to June 2015 with an average follow-up of 4. 2 years. There were 16 males and 8 females in an age group of 2-10 years. 30 feet belonged to the severe and most severe group as per the Dimeglio Scoring System. All patients achieved correction of all components of the clubfoot. However, one patient required tibialis anterior transfer for dynamic forefoot adduction at the end of treatment. The mean total duration in JESS fixation was 69.5 days/foot (range 44-123 days) and the mean time to achieve correction within JESS averaged 52 days. The deformities improved from a mean Dimeglio score of 14.06 to 2.93. The objective radiological assessment of the deformities revealed improvements in the talocalcaneal angle on AP view from 16.39° to 34.52° and on lateral view from 15.97° to 33.03°. The Talo-1st metatarsal angle (AP view) improved from 35.29° to 7°. Complications included 11 cases of superficial pin tract infection, two instances of pin loosening and a case of pin cut out. There were three cases of 1st metatarsophalangeal dislocation that were managed by reversing the process of distraction. JESS is an effective method for managing difficult clubfeet.

Results of JESS (Joshi’s External Stabilizing System) in Relapsed, Neglected and Neurogenic Clubfoot in an Age Group of 2-10 Years

Background. Joshi’s External Stabilization System (JESS) is an external fixator based methodology to correct different deformities of club foot using differential distraction. Material and methods. 31 difficult clubfeet feet in 24 patients who were neglected, neurogenic or relapsed were treated using JESS between July 2013 to June 2015 with an average follow-up of 4. 2 years. There were 16 males and 8 females in an age group of 2–10 years. 30 feet belonged to the severe and most severe group as per the Dimeglio Scoring System. All patients achieved correction of all components of the clubfoot. Results. However, one patient required tibialis anterior transfer for dynamic forefoot adduction at the end of treatment. The mean total duration in JESS fixation was 69.5 days/foot (range 44-123 days) and the mean time to achieve correction within JESS averaged 52 days. The deformities improved from a mean Dimeglio score of 14.06 to 2.93. The objective radiological assessment of the deformities revealed improvements in the talocalcaneal angle on AP view from 16.39° to 34.52° and on lateral view from 15.97° to 33.03°. The Talo-1st metatarsal angle (AP view) improved from 35.29° to 7°. Complications included 11 cases of superficial pin tract infection, two instances of pin loosening and a case of pin cut out. There were three cases of 1st metatarsophalangeal dislocation that were managed by reversing the process of distraction. Conclusion. JESS is an effective method for managing difficult clubfeet.

Does the long-term use of medial arch support insole induce the radiographic structural changes for pediatric flexible flat foot? — A prospective comparative study

BackgroundSeveral conservative treatment methods, from intrinsic muscle exercises to orthoses, including insoles or specially designed shoes, have been introduced for pediatric flexible flat foot (PFFF). However, the structural effects of a long-term use of medial arch support insole remain unclear because the normal physiological maturation of the medial longitudinal arch cannot be ruled out. MethodsFrom January 2005 to June 2015, 18 patients (34 feet) in group 1 (continuously insole applied group) and 13 patients (26 feet) in group 2 (untreated group) were enrolled. Medial arch support insole was applied from the age 10–11years to radiographic physeal closure. ResultsIn group 1, talonavicular coverage angle, lateral talo-1st metatarsal angle, calcaneal pitch angle and medial cuneiform height were significantly changed at final follow-up, although all values were still within the abnormal range. Further, no significant differences were found in any of the increments of the radiographic parameters between group 1 and 2. ConclusionsRadiographic improvements were found in both of medial arch support insole treated or untreated group despite all radiographic values were still within the abnormal range. It was meaningful that the PFFF could be improved somewhat until the physes were closed. And the hindfoot alignment remained unchanged regardless of medial arch support insole application.

Radiological study of anatomical bony arrangement of the clubfoot deformity and its correlation with the Pirani clinical scoring system: A multicenter study.

Club foot or congenital talipes equinovarus (CTEV) is a common developmental disorder of the foot, affecting 1 per 1,000 live births. The main goal of this study is to evaluate the anatomical bony arrangement of the clubfoot deformity radiologically and to correlate this arrangement with the Pirani clinical scoring system. This descriptive, analytical study was conducted in three centres in Sudan. It recruited all the patients of both sexes with CTEV attending these centres, and excluding children on conservative cast and those who already had surgery. Data were collected using structured questionnaire. Pirani clinical scoring system, a reliable clinical assessment method, was applied. Four angles were used to measure each component of the deformity and correlate this with the Pirani score. Feet radiology was performed to assess the bone anatomy. The index cases number was 25 with male-to-female ratio of 1.6:1. Both feet were involved simultaneously in about half of the cases. Only the dorsoplanter (DP) and lateral (L) views talo-1st metatarsal angle was used to describe the forefoot adduction and mid-foot cavus, respectively. These correlated significantly with the clinical score of Pinari, whereas the other two measures for the equinus and varus did not. The results matched with the demographic description of the deformity found in the literature. Further studies are warranted that combine both the clinical assessment and the X-ray measurements in one score to classify the severity of the deformity and guide the management options.

Pathology and management of flexible flat foot in children

We describe the pathology and treatment of flexible flat foot in children. The flexible flat foot is seen in the overly flexible foot and usually involves hypermobility of the subtalar joint. It typically occurs in childhood and may continue to adulthood. The arch develops spontaneously during the first decade of life in most children and comes within the normal range observed in adult feet. We prescribed orthoses for the treatment of flexible flat foot patients. Lateral weight-bearing radiographs and ultrasonography were helpful for the evaluation of the flat foot. Bleck recommended the UCBL shoe insert in cases of flexible flat foot if the standing or lateral rentgenogram demonstrates a talar plantar flexion angle (TPF) of 45° or greater. Bordelon suggested that cases of flexible flat foot should be treated if the standing or lateral roentgenogram demonstrates a Meary's talo-1st metatarsal angle (T1-MTA) of −15°or greater. However, the radiograph of a young child's foot poses some difficulties in making an accurate evaluation, because of the radiolucent cartilage zone. In this situation, a sagittal image obtained by ultrasonography has proved to be a powerful aid to evaluate the type of the flat foot. We classified the flat foot into three types: talo-navicular sag (T-N sag), naviculo-cuneiform sag (NC sag) and talo-navicular and naviculo-cuneiform sag (Mixed sag) following the criteria of Tachdjian. We recommended the NC sag and Mixed sag groups to be treated by using orthoses, while we kept a status of watchful waiting for the T-N sag group. However, we should consider the increasing complaints of children and their parents during the orthotic treatment. A through discussion between the parents of patients and the pediatric orthopedic doctors is necessary before orthotic treatment is started.

Natural Progression of Radiographic Indices in Juvenile Hallux Valgus Deformity

Category: Bunion Introduction/Purpose: There is a lack of quantitative studies on the progression of juvenile hallux valgus deformity. Therefore, we performed this study to estimate an annual change of radiographic indices for juvenile hallux valgus. Methods: We reviewed medical records of consecutive patients under the age of 15 with juvenile hallux valgus who underwent weight-bearing foot radiographs more than twice, and were followed over a period of one year or more. A total of 133 feet from 69 patients were included. Hallux valgus angle, hallux interphalangeal angle, intermetatarsal angle, metatarsus adductus angle, distal metatarsal articular angle, anteroposterior talo-1st metatarsal angle, anteroposterior talo-2nd metatarsal angle, and lateral talo-1st metatarsal angle were measured and were used as a study criteria. The progression rate of hallux valgus angle was adjusted by multiple factors including the use of a linear mixed model with gender and radiographic measurements as the fixed effects and laterality and each subject as the random effect. Results: Our results demonstrate that the value of hallux valgus angle on the radiographs progressed as the patients grew older. The hallux valgus angle increased by 0.8° per year (p<0.001)(Figure). The distal metatarsal articular angle also increased by 0.8 per year (p=0.003). Conversely, hallux interphalangeal angle decreased by 0.2° per year (p=0.019). Progression of the intermetatarsal angle and metatarsus adductus angle with aging were not statistically significant. There was a difference in progression of radiographic indices between older patients (≥10 years) and younger patients (<10 years). The hallux valgus angle increased by 1.5° per year (p<0.001) in younger patients, progression of the hallux valgus angle in older patients was not statistically significant (p=0.869) as children grew up. Conclusion: These results suggest that the hallux valgus angle increased in patients with juvenile hallux valgus under 10 years old, unlike the patients aged 10 or older. We believed that our results can help surgeons to determine a treatment strategy that uses the growth potential to achieve correction of deformity such as lateral hemiepiphyseodesis of the 1st metatarsal to patients with juvenile hallux valgus.

The Influence of Percentile Weight Bearing on Foot Radiographs

Category: Midfoot/Forefoot Introduction/Purpose: Clinical decisions are often made based on the measurements of foot radiographs. Orthopaedic patients who have had lower extremity trauma or surgery are often given different weight bearing conditions including non-weight bearing, touch-down weight bearing, partial weight bearing (of various percent of body weight), and weight bearing as tolerated. However, it is largely unknown how these various weight bearing conditions alter specific parameters of foot radiographs. As such, the purpose of this study was to determine whether percent weight bearing influences radiographic measurements of the foot on anteroposterior (AP) and lateral radiographs? Methods: A total of 20 healthy subjects had AP and lateral radiographs of the foot under five weight bearing conditions (non-weight bearing, 10% body weight, 25% body weight, 50% body weight, and 100% body weight). Measurements were then made of hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), talonavicular coverage angle (TNCA), talo-calcaneal angle (TCA), forefoot width, LisFranc distance, cuboid height to ground (CHG), and talo-1st metatarsal angle (TMA) of each weight bearing condition. Statistical differences of each measurement for each weight bearing condition were then determined. Measurements were made by a radiologist and orthopaedic surgeon and inter-observer reliability determined for each measurement. For each radiographic measurement, a single factor ANOVA determined whether measurements were different between non-weight bearing, touchdown weight bearing, 25% weight bearing, 50% weight bearing, and 100% weight bearing. When a significant difference was detected, a post-hoc Tukey’s determined which categories of weight bearing were different. Results: The inter-observer reliability determined by the intraclass correlation coefficient was excellent to good in all measurements except for the TCA which was fair. For measurements made on the AP radiographs of the foot, the measurements that changed with percent weight bearing were the TNCA (p = 0.0009) and TCA (p = 0.0446) (Table 1). Weight bearing did not change the HVA (p = 0.2564, IMA (p = 0.1698), forefoot width (p = 0.2431), or LisFranc distance (p = 0.9854). For measurements made on the lateral radiographs of the foot, the measurement that changed with percent weight bearing was the CHG (p = 0.006). Weight bearing did not change the TMA (p = 0.9889). Conclusion: This study demonstrates a flattening of the medial arch with increasing percent body weight applied to a foot. This results in an increase in the TNCA as well as a decrease in the CHG. In addition, increasing percent body weight to the foot increases the hindfoot alignment. However, percent body weight does not alter measurements of the forefoot. Percentage body weight increase may not influence clinical preoperative/non-operative treatment as much as we expect; however, our findings do show that certain parameters increase with increasing weight bearing.

Mid-term follow up results of Calcaneal Reconstruction for the Late Complication of Calcaneus Fracture

Category: Trauma Introduction/Purpose: Calcaneal fracture is the most common fracture in hindfoot. The treatment is challenging, because of various patterns of fractures and high complication rates which leads to high level of dysfunction and low satisfaction of the patients. There are many previous studies reporting various methods about treatment of calcaneal malunion, such as subtalar arthrodesis, corrective osteotomy and corrective osteotomy with subtalar arthrodesis. However, there are no mid-term clinical results reporting about lateral ostectomy and sliding osteotomy, which is called calcaneal reconstruction. The purpose of this study is to evaluate the mid-term clinical and radiologic results of calcaneal reconstruction in the patients who have chronic complications after calcaneal fracture. Methods: Between January 2009 to May 2014, 196 patients (257 feet) were treated by calcaneal fracture. 34 patients (37 feet) underwent calcaneal reconstruction because of the dysfunction and the pain caused by malunion. Inclusion criteria were those whom underwent calcaneal reconstruction and able to be followed up at least 4 years postoperatively. The patients who had severe subtalar arthritis or whom underwent subtalar arthrodesis or simple bone resection were excluded. We reviewed 10 patients (10 feet) postoperatively and at mid-term follow up. Radiologic results including Böhler angle, calcaneal pitch, talocalcaneal height, talar inclination, talocalcaneal angle, talo-1st metatarsal angle, calcaneal width were measured and clinical results including AOFAS Ankle-Hindfoot scale and VAS score were checked preoperative, postoperatively and at the last follow up. The satisfaction of the patient was checked by survey. Results: The mean interval between the first operation and reconstructive operation was 16.6 months. The mean follow-up period after calcaneal reconstruction was 67.1 months. The most common symptom of the patient were pain on the inferior aspect of the lateral malleolus (4 patients) and heel area (3 patients). After calcaneal reconstruction, all the mean values of talocalcaneal height, calcaneal pitch, and Böhler angle were improved, which was statistically significant, respectively. In the postoperative period, 3 patients were very satisfied, 5 were satisfied, and 2 were not satisfied. The results maintained till mid-term follow up. Also, AOFAS and VAS score were improved comparing pre-reconstruction and mid-term follow up. Although the pain did not completely resolved, most of the patients were satisfied postoperatively. Conclusion: In patients without severe subtalar arthritis, the known main causes of the pain in calcaneal malunion are the loss of calcaneal height and hindfoot widening rather than subtalar arthritis. Our results showed signigficant clinical and radiological results by calcaneal reconstruction. And the outcome maintained till mid-term follow up. Calcaneal reconstruction can be a good choice for chronic pain which is caused by malunion of calcaneal fracture without severe subtalar arthritis.

Z-cut Osteotomy for Correction of Adult Acquired Pes Planovalgus Deformity

Category: Ankle Introduction/Purpose: Medial displacement calcaneus tuberosity osteotomy and anterior process lengthening calcaneus osteotomy are traditional single-plane osteotomy techniques used in adult acquired flatfoot deformity reconstruction. More recently, three plane step-cut osteotomies were described for each of these and offer improved rotational stability via the horizontal limb. However, a major technical challenge is achieving a sufficiently long horizontal limb to correct deformity through lengthening without losing bony apposition. Combining the anterior process and tuberosity step-cuts using an elongated horizontal limb (“Z-cut”, Figure 1) alleviates this technical challenge, creates a very large surface area for bony healing, and utilizes a single incision. We hypothesized that the Z-cut osteotomy achieves clinical and radiographic flatfoot deformity correction with a high union rate. Methods: This was an IRB-approved retrospective study of 17 patients who underwent Z-cut osteotomy for treatment of moderate to severe symptomatic adult acquired flatfoot deformity, Stage IIB. Mean follow up was 8.3 months. Radiographic correction was assessed via weight bearing radiographs taken pre-operatively and at a mean of 26 +/- 2 weeks post operatively. Measurements included Meary’s angle (talo-1st metatarsal angle), talonavicular joint (TN) uncoverage percentage, TN incongruency angle, medial cuneiform to fifth metatarsal height, and calcaneal pitch. Union rates, calcaneocuboid joint arthritic changes and clinical outcomes via Foot Function Index (FFI) score were assessed preoperatively and at a mean of 29 months following surgery. Paired t-test was used to compare both clinical and radiographic outcomes with statistical significance set at p<0.05. Results: Nine patients returned an FFI questionnaire with a mean improvement of 52.1 to 10.3 (p = .002). Calcaneal pitch improved from 13.2 to 15.3 (p = .004), medial cuneiform/5th metatarsal distance improved from 13.3 to 18.5 (p = .004), TN coverage angle improved from 22.4 to 9.7 (p < .001), TN uncoverage % improved from 34.3 to 21.2 (p <.001), TN incongruency angle improved from 39 to 20.1 (p < .001). Deformity correction was well maintained in 14 of 17 patients at final follow up. Union rate of the osteotomy was 100%. Three patients had symptomatic hardware initially, one patient required removal of hardware. One patient developed a superficial infection that cleared. Another patient developed peroneal tendonitis, which resolved with corticosteroid injection. Conclusion: The Z-cut osteotomy is a novel, technically simplified, single incision, single osteotomy alternative to previously described double calcaneus osteotomy techniques for reconstructing flexible moderate to severe adult acquired flatfoot deformity which offers comparable short term clinical and radiographic outcomes with acceptably low complications.

Use of autologous bone grafting from the calcaneus and interconnected porous hydroxyapatite ceramic for bone transplantation in rheumatoid foot surgery

Cancellous bone grafts from the calcaneus have been used for the foot and ankle as well as iliac bone graft; however, there is a sparse report for calcaneal bone transplantation in the field of rheumatoid foot surgery. In this study, safety and usefulness of calcaneal bone grafts, and combination with interconnected porous hydroxyapatite ceramic, was evaluated in rheumatoid arthritis foot surgeries. Of six rheumatoid arthritis cases, three (talo-navicular joint fusion) used a calcaneal bone graft alone, and the remaining three cases (subtalar joint and talo-navicular joint fusion) used a combination of calcaneal bone graft and interconnected porous hydroxyapatite ceramic augmented with dense calcium hydroxyapatite for subtalar bony defect (1.5–2.0 cm) after the correction. Pre- and postoperative Japanese Society for Surgery of the Foot rheumatoid arthritis foot ankle scale scores were obtained for the clinical assessment. As radiographic assessment, tibio-calcaneal angle, calcaneal pitch, talo-1st metatarsal angle, and pronated foot index were also evaluated. After starting weight-bearing or walking, there was no pain and skin trouble at the fusion and harvesting sites. All cases achieved bony fusion within 6–10 weeks. Japanese Society for Surgery of the Foot rheumatoid arthritis foot ankle score was improved in all six cases. Furthermore, tibio-calcaneal angle, talo-1st metatarsal angle, and pronated foot index were also improved at latest follow-up in all cases. In conclusion, autologous bone grafting from the calcaneus was safe and convenient even in rheumatoid foot surgeries. For larger bony defects (1.5–2.0 cm), combination use with interconnected porous hydroxyapatite ceramic augmented with dense calcium hydroxyapatite was also useful.

Correction of Severe Flexible Pes Planovalgus Deformity Using Trabecular Metallic Wedges

Category: Hindfoot, Midfoot/Forefoot Introduction/Purpose: Lateral column lengthening and a medial cuneiform plantarflexion (Cotton) osteotomy are procedures commonly used in the treatment of symptomatic flexible pes planovalgus. Traditionally, structural autograft or allograft have been used for both osteotomies. While union rates for both types of graft have been shown to be comparably high, the use of allograft or autograft each come with their own set of inherent risks and/or potential complications. A trabecular titanium wedge implant provides an attractive alternative that avoids the concerns associated with autograft and allograft use, and has previously been shown in the literature to demonstrate similar union rates. The purpose of this study was to retrospectively review the radiographic outcomes of corrective osteotomies utilizing trabecular metal wedges to address severe flexible pes planovalgus deformity. Methods: 115 feet in 109 patients who were treated with corrective osteotomies using a trabecular titanium wedges performed by one surgeon were retrospectively reviewed. All patients had symptomatic flexible pes planovalgus, mostly secondary to stage IIB posterior tibialis tendon dysfunction. Other diagnoses included pes planovalgus secondary to the adolescent idiopathic flexible subtype, traumatic posterior tibialis tendon rupture, coalition, or an accessory navicular. Preoperative radiographic parameters assessing severity of deformity were recorded and compared to the postoperative measurements taken at the time of most recent follow up visit to assess for correction. The radiographic measurements included the (1) AP talo-1st metatarsal angle (2) Lateral talo-1st metatarsal angle (3) Calcaneal pitch (4) Lateral talo-calcaneal angle and (5) Talonavicular uncoverage angle. All angles were measured off standard weight-bearing radiographs by one author using our institution’s picture archiving and communication system (PACS) software. All complications were also recorded. Results: At an average follow up time of 40 weeks, there were statistically significant corrective changes in the AP-talo-1st metatarsal angle (-12.56), lateral talo-1st metatarsal angle (+14.15), calcaneal pitch (+5.23), lateral talo-calcaneal angle (-3.87) and talonavicular uncoverage angle (-17.76). There were 3 nonunions (2.6%) confirmed by CT, 2 of which were eventually revised. There were a total of 9 complications (7.8%). Other than the nonunion revisions, none of these complications required a return to the operating room. There were no cases of collapse or loss of correction at the time of followup, as compared to the initial post-operative radiographs. Conclusion: In our study population corrective osteotomies using a trabecular titanium wedge was effective in improving radiographic parameters associated with flexible pes planovalgus deformity. The nonunion and overall complication rates using a trabecular titanium wedge were shown to be comparable or superior to what has previously been reported in the literature using allograft or autograft.

Natural Progression of Radiographic Indices in Juvenile Hallux Valgus Deformity

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: There is a lack of quantitative studies on the progression of juvenile hallux valgus deformity. Therefore, we performed this study to estimate an annual change of radiographic indices for juvenile hallux valgus. Methods: We reviewed medical records of consecutive patients under the age of 15 with juvenile hallux valgus who underwent weight-bearing foot radiographs more than twice, and were followed over a period of one year or more. A total of 133 feet from 69 patients were included. Hallux valgus angle, hallux interphalangeal angle, intermetatarsal angle, metatarsus adductus angle, distal metatarsal articular angle, anteroposterior talo-1st metatarsal angle, anteroposterior talo-2nd metatarsal angle, and lateral talo-1st metatarsal angle were measured and were used as a study criteria. The progression rate of hallux valgus angle was adjusted by multiple factors including the use of a linear mixed model with gender and radiographic measurements as the fixed effects and laterality and each subject as the random effect. Results: Our results demonstrate that the value of hallux valgus angle on the radiographs progressed as the patients grew older. The hallux valgus angle increased by 0.8° per year (p<0.001)(Figure). The distal metatarsal articular angle also increased by 0.8 per year (p=0.003). Conversely, hallux interphalangeal angle decreased by 0.2° per year (p=0.019). Progression of the intermetatarsal angle and metatarsus adductus angle with aging were not statistically significant. There was a difference in progression of radiographic indices between older patients (=10 years) and younger patients (<10 years). The hallux valgus angle increased by 1.5° per year (p<0.001) in younger patients, progression of the hallux valgus angle in older patients was not statistically significant (p=0.869) as children grew up. Conclusion: These results suggest that the hallux valgus angle increased in patients with juvenile hallux valgus under 10 years old, unlike the patients aged 10 or older. We believed that our results can help surgeons to determine a treatment strategy that uses the growth potential to achieve correction of deformity such as lateral hemiepiphyseodesis of the 1st metatarsal to patients with juvenile hallux valgus.

Mid-term Outcomes & Complications Following the Use of an Arthroereisis Implant to Aid in Stage II Flat-Foot Correction in Adults

Category: Hindfoot Introduction/Purpose: The use of an arthroereisis implant to augment a stage II, flat-foot reconstruction in adults has been described and may improve postoperative alignment. Yet, painful hardware has been reported. Additionally, there are no reports of mid-term follow up on these implants. The purpose of this study is to describe the mid-term clinical and radiographic outcomes as well as complications with the use of an arthroereisis implant as an adjunct procedure for patients undergoing surgical correction of a flexible acquired, stage II, flat-foot deformity as compared to controls Methods: With IRB approval, all patients undergoing stage II, flat-foot reconstruction by the senior author were identified from 2010-2015. A search was conducted to identify patients within this group undergoing implantation of an adjunctive arthroereisis implant during reconstruction. A 2:1 match using age and gender was performed to identify controls undergoing flexor digitorum longus transfer, medial calcaneal osteotomy, spring ligament repair, and Strayer lengthening during the study period. Demographic information, patient records, operative reports, and follow-up radiographs were reviewed. Preoperative and final follow-up, AP and lateral, weightbearing, radiographs measuring talo-1st metatarsal angle, talo-2nd metatarsal angle, and talo-navicular coverage angle were reviewed and recorded. Clinical follow-up was performed to administer satisfaction SF-36 scoring, and to determine survivorship. Patients undergoing additional corrective procedures at the initial surgery or incomplete records were excluded. Results: 48 patients, age 49.7 (range, 16-68), were included, 16 patients received an arthroereisis implant, 4 were metallic and 12 were bioabsorbable. Follow-up was conducted at 3.54 years (range, 1.4-6 years). Radiographic analysis demonstrated significant improvement in alignment from preoperative to mid-term follow-up in both groups. In addition, arthroereisis patients had a statistically significant improvement in correction of talo-navicular coverage angle at final follow-up, 5 degrees ± 3.9, compared to controls, 10.6 degrees ± 6.8. Average SF-36 scores at mid-term follow-up were comparable with no significant difference between cases, 74.6 ± 21.8, and controls, 76.1 ± 15.3 p=0.89. Overall, 84% of patients noted good or excellent satisfaction. Complications included one arthroereisis failure from painful hardware (1/16), one infection in the controls (1/32), and an unrelated mortality. Conclusion: Arthroereisis implants as an adjunct to stage II, flat-foot correction result in improved and maintained radiographic alignment with comparable clinical results to controls at mid-term follow-up. Additionally, the use of the implant demonstrates improved talo-navicular coverage on mid-term radiographs. While painful hardware was noted in a metallic implant, bioabsorbable implants have demonstrated few complications and may be a safe adjunct to stage II, flat-foot correction in adults.

Intramedullary fixation in severe Charcot osteo-neuroarthropathy with foot deformity results in adequate correction without loss of correction - Results from a multi-centre study.

Charcot osteo-neuroarthropathy (CN) of the foot can induce severe instability and deformity. Results of a consecutive clinical multi-centre study with Midfoot Fusion Bolt (MFB, Synthes GmbH, Oberdorf, Switzerland) are reported. All patients (aged 18 years and older) treated between 2009 and 2013 with surgical reconstruction of the midfoot with MFB for CN were included. Demographics, pre-surgical health status, details of foot pathology, details of surgery, postoperative treatment, treatment failure, and adverse events were registered. The following radiographic angles were measured on pre-op, post-op and last follow-up radiographs: talo-1st metatarsal (TMT) angle dorsoplantar and lateral view, and calcaneo-5th metatarsal angle. Forty-seven patients (48 feet) were included in three centres. In 38 patients (80.1%) diabetes was diagnosed. Wound healing problems occurred in 21% of patients and recurrent ulceration in 13%. Revision surgery for loss of correction was performed in three cases (6%). Union rate at final follow-up was 98%. Major amputation for deep infection was performed in two patients (4%), minor amputation at the foot level in three cases (6%). Failure was more frequent when only one MFB (instead of 2 or 3) was used and no Gastrocnemius lengthening was performed. Radiographic alignment significantly improved pre- versus postoperatively and preoperatively versus follow-up. Realignment and fixation with MFB in severe CN result in adequate correction with minimal loss of correction in the observed clinical course. The non-union rate was lower than previously reported. Stable fixation with MFB is a valuable treatment option for CN with minimal loss of correction and high union rates. The use of a minimum of two bolts is recommended to avoid recurrent deformity. Clinical Trials.gov: NCT01770639.

Diagnostic Availability of Pedobarography and Correlation of Radiographic and Pedobarographic Measurements in Pediatric Flexible Flatfoot

Purpose: The purpose of this study was to analyze the diagnostic availability and to examine the co-relation between pedobaragraphy and radiography of pediatric flexible flatfoot. Materials and Methods: Seventeen patients and ten normal children were studied. In radiographic evaluation, the talo-1st metatarsal angle was measured on anteroposterior radiographs; and the talo-1st metatarsal angle, the talo-horizontal angle, the calcaneal pitch, and the talocalcaneal angle were measured on lateral radiographs. In pedobarography, foot pressures were subdivided into eight areas for measurement of contact time, ratio of measured area and to investigate the relation between the degree of the medial deviation of the Center of pressure line and the radiographic measurements. Results: Flat foot group and normal group showed statistically significant difference in every angle measured in lateral radiographs. The foot pressure ratios of the lateral sides in forefoot and the medial and lateral sides of midfoot and the medial side of hindfoot between the flexible flatfoot group and normal group showed statistically significant difference in pedobarography and ratio of contact area in forefoot and hindfoot showed significant change in statistics but no changes in contact time. The relation between pedobarography and radiography was investigated: foot pressure of the medial and lateral side of forefoot and the talocalcaneal angle showed significant relation in statistics and foot pressure of the medial and lateral side of mid foot and every angle measured in lateral radiographs showed significant relation in statistics. Contact time of midfoot and every radiographic value measured in lateral radiograph showed significant relation in statistics and contact area of forefoot and midfoot showed significant relation with every radiographic value measured in lateral radiographs. In addition, medial deviation of center of pressure line showed significant relation in statistics with talus-first metatarsal angle measured on anteroposterior radiographs and talo-horizontal angle and talus-first metatarsal angle measured on lateral radiographs. Conclusion: The results of this study showed correlation between radiologic methods and pedobarography in diagnosis of pediatric flexible flatfoot and pedobarography is an useful tool in quantitative and qualitative analysis of the degree of foot deformity and medial deviation of center of pressure line.

Validation of a population of patient‐specific adult acquired flatfoot deformity models

Adult acquired flatfoot deformity (AAFD) is a degenerative disease resulting in malalignment of the mid- and hindfoot secondary to posterior tibial tendon dysfunction and increasing implication of ligament pathologies. Despite the complex 3D nature of AAFD, 2D radiographs are still employed to diagnose and stage the disease. Computer modeling techniques allow for accurate 3D recreations of musculoskeletal systems for the investigation of biomechanical factors contributing to disease. Following Institutional Review Board approval, the lower limbs of six diagnosed AAFD sufferers were imaged with MRI, photographs, and X-ray. Next, a radiologist graded the MRI attenuation of eight soft-tissues implicated in AAFD. Six patient-specific rigid-body models were then created and loaded according to patient weight, graded soft-tissues, and extrinsic muscles. Model function was validated using clinically relevant kinematic measures in three planes. Agreement varied depending on the measure, with average absolute deviations of < 7° for angles and <4 mm for distances. Additionally, the clinically favored AP talonavicular coverage angle, ML talo-1st metatarsal angle, and ML 1st cuneiform height showed strong correlations of R(2) = 0.63, 0.75, and 0.85, respectively. Thus, computer modeling offers a promising methodology for the non-invasive investigation of in vivo kinematic behavior in pathologic feet and, once validated, may further be used to investigate biomechanical parameters that are difficult to measure clinically.

V Osteotomy and Ilizarov Technique for Residual Idiopathic or Neurogenic Clubfeet

To report the treatment outcomes of V osteotomy and Ilizarov technique for residual idiopathic or neurogenic clubfeet. 13 patients (14 feet) aged 8 to 18 years underwent V osteotomy via the calcaneus and talus, followed by gradual distraction of soft tissue and bone for foot reconstruction. Eight of the clubfeet were idiopathic and had undergone previous surgeries. The remaining 6 were neurogenic and their pathologies were: Charcot-Marie-Tooth disease (n=2), myelomeningocele (n=2), neurofibromatosis (n=1), and distal arthrogryposis (n=1). Three of them had undergone previous surgeries. The Ilizarov frames were retained for 3 to 6 months and the patients were followed up for 1.8 to 8.9 years. Range of movement of the ankle and foot, appearance and position, gait, pain, function, and patient satisfaction were assessed according to the modified clubfoot grading system. The talo-1st metatarsal angle was measured on anteroposterior radiographs. Scores associated with the appearance and position of the foot, and thus patient satisfaction were significantly improved, but not for range of movement, pain, and function. The mean preoperative and final talo-1st metatarsal angles were 39.7 and 8.7 degrees, respectively (p<0.01). Ten feet achieved the plantigrade position, one had residual equinus, and 3 had residual adduction and supination. Patient satisfaction improved significantly despite no major improvement in pain, function, and range of movement of the ankle and foot. This reflects the importance of the appearance and position of the foot, and justifies the decision to undergo this long and demanding procedure.

Use of Allograft in Skeletally Immature Patients for Calcaneal Neck Lengthening Osteotomy

PurposeTo date, there have been no studies evaluating the usefulness of allograft as a substitute for autograft in calcaneal neck lengthening osteotomy. This retrospective study examined the results of calcaneal neck lengthening osteotomy using allograft for pathologic flatfoot deformity in children and adolescents with various neuromuscular diseases.Materials and Methods118 feet in 79 children treated surgically between Mar 2000 and July 2005 were reviewed. The mean age at the time of the operation was 9 + 3 years (range, 3 - 17 years) and follow-up averaged 15.4 months (range, 13 - 21 months) postoperatively. Talo-1st metatarsal angle, talo-calcaneal angle, calcaneal pitch were measured before and after operation and bony union was estimated.ResultsBony union was noted at the latest follow-up and there were no postoperative complications such as reduction loss, infection, nonunion, delayed union or graft loss during the follow-up period in all but one foot. All radiographic indices were improved postoperatively in all cases.ConclusionOur results indicate that use of allograft in calcaneal neck lengthening osteotomy is a useful option for correction of the planovalgus deformity in skeletally immature patients whose enough autobone can not be obtained.

Surgical management of severe deformity resulting from posterior tibial tendon dysfunction.

A retrospective case study format was used to evaluate the results of surgical treatment of severe deformities due to long-standing tibialis posterior tendon dysfunction. To be included in the study, the peri-talar (talonavicular) subluxation on a weight-bearing AP X-ray should have been at least 75%. This criterion limited the field to patients with long-standing, rigid, severe deformities. Surgical correction was obtained through a two-incision approach, dorsomedial and dorsolateral. Significant shortening of the medial column and extensive removal of adaptive bone formation was necessary to allow reduction of the hind- and midfoot deformity. Stable internal fixation using multiple screws was used to secure the reduction. Eleven patients, 12 feet were evaluated. The patients were evaluated using the American Orthopedic Foot and Ankle Society Ankle and Hindfoot Score as well as a questionnaire on footwear and satisfaction rating. The average score improved from 30 points pre-op to 74 points post-op (out of 100). P-value 0.0001. Pain score improved from 11/40 to 33/40. Function improved from 19/50 to 33/50. Alignment improved from 0/10 to 8/10. The radiological parameters showed an average improvement of 31 degrees in the lateral talo-1st metatarsal angle, 11 degrees in the calcaneal pitch, and 35 degrees in the AP talo-1st metatarsal angle. All three parameters were highly significant with P-values of 0.0001. Multiple complications occurred. This included two delayed unions with breakage of screws and partial loss of correction, four wound problems, two sural nerve impairments and three patients requiring hardware removal. Even though it is an extensive procedure with multiple potential complications it still offers a substantial improvement in quality of life.

Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency.

The surgical treatment of flexible pes planovalgus deformities resulting from Stage 2 posterior tibial tendon insufficiency is controversial and many techniques have been proposed. We retrospectively reviewed the results of subtalar arthrodesis combined with spring ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular. There were sixteen patients (seventeen feet) with an average follow-up of 27 months (9-52). All deformities were passively correctable. The average age was 56 yrs (39-78). All patients had failed conservative management, 88% had previously been treated with orthotics, and 53% had lateral pain from subfibular impingement. Two patients were noted to have degenerative changes of the subtalar joint. Successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5-24). The average AOFAS hindfoot score and Maryland foot score postoperatively was 82 and 86 respectively. Standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6 degrees (24 degrees preoperative, 18 degrees postoperative). The talonavicular coverage angle improved an average of 17 degrees (34 degrees preoperative, 17 degrees postoperative). The lateral talo-1st metatarsal angle improved an average of 10 degrees (18 degrees preoperative, 8 degrees postoperative). The lateral talocalcaneal angle decreased an average of 21o (55 degrees preoperative, 34 degrees postoperative). The distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively (avg. improvement 6mm). The combination of the flexor digitorum longus tendon transfer and spring ligament repair with subtalar arthrodesis is an effective and reliable procedure which provides excellent correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the longitudinal arch. These results compare favorably with flexor transfer combined with either calcaneal osteotomy or lateral column lengthening.