Talonavicular Angle Research Articles

The Efficacy of Graded Arch Support Insoles in Patients with Common Foot Ailments; A Clinical Trial

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Arch-support insoles are frequently used as part of the treatment protocol for a variety of common foot ailments including metatarsalgia, and plantar fasciitis. While custom-molded insoles are considered to be the most efficacious ones, prefabricated insoles are still preferred due to their lower price and availability. However, there's ongoing skepticism about their capacity to meet the diverse and changing biomechanical requirements of every individual over time. In this study, we investigated the effect of a patient-specific, three-level-graded arch support system for the treatment of common foot ailments using patient-reported outcome measures of pain. Methods: A single-armed clinical trial was conducted including patients aged >18 years with a diagnosis of plantar fasciitis or metatarsalgia. Based on initial measurements, each participant was given three specific arch support orthotics (Good Feet™, Dr.’s Own, LLC) with varying arch heights, to be worn at tolerance, along with a pair of sneakers for standardization of the footwear condition. Symptomatic relief was measured at the baseline-, fourth-, eighth-, and twelfth-week appointments using the Patient Reported Outcomes Measurement System (PROMIS) for pain Intensity, pain Interference, and the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire. Moreover, the structural changes of the foot were also measured using Weight-bearing Computed Tomography (WBCT) scans, and X-rays of the foot with and without the insoles at the initial visit. Data were analyzed employing the T-test, Wilcoxon Signed Rank, and Friedman tests where applicable. A p-value below 0.05 was considered to be statistically significant. Results: A total of 43 patients with a mean (SD) age of 41.69 (12.21) years, a female-to-male ratio of 1.3:1, and a body mass index (SD) of 25 (4.04) were included in the study. PROMIS pain interference and intensity scores improved significantly starting from the fourth week (p=0.017, and 0.003, respectively). Additionally, the AOFAS questionnaire demonstrated enhanced scores notably on the lesser metatarsophalangeal-interphalangeal, and midfoot subscales with p-values of 0.001, and < 0.001, respectively (Figure 1.). Moreover, the navicular height on WBCT and the talo-navicular angle on lateral view X-rays increased when the insoles were utilized (p=0.046, and < 0.001, respectively; Figure 2.). Conclusion: This study revealed the significance of prefabricated graded arch supports for the symptomatic relief of patients with plantar fasciitis and metatarsalgia. These clinical improvements were also supported by discernable anatomical changes as evidenced by foot radiography and WBCT assessments. Given these findings, we believe future research should be focused on evaluating the efficacy of these insoles in managing additional foot pathologies. Moreover, it is imperative to explore the biomechanical ramifications of such supports on the dynamic alignment of the foot, to further understand their role in altering foot structure and function.

Change in Talar Axial Rotation and Pain Intensity Following Correction of Progressive Collapsing Foot Deformity.

The talus is more internally rotated within the ankle mortise in progressive collapsing foot deformity (PCFD) patients. However, no studies have investigated the change in talar axial rotation (AR) in PCFD postoperatively. The primary aim was to investigate the change in talar AR following PCFD reconstruction. Secondary aims were to determine whether talar AR changes were associated with other radiographic measurements or specific procedures, and whether postoperative talar AR was associated with 2-year patient-reported outcome scores. Twenty-seven patients older than 18 years who underwent flexible PCFD reconstruction with preoperative and at least 5-month postoperative weightbearing computed tomographic (WBCT) scans and radiographs and had preoperative and at least 2-year postoperative PROMIS scores were included. Patients with talonavicular fusions were excluded. Talar AR was the angle between the transmalleolar axis and talar axis on WBCT scans, with smaller angles representing more internal rotation as described by Kim et al. Hindfoot moment arm, Meary angle, fibulocalcaneal and talocalcaneal distance, subtalar middle facet uncoverage, and talonavicular angle were measured on radiographs. Postoperative talar AR was 49.7 degrees (IQR, 45.9, 57.3), which was more externally rotated than preoperative AR by a median of 8.3 degrees (IQR, 2.2, 15.7) (P > .001). The change in talar AR was not associated with changes in any radiographic parameter. Increasing external talar AR was associated with an increase in postoperative PROMIS pain intensity (rs = 0.38, 95% CI 0.00, 0.67). Lateral column lengthening and subtalar fusion procedures were not associated with changes in talar AR (P > .10). PCFD reconstruction results in external rotation of the talus within the ankle mortise. Kim et al found that control patients had approximately 40 to 60 degrees of talar AR, which is similar to this study's corrected position of the talus. However, increasing talar external rotation resulted in worse postoperative PROMIS pain intensity, suggesting the possibility of overcorrecting the internal AR deformity.

Change in Axial Rotation of the Talus Following Reconstruction of the Progressive Collapsing Foot Deformity

Category: Hindfoot; Other Introduction/Purpose: In addition to peri-talar subluxation of the foot, previous studies have demonstrated that the talus is more internally rotated with respect to the trans-malleolar axis of the ankle in PCFD patients compared with normal patients. However, no studies have investigated the change in rotation of the talus in PCFD postoperatively and its association with outcomes. The primary aim of this study was to investigate the preoperative to postoperative change in rotation of the talus following reconstruction of the flexible PCFD. Secondary aims were to determine whether changes in rotation of the talus were associated with radiographic measurements of PCFD or specific reconstructive procedures and whether postoperative talar rotation was associated with two-year patient-reported outcome scores. Methods: Thirty-four consecutive patients over the age of 18 years old who underwent reconstruction of a flexible PCFD with preoperative and at least 5-month postoperative weightbearing CT (WBCT) scans and plain radiographs and had preoperative and at least two-year postoperative PROMIS scores were included in the study. Patients were excluded if they underwent a talonavicular fusion. Talar axial rotation was the angle between the transmalleolar axis and talar axis on preoperative and postoperative WBCT scans as previously described by Kim et al (2023) with smaller angles representing more internal rotation. Hindfoot moment arm, Meary’s angle, and talonavicular angle were measured on plain radiographs. Due to small sample sizes, descriptive statistics are reported as median and interquartile ranges (IQRs). Wilcoxon signed rank and Mann Whiney U tests were used to investigate differences between groups. Spearman correlation coefficients were employed to detect associations between variables and reported using 95% confidence intervals (95% CIs). Results: Median preoperative and postoperative talar axial rotation were 39.9° (IQR 36.7°, 45.3°) and 49.7° (IQR 45.9°, 57.3°, P < 0.001), respectively. The talus externally rotated by a median of 8.3° (IQR 4.1°, 13.1°) following surgery. The preoperative to postoperative change in talar rotation was not associated with changes in any plain radiographic parameter (Table 1). Increasing external rotation of the talus was associated with an increase in postoperative PROMIS Pain Intensity (rho=0.38, 95% CI 0.00, 0.67) with similar trends in the PROMIS Physical Function (rho=-0.22, 95% CI -0.55, 0.18) and Pain Interference (rho=0.19, 95% CI -0.21, 0.53) domains (Figure 1). Lateral column lengthening and subtalar fusion procedures were not associated with changes in talar rotation (both P > 0.10). Conclusion: Reconstruction of the flexible PCFD distal to the talus results in external rotation of the talus within the ankle mortise. Talar rotation was not associated with common measures of deformity or specific procedures. Kim et al. found that control patients had approximately 40°-60° of talar axial rotation, which is similar to the corrected position of the talus in our study. However, increasing talar external rotation resulted in worse postoperative PROMIS Pain Intensity scores with a similar trend seen in other PROMIS domains and raises the possibility of overcorrecting the internal rotational deformity of the talus in flexible PCFD.

Comparative Analysis of Structural Differences in Progressive Collapsing Foot Deformities with and without Hallux Valgus

Category: Bunion; Hindfoot Introduction/Purpose: Progressive collapsing foot deformity (PCFD) and Hallux Valgus (HV) are common foot and ankle pathologies, each associated with over-pronation. Although hindfoot pronation is known to potentially increase forefoot pronation, not all patients with PCFD ultimately develop HV deformity. This study aims to explore the structural differences in patients with PCFD, with and without HV deformities, using weight-bearing computed tomography (WBCT). We hypothesize that specific structural variations exist, which could potentially inform and enhance future therapeutic strategies and preventive measures for HV deformity in patients with PCFD. Methods: Adult PCFD patients underwent WBCT at our institution between May 2023 and December 2023 were included. Semi-automatically measured parameters include Meary angle (axial and sagittal), calcaneal inclination angle, hindfoot moment arm, hindfoot angle, axial talonavicular angle, intermetatarsal angle, HV angle were recorded. WBCT manual measurement include foot and ankle offset, angle between inferior facet of the talus and the ground (inftal-hor), angle between inferior and superior facets of the talus (inftal-suptal), angle between inferior facet of the talus and superior facet of the calcaneus (inftal-supcal), and forefoot arch angle. Additionally, using the ground as a reference, the coronal plane pronation of the navicular, medial cuneiform, first metatarsal base, and first metatarsal head were also recorded. HV deformity was defined as having a Hallux Valgus Angle (HVA) greater than 15 degrees. Pronation/valgus were defined as positive values. Results: Our study included 58 patients (72 feet), 33 feet with HV and 39 without HV. In the coronal plane, the PCFD with HV group exhibited higher inftal-suptal angle (p=0.001), and higher pronation of the first tarsal-metatarsal joint (p=0.006), first metatarsal bone(p=0.002), and first metatarsal head(p< 0.001). Additionally, this group also demonstrated higher navicular-cuneiform joint supination (p < 0.001). In axial plane, the axial talar-1st metatarsal angle higher in the PCFD without HV group (p=0.043). Nominal logistic regression analysis indicated parameters include 1st metatarsal head rotation (p< 0.001), medial cuneiform rotation(p< 0.001), inftal-suptal angle (p< 0.001), axial talar-1st metatarsal angle (p< 0.001), navicular rotation (p=0.007), first metatarsal base rotation (p=0.012), and inftal-hor angle (p=0.016) are significantly correlated with the presence of HV in PCFD patients. (R2 (U)=0.79) Conclusion: Our findings reveal distinct structural differences in PCFD patients with HV compared to those without, which corroborates our hypothesis. Significant correlations exist between HV presence and rotation of the navicular, medial cuneiform, first metatarsal base, and first metatarsal head. Talus morphology, including inftal-suptal and inftal-hor angles, also correlated with HV deformity. Talar-first metatarsal angle was the only traditional two-dimensional radiographic parameter that correlated with HV deformity. Based on our findings, PCFD patients displaying these features might need HV preventive measures. Prospective longitudinal studies or dynamic research may be required to further elucidate the relationships between these two deformities.

3D Semi-Automated Analysis of Joint Sparing Charcot-Marie-Tooth Cavovarus Reconstruction Using Preoperative and Postoperative Weightbearing Computed Tomography

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Charcot-Marie-Tooth (CMT) disease is the most common cause of cavus foot. The complex deformities in cavovarus feet of CMT disease are difficult to evaluate. The bone axes of CMT may be difficult to calculate by conventional weightbearing computed tomography (WBCT). For this reason, 3D automated measurements have been used to assess complex anatomy. The aim of this study was to quantitatively assess deformity correction following joint sparing CMT cavovarus reconstruction surgery. This is the first study investigating preoperative and postoperative WBCT findings in CMT feet using semi-automated 3D measurements. Methods: The study was approved by our institutional review board and informed consent was obtained from all patients. Joint sparing CMT surgery was performed with multiple soft tissue releases and bony procedures. Among the 170 cases from May 2021 to May 2023, twenty-nine CMT patients who had both pre- and postoperative WBCTs were retrospectively analyzed. 3D measurements of WBCT were performed using semi-automated software (Bonelogic 2.1, Disior) to investigate changes in sagittal, axial, and coronal parameters. Pre- and postoperative data was compared using a Wilcoxon signed-ranks test and these data were also compared with normative data using a Welch's t-test. Correlation among these sagittal, axial, and coronal parameters were analyzed using Spearman’s rank correlation coefficient test. Results: The sagittal, axial, and coronal malalignment of the hindfoot, and the sagittal and axial malalignment of the forefoot was significantly improved after corrective surgery (P < .05). Sagittal Meary’s angle (from 14.8 degrees to 0.1 degrees), axial talonavicular angle (TNA, from 3.6 degrees to 19.2 degrees), and coronal hindfoot alignment (from 11.0 degrees to -11.1 degrees) showed significant changes postoperatively (P < .001). Hindfoot, forefoot sagittal and forefoot axial parameters reached comparable outcomes compared to normative value (P > .05). Regarding amount of correction, Spearman’s correlation demonstrated that axial Meary’s angle and TNA were most strongly related to improvement in sagittal Meary’s angle and coronal hindfoot alignment. Conclusion: Preoperative and postoperative WBCT measurements demonstrated that joint sparing CMT cavovarus reconstruction significantly improved sagittal, axial, and coronal deformities of CMT, and sagittal Meary’s angle was restored toward normative values. Apparent axial plane correction, the majority of which occurred at the talonavicular joint, had the strongest correlation with deformity correction in multiple planes. This suggests that soft tissue releases and correction of the talonavicular joint may be a key component of a CMT cavovarus foot correction. Figure. (A) CMT surgery with soft tissue releases and bony procedures, (B) Pre- and postoperative radiographic results, and gross photos of the operated right foot of a 17-year-old male patient.

3D Analysis of Joint-Sparing Charcot-Marie-Tooth Surgery Effect on Initial Standing Foot Alignment.

The complex deformities in cavovarus feet of Charcot-Marie-Tooth (CMT) disease are difficult to evaluate. The aim of this study was to quantify the initial standing alignment correction achieved after joint-sparing CMT cavovarus reconstruction using pre- and postoperative weightbearing computed tomography (WBCT). Twenty-nine CMT cavovarus reconstructions were retrospectively analyzed. Three-dimensional measurements were performed using semiautomated software (Bonelogic 2.1) to investigate changes in sagittal, axial, and coronal parameters. Pre- and postoperative data were compared, along with normative data. Correlation among the preoperative measurements and the amount of correction in sagittal, axial, and coronal parameters were analyzed. The sagittal, axial, and coronal malalignment of the hindfoot, and the sagittal and axial malalignment of the forefoot, was significantly improved after corrective surgery (P < .05). Sagittal Meary angle (from 14.8 to 0.1 degrees), axial talonavicular angle (TNA, from 3.6 to 19.2 degrees), and coronal hindfoot alignment (from 11.0 to -11.1 degrees) showed significant changes postoperatively (P < .001). Hindfoot, forefoot sagittal, and forefoot axial parameters reached comparable outcomes compared with normative value (P > .05). Regarding amount of correction, Spearman correlation demonstrated that axial Meary angle and TNA were most strongly related to improvement in sagittal Meary angle and coronal hindfoot alignment. Preoperative and postoperative WBCT measurements demonstrated that joint sparing CMT cavovarus reconstruction significantly improved sagittal, axial, and coronal deformities of CMT, and sagittal Meary angle was restored toward normative values. Apparent axial plane correction, the majority of which occurred at the talonavicular joint, had the strongest correlation with deformity correction in multiple planes. This suggests that soft tissue releases and correction of the talonavicular joint may be a key component of a cavovarus foot correction. Level IV, retrospective case series.

Comparison of the effectiveness of foot orthosis use in pes planus treatment with combination of kinesio taping

Aims: The aim of this study was to compare the clinical evaluations, disease impact, disability and foot function of symptomatic flexible pes planus (SFPP) deformity patients treated with the University of California at Berkeley Laboratory (UCBL) foot orthosis and Kinesio tape (KT) to those treated only with the UCBL orthosis. Methods: A total of 100 feet in 50 subjects with a mean age of 77.10 months were included in the study. The subjects were divided into two groups: Group 1 (UCBL foot orthosis with KT, n=27) and Group 2 (UCBL-alone, n=23). Group 1 consisted of 27 patients (14 girls, 13 boys) with an average age of 62 months (range: 25 to 165), while Group 2 consisted of 23 patients (10 girls,13 boys) with an average age of 63 months (range: 30 to 166). Various assessments, including American Orthopaedic Foot and Ankle Society (AOFAS) scores, anteroposterior and lateral talocalcaneal and talo-first metatarsal angles, talonavicular angle, calcaneal pitch angle and clinical examinations, were conducted to foot-specific disease activity, and foot function. Results: Group 1 exhibited mild-to-moderate foot disability and impairments, along with low levels of disease activity. Treatment with UCBL orthosis and Kinesio tape led to significant improvements in all AOFAS scores and foot angles. Substantial improvement in AOFAS scores was observed during the follow-up examination, except for the midfoot score. Discussion: The use of UCBL foot orthosis in conjunction with Kinesio tape appears to be a preferable treatment strategy for children and adolescents with SFPP. This combined approach is associated with a lower rate of complications, higher patient comfort levels, and faster improvement in both radiological and clinical findings when compared to the use of the UCBL orthosis alone.

Correlation analysis between Pirani score and talo-navicular angle,calcaneo-cuboid angle and tibio-calcaneall angle of infant clubfoot under ultrasound

Objective: To explore the evaluation effect of ultrasonography and Pirani score on tarsal deformity, treatment effect and pseudo-correction of congenital clubfoot in infants and young children, and the correlation between the two methods. Methods: This is a retrospective case series study. The clinical data of 26 children (40 feet) with congenital clubfoot who were evaluated by ultrasonography in the Third Affiliated Hospital of Zhengzhou University from January 2020 to January 2023 were retrospectively collected. There were 16 males and 10 females. The age at the first ultrasound examination was (M(IQR)) 9.0 (18.0) days (range: 1 to 46 days). All patients were treated with Ponseti method by the same physician. The Pirani scores before and after treatment and at the last examination, and the talonavicular angle, calcaneocuboid angle and tibiocalcaneal angle measured by ultrasound were collected, and the treatment and follow-up were recorded. Paired sample t test, repeated measures analysis of variance or Kruskal-Wallis test were used for data comparison, and Spearman correlation analysis was used for correlation analysis. The receiver operating characteristic curve was used to calculate the efficacy of ultrasound in evaluating different Pirani scores. Results: The number of plaster fixation in 26 children was 4.0 (1.0) times (range: 2 to 8 times). The medial talonavicular angle and posterior tibiocalcaneal angle were significantly improved after treatment and at the last follow-up compared with those before treatment, and the differences were statistically significant (all P<0.01). There was no difference in lateral calcaneocuboid angle before and after treatment and at the last follow-up (F=1.971, P>0.05). Pseudo-correction occurred in 2 cases (2 feet) during the treatment, with an incidence of 5%. Correlation analysis showed that there was a moderate positive correlation between talonavicular angle and Pirani midfoot score (r=0.480, P<0.01). There was no correlation between calcaneocuboid angle and Pirani midfoot score (r=0.114, P=0.105). There was a moderate negative correlation between tibial heel angle and Pirani hindfoot score (r=-0.566, P<0.01). The cut-off point of Pirani midfoot score of 1.5 was 38.78°, the sensitivity was 0.90, the specificity was 0.56, and the area under the curve was 0.75. The cut-off value of angle was 27.51 °, the sensitivity was 0.16, the specificity was 0.92, and the area under the curve was 0.44.The cut-off points of Pirani midfoot score of 3.0 were 45.08°and 9.96°, the sensitivity was 0.94 and 0.91, the specificity was 0.37 and 0.42, and the area under the curve was 0.59 and 0.62, respectively. The cut-off values of Pirani hindfoot score of 2.0 and 3.0 were 167.46° and 160.15°, respectively. The sensitivity was 0.75 and 0.67, the specificity was 0.81 and 0.83, and the area under the curve was 0.78 and 0.71, respectively. Conclusion: Ultrasound can complement with Pirani score, visually and dynamically observe the morphology and position changes of talonavicular joint, calcaneocuboid joint and tibiotalocalcaneal joint, monitor the recovery and pseudo-correction of tarsal bones, and better evaluate the therapeutic effect.

Proposals for talonavicular joint assessment using ultrasound imaging and its reliability and validity

[Purpose] We aimed to develop a noninvasive specific ultrasonographic assessment of the talonavicular joint during loading to facilitate the analysis of treatment of flatfoot. [Participants and Methods] Sixty healthy participants underwent ultrasound imaging of the talonavicular joint while sitting and standing. The talonavicular angle was defined as the intersection of the line connecting the navicular and talar heads and the line connecting the talar head and sustentaculum tali. Talonavicular coverage was assessed using X-ray images of 15 participants. [Results] Ultrasonographic assessment of the talonavicular joint showed a lateral shift of the navicular relative to the head of the talus from sitting to standing. The talonavicular angle was significantly larger when standing than in the sitting position. The difference in talonavicular angle values between sitting and standing significantly correlated with the differences in the talonavicular coverage values. [Conclusion] We showed that ultrasonographic talonavicular angle assessment has good reliability and moderate validity for detecting significant alignment changes in the talonavicular joints due to loading. In the future, this evaluation method should be performed before and after exercise therapy to assess and develop appropriate exercise therapy for flatfoot.

Relationship Between Obesity and Medial Longitudinal Arch Bowing.

There have been reports about the association between obesity and the medial longitudinal arch (MLA) of foot. The purpose of this study is to investigate the change of various parameters related to the MLA according to obesity classification severity by the World Health Organization using weightbearing computed tomography (WBCT). WBCT data of the noninvolved side of patients presenting with unilateral foot and ankle problems or healthy candidates from September 2014 to October 2022 were extracted from a single referral hospital. Forty-four cases in each of 5 obesity classes were selected sequentially. Two orthopaedic surgeons measured foot and ankle offset, forefoot arch angle (FAA), hindfoot moment arm, percentage of uncoverage of the middle facet of the subtalar joint, talonavicular angle (TNA), navicular-medial cuneiform angle, medial cuneiform-first metatarsal angle, talus-first metatarsal angle (TMT1A), first tarsometatarsal subluxation (TMT1S), talonavicular coverage angle, navicular floor distance (NFD), and NFD per height. Positive values indicate plantar collapse. Intra- and interobserver reliabilities were assessed using intraclass correlation coefficients. One-way analysis of variance tests were performed for parametric data with equal variances, and Welch's test for unequal variances. Kruskal-Wallis test was performed for nonparametric data. Post hoc analysis was performed for statistically significant parameters. Correlation analysis between body mass index (BMI) and 12 parameters were performed using Pearson test. Intraobserver and interobserver reliability were excellent, except for TMT1S. The TNA and TMT1A showed a statistically significant difference. FAA (r = -0.2), TNA (r = 0.182), TMT1A (r = 0.296), and NFD (r = -0.173) showed a statistically significant correlation with BMI. In nonsymptomatic feet, we found that the talonavicular joint, as measured by the TNA, to be influenced by obesity classification. Obesity and increased BMI was associated with a negative influence on the MLA. Level III, retrospective cohort study.

ROLE OF ULTRASOUND AS PROGNOSTIC INDICATOR DURING PRONSETI CORRECTION

Objective: Clubfoot ultrasonography is an objective means of determining severity. The purpose of this study is to evaluate the reliability of measuring clubfoot severity by sonographic evaluation of the talonavicular angle (TNA) and the reliability of assessing angle change on simulated Ponseti manipulation. Methods: Twenty-six infants with unilateral idiopathic clubfoot were evaluated prospectively using clinical scoring and Pirani scoring and sonographic measurements of TNA at the start of treatment, after midfoot correction, and after the complete correction was achieved. The TNA and its change during simulated Ponseti manipulation were recorded. Results: In static posture, the mean TNA of the clubfoot (66.46°) differed substantially from that of the contralateral normal foot (101.3°). The mean shift in TNA after simulated Ponseti manipulation was 22.54° (5-50°), and it correlated negatively with clinical ratings and the total number of casts required for final correction (p&lt;0.05). Linear regression research demonstrated that the change in TNA on simulated Ponseti manipulation was the strongest predictor of treatment outcome in CTEV (with a prediction of 60% compared to 25% for Pirani scores). Conclusion: The severity of clubfoot in babies can be better accessed via sonographic examination of TNA and change in TNA following simulated Ponseti manipulation. This objective form of assessment is less expensive, more reproducible in clinical settings, and can better predict treatment outcomes.

A four-year clinical and sonographic longitudinal follow-up of clubfeet treated according to Ponseti with normal references.

To follow children with a clubfoot by ultrasonography during the entire treatment period up to 4 years and compare with controls. Thirty clubfeet in 20 children treated using the Ponseti method and 29 controls were followed by repeated ultrasonography investigations from neonates to the age of 4 years. The previously established coronal medial and lateral, sagittal dorsal and posterior projections were used. Changes over time, correlations to the Diméglio score, and the course of treatment were studied. The medial malleolus-navicular distance was shorter, while the talar tangent-navicular distance and the talo-navicular angle were larger in clubfeet than in controls even after the initial correction. The healthy feet in unilateral cases did not differ significantly from the controls. The range of motion in the talo-navicular joint was approximately 20° less in clubfeet than in controls during the first four years of life. The medial malleolus-navicular distance (r = -0.58) and the talo-navicular angle (r = 0.66) at the first ultrasonography showed the highest correlation to the number of casts needed to correct the deformities. Ultrasonography can be used to evaluate the initial degree of deformities in clubfeet and to follow the progress of the treatment and growth. Ultrasonography showed a clear difference between clubfeet and controls during the first four years of life. Although it was not possible to define specific limit values as benchmarks in the treatment, dynamic ultrasonography can provide valuable support in the decision-making process when complementary treatment may be needed. III.

Radiographic Outcomes of Titanium Augment vs Bone Graft in Lateral Column Lengthening for Adult-Acquired Flatfoot Deformity.

Lateral column lengthening (LCL) is a surgical procedure used to manage forefoot abduction and, in theory, also increases the longitudinal arch by plantarflexion of the first ray through tensioning the peroneus longus for patients with stage IIB adult acquired flatfoot deformity (AAFD). This procedure utilizes an opening wedge osteotomy of the calcaneus, which is then filled with autograft, allograft, or a porous metal wedge. The primary aim of this study was to compare the radiographic outcomes of these different bone substitutes following LCL for stage IIB AAFD. We conducted a retrospective review of all patients who underwent LCL from October 2008 until October 2018. Preoperative weightbearing radiographs, initial postoperative radiographs, and 1-year weightbearing radiographs were reviewed. The following radiographic measurements were recorded: incongruency angle, talonavicular coverage angle (TNCA), talar-first metatarsal angle (T-1MT), and calcaneal pitch. A total of 44 patients were included in our study. The mean age of the cohort was 54 (range, 18-74). The study cohort was divided into 2 groups. There were 17 (38.7%) patients who received a titanium metal wedge and 27 (61.5%) that received autograft or allograft. Patients that underwent LCL with the autograft/allograft group were significantly older (59 vs 47 years old, P = .006). Patients who underwent LCL with a titanium wedge had a significantly higher preoperative talonavicular angle (32 vs 27 degrees, P = .013). There were no significant differences in postoperative TNCA, incongruency angle, or calcaneal pitch at 6 months or 1 year. At 6 months and 1 year, no radiographic differences were found between autograft/allograft bone substitutes vs titanium wedge in LCL. Level III, retrospective cohort study.

Does a 1st Metatarsophalangeal Fusion in a Patient with Pes Planus Improve the Pes Planus Deformity? A Retrospective Case Series

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: A pes planus deformity is a pathology relating to the loss of normality of the complex interaction of the bones and joints of the foot resulting in a flattening of the medial longitudinal arch with or without abduction of the midfoot. The distal aspect of the medial longitudinal arch can be a feature of the deformity. The fusion of the 1st metatarsophalangeal joint (MTPJ) is a common operation. In patients with concomitant pes planus deformity, it is unknown if reducing and stabilising the distal aspect of the medial ray through a 1st MTPJ fusion can subsequently improve the pes planus deformity. We sought to analyse the pes planus deformity pre and post 1st MTPJ fusion with the null hypothesis that there was no difference. Methods: We identified patients who had undergone 1st MTPJ fusion using our electronic database from January 2011 to October 2021. To meet the inclusion criteria, cases required pre- and post-operative weightbearing plain radiographs, with a Meary's angle of &gt;4 degrees on pre-operative imaging. Routine pes planus measurements were undertaken by 2 independent observers. Pre- and post-operative measurements were tested for significant change using Wilcoxon Signed Rank Test or Paired T-Test depending on the normality testing of the data. Routine demographic data was also collected. Data was analysed using IBM SPSS v.27. Results: Following radiographic analysis, 25 feet fitted the inclusion criteria. The mean patient age was 63 years. There was no pre-operative correlation between Meary's angle and the hallux valgus angle (Kendall's tau p=.441). Pre-operatively, Meary's line broke at the talo-navicular and navicular-cuneiform joints in 12 cases each; the remaining case broke at the tarsal-metatarsal joint. A statistically significant improvement between the pre- and post-operative measurements was identified in Meary's angle, calcaneal pitch angle, talo-navicular coverage angle, intermetatarsal angle and talo-navicular angle (see table). Significant changes were also noted in the medial cuneiform height (mean increase of 2.74mm; p=.022). A post-operative Meary's angle of &lt;4°was only achieved in 4/25 (16%) of cases. Of the remaining 21 cases, the point at which Meary's line broke moved proximally one joint in 4 and distally one joint in 3 cases; it remained at the same joint in 14 cases. Conclusion: Our results suggest that 1st MTPJ fusion improves axial alignment of the foot as well as reducing Meary's angle by a statistically significant amount, although diagnostic criteria for pes planus remained in most cases.

Interobserver Reliability of Radiographic Angles and Measurements in Flat Foot Deformity

Category: Other Introduction/Purpose: Radiographic angles and measurements are widely used in foot and ankle pathologies to define normal and abnormal skeletal alignment. In spite of this the inter-observer reliability of these parameters is debatable. The aim of this study was to determine the inter-observer reliability of various radiographic angles and measurements in flat foot deformity. Methods: Antero-posterior (AP) and lateral foot radiographs of 18 patients with flatfoot deformity were analysed by eight clinicians of various grade of experience (2 consultants, 4 fellows / registrars and 2 core training grades) with 11 different radiological parameters. A digital presentation demonstrating the method of measurement of all parameters using same software was provided to the participants. The inter-observer reliability was analysed using interclass correlation (ICC) model mixed for reliability at 95% confidence interval for individual parameters and different grade of experience. Results: The inter-observer reliability was excellent (&gt;0.9) in calcaneal pitch angle (CPA), medial cuneiform height (C1H) and lateral incongruency angle (LIA). It was good (0.75 - 0.90) in talo-navicular angle (TNA), medial cuneiform articular angle (CAA), medial arch sag angle (MASA), medial cuneiform - 1st MT angle (C1MTA), talonavicular coverage angle (TNCA)andtalar - 1st MT angle on AP radiograph (T1MTA). The inter-observer reliability was moderate (0.5 - 0.75) in Meary's angle and talo-navicular uncoverage percentage (TNUP). The reliability did not differ with the grade of surgeon on sub-group analysis. Conclusion: This is first study to analyse the interobserver reliability of radiographic measurements in a flatfoot deformity, including grade of surgeon. The results suggest that these radiological parameters can be reliably used in clinical practice if standard measurement techniques are followed by clinicians of all grades.

Magnetic Resonance Imaging of Clubfoot Treated With the Ponseti Method: A Short-Term Outcome Study.

ObjectiveTo quantitatively evaluate the effectiveness of the Ponseti method for the correction of clubfoot, we decided to use magnetic resonance imaging (MRI) to evaluate changes in the tarsal bone relationship.MethodsThis is a retrospective study of fifteen children with clubfeet who were treated with the Ponseti method. MRI studies were obtained using a 3.0T Machine (GE Healthcare, United States). T1-weighted and T2-weighted images were acquired in the standard anatomic sagittal, transverse, and coronal planes. For the measurement, the best slice that clearly demonstrated the anatomy was chosen. Sagittal talocalcaneal angle, sagittal tibiocalcaneal angle, coronal tibiocalcaneal angle, transverse talar neck angle, transverse talonavicular angle, and transverse talocalcaneal angle were measured. The eighteen corrected clubfeet were compared with the twelve unilateral normal feet at clinical and radiological levels using a Pirani scoring system and MRI, respectively.ResultsIn total, 15 cases (twelve boys and three girls) with clubfeet were examined by using MRI. Twelve cases had unilateral and three had bilateral involvement (eleven left clubfeet and seven right clubfeet), giving a total of eighteen clubfeet when compared with twelve normal feet. The mean age of patients at examination was 47.7 months (8–96 months). The recovery of the corrected clubfoot in these patients met the goals of Ponseti treatment (functional, normal looking, pain-free, and plantigrade foot). Before Ponseti treatment, the mean Pirani score of clubfoot was 5.5 (5–6). During this follow-up, the Pirani score was 0.07 (0–0.05). The results of the MRI indicated that only the transverse talonavicular angle showed a significant difference between the treated clubfeet and the normal feet (p < 0.001). One case had dorsal talonavicular subluxation in the sagittal plane and had the lateral subluxation of the navicular in the transverse plane, which has never been reported in previous studies.ConclusionAlthough the appearance and function of clubfoot were recovered well after the Ponseti method, the results of MRI indicated that the Ponseti method successfully corrected the varus, cavus, and equinus deformities and incompletely corrected the adduction deformity regarding transverse talonavicular angle. At the same time, the Ponseti method may cause dorsal talonavicular subluxation in the sagittal plane and lateral subluxation of the navicular in the transverse plane on MRI.

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

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

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

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

Radiographic Outcomes in the Treatment of Type II Adult Acquired Flatfoot Deformity Following Lateral Column Lengthening with a Titanium Wedge versus Autograft or Allograft

Category:Midfoot/ForefootIntroduction/Purpose:Lateral column lengthening (LCL) is a surgical procedure used to manage forefoot abduction occurring in patients with stage IIB Adult Acquired Flat Foot Deformity (AAFD). This procedure utilizes an opening wedge osteotomy of the calcaneus which is then filled with autograft, allograft, or a titanium wedge. The primary aim of this study was to compare the radiographic outcomes of these different bone substitutes in the setting of stage IIB AAFD with the use of LCL.Methods:All patients who underwent LCL from October 2008 until October 2018 were retrospectively reviewed. Preoperative weight bearing radiographs, initial postoperative radiographs and 1-year weight bearing radiographs were reviewed. The following radiographic measurements were recorded: talonavicular uncoverage angle, incongruency angle, and calcaneal pitch.Results:A total of 44 patients were included in our study. The mean age of the cohort was 54 (range 18-74). The study cohort was divided into two groups. There were 17 (38.7%) patients that received a titanium wedge and 27 (61.5%) that received autograft or allograft. Patients that underwent LCL with the autograft/allograft group were significantly older (p=0.006). Patients who underwent LCL with a titanium wedge had a significantly higher preoperative talonavicular angle (p=0.013). There were no significant differences in post-operative talonavicular uncoverage angle, incongruency angle or calcaneal pitch at 6 months or 1 year.Conclusion:Adult acquired flat foot deformity is a difficult disorder to treat surgically. Lateral column lengthening is a common surgical procedure used to treat forefoot abduction that occurs. Our results show that at 6 months and 1 year no radiographic difference exists between autograft/allograft bone substitutes versus titanium wedge in LCL. Future research should evaluate the differences in patient reported outcomes between autograft/allograft versus titanium wedge bone substitutes.

Fusion Versus Joint-Sparing Reconstruction for Patients With Flexible Flatfoot.

Passively correctible, adult-acquired flatfoot deformities (AAFD) are treated with joint-sparing procedures. Questions remain as to the efficacy of such procedures when clinical deformities are severe. In severe deformities, a primary fusion may lead to predictable outcomes, but risks nonunion. We evaluated pre- and postsurgical flexible AAFD patients undergoing joint-sparing or fusion procedures, comparing reoperation and complication rates. We identified patients with flexible AAFD between January 1, 2001 and 2016. Exclusion criteria were incomplete medical record, rigid AAFD, and prior flatfoot surgery. Patient demographics, pre- and postsurgical radiographic measurements, surgery performed, and postoperative complications were evaluated by bivariate analysis, comparing joint-sparing versus fusion procedures. Of 239 patients (255 feet) (mean follow-up 62 ± 50 months), 209 (87%) underwent joint-sparing reconstructions, 30 (12.6%) underwent fusions. Fifty-four (24.1%) feet underwent joint-sparing reconstruction with reoperation versus 11 (35.5%) in fusion patients (P = .17). Radiographic improvement in talonavicular angle, talar first-metatarsal (anteroposterior view), and Meary's angle was higher in fusion patients (P < .001, P < .001, and P = .003, respectively). More nonunion reoperations among fusion patients were offset by reoperations in joint-sparing patients. Fusion uniquely corrected Meary's angle. Nonunion is of less concern for joint-sparing versus fusion for patients with severe flexible AAFD. Degree of deformity versus advantage of joint motion should improve decision making. Level IV: Retrospective case series.