Talonavicular Angle Research Articles

Correlations between physical and ultrasound findings in congenital clubfoot at birth.

At birth, clinical classifications are the only available tools for evaluating the severity of congenital clubfoot. Ultrasound provides an assessment of the anatomical abnormalities. The objective of this study was to assess correlations between physical and ultrasound findings at birth. Physical and ultrasonography provide different findings in congenital clubfoot and should therefore be used in conjunction. One hundred and forty-five clubfeet in 108 patients born between 2006 and 2010 were included in a retrospective study. Clubfoot severity was classified using two methods, the modified Dimeglio classification based on physical findings and an ultrasound score based on the talo-navicular angle (TNA) and metaphyso-talo-calcaneal angle (MTCA). Each of these two methods distinguished three severity grades. Agreement between the two methods was assessed by computing the coefficient. The results confirmed the hypothesis by showing low agreement between the clinical and ultrasound classifications. The severity grades were identical with the two methods for only 83/145 (57%) feet. The coefficient was 0.086. The two ultrasound views used to measure the TNA and MTCA, respectively, added an assessment of the three main deformities that characterise congenital clubfoot (equinus, adduction of the forefoot, and adduction of the calcaneo-pedal unit). Ultrasonography complements the physical examination at birth. In the future, using both physical examination and ultrasound scanning to monitor babies with clubfoot may allow early treatment adjustments aimed at optimising the outcome. IV, retrospective observational study.

Radiological evaluation of the longitudinal arch after posterior tibial tendon transfer

Objectives: To evaluate radiographic findings of medial longitudinal arch decreases of the foot based on examinations performed before and after posterior tibial transfer surgery to treat motor deficits caused by complete lesions of the peroneal nerve. Methods: A descriptive and analytical study was conducted based on information collected from medical records. Patients with at least two years of follow-up after surgery were included, and their radiographs were evaluated before and after the procedure. In the radiographs with the anteroposterior incidence of the foot, the talocalcaneal, talometatarsal and talonavicular congruence angles were evaluated. In the lateral view, the talocalcaneal, Meary’s and calcaneal pitch angles were analyzed. Data were collected regarding patient profiles, trauma mechanisms and follow-up times. Results: One patient had radiographic results suggestive of a decrease in the plantar arch after posterior tibial tendon transfer. Angular variation among the patients, which was within the normal range, was not significant. Conclusions: No significant decreases in the longitudinal arch of the foot were observed in the studied patients. Level of Evidence III; Retrospective Comparative Study.

Limits of Calcaneal Lengthening for Treating Planovalgus Foot Deformity in Children With Cerebral Palsy.

Calcaneal lengthening is used to correct symptomatic planovalgus foot deformity, but outcomes have been less satisfactory in children with cerebral palsy. This study aimed to define limits of calcaneal lengthening by analyzing the risk factors for undercorrection of deformity. We retrospectively reviewed 20 cases of children with cerebral palsy who underwent calcaneal lengthening of 30 planovalgus feet at a mean age of 11.9 years. Foot deformities were evaluated by the anteroposterior talo-first metatarsal angle (normal, 10 ± 7.0 degrees), lateral talo-first metatarsal angle (normal, 13 ± 7.5 degrees), and lateral calcaneal pitch angle (normal, 17 ± 6.0 degrees) on standing foot radiographs. Among these parameters, a corrected foot was defined as 2 or 3 parameters being corrected to within a normal range, and an undercorrected foot was only 1 or no parameter being corrected to within a normal range. Factors were compared between the corrected group and undercorrected group for significant predictors, and cutoff values of predictors were calculated for use as a clinical guideline. Seventeen planovalgus feet were corrected satisfactorily by calcaneal lengthening, while the other 13 feet were undercorrected. Undercorrected feet had a greater preoperative anteroposterior talonavicular angle (33.7 vs 22.8 degrees, P = .001) and a smaller lateral calcaneal pitch (-1.7 vs 5.6 degrees, P = .03). A talonavicular angle of more than 24 degrees and calcaneal pitch less than -5 degrees were identified as cutoff values using a receiver operating characteristic curve. The predicted probability of undercorrection was 100% (9/9 feet) for 2 positive predictors, 50% (8/16 feet) for 1 positive predictor, and 0 (0/5 feet) for zero predictors. A talonavicular lateral subluxation of more than 24 degrees on the anteroposterior radiograph and a calcaneal pitch angle less than -5 degrees on the lateral radiograph were 2 independent predictors that could be used to identify a planovalgus deformity that would be beyond the corrective capacity of calcaneal lengthening to restore normal alignment. Level of Evidence Retrospective case control study, level III.

Union Rates and Complications of Lateral Column Lengthening Using the Interposition Plating Technique: A Radiographic and Medical Record Review

Lateral column lengthening is a common procedure for correction of pes planovalgus. A tricortical bone graft has been a standard among foot and ankle surgeons. The purpose of the present study was to compare the union rates and complications between the 2 forms of fixation for lateral column lengthening. The present study was a retrospective medical record and radiograph review of 52 patients divided into 2 equal groups, allograft (group A) and opening wedge plate (group B). The radiographic analyses compared the preoperative, postoperative and long-term measurements of cuboid abduction and talonavicular angles. The outcome measures included nonunion, hardware removal, and infection. The median follow-up duration for each group was 34.5 (range 6.3 to 89.5) months and 12.6 (range 6.5 to 56.8) months for groups A and B, respectively. Group A had 4 nonunions (15.4%) and group B had 2 nonunions (7.7%). The mean radiographic measurements of cuboid abduction and talonavicular articulation for each group improved significantly. The incidence of hardware removal was greater for group A than for group B (30.8% versus 15.4%), although the difference was not statistically significant. The median time to osseous healing for group A was 12.0 (range 8.0 to 80.0) weeks and for group B was 10.0 (range 6.0 to 36.0) weeks. The interposition plating techniques for lateral column lengthening procedures had a lower nonunion rate and incidence of hardware removal compared with the traditional use of tricortical bone grafting. The findings from the present study will aid surgeons in alternative fixation for lateral column lengthening procedures.

Is Pes Cavus Alignment Associated With Lisfranc Injuries of the Foot?

Lisfranc (tarsometatarsal joint) injuries are relatively rare, accounting for less than 1% of all fractures, and as many as 20% of subtle Lisfranc injuries are missed at the initial patient presentation. An undiagnosed Lisfranc injury can have devastating consequences to the patient. Therefore, any factor that can raise a clinician's index of suspicion to make this diagnosis is potentially important. The cavus foot has been associated with various maladies of the lower extremity, but to our knowledge, it has not been reported to be associated with Lisfranc injury. Do patients who experience a low-energy Lisfranc injury have greater talar head coverage and a greater talo-first metatarsal angle than control subjects? A retrospective, case-control study was conducted from September 2011 to December 2014 to identify patients diagnosed and treated for a low-energy Lisfranc injury. Twenty-three adult patients with an average age of 42.6 years (SD, 16.3 years) were identified and compared with 61 adult control subjects with an average age of 49.4 years (SD, 14.1 years). Control subjects came from the practice of a fellowship-trained foot and ankle orthopaedic surgeon. Control subjects underwent a history and physical, clinical examination, and diagnostic imaging to confirm that they had no prior foot disorder, no prior foot surgeries, were within 3 years of age of a patient with a Lisfranc injury, and were independent ambulators. Two authors (DSD and JDP) measured the talonavicular and talo-first metatarsal angles on weightbearing AP and lateral radiographs of the foot. The intrarater reliability and interrater reliability for the talo-first metatarsal angle and the talonavicular angle showed high agreement. The intrarater intraclass correlation coefficients (ICC) of the talo-first metatarsal angle were 0.94 (95% CI, 0.91-0.96) and 0.93 (95% CI, 0.9-0.96). For the talonavicular angle the ICCs were 0.83 (95% CI, 0.75-0.89) and 0.88 (95% CI, 0.81-0.92) for Raters 1 and 2 respectively. The interrater ICCs were 0.91 (95% CI, 0.69-0.96) for the talo-first metatarsal angle and 0.9 (95% CI, 0.85-0.94) for the talonavicular angle. The patients and controls were compared to determine if the patients who sustained a Lisfranc injury were more likely to have a pes cavus foot alignment. We performed a mixed modeling analysis to control for potential cofounding variables and determine if there was an association of Lisfranc injury with the talo-first metatarsal angle and the talonavicular angle. After controlling for confounding variables such as the effect of the measurement round effect and the effect of the rater, our repeated measures analysis via mixed model showed patients were associated with a higher talo-first metatarsal angle than control subjects (adjusted least square mean for patients = 3.05; for controls = -2.65; mean difference, 5.7; p = 0.001). Repeated measures analysis via mixed model showed that patients also were associated with a more positive talonavicular angle than control subjects (adjusted least square mean for patients = -4.83, for controls = -11; mean difference, 6.17; p = 0.002). Patients with Lisfranc injuries had a higher mean talo-first metatarsal angle than did control subjects (1.9° ± 7.9° versus -2.2° ± 7.3°; mean difference, 4.1°; 95% CI, -7.7° to -0.5°; p = 0.028), and less talar uncovering (-4.2° ± 9.7° versus -11° ± 8°; mean difference, 6.7°; 95% CI, -6.7° to -10.8°; p = 0.001). We found that cavus midfoot alignment was more prevalent among patients with Lisfranc injuries than among individuals with no foot injury or disorder. Although this does not suggest that cavus alignment causes or predisposes patients to this injury, we believe the finding is important because this provides a radiographic parameter that clinicians can use to raise their index of suspicion for a Lisfranc injury and aggressively pursue this diagnosis. Future studies would benefit from obtaining contralateral foot imaging at the time of injury in all patients with Lisfranc injury or prospectively following patients with foot imaging and recording the incidence of future foot injury. Level III, prognostic study.

Symptomatic flexible flatfoot in adults: subtalar arthroereisis.

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

Navicular index for differentiation of flatfoot from normal foot.

The height of navicular bone from the floor is in proportion with the height of longitudinal arch of the foot. The study was conducted to evaluate correlation of navicular bone height with most often used angles, heel valgus and a foot print in order to simplify the procedure for the diagnosis of flatfoot. A total of 218 operated children (436 feet) because of flexible flatfoot were evaluated clinically and radiologically. Meary angle, lateral talonavicular angle, talocalcaneal angle, calcaneal pitch, heel valgus and arch index (Staheli) were evaluated pre-operatively and postoperatively. In 121 (242 feet) chosen children (age eight to 15) with all clinical values and pre-operative angles corresponding flatfoot, all postoperatively measured values were within the normal range. We got the navicular index by dividing length of longitudinal arch with navicular height. Values of navicular index were then compared with pre-operatively and postoperatively measured values. Pearson correlation and ROC test were used for statistical analysis. Values of the navicular index for flatfeet were in the interval from 4.75 to 31.2 (median 8.98), and for normal-arched feet 3.58-22.6 (median 5.48). Pearson correlation of arch index and measured parameters were significant in majority, and degree according to Colton was good. Area under the ROC curve was 0.861 (p = 0.0001). The cut-off value with 86 % sensitivity and 75 % specificity was 6.7407. Navicular index can be used reliably, without measures of the other parameters, to differentiate flatfoot from normal-arched foot. Therefore, the navicular index has an ability to distinguish between the flatfoot and normal-arched foot.

Medial Arch Orthosis for Paediatric Flatfoot

To evaluate any correlation between various foot angles and their respective American Orthopaedic Foot and Ankle Society (AOFAS) scores for pain, and the effectiveness of a medial arch orthosis. 81 children with bilateral symptomatic flatfoot were randomised into orthosis (n=55) and control (n=26) groups. The orthosis group consisted of 33 male and 22 female patients aged 36 to 204 (mean, 99) months and they were given a medial arch support. The control group consisted of 15 male and 11 female patients aged 36 to 192 (mean, 100) months and they were managed with analgesics. Foot angles including anteroposterior (AP) and lateral talocalcaneal (TC) angles, AP and lateral talo- first metatarsal (TFM) angles, calcaneal pitch angle (in lateral plane), and talonavicular (TN) angle were measured, as were AOFAS scores for pain for the forefoot, midfoot, and hindfoot. After orthosis treatment, all AOFAS scores and all foot angles (except for the AP-TN angle) improved significantly. In the controls, all AOFAS scores (except for the midfoot score) and only the AP-TFM angle improved significantly. In the orthosis group, the AOFAS hindfoot score correlated positively with the lateral TC angle of the left foot (r=0.345, p=0.010) and negatively with the calcaneal pitch angle of the right foot (r=-0.33, p=0.015). In the control group, the lateral TFM angle of the left foot correlated negatively with the AOFAS forefoot (r=-0.566, p=0.003) and midfoot scores (r=-0.497, p=0.001), whereas the calcaneal pitch angle of the left foot correlated positively with the AOFAS forefoot score (r=0.497, p=0.010). Medial arch support orthosis significantly improved AOFAS scores and foot angles. Calcaneal pitch angle and lateral TC angle correlated well with AOFAS hindfoot scores.

Radiographic Factors and Effect of Fifth Metatarsal Jones and Diaphyseal Stress Fractures on Participation in the NFL

Jones fracture and proximal diaphyseal stress fracture of the fifth metatarsal have been associated with prolonged healing times and nonunions. We hypothesized that the Jones fracture and proximal diaphyseal stress fracture have a high incidence in elite collegiate football players and that they lead to a decrease in participation in the NFL. Also, we hypothesized that these fractures are associated with a cavovarus foot alignment. The database collected by a single NFL team during the 2004 to 2009 NFL Combines was reviewed to identify players with Jones and proximal diaphyseal fifth metatarsal fractures. A total of 74 fifth metatarsal fractures were identified in 68 players. Subsequent participation data also were collected through the NFL.com website and included games played and years played. Digital plain radiographs and additional imaging studies also were reviewed to determine the extent of healing, types of fixation utilized, and foot alignment. The locations of fractures in the proximal fifth metatarsal were 45 (61%) in the Jones area, 15 (20%) in the proximal diaphyseal area, and 14 (19%) of indeterminate location. The number of patients treated with intramedullary fixation was 55/74 (74%). Of 74 proximal fifth metatarsal fractures, 9 (12.2%) were nonunions at the time of the NFL Combine medical examinations. With the numbers available, the average number of games played in the NFL was not significantly different in the fifth metatarsal fracture group, 16.9, compared to the control group, 24.9 (P > .05). The average number of games started was 7.4 in the fracture group versus 12.1 in the control group (P > .05). No significant differences were noted in the number of years played in the NFL. Except for talonavicular angle measurements, all measurements of coronal plane alignment demonstrated significant differences across groups, but no differences were noted in sagittal plane alignment. No statistically significant difference was noted in participation in the NFL following Jones fractures and proximal diaphyseal stress fractures of the fifth metatarsal, although a trend toward decreased participation was noted. Radiographic abnormalities were noted in the coronal plane with varus alignment, but not in the sagittal plane.

Correlation of radiographic and pedobarograph measurements in planovalgus foot deformity

Planovalgus foot deformity is common in children with cerebral palsy. Several pathologies contribute to the deformity. It begins with the lateral displacement of the navicular and the talar head becomes uncovered and prominent in the medial side of the midfoot. The purpose of this study was to assess the correlation between the radiographic and the pedobarographic measurements and the ability to predict foot pressure components using radiographic measurement. The patient sample included 43 patients with cerebral palsy who were ambulatory and had planovalgus foot deformity (76 feet). Medial midfoot pressure showed correlation with talonavicular uncoverage index, talonavicular angle, medial arch angle, Meary angle, and lateral talocalcaneal angle. Heel impulse showed negative correlation with talonavicular uncoverage index and talonavicular angle. Simple linear regression was used to assess the relationship between radiographic and foot pressure component measurements. For every unit change in talonavicular uncoverage index, the predicted value of medial midfoot pressure was [9.9+27 (talonavicular uncoverage index)]. This equation accounted for 17.9% of the changes in the medial midfoot pressure. Tibial foot angle and maximum knee extension also contributed to the heel impulse. The radiographic indices of the planovalgus foot can explain the changes in some foot pressure components.

Is Sonographic Calculation of Talonavicular Angle During Ponseti Correction of Clubfoot a Reliable Prognostic Indicator?

ABSTRACT Background Ultrasonographic evaluation of clubfoot is an objective method of severity assessment. The objective of this article is to assess the reliability of clubfoot severity assessment by sonographic evaluation of talonavicular angle (TNA) and the reliability of assessing change in angle on simulated Ponseti manipulation. Materials and methods Twenty-six infants with unilateral idiopathic clubfoot, treated by serial manipulation and casting by Ponseti technique, were prospectively evaluated by clinical scoring (Dimeglio and Pirani scores) and sonographic measurements of TNA at the start of treatment, after midfoot correction and after complete correction achieved. The TNA and the change in TNA on simulated Ponseti manipulation were noted. Total number of POP casts required to achieve final correction were noted; and correlated with change in TNA on attempted Ponseti manipulation. Results Mean TNA in clubfoot (66.46°) in static position was significantly different from that of contralateral normal foot (101.3°). Mean change in TNA on simulated Ponseti manipulation was 22.54° (5-50°) and it showed negative correlation with clinical scores and total number of casts required for final correction (p &lt; 0.05). Linear regression analysis revealed that the change in TNA on simulated Ponseti manipulation was the best predictor of treatment outcome in congenital talips equinovarus (CTEV) (with predictability of 60% compared to 19 and 25% of Dimeglio score and Pirani score respectively). Conclusion Sonographic evaluation of TNA and change in TNA on simulated Ponseti manipulation can better assess the severity of clubfoot in infants. This objective method of assessment is less expensive, clinically applicable reproducible and it can better predict the treatment outcome. How to cite this article Gupta N, Sudesh P, Prakash M, Tripathy SK, Dhillon MS. Is Sonographic Calculation of Talonavicular Angle During Ponseti Correction of Clubfoot a Reliable Prognostic Indicator? J Postgrad Med Edu Res 2012;46(4):190-195.

Beaming the Columns for Charcot Diabetic Foot Reconstruction: A Retrospective Analysis

This study explored the concept of “beaming” the medial and lateral longitudinal columns as a variation of the current technique for hindfoot and Lisfranc Charcot reconstruction. We reviewed radiographic changes and outcomes for patients who underwent Charcot foot reconstruction at our facility over the 14-year period from January 1994 to January 2008. Beaming was performed on 71 Charcot foot deformities in 70 patients, 22 (31%) of which displayed an isolated hindfoot deformity, 20 (28%) an isolated Lisfranc deformity, and 29 (41%) with a combination of hindfoot and Lisfranc deformities. The average radiographic follow up was 31.00 ± 22.97 months. Group 1 consisted of reconstructions that involved only medial and lateral column beams and showed significant improvements in radiographic alignment between the preoperative and postoperative measurements, including Meary’s angle ( P < .001), calcaneal inclination angle ( P = .004), tarsometatarsal angle ( P = .002), talonavicular angle ( P = .035), and the calcaneocuboid angle ( P = .006). Group 2, which consisted of reconstructions that involved medial and lateral column beams and either a subtalar arthroereisis (n = 18) or a subtalar joint fusion (n = 10), also showed significant improvements, including Meary’s angle ( P < .001), tarsometatarsal angle ( P < .001), talonavicular angle ( P = .002), and the calcaneocuboid angle ( P < .001), although calcaneal inclination did not statistically significantly change ( P = .054). In both groups, the surgical intervention maintained the correction and was useful for Charcot reconstruction. Complications included pin tract infections, broken pin, osteomyelitis, transfer lesions, and ulcerations.

Reconstruction of the Spring Ligament Using a Peroneus Longus Autograft Tendon Transfer

The spring (calcaneonavicular) ligament provides one of the main static supports of the medial arch of the foot. The purpose of this study was to retrospectively assess the results of patients having undergone reconstruction of the spring ligament using a peroneus longus tendon autograft left at its distal attachment and passed through the navicular followed by either a calcaneal or tibial drill hole, a technique not previously reported. Thirteen consecutive patients (14 feet) (mean age, 63.5 +/- 12.3 years) undergoing flatfoot surgery with spring ligament reconstruction for cases in which lateral column lengthening failed to correct talonvavicular deformity were reviewed. The AOFAS, FAOS, and SF-36 were assessed along with standard weightbearing radiographs at a followup visit at a mean of 8.9 +/- 1.8 years after surgery. Hindfoot alignment and eversion strength were measured. The AOFAS ankle-hindfoot score increased from 43.1 to 90.3 (\hbox{p}\leq 0.001). The postoperative FAOS pain subscale and overall SF-36 were 83.7 (range, 67.9 to 100), and 77.3 (range 37.8 to 95.6) respectively. The AP first tarsometatarsal angle (p = 0.015), talonavicular coverage angle (p = 0.003), lateral calcaneal pitch (p = 0.002), and lateral talonavicular angle (p = 0.017) improved significantly and were within normal ranges postoperatively. The mean hindfoot alignment measured 2.7 degrees of valgus. All but one patient had normal (5/5) eversion strength. Reconstruction of the spring ligament resulted in few complications and might be considered as an alternative to arthrodesis in patients with ruptures of the spring ligament and deformity that does not correct fully with bony procedures alone.

A comparison of two different techniques in the surgical treatment of flexible pes planovalgus: calcaneal lengthening and extra-articular subtalar arthrodesis

The objective of this study was to compare the results of calcaneal lengthening and Dennyson-Fulford extra-articular subtalar arthrodesis operations performed in patients with flexible pes planovalgus owing to various etiologies and to compare their effectiveness in realigning the foot. Two patient groups were retrospectively formed out of the patients in whom calcaneal lengthening (25 feet of 13 patients) and subtalar extra-articular arthrodesis (27 feet of 15 patients) operations were performed. The modified Evans technique for the calcaneal lengthening operation and the Dennyson-Fulford technique for the subtalar extra-articular arthrodesis operation were applied. Any special criterion to choose the indication was not considered. The main indication for the surgery was pain during daily routine activities in both groups. The patients were evaluated preoperatively and during the last visit, both clinically and radiographically. The groups were homogenous for sex and mean age for the process, but in the subtalar extra-articular arthrodesis group, the deformity was more severe in some parameters, mean follow-up period was significantly longer and neurologic etiologies were more dominant. Anteroposterior talocalcaneal and talonavicular angles were worse in the subtalar extra-articular arthrodesis group preoperatively (P<0.05). Both groups showed significant correction (P<0.05) in all parameters postoperatively. In the last visit, lateral talocalcaneal, anteroposterior, and lateral talonavicular angles were worse in the calcaneal lengthening group (P<0.05) and calcaneal pitch angle was worse in the subtalar extra-articular arthrodesis group (P<0.05). Both groups showed significant clinical correction (P<0.05) in all parameters postoperatively, but there was no significant difference between the groups during the last visit in terms of total clinical scores (P>0.05). Pain, the parameter that was the main indication for surgery, was eliminated in all patients except for one in the calcaneal lengthening group. The evaluation of the effectiveness of the surgical technique on the results made by performing repeated measures from general linear models showed significantly better correction in anteroposterior and lateral talocalcaneal angles, anteroposterior and lateral talonavicular angles, and medial longitudinal arc angle in the subtalar extra-articular arthrodesis group (P<0.05). In conclusion, in this study group, the subtalar extra-articular arthrodesis technique was superior in talocalcaneonavicular joint complex reduction and medial longitudinal arc reconstruction in the surgical treatment of flexible pes planovalgus, and calcaneal lengthening provided better correction of calcaneal equinus. Therefore, it is better to use the calcaneal lengthening technique in mild or moderate deformities because of its physiological advantages, and subtalar extra-articular arthrodesis technique in severe and/or rigid deformities because of its superior potential to correct the deformity and stabilize the foot in the corrected position.

Ethnic Radiographic Foot Differences

The prevalence of foot and ankle conditions varies among different ethnic groups. It is not known if this difference is due to any distinctive skeletal morphological characteristics of the foot. The purpose of this study was to determine if ethnic differences exist in the morphometric measurements on radiographs of the weightbearing foot. A morphometric study of weightbearing radiographs of feet was performed prospectively. Radiographic parameters were measured on digital monitors using digital tools. These were the hallux valgus angle (HVA), intermetatarsal angle (IMA), talonavicular angle (TNA), talonavicular coverage angle (TNCovA), metatarsal span (MS) on anteroposterior (AP) radiographs and talo-first metatarsal angle (T-1(st)MTA), calcaneal pitch (CP), and lateral talocalcaneal angle (LTCA) on lateral radiographs. A total of 237 feet in 126 patients (45 African Americans, 59 Caucasians, and 22 Hispanics) were studied. Statistically significant differences were found in the CP, LTCA, and MS. African Americans have significantly lower CP than Caucasians (p < 0.0001). African Americans have significantly lower CP than Hispanics (p < 0.0016). Caucasians have significantly higher TCA than African Americans (p < 0.0004). Males have a larger MS than females (p < 0.0001). There are differences in the radiographic morphology of feet among different ethnic groups. A larger prospective community-based study of morphological differences is needed for better understanding of the genetic and environmental factors influencing the prevalence of foot and ankle conditions. The clinical relevance between having a lower CP angle and a higher incidence of flat feet in African Americans warrants further investigation. It is not known if there is a relationship between posterior tibialis insufficiency and low CP.

Calcaneocuboid Distraction Arthrodesis and First Metatarsocuneiform Arthrodesis for Correction of Acquired Flatfoot Deformity in a Cadaver Model

Lateral column lengthening has been associated with residual forefoot supination and symptomatic lateral overload in treatment of acquired flatfoot. A medial column procedure may be useful to redistribute load to the medial column. We evaluated radiographic and pressure changes in a severe flatfoot model with lateral column lengthening and investigated the effect of an added first metatarsocuneiform arthrodesis. Ten cadaver specimens were loaded in simulated double-legged stance, and radiographic and pressure data were collected for all tested states. Calcaneocuboid arthrodesis was done with a 10-mm foam wedge. Residual forefoot varus was corrected through the first metatarsocuneiform joint. Differences in the mean lateral talar-first metatarsal angle, talonavicular angle, talocalcaneal angle, and calcaneal pitch were significant between the intact foot and the flatfoot. After calcaneocuboid distraction arthrodesis and tendon transfer, the lateral talar-first metatarsal angle, talonavicular angle, and calcaneal pitch were significantly different from the flatfoot. After added first metatarsocuneiform arthrodesis, the talonavicular angle was not significantly different from the intact foot. Lateral forefoot pressure increased in the flatfoot after lateral column lengthening but was not significantly different from the intact foot after first metarsocuneiform arthrodesis was added. Adding first metatarsocuneiform arthrodesis to calcaneocuboid distraction arthrodesis for treatment of flatfoot deformity provided improvement in radiographic and pedobarographic parameters of a severe model of stage II posterior tibial tendon dysfunction.

Lateral Column Calcaneal Lengthening, Flexor Digitorum Longus Transfer, and Opening Wedge Medial Cuneiform Osteotomy for Flexible Flatfoot: A Biomechanical Study

Lengthening of the lateral column is commonly used for reconstruction of the adult and pediatric flatfoot, but can result in supination of the foot and symptomatic lateral column overload. The addition of a medial cuneiform osteotomy has been used to redistribute forces to the medial column. The combined use of a lateral column lengthening and medial cuneiform osteotomy in a reproducible cadaver flatfoot model was evaluated. Twelve cadaver specimens were physiologically loaded and each was evaluated radiographically and pedobarographically in the following conditions: 1) intact, 2) severe flatfoot, 3) lateral column lengthening with simulated flexor digitorum longus transfer, and 4) lateral column lengthening and flexor digitorum longus (FDL) transfer with added medial cuneiform osteotomy. The lateral column lengthening was performed with a 10-mm foam bone wedge through the anterior process of the calcaneus, and the medial cuneiform osteotomy was performed with a dorsally placed 6-mm wedge. Lateral column lengthening with simulated FDL transfer on a severe flatfoot model resulted in a significant change as compared with the flatfoot deformity in three measurements: in lateral talus-first metatarsal angle (-17 to -7 degrees; p<0.001), talonavicular angle (46 to 24 degrees; p<0.001), and medial cuneiform height (16 to 20 mm; p<0.001). Lateral forefoot pressure increased from 24.6 to 33.9 kPa (p<0.001) after these corrections as compared with the flatfoot. Adding a medial cuneiform osteotomy decreased the lateral talar-first metatarsal angle from -7 to -4 degrees, decreased the talonavicular coverage angle from 24 to 20 degrees, and increased the medial cuneiform height from 20 to 25 mm. After added medial cuneiform osteotomy, lateral pressure was significantly different from that of the flatfoot (p=0.01) and was not significantly different from that of the intact foot (p=0.14). Medial forefoot pressure was overcorrected as compared with the intact foot with added medial cuneiform osteotomy. Lateral column lengthening increased lateral forefoot pressures in a severe flatfoot model. An added medial cuneiform osteotomy provided increased deformity correction and decreased pressure under the lateral forefoot.

Correction of Moderate and Severe Acquired Flexible Flatfoot with Medializing Calcaneal Osteotomy and Flexor Digitorum Longus Transfer

Acquired flexible flatfoot encompasses a wide spectrum of disease, and there is no validated treatment protocol. We hypothesized that a medializing calcaneal osteotomy with a flexor digitorum longus transfer is adequate to correct a less severe acquired flexible flatfoot but not a more severe flatfoot. We also hypothesized that use of an additional procedure would further correct the flatfoot. The study included seven pairs of cadaver specimens, with one side randomly selected for the creation of a mild flatfoot deformity and the other, for the creation of a severe flatfoot deformity. Cyclic axial load was applied to the intact foot, to the flatfoot, after correction with a medializing calcaneal osteotomy and a flexor digitorum longus transfer, and after the addition of a subtalar arthroereisis. Radiographic and pedobarographic data were obtained at each stage. A repeated-measures analysis of variance with post hoc analysis was used to compare all parameters in the intact foot with those in the flatfoot and corrected specimens. A Student t test was used to compare flatfoot severity between the mild and severe models. Compared with the intact foot, the mild and severe flatfoot models showed a significant change in the talar-first metatarsal angle (p = 0.01 and 0.03, respectively), talonavicular angle (p = 0.04 and 0.04), and medial cuneiform height (p = 0.03 and 0.05). The mild and severe models were significantly different from each other with regard to the talar-first metatarsal angle (p = 0.003) and talonavicular angle (p = 0.002). After the osteotomy and tendon transfer in the mild-flatfoot model, the talar-first metatarsal angle and talonavicular angle were not significantly different from those in the intact state. In the severe-flatfoot model, the talar-first metatarsal angle, talonavicular angle, and medial cuneiform height remained significantly undercorrected after the osteotomy and tendon transfer. After the arthroereisis, the talonavicular angle and medial cuneiform height were not significantly different from the values for the intact foot. In a cadaver model, the effectiveness of different procedures on radiographic and pedobarographic parameters varies with the severity of an acquired flatfoot deformity.

CORRECTION OF MODERATE AND SEVERE ACQUIRED FLEXIBLE FLATFOOT WITH MEDIALIZING CALCANEAL OSTEOTOMY AND FLEXOR DIGITORUM LONGUS TRANSFER

Background: Acquired flexible flatfoot encompasses a wide spectrum of disease, and there is no validated treatment protocol. We hypothesized that a medializing calcaneal osteotomy with a flexor digitorum longus transfer is adequate to correct a less severe acquired flexible flatfoot but not a more severe flatfoot. We also hypothesized that use of an additional procedure would further correct the flatfoot. Methods: The study included seven pairs of cadaver specimens, with one side randomly selected for the creation of a mild flatfoot deformity and the other, for the creation of a severe flatfoot deformity. Cyclic axial load was applied to the intact foot, to the flatfoot, after correction with a medializing calcaneal osteotomy and a flexor digitorum longus transfer, and after the addition of a subtalar arthroereisis. Radiographic and pedobarographic data were obtained at each stage. A repeated-measures analysis of variance with post hoc analysis was used to compare all parameters in the intact foot with those in the flatfoot and corrected specimens. A Student t test was used to compare flatfoot severity between the mild and severe models. Results: Compared with the intact foot, the mild and severe flatfoot models showed a significant change in the talar-first metatarsal angle (p = 0.01 and 0.03, respectively), talonavicular angle (p = 0.04 and 0.04), and medial cuneiform height (p = 0.03 and 0.05). The mild and severe models were significantly different from each other with regard to the talar-first metatarsal angle (p = 0.003) and talonavicular angle (p = 0.002). After the osteotomy and tendon transfer in the mild-flatfoot model, the talar-first metatarsal angle and talonavicular angle were not significantly different from those in the intact state. In the severe-flatfoot model, the talar-first metatarsal angle, talonavicular angle, and medial cuneiform height remained significantly undercorrected after the osteotomy and tendon transfer. After the arthroereisis, the talonavicular angle and medial cuneiform height were not significantly different from the values for the intact foot. Conclusions: In a cadaver model, the effectiveness of different procedures on radiographic and pedobarographic parameters varies with the severity of an acquired flatfoot deformity. Clinical Relevance: This study suggests that less severe acquired flexible flatfoot might be appropriately treated with a combined medializing calcaneal osteotomy and flexor digitorum longus transfer and that severe flatfoot might require an additional procedure for adequate correction.

MR evaluation of talonavicular angle in congenital talipes equinovarus

The talonavicular relationship in 14 patients with talipes equinovarus was quantified using gradient echo sequences. The angle formed between the short axis of the navicular and the long axis of the talus was measured. There is a significant difference in the talonavicular angle between patients who had posteromedial release (PMR) and those who had posterior release (PR) or casting only ( P=.0004). This method provides an objective assessment of residual deformity following surgical and conservative management of talipes equinovarus.