Treatment Of Adult Acquired Flatfoot Deformity Research Articles

Analysis of Patient-Reported Outcomes Following Triple Arthrodesis: A Minimum Two-Year Followup

Category: Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is a debilitating condition that is common in the United States. Triple arthrodesis (TA) is a treatment option reserved for advanced disease. Evidence on patient outcomes following this procedure remains limited. This study aims to report patient-reported outcomes following TA via patient reported outcome measurement information systems (PROMIS). Secondary aims are to delineate any demographics or patient characteristics that significantly impact PROMIS scoring. Methods: In this single institution study, we identified all patients who underwent triple arthrodesis between 2014 and 2021 based on CPT coding. Patients who underwent a TA procedure for AAFD with a minimum of 24 months follow-up were eligible for inclusion in this study. Patients under the age of 18, those undergoing revision surgeries, or those with pathologies other than AAFD were excluded from this study. Patient demographics and surgical complications were collected through chart review. The Patient Reported Outcomes Measurement Information System (PROMIS) survey and Foot Function Index (FFI) scores were collected via telephone interview. PROMIS scores were analyzed with a Type III “SS” ANOVA test to stratify independent risk factors and account for confounding variables. Results: 49 patients (43%) submitted responses to the survey. Patient outcomes were collected at an average of 5.50 years postoperatively. There were no significant differences in the rates of complications among any of the variables analyzed. The average PROMIS physical function score was 38.35, the average pain interference score was 61.52, and the average depression score was 49.82. Males and patients with prior foot and ankle procedures had significant increases in PROMIS physical function scores (p <.05). The mean FFI scores were 58.56 for pain, 60.07 for disability, and 48.07 for activity limitation. Patients > 50 years old had significantly higher FFI pain, disability, and total scores (p <.05). VAS scores decreased preoperatively to postoperatively from 5.4 to 2.6. Conclusion: Our study is the first to examine variables significantly impacting PROMIS, FFI and VAS scores for patients undergoing TA for AAFD. Treatment of AAFD with TA appears to be beneficial in long-term reduction of pain. This study is one of the largest to date involving patient reported outcomes following TA and can serve as a prognostic tool for physicians to use when counseling patients prior to this procedure.

Adult Acquired Flatfoot Deformity: A Narrative Review about Imaging Findings.

Adult acquired flatfoot deformity (AAFD) is a disorder caused by repetitive overloading, which leads to progressive posterior tibialis tendon (PTT) insufficiency. It mainly affects middle-aged women and occurs with foot pain, malalignment, and loss of function. After clinical examination, imaging plays a key role in the diagnosis and management of this pathology. Imaging allows confirmation of the diagnosis, monitoring of the disorder, outcome assessment and complication identification. Weight-bearing radiography of the foot and ankle are gold standard for the diagnosis of AAFD. Magnetic Resonance Imaging (MRI) is not routinely needed for the diagnosis; however, it can be used to evaluate the spring ligament and the degree of PTT damage which can help to guide surgical plans and management in patients with severe deformity. Ultrasonography (US) can be considered another helpful tool to evaluate the condition of the PTT and other soft-tissue structures. Computed Tomography (CT) provides enhanced, detailed visualization of the hindfoot, and it is useful both in the evaluation of bone abnormalities and in the accurate evaluation of measurements useful for diagnosis and post-surgical follow-up. Other state-of-the-art imaging examinations, like multiplanar weight-bearing imaging, are emerging as techniques for diagnosis and preoperative planning but are not yet standardized and their scope of application is not yet well defined. The aim of this review, performed through Pubmed and Web of Science databases, was to analyze the literature relating to the role of imaging in the diagnosis and treatment of AAFD.

Radiographic Outcomes of Cotton Osteotomy in Treatment of Adult-Acquired Flatfoot Deformity.

We investigated the long-term radiographic outcomes of the Cotton osteotomy performed at our institution by the 2 senior authors in conjunction with other reconstruction procedures to correct adult-acquired flatfoot deformity (AAFD). We retrospectively studied patients who underwent Cotton osteotomy between 2005 and 2010 with minimum 4-year follow-up. Radiographic assessment was made on weightbearing radiographs taken at 4 different time intervals: preoperative, early (first postoperative full weightbearing), intermediate (between 1 and 4 years postoperatively), and final (over 4 years postoperatively). Nineteen patients were included. Final follow-up was 8.6 ± 2.6 years. The lateral talus-first metatarsal angle improved significantly from preoperative to early radiographs (n = 15; mean change: 30 degrees, 95% CI, 21.6-38.7; P < .0001). A significant loss of correction was observed between intermediate and final radiographs (n = 11; mean change: 17 degrees, 95% CI, 8.1-26.4; P < .0001). Of 14 patients with early radiographs, 8 lost >50% of the correction initially achieved. Medial column height decreased by 3.0 mm (95% CI, 1.80-7.90; P = .35) between early radiographs and final follow-up. This is the longest reported radiographic follow-up of the Cotton osteotomy performed to address forefoot varus deformity as part of AAFD. The Cotton osteotomy achieved radiographic correction of the medial longitudinal arch at early follow-up, but approximately half of the patients had lost over 50% of that correction at final follow-up. The lengthened angular shape of the cuneiform did not collapse, implying that further collapse occurred through the medial column joints. Level IV, case series.

Outcomes Following the Use of Subtalar Arthroereisis in the Correction of Adult Acquired Flatfoot: A Systematic Review.

Adult acquired flatfoot deformity (AAFD) is a condition affecting approximately 3% of the adult population. It can lead to severe morbidity, and therefore, prompt treatment is of the upmost importance in maintaining and restoring function. Recently, the use of subtalar arthroereisis has become more widespread in the treatment of AAFD. The purpose of this systematic review is to examine the clinical and radiological outcomes of AAFD when treated with subtalar arthroereisis. Studies involving the use of subtalar arthroereisis for the management of AAFD were reviewed, and appropriate studies selected based on inclusion and exclusion criteria. Studies were reviewed for both clinical and radiological outcomes following the use of subtalar arthroereisis as well as reported complications. Nine studies met our inclusion criteria, with most of these involving stage II AAFD. A total of 190 subtalar arthroereisis procedures were performed with all studies demonstrating improvement in both clinical and radiological scores with a low rate of complications. Subtalar arthroereisis may have benefits when used as an adjunct to treat stage II AAFD. However, more high-quality studies are needed to establish its best use. Level IV: Systematic review.

Contribution of First-Tarsometatarsal Joint Fusion to Deformity Correction in the Treatment of Adult-Acquired Flatfoot Deformity.

Background:Severe adult-acquired flatfoot deformity (AAFD) is often associated with painful medial column collapse at the naviculocuneiform (NC) joint. However, many surgeons surgically correct the deformity without directly addressing this joint. The purpose of this study was to examine the role of first-tarsometatarsal (TMT) fusion combined with subtalar fusion in correcting deformity at the NC joint.Methods:We retrospectively analyzed 40 patients (41 feet) who underwent first-TMT and subtalar (ST) fusion as part of a flatfoot reconstructive procedure. We assessed 6 radiographic parameters both preoperatively and at a minimum of 6 months postoperatively, including talonavicular (TN) coverage angle, lateral talo–first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, hindfoot moment arm, and a newly defined navicular-cuneiform incongruency angle (NCIA). Patient-Reported Outcomes Measurement Information System (PROMIS) clinical outcomes were assessed preoperatively and at a minimum 1-year follow-up.Results:The NCIA demonstrated excellent interobserver reliability, with no significant change between pre- and postoperative measurements. All other radiographic parameters, except calcaneal pitch, demonstrated statistically significant improvement postoperatively (P < .01). Overall, patients had statistically significant improvement in all PROMIS domains (P < .01), except for depression. Worsening NC deformity was not associated with worse patient-reported outcomes.Conclusions:Our data suggest that when addressing painful collapse of the medial arch in patients with AAFD, fusion of the first-TMT joint in combination with other procedures leads to acceptable radiographic and clinical outcomes. There was no change in deformity at the NC joint in our patient cohort at short-term follow-up, and patients achieved significant improvement in multiple PROMIS domains. Although TMT fusion had no effect on NC deformity, residual or worsening NC deformity did not significantly affect clinical outcomes. In addition, the NCIA was found to be a reliable radiographic parameter to assess NC deformity in the presence of talonavicular and/or first-TMT fusion.Level of Evidence:Level III, retrospective comparative study.

The Flatfoot Through a Pinhole: Do It Percutaneously!

Surgical treatment of adult-acquired flatfoot deformity typically requires multiple soft tissue and bony procedures, many of which can be effectively performed with minimally invasive surgery techniques. Use of minimal skin incisions helps limit the morbidity of surgery, reducing postoperative pain and the incidence of wound complications. This chapter will focus primarily on the bony procedures which can be accomplished through minimally invasive surgery, including the medializing calcaneal osteotomy and the first tarsometatarsal fusion. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Increasing Values of the Lateral Talar-First Metatarsal Angle Preoperatively Predict Spring Ligament Attenuation in Adult Acquired Flat Foot Deformity

Category:Ankle, Hindfoot, TraumaIntroduction/Purpose:Adult acquired flat foot deformity (AAFD) is responsible for numerous adult foot and ankle deformities, and spring ligament damage has been implicated in the pathology of AAFD. Treatment of AAFD may involve attempts to address spring ligament incompetency, and preoperative knowledge of spring ligament integrity would be valuable in planning for such procedures. To our knowledge, there have been no attempts to correlate preoperative radiographs with direct intraoperative evaluation of spring ligament competency. This study aims to examine the relationship between preoperative radiographic measures specific to flatfoot deformity and intraoperative competency of the spring ligament during flatfoot reconstruction in order to find radiographic measures predicting spring ligament attenuation.Methods:The operative reports of 3 fellowship trained orthopaedic foot and ankle surgeons were searched over a 5-year period from 2012-2017. Patients with pre-operative standing AP and lateral radiographs along with an operative report directly visualizing and commenting on spring ligament integrity were included in the study. Investigators reviewed operative reports to identify patients with spring ligament tears and evaluated pre-operative radiographs. Five common radiographic parameters were measured: lateral talar-first metatarsal angle, AP talar-first metatarsal angle, talonavicular coverage angle, talonavicular coverage percentage, and calcaneal pitch. Chi-square and logistic regression analysis were used to evaluate the five radiographic parameters for association with spring ligament tear.Results:The study enrolled 58 patients with 29 patients having confirmed spring ligament tears and 29 patients having an intact spring ligament. Increasing values for each of the 5 radiographic measures were statistically significant predictors for spring ligament tear on univariate analysis (p=0.001) with the lateral talar-first metatarsal angle being the most significant predictor for spring ligament tear (p<0.001). On logistic regression analaysis, LT-1st angle was a significant predictor of spring ligament tear (p<0.001). A lateral talar-first metatarsal angle =30 degrees had a sensitivity and specificity of 65% and 100% for spring ligament attenuation. The positive predictive value of spring ligament tear with a lateral talar-first metatarsal angle =30 degrees was 100% and the negative predictive value was 74%.Conclusion:This study is the first to correlate preoperative radiographs with direct visualization and evaluation of spring ligament competency. Increasing severity of common radiographic measures of flat foot deformity, particularly the lateral talar-first metatarsal angle, correlate significantly with spring ligament tear and may assist surgeons in planning appropriate preoperative interventions.

Current concepts in adult acquired flatfoot deformity

Adult acquired flatfoot deformity (AAFD) is associated with medial soft-tissue break of the posterior tibial tendon and ligaments of the arch. Failure of other ligaments that support the arch of the foot can occur before, during, or after tendon failure. Deformity at different levels may be directly related to specific structures that fail. Deformity often consists of a combination of plantar sag, midfoot abduction, and heel valgus. The cause of AAFD is multifactorial with the most common etiologic factor probably being a preexisting flatfoot. Other contributing factors include obesity and relative hypovascularity of the posterior tibial tendon. Currently, patients are grouped into four clinical stages that help describe the severity and flexibility of the deformity and guide treatment. AAFD is generally diagnosed through patient history, physical examination, and standing radiographs of the foot and ankle. Definitive treatment for stage I and initial treatment for the other stages should start with nonoperative measures. In general, surgical treatment algorithms should match individual components of the pathology or deformity with specific surgical treatments. Outcomes after treatment of AAFD have been documented. In general, preserving motion of the joints of the foot leads to better functional outcomes than fusion. Currently, the most controversy surrounds the surgical treatment of stage II deformity.

Nonoperative Care for the Treatment of Adult-acquired Flatfoot Deformity

Nonoperative therapy for adult-acquired flatfoot is a reasonable treatment option that is likely to be beneficial for most patients. In this article, we describe the results of a retrospective cohort study that focused on nonoperative measures, including bracing, physical therapy, and anti-inflammatory medications, used to treat adult-acquired flatfoot in 64 consecutive patients. The results revealed the incidence of successful nonsurgical treatment to be 87.5% (56 of 64 patients), over the 27-month observation period. Overall, 78.12% of the patients with adult-acquired flatfoot were obese (body mass index [BMI] ≥ 30), and 62.5% of the patients who failed nonsurgical therapy were obese; however, logistic regression failed to show that BMI was statistically significantly associated with the outcome of treatment. The use of any form of bracing was statistically significantly associated with successful nonsurgical treatment (fully adjusted OR = 19.8621, 95% CI 1.8774 to 210.134), whereas the presence of a split-tear of the tibialis posterior on magnetic resonance image scans was statistically significantly associated with failed nonsurgical treatment (fully adjusted OR = 0.016, 95% CI 0.0011 to 0.2347). The results of this investigation indicate that a systematic nonsurgical treatment approach to the treatment of the adult-acquired flatfoot deformity can be successful in most cases.