Quantitative segmental analysis of weight-bearing radiographs of the foot and ankle for children: normal alignment

Symptomatic flatfoot in cerebral palsy

PURPOSE OF REVIEW

The purpose of this review is to evaluate the current literature and best practices in the evaluation and treatment of symptomatic flatfoot in cerebral palsy.

RECENT FINDINGS

While techniques to reconstruct the neuromuscular flatfoot and reestablish bony levers have remained similar over time, the concept of surgical dosing has helped guide appropriate interventions based on the magnitude of disease and functional level of the child. Moreover, the utilization of multisegment foot modeling in motion analysis has allowed quantitative description of such deformities and their impact on gait.

SUMMARY

Future research should focus on refining operative indications and interventions with larger, multicenter, prospective cohorts to provide more robust evidence in surgical decision making. Long-term data are needed to confirm and compare efficacy of procedures. Radiographic data alone are not sufficient for describing functional foot position. Gait analysis with foot modeling and pedobarography along with patient-centered subjective outcomes will be needed in such investigations to make conclusive recommendations.

Radiologic foot alignment and clinical outcome after percutaneous drilling for symptomatic accessory navicular in skeletally immature children

Various surgical treatments are available for a symptomatic AN, including percutaneous drilling (PD). PD is reportedly effective for ANs in skeletally immature children. However, no reports have described the foot alignment after PD in skeletally immature children. This study was performed to compare the radiographic parameters between the preoperative period and the final follow-up after PD for symptomatic ANs in skeletally immature children. From October 2013 to December 2020, PD was performed on 13 feet in 10 skeletally immature children. The patients comprised 5 boys and 5 girls with a mean age at surgery of 11.9 years. The mean follow-up period was 14.8 months. We measured 5 radiographic findings preoperatively and at the final follow-up: calcaneal pitch angle (CPA), talocalcaneal angle (TCA), talonavicular coverage angle (TNCA), anteroposterior talo-first metatarsal angle (ATMA), and lateral talo-first metatarsal angle (LTMA). Ten feet were assessed as excellent, 1 as fair, and 2 as poor. Ten unions (76.9%) were achieved among the 13 feet. The mean CPA improved from 16.4 ± 4.1 degrees preoperatively to 18.2 ± 3.4 degrees at the final follow-up, the TCA improved from 43.0 ± 3.7 to 45.2 ± 4.4 degrees, and the TNCA improved from 19.9 ± 4.4 to 15.4 ± 5.0 degrees (P < .05). The ATMA and LTMA were not significantly different between the preoperative period and final follow-up. We found that PD for symptomatic ANs in skeletally immature children was effective treatment, and some radiographic parameters showed significant differences between the preoperative period and final follow-up.

An evaluation of subtalar titanium screw arthroereisis for the treatment of symptomatic paediatric flatfeet - early results

BACKGROUND

Idiopathic flexible flatfoot is a common condition in children which typically improves with age and remains asymptomatic. However, the condition can sometimes be more severe, and cause mechanical impairment or pain. The aim of the study was to perform a prospective clinical, radiological, podoscopic and pedobarographic assessment (static and dynamic) of subtalar titanium screw arthroereisis for the treatment of symptomatic, idiopathic, flexible flatfeet.

METHODS

A prospective, consecutive, non-controlled, cohort, clinical follow-up study was performed. In total, 30 patients (41 feet), mean age 10 (6 to 16 years), were evaluated. Clinical and standing radiological assessments, static and dynamic pedobarography, as well as podoscopy, were performed before surgery and at final follow-up.

RESULTS

Treatment was associated with significant improvements in heel valgus angle, radiographic parameters (lateral and dorso-planar talo-first metatarsal angle, calcaneal inclination angle, talar declination angle, longitudinal arch angle) and podoscopic parameters (Clark's angle, Staheli's arch index and Chippaux-Smirak index). Significant increases were noted for lateral loading, forefoot contact phase and double support / swing phase, and reduced medial loading (dynamic pedobarography), as well as lateral midfoot area and loading, but decreased were observed for medial forefoot loading (static pedobarography). Four patients reported persistent pain in the sinus tarsi region (six feet), and in one case, the implant was replaced for a larger one due to undercorrection. No overcorrections or infection complications were noted in the study group.

CONCLUSIONS

Subtalar arthroereisis is a minimally-invasive and effective surgical method for treating symptomatic, idiopathic, flexible flatfeet; it has an acceptable complication rate with good early clinical results.

LEVEL OF EVIDENCE

II b.

Radiographic Measurements Associated With Ankle Power Generation During Gait in Patients With Cerebral Palsy

BACKGROUND

Pes planovalgus (PV) deformity accounts for lever arm dysfunction and compromises gait in patients with cerebral palsy (CP). However, the association between ankle power generation and radiographic indices is not yet understood. We aimed to investigate the association between ankle power and radiographic indices during gait in patients with CP concomitant with PV deformity.

METHODS

Patients older than 14 years with ambulatory CP and PV deformity were included. All the patients underwent 3-dimensional gait analysis and weight-bearing foot radiography. Gait data were collected, including foot progression angle, tibial rotation, hip rotation, and ankle power generation. Radiographic measurements included anteroposterior (AP) talo-first metatarsal angle, lateral talo-first metatarsal angle, and hindfoot angle. A linear mixed-effects model was performed to identify significant radiographic indices associated with ankle power generation.

RESULTS

Thirty-one limbs from 15 patients with spastic diplegia and 6 with spastic hemiplegia were included. Statistical analysis demonstrated that ankle power generation was significantly correlated with the CP type ( P =0.0068) and AP talo-1 st metatarsal angle ( P =0.0230).

CONCLUSION

Ankle power generation was significantly associated with the AP talo-first metatarsal angle. Surgeons might need to pay attention to correcting forefoot abduction to restore ankle power when planning surgeries for pes PV deformities in patients with CP.

LEVEL OF EVIDENCE

Prognostic Level III.

MODIFIED MUBARAK TECHNIQUE FOR FLEXIBLE FLATFOOT CORRECTION IN CHILDREN AND ADOLESCENTS

Objective

To describe the technique, analyze possible radiographic correction and evaluate the clinical result of medial and plantar calcaneal displacement osteotomy associated with opening wedge cuboid osteotomy for flexible flatfoot correction.

Methods

23 patients (30 feet) diagnosed with flexible flat foot treated with plantar and medial calcaneal displacement osteotomy associated with opening wedge cuboid osteotomy were evaluated retrospectively. In the lateral radiographs calcaneal pitch and Meary's angle were the radiographic parameters evaluated; while the talonavicular coverage angle was evaluated in the anteroposterior radiographs. To assess the clinical outcome of the surgical procedure, the American Orthopedic Foot and Ankle Society Score (AOFAS) for the ankle and hindfoot was adopted.

Results

The mean values of the evaluated angles and AOFAS score for ankle and hindfoot significantly improved when comparing pre- and postoperative values.

Conclusion

Plantar and medial calcaneal displacement osteotomy associated with an opening wedge cuboid osteotomy is able to improve radiological and clinical parameters of child patients with flexible flatfoot. Level of Evidence III, Retrospective Comparative Study.

Split Transfer of the Tibialis Anterior Tendon Combined With Calcaneocuboid Fusion vs Split Transfer of the Tibialis Anterior Tendon Alone to Treat Equinovarus Foot Deformity in Children With Cerebral Palsy

BACKGROUND

The study aimed to compare the outcomes of combined calcaneocuboid arthrodesis and split anterior tibialis tendon transfer (SPLATT) procedure to isolated SPLATT surgery for the treatment of the spastic equinovarus deformity in children with cerebral palsy (CCP).

METHODS

Forty-one ambulatory CCP with 56 equinovarus feet, with positive flexor withdrawal reflex test results, were studied. The average age was 9.1 ± 3.2 years (range 3-22). Patients were assigned into 2 groups based on the surgical procedures. Patients in group 1 underwent isolated SPLATT surgery, whereas patients in group 2 underwent the SPLATT procedure combined with calcaneocuboid arthrodesis. All feet were followed for at least 12 months after surgery. Patients were evaluated preoperatively and at the most recent follow-up visit. The hindfoot positions were assessed using Chang's criteria, the functional outcomes were assessed using Kling's criteria, and the ambulatory levels were assessed using the Gross Motor Function Classification System (GMFCS).

RESULTS

Patients were followed for an average of 30.4 ± 14 (range 14-84) months. We found no difference between the groups in Chang's scoring (P = .550), better clinical outcomes (P = .034) according to the Kling criteria in SPLATT with calcaneocuboid fusion group, and postoperative GMFCS levels better in the SPLATT with calcaneocuboid fusion group (P = .025).

CONCLUSION

In this retrospective comparative study to treat children with spastic equinovarus feet, patients who had the SPLATT procedure combined with calcaneocuboid arthrodesis generally resulted in better functional outcomes compared to isolated SPLATT surgery in spastic equinovarus foot.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The efficacy of split tibial tendon transfers on functional gait outcomes for children and youth with cerebral palsy and spastic equinovarus foot deformities

To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity. Five databases (CENTRAL, CINAHL, PubMed, Embase, Web of Science) were systematically screened for studies investigating split tibialis anterior or split tibialis posterior tendon transfer for spastic equinovarus foot deformity, with gait-related outcomes (published pre-September 2022). Study quality and evidence were assessed using the Methodological Index for Non-Randomized Studies, the Risk of Bias In Non-Randomized Studies of Interventions, and the Grading of Recommendations Assessment, Development and Evaluation. Overall, 17 studies (566 feet) were included: 13 studies used clinical grading criteria to report a postoperative 'success' of 87% (75% to 100%), 14 reported on orthotic use with 88% reduced postoperative use, and one study reported on ankle kinematics improvements. Ten studies reported post-surgical complications at a rate of 11/390 feet (2.8%), but 84 feet (14.8%) had recurrent varus (68 feet, 12%) or occurrence of valgus (16 feet, 2.8%). Only one study included a patient-reported outcome measure (pain). Split tendon transfers are an effective treatment for children and youth with CP and spastic equinovarus foot deformities. Clinical data presented can be used for future study designs; a more standardized functional and patient-focused approach to evaluating outcomes of surgical intervention of gait may be warranted.

Automated diagnosis of flatfoot using cascaded convolutional neural network for angle measurements in weight-bearing lateral radiographs

OBJECTIVES

Diagnosis of flatfoot using a radiograph is subject to intra- and inter-observer variabilities. Here, we developed a cascade convolutional neural network (CNN)-based deep learning model (DLM) for an automated angle measurement for flatfoot diagnosis using landmark detection.

METHODS

We used 1200 weight-bearing lateral foot radiographs from young adult Korean males for the model development. An experienced orthopedic surgeon identified 22 radiographic landmarks and measured three angles for flatfoot diagnosis that served as the ground truth (GT). Another orthopedic surgeon (OS) and a general physician (GP) independently identified the landmarks of the test dataset and measured the angles using the same method. External validation was performed using 100 and 17 radiographs acquired from a tertiary referral center and a public database, respectively.

RESULTS

The DLM showed smaller absolute average errors from the GT for the three angle measurements for flatfoot diagnosis compared with both human observers. Under the guidance of the DLM, the average errors of observers OS and GP decreased from 2.35° ± 3.01° to 1.55° ± 2.09° and from 1.99° ± 2.76° to 1.56° ± 2.19°, respectively (both p < 0.001). The total measurement time decreased from 195 to 135 min in observer OS and from 205 to 155 min in observer GP. The absolute average errors of the DLM in the external validation sets were similar or superior to those of human observers in the original test dataset.

CONCLUSIONS

Our CNN model had significantly better accuracy and reliability than human observers in diagnosing flatfoot, and notably improved the accuracy and reliability of human observers.

KEY POINTS

• Development of deep learning model (DLM) that allows automated angle measurements for landmark detection based on 1200 weight-bearing lateral radiographs for diagnosing flatfoot. • Our DLM showed smaller absolute average errors for flatfoot diagnosis compared with two human observers. • Under the guidance of the model, the average errors of two human observers decreased and total measurement time also decreased from 195 to 135 min and from 205 to 155 min.

Associated correction of forefoot alignment with hindfoot fusion for pes planovalgus deformity

BACKGROUND

The present study aimed to investigate changes in hallux alignment after corrective surgery for adult-acquired flatfoot deformity (AAFD).

PATIENTS AND METHODS

The present study retrospectively investigated the changes of hallux alignment in 37 feet (33 patients) which were treated with double or triple arthrodesis of the hindfoot for AAFD between 2015 and 2021 and could be followed up to one year postoperatively.

RESULTS

Hallux valgus (HV) angle significantly decreased by a mean 4.1° among the whole 37 subjects and by a mean 6.6° among the 24 subjects who had a preoperative HV angle of 15° or more. Those who had HV correction (HV angle correction ≥ 5°) demonstrated more near-normal postoperative alignment of the medial longitudinal arch and hindfoot than those without HV correction.

CONCLUSIONS

Hindfoot fusion for AAFD could improve preoperative HV deformity to some degree. HV correction was associated with proper realignment of the midfoot and hindfoot.

LEVEL OF EVIDENCE

Level IV; retrospective case series.

Improved Gait and Radiological Measurements After injection of Botulinum Toxin Into Peroneus Longus in Young Children With USCP and Equinovalgus Gait

BACKGROUND

Children with cerebral palsy develop foot deformities due to a combination of factors including muscle shortening, hypertonia, weakness, and cocontraction of muscles acting at the ankle joint resulting in an altered gait pattern. We hypothesized these factors affect the peroneus longus (PL) and tibialis anterior (TA) muscles couple in children who develop equinovalgus gait first followed by planovalgus foot deformities. Our aim was to evaluate the effects of abobotulinum toxin A injection to the PL muscle, in a cohort of children with unilateral spastic cerebral palsy and equinovalgus gait.

METHODS

This was a prospective cohort study. The children were examined within 12 months before and after injection to their PL muscle. Twenty-five children of mean age 3.4 (S.D.: 1.1) years were recruited.

RESULTS

We found significant improvement in foot radiology measures. Passive extensibility of the triceps surae did not change, whereas active dorsiflexion increased significantly. Nondimensional walking speed increased by 0.1 (95% confidence interval [CI], [0.07, 0.16]; P < 0.001), and the Edinburgh visual gait score improved by 2.8 (95% CI, [-4.06, -1.46]; P < 0.001). Electromyography showed increased recruitment for gastrocnemius medialis (GM) and TA but not for PL during the reference exercises (standing on tip toes for GM/PL, active dorsiflexion for TA) and decreased activation percentages for PL/GM and TA across sub-phases of gait.

CONCLUSIONS

One key advantage of treating the PL muscle only might be to address foot deformities without interfering with the main plantar flexors that are instrumental to support body weight during gait.

Clinical, Radiographic and Gait Parameters Associated with Medial Arch Pain in the Flexible Pediatric Flatfoot

Pain in the flexible flatfoot is a common complaint, if present it is important to find its exact location and causes Therefore, the study aimed to find differences between children with and without medial arch pain and relate them to the reduction of pain following surgical treatment. Children with idiopathic flexible flatfeet were retrospectively included in the study. All children underwent a clinical, radiographic, and gait examination. The feet were subdivided into 2 groups: asymptomatic and those with medial arch pain. Factors associated with medial arch pain were identified via t test. Significant radiological and gait parameters were correlated to the change in medial arch pain score following surgery. Included were 322 feet belonging to 177 children, with the mean age of 11.8 (SD = 2.2) years. The pain was perceived in 52% of the feet, of these, 74% in the medial arch. In the group with pain, 31 feet received a gait analysis following surgery. The radiological parameters, talus-1 and -2 metatarsal angles and the gait parameter, calcaneal lateral shift during walking showed a significant difference (p ≤ .004) between the no pain and pain groups and were associated (R² ≥0.14, p ≤ .04) with the reduction in pain following surgery. The increased talus-1 and -2 metatarsal angles and the calcaneal lateral shift may cause increased tension on the soft-tissues along the medial side of the foot and may produce pain. Therapies aiming at improving the medial arch pain should be directed to normalize the talus-1 or -2 metatarsal angles and the calcaneal lateral shift.

Surgical Management of Severe Equinus Deformity in Ambulatory Children With Cerebral Palsy

BACKGROUND

Tendo Achilles lengthening (TAL) for the management of equinus contractures in ambulatory children with cerebral palsy (CP) is generally not recommended due to concerns of over-lengthening, resulting in weakness and plantar flexor insufficiency. However, in some cases, surgical correction of severe equinus deformities can only be achieved by TAL. The goal of this study is to assess the outcomes following TAL in these cases.

METHODS

A retrospective cohort study of children with CP with severe equinus contractures (ankle dorsiflexion with the knee extended of -20 degrees or worse) who underwent TAL as part of a single event multilevel surgery, with preoperative and postoperative gait analysis studies. Continuous data were analyzed by paired t test, and categorical data by McNemar Test.

RESULTS

There were 60 subjects: 42 unilateral, 18 bilateral CP; 41 GMFCS II, 17 GMFCS I; mean age at surgery was 10.6 years, mean follow-up was 1.3 years. Ankle dorsiflexion with the knee extended improved from -28 to 5 degrees (P<0.001). The ankle Gait Variable Score improved from 34.4 to 8.6 (P<0.001). The ankle moment in terminal stance improved from 0.43 to 0.97 Nm/kg (P<0.001). Significant improvements (P<0.001) were seen in radiographic measures of foot alignment following surgery. There were few significant differences in the outcome parameters between subjects with unilateral versus bilateral CP (eg, only the bilateral group showed improved but persistent increased knee flexion in mid-stance).

CONCLUSIONS

The outcomes following TAL for the management of severe equinus deformity in ambulatory children with CP were favorable 1 year after surgery, with significant improvements in all domains measured.

SIGNIFICANCE

This study does not advocate for the widespread use of TAL to correct equinus deformity in children with CP. However, it does show that good short-term outcomes following TAL are possible in properly selected subjects with severe contractures when the dosing of the surgery is optimal (correction of contracture to between 0 and 5 degrees of dorsiflexion with the knee extended) and the procedure is performed in the setting of single event multilevel surgery with subsequent proper orthotic management and rehabilitation.

Prospective Comparison of Subtalar Arthroereisis With Calcaneal Lengthening in the Management of Planovalgus Feet of Ambulatory Children With Spastic Cerebral Palsy?

BACKGROUND

Pes planovalgus (PPV) deformity is common among cerebral palsy (CP) patients. There is no true consensus about the best way of treating this common deformity, especially when surgical interference is required. Treatment options range from orthotics to complex surgical procedures. The purpose of this prospective study was to evaluate and compare the effectiveness of 2 different procedures in the correction of symptomatic flexible PPV in ambulatory CP patients.

METHODS

A total of 57 feet in 35 patients were divided into 2 groups: group 1, subtalar arthroereisis group, using the calcaneostop technique; group 2, lateral column lengthening group, using Evans osteotomy. Patients were assessed clinically by the clinical score proposed by Yoo et al and radiologically by measuring 7 weight-bearing angles, both preoperatively and 12 months postoperatively. Patients' (or parents') satisfaction and their tolerance to braces or shoes were assessed 12 months after surgery as secondary outcome parameters.

RESULTS

There was a statistically significant improvement in both primary and secondary outcome parameters after both procedures in comparison to the preoperative parameters. No statistically significant differences were observed between the 2 groups regarding the outcomes of both procedures except for the greater power of arthroereisis in the correction of hindfoot valgus, which was statistically significant both clinically and radiographically.

CONCLUSION

Both procedures are valid options for the surgical management of PPV in ambulatory children with spastic CP. The less-invasive nature and lower potential morbidity suggest that judicious use of arthroereisis is appropriate for some patients, especially in the context of single-event multilevel surgery.

LEVELS OF EVIDENCE

Level II: Prospective, comparative study.

Foot radiographic angle variation as a function of weightbearing magnitude

Weightbearing radiographs are widely used to investigate foot disorders. However, it is unclear how imaging during partial weightbearing affects foot alignment measurements. This study aimed to determine a partial weightbearing threshold that yields consistent measurements of various radiographic angles. Eighteen normal fresh-frozen cadaveric foot specimens were dissected and prepared for mechanical testing using a custom-designed, computed tomography-compatible loading frame. Specimens were placed in a neutral ankle position and scanned in five axial loading conditions (0%, 12.5%, 25%, 37.5%, and 50% bodyweight) using weightbearing computed tomography. (Note 50% bodyweight per foot represents full bodyweight in quiet stance.) The lateral first talometatarsal and calcaneal pitch angles were measured on lateral radiographic projections, and the hallux valgus angle and first-second, fourth-fifth, and first-fifth intermetatarsal angles were measured on axial projection images. The lateral first talometatarsal angle decreased significantly with increased bodyweight loading (p < 0.01). Mean significant decreases in the lateral first talometatarsal angle compared to 0% were 6.6° for 12.5%, 7.6° for 25%, 8.8° for 37.5%, and 10.0° for 50% bodyweight loading; 12.5% to 50% was also significant. There was no significant differences between other loading condition pairings or with increased axial load at other angles. The medial longitudinal arch flattened with increasing axial load, resulting in a decreased lateral first talometatarsal angle. However, this radiographic parameter did not change between the 25% and 50% bodyweight conditions, indicating that partial weightbearing imaging (between 12.5% and 25% bodyweight) might be enough to reproduce the sagittal foot alignments observed under full weightbearing conditions in normal feet.

Ankle Mortise Instability in Multiple Hereditary Exostoses

Ankle valgus is commonly reported in patients with multiple hereditary exostoses (MHE). We report the characteristics of mortise widening in MHE, its progression over time, and the resultant ankle pain and function at skeletal maturity. Mortise medial space (M), talocrural angle (TC), and tibiotalar angle (TT) measurements were collected on preoperative and last follow-up radiographs. Operative data and complications were recorded. American Orthopaedic Foot and Ankle Society (AOFAS) and short form-36 scores at skeletal maturity were collected. A total of 16 patients (19 ankles) had MHE and mortise widening. Thirteen patients had surgery. Preoperatively, no patient complained of instability. However, 11 ankles (57.9%) were painful and 15 (78.9%) were clinically in valgus. Patients underwent surgery at a mean age of 11.8 ± 2.2 y. Operative interventions included medial distal tibia hemiepiphysiodesis for the majority of patients. There were no statistically significant differences between pre and postoperative M, TC, TT angles. Operative patients showed an improved mean M (5.17 ± 1.17 to 4.63 ± 1.06 mm) and TT (8.71 ± 5.40° to 4.54 ±7.58°), however, neither angle reached normal values. TC representing fibular length-maintained measurements within normal limits (82.2 ± 5.3° to 84.8 ±5.8°). Questionnaires were obtained for 10 (52.6%) ankles. Mean age at questionnaires collection was 19.0 ± 3.6 y. Mean AOFAS score was 74.8 ± 17.6 out of 100. Patients scored 6.5 ± 4.1 out of 10 for alignment, 33.0 ± 6.7 out of 40 for pain, 35.3 ± 9.5 out of 50 for function. All short form-36 scores were above the national mean. Improvement of M and TT angles was modest. TC angle was within normal limits but showed an overall fibular shortening and decreased lateral buttress and potential for talar shift, as reflected in AOFAS score. The underwhelming amount of mortise widening correction achieved may not provide for a stable ankle joint.

Deep learning-based tool affects reproducibility of pes planus radiographic assessment

Angle measurement methods for measuring pes planus may lose consistency by errors between observers. If the feature points for angle measurement can be provided in advance with the algorithm developed through the deep learning method, it is thought that the error between the observers can be reduced. A total of 300 weightbearing lateral radiographs were used for the development of the deep learning-based algorithm, and a total of 95 radiographs were collected for the clinical validation test set. Meary angle (MA) and calcaneal pitch (CP) were selected as measurement methods and measured twice by three less-experienced physicians with the algorithm-based tool and twice without. The intra- and inter-observer agreements of MA and CP measures were assessed via intra-class correlation coefficient. In addition, verification of the improvement of measurement performance by the algorithm was performed. Interobserver agreements for MA and CP measurements with algorithm were more improved than without algorithm. As for agreement with reference standard, combining the results of all readers, both MA and CP with algorithm were greater than those without algorithm. The deep learning algorithm tool is expected to improve the reproducibility of radiographic measurements for pes planus, especially by improving inter-observer agreement.

Meary angle for the prediction of mitral valve prolapse risk in non-syndromic patients with pes planus, a cross-sectional study

Objectives

Mitral Valve Prolapse (MVP) is a common valvular abnormality accounting for 2% of the population. There is a reported association between pes planus (PP) and MVP in some syndromes such as Marfan. However, this association has not been tested in non-syndromic cases. The primary outcome of this study is to measure the prevalence of MVP in a population of patients with PP. The secondary outcome parameter is to determine if the Meary angle (MA), a measure of the severity of flat foot, can be effectively used in the prediction of the presence of MVP. Forty-one patients with PP were screened using a lateral x-ray foot to determine MA while echocardiography was utilized to identify the presence and grade of MVP.

Results

88% of screened patients were diagnosed with MVP. MA was correlated with the grade of MVP and showed high diagnostic accuracy (sensitivity 100% and specificity 90%) in predicting MVP risk when higher than 5. Children with PP are at a higher risk for MVP than the general population. Accordingly, the utilization of MA in such a specific population for the determination of patients at a higher need for echocardiography seems to be a worthwhile strategy in diagnosing MVP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-06032-0.

Assessment of foot alignment and function for ambulatory children with cerebral palsy: Results of a modified Delphi technique consensus study

PURPOSE

The purpose of this study was to establish consensus for the assessment of foot alignment and function in ambulatory children with cerebral palsy, using expert surgeon's opinion through a modified Delphi technique.

METHODS

The panel used a five-level Likert-type scale to record agreement or disagreement with 33 statements regarding the assessment of foot alignment and function. Consensus was defined as at least 80% of responses being in the highest or lowest of two of the five Likert-type ratings. General agreement was defined as 60%-79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached.

RESULTS

Consensus was achieved for 25 (76%) statements, general agreement for 4 (12%) statements, and lack of consensus for 4 (12%) of the statements. There was consensus that the functional anatomy of the foot is best understood by dividing the foot into three segments and two columns. Consensus was achieved concerning descriptors of foot segmental alignment for both static and dynamic assessment. There was consensus that radiographs of the foot should be weight-bearing. There was general agreement that foot deformity in children with cerebral palsy can be classified into three levels based on soft tissue imbalance and skeletal malalignment.

CONCLUSION

The practices identified in this study can be used to establish best care guidelines, and the format used will be a template for future Delphi technique studies on clinical decision-making for the management of specific foot segmental malalignment patterns commonly seen in children with cerebral palsy.

LEVEL OF EVIDENCE

V.

Foot Typology, Dynamic and Static Weight Distribution, and Radiographic Changes After Subtalar Arthroereisis in Juvenile Symptomatic Flexible Flat Feet

Flexible flatfoot is among the most common skeletal disorders in childhood. This study describes the dynamic and static correction effects of subtalar arthroereisis in adolescents with flexible symptomatic flatfeet in comparison to normal subjects as well as to results before and after removal of metal. Eighteen adolescents with 25 symptomatic flexible flatfeet were treated surgically with a subtalar arthroereisis at a mean of 12.5 (10-16) years. At follow-up (mean 3.9 years, range 0.4-8), patients filled out the American Orthopaedic Foot and Ankle Society questionnaire, received radiographs and were examined using dynamic and static pedobarography as well as static hindfoot axis examination. Results were compared to healthy controls (n = 13; 26 feet). Surgically treated feet (n = 25) had better questionnaire results after surgery than before, but lower scores than healthy feet. Radiological parameters improved significantly after surgery. Removal of metal did not influence post-surgical results (follow-up 2.8 years). Surgically treated feet had larger contact areas than normal feet with predominance to the midfoot region. The relative maximum force, relative peak pressure and contact time were higher in the midfoot of treated feet compared to controls. When comparing pedobarography data of treated versus untreated feet of the same patients (subgroup n = 11 feet), there were no differences. Subtalar arthroereisis was able to effectively treat symptomatic flexible flatfeet in this population. Results improved significantly evaluating a questionnaire, radiographs, dynamic and static weight distribution, but were still worse than results of healthy feet. There was no relapse after removal of metal.

Does the way of weight-bearing matter? Single-leg and both-leg standing radiographic and pedobarographic differences in pediatric flatfoot

BACKGROUND

An exact definition is lacking for the term "weight-bearing" or different standing modalities when implementing foot radiographs for children and adults; moreover, only few studies have investigated the relationship between radiographic and pedobarographic measurements.

RESEARCH QUESTION

We hypothesized that the method of weight-bearing in single-leg and both-leg standing positions could influence the measurement results in radiographs and the distribution of foot pressure.

METHODS

This prospective study evaluated 33 children (66 feet) with flexible flatfoot deformities scheduled for subtalar screw arthroereisis surgery. Radiographs in the lateral and anteroposterior (AP) views were assessed independently in the single-leg and both-leg standing positions. Static pedobarography was performed as that for measuring weight-bearing. Standardized radiographic angles and pedobarographic data were analysed and correlated.

RESULTS

There were differences in radiographic measurements between the single-leg and both-leg standing positions, including the AP talocalcaneal angle (p = 0.032), AP talus-first metatarsal base angle (p = 0.003), AP talus-first metatarsal angle (p = 0.003), lateral calcaneal pitch angle (p = 0.001), talus-first metatarsal index (p = 0.004), and talocalcaneal index (p = 0.029). Moreover, differences between these two standing modalities were found in most of the static pedobarographic data, including the contact area (p = 0001), maximal force (p = 0.001), and peak pressure (p = 0.007). Overall, medial foot pressure increased more in both-leg standing than in the single-leg standing position, whereas radiographic measurements showed a more pronounced flatfoot deformity in the single-leg standing position. The AP talus-first metatarsal angle was the only angle or index with a significant association to some pedobarographic measurements in both standing modalities.

SIGNIFICANCE

As there are significant differences between single-leg standing and both-leg standing radiographic and static pedobarographic values, observers have to be precise in the definition of "weight-bearing" to gain reproducible and comparable study values in children and adults. We recommend acquiring both-leg standing foot radiographs because children with flexible flatfeet can stand more steadily in this position than in the single-leg standing position.

Evaluation of the Foot Arch in Partial Weightbearing Conditions

BACKGROUND

Weightbearing plain radiography or computed tomography (CT) is used for diagnosis or treatment selection in foot disorders. This study compared foot alignment between full weightbearing (50% body weight [BW] per foot) plain radiography and nonweightbearing (0% BW) or partial weightbearing (10% BW per foot) CT scans.

METHODS

Subjects had both full (50% BW per foot) weightbearing plain radiographs and either a nonweightbearing (0% BW) or a partial weightbearing (20% BW or 10% BW per foot) CT scan. Feet (n = 89) had been previously classified as pes cavus (n = 14/17 [subjects/feet]), neutrally aligned (NA; 20/30), asymptomatic pes planus (APP; 18/24), and symptomatic pes planus (SPP; 15/18). Lateral talometatarsal angle (LTMA) and calcaneal pitch angle were compared between weightbearing radiography and maximum-intensity projection images generated from CT.

RESULTS

Significant differences in LTMA were found between nonweightbearing CT scans and full (50% BW per foot) weightbearing plain radiographs: the mean difference was 6.6 degrees in NA, 9.2 degrees in APP, and 11.3 degrees in SPP (P < .0001); no significant difference in LTMA was found for pes cavus. Although the interaction of foot type (P = .084) approached statistical significance, pairwise differences between 10% weightbearing and 50% weightbearing images by foot type were significant but small. The 50% weightbearing condition resulted in calcaneal pitch angles the same or slightly lower or higher than those of the 10% weightbearing and nonweightbearing images. LTMA and calcaneal pitch angle measurements made on full (50% BW per foot) weightbearing plain radiographs and non- (0%) or partial (10% BW per foot) weightbearing angles from CT scans were strongly correlated.

CONCLUSION

Different foot types have similar 2-dimensional sagittal plane morphologies with partial weightbearing (10% BW per foot) CT scans and, to a lesser degree, nonweightbearing (0%) neutral-position CT scans when compared to full weightbearing (50% BW per foot) plain radiographs.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

A Long-Term Study of Alignment Correction Following Proximal Femoral Varus Osteotomy and Pemberton Osteotomy in Children With Legg-Calvé-Perthes Disease and Developmental Dysplasia of the Hip

Proximal femoral varus osteotomy (PFVO) is a common procedure performed in children with developmental dysplasia of the hip (DDH) and Legg-Calvé-Perthes disease (LCPD). However, the long-term effect on angular deformities of the knees and ankles following PFVO remains controversial. This study investigated the relationship between PFVO and alignment changes in the knee and ankle after the procedure. Twenty-five patients undergoing PFVO procedure with a minimum 4-year evaluation period were enrolled in the study, including 14 unilateral LCPD and 11 unilateral DDH. The standing scanogram examinations were collected before the operation, immediately following surgery, after a 1-year follow-up, after a 3-year follow-up, and at the final visit to the clinic. The radiographic parameters included leg length, femoral neck-shaft angle (FNSA), femorotibial angle (FTA), mechanical axis deviation (MAD), tibiotalar angle (TTA), and mechanical lateral distal femoral angle (mLDFA). At the final examination, FNSA demonstrated insignificant change between the operative and non-operative limbs in the DDH group. Compared with the postoperative result, FNSA significantly improved in the LCPD group (p = 0.039). Both groups did not develop statistical significance in TTA, mLDFA, MAD, and leg length discrepancy after more than a 5-year follow-up. From a biomechanical perspective that the foot passes more medial to the knee under the center of leg mass, varus knee was prone to develop. In order to correct the mechanical axis, the knee reverted to a valgus position gradually. Our study indicates that patients with LCPD or DDH receiving PFVO and Pemberton osteotomy narrow the gap of angular growth in knees and ankles between the operative and non-operative limbs after a long-term follow-up.

Surgical Management of Foot and Ankle Deformities in Cerebral Palsy

Children with cerebral palsy (CP) are at a high risk of developing foot and ankle deformities that can impact function, brace/shoe fit, and seating. The 3 commonly observed foot and ankle segmental malalignment patterns include equinus, planovalgus, and equinovarus. Assessment of foot deformities is multifaceted, requiring the collection and integration of data from a combination of sources that include the clinical history, standardized physical examination, observational and quantitative gait analysis, GMFCS classification, and radiographic findings. Surgical procedures are determined by identifying all segmental malalignments and assessing the contribution of dynamic or flexible soft-tissue imbalance, fixed soft-tissue imbalance, and skeletal deformities.

Bony Procedures for Correction of the Flexible Pediatric Flatfoot Deformity

The pediatric flexible flatfoot is a common foot shape that is most often asymptomatic and may be a physiologic variant of normal. Surgery is only indicated when nonoperative interventions have failed to resolve symptoms. The goal of surgery is to alleviate symptoms by improving hindfoot alignment and restoring the medial arch while preserving joint mobility. This article focuses on the common bony techniques for surgical correction of the pediatric flexible flatfoot that has failed nonoperative management, including calcaneal, midfoot, and supramalleolar osteotomies and distal tibial hemiepiphyseodesis.

Relationship Between Plantar Callosity and Foot Deformity in Hallux Valgus Using Weightbearing Computed Tomography

Plantar callosities under lesser metatarsals are often accompanied by the hallux valgus, and the cause of callosity is thought to be associated with the foot deformity, such as the metatarsal length discrepancy, the abnormal metatarsal head height, cavus, flat foot, and rheumatoid conditions. However, it is unclear which variable is most involved in the cause of callosity in hallux valgus deformity. To clarify the factors associated with the callosity with hallux valgus deformity, we conducted multiple image assessments based on weightbearing radiography and computed tomography. A retrospective review was performed based on the collection of clinical records from all patients with hallux valgus treated from 2010 to 2019 in our institution. We measured the hallux valgus angle, intermetatarsal angles, calcaneal pitch angles, talo-first metatarsal angles, metatarsal length, metatarsal head height, first metatarsal pronation angles, and sesamoid position with weightbearing radiography and computed tomography. We analyzed the relation between callosity formation and imaging assessments using univariate and multivariate logistic regression models. Fifty feet were retrospectively evaluated, and multiple logistic analyses by the stepwise method revealed that the first metatarsal-lateral-sesamoid distance was the only radiographical variable associated with callosity formation among all the tested variables (p < .001). As the grade of the callosity became more severe, the lateral shift of the lateral sesamoid increased. The position of the sesamoid bone appears to have a critical role in the assessment and choice of treatment protocols and further research needs to be conducted on the relationship with the position of sesamoid bone to elucidate the mechanism of callus formation.

Multimodality imaging of the paediatric flatfoot

Flatfoot is commonly encountered in the paediatric population and describes a spectrum of clinical and radiological presentations which encompass both normally developing and pathological feet. Flatfoot can be categorised as flexible or rigid, a distinction which has important implications when considering the potential underlying aetiology and treatment options, and therefore imaging is an important component of the diagnostic workup. Weight-bearing plain radiographs are established initial investigations, although the significance of a number of the commonly derived quantitative parameters in children remains unclear. CT and MRI are important additional imaging modalities reserved for the investigation of symptomatic cases or those in which an underlying structural abnormality is suspected, rigid flatfoot commonly falling into one of these two categories. We review and illustrate the multimodality imaging of the paediatric flatfoot, with reference to both qualitative and quantitative radiographic assessment and cross-sectional imaging appearances.

Comparison of outcome between idiopathic and non-idiopathic congenital vertical talus treated with soft tissue release

The aim of the study was to compare the clinical, radiological and functional outcomes between idiopathic and non-idiopathic congenital vertical talus (CVT) treated with soft tissue release. All the consecutive cases with CVT treated with soft tissue release were prospectively followed up. Indication for soft tissue release was either late presented or failed serial manipulation and cast application. Nineteen children (33 feet) with a minimum follow-up of 2 years following the soft tissue release (the mean 5.5 years follow-up) were included. The children without any other joint involvement with the normal spine without syndromic association were categorized as idiopathic (15 feet) and the rest were categorized as non-idiopathic (18 feet). Clinical and radiological scoring was done using Adelaar and Kodros scores. The morphological, functional and radiological outcomes were assessed using the International Clubfoot Study Group evaluation scale. The clinical, radiological and functional outcomes of the idiopathic and non-idiopathic groups were compared. The range of motion was significantly higher in the idiopathic group. The functional outcome was satisfactory in both groups. All the radiological parameters improved significantly in both groups. The functional outcome was considerably better in the idiopathic group. There was no significant difference in clinical and radiological outcomes among the two groups. Soft tissue release is an effective surgery for deformity correction in children with CVT. A good clinical outcome is observed in both groups. The range of motion was significantly higher in the idiopathic group. The overall outcome was similar in both groups.

Analysis of factors influencing improvement of idiopathic flatfoot

Idiopathic flatfoot is common in infants and children, and patients with this condition are frequently referred to pediatric orthopedic clinics. Flatfoot is a physiologic process, and that the arch of the foot elevates spontaneously in most children during the first decade of life. To achieve a consensus as the rate of spontaneous improvement of flatfoot, the present study aimed to estimate the rate of spontaneous improvement of flatfoot and to analyze correlating factors.We reviewed the records of patients examined between May 2013 and May 2019 so as to identify those factors associated with idiopathic flatfoot below 12 years of age. We included patients with who had been followed for >6 months, and those for whom ≥2 (anteroposterior and lateral) weight-bearing bilateral radiographs of the foot had been obtained. The progression rates of the anteroposterior (AP) talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle, and calcaneal pitch angle were adjusted by multiple factors using a linear mixed model, with sex, body mass index, and Achilles tendon contracture as the fixed effects and age and each subject as the random effects.We found that 4 of the radiographic measurements improved as patients grew older. The AP talo-first metatarsal angle, talonavicular coverage angle, and the lateral talo-first metatarsal angle decreased, while the calcaneal pitch angle increased. The AP talo-first metatarsal angle (P < .001), talonavicular coverage angle (P < .001), and lateral talo-first metatarsal angle (P < .001) improved significantly; however, the calcaneal pitch angle (P = .367) did not show any significant difference. In general, the flatfeet showed an improving trend; after analyzing the factors, no sex difference was observed (P = .117), while body mass index (P < .001) and Achilles tendon contracture (P < .001) showed a negative correlation.The study demonstrated that children's flatfeet spontaneously improved at the age of 12 years. It would be more beneficial if the clinician shows the predicted appearance of the foot at the completion of growth by calculating the radiographic indices and identifying the correlating factors in addition to explaining that flatfoot may gradually improve. This will prevent unnecessary medical expenses and the psychological adverse effects to the children caused by unnecessary treatment.

Relationship between Hallux Valgus and Pes Planus in Adult Patients

This study aimed to determine whether the degree of pes planus was associated with hallux valgus severity and hallux valgus surgery outcomes. A total of 122 feet were retrospectively analyzed after hallux valgus surgery. The hallux valgus angle, inter-metatarsal angle, lateral talo-first metatarsal angle, calcaneal pitch, and talonavicular coverage angle were measured. The Foot and Ankle Outcome Score and Foot Function Index were evaluated. A significant correlation between radiographic parameters of pes planus and hallux valgus severity, radiographic outcomes, Foot and Ankle Outcome Score, and Foot Function Index were not noted. The hallux valgus angle and inter-metatarsal angle changed significantly after the surgery (p < .001 and p < .001, respectively); however, a significant difference was not noted between the pes planus and non-pes planus groups (p = .279 and p = .632, respectively). A significant interaction between the time points and groups was not observed with respect to the hallux valgus angle (p = .311) and inter-metatarsal angle (p = .417). Multivariable logistic regression revealed that none of the radiographic parameters for pes planus affected hallux valgus recurrence. Pes planus in adult patients is not significantly associated with hallux valgus severity and recurrence, radiographic outcomes, or clinical scores.

[The talometatarsal-index ("TMT-Index") : A valuable X-ray parameter for differentiating between normal feet and planovalgus deformity in children and adolescents]

INTRODUCTION

The development of the shape of the shape from childhood to adulthood is a complex continuum. Deviations from this process occur frequently and, especially in asymptomatic patients, do not always include the need for therapeutic intervention. In the current S2-guideline on the juvenile flexible flatfoot, established x‑ray parameters for assessing the flatfoot deformity were judged to be sensitive, whereby no statement was made regarding the value of the parameters among themselves. The aim of the present work is to assess the talometatarsal Index (TMTInd) in comparison to established angle measurements.

METHODS

Twenty-two feet with and 22 feet without planovalgus deformity (age: 10-14 years) were investigated. Established radiological parameters (lateral view: talocalcaneal angle (TC-lat), calcaneal pitch angle (Calc-B), Costa-Bartani angle (Costa-B), talometatarsal‑I angle (TMTI-lat); dorsoplantar view: talometatarsal-I-basis angle (TMTIB), talonavicular coverage (TNG), calcaneal metatarsal- V angle (Calc-MTV), talocalcaneal angle (TC-dp), and talometatarsal‑I angle (TMTI-dp)) were measured on standardized X‑ray images and compared with the values of the TMTInd.

RESULTS

All parameters other than Calc-MTV, TC-dp, TC-lat and Calc‑B, showed a statistically significant difference between normal and planovalgus feet, although for almost all values measured (apart from TMTI-lat and TMTInd) there was a large overlap area (>10°) between the two groups. The comparison of TMTInd to all other parameters showed the highest discrimination factor (area-under-the-curve) for the TMTInd in the distinction between the groups.

CONCLUSION

Compared to conventional radiological parameters, the TMTInd shows the highest validity in the distinction between normal and planovalgus feet and can provide valuable information in clinical decision-making with regard to therapy specification.

Split anterior tibialis tendon transfer to peroneus brevis for spastic equinovarus in children with hemiplegia

PURPOSE

The aim of this study is to report the safety and eff-cacy of soft-tissue surgery incorporating split transfer of tibi-alis anterior to peroneus brevis (SPLATT-PB) for children with hemiplegic spastic equinovarus.

METHODS

This was a retrospective case series of children and adolescents with spastic hemiplegia who had a novel combination of SPLATT-TB, intramuscular tenotomy of tibialis posterior and either spasticity management or gastrocsole-us lengthening as the index surgery. The principal outcome measures were changes in pain and difficulty with shoe wear and radiological parameters obtained from weight-bearing anteroposterior and lateral radiographs of the affected foot before and after surgery.

RESULTS

A total of 63 patients with symptomatic spastic equinovarus met the inclusion criteria. Mean age at surgery was 9.8 years (6 to 18) and the mean follow-up was seven years (range 3 to 10 years). Foot pain and problems with shoe wear improved after surgery. Seven radiological criteria showed a clinically and statistically significant improvement at follow-up, the majority being in the normal range. There were 11 surgical adverse events, all classified as Modified Cla-vien-Dindo Grade II. Three patients required further surgery for recurrent equinus, eight patients required further surgery for valgus deformities and four patients required bony surgery for residual varus deformities.

CONCLUSION

Soft-tissue surgery for spastic equinovarus was successful in the majority of children with spastic hemiplegia, particularly between ages eight and 12 years, resulting in a plantigrade, flexible foot with minimal pain or limitations in shoe-wear. Children younger than 8 years at index surgery were more prone to overcorrection into valgus. Children older than 12 years had persistent varus deformities requiring bony surgery.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Inter-observer and intra-observer reliability in the radiographic measurements of paediatric forefoot alignment

BACKGROUND

Foot bones in children have more rounded shapes in radiograms than adults. Thus, the goal of this work was assessing inter- and intra-observer reliability in paediatric forefoot angle measurements.

MATERIAL AND METHODS

Six forefoot angles in 34 AP standing paediatric foot radiographs were measured by 5 researchers. A classic statistical analysis with use of IBM SPSS Statistics 25 was performed and a new method with two-way analysis of variance was applied.

RESULTS

Results of statistical analysis revealed the properties of a subjective assessment related to specific angles. Kilmartin's angle, calcaneus-fifth metatarsal angle and first ray angle are the most reliable; metatarsus adductus angle should be used with great caution in pediatric population. Engel's angle is the most difficult for measuring and measurement error is the highest.

CONCLUSION

The power of paediatric forefoot measurements is various. Several angles are reliable, while Engle's angle is the most doubtful.

Relationship Between the of Type of Accessory Navicular Bone and Radiological Parameters of the Foot

BACKGROUND

In this study, we evaluated to the relationship between the type of accessory navicular bone (ANB) and radiological parameters of foot in patients with bilateral ANB of different types.

METHODS

Patients with bilateral ANB of different types participated in this study, from May 2019 to April 2020. Patient data, including age, sex, body mass index (BMI), and presence of symptoms were obtained. We aimed to compare the radiological parameters of both the feet for evaluate the differences from one another in patients with bilateral ANB of different types (one side type 1 and contralateral side type 2) because the foot angles may differ in each person. Seven radiographic parameters were measured, including calcaneal pitch angle, talocalcaneal angle, tibiocalcaneal angle, naviculocuboid overlap, talonavicular coverage angle, anteroposterior talo-first metatarsal angle, and the lateral talo-first metatarsal angle, which evaluated hindfoot, midfoot, and forefoot alignment.

RESULTS

Twenty patients (13 women and 7 men) with a mean age (and standard deviation) of 38.5 {plus minus} 12.3 years were included in the study. The patients had a mean height of 168.1 {plus minus} 7.1 cm, a mean weight of 77.2 {plus minus} 10.5 kg, and a mean BMI of 27.4 {plus minus} 4.3 kg/m2. There was no significant difference between type 1 and type 2 in all radiological parameters. There was no significant correlation between radiological parameters and age, BMI, or the presence of symptoms.

CONCLUSIONS

We found that the type of ANB had no effect on the radiological measurements of the foot in which we evaluate the parameters patients with bilateral ANB of different types. Additionally, age, BMI, and the presence of symptoms, also demonstrated no correlation with the radiological parameters of the foot.

Radiographic and plantar pressure assessment of pes planovalgus severity in children with cerebral palsy

BACKGROUND

Pes planovalgus is common in children with cerebral palsy. Although severity influences treatment, there still lacks standard clinical measurements to objectively quantify pes planovalgus in this population. The comparison of pedobarographic data and radiographic measurements to clinical evaluation has not been reported in this population.

METHODS

395  feet were identified from a population of ambulatory pediatric patients with cerebral palsy. Each patient initially underwent clinical evaluation by an experienced physical therapist who classified feet as: 136 controls, 116 mild, 100 moderate, and 43 severe pes planovalgus. Quantitative measurements were then calculated from antero-posterior and lateral radiographs of the foot. Pedobarographic analysis included the arch index, center of pressure index, and a newly defined medial index.

FINDINGS

A multivariate analysis was performed on the radiographic and pedobarographic measurements collected. It identified seven variables that improved objective classification of pes planovalgus severity when utilized together. These include the foot progression angle, initial contact force, arch index, medial index, antero-posterior talonavicular coverage, lateral calcaneal pitch and lateral Meary's angle. While the lateral calcaneal pitch angle statistically differed amongst all severity classes, no pedobarographic value statistically differed between all severity classes.

INTERPRETATION

Overall, the combination of radiographic and pedobarographic measurements provides valuable information for objectively classifying severity of pes planovalgus in children with cerebral palsy by utilizing these values together rather than independently. In a clinical setting, radiographs and pedobarographic data may be obtained to enhance assessment of severity and guide treatment.

Calcaneocuboid distraction arthrodesis for children with symptomatic pes planovalgus: does fixation improve outcomes?

Lateral column lengthening is a common surgical procedure for addressing symptomatic pes planovalgus foot deformity. For more severe cases, the use of a calcaneocuboid distraction arthrodesis (CCDA) can allow for more powerful correction. Previous reports have cited an increased risk of graft collapse with loss of correction when this procedure is performed without supplemental hardware fixation. The purpose of this study was to assess the outcomes of CCDA in children with and without supplemental locking fixation. A retrospective review from 2008 to 2016 of CCDA procedures with and without supplemental fixation was performed. The primary endpoint was graft collapse. Secondary objectives included evaluation of radiographic loss of correction, hardware failure, pain at 1-year follow-up, reoperations, and changes in the foot loading pattern foot per pedobarography. Twenty-nine feet in 24 patients were eligible for review. Supplemental locked fixation was used in 18 feet [hardware (HW)], with the remaining 11 feet managed without fixation [no hardware (NoHW)]. The overall failure rate on the basis of graft collapse and loss of correction was 55% (56% for the HW group, 55% for the NoHW group). Eleven patients (61%) in the HW group experienced hardware failure, with six (33%) of these requiring hardware removal. Fifty-six percent of the HW group and 45% of the NoHW group reported continued pain at 1-year follow-up. One patient from each group underwent revision arthrodesis. Supplemental locked fixation did not provide additional benefit in preventing graft collapse and loss of correction in this cohort. Alternative strategies should be considered to improve the outcomes for this procedure.

Functional and radiographic comparison of subtalar arthroereisis and lateral calcaneal lengthening in the surgical treatment of flexible flatfoot in children

PURPOSE

One of the most widespread diseases of children's orthopaedic problems is flatfoot. If conservative therapy failed, surgical treatment would be indicated. Lateral calcaneal lengthening (LCL) and subtalar arthroereisis (SA) are two types of operations used to correct symptomatic flexible flatfoot (FFF). The purpose of this study is to compare the functional and radiographic features of these two surgical procedures.

PATIENTS AND METHODS

In this prospective randomized clinical trial study, we recruited 66 patients between 2018 and 2019. For clinical assessment, American Orthopedics Foot and Ankle Society (AOFAS), visual analog scale (VAS), subtalar motion, presence of medial longitudinal arch, and family satisfaction were measured. Evaluation of radiographic angles was based on AP (AP Tal-1Met) and Lat (Lat Tal-1Met) view of Talus-1st metatarsal angle (Meary's angle) and calcaneal pitch.

RESULT

There was no significant difference between the two types of surgery regarding Lat Tal-1Met and AP Tal-1Met. The significantly larger angle in the LCL group was calcaneal pitch (P value < 0.001). AOFAS significantly increased from 68.71 ± 5.70 to 87.87 ± 7.14 (P value < 0.001) and from 67.28 ± 6.01 to 86.14 ± 7.56 (P value < 0.001) in LCL and SA respectively. Family satisfaction was significantly higher in the SA (8.14 ± 0.97) comparing to LCL (7.29 ± 0.86) at the latest follow-up (P value < 0.001).

CONCLUSION

While both groups have substantial improvement in clinical and radiographic aspects, the SA technique is less-invasive, rapid symptom relief, and has early weight-bearing capacity.

TRIAL REGISTRATION

IRCT20180823040853N1.

Effect of Unilateral Accessory Navicular Bone on Radiologic Parameters of Foot

BACKGROUND

This study aimed to compare the radiologic parameters of both feet in patients with unilateral accessory navicular bone (ANB) and evaluate the differences from one another.

METHODS

Forty-one patients with unilateral ANB volunteered to participate in this study from August 2019 to January 2020. Patient data, including age, sex, body mass index (BMI), type of ANB, and presence of symptoms were obtained. Group 1 comprised 23 patients with asymptomatic unilateral ANB, and group 2 comprised 18 patients with symptomatic unilateral ANB. Seven radiologic parameters were evaluated assessing hindfoot, midfoot, and forefoot alignment-calcaneal pitch angle, talocalcaneal angle, tibiocalcaneal angle, naviculocuboid overlap (NCO), talonavicular coverage angle (TNCA), anteroposterior talo-first metatarsal angle, and lateral talo-first metatarsal angle.

RESULTS

The mean age of patients was 40.1 years in group 1 and 42.6 years in group 2. Mean BMI was 25.2 in group 1 and 26.6 in group 2. No significant differences were noted in the radiologic parameters between the ANB and contralateral sides in all patients. The radiologic parameters of both feet in symptomatic and asymptomatic patients were not significantly different. No significant differences were noted between the affected sides of type 1 and 2 ANB and contralateral sides in terms of the radiologic parameters. BMI was significantly correlated with NCO and TNCA.

CONCLUSION

This study demonstrated that the presence of an accessory navicular bone did not affect radiologic parameters of the foot. Radiologic parameters of both feet in symptomatic patients were not significantly different.

LEVEL OF EVIDENCE

Level III, diagnostic, comparative study.

Radiographic differences in the concomitant deformities in two types of medial ankle osteoarthritis

Objectives

Motion preserving surgeries could be unsuccessful because of underestimation of deformities of the foot and knee in ankle osteoarthritis. This study aimed to investigate the concomitant deformities in medial ankle osteoarthritis and the difference between the two types, varus angulation and medial translation.

Methods

A retrospective study was conducted using medical records and radiographic data. Patients with medial ankle osteoarthritis that underwent weight-bearing X ray imaging and radiographic measurements including tibial plafond inclination (TPI), tibiotalar tilt angle (TT), lateral talo-first metatarsal angle, naviculo-cuboid overlap, and mechanical tibiofemoral angle (mTFA) were studied. The patients were categorized into two groups, the varus angulation group (TT ≥4°) and medial translation group (TT <4°). The radiographic measurements were compared between the two groups.

Results

A total of 102 patients (male = 44; female = 58) were included; the mean age was 64.9 years (SD 8.3 years). The varus rotation group (N = 66) showed a significantly smaller lateral talo-first metatarsal angle (p<0.001), naviculo-cuboid overlap (p<0.001), and mTFA (p = 0.019) compared to the medial displacement group (N = 36). The TT showed a significant correlation with lateral talo-first metatarsal angle (r = -0.520, p<0.001), naviculo-cuboid overlap (r = -0.501, p<0.001), and mTFA (r = -0.243, p = 0.014). Lateral talo-first metatarsal angle was found to be the significant factor (p = 0.018) discriminating varus angulation and medial translation types in the binary logistic analysis.

Conclusions

Varus angulation of the ankle was correlated with knee alignment and foot deformity. Radiographic indices were different between the varus angulation and medial translation groups. The role of concomitant deformities needs to be further investigated in terms of a causal relationship. Surgeons need to pay attention to concomitant deformities in the treatment of medial ankle osteoarthritis.

Changes in the bony alignment of the foot after tendo-Achilles lengthening in patients with planovalgus deformity

Background

This study was performed to investigate the change in the bony alignment of the foot after tendo-Achilles lengthening (TAL) and the factors that affect these changes in patients with planovalgus foot deformity.

Methods

Consecutive 97 patients (150 feet; mean age 10 years; range 5.1–35.7) with Achilles tendon contracture (ATC) and planovalgus foot deformity who underwent TAL were included. All patients underwent preoperative and postoperative weight-bearing anteroposterior (AP) or lateral (LAT) foot radiographics. Changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, LAT talo-1st metatarsal angle, and calcaneal pitch angle and the factors affecting such changes after TAL were analyzed using lineal mixed model.

Results

There were no significant change in AP talo-1st metatarsal angle and AP talo-2nd metatarsal angle after TAL in patients with cerebral palsy (CP) (p = 0.236 and 0.212). However, LAT talo-1st metatarsal angle and calcaneal pitch angle were significantly improved after TAL (13.0°, p < 0.001 and 4.5°, p < 0.001). Age was significantly associated with the change in LAT talo-1st metatarsal angle after TAL (p = 0.028). The changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, and calcaneal pitch angle after TAL were not significantly associated with the diagnosis (p = 0.879, 0.903, and 0.056). However, patients with CP showed more improvement in LAT talo-1st metatarsal angle (− 5.0°, p = 0.034) than those with idiopathic cause.

Conclusion

This study showed that TAL can improve the bony alignment of the foot in patients with planovalgus and ATC. We recommend that physicians should consider this study’s findings when planning operative treatment for such patients.

Surgical Outcomes for Severe Idiopathic Toe Walkers

BACKGROUND

Idiopathic toe walking (ITW) is a diagnosis of exclusion and represents a spectrum of severity. Treatment for ITW includes observation and a variety of conservative treatment methods, with surgical intervention often reserved for severe cases. Previous studies reviewing treatment outcomes are often difficult to interpret secondary to a mixture of case severity. The goal of this study was to review surgical outcomes in patients with severe ITW who had failed prior conservative treatment, as well as determine differences in outcomes based on the type of surgery performed.

METHODS

After IRB approval, all patients with surgical management of severe ITW at a single institution were identified. Zone II or zone III plantar flexor lengthenings were performed in all subjects. Clinical, radiographic, and motion analysis data were collected preoperatively and at 1 year following surgery.

RESULTS

Twenty-six patients (46 extremities) with a diagnosis of severe ITW from 2002 to 2017 were included. Zone II lengthenings were performed in 25 extremities (mean age=9.9 y) and zone III lengthenings were performed in 21 extremities (mean age=8.6 y). At the most recent follow-up, 100% of zone III lengthening extremities and 88% of zone II lengthening demonstrated decreased severity of ITW. Six extremities required additional treatment, all of which were initially managed with zone II lengthenings.

CONCLUSIONS

Severe ITW or ITW that has not responded to conservative treatment may benefit from surgical intervention. More successful outcomes, including continued resolution of toe walking, were observed in subjects treated with zone III lengthenings.

LEVEL OF EVIDENCE

Level III-case series.

Outcomes of Naviculectomy for Severe Recurrent Clubfoot Deformity

Background:

Naviculectomy was originally described for resistant congenital vertical talus deformity but was later expanded to use in rigid cavus deformity. This study reviews the operative outcomes of complete excision of the navicular for recurrent deformity in the talipes equinovarus (TEV) population.

Methods:

After institutional review board approval, all patients undergoing naviculectomy at a single institution were identified. Clinical, radiographic, and pedobarographic data (minimum 2 years’ follow-up) were reviewed.

Results:

Twelve patients (14 feet) with TEV from 1984 to 2019 were included. All feet had minimum 1 prior operative intervention on the affected foot (mean age = 4.0 years, range 0.2-14.5), with 8/14 having at least 3 prior operative procedures. Complete navicular excision with concomitant procedures was performed in all patients (mean age = 11.7 years, range 5.5-16.1). Mean clinical follow-up from naviculectomy was 5.1 years (range, 2.2-11.2). During follow-up, 6 patients required subsequent surgery, most often secondary to pain and progressive deformity. One patient underwent elective below-knee amputation of the affected extremity. Of the remaining 11 patients, 7 of 11 reported continued pain and 8 of 11 maintained adequate range of motion at the ankle at the most recent follow-up.

Conclusion:

Clinical follow-up demonstrated deteriorating results in a large percentage of patients. The high rate of additional procedures and continued pain in the current series suggests that even as a salvage procedure, naviculectomy may not provide adequate results for patients.

Level of Evidence:

Level IV, case series.

Is it possible to define reference values for radiographic parameters evaluating juvenile flatfoot deformity? A case-control study

Background

Numerous radiographic parameters are described to evaluate juvenile flexible flatfeet. Reference values for these measurements are based on few studies. The purpose of this study was to determine boundary values among the most widely used radiographic measurements to evaluate juvenile flatfeet.

Methods

Twenty-two patients with normal hind-, midfoot configuration (group A: control group; 22 ft, mean age: 12,1 years) and 19 patients with flatfoot deformity (group B: study group; 22 ft, mean age: 12,4 years) were retrospectively analyzed. Nine radiographic parameters were measured (Talocalcaneal-angles, Calcaneal-pitch-angle, Costa-Bartani-angle, Talo-metatarsal-I-angles, Talo-first-metatarsal-base-angle, Talo-navicular-coverage, Calcaneus-fifth-metatarsal-angle). ROC curve analysis was used to calculate optimal differentiating thresholds of each parameter.

Results

Four out of nine parameters (TC-dp, TC-lat, Calc-MTV, Calc-P) were not statistically different between the groups and their ability to distinct between normal foot and flatfoot was low (AUC values = 0,660 - 0,819). Calculation of reference values for these parameters was not performed due to threshold ranges between the groups of > 10°. Reference values could be defined only for three parameters: TMTInd >(−)31°, TMTIB >(−)7,5°, TMT-lat > (−)13,5°. The TMTInd was shown to be a very reliable and valid combination of two measurements (TMTIB and TMT-lat) in the differentiation of normal feet and flatfeet (AUC = 0,998).

Conclusion

The calculation of reference values for established radiographic parameters used to evaluate juvenile flatfeet is difficult for most parameters. The TMTInd as a combination of TMTIB and TMT-lat has been shown to be reliable and valuable to distinct normal feet from flatfeet.

Subtalar arthroereisis for treatment of children with flexible planovalgus foot deformity and analysis of CT data in long-term period

The aim of the study is to analyze the long-term results of the subtalar arthroereisis of the feet according to Grice in children with flexible symptomatic planovalgus foot deformity.

Methods

29 children (58 feet) were treated with symptomatic flexible planovalgus foot deformity.

Results

The average value of AOFAS increased from 63 (51-84) to 92 (53-96) points. According to CT size of the bone graft corresponded to 83% of the size of the subtalar sinus.

Conclusion

In compliance with all the technical features of this operation, it is effective for correction of flexible planovalgus foot deformity with pronounced verticalization of talus.

Level of evidence

IV.

Is there a correlation between static radiographs and dynamic foot function in pediatric foot deformities?

BACKGROUND

Idiopathic flexible flatfeet, congenital clubfeet and pes cavovarus are the most common foot deformities in children. Accurate assessment to quantify the severity of these deformities by clinical examination alone can be challenging. Radiographs are a valuable adjunct for accurate diagnosis and effective treatment. However, static radiographs during relaxed standing may not reflect the dynamic changes in the foot skeleton during functional activities such as walking. Therefore, the aim of this study is to predict dynamic foot movements during walking from planar standing radiographs to reveal the significance of the radiographic analysis for the assessment of foot function.

METHODS

Patients 8-17 years with flexible flatfeet (FFF, n=217) recurrent clubfeet (RCF n=38) and overcorrected clubfeet (OCCF, n=71) of non-neurogenic or syndromic origin and pes cavovarus due to peripheral neuropathy (PNP, n=48) were retrospectively included. Patients underwent gait analysis with the Oxford Foot Model and radiographic examination in anterior-posterior and lateral view during standing. Multilinear predictor analysis of selected gait parameters was performed based on radiographic measures.

RESULTS

The variance that was explained by radiography was greatest for the transverse plane forefoot abduction with 33% for OCCF, 50% for RCF and 59% for PNP. Flatfeet and foot kinematics in the other planes or between rearfoot and tibia showed little or no relation.

CONCLUSIONS

The static measures of foot deformities by radiography could explain only a small amount of variance in foot kinematics during walking, in particular for FFF. An explanation may be that the forces during weight bearing bear little resemblance to those during gait in terms of neither magnitude nor direction. These findings suggest that foot function cannot be accurately assessed solely from static radiographic observations of the foot, commonly undertaken in clinical practice.

Medium-term results of calcaneus lengthening in idiopathic symptomatic flat foot in children and adolescents

PURPOSE

Calcaneus lengthening can be used in symptomatic flat foot in children, but few details on its medium-term results and complementary procedures are available.

METHODS

A total of 20 flexible, symptomatic, idiopathic valgus flat feet (in 15 children; mean age 13.9 years (10 to 17)) were operated on. Complementary procedures were based on preoperative and intraoperative analyses. Radiographic measurements were obtained preoperatively and with at least four years follow-up.

RESULTS

At a mean of 8.3 years (4 to 15) postoperatively, 13 feet had good clinical and radiological results, with significant improvement in American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scale scores and radiological measurements. Seven feet had residual pain. Six of them had no osteotomy of the first cuneiform.

CONCLUSION

Calcaneus lengthening with adequate complementary musculo-tendinous and/or bone procedures according to preoperative and intraoperative foot deformation leads to good medium-term results. Forefoot supination is the most frequent residual defect. If present intraoperatively, first cuneiform pronation-flexion osteotomy is indicated.

LEVEL OF EVIDENCE

IV.

In-toeing gait in children with clubfoot and the effect of tibial rotation osteotomy

In-toeing gait is common after treatment for clubfoot deformity and is often secondary to residual internal tibial torsion. The purpose of the current study was to characterize the gait pattern in children with an intoeing gait pattern associated with talipes equinovarus (TEV) deformity, identify secondary changes at the hip that occur with intoeing, and determine if these secondary effects resolve after correction of tibial torsion. Patients with a diagnosis of TEV deformity, in-toeing gait secondary to residual internal tibial torsion corrected with tibial rotation osteotomy (TRO) and complete preoperative and postoperative motion analysis studies obtained approximately 1 year apart, were included in the study. Nineteen children (19 left extremities) with a TRO at a mean age of 8.2 years met inclusion criteria. Clinical examination showed improvement in tibial torsion assessment by measure of the thigh foot axis and transmalleolar axis. Kinematically, an abnormal internal FPA was present in all cases preoperatively, was corrected to normal in 12 (63%), remained internal in 5 (26%), and was abnormally external in 2 (11%). External hip rotation was identified in 13 (68%) cases preoperatively. Hip rotation was normalized postoperatively in 7 (54%), and was unchanged in the remaining 6 (46%). TRO provides effective correction of excessive internal tibial torsion, resolution of kinematic internal knee rotation, and normalization of the internal foot progression angle in the majority of patients with TEV deformity. External hip rotation resolved in approximately 50% of cases. Overcorrection of the internal FPA is possible when secondary changes at the hip do not resolve.

Treatment Outcomes at Skeletal Maturity after Calcaneo-Cuboid-Cuneiform Osteotomy for Symptomatic Flatfoot Deformity in Children

Background

The purpose of this study was to evaluate clinical and radiological outcomes at skeletal maturity after a calcaneo-cuboid-cuneiform osteotomy (triple C osteotomy) for symptomatic flatfoot deformity compared with healthy young adult controls.

Methods

Nineteen patients (30 feet) who undergone a triple C osteotomy for idiopathic symptomatic flatfeet from July 2006 to April 2013 were compared with 19 controls (38 feet). Radiographic measurements at preoperative examination, 1-year postoperative follow-up, and follow-up at skeletal maturity were evaluated. Functional outcomes were assessed by using the validated visual analog scale foot and ankle (VAS-FA) and the modified American Orthopaedic Foot and Ankle Surgery (AOFAS) score.

Results

In the triple C osteotomy group, 11 of 12 radiographic measurements were significantly improved at 1 year postoperatively and the last follow-up (p < 0.001). There was no recurrence at skeletal maturity (p > 0.05). There were no significant differences in nine of 12 radiographic measurements between the triple C osteotomy group at maturity and the control group (p > 0.05). Average VAS-FA and AOFAS scores were significantly improved at the time of skeletal maturity (p < 0.001).

Conclusions

Surgical correction of symptomatic flatfoot deformity in childhood resulted in favorable outcomes after the triple C osteotomy. Deformity correction was also maintained during follow-up at skeletal maturity.