A modified lateral column lengthening for the treatment of flexible flatfoot: From clinical applications to finite element analysis

BACKGROUND

Finite element (FE) analysis and clinical follow-up were used to evaluate the efficacy of a modified lateral column lengthening (H-LCL) for treating flexible flatfoot.

METHODS

By applying inclusion and exclusion criteria, we selected patients who underwent H-LCL surgery at our institution from January 2019 to January 2023. We compared the Visual Analog Scale (VAS) scores, American Orthopaedic Foot and Ankle Society (AOFAS) scores, Pain Interference (PI), and Physical Function (PF) scores in Patient-Reported Outcomes Measurement Information System (PROMIS) between preoperative and final follow-up assessments of patients, as well as FE submodels. Furthermore, evaluate the H-LCL's biomechanical characteristics and clinical outcome before and after surgery.

RESULTS

A total of 66 patients met the criteria. The average surgery time was 69.47 ± 13.22 min, and the follow-up duration was 15.18 ± 6.40 months. In the last follow-up, VAS and PI decreased compared to before surgery, while AOFAS and PF increased compared to before surgery. Meary's angle (dorsoplantar image and lateral image), calcaneal valgus angle, and talonavicular coverage angle decreased compared to before surgery, while the pitch angle increased compared to before surgery. In FE analysis, postoperative tension on the plantar fascia (PF), spring ligament (SL), and posterior tibial tendon (PTT) decreased compared to before surgery, pressure on the talonavicular joint and subtalar joints also decreased compared to before surgery, and there was no significant change in pressure on the calcaneocuboid joint.

CONCLUSION

H-LCL in correcting flexible flatfoot resulted in a significant improvement of clinical outcome scores and led to good radiological correction of flatfoot deformities. It can reduce the soft tissue and interosseous pressure in maintaining the foot arch.

Investigation of inter-rater and test-retest reliability of Y balance test in college students with flexible flatfoot

BACKGROUND

The Lower Quarter Y Balance Test (YBT-LQ) has been widely used to assess dynamic balance in various populations. Dynamic balance in flexible flatfoot populations is one of the risk factors for lower extremity injuries, especially in college populations in which more exercise is advocated. However, no study has demonstrated the reliability of the YBT-LQ in a college student flexible flatfoot population.

METHODS

A cross-sectional observational study. 30 college students with flexible flatfoot were recruited from Beijing Sports University. They have been thrice assessed for the maximal reach distance of YBT under the support of the lower limb on the flatfoot side. Test and retest were performed with an interval of 14 days. The outcome measures using the composite score and normalized maximal reach distances in three directions (anterior, posteromedial, and posterolateral). The relative reliability was reported as the Intraclass Correlation Coefficient (ICC). Minimal Detectable Change (MDC), Smallest worthwhile change (SWC), and Standard Error of Measurement (SEM) were used to report the absolute reliability.

RESULTS

For inter-rater reliability, the ICC values for all directions ranged from 0.84 to 0.92, SEM values ranged from 2.01 to 3.10%, SWC values ranged from 3.67 to 5.12%, and MDC95% values ranged from 5.58 to 8.60%. For test-retest reliability, the ICC values for all directions ranged from 0.81 to 0.92, SEM values ranged from 1.80 to 2.97%, SWC values ranged from 3.75 to 5.61%, and MDC95% values ranged from 4.98 to 8.24%.

CONCLUSIONS

The YBT-LQ has "good" to "excellent" inter-rater and test-retest reliability. It appears to be a reliable assessment to use with college students with flexible flatfoot.

TRIAL REGISTRATION

This trial was prospectively registered at the Chinese Clinical Trial Registry with the ID number ChiCTR2300075906 on 19/09/2023.

Acute effects of athletic taping on arch deformity and plantar pressure in young female adults with flexible flatfoot

OBJECTIVE

This work aimed to explore the acute effects of athletic taping techniques on foot arch deformity and plantar pressure in young female adults with flexible flatfoot (FFT).

METHODS

Twenty young female adults with FFT were recruited in the current study. Each participant was randomly divided into two taping groups, namely, augmented low-dye (ALD) and modified low-dye (MLD). The foot arch deformity and plantar pressure were measured at baseline, after taping and after 20 min of walking. The foot arch deformity was determined based on navicular drop distance (NDD) and resting calcaneal stance position (RCSP).

RESULTS

Compared with baseline, the NDD values were significantly lower after taping. After 20 min of walking, ALD taping resulted in a lower NDD value than MLD (p < 0.001). ALD maintained a higher RCSP than baseline after 20 min of walking (p = 0.004). Furthermore, compared with baseline, medial midfoot force-time integration (p = 0.013) and contact area (p = 0.022) increased after taping with MLD, and peak pressure in the medial midfoot increased after walking for 20 min with MLD (p = 0.026). Peak pressure in the second to fifth toes significantly decreased after 20 min of walking with ALD compared with that after taping immediately (p = 0.002).

CONCLUSIONS

ALD and MLD taping could improve FFT arch deformity and plantar pressure distribution, prospectively changing peak pressure of the second to fifth toe area and medial midfoot after 20 min of walking, integrated contact area and force-time integration medial midfoot during walking in young female adults. Furthermore, ALD taping could improve FFT deformity more than using MLD after 20 min of walking. Thus, when treating FFT in young female adults, ALD taping should be considered adaptively to guide arch support production and correct midfoot pronation.

Accessory navicular in children

Accessory navicular (AN) is a developmental variation of the secondary ossification center of the navicular tuberosity. Ten percent of patients with AN will have pain symptoms that affect walking and life. As the AN changes the position of the posterior tibial tendon insertion, children with AN often have posterior tibial tendon function insufficiency and flexible flat foot. Surgical treatment is often required after failure of conservative treatment. This article reviewed the etiology, clinical manifestations, complications, and treatment methods of AN.

[Comparison of the effectiveness of two kinds of surgeries for treatment of flexible flatfoot combined with painful accessory navicular bone in children]

Objective

To compare the effectiveness of subtalar arthroereisis (STA) combined with modified Kidner procedure versus STA alone in the treatment of flexible flatfoot combined with painful accessory navicular bone in children.

Methods

The clinical data of 33 children with flexible flatfoot combined with painful accessory navicular bone who were admitted between August 2018 and August 2021 and met the selection criteria were retrospectively analyzed. They were divided into a combination group (17 cases, treated by STA combined with modified Kidner procedure) and a control group (16 cases, treated by STA alone) according to the surgical methods. There was no significant difference in baseline data between the two groups ( P>0.05), such as gender, age, affected side of the foot, disease duration, and preoperative visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, talus-first metatarsal angle (T1MT), talus-second metatarsal angle (T2MT), talonavicular coverage angle (TCA), talus first plantar angle (Meary angle), calcaneal inclination angle (Pitch angle), and heel valgus angle (HV). The operation time, incision length, intraoperative blood loss, number of intraoperative fluoroscopies, and perioperative complications were recorded in both groups. The anteroposterior, lateral, and calcaneal axial X-ray films for the affected feet were taken regularly, and T1MT, T2MT, TCA, Meary angle, Pitch angle, and HV were measured. The VAS score, AOFAS ankle-hindfoot score were used to evaluate pain and functional recovery before and after operation.

Results

Surgeries in both groups were successfully performed without surgical complication such as vascular, nerve, or tendon injuries. Less operation time, shorter incision length, less intraoperative blood loss, and fewer intraoperative fluoroscopies were found in the control group than in the combination group ( P<0.05). One case in the combination group had partial necrosis of the skin at the edge of the incision, which healed after the dressing change and infrared light therapy, and the rest of the incisions healed by first intention. All children were followed up 12-36 months, with a mean of 19.6 months. At last follow-up, VAS score and AOFAS ankle-hindfoot score significantly improved in both groups when compared with preoperative ones ( P<0.05), and the differences of these scores between before and after operation improved more significantly in the combination group than in the control group ( P<0.05). Imaging results showed that the T1MT, T2MT, TCA, Meary angle, and HV significantly improved in both groups at last follow-up when compared with preoperative ones ( P<0.05), and the Pitch angle had no significant difference when compared with preoperative one ( P>0.05). But there was no significant difference in the difference of these indicators between before and after operation between the two groups ( P>0.05).

Conclusion

Both procedures are effective in the treatment of flexible flatfoot children with painful accessory navicular bone. STA has the advantage of minimally invasive, while STA combined with modified Kidner procedure has better effectiveness.

Union in Lateral Column Lengthening by Plate Fixation Without Bone Graft in Flexible Flatfoot: A Case Series

Purpose

This study's goal was to evaluate the outcomes of lateral column lengthening by plate fixation without bone graft in the management of symptomatic flexible flatfoot.

Methods

A prospective randomized trial study included 30 feet (27 patients) and was performed from March 2017 to December 2019. Functional and radiological evaluations were done pre-operative and at the final post-operative follow-up. The functional assessment was done using the American Orthopaedic Foot and Ankle Society (AOFAS) score.

Results

The mean follow-up was 16.5 ± 3.027 months. The mean age of patients was 22.6 ± 6.29 years. All cases showed union ranging from 8 to 12 weeks, with a mean of 10 ± 1.88 weeks. The mean AOFAS score improved from 51.6 ± 6.75 to 92.2 ± 6.21. The mean anteroposterior (AP) talo-first metatarsal angle improved from 25.3° ± 8.31° to 3.4° ± 5.10°. The mean anteroposterior (AP) talo-navicular coverage improved from 22.10° ± 4.28° to 2.3° ± 3.46°. The mean Lateral talo-first metatarsal angle improved from 18.6° ± 4.79° to 3.3° ± 3.16°. The calcaneal pitch angle improved from 9.6° ± 4.14° to 15.1° ± 4.43°. The mean lateral talo-calcaneal angle improved from 45.7° ± 3.77° to 37.5° ± 3.47°.

Conclusion

Using an interposition wedge plate for LCL without bone graft leads to a high union rate, maintains the correction, and avoids possible complications of autografts and allografts.

Effects of short foot exercise combined with lower extremity training on dynamic foot function in individuals with flexible flatfoot: A randomized controlled trial

BACKGROUND

Flexible flatfoot has demonstrated biomechanical linkages between distal and proximal lower extremities. However, supporting evidence is required to investigate the benefits of short foot exercise (SF) and short foot exercise in combination with lower extremity training (SFLE) on dynamic foot function.

RESEARCH QUESTION

This study aimed to determine the effects of a 6-week SF, 6-week SFLE, or control condition (no intervention) on dynamic foot function during gait in individuals with flexible flatfoot.

METHODS

Forty-five individuals with flexible flatfoot were randomly assigned into three conditions: (1) SF, (2) SFLE, and (3) control conditions. Participants in two intervention programs performed daily training via telerehabilitation and a home-based exercise program. Foot kinematics and center of pressure excursion index (CPEI) during the gait, intrinsic foot muscle test, and navicular drop test were assessed at baseline and after the 6-week intervention program.

RESULTS

Post-intervention participants in the SF and SFLE conditions showed a shorter time to the lowest medial longitudinal arch (MLA) and improved MLA motion during the stance phase compared with the baseline. In addition, participants in the SFLE conditions showed greater changes in CPEI than in the SF and control conditions. Improvements in intrinsic foot muscle and navicular drop tests were also observed in participants in both intervention programs post-intervention.

SIGNIFICANCE

A major finding of the study was the improvement in dynamic foot function during gait in individuals with flexible flatfoot after the six weeks of the SF and SFLE intervention programs. Both intervention programs appear to have the potential for inclusion in a corrective program for individuals with flexible flatfoot.

Tibialis anterior rerouting combined with calcaneal lengthening osteotomy as a single-stage reconstruction of symptomatic flexible flatfoot in children and adolescents

BACKGROUND

Symptomatic flexible flatfoot in children and adolescents should be surgically managed only if conservative measures have failed. The aim of this study was to assess functional and radiological results of tibialis anterior rerouting combined with calcaneal lengthening osteotomy as s single-stage reconstruction of symptomatic flexible flatfoot.

METHODS

The current study was a prospective study of patients with symptomatic flexible flatfoot treated by single-stage reconstruction in the form of tibialis anterior tendon rerouting combined with calcaneal lengthening osteotomy. The American Orthopaedic Foot and Ankle Society score (AOFAS) was utilized to evaluate the functional outcomes. The evaluated radiological parameters included the standing anteroposterior (AP) and lateral talo-first metatarsal angle, talar head coverage angle, and calcaneal pitch angle.

RESULTS

 The current study included 16 patients (28 feet) with a mean age of 11.6 ± 2.1 years. There was a statistically significant improvement in the mean AOFAS score from 51.6 ± 5.5 preoperatively to 85.3 ± 10.2 at final follow-up. Postoperatively, there was a statistically significant reduction in the mean AP talar head coverage angle from 13.6 ± 4.4° to 3.9 ± 3°, the mean AP talo-first metatarsal angle from 16.9 ± 4.4° to 4.5 ± 3.6°, and the mean lateral talo-first metatarsal angle from 19.2 ± 4.9° to 4.6 ± 3.2°, P < 0.001. Additionally, the mean calcaneal pitch angle increased significantly from 9.6 ± 1.9° to 23.8 ± 4.8°, P < 0.001. Superficial wound infection occurred in three feet and was treated adequately by dressing and antibiotics.

CONCLUSION

 Symptomatic flexible flatfoot in children and adolescents can be treated with combined lateral column lengthening and tibialis anterior rerouting with satisfactory radiological and clinical outcomes. Level of evidence Level IV.

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.

Subtalar Arthroereisis for Surgical Treatment of Flexible Flatfoot

Various surgical techniques are known for the treatment of flexible flatfoot in children after failure of nonsurgical attempts. Data collected in a review of the last 10-year period (2010-2020) show that among the 691 feet undergoing subtalar arthroereisis with endorthesis, average age at surgery was 11.40 years and in the 1856 feet that underwent subtalar arthroereisis with calcaneo-stop 11.69 years, while the complications rate was 9.00% and 6.38%, respectively. These data confirm that subtalar arthroereisis with calcaneo-stop may have an advantage over subtalar arthroereisis with endorthesis as the screw is not placed across the subtalar joint but instead into the calcaneus.

Calcaneal lengthening using ipsilateral fibula autograft in the treatment of symptomatic pes valgus in adolescents

Background

Evans calcaneal lengthening osteotomy is used to treat symptomatic flexible flatfoot when conservative treatment fails. Grafts such as autologous iliac bone grafts, allografts, and xenografts are implanted at the osteotomy site to lengthen the lateral column of the hindfoot. This study aimed to present the outcomes of an autologous mid-fibula bone graft used for calcaneal lengthening in symptomatic pes valgus in adolescents.

Methods

We retrospectively examined 23 ft of 13 adolescents who underwent surgery between July 2014 and January 2018. The radiological and clinical outcomes (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores) were assessed during a mean follow-up of 49.7 (range, 30.9–73.4) months. The mean distance of the lengthening site was measured to evaluate graft sinking or collapse. The Goldberg scoring system was used to determine the degree of union at the donor and recipient sites.

Results

The calcaneal pitch and the anteroposterior and lateral talo-first metatarsal (Meary) angles showed significant correction, from 14.4 to 19.6 (p < 0.001), and from 14.5 to 4.6 (p < 0.001) and 13.5 to 8.5 (p < 0.001), respectively. The mean distance of the lengthening site showed no significant change (p = 0.203), suggesting no graft sinking or postoperative collapse. The lateral distal tibial angle showed no significant difference (p = 0.398), suggesting no postoperative ankle valgus changes. Healing of the recipient and donor sites occurred in 23 and 21 ft, respectively. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scores improved significantly, from 68.0 to 98.5 (p < 0.001).

Conclusions

Evans calcaneal lengthening using an ipsilateral mid-fibula bone autograft resulted in significant improvement in clinical and radiological outcomes without ankle valgus deformity. Hence, it could be a treatment option for lateral column calcaneal lengthening in adolescents.

Biomechanical assessment of two types and two different locations of subtalar arthroereisis implants for flexible flatfoot: A cadaveric study

BACKGROUND

Subtalar arthroereisis refers to the implantation of a sinus tarsi implant for the treatment of flexible flatfoot. The purpose of this study was to compare the ability to correct the flatfoot deformity and contact pressure of the posterior subtalar joint between two types of self-locking wedge implants and between two different positions for the same device in a cadaveric flatfoot model.

METHODS

The flatfoot model was created in ten cadaver feet through ligament sectioning and cyclic loading. Three kinds of arthroereisis procedures were evaluated: Talar-Fit (type I self-locking wedge implant) anchored in the sinus portion of the tarsal sinus (T-sinus group), Talar-Fit in the canalis portion (T-canalis group), and HyProCure (type II) in the canalis portion (H group). Corrective ability in the sagittal and transverse planes were measured with clinometers. Contact pressure was measured with pressure-sensitive films.

FINDINGS

T-canalis group provided more sagittal (mean difference for size 10 mm: 1.9°, P = 0.014; mean difference for size 11 mm: 3.1°, P = 0.037) and transverse (mean difference for size 8 mm: 1.8°, P = 0.049; mean difference for size 11 mm: 2.2°, P = 0.049) corrections than T-sinus group. The flattening process shifted the peak pressure of the posterior subtalar joint to the posteromedial side (P < 0.05) and arthroereisis helped the distribution of contact pressure restore uniformity (all P > 0.05).

INTERPRETATION

A self-locking wedge implant inserted in the canalis portion of the tarsal sinus achieved better correction than an implant inserted in the sinus portion.

Surgical Management of Musculotendinous Balance in the Progressive Collapsing Foot Deformity: The Role of Peroneal and Gastrocnemius Contracture

Surgical treatment of progressive collapsing foot deformity (PCFD) relies on understanding the dynamic and deforming musculotendinous structures that contribute to hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. Equinus commonly is seen in PCFD and consideration should be given to isolated gastrocnemius or Achilles lengthening. Although transfer of the flexor digitorum longus tendon is performed in PCFD attributed to dysfunction and pathology of the posterior tibialis tendon (PTT), retention of PTT is an area for further research. The peroneus brevis, which contributes to hindfoot imbalance in chronic cases, is a possible component of tendon rebalancing.

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.

Long-term results of subtalar arthroereisis for the treatment of symptomatic flexible flatfoot in children: an average fifteen year follow-up study

AIM OF THE STUDY

The aim of this study is to report the long-term outcomes of a homogenous series of patients who underwent subtalar arthroereisis (STA) for the treatment of symptomatic flexible flatfoot (FFF).

METHODS

Thirty-four pediatric patients who underwent STA with a bioabsorbable implant were enrolled and radiographic measurements, clinical outcomes, and patients' satisfaction were evaluated.

RESULTS

At a mean 180 months follow-up, radiographic measurements showed significant improvement. A physiological footprint and a proper hindfoot alignment were shown in more than 70% of patients. Mean AOFAS score was 90.4 ± 9.2 (72-100), mean SF-12 was 44.7 with 30 out of 34 patients (88.2%) satisfied with the procedure.

CONCLUSION

STA with a bioabsorbable implant showed satisfactory long-term results. Based on the data subgroup analysis, nine to 11.5 years for female and nine to 13.5 years for male appeared to be the most appropriate age for surgery.

Mid-term Results of Subtalar Arthroereisis with Talar-Fit Implant in Pediatric Flexible Flatfoot and Identifying the Effects of Adjunctive Procedures and Risk Factors for Sinus Tarsi Pain

Objectives

To (i) report the mid‐term outcomes of subtalar arthroereisis using Talar‐Fit implant for the treatment of flexible flatfoot patients; (ii) compare clinical and radiographic outcomes between arthroereisis with and without adjunctive operative procedures to investigate the effects of adjuncts on the outcomes; and (iii) analyze the risk factors associated with sinus tarsi pain, which is the most common postoperative complication of arthroereisis.

Methods

Thirty‐one flexible flatfoot children and adolescents (46 feet) treated with subtalar arthroereisis using Talar‐Fit implant from June 2014 to May 2019 were retrospectively analyzed. The feet were divided into four treatment groups: (i) arthroereisis alone, (ii) arthroereisis with gastrocnemius recession, (iii) arthroereisis with Kidner procedure, and (iv) arthroereisis with gastrocnemius recession and Kidner procedure. Clinical function was evaluated based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score. The following angles were measured for radiographic evaluation: talar‐first metatarsal angle, calcaneal pitch angle, and talar declination angle on the lateral view; and talar‐first metatarsal angle, talocalcaneal angle, and anteroposterior talonavicular coverage angle on the anteroposterior (AP) view. The paired Student's t‐test was used to compare the pre‐ and postoperative angular measurements and AOFAS scores. The Wilcoxon rank‐sum test was undertaken to determine the outcome differences among four treatment groups. Multivariate logistic regression analysis was used to analyze risk factors for sinus tarsi pain. P value <0.05 is considered statistically significant.

Results

The mean follow‐up of the feet was 32.8 months (range, 10–71 months). The mean AOFAS score significantly improved from 55.5 ± 14.5 preoperatively to 86.3 ± 9.9 (P < 0.001). Comparison of radiographic outcomes showed that the lateral talar‐first metatarsal angle decreased by a mean of 19.1° ± 11.9° (P < 0.001), the calcaneal pitch angle increased by a mean of 5.4° ± 3.4° (P < 0.001), the talar declination angle decreased by a mean of 14.8° ± 9.9° (P < 0.001), the AP talar‐first metatarsal angle decreased by a mean of 15.6° ± 10.3° (P < 0.001), the AP talocalcaneal angle decreased by a mean of 7.2° ± 8.3° (P = 0.001), and the AP talonavicular coverage angle decreased by a mean of 20.4° ± 9.0° (P < 0.001). There were no statistically significant differences with regard to AOFAS score and all angle measurements on both the AP and lateral views among the four treatment groups. There was one dislocation case caused by a fall 6 weeks after surgery, which was treated nonoperatively. The incidence of sinus tarsi pain was 13% and logistic regression analysis indicated that patients with a longer distance from the tail end of the implant to the lateral calcaneal wall had 38.8% greater odds of developing sinus tarsi pain.

Conclusions

The mid‐term clinical and radiographic results were satisfactory in patients who underwent the subtalar arthroereisis procedure using Talar‐Fit implant, alone or in combination with other adjuncts, for the treatment of flexible flatfoot.

A valuable option: Clinical and radiological outcomes of braided suture tape system augmentation for spring ligament repair in flexible flatfoot

BACKGROUND

The purpose of this study was to evaluate the clinical and radiological outcomes of the briaded suture tape system augmentation in the treatment of flexible flatfoot.

METHODS

Patients who underwent suture tape system augmentation in addition to spring ligament repair and flexor digitorum longus (FDL) transfer were reviewed. Clinical and radiological outcomes were studied. The results were compared to a matched control group who underwent the conventional surgical treatment, which involved FDL transfer only or FDL transfer plus medial sliding calcaneal osteotomy.

RESULTS

A total of 40 patients (11 males and 29 females) who underwent hindfoot reconstruction for flexible flatfoot (Johnson stage 2) were reviewed. There were 18 patients in the suture tape system group and 22 patients in the control group. In the suture tape system group, there was excellent improvement in patients' symptoms, AOFAS score (97.9 improved from 76.7) and significantly more number of patients with stable single leg stance. Radiographic parameters improved postoperatively too.

CONCLUSIONS

This is the first clinical study which studied the outcome of suture tape system augmentation for spring ligament repair. Patients with suture tape system reconstruction showed more number of patients with single leg stance and better correction of forefoot abduction. It is a reasonable component of hindfoot reconstruction.

Osteotomies combined with soft tissue procedures for symptomatic flexible flatfoot deformity in children

BACKGROUND

The indications for surgery, timing, and procedure in children with flexible flatfoot deformity remain controversial. This study aims to evaluate the efficacy of osteotomies combined with soft tissue procedures in children with flexible flatfoot aged 9-14 years.

METHODS

Twenty-eight children (47 feet) with flexible flatfoot who underwent osteotomy combined with soft tissue surgery between July 2014 and October 2017 were included in this study. The main observational indexes included the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Foot and Ankle Outcome Score (FAOS), talo-navicular coverage angle (TNCA), talar-first metatarsal angle (T1MA) on the foot anteroposterior (AP) view, calcaneal pitch angle and Meary's angle on the foot lateral view, and calcaneus valgus angle (CVA) on the Saltzman view. Intra- and interobserver reliabilities were assessed using intra-class correlation coefficient (ICC). Patient's satisfaction was assessed.

RESULTS

All patients were followed up for an average duration of 29.7±8.6 months. The results showed that the mean AOFAS and FAOS had improved significantly from 56.6±8.0 and 47.4±9.5 preoperatively to 88.4±3.9 and 83.2±6.8 at final follow-up (P<0.001), respectively. There were statistically significant differences between preoperative and postoperative scores in all FAOS subscales (P<0.001). Radiographic parameters, such as TNCA (P<0.001) and T1MT (P<0.001) on foot AP views, calcaneal pitch angle (P=0.014) and Meary's angle (P<0.001) on foot lateral views, and CVA (P<0.001) on Saltzman views, had improved significantly. We observed overall substantial to perfect intra- and inter-observer agreements for all radiographic measurements preoperatively and final follow-up. All patients and their parents were satisfied with the functional outcomes.

CONCLUSION

Osteotomies combined with soft tissue procedures is an effective strategy for flexible flatfoot deformity in children, as it results in favorable radiographic and functional outcomes.

Is subtalar extra articular screw arthroereisis (SESA) reducing pain and restoring medial longitudinal arch in children with flexible flat foot?

Subtalar arthroereisis has been accounted for as a minimally invasive, successful and generally safe technique in the treatment of flatfoot in children. The primary aim of our study was to evaluate the subtalar extra-articular screw arthroereisis (SESA) in children with flexible flatfoot clinically and radiologically. This prospective case series study included 84 feet of 42 patients who underwent Subtalar Extra-articular Screw Arthroereisis (SESA) due to symptomatic flexible flatfoot. This study included 26 males (62 ℅) and 16 females (38℅). The mean age at surgery was (9.92 years); range from (7-15 years).The average follow up period was 29.1 months (ranged from 2 to 48 months). The values of the pre- and post-SESA weight bearing X-ray angles were 149 ± 6 and 127° ± 8° respectively for the Costa-Bartani angle, 43° ± 8° and 25° ± 6° respectively for the lateral T-1stMT angle and 26° ± 7° and 8° ± 3° respectively for calcaneal pitch angle 6° ± 4° and 15° ± 5°. The average AOFAS preoperative score was 68.7 ± 5.7 (Range, 58 to 78) whereas post operative AOFAS score was 97.4 ± 2.3 (range, 94 to 100). All data were analyzed statistically with graph instat. With final conclusion that SESA is an optimal technique for the correction of flexible flatfoot (FFF) as it is simple and can be performed rapidly and is effective procedure in reducing pain and restoring medial longitudinal arch in children with flexible flat foot. Level of clinical evidence (LOCE): Level 4.

Effects of Kinesio tape on supporting medial foot arch in runners with functional flatfoot: a preliminary study

This study aimed to evaluate the anti-pronation effects of Kinesio tape on flexible flatfoot during running. Nine volunteers participated in a crossover trail of two conditions: with Kinesio tape (KT) or without taping (NT). The running consisted of 9 stages of different inclines on a treadmill over 28 minutes. Navicular drop distance (NDD) was measured before and after the running. Electromyography, the relative plantar pressure, Rating of Perceived Exertion and Visual Analogue Scale were recorded at each stage. After the application of Kinesio tapes over the tibialis posterior and transverse arch, the NDD reduced significantly and the relative posterior pressure reduced during stage 8. Without taping, the NDD decreased slightly after exercise. Comparing between conditions, the tibialis anterior were more activated with Kinesio tape in stages 4 and 5. During the latter half of the running, the medial gastrocnemius and peroneus longus reduced their activity in the KT and NT conditions respectively. In conclusion, the Kinesio tapes intended to facilitate the tibialis posterior and reinforce the transverse arch can reduce NDD in individuals with flexible flatfoot immediately after application, and increase muscle activity of their tibialis anterior during the first 15 minutes of the running.

H-reflex in abductor hallucis and postural performance between flexible flatfoot and normal foot

OBJECTIVE

Morphological changes of the abductor hallucis muscle (AbH) in flexible flatfoot (FF) individuals influence regulations of the medial longitudinal arch (MLA). Prolonged and repeated stretching of AbH in flexible flatfoot may cause changes in muscle reflex properties and further influence postural performance. However, AbH muscle reflex under different postural conditions have never been examined. The purpose of this study was to investigate differences in AbH H-reflex and postural performance between individuals with normal foot (NF) alignment and FF under prone, double-leg stance (DLS), and single-leg stance (SLS) conditions.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

Individuals with FF (n = 12) and NF (n = 12).

MAIN OUTCOME MEASURES

AbH H-reflex, AbH EMG and center of pressure (CoP) displacement.

RESULTS

Under all postural conditions, AbH H-reflex was significantly lower in the FF group (P < .05). Under the SLS condition, AbH EMG was significantly higher in the FF group (P < .05), and CoP displacement for the medial-lateral and anterior-posterior directions were significantly higher in the FF group (P < .05).

CONCLUSIONS

With increased postural demand, FF individuals maintained their postural stability by recruiting greater AbH activities than through automatic stretch reflex, but FF individuals still showed inferior posture stability.

Are there benefits of a 2D gait analysis in the evaluation of the subtalar extra-articular screw arthroereisis? Short-term investigation in children

BACKGROUND

A juvenile flexible flatfoot is a common abnormality during growth. For children with a pathological manifestation, subtalar extra-articular screw arthroereisis is a popular operative technique. Although this minimally invasive operation technique has been performed for >45 years, complications still occasionally occur. For this reason, we created this pilot study to investigate whether a two-dimensional (2D) gait analysis is able to identify functional movement deficits after surgery.

METHODS

Fourteen children (27 ft) with a mean age of 12.38 years (SD, 1.40 years) were analyzed. Biomechanics were examined before and 4 weeks after surgery using a 2D gait analysis. For this purpose, the patients were filmed on a treadmill. In focus were static and dynamic recordings of the heel angle, rearfoot angle, and the leg axis angle. In addition, the step length and self-selected speed were measured.

FINDINGS

After surgery rearfoot angle showed significant reduction (p < 0.001) from 12.49° to 3.63° under static conditions and from 12.65° to 4.58° under dynamic conditions. Heel angle responded similar (p < 0.001). There were no significant differences in self-selected speed or step length. Undoubtedly, gait analysis was able to identify intraindividual deficits, leading to a closer monitoring of five patients and an adjustment of the screw in one foot.

INTERPRETATION

By means of the 2D gait analysis, we were able to show functional improvement after subtalar extra-articular screw arthroereisis. Nonetheless, we identified a few children who still had functional abnormalities. Certainly, it is unclear whether this additional examination is able to reveal all complications that would have occurred later.

The arthroereisis procedure in adult flexible flatfoot grade IIA due to insufficiency of posterior tibial tendon

BACKGROUND

To report on the functional, biomechanical, and radiographic results of patients who had undergone arthroereisis plus tensioning of the posterior tibial tendon for flexible flatfoot. The hypothesis is that arthroereisis associated to a tensioning of the posterior tibial tendon give a good correction with great satisfaction in patients with flexible flatfoot in grade IIA.

METHODS

We evaluated 29 patients (31 feet), mean age of 46.4 years, who had been surgically treated for adult flatfoot grade IIA according to Myerson. Mean follow-up was 34.15 months. For clinical evaluation, the AOFAS hindfoot and VAS-FA scores were used.

RESULTS

Postoperative results showed significant increases in both AOFAS and VAS-FA scores: 54.2-81.9 and 61.5-83.2 points, respectively. For the X-ray parameters, we observed a significant variation in the talo-first metatarsal angle, from 13.8° in pre-op to 7.4° in post-op. In lateral view, Djian Annonier angle was improved from 146.6° to 134.1°. The Meary's angle, compared to an average of 8.8° in pre-operative stage improved to 4.3° in the post-operative stage. Postoperative satisfaction was excellent-good according to 23 patients (79.4%). Pain in the tarsal sinus was reported in 5 out of 31 feet (16.1%) for the first three months after surgery.

CONCLUSIONS

Arthroereisis and tensioning of the posterior tibial tendon provided good functional outcomes for patients under 60 years of age having stage IIA flexible flatfoot without arthritic manifestations.

Double calcaneal osteotomy with minimally invasive surgery for the treatment of severe flexible flatfeet

BACKGROUND

Severe flexible flatfoot deformity in children and adolescents is a complex problem. Calcaneal lengthening remains the gold standard for surgical correction at this institution. However, in a minority of patients, inadequate correction of valgus is noted at surgery and a further calcaneal shift osteotomy is done.

METHODS

We have conducted a retrospective review of ten patients who received 15 combined minimally invasive calcaneal shift and calcaneal lengthening osteotomies, which were all performed by the senior author. All patients had failed conservative treatment. We describe our technique for double calcaneal osteotomy combining minimally invasive surgery (MIS) for the medial calcaneal shift with traditional open calcaneal lengthening osteotomy for treating children and adolescents with severe flexible flatfoot deformity.

RESULTS

The average shift achieved was 8.07 mm. The average improvement in Meary's angle was 14.99°. All of them had radiological and clinical union at 12 weeks. None of the patients developed sural nerve injury, wound breakdown, or infection of the MIS incision.

CONCLUSION

In double calcaneal osteotomies, the MIS calcaneal medial shift technique can be used safely with potentially lower risks of wound complications and sufficient medial shift, compared to conventional open extensive surgery.

IMPLICATIONS

MIS calcaneal shift osteotomy has an advantage over open conventional open technique in cases where the skin is under tension like in combined calcaneal lengthening osteotomy. With experience, the procedure can be faster than an open procedure.

Gait Analysis of Symptomatic Flatfoot in Children: An Observational Study

Background

Flatfoot deformity is a lever arm disease that incurs kinetic inefficiency during gait. The purpose of this study was to measure the degree of kinetic inefficiency by comparing the gait analysis data of a flatfoot group with a normal control group.

Methods

The patient group consisted of 26 children (21 males and 5 females) with symptomatic flatfoot. They were examined with gait analysis between May 2005 and February 2014. Exclusion criteria were patients with secondary flatfoot caused by neuromuscular disorders, tarsal coalition, vertical talus, or others. Patients' mean age was 9.5 years (range, 7 to 13 years). The gait analysis data of the study group and the normal control group were compared.

Results

The mean vertical ground reaction force (GRF) in the push-off phase was 0.99 for the patient group and 1.15 for the control group (p < 0.05). The mean ankle moment in the sagittal plane during the push-off phase was 0.89 for the patient group and 1.27 for the control group (p < 0.05). The mean ankle power in the sagittal plane during the push-off phase was 1.38 for the patient group and 2.52 for the control group (p < 0.05). The aforementioned results show that patients with pes planovalgus had a reduction of moment, power, and GRF in the push-off phase during gait.

Conclusions

Symptomatic flatfeet had a moment inefficiency of 30% and power inefficiency of 45% during gait compared to feet with preserved medial longitudinal arches.

Plantar pressure differences among adults with mild flexible flatfoot, severe flexible flatfoot and normal foot when walking on level surface, walking upstairs and downstairs

[Purpose] This study observed the plantar pressure between flexible flatfoot and normal foot on different walking conditions to find out if flexible flatfoot needs the treatment and how the plantar pressure change while walking upstairs and downstairs. [Subjects and Methods] Fifteen adults with mild flexible flatfoot, fifteen adults with severe flexible flatfoot and fifteen adults with normal foot were examined while walking on a level surface, walking up and down 10 cm and 20 cm stairs. The max force and the arch index were acquired using the RSscan system. The repeated measures ANOVA was performed to analyze the data. [Results] Compared with normal foot, both max force and arch index of severe flatfoot were significantly increased on different walking conditions. When walking down 10 cm and 20 cm stairs, the plantar data of both normal foot and flatfoot were significantly increased. [Conclusion] The plantar pressure of severe flexible flatfoot were significantly larger than that of normal foot on different walking conditions. In addition, the arches of both normal foot and flatfoot were obviously deformed when walking downstairs. It is therefore necessary to be treated for severe flexible flatfoot to prevent further deformation.

Surgical treatment results for flexible flatfoot in adolescents

Objective

Idiopathic flexible pes planus (IFPP) is a common foot problem in adolescents and young adults. Hypothesis for the present study was that combination of procedures for IFPP can achieve results in adolescents and young adults that are as good as those seen in adult-acquired pes planovalgus (AAPP) treatment in adults.

Methods

A total of 21 feet of 18 patients (10 boys, 8 girls) with mean age of 15.6 years underwent surgical reconstruction for flatfoot deformity. Symptomatic patients who had been unresponsive to conservative treatment were included in study group. Mean follow-up time was 39.2 months. American Orthopedic Foot and Ankle Society (AOFAS) scores were calculated for all patients, and based on final results, all families were asked whether or not they would elect to have the surgery again in same circumstances.

Results

All procedures were performed by the same surgeon: lateral column calcaneal lengthening osteotomy on 21 feet; percutaneous lengthening or gastrocnemius recession for Achilles tendon on 21 feet; medializing calcaneal osteotomy on 15 feet; flexor digitorum longus tendon transfer on 15 feet; medial cuneiform opening wedge osteotomy on 5 feet, spring ligament plication on 3 feet, and accessory navicular bone excision on 2 feet.

Preoperative mean AOFAS score increased significantly from 56.76 to 95.29. All parents stated that they were satisfied with surgery results and would choose to have the same surgery performed again.

Conclusion

Soft tissue and bony procedures used for reconstruction of AAPP can be used safely for IFPP in adolescents and young adults.

Level of clinical evidence

Level IV, Therapeutic study.

Imaging findings of arthroereisis in planovalgus feet

Arthroereisis is a rare and disputed procedure, where an implant screw is inserted into the sinus tarsi to treat flatfoot deformity. Weight-bearing radiographs are the most essential examinations to assess the correct localization and related measurements. Hardware loosening is the most common complication seen as localized lucency and as dislocation of the implant. Computed tomography yields superior resolution with reconstruction capabilities. On magnetic resonance imaging, the implant appears as a dark signal focus on T1 and T2-weighted images with a hyperintense T2-signal rim. As the data on the imaging of arthroereisis are scarce, we aimed here to review the typical imaging findings.

Effects of orthotic insoles on adults with flexible flatfoot under different walking conditions

[Purpose] This study was to evaluate the effects of orthotics on adults with flexible flatfoot when wearing orthotic insoles while walking on horizontal ground, walking up and down stairs and to determine if flexible flatfoot needs treatment. [Subjects and Methods] Fifteen college students with flexible flatfoot and fifteen college students with normal feet were recruited. First, load rate and contact area were measured by RSscan force plate when the subjects were walking on horizontal ground, walking up and down 10 cm and 20 cm stairs. Then the subjects with flexible flatfoot were instructed to wear orthotic insoles for 3 months, and plantar pressure was measured again. Finally, the data were subjected to repeated measures ANOVA. [Results] After treatment for 3 months, the plantar pressure of flatfoot was significantly improved. In addition, the data of the subjects with normal feet and flatfoot were significantly influenced by walking down 10 cm or 20 cm stairs. [Conclusion] Orthotic insoles could significantly improve the plantar pressure of flatfoot. Additionally, the arches of subjects with normal feet and flatfoot can be significantly deformed when walking down stairs. Therefore, it is essential for subjects with flexible flatfoot to wear orthotic insoles to avoid needless injury.

[SHORT-TERM EFFECTIVENESS OF Hyprocure SUBTALAR STABILIZATION IN TREATMENT OF ADOLESCENT FLEXIBLE FLATFOOT]

OBJECTIVE

To evaluate the short-term effectiveness of Hyprocure subtalar stabilization for adolescent flexible flatfoot.

METHODS

Between December 2013 and September 2015, 14 cases (26 feet) of adolescent flexible flatfoot were treated with Hyprocure subtalar stabilization. There were 10 males (18 feet) and 4 females (8 feet) with the average age of 14.5 years (range, 12-18 years). There were 12 cases (24 feet) of congenital flatfoot and 2 cases (2 feet) of flatfoot caused by neurological diseases. The preoperative pain visual analogue scale (VAS) was 4.2±0.4; the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and foot function score was 72.2±12.3. Simple Hyprocure subtalar stabilization was used in 8 feet, and a combination of minimally invasive percutaneous Achilles tendon lengthening or gastrocnemius lysis, preposing of posterior tibial tendon and spring ligament tightening surgery, or open dorsal medial cuneiform osteotomy and bone graft in 18 feet. The VAS score and AOFAS ankle and foot function score were used to evaluate the effectiveness. The talus-the first metatarsal angle (T1MT), the talus-the second metatarsal angle (T2MT), and talonavicular coverage angle (TCA) were measured on the anteroposterior X-ray film; the Meary's angle, calcaneal inclination angle (CI), and the talar declination (TD) were measured on the lateral X-ray film.

RESULTS

All incisions healed well. Two cases (2 feet) had tarsal sinus pain, which was cured after symptomatic treatment. All patients were followed up 5-24 months (mean, 14.5 months). Pain was obviously relieved. At last follow-up, VAS score was significantly decreased to 1.4±0.3 (t=27.676, P=0.000). AOFAS ankle and foot function score was significantly increased to 94.5±10.8 (t=7.765, P=0.000). The postoperative X-ray film showed that medial arch was elevated after the Hyprocure subtalar stabilization was placed in tarsal sinus. At last follow-up, the T1MT, T2MT, TCA, Meary's angle, and TD were significantly improved when compared with preoperative ones (P<0.05); CI has no significant improvement (t=0.109, P=0.598).

CONCLUSIONS

Hyprocure subtalar stabilization is simple, effective for adolescent flexible flatfoot, the short-term effectiveness is good. But the indications should be strictly controlled, treatment should be individualized, corresponding auxiliary soft tissue and bone surgery is needed. The long-term effectiveness needs further follow-up.

Ultrasonographic evaluation of Achilles tendon in children with flatfoot: A case-control morphometric study

PURPOSE

The purpose of this study was to investigate whether any relationships exist between the presence of flatfoot and ultrasonographic morphometric findings of Achilles tendon in children.

MATERIALS AND METHODS

The study included 30 pediatric patients with a mean age of 11.96±2.44 (SD) years (range: 9-16 years) with flexible flatfoot and 29 healthy pediatric controls who were matched for age and served as a control group. Demographic data of both groups such as age, height and weight, and anthropometric measurements including leg length and, length and cross-sectional area of the Achilles tendon on ultrasonography were tabulated. Relationships between the cross-sectional area of Achilles tendon and flatfoot and the other parameters were searched for using backward multiple regression analysis.

RESULTS

No associations between flatfoot and length and cross-sectional area of the Achilles tendon, age, height, leg and foot length were found. A negative correlation was found between the cross-sectional area of Achilles tendon and presence of flatfoot (Beta=-4.93, P=0.01) and age (Beta=-1.96, P=0.04). A positive correlation was found between the cross-sectional area of Achilles tendon and shoe size (Beta=2.13, P=0.007).

CONCLUSIONS

Flatfoot, shoe size, age and weight must be kept in mind as a clue for a thinner Achilles tendon morphometry which can be a risk factor in lower limb pathologies.

Painful Flexible Flatfoot

Flatfoot is commonly encountered by pediatric orthopedic surgeons and pediatricians. A paucity of literature exists on how to define a flatfoot. The absence of the medial arch with a valgus hindfoot is the hallmark of this pathology. Flatfoot can be flexible or rigid. This review focuses on the diagnosis and treatment of the flexible flatfoot. Most flatfeet are flexible and clinically asymptomatic, and warrant little intervention. If feet are symptomatic, treatment is needed. Most patients who require treatment improve with foot orthotics and exercises. Only feet resistant to conservative modalities are deemed surgical candidates. The presence of a tight heel cord is often found in patients who fail conservative management.

The effects of total contact insole with forefoot medial posting on rearfoot movement and foot pressure distributions in patients with flexible flatfoot

The purpose of this study is to evaluate the therapeutic effect of total contact insole with forefoot medial posting (TCIFMP) orthosis in patients with flexible flatfoot. The TCIFMP insole was custom- mode, made from semi-rigid plastazote and PPT. Using the gait analysis and the plantar-pressure measure systems, we investigate rearfoot motion and plantar pressure redistribution in these patients. The results of this study showed that the excessive valgus movement of the rearfoot can be reduced significantly by the TCIFMP insole in these patients. Besides, there were significant decreases in the peak pressure under the toe, lateral metatarsal, lateral foot and heel areas. Therefore, we suggested that the TCIFMP insole is an effective orthotic device for rearfoot motion control, plantar pressure reduction and re-distribution in patients with flexible flatfoot.

Does excessive flatfoot deformity affect function? A comparison between symptomatic and asymptomatic flatfeet using the Oxford Foot Model

Treatment of asymptomatic flexible flatfeet is a subject of great controversy. The purpose of this study was to examine foot function during walking in symptomatic (SFF) and asymptomatic (ASFF) flexible flatfeet. Thirty-five paediatric and juvenile patients with idiopathic flexible flatfeet were recruited from an orthopaedic outpatient department (14 SFF and 21 ASFF). Eleven age-matched participants with typically developing feet served as controls (TDF). To study foot function, 3D multi-segment foot kinematics and ankle joint kinetics were captured during barefoot gait analysis. Overall, alterations in foot kinematics in flatfeet were pronounced but differences between SFF and ASFF were not observed. Largest discriminatory effects between flatfeet and TDF were noticed in reduced hindfoot dorsiflexion as well as in increased forefoot supination and abduction. Upon clinical examination, restrictions in passive dorsiflexion in ASFF and SFF were significant. During gait, the hindfoot in flatfeet (both ASFF and SFF) was more everted, but less flexible. In sagittal plane, limited hindfoot dorsiflexion of ASFF and SFF was compensated for by increased forefoot mobility and a hypermobile hallux. Concerning ankle kinetics, SFF lacked positive joint energy for propulsion while ASFF needed to absorb more negative ankle joint energy during loading response. This may risk fatigue and overuse syndrome of anterior shank muscles in ASFF. Hence, despite a lack of symptoms flatfoot deformity in ASFF affected function. Yet, contrary to what was expected, SFF did not show greater deviations in 3D foot kinematics than ASFF. Symptoms may rather depend on tissue wear and subjective pain thresholds.