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Piraino JA, Theodoulou MH, Ortiz J, Peterson K, Lundquist A, Hollawell S, Scott RT, Joseph R, Mahan KT, Bresnahan PJ, Butto DN, Cain JD, Ford TC, Knight JM, Wobst GM. American College of Foot and Ankle Surgeons Clinical Consensus Statement: Appropriate Clinical Management of Adult-Acquired Flatfoot Deformity. J Foot Ankle Surg 2021; 59:347-355. [PMID: 32131002 DOI: 10.1053/j.jfas.2019.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This clinical consensus statement of the American College of Foot and Ankle Surgeons focuses on the highly debated subject of the management of adult flatfoot (AAFD). In developing this statement, the AAFD consensus statement panel attempted to address the most relevant issues facing the foot and ankle surgeon today, using the best evidence-based literature available. The panel created and researched 16 statements and generated opinions on the appropriateness of the statements. The results of the research on this topic and the opinions of the panel are presented here.
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Affiliation(s)
- Jason A Piraino
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL.
| | - Michael H Theodoulou
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Julio Ortiz
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Kyle Peterson
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Andrew Lundquist
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Shane Hollawell
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Ryan T Scott
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Robert Joseph
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Kieran T Mahan
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Philip J Bresnahan
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Danielle N Butto
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Jarrett D Cain
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Timothy C Ford
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Jessica Marie Knight
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
| | - Garrett M Wobst
- Adult-Acquired Flatfoot Deformity Clinical Consensus Statement Panel of the American College of Foot and Ankle Surgeons, Chicago, IL
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Abstract
The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is commonly performed; however, the outcomes are rarely reported owing to the adjunctive nature of the procedure. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical because the preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated by arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus or an iatrogenic deformity after base wedge osteotomy for hallux valgus. We undertook an institutional review board-approved retrospective review of 32 consecutive patients (37 feet) who had undergone Cotton osteotomy as a part of flatfoot reconstruction. All but 1 case (2.7%) had radiographic evidence of graft incorporation at 10 weeks. No patient experienced graft shifting. Three complications (8.1%) were identified, including 2 cases with neuritis (5.4%) and 1 case of delayed union (2.7%) that healed with a bone stimulator at 6 months postoperatively. Meary's angle improved an average of 17.75°, from -17.24°± 8.00° to 0.51°± 3.81°, and this change was statistically significant (p < .01). The present retrospective series highlights our experience with the use of the Cotton osteotomy as an adjunctive procedure in flatfoot reconstructive surgery.
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Affiliation(s)
- Troy J Boffeli
- Director, Foot and Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN
| | - Katherine R Schnell
- Second Year Resident, Foot and Ankle Surgery Residency Program, Regions Hospital/HealthPartners Institute for Education and Research, St. Paul, MN.
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Giannini S, Cadossi M, Mazzotti A, Persiani V, Tedesco G, Romagnoli M, Faldini C. Bioabsorbable Calcaneo-Stop Implant for the Treatment of Flexible Flatfoot: A Retrospective Cohort Study at a Minimum Follow-Up of 4 Years. J Foot Ankle Surg 2018. [PMID: 28633776 DOI: 10.1053/j.jfas.2017.02.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Arthroereisis of the subtalar joint is a common surgical technique in Europe for the management of flexible flatfoot in the pediatric population. In most cases, it is performed using a calcaneo-stop metallic screw. Despite the good clinical results, screw removal is always advised after 2 to 3 years. The use of a bioabsorbable screw might overcome the need for a second operation to remove a nonabsorbable device. We report the results of a biodegradable calcaneo-stop screw at a minimum of 4 years of follow-up. Eighty-eight procedures were performed on 44 children. All patients were clinically and radiologically evaluated preoperatively and at a minimum 4-year follow-up period. Patient satisfaction and plantar collapse using Viladot's classification were recorded. Meary's talus-first metatarsal angle and talocalcaneal angle were measured on radiographs preoperatively and at the last follow-up visit. The presence of the device at the last follow-up examination was assessed by magnetic resonance imaging. The mean follow-up duration was 56 months. Of the 44 patients, 33 (75%) reported excellent clinical outcomes, 9 (20.5%) good outcomes, and 2 (4.5%) poor. Foot print improvement was registered for all patients. The mean Meary's talus-first metatarsal angle had improved from 160.6° ± 7.7° preoperatively to 170.6° ± 6.5° at the last follow-up visit (p < .001). The talocalcaneal angle had decreased from 39.9° ± 5.2° preoperatively to 29.4° ± 4° at the last follow-up examination (p < .001). At the 4-year follow-up point, the implant could be seen to have almost completely biodegraded on magnetic resonance imaging. Two screw breakages occurred. The bioabsorbable calcaneo-stop screw seems to be an effective solution for flexible flatfoot in pediatric patients. Also, owing to its biodegradable composition, the need of a second operation for implant removal will not always be necessary.
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Affiliation(s)
- Sandro Giannini
- Professor Emeritus, Istituto Ortopedico Rizzoli, Bologna University, Bologna, Italy
| | - Matteo Cadossi
- Orthopaedic Surgeon, II Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna University, Bologna, Italy
| | - Antonio Mazzotti
- Medical Doctor, II Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna University, Bologna, Italy.
| | - Valentina Persiani
- Orthopaedic Surgeon, II Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna University, Bologna, Italy
| | - Giuseppe Tedesco
- Orthopaedic Surgeon, II Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna University, Bologna, Italy
| | - Matteo Romagnoli
- Orthopaedic Surgeon, II Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna University, Bologna, Italy
| | - Cesare Faldini
- Professor and Director, II Clinic of Orthopaedic and Traumatology, Istituto Ortopedico Rizzoli, Bologna University, Bologna, Italy
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Schuberth JM, Christensen JC, Seidenstricker CL. Total Ankle Replacement with Severe Valgus Deformity: Technique and Surgical Strategy. J Foot Ankle Surg 2017; 56:618-627. [PMID: 28268144 DOI: 10.1053/j.jfas.2017.01.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Indexed: 02/03/2023]
Abstract
Correction of severe valgus deformity of the foot and ankle with ankle replacement is challenging. We describe the controversies and specific issues of surgical management and provide a detailed surgical strategy for management of this common deformity. A reliable technique for deltoid reconstruction is also described and illustrated in detail.
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Affiliation(s)
- John M Schuberth
- Chief, Foot and Ankle Surgery, Department of Orthopedic Surgery, Kaiser Foundation Hospital, San Francisco, CA.
| | - Jeff C Christensen
- Attending Surgeon, Division of Podiatric Surgery, Department of Orthopedic, Swedish Medical Center-First Hill Campus, Seattle, WA
| | - Chad L Seidenstricker
- Third-Year Resident, Division of Podiatric Surgery, Department of Orthopedic, Swedish Medical Center-First Hill Campus, Seattle, WA
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Patrick N, Lewis GS, Roush EP, Kunselman AR, Cain JD. Effects of Medial Displacement Calcaneal Osteotomy and Calcaneal Z Osteotomy on Subtalar Joint Pressures: A Cadaveric Flatfoot Model. J Foot Ankle Surg 2016; 55:1175-1179. [PMID: 27545512 DOI: 10.1053/j.jfas.2016.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Indexed: 02/03/2023]
Abstract
Medial displacement calcaneal osteotomies have been shown to be successful in the surgical management of adult acquired flatfoot, in particular, stage 2 deformity. Classically, the medial displacement calcaneal osteotomy technique has been performed. However, a calcaneal Z osteotomy has been more recently described and applied in the surgical management of flatfoot deformity. Although the potential advantages of the calcaneal Z technique have been reported, data on its effect on the subtalar joint are lacking. A validated flatfoot model was induced in 8 cadaveric feet that had been randomly assigned to either medial displacement calcaneal osteotomy (n = 4) or calcaneal Z osteotomy (n = 4). The feet were loaded through the tibia with a constant ground reaction force of 400 N, with a simultaneous increase in the Achilles tendon force to 300 or 500 N. The subtalar joint pressures were recorded before and after osteotomy. We did not detect any statistically significant differences between the 2 techniques in terms of their effects on subtalar joint pressure.
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Affiliation(s)
- Nathan Patrick
- PGY-5 Orthopaedic Resident, Department of Orthopaedics and Rehabilitation, Penn State Hershey Medical Center, Hershey, PA
| | - Gregory S Lewis
- Assistant Professor, Department of Orthopaedics, Penn State College of Medicine
| | - Evan P Roush
- Research Engineering Specialist, Division of Musculoskeletal Science, Penn State College of Medicine, Hershey, PA
| | - Allen R Kunselman
- Senior Instructor, Department of Public Health Science, Penn State College of Medicine, Hershey, PA
| | - Jarrett D Cain
- Assistant Professor, Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, Penn State Hershey Medical Center, Hershey, PA.
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Ikoma K, Ohashi S, Maki M, Kido M, Hara Y, Kubo T. Diagnostic Characteristics of Standard Radiographs and Magnetic Resonance Imaging of Ruptures of the Tibialis Posterior Tendon. J Foot Ankle Surg 2016; 55:542-6. [PMID: 26872525 DOI: 10.1053/j.jfas.2016.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Indexed: 02/03/2023]
Abstract
The present study aimed to diagnose complete rupture (CR) and longitudinal rupture (LR) of the posterior tibial tendon (PTT) from the magnetic resonance imaging findings in patients with PTT dysfunction and to analyze and compare the radiographs from each group to identify radiographic indicators related to the progression of PTT injury that would allow the radiographic diagnosis of CR. We evaluated 32 feet in 27 patients with PTT dysfunction (mean age 66.5, range 49 to 82, years). Radiographs were used to acquire weightbearing anteroposterior images of the foot, which were used to measure the talonavicular coverage angle. Lateral images of the foot were also acquired with the patients in the standing position. These were used to measure the lateral talometatarsal angle, calcaneal pitch angle, and medial cuneiform-fifth metatarsal height. From the axial MRI findings, the patients were divided into a CR group and an LR group, and the radiographic attributes of the CR group were analyzed. Of the 32 feet in 27 patients, 12 feet (37.5%) in 11 patients displayed CR and 20 feet (62.5%) in 18 patients displayed LR. The talonavicular coverage angle was 48.3° ± 17.3° in the CR group and 33.6° ± 13.6° in the LR group (p = .012), and the talometatarsal angle was -28.8° ± 22.5° in the CR group and -25.4° ± 14.4° in the LR group (p = .596). The calcaneal pitch angle was 10.4° ± 6.7° in the CR group and 10.2° ± 8.0° in the LR group (p = .935). Finally, the medial cuneiform-fifth metatarsal height was -4.2 ± 7.1 mm in the CR group and 2.1 ± 4.7 mm in the LR group (p = .005). When a medial cuneiform-fifth metatarsal height of ≤0 mm or talonavicular coverage angle of ≥50° was used as the diagnostic criterion for CR on weightbearing radiographs, the sensitivity was 71.4%, specificity 88.9%, and diagnostic accuracy 81.3%; hence, we believe these to be satisfactory diagnostic criteria for CR.
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Affiliation(s)
- Kazuya Ikoma
- Associate Professor, Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Suzuyo Ohashi
- Assistant Professor, Department of Rehabilitation Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Maki
- Assistant Professor, Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masamitsu Kido
- Assistant Professor, Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Hara
- Assistant Professor, Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshikazu Kubo
- Professor, Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Cao HH, Tang KL, Lu WZ, Xu JZ. Medial displacement calcaneal osteotomy with posterior tibial tendon reconstruction for the flexible flatfoot with symptomatic accessory navicular. J Foot Ankle Surg 2014; 53:539-43. [PMID: 24856662 DOI: 10.1053/j.jfas.2014.04.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Indexed: 02/03/2023]
Abstract
We investigated the clinical outcomes after medial displacement calcaneal osteotomy with reconstruction of the posterior tibial tendon insertion on the navicular, in patients with flexible flatfoot with accessory navicular symptoms. From December 2008 to July 2011, 16 patients (21 feet) with a flexible flatfoot, symptomatic accessory navicular, and obvious heel valgus underwent medial displacement calcaneal osteotomy and reconstruction with posterior tibial tendon insertion on the navicular bone. The patients were evaluated preoperatively, 6 weeks and 3, 6, and 12 months postoperatively, and every 6 months thereafter. The clinical examination was undertaken using the American Orthopaedic Foot and Ankle Society ankle and midfoot scores. The radiologic assessments included the arch height, calcaneus inclination angle, talocalcaneal angle, and talar first metatarsal angle on the lateral weightbearing radiograph. The talocalcaneal angle and talar first metatarsal angle was assessed on the anteroposterior view of the weightbearing foot. Heel valgus alignment was assessed on the axial hindfoot radiographs. The mean follow-up duration was 28.5 months (range 18 to 48). All patients were satisfied with the clinical results and were pain free 6 months postoperatively. No cases of wound infection or nerve injury developed. The mean American Orthopaedic Foot and Ankle Society score improved from 53.3 ± 6.5 to 90.8 ± 1.4 at the last follow-up visit (p < .01). The improvements in all radiographic parameters were statistically significant between the preoperative and last follow-up examinations (p < .01). The heel valgus of all patients was corrected. Our results have shown that medial displacement calcaneal osteotomy with reconstruction of the posterior tibial tendon insertion on the navicular bone is an effective treatment of flexible flatfoot with symptomatic accessory navicular, associated with excellent clinical outcomes and correction of the deformity.
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Affiliation(s)
- Hong-Hui Cao
- Department of Orthopaedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing People's Republic of China
| | - Kang-Lai Tang
- Department of Orthopaedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing People's Republic of China.
| | - Wei-Zhong Lu
- Department of Orthopaedic Surgery, Traditional Chinese Medical Hospital of Chongqing, Chongqing, People's Republic of China
| | - Jian-Zhong Xu
- Department of Orthopaedic Surgery, Southwest Hospital, Third Military Medical University, Chongqing People's Republic of China
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Xu J, Muhammad H, Wang X, Ma X. Botulinum Toxin Type A Injection Combined With Cast Immobilization for Treating Recurrent Peroneal Spastic Flatfoot Without Bone Coalitions: A Case Report and Review of the Literature. J Foot Ankle Surg 2014; 54:697-700. [PMID: 24774990 DOI: 10.1053/j.jfas.2014.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Indexed: 02/03/2023]
Abstract
Peroneal spastic flatfoot is an uncommon condition. It often presents as a rigid and usually painful valgus deformity in the hindfoot with peroneal muscles spasms. Although tarsal coalition is an important cause, a few patients have not undergone bone coalitions. We describe a 27-year-old female who experienced recurrent peroneal spastic flatfoot after an injury. She was treated successfully with a combination of botulinum toxin type A and immobilization of the foot in a neutral position with a cast. After 3 years, the condition had not recurred, and she was pain free and walked normally, with no increase in muscle tone. This unique treatment could be of potential use to treat many patients with such conditions.
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Affiliation(s)
- Jian Xu
- Resident, Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Hassan Muhammad
- Resident, Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Wang
- Associate Professor, Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Ma
- Professor, Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China.
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