Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit

PURPOSE

We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents.

METHODS

A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test.

RESULTS

The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal.

CONCLUSION

Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

[Flatfoot in children]

The diagnosis of flatfoot in children is made clinically. In most cases it is an age-appropriate benign physiological variant, as long as it can be passively and actively redressed and the child does not show any neurological abnormalities, especially under the age of 6 years. Treatment is only indicated for symptomatic variants. In the case of rigid flatfeet, further diagnostics are necessary to exclude neurological or structural causes. Subtalar arthroereisis has become established and is an effective but slightly invasive procedure. Further options include the lengthening and medial translational osteotomy of the calcaneus or the Cotton operation; however, the indications must always be critically questioned, especially for surgical but also for conservative treatment, even if it is the wish of the family.

Patient Reported Outcomes Following Triple Arthrodesis for Adult Acquired Flat Foot Deformity: Minimum Two Year Follow Up

The aim of this study is to analyze patient-reported outcomes following this procedure as well as any demographics that may confer prognostic capability. A retrospective analysis was conducted of patients who underwent Triple Arthrodesis at our facility from 2014-2021. Patients were selected if they underwent an isolated triple arthrodesis. All cases included either a gastrocnemius recession versus a percutaneous tendo-achilles lengthening depending on the patient's Silverskiold examination. The electronic medical record was utilized to collect basic patient demographics, previous foot and ankle surgeries, hardware failures, additional procedures, and surgical complications. To evaluate outcomes, we compared patient reported outcomes measurement information system (PROMIS) survey scores with the general population and preoperative versus postoperative visual analog scale (VAS) scores. Foot function index (FFI) scores and scores were utilized as a validation tool for our results. A total of 132 patients met the criteria for our study with a total of 50 participants completing the PROMIS and FFI surveys. The average time point at which the outcomes were collected was 5.50 y postoperatively, ranging from 1.65 to 7.57 y. The average PROMIS physical function was 38.35, pain interference was 61.52, and depression was 49.82 for this population. The mean FFI scores were 58.56 for pain, 60.07 for disability, and 48.07 for activity limitation. There was a significant decrease in preoperative and postoperative VAS scores from 5.4 to 2.55 (p < .001). Three patients experienced wound complications related to decreased sensation. Our results indicated that only PROMIS depression scores were within one standard deviation of the population mean following a triple arthrodesis procedure. PROMIS physical function and pain interference were both outside of one standard deviation for the population.

Flatfoot Reconstruction for Painful Pediatric Idiopathic Flexible Flatfoot: Prospective Study Demonstrates Improved Alignment, Function, and Patient-reported Outcomes

BACKGROUND

This prospective study was undertaken to report outcomes following reconstructive surgery for patients with painful pediatric idiopathic flexible flatfoot.

METHODS

Twenty-five patients with pediatric idiopathic flexible flatfoot were evaluated pre- and post flatfoot reconstruction with lateral column lengthening (LCL). All patients had lengthening of the Achilles or gastrocnemius, while 13 patients had medial side soft tissue (MSST) procedures, 7 underwent medial cuneiform plantarflexion osteotomy (MCPO), and 5 had medializing calcaneal osteotomy. Measures of static foot alignment-both radiographic parameters and clinical arch height indices-were compared, as were measures of dynamic foot alignment and loading, including arch height flexibility and pedobarography. Preoperative and postoperative patient-reported outcome (PRO) scores were compared between those treated with or without MSST procedures.

RESULTS

The median subject age was 13.8 years (range: 10.3 to 16.5) at the time of surgery. All radiographic parameters improved with surgery ( P <0.001). The mean sitting arch height index showed a modest increase after surgery ( P =0.023). Arch height flexibility was similar after surgery. The mean center-of-pressure excursion index increased from 14.1% to 24.0% ( P <0.001), and the mean first metatarsal head (MH) peak pressure dropped ( P <0.001), while the mean fifth MH peak pressure increased ( P =0.018). The ratio of peak pressure in the fifth MH to peak pressure in the second MH increased ( P =0.010). The ratio of peak pressure in the first MH to peak pressure in the second MH decreased when an MCPO was not used ( P <0.002), but it remained stable when an MCPO was included. Mean scores in all PRO domains improved ( P <0.001). Patients treated without MSST procedures showed no difference in PROMIS Pain Interference scores compared to those without MSST procedures.

CONCLUSIONS

Flatfoot reconstruction surgery using an LCL with plantarflexor lengthening results in improved PROs. LCL changes but does not normalize the distribution of MH pressure loading. The addition of an MCPO can prevent a significant reduction in load-sharing by the first MH.

Medial column fusion for degenerative pesplanovalgus deformity. Report of 9 patients

Degenerative pesplanovalgus is a progressive disabling condition; there are more than one surgical procedure used in the treatment with varied outcomes. The aim of the current study is to highlight the benefits of the medial column fusion surgery in the treatment of this condition. Nine adult patients with rigid degenerative pesplanovalgus (without significant valgus heel deformity) underwent medial column fusion between January 2015 to December 2020. The procedure was combined with subtalar fusion in four patients and lateral column lengthening in one patient. The mean follow-up period was 19.5 months (range, 15-27). Regular clinical and radiological reviews was carried out in the postoperative period. The mean Manchester Oxford foot score was good in 7 patients, and fair in two patients. The mean Meary angle was 5.8 ± 5.4° preoperatively and improved to 0.9 ± 7.7° at final follow-up, and the mean Pitch angle also improved from 12.5 ± 3.7° preoperatively to 23.2 ± 4.1° (P < .001). In a patient, and at a different stage, talo-navicular fusion was added to the medial column fusion.The outcome of this series of cases was encouraging and medial column fusion continues to be a good option in the management of rigid pesplanovalgus deformity.

Minimally invasive surgery in medial displacement calcaneal osteotomy for acquired flatfoot deformity: a systematic review of the literature

BACKGROUND

Minimally invasive surgery (MIS) in medial displacement calcaneus osteotomy (MDCO) has been proposed for surgical correction of adult-acquired flat foot deformity (AAFD) to reduce complications of open approaches. The aim of our study is to systematically analyze complications and the clinical and radiological results of MIS- MDCO.

METHODS

A systematic review of the English literature was performed on 30th October 2023. Randomized controlled trials and non-randomized trials, cohort studies, case-control studies and case series concerning surgical correction of AAFD with MIS-MDCO and with at least 15 patients were included. Case reports, technical notes, animal or cadaveric studies were excluded. The quality and risk of bias of the studies included were evaluated using GRADE and MINORS systems. Complications rate, clinical and radiological results were inferred from the studies included.

RESULTS

Nine articles were included. A total of 501 cases treated with MIS-MDCO were analysed with a mean follow-up of 11.9 ± 5.1 months. The reported wound infection rate was about 3% and sural neuropathy was rated about 1%. Only 4% of the cases required removal of the screw for pain. In the comparative studies (MIS versus Open MDCO), comparable clinical results but with significant differences (P < 0.001) in infection rates (1% versus 14%) and sural neuropathy (2% versus 1%) were observed.

CONCLUSION

AAFD correction performed with MIS-MDCO, with the limitation of a poor quality and high risk of bias of the included studies, seems to provide good clinical results and high subjective satisfaction with a lower complication rate compared to open approach. Further high-quality long-term comparative studies could better clarify complications and clinical and radiological outcomes of the MIS technique in the treatment of AAFD.

LEVEL OF EVIDENCE

Level IV.

Biomechanical Effects of Subtalar Joint Fusion and Medial Ligament Reconstruction in Simulated Progressive Collapsing Foot Deformity

BACKGROUND

The purpose of this study is to investigate the biomechanical effect of medial displacement calcaneal osteotomy (MDCO), subtalar joint fusion (SF), and medial ligament reconstruction (MLR: deltoid-spring ligament) in a severe flatfoot model. We hypothesized that (1) combination of MDCO and SF improves the tibiotalar and foot alignment in severe progressive collapsing foot deformity (PCFD) cadaver model. (2) However, if a residual valgus heel alignment remains after MCDO and SF, it can lead to increased medial ligament strain, foot malalignment, and tibiotalar valgus tilt, which will be mitigated by the addition of MLR.

METHODS

Ten fresh-frozen cadaveric foot specimens were used to create a severe flatfoot model. The foot alignment changes, including the talo-first metatarsal angle in the axial and sagittal planes, subtalar angle, and tibiotalar angle in the coronal plane, were measured. The angles were measured at the initial condition, after creating the severe flatfoot model, and after each successive reconstructive procedure in the following order: (1) MDCO, (2) SF, and (3) MLR.

RESULTS

Tibiotalar valgus tilt was decreased with the MDCO procedure: 4.4 vs 1.0 degrees (P = .04). Adding in situ SF to the MDCO led to increased tibiotalar tilt to 2.5 degrees was different from the initial condition (P = .01). Although the tibiotalar valgus tilt was significantly decreased after adding the MLR to the MDCO/SF procedure compared with the severe flatfoot model (0.8 vs 4.4 degrees, P = .03), no significant difference in the tibiotalar valgus tilt was observed between MDCO/SF and MDCO/SF with MLR.

CONCLUSION

Our results demonstrated that MDCO significantly improved forefoot abduction and medial arch alignment, with no significant additional improvement observed with addition of SF. Following SF, a residual valgus heel alignment can contribute to subsequent tibiotalar valgus tilt. The addition of MLR did not show significantly decreased tibiotalar valgus tilt following SF.

CLINICAL RELEVANCE

Residual valgus heel alignment after subtalar joint fusion in the surgical treatment of PCFD can lead to increased medial ligament strain. Although MLR might be considered for providing medial stability, it may not necessarily prevent the development of tibiotalar valgus tilt.

Does the Presence of Asymptomatic Flatfoot Deformity Impact the Clinical and Radiographic Outcomes of the Minimally Invasive Chevron and Akin Bunionectomy?

BACKGROUND

Flatfoot deformity is believed to play a role in hallux valgus development and recurrence. While symptomatic flatfoot deformity can be treated with separate procedures at the time of hallux valgus correction, the question remains whether the patient undergoing correction of a symptomatic hallux valgus deformity should have their asymptomatic flatfoot concurrently addressed. We aimed to investigate whether the presence of asymptomatic flatfoot influences patient-reported and radiographic outcomes of the minimally invasive chevron and Akin bunionectomy.

METHODS

A total of 104 patients were included in this study. Forty-two asymptomatic patients met the radiographic criteria for flatfoot while 62 had a normal arch. Patient-reported outcomes were evaluated and compared between the two groups using validated PROMIS measures preoperatively and at a minimum one-year postoperatively. Radiographic outcomes including hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary's angle, calcaneal pitch (CP), and talonavicular coverage angle (TNCA) were measured and compared preoperatively and minimum six-months postoperatively.

RESULTS

Both groups demonstrated similar preoperative and postoperative PROMIS scores with significant improvements in physical function, pain interference, pain intensity, and global physical health. Preoperatively, HVA was similar between both groups, however the flatfoot group showed a greater IMA, Meary's angle, TNCA, and lower CP. Postoperatively, HVA and IMA were similar between groups, although patients in the flatfoot group retained a significantly greater Meary's angle, TNCA, and lower CP. Both groups showed significant improvements in HVA, IMA, and TNCA.

CONCLUSION

Our study indicates that the minimally invasive chevron and Akin bunionectomy leads to improved clinical and radiographic hallux valgus outcomes without adversely impacting radiographic flatfoot parameters. Therefore, the MIS bunionectomy may be an effective option for hallux valgus correction in patients with mild, asymptomatic flatfoot.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

"Biological Fixation" of Flexor Digitorum Longus: A New Modification of Tendon Transfer for Treatment of Posterior Tibialis Tendon Dysfunction

Numerous surgical procedures for the treatment of posterior tibialis tendon (PTT) dysfunction have been developed, including tendon transfers, osteotomies, and arthrodesis. Among these methods, foot and ankle surgeons most frequently use flexor digitorum longus (FDL) tendon transfer in conjunction with medial translational osteotomy of the calcaneus. Formerly, some less invasive techniques have been described to reduce surgical-related complications after FDL tendon transfer. Herein, we introduced a new modification of short-stump FDL tendon fixation to the navicular bone and reported the functional outcomes of the current technique in a patient with PTT dysfunction. In the current technique, the FDL tendon was fixed to the navicular bone via a trans-osseous tunnel using a split PTT stump. This method does not require any kind of fixation devices, such as an interference screw or anchor suture.Level of Evidence: V.

Endoscopic assisted flexor digitorum longus transfer in flexible flatfoot

BACKGROUND

Posterior tibial tendon insufficiency is the commonest cause of adult flexible flatfoot. Transfer of the flexor digitorum longus (FDL) has been described a therapeutic arsenal in flexible flat feet and posterior tibial tendon disorders. It is often combined with bony procedure (open or percutaneous calcaneal osteotomy).

METHODS

We describe a technique and the steps endoscopic approach of FDL transfer.

RESULTS

The procedure is able to be performed safely and reproducible under perfect viewing CONCLUSION: In the future with a clinical study investigating, we purpose the results of such surgery in a cohort of patients with flexible flatfoot. Level IV Therapeutic study: case serie. No funding was received for this research project.

Biomechanical effects of Evans versus Hintermann osteotomy for treating adult acquired flatfoot deformity: a patient-specific finite element investigation

BACKGROUND

Evans and Hintermann lateral column lengthening (LCL) procedures are both widely used to correct adult acquired flatfoot deformity (AAFD), and have both shown good clinical results. The aim of this study was to compare these two procedures in terms of corrective ability and biomechanics influence on the Chopart and subtalar joints through finite element (FE) analysis.

METHODS

Twelve patient-specific FE models were established and validated. The Hintermann osteotomy was performed between the medial and posterior facets of the subtalar joint; while, the Evans osteotomy was performed on the anterior neck of the calcaneus around 10 mm from the calcaneocuboid joint surface. In each procedure, a triangular wedge of varying size was inserted at the lateral edge. The two procedures were then compared based on the measured strains of superomedial calcaneonavicular ligaments and planter facia, the talus-first metatarsal angle, and the contact characteristics of talonavicular, calcaneocuboid and subtalar joints.

RESULTS

The Hintermann procedure achieved a greater correction of the talus-first metatarsal angle than Evans when using grafts of the same size, indicating that Hintermann had stronger corrective ability. However, its distributions of von-Mises stress in the subtalar, talonavicular and calcaneocuboid joints were less homogeneous than those of Evans. In addition, the strains of superomedial calcaneonavicular ligaments and planter facia of Hintermann were also greater than those of Evans, but both generally within the safe range (less than 6%).

CONCLUSION

This FE analysis study indicates that both Evans and Hintermann procedures have good corrective ability for AAFD. Compared to Evans, Hintermann procedure can provide a stronger corrective effect while causing greater disturbance to the biomechanics of Chopart joints, which may be an important mechanism of arthritis. Nevertheless, it yields a better protection to the subtalar joint than Evans osteotomy.

CLINICAL RELEVANCE

Both Evans and Hintermann LCL surgeries have a considerable impact on adjacent joints and ligament tissues. Such effects alongside the overcorrection problem should be cautiously considered when choosing the specific surgical method.

LEVEL OF EVIDENCE

Level III, case-control study.

In silico comparative biomechanical analysis of oblique and chevron medial displacement calcaneal osteotomies for pes planus deformity

BACKGROUND

Medializing displacement calcaneal osteotomy is commonly performed as part of reconstructive surgery for patients with valgus hindfoot and progressive pes planus deformity. Among several types of calcaneal osteotomies, the oblique and Chevron osteotomy patterns have been commonly described in the literature and gained popularity as they are easily reproducible through percutaneous techniques. Currently, there is scarce evidence in the literature on which cut pattern is superior in terms of stability. To investigate the impact of cut pattern and posterior fragment medialization level on foot biomechanics, computational methods are employed.

METHODS

Ankle weightbearing computer tomography (CT) scans of seven patients diagnosed with stage II pes planus deformity are segmented and converted into 3D computational models. Oblique and Chevron osteotomy patterns are modeled independently for each patient. The posterior fragments are medially translated by 8-, 10- and 12-mm and subsequently fixated to the anterior calcaneus with two screws. A total of 42 models are exported to finite element software for biomechanical simulations. Among the investigated parameters, the higher stiffness and lower von Mises stress at the osteotomy interface and the screw site are assumed to be precursors of better stability.

RESULTS

It is recorded that as the medialization level increases, the stiffness decreases, and overall stresses increase. Also, it is observed that the Chevron cut produces a stiffer construct while the overall stresses are lower, indicating better stability when compared to the oblique cut. The statistical comparisons of the relevant groups that support these trends are found to be significant (p < 0.05).

CONCLUSION

Chevron osteotomy showed superior stability compared to the oblique osteotomy while underscoring the negative impact of increased medialization of the posterior fragment.

CLINICAL RELEVANCE

Opting for a lower medialization level and implementing the Chevron technique may facilitate union and earlier weightbearing.

Medializing Calcaneal Osteotomy for progressive collapsing foot deformity alters the three-dimensional subtalar joint alignment

BACKGROUND

A medializing calcaneal osteotomy (MCO) is considered as one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the post-operative hind- and midfoot alignment, alternations of the subtalar joint alignment remained obscured by superposition on plain radiography. Therefore, we aimed to assess the hind-, midfoot- and subtalar joint alignment pre- compared to post-operatively using 3D weightbearing CT (WBCT) imaging.

METHODS

Seventeen patients with a mean age of 42 ± 17 years were retrospectively analyzed. Inclusion criteria consisted of PCFD deformity corrected by a medializing calcaneal osteotomy (MCO) as main procedure and imaged by WBCT before and after surgery. Exclusion criteria were patients who had concomitant calcaneal lengthening osteotomies, mid-/hindfoot fusions, hindfoot coalitions, and supramalleolar procedures. Image data were used to generate 3D models and compute the hindfoot (HA), midfoot (MA) - and subtalar joint (STJ) alignment in the coronal, sagittal and axial plane, as well as distance maps.

RESULTS

Pre-operative measurements of the HA and MA improved significantly relative to their post-operative equivalents p < 0.05). The post-operative STJ alignment showed significant inversion (2.8° ± 1.7), abduction (1.5° ± 1.8), and dorsiflexion (2.3° ± 1.7) of the talus relative to the calcaneus (p < 0.05) compared to the pre-operative alignment. The displacement between the talus and calcaneus relative to the sinus tarsi increased significantly (0.6 mm±0.5; p < 0.05).

CONCLUSION

This study detected significant changes in the sagittal, coronal, and axial plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings contribute to our clinical practice by demonstrating the magnitude of alteration in the subtalar joint alignment that can be expected after PCFD correction with MCO as main procedure.

Feasibility and safety of minimally invasive calcaneal osteotomy (MICO) through a medial approach: a case-control study

INTRODUCTION

Minimally invasive calcaneal osteotomy (MICO) is already an established surgical procedure for correcting hindfoot deformities using a lateral approach. So far, no description of a medial approach for MICO has been published.

MATERIAL AND METHODS

Between August 2022 and March 2023, 32 consecutive patients (MICO with medial approach, MMICO: n = 15; MICO with lateral approach, LMICO: n = 17) underwent MICO as part of complex reconstructive surgery of the foot and ankle with concomitant procedures. The amount of correction in the axial view of the calcaneus and consolidation rates were evaluated radiographically. Subjective satisfaction, stiffness of the subtalar joint, and pain level (numeric rating scale, NRS) at the level of the heel were assessed clinically. The last follow-up was at 6 months.

RESULTS

All osteotomies consolidated within 6 months after surgery. Displacement of the tuber was 9 mm on average in either group. Relevant subtalar joint stiffness was detected in 5 MMICO and 6 LMICO patients. No relevant differences between the groups were detected for wound healing problems, nerve damage, heel pain or patient satisfaction.

CONCLUSION

In this study lateral and medial approaches for MICO were performed. Similar degrees of correction and low complication rates were found in both groups. The medial approach for MICO is safe and can be beneficial regarding patient positioning and arrangement of the C‑arm.

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.

A 28-Year-Old Woman with Down Syndrome, Congenital Heart Disease, and a History of Knee Surgery and Plantar Fasciitis, with Hallux Abducto Valgus (Bunion) and Lapiplasty Three-Dimensional Correction Surgery

BACKGROUND Tarsometatarsal joint (TMJ) arthrodesis is common method used for correcting hallux abductus valgus (HAV). Its popularity has grown due to studies revealing HAV's triplanar deformity with frontal plane rotation. This case report presents a 28-year-old woman with Down syndrome, congenital heart disease, and a history of knee surgery and plantar fasciitis, with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. CASE REPORT Examination revealed severe foot deformities, and radiographic studies confirmed the condition. A surgical intervention was planned, and the patient's cardiologist confirmed she was fit for the procedure. The modified Lapidus technique with frontal plane rotational correction included realigning the metatarsal joint, resecting spurs, osteosynthesis material, and arthrosis in the sinus tarsi. After surgery, the patient underwent a recovery period without support for 8 weeks and received appropriate medical care. Radiographs showed successful alignment, and the patient gradually resumed her daily activities. The patient had an uneventful recovery, and postoperative radiographs showed good alignment in all planes. CONCLUSIONS The hyperlaxity associated with Down syndrome makes the incidence of HAV more frequent, and TMJ fusion is preferable to correction by osteotomy. The modified Lapidus technique with frontal plane rotational correction could be a good technique to achieve satisfactory correction in patients with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. TMJ fusion is indicated when severe or recurrent rotational component is observed in X-rays.

[A painful collapse: the flat foot management]

Flatfoot is a progressive deformity with a collapse of the foot. Its therapeutic approach has undergone a conceptual shift. Initially focused on posterior tibial tendon insufficiency, it is now defined by a sum of anatomical alterations resulting in a three-dimensional deformity. If the deformity is symptomatic, we look for hindfoot valgus, forefoot abduction and varus, as well as valgus ankle instability. The clinical rigidity of the deformities and the weight-bearing radiological examinations help guide treatment. Although plantar supports and rigid orthoses are sufficient for mild cases, surgical treatment using bone, ligament, tendon or even prosthetics procedures are the final stage of management for severe cases.

Changes in gait pattern and quality of life of adolescents with flexible flat foot after Calcaneal Lengthening Osteotomy

BACKGROUND

Calcaneal Lengthening Osteotomy is a surgical technique to correct flexible flat foot deformities in patients who did not show any change in their symptoms after conservative treatment. In this study, the effects of CLO on the kinematic and kinetic changes of gait was analyzed and the clinical and quality of life improvements in children treated by CLO for moderate to severe symptomatic flexible flat foot deformities were assessed.

METHODS

Participants were seven adolescents (13 feet) with symptomatic FFF who underwent during 2019-2022 and seven (10 feet) healthy children as control group. Three items were evaluated in each foot before and after surgery including: 1. Clinical examination 2.quality of life (using Pediatric Quality of Life Inventory version 4 questionnaire) 3. Gait analysis (Vicon motion systems, Oxford metrics Inc., UK). Also, the kinetic and kinematic analysis between patients and healthy groups were compared.

RESULTS

Kinematic results of control was significantly better than FFF group. Ankle range of motion(32.94 ± 13.39 compared to 32.94 ± 13.39,P-Value:0.01),foot progression angle (-9.26 ± 7.67 compared to -16.07 ± 9.00,P-Value:0.01),and internal rotation of ankle was higher in control group compared to FFF. FFF patients demonstrated improvement in kinematic results after CLO surgery. Foot progression angle was improved after surgery (-11.31 ± 6.07 compared to -16.19 ± 7.06, P-value:0.00), maximum plantar flexion decreased after CLO surgery due to achil tendon procedure during CLO surgery. Kinetic results of FFF patients showed significant increase in ankle Power in coronal and transverse plane, Also knee and hip power showed similar results.Quality of life parameters showed significant improve in all parameters (Physical,Social, emotional and school function), Also ADKE and ADKF improved after surgery.

CONCLUSION

CLO surgery significantly improved patients' quality of life of patients with symptomatic FFF. Also, kinetic results showed improvement in some parameters of gait results after CLO surgery. Thus, our study suggested CLO surgery as an excellent surgical option for symptomatic FFF.

Effect of flatfoot correction on the ankle joint following lateral column lengthening: A radiographic evaluation

OBJECTIVES

The effects of foot deformities and corrections on the ankle joint without osteoarthritis has received little attention. This study aimed to investigate the effect of flatfoot correction on the ankle joint of patients without osteoarthritis.

METHODS

Thirty-five patients (24 men and 11 women; mean age 17.5 years) who underwent lateral column lengthening for flatfoot deformities were included. The mean postoperative follow-up period was 20.5 months (standard deviation [SD]: 15.7 months). Radiographic indices were measured pre- and postoperatively, including anteroposterior (AP) and lateral talo-first metatarsal angles, naviculocuboid overlap, position of the articulating talar surface, and lateral talar center migration. Postoperative changes in the radiographic indices were statistically analyzed.

RESULTS

There was significant postoperative improvement in flatfoot deformity in terms of AP and lateral talo-first metatarsal angles (p<0.001 and p<0.001, respectively) and naviculocuboid overlap (p<0.001). On lateral radiographs, the talar articulating surface dorsiflexed by 7.3% (p<0.001), and the center of the talar body shifted anteriorly by 0.85 mm (p<0.001) postoperatively.

CONCLUSIONS

Flatfoot correction using lateral column and Achilles tendon lengthening caused dorsiflexion and an anterior shift of the articular talar body in patients without osteoarthritis. Correction of flatfoot deformity might affect the articular contact area at the ankle joint. The biomechanical effects of this change need to be investigated further.

Surgical management of clubfoot overcorrection: a case series

INTRODUCTION

Overcorrection is a possible complication of clubfoot treatment, whose prevalence varies from 5 to 67%. Overcorrected clubfoot usually presented as a complex flatfoot with different degrees of hindfoot valgus, flat top talus, dorsal bunion, and dorsal navicular subluxation. The management of clubfoot overcorrection is challenging, and both conservative and surgical treatments are available. This study aims to present our experience in the surgical management of overcorrected clubfoot and to provide an overview of actual treatment options for each specific sub-deformity.

MATERIALS AND METHODS

A retrospective cohort study of patients surgically treated for an overcorrected clubfoot from 2000 to 2015 at our Institution was conducted. Surgical procedures were tailored to the type and symptomatology of the deformity. A medializing calcaneal osteotomy or subtalar arthrodesis was performed for hindfoot valgus. Subtalar and/or midtarsal arthrodesis were considered in cases of dorsal navicular subluxation. The first metatarsus elevatus was addressed through a proximal plantarflexing osteotomy, sometimes associated with a tibialis anterior tendon transfer. Clinical scores and radiographic parameters were obtained pre-operatively and at the last follow-up.

RESULTS

Fifteen consecutive patients were enrolled. The series included 4 females and 11 males, with a mean age at surgery of 33,1 (18-56) years, and a mean follow-up of 4,46 (2-10) years. Seven medializing calcaneal osteotomies, 5 subtalar arthrodesis, 11 first metatarsal plantarflexing osteotomies, and 7 anterior tibialis tendon transfers were performed. A statistically significant improvement in both clinical and radiographic scores was observed.

CONCLUSIONS

Management of overcorrected clubfoot involves many surgical techniques because of the high interpersonal variability of the deformities. The surgical approach showed positive results, as long as the indication is based on clinical symptoms and functional impairment rather than morphological alterations and radiographic findings.

Effect of Peritalar Subluxation Correction for Progressive Collapsing Foot Deformity on Patient-Reported Outcomes

BACKGROUND

Peritalar subluxation (PTS) is part of progressive collapsing foot deformity (PCFD). This study aimed to evaluate initial deformity correction and PTS optimization in PCFD patients with flexible hindfoot deformity undergoing hindfoot joint-sparing surgical procedures and its relationship with improvements in patient-reported outcome measures (PROMs) at latest follow-up. We hypothesized that significant deformity/PTS correction would be observed postoperatively, positively correlating with improved PROMs.

METHODS

A prospective comparative study was performed with 26 flexible PCFD patients undergoing hindfoot joint-sparing reconstructive procedures, mean age 47.1 years (range, 18-77). We assessed weightbearing computed tomography (WBCT) overall deformity (foot and ankle offset [FAO]) and PTS markers (distance and coverage maps) at 3 months, as well as PROMs at final follow-up. A multivariate regression model assessed the influence of initial deformity correction and PTS optimization in patient-reported outcomes.

RESULTS

Mean follow-up was 19.9 months (6-39), and the average number of procedures performed was 4.8 (2-8). FAO improved from 9.4% (8.4-10.9) to 1.9% (1.1-3.6) postoperatively (P < .0001). Mean coverage improved by 69.6% (P = .012), 12.1% (P = .0343) and 5.2% (P = .0074) in, respectively, the anterior, middle, and posterior facets, whereas the sinus tarsi coverage decreased by an average 57.1% (P < .0001) postoperatively. Improvements in patient-reported outcomes were noted for all scores assessed (P < .03). The multivariate regression analysis demonstrated that improvement in both FAO and PTS measurements significantly influenced the assessed PROMs.

CONCLUSION

This study demonstrated significant improvements in the overall 3D deformity, PTS markers, and PROMs following hindfoot joint-sparing surgical treatment in patients with flexible PCFD. More importantly, initial 3D deformity correction and improvement in subtalar joint coverage and extraarticular impingement have been shown to influence PROMs significantly and positively. Addressing these variables should be considered as goals when treating PCFD.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Relationship Between Obesity and Medial Longitudinal Arch Bowing

BACKGROUND

There have been reports about the association between obesity and the medial longitudinal arch (MLA) of foot. The purpose of this study is to investigate the change of various parameters related to the MLA according to obesity classification severity by the World Health Organization using weightbearing computed tomography (WBCT).

METHODS

WBCT data of the noninvolved side of patients presenting with unilateral foot and ankle problems or healthy candidates from September 2014 to October 2022 were extracted from a single referral hospital. Forty-four cases in each of 5 obesity classes were selected sequentially. Two orthopaedic surgeons measured foot and ankle offset, forefoot arch angle (FAA), hindfoot moment arm, percentage of uncoverage of the middle facet of the subtalar joint, talonavicular angle (TNA), navicular-medial cuneiform angle, medial cuneiform-first metatarsal angle, talus-first metatarsal angle (TMT1A), first tarsometatarsal subluxation (TMT1S), talonavicular coverage angle, navicular floor distance (NFD), and NFD per height. Positive values indicate plantar collapse. Intra- and interobserver reliabilities were assessed using intraclass correlation coefficients. One-way analysis of variance tests were performed for parametric data with equal variances, and Welch's test for unequal variances. Kruskal-Wallis test was performed for nonparametric data. Post hoc analysis was performed for statistically significant parameters. Correlation analysis between body mass index (BMI) and 12 parameters were performed using Pearson test.

RESULTS

Intraobserver and interobserver reliability were excellent, except for TMT1S. The TNA and TMT1A showed a statistically significant difference. FAA (r = -0.2), TNA (r = 0.182), TMT1A (r = 0.296), and NFD (r = -0.173) showed a statistically significant correlation with BMI.

CONCLUSION

In nonsymptomatic feet, we found that the talonavicular joint, as measured by the TNA, to be influenced by obesity classification. Obesity and increased BMI was associated with a negative influence on the MLA.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.

[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.

[Comparation of outcomes of iliac crest bone graft and accessory navicular bone graft in the Cotton osteotomy for pediatric and adolescent flexible flatfoot]

Objective: To compare the outcomes between iliac crest and accessory navicular as different bone grafts in the Cotton osteotomy in the treatment of pediatric flexible flatfoot deformity. Methods: A retrospective cohort study. The clinical data of pediatric flexible flatfoot patients with symptomatic accessory navicular received operations from July 2018 to March 2022 in Beijing Tongren Hospital were retrospectively analyzed. All the patients were treated with Cotton osteotomy. According to the different sources of bone grafting in Cotton osteotomy, the patients were divided into iliac crest group and accessory navicular group. There were 12 patients (19 feet) in iliac crest group, including 9 males and 3 females with a median age M(Q1, Q3) of 11(11, 12) years and were followed-up for 36(6, 48) months. There were 9 patients (16 feet) in accessory navicular group, including 6 males and 3 females, with a median age M(Q1, Q3) of 11(11, 11) years and were followed-up for 12(6, 17) months. Radiographic evaluations were reviewed and compared between the two groups before surgical treatment and at final follow-up, included talo-1st metatarsal angle (T1MT), talonavicular coverage angle (TNCA), talocalcaneal angle (TCA) in weight bearing anteroposterior view, and Meary angle, calcaneal Pitch angle, Kite angle, cuneiform articular angle (CAA) in weight bearing lateral view, and hindfoot alignment angle (HAA) in calcaneal long axial view. Functional scores included American Orthopedic Foot and Ankle Society (AOFAS), visual analog scale (VAS), and Maryland scores were recorded and compared before and after the operation. The complications were also recorded. Results: Total of 21 patients were successfully followed in this study. The radiographic measurements in the two groups, such as T1MT, TNCA, Meary angle, Pitch angle, Kite angle, CAA, HAA, were all significantly improved at the last follow-up when compared with those before the surgery (all P<0.05); and the AOFAS, VAS, Maryland scores in both groups were all improved after the surgery (all P<0.05). There was a significant difference in CAA alteration (∆CAA) after the operation between the two groups, the ∆CAA in iliac crest group and the accessory navicular group was 6.0°±2.6° and 4.3°±1.3°, respectively (P=0.017). There was no significant differences in the improvement of other radiographic measurements between the two groups (all P>0.05). All the patients had a successful bone union. Two patients had donor site pain in the iliac crest group and were treated conservatively. Conclusion: Compared with iliac crest bone graft, accessory navicular bone graft could achieve comparable outcomes in radiographic measurements and functional scores in the treatment of pediatric flexible flatfoot with accessory navicular pain.

[Pelvic coronal inclination change in adolescent flexible flatfoot surgically treated with arthroereisis]

Objective: To evaluate adolescent pelvic coronal inclination angle change after flatfoot treated with arthroereisis. Method: A case-series study. From June 2018 to September 2020, 25 children with flexible flat foot and pelvic obliquity were included in this retrospective study in Peking University Shenzhen Hospital. There were 17 males and 8 females with a mean age of (11.2±2.2) years (9-15 years). There were 5 cases of unilateral flatfoot and 20 cases of bilateral flatfoot. All of the patients were surgically treated with arthroereisis. Regular follow-up was done in 3 months, 1 and 2 years postoperatively. Weightbearing fluoroscopy of entire lower limb and foot were investigated to measure Meary's angle, calcaneal pitch angle, height difference at ankle and pelvic plane, pelvic inclination and sacrum-iliac distance (F value) on coronal plane. Results: The mean Mearys' angle at 3 month postoperatively was improved when compared with that before the operation (3.1°±1.5° vs 25.9°±4.3°, P<0.001), and it remained at the same level 2 years after the operation (compared with that at 1 year after the operation, P=0.748). The calcaneal pitch angle improved significantly at 3-month follow-up when compared with that before the operation (16.6°±2.4° vs 9.9°±1.5°, P<0.001), and there was no significant change between 1 year and 2 years after operation (P=0.542). The height difference at mortise plane were also reduced at the 3-month follow-up(P<0.001), and it remained at the same level at 1 year and 2 years after the operation (P=0.159). Pelvic height difference decreased dramatically from (12.4±1.7) mm (before operation) to (7.1±1.2) mm(3 month after the operation) (P<0.001), it decreased to (3.6±1.8) mm 1 year after the operation (compared with that at 3 months after the operation, P<0.001), and no further reduction was observed 2 years after the surgery (P=0.483). The pelvic inclination angle and sacrum-iliac distance were also improved at 3-month follow-up when compared with those before the operation (both P<0.001), and they declined further 1 year after the operation(both P<0.05), but the decreasing trend disappeared at the 2-year follow-up (both P>0.05). Conclusion: For adolescent flexible flat foot patients with pelvic obliquity, the coronal inclination and pelvic height discrepancy would partially recovered with correction of flatfoot deformity, but it could not be completely corrected in the mean follow-up period of 2 years after the operation.

Incidence and predictors of valgus tibiotalar tilt after progressive collapsing foot deformity reconstruction using subtalar fusion with concomitant procedures

PURPOSE

Development of valgus tibiotalar tilt is a significant complication after subtalar fusion for progressive collapsing foot deformity (PCFD) correction. However, its incidence and etiologic factors have not been extensively studied. The purpose of this study was to define the incidence of valgus tibiotalar tilt after subtalar fusion for PCFD reconstruction, and to determine predictors of this complication.

METHODS

This study included 59 patients who underwent PCFD reconstruction with subtalar fusion. Patients with tibiotalar tilt prior to surgery were excluded. On standard weightbearing radiographs, the talonavicular coverage angle, talo-1st metatarsal angle, calcaneal pitch, hindfoot moment arm (HMA), and medial distal tibial angle were measured. Weightbearing computed tomography (WBCT) was used to determine the presence of lateral bony impingement. A radiologist evaluated the superficial and deep deltoid ligaments using magnetic resonance imaging (MRI). Univariate regression analysis was used to identify the factors associated with development of postoperative valgus tibiotalar tilt, defined as tilt > 2 degrees.

RESULTS

Seventeen patients (28.8%) developed postoperative valgus tibiotalar tilt at a mean of 7.7 (range 2-31) months. Eight (47.1%) of these patients developed valgus tibiotalar tilt within 3 months. Univariate logistic regression demonstrated association between preoperative HMA and postoperative valgus tibiotalar tilt (odds ratio 1.06, P = 0.026), with a 6% increase in risk per millimeter of increased HMA. Deltoid ligament status and concomitant procedures on other joints did not correlate with postoperative valgus tilt.

CONCLUSION

Our findings indicate that surgeons should be cognizant of patients with a greater degree of preoperative hindfoot valgus and their propensity to develop a valgus ankle deformity. Additionally, our relatively high incidence of valgus tibiotalar tilt suggests that weightbearing ankle radiographs should be included in the initial and subsequent follow-up of PCFD patients with hindfoot valgus treated with subtalar fusion.

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.

Three-Dimensional Distance Mapping to Identify Safe Zones for Lateral Column Lengthening

BACKGROUND

Evans (E-LCL) and Hintermann LCL (H-LCL) lateral column lengthening osteotomies are standard surgical solutions for flexible, progressive collapsing feet. E-LCL is performed between the anterior and middle facets and endangers specific os calcis subtalar joint (OCST) subtypes without distinct facets. H-LCL is oriented between the posterior and middle facets and should be suitable for all OCSTs. Both osteotomies are associated with increased subtalar osteoarthritis, indicating iatrogenic damage. Distance mapping (DM) enables visualization of the relative distance between 2 articular surfaces represented by color patterns. This study aims to measure the safe zones for LCL using 3-dimensional (3D) models and DM; we hypothesize that it could be measured with high reproducibility.

METHODS

Two raters categorized 200 feet across 134 patients into OCSTs based on the Bruckner classification. Four angles were measured independently. The proximal and distal extents of the posterior safe zone (PSZ) angles were determined for H-LCL osteotomies; similarly, the proximal and distal extents of the anterior safe zone (ASZ) angles were identified for E-LCL osteotomies. Consequently, the surface available for safe osteotomies were calculated. An interclass correlation was used to assess the agreement between the 2 raters. Additionally, analysis of variance and Mann-Whitney U test were used to compare the safe zones between OCSTs.

RESULTS

The mean proximal and distal extents of the PSZ angles were 68 ± 7 and 75 ± 5 degrees from a line parallel to the lateral border of the calcaneus, respectively, and the proximal and distal extent of the ASZ angles were 89 ± 6 and 95 ± 5 degrees, respectively. There were no statistically significant differences between the OCSTs. Two raters measured the angles with good to excellent interrater and intrarater agreement. In 18 cases, we were unable to plan for H-LCL or E-LCL osteotomies.

CONCLUSION

Distance mapping could be used to measure the safe zone, tailor a preoperative plan, and potentially reduce the risk for iatrogenic damage in LCL. 3D models and DM can increase the reliability of preoperative plans in bones with complex 3D structures.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Congenital vertical talus deformity in children with distal arthrogryposis: good clinical outcomes despite high rate of residual radiographic deformity

Patients with a diagnosis of arthrogryposis often present with various orthopedic conditions, one of which is congenital vertical talus (CVT). This is the first study of this specific subset of syndromic patients to evaluate the medium-term outcomes of CVT correction using the minimally invasive Dobbs method. All patients with vertical talus and distal arthrogryposis who received treatment at our institution between January 2006 and June 2021 were identified. Radiographs, clinical notes and Patient-Reported Outcome Measurement Information System (PROMIS) scores (when available) were retrospectively reviewed. An alpha of 0.05 was used for all statistical analyses. In total 12 patients (19 feet) met all inclusion criteria and were included in the final analysis. By the time of the most recent visit, the average lateral Talar-Axis First Metatarsal Base Angle of the entire cohort increased from 13.73 ± 9.75 degrees 2 weeks postoperatively to 28.75 ± 23.73 degrees ( P  = 0.0076). Radiographic recurrence of the talonavicular deformity was seen in nine feet (47.4%), 4 (21.1%) of which required additional unplanned surgery, The average PROMIS scores of the entire cohort in the pain interference, mobility and peer relationship domains were 48.97 ± 9.56, 47.9 ± 11.60 and 52.87 ± 8.31, respectively. Despite a higher radiographic recurrence rate of talonavicular deformity in this specific subset of syndromic patients, these patients still report PROMIS scores near the population average in the pain interference, mobility and peer relationships domains. We believe that the minimally invasive Dobbs method should be recommended as the first-line treatment method for these patients. Level of evidence: Level III.

Unique shape variations of hind and midfoot bones in flatfoot subjects-A statistical shape modeling approach

Flatfoot deformity is a prevalent hind- and midfoot disorder. Given its complexity, single-plane radiological measurements omit case-specific joint interaction and bone shape variations. Three-dimensional medical imaging assessment using statistical shape models provides a complete approach in characterizing bone shape variations unique to flatfoot condition. This study used statistical shape models to define specific bone shape variations of the subtalar, talonavicular, and calcaneocuboid joints that characterize flatfoot deformity, that differentiate them from healthy controls. Bones of the aforementioned joints were segmented from computed tomography scans of 40 feet. The three-dimensional hindfoot alignment angle categorized the population into 18 flatfoot subjects (≥7° valgus) and 22 controls. Statistical shape models for each joint were defined using the entire study cohort. For each joint, an average weighted shape parameter was calculated for each mode of variation, and then compared between flatfoot and controls. Significance was set at p < 0.05, with values between 0.05 ≤ p < 0.1 considered trending towards significance. The flatfoot population showed a more adducted talar head, inferiorly inclined talar neck, and posteriorly orientated medial subtalar articulation compare to controls, coupled with more navicular eversion, shallower navicular cup, and more prominent navicular tuberosity. The calcaneocuboid joint presented trends of a more adducted calcaneus, more abducted cuboid, narrower calcaneal roof, and less prominent cuboid beak compared to controls. Statistical shape model analysis identified unique shape variations which may enhance understanding and computer-aided models of the intricacies of flatfoot, leading to better diagnosis and, ultimately, surgical treatment.

Clinical Outcomes Following Treatment of Recurrent Talotarsal Joint Dislocation Using a Type II Extraosseous Talotarsal Stabilization Implant-A Long-Term Follow-Up Study

Collapsing foot deformity (CFD) and its resulting sequelae caused by recurring talotarsal joint dislocation (RTTJD) affects pediatric and adult patients. An extraosseous talotarsal stabilization (EOTTS) procedure, a subset of subtalar arthroereisis (SA) procedures, is recommended as a minimally invasive, first in-line surgical treatment option for CFD. The aim of this multicenter, retrospective study was to evaluate patient-reported outcomes measures in patients who were treated for RTTJD with Type II EOTTS implants. Sixty-seven cases having a median age of 38 years (range: 10-74) with more than 5 years of follow-up were included in this study. The mean postoperative visual analog scale and Maryland Foot Score was 1.0 ± 1.9 and 92.3 ± 11.3, respectively, indicating excellent clinical outcomes. Subjectively, 88% cases reported as being satisfied with the outcome, 94% cases said they would recommend EOTTS, and 93% said that, if necessary, they would repeat it on their contralateral foot. A subgroup analysis revealed that while not statistically significant, clinical outcomes were slightly better in pediatric patients compared to adults. Implant removal rate was 4.5% (3 cases), and these were in the adult group only. Rate of minor issues such as pain, stiffness, discomfort, etc. was 15%; however, no serious adverse effects or complications were observed in any patient. This study suggests that EOTTS is an effective surgical treatment option wherein successful long-term clinical outcomes with low failure rates can be achieved in a select patient population.

Flatfoot over the centuries: the background of current conservative and operative treatments

PURPOSE

Although flatfoot is a widespread human condition, historical medical texts and ancient illustrations on this deformity are extremely rare. Nowadays, doubts regarding its management remain unsolved. This historical review aims to identify the presence of pes planus since the prehistoric era and examine the treatments proposed over the centuries up to the present.

METHOD

For this propose, we performed an extensive electronic search of the relevant literature, complemented by a manual search of additional sources from archaeological to artistic, literary, historical, and scientific accounts, describing flatfoot and its treatment in different eras.

RESULTS

Flatfoot accompanied the evolutionary timeline of human species: from Lucy Australopithecus to Homo Sapiens. It was described among various diseases suffered by Tutankhamun (1343-1324 B.C.), while the first anatomical description dates to Emperor Trajan (53-117 A.D.) and the medical studies of Galen (129-201 A.D.). It was also represented in the anatomical drawings of Leonardo da Vinci (1452-1519) and Girolamo Fabrici d'Acquapendente (1533-1619). Historically, the conservative treatment by insoles was the only one proposed until the nineteenth century. Since then, the most popular surgical procedures performed for correction have been osteotomies, arthrodesis, arthrorisis, and tendon lengthening and transfer.

CONCLUSION

During the centuries, conservative therapeutic strategies have not radically changed in their substance, while operative ones have become the protagonists during the twentieth century up to the present. Nevertheless, after more than 2000 years of history, there is no consensus regarding the best indication for the flatfoot and if it really needs to be treated.

Coalition excision and corrective osteotomies versus coalition excision and arthroereisis in management of pes planovalgus with talo-calcaneal coalition in adolescents: A randomized controlled trial

BACKGROUND

Talocalcaneal coalition is the most common cause of rigid flat foot in adolescents. It presents with recurrent ankle sprains, foot and ankle pain, and foot deformity. Management is still controversial. Multiple options were utilized during the last 40 years, including coalition excision only or coalition excision with hind foot arthrodesis or corrective osteotomies. However, the effect of arthroereisis after coalition excision is still questionable.

PATIENTS AND METHODS

Thirty feet in 28 patients with rigid flat foot due to talocalcaneal coalition, who presented to our institution between September 2018 and April 2020, were prospectively analyzed. Randomization was performed by random allocation using a computer-based system into two groups: group A for coalition excision and arthroereisis, group B for coalition excision and osteotomies. Functional and radiological outcomes and complications were recorded and analyzed using Statistical Package for the Social Sciences software.

RESULTS

Thirty feet in 28 patients were included in the final analysis (15 feet in each group). One patient in each group had bilateral affection. The mean age was 14.5 years, and the mean follow-up duration was 24 months. At final follow-up, the mean AOFAS was 78.8 ± 4.04 in group A and 76.73 ± 4.66 in group B, while the FAAM scores were 80 ± 5 and 79 ± 3 in groups A and B, respectively. The complication rate was higher in group A, however with no statistical significance.

CONCLUSION

The combination of talocalcaneal coalition resection with either corrective osteotomies or arthroereisis had a significant improvement of functional and radiological outcomes in the management of rigid pes planovalgus.

Spring Ligament Reconstruction for Progressive Collapsing Foot Deformity: Contemporary Review

The spring ligament is one of the main stabilizers of the medial arch of the foot and the primary static supporter of the talonavicular joint. Attenuation or rupture of this ligament is thought to play a central role in the pathophysiology of progressive collapsing foot deformity. Traditional correction of flexible flatfoot consists of posterior tibial tendon augmentation along with various osteotomies or hindfoot fusions. Repair or reconstruction of the spring ligament has not been as widely pursued. In recent years, newer techniques have been explored and may improve outcomes of traditional procedures, or possibly entirely replace some osteotomies. Combined spring-deltoid ligament reconstruction is also gaining traction as a viable technique, particularly as the ankle begins to deform into valgus. This review summarizes the variety of nonanatomic and anatomic reconstruction techniques that have been described, including autologous tendon transfers, allografts, and synthetic augmentation. Although many have only been characterized in biomechanical cadaver studies, this article reviews preliminary clinical studies that have shown promising results. There is a need for more high-quality studies evaluating the clinical, radiographic, and patient-reported outcomes following spring ligament reconstruction.

Outcomes of Combined Posterior Tibial Tendon Tendoscopy and Medializing Calcaneal Osteotomy for Stage IA Progressive Collapsing Foot Deformity

BACKGROUND

Posterior tibial tendon (PTT) tendoscopy and medializing calcaneal osteotomy (MCO) are among the available techniques for patients presenting with symptomatic flexible hindfoot valgus (stage IA) progressive collapsing foot deformity (PCFD). The aim of this study was to determine clinical and radiographic outcomes of combined PTT tendoscopy and MCO for patients presenting with symptomatic stage IA PCFD.

METHODS

A retrospective cohort study was performed in order to determine clinical and radiographic outcomes of 30 combined PTT tendoscopies and MCO on 27 patients presenting with symptomatic stage IA PCFD, with a minimum follow-up of 24 months. Patient satisfaction was assessed at last available follow-up as very satisfied, satisfied, and unsatisfied. Clinical assessment was performed evaluating preoperative and last available follow-up visual analog scale for pain (VAS-P), Foot and Ankle Outcome Score (FAOS), and the 36-Item Short Form Health Survey (SF-36). Magnetic resonance imaging (MRI) was performed preoperatively on all patients. Standard weightbearing anteroposterior, lateral, and long axial view radiographs of the foot and ankle were taken preoperatively, immediate postoperatively, at 6 weeks, 3 months, 6 months, 1 year postoperatively, and last follow-up evaluation available for each patient.

RESULTS

The mean follow-up was 38.6 (range, 26-62) months. We registered 27 very satisfied, 1 satisfied, and 2 unsatisfied patients. There was statistically significant improvement on all clinical scores (VAS-P, FAOS and SF-36), as well as on lateral talo-first metatarsal and hindfoot alignment angles. We found low-grade PTT tears in 5 patients (16.67%) in whom preoperative MRI documented PTT tenosynovitis alone.

CONCLUSION

We found that combined PTT tendoscopy and MCO provide significant clinical and radiographic improvement for patients presenting with symptomatic stage IAB PCFD. PTT tendoscopy should be considered in the treatment of all surgically addressed flexible valgus feet as it detects tendon tears which are frequently missed on an MRI.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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.

Comparison of Different Surgical Techniques in Correction of Congenital Vertical Talus Deformity: A Systematic Review and Meta-Analysis of the Literature

BACKGROUND

Congenital Vertical Talus (CVT) is a rare form of congenital rigid flatfoot. Numerous surgical techniques have been developed over the years in an attempt to definitively correct this deformity. We performed a systematic review and meta-analysis of the existing literature to compare the outcomes of children with CVT treated with different methods.

METHODS

A detailed systematic search was conducted in accordance with PRISMA guidelines. Radiographic recurrence of the deformity, reoperation rate, ankle arc of motion, and clinical scoring was compared between the following 5 methods: Two-Stage Coleman-Stelling Technique, Direct Medial Approach, Single-Stage Dorsal (Seimon) Approach, Cincinnati Incision, and Dobbs Method. Meta-analyses of proportions were performed, and data were pooled through a random effects model using the DerSimonian and Laird approach. Heterogeneity was assessed using I^2 statistics. The authors used a modified version of the Adelaar scoring system to assess clinical outcomes. An alpha of 0.05 was used for all statistical analysis.

RESULTS

Thirty-one studies (580 feet) met the inclusion criteria. The reported incidence of radiographic recurrence of talonavicular subluxation was 19.3%, with 7.8% requiring reoperation. Radiographic recurrence of the deformity was highest in the children treated with the direct medial approach (29.3%) and lowest in the Single-Stage Dorsal Approach cohort (11%) ( P <0.05). The reoperation rate was significantly lower in the Single-Stage Dorsal Approach cohort (2%) compared with all other methods ( P <0.05). There was no significant difference in the reoperation rates between the other methods. The highest clinical score was seen in the Dobbs Method cohort (8.36), followed by the group treated with the Single-Stage Dorsal Approach (7.81). The Dobbs Method resulted in the largest ankle arc of motion.

CONCLUSION

We found the lowest radiographic recurrence and reoperation rates in the Single-Stage Dorsal Approach cohort, while the highest rate of radiographic recurrence was seen in those treated with the Direct Medial Approach. The Dobbs Method results in higher clinical scores and ankle arc of motion. Future long-term studies focusing on patient-reported outcomes are needed.

LEVEL OF EVIDENCE

Level III.

Association of Fusion of the First Metatarsophalangeal Joint and Pes Planus Deformity Correction

BACKGROUND

There has been scant investigation on the relationship between the distal aspect of the medial longitudinal arch and pes planus deformity. The aim of this study was to investigate whether the reduction and stabilization of the distal aspect of the medial longitudinal arch through fusion of the first metatarsophalangeal joint (MTPJ) can subsequently improve pes planus deformity parameters. This could be useful in both further understanding the role of the distal medial longitudinal arch in patients with pes planus and planning operative intervention in patients with multifactorial medial longitudinal arch problems.

METHODS

A retrospective cohort study was undertaken between January 2011 and October 2021, including patients undergoing first MTPJ fusion with a pes planus deformity on weightbearing preoperative radiographs. These were compared to postoperative images, and multiple pes planus measurements were taken for comparison.

RESULTS

A total of 511 operations were identified for further analysis, with 48 feet meeting the inclusion criteria. There was a statistically significant reduction identified between the pre- and postoperative measurements of Meary angle (3.75 degrees, 95% CI 2.9-6.47 degrees) and talonavicular coverage angle (1.48 degrees, 95% CI 1.09-3.44 degrees). There was a statistically significant increase between the pre- and postoperative measurements of calcaneal pitch angle (2.32 degrees, 95% CI 0.24-4.41 degrees) and medial cuneiform height (1.25 mm, 95% CI 0.6-1.92 mm). Reduced intermetatarsal angle was significantly associated with an increase in first MTPJ angle postfusion. Many of the measurements made were found "almost perfectly" reproducible by the Landis and Koch description.

CONCLUSION

Our results demonstrate that fusion of the first MTPJ is associated with improvement of medial longitudinal arch parameters of a pes planus deformity but not to levels considered to be clinically normal. Therefore, the distal aspect of the medial longitudinal arch could, to some degree, be a feature in the pes planus deformity etiology.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Addressing Medial Column Instability in Flatfoot Deformity

A stable medial column is important to the normal function of the foot and ankle. Medial column instability and forefoot varus can result in compensatory hindfoot motion leading to stress along the medial soft-tissue structures. Medial column stabilization should therefore be considered when (1) forefoot varus deformity is identified following hindfoot realignment; (2) pronounced medial column instability is present, even in the absence of forefoot varus; and (3) when degenerative changes are present within the medial column articulations. Common surgical procedures include arthrodesis of the talonavicular joint, naviculocuneiform joint, and first tarsometatarsal joint, as well as osteotomy of the medial cuneiform (Cotton osteotomy).

Corrective bandages and daily manipulations for treatment of congenital vertical talus: a thirteen year follow-up

PURPOSE

To analyze the results of a conservative method for treating congenital vertical talus in children with early start and to know in which cases surgical treatment was needed.

METHODS

A retrospective analysis of all children diagnosed with idiopathic vertical talus was carried out during the years 2008-2021. Thirty-two children (46 feet) were finally included. Children were treated with serial manipulations, muscle stimulation, and corrective bandages. Age at the time of initiation of treatment, duration of treatment, and correction or not of the deformity without surgical intervention were recorded as variables of interest. The talocalcaneal angle, TAMBA, and ankle range of motion were measured before treatment, after treatment, and at the end of the follow-up period. Statistics decision tree was used to determine which variable best discriminated whether the patient needed surgery. To complement the tree diagram, a two-step cluster analysis was carried out.

RESULTS

After treatment, TAMBA and talocalcaneal angle changed from "vertical" to "oblique" category in 45 and 37 feet, respectively. The pathological dorsal flexion of the ankle changed to normal in 37 feet and ankle plantar flexion was normal in 46 feet. These variables showed significant changes between the three measurement moments. The results of the statistics decision tree and cluster analysis indicate that "No surgery" was associated with an age equal to or lower than one week when treatment was started, and with an ankle plantar flexion range of motion lower than 36°.

CONCLUSIONS

The beginning of this conservative treatment in the first week of life and having a plantar flexion of the ankle lower than 36° were related to the success of the treatment without surgery.

Percutaneous minimal invasive Achilles tendon lengthening improves clinical and radiographic outcomes in severe flexible flatfeet with shortened triceps sureae complex in early childhood: A retrospective study

BACKGROUND

Severe flexible flatfeet with triceps surae complex shortening are prognostically unfavorable in early childhood and may compromise normal foot development.

METHODS

This retrospective, IRB-approved study included 20 children (38 feet) under 6 years with severe flexible flatfeet and triceps surae complex shortening. Treatment included minimally invasive percutaneous achilles tendon lengthening followed by a 4-week cast fixation and corrective orthotic therapy under talo-navicular reposition for at least 6-months. Preoperative weightbearing x-rays and at the last available follow-up included anteroposterior talus-first metatarsal angle and lateral talus pitch, Meary's and talocalcaneal angle and were compared to reference values. ROM, surgeon-rated clinical outcomes and complications/re-interventions were evaluated.

RESULTS

Age at surgery was 3.7 years (1.3-5.9 y) and follow-up time was 4.3 years (1.1-8.9 y). No complications occurred. Clinical outcome was good (68 %) to very good (26 %). Ratio of normal angles increased significantly for three angles. Dorsiflexion ROM improved from -5.0 ± 6.8° at baseline to 15.7 ± 7.6°.

CONCLUSIONS

With significant improvements in clinical and radiographic outcomes, minimal-invasive percutaneous Achilles tendon lengthening followed by orthotic therapy seems to be a valuable treatment option for selected preschool-aged patients with severe, flexible flatfeet with significantly shortened triceps surae.

LEVEL OF EVIDENCE

IV.

[Not Available]

Pes planovalgus (PV) in early childhood is a common physiological state, and usually resolves throughout childhood. Parental concern often leads to seeking medical advice. This review summarises the current knowledge of the different types of PV. Asymptomatic PV does not need treatment, but corrective footwear can be utilised for painful PV. Orthopaedic referral is needed if conservative treatment is not sufficient. It is important to distinguish between flexible and rigid PV, since rigid PV can be a sign of underlying pathologies and needs referral to orthopaedic surgeons. Further studies are needed to investigate for predictive factors to develop painful PV.

Untreated congenital vertical talus deformity in walking age: minimally invasive method works

There is sparse literature evaluating the outcomes in toddlers with congenital vertical talus (CVT) deformity who undergo treatment with the recently introduced minimally invasive Dobbs Method. We present the first study of this patient cohort to determine the efficacy of this method in patients 18 months of age and older. A list of all patients over 18 months of age who underwent CVT correction at our institution was created. Retrospective chart review was performed, and all follow-up notes were reviewed for clinical outcomes and complications. Eligible patients completed Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires. Statistical analysis was performed using an alpha of 0.05. Sixteen children (24 feet) met all inclusion criteria and were included in the final analysis. Initial radiographic correction of all measured angles was seen, but by the latest follow-up, the average lateral TAMBA had increased from 12.04 degrees immediately postoperatively to 28.8 degrees at the latest follow-up ( P = 0.0012). Radiographic recurrence of deformity was seen in 9 (37.5%) feet and additional unplanned surgery was required in 3 (12.5%) feet. Residual radiographic pes planus was seen in 5 (20.8%) feet. PROMIS pain interference and peer relationship scores were near the population mean. Although the recurrence rate in this patient population seems to be higher than that of younger patients, the majority of toddlers who undergo treatment with this method do experience successful outcomes. We recommend attempting this treatment method in toddlers before performing extensive soft tissue releases or salvage procedures.

Surgical Treatment of the Flexible, Progressive Collapsing Foot: Deformities, Definitions, and Decisions

The complex adult acquired flatfoot deformity involves progressive collapse of the foot with attenuation of medial soft tissues such as the posterior tibialis tendon and spring ligament complex. Multiple deformities at different levels can coexist in the collapsed foot, including hindfoot valgus, midfoot abduction, forefoot varus, and valgus ankle instability. Definitions of flatfoot have evolved to encapsulate the peritalar basis of the deformity, with instability around the talus as the fulcrum. The goals of treatment are to minimize pain, dysfunction, and progressive deformity. Some treatment options directly address the pathologic areas, such as tendon transfer for posterior tibialis tendon dysfunction and spring ligament reconstruction. Others such as calcaneal osteotomies secondarily counteract the primary ligamentous dysfunction and realign the foot to neutralize deforming forces. Selective fusions of the hindfoot and medial column are also viable options to correct the deformity at the joint level when appropriate. The treatment selected depends on flexibility and locations of the deformity, and ultimately patient-specific factors.

Satisfactory outcomes of post-operative subtalar extra-articular arthroereisis in juvenile flexible flat foot

OBJECTIVES

To analyze the surgical outcomes of subtalar extra-articular arthroereisis and the patient/parent satisfaction regarding the foot's shape, foot pain, ability to walk, ability to jump, and shoe wear.

METHODS

Our retrospective cross-sectional study was carried out through an online-based questionnaire to assess patient satisfaction postoperatively at 3 hospitals (King Khalid University Hospital, Sultan bin Abdulaziz Humanitarian City, and Dallah Hospital, Riyadh, Saudi Arabia) between the years 2014-2021.

RESULTS

A total of 65 patients participated in our study. Approximately 86.1% of them had the operation bilaterally. The most important aspects where patients noticed the most improvement were the foot's shape (90.8%), pain (81.5%), and ability to walk (76.9%).

CONCLUSION

Several studies have been carried out highlighting the surgical technique and complications of the procedure. However, a limited number of studies have been carried out to assess patient satisfaction with the procedure, especially in Saudi Arabia, as the procedure is considered relatively new in the region with insufficient data regarding it. Therefore, this study is considered one of the few articles regarding subtalar extra-articular arthroereisis in the region.

Quality of life in flexible painful flatfoot treated by anterograde calcaneo-stop procedure: The patient's and family's perspective

PURPOSE

This study aimed to evaluate the quality of life and satisfaction about the surgical treatment in patients with symptomatic flexible flatfoot.

METHODS

The Oxford Ankle Foot Questionnaire for children (one to fill in before the surgical correction and another 6-12 months after the screw's removal), the PedsQLTM Healthcare Satisfaction Generic Module and the PedsQLTM General Well-Being Scale were administered to all patients who underwent the anterograde calcaneo-stop procedure for flexible painful flatfoot between January 2012 and December 2015.

RESULTS

One hundred forty patients were sent the questionnaires and 74 (40 male and 34 female) of them responded. The surgical correction was performed at a medium age of 11,84±1,65 years. When the Oxford Ankle Foot Questionnaire for children scores before surgical correction and after the screw removal were compared, the latter scored significantly higher for all domains. Healthcare satisfaction was good in all families. Most of the patients scored medium-high on the PedQLTM General Well-Being both when asked about themselves (mean 86,50±7,44) and in general about their health (76,06±12,32).

CONCLUSION

Our results confirmed that flexible painful flatfoot is significantly affecting the quality of life of children and that the anterograde calcaneo-stop procedure is a valuable technique, which improves their quality of life and the family wellbeing.