Update on the reliability of gait analysis interpretation in cerebral palsy: Inter-institution agreement

BACKGROUND

Studies have shown good reliability for gait analysis interpretation among surgeons from the same institution. However, reliability among surgeons from different institutions remains to be determined.

RESEARCH QUESTION

Is gait analysis interpretation by surgeons from different institutions as reliable as it is for surgeons from the same institution?

METHODS

Gait analysis data for 67 patients with cerebral palsy (CP) were reviewed prospectively by two orthopedic surgeons from different institutions in the same state, each with > 10 years' experience interpreting gait analysis data. The surgeons identified gait problems and made treatment recommendations for each patient using a rating form. Percent agreement between raters was calculated for each problem and treatment, and compared to expected agreement based on chance using Cohen's kappa.

RESULTS

For problem identification, the greatest agreement was seen for equinus (85% agreement), calcaneus (88%), in-toeing (89%), and out-toeing (90%). Agreement for the remaining problems ranged between 66-78%. Percent agreement was significantly higher than expected due to chance for all issues (p ≤ 0.01) with modest kappa values ranging from 0.12 to 0.51. Agreement between surgeons for treatment recommendations was highest for triceps surae lengthening (89% agreement), tibial derotation osteotomy (90%), and foot osteotomy (87%). Agreement for the remaining treatments ranged between 72-78%. Percent agreement for all treatments was significantly higher than the expected values (p ≤ 0.002) with modest kappa values ranging from 0.22 to 0.52.

SIGNIFICANCE

Previous research established that computerized gait analysis data interpretation is reliable for surgeons within a single institution. The current study demonstrates that gait analysis interpretation can also be reliable among surgeons from different institutions. Future research should examine reliability among physicians from more institutions to confirm these results.

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.

How Important Is a Lesser Metatarsal Osteotomy in Preventing Second Hammertoe Recurrence?

Hammertoes with greater preoperative transverse plane deformity are more likely to recur after corrective surgery; however, it is unclear whether this represents an inherent (fixed, nonmodifiable) risk, or whether steps can be taken intraoperatively to mitigate this risk. In this study, we examined whether transverse plane transposition and/or shortening of the second metatarsal during second hammertoe surgery influenced recurrence. We performed a secondary analysis of pre-existing data from patients that had previously undergone second hammertoe surgery at our institution between January 1, 2011 and December 31, 2013. One hundred two patients (137 toes) were followed for a mean 28 ± 7.8 months postoperatively. Thirty-seven toes required, at the surgeon's discretion, an additional/concomitant Weil metatarsal osteotomy. Magnitude of transverse plane transposition and shortening of the second metatarsal, and joint angular measurements were obtained from the second metatarsophalangeal joint on weightbearing AP radiographs preoperatively and at 6 to 10 weeks postoperatively. Cox regression analysis was used to identify predictors of hammertoe recurrence using these new variables and a set of known predictors. In the final regression model, failure to establish a satisfactory postoperative metatarsal parabola (i.e., long second metatarsal; Nilsonne values <-4 mm, multivariate hazards ratio [HR] 1.96, p = .097), and intraoperative lateral transposition of the metatarsal head (multivariate HR 3.45, p = .028) seemed to confer additional risk for hammertoe recurrence. We conclude that shortening osteotomies may be assistive in some individuals, while further inquiry is still needed to determine whether similar benefits can be derived from medial head transposition in medial toe deformities.

Talocalcaneal Ligament Reconstruction Kinematic Simulation for Progressive Collapsing Foot Deformity

BACKGROUND

In progressive collapsing foot deformity (PCFD), an internal and plantar rotation of the talus relative to the calcaneus may result in painful peritalar subluxation. Medial soft tissue procedures (eg, spring ligament repair) aim to correct the talar position via the navicular bone if bony correction alone is not sufficient. The effect of the medial soft tissue reconstruction on the talar reposition remains unclear. We hypothesized that a subtalar talocalcaneal ligament reconstruction might be favorable in PCFD to correct talar internal malposition directly. This pilot study aims to evaluate the anatomical feasibility and kinematic behavior of a subtalar ligament reconstruction in PCFD.

METHODS

Three-dimensional surface model from 10 healthy ankles were produced. A total of 1089 different potential ligament courses were evaluated in a standardized manner. A motion of inversion/eversion and talar internal/external in relation to the calcaneus were simulated and the ligament strain, expressed as a positive length variation, for each ligament was analyzed. The optimal combination for the ligament reconstruction with increased length in internal rotation of the talus, isometric kinematic behavior in inversion/eversion, and extraarticular insertion on talus and calcaneus was selected.

RESULTS

A laterodistal orientation of the talar insertion point in respect to the subtalar joint axis and laterodistal deviation of the calcaneal insertion point presents the highest ligament lengthening in internal talar rotation (+0.56 mm [3.8% of total length]) and presented a near-isometric performance in inversion/eversion (+0.01 to -0.01 mm [0.1% of total length]).

CONCLUSION

This kinematic model shows that a ligament reconstruction in the subtalar space presents a pattern of length variation that may stabilize the internal talar rotation without impeding the physiological subtalar motion.

CLINICAL RELEVANCE

This study investigates the optimal location, feasibility, and kinematic behavior of a ligament reconstruction that could help stabilize peritalar subluxation in progressive collapsing foot deformity.

[Formula: see text].

Radiographic Evaluation of the Association between Foot Deformities and Ankle Medial Osteoarthritis

Background

Foot deformities can cause abnormal biomechanics of the ankle joint and the development of osteoarthritis. It was hypothesized that foot deformities would be related to medial ankle osteoarthritis, and this study investigated this relationship using radiographic measurements.

Methods

Seventy-six ankles of 76 patients (32 men and 44 women; mean age, 69.0 years) with medial ankle osteoarthritis were included. Eleven radiographic measurements evaluated ankle joint orientation (tibial plafond inclination [TPI], medial distal tibial angle [MDTA], and anterior distal tibial angle [ADTA]), ankle joint incongruency (tibiotalar tilt [TT]), foot deformities (lateral talo-first metatarsal angle [Lat talo-1MT], anteroposterior talo-first metatarsal angle [AP talo-1MT], and talonavicular coverage), talar body migration (medial talar center migration [MTCM] and anterior talar center migration [ATCM]), internal rotation (IR) of the talus, and mechanical tibiofemoral angle. All were statistically analyzed using Pearson's correlation coefficients and regression analyses.

Results

Ankle joint orientation to the ground (TPI, p = 0.002), increased foot arch (Lat talo-1MT, p < 0.001), and IR of the talus (p = 0.001) were significantly associated with ankle joint incongruency (TT) in linear regression analysis. Ankle joint incongruency (TT, p = 0.003), medial talar body migration (MTCM, p = 0.042), and increased foot arch (Lat talo-1MT, p = 0.022) were significantly associated with IR of the talus in the binary logistic regression analysis. MTCM was significantly correlated with TPI (r = 0.251, p = 0.029), TT (r = 0.269, p = 0.019), MDTA (r = 0.359, p = 0.001), ATCM (r = -0.522, p < 0.001), and AP talo-1MT (r = 0.296, p = 0.015). ATCM was significantly correlated with TPI (r = -0.253, p = 0.027), ADTA (r = 0.349, p = 0.002), and Lat talo-1MT (r = -0.344, p = 0.002).

Conclusions

Ankle joint orientation, foot deformities, and talar rotation were associated with ankle joint incongruency in medial ankle osteoarthritis when evaluated radiographically. These findings need to be considered during surgical treatment for medial ankle osteoarthritis. However, the biomechanical significance of these radiographic measurements requires further investigation.

Comparison of foot kinematics and ground reaction force characteristics during walking in individuals with highly and mildly pronated feet

BACKGROUND

Individuals with highly pronated feet (PF) are more prone to lower extremity injuries than those with mildly PF. However, whether foot kinematics and ground reaction force (GRF) characteristics differ according to the severity of PF deformity is unclear.

RESEARCH QUESTION

Are there differences in foot kinematics and GRF characteristics during walking between individuals with mildly PF and those with highly PF?

METHODS

Ten individuals with mildly PF and 10 with highly PF (six-item foot posture index scores: 6-9 and 10-12 points, respectively) participated in this study. A three-dimensional motion analysis system measured participants' foot kinematics and GRF characteristics during gait trials.

RESULTS

Participants with highly PF exhibited significantly lower medial longitudinal arch heights than those with mildly PF from 0 % to 90 % of the stance phase (p < 0.05). No significant differences were observed in any of the angles between the foot segments. Additionally, participants with highly PF exhibited significantly larger posterior GRF than those with mildly PF from 2 % to 7 % of the stance phase (p < 0.05). Participants with highly PF also exhibited significantly larger anterior GRF than those with mildly PF, from 62 % to 82 % of the stance phase (p < 0.05).

SIGNIFICANCE

The results of this study suggest that the more severe the PF deformity, the more inefficient the foot ground force transmission, and the stronger the load applied to the foot. These results may be related to the higher incidence of lower extremity injuries in individuals with highly PF than in those with mildly PF.

A Novel de novo KIF1A Mutation in a Patient with Ataxia, Intellectual Disability and Mild Foot Deformity

Early-onset ataxias are often difficult to diagnose due to the genetic and phenotypic heterogeneity of patients. Whole exome sequencing (WES) is a powerful method for determining causative mutations of early-onset ataxias. We report a case in which a novel de novo KIF1A mutation was identified in a patient with ataxia, intellectual disability and mild foot deformity.A patient presented with sporadic forms of ataxia with mild foot deformity, intellectual disability, peripheral neuropathy, pyramidal signs, and orthostatic hypotension. WES was used to identify a novel de novo mutation in KIF1A, a known causative gene of neurodegeneration and spasticity with or without cerebellar atrophy or cortical visual impairment syndrome (NESCAVS).We report a novel phenotype of NESCAVS that is associated with a novel de novo missense mutation in KIF1A, which provides valuable information for the diagnosis of NESCAVS even in the era of WES. Early rehabilitation of patients with NESCAVS may prevent symptom worsening and improve the disease course.

Prevalence and associated factors of foot deformity among adult diabetic patients on follow-up at Debre Markos comprehensive specialized hospital, Northwest Ethiopia, 2022, cross-sectional study

INTRODUCTION

Diabetes foot deformity is among the major causes of diabetic foot ulceration, resulting in lower limb amputation. However, the study on the distribution of foot deformity and its risk factor among diabetic patients in Ethiopia is limited. This study determined the overall prevalence and associated factors of foot deformity among adult diabetic patients on follow-up at Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia.

METHODS

Hospital-based cross-sectional study was conducted among 392 diabetic patients using a systematic random sampling technique at Debre Markos Comprehensive Specialized Hospital. Data were collected by pre-tested, semi-structured questionnaires and diabetic foot assessment format. Multivariable binary logistic regression was used to determine the association between dependent and independent variables. Adjusted odds ratios (AOR) with their 95% confidence interval (CI) were used to determine the strength of the association, and a variable with a p-value < 0.05 was statistically significant factors of diabetes foot deformity.

RESULT

The overall prevalence of foot deformity was 33.4% [95% CI: 28.9-38.3]. In the final logistic regression analysis, rural residency [AOR = 2.64, 95% CI: 1.31, 5.31], poor glycemic control [AOR = 2.41; 95% CI: 1.34, 4.33], diabetes duration ≥ 10 years [AOR = 2.74; 95% CI: 1.50, 5.02], inadequate footwear [AOR = 2.11; 95% CI: 1.17, 3.82] and presence of peripheral neuropathy [AOR = 8.21; 95% CI: 4.54, 14.84] were statistically significant associated factors with diabetes foot deformity.

CONCLUSION

The prevalence of foot deformity among adult diabetic patients was high. It is recommended to incorporate foot deformity screening in routine diabetic patient follow-ups especially for those with poor glycaemic control, rural residency, long diabetes duration, inadequate footwear, and diabetic peripheral neuropathy.

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.

Outcome measures for assessing the effectiveness of physiotherapy interventions on equinus foot deformity in post-stroke patients with triceps surae spasticity: A scoping review

OBJECTIVE

Equinus foot deformity (EFD) is the most common deviation after stroke. Several physiotherapy interventions have been suggested to treat it. However, studies evaluating the efficacy of these treatments vary widely in terms of assessment modalities, type of data analysis, and nomenclature. This scoping review aimed to map current available evidence on outcome measures and the modalities employed to assess the effectiveness of physiotherapy programs for the reduction of triceps surae (TS) spasticity and EFD in patients with stroke.

METHODS

Scoping review methodological frameworks have been used. Three databases were investigated. Primary literature addressing TS spasticity in adult patients with stroke using physiotherapy interventions was included. Findings were systematically summarized in tables according to the intervention used, intervention dosage, control group, clinical, and instrumental outcome measures.

RESULTS

Of the 642 retrieved studies, 53 papers were included. TS spasticity was assessed by manual maneuvers performed by clinicians (mainly using the Ashworth Scale), functional tests, mechanical evaluation through robotic devices, or instrumental analysis and imaging (such as the torque-angle ratio, the H-reflex, and ultrasound images). A thorough critical appraisal of the construct validity of the scales and of the statistics employed was provided, particularly focusing on the choice of parametric and non-parametric approaches when using ordinal scales. Finally, the complexity surrounding the concept of "spasticity" and the possibility of assessing the several underlying active and passive causes of EFD, with a consequent bespoke treatment for each of them, was discussed.

CONCLUSION

This scoping review provides a comprehensive description of all outcome measures and assessment modalities used in literature to assess the effectiveness of physiotherapy treatments, when used for the reduction of TS spasticity and EFD in patients with stroke. Clinicians and researchers can find an easy-to-consult summary that can support both their clinical and research activities.

[Interpretation of expert consensus for progressive collapsing foot deformity]

Adult flatfoot is a common foot deformity, mainly manifested as medial arch collapsing, hindfoot valgus and forefoot abduction. People have a more thorough understanding of the pathological changes and pathogenesis of flatfoot with further research. There is a new expert consensus for adult flatfoot published in Foot & Ankle Inter. in 2020. The expert panel reviewed the latest literature to develop consensus recommendations for flatfoot, including its nomenclature, diagnosis, classification and operative treatment. The consensus represents a new understanding of the disease and a new concept because of the authority of its authors and the comprehensiveness of its content, and it is also a phased summary of the theoretical and clinical progress of adult flatfoot. This article gives a detailed interpretation of the content in the consensus.

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.

Cervical Ligament Insufficiency in Progressive Collapsing Foot Deformity: It May Be More Important Than We Know

BACKGROUND

Subluxation at the subtalar joint is one of the major radiographic features that characterize progressive collapsing foot deformity (PCFD). Although it is recognized that the cervical ligament plays an important function in maintaining the subtalar joint's stability, its role and involvement in PCFD is largely unknown. The purpose of this study was to assess the prevalence of cervical ligament insufficiency in patients with PCFD and to establish if the degree of its pathology changes with increasing axial plane deformity.

METHODS

This study retrospectively reviewed magnetic resonance imaging (MRI) of 78 PCFD patients and age- and gender-matched controls. The structures evaluated were the cervical, spring, and talocalcaneal interosseous ligaments. Structural derangement was graded on a 5-part scale (0-4), with grade 0 being normal and grade 4 indicating a tear of greater than 50% of the cross-sectional area. Plain radiographic parameters (talonavicular coverage angle [TNC], lateral talo-first metatarsal [Meary] angle, calcaneal pitch, and hindfoot moment arm) as well as axial plane orientation of the talus (TM-Tal) and calcaneus (TM-Calc) relative to the transmalleolar axis and talocalcaneal subluxation (Diff Calc-Tal) were correlated with the cervical ligament MRI grading system.

RESULTS

The overall distribution of the degree of cervical ligament involvement was significantly different between the PCFD and control groups (P < .001). MRI evidence of a tear in the cervical ligament was identified in 47 of 78 (60.3%) feet in the PCFD group, which was significantly higher than the control group (10.9%) and comparable to that of superomedial spring (43.6%) and talocalcaneal interosseous (44.9%) ligaments. Univariate ordinal logistic regression modeling demonstrated a predictive ability of TM-Calc (odds ratio [OR] 1.17, 95% CI 1.06-1.30, P = .004), Diff Calc-Tal (OR 1.15, 95% CI 1.06-1.26, P = .002), TNC (OR 1.08, 95% CI 1.03-1.13, P = .003), and Meary angle (OR 1.05, 95% CI 1.02-1.10, P = .006) in determining higher cervical ligament grade on MRI.

CONCLUSION

This study found that cervical ligament insufficiency is more often than not associated with PCFD, and that an increasing axial plane deformity appears to be associated with a greater degree of insufficiency.

LEVEL OF EVIDENCE

Level III, case-control study.

Comparison of different surgical treatments for stage II progressive collapsing foot deformity: a finite element analysis

BACKGROUND

This study analyzed the advantages and disadvantages of different procedures for stage IIA progressive collapsing foot deformity (PCFD) through three-dimensional finite element models.

METHODS

A previous validated stage IIA PCFD FEA model was established consisting of 16 bones, 56 ligaments, 5 muscles and soft tissues. The ligament properties of the spring, deltoid, short plantar and long plantar ligaments, and plantar fascia were attenuated according to a previous publication. Medial column fusion (MCF), medializing calcaneal osteotomy (MCO), lateral column lengthening (LCL), and subtalar joint arthroereisis (SJA) operations were simulated in this model. The indexes of plantar stress distribution, maximum von Mises of the medial and lateral columns, strain of the medial ligaments and plantar fascia that supported the medial longitudinal arch, arch height, talo-first metatarsal angle, calcaneus pitch angle, and talonavicular coverage angle were all compared before and after simulated single-foot weight loading.

RESULTS

The maximum plantar stress of PCFD decreased with MCO and SJA but increased with MCF and LCL. MCF and LCL failed to significantly reduce the stress on the medial column fragments, thereby increasing their stress. Both MCO and SJA relieved medial plantar stress. MCF had no significant effect on stress relief of the medial ligament. MCO, LCL, and SJA were all shown to reduce the pressure on the medial plantar ligament, with LCL having the most obvious effect. All four procedures corrected the arch deformity; however, MCF was not as effective as the other methods. SJA is the best method for restoring arch height and correcting arch deformities. For stage IIA PCFD, isolated MCF failed to reduce pressure on the medial column; however, isolated MCO significantly reduced the pressure on the medial plantar and ligamentous soft tissues while restoring the foot's arch and correcting the hindfoot valgus.

CONCLUSION

SJA with type II sinus tarsi implant effectively transferred pressure from the medial plantar tract to the lateral side and restored the arch. Isolated LCL was not found suitable for stage IIA PCFD.

Imaging of the post-operative hallux valgus: what do radiologists need to know?

Hallux valgus surgery concerns many patients and various techniques are performed. The assessment of the first toe deformity correction is mainly visual and imaging is required to analyze the intermetatarsal angle and depict complications. However, it is often difficult for the radiologist to distinguish normal and pathological conditions, especially in case of osteotomies which may show various aspects of bone mineralization and healing. In this review, the most relevant imaging features of the post-operative hallux valgus are summarized.

Joint coverage analysis in progressive collapsing foot deformity

Progressive collapsing foot deformity (PCFD) is characterized by a progressive subluxation of the peritalar bones and respective joints. Two-dimensional conventional radiographs are limited in their ability to visualize the peritalar bones and joints with adequate detail to describe the complex three-dimensional deformity. An improved understanding of the relationship between joint coverage and deformity would allow clinicians to use coverage analysis to distinguish among the stages of PCFD. The aim of this study was to analyze the joint coverage of the six articular relationships within the talocrural, subtalar, and Chopart joints using weightbearing computed tomography (WBCT) scans. Ten individuals with a flexible hindfoot and ten individuals with a rigid hindfoot presentation of PCFD were compared to twenty-seven asymptomatic control individuals. The three most relevant findings are: (I) the anterior-medial facet of the subtalar joint contains the greatest reduction in coverage for patients with a rigid deformity, (II) an increase in talonavicular overlap (TNO) moderately correlated with a decreased coverage in the: tibiotalar, anterior-medial subtalar, talonavicular joints, and (III) the calcaneocuboid joint lacks radiographic values to adequately quantify alignment and coverage. To conclude, there were significant differences in coverage area of various articulating regions throughout the hind- and midfoot when comparing PCFD patients to asymptomatic control individuals. Relevant radiographic measures correlating to articular coverage areas of clinical interest were identified, possibly helping to better quantify PCFD in clinical practice.

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.

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.

Decoding foot deformity and joint-destruction pathways in diabetes: Emerging insights from in-vivo foot joint kinetic measures

BACKGROUND

A comprehensive insight into the effect of longstanding diabetes mellitus and neuropathy on foot joint kinetics during walking is lacking. Our goal was to assess the in-vivo kinetics of major foot joints in persons with diabetes.

METHODS

Three groups, matched for age, sex and walking speed were recruited in this study: 1) people with diabetic peripheral neuropathy, 2) people with diabetes without peripheral neuropathy, and 3) control subjects without diabetes. Participants were instrumented with retroreflective markers on both feet and lower limbs and underwent a barefoot gait analysis using a state-of-the-art multi-segment kinetic foot modelling approach in order to provide accurate joint loading measures at the ankle, midtarsal, tarso-metatarsal and hallux joints.

FINDINGS

The group with neuropathy showed reduced ankle peak plantarflexion angular velocity compared to the control group (P = 0.002). Both groups with diabetes showed a significantly reduced midtarsal peak plantarflexion angular velocity, peak power generation and positive work compared to the control group (p < 0.01). Groups showed significant differences with respect to the tarsometatarsal peak dorsiflexion (p = 0.006) and plantarflexion angular velocity (P < 0.05).

INTERPRETATION

This study shows that both diabetes groups have similar joint loading and power absorption capacity but seem to lose their power generation capacity especially at the midtarsal joint. This loss of power generation capacity and the resulting decreased net mechanical work of the foot potentially embodies a foot that poorly supplements the body's mechanical energy during push-off. This phenomenon may cause excessive tissue stresses that contribute to foot deformity and joint-destruction mechanisms.

The Foot and Ankle Kinematics of a Simulated Progressive Collapsing Foot Deformity During Stance Phase: A Cadaveric Study

BACKGROUND

Progressive collapsing foot deformity (PCFD) is a complex pathology associated with tendon insufficiency, ligamentous failure, joint malalignment, and aberrant plantar force distribution. Existing knowledge of PCFD consists of static measurements, which provide information about structure but little about foot and ankle kinematics during gait. A model of PCFD was simulated in cadavers (sPCFD) to quantify the difference in joint kinematics and plantar pressure between the intact and sPCFD conditions during simulated stance phase of gait.

METHODS

In 12 cadaveric foot and ankle specimens, the sPCFD condition was created via sectioning of the spring ligament and the medial talonavicular joint capsule followed by cyclic axial compression. Specimens were then analyzed in intact and sPCFD conditions via a robotic gait simulator, using actuators to control the extrinsic tendons and a rotating force plate underneath the specimen to mimic the stance phase of walking. Force plate position and muscle forces were optimized using a fuzzy logic iterative process to converge and simulate in vivo ground reaction forces. An 8-camera motion capture system recorded the positions of markers fixed to bones, which were then used to calculate joint kinematics, and a plantar pressure mat collected pressure distribution data. Joint kinematics and plantar pressures were compared between intact and sPCFD conditions.

RESULTS

The sPCFD condition increased subtalar eversion in early, mid-, and late stance (P < .05), increased talonavicular abduction in mid- and late stance (P < .05), and increased ankle plantarflexion (P < .05), adduction (P < .05), and inversion (P < .05). The center of plantar pressure was significantly (P < .01) medialized in this model of sPCFD and simulated stance phase of gait.

DISCUSSION

Subtalar and talonavicular joint kinematics and plantar pressure distribution significantly changed with the sPCFD and in the directions expected from a PCFD foot. We also found that ankle joint kinematics changed with medial and plantar drift of the talar head, indicating abnormal talar rotation. Although comparison to an in vivo PCFD foot was not performed, this sPCFD model produced changes in foot kinematics and indicates that concomitant abnormal changes may occur at the ankle joint with PCFD.

CLINICAL RELEVANCE

This study describes the dynamic kinematic and plantar pressure changes in a cadaveric model of simulated progressive collapsing foot deformity during simulated stance phase.

Effects of Flexor Digitorum Longus Muscle Anatomical Structure on the Response to Botulinum Toxin Treatment in Patients with Post-Stroke Claw Foot Deformity

(1) Background: The purpose of this retrospective case-control study was to determine the relationship between the control of toe movements by flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles and the response to treatment with botulinum toxin (BoNT) in post-stroke patients with claw toe. (2) Methods: Subjects with stroke-related leg paralysis/spasticity and claw toes received multiple injections of BoNT (onabotulinumtoxin A) into the FHL or FDL muscles. We investigated the relationship between the mode of transmission of FHL and FDL muscle tension to each toe (MCT) and treatment outcome using the data of 53 patients who received 124 injections with clinically recorded treatment outcome. We also dissected the potential variables that could determine the treatment outcome. (3) Results: The effectiveness of BoNT treatment was significantly altered by FDL-MCT (OR = 0.400, 95% CI = 0.162–0.987, p = 0.047). Analysis of the response to the first BoNT injection showed an odds ratio of FDL-MCT of approximately 6.0 times (OR = 0.168, 95% CI = 0.033–0.857, p = 0.032). The more tibial the influence of the FDL muscle on each toe, the better the treatment outcome on the claw toe. (4) Conclusions: The anatomic relation between FDL muscle and each toe seems to affect the response to treatment with BoNT in post-stroke patients with claw toes.

Prevalence of flatfoot among young Korean males and the correlation among flatfoot angles measured in weight-bearing lateral radiographs

Flatfoot causes significant fatigue and pain while walking, and even asymptomatic flatfoot may increase the risk of metatarsal stress fracture during long-distance walking. While most studies have used physical examination or plantar footprints to diagnose flatfoot, a weight-bearing radiograph of the foot provides more objective data. However, data on the prevalence of flatfoot in Asian populations gathered in a nationwide cohort of a specific age group is lacking. We examined the prevalence of flatfoot among 19-year-old male Korean army recruits using a weight-bearing lateral radiograph and evaluated the correlation among flatfoot angles. A total of 560,141 19-year-old Korean males were examined at the regional Military Manpower Administration offices between April 2018 and April 2020. Weight-bearing lateral radiographs of the foot were obtained using an X-ray system while the subjects were standing on a table with their feet in a neutral position. Based on these radiographs, military orthopedic surgeons and radiologists measured the talo-first metatarsal angle (TMA) and calcaneal pitch angle (CPA) for flatfoot diagnosis. Mild flatfoot was diagnosed when the TMA ranged from 6 to 15° or the CPA was <17°, and moderate-to-severe flatfoot was diagnosed when the TMA was 15° or greater or the CPA was <10°. Pearson correlation coefficients and scatter plot matrix were used to evaluate the correlation among the flatfoot angles. Finally, we evaluated the relationship between body mass index (BMI) and flatfoot angles and compared the BMI in subjects with or without self-checked foot deformities including flatfoot and pes cavus. Of the 560,141 subjects, 16,102 (2.9%) were diagnosed as flatfoot, and 5265 (0.9%) were diagnosed with moderate-to-severe flatfoot. The coefficients between TMA and CPA ranged from 0.342 to 0.449 (all P values < 0.001), and those between the 2 sides of TMA and CPA were 0.709 and 0.746 (all P values < 0.001), respectively. BMI had a significant correlation with both TMA and CPA in subjects with flatfoot, and those with self-checked foot deformities had a significantly higher BMI than the group without foot deformities. The prevalence of total flatfoot and moderate-to-severe flatfoot in 19-year-old Korean males based on a weight-bearing lateral radiograph was 2.9% and 0.9%, respectively. The correlation coefficients between TMAs and CPAs showed a low degree of positive correlation. Higher BMI was associated with the likelihood of the presence of flatfoot.

Grice extra-articular subtalar fusion for spastic pes planovalgus

INTRODUCTION

A pes planovalgus deformity, an unstable foot deformity, affects the gait of children with cerebral palsy (CP). Treatments, including subtalar fusion, were proposed. The Grice procedure maintains foot stability, but bone graft non-union poses a challenge. This study aimed to identify the rate and factors related to post-operative bone graft non-union.

METHODS

Thirty-one paediatric CP patients (age, 8.9 ± 1.8 years) who underwent the Grice procedure (53 feet) using ipsilateral tibial bone grafts were reviewed. Pre-operative gross motor function classification system (GMFCS) classes were class 1 in five, 2 in five, 3 in 14, and 4 in seven patients. Standing foot radiographs were assessed for signs of non-union, and parameters (talocalcaneal and talar declination angles and talar head uncovering index) measured pre-operatively, post-operatively, and at the most recent evaluation were compared. Factors associated with bone graft non-union were analysed by regression analysis. P < 0.05 was considered statistically significant. Degenerative changes in hindfoot joints were evaluated by Bargon's criteria.

RESULTS

At the average follow-up evaluation at 5.4 ± 4.3 years, the GMFCS class was improved or was maintained in 29/31 patients. Post-operative radiographic measurements were restored and were maintained over the follow-up period (P < 0.001). A total of 14/53 feet (26%) had non-union. The pre-operative lateral talocalcaneal angle (OR 1.08, p = 0.04) and follow-up duration (OR 1.18, p = 0.03) were identified in univariate analysis as potential factors related to non-union but were not confirmed in a multivariate model. Hindfoot joints in most feet showed mild degenerative changes.

CONCLUSION

Grice subtalar fusion in patients with a higher pre-operative lateral talocalcaneal angle might lead to bone graft non-union.

Association of Decreased Physical Activity with Rheumatoid Mid-Hindfoot Deformity/Destruction

Foot/ankle problems remain important issues in rheumatoid arthritis (RA) patients. Although forefoot deformity generally takes a major place in surgical treatment, concomitant mid-hindfoot deformity is also commonly seen. In this situation, it can be easy to overlook that mid-hindfoot deformity can also induce or exacerbate clinical problems behind the forefoot events. Thus, the relationship between mid-hindfoot deformity/destruction and physical activity/ADL was investigated. Radiographic findings of 101 lower limbs (59 patients) were retrospectively evaluated. Alignment parameters in the lower extremity and joint destruction grade (Larsen grade) were measured. The timed-up-and-go (TUG) test, modified health assessment questionnaire (mHAQ), pain, self-reported scores for the foot and ankle (SAFE-Q), and RA disease activity were investigated to assess clinical status. The relationships among these parameters were evaluated. Subtalar joint destruction was correlated with TUG time (r = 0.329), mHAQ score (r = 0.338), and SAFE-Q: social functioning (r = 0.332). TUG time was correlated with the HKA (r = −0.527), talo-1st metatarsal angle (r = 0.64), calcaneal pitch angle (r = −0.433), M1-M5A (r = −0.345), and M2-M5A (r = −0.475). On multivariable linear regression analysis, TUG time had a relatively strong correlation with the talo-1st metatarsal angle (β = 0.452), and was negatively correlated with calcaneal pitch angle (β = −0.326). Ankle joint destruction was also correlated with TUG time (β = 0.214). Development of structural problems or conditions in mid-hindfoot, especially flatfoot deformity, were related with decreased physical activity in RA patients. Wearing an insole (arch support) as a preventative measure and short foot exercise should be considered from the early phase of deformity/destruction in the mid-hindfoot in the management of RA.

Are foot deformity and plantar sensitivity impairment associated with physical function of community-dwelling older adults?

BACKGROUND

Foot deformities are highly prevalent in older adults and negatively impact their mobility and quality of life. However, the association between foot problems and physical function is still unclear.

OBJECTIVE

To investigate whether structural foot deformities and plantar tactile sensitivity are associated with lower extremity physical function impairment in community-dwelling older adults.

METHODS

We included 200 men and women aged 60 years and older from a community-based program. The foot assessment included toe deformities and calluses inspection and evaluation of plantar tactile sensitivity using monofilaments. The Short Physical Performance Battery (SPPB) was used to assess lower extremity physical function. We conducted a multivariate logistic regression analysis to investigate the association between foot problems and lower extremity physical function.

RESULTS

Hallux valgus was the most prevalent deformity among older adults. Those participants with reduced plantar tactile sensitivity (OR= 2.77; 95% CI: 1.38, 5.55) and a hallux valgus (OR= 2.23; 95% CI: 1.10, 4.52) were more likely to present poor lower extremity physical function.

CONCLUSION

Hallux valgus and impaired plantar sensitivity were associated with reduced lower extremity physical function in older adults. Further studies are necessary to identify this causality and to what extent management of these foot problems can improve general mobility and quality of life of older adults.

I am Afraid of Lateral Column Lengthening. Should I Be?

Lateral column lengthening has long been used in conjunction with other soft tissue and bony procedures to correct the midforefoot abduction seen in class B progressive collapsing foot deformity. The effectiveness of this osteotomy to restore the physiologic shape of the foot has been used by foot and ankle surgeons around the world to provide functional improvement for patients suffering from this disease. The overall low complication rates, low nonunion rates, and improved radiographic and functional outcomes provided by lateral column lengthening make this a valuable option for the treatment of class B progressive collapsing foot deformity.

Tendon Transfer versus Allograft Reconstruction in Progressive Collapsing Foot Deformity

The posterior tibial tendon (PTT) is the principal dynamic stabilizer of the medial longitudinal arch of the foot. The basic goal of surgically reconstructing PCFD is to restore the foot's medial longitudinal arch, often through a combination of bony and soft tissue procedures. While the FDL transfer has long been the gold standard for reconstruction, allograft reconstruction of the PTT has recently been increasing in popularity.

Spring and Deltoid Ligament Insufficiency in the Setting of Progressive Collapsing Foot Deformity. An Update on Diagnosis and Management

The spring ligament and deltoid ligament are important stabilizers of the medial ankle. Together, they form a complex along the medial ankle and foot that is critical to stability of both the ankle and the medial longitudinal arch. Incompetence of the spring and deltoid ligament is a component of both the early and late stages of progressive collapsing foot deformity. As the importance of this medial ligament complex has been recognized, repair and reconstruction of these ligaments have progressively evolved, initially as separate reconstructions, and more recently as combined techniques.

Treatment of Cleft Foot Deformity using Fish Mouth Incision and Suture-Button in Paediatric Foot

Cleft foot is a congenital anomaly characterized by absence of the metatarsal bones and phalanges. It is commonly seen in children with Ectrodactyly-ectrodermal dysplasia and clefting syndrome (EEC) ranging from a median cleft up to the mid metatarsals to a deep cleft up to the tarsal bones. Surgical treatment in the form of cleft closure, excision of the rudimentary metatarsal bone and cross K-wire fixation of metatarsal bones have been tried for the management of such cases. Here, we report a case of one year old child with Type III cleft foot having four metatarsals, who was treated with suture-endobutton system using three transverse tunnels in the 2nd and 3rd metatarsal bones in order to bring them closer. We were able to achieve a satisfactory outcome with a normal fitting shoe wear. Keywords: Cleft foot; suture-button; fish mouth incision.

Complications associated with talectomy in paediatric patients: a comparative retrospective study of two surgical techniques

BACKGROUND

Studies describing the surgical approaches utilized for talectomy and their associated complications are scarce. We aimed to compare the surgical techniques and associated procedures from two groups of patients who underwent talectomy using two approaches. The main purpose of this study was to describe the complications and recurrence rates associated with each technique.

METHODS

Between January 2004 and December 2019, 62 talectomies were performed in 48 pediatric patients with different pathologies. All patient data were reviewed retrospectively, and data of 31 patients were included in the study. The patients were divided into two groups based on the surgical technique used, and the baseline characteristics, along with the post-operative findings, and the intervention types in relation to complications were analyzed.

RESULTS

In the terms of hindfoot varus, midfoot adductus, forefoot supination, and dorsal bunions, the prevalence of these deformities was higher in group (A). Group (B) patients tolerated braces (88.9 %) better than group (A) patients (84.0 %). More adjunct procedures were required in group (A) than group (B) Furthermore, the frequency and types of complications, as well as the need for further surgeries were also higher in group (A). There was a higher rate of recurrence in group A than group B.

CONCLUSIONS

Talectomy is an effective procedure for the treatment of persistent foot deformities despite associated complications. Surgical details and addressing associated deformities with adjunct surgical interventions should be considered.

Neglected Stiff Equinocavus Foot Deformity Treated with Cole Osteotomy, Combined with External Ilizarov Hinged Frame Fixation, Soft-Tissue Release, and Achilles Tendon Lengthening: A Case Report

Stiff equinocavus foot deformities are challenging clinical entities that may be treated with osteotomies and extensive soft-tissue release. The most common causes of such lesions are neglected trauma and Charcot-Marie-Tooth disease; other causes include burns, neurologic diseases, and compartment leg syndrome. Conventional treatments, including extensive soft-tissue release, osteotomies, and arthrodesis combined with or without internal splinting, may result in severe complications such as neurovascular or soft-tissue damage and shortening of the foot. The Ilizarov technique may be superior to the traditional approach, because it allows surgeons to apply gradual and titrated correction of individual components of complex deformities and results in minimal surgical morbidity without shortening of the foot. This is the first case report in the literature describing the simultaneous use of Cole osteotomy, combined with external Ilizarov hinged frame fixation, soft-tissue release, and Achilles tendon lengthening for the treatment of an extreme neglected stiff equinocavus foot deformity.

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

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

Forefoot Success

The goal of this chapter is to familiarize orthopaedic surgeons with the latest information pertaining to typical problems of the forefoot. Painful and deforming problems of the forefoot are surprisingly common. The understanding of forefoot deformity and pathology has evolved considerably over the past decade. A more precise understanding of the mechanics of deformity and resulting pathology has resulted in significant improvements in nonsurgical and surgical managements. This chapter provides an up-to-date examination of the literature regarding the management of forefoot pathology. First, a review of recent advances in the understanding of the pathology and mechanics of these problems and then a thorough review of specific diseases are presented. These include management of the bunion deformity, hallux rigidus, metatarsalgia and plantar plate disruption, hammer toe deformities, and interdigital neuritis. Nonsurgical and surgical options are described. This chapter provides information that will lead to thoughtful treatment options for surgeons.

A Narrative Review on the Tests Used in Biomechanical Functional Assessment of the Foot and Leg: Diagnostic Tests of Deformities and Compensations

BACKGROUND

To date, scientific literature has not as yet come up with any review showing the diagnostic tests used for functional assessment of the foot and leg.

METHODS

A literature review was conducted of electronic databases (MEDLINE, PEDro, DOAJ, BioMed Central, PLOS, and Centre for Reviews and Dissemination at the University of York) up to December 8, 2018. The biomechanical tests, which have adequate supportive literature, were divided into qualitative tests that provide a dichotomy/trichotomy-type answer to clinical diagnostic questions; semiquantitative tests that provide numerical data to clinical diagnostic questions; and quantitative tests that record continuous numerical data (in analogue or digital form).

RESULTS

These tests produce a useful functional evaluation model of the foot and leg for different purposes: evaluation of lower limb deficits or abnormalities in healthy patients and in athletes (in sports or other physical activities); assessment of tissue stress syndromes caused by pathomechanics; evaluation of lower limb deficits or abnormalities in rheumatic disease and diabetic foot patients; and to determine the appropriate functional or semifunctional foot orthotic therapy and therapeutic path used in gait rehabilitation.

CONCLUSIONS

Many of these tests have adequate diagnostic reliability and reproducibility and therefore can be considered diagnostic. Few of these are validated, and some have initiated the validation process by determining their sensitivity and specificity. The widespread use of these tools in clinical practice (diagnosis of function) lacks scientific evidence and in-depth analysis of their limitations.

The Evaluation of Radiologic Angular Measurements in Patients with Foot Pain

BACKGROUND

The aim of this study was to investigate the relationship between foot deformities by comparing foot radiographs of patients with complaints of foot pain with those of healthy individuals.

METHODS

The study included 30 patients with pes cavus, 30 patients with pes planus, 30 patients with calcaneal spur, and 30 controls aged 30 to 60 years. All participants underwent measurement of right and left foot length; metatarsophalangeal width; and calcaneal pitch (CA), talohorizontal (TA), talometatarsal (TM), and lateral talocalcaneal (LTC) angles from lateral radiographs.

RESULTS

There were no statistically significant differences between all participants regarding sex, age, weight, and body mass index (P > .05). Among patients with clinically diagnosed pes cavus, the diagnostic rate of CA was 100% in both feet, and 83.3% in the right foot and 96.7% in the left foot according to the TM angle. The diagnostic rates of angular measurements in patients with pes planus were as follows: 20% in the right foot and 30% in the left foot depending on the CA angle, 100% in both feet depending on the TM angle, and 66.7% in the right foot and 46.7% in the left foot depending on the LTC angle. A very strong positive correlation was found between the CA and LTC angles in patients with calcaneal spur and pes planus (P < .001); also, statistically significant positive correlation was found between the CA and TA angles (P < .05). The angular measurements in patients with calcaneal spur were found to be consistent with pes planus with a high rate.

CONCLUSIONS

Angular changes caused by deterioration of foot biomechanics lead to various deformities. Pes planus ranks first among these. Therefore, we believe that radiographic angular measurements in patients presenting with foot pain in addition to clinical evaluation would be useful in considering associated deformities and planning treatments.

The Two-Component Implant for Interphalangeal Fusion in Toe Deformities

BACKGROUND

Although Kirschner wire implantation is popular for treating toe deformities, complications frequently occur. To prevent pin-tract infection and difficult Kirschner wire extraction, several implants have been developed to improve treatment outcomes.

METHODS

Patients who had undergone an interphalangeal fusion by two-component implant for the treatment of toe deformities were included. Thirty-one toes of 21 patients were evaluated retrospectively. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were used in clinical evaluation.

RESULTS

The mean operation duration per toe was 16.4 min (range, 13-26 min). The average AOFAS forefoot score was 42.76 (range, 23-57) preoperatively and 88.76 (range, 70-95) at 34.4 months (range, 26-46 months) after surgery. Mean follow-up was 14.8 months (range, 12-19 months). Compared with before surgery, the AOFAS score was increased significantly after surgery (P = .03 by t test). Three minor complications were encountered. In one patient an infection was observed. After the implants were removed (first month) she was treated successfully by debridement and antibiotic agents and, finally, Kirschner wire placement. The second patient had a fissure fracture at the proximal phalanx, but routine follow-up did not change. In the third patient, the locking mechanism had become loose (detected on day 1 radiography); it was remounted under fluoroscopy without opening the wound. No patients had a cutout, loss of alignment, recurrence, or persistent swelling.

CONCLUSIONS

Outcomes of arthrodesis using the two-component implant were found to be safe and reliable, especially for hammer toe and fifth toe deformities.

Characteristics of Patients with Charcot's Arthropathy and its Complications in the Saudi Diabetic Population: A Cross-Sectional Study

BACKGROUND

Charcot's arthropathy (CA) is a destructive rare complication of diabetes, and its diagnosis remains challenging for foot specialists and surgeons. We aimed to assess the clinical presentation and characteristics of CA and the frequencies of its various types.

METHODS

This cross-sectional study was conducted from January 1, 2007, to December 31, 2016, and included 149 adults with diabetes diagnosed as having CA. Cases of CA were classified based on the Brodsky anatomical classification into five types according to location and involved joints.

RESULTS

The mean ± SD age of the studied cohort was 56.7 ± 11 years, with a mean ± SD diabetes duration of 21.2 ± 7.0 years. The CA cohort had poorly controlled diabetes and a high rate of neuropathy and retinopathy. The most frequent type of CA was type 4, with multiple regions involved at a rate of 56.4%, followed by type 1, with midfoot involvement at 34.5%. A total of 47.7% of the patients had bilateral CA. Complications affected 220 limbs, of which 67.7% had foot ulceration. With respect to foot deformity, hammertoe affected all of the patients; hallux valgus, 59.5%; and flatfoot, 21.8%.

CONCLUSIONS

There is a high rate of bilateral CA, mainly type 4, which could be attributed to cultural habits in Saudi Arabia, including footwear. This finding warrants increasing awareness of the importance of maintaining proper footwear to avoid such complications. Implementation of preventive measures for CA is urgently needed.

[Evans lateral lengthening calcaneal osteotomy in treatment of talocalcaneal coalition with hindfoot valgus deformity]

OBJECTIVE

To investigate the effectiveness of the Evans lateral lengthening calcaneal osteotomy (E-LLCOT) in treatment of talocalcaneal coalition (TCC) with hindfoot valgus deformity.

METHODS

Between January 2014 and October 2017, 10 patients (13 feet) of TCC with hindfoot valgus deformities underwent E-LLCOTs. There were 6 males (8 feet) and 4 females (5 feet) with an age of 13-18 years (mean, 15.8 years). The disease duration was 10-14 months (mean, 11.5 months). The foot deformity was characterized by hindfoot valgus, forefoot abduction, and collapse of the medial arch. Pain site was the tarsal sinus in 4 feet, TCC in 5 feet, and ankle joint in 4 feet. There were tightness of the gastrocnemius in 3 cases (4 feet) and Achilles tendon in 7 cases (9 feet) on Silverskiold test. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 46.54±9.08 and visual analogue scale (VAS) score was 6.54±0.88 after walking 1 kilometer. The AOFAS ankle-hindfoot score and VAS score were adopted to evaluate the postoperative function of the foot. The talar-first metatarsal angle (T1MT), talonavicular coverage angle (TCA), talar-horizontal angle (TH), calcaneal pitch angle (CP), and heel valgus angle (HV) were measured after operation.

RESULTS

All incisions healed by first intention. All patients were followed up 12-30 months (mean, 18 months). At last follow-up, the AOFAS ankle-hindfoot score and VAS score were 90.70±6.75 and 1.85±0.90, respectively, showing significant differences when compared with preoperative scores ( t=-23.380, P=0.000; t=35.218, P=0.000). X-ray films showed that the osteotomy healed at 2-4 months (mean, 3 months) after operation. At last follow-up, the T1MT, TCA, TH, and HV were significantly lower than preoperative ones ( P<0.05), and the CP was significantly higher than preoperative one ( P<0.05). During the follow-up, the pain did not relieve obviously in 1 patient (1 foot), and the cutaneous branch of the sural nerve injured in 1 patient (1 foot).

CONCLUSION

For TCC with severe hindfoot valgus deformity, E-LLCOT can effectively correct deformity and relieve pain.

The Role of 3D Modeling in Education of Orthopedic Trainees for the Treatment of Foot Deformities

PURPOSE OF THE STUDY We hypothesized that preoperative planning with 3D modeling of complex foot deformities would be useful for the education of orthopedics and traumatology residents. MATERIAL AND METHODS This study is prospectively designed study with a control group. Twenty eight residents (study group) who assisted the surgeons during the interventions and ten senior surgeons (control group) were included in the study. All participants assessed virtual 3D-CT images and videos of the cases before the surgery. Ten adult cases of foot bone deformities were evaluated. 3D-CT reconstruction was performed and a 3D model of each deformity was created using the hospital's picture archiving and communication system. The completed 3D models were sterilized in hydrogen peroxide and put on the surgical table in a sterile manner. After surgery, the residents (group I) and surgeons (group II) were questioned regarding their satisfaction with 3D modeling. Responses were structured by a five-point Likert scale (1, strongly disagree; 2, disagree; 3, neither agree nor disagree; 4, agree; and 5, strongly agree). RESULTS The surgeons (group II, n = 10) were satisfied with the sterilized 3D models, which they could touch and re-examine on the operating table. The residents (group I, n = 28) were significantly more satisfied than the senior surgeons (p=0.01). The 3D modeling met both the surgeons' and residents' expectations. DISCUSSION The survey results for the surgeons (group II) were satisfied with the sterilized 3D models, which they could touch and reexamine on the operating table (question 3). They gave the best scores (mean, 4.8/5) for clarity of the 3D model. On the other hand, they gave the lowest scores (mean 3.1/5) to 3D models due to its contribution in understanding deformity over virtual 3D-CT evaluations (question 2 and 5). The residents (group I) differed from those for the senior surgeons. Residents gave the highest scores for understanding of the deformity (question 2 and 5) and clarity (question 1). These outcomes may be interpreted to indicate i) that 3D modeling may be used for education, and ii) that younger surgeons are more interested in novel technological developments. Therefore, the outcomes did differ significantly between the senior surgeons and residents (Table 1). These outcomes may be explicated as; 3D modeling of the foot deformities may not be mandatory for the experienced surgeons for understanding the deformity. On the other hand 3D modeling would be useful tools for younger surgeons and for their education. CONCLUSIONS 3D modeling of foot deformities is more informative than virtual 3D videos. However, with consideration of costs and long processing times, 3D printing may be used optimally for rare deformities. When considering the role of touch sense in surgical learning, 3D modeling gives more detailed and more satisfactory planning than virtual 3D videos. 3D modeling is more useful for young surgeons, and it will be used mainly for education in the future. Key words: 3D printing, deformity, foot and ankle, simulation.

Assessment and Management of the Pediatric Cavovarus Foot

The cavovarus foot is challenging to treat. The deformity is typically progressive with an unpredictable natural history. There are concurrent deformities in the fore-, mid-, and hindfoot: the medial arch is elevated, the first ray is plantarflexed, and the heel is in varus. Muscle imbalance and joint contractures are common. Successful correction requires confirmation of the underlying diagnosis and the application of principles to select the appropriate surgical procedures.

Rubinstein-Taybi Syndrome in a 19-years old boy

INTRODUCTION

Rubinstein-Taybi syndrome is a rare genetic multisystem disorder comprising motor organ dysfunction, craniofacial dysmorphism and psychomotor retardation, frequently with the abnormalities of the thyroid gland.

OBJECTIVE

Presentation of a case of a 19-year-old patient with Rubinstein-Taybi syndrome in whom serum TSH, fT3 and fT4 levels were assessed.

CASE

Craniofacial abnormalities including: microcephaly, underdeveloped maxilla, micrognathia, high arched palate, malocclusion, down-slanting palpebral fissures, thick eyelashes and full eyebrows. Clinodactyly, broad thumbs and toes were observed in the musculoskeletal system. The patient presented with moderate mental retardation, short stature and obesity. Furthermore, I° thoracolumbar scoliosis, elbow joint deformation resulting from the radial head dislocation and limitation of the right hip motion as a consequence of Perthes disease were found. Genetic testing revealed a mutation affecting the CREBBP gene located on the short arm of chromosome 16. The measured serum TSH level was 1.510 μlU/ml (normal range 0.27-4.20), fT3 5.1 pmol/l (normal range 4.1-6.7), fT4 15.5 pmol/l (normal range 13.1-21.3). The patient is subjected to long-term rehabilitation.

CONCLUSIONS

The obtained results of laboratory tests of serum TSH, fT3 and fT4 levels point to a lack of thyroid gland dysfunction in the patient with Rubinstein-Taybi syndrome. Rehabilitation treatment of patients with RTS is necessary to improve the patient's mobility.