Management of Checkrein Deformity.

Checkrein deformity is characterized by the dynamic status of the hallux, in which flexion deformity is aggravated by ankle dorsiflexion and relieved by ankle plantarflexion. In most cases, a checkrein deformity occurs secondary to trauma or following surgery. It has been suggested that the flexor hallucis longus tendon tethers or entraps scar tissue or fracture sites. Improvement with conservative treatment is difficult once the deformity has already become entrenched, and surgical management is usually required in severe cases. Various surgical options are available for the correction of checkrein deformities. It includes a simple release of adhesion at the fracture site; lengthening of the flexor hallucis longus by Z-plasty at the fracture site combined with the release of adhesion; lengthening of the flexor hallucis longus by Z-plasty at the midfoot, retromalleolar, or tarsal tunnel area; and flexor hallucis longus tenotomy with interphalangeal arthrodesis for recurrent cases. This review aimed to summarize the overall etiology, relevant anatomy, diagnosis, and treatment of checkrein deformities described in the literature.

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.

A comparison between the Bluman et al. and the progressive collapsing foot deformity classifications for flatfeet assessment.

INTRODUCTION: Bluman et al., flatfoot classification is based on posterior tibial tendon (PTT) dysfunction leading to a chronological appearance of several foot deformities. An expert consensus recently proposed a new classification named Progressive Collapsing Foot Deformity (PCFD) in which the focus was shifted to five different independent foot and ankle deformities and their flexibility or rigidity. The aim of this study was to compare Bluman and PCFD classifications. We hypothesize that both classifications will be reliable and that the PCFD classification will allow a larger distribution of the different types of foot deformity. MATERIALS AND METHODS: We performed a retrospective IRB-approved study including 92 flatfeet. Three foot and ankle surgeons reviewed patient files and radiographs to classify each foot using both classifications. Bluman classification was performed one time as initially described and a second time after removing the Angle of Gissane sclerosis sign. Interobserver reliabilities were determined with Fleiss' kappa values. RESULTS: Interobserver reliabilities of Bluman and PCFD classifications were, respectively, substantial 0.67 and moderate 0.55. PCFD Class C and D reliabilities were, respectively, slight 0.07 and fair 0.28. The 276 readings were spread into 10 substages in Bluman and 65 subclasses in PCFD. The progressivity of the Bluman classification prevented the combination of flexible hindfoot valgus (II Bluman, 1A PCFD), midfoot abduction (IIB, 1B) and medial column instability (IIC, 1C) which was frequent in our study (112/276 readings, 40.6%). By removing the Angle of Gissane sclerosis sign from the Bluman classification, the prevalence of stage III decreased from 44.2 to 10.1%. CONCLUSIONS: Bluman and PCFD classifications were reliable. The PCFD classification showed a larger distribution of different types of flatfeet but Classes C and D need better definition. The progressivity of Bluman classification causes inconsistencies and Gissane angle sclerosis sign is inappropriately used and might lead to incorrect surgical indications.

Complications from ankle arthrodesis in diabetes-related Charcot foot syndrome.

INTRODUCTION: Charcot neuroarthropathy (CN) is an inflammatory arthropathy associated with bony destruction, dislocation, and deformity in patients with neuropathy. Surgical procedures involving foot and ankle in CN for deformity correction have been shown to result in high rate of complications. The purpose of this study was to compare post-operative outcomes and assess odds of complication after ankle arthrodesis among patients with diabetes-related Charcot neuroarthropathy, non-Charcot patients with diabetes, and non-Charcot patients without diabetes. METHODS: The PearlDiver Patient Records Database was queried for patients who underwent ankle fusion and maintained at least one year of post-operative follow-up. The following post-operative complications were assessed among groups: overall nonunion and amputation, one-year nonunion, amputation, and hardware removal, 90-day and 30-day surgical site infection, dehiscence, acute kidney injury, and pneumonia, and 90-day myocardial infarction and deep vein thrombosis. The odds and prevalence of each complication for each group were assessed and compared. RESULTS: Higher rates of amputation (OR 3.43, CI 2.89-4.06), hardware removal (OR 1.63, CI 1.45-1.83), wound dehiscence (OR 1.75, CI 1.44-2.13), acute kidney injury (OR 2.87, CI 2.32-3.54), pneumonia (OR 1.53, CI 1.13-2.07), and surgical site infection (OR 2.46, CI 2.12-2.85), were observed in patients with diabetes-related CN compared to non-Charcot patients with diabetes. In patients without CN, higher rates of nonunion (OR 1.38, CI 1.19-1.61), amputation (OR 2.26, CI 1.74-2.93), surgical site infection (OR 1.57, CI 1.30-1.90), and acute kidney injury (OR 1.57, CI 1.18-2.09) were observed in patients with diabetes compared to patients without diabetes. Time to hardware removal was significantly shorter in diabetes-related Charcot patients compared to non-Charcot patients without diabetes (368.0 ± 446.7 vs 438.5 ± 487.5 days, P < 0.001). CONCLUSION: Patients with diabetes demonstrated increased odds of nonunion, amputation, surgical site infection, and acute kidney injury compared to patients without diabetes. In the population of patients with diabetes, odds of most of these complications were further increased with the addition of Charcot diagnosis compared to patients without diabetes. Other local and multisystemic medical conditions, including pneumonia and wound dehiscence, also demonstrated increased odds in patients of CN. LEVEL OF EVIDENCE: Cohort study; Level of evidence, 3.

Supramalleolar osteotomy with a hexapod type external fixator for the treatment of ankle joint three planar deformity: Case report.

The varus ankle deformity can lead to osteoarthritis; therefore, numerous supramalleolar tibia osteotomy techniques are described to correct this deformity. Many of these techniques are more suitable for uniplanar ankle deformity. Particularly, if there are multiplane ankle deformities, the use of the six-axis deformity correction system may be successful in solving the problems which may occur during the correction. In this article, we report two cases of three plane deformities of ankle joint due to trauma sequelae, which were treated with supramalleolar osteotomy using a hexapod fixator which is called the Smart Correction Frame®.

Neglected Iatrogenic Flexor Hallucis Longus Tendon Rupture After Haglund's Endoscopic Surgery: A Case Report.

Rupture of the flexor hallucis longus (FHL) tendon is a rare condition that can occur with direct or indirect trauma; most of the injuries are complete ruptures resulting from laceration. Endoscopic calcaneoplasty is used for treatment of symptomatic Haglund's deformity, and complications of this procedure are rare. Iatrogenic FHL tendon rupture occurring after endoscopic calcaneoplasty has not been reported previously. This case report presents a rare complication after endoscopic calcaneoplasty and the proper method of treatment.

Surgical management of acute compartment syndrome and sequential complications.

BACKGROUND: Acute compartment syndrome occurs when pressure within a compartment increases and affects the function of the muscle and tissues after an injury. Compartment syndrome is most common in lower leg and may lead to permanent injury to the muscle and nerves if left untreated. METHODS: 46 patients with acute compartment syndrome were enrolled, including 8 cases with serious complications, between January 2008 and December 2012. The protocols combining early management and the correction of deformities were adjusted in order to attempt to enable full recovery of all patients. RESULTS: All patients had necrotic muscles and nerves, damaged vascular, and severe foot deformities. In the early stage, each patient received systemic support and wound debridement to promote wound healing. For patients with serious complications, a number of medical measures, including installation of Ilizarov external frames, arthrodesis, osteotomy fusion, arthroplasty, or tendon lengthening surgery, were performed to achieve satisfactory clinical outcomes. All the patients resumed weight-bearing walking and daily exercises. CONCLUSION: Acute compartment syndrome and sequential complications could be managed using a number of medical procedures.

Surgical treatment of the Charcot foot.

With the increased number of diabetics worldwide and the increased incidence of morbid obesity in more prosperous cultures, there has become an increased awareness of Charcot arthropathy of the foot and ankle. Outcome studies would suggest that patients with deformity associated with Charcot Foot arthropathy have impaired health related quality of life. This awareness has led reconstructive-minded foot and ankle surgeons to develop surgical strategies to treat these acquired deformities. This article outlines the current clinical approach to this disabling medical condition.

Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes.

BACKGROUND: Charcot neuroarthropathy (CN) of the ankle and hindfoot (Sanders/Frykberg Type IV) is challenging to treat surgically or nonsurgically. The deformities associated with ankle/hindfoot CN are often multiplanar, resulting in sagittal, frontal and rotational malalignment. In addition, shortening of the limb often occurs from collapse of the distal tibia, talus and calcaneus. These deformities also result in significant alterations in the biomechanics of the foot. For example, a varus ankle/hindfoot results in increased lateral column plantar pressure of the foot, predisposing the patient to lateral foot ulceration. Collapse of the talus, secondary to avascular necrosis or neuropathic fracture, further accentuates these deformities and contributes to a limb-length inequality. SURGICAL MANAGEMENT: The primary indication for surgical reconstruction is a nonbraceable deformity associated with instability. Other indications include impending ulceration, inability to heal an ulcer, recurrent ulcers, presence of osteomyelitis and/or significant pain. Arthrodesis of the ankle and/or hindfoot is the method of choice when surgically correcting CN deformities in this region. The choice of fixation (i.e. internal or external fixation) depends on largely on the presence or absence of active infection and bone quality. CONCLUSION: Surgical reconstruction of ankle and hindfoot CN is associated with a high rate of infectious and noninfectious complications. Despite this high complication rate, surgeons embarking on surgical reconstruction of ankle and hindfoot CN should strive for limb salvage rates approximating 90%. Preoperative measures that can improve outcomes include assessment of vascular status, optimization of glycemic control, correction of vitamin D deficiency and cessation of tobacco use.

Effect of Pedal Deformity on Gait in a Patient With Total Knee Arthroplasty.

The authors present the case of an 81-year-old man who, despite an anatomically aligned total knee arthroplasty, continued to have knee pain. The patient's ipsilateral rigid flatfoot caused by an earlier partial pedal amputation resulted in a valgus moment during gait, thus creating clinical symptoms in the total knee arthroplasty. Because of the deformity and scarring within the flatfoot, this valgus deformity was corrected through a varus distal femoral osteotomy. The result was normalization of the mechanical axis of the lower limb and a pain-free total knee arthroplasty with an excellent clinical outcome. This case shows the importance of comprehensive lower-extremity clinical and radiographic examination as well as gait analysis to understand the biomechanical effect on total knee arthroplasty. Recognition of pedal deformities and lower limb malalignment is paramount for achieving optimal outcomes and long-term success of total knee arthroplasty. The authors show that a rigid or nonflexible pedal deformity can have negative biomechanical effects on total knee arthroplasty.

Surgical treatment of the adult acquired flexible flatfoot.

In this review article, the authors give an overview of the currently available soft tissue and bony procedures in the treatment of the adult acquired flexible flatfoot. Instead of starting from the classification for posterior tibial tendon dysfunction, described by Johnson and Storm, the authors address the flatfoot from a more anatomical point of view. Based on this, they will try to define a treatment algorithm.

Lifelong bound feet in China: a quantitative ultrasound and lifestyle questionnaire study in postmenopausal women.

OBJECTIVE: The phenomenon of foot binding, also known as 'lotus feet', has an enduring and influential history in China. To achieve a man-made smaller foot size, lifelong foot binding may have had adverse effects on the skeleton. We investigated bone properties in postmenopausal women with bound feet, which may provide new information for developing countermeasures for prevention of fragility fractures. DESIGN: Population-based cohort study. PARTICIPANTS: This study involved 254 postmenopausal women aged 65-80, including 172 with bound feet and 82 age- and gender-matched control subjects, living in a remote region of China. OUTCOMES: Anthropometric, SF-36 Lifestyle Questionnaire and heel quantitative ultrasound (QUS) data were collected for the whole study population. A small subset of two cases was also invited for assessment of bone mineral density and microarchitecture at the distal tibia using high-resolution peripheral quantitative CT (HR-pQCT) and gait and balance tests. RESULTS: Women with bound feet had significantly lower QUS values than age-matched women with normal feet; this was supported by HR-pQCT data. However, SF-36 Questionnaire results did not reveal any statistically significant differences in any categorical responses, including physical functioning, general health vitality and physical component summary score, and number of previous fractures. No impairment of body balance was found in the small subset. CONCLUSIONS: The man-made changes caused by foot binding led to reduced physical activity, making the subjects prone to osteoporosis. Women with bound feet and osteoporosis did not have a higher incidence of fragility fractures than controls. This might be explained by compensation in physical activity to improve body balance, implying the importance of improving or maintaining body balance in overall prevention strategies against fragility fractures.

Assessment of coronal plane subtalar joint alignment in peritalar subluxation via weight-bearing multiplanar imaging.

BACKGROUND: Patients with adult-acquired flatfoot deformity (AAFD) develop peritalar subluxation, which may stem from valgus inclination of the inferior surface of the talus. We hypothesized that patients with AAFD would have an increased valgus tilt of the subtalar joint in the coronal plane compared to controls when assessed with a novel multiplanar weight-bearing imaging (MP-WB). METHODS: Eighteen normal and 36 stage II AAFD patients scheduled to undergo operative reconstruction were evaluated by MP-WB through measuring 3 novel angles of the subtalar joint in the coronal view: (1) angle between inferior facet of the talus and the horizontal/floor (inftal-hor), (2) angle between inferior and superior facets of the talus (inftal-suptal), and (3) angle between inferior facet of the talus and superior facet of the calcaneus (inftal-supcal). Intra- and interobserver reliability were evaluated via intraclass correlation coefficients (ICCs). Differences in angles between AAFD patients and controls were evaluated using Wilcoxon rank-sum test. RESULTS: Intra- and interobserver reliability were excellent for inftal-hor (ICC .942 and .991, respectively) and inftal-suptal (ICC .948 and .989, respectively), and moderate-good for inftal-supcal (ICC .604 and .742, respectively). Inftal-hor and inftal-suptal angles were found to be significantly greater in AAFD patients (P < 0.001) at all 3 locations along the posterior subtalar joint, while inftal-supcal did not demonstrate a significant difference (P = .741). While controls exhibited varus orientation at the anterior aspect of the joint, AAFD patients maintained a valgus orientation throughout. CONCLUSION: Inftal-hor and inftal-suptal angles provided a reliable means of evaluating the orientation of the subtalar joint axis in AAFD via MP-WB, and showed that the subtalar joint had increased valgus orientation in AAFD compared to controls. This may allow for identification of patients at risk for developing AAFD, and could potentially be used in guiding operative reconstruction.

Tibialis posterior tendon transfer corrects the foot drop component of cavovarus foot deformity in Charcot-Marie-Tooth disease.

BACKGROUND: The foot drop component of cavovarus foot deformity in patients with Charcot-Marie-Tooth disease is commonly treated by tendon transfer to provide substitute foot dorsiflexion or by tenodesis to prevent the foot from dropping. Our goals were to use three-dimensional foot analysis to evaluate the outcome of tibialis posterior tendon transfer to the dorsum of the foot and to investigate whether the transfer works as an active substitution or as a tenodesis. METHODS: We prospectively studied fourteen patients with Charcot-Marie-Tooth disease and cavovarus foot deformity in whom twenty-three feet were treated with tibialis posterior tendon transfer to correct the foot drop component as part of a foot deformity correction procedure. Five patients underwent unilateral treatment and nine underwent bilateral treatment; only one foot was analyzed in each of the latter patients. Standardized clinical examinations and three-dimensional gait analysis with a special foot model (Heidelberg Foot Measurement Method) were performed before and at a mean of 28.8 months after surgery. RESULTS: The three-dimensional gait analysis revealed significant increases in tibiotalar and foot-tibia dorsiflexion during the swing phase after surgery. These increases were accompanied by a significant reduction in maximum plantar flexion at the stance-swing transition but without a reduction in active range of motion. Passive ankle dorsiflexion measured in knee flexion and extension increased significantly without any relevant decrease in passive plantar flexion. The AOFAS (American Orthopaedic Foot & Ankle Society) score improved significantly. CONCLUSIONS: Tibialis posterior tendon transfer was effective at correcting the foot drop component of cavovarus foot deformity in patients with Charcot-Marie-Tooth disease, with the transfer apparently working as an active substitution. Although passive plantar flexion was not limited after surgery, active plantar flexion at push-off was significantly reduced and it is unknown whether this reduction was the result of a tenodesis effect or calf muscle weakness.

Percutaneous tenotomy for the treatment of diabetic toe ulcers.

BACKGROUND: Foot ulcers have been implicated as a causative factor in diabetic foot amputations. The purpose of this study was to evaluate treating foot ulcers in patients with diabetes by percutaneous tenotomy. METHODS: We retrospectively reviewed the computerized medical files of 83 patients treated for foot ulcers by percutaneous tenotomies. Results were analyzed on the basis of indication and per patient. RESULTS: The 83 patients had 160 tenotomies for 4 indications: 103 tip-of-toe ulcers (treated by flexor digitorum longus tenotomy), 26 cock-up/dorsal ulcers (extensor digitorum longus tenotomy), 21 kissing ulcers (extensor digitorum longus and/or flexor digitorum longus tenotomies), and 10 plantar metatarsal ulcers (extensor digitorum longus with or without flexor digitorum longus tenotomy). Healing at 4 weeks was 98%, 96%, 81%, and 0%, respectively. The complication rate was very low, with the exception of "transfer lesions," where an adjacent toe became involved and needed subsequent tenotomy in 8% of tip-of-toe ulcers. CONCLUSIONS: Percutaneous tenotomy was an effective and safe method for treating toe ulcers in neuropathic patients. It was not effective in treating plantar metatarsal ulcers. LEVEL OF EVIDENCE: Level IV, case series.

Intrinsic foot muscle deterioration is associated with metatarsophalangeal joint angle in people with diabetes and neuropathy.

BACKGROUND: Metatarsophalangeal joint deformity is associated with skin breakdown and amputation. The aims of this study were to compare intrinsic foot muscle deterioration ratios (ratio of adipose to muscle volume), and physical performance in subjects with diabetic neuropathy to controls, and determine their associations with 1) metatarsophalangeal joint angle and 2) history of foot ulcer. METHODS: 23 diabetic, neuropathic subjects [59 (SD 10) years] and 12 age-matched controls [57 (SD 14) years] were studied. Radiographs and MRI were used to measure metatarsophalangeal joint angle and intrinsic foot muscle deterioration through tissue segmentation by image signal intensity. The Foot and Ankle Ability Measure evaluated physical performance. FINDINGS: The diabetic, neuropathic group had a higher muscle deterioration ratio [1.6 (SD 1.2) vs. 0.3 (SD 0.2), P<0.001], and lower Foot and Ankle Ability Measure scores [65.1 (SD 24.4) vs. 98.3 (SD 3.3) %, P<0.01]. The correlation between muscle deterioration ratio and metatarsophalangeal joint angle was r=-0.51 (P=0.01) for all diabetic, neuropathic subjects, but increased to r=-0.81 (P<0.01) when only subjects with muscle deterioration ratios >1.0 were included. Muscle deterioration ratios in individuals with diabetic neuropathy were higher for those with a history of ulcers. INTERPRETATION: Individuals with diabetic neuropathy had increased intrinsic foot muscle deterioration, which was associated with second metatarsophalangeal joint angle and history of ulceration. Additional research is required to understand how foot muscle deterioration interacts with other impairments leading to forefoot deformity and skin breakdown.

Rheumatoid arthritis: preoperative evaluation for total hip and total knee replacement surgery.

The role of total joint replacement surgery remains significant in the contemporary management of patients with rheumatoid arthritis (RA), despite the impact of potent biologic and synthetic disease-modifying drugs. Patients with RA have a systemic polyarticular disease, with extra-articular manifestations such as anemia as well as specific comorbidities such as cardiovascular disease, which require careful preoperative assessment for optimal outcomes and fewer adverse events. This review describes the important preoperative considerations taken to prepare a patient with RA for total hip and total knee replacement surgery.

Treatment of the arthritic valgus ankle.

The ankle joint is part of a biomechanical hindfoot complex. Approximately 1% of the world's adult population is affected by ankle osteoarthritis (AO). Trauma is the primary cause of ankle OA, often resulting in varus or valgus deformities. Only 50% of patients with end-stage ankle OA have a normal hindfoot alignment. The biomechanics and morphology of the arthritic valgus ankle is reviewed in this article and therapeutic strategies, including joint preserving and nonpreserving modalities are presented. Pitfalls are discussed and the literature is reviewed regarding outcomes in patients with valgus deformity who underwent total ankle replacement.

Surgical treatment of the arthritic varus ankle.

Within the past several years, the arthritic varus ankle has been addressed extensively in Foot and Ankle Clinics, with numerous excellent reviews by particularly knowledgeable authors. To support these outstanding contributions, this article provides a practical approach to this challenging constellation of foot and ankle abnormalities. Varus ankle arthritis exists on a continuum that prompts the treating surgeon to be familiar with a spectrum of surgical solutions, including joint-sparing realignment, arthroplasty, and arthrodesis. Each of these treatment options is addressed with several expanded case examples and supports the management approaches with the available pertinent literature.