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

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

[Flatfoot in children]. / Kindlicher Knick-Senk-Fuß.

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

Impact of the medial displacement calcaneal osteotomy on foot biomechanics: a systematic literature review.

INTRODUCTION: Progressive collapsing foot deformity (PCFD), formally known as "adult-acquired flatfoot deformity" (AAFFD), is a complex foot deformity consisting of multiple components. If surgery is required, joint-preserving procedures, such as a medial displacement calcaneal osteotomy (MDCO), are frequently performed. The aim of this systematic review is to provide a summary of the evidence on the impact of MDCO on foot biomechanics. MATERIALS AND METHODS: A systematic literature search across two major sources (PubMed and Scopus) without time limitation was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) criteria. Only original research studies reporting on biomechanical changes following a MDCO were included. Exclusion criteria consisted of review articles, case studies, and studies not written in English. 27 studies were included and the methodologic quality graded according to the QUACS scale and the modified Coleman score. RESULTS: The 27 included studies consisted of 18 cadaveric, 7 studies based on biomechanical models, and 2 clinical studies. The impact of MDCO on the following five major parameters were assessed: plantar fascia (n = 6), medial longitudinal arch (n = 9), hind- and midfoot joint pressures (n = 10), Achilles tendon (n = 5), and gait pattern parameters (n = 3). The quality of the studies was moderate to good with a pooled mean QUACS score of 65% (range 46-92%) for in-vitro and a pooled mean Coleman score of 58 (range 56-65) points for clinical studies. CONCLUSION: A thorough knowledge of how MDCO impacts foot function is key in properly understanding the postoperative effects of this commonly performed procedure. According to the evidence, MDCO impacts the function of the plantar fascia and Achilles tendon, the integrity of the medial longitudinal arch, hind- and midfoot joint pressures, and consequently specific gait pattern parameters.

Clinical report of microsurgical treatment of Kohler's disease.

The conservative treatment for Kohler's disease will take several months, but some patients still have flatfoot and persistent pain. From October 2013 to July 2015, 3 children with Kohler's disease underwent navicular decompression and micro-circulation reconstruction surgery in our hospital. All the patients have received conservative treatment for more than 3 months and the effect was poor. X-ray showed the bone density of navicular increased significantly. All patients were followed up over 1 year. The 3 patients recovered well. VAS score decreased from 7.0 to 2.6 at 1 month after the operation. The pain symptom disappeared completely on 3 months after surgery. The density of navicular bone recovered to normal. Navicular decompression and micro-circulation reconstruction surgery may quickly improve the ischemic status of navicular bone, alleviate pain symptom and enable patients to resume normal activity as soon as possible.

Effect of foot orthoses on balance among individuals with flatfoot: A systematic review and meta-analysis.

Individuals with flatfoot have impaired proprioception owing to ligament laxity and impaired tendons, which can result in poor balance. Foot orthoses (FOs) have been reported to stimulate plantar mechanical receptors and are used to manage foot overpronation in individuals with flatfoot. However, the results of the use of FOs to improve balance are inconsistent. In this systematic review and meta-analysis, we aimed to identify and investigate the effects of FOs on balance in individuals with flatfoot. Electronic databases were searched for articles published before March 2023. Peer-reviewed journal studies that included adult participants with flexible flatfoot and reported the effects of FOs on balance were included and classified based on the study design: randomized control trials (RCT) and non-RCTs. Four RCT studies were retained, and their methodological quality was assessed (mean, 63.2%; range 47.3%-73.1%: high), as were three non-RCT studies (mean, 54.1%; range, 42.1%-68.4%: high). Meta-analysis was performed by calculating the effect size using the standardized mean differences between the control and FO conditions. Transverse-arch insoles immediately improved static balance after use. However, no immediate significant effect was found for medial archsupport FOs, cuboid-posting FOs, or University of California Berkeley Laboratory FOs during the study period (2-5 weeks) when compared with the controls. The transverse-arch insole is the most effective FO feature for improving static balance. However, the high heterogeneity between study protocols contributes to the lack of evidence for the effects of FO on balance in people with flatfoot.

Exploring flatfeet morphology in children aged 6-12 years: relationships with body mass and body height through footprints and three-dimensional measurements.

The aim of the study was to determine the relationship between flatfoot morphology and body mass and height in children aged 6-12 years. A total of 6471 Chinese children (mean age 9.0 ± 1.9 years, 41% female) were assessed for foot morphometry, body height, and body mass index. Foot morphology, including foot length, width, girth, arch height, hallux valgus angle, and rearfoot valgus angle, was measured using a 3D laser scanner. Flatfoot evaluations were conducted using the Sztriter-Godunov index (KY) from footprints. All measurements were analyzed by age and sex using the mean values of the left and right sides. Comparisons were performed between flatfoot groups, between body mass index (BMI) groups, and between body height groups. The study revealed a significant decrease in the incidence of bipedal flatfoot with age (p < 0.001), whereas the prevalence of obesity remained consistent (p > 0.05). Bipedal flatfoot was associated with distinct morphological changes, including lower arches, reduced instep height, diminished ankle heights and a greater rearfoot valgus angle (p < 0.05). When comparing the BMI groups, overweight children had larger and thicker feet (p < 0.05), but no differences were found in arch height and ankle height (p > 0.05). When comparing the body height groups, short-statured children had a shorter feet girth, shorter arches, and shorter ankle height (p < 0.05), but no differences were found in the rearfoot valgus angle (p > 0.05). CONCLUSION: The main characteristics of flat feet include lower arches and instep heights and ankle heights but higher rearfoot valgus angles. In general, overweight children's feet do not have the common features of flat feet. In contrast, short children had similar features of flatfoot except for rearfoot valgus. Assessment of posture, such as rearfoot valgus, can be critical in identifying children with flat feet. WHAT IS KNOWN: • The morphology of children's feet is associated with body growth, but the relationship between flatfeet and body mass and height remains controversial. WHAT IS NEW: • Three-dimensional foot measurement shows that body mass is generally not associated with flatfeet, while short children have lower arches but no rearfoot valgus.

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

BACKGROUND: Evans and Hintermann lateral column lengthening (LCL) procedures are both widely used to correct adult acquired flatfoot deformity (AAFD), and have both shown good clinical results. The aim of this study was to compare these two procedures in terms of corrective ability and biomechanics influence on the Chopart and subtalar joints through finite element (FE) analysis. METHODS: Twelve patient-specific FE models were established and validated. The Hintermann osteotomy was performed between the medial and posterior facets of the subtalar joint; while, the Evans osteotomy was performed on the anterior neck of the calcaneus around 10 mm from the calcaneocuboid joint surface. In each procedure, a triangular wedge of varying size was inserted at the lateral edge. The two procedures were then compared based on the measured strains of superomedial calcaneonavicular ligaments and planter facia, the talus-first metatarsal angle, and the contact characteristics of talonavicular, calcaneocuboid and subtalar joints. RESULTS: The Hintermann procedure achieved a greater correction of the talus-first metatarsal angle than Evans when using grafts of the same size, indicating that Hintermann had stronger corrective ability. However, its distributions of von-Mises stress in the subtalar, talonavicular and calcaneocuboid joints were less homogeneous than those of Evans. In addition, the strains of superomedial calcaneonavicular ligaments and planter facia of Hintermann were also greater than those of Evans, but both generally within the safe range (less than 6%). CONCLUSION: This FE analysis study indicates that both Evans and Hintermann procedures have good corrective ability for AAFD. Compared to Evans, Hintermann procedure can provide a stronger corrective effect while causing greater disturbance to the biomechanics of Chopart joints, which may be an important mechanism of arthritis. Nevertheless, it yields a better protection to the subtalar joint than Evans osteotomy. CLINICAL RELEVANCE: Both Evans and Hintermann LCL surgeries have a considerable impact on adjacent joints and ligament tissues. Such effects alongside the overcorrection problem should be cautiously considered when choosing the specific surgical method. LEVEL OF EVIDENCE: Level III, case-control study.

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

BACKGROUND: The purpose of this study is to investigate the biomechanical effect of medial displacement calcaneal osteotomy (MDCO), subtalar joint fusion (SF), and medial ligament reconstruction (MLR: deltoid-spring ligament) in a severe flatfoot model. We hypothesized that (1) combination of MDCO and SF improves the tibiotalar and foot alignment in severe progressive collapsing foot deformity (PCFD) cadaver model. (2) However, if a residual valgus heel alignment remains after MCDO and SF, it can lead to increased medial ligament strain, foot malalignment, and tibiotalar valgus tilt, which will be mitigated by the addition of MLR. METHODS: Ten fresh-frozen cadaveric foot specimens were used to create a severe flatfoot model. The foot alignment changes, including the talo-first metatarsal angle in the axial and sagittal planes, subtalar angle, and tibiotalar angle in the coronal plane, were measured. The angles were measured at the initial condition, after creating the severe flatfoot model, and after each successive reconstructive procedure in the following order: (1) MDCO, (2) SF, and (3) MLR. RESULTS: Tibiotalar valgus tilt was decreased with the MDCO procedure: 4.4 vs 1.0 degrees (P = .04). Adding in situ SF to the MDCO led to increased tibiotalar tilt to 2.5 degrees was different from the initial condition (P = .01). Although the tibiotalar valgus tilt was significantly decreased after adding the MLR to the MDCO/SF procedure compared with the severe flatfoot model (0.8 vs 4.4 degrees, P = .03), no significant difference in the tibiotalar valgus tilt was observed between MDCO/SF and MDCO/SF with MLR. CONCLUSION: Our results demonstrated that MDCO significantly improved forefoot abduction and medial arch alignment, with no significant additional improvement observed with addition of SF. Following SF, a residual valgus heel alignment can contribute to subsequent tibiotalar valgus tilt. The addition of MLR did not show significantly decreased tibiotalar valgus tilt following SF. CLINICAL RELEVANCE: Residual valgus heel alignment after subtalar joint fusion in the surgical treatment of PCFD can lead to increased medial ligament strain. Although MLR might be considered for providing medial stability, it may not necessarily prevent the development of tibiotalar valgus tilt.

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

BACKGROUND: Flatfoot deformity is believed to play a role in hallux valgus development and recurrence. While symptomatic flatfoot deformity can be treated with separate procedures at the time of hallux valgus correction, the question remains whether the patient undergoing correction of a symptomatic hallux valgus deformity should have their asymptomatic flatfoot concurrently addressed. We aimed to investigate whether the presence of asymptomatic flatfoot influences patient-reported and radiographic outcomes of the minimally invasive chevron and Akin bunionectomy. METHODS: A total of 104 patients were included in this study. Forty-two asymptomatic patients met the radiographic criteria for flatfoot while 62 had a normal arch. Patient-reported outcomes were evaluated and compared between the two groups using validated PROMIS measures preoperatively and at a minimum one-year postoperatively. Radiographic outcomes including hallux valgus angle (HVA), intermetatarsal angle (IMA), Meary's angle, calcaneal pitch (CP), and talonavicular coverage angle (TNCA) were measured and compared preoperatively and minimum six-months postoperatively. RESULTS: Both groups demonstrated similar preoperative and postoperative PROMIS scores with significant improvements in physical function, pain interference, pain intensity, and global physical health. Preoperatively, HVA was similar between both groups, however the flatfoot group showed a greater IMA, Meary's angle, TNCA, and lower CP. Postoperatively, HVA and IMA were similar between groups, although patients in the flatfoot group retained a significantly greater Meary's angle, TNCA, and lower CP. Both groups showed significant improvements in HVA, IMA, and TNCA. CONCLUSION: Our study indicates that the minimally invasive chevron and Akin bunionectomy leads to improved clinical and radiographic hallux valgus outcomes without adversely impacting radiographic flatfoot parameters. Therefore, the MIS bunionectomy may be an effective option for hallux valgus correction in patients with mild, asymptomatic flatfoot. LEVEL OF EVIDENCE: Level III, retrospective cohort.

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

BACKGROUND: Minimally invasive surgery (MIS) in medial displacement calcaneus osteotomy (MDCO) has been proposed for surgical correction of adult-acquired flat foot deformity (AAFD) to reduce complications of open approaches. The aim of our study is to systematically analyze complications and the clinical and radiological results of MIS- MDCO. METHODS: A systematic review of the English literature was performed on 30th October 2023. Randomized controlled trials and non-randomized trials, cohort studies, case-control studies and case series concerning surgical correction of AAFD with MIS-MDCO and with at least 15 patients were included. Case reports, technical notes, animal or cadaveric studies were excluded. The quality and risk of bias of the studies included were evaluated using GRADE and MINORS systems. Complications rate, clinical and radiological results were inferred from the studies included. RESULTS: Nine articles were included. A total of 501 cases treated with MIS-MDCO were analysed with a mean follow-up of 11.9 ± 5.1 months. The reported wound infection rate was about 3% and sural neuropathy was rated about 1%. Only 4% of the cases required removal of the screw for pain. In the comparative studies (MIS versus Open MDCO), comparable clinical results but with significant differences (P < 0.001) in infection rates (1% versus 14%) and sural neuropathy (2% versus 1%) were observed. CONCLUSION: AAFD correction performed with MIS-MDCO, with the limitation of a poor quality and high risk of bias of the included studies, seems to provide good clinical results and high subjective satisfaction with a lower complication rate compared to open approach. Further high-quality long-term comparative studies could better clarify complications and clinical and radiological outcomes of the MIS technique in the treatment of AAFD. LEVEL OF EVIDENCE: Level IV.

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

BACKGROUND: Medializing displacement calcaneal osteotomy is commonly performed as part of reconstructive surgery for patients with valgus hindfoot and progressive pes planus deformity. Among several types of calcaneal osteotomies, the oblique and Chevron osteotomy patterns have been commonly described in the literature and gained popularity as they are easily reproducible through percutaneous techniques. Currently, there is scarce evidence in the literature on which cut pattern is superior in terms of stability. To investigate the impact of cut pattern and posterior fragment medialization level on foot biomechanics, computational methods are employed. METHODS: Ankle weightbearing computer tomography (CT) scans of seven patients diagnosed with stage II pes planus deformity are segmented and converted into 3D computational models. Oblique and Chevron osteotomy patterns are modeled independently for each patient. The posterior fragments are medially translated by 8-, 10- and 12-mm and subsequently fixated to the anterior calcaneus with two screws. A total of 42 models are exported to finite element software for biomechanical simulations. Among the investigated parameters, the higher stiffness and lower von Mises stress at the osteotomy interface and the screw site are assumed to be precursors of better stability. RESULTS: It is recorded that as the medialization level increases, the stiffness decreases, and overall stresses increase. Also, it is observed that the Chevron cut produces a stiffer construct while the overall stresses are lower, indicating better stability when compared to the oblique cut. The statistical comparisons of the relevant groups that support these trends are found to be significant (p < 0.05). CONCLUSION: Chevron osteotomy showed superior stability compared to the oblique osteotomy while underscoring the negative impact of increased medialization of the posterior fragment. CLINICAL RELEVANCE: Opting for a lower medialization level and implementing the Chevron technique may facilitate union and earlier weightbearing.

Comparison of 2 Conservative Treatment Approaches for the Flat Foot in Children Aged 5 to 10: Foot Orthoses Versus Foot Orthoses Supplemented With Zukunft-Huber Manual Therapy.

The aim was to find if foot orthotics alone can improve flat feet in children and analyze how the addition of Zukunft-Huber manual therapy and corrective bandaging changes the outcome. Forty-nine children aged 5 to 10 with asymptomatic flexible flat feet were divided into 2 groups. The first was treated with foot orthoses alone, in the second wearing foot orthoses was supplemented with Zukunft-Huber manual therapy and corrective bandaging. Pedobarography during gait was performed before the therapy and after a year. In the first group decrease in arch index, width, force, and area of midfoot, increase in force MH2 and area hindfoot was found, in the second decrease in arch index, width, force, and area of midfoot, increase in force under metatarsal head second, third, fourth, and fifth, area metatarsal head fourth and area hindfoot. Both methods showed positive changes, but foot orthoses with additional intervention were more effective.

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

INTRODUCTION: Minimally invasive calcaneal osteotomy (MICO) is already an established surgical procedure for correcting hindfoot deformities using a lateral approach. So far, no description of a medial approach for MICO has been published. MATERIAL AND METHODS: Between August 2022 and March 2023, 32 consecutive patients (MICO with medial approach, MMICO: n = 15; MICO with lateral approach, LMICO: n = 17) underwent MICO as part of complex reconstructive surgery of the foot and ankle with concomitant procedures. The amount of correction in the axial view of the calcaneus and consolidation rates were evaluated radiographically. Subjective satisfaction, stiffness of the subtalar joint, and pain level (numeric rating scale, NRS) at the level of the heel were assessed clinically. The last follow-up was at 6 months. RESULTS: All osteotomies consolidated within 6 months after surgery. Displacement of the tuber was 9 mm on average in either group. Relevant subtalar joint stiffness was detected in 5 MMICO and 6 LMICO patients. No relevant differences between the groups were detected for wound healing problems, nerve damage, heel pain or patient satisfaction. CONCLUSION: In this study lateral and medial approaches for MICO were performed. Similar degrees of correction and low complication rates were found in both groups. The medial approach for MICO is safe and can be beneficial regarding patient positioning and arrangement of the C­arm.

Effects of rigid and kinesio taping on plantar pressure distribution in patients with Lisfranc fracture sequelae.

BACKGROUND: Patients with Lisfranc fractures may regain functional status after anatomical fixation, but they may experience sequelae such as flatfoot deformity and pain associated with foot pressure distribution during weight-bearing. RESEARCH QUESTION: What is the impact of Lisfranc fracture sequelae on both the injured and uninjured sides, and how does the antipronation taping affect plantar pressure distribution parameters? METHODS: Twenty-six patients who underwent anatomical fixation for Lisfranc fracture, displaying pronation on the injured side based on the Foot Posture Index-6 test, as well as 15 healthy subjects, participated in this study. Plantar pressure distribution measurements were conducted during barefoot walking for the healthy subjects. In the patient group, measurements were taken under two antipronation taping conditions (kinesio and rigid taping), as well as during barefoot walking. RESULTS: Participants who received anatomical fixation after Lisfranc fracture exhibited significant alterations in plantar pressure distribution parameters on both the injured and uninjured sides, as compared to the control group. After the application of Kinesio Taping to the injured side, there was no significant change observed in the plantar pressure distribution values (p > 0.05). The analysis of the rigid taping on the injured side revealed statistically worse values in peak pressure of the hindfoot (p = 0.027) and maximum force of the midfoot and toes (p = 0.005 and p = 0.013, respectively) compared to the injured barefoot condition. SIGNIFICANCE: Lisfranc fracture sequelae affected plantar pressure distribution on both injured and uninjured sides. Anti-pronation taping (kinesio and rigit), commonly used for foot conditions, did not lead to foot pressure distribution becoming more similar to that of the control group.

Morphological and mechanical characteristics of the intrinsic and extrinsic foot muscles under loading in individuals with flat feet.

BACKGROUND: The intrinsic and extrinsic foot softtissue structures that apply force and support the medial longitudinal arch (MLA) have been implicated in the development of flat feet. However, the relationship between the changes in MLA height under increasing load and the morphological and mechanical properties of individual intrinsic and extrinsic foot soft tissue structures is not fully understood. RESEARCH QUESTION: To examine the morphological and mechanical characteristics of the foot soft tissue structures in flat feet when subjected to loading. METHODS: This study consisted of two studies focusing on the extrinsic foot muscles (10 normal feet/11 flat feet) and intrinsic foot muscles (14 normal feet/13 flat feet). Images of the extrinsic and intrinsic foot muscles and plantar fascia (PF) under 10%, 50%, and 90% body weight conditions were obtained using ultrasound-based shear-wave elastography. RESULTS: The cross-sectional area (CSA) of the peroneus brevis was larger in the flat-foot group than in the normal-foot group under all loading conditions. The CSAs of the intrinsic foot muscles (abductor hallucis, flexor digitorum brevis, and quadratus plantae) and thickness of the PF in the flat-foot group decreased significantly with increasing load. As for mechanical characteristics, the stiffness of the flexor digitorum longus and abductor hallucis was higher in the flat-foot group than in the normal group under high loading conditions. In addition, flat feet with greater flexibility tended to exhibit a greater decrease in PF thickness and smaller increase in stiffness. SIGNIFICANCE: Excessive stretching of the intrinsic foot muscles and PF occurs in flat feet, and excessive contraction of the flexor digitorum longus may counteract the excessive lowering of the foot arch. Therefore, it is necessary to promote the contraction of the intrinsic foot musculature in feet with greater flexibility of the MLA during loading.