Does the Sagittal Radiographic Morphology of Subtalar Joint Affect the Alignment of Foot?

OBJECTIVES: The etiology of flatfoot and cavus foot is multicausal and controversial. So far, no literature reports the relationship between the sagittal morphology of subtalar joint and the alignment of foot. The purpose of this study was to explore whether the subtalar alignment would influence the configuration of foot. METHODS: From January 2017 to January 2020, we included 109 feet in the flatfoot group, 95 feet in the cavus group, and 104 feet in the control group in this retrospective comparative study. The Gissane angle and calcaneal posterior articular surface inclination angle represented the sagittal morphology of the subtalar joint. Meary's angle, calcaneal pitch angle, and talar pitch angle reflected the alignment of foot. They were measured in the weightbearing foot X-rays. The angles in different groups were compared via Mann-Whitney U test. We calculated the correlation between the sagittal alignment of subtalar joint and the alignment of foot using Spearman's correlation analysis. Interobserver and intraobserver reliability were calculated. RESULTS: The Gissane angle, calcaneal posterior articular surface inclination angle, Meary's angle, talar pitch angle, and calcaneal pitch angle were significantly different in the three groups. The Gissane angle had an excellent correlation with the Meary's angle (r = 0.850, p < 0.0001), and the talar pitch angle (r = -0.825, p < 0.0001), and a good correlation with the calcaneal pitch angle (r = 0.638, p < 0.0001). The calcaneal posterior articular surface inclination angle had an excellent correlation with the Meary's angle (r = -0.902, p < 0.001), and the talar pitch angle (r = 0.887, p < 0.0001), and a good correlation with the calcaneal pitch angle (r = -0.702, p < 0.0001). The interobserver and intraobserver reliability for all radiographic measurements was good to excellent. CONCLUSION: A subtalar joint with a larger Gissane angle and a more horizontal calcaneal posterior articular surface angle tended to have a higher foot arch and vice versa. The inspiration from this study was that the deformities of flatfoot and cavus foot may relate to the subtalar deformity.

Pes Cavus Deformity: Anatomic, Functional Considerations, and Surgical Implications.

Pes cavus is a complicated, multiplanar deformity that requires a thorough understanding in order to provide the appropriate level of care. The foot and ankle surgeon should perform a comprehensive examination, including a neurologic evaluation, in the workup of this patient population. Understanding the cause of the patient's deformity is a critical step in predicting the disease course as well as the most acceptable form of treatment. The surgical correlation with the patient's pathologic anatomy requires an in-depth clinical evaluation, in addition to the radiographic findings, as the radiographic findings do not necessarily correlate with the patient's discomfort.

The Subtle Cavovarus Foot Deformity: The Nonneurologic Form of Cavus Foot Deformity.

Conditions of ankle instability, peroneal tendon tears, and stress fractures of the lateral metatarsals are commonly encountered in a clinical foot and ankle practice. Evaluation of the supporting foot structure is critical to prevent failure of index procedures. The prominence of the subtle cavus foot is now a recognized entity and must be properly diagnosed and addressed surgically.

The Cavovarus Ankle: Approaches to Ankle Instability and Inframalleolar Deformity.

Pathologic affects from a cavus foot deformity range from flexible subtle to rigid severe deformities and are related to many pathologic conditions of the foot and ankle. Understanding the underlying deformity and the deforming force is essential in treating the cavus ankle and foot. Every deformity is different and unique to a given patient; therefore, surgical plans should be modified to each patient.

Pes cavovarus in Charcot-Marie-Tooth compared to the idiopathic cavovarus foot: A preliminary weightbearing CT analysis.

BACKGROUND: Pes cavovarus is a foot deformity that can be idiopathic (I-PC) or acquired secondary to other pathology. Charcot-Marie-Tooth disease (CMT) is the most common adult cause for acquired pes cavovarus deformity (CMT-PC). The foot morphology of these distinct patient groups has not been previously investigated. The aim of this study was to assess if morphological differences exist between CMT-PC, I-PC and normal feet (controls) using weightbearing computed tomography (WBCT). METHODS: A retrospective analysis of WBCT scans performed between May 2013 and June 2017 was undertaken. WBCT scans from 17 CMT-PC, 17 I-PC and 17 healthy normally-aligned control feet (age-, side-, sex- and body mass index-matched) identified from a prospectively collected database, were analysed. Eight 2-dimensional (2D) and three 3-dimensional (3D) measurements were undertaken for each foot and mean values in the three groups were compared using one-way ANOVA with the Bonferroni correction. RESULTS: Significant differences were observed between CMT-PC or I-PC and controls (p<0.05). Two-dimensional measurements were similar in CMT-PC and I-PC, except for forefoot arch angle (p=0.04). 3D measurements (foot and ankle offset, calcaneal offset and hindfoot alignment angle) demonstrated that CMT-PC exhibited more severe hindfoot varus malalignment than I-PC (p=0.03, 0.04 and 0.02 respectively). CONCLUSIONS: CMT-related cavovarus and idiopathic cavovarus feet are morphologically different from healthy feet, and CMT feet exhibit increased forefoot supination and hindfoot malalignment compared to idiopathic forms. The use of novel three-dimensional analysis may help highlight subtle structural differences in patients with similar foot morphology but aetiologically different pathology. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Influência do arco longitudinal medial na distribuição plantar e na flexibilidade posterior / La influencia del arco longitudinal medial en la distribución plantar y la flexibilidad posterior / The influence of medium longitudinal arch on plant distribution and posterior pliability

RESUMO O objetivo deste estudo foi verificar se a formação do arco longitudinal do pé interfere na distribuição da pressão plantar e na flexibilidade dos músculos posteriores da coxa. O método de estudo foi transversal e as impressões plantares foram obtidas usando o plantígrafo e analisadas segundo o método Viladot. A distribuição plantar e a flexibilidade foram avaliadas pela baropodometria e pelo banco de Wells, respectivamente. Foi observado que crianças com pés cavos apresentam maior flexibilidade quando comparadas às que têm o pé normal (p=0,02); e também que pés cavos apresentam maior pressão, ou seja, maior sobrecarga em calcâneo quando comparados àqueles com o arco plantar normal (p=0,02 membro inferior direito e p=0,03 membro inferior esquerdo). A avaliação do arco longitudinal medial mostra que crianças com pés cavos apresentam maior flexibilidade dos músculos posteriores de membro inferior. Os pés cavos também estão associados com maior descarga de peso em região de calcâneo.

RESUMEN El objetivo de este estudio fue verificar si la formación del arco longitudinal del pie interfiere con la distribución de la presión plantar y la flexibilidad de los músculos posteriores del muslo. El método de estudio fue transversal y las huellas plantar se obtuvieron utilizando el plantigraph y se analizaron según el método de Viladot. La distribución plantar y la flexibilidad se evaluaron mediante baropodometría y el banco de Wells, respectivamente. Se observó que los niños con pies huecos tienen mayor flexibilidad en comparación con aquellos con pies normales (p=0,02); y también que los pies huecos tienen una mayor presión, es decir, una mayor sobrecarga del talón en comparación con aquellos con arco plantar normal (p=0,02 miembro inferior derecho y p=0,03 miembro inferior izquierdo). La evaluación del arco longitudinal medial muestra que los niños con pies huecos tienen una mayor flexibilidad en los músculos posteriores de la extremidad inferior. Los pies huecos también están asociados con una mayor descarga de peso en la región del talón.

ABSTRACT Objective: To evaluate whether the formation of the longitudinal arch of the foot interferes with the distribution of plantar pressure and the pliability of the posterior thigh muscles. Methodology: a cross-sectional study and the footprints were obtained using the footprinting mat and analyzed according to the Viladot method. Plantar distribution and pliability were assessed by baropodometry and Wells' bank, respectively. Results: It was observed that children with cavus feet present greater pliability when compared to those with normal feet (p=0.02). Also, the cavus feet exhibit higher pressure, that is, a greater heel overload compared to those with normal plantar arch (p=0.02 lower right limb and p=0.03 lower left limb). Conclusions: The evaluation of the medial longitudinal arch shows that children with cavus feet have greater pliability of the lower limb posterior muscles. The cavus feet are also associated with higher pressure in the calcaneal region.

Intraobserver and interobserver reliability of cone beam weightbearing semi-automatic three-dimensional measurements in symptomatic pes cavovarus.

INTRODUCTION: Pes cavovarus is a three-dimensional (3D) foot deformity. New 3D semi-automatic measurements utilising weightbearing computerised topography (WBCT) images have recently been proposed to assess hindfoot alignment, but reliability in pes cavovarus has never been investigated. The aim of this study was to assess intraobserver and interobserver reliability of the foot ankle offset (FAO), calcaneal offset (CO) and hindfoot alignment angle (HAA) in pes cavovarus. METHODS: Anonymised WBCT datasets from 51 feet (17 Charcot-Marie-Tooth related cavovarus, 17 idiopathic cavovarus and 17 controls) were retrospectively reviewed. Three observers (two senior foot and ankle fellows and one orthopaedic resident) independently measured FAO, CO and HAA using dedicated software, with measurements repeated two weeks apart. Subgroup analysis was performed to assess whether aetiology or severity of varus deformity and level of seniority affected reliability. RESULTS: Mean values for intra and interobserver reliability for FAO (r=0.98; ICC: 0.99), CO (r=0.97; ICC: 0.98) and HAA measurements (r=0.97; ICC: 0.98) were excellent. Subgroup analyses showed that FAO, CO and HAA's intra (r/ρ range, 0.77-0.95) and interobserver (ICC range, 0.88-0.98) reliability remained excellent in patients with Charcot-Marie-Tooth related cavovarus, idiopathic pes cavovarus and normal feet, regardless of the severity of deformity. No difference was found in FAO, CO and HAA mean values from three observers (p>0.05 in all cases). DISCUSSION: This study demonstrates that 3D semi-automatic measurements of WBCT images have excellent intra and interobserver reliability in the assessment of hindfoot alignment in pes cavovarus. Aetiology and severity of deformity, and level of seniority do not affect reliability of these measurements. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Inframalleolar Varus Deformity: Role of Calcaneal Osteotomies.

The cavo varus foot is a complex pathology due to skeletal deformity and neuro-muscular unbalance. The key concept for a successful treatment is to consider the whole foot and ankle complex from a bone and soft tissue perspective. Undercorrection is the main issue in cavo varus foot management, which may be attributed to intrinsic correction defects of the described calcaneal osteotomies or to a lack of understanding about the pathology and the subsequent algorithm of treatment. The authors disclose their daily algorithm of treatment, considering the foot and ankle complex and the role of calcaneal osteotomies in ankle inframalleolar deformities.

Failure of Surgical Treatment in Patients with Cavovarus Deformity: Why Does This Happen and How Do We Approach Treatment?

Recurrent deformity after surgical treatment of the cavus foot occurs because a procedure is not performed at the apex of the deformity. In many instances there are multiple apices and, in addition to hindfoot osteotomy or arthrodesis, the midfoot must be corrected. There is not much of a role for the Coleman block test to determine flexibility of the foot, and this has led to many failures where the foot was believed flexible and an osteotomy was insufficient treatment. Skeletal correction, even if perfect, does not last unless the foot is balanced with appropriate tendon transfers.

Neurovascular and Clinical Outcomes of the Percutaneous Endoscopically Assisted Calcaneal Osteotomy (PECO) Technique to Correct Hindfoot Malalignment.

BACKGROUND:: Standard open calcaneal osteotomies to correct hindfoot malalignment have been associated with high complication rates, including nerve damage and wound infection. This has resulted in the development of minimally invasive techniques such as the percutaneous endoscopically assisted calcaneal osteotomy (PECO), which in cadaver studies has been shown to be potentially safer than open surgeries. The aim of this study was to demonstrate the safety and effectiveness of PECO in a clinical setting, with regard to neurovascular injury rates, infection, and short-term radiographic and functional outcomes. METHODS:: Forty-one (41) patients with planovalgus or cavovarus foot deformities underwent treatment using PECO. Outcomes were analyzed at 6 months and primarily included neurovascular outcomes and wound infection rates. Secondarily, radiographic and functional (visual analog scale for pain [VAS], 36-Item Short Form Medical Outcomes Survey [SF-36], and Foot Function Index [FFI] scores) outcomes were also assessed. RESULTS:: There were no reported cases of superficial wound infections, lateral calcaneal or sural nerve dysesthesia. Minor complications occurred in 6/41 feet. The mean postoperative hindfoot correction was 8.3 ± 2.2 mm (range: 6-15mm) compared to preoperative status. Compared to preoperative status, significant improvements ( P = .001 for all) were seen in the VAS, SF-36, and FFI at 6 months postoperatively. CONCLUSIONS:: PECO resulted in minimal complications with no lateral calcaneal or sural nerve dysesthesias and no wound complications. It also resulted in significant improvements in postoperative radiographic and functional outcomes from baseline to 6-months postoperatively, demonstrating its use as a safe and effective means of treating hindfoot malalignment. LEVEL OF EVIDENCE:: Level IV, retrospective case series.

An Analysis of Relative Gait Impairment in Commonly Diagnosed Pediatric Conditions.

BACKGROUND: Gait indices were developed to represent the magnitude of impairment extracted from a gait analysis with a single value. The Gillette Gait Index (GGI), and the Gait Deviation Index (GDI) are 2 widely used indices that represent gait impairment differently based on their statistical properties. Our purpose was to (1) report on the results of gait analysis for a broad spectrum of pediatric conditions using the GGI and GDI, and (2) identify the parameters that dominate impairment. METHODS: A total of 1439 children with 13 different diagnoses with a complete, baseline gait analysis were identified. The GGI and its 16 parameters were calculated in all cases, and the GDI was calculated from a smaller subset. T tests, and z-scores were used to compare each of these values to typically developing children for each diagnosis. A separate linear regression controlling for age, sex, and use of an orthosis, or assistive device was performed for the GGI. RESULTS: In our series, there were 71 typically developing children with a GGI of 31. We qualify relative gait impairment as severe, mild, or moderate as based on the GGI, and propose that values <100 represent mild, 100 to 200 represent moderate, and >200 represents severe impairment. On the basis of strong correlation between the GGI and GDI, we suggest that GDI values >80 represent mild, and values <70 represent severe impairment. T tests and z-scores demonstrated that both the number and magnitude of abnormal parameters increase the GGI. These tests also identified the most clinically relevant parameters contributing to functional impairment for each diagnosis. Multivariate linear regression showed that all diagnoses except flatfoot and scoliosis demonstrated statistically significant differences in GGI scores. CONCLUSIONS: This is the first study to apply these gait indices to a large population of diverse pediatric conditions. We propose GGI and GDI values to qualify gait impairment among these conditions as severe, moderate, or mild. Furthermore, impairment in gait reflects both the number and magnitude of abnormal parameters within each condition. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Is non-operative management of childhood neurologic cavovarus foot effective?

INTRODUCTION: Neurologic pes cavus is a progressive deformity that is difficult to treat during growth. The present study reports results of non-operative management, based on the pathophysiology of the deformity, by untwisting nocturnal splint, preceded in some cases by untwisting walking cast. The objective was to assess efficacy and impact on indications for surgery. METHOD: Twenty-three children (35 feet) were included. All had neurologic cavovarus foot, which was progressive in 24 feet (69%) (Charcot-Marie-Tooth disease). Mean age at initiation of treatment was 8.8 years. In 13 feet (38%), treatment began with a untwisting walking cast and in 22 (62%) began directly with the splint. RESULTS: Mean follow-up was 4.5 years. Fifteen feet showed very good and 8 good clinical results (65%); 9 children (12 feet) had moderate or poor results, requiring renewed treatment in 11 feet at a mean 4.5 years after initiation of non-operative treatment. Thirteen patients (56.5%, 21 feet) had reached end of growth by last follow-up; 10 of these feet (48%) had good or very good results without surgery. No triple arthrodeses were required. Factors weighing against good outcome comprised young age at treatment initiation and poor compliance with the splint. Primary deformity severity did not affect outcome. CONCLUSION: The present study demonstrated efficacy for non-operative treatment of childhood neurologic cavovarus foot. Surgery was either avoided (in half of the cases followed up to end of growth) or delayed by a mean 4.5 years, allowing a single procedure before end of growth. We recommend initiating non-operative treatment of childhood cavovarus foot, associating untwisting walking cast and untwisting nocturnal splint, as soon as clinical progression is detected and/or Méary angle on lateral X-ray with block reaches 15°. LEVEL OF EVIDENCE: IV.

Pé cavo: revisão da literatura / Cavus foot: review

OBJETIVO: Realizar uma revisão sobre o pé cavo, sua fisiopatologia, avaliação clínica, diagnósticos diferenciais com ênfase na doença de Charcot-Marie-Tooth e tratamento. MÉTODO: Revisão não sistemática de artigos abordando a fisiopatologia do pé cavo, avaliação clínica, diagnósticos diferenciais e tratamento. RESULTADOS E DISCUSSÃO: Foram utilizados 33 artigos de língua inglesa e 02 artigos em português para a confecção desta revisão. CONCLUSÃO: O pé cavo é geralmente secundário a doenças neurológicas, em especial a doença de Charcot-Marie-Tooth e raramente é originado por doenças não neurológicas. O diagnóstico etiológico do pé cavo permite um melhor tratamento, cirúrgico ou não, com adequada orientação ao paciente quanto ao prognóstico e eficácia da terapia.

OBJECTIVE: We realize a review about cavus foot, discussing pathophysiology, clinical evaluation, differential diagnosis with emphasis on Charcot-Marie-Tooth Disease and treatment. METHOD: We perform a non-systematic review of articles about cavus foot pathophysiology, physical examination, etiology and treatment. RESULTS AND DISCUSSION: We used 33 articles in english and 02 articles in portuguese for this review. CONCLUSION: The cavus foot is mostly a consequence of neurological etiologies, in particular Charcot-Marie-Tooth disease and rarely is caused by non-neurological diseases. The correct diagnosis allows better treatment, conservative or surgical, with appropriate guidance to patients in terms of prognosis and therapy effectiveness.