[Long-term clinical and radiological results of metatarsophalangeal resection arthroplasty in patients with large forefoot deformities]. / Resultados clínicos y radiológicos a largo plazo de la artroplastía de resección metatarsofalángica en pacientes con grandes deformidades del antepié.

INTRODUCTION: metatarsophalangeal resection arthroplasty is considered a salvage surgical procedure able to improve the quality of life of patients with major forefoot deformities. MATERIAL AND METHODS: a retrospective observational study of 31 patients (36 feet) with major forefoot deformities operated at our institution was performed. Thirty two feet required additional surgery involving the first ray, most of them (72.2%) through MTP joint fusion. The mean follow-up period was 10.3 ± 4.6 years. Most patients were women (87.1%), the mean age was 74.2 ± 11.5 years. RESULTS: at the final follow-up, mean AOFAS score was 77.9 ± 10.2 points and mean MOxFQ score was 18.3 ± 8.3 points. Visual analog scale (VAS) for pain improved significantly from 7.5 ± 1.2 points to 3.4 ± 2.1 points on average. Good clinical results were also reported on ability to put on shoes comfortably. The mean resection arthroplasty spaces at the end of the study were 1.3, 1.8, 2.5 and 4.4 mm, for second to fifth rays, respectively. The mean sizes of remodeling osteophytes at the end of the study were 1.6, 1.4, 1.1 and 0.7 mm, respectively. Significant improvement was also achieved in the hallux valgus angle (HVA) and intermetatarsal angle (IMA) at the end of the study. CONCLUSION: in our experience, metatarsophalangeal resection arthroplasty continues to be a valid choice in patients with major forefoot deformities, with satisfactory long-term clinical and radiographic results.

INTRODUCCIÓN: la artroplastía de resección metatarsofalángica se considera un procedimiento quirúrgico de salvamento capaz de mejorar la calidad de vida de pacientes con deformidades importantes en el antepié. MATERIAL Y MÉTODOS: se realizó un estudio observacional retrospectivo de 31 pacientes (36 pies) con deformidades importantes en el antepié operados en nuestra institución. Treinta y dos pies requirieron cirugía adicional que involucró el primer metatarsiano, la mayoría de ellos (72.2%) a través de la fusión de la articulación metatarsofalángica. El período de seguimiento promedio fue 10.3 ± 4.6 años. La mayoría de los pacientes fueron mujeres (87.1%), con una edad promedio de 74.2 ± 11.5 años. RESULTADOS: en la última visita de seguimiento, la puntuación AOFAS promedio fue de 77.9 ± 10.2 puntos y la puntuación MOxFQ promedio fue de 18.3 ± 8.3 puntos. La escala visual analógica (EVA) para el dolor mejoró significativamente, pasando de 7.5 ± 1.2 puntos a 3.4 ± 2.1 puntos de media. También se constataron buenos resultados clínicos en cuanto a la capacidad de calzarse con comodidad. Los espacios de resección promedio al final del estudio fueron 1.3, 1.8, 2.5 y 4.4 mm para el segundo al quinto radio, respectivamente. Los tamaños promedio de los osteofitos por remodelación al final del estudio fueron de 1.6, 1.4, 1.1 y 0.7 mm, respectivamente. También se logró una mejora significativa en el ángulo de hallux valgus (AHV) y en el ángulo intermetatarsiano (IMA) al final del estudio. CONCLUSIÓN: en nuestra experiencia, la artroplastía de resección metatarsofalángica sigue siendo una opción válida en pacientes con deformidades graves del antepié, con resultados clínicos y radiográficos satisfactorios a largo plazo.

Risk Factors for Midfoot Arthritis Associated With Medical History by Weight Bearing Computed Tomography.

Tarso-metatarsal joints and naviculocuneiform joints comprising midfoot is the second most commonly involved joints following the first metatarsophalangeal joint in the foot. However, related factors of midfoot arthritis (MA) have been rarely reported. The bony structure and alignment can be more precisely assessed using Weight-Bearing Computed Tomography (WBCT) than conventional radiographs. Therefore, the aim of this study was to investigate risk factors for MA related to medical history and comorbid foot deformities using WBCT. WBCT data from September 2014 to April 2022 were extracted from a single referral hospital. All cases were divided into two groups by the presence of MA. Twenty-five potential related factors including demographics, etiology, and common co-occurring foot deformities were collected for comparison. Six hundred six cases (247 males and 359 females) among consecutive 1316 cases between September 2014 to April 2022 were selected. One hundred thirty-nine male cases (56.3%) and 210 female cases (58.5%) showed MA. In stepwise multiple logistic regression analysis, 5 factors remained statistically significant. The multivariate-adjusted odds ratios for age, laterality, body mass index (BMI), Progressive Collapsing Foot Deformity (PCFD), and lesser toe deformities (LTD) were 1.08, 1.54, 1.05, 6.62, and 3.03 respectively. Risk factors for MA associated with medical history and foot deformities included age, laterality, BMI, PCFD, and LDT.

Forefoot Morphotypes in Cavovarus Feet: A Novel Assessment of Deformity.

BACKGROUND: The cavovarus foot is a complex 3-dimensional deformity. Although a multitude of techniques are described for its surgical management, few of these are evidence based or guided by classification systems. Surgical management involves realignment of the hindfoot and soft tissue balancing, followed by forefoot balancing. Our aim was to analyze the pattern of residual forefoot deformities once the hindfoot is corrected, to guide forefoot correction. METHODS: We included 20 cavovarus feet from 16 adult patients with Charcot-Marie-Tooth who underwent weightbearing CT (mean age 43.4 years, range: 22-78 years, 14 males). Patients included had flexible deformities, with no previous surgery. Using specialized software (Bonelogic 2.1, Disior) a 3-dimensional, virtual model was created. Using morphologic data captured from normal feet in patients without pathology as a guide, the talonavicular joint of the cavovarus foot was digitally reduced to a "normal" position to simulate the correction that would be achieved during surgical correction. Models of the corrected position were exported and geometrically analyzed using Blender 3.64 to identify anatomical trends. RESULTS: We identified 4 types of cavovarus forefoot morphotypes. Type 0 was defined as a balanced forefoot (2 cases, 10%). Type 1 was defined as a forefoot where the first metatarsal was relatively plantarflexed to the rest of the foot, with no significant residual adduction after talonavicular joint correction (12 cases, 60%). Type 2 was defined as a forefoot where the second and first metatarsals were progressively plantarflexed, with no significant adduction (4 cases, 20%). Type 3 was defined as a forefoot where the metatarsals were adducted after talonavicular derotation (2 cases, 10%). CONCLUSION: In this relatively small cohort, we identified 4 forefoot morphotypes in cavovarus feet that might help surgeons to recognize and anticipate the residual forefoot deformities after hindfoot correction. Different treatment strategies may be required for different morphotypes to achieve balanced correction. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Does foot shape really matter? Correlation of patient reported outcomes with radiographic assessment in progressive collapsing foot deformity reconstruction: A systematic review.

BACKGROUND: In progressive collapsing foot deformity (PCFD), the goal of surgery is to obtain a well-balanced plantigrade foot. It remains unclear if restoration of the alignment and subsequent improvement in radiological parameters is associated with improved patient-reported outcome measures (PROMs). The aim of the current systematic review was to investigate whether there is a correlation between radiographic assessment and PROMs in patients treated surgically for flexible PCFD. MATERIALS AND METHODS: The study was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. A comprehensive literature search was performed in Pubmed, EMBASE, Cochrane Central Register of Controlled Trails (CENTRAL), and KINAHL. We included all the studies reporting both PROMs and radiological outcomes in patients treated surgically for PCFD. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal tool. RESULTS: Six retrospective studies were included. Radiological parameters related to forefoot plantarflexion were associated with statistically significant differences in postoperative PROMs. A neutral hindfoot and midfoot position was positively correlated with postoperative PROMs but a statistically significant difference could not be established in all studies. The medial arch height was positively correlated with PROMs, but in one study this was the case only in revision surgeries. CONCLUSION: The literature so far suggests restoration of the alignment may be associated with improved PROMs. Future prospective studies that investigate possible radiological and clinical correlations in PCFD surgery are needed. LEVEL OF EVIDENCE: III.

The Reliability of Common Radiographic Measurements Used to Describe Foot Deformities.

Radiographic measurements are frequently used to classify deformity and determine treatment options. Correlation coefficients can be used to determine inter- and intrarater reliability. Reliability is a required feature of any measurement if the measurement is to provide valid information. We calculated correlation coefficients for standard radiographic measurements used to categorize foot deformities: this was done for 52 sets of radiographs assessed by 5 raters. We aimed for generalizability, and kept rater instructions to match what was originally published for each measurement of interest with schematic illustration. Overall, our results mostly showed a lack of inter-rater reliability (correlation coefficients <0.4), and strong intrarater reliability (correlation coefficients >0.6), for 12 forefoot and 12 rearfoot radiographic measurements that are commonly used. The results of this investigation bring into question the routine use of radiographic measurements to categorize deformity, select treatments, and measure surgical outcomes, between surgeons, because the validity of these measurements appears to be threatened by weak inter-rater reliability. In order for these measurements to be considered useful, it may be necessary for surgeons to more rigorously define and practice making standard radiographic measurements.

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

BACKGROUND: A medializing calcaneal osteotomy (MCO) is considered as one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the post-operative hind- and midfoot alignment, alternations of the subtalar joint alignment remained obscured by superposition on plain radiography. Therefore, we aimed to assess the hind-, midfoot- and subtalar joint alignment pre- compared to post-operatively using 3D weightbearing CT (WBCT) imaging. METHODS: Seventeen patients with a mean age of 42 ± 17 years were retrospectively analyzed. Inclusion criteria consisted of PCFD deformity corrected by a medializing calcaneal osteotomy (MCO) as main procedure and imaged by WBCT before and after surgery. Exclusion criteria were patients who had concomitant calcaneal lengthening osteotomies, mid-/hindfoot fusions, hindfoot coalitions, and supramalleolar procedures. Image data were used to generate 3D models and compute the hindfoot (HA), midfoot (MA) - and subtalar joint (STJ) alignment in the coronal, sagittal and axial plane, as well as distance maps. RESULTS: Pre-operative measurements of the HA and MA improved significantly relative to their post-operative equivalents p < 0.05). The post-operative STJ alignment showed significant inversion (2.8° ± 1.7), abduction (1.5° ± 1.8), and dorsiflexion (2.3° ± 1.7) of the talus relative to the calcaneus (p < 0.05) compared to the pre-operative alignment. The displacement between the talus and calcaneus relative to the sinus tarsi increased significantly (0.6 mm±0.5; p < 0.05). CONCLUSION: This study detected significant changes in the sagittal, coronal, and axial plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings contribute to our clinical practice by demonstrating the magnitude of alteration in the subtalar joint alignment that can be expected after PCFD correction with MCO as main procedure.

The spectrum of foot deformities in Loeys-Dietz syndrome.

Loeys-Dietz syndrome (LDS) is characterized by a wide spectrum of musculoskeletal manifestations, including foot deformities. The spectrum of foot deformities in LDS has not been previously characterized. Our objective was to describe the incidence and characteristics of foot deformities in LDS. We retrospectively reviewed the demographic, clinical and imaging data for patients diagnosed with LDS who were seen at our Orthopedic surgery department from 2008 to 2021. We performed descriptive analyses and compared distributions of deformities by LDS genetic mutations. Of the 120 patients studied, most presented for evaluation of foot deformities ( N = 56, 47%) and scoliosis ( N = 45; 38%). Ninety-seven patients (81%) had at least one foot deformity, and 87% of these patients had bilateral foot deformities. The most common deformities were pes planovalgus (53%) and talipes equinovarus (34%). Of patients with foot deformities, 58% presented for evaluation of the feet. Of patients with pes planovalgus, only 17% presented for evaluation of the feet. Among patients with pes planovalgus, 2% underwent surgery and 16% used orthotics compared with 76% and 42%, respectively, for patients with talipes equinovarus. We found no association between deformities and genetic mutations. Bilateral foot deformities are highly prevalent in patients with LDS and are the most common reason for presentation to orthopedic surgeons. Although pes planovalgus is the most common deformity, it rarely prompted surgical treatment. Orthopedic surgeons treating LDS patients should be aware of the unique characteristics of foot deformities in LDS.

Assessment of foot deformities in individuals with cerebral palsy using weight-bearing CT.

OBJECTIVE: The aims of this study were to visualize and quantify relative bone positions in the feet of individuals with cerebral palsy (CP) with a foot deformity and compare bone positions with those of typically developed (TD) controls. MATERIALS AND METHODS: Weight-bearing CT images of 14 individuals with CP scheduled for tendon transfer and/or bony surgery and of 20 TD controls were acquired on a Planmed Verity WBCT scanner. Centroids of the navicular and calcaneus with respect to the talus were used to quantify foot deformities. All taluses were aligned and the size and dimensions of the individuals' talus were scaled to correct for differences in bone sizes. In order to visualize and quantify variations in relative bone positions, 95% CI ellipsoids and standard deviations in its principle X-, Y-, and Z-directions were determined. RESULTS: In individuals with CP (age 11-17), a large variation in centroid positions was observed compared to data of TD controls. Radiuses of the ellipsoids, representing the standard deviations of the 95% CI in the principle X-, Y-, and Z-directions, were larger in individuals with CP compared to TD controls for both the calcaneus (3.16 vs 1.86 mm, 4.26 vs 2.60 mm, 9.19 vs 3.60 mm) and navicular (4.63 vs 1.55 mm, 5.18 vs 2.10 mm, 16.07 vs 4.16 mm). CONCLUSION: By determining centroids of the calcaneus and navicular with respect to the talus on WBCT images, normal and abnormal relative bone positions can be visualized and quantified in individuals with CP with various foot deformities.

Does tibialis posterior dysfunction correlate with a worse radiographic overall alignment in progressive collapsing foot deformity? A retrospective study.

BACKGROUND: Posterior Tibial Tendon (PTT) dysfunction is considered to have an important role in Progressive Collapsing Foot Deformity (PCFD). The objective of our study was to assess the relationship between PTT status and three-dimensional foot deformity in PCFD. METHODS: Records from 25 patients with PCFD were included for analysis. The PTT was considered deficient in patients with a positive single heel rise test or a deficit in inversion strength. Three-dimensional foot deformity was assessed using the Foot and Ankle Offset (FAO) from Weight-Bearing-CT imaging. Hindfoot valgus, midfoot abduction and medial longitudinal arch collapse were assessed on X-Rays using hindfoot moment arm, talonavicular coverage angle and Meary's angle respectively. Deland and Rosenberg MRI classifications were used to classify PTT degeneration. RESULTS: PCFD with PTT deficit (13/25) had a mean FAO of 7.75 + /- 3.8% whereas PCFD without PTT deficit had a mean FAO of 6.68 + /- 3.9% (p = 0.49). No significant difference was found between these groups on the hindfoot moment arm and the talonavicular coverage angle (respectively p = 0.54 and 0.32), whereas the Meary's angle was significantly higher in case of PCFD with PTT deficit (p = 0.037). No significant association was found between PTT degeneration on MRI and FAO. CONCLUSION: PCFD associated three-dimensional deformity, hindfoot valgus and midfoot abduction were not associated with PTT dysfunction. PTT dysfunction was only associated with a worse medial longitudinal arch collapse in our study. Considering our results, it does not appear that PTT is the main contributor to PCFD. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Presencia de huesos accesorios del tarso: variantes anatómicas normales con potencialidad patológica / Presence of accessory bones of the tarsus: normal anatomical variants with pathological potential / Presença de ossos acessórios do tarso: variantes anatômicas normais com potencial patológico

El conjunto de patologías bajo el nombre de síndromes dolorosos de pie y tobillo engloban diferentes tendinopatías asociadas entre varios factores clínicos a la presencia de huesos accesorios tarsianos. La correcta identificación y diferenciación radiológica de estas variantes anatómicas en virtud de su capacidad de influir en la dinámica normal del tarso motivan el estudio de su incidencia. Nuestro objetivo es determinar la presencia de distintos huesos accesorios tarsianos en una muestra poblacional. Se expone el resultado de un estudio observacional retrospectivo en 240 pacientes entre 15 y 85 años de edad atendidos en un centro privado de la ciudad de Las Piedras, Canelones, con radiografías de pie y tobillo preexistentes en la base de datos institucional. Se determinó presencia de huesos accesorios tarsianos en 23 pacientes (9,58%), identificando hallazgos de Os Trigonum (1,66%), Proceso de Stieda (3.33%), Os Peroneum (2,93%) y Os Navicular (1,66%). Se presenta en tablas el análisis de frecuencia correspondiente y estudio de contingencia entre variantes encontradas, edad y sexo del paciente. El resultado de la investigación busca aportar al conocimiento de variantes anatómicas normales correlativas a procesos patológicos infradiagnosticados, desde el rol de la anatomía radiológica.

The group of pathologies under the name of foot and ankle pain syndromes encompass different tendinopathies associated among various clinical factors with the presence of accessory tarsal bones. The correct identification and radiological differentiation of these anatomical variants, by virtue of their ability to influence the normal dynamics of the tarsus, motivated the study of their incidence. Our objective is to determine the presence of different tarsal accessory bones in a population sample. Here we present the results of a retrospective observational study in 240 patients between 15 and 85 years of age, treated in a private health center in the city of Las Piedras, Canelones, with pre-existing ankle and foot x-rays in the institutional database. The presence of tarsal accessory bones was determined in 23 patients (9.58%), identifying findings of Os Trigonum (1.66%), Stieda Process (3.33%), Os Peroneum (2.93%) and Os Navicular (1, 66%). The corresponding frequency analysis and contingency study between the variants found, age and sex of the patient are exposed in tables. The result of the research seeks to contribute to the knowledge of normal anatomical variants correlative to under diagnosed pathological processes, from the role of radiological anatomy.

O grupo de patologias com a denominação de síndromes dolorosas no pé e tornozelo engloba diferentes tendinopatias associadas entre diversos fatores clínicos à presença de ossos acessórios do tarso. A correta identificação e diferenciação radiológica dessas variantes anatômicas em virtude de sua capacidade de influenciar a dinâmica normal do tarso motiva o estudo de sua incidência. Nosso objetivo é determinar a presença de diferentes ossos acessórios do tarso em uma amostra populacional. É apresentado o resultado de um estudo observacional retrospectivo em 240 pacientes entre 15 e 85 anos de idade atendidos em um centro privado na cidade de Las Piedras, Canelones, com radiografias de pé e tornozelo pré-existentes no banco de dados institucional. A presença de ossos acessórios do tarso foi determinada em 23 pacientes (9,58%), identificando achados de Os Trigonum (1,66%), Processo de Stieda (3,33%), Os Peroneum (2,93%) e Os Navicular (1,66%). A correspondente análise de frequência e estudo de contingência entre as variantes encontradas, idade e sexo do paciente são apresentados em tabelas. O resultado da pesquisa busca contribuir para o conhecimento das variantes anatômicas normais correlativas aos processos patológicos subdiagnosticados, a partir do papel da anatomia radiológica.

Foot Deformity Correction Planning in the Sagittal Plane Based on the Vitruvian Foot First Metatarsal Mechanical Axis and Calcaneus Anatomic Axis.

The aim of the study was to test a novel planning method for simultaneous midfoot and hindfoot deformity correction, based on reference lines and angles (RLA) of the talus, calcaneus and first metatarsal in 64 normal radiographs from 55 patients. Talus Joint Line (TJL), from the border of the articular surface of the talus and the posterior process of talus, and mechanical axis of the first metatarsal form the mechanical Lateral Talometatarsal Angle (mLTMA) = 23.6º (±3.2). The length of the first metatarsal line was measured from its intersections with the TJL and first metatarsal head and it was 4.3 (±0.94) times longer that TJL (k). For hindfoot correction planning, we used an axis of the calcaneus formed by a line starting at the middle of the back of the calcaneal tuberosity and going perpendicular to a line from the top point to the bottom point of the calcaneal tuberosity. The intersection of the calcaneal line and the anterior continuation of TJL form the lateral heel angle (LHA) = 15.2º (±3.4).The following parameters were identified: the length from the intersection point of the lines and anterior point of TJL was 2.56 ± 1.1 longer than TJL (k1). The length from the intersection point and posterior border of the calcaneus was 4.59 ± 1.0 times longer than TJL (k2). Planning using the new method was demonstrated and confirmed on 3 case examples. A novel method for analysis and planning of midfoot and hindfoot sagittal plane deformity correction may be used separately or simultaneously for complex deformity correction.

Podoscopic classification of second toe deformities.

BACKGROUND: The AFCP (French Association of Foot Surgery) classification was recently introduced as a reliable and quick visual method for the assessment of sagittal plane deformities of the second toe. The aim of this study was four-fold: (1) to describe a new toe-ground area score (TAS) as an additional dynamic tool of such classification, (2) to verify whether all second toe deformities could be classified, (3) to assess the TAS intra- and inter-observer reliability and (4) to evaluate the TAS learning curve. METHODS: In this retrospective study 52 s toes were evaluated using a podoscope. Ten foot and ankle surgeons assessed independently standardised videos of each case acquired in a blinded fashion. Assessment was repeated three times, 15 days apart. Intra- (Intraclass Correlation Coefficient or ICC) and inter-observer reliability (Fleiss' Kappa coefficient) were calculated. Mean time to assess a deformity was also recorded. RESULTS: All the 522 observations (52 feet assessed by 10 surgeons) were successfully rated using the TAS. Intra- and inter-observer reliability were substantial for the first round (ICC: 0.79; Kappa: 0.76) and excellent for the second (ICC: 0.88; Kappa: 0.8) and third round (ICC: 0.84; Kappa: 0.81). Mean assessment time ± standard deviation was 22 ± 11 s per case for the last two rounds. CONCLUSIONS: The TAS has been proven reliable and quick in the assessment of second toe deformities. When combined with a static segmentary classification of the toe (such as the AFCP classification) it might provide further dynamic informations about the ability of the toe to engage the ground. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Combined weightbearing CT and MRI assessment of flexible progressive collapsing foot deformity.

BACKGROUND: The objective of this study was to evaluate the correlation between Weightbearing CT (WBCT) markers of pronounced peritalar subluxation (PTS) and MRI findings of soft tissue insufficiency in patients with flexible Progressive Collapsing Foot Deformity (PCFD). We hypothesized that significant correlation would be found. METHODS: Retrospective comparative study with 54 flexible PCFD patients. WBCT and MRI variables deformity severity were evaluated, including markers of pronounced PTS, as well as soft tissue degeneration. A multiple regression analysis and partition prediction models were used to evaluate the relationship between bone alignment and soft tissue injury. P-values of less than .05 were considered significant. RESULTS: Degeneration of the posterior tibial tendon was significantly associated with sinus tarsi impingement (p = .04). Spring ligament degeneration correlated to subtalar joint subluxation (p = .04). Talocalcaneal interosseous ligament involvement was the only one to significantly correlate to the presence of subfibular impingement (p = .02). CONCLUSION: Our results demonstrated that WBCT markers of pronounced deformity and PTS were significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal interosseus ligaments. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

The Use of Virtual Planning and Patient-specific Guides to Correct Complex Deformities of the Foot and Ankle.

This article provides an overview regarding the virtual planning and precise execution of corrective osteotomies around the foot and ankle. Based on 3-dimensional data obtained from CT scans, surgeons are able to create a virtual plan of how to correct a complex deformity. This plan is transferred into the production of true patient-specific guides, designed to perform a specific surgical intervention. The authors have extensive experience with this technique and were involved in the development of the method. The current article provides an overview regarding the virtual planning and precise execution of corrective osteotomies around the foot and ankle.

Foot Deformity Correction Planning in the Sagittal Plane Based on the Vitruvian Foot First Metatarsal Anatomic Axis.

The aim of this study was to test a novel planning method for midfoot deformity correction, based on reference lines and angles (RLA) of talus and first metatarsal of 64 normal radiographs from 55 patients. The anatomic lateral talometatarsal angle (aLTMA), resulting from the intersection of talus joint line (TJL), from the border of the articular surface of the talus to the posterior process of talus, and the anatomic axis of the first metatarsal, was 28.5° ± 4.5°. The intersection of those 2 lines divided the TJL in 2 segments (ac and ab) with the ratio k1 = 0.7 ± 0.3. The length of the first metatarsal line was measured from its intersection with the TJL and first metatarsal head, and it was 3.6 times longer that of the TJL (k2). To analyze foot deformity, we propose to draw the TJL line as follows. Use the k1 ratio to determine the point where the aLMTA intersects the TJL. From this point, an idealized anatomic first metatarsal line should be drawn, at 28.5° from the TJL. The distal end of that line is based on the k2 ratio (3.6 × TJL length). Next, the actual anatomic lateral talometatarsal line of the deformed foot is drawn. The intersection between these 2 lines identifies the apex and magnitude of the deformity. Deformity correction planning using the proposed method was demonstrated and confirmed in 2 cases. A reference method for analysis and planning of midfoot sagittal plane deformity correction independent of foot position relative to the ankle joint or the presence of concomitant hindfoot deformity appears promising for future investigation and use.

Update on Investigation Methods for Lower Extremity Biomechanics.

Imaging with biomechanical analysis augments the clinical examination and improves outcomes by correlating imaging findings with the examination. Plain film radiographs are the gold standard to assess osseous alignment. The biomechanical examination provides information to formulate an accurate assessment. Weightbearing computed tomography scanning is a potentially valuable for functional information about joint biomechanics. True alignment of the lower extremity can be appreciated on weightbearing computed tomography scanning. Soft tissue structures can be assessed with diagnostic ultrasound examination. Acute and chronic injuries that compromise joint stability can be identified.

The impact of associated tenotomies on the outcome of incomplete phalangeal osteotomies for lesser toe deformities.

BACKGROUND: Partial or incomplete osteotomy (IO) of the phalanx is recently described in the literature. However, the clinical outcome and the rate of complications when applied to lesser toe deformities (LTD) have been never addressed. This study aims to find out if the association of tenotomies to incomplete or partial phalanx osteotomies has a significant impact on the clinical outcomes, the occurrence of complications, and the recovery time after surgery. METHODS: A retrospective review of two cohorts of cases operated in our institution for hallux abductus valgus (HAV) and associated LTD from 2008 to 2014 was carried out. The surgical correction of both HAV and the associated LTD was always performed by minimally invasive techniques. The study included a total of 223 patients (723 IO in 556 toes). In 129 cases, the IO for LTD correction was performed without tenotomies, and in 94, the procedure was combined with flexor and/or extensor tenotomies. Patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire before surgery and at 6- and 12-month follow-up. RESULTS: The mean preoperative AOFAS score before surgery was similar in both cohorts. At 12-month follow-up, the cohort without tenotomies showed better recovery (95.7 ± 2.8 versus 92.5 ± 6.8; p < 0.01). AOFAS scores decreased as the number of associated LTD increased (r = - 0.814; p < 0.001). Cases operated on by PO + tenotomy showed a high rate of complications such as delayed union of the osteotomy (p < 0.01), hypertrophic callus (p < 0.01), phalangeal fracture at the osteotomy site (p < 0.01), and lack of correction (p < 0.05). The overall occurrence of adverse events was 38.6% in cases operated by PO + tenotomy and 13.9% in cases receiving PO alone (p < 0.0001). Cases operated on without tenotomy showed a shorter time to complete recovery for daily life activities (37.4 ± 2.3 versus 43.0 ± 1.7 days; p < 0.01). CONCLUSION: The performance of associated tenotomies to incomplete phalanx osteotomies provides worse clinical outcomes, higher complication rates, and longer recovery time as compared to similar forefoot surgeries without tenotomies. TRIAL REGISTRATION: The study was based on retrospectively registered data starting on May 24, 2008.

New Sagittal Plane Reference Parameters for Foot Deformity Correction Planning: The Vitruvian Foot.

Currently available methods for analysis and planning of post-traumatic or congenital deformity correction of the foot have some limitations. The aim of this retrospective study was to establish reference lines and angles (RLAs), and the resulting ratios, based on reproducible anatomic points on sagittal feet radiographs. The key starting point of our evaluation was the previously undescribed length and position of the talus joint line (TJL), from the border of the articular surface of the talus and the posterior process of talus. First, we calculated the relationships between the TJL and the axes of the foot, particularly the anatomic and mechanical lateral talometatarsal angle axes of the first metatarsal. Then, we assessed the relationships with the calcaneus, particularly the lateral heel angle. Finally, we calculated the parameters (angles and coefficients k) derived from the TJL and the foot-bearing points (foot quadrilateral). A total of 64 normal radiographs from 55 patients were analyzed. The values that resulted are as follows: anatomic lateral talometatarsal angle = 28.5° ± 4.5°, mechanical lateral talometatarsal angle = 23.6° ± 3.2°, lateral heel angle = 15.2° ± 3.4°, foot quadrilateral: abc = 144.6° ± 9.4°, bcd = 31.3° ± 2.6°, cda = 79.2° ± 9.8°, dab = 105.0° ± 8.3°, k1 = 3.09 ± 0.4, k2 = 3.77 ± 0.78, and k3 = 1.56 ± 0.24. Sagittal plane reference lines and angles are proposed, providing quantitative values for reference. These parameters have the potential to be easily implemented in foot deformity analysis and correction planning.

The circular arc shaped nail for fixing the tibiotalocalcaneal arthrodesis. After clinical results.

BACKGROUND: Tibiotalocalcaneal arthrodesis is commonly considered a salvage option for a variety of hindfoot disorders involving the ankle and subtalar joint mostly with concomitant deformity. Retrograde interlocking nailing represents one of the biomechanically most stable fixation modes after reduction of hindfoot geometry. The considerable complications, non-union and revision rates at a moderate outcome reported even with modern retrograde nails underscore the idea that the development of an optimized retrograde nail may be warranted. METHODS: A novel circular shaped nail was designed with a perfect fit to the reamed canal and the implant geometry which respects physiologic hindfoot anatomy and alignment. The present clinical series reports the experience and the clinical and radiographic outcomes after application of the implant in the first 30 consecutive patients. Assessments included validated versions of the AOFAS Ankle/Hindfoot Score and the Foot Function Index. RESULTS: Anatomical alignment was achieved and maintained in 29/30 cases with a single case of later loss of reduction due to a technical error which led to surgical reintervention two months after the index procedure. The overall union rate reached 93%. Two non-unions (one ankle, one subtalar joint) were observed without necessitating further surgery. Three superficial surgical site infections were registered which made a local flap coverage necessary in two patients due to local skin break-down. No deep infection occurred. There were 2 implant removals, one was not related to hindfoot nailing. At the time of follow-up, the AOFAS Ankle/Hindfoot Score was 57 (median) from a maximum of 86 points. The self-assessment via the Foot Function Index improved from preoperative 155 points to 62.5 postoperatively (median values, p<0.001, Wilcoxon test). CONCLUSION: On the basis of our results, which saw a high rate of successful fusion and patient satisfaction and where the hindfoot reduction was maintained until definite healing in the vast majority of cases, the novel circular arc nail represents a viable and safe option for tibiotalocalcaneal arthrodesis with a low complication rate.

Double hindfoot arthrodesis technique for the treatment of severe equino-plano-valgus foot deformity in cerebral palsy: long-term results and radiological evaluation.

The aim of this study was to evaluate the clinical and radiological results of a double arthrodesis technique for the treatment of equino-plano-valgus foot deformity in pediatric patients affected by cerebral palsy. A retrospective evaluation was performed on 175 feet surgically treated with a talonavicular and calcaneocuboid joint fusion technique. The average age at surgery was 14.7 years (range: 12-20 years). Visual analogue scale for pain score, Gross Motor Function Classification System scale, talonavicular angle, Costa-Bertani angle, and Kite's angle on standard weight bearing radiographs were evaluated preoperatively and postoperatively. The mean clinical follow-up was 62.4 months (range: 12-112 months). The mid Gross Motor Function Classification System scale value did not show a significant improvement in any of the subgroups considered. A significant improvement in the visual analogue scale for pain score value was evident 6 months after surgery. Radiological examination showed a statistically significant improvement in the talonavicular angle (average 7.4°) and the Costa-Bertani angle (average 128.5°). Complications occurred in 8.6% of cases. The described surgical technique is safe and efficacious, and could represent a useful option of treatment of equino-plano-valgus severe deformity in cerebral palsy patients older than 12 years of age.