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.

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.

Radiographic Analysis and Clinical Efficacy of Hindfoot Arthrodesis With Versus Without Cotton Osteotomy in Stage III Adult Acquired Flatfoot Deformity.

Forefoot varus develops as a result of longstanding adult-acquired flatfoot deformity (AAFD). This occurs with varying degrees of deformity and flexibility. Residual forefoot varus following hindfoot realignment in AAFD can lead to lateral column loading and a persistent pronatory moment in efforts to reestablish contact between the forefoot and the ground. The Cotton osteotomy may serve as a reasonable adjunct procedure to help avoid complications and poor outcomes associated with residual forefoot varus in patients undergoing hindfoot arthrodesis for stage III AAFD. The aim of this study was to compare the radiographic outcomes in patients undergoing isolated hindfoot arthrodesis to patients undergoing hindfoot arthrodesis with adjunctive cotton osteotomy. We retrospectively reviewed 47 patients matched based upon age, sex, and comorbidities who underwent hindfoot reconstruction for the treatment of stage III AAFD between 2015 and 2019. A retrospective radiographic review was performed on standard weightbearing radiographs including anterior-posterior and lateral views preoperatively, postoperatively at the initiation of full weightbearing, and at final follow-up. Statistical analysis utilizing paired t test to calculate p values where <.05 was statistically significant. At final follow-up, radiographic measurements showed statistically significant differences in CAA, calcaneal inclination, talo-calcaneal, and talar tilt (p value <.05). The Cotton osteotomy group showed a quicker return to presurgical activity level and a decreased incident of tibiotalar valgus. Our study suggests that the Cotton osteotomy can address residual forefoot varus and potentially prevent further progression of ankle valgus in AAFD when used in combination with hindfoot arthrodesis.

Musculoskeletal abnormalities in a large international cohort of boys with 49,XXXXY.

49,XXXXY is the rarest X and Y chromosomal variation, with an incidence of 1 in 80,000-100,000 live male births and has been associated with numerous musculoskeletal abnormalities. Data was collected from an international cohort of boys with 49,XXXXY over 10 years. Children were evaluated by a multidisciplinary team consisting of a pediatric orthopedist, a neurogeneticist, a neurodevelopmentalist, and two physical therapists. Increased rates of torticollis (32.4%), hamstring tightness (42%), radioulnar synostosis (67.6%), pes planus (65.2%), and other foot abnormalities (86.9%) were observed. Several anomalies increased with age, specifically hamstring tightness, kyphosis, and scoliosis. The elucidation of the orthopedic profile of this population is necessary in order to provide healthcare providers with current medical information. This research further supports the necessity for the comprehensive multidisciplinary treatment of boys with 49,XXXXY.

Fibular Tip Periostitis: New Radiographic Sign Predictive of Chronic Peroneal Tendon Subluxation-Dislocation in Pes Planovalgus.

BACKGROUND. Tearing of the superior peroneal retinaculum is a known cause of peroneal tendon subluxation-dislocation. However, with the exception of cortical avulsions at the fibular attachment, superior peroneal retinaculum injury and subsequent peroneal tendon subluxation-dislocation are typically radiographically occult. OBJECTIVE. The purpose of this study was to evaluate the previously undescribed association between radiographic fibular tip periostitis and MRI evidence of peroneal tendon subluxation-dislocation in patients with hindfoot valgus. METHODS. Thirty-five patients with radiographic fibular tip periostitis and 35 ageand sex-matched individuals without periostitis were selected from among 220 consecutively registered patients with hindfoot valgus who had undergone both ankle radiography and MRI. Studies were retrospectively assessed by two musculoskeletal radiologists in consensus and by two additional blinded radiologists independently for the presence of peroneal tendon subluxation-dislocation, presence of subfibular impingement, and hindfoot valgus angle measurements. Interobserver agreement and accuracy, sensitivity, and specificity in the detection of fibular periostitis, peroneal tendon subluxation-dislocation, and subfibular impingement were calculated, and Fischer exact, Mann-Whitney, kappa coefficient, and intraclass correlation tests were performed. RESULTS. Both the consensus and the two independent interpretations showed that the frequency of peroneal tendon subluxation-dislocation was significantly greater in the group with periostitis (62.9%, 65.7%, and 85.7%) than in the group without periostitis (5.7%, 0%, and 14.3%) (p < .001). The finding of periostitis was specific and highly sensitive for predicting peroneal tendon subluxation-dislocation. The frequency of subfibular impingement was also statistically higher in the group with periostitis than in the group without it (p < .001). The hindfoot valgus angle was statistically larger in the group with periostitis than in the control group (p = .01-.002) and among patients with versus those without peroneal tendon subluxation-dislocation (p = .002 to p < .001). The blinded readers had substantial or almost perfect agreement on all imaging interpretations (concordance rate, 82.9-95.7%; κ = 0.66-0.91). CONCLUSION. The radiographic finding of fibular tip periostitis in patients with hindfoot valgus can be a predictor of peroneal tendon subluxation-dislocation and may also suggest advanced hindfoot valgus and subfibular impingement. These radiographic associations should be recognized by the radiologist, and MRI may be recommended as clinically indicated. CLINICAL IMPACT. Chronic undiagnosed peroneal tendon subluxation-dislocation can be a persistent cause of lateral ankle pain, leading to further degeneration and the possibility of complete peroneal tendon tears. Distal fibular periostitis in patients with hindfoot valgus can be a reliable radiographic indicator of this entity and may suggest the presence of subfibular impingement.

Core muscles' endurance in flexible flatfeet: A cross - sectional study.

OBJECTIVE: Flexible flatfoot is a common deformity in adults that has been thought to be a causative factor of a lot of lower limb injuries and back pain. Core muscles act as stabilizers for the trunk and weak core places a person at greater risk of low back pain and lower limb injuries. We aimed to compare the core muscles' endurance between individuals with and without flatfeet. METHODS: Thirty subjects with bilateral flexible flatfeet (study group) were compared with thirty healthy subjects (control group). Navicular drop test was used to evaluate the medial longitudinal arch. Modified back extensors, modified flexion and lateral muscles' endurance tests were used to evaluate the endurance of the core muscles. RESULTS: The lateral muscles' endurance time in the flatfeet group was found to be significantly lower than that of the healthy group on both sides (p=0.0001). However, no significant difference was found in the trunk flexors' (p=0.15) and trunk extensors' (p=0.27) endurance time between both groups. CONCLUSIONS: Impairment of the lateral core muscles' endurance was observed in subjects with bilateral flexible flatfeet which may predispose to low back pain and other lower limb injuries in those subjects.

Operative versus nonoperative treatment in children with painful rigid flatfoot and talocalcaneal coalition.

BACKGROUND: The management of painful rigid flatfoot (RFF) with talocalcaneal coalition (TCC) is controversial. We aimed to compare operative and nonoperative treatment in children with RFF and TCC. METHODS: We retrospectively reviewed medical records and radiographs of children with RFF and TTC treated between 2005 and 2015. The nonoperative treatment consisted of manipulation under anesthesia, cast immobilization and shoe insert after cast removal. The operative treatment consisted of combined TCC resection, graft interposition and subtalar arthroereisis. RESULTS: Thirty-four children (47 ft) in the nonoperative group and twenty-one children (34 ft) in the operative group were included. No differences were found between groups, concerning baseline characteristics. The mean age at treatment was 11.8 years (9-17): 11.6 (9-17) for the nonoperative group, 12.2 (10-15) for the operative group. The mean follow-up averaged 6.6 (3-12) years and was significantly longer in the nonoperative group (7.8 versus 4.7 years; p < 0.0005), since the operative procedure was increasingly practiced in the latest years. There were no complications in either groups, but 6 patients (7 ft) in the nonoperative group were unsatisfied and required surgery. At the latest follow-up, the AOFAS-AHS improved in both groups, although the operative group showed significantly better improvement. The operative group reported also significantly better FADI score, after adjustment for follow-up and baseline variables. CONCLUSION: The operative treatment showed better results compared to the nonoperative treatment. Symptomatic RFF with TCC in children can be effectively treated in one step with resection, graft interposition and subtalar arthroereisis. Further prospective randomized studies are needed to confirm our findings and to identify the best operative strategy in this condition.

Relationship Between Hallux Valgus and Pes Planus: Real or Fiction?

Hallux valgus is one of the most common and painful deformities, occurring due to adductor/abductor imbalance of the big toe. Many structural foot disorders have been suggested as the cause of hallux valgus deformity. In this study, we aimed to show the relationship between hallux valgus and pes planus in adult males. A total of 213 patients were included in this study between May 2013 and May 2014. 54 patients with hallux valgus angle (HVA) >20° and intermetatarsal angle (IMA) >9° were evaluated in the case group and 159 patients randomly selected from those admitted for a recent foot ankle trauma with the HVA <15° and IMA <9° were the control group. All patients' HVA, IMA, and talonavicular coverage angle on anteroposterior (AP) foot radiographs and talar-first metatarsal angle (Meary's angle), calcaneal pitch angle, and lateral talocalcaneal angle on lateral foot radiographs were measured. There was no significant difference in talonavicular and Meary's angles between the groups. Calcaneal pitch angle was significantly lower in the case group, whereas talonavicular angle was higher in the control group. Calcaneal pitch angle and lateral talocalcaneal angle showed significant negative correlation with HVA and IMA. There are few reports in the literature about the relationship between pes planus and hallux valgus. Our results strongly showed a high correlation between pes planus and hallux valgus. Further larger patient cohort studies are needed to support our results.

Plantar Approach for Midfoot Wedge Resection to Reconstruct the Rocker Bottom Foot.

Chronic deformity of the foot can lead to ulceration, infection, and amputation. Midfoot wedge osteotomy for deformity correction has been described in the literature; however, most reports are case review or small series. Wedge osteotomy can be performed from a medial or plantar approach, but there are limited data on outcomes regarding these relatively uncommon procedures. This study aims to review a population of patients with a rocker bottom foot deformity that underwent a midfoot wedge resection performed from the plantar surface for deformity correction, wound healing, and limb salvage. A review of medical records from a single foot and ankle surgeon was undertaken. Patients who had a midfoot wedge performed from the plantar surface to address rocker bottom deformity resulting from Charcot neuroarthropathy or severe flatfoot were included. Thirty patients met inclusion criteria. The outcome measures evaluated were minor and major complications, wound healing, and functional limb status. Statistical analysis was performed to evaluate factors that influenced outcomes. At time of final follow up, 17 of 20 (85%) preoperative wounds had healed. Mean preoperative talo-first metatarsal angle was -25° and improved to -5° postoperatively. An 87% limb salvage rate (26/30) was demonstrated. Body mass index was the only statistically significant factor that influenced functional limb status. Maintaining a functional limb can have profound effects on a patient's quality of life. Generally, patients with this severe rocker bottom foot deformity have multiple comorbidities and are at an increased risk of major amputation and early death. The current study has shown that patients with a rocker bottom foot deformity can benefit from midfoot wedge resection from a plantar approach to achieve a plantigrade foot.

Adult Flat Foot With Multiple Accessory Navicular Bones Treated Surgically: A Case Report and Review of the Literature.

Multiple accessory navicular bones is an extremely rare condition. To the best of our knowledge, only 8 cases in 2 imaging studies have been published. We report a case of a patient with flat foot with 2 accessory navicular bones. This patient needed to be treated surgically, and the surgery was successful, with short-term follow-up. We believe this is the first case of multiple accessory navicular bones to be treated surgically in English literature. The incidence of multiple accessory navicular bones might be higher. There is a risk to remaining ossicles without resection or fixation during surgery; therefore, we strongly recommend using not only radiographs, but also 3-dimensional computed tomography scans or magnetic resonance imaging scans to confirm the type of accessory navicular bone, at least before surgery, for both painful accessory navicular bone and flat foot with accessory navicular bone.

Surgical treatment of hallux valgus associated with flexible flatfoot during growing age.

PURPOSE: During growth, hallux valgus could present associated with flatfoot. Considering the current disagreement about correction of hallux valgus during growth and the lack of reports about simultaneous correction of hallux valgus associated with flexible flatfoot, we present simultaneous treatment of both deformities during growth combining subtalar arthroeresis and SERI first metatarsal osteotomy, reporting results at an average five-year follow-up. METHODS: Thirty-two children (64 feet, age range 8-12 years) affected by hallux valgus associated with flexible flatfoot underwent surgical treatment combining SERI first metatarsal osteotomy and subtalar arthroereisis with bioabsorbable endorthotic implant. Clinical evaluation was summarized with AOFAS score, and standard standing radiographs were performed. RESULTS: AOFAS score ranged from 86 ± 2 to 98 ± 2 (hindfoot) and from 80 ± 4 to 98 ± 2 (forefoot). HVA ranged from 21° ± 2 to 5° ± 2, IMA from 14° ± 2 to 7° ± 2, DMAA from 18° ± 2 to 2° ± 2, and Meary's angle from 162° ± 11 to 175° ± 4. Complications included one case of delayed wound healing, inflammatory skin reaction around the outlet of the percutaneous Kirschner wire in two cases, displacement of the endorthotic implant in one case, and a second surgery to replace the implant. CONCLUSIONS: SERI osteotomy and subtalar arthroereisis resulted in an effective, technically simple and easily combined approach, with a high rate of good results and low rate of complications at mid-term follow-up. These techniques performed simultaneously represent a viable option in case of hallux valgus associated with flexible flatfoot during growth. Nevertheless, considering the limitations of this study, we believe that a larger case series and a longer follow-up should be desirable.

Radiologic Patterning of Hallux Deformity in Rheumatoid Arthritis and Its Relationship to Flatfoot.

Hallux deformities other than hallux valgus, especially those in the sagittal plane, have not yet been elucidated in the feet of patients with rheumatoid arthritis. The objectives of the present study were to classify rheumatoid arthritis hallux deformity in both the horizontal and the sagittal planes and investigate its relationship with flatfoot. Using a cross-sectional study design, we assessed patients with rheumatoid arthritis (527 feet in 274 patients) using radiographs and classified the deformity patterns of the great toes using cluster analysis. Of the 274 patients, the range of motion in the metatarsophalangeal joint was clinically investigated in 44 (16.1%) patients. The great toes could be divided into 5 clusters according to the characteristic configuration as follows: cluster I (normal type), cluster II (hallux valgus type), cluster III (boutonniere type), cluster IV (boutonniere with hallux valgus type), and cluster V (swan-neck type). Radiographic measurements revealed the characteristic deformities of each cluster, including splayed foot for cluster II; flat foot, metatarsal primus elevatus, and plantar displacement of the proximal phalanx for cluster III; and a mixture of these characteristics for cluster IV. Plantar displacement of the proximal phalanx, which was a specific characteristic of the boutonniere deformity, correlated significantly with the decreased dorsiflexion in the metatarsophalangeal joint. Our classification method revealed the relationship of hallux deformity in the sagittal plane to flatfoot and also demonstrated the usefulness of measuring basal phalanx displacement in predicting the range of motion of the metatarsophalangeal joint.

Surgery for adult acquired flatfoot due to posterior tibial tendon dysfunction reduces pain, improves function and health related quality of life.

BACKGROUND: Patients with adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD) may require surgery but few reports have evaluated the outcome. METHODS: We evaluated 21 patients with a median age of 60 (range 37-72) years who underwent different surgical reconstructions due to stage II AAFD before and 6 and 24 months after surgery by the validated Self-Reported Foot and Ankle Score (SEFAS), Short Form 36 (SF-36) and Euroquol 5 Dimensions (EQ-5D). RESULTS: The improvement from before to 24 months after surgery was in SEFAS mean 12 (95% confidence interval 8-15), SF-36 physical function 21 (10-22), SF-36 bodily pain 28 (17-38), EQ-5D 0.2 (0.1-0.3) and EQ-VAS 11 (2-21). CONCLUSION: Surgery for AFFD due to PTTD results in reduced pain and improved function and health related quality of life. The outcome scores have been demonstrated as useful. It has also been shown, since there is a further improvement between 6 and 24 months after surgery, that a minimum follow-up of 2 years is needed. LEVEL OF CLINICAL EVIDENCE: III - prospective observational cohort study.

Equivalent pain relief with and without resection of the posterior tibial tendon in adult flatfoot reconstruction.

Transfer of the flexor digitorum longus (FDL) is indicated to compensate for the loss of posterior tibial tendon (PTT) function in the treatment of adult acquired flatfoot deformity (AAFD). The aim of this study was to determine the effect of PTT resection on pain relief following surgical treatment of stage II AAFD. A retrospective review of patients who underwent surgical treatment for stage II AAFD was performed. Patients were divided into two groups based on whether the degenerated PTT was resected or left in situ. A visual analog scale (VAS) score for pain was recorded for each patient preoperatively. Concomitant surgical procedures and the incidence of postoperative pain were also reported for each group. Deformity correction was assessed with standard weight-bearing radiographs. Thirty-four patients with a mean follow-up of 14 months were included in the study. There was no difference in preoperative VAS pain scores, and patients in both groups demonstrated excellent pain relief postoperatively. Five patients in the PTT resection group and one patient in the PTT in situ group reported lateral-sided foot pain postoperatively. Resection of the PTT did not significantly affect postoperative pain relief. Future prospective studies are needed to determine whether resection of the degenerated PTT is necessary at the time of surgery for stage II AAFD.

Biomechanical investigation of a custom-made insole to decrease plantar pain of children with flatfoot: A technical note.

OBJECTIVE: The abnormal plantar pressure of flatfoot patients is a common condition. The main objective of the present study was to investigate the effect of custom-molded insole on the plantar pain of flatfoot METHODS: 105 patients (representing 174 feet) participated in evaluating a custom-made orthotic insole from June 2018 to March 2019. The height of the navicular tubercle (HNT) and the deflection angle of calcaneus (DAC) in flatfoot patients after using orthotic insoles for 6 months were recorded by X-ray imaging and scanning measurements. Plantar pressure on metatarsals 1-5 was measured by using an RSscan system RESULTS: Without the use of an orthotic insole, mean HNT was 0.99±0.34 cm and mean DAC was 20.0 ± 3.78 ° during the bearing weight. After using the insole, mean HNT and DAC values reduced to 0.87±0.30 cm and 14.3 ± 3.45 °, respectively (P < 0.05). Hindfoot plantar pressure did not change significantly (P > 0.05). Furthermore, pressure at metatarsals 1-3 decreased by 48.5 %, 45.6 %, and 14.3 %, respectively; that at metatarsals 4-5 increased by 33.3 % and 137.5 %, separately, when using the custom-made insole CONCLUSIONS: Visual analog scale score for plantar pain was significantly reduced. These findings indicate that metatarsal pain of flatfoot patients might be the cause of load imbalance in plantar foot.

Foot-related impairment in children with juvenile idiopathic arthritis.

AIM: Foot involvement is present in approximately 60%-90% of children with Juvenile idiopathic arthritis (JIA). It is a major cause of disability, which can lead to deterioration in daily activities and quality of life. However, it is often overlooked and can compromise patient management. PURPOSE: Our objective was to describe the ankle and foot involvement in JIA and to appraise the functional impact of this damage on the child's performance and quality of life by using validated scores. METHODS: The cross-sectional study included patients with JIA. Functional impairment was assessed through the Juvenile Arthritis Functionality Scale (JAFS) and the Oxford Ankle and Foot Questionnaire for children. RESULTS: Twenty-three patients aged 12.75 ± 3.9 and with 41 months of disease duration. After completing the Oxford score, the physical domain appeared to be the most altered. A long delay in diagnosis was associated with an alteration in the emotional domain of the Oxford score. Higher disease activity was significantly associated with impairment in both the physical activity and the footwear domains of the Oxford score. As regards clinical examination data, the presence of foot pain as well as the presence of tendinopathy were associated with an alteration of all Oxford score domains. The presence of flat feet significantly affected all domains of the Oxford score. The JAFS was reported to affect the child's performance ability and was associated with impairment in physical activity, school and play, and emotional domains. CONCLUSION: Ankle and foot involvement was common in our study. Functional ability was most impaired in the lower limbs. High disease activity, foot and ankle pain, tenosynovitis, and flat feet were associated with poorer quality of life and higher functional impact.

Nonneurologic Cavovarus Feet in Skeletally Immature Patients: Main Causes and Principles of Treatment.

The foot resembles a tripod. The 3 legs consist of (1) the tip of the heel, (2) the first metatarsal, and (3) the fifth metatarsal. This concept is useful to explain cavus or flat feet. When the tips of the tripod move closer, the arch becomes higher. The leg of the tripod that moves the most will determine the type of cavus feet, which can be hindfoot cavus, forefoot cavus, or first metatarsal cavus. Cavovarus foot denotes the presence of a three-dimensional deformity of the foot, but it is much more a descriptive feature than a diagnosis.

Clinical Outcomes of Fusion in Type II Accessory Naviculars With or Without Asymptomatic Flatfeet.

BACKGROUND: Few studies have reported the clinical outcomes of fusion surgeries for type II accessory naviculars. Whether the combination of accessory naviculars and asymptomatic flatfoot will result in worse outcomes in accessory navicular surgeries remains to be elucidated. Our study aims to report the clinical outcomes of fusion for type II accessory naviculars and make a subgroup comparison among accessory navicular patients with or without asymptomatic flatfeet. METHODS: From May 2017 to June 2021, all painful type II accessory naviculars with or without asymptomatic flatfeet in our inpatient center were reviewed, and those who only underwent fusion surgeries were included in the retrospective study. Visual analog scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scores, Tegner activity level scores, complications, patient-reported satisfaction, and imaging results (Meary angle in the weightbearing lateral view, talo-first metatarsal angle and talonavicular coverage angle in the weightbearing anteroposterior view) were used to describe outcomes. RESULTS: Thirty-two eligible patients responded to the latest follow-up request and were included in this study. The mean follow-up duration was 37.1 ± 16.0 months. The average VAS pain score improved from 4.7 ± 1.8 preoperatively to 0.9 ± 1.2 at the latest follow-up (P<.001). The average AOFAS midfoot score improved from 67.1 ± 8.5 preoperatively to 90.2 ± 10.7 at the latest follow-up (P<.001). The preoperative and postoperative Tegner activity level scores were similar (3.3 ± 1.5 vs 3.5 ± 1.6, P=.136). The overall complication rate was 37.5%. The most common complication was nonunion (31.3%). The overall satisfaction rate was 90.6%. Similar outcomes were observed between the flatfoot and the nonflatfoot subgroups. CONCLUSION: Fusion for painful type II accessory naviculars resulted in good symptom relief, function improvement, and patient satisfaction at midterm follow-up, but the nonunion rate was relatively high. Fusion for painful type II accessory naviculars with or without asymptomatic mild to moderate flatfoot brought about similar clinical outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Joint Preservation Surgery for Varus and Posterior Ankle Arthritis Associated with Flatfoot Deformity.

This article introduces novel types of ankle arthritis related to a flatfoot deformity. There has been a long-held belief that severe unmanaged flatfoot deformity leads to valgus ankle arthritis, due to deltoid ligament insufficiency. However, flatfoot deformity can also give rise to varus ankle arthritis as the talus and calcaneus subluxate into opposite directions. Plantarflexion and posterior translation of the talus in the sagittal plane contributes to the eccentric narrowing of the posterior aspect of the tibiotalar joint, which the authors termed posterior ankle arthritis. Subtalar arthrodesis was performed to address the opposing dynamics of the talus and calcaneus, and was combined with a medial longitudinal arch reconstruction in most cases of posterior ankle arthritis and in selected cases of varus ankle arthritis, and satisfactory clinical and radiological results were achieved.

Meary angle for the prediction of mitral valve prolapse risk in non-syndromic patients with pes planus, a cross-sectional study.

OBJECTIVES: Mitral Valve Prolapse (MVP) is a common valvular abnormality accounting for 2% of the population. There is a reported association between pes planus (PP) and MVP in some syndromes such as Marfan. However, this association has not been tested in non-syndromic cases. The primary outcome of this study is to measure the prevalence of MVP in a population of patients with PP. The secondary outcome parameter is to determine if the Meary angle (MA), a measure of the severity of flat foot, can be effectively used in the prediction of the presence of MVP. Forty-one patients with PP were screened using a lateral x-ray foot to determine MA while echocardiography was utilized to identify the presence and grade of MVP. RESULTS: 88% of screened patients were diagnosed with MVP. MA was correlated with the grade of MVP and showed high diagnostic accuracy (sensitivity 100% and specificity 90%) in predicting MVP risk when higher than 5. Children with PP are at a higher risk for MVP than the general population. Accordingly, the utilization of MA in such a specific population for the determination of patients at a higher need for echocardiography seems to be a worthwhile strategy in diagnosing MVP.