Reverse V-shaped osteotomy for ankylosing rocker-bottom foot deformity in patients with rheumatoid arthritis: A report of three cases.

This study evaluated a reverse V-shaped osteotomy for ankylosing rocker-bottom foot deformity in patients with rheumatoid arthritis. Three feet were presented in this study: rheumatoid rocker-bottom deformities with painful and/or infectious bony prominence towards the bottom of the foot, treated with a reverse V-shaped osteotomy in the mid-hindfoot. In all three cases, significant correction was achieved with restoration of the medial longitudinal arch, and improvement in clinical scores was confirmed. Reverse V-shaped osteotomy has the potential to be a useful and definitive procedure for ankylosing rocker-bottom deformity in patients with rheumatoid arthritis.

Impact of Footwear and Foot Deformities in patients with Parkinson's disease: A Case-Series Study.

Background: Parkinson's disease (PD) is a common and complex neurological problem. Gait abnormalities are frequent in PD patients, and this increases the risk of falls. However, little is known about foot deformities and footwear in this vulnerable population. Here we investigate whether patients with PD use an appropriate shoe size and know if they have foot deformities or alterations. Methodology: A study of a series of observational descriptive cases in a convenience sample (n = 53 patients) diagnosed with Parkinson's disease. One trained investigator evaluated foot and ankle health. The footwear and foot measurements were obtained using a Brannock device. Results: The podiatric examination and footwear examination detected a high presence of podiatric pathologies and inappropriate footwear. This has a negative impact on the quality of life of these patients. Conclusions: This research detected an elevated number of people with foot deformities or alterations. Moreover, a high proportion of participants with PD wear inadequate footwear (in length, width, or both).

Minimally invasive correction for symptomatic, fixed curly toe deformity.

BACKGROUND: Curly toe deformity is a relatively common deformity that generally occurs at the 4th and 5th proximal and/or middle phalanges but rarely presents with symptoms. Although numerous open operative techniques have been introduced, there is no established treatment yet. We report the results of minimally invasive correction for symptomatic, fixed curly toe deformity. METHODS: Between 2016 and 2018, 25 consecutive percutaneous dorsolateral closing wedge-shaped osteotomies with Shannon burrs at the proximal and/or middle phalanx were performed. We assessed the postoperative clinical and radiological changes at a mean of 22.51 months of follow-up. RESULTS: The locations of osteotomy were at the middle phalanx in 10 cases, proximal phalanx in 13 cases, and both in one case. The mean amount of corrections of varus inclination and shortening were 16.54° and 2.24 mm, respectively. The Foot and Ankle Ability Measure Activities of Daily Living scores significantly improved from 59.09 preoperatively to 74.55 at the last follow-up. There was one case of pin site infection and one case of incision site numbness due to digital nerve injury. CONCLUSIONS: Minimally invasive dorsolateral closing wedge-shape osteotomy is a simple, safe, and effective correction for symptomatic, fixed curly toe deformity.

[Adult acquired flatfoot deformity-operative management for the early stages of flexible deformities]. / Der erworbene Plattfuß des Erwachsenen ­ Operative Therapie der flexiblen Deformität im frühen Stadium.

Flexible adult acquired flatfoot deformity includes a wide spectrum of fore- and hindfoot pathologies and remains a complex clinical challenge. Clinical history, inspection and accurate physical examination are paramount for diagnosis. Early stages of flexible adult acquired flatfoot deformity present with increased hindfoot valgus and medial arch collapse. Operative management typically consists of an open medializing calcaneal osteotomy and an augmentation of the insufficient posterior tibial muscle using a flexor digitorum longus tendon transfer. New surgical techniques and a deeper understanding of pathophysiology may change traditional treatment pathways.

Using Normative Data and Unilateral Hopping Tests to Reduce Ambiguity in Return-to-Play Decisions.

CONTEXT: After a lower extremity injury, patients often return to sport (RTS) when the injured limb's performance on unilateral hopping tests is similar to that of the uninjured limb. However, the exact target symmetry value patients must reach before the RTS is unclear. OBJECTIVE: To identify variables that predict limb symmetry index (LSI) values on 6 unilateral hopping tests in healthy, physically active adults. DESIGN: Cross-sectional study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: In total, 275 healthy, physically active adults, consisting of recreational athletes (n = 198), National Collegiate Athletic Association Division I student-athletes (n = 56), and Army Reserve Officer Training Corps cadets (n = 21), volunteered to participate (143 men, 132 women, age = 20.16 ± 2.19 years, height = 172.66 ± 10.22 cm, weight = 72.64 ± 14.29 kg). INTERVENTION(S): Each participant completed 3 speed (6-m crossover-hop, side-hop, figure-8 hop) and 3 distance (triple-crossover-hop, lateral-hop, medial-hop) functional performance tests on both limbs. MAIN OUTCOME MEASURE(S): Mean performance of the dominant and nondominant limbs and LSI values. Two multiple regression models were used to find variables that might help to predict a participant's LSI for each functional performance test. RESULTS: The models helped to predict limb symmetry for 10 of the 12 multiple regressions. Unilateral limb performance was the best predictor of LSI values, as it was statistically significant in 11 of the 12 regression models. Sex and body mass index were significant predictor variables for the side hop and figure-8 hop, respectively. CONCLUSIONS: We found significant predictor variables that clinicians can use in the absence of baseline testing to determine patient-specific LSI values. Individualizing RTS decisions in this way may help to minimize subjectivity in the decision-making process and ensure a safe and timely return to competition.

Guided Growth for Ankle Valgus Deformity: The Challenges of Hardware Removal.

BACKGROUND: Ankle valgus deformity is associated with conditions such as clubfoot, cerebral palsy, and myelodysplasia. Guided growth strategies using a transphyseal screw provide effective correction of ankle valgus deformity. When correction occurs before skeletal maturity, screw removal is required to prevent overcorrection in the coronal plane. In this study, we reviewed the outcomes of guided growth procedures for correction of ankle valgus and related difficulty with hardware extraction. METHODS: A retrospective review of patients with ankle valgus managed with transphyseal screw placement was performed. Clinical and radiographic data, including the lateral distal tibial angle (LDTA), type of screw placed, and time to correction was recorded. At hardware removal, we reviewed elements associated with difficult extraction defined as requiring the use of specialized screw removal/extraction sets or inability to remove the entirety of the screw. RESULTS: One hundred nineteen patients (189 extremities) with a mean age of 11.7 years at time of screw placement met study inclusion criteria. Following correction of the valgus deformity, hardware removal occurred at an average of 18.4 months after placement of the screw. Preoperatively, the mean LDTA for the entire cohort was 81.3 degrees, and was corrected to a mean LDTA of 91.1 degrees. Complicated hardware removal occurred in 69 (37%) extremities. These 69 extremities had hardware in place an average of 1.8 years compared with an average of 1.4 years in extremities without difficult extraction (P<0.01). Six (9%) screws were unable to be removed in their entirety. Rebound valgus deformity occurred in 5 extremities (3%). CONCLUSIONS: Extraction of transphyseal screws in the correction of ankle valgus can be problematic. Specialized instrumentation was required in approximately one third of cases. Longevity of screw placement may be a factor that affects the ease of extraction. Additional exposure, access to specialized instrumentation, and additional operative time may be required for extraction. LEVEL OF EVIDENCE: Level IV-case series.

Subtalar Arthroereisis Implantation in Acquired Neuropathic Pes Planus: A Preliminary Report Detailing a Minimally Invasive Approach to Healing Medial Column Ulcerations.

Ulcerations under the medial column in patients with acquired neuropathic pes planus may be intractable to conservative techniques such as regular debridement, offloading, bracing, and accommodative shoes. When surgery becomes necessary for these patients, the foot and ankle surgeon has the option of exostectomy, medial column beaming, medial column fusion, and external fixation, among others. In the case of a flexible midfoot collapse, the option of arthroereisis for indirect medial column support may be warranted. In this preliminary report, the authors detail a technique of Achilles tendon lengthening, arthroereisis implantation, and advanced cellular tissue product application in an attempt at wound coverage and prevention of recurrence. Three patients presenting with intractable medial column ulcerations of ∼1 year's duration underwent this procedure, and within 7 weeks (range 5 to 7), all medial column ulcerations healed. These patients remained healed at last follow-up (average 29 months; range 8 to 44). This preliminary report provides evidence for a minimally invasive procedure aimed at offloading, healing, and preventing recurrence of medial column ulcerations in patients with flexible neuropathic pes planus.

Management of Tibial Bow in Fibular Deficiency.

BACKGROUND: Deformity of the tibia, including shortening and angulation, may accompany severe forms of postaxial hypoplasia (fibular deficiency). The current literature reflects varying opinions on the appropriate management for tibial deformity in the setting of fibular deficiency. METHODS: We performed a retrospective review to determine outcomes of tibial deformity correction in patients with a primary diagnosis of fibular deficiency. Clinical and radiographic outcomes of patients treated with foot ablation were reviewed to establish indications for tibial deformity correction, identify occurrence of additional surgical procedures related to limb alignment or deformity, and characterize difficulties with prosthetic wear potentially related to residual or recurrent tibial deformity. RESULTS: From 1989 to 2016, 51 patients (57 extremities) with fibular deficiency were managed with a foot ablation procedure. Twenty-five (44%) had simultaneous correction of the tibial deformity. The initial tibial deformity measured 42.5 degrees, was corrected to 5.6 degrees intraoperatively, and measured 18.6 degrees at follow-up, suggesting recurrent deformity. In follow-up, approximately half of the patients complained of redness and one third complained of a continued prominence along the anterior tibia. Thirty-two extremities had an isolated foot ablation procedure without tibial osteotomy. Radiographic review demonstrated mild tibial bowing at the time of amputation with a mean angular deformity of 15.4 degrees and remained unchanged during the follow-up period (mean, 12.7 degrees). Similar to the osteotomy group, approximately half of the patients complained of redness and erythema over the anterior bow, with one fourth noting prominence, and only 2 reporting significant pain. CONCLUSIONS: Tibial osteotomies in patients with more significant degrees of angular deformity can be safely performed at the same setting as foot ablative procedures for fibular deficiency. Recurrent deformity with growth may occur. Patients and their caregivers should be aware that rebound deformity may occur, but typically can be managed with prosthetic adjustment and without significant disruption to the child's daily activities. LEVEL OF EVIDENCE: Level IV (case series).

Simple semi-permanent blockade against rigid varus foot in a case with spasticity: possible practical benefits in ambulatory adults.

A 55-year-old ambulatory woman with hemiplegia and varus foot deformity had several problems in her daily life, including load pain and stance instability in the affected foot, easy fatigue of the non-paralysed leg, low back pain, neck stiffness and rapid shoe-rubber wear on the deformed side. We began repeated focal blockades using botulinum toxin to the tibialis posterior muscle to control varus spasticity. Distant influences presenting in the whole body were relieved soon after the first blockade, and shoe wear also stopped. Although, neither the deformed appearance nor foot contact pattern on walking changed in the initial period after beginning the blockade, the foot contact pattern revealed gradual improvement over several years. Generally, surgical correction is indicated for the treatment of deformed feet. The present case suggests that, in case of varus-deformed foot with some spastic elements, trial of focal blockade for varus spasticity may be worthwhile.

Digital Deformity Assessment Prior to Percutaneous Flexor Tenotomy for Managing Diabetic Foot Ulcers on the Toes.

The aim of this study is to evaluate the prevalence of digital deformities in patients with diabetes mellitus according to the McGlamry classification and relate the types of digital deformities with the history of digital ulcer. A cross-sectional study was performed in the diabetic foot unit between September 2016 and September 2017. All consecutive patients were classified by digital deformities according to the McGlamry classification (flexor stabilization, flexor substitution, and extensor substitution) using slow-motion videos. In all patients, the Foot Posture Index 6 was performed and previous toe ulceration, toe calluses, and nail dystrophy were evaluated. A total of 142 feet were evaluated, in which 29 (20.27%) feet did not show dynamic deformities, 65 (57.5%) were classified as flexor stabilization, 9 (8%) as flexor substitution, and 39 (34.5%) as extensor substitution. In total, 23% the feet with previous ulcer were classified as extensor substitution. A previous toe ulcer on the tip (p = .033; confidence interval [CI] 1.06 to 4.99; odds ratio [OR] 2.3), pronated foot according to the Foot Posture Index 6 (p = .048; 95% CI 0.9 to 8.9; OR 2.9), and callus on the tip (p = .002; 95% CI 1.47 to 6.41; OR 3.07) were associated with flexor stabilization deformities. Flexor stabilization, associated with the pronated foot, was the most prevalent dynamic deformity. Extensor substitution was present in approximately 40% of the patients and in 20% of the patients with previous ulcer, in whom flexor tenotomy could aggravate the digital deformity. An evaluation of dynamic deformities during gait should be included as a presurgical assessment to achieve successful surgical results.

Hindfoot alignment of adult acquired flatfoot deformity: A comparison of clinical assessment and weightbearing cone beam CT examinations.

BACKGROUND: Clinical assessment of hindfoot alignment (HA) in adult acquired flatfoot deformity (AAFD) can be challenging and weightbearing (WB) cone beam CT (CBCT) may potentially better demonstrate this three-dimensional (3D) deformity. Therefore, we compared clinical and WB CBCT assessment of HA in patients with AAFD. METHODS: In this prospective study, we included 12 men and 8 women (mean age: 52.2, range: 20-88) with flexible AAFD. All subjects also underwent WB CBCT and clinical assessment of hindfoot alignment. Three fellowship-trained foot and ankle surgeons performed six hindfoot alignment measurements on the CT images. Intra- and Inter-observer reliabilities were calculated using intra-class correlation (ICC). Measurements were compared by paired T-tests, and p-values of less than 0.05 were considered significant. RESULTS: The mean of clinically measured hindfoot valgus was 15.2 (95% confidence interval [CI]: 11.5-18.8) degrees. It was significantly different from the mean values of all WB CBCT measurements: Clinical Hindfoot Alignment Angle, 9.9 (CI: 8.9-11.1) degrees; Achilles tendon/Calcaneal Tuberosity Angle, 3.2 (CI: 1.3-5.0) degrees; Tibial axis/Calcaneal Tuberosity Angle, 6.1 (CI: 4.3-7.8) degrees; Tibial axis/Subtalar Joint Angle 7.0 (CI: 5.3-8.8) degrees, and Hindfoot Alignment Angle 22.8 (CI: 20.4-25.3) degrees. We found overall substantial to almost perfect intra- (ICC range: 0.87-0.97) and inter-observer agreements (ICC range: 0.51-0.88) for all WB CBCT measurements. CONCLUSIONS: Using 3D WB CBCT can help characterize the valgus hindfoot alignment in patients with AAFD. We found the different CT measurements to be reliable and repeatable, and to significantly differ from the clinical evaluation of hindfoot valgus alignment. LEVEL OF EVIDENCE: Level II-prospective comparative study.

Appearance of hindfoot valgus deformity and recurrence of hallux valgus in the very early period after hallux valgus surgery in a poorly controlled rheumatoid arthritis case: A case report.

Control of rheumatoid arthritis (RA) disease activity is an important factor related to the development of hallux valgus (HV) deformity. Furthermore, if valgus hindfoot remains and/or appears after HV surgery, the affected foot is at risk of recurrence of HV deformity. We experienced a case suggesting the possibility that hindfoot valgus deformity appeared after HV surgery because of poor control of RA disease activity, and the HV deformity recurred in the very early period after surgery.

Coalitions of the Tarsal Bones.

Tarsal coalitions are the result of impaired mesenchymal separation of the tarsal bones. The most common types include calcaneonavicular or talocalcaneal coalitions. Subtalar stiffness results in pathologic kinematics with increased risk of ankle sprains, planovalgus foot deformity, and progressive joint degeneration. Resection of the coalition yields good results. Tissue interposition may reduce the risk of reossification, and concomitant deformity should be addressed in the same surgical setting.

Ilio-Iliac Arteriovenous Fistulae-An Unusual Diagnosis with an Even More Unusual Clinical Presentation.

BACKGROUND: Major pelvic ilio-iliac arteriovenous fistula (AVF) is an exceedingly rare diagnosis with only a few described cases in the literature, most of them related to congenital defects or trauma. In this case report, we aim to present a case of an ilio-iliac AVF with an atypical clinical presentation. METHODS: Relevant medical data were collected from hospital database. RESULTS: The patient is a 77-year-old woman, with a relevant medical history of a temporally remote hysterectomy. She developed an exuberant unilateral right leg edema and was diagnosed with a femoro-iliac deep vein thrombosis (DVT) and started on anticoagulation and daily use of elastic compression stockings. No improvement in leg edema was evident, and she reported painful complaints refractory to medication. She also progressively developed right foot numbness and foot drop. A computed tomography angiography (CTA) was performed to exclude any compressive or paraneoplastic syndrome, with no remarkable findings other than common iliac vein (CIV) occlusion. As the patient's symptoms continued to worsen, a new CTA was performed 5 months later, which revealed an ilio-iliac AVF that was confirmed by angiography. After 2 ineffective attempts to embolize AVF afferents, we chose to completely embolize the arterial component of the AVF with Helix EV3 coils and Onyx glue (Covidien, Irvine, CA, USA). CIV recanalization and deployment of a Venovo stent (Bard Inc, Tempe, AZ, USA) was also performed. The final angiograms showed exclusion of the AVF and rapid venous flow through the stent. There was progressive improvement of edema and pain but little improvement of foot drop. CONCLUSION: AVF etiology and mechanism of neurologic deficits are controversial, with multiple possible explanations. Endovascular treatment modalities are promising a safer and more efficient approach when compared with open surgery. Our experience in this case was encouraging, but long-term results are currently lacking.

Weightbearing CT in normal hindfoot alignment - Presence of a constitutional valgus?

BACKGROUND: The normal hindfoot angle is estimated between 2° and 6° of valgus in the general population. These results are solely based on clinical findings and plain radiographs. The purpose of this study is to assess the hindfoot alignment using weightbear CT. METHODS: Forty-eight patients, mean age of 39.6±13.2 years, with clinical and radiological absence of hindfoot pathology were included. A weightbear CT was obtained and allowed to measure the anatomical tibia axis (TAx) and the hindfoot alignment (HA). The HA was firstly determined using the inferior point of the calcaneus (HAIC). A density measurement of this area was subsequently performed to analyze if this point concurred with an increased ossification, indicating a higher load exposure. Secondly the HA was determined by dividing the calcaneus in the long axial view (HALA) and compared to the (HAIC) to point out any possible differences attributed to the measurement method. Reliability was assessed using an intra class correlation coefficient (ICC). RESULTS: The mean HAIC equaled 0.79° of valgus±3.2 (ICCHA IC=0.73) with a mean TAx of 2.7° varus±2.1 (ICCTA=0.76). The HALA equaled 9.1° of valgus±4.8 (ICCHA LA=0.71) and differed significantly by a P<0.001 from the HAIC, which showed a more neutral alignment. Correlation between both was shown to be good by a Spearman's correlation coefficient of 0.74. The mean density of the inferior calcaneal area equaled 271.3±84.1 and was significantly higher than the regional calcaneal area (P<0.001). CONCLUSIONS: These results show a more neutral alignment of the hindfoot in this group of non-symptomatic feet as opposed to the generally accepted constitutional valgus. This could have repercussion on hindfoot position during fusion or in quantifying the correction of a malalignment. The inferior calcaneus point in this can be used during pre-operative planning of a hindfoot correction as an anatomical landmark due to its shown influence on load transfer.

Study on the foot shape characteristics of the elderly in China.

BACKGROUND: With aging, the feet of the elderly above 60 years old in China present degenerative changes, deformities, and diseases, which significantly affect their daily activities. OBJECTIVES: The authors aimed to study the morphological characteristics of the feet and identify the foot type according to size (length and width) and defect characteristics of elderly feet in China. METHODS: A convenient sample of 1000 subjects above 60 years old was recruited mainly in the regions of Shanghai, Shaanxi, Henan, Hebei, and Sichuan in China. Foot images were collected, and 800 (male 398, female 402) valid questionnaires were recovered. A total of 800 elderly subjects as the test group were invited to measure their foot sizes by means of a Footprint Collector (Tong Yuan Tang Health Management Limited, Qingdao in Shandong province). The foot type of the elderly was compared with that of the general adult Chinese population as the control group using the t-test for independent samples. RESULTS: Hallux valgus (46.9%) and flat foot (50.0%) were the most common foot shape deformities. The most frequent foot diseases were foot scaling (91.2%) and calluses (96.3%). The medial width of the first metatarsal-toe joint of the elderly was significantly higher (elderly female, 44.95±4.86mm; elderly male, 48.55±4.94mm) than that of the general adult population (adult female, 40.18±3.43mm; adult male, 43.22±3.20mm) (p<0.01). CONCLUSION: The foot length of the elderly was not significantly different from that of the general adult Chinese population. The width of the first metatarsal-toe joint in the forefoot of the elderly was significantly higher than that of the general adult Chinese population, which was consistent with the result that a high proportion of elderly subjects presented hallux valgus.

Foot health in patients with rheumatoid arthritis-a scoping review.

Rheumatoid arthritis affects joints and can cause significant impairments in daily life. The foot is often the first site of symptoms and foot problems are strongly related to RA. The aim of this review was, therefore, to describe foot health in patients with rheumatoid arthritis and to identify how patients perform foot self-care. With this knowledge interventions to support foot health and functional ability in RA patients can be developed. The design of the review was a scoping review. A systematic literature search of three electronic databases, MEDLINE, CINAHL and Embase, was conducted in June 2016. The search yielded 1205 studies, of which 32 were selected for the review. The data were analysed by means of content analysis. Foot problems in RA patients are prevalent and impair their daily activities. Foot pain and foot structural deformities were the most prevalent problems. RA patients have difficulties caring their own feet and in finding proper footwear. Many different instruments were used to measure different aspects of foot health. Patients with RA have a high prevalence of foot and ankle problems. These foot problems are a major burden to patients themselves. RA patients' ability to self-care ability can be diminished, since RA also affects joints in the hands. In future cross-cultural validation studies are needed to ensure psychometrically sound instrumentation. Methods to alleviate foot pain and to prevent foot problems in RA patients need to be developed and tested.

Clinical and radiological outcomes of midfoot derotational osteotomy for midfoot-forefoot varus deformity.

BACKGROUND: Moderate to severe midfoot-forefoot varus deformities are commonly found in several conditions. However, few techniques are available to correct these deformities. So, we evaluated the clinical and radiological outcomes of patients who underwent midfoot derotational osteotomy to achieve plantigrade foot. METHODS: From 2006 to 2014, 6 patients (7 feet) underwent midfoot derotational osteotomy. A visual analog scale (VAS) pain and the American Orthopedic Foot & Ankle Society (AOFAS) functional score were evaluated. Radiographic parameters, including tibiocalcaneal angle (TCA) and navicular height (NH), were assessed. RESULTS: The mean patient age at surgery was 48.0 years (37-58). From before the operation to the final follow-up, the mean VAS score decreased from 6.5 (2-9) to 1.3 (0-4) and the mean AOFAS score improved from 42.7 (34-58) to 77 (68-87). All patients were satisfied with outcomes. The mean TCA significantly improved from 33.8° (9.9-66.7) to 12.7 (5.1-27.6) (p = 0.018)and the mean NH decreased from 46.7 mm (32.8-67) to42.6 (30.1-60.8) (p = 0.018). CONCLUSION: Severe midfoot-forefoot varus deformities can be efficiently corrected by midfoot derotational osteotomy resulting in favorable clinical and radiological outcomes and high patient satisfaction. LEVEL OF EVIDENCE: IV, case series.