Simultaneous subtalar arthroeresis, midfoot soft tissue release, and talo-navicular arthrodesis in children with planovalgus neurologic foot.

PURPOSE: Planovalgus foot deformity (PVFD) is common in children with neuromuscular conditions and severe deformity may require surgical correction. This study aims to assess clinical and radiological outcomes of PVFD secondary to neuromuscular disease managed by subtalar arthroeresis (SuAE), midfoot soft tissue release and talo-navicular arthrodesis (TNA). METHODS: A retrospective analysis of children with neuromuscular disease and nonreducible PVFD who underwent SuAE, midfoot soft tissue release, and TNA and with a minimum follow-up of 5 years was performed. A total of 60 patients with neuromuscular disease (108 feet) including cerebral palsy were reviewed. Mean age at surgery was 12.7 ± 4.6 years (6-17). Mean follow-up was 7 ± 2.9 years (5-10). Clinical outcomes and radiologic correction at final follow-up were compared with preoperative values. Statistical analysis was performed and significance was set at P < 0.01. RESULTS: Statistically significant radiological improvements between pre- and postoperative values were found for all angle values. At final follow-up, there was a significant improvement in VAS score (4.8 vs. 2; P < 0.01). There was also a positive trend in the improvement of walking ability. No cases of pseudoarthrosis were reported at final follow-up. Screw removal was required in 5 out of 108 feet (4.6%) and 2 feet (3.3%) had delayed medial wound healing. CONCLUSIONS: SuAE combined with TNA and midfoot soft tissue is a safe and feasible procedure that can provide good clinical and radiologic results in patients with neuromuscular disease and nonreducible PVFD; the procedure can improve foot stability, and has a limited number of complications. LEVEL OF EVIDENCE: IV.

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

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

Patient Reported Outcomes Following Triple Arthrodesis for Adult Acquired Flat Foot Deformity: Minimum Two Year Follow Up.

The aim of this study is to analyze patient-reported outcomes following this procedure as well as any demographics that may confer prognostic capability. A retrospective analysis was conducted of patients who underwent Triple Arthrodesis at our facility from 2014-2021. Patients were selected if they underwent an isolated triple arthrodesis. All cases included either a gastrocnemius recession versus a percutaneous tendo-achilles lengthening depending on the patient's Silverskiold examination. The electronic medical record was utilized to collect basic patient demographics, previous foot and ankle surgeries, hardware failures, additional procedures, and surgical complications. To evaluate outcomes, we compared patient reported outcomes measurement information system (PROMIS) survey scores with the general population and preoperative versus postoperative visual analog scale (VAS) scores. Foot function index (FFI) scores and scores were utilized as a validation tool for our results. A total of 132 patients met the criteria for our study with a total of 50 participants completing the PROMIS and FFI surveys. The average time point at which the outcomes were collected was 5.50 y postoperatively, ranging from 1.65 to 7.57 y. The average PROMIS physical function was 38.35, pain interference was 61.52, and depression was 49.82 for this population. The mean FFI scores were 58.56 for pain, 60.07 for disability, and 48.07 for activity limitation. There was a significant decrease in preoperative and postoperative VAS scores from 5.4 to 2.55 (p < .001). Three patients experienced wound complications related to decreased sensation. Our results indicated that only PROMIS depression scores were within one standard deviation of the population mean following a triple arthrodesis procedure. PROMIS physical function and pain interference were both outside of one standard deviation for the population.

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.

Associated correction of forefoot alignment with hindfoot fusion for pes planovalgus deformity.

BACKGROUND: The present study aimed to investigate changes in hallux alignment after corrective surgery for adult-acquired flatfoot deformity (AAFD). PATIENTS AND METHODS: The present study retrospectively investigated the changes of hallux alignment in 37 feet (33 patients) which were treated with double or triple arthrodesis of the hindfoot for AAFD between 2015 and 2021 and could be followed up to one year postoperatively. RESULTS: Hallux valgus (HV) angle significantly decreased by a mean 4.1° among the whole 37 subjects and by a mean 6.6° among the 24 subjects who had a preoperative HV angle of 15° or more. Those who had HV correction (HV angle correction ≥ 5°) demonstrated more near-normal postoperative alignment of the medial longitudinal arch and hindfoot than those without HV correction. CONCLUSIONS: Hindfoot fusion for AAFD could improve preoperative HV deformity to some degree. HV correction was associated with proper realignment of the midfoot and hindfoot. LEVEL OF EVIDENCE: Level IV; retrospective case series.

Radiographic factors associated with painful callosities after forefoot surgery in patients with rheumatoid arthritis.

OBJECTIVES: Operative procedures for rheumatoid forefoot deformities have gradually changed from arthrodesis or resection arthroplasty to joint-preserving surgery. Although joint-preserving arthroplasty has yielded good outcomes, painful plantar callosities may occur post-operatively. This study aimed to reveal the radiographic factors associated with painful callosities after joint-preserving surgery for forefoot deformities in patients with rheumatoid arthritis (RA). METHODS: We retrospectively evaluated 166 feet in 133 patients with RA who underwent forefoot joint-preserving arthroplasty, including proximal rotational closing-wedge osteotomies of the first metatarsal, between January 2012 and December 2015. Logistic regression analysis was performed with the objective variable set as the presence/absence of painful plantar callosities at the final observation and the explanatory variables set as several radiographic factors, including post-operative relative first metatarsal length (RML), amount of dorsal dislocation of the fifth metatarsal (5DD), and arc failure of the lesser toes. RESULTS: At the final follow-up, 42 of the 166 feet (25.3%) had painful callosities under the metatarsal heads post-operatively. Logistic regression analysis showed that the RML, 5DD, and lesser toes' arc failure were significantly associated with painful callosities. CONCLUSIONS: We identified that RML, 5DD, and arc failure of the lesser toes were associated with painful plantar callosities after the surgery.

Subjective and Objective Outcomes of Surgery for Rheumatoid Forefoot Deformities Under the Current Treatment Paradigm.

We investigated the clinical outcomes of surgical procedures for the treatment of forefoot deformities in patients with rheumatoid arthritis. Twenty feet in 16 women (mean age 62.1 years) underwent corrective osteotomy of the first metatarsal bone with shortening oblique osteotomy of the lesser metatarsophalangeal joints (joint-preservation group), while 13 feet in 12 women (mean age 67.4 years) underwent arthrodesis of the first metatarsophalangeal joint with resection arthroplasty of the lesser metatarsophalangeal joints (joint-sacrifice group); mean follow-up for each group was 25.8 and 23.8 months, respectively. The mean total Japanese Society for Surgery of the Foot (JSSF) scale improved significantly from 64.2 to 89.2 in the joint-preservation group (p < .001), and from 54.2 to 74.2 in the joint-sacrifice group (p = .003). In the joint-preservation group, the postoperative range of motion (ROM) of the joint, walking ability, and activities of daily living scores of the JSSF scale were significantly higher than those in the joint-sacrifice group (p = .001, p = .001, and p = .019, respectively). There were no differences in the subscale scores of the self-administered foot evaluation questionnaire between 2 groups either pre- or postoperatively. No differences in the postoperative complications were found between 2 groups. Although the joint-sacrificing procedure resulted in lower objective outcomes than the joint-preserving procedure regarding the ROM of the joint, the walking ability, and the level of activities of daily living, both procedures resulted in similar treatment outcomes when evaluated by the subjective measures.

SUBJECTIVE AND CLINICAL OUTCOMES OF SURGERY FOR CORRECTION OF RHEUMATOID FOREFOOT DEFORMITIES.

Hoffmann-Clayton procedures appears to be promising surgical treatment in severe rheumatoid forefoot deformities. It has been reported that 80% to 90% of foot deformities in adults are due to rheumatoid arthritis. Despite of various surgical approaches, early functional and cosmetic results have been the greatest concern among patients. Thus, optimal surgical approach in correction of severe rheumatoid forefoot deformities is of vital importance for better subjective and clinical results. Clinical study was conducted on 56 painful chronic rheumatoid foot who were treated by arthrodesis of 1st metatarsophalangeal (MTP) and lesser metatarsal head resections. They were divided into 2 groups based on surgical approach in lesser metatarsal head resections. 1st group had 25 feet with dorsal approach (Clayton) and 2nd group - 31 feet with plantar approach (Hoffmann). Subjective and clinical outcomes were evaluated in both groups. The mean post-operative AOFAS scores were 67.82 (range: 32 - 82) and mean post-operative Foot Function Index (FFI) was 0.51 (range: 0.23 to 0.63) in both groups. Eighty seven percent (48/56 feet) reported early pain relief, improved cosmetic appearance, and improved footwear comfort in Hoffmann group. The mean hallux valgus angles improved from 37 to 15 degrees and the 1st intermetatarsal angle from 17 to 8 degrees in both groups. Four feet had non-union of the 1st MTP joint arthrodesis and three among them were re-operated. Hoffmann and Clayton procedures are optimal methods for excision arthroplasty of lesser metatarsal heads. However, Hoffmann (plantar approach) serves to be more convenient resulting in early recovery, adequate functional stability, rehabilitation and better cosmetic results.

Is Arthrodesis Sufficient in the Setting of Complex, Severe and Rigid Progressive Collapsing Foot Deformities?

Arthrodesis of the hindfoot is typically used for the correction of severe and arthritic progressive collapsing foot deformity. Concomitant bony or soft tissue procedures may be helpful in patients with congenital abnormalities including the ball-and-socket ankle or congenital vertical talus. Dysplasia of the hindfoot bones may be more common than previously recognized, and corrective procedures or alterations in technique may need to be performed during hindfoot arthrodesis to account for bony deformity. Intraarticular osteotomies, extraarticular osteotomies, tendon lengthening, and tendon transfer procedures may be used in specific instances to aid in deformity correction and improve overall function.

Joint-Preserving Surgery for Forefoot Deformities in Patients with Rheumatoid Arthritis: A Literature Review.

The combination of first metatarsophalangeal joint arthrodesis and resection arthroplasty of all lesser metatarsal heads has been historically considered the golden standard treatment for rheumatoid forefoot deformities. However, as recent improved management of rheumatoid arthritis have reduced progression of joint destruction, the surgical treatments for rheumatoid forefoot deformities have gradually changed from joint-sacrificing surgery, such as arthrodesis and resection arthroplasty, to joint-preserving surgery. The aim of this literature review was to provide current evidence for joint-preserving surgery for rheumatoid forefoot deformities. We focused on the indications, specific outcomes, and postsurgical complications of joint-preserving surgery in this review.

Open reduction and internal fixation for displaced Salter-Harris type II fractures of the distal tibia: a retrospective study of sixty-five cases in children.

BACKGROUND: The treatment for displaced Salter-Harris II (S-H II) distal tibia fractures remains controversial. The purpose of this study was to review S-H II distal tibia fractures and evaluate the rate of premature physeal closure (PPC) treated by open reduction and internal fixation (ORIF). METHODS: We reviewed the charts and radiographs of S-H II fractures of the distal tibia with displacement > 3 mm between 2012 and 2019 treated by ORIF. Patients were followed up for a minimum of 6 months. CT scans of injured side or contralateral ankle radiograph were obtained if there was any evidence of PPC. Any angular deformity or shortening of the involved leg was documented. Multivariable logistic regression was performed to identify risk factors for the occurrence of PPC. RESULTS: A total of 65 patients with a mean age of 11.8 years were included in this study. The mean initial displacement was 8.0 mm. All patients but one were treated within 7 days after injury and the mean interval was 3.7 days. Supination-external rotation injuries occurred in 50 patients, pronation-eversion external rotation in 13, and supination-plantar flexion in two. The residual gap was less than 1 mm in all patients following ORIF and all fractures healed within 4-6 weeks. Superficial skin infection developed in one patient. Ten patients complained of the cosmetic scar. The rate of PPC was 29.2% and two patients with PPC developed a varus deformity of the ankle. Patients with associated fibular fracture had 7 times greater odds of developing PPC. Age, gender, injured side, mechanism of injury, amount of initial displacement, interval from injury to surgery, or energy of injury did not significantly affect the rate of PPC. CONCLUSIONS: ORIF was an effective choice of treatment for S-H II distal tibia fractures with displacement > 3 mm to obtain a satisfactory reduction. PPC is a common complication following ORIF. The presence of concomitant fibula fracture was associated with PPC.

Functional results and quality of life after joint preserving or sacrificing surgery in Charcot-Marie-Tooth foot deformities.

INTRODUCTION: The purpose of this study was to assess the functional results, quality of life, and complications in two groups of Charcot-Marie-Tooth (CMT) patients according to the type of surgical operations, joint preserving, or joint sacrificing surgery. METHODS: Fifty-two feet in forty-six patients with CMT who had undergone surgical deformity correction were divided into two groups based on the main surgical procedure for the correction: Class I (joint preserving surgery) and class II (joint sacrificing surgery). Foot ankle disability index (FADI) and short form 12 version 2 (SF12V2) were documented pre-operative and 12 months post-operative. The complications of both groups were monitored with a mean follow-up time of 20.5 months (range, 13-71.5). RESULTS: After surgical treatment, FADI scores showed differences (p=0.005) between both groups. The functional improvement was 29 (20-46; p<0.001) in class I and 10 (2-36; p=0.001) in class II. The patients in both groups acquired a better quality of life as demonstrated in physical component summary of SF12 but without statistically difference. Three feet needed reintervention in class I (two for cavovarus recurrence and one for hallux flexus) at the end of follow-up. In contrast, five feet needed a new operation for cavovarus recurrence, claw toes recurrence, and ankle osteoarthritis after the progression of the condition. DISCUSSION: An early surgical intervention to neutralize the deforming forces in CMT patients could be a useful strategy to delay or prevent the need for extensive reconstruction and potential future complications. CONCLUSION: Based on the type of surgical intervention in CMT patients, the joint preserving surgery in addition to soft tissue balancing procedures obtained better functional outcomes and lower rate of complications when compared to the group of joint sacrificing surgery.

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).

A Surgical Approach to Location-specific Neuropathic Foot Ulceration.

The management of pedal ulcerations is often challenging because of a failure to correct underlying biomechanical deformities. Without correcting the biomechanical driving force creating the increased plantar pressures, it is unlikely for routine wound care to provide lasting solutions to pedal ulcerations. Patients with diabetes often experience glycosylation of their tendons, leading to contracture and pursuant deformity, creating imbalanced pressure distributions and eventual plantar ulceration. This article evaluates the efficacy of various lower extremity tendon transfers to balance the foot and redistribute plantar pressures to prevent or heal ulceration.

[Surgical treatment options of foot deformities caused by neuromuscular disorders].

Many neuromuscular diseases can lead to paresis and/or spasticity of the peripheral muscles. Due to an unbalance between agonists and antagonists deformities of the foot and ankle may develop. These deformities can often be handled by nonoperative measures but in some patients the effect is insufficient. In these cases, surgical treatment with tendon transfers, osteotomies or arthrodesis can lead to satisfying results. The purpose of this review is to create an overview of the treatment concepts and options for these diseases.

Osteochondroma of the talus: three varying cases.

Osteochondroma of the talus is a rare entity that can cause pain, swelling, restriction of movements, synovitis and tarsal tunnel syndrome (TTS). We present three such cases with varying presentation. Case 1 presented with synovitis of the ankle along with a bifocal origin of the talar osteochondroma. Case 2 presented with TTS as a result of compression of the posterior tibial nerve. Case 3 presented with deformity of the foot. In all the three cases, the mass was excised en bloc and histologically proven to be osteochondroma. In case 3, the ankle joint was reconstructed with plate, bone graft and arthrodesis of the inferior tibiofibular joint. All the three cases had good clinical outcomes.