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.

Isolated Subtalar Repositional Arthrodesis Compared With Triple Arthrodesis for the Treatment of Progressive Collapsing Foot Deformity.

The optimal extent of arthrodesis for severe and rigid progressive collapsing foot deformity is controversial. Traditionally, triple arthrodesis has been recommended; however, good results have been reported using subtalar arthrodesis only. We compared the results of triple arthrodesis and isolated subtalar repositional arthrodesis. A total of 22 symptomatic feet were evaluated retrospectively. Isolated subtalar repositional arthrodesis was performed in 13 cases (the subtalar group) and double or triple arthrodesis in 9 cases (the triple group). Various radiographic variables for assessing flatfoot and osteoarthritic changes in ankle and tarsal joints were measured and compared between the 2 groups at 3 time points: preoperatively, 3 months postoperatively, and 4 y postoperatively. Additionally, we analyzed various factors that affect postoperative valgus talar tilt in the ankle joint, which has been associated with poor prognosis. There were no differences in preoperative demographic data and the severity of the disease between the 2 groups; both groups showed improvement in radiographic parameters postoperatively compared with preoperative results. With the numbers available, no significant differences could be detected in postoperative radiographic measurements between the 2 groups. Of all the variables analyzed, postoperative hindfoot alignment angle was associated with postoperative talar tilt development. Additionally, postoperative talar tilt was observed more in triple group than in subtalar group. In conclusion, isolated subtalar repositional arthrodesis is an effective procedure to correct advanced progressive collapsing foot deformity. In addition, Chorpart joint arthrodesis with improper position can cause valgus talar tilt in the ankle joint.

Management of Checkrein Deformity.

Checkrein deformity is characterized by the dynamic status of the hallux, in which flexion deformity is aggravated by ankle dorsiflexion and relieved by ankle plantarflexion. In most cases, a checkrein deformity occurs secondary to trauma or following surgery. It has been suggested that the flexor hallucis longus tendon tethers or entraps scar tissue or fracture sites. Improvement with conservative treatment is difficult once the deformity has already become entrenched, and surgical management is usually required in severe cases. Various surgical options are available for the correction of checkrein deformities. It includes a simple release of adhesion at the fracture site; lengthening of the flexor hallucis longus by Z-plasty at the fracture site combined with the release of adhesion; lengthening of the flexor hallucis longus by Z-plasty at the midfoot, retromalleolar, or tarsal tunnel area; and flexor hallucis longus tenotomy with interphalangeal arthrodesis for recurrent cases. This review aimed to summarize the overall etiology, relevant anatomy, diagnosis, and treatment of checkrein deformities described in the literature.

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.

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.

Management of Infections and Osteomyelitis in Patients With Charcot Foot Arthropathy.

There is growing interest in performing reconstruction of deformities associated with Charcot foot arthropathy. At least half of the patients undergoing this reconstruction will have chronic wounds and osteomyelitis overlying the deformity. It is important to provide orthopaedic surgeons with tools for making the diagnosis of osteomyelitis in this patient population and creating a strategy for treatment.

A case of closed isolated medial subtalar dislocation / Un caso de luxación subastragalina medial aislada y cerrada

Introduction: Closed isolated subtalar dislocations are very rare and major cause of subtalar dislocation remains to be road traffic accidents. Objective: Identify isolated medial subtalar closed dislocations and their forms a management. Presentation of case: 22-year-old male sustained road traffic accident following which he had deformed foot with inability to bear weight. On evaluation he was found to have medial subtalar dislocation reduced with manual traction. One year follow up showed, no residual deformity or pain and had very good functional outcome. Conclusions: It is of great importance to identify the difference between medial subluxation or dislocation and medial swivel injury which have different mechanisms as well as different reduction maneuvers(AU)

Introducción: Las luxaciones subastragalinares aisladas cerradas son muy raras y la principal causa de luxación subastragalina resultan los accidentes de tráfico. Objetivo: Identificar las luxaciones cerradas subastragalina medial aisladas y su tratamiento. Presentación del caso: Un paciente hombre de 22 años sufrió un accidente de tránsito tras el cual quedó deformado el pie sin poder soportar peso. En la evaluación se encontró la luxación subastragalina medial que se redujo con tracción manual. El seguimiento al año no mostró deformidad residual ni dolor y tuvo muy buen resultado funcional. Conclusiones: Es de gran importancia identificar la diferencia entre subluxación o luxación medial y lesión por giro medial, las cuales tienen diferentes mecanismos, así como diferentes maniobras de reducción(AU)

Acroosteólisis y dismorfia facial: un nuevo caso de síndrome de Hajdu-Cheney / Acroosteolysis and facial dysmorphia: a new case of Hajdu-Cheney Syndrome

El síndrome de Hajdu-Cheney o síndrome acro-dento-osteo-displasia es una enfermedad rara caracterizada por osteólisis en banda de las falanges distales y dismorfia facial, entre otras manifestaciones. Describimos el caso de un varón de 45 años que consultó por dolor articular de características mecánicas en las manos, asociando dismorfia facial, alteraciones craneofaciales y deformidades digitales en telescopaje con acroosteólisis.(AU)

Hajdu-Cheney syndrome or acro-dento-osteo-dysplasia syndrome is a rare disease characterized by band osteolysis of distal phalanges and facial dysmorphia, among other manifestations. We present the case of a 45-year-old male who consulted for mechanical joint pain of both hands, facial dysmorphism, cranio-facial alterations, and digital telescoping with acroosteolysis.(AU)

Charcot-Marie-Tooth Disease: A Surgical Algorithm.

In Charcot-Marie-Tooth (CMT) cavovarus surgery, a regimented approach is critical to create a plantigrade foot, restore hindfoot stability, and generate active ankle dorsiflexion. The preoperative motor examination is fundamental to the algorithm, as it is not only guides the initial surgical planning but is key in the decision making that occurs throughout the operation. Surgeons need to be comfortable with multiple techniques to achieve each surgical goal. There is no one operation that works for all patients with CMT. A plantigrade foot is the most important of the surgical goals as hindfoot stability and ankle dorsiflexion can be augmented with bracing.

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.

Spring Ligament Reconstruction for Progressive Collapsing Foot Deformity: Contemporary Review.

The spring ligament is one of the main stabilizers of the medial arch of the foot and the primary static supporter of the talonavicular joint. Attenuation or rupture of this ligament is thought to play a central role in the pathophysiology of progressive collapsing foot deformity. Traditional correction of flexible flatfoot consists of posterior tibial tendon augmentation along with various osteotomies or hindfoot fusions. Repair or reconstruction of the spring ligament has not been as widely pursued. In recent years, newer techniques have been explored and may improve outcomes of traditional procedures, or possibly entirely replace some osteotomies. Combined spring-deltoid ligament reconstruction is also gaining traction as a viable technique, particularly as the ankle begins to deform into valgus. This review summarizes the variety of nonanatomic and anatomic reconstruction techniques that have been described, including autologous tendon transfers, allografts, and synthetic augmentation. Although many have only been characterized in biomechanical cadaver studies, this article reviews preliminary clinical studies that have shown promising results. There is a need for more high-quality studies evaluating the clinical, radiographic, and patient-reported outcomes following spring ligament reconstruction.

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.

Anatomic and Biomechanical Considerations of Flatfoot Deformity.

In this article, the authors present essential anatomy in the presence of the postural flat foot. There is a recognition of static versus dynamic stabilizers of the foot. In the continuum of the collapsed foot, there is an exploration of anatomic and pathologic changes. Providing this fundamental knowledge will allow the reader to appreciate the disease process to establish a prognosis and consider treatment alternatives.

Ligament Insufficiency with Flatfoot: Spring Ligament and Deltoid Ligament.

The objective of this article was to review the deltoid ligament and spring ligament specifically as they pertain to ligament insufficiency and adult-acquired flatfoot deformity. Discussion includes the normal and abnormal biomechanical forces that extend through these ligaments in normal and flatfoot deformity. Current literature related to spring ligament repair as part of the flatfoot deformity reconstruction is also reviewed.

Double versus Triple Arthrodesis for Flatfoot Deformity: When, Why, and How?

Different types of arthrodesis for flatfoot deformity have a long history in foot and ankle surgery. Arthrodesis of the rearfoot can be a useful tool in helping correct deformity and maintaining that correction with good long-term results. Questions have risen recently however about the necessity of including the calcaneocuboid joint in the traditional rearfoot arthrodesis or triple arthrodesis. The double arthrodesis of the talonavicular and subtalar joints has grown in popularity and this review helps the reader choose with a review of the biomechanics, surgical approaches, fixation techniques and recent literature outcomes of both procedures.

Surgical Considerations for Revision Flatfoot Reconstruction: Overcorrection/Undercorrection.

Reconstructive surgery of the symptomatic pes planus deformity is a very common procedure with relatively good outcomes. Many factors such as patient selection, patient expectations, and surgical execution can influence the results. In addition to achieving osseous union, the overall postoperative alignment is critical in determining functional outcome. Specifically, under- and over-correction respectively present their own unique problems and symptomatology. The purpose of this review is to discuss the adverse outcomes after mal-reduction of flatfoot reconstruction and emphasize the strategies to correct the subsequent deformity.

A comparison between the Bluman et al. and the progressive collapsing foot deformity classifications for flatfeet assessment.

INTRODUCTION: Bluman et al., flatfoot classification is based on posterior tibial tendon (PTT) dysfunction leading to a chronological appearance of several foot deformities. An expert consensus recently proposed a new classification named Progressive Collapsing Foot Deformity (PCFD) in which the focus was shifted to five different independent foot and ankle deformities and their flexibility or rigidity. The aim of this study was to compare Bluman and PCFD classifications. We hypothesize that both classifications will be reliable and that the PCFD classification will allow a larger distribution of the different types of foot deformity. MATERIALS AND METHODS: We performed a retrospective IRB-approved study including 92 flatfeet. Three foot and ankle surgeons reviewed patient files and radiographs to classify each foot using both classifications. Bluman classification was performed one time as initially described and a second time after removing the Angle of Gissane sclerosis sign. Interobserver reliabilities were determined with Fleiss' kappa values. RESULTS: Interobserver reliabilities of Bluman and PCFD classifications were, respectively, substantial 0.67 and moderate 0.55. PCFD Class C and D reliabilities were, respectively, slight 0.07 and fair 0.28. The 276 readings were spread into 10 substages in Bluman and 65 subclasses in PCFD. The progressivity of the Bluman classification prevented the combination of flexible hindfoot valgus (II Bluman, 1A PCFD), midfoot abduction (IIB, 1B) and medial column instability (IIC, 1C) which was frequent in our study (112/276 readings, 40.6%). By removing the Angle of Gissane sclerosis sign from the Bluman classification, the prevalence of stage III decreased from 44.2 to 10.1%. CONCLUSIONS: Bluman and PCFD classifications were reliable. The PCFD classification showed a larger distribution of different types of flatfeet but Classes C and D need better definition. The progressivity of Bluman classification causes inconsistencies and Gissane angle sclerosis sign is inappropriately used and might lead to incorrect surgical indications.

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.

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.