Developmental Foot Deformities in Patients with Connective Tissue Disorders.

¼: Foot deformities make up a large percentage of all orthopaedic complaints in patients with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, Larsen syndrome, and osteogenesis imperfecta. ¼: Some common causes of foot deformities in these conditions include increased ligament laxity, hypotonia, and hypermobility of the joints. ¼: Treatment options for syndromic foot deformities include the use of foot orthoses, physical therapy, bracing, and various surgical procedures. ¼: There is limited evidence supporting the use of surgical intervention to correct foot deformities associated with Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, Larsen syndrome, and osteogenesis imperfecta. Therefore, further research is needed to determine the short-term and long-term outcomes of these procedures.

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.

Prevalence and pattern of lateral impingements in the progressive collapsing foot deformity.

INTRODUCTION: The prevalence of lateral bony impingements [i.e., Sinus Tarsi (STI), Talo-Fibular (TFI) and Calcaneo-Fibular (CFI)] and their association with Peritalar Subluxation (PTS) have not been clearly established for progressive collapsing foot deformity (PCFD).This study aims to assess the prevalence of STI, TFI and CFI in PCFD, in addition to their association with PTS. We hypothesized that STI and TFI would be more prevalent than CFI. MATERIALS AND METHODS: Seventy-two continuous symptomatic PCFD cases were retrospectively reviewed. Weightbearing computed tomography (WBCT) was used to assess lateral impingements and classified as STI, TFI and CFI. PTS was assessed by the percent of uncovered and the incongruence angle of the middle facet, and the overall foot deformity was determined by the foot and ankle offset (FAO). Data were collected by two fellowship-trained independent observers. RESULTS: Intra-observer and inter-observer reliabilities for impingement assessment ranged from substantial to almost perfect. STI was present in 84.7%, TFI in 65.2% and CFI in 19.4%. PCFD with STI showed increased middle facet uncoverage (p = 0.0001) and FAO (p = 0.0008) compared to PCFD without STI. There were no differences in FAO and middle facet uncoverage in PCFD with TFI and without TFI. PCFD with CFI was associated with STI in 100% of cases. PCFD with CFI showed decreased middle facet incongruence (p = 0.04) and higher FAO (p = 0.006) compared to PCFD without CFI. CONCLUSIONS: STI and TFI were more prevalent than CFI in PCFD. However, only STI was associated with PTS. Conversely, CFI was associated with less PTS, suggesting a different pathological mechanism which could be a compensatory subtalar behavior caused by deep layer failure of the deltoid ligament and talar tilt.

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.

[Treatment of a Progressive Collapsing Foot Deformity]. / Behandlung des Plattfusses.

Treatment of a Progressive Collapsing Foot Deformity Abstract. The so-called "flat foot" can be more accurately described in German as "Knick-Senkfuss" or "kinking-flatfoot". The "kink" refers to the hindfoot axis as such, which can be identified by the intersection of the longitudinal axes of the Achilles tendon and the tuber calcanei. The designation "flat foot" marks the appearance of the longitudinal axis, that is, the medial longitudinal arch, which is easy to determine clinically. Nowadays, a new terminology has been added: Progressive collapsing foot deformity (PCFD). The forms of a PCFD are manifold, as are the possible causes. For this reason, the forms of therapy to be used are often not very simple and must be carefully considered and applied. Not always are PCFD in need of treatment. That means that there are people who have always had such deformities but never develop symptoms. For this reason, only symptomatic patients suffering from a PCFD need treatment. The degree of treatment and its success depends on the careful examination and interpretation of the findings by the orthopedic surgeon. This article deals with treatment of PCFD and attempts to provide a logical overview.

Quality of Life Improvement Following Reconstruction of Midtarsal Charcot Foot Deformity: A Five Year Follow-Up.

Background: There is increasing interest in reconstruction of diabetes-associated Charcot foot arthropathy with the goal of improving quality of life. Methods: Twenty-four patients who completed the Short Musculoskeletal Function Assessment (SMFA) at baseline and one year following Charcot foot reconstruction were contacted and asked to complete the survey at five years following surgery. Results: Fourteen of the 24 patients completed the SMFA preoperatively, one year following surgery and five years postoperatively. Two patients underwent below knee amputation in the interim. Improvement was noted in all domains measured by the SMFA, with a statistically significant improvement in difficulty with daily activities at five years. Conclusion: Correction of non-plantigrade Charcot foot arthropathy results in clinically meaningful improvement in health-related quality of life at both one and five years postoperatively, including independence with daily activities. The improvement is maintained when reevaluated at five years. This supports the modern paradigm shift towards reconstruction of this deformity. Level of Evidence: III.

Risk Factors for Diabetic Peripheral Neuropathy, Peripheral Artery Disease, and Foot Deformity Among the Population With Diabetes in Beijing, China: A Multicenter, Cross-Sectional Study.

Diabetic peripheral neuropathy (DPN), peripheral artery disease (PAD), and foot deformity are the most common causes of diabetic foot, which can considerably worsen the patient's quality of life. In this study, we aimed to investigate the prevalence and risk factors associated with DPN, PAD, and foot deformity among patients with diabetes living in Beijing, China. In total, 3,898 diabetes patients from 11 hospitals in Beijing were evaluated using questionnaires and physical examinations, and 3,758 patients were included in the analysis. We compared the demographic, clinical, biological characteristics, and comorbidities of patients with and without DPN, PAD, or foot deformity, and used binary logistic regression analysis to identify potential factors associated with these outcomes. Overall, 882 patients (23.5%) had DPN, 437 patients (11.6%) had PAD, and 1,117 patients (29.7%) had foot deformities, including callus. The risk factors for DPN included: age ≥40 years, a ≥10+year duration of diabetes, a body mass index of <18.5 kg/m2 or ≥24 kg/m2, a systolic blood pressure (SBP) of ≥140 mm Hg, a hemoglobin A1c (HbA1c) level of ≥7%, chronic kidney disease, and cerebrovascular disease. The risk factors for PAD included: a 15+ year diabetes duration, a body mass index of <18.5 kg/m2, a SBP of ≥140 mm Hg, a HbA1c level of ≥7%, chronic kidney disease, coronary heart disease, and cerebrovascular disease. The risk factors for skeletal foot deformities included: women, age ≥40 years, a SBP ≥140 mm Hg, and hyperlipidemia. The risk factors for callus formation included: women, a SBP ≥140 mm Hg, and hyperlipidemia. In conclusion, the prevalence of foot deformities was higher than DPN and PAD in patients with diabetes. Managing the risk factors for DPN, PAD, and foot deformity is important for reducing the risk of diabetic foot.

Caracterización y resultados del manejo de úlceras en pie diabético en una institución terciaria / Characterization and results of the management of diabetic foot ulcers in a tertiary institution

Antecedentes: La diabetes mellitus causa complica- ciones importantes, entre estas el pie diabético que se asocia a mayor riesgo de morbilidad y mortalidad. Objetivo: Describir las características y resultados del manejo de úlceras en pacientes con pie diabético de una institución terciaria. Métodos: Estudio retrospectivo descriptivo, llevado a cabo en Hospital de Especia- lidades, Instituto Hondureño de Seguridad Social, abril 2018-abril 2020. Se revisaron expedientes clínicos de pacientes con diag- nóstico de pie diabético. Resultados: La edad promedio de los pacientes fue 62.9 años, con una desviación estándar (DE) (+/- 10.8); de predominio masculino 77.5% (55/71). Un 79.0% (56/71) tenía antecedentes de más de 10 años de diagnóstico de diabe- tes mellitus tipo II. Según clasificación de Wagner fue Grado 3 en 50.7% (36/71). El 69.0% (49/71) presentaron una úlcera en región plantar pie izquierdo. El manejo fue con apósitos impregnados con solución de factor de crecimiento epidérmico y aceite ozonizado en 43.7% (31/71); los antibióticos administrados fueron clindamicina 71.8% (51/71) y ceftriaxone 55.7% (41/71). El número de desbrida- mientos fue entre 1-2 en 49.3% (35/71) y el número de curaciones realizadas entre 6-10 en 38.0% (27/71). El resultado terapéutico fue cierre total de la úlcera en 33.8% (24/71) y las complicaciones (amputación/infección) se presentaron en 16.9% (12/71). No se reportó mortalidad. Discusión: El paciente con diagnóstico de pie diabético es manejado en la institución con desbridamientos, cu- raciones y antibioticoterapia, logrando cierre total de la ulceración en un tercio de los casos, algunos casos se complican y finalizan en amputación, similares resultados reportado por otros autores...(AU)

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

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

Effects of idiopathic flatfoot deformity on knee adduction moments during walking.

INTRODUCTION: Flatfoot deformity is commonly characterized by a subtalar valgus, a low medial longitudinal arch, and abduction of the forefoot. Although flatfoot deformity has been associated with lower first (KAM1) and second (KAM2) peak knee adduction moments during walking, the biomechanical connection remains unknown. RESEARCH QUESTION: We hypothesized that hindfoot eversion, lateral calcaneal shift correlate with KAM1 and forefoot abduction and arch height with KAM2, due to the lateralization of the ground reaction force vector resulting from shifted heel and forefoot in flatfoot deformity. METHODS: Gait data from 103 children with flatfoot deformity who underwent three-dimensional gait analysis with the Oxford Foot Model were retrospectively included. Children with knee varus/valgus, in- and out-toeing were excluded. Fifteen healthy children with a rectus foot type were also collected from the database. Lateral calcaneal shift was defined as the distance between the projection of the ankle joint center onto the calcaneal axis and the midpoint of the calcaneal axis formed by the medial and lateral calcaneal markers. A subgroup of children with idiopathic flatfoot deformity that had received corrective surgery was also identified. Statistical analysis included Pearson's correlations and independent and paired t-tests (α < .05). RESULTS: When compared to a norm cohort, flatfooted children had significant lower KAM1 and KAM2 (t-test, P < .001). Lateral calcaneal shift correlated with KAM1 and KAM2 (r = 0.42, p < .001 and r = 0.32, P < .001, respectively). Arch height correlated with KAM2 (r = 0.23, p = 0.017). KAM1 and KAM2 normalized after surgery and the change in KAM1 correlated with the change in lateral calcaneal shift for children who underwent corrective surgery. SIGNIFICANCE: Lateral calcaneal shift explains the reduction of KAM1 by lateralization of the point of force application in flatfooted children. It is recommended to consider the lateral calcaneal shift when investigating KAM in gait analysis research.

Complex foot deformities associated with lower limb deformities: a new therapeutic strategy for simultaneous correction using Ilizarov procedure together with osteotomy and soft tissue release.

AIM: The aim of the current study is to introduce a new therapeutic strategy for simultaneous correction of complex foot deformities (CFD) and the associated lower limb deformities (LLD) by using Ilizarov technique with osteotomy and soft tissue procedure and to report its early clinical results. METHODS: A retrospective review of CFD associated with LLD simultaneous correction utilizing the Ilizarov procedure together with osteotomy and soft tissue balance from 2015 to 2019 was conducted. RESULTS: Thirty-two patients were followed for an average of 42.8 months. The mean external fixation time (EFT) was 6.5 months. The mean healing index (HI) was 1.7 months/cm. At the time of fixator removal, plantigrade feet were achieved in all patient and lower limb deformities were corrected. No recurrence of the deformities occurred. The mean LLRS AIM score was improved from 7.5 to 0.3. At the final follow-up, the ASAMI-Paley score was graded as excellent in all limbs in the aspect of bone results, and functional results were defined as excellent in 29 (90.6%) limbs and good in 3 (9.4%) limbs. The mean modified Dimeglio score was significantly improved from 7.2 to 1.3. No deep infection of the osteotomy site or nonunion was noted in the current study. CONCLUSION: The therapeutic strategy by using the Ilizarov procedure together with osteotomy and soft tissue balance is a safe and effective way to simultaneously correct CFD and LLD. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Research on lower extremity health in patients with multiple sclerosis: a systematic scoping review.

BACKGROUND: Multiple sclerosis (MS) often affects ambulation and the function of the lower limbs. However, little is known about how much research has been conducted on lower extremity health in patients with MS. OBJECTIVE: To analyse empirical studies and their evidence on lower extremity health in patients with MS, in order to identify the need for future studies in key areas. METHODS: A systematic scoping review was conducted. A literature search of Medline (PubMed), CINAHL (EBSCO) and the Cochrane Library databases was performed. The search covered the period up to 15 January 2020 from the earliest records available. This led to the inclusion of 42 empirical articles. The data were analysed using content analysis and quantification techniques. RESULTS: The research on lower extremity health focused primarily on two main areas: gait and lower extremity muscle strength. Lower extremity health was assessed using a variety of methods, most of which consisted of objective physical tests and gait analysis. Patients with MS had many problems with the health of their lower extremities, which manifested in walking difficulties, balance problems, muscle weaknesses and spasticity. In the feet, pes cavus, claw toes, oedema and altered foot sensation were common. CONCLUSIONS: MS affects lower limb and foot health, and these problems can affect patients' daily lives. However, the extent of these problems is poorly understood, partly due to the dearth of research on lower limb and foot health. Therefore, further research is warranted in order to better understand the impact of MS on foot and lower limb health in everyday life.

Alteraciones podológicas en el síndrome de Ehlers-Danlos / Podiatry alterations in Ehlers-Danlos syndrome

ANTECEDENTES Y OBJETIVO: En este trabajo se pretende describir el tipo de pie y las alteraciones podológicas más frecuentes, el nivel de dolor, la discapacidad, la fatiga y la alteración de la calidad de vida que presentan los pacientes con síndrome de Ehlers-Danlos (SED). MATERIALES Y MÉTODOS: Treinta y ocho individuos con SED tipo hipermóvil o clásico fueron reclutados. Se registró el porcentaje de dolor en el pie y las deformidades, y se les aplicaron distintos cuestionarios. El tipo de pie se clasificó según la huella y el Foot Posture Index. RESULTADOS: Se registra un alto grado de dolor, discapacidad, intensidad de la fatiga y bajo nivel de calidad de vida en estos pacientes. Según la huella el 20% presentó pies planos, el 47% pies normales y el 33% pies cavos. CONCLUSIONES: Los participantes en este estudio presentaron un alto porcentaje de problemas podológicos, altos niveles de dolor y limitación de la funcionalidad en los pies. La calidad de vida de estos pacientes aparece disminuida. Se han observado tipos de pies según la huella y de deformidades similares a la población general

BACKGROUND AND OBJECTIVE: This paper aims to describe the type of foot and most frequent podiatric alterations, as well as the level of pain, disability, fatigue and alteration of quality of life in patients with Ehlers-Danlos syndrome (EDS). MATERIALS AND METHODS: Thirty-eight individuals with hypermobile or classic EDS participated. The percentage of pain in the foot and deformities was recorded, and several questionnaires were administered. The type of foot was classified according to the footprint and the Foot Posture Index. RESULTS: There was a high degree of pain, disability, intensity of fatigue and low quality of life in these patients. According to the footprint, 20% presented flat feet, 47% normal feet and 33% cavus feet. CONCLUSIONS: The participants in this study had a high percentage of foot problems related to high levels of pain and limited functionality in the feet. The quality of life of these patients appeared diminished. Foot types were observed according to the footprint and deformities similar to those of the general population

Incidence of thyroid disease in patients with forefoot deformity.

BACKGROUND: Hallux valgus and lesser toe deformities are common foot disorders with substantial functional consequences. While the exact etiologies are multi-factorial, it is unknown if certain endocrine abnormalities, such as thyroid dysfunction, may be associated with these pathologies. The current study sought to investigate the prevalence of thyroid disease in patients with hallux valgus or lesser toe deformities. METHODS: Every new patient who presented to our institution's foot and ankle clinic during a three-month time period was given a survey to determine the presence of a known thyroid disorder. The diagnosis for each visit was then recorded. Additionally, a national, publicly available database was queried for patients diagnosed with thyroid disease and concomitant hallux valgus or specific forefoot pathology. Odds ratios for the presence of thyroid dysfunction were then calculated for each patient group. RESULTS: Three-hundred and fifty initial visit patient surveys were collected, and 74 (21.1%) patients had a known diagnosis of thyroid disease. The most common diagnoses were primary hypothyroidism (n = 61, 17.4%), secondary hypothyroidism (n = 6, 1.7%), thyroiditis (n = 4, 1.1%), and hyperthyroidism (n = 3, 0.9%). Thyroid disease was present in 16 of 26 patients (61.5%) with a diagnosis of hallux valgus (OR 7.3, CI[3.16-16.99], p < 0.0001). Lesser toe deformities, including hammertoes, mallet toes, bunionettes and crossover toes, were also significantly associated with thyroid disease (OR 5.45, CI[1.83-16.26], p < 0.002). The national database revealed 905,924 patients with a diagnosis of a specific forefoot deformity, and 321,656 of these patients (35.5%) had a concomitant diagnosis of a thyroid condition (OR 2.11, CI[2.10-2.12], p < 0.0001). CONCLUSIONS: The current study suggests a significant association between forefoot pathology and thyroid dysfunction, especially hallux valgus and lesser toe deformities. Increased understanding of these correlations may offer an important opportunity in population health management, both in diagnosis and treatment. While further studies with long-term outcomes are necessary, the early diagnosis of thyroid disease may provide an opportunity to predict and potentially alter the course of forefoot pathology.

Feet deformities and their close association with postural stability deficits in children aged 10-15 years.

BACKGROUND: Children and young people make up an age group most vulnerable to falls. Various stability disorders may become instrumental in sustaining more frequent falls and resultant fractures. Correct morphological structure impacts overall efficiency of the foot, as well as offers significant diagnostic potential. Even minor foot disorders may affect the entire bio kinematic chain, also impacting the foot's motility. Structural alterations within a foot may also impair balance in the standing position, and contribute to more frequent injuries. The study aimed to assess the relationship between feet deformities and postural stability deficits in schoolchildren prone to sustain accidental falls. METHODS: The study involved 200 children (101 girls and 99 boys) aged 10-15 years, randomly selected from primary schools. A 2D podoscan was used to assess the plantar part of the foot, while stabilometric examination was aided by the FreeMed dynamometric platform. RESULTS: Correlation between respective variables was reflected by Spearman's rank coefficient. The subjects' age negatively correlated with the COP range of movement along the Y axis, and the COP surface area, while their BMI negatively correlated with the COP trajectory's length. Step regression analysis indicated that the width of the left foot, the left foot Wejsflog index, the left foot Clark's angle, the hallux valgus angle were the essential predictors of stabilometric variables in girls. In boys, though, predictive value was associated with Clarke's angle of the left and right foot, Wejsflog index of the right foot, and the width of both the left and right foot. CONCLUSIONS: There is a statistically significant correlation between morphological variables of the foot and postural stability. When assessing the key variables of the foot and their interrelationship with postural stability, the Clarke's angle, Wejsflog index, hallux valgus angle, and foot width, should be granted due prominence in the girls. As regards the boys, the following variables were established as predictive in assessing postural stability: Clarke's angle, Wejsflog index, and foot width.

Brachymetatarsia: One-stage Versus Two-Stage Procedures.

Brachymetatarsia is a rare deformity with controversial clinical presentation. Multiple acute and gradual lengthening surgical techniques have been described for correction of this type of foot deformity. All techniques try to create a better appearance, facilitate shoeing, or solve possible transfer metatarsalgia. Either acute lengthening (1-stage procedure) or gradual lengthening (2 stages) is selected based on the patient's deformities, concerns, and clinical needs.

Lesser Metatarsophalangeal Joint Instability: Treatment with Tendon Transfers.

Complex digital deformities and metatarsophalangeal joint instability encompass a wide range of pathology, and we must identify the different degrees of ligamentous disruption. It is important to address a combination of procedures to treat gross deformities of the lesser toes. Surgical treatment should be individualized and requires a sequential process for adequate reduction and deformity correction. There is no gold standard procedure for every deformity. Although residual stiffness can result from tendon transfer, overall patient satisfaction levels remain high when it is performed under the proper indications and concomitantly with other procedures to gain full correction of these challenging deformities.

Stress Fracture of the Fifth Metatarsal in Foot Deformity Secondary to Neuromuscular Disease: Experiences of Deformity Correction Treatment-A Report of 3 Cases and Review of the Literature.

Fractures at the proximal metaphyso-diaphyseal junction of the fifth metatarsal are associated with high rates of delayed union. When these fractures are the result of repeated stress in patients with equinovarus hindfoot, which in turn is caused by neurological disorders, delayed union is the rule. Therefore, in neurological patients with stress fractures, optimal treatment would be to achieve a plantigrade foot enabling them to relieve the fifth metatarsal overload, which prevents the consolidation. We report 3 cases of fifth metatarsal stress fracture resulting from an equinovarus hindfoot deformity caused by a neuromuscular disease. Our surgical indication was to correct the foot deformity with no direct action on the fracture. Once a good alignment (plantigrade foot) was obtained, stress causing the fracture disappeared, and union was achieved with optimal biomechanical function in all 3 fractures. When stress fracture of the fifth metatarsal is caused by a secondary foot deformity, treating the deformity can lead to healing the fracture efficiently and should be considered prior to indicating surgical stabilization of the fracture itself. Primary treatment of the fracture with no correction of the deformity leads to therapeutic failure. LEVELS OF EVIDENCE: Therapeutic, Level IV.

What's New in the Management of Foot Deformities in Children With Cerebral Palsy.

BACKGROUND: Foot deformities have been frequently reported in cerebral palsy (CP), and numerous diagnostic modalities and treatment options have recently been developed to achieve a better level of management for children with CP. METHODS: A thorough search of the English literature, published between January 2013 and March 2016, was performed. A summary of the new findings that had not previously described was reported. The review included recent advances regarding clinical and gait evaluation, orthotic management, botulinum toxin A treatment, and surgical correction. RESULTS: The review summarized new findings reported in 46 articles and abstracts that were published between January 2013 and March 2016. Older articles were included and cited when an original description was mentioned, or when a change or development of some findings was discussed. CONCLUSIONS: Foot deformity forms an essential part of evaluating children with CP. Dramatic advances have been achieved in gait assessment, conservative management, and surgical correction. Promising results have been reported with the goal to reach a higher level of orthopaedic care and optimize the functional potentials for children with CP. LEVEL OF EVIDENCE: Level IV-literature review.

A podoscopic and descriptive study of foot deformities in patients with Down syndrome.

INTRODUCTION: Subjects with Down syndrome (DS) are known to be affected by various foot deformities. Despite the fact that some of these deformities have been reported in the literature, a more comprehensive description would be of benefit. The aim of this study is to investigate the prevalence of known foot deformities in patients with DS and of other previously non-described foot anomalies in this population. HYPOTHESIS: Subjects with DS have an increased prevalence of foot deformities compared to control subjects. METHODS: Fifty-five subjects with DS (age: 14.6±7.4 years) had undergone podiatric clinical and podoscopic examinations to study their main foot deformities and their footprints, respectively. The results of these examinations were compared to those of an age-matched asymptomatic control group of fifty-three subjects (age: 13.4±11.2 years). RESULTS: Significantly more prevalent foot deformities were found in the DS group: hallux valgus (36.4%), syndactyly between the 2nd and 3rd toes (9.1%), grade II pes planus (39.1%) and grade III pes planus (30%). Moreover, joint laxity (43.6%) was significantly more prevalent in the DS group. Furthermore, the presence of an increased space between the 1st and 2nd toes in patients with DS and its prevalence (73.6%) were described for the first time. A multivariate analysis revealed a significant relationship between the presence of joint laxity and flatfoot in only the control but not the DS group. Other foot deformities were found to be consistently more frequent in the DS population but not significantly higher than the control group. DISCUSSION: Although subjects with DS had significantly greater joint laxity and BMI compared to the control group, neither of these factors was found to be related to the increased prevalence of flatfoot in DS patients. LEVEL OF EVIDENCE: IV-retrospective study.