The Diagnostic Capacity of Physical Examinations in Diagnosing Musculoskeletal Disorders of the Lower Limbs in Children with Down Syndrome.

Background and Objectives: although musculoskeletal alterations are common in patients with Down syndrome (DS), studies investigating this association are scarce, and proposals for diagnostic standardization are limited. We aimed to evaluate the prevalence of musculoskeletal disorders in the lower limbs in a sample of children and adolescents with DS and to investigate the diagnostic capacity of orthopedic clinical examinations performed by orthopedists and pediatricians to diagnose these alterations. Materials and Methods: Twenty-two patients aged between three and ten years with DS were included. Patients and guardians answered a simple questionnaire regarding orthopedic complaints and underwent a systematic orthopedic physical examination, performed twice: once by an orthopedist and again by a pediatrician. Patients underwent a series of radiographs to diagnose anisomelia, hip dysplasia, epiphysiolysis, flatfoot valgus, mechanical axis varus, and mechanical axis valgus. The radiological diagnosis was considered the gold standard, and the diagnostic capacity of the physical examination performed by each physician was determined. Results: The median age was 6.50 years. Only four patients (18.2%) presented with orthopedic complaints. All patients were diagnosed with at least one musculoskeletal disorder. The only musculoskeletal disorder with a good diagnostic capacity was flatfoot valgus. Limited sensitivity values were found for hip dysplasia, mechanical axis varus, and mechanical axis valgus. The agreement between the orthopedic physical examinations performed by the two examiners was weak, poor, or indeterminate for most of the analyzed items. Conclusions: There was a high prevalence of orthopedic alterations in children with DS who did not present with musculoskeletal complaints. The diagnostic capacity of the physical examination was limited. Therefore, all children with DS should undergo a radiological evaluation of the musculoskeletal system and subsequent specialized orthopedic evaluation. Level of Evidence: Level II (Diagnostic Studies).

The Potential of Endoscopic Spring Ligament Repair in Flatfoot Reconstruction.

BACKGROUND: Spring ligament fulfills 2 main important functions: one, supporting the head of the talus and stabilizing the talonavicular joint, and the other, maintaining the longitudinal arch by acting as a static support. In this preliminary report, we describe an endoscopic repair for spring ligament injuries with modified portals. METHODS: We performed a retrospective case series study from February 2019 to January 2022. Posterior tibial tendon and/or associated bone deformities were assessed at the same surgical procedure. All patients were ≥18 years old and they had more than 6 months of follow-up. The procedure was performed in 11 patients. Mean age was 46 years (range 18-63). Ten had concomitant bony realignment surgery, and 8 had posterior tibial tendon surgery. RESULTS: In all patients, endoscopic spring ligament repair could be technically done. The modified portals were used in all procedures as described in the surgical technique. Three patients had a superficial lesion, 1 had a rupture <5 mm, 7 had a rupture >5 mm but not a complete rupture through the entire spring ligament. Most of the patients had good clinical results from the surgery that included endoscopic spring ligament debridement and/or repair at 2 years follow up. CONCLUSION: In this small series we found that endoscopy may be an effective technique to diagnose and treat incomplete spring ligament injuries. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Osteotomía de Evans sin injerto óseo en el pie plano estadio IIB del adulto / Evans osteotomy without bone graft in stage IIB adult flatfoot deformity

Objetivo: Evaluar los resultados radiográficos y funcionales al año de la cirugía, en una serie consecutiva de pacientes con diagnóstico de pie plano valgo estadio IIB, sometidos a una osteotomía de Evans sin injerto óseo. Materiales y Métodos: Se evaluó, en forma retrospectiva, a dos grupos de pacientes: grupo 1 (placa con espaciador, n = 12) y grupo 2 (celdas de PEEK, n = 14). La edad promedio era de 47 años (DE 18) en el grupo 1 y de 54 años (DE 12) en el grupo 2. Resultados:Se evaluó a 26 pacientes (28 pies operados); 20 (77%) eran mujeres. Las mediciones radiográficas: ángulo de inclinación del calcáneo, ángulo astrágalo-calcáneo (perfil), ángulo astrágalo-calcáneo (frente), cobertura astragalonavicular, altura de la columna medial, longitud de la columna externa, arrojaron diferencias estadísticamente significativas entre las determinaciones preoperatorias y al año de la cirugía. El puntaje promedio de la escala de la AOFAS al año fue de 96 (DE 4,70) en el grupo 1 y de 95 (DE 4,98) en el grupo 2. El puntaje en la escala analógica visual para dolor fue de 1,2 (DE 0,42) en el grupo 1 y 1,16 (DE 0,46) en el grupo 2.Conclusiones:De acuerdo con los resultados obtenidos, concluimos en que la osteotomía de Evans sin el uso de injerto óseo logra preservar las correcciones obtenidas en el mediano plazo utilizando placas con espaciador o celdas de PEEK. Nivel de Evidencia: III

Objective: To evaluate the radiological and functional outcomes one year after surgery in a consecutive series of patients diagnosed with stage IIB adult-acquired flatfoot deformity who underwent Evans osteotomy without the use of bone graft. Materials and Methods: Two groups of patients were retrospectively evaluated: group 1 (spacer plate, n=12) and group 2 (PEEK cage, n=14). The mean age was 47 years (SD 18) in group 1 and 54 years (SD 12) in group 2. Results:26 patients (28 feet) were evaluated; 14 (84%) of the patients were women. Radiographic measurements calcaneal pitch angle, (lateral) talocalcaneal angle, (AP) talocal-caneal angle, talonavicular coverage angle, medial column height, lateral column length yielded statistically significant differences between preoperative measurements and those taken one year after surgery. The mean score on the AOFAS scale one year after surgery was 96 (SD 4.70) in group 1 and 95 (SD 4.98) in group 2. Regarding the visual analog scale, it was 1.2 (SD 0.42) in group 1 and 1.16 (SD 0.46) in group 2. Conclusions: According to the results obtained, we conclude that Evans osteotomy without the use of bone graft manages to preserve the corrections obtained in the medium term, using either spacer plates or PEEK cages. Level of Evidence: III

Seguridad de los portales para la reparación endoscópica del ligamento calcaneonavicular: estudio cadavérico / Endoscopic Spring ligament repair. Anatomic evaluation of portal safety

Introducción: La lesión del ligamento calcaneonavicular ha sido descrita como una de las causas de la deformidad en el pie plano del adulto. El objetivo de este artículo es describir portales modificados para el diagnóstico y la reparación endoscópica de las lesiones del fascículo superomedial del ligamento calcaneonavicular y evaluar la seguridad de los portales utilizados. Materiales y Métodos:Se llevó a cabo un estudio cadavérico con seis preparados reproduciendo una lesión del fascículo superomedial del ligamento calcaneonavicular con una punta de corte de radiofrecuencia y la posterior reparación endoscópica. Se crearon dos portales modificados para el abordaje. Luego se procedió a la disección anatómica para evaluar la seguridad de los portales en relación con las estructuras anatómicas. El primer portal se realiza inmediatamente proximal a una línea trazada desde la punta del maléolo medial dirigida al centro del talón, el segundo portal se emplaza 0,5 cm proximal a la inserción del tendón tibial posterior en el escafoides por transiluminación. Si es necesario, se coloca un portal accesorio inmediatamente dorsal al tendón tibial posterior a mitad de camino entre los dos portales antes descritos. Resultados:En todos los casos, fue posible la reparación del ligamento con el procedimiento endoscópico. En la disección anatómica de los portales, se observó una distancia promedio a las estructuras vasculonerviosas de 11,83 mm del portal proximal y de 9,66 mm del portal distal. Conclusión: Los portales modificados son seguros y permiten la visualización directa del haz superomedial del ligamento calcaneonavicular y su reparación endoscópica. Nivel de Evidencia: IV

Introduction: Calcaneonavicular ligament injury has been described as a cause of adult flat foot deformity. The objective of this study is to describe modified portals for the diagnosis and treatment of injuries to the superomedial bundle of the calcaneonavicular ligament and to evaluate the safety of the portals used. Materials and Methods: We performed a cadaveric specimen study on 6 feet, where we reproduced a lesion of the superomedial bundle of the calcaneonavicular ligament with a radiofrequency ablation device and repaired it endoscopically. Two modified portals were created for the approach and an anatomical dissection was performed to assess the safety of the portals in relation to the anatomical structures. The first portal was placed immediately proximal to a line drawn from the tip of the medial malleolus toward the center of the heel; the second portal was placed 0.5 cm proximal to the posterior tibial tendon insertion into the navicular bone, guided by transillumination. If needed, an accessory portal was placed halfway between the two previously described portals immediately dorsal to the posterior tibial tendon. Results:In all cases, ligament repair was achieved with the endoscopic procedure. In the anatomical dissection of the portals, we observed an average distance of 11.83 mm from the proximal portal and 9.66 mm from the distal portal to neurovascular structures. Conclusion:Modified portals are safe and allow direct visualization of the superomedial bundle of the calcaneonavicular ligament to perform endoscopic repair. Level of Evidence: IV

[Lateral osteotomy of the calcaneus in the treatment of Müller-Weiss disease]. / Osteotomía lateral de calcáneo en el tratamiento de la enfermedad de Müller-Weiss.

INTRODUCTION: The deforming condition of the navicular bone known as Müller-Weiss disease (MWD) is a rare disease. Patients present with chronic pain in the talonavicular joint and a paradoxical flat foot with a varo hindfoot. OBJECTIVE: To analyze the clinical results of a lateral osteotomy of calcaneus applied to patients with MWD. MATERIAL AND METHODS: Retrospective observational study carried out in two hospitals. The series consists of nine cases in eight patients, all of them with symptomatic Müller-Weiss disease, treated by lateral osteotomy of the calcaneus between 2012 and 2017, obtaining an average follow-up of 4 years (2-6). The mean age was 62 years (50-75). In all patients, Costa-Bartani angles (CB), Kite angle and Calcaneal Inclination (CI) were measured. In addition, the Manchester Oxford Scale (MO) to measure the post-surgical satisfaction of patients. RESULTS: All patients report having improved their pain by obtaining a postoperative score on the mean Manchester Oxford scale of 32.54 points (15.62-53.75). In 66% of patients the CB angle improves, the Kite angle in 89% and the CI in 33%. CONCLUSION: The improvement in the pain of the patients in our series is not accompanied by radiological changes in the same proportion, it is a simple and uncomplicated technique in our follow-up.

INTRODUCCIÓN: La afección deformante del hueso navicular conocida como enfermedad de Müller-Weiss (EMW) es una enfermedad rara. Los pacientes presentan dolor crónico en la articulación talonavicular y un pie plano paradójico con retropié varo. OBJETIVO: Analizar los resultados clínicos de la osteotomía valguizante de calcáneo aplicada a pacientes con EMW. MATERIAL Y MÉTODOS: Estudio observacional, retrospectivo, realizado en dos centros hospitalarios. La serie consta de nueve casos en ocho pacientes, todos ellos con enfermedad de Müller-Weiss sintomática, fueron tratados mediante osteotomía valguizante de calcáneo entre 2012 y 2017, con un seguimiento medio de cuatro años (dos a seis). La edad media fue de 62 años (50-75). En todos los pacientes se midieron los ángulos de Costa-Bartani (CB), el ángulo de Kite y la inclinación calcánea (IC). Además, se utilizó la escala Manchester Oxford (MO) para medir la satisfacción postquirúrgica de los pacientes. RESULTADOS: Todos los pacientes refieren haber mejorado en su dolor, obteniendo una puntuación postoperatoria media de 32.54 puntos (15.62-53.75) en la escala Manchester Oxford. En 66% de los pacientes el ángulo CB mejoró, al igual que en el ángulo de Kite en 89% y la IC en 33%. CONCLUSIÓN: La mejoría en el dolor de los pacientes de nuestra serie no está acompañada por cambios radiológicos en la misma proporción, es una técnica sencilla y sin complicaciones en nuestro seguimiento.

Radiographic Outcomes of Talonavicular Joint Arthrodesis With Varying Fixation Techniques in Stage III Adult Acquired Flatfoot Reconstruction.

Utilization of the talonavicular joint (TN) arthrodesis as an isolated procedure or in combination with hindfoot arthrodesis has been described in the literature for treatment of numerous hindfoot conditions. When used in isolation or with concomitant hindfoot arthrodesis, the TN joint has demonstrated nonunion rates reported as high as 37% in the literature. Despite previous research, there remains a lack of agreement upon the ideal fixation technique for TN joint arthrodesis with and without concomitant subtalar joint arthrodesis. The purpose of this study was to retrospectively compare the radiographic and clinical results of TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs in the treatment of advanced hindfoot malalignment in stage III adult-acquired flatfoot deformity. We retrospectively reviewed 105 patients who underwent TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs. Our results demonstrated a nonunion rate of 16.2%, with 17 nonunions identified within our patient population. One (2.4%) nonunion was observed in the 3-screw cohort, 7 (33.3%) nonunions were observed in the 2-screw cohort, 4 (16.0%) nonunions were observed in the 2-screw plus plate cohort, and 5 (29.4%) nonunions were observed in the 1-screw plus plate cohort. The difference in nonunion rate between the 4 cohorts was statistically significant. Based on these results, we conclude that the use of a 3-screw construct for TN joint arthrodesis as part of double arthrodesis procedure demonstrates a statistically significant reduction in nonunion rate and should be considered a superior fixation construct for this procedure.

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

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

Imaging of progressive collapsing foot deformity with emphasis on the role of weightbearing cone beam CT.

The term progressive collapsing foot deformity (PCFD) is currently recommended as the replacement to adult-acquired flatfoot deformity and posterior tibial tendon dysfunction to better reflect its pathology, which consists of a complex three-dimensional deformity involving the foot and ankle. The new consensus has also provided a new classification that requires clinical and radiographic findings for patient stratification into each class. However, conventional radiographs are susceptible to errors resulting from the inadequate positioning of patients, incorrect angulation of the X-ray tube, and overlapping of bone structures. Weightbearing cone beam computed tomography (WBCBCT), which has greater diagnostic accuracy than conventional radiograph, is useful for evaluating progressive collapsing foot deformity to determine medial arch collapse, hindfoot alignment, peritalar subluxation, posterior subtalar joint valgus, intrinsic talus valgus, and lateral extra-articular bone impingement. The present review aimed to discuss the new recommendations for nomenclature, classification, and imaging evaluation of PCFD, with an illustrative and quantitative focus on the measurements used in conventional radiography and WBCBCT. The measurements presented here are important criteria for decision-making.

[Acquired flat foot of the adult by posterior tibial dysfunction. Options for surgical treatment]. / Pie plano adquirido del adulto por disfunción del tibial posterior. Opciones para el tratamiento quirúrgico.

We present the possible etiopatogenic causes of posterior tibial dysfunction or painful flat foot of the adult and the cause-and-effect relationship that may exist. We also expose the gradation of the lesion and the different therapeutic options for the surgical treatment of the deformity. Since 1939, multiple articles have been published, which have been endorsed by clinical, experimental, electromyographic and biomechanical studies; publications that have been consulted and evaluated for the development of this review. In our opinion: the dysfunction of the posterior tibial is caused in principle by a failure of the plantar navicular calcaneus ligament (spring ligament), the main passive stabilizer of the internal plantar arch. This failure would, in time, mean an increase in work of the posterior tibial tendon, in itself "insufficient", which would go into fatigue, until it reached a partial or total rupture. Published work on soft-part procedures acting on the posterior tibial tendon in stage II has not had the expected result in the natural history of deformity. Arthrodesis, on the other hand, has been effective in other stages, but is associated with a loss of movement dynamics in the back foot and increased pressure on adjacent joints.

Presentamos la posible causa etiopatogénica de la disfunción del tibial posterior o pie plano doloroso del adulto y la relación causa-efecto que puede existir. También exponemos la clasificación de la lesión y las diferentes opciones para el tratamiento quirúrgico de la deformidad. Desde 1939, múltiples artículos han sido publicados, avalados por la clínica, así como por estudios experimentales, electromiográficos y biomecánicos; publicaciones consultadas y evaluadas para el desarrollo de esta revisión, según nuestro criterio: el primum movens de la disfunción del tibial posterior es ocasionado por un fallo del ligamento en hamaca o calcáneo navicular plantar (spring ligament), principal estabilizador pasivo del arco plantar interno. Este fallo supondría en el tiempo un aumento de trabajo del tendón tibial posterior, de por sí "insuficiente", que entraría en fatiga hasta llegar a la rotura parcial o total. Los trabajos publicados en relación con los procedimientos de partes blandas que actúan sobre el tendón tibial posterior en el estadio II no han tenido el resultado esperado en la historia natural de la deformidad. La artrodesis por el contrario, ha sido efectiva en otros estadios, pero está asociada a una pérdida de la dinámica del movimiento en el retropié y a un aumento de la presión en las articulaciones adyacentes.

Influence of the medial longitudinal arch of the foot in adult women in ankle isokinetic performance: a cross-sectional study.

BACKGROUND: Maintenance of the medial longitudinal arch (MLA) of the foot is fundamental during functional tasks and disorders can lead to clinical alterations. Studies have demonstrated that deficits in ankle isokinetic performance can predispose an individual to lower limb injuries. OBJECTIVES: To evaluate the muscular performance of cavus, planus, and normal feet by means of torque/body mass and the isokinetic phases, to generate 3D surface map analysis, and to verify whether there is a relationship between MLA height and arch height flexibility with isokinetic performance. METHODS: The sample consisted of 105 healthy adult women, divided into three groups: normal, cavus, and planus. Assessment in concentric mode at 30, 60, and 90 °/s in the dorsiflexion and plantarflexion of the ankle joint were analyzed during the three isokinetic phases (acceleration, sustained velocity, and deceleration). The variables total range of motion, peak of torque (PT), and angle of PT were extracted within the sustained velocity. RESULTS: In dorsiflexion at 60 °/s, the phase where the velocicty is sustained (load range phase) was higher in the planus group (MeanDifference=10.9 %; ω2p = 0.06) when compared with the cavus group. Deficits in the peak torque/body mass in dorsiflexion at 60 °/s (cavus feet: MD=-3 N.m/kg; ω2p = 0.06; and planus feet: MD=-1.1 N.m/kg; ω2p = 0.06) were also observed as well as in the 3D surface maps, when compared with the normal group. The flexibility of MLA had a negative correlation of PT at 30 °/s in cavus group. The heigth of MLA had a postive correlation with the PT for the cavus and planus group ate 60 °/s. All other results did not show differences between the groups. CONCLUSIONS: The planus groups showed a better capacity of attain and sustained the velocity in dorsiflexion in relation the cavus group. The cavus and planus group had deficts in torque in relation the normal. The correlations were weak between the measures of MLA and PT. Thereby, in general the differences between foot types showed small effect in isokinetic muscle performance measures of the plantar and dorsi flexores. TRIAL REGISTRATION: Study design was approved by the IRB (#90238618.8.0000.5231).

Double hindfoot arthrodesis using a single-incision medial approach in the correction of adult-acquired flatfoot deformity: a case series.

BACKGROUND: Hindfoot arthrodesis is used in patients with advanced-stage acquired flatfoot, usually associated with degenerative joint disease. The objective of the present study was to evaluate the clinical and radiographic results of hindfoot arthrodesis using the single-incision medial approach. METHODS: A case series of 18 consecutive patients undergoing surgical correction between 2015 and 2018 with hindfoot arthrodesis using the medial approach was evaluated. The clinical assessment used the visual analog pain scale, AOFAS hindfoot score, SF-36, and foot function index. Radiographs and personal satisfaction criteria were also analyzed. RESULTS: All radiographic parameters evaluated showed a significant improvement (p < .05), except the calcaneal pitch. Pain decreased by 5.1 points (p < .001), and the mean final AOFAS score was 72.6. In three feet, a new surgery was required. Two feet developed talar necrosis. None of the cases presented surgical wound dehiscence, and two presented with superficial infection, which was resolved with the use of oral antibiotics. CONCLUSION: Double arthrodesis (subtalar and talonavicular) to correct adult-acquired valgus flatfoot using a medial approach has a low risk of soft tissue complications and presents satisfactory functional results. Avascular necrosis is a serious complication that was present in 11% of cases.

Evaluación comparativa del pie plano en preescolares / Comparative assessment of flatfoot in preschool children

Resumen Introducción: El aumento o la reducción del arco longitudinal medial (ALM) puede afectar funciones esenciales en la biomecánica del pie, con repercusiones en la salud a largo plazo. El objetivo del presente estudio fue determinar la altura del ALM en niños de 3 a 6 años, a través de cinco métodos de análisis de huella para el diagnóstico de pie plano. Métodos: Se realizó un estudio observacional transversal con 367 niños de 3 a 6 años en un municipio del Estado de México. Se llevó a cabo una evaluación postural completa, plantoscopía por medio de la clasificación de Viladot y análisis de la huella en pedigrafía, calculando la altura del ALM mediante el ángulo de Clarke (AC), el índice de Staheli (IS), el índice de Chippaux-Smirak (ICS) y el ángulo gamma (Ag). Resultados: La prevalencia de pie plano utilizando el podoscopio fue del 57.7%. Mediante los ángulos y los índices, la prevalencia fue del 86.9% por IS, del 83.3% por ICS, del 95.9% por AC y del 22.3% por Ag. El Ag fue menos sensible para la detección de pie plano en comparación con el ICS, el IS y el AC. Conclusiones: De acuerdo con los resultados del presente estudio, se propone utilizar métodos de análisis de huella para el diagnóstico de pie plano, además de la valoración clásica con el podoscopio. Se recomienda incluir el diagnóstico y la vigilancia del pie plano en la consulta del niño sano, ya que desde edades tempranas puede detectarse la tendencia en la arquitectura podálica.

Abstract Background: The increase or reduction of the medial longitudinal arch (MLA) can affect essential functions in the foot biomechanics with long-term health consequences. The aim of the present study was to determine the height of the MLA in children from 3 to 6 years of age through five methods of footprint analysis for the diagnosis of flat foot. Methods: A cross-sectional observational study was conducted with 367 children aged 3 to 6 years in a municipality of the State of Mexico. We conducted a complete postural evaluation, plantoscopy by Viladot classification, and footprint analysis calculating the height of the ALM using the Clarke angle (CA), the Staheli index (SI), the Chippaux-Smirak index (CSM), and the gamma angle (gA). Results: The prevalence of flat feet using the podoscope was 57.7%. Through the angles and indexes, the prevalence was 86.9% for SI, 83.3% for CSI, 95.9% for CA, and 22.3% for gA. The gA was less sensitive for flat foot detection compared to CSI, SI and CA. Conclusions: Based on the present results, we propose that footprint analysis should be used for flat foot diagnosis besides the classic evaluation by podoscope. We recommend that flat foot diagnosis and surveillance should be included on in the consultation of the healthy child, as a trend for podalic architecture can be detected from early ages.

Comparative assessment of flatfoot in preschool children.

Background: The increase or reduction of the medial longitudinal arch (MLA) can affect essential functions in the foot biomechanics with long-term health consequences. The aim of the present study was to determine the height of the MLA in children from 3 to 6 years of age through five methods of footprint analysis for the diagnosis of flat foot. Methods: A cross-sectional observational study was conducted with 367 children aged 3 to 6 years in a municipality of the State of Mexico. We conducted a complete postural evaluation, plantoscopy by Viladot classification, and footprint analysis calculating the height of the ALM using the Clarke angle (CA), the Staheli index (SI), the Chippaux-Smirak index (CSM), and the gamma angle (gA). Results: The prevalence of flat feet using the podoscope was 57.7%. Through the angles and indexes, the prevalence was 86.9% for SI, 83.3% for CSI, 95.9% for CA, and 22.3% for gA. The gA was less sensitive for flat foot detection compared to CSI, SI and CA. Conclusions: Based on the present results, we propose that footprint analysis should be used for flat foot diagnosis besides the classic evaluation by podoscope. We recommend that flat foot diagnosis and surveillance should be included on in the consultation of the healthy child, as a trend for podalic architecture can be detected from early ages.

Background: Introducción">El aumento o la reducción del arco longitudinal medial (ALM) puede afectar funciones esenciales en la biomecánica del pie, con repercusiones en la salud a largo plazo. El objetivo del presente estudio fue determinar la altura del ALM en niños de 3 a 6 años, a través de cinco métodos de análisis de huella para el diagnóstico de pie plano. Métodos: Se realizó un estudio observacional transversal con 367 niños de 3 a 6 años en un municipio del Estado de México. Se llevó a cabo una evaluación postural completa, plantoscopía por medio de la clasificación de Viladot y análisis de la huella en pedigrafía, calculando la altura del ALM mediante el ángulo de Clarke (AC), el índice de Staheli (IS), el índice de Chippaux-Smirak (ICS) y el ángulo gamma (Ag). Resultados: La prevalencia de pie plano utilizando el podoscopio fue del 57.7%. Mediante los ángulos y los índices, la prevalencia fue del 86.9% por IS, del 83.3% por ICS, del 95.9% por AC y del 22.3% por Ag. El Ag fue menos sensible para la detección de pie plano en comparación con el ICS, el IS y el AC. Conclusiones: De acuerdo con los resultados del presente estudio, se propone utilizar métodos de análisis de huella para el diagnóstico de pie plano, además de la valoración clásica con el podoscopio. Se recomienda incluir el diagnóstico y la vigilancia del pie plano en la consulta del niño sano, ya que desde edades tempranas puede detectarse la tendencia en la arquitectura podálica.

Finite element analysis of secondary effect of midfoot fusions on the spring ligament in the management of adult acquired flatfoot.

BACKGROUND: Surgical treatment of adult acquired flatfoot deformity can involve arthrodesis of the midfoot to stabilize the medial column. Few experimental studies have assessed the biomechanical effects of these fusions, because of the difficulty of measuring these parameters in cadavers. Our objective was to quantify the biomechanical stress caused by various types of midfoot arthrodesis on the Spring ligament. To date this is not known. METHODS: An innovative finite element model was used to evaluate flatfoot scenarios treated with various combinations of midfoot arthrodesis. All the bones, cartilages and tissues related to adult acquired flatfoot deformity were included, respecting their biomechanical characteristics. The stress changes on the Spring ligament were quantified. Both foot arch lengthening and falling were measured for each of the midfoot arthrodeses evaluated. FINDINGS: Arthrodesis performed for stabilization of the talonavicular joint leads to a higher decrease in stress on the Spring ligament. Talonavicular fusion generated a Spring ligament stress decrease of about 61% with respect to the reference case (without any fusion). However, fusing the naviculocuneiform joints leads to an increase in the stress on the Spring ligament. INTERPRETATION: This important finding has been unknown to date. We advocate caution regarding fusion of the naviculocuneiform joint as it leads to increased stresses across the Spring ligament and therefore accelerates the development of planovalgus.

Posterior Tibial Tendon Allograft Reconstruction for Stage II Adult Acquired Flatfoot: A Case Series.

Surgical treatment for a stage II adult acquired flatfoot has consisted of reconstruction of the diseased posterior tibial tendon with flexor digitorum longus tendon transfer, combined with osteotomies to address the underlying deformity. This case series presents an alternative to tendon transfer using allograft tendon for posterior tibial tendon reconstruction. Four patients who underwent stage II flatfoot reconstruction with posterior tibial tendon allograft transplantation were included. All patients had preoperative radiographs demonstrating flatfoot deformity and magnetic resonance imaging showing advanced tendinopathy of the posterior tibial tendon. Allograft tendon transplant was considered in patients demonstrating adequate posterior tibial tendon excursion during intraoperative assessment. Additional procedures were performed as necessary depending on patient pathology. Postoperatively, all patients remained non-weightbearing in a short leg cast for 6 weeks. Radiographs performed during the postoperative course demonstrated well-maintained and improved alignment. No complications were encountered. Each patient demonstrated grade 5 muscle strength and were able to perform a single-limb heel rise at the time of final follow-up. The average follow-up duration was 19.0 months. Flexor digitorum longus transfer has been studied extensively for stage II adult acquired flatfoot. However, the flexor digitorum longus has been shown to be much weaker relative to the posterior tibial tendon, and concern remains regarding its ability to recreate the force of the posterior tibial tendon. Our results demonstrate that posterior tibial tendon allograft reconstruction combined with flatfoot reconstruction is a reasonable option. This alternative has the advantage of preserving the stronger muscle without disturbing regional anatomy.

Analysis of biomechanical stresses caused by hindfoot joint arthrodesis in the treatment of adult acquired flatfoot deformity: A finite element study.

BACKGROUND: Treatments of adult acquired flatfoot deformity in early stages (I-IIa-IIb) are focused on strengthening tendons, in isolation or combined with osteotomies, but in stage III, rigidity of foot deformity requires more restrictive procedures such as hindfoot joint arthrodesis. Few experimental studies have assessed the biomechanical effects of these treatments, because of the difficulty of measuring these parameters in cadavers. Our objective was to quantify the biomechanical stress caused by both isolated hindfoot arthrodesis and triple arthrodesis on the main tissues that support the plantar arch. METHODS: An innovative finite element model was used to evaluate some flatfoot scenarios treated with isolated hindfoot arthrodesis and triple arthrodesis. RESULTS AND CONCLUSIONS: When arthrodeses are done in situ, talonavicular seems a good option, possible superior to subtalar and at least equivalent to triple. Calcaneocuboid arthrodesis reduces significantly both fascia plantar and spring ligament stresses but concentrates higher stresses around the fused joint.

Prevalência e fatores associados à Síndrome da dor Patelofemoral em escolares de Natal/RN / Prevalence and factors associated with Patellofemoral pain syndrome in schoolchildren from Natal/RN

Objetivo: Estimar a prevalência e analisar os fatores relacionados à Síndrome da dor Patelofemoral (SDPF) em escolares de ambos os sexos, entre 10 e 18 anos, matriculados no ensino público fundamental e médio do município de Natal/RN. Métodos: A pesquisa teve caráter exploratório descritivo, transversal e quantitativo realizada no município de Natal-RN. Foi avaliada a presença da SDPF, o nível de atividade física, a qualidade do movimento, o índice de massa corporal (IMC), o tipo de pé, o nível de dor e o comprometimento funcional. As prevalências foram calculadas a partir do desenho complexo de amostragem com a inclusão dos pesos e efeitos de cluster. Para a análise de associação, foram calculadas as Razões de Prevalência (RP) ajustadas e os respectivos intervalos de confiança (95%) do desfecho em relação às variáveis independentes e adotado um nível de significância de 5%. Resultados: Participaram da pesquisa 144 escolares, 51,4 % (IC:41,6 ­ 61,1) da amostra tem o sexo masculino. Foi observada uma prevalência de 29,7% (IC:21,5 ­ 39,4) da SDPF. No modelo ajustado a SDPF foi mais prevalente no sexo feminino (p = 0,02) (RP: 1,82 IC: 1,0 ­ 3,0), nos indivíduos ativos (p = 0,02) (RP:2,3 IC: 1,13 ­ 4,9), nos jovens abaixo do peso (p = 0,03) (RP: 1,9 IC:1,0 ­ 3,6). Quando avaliados por sexo, os homens apresentaram uma associação positiva entre a pobre qualidade do movimento do membro direito (p: 0,01) (RP: 6,0 IC: 1,3 ­ 26) e o desfecho e o sexo feminino obteve uma associação com a presença do valgo dinâmico do joelho esquerdo (p: 0,03) (RP: 2,4 IC:1,0 ­ 5,8). Conclusões: A prevalência da SDPF foi maior no sexo feminino, em jovens ativos, e com baixo peso, ao mesmo tempo, a pobre qualidade do movimento foi associada aos jovens homens com a síndrome e a presença do valgo dinâmico do joelho nas jovens (AU).

Objective: To estimate the prevalence and analysis the factors related to patellofemoral pain syndrome (PFPS) in schoolchildren of both genders, between 10 and 18 years old, enrolled in public elementary and high school in the city of Natal / RN. Methods: The research had an exploratory, descriptive, transversal, and quantitative character carried out in the city of NatalRN. The presence of PFPS was evaluated, as well as the level of physical activity through IPAQ, the quality of movement, body mass index, navicular drop test, pain level and Kujala questionnaire. The prevalence was calculated from the complex sampling design with the inclusion of weights and cluster effects. For an association analysis, adjusted Prevalence Ratios (PR) and the confidence intervals (95%) of the outcome in relation to the independent variables were calculated and a significance level of 5% was adopted. Results: 144 students participated in the research, 51.4% (CI: 41.6 - 61.1) of the sample is male. A prevalence of 29.7% (CI: 21.5 - 39.4) of PFPS was observed. In the adapted model, the PFPS was more prevalent in females (p = 0.02) (PR: 1.82 CI: 1.0 - 3.0), in physical active (p = 0.02) (PR: 2, 3 CI: 1.13 - 4.9), in underweight youth (p = 0.03) (PR: 1.9 CI: 1.0 - 3.6). When obtained by sex, men associated a positive association between poor quality of movement of the right limb (p: 0.01) (PR: 6.0 CI: 1.3 - 26) and the outcome and the female sex obtained an association with the presence of the dynamic valgus of the left knee (p: 0.03) (PR: 2.4 CI: 1.0 - 5.8). Conclusions: The prevalence of PFPS was higher in females, in active young people, and with low weight, at the same time, the poor quality of movement associated with young male people with the syndrome and the presence of dynamic knee valgus in young women (AU).