Foot deformities in rheumatoid arthritis and relevance of foot function index

The aim of this study were to assess what type of foot deformities are found in rheumatoid arthritis (RA) patients, to detect frequency of deformities, and to evaluate deformities affecting Foot Function Index (FFI) and patient functional capacity. Anteroposterior and lateral weight-bearing radiographs of 156 feet of 78 patients who had RA for > or =2 years and of 76 feet of 38 healthy controls were studied. We measured hallux valgus angle, intermetatarsal angle between first and second (M1/2) and intermetatarsal angle between first and fifth (M1/5) on anteroposterior radiographs, and calcaneal pitch on the lateral radiographs. We examined the feet of all RA patients and healthy controls for hallux rigidus, cock-up deformity, clawing toe, and mallet finger, and measured calcaneal valgus angle. FFI, comprised of pain, disability, and activity limitation subscales, was administered to all RA patients. Their Steinbrocker Functional Class (SFC) and Health Assessment Questionnaire (HAQ) scores were determined. We determined frequency of deformities as 96.2% in RA patients and 97.4% in controls by radiological and physical examination (p>0.05). The frequency of each deformity was markedly increased in RA patients, with the exception of calcaneal valgus deformity. There was significant correlation between SFC and HAQ with FFI and subscales (respectively, r=0.46, p=0.001; r=0.67, p=0.001). For FFI and subscales, HAQ was the most important predictor factor, followed by gender and hallux rigidus. Foot deformities are seen very frequently in RA. These deformities may affect patient functional foot, especially hallux rigidus and calcaneal valgus.

Correlation of chronological age and bone age with the correction of ankle valgus by surface epiphysiodesis of the distal medial tibial physis

A review of the results of medial distal tibial surface epiphysiodesis to correct valgus deformity in the growing child indicates that the bone age can be used to predict correction. When performed at the appropriate bone age, it may have some advantage over the use of staples or screws.

The effect of first metatarsophalangeal arthrodesis on transverse plane deviation of the second toe: a retrospective radiographic study

The purpose of this retrospective, radiographic study was to examine the effect of first metatarsophalangeal arthrodesis on the transverse plane deviation of the second metatarsophalangeal joint. Sixty-nine patients (76 feet) were separated into 3 groups based on preoperative diagnosis: group 1, hallux valgus; group 2, hallux rigidus; and group 3, rheumatoid forefoot deformity with concomitant lesser metatarsal head resection. Intermetatarsal, hallux abduction, and second metatarsophalangeal angles were measured on preoperative and follow-up anteroposterior radiographs. Multivariate analysis found a significant postoperative change (P < .001) in both the intermetatarsal and hallux abduction angles for all groups, but no significant change in the second metatarsophalangeal angle for any group. There was also no significant difference in the number of patients with medial versus lateral second toe deviation in each group. The addition of a second ray procedure, such as a digital arthrodesis or second metatarsal decompression osteotomy, in groups 1 and 2 did not correlate to the amount of change in second metatarsophalangeal deviation. However, there was a significant correlation (r = .330; P = .004) between the amount of change in the hallux abduction angle and the amount of change in the second metatarsophalangeal angle. A lack of change in the second metatarsophalangeal angle in patients with hallux valgus and hallux rigidus suggests that the creation of a stable medial buttress may protect the lesser digits. However, in patients with rheumatoid, this lack of change denotes a postoperative recurrence of lateral deviation of the second toe despite lesser metatarsal head resection and stabilization of the hallux.

Correction of cavovarus foot deformity in Charcot-Marie-Tooth disease

Operative correction of cavovarus foot deformity in Charcot-Marie-Tooth disease (CMT) is challenging. This progressive peripheral sensory and motor neuropathy commonly involves the forefoot, midfoot, hindfoot, and toes. The authors present a new imaging technique that allows the surgeon to assess the flexibility of the hindfoot in patients with CMT to determine the best operative procedure to correct the deformity. Twenty-five patients (41 feet) with CMT and cavovarus foot deformity were evaluated and a new radiographic technique was studied in some of these patients to determine the usefulness of this imaging modality. The authors believe that this new imaging method will aid in determining the optimal operation for correcting this complex deformity.

Calcaneal lengthening for planovalgus foot deformity in children with spastic cerebral palsy

The purpose of this study was to evaluate the effectiveness of calcaneal lengthening in the treatment of planovalgus foot deformity of children with spastic cerebral palsy. Sixteen children (27 feet) with spastic cerebral palsy underwent calcaneal lengthening along with peroneal tendons. The results were assessed clinically and radiographically. Over an average of 3.2 years of follow-up (2.0-5.0), 20 (74.1%) feet showed a satisfactory clinical result, and 21 (77.8%) feet showed a satisfactory radiographic result, according to the modified Mosca's criteria. Dependent ambulators with severe pes planovalgus showed unsatisfactory results compared with independent ambulators with mild to moderate pes planovalgus. These findings suggest that for severe pes planovalgus of children with cerebral palsy, it may be difficult to correct the foot deformity by calcaneal lengthening with peroneal tendons.

Lengthening procedures of small bones of foot and foot stump

Foot length discrepancy may result from congenital or acquired causes. If the absence of the foot is more proximal than the metatarsal level, push off and foot resilience will be disturbed and rapid walking and spring will be awkward. Those patients have to be fitted with a prosthesis extending above the ankle to the distal leg. The functional impairment and poor cosmetic appearance become social problems especially for adolescents. Twelve cases underwent a lengthening procedure of small bones of the foot in our clinic since 1995 to lengthen the foot or a foot stump. Results were satisfactory.

Isolated medial column stabilization improves alignment in adult-acquired flatfoot

In some patients with painful flatfoot, realignment and arthrodesis of the medial naviculocuneiform and first tarsometatarsal joints can be done to correct alignment and relieve symptoms. The primary purpose of this radiographic study was to assess the ability of isolated medial column arthrodesis to improve hindfoot alignment. We also assessed the ability of the procedure to correct radiographic parameters of overall foot structure in acquired flatfoot. Preoperative and postoperative radiographs of 19 patients who had naviculocuneiform and/or tarsometatarsal realignment and arthrodesis for adult-acquired flatfoot were examined by two reviewers. All parameters improved, with the lateral talometatarsal angle approaching normal. A decrease in talonavicular subluxation in the axial plane suggests passive improvement in hindfoot position without direct manipulation of any hindfoot bones or joints. These observations provide evidence for a link between stability of the midfoot and alignment of the hindfoot. In carefully selected patients, medial column realignment may restore normal anatomy without fusing essential joints. Modern clinical outcome studies are the next step in the objective evaluation of this procedure.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series-no, or historical, control group) See the Guidelines for Authors for a complete description of levels of evidence.

Tibial lengthening and concomitant foot deformity correction in 14 patients with permanent deformity after poliomyelitis

BACKGROUND

In neuromuscular diseases, limb lengthening and foot deformity correction are associated with a high risk of complications associated with distraction callus and joint contracture. We have found no published articles of tibial lengthening and concomitant foot deformity correction using the Ilizarov method or traditional methods. To compare result of gradual distraction with triple arthrodesis for foot deformity combined with tibial lengthening, we investigated healing index and complications of two methods.

PATIENTS AND METHODS

We reviewed 14 patients with permanent deformity after poliomyelitis who underwent tibial lengthening and concomitant foot deformity correction using the Ilizarov external fixator. Tibial lengthening over an intramedullary nail was performed in 3 patients and lengthening without a nail was performed in 11 patients.

RESULTS

The mean external fixation time was 6 (3.6-10) months without nail and 1.6 (1.5-1.7) months with nail, whereas the mean healing index was 1.8 (0.8-3.1) months/cm without nail and 2 (1.8-2.3) months/cm with nail. Concomitant foot treatments included triple arthrodesis in 7 patients, pantalar arthrodesis in 2 patients with flail ankle, and gradual foot frame distraction without bony foot procedures in 5 patients. Delayed consolidation and recurrent equinus contracture of the ankle requiring additional lengthening of the Achilles tendon were the most common bone and joint complications during tibial lengthening.

INTERPRETATION

The gradual foot frame distraction method was associated with major complications, such as recurrent foot deformity, joint luxation, and arthritis. We therefore recommend triple arthrodesis as a concomitant procedure during tibial lengthening

Assessment of percutaneous V osteotomy of the calcaneus with Ilizarov application for correction of complex foot deformities

Complex foot deformity can be described as a foot with multiplanar abnormalities with or without shortening of the foot. Conventional surgical treatment may not be able to correct these deformities. In this study we evaluate the results of percutaneous V osteotomy of the calcaneus with an Ilizarov external fixator for treatment of complex foot deformity. Twenty feet with a complex deformity were treated by the Ilizarov method in 15 patients. The aetiologic factors were neglected or relapsed clubfoot (13 patients) and poliomyelitis (2 patients). All patients underwent percutaneous V osteotomy of the calcaneus and gradual correction of the deformity using Ilizarov's method. The mean duration of fixator application was 9.5 months (range, 6-13 months). The mean follow-up period was 1.8 years (range, 1 to 3 years). At the time of fixator removal, a plantigrade foot was achieved in 18 cases; gait was improved in all patients. There was residual varus deformity in two patients. A pin-tract infection was observed in all patients. No recurrence of the deformity occurred. The V osteotomy offers the most options for correction of complex foot deformities. Percutaneous technique is particularly useful for the complex foot deformity that has poor skin coverage, with poor blood supply. Gradual correction with the Ilizarov method yields good results for complex foot deformities.

Iatrogenic medial dislocation of hallucal sesamoids with hallux varus in an adolescent

BACKGROUND

Iatrogenic hallux varus is a rare deformity linked to bunion surgery at late adult age. Here reported is the first adolescent case of acquired hallux varus and medial dislocation of both sesamoid bones.

CASE REPORT

The patient had had a surgical intervention under his first metatarsophalangeal joint when he was 10 years old. Correction of the deformity with a tendon transfer and medial capsular release alone-as was recommended for adults-was impossible in this adolescent, 8 years after the index surgery. Excision of the contracted medial structures and repair of the lateral retinaculum of the fibular sesamoid obtained a perfect correction of the dislocated sesamoid bones.

Acute posttraumatic planovalgus foot deformity involving hindfoot ligamentous pathology

This article outlines the pathology of posttraumatic adult flat foot deformity that involves hindfoot ligamentous injury. The clinical presentation, radiographic findings, and pathology that are noted at the time of reconstruction are described. A proposed surgical reconstruction is presented that has successfully reconstructed the longitudinal arch of the affected foot.

Adult acquired flat foot deformity: clinical and radiographic examination

Symptomatic adult acquired flat foot deformity is encountered in the orthopedic office on a frequent basis. Although many causes exist, a careful history and a stepwise approach to the physical examination will clue the examiner into making the correct diagnosis and provide appropriate treatment. Radiographs serve as an adjunct and assist in verifying the examination findings. CT, US, and MRI are helpful modalities for surgical planning or when the diagnosis remains questionable.

Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot

Adult acquired flatfoot is generally characterized by loss of the longitudinal arch, hindfoot valgus, and forefoot abduction, but the precise deformity has not been adequately described at the level of individual joints. Simulated weightbearing CT scans and plain radiographs of 37 symptomatic flat feet were examined in this study. The degree of arthritic degeneration was assessed in the major hindfoot and midfoot joints, and the location of deformity was studied along the medial column of the arch. Moderate to severe degeneration was seen in about one-third of talonavicular, subtalar, and calcaneocuboid joints. The medial column of the arch collapsed through the talonavicular joint in some feet, through the medial naviculocuneiform joint in others, but rarely through both. First tarsometatarsal joint subluxation was a frequent finding as well. In this small series, neither the degree of degenerative arthritis nor the amount of joint deformity was seen to correlate with patient age. Furthermore, no correlation was observed between foot deformity and joint degeneration.

[Computer-assisted radiologic quantification of hand and foot changes in rheumatoid arthritis]

Driven by the increasing implementation of electronical picture archiving and communications system (PACS) into every days practice a fully operative Java application software was developed to support the efficacy of the scoring process in rheumatoid arthritis. This software, namely the "Rheuma-Coach" offers the possibility to use the Larsen- or the Ratingen-Score. We measured time savings of approximately 20% per case if this computer assistance was used. The lack of a standard for the positioning of limbs was confirmed.

[Radiologic progression of rheumatoid arthritis in early basic drug therapy]

For therapy and follow-up control in early disease modifying antirheumatic drug (DMARD) treated rheumatoid arthritis (RA), objective quantification is still lacking. Therefore, radiological analyses are considered the most appropriate method. One aim of this study was to retrospectively determine the time-dependent progression of joint damage in RA patients on DMARDs. Outpatient records and radiographs from hands and feet of 54 RA patients on DMARDs were evaluated. Radiographs were quantified by using the original Larsen score and a newly developed computer-assisted quantification software. Our observations showed that radiologically-detectable damage in all patients, regardless of their treatment, is most pronounced during the first year of disease, being mitigated and generally progressing linearly in the subsequent years. Cumulative ESR correlated with RA progression, and its reduction with therapeutic efficacy.

[Dennyson-Fulford subtalar extra-articular arthrodesis in the treatment of paralytic pes planovalgus and its value in the alignment of the foot]

OBJECTIVES

We evaluated the results of Dennyson-Fulford subtalar extra-articular arthrodesis performed in patients with paralytic planovalgus deformity and its success in realignment of the foot.

METHODS

Dennyson-Fulford subtalar extra-articular arthrodesis was performed in 19 feet of 12 patients (5 girls, 7 boys; mean age 97.5 months; range 79-138 months) with paralytic planovalgus deformity. The underlying causes were poliomyelitis (n=5), cerebral palsy (n=5), and meningomyelocele (n=2). Seven patients had bilateral involvement; the remaining deformities were on the right in four patients, and on the left in one patient. Simultaneous operations were performed in six patients with bilateral deformity. The results were assessed both clinically and radiologically. The mean follow-up was 35.8 months (range 7 to 82 months).

RESULTS

Union was achieved in all patients within sufficient degree and time. Clinical results were good in 10 feet (52%), moderate in eight feet (42%), and poor in one foot (6%). Radiological results were good in five feet (26%), moderate in 12 feet (64%), and poor in two feet (10%). None of the patients developed pseudoarthrosis or arthrosis of the neighboring joints. Sclerosis was observed around the screws in two patients, in one of whom sclerosis of more than 1 mm was associated with a poor clinical and radiologic outcome.

CONCLUSION

Successful functional and radiologic results are obtained by Dennyson-Fulford subtalar extra-articular arthrodesis in the surgical treatment of paralytic planovalgus deformity in children with neuromuscular disorders.

[Posttraumatic deformity correction at the foot]

Posttraumatic foot deformities requiring correction result from overlooked or inadequately treated injuries and, on the other hand, from protracted courses because of avascular necrosis, non-union or infection after primary surgery. To achieve a maximum benefit, corrective surgery has to be carried out early before arthritic involvement of adjacent joint becomes evident. As salvage procedures, arthrodeses should be restricted to the affected joints. Especially talus malunion and non-union should be corrected with preservation of the joints whenever possible to achieve favourable functional outcomes. In case of calcaneal malunion with consequential lateral translation a reorientating subtalar arthrodesis should be supplemented by corrective osteotomy of the fracture line. Corrections at the level of Chopart's and Lisfranc's (mid-tarsal and tarsometatarsal) joints must restore the exact relationship between the medial and lateral foot columns. Malunions of the metatarsals and toes are corrected in cases of symptomatic malalignment. This paper reviews corrective procedures for posttraumatic deformities at the different foot regions. A therapy-based classification for mal-unions of the talus and calcaneus is proposed.

The Viladot-Regnauld operation for hallux valgus

Of 54 patients, we reviewed 26 with 28 operations for hallux valgus according to the Viladot-Regnauld technique. Follow-up was 18.7 (12-26) years. In 26 operations, the score according to Kitaoka and modified by Calder was excellent or good, and in two, fair. There were no complications. Average valgus angle correction was 15 degrees (8 degrees-29 degrees) and average intermetatarsal angle correction was 7 degrees (4 degrees-12 degrees). Sesamoids were medialised, on average, by at least 25% compared to the pre-operative situation. The results confirm the validity of this surgical procedure.

Effect on balance and gait secondary to removal of the second toe for digital reconstruction: 5-year follow-up

Foot anatomy and lower limb function were analyzed in 11 children (aged 6.5-12.5 y) 5 years after removal of one or two second toes for digital reconstruction. In addition to physical examination and x-rays, postural balance and three-dimensional measurements of gait were analyzed. Among the 15 operated feet, five had bridle scars, three had claw deformities of the third toe, five had pain in the first intermetatarsal space, and seven had overt or early-stage hallux valgus (including five after unilateral toe removal). Hallux valgus deformation was also observed in three nonoperated feet. Maintenance of balance and rate of displacement of the center of pressure when standing on one foot with eyes closed were significantly altered for operated limbs compared with nonoperated limbs. Gait was rapid because of increased step cadence. Foot progression angle and ankle and knee joint sagittal kinematics during walking were normal. Although children appeared to not be affected in their daily life by the removal of the second toe(s), related foot anatomic and functional modifications require further follow-up.

Valgus deformity after fibular resection in children

The authors present a retrospective study of 23 patients in their growing period who underwent resection of more than 2 cm of the fibula. Long-term effects in the ankle and tibia were analyzed. The patients were radiologically studied using the contralateral side as control. Representative radiologic findings were distal migration of the fibula head in 75% (but without clinical relevance), thickening of the external tibial cortex in 20%, talar tilt in 45%, proximal migration of the lateral malleolus in 55%, and diaphyseal valgus of the tibia in 20% of the cases. Incomplete regeneration of fibula was observed in 58% of the cases. Two patients suffered a spiral diaphyseal fracture and another a slow physeal fracture of the distal tibia. In this study, many radiologic changes were observed after fibula resection. The authors suggest using reconstruction methods after fibula resection when it is possible.

[The treatment of rheumatoid foot deformities]

Rheumatoid hindfoot deformity presents with hindfoot eversion, flattening of the longitudinal arch and abduction of the forefoot. Splayfoot, as the typical rheumatoid forefoot deformity, is mostly associated with various toe malformations, i.e. hallux valgus,hammer toe and claw toe,which may either be attributed to hindfoot malalignment or develop as a separate entity. The algorithm of treatment, comprising clinical assessment of both lower limbs, includes both orthotic shoe devices and surgical treatment. In rheumatoid flatfoot, arthrodesis of the hindfoot with lengthening of the lateral column and reorientation of joint congruency represent the gold standard of treatment. Despite this principle, the ankle joint should be kept mobile to facilitate standing and walking. Therefore, total ankle prosthesis is thought to be superior. Methods involving the preservation of the lesser metatarsophalangeal joints may be of benefit in providing sufficient ground contact with the toes. Nevertheless, resection arthroplasties are frequently required in cases of arthritic joint destruction. Arthrodesis of the first metatarsophalangeal joint may provide an adequate push-off for the big toe which can not be expected from resectional arthroplasties.

Fixed subtalar subluxation in a pediatric patient: an unusual entity

Atraumatic, fixed subluxation of the subtalar joint in the pediatric population has not been described. This report describes such a case in a skeletally immature boy.

The "Braids Lady" of Arezzo: a case of rheumatoid arthritis in a 16th century mummy

OBJECTIVE

To diagnose a probable case of rheumatoid arthritis in a mummified female body from the 16th century and to backdate the first clinical diagnosis, entering the diatribe regarding the ancientness of the disease.

METHODS

Image techniques such as normal X-ray, X-ray by mammography, total body CT and high resolution CT were used. Microscopic examination by stereomicroscopy was performed. Samples of tissue were submitted to histology. These data and the review of past literary references, of artistic representations and of paleopathological cases provided an interesting contribution to reconstruct the history of the disease.

RESULTS

The body of the "Braids Lady" showed all the "stigmata" of the disease. The left hand revealed large erosions of the metacarpophalangeal joints of both the third and the fourth fingers, volar metacarpophalangeal subluxation of both the third and the fourth fingers and lateral deviation of all the fingers. The carpus showed some minute and marginal erosions of the bones. The bases of the first phalanges were slightly flared. The toes showed partially overlapped fibular deflection. CT evidenced subluxations of the joints. The body showed no involvement of sacroiliac articulation.

CONCLUSIONS

The "Braids Lady" was affected by rheumatoid arthritis. A large number of features typical of the disease were recorded. Differential diagnosis supported the findings. The death of the lady was established at the end of 16th century, namely 200 years before the first clinical diagnosis worked out by Landré Beauvais in the early 1800s.

Rheumatoid flat foot and deformity of the first ray

OBJECTIVE

To study the relationship between flat foot and forefoot deformities in rheumatoid arthritis (RA) in order to improve understanding of the progression of deformity and thus provide more appropriate treatment.

METHODS

Anteroposterior and lateral weight-bearing radiographs were obtained of 308 feet of patients with RA and 202 feet of patients with neck pain (control feet).

RESULTS

In women with RA, we observed with disease duration an increased frequency of flat foot that was correlated with first ray deformity (chiefly metatarsus primus adductus) and severe stages of disability. Flat foot increased very markedly after 3-4 years of disease duration. In control women, flat feet were more frequent after the age of 50 years.

CONCLUSION

In RA the inflammatory and mechanical factors leading to foot deformity must receive early medical treatment to avoid progressive hindfoot deformities that lead to disability.

Avascular necrosis after osteotomy of the talar neck to correct residual club-foot deformity in children. A long-term review

In order to determine the incidence of avascular necrosis after osteotomy of the talar neck, we re-evaluated 11 patients (16 feet) with idiopathic club foot who had undergone this procedure at a mean age of eight years (5 to 13) to correct a residual adduction deformity. All had been initially treated conservatively and operatively. The mean follow-up was 39 years (36 to 41). Surgery consisted of a closing-wedge osteotomy of the talar neck combined, in 14 feet, with lengthening of the first cuneiform and a Steindler procedure. At follow-up eight feet were free from pain, three had occasional mild pain and five were regularly painful after routine activities. Two patients were unlimited in their activity, six occasionally limited after strenuous and three regularly limited after strenuous activity. Using the Ponseti score, the feet were rated as good in four, fair in three and poor in nine. In seven feet avascular necrosis with collapse and flattening of the talar dome had occurred. In all of these feet the children were younger than ten years of age at the time of surgery. In three feet, avascular necrosis of the talar head was also observed. We conclude that osteotomy of the talar neck in children under the age of ten years can cause avascular necrosis and should be abandoned.

Correction of foot deformities by the Ilizarov method without corrective osteotomies or soft tissue release

Twenty-three foot deformities in 22 patients had been treated without any real surgical incision, 'the bloodless technique', after the application of the Ilizarov external fixator. The ages of the patients ranged from 2 years and 6 months to 49 years. After an average follow-up of 18.3 months (range 8-40 months), all patients had a plantigrade foot. There was no need for soft tissue release or osteotomy. Pin tract infection occurred mostly in the metatarsal wire. However it did not affect final results. The bloodless technique is an effective way of treating foot deformities in children and adults.

Progressive bone and joint abnormalities of the spine and lower extremities in cerebral palsy

Bone and joint changes in cerebral palsy result from muscle spasticity and contracture. The spine and the joints of the lower extremity are most commonly affected. Scoliosis may progress rapidly and may continue after skeletal maturity. Increased thoracic kyphosis and lumbar lordosis, spondylolisthesis, spondylolysis, and pelvic obliquity may accompany the scoliosis. Progressive hip flexion and adduction lead to windswept deformity, increased femoral anteversion, apparent coxa valga, subluxation, deformity of the femoral head, hip dislocation, and formation of a pseudoacetabulum. In the knee, flexion contracture, patella alta, and patellar fragmentation are the most commonly seen abnormalities. Recurvatum deformity can also develop in the knee secondary to contracture of the rectus femoris muscle. Progressive equinovalgus and equinovarus of the foot and ankle are associated with rocker-bottom deformity and subluxation of the talonavicular joint. Early recognition of progressive deformity in patients with cerebral palsy allows timely treatment and prevention of irreversible change.

Management of the neuromuscular foot deformities with the Ilizarov method

Nine feet of eight patients with neurologic foot deformities caused from poliomyelitis, Charcot-Marie-Tooth disease, and traumatic nerve injury were treated with V-osteotomy and the Ilizarov method. A painless and plantigrade foot was obtained in all but one patient. A residual deformity occurred in this case because of the soft-tissue problems during the correction period. No major complication had been encountered by the latest follow-up at a mean of 42 months. The results of the current study indicate that the V-osteotomy and the Ilizarov method, while technically difficult, is an effective method for correcting neurologic foot deformities and obtaining a stable, plantigrade, painless foot, especially when complicated with other lower leg problems (i.e., leg length discrepancy, joint contractures).

Correction of complex foot deformities using the Ilizarov external fixator

There are many drawbacks to using conventional approaches to the treatment of complex foot deformities, like the increased risk of neurovascular injury, soft-tissue injury, and the shortening of the foot. An alternative approach that can eliminate these problems is the Ilizarov method. In the current study, a total of 23 deformed feet in 22 patients were treated using the Ilizarov method. The etiologic factors were burn contracture, poliomyelitis, neglected and relapsed clubfoot, trauma, gun shot injury, meningitis, and leg-length discrepancy (LLD). The average age of the patients was 18.2 (5-50) years. The mean duration of fixator application was 5.1 (2-14) months. We performed corrections without an osteotomy in nine feet and with an osteotomy in 14 feet. Additional bony corrective procedures included three tibial and one femoral osteotomies for lengthening and deformity correction, and one tibiotalar arthrodesis in five separate extremities. At the time of fixator removal, a plantigrade foot was achieved in 21 of the 23 feet by pressure mat analysis. Compared to preoperative status, gait was subjectively improved in all patients. Follow-up time from surgery averaged 25 months (13-38). Pin-tract problems were observed in all cases. Other complications were toe contractures in two feet, metatarsophalangeal subluxation from flexor tendon contractures in one foot, incomplete osteotomy in one foot, residual deformity in two feet, and recurrence of deformity in one foot. Our results indicate that the Ilizarov method is an effective alternative means of correcting complex foot deformities, especially in feet that previously have undergone surgery.

Foot progression angle after distal tibial physeal fractures

Twenty-three patients with Salter 1 or 2 fractures of the distal tibia had follow-up with footprints to assess rotational deformities. Fourteen had external rotation deformity >+2 SD of the normal mean of 5 degrees to 6 degrees. Eight of the 14 had the finding of physeal widening of 2 mm or more. The widening was most commonly wedge-shaped and based anteriorly. The mean foot progression angle of the fractured sides was externally rotated 14 degrees, and the mean foot progression angle of the uninjured sides was externally rotated 10 degrees; both exceeded the normal mean. The fractured side mean was significantly more externally rotated than the uninjured side mean. Preexisting external rotation deformity may be a risk factor for these fractures. Closed reduction with long leg bent-knee casting is justified in more than half of these patients.

Surgical management of severe deformity resulting from posterior tibial tendon dysfunction

A retrospective case study format was used to evaluate the results of surgical treatment of severe deformities due to long-standing tibialis posterior tendon dysfunction. To be included in the study, the peri-talar (talonavicular) subluxation on a weight-bearing AP X-ray should have been at least 75%. This criterion limited the field to patients with long-standing, rigid, severe deformities. Surgical correction was obtained through a two-incision approach, dorsomedial and dorsolateral. Significant shortening of the medial column and extensive removal of adaptive bone formation was necessary to allow reduction of the hind- and midfoot deformity. Stable internal fixation using multiple screws was used to secure the reduction. Eleven patients, 12 feet were evaluated. The patients were evaluated using the American Orthopedic Foot and Ankle Society Ankle and Hindfoot Score as well as a questionnaire on footwear and satisfaction rating. The average score improved from 30 points pre-op to 74 points post-op (out of 100). P-value 0.0001. Pain score improved from 11/40 to 33/40. Function improved from 19/50 to 33/50. Alignment improved from 0/10 to 8/10. The radiological parameters showed an average improvement of 31 degrees in the lateral talo-1st metatarsal angle, 11 degrees in the calcaneal pitch, and 35 degrees in the AP talo-1st metatarsal angle. All three parameters were highly significant with P-values of 0.0001. Multiple complications occurred. This included two delayed unions with breakage of screws and partial loss of correction, four wound problems, two sural nerve impairments and three patients requiring hardware removal. Even though it is an extensive procedure with multiple potential complications it still offers a substantial improvement in quality of life.

Surgically induced Charcot's foot

The neuropathic foot has the potential to develop Charcot arthropathy. This study describes multiple cases of Charcot's foot following surgery. Of all the cases described, only one patient had any preexisting Charcot deformity or acute Charcot event. The study concludes that alterations of mechanical forces in the foot play an important role in triggering an acute Charcot episode.

Lateral plate-washer technique for revision tibiocalcaneal fusion

Tibiocalcaneal fusion using intramedullary rods for severe end-stage Charcot deformity is challenging. Complications such as nonunion, delayed union, recurrent deformity, wound problems, and infection are common. Revision cases present the additional obstacle of obtaining bony purchase in the calcaneal screws. We present a technique using readily available instrumentation to obtain reliable calcaneal fixation.

Reestablishment of foot-stability with external fixation in cases of neurogenic osteoarthropathy

The localization of neurogenic osteopathy in the hindfoot often results in deformities which cannot be corrected by conservative methods. Indications for operation are recurring ulcers, deep infection, and reduced stability with progressive deformity. The aim of this study was to ascertain whether external fixation enables reestablishment of foot stability even when the osteoarthropathic processes have not entirely ceased. A bilaterally mounted Hoffman 2 fixator was used for open repositioning and restabilization on 14 patients with osteoarthropathy of the hindfoot: 12 had diabetes mellitus and 13 had florid processes. Revision with axial correction was necessary in 2 patients. One underwent amputation according to Syme and received a prosthesis. Thirteen were completely remobilized: ten were fitted with an orthosis and three with a rigid orthopedic shoe. Complicated deformities of the hindfoot from neurogenic arthropathy can be satisfactorily restabilized in the edematous and demineralizing stages by surgery and the application of external fixation.

Cavovarus foot treated with combined calcaneus and metatarsal osteotomies

Twenty-one feet in fifteen patients underwent osteotomies of the calcaneus and one or more metatarsals for symptomatic cavovarus foot deformity. Seven (nine feet) were male, and eight (twelve feet) were female. The etiology included hereditary motor sensory neuropathy (HMSN) (fifteen feet), post-polio syndrome (two feet), sacral cord lipomeningocele (two feet), parietal lobe porencephalic cyst (one foot), and idiopathic peripheral neuropathy (one foot). Presenting complaints were metatarsalgia (fifteen feet), ankle instablility (five), and ulceration beneath the second metatarsal head (one foot). Eleven feet were assessed using the Maryland Foot Rating Score. Maryland Foot Rating Score (University of Maryland, Baltimore, MD) improved from 72.1 (avg.) preoperatively to 89.9 (avg.) post-operatively (follow-up 70.9 months avg.). Eight feet were assessed using the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot and Midfoot Scores. The AOFAS Ankle-Hindfoot Score improved from 46.3 (avg.) pre-operatively to 89.1 (avg.) post-operatively, and the AOFAS Midfoot Score improved from 40.9 (avg.) pre-operatively to 88.8 (avg.) post-operatively (follow-up 20.8 months avg.). The postoperative AOFAS Ankle-Hindfoot Score for all nineteen feet was 90.8 (avg.) and the post-operative AOFAS Midfoot Score for all nineteen feet was 90.2 (avg.). Two patients were lost to follow-up and were not included in the study. Ankle, hindfoot, and midfoot motion was maintained or improved in sixteen feet. Complications included delayed union in two and nonunion in three of 66 metatarsal osteotomies. While three patients required an AFO (ankle-foot orthosis) for ambulation preoperatively, all patients were brace free postoperatively. All patients expressed willingness to undergo the same procedure again if it were necessary. Weight-bearing radiographs were available for 17 feet. Radiographic analysis revealed a decrease in forefoot adduction (9.6 degrees avg.) and a reduction in both hindfoot (9.1 degrees avg.) and forefoot cavus (10.6 degrees) leading to an overall 13 percent reduction in the height of the longitudinal arch. Lateral sliding elevating calcaneal osteotomy combined with dorsolateral closing wedge osteotomies of one or more metatarsal bases in the severe symptomatic cavovarus foot can provide a pain-free, plantigrade foot with a lowered longitudinal arch and a stable ankle without sacrificing motion.

[Radiological evaluation of foot deformities in rheumatoid arthritis]

Deformities of the feet are common in patients with rheumatoid arthritis (RA). We investigated whether there was any correlation among forefoot deformities, flat foot or articular destruction of the midfoot and hindfoot, in 146 feet of 73 RA patients whose age varied from 26 to 81 years (mean 58.5 years). In all patients, anteroposterior (AP) and lateral radiographs of the feet with weight bearing were obtained. The hallux valgus angle (HVA), the intermetatarsal angle between the 1st and 2nd metatarsals (M 1 M 2), and the intermetatarsal angle between the 1st and 5th metatarsals (M 1 M 5) were measured on AP radiographs. On slateral radiographs, the height of the arch was measured and articular destruction of the talocalcaneal, talocrural, talonavicular, cuneonavicular and cuneometatarsal joints was measured and classified using Steinbrocker's classification. The average HVA was 23.4 degrees, the average M 1 M 2 was 11.1 degrees, and the average M 1 M 5 was 28.4 degrees. There was no correlation between forefoot deformities and flat foot. There were significant correlations between arthritic destruction of the cuneometatarsal joint and HVA, M 1 M 2 and M 1 M 5. The correlations between arthritic destruction of the cuneonavicular joint and HVA or M 1 M 2 were also significant, although weaker. Thas, we found some relationships between forefoot deformity and arthritics destruction of midfoot joints. Especially, the correlations between arthritic destruction of the cuneonavicular and cuneometatarsal joints and forefoot deformities were significant. Many radiographic methods for the assessment of RA have been reported, however, it is difficult to assess sarthritic destruction of rheumatoid feet with the existing methods. Accordingly, a new method should be established.

Skewfoot in patients with osteogenesis imperfecta

We report skewfoot deformities in two patients who have osteogenesis imperfecta. A discussion will follow proposing etiologies of skewfoot, speculating that the ligamentous laxity often present in children who have osteogenesis imperfecta may predispose the development of skewfoot.

Tibiocalcaneal arthrodesis for the management of severe ankle and hindfoot deformities

PURPOSE

The purpose of this investigation was to evaluate the outcome of tibiocalcaneal arthrodesis using an adolescent condylar blade plate for severe ankle and hindfoot deformities.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients managed at our institutions between 1989 and 1996 whose tibiocalcaneal arthrodeses were performed with adolescent condylar blade plates and allograft bone. In these 30 patients (14 men, 16 women; average age, 53 years), the etiologies of the nonbraceable deformity included: diabetic neuroarthropathy with talar fragmentation and resorption (26), inflammatory arthritis (3), and posttraumatic avascular necrosis of the talus with collapse (1). Due to the severity of the deformity in 28 of these patients, the alternative treatment would have been amputation. Thirteen patients had undergone previous surgeries, eight had documented osteomyelitis, and 13 had ulcers ranging from 2 to 27 mm. At surgery, the remnants of the talus were removed. Morcellized bone graft mixed with tobramycin/vancomycin powder was inserted into the arthrodesis site and then fixed with a rigid plate. Intravenous antibiotics, followed by oral antibiotics, were given until wound healing and suture removal. Follow-up averaged 48 months (19 to 112 months).

RESULTS

Tibiocalcaneal fusion was achieved in 28/30 patients at an average of 16 weeks (12 to 18 weeks). Complications occurred in seven patients: two developed stress fractures of the tibia at the proximal end of the blade plate, three had superficial cellulitis that resolved with antibiotic therapy, and two had nonunions.

CONCLUSION

Tibiocalcaneal arthrodesis using an adolescent condylar blade plate and allograft bone can be a successful procedure in the patient with severe neuropathic ankle deformity and can achieve a stable plantigrade foot for limited community ambulation with relatively few complications.

Acute compartment syndrome following revisional arthroplasty of the forefoot: the dangers of ankle-block

A case of acute compartment syndrome of the forefoot after revisional arthroplasty of the forefoot is presented. Shortening of the compartments due to bony resection and extensive dissection due to previous scarring may have predisposed to the pathological condition. Prompt decompression based on clinical grounds prevented any long term sequelae. Allowance must be made for the concomitant use of local anaesthetic procedures which may obscure the clinical picture.

[Tumoral calcinosis of the foot in patient on hemodialysis]

We report a new case of tumoral calcinosis in a renal failure patient. In this patient the pseudotumoral formation was found in an unusual localization on the medial border of the foot. The condition progressed with successive development of bilateral tumors and septic contamination. Pathology confirmed the diagnosis. The patient was successfully treated with tumor resection and renal graft. The origin of these pseudotumors remains a question of debate. Several pathogenc mechanisms have been put forward. Pronosis is always favorable. Several authors have suggested a phosphorus calcium work-up can be useful for classifying these tumors, guiding surgical treatment if required and managing the underlying cause.

[Long-term outcome of metatarsal head resection in rheumatoid arthritis]

Between January 1983 and December 1987, metatarsal head-resections were performed on 203 patients, comprising a total of 370 feet, using the Hueter/Mayo and Hoffmann procedure. Seventy-two patients, comprising a total of 126 feet, were available for post-operative review after an average of 11.4 years from the date of the original operations. The information obtained from standardized questionnaires was compared to the information found in each patient's file. In addition, every available pre- and post-operative x-ray taken from 1983 to 1987 was analyzed. Thus, with an average follow-up period of 5.6 years, the changes found in the pre- and post-operative x-rays from a total of 183 feet could be compared. Before the operations, nearly 100% of the examined feet suffered from painful synovial hypertrophy and erosion of the metatarsophalangeal joints with dislocation and subluxation, causing approximately 70% of all patients to have great difficulties in walking. After the operations, however, 90.2% of the patients reported that this condition had noticeably improved or had completely disappeared. In fact, 87.5% of all patients reported a lasting improvement in their ability to walk longer distances. As the main criteria in determining the success of an operation (namely, the noticeable reduction of pain and increased mobility) were achieved in 87.5% of the patients, we consider the metatarsal head-resection a reliable method of correcting forefoot deformities in rheumatoid arthritis.

[Tendon transfers in postoperative hallux varus. Apropos of 12 cases]

PURPOSE OF THE STUDY

Iatrogenic hallux varus deformity after bunion surgery is a post-operative condition in which the great toe is oriented in medial deviation in relation to the first metatarsal head. This overcorrection can be a disabling complication with poor cosmetic appearance. A review of the surgical literature showed a reported hallux varus incidence range of 2 p. 100 to 13 p. 100. Various surgical interventions to treat hallux varus are described in the literature and we present here our experience in operative management of acquired hallux varus based on the results of surgical repair with the Johnson (extensor hallucis longus tendon) EHLT transfer procedure and the Hawkins (abductor hallucis tendon) procedure in 12 patients.

MATERIAL AND METHODS

All of the patients suffered from painful iatrogenic hallux varus and conservative treatment was unsuccessful in all cases. The mean duration of follow-up was 42 months (range 8-96). The average age was 37 years (range: 17 to 58). The index procedure in eleven patients was a Mc Bride bunionectomy and in one case a Petersen procedure. On physical examination, a claw deformity of the hallux characterized by extension of the metatarsophalangeal joint and flexion of the interphalangeal joint was noted in all feet. Eight transfers of the abductor hallucis tendon and four complete transfers of the extensor hallucis longus tendon with interphalangeal joint fusion were done. At the time of the final follow-up, patients were interviewed and graded using a standardized questionnaire based on pain, metatarso-phalangeal range of motion, alignment of the hallux, footwear requirements, walking capabilities and first ray rest.

RESULTS

Eleven patients reported satisfactory results and one patient a fair result. Overcorrection was a potential complication and in this retrospective study, one bunion deformity recurred but was asymptomatic. On radiographic evaluation the hallux abductus angle was improved by a mean 26.6 degrees and the average first intermetatarsal angle was 7 degrees (range: 3 degrees to 12 degrees ). A narrowing of the metatarso-phalangeal joint was observed in four cases (2 Johnson and 2 Hawkins).

DISCUSSION

The addition of a tendon transfer to the medial soft tissue release is recommanded in most cases of hallux varus in active patients without osteoarthritis of the metatarso-phalangeal joint. Our experience with the EHLT transfer or the abductor hallucis tendon transfer demonstrated excellent correction of the hallux varus deformity; however metatarso-phalangeal joint stiffness was frequently observed. As originally described by Johnson et Spiegl, the entire extensor hallucis longus tendon was used in conjunction with an interphalangeal joint arthrodesis in the presence of a fixed and painful deformity of the hallux interphalangeal joint. If no fixed claw deformity was present an abductor hallucis tendon transfer was preferred. Onset of degenerative disease involving the metatarso-phalangeal joint in four cases may jeopardize long term survival of these surgical results.

The radiological analysis of pes cavus deformity in Charcot Marie Tooth disease

Charcot Marie Tooth (CMT) is a progressive hereditary peripheral neuropathy. The most prevalent subtype is CMT-1A, wherein patients develop a characteristic cavovarus deformity. We have reviewed a series of standing lateral foot radiographs of patients with foot deformity due to CMT, and found that the hind foot of these patients is in dorsiflexion, not equinus, and that the apparent equinus is due to plantar flexion of the forefoot on the midfoot, and actually represents a cavus deformity.

Rheumatoid forefoot reconstruction. A long-term follow-up study

BACKGROUND

The purpose of the present study was to assess the results of reconstruction of the rheumatoid forefoot with arthrodesis of the metatarsophalangeal joint of the great toe, resection arthroplasty of the metatarsal heads of the lesser toes, and open repair of hammer-toe deformity (arthrodesis of the proximal interphalangeal joint) of the lesser toes when this deformity was present.

METHODS

A retrospective study of forty-three consecutive patients (fifty-eight feet) with severe rheumatoid forefoot deformities was performed. Six patients (six feet) died before the most recent follow-up, and five patients (five feet) were excluded because a subtotal procedure had been performed. No patient was lost to follow-up. Thus, the study included thirty-two patients (forty-seven feet) in whom reconstruction of a rheumatoid forefoot had been performed by the author.

RESULTS

All first metatarsophalangeal joints had successfully fused at an average of seventy-four months (range, thirty-seven to 108 months) postoperatively. The average postoperative hallux valgus angle was 20 degrees and the average postoperative angle subtended by the axes of the proximal phalanx and the metatarsal of the second ray (the MTP-2 angle) was 14 degrees, demonstrating that a stable first ray protected the lateral rays from later subluxation. One hundred and thirty-two (70 percent) of the 188 lesser metatarsophalangeal joints were dislocated preoperatively, compared with thirteen (7 percent) postoperatively. The result of the procedure (as rated subjectively by the patient) was excellent for twenty-three feet, good for twenty-two, and fair for two. There were no poor results. The average postoperative score according to the system of the American Orthopaedic Foot and Ankle Society was 69 points. Postoperative pain was rated as absent in eighteen feet, mild in twenty-five, moderate in four, and severe in none. Fifteen feet were not associated with any functional limitations, twenty-eight were associated with limitation of recreational activities, and four were associated with limitation of daily activities. At the time of the most recent follow-up, no special shoe requirements were reported. Fourteen feet (30 percent) had a reoperation for the removal of hardware from the first metatarsophalangeal joint, a procedure on the interphalangeal joint of the great toe, or additional procedures on the lesser toes or lesser metatarsophalangeal joints.

CONCLUSIONS

In the present study, arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsal heads, and repair of fixed hammer-toe deformities with intramedullary Kirschnerwire fixation resulted in a stable repair with a high percentage of successful results at an average of six years after the procedures.

Function after correction of a clawed great toe by a modified Robert Jones transfer

We carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer. The mean follow-up was 42 months (9 to 88). In all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity. All patients were evaluated clinically and radiologically. The overall rate of patient satisfaction was 86%. The deformity of the hallux was corrected in 80 feet. Catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications. Hallux limitus was more likely when elevation of the first ray occurred (p = 0.012). Additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001). The deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered. The muscle balance and stability of the entire first ray should be taken into consideration in the management of clawed hallux.