Multimodality imaging of the paediatric flatfoot

Postoperative Calcaneocuboid Joint Subluxation and Midtarsal Joint Changes in Pediatric Idiopathic Flexible Flatfoot Treated With Calcaneal Lengthening Osteotomy: A Midterm Follow-up Study

BACKGROUND

Calcaneal lengthening osteotomy (CLO) is one of the main surgical options for treatment of pediatric idiopathic flexible flatfoot (FFF). Reportedly, calcaneocuboid (CC) joint subluxation occurs after CLO; however, its effect on the midfoot remains unclear. This study aimed to investigate the radiologic midterm results after CLO treatment in pediatric idiopathic FFF.

METHODS

We evaluated 23 pediatric patients with idiopathic FFF aged ≥8 years, who underwent CLO from 1999 to 2017 owing to moderate to severe flatfoot deformity (assessed by visual inspection). Patients aged between 8 and 14 years were included (mean follow-up: 6.3 years; range, 3.1-11.4 years). Anteroposterior and lateral weightbearing foot radiographs were assessed for radiologic parameters preoperatively and at the 3-month, 1-year, and final follow-ups postoperatively.

RESULTS

All patients had immediate postoperative radiologic correction of the flatfoot deformity, and these improvements were maintained until the final follow-up. The mean allograft length inserted was 9 (range, 8-10) mm. There was increased CC joint subluxation after CLO, but it improved continuously until the final follow-up. A CC joint spur was newly noted in 1 case. There were 24 cases (24/39, 61.5%) of talonavicular (TN) joint spurs at the final follow-up, but 19 of these were already present on the preoperative radiographs (19/24, 79.2%). Further, the new-onset TN joint spurs were not associated with preoperative clinicoradiologic factors.

CONCLUSION

In pediatric patients with idiopathic FFF receiving CLO treatment, preoperative radiologic angles improved. CC joint subluxation increased after surgery; however, it gradually reduced without evidence of CC joint arthritic changes over the time period studied in this cohort.

Pediatric Foot: Development, Variants, and Related Pathology

Pediatric foot development throughout childhood and adolescence can present a diagnostic dilemma for radiologists because imaging appearances may be confused with pathology. Understanding pediatric foot development and anatomical variants, such as accessory ossification centers, is essential to interpret musculoskeletal imaging in children correctly, particularly because many of these variants are incidental but others can be symptomatic. We first briefly review foot embryology. After describing common accessory ossification centers of the foot, we explain the different patterns of foot maturation with attention to irregular ossification and bone marrow development. Common pediatric foot variants and pathology are described, such as tarsal coalitions and fifth metatarsal base fractures. We also discuss pediatric foot alignment and various childhood foot alignment deformities.

Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit

PURPOSE

We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents.

METHODS

A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test.

RESULTS

The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal.

CONCLUSION

Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

Quantitative Skeletal Imaging and Image-Based Modeling in Pediatric Orthopaedics

PURPOSE OF REVIEW

Musculoskeletal imaging serves a critical role in clinical care and orthopaedic research. Image-based modeling is also gaining traction as a useful tool in understanding skeletal morphology and mechanics. However, there are fewer studies on advanced imaging and modeling in pediatric populations. The purpose of this review is to provide an overview of recent literature on skeletal imaging modalities and modeling techniques with a special emphasis on current and future uses in pediatric research and clinical care.

RECENT FINDINGS

While many principles of imaging and 3D modeling are relevant across the lifespan, there are special considerations for pediatric musculoskeletal imaging and fewer studies of 3D skeletal modeling in pediatric populations. Improved understanding of bone morphology and growth during childhood in healthy and pathologic patients may provide new insight into the pathophysiology of pediatric-onset skeletal diseases and the biomechanics of bone development. Clinical translation of 3D modeling tools developed in orthopaedic research is limited by the requirement for manual image segmentation and the resources needed for segmentation, modeling, and analysis. This paper highlights the current and future uses of common musculoskeletal imaging modalities and 3D modeling techniques in pediatric orthopaedic clinical care and research.

Pediatric Flatfoot: Is There a Need for Surgical Referral?

Pediatric foot deformities are a common finding, concerning up to 44% of preschool aged children. The absence of accepted international guidelines, as well as heterogeneity in definitions and measurements, makes management of pediatric flatfoot a challenge, and decisions surrounding specialized care referral confusing and biased. The objective of this narrative review is to provide guidance to primary care physicians treating these patients. A non-systematic review of the literature regarding the development, etiology, and clinical and radiographic assessment of flatfeet using the PubMed and Cochrane Library databases was performed. The exclusion criteria for the review were adult populations, papers detailing the outcome of a specific surgical procedure, and publications prior to 2001. The included articles showed great heterogeneity in definition and proposed management, which makes the study of pediatric flatfoot challenging. Flatfoot is a common finding in children under 10 years old, and should not be considered pathological unless stiffness or functional limitation are present. Surgical referral should be reserved to children with stiff or painful flatfoot, while simple observation is indicated for flexible, asymptomatic flatfeet.

Ankle and Foot Deformities in Children

Ankle and foot deformity is one of the most common musculoskeletal disorders in children and a leading cause of functional impairment and diminished quality of life when not treated. A spectrum of conditions may produce foot and ankle deformities, with congenital disorders the most frequent cause, followed by acquired conditions. Congenital disorders include congenital talipes equinovarus or congenital clubfoot, metatarsus adductus, skewfoot, congenital vertical talus, and tarsal coalition.Some of these deformities are frequent and easily diagnosed based on clinical features, but clinical overlap between pathologies can be challenging. Thus imaging plays a paramount role in evaluating these patients. Radiographs are the first imaging modality of choice, but they may not be sufficient in infants due to the lack of ossification of the tarsal bones. Ultrasonography allows not only a detailed visualization of the cartilaginous structures but also permits a dynamic study of the foot and ankle. Computed tomography may be necessary in certain conditions such as tarsal coalitions.

A Novel Deep Transfer Learning-Based Approach for Automated Pes Planus Diagnosis Using X-ray Image

Pes planus, colloquially known as flatfoot, is a deformity defined as the collapse, flattening or loss of the medial longitudinal arch of the foot. The first standard radiographic examination for diagnosing pes planus involves lateral and dorsoplantar weight-bearing radiographs. Recently, many artificial intelligence-based computer-aided diagnosis (CAD) systems and models have been developed for the detection of various diseases from radiological images. However, to the best of our knowledge, no model and system has been proposed in the literature for automated pes planus diagnosis using X-ray images. This study presents a novel deep learning-based model for automated pes planus diagnosis using X-ray images, a first in the literature. To perform this study, a new pes planus dataset consisting of weight-bearing X-ray images was collected and labeled by specialist radiologists. In the preprocessing stage, the number of X-ray images was augmented and then divided into 4 and 16 patches, respectively in a pyramidal fashion. Thus, a total of 21 images are obtained for each image, including 20 patches and one original image. These 21 images were then fed to the pre-trained MobileNetV2 and 21,000 features were extracted from the Logits layer. Among the extracted deep features, the most important 1312 features were selected using the proposed iterative ReliefF algorithm, and then classified with support vector machine (SVM). The proposed deep learning-based framework achieved 95.14% accuracy using 10-fold cross validation. The results demonstrate that our transfer learning-based model can be used as an auxiliary tool for diagnosing pes planus in clinical practice.

MRI for paediatric flatfoot: is it necessary?

OBJECTIVE

To determine the additional benefit of MRI for children with flatfoot deformity assessed with weight-bearing radiographs in a specialist paediatric orthopaedic unit.

METHODS AND MATERIALS

Patient cohort was obtained by searching the Radiology Information System for children referred for investigation of flatfoot. All patients with flatfoot on weight-bearing radiographs who had undergone MRI were included. Radiographs were classified by a consultant musculoskeletal radiologist as showing no underlying abnormality, talo-calcaneal coalition, calcaneonavicular coalition, accessory navicular or other abnormality. MRI studies were classified similarly by a different consultant musculoskeletal radiologist blinded to the radiographic findings.

RESULTS

33 males and 24 females were included (mean age 12.5 years; range 3-18 years). 24 had bilateral abnormality, so 81 feet were assessed. Radiographs showed no specific abnormality (n = 51), talocalcaneal coalition (n = 6), calcaneonavicular coalition (n = 3), os naviculare (n = 12) or other abnormality (n = 9). MRI showed no specific abnormality (n = 40), talocalcaneal coalition (n = 10), calcaneonavicular coalition (n = 5), os naviculare (n = 12) or other abnormality (n = 14). Assuming MRI as the diagnostic gold-standard, additional relevant diagnostic information was identified in 19 (23.5%) cases, while in the 51 cases for which radiographs provided no specific diagnosis MRI confirmed no underlying abnormality in 31 (60.8%).

CONCLUSION

MRI is a valuable adjunct to weight-bearing radiography for investigating paediatric flatfoot deformity.

ADVANCES IN KNOWLEDGE

MRI is of value in the assessment of paediatric flatfoot, additional diagnostic information to radiography being identified in 23.5% cases, while in 60.8% of cases for which radiographs provided no specific diagnosis MRI confirmed no underlying abnormality.