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Conti MS, Kim J, Hoffman J, Jones CP, Ellis SJ, Deland JT, Steineman B. Peroneus Brevis to Longus Tendon Transfer in the Treatment of Flexible Progressive Collapsing Foot Deformity: A Cadaveric Study. Foot Ankle Int 2024; 45:656-663. [PMID: 38504500 DOI: 10.1177/10711007241238209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Although operative treatment of the flexible progressive collapsing foot deformity (PCFD) remains controversial, correction of residual forefoot varus and stabilization of the medial column are important components of reconstruction. A peroneus brevis (PB) to peroneus longus (PL) tendon transfer has been proposed to address these deformities. The aim of our study was to determine the effect of an isolated PB-to-PL transfer on medial column kinematics and plantar pressures in a simulated PCFD (sPCFD) cadaveric model. METHODS The stance phase of level walking was simulated in 10 midtibia cadaveric specimens using a validated 6-degree of freedom robot. Bone motions and plantar pressure were collected in 3 conditions: intact, sPCFD, and after PB-to-PL transfer. The PB-to-PL transfer was performed by transecting the PB and advancing the proximal stump 1 cm into the PL. Outcome measures included the change in joint rotation of the talonavicular, first naviculocuneiform, and first tarsometatarsal joints between conditions. Plantar pressure outcome measures included the maximum force, peak pressure under the first metatarsal, and the lateral-to-medial forefoot average pressure ratio. RESULTS Compared to the sPCFD condition, the PB-to-PL transfer resulted in significant increases in talonavicular plantarflexion and adduction of 68% and 72%, respectively, during simulated late stance phase. Talonavicular eversion also decreased in simulated late stance by 53%. Relative to the sPCFD condition, the PB-to-PL transfer also resulted in a 17% increase (P = .045) in maximum force and a 45-kPa increase (P = .038) in peak pressure under the first metatarsal, along with a medial shift in forefoot pressure. CONCLUSION The results from this cadaver-based simulation suggest that the addition of a PB-to-PL transfer as part of the surgical management of the flexible PCFD may aid in correction of deformity and increase the plantarflexion force under the first metatarsal. CLINICAL RELEVANCE This study provides biomechanical evidence to support the addition of a PB-to-PL tendon transfer in the surgical treatment of flexible PCFD.
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Affiliation(s)
- Matthew S Conti
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
| | - Jaeyoung Kim
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
| | - Jeffrey Hoffman
- Biomechanics, Hospital for Special Surgery, New York, NY, USA
| | | | - Scott J Ellis
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan T Deland
- Foot and Ankle Service, Hospital for Special Surgery, New York, NY, USA
| | - Brett Steineman
- Biomechanics, Hospital for Special Surgery, New York, NY, USA
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2
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Lendrum JA, Hunt KJ. Medial Column Fusions in Flatfoot Deformities: Naviculocuneiform and Talonavicular. Foot Ankle Clin 2022; 27:769-786. [PMID: 36368796 DOI: 10.1016/j.fcl.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Progressive collapsing foot deformity (PCFD; commonly referred to as flatfoot deformity) is a complex condition classically characterized by hindfoot valgus, midfoot abduction, and forefoot varus. Medial column arthrodesis can be used to reliably correct severe, arthritic, and unstable PCFD involving the medial column. Although both naviculocuneiform arthrodesis and talonavicular arthrodesis have their own indications, patient selection and careful radiographic and clinical assessment are crucial for any medial column arthrodesis. Herein, the authors discuss the indications for medial column arthrodesis procedures, outcomes as reported in the literature, and several case examples using medial column arthrodesis in deformity correction.
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Affiliation(s)
- James A Lendrum
- Department of Orthopedics, University of Colorado, 12631 East 17th Avenue, Mail Stop B202, Aurora, CO 80045, USA
| | - Kenneth J Hunt
- Department of Orthopedics, University of Colorado, 12631 East 17th Avenue, Mail Stop B202, Aurora, CO 80045, USA.
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3
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Wininger AE, Klavas DM, Gardner SS, Ahuero JS, Harris JD, Varner KE. Plantar Plating for Medial Naviculocuneiform Arthrodesis in Progressive Collapsing Foot Deformity. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221088517. [PMID: 35386584 PMCID: PMC8978315 DOI: 10.1177/24730114221088517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Medial column procedures are commonly used to treat progressive collapsing foot deformity (PCFD) reconstruction. The aim of this research is to present the clinical results of plantar plating for medial naviculocuneiform (NC) arthrodesis when NC joint pathology contributes to medial arch collapse. The authors hypothesized that lag screws with a plantar neutralization plate would result in a satisfactory NC joint fusion rate. Methods: A single-surgeon, retrospective case series was performed on patients with flexible PCFD who underwent NC arthrodesis using lag screws and a contoured neutralization plate applied plantarly across the medial NC joint as part of PCFD reconstruction. Thirteen patients (11 females, 2 males; mean age 53.1 [34-62] years) between 2016 and 2019 were identified for inclusion. Mean follow-up was 25.2 ± 12.7 months. Preoperative and postoperative anteroposterior talo–first metatarsal angle, lateral talo–first metatarsal angle, talonavicular coverage angle, and calcaneal pitch were measured. Union was evaluated radiologically. AOFAS midfoot scores were recorded at final follow-up. Results: All parameters demonstrated a significant improvement. Fusion was confirmed in 11 of 13 patients (85%) at a mean 5.7 ± 2.1 months. One patient required a revision of their NC fusion because of symptomatic nonunion. There were no cases of symptomatic plantar hardware. Conclusion: The results of this small cohort series suggest that lag screw with plantar plate NC arthrodesis yielded generally improved short-term radiographic and clinical outcomes in PCFD patients with medial arch collapse through the NC joint. Level of Evidence: Level IV, retrospective case series.
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Affiliation(s)
| | - Derek M. Klavas
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX, USA
| | | | - Jason S. Ahuero
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX, USA
| | - Joshua D. Harris
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX, USA
| | - Kevin E. Varner
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX, USA
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Kuestermann H, Ettinger S, Yao D, Schwarze M, Plaass C, Stukenborg-Colsman C, Claassen L. Biomechanical evaluation of naviculocuneiform fixation with lag screw and locking plates. Foot Ankle Surg 2021; 27:911-919. [PMID: 33483221 DOI: 10.1016/j.fas.2020.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/27/2020] [Accepted: 12/20/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND There have been no biomechanical evaluations of naviculocuneiform (NC) joint fixation. This study compared biomechanically 3 different fixation constructs for NC-1-3 joint fixation. METHODS The present study compared the three fixation constructs lag screw with locking plate for each NC joint, two crossed lag screws for each NC joint and a separate lag screw for each NC joint with bridging locking plates. NC-1-3 fixation was performed stepwise, and rotation of each joint was evaluated after the application of each lag screw or locking plate and their removal. RESULTS All examined fixation techniques led to a significant reduced rotation of the NC joints. For NC-1 rotation decreased from 2.8° (Range 1.2-6.6°) to 0.6° (0.2-3.0°) for lag screw and locking plate (p = 0.002) and from 5.0° (1.7-9.8°) to 1.0° (0.1-3.6°) for crossed lag screws (p = 0.002). For NC-2, locking plate constructs were better with 0.2° (0.1-0.5°) compared to crossed lag screw osteosynthesis with 0.9° (0.2-1.6°) (p = 0.011). CONCLUSION Each evaluated fixation technique led to a reduced NC joint rotation. The fixation of any NC joint had no relevant effect on the adjacent NC joints. The results might support surgeons treating NC joint disorders.
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Affiliation(s)
- Henry Kuestermann
- Diakovere Annastift - Orthopedic Department of the Hannover Medical School (MHH), Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany.
| | - Sarah Ettinger
- Diakovere Annastift - Orthopedic Department of the Hannover Medical School (MHH), Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany.
| | - Daiwei Yao
- Diakovere Annastift - Orthopedic Department of the Hannover Medical School (MHH), Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany.
| | - Michael Schwarze
- Laboratory for Biomechanics and Biomaterials of the Hannover Medical School, Haubergstrasse 3, 30625 Hannover, Germany.
| | - Christian Plaass
- Diakovere Annastift - Orthopedic Department of the Hannover Medical School (MHH), Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany.
| | - Christina Stukenborg-Colsman
- Diakovere Annastift - Orthopedic Department of the Hannover Medical School (MHH), Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany.
| | - Leif Claassen
- Diakovere Annastift - Orthopedic Department of the Hannover Medical School (MHH), Anna-von-Borries-Straße 1-7, 30625 Hannover, Germany.
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Calcaneal Osteotomies in the Treatment of Progressive Collapsing Foot Deformity. What are the Restrictions for the Holy Grail? Foot Ankle Clin 2021; 26:473-505. [PMID: 34332731 DOI: 10.1016/j.fcl.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The progressive collapsing foot deformity is a complex three-dimensional deformity, including valgus malalignment of the heel. The medial displacement calcaneal osteotomy is an established surgical procedure reliably resulting in an efficient correction of the inframalleolar alignment. However, complications are common, including undercorrection of underlying deformity, progression of hindfoot osteoarthritis and/or deformity, and/or symptomatic hardware.
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Conti MS, Ellis SJ. Spare the Talonavicular Joint! The Role of Isolated Subtalar Joint Fusion in the Treatment of Progressive Collapsing Foot Deformity. Foot Ankle Clin 2021; 26:591-607. [PMID: 34332737 DOI: 10.1016/j.fcl.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical management of progressive collapsing foot deformity continues to evolve. Previous studies have demonstrated that fusion of the talonavicular joint results in limited hindfoot motion and, therefore, may accelerate adjacent-joint arthrosis. Recent literature has supported using alternative arthrodesis constructs that spare the talonavicular joint, such as naviculocuneiform or isolated subtalar fusions, which may maintain some hindfoot motion through the talonavicular joint yet adequately address a patient's deformity. Concomitant reconstructive procedures may be used in addition to subtalar fusion to address severe deformities. Isolated subtalar fusions may be considered in cases of sinus tarsi or subfibular impingement deformities.
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Affiliation(s)
- Matthew S Conti
- Academic Training Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. https://twitter.com/matthew_conti
| | - Scott J Ellis
- Foot and Ankle Service, Hospital for Special Surgery, 523 East 72nd Street, 5th Floor, New York, NY 10021, USA.
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7
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Parupia Y, Klaver S, Merchant M, Haas Z, Cobb M, Patel S. Pre and Postoperative Analysis of Flatfoot Reconstruction Sparing the Talonavicular Joint. J Foot Ankle Surg 2021; 60:650-654. [PMID: 33744066 DOI: 10.1053/j.jfas.2020.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/07/2020] [Accepted: 04/02/2020] [Indexed: 02/03/2023]
Abstract
Surgical correction of a flatfoot deformity is controversial. The purpose of our study was to evaluate the structural radiographic changes of the flatfoot deformity while maintaining the mobile adapter of the foot. We conducted a retrospective analysis of 56 patients that underwent this procedure comparing their pre- to postoperative angular changes during a follow-up period. The mean age of our study cohort was 53.6 (range, 20-77) years and mean follow-up period was 23 (range, 4-73) months. Radiographic union was achieved in 48 patients (86%). Forty-six patients (82%) had all required radiographs completed through final follow-up visit. We illustrated statistically significant changes to the talonavicular, Meary, talocalcaneal, calcaneal inclination, and talar declination angles, and navicular height at 3 months and final follow-up. This study suggests surgical correction of the flatfoot deformity that fused the subtalar but spared the talonavicular joint appears to achieve and maintain radiographic angular changes and achieve union.
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Affiliation(s)
- Yaseer Parupia
- Resident, Kaiser Permanente Sacramento Medical Center - Primary, Sacramento, CA.
| | - Silas Klaver
- Resident, Yakima Podiatry Associates, Yakima, WA
| | | | - Zachary Haas
- Surgeon, Albuquerque Associated Podiatrists, Albuquerque, NM
| | - Matthew Cobb
- Surgeon, Albuquerque Associated Podiatrists, Albuquerque, NM
| | - Sandeep Patel
- Surgeon, Kaiser Permanente Antioch Medical Center, Antioch, CA
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8
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Abstract
Undiagnosed medial ankle instability can be a prerequisite for pathogenic progression in the foot, particularly for adult acquired flatfoot deformity. With the complex anatomy in this region, and the limitations of each individual investigational method, accurately identifying peritalar instability remains a serious challenge to clinicians. Performing a thorough clinical examination aided by evaluation with advanced imaging can improve the threshold of detection for this condition and allow early proper treatment to prevent further manifestations of the instability.
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Affiliation(s)
- Yantarat Sripanich
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA; Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, 315 Rajavithi Road, Tung Phayathai, Ratchathewi, Bangkok 10400, Thailand
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA; Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Hamburg, Martinistr. 52, Hamburg 20246, Germany.
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9
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Hintermann B, Deland JT, de Cesar Netto C, Ellis SJ, Johnson JE, Myerson MS, Sangeorzan BJ, Thordarson DB, Schon LC. Consensus on Indications for Isolated Subtalar Joint Fusion and Naviculocuneiform Fusions for Progressive Collapsing Foot Deformity. Foot Ankle Int 2020; 41:1295-1298. [PMID: 32851856 DOI: 10.1177/1071100720950738] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Peritalar subluxation represents an important hindfoot component of progressive collapsing foot deformity, which can be associated with a breakdown of the medial longitudinal arch. It results in a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and pronation. Loss of peritalar stability allows the talus to rotate and translate on the calcaneal and navicular bone surfaces, typically moving medially and anteriorly, which may result in sinus tarsi and subfibular impingement. The onset of degenerative disease can manifest with stiffening of the subtalar (ST) joint and subsequent fixed and possibly arthritic deformity. While ST joint fusion may permit repositioning and stabilization of the talus on top of the calcaneus, it may not fully correct forefoot abduction and it does not correct forefoot varus. Such varus may be addressed by a talonavicular (TN) fusion or a plantar flexion osteotomy of the first ray, but, if too pronounced, it may be more effectively corrected with a naviculocuneiform (NC) fusion. The NC joint has a curvature in the sagittal plane. Thus, preserving the shape of the joint is the key to permitting plantarflexion correction by rotating the midfoot along the debrided surfaces and to fix it. Intraoperatively, care must be also taken to not overcorrect the talocalcaneal angle in the horizontal plane during the ST fusion (eg, to exceed the external rotation of the talus and inadvertently put the midfoot in a supinated position). Such overcorrection can lead to lateral column overload with persistent lateral midfoot pain and discomfort. A contraindication for an isolated ST fusion may be a rupture of posterior tibial tendon because of the resultant loss of the internal rotation force at the TN joint. In these cases, a flexor digitorum longus tendon transfer is added to the procedure. LEVEL OF EVIDENCE Level V, consensus, expert opinion.
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Affiliation(s)
| | | | - Cesar de Cesar Netto
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | | | | | - Mark S Myerson
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Lew C Schon
- Mercy Medical Center, Baltimore, MD, USA.,New York University Grossman School of Medicine, New York, NY, USA.,Johns Hopkins School of Medicine, Baltimore, MD, USA.,Georgetown School of Medicine, Washington, DC, USA
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10
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Chan F, Bowlby MA, Christensen JC. Medial Column Biomechanics: Nonsurgical and Surgical Implications. Clin Podiatr Med Surg 2020; 37:39-51. [PMID: 31735268 DOI: 10.1016/j.cpm.2019.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Understanding of medial column biomechanics is paramount to a successful outcome in both conservative and surgical treatment. Dysfunctions of the dynamic stabilizers as well as the static stabilizers of the medial column play a role in pathomechanics. Conservative options for addressing the medial column include custom foot orthotics and bracing. Options for addressing the medial column surgically with the goal to restore a stable tripod configuration, include first tarsometatarsal joint arthrodesis, opening plantarflexory medial cuneiform osteotomy, and naviculocuneiform arthrodesis.
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Affiliation(s)
- Francis Chan
- Private Practice, 5000 Kingsway, Suite #320, Burnaby, BC V5H 2E4, Canada.
| | - Melinda A Bowlby
- Department of Orthopedics, Swedish Medical Center, Seattle, WA, USA; Department of Orthopedics, Providence Medical Center, Everett, WA, USA
| | - Jeffrey C Christensen
- Department of Orthopedics, Swedish Medical Center, Seattle, WA, USA; Department of Orthopedics, Providence Medical Center, Everett, WA, USA
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11
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Chu AK, Wilson MD, Lee J, So E, Prissel MA, Hyer CF. The Incidence of Nonunion of the Naviculocuneiform Joint Arthrodesis:A Systematic Review. J Foot Ankle Surg 2019; 58:545-549. [PMID: 30876812 DOI: 10.1053/j.jfas.2018.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Indexed: 02/03/2023]
Abstract
Naviculocuneiform (NC) joint arthrodesis is an effective procedure to treat pain and provide stability to the medial column. Various forms of fixation have been described for NC arthrodesis. Despite this, the available literature is scant and questions remain regarding nonunion rate and contributory factors. A systematic review of the literature was undertaken to determine the rate of nonunion for NC joint arthrodesis. Seven studies involving 139 NC joint arthrodeses met inclusion criteria. The nonunion rate was 6.5% at a weighted mean follow-up of 73.2 months. There is insufficient evidence to provide a practice guideline based on the current literature. Adequately powered prospective clinical trials comparing well-matched patient groups with long-term follow-up are required to limit systematic error and enhance external validity. Specific outcomes measures should include union, functional assessment, complications, and cost-benefit analysis.
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Affiliation(s)
- Anson K Chu
- Resident Physician, Grant Medical Center, Columbus, OH.
| | | | - Jonathan Lee
- Resident Physician, Grant Medical Center, Columbus, OH
| | - Eric So
- Resident Physician, Grant Medical Center, Columbus, OH
| | - Mark A Prissel
- Faculty, Grant Medical Center, Columbus, OH; Fellowship-Trained Foot and Ankle Surgeon, Orthopedic Foot and Ankle Center, Westerville, OH
| | - Christopher F Hyer
- Faculty, Grant Medical Center, Columbus, OH; Fellowship-Trained Foot and Ankle Surgeon, Orthopedic Foot and Ankle Center, Westerville, OH; Residency Program Director, Grant Medical Center, Columbus, OH
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12
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Gerrity M, Williams M. Naviculocuneiform Arthrodesis in Adult Flatfoot: A Case Series. J Foot Ankle Surg 2019; 58:352-356. [PMID: 30612870 DOI: 10.1053/j.jfas.2018.08.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Indexed: 02/03/2023]
Abstract
Medial column arthrodesis and calcaneal osteotomies are commonly used for adult-acquired flatfoot surgical reconstruction. In this case series, 10 patients (11 feet) with a mean age of 54 ± 13 years underwent a medial column arthrodesis, with or without calcaneal osteotomy, between 2010 and 2017. The indication for surgery was a painful flatfoot deformity with peritalar subluxation and a fault in the naviculocuneiform joint. At a mean of 9.9 (range 2.5 to 33.1) months after surgery, in patients who underwent a medial column arthrodesis, radiographs showed a mean decrease in the talonavicular coverage angle of 8.4° ± 8.5° (p = .013), and mean increases in the lateral talometatarsal and calcaneal inclination angle of 10.6° ± 10.3° (p = .002) and 2.2° ± 4.4° (p = .067), respectively. One nonunion (1 of 11 [9.1%]) occurred at the naviculocuneiform. These findings demonstrate marked improvement of radiographic flatfoot parameters after medial column arthrodesis.
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Affiliation(s)
- Michael Gerrity
- Podiatrist, Department of Podiatry, Mid-Atlantic Permanente Medical Group, Rockville, MD.
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13
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Abstract
Surgical interventions at the naviculocuneiform joint are not uncommon to deal with various pathologies of the joint and correction of different foot deformities. To minimize the soft tissue dissection, naviculocuneiform arthroscopy has been described. The purpose of this Technical Note is to report the details of this arthroscopic approach.
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Affiliation(s)
- Tun Hing Lui
- Address correspondence to Tun Hing Lui, M.B.B.S.(H.K.), F.R.C.S.(Edin.), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui New Territories, Hong Kong SAR 999077, China.
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14
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Did Failure Occur Because of Medial Column Instability That Was Not Recognized, or Did It Develop After Surgery? Foot Ankle Clin 2017; 22:545-562. [PMID: 28779806 DOI: 10.1016/j.fcl.2017.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Medial column instability is a primary deforming force in the setting of pes planovalgus deformity. Consideration for medial column stabilization only after correction of the hindfoot deformity may result in creating a rigid hindfoot, compromising clinical outcomes. Careful analysis of the lateral radiograph to determine whether the deformity is secondary to the medial column or true peritalar subluxation may allow superior outcomes. Iatrogenic creation of an excessively rigid medial column may lead to significant instability of the remaining joints in the short term and arthrosis in the long term. Medial column arthrodesis should be used selectively to correct gross instability.
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15
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Abstract
Sag at the naviculocuneiform (NC) joint represents an important aspect of the flatfoot deformity. Failure to address medial column instability could lead to continued deformity and poor patient outcomes. No single procedure is enough to address the complexity of the adult acquired flatfoot deformity. Whether in combination with other procedures or in isolation, NC fusion and Cotton osteotomy are important pieces of the armamentarium to address all aspects of the flatfoot deformity.
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Affiliation(s)
- Joshua A Metzl
- Department of Orthopaedics, UC Health Steadman Hawkins Clinic Denver, 8200 East Belleview Avenue Suite 615, Greenwood Village, CO 80111, USA.
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16
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Renner K, McAlister JE, Galli MM, Hyer CF. Anatomic Description of the Naviculocuneiform Articulation. J Foot Ankle Surg 2017; 56:19-21. [PMID: 27989339 DOI: 10.1053/j.jfas.2016.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Indexed: 02/03/2023]
Abstract
The naviculocuneiform articulation is composed of the navicular proximally and the 3 cuneiforms distally. It is not uncommon to perform surgical interventions at this joint for multiple pathologic foot etiologies. To date, no detailed anatomic measurement is available for each cuneiform articulation on the navicular. The purpose of the present study was to present an anatomic description of this complex joint to aid in better surgical understanding and improve surgical outcomes. Ten fresh, frozen, and thawed below-the-knee cadaveric specimens were used for anatomic dissection of the navicular and associated cuneiforms. The height and width were recorded across the largest span of the entire navicular-cuneiform joint complex and each facet. The mean navicular height and width was 19.9 mm and 34.7 mm, respectively. The medial cuneiform facet mean height and width was 19.9 mm and 15.8 mm, respectively. The intermediate cuneiform facet mean height and width was 20.4 mm and 16.9 mm, respectively. The lateral cuneiform facet mean height and width was 17.5 mm and 14.7 mm, respectively. A detailed description of this joint complex will aid foot and ankle surgeons in screw placement and surgical decision-making when performing complex medial column fusions. Advanced 3-dimensional weightbearing computed tomography would give us a better idea of the motion that occurs within this complex joint.
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Affiliation(s)
- Kevin Renner
- Postgraduate Year 2 Resident, OhioHealth Grant Medical Center, Columbus, OH
| | | | | | - Christopher F Hyer
- Fellowship Director, Attending Physician, Orthopedic Foot & Ankle Center, Westerville, OH.
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17
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Abstract
Concomitant hindfoot and midfoot deformity is common. Hindfoot fusion is associated with prolonged recovery and significant disability. Further surgery is often required to obtain a plantigrade foot. Understanding normal structural and kinematic relationships between the midfoot and hindfoot, as well as recognizing common combined patterns of midfoot and hindfoot deformity, can minimize the unanticipated consequences of hindfoot fusion. Treatment of residual or resultant midfoot deformity requires a thorough analysis of the deformity and familiarity with a variety of operative techniques for correction.
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Affiliation(s)
- Paul T Fortin
- Department of Orthopaedic Surgery, School of Medicine, Oakland University William Beaumont, 30575 Woodward Avenue, Royal Oak, MI 48073, USA.
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18
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Ajis A, Geary N. Surgical technique, fusion rates, and planovalgus foot deformity correction with naviculocuneiform fusion. Foot Ankle Int 2014; 35:232-7. [PMID: 24357679 DOI: 10.1177/1071100713517098] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arthrodesis of the naviculocuneiform (NC) joints is not a common procedure, as it is perceived by many to be less reliable or less predictable than arthrodesis of proximal or distal joints in the medial column. There is a subset of patients with planovalgus feet, cavovarus feet, and degenerative arthritis who also have an apex of deformity at the NC joints in whom fusion is indicated. The surgical technique, fusion rates, and deformity correction data for NC fusion in planovalgus feet are evaluated in this report. METHODS Twenty-eight patients (33 feet) who underwent surgery between October 2008 and November 2012 were identified who had NC fusion as their only arthrodesis procedure. Medical records and radiographs were reviewed, and time to union was calculated. Twenty patients from that group underwent NC fusion for symptomatic planovalgus feet, and their preoperative and last postoperative weight-bearing radiographs were reviewed and compared for deformity correction. All patients were operated on by the senior author or a senior foot and ankle trainee during fellowship using the same surgical technique, and all patients followed a standardized postoperative rehabilitation protocol. RESULTS Mean time to union for all 33 NC fusions was 21.7 ± 2 weeks (mean ± SEM). One patient underwent revision for nonunion, resulting in an arthrodesis rate of 97%. For NC fusions in those with planovalgus feet, an improvement in mean lateral talus-first metatarsal angle (Meary's line) from 12.3 ± 1.3 degrees to 5.2 ± 1.2 degrees (P < .05) was found. There was also a mean improvement in talonavicular coverage angle from 14.1 ± 1.8 degrees to 7.4 ± 1.3 degrees (P < .05). There were 2 superficial wound infections that were successfully treated with oral antibiotics, there were no cases of deep vein thrombosis or pulmonary embolism, and all patients came out of cast at 6 weeks into a fixed angle boot to commence weight bearing. Patients were happy with 32 of the 33 procedures and required no further treatment for their condition. CONCLUSIONS NC fusion was a safe and predictable procedure for any of its indications, with a fusion rate similar to that of other joints in the foot albeit with a longer time to union. For patients with symptomatic and flexible planovalgus feet, NC fusion resulted in deformity correction in multiple planes and good symptomatic relief. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Adam Ajis
- Western Sussex Hospitals NHS Trust, Worthing, UK
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Hintermann B, Knupp M, Barg A. Gelenkerhaltende Therapieoptionen bei peritalarer Instabilität. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.fuspru.2013.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
A varus or valgus talar tilt that increases under weight-bearing is commonly seen in osteoarthritic ankles. Loss of peritalar stability may be the underlying cause for the talus shifting and rotating on the calcaneonavicular surfaces, as given by applied forces. The instability pattern and the resulting deformity can be assessed and classified using weight-bearing conventional radiographs. Appropriate osseous balancing may be the most appropriate treatment to restore a regular position of talus within the ankle mortise. In cases with severe peritalar instability, subtalar fusion may be advised. Soft tissue reconstruction may be needed to achieve physiologic balance of the hindfoot complex.
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Hintermann B, Zwicky L, Knupp M, Henninger HB, Barg A. HINTEGRA Revision Arthroplasty for Failed Total Ankle Prostheses: Surgical Technique. JBJS Essent Surg Tech 2013; 3:e12. [PMID: 30881743 DOI: 10.2106/jbjs.st.m.00021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction In our experience, revision ankle arthroplasty with a three-component total ankle prosthesis following a failed total ankle replacement has provided encouraging midterm results with substantial pain relief while preserving the range of motion of the replaced ankle. Step 1 Preoperative Assessment and Planning Determine the treatment using a decision algorithm. Step 2 Patient Positioning Use spinal or general anesthesia, administer intravenous antibiotics, position the patient supine, and apply a tourniquet. Step 3 Surgical Approach to the Failed Prosthesis Use an anterior approach to expose the failed ankle prosthesis. Step 4 Removal of the Prosthesis Remove the polyethylene insert, the talar component, and the tibial component, making sure to not compromise any remaining bone stock. Step 5 Revision Ankle Arthroplasty Prepare the tibial and talar bone stock to obtain solid osseous surfaces, and use the appropriate prosthetic components. Step 6 Additional SurgicalProcedures If Necessary If necessary, perform arthrodesis of adjacent joints, correcting osteotomies of the distal parts of the tibia and fibula, calcaneal osteotomy, and/or ligamentoplasty. Step 7 Closure of All Incisions Close all incisions. Step 8 Postoperative Care A short leg splint is worn for two days, followed by partial weight-bearing; the ankle is protected in a splint at night and with a walking boot during the day for six to eight weeks. Results Between 2000 and 2010, 117 ankles in 116 patients (fifty-six female and sixty male; mean age, 55.0 ± 12.0 years) who presented with a failed total ankle arthroplasty after a mean of 4.3 ± 3.9 years were treated by revision arthroplasty with use of the HINTEGRA three-component total ankle prosthesis12. What to Watch For IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Beat Hintermann
- Clinic of Orthopaedic Surgery, Kantonsspital Baselland Liestal, Rheinstrasse 26, CH-4410 Liestal, Switzerland
| | - Lukas Zwicky
- Clinic of Orthopaedic Surgery, Kantonsspital Baselland Liestal, Rheinstrasse 26, CH-4410 Liestal, Switzerland
| | - Markus Knupp
- Clinic of Orthopaedic Surgery, Kantonsspital Baselland Liestal, Rheinstrasse 26, CH-4410 Liestal, Switzerland
| | - Heath B Henninger
- Harold K. Dunn Orthopaedic Research Laboratory, Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108
| | - Alexej Barg
- Department of Orthopaedic Surgery, University Hospital of Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland. E-mail address for A. Barg:
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Barg A, Pagenstert GI, Leumann AG, Müller AM, Henninger HB, Valderrabano V. Treatment of the arthritic valgus ankle. Foot Ankle Clin 2012; 17:647-63. [PMID: 23158375 DOI: 10.1016/j.fcl.2012.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The ankle joint is part of a biomechanical hindfoot complex. Approximately 1% of the world's adult population is affected by ankle osteoarthritis (AO). Trauma is the primary cause of ankle OA, often resulting in varus or valgus deformities. Only 50% of patients with end-stage ankle OA have a normal hindfoot alignment. The biomechanics and morphology of the arthritic valgus ankle is reviewed in this article and therapeutic strategies, including joint preserving and nonpreserving modalities are presented. Pitfalls are discussed and the literature is reviewed regarding outcomes in patients with valgus deformity who underwent total ankle replacement.
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Affiliation(s)
- Alexej Barg
- Orthopaedic Department, University Hospital of Basel, University of Basel, Spitalstrasse 21, Basel CH-4031, Switzerland.
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Abstract
The traditional surgical treatment for adults with a rigid, arthritic flatfoot is a dual-incision triple arthrodesis. Over time, this procedure has proved to be reliable and reproducible in obtaining successful deformity correction through fusion and good clinical results. However, the traditional dual-incision triple arthrodesis is not without shortcomings. Early complications include lateral wound problems, malunion, and nonunion. Long-term follow-up of patients after a triple arthrodesis has shown that many develop adjacent joint arthritis at the ankle or midfoot. This particular problem should be considered an expected consequence, rather than a failure of the procedure. Although the indications for and surgical techniques used in triple arthrodesis have evolved and improved with time (predictably improving results in the intermediate term), the triple arthrodesis should be regarded as a salvage procedure. Certain measures can be taken by the surgeon to avoid some problems. If patients are at risk for lateral wound complications, the arthrodesis could be performed through a single medial incision. However, this can make some aspects of the CC fusion more difficult. Implants would have to be inserted percutaneously, which prevents the surgeon from using either staples or plates. If a patient were to need a lateral column lengthening through a CC distraction fusion, this would not be possible medially. If either the ST or CC joints have minimal degenerative changes, they could be spared through a double or modified double arthrodesis, respectively. Although these procedures that deviate from the traditional triple arthrodesis offer promise, further study is required to better define their role in treatment of the rigid, arthritic AAFD. Triple arthrodesis is, by no means, a simple surgery. It requires preoperative planning, meticulous preparation of bony surfaces, cognizance of hindfoot positioning, and rigidity of fixation. The procedure also requires enough experience on the part of the operating surgeon to anticipate postoperative problems and provide modifications in traditional technique for certain patients.
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Hintermann B, Barg A, Knupp M. [Revision arthroplasty of the ankle joint]. DER ORTHOPADE 2012; 40:1000-7. [PMID: 21996936 DOI: 10.1007/s00132-011-1829-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In the last 20 years total ankle replacement has become a viable alternative to arthrodesis for end-stage osteoarthritis of the ankle. Numerous ankle prosthesis designs have appeared on the market in the past and attracted by the encouraging intermediate results reported in the literature, many surgeons have started to perform this procedure. With increased availability on the market the indications for total ankle replacement have also increased in recent years. In particular, total ankle replacement may now be considered even in younger patients. Therefore, despite progress in total ankle arthroplasty the number of failures may increase. Up to now, arthrodesis was considered to be the gold standard for salvage of failed ankle prostheses. Because of extensive bone loss on the talar side, in most instances tibiocalcaneal fusion is the only reliable solution. An alternative to such extended hindfoot fusions would be revision arthroplasty. To date, however, there are no reported results of revision arthroplasty for salvage of a failed ankle replacement.Based on our experience prosthetic components with a flat undersurface are most likely to be able to find solid support on remaining bone stock. The first 83 cases (79 patients, 46 males, 33 females, average age 58.9 years, range 30.6-80.7 years) with a average follow-up of 5.4 years (range 2-11 years) showed excellent to good results in 69 cases (83%), a satisfactory result in 12 cases (15%) and a fair result in 2 cases (2%) and 47 patients (56%) were pain free. Primary loosening was noted in three cases and of these two cases were successfully revised by another total ankle replacement and in one case with arthrodesis. Another case with hematogenous infection was also revised by arthrodesis. At the last follow-up control two components were considered to be loose and the overall loosening rate was thus 6%.This series has proven that revision arthroplasty can be a promising option for patients with failed total ankle prosthesis. The most challenging issue is the solid anchoring of available components on residual bone. More experience is needed, however, to better define the possibilities and limitations of revision arthroplasty.
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Affiliation(s)
- B Hintermann
- Klinik für Orthopädie und Traumatologie des Bewegungsapparates, Kantonsspital Liestal, Rheinstr. 26, CH-4410, Liestal, Schweiz.
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