Role of Minimally Invasive Surgery in Adult Flatfoot Deformity

Displacement after Open vs Saw-Based Minimally Invasive Medial Displacement Calcaneal Osteotomy: A Cadaveric Study

Background

Medial displacement calcaneal osteotomy (MDCO) is routinely used in hindfoot valgus realignment. Minimally invasive surgery (MIS) calcaneal osteotomies have been reported to be as safe and effective compared to open techniques. The aim of this cadaveric study was to compare the amount of medial tuberosity displacement obtained with fine-cut saw-based MIS vs open MDCO techniques.

Methods

Eight matched cadaveric specimens had one side randomly assigned to either open or MIS MDCO. The contralateral limb was then assigned to the alternative osteotomy. The amount of medial displacement provided by the osteotomy was measured manually using a flexible metric ruler and radiographically on standardized axial calcaneal radiographs.

Results

Manual measurements showed that a mean displacement of the MIS osteotomy was 7.9 mm compared with 8.7 mm for the open technique (P = .36). Radiograph measurement showed a mean displacement of the MIS osteotomy was 7.1 mm compared with 7.4 mm for the open technique (P = .83). No significant difference was found on manual and radiographic measurement of medial displacement between MIS and open MDCO.

Conclusion

In a cadaveric model, we found similar magnitude of calcaneal tuberosity displacement using fine-cut saw-based MIS and open techniques for medial displacement calcaneal osteotomies.

Level of Evidence

Level V, cadaveric study.

Clinical Outcomes Following Treatment of Recurrent Talotarsal Joint Dislocation Using a Type II Extraosseous Talotarsal Stabilization Implant-A Long-Term Follow-Up Study

Collapsing foot deformity (CFD) and its resulting sequelae caused by recurring talotarsal joint dislocation (RTTJD) affects pediatric and adult patients. An extraosseous talotarsal stabilization (EOTTS) procedure, a subset of subtalar arthroereisis (SA) procedures, is recommended as a minimally invasive, first in-line surgical treatment option for CFD. The aim of this multicenter, retrospective study was to evaluate patient-reported outcomes measures in patients who were treated for RTTJD with Type II EOTTS implants. Sixty-seven cases having a median age of 38 years (range: 10-74) with more than 5 years of follow-up were included in this study. The mean postoperative visual analog scale and Maryland Foot Score was 1.0 ± 1.9 and 92.3 ± 11.3, respectively, indicating excellent clinical outcomes. Subjectively, 88% cases reported as being satisfied with the outcome, 94% cases said they would recommend EOTTS, and 93% said that, if necessary, they would repeat it on their contralateral foot. A subgroup analysis revealed that while not statistically significant, clinical outcomes were slightly better in pediatric patients compared to adults. Implant removal rate was 4.5% (3 cases), and these were in the adult group only. Rate of minor issues such as pain, stiffness, discomfort, etc. was 15%; however, no serious adverse effects or complications were observed in any patient. This study suggests that EOTTS is an effective surgical treatment option wherein successful long-term clinical outcomes with low failure rates can be achieved in a select patient population.

Flatfoot over the centuries: the background of current conservative and operative treatments

PURPOSE

Although flatfoot is a widespread human condition, historical medical texts and ancient illustrations on this deformity are extremely rare. Nowadays, doubts regarding its management remain unsolved. This historical review aims to identify the presence of pes planus since the prehistoric era and examine the treatments proposed over the centuries up to the present.

METHOD

For this propose, we performed an extensive electronic search of the relevant literature, complemented by a manual search of additional sources from archaeological to artistic, literary, historical, and scientific accounts, describing flatfoot and its treatment in different eras.

RESULTS

Flatfoot accompanied the evolutionary timeline of human species: from Lucy Australopithecus to Homo Sapiens. It was described among various diseases suffered by Tutankhamun (1343-1324 B.C.), while the first anatomical description dates to Emperor Trajan (53-117 A.D.) and the medical studies of Galen (129-201 A.D.). It was also represented in the anatomical drawings of Leonardo da Vinci (1452-1519) and Girolamo Fabrici d'Acquapendente (1533-1619). Historically, the conservative treatment by insoles was the only one proposed until the nineteenth century. Since then, the most popular surgical procedures performed for correction have been osteotomies, arthrodesis, arthrorisis, and tendon lengthening and transfer.

CONCLUSION

During the centuries, conservative therapeutic strategies have not radically changed in their substance, while operative ones have become the protagonists during the twentieth century up to the present. Nevertheless, after more than 2000 years of history, there is no consensus regarding the best indication for the flatfoot and if it really needs to be treated.

Adult Acquired Flatfoot Deformity: A Narrative Review about Imaging Findings

Adult acquired flatfoot deformity (AAFD) is a disorder caused by repetitive overloading, which leads to progressive posterior tibialis tendon (PTT) insufficiency. It mainly affects middle-aged women and occurs with foot pain, malalignment, and loss of function. After clinical examination, imaging plays a key role in the diagnosis and management of this pathology. Imaging allows confirmation of the diagnosis, monitoring of the disorder, outcome assessment and complication identification. Weight-bearing radiography of the foot and ankle are gold standard for the diagnosis of AAFD. Magnetic Resonance Imaging (MRI) is not routinely needed for the diagnosis; however, it can be used to evaluate the spring ligament and the degree of PTT damage which can help to guide surgical plans and management in patients with severe deformity. Ultrasonography (US) can be considered another helpful tool to evaluate the condition of the PTT and other soft-tissue structures. Computed Tomography (CT) provides enhanced, detailed visualization of the hindfoot, and it is useful both in the evaluation of bone abnormalities and in the accurate evaluation of measurements useful for diagnosis and post-surgical follow-up. Other state-of-the-art imaging examinations, like multiplanar weight-bearing imaging, are emerging as techniques for diagnosis and preoperative planning but are not yet standardized and their scope of application is not yet well defined. The aim of this review, performed through Pubmed and Web of Science databases, was to analyze the literature relating to the role of imaging in the diagnosis and treatment of AAFD.