Tibiofibular torsion in congenital clubfoot

Parameters That Can Be Used to Quantify Reduction Accuracy in Talar Neck Fractures and Malunions: A PRISMA-Compliant Scoping Review and Meta-Analysis

Understanding the three-dimensional anatomy of the talar neck is essential in assessing the accuracy of reduction in talar neck fractures as well as for planning surgical correction for talar malunions. However, the geometrical parameters that describe this anatomy are sparsely reported in the orthopedics literature. We aimed to identify from the existing literature, geometrical parameters that describe the anatomy of the talar neck, determine how these are measured, and their normative values. A scoping literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. The primary searches were conducted on the PubMed, Embase, and Scopus databases. Any original research study looking at the human talus neck geometry was included. Parameters that described the anatomy of the talar neck were identified, and pooled estimates were determined by the random-effects meta-analysis model. Heterogeneity was assessed by the I2 test and leave-one-out meta-analysis. Subgroup analysis was done to compare the values of parameters between the Asian and Non-Asian populations. The risk of bias was assessed by the National Institutes of Health (NIH) Case Series Tool. The combined searches yielded 6326 results, of which 21 studies were included in the review and 15 in six different sets of metanalysis. The majority of the studies (n=19, 90.5%) evaluated adult tali, and only two (9.5%) evaluated pediatric tali. In most of the studies (n=13, 61.9%), talus neck geometry was evaluated on dry bones or anatomical specimens; evaluation by imaging techniques (radiographs, CT, MRI, and radiostereometric analysis) was used in eight studies, (39.1%). A total of eight different geometrical parameters (neck length, height, width, declination angle, inclination angle, torsion angle, circumference, and cross-sectional area) were identified. Except for talar torsion, variability was noted in methods of measurement of all other parameters. Subgroup analysis revealed that Asians had a higher neck height as compared to non-Asians; other parameters were not significantly different. Although the literature reports geometrical parameters to assess the talar geometry, the methods of measurement of these parameters are variable. Most of the available literature describes measurement techniques on cadaveric tali, and there is no literature on how these parameters should be measured on conventional CT or MRI slices. Further research needs to focus on the standardization of measurement techniques for these parameters on conventional CT and/or MRI scans.

Congenital Clubfoot - Is the Ponseti Method the Definitive Solution?

Congenital clubfoot is one of the most common deformities at birth. The inadequacy or absence of treatment causes serious limitations for people with this condition. The initial treatment using the Ponseti method ensures functional results superior to other treatment modalities previously proposed. However, recurrences and neglected feet are still a challenge today. An understanding of the pathophysiology of the disease, as well as of the anatomy and local biomechanics and a thorough clinical and radiological evaluation of patients are essential to understanding the limits of the method and choosing the best treatment.

Medial subtalar dislocation from a low-energy trauma. A case report and review of the literature

INTRODUCTION

Subtalar dislocation is a rare injury characterized by a simultaneous dislocation of the talocalcaneal and talonavicular joints. The most common type is caused by high-energy trauma with medial dislocation of the foot. This injury is frequently associated with fractures, but isolated dislocations are also reported.

CASE PRESENTATION

We report a rare case of medial subtalar dislocation secondary to low-energy injury in a 61-year-old woman. Following X-rays and CT scan, prompt closed reduction was performed under sedation and, after reduction, X-rays showed a good realignment of the foot. The CT scan revealed an occult non-displaced fracture of the posterior part of the talus. The patient was managed conservatively by a non-weight bearing cast for four weeks, followed by a rehabilitation program. At follow-up, six months later, we observed a good clinical and radiographic result.

DISCUSSION

The reported case confirms that the mechanism of injury is an important factor in predicting the final result, since subtalar dislocations secondary to a high-energy trauma are often associated with significant complications. We believe, in agreement with other authors, that a low-energy trauma generally doesn't produce long-term morbidity. Prompt reduction is very important in order to minimize soft tissue and neurovascular complications, although a CT is recommended to identify occult fractures.

CONCLUSION

Subtalar dislocations, caused by low energy trauma, if adequately reduced in the emergency room, generally heal with conservative treatment, reducing the risk of significant complications. However, since we report a single patient, further case analysis is needed to make solid conclusions.

Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans-Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.'s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary's angle and Costa–Bertani's angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.'s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary's angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani's angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Assessment of the talar deformity and alignment in congenital clubfoot using three-dimensional MRI after Ponseti method

BACKGROUND

Ponseti method have been widely accepted as the initial treatment of congenital idiopathic clubfoot because its excellent primary result. On the other hand, relapses after Ponseti method are not uncommon and the cause of relapses have not been fully elucidated. We investigated detailed morphology and alignment of tarsal bones in clubfoot after Ponseti method using three-dimensional MRI analysis.

METHODS

We performed MRI with 10 patients of unilateral clubfoot at three months after Achilles tenotomy. Based on the MRI volume data, we reconstructed three-dimensional bone surface model using the marching cubes method. We evaluated the volume of the talus and navicular bone, medial and planter deviation of the talar head and neck, medial deviation of the navicular bone, and internal rotation angle of the distal tibiofibular joint.

RESULTS

In clubfoot, the volume of talus and navicular bone were significantly smaller compared with the contralateral side. Deviation of the talar head and neck varied from medially to almost the same as that on the contralateral side. The degree of deformity of the talus and alignment of the navicular bone and distal tibiofibular joint showed correlations.

CONCLUSIONS

Patients with the medial deviated talar neck might have the alignment change of navicular bone and distal tibiofibular joint. Deformity of talar neck might to be compensated by talonavicular joint and distal tibiofibular joint through the manipulation of Ponseti method.

In-toeing gait in children with clubfoot and the effect of tibial rotation osteotomy

In-toeing gait is common after treatment for clubfoot deformity and is often secondary to residual internal tibial torsion. The purpose of the current study was to characterize the gait pattern in children with an intoeing gait pattern associated with talipes equinovarus (TEV) deformity, identify secondary changes at the hip that occur with intoeing, and determine if these secondary effects resolve after correction of tibial torsion. Patients with a diagnosis of TEV deformity, in-toeing gait secondary to residual internal tibial torsion corrected with tibial rotation osteotomy (TRO) and complete preoperative and postoperative motion analysis studies obtained approximately 1 year apart, were included in the study. Nineteen children (19 left extremities) with a TRO at a mean age of 8.2 years met inclusion criteria. Clinical examination showed improvement in tibial torsion assessment by measure of the thigh foot axis and transmalleolar axis. Kinematically, an abnormal internal FPA was present in all cases preoperatively, was corrected to normal in 12 (63%), remained internal in 5 (26%), and was abnormally external in 2 (11%). External hip rotation was identified in 13 (68%) cases preoperatively. Hip rotation was normalized postoperatively in 7 (54%), and was unchanged in the remaining 6 (46%). TRO provides effective correction of excessive internal tibial torsion, resolution of kinematic internal knee rotation, and normalization of the internal foot progression angle in the majority of patients with TEV deformity. External hip rotation resolved in approximately 50% of cases. Overcorrection of the internal FPA is possible when secondary changes at the hip do not resolve.

[Pediatric clubfoot : Treatment of recurrence]

Over the last 10 years the Ponseti method has become established as the gold standard for initial treatment of clubfeet nearly worldwide. Nevertheless, there are considerable fluctuations regarding the authenticity and quality in the application of the Ponseti method. Especially the efforts to ensure and promote compliance with the foot abduction brace and subsequently the recurrence rate show great variation. As a result, we are still faced with a significant number of recurrent or residual clubfeet. In recent years it has been shown in high-volume clinics that even these can almost always be successfully treated with recasting and with minor interventions, such as anterior tibial tendon transfer and lengthening of the Achilles tendon. More invasive surgical procedures are only very rarely indicated and are reserved for severe recurrence in previously surgically treated and secondary clubfeet.

Treatment of Severe Recurrent Clubfoot

Understanding the pathoanatomy of severe recurrent clubfoot and its implication on treatment options is important for the successful treatment. A comprehensive clinical evaluation of the different components helps in selecting procedures. Individual needs and social and psychological factors influencing treatment and the impact of treatment on the child have to be considered. With increasing dissemination and improved understanding of the Ponseti method, a further decrease in the frequency of severe recurrent clubfoot can be hoped for and expected.

Treatment of the neglected and relapsed clubfoot

Treatment of the neglected and the relapsed clubfoot is one of the most controversial topics in pediatric foot care. This article reviews the breadth of treatment options for practicing podiatrists or orthopedists with a specialty in complex clubfoot treatment. Discussion includes the appropriate circumstances for the use of the different procedures presented and the author's preferred treatment algorithm, based on 15 years of treating neglected, relapsed, and nonidiopathic clubfeet.

Idiopathic congenital clubfoot: Initial treatment

Clubfoot (talipes equinovarus) is a three-dimensional deformity of unknown etiology. Treatment aims at correction to obtain a functional, plantigrade pain-free foot. The "French" functional method involves specialized physiotherapists. Daily manipulation is associated to immobilization by adhesive bandages and pads. There are basically three approaches: the Saint-Vincent-de-Paul, the Robert-Debré and the Montpellier method. In the Ponseti method, on the other hand, the reduction phase using weekly casts usually ends with percutaneous tenotomy of the Achilles tendon to correct the equinus. Twenty-four hour then nighttime splinting in abduction is then maintained for a period of 3 to 4 years. Recurrence, mainly due to non-compliance with splinting, is usually managed by cast and/or anterior tibialis transfer. The good long-term results, with tolerance of some anatomical imperfections, in contrast with the poor results of extensive surgical release, have led to a change in clubfoot management, in favor of such minimally invasive attitudes. The functional and the Ponseti methods reported similar medium term results, but on scores that were not strictly comparable. A comparative clinical and 3D gait analysis with short follow-up found no real benefit with the increasingly frequent association of Achilles lengthening to the functional method (95% to 100% initial correction). Some authors actually suggest combining the functional and Ponseti techniques. The Ponseti method seems to have a slight advantage in severe clubfoot; if it is not properly performed, however, the risk of failure or recurrence may be greater. "Health economics" may prove decisive in the choice of therapy after cost-benefit study of each of these treatments.