A comparison of lateral column lengthening and medial translational osteotomy of the calcaneus for the reconstruction of adult acquired flatfoot

Isolated Subtalar Repositional Arthrodesis Compared With Triple Arthrodesis for the Treatment of Progressive Collapsing Foot Deformity

The optimal extent of arthrodesis for severe and rigid progressive collapsing foot deformity is controversial. Traditionally, triple arthrodesis has been recommended; however, good results have been reported using subtalar arthrodesis only. We compared the results of triple arthrodesis and isolated subtalar repositional arthrodesis. A total of 22 symptomatic feet were evaluated retrospectively. Isolated subtalar repositional arthrodesis was performed in 13 cases (the subtalar group) and double or triple arthrodesis in 9 cases (the triple group). Various radiographic variables for assessing flatfoot and osteoarthritic changes in ankle and tarsal joints were measured and compared between the 2 groups at 3 time points: preoperatively, 3 months postoperatively, and 4 y postoperatively. Additionally, we analyzed various factors that affect postoperative valgus talar tilt in the ankle joint, which has been associated with poor prognosis. There were no differences in preoperative demographic data and the severity of the disease between the 2 groups; both groups showed improvement in radiographic parameters postoperatively compared with preoperative results. With the numbers available, no significant differences could be detected in postoperative radiographic measurements between the 2 groups. Of all the variables analyzed, postoperative hindfoot alignment angle was associated with postoperative talar tilt development. Additionally, postoperative talar tilt was observed more in triple group than in subtalar group. In conclusion, isolated subtalar repositional arthrodesis is an effective procedure to correct advanced progressive collapsing foot deformity. In addition, Chorpart joint arthrodesis with improper position can cause valgus talar tilt in the ankle joint.

Medializing Calcaneal Osteotomy for progressive collapsing foot deformity alters the three-dimensional subtalar joint alignment

BACKGROUND

A medializing calcaneal osteotomy (MCO) is considered as one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the post-operative hind- and midfoot alignment, alternations of the subtalar joint alignment remained obscured by superposition on plain radiography. Therefore, we aimed to assess the hind-, midfoot- and subtalar joint alignment pre- compared to post-operatively using 3D weightbearing CT (WBCT) imaging.

METHODS

Seventeen patients with a mean age of 42 ± 17 years were retrospectively analyzed. Inclusion criteria consisted of PCFD deformity corrected by a medializing calcaneal osteotomy (MCO) as main procedure and imaged by WBCT before and after surgery. Exclusion criteria were patients who had concomitant calcaneal lengthening osteotomies, mid-/hindfoot fusions, hindfoot coalitions, and supramalleolar procedures. Image data were used to generate 3D models and compute the hindfoot (HA), midfoot (MA) - and subtalar joint (STJ) alignment in the coronal, sagittal and axial plane, as well as distance maps.

RESULTS

Pre-operative measurements of the HA and MA improved significantly relative to their post-operative equivalents p < 0.05). The post-operative STJ alignment showed significant inversion (2.8° ± 1.7), abduction (1.5° ± 1.8), and dorsiflexion (2.3° ± 1.7) of the talus relative to the calcaneus (p < 0.05) compared to the pre-operative alignment. The displacement between the talus and calcaneus relative to the sinus tarsi increased significantly (0.6 mm±0.5; p < 0.05).

CONCLUSION

This study detected significant changes in the sagittal, coronal, and axial plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings contribute to our clinical practice by demonstrating the magnitude of alteration in the subtalar joint alignment that can be expected after PCFD correction with MCO as main procedure.

Union in Lateral Column Lengthening by Plate Fixation Without Bone Graft in Flexible Flatfoot: A Case Series

Purpose

This study's goal was to evaluate the outcomes of lateral column lengthening by plate fixation without bone graft in the management of symptomatic flexible flatfoot.

Methods

A prospective randomized trial study included 30 feet (27 patients) and was performed from March 2017 to December 2019. Functional and radiological evaluations were done pre-operative and at the final post-operative follow-up. The functional assessment was done using the American Orthopaedic Foot and Ankle Society (AOFAS) score.

Results

The mean follow-up was 16.5 ± 3.027 months. The mean age of patients was 22.6 ± 6.29 years. All cases showed union ranging from 8 to 12 weeks, with a mean of 10 ± 1.88 weeks. The mean AOFAS score improved from 51.6 ± 6.75 to 92.2 ± 6.21. The mean anteroposterior (AP) talo-first metatarsal angle improved from 25.3° ± 8.31° to 3.4° ± 5.10°. The mean anteroposterior (AP) talo-navicular coverage improved from 22.10° ± 4.28° to 2.3° ± 3.46°. The mean Lateral talo-first metatarsal angle improved from 18.6° ± 4.79° to 3.3° ± 3.16°. The calcaneal pitch angle improved from 9.6° ± 4.14° to 15.1° ± 4.43°. The mean lateral talo-calcaneal angle improved from 45.7° ± 3.77° to 37.5° ± 3.47°.

Conclusion

Using an interposition wedge plate for LCL without bone graft leads to a high union rate, maintains the correction, and avoids possible complications of autografts and allografts.

Medium- to Long-term Results of Nonanatomic Spring Ligament Reconstruction Using an Allograft Tendon in Progressive Collapsing Foot Deformity With Severe Abduction Deformity

BACKGROUND

Spring ligament reconstruction (SLR) has been suggested as an adjunct to other reconstructive procedures to potentially avoid talonavicular joint fusion in progressive collapsing foot deformity (PCFD) with severe abduction deformity. Most clinical reports present short-term follow-up data and a small number of patients. The purpose of this study was to examine the medium- to long-term outcomes of an SLR using allograft tendon augmentation as part of PCFD surgical reconstruction. This study to our knowledge represents the largest number of patients and the longest follow-up to date.

METHODS

This study retrospectively reviewed 26 patients (27 feet, mean age of 61.4 years) who underwent SLR with allograft tendon as part of PCFD reconstruction. The mean follow-up of the cohort was 8 years (range, 5-13.4). Radiographic evaluation consisted of 5 parameters including talonavicular coverage angle (TNC), with the maintenance of correction being evaluated by comparing parameters from the early postoperative period (mean: 11.6 months, range, 8-17) to final follow-up. Foot and Ankle Outcome Score (FAOS) and patient satisfaction questionnaires were collected at final follow-up. Conversion to talonavicular or subtalar fusion was considered as a failure.

RESULTS

Final radiographs demonstrated successful abduction correction, with the mean TNC improving from 43.7 degrees preoperatively to 14.1 degrees postoperatively (P < .0001). All other radiographic parameters improved significantly and exhibited maintenance of the correction. All FAOS subscales showed significant improvement. Responses to the satisfaction questionnaire were received from all except 1 patient, of whom 88.5% (23/26) were satisfied with the results, 96.2% (25/26) would undergo the surgery again, and 88.5% (23/26) would recommend the surgery. Eight feet (29.6%) required painful hardware removal and 1 (3.7%) developed nonunion of the lateral column lengthening osteotomy. No patient required conversion to talonavicular or subtalar fusion.

CONCLUSION

This study demonstrates favorable medium- to long-term outcomes following PCFD reconstruction including an SLR with allograft tendon augmentation.

LEVEL OF EVIDENCE

Level IV, case series.

Types of Sliding Calcaneal Osteotomy Fixation: A Systematic Review and Meta-Analysis

Introduction Different methods are used to fix a sliding calcaneal osteotomy for hindfoot varus and valgus deformity. However, information about the effectiveness and limitations of each method is limited. In this meta-analysis, we compare the hardware removal rate, union rate, and complications of three different methods of fixation: plate, headed screw, and headless screw. Methods A systematic review and meta-analysis of published articles were carried out, following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We investigated diverse databases, Web of Science, PubMed, the Cochrane Library, Excerpta Medica database (EMBASE), and Cumulative Index of Nursing and Allied Health Literature (CINAHL), to search articles reporting the use of different calcaneal osteotomy fixations from database inception to October 2021. The primary outcome was the hardware removal rate, and the secondary outcomes of interest were the union rate and complications. Results Of 1,903 articles identified, eight met the inclusion criteria. The highest risk ratio (RR) of the hardware removal rate was detected in the headed screw method (RR: 0.39, 95% confidence interval (CI): 0.26-0.58). However, the highest RR of nonunion was detected in the plate method (RR: 0.02, 95%CI: 0.01-0.07). Regarding complications (infections), the headed screw method presented the highest RR of infection (RR: 0.24, 95%CI: 0.06-0.97). Conclusion This comprehensive review and meta-analysis revealed that the headless screw method may be the most effective fixation option for calcaneal osteotomy with the lowest risk of hardware removal rate, nonunion rate, and complications. Obviously, further studies are needed on a larger number of patients to confirm this finding.

Evans Calcaneal Osteotomy: Assessment of Multiplanar Correction

Flatfoot deformity consists of collapse of the medial arch, forefoot abduction, increased talonavicular uncoverage, and hindfoot valgus. Although numerous soft tissue and bony procedures have been proposed to correct each plane of deformity, there is a lack of objective data in the literature quantifying the amount of structural correction. The purpose of this study was to quantify the multiplanar deformity correction of the lateral column lengthening osteotomy (Evans) on hindfoot alignment through objective, reproducible, radiographic measurements. We retrospectively reviewed 45 Evans calcaneal osteotomy procedures in 24 female (53%) and 21 male (47%) feet performed on 40 patients (5 bilateral). The mean follow-up was 53 weeks (range, 32-116). The mean age at the time of surgery was 35 years (range, 11-73). Statistically significant improvement in radiographic alignment was found in the calcaneal inclination angle, tibial-calcaneal angle, tibial-calcaneal position, and the anteroposterior talo-first metatarsal angle (p < .0001 for all). Although a direct correlation between graft size and degree of angular correction was not observed, it should be noted the calcaneal graft size (mean, 11.8 mm) and the amount of hindfoot valgus correction (mean, 12.6°) appear to be clinically related. The results of this study support that the Evans calcaneal osteotomy corrects the hindfoot alignment in 3 planes as evidenced by our multiplanar radiographic measurements.

Subtalar Arthroereisis as an Adjunct Procedure Improves Forefoot Abduction in Stage IIb Adult-Acquired Flatfoot Deformity

BACKGROUND

Our aims were (a) to determine whether subtalar arthroereisis (STA) as adjunct procedure improved radiographic correction of stage IIb adult-acquired flexible flatfoot deformity (AAFD); (b) to assess the STA-related complication rate.

METHODS

A retrospective analysis of 22 feet (21 patients) diagnosed with stage IIb AAFD treated by medializing calcaneal osteotomy (MCO), flexor digitorum longus (FDL) transfer, spring ligament (SL) repair with or without Cotton osteotomy and with or without STA in a single institution was carried out. Seven measurements were recorded on pre- and postoperative (minimum 24 weeks) radiographs by 2 observers and repeated twice by 1 observer. Inter- and intraobserver reliabilities were assessed. The association of demographic (gender, side, age, body mass index) and surgical variables (Cotton, STA) with radiographic change was tested with univariate analysis followed by a multivariable regression model.

RESULTS

Excellent inter- and intraobserver reliabilities were demonstrated for all measurements (intraclass correlation coefficient range, 0.75-0.99). Gender, side, Cotton osteotomy, and STA were included in the multivariable analysis. Regression showed that STA was the only predictor of change in talonavicular coverage angle (TNCA) (R² = 0.31; P = .03) and in calcaneo-fifth metatarsal angle (CFMA) (R² = 0.40; P = .02) on dorsoplantar view. STA was associated to a greater change in TNCA by 10.1° and in CFMA by 5°. Four patients out of 12 STA complained of sinus tarsi pain after STA, and removal of the implant resolved symptoms in 3 of them.

CONCLUSION

In this series, STA as an adjunct procedure to MCO, FDL transfer, SL repair in the treatment of stage IIb AAFD led to improvement in correction of forefoot abduction. STA-related complication and removal rates were 33%.

LEVELS OF EVIDENCE

Level IV: Retrospective cohort study.

Subtalar Fusion for Correction of Forefoot Abduction in Stage II Adult-Acquired Flatfoot Deformity

BACKGROUND

Correction of talonavicular uncoverage (TNU) in adult-acquired flatfoot deformities (AAFD) can be a challenge. Lateral column lengthening (LCL) traditionally is utilized to address this. The primary study objective is examining stage II AAFD patients and determining if correction can be achieved with subtalar fusion (STF) comparable to LCL.

METHODS

Following institutional review board approval, retrospective chart review performed identifying patients meeting criteria for stage IIB AAFD who underwent either STF with concomitant flatfoot procedures (but not LCL) to correct TNU, or who underwent LCL as part of their flatfoot reconstruction. Patients indicated for STF had one or more of the following: higher body mass index (BMI), were older, had greater deformity, lateral impingement pain, intraoperative spring ligament hyperlaxity. Patients without 1-year follow-up or compete records were excluded. All other patients were included. A total of 27 isolated STFs identified, along with 143 who underwent LCL. Pre-/postoperative radiographic parameters obtained as well as PROMIS (Patient-Reported Outcomes Measurement Information System) and FAOS (Foot and Ankle Outcome Score) scores. Radiographic and patient reported outcomes both preoperatively and at 1-year follow-up evaluated for both groups.

RESULTS

STF patients were older (P < .05), with higher BMIs (P < .004). STF had significantly worse TNU (P < .001) than LCL patients, and average change in STF TNU was larger than LCL change postoperatively (P = .006), after adjusting for age, BMI, gender. PROMIS STF improvement reached statistical significance in Physical Function (P 0.011), for FAOS Pain (P 0.025) and Function (P = 0.04).

CONCLUSIONS

STF can be used in appropriately indicated patients to correct flatfoot deformity without compromising radiographic or clinical, correcting not only hindfoot valgus, but also talonavicular uncoverage (TNU) and corresponding medial arch collapse.

LEVELS OF EVIDENCE

Level III: Retrospective chart review comparison study (case control).

Soft Tissue Reconstruction and Osteotomies for Pes Planovalgus Correction

The correction of the flexible pes planovalgus foot and ankle is a complicated and somewhat controversial topic. After conservative methods fail, there is a wide range of possible soft tissue and bony procedures. The appropriate work up and understanding of the pathomechanics are vital to the correct choice of procedures to correct these deformities. Once the work up and procedure selection are done, the operation must also be technically performed well and with efficiency, as most often the condition is corrected with a variety of procedures. This article discusses some of the most common procedures necessary to fully correct the pes planovalgus foot and discusses the authors' technique and pearls.

How does the postoperative medial arch height influence the patient reported outcomes of stage Ⅱ acquired adult flatfoot deformity?

BACKGROUND

This study aimed to assess how the postoperative medial arch height influenced postoperative patient-reported clinical outcomes after surgery for stage Ⅱ acquired adult flatfoot deformity.

METHODS

A total of 30 feet of 30 patients (7 males, 23 females) who underwent surgery for stage Ⅱ acquired adult flatfoot deformity and could be followed up for at least 2 years were included. The average age at surgery was 60.0 (standard deviation, 13.0) years, and the average follow-up period was 40 (standard deviation, 15.4) months. Among them, 16 patients underwent lateral column lengthening and 14 patients did not. Patient-reported clinical outcomes were evaluated using the Self-Administered Foot Evaluation Questionnaire. Radiographic alignment was evaluated by the talonavicular coverage angle, lateral talo-1st metatarsal angle, medial cuneiform height, medial cuneiform to 5th metatarsal height, and calcaneal pitch. The correlation between postoperative Self-Administered Foot Evaluation Questionnaire and radiographic alignment was assessed with Pearson's correlation analysis.

RESULTS

Self-Administered Foot Evaluation Questionnaire and radiographic alignment significantly improved postoperatively in all patients (P < 0.0001). In patients with severe deformity who needed lateral column lengthening, lateral talo-1st metatarsal angle was negatively and medial cuneiform to 5th metatarsal height was positively correlated with physical functioning Self-Administered Foot Evaluation Questionnaire subscales (r = -0.56 and 0.55), and medial cuneiform height was positively correlated with physical functioning, social functioning and general health Self-Administered Foot Evaluation Questionnaire subscales (r = 0.70, 0.55 and 0.73, respectively).

CONCLUSION

Postoperative medial arch height could influence physical functioning, social functioning, and general health in patients with severe stage II adult-acquired flatfoot deformity.

The Plantar Fascia Talar Head Correlation: A Radiographic Parameter With a Distinct Threshold to Validate Flatfoot Deformity and Its Corrective Surgery on Conventional Weightbearing Radiographs

BACKGROUND

Corrective surgery for flexible flatfoot deformity (FD) remains controversial, and one of the main reasons for this is the lack of standardized radiographic measurements to define an FD. Previously published radiographic parameters to differentiate between a foot with and without an FD do not have a commonly accepted and distinct threshold.

METHODS

The plantar fascia-talar head correlation (PTC) with its defined threshold was assessed by measuring the distance between the medial border of the plantar fascia and the center of the talar head (DPT) on conventional dorsoplantar and lateral weightbearing radiographs; the authors were blinded to the clinical diagnosis of the 189 patients' first visits. Feet were sorted into groups with and without an FD based on their clinical examination. The effect of operative corrections of FD on the PTC was retrospectively evaluated on an additional 38 patients.

RESULTS

The sensitivity of the PTC was 0.98 (95% CI: 0.9-1) and specificity 0.96 (95% CI: 0.92-0.98), respectively, to identify an FD, consistent with the clinical examination. Thirty-five of 38 surgeries sufficiently corrected the FD and the PTC comparable to that in subjects without an FD. Three corrections with a residual FD did not adequately correct the PTC.

CONCLUSION

The PTC is a reliable radiographic parameter with a distinct threshold that is sensitive and specific for the differentiation of feet with and without an FD including feet with and without residual FD after corrective surgery. The PTC is applicable to monitor the needed intraoperative amount of correction using simulated weightbearing fluoroscopy.

LEVEL OF EVIDENCE

Level III, diagnostic.

Adult-Acquired Flatfoot Deformity: Combined Talonavicular Arthrodesis and Calcaneal Displacement Osteotomy versus Double Arthrodesis

Background: Adult-acquired flatfoot deformity due to posterior tibial tendon dysfunction (PTTD) is one of the most common foot deformities among adults. Hypothesis: Our study aimed to confirm that the combined procedures of calcaneal displacement osteotomy and talonavicular arthrodesis are equivalent to double arthrodesis. Methods: Between 2016 and 2020, 41 patients (13 male and 28 females, mean age of 63 years) were retrospectively enrolled in the comparative study. All deformities were classified into Stages II and III of PTTD, according to Johnson and Strom. All patients underwent isolated bony realignment of the deformity: group A (n = 19) underwent calcaneal displacement osteotomy and talonavicular arthrodesis, and group B (n = 23) underwent double arthrodesis. Measurements from the Foot Function Index-D (FFI-D) and the SF-12 questionnaire were collected, with a comparison of pre- and post-operative radiographs conducted. The mean follow-up period for patients was 3.4 years. Results: The mean FFI-D was 33.9 (group A: 34.5; group B: 33.5), the mean SF-12 physical component summary was 43.13 (group A: 40.9; group B: 44.9), and the mean SF-12 mental component summary was 43.13 (group A: 40.9; group B: 44.9). The clinical data and corrected angles showed no significant intergroup differences. Conclusion: Based on the available data, our study confirmed that the combined procedures of talonavicular arthrodesis and calcaneal shift, with preservation of the subtalar joint, can be considered equivalent to the established double arthrodesis, with no significant differences in terms of clinical and radiological outcomes.

A Retrospective Radiographic Evaluation of a Modified Method of Lateral Column Lengthening

Background: Lateral column lengthening (LCL) is a commonly performed procedure for patients with stage II adult-acquired flatfoot deformity (AAFD) to correct forefoot abduction. This procedure is frequently completed concomitantly with both soft-tissue and bony procedures, including a medial slide calcaneal osteotomy to further reduce hindfoot valgus. The purpose of this study is to investigate and identify the radiographic outcomes of a modified step-cut LCL utilized as an alternative approach for correction of stage II AAFD. Methods: A retrospective radiographic review was performed on 15 feet in 14 patients who underwent correction of stage II AAFD using a step-cut LCL between August 2009 and January 2012. Two independent examiners utilizing 6 radiographic parameters evaluated preoperative and postoperative weight-bearing radiographs of the foot. Results: At a mean follow-up of 13.4 (range 12-16) weeks, weight-bearing radiographs demonstrated a significant median decrease in the lateral talometatarsal angle of 14.4° (P < .001), lateral talocalcaneal angle of 7° (P < .001), anteroposterior talometatarsal angle of 14.5° (P < .001), anteroposterior talocalcaneal angle of 5.5° (P < .001), and talonavicular coverage angle of 26.5° (P < .001). Additionally, a significant median increase in calcaneal pitch of 8.5° (P < .001) was noted. Conclusion: This study demonstrates statistically significant improvement of radiographic outcomes with use of a modified step-cut LCL as an alternative approach for correction of stage II AAFD.Levels of Evidence: Level IV: Retrospective case series.

I am Afraid of Lateral Column Lengthening. Should I Be?

Lateral column lengthening has long been used in conjunction with other soft tissue and bony procedures to correct the midforefoot abduction seen in class B progressive collapsing foot deformity. The effectiveness of this osteotomy to restore the physiologic shape of the foot has been used by foot and ankle surgeons around the world to provide functional improvement for patients suffering from this disease. The overall low complication rates, low nonunion rates, and improved radiographic and functional outcomes provided by lateral column lengthening make this a valuable option for the treatment of class B progressive collapsing foot deformity.

Medial displacement calcaneal osteotomy versus lateral column lengthening to treat stage II tibialis posterior tendon dysfunction, a prospective randomized controlled study

PURPOSE

Adult-acquired flatfoot deformity (AAFD) requires optimum planning that often requires several procedures for deformity correction. The objective of this study was to detect the difference between MDCO versus LCL in the management of AAFD with stage II tibialis posterior tendon dysfunction regarding functional, radiographic outcomes, efficacy in correction maintenance, and the incidence of complications.

PATIENT AND METHODS

42 Patients (21 males and 21 females) with a mean age of 49.6 years (range 43-55), 22 patients had MDCO while 20 had LCL. Strayer procedure, spring ligament plication, and FDL transfer were done in all patients. Pre- and Postoperative (at 3 and 12 months) clinical assessment was done using AOFAS and FFI questionnaire. Six radiographic parameters were analyzed, Talo-navicular coverage and Talo-calcaneal angle in the AP view, Talo- first metatarsus angle, Talo-calcaneal angle and calcaneal inclination angle in lateral view and tibio-calcaneal angle in the axial view, complications were reported.

RESULTS

At 12 months, significant improvement in AOFAS and FFI scores from preoperative values with no significant difference between both groups. Postoperative significant improvements in all radiographic measurements in both groups were maintained at 12 months. However, the calcaneal pitch angle and the TNCA were better in the LCL at 12 months than MDCO, 17̊±2.8 versus 13.95̊±2.2 (p=0.001) and 13.70̊±2.2 versus 19.05̊±3.2 (p<0.001) respectively. 11 patients (26.2%) had metal removal, seven (16.6%) in the MDCO, and four (9.6%) in the LCL. Three (7.1%) in the LCL group had subtalar arthritis, only one required subtalar fusion.

CONCLUSION

LCL produced a greater change in the realignment of AAFD, maintained more of their initial correction, and were associated with a lower incidence of additional surgery than MDCO, however, a higher incidence of degenerative change in the hindfoot was observed with LCL.

Radiographic changes of the mid-tarsal joint after calcaneal lengthening for planovalgus foot deformity

BACKGROUND

This study evaluate the radiographic changes in the mid-tarsal joint, including the calcaneocuboid and talonavicular (TN) joints after calcaneal lengthening for planovalgus deformity in children.

METHODS

This study included 38 patients (68 feet) who underwent calcaneal lengthening for planovalgus deformity. Radiographic osteoarthritic changes at the CC or TN joint were defined as modified Kellgren-Lawrence grade of ≥1.

RESULTS

Among the 68 feet, 31 feet (45.6%) showed radiographic osteoarthritic changes at the CC joint and 20 (29.4%) showed changes at the TN joint. Risk of radiographic osteoarthritic changes at the CC joint was associated with increased age at surgery (OR = 1.2, p = 0.038). Risk of radiographic osteoarthritic changes at the TN joint was associated with increased age at surgery (OR = 2.2; p = 0.002), preoperative AP talus-1st metatarsal angle (OR = 1.1; p = 0.044), and degree of CC subluxation (OR = 2.1; p = 0.007).

CONCLUSIONS

Surgeons should consider the risk factors in the surgical correction of planovalgus deformity to prevent mid-tarsal arthritis.

Outcomes of Reconstruction of the Flexible Adult-acquired Flatfoot Deformity

Reconstruction of the flexible adult-acquired flatfoot deformity (AAFD) is controversial, and numerous procedures are frequently used in combination, including flexor digitorum longus transfer, medializing calcaneal osteotomy (MCO), heel cord lengthening/gastrocnemius recession, lateral column lengthening (LCL), Cotton osteotomy or first tarsometatarsal fusion, and spring ligament reconstruction. This article summarizes recent studies demonstrating that patients have significant improvements after operative treatment of flexible AAFD. It reviews current literature on clinical and radiographic outcomes of the MCO, LCL, and Cotton osteotomies. The authors describe how this information can be used in surgical decision making in order to tailor operative treatment to an individual patient's deformity.

Outcomes of the Extended Z-Cut Osteotomy for Correction of Adult Acquired Flatfoot Deformity

BACKGROUND

Medial displacement calcaneus tuberosity osteotomy and anterior process lengthening calcaneus osteotomy are traditional single-plane osteotomy techniques used in adult acquired flatfoot deformity reconstruction. More recently, 3-plane step-cut osteotomies were described for each of these and shown to offer improved rotational stability via the horizontal limb. However, a major technical challenge is achieving a sufficiently long horizontal limb to correct deformity through lengthening without losing bony apposition. Combining the anterior process and tuberosity step-cuts using an elongated horizontal limb alleviates this technical challenge, creates a very large surface area for bony healing, and utilizes a single incision. We hypothesized that the Z-cut osteotomy would achieve clinical and radiographic flatfoot deformity correction with a high union rate.

METHODS

This was an institutional review board-approved retrospective study of 16 patients who underwent Z-cut osteotomy for the treatment of moderate to severe symptomatic adult acquired flatfoot deformity, stage IIA/B. The mean radiographic follow-up was 8.8 months, while the mean clinical follow-up was 2.36 years. Radiographic correction was assessed via weightbearing radiographs taken preoperatively and at a mean of 26 ± 2 weeks postoperatively. Measurements included Meary's angle (talo-first metatarsal angle), talonavicular (TN) joint uncoverage percentage, TN incongruency angle, medial cuneiform to fifth metatarsal height, and calcaneal pitch. Union rates and clinical outcomes via the Foot Function Index (FFI) score were assessed preoperatively and at a mean of 29 months following surgery. Paired t test was used to compare both clinical and radiographic outcomes with statistical significance set at P < .05.

RESULTS

Fifteen of 16 patients returned an FFI questionnaire with a mean improvement of 52.1 to 10.3 (P = .002). The calcaneal pitch improved from 12.7 to 15.2 degrees (P = .002), the medial cuneiform-fifth metatarsal distance improved from 12.8 to 18.5 mm (P = .002), the TN coverage angle improved from 21.3 to 9.1 degrees (P < .001), the TN uncoverage percentage improved from 32.9% to 20.3% (P < .001), and the TN incongruency angle improved from 41.4 to 19.9 degrees (P < .001). Deformity correction was well maintained in 13 of 16 patients at final follow-up. The union rate of the osteotomy was 100%. Three patients had symptomatic hardware initially; 1 patient required removal of hardware. One patient developed a superficial infection that cleared. Another patient developed peroneal tendonitis, which resolved with corticosteroid injection.

CONCLUSION

The Z-cut osteotomy is a novel, technically simplified, single-incision, single-osteotomy alternative to the previously described double calcaneus osteotomy techniques for reconstructing flexible moderate to severe adult acquired flatfoot deformity that offers comparable short-term clinical and radiographic outcomes with acceptably low complications.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Surgical procedures for treatment of adult acquired flatfoot deformity: a network meta-analysis

Background

Adult acquired flatfoot deformity (AAFD) represents a spectrum of deformities affecting the foot and the ankle. The optimal management of AAFD remains controversial. We evaluated the efficacy of surgical treatments of AAFD using both direct and indirect evidences.

Methods

We searched PubMed, EmBase, and the Cochrane Library to identify eligible studies conducted through November 2018. To compare different surgical strategies, we performed a network meta-analysis. A traditional meta-analysis using a random-effects model was used to evaluate the pooled outcome.

Results

A total of 21 studies including 498 patients were collected and analyzed. Network meta-analysis results based on lateral angle talocalcaneal-calcaneal pitch (LAT-CP) indicated that medial displacement calcaneal osteotomy (MDCO) has the highest probability to be the best course of AAFD treatment. However, analyses based on anteroposterior talo-first metatarsal (AP-TMT1) and lateral angle talocalcaneal talo-first metatarsal (LAT-TMT1) suggested that lateral column lengthening (LCL) was the best treatment, while those based on lateral angle talocalcaneal-arch height, anteroposterior talocalcaneal (AP-TC), lateral angle talocalcaneal-talocalcaneal (LAT-TC), anteroposterior-talonavicular coverage (AP-TNC), talonavicular coverage (TNC), and the American Orthopedic Foot and Ankle Society (AOFAS) indicated triple arthrodesis (TAO) as the best treatment. Moreover, double arthrodesis (DAO) provided the best treatment effect on the function score. Furthermore, according to traditional meta-analysis, the summary of standardized mean differences (SMD) indicated that the surgical interventions are associated with significant improvements in LAT-CP (SMD − 1.78), LAT-arch height (SMD − 4.95), AOFAS (SMD − 5.24), AP-TMT1 (SMD 2.45), LAT-TMT1 (SMD 1.97), AP-TC (SMD 3.05), LAT-TC (SMD 2.20), AP-TNC (SMD 2.07), TNC (SMD 1.70), and function score (SMD 0.95).

Conclusions

Our findings indicated that MDCO, LCL, TAO, or DAO might be the best surgical approaches for AAFD treatment. Furthermore, patients who received surgical interventions had significant improvements in symptoms and function.

Electronic supplementary material

The online version of this article (10.1186/s13018-019-1094-0) contains supplementary material, which is available to authorized users.

Adult-Acquired Flatfoot Deformity

Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched.

Spring ligament tear decreases static stability of the ankle joint

BACKGROUND

Spring ligament tear is often found in advanced adult acquired flatfoot deformity and its reconstruction in conjunction with the deltoid ligament has been proposed to restore the tibiotalar and talonavicular joint stability. The aim of the present study is to determine the effect of spring ligament injury and subsequent reconstruction on static joint reactive force using a non-invasive method of measurement.

METHODS

Ten fresh-frozen human cadaveric lower legs were disarticulated at the knee joint. Static joint reactive force of the tibiotalar and talonavicular joint were measured at baseline, after spring ligament injury, and after ligament reconstruction. Reconstruction consisted of a forked semitendinosis allograft with dual limbs to reconstruct the tibionavicular and tibiocalcaneal ligaments.

FINDINGS

The mean baseline joint reactive force of the tibiotalar and talonavicular joints were 37.2 N + 8.1 N and 13.4 N + 4.2 N, respectively. The spring ligament injury model resulted in a significant 29% decrease in tibiotalar joint reactive force. Reconstruction of the tibionavicular limb resulted in a significant increase in tibiotalar and talonavicular joint reactive force compared to those seen in the injury state. Furthermore, the addition of the tibiocalcaneal limb significantly increased tibiotalar joint reactive force compared to those results obtained from the injury state and the tibionavicular limb alone.

INTERPRETATION

This is the first study to demonstrate diminished tibiotalar static joint reactive force in a spring ligament injury model with subsequent joint reactive force restoration using two-limbed reconstruction of the deltoid and spring ligament.

LEVEL OF EVIDENCE

Biomechanical Study.

Porous Titanium Wedges in Lateral Column Lengthening for Adult-Acquired Flatfoot Deformity

Lateral column lengthening (LCL) is a common procedure for reconstruction of stage II flexible adult-acquired flatfoot deformity (AAFD). The recent development of porous titanium wedges for this procedure provides an alternative to allograft and autograft. The purpose of this study was to report radiographic and clinical outcomes achieved with porous titanium wedges in LCL. A retrospective analysis of 34 feet in 30 patients with AAFD that received porous titanium wedges for LCL from January 2011 to October 2014. Deformity correction was assessed using both radiographic and clinical parameters. Radiographic correction was assessed using the lateral talo-first metatarsal angle, the talonavicular uncoverage percentage, and the first metatarsocuneiform height. The hindfoot valgus angle was measured. Patients were followed from a minimum of 6 months up to 4 years (mean 16.1 months). Postoperative radiographs demonstrated significant correction in all 3 radiographic criteria and the hindfoot valgus angle. We had no cases of nonunion, no wedge migration, and no wedges have been removed to date. The most common complication was calcaneocuboid joint pain (14.7%). Porous titanium wedges in LCL can achieve good radiographic and clinical correction of AAFD with a low rate of nonunion and other complications.

LEVELS OF EVIDENCE

Level IV: Case series.

Double calcaneal osteotomy with minimally invasive surgery for the treatment of severe flexible flatfeet

BACKGROUND

Severe flexible flatfoot deformity in children and adolescents is a complex problem. Calcaneal lengthening remains the gold standard for surgical correction at this institution. However, in a minority of patients, inadequate correction of valgus is noted at surgery and a further calcaneal shift osteotomy is done.

METHODS

We have conducted a retrospective review of ten patients who received 15 combined minimally invasive calcaneal shift and calcaneal lengthening osteotomies, which were all performed by the senior author. All patients had failed conservative treatment. We describe our technique for double calcaneal osteotomy combining minimally invasive surgery (MIS) for the medial calcaneal shift with traditional open calcaneal lengthening osteotomy for treating children and adolescents with severe flexible flatfoot deformity.

RESULTS

The average shift achieved was 8.07 mm. The average improvement in Meary's angle was 14.99°. All of them had radiological and clinical union at 12 weeks. None of the patients developed sural nerve injury, wound breakdown, or infection of the MIS incision.

CONCLUSION

In double calcaneal osteotomies, the MIS calcaneal medial shift technique can be used safely with potentially lower risks of wound complications and sufficient medial shift, compared to conventional open extensive surgery.

IMPLICATIONS

MIS calcaneal shift osteotomy has an advantage over open conventional open technique in cases where the skin is under tension like in combined calcaneal lengthening osteotomy. With experience, the procedure can be faster than an open procedure.

Reported selection criteria for adult acquired flatfoot deformity and posterior tibial tendon dysfunction: Are they one and the same? A systematic review

BACKGROUND

Posterior tibial tendon dysfunction (PTTD) and adult acquired flatfoot deformity (AAFD) are used interchangeably, although both suggest quite different pathological processes.

OBJECTIVE

To investigate key differences in selection criteria used for inclusion into research studies.

METHODS

An electronic database search was performed from inception to June 2016. All primary research articles with clear inclusion/diagnostic criteria for PTTD or AAFD were included in the review. All criteria were extracted and synthesised into one aggregate list. Frequencies of recurring criteria were calculated and reported for each stage of the conditions.

RESULTS

Of the potentially eligible papers, 148 (65%) did not specify inclusion/selection criteria for PTTD or AAFD and were excluded. Eligibility criteria were reported 82 times in the 80 included papers, with 69 descriptions for PTTD and 13 for AAFD. After synthesis of criteria from all papers, there were 18 key signs and symptoms. Signs and symptoms were considered to be those relating to tendon pathology and those relating to structural deformity. The total number of individual inclusion/diagnostic criteria ranged from 2 to 9. The majority of articles required signs of both tendon dysfunction and structural deformity (84% for AAFD and 81% for PTTD). Across both groups, the most frequently reported criteria were abduction of the forefoot (11.5% of total criteria used), the presence of a flexible deformity (10.2%) and difficulty performing a single leg heel raise (10.0%). This was largely the case for the PTTD articles, whereas the AAFD articles were more focused on postural issues such as forefoot abduction, medial arch collapse, and hindfoot valgus (each 16.7%).

CONCLUSION

As well as synthesising the available literature and providing reporting recommendations, this review has identified that many papers investigating PTTD/AAFD do not state condition-specific selection criteria and that this limits their clinical applicability. Key signs and symptoms of PTTD and AAFD appear similar, except in early PTTD where no structural deformity is present. We recommend that PTTD is the preferred terminology for the condition associated with signs of local tendon dysfunction with pain and/or swelling along the tendon and difficulty with inversion and/or single leg heel raise characterising stage I and difficulty with single leg heel raise and a flexible flatfoot deformity characterizing stage II PTTD. While AAFD may be useful as an umbrella term for acquired flatfoot deformities, the specific associated aetiology should be reported in studies to aid consolidation and implementation of research into practice.

TRIAL REGISTRATION

Prospero ID: 42016046943.

Patient specific computational models to optimize surgical correction for flatfoot deformity

Several surgically corrective procedures are considered to treat Adult Acquired Flatfoot Deformity (AAFD) patients, relieve pain, and restore function. Procedure selection is based on best practices and surgeon preference. Recent research created patient specific models of AAFD to explore their predictive capabilities and examine effectiveness of the surgical procedure used to treat the deformity. The models' behavior was governed solely by patient bodyweight, soft tissue constraints, muscle loading, and joint contact without the assumption of idealized joints. The current work expanded those models to determine if an alternate procedure would be more effective for the individual. All procedures incorporated first a tendon transfer and then included one hindfoot procedure, the Medializing Calcaneal Osteotomy (MCO), and one of three lateral column procedures: Evans osteotomy, Calcaneocuboid Distraction Arthrodesis (CCDA), Z osteotomy, and the combination procedures MCO & Evans osteotomy, MCO & CCDA, and MCO & Z osteotomy. The combination MCO & Evans and MCO & Z procedures were shown to provide the greatest amount of correction for both forefoot abduction and hindfoot valgus. However, these two procedures significantly increased joint contact force, specifically at the calcaneocuboid joint, and ground reaction force along the lateral column. With exception to the lateral bands of the plantar fascia and middle spring ligament, the strain present in the plantar fascia, spring, and deltoid ligaments decreased after all procedures. The use of patient specific computational models provided the ability to investigate effects of alternate surgical corrections on restoring biomechanical function in these flatfoot patients. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1523-1531, 2017.

Contribution of Lateral Column Lengthening to Correction of Forefoot Abduction in Stage IIb Adult Acquired Flatfoot Deformity Reconstruction

BACKGROUND

Correction of forefoot abduction in stage IIb adult acquired flatfoot likely depends on the amount of lateral column lengthening (LCL) performed, although this represents only one aspect of a successful reconstruction. The purpose of this study was to evaluate the correlation between common reconstructive variables and the observed change in forefoot abduction.

METHODS

Forty-one patients who underwent flatfoot reconstruction involving an Evans-type LCL were assessed retrospectively. Preoperative and postoperative anteroposterior (AP) radiographs of the foot at a minimum of 40 weeks (mean, 2 years) after surgery were reviewed to determine correction in forefoot abduction as measured by talonavicular coverage (TNC) angle, talonavicular uncoverage percent, talus-first metatarsal (T-1MT) angle, and lateral incongruency angle. Fourteen demographic and intraoperative variables were evaluated for association with change in forefoot abduction including age, gender, height, weight, body mass index, as well as the amount of LCL and medializing calcaneal osteotomy performed, LCL graft type, Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament repair, gastrocnemius recession and any one of the modified McBride/Akin/Silver procedures.

RESULTS

Two variables significantly affected the change in lateral incongruency angle. These were weight (P = .04) and the amount of LCL performed (P < .001). No variables were associated with the change in TNC angle, talonavicular uncoverage percent, or T-1MT angle. Multivariate regression analysis revealed that LCL was the only significant predictor of the change in lateral incongruency angle. The final regression model for LCL showed a good fit (R2 = 0.70, P < .001). Each millimeter of LCL corresponded to a 6.8-degree change in lateral incongruency angle.

CONCLUSION

Correction of forefoot abduction in flatfoot reconstruction was primarily determined by the LCL procedure and could be modeled linearly. We believe that the lateral incongruency angle can serve as a valuable preoperative measurement to help surgeons titrate the proper amount of correction performed intraoperatively.

Optimal Position of the Heel Following Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity

BACKGROUND

While previous work has demonstrated a linear relationship between the amount of medializing calcaneal osteotomy (MCO) and the change in radiographic hindfoot alignment following reconstruction, an ideal postoperative hindfoot alignment has yet to be reported. The aim of this study was to identify an optimal postoperative hindfoot alignment by correlating radiographic alignment with patient outcomes.

METHODS

Fifty-five feet in 55 patients underwent flatfoot reconstruction for stage II adult-acquired flatfoot deformity (AAFD) by 2 fellowship-trained foot and ankle orthopedic surgeons. Hindfoot alignment was determined as previously described by Saltzman and el-Khoury.(23) Changes in pre- and postoperative scores in each Foot and Ankle Outcome Score (FAOS) subscale were calculated for patients in postoperative hindfoot valgus (≥0 mm valgus, n = 18), mild varus (>0 to 5 mm varus, n = 17), and moderate varus (>5 mm varus, n = 20). Analysis of variance and post hoc Tukey's tests were used to compare the change in FAOS results between these 3 groups.

RESULTS

At 22 months or more postoperatively, patients corrected to mild hindfoot varus showed a significantly greater improvement in the FAOS Pain subscale compared with patients in valgus (P = .04) and the Symptoms subscale compared with patients in moderate varus (P = .03). Although mild hindfoot varus did not differ significantly from moderate varus or valgus in the other subscales, mild hindfoot varus did not perform worse than these alignments in any FAOS subscale. No statistically significant correlations between intraoperative MCO slide distances and FAOS subscales were found.

CONCLUSIONS

Our study indicates that correction of hindfoot alignment to between 0 and 5 mm of varus on the hindfoot alignment view (clinically a straight heel) following stage II flatfoot reconstruction was associated with the greatest improvement in clinical outcomes following hindfoot reconstruction in stage II AAFD.

LEVEL OF EVIDENCE

Level III, comparative series.

Radiographic Outcomes Following Lateral Column Lengthening With a Porous Titanium Wedge

BACKGROUND

Lateral column lengthening (LCL) is commonly utilized in treating stage II posterior tibialis tendon dysfunction. This study aimed to analyze the outcomes of LCL with porous titanium wedges compared to historic controls of iliac crest autograft and allograft. We hypothesized that the use of a porous titanium wedge would have radiographic improvement and union rates similar to those with the use of autograft and allograft in LCL.

METHODS

Between May 2009 and May 2014, 28 feet in 26 patients were treated with LCL using a porous titanium wedge. Of the 26 patients, 9 were males (34.6%). The average age for males was 43 years (range, 17.9-58.7), 48.7 years (range, 21-72.3) for females. Mean follow-up was 14.6 months. Radiographs were examined for correction of the flatfoot deformity and forefoot abduction. All complications were noted.

RESULTS

Radiographically, the patients had a significant deformity correction in the anteroposterior talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle, and calcaneal pitch. All but 1 patient (96%) had bony incorporation of the porous titanium wedge. The average preoperative visual analog scale pain score was 5; all patients but 3 (12%) had improvements in their pain score, with a mean change of 3.4.

CONCLUSION

LCL with porous titanium had low nonunion rates, improved radiographic correction, and pain relief.

LEVEL OF EVIDENCE

Level IV, case series.

Hindfoot deformity and calcaneal tuberosity osteotomies

Calcaneal tuberosity osteotomies are commonly used to treat coronal plane deformities of the hindfoot. Assessing hindfoot alignment can be difficult and there is little evidence to guide the physician when considering the surgical treatment of these deformities. The indications for a calcaneal osteotomy are unclear in the literature because most of the published studies supporting their use are confounded by concurrent procedures such as in adult-acquired flatfoot correction or cavovarus reconstruction. For the same reason, the biomechanical consequences, long-term effects, and performance in vivo are largely unknown.

LEVEL OF EVIDENCE

Expert opinion, Level V.

Comparison of rates of union and hardware removal between large and small cannulated screws for calcaneal osteotomy

BACKGROUND

The calcaneal osteotomy is a common procedure to correct hindfoot malalignment. Reported union rates are high, utilizing fixation methods including staples, plates, and most commonly cannulated screws. We began our practice using 6.5 mm and 7.3 mm cannulated screws, but complaints of postoperative posterior heel pain led to hardware removal in many patients. A switch to smaller 4.5 mm cannulated screws resulted in fewer symptoms, thus we hypothesized that using a smaller screw would decrease screw removal while maintaining an equally high union rate.

METHODS

The records of patients who underwent a calcaneal osteotomy by 2 surgeons between January 1996 and April 2012 were retrospectively reviewed. The rates of hardware removal and union were compared between osteotomies held with two 7.3 mm, 6.5 mm, and 4.5 mm cannulated screws.

RESULTS

There were 272 feet that met the inclusion criteria. The hardware removal rate for 130 osteotomies held with two 7.3 mm screws was 29.2% and the removal rate for 115 osteotomies held with 4.5 mm screws was 13.0%, which was significantly different (P < .05). The removal rate for 27 osteotomies with 6.5 mm screws was 33.3%. The union rate for all groups was 100%.

CONCLUSION

Fixation of calcaneal osteotomies with two 4.5 mm screws is advantageous over larger screws with respect to future hardware removal. There was no loss of position from the smaller screws and we feel that the 4.5mm cannulated screw provides sufficient compression and achieves a high rate of union equal to that of the larger screws.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Procedure selection for the flexible adult acquired flatfoot deformity

Adult acquired flatfoot represents a spectrum of deformities affecting the foot and the ankle. The flexible, or nonfixed, deformity must be treated appropriately to decrease the morbidity that accompanies the fixed flatfoot deformity or when deformity occurs in the ankle joint. A comprehensive approach must be taken, including addressing equinus deformity, hindfoot valgus, forefoot supinatus, and medial column instability. A combination of osteotomies, limited arthrodesis, and medial column stabilization procedures are required to completely address the deformity.

Biomechanical assessment of flexible flatfoot correction: comparison of techniques in a cadaver model

BACKGROUND

Options for surgical correction of acquired flexible flatfoot deformity involve bone and soft-tissue reconstruction. We used an advanced cadaver model to evaluate the ability of key surgical procedures to correct the deformity and to resist subsequent loss of correction.

METHODS

Stage-IIB flatfoot deformity was created in ten cadaver feet through ligament sectioning and repetitive loading. Six corrective procedures were evaluated: (1) lateral column lengthening, (2) medial displacement calcaneal osteotomy with flexor digitorum longus transfer, (3) Treatment 2 plus lateral column lengthening, (4) Treatment 3 plus "pants-over-vest" spring ligament repair, (5) Treatment 3 plus spring ligament repair with use of the distal posterior tibialis stump, and (6) Treatment 3 plus spring ligament repair with suture and anchor. Correction of metatarsal dorsiflexion and of navicular eversion were quantified initially and periodically during postoperative cyclic loading.

RESULTS

Metatarsal dorsiflexion induced by arch flattening was initially corrected by 5.5° to 10.6°, depending on the procedure. Navicular eversion was initially reduced by 2.1° to 7.7°. The correction afforded by Treatments 1, 3, 4, 5, and 6 exceeded that of Treatment 2 initially and throughout postoperative loading. Inclusion of spring ligament repair did not significantly enhance correction.

CONCLUSIONS

Under the tested conditions, medial displacement calcaneal osteotomy with flexor digitorum longus tendon transfer was inferior to the other evaluated treatments for stage-IIB deformity. Procedures incorporating lateral column lengthening provided the most sagittal and coronal midfoot deformity correction. Addition of spring ligament repair to a combination of these three procedures did not substantially improve correction.

CLINICAL RELEVANCE

An understanding of treatment effectiveness is essential for optimizing operative management of symptomatic flatfoot deformity. This study provides empirical evidence of the advantage of lateral column lengthening and novel information on resistance to postoperative loss of correction.

Congenital talotarsal joint displacement and pes planovalgus: evaluation, conservative management, and surgical management

The diagnosis of and preferred treatment regimens for pediatric flatfoot, a complex and ambiguous deformity, continues to be debated. Incongruence of the talotarsal joint, whether flexible or rigid, is always present in pes planovalgus. However, it is important to note that talotarsal dislocation can occur without a flatfoot. The displacement of the talus on the hindfoot bones serves as the apex of the deformity. External measures, such as conservative care, are limited in providing correction to this internal deformity. Extraosseous talotarsal stabilization provides a minimally invasive internal option that should be considered before more radical surgical intervention is decided upon.

Short-term radiographic analysis of operative correction of adult acquired flatfoot deformity

BACKGROUND

Multiple procedures have been described to treat stage II (flexible) deformities driven by the clinical presence of "mild" versus "severe" deformity. The purpose of this study was to identify the radiographic correction after bony realignment procedures and to compare preoperative measures with postoperative measures to better understand the clinical application of these procedures.

METHODS

Seventy-two feet in 68 patients treated for stage II deformity between January 1999 and December 2010 were available for retrospective chart review. The average age of the patients was 55 years, and final radiographs were evaluated at an average of 9 months postoperatively. All patients had a flexor digitorum longus transfer to the navicular and bony realignment. Radiographic parameters measured included lateral talus-first metatarsal angle, medial cuneiform-floor distance, calcaneal pitch, anteroposterior talus-second metatarsal angle, and talonavicular coverage angle. Differences in pre- and postoperative measurements and between group comparisons were analyzed.

RESULTS

Three patient groups were identified: medial displacement calcaneal osteotomy (group 1), lateral column lengthening (group 2), and both medial displacement calcaneal osteotomy and lateral column lengthening (group 3). The lateral talus-first metatarsal angle mean difference was 5.1 degrees in group 1, 16.2 degrees in group 2, and 16.5 degrees in group 3. The talonavicular coverage angle mean difference was 5.7 degrees in group 1, 24.2 degrees in group 2, and 19.4 degrees in group 3. Changes in pre- to postoperative measures were statistically significant for all groups for the parameters measured. The pairwise group comparison revealed a statistically significant difference in the correction obtained in group 3 compared with that of group 1.

CONCLUSION

Clinical and radiographic parameters are a consideration when choosing bony realignment procedures to reconstruct a flexible flatfoot deformity. In the treatment of more severe deformities, lateral column lengthening resulted in a greater radiographic improvement in alignment. A medial displacement osteotomy alone is also a valuable tool to correct these deformities although it provided a different level of correction compared with the lateral column lengthening.

LEVEL OF EVIDENCE

Level III, comparative case series.

Clinical outcomes and static and dynamic assessment of foot posture after lateral column lengthening procedure

BACKGROUND

Lateral column lengthening (LCL) has been shown to radiographically restore the medial longitudinal arch. However, the impact of LCL on foot function during gait has not been reported using validated clinical outcomes and gait analysis.

METHODS

Thirteen patients with a stage II flatfoot who had undergone unilateral LCL surgery and 13 matched control subjects completed self-reported pain and functional scales as well as a clinical examination. A custom force transducer was used to establish the maximum passive range of motion of first metatarsal dorsiflexion at 40 N of force. Foot kinematic data were collected during gait using 3-dimensional motion analysis techniques.

RESULTS

Radiographic correction of the flatfoot was achieved in all cases. Despite this, most patients continued to report pain and dysfunction postoperatively. Participants post LCL demonstrated similar passive and active movement of the medial column when we compared the operated and the nonoperated sides. However, participants post LCL demonstrated significantly greater first metatarsal passive range of motion and first metatarsal dorsiflexion during gait than did controls (P < .01 for all pairwise comparisons).

CONCLUSION

Patients undergoing LCL for correction of stage II adult-acquired flatfoot deformity experience mixed outcomes and similar foot kinematics as the uninvolved limb despite radiographic correction of deformity. These patients maintain a low arch posture similar to their uninvolved limb. The consequence is that first metatarsal movement operates at the end range of dorsiflexion and patients do not obtain full hindfoot inversion at push-off. Longitudinal data are necessary to make a more valid comparison of the effects of surgical correction measured using radiographs and dynamic foot posture during gait.

LEVEL OF EVIDENCE

Level III, comparative series.

Comparison of three different fixation methods of calcaneal osteotomies

BACKGROUND

There are various methods available to fix a calcaneal osteotomy, ranging from screws to plates and staples. It is not clear if one method is superior to the other. In this series we compare the complications and union rates of 3 different methods of fixation.

METHODS

A retrospective review of the records of a consecutive series of patients who had a calcaneal osteotomy was undertaken. All patients had their osteotomy by the same technique, however the subsequent fixation was performed using 3 different methods: a lateral locking plate, a headless, or a headed screw. The screws were placed through a separate stab incision inserted from the infero-posterior heel. Records were kept of subsequent symptoms from the hardware and need for hardware removal as well as any complications. When screws were inserted, the entry point in relation to the weight-bearing surface of the calcaneus was also recorded. Sixty-seven osteotomies were investigated, of which 17 were fixed using a headed screw, 18 using a headless screw, and the remaining 32 were fixed using a lateral plate.

RESULTS

There was an overall 97% union rate. The only 2 cases of delayed union were both fixed using a lateral plate. Overall, 47% of the headed screws, 11% of the headless screws, and 6% of the lateral plates were removed to address symptoms that were suspected to arise from the hardware. There was a 10% rate of wound complication in the lateral plate cohort. There were no cases of sural nerve injury or neuroma. No correlation was found between entry position of screw and subsequent hardware symptoms.

CONCLUSIONS

Calcaneal osteotomies have high union rates regardless of fixation method. Fixation using a headed screw is associated with a high rate of secondary screw removal. This was unrelated to the position of the screw in relation to the weight-bearing surface of the calcaneus in our series. Hardware problems were less frequent in the headless screw or the lateral plate groups; however, the incidence of local wound complications and radiological delayed union was higher in the group fixed with a lateral plate. This may be related to the greater soft tissue dissection and lesser compression achieved at the osteotomy site.

LEVEL OF EVIDENCE

Level III, retrospective case control study.

Substitutes of structural and non-structural autologous bone grafts in hindfoot arthrodeses and osteotomies: a systematic review

Background

Structural and non-structural substitutes of autologous bone grafts are frequently used in hindfoot arthrodeses and osteotomies. However, their efficacy is unclear.

The primary goal of this systematic review was to compare autologous bone grafts with structural and non-structural substitutes regarding the odds of union in hindfoot arthrodeses and osteotomies.

Methods

The Medline and EMBASE and Cochrane databases were searched for relevant randomized and non-randomized prospective studies as well as retrospective comparative chart reviews.

Results

10 studies which comprised 928 hindfoot arthrodeses and osteotomies met the inclusion criteria for this systematic review. The quality of the retrieved studies was low due to small samples sizes and confounding variables. The pooled random effect odds for union were 12.8 (95% CI 12.7 to 12.9) for structural allografts, 5.7 (95% CI 5.5 to 6.0) for cortical autologous grafts, 7.3 (95% CI 6.0 to 8.6) for cancellous allografts and 6.0 (95% CI 5.7 to 6.4) for cancellous autologous grafts. In individual studies, the odds of union in hindfoot arthrodeses achieved with cancellous autologous grafts was similar to those achieved with demineralised bone matrix or platelet derived growth factor augmented ceramic granules.

Conclusion

Our results suggest an equivalent incorporation of structural allografts as compared to autologous grafts in hindfoot arthrodeses and osteotomies. There is a need for prospective randomized trials to further clarify the role of substitutes of autologous bone grafts in hindfoot surgery.

The contribution of medializing calcaneal osteotomy on hindfoot alignment in the reconstruction of the stage II adult acquired flatfoot deformity

BACKGROUND

Successful correction of hindfoot alignment in adult acquired flatfoot deformity (AAFD) is likely influenced by the degree of medializing calcaneal osteotomy (MCO) performed, but it is not known if other reconstruction procedures significantly contribute as well. The purpose of this study was to evaluate the correlation between common preoperative and postoperative variables and hindfoot alignment.

METHODS

Thirty patients with stage II AAFD undergoing flatfoot reconstruction were followed prospectively. Preoperative and postoperative radiographs were reviewed to assess for correction in hindfoot alignment as measured by the change in hindfoot moment arm. Nineteen variables were analyzed, including age, gender, height, weight, body mass index (BMI), medial cuneiform-fifth metatarsal height, anteroposterior (AP) talonavicular coverage, AP talus-first metatarsal, lateral talus-first metatarsal and calcaneal pitch angles as well as intraoperative use of the MCO, lateral column lengthening (LCL), Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament reconstruction, and gastrocnemius recession or Achilles lengthening. Mean age was 57.3 years (range, 22-77). Final radiographs were obtained at a mean of 47 weeks (range, 25-78) postoperatively.

RESULTS

Seven variables were found to significantly affect hindfoot moment arm. These were gender (P < .05), the amount of MCO performed (P < .001), LCL (P < .01), first tarsometatarsal fusion (P < .01), spring ligament reconstruction (P < .01), medial cuneiform-fifth metatarsal height (P < .001), and calcaneal pitch angle (P < .05). Multivariate regression analysis revealed that MCO was the only significant predictor of hindfoot moment arm. The final regression model for MCO showed a good fit (R(2) = .93, P < .001).

CONCLUSION

Correction of hindfoot valgus alignment obtained in flatfoot reconstruction is primarily determined by the MCO procedure and can be modeled linearly. We believe that the hindfoot alignment view can serve as a valuable preoperative measurement to help surgeons adjust the proper amount of correction intraoperatively.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Comparison of lateral opening wedge calcaneal osteotomy and medial calcaneal sliding-opening wedge cuboid-closing wedge cuneiform osteotomy for correction of planovalgus foot deformity in children

The purpose of the present study was to compare the clinical and radiographic results between 2 procedures, lateral opening wedge calcaneal osteotomy (LCL) and medial calcaneal sliding-opening wedge cuboid-closing wedge cuneiform osteotomy (3C) in patients with planovalgus foot deformity. A total of 38 patients who underwent either LCL (18 patients, 28 feet) or 3C (20 patients, 32 feet) were included in the present study. The etiology of the planovalgus foot deformity was idiopathic in 16 feet and cerebral palsy in 44 feet. The 2 procedures used in the present study were indicated in symptomatic (pain or callus) children in whom conservative treatment, such as shoe modifications or orthotics, had been applied for more than 1 year but had failed. The patients were evaluated preoperatively, postoperatively, and at the last follow-up visit, both clinically and radiologically, and the interval to union and postoperative courses were compared between the 2 groups. In the LCL group, 19 of the 28 feet (68%) showed a satisfactory outcome and 9 (32%) an unsatisfactory outcome. In the 3C group, 28 of the 32 feet (88%) showed a satisfactory outcome and 4 (12%) an unsatisfactory outcome. The clinical results were not significantly different between the 2 groups, with mild to moderate pes planovalgus deformity. However, the clinical results were better in the 3C group with severe pes planovalgus deformity than in the LCL group with severe pes planovalgus deformity. All 4 radiographic parameters were improved at the last follow-up visit in both groups. In particular, the talar-first metatarsal angle and the calcaneal pitch angle on the weightbearing lateral radiographs were significantly improved in the 3C group with mild to moderate planovalgus foot deformity. All 4 parameters were significantly improved in the 3C group with severe planovalgus foot deformity. No significant differences were observed between the 2 groups in terms of the interval to union and postoperative care. No case of postoperative deep infection or nonunion was encountered in either group. 3C is a more effective procedure than LCL for the correction of pes planovalgus deformity in children, especially severe pes planovalgus deformities.

Comparison of the calcaneo-cuboid-cuneiform osteotomies and the calcaneal lengthening osteotomy in the surgical treatment of symptomatic flexible flatfoot

BACKGROUND

Surgery is indicated in symptomatic flatfoot when conservative treatment fails to relieve the symptoms. Osteotomies appear to be the best choice for these painful feet. The purpose of this study was to compare the clinical and radiographic outcome of the calcaneo-cuboid-cuneiform osteotomies (triple C) and the calcaneal-lengthening osteotomy in the treatment of children with symptomatic flexible flatfoot.

METHODS

The surgeries were performed by senior surgeons who preferred either triple C or calcaneal lengthening. The results were graded by an orthopaedic surgeon uninvolved with the cases. The clinical and radiographic outcome was evaluated in 30 feet (21 patients) with a triple C osteotomy and 33 feet (21 patients) with a calcaneal-lengthening osteotomy. We used the American College of Foot and Ankle Surgeons (ACFAS) score (flatfoot module) for clinical assessment, which contains a subjective and objective test. We measured and compared 12 parameters on the anteroposterior and lateral weight-bearing radiographs. The effect of additional procedures (Kidner procedure, medial reefing of the talonavicular capsule, tendo-Achilles lengthening, peroneous brevis lengthening and, in the calcaneal-lengthening group, a medial cuneiform osteotomy) on the clinical and radiographic result was also evaluated.

RESULTS

Average age at the time of surgery was similar (triple C: 11.2 ± 3 y, calcaneal lengthening: 11.6 ± 2.5 y, P = 0.51). Average follow-up was 2.7 ± 2.2 years in the triple C group and 5.3 ± 4 years in the calcaneal-lengthening group. There were no significant differences in the clinical outcome measured by the ACFAS subjective test in the calcaneal-lengthening group (P = 0.003). There were no significant differences in the ACFAS score, both the subjective test (triple C: 43.3 ± 6.1, calcaneal lengthening: 44.7 ± 7.6, P = 0.52) and the ACFAS objective test (triple C: 28.6 ± 2, calcaneal lengthening: 25.9 ± 7, P = 0.13). We found significant differences in 2 of the 12 radiographic measurements: anteroposterior talo-first metatarsal angle (triple C: 15.5 ± 11.1, calcaneal lengthening: 7.4 ± 7.3, P = 0.001) and talonavicular coverage (triple C: 28 ± 14.7, calcaneal lengthening: 13.7 ± 12.4, P<0.001). None of the additional procedures improved the clinical outcome. There were 3 (10%) complications in the triple C group and 6 (18%) complications in the calcaneal-lengthening group. Also, calcaneocuboid subluxation was present in 17 (51.5%) feet of the calcaneal-lengthening group.

CONCLUSIONS

Both techniques obtain good clinical and radiographic results in the treatment of symptomatic idiopathic flexible flatfoot in a pediatric population. The calcaneal-lengthening osteotomy achieves better improvement of the relationship of the navicular to the head of the talus but it is associated with more frequent and more severe complications. Additional soft-tissue procedures have not proven to improve clinical or radiographic results.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment of the arthritic valgus ankle

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.

Outcome of medial displacement calcaneal osteotomy for correction of adult-acquired flatfoot

BACKGROUND

The results of medial displacement calcaneal osteotomy (MDCO) with flexor digitorum longus (FDL) tendon transfer were reviewed, as well as postoperative radiographic changes, to determine quantitative x-ray-based indications for MDCO with FDL tendon transfer in cases of adult-acquired flatfoot.

MATERIALS AND METHODS

Twenty-five patients, ages 42 to 71 years, underwent MDCO with FDL tendon transfer for stage II posterior tibial tendon dysfunction. Follow-up was 2.6 to 10.2 years. Preoperative and postoperative Japanese Society for Surgery of the Foot (JSSF), Foot Function Index, and SF-36 scores and physical and radiographic findings were compared. Eight measures of foot alignment were obtained from weight-bearing radiographs at 3, 6, 9, and 12 months after surgery and every 6 months thereafter. Differences in scores and values over time were analyzed statistically.

RESULTS

Average JSSF scores improved from 59 preoperatively to 91.3 postoperatively (p < .001). The only x-ray parameters that improved significantly and showed maintenance of the surgical correction were the lateral talometatarsal (LTMT) and tibiocalcaneal (TBC) angles. With preoperative LTMT and TBC angles of >25° and >15°, respectively, correction was inadequate.

CONCLUSIONS

It was concluded that indications for MDCO with FDL tendon transfer in cases of adult-acquired flatfoot are a preoperative LTMT angle of <25° and hindfoot coronal alignment (TBC angle) of <15°.

PTT functional recovery in early stage II PTTD after tendon balancing and calcaneal lengthening osteotomy

BACKGROUND

The decision to offer surgery for Stage II posterior tibial tendon deficiency (PTTD) is a difficult one since orthotic treatment has been documented to be a viable alternative to surgery at this stage. Taking this into consideration we limited our treatment to bony realignment by a lengthening calcaneus Evans osteotomy and tendon balancing. The goal of the study was to clinically evaluate PTT functional recovery with this procedure.

METHOD

The patient population included 17 feet in 13 patients. Inclusion was limited to early Stage II PTTD flatfeet with grossly intact but deficient PTT. Deficiency was assessed by the lack of hindfoot inversion during single heel rise test. The surgical procedure included an Evans calcaneal opening wedge osteotomy with triceps surae and peroneus brevis tendon lengthening. PTT function at follow up was evaluated by an independent examiner. Evaluation was performed at an average of 4 (range, 2 to 6.3) years.

RESULTS

One case presented postoperative subtalar pain that required subtalar fusion. Every foot could perform a single heel rise with 13 feet having active inversion of the hindfoot during elevation.

CONCLUSIONS

The results of this study provide evidence of PTT functional recovery without augmentation in early Stage II. It challenges our understanding of early Stage II PTTD as well as the surgical guidelines recommending PTT augmentation at this specific stage.

Lateral column lengthening osteotomies

Lateral column lengthening procedures, either an Evans-type procedure or a calcaneocuboid distraction arthrodesis, clearly have a role to play in the management of a pes planovalgus foot deformity, as is evident from clinical outcome studies. Despite an abundance of literature intricately detailing the biomechanical effects of different operative procedures on the hindfoot, there is no clear consensus as to the best procedure or procedures to perform for a flexible pes planovalgus foot deformity. There is, therefore, no single solution to this problem; the surgeon must treat each patient as an individual and choose the procedure that will work best in their hands for any given foot pathology they are presented with. The surgeon must also be aware that to improve the kinematics of a planovalgus foot deformity, one may often have to perform multiple procedures and not a lateral column lengthening in isolation.

Calcaneal osteotomy in the treatment of adult acquired flatfoot deformity

Calcaneal osteotomies are an essential part of our current armamentarium in the treatment of AAFD. Soft tissue correction or bony realignment alone have failed to adequately correct the deformity; therefore, both procedures are used simultaneously to achieve long-term correction. Medial displacement and lateral column lengthening osteotomies in isolation or in combination and the Malerba osteotomy have been employed along with soft tissue balancing to good effect by various authors. The goal is to create a stable bony configuration with adequate soft tissue balance to maintain dynamic equilibrium in the hindfoot. In “pronatory syndromes,” the relation of the osteotomy to the posterior subtalar facet modifies the biomechanics of the hindfoot in different ways. Anterior calcaneal osteotomies correct deformities in the transverse plane (forefoot abduction), whereas posterior tuberosity osteotomies result in “varization” of the calcaneus and correct the frontal plane deformity. The choice of osteotomy depends on the plane of the dominant deformity. If the subtalar axis is more horizontal than normal, transverse plane movement is cancelled out and the frontal plane eversion–inversion is predominant. The patient presents with marked hindfoot valgus without significant forefoot abduction. Conversely, if the subtalar axis is more vertical than normal, transverse plane movement is predominant and the patient presents with forefoot abduction and instability of the medial midtarsal joints, although without significant hindfoot valgus. In this situation, a lateral column lengthening procedure is recommended to decrease the uncovering of the talar head and improve the height of the arch while correcting the forefoot abduction. With a predominant frontal plane deformity, medialization of the calcaneal tuberosity is used to displace the calcaneal weight bearing axis medially, aligning it with the tibial axis and restoring the function of the gastrosoleus as a heel invertor. An essential prerequisite for this is the absence of arthritis affecting the subtalar joint. The Achilles tendon may need to be lengthened at the same time.

Results of calcaneocuboid distraction arthrodesis

BACKGROUND

One powerful method of reconstructing an adult acquired flatfoot deformity is a calcaneocuboid distraction arthrodesis. We performed a retrospective review of a small series of patients who underwent a calcaneocuboid distraction arthrodesis with a femoral head allograft.

MATERIALS AND METHODS

Sixteen feet (14 patients) were identified with an average follow up of 23 months (8-39 months) and an average age of 43 years (16-60 years). A calcaneocuboid distraction arthrodesis was performed with a femoral head allograft, secured with a 3 hole 1/3 tubular plate with 7 of the grafts being supplemented with platelet rich plasma (PRP). Patients were kept non-weight bearing for 6 weeks with an additional 6 weeks in a walking cast or boot. Plain radiographs and if necessary a CT or MRI were used to evaluate for union.

RESULTS

Seven of the 16 feet developed a nonunion. Five of 9 patients without PRP developed a nonunion vs 2 of 7 patients where PRP was used.

CONCLUSION

Due to the unacceptably high complication rate with this procedure, the authors have abandoned this procedure. If an allograft is to be used for a calcaneocuboid arthrodesis, the authors strongly recommend using rigid locking fixation with a longer period of protected immobilization.