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

Effect of flatfoot correction on the ankle joint following lateral column lengthening: A radiographic evaluation

OBJECTIVES

The effects of foot deformities and corrections on the ankle joint without osteoarthritis has received little attention. This study aimed to investigate the effect of flatfoot correction on the ankle joint of patients without osteoarthritis.

METHODS

Thirty-five patients (24 men and 11 women; mean age 17.5 years) who underwent lateral column lengthening for flatfoot deformities were included. The mean postoperative follow-up period was 20.5 months (standard deviation [SD]: 15.7 months). Radiographic indices were measured pre- and postoperatively, including anteroposterior (AP) and lateral talo-first metatarsal angles, naviculocuboid overlap, position of the articulating talar surface, and lateral talar center migration. Postoperative changes in the radiographic indices were statistically analyzed.

RESULTS

There was significant postoperative improvement in flatfoot deformity in terms of AP and lateral talo-first metatarsal angles (p<0.001 and p<0.001, respectively) and naviculocuboid overlap (p<0.001). On lateral radiographs, the talar articulating surface dorsiflexed by 7.3% (p<0.001), and the center of the talar body shifted anteriorly by 0.85 mm (p<0.001) postoperatively.

CONCLUSIONS

Flatfoot correction using lateral column and Achilles tendon lengthening caused dorsiflexion and an anterior shift of the articular talar body in patients without osteoarthritis. Correction of flatfoot deformity might affect the articular contact area at the ankle joint. The biomechanical effects of this change need to be investigated further.

Comparison of different surgical treatments for stage II progressive collapsing foot deformity: a finite element analysis

BACKGROUND

This study analyzed the advantages and disadvantages of different procedures for stage IIA progressive collapsing foot deformity (PCFD) through three-dimensional finite element models.

METHODS

A previous validated stage IIA PCFD FEA model was established consisting of 16 bones, 56 ligaments, 5 muscles and soft tissues. The ligament properties of the spring, deltoid, short plantar and long plantar ligaments, and plantar fascia were attenuated according to a previous publication. Medial column fusion (MCF), medializing calcaneal osteotomy (MCO), lateral column lengthening (LCL), and subtalar joint arthroereisis (SJA) operations were simulated in this model. The indexes of plantar stress distribution, maximum von Mises of the medial and lateral columns, strain of the medial ligaments and plantar fascia that supported the medial longitudinal arch, arch height, talo-first metatarsal angle, calcaneus pitch angle, and talonavicular coverage angle were all compared before and after simulated single-foot weight loading.

RESULTS

The maximum plantar stress of PCFD decreased with MCO and SJA but increased with MCF and LCL. MCF and LCL failed to significantly reduce the stress on the medial column fragments, thereby increasing their stress. Both MCO and SJA relieved medial plantar stress. MCF had no significant effect on stress relief of the medial ligament. MCO, LCL, and SJA were all shown to reduce the pressure on the medial plantar ligament, with LCL having the most obvious effect. All four procedures corrected the arch deformity; however, MCF was not as effective as the other methods. SJA is the best method for restoring arch height and correcting arch deformities. For stage IIA PCFD, isolated MCF failed to reduce pressure on the medial column; however, isolated MCO significantly reduced the pressure on the medial plantar and ligamentous soft tissues while restoring the foot's arch and correcting the hindfoot valgus.

CONCLUSION

SJA with type II sinus tarsi implant effectively transferred pressure from the medial plantar tract to the lateral side and restored the arch. Isolated LCL was not found suitable for stage IIA PCFD.

Comparative study between medial displacement calcaneal osteotomy using modified step plate and arthroereisis for management of planovalgus feet

Background: Flexible flatfoot is a common condition that is characterized by hindfoot valgus with longitudinal medial-arch collapse. Many strategies for treatment have been reported but according to the current literature, controversy remains. Objectives: To compare the clinical and radiological outcomes of medializing calcaneal osteotomy utilizing modified step plate and subtalar arthroereisis utilizing conical subtalar implant for patients with symptomatic flexible pes planus. Methods: A prospective, randomized, double center study was conducted between May 2017 and May 2019 at the Foot and Ankle Department of Cairo University Hospital and El Sahel Teaching Hospital on 26 patients (37 feet) with flexible flat feet to compare between medial displacement calcaneal osteotomy using modified locked step plate (group A) compromising 17 feet and arthroereisis using subtalar implant (group B) compromising 20 feet. Results: By the end period of the study, 25 males and 12 females were available for our analysis of results with a mean follow-up period of 10.14 months (range 7–14 months), clinical scoring (American Orthopaedic Foot and Ankle Society score, Foot Functional Index) with radiological analysis revealed a non-significant difference between both groups, the overall complication rate was 16.2%. Conclusion: Both medial displacement calcaneal osteotomy and subtalar arthroereisis significantly improved radiographic and subjective clinical outcome measures in the surgical treatment of painful flexible planovalgus feet. The less-invasive nature and lower potential morbidity suggest that judicious use of arthroereisis implants is an appropriate alternative.

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.

Effectiveness of calcaneal osteotomy in surgical treatment of foot conditions: A Prisma statement guidelines compliant systematic review

Calcaneal osteotomy is a commonly established method used to correct various foot malalignment surgery problems that produce varus and valgus hindfoot abnormality as well as Haglund's deformity, cavovarus foot reconstruction, flatfoot deformity, plantar fasciitis, posterior tibial tendon insufficiency and planovalgus foot. After decades, several procedures in orthopaedic foot surgery have been suggested for reducing the risk of wound and neurovascular complications. The goal of this Prisma statement guidelines compliant systematic review was to establish the effectiveness and safety of calcaneal osteotomy in foot surgery. We have performed a novel systematic review of the current published literature in order to evaluate the scientific evidence now available on this association, assigning predefined exclusion and inclusion criteria. Eight investigations were selected which had 191 cases. The adult flatfoot, tibialis posterior reconstruction and cavovarus foot deformity were treated with different procedures of calcaneal osteotomy techniques. The adequate level of effectiveness of calcaneal osteotomy is associated with the kind and location of the incision, with or without screw application, in each specific foot condition. There is a limited number of scientific investigations of the effectiveness and safety of the different kinds of calcaneal osteotomy in foot surgery, and there is the need to enhance outcome knowledge on this foot surgery technique.

Managing Complications of Foot and Ankle Surgery: Reconstruction of the Progressive Collapsing Foot Deformity

Our understanding of the cause and principles of treatment of progressive collapsing foot deformity (PCFD) has significantly evolved in recent decades. The goals of treatment remain improvement in symptoms, correction of deformity, maintenance of joint motion, and return of function. Although notable advancements in understanding the deformity have been made, complications still occur and typically result from (1) poor decision making, (2) technical errors, and (3) patient-related conditions. In this article, we discuss common surgical modalities used in the treatment of PCFD and further highlight the common complications that occur and the techniques that can be used to prevent them.

Fusion Versus Joint-Sparing Reconstruction for Patients With Flexible Flatfoot

AIMS

Passively correctible, adult-acquired flatfoot deformities (AAFD) are treated with joint-sparing procedures. Questions remain as to the efficacy of such procedures when clinical deformities are severe. In severe deformities, a primary fusion may lead to predictable outcomes, but risks nonunion. We evaluated pre- and postsurgical flexible AAFD patients undergoing joint-sparing or fusion procedures, comparing reoperation and complication rates.

METHODS

We identified patients with flexible AAFD between January 1, 2001 and 2016. Exclusion criteria were incomplete medical record, rigid AAFD, and prior flatfoot surgery. Patient demographics, pre- and postsurgical radiographic measurements, surgery performed, and postoperative complications were evaluated by bivariate analysis, comparing joint-sparing versus fusion procedures.

RESULTS

Of 239 patients (255 feet) (mean follow-up 62 ± 50 months), 209 (87%) underwent joint-sparing reconstructions, 30 (12.6%) underwent fusions. Fifty-four (24.1%) feet underwent joint-sparing reconstruction with reoperation versus 11 (35.5%) in fusion patients (P = .17). Radiographic improvement in talonavicular angle, talar first-metatarsal (anteroposterior view), and Meary's angle was higher in fusion patients (P < .001, P < .001, and P = .003, respectively).

DISCUSSION

More nonunion reoperations among fusion patients were offset by reoperations in joint-sparing patients. Fusion uniquely corrected Meary's angle. Nonunion is of less concern for joint-sparing versus fusion for patients with severe flexible AAFD. Degree of deformity versus advantage of joint motion should improve decision making.

LEVELS OF EVIDENCE

Level IV: Retrospective case series.

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.

Bony Procedures for Correction of the Flexible Pediatric Flatfoot Deformity

The pediatric flexible flatfoot is a common foot shape that is most often asymptomatic and may be a physiologic variant of normal. Surgery is only indicated when nonoperative interventions have failed to resolve symptoms. The goal of surgery is to alleviate symptoms by improving hindfoot alignment and restoring the medial arch while preserving joint mobility. This article focuses on the common bony techniques for surgical correction of the pediatric flexible flatfoot that has failed nonoperative management, including calcaneal, midfoot, and supramalleolar osteotomies and distal tibial hemiepiphyseodesis.

Calcaneal Osteotomies in the Treatment of Progressive Collapsing Foot Deformity. What are the Restrictions for the Holy Grail?

The progressive collapsing foot deformity is a complex three-dimensional deformity, including valgus malalignment of the heel. The medial displacement calcaneal osteotomy is an established surgical procedure reliably resulting in an efficient correction of the inframalleolar alignment. However, complications are common, including undercorrection of underlying deformity, progression of hindfoot osteoarthritis and/or deformity, and/or symptomatic hardware.

Calcifying aponeurotic fibroma around posterior tibialis tendon in an elderly patient with flatfoot: A case report

RATIONALE

Calcifying aponeurotic fibroma (CAF) is a rare benign fibroblastic tumor that is commonly in the hand or foot of children or adolescents.

PATIENT CONCERNS

A 74-year-old female presented with a progressive pain on the medial foot for 3 years ago. The pain aggravated while walking or in a standing position for more than 20 minutes. She also complained of skin contact along the medial aspect of the foot while trying to wear a shoe.

DIAGNOSIS

Physical examination revealed a firm, immobile, nontender mass accompanied with flexible flatfoot. On the single heel raise test, loss of the balance and intensification of the pain were observed. Faintly calcified soft tissue mass is shown in plain radiographs without bone involvement. Magnetic resonance imaging revealed a subcutaneous mass with ill-defined circumscribed subcutaneous mass adherent to the thickened PTT.

INTERVENTIONS

The patient underwent a complete excisional biopsy, followed by medial displacement calcaneal osteotomy.

OUTCOMES

The excised mass was diagnosed to be CAF on the histologic examination. At the 1-year follow-up, patient remained asymptomatic with no evidence of recurrence and all the radiographic parameters demonstrating flat foot improved.

LESSONS

This is the first case of CAF located at PTT presenting with both foot pain and functional disability. In this case, complete excision of the causative structure along with alignment correction can contribute to successful postoperative outcome.

Medial Displacement Calcaneal Osteotomy for Unilateral Adult Acquired Flatfoot: Effects of Minimally Invasive Surgery on Pain, Alignment, Functioning, and Quality of Life

We aimed to assess the effects of medial displacement calcaneal osteotomy (MDCO) through a minimal skin incision in terms of pain, function, and alignment in patients with unilateral adult acquired flatfoot. American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scale and Numeric Pain Rating Scale (NPRS) were assessed as outcomes at the baseline (T0), at 6 months (T1), and at 1 year (T2) from surgery. We analyzed data of 20 patients (7 male and 13 female), mean aged 46.6 ± 5.34 years, showed significant differences after 6 months in terms of AOFAS total score (44.30 ± 7.39 vs 96.50 ± 4.89; p = .0001), AOFAS subitems (p < .001), and pain (NPRS: 7.95 ± 1.36 vs 1.05 ± 1.05; p = .0001). At 1 year after surgery (T2), all outcome measures still significantly differ from baseline (p < 01). Therefore, percutaneous MDCO through a minimal skin incision seemed to be safe and effective in the middle and long term in reducing pain and improving function and alignment in patients with unilateral adult acquired flatfoot.

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.

Natural History of 321 Flatfoot Reconstructions in Adult Acquired Flatfoot Deformity Over a 14-Year Period

The purpose of this study was to report the natural history, demographics, and mechanisms of requirement for additional surgery in patients undergoing flatfoot reconstruction for adult acquired flatfoot. A total of 321 consecutive patients undergoing flatfoot reconstruction over a 14-year period were included (2002-2016). All procedures were performed by a senior orthopaedic foot and ankle surgeon at our institution. Demographic data, operative reports, clinic notes, and radiographs were available for review. Statistical analysis included calculation of relative risk (RR) ratios. The majority of patients were female (83.2%,) and most patients were overweight with a body mass index greater than 25 kg/m² (56.4%). Patient comorbidities included diabetes (13.7%) and rheumatoid arthritis (3.7%). Additional surgery was required for 54 patients (16.8%). The most common reasons for additional surgery were the following: painful calcaneal hardware (57.4%), conversion to triple arthrodesis (16.7%), and wound healing complications (9.1%). An increased risk of need for additional surgery was associated with female gender (RR = 3.4; P = .0005), smoking status (RR = 1.9; P = .0081), and age (<60 years of age; RR = 1.8; P = .042). Although retrospective, the results provide insight into the natural history of this procedure. Clinicians may use these data to appropriately counsel patients who are at increased risk of requirement for additional surgery, such as smokers, women, and patients <60 years old, regarding treatment options.Levels of Evidence: Level IV.

An unusual presentation of acute isolated spring ligament injury in an adolescent: A case report

Spring ligament is an important stabilizing soft tissue structure on the plantar aspect of calcaneo-navicular joint. It is principal stabilizing structure to maintain the medial longitudinal arch during weight bearing. Attenuation of spring ligament along with tibialis posterior tendon deficiency usually results in adult acquired flat foot. However, cases of isolated injury to spring ligament are rare in the literature. A case of neglected spring ligament injury in a 15 years old girl with an unusual and dramatic presentation is described. Head of talus used to dislocate medially and plantarwards on every step of walking. This was treated successfully with talonavicular fusion. Level of clinical evidence: Level IV.

Lateral open wedge calcaneus osteotomy with bony allograft augmentation in adult acquired flatfoot deformity. Clinical and radiological results

Abstract

The aim of this study is to evaluate the results of patients underwent lateral open wedge calcaneus osteotomy with bony allograft augmentation combined with tibialis posterior and tibialis anterior tenodesis. Twenty-two patients underwent adult-acquired flatfoot deformity were retrospectively evaluated with a minimum 2-year follow-up. Radiographic preoperative and final comparison of tibio-calcaneal angle, talo–first metatarsal and calcaneal pitch angles have been performed. The Visual Analog Scale, American Orthopedic Foot and Ankle Score, the Foot and Ankle Disability Index and the Foot and Ankle Ability Measure were used for subjective and functional assessment. The instrumental range of motion has been also assessed at latest follow-up evaluation and compared with preoperative value. There was a significant improvement of final mean values of clinical scores (p < 0.001). Nineteen out of 22 (86.4%) patients resulted very satisfied or satisfied for the clinical result. There was a significant improvement of the radiographic parameters (p < 0.001). There were no differences between preoperative and final values of range of motion. One failure occurred 7 years after surgery. Adult-acquired flatfoot deformity correction demonstrated good mid-term results and low recurrence and complications rate.

Level of evidence

Level 4, retrospective case series.

Patient-Reported Outcomes and Radiographic Assessment in Primary and Revision Stage II, III, and IV Progressive Collapsing Foot Deformity Surgery

BACKGROUND

Progressive collapsing foot deformity (PCFD) is a progressive hindfoot and midfoot deformity causing pain and disability. Although operative treatment is stage dependent, few studies have looked at patient-reported and radiographic outcomes stratified by primary vs revision stage II, III, and IV reconstruction surgery. Our goal was to assess operative improvement using Patient-Reported Outcomes Measurement Information System (PROMIS) and to determine whether radiographic parameter improvement correlates with patient-reported outcomes.

METHODS

PROMIS Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent PCFD reconstruction between November 2013 and January 2019. Thirty-six patients completed pre- and postoperative PROMIS surveys, 6 patients completed only preoperative PROMIS surveys, and 4 patients completed 12-month postoperative PROMIS surveys but did not complete preoperative PROMIS surveys. Minimum follow-up was 12 (average, 23) months. Radiographic correction was measured with pre- and postoperative weightbearing radiographs and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percentage, anteroposterior talo-first metatarsal angle, Meary angle, medial cuneiform height (MCH), and medial cuneiform-fifth metatarsal height.

RESULTS

For the overall cohort, PROMIS PF increased significantly from 37.5±5.6 to 42.3±7.1 (P = .0014). PROMIS PI improved significantly from 64.5±6.0 to 55.1±9.8 (P < .0001). Preoperative, postoperative, and change in PROMIS scores were not statistically different between PCFD stages. Change in PROMIS PI was significantly greater in primary (-12.3) vs revision (-3.7) surgery (P = .0157). Change in PROMIS PF was greater in primary (+6.0) vs revision surgery (+2.3) but did not reach statistical significance. All radiographic measurements improved significantly (P < .05). In primary stage II PCFD, postoperative PROMIS scores correlated with postoperative MCH (PF: r = 0.7725, P = .0020; PI: r = -0.5692, P = .0446).

CONCLUSION

Patient-reported and radiographic outcomes improved significantly after PCFD reconstruction. We found no significant difference in preoperative, postoperative, or change in PROMIS scores between PCFD stages. However, stage III patients had smaller improvements in PROMIS PF, which we feel may be secondary to change in function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II PCFD, reconstructing the medial arch height correlated significantly with improvement in pain and functionality.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Consensus for the Indication of a Medializing Displacement Calcaneal Osteotomy in the Treatment of Progressive Collapsing Foot Deformity

RECOMMENDATION

There is evidence that the medial displacement calcaneal osteotomy (MDCO) can be effective in treating the progressive collapsing foot deformity (PCFD). This juxta-articular osteotomy of the tuberosity shifts the mechanical axis of the calcaneus from a more lateral position to a more medial position, which provides mechanical advantage in the reconstruction for this condition. This also shifts the action of the Achilles tendon medially, which minimizes the everting deforming effect and improves the inversion forces. When isolated hindfoot valgus exists with adequate talonavicular joint coverage (less than 35%-40% uncoverage) and a lack of significant forefoot supination, varus, or abduction, we recommend performing this osteotomy as an isolated bony procedure, with or without additional soft tissue procedures. The clinical goal of the hindfoot valgus correction is to achieve a clinically neutral heel, as defined by a vertical axis from the heel up the longitudinal axis of the Achilles tendon and distal aspect of the leg. The typical range when performing a MDCO, while considering the location and rotation of the osteotomy, is 7 to 15 mm of correction.

LEVEL OF EVIDENCE

Level V, consensus, expert opinion.

Outcomes of Idiopathic Flexible Flatfoot Deformity Reconstruction in the Young Patient

Background:

Operative correction of flatfoot deformity has been well studied in the older population. There is a subset of younger patients without congenital foot deformity that also develop a collapsing flatfoot. However, assessment of outcomes across age groups is limited, especially in the young demographic. The purpose of our study was to compare operative outcomes of flatfoot reconstruction between these 2 age groups.

Methods:

Seventy-six feet (41 left, 35 right) in 71 patients who underwent flexible flatfoot reconstruction were divided into 2 groups based on age: ≤30 years (n = 22) and >30 years (n = 54). Exclusion criteria included congenital causes of flatfoot (tarsal coalition, vertical talus, overcorrected clubfoot). Average age was 20.8 years (range, 14-30) and 55.4 years (range, 35-74) in the younger and older cohorts, respectively. Preoperative and minimum 2-year postoperative Patient-Reported Outcomes Measurement Information Systems (PROMIS) scores were compared. Five radiographic parameters were assessed pre- and postoperatively: talonavicular coverage angle, lateral talo–first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, and hindfoot moment arm. Procedures performed and incidence of minor (removal of symptomatic hardware) and major (revision) reoperations were compared.

Results:

Younger patients were less likely to undergo flexor digitorum longus transfer, first tarsometatarsal fusion, spring ligament repair, and posterior tibial tendon repair (all P < .05). Both younger and older cohorts demonstrated significant improvement in multiple PROMIS domains at an average follow-up of 30.6 (range, 24-44) and 26.8 (range, 24-45) months, respectively ( P = .07). Younger patients demonstrated significantly higher pre- and postoperative Physical Function (mean difference postoperatively, 4.6; 95% confidence interval, 1.5-7.8; P = .03). There were no differences in radiographic parameters postoperatively. There were 8 (36.4%) reoperations (all minor) in the younger group, and 21 (38.9%) reoperations (6 major, 15 minor) in the older group ( P = .84).

Conclusion:

Our data suggest that age may play a role in clinical outcomes, procedures indicated, and subsequent corrective reoperations. Younger patients maintained greater physical function with comparable radiographic correction, with less frequent indication for tendon transfers, arthrodesis, and additional corrective surgeries.

Level of Evidence:

Level III, retrospective comparative study.

Comparative Study of Spring Ligament Reconstructions Using Either Hamstring Allograft or Synthetic Ligament Augmentation

BACKGROUND

Idiopathic flatfeet are usually caused by attenuation of the medial soft tissues rather than a lateral osseous deficiency. Debate continues on whether spring ligament attenuation or posterior tibial tendon (PTT) dysfunction is the initial driver for the deformity. Our comparative prospective study aimed to quantify the radiological and clinical outcomes of 2 techniques for spring ligament reconstruction using a hamstring graft or a synthetic ligament.

METHODS

Seventeen spring ligament reconstructions (SLRs) were performed in 17 patients using synthetic ligament augmentation and 16 SLRs were performed using hamstring allograft in 13 patients. Additional procedures such as gastrocnemius recession, PTT advancement, flexor digitorum longus transfer, and calcaneal osteotomy were performed as required. A minimum of 12 months of follow-up was available for all cases. Radiographic analysis was performed with standardized parameters.

RESULTS

Following SLR with synthetic ligament augmentation, all radiological parameters significantly improved (P < .05). Hamstring allograft SLR also demonstrated significantly improved radiographic parameters in all but Meary's line at final follow-up. At 12 months, patient outcome scores were significantly better in the synthetic ligament group.

CONCLUSION

Reconstruction of the spring ligament using either hamstring allograft or synthetic ligament augmentation provided significant improvements in radiological alignment; however, superior patient-reported outcomes were found in the synthetic ligament augmentation group.

LEVELS OF EVIDENCE

Level III, retrospective cohort study.

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.

Adult Flat Foot With Multiple Accessory Navicular Bones Treated Surgically: A Case Report and Review of the Literature

Multiple accessory navicular bones is an extremely rare condition. To the best of our knowledge, only 8 cases in 2 imaging studies have been published. We report a case of a patient with flat foot with 2 accessory navicular bones. This patient needed to be treated surgically, and the surgery was successful, with short-term follow-up. We believe this is the first case of multiple accessory navicular bones to be treated surgically in English literature. The incidence of multiple accessory navicular bones might be higher. There is a risk to remaining ossicles without resection or fixation during surgery; therefore, we strongly recommend using not only radiographs, but also 3-dimensional computed tomography scans or magnetic resonance imaging scans to confirm the type of accessory navicular bone, at least before surgery, for both painful accessory navicular bone and flat foot with accessory navicular bone.

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.

Postoperative Medial Cuneiform Position Correlation With Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity

BACKGROUND

Residual supination of the midfoot during reconstruction of the stage II adult-acquired flatfoot deformity (AAFD) is often addressed with a medial cuneiform (Cotton) osteotomy after adequate correction of the hindfoot valgus deformity. The purpose of this study was to determine if there was a correlation between postoperative alignment of the medial cuneiform and patient-reported outcomes.

METHODS

Sixty-three feet in 61 patients with stage II AAFD who underwent a Cotton osteotomy as part of a flatfoot reconstruction were included in the study. Radiographic angles were measured on weightbearing lateral radiographs at a minimum of 40 weeks postoperatively. Pearson's correlation analysis was used to determine if there was an association between postoperative radiographic angles and Foot and Ankle Outcome Score (FAOS) at a minimum of 24 months postoperatively. Patients were also divided into mild plantarflexion (cuneiform articular angle [CAA] ≥-2 degrees) and moderate plantarflexion (CAA <-2 degrees) groups to evaluate for differences in clinical outcomes.

RESULTS

Postoperative CAA was significantly positively correlated with the postoperative FAOS symptoms ( r = .27, P = .03), daily activities ( r = .29, P = .02), sports activities ( r = .26, P = .048), and quality of life ( r = .28, P = .02) subscales. Patients in the mild plantarflexion group had statistically and clinically better outcomes compared with the moderate plantarflexion group in the FAOS symptoms ( P = .04), daily activities ( P = .04), and sports activities ( P = .01) subscales.

CONCLUSIONS

Our study suggests that the surgeon should avoid excessive plantarflexion of the medial cuneiform and use the Cotton osteotomy judiciously as part of a flatfoot reconstruction for stage II AAFD.

LEVEL OF EVIDENCE

Level III, comparative 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.

Neurovascular and Clinical Outcomes of the Percutaneous Endoscopically Assisted Calcaneal Osteotomy (PECO) Technique to Correct Hindfoot Malalignment

BACKGROUND:

Standard open calcaneal osteotomies to correct hindfoot malalignment have been associated with high complication rates, including nerve damage and wound infection. This has resulted in the development of minimally invasive techniques such as the percutaneous endoscopically assisted calcaneal osteotomy (PECO), which in cadaver studies has been shown to be potentially safer than open surgeries. The aim of this study was to demonstrate the safety and effectiveness of PECO in a clinical setting, with regard to neurovascular injury rates, infection, and short-term radiographic and functional outcomes.

METHODS:

Forty-one (41) patients with planovalgus or cavovarus foot deformities underwent treatment using PECO. Outcomes were analyzed at 6 months and primarily included neurovascular outcomes and wound infection rates. Secondarily, radiographic and functional (visual analog scale for pain [VAS], 36-Item Short Form Medical Outcomes Survey [SF-36], and Foot Function Index [FFI] scores) outcomes were also assessed.

RESULTS:

There were no reported cases of superficial wound infections, lateral calcaneal or sural nerve dysesthesia. Minor complications occurred in 6/41 feet. The mean postoperative hindfoot correction was 8.3 ± 2.2 mm (range: 6-15mm) compared to preoperative status. Compared to preoperative status, significant improvements ( P = .001 for all) were seen in the VAS, SF-36, and FFI at 6 months postoperatively.

CONCLUSIONS:

PECO resulted in minimal complications with no lateral calcaneal or sural nerve dysesthesias and no wound complications. It also resulted in significant improvements in postoperative radiographic and functional outcomes from baseline to 6-months postoperatively, demonstrating its use as a safe and effective means of treating hindfoot malalignment.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

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.

Comparison of Anatomic Structures at Risk With 2 Lateral Lengthening Calcaneal Osteotomies

BACKGROUND:

Lateral lengthening calcaneal osteotomies (LLCOT) are commonly used to treat flexible pes planovalgus deformity. Different operative techniques have been described. The aim of this study was to examine which anatomic structures were affected by 2 different osteotomy techniques.

METHODS:

Two experienced foot and ankle surgeons each performed an Evans (E)- or Hintermann (H) osteotomy on 7 cadaver feet. The mean age of the donors was 80.4 ± 4.4 years. Eight left and 6 right feet were prepared. Previously identified structures at risk were prepared and evaluated.

RESULTS:

After H-LLCOT, there was no damage of the peroneus longus tendon, whereas after E-LLCOT, damage was noted in 1 case (14.3%). The peroneus brevis tendon was once cut after H-LLCOT and eroded after E-LLCOT. In one cadaver, the sural nerve was partially damaged after H-LLCOT but in no case after E-LLOCT. The calcaneal anterior and medial articular facets were intact after H-LLCOT in 100% and 85.7% and after E-LLCOT in 42.9% and 71.4%, respectively. The posterior articular surface was not affected in any cadaver.

CONCLUSION:

Anatomic structures can be damaged after both osteotomies. With the Hintermann osteotomy, the calcaneal anterior and medial articular surface can be protected to a larger extent than with the Evans osteotomy.

CLINICAL RELEVANCE:

The Hintermann osteotomy seems to be superior, regarding damage of the articular surfaces of the subtalar joint. These findings have to be correlated with biomechanical and clinical studies before a final recommendation can be given, which osteotomy is superior.

Valgus Ankle Degenerative Arthritis with an Isolated Deltoid Insufficiency and Tibial Varus: A Case Report

We report a case of valgus ankle degenerative arthritis due to chronic isolated deltoid insufficiency combined with tibial varus that was treated successfully with ankle joint preserving surgery. A 63-year-old male complained of right lateral ankle pain with 10 minutes of maximal pain-free walking time. The assessed American Orthopaedic Foot and Ankle ankle-hindfoot scale score was 33 points. The ankle joint showed 18° of valgus deformity with 6° of tibia varus. Medial displacement calcaneal osteotomy, supramalleolar open wedge osteotomy, and deltoid ligament imbrication were performed. At the 2-year follow-up examination, the ankle joint showed 10° of valgus and the tibial plafond showed flattening. The hindfoot showed 7° of valgus. He could run for 2 hours on the treadmill without pain. The American Orthopaedic Foot and Ankle ankle-hindfoot scale score was 90 points. In conclusion, valgus ankle degenerative arthritis with isolated deltoid insufficiency and tibial varus could be treated successfully with realignment using a double osteotomy and additional deltoid imbrication.

Return to sport activities after medial displacement calcaneal osteotomy and flexor digitorum longus transfer

PURPOSE

Medial displacement calcaneal osteotomy with flexor digitorum longus transfer is a common treatment for the management of the adult flatfoot associated with posterior tibial tendon dysfunction. In the literature, there is a paucity of information regarding the ability of patients to return to sport and recreational activities after this surgical procedure. The purpose of this retrospective clinical study was to assess the rate and type of athletic activities that patients participated in before and after medial displacement calcaneal osteotomy with flexor digitorum longus transfer.

METHODS

A consecutive series of 42 patients with a mean age at surgery of 41 years (range 19-74 years) was evaluated with a minimum follow-up of 24 months (range 18-31 months). Pre- and post-operative sporting activities were assessed. At final follow-up, patients were asked to complete a Sports Athlete Foot and Ankle Score (SAFAS). Each patient was also evaluated with weight-bearing radiographs of the foot before surgery and at final follow-up.

RESULTS

Preoperatively, 27 of 42 (64.3 %) patients were engaged in athletic activities, participating in an average of 1.4 h/week (range 0-6 h/week); post-operatively, 36/42 (85.7 %) participated in sport and recreational activities for an average of 3.5 h/week (range 0-15 h/week). Meary's angle improved significantly from 11.5 ± 6.2 degrees preoperatively to 7.0 ± 5.7 degrees at final follow-up (p < 0.01); calcaneal pitch improved significantly from 16.5 ± 4.6 degrees to 19.0 ± 5.0 degrees (p < 0.01). At final follow-up, patients demonstrated good SAFASs in symptom tolerance (86.4 %), pain tolerance (89.0 %), daily living performance (96.1 %), and sports performance (86.7 %).

CONCLUSION

The majority of patients returned to sports and recreational activity after medial displacement calcaneal osteotomy and flexor digitorum longus for the treatment of adult flatfoot associated with posterior tibial tendon dysfunction.

LEVEL OF EVIDENCE

III.

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.

CT and MR Imaging of the Postoperative Ankle and Foot

A variety of surgical procedures exist for repair of both traumatic and degenerative osseous and soft-tissue pathologic conditions involving the foot and ankle. It is necessary for the radiologist to be familiar with these surgical procedures, so as to assess structural integrity, evaluate for complicating features, and avoid diagnostic pitfalls. Adequate interpretation of postoperative changes often requires access to surgical documentation to evaluate not only the surgery itself but the expected timeline for resolution of normal postoperative changes versus progressive disease. Appropriate use of surgical language in radiology reports is another important skill set to hone and is instrumental in providing a high-quality report to the referring surgeons. The pathophysiology of a myriad of surgical complaints, beginning from the Achilles tendon and concluding at the plantar plate, are presented, as are their common appearances at computed tomography and magnetic resonance imaging. Commonly encountered entities include Achilles tendon tear, spastic equinus, nonspastic equinus, talar dome osteochondral defect, tarsal tunnel syndrome, plantar fasciitis, pes planovalgus, pes cavovarus, peroneal tendinosis, lateral ligament complex pathology, Morton neuroma, plantar plate tear, and metatarsophalangeal joint instability. Computer-generated three-dimensional models are included with many of the procedures to provide a more global view of the surgical anatomy. Correlation with intraoperative photographs is made when available. When appropriate, discussion of postoperative complications, including entities such as infection and failure of graft integration, is presented, although a comprehensive review of postoperative complications is beyond the scope of this article. Notably absent from the current review are some common foot and ankle procedures including hallux valgus and hammertoe corrections, as these are more often evaluated radiographically than with cross-sectional imaging. ^©RSNA, 2016.

Overcorrected Flatfoot Reconstruction

The overcorrected flatfoot reconstruction is a less common but often difficult sequelae of surgical treatment of the adult acquired flatfoot deformity. Understanding the patient's symptoms and how they correlate to the procedures performed during the index surgery are paramount to determining the appropriate course of treatment. Patients' symptoms may resemble those seen in the cavovarus foot condition, often secondary to overlengthening of the lateral column or excessive displacement of the calcaneal tuberosity. Osteotomies of the calcaneus, midfoot, and often the first metatarsal may be sufficient to revise the overcorrection. However, hindfoot and/or midfoot arthrodesis may be required in more severe or rigid cases.

Calcaneal Osteotomies: Pearls and Pitfalls

Adult acquired flatfoot deformity is a debilitating condition typically affecting middle-aged patients. The multiple components include hindfoot valgus, first ray elevation, medial soft tissue compromise, and forefoot abduction. As the foot becomes unbalanced, the deformity progresses with repetitive loading and time. Untreated patients often need significant reconstructions or extensive arthrodesis after arthritis and joint contractures present. Medializing calcaneal osteotomy is the workhorse operation for correction of hindfoot valgus, reliably correcting deformity with a relatively low complication risk. This article reviews indications, techniques, complications, and outcomes for the medializing calcaneal osteotomy.

Minimally Invasive Calcaneal Displacement Osteotomy Site Using a Reference Kirschner Wire: A Technique Tip

As a standard open approach, the lateral oblique incision has been widely used for calcaneal displacement osteotomy. However, just as with other orthopedic procedures that use an open approach, complications, including wound healing problems and neurovascular injury in the heel, have been reported. To help avoid these limitations, a percutaneous technique using a Shannon burr for calcaneal displacement osteotomy was introduced. However, relying on a free-hand technique without direct visualization at the osteotomy site has been a major obstacle for this technique. To address this problem, we developed a technical tip using a reference Kirschner wire. A reference Kirschner wire technique provides a reliable and accurate guide for minimally invasive calcaneal displacement osteotomy. Also, the technique should be easy to learn for surgeons new to the procedure.

Effect of Obesity on Clinical and Radiographic Outcomes Following Reconstruction of Stage II Adult Acquired Flatfoot Deformity

BACKGROUND

Obesity is a known risk factor for the development of adult acquired flatfoot deformity (AAFD), but obesity's effects on outcomes following AAFD reconstruction are unknown. We hypothesized that obesity would negatively impact outcomes following joint-preserving stage II AAFD reconstruction.

METHODS

This retrospective study compared the outcomes of normal-weight (18.5 kg/m(2) ≤ BMI < 25 kg/m(2)), overweight (25 kg/m(2) ≤ BMI < 30 kg/m(2)), and obese (BMI ≥ 30 kg/m(2)) patients after AAFD reconstruction. Clinical outcome measures included the Foot and Ankle Outcome Score (FAOS), Short-Form 12 (SF-12), and Numeric Rating Scale of Pain (NRS Pain) administered preoperatively and at least 1 year postoperatively. Anteroposterior and lateral radiographs were taken preoperatively and at least 6 months postoperatively. Pre- to postoperative changes in outcome measures were assessed within BMI classes. Preoperative, postoperative, and pre- to postoperative changes in outcomes were compared among BMI classes. There were 41 normal-weight patients, 39 overweight patients, and 44 obese patients with a mean age of 56 years, FAOS follow-up of 2.9 years, and radiographic follow-up of 2.1 years. Demographics and reconstructive procedures were comparable among the 3 BMI classes.

RESULTS

All outcomes significantly increased pre- to postoperatively in the 3 groups with the exception of the FAOS Symptoms subscale for normal-weight patients (P = .340) and SF-12 Mental Component score for all 3 BMI classes (P > .999). Preoperatively, obese patients had more symptoms than normal-weight patients, scoring 12 points lower on the FAOS Symptoms subscore (P = .008). Obese patients also scored 11 points lower preoperatively on the SF-12 Overall score (P = .028) and had 31% greater pain than normal-weight patients (P = .003). There were no differences among the 3 BMI classes in any postoperative outcomes assessed.

CONCLUSION

Although obese patients had significantly worse symptoms, overall health, and NRS pain scores preoperatively, the short-term clinical and radiographic outcomes of stage II AAFD reconstruction were similar for normal-weight, overweight, and obese patients. We suggest that joint-preserving reconstruction remains a viable alternative to fusion of the triple joint complex for the treatment of overweight and obese stage II AAFD patients.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Surgery for adult acquired flatfoot due to posterior tibial tendon dysfunction reduces pain, improves function and health related quality of life

BACKGROUND

Patients with adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD) may require surgery but few reports have evaluated the outcome.

METHODS

We evaluated 21 patients with a median age of 60 (range 37-72) years who underwent different surgical reconstructions due to stage II AAFD before and 6 and 24 months after surgery by the validated Self-Reported Foot and Ankle Score (SEFAS), Short Form 36 (SF-36) and Euroquol 5 Dimensions (EQ-5D).

RESULTS

The improvement from before to 24 months after surgery was in SEFAS mean 12 (95% confidence interval 8-15), SF-36 physical function 21 (10-22), SF-36 bodily pain 28 (17-38), EQ-5D 0.2 (0.1-0.3) and EQ-VAS 11 (2-21).

CONCLUSION

Surgery for AFFD due to PTTD results in reduced pain and improved function and health related quality of life. The outcome scores have been demonstrated as useful. It has also been shown, since there is a further improvement between 6 and 24 months after surgery, that a minimum follow-up of 2 years is needed.

LEVEL OF CLINICAL EVIDENCE

III - prospective observational cohort study.

Interference screw for fixation of FDL transfer in the treatment of adult acquired flat foot deformity stage II

INTRODUCTION

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy have shown favourable results in the treatment of adult acquired flat foot deformity stage 2. Little is known about the resorbable interference screw for tendon fixation and postoperative patient satisfaction though. Moreover possible changes of radiographic parameters at final follow-up, possible implant-associated complications and differences concerning clinical results at final follow-up to other studies using bone tunnel techniques for fixation of the FDL tendon were investigated.

MATERIALS AND METHODS

21 feet in 21 patients with a mean age of 51 years were evaluated pre- and postoperatively after a standardised operative procedure using MDCO and FDL transfer with interference screw fixation. Patients were evaluated with the American Orthopaedic Foot and Ankle Society Hindfoot Score and the Visual Analogue Scale at an average follow-up of 20 months. Hindfoot radiographic parameters were evaluated according to AOFAS guidelines. For statistical analysis SPSS v.15.0.1 was used.

RESULTS

The average AOFAS Score (from 42 to 95 points) and VAS (from 0.5 to 8 points) both increased significantly (p < 0.001 each) from preoperative to final follow-up as well as the hindfoot valgus (from 10 to 4 degrees (p = 0.005)) and the lateral talo-first metatarsal angle (from 13.6 preoperative to 5.2° at follow-up). 88 percent of patients evaluated the postoperative result with "very good" or "good". Implant-associated complications could not be detected.

CONCLUSION

We conclude that interference screw fixation for FDL transfer is a safe and promising operative technique, allowing a smaller skin incision without disrupting the normal interconnections at the knot of Henry, while achieving very high patient satisfaction and improving postoperative function as well as relieving pain. This method is technically easy to perform, has a low complication risk and we, therefore, recommend this fixation technique in patients with adult acquired flatfoot deformity stage 2.

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.

Minimally Invasive Calcaneal Osteotomy: Does the Shannon Burr Endanger the Neurovascular Structures? A Cadaveric Study

Calcaneal osteotomies are used to correct hindfoot alignment. Traditional open procedures have been plagued with complications. Various minimally invasive techniques have been described but are laborious and time-consuming. A percutaneous technique using a side cutting "Shannon" burr offers a simple and reliable alternative; however, little evidence is available to address the safety concerns. The aim of the present study was to quantify the risk posed to the medial and lateral neurovascular structures using this technique. The study was performed at the anatomy department, University of Sussex, using 13 fresh-frozen, below-the-knee cadaveric specimens during a training session held by WG Healthcare UK, Ltd. (Letchworth, Herts). The participants were 11 consultant orthopedic surgeons, who were inexperienced in minimally invasive surgery, and 2 demonstrators. Each performed a chevron calcaneal osteotomy using a Shannon burr by way of a lateral percutaneous approach under fluoroscopic guidance. The authors subsequently dissected the specimens to identify the neurovascular structures, describe their anatomic relations and proximity to the burr, and note any damage incurred. No evidence was found of significant neurovascular injury. Two very small proximal branches of the sural nerve were transected, the nerve itself passing safely 9 to 21 mm anterosuperior to the entry point. The medial neurovascular bundle crossed the path of the osteotomy in 4 specimens but was protected by the medial head of the quadratus plantae muscle. In conclusion, the Shannon burr for calcaneal osteotomy has the potential to minimize the surgical morbidity and maximize surgical efficiency without compromising safety in all patients with normal anatomy of the quadratus plantae muscle.

Screw size and insertion technique compared with removal rates for calcaneal displacement osteotomies

BACKGROUND

The calcaneal displacement osteotomy is frequently used by foot and ankle surgeons to correct hindfoot angular deformity. Headed compression screws are often used for this purpose, but a common complication is postoperative plantar heel pain from prominent hardware. We evaluated hardware removal rates after calcaneal displacement osteotomies and analyzed technical factors including screw size, position, and angle. We hypothesized that larger screws placed more plantarly would have been removed more frequently. We also believed that although 2 smaller screws cost more initially, when removal rates and cost are accounted for, savings would be demonstrated with this technique.

METHODS

We retrospectively collected data on type of fixation, cost of fixation, and frequency of removal. After exclusions we had 30 patients in our screw removal cohort and 119 in our screws retained cohort. A basic cost analysis and statistical analysis was performed.

RESULTS

The small screw group had a hardware removal rate of 9% (4/43) compared to 25% (26/104) of the larger screw group (P = .032). While the cost of 2 smaller screws is more than that of 1 larger screw, when the cost of removal and the rates of doing so are considered, the smaller screws resulted in substantial cost savings.

CONCLUSION

Technical considerations for the medial displacement calcaneal osteotomy, including the use of multiple smaller screws, provided for a lower rate of hardware removal and likely decreased long-term costs.

LEVEL OF EVIDENCE

Level III, comparative series.

Correlation of postoperative midfoot position with outcome following reconstruction of the stage II adult acquired flatfoot deformity

BACKGROUND

No studies investigating the effect of the midfoot (talonavicular joint) position on clinical outcomes following flatfoot reconstruction have been performed. The purpose of our study was to determine whether a postoperative abducted or adducted forefoot alignment, as determined from anteroposterior (AP) radiographs, was associated with a difference in outcomes using the Foot and Ankle Outcome Score (FAOS).

METHODS

Midfoot abduction was defined on postoperative AP radiographs, evaluated at a mean of 1.9 years in 55 patients from the authors' institution who underwent flatfoot reconstruction for a stage II adult acquired flatfoot deformity (AAFD), as a lateral incongruency angle greater than 5 degrees, a talonavicular uncoverage angle greater than 8 degrees, and a talo-first metatarsal angle greater than 8 degrees based on previously reported measurements. Patients with 2 or more measurements in the abduction category were classified as the abduction group (n = 30); those with 1 or fewer measurements in the abduction category were placed in the adduction group (n = 25). The preoperative and postoperative FAOS values with a mean follow-up of 3.1 years were compared using Wilcoxon rank-sum tests.

RESULTS

Patients corrected to a position of adduction showed significantly lower improvement in the FAOS daily activities (P = .012) and quality of life subscales (P = .046). The mean improvement in subscale scores for the adducted group was lower for pain (P = .052) and sports activities (P = .085) but did not reach statistical significance. No significant difference in the FAOS symptoms subscale (P = .372) between groups was found.

CONCLUSION

Correction of the talonavicular joint to a position of adduction following a stage II AAFD was associated with decreased patient outcomes in daily activities and quality of life compared with an abducted position. These results suggest that overcorrection to a position of midfoot adduction leads to a lesser amount of individual patient improvement in reconstruction of a stage II AAFD.

Comparing fixation used for calcaneal displacement osteotomies: a look at removal rates and cost

BACKGROUND

The calcaneal displacement osteotomy is a procedure frequently used by foot and ankle surgeons for hindfoot angular deformity. Traditional techniques use compression screw fixation that can result in prominent hardware. While the results of the procedure are generally good, a common concern is the development of plantar heel pain related to prominent hardware. The primary purpose of this study is to retrospectively compare clinical outcomes of 2 fixation methods for the osteotomy. Secondarily a cost analysis will compare implant costs to hardware removal costs.

METHODS

Records were reviewed for patients who had undergone a calcaneal displacement osteotomy fixated with either lag screw or a locked lateral compression plate (LLCP). Neuropathy, previous ipsilateral calcaneus surgery, heel pad trauma, or incomplete radiographic follow-up were exclusionary.

RESULTS

Thirty-two patients (19.4%) required hardware removal from the screw fixation group compared to 1 (1.6%) of the LLCP group, which is significant (P < .05). Time to radiographic healing was not significantly different (P = .87). The screw fixation group required more follow-up visits over a longer period of time (P < .05). Implant cost was remarkably different with screw fixation costing on average $247.12, compared to the LLCP costing $1175.59. Although the LLCP cost was significantly higher, cost savings were identified when the cost of removal and removal rates were included.

CONCLUSION

This study demonstrates that this device provides adequate stabilization for healing in equivalent time to screw fixation. The LLCP required decreased rates of hardware removal with fewer postoperative visits over a shorter period of time. Significant savings were demonstrated in the LLCP group despite the higher implant cost.

LEVELS OF EVIDENCE

Therapeutic, Level III, Retrospective Comparative Study.

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.

Surgical management of stage 2 adult acquired flatfoot

Adult acquired flatfoot deformity is a progressive disorder with multiple symptoms and degrees of deformity. Stage II adult acquired flatfoot can be divided into stage IIA and IIB based on severity of deformity. Surgical procedures should be chosen based on severity as well as location of the flatfoot deformity. Care must be taken not to overcorrect the flatfoot deformity so as to decrease the possibility of lateral column overload as well as stiffness.

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.

Approach and treatment of the adult acquired flatfoot deformity

Adult acquired flatfoot deformity (AAFD), embraces a wide spectrum of deformities. AAFD is a complex pathology consisting both of posterior tibial tendon insufficiency and failure of the capsular and ligamentous structures of the foot. Each patient presents with characteristic deformities across the involved joints, requiring individualized treatment. Early stages may respond well to aggressive conservative management, yet more severe AAFD necessitates prompt surgical therapy to halt the progression of the disease to stages requiring more complex procedures. We present the most current diagnostic and therapeutic approaches to AAFD, based on the most pertinent literature and our own experience and investigations.

The calcaneal scarf osteotomy: surgical correction of the adult acquired flatfoot deformity and radiographic results

PURPOSE

Surgical correction of the adult acquired flatfoot deformity (AAFD) is continually evolving. This technique article presents the technique of the calcaneal scarf osteotomy (CSO) and radiographic evidence supporting the ability of this procedure to correct an AAFD.

METHOD

The technique described here is a single osteotomy that corrects flatfoot deformity in all 3 planes. Retrospectively, medical records were reviewed to identify patients who underwent a CSO for surgical correction of AAFD. Pre- and postoperative radiographs were reviewed.

RESULTS

Thirty patients (32 feet) had an average age of 49.0 ± 17.2 years (range = 35-73 years) with an average of 5.7 ± 2.0 years (range = 1-11 years) of follow-up. Anteroposterior and lateral radiographic parameters were significantly altered with this procedure (P < .001). CSO-induced calcaneal-cuboid joint arthritis did not occur.

DISCUSSION AND CONCLUSIONS

The results of the current study demonstrate that the CSO significantly changes radiographic exam parameters in patients who suffer from AAFD. Therefore, the CSO provides triplanar correction through one osteotomy with early return to weight bearing and lacks the complications such as lateral column pain associated with other calcaneal osteotomies.

LEVELS OF EVIDENCE

Level IV, Retrospective cohort study.