Does the Sagittal Radiographic Morphology of Subtalar Joint Affect the Alignment of Foot?

OBJECTIVES

The etiology of flatfoot and cavus foot is multicausal and controversial. So far, no literature reports the relationship between the sagittal morphology of subtalar joint and the alignment of foot. The purpose of this study was to explore whether the subtalar alignment would influence the configuration of foot.

METHODS

From January 2017 to January 2020, we included 109 feet in the flatfoot group, 95 feet in the cavus group, and 104 feet in the control group in this retrospective comparative study. The Gissane angle and calcaneal posterior articular surface inclination angle represented the sagittal morphology of the subtalar joint. Meary's angle, calcaneal pitch angle, and talar pitch angle reflected the alignment of foot. They were measured in the weightbearing foot X-rays. The angles in different groups were compared via Mann-Whitney U test. We calculated the correlation between the sagittal alignment of subtalar joint and the alignment of foot using Spearman's correlation analysis. Interobserver and intraobserver reliability were calculated.

RESULTS

The Gissane angle, calcaneal posterior articular surface inclination angle, Meary's angle, talar pitch angle, and calcaneal pitch angle were significantly different in the three groups. The Gissane angle had an excellent correlation with the Meary's angle (r = 0.850, p < 0.0001), and the talar pitch angle (r = -0.825, p < 0.0001), and a good correlation with the calcaneal pitch angle (r = 0.638, p < 0.0001). The calcaneal posterior articular surface inclination angle had an excellent correlation with the Meary's angle (r = -0.902, p < 0.001), and the talar pitch angle (r = 0.887, p < 0.0001), and a good correlation with the calcaneal pitch angle (r = -0.702, p < 0.0001). The interobserver and intraobserver reliability for all radiographic measurements was good to excellent.

CONCLUSION

A subtalar joint with a larger Gissane angle and a more horizontal calcaneal posterior articular surface angle tended to have a higher foot arch and vice versa. The inspiration from this study was that the deformities of flatfoot and cavus foot may relate to the subtalar deformity.

Feasibility and safety of minimally invasive calcaneal osteotomy (MICO) through a medial approach: a case-control study

INTRODUCTION

Minimally invasive calcaneal osteotomy (MICO) is already an established surgical procedure for correcting hindfoot deformities using a lateral approach. So far, no description of a medial approach for MICO has been published.

MATERIAL AND METHODS

Between August 2022 and March 2023, 32 consecutive patients (MICO with medial approach, MMICO: n = 15; MICO with lateral approach, LMICO: n = 17) underwent MICO as part of complex reconstructive surgery of the foot and ankle with concomitant procedures. The amount of correction in the axial view of the calcaneus and consolidation rates were evaluated radiographically. Subjective satisfaction, stiffness of the subtalar joint, and pain level (numeric rating scale, NRS) at the level of the heel were assessed clinically. The last follow-up was at 6 months.

RESULTS

All osteotomies consolidated within 6 months after surgery. Displacement of the tuber was 9 mm on average in either group. Relevant subtalar joint stiffness was detected in 5 MMICO and 6 LMICO patients. No relevant differences between the groups were detected for wound healing problems, nerve damage, heel pain or patient satisfaction.

CONCLUSION

In this study lateral and medial approaches for MICO were performed. Similar degrees of correction and low complication rates were found in both groups. The medial approach for MICO is safe and can be beneficial regarding patient positioning and arrangement of the C‑arm.

Toes Deformities in Cavovarus: How to Approach Them

Sagittal lesser toe deformities (LTD) are the most common in cavus foot. They are mainly the result of muscular imbalance between intrinsic and extrinsic muscles. Surgery is the second-line treatment if medical treatment fails. The aim of the present study was to provide an update on classification and surgical management of LTD in cavus foot including percutaneous procedures with a special focus on sagittal deformities. Joint sparing procedures are preferred for reducible LTD, whereas lesser toe fusions are used for rigid one in association with tendon transfer or percutaneous procedures depending of surgeon's experience and patient's clinical examination.

Cavus Foot Deformity with Calcaneonavicular and Medial Cuneiform-Navicular Coalition: A Case Series

Tarsal coalitions have only very infrequently been observed in the context of cavus foot abnormalities. Recognizing this diagnosis could be crucial to effective cavus repair. We report tarsal coalitions observed in cavus deformity here. Between 2022 and 2023, the records of every patient treated by one of the authors for a varus deformity who was later determined to have either a unilateral or bilateral tarsal coalition were examined. Two patients with cavus deformities who were treated by one of the authors have either a unilateral or bilateral tarsal coalition. Three foot (medial cuneiform-navicular n = 1 and calcaneonavicular n = 2) with tarsal coalition were examined. All of these cases occurred in patients with idiopathic cavus deformity. Computed tomography scans were used to make a firm diagnosis for each patient. We advise surgeons to keep an awareness for this potential comorbid issue in all cavus foot abnormalities and to take advanced imaging into consideration. In these uncommon cases, the medial cuneiform-navicular and calcaneonavicular joints formed an osseous coalition with pes cavus deformity, which successfully resolved with conservative and surgical treatment, respectively. Level of Clinical Evidence: IV.

Non-radiographic validity and reliability measures for assessing foot types: A systematic review

BACKGROUND

Foot type classification is well recognized in clinical practice and orthopedic literature, a universally accepted classification or standardized measures to determine foot types are lacking. The objective of this study was to identify which non-radiographic assessment methods are considered valid and/or reliable for the classification of foot types.

METHOD

A systematic database search was performed. Only cross-sectional studies that performed reliability and/or validity analysis of non-radiographic methods were included. To evaluate the risk of bias, the Critical Appraisal Tool (CAT) was used to evaluate the measurement properties of objective clinical methods.

RESULTS

Twenty-six studies were included. The results of reliability and validity, in general, demonstrated high scores, but, inconsistencies were related to the variability of the measurements, heterogeneity of the methods used to determine reliability and validity, and lack of parameters for classifying foot types, which resulted in few elements to determine which method of foot type evaluation is valid and reliable.

CONCLUSION

Given the Intraclass Correlation Coefficient and CAT results and the presence of normative values, the static measurements of the "Arch Height Index", "Foot Posture Index", and "Staheli Arch Index" can be suggested to classify foot types.

Hallux and Lesser Digits Deformities Associated with Cavus Foot

It is important to identify the level of the deformity or deformities. It is important to get the limb as close to anatomic alignment as possible. Many levels and multiple procedures may be involved with this reconstruction.

Managing the Complex Cavus Foot Deformity

This article describes approaches to and the management of complex cavus foot deformities. Correction of rigid multiplanar deformities can be very challenging, given the presence of skeletal deformities in multiple planes and combined with a varying degree of muscle imbalance. The complexity of these cases always requires a case-by-case approach. Some of the cases presented here occur in patients who have previously undergone surgical management for their deformity, several of which are complicated by additional deformities. With a firm understanding and application of the principles of deformity correction, however, one may reliably offer satisfactory results.

Reproducibility of radiographic methods for assessing longitudinal tarsal axes Part 2: Severe cavus or flatfoot study

INTRODUCTION

Calcaneal pitch angle and Meary's angle are commonly used to assess longitudinal foot arches on lateral-view radiographs. The aim of this study was to examine and evaluate the radiographic longitudinal foot arch measurement methods with the best intraobserver and interobserver reliabilities for patients with (1) severe cavus deformity and (2) severe flatfoot deformity.

METHODS

Standing radiographic images of 22feet with severe cavus foot deformity and 49feet with severe flatfoot deformity were obtained to measure the longitudinal axes of the talus, first metatarsal, calcaneus and plantar surface, which were defined using six, five, four and three different methods, respectively, selected from previous reports. Intraobserver and interobserver correlation coefficients were calculated.

RESULTS

The results are generally consistent with those of Part 1. The best intraobserver and interobserver correlation coefficients for the tarsal axes were obtained using methods involving a line bisecting the angle formed by the lines tangential to the superior and inferior margins of the talus, a line connecting the centre of the first metatarsal head and the midpoint of the visualized base of the first metatarsal, and a line drawn tangential to the inferior surface of the calcaneus. For the plantar axis, a method that used the horizontal plane (as a reference axis) was regarded as the best approach.

CONCLUSIONS

The aforementioned methods were considered to be optimal for the radiographic assessment of longitudinal foot arches in patients with severe cavus or flatfoot deformity. This study may contribute to the more accurate assessment of any foot deformity.

Failure of Surgical Treatment in Patients with Cavovarus Deformity: Why Does This Happen and How Do We Approach Treatment?

Recurrent deformity after surgical treatment of the cavus foot occurs because a procedure is not performed at the apex of the deformity. In many instances there are multiple apices and, in addition to hindfoot osteotomy or arthrodesis, the midfoot must be corrected. There is not much of a role for the Coleman block test to determine flexibility of the foot, and this has led to many failures where the foot was believed flexible and an osteotomy was insufficient treatment. Skeletal correction, even if perfect, does not last unless the foot is balanced with appropriate tendon transfers.

Cavus Foot: Deciding Between Osteotomy and Arthrodesis

Mild to moderate cavus deformity creates a dilemma in terms of surgical decision-making. The decision to pursue osteotomy or arthrodesis is not always clear. This article provides a framework for guiding management of these deformities, followed by a detailed surgical approach to correcting moderate cavus deformities, which emphasizes the use of a midfoot osteotomy-arthrodesis.

[Triple arthrodesis for correction of cavovarus deformity]

OBJECTIVE

The aim is to correct the underlying cavovarus deformity and to achieve a pain-free and stable hindfoot.

INDICATIONS

Rigid neurologic, posttraumatic, congenital, and idiopathic cavovarus deformities.

CONTRAINDICATIONS

General surgical or anesthesiological risks, infections, critical soft tissue conditions, neurovascular impairment of the lower extremity, noncompliance, patients with severely reduced bone quality, insulin-dependent diabetes mellitus, smoking.

SURGICAL TECHNIQUE

The talonavicular and subtalar joints are exposed using a single medial approach. Joint cartilage is carefully debrided. Hindfoot reposition with complete correction of cavovarus deformity in all three planes. Joints are stabilized using cannulated screws, followed by wound closure.

POSTOPERATIVE MANAGEMENT

A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 using a stabilizing walking boot or cast for 6 weeks with 15 kg partial weight bearing. Clinical and radiographic follow-up 6 weeks postoperatively to assess osseous consolidation at the arthrodesis site. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is gradually initiated.

RESULTS

Between January 2012 and July 2014, triple arthrodesis was performed in 11 patients with a mean age of 62 ± 14 years due to cavovarus deformity. The mean follow-up was 34 ± 8 months (range 24-48 months). In all patients, the cavovarus deformity was substantially corrected. Significant pain relief from 7.1 ± 2.2 (range 5-10) to 1.8 ± 1.5 (range 0-4) on the visual analogue scale was observed.

Surgical Correction of Rigid Equinovarus Contracture Utilizing Extensive Soft Tissue Release

Although deforming contractures of the lower extremities after acute cerebrovascular events are well documented in the literature, there is limited literature regarding specific surgical considerations for the correction of these deformities, which are nonosseus in nature. The equinovarus foot, regardless of its origin, is a challenging pathologic condition for the foot and ankle surgeon. It is critical to have a firm understanding of the cause and symptoms behind an equinovarus deformity before treatment. The clinical presentation is discussed with special attention to deformities in adults with rigid equinovarus deformities after cerebrovascular-related accidents or peripheral ischemic events.

Jones Tendon Transfer

Hallux malleus is a deformity of the great toe. There is a dorsiflexion contracture at the metatarsophalangeal joint and plantar flexion of the interphalangeal joint. The deformity is commonly attributed to muscular imbalances of the various structures acting on the great toe. Jones tendon transfer is a procedure used to remove the deforming force to the clawed hallux. It is most often performed in conjunction with a hallux interphalangeal joint fusion. Typically there is a neurologic component causing a deformity to the entire foot, necessitating adjunct procedures. The Jones tendon transfer has shown to have reproducible results.

Cavus Foot

Cavus foot is usually related to neurologic abnormalities and then requires complete clinical and imaging evaluation. It is important to identify whether the deformity is flexible or rigid, and combine different soft tissue and bony techniques to accomplish the best lasting results. On rigid feet, it is crucial to determine the apex of the deformity to guide the bony procedures indicated for each specific case. Tarsectomies are preferred to arthrodesis in these rigid feet with the aim of achieve a plantigrade foot.

The cavus foot

The cavus, or high-arched, foot can present in either childhood or adulthood as a function of muscle imbalance. Neurologic, traumatic, and idiopathic processes have been identified, along with residual clubfoot, as the primary causes of adult cavus foot deformity. A thorough history and physical examination is important and can help identify the underlying cause of deformity. Conservative treatment modalities are always used first, with surgical intervention reserved for refractory cases. The goal of surgery is to correct muscle imbalance, which can be achieved via tendon transfers, corrective osteotomies, and, in the most severe cases, fusion.

Comparison of plantar pressures and contact area between normal and cavus foot

BACKGROUND

In pes cavus, the medial longitudinal arch elevation reduces the contact surface area and consequently increases the corresponding plantar pressure measurements. This poor distribution of loads may produce associated pathology and pain in this or other areas of the body. Normal reference values need to be established in order to determine which patterns are prone to pathology.

OBJECTIVES

To compare the plantar pressures and weight-bearing surface in a population with pes cavus to a population with neutral feet.

METHOD

The sample comprised 68 adults, 34 with pes cavus and 34 with neutral feet. The Footscan USB Gait Clinical System(®) was used as a platform to measure the total contact area and plantar pressure under the forefoot, midfoot, hindfoot, each metatarsal head, and the overall metatarsal area. A statistical analysis of the data was performed using Student's t-test for independent samples.

RESULTS

The pes cavus subjects showed a significant reduction in their weight-bearing area [neutral feet: 165.04 ( ± 20.68) cm(2); pes cavus: 118.26 ( ± 30.31) cm(2); p < 0.001] and significantly increased pressures under all zones of the forefoot except the fifth metatarsal [metatarsal pressure: in neutral feet 503,797 ( ± 9.32) kPa; in pes cavus 656.12 ( ± 22.39) kPa; p < 0.001].

CONCLUSIONS

Compared to neutral feet, pes cavus feet show a reduction in total contact surface and the load under the first toe. A significant increase is present in the load under the metatarsal areas, but the relative distribution of this load is similar in both groups.

What is the role of tendon transfer in the cavus foot?

Cavovarus deformity results from an imbalance of the foot's extrinsic musculature. Conditions leading to weakness of an isolated muscle result from nerve injury or sequelae of a compartment syndrome. When weakness of a muscle group presents, an underlying neurologic disorder must be suspected. Patients with hereditary sensory motor neuropathy present with a progressive pattern of imbalance and deformity. The deformity starts out flexible but becomes rigid over time. Rebalance muscle pull to realign the foot and ankle is important. Osteotomies and arthrodesis to realign the hindfoot will not maintain alignment as long as the agonist-antagonist pattern is not re-established.