Article

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

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Background Our aims were (a) to determine whether subtalar arthroereisis (STA) as adjunct procedure improved radiographic correction of stage IIb adult-acquired flexible flatfoot deformity (AAFD); (b) to assess the STA-related complication rate. Methods A retrospective analysis of 22 feet (21 patients) diagnosed with stage IIb AAFD treated by medializing calcaneal osteotomy (MCO), flexor digitorum longus (FDL) transfer, spring ligament (SL) repair with or without Cotton osteotomy and with or without STA in a single institution was carried out. Seven measurements were recorded on pre- and postoperative (minimum 24 weeks) radiographs by 2 observers and repeated twice by 1 observer. Inter- and intraobserver reliabilities were assessed. The association of demographic (gender, side, age, body mass index) and surgical variables (Cotton, STA) with radiographic change was tested with univariate analysis followed by a multivariable regression model. Results Excellent inter- and intraobserver reliabilities were demonstrated for all measurements (intraclass correlation coefficient range, 0.75-0.99). Gender, side, Cotton osteotomy, and STA were included in the multivariable analysis. Regression showed that STA was the only predictor of change in talonavicular coverage angle (TNCA) ( R ² = 0.31; P = .03) and in calcaneo–fifth metatarsal angle (CFMA) ( R ² = 0.40; P = .02) on dorsoplantar view. STA was associated to a greater change in TNCA by 10.1° and in CFMA by 5°. Four patients out of 12 STA complained of sinus tarsi pain after STA, and removal of the implant resolved symptoms in 3 of them. Conclusion In this series, STA as an adjunct procedure to MCO, FDL transfer, SL repair in the treatment of stage IIb AAFD led to improvement in correction of forefoot abduction. STA-related complication and removal rates were 33%. Levels of Evidence Level IV: Retrospective cohort study

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Over the last two decades there is a growing interest in the adult literature for subtalar joint arthroereisis. Parallel to this interest, there have been improvements in the design and biomechanics of the implant, although the main indication of subtalar joint arthroereisis in adults is not clear. Most studies show significant improvement in postoperative clinical scores and visual analog scores. Sinus tarsi pain, being the most common complication, is the main determinant of clinical satisfaction. This review focuses on the role and complications of subtalar joint arthroereisis in the adult population.
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Undiagnosed medial ankle instability can be a prerequisite for pathogenic progression in the foot, particularly for adult acquired flatfoot deformity. With the complex anatomy in this region, and the limitations of each individual investigational method, accurately identifying peritalar instability remains a serious challenge to clinicians. Performing a thorough clinical examination aided by evaluation with advanced imaging can improve the threshold of detection for this condition and allow early proper treatment to prevent further manifestations of the instability.
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Subtalar arthroereisis has been reported as a minimally-invasive, effective and low-risk procedure in the treatment of flatfoot mainly in children but also in adults. It has been described as a standalone or adjunctive procedure, and is indicated in the treatment of flexible flatfoot, tibialis posterior tendon dysfunction, tarsal coalition and accessory navicular syndrome. Different devices for subtalar arthroereisis are currently used throughout the world associated with soft-tissue and bone procedures, depending on the surgeon rather than on standardised or validated protocols. Sinus tarsi pain is the most frequent complication, often requiring removal of the implant. To date, poor-quality evidence is available in the literature (Level IV and V), with only one comparative non-randomised study (Level II) not providing strong recommendations. Long-term outcome and complication rates (especially the onset of osteoarthritis) are still unclear. Cite this article: EFORT Open Rev 2017;2:438–446. DOI: 10.1302/2058-5241.2.170009
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Purpose: Early stage adult acquired flatfoot deformity (AAFD) is traditionally treated with osteotomy and tendon transfer. Despite a high success rate, the long recovery time and associated morbidity are not sufficient. This study aims to evaluate the functional and radiological outcomes following the use of the arthroereisis screw with tendoscopic delivered PRP for early stage AAFD. Methods: Patients with stage IIa AAFD who underwent the use of the arthroereisis screw with tendoscopic delivered PRP with a minimum follow-up time of 24 months were retrospectively evaluated. Clinical outcomes for pain were evaluated with the Foot and Ankle Outcomes Score (FAOS) and Visual Analog Score (VAS). Radiographic deformity correction was assessed using weight-bearing imaging. Results: Thirteen patients (13 feet) with mean follow-up of 29.5 months were included. The mean age was 37.3 years (range, 28-65 years). FAOS-reported symptoms, pain, daily activities, sports activities, and quality of life significantly improved from 52.1, 42.6, 57.6, 35.7, and 15.4 pre-operatively to 78.5, 68.2, 83.3, 65.0, and 49.6 post-operatively, respectively (p < 0.05). Statistically significant radiographic improvements (lateral talus first metatarsal angle, calcaneal pitch, and cuneiform to ground distance) were also observed between the pre- and post-operative images. Conclusions: This study elucidates the successful implementation of a less invasive approach to stage IIa AAFD. Through the use of a subtalar arthroereisis screw, PTT tendoscopy, and PRP injection, clinical and radiographic outcomes were improved.
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Subtalar joint arthroereisis (STA) can be used in the management of adult acquired flatfoot deformity (AAFD), including posterior tibial tendon dysfunction. The procedure is quick and normally causes little morbidity; however, the implant used for STA often needs to be removed because of sinus tarsi pain. The present study evaluated the rate and risk factors for removal of the implant used for STA in adults treated for AAFD/posterior tibial tendon dysfunction, including patient age, implant size, and the use of endoscopic gastrocnemius recession. Patients undergoing STA for adult acquired flatfoot were prospectively studied from 1996 to 2012. The inclusion criteria were an arthroereisis procedure for AAFD/posterior tibial tendon dysfunction, age >18 years, and a follow-up period of ≥2 years. The exclusion criteria were hindfoot arthritis, age <18 years, and a follow-up period of <2 years. A total of 100 patients (average age 53 years) underwent 104 STA procedures. The mean follow-up period was 6.5 (range 2 to 17) years. The overall incidence of implant removal was 22.1%. Patient age was not a risk factor for implant removal (p = .09). However, implant size was a factor for removal, with 11-mm implants removed significantly more frequently (p = .02). Endoscopic gastrocnemius recession did not exert any influence on the rate of implant removal (p = .19). After STA for AAFD, 22% of the implants were removed. No significant difference was found in the incidence of removal according to patient age or endoscopic gastrocnemius recession. However, a significant difference was found for implant size, with 11-mm implants explanted most frequently.
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Background: Successful correction of hindfoot alignment in adult acquired flatfoot deformity (AAFD) is likely influenced by the degree of medializing calcaneal osteotomy (MCO) performed, but it is not known if other reconstruction procedures significantly contribute as well. The purpose of this study was to evaluate the correlation between common preoperative and postoperative variables and hindfoot alignment. Methods: Thirty patients with stage II AAFD undergoing flatfoot reconstruction were followed prospectively. Preoperative and postoperative radiographs were reviewed to assess for correction in hindfoot alignment as measured by the change in hindfoot moment arm. Nineteen variables were analyzed, including age, gender, height, weight, body mass index (BMI), medial cuneiform-fifth metatarsal height, anteroposterior (AP) talonavicular coverage, AP talus-first metatarsal, lateral talus-first metatarsal and calcaneal pitch angles as well as intraoperative use of the MCO, lateral column lengthening (LCL), Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament reconstruction, and gastrocnemius recession or Achilles lengthening. Mean age was 57.3 years (range, 22-77). Final radiographs were obtained at a mean of 47 weeks (range, 25-78) postoperatively. Results: Seven variables were found to significantly affect hindfoot moment arm. These were gender (P < .05), the amount of MCO performed (P < .001), LCL (P < .01), first tarsometatarsal fusion (P < .01), spring ligament reconstruction (P < .01), medial cuneiform-fifth metatarsal height (P < .001), and calcaneal pitch angle (P < .05). Multivariate regression analysis revealed that MCO was the only significant predictor of hindfoot moment arm. The final regression model for MCO showed a good fit (R(2) = .93, P < .001). Conclusion: Correction of hindfoot valgus alignment obtained in flatfoot reconstruction is primarily determined by the MCO procedure and can be modeled linearly. We believe that the hindfoot alignment view can serve as a valuable preoperative measurement to help surgeons adjust the proper amount of correction intraoperatively. Level of evidence: Level IV, prospective case series.
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Subtalar joint arthroereisis is a surgical modality that has been shown to be an effective procedure for flexible flatfoot in both pediatric and adult populations. Despite advances in understanding its mechanics and function, complication and implant removal rates remain as high as 30% to 40%. Analysis was performed to determine the survivability of 2 subtalar joint arthroereisis implants, absorbable and nonabsorbable, used alone and in combination with other procedures in both the adult and pediatric populations. The 95 total arthroereisis procedures were analyzed in several major categories: absorbable implants versus nonabsorbable implants and adult versus pediatric patients. Each major group was then further subdivided to create further subgroups: absorbable isolated procedures, absorbable combined procedures, nonabsorbable isolated procedures, and nonabsorbable combined procedures. The overall survival rates were 83% for absorbable implants and 81% for nonabsorbable implants. A total of 11 (17%) absorbable implants and 6 (19%) nonabsorbable implants were removed, respectively, at an average of 9 months and 23 months postoperatively. When used alone and in combination with other procedures, 36% and 13% of absorbable implants and 18% and 19% of nonabsorbable implants, respectively, were removed. When comparing adult versus pediatric populations, the overall survival rates of the absorbable and nonabsorbable implants were 81% for absorbable implants and 79% for nonabsorbable implants in the adult population and 85% for absorbable implants and 100% for nonabsorbable implants in the pediatric population. Level of Evidence: Therapeutic, Level III; Retrospective comparative series
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Pediatric flexible flatfoot is a common deformity for which a small, but significant number undergo corrective surgery. Arthroereisis is a technique for treating flexible flatfoot by means of inserting a prosthesis into the sinus tarsi. The procedure divides opinion in respect of both its effectiveness and safety. A database search up until 2010 was used to find articles regarding arthroereisis in pediatric patients. We summarized the findings of this study. Seventy-six studies were identified. Eight of the nine radiographic parameters reported show significant improvement following arthroereisis reflecting both increased static arch height and joint congruency. Calcaneal inclination angle demonstrated the least change with only small increases following arthroereisis. Arthroereisis remains associated with a number of complications including sinus tarsi pain, device extrusion, and under-correction. Complication rates range between 4.8% and 18.6% with unplanned removal rates between 7.1% and 19.3% across all device types. Current evidence is limited to consecutive case series or ad hoc case reports. Limited evidence exists to suggest that devices may have a more complex mode of action than simple motion blocking or axis altering effects. The interplay between osseous alignment and dynamic stability within the foot may contribute to the effectiveness of this procedure. Although literature suggests patient satisfaction rates of between 79% to 100%, qualitative outcome data based on disease specific, validated outcome tools may improve current evidence and permit comparison of future study data.
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Treatment of adult acquired flexible flat foot deformity can be problematic. Triple arthrodesis for structural correction has been the standard of care, thus sacrificing hind foot motion. The objective of this study was to assess the value of double calcaneal osteotomies in improving structural alignment while maintaining hind foot motion, which may further protect the function of adjacent motion segments. Double calcaneal osteotomies (Evans osteotomy and posterior calcaneal displacement osteotomy) were performed on 17 feet of 14 patients. Postoperative follow-up showed significant improvement in clinical foot and ankle scores.
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Stage II flatfoot secondary to posterior tibial tendon insufficiency may be subclassified into mild (IIa) and severe (IIb) deformity based on the degree of talonavicular abduction. Current assessment of this abduction is difficult. We hypothesized that two new anteroposterior radiographic parameters, the lateral talonavicular incongruency angle (IA) and incongruency distance (ID) would demonstrate good reliability, correlate with current abduction parameters, and differ in IIb deformity, IIa deformity, and controls. Preoperative radiographs for consecutive patients undergoing flatfoot reconstruction were reviewed and subdivided into those with a Stage IIb (n = 32) or Stage IIa (n = 8) deformity. A third group of patients without flatfoot served as control (n = 30). Radiographs were measured blindly by two investigators. Reliability was assessed with intraclass correlation coefficients (ICC), correlation with existing parameters with Pearson coefficients, and comparison between groups with analysis of variance. The mean intrarater and interrater ICC's for the IA (0.88 and 0.81, respectively) were high. The IA correlated well with the coverage angle (r = 0.86) and uncoverage percent (r = 0.76). The IA was higher in the IIb versus IIa patients (p = 0.007) and in the IIb group versus control (p < 0.001). The ID demonstrated excellent reliability (ICC's of 0.83 and 0.83), but correlated poorly with the two other abduction parameters (r = -0.59 and -0.49) and failed to differentiate between the three groups (p = 0.0528). This data suggests that the IA is reliable and may help subclassify Stage II flatfoot deformity.
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Background: The role of subtalar arthroereisis (STA) for treating flexible flatfoot (FFF) in children is controversial. We hypothesized that (1) STA provided significant radiographic correction of low longitudinal arch and forefoot abduction in paediatric FFF and that (2) mid-term clinical outcomes were satisfactory and comparable to a normal population. Methods: A retrospective comparative study was performed of paediatric patients with symptomatic FFF who underwent STA between 2012 and 2015. Multiple measurements on preoperative and latest follow-up radiographs were recorded by two observers and compared to assess for correction of the FFF. Intra- and inter-observer reliability was also assessed. Ankle and hindfoot range of motion (ROM), AOFAS hindfoot score and VAS-FA score were compared with controls without foot symptoms or deformity. From 70 consecutive feet, 62 (31 patients) treated at 10.5 years of age were identified and compared to 48 controls (24 patients). Mean follow-up was 62 months. Results: Intra- and inter-observer reliability was excellent for all angles (range, 0.81-0.97). Radiographic measurements demonstrated significant improvement after surgery (p<0.001) but significance was not reached in talonavicular coverage angle (p=0.49) and calcaneo-fifth metatarsal angle (p=0.53) on dorsoplantar view. At latest follow-up, patients had less hindfoot inversion than controls (15.1̊ vs. 19.3̊, p=0.03), lower AOFAS scores (94.1 vs. 99.6 points, p=0.01), due to pain (p=0.01) and alignment (p=0.006) subscores. Using the VAS-FA score, patients were found to demonstrate higher pain at rest (prange, 0.02-0.03) and during activity (p=0.009), and felt limited when standing on one leg (p range, 0.01-0.03) and running (p=0.04). No loss of correction was found after removal of the implant. Conclusion: This study showed that STA corrected the low longitudinal arch in symptomatic paediatric FFF, but did not correct forefoot abduction in relation to the hindfoot. Mid-term assessment revealed STA provided satisfactory ankle and hindfoot ROM, pain and function levels, but limitations are witnessed compared to unaffected individuals. This aspect should be considered when counselling patients and their parents or caregivers to allow for realistic expectations. Level of evidence: III, retrospective comparative study.
Article
Background:: Evans (E) and Hintermann (H) lateral lengthening calcaneal osteotomies (LLCOTs) are commonly used to correct flexible flatfoot deformities. Both methods are well accepted and produce good clinical results. The aim of this study was to compare the postoperative outcomes of both osteotomies. Methods:: We retrospectively examined 53 patients with flatfoot deformities, who received surgery between October 2008 and March 2014. Seventeen E-LLCOT and 36 H-LLCOT procedures were performed during this time period, with a mean follow-up of 67.7 ± 20.6 and 40 ± 12.9 months, respectively. Data were collected using clinical and radiological examination, as well as clinical scores (Foot and Ankle Outcome Score [FAOS], University of California at Los Angeles [UCLA] activity score, numerical rating scale [NRS], and the Short-Form 36-item Health Survey [SF-36]) during regular follow-up. Results:: For both groups of patients, the FAOS score, pain-NRS, and SF-36 improved significantly following surgery ( P < .05). The talus-second metatarsal angle, talonavicular coverage, and naviculocuneiform overlap showed significant correction ( P < .05). Postoperatively, radiographic degenerative changes were detected in the calcaneocuboid (CC) and subtalar joint in both groups of patients: 41% and 18% after E-LLCOT compared with 25% and 14% after H-LLCOT, although these changes did not have any clinical relevance ( P < .05). No secondary arthrodesis was necessary. There were no significant differences in the clinical or radiological outcome parameters when compared between the 2 groups. Conclusion:: Both surgical techniques resulted in a significant improvement of clinical outcome scores and led to good radiological correction of flatfoot deformities. It appears that the CC joint develops less degenerative changes following the H-LLCOT procedure. Level of evidence:: Level III, comparative series.
Article
Methods: Seventy-nine feet in 74 patients undergoing Cotton osteotomy as part of flatfoot reconstruction were reviewed retrospectively. Preoperative and minimum 40-week postoperative lateral foot weightbearing radiographs were compared to assess correction of longitudinal arch collapse as measured by 13 radiographic parameters, with particular emphasis on the cuneiform articular angle (CAA). Additional demographic and intraoperative variables analyzed for association with radiographic change included age, gender, body mass index, amounts and graft types of Cotton osteotomy and lateral column lengthening, and amount of medializing calcaneal osteotomy. A multivariate linear regression model was developed for each variable found to be significant in univariate analysis. Results: The Cotton osteotomy graft size was significantly associated with changes in the CAA ( P < .001), calcaneal pitch ( P = .03), lateral talonavicular Cobb angle ( P = .03), and lateral naviculomedial cuneiform Cobb angle ( P = .03). The Cotton graft size was the only factor found to significantly predict a change in the CAA in the final linear regression model ( P < .001, R2= 0.27), with each millimeter of Cotton corresponding to a 2.1-degree decrease of the CAA. Conclusion: Correction of longitudinal arch collapse, as measured by the CAA, was primarily influenced by the size of the graft used for the Cotton osteotomy in a linear fashion. The preoperative CAA may help surgeons titrate the proper amount of graft placed intraoperatively. Level of evidence: Level IV, Retrospective Case Series.
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Background: The forefoot abduction component of the flexible adult-acquired flatfoot can be addressed with lengthening of the anterior process of the calcaneus. We hypothesized that the step-cut lengthening calcaneal osteotomy (SLCO) would decrease the incidence of nonunion, lead to improvement in clinical outcome scores, and have a faster time to healing compared with the traditional Evans osteotomy. Methods: We retrospectively reviewed 111 patients (143 total feet: 65 Evans, 78 SLCO) undergoing stage IIB reconstruction followed clinically for at least 2 years. Preoperative and postoperative radiographs were analyzed for the amount of deformity correction. Computed tomography (CT) was used to analyze osteotomy healing. The Foot and Ankle Outcome Scores (FAOS) and lateral pain surveys were used to assess clinical outcomes. Mann-Whitney U tests were used to assess nonnormally distributed data while χ(2) and Fisher exact tests were used to analyze categorical variables (α = 0.05 significant). Results: The Evans group used a larger graft size ( P < .001) and returned more often for hardware removal ( P = .038) than the SLCO group. SLCO union occurred at a mean of 8.77 weeks ( P < .001), which was significantly lower compared with the Evans group ( P = .02). The SLCO group also had fewer nonunions ( P = .016). FAOS scores improved equivalently between the 2 groups. Lateral column pain, ability to exercise, and ambulation distance were similar between groups. Conclusion: Following SLCO, patients had faster healing times and fewer nonunions, similar outcomes scores, and equivalent correction of deformity. SLCO is a viable technique for lateral column lengthening. Level of evidence: Level III, retrospective cohort study.
Article
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Article
Correction of forefoot abduction in stage IIb adult acquired flatfoot likely depends on the amount of lateral column lengthening (LCL) performed, although this represents only one aspect of a successful reconstruction. The purpose of this study was to evaluate the correlation between common reconstructive variables and the observed change in forefoot abduction. Forty-one patients who underwent flatfoot reconstruction involving an Evans-type LCL were assessed retrospectively. Preoperative and postoperative anteroposterior (AP) radiographs of the foot at a minimum of 40 weeks (mean, 2 years) after surgery were reviewed to determine correction in forefoot abduction as measured by talonavicular coverage (TNC) angle, talonavicular uncoverage percent, talus-first metatarsal (T-1MT) angle, and lateral incongruency angle. Fourteen demographic and intraoperative variables were evaluated for association with change in forefoot abduction including age, gender, height, weight, body mass index, as well as the amount of LCL and medializing calcaneal osteotomy performed, LCL graft type, Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament repair, gastrocnemius recession and any one of the modified McBride/Akin/Silver procedures. Two variables significantly affected the change in lateral incongruency angle. These were weight (P = .04) and the amount of LCL performed (P < .001). No variables were associated with the change in TNC angle, talonavicular uncoverage percent, or T-1MT angle. Multivariate regression analysis revealed that LCL was the only significant predictor of the change in lateral incongruency angle. The final regression model for LCL showed a good fit (R(2) = 0.70, P < .001). Each millimeter of LCL corresponded to a 6.8-degree change in lateral incongruency angle. Correction of forefoot abduction in flatfoot reconstruction was primarily determined by the LCL procedure and could be modeled linearly. We believe that the lateral incongruency angle can serve as a valuable preoperative measurement to help surgeons titrate the proper amount of correction performed intraoperatively. Level III, retrospective comparative study. © The Author(s) 2015.
Article
Subtalar arthroereisis (SA) has been a procedure used for the correction of painful flexible flatfoot deformity in adults and children. Clinical studies of patients who had a SA are sparse and with mixed results and variable indications. The purpose of this study was to determine the current practice among orthopaedic foot and ankle specialists regarding SA. Web-based questionnaires were e-mailed to members of the American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and practice patterns in regard to performing SA surgery. A total of 572 respondents completed the survey (32% response rate). A total of 273 respondents (48%) have performed SA. Of this group, 187 respondents (69%) still perform this procedure (33% of total respondents currently perform SA). Of the respondents, 401 (70%) practice in the United States, 40% have performed SA, and 60% of those still perform this procedure. Of non-US respondents, 66% have performed SA, and 80% of those still perform it. The most common US indications are painful congenital flatfoot, posterior tibial tendon dysfunction, and flatfoot associated with accessory navicular. Many doctors have performed SA, and a significant number no longer perform this procedure for various reasons. A greater percentage of non-US practitioners have performed and continue to perform SA than their counterparts in the United States. There is a common list of surgical indications. Most doctors who still perform this procedure have removed the implants, commonly for pain. SA is still being performed in the United States and throughout the world. © 2015 The Author(s).
Article
Clubfoot is a common structural malformation, occurring in approximately 1/1,000 live births. Previous studies of sociodemographic and pregnancy-related risk factors have been inconsistent, with the exception of the strong male preponderance and association with primiparity. Hypotheses for clubfoot pathogenesis include fetal constraint, Mendelian-inheritance, and vascular disruption, but its etiology remains elusive. We conducted a population-based case-control study of clubfoot in North Carolina, Massachusetts, and New York from 2007 to 2011. Mothers of 677 clubfoot cases and 2,037 non-malformed controls were interviewed within 1 year of delivery about socio-demographic and reproductive factors. Cases and controls were compared for child's sex, maternal age, education, cohabitation status, race/ethnicity, state, gravidity, parity, body mass index (BMI), and these pregnancy-related conditions: oligohydramnios, breech delivery, bicornuate uterus, plural birth, early amniocentesis (<16 weeks), chorionic villous sampling (CVS), and plural gestation with fetal loss. Odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for state. Cases were more likely to be male (OR: 2.7; 2.2-3.3) and born to primiparous mothers (1.4; 1.2-1.7) and mothers with BMI ≥30 kg/m(2) (1.4; 1.1-1.8). These associations were greatest in isolated and bilateral cases. ORs for the pregnancy-related conditions ranged from 1.3 (breech delivery) to 5.6 (early amniocentesis). Positive associations with high BMI were confined to cases with a marker of fetal constraint (oligohydramnios, breech delivery, bicornuate uterus, plural birth), inheritance (family history in 1st degree relative), or vascular disruption (early amniocentesis, CVS, plural gestation with fetal loss). Pathogenetic factors associated with obesity may be in the causal pathway for clubfoot. © 2013 Wiley Periodicals, Inc.
Article
This study aimed to assess and provide prospective outcome data following reconstruction of Stage II posterior tibial tendon insufficiency, as well as evaluate the effect of reconstruction with gastrocnemius recession on plantarflexion strength. A prospective evaluation of 24 patients undergoing reconstruction for Stage II posterior tibial tendon insufficiency was granted IRB approval. The reconstructive procedures consisted of a flexor digitorum longus transfer, medial displacement calcaneal osteotomy, lateral column lengthening, and gastrocnemius recession. Patients were asked to complete multiple outcome measures preoperatively, 6 months, 1 year, and 2 years postoperatively. A dynamometer was utilized to evaluate peak torque plantarflexion preoperatively, 6 months, and 1 year postoperatively. In the study, 14 patients completed preoperative surveys, and 23 patients had 2-year followup. Patients were highly satisfied with the results of their surgery. All outcome measures showed statistically significant improvement. Improvement was seen at 6 months, but results continued to improve at the 1-year mark. By the second year, improvement largely reached a plateau. Biodex testing showed no loss of plantarflexion strength after reconstruction and gastrocnemius recession. Reconstruction of the flexible adult acquired flatfoot with FDL transfer, double calcaneal osteotomy, and gastrocnemius recession yielded excellent functional results for the treatment of Stage II posterior tibial tendon insufficiency. Plantarflexion weakness was not found to be a concern. A good functional outcome can be anticipated after the early postoperative period. However, it should be expected to take at least 1 year for maximal benefit.
Article
Lateral column lengthening procedures, either an Evans-type procedure or a calcaneocuboid distraction arthrodesis, clearly have a role to play in the management of a pes planovalgus foot deformity, as is evident from clinical outcome studies. Despite an abundance of literature intricately detailing the biomechanical effects of different operative procedures on the hindfoot, there is no clear consensus as to the best procedure or procedures to perform for a flexible pes planovalgus foot deformity. There is, therefore, no single solution to this problem; the surgeon must treat each patient as an individual and choose the procedure that will work best in their hands for any given foot pathology they are presented with. The surgeon must also be aware that to improve the kinematics of a planovalgus foot deformity, one may often have to perform multiple procedures and not a lateral column lengthening in isolation.
Article
The authors present a retrospective study of 35 consecutive patients (60 feet) treated with the Maxwell-Brancheau Arthroereisis (MBA) implant. The mean age of the cohort at the time of surgery was 14.3 (range 5 to 46) years, and 22 (62.86%) men and 13 (37.14%) women were included. Preoperative and postoperative anteroposterior and lateral foot radiographs were compared at a mean of 36 (range 18 to 48) months postoperatively, and the following mean changes were reported: talocalcaneal angle 24.15° ± 7.97° to 18.53° ± 8.23°, calcaneocuboid angle 18.67° ± 8.72° to 11.76° ± 8.49°, first to second intermetatarsal angle 9.42° ± 2.67° to 7.61° ± 2.69°, calcaneal inclination angle 11.93° ± 6° to 14.93° ± 5.85°, and talar declination angle 34.0° ± 8.59° to 28.02° ± 6.85°; all of these differences were statistically significant (p < .0001). A subgroup of 24 (68.57%) patients also answered a subjective questionnaire at a mean of 33 (range 12 to 55) months postoperatively. The presenting chief complaints were resolved in 23 patients (95.83%) of the subgroup, and 21 patients (87.5%) returned postoperatively to either the same or a greater activity level in sports. Twenty-three (95.83% of the subgroup) patients said they were 75% to 100% satisfied with their surgical outcome, and that they would recommend the surgery to a friend or family member with the same condition, whereas 1 (4.17%) claimed 0% satisfaction after placement of inappropriately sized implants (which were later replaced to the patient's clinical satisfaction) in both feet.
Article
Forefoot varus deformity and medial column instability can develop or be present in association with ankle and hindfoot pathology. This study aimed to confirm the utility of medial cuneiform opening wedge osteotomy as part of hindfoot and ankle deformity correction. Patients requiring operative management of flatfoot deformity between January 2002 and December 2007 were prospectively entered in a database. We selected all patients who underwent medial cuneiform opening wedge osteotomy. One hundred and one feet in 86 patients of mean age 36 (range, 9 to 80) years were evaluated. Eighty-one feet had adequate radiographic imaging for assessment. Concomitant procedures were performed. We measured standardized, validated radiographic parameters on pre- and postoperative weightbearing foot radiographs. Variables including concomitant surgical procedures, osteotomy union, malunion, and midfoot arthritis were noted. The mean lateral talus-first metatarsal angle improved from 23 degrees to 1 degrees (p < 0.001); mean medial cuneiform to floor distance improved from 20 mm to 34 mm (p < 0.001); mean talar declination angle improved from 39 degrees to 27 degrees (p < 0.001); mean calcaneal-talar angle improved from 64 degrees to 55 degrees (p < 0.001); calcaneal pitch angle improved from 14 degrees to 23 degrees (p < 0.001); mean first metatarsal declination angle improved from 17 degrees to 26 degrees (p < 0.001); mean talonavicular coverage angle improved from 45 degrees to 18 degrees (p < 0.001); and mean anteroposterior talus-first metatarsal angle improved from 19 degrees to 0 degrees (p < 0.001). Radiographical analysis showed that medial cuneiform opening wedge osteotomy combined with other corrective procedures corrected forefoot varus, elevated first metatarsal and medial column instability radiographic parameters that are most commonly associated with flatfoot deformity.
Article
Pediatric and juvenile flatfoot is a common problem in childhood, present in one in nine children. The morphologic characteristics of this condition are heel valgus and flattening of the medial longitudinal arch. Other characteristics are usually observed, such as supination and abduction of the forefoot, tightening of the Achilles tendon, and hypertonia of the peroneal muscles. Most children with flatfoot will undergo spontaneous correction or become asymptomatic; those that are symptomatic require treatment. Subtalar arthroereisis, often combined with Achilles tendon lengthening, is a simple and effective way to treat flexible flatfoot in children. Mid- and long-term results are good, and the procedure does not prevent future treatments.
Article
Lateral column lengthening, a commonly used adjuvant for the reconstruction of adult flatfoot deformity, can lead to postoperative complaints of lateral plantar pain or discomfort. We hypothesized that patients with such symptoms would have increased lateral plantar pressures when compared with matched controls without these symptoms. Ten subjects who had undergone lateral column lengthening and were experiencing pain or discomfort in the plantar-lateral aspect of the foot were selected. Controls who had undergone lateral column lengthening but who were not experiencing such symptoms were matched for age, sex, accessory reconstructive procedures, and time from surgery. At the time of the present study, the patients had been followed for at least two years after the reconstruction and had had removal of hardware. Radiographs of each foot were assessed before and after surgery. The patients completed the Short Form-36 (SF-36) and Foot and Ankle Outcome Score surveys, and standing plantar pressure measurements were obtained. Average mean pressure, peak pressure, and maximum force were assessed at twelve anatomic regions and the two groups were compared. There were no significant preoperative differences between the two groups in terms of radiographic parameters. Patients with pain had significantly lower SF-36 Physical Health Summary scores (p < 0.05), SF-36 Physical Function Subscale scores (p < 0.05), and average Foot and Ankle Outcome Scores (p < 0.05). Patients with pain had significantly higher lateral midfoot average mean pressure (p < 0.05), peak pressure (p < 0.05), and maximum force (p < 0.05). No differences were found in the hindfoot or forefoot regions. Patients who have undergone lateral column lengthening and who experience lateral plantar pain have increased plantar pressure values in the lateral aspect of the midfoot. The increased pressures in this area cannot be accounted for solely by radiographic or demographic factors.
Article
Procedures utilized to address the flatfoot in this study included medializing calcaneal osteotomy, posterior tibial tendon reconstruction with flexor digitorum longus tendon transfer, and in patients with more severe deformity, lateral column lengthening. We evaluated patients age 50 and less at the time of surgery, who underwent surgical reconstruction for Stage 2 posterior tibial tendon dysfunction. Pre- and postoperative activity levels were evaluated to assess the effect of surgical reconstruction in the younger patient. Thirty-four feet in 30 patients (11 male, 19 female) with an average age of 41.2 (range, 17 to 50) years had surgery between 1997 and 2004. All feet were examined at an average followup of 44.5 (range, 24 to 65) months and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score and SF-36 score. The average preoperative AOFAS-Score was 53.1 +/- 14.5 points and 83.2 +/- 12.2 points at final postoperative followup. The mean improvement was 29.5. The difference between the preoperative and postoperative AOFAS score was significant (p < 0.0001) using a two-tailed t-test. The difference in the AOFAS pain and alignment subscales was also significant (p < 0.0001). The function subscale improvement was also significant (p = 0.018). The mean physical function component of the postoperative SF-36 score was 79.2. A correlation was found between the SF-36 physical component score and the post operative AOFAS score (r(2) = 0.754). While some lateral discomfort or pain occurred in patients with or without a lateral column lengthening, the posterior tibial tendon reconstruction utilizing medial calcaneal displacement osteotomy with flexor digitorum longus transfer and a lateral column lengthening with more deformity was successful in the higher-functioning, younger patients.
Article
62 patients with 28 pes planovalgus feet secondary to Johnson stage 2 posterior tibial tendon insufficiency were treated with flexor digitorum longus tendon transfer, lateral column lengthening, medial displacement calcaneal osteotomy, and heel cord lengthening. The mean patient age at surgery was 48.5 years. The AOFAS ankle-hindfoot scale was applied postoperatively to assess clinical outcome. Preoperative and postoperative standing radiographs of the foot and ankle were analyzed to determine radiographic correction of the pes planovalgus deformities. The mean follow-up to date is 5 years. The mean ankle-hindfoot score was 90 postoperatively. The medial cuneiform to fifth metatarsal distance improved from −0.2 mm preoperatively to 7.6 mm postoperatively. Similarly, the talonavicular distance improved from 19.4 mm preoperatively to 10.9 postoperatively. There were no nonunions. Four feet (14%) displayed radiographic signs of calcaneocuboid arthritis at follow-up. Only one was symptomatic requiring calcaneocuboid joint fusion. The double osteotomy technique provides symptomatic relief and lasting correction of the pes planovalgus deformity associated with stage 2 posterior tibial tendon insufficiency at intermediate follow-up. It has a high patient satisfaction based on the AOFAS ankle-hindfoot scale and radiographic measurements demonstrate maintenance of correction of the adult acquired flatfoot.
Article
The purpose of this study was to determine the functional outcomes and radiographic results of adult patients who had an operation for flexible flatfeet without any hindfoot osteotomies or fusions. Twenty-eight feet in 23 patients with problems caused by their flexible flatfoot deformities had reconstructive foot and ankle surgery that included a subtalar arthroereisis (the restriction of the range of motion of a joint) with the Maxwell-Brancheau Arthroereisis (MBA) sinus tarsi implant. The American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot Scale and a patient assessment questionnaire were obtained from all patients before surgery and at final follow-up. Preoperative and postoperative standing radiographs were analyzed to determine radiographic correction of the deformities. The average followup was 44 months. The MBA implant was surgically removed in 11 of 28 feet (39%) because of sinus tarsi pain. The average preoperative AOFAS score was 52 and had improved to 87 (p<0.00001) at final followup. The average response to four of five questions in the patient assessment had significantly improved (p<0.05). On a 10-point scale, average patient satisfaction was 8.3 points; 78% said that they would have the surgery again. Correction after surgery was significant (p<0.0001) in each of the three radiographic parameters evaluated for 'correction with MBA' and 'final correction.' With the numbers available, no significant differences could be detected after the MBA was removed. Complications included sinus tarsi pain in 46% (13) of the 28 feet in this study; after implant removal, 73% (8) of 11 feet had less discomfort than before surgery with AOFAS scores 80 or better. Reconstructive foot and ankle surgery that included a subtalar arthroereisis with the MBA sinus tarsi implant resulted in favorable clinical outcomes and patient satisfaction in 78% (18) of 23 patients. In spite of the high incidence of temporary sinus tarsi pain until the implant was removed, this operative approach compares favorably with other operations for flexible flatfoot deformities in adults.
Article
Acquired flexible flatfoot encompasses a wide spectrum of disease, and there is no validated treatment protocol. We hypothesized that a medializing calcaneal osteotomy with a flexor digitorum longus transfer is adequate to correct a less severe acquired flexible flatfoot but not a more severe flatfoot. We also hypothesized that use of an additional procedure would further correct the flatfoot. The study included seven pairs of cadaver specimens, with one side randomly selected for the creation of a mild flatfoot deformity and the other, for the creation of a severe flatfoot deformity. Cyclic axial load was applied to the intact foot, to the flatfoot, after correction with a medializing calcaneal osteotomy and a flexor digitorum longus transfer, and after the addition of a subtalar arthroereisis. Radiographic and pedobarographic data were obtained at each stage. A repeated-measures analysis of variance with post hoc analysis was used to compare all parameters in the intact foot with those in the flatfoot and corrected specimens. A Student t test was used to compare flatfoot severity between the mild and severe models. Compared with the intact foot, the mild and severe flatfoot models showed a significant change in the talar-first metatarsal angle (p = 0.01 and 0.03, respectively), talonavicular angle (p = 0.04 and 0.04), and medial cuneiform height (p = 0.03 and 0.05). The mild and severe models were significantly different from each other with regard to the talar-first metatarsal angle (p = 0.003) and talonavicular angle (p = 0.002). After the osteotomy and tendon transfer in the mild-flatfoot model, the talar-first metatarsal angle and talonavicular angle were not significantly different from those in the intact state. In the severe-flatfoot model, the talar-first metatarsal angle, talonavicular angle, and medial cuneiform height remained significantly undercorrected after the osteotomy and tendon transfer. After the arthroereisis, the talonavicular angle and medial cuneiform height were not significantly different from the values for the intact foot. In a cadaver model, the effectiveness of different procedures on radiographic and pedobarographic parameters varies with the severity of an acquired flatfoot deformity.
Article
Lengthening of the lateral column is commonly used for reconstruction of the adult and pediatric flatfoot, but can result in supination of the foot and symptomatic lateral column overload. The addition of a medial cuneiform osteotomy has been used to redistribute forces to the medial column. The combined use of a lateral column lengthening and medial cuneiform osteotomy in a reproducible cadaver flatfoot model was evaluated. Twelve cadaver specimens were physiologically loaded and each was evaluated radiographically and pedobarographically in the following conditions: 1) intact, 2) severe flatfoot, 3) lateral column lengthening with simulated flexor digitorum longus transfer, and 4) lateral column lengthening and flexor digitorum longus (FDL) transfer with added medial cuneiform osteotomy. The lateral column lengthening was performed with a 10-mm foam bone wedge through the anterior process of the calcaneus, and the medial cuneiform osteotomy was performed with a dorsally placed 6-mm wedge. Lateral column lengthening with simulated FDL transfer on a severe flatfoot model resulted in a significant change as compared with the flatfoot deformity in three measurements: in lateral talus-first metatarsal angle (-17 to -7 degrees; p<0.001), talonavicular angle (46 to 24 degrees; p<0.001), and medial cuneiform height (16 to 20 mm; p<0.001). Lateral forefoot pressure increased from 24.6 to 33.9 kPa (p<0.001) after these corrections as compared with the flatfoot. Adding a medial cuneiform osteotomy decreased the lateral talar-first metatarsal angle from -7 to -4 degrees, decreased the talonavicular coverage angle from 24 to 20 degrees, and increased the medial cuneiform height from 20 to 25 mm. After added medial cuneiform osteotomy, lateral pressure was significantly different from that of the flatfoot (p=0.01) and was not significantly different from that of the intact foot (p=0.14). Medial forefoot pressure was overcorrected as compared with the intact foot with added medial cuneiform osteotomy. Lateral column lengthening increased lateral forefoot pressures in a severe flatfoot model. An added medial cuneiform osteotomy provided increased deformity correction and decreased pressure under the lateral forefoot.
Article
In the absence of bony deformity, ankle equinus is generally the result of shortening within the gastrocnemius-soleus complex. Restriction of ankle dorsiflexion as a proxy for equinus contracture has been linked to increased mechanical strains and resultant foot and ankle pathology for a long time. This entity has many known causes, and data suggest it can manifest as either an isolated gastrocnemius or combined (Achilles) contracture. Numerous disorders of the foot and ankle have been linked with such "equinus disease", and although some of these relationships remain controversial, a reasonably convincing relationship between equinus contracture and the development of flatfoot exists. What is still perhaps most misunderstood is the temporal association between these two pathologies, and hence higher levels of evidence are needed in the future to define more precisely the interplay between flatfoot deformity and gastrocnemius-soleus tightness.
Article
Subtalar arthroereisis as an adjunct procedure may hold promise for patients who have mild and more severe variants of posterior tibial tendon dysfunction (PTTD). The biomechanics of the implant function have not been fully elucidated, and questions remain about the best clinical indications for the device. This article reviews the limited existing literature and describes the author's personal experience testing subtalar arthroereisis in the laboratory and using the implant clinically for correction of adult flexible flatfoot.
Article
This study compared the effects of lateral column lengthening and medial translational calcaneal osteotomy on pedal realignment and degeneration of adjacent hindfoot joints noted on radiographs. Forty patients who had either a lateral column lengthening (25 feet) or calcaneal osteotomy (17 feet) to reconstruct a flatfoot were retrospectively reviewed as two groups. Six parameters of foot alignment were measured from weightbearing preoperative, early postoperative, and latest followup radiographs. The magnitude of realignment achieved initially and preserved at latest followup was determined for each group. The talonavicular and subtalar joints were graded for radiographic evidence of arthritis before the reconstruction and at latest followup. Demographic information, complication rate, and reoperation associated with each group also were determined by chart review. The group that received a lateral column lengthening demonstrated a greater initial realignment than the group treated with a calcaneal osteotomy. The lengthening group also demonstrated greater realignment than the osteotomized group when they were compared at their respective latest followup. The lengthening group had a higher number of adjacent joints with progression of arthritis. The rate of nonunion was higher with a lateral column lengthening; however, the rate of reoperation after an osteotomy was more than twice that observed after a lateral column lengthening. The lateral column lengthening group achieved greater realignment initially and maintained correction better over time than the calcaneal osteotomy group while having a lower reoperation rate despite a higher incidence of nonunion and radiographic progression of adjacent joint arthritis.
Article
Originally known as posterior tibial tendon dysfunction or insufficiency, adult-acquired flatfoot deformity encompasses a wide range of deformities. These deformities vary in location, severity, and rate of progression. Establishing a diagnosis as early as possible is one of the most important factors in treatment. Prompt early, aggressive nonsurgical management is important. A patient in whom such treatment fails should strongly consider surgical correction to avoid worsening of the deformity. In all four stages of deformity, the goal of surgery is to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex. However, controversy remains as to how to manage flexible deformities, especially those that are severe.
Midterm assessment of subtalar arthroereisis for correction of flexible flatfeet in children
  • A Bernasconi
  • C Iervolino
  • R Alterio
  • F Lintz
  • S Patel
  • F Sadile