Rückfu?valgus

The clinical finding of flatfoot is characterized by a flattening of the medial longitudinal arch and valgus deformity of the hindfoot. The differential diagnosis of flatfoot is the physiological, flexible, contracted flatfoot, which occurs as a congenital or acquired deformity. Congenital flatfoot deformity requires early intensive therapy, while a flexible flatfoot in children has a good prognosis and conservative treatment usually leads to a stable and sufficient load-bearing foot. Severe flatfoot in children can be corrected successfully by simple, minimally invasive procedures. In adults with symptomatic flatfoot, which usually occurs due to an insufficiency of the tendon of the tibialis posterior, conservative therapy with insoles, shoe modifications and physiotherapeutic measures can lead to significant improvement, otherwise surgical correction is recommended. Early, stage-appropriate therapy helps to prevent an impending decompensation of the hindfoot.     

Hindfoot valgus. Diagnosis and therapy of flatfoot

The clinical finding of flatfoot is characterized by a flattening of the medial longitudinal arch and valgus deformity of the hindfoot. The differential diagnosis of flatfoot is the physiological, flexible, contracted flatfoot, which occurs as a congenital or acquired deformity. Congenital flatfoot deformity requires early intensive therapy, while a flexible flatfoot in children has a good prognosis and conservative treatment usually leads to a stable and sufficient load-bearing foot. Severe flatfoot in children can be corrected successfully by simple, minimally invasive procedures. In adults with symptomatic flatfoot, which usually occurs due to an insufficiency of the tendon of the tibialis posterior, conservative therapy with insoles, shoe modifications and physiotherapeutic measures can lead to significant improvement, otherwise surgical correction is recommended. Early, stage-appropriate therapy helps to prevent an impending decompensation of the hindfoot.     

Flexor-Digitorum-Longus-Transfer und medialisierende Kalkaneusosteotomie zur Therapie der zweitgradigen erworbenen Plattfußdeformität

Acquired flatfoot deformity is characterized by flatening of the longitudinal arch of the foot and a varus alignement of the hindfoot due to insufficiency of the postero-medial soft tissue structures and is divided in four different stages. Stage II represents a flexible flatfoot deformity without active hindfoot inversion due to insufficiency of the Tendon of the posterior tibial muscle. Symptoms include pain at the medial hindfoot and difficulites associated with walking on uneven surfaces. Clinically, there occurs hindfoot varus and excessive forefoot abduction (‚too many toes sign’). Imaging studies include weight bearing a/p and lateral xrays as well as MRI scans in order to visualize tendon degeneration. Conservative treatment options include longitudinal arch support and physical therapy respectively. In case of failure of conservative treatment surgical options include flexor digitorum longus transfer and medial displacement calcaneal osteotomy. This procedure reveals good functional results with the restoration of single heel rise.     

Cotton Osteotomy in Flatfoot Reconstruction: A Case Report Highlighting Surgical Technique and Modified Incision to Protect the Medial Dorsal Cutaneous Nerve

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is rarely performed in isolation. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical, because preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated with arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus, or iatrogenic deformity after base wedge osteotomy in hallux valgus. We present the case of an adolescent patient who underwent flatfoot reconstruction, including Cotton osteotomy for correction of forefoot varus that was accentuated after double heel osteotomy. This case highlights our preferred procedure technique, including the use of a nerve-centric incision design. The use of an oblique dorsal medial incision is primarily intended to minimize the risk of trauma to the medial dorsal cutaneous nerve. At 20 months postoperatively for the right extremity and 12 months postoperatively for the left extremity, sensation remained intact, and the patient had not experienced any postoperative nerve symptoms. The patient had returned to playing sports without pain or restrictions.     

Influence of heel height and shoe insert on comfort perception and biomechanical performance of young female adults during walking

BACKGROUND: The possible negative effects of high-heeled shoes on subjective comfort perception and objective biomechanical assessment have been noted. Although shoe inserts have been widely applied in footwear to increase comfort and to reduce the frequency of movement-related injury, no study has attempted to identify insert effectiveness in high heels. The purpose of this study was to determine the effects of heel height and shoe inserts on comfort and biomechanics as represented by plantar pressure and ground reaction force (GRF). METHODS: Twenty young female adults performed the test conditions formed by the cross-matching of shoe inserts (shoe without insert and shoe with total contact insert [TCI]) and heel height (a flat, a low heel [3.8 cm] and a high heel [7.6 cm]). Two-way analyses of variance for repeated measures design were used to test condition effects on comfort rating, plantar pressure, and GRF during gait. To determine the biomechanical variables that can predict comfort, a multiple linear regression with stepwise method was done. RESULTS: The results showed that discomfort increased with heel height. In high heels, the plantar pressure in the heel and midfoot shifted to the medial forefoot, and the vertical and anteroposterior GRF increased. Use of the TCI reduced the peak pressure in the medial forefoot. Interestingly, the effectiveness of the TCI was greater in the higher heels than in the lower heels and in flat heels. The peak pressure in the medial forefoot, impact force, and the first peak vertical GRF could explain 75.6% of the variance of comfort in high-heeled gait. CONCLUSIONS: These findings suggest that higher heels result in decreased comfort, which can be reflected by both the subjective rating scale and biomechanical variables. Use of a TCI altered the biomechanics and therefore improved the comfort in high-heeled shoes.     

Can the use of a terminal device augment plantar pressure reduction with a total contact cast?

HYPOTHESES/PURPOSE: Total contact casting (TCC) has been shown to promote the healing of plantar neurotrophic ulcers by reducing plantar pressures and has become the established treatment standard by which all others are measured. The purpose of this study was to determine if terminal cast devices (cast shoes and heels) significantly affect the amount of plantar pressure reduction when used with a total contact cast. METHODS/RESULTS: Plantar pressures were measured in the right feet of 28 healthy adult volunteers using the Novel EMED PEDAR system (Novel GmbH, Munich, Germany) for six conditions: athletic shoe (i.e., control), TCC alone, TCC with a conventional cast shoe (EBI, Parsipanny, NJ), TCC with a custom rigid rocker cast shoe (NPS, St. Louis, MO), TCC with a rubber rocker heel (Cast Walker, DM Systems Inc., Evanston, IL), and TCC with a traditional flat rubber heel (Zimmer, Warsaw, IN). Peak plantar pressures were recorded from the forefoot, midfoot, and hindfoot. Analysis of variance (ANOVA) was used to determine statistical significance. The greatest reductions in forefoot plantar pressures compared to the athletic shoe control were seen in the TCC with the conventional cast shoe and the TCC with the rigid rocker shoe; a mean plantar pressure reduction of 30% was observed for both conditions (p < .001). Significant midfoot plantar pressure reductions (p < .001) were achieved with the TCC alone, TCC with the conventional cast shoe, TCC with the rigid rocker heel, TCC with the flat rubber heel, and TCC with the rubber rocker heel. Mean reductions were 42%, 51%, 47%, 40%, and 46%, respectively. While athletic shoe peak hindfoot pressures were only reduced by 15% by TCC alone, the addition of the rubber rocker heel to TCC reduced athletic shoe pressures by 32% and the addition of the flat rubber heel to TCC reduced athletic shoe pressures by 29%. The reductions with TCC and the heels were both significant when using the athletic shoe as the control (p < .001) and the TCC alone as the control (p < .05). CONCLUSION: Plantar pressure reduction with TCC can be augmented with the addition of a terminal cast device and the effects shown in this study are significantly different than previously reported. These results suggest that terminal cast devices should be chosen according to location of the neuropathic ulcer. In this study, forefoot pressures were reduced the most with TCC and either the conventional cast shoe or the rigid rocker shoe. The authors therefore recommend these combinations for forefoot ulcers. TCC alone or combined with any of the terminal devices proved equally effective for midfoot plantar pressure reduction. Hindfoot ulcers should be treated with TCC and the rubber rocker heel or the flat rubber heel as these provided the best hindfoot pressure reductions.     

Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity

BACKGROUND: Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. METHODS: Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). RESULTS: Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (-13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. CONCLUSIONS: Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.     

Foot-ground pressure pattern of flexible flatfoot in children, with and without correction of calcaneovalgus.

The footprint-measuring instrument was used to establish foot-ground pressure pattern of flexible flatfeet in male and female children, aged four to six years. Standing at ease, the children exerted most of their ground pressure by the posterior weight-bearing area (WBA). The rest was distributed between the middle and anterior WBAs, with the middle area usually exerting about 17%, and in extreme cases, as much as 30% of the total foot-ground pressure. Correcting valgus inclination of the calcaneus into neutral by inserting a leather wedge under the medial portion of the heel restored the longitudinal arch and the normal distribution of the foot-ground pressure of the standing child. The middle WBA exerted only 6% of the total pressure. This measuring system can differentiate between a normal foot, a flexible flatfoot, and a rigid flatfoot. It also can measure the exact amount of abnormal pressure being exerted by the middle WBA.     

The severe flexible flatfoot: a combined reconstructive procedure with rerouting of the tibialis anterior tendon.

A combined procedure is described that addresses all the components at fault in the severely flexible flatfoot deformity in children. The Evans calcaneal distraction wedge osteotomy will lengthen the lateral column, correcting the heel valgus and forefoot abduction. A naviculo--first cuneiform wedge resection (medial and plantar) and fusion will shorten and reshape the collapsed medial arch. This is augmented by reconstruction and plication of the lengthened plantar ligaments, with plantar rerouting of the tibialis anterior tendon to act as a strong plantar ligament. In addition, shifting the tibialis anterior's pull proximally acts as a sling to the talar head. Z plasty of the tight tendo Achillis is always needed. Nineteen feet in 11 patients were the subject of this study. The period of follow-up ranged from 8 to 42 months. The results were assessed according to the relief of foot strain and calf pains, improvement in shoewear, general activity, and foot shape. To evaluate foot shape, reconstruction of the medial arch and heel posture were assessed. The children and parents were satisfied with the final results in 17 feet (89.5%). Improvement of the radiological measurements was evident and was statistically significant.     

Lateral column calcaneal lengthening, flexor digitorum longus transfer, and opening wedge medial cuneiform osteotomy for flexible flatfoot: a biomechanical study

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

The effect of eliminating leg length difference on plantar foot pressure distribution in patients wearing forefoot offloading shoe

Background and purposeElevated heel construction offloads the forefoot after surgery. However, side-to-side height difference alters limb kinetics, whereas leg-length equalizing-sole at non-operated side may have beneficial effects on foot loading. The purpose of this study was to characterize leg-length equalizing sole effect on bilateral plantar pressures when using heel-lift forefoot-offloading shoe.Materials and methodsTwenty men were tested walking. Plantar peak pressures (PP) and pressure-time integrals (PTI) in the forefoot-offloading shoe and in contralateral running shoe were compared between two conditions: one with- and the other without leg-length equalizing sole elevation at the running shoe.ResultsAdding leg-length equalizing sole to the running shoe resulted in the following changes in the forefoot-offloading shoe: increased lateral midfoot PP (8.7%, p = 0.03), increased lateral midfoot (11.3%, p = 0.05) and lateral metatarsals PTI (10.3%, p = 0.04), and decreased medial and lateral heel PTI (>5%, p = 0.02). These changes were non-significant when applying a Bonferroni correction. Changes in the running shoe were: increased medial midfoot (20.5%, p = 0.03) and decreased 2nd and lateral metatarsals PP (23%, p < 0.01). PTI increased in medial and lateral heel (>25%, p < 0.01), medial midfoot (63.2%, p < 0.01) and lateral midfoot (9.2%, p = 0.04) and decreased in 2nd and lateral metatarsals (>24.5%, p < 0.01).ConclusionLeg-length equalizing sole at contralateral running shoe in subjects wearing forefoot-offloading shoe results in lateral load shift alongside heel pressure attenuation within the forefoot-offloading shoe, which is beneficial during first month after medial forefoot surgery. Reciprocal medial load-shift in the elevated running shoe itself should yet be considered when bilateral medial forefoot pathology is present.     

Talonavicular arthrodesis for correction of posterior tibial tendon dysfunction.

The awareness of PTTD has increased because of the efforts of McGlamry and Mueller. The treatment for PTTD depends on the patient's age and weight, systemic factors, length of time of the disease course, and the extent of foot collapse. The period of time from injury to diagnosis often is delayed because of the gradual progression of the condition. The patient that presents with an acute injury often responds well to a soft-tissue procedure. The delay in treatment usually necessitates the performance of an osseous procedure to correct the deformity and align the foot. The talonavicular arthrodesis is indicated in the flexible flatfoot deformity when degenerative changes of the subtalar joint are not present. The talonavicular arthrodesis is effective for correcting the flexible flatfoot deformity because it reduces the forefoot abduction, increases the height of the arch, stabilizes the medial column, and prevents excessive subtalar joint pronation. The primary complications associated with the talonavicular arthrodesis are nonunions and development of arthritis in adjacent joints. The incidence of nonunion can be directly attributed to poor surgical technique and early weight bearing during the postoperative period. The degenerative changes that occur in adjacent joints are often present preoperatively because of the long-standing valgus deformity. The procedure effectively maintains the correction of the flatfoot over a long period of time, and allows the patient to return to a pain-free lifestyle. The talonavicular arthrodesis is the procedure of choice in the flexible flatfoot deformity because the procedure corrects the malalignment of the subtalar and midtarsal joints and prevents excessive subtalar joint pronation.     

A valuable option: Clinical and radiological outcomes of braided suture tape system augmentation for spring ligament repair in flexible flatfoot

BackgroundThe purpose of this study was to evaluate the clinical and radiological outcomes of the briaded suture tape system augmentation in the treatment of flexible flatfoot.MethodsPatients who underwent suture tape system augmentation in addition to spring ligament repair and flexor digitorum longus (FDL) transfer were reviewed. Clinical and radiological outcomes were studied. The results were compared to a matched control group who underwent the conventional surgical treatment, which involved FDL transfer only or FDL transfer plus medial sliding calcaneal osteotomy.ResultsA total of 40 patients (11 males and 29 females) who underwent hindfoot reconstruction for flexible flatfoot (Johnson stage 2) were reviewed. There were 18 patients in the suture tape system group and 22 patients in the control group. In the suture tape system group, there was excellent improvement in patients’ symptoms, AOFAS score (97.9 improved from 76.7) and significantly more number of patients with stable single leg stance. Radiographic parameters improved postoperatively too.ConclusionsThis is the first clinical study which studied the outcome of suture tape system augmentation for spring ligament repair. Patients with suture tape system reconstruction showed more number of patients with single leg stance and better correction of forefoot abduction. It is a reasonable component of hindfoot reconstruction.     

Biomechanical Evaluation of a Cadaveric Flatfoot Model and Lateral Column Lengthening Technique

Patients with adult acquired flatfoot have progressive worsening of bony alignment with many being unable to perform a heel rise. Following reconstruction, pathologic skeletal alignment is corrected and the ability to perform a heel rise is often restored. The purpose of this study was to evaluate the relationship between forefoot liftoff forces and skeletal alignment in a cadaveric flatfoot model by assessing the effect of sequential lengthening of the lateral column using an Evans-type calcaneal osteotomy. Bony alignment was measured in 8 cadaveric specimens with the use of a 3-dimensional digitizing system. Transection of the spring ligament, pie-crusting of the plantar fascia, and cyclic axial loading of the foot was performed to create an anatomic and functional flatfoot model. An Evans-type calcaneal osteotomy using 6, 8, 10, and 12 mm wedges was performed. Specimens were mounted to a custom jig that applies tensile loads to the Achilles, peroneus brevis, peroneus longus, and tibialis posterior tendons. Creation of a flatfoot reduced the lateral talo-first metatarsal angle (Meary's angle) by 13° (23.6° ± 2.8° vs 10.6° ± 3.8°, p < .05) and forefoot force by 7% (199.3 N ± 7.3 N vs 185.4 N ± 9 N, p < .05). Sequential lengthening of the lateral column restored skeletal alignment and force transfer to the forefoot (12 mm wedge: Meary's angle 22.7° ± 3.9°, liftoff force 206.8 N ± 7.5 N). The cadaveric flatfoot model demonstrated decreased forefoot forces that were restored with an Evans-type calcaneal osteotomy wedge. This highlights the importance of restoring skeletal alignment when correcting advanced adult acquired flatfoot.     

Talar neck osteotomy for the treatment of severe structural flatfoot deformities

A new surgical procedure for the treatment of severe structural flatfoot with forefoot varus is presented. The talar osteotomy for flatfoot deformity and the pathology in the talus with medial column forefoot varus is described. The flatfoot considerations, adjunctive deformities, and the surgical reduction are presented. The talar osteotomy has been performed on 47 feet with a follow-up that is intermediate in length from 1 to 7 years. The results indicate that the procedure is specific and allows for good reduction when indicated in the majority of the cases.     

Hypermobile flatfoot in children. Comprehension, evaluation, and treatment

Comprehension of the hypermobile flatfoot deformity depends on an understanding of the three structural deformities of the foot associated with the condition: (1) abduction of the forefoot relative to the weight-bearing line; (2) supination of the forefoot; and (3) heel valgus. Evaluation of the hypermobile flatfoot deformity is by clinical examination to determine the position of the foot with the talonavicular joint in the congruous position: position and motion of these components are determined from this starting point. A standing lateral talometatarsal angle is used to evaluate the deformity roentgenographically. Treatment in the newborn or infant is by casting, inflare shoes, and Denis-Browne night splints for severe deformities. Support with shoes is used in children one to three years of age. Complete clinical and roentgenographic examinations should be performed when the child is three years of age. If a painful or grossly abnormal flatfoot deformity is present, custom-molded inserts are used during the period of growth. After growth has ceased flatfoot is treated only if it is painful or produces impairment. Treatment is then by shoes, inserts, or orthotics. Surgery is considered only if these devices do not alleviate the difficulty and the patient is incapacitated. Surgical procedures are designed to correct the structural abnormalities without fusing joints in an attempt to restore the normal position and motion of the components of the foot.     

Influence of postoperative shoes on plantar pressure patterns

AIM: There are several different types of shoe devices in the postoperative treatment of forefoot surgery. They all have the aim to unload the operated region. Examples for forefoot surgery are hallux valgus operations or correction of claw toes. The aim of this study was to compare a special forefoot shoe (Darco's Ortho Wedge) with a lengthwise and crosswise prepared postoperative shoe (Darco's Medical Surgical). METHOD: Plantar pressure distribution measurements were used to evaluate the unloading effect of the shoe conditions. The pressure in a standard shoe (Nike's Air Triax) was measured for further comparison. RESULTS: The results demonstrate that all analyzed shoes relieve weight under the medial forefoot region. The lengthwise prepared Medical Surgical achieves the highest pressure reduction under the medial forefoot, but the midfoot and the lateral forefoot are subjected to significantly higher loads. The Ortho Wedge reduces the load under the toes and the forefoot and relieves the midfoot region. The pressure is redistributed under the hindfoot. The crosswise prepared Medical Surgical also relieves pressure under the forefoot but not to the same extent as the Ortho Wedge. CONCLUSION: In conclusion it can be stated that the Ortho Wedge shows the best results of the tested shoes for pressure relief and load transfer under the forefoot.     

Flexible arch of the foot

Many parents are anxious because of the insufficient arch of the feet of their children. A true congenital deformity (congenital vertical talus) is extremely rare. In children the arch is physiologically flattened with a hypervalgus of the hindfoot. Those feet do not need treatment. If there is no medial recess in the footprint in a child over 3 years of age, then we are talking about a flexible flatfoot. When the load of the foot is more pronounced at the medial rather than at the lateral side, operative treatment can be indicated, such as a lengthening osteotomy of the calcaneum. If the flatfoot is rigid, the reason for it is usually a tarsal coalition. Operative transection of the osseous bridge with fat interposition can solve the problem. Flatfeet may also occur in neuromuscular diseases. Depending on the severity of the deformity, splints can be effective, or--in the more severe cases--operative treatment such as a triple arthodesis can be indicated.     

Calcaneocuboid distraction arthrodesis and first metatarsocuneiform arthrodesis for correction of acquired flatfoot deformity in a cadaver model

BACKGROUND: Lateral column lengthening has been associated with residual forefoot supination and symptomatic lateral overload in treatment of acquired flatfoot. A medial column procedure may be useful to redistribute load to the medial column. We evaluated radiographic and pressure changes in a severe flatfoot model with lateral column lengthening and investigated the effect of an added first metatarsocuneiform arthrodesis. METHODS: Ten cadaver specimens were loaded in simulated double-legged stance, and radiographic and pressure data were collected for all tested states. Calcaneocuboid arthrodesis was done with a 10-mm foam wedge. Residual forefoot varus was corrected through the first metatarsocuneiform joint. RESULTS: Differences in the mean lateral talar-first metatarsal angle, talonavicular angle, talocalcaneal angle, and calcaneal pitch were significant between the intact foot and the flatfoot. After calcaneocuboid distraction arthrodesis and tendon transfer, the lateral talar-first metatarsal angle, talonavicular angle, and calcaneal pitch were significantly different from the flatfoot. After added first metatarsocuneiform arthrodesis, the talonavicular angle was not significantly different from the intact foot. Lateral forefoot pressure increased in the flatfoot after lateral column lengthening but was not significantly different from the intact foot after first metarsocuneiform arthrodesis was added. CONCLUSIONS: Adding first metatarsocuneiform arthrodesis to calcaneocuboid distraction arthrodesis for treatment of flatfoot deformity provided improvement in radiographic and pedobarographic parameters of a severe model of stage II posterior tibial tendon dysfunction.     

Pneumatic bracing and total contact casting have equivocal effects on plantar pressure relief

The purpose was to examine and compare plantar pressures produced in healthy subjects while wearing a running shoe (RS), total contact cast (TCC) and 'customized' pneumatic pre-fabricated walking brace (PWB). A repeated measures design was used to compare the plantar pressures recorded for three footwear types (RS, TCC, PWB) in two body regions (forefoot, heel). Nine healthy subjects walked at a self-selected walking pace on a motorized treadmill while wearing the RS, TCC and PWB (ordered randomization). Following a five-minute acclimatization period on the treadmill with each footwear device, plantar pressures were recorded from 84 constant gait speed and step length steps using the Pedar system of in-shoe array of capacitive sensors embedded in an insert. Mean spatially averaged peak plantar pressures were recorded for the metatarsal heads and heel region for each footwear device worn by each subject. A two-way analysis of variance with repeated measures and post-hoc Tukey tests analysed the data with a significance level of p=.05. The main effects of footwear (p=.005) and body region (p=.000), and interaction effect (body region x footwear device) (p=.000) were significant. Unloading of the forefoot was 63.72% and 58.77% for the TCC and PWB, respectively, whereas loading under the heel was increased 37.09% and 34.11% for the same two devices, respectively. Patients who develop neuropathic plantar ulcers in the forefoot region, but not in the heel region, may benefit from a reduction in plantar pressures by using either the TCC or a 'customized' PWB. An alternative footwear device still needs to be found for those patients with heel ulceration.