Transcuneiform and opening wedge medial cuneiform osteotomy with closing wedge cuboid osteotomy in relapsed clubfoot

Ten patients (13 feet) aged 4 to 11 years with idiopathic clubfeet underwent bony correction for resistant supination and adduction deformities. A closing wedge cuboid osteotomy and medial cuneiform opening wedge and transcuneiform osteotomy were performed in all cases. The average improvement in anteroposterior talo-first metatarsal angle of 22 degrees, calcaneo-fifth metatarsal angle of 13 degrees, and lateral calcaneo-first metatarsal of 9 degrees confirmed the clinically satisfactory correction in all feet. However, one foot required repeat surgery 2 years after the index procedure.     

Combined midfoot osteotomy for severe forefoot adductus

A one-stage procedure combining a closing wedge osteotomy of the cuboid with an opening wedge of the medial cuneiform was used for the treatment of severe forefoot adductus. Results were reviewed in 33 patients (50 feet) followed-up for at least 2 years postoperatively. Clinical and radiographic improvement in forefoot position was achieved in 90% of cases. The mean calcaneo-second metatarsal angle improved from 37 degrees preoperatively to 18 degrees at final follow-up. The mean talo-first metatarsal angle improved from 15 degrees preoperatively to 3 degrees at final follow-up. The medial to lateral column ratio demonstrated 33% improvement after surgical treatment. Two feet were unimproved because of graft migration. Patients younger than age 5 years without a well-defined medial cuneiform ossific nucleus had a high rate of medial graft extrusion with loss of correction. This procedure should be reserved for patients aged 5 years or older. Ten patients followed-up for more than 6 years had no deterioration in results. This procedure provides effective, safe, predictable, and lasting correction of forefoot adductus.     

Opening wedge osteotomy of the medial cuneiform before age 4 years in the treatment of forefoot adduction

Thirty-seven feet in 25 children (12 girls, 13 boys) treated surgically with medial cuneiform opening wedge osteotomy to correct forefoot adduction were assessed. Thirteen patients had unilateral deformity. Primary diagnoses were congenital clubfoot (33 feet), congenital forefoot adduction (3 feet), and skewfoot (1 foot). All children underwent operation before age 4 years. The age at operation ranged from 21 to 47 months (mean 35). In 18 feet, allografts were used. In 5 feet, autograft was used. In 14 feet, ceramic material was inserted as opening wedge. Follow-up ranged from 3 to 8 years (mean 4). In four feet, the ossification center of the medial cuneiform was invisible. The correction of the deformity was assessed clinically and radiographically. The first ray angle and talo-first metatarsal angle were evaluated on anteroposterior radiographs, the latter was evaluated on lateral radiographs, also. In 26 feet, normal position of the forefoot was achieved. In five feet, overgrowth of the medial cuneiform in comparison with the normal side was observed. Forefoot adduction persisted in six feet. The ossification center was often divided into two parts by bone graft, and subsequent independent growth of both parts was observed. This technique is safe and useful for correction of forefoot adduction in young children. It can be performed even in cartilaginous bone. The osteotomy causes overgrowth of the medial cuneiform and the medial ray.     

Relationship Between Grading With Magnetic Resonance Imaging and Radiographic Parameters in Posterior Tibial Tendon Dysfunction

The objective of the present study was to elucidate the relationship between the state of the posterior tibial tendon (PTT) on magnetic resonance images and foot deformity. The cases included 34 feet in 27 patients with PTT deformity and the controls included 18 feet in 12 patients who had undergone magnetic resonance imaging for other foot diseases. The PTT was closely examined on the magnetic resonance images and classified using the Conti classification. The control feet with no injury to the PTT were classified as grade 0. The talonavicular coverage angle, lateral talo-first metatarsal angle, medial cuneiform to fifth metatarsal height, calcaneal pitch angle, and varus–valgus angle were measured as radiographic parameters for flatfoot deformation, and the relation between the Conti classification and each parameter was examined statistically. A significant difference was observed in the talonavicular coverage angle between grade 0 and the other grades; the lateral talo-first metatarsal angle between grade 0 and the other grades and between grades 1 and 3; the medial cuneiform to fifth metatarsal height among grades 0, 2, and 3 and grades 1, 2, and 3; the calcaneal pitch angle between grades 1 and 3; and the varus–valgus angle among grades 0, 2, and 3 and between grades 1 and 3. Eversion of the forefoot was observed, along with an advanced collapse in the medial longitudinal arch, from an early stage of PTT injury.     

Combined double tarsal wedge osteotomy and transcuneiform osteotomy for correction of resistant clubfoot deformity (the “bean-shaped” foot)

Purpose

The “bean-shaped foot” exhibits forefoot adduction and midfoot supination, which interfere with function because of poor foot placement. The purpose of the study is a retrospective evaluation of patients who underwent a combined double tarsal wedge osteotomy and transcuneiform osteotomy to correct such a deformity.

Methods

Twenty-seven children with 35 idiopathic clubfeet were treated surgically by combined double tarsal wedge osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) and transcuneiform osteotomy between 2008 and 2012. The age of children at surgery ranged from 4 to 9 years. There were 19 boys and 8 girls. Pre- and postoperative X-rays were used, considering: on the AP radiograph, the calcaneo-fifth metatarsal angle and the talo-first metatarsal angle (indicators of forefoot adduction); on the lateral radiograph, the talo-first metatarsal angle (an indication of supination deformity) and calcaneo-first metatarsal angles (an indication of cavus deformity). These radiological parameters were compared with the clinical results.

Results

Follow-up was conducted for 24–79 months following surgery. Clinical and radiographic improvements in forefoot position were achieved in all cases. An average improvement in the anteroposterior talo-first metatarsal angle of 21°, calcaneo-fifth metatarsal angle of 14°, lateral talo-first metatarsal angle of 10°, and lateral calcaneo-first metatarsal of 12° confirmed the clinically satisfactory correction in all feet. One patient had a wound infection postoperatively, which resolved with removal of the wires and administration of oral antibiotics. Eight patients followed up for more than 5 years had no deterioration of results.

Conclusions

Combined double tarsal wedge osteotomy as well as transcuneiform osteotomy is an effective and safe procedure for lasting correction of the bean-shaped foot.     

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.     

Proximal spherical metatarsal osteotomy for the foot with severe hallux valgus

BACKGROUND: A proximal spherical metatarsal osteotomy was devised to correct not only varus deviation of the first metatarsal, but also dorsiflexion. We expected to increase the medial longitudinal arch by adding plantar flexion at the osteotomy site. To investigate the limitations of this procedure for feet with severe hallux valgus, a followup study was performed on patients with preoperative hallux valgus angles greater than or equal to 40 degrees. MATERIALS AND METHODS: Forty-eight feet in 37 patients (10 male, 27 female) (60 years; range, 20 to 84 years) were investigated. Mean followup was 4 years and 1 month, ranging from 2 to 8 years. The spherical osteotomy was performed using a curved chisel. A distal soft tissue procedure was done at the same time. Twenty feet received combined operations for their combined deformities. RESULTS: While 81% of patients were satisfied with the results, 50% of those with preoperative hallux valgus angles greater than or equal to 50 degrees had postoperative hallux valgus angle greater than or equal to 20 degrees. In these patients, correction of metatarsus primus varus was good, but correction of valgus deviation of the hallux was fair. Mean correction toward plantar flexion was 1.5 degrees and no increase in arch height was achieved. CONCLUSION: The proximal spherical osteotomy could consistently achieve satisfactory results for the patients with hallux valgus angles less than 50 degrees. However, the corrections were worse in feet with more severe deformities. Furthermore, plantarflexion at the osteotomy site was offset by displacement at the first tarsometatarsal joint. If plantarflexion is indispensable, arthrodesis of the tarsometatarsal joint is recommended.     

Medial column procedures in the correction of adult acquired flatfoot deformity

AAFD is a complex problem with a wide variety of treatment options. No single procedure or group of procedures can be applied to all patients with AAFD because of the variety of underlying etiology and grades of deformity. As the posture of the foot progresses into hindfoot valgus and forefoot abduction through attenuation of the medial structures of the foot, the medial column begins to change shape. The first ray elevates and the joints of the medial column may begin to collapse. Careful physical examination and review of weight-bearing radiographs determines which patients have an associated forefoot varus deformity that may require correction at the time of flatfoot reconstruction. Correction of an AAFD requires a combination of soft-tissue procedures to restore dynamic inversion power and bony procedures to correct the hindfoot and midfoot malalignments. If after these corrections forefoot varus deformity remains, the surgeon should consider use of a medial column procedure to recreate the “triangle of support” of the foot that Cotton described.5 If the elevation of the medial column is identified to be at the first NC or the first TMT joint, then the joint should be carefully examined for evidence of instability, hypermobility, or arthritic change. If none of these problems exist, then the surgeon can consider use of the joint-sparing Cotton medial cuneiform osteotomy to correct residual forefoot varus. However, if instability, hypermobility, or arthritic change is present, then the surgeon should consider use of an arthrodesis of the involved joint to correct residual forefoot varus. Either procedure provides a safe and predictable correction to the medial column as part of a comprehensive surgical correction of AAFD.     

Treatment of severe residual clubfoot deformity by trans-midtarsal osteotomy.

This study reviews the preliminary results of transmidtarsal osteotomy performed on 11 patients (12 feet) who previously underwent surgery for resistant clubfoot and needed further surgery for severe residual deformities. Opening wedge medial cuneiform osteotomy, closing wedge cuboid osteotomy, and truncated wedge middle and lateral cuneiform osteotomy were performed. The procedure was performed initially on normal cadaver feet. The average improvement of anteroposterior talo-first metatarsal angle was 20 degrees and lateral calcaneo-first metatarsal angle was 16 degrees. The authors conclude that with this simple procedure, angular and rotational correction in three planes can be obtained simultaneously in severe residual clubfoot deformity without the need for extensive soft tissue release.     

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.     

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.     

Short- to Intermediate-Term Radiographic Outcomes Following Cotton Osteotomy

The cotton osteotomy or the medial cuneiform opening wedge osteotomy has been a common adjunct procedure in flatfoot reconstruction to correct for forefoot varus or a dorsiflexed first ray. The main goal of the study is to retrospectively review outcomes specifically in the short-intermediate term for the cotton osteotomy. The medical records of a single foot and ankle surgeon (PRB) were reviewed for patients who met inclusion and exclusion criteria. The study period was from January 2006 to October 2018. The analysis was performed using information obtained from chart-review to examine union and complication rates, as well as changes in the cuneiform articular angle based on graft size and type. A total of 71 feet in 61 patients underwent cotton osteotomies for flatfoot reconstruction. Overall complication rate was 5.6% (4/71) with 2 nonunions (2/47) in those that had radiographic follow-up of greater than 9 months. Change in cuneiform articular angle (CAA) showed 0.91° of correction per 1-millimeter increase in graft wedge size from preoperative to 3 weeks. Change for anterior-posterior medial cuneiform bisection dorsal length (AP length) was 0.70 mm per 1 mm of graft used from preoperative to 3 weeks. 6 weeks to 10 weeks showed statistically significant changes in the CAA (p = .01) and the AP length (p = .002). The cotton osteotomy showed statistically significant radiographic loss of correction between the 6- and 10-week time points when patients were allowed to begin weightbearing. Metal grafts may provide maintenance of correction which warrants future studies on their efficacy.     

Cotton Osteotomy in Flatfoot Reconstruction: A Review of Consecutive Cases

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is commonly performed; however, the outcomes are rarely reported owing to the adjunctive nature of the procedure. 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 the preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated by 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 an iatrogenic deformity after base wedge osteotomy for hallux valgus. We undertook an institutional review board-approved retrospective review of 32 consecutive patients (37 feet) who had undergone Cotton osteotomy as a part of flatfoot reconstruction. All but 1 case (2.7%) had radiographic evidence of graft incorporation at 10 weeks. No patient experienced graft shifting. Three complications (8.1%) were identified, including 2 cases with neuritis (5.4%) and 1 case of delayed union (2.7%) that healed with a bone stimulator at 6 months postoperatively. Meary's angle improved an average of 17.75°, from ?17.24°± 8.00° to 0.51°± 3.81°, and this change was statistically significant (p < .01). The present retrospective series highlights our experience with the use of the Cotton osteotomy as an adjunctive procedure in flatfoot reconstructive surgery.     

Percutaneous sagittal plane closing wedge osteotomy of the first metatarsal

Osteotomy of the first metatarsal in the sagittal plane is useful in correction of numerous deformity of the foot. Plantarflexion osteotomy of the first metatarsal can be used to treat hallux rigidus, hallux limitus, forefoot varus in flatfoot deformity and iatrogenic metatarsus primus elevates. Dorsiflexion osteotomy of the first metatarsal is an important component in surgical correction of pes cavus. It is also indicated in recalcitrant diabetic neuropathic ulcers at the first metatarsal head. We described a minimally invasive technique of sagittal plane corrective osteotomy of the first metatarsal, which can be either a plantarflexion or dorsiflexion one.     

Results of treatment of stage II posterior tibial tendon rupture with flexor digitorum longus tendon transfer and calcaneal osteotomy

In a retrospective study, we reviewed our results of treatment of stage II posterior tibial tendon rupture in 129 patients for whom surgery was performed between 1990 and 1997. During this period of time, 148 patients were treated with surgery following failure of nonsurgical methods of treatment. The 129 patients (117 females, 12 males) with an average age of 53 years (range, 34–75 years) had been symptomatic for an average of 2.8 years (range, 0.5–7 years). The indication for surgery was the presence of foot pain, which was refractory to shoe modifications, orthoses, and brace support. All patients had a painful flexible flatfoot without a fixed forefoot supination deformity. The surgery performed included a medial translational osteotomy of the calcaneus and transfer of the flexor digitorum longus tendon into the navicular. There were additional surgeries performed in 49 patients including repair of a tear of the spring ligament, talonavicular capsule or deltoid ligament (45), lengthening of the Achilles tendon (26), correction of hallux valgus deformity (5), and arthrodesis of the first tarsometatarsal joint (4). All patients were examined, radiographs obtained, and isokinetic evaluation of both feet and lower limbs performed with the KinCom apparatus at a mean of 4.6 years following surgery (range, 3–8 years). The AOFAS hindfoot scale was used to evaluate each patient, although, due to the time elapsed from the initiation of treatment, preoperative AOFAS scores were not retrospectively determined. The mean AOFAS score at the time of the follow-up examination was 79 points (range, 54–93). There were 7 significant complications in 6 patients including: significant progressive hindfoot valgus deformity in 1 patient treated with a triple arthrodesis; overcorrection of the hindfoot in 2 patients necessitating revision with a lateral closing wedge calcaneus osteotomy; 3 patients with symptomatic sural neuritis, and 1 patient with weakness of the gastrocnemius resulting from overlengthening of the Achilles tendon. Isokinetic inversion and plantarflexion power and strength were compared with the contralateral limb for 121 patients, and were noted to be symmetric in 95, mildly weak in 18, and moderately weak in 8. Motion of the subtalar joint was normal in 44%, slightly decreased in 51%, and moderately decreased in 5% of patients. Anteroposterior and lateral radiographs were evaluated for the talonavicular coverage angle, talus-first metatarsal angle, talocalcaneal angle, and the height of the medial cuneiform to the floor. For 4 of these 5 parameters evaluated, the correction obtained was statistically significant (p < 0.05). Of the patients examined, 123 were entirely satisfied, 4 partially satisfied, and 2 were dissatisfied with the outcome of the procedure. Most patients experienced pain relief (97%), an improvement of function (94%), noted an improvement in the arch of the foot (87%), and were able to wear shoes comfortably without resorting to shoe modifications or orthotic arch support (84%). In conclusion, the surgical correction of stage II posterior tibial tendon rupture with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular yielded excellent results with minimal complications, and a high patient satisfaction rate.     

Different faces of the triple arthrodesis

Patients with severe pes planovalgus or cavovarus foot deformities who fail conservative treatment may require a triple arthrodesis. Modifying the triple arthrodesis to include extended bone wedge resections allows for improved correction. The goal of each procedure is to obtain a less painful, plantigrade foot, and to improve function. Additional hindfoot or midfoot osteotomies may be needed in the modified triple arthrodesis. Midfoot or forefoot cavus can be addressed with either the Japas, Cole, or Jahss osteotomies, as described above. Residual hindfoot valgus can be adequately corrected with a medial displacement osteotomy of the calcaneus. Residual hindfoot varus is preferably corrected through a lateral closing wedge calcaneal osteotomy. This allows for adequate correction without the need for bone graft or an extended medial incision in the area of the tibial neurovascular bundle. Good results have been obtained with these types of complicated reconstructive procedures.     

Metatarsal osteotomy in rheumatoid arthritis

Thirty-eight feet in 28 patients with rheumatoid forefoot deformity were operated on with a proximal valgus osteotomy of the first metatarsal bone to reduce splaying of the forefoot. Each patient also underwent additional surgical procedures for associated conditions of the forefoot. The mean follow-up period was 3.7 years. Both the entire forefoot and the medial border of the foot were substantially improved in all but 2 cases. Residual symptoms were slightly more pronounced in the anterior footpad and the lesser toes (5 cases). A proximal valgus osteotomy of the first metatarsal bone, performed in combination with other surgical procedures, affords a good correction of the rheumatoid foot deformity with long-term improvement.     

Basal closing wedge osteotomy for correction of hallux valgus and metatarsus primus varus: 10- to 22-year follow-up

Between 1974 and 1985, 59 patients (83 feet) underwent basal closing wedge osteotomy in combination with a bunionectomy and a lateral soft tissue release for correction of hallux valgus and metatarsus primus varus at this institution. Of the original 59 patients, 42 patients (60 feet) with at least 10 years of follow-up (average, 194 months; range, 144-266 months) were available for this study. Results were analyzed by review of the medical records and plain radiographs, a standardized clinical questionnaire, and physical examination. Of the 60 feet, patients rated outcomes as excellent or good in 51 feet (85%) and rated cosmesis as excellent or good in 44 feet (73%). Radiographically at final follow-up, hallux valgus and intermetatarsal angles averaged 19.9 degrees (range, 0-40 degrees) and 6.7 degrees (range, 0-18 degrees), respectively. The sesamoid position was corrected from an average preoperative grade of 2.6 to a grade of 0.9 at final follow-up. The average shortening of the first metatarsal was 5 mm. The disadvantages of the closing wedge osteotomy are that it is technically demanding and it entails the risk of shortening, dorsal malalignment, and metatarsalgia. In the current study, long-term complications included hallux varus deformity (16 feet), dorsal malalignment (15 feet), and metatarsalgia (14 feet). Despite good correction of the intermetatarsal angle and sesamoid position, the clinical results and the incidence of complications after basal closing wedge osteotomy were not as favorable as those reported for other procedures in the literature. Therefore, alternative procedures, such as the basal crescentic osteotomy or the basal chevron osteotomy, should be used.     

高弓马蹄内翻足术后复发与跟骨截骨

目的 探讨高弓内翻足手术治疗后的内翻复发,跟骨截骨外移的矫正度与内翻复发的关系.方法 23例(31足)成人高弓内翻足患者,年龄13～59岁,平均36岁.以术前Coleman试验可否矫正、经内侧软组织和(或)肌腱松解后后足内翻被动矫正情况以及是否行跟骨截骨,将患足分为4组.并以被动可矫正至中立位和外翻5°以上为两个界限.进行统计.跟骨截骨可以为跟骨轴位水平方向上的截骨外移,截骨外移后的欠状面上的上移,以及跟骨的楔形闭合截骨.结果 内翻复发9足,5°以下5足,5°以上4足,平均4.23°±2.15°.末行跟骨截骨12足中,术前Coleman试验可矫正至中立位3足均复发,术前Coleman试验可矫正至外翻5°以上的4足均未复发.术前Coleman试验不町矫正,术中经软组织松解后可矫正至中立位的2足,术后均复发;术前Coleman试验不可矫正,术中可矫正至外翻5°以上的3足,内翻复发1足.行跟骨外移截骨19足中,术前Coleman试验可矫正至中立位9足,1足内翻复发;术前Coleman试验不可矫正,术中可矫正至中立位的7足,术后2足复发;术前Coleman试验不可矫正,术中可矫正至外翻5°以上者3足,无内翻复发.结论 Coleman试验能否矫正后足的内翻,并非是否行跟骨外移截骨术的依据;而被动手法矫正是判断是否行跟骨截骨的关键,外翻5°是一个重要的指标.     

Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency

The surgical treatment of flexible pes planovalgus deformities resulting from Stage 2 posterior tibial tendon insufficiency is controversial and many techniques have been proposed. We retrospectively reviewed the results of subtalar arthrodesis combined with spring ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular. There were sixteen patients (seventeen feet) with an average follow-up of 27 months (9-52). All deformities were passively correctable. The average age was 56 yrs (39-78). All patients had failed conservative management, 88% had previously been treated with orthotics, and 53% had lateral pain from subfibular impingement. Two patients were noted to have degenerative changes of the subtalar joint. Successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5-24). The average AOFAS hindfoot score and Maryland foot score postoperatively was 82 and 86 respectively. Standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6 degrees (24 degrees preoperative, 18 degrees postoperative). The talonavicular coverage angle improved an average of 17 degrees (34 degrees preoperative, 17 degrees postoperative). The lateral talo-1st metatarsal angle improved an average of 10 degrees (18 degrees preoperative, 8 degrees postoperative). The lateral talocalcaneal angle decreased an average of 21o (55 degrees preoperative, 34 degrees postoperative). The distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively (avg. improvement 6mm). The combination of the flexor digitorum longus tendon transfer and spring ligament repair with subtalar arthrodesis is an effective and reliable procedure which provides excellent correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the longitudinal arch. These results compare favorably with flexor transfer combined with either calcaneal osteotomy or lateral column lengthening.