Möglichkeiten und Grenzen der subtalaren Arthrorise im Kindesalter

The minimally invasive subtalar screw arthroereisis procedure is becoming an increasingly more established option for treating juvenile flexible flatfoot. The procedure is indicated in children who are 9–13 years old and have idiopathic juvenile flexible flatfoot that has progressed to a symptomatic pathology. Minimally invasive subtalar screw arthroereisis functions by a combination of mechanical and proprioceptive effects that allow for growth adjustment of the subtalar joint and with a low complication rate. This surgical intervention is contraindicated for treating fixed and secondary pes plano valgus. The subtalar screw is removed once the pediatric foot has stopped growing and results in permanent correction of the flexible flatfoot.     

Correction of flexible pes planus deformity: medial column stabilization procedure

A review of five distinct medial column stabilization procedures sets forth criteria specific to certain presentations of pes planus deformity. The importance of considering the manifestation of the condition and its implications with regard to the overall health of the particular patient cannot be overemphasized. The collective goal of all such corrective procedures is identical; it is the variable factors particular to a specific presentation that dictate the preferred corrective action. The course selected by a physician with respect to surgical correction of flexible pes planus must be determined by taking both the procedure and the presentation of the condition under advisement.     

Is Kidner procedure necessary during subtalar arthroereisis for pediatric flexible flatfoot that combined with symptomatic type 2 accessory navicular? A retrospective comparative study

BackgroundKidner procedure is thought to be able to eliminate the medial foot pain and contribute to restoring the medial longitudinal foot arch, making it particularly suitable for surgical treatment of pes planus that combined with symptomatic type 2 accessory navicular (AN). However, controversy remains, and the clinical evidence is still lacking. The aim of the current study is to verify the necessity of Kidner procedure during subtalar arthroereisis (STA) for pediatric flexible flatfoot (PFF) that combined with symptomatic type 2 AN.MethodsForty pediatric patients (72 feet) who had undergone STA for flexible flatfoot and were also diagnosed with symptomatic type 2 AN concomitantly were reviewed retrospectively and divided into two groups (STA + Kidner vs STA alone). The visual analog scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Oxford ankle foot questionnaire for children (OAFQC), and the radiographic parameters that quantifying pes planus were evaluated as primary outcomes. Secondary outcomes included the incidence of complications.ResultsThere were 35 feet in the STA + Kidner group and 37 feet in the STA alone group, with mean follow-up periods of 2.7 years and 2.1 years, respectively. The VAS, AOFAS, OAFQC scores and radiographic parameters presented no significant difference between the two groups both preoperatively and at final follow-up (P > 0.05 for each). The complications of STA surgery occurred equally in both groups, and Kidner procedure could lead to more incision problems (22.9% vs. 2.7%) and a longer time to return to activity.ConclusionKidner procedure may be unnecessary during surgical treatment of PFF that combined with painful type 2 AN. Correcting the PFF while leaving the AN alone has a high possibility of relieving the pain in the AN region, and tibialis posterior tendon (TPT) rerouting hardly aids in reconstruction of the medial foot arch.Level of EvidenceIII.     

Calcaneal Z Osteotomy for Extra-articular Correction of Hindfoot Valgus

The lateral column lengthening procedure has been used in the surgical management of congenital and adult-acquired pes planus. Lateral column lengthening allows correction of the abducted forefoot and subsequent improvement in the medial longitudinal arch. However, owing to the inconsistent healing times and complications, we opted to pursue a novel approach to the lateral column lengthening procedure, the calcaneal Z osteotomy.     

Arthroereisis for Symptomatic Flexible Flatfoot Deformity in Young Children: Radiological Assessment and Short-Term Follow-Up

The purpose of this study is to recognize those young patients with symptomatic flexible flatfoot deformity who need treatment and to provide radiological evidence that arthroereisis is capable of relocating the talus properly over the calcaneus. We included 28 feet in 14 children who underwent subtalar arthroereisis in association with percutaneous triple-hemisection Achilles tendon lengthening. Selected for arthroereisis were children with symptomatic flexible flatfoot deformity who complained of foot and leg pain, had decreased endurance in sports activities and long walks, who did not respond to conservative treatment modalities for at least 6 months, and in whom at radiological assessment on stance position with the medial arch support orthosis the talonavicular joint lateral subluxation still remained, with Meary's angle in anteroposterior (A/P) and lateral view remaining increased. The mean age at surgery was 10.71 ± 1.58 (range 8 to 14) years. The minimum follow-up duration was 19 months, with mean follow-up duration of 35.14 ± 9.82 (range 19 to 60) months. For estimation of the efficacy of the surgical procedure, the American Orthopaedic Foot and Ankle Society (AFOAS) rating scale was used preoperatively and postoperatively in all patients. The mean preoperative AFOAS ankle-hind foot rating score was 65.14 ± 7.16 (range 58 to 75) points. The mean postoperative AFOAS score was 88.851 ± 5.61 (range 83 to 97) points and the 2-tailed p value <.0001. After arthroereisis surgical treatment, all AOFAS scores and all foot angles improved significantly, except the calcaneal inclination angle which improved slightly.     

Prevention and Treatment of Ulcerations of the Foot in Unilaterally Amputated Diabetic Patients

In unilaterally amputated diabetic patients the prognosis for the remaining leg is poor. Often the patients suffer from diabetic neuropathy, angiopathy and/or arteriosclerosis. Furthermore, the load pattern of the remaining foot is frequently abnormal. In order to assess the extent of the problem, as well as the possibility of preventive care, 20 patients in the outpatient clinic of the Steno Memorial Hospital were followed for a period of 17 months.

Eighteen patients showed signs of peripheral neuropathy and 19 an abnormal load pattern. Following preliminary assessment the dynamic load pattern of the ambulant patients was recorded and their shoes were fitted with a corrective insole made of Rubazote®. In the presence of ulcerations the insoles were continuously modified according to the diminishing size of the ulcer. Supplementary local dressing and systemic antibiotics were administered according to need.

Initially 11 patients had pedal ulcerations, 5 ischemic and 6 neuropathic. All of the neuropathic ulcerations healed during the period of observation and no new ulcerations were seen. Two of the ischemic ulcerations healed whereas the remaining 3 persisted. It is concluded that regulation of the pedal load pattern in unilaterally amputated diabetic patients has a considerable curative and preventive effect.     

Weightbearing CT scan of severe flexible pes planus deformities

BACKGROUND: The three-dimensional relationships of the bones in the foot in a flatfoot deformity are difficult to assess with standard radiographs. CT scans demonstrate these relationships but are typically made in a nonweightbearing mode. Our objective was to assess the use of a weightbearing CT apparatus to image the feet in patients with severe flexible pes planus deformities and to better define the anatomical changes that occur. MATERIALS AND METHODS: A specialized device was designed and constructed to simulate weightbearing to the feet during CT examination. Eighteen normal feet and 30 painful severe and flexible pes planus feet were imaged in both the non weightbearing and weightbearing states, set at 50% of body weight. Several measurements of intertarsal relationships were made of the pes planus and normal feet. Navicular floor to skin distance, forefoot arch angle, and subtalar joint subluxation were measured in the coronal plane in both the weightbearing and nonweightbearing states. T-tests were used to analyze measurements of navicular floor to skin distance and forefoot arch angle. RESULTS: The weightbearing device had a significant effect on foot configuration for both normal and pes planus feet (p = 0.0008) and (p < 0.0001) respectively for both floor to skin distance and forefoot arch angle. There was a significant difference between normal feet and pes planus feet with regard to the forefoot arch angle in the nonweightbearing (p = 0.02) and weightbearing states (p = 0.01). Four of the pes planus patients had evidence of subtalar joint subluxation which was more pronounced in the weightbearing state. There was no significant difference between the navicular floor to skin distance in the normal versus pes planus feet in either the non weightbearing (p = 0.05) or the weightbearing states (p = 0.07). CONCLUSION: A device was designed and constructed to apply a weightbearing load equal to that of 50% body weight with minimal to no patient discomfort. The resultant effects on foot configuration were significant, and are useful for assessment of degree of flexible flat foot deformity, thus guiding clinical management. The measure which most significantly differed between pes planus patients and normal volunteers was the forefoot arch angle. Forefoot arch angle may therefore be the most useful measure for the imaging diagnosis of flexible pes planus, and the degree of planus deformity.     

New and Recurrent Ulcerations after Percutaneous Achilles Tendon Lengthening in Transmetatarsal Amputation

The purpose of the study was to review the incidence rate of new and recurrent ulcerations in transmetatarsal amputations after original ulcers healed with percutaneous Achilles' tendon lengthening as an isolated procedure. We reviewed 35 charts from period of January 1995 to March 2007, and 28 were included for the final review. Twenty-four ulcers were grade 1A, 2 were 0A and 1B, and 1 was 1C using the University of Texas Grading System. Time to heal of ulceration post-TAL was 9.4 weeks (range 3-72 weeks). For statistical analysis, we used binomial distribution for dichotomous variables. Results demonstrated 4 limbs did not heal, 10 patients had an ulcer recurrence (p<0.001), and 6 developed new ulcers. Of the 28 patients in which TAL was performed, 16 developed new neuropathic ulcers (including recurrent ulcers; p=0.0099). High recurrence and new ulcers formation exist after TAL in patients with an unbalanced metatarsal amputation, and extrinsic/ intrinsic factors may need to be addressed to prevent recurrence. LEVEL OF CLINICAL EVIDENCE: 4.     

Arthroereisis in juvenile flexible flatfoot: Which device should we implant? A systematic review of literature published in the last 5 years

BACKGROUNDFlexible flatfoot (FFF) is a very common condition in children, characterized by the loss of the medial arch and by an increase in the support base with valgus of the hindfoot. Arthroereisis (AR) procedures are widely performed corrective surgeries and are classified as subtalar AR and calcaneo-stop (CS).AIMWe investigated the literature published in the last 5 years with the aim of providing an update on the evidence related to AR treatment in FFF patients. We report the principal findings of subtalar AR and CS procedures concerning clinical and radiological outcomes and complication rates in the general population, young athletes, and obese people according to material device.METHODSFollowing the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic review of studies published in the past 5 years and included the PubMed and Science Direct databases was performed on May 6, 2020. The research string used was (pediatric OR children OR Juvenile NOT adult) AND (flexible NOT rigid) AND (flat foot OR pes planus) AND (calcaneo-Stop OR arthroereisis OR subtalar extra-articular screw OR SESA OR subtalar arthroereisis OR endosinotarsal). The risk of bias assessment was performed using the Dutch checklist form for prognosis.RESULTSA total of 47 articles were found. Ultimately, after reading the full text and checking reference lists, we selected 17 articles that met the inclusion and exclusion criteria. A total of 1864 FFFs were identified. Eight studies concerned the subtalar AR (47.1%) and nine concerning CS (52.9%). The average age of patients at start of treatment was 11.8 years, the average follow-up of the studies was 71.9 mo (range 29.1-130). Globally, complications occurred in 153 of the 1864 FFF treated, with a rate of 8.2%.CONCLUSIONBoth AR procedures are valid surgical techniques for treating FFF. Surgeon experience, implant cost, and cosmetic correction are the most common considerations included in the orthopedic device decision-making process. In obese patients, the subtalar AR is not recommended. In adolescents who need to improve sports performance, the CS screw had better results compared with other implants.     

Posterior Tibial Tendinopathy and Osteopenia as Primary Symptoms of Celiac Disease: A Case Report

This case report describes posterior tibial tendon (PTT) tendinopathy, valgus deformity with tenosynovitis, and osteopenia at the medial malleolus as the primary symptoms of a young patient with celiac disease (CD) without gastrointestinal symptoms. CD is an autoimmune condition that is a chronic inflammatory disorder of the small intestine triggered by ingestion of gluten in individuals with a particular genetic background. Without typical gastrointestinal symptoms, CD patients are often misdiagnosed or undiagnosed. The patient was diagnosed with CD by duodenal biopsy. He underwent a surgical procedure, including medial displacement calcaneal osteotomy, tenosynovectomy of the PTT and flexor digitorum longus (FDL), FDL transfer to the navicular for a pes planovalgus deformity, and drilling of the medial malleolus for a stress reaction. The mechanism of the PTT tear and associated heel valgus deformity was assumed to be related to the fact that his heel alignment on the affected side changed gradually from normal to valgus and pes planus owing to CD and mechanical stress, because his normal-side heel alignment was neutral before surgery and at final follow-up. His operated ankle was pain-free, with full range of motion, 1.5 years after surgery. The patient was able to restart running and exercise gradually. Foot and ankle specialists should consider the possibility of CD in patients presenting with a PTT tear without injury or trauma and osteopenia with no obvious reason.     

Reverse Sural Artery Flap for the Reconstruction of Chronic Lower Extremity Wounds in High-Risk Patients

Soft tissue defects in patients with chronic comorbidities place these patients at high risk for amputation, even when their underlying problems are controlled. The reverse sural artery flap is an effective technique for closing these defects and saving the limb. We retrospectively reviewed 15 consecutive high-risk patients who underwent a sural artery flap procedure between 2003 and 2005 as a final attempt to prevent having a below-the-knee amputation. All of our patients presented with at least 1 comorbidity, with a majority having multiple. Comorbidities in our patient population consisted primarily of diabetes mellitus with neuropathy, critical limb ischemia, end-stage renal disease, and various cardiomyopathies. All patients presented before surgical intervention with a longstanding history of chronic ulcerations that had failed multiple healing strategies. Ulcerations were located at various regions of the foot and ankle such as the heel, lateral malleolus, medial malleolus, and the lateral midfoot. Of those 15 procedures, three failed completely and two had complete dermal necrosis with viable adipose tissue that healed secondarily. The remaining ten flaps healed primarily. We used negative pressure therapy preoperatively in seven patients and postoperatively in five patients. We obtained a success rate of 80%. The reverse sural artery flap has many advantages over free flaps, which has made it a viable treatment option in chronic ulcerations that have failed conservative attempts.     

Extensive Implant Reaction in Failed Subtalar Joint Arthroereisis: Report of Two Cases

Foreign body synovitis with extensive granulomatous giant cell reaction to refractile polyethelene debris is a complication of subtalar arthroereisis not previously reported. We present two cases whereby STA-peg implants were used to treat bilateral painful flexible flatfoot deformities in children. Two boys, presented at 7 and 10 years of age, 2 years after STA-peg procedures and tendo-Achilles lengthening for painful flatfeet. They each had minimal subtalar motion and pain at the sinus tarsi. Radiographs demonstrated surgical defects in the calcaneus with surrounding high signal on the magnetic resonance imaging (MRI) in the subchondral bone of the calcaneus and talus. Both patients failed conservative management and had their implants removed with good relief of their pain. Histology was submitted at the time of implant removal. We present the radiographic and pathologic findings seen in these two patients with failed subtalar arthroereisis due to extensive implant reaction. The pathologic process seen in these patients is a previously unreported complication of this procedure. We do not recommend arthroereisis in the treatment of painful flexible flatfoot in children.     

Defining flatfoot.

Pes planus is a term frequently used in describing flatfoot; however, no study has objectively defined flatfoot. We evaluated the single leg stance footprint of 40 feet in 21 people with no history of foot problems, using pressure-sensitive film and a Harris mat. The medial and lateral aspects of the forefoot, midfoot, and hindfoot were assessed. The midfoot was further analyzed by dividing the medial midfoot force by the total midfoot force. The mean medial midfoot force/total midfoot force was 11.1% (SD = 6.5%). Pes planus was defined as the medial midfoot force/total midfoot force > 24.0% (mean + 2 SD). A population associated with pes planus (124 feet in 63 patients with Marfan syndrome) was then evaluated in the same fashion. Although the mean medial midfoot force/total midfoot force was not statistically different (16.0%), a distinct group of patients (25%) had forces that were outside the range of normal midfoot forces.     

Total contact casting and Keller arthoplasty for diabetic great toe ulceration under the interphalangeal joint

Interphalangeal (IP) ulcerations of the great toe are frequently encountered in neuropathic diabetic feet. While total contact casting is usually effective as a first line treatment, recalcitrant ulcers continue to present substantial management challenges. The authors retrospectively reviewed the results of Keller arthroplasty employed to accelerate ulcer resolution with total contact casting in fourteen patients with neuropathic ulcers under the great toe interphalangeal (IP) joint that were resistant to casting alone. These data were compared to a group of similar patients whose ulcers were successfully treated by non-operative measures. No operative complications were observed, and all ulcers healed within twenty-four days with no recurrence documented at an average follow-up of 26 weeks. In cases of resistant great toe IP plantar ulcers associated with hallux rigidus that have failed casting trials, this treatment method can be effective.     

Combination of Evans calcaneal osteotomy and STA-Peg arthroreisis for correction of the severe pes valgo planus deformity.

Twenty patients with 25 symptomatic severe flexible pes valgo planus were treated with a combined surgical technique. All patients underwent an Evans calcaneal osteotomy with allogenic bone graft and subtalar joint arthroreisis (STA-Peg) procedure. Adjunctive procedures as deemed necessary included Achilles tendon lengthening, navicular-cuneiform fusion, Lapidus first metatarsal cuneiform fusion, Cotton medial cuneiform plantarflexory wedge osteotomy with allogenic bone graft, plantarflexory medial cuneiform osteotomy, and excision of os tibiale externum. A retrospective pre- and postoperative radiographic evaluation revealed the following mean changes: lateral talo-first metatarsal angle, 16.9 degrees to -0.6 degrees; calcaneal cuboid abduction angle, 24.8 degrees-2.8 degrees; anterior posterior talocalcaneal angle, 25.3 degrees-15.4 degrees; talonavicular coverage angle, 22.7 degrees-5.2 degrees; calcaneal inclination angle, 10.6 degrees-18.6 degrees; talar declination angle, 32.4 degrees-16.4 degrees; lateral talocalcaneal angle, 18.3 degrees-5.2 degrees. A subjective questionnaire revealed that 100% of the patients stated they were satisfied or very satisfied with the surgery and achieved an average score of 93 based on a 100-point scale.     

Der kindliche Knick-Senk-Fuß

Flexible flatfoot in childhood is a common cause for repetitive consultations and the diagnosis is verified by the clinical examination. In most cases the findings are age-dependent variants of the norm and if asymptomatic there is no need for treatment. In the first decade of life symptomatic flexible flatfoot should initially be treated with shoe inserts. Further diagnostic steps are required once conservative treatment is unsuccessful or a rigid structural deformity is found in the clinical examination. The underlying reasons may be neuropathic or structural anatomical in origin. Lateral column lengthening as described by Evans or minimally invasive arthroereisis are well established surgical options but for arthroereisis the number of long-term studies is low. In general the indications for surgical and conservative therapy have to be judged with caution although parents often see an urgent need for treatment.     

Comparison of Extraosseous Talotarsal Stabilization Implants in a Stage II Adult-Acquired Flatfoot Model: A Finite Element Analysis

Subtalar arthroereisis has been proved to be an efficient method for correcting flexible adult flatfoot. However, the optimal sinus tarsi implant is still debated and yet to be determined. In the present study, we compared the biomechanical effects of type I and II sinus tarsi implants in stage II adult-acquired flatfoot deformity (AAFD). First, a finite element model of stage II AAFD was established in which virtual surgery of subtalar arthroereisis was simulated. The indexes of plantar stress distribution, peak von Mises of the medial and lateral columns, strain of the medial ligaments and plantar fascia, arch height, talo-first metatarsal angle, calcaneus pitch angle, talonavicular coverage angle, and hindfoot valgus angle were all compared and analyzed. The results of the present study have validated the stage II AAFD finite element model by comparing the simulation results with the same parameters measured from weightbearing radiographs in the midstance phase. All the indexes showed that both types of arthroereisis can lower the plantar pressure and the strain of the medial ligaments that support the medial longitudinal arch and can shift the load of the medial column to the lateral column. They can also help to correct the deformity and restore the arch. However, the type II sinus tarsi implant design exhibited a more obvious effect than that of type I.     

Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults

BACKGROUND: The successful correction of flatfoot in children through lengthening of the lateral column, osteotomy of the medial cuneiform, and advancement of the posterior tibial tendon led to the introduction of similar procedures to treat acquired pes planovalgus secondary to attrition or rupture of the posterior tibial tendon in adults. However, to our knowledge, no study has been published documenting whether these procedures are effective treatment for acquired flatfoot in adults. METHODS: The functional and radiographic results of complex reconstruction of a painful, flexible flatfoot associated with attrition or rupture of the posterior tibial tendon were evaluated in thirty-six patients (forty-one feet) with use of a detailed questionnaire, a comprehensive physical examination, and a review of the radiographs and the medical record. RESULTS: At a mean of thirty-four months (range, twenty-four to fifty months) postoperatively, thirty-six feet (88 percent) were less painful compared with the preoperative status or were pain-free and five of the six parameters that had been used to assess correction of the deformity radiographically had improved significantly (p<0.0001). Eight feet (20 percent) had a non-union at the calcaneocuboid joint, and thirteen feet (32 percent) had anesthesia or paresthesia of the sural nerve. Twenty-nine feet (71 percent) had had additional operations, including removal of hardware from twenty feet; bone-grafting to treat a nonunion at the site of the calcaneocuboid arthrodesis and revision of the internal fixation in four feet; a medial displacement calcaneal osteotomy because of recurrent valgus angulation of the hindfoot in two feet; and a Lapidus procedure because of a hypermobile tarsometatarsal joint with hallux valgus, a triple arthrodesis because of a nonunion at the site of the calcaneocuboid arthrodesis associated with loss of correction, and a dorsiflexion-abduction wedge osteotomy through the site of the calcaneocuboid arthrodesis (which had healed) for alignment of an overcorrected foot in one foot each. The outcomes of the procedures in thirty-five feet (85 percent) were rated by the patients as satisfactory, and thirty-three (92 percent) of the thirty-six patients (thirty-eight [93 percent] of the forty-one feet) stated that they would have the procedure again if the circumstances were similar. CONCLUSIONS: Despite the high prevalence of postoperative complications, most of our patients were satisfied with the result of the procedure after the short duration of follow-up. We believe that the relief of pain and the restoration of function achieved through effective correction of the severe pes planovalgus deformity account for the satisfactory outcomes in our patients.     

Flatfoot overview

The pathologic condition pes planus has been noted in orthopedic and podiatric literature for a number of years. The many scientific and technical terms assigned to the condition have become synonymous, emerging in the vernacular as the common term "flatfoot." In the broadest sense, flatfoot refers to the weight-bearing or nonweight-bearing foot that exhibits collapse of the medial column. A discussion of the history and attitudes toward flatfoot is presented.