Osteotomies in the midfoot and the calcaneal part of the foot in relapsed clubfoot

There are no clear guidelines on the treatment of relapsed clubfoot, which is a relatively frequent and difficult problem in paediatric orthopaedics. Numerous operative interventions are mentioned in the literature as suitable for correction of a residual deformity of the food. There are numerous soft tissue procedures (release operations, tendon extensions, tendon transfers and redressement by means of a fixateur externe) and osseous interventions (osteotomies, arthrodeses) that can be carried out in isolation or in combination. In the present article two types of osteotomy are described that make it possible to correct the most frequent forms of relapsed clubfoot: combined closing wedge cuboid and opening wedge cuneiform osteotomy for correction of adductus and supination of the forefoot and the calcaneal osteotomy after Dwyer for correction of varus position of the calcaneal part of the foot. The combined osteotomy in the midfoot involves shortening of the lateral ray with simultaneous lengthening of the medial ray, with the wedge out of the cuboid bone inserted into the medial cuneiform bone, which leads mainly to correction of the adductus, but does also make it possible to achieve partial correction of the supination with an osteotomy right through the cuneiform bone. In the case of rigid foot deformities it is advisable to carry out preliminary stretching by means of a fixateur externe, while in the case of a bean-shaped foot a combination of osteotomy and medial and lateral release is recommended. Results of a follow-up study of our own patients treated with this operation have shown that no revision operations were necessary in any of the patients with idiopathic clubfoot. Other types of osteotomy described in the literature as suitable for correction of residual forefoot adductus and supination are also mentioned in this paper. Thecalcaneal osteotomy after Dwyer, for which a lateral approach is always used, generally leads to satisfactory correction of varus position of the calcaneal part of the foot. It the calcaneus is found to have a short posterior part this osteotomy is modified so that instead of taking the form of a wedge osteotomy with lateral closing it is followed by a lateral displacement. In this way it is possible to prevent making the already short posterior calcaneus even shorter. Both the combined midfoot osteotomy and the calcaneal osteotomy after Dwyer can be performed alone or in combination with each other or with different operative interventions.     

Posterior calcaneal osteotomy with wedge: cadaver testing of a new procedure for insufficiency of the posterior tibial tendon.

Insufficiency of the posterior tibial tendon is challenging to treat. When the deformity is flexible, treatment options have included tendon transfer, often combined with a medial slide calcaneal osteotomy and/or a lengthening of the lateral column. Posterior calcaneal osteotomy has been shown to give correction, although not full correction. Lengthening of the lateral column also has been shown to give correction and has been used in the more severe flexible deformities, but it involves either fusion of the calcaneocuboid joint or risk of arthritis at this joint. An osteotomy combining the calcaneal medial slide with a lengthening of the lateral column at the same osteotomy site has been tested in the laboratory. This combined osteotomy provides a lengthening of the lateral column, but it is positioned away from the calcaneocuboid joint. In this study, the osteotomy was compared with a medial slide calcaneal osteotomy and an Evans lengthening of the lateral column, using a cadaver flatfoot model. Radiographic measurements were made to evaluate correction of the planovalgus deformity after each of these procedures. There was statistically significant improved correction with the new osteotomy compared with that in a standard medial slide, and correction was comparable to that in the lengthening of the lateral column. This combined osteotomy may be a reasonable alternative when more correction is desired than can be obtained from a medial slide alone and when the surgeon wishes to avoid an osteotomy near the calcaneocuboid joint.     

Operative treatment of the difficult stage 2 adult acquired flatfoot deformity

In the flexible pes planovalgus deformity of stage 2 posterior tibial tendon dysfunction, osteotomies appear to have a significant role in operative management by restoring more normal biomechanics, allowing tendon transfers to function successfully. The options when considering osteotomies for stage 2 disease include lateral column lengthening, medial displacement calcaneal osteotomy, and combined double osteotomy technique. The tight Achilles tendon should be lengthened as well. Lateral column lengthening has been used extensively for treatment of flexible flatfeet. It has been shown clinically and radiographically to address all 3 components of the pes planovalgus deformity present in stage 2 posterior tibial tendon dysfunction. Lateral column lengthening is used in combination with a medial soft tissue rebalancing procedure. The mechanism of action is still speculative but clearly is not owing to tensioning of the plantar fascia as previously thought. Despite the excellent correction of foot posture obtained by use of lateral column lengthening for adult acquired flatfoot, many clinicians have reservations about its use because of reported secondary increases in the calcaneocuboid joint pressures. This increase in pressure has been shown to occur experimentally, increasing the potential risk of calcaneocuboid joint arthrosis. This experimental evidence is supported by Phillips' study of the original Evans procedure, which resulted in a 65% incidence of calcaneocuboid joint arthrosis at 13-year follow-up. Mosier-LaClair et al reported a 14% incidence of calcaneocuboid joint arthritis at 5-year follow-up after double osteotomy for stage 2 posterior tibial tendon dysfunction. This incidence has not been proved true in the remainder of the literature surrounding this procedure and its use for flexible flatfoot. To address the concern regarding potential calcaneocuboid arthrosis secondary to lateral column lengthening, calcaneocuboid joint distraction arthrodesis has been explored as an alternative technique. The results show good initial correction, but the follow-up is extremely limited, and one study reported loss of correction over time. Longer follow-up is needed to determine whether or not this technique would provide the lasting correction seen with the Evans procedure. Calcaneocuboid joint lengthening arthrodesis does result in some limitation of adjacent hindfoot motion. Although this limitation is significantly less compared with talonavicular and subtalar joint fusion, this procedure may result in increased local pressures and arthrosis of the midfoot or hindfoot. For the above-mentioned reasons, longer follow-up studies are needed to determine whether calcaneocuboid joint distraction arthrodesis would prove to be a reliable and safe alternative for lateral column lengthening in the treatment of adult acquired flatfoot. Medial displacement calcaneal osteotomy has been used for correction of the pes planovalgus foot in posterior tibial tendon dysfunction. It has been used extensively for the surgical treatment of flexible flatfoot throughout the literature. Medial displacement osteotomy, in combination with flexor digitorum longus tendon transfer, can address all 3 components of adult acquired flatfoot. It does not recreate the medial longitudinal arch in all patients, however. Although the mechanism of action of medial displacement calcaneal osteotomy is unknown, it has been proved that it is not through the tightening of the plantar fascia in a windlass effect as previously thought. In contrast to lateral column lengthening, however, medial displacement calcaneal osteotomy does address the deforming valgus force of the Achilles tendon. Functionally transferring the insertion of the Achilles tendon medially removes a constant valgus-deforming force. The osteotomy can then act as a double tendon transfer with the flexor digitorum longus tendon to aid in foot inversion. For stage 2 posterior tibial tendon insufficiency, the authors favor the combination double osteotomy technique with a flexor digitorum longus tendon-to-medial cuneiform tendon transfer, débridement or removal of the posterior tibial tendon, and percutaneous heel cord lengthening. Early results were positive at 1.5 years after surgery with respect to maintenance of correction and functional improvement with no evidence of calcaneocuboid arthrosis. More recently, the intermediate 5-year follow-up has been assessed for this combination of procedures, and similar results were found. There was a high rate of patient satisfaction and functional improvement, and surgical correction of the flatfoot deformity was maintained and compared favorably with the contralateral normal foot. Although the intermediate follow-up found a 14% incidence of calcaneocuboid arthrosis, 50% of these patients had preoperative evidence of calcaneocuboid joint arthritis. (ABSTRACT TRUNCATED)     

Plantar Fascia Release Through a Single Lateral Incision in the Operative Management of a Cavovarus Foot: A Cadaver Model Analysis of the Operative Technique

Plantar fascia release and calcaneal slide osteotomy are often components of the surgical management for cavovarus deformities of the foot. In this setting, plantar fascia release has traditionally been performed through an incision over the medial calcaneal tuberosity, and the calcaneal osteotomy through a lateral incision. Two separate incisions can potentially increase the operative time and morbidity. The purpose of the present study was threefold: to describe the operative technique, use cadaveric dissection to analyze whether a full release of the plantar fascia was possible through the lateral incision, and examine the proximity of the medial neurovascular structures to both the plantar fascia release and calcaneal slide osteotomy when performed together. In our cadaveric dissections, we found that full release of the plantar fascia is possible through the lateral incision with no obvious damage to the medial neurovascular structures. We also found that the calcaneal branch of the tibial nerve reliably crossed the osteotomy in all specimens. We have concluded that both the plantar fascia release and the calcaneal osteotomy can be safely performed through a lateral incision, if care is taken when completing the calcaneal osteotomy to ensure that the medial neurovascular structures remain uninjured.     

The contribution of the medial calcaneal osteotomy to the correction of flatfoot deformities

HYPOTHESES/PURPOSE: The success of the medial displacement calcaneal osteotomy in correcting flatfoot deformities is likely to be the result of a shift of the Achilles tendon forces on the hindfoot. The purpose of this study was twofold: 1) to define the contribution of the Achilles tendon to the flatfoot deformity, and 2) to define the effect of a calcaneal medial displacement osteotomy. METHODS: We used six different experimental dynamic stages: 1) intact foot without Achilles loading; 2) intact foot with Achilles loading; 3) flatfoot without medial calcaneal displacement osteotomy and without Achilles loading; 4) flatfoot without medial calcaneal displacement osteotomy but with Achilles loading; 5) flatfoot with medial calcaneal displacement osteotomy but without Achilles loading; and 6) flatfoot with medial calcaneal displacement osteotomy and with Achilles loading. The experimental flaffoot was developed by releasing the posterior tibial tendon, spring ligament, and plantar fascia and applying 7,000 cycles of axial fatigue load (range, 700 to 1,400 N; 1-Hz frequency). To simulate the phase of midstance, the peroneus longus, peroneus brevis, flexor digitorum longus, and flexor hallucis longus tendons were grasped by clamps, connected to pneumatic actuators, and loaded with precalculated forces. Anteroposterior and lateral radiographs were obtained for each stage on which the following measurements were made: talonavicular coverage angle, talar-first metatarsal angle, talocalcaneal angle, and height of the medial cuneiform. These measurements were compared with a one-way ANOVA. RESULTS: Between stages 1 and 2, all measurements were statistically insignificant. Between stages 3 and 4, for all measurements, Achilles tendon loading aggravated the flatfoot deformity (p < 0.05). After medial calcaneal osteotomy (stages 5 and 6), the Achilles tendon contributed less to the arch-flattening. We found that the medial displacement osteotomy plays an important role in reducing and/or delaying the progress of flatfoot deformity. CONCLUSIONS/SIGNIFICANCE: In the flatfoot, loading of the Achilles tendon increases the deformity. Medial calcaneal osteotomy significantly decreases the arch-flattening effect of this tendon and therefore limits the potential increase of the deformity.     

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.     

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.     

Management of the Recurrent Deformity in a Flexible Foot Following Failure of Tendon Transfer: Is Arthrodesis Necessary?

Recurrent deformity in the adult flatfoot following previous tendon transfer represents a challenging treatment dilemma for even the most experienced foot and ankle surgeon. The evaluation must be comprehensive, resulting in a clear understanding of the extent to which previous surgical procedures either failed to address the deformity initially or led to progressive recurrence. Particularly in younger, more high-demand patients, every effort to preserve normal joint mechanics while alleviating pain and restoring functional alignment must be made. LCL coupled with MDCO and a comprehensive medial soft tissue reconstruction represents a joint-sparing modality for approaching even the most challenging flexible flatfoot deformities. Care to avoid overcorrection, particularly with a double calcaneal osteotomy, must be taken. In the presence of progressive degenerative changes or patient factors such as morbid obesity and advanced age, hindfoot arthrodesis, particularly realignment subtalar joint arthrodesis, provides a technically straightforward, predictable means of achieving a pain-free plantigrade foot. Talonavicular arthrodesis and double arthrodesis, although reliable means of achieving pain relief and functional alignment, do sacrifice considerably more hindfoot motion and are likely more appropriately reserved for elderly, low-demand patients or those with more severe fixed deformities.     

Young's procedure for the treatment of valgus flatfoot deformity caused by a posterior tibial tendon dysfunction, stage II

Young’s procedure contains an action mechanism that works better than other techniques on the pathophysiology of FFD. It respects the anatomy and biomechanics of the foot to reach the necessary muscular balance. The benefits of this technique include that the ATT is not detached, so its function mechanism is still active; the new trajectory of the ATT provides a powerful sling function at the level of the navicular; and the horizontal trajectory of the ATT and the osteoperiosteal flaps constitute a powerful inner capsular–tendinous–ligamentous support. What is more, an insufficiency of the ATT is created, which results in a predominance of the peroneus lateral longus, that descends and prones the forefoot. Additional procedures, such as medial displacement calcaneal osteotomy, should be considered to correct the entire deformity. The combination of these techniques do not sacrifice the joint mobility.     

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.     

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.     

Medial-sided bony procedures: why, what, and how?

The adult acquired flat foot deformity is a common clinical entity; rupture or incompetence of the posterior tibial tendon is a frequent cause. The natural history is characterized by progressively worsening deformity and early recognition is important. Nonoperative treatment can alleviate symptoms and control progression in nearly all stages of the disease. Should this fail to control symptoms or prevent progression of deformity, operative intervention should be considered. In stage I disease, exploration and debridement, with or without FDL tendon transfer, is a viable option. In stage II disease, the PTT becomes elongated and the medial soft tissues become attenuated. Exploration and debridement of the PTT is performed, but frequently a FDL tendon transfer or side-to-side anastomosis is required. It has been shown that soft tissue procedures alone may fail to correct deformity and this can lead to deterioration of results over time. Combined procedures, including soft tissue reconstructions to restore PTT function and bony procedures to correct deformity, have become popular. When the PTT is intact and degeneration or elongation is minimal, as in stage I or early stage II disease, reconstruction of the medial column with advancement of an osteoperiosteal flap based on the PTT insertion, combined with selective arthrodeses of the medial column, may be considered. These procedures have been well described for the treatment of symptomatic flexible flat foot in children and adolescents but experience in adults is lacking. Although it may be theoretically possible to passively correct hindfoot valgus with these procedures, it seems prudent to limit the indications to patients who have early disease accompanied by an isolated midfoot sag. In more advanced stage II disease, correction of deformity with a tendon transfer combined with a medial displacement calcaneal osteotomy or a lateral column lengthening is currently recommended. This allows for correction of deformity while sparing the hindfoot joints, which may be particularly important in young or active patients. Short-term studies showed excellent results, but long-term results are lacking. In stage III disease, in which the deformity is fixed, arthrodesis is the procedure of choice. Isolated talonavicular arthrodesis has been shown to correct nearly all aspects of the deformity with long-lasting results. This procedure results in nearly complete lack of hindfoot motion and may predispose the patient to adjacent joint arthrosis. In a patient who has stage III disease with arthrosis confined to the talonavicular joint, isolated talonavicular arthrodesis may be considered. This clinical situation is rare, and, in most patients, a triple arthrodesis is probably preferred. If residual deformity is present after these procedures, it must be addressed. Residual medial column instability may be addressed by adding a selective arthrodesis of the naviculo-cuneiform or first metatarsocuneiform joint, whereas residual forefoot varus or supination may be addressed with selected midfoot fusions with or without a cuneiform osteotomy.     

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.     

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.     

Spectrum of operative treatments and clinical outcomes for atraumatic osteoarthritis of the tarsometatarsal joints

BACKGROUND: The purpose of this study was to identify subtypes of atraumatic osteoarthritis of the tarsometatarsal joints based on accompanying foot deformities and to determine whether concurrent procedures done for each subtype were effective. METHODS: The study included 59 patients (67 feet) with atraumatic tarsometatarsal joint osteoarthritis treated with tarsometatarsal fusion. The average patient age was 60.2 years with 40.6 months followup. Patients were evaluated with radiographs, the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, the Foot Function Index, and the Short Form-36 Health Survey Questionnaire (SF-36). RESULTS: Four main subtypes were identified based on associated foot deformities: pes planovalgus (27), hallux valgus (11), in-situ without deformities (eight), and rockerbottom (five). Plantar-medial closing-wedge resection was used to correct rockerbottom deformity. For pes planovalgus deformity, a medial sliding calcaneal osteotomy was done. Lateral column lengthening with medial sliding calcaneal osteotomy was done for tarsometatarsal osteoarthritis with severe pes planovalgus, and triple arthrodesis was done for rigid pes planovalgus. Tarsometatarsal osteoarthritis with hallux valgus deformity was corrected with the Lapidus procedure. There were 29 complications, most commonly sesamoid pain. The pes planovalgus group showed significant radiographic improvements in four of five parameters measured. AOFAS scores improved from retrospectively assigned preoperative 34.1 points to postoperative 83.9 points. The Foot Function Index showed a high satisfaction rate (86.6%). SF-36 scores averaged 50.6 postoperatively. CONCLUSIONS: When feet with atraumatic tarsometatarsal osteoarthritis are classified into four main categories based on associated deformities, appropriate concurrent procedures can be done with high satisfaction and improved function scores. Pes planovalgus feet, in particular, may benefit from concurrent procedures with improved radiographic measures.     

Medial ankle instability

Medial instability is suspected on the basis of a patient's ankle feeling like it is "giving way," especially medially, when walking on uneven ground, downhill, or down stairs, pain at the anteromedial aspect of the ankle, and sometimes pain in the lateral ankle, especially during dorsiflexion of the foot. A history of a chronically unstable feeling that is manifested by recurrent injuries with pain, tenderness, and sometimes bruising over the medial and lateral ligaments, is considered to indicate combined medial and lateral instability that is believed to result in rotational instability of the talus in the ankle mortise. Pain on the medial gutter of the ankle and a valgus and pronation deformity of the foot are hallmarks of the disorder. The deformity typically can be corrected by the activation of the posterior tibial muscle. In contrast to stress radiographs, arthroscopy is a helpful diagnostic tool in verifying medial instability; it proved that the lateral ankle ligaments also can be involved. The treatment for symptomatic medial instability of the ankle might include reconstruction of all involved ligaments at the medial, and, if necessary, the lateral ankle. In the case of progressed foot deformity or bilateral long-standing valgus and pronation deformity of the foot, an additional calcaneal lengthening osteotomy might be considered. A classification of the instability into three types has been helpful for determining surgical treatment and the after treatment. This treatment concept provides high patient satisfaction and reliable clinical results.     

Posterior calcaneal osteotomy. Effect, technique, and indications

Posterior calcaneal osteotomy is a technically simple procedure that may be used to correct frontal, transverse, or sagittal plane displacement of the calcaneus associated with flatfoot deformity. In selected individuals, subluxation about the oblique axis of the midtarsal joint may be stabilized. Forefoot supinatus may be expected to reduce secondary to the reduction of heel valgus obtained, although with deformity chronicity, adaptive midtarsal joint changes may necessitate medial column stabilization. Posterior calcaneal osteotomy increases rotational stability of the subtalar joint in a supinatory direction. In addition, displacement of the posterior calcaneal fragment effects a dynamic correction force by translocation of the Achilles tendon and its posterior relation to the axis of the subtalar joint.     

Distal calcaneal osteotomy in resistant talipes equinovarus

In resistant talipes equinovarus deformity, posterior medial release alone may be inadequate. Procedures involving the lateral column are sometimes necessary. Thirty-nine patients were treated by a distal calcaneal osteotomy and plantar fasciotomy. Good results were obtained in 30 of 39 patients; two had fair results and seven of 39 had poor results. Of the lateral column procedures, distal calcaneal osteotomy avoids the articular surfaces and provides for easier rotational positioning and correction of the forefoot. Older patients who have had multiple operations and, potentially, more severe pathology do not do well with this procedure. Preoperative evaluation of certain radiographic parameters is important in patient selection for these procedures.     

Calcaneocuboid joint pressure after lateral column lengthening in a cadaveric planovalgus deformity model

The purpose of this study is twofold: first, to measure the joint contact pressure across the calcaneocuboid joint in a planovalgus deformity and compare the results to pressures measured in a normal foot; and second, to determine the change in pressure across the calcaneocuboid joint after an Evan's-type calcaneal lengthening osteotomy. The effect of this procedure on the calcaneocuboid joint was evaluated using seven cadaver feet to measure peak pressure across the calcaneocuboid joint under a constant load. Each foot was sectioned medially to reproduce a deformity consistent with an adult, acquired flatfoot. Each flatfoot deformity was then corrected using a ten-millimeter lateral column lengthening osteotomy. Joint pressures were measured in the normal foot, the created flatfoot and then in the corrected flatfoot. Peak pressures across the joint increased significantly from baseline in the flatfoot (p <0.05). However, the change in pressure from the flatfoot to the corrected foot was not significant, and in some cases peak pressures in the corrected foot were actually lower than in the flatfoot. These findings indicate that calcaneal lengthening through an Evan's osteotomy does not increase pressure across the calcaneocuboid joint beyond physiologic loads in the flatfoot.     

Correction of moderate and severe acquired flexible flatfoot with medializing calcaneal osteotomy and flexor digitorum longus transfer

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: In a cadaver model, the effectiveness of different procedures on radiographic and pedobarographic parameters varies with the severity of an acquired flatfoot deformity.