The cavovarus/supinated foot deformity and external tibial torsion: the role of the posterior tibial tendon

This article describes one surgeon's experience in pediatric orthopedic surgery. His experiences treating cavovarus/supinated foot deformities and external tibial torsion are described.     

The influence of mediolateral deformity,tibial torsion,and foot position on femorotibial load

Summary The influence of mediolateral deformity, tibial torsion, and different centers of foot support was studied with a three-dimensional computer model that incorporates the significant muscles of the lower extremities needed for quasi-static walking. This theoretical method avoids the variability in gait pattern from the pain and discomfort associated with deformity in patients. The study illustrates the possible importance of the muscle force on the load across the knee and ankle. High strains in the medial gastrocnemius and the medial hamstring created particularly high loads in the medial compartment of the knee. Internal torsion and varus deformity were associated with the highest loads in the medial compartment of the knee, although the peak load for each deformity occurred in different phases of the gait cycle. Both external torsion and valgus deformity generally decreased the load in the medial compartment, but early in the gait cycle external torsion increased the loads on the medial side. In addition, when the center of support of the body was in the forefoot, the loads through the knee were lower than when foot support was at the heel. As expected, if the center of support was on the lateral foot line, the lateral compartment was subjected to more load and, conversely, when the center of support was on the medial part of the foot the medial compartment of the knee was more loaded. Although the predicted forces agree well with those found with other methods, we think that the model is best used to measure the direction of influence of specific factors.     

Correction of tibial deformity in adults

 This report from five hospitals in Japan describes the results of correcting adult tibial deformities using external fixation. There were 49 patients with 59 lower limb deformities, with trauma being the most common cause of the deformity. Varus angulation was the most common deformity, and the most common magnitude was 11°–30°. Twenty-two patients had a leg-length discrepancy. The aim of the correction was to normalize both the mechanical axis and the inclination of the knee and ankle joints. In 63% of the patients corrections were performed gradually during bone lengthening or acutely after bone lengthening. Altogether, 71% of the patients were completely corrected, and no leg-length discrepancies remained after correction in 47%. Complications were encountered in 22 patients, about half of which were pin tract infections, 28% refractures, and the remainder delayed consolidation or fixator failure. There were no neurological or circulatory complications. The average fixation duration was 9 months. The average hospital charges were 3 740 000 yen in bilateral correction patients and 1 940 000 yen in unilateral correction patients. External fixation can correct not only the mechanical axis and joint inclination but also leg-length discrepancy simultaneously. Received: June 10, 2002 / Accepted: January 14, 2003 RID="*" ID="*" Offprint requests to: W. Sato     

Subtalar joint arthrodesis for postpoliomyelitis valgus foot deformity.

The purpose of this study was to evaluate the results of full versus partial subperiosteal fibular bone graft for subtalar joint arthrodesis in patients with pes planovalgus foot deformity associated with residual polio myelitis. A prospective study was carried out on 16 patients with postpoliomyelitis valgus foot deformity secondary to invertor muscle paralysis. All patients were treated by peroneal tendon transfer to the medial metatarsals and subtalar extra-articular arthrodesis. In 12 patients, subperiosteal partial fibular graft was used, while four patients received a full fibular graft. Patients were followed for an average of 2.5 years following surgery and were assessed using Axer's criteria. Partial fibular subperiosteal bone grafts (n = 12) were not associated with any major biomechanical sequalae of the ankle and foot, while full fibula grafts had 75% (n = 4) adverse sequelae.     

Correction of valgus knee deformity with a supracondylar V osteotomy

Valgus deformities at the knee can be successfully corrected with V-shaped supracondylar osteotomy. The advantages of this relatively simple technique are low morbidity, good stability with early weight-bearing, no need for internal fixation, and ability to adjust alignment with postoperative cast. Healing is relatively rapid (two months), and the range of motion returns (two months after cast removal) to preoperative values. This technique proved useful for deformities in both young and old patients with osteoarthritis. This is a preliminary report of the surgical technique, postoperative management, and short-term results of a prospectively evaluated series of 14 consecutive cases.     

Correction of cavovarus foot deformity in Charcot-Marie-Tooth disease

Operative correction of cavovarus foot deformity in Charcot-Marie-Tooth disease (CMT) is challenging. This progressive peripheral sensory and motor neuropathy commonly involves the forefoot, midfoot, hindfoot, and toes. The authors present a new imaging technique that allows the surgeon to assess the flexibility of the hindfoot in patients with CMT to determine the best operative procedure to correct the deformity. Twenty-five patients (41 feet) with CMT and cavovarus foot deformity were evaluated and a new radiographic technique was studied in some of these patients to determine the usefulness of this imaging modality. The authors believe that this new imaging method will aid in determining the optimal operation for correcting this complex deformity.     

Assessment of tibial torsion and rotational deformity with a new fluoroscopic technique

No conventional technique for routine assessment of tibial torsion and the twist of the distal versus the proximal articular axis of the tibia after reduction of a fracture has yet gained general acceptance. Considering the demands for availability, simplicity, applicability, and precision, a new method employing a mobile C-arm fluoroscope equipped with a protractor is used for assessment. After fracture reduction and stabilization by a mechanical method of fixation or by a conservative method with a plaster cast, the rotational situation of the tibia can be determined before the patient leaves the operating room. Measurements can be performed under sterile conditions. The method was applied clinically and in a study of tibial torsion in normal adults. The standard error of a single measurement was less than 1 degree. The maximum difference in tibial torsion between the legs of the same normal individual reached 15 degrees.     

Cavus deformity of the foot after fracture of the tibial shaft.

Twenty-three cases of claw foot with limited talocrural and subtalar mobility were the result of muscle contracture of the leg after tibial-shaft fracture. A roentgenographic study including arteriography was performed. It was concluded that the typical short cavus foot is due to fibrous contracture of the muscles in the deep posterior compartment caused by vascular damage, swelling in the deep posterior compartment, or severe muscle laceration. On physical examination the distance between the lateral malleolus and the Achilles tendon was shortened in comparison with the sound side in all cases. This was found to be caused by dorsiflexion in the talocrural joint coincident with adduction in the mid-tarsal joint. The angulation of the foot forced the patients to rotate the leg outward in order to get the feet in parallel position for walking. This deformity could be misinterpreted as an inward malrotation of the tibial fracture. In severe cases a derotating three-dimensional wedge osteotomy of the distal part of the tibia was performed with promising results.     

Correction of hallux valgus deformity using the center of rotation of angulation method

Background  To correct a hallux valgus (HV) deformity quantitatively and prevent unexpected postoperative deformity, the center of rotation of angulation (CORA) method was applied during HV surgery. To correct a hallux valgus (HV) deformity quantitatively and prevent unexpected postoperative deformity, the center of rotation of angulation (CORA) method was applied during HV surgery. Methods  To create a normal foot model, radiographs of 64 normal female feet were measured. Points A and B were defined as the intersection of the intermetatarsal angle and the HV angle. CORA1 and CORA2 were defined as the intersection of the axes of the first metatarsal and the first proximal phalanx in the normal and HV models, respectively. Procedures to correct HV deformity using the CORA method were devised and were applied to HV feet, which underwent a focal dome osteotomy or medial wedge osteotomy. Results  Point A was 2.3 times the length of the second metatarsal proximally from the top of the second metatarsal head, and point B was 0.17 times the length of the first metatarsal proximally from the top of the first metatarsal head. Two methods were used to correct the deformity. With one method, a focal dome osteotomy was performed at the first metatarsal on the circle at the CORA1 and the distal fragment was moved to the standard first metatarsal axis. The first proximal phalanx was then moved around the metatarsal head to the standard axis of the first proximal phalanx at the CORA2. With the other method, a medial wedge osteotomy was performed on or proximal to the CORA2, and the distal fragment was moved to the first standard metatarsal axis. Conclusions  We propose a preoperative plan to use the CORA method to correct deformities that prevent translation of the axis or an angulation deformity. HV deformity can be corrected effectively using the CORA method.     

Reliability and validity of measures of hammer toe deformity angle and tibial torsion

BackgroundMeasures of second–fourth metatarsophalangeal joint (MTPJ) angle (indicator of hammer toe deformity) and clinical measures of tibial torsion have limited evidence for validity and reliability. The purposes of this study are to determine: (1) reliability of using a 3D digitizer (Metrecom) and computed tomography (CT) to measure MTPJ angle for toes 2–4; (2) reliability of goniometer, 3D digitizer, and CT to measure tibial torsion; (3) validity of MTPJ angle measures for toes 2–4 using goniometry and 3D digitizer compared to CT (gold standard) and (4) validity of tibial torsion measures using goniometry and 3D digitizer (Metrecom) compared to CT (gold standard).MethodsTwenty-nine subjects participated in this study. 27 feet with hammer toe deformity and 31 feet without hammer toe deformity were tested using standardized gonimetric, 3D digitizer and CT methods. ICCs (3,1), standard error of the measurement (SEM) values, and difference measures were used to characterize intrarater reliability. Pearson correlation coefficients and an analysis of variance were used to determine associations and differences between the measurement techniques.Findings3D digitizer and CT measures of MTPJ angle had high test–retest reliability (ICC = 0.95–0.96 and 0.98–0.99, respectively; SEM = 2.64–3.35° and 1.42–1.47°, respectively). Goniometry, 3D digitizer, and CT measures of tibial torsion had good test–retest reliability (ICC = 0.75, 0.85, and 0.98, respectively; SEM = 2.15°, 1.74°, and 0.72°, respectively). Both goniometric and 3D digitizer measures of MTPJ angle were highly correlated with CT measures of MTPJ angle (r = 0.84–0.90, r = 0.84–0.88, respectively) and tibial torsion (r = 0.72, r = 0.83). Goniometry, 3D digitizer, and CT measures were all different from each other for measures of hammer toe deformity (p < 0.001). Goniometry measures were different from CT measures and 3D digitizer measures of tibial torsion (p < 0.002). CT measures and 3D digitizer measures of tibial torsion were similar (p = 0.112).InterpretationsThese results suggest that 3D digitizer and CT scan measures of MTPJ angle and goniometric, 3D digitizer, and CT scan measures of tibial torsion are reliable. Goniometer and 3D digitizer measures of MTPJ angle and tibial torsion measures are highly correlated with the gold standard CT method indicating good validity of measures, but the measures are not interchangeable.     

Hallux valgus deformity of foot with tumoral calcinosis: An unusual presentation

Tumoral calcinosis is an uncommon disorder and characterized by development of calcified masses within the soft tissues near the large joints such as the hip, elbow, and shoulder and rarely occurs in the foot. We report a case of tumoral calcinosis at the first meta-tarso-phalangeal (MTP) joint of foot with hallux valgus deformity associated with bunion which required resection. Surgical excision of the calcific mass alone, without surgery to the minimal hallux valgus, resulted in resolution of symptoms, without recurrence of the lesion. Subsequently, speculative etiology, differential diagnostic considerations as well as the therapeutic interventions for tumoral calcinosis are discussed taking into consideration the current literature. We conclude that tumoral calcinosis should be considered in the differential diagnosis of a painful mass that develops in the small joints of the foot.     

Bipartite tibial sesamoid and hallux abducto valgus deformity: a previously unreported correlation.

A retrospective radiographic study was undertaken to determine the incidence of a bipartite tibial sesamoid and its relationship in hallux abducto valgus (HAV) deformity. It was found that the incidence of a bipartite tibial sesamoid associated with HAV deformity was twice as frequent than a bipartite tibial sesamoid in a general foot population. The authors conclude that the tibial sesamoid plays an important role in the development of HAV deformity.     

Correction of tibial deformity in Paget's disease using the Taylor spatial frame

A 64-year-old man presented with a severe deformity of the tibia caused by Paget's disease and osteoarthritis of the ipsilateral knee. Total knee replacement required preliminary correction of the tibial deformity. This was successfully achieved by tibial osteotomy followed by distraction osteogenesis using the Taylor spatial frame. The subsequent knee replacement was successful, with no recurrence of deformity.     

Correction of hallux valgus deformity with distal soft tissue realignment and proximal metatarsal osteotomy

Abstract Fifty moderate to severe hallux valgus deformities were corrected with a distal soft tissue realignment and proximal crescentic metatarsal osteotomy. With an average follow-up of 5.6 years, 40 feet (80%) were pain free and 42 (84%) caused no functional limitation. The average hallux valgus angle improved from 38.2° preoperatively to 12.4° at follow-up. The average intermetatarsal angle improved from 15.4° to 6.8°. The arch of motion of the first metatarsophalangeal joint was 75° preoperatively and 62° at follow-up. According to the AOFAS scoring system, 29 results (58%) were excellent, 14 (28%) good, 2 (4%) fair and 5 (10%) poor. The 5 poor results were attributed to recurrence of hallux valgus (2 cases), stiffness (1), hallux varus (1) and malunion of the osteotomy in dorsiflexion (1). The incidences of hallux varus and malunion in dorsiflexion were 8% and 14%, respectively. This technique is valuable in correction of moderate to severe hallux valgus deformities.     

Correction of ankle valgus deformity secondary to multiple hereditary osteochondral exostoses with Ilizarov

The following case report highlights basic aspects of Multiple Hereditary Osteochondral Exostoses (MHOCE) and discusses the successful treatment of an adult with ankle pain secondary to growth arrest and foreshortening of the fibula. Two salient features include the age of the patient at presentation and the success of the procedure. Symptomatic valgus deformities of the ankle secondary to MHOCE are normally corrected during adolescence, prior to physeal closure. Reducing the ankle mortise by distally displacing the fibula and correcting rotational and angular ankle deformities with Ilizarov external fixation improved this patient's ankle function and relieved his pain.     

Wedge-shaped distal tibial epiphysis in the pathogenesis of equinovalgus deformity of the foot and ankle in tibial lengthening for fibular hemimelia

Fibular hemimelia is associated with an equinovalgus deformity of the foot and ankle and different degrees of wedging of the distal tibial epiphysis. This deformity is often a major problem during lengthening of the shortened tibia. To determine the significance of the wedge-shaped distal tibial epiphysis in the pathogenesis of the equinovalgus deformity of the foot and ankle during and after lengthening, we reviewed 20 patients who had undergone tibial lengthening by either the Wagner or the Ilizarov technique. The mean duration of follow-up after removal of the fixator was 5.2 years (range, 2.3-9.7 years). Three types of wedge-shaped distal tibial epiphyses were identified. A mildly wedged (type I) epiphysis was found in seven patients, a moderately wedged (type II) epiphysis was found in seven patients, and a severely wedged (type III) epiphysis, in six patients. Premature fusion of the lateral part of the distal tibial physis and growth retardation of the tibia were common after lengthening in patients with the type II or type III epiphysis. After lengthening, all patients with a type II or type III epiphysis had a recurrence or aggravation of foot deformities that existed before lengthening. This usually necessitated various secondary operative procedures to obtain a plantigrade foot. We believe that after lengthening, one should anticipate varying degrees of mild growth retardation and minimal foot deformity in patients with type I epiphysis, worsened asymmetric growth retardation and progressive foot deformity in patients with type II epiphysis, and severe growth retardation and severe foot deformity in patients with type III epiphysis.