Radiographic Analysis and Clinical Efficacy of Hindfoot Arthrodesis With Versus Without Cotton Osteotomy in Stage III Adult Acquired Flatfoot Deformity

Forefoot varus develops as a result of longstanding adult-acquired flatfoot deformity (AAFD). This occurs with varying degrees of deformity and flexibility. Residual forefoot varus following hindfoot realignment in AAFD can lead to lateral column loading and a persistent pronatory moment in efforts to reestablish contact between the forefoot and the ground. The Cotton osteotomy may serve as a reasonable adjunct procedure to help avoid complications and poor outcomes associated with residual forefoot varus in patients undergoing hindfoot arthrodesis for stage III AAFD. The aim of this study was to compare the radiographic outcomes in patients undergoing isolated hindfoot arthrodesis to patients undergoing hindfoot arthrodesis with adjunctive cotton osteotomy. We retrospectively reviewed 47 patients matched based upon age, sex, and comorbidities who underwent hindfoot reconstruction for the treatment of stage III AAFD between 2015 and 2019. A retrospective radiographic review was performed on standard weightbearing radiographs including anterior-posterior and lateral views preoperatively, postoperatively at the initiation of full weightbearing, and at final follow-up. Statistical analysis utilizing paired t test to calculate p values where <.05 was statistically significant. At final follow-up, radiographic measurements showed statistically significant differences in CAA, calcaneal inclination, talo-calcaneal, and talar tilt (p value <.05). The Cotton osteotomy group showed a quicker return to presurgical activity level and a decreased incident of tibiotalar valgus. Our study suggests that the Cotton osteotomy can address residual forefoot varus and potentially prevent further progression of ankle valgus in AAFD when used in combination with hindfoot arthrodesis.     

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.     

Calcaneal osteotomy in the treatment of adult acquired flatfoot deformity

Calcaneal osteotomies are an essential part of our current armamentarium in the treatment of AAFD. Soft tissue correction or bony realignment alone have failed to adequately correct the deformity; therefore, both procedures are used simultaneously to achieve long-term correction. Medial displacement and lateral column lengthening osteotomies in isolation or in combination and the Malerba osteotomy have been employed along with soft tissue balancing to good effect by various authors. The goal is to create a stable bony configuration with adequate soft tissue balance to maintain dynamic equilibrium in the hindfoot. In “pronatory syndromes,” the relation of the osteotomy to the posterior subtalar facet modifies the biomechanics of the hindfoot in different ways. Anterior calcaneal osteotomies correct deformities in the transverse plane (forefoot abduction), whereas posterior tuberosity osteotomies result in “varization” of the calcaneus and correct the frontal plane deformity. The choice of osteotomy depends on the plane of the dominant deformity. If the subtalar axis is more horizontal than normal, transverse plane movement is cancelled out and the frontal plane eversion–inversion is predominant. The patient presents with marked hindfoot valgus without significant forefoot abduction. Conversely, if the subtalar axis is more vertical than normal, transverse plane movement is predominant and the patient presents with forefoot abduction and instability of the medial midtarsal joints, although without significant hindfoot valgus. In this situation, a lateral column lengthening procedure is recommended to decrease the uncovering of the talar head and improve the height of the arch while correcting the forefoot abduction. With a predominant frontal plane deformity, medialization of the calcaneal tuberosity is used to displace the calcaneal weight bearing axis medially, aligning it with the tibial axis and restoring the function of the gastrosoleus as a heel invertor. An essential prerequisite for this is the absence of arthritis affecting the subtalar joint. The Achilles tendon may need to be lengthened at the same time.     

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.     

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.     

Hypermobility of the first metatarsal bone in patients with Rheumatoid arthritis treated by lapidus procedure

ABSTRACT: BACKGROUND: Foot deformities and related problems of the forefoot are very common in patients with rheumatoid arthritis. The laxity of the medial cuneometatarsal joint and its synovitis are important factors in the development of forefoot deformity. The impaired joint causes the first metatarsal bone to become unstable in the frontal and sagittal planes. In this retrospective study we evaluated data of patients with rheumatoid arthritis who underwent Lapidus procedure. We evaluated the role of the instability in a group of patients, focusing mainly on the clinical symptoms and X-ray signs of the instability. METHODS: The study group included 125 patients with rheumatoid arthritis. The indications of the Lapidus procedure were a hallux valgus deformity greater than 15 degrees and varus deformity of the first metatarsal bone with the intermetatarsal angle greater than 15 degrees on anterio-posterior weight-bearing X-ray. RESULTS: Data of 143 Lapidus procedures of 125 patients with rheumatoid arthritis, who underwent surgery between 2004 and 2010 was evaluated. Signs and symptoms of the first metatarsal bone instability was found in 92 feet (64.3 %) in our group. The AOFAS score was 48.6 before and 87.6 six months after the foot reconstruction. Nonunion of the medial cuneometatarsal joint arthrodesis on X-rays occurred in seven feet (4.9 %). CONCLUSION: The Lapidus procedure provides the possibility to correct the first metatarsal bone varus position and its instability, as well as providing the possibility to achieve a painless foot for walking. We recommend using the procedure as a preventive surgery in poorly symptomatic patients with rheumatoid arthritis in case of the first metatarsal bone hypermobility.     

Adult cavovarus foot

Cavovarus foot deformity, which often results from an imbalance of muscle forces, is commonly caused by hereditary motor sensory neuropathies. Other causes are cerebral palsy, cerebral injury (stroke), anterior horn cell disease (spinal root injury), talar neck injury, and residual clubfoot. In cavovarus foot deformity, the relatively strong peroneus longus and tibialis posterior muscles cause a hindfoot varus and forefoot valgus (pronated) position. Hindfoot varus causes overload of the lateral border of the foot, resulting in ankle instability, peroneal tendinitis, and stress fracture. Degenerative arthritic changes can develop in overloaded joints. Gait examination allows appropriate planning of tendon transfers to correct stance and swing-phase deficits. Inspection of the forefoot and hindfoot positions determines the need for soft-tissue release and osteotomy. The Coleman block test is invaluable for assessing the cause of hindfoot varus. Prolonged use of orthoses or supportive footwear can result in muscle imbalance, causing increasing deformity and irreversible damage to tendons and joints. Rebalancing tendons is an early priority to prevent unsalvageable deterioration of the foot. Muscle imbalance can be corrected by tendon transfer, corrective osteotomy, and fusion. Fixed bony deformity can be addressed by fusion and osteotomy.     

The Cotton osteotomy: indications and techniques

Stage II posterior tibial tendon dysfunction (PTTD) is characterized by an incompetent posterior tibial tendon that results in a flexible pes planovalgus deformity. As the hindfoot drifts into valgus, compensatory varus develops in the forefoot. Alternatively, in some cases medial column instability can result in primary forefoot varus that drives the hindfoot into valgus. Recently, there has been increasing awareness of the importance of forefoot varus in PTTD.     

Combined calcaneal and metatarsal osteotomies for the treatment of cavus foot.

Cavovarus foot can be painful and disabling owing to deformity and instability. A method of surgical correction is presented with osteotomies of the forefoot and the hindfoot. The technique avoids arthrodesis while preserving joint motion, lowering the height of the arch, and correcting varus and adductus deformity. Increased ankle stability, elimination of the risk of stress fracture, decreased pain are expected outcomes.     

Lateral-sided bony procedures

Treatment of any hindfoot deformity should include correction of the deformity and preservation of complex hindfoot motion. This important motion is protective of adjacent, and more removed, joints in that it serves a shock-absorbing function and protects them from stresses. Lateral column lengthening combined with a medial soft-tissue procedure is the treatment of choice for stage II flat foot. Patients who have significant subluxation of the subtalar joint will also need a medial displacement calcaneal osteotomy to correct the hindfoot valgus. Only patients who have a rigid foot secondary to degenerative changes will require an arthrodesis to correct the deformity and provide pain relief. Unfortunately, although fusion works well to correct deformity, it accelerates future degenerative changes.     

Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot

Adult acquired flatfoot is generally characterized by loss of the longitudinal arch, hindfoot valgus, and forefoot abduction, but the precise deformity has not been adequately described at the level of individual joints. Simulated weightbearing CT scans and plain radiographs of 37 symptomatic flat feet were examined in this study. The degree of arthritic degeneration was assessed in the major hindfoot and midfoot joints, and the location of deformity was studied along the medial column of the arch. Moderate to severe degeneration was seen in about one-third of talonavicular, subtalar, and calcaneocuboid joints. The medial column of the arch collapsed through the talonavicular joint in some feet, through the medial naviculocuneiform joint in others, but rarely through both. First tarsometatarsal joint subluxation was a frequent finding as well. In this small series, neither the degree of degenerative arthritis nor the amount of joint deformity was seen to correlate with patient age. Furthermore, no correlation was observed between foot deformity and joint degeneration.     

Patient specific computational models to optimize surgical correction for flatfoot deformity

Several surgically corrective procedures are considered to treat Adult Acquired Flatfoot Deformity (AAFD) patients, relieve pain, and restore function. Procedure selection is based on best practices and surgeon preference. Recent research created patient specific models of AAFD to explore their predictive capabilities and examine effectiveness of the surgical procedure used to treat the deformity. The models’ behavior was governed solely by patient bodyweight, soft tissue constraints, muscle loading, and joint contact without the assumption of idealized joints. The current work expanded those models to determine if an alternate procedure would be more effective for the individual. All procedures incorporated first a tendon transfer and then included one hindfoot procedure, the Medializing Calcaneal Osteotomy (MCO), and one of three lateral column procedures: Evans osteotomy, Calcaneocuboid Distraction Arthrodesis (CCDA), Z osteotomy, and the combination procedures MCO & Evans osteotomy, MCO & CCDA, and MCO & Z osteotomy. The combination MCO & Evans and MCO & Z procedures were shown to provide the greatest amount of correction for both forefoot abduction and hindfoot valgus. However, these two procedures significantly increased joint contact force, specifically at the calcaneocuboid joint, and ground reaction force along the lateral column. With exception to the lateral bands of the plantar fascia and middle spring ligament, the strain present in the plantar fascia, spring, and deltoid ligaments decreased after all procedures. The use of patient specific computational models provided the ability to investigate effects of alternate surgical corrections on restoring biomechanical function in these flatfoot patients. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1523–1531, 2017.

     

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.     

Case report: correction of neglected club foot deformity by arthroscopic assisted triple arthrodesis

Neglected club foot deformity at the adulthood is difficult to correct. It is usually a rigid deformity associated with arthritic change of the hindfoot joint. Combined bone and soft tissue procedure is necessary to correct the deformity. We present a case of neglected club foot in adulthood who was successfully corrected with arthroscopic triple arthrodesis.     

The cavovarus foot deformity. Etiology and management

The cavovarus foot is a complex deformity of the forefoot and hindfoot, frequently of neuropathologic etiology. A progressive spinal or peripheral neuromuscular disorder must be excluded by a thorough clinical evaluation. With the failure of nonoperative modalities, surgical options depend on patient age, etiology of the deformity, and the constellation and flexibility of the defects observed. If the hindfoot varus is flexible, correction of the cavus and forefoot pronation through extensive plantar release and metatarsal osteotomies is reliable. The underlying muscle imbalance must be addressed through tendon transfers to prevent further progression. In the young child, a rigid hindfoot varus will often be corrected by a radical plantar-medial release, but the more mature foot may require midtarsal osteotomy and calcaneal osteotomy or triple arthrodesis. The surgery is usually staged to provide correction of deformity and stabilization of the hindfoot prior to tendo Achilles lengthening or tendon transfer. Arthrodesis of a previously well-corrected foot is common due to progression of the neurologic deficit or failure to achieve muscular balance. The claw toe deformity also must be corrected by tendon transfer, osteotomy, and arthrodesis for reasons of both comfort and function.     

Management of the rigid arthritic flatfoot in adults: triple arthrodesis

The traditional surgical treatment for adults with a rigid, arthritic flatfoot is a dual-incision triple arthrodesis. Over time, this procedure has proved to be reliable and reproducible in obtaining successful deformity correction through fusion and good clinical results. However, the traditional dual-incision triple arthrodesis is not without shortcomings. Early complications include lateral wound problems, malunion, and nonunion. Long-term follow-up of patients after a triple arthrodesis has shown that many develop adjacent joint arthritis at the ankle or midfoot. This particular problem should be considered an expected consequence, rather than a failure of the procedure. Although the indications for and surgical techniques used in triple arthrodesis have evolved and improved with time (predictably improving results in the intermediate term), the triple arthrodesis should be regarded as a salvage procedure. Certain measures can be taken by the surgeon to avoid some problems. If patients are at risk for lateral wound complications, the arthrodesis could be performed through a single medial incision. However, this can make some aspects of the CC fusion more difficult. Implants would have to be inserted percutaneously, which prevents the surgeon from using either staples or plates. If a patient were to need a lateral column lengthening through a CC distraction fusion, this would not be possible medially. If either the ST or CC joints have minimal degenerative changes, they could be spared through a double or modified double arthrodesis, respectively. Although these procedures that deviate from the traditional triple arthrodesis offer promise, further study is required to better define their role in treatment of the rigid, arthritic AAFD. Triple arthrodesis is, by no means, a simple surgery. It requires preoperative planning, meticulous preparation of bony surfaces, cognizance of hindfoot positioning, and rigidity of fixation. The procedure also requires enough experience on the part of the operating surgeon to anticipate postoperative problems and provide modifications in traditional technique for certain patients.     

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.     

Lesser toe deformities

Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.     

Combined split anterior tibial-tendon transfer and intramuscular lengthening of the posterior tibial tendon. Results in patients who have a varus deformity of the foot due to spastic cerebral palsy

Twenty patients who had a varus deformity of the foot secondary to spastic cerebral palsy had twenty-two operations involving combined split anterior tibial-tendon transfer and intramuscular lengthening of the posterior tibial tendon, with and without concomitant lengthening of the Achilles tendon. Preoperatively, all patients had had a dynamic varus deformity of the hindfoot and adduction of the forefoot in both the stance phase and the swing phase of gait. At an average follow-up of 6.2 years (range, 2.3 to 8.8 years), there were fourteen excellent, four good, and four poor clinical results. Two patients who had a fixed varus deformity of the hindfoot and one patient who had a very weak anterior tibial muscle had a poor result. We concluded that the combined procedure is effective for correction of a flexible varus deformity of the foot in patients who have spastic cerebral palsy.