Double calcaneal osteotomy in treatment of flexible planovalgus foot deformity in ambulatory cerebral palsy. A case series study

BackgroundThe aim of this prospective non randomized case series study was to assess the intermediate-term outcomes of double calcaneal osteotomy (lateral column lengthening and medial slide calcaneal osteotomy) use in ambulatory cerebral palsy with flexible planovalgus feet.Methods16 cases with planovalgus feet were surgically treated by double calcaneal osteotomy and observed over an average of 33.5 months. The mean age at the time of surgery was 10.74 years. The functional outcomes were assessed clinically and radiologically.ResultsThere were a statistical improvement of clinical heel valgus and all radiological parameters as regard talar head uncoverage, calcaneal pitch, talo-calcaneal angle, and talus 1st metatarsal angle at the end of follow up period.ConclusionDouble calcaneal osteotomy is a good option in the treatment of flexible planovalgus feet in ambulatory cerebral palsy patients.     

Development of the hip joints in unoperated children with cerebral palsy: A radiographic study of 76 patients

Background?The aims of the present study were to assess the development of hip dysplasia in children with bilateral spastic cerebral palsy and to evaluate the factors that influence the progression.

Patients and methods?76 children, 42 with spastic quadriplegia and 34 with diplegia, were included in the study. Their mean age at the first radiographic examination was 3.5 (1–11) years. The patients were followed up until operative treatment (54 subjects) or until the most recent radiograph in those who did not undergo hip surgery. The mean length of follow-up was 4.8 (1–13) years. On the initial and most recent radiographs, the migration percentage (MP) was measured, which is the percentage of the femoral head lateral to the acetabular rim.

Results?The mean MP of the side with the largest displacement was 25% (-18–66) at the initial radiographic examination and 51% (9–100) at the last follow-up. The mean increase in MP was 7% (-2–33) per year. Linear multiple regression revealed that gait function and age were the most important variables that influenced the rate of MP progression. Children who could not walk had significantly greater MP progression per year (12%) than those who walked with or without support (2%). In the quadriplegics, the maximal yearly increase in MP was 13% under 5 years of age and 7% in older children. This difference was statistically significant, whereas no significant difference in relation to patient age was seen in the diplegics.

Interpretation?There is a pronounced trend towards displacement of the hips in quadriplegic CP patients who are under 5 years of age and cannot walk. Because hip dislocation may lead to severe problems, close follow-up is important in finding the appropriate time for hip surgery in order to avoid progression towards dislocation. The risk of severe hip dysplasia is considerably less in spastic diplegia.??     

Evaluation of the anterior and middle talocalcaneal articular facets and the evans osteotomy

The purpose of this study was to determine the occurrence of discrete anterior and middle talocalcaneal facets and the distance of these facets from the anterior border of the calcaneus as it relates to the Evans osteotomy. Seven hundred sixty-eight calcanei were examined from the human osteology archive at the Cleveland Museum of Natural History. Measurements taken included: 1) distance from the proximal border of the anterior facet to the anterior border of the calcaneus (DTAF), 2) distance from the distal border of the middle facet to the anterior border of the calcaneus (DTMF), and 3) width of facet separation (WFS). The results revealed that 310 of 755 (41.06%) had discrete anterior and middle facets and 423 of 755 (56.03%) had a conjoined facet. In those with discrete facets, the mean DTAF, DTMF, and WFS were 11.04 mm, 15.47 mm, and 3.85 mm, respectively. In those with discrete facets, an osteotomy begun between 11.5 mm and 15 mm from the calcaneocuboid joint should pass between the anterior and middle facets and avoid damaging these articular surfaces. This information may aid the foot and ankle surgeon in patient selection and in attaining optimal surgical outcome for the Evans lateral column lengthening procedure.     

The Calcaneal Osteotomy of Dwyer: An Indication for Kiel Bone

Kiel bone has been used with uniformly good results as a bone graft in 15 cases of Dwyer's calcaneal osteotomy. It is suggested that Kiel bone is indicated for this operation in preference to autogenous bone.     

A Comparative Study of Incorporation Rates between Non-xenograft and Bovine-based Structural Bone Graft in Foot and Ankle Surgery

Several types of structural bone grafts are available, each with different characteristics. Our previous study showed poor performance with the bovine-based xenograft in foot and ankle applications. In the present study, we compared the incorporation rates of non-xenografts, including allografts and autografts, with the bovine-based xenograft to determine whether the poor result was unique to the graft type and not institutional. The proportion of incorporated grafts at 12, 24, 36, and 48 weeks was compared between the nonxenograft and xenograft groups. Furthermore, Cox regression analysis was used to evaluate the factors associated with nonunion. A total of 61 patients (23 women and 38 men) with a median age of 24.0 years were enrolled. The factors associated with slower incorporation included side of operation (p = .033), tobacco use (p = .010), and graft type (p = .001). At 48 weeks, 5% of the nonxenografts and 58% of the xenografts were not incorporated. The median incorporation time for the non-xenograft and xenograft group was 16 and 57 weeks, respectively. We have concluded that it is not advisable to use a bovine-based bone xenograft in foot and ankle surgery.     

Effects of variations in Dwyer calcaneal osteotomy determined by three-dimensional printed patient-specific modeling

Dwyer (lateral calcaneal closing wedge) osteotomy is commonly used in surgical correction of heel varus deformity. The purpose of this study was to determine the effect of wedge size and angle of osteotomy on deformity correction using preoperative imaging analysis with three-dimensional (3D) printed modeling. Seven patients diagnosed with pes cavovarus deformity who underwent Dwyer calcaneal osteotomy were identified retrospectively. Preoperative computed tomogrphy scans were used to create 3D printed models of the foot. After18 variations of osteotomy and fixation performed for each foot, Harris heel and Saltzman images were obtained. The angle between the tibia-talus axis and calcaneal-tuber axis was measured and compared to pre-osteotomy state. Change in the calcaneal lengths was also analyzed. The average degree correction of deformity per mm of bone resected was 3.8 ± 0.2 degrees in the Harris Heel view and 2.7 ± 0.8 degrees in the Saltzman view. A significant increase in correction was obtained with 10 mm compared with 5 mm wide wedges (P < .001). The difference in correction was not statistically significant between 30 and 45 degree cuts or osteotomy distance from the posterior calcaneal tuberosity, but a 45 degree sagittal angle resulted in less calcaneal shortening compared to 30 degrees (P = .02). A clinically driven method using patient-specific 3D models for determining effects of calcaneal osteotomy variables in correcting hindfoot alignment was developed. In summary, the amount of wedge resected impacts hindfoot alignment more than location and sagittal angle of the cut. Calcaneal shortening depends on sagittal angle of the cut.     

跟骨内移截骨术中跟骨内侧的截骨安全区

目的探讨跟骨内移截骨术中跟骨内侧的截骨安全区。方法 10具防腐成人尸体的20只足部标本上,取跟骨结节内缘最低点为A点,内踝尖最低点为B点,足舟骨结节为C点。显露跟骨内侧各神经血管结构后,用游标卡尺测量AB、AC长度,以及各神经血管结构与AB、AC线段交点与A点间的长度。经统计学检验,各组长度符合正态分布,所以可以用后者的长度均值除以AB、AC长度的均值,计算出各神经血管结构在AB、AC上的分布比例。结果跟骨内侧神经、足底外侧神经、足底内侧神经、胫后动脉在AB线上分别位于A点后的：29%、57%、66%、60%;而在AC线上跟骨内侧神经、足底外侧动脉、足底外侧神经、足底内侧动脉、足底内侧神经分别位于A点后的：20%、45%、50%、60%、66%。结论 AB线上A点后29%-57%,AC线上A点后20%45%的区域无重要神经血管走行,满足跟骨内移截骨术在跟骨中后部截骨的要求,可作为跟骨内移截骨术的手术安全区。 更多还原     

Surgical Management of Stage 2 Adult and Pediatric Acquired Flatfoot Without Tendon Transfer or Arthrodesis: A Retrospective Study

Posterior tibial tendon dysfunction (PTTD) is a common pathology of the foot and ankle. Numerous techniques are available to reconstruct the flatfoot. Fusions and tendon transfers are popular methods; however, a wide range of complications have been associated with these procedures. The objective of the present study was to demonstrate the outcomes of reconstructive surgery for flatfoot correction without tendon transfer or arthrodesis. We performed a retrospective study of 43 patients and 56 feet who had undergone flatfoot reconstructive surgery from November 2011 to June 2016, with a mean follow-up period of 60 weeks (range 12 to 60 months). Each patient demonstrated a stage 2 flatfoot deformity classified using the Johnson and Strom classification. Depending on the patient's deformity, the procedures consisted of different variations of gastrocnemius recession, medial displacement calcaneal osteotomy, Evans osteotomy, and Cotton osteotomy. Six different preoperative and postoperative angles were radiographically measured on each foot studied. In all cases, the differences in the preoperative versus postoperative measurements were statistically significant (p?<?.003). We believe the foot and ankle surgeon can correct flatfoot deformity with the use of extraarticular procedures and create a plantigrade functional foot without fusion or tendon transfer.     

Percutaneous Zadek osteotomy for the treatment of insertional Achilles tendinopathy

BackgroundInsertional Achilles tendinopathy (IAT) is a challenging common lower extremity disorder, despite several treatment options described in literature. Open dorsal closing wedge calcaneal osteotomy or Zadek Osteotomy (ZO), for the treatment of the IAT has good clinical results but a high rate of postoperative complications. The purpose of this study is to describe percutaneous ZO for the treatment of the IAT and to evaluate its impact on the clinical and functional postoperative outcomes.MethodsTwenty-six consecutive patients presenting with unilateral IAT refractory to nonoperative measures were treated with percutaneous ZO. Visual Analogue Scale (VAS) and Foot Function Index Score (FFI) were recorded preoperatively and at final follow-up visit (12 ± 3) months. Postoperative complications, satisfaction, and relief of the pain were also recorded.ResultsThe percutaneous ZO showed a significant improvement (p < 0.0001) in preoperative to postoperative FFI (from 65 ± 9 to 8 ± 12) and VAS (from 9 ± 1 to 1 ± 2). Two postoperative complications (8%) were observed: a case of symptomatic non-union and hardware pain, both in healthy patients. The overall rate of satisfaction after surgery was (92%). The relief from pain was achieved after an average period of 12 weeks.ConclusionsZO is a safe and effective procedure for the treatment of IAT. The use of a minimally invasive surgical approach is associated with excellent pain reduction (VAS score) and improved clinical function (FFI score). When compared to the open surgical approach, the percutaneous ZO may decrease recovery time and postoperative complications.Level of evidence: III, retrospective case series.     

Modified Dwyer Osteotomy with Rotation and Reinsertion of Autograft Bone Wedge for Residual Heel Deformity Despite Previous Delayed Subtalar Joint Arthrodesis After Calcaneal Fracture

Calcaneal fracture patterns vary widely, and many factors determine the type and timing of the treatment rendered. Severe calcaneus fractures involving joint damage, loss of heel height, and varus deformity of the tuberosity are ideally treated with open reduction and internal fixation to repair the joint surface and re-establish anatomic structure. This is not always possible owing to delayed presentation, soft tissue compromise, unrelated injuries, unstable medical condition, or lack of expertise by the treating physician. We present the case of a patient who had residual forefoot and rearfoot deformity despite undergoing delayed subtalar joint arthrodesis at an outside hospital 10 years before for a calcaneal fracture that was initially treated nonoperatively. At 4 years of follow-up after modified Dwyer calcaneal osteotomy with rotation and reinsertion of the autograft bone wedge and Cotton midfoot osteotomy, the postoperative gait was relatively normal, other than the expected lack of hindfoot mobility. The lateral column pain was resolved. The patient remained highly satisfied with the outcome at long-term follow-up of 48 months, with improved heel alignment, lack of a wide stance gait, a functional medial column, and a relatively normal gait. This case demonstrates the value of periarticular calcaneal osteotomies without the need to revise the subtalar joint arthrodesis for this challenging clinical situation.     

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.     

Biomechanical consequences of lateral column lengthening of the calcaneus: part I. long plantar ligament strain

Lateral column lengthening of the calcaneus has been a powerful tool used to correct peritalar subluxation in symptomatic flat feet. The mechanical basis and limits for correction with this procedure are not well understood. A flatfoot model was created on 8 fresh-frozen cadaver feet by sectioning the deltoid ligament, talonavicular capsule, and spring ligament. Strain-gauge analysis of the long plantar ligament was performed (on 6 specimens) as the lateral column was sequentially lengthened from 4 to 12 mm in 2-mm increments. Results showed that only the lateral most one-third of the long plantar ligament measured positive strain during this procedure. The medial two-thirds of the long plantar ligament and plantar fascia decreased in tension and became fully lax during lengthening. Maximum tension in the long plantar ligament was measured after placing grafts 6 mm in thickness (P <.05). Larger grafts produced additional strain in the ligament, but were not significant. The authors conclude that grafts >6 mm have no additional corrective capacity without compromising the long plantar ligament. Either larger graft size or loss of the long plantar ligament could compromise the intrinsic stability of the lateral column of the foot. These findings may decrease the incidence of complications with this procedure, specifically lateral column pain, instability, and calcaneocuboid arthrosis.     

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.     

跟骨内移截骨治疗获得性扁平足临床分析

[目的]探讨跟骨内移截骨治疗扁平足的要点及临床疗效.[方法]自2006年1月～2009年12月,采取跟骨内移截骨及联合手术治疗扁平足3l例,男17例,女14例;年龄19～50岁(平均26.7岁).术前均摄足侧位及跟骨轴位X线片及跟骨CT,测量第1跖距角5°～32°(平均22.3°).均有跟腱挛缩、外移、跟骨外翻、前足旋前外展(负重位外观),有疼痛,根据美国矫形足踝协会(AOFAS)踝后足评分标准评分平均45.8分.胫后肌腱功能不全均二级.单纯跟骨内移截骨13例,跟骨内移截骨加跟腱延长4例,跟骨内移截骨加跟腱延长及趾长屈肌腱移位14例.[结果]术后随访6～26个月(平均18.8个月),内侧纵弓较手术前增加,内侧柱高度由术前(8.5±3.2)mm增至(16.3±4.1)mm(t=8.35,P≤0.001),10例疼痛消失,15例减轻,6例无明显改变.第1跖距角由术前5°～32°(平均22.3°±4.5°)降至0°～7°(平均3.2°±1.4°) (t=22.57,P≤0.001).足外翻及外展明显改善,有效率80.6%(25/31),(AOFAS)踝后足评分平均84.5分.[结论]跟骨体部截骨手术治疗可屈性平足疗,能够可靠地纠正平足症的跟骨外翻畸形,部分恢复其内侧纵弓,改善足的负重和足踝部生物力学特性,术中根据情况联合其他术式提高疗效,同时应严格掌握适应证.     

Evans跟骨外侧延长术治疗距跟联合合并后足外翻畸形

目的探讨Evans跟骨外侧延长术治疗距跟联合合并后足外翻畸形的疗效。方法2014年1月—2017年10月,采取Evans跟骨外侧延长术治疗10例(13足)距跟联合合并后足外翻畸形患者。男6例(8足),女4例(5足);年龄13~18岁,平均15.8岁。病程10~14个月,平均11.5个月。患侧跟骨外翻、前足外展、足弓低平。疼痛部位:跗骨窦4足、距跟联合5足、踝关节4足。Silverskiold试验腓肠肌腱膜紧张3例(4足),跟腱挛缩7例(9足)。术前美国矫形外科足踝协会(AOFAS)踝与后足评分为(46.54±9.08)分,行走1 km后疼痛视觉模拟评分(VAS)为(6.54±0.88)分。术后采用AOFAS踝与后足评分、VAS评分,以及X线片测量距骨-第1跖列角(talar-first metatarsal angle,T1MT)、距舟覆盖角(talonavicular coverage angle,TCA)、距骨倾斜角(talar-horizontal angle,TH)、跟骨倾斜角(calcaneal pitch angle,CP)、跟骨外翻角(heel valgus angle,HV),评价手术疗效。结果术后切口均Ⅰ期愈合。10例患者均获随访,随访时间12~30个月,平均18个月。末次随访时,AOFAS踝与后足评分为(90.70±6.75)分,VAS评分为(1.85±0.90)分,均较术前明显改善(t=-23.380,P=0.000;t=35.218,P=0.000)。X线片复查示截骨均达骨性愈合,愈合时间为2~4个月,平均3个月。末次随访时,T1MT、TCA、TH、HV均较术前明显降低,CP明显提高,差异有统计学意义(P<0.05)。随访期间1例(1足)疼痛缓解不明显,1例(1足)出现腓肠神经皮支损伤症状。结论对于距跟联合合并后足外翻畸形患者,Evans跟骨外侧延长术可以有效纠正畸形、缓解疼痛。     

Three-dimensional displacement after a medializing calcaneal osteotomy in relation to the osteotomy angle and hindfoot alignment

BackgroundA medializing calcaneal osteotomy is frequently performed to correct adult-acquired flatfoot deformities, but there is lack of data on the associated three-dimensional variables defining the final correction. The aim of this study was to assess the correlation between the pre-operative hindfoot valgus deformity and calcaneal osteotomy angles and the post-operative calcaneal displacement.MethodsWeight-bearing CT scans obtained pre- and post-operatively were retrospectively analyzed for sixteen patients. Corresponding three-dimensional bone models were used to measure valgus deformity pre- and post-operatively, inclination of the osteotomy and displacement of the calcaneus. Linear regression was conducted to assess the relationship between these measurements.ResultsOn average, the hindfoot valgus changed from 13.1° (±4.6) pre-operatively to 5.7° (±4.3) post-operatively. A mean inferior displacement of 3.2 mm (±1.3) was observed along the osteotomy with a mean inclination of 54.6° (±5.6), 80.5° (±10.7), −13.7° (±15.7) in the axial, sagittal and coronal planes, respectively. A statistically significant positive relationship (p < .05, R² = 0.6) was found between the pre-operative valgus, the axial osteotomy inclination, and the inferior displacement.ConclusionsThis study shows that the degree of pre-operative hindfoot valgus and the axial osteotomy angle are predictive factors for the amount of post-operative inferior displacement of the calcaneus. These findings demonstrate the added value of a computer-based pre-operative planning in clinical practice.Level of evidence II Prospective comparative study.     

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for the treatment of stage II posterior tibial tendon dysfunction: kinematic and functional results of fifty one feet

Purpose

Stage II posterior tibial tendon dysfunction (PTTD) can be treated by flexor digitorum longus (FDL) tendon transfer and medial displacement calcaneal osteotomy (MDCO). Numerous authors have studied the clinical and radiographic results of this procedure. However, little is known about the kinematic changes. Therefore, the purpose of this study was to assess plantar-pressure distribution in these patients.

Methods

Seventy-three patients with PTTD stage II underwent FDL tendon transfer and MDCO. Plantar pressure distribution and American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed 48 months after surgery. Pedobarographic parameters included lateral and medial force index of the gait line, peak pressure (PP), maximum force (MF), contact area (CA), contact time (CT) and force-time integral (FTI).

Results

In the lesser-toe region, PP, MF, CT, FTI and CA were reduced and MF in the forefoot region was increased. These changes were statistically significant. We found statistically significant correlations between AOFAS score and loading parameters of the medial midfoot.

Conclusions

Study results reveal that FDL tendon transfer and MDCO leads to impaired function of the lesser toes during the stance phase. However, there seems to be a compensating increased load in the forefoot region.