Jeremy Y. Chan

The contribution of medializing calcaneal osteotomy on hindfoot alignment in the reconstruction of the stage II adult acquired flatfoot deformity.

Background: Successful correction of hindfoot alignment in adult acquired flatfoot deformity (AAFD) is likely influenced by the degree of medializing calcaneal osteotomy (MCO) performed, but it is not known if other reconstruction procedures significantly contribute as well. The purpose of this study was to evaluate the correlation between common preoperative and postoperative variables and hindfoot alignment. Methods: Thirty patients with stage II AAFD undergoing flatfoot reconstruction were followed prospectively. Preoperative and postoperative radiographs were reviewed to assess for correction in hindfoot alignment as measured by the change in hindfoot moment arm. Nineteen variables were analyzed, including age, gender, height, weight, body mass index (BMI), medial cuneiform-fifth metatarsal height, anteroposterior (AP) talonavicular coverage, AP talus-first metatarsal, lateral talus-first metatarsal and calcaneal pitch angles as well as intraoperative use of the MCO, lateral column lengthening (LCL), Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament reconstruction, and gastrocnemius recession or Achilles lengthening. Mean age was 57.3 years (range, 22-77). Final radiographs were obtained at a mean of 47 weeks (range, 25-78) postoperatively. Results: Seven variables were found to significantly affect hindfoot moment arm. These were gender (P < .05), the amount of MCO performed (P < .001), LCL (P < .01), first tarsometatarsal fusion (P < .01), spring ligament reconstruction (P < .01), medial cuneiform-fifth metatarsal height (P < .001), and calcaneal pitch angle (P < .05). Multivariate regression analysis revealed that MCO was the only significant predictor of hindfoot moment arm. The final regression model for MCO showed a good fit (R2 = .93, P < .001). Conclusion: Correction of hindfoot valgus alignment obtained in flatfoot reconstruction is primarily determined by the MCO procedure and can be modeled linearly. We believe that the hindfoot alignment view can serve as a valuable preoperative measurement to help surgeons adjust the proper amount of correction intraoperatively. Level of Evidence: Level IV, prospective case series.

Contribution of Lateral Column Lengthening to Correction of Forefoot Abduction in Stage IIb Adult Acquired Flatfoot Deformity Reconstruction.

Background: Correction of forefoot abduction in stage IIb adult acquired flatfoot likely depends on the amount of lateral column lengthening (LCL) performed, although this represents only one aspect of a successful reconstruction. The purpose of this study was to evaluate the correlation between common reconstructive variables and the observed change in forefoot abduction. Methods: Forty-one patients who underwent flatfoot reconstruction involving an Evans-type LCL were assessed retrospectively. Preoperative and postoperative anteroposterior (AP) radiographs of the foot at a minimum of 40 weeks (mean, 2 years) after surgery were reviewed to determine correction in forefoot abduction as measured by talonavicular coverage (TNC) angle, talonavicular uncoverage percent, talus–first metatarsal (T-1MT) angle, and lateral incongruency angle. Fourteen demographic and intraoperative variables were evaluated for association with change in forefoot abduction including age, gender, height, weight, body mass index, as well as the amount of LCL and medializing calcaneal osteotomy performed, LCL graft type, Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament repair, gastrocnemius recession and any one of the modified McBride/Akin/Silver procedures. Results: Two variables significantly affected the change in lateral incongruency angle. These were weight (P = .04) and the amount of LCL performed (P < .001). No variables were associated with the change in TNC angle, talonavicular uncoverage percent, or T-1MT angle. Multivariate regression analysis revealed that LCL was the only significant predictor of the change in lateral incongruency angle. The final regression model for LCL showed a good fit (R2 = 0.70, P < .001). Each millimeter of LCL corresponded to a 6.8-degree change in lateral incongruency angle. Conclusion: Correction of forefoot abduction in flatfoot reconstruction was primarily determined by the LCL procedure and could be modeled linearly. We believe that the lateral incongruency angle can serve as a valuable preoperative measurement to help surgeons titrate the proper amount of correction performed intraoperatively. Level of Evidence: Level III, retrospective comparative study.

Crossed-Screws Provide Greater Tarsometatarsal Fusion Stability Compared to Compression Plates

Background. Hallux valgus is a common deformity that is often treated with a fusion of the first tarsometatarsal (TMT) joint. Crossed-screws are currently the accepted standard but advances in plate systems present opportunities for improved clinical outcomes; however, in vitro testing should be performed prior to clinical implementation. The purpose of this study was to determine whether a locking plate with surgeon-mediated compression provides similar fusion stability compared to crossed-screws and if bone density or joint size are related to construct success. Methods. Ten matched-pair cadaveric specimens received first TMT fusions with either crossed-screws or a compression plate and were loaded for 1000 cycles to assess the amount of joint motion measured as plantar gapping. Bone density was quantified using computed tomography images of each specimen, and joint height was measured with calipers. Results. Crossed-screws provided 3 times greater resistance to plantar gapping compared to compression plates after 1000 cycles. Bone density and joint size did not affect resistance to plantar gapping for either construct. Conclusion. Lag screws or a plantarly applied plate are needed to maximize TMT fusion stability prior to osseous union. Dorsomedially applied plates are also effective when paired with a lag screw placed across the TMT joint. These constructs do not appear to depend on bone density or joint size, suggesting that patients with osteoporosis are viable candidates. Clinical Relevance. The results of this study suggest that traditional, lagged cross-screws provide greater stability to that of a dorsally place compression plate and may lead to better rates of union. Levels of Evidence: Therapeutic, Level V: Cadaveric Study

New radiographic parameter assessing hindfoot alignment in stage II adult-acquired flatfoot deformity.

Background: The hindfoot moment arm is a reliable measurement of hindfoot valgus deformity in stage II adult-acquired flatfoot deformity (AAFD) and can be used to guide intraoperative correction of the hindfoot. There is currently little understanding of how the hindfoot moment arm relates to angular measurements of hindfoot alignment. The purpose of this study was to develop a new hindfoot alignment angle that can reliably quantify hindfoot valgus in patients with AAFD and to establish the relationship of this angle with the hindfoot moment arm. Methods: Preoperative hindfoot alignment radiographs were reviewed for 10 consecutive patients (10 feet) who were indicated for reconstruction for stage II AAFD. A second group of 10 patients (10 feet) without flatfoot were identified to serve as normal controls. The hindfoot moment arm and the new hindfoot alignment angle were measured in blinded fashion by 2 readers. Reliability was assessed using intraclass correlation coefficients (ICCs). The difference in angle between normal and flatfoot patients was assessed with a Mann-Whitney U test. A linear regression model was used to assess the relationship between hindfoot moment arm and the new hindfoot alignment angle. Results: Intra- and interrater reliability for the hindfoot alignment angle was excellent (ICC = 0.979 and 0.965, respectively). Flatfoot patients had greater mean angles than did normal patients (22.5 ± 4.9 vs 5.6 ± 5.4 degrees, P < .001). The hindfoot moment arm was correlated significantly with the hindfoot alignment angle (P < .001), increasing by 0.81 mm for every degree increase in angle (adjusted R2 = 0.9046). Conclusion: These results indicate that the new hindfoot alignment angle is a reliable measure of hindfoot valgus and can differentiate between flatfoot and normal patients. In addition, the strong linear relationship between the hindfoot alignment angle and moment arm may allow for the use of this angle in the intraoperative correction of hindfoot valgus. Level of Evidence: Level III, retrospective case control study.

Optimal Position of the Heel Following Reconstruction of the Stage II Adult-Acquired Flatfoot Deformity:

Background: While previous work has demonstrated a linear relationship between the amount of medializing calcaneal osteotomy (MCO) and the change in radiographic hindfoot alignment following reconstruction, an ideal postoperative hindfoot alignment has yet to be reported. The aim of this study was to identify an optimal postoperative hindfoot alignment by correlating radiographic alignment with patient outcomes. Methods: Fifty-five feet in 55 patients underwent flatfoot reconstruction for stage II adult-acquired flatfoot deformity (AAFD) by 2 fellowship-trained foot and ankle orthopedic surgeons. Hindfoot alignment was determined as previously described by Saltzman and el-Khoury. 23 Changes in pre- and postoperative scores in each Foot and Ankle Outcome Score (FAOS) subscale were calculated for patients in postoperative hindfoot valgus (≥0 mm valgus, n = 18), mild varus (>0 to 5 mm varus, n = 17), and moderate varus (>5 mm varus, n = 20). Analysis of variance and post hoc Tukey’s tests were used to compare the change in FAOS results between these 3 groups. Results: At 22 months or more postoperatively, patients corrected to mild hindfoot varus showed a significantly greater improvement in the FAOS Pain subscale compared with patients in valgus (P = .04) and the Symptoms subscale compared with patients in moderate varus (P = .03). Although mild hindfoot varus did not differ significantly from moderate varus or valgus in the other subscales, mild hindfoot varus did not perform worse than these alignments in any FAOS subscale. No statistically significant correlations between intraoperative MCO slide distances and FAOS subscales were found. Conclusions: Our study indicates that correction of hindfoot alignment to between 0 and 5 mm of varus on the hindfoot alignment view (clinically a straight heel) following stage II flatfoot reconstruction was associated with the greatest improvement in clinical outcomes following hindfoot reconstruction in stage II AAFD. Level of Evidence: Level III, comparative series.

Correlation of Postoperative Midfoot Position With Outcome Following Reconstruction of the Stage II Adult Acquired Flatfoot Deformity

Background: No studies investigating the effect of the midfoot (talonavicular joint) position on clinical outcomes following flatfoot reconstruction have been performed. The purpose of our study was to determine whether a postoperative abducted or adducted forefoot alignment, as determined from anteroposterior (AP) radiographs, was associated with a difference in outcomes using the Foot and Ankle Outcome Score (FAOS). Methods: Midfoot abduction was defined on postoperative AP radiographs, evaluated at a mean of 1.9 years in 55 patients from the authors’ institution who underwent flatfoot reconstruction for a stage II adult acquired flatfoot deformity (AAFD), as a lateral incongruency angle greater than 5 degrees, a talonavicular uncoverage angle greater than 8 degrees, and a talo–first metatarsal angle greater than 8 degrees based on previously reported measurements. Patients with 2 or more measurements in the abduction category were classified as the abduction group (n = 30); those with 1 or fewer measurements in the abduction category were placed in the adduction group (n = 25). The preoperative and postoperative FAOS values with a mean follow-up of 3.1 years were compared using Wilcoxon rank-sum tests. Results: Patients corrected to a position of adduction showed significantly lower improvement in the FAOS daily activities (P = .012) and quality of life subscales (P = .046). The mean improvement in subscale scores for the adducted group was lower for pain (P = .052) and sports activities (P = .085) but did not reach statistical significance. No significant difference in the FAOS symptoms subscale (P = .372) between groups was found. Conclusion: Correction of the talonavicular joint to a position of adduction following a stage II AAFD was associated with decreased patient outcomes in daily activities and quality of life compared with an abducted position. These results suggest that overcorrection to a position of midfoot adduction leads to a lesser amount of individual patient improvement in reconstruction of a stage II AAFD. Level of Evidence: Level III, comparative series.

A case of acute tarsal tunnel syndrome following lateralizing calcaneal osteotomy.

Surgical correction of hindfoot varus is frequently performed with a lateral displacement calcaneal osteotomy. It has rarely been associated with iatrogenic tarsal tunnel syndrome in patients with pre-existing neurological disease. We report the first case of acute postoperative tarsal tunnel syndrome in a neurologically intact patient with post-traumatic hindfoot varus. Early diagnosis and emergent operative release afforded an excellent clinical outcome. Imaging studies can help outrule a compressive hematoma and assess for possible nerve transection; however it is paramount that a high index of suspicion is utilized with judicious operative intervention to minimize long-term sequelae.

Reconstruction of achilles rerupture with peroneus longus tendon transfer.

Although operative treatment of Achilles tendon ruptures is commonly performed to reduce the risk of rerupture, subsequent failure can still occur in approximately 3% of patients. Treatment in this setting is challenging, particularly when previous tendon transfers have failed or infection is present as an underlying cause. We describe the case of using a peroneus longus tendon transfer to salvage an Achilles rerupture that occurred, in part, because of infection and despite having previously used a flexor hallucis longus (FHL) transfer. The patient’s history had included a Haglund’s excision and tendon debridement. To our knowledge, there has only been a single reported case in the literature using the peroneus longus tendon as a double-stranded, free graft that was fixed with an endobutton placed on the plantar aspect of the heel. Tendon transfer provides a simpler technique that offers the theoretical advantage of added plantar flexion strength. The goal of this report was to present an alternate method to salvage complex failures of the Achilles tendon.

Uncemented Metal-Backed Tantalum Patellar Components in Total Knee Arthroplasty Have a High Fracture Rate at Midterm Follow-Up

BACKGROUND There is interest in uncemented total knee arthroplasty due to the hope for long-term biologic fixation, but limited data are available regarding uncemented tantalum patellar components. The purpose of this study was to evaluate the radiographic outcomes of uncemented tantalum patellar implants at midterm follow-up. METHODS We retrospectively reviewed a consecutive series of 30 knees in 29 patients who underwent cementless total knee arthroplasty with an uncemented metal-backed tantalum patella between September 2006 and April 2009. Patients were required to have a minimum radiographic follow-up of 2 years. Anteroposterior and lateral radiographs of the knee were evaluated for signs of implant fracture or gross loosening. Clinical follow-up was obtained by reviewing each patients most recent orthopedic record. RESULTS Thirty knees in 29 patients met inclusion criteria. The mean age of the cohort was 59.1 years with a mean body mass index of 31.9 kg/m2. Mean postoperative radiographic follow-up time was 5.5 years. Six fractures of the patellar component were noted. This represented a fracture rate of 20% among the entire cohort and 35% among the 17 knees with visible patellae on anteroposterior radiograph. All fractures had a transverse pattern. No gross patellar component loosening was noted. Among patients with component fractures, 2 required revisions for instability and 1 revision was for infection. CONCLUSION Our results suggest a minimum 20% rate of component fracture at midterm follow-up. Although many of these patellar component fractures were asymptomatic, they have the potential to impact revision rates in the longer term.

Reconstruction of the Stage IIA Adult-acquired Flatfoot Deformity

Stage IIA adult-acquired flatfoot deformity is defined by a characteristic collapse of the medial arch with passively correctible hindfoot valgus, limited forefoot abduction, and forefoot varus deformities. Operative treatment for symptomatic patients who fail conservative therapy is determined by the deformities present, but can include a medializing calcaneal osteotomy, flexor digitorum tendon transfer to the navicular, gastrocnemius recession, repair of the posterior tibial tendon, and spring ligament as well as medial column procedures including a Cotton osteotomy or first tarsometatarsal fusion. These procedures have been shown to restore alignment radiographically and to improve both pain and quality of life. In this article, we describe our technique for reconstruction of the stage IIA flatfoot and address common concerns that occur both intraoperatively and postoperatively.