RESUMO
Adult acquired flat foot deformity (AAFD) is a progressive, tri-planar deformity involving collapse of the medial longitudinal arch, valgus deformity of the rear foot, and abduction of the mid-foot on the rear foot. There are a wide variety of surgical treatment options for this deformity, including lateral column lengthening (LCL) which results in tri-planar correction of AAFD. We retrospectively reviewed weightbearing preoperative radiographs and weight-bearing 6-week postoperative radiographs of 34 patients with stage II AAFD who underwent LCL (with and without concurrent procedures) with a minimum of 1-year of follow up. Outcomes, including complications and postoperative differences in 6 types of angle measurements were evaluated. Radiographic evaluation showed statistically significant differences in preoperative and postoperative measures in the following angles: calcaneal inclination, Meary's, Simmons, talocalcaneal, and metatarsus adductus (each p ≤ .05). Postoperative Engel's angle difference did not reach statistical significance (p = .07). Paired t tests showed TN coverage angles increased greater with LCL plus a Cotton osteotomy as compared to isolated LCL. Additionally, there was no significant difference in TN coverage angle based on LCL graft size (p = .20). Furthermore, the distance of the osteotomy from the calcaneocuboid joint on anteroposterior and lateral radiographs did not significantly predict TN coverage angle change. Our study suggests that LCL corrects AAFD in three planes while decreasing the metatarsus adductus angle. LCL appears to be more effective when performed with a Cotton osteotomy. Wedge size (6 mm, 8 mm, 10 mm) and osteotomy location did not demonstrate a relationship with postoperative TN coverage angle or incidence of lateral column overload.
RESUMO
Utilization of the talonavicular joint (TN) arthrodesis as an isolated procedure or in combination with hindfoot arthrodesis has been described in the literature for treatment of numerous hindfoot conditions. When used in isolation or with concomitant hindfoot arthrodesis, the TN joint has demonstrated nonunion rates reported as high as 37% in the literature. Despite previous research, there remains a lack of agreement upon the ideal fixation technique for TN joint arthrodesis with and without concomitant subtalar joint arthrodesis. The purpose of this study was to retrospectively compare the radiographic and clinical results of TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs in the treatment of advanced hindfoot malalignment in stage III adult-acquired flatfoot deformity. We retrospectively reviewed 105 patients who underwent TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs. Our results demonstrated a nonunion rate of 16.2%, with 17 nonunions identified within our patient population. One (2.4%) nonunion was observed in the 3-screw cohort, 7 (33.3%) nonunions were observed in the 2-screw cohort, 4 (16.0%) nonunions were observed in the 2-screw plus plate cohort, and 5 (29.4%) nonunions were observed in the 1-screw plus plate cohort. The difference in nonunion rate between the 4 cohorts was statistically significant. Based on these results, we conclude that the use of a 3-screw construct for TN joint arthrodesis as part of double arthrodesis procedure demonstrates a statistically significant reduction in nonunion rate and should be considered a superior fixation construct for this procedure.
Assuntos
Pé Chato , Articulações Tarsianas , Adulto , Artrodese/métodos , Parafusos Ósseos , Pé Chato/diagnóstico por imagem , Pé Chato/cirurgia , Humanos , Estudos Retrospectivos , Articulações Tarsianas/diagnóstico por imagem , Articulações Tarsianas/cirurgiaRESUMO
Subtalar joint (STJ) arthrodesis is a well-established and accepted surgical procedure utilized for the treatment of various hindfoot conditions including primary or posttraumatic subtalar osteoarthritis, hindfoot valgus deformity, hindfoot varus deformity, complex acute calcaneal fracture, symptomatic residual congenital deformity, tarsal coalition, and other conditions causing pain and deformity about the hindfoot. Union rates associated with isolated subtalar joint arthrodesis are generally thought to be favorable, though reports have varied significantly, with non-union rates ranging from 0 to 46%. Various fixation constructs have been recommended for STJ arthrodesis. The purpose of this study was to compare radiographic union in a 2-screw fixation technique to a 3-screw fixation technique for patients undergoing primary isolated STJ arthrodesis. To this end, we retrospectively reviewed 54 patients; 26 in the 2-screw group and 28 in the 3-screw group. We found the median time to radiographic union to be 9 weeks for the 2-screw cohort and 7 weeks for the 3-screw cohort. Additionally, we found that the 2-screw fixation cohort had a radiographic non-union rate of 26.9% while the 3-screw cohort had no non-unions. We conclude that the use of a 3-screw construct for isolated STJ arthrodesis has a lower non-union rate and time to union when compared to the traditional 2-screw construct and should be considered as a fixation option for STJ arthrodesis.
Assuntos
Osteoartrite , Articulação Talocalcânea , Artrodese/métodos , Parafusos Ósseos , Humanos , Estudos Retrospectivos , Articulação Talocalcânea/diagnóstico por imagem , Articulação Talocalcânea/cirurgiaRESUMO
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.
Assuntos
Pé Chato , Adulto , Artrodese/métodos , Pé Chato/complicações , Pé Chato/diagnóstico por imagem , Pé Chato/cirurgia , Humanos , Osteotomia/métodos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Hindfoot arthrodesis is used in patients with advanced-stage acquired flatfoot, usually associated with degenerative joint disease. The objective of the present study was to evaluate the clinical and radiographic results of hindfoot arthrodesis using the single-incision medial approach. METHODS: A case series of 18 consecutive patients undergoing surgical correction between 2015 and 2018 with hindfoot arthrodesis using the medial approach was evaluated. The clinical assessment used the visual analog pain scale, AOFAS hindfoot score, SF-36, and foot function index. Radiographs and personal satisfaction criteria were also analyzed. RESULTS: All radiographic parameters evaluated showed a significant improvement (p < .05), except the calcaneal pitch. Pain decreased by 5.1 points (p < .001), and the mean final AOFAS score was 72.6. In three feet, a new surgery was required. Two feet developed talar necrosis. None of the cases presented surgical wound dehiscence, and two presented with superficial infection, which was resolved with the use of oral antibiotics. CONCLUSION: Double arthrodesis (subtalar and talonavicular) to correct adult-acquired valgus flatfoot using a medial approach has a low risk of soft tissue complications and presents satisfactory functional results. Avascular necrosis is a serious complication that was present in 11% of cases.
Assuntos
Artrodese/métodos , Calcâneo , Pé Chato , Adulto , Pé Chato/diagnóstico por imagem , Pé Chato/cirurgia , Pé , Humanos , OsteotomiaRESUMO
Surgical treatment for a stage II adult acquired flatfoot has consisted of reconstruction of the diseased posterior tibial tendon with flexor digitorum longus tendon transfer, combined with osteotomies to address the underlying deformity. This case series presents an alternative to tendon transfer using allograft tendon for posterior tibial tendon reconstruction. Four patients who underwent stage II flatfoot reconstruction with posterior tibial tendon allograft transplantation were included. All patients had preoperative radiographs demonstrating flatfoot deformity and magnetic resonance imaging showing advanced tendinopathy of the posterior tibial tendon. Allograft tendon transplant was considered in patients demonstrating adequate posterior tibial tendon excursion during intraoperative assessment. Additional procedures were performed as necessary depending on patient pathology. Postoperatively, all patients remained non-weightbearing in a short leg cast for 6 weeks. Radiographs performed during the postoperative course demonstrated well-maintained and improved alignment. No complications were encountered. Each patient demonstrated grade 5 muscle strength and were able to perform a single-limb heel rise at the time of final follow-up. The average follow-up duration was 19.0 months. Flexor digitorum longus transfer has been studied extensively for stage II adult acquired flatfoot. However, the flexor digitorum longus has been shown to be much weaker relative to the posterior tibial tendon, and concern remains regarding its ability to recreate the force of the posterior tibial tendon. Our results demonstrate that posterior tibial tendon allograft reconstruction combined with flatfoot reconstruction is a reasonable option. This alternative has the advantage of preserving the stronger muscle without disturbing regional anatomy.
Assuntos
Calcâneo , Pé Chato , Disfunção do Tendão Tibial Posterior , Adulto , Aloenxertos , Pé Chato/diagnóstico por imagem , Pé Chato/cirurgia , Humanos , Disfunção do Tendão Tibial Posterior/diagnóstico por imagem , Disfunção do Tendão Tibial Posterior/cirurgia , Transferência Tendinosa , Tendões/cirurgiaRESUMO
Posterior tibial tendon dysfunction (PTTD) is a progressive disorder secondary to advanced degeneration of the posterior tibial tendon, leading to the abduction of the forefoot, valgus rotation of the hindfoot, and collapse of the medial longitudinal arch. Eventually, the disease becomes so advanced that it begins to affect the deltoid ligament over time. This attenuation and eventual tear of the deltoid ligament leads to valgus deformity of the ankle. Surgical correction of PTTD is performed to protect the ankle joint at all costs. Generally, this is performed using osteotomies of the calcaneus and repair or augmentation of the deltoid ligament. Unfortunately, there has been no universal procedure adapted by foot and ankle surgeons for repair or augmentation of the deltoid ligament. Articles have discussed the use of suture and suture anchors, suture tape, nonanatomic allograft repair, nonanatomic autograft repair with plantaris, peroneal and extensor halluces longus tendons to repair and augment the deltoid ligament. There is very little literature, however, in regard to using the posterior tibial tendon to augment the deltoid ligament in accordance with hindfoot fusion for end-stage PTTD deformity. In general, the posterior tibial tendon in triple and medial double arthrodesis is generally removed because it is thought to be a pain generator. This article presents a case study and novel technique using the posterior tibial tendon to augment and repair the laxity of the deltoid ligament in an advanced flatfoot deformity.
Assuntos
Ligamentos Articulares/cirurgia , Disfunção do Tendão Tibial Posterior/cirurgia , Transferência Tendinosa/métodos , Adulto , Humanos , MasculinoRESUMO
Lateral hindfoot pain associated with stage 2 to 3 adult-acquired flatfoot is often attributed to subfibular impingement. Preoperative magnetic resonance imaging (MRI) is generally performed to assess the extent of degeneration within the posterior tibial tendon, attenuation of medial soft tissue constraints, and degeneration of hindfoot and/or ankle articulations. The purpose of this study is to determine the incidence of lateral collateral ligament disease/injury associated with stages 2 and 3 adult-acquired flatfoot. The subjects were identified using a searchable computerized hospital database between 2015 and 2017. Stage 2 or 3 adult-acquired flatfoot deformity was confirmed in patients via chart review and MRI analysis. Lateral ankle ligament injury was confirmed using patient MRI results per the hospital radiologist and documented within the patients' chart. Inclusion criteria required that patients be diagnosed with Johnson and Strom stage 2 or 3 flatfoot deformity with documented lateral ankle pain and that preoperative MRI scans be available with the radiologist's report. Patient exclusion criteria included patients <18 years of age, patients with flatfoot deformity caused by previous trauma, tarsal coalition, neuropathic arthritis, patients with previous surgery, or patients with incomplete medical records. In total, 118 patients were identified with these parameters. Of the 118 patients, 74 patients (62.7%) had documented lateral ankle ligament injury on MRI. Of the 77 patients with stage 2 adult-acquired flatfoot, 55 (71.4%) had confirmed lateral ankle ligament injury on MRI. Of the 41 patients with stage 3 adult-acquired flatfoot, 19 (46.3%) had confirmed lateral ankle ligament injury on MRI. This study demonstrates a relatively high incidence of lateral ligament disease associated with adult-acquired flatfoot deformity. These findings might have long-term implications regarding ankle arthritis after surgical management of adult-acquired flatfoot.
Assuntos
Deformidades Adquiridas do Pé/epidemiologia , Ligamentos Laterais do Tornozelo/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Disfunção do Tendão Tibial Posterior/cirurgia , Amplitude de Movimento Articular/fisiologia , Adulto , Idoso , Traumatismos do Tornozelo/complicações , Traumatismos do Tornozelo/diagnóstico por imagem , Estudos de Coortes , Intervalos de Confiança , Bases de Dados Factuais , Feminino , Pé Chato/diagnóstico por imagem , Pé Chato/etiologia , Pé Chato/cirurgia , Deformidades Adquiridas do Pé/etiologia , Deformidades Adquiridas do Pé/fisiopatologia , Humanos , Ligamentos Laterais do Tornozelo/fisiopatologia , Ligamentos Laterais do Tornozelo/cirurgia , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos/métodos , Disfunção do Tendão Tibial Posterior/complicações , Disfunção do Tendão Tibial Posterior/diagnóstico por imagem , Prevalência , Prognóstico , Recuperação de Função Fisiológica/fisiologia , Estudos Retrospectivos , Medição de Risco , Estatísticas não Paramétricas , Resultado do TratamentoRESUMO
Como resultado de la insuficiencia del tendón tibial posterior (TTP), el arco longitudinal medial se derrumba en forma progresiva. Los intentos de restaurar la función del TTP mediante reparación directa no han sido satisfactorios. Por lo tanto, se ha recomendado la sustitución del TTP por medio de la transferencia de tendones aunque eso no corrige la deformidad. Debido a esto es necesario agregar una osteotomía. La osteotomía por preferencia es la medialización de la tuberosidad posterior del calcáneo. Respecto al método de fijación de la osteotomía existen diferentes alternativas de fijación. El objetivo del trabajo es presentar los resultados radiográficos y clínicos del tratamiento de la insuficiencia del TTP Grado II y sus deformidades resultantes mediante osteotomía de desplazamiento medial del calcáneo fijada con placa escalonada y otros procedimientos. (AU)
As a result of posterior tibial tendon insufficiency (PTT), the medial longitudinal arch collapses progressively. Attempts to restore the TTP function through direct repair have not been satisfactory.2 Therefore, TTP replacement has been recommended by means of tendon transfer although this does not correct the deformity. Because of this it is necessary to add an osteotomy. The osteotomy by preference is the medialization of the posterior tuberosity of the calcaneus. Regarding the fixation method of the osteotomy, there are different fixation alternatives. The objective of this study was to present the radiographic and clinical results of the treatment of TTP grade II insufficiency and its resulting deformities by osteotomy of the medial displacement of the calcaneus fixed with stepped plaque and other procedures. (AU)