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
Tarsometatarsal joint arthrodesis is a commonly accepted procedure for hallux valgus associated with severe deformity and first ray hypermobility or medial column instability. This study evaluates the correction of hallux valgus deformity and the maintenance of correction with and without the use of a stabilization screw between the first and second metatarsal bases. Through retrospective review of first tarsometatarsal joint arthrodesis within our institution we evaluated 63 patients. Twenty-seven patients did not have a first to second metatarsal base screw and were placed into the no screw cohort. Thirty-six patients did have a first to second metatarsal base screw and were placed into the screw cohort. This study population had an osseous union rate of 95%. Clinical and radiographic recurrence occurred in 5 of 63 patients (8%). At 1-y postop the measurements demonstrated that the screw cohort had an average intermetatarsal angle correction of 11.6 degrees while the no screw cohort had an average correction of 7.8 degrees. Additionally, at 1-y postop the screw cohort had greater maintenance of the intermetatarsal angle correction with an average change of 0.5 degrees compared to 2.3 degrees in the no screw cohort. We conclude that the addition of the stabilization screw improves the first tarsometatarsal joint arthrodesis construct resulting in a greater degree of realignment and maintenance of correction.
RESUMO
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
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
Long-segment disease involving the insertional region of the Achilles tendon can be a challenging problem. These patients often have significant disability and functional problems. Surgical management requires some type of tissue replacement, regional tissue rearrangement or tendon transfer. Various types of allograft tissue as well as synthetic materials have been described. Patients often have residual weakness and functional deficits following surgery. We have utilized an Achilles tendon-bone block allograft in combination with a flexor hallucis longus tendon transfer for long-segment Achilles tendon deficits involving the insertion. A retrospective review was performed on this group of patients to assess complication rates. A chart review was performed on 14 patients who underwent this procedure. The average postoperative follow-up duration was 24.7 months (range 6-48). Postoperatively, all patients exhibited grade 5 muscle strength with manual muscle testing and 12 of 14 patients were able to perform a single limb heel rise. This case series reviews the surgical technique as well as the patient demographics and complication rates. This procedure has been reliable for those patients with long-segment Achilles tendon deficits involving the insertion who desire to resume a high demand occupation or active lifestyle. The complication rate is relatively low.
Assuntos
Tendão do Calcâneo , Tendinopatia , Tendão do Calcâneo/cirurgia , Aloenxertos , Humanos , Estudos Retrospectivos , Ruptura , Tendinopatia/cirurgia , Transferência TendinosaRESUMO
The purpose of this study is to demonstrate the effect of first tarsometatarsal (modified Lapidus) arthrodesis on hindfoot alignment. We reviewed the radiographs of 39 patients, 40 feet (16 right feet and 24 left feet in 6 males and 34 females; mean age 43 years) who underwent hallux valgus reconstruction and isolated first tarsometatarsal arthrodesis. Patients who had ancillary osseous procedures were excluded from the study, with the exception of proximal phalangeal osteotomy to address hallux interphalangeus. The mean time to follow up was 33.78 weeks (8.45 months), median 21.5 weeks. Statistically significant differences were found between preoperative and postoperative measurements for talar declination (-3.3 ± 3.5), lateral talocalcaneal angle (-3.1 ± 3.9), lateral Meary's angle (-4.2 ± 4.9), medial cuneiform height (3.5 ± 4.6), medial cuneiform to fifth metatarsal distance (4.7 ± 4.5), AP talocalcaneal angle (-2.8 ± 5.3), and percentage of talar head uncovering (-6.6 ± 7.6). Our results suggest that first tarsometatarsal arthrodesis can affect hindfoot alignment on AP and lateral radiographs.
Assuntos
Artrodese , Hallux Valgus , Ossos do Metatarso , Ossos do Tarso , Adulto , Feminino , Hallux Valgus/diagnóstico por imagem , Hallux Valgus/cirurgia , Humanos , Masculino , Ossos do Metatarso/diagnóstico por imagem , Ossos do Metatarso/cirurgia , 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
Subtalar joint distraction arthrodesis has been recommended for the treatment of conditions such as nonunion or malunion of subtalar joint arthrodesis posttraumatic arthritis. Both conditions are difficult to treat, because the deformities created in the frontal and sagittal planes of these conditions are complex. If these malalignments are not addressed, ankle joint instability and wear occur over time. In general, either autograft or allograft bone has been used to perform distraction arthrodesis of the subtalar joint. Although studies have shown successful use, there have been complications. Autografts have resulted in donor site morbidity and limitations on graft size, and allografts have shown high nonunion rates. Both autografts and allografts have shown graft collapse over time. Recent literature has discussed the use of tantalum technology to span large defects in bone healing. Studies have shown that tantalum provides superior strength and bone incorporation compared with autografts and allografts. This case series presents 2 cases in which tantalum truss technology was used for distraction arthrodesis. Although this series is limited in patient numbers, both cases show effective graft incorporation with no loss in height over time and earlier return to activity compared with previous studies that used autograft and allograft wedges.
Assuntos
Artrite/cirurgia , Artrodese/métodos , Calcâneo/lesões , Fraturas Mal-Unidas/cirurgia , Articulação Talocalcânea/cirurgia , Tornozelo/diagnóstico por imagem , Artrite/etiologia , Calcâneo/diagnóstico por imagem , Feminino , Fraturas Ósseas/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Osteogênese por Distração , Complicações Pós-Operatórias/cirurgia , Radiografia , Amplitude de Movimento Articular , Articulação Talocalcânea/diagnóstico por imagem , Titânio , Tomografia Computadorizada por Raios XRESUMO
Calcific insertional Achilles tendinopathy (CIAT) is a relatively common musculoskeletal entity that results in significant pain and disability, as well as posterior muscle group weakness. There is a lack of evidence criteria to support the timing of operative intervention, choice of procedures, or whether equinus requires treatment. The purpose of this study was to retrospectively review 45 patients (48 feet) who have undergone surgical management of CIAT with concomitant posterior muscle group weakness with the single heel rise testing. All patients underwent debridement and repair of the Achilles tendon with reattachment of the Achilles tendon to the calcaneus, ostectomy of the calcaneus, and flexor hallucis longus tendon transfer. Those patients with equinus also underwent gastrocnemius recession. The focus includes patient-reported satisfaction, time to return to normal shoe gear, and the incidence of revision surgery. The overall average of time to weightbearing was 4.3 weeks. After surgery, 73.3% (nâ¯=â¯33) of the 45 patients responded to the following question: "Would you have this surgery done again?" Of these patients, 93.9% (nâ¯=â¯31) responded "Yes" and 6.1% (nâ¯=â¯2) responded "Unsure." Of the same 33 patients, 84.8% (nâ¯=â¯28) responded that they were "Very Satisfied" with the procedure and 15.2% (nâ¯=â¯5) responded that they were "Satisfied." Twelve patients (26.7%) did not respond to either question. One of the 12 patients (8.3%) who did not respond had bilateral procedures. None of the patients experienced tendon rupture, deep vein thrombosis, or the need for revision surgery. Four patients (8%) experienced a superficial infection, whereas 1 patient (2%) had development of a deep infection. No correlations were found when looking at the relationship between body mass index and return to weightbearing/normal shoe gear with Spearman analysis.