Progressive Collapsing Foot Deformity: Consensus on Goals for Operative Correction

Recommendation: In the treatment of progressive collapsing foot deformity (PCFD), the combination of bone shape, soft tissue failure, and host factors create a complex algorithm that may confound choices for operative treatment. Realignment and balancing are primary goals. There was consensus that preservation of joint motion is preferred when possible. This choice needs to be balanced with the need for performing joint-sacrificing procedures such as fusions to obtain and maintain correction. In addition, a patient’s age and health status such as body mass index is important to consider. Although preservation of motion is important, it is secondary to a stable and properly aligned foot. Level of Evidence: Level V, consensus, expert opinion.

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Consensus for the Use of Weightbearing CT in the Assessment of Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950734 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1277-1282

Author(s):

Cesar de Cesar Netto ◽

Mark S. Myerson ◽

Jonathan Day ◽

Scott J. Ellis ◽

Beat Hintermann ◽

...

Keyword(s):

Computed Tomography ◽

Expert Opinion ◽

Subtalar Joint ◽

Surgical Planning ◽

Foot Deformity ◽

Level Of Evidence ◽

Hindfoot Alignment ◽

Sinus Tarsi ◽

Weightbearing Ct ◽

Consensus Expert

Recommendation: There is evidence that the use of WEIGHTBEARING imaging aids in the assessment of progressive collapsing foot deformity (PCFD). The following WEIGHTBEARING conventional radiographs (CRs) are necessary in the assessment of PCFD patients: anteroposterior (AP) foot, AP or mortise ankle, and lateral foot. If available, a hindfoot alignment view is strongly recommended. If available, WEIGHTBEARING computed tomography (CT) is strongly recommended for surgical planning. When WEIGHTBEARING CT is obtained, important findings to be assessed are sinus tarsi impingement, subfibular impingement, increased valgus inclination of the posterior facet of the subtalar joint, and subluxation of the subtalar joint at the posterior and/or middle facet. Level of Evidence: Level V, consensus, expert opinion.

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Titrating the Amount of Bony Correction in Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950741 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1292-1295

Author(s):

Scott J. Ellis ◽

Jeffrey E. Johnson ◽

Jonathan Day ◽

Cesar de Cesar Netto ◽

Jonathan T. Deland ◽

...

Keyword(s):

Reconstructive Surgery ◽

Wedge Osteotomy ◽

Foot Deformity ◽

Level Of Evidence ◽

Opening Wedge ◽

Lateral Column ◽

Medial Cuneiform ◽

Lateral Column Lengthening ◽

Typical Range ◽

Consensus Expert

Recommendation: There is evidence indicating that the amount of bony correction performed in the setting of progressive collapsing foot deformity reconstructive surgery can be titrated within a recommended range for a variety of procedures. The typical range when performing a medial displacement calcaneal osteotomy should be 7 to 15 mm of medialization of the tuberosity. The typical range when performing an Evans lateral column lengthening should be 5 to 10 mm of a laterally based wedge in the anterior calcaneus. The typical range when performing a plantarflexion opening wedge osteotomy of the medial cuneiform (Cotton) osteotomy should be 5 to 10 mm of a dorsal wedge. Level of Evidence: Level V, consensus, expert opinion.

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Consensus for the Indication of a Medializing Displacement Calcaneal Osteotomy in the Treatment of Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950747 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1282-1285 ◽

Cited By ~ 1

Author(s):

Lew C. Schon ◽

Cesar de Cesar Netto ◽

Jonathan Day ◽

Jonathan T. Deland ◽

Beat Hintermann ◽

...

Keyword(s):

Achilles Tendon ◽

Vertical Axis ◽

Longitudinal Axis ◽

Lateral Position ◽

Foot Deformity ◽

Level Of Evidence ◽

Calcaneal Osteotomy ◽

Distal Aspect ◽

Typical Range ◽

Consensus Expert

Recommendation: There is evidence that the medial displacement calcaneal osteotomy (MDCO) can be effective in treating the progressive collapsing foot deformity (PCFD). This juxta-articular osteotomy of the tuberosity shifts the mechanical axis of the calcaneus from a more lateral position to a more medial position, which provides mechanical advantage in the reconstruction for this condition. This also shifts the action of the Achilles tendon medially, which minimizes the everting deforming effect and improves the inversion forces. When isolated hindfoot valgus exists with adequate talonavicular joint coverage (less than 35%-40% uncoverage) and a lack of significant forefoot supination, varus, or abduction, we recommend performing this osteotomy as an isolated bony procedure, with or without additional soft tissue procedures. The clinical goal of the hindfoot valgus correction is to achieve a clinically neutral heel, as defined by a vertical axis from the heel up the longitudinal axis of the Achilles tendon and distal aspect of the leg. The typical range when performing a MDCO, while considering the location and rotation of the osteotomy, is 7 to 15 mm of correction. Level of Evidence: Level V, consensus, expert opinion.

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Consensus on Indications for Medial Cuneiform Opening Wedge (Cotton) Osteotomy in the Treatment of Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950739 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1289-1291

Author(s):

Jeffrey E. Johnson ◽

Bruce J. Sangeorzan ◽

Cesar de Cesar Netto ◽

Jonathan T. Deland ◽

Scott J. Ellis ◽

...

Keyword(s):

Varus Deformity ◽

Radiographic Examination ◽

Foot Deformity ◽

Level Of Evidence ◽

Opening Wedge ◽

Medial Cuneiform ◽

Varus Angulation ◽

Forefoot Varus ◽

Varus Position ◽

Consensus Expert

Recommendation: Forefoot varus is a physical and radiographic examination finding associated with the Progressive Collapsing Foot Deformity (PCFD). Varus position of the forefoot relative to the hindfoot is caused by medial midfoot collapse with apex plantar angulation of the medial column. Some surgeons use the term forefoot supination to describe this same deformity (see Introduction section with nomenclature). Correction of this deformity is important to restore the weightbearing tripod of the foot and help resist a recurrence of foot collapse. When the forefoot varus deformity is isolated to the medial metatarsal and medial cuneiform, correction is indicated with an opening wedge medial cuneiform (Cotton) osteotomy, typically with interposition of an allograft bone wedge from 5 to 11 mm in width at the base. When the forefoot varus is global, involving varus angulation of the entire forefoot and midfoot relative to the hindfoot, other procedures are needed to adequately correct the deformity. Level of Evidence: Level V, consensus, expert opinion.

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Analysis of anterior soft tissue thickness using ultrasonogram, body mass index and neck circumference in predicting difficult intubation

MedPulse International Journal of Anesthesology ◽

10.26611/1015718 ◽

2018 ◽

Vol 7 (1) ◽

pp. 40-42

Author(s):

B Ravindran ◽

◽

V Murali Magesh ◽

B Vignesh ◽

K Vinoth Kumar ◽

...

Keyword(s):

Body Mass Index ◽

Soft Tissue ◽

Body Mass ◽

Difficult Intubation ◽

Neck Circumference ◽

Tissue Thickness ◽

Soft Tissue Thickness

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Confirming Proper Button Deployment of Suspensory Fixation During ACL Reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120974349 ◽

2021 ◽

Vol 9 (1) ◽

pp. 232596712097434

Author(s):

Daniel F. O’Brien ◽

Lilah Fones ◽

Victoria Stoj ◽

Cory Edgar ◽

Katherine Coyner ◽

...

Keyword(s):

Soft Tissue ◽

Acl Reconstruction ◽

Sports Medicine ◽

Cruciate Ligament ◽

Case Series ◽

Graft Fixation ◽

Level Of Evidence ◽

Lateral Cortex ◽

Suture Button ◽

Suspensory Fixation

Background: Suspensory fixation of anterior cruciate ligament (ACL) reconstruction (ACLR) grafts has emerged as a popular device for femoral graft fixation. However, improper deployment of the suspensory fixation can compromise proper graft tensioning, leading to failure and revision. Also, soft tissue interposition between the button and bone has been associated with graft migration and pain, occasionally requiring revision surgery. Many surgeons rely on manual testing and application of distal tension to the graft to confirm proper button deployment on the lateral cortex of the femur for ACL graft fixation. Purpose: To determine the reliability of the manual resistance maneuver when applying distal tension to deploy the suspensory device along the lateral cortex of the femur. Study Design: Case series; Level of evidence, 4. Methods: All patients undergoing ACLR with a suture button suspensory device for femoral fixation were eligible for enrollment in the study. The surgeries were performed by 3 board-certified, sports medicine fellowship–trained orthopaedic surgeons at a single outpatient surgical center between May 2018 and June 2019. All grafts were passed in a retrograde manner into the femoral tunnel, and a vigorous manual tensioning maneuver in a distal direction was placed on the graft to deploy and secure along the lateral cortex of the femur. Intraoperative mini c-arm fluoroscopy was obtained to demonstrate proper suture button positioning. If interposing tissue or an improperly flipped button was identified, rectifying steps were undertaken and recorded. Results: A total of 51 patients with a mean age of 33.3 years were included in the study. Of these patients, 74.5% had normal suture button positioning identified via intraoperative fluoroscopic imaging, while 15.7% had interposed soft tissue and 9.8% had an improperly flipped button. In all cases, the surgeon was able to rectify the malpositioning intraoperatively. Conclusion: Despite the manual sensation of proper suspensory button positioning, intraoperative fluoroscopy identified suture button deployment errors in ACLR 25% of the time. Correcting the malpositioning is not technically demanding. These findings advocate for routine intraoperative surveillance to confirm appropriate suture button seating during ACLR.

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Soft tissue abnormalities in Wassel Type VI radial polydactyly: a detailed anatomical study

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193421990212 ◽

2021 ◽

Vol 46 (4) ◽

pp. 352-359

Author(s):

Susumu Saito ◽

Itaru Tsuge ◽

Hiroki Yamanaka ◽

Naoki Morimoto

Keyword(s):

Soft Tissue ◽

Three Dimensional ◽

Anatomical Study ◽

Metacarpophalangeal Joint ◽

Abductor Pollicis Brevis ◽

Level Of Evidence ◽

Thenar Muscle ◽

Pulley System ◽

Radial Deviation ◽

Tissue Abnormalities

Wassel VI radial polydactyly is associated with metacarpal adduction and radial deviation of the metacarpophalangeal joint of the ulnar duplicate. The soft tissue abnormalities responsible for these deformities were characterized using preoperative multi-planar three-dimensional ultrasound and intraoperative observation in four patients. In all patients, the abductor pollicis brevis and superficial head of the flexor pollicis brevis inserted into the radial first metacarpal, whereas the adductor pollicis and deep head of the flexor pollicis brevis inserted into the ulnar thumb. Aberrant location of the flexor pollicis longus and absence of the A1 pulley system was associated with severe radial deviation. An additional superficial thenar muscle along the ulnar metacarpal was associated with minimal metacarpal adduction. Uneven forces on the ulnar duplicate could be associated with these characteristic deformities and joint instability. Knowledge of these abnormalities allows better planning of surgery and further insight into this rare radial polydactyly configuration. Level of evidence: II

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Distal Tibiofibular Syndesmotic Widening in Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720982907 ◽

2021 ◽

pp. 107110072098290

Author(s):

Elijah Auch ◽

Nacime Salomao Barbachan Mansur ◽

Thiago Alexandre Alves ◽

Christopher Cychosz ◽

Francois Lintz ◽

...

Keyword(s):

Case Control Study ◽

Mean Difference ◽

Foot And Ankle ◽

Spearman Correlation ◽

Foot Deformity ◽

Weak Correlation ◽

Level Of Evidence ◽

Valgus Instability ◽

Retrospective Comparative Study ◽

Control Study

Background: Lateral overload in progressive collapsing foot deformity (PCFD) takes place as hindfoot valgus, peritalar subluxation, and valgus instability of the ankle increase. Fibular strain due to chronic lateral impingement may lead to distraction forces over the distal tibiofibular syndesmosis (DTFS). This study aimed to assess and correlate the severity of the foot and ankle offset (FAO) as a marker of progressive PCFD with the amount of DTFS widening and to compare it to controls. Methods: In this case-control study, 62 symptomatic patients with PCFD and 29 controls who underwent standing weightbearing computed tomography (WBCT) examination were included. Two fellowship-trained blinded orthopedic foot and ankle surgeons performed FAO (%) and DTFS area measurements (mm2). DTFS was assessed semiautomatically on axial-plane WBCT images, 1 cm proximal to the apex of the tibial plafond. Values were compared between patients with PCFD and controls, and Spearman correlation between FAO and DTFS area measurements was assessed. P values of less than .05 were considered significant. Results: Patients with PCFD demonstrated significantly increased FAO and DTFS measurements in comparison to controls. A mean difference of 6.9% ( P < .001) in FAO and 10.4 mm2 ( P = .026) in DTFS was observed. A significant but weak correlation was identified between the variables, with a Þ of 0.22 ( P = .03). A partition predictive model demonstrated that DTFS area measurements were highest when FAO values were between 7% and 9.3%, with mean (SD) values of 92.7 (22.4) mm2. Conclusion: To our knowledge, this was the first study to assess syndesmotic widening in patients with PCFD. We found patients with PCFD to demonstrate increased DTFS area measurements compared to controls, with a mean difference of approximately 10 mm2. A significantly weak positive correlation was found between FAO and DTFS area measurements, with the highest syndesmotic widening occurring when FAO values were between 7% and 9.3%. Our study findings suggest that chronic lateral impingement in patients with PCFD can result in a negative biomechanical impact on syndesmotic alignment, with increased DTFS stress and subsequent widening. Level of Evidence: Level III, retrospective comparative study.

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