Radiographic Outcomes in the Treatment of Type II Adult Acquired Flatfoot Deformity Following Lateral Column Lengthening with a Titanium Wedge versus Autograft or Allograft

Category: Midfoot/Forefoot Introduction/Purpose: Lateral column lengthening (LCL) is a surgical procedure used to manage forefoot abduction occurring in patients with stage IIB Adult Acquired Flat Foot Deformity (AAFD). This procedure utilizes an opening wedge osteotomy of the calcaneus which is then filled with autograft, allograft, or a titanium wedge. The primary aim of this study was to compare the radiographic outcomes of these different bone substitutes in the setting of stage IIB AAFD with the use of LCL. Methods: All patients who underwent LCL from October 2008 until October 2018 were retrospectively reviewed. Preoperative weight bearing radiographs, initial postoperative radiographs and 1-year weight bearing radiographs were reviewed. The following radiographic measurements were recorded: talonavicular uncoverage angle, incongruency angle, and calcaneal pitch. Results: A total of 44 patients were included in our study. The mean age of the cohort was 54 (range 18-74). The study cohort was divided into two groups. There were 17 (38.7%) patients that received a titanium wedge and 27 (61.5%) that received autograft or allograft. Patients that underwent LCL with the autograft/allograft group were significantly older (p=0.006). Patients who underwent LCL with a titanium wedge had a significantly higher preoperative talonavicular angle (p=0.013). There were no significant differences in post-operative talonavicular uncoverage angle, incongruency angle or calcaneal pitch at 6 months or 1 year. Conclusion: Adult acquired flat foot deformity is a difficult disorder to treat surgically. Lateral column lengthening is a common surgical procedure used to treat forefoot abduction that occurs. Our results show that at 6 months and 1 year no radiographic difference exists between autograft/allograft bone substitutes versus titanium wedge in LCL. Future research should evaluate the differences in patient reported outcomes between autograft/allograft versus titanium wedge bone substitutes. [Table: see text]

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A Retrospective Radiographic Evaluation of a Modified Method of Lateral Column Lengthening

Foot & Ankle Specialist ◽

10.1177/1938640020919187 ◽

2020 ◽

pp. 193864002091918

Author(s):

Keith Wapner ◽

Erik Freeland ◽

Gregory Kirwan ◽

Keith Baldwin

Keyword(s):

Weight Bearing ◽

Case Series ◽

Stage Ii ◽

Radiographic Evaluation ◽

Retrospective Case ◽

Lateral Column ◽

Modified Method ◽

Radiographic Outcomes ◽

Alternative Approach ◽

Lateral Column Lengthening

Background: Lateral column lengthening (LCL) is a commonly performed procedure for patients with stage II adult-acquired flatfoot deformity (AAFD) to correct forefoot abduction. This procedure is frequently completed concomitantly with both soft-tissue and bony procedures, including a medial slide calcaneal osteotomy to further reduce hindfoot valgus. The purpose of this study is to investigate and identify the radiographic outcomes of a modified step-cut LCL utilized as an alternative approach for correction of stage II AAFD. Methods: A retrospective radiographic review was performed on 15 feet in 14 patients who underwent correction of stage II AAFD using a step-cut LCL between August 2009 and January 2012. Two independent examiners utilizing 6 radiographic parameters evaluated preoperative and postoperative weight-bearing radiographs of the foot. Results: At a mean follow-up of 13.4 (range 12-16) weeks, weight-bearing radiographs demonstrated a significant median decrease in the lateral talometatarsal angle of 14.4° (P < .001), lateral talocalcaneal angle of 7° (P < .001), anteroposterior talometatarsal angle of 14.5° (P < .001), anteroposterior talocalcaneal angle of 5.5° (P < .001), and talonavicular coverage angle of 26.5° (P < .001). Additionally, a significant median increase in calcaneal pitch of 8.5° (P < .001) was noted. Conclusion: This study demonstrates statistically significant improvement of radiographic outcomes with use of a modified step-cut LCL as an alternative approach for correction of stage II AAFD. Levels of Evidence: Level IV: Retrospective case series

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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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A biomechanical analysis of the effect of lateral column lengthening calcaneal osteotomy on the flat foot

Clinical Biomechanics ◽

10.1016/j.clinbiomech.2006.11.004 ◽

2007 ◽

Vol 22 (4) ◽

pp. 472-477 ◽

Cited By ~ 28

Author(s):

George A. Arangio ◽

Vikram Chopra ◽

Arkady Voloshin ◽

Eric P. Salathe

Keyword(s):

Biomechanical Analysis ◽

Flat Foot ◽

Lateral Column ◽

Calcaneal Osteotomy ◽

Lateral Column Lengthening

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Consensus for the Indication of Lateral Column Lengthening in the Treatment of Progressive Collapsing Foot Deformity

Foot & Ankle International ◽

10.1177/1071100720950732 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1286-1288

Author(s):

David B. Thordarson ◽

Lew C. Schon ◽

Cesar de Cesar Netto ◽

Jonathan T. Deland ◽

Scott J. Ellis ◽

...

Keyword(s):

Subtalar Joint ◽

Consensus Statement ◽

Talonavicular Joint ◽

Foot Deformity ◽

Foot Care ◽

Level Of Evidence ◽

Lateral Column ◽

Fluoroscopic Imaging ◽

Lateral Column Lengthening ◽

Important Sign

Recommendation: Progressive collapsing foot deformity (PCFD) is a complex 3D deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot supination. Although a medial displacement calcaneal osteotomy can correct heel valgus, it has far less ability to correct forefoot abduction. More severe forefoot abduction, most frequently measured preoperatively by assessing talonavicular coverage on an anteroposterior (AP) weightbearing conventional radiographic view of the foot, can be more effectively corrected with a lateral column lengthening procedure than by other osteotomies in the foot. Care must be taken intraoperatively to not overcorrect the deformity by restricting passive eversion of the subtalar joint or causing adduction at the talonavicular joint on simulated AP weightbearing fluoroscopic imaging. Overcorrection can lead to lateral column overload with persistent lateral midfoot pain. The typical amount of lengthening of the lateral column is between 5 and 10 mm. Level of Evidence: Level V, consensus, expert opinion. CONSENSUS STATEMENT ONE: Lateral column lengthening (LCL) procedure is recommended when the amount of talonavicular joint uncoverage is above 40%. The amount of lengthening needed in the lateral column should be judged intraoperatively by the amount of correction of the uncoverage and by adequate residual passive eversion range of motion of the subtalar joint. Delegate vote: agree, 78% (7/9); disagree, 11% (1/9); abstain, 11% (1/9). (Strong consensus) CONSENSUS STATEMENT TWO: When titrating the amount of correction of abduction deformity intraoperatively, the presence of adduction at the talonavicular joint on simulated weightbearing fluoroscopic imaging is an important sign of hypercorrection and higher risk for lateral column overload. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus) CONSENSUS STATEMENT THREE: The typical range for performing a lateral column lengthening is between 5 and 10 mm to achieve an adequate amount of talonavicular coverage. Delegate vote: agree, 100% (9/9); disagree, 0%; abstain, 0%. (Unanimous, strongest consensus)

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Comparison of Radiographic Outcomes Between Dynamic Medial Column Stabilization and Lateral Column Lengthening

Foot & Ankle Orthopaedics ◽

10.1177/2473011416s00068 ◽

2016 ◽

Vol 1 (1) ◽

pp. 2473011416S0006

Author(s):

Woo-Chun Lee ◽

Ji-Beom Kim ◽

Young Yi ◽

Jae-Young Kim

Keyword(s):

Lateral Column ◽

Radiographic Outcomes ◽

Lateral Column Lengthening

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Graft Collapse and Loss of Fixation in Lateral Column Lengthening

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00177 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0017

Author(s):

Christina E. Freibott ◽

Seth C. Shoap ◽

Maria C. Evangelista ◽

J. Turner Vosseller ◽

Justin K. Greisberg

Keyword(s):

Iliac Crest ◽

Proximal Tibia ◽

Weight Bearing ◽

Case Series ◽

High Rate ◽

Hindfoot Alignment ◽

Lateral Column ◽

Second Surgery ◽

Lateral Column Lengthening

Category: Ankle Introduction/Purpose: Lateral Column lengthening through an osteotomy of the anterior process of the calcaneus is one of the most effective procedures for restoring arch alignment in the adult acquired flatfoot, without fusing essential joints. Despite remarkable radiographic corrections, previous studies have found persistent lateral hindfoot pain remains a challenge. In this study, we reviewed a large series of patients who underwent lateral column lengthening as part of flat foot reconstructive surgery, using either autograft or allograft. Rates of graft collapse and loss of fixation were determined with two different graft sources. Methods: After Institutional Review Board approval, all patients who underwent lateral column lengthening between 2002 and 2018 were reviewed for clinical and radiographic outcomes. Variables such as age, gender, diagnosis, type of bone graft, subsequent surgery, screw/hardware breakage, length of follow-up, time until weight bearing, and length of radiographic follow-up were recorded. Approximately half the patients had iliac crest allograft for the distraction, and the others had proximal tibial structural autograft. Results: 52 patients met inclusion criteria. The average age was 47±14 years (range 18-86), with 32 women (62%) and 20 men (38%). 25 (48%) patients had a second surgery, most often for hardware removal. Two patients had repair of a nonunion. Twenty- five percent of patients who had proximal tibial autograft had hardware breakage and some degree of graft collapse, whereas none had hardware breakage in the iliac crest allograft group (p<0.05). Twenty-one of the 36 patients in the proximal tibia autograft group underwent a second surgery for persistent lateral column pain, with removal of hardware and bone debridement, compared to only 4 in the allograft group (p<0.05). Conclusion: Proximal tibia autograft performed relatively poorly in this case series, with a higher rate of graft collapse and lateral column pain. The allograft group had less complications, but even in this group, the rate of revision surgery is higher than might be expected for foot surgery in general. Lateral column lengthening is a powerful procedure for restoring hindfoot alignment without sacrificing essential joints, but suffers from a relatively high rate of persistent lateral column pain (which usually is not present prior to surgery) and reoperation.

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Outcome of Bunion Correction with First Tarsometatarsal Arthrodesis in Adult Acquired Flatfoot Deformity Correction

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00124 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0012

Author(s):

Thomas B. Bemenderfer ◽

Jacob B. Boersma ◽

Michael J. Pryor ◽

John D. Maskill ◽

Donald R. Bohay ◽

...

Keyword(s):

Hallux Valgus ◽

Wound Care ◽

Weight Bearing ◽

Case Series ◽

Deformity Correction ◽

Lateral Column ◽

Radiographic Outcomes ◽

Radiographic Measurements ◽

Tertiary Center ◽

Adult Acquired Flatfoot Deformity

Category: Bunion; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Arthrodesis of the first tarsometatarsal (TMT-1) joint is a widely accepted procedure for treatment of hallux valgus (HV) with medial column instability secondary to unstable first ray, midfoot arthritis, and severe or recurrent deformities with high intermetatarsal angles (IMA). This study aimed to evaluate clinical and radiographic outcomes in patients with mild-to-severe HV who underwent TMT-1 arthrodesis and proximal hindfoot correction for adult acquired flatfoot deformity (AAFD). Methods: All patients with symptomatic HV and AAFD who failed conservative management underwent TMT-1 fusion and proximal hindfoot correction (medial displacement calcaneal osteotomy, lateral column lengthening, subtalar fusion, or tibiotalocalcaneal fusion) by one of three senior foot and ankle surgeons at a single tertiary center between January 2006 and December 2018 were included in our retrospective case series. Demographics, clinical outcomes, patient comorbidity information, and radiographic outcomes including hallux valgus angle (HVA), IMA 1-2, hallux valgus interphalangeus angle, distal metatarsal articular angle, and sesamoid station were collected. The primary outcome was change in HVA measured as the difference between final postoperative and preoperative weight bearing HVA measurements. Secondary outcomes were reoperation, minor complications (local wound care, use of antibiotics, and skin dehiscence), and change in radiographic measurements. Results: With an average follow up of 26 months, 155 patients (17.4% male, 82.6% female; average age 59.0 years old, range 18 to 84) met inclusion. The average change in HVA was -18.6 degrees (range +15.8 to -81.0). There was a total of 85 reoperations in 35.5% (n=55; 48 hardware removal). Minor complications were present in 18.7% (n=29; 25 local wound care, 23 use of antibiotics, and 10 skin dehiscence). 44.5% (n=69) had no evidence of recurrent HV while mild, moderate, and severe grade bunions were present in 40.0% (n=62), 5.2% (n=8), and 0.6% (n=1). Improvement in overall bunion grade was maintained in 69.7% (n=108) with no change in 19.4% (n=30). Hallux varus was present in 9.7% (n=15; 3 underwent TMT-1 arthrodesis). Conclusion: The present study demonstrates a significant improvement in HVA following TMT-1 arthrodesis and proximal hindfoot correction for AAFD. The majority of patients undergoing TMT-1 arthrodesis and proximal hindfoot correction for AAFD obtain and maintain improvement in the radiographic severity of their bunions. However, patients should be counseled concerning expectations with regards to outcomes associated with complex AAFD reconstructions.

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Patient-Reported Outcomes and Radiographic Assessment in Primary and Revision Stage II, III, and IV Progressive Collapsing Foot Deformity Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011421992111 ◽

2021 ◽

Vol 6 (1) ◽

pp. 247301142199211

Author(s):

Rusheel Nayak ◽

Milap S. Patel ◽

Anish R. Kadakia

Keyword(s):

Patient Reported Outcomes ◽

Statistical Significance ◽

Stage Ii ◽

Foot Deformity ◽

Primary Stage ◽

Radiographic Outcomes ◽

Metatarsal Angle ◽

Medial Cuneiform ◽

Significant Difference ◽

Patient Reported

Background: Progressive collapsing foot deformity (PCFD) is a progressive hindfoot and midfoot deformity causing pain and disability. Although operative treatment is stage dependent, few studies have looked at patient-reported and radiographic outcomes stratified by primary vs revision stage II, III, and IV reconstruction surgery. Our goal was to assess operative improvement using Patient-Reported Outcomes Measurement Information System (PROMIS) and to determine whether radiographic parameter improvement correlates with patient-reported outcomes. Methods: PROMIS Physical Function (PF) and Pain Interference (PI) scores were prospectively obtained on 46 consecutive patients who underwent PCFD reconstruction between November 2013 and January 2019. Thirty-six patients completed pre- and postoperative PROMIS surveys, 6 patients completed only preoperative PROMIS surveys, and 4 patients completed 12-month postoperative PROMIS surveys but did not complete preoperative PROMIS surveys. Minimum follow-up was 12 (average, 23) months. Radiographic correction was measured with pre- and postoperative weightbearing radiographs and correlated with PROMIS scores. Measurements included the talonavicular uncoverage angle, talonavicular uncoverage percentage, anteroposterior talo–first metatarsal angle, Meary angle, medial cuneiform height (MCH), and medial cuneiform–fifth metatarsal height. Results: For the overall cohort, PROMIS PF increased significantly from 37.5±5.6 to 42.3±7.1 ( P = .0014). PROMIS PI improved significantly from 64.5±6.0 to 55.1±9.8 ( P < .0001). Preoperative, postoperative, and change in PROMIS scores were not statistically different between PCFD stages. Change in PROMIS PI was significantly greater in primary (–12.3) vs revision (–3.7) surgery ( P = .0157). Change in PROMIS PF was greater in primary (+6.0) vs revision surgery (+2.3) but did not reach statistical significance. All radiographic measurements improved significantly ( P < .05). In primary stage II PCFD, postoperative PROMIS scores correlated with postoperative MCH (PF: r = 0.7725, P = .0020; PI: r = –0.5692, P = .0446). Conclusion: Patient-reported and radiographic outcomes improved significantly after PCFD reconstruction. We found no significant difference in preoperative, postoperative, or change in PROMIS scores between PCFD stages. However, stage III patients had smaller improvements in PROMIS PF, which we feel may be secondary to change in function after arthrodesis. Primary operations had better patient-reported outcomes compared to revision operations. In primary stage II PCFD, reconstructing the medial arch height correlated significantly with improvement in pain and functionality. Level of Evidence: Level II, prospective cohort study.

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PO 18239 - Malerba Z-type osteotomy for the treatment of adult acquired flatfoot deformity

Scientific Journal of the Foot & Ankle ◽

10.30795/scijfootankle.2019.v13.1050 ◽

2019 ◽

Vol 13 (Supl 1) ◽

pp. 55S

Author(s):

Nacime Salomão Barbachan Mansur ◽

Lucas Furtado da Fonseca ◽

André Vitor Kerber Cavalcante Lemos ◽

Vinicius Felipe Pereira ◽

Celso Garreta Parts Dias ◽

...

Keyword(s):

Weight Bearing ◽

Deformity Correction ◽

Triceps Surae ◽

Tarsal Tunnel ◽

Flat Foot ◽

Essential Condition ◽

Radiographic Outcomes ◽

Tissue Healing ◽

Pain Visual Analog Scale ◽

Limb Deformities

Introduction: Adult acquired flat foot deformity (AAFD) is a condition characterized by tendon and ligament failure that leads to progressive midfoot collapse and to hindfoot valgus. Calcaneal osteotomies are among the oldest and most conventional procedures for the treatment of angular limb deformities; they aim to reestablish the alignment and the line of action vector of the triceps surae muscle. Various disadvantages of classic osteotomies have been established in recent years, such as fixation loss, insufficient correction and reduced tarsal tunnel volume. Malerba Z-type osteotomy aims to resolve possible complications resulting from the usual incisions, to enhance the procedure and to allow multiplane corrections. Objective: To describe the functional and radiographic outcomes of Malerba Z-type osteotomy in patients with AAFD subjected to reconstructive surgery. Methods: Ten patients diagnosed with AAFD, with a mean age of 45 years (35-55), were operated on from January 2017 to January 2018. All patients underwent weight-bearing radiographs and alignment measurements and functional assessment using the pain visual analog scale (VAS) and the American Orthopedic Foot and Ankle Society (AOFAS) scale preoperatively and at the final evaluation at a mean of 12 months (6-18 months) after surgery. Results: The 10 patients showed positive progression after the surgery, reporting no major complications. Only one case of superficial dehiscence and one case of transient sural nerve neuropraxia (in different patients) were observed. On average, the AOFAS score increased by 50 points on average (25.7 to 76.6), and the VAS score decreased by 4 points (8.3 to 3.4). The mean calcaneal pitch increased from 5.5° to 15.2°. Nine patients transitioned from valgus malalignment (hindfoot angle greater than 10°) to the physiological (5 to 10° valgus) range. Conclusion: Ankle-foot realignment is an essential condition for surgical success in AAFD; it promotes a soft-tissue healing environment while maintaining an adequate muscle line of action. Malerba Z-type osteotomy was found to be a safe technique with high potential for deformity correction, leading to functional and radiographic improvement in patients who undergo this surgery.

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