A morphometric study on the articulating facets of talus in North Indian population

Background: Morphometry of talus will be helpful for radiologists, orthopaedicians and surgeons for diagnosis and treatment of talar fractures and making bone prosthesis. Aims and Objectives: The purpose of our study is to do a morphometric analysis of talus to facilitate orthopedicians in planning surgeries for subtalar implants and foot prostheses. This will be of great use to forensic anthropologists. Materials and Methods: For the study, 60 dry adult human tali (24 left and 26 right) were obtained from the Department of Anatomy, SGT Medical College, Budhera. The morphometry of talar surfaces was done using a digital caliper accurate to 0.01 mm and data was recorded. Results: The mean values of medial, central and lateral length on the trochlear surface were 27.0cm, 28.1cm, 27.4cm on right side and 29.4cm, 27.0cm, 29.1cm on left side. Mean anterior, central and posterior widths on the trochlear surface were 27.6cm, 26.2cm, 21.1cm on right side and 27.0cm, 24.0cm, 23.1cm on left side. The mean central height and width on the lateral articular surface was 26.2 cm and 21.9 cm on the right side respectively and 23.0 cm and 16.8 cm on the left side respectively. The mean central height and central width on the medial articular surface was 13.6 cm and 25.9 cm on the right side respectively and 10.8cm and 17.9 cm on the left side respectively. Conclusions: The current study would be helpful as an important tool for reconstruction surgeries of hindfoot deformities and foot reconstruction procedures. Also it would be useful to orthopaedicians to design accurate talus bone prosthesis and talar implants. Morphometry of talus will be of use in objective categorization and racedetermination for forensic purposes.

POS0538 RELATIONSHIP BETWEEN HINDFOOT DEFORMITIES AND ULTRASOUND TENOSYNOVITIS IN RHEUMATOID ARTHRITIS

Background:Rheumatoid arthritis (RA) is an inflammatory disease that frequently affects the joints and soft tissues of the feet. Tibialis posterior tenosynovitis has a reported prevalence between 13 and 64% in RA. The condition is associated with a progressive flat foot deformity and significant gait disability. However, few studies have investigated the relationship between foot deformities and the involvement of tendons. Recently, ultrasonography (US) has been reported as the gold standard for the investigation of tendons.Objectives:This study aimed to assess the relationship between hindfoot deformities and US tenosynovitis in RA.Methods:We conducted a cross-sectional study including patients with RA (ACR/EULAR 2010). Demographic data and disease parameters were collected. For each patient, a podoscope examination of both feet was performed by a rheumatologist. A radiologist experienced in musculoskeletal imaging performed a US examination using a Philips HD11 device with a high-frequency linear transducer. The assessed lesions were synovitis of the tibiotalar, talonavicular, and subtalar joints, and tenosynovitis of tibialis anterior (TA), extensor hallucis longus (EHL), extensor digitorum longus (EDL), tibialis posterior (TP), flexor digitorum longus (FDL), flexor hallucis longus (FHL), fibularis brevis (FB) and fibularis longus (FL) tendons. The presence or absence of synovitis and tenosynovitis was recorded, and the composite synovitis score (power doppler/grayscale ultrasound (PDUS)) was measured for each joint. The US score of each patient was defined by the sum of the composite scores of the joints studied (0-30). A p-value <0.05 was considered significant.Results:Sixty-two feet were examined in 31 RA patients (25 women and six men) with a mean age of 54.8±10.8 years old [32-70]. The mean disease duration was 8.5±7.2 years [1-37]. Rheumatoid Factor (RF) and Anti-Citrullinated Peptides Antibodies (ACPA) were positive in respectively 61.3% and 83.8% of cases. The mean DAS28 ESR was 3.8±1.5 [0.6-7].Podoscope examination revealed pes planus valgus (PPV) in 55.6% of cases and pes cavus varus (PCV) in 18.5% of cases. US showed tibiotalar synovitis in 59.3% of cases, talonavicular synovitis in 64.8% of cases, and subtalar synovitis in 46.3% of cases. In the anterior compartment, tenosynovitis of TA was noted in 5.6% of cases, of EHL in 1.9% of cases, and EDL in 9.3% of cases. In the medial compartment, tenosynovitis of TP was found in 22.2% of cases, of FDL in 5.6% of cases, and FHL in 0% of cases. In the lateral compartment, tenosynovitis of FB and FL was found in 25% and 11.1% of cases respectively.An association between PPV and synovitis of the tibiotalar joint (p<0.001) and the subtalar joint (p=0.007) was found. An association was also noted with FL tenosynovitis (p=0.045) but not with the other assessed tendons.No association was noted between PCV and synovitis or tenosynovitis of the assessed structures.Conclusion:PPV was frequent among RA patients. This condition was associated with tibiotalar and subtalar synovitis and FL tenosynovitis. It is important to detect and correct foot deformities in order to ensure optimal control of the disease.Disclosure of Interests:None declared

Outcomes of Tibiotalocalcaneal Arthrodesis with a Femoral Nail

Background Retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis (TTCA) is used for severe hindfoot deformities, end-stage arthritis, and limb salvage. The procedure is technically demanding, with complications such as infection, hardware failure, nonunion, osteomyelitis, and possible limb loss or death. This study reports the outcomes and complications of patients undergoing TTCA with a femoral nail, which is widely available and offers an extensive range of lengths and diameters. Methods We performed a retrospective review of 104 patients who underwent 109 TTCAs using a femoral nail as the primary procedure (January 2006 through December 2016). Demographic data, risk factors, and outcomes were evaluated. Results At final follow-up, the overall clinical union rate was 89 of 109 (81.7%). Diabetes mellitus was negatively associated with limb salvage (P = .03), and peripheral neuropathy (P = .02) and Charcot's neuroarthropathy (P = .03) were negatively associated with clinical union. Only four patients (3.8%) underwent proximal amputation, at an average of 6.1 months, and 11 patients (10.6%) died, at a mean of 38.0 months. The most common complication was ulceration in 27 of 109 limbs (24.8%), followed by infection in 25 (22.9%). Twenty-three patients (22.1%) underwent revision procedures, at a mean of 9.4 months. Thirteen of these 23 patients (56.5%) had antibiotic cement rod spacers/rods for deep infection–related complications. Conclusions Use of a femoral nail has been shown to provide similar outcomes and limb salvage rates compared with other methods of TTCA reported for similar indications in the literature.

New classification of osteochondral lesions of the talus in adults

Osteochondral lesions (OCL) of the ankle in adults are frequent lesions that mainly affect the cartilage and the subchondral bone, are relatively common, and have varied etiologies. However, in 50% of patients, these lesions may occur concomitantly with chronic instability of the ankle associated with lower limb deformities, acute sprains of the ankle, or fractures. We propose a classification into four types of lesions (traumatic, non-traumatic, with lateral instability of the ankle, and with mechanical axis defects), focusing not only on the diagnosis and treatment of OCL but also on associated injuries, such as instability and/or supramalleolar and hindfoot deformities. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Examination of Safe Zone to Avoid Injury of the Lateral Plantar Artery During Calcaneal Osteotomy: A Fresh Cadaveric Study

Background: Calcaneal osteotomy are used to treat various pathologies in the correction of hindfoot deformities. But lateral plantar artery (LPA) pseudoaneurysms have been reported following calcaneal osteotomy, and LPA pseudoaneurysms may be at risk for rupture. Although the vascular structures in close proximity to calcaneal osteotomies have variable courses and branching patterns, there is little information on safe zone for LPA during calcaneal osteotomy. The aims of this study were to identify the safety zone to avoid the LPA injury during calcaneal osteotomy. Methods: Enhanced computed tomography scans of 25 fresh cadaveric feet (male, n = 13; female, n = 12; mean age 79.0 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery. Line A is the landmark line and extends from the posterosuperior aspect of the calcaneal tuberosity to the plantar fascia origin, and the perpendicular distance between the LPA and line A at its closest point was measured on sagittal images. Results: The average perpendicular distance between the LPA and line A at its closest point was 15.2 ± 2.9 mm. In 2 cases (8.0 %), the perpendicular distance between the LPA and line A at its closest point was very close, approximately 9 mm. In 18 of 25 feet (72.0%), the point where perpendicular distance from the line A to LPA is the closest was the bifurcation of one of the medial calcaneal branches from LPA, and in 7 feet in 25 feet (28.0%) feet the point where perpendicular distance from the line A to LPA is the closest was the trifurcation of LPA, medial plantar artery, and one of the medial calcaneal branches. Conclusions: Calcaneal osteotomy approximately more than 9 mm from the line A could injure the LPA in overpenetration into the medial aspect of tcalcaneal osteotomy. Completion of the osteotomy on the medial side should be performed with caution to avoid iatrogenic injury of the LPA. Levels of Evidence:: Level IV, Cadaveric study

Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

Category: Hindfoot Introduction/Purpose: Calcaneal osteotomies are often required in correction of hindfoot deformities. The traditional open techniques as lateral or oblique incision are occasionally associated with wound healing problems and neurovascular injury. Methods: In a prospective study 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. 58 patients were operated using an open incision technique and 64 patients with 66 feet using a percutaneous technique. Clinical and radiological assessments were performed preoperatively, six weeks and one year postoperatively. Results: The AOFAS score and VAS improved in both groups postoperatively. The difference was not significant. The results of the radiological measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in both groups. The comparison of both groups showed a significant lesser risk for wound healing problems in percutaneous group (B). The hospitalisation time was significantly shorter in the percutaneous group. Conclusion: Due to the excellent results with the percutaneous calcaneal osteotomy the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy at our clinic.

FRI0415 BODY MASS INDEX AND STATIC FOOT DISORDERS IN GONARTHROSIC PATIENTS

Background:Several studies have shown that there is a link between body mass index (BMI) and painful foot imputed to a biomechanical change in foot structure [1].Objectives:Our objective was to study the association between BMI and static foot disorders in gonarthrosic subjects.Methods:It was a prospective descriptive study conducted in the rheumatology department of the Mohamed Kassab Institute of Orthopedics with 60 patients with Gonarthrosis. The socio-demographic data of the patients were studied. BMI was calculated for all patients. Static foot disorders have been studied.Results:Sixty patients were included, 83.3% of whom were female. The average age was 55.2 years [38-78 years]. The disease has been evolving for an average of 6 years [1-13 years]. The lesion was bilateral in 80% of cases, the average body mass index was 30.4 kg / m2 [24-36]. Knee arthritis was classified as stage I, II and III according to the Kellgren and Lawrence classification in 18.5%, 55.6% and 25.9% of patients respectively. The foot examination involved 108 gonarthrosic limbs. Examination of the integuments showed hyperkeratosis in 94.4% of the cases (79.6% calluses and 83.3% callosities). Forefoot deformities were Hallux valgus (HV) in 52.8% of cases and overlapping toes in 18.5% of cases. Pronation deformity using the Foot Posture Index (FPI) was found in 51.9% of cases. Abnormal lowering of navicular bone was noted in 51.9%. The podoscopic impression revealed flat feet in 73.2% of the cases.A statistically significant association was found between BMI and the presence of calluses (31.21 ± 2.897 vs26.83 ± 1.425, p <0.001), with HV (31.37 ± 3.086 vs29.49 ± 2.969, p = 0.002), at the overlap of the toes (33.2 ± 1.361vs29.86 ± 1.130, p <0.001), with the lowering of the navicular bone (31.17 ± 2.885vs29.68 ± 3.304, p = 0.015), FPI (p = 0.003) and flat podoscopic impression (p <0.001).Conclusion:BMI is strongly associated with static feet disorders in gonarthrosic patients by aggravating the postural changes in the foot caused by knee osteoarthritis [2]. Obesity is associated mainly with the existence of flat feet, pronation of the foot, toes deformities and hyperkeratosis.References:[1]Steele JR, Mickle KJ, Munro B. Fat flat frail feet: how does obesity affect the older foot. XXII Congress of the International Society of Biomechanics; 2009[2]Norton AA, Callaghan JJ, Amendola A, Phisitkul P, Wongsak S, Liu SS, et al. Correlation of knee and hindfoot deformities in advanced knee OA: compensatory hindfoot alignment and where it occurs. Clin Orthop Relat Res. 2015;473(1):166-74Disclosure of Interests:None declared

The Association Between a Hindfoot Deformity Assessed by Weightbearing CT and the Full Leg Alignment

Category: Hindfoot Introduction/Purpose: The exact relationship between different types of hindfoot deformities and the full leg alignment is currently unclear. Therefore, our aim is to assess hindfoot alignment on a weight-bearing CT (WBCT) and its association with the full leg radiographic alignment. Methods: A retrospective analysis was performed on a study population of 109 patients (mean age of 53 years ± 14.49) with a varus or valgus hindfoot deformity and the presence or absence of ankle osteoarthritis (OA) based on the Takakura classification. The mechanical hindfoot - (mHA) and subtalar vertical angle (SVA) were determined on WBCT, while the mechanical tiba – (mTA) and mechanical tibiofemoral angle (mTFA) were measured on full leg radiographs. Results: In patients with ankle OA, a hindfoot valgus deformity was associated with a significantly higher mean varus alignment of the knee (mTFA = -1.8°±2.1; mTAx= -4.3°±1.9) compared to a valgus alignment of the knee (mTFA = 0.3°±2.6; mTAx= -1.4°±2.2; P <0.001) in patients with a varus hindfoot (Fig1A, B). The opposite relation was found in patients without ankle OA (P <0.001). The SVA was significantly more orientated in valgus (mean=106.9°±8.0) for patients with a hindfoot valgus compared to a higher varus orientation (mean=89.3°±13.9) in patients with a hindfoot varus deformity (P <0.001). The same pattern was found in patients without ankle OA, but not significant (P >0.05). Conclusion: A valgus hindfoot deformity demonstrated a higher varus alignment of the knee when compared to patients with a hindfoot varus deformity, if ankle OA was present. The subtalar joint did not attain an overall compensatory correction towards the hindfoot deformity as opposed to a compensatory orientation of the tibia alignment. In clinical practice, these findings could improve the current understanding of both joint preserving as well as joint replacing procedures of the hindfoot and the knee.

Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

Background: Calcaneal osteotomies are often required in the correction of hindfoot deformities. The traditional open techniques, which include a lateral or oblique incision, are occasionally associated with wound healing problems and neurovascular injury. Methods: A total of 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. Fifty-eight patients were operated using an open incision technique and 64 patients (66 feet) using a percutaneous technique. Clinical and radiologic assessments were performed preoperatively, at 6 weeks, and 1 year postoperatively. Results: The American Orthopaedic Foot & Ankle Society scale scores and visual analog scale pain scores improved in both groups postoperatively. The difference between the groups was not significant. The results of the radiologic measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in either group. The comparison of both groups showed a significantly lower risk for wound healing problems in the percutaneous group. The hospitalization time was significantly shorter in the percutaneous group. Conclusion: Because of the excellent results with the percutaneous calcaneal osteotomy, the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy, especially patients at high risk for wound healing problems. Level of Evidence: Level III, comparative series.