MRI for paediatric flatfoot: Is it necessary?

Objective: To determine the additional benefit of MRI for children with flatfoot deformity assessed with weight-bearing radiographs in a specialist paediatric orthopaedic unit. Methods and materials: Patient cohort was obtained by searching the Radiology Information System for children referred for investigation of flatfoot. All patients with flatfoot on weight bearing radiographs who had undergone MRI were included. Radiographs were classified by a consultant musculoskeletal radiologist as showing no underlying abnormality, talo-calcaneal coalition, calcaneo-navicular coalition, accessory navicular or other abnormality. MRI studies were classified similarly by a different consultant musculoskeletal radiologist blinded to the radiographic findings. Results: 33 males and 24 females were included (mean age 12.5 years; range 3–18 years). Twenty-four had bilateral abnormality, so 81 feet were assessed. Radiographs showed no specific abnormality (n = 51), talo-calcaneal coalition (n = 6), calcaneo-navicular coalition (n = 3), os naviculare (n = 12) or other abnormality (n = 9). MRI showed no specific abnormality (n = 40), talo-calcaneal coalition (n = 10), calcaneo-navicular coalition (n = 5), os naviculare (n = 12) or other abnormality (n = 14). Assuming MRI as the diagnostic gold standard, additional relevant diagnostic information was identified in 19 (23.5%) cases, while in the 51 cases for which radiographs provided no specific diagnosis MRI confirmed no underlying abnormality in 31 (60.8%). Conclusion: MRI is a valuable adjunct to weight bearing radiography for investigating paediatric flatfoot deformity. Advances in knowledge: MRI is of value in the assessment of paediatric flatfoot, additional diagnostic information to radiography being identified in 23.5% cases, while in 60.8% of cases for which radiographs provided no specific diagnosis MRI confirmed no underlying abnormality.

Clinical Outcomes of Single Excision Versus Kidner Procedure for Type II Accessory Navicular Associated with Flatfoot in Adults: Does accessory navicular induce flexible flatfoot?

Background Patients with type II accessory navicular (AN) originally complain of the medial pain of foot. With increasing frequency, some of them has been recognized flexible flatfoot (FFF) at the first weightbearing radiographic examination. Posterior tibial tendon (PTT) dysfunction is widely accepted as a significant contributor to FFF. However, the PTT was not affected in these patients. The relationship between AN and FFF remains controversial. The contribution of AN to FFF was designed in this study. Methods Adult patients who complained of medial pain and bone eminence between January 2014 and January 2020 were included. 61 patients were confirmed to have the AN with flatfoot and randomly divided into two operative groups. The AN was excised in Group A, and the PTT was reconstructed to the navicular region with an anchor in Group B. Preoperative and postoperative evaluations were performed, including clinical evaluations, the American Orthopedic Foot and Ankle Society (AOFAS) mid-foot scale, a visual analog scale (VAS) and radiographic assessments of Meary’s angle, Pitch angle, talonavicular coverage, Kite’s angle and naviculocuboid overlap. PTT decline angle (PDA) and AN-Navicular joint inclination angle (ANJCA) in the lateral view were designed to evaluate the effect of AN on FFF. Results Fifty-six patients (56 feet) were included in this study because 5 patients were excluded. The mean follow-up period was 22.29 months with single excision (Group A) and 20.86 months with Kidner procedure (Group B). The AOFAS mid-foot score improved from 70.39±7.78 pre-operationally to 89.46±7.06 at the last follow-up in Group A and from 67.14±8.14 pre-operationally to 89.64±6.88 at the last follow-up in Group B. The VAS score decreased from 2.82±0.39 and 2.86±0.36 to 0.89±0.31 and 0.79±0.42, respectively. The radiographic results representing flatfoot significantly increased in the two groups. In the lateral view, PDA significantly increased after the operation, and the effect of PTT on the arch upward was induced by pull angulations and shorter distances. Conclusion The FFF with AN may be induced by AN and its synchondrosis. The weakened plantar ligament of synchondrosis was impaired under chronic tension and shear forces may be implicated as the etiologic biomechanical mechanism. AN excision or it with PTT reconstruction could release the pain and benefit the PTT pulling sufficiency.

Accessory Ossicles in the Region of the Foot and Ankle: An Epidemiologic Survey in a Jordanian Population

Background and Objectives: The incidence of accessory bones in the region of foot and ankle is quite variable between studies and are often confused with avulsion fractures in trauma patients with musculoskeletal injuries. The aim of this study was to assess the incidence of accessory ossicles of the foot and ankle according to gender, side and coexistence, and to determine how frequently accessory ossicles were misdiagnosed as avulsion fractures. Materials and Methods: Oblique and/or lateral foot radiographs of 1000 adult patients referred from emergency departments to foot and ankle clinic were retrospectively reviewed for the presence of accessory ossicles. The Kappa statistic was used in order to assess the validity of radiographic interpretation for the presence of these bones. Results: Accessory ossicles were detected in 40.2% of the radiographs. The incidence rates for the accessory ossicles in order of frequency were: Os trigonum (15.4%), accessory navicular (13.7%), os peroneum (11.5%), os vesalianum (1.1%), os supranaviculare (0.7%), os subfibulare (0.6%), os talotibiale (0.4%), os calcaneus secundarius (0.3%), os supratalare (0.3%), os infranaviculare (0.3%), os intermetatarseum (0.2%), and os subtibiale (0.1%). Coexistence of two or three ossicles in the same foot was observed in 4.4% of the cases, mostly coexistence with os peroneum (2.9%), followed by accessory navicular (1.6%). 2.7% of accessory ossicles were initially misdiagnosed as avulsion fractures at emergency departments. Interrater agreement over identification of different accessory ossicles was found to be reasonably reliable, with a Kappa greater than 0.80 for all assessed bones. Conclusions: In clinical practice, a thorough knowledge of normal anatomical variants is essential to facilitate appropriate diagnosis and treatment and can help to prevent diagnostic errors.

SURGICAL OUTCOMES OF ACCESSORY NAVICULAR IN ADOLESCENT ATHLETES

Introduction: An accessory navicular (AN) is a plantar medial enlargement of the navicular bone of the foot. Patients with AN present with a foot bump. Only some patients are symptomatic with pain. The purpose of this study is to report the surgical outcomes in a consecutive series of adolescent athletes with symptomatic AN. Methods: The study was approved by the College of Medicine IRB. 16 patients were evaluated. Patient gender, age, complaints, family history, sports played, conservative treatments attempted, duration of symptoms, surgical technique, complications, outcomes, average follow up, time to return to normal activity, # that returned to sports, and the time to return to sports were recorded. Radiographs were used to identify the type of AN (Coughlin system), skeletal maturity, and presence of pes planus. Pes planus was determined by standing lateral foot radiograph talo-first metatarsal angle. Results: 16 patients and 17 feet were studied. 15 were female (94%). The average age at surgery was 13 years (range 10 to 18 years). 0 patients had a family history of AN. The presenting complaint was foot pain and a bump. Sports including 2 basketball, 2 cheer, 4 gymnastics, 3 soccer, 1 volleyball, 1 dance, 1 softball, 2 multiple sports. The average duration of symptoms was 22 months (range 1 to 36 months). Conservative care methods attempted included: shoe inserts, activity modification, anti-inflammatory medications, icing, crutches, and changes in footwear. Pre-op radiographs demonstrated 9 Coughlin Type 1, 3 Type 2, and 5 Type 3 AN’s. Pre-op radiographs demonstrated 8 feet (47%) had flat foot. 9 feet (53%) had fused the calcaneal growth plate. All patients had a simple excision of the AN and 13 feet (76%) had an additional reefing of the posterior tibial tendon. The average time to return to normal activities was 13 weeks (range 8 to 16 weeks). 15/16 patients (94%) were able to return to their pre surgery sports. The average follow-up time was 8.5 months. At final follow up, 13 feet (76%) reported no pain, 3 (18%) with minimal pain, and 1 (6%) with no change in pain. No complications were reported. Discussion and Conclusion: Symptomatic AN is more common in females. Surgical success was unrelated to a closed growth plate. Surgery eliminated pain in 76% of patients and allowed 94% of patients to return to sport. Residual pain in 4 patients was correlated with a pre-op flat foot (4/8 patients: 50%).

Relationship Between the of Type of Accessory Navicular Bone and Radiological Parameters of the Foot

BACKGROUND:In this study, we evaluated to the relationship between the type of accessory navicular bone (ANB) and radiological parameters of foot in patients with bilateral ANB of different types. METHODS:Patients with bilateral ANB of different types participated in this study, from May 2019 to April 2020. Patient data, including age, sex, body mass index (BMI), and presence of symptoms were obtained. We aimed to compare the radiological parameters of both the feet for evaluate the differences from one another in patients with bilateral ANB of different types (one side type 1 and contralateral side type 2) because the foot angles may differ in each person. Seven radiographic parameters were measured, including calcaneal pitch angle, talocalcaneal angle, tibiocalcaneal angle, naviculocuboid overlap, talonavicular coverage angle, anteroposterior talo-first metatarsal angle, and the lateral talo-first metatarsal angle, which evaluated hindfoot, midfoot, and forefoot alignment. RESULTS: Twenty patients (13 women and 7 men) with a mean age (and standard deviation) of 38.5 {plus minus} 12.3 years were included in the study. The patients had a mean height of 168.1 {plus minus} 7.1 cm, a mean weight of 77.2 {plus minus} 10.5 kg, and a mean BMI of 27.4 {plus minus} 4.3 kg/m2. There was no significant difference between type 1 and type 2 in all radiological parameters. There was no significant correlation between radiological parameters and age, BMI, or the presence of symptoms. CONCLUSIONS: We found that the type of ANB had no effect on the radiological measurements of the foot in which we evaluate the parameters patients with bilateral ANB of different types. Additionally, age, BMI, and the presence of symptoms, also demonstrated no correlation with the radiological parameters of the foot.