Treatment of Cleft Foot Deformity using Fish Mouth Incision and Suture-Button in Paediatric Foot

Cleft foot is a congenital anomaly characterized by absence of the metatarsal bones and phalanges. It is commonly seen in children with Ectrodactyly-ectrodermal dysplasia and clefting syndrome (EEC) ranging from a median cleft up to the mid metatarsals to a deep cleft up to the tarsal bones. Surgical treatment in the form of cleft closure, excision of the rudimentary metatarsal bone and cross K-wire fixation of metatarsal bones have been tried for the management of such cases. Here, we report a case of one year old child with Type III cleft foot having four metatarsals, who was treated with suture-endobutton system using three transverse tunnels in the 2nd and 3rd metatarsal bones in order to bring them closer. We were able to achieve a satisfactory outcome with a normal fitting shoe wear. Keywords: Cleft foot; suture-button; fish mouth incision.

Split anterior tibialis tendon transfer to peroneus brevis for spastic equinovarus in children with hemiplegia

Purpose The aim of this study is to report the safety and eff-cacy of soft-tissue surgery incorporating split transfer of tibi-alis anterior to peroneus brevis (SPLATT-PB) for children with hemiplegic spastic equinovarus. Methods This was a retrospective case series of children and adolescents with spastic hemiplegia who had a novel combination of SPLATT-TB, intramuscular tenotomy of tibialis posterior and either spasticity management or gastrocsole-us lengthening as the index surgery. The principal outcome measures were changes in pain and difficulty with shoe wear and radiological parameters obtained from weight-bearing anteroposterior and lateral radiographs of the affected foot before and after surgery. Results A total of 63 patients with symptomatic spastic equinovarus met the inclusion criteria. Mean age at surgery was 9.8 years (6 to 18) and the mean follow-up was seven years (range 3 to 10 years). Foot pain and problems with shoe wear improved after surgery. Seven radiological criteria showed a clinically and statistically significant improvement at follow-up, the majority being in the normal range. There were 11 surgical adverse events, all classified as Modified Cla-vien-Dindo Grade II. Three patients required further surgery for recurrent equinus, eight patients required further surgery for valgus deformities and four patients required bony surgery for residual varus deformities. Conclusion Soft-tissue surgery for spastic equinovarus was successful in the majority of children with spastic hemiplegia, particularly between ages eight and 12 years, resulting in a plantigrade, flexible foot with minimal pain or limitations in shoe-wear. Children younger than 8 years at index surgery were more prone to overcorrection into valgus. Children older than 12 years had persistent varus deformities requiring bony surgery. Level of evidence Level IV, retrospective case series

Longitudinal Analysis of Plantar Pressures with Wear of a Running Shoe

Running shoes typically have a lifespan of 300–1000 km, and the plantar pressure pattern during running may change as the shoe wears. So, the aim of this study was to determine the variation of plantar pressures with shoe wear, and the runner’s subjective sensation. Maximun Plantar Pressures (MMP) were measured from 33 male recreational runners at three times during a training season (beginning, 350 km, and 700 km) using the Biofoot/IBV® in-shoe system (Biofoot/IBV®, Valencia, Spain). All the runners wore the same shoes (New Balance® 738, Boston, MA, USA) during this period, and performed similar training. The zones supporting most pressure at all three study times were the medial (inner) column of the foot and the forefoot. There was a significant increase in pressure on the midfoot over the course of the training season (from 387.8 to 590 kPa, p = 0.003). The runners who felt the worst cushioning under the midfoot were those who had the highest peak pressures in that area (p = 0.002). The New Balance® 738 running shoe effectively maintains the plantar pressure pattern after 700 km of use under all the zones studied except the midfoot, probably due to material fatigue or deficits of the specific cushioning systems in that area.

Fulfillment of Expectations after Orthopaedic Foot and Ankle Surgery: An Analysis of 271 Patients with 2-year Follow-up

Category: Ankle, Ankle Arthritis, Arthroscopy, Bunion, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, General Foot/Ankle, Outcomes, Satisfaction Introduction/Purpose: Success in orthopaedic surgery was traditionally defined by postoperative radiographs or legacy outcomes scores, but increasingly incorporates more patient-centered metrics. Patient expectations are one such measure, and have been described using a new validated survey for foot/ankle patients. Understanding patients’ expectations of surgery is critical in order to facilitate shared decision-making and set reasonable goals for outcomes. In other specialties, postoperative expectations surveys have also been created and shown to correlate with measures of satisfaction and traditional patient-reported outcomes scores. However, there are no such studies in the foot and ankle literature. This study aimed to validate a method of assessing expectation fulfillment in foot/ankle patients postoperatively. We hypothesized that the survey would significantly correlate with measures of improvement, satisfaction, and clinical outcomes scores. Methods: This is a single-center prospective study of patients undergoing elective foot and ankle procedures. Preoperative demographics, clinical data, and Foot & Ankle Outcomes Score (FAOS) were collected. Patients completed the expectations survey, consisting of 23 questions for domains including pain, ambulation, daily functioning, exercise/sports, shoe wear, and generalized items like “improving confidence in foot/ankle” and ”going back to normal.” Postoperatively, patients answered how much improvement they received for each item listed on the preoperative survey. Using previously validated methods, the proportion of expectations fulfilled was calculated as a ratio of the preoperative to postoperative expectations score, with values of 0 -1 indicating some expectations met, 1 indicating expectations met; and >1 indicating expectations surpassed. Receiver operator characteristic (ROC) curves and areas under the curve (AUC) with 95% confidence intervals (CI) were used to compare the expectations survey to other outcomes scales, including FAOS, perceived improvement, overall fulfillment, Delighted-Terrible scale, and satisfaction. Results: 271/340 (80%) of patients with preoperative data completed 2-year follow-up (mean age 55.4 years, mean BMI 27.5, 65% female). Most common diagnoses were hallux valgus (25%), flatfoot (11%), hallux rigidus (11%), and ankle arthritis (10%). Mean proportion of expectations fulfilled was 1.15, indicating surpassed expectations. The proportion of expectations fulfilled correlated best with perceived improvement, global expectation fulfillment, and the Delighted-Terrible scale, and to a lesser degree with satisfaction and change in FAOS (all except activity). Based on the inflection point of the ROC curves corresponding to greatest AUC (Table), a clinically important proportion of expectations fulfilled was 0.81 and correlated with feeling delighted (sensitivity 0.88, specificity 0.85), improvement (sensitivity 0.89, specificity 0.83), overall expectations (sensitivity 0.91, specificity 0.81), and satisfaction (sensitivity 0.85, specificity 0.81). Conclusion: The proportion of expectations fulfilled is a valid outcome tool for foot and ankle surgery. It is uniquely able to capture pre- and postoperative data in one value and can be tailored to each patient’s specific goals. This survey can be used by surgeons after a variety of procedures to assess if a patient’s specific expectations have been fulfilled after surgery. We can use this tool to assess which patient and surgical factors may influence the fulfillment of expectations. This, in turn, will help surgeons better indicate the appropriate procedure in the optimal patient to achieve the greatest postoperative success.

Fulfillment of Expectations After Orthopedic Foot and Ankle Surgery

Background: To date, no study has assessed fulfillment of patients’ expectations after foot and ankle surgery. This study aimed to validate a method of assessing expectation fulfillment in foot/ankle patients postoperatively. Methods: Preoperatively, patients completed the expectations survey, consisting of 23 questions for domains including pain, ambulation, daily function, exercise, and shoe wear. At 2 years postoperatively, patients answered how much improvement they received for each item cited preoperatively. A fulfillment proportion (FP) was calculated as the amount of improvement received versus the amount of improvement expected. The FP ranges from 0 (no expectations fulfilled), to between 0 and 1 (expectations partially fulfilled), to 1 (expectations met), to greater than 1 (expectations surpassed). Receiver operating characteristic (ROC) curves and areas under the curve (AUCs) with 95% confidence intervals (CIs) were used to compare the expectations survey to other outcome surveys, including Foot and Ankle Outcome Score, improvement, overall fulfillment, Delighted-Terrible scale, and satisfaction. Results: Of the 271 patients (mean age 55.4 years, mean BMI 27.5, 65% female), 34% had expectations surpassed (FP >1), 4% had expectations met, 58% had expectations partially fulfilled (FP between 0 and 1), and 5% had no expectations met. The mean FP was 0.84 ± 0.41 (range 0-3.13), indicating partially fulfilled expectations. FP correlated significantly with all outcome measures ( P ≤ .007). FP was associated most closely with satisfaction ( r = 0.66 [95% CI 0.57-0.75]; AUC = 0.92 [95% CI 0.88-0.96]; P < .001) and improvement ( r = 0.73 [95% CI 0.64-0.81]; AUC = 0.94 [95% CI 0.91-0.96]; P < .001). Based on the associations with satisfaction and improvement outcomes, a clinically important proportion of expectations fulfilled is 0.68, with sensitivity 0.85-0.90 and specificity 0.84-0.86. Conclusion: The proportion of expectations fulfilled is a novel patient-centered outcome that correlated with validated outcome measures. The expectations survey may be used by surgeons to counsel patients preoperatively and also to assess patients’ results postoperatively. Level of Evidence: Level II, prospective comparative series.

Ankle Arthritis

Ankle arthritis is a major source of morbidity impacting a younger working age population than hip and knee arthritis. Unlike the hip and knee, more than 70% of ankle arthritis cases are post-traumatic, with the remainder being inflammatory or primary arthritis. Nonoperative treatment begins with lifestyle and shoe-wear modifications and progresses to bracing, physical therapy, anti-inflammatory medications, and intra-articular injections. Ankle arthrodesis and total ankle arthroplasty are the 2 main surgical options for end-stage ankle arthritis, with debridement, realignment osteotomy, and distraction arthroplasty being appropriate for limited indications.Level of Evidence:Level V, expert opinion.

Simple semi-permanent blockade against rigid varus foot in a case with spasticity: possible practical benefits in ambulatory adults

A 55-year-old ambulatory woman with hemiplegia and varus foot deformity had several problems in her daily life, including load pain and stance instability in the affected foot, easy fatigue of the non-paralysed leg, low back pain, neck stiffness and rapid shoe-rubber wear on the deformed side. We began repeated focal blockades using botulinum toxin to the tibialis posterior muscle to control varus spasticity. Distant influences presenting in the whole body were relieved soon after the first blockade, and shoe wear also stopped. Although, neither the deformed appearance nor foot contact pattern on walking changed in the initial period after beginning the blockade, the foot contact pattern revealed gradual improvement over several years. Generally, surgical correction is indicated for the treatment of deformed feet. The present case suggests that, in case of varus-deformed foot with some spastic elements, trial of focal blockade for varus spasticity may be worthwhile.