Effect of Foot Orthoses in Children With Symptomatic Flexible Flatfoot Based on Ultrasonography of the Ankle Invertor and Evertor Muscles

Objective To examine the changes in the cross-sectional area (CSA) ratio of the ankle invertors and evertors following rigid foot orthosis (RFO) application in children with symptomatic flexible flatfoot and to determine the correlation between the degree of change in CSA ratio and pain-severity after RFO application.Methods We included 24 children with symptomatic flexible flatfoot without comorbidities and measured the CSAs of tibialis anterior (TA), tibialis posterior (TP), and peroneus longus (PL) using ultrasonography, resting calcaneal stance position (RCSP) angle, calcaneal pitch (CP), Meary’s angle, talonavicular coverage angle, and talocalcaneal angle using radiography, and foot function index (FFI) at baseline and 12 months after RFO application. We analyzed 48 data by measuring both feet of 24 children. The CSA ratios, the ratio of CSA of each muscle to the sum of CSA of TA, TP, and PL, were also compared. Correlations between the degree of change in FFI, each muscle’s CSA ratio, RCSP angle, and radiographic measurements were investigated.Results Following RFO application, significant increase in the PL ratio and CP and significant decrease in the RCSP angle, FFI total, pain, and disability scores were observed. The degree of change in the total score, pain, and disability score of FFI were significantly correlated with the degree of change in the PL ratio and RCSP angle.Conclusion RFOs applied to children with symptomatic flexible flatfoot might reduce the compensatory activities of the ankle invertors, thereby increasing the PL ratio, and pain decreases as the PL ratio increases.

Ultrasonographic Evaluation of Three Approaches for Botulinum Toxin Injection into Tibialis Posterior Muscle in Chronic Stroke Patients with Equinovarus Foot: An Observational Study

Spastic equinovarus (SEV) foot deformity is commonly observed in patients with post-stroke spasticity. Tibialis posterior (TP) is a common target for botulinum toxin type-A (BoNT-A) injection, as a first-line treatment in non-fixed SEV deformity. For this deep muscle, ultrasonographic guidance is crucial to achieving maximum accuracy for the BoNT-A injection. In current clinical practice, there are three approaches to target the TP: an anterior, a posteromedial, and a posterior. To date, previous studies have failed to identify the best approach for needle insertion into TP. To explore the ultrasonographic characteristics of these approaches, we investigated affected and unaffected legs of 25 stroke patients with SEV treated with BoNT-A. We evaluated the qualitative (echo intensity) and quantitative (muscle depth, muscle thickness, overlying muscle, subcutaneous tissue, cross-sectional area) ultrasound characteristics of the three approaches for TP injection. In our sample, we observed significant differences among almost all the parameters of the three approaches, except for the safety window. Moreover, our analysis showed significant differences in cross-sectional area between treated and untreated. Advantages and disadvantages of each approach were investigated. Our findings can thus provide a suitable reference for clinical settings, especially for novice operators.

Irregularity in Plantar Fascia, Muscle Edema and Tendon Thickness in Patients with High-Risk for Diabetic Foot

Aim To investigate the alterations in the plantar fascia (PF), intrinsic muscles, and tendons in the feet of patients at high risk for developing diabetic foot. Methods The healthy feet of 22 patients with type 2 diabetes, who had developed diabetic foot ulcers on a single foot without any pathology on the contralateral extremity, and those of 22 healthy volunteers were evaluated by magnetic resonance imaging. The volume of the Achilles tendon (AT), the surface area of the PF, the thickness of AT, flexor hallucis longus, flexor digitorum longus, tibialis posterior, and peroneus longus tendons, irregularity in the PF, and edema of intrinsic foot muscles were examined. Results Nineteen patients (86%) had irregularity in the PF, whereas none of the healthy controls had any (p<0.001). Intrinsic muscle edema was more common in the group with diabetes (p=0.006). The volume of AT and the surface area of PF were decreased in patients with peripheral arterial disease (PAD) (p<0.05). Patients with diabetes mellitus but without PAD had a larger surface area of PF than that of controls (p<0.05). There were no differences in the volume of AT, the surface area of the PF, and other tendon thickness between the groups. Conclusion Irregularity in the PF and muscle edema may indicate a high risk for the diabetic foot. The presence of PAD may lead to regression in the structure of AT and PF.

Topographic-anatomical characteristics of artery tibialis posterior and its branches in the area of ankle canal

AIM: To clarify peculiarities of the anatomy and topography of the plantar vessels in the area of the ankle canal, to justify access to the bifurcation of the artery tibialis posterior and ultrasound examination of the plantar arteries. The results of anatomical preparations of 10 amputated lower limbs, and of ultrasound duplex angioscanning (DUS) of 30 healthy volunteers without pathology of the vascular system performed using a linear transducer with frequency of 7–12 MHz, were studied. According to the data of anatomical preparation and ultrasound examination, the bifurcation level of the artery tibialis posterior was 1.7 ± 0.4 cm (min 0.5 cm — max 2 cm) below the level of the posterior edge of the medial ankle and was slightly covered by the musculus abductor hallucis. The average diameter of the artery tibialis posterior above the bifurcation level was 2.56 ± 0.4 mm, of the medial plantar artery 1.4±0.44 mm, and of the lateral plantar artery 1.8 ± 0.5 mm. The lateral plantar artery was 90% larger in diameter than the medial plantar artery. In 7% of cases, the medial plantar artery was larger, and in 3% of cases, the diameters of both arteries were equal. When taking the bifurcation of the posterior tibial artery as the central point, the plantar vessels on the DUS can be traced distally down under the abdomen of the musculus abductor hallucis: the medial vessels lie more anteriorly at 2 o’clock position, and the lateral vessels lie somewhat posteriorly at 1 o’clock. Assessment of blood flow at this level gives an idea of the state of the foot vessels. The level of bifurcation of the artery tibialis posterior is located 1.7 ± 0.4 cm below the posterior edge of the medial malleolus, which makes it possible to identify the location of access to it. The location of the DUS probe from this point at 2 o'clock position corresponds to the projection of the medial plantar artery, at 1 o'clock — to the lateral plantar artery on the right lower limb, on the left lower limb — at 10 and 11 o'clock, respectively.

Tendon transfer in foot drop: a systematic review

Introduction Foot drop is a disorder that impairs walking and leads to tripping and falling. Tendon transfer (e.g., tibialis posterior tendon) is a typical secondary procedure in foot drop treatment. The purpose of this systematic review was to identify the most common tendon transfer techniques for treating foot drop and to analyze the reported functional outcomes. Furthermore, it was of interest if the type of surgical technique affects the functional outcome. Methods A PubMed and MEDLINE literature search was performed according to PRISMA guidelines. The search terms used were (“tendon transfer” OR “tendon transposition”) AND (“foot drop” OR “peroneal neuropathies”). Any study published before January 2020 was considered for inclusion. No case reports or reviews were included. Common outcome measures (Stanmore score, AOFAS, FAAM, AFO use, patient satisfaction and active ankle dorsiflexion) were evaluated. The quality of the included studies was assessed using the Coleman Methodology Score. Results Of the 125 reviewed publications, 37 met the inclusion criteria. 42 cohorts were analyzed. The frequently reported tendon transfer technique was the tibialis posterior tendon transfer through the interosseus membrane. The most used fixation technique was tendon on tendon fixation; however in recent years, a tendon to bone fixation has gained popularity. There was an increase in Stanmore scores and AOFAS postoperatively and a decrease of AFO use postoperatively observed. Conclusions Due to various outcome measures and lack of preoperative assessment in the included studies, a meta-analysis of the pooled results was not possible. Nevertheless, the findings of this study show that tendon transfer increases mobility and self-independency leading to patient satisfaction. The choice of the surgical technique does not affect the outcome. A prospective collection of patient data and standardized outcome measures will be important to further analyze the efficacy of tendon transfer techniques.