Surgical resection of the persistently painful talocalcaneal tarsal coalition has not been shown to reliably relieve symptoms in patients with coalitions that are large and have associated hindfoot valgus and subtalar arthrosis. It has been recommended that these patients undergo triple arthrodesis, a procedure that is known to lead to premature arthrosis of the ankle joint. To avoid additional stress on this important joint, treatment of this patient group using calcaneal lengthening osteotomy (CLO), with or without resection of the coalition, has been performed at our institution for the last 15 years. A retrospective review of all patients with talocalcaneal coalitions who had undergone CLO was performed. Clinical and radiographic records were reviewed. Demographic data, and pre- and post-operative pain and function were recorded. Pre- and post-operative radiographs and computed tomography (CT) scans were reviewed and measurements recorded. CT scans were used to calculate the degree of hindfoot valgus and the size of the coalition. Patients were invited to return for clinical examination and follow-up x-rays if two years had passed since their operation. They completed American foot and ankle hindfoot scores, VAS pain scores and were asked satisfaction questionnaires. Radiographic measurements were performed. There were 13 patients who underwent 19 CLOs. Of these 13 patients, eight patients with 13 CLO’s returned for clinical examination and radiographs. Five patients had nine CLO’s to correct deformity without resection of a large middle facet talocalcaneal coalition with severe hindfoot deformity. All patients had restoration of normal foot shape with improvement in comfort and function. One patient had improvement in comfort and function following bilateral simultaneous coalition resection of cartilaginous coalition and CLO to correct significant hindfoot deformity. Two patients had improvement in pain and function in a foot that had residual pain and deformity following prior talocalcaneal coalition resection. CLO, usually accompanied by a heel cord lengthening, is a useful operation both in the failed middle facet resection where there is persistent pain and deformity, and also in the very large coalition with associated deformity and/or arthrosis that is not appropriate for resection. It corrects the foot deformity, improves comfort and function, maintains motion in Chopart’s joints and therefore, unlike triple arthrodesis, avoids additional stresses in the ankle joint

Introduction:. Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe a purely arthroscopic technique for excising talocalcaneal coalitions. We present a retrospective two-surgeon case series of the first eight patients (nine feet). Methods:. Subtalar arthroscopy is performed from two standard sinus tarsi portals with the patient in a saggy lateral position. Coalitions are resected with a barrel burr after soft tissue clearance with arthroscopic shavers. Early postoperative mobilisation and non-steroidal anti-inflammatory drugs prevent recurrence of coalition. Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years. Results:. Pain and SAFAS scores improved in 7 patients. Subtalar movements were improved in all feet and were sustained to final follow-up. All patients achieved early good function and returned to sports and demanding jobs. One patient's pain recurred requiring subsequent fusions. One posterior tibial nerve was damaged. Both of these patients had coalitions extending across more than one quarter of the posterior facet. Conclusion:. Minimal destruction of bone and soft tissues with an arthroscopic technique allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from both open and arthroscopic excision of tarsal coalitions. Patient selection and preoperative planning are crucial to avoid relapse and complication. If significant degenerative changes are present at surgery or resections are too extensive onto the posterior facet early recurrence of pain may occur. This series from two independent surgeons supports the feasibility and effectiveness of this technique

Aim

Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, recent evidence suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomitant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes.

Introduction. The arch of the foot has been described as a truss where the plantar fascia (PF) acts as the tensile element. Its role in maintaining the arch has likely been underestimated because it only rarely torn in patients with progressive collapsing foot deformity (PCFD). We hypothesized that elongation of the plantar fascia would be a necessary and sufficient precursor of arch collapse. Method. We used a validated finite element model of the foot reconstructed from CT scan of a female cadaver. Isolated and combined simulated ligament transection models were created for each combination of the ligaments. A collapsed foot model was created by simulated transection of all the arch supporting ligaments and unloading of the posterior tibial tendon. Foot alignment angles, changes in force and displacement within each of the ligaments were compared between the intact, isolated ligament transection, and complete collapse conditions. Result. Isolated release of the PF did not cause deformity, but lead to increased force in the long (142%) and short plantar (156%), deltoid (45%), and spring ligaments (60%). The PF was the structure most able to prevent arch collapse and played a secondary role in preventing hindfoot valgus and forefoot abduction deformities. Arch collapse was associated with substantial attenuation of the spring (strain= 41%) and interosseous talocalcaneal ligaments (strain= 27%), but only a small amount in the plantar fascia (strain= 10%). Conclusion. Isolated PF release did not cause arch collapse, but arch collapse could not occur without at least 10% elongation of the PF. Simulated transection of the PF led to substantial increase in the force in the other arch supporting ligaments, putting the foot at risk of arch collapse over time. Chronic degeneration of the PF leading to plantar fasciitis may be an early sign of impending PCFD

A medializing calcaneal osteotomy (MCO) is one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the hind- and midfoot alignment after PCFD correction, the subtalar joint remained obscured by superposition on plain radiography. Therefore, we aimed to perform a 3D measurement assessment of the hind- and subtalar joint alignment pre- compared to post-operatively using weightbearing CT (WBCT) imaging. Fifteen patients with a mean age of 44,3 years (range 17-65yrs) were retrospectively analyzed in a pre-post study design. Inclusion criteria consisted of PCFD deformity correct by MCO and imaged by WBCT. Exclusion criteria were patients who had concomitant midfoot fusions or hindfoot coalitions. Image data were used to generate 3D models and compute the hindfoot - and talocalcaneal angle as well as distance maps. Pre-operative radiographic parameters of the hindfoot and subtalar joint alignment improved significantly relative to the post-operative position (HA, MA. Sa. , and MA. Co. ). The post-operative talus showed significant inversion, abduction, and dorsiflexion of the talus (2.79° ±1.72, 1.32° ±1.98, 2.11°±1.47) compared to the pre-operative position. The talus shifted significantly different from 0 in the posterior and superior direction (0.62mm ±0.52 and 0.35mm ±0.32). The distance between the talus and calcaneum at the sinus tarsi increased significantly (0.64mm ±0.44). This study found pre-dominantly changes in the sagittal, axial and coronal plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings demonstrate the amount of alternation in the subtalar joint alignment that can be expected after MCO. However, further studies are needed to determine at what stage a calcaneal lengthening osteotomy or corrective arthrodesis is indicated to obtain a higher degree of subtalar joint alignment correction

Tarsal coalition has been well recognized as the commonest cause of peroneal spastic flat feet in children and adolescents (Mosier and Asher 1984). Other rare causes are tuberculosis and rheumatoid arthritis. If no etiology can be found the term idiopathic peroneal spastic flat foot has been coined by Schoenecker (2000). We prospectively assessed all children and adolescents with peroneal spastic flat feet seen at our clinic in the period 2002 to 2004. Twelve patients (17 feet) were assessed. The average age was 11,9 years (range10 to15years). Seventy five percent of the patients were above the 95th percentile weight for age. Screening for tuberculosis (ESR, Mantoux and chest radiograph) was negative in all patients. Rheumatoid factor was positive in one patient with juvenile idiopathic arthritis (JIA). Radiology was standardized. Plain radiographs were standing lateral and 45 degree oblique views. CT and MRI:. axial: parallel to plantar surface;. coronal oblique: gantry perpendicular to the plane of the subtalar joint. This latter view best illustrates a talocalcaneal coalition (Newman 2000). Two patients (four feet) had a calcaneonavicular coalition on the 45 degree oblique plane radiographs. This was also shown on the axial CT and MRI views. No talocalcaneal coalition was visualized on the coronal oblique CT and MRI views. In order to find a diagnosis and to confirm the accuracy of the MRI and CT, the middle facet of the talocalcaneal joint was explored in eight feet and a synovial biopsy done. No talocalcaneal coalition was found. JIA was histologically confirmed in one patient. The authors concluded that the idiopathic type is by far the commonest peroneal spastic flat foot seen in our clinic. The 45 degree oblique plain radiograph is as accurate as axial CT and MRI to diagnose calcaneonavicular coalition. The coronal oblique CT and MRI views are equally accurate to exclude a talocalcaneal coalition

Introduction: Congenital tarsal coalition is one of the most prevalent (1–6%) anomalies of the hindfoot and midfoot. Its etiology is unknown. By definition there are boney, cartilaginous or fibrous brigdes between 2 bones of the hindfoot and midfoot, which are classified by their localization; the most common coalitions are calcaneonavicular (53%) and talocalcaneal (37%). Patients and Methods: From 2001 to 2007 28 patients with 37 coalitions had surgery at the Orthopedic Hospital Vienna-Speising. 32 calcaneonavicular coalitions were surgically excised and an autogenous free fat graft was interponed to prevent a relapse. 1 calcaneonavicluar coalition also had an interposition of the extensor digitorum brevis after resection, while 1 calcaneonavicular coalition had lengthening of the short peroneal tendon in addition to excision and autogenous free fat graft. 1 calcaneonavicular coalition had to have an arthrodesis of the talocalcaneal joint. From 2 talocalcaneal coalitions 1 had excision the other 1 talocalcaneal arthrodesis. Both of the coalitions that had arthrodesis had short-leg plastercasts for 12 to 13 weeks. For patients with bilateral coalition pedobarography was performed and the foot that had been treated compared to the untreated contralateral side. For these patients the AOFAS ankle and hind foot score and pain according to the VAS were evaluated. Results: 22 coalitions that had had surgery were uncomplaining after intervention, including 1 patient who had had arthrodesis. 3 calcaneonavicular coalitions that had had excision and autogenous free fat graft had a relapse within 2 to 3 years. 2 of them had a revision and second-look excision of the bridge. 1 patient showed a suspicious relapse in MRI after excision of a calcaneonavicular coalition. 1 talocalcaneal coaltion that had had excision continued to have pain after surgery. Both patients did not want a revision. 1 patient who was treated by an arthrodesis of the subtalar joint had a fracture of the tibial head, where autogenous bone graft had been taken. Osteosynthesis of the tibia was performed. 4 patients had pain after excision of a calcaneonavicular coalition but could be relieved by conservative treatment. For 5 patients adequate follow up is still pending due to short interval to surgery. Pedobarography showed tendecies of improved pressure distribution of the treated feet that were not significant. Conclusion: Excision and autogenous free fat graft should be first approach to surgery of symptomatical congenital tarsal coalitions for whom conservative treatment was not satisfying. When resected sufficiently the rate of relapse of the boney, cartilaginous or fibrous bridge is 7%. Depending on the patients age, the size of the affected area of the joint (50%) and secondary arthrotic changes of the joint an arthrodesis of the talo-calcaneal joint should be performed

Introduction: Distraction bone block arthrodesis has been advocated in the literature to treat the late sequelae of os calcis fracture with loss of heel height including the prevention of anterior impingement. We have studied a consecutive series of subjects who have had in situ arthrodesis for subtalar arthrosis as a consequence of os calcis fracture with marked loss of talocalcaneal height paying particular attention to range of movement and anterior impingement. Materials and Methods: Between 1997 and 2003 31 consecutive subjects underwent subtalar arthrodesis. Five subjects who had undergone ORIF, two non-unions and three subjects with bilateral injuries were excluded. Two subjects who had marked coronal displacement that required additional surgery at the time of arthrodesis were also excluded. Two subjects were lost to follow up leaving 17 for assessment. AOFAS hind foot scores improved from 29.8 (range 13–48) preoperatively to 77.8 (range 48–94) postoperatively. Mean loss of talocalcaneal height was 10.3mm and the mean talar declination angle was 6.7 degrees which was 35% of the normal side. One subject suffered anterior ankle pain but none had anterior impingement. Two subjects complained of difficulty ascending slopes and stairs and four of difficulty descending. Mean ankle dorsiflexion was 11.6 degrees (range 0–24) compared to 14.7 degrees on the normal side: A reduction of 21.1%. Mean plantarflexion was 35.5 degrees (range 24–60) compared to 44.6 degrees on the normal side: A reduction of 20.4%. Discussion: Our results suggest that anterior impingement is not a significant problem in os calcis fracture, even when loss of talocalcaneal height is marked. We recommend ISA combined with lateral wall ostectomy for all cases of subtalar arthrosis as a result of os calcis fracture, without marked coronal deformity, regardless of the degree of talocalcaneal height loss

The purpose of this study was to evaluate the longterm results of 736 cases of operatively treated clubfeet, and to examine if there is any difference in the results between our patients and referred patients. A follow-up examination was carried out in 736 cases of clubfeet operated on between 1966 and 1990. The average follow-up period was 14.7 years. Treatment was based on three pillars: well-organized care, conservative treatment and early operative treatment. In all of the reviewed cases, posteromedial soft tissue release was performed. Surgical intervention was indicated in cases of residual deformity after conservative treatment, cases of recurrent deformity, and cases of untreated clubfeet. Clinical evaluation contained the examination of residual deformities and the passive and active motions of the foot. In the radiological assessment, the anteroposterior talocalcaneal angle, the lateral talocalcaneal angle and the talometatarsal angle was measured. In the clinical evaluations equinus deformity was found in 3.35%, varus in 7.23%, valgus in 8.55%, adducted forefoot in 30.8%, inflexion of the forefoot in 7.14%, and overcorrection to the vertical talus in 3.35%. Range of motion was normal in only 36% of the cases. Average anteroposterior talocalcaneal angle was 13.05 preoperatively and 22.13 postoperatively. Average lateral talocalcaneal angle was 10.78 preoperatively and 27.66 postoperatively. Average talometatarsal angle changed from 26 to 5.5 after the operation. The overall success rate of the operated cases was 65%. After long-term follow-up, 65% of the cases were classified as successful. When comparing our patients with referred patients, there were considerable differences found in the rate of reoperation, age at the time of the first operation, and also in the results. These differences point out the importance of the early beginning of operative treatment, with regular follow-up and care

The purpose of this study was to evaluate the longterm results of 736 cases of operatively treated clubfeet, and to examine if there is any difference in the results between our patients and referred patients. A follow-up examination was carried out in 736 cases of clubfeet operated on between 1966 and 1990. The average follow-up period was 14.7 years. Treatment was based on three pillars: well-organized care, conservative treatment and early operative treatment. In all of the reviewed cases, posteromedial soft tissue release was performed. Surgical intervention was indicated in cases of residual deformity after conservative treatment, cases of recurrent deformity, and cases of untreated clubfeet. Clinical evaluation contained the examination of residual deformities and the passive and active motions of the foot. In the radiological assessment, the anteroposterior talocalcaneal angle, the lateral talocalcaneal angle and the talometatarsal angle was measured. In the clinical evaluations equinus deformity was found in 3.35%, varus in 7.23%, valgus in 8.55%, adducted forefoot in 30.8%, inflexion of the forefoot in 7.14%, and overcorrection to the vertical talus in 3.35%. Range of motion was normal in only 36% of the cases. Average anteroposterior talocalcaneal angle was 13.05 preoperatively and 22.13 postoperatively. Average lateral talocalcaneal angle was 10.78 preoperatively and 27.66 postoperatively. Average talometatarsal angle changed from 26 to 5.5 after the operation. The overall success rate of the operated cases was 65%. After long-term follow-up, 65% of the cases were classified as successful. When comparing our patients with referred patients, there were considerable differences found in the rate of reoperation, age at the time of the first operation, and also in the results. These differences point out the importance of the early beginning of operative treatment, with regular follow-up and care

Objective. The objective of this study was to evaluate the rotation and translation of each joint in the hindfoot and compare the load response in healthy feet with that in stage II posterior tibial tendon dysfunction (PTTD) flatfoot by analysing the reconstructive three-dimensional (3D) computed tomography (CT) image data during simulated weight-bearing. . Methods. CT scans of 15 healthy feet and 15 feet with stage II PTTD flatfoot were taken first in a non-weight-bearing condition, followed by a simulated full-body weight-bearing condition. The images of the hindfoot bones were reconstructed into 3D models. The ‘twice registration’ method in three planes was used to calculate the position of the talus relative to the calcaneus in the talocalcaneal joint, the navicular relative to the talus in talonavicular joint, and the cuboid relative to the calcaneus in the calcaneocuboid joint. Results. From non- to full-body-weight-bearing condition, the difference in the talus position relative to the calcaneus in the talocalcaneal joint was 0.6° more dorsiflexed (p = 0.032), 1.4° more everted (p = 0.026), 0.9 mm more anterior (p = 0.031) and 1.0 mm more proximal (p = 0.004) in stage II PTTD flatfoot compared with that in a healthy foot. The navicular position difference relative to the talus in the talonavicular joint was 3° more everted (p = 0.012), 1.3 mm more lateral (p = 0.024), 0.8 mm more anterior (p = 0.037) and 2.1 mm more proximal (p = 0.017). The cuboid position difference relative to the calcaneus in the calcaneocuboid joint did not change significantly in rotation and translation (all p ≥ 0.08). . Conclusion. Referring to a previous study regarding both the cadaveric foot and the live foot, joint instability occurred in the hindfoot in simulated weight-bearing condition in patients with stage II PTTD flatfoot. The method used in this study might be applied to clinical analysis of the aetiology and evolution of PTTD flatfoot, and may inform biomechanical analyses of the effects of foot surgery in the future. Cite this article: Bone Joint Res 2013;2:255–63

Background: Heel valgus and flattening of arch are common in rheumatoid arthritis (RA). The progression of hindfoot valgus deformity results in pain and debilitating disability, and causes the excessive stress on the ankle joint. Subtalar arthrodesis is often indicated in these cases to reduce the pain and to correct the talocalcaneal alignment. However, accurate correction is not easy without bone grafting, because bone defect often appears after correction. Bone grafting is necessary for accurate correction in these cases, but we have avoided it because of following reasons; donor site problem like insufficiency fractures of pelvis, supply limitation of autograft for possible multiple operations during long term disease progression of RA and the lack of bone graft substitutes, which possesses enough osteoconductivity. Now we have developed the interconnected porous calcium hydroxyapatite (IP-CHA) which possesses good osteoconductivity and achieves major incorporation with host bone much more rapid than the other porous calcium hydroxyapatite. So, we evaluated the usefulness of the packing with the newly developed IP-CHA in bone defect after correction of pes planovalgus deformity of RA patients. Methods: The best possible correction of talonavivular alignment and fixation is performed using one cubic hydroxyapatite block (1x1x1cm), staple and Kirschner wire. Then granular IP-CHA is implanted in bone defect existing mainly in talar body, gap of talonavicular joint and sinus tarsi. Six planovalgus feet were treated with subtalar arthrodesis in 4 female RA patients (3; triple arthrodesis, 3; subtalar and talonavicular arthrodesis). The average age was 56.8 years. Angle of internal arch (IA), tibiocalcaneal (TC) angle in modified Cobey’s method, talocalcaneal height (TCH) in standing position were assessed on the basis of the radiographies at just before operation and final follow-up (average 17.5 months, range 7 to 25 months). Results: Mean IA angle was 138.9 degrees pre-operatively and 132.4 at the last follow-up. Mean TC angle was 14.9 degrees pre-operatively and 7.2 at the last follow-up. No collapse or deformity of hydroxyapatite implanted in the bone defect was observed. Conclusion: Our original technique using IP-CHA was shown to prevent from initial sinking or loss of correction. This technique could make it quit easy to correct the malalignment of talocalcaneal joint with regaining of TCH in painful planovalgus deformity of RA patients

Conservative management of talipes equinovarus has a good effect on adductus deformity of the forefoot, whereas equinus deformity cannot usually be treated well conservatively. However, adductus is the most common recurrent deformity after operations. The aim of the study was to use radiological analysis to explore the reasons that lead to recurrent adductus. In 86.7% of the cases, either a correction was evaluated as radiologically inadequate but seemed to be good physically, or compensation for an operative over-correction resulted in recurrent adductus some years later. In spite of adequate correction from both a physical and radiological view, recurrent adductus developed in 13.3% of the cases. In our opinion, these recurrences were due to persistent muscle imbalance. In our department, 458 children were operated on for clubfoot from 1982 to 1997. The patients involved in this study were those managed by medial and posterior soft tissue release after an ineffective six to nine month period of conservative treatment that was started when they were one to two weeks old. Children treated previously in another hospital were excluded from the study. We controlled 228 feet and 42 cases of recurrent adductus were found 2 to 16 years (mean 6.8) after the operations. The radiographs were examined at the end of ineffective conservative treatment, during the early postoperative days, and finally at the follow-up. The anteroposterior talocalcaneal (ATC) angle, the talometatarsal (TM) angle and the naviculometatarsal (NM) angle were measured in all of the radiographs. Based on the measured angles, three main groups of patients were formed. Recurrent adductus in 24 feet (Group A) was caused by inadequate operative corrections, including inappropriate correction of either the hind foot (reduced ATC angle) or the forefoot (reduced NM angle), or both. Although the talocalcaneal and talometatarsal positions were normal in early postoperative radiographs, adductus developed again two to five years later in seven cases (Group B). In these cases, we think that persistent muscle imbalance was responsible for the recurrent deformity. In 11 feet the ATC angles were in normal range or increased (Group C). These adductus deformities were caused by either an overcorrected talocalcaneal position resulting in compensatory metatarsal varus or medial subluxation of the talonavicular joint, which had been only partially compensated by the lateral deviation of the 1st ray

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet). Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years. Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient. Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique

The assortment of primary operative techniques starts with posterior release and ends with the most sophisticated ones such as complete subtalar release. The proper selection of one of them is a key to success and has to be done on the basis of clinical and radiographic parameters. Posterior release: The indication for this procedure is determined by persistent equinus. On AP and lateral radiographs the normal talocalcaneal angle is visible AP greater than 20; lateral greater than 35 degrees). On the lateral radiograph in corrected equinus or standing, the angle between the calcaneus and tibia should be smaller than 80 degrees. A physical examination con- firms equinus position more precisely. Attention should be paid to the possibility of iatrogenic rocker bottom deformity. In such cases posterior release should be combined with dorsal release of the calcaneocuboid and talonavicular joint. Posteromedial release: Clinical indications for this procedure are hindfoot equinus and varus and passively corrected medial spin measured with a bimalleolar angle less than 85 degrees. This angle should be checked during surgery when the posteromedial release is completed. If overcorrection is not achieved, the procedure has to be extended in sequence to lateral release or complete subtalar release. Radiographic indications are as follows: diminished talocalcaneal angle on AP (less than 20 degrees) and/or on lateral radiographs (less than 35 degrees), as well as partial overlap of the talus and calcaneus on AP radiographs. Posteromedial-lateral, posterolateral-medial and partial subtalar release: Indications for these techniques are the same as for posteromedial release. The difference concerns the not corrigible medial spin. The decision about which technique should be used is made before surgery, but its conversion during surgery to another one is possible and depends on obstacles appearing during release. Intraoperative radiographs may help in making the decision. Complete subtalar release: The clinical indication for this technique is primarily stiff varus and medial spin. The selection of this procedure may be the result of the primary decision or incomplete correction after less extensive procedures. To overcome the obstacles, the talocalcaneal interosseous ligament must be completely cut. Radiographic indications are the same as for posteromedial- lateral or partial subtalar release. Complete overlapping of the talus and calcaneus on AP radiograph inclines the surgeon to choose this method. All techniques mentioned can be extended to the correction of forefoot adduction. A metatarsal first ray angle lower than 70 degrees is indicated for correction. For small children, the opening of the cuneonavicular and first cuneometatarsal joint with a slight transposition of the tibialis anterior is preferred. In older children, open wedge osteotomy of the medial cuneiform is done. For correction of calcaneocuboid displacement, no open reduction is performed even if a +2 displacement of the cuboid is seen on AP radiograph, because self-existent reduction occurred. However, closed stabilisation of this joint by K-wire is performed. A stable subtalar complex can be rotated as a block during partial or complete subtalar release

Purpose of study. Serial manipulations and casting for the treatment of congenital clubfoot has long been the practice internationally. There are, however, a great variety of manipulative techniques being practiced with differing results. We aim to determine how the rate of major surgery, ie. a full posteromedial-release (PMR), as initial surgical intervention has changed since introducing the Ponseti method of plastering at our centre in 2002. We also aim to determine whether pre-operative radiographs have any bearing on the type of surgery performed. Methods. Clinical records and radiographs of all patients presenting to our clubfoot clinic in the years 1999–2000 and 2009–2010 respectively were reviewed. Patients were included if they had clinical clubfoot, and excluded if they presented after 3 months of age, had undergone prior treatment or suffered from associated congenital anomalies. We then determined which patients underwent PMR as primary surgical intervention following serial castings. We also measured the radiographic parameters on all available radiographs (tibiocalcaneal, talometatarsal-I, lateral and AP talocalcaneal angles) and performed a statistical analysis to determine their value in predicting the type of surgery required. Results. In the pre-Ponseti group we included 83 feet of which 34 had undergone PMR. In the Ponseti group there were 68 feet, of which none had undergone PMR. This was found to be statistically significant. Of the measured angles, the tibiocalcaneal and lateral talocalcaneal had the highest correlation with clinical severity (.67 and −.45 respectively). Conclusion. Employing the Ponseti method of plastering has significantly decreased the need for major surgery at our centre. This is in keeping with published results internationally. We found the tibiocalcaneal angle to be the most predictive of need for major surgery, and the talometatarsal-I to be the least predictive. The role of pre-operative X-rays, however, remains unclear as surgical decisions are made on clinical grounds. NO DISCLOSURES

Introduction: A retrospective evaluation of early results of arthroereisis. Material and Methods: Eight feet in five patients with pathological flexible planovalgus deformity that had failed non-operative management were treated with subtalar arthroereisis using the Kalix prosthesis. Diagnosis include oblique talus (2), vertical talus (1), diplegia secondary to head injury (1) and type I neurofibromatosis (1). The average age of patients was 6.4 years (range 4–12), and average follow-up was 9.9 months(range 4–20). Outcome was assessed using clinical assessment of the foot axis and functional improvement and radiographic measurements of change in the talocalcaneal angle and talonavicular sag. Results: Arthroereisis was never performed in isolation, additional procedure included achilles tendon lengthening (2), gastrocnemius recession (6), talonavivular and spring ligament plication (5) and split tibialis anterior tendon transfer (1). All patients had improvement of foot function and restoration of foot axis to a position parallel to the axis of progression. Restoration and maintenance of the talocalcaneal angle was excellent in all cases with preoperative average of 42 degrees (range 20–70), improved to a postoperative average of 23 (range, 0 – 40). Talonavicular sag improved from preoperative average of 16.5 degrees (range 0–32), to post operative average of 26 degrees (range 18–35). Complications include persistent first ray extension which required a Lapidus procedure (1), Ongoing minor discomfort (1). No patients or parents were dissatisfied. Discussion: The preliminary report supports the use of this technique in selected cases. Sizing of the implant and intraoperative assessment of correction of deformity and balanced surgery are critical to success. It is a simple and rapid procedure with advantages over alternatives such as Osteotomy and fusion. Long term results need further evaluation

Purpose: The current study assessed the post-operative long-term outcome of up to 9 years follow-up of tarsal coalition treated with resection, utilizing the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. To the best of our knowledge this is the first study utilizing that score in regard to Tarsal coalition resection as a sole treatment. Materials and Methods: Between 1988 and 1999, 36 patients (36 feet) with painful flatfoot and restricted range of motion attributable to talocalcaneal and calcaneonavicular coalition were treated with resection of the coalition in multiple medical centers in Israel. Thirty-one patients were male and five female. Twentyfive patients had unilateral coalition and eleven patients had bilateral coalition. Coalition types were talocalcaneal(29) and calcaneonavicular(7). The patients were interviewed and examined during a follow-up period of 12 to 108 months, with an average of 51.6 months. Results: Outcome was based on the ankle hindfoot clinical rating system of the American Orthopaedic Foot and Ankle Society. The clinical results were also evaluated statistically. Favorable outcome was evident in only 50% of cases. Average score was 79.2 in talocalcaneal coalition patients and 85.4 in calcaneonavicular coalition patients (not statistically significant). A multivariate statistical analysis was done and an equation was found, which elucidates the connection between age, gender and diagnosis, and AOFAS score. Conclusions: On the basis of these results, three parameters were found to affect the operative outcome: age, type of coalition and gender. Age itself stands alone as a predictive tool to the postoperative outcome. The equation that was found to correlate age, type of coalition and gender with the score can act as a predictive tool of the outcome and aid in preoperative patient selection for tarsal coalition resection

The authors provide an analysis of the results of surgery for clubfoot at the Vilnius University Children’s Hospital in Lithuania from 1979 to 1999. We operated 565 clubfeet in 464 patients. Average age of the patients was 4.1 years. From 1979 to 1993, 172 feet were operated. Most patients had the so-called Zacepin procedure for clubfoot release that contains a multi-stage release of different clubfoot components, but without attention to bony alignment restoration. At that time most patients were operated from 1.5 to 4 years of age. In that group 45% of the patients had a recurrence of the deformity and an additional operation was necessary. From 1993 to 1999, 393 clubfeet were operated. Mean age of the patients was 2.7 years (range 6 months to 7.4 years.). A more extensive release was introduced using the Cincinnati approach and restoration of normal talocalcaneal and talonavicular alignment following adequate soft tissue release. In this group 14% of the patients had a recurrence. The main goal of the clubfoot surgery was an exact reposition and fixation of the talocalcaneal and talonavicular alignment with adequate soft tissue release. The Cincinnati approach was the most effective and safe for correcting all of the components of the deformity. The best results were found in the patients who were operated at the age of six to eight months. In order to get a better functional outcome, at three to four years of age a number of our operated patients required an additional procedure such as a split tibialis anterior tendon transfer, a lateral column shortening, or a medial column lengthening. An excessive reposition of the talus produces a strange and severe foot deformity that is difficult to manage

Purpose: Subtalar dislocation is an exceptional finding. En bloc dislocation under the talus leads to talocalcaneal talonavicular luxation, generally observed in young active adults. Prognsosis is related to the risk of infection and talar necrosis. We report a retrospective series searching for featues influencing long-term clinical outcome. Material and methods: Between 1984 and 1990, twelve cases of subtalar dislocation were treated in our unit. There were nine lateral and three medial cases. Six lateral dislocations were open injuries, the head of the talus exposed medially. Treatment consisted in emergency orthopaedic reduction associated with debride-ment and closure in case of open injury. Temporary pinning (45 days) between the talus and the calcaneus was used in six cases. There were two lesions of the posterior tibial bundle which were repaired in the emergency setting. A supramalleolar lateral flap (Masquelet) was needed in one patient who developed cutaneous necrosis exposing the anterior tibial. Postoperative immobilisation consisted in a plaster boot for 45 days in all cases. Results: Mean follow-up was ten years. Clinical outcome was good in eleven patients (slightly limited dorsal flexion, 10°) and fair to poor in one. We did not have any case of talar necrosis or subtalar degeneration. Discussion: This series confirms data in the literature. Pure dislocation has as a rule a good prognosis although there is some discrepancy in the literature. In our series, lateral dislocation was more frequent than medial dislocation. Skin opening is frequent and is not a factor of poor prognosis. The absence of talar necrosis is related to preservation of the deltoid branch of the posterior tibial artery and respect of the fibular artery collaterals which supply the posteriolateral tubercle and the tarsal sinus. Emergency reduction of peritalar dislocations eliminates vascular suffering and limits the risk of infection. A temporary talocalcaneal pin is indispensable if the joint is unstable after reduction