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

The December 2022 Foot & Ankle Roundup³⁶⁰ looks at: Evans calcaneal osteotomy and multiplanar correction in flat foot deformity; Inflammatory biomarkers in tibialis posterior tendon dysfunction; Takedown of ankle fusions and conversion to total ankle arthroplasty; Surgical incision closure with three different materials; Absorbable sutures are not inferior to nonabsorbable sutures for tendo Achilles repair; Zadek’s osteotomy is a reliable technique for treating Haglund’s syndrome; How to best assess patient limitations after acute Achilles tendon injury; Advances in the management of infected nonunion of the foot and ankle.

In the current healthcare environment, cost containment has become more important than ever. Perioperative services are often scrutinized as they consume more than 30% of North American hospitals’ budgets. The procurement, processing, and use of sterile surgical inventory is a major component of the perioperative care budget and has been recognized as an area of operational inefficiency. Although a recent systematic review supported the optimization of surgical inventory reprocessing as a means to increase efficiency and eliminate waste, there is a paucity of data on how to actually implement this change. A well-studied and established approach to implementing organizational change is Kotter's Change Model (KCM). The KCM process posits that organizational change can be facilitated by a dynamic 8-step approach and has been increasingly applied to the healthcare setting to facilitate the implementation of quality improvement (QI) interventions. We performed an inventory optimization (IO) to improve inventory and instrument reprocessing efficiency for the purpose of cost containment using the KCM framework. The purpose of this quality improvement (QI) project was to implement the IO using KCM, overcome organizational barriers to change, and measure key outcome metrics related to surgical inventory and corresponding clinician satisfaction. We hypothesized that the KCM would be an effective method of implementing the IO. This study was conducted at a tertiary academic hospital across the four highest-volume surgical services - Orthopedics, Otolaryngology, General Surgery, and Gynecology. The IO was implemented using the steps outlined by KCM (Figure 1): 1) create coalition, 2) create vision for change, 3) establish urgency, 4) communicate the vision, 5) empower broad based action, 6) generate general short term wins, 7) consolidate gains, and 8) anchor change. This process was evaluated using inventory metrics - total inventory reduction and depreciation cost savings; operational efficiency metrics - reprocessing labor efficiency and case cancellation rate; and clinician satisfaction. The implementation of KCM is described in Table 1. Total inventory was reduced by 37.7% with an average tray size reduction of 18.0%. This led to a total reprocessing time savings of 1333 hours per annum and labour cost savings of $39 995 per annum. Depreciation cost savings was $64 320 per annum. Case cancellation rate due to instrument-related errors decreased from 3.9% to 0.2%. The proportion of staff completely satisfied with the inventory was 1.7% pre-IO and 80% post-IO. This was the first study to show the success of applying KCM to facilitate change in the perioperative setting with respect to surgical inventory. We have outlined the important organizational obstacles faced when making changes to surgical inventory. The same KCM protocol can be followed for optimization processes for disposable versus reusable surgical device purchasing or perioperative scheduling. Although increasing efforts are being dedicated to quality improvement and efficiency, institutions will need an organized and systematic approach such as the KCM to successfully enact changes. For any figures or tables, please contact the authors directly

Purpose of study and background. Spinal surgery is a high-risk surgical speciality, a patient's understanding of surgical interventions, alternative treatment options, and the benefits and risks must be ascertained to gain informed consent. This pilot study aims to evaluate if the provision of a digital recording of a patient's consultation enhances patient satisfaction, improves recall of clinical diagnosis, recall of treatment options and the risks and benefits of Spinal Surgery. Methodology and results. A coalition team was identified. A safe and secure process for recording and storage identified. Both qualitative and quantitative data was collected via questionnaires. 62 patients were invited to participate in the pilot, 12 declined. Data was collected immediately post consultation, and two weeks following the consultation via telephone. Comparison was made of the relative increase or decrease in patient recall of the clinical diagnosis, treatment options, and the benefits and the risks of spinal surgery. Patient satisfaction was measured pre- and post- consultation. 50 patients (81%) participated. 32 participants (52%) responded to follow up questionnaire at 2 weeks. Recall of risk for surgical intervention increased by 37%, and of benefit by 36%. Patient satisfaction was rated excellent or very satisfied in 93% at initial consultation and at 2 week follow up all participant's rated satisfaction as excellent or very satisfied. Conclusion. This pilot study was small. COVID delayed further recruitment. Initial outcomes demonstrated high levels of patient satisfaction and appear to demonstrate improved recall. Significant technological issues were identified. Further collaborative work needs to be undertaken. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Background. A calcaneal medial osteotomy (CMO) is a surgical procedure frequently performed to correct a valgus alignment of the hindfoot. However currently little is known on its accurate influence on hindfoot alignment (HA). Aim. To assess the influence of a CMO on HA in both 2D and 3D measurements using weightbearing CT (WBCT). Methods. Twelve patients with a mean age of 49,4 years (range 18–67yrs) were prospectively included. Indications for surgical correction by a CMO with a solitary translation of the calcaneus consisted of an adult acquired flat foot stage II (N=10) and a talocalcaneal coalition (N=2). Fixation of the osteotomy was performed either using a step plate or double screw. A WBCT was obtained pre- and post-operative. HA was assessed by an angle between the anatomical tibia axis and the axis connecting the inferior calcaneus point and the middle of the talus in the coronal plane (HA. 2D. ) using Curvebeam® software. The tibia in the HA was separately assessed by the anatomical tibia axis (TA. X 2D. ). The same method was translated in 3D using 3-Matic® software with a Cartesian coordinate system originating in the inferior point of the calcaneus (HA. 3D. and TA. x 3D. ). Results. Both the mean pre-op HA. 2D. =12.8°± 4.5 and HA. 3D. =21.1°± 8.4 of valgus improved significantly post-operatively to a HA. 2D. =4.2°±4.5 and a HA. 3D. =11,9°± 6.1 (P < 0.001). Additionally, the mean pre-op TA. X 2D. = 4°± 2.6 and TA. X 3D. = 7,2 °± 3.2 showed a significant improvement to a TA. X 2D. = 3.1°± 2.7 and a TA. X 3D. = 6.1 °± 3.4 post-operatively (P < 0.05). The inter-rater reliability of the 2D measurement method with a mean ICC. HA2D. =0.74 and a mean ICC. TA2D. = 0.77 showed to be lower when compared to the 3D measurement method with a mean ICC. HA3D. =0.94 and a mean ICC. TA3D. =0.89. Conclusion. This study shows an effective correction of the valgus position from the calcaneus measured both in 2D and 3D when using a surgical CMO. The novelty is the marked influence on the tibia, which could now be accurately assessed using a weightbearing CT and additional 3D measurements. This resulted in 10% of the achieved HA correction, when analyzed both in 2D and 3D. This information could be of use when performing a pre-operative planning of a hindfoot deformity

Aims

To assess the effect of high tibial and distal femoral osteotomies (HTO and DFO) on the pressure characteristics of the ankle joint.

We present the validation of a translation into Danish of the Oxford ankle foot questionnaire (OxAFQ). We followed the Isis Pros guidelines for translation and pilot-tested the questionnaire on ten children and their parents. Following modifications we tested the validity of the final questionnaire on 82 children (36 boys and 45 girls) with a mean age of 11.7 years (5.5 to 16.0) and their parents. We tested the reliability (repeatability (test–retest), child–parent agreement, internal consistency), feasibility (response rate, time to completion, floor and ceiling effects) and construct validity. The generic child health questionnaire was used for comparison. We found good internal consistency for the physical and the school and play domains, but lower internal consistency for the emotional domain. Overall, good repeatability was found within children and parents as well as agreement between children and parents. The OxAFQ was fast and easy to complete, but we observed a tendency towards ceiling effects in the school and play and emotional domains. To our knowledge this is the first independent validation of the OxAFQ in any language. We found it valid and feasible for use in the clinic to assess the impact on children’s lives of foot and/or ankle disorders. It is a valuable research tool.

Cite this article: Bone Joint J 2015;97-B:420–6.

Purpose. To establish the early outcome, satisfaction and complications of sinus tarsi implants in the management of symptomatic flexible flatfeet for a paediatric population. Methods and results. We included all patients aged 18 years or less who were treated for flexible flatfeet with a sinus tarsi implant between January 2010 and June 2012. We excluded patients who had a history of clubfeet or tarsal coalition. 34 patients had 59 implants. The mean age at surgery was 13.7 yrs (9–17 yrs), with mean follow-up of 22 months (range 10–35). Mean AOFAS improved from 65.7 to 87.9 (p<0.001), with an improvement in AOFAS pain scores (p=0.0001). Radiographic correction occurred in all feet, with average improvement of the anteroposterior talar-second metatarsal angle of 16 degrees, and the lateral talar-first metatarsal angle of 9 degrees. Implant placement satisfaction rate was 86%, with 81% claiming that they would have the procedure again. Complications included peroneal spasm (8%), extrusion (7%), revision (5%), and removal (5%). Peroneal spasm was recalcitrant in 3 of the 5 cases, and those with spasm had a higher average forefoot abduction measurement (35 degrees) than the remaining treated cases (25 degrees). Conclusion. In paediatric patients with flexible flatfeet, utilisation of the sinus tarsi implant has good short-term outcome, with our failure and revision rates comparable to other published studies in the adult population. We introduce the concept of isolated subtalar hyperlaxity which appeared to be a distinct etiological factor. A learning curve in assessing implant size was noted. Overcorrection and implant migration were the indications for revision surgery. Severe forefoot abduction appears to have a poorer outcome, and may be associated with peroneal spasm. Level of evidence: IV

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. Method. We identified eleven children (13 feet) who had resections of middle facet tarsal coalitions with or without complex foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) for concurrent severe planovalgus between 2003 and 2011. Clinical examination, American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction. Results. Isolated coalition resection provided short to intermediate term pain relief for three children that had this as a solitary procedure. Calcaneal lengthening osteotomy performed as an additional procedure in patients with very severe and stiff planovalgus provided excellent correction and symptomatic pain relief in all six patients (Mean AOFAS: 91). Two patients had insertion of sinus tarsi implants in addition to resection also had satisfactory hind foot function (Mean AOFAS: 87.3) post operatively. Conclusion. This study shows that calcaneal lengthening osteotomy in addition to coalition resection in patients with severe rigid flat feet provides excellent pain relief and function. Rigid flat feet should be considered as a significant contributor to the pain complex in this cohort of patients

Introduction. Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, a review of literature suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomittant 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. Methods. Thirteen consecutively treated patients (eighteen feet) were retrospectively reviewed from the senior author's practice. Clinical examination, American Orthopaedic foot and Ankle Society (AOFAS) hindfoot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction. Results. All patients with resection and simultaneous flat foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) were satisfied and would have the same procedure again. Most patients were able to return to a higher level of sporting activity compared with preoperative ability. None of the patients had a fair or poor outcome as adjudged by their AOFAS scores. Conclusion. Our study shows that concomittant flatfoot reconstruction in patients with symptomatic middle facet tarsal coalition increased hindfoot motion, corrected malalignment and significantly improved pain. We believe that coalition resection and concomitant flatfoot reconstruction is better option than surgical resection alone or hindfoot fusion in this cohort of patients. Triple arthrodesis should be reserved as a salvage procedure

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