Biomedical imaging is essential in the diagnosis of musculoskeletal pathologies and postoperative evaluations. In this context, Cone-Beam technology-based Computed Tomography (CBCT) can make important contributions in orthopaedics. CBCT relies on divergent cone X-rays on the whole field of view and a rotating source-detector element to generate three-dimensional (3D) volumes. For the lower limb, they can allow acquisitions under real loading conditions, taking the name Weight-Bearing CBCT (WB-CBCT). Assessments at the foot, ankle, knee, and at the upper limb, can benefit from it in situations where loading is critical to understanding the interactions between anatomical structures. The present study reports 4 recent applications using WB-CBCT in an orthopaedic centre. Patient scans by WB-CBCT were collected for examinations of the lower limb in monopodal standing position. An initial volumetric reconstruction is obtained, and the DICOM file is segmented to obtain 3D bone models. A reference frame is then established on each bone model by virtual landmark palpation or principal component analysis. Based on the variance of the model point cloud, this analysis automatically calculates longitudinal, vertical and mid-lateral axes. Using the defined references, absolute or relative orientations of the bones can be calculated in 3D. In 19 diabetic patients, 3D reconstructed bone models of the foot under load were combined with plantar pressure measurement. Significant correlations were found between bone orientations, heights above the ground, and pressure values, revealing anatomic areas potentially prone to ulceration. In 4 patients enrolled for total ankle arthroplasty, preoperative 3D reconstructions were used for prosthetic design customization, allowing prosthesis-bone mismatch to be minimized. 20 knees with femoral ligament reconstruction were acquired with WB-CBCT and standard CT (in unloading). Bone reconstructions were used to assess congruency angle and patellar tilt and TT-TG. The values obtained show differences between loading and unloading, questioning what has been observed so far. Twenty flat feet were scanned before and after Grice surgery. WB-CBCT allowed characterization of the deformity and bone realignment after surgery, demonstrating the complexity and multi-planarity of the pathology. These applications show how a more complete and realistic 3D geometric characterization of the of lower limb bones is now possible in loading using WB-CBCT. This allows for more accurate diagnoses, surgical planning, and postoperative evaluations, even by automatisms. Other applications are in progress

Aims

The health-related quality of life (HRQoL) of paediatric patients with orthopaedic conditions and spinal deformity is important, but existing generic tools have their shortcomings. We aim to evaluate the use of Paediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales in the paediatric population with specific comparisons between those with spinal and limb pathologies, and to explore the feasibility of using PedsQL for studying scoliosis patients’ HRQoL.

Purpose. Flat feet are an important cause of foot problems in children. The flexible flat foot is the most common form and is normally physiological and asymptomatic. Further assessment is necessary when a symptomatic flat foot persists. Surgical interventions are indicated when conservative therapies have failed. The Kalix arthroereisis is a surgical option and is placed in the subtalar joint of the foot, thereby preventing hyperpronation, and stabilizes the foot against excessive movements. The purpose of this study was to evaluate the functional and radiological outcomes of pediatric patients who had undergone a Kalix implantation for the treatment of a symptomatic flexible flat foot. Methods. Patient files of our institution were searched for patients who underwent a Kalix implantation between 2009 and 2014. Sixteen patients (26 feet) with symptomatic flexible flat feet were clinically and radiographically evaluated in this retrospective study. The calcaneal pitch and Meary”s angle were measured on the pre-, and postoperative follow-up radiographs and patient satisfaction survey was performed at follow-up to gain insight into functional outcome and satisfaction after the intervention. Results. Surgery was performed on an average age at 12.5 (range:10–15) years with a mean time from surgery to follow-up of 45.1±3.16 (range:18–78) months. There was a statistically significant increase in calcaneal pitch of 2.9° (11.7°to14.6°) and decrease in Meary”s angle of 15.8° (23.2° to7.85°) after surgery. The postoperative angles were maintained during follow-up, for both the calcaneal pitch (13.89°) and Meary”s angle (8.67°) in patients with the Kalix in situ (n=9/26) and in patients with the Kalix removed (15.4° and 7.8° respectively, n=17/26). The patient satisfaction survey shows that the majority of patients were satisfied regarding the state (81%) and appearance (75%) of their feet at follow-up. The majority never complained about their feet (81%) and heavy exercise was the major cause of complaints (23%). Limitations during walking were usually not the case (81%), though some patient experienced limitations during running (57%). Most reported preoperative complaints were pain, walking problems or a combination of both. The majority of these are relieved after surgery and patients were still asymptomatic at follow up. Conclusion. Kalix implantation improves the calcaneal pitch and Meary”s angle, thereby restoring foot anatomy towards a normal anatomy. These improvements were observed directly postoperatively and remained at follow-up. In addition, relieve of symptoms was observed postoperatively and the majority of patients were even satisfied at follow-up. We therefore suggest that Kalix arthroereisis is an appropriate treatment option for pediatric patients with symptomatic flexible flat feet. Significance. This was the first study evaluating functional and radiological outcomes of the Kalix arthroereisis in patients with symptomatic flexible flat feet

We present a review of our Specialist Physiotherapy clinic for normal physiological variations of the lower limb (SPNV) clinics, demonstrating them to be clinically effective and cost effective. Children with normal variation of rotational profile and limb angulation present much anxiety to parents and primary care. Providing consultation: to eliminate significant pathology and reassure families, is an important service that a Paediatric Orthopaedic department provides. In our tertiary referral department we have a Specialist Physiotherapy led clinics into which primary care practitioners refer children with whom there are concerns about lower limb development variation. The (SPNV) Clinic was first set up by a Consultant and Senior Physiotherapist in 1999. The aim of the clinic was to reduce the waiting times for incoming referrals but ensuring they are seen in an appropriate environment by an experienced health care professional. Clinics are run by Senior Specialist Physiotherapists, alongside Consultant clinics who are available for advice and direction. This provides security for the physios, the Trust and the patient. Over 15 years there have been more than 4000 patient visits to this clinic. Over 80% were new patient visits. 70% of these visits were discharged in one or two reviews. 97.4% of new referrals were discharged without subsequent review by an orthopaedic surgeon. The most common conditions reviewed were Genu valgum (25%), Genu Varum (16%), intoeing (17%) and flexible flat feet (11%). The clinic has proven to be cost effective as well in drawing in up to £500,000 revenue into the trust in a single year. The department has been approached by other trusts to assist in the implementation of similar clinics. We present this review of the patients, as a template for supporting the work of Paediatric Orthopaedic Departments. This service has facilitated the streamlining of our Consultant Paediatric Orthopaedic clinics

Aims

There is increasing evidence that flexible flatfoot (FF) can lead to symptoms and impairment in health-related quality of life. As such we undertook an observational study investigating the aetiology of this condition, to help inform management. The hypothesis was that as well as increased body mass index (BMI) and increased flexibility of the lower limb, an absent anterior subtalar articulation would be associated with a flatter foot posture.

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy is a well-recognised form of treatment for stage II posterior tibial tendon dysfunction. Although excellent short- and medium-term results have been reported, the long-term outcome is unknown. We reviewed the clinical outcome of 31 patients with a symptomatic flexible flat-foot deformity who underwent this procedure between 1994 and 1996. There were 21 women and ten men with a mean age of 54.3 years (42 to 70). The mean follow-up was 15.2 years (11.4 to 16.5). All scores improved significantly (p < 0.001). The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up. The mean pain component improved from 12.3 to 35.2 (20 to 40). The mean function score improved from 35.2 to 45.6 (30 to 50). The mean visual analogue score for pain improved from 7.3 to 1.3 (0 to 6). The mean Short Form-36 physical component score was 40.6 (sd 8.9), and this showed a significant correlation with the mean AOFAS score (r = 0.68, p = 0.005). A total of 27 patients (87%) were pain free and functioning well at the final follow-up. We believe that flexor digitorum longus transfer and calcaneal osteotomy provides long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Cite this article: Bone Joint J 2015;97-B:346–52.

The February 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Hip dislocation in children with CTEV: two decades of experience; Population-based prevention of DDH in cerebral palsy: 20 years’ experience; Shoulder derotation in congenital plexus palsy; Back pain in the paediatric population: could MRI be the answer?; Intercondylar fracture of the humerus in children; The Dunn osteotomy in SUFE; Radiocapitellar line a myth!; Do ‘flatfooted’ children suffer?

In this study we evaluated the results of midtarsal release and open reduction for the treatment of children with convex congenital foot (CCF) (vertical talus) and compared them with the published results of peritalar release. Between 1977 and 2009, a total of 22 children (31 feet) underwent this procedure. In 15 children (48%) the CCF was isolated and in the remainder it was not (seven with arthrogryposis, two with spinal dysraphism, one with a polymalformative syndrome and six with an undefined neurological disorder).

Pre-operatively, the mean tibiotalar angle was 150.2° (106° to 175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°). The procedure included talonavicular and calcaneocuboid joint capsulotomies, lengthening of tendons of tibialis anterior and the extensors of the toes, allowing reduction of the midtarsal joints. Lengthening of the Achilles tendon was necessary in 23 feet (74%).

The mean follow-up was 11 years (2 to 21). The results, as assessed by the Adelaar score, were good in 24 feet (77.4%), fair in six (19.3%) and poor in one foot (3.3%), with no difference between those with isolated CCF and those without. The mean American Orthopaedic Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8 (36 to 93) for those with isolated CCF and those without, respectively. At the final follow-up, the mean tibiotalar (120°; 90 to 152) and calcaneal pitch angles (4°; -13 to 22) had improved significantly (p < 0.0001). Dislocation of the talonavicular and calcaneocuboid joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet, respectively. Three children (five feet) underwent further surgery at a mean of 8.5 years post-operatively, three with pes planovalgus and two in whom the deformity had been undercorrected. No child developed avascular necrosis of the talus.

Midtarsal joint release and open reduction is a satisfactory procedure, which may provide better results than peritalar release. Complications include the development of pes planovalgus and persistent dorsal subluxation of the talonavicular joint.

Cite this article: Bone Joint J 2014;96-B:837–44.

The August 2013 Foot & Ankle Roundup³⁶⁰ looks at: mobility, ankles and fractures; hindfoot nailing: not such a bad option after all?; little treatment benefit for blood injection in tendonitis; fixed bearing ankles successful in the short term; hindfoot motion following STAR ankle replacement; minimally invasive calcaneal fracture fixation?; pes planus in adolescents; and subluxing peroneals and groove deepening

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

At our institution surgical correction of symptomatic flat foot deformities in children has been guided by a paradigm in which radiographs and pedobarography are used in the assessment of outcome following treatment. Retrospective review of children with symptomatic flat feet who had undergone surgical correction was performed to assess the outcome and establish the relationship between the static alignment and the dynamic loading of the foot. A total of 17 children (21 feet) were assessed before and after correction of soft-tissue contractures and lateral column lengthening, using standardised radiological and pedobarographic techniques for which normative data were available. We found significantly improved static segmental alignment of the foot, significantly improved mediolateral dimension foot loading, and worsened fore-aft foot loading, following surgical treatment. Only four significant associations were found between radiological measures of static segmental alignment and dynamic loading of the foot. Weakness of the plantar flexors of the ankle was a common post-operative finding. Surgeons should be judicious in the magnitude of lengthening of the plantar flexors that is undertaken and use techniques that minimise subsequent weakening of this muscle group. Cite this article: Bone Joint J 2013;95-B:706–13

Flexible flat foot is considered one of the commonest normal variants in children's orthopaedic practice. The weightbearing foot is usually regarded as flexible on the basis of results from clinical and radiographic examination as well as measured foot-ground pressure pattern. Our aim was to compare the pedobarographic and radiographic findings of normal arched and symptomatic flexible flat feet and investigate if there were sensitive markers that could be used in selecting patients for surgical correction. We retrospectively collected data from eighteen patients (ten to sixteen year old). Our control group consisted of ten patients (twenty feet) with normal arched feet and the study group of eight patients (fifteen feet) with symptomatic flat feet who were awaiting surgical correction. The mean and standard deviations of three radiographic markers (Calcaneal pitch, Naviculocuboid overlap and lateral Talo-1st metatarsal angle) in addition to foot pressures measured at the hindfoot, medial/lateral/total midfoot (MMF, LMF, TMF), forefoot and the percentage of weight going through the MMF over the TMF (medial midfoot ratio (MMFR) during the mid-stance gait phase are reported. In addition, the sensitivity, specificity, positive predictive value and negative predictive value of the pedobarographic parameters were estimated. There was a significant difference in the Naviculocuboid overlap (P<0.001 T test) and Calcaneal pitch (P<0.05 T test) between both groups. The flat feet group had significantly higher MMF, LMF, TMF and MMFR (P < 0.001 Mann-Whitney). LMF had the highest sensitivity and negative predictive value (94%) whereas MMF, TMF and MMFR had the highest specificity and positive predictive value (100%). Compared to our control group, patients with symptomatic flexible flat feet had significantly higher pressures distributed in the midfoot, in particular in the medial midfoot. Pedobarography appears to be a sensitive and specific tool that can be used, in conjunction with clinical and radiographic findings, in diagnosing flat feet. Our study suggests that pedobarography could be used to measure the degree of deformity before and after surgical intervention

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

Twenty-one symptomatic flat feet from the surgical wait list were compared with twenty-one matched controls. The radiographs were digitized, blinded and the measurements made two occasions by two observers in different order. On the lateral radiograph the talar to first metatarsal angle reached greatest significance at p< 0.0001, and had an inter and intra observer reliability of 0.83 and 0.75 respectively (r. 2. value). Only three other of the twelve measurements made reached statistical significance. Radiographic assessment of reconstructive procedures should show restoration of the arch of the foot: We recommend using the talar neck to first metatarsal angle on the lateral view as the correct indicator of loss or restoration of an arch. The purpose of this study was to determine the radiographic measures that differentiate the symptomatic adult flat foot from a normal foot, and determine the reliability of the measurements. Although many radiographic measures of flat foot are described, only four out of twelve measurements studied were significantly different between symptomatic adult flat foot and normal adults. Radiographic assessment of reconstructive procedures should show restoration of the arch of the foot: We recommend using the talar neck to first metatarsal angle on the lateral view as the correct indicator of loss or restoration of an arch. Twenty-one symptomatic flat feet from the surgical wait list were compared with twenty-one matched controls. Diagnoses included rheumatoid arthritis and posterior tibial tendonitis. All previously described measures of loss of arch were measured on standing AP and lateral radiographs of the foot taken using the same radiographic technique at a single facility. The radiographs were digitized, blinded and the measurements made two occasions by two observers in different order. On the lateral radiograph the talar to first metatarsal angle reached greatest significance at p< 0.0001, and had an inter and intra observer reliability of 0.83 and 0.75 respectively (r. 2. value). The medial cuniform to 5. th. metatarsal height also reached signficance, but had poor intraobserver reliability (r. 2. =0.09). On the AP view, only the talar head uncoverage distance reached significance (p< 0..0001) but had poor inter and intraobserver reliability (r. 2. =0.05 and 0.08)

Introduction: Planovalgus is a clinical deformity on weightbearing. Extra-articular calcaneal lengthening osteotomy, is a recognised surgical treatment for symptomatic flat feet. The aim of this study was to assess the difference in pedal pressures and radiographic parameters in the assessment of patients undergoing lateral column lengthening for planovalgus deformity. Methods: Operative records of one surgeon were reviewed over a 5 year period to identify those who had undergone a lateral column lengthening procedure. 10 patients, 14 feet were identified. Patients were recalled for post-operative pedobarography and pre- and post-operative X-rays were identified. Peak plantar pressures were measured at 8 sites and a line plotted to show maximum deviation of pressure progression from the anatomical axis of the foot. 5 angles on X-rays were measured by 2 observers on 2 occasions. Results: Difference in pressure under the 3. rd. metatarsal head (p=0.0004), hallux (p=0.02) and medial midfoot (0.001) suggested a highly significant change. Results for the first (p=0.41) and second (p=0.91) metatarsal heads showed no change. The centre of pressure maximum deviation, plotted using a line drawn between the second toe and the rear of the heel was found to be highly significant postoperatively (p=0.00051) indicating that load bearing shifted from medial to lateral. Changes in X-ray angles of the lateral talo-1. st. metatarsal angle(p=0.006), calcaneal pitch(p=0.002), AP talocalcaneal angle(0.0001) and talonavicular coverage(p=0.003) were all highly significant. Discussion: Lateral lengthening in adolescent feet changes the pedal pressures in an advantageous way

Our aim was to evaluate the results of triple arthrodesis, performed without the use of supplementary bone graft. We carried out a retrospective review of 100 consecutive triple arthrodeses. All the operations had been performed by the senior author (TSS) using a standard technique. Only local bone graft from the excised joint surfaces had been used, thereby avoiding complications at the donor site.

The mean age of the patients at surgery was 58 years (18 to 84). The mean time to union was 5.1 months (3 to 17). There were 75 good, 20 fair and five poor results. There were four cases of nonunion.

Our study has shown that comparable rates of union are achieved without the need for supplementary bone graft from the iliac crest or other donor site.

We studied the long-term results of the Miller operation at a mean age of 13 years in 22 patients (38 feet) with persistently symptomatic mobile flat feet associated with an isolated naviculocuneiform break. At a mean of 12 years (3 to 27) after surgery, 84% of the feet had a satisfactory clinical result. We conclude that the Miller operation is a useful procedure for adolescent patients with persistently symptomatic flat feet with an isolated break at the naviculocuneiform joint

For clinical, psychological and social reasons the diagnosis of Duchenne muscular dystrophy should be established as early as possible. In a survey of 83 families with 93 affected boys, the diagnosis was missed in every case referred to an orthopaedic surgeon (37 patients). In the whole group there was a mean delay of 2.0 years (0 to 6 years) during which time inappropriate treatment, difficulties in communication with parents, much parental anxiety and further pregnancies occurred. A serum creatine kinase estimation is a simple outpatient test which should be carried out on any boy with clumsy or abnormal gait, with flat feet or with an unexplained equinus deformity