Background. The adult acquired flat foot is caused by a complete or partial tear of the tibialis posterior tendon. We present the results of flexor digitorum longus transfer and medializing calcaneal osteotomy for recontruction of the deformity. Material & Methods. Twenty-six patients (31 feet) with an average age of 58 years (36–75) were operated for an acquired flat foot deformity. The patients were seen before surgery, one year after surgery and an average of 85 months after surgery to assess the following parameters: AOFAS Score, VAS Score for pain (0–10). Foot x-rays in full weightbearing position (dorsoplantar and lateral) were done at every visit in order to assess the following parameters: tarsometatarsale angle on the dorsoplantar and lateral x-ray, talocalcaneal angle on the lateral x-ray, calcaneal pitch angle and medial cuneiforme height on the lateral x-ray. Results. The AOFAS hindfoot score improved from 46.4 to 89.5 (max.: 100) points 1 year postoperatively und decreased to 87.8 points at the last follow-up. VAS for pain decreased from 6.6 to 1.1 at the one year follow-up and increased to 1.5 at the last follow-up. All radiologic parameters improved and stayed without significant changes over time. Following complications were seen: one recurrence, two patients with irritation of the sural nerve, one patient with hypesthesia of the big toe. In six patients the screws had to be removed. Apart from that no other revision surgery had to be done. Conclusion. Flexor digitorum longus transfer together with medializing calcaneal osteotomy provides excellent results for the therapy of acquired flat foot deformity. The results did not change significantly over time

Aim. We report the results of Cobb I procedure and Rose calcaneal osteotomy for stage II posterior tibial dysfunction in a consecutive series of thirty patients. Methods. These patients were reviewed prospectively after average of 30 months (range: 12-92 months). An experienced independent, biomechanics specialist carried out the ultrasound examination to assess dynamic function of the posterior tibial tendon at final follow-up. Results. Twenty-eight patients were available for final follow-up. Two patients died of unrelated causes. Mean age was 60 years (range: 40-81 years). Average AOFAS score improved from 53.6 pre-operatively to 89.8 at final follow-up. Twenty-five (89%) patients were able to perform single heel raise. Six (22%) were using some form of orthotics at final follow-up. All calcaneal osteotomies united. On ultrasound examination, the posterior tibial tendon was intact in all patients and it was found to be mobile in twenty-six (93%) patients. There was one superficial wound infection and two prominent screws were removed. Three patients had subtalar joint arthritis. The surgical intervention improved the quality of life in all but two patients and only two patients were not satisfied with the surgery. Conclusion. These results suggest that a combination of Cobb I procedure and Rose Calcaneal osteotomy is a safe, effective, reliable and attractive option for the treatment of stage II posterior tibial tendon dysfunction, which provides dynamic function of posterior tibial tendon without sacrificing the primary function of long flexor tendons in foot and ankle

Introduction. Charcot Arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. The traditional surgical method of extensive surgical exposure, excision of bone, acute correction and internal fixation is not always appropriate in presence of active ulceration, deep infection and poor bone quality. Minimally invasive osteotomies and gradual correction of deformities with a circular frame are proving helpful in minimizing complications. We present our experience with the use of Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. Materials and Methods. Our indication for the treatment with TSF is recurrent or intractable ulceration with or without active bone infection or a history of infection in a deformed foot and/or ankle. There are 2 female and 8 male patients in this cohort. We used a long bone module for ankle and hindfoot deformities (3 patients) and a forefoot 6×6 butt frame (7 patients) for midfoot deformities. An osteotomy through midfoot was performed in all chronic stable midfoot deformity cases and a calcaneal osteotomy and gradual correction through ankle in when hindfoot and ankle deformities co-existed. Results. Our outcome measures are a complete healing of ulcer and infection without recurrence, clinically plantigrade foot and ability to wear regular shoes or diabetic footwear. We achieved this outcome in 9 out of 10 patients. Successful patients remain ulcer free at minimum 7 and maximum 14 years follow up. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. Conclusions. Our results confirm that Taylor Spatial Frame treatment is a good alternative to traditional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities

Chronic postoperative pain (CPP) can occur in elective mid/hindfoot and ankle surgery patients. Multimodal pain management has been reported to reduce postoperative pain and opioid use, which may prevent the development of CPP. However, few studies have examined the impact of multimodal pain management strategies on CPP following complex elective mid/hindfoot and ankle surgery. The purpose of this study was to 1) evaluate current pain management strategies and 2) determine current definitions, incidence, and prevalence of CPP after elective mid/hindfoot and ankle surgery. Three databases (MEDLINE, Embase and Cochrane Library) were manually and electronically searched for English language studies published between 1990 and July 2017. For the first aim, we included comparative studies of adults undergoing elective mid/hindfoot and ankle surgery that investigated pre-, peri- or postoperative pain management. For the second aim, we included observational studies examining CPP definition, incidence, and prevalence. Two reviewers independently screened titles and abstracts, followed by full texts. Conflicts were resolved through discussion with a third reviewer. Reviewers also independently assessed the quality of studies meeting inclusion criteria using the Joanna Briggs Institute Critical Appraisal Checklist. For the first aim, 1159 studies were identified by the primary search, and seven high quality randomized controlled trials were included. Ankle arthroplasty or fusion and calcaneal osteotomy were the most common procedures performed. The heterogeneity of study interventions, though all regional anesthesia techniques, precluded meta-analysis. Most investigated continuous popliteal, sciatic and/or femoral nerve blockade. Participants were typically followed up to 48 hours postoperatively to examine postoperative pain levels and morphine consumption in hospital. Interventions effective at reducing postoperative pain and/or morphine consumption included inserting popliteal catheters using ultrasound instead of nerve stimulation guidance, perineural dexamethasone, and adding continuous femoral blockade to continuous popliteal blockade. Using more than one analgesic was generally more effective than using a single agent. Only two studies examined longer term pain management. One found no difference in pain levels and opioid consumption at two weeks with perineural or systemic dexamethasone use. The other found that pain with activity was significantly reduced at six months postoperatively with the addition of a femoral catheter infusion to a popliteal catheter infusion. For the second aim, only two studies of the 747 identified were selected. One prospective observational study defined CPP as moderate-to-severe pain at one year after foot and ankle surgery, and reported 21% and 43% of patients as meeting their definition at rest and with activity, respectively. The other study was a systematic review that reported 23–60% of patients experienced residual pain after total ankle arthroplasty. There is no standardized definition of CPP in this population, and incidence and prevalence are rarely reported and vary largely based on definition. Although regional anesthesia may be effective at reducing in-hospital pain and opioid consumption, evidence is very limited regarding longer-term pain management and associated outcomes following elective mid/hindfoot and ankle surgery

Tarsometatarsal arthritis must be evaluated in conjunction with naviculocuneiform joint arthritis, as the two generally coexist. Primary osteoarthritis or systemic arthritis generally leads to uncomplicated non-deformity correction through arthrodesis. Challenges in correction become more pronounced following Lisfranc injury, where deformity and ligament instability introduce malalignment that mandates osteotomies to correct deformity. Diagnosis hinges on both CT scan data and selective diagnostic injections under fluoroscopy. The surgeon must simultaneously consider minimising bone resection to lessen the impact of metatarsal shortening. In addition, the three columns of the foot must be respected with reference to midfoot arthrodesis rules, introducing challenges in operative reconstruction as the lateral column mandates preserved flexibility. In addition, collapse at the midfoot often leads to a rigid pes planovalgus deformity, and the surgeon must consider when it is appropriate to add a medial slide calcaneal osteotomy and gastrocnemius recession. Finally, naviculocuneiform joint arthrodesis, if required, introduces significant technical challenges in both alignment and fixation that will be addressed

Background. Lateral column lengthening combining bony and soft tissue procedures has been described for symptom relief and deformity correction in the planovalgus foot. There are relatively few reports on its outcomes in childhood. We present our medium term outcomes using this technique in children. Methods. Twenty-five symptomatic mobile planovalgus feet in fifteen patients were operated upon between 2005 and 2008. The mean age at surgery was 12 years 6 months. Ten patients had idiopathic pes planovalgus, two had overcorrected congenital talipes equinovarus, and one had skewfoot deformity. The surgery included one or more bony elements - lengthening calcaneal osteotomy, heel shift, medial cuneiform osteotomy - iliac crest tricortical bone graft harvest and one or more soft tissue procedures - peroneus brevis/peroneus longus transfer, plantar fascia release and tibialis posterior advancement. The extent of surgery was decided per-operatively in an a la carte fashion. The Visual Analogue Score for Foot and Ankle (VAS FA) and American Foot and Ankle Association (AOFAS) ankle-hindfoot and midfoot scores were measured. Clinical findings and complications were recorded. Results. Twenty feet in twelve patients were available for follow up at a mean post-operative interval of 4 years 6 months. The mean VAS FA, AOFAS ankle-hindfoot and midfoot scores were 82 ± 17, 87 ± 14 and 80 ± 10 respectively. In all patients the medial arch was restored. One patient required bilateral lateral column shortening and medial cuneiform osteotomy to address overcorrection and supination, one had bilateral calcaneal screw removal and one had a subsequent heel shift. Conclusions. A la carte lateral column lengthening combining bony and soft tissue procedures for the symptomatic planovalgus foot is a powerful technique. We have shown satisfactory functional medium term outcomes with this surgery, and believe it can be used in childhood for symptomatic planovalgus foot deformity correction