Reliability and correlation analysis of computed methods to convert conventional 2D radiological hindfoot measurements to a 3D setting using weightbearing CT.

PURPOSE: The exact radiographic assessment of the hindfoot alignment remains challenging. This is reflected in the different measurement methods available. Weightbearing CT (WBCT) has been demonstrated to be more accurate in hindfoot measurements. However, current measurements are still performed in 2D. This study wants to assess the use of computed methods to convert the former uniplanar hindfoot measurements obtained after WBCT towards a 3D setting. METHODS: Forty-eight patients, mean age of 39.6 ± 13.2 years, with absence of hindfoot pathology were included. A WBCT was obtained, and images were subsequently segmented and analyzed using computer-aided design operations. In addition to the hindfoot angle (HA), other ankle and hindfoot parameters such as the anatomical tibia axis, talocalcaneal axis (TCA), talocrural angle, tibial inclination (TI), talar tilt, and subtalar vertical angle were determined in 2D and 3D. RESULTS: The mean [Formula: see text] was [Formula: see text] of valgus ± 3.2 and the [Formula: see text] was [Formula: see text] of valgus ± 6.5. These angles differed significantly from each other with a [Formula: see text]. The correlation between both showed to be good by [Formula: see text] Pearson correlation coefficient (r) of 0.72 ([Formula: see text]). The [Formula: see text] showed to be excellent when compared to the [Formula: see text], which was good. Similar findings were obtained in other angles. The highest correlation was seen between the [Formula: see text] and [Formula: see text] (r = 0.83, [Formula: see text]) and an almost perfect agreement in the [Formula: see text] ([Formula: see text]). CONCLUSION: This study shows a good and reliable correlation between the [Formula: see text] and [Formula: see text]. However, the [Formula: see text] overcomes the shortcomings of inaccuracy and provides valuable spatial data that could be incorporated during computer-assisted surgery to assess the multiplanar correction of a hindfoot deformity.

Weightbearing CT in normal hindfoot alignment - Presence of a constitutional valgus?

BACKGROUND: The normal hindfoot angle is estimated between 2° and 6° of valgus in the general population. These results are solely based on clinical findings and plain radiographs. The purpose of this study is to assess the hindfoot alignment using weightbear CT. METHODS: Forty-eight patients, mean age of 39.6±13.2 years, with clinical and radiological absence of hindfoot pathology were included. A weightbear CT was obtained and allowed to measure the anatomical tibia axis (TAx) and the hindfoot alignment (HA). The HA was firstly determined using the inferior point of the calcaneus (HAIC). A density measurement of this area was subsequently performed to analyze if this point concurred with an increased ossification, indicating a higher load exposure. Secondly the HA was determined by dividing the calcaneus in the long axial view (HALA) and compared to the (HAIC) to point out any possible differences attributed to the measurement method. Reliability was assessed using an intra class correlation coefficient (ICC). RESULTS: The mean HAIC equaled 0.79° of valgus±3.2 (ICCHA IC=0.73) with a mean TAx of 2.7° varus±2.1 (ICCTA=0.76). The HALA equaled 9.1° of valgus±4.8 (ICCHA LA=0.71) and differed significantly by a P<0.001 from the HAIC, which showed a more neutral alignment. Correlation between both was shown to be good by a Spearman's correlation coefficient of 0.74. The mean density of the inferior calcaneal area equaled 271.3±84.1 and was significantly higher than the regional calcaneal area (P<0.001). CONCLUSIONS: These results show a more neutral alignment of the hindfoot in this group of non-symptomatic feet as opposed to the generally accepted constitutional valgus. This could have repercussion on hindfoot position during fusion or in quantifying the correction of a malalignment. The inferior calcaneus point in this can be used during pre-operative planning of a hindfoot correction as an anatomical landmark due to its shown influence on load transfer.

Measuring hindfoot alignment in weight bearing CT: A novel clinical relevant measurement method.

BACKGROUND: A precise pre-operative measurement of hindfoot malalignment is paramount to plan and obtain an accurate surgical correction. Hindfoot alignment is currently determined on standard weightbearing radiographs. However this is hampered by the superposition of the skeletal structures. Recent technology developed weightbearing cone beam CT to overcome this problem. The objective is to introduce a clinically relevant and reproducible method to measure hindfoot alignment on weightbearing CT. METHODS: Sixty malalignments of the hindfoot were divided in to two groups; group one containing a valgus alignment (n=30) and group two a varus alignment (n=30) of the hindfoot. Imaging techniques used were standard radiographs and a weightbearing CT (pedCAT®). Following angles were measured by two different authors: standard long axial hindfoot angle both on standard radiographs and on CT, clinical hindfoot, novel hindfoot angle, talar shift (distance from a neutral alignment), tibial inclination angle, talar tilt and subtalar vertical angle on CT. RESULTS: Hindfoot alignment angles showed to significantly differ from each other (P<0.001). The novel hindfoot alignment angle showed the highest correlation with the clinical measurement method. Correlation of this novel angle with the talar shift showed a Spearman's correlation coefficient=0.87. Interclass correlation coefficient of the novel hindfoot alignment angle=0.72 and was the highest among the hindfoot alignment angles. CONCLUSION: Weightbearing CT is allows to objectively assess hindfoot alignment. The proposed novel hindfoot alignment angle showed to be both clinically relevant and reproducible as compared to previous methods. The lateral tibiocalcaneal shift, on which the angle is highly correlated to, can help the surgeon in determining how much translation is necessary to obtain a neutral alignment during a calcaneal osteotomy. LEVEL OF EVIDENCE: Level III: retrospective cohort study.

Tendon balancing in hallux valgus surgery.

Recurrent valgus of the hallux after hallux valgus surgery is an unpleasant complication. A possible cause is the imbalance and maltracking of particularly the extensor hallucis longus (EHL) and less frequently the flexor hallucis longus (FHL) or extensor hallucis brevis (EHB) tendon of the hallux. In patients with a tight achilles tendon, the EHL tendon can be recruited to aid dorsiflexion of the foot, creating imbalance. The literature on this subject is very scarce. In 10 patients with severe hallux valgus, a perioperative evaluation after performing the osteotomies and capsular closure showed tight extensor or flexor tendons of the hallux with residual valgus maltracking. A balancing of the tendons was performed with a -realignment -lengthening procedure. A good clinical result was obtained in all patients. No adverse effects were seen after tendon balancing. Strength in all tendons was at least 3+, except in one patient with multiple sclerosis. No weaknesses or -difficulties during walking were reported. Tendon balancing could play a role in prevention of hallux valgus recurrences and can be performed without loss of strength or compromising of walking ability.

Midfoot arthritis: diagnosis and treatment.

BACKGROUND: Midfoot arthritis is a challenging problem causing chronic foot pain and impeding daily activity. There is not much written about this subject in literature and is often not well known by orthopaedic surgeons. The primary aim of treatment is to afford pain relief by enhancing midfoot stability and modifying loads sustained at the inflamed joints. The initial treatment is conservative with inserts and orthoses. Surgery, more specifically midfoot arthrodesis, is the next step when conservative management fails. The arthrodesis should be limited to the symptomatic joints but it is often difficult to determine which joints cause the symptoms. With this manuscript we would like to underline the importance of a precise anatomic preoperative diagnosis, review our surgical experience and discuss the different surgical fixation possibilities in midfoot arthrodesis. METHODS: Between 2006 and 2011 24 patients (26 feet) with midfoot osteoarthritis underwent selective arthrodesis after conservative management had failed. Preoperative examinations, fixation method, complications and outcome were noted. RESULTS: We achieved union in 25 feet. There was one delayed union and one non-union. There were no infections but 3 patients had chronic regional pain syndrome. Reoperation was required in one foot because of non-union and one for symptomatic hardware removal. CONCLUSION: Midfoot arthrodesis is an effective treatment for osteoarthritis of the joint. Identification of the affected joints is important to stipulate the extensiveness of the arthrodesis.

[Vascularized bone graft in carpal bone reconstruction]. / Greffon osseux vascularisé dans la reconstruction des os du carpe.

We report our experience of vascularized bone graft harvested from the volar aspect of the distal radius for carpal bone reconstruction. Thirty cadaveric dissections showed in all cases the volar carpal artery which born from the radial artery. Between 1994 to 2001, we treated 87 scaphoid non-unions with an average follow-up of 41 months (range 6 to 65 months). Union was obtained in 80 patients (92%) with an average delay of 8.6 weeks (range 6 to 24). Between 1994 to 2000 we treated 22 patients with a Kienbock's disease. A radius shortening was always added to the revascularization of lunate by this vascularized bone graft. Preoperative and postoperative MRI was systematically done. The average follow-up was 55 months (range 24 to 92 months). MRI showed healing with good revascularization in 16 cases (74%). Lesions of lunate were stabilized in five cases and we had one failure with secondary palliative procedure. This simple but meticulous technique needs only one approach and allows a sufficient revascularisation.

Pedicled fat flap coverage of the median nerve after failed carpal tunnel decompression.

We reviewed 14 patients treated with either an ulnar or a hypothenar fat flap for recurrent carpal tunnel syndrome and scar tenderness. Nine patients were satisfied and there were few complications. One patient had delayed skin healing and another developed a hypertrophic scar.

Closed traumatic rupture of the flexor pulleys of a long finger associated with avulsion of the flexor digitorum superficialis.

We report a closed rupture of the second, third and fourth annular pulleys associated with avulsion of the flexor digitorum superficialis tendon in the ring finger of a healthy, 48-year-old patient. It was caused by sudden and violent flexion of the finger and led to a serious impairment of the proximal interphalangeal joint motion, despite physiotherapy and dynamic splinting. The patient was treated surgically, 3 months after the injury, with reconstruction of the second (A2) and fourth (A4) annular pulleys and excision of the distal portion of the superficialis tendon. The final functional result was satisfactory.

Subcutaneous herniation of tendon interposition after trapeziectomy in three cases: explanation and implications.

We report a complication following trapeziectomy and tendon interposition. Subcutaneous herniation of the tendon interposition occurred in 3 of 412 cases in which trapeziectomy, ligament reconstruction, and tendon interposition were performed. This herniation occurred posterolaterally in the early postoperative period and resulted in dorsal swelling and superficial pain. Magnetic resonance imaging was helpful in confirming the diagnosis and excision of the herniated interposition material resulted in satisfactory pain relief and functional outcome as long as metacarpal stability was present.

The Weil osteotomy of the lesser metatarsals: a clinical and pedobarographic follow-up study.

The clinical results with pedobarographic analysis were assessed in 32 patients (59 metatarsals) who underwent a distal metatarsal shortening (Weil) osteotomy for either intractable plantar keratoses or chronically dislocated lesser metatarsal phalangeal joints. All patients had increased pressure under the involved metatarsal heads. Thirty three of the 59 metatarsophalangeal (MTP) joints were chronically dislocated. At an average follow-up of 30 months, patients rated the result as excellent or good for 32 of the 37 feet (86%). The mean preoperative AOFAS score was 59 (maximum 100), which improved to 81 post-operatively. This difference is significant: p = 0.00001 (with t-test). Comparison of the pre and post-operative pedobarographic measurements showed a significant decreased load under the affected metatarsal heads (p = 0.05). A complete disappearance of the callus was noted under 44 operated metatarsals (75%) and partial disappearance under 12 metatarsals (20%). Two symptomatic transfer lesions occurred under an adjacent metatarsal head. Recurrent dislocations occurred in 5 joints (15%). While metatarsophalangeal joint range of motion was significantly diminished, toe strength was maintained. Average metatarsal shortening was 5.9 mm with no nonunions, delayed unions, or malunions. The Weil shortening osteotomy is a simple and reliable procedure which can effectively reduce the load under the lesser metatarsophalangeal joints and is helpful for the reduction of dorsally dislocated MTP joints.

Avulsion of both extensor carpi radialis tendons: a case report.

Closed traumatic avulsion of both extensor carpi radialis tendons is reported in a young healthy patient. Early diagnosis important because the tendons tend to retract and anatomic repositioning is more difficult to perform with passing time. Diagnostic markers are the inability to actively extend the wrist and the presence of dorsal bone fragments on the lateral radiograph of the wrist. We recommend fixation of the avulsed fragments to restore the length and strength of the wrist extensors.

Forefoot reconstruction in rheumatoid arthritis patients: Keller-Lelièvre-Hoffmann versus arthrodesis MTP1-Hoffmann.

The aim of this study was to compare the subjective, clinical and pedodynographic results of two large groups of patients operated on in our department. From January 1987 to December 1992, 38 rheumatoid patients (59 feet) underwent a Keller-Lelièvre arthroplasty of the first metatarsophalangeal (MTP1) joint and a Hoffmann resection of the lesser metatarsal heads. The mean follow-up was 35 months. From June 1992 to August 1997 48 patients (62 feet) with rheumatoid arthritis underwent an arthrodesis of the MTP1 joint and Hoffmann resection of the lesser metatarsal heads. The mean follow-up was 25 months. In 10 feet the arthrodesis was performed as a revision procedure of a failed Keller-Lelièvre arthroplasty. The patients of both series were assessed in the same way: personal interview, clinical examination, radiographs, bilateral footprints, and pedodynographic measurements. Static and dynamic pedodynographic measurements were taken with a 64-sensor matrix insole in a standard shoe. Six of our patients had an arthrodesis-Hoffmann procedure performed on one foot and a Keller-Lelièvre-Hoffmann procedure on the contralateral side. Although there is better loadbearing of the first ray with relative unloading of the central metatarsal heads in the arthrodesis MTP1-Hoffmann group, subjective evaluation of the procedure was slightly better in the Keller-Lelièvre-Hoffmann group. Ninety-three percent of the patients in the Keller group were satisfied or satisfied with minor reservations versus 87 percent in the arthrodesis group. This difference is not statistically significant. Recurrent deformity was not more prominent in the Keller-Lelièvre-Hoffmann group; however, it may be that with a longer follow-up, the feet in the arthrodesis-Hoffmann group hold up better over time. The arthrodesis MTP1-Hoffmann procedure can be used as a revision procedure for a failed Keller- Hoffmann operation, although these procedures were more difficult and needed a longer recovery time than the primary MTP1 arthrodesis.