Category: Bunion; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Radiographic measurements are an essential tool to determine the appropriate surgical treatment and outcome for Hallux Valgus (HV). WBCT already demonstrates significant advances that include the ability to perform traditional measurements for HV in the 3D setting reliably, as well as a more complete and accurate evaluation of the deformity. In addition, new software with an advanced semi-automated segmentation system obtains semi-automatic 3D measurements of WBCT scan data sets, minimizing the errors in reading angular measurements. The objective was (1) to assess the reliability of WBCT computer-assisted semi-automatic imaging measurements in HV, (2) to compare semi-automatic with manual measurements in the setting of an HV, and (3) to compare semi-automatic measurements between HV and control group. Methods: In this retrospective IRB (ID# 201904825) approved study, we assessed patients with hallux valgus deformity. The sample size calculation was based on the hallux valgus angle (HVA). Thus, to obtain the 0.8 power, including 26 feet with HV in this study, was necessary. Our control group consisted of 19 feet from 19 patients without HV. Raw multiplanar data was evaluated using software CubeVue. In the axial plane, hallux valgus angle (HVA), intermetatarsal angle (IMA), and interphalangeal angle (IPA) were measured. The semiautomatic 3D measurements were performed using the Bonelogic Software. Inter-rater reliabilities were performed using ICC. Agreement between methods was tested using the Bland-Altman plots. The difference between Pathologic and Control cases using semi-automatic measurements was assessed with the Wilcoxon signed-rank test. Alpha risk was set to 5% (α = 0.05). P<= 0.05 was considered significant. Results: Intraobserver and Interobserver agreement and consistency for Manual and Semi-automatic WBCT measurements assessed by ICC demonstrated excellent reliability in both cases. However, when comparing Manual and Semi-automatic measurements for HVA, IMA, and IPA, Semi-automatic measurements showed the highest values. Agreement between manual (M) and semi-automatic (SA) methods was tested for HVA, IMA and IPA using the Bland-Altman plots. The results indicated a high correlation between the parameters calculated from the manual and semi-automatic measurements, and a strong agreement between the readers and the software. Comparison between pathological group with HV and control (standard) group without HV using semi-automatic measurements was capable of differentiating pathological (HV) from non-pathological conditions for the HVA and IMA angles (p < 0,05). Conclusion: Semi-automatic measurements are reproducible and comparable to measurements performed manually. The software differentiated pathological from non-pathological conditions when subjected to semi-automatic measurements. The development of advanced semi-automatic segmentation software with minimal user intervention is essential for the establishment of big data and can be integrated into clinical practice, facilitating decision-making.
Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Peritalar subluxation (PTS) of the hindfoot is a critical finding in Progressive Collapsing Foot Deformity (PCFD). Subluxation of the middle facet and sinus tarsi recently been shown to represent essential markers of pronounced and potentially progressive deformity. Weightbearing CT (WBCT) imaging and three-dimensional (3D) distancing coverage maps (CM) allow a complete and accurate assessment of PTS markers across the entire peritalar surface. This prospective comparative study aimed to assess the effectiveness of joint-sparing realignment surgical treatment for flexible PCFD in reducing PTS and to correlate the improvement with patient-reported outcomes (PROs). We hypothesized that would significantly improve PTS markers, mainly decreasing sinus tarsi coverage/impingement and middle facet subluxation, and that this improvement would correlate with increased PROs. Methods: In this IRB-approved prospective and comparative study, we enrolled patients with flexible PCFD, no prior surgeries, and failed conservative treatment. Included females/3 males, mean age 57.2, range 37-74) underwent joint-sparing surgical realignment procedure by a single surgeon. Standing weightbearing CT (WBCT) was complete 3-months postoperatively. Following automatic bone segmentation, 3D distance maps (DMs) of the entire peritalar surface were generated, and coverage of the subtalar joint (anterior, middle, and posterior) and sinus tarsi were assessed as markers of PTS. Joint coverage was defined as the percentage of articular space where DMs were <5 mm. CM were built highlighting areas of adequate joint interaction (blue), joint subluxation (pink), and impingement (red). PROs were evaluated preoperatively and at the latest follow-up between preop/postop measurements and PROs were assessed by independent t-tests/Wilcoxon and bivariate analysis. P-values <.05 were considered significant. Results: The overall follow-up was 8.2 months (6-13 months). Medial displacement calcaneal osteotomies, lateral column lengthening, and first ray realignment procedure osteotomy or Lapidus) were performed in all patients. Foot and Ankle Offset significantly improved from 10.6% preoperatively to 3.1% postoperatively (p=0.0005), on averaged improvement was also observed in anterior facet joint coverage (61.6%), as well as a reduction in sinus tarsi coverage/impingement (-43.2%) (both p<0.001). Middle posterior facet joint coverage (3.5%, p=0.06) also demonstrated improvements, however not significant. PROs improved significantly on average postoperatively, with the E Ankle Surgery (EFAS) Score increasing from 3.1 to 7.3 (p=0.02) and the Foot Function Index (FFI) improving from 71.5 to 48.7 (p=0.01). Improvements in EFAS scores and FFI s with improvements in middle facet coverage (R2 0.89, p=0.0154) and anterior facet coverage (R2 0.80, p=0.04), respectively. Conclusion: Our study was the first to evaluate WBCT 3D distance mapping's role in the assessment of surgical correction of PTS in patients with PCFD. We found significant subtalar joint anterior facet coverage and sinus tarsi impingement following surgical reconstruction, with a trend to significant improvements in middle and posterior facet j importantly, improvements in middle and anterior facet coverage correlated significantly with improved PROs (EFAS score and FFI, respectively). Significance/Clinical Relevance: Based on our study results, optimization of subtalar joint coverage and reduction of PTS should be goals of surgical treatment of PC
Category: Midfoot/Forefoot; Bunion; Hindfoot Introduction/Purpose: An unstable medial column lever arm may be associated with many conditions, particularly progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA). Restauration of the first metatarsal length and its lever in the tripod is essential when surgically treating these deformities. Fusion of the first tarsometatarsal joint (TMT) using a structural graft aims to correct the first metatarsal malalignment and create a firm construct on the medial arch. This study aimed to assess early results, healing, and complication rate of a distraction dorsal opening plantarflexion wedge allograft first tarsometatarsal joint fusion in patients with collapse/instability of the medial column. Our main hypothesis is that using a structural allograft on a TMT fusion might present a considerable rate of nonunion. Methods: In this IRB-approved prospective cohort study, patients with a clinical diagnosis of PCFD, HV, MA that underwent a TMT distraction arthrodesis at our institution were evaluated. Adults undergoing the procedure and had performed a weight- bearing computed tomography (WBCT) at 12 weeks postoperatively were included. The technique was carried using a pre-shaped anatomically specific structural allograft and specific implants. Fusion was defined by two fellowship-trained orthopedic foot and ankle surgeons and one fellowship-trained musculoskeletal radiologist, unrelated to the study. A percentage higher than 50% of crossing trabeculae over the entire proximal and distal allograft surfaces had to be noticed. Complications were established as minor (superficial dehiscence, superficial infection, and neuropraxia) and major (deep dehiscence, deep infection, nerve damage, residual deformity, sesamoiditis, limited motion, lateral overload, and reoperation). Collapse correction was assessed by the talus- first metatarsal angle (TFMA). Results: A total of 22 patients (22 feet) were included (11 PCFD, 6 MA, and 5 HV patients) with a mean age of 52.6 years (range, 19-75 years; SD, 14.4), and a mean body mass index (BMI) of 32.9kg/m2 (95% CI, 29.2 to 36.5). Mean follow-up was 5.9 months (range, 3-12), and median allograft size was 8mm (range 5-19mm). Bone healing was observed on 91% of cases, and two patients (one PCFD and one MA) presented a non-union. Two minor complications (9%, both superficial dehiscence) and one major complication (4.5%, deep infection on a MA patient) were observed. Inter-observer reliability for TFMA measurements was excellent, with an ICC of 0.86. Statistically significant improvement of the sagittal plane TFMA was observed, with a mean enhancement of 9.4 degrees (95% CI, 6.7 to 12.1 degrees; p<.0001). Conclusion: In this prospective cohort study of 22 patients treated with the TMT distraction arthrodesis for medial longitudinal arch collapse/instability, we observed a low complication rate (9% minor, 4.5% major). A high healing rate after 3 months (91%), one clinically stable radiographic non-union (4.5%), and one unstable non-union (4.5%) needing reoperation were noted, despite the use of a structural allograft requiring healing at two surfaces. Our results demonstrate promising initial outcomes for this technique in treating collapse of the medial longitudinal arch in patients with PCFD, MA, and HV deformities. Long-term results are needed to confirm these promising results.
Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Posterior Tibial Tendon (PTT) dysfunction is considered to play an important role in Adult Acquired Flatfoot Deformity recently renamed Progressive Collapsing Foot Deformity (PCFD). Previous flatfoot classifications are mainly based on a progressive mechanical failure of the PTT causing chronological appearance of deformities. A consensus of experts recently met and decided to remove the central place of the PTT dysfunction from the PCFD classification system. The primary objective of our study was to assess the relation between the PTT clinical status and the three-dimensional overall foot deformity. The secondary objective was to assess the relation between the degeneration of PTT at the MRI and the three- dimensional overall foot deformity. We hypothesized that the more damaged the PTT, the more severe the deformity of the foot. Methods: We retrospectively identified all symptomatic PCFD over 18 years old who consulted our center from 01/01/2019 to 12/31/2020. PCFD with concomitant (< 3 mois) clinical examination, Weight-Bearing CT (WBCT) and MRI were included. PCFD presenting with previous surgical intervention were excluded. Finally 25 PCFD were included in the analysis (19 Women, mean age 53.96+/-14.9 years, mean BMI 33.2+/-8.1 kg/m2;)A PCFD presenting either a deficit on the single heel rise test or a decrease in inversion strength (superior or equal to 3/5) was classified PTT deficient. The MRI of all these PCFD were analyzed, and PTT degeneration was classified according to Deland and Rosenberg classifications. The three-dimensional overall deformity of each PCFD was assessed on WBCT by the Foot and Ankle Offset (FAO). Normality of different variables were assessed using Shapiro- Wilk test. Comparisons were performed using Student's t-test or Anova for normal, and Mann-Whitney or Kruskal-Wallis's test for non-normal variables. Results: Patients with clinically deficient PTT (13/25 PCFD, 52%) had a mean FAO of 7.75+/-3.8% whereas patients without PTT deficit (12/25 PCFD, 48%) had a mean FAO of 6.68+/-3.9%, without significant difference between groups (p=0.49). According to Deland classification, 4/25 PTT (16%) were classified grade 0, 7/25 (28%) grade 1, 4/25 (16%) grade 2, 5/25 (20%) grade 3 and 5/25 (20%) grade 4 without any significant difference between groups (p=0.36).According to Rosenberg classification, 4/25 PTT (16%) were classified type 0, 15/25 (60%) type 1, 2/25 (8%) type 2 and 4/25(16%) type 3 without any significant difference between groups (p=0.79).Seven PCFD had a FAO>10%. Among them, 42.9% had a PTT without clinical deficit and 57.1% had a PTT with little or no damage on the MRI. Nine PCFD had a FAO<5%. Among them, 44.4% had a PTT clinically deficient and 22.2% had a PTT with important damage on the MRI. Conclusion: The importance of three-dimensional overall foot deformity in PCFD was neither correlated with the clinical presence or absence of PTT deficiency, nor with the PTT degeneration on MRI in our study. A patient with important deformity may have an intact PTT and a patient with small deformity can present a deficient PTT. Despite the obvious lack of power in this study, it does not appear that PTT plays a significant role in the PCFD overall deformity.
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