Can Surgeons Correct Stage 2 Flatfoot Without Fusions Or Tendon Transfers?
For patients with stage 2 flatfoot, surgeons can use extraarticular procedures to reconstruct a plantigrade, functional foot without the need for fusions or tendon transfers, according to a new study in the Journal of Foot and Ankle Surgery.
The study authors investigated the outcomes of flatfoot reconstructive surgery with the retrospective study focusing on 56 feet in 43 adult and pediatric patients with stage 2 flatfoot. Surgical procedures included variations of gastrocnemius recessions, medial displacement calcaneal osteotomies, Evans osteotomies and Cotton osteotomies. At a mean follow-up of 60 months, the authors note the radiographic preoperative and postoperative angles showed significant differences in all feet, indicating more plantigrade feet with better function.
The advantage of extraarticular osseous procedures is their preservation of the normal function of the joints of the foot in pediatric patients, notes study coauthor Lawrence Fallat, DPM, FACFAS, the Director of the Podiatric Surgery Residency Program at Beaumont Hospital Wayne in Wayne, Mich. Most commonly for pediatric patients with flexible flatfoot, he will use a transpositional calcaneal osteotomy, Evans osteotomy with allogenic bone graft or a Cotton osteotomy with allogenic bone graft. As he says, there are no disadvantages to these procedures if the surgeon selects the correct combination of procedures for the flatfoot deformity.
Dr. Fallat says fusion would only be indicated for a rigid pes planus, like one might see with a medial facet coalition or end-stage flatfoot deformity, possibly the type of rigid pes planus that arises in a vertical talus. Fusion of a joint to correct flexible flatfoot in a child “would cause a wear and tear arthritis in the adjacent joints that could become painful,” maintains Dr. Fallat.
For stage 2 flatfoot, Troy Boffeli, DPM, will use a few different combinations of procedures based on specific criteria. His criteria include the age of the patient, foot structure, apex of deformity and anticipated post-op activity requirements. Dr. Boffeli will frequently perform an extraarticular repair and also do a subtalar joint fusion in combination with a midfoot osteotomy or midfoot fusion.
Medial column fusion is best in patients with first tarsometatarsal joint and/or naviculocuneiform joint sag, medial column degenerative joint disease, or symptomatic hallux valgus, according to Dr. Boffeli, a Fellow of the American College of Foot and Ankle Surgeons, and the Director of the Foot and Ankle Surgical Program at Regions Hospital and the HealthPartners Institute for Education and Research in Bloomington, Minn. He does not do a tendon transfer unless the posterior tibial tendon is torn as he anticipates most intact tendons will recover after the correction of a foot deformity. As Dr. Boffeli says, torn tendons either need direct repair or repair and transfer, so not all tears require a transfer.
“I don’t feel tendon transfers are necessary in the typical flexible flatfoot. Extraarticular osteotomies will correct the deformity without sacrificing the function of a tendon,” says Dr. Fallat.
By Brian McCurdy, Managing Editor
In a recent study, researchers note the efficacy of extracorporeal shockwave therapy (ESWT) for plantar fasciitis in active duty military personnel and add that pain relief was even greater in patients who are not on active duty.
The authors of the study, published in the Journal of Foot and Ankle Surgery, assessed 111 heels in 76 patients who had ESWT for chronic plantar fasciitis. Seventy-three percent of the patients were active duty military. During a mean follow-up time of 42 months, the study notes the mean preoperative pain score of 7.8 on the Visual Analogue Scale had improved to 2.5. Furthermore, researchers say active duty patients reported a mean 4.8 point improvement in pain in comparison with a better improvement of 6.8 points in non-active duty patients. The authors add that 10 patients left the military because of continued foot pain.
Brian Fullem, DPM, calls ESWT “highly effective in any patient population,” noting that the American College of Foot and Ankle Surgeons recommends ESWT as a treatment of choice for plantar fasciitis with or without a plantar spur when non-operative treatment has failed.
Extracorporeal shockwave has an excellent long-term effect as it theoretically works via neovascularization with the peak effect taking place between 12 and 20 weeks, according to Dr. Fullem, a Fellow of the American Academy of Podiatric Sports Medicine, who is in private practice in Clearwater, Fla. He cites studies noting that plantar fascia thickness and bone marrow edema both decrease following ESWT treatment.
In active patients, Dr. Fullem would expect about a 70 percent success rate with ESWT for heel pain. He cites a study noting 70 percent excellent or good results in runners treated with shockwave for heel pain.
“ESWT is an extremely effective treatment and may even be more desirable in the athletic population because there are virtually no contraindications to treatment in the foot, athletes do not require any downtime post-treatment and there are essentially no serious side effects or complications from the treatment,” says Dr. Fullem. “ESWT has been proven in the medical literature to be one of the most effective treatments for plantar fasciitis.”
By Brian McCurdy, Managing Editor
The randomized multicenter trial involved 1,010 patients over the age of 65, who received either podiatry intervention (including foot and ankle strengthening exercises, foot orthoses, and new footwear) and a leaflet on fall prevention, or received standard care plus a fall prevention leaflet. The study notes the podiatry intervention group showed a small, non-statistically significant reduction in falls and had marginally higher quality-adjusted life years than those who received standard care. The U.K.-based study notes intervention costs were an average 252 pounds more per patient in comparison to those who had standard care.
Doug Richie Jr., DPM, FACFAS, says his practice uses ankle joint strengthening exercises to improve ankle joint range of motion and toe flexion strengthening exercises for elderly patients at risk of falls. He notes patients “almost universally report improved balance, stability in gait and reduced fear of falling.”
Dr. Richie’s practice also uses custom functional foot orthoses for patients at risk of falling, finding that patients report improvements in stability during standing and walking with foot orthoses. His program also uses a change of footwear to shoes associated with a reduced fall risk, a protocol that has shown “excellent improvement in stability during standing and walking,” according to Dr. Richie, an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif.
Research shows that overall, exercise programs that target strength, balance, flexibility or endurance can most effectively prevent falls in the elderly, notes Dr. Richie. He says exercising in supervised groups, participating in tai chi and carrying out individually prescribed exercise programs at home are all effective.
“Considering the life-threatening sequelae of one traumatic fall in this patient population, the cost/benefit ratio is very favorable,” says Dr. Richie.