The Cole Osteotomy: Maximizing Sagittal Plane Cavus Correction

Radiographic evaluation of naviculo-cuneiform sag deformity following triplane bunion correction via first tarsometatarsal joint arthrodesis

PurposeWe aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents.MethodsA prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary’s angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary’s angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test.ResultsThe mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary’s angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary’s angle from − 15.67° ± 6.31 to − 5.63° ± 5.03, TNCA from − 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from − 14.04° ± 3.15 to − 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal.ConclusionCareful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

We do not yet fully understand how the subtalar joint position is related to the varus osteoarthritic ankle joint. The purposes of this study were (1) to investigate the coronal orientation of the calcaneus relative to the talus according to the ankle osteoarthritis stage, talar tilt (TT), and (2) to determine if there is TT threshold at which apparent subtalar compensation begins to fade. We retrospectively reviewed 132 ankles that underwent weightbearing computed tomography (WBCT) for varus ankle osteoarthritis. The TT, subtalar inclination angle (SIA), and calcaneal inclination angle (CIA) were measured using WBCT. Ankles were divided into 5 groups according to Takakura stage and 2 groups according to the apparent compensation status of the subtalar joint and compared the index of the inclination of the subtalar joint relative to the ankle (SIA) or the index of the inclination of the calcaneus relative to the ankle (CIA). Additionally, we explored the relationship between SIA or CIA and the TT. Apparent subtalar compensation (SIA and CIA) was significantly lower in Takakura stages 3b and 4. The SIA and CIA significantly differed according to the apparent compensation status (P < .001 and P = .030, respectively). The CIA of the noncompensated group varied widely, whereas the SIA was relatively constant. Furthermore, TT was greater than 9.5, which indicated a high probability of a noncompensated heel (sensitivity, 92.6%; specificity, 89.7%). The position of the calcaneus appears compensatory with coronal plane orientation in varus ankle osteoarthritis when the TT is ≤9.5 degrees. Level IV, case series.

Flat foot is a postural deformity in which the plantar part of the foot is either completely or partially contacted with the ground. In recent clinical practices, X-ray radiographs have been introduced to detect flat feet because they are more affordable to many clinics than using specialized devices. This research aims to develop an automated model that detects flat foot cases and their severity levels from lateral foot X-ray images by measuring three different foot angles: the Arch Angle, Meary’s Angle, and the Calcaneal Inclination Angle. Since these angles are formed by connecting a set of points on the image, Template Matching is used to allocate a set of potential points for each angle, and then a classifier is used to select the points with the highest predicted likelihood to be the correct point. Inspired by literature, this research constructed and compared two models: a Convolutional Neural Network-based model and a Random Forest-based model. These models were trained on 8000 images and tested on 240 unseen cases. As a result, the highest overall accuracy rate was 93.13% achieved by the Random Forest model, with mean values for all foot types (normal foot, mild flat foot, and moderate flat foot) being: 93.38 precision, 92.56 recall, 96.46 specificity, 95.42 accuracy, and 92.90 F-Score. The main conclusions that were deduced from this research are: (1) Using transfer learning (VGG-16) as a feature-extractor-only, in addition to image augmentation, has greatly increased the overall accuracy rate. (2) Relying on three different foot angles shows more accurate estimations than measuring a single foot angle.

To compare the effectiveness of subtalar arthroereisis (STA) combined with modified Kidner procedure versus STA alone in the treatment of flexible flatfoot combined with painful accessory navicular bone in children. The clinical data of 33 children with flexible flatfoot combined with painful accessory navicular bone who were admitted between August 2018 and August 2021 and met the selection criteria were retrospectively analyzed. They were divided into a combination group (17 cases, treated by STA combined with modified Kidner procedure) and a control group (16 cases, treated by STA alone) according to the surgical methods. There was no significant difference in baseline data between the two groups ( P>0.05), such as gender, age, affected side of the foot, disease duration, and preoperative visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, talus-first metatarsal angle (T1MT), talus-second metatarsal angle (T2MT), talonavicular coverage angle (TCA), talus first plantar angle (Meary angle), calcaneal inclination angle (Pitch angle), and heel valgus angle (HV). The operation time, incision length, intraoperative blood loss, number of intraoperative fluoroscopies, and perioperative complications were recorded in both groups. The anteroposterior, lateral, and calcaneal axial X-ray films for the affected feet were taken regularly, and T1MT, T2MT, TCA, Meary angle, Pitch angle, and HV were measured. The VAS score, AOFAS ankle-hindfoot score were used to evaluate pain and functional recovery before and after operation. Surgeries in both groups were successfully performed without surgical complication such as vascular, nerve, or tendon injuries. Less operation time, shorter incision length, less intraoperative blood loss, and fewer intraoperative fluoroscopies were found in the control group than in the combination group ( P<0.05). One case in the combination group had partial necrosis of the skin at the edge of the incision, which healed after the dressing change and infrared light therapy, and the rest of the incisions healed by first intention. All children were followed up 12-36 months, with a mean of 19.6 months. At last follow-up, VAS score and AOFAS ankle-hindfoot score significantly improved in both groups when compared with preoperative ones ( P<0.05), and the differences of these scores between before and after operation improved more significantly in the combination group than in the control group ( P<0.05). Imaging results showed that the T1MT, T2MT, TCA, Meary angle, and HV significantly improved in both groups at last follow-up when compared with preoperative ones ( P<0.05), and the Pitch angle had no significant difference when compared with preoperative one ( P>0.05). But there was no significant difference in the difference of these indicators between before and after operation between the two groups ( P>0.05). Both procedures are effective in the treatment of flexible flatfoot children with painful accessory navicular bone. STA has the advantage of minimally invasive, while STA combined with modified Kidner procedure has better effectiveness.

Background/Objectives: This study aimed to clinically investigate how variations in foot morphology influence spinal and lower limb alignment, based on the concept of an ascending kinetic chain. Methods: We analyzed the medical records of 100 patients who met the inclusion criteria. The X-ray image data used in the analysis included weight-bearing lateral views of both feet, whole-spine anteroposterior (AP) and lateral views, and full-length standing AP scanograms of the lower legs. In the obtained X-ray images, Calcaneal Inclination Angle (CIA), Tibiotalar Tilt Angle (TTA), Tibiotalar Angle (TA), Quadriceps Angle (Q-angle), Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), and L1-S1 Lordosis (LL) were measured. Participants were categorized into subgroups based on their CIA values: Pes Planus, Normal, and Pes Cavus. These subgroups were analyzed by foot orientation (right and left) using one-way analysis of variance (ANOVA) and Pearson correlation coefficient analysis. Results: The one-way ANOVA identified significant differences in mean right foot PT values among subgroups. Correlation analysis shows moderate associations between foot CIA and Q-angle of the knee, as well as pelvic parameters including PI, PT, SS, and LL. Conclusions: Analysis of the correlation between foot parameters and body alignment, in the context of diagnostic and evaluative aspects of Chuna manual medicine (CMM), revealed moderate correlations among the foot, ankle, knee, pelvis, and lumbosacral regions. These findings suggest that foot morphology may play a clinically relevant role in posture-related disorders and could contribute to preventive and corrective strategies for musculoskeletal alignment.

In the present study, we aimed to determine the relationship of HV angle with angles and measurements obtained from lateral and anteroposterior (AP) radiological images of the foot in individuals with HV. The present study had a retrospective design, and the participants consisted of 66 female patients between the ages of 19 and 64 who applied to Orthopedics and Traumatology and were diagnosed with Hallux valgus. Metatarsus adductus angle, metatarsus primus adductus angle, hallux valgus angle, hallux interphalangeal angle, metatarsal break angle, first metatarsal protrusion distance, metatarsal width, talocalcaneal angle, AP Meary's angle were measured on AP view and calcaneal inclination angle, talar declination angle, lateral talocalcaneal angle, first metatarsal declination angle, fifth metatarsal declination angle, navicular height, lateral Meary's angle, tibiotalar angle were measured on a lateral radiograph. The IBM SPSS 21.0. program was used for statistical analysis, and the level of significance was taken as p < 0.05. There were statistically significant differences between the right and left feet in MPA and AMA measurements. The results showed that HV angle (HVA) had a weak relationship with MAA and MW, as well as a moderately positive relationship with MPA. However, it had a moderately negative relationship with AMA and a weak negative relationship with HIPA. We believe that in addition to the HVA angle, MPA and AMA angles should be considered in the diagnosis of HV, especially as the HVA angle is moderately positively correlated with the MPA angle and moderately negatively correlated with the AMA angle.

Objective: Weight resistance during exertion and overactivity in athletes is at risk of injury to the lower extremities and will decrease curvature of the plantar arch. With radiographs, we can perform initial imaging studies for evaluation of flat-foot, and there are several radiographic measurements that can indicate the degree of flat-foot deformity. Therefore, it is necessary to evaluate the radiographic measurements of the feet that can predict flat-foot in athletes with plantar fasciitis Materials and Methods: The sample consisted of 112 samples from 56 athletes (n = 112) with complaints such as foot pain and from an ultrasound study proved to have plantar-fasciitis assuming a plantar-fascia approximately 4 mm. This is a descriptive observational retrospective study with cross sectional design. The study data consisted of the patient's medical records , ankle radiographic and plantar-fascia ultrasound study results which were collected through consecutive sampling. Foot arch type determined using radiographic ankle with calcaneal inclination angle and tarsal first metatarsal angle. Results: After selecting the sample based on the inclusion and exclusion criteria, the number of samples was 112. Flat-foot was found in 75 sample (70,5 %) with calcaneal inclination angle, 54 sample (48,2%) have flat-foot and plantar-fasciitis. With talar fist metatarsal angle examination found 62 sample (55%) flatfoot, 39 sample (34,8%) have flat-foot and plantar-fasciitis Conclusion: Flat-foot can be predicted by radiographic evaluation using calcaneal inclination angle and talar first metatarsal angle examination. Calcaneal inclination angle is considered more helpful to determine flatfoot than talar first metatarsal angle

Normal alignment of the arches and adequate stability is essential for the foot to function correctly. Pes planus and pes cavus are fairly common foot deformities, but it is uncommon to see both in the same patient simultaneously. This study aimed to describe the clinical presentation and prognosis of an uncommon combination of bilateral foot abnormalities named “windswept heels” resembling windswept knees. A 43-year-old female employee experienced frequent pain in her right foot and swelling and pain in her left foot, mainly when walking barefoot. She had a severe cavovarus deformity of the right foot with pressure callosities on the lateral side, clawing of the toes, and a positive Coleman’s block test. With the loss of the medial arch, severe heel valgus, and forefoot abduction, the left foot developed a planovalgus deformity. The left foot’s talus-first metatarsal angle and the right foot’s calcaneal inclination angle increased on weight-bearing radiographs. The left foot underwent staged surgical treatments, including medial sliding calcaneal osteotomy, gastrocnemius recession, and cotton osteotomy. For the right foot, lateral sliding calcaneal osteotomy, plantar fasciotomy, and peroneus longus tendon transfer. The American Orthopaedics Foot and Ankle Society Score (AOFAS) was used to measure the clinical and functional outcomes. At 1 year, her AOFAS scale was 85 compared to 59 before surgery. Since this presentation resembles the windswept knee deformity, we propose calling this disorder windswept heel deformity.

Radiographic Outcomes of Adult Acquired Flatfoot Corrected by Medial Column Arthrodesis with or without a Medializing Calcaneal Osteotomy

Objective To analyze the related risk factors for Lisfranc injury resulting from low energy violence. Methods A retrospective study was performed for 61 cases (35 males, 26 females) with low-energy foot injury hospitalized from June 2008 to June 2014. Mean age was 36.7 years (range, 16-57 years). Fall injuries were noted in24 cases, sports injuries in 21 cases, and twist injuries in 16 cases. The cases were divided into Lisfranc injury group(n=23) and non-Lisfranc injury group (n=38) according to the different diagnosis. Univariate analysis and multi-factor logistic regression analysis were used to identify the factors that may lead to the occurrence of Lisfranc injury including age, gender, body mass index, operation history, smoking, alcohol abuse, injury reason, medial depth of the mortise/ second metatarsal length(b/a), lateral depth of the mortise/ second metatarsal length(c/a), first metatarsal-to-talus angle, first intermetatarsal angle, second metatarsal length/ foot length(a/g), calcaneal inclination angle and cuboid-navicular overlap/cuboid vertical height(e/e+ f). Results Univariate analysis showed between-group differences were significant in age (χ2=7.385, P<0.05), injury reason (χ2=8.663, P<0.05), calcaneal inclination angle(t=3.958, P<0.05), b/a (t=5.051, P<0.05) and a/g(t=4.618, P<0.05). Logistic regression analysis identifiedb/a(OR=1.036, 95%CI 0.018-0.450, P<0.01) and a/g(OR=1.013, 95%CI 0.005-0.374, P<0.01) as independent risk factors for low-energy Lisfranc injury. Conclusion Low-energy Lisfranc injury is independently associated with b/a and a/g, and may relate to the decreased medial depth of the mortise and increased foot length. Key words: Foot injuries; Risk factors; Lisfranc injury

The morphology of osseous structure in subtalar joint with chronic ankle instability

Progressive Collapsing Foot Deformity (PCFD), previously termed Adult Acquired Flatfoot Deformity (AAFD), is a progressive condition characterized by failure of medial soft tissue structures leading to painful biomechanical dysfunction. Traditional reconstructions often rely on nonanatomic osteotomies, such as lateral column lengthening, which carry notable risks. This study evaluates a novel soft tissue reconstruction of the spring-deltoid ligament complex combined with medial column osteotomies for stage II PCFD. Methods: A retrospective case series was performed on 9 feet in 8 patients (mean age 44.7 years) treated between September 2021 and December 2024. The surgical technique included spring ligament InternalBrace™ augmentation with Flexor Digitorum Longus (FDL) transfer, Cotton osteotomy with titanium wedge and minimally invasive Medial Calcaneal Osteotomy (MICO). Pre- and postoperative radiographs were analyzed for Meary’s angle, talocalcaneal angle, calcaneal inclination angle, calcaneocuboid angle and intermetatarsal angle. Functional outcomes were assessed using FAOS and AOFAS hindfoot scores. Paired t-tests determined statistical significance (p &lt; 0.05). Results: All radiographic parameters demonstrated significant improvement: Meary’s angle (14.56° → 2.11°), talocalcaneal angle (28.11° → 18.44°), calcaneal inclination (11.67° → 15.89°), calcaneocuboid angle (21.11° → 12.11°) and intermetatarsal angle (11.11° → 6.67°) (all p &lt; 0.05). Functional outcomes also improved, with mean FAOS of 79.1 ± 10.5 and mean AOFAS of 84.3 ± 3.8 at an average of 21 month follow-up. No patients required adjunctive lateral column lengthening and no construct failures or major complications were observed. Conclusion: Spring-deltoid ligament reconstruction with InternalBrace™ augmentation, combined with MICO and Cotton osteotomy, achieved significant radiographic and functional correction in stage II PCFD without the need for nonanatomic lateral column lengthening. This technique may provide a safer, anatomic alternative to traditional reconstructions, offering reliable restoration of medial column stability and improved patient-reported outcomes. Level of Evidence: IV (Retrospective case series).

To explore the operative approach and efficacy of flatfoot after calcaneal fractures malunion. A total of 116 flatfoot patients after old calcaneal fractures were treated from January 1998 to January 2008. There were 94 males and 22 females with an average age of 33.5 years old (range: 16 - 46). They included unilateral flatfoot after old calcaneal fractures (n = 110) and bilateral flatfoot after old calcaneal fractures (n = 6). The surgical treatments included open reduction, calcaneal osteotomy without subtalar fusion or a reconstruction of calcaneal thalamus and subtalar arthrodesis. A total of 101 patients were followed up for an average of 14 months (range: 12 - 24). No wound healing problem or infection was observed. Solid union was obtained without redislocation in all patients. The mean time of bone union was 12 weeks (range: 10 - 14). The mean time of complete weight loading was 13 weeks (range: 11 - 15 weeks). The height of foot arch increased from 4.2 mm ± 1.7 mm to 14.1 mm ± 4.1 mm (P < 0.05). Calcaneal inclination angle increased from 11.2° ± 2.5° to 19.1° ± 4.4° (P < 0.05). Bohler angle increased from 5.4° ± 3.5° to 25.8° ± 5.2° (P < 0.05). Meary angle recovered from 22.2° ± 4.4° to 5.1° ± 3.2° (P < 0.05). The mean AOFAS Ankle and Hindfoot score increased from 33.4 (range: 27 - 43) to 85.8 (range: 78 - 98). As to flatfoot after old calcaneal fractures, surgical treatment has a favorable efficacy. A customized operative approach may achieve a satisfactory outcome.

The study compared lower extremity kinematics and kinetics between male subjects with flat and normal feet when landing on both feet from platforms at different heights. Ten subjects with a flat feet arch and 10 subjects with a normal foot arch were recruited. They performed a double limb drop landing from 20, 40, and 60 cm onto a force-plate. A three-dimensional motion analysis system, force plates, and electromyography were used to analyze lower extremity kinetic and kinematic data. The GRF and angle of sagittal plane significantly increased with landing height in the flat foot group. In particular, hip joint angles at a height of 60 cm were significantly greater. The electromyography values were significantly higher for the tibialis anterior and vastus lateralis muscles, but were significantly lower in the abductor hallucis, gastrocnemius, and biceps femoris muscles in the flat foot group. GRF, joint angles, and muscle activity patterns in the lower extremities increases more with height in flat footed individuals than in people with a normal foot arch. Flat feet may aggravate the risk of shock on landing from a height; this might be ameliorated by a compensatory strategy at the hip joints to facilitate load distribution.