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Degree of medialization determines postoperative hindfoot alignment
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KEYSTONE, Colo. – Knowing the precise amount to slide the heel in the operating room could improve the results of surgery for the adult acquired flatfoot, according to authors of a study presented at the 2011 Annual Meeting of the American Orthopaedic Foot and Ankle Society.
“We wanted to first find out, could we correlate the amount that we correct the heel in the operating room with a patient’s standing alignment of the heel postoperatively,” Jonathan T. Deland, MD, one of the study authors, said.
Deland and his colleagues looked at each procedure necessary for hindfoot alignment to see if they correlated with alignment postoperatively, including medializing calcaneal osteotomy, cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament reconstruction and gastrocnemius recession. They looked at the feet of 32 patients with a mean age of 58 years who had stage II adult-acquired flatfoot deformity and underwent flatfoot correction.
Parameters for determination of hindfoot alignment included the moment arm between the tibial axis and contact point of the heel, anteroposterior talonavicular uncoverage, and anteroposterior and lateral talus first metatarsal angles.
According to the study abstract, “the model for medializing calcaneal osteotomy showed a good fit and indicated that each millimeter of medialization performed corresponded to a 1.53-mm change in moment arm.”
Anteroposterior talonavicular uncoverage and anterposterior and lateral talus first metatarsal angles did not significantly correlate with the change in moment arm. Lateral column lengthening and spring ligament reconstruction had no major influence on the hindfoot view.
As a next step, Deland and the team plan to compare medial slide and lateral column lengthening to determine how much they change the alignment of the heel. – by Renee Blisard
Reference:
- Chan J, Williams B, Young E, Sofka C, et al. The effect of medializing calcaneal osteotomy on hindfoot alignment in the reconstruction of adult acquired flatfoot deformity. Paper #94. Presented at the 2011 Annual Meeting of the American Orthopaedic Foot and Ankle Society. July 13-16. Keystone, Colo.
- Jonathan T. Deland, MD, can be reached at the Hospital for Special Surgery, East River Professional Building, 523 E. 72nd St., 5th Floor, New York, NY 10021; 212-606-1665; email: delandj@hss.edu.
- Disclosure: Deland is a consultant to Arthrex, Zimmer and Tornier.
Dr. Chan and colleagues have nicely demonstrated a linear relationship between the amount of displacement achieved with a medializing calcaneal osteotomy (MCO) and the correction in hindfoot alignment. Based on this finding, I agree with their conclusion that the hindfoot alignment view can be used as a preoperative tool to determine the amount of correction needed intraoperatively. While the linear relationship is not surprising considering the shift achieved with a MCO is performed in the same plane as the hindfoot alignment view, being able to predict the change in hindfoot moment arm per millimeter of shift is a nice addition to a preoperative plan.
The adult acquired flatfoot deformity (AAFD) is a complicated deformity with many potential components in addition to hindfoot valgus, including dorsolateral peritalar subluxation, gastrocnemius tightness, forefoot supination and medial column instability. Procedures, such as a lateral column lengthening and medial column fusion, have been shown to create a relative varus movement of the calcaneus due to an increase in forefoot adduction and arch elevation. It should be emphasized that each component of the AAFD should be recognized and addressed with the appropriate surgical solution.
— Todd A. Irwin, MD
Assistant Professor
Department of Orthopaedic Surgery
Division of Foot and Ankle Surgery
University of Michigan
Ann Arbor, Mich.