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Oxford foot model and weight bearing CT (pedCAT): Comparison of tibia-hindfoot angle and arch height
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Abstracts / Foot and Ankle Surgery 23(S1) (2017) 1–28
Results: Preoperatively, the deep fibers of the MCL did not appear striated in 29 ankles and high-intensity signal changes were observed in 23 ankles on T2-weighted MRI images. MCL ruptures were confirmed with arthroscopy. Medial impingement lesions were confirmed in 10 ankles. Histology of the reconstructed MCL showed dense collagen fibers with vessels. There was a significant change between pre- and post-operative Karlsson scores (69.0 versus 96.1) and JSSF score (69.8 versus 94.5). On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperatively, all 23 athletes returned to their pre-injury level of sports participation. Conclusion: Outcomes in our patient group indicate that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined injury of the MCL and LCL. http://dx.doi.org/10.1016/j.fas.2017.07.1082 39 IFFAS S08 04 Influence of learning curve of Achilles tendon rupture repair for surgical complications and no influence on patient related complications A. Makulavicius 1,∗ , G. Mazarevicius 2 , N. Porvaneckas 1 , V. Uvarovas 1 , I. Gvozdovic 1 , M. Klinga 2 1 2
Vilnius University, Lithuania Republican Vilnius University Hospital, Lithuania
Background: The optimal treatment of acute ruptures of the Achilles tendon is still controversial. We believe that complications should be patient and surgeon related, not only method related. We strive to show, that early complications are more surgeon dependent and functional results are more patient related. Methods: 100 patients were enrolled in our prospective randomized study. Method of surgical treatment was randomized. Method I: an open repair. Method II: percutaneous method. Three surgeons performed the operations. Complications and functional results were compared for first 50 and second 50 patients group. Results of the first year are reported. Results: Mean patient age was 36.9 years, 88 being males, 12 females. 68 smokers, 32 non-smokers. No significant difference in functional results (ATRS, ankle ROM and days-off work) was seen between methods or groups. There were 4 reruptures (2 in each group, 2 in each method). No statistical difference in rate of superficial infection was seen between groups (3 vs 2) or methods (3 vs 2). Three sural nerve entrapments were reported in group 1 (0 in group 2). There were four keloid scars and one marginal wound necrosis in group 1 and one keloid scar in group 2. Two DVTs in group 1, 0 in group 2. What’s interesting – smokers had one superficial infections, nonsmokers four. Conclusions: Rate of surgeon related complications changes with experience. Rerupture and infection rate is more patient dependent. http://dx.doi.org/10.1016/j.fas.2017.07.1083
40 IFFAS S08 05 The influence of a calcaneal medial osteotomy on hindfoot alignment using a pre- and post-operative weightbearing CT A. Burssens 1,∗ , S. Clockaerts 2 , T. Leenders 3 , M. Peiffer 1 , G. Vandeputte 4 , J. Victor 1 1
University Hospital of Ghent, Belgium AZ Groeninge, Belgium 3 AZ Monica, Belgium 4 HH Lier, Belgium 2
Background: A calcaneal medial osteotomy (CMO) is a surgical procedure frequently performed to correct a valgus alignment of the hindfoot. However currently little is known on its accurate influence on hindfoot alignment (HA). Aim: To assess the influence of CMO on HA using a weightbearing CT (WBCT). Methods: Twelve patients with a mean age of 49.4 years (range 18–67 years) were prospectively included. Indications for surgical correction by a CMO with a solitary translation of the calcaneus consisted out of a adult acquired flat foot stage II (N = 10) and a talocalcaneal coalition (N = 2). Fixation of the osteotomy was performed either by a step plate or double screw. A WBCT was obtained pre- and post-operative. HA was assed by a method referencing the inferior calcaneus point according to the tibia and talus HATib and a method according to the forefoot and talus by the TALAS software HATal. The tibia in the HATib was separately assessed by the anatomical tibia axis (TAx). Results: Both the mean pre-op HATib = 12.8◦ ± 4.5 and HATal = 21.1◦ ± 8.4 of valgus improved significantly postoperatively to a HATib = 4.2◦ ± 7.1 and HATal = 7.7◦ ± 9.6 (P < 0.001). Regression analysis of both measurement methods showed a good Spearman correlation coefficient of 0.74. Additionally the TAx showed a significant improvement from 3.9◦ ± 2.4 pre-operatively to 2.1◦ ± 3.1 post-operatively (P < 0.05). Conclusion: A CMO not only corrects effectively the valgus position of the calcaneus, but also of the tibia by 10% of the achieved HA correction. This information is of use when performing a preoperative planning of a hindfoot deformity. http://dx.doi.org/10.1016/j.fas.2017.07.1084 41 IFFAS S09 01 Oxford foot model and weight bearing CT (pedCAT): Comparison of tibia-hindfoot angle and arch height M.R. Wachowsky ∗ , S. D’Souza, T. Wirth Klinikum Stuttgart – Olgahospital, Germany Introduction: Oxford foot model (OFM) is commonly used in assessment of pathological foot gait in 3D gait analysis [1] and has been tested for repeatability [2]. PedCAT (CurveBeam, USA) allows 3D imaging with full weight bearing in standing position, not influenced by beam projection and/or foot orientation [3]. Research question: Are tibia-hindfoot angle and arch height comparable between OFM and PedCAT whilst standing? Methods: 8 patients (16 feet) with different foot pathologies who had a 3D gait analysis (Qualisys AB, Sweden) including OFM and a PedCAT examination were included. Static tibia-hindfoot inversion and arch height were calculated from OFM [2] in Visual3D
Abstracts / Foot and Ankle Surgery 23(S1) (2017) 1–28
(C-Motion, Canada). Multiplanar reconstruction of the PedCAT images was implemented (Agfa Impax, Belgium). Tibia-hindfoot angle was calculated perpendicular to the foot axis. Arch height was defined from the most inferior point of the navicular bone to the horizontal [4]. Spearmans correlation coefficient (r) between radiological measurements and OFM were calculated (Excel 2010). Results: All values of PedCAT and the OFM differ. There is a low correlation in arch height (r = 0.46) and moderate correlation in hindfoot-tibia alignment (r = 0.63). With larger deformities (hindfoot varus and valgus), OFM underestimates the tibia-hindfoot angle compared to PedCAT. Conclusion: The angles calculated by OFM vary from the angles measured from the 3D imaging of PedCAT. PedCAT offers the possibility to adjust the static model of OFM. References [1] [2] [3] [4]
Deschamps. Gait Posture 2011;33:338–49. Stebbins. Gait Posture 2006;23:401–10. Richter. Foot Ankle Sur 2014;20:201–7. Chen. Arch Phys Med Rehabil 2006:87.
http://dx.doi.org/10.1016/j.fas.2017.07.1085 42 IFFAS S09 02 Combination of PedCAT with pedography shows relationship of foot center and center of gravity M. Richter 1,∗ , F. Lintz 2 , S. Zech 1 , S. Meissner 1 1 Department for Foot and Ankle Surgery Nuremberg and Rummelsberg, Germany 2 Clinique de I’Union Toulouse, France
Introduction: PedCAT (Curvebeam, Warrington, USA) is a technology for 3D-imaging with full weight bearing. For this study a customized pedography sensor (Pliance, Novel, Munich, Germany) was inserted into the pedCAT. The aim of this study was to analyze difference of morphology (Bone/PedCAT) based FC and Force/Pressure (Pedography) based COG. Methods: In a prospective consecutive study starting November 28, 2016, 90 patients/180 feet were included. A pedCAT scan with simultaneous pedography with full weight bearing in standing position was performed. The morphology based definition of the FC was performed with the pedCAT taking bony landmarks into consideration. The force/pressure based COG was defined with the pedography data. The distance between FC and COG and the direction of a potential shift (distal-proximal; medial lateral) was measured and analyzed. Results: Mean age of patients was 53.8 (range, 17–84) years, 57 (63%) were female. The distance between FC and COG was 28.7 mm on average (range, 0–60). FC was distally to COG in 179 feet (99%) (mean, 27.5 mm; range, −15 to 50), and laterally in 57 feet (82%; mean, 2.0 mm; range, −18 −20). No difference between right and left side occurred (t-test, each p ≥ 0.5). Conclusions: There is a difference between FC and COG. This expected finding was quantified with this study. There is a shift between COG and FC in the investigated 90 subjects/180 feet (27.5 mm distally and 2 mm laterally on average) with a high variation. The data are a basis for prediction of COG based on FC without additional pedography. http://dx.doi.org/10.1016/j.fas.2017.07.1086
15
43 IFFAS S09 03 Flatfoot hindfoot alignment: A comparison of clinical assessment and weightbearing conebeam CT C. de Cesar Netto 1,∗ , S. Demehri 2 , A. Chinanuvathana 3 , A. Mousavian 3 , G. Thawait 2 , D. Shakoor 2 , L. Fonseca 3 , L. Schon 3 1 University of Alabama at Birmingham, United States 2 Johns Hopkins University, United States 3 Medstar Union Memorial Hospital, United States
Introduction: We compared clinical assessment of hindfoot valgus alignment in adult acquired Flatfoot deformity (AAFD) patients with different possible measurements performed on WB CBCT images. Methods: Prospective study, 20 patients (20 feet) with clinical diagnosis of flexible AAFD. 12 males and 8 females, mean age of 52.2 years (20;88), average BMI of 30.35 kg/m2 (19.00–46.09). Patients underwent clinical and WB CBCT assessment of hindfoot alignment. Two independent and blinded observers performed different hindfoot alignment measurements on the WB CBCT images: 3D; clinical; alignment; Achilles tendon axis/calcaneal tuberosity angle; angles between the tibial axis and the calcaneal tuberosity, calcaneal axis and line connecting midpoint of subtalar joint and most inferior part of calcaneal tuberosity. Differences were compared by paired T-test. Intra- and Interobserver reliability for the WB CBCT measurements were evaluated. Results: Mean clinical hindfoot valgus measured was 15.15◦ (SD 7.7◦ ). It was found to be significantly different from all WB CBCT angles: 3D; clinical; alignment (10.42◦ ); Achilles tendon/calcaneal tuberosity angle (2.96◦ ); tibial axis/calcaneal tuberosity angle (5.42◦ ); tibial axis/subtalar joint angle (7.52◦ ) and tibial axis/calcaneal axis angle (20.39◦ ). We found excellent intraobserver agreement for all CBCT measurements (range, 0.8863; 0.9713). There was also good to excellent inter-observer reliability, with the exception of the 3D; clinical; alignment, that showed moderate agreement. Conclusion: The use of 3D WB CBCT imaging can help characterize the valgus hindfoot alignment in patients with AAFD. We found the different CBCT measurements modalities to be reliable and repeatable, and to significantly differ from the clinical evaluation. http://dx.doi.org/10.1016/j.fas.2017.07.1087
Abstracts / Foot and Ankle Surgery 23(S1) (2017) 1–28
Results: Preoperatively, the deep fibers of the MCL did not appear striated in 29 ankles and high-intensity signal changes were observed in 23 ankles on T2-weighted MRI images. MCL ruptures were confirmed with arthroscopy. Medial impingement lesions were confirmed in 10 ankles. Histology of the reconstructed MCL showed dense collagen fibers with vessels. There was a significant change between pre- and post-operative Karlsson scores (69.0 versus 96.1) and JSSF score (69.8 versus 94.5). On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperatively, all 23 athletes returned to their pre-injury level of sports participation. Conclusion: Outcomes in our patient group indicate that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined injury of the MCL and LCL. http://dx.doi.org/10.1016/j.fas.2017.07.1082 39 IFFAS S08 04 Influence of learning curve of Achilles tendon rupture repair for surgical complications and no influence on patient related complications A. Makulavicius 1,∗ , G. Mazarevicius 2 , N. Porvaneckas 1 , V. Uvarovas 1 , I. Gvozdovic 1 , M. Klinga 2 1 2
Vilnius University, Lithuania Republican Vilnius University Hospital, Lithuania
Background: The optimal treatment of acute ruptures of the Achilles tendon is still controversial. We believe that complications should be patient and surgeon related, not only method related. We strive to show, that early complications are more surgeon dependent and functional results are more patient related. Methods: 100 patients were enrolled in our prospective randomized study. Method of surgical treatment was randomized. Method I: an open repair. Method II: percutaneous method. Three surgeons performed the operations. Complications and functional results were compared for first 50 and second 50 patients group. Results of the first year are reported. Results: Mean patient age was 36.9 years, 88 being males, 12 females. 68 smokers, 32 non-smokers. No significant difference in functional results (ATRS, ankle ROM and days-off work) was seen between methods or groups. There were 4 reruptures (2 in each group, 2 in each method). No statistical difference in rate of superficial infection was seen between groups (3 vs 2) or methods (3 vs 2). Three sural nerve entrapments were reported in group 1 (0 in group 2). There were four keloid scars and one marginal wound necrosis in group 1 and one keloid scar in group 2. Two DVTs in group 1, 0 in group 2. What’s interesting – smokers had one superficial infections, nonsmokers four. Conclusions: Rate of surgeon related complications changes with experience. Rerupture and infection rate is more patient dependent. http://dx.doi.org/10.1016/j.fas.2017.07.1083
40 IFFAS S08 05 The influence of a calcaneal medial osteotomy on hindfoot alignment using a pre- and post-operative weightbearing CT A. Burssens 1,∗ , S. Clockaerts 2 , T. Leenders 3 , M. Peiffer 1 , G. Vandeputte 4 , J. Victor 1 1
University Hospital of Ghent, Belgium AZ Groeninge, Belgium 3 AZ Monica, Belgium 4 HH Lier, Belgium 2
Background: A calcaneal medial osteotomy (CMO) is a surgical procedure frequently performed to correct a valgus alignment of the hindfoot. However currently little is known on its accurate influence on hindfoot alignment (HA). Aim: To assess the influence of CMO on HA using a weightbearing CT (WBCT). Methods: Twelve patients with a mean age of 49.4 years (range 18–67 years) were prospectively included. Indications for surgical correction by a CMO with a solitary translation of the calcaneus consisted out of a adult acquired flat foot stage II (N = 10) and a talocalcaneal coalition (N = 2). Fixation of the osteotomy was performed either by a step plate or double screw. A WBCT was obtained pre- and post-operative. HA was assed by a method referencing the inferior calcaneus point according to the tibia and talus HATib and a method according to the forefoot and talus by the TALAS software HATal. The tibia in the HATib was separately assessed by the anatomical tibia axis (TAx). Results: Both the mean pre-op HATib = 12.8◦ ± 4.5 and HATal = 21.1◦ ± 8.4 of valgus improved significantly postoperatively to a HATib = 4.2◦ ± 7.1 and HATal = 7.7◦ ± 9.6 (P < 0.001). Regression analysis of both measurement methods showed a good Spearman correlation coefficient of 0.74. Additionally the TAx showed a significant improvement from 3.9◦ ± 2.4 pre-operatively to 2.1◦ ± 3.1 post-operatively (P < 0.05). Conclusion: A CMO not only corrects effectively the valgus position of the calcaneus, but also of the tibia by 10% of the achieved HA correction. This information is of use when performing a preoperative planning of a hindfoot deformity. http://dx.doi.org/10.1016/j.fas.2017.07.1084 41 IFFAS S09 01 Oxford foot model and weight bearing CT (pedCAT): Comparison of tibia-hindfoot angle and arch height M.R. Wachowsky ∗ , S. D’Souza, T. Wirth Klinikum Stuttgart – Olgahospital, Germany Introduction: Oxford foot model (OFM) is commonly used in assessment of pathological foot gait in 3D gait analysis [1] and has been tested for repeatability [2]. PedCAT (CurveBeam, USA) allows 3D imaging with full weight bearing in standing position, not influenced by beam projection and/or foot orientation [3]. Research question: Are tibia-hindfoot angle and arch height comparable between OFM and PedCAT whilst standing? Methods: 8 patients (16 feet) with different foot pathologies who had a 3D gait analysis (Qualisys AB, Sweden) including OFM and a PedCAT examination were included. Static tibia-hindfoot inversion and arch height were calculated from OFM [2] in Visual3D
Abstracts / Foot and Ankle Surgery 23(S1) (2017) 1–28
(C-Motion, Canada). Multiplanar reconstruction of the PedCAT images was implemented (Agfa Impax, Belgium). Tibia-hindfoot angle was calculated perpendicular to the foot axis. Arch height was defined from the most inferior point of the navicular bone to the horizontal [4]. Spearmans correlation coefficient (r) between radiological measurements and OFM were calculated (Excel 2010). Results: All values of PedCAT and the OFM differ. There is a low correlation in arch height (r = 0.46) and moderate correlation in hindfoot-tibia alignment (r = 0.63). With larger deformities (hindfoot varus and valgus), OFM underestimates the tibia-hindfoot angle compared to PedCAT. Conclusion: The angles calculated by OFM vary from the angles measured from the 3D imaging of PedCAT. PedCAT offers the possibility to adjust the static model of OFM. References [1] [2] [3] [4]
Deschamps. Gait Posture 2011;33:338–49. Stebbins. Gait Posture 2006;23:401–10. Richter. Foot Ankle Sur 2014;20:201–7. Chen. Arch Phys Med Rehabil 2006:87.
http://dx.doi.org/10.1016/j.fas.2017.07.1085 42 IFFAS S09 02 Combination of PedCAT with pedography shows relationship of foot center and center of gravity M. Richter 1,∗ , F. Lintz 2 , S. Zech 1 , S. Meissner 1 1 Department for Foot and Ankle Surgery Nuremberg and Rummelsberg, Germany 2 Clinique de I’Union Toulouse, France
Introduction: PedCAT (Curvebeam, Warrington, USA) is a technology for 3D-imaging with full weight bearing. For this study a customized pedography sensor (Pliance, Novel, Munich, Germany) was inserted into the pedCAT. The aim of this study was to analyze difference of morphology (Bone/PedCAT) based FC and Force/Pressure (Pedography) based COG. Methods: In a prospective consecutive study starting November 28, 2016, 90 patients/180 feet were included. A pedCAT scan with simultaneous pedography with full weight bearing in standing position was performed. The morphology based definition of the FC was performed with the pedCAT taking bony landmarks into consideration. The force/pressure based COG was defined with the pedography data. The distance between FC and COG and the direction of a potential shift (distal-proximal; medial lateral) was measured and analyzed. Results: Mean age of patients was 53.8 (range, 17–84) years, 57 (63%) were female. The distance between FC and COG was 28.7 mm on average (range, 0–60). FC was distally to COG in 179 feet (99%) (mean, 27.5 mm; range, −15 to 50), and laterally in 57 feet (82%; mean, 2.0 mm; range, −18 −20). No difference between right and left side occurred (t-test, each p ≥ 0.5). Conclusions: There is a difference between FC and COG. This expected finding was quantified with this study. There is a shift between COG and FC in the investigated 90 subjects/180 feet (27.5 mm distally and 2 mm laterally on average) with a high variation. The data are a basis for prediction of COG based on FC without additional pedography. http://dx.doi.org/10.1016/j.fas.2017.07.1086
15
43 IFFAS S09 03 Flatfoot hindfoot alignment: A comparison of clinical assessment and weightbearing conebeam CT C. de Cesar Netto 1,∗ , S. Demehri 2 , A. Chinanuvathana 3 , A. Mousavian 3 , G. Thawait 2 , D. Shakoor 2 , L. Fonseca 3 , L. Schon 3 1 University of Alabama at Birmingham, United States 2 Johns Hopkins University, United States 3 Medstar Union Memorial Hospital, United States
Introduction: We compared clinical assessment of hindfoot valgus alignment in adult acquired Flatfoot deformity (AAFD) patients with different possible measurements performed on WB CBCT images. Methods: Prospective study, 20 patients (20 feet) with clinical diagnosis of flexible AAFD. 12 males and 8 females, mean age of 52.2 years (20;88), average BMI of 30.35 kg/m2 (19.00–46.09). Patients underwent clinical and WB CBCT assessment of hindfoot alignment. Two independent and blinded observers performed different hindfoot alignment measurements on the WB CBCT images: 3D; clinical; alignment; Achilles tendon axis/calcaneal tuberosity angle; angles between the tibial axis and the calcaneal tuberosity, calcaneal axis and line connecting midpoint of subtalar joint and most inferior part of calcaneal tuberosity. Differences were compared by paired T-test. Intra- and Interobserver reliability for the WB CBCT measurements were evaluated. Results: Mean clinical hindfoot valgus measured was 15.15◦ (SD 7.7◦ ). It was found to be significantly different from all WB CBCT angles: 3D; clinical; alignment (10.42◦ ); Achilles tendon/calcaneal tuberosity angle (2.96◦ ); tibial axis/calcaneal tuberosity angle (5.42◦ ); tibial axis/subtalar joint angle (7.52◦ ) and tibial axis/calcaneal axis angle (20.39◦ ). We found excellent intraobserver agreement for all CBCT measurements (range, 0.8863; 0.9713). There was also good to excellent inter-observer reliability, with the exception of the 3D; clinical; alignment, that showed moderate agreement. Conclusion: The use of 3D WB CBCT imaging can help characterize the valgus hindfoot alignment in patients with AAFD. We found the different CBCT measurements modalities to be reliable and repeatable, and to significantly differ from the clinical evaluation. http://dx.doi.org/10.1016/j.fas.2017.07.1087