This Article Abstract Full Text (PDF) Free Letters to the Editor: Submit a response Alert me when this article is cited Alert me when Letters to the Editor are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by TOOLAN, B. C. Articles by HANSEN, S. T. Search for Related Content PubMed PubMed Citation Articles by TOOLAN, B. C. Articles by HANSEN, S. T. Social Bookmarking                   What's this?

Complex Reconstruction for the Treatment of Dorsolateral Peritalar Subluxation of the Foot. Early Results After Distraction Arthrodesis of the Calcaneocuboid Joint in Conjunction with Stabilization of, and Transfer of the Flexor Digitorum Longus Tendon to, the Midfoot to Treat Acquired Pes Planovalgus in Adults*

BRIAN C. TOOLAN, M.D., BRUCE J. SANGEORZAN, M.D. and SIGVARD T. HANSEN, JR., M.D., SEATTLE, WASHINGTON

Investigation performed at Harborview Medical Center, Seattle

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion Appendix References

 
Background: The successful correction of flatfoot in children through lengthening of the lateral column, osteotomy of the medial cuneiform, and advancement of the posterior tibial tendon led to the introduction of similar procedures to treat acquired pes planovalgus secondary to attrition or rupture of the posterior tibial tendon in adults. However, to our knowledge, no study has been published documenting whether these procedures are effective treatment for acquired flatfoot in adults. Methods: The functional and radiographic results of complex reconstruction of a painful, flexible flatfoot associated with attrition or rupture of the posterior tibial tendon were evaluated in thirty-six patients (forty-one feet) with use of a detailed questionnaire, a comprehensive physical examination, and a review of the radiographs and the medical record. Results: At a mean of thirty-four months (range, twenty-four to fifty months) postoperatively, thirty-six feet (88 percent) were less painful compared with the preoperative status or were pain-free and five of the six parameters that had been used to assess correction of the deformity radiographically had improved significantly (p < 0.0001). Eight feet (20 percent) had a nonunion at the calcaneocuboid joint, and thirteen feet (32 percent) had anesthesia or paresthesia of the sural nerve. Twenty-nine feet (71 percent) had had additional operations, including removal of hardware from twenty feet; bone-grafting to treat a nonunion at the site of the calcaneocuboid arthrodesis and revision of the internal fixation in four feet; a medial displacement calcaneal osteotomy because of recurrent valgus angulation of the hindfoot in two feet; and a Lapidus procedure because of a hypermobile tarsometatarsal joint with hallux valgus, a triple arthrodesis because of a nonunion at the site of the calcaneocuboid arthrodesis associated with loss of correction, and a dorsiflexion-abduction wedge osteotomy through the site of the calcaneocuboid arthrodesis (which had healed) for alignment of an overcorrected foot in one foot each. The outcomes of the procedures in thirty-five feet (85 percent) were rated by the patients as satisfactory, and thirty-three (92 percent) of the thirty-six patients (thirty-eight [93 percent] of the forty-one feet) stated that they would have the procedure again if the circumstances were similar. Conclusions: Despite the high prevalence of postoperative complications, most of our patients were satisfied with the result of the procedure after the short duration of follow-up. We believe that the relief of pain and the restoration of function achieved through effective correction of the severe pes planovalgus deformity account for the satisfactory outcomes in our patients.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion Appendix References

 
Contraction of the posterior tibial muscle causes adduction and plantar flexion of the midfoot by rotation through the talonavicular joint. This action inverts the hindfoot and locks the transverse tarsal joint, establishing a rigid medial column and a long lever arm for forceful push-off during gait^21,40. Rupture or attritional splitting of the posterior tibial tendon incapacitates the normally coupled motions between the hindfoot and the midfoot, stressing the plantar capsular and ligamentous restraints within the foot^{7,16,22,36,44}. Moreover, rupture or attrition of the posterior tibial tendon eliminates the dynamic support of the medial longitudinal arch and initiates progressive structural changes in the foot, which lead to pes planovalgus deformity^10,18-20,28. Over time, a flatfoot deformity develops and gait becomes apropulsive (that is, instead of having a fluid, continuous stride with a reciprocating gait, the patient has a halting, so-called stop-and-start gait) because of ineffective push-off²⁶.

Clinically, a flatfoot is characterized by a depressed or absent medial longitudinal arch accompanied by abduction and, in some cases, by supination of the forefoot and valgus angulation of the hindfoot⁴⁴. Acquired flatfoot in adults frequently is the result of progressive tendinopathy, but it also may be due to Charcot osteoarthropathy; rheumatoid or seronegative inflammatory disease; arthritis of the midfoot or the hindfoot; paralysis or laceration of the posterior tibial tendon; rupture of the plantar fascia, talonavicular ligament, or superomedial calcaneonavicular (spring) ligament; or injury of the talus, midfoot, or Lisfranc joint^26,33. Radiographs made while the patient is bearing weight often demonstrate malalignment of the medial column of the foot, primarily at the talonavicular joint. Lateral radiographs, made with the patient standing, reveal dorsal translation of the navicular relative to the talus, with distraction between the two bones at their inferior surface, creating a plantar wedged-shaped opening of the talonavicular joint. Uncovering of the head of the talus, as seen on anteroposterior radiographs, occurs secondary to lateral subluxation of the navicular on the talus^28,43. These radiographic changes have led to the introduction of the term dorsolateral peritalar subluxation of the foot to describe the abnormal biplanar relationship between the talus and the navicular resulting from attrition or rupture of the posterior tibial tendon. The treatment of a symptomatic flatfoot with mild deformity begins with use of an orthosis, modifications of shoewear, and administration of nonsteroidal anti-inflammatory medication. However, severe, progressive dorsolateral peritalar subluxation of the foot can be very painful and debilitating, often necessitating operative intervention^5,41.

Several procedures have been used for the operative treatment of symptomatic flatfoot. A variety of arthrodeses, osteotomies, and tendon transfers have been performed independently or in combination to treat the osseous and soft-tissue derangements that contribute to dorsolateral peritalar subluxation of the foot^{6,9,11,13,17,24,25,27,32,35,42}. To our knowledge, the long-term results of these procedures have not been reported; however, the eventual onset of arthritis of the ankle and midfoot after triple arthrodesis for the treatment of pes planovalgus deformity has been reported^2,4,12,15,46. Current opinion suggests that this procedure should be used only in elderly patients and in patients who have a fixed deformity or severe degeneration of the joints of the hindfoot^13,20. The advantage of correcting a supple flatfoot deformity while preserving accommodative subtalar motion has recently popularized the use of selective arthrodesis of the hindfoot^3,25.

Lengthening of the lateral column of the foot has been successful in the treatment of symptomatic pes planus in children and adolescents. Evans reported on fifty-six flatfeet in children and adolescents that had been treated successfully with lengthening of the lateral column by means of a calcaneal osteotomy and interposition of an iliac-crest bone graft⁸. Phillips³⁴ evaluated the long-term results of twenty-three of the fifty-six flatfeet from the series of Evans; specifically, he sought to determine if there had been clinical deterioration or if arthritis had developed. He found that seventeen feet were asymptomatic, with no or mild arthritic changes seen on radiographs made between seven and twenty years postoperatively. Anderson and Fowler¹ as well as Mosca³¹ investigated the results of anterior calcaneal osteotomy performed in conjunction with an osteotomy of the medial cuneiform for the treatment of pes planovalgus. Mosca reported that twenty-nine of thirty-one children who had severe, symptomatic flatfoot or skewfoot had a satisfactory result after lengthening of the lateral column alone or in combination with a corrective osteotomy of the medial cuneiform. He concluded that lengthening of the lateral column reliably relieved symptoms, restored function, and protected the ankle and midtarsal joints from early degenerative arthritis in patients who had severe valgus deformity of the hindfoot.

The results of lengthening of the lateral column of the foot through distraction arthrodesis of the calcaneocuboid joint in adults who have severe, symptomatic dorsolateral peritalar subluxation have not been reported, to our knowledge. In the current investigation, we retrospectively reviewed the functional and radiographic results of distraction arthrodesis of the lateral column in conjunction with (in most patients) stabilization of the medial column by arthrodesis of the first tarsometatarsal joint or the naviculocuneiform joint, or both joints, and with transfer of the flexor digitorum longus tendon.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion Appendix References

 
This investigation was approved for implementation by the Human Subjects Review Committee of the University of Washington School of Medicine. All patients gave voluntary written consent before participating in the study and after the examiner (B. C. T.) had informed them of the purpose of the study, the methods and risks of the procedure, and the confidentiality of the data that were obtained.

A review of the operative log of the senior one of us (S. T. H., Jr.) led to the identification of a consecutive series of forty-three patients who had had a reconstruction with use of distraction arthrodesis of the calcaneocuboid joint in conjunction with (in most patients) stabilization of the medial column by arthrodesis of the first tarsometatarsal joint or the naviculocuneiform joint, or both joints, and with transfer of the flexor digitorum longus tendon to the medial column for the treatment of severe, symptomatic dorsolateral peritalar subluxation of the foot. Of these forty-three patients, one refused to participate in the study and six could not be contacted. The remaining thirty-six patients returned to the Harborview Medical Center for an evaluation between December 1996 and August 1997. Five patients had had a staged, bilateral procedure; thus, data for forty-one feet served as the basis for the study.

All patients completed a detailed questionnaire regarding their preoperative and postoperative symptoms and their functional status (Appendix). The patients were asked to comment specifically on their overall satisfaction with the result of the operation and on their willingness to have the procedure again if the circumstances were similar. One of us (B. C. T.), who had not been involved with the index procedure, performed a comprehensive bilateral examination on each patient to determine the range of motion, muscle strength, alignment, neurovascular status, and the presence of tenderness, on palpation, in the foot and ankle. The site from which the bone graft from the posterior iliac crest had been obtained was assessed for tenderness and wound-healing. Each patient was asked about his or her height, weight, and history of tobacco use. Coincident with this evaluation, and as part of the routine follow-up, anteroposterior and lateral radiographs of the involved foot were made with the patient bearing weight.

The examiner reviewed each patient's medical record after the questionnaire had been completed and the physical examination had been performed. Pertinent diagnoses of comorbidities, operative findings, and specific details of the postoperative course, including the prevalence and nature of postoperative complications and subsequent operations related to the initial procedure, were recorded. The time to union after the lengthening of the lateral column was determined on the basis of the surgeon's follow-up notes.

Radiographic Evaluation
The examiner measured six parameters on the preoperative radiographs and on the radiographs made at the latest follow-up examination. All radiographs were made with the patient in a full weight-bearing stance. The effects of lengthening of the lateral column on the relationships between the hindfoot, midfoot, and forefoot were determined with use of a technique that we described previously³⁹. According to this method, the talo-first metatarsal, talocalcaneal, and talonavicular coverage angles were measured on the anteroposterior radiograph and the talo-first metatarsal, talocalcaneal, and calcaneal pitch angles were measured on the lateral radiograph. On the anteroposterior radiograph, the talo-first metatarsal angle was defined as the angle formed by a line connecting the midpoints of the mediolateral width of the first metatarsal at its proximal and distal metaphyseal-diaphyseal junctions and a perpendicular line drawn through the midpoint of a line connecting the medial and lateral margins of the articular surface of the talus, the talocalcaneal angle was defined as the angle formed by a line drawn parallel to the lateral border of the calcaneus and a perpendicular line drawn through the midpoint of a line connecting the medial and lateral margins of the articular surface of the talus, and the talonavicular coverage angle was defined as the angle formed by a perpendicular line drawn through the midpoint of a line connecting the medial and lateral margins of the articular surface of the talus and another perpendicular line drawn through the midpoint of a line connecting the same margins of the navicular. On the lateral radiograph, the talo-first metatarsal angle was defined as the angle formed by a line connecting the midpoints of the cephalocaudad width of the first metatarsal at its proximal and distal metaphyseal-diaphyseal junctions and a line connecting the midpoints of the cephalocaudad width of the neck and dome of the talus, the talocalcaneal angle was defined as the angle formed by a line connecting the midpoints of the cephalocaudad width of the neck and dome of the talus and a line connecting the cephalocaudad width of the tuberosity and the anterior process of the calcaneus, and the calcaneal pitch angle was defined as the angle formed by lines connecting the plantar aspect of the calcaneus to the plantar aspect of the base of the fifth metatarsal and the plantar aspect of the calcaneus at the calcaneocuboid joint.

The mean value and the standard deviation for each radiographic parameter were calculated. Paired Student t tests with Bonferroni's correction were performed for each pair of preoperative and postoperative radiographic measurements. Significance was set at a p value of 0.001 for each test.

Indications and Preoperative Care
The criteria established for inclusion in the study mandated that the patient had to have been at least eighteen years old at the time of the index reconstructive procedure on the foot, that at least two years had to have elapsed since the time of the index procedure, and that an operation on the hindfoot could not have been performed before the reconstruction. Every patient who was eligible to participate in this study had evidence of stage-II disease of the posterior tibial tendon (defined by Johnson and Strom as that resulting in pronation of the midfoot and abduction of the forefoot with a flexible valgus deformity of the hindfoot²⁰) at the time that they were first seen by the senior one of us (S. T. H., Jr.). Every patient had pain in the medial longitudinal arch, the dorsal aspect of the midfoot, or the sinus tarsi, or at a combination of these locations, as well as no or decreased strength to perform manually resisted inversion of the foot.

Because of the nature of the specialty practice of the senior one of us, all patients had been referred for operative management by their primary-care physician, a podiatrist, or an orthopaedic surgeon after nonoperative management of the painful flatfoot had failed. The previous treatments had included nonsteroidal anti-inflammatory medication, taken orally; at least one injection of a local anesthetic and corticosteroids; and use of a custom or off-the-shelf orthosis, ankle stirrup brace, commercial walker, or below-the-knee weight-bearing cast.

Operative Findings, Operative Technique, and Postoperative Care
Of the forty-one feet, sixteen (39 percent) were noted by the surgeon to have a ruptured posterior tibial tendon at the time of the index reconstruction. Rupture was defined as loss of continuity of a normal-appearing tendon into dense scar tissue adherent to the tendon sheath immediately proximal to the navicular insertion and the absence of distal excursion when longitudinal traction was applied to the intact tendon proximal to the rupture. Two tendons were partially disrupted, and one patient who had bilateral reconstruction had insertion of the posterior tibial tendon primarily into a large accessory navicular. In the remaining twenty-one feet (51 percent), the tendon had become thickened and discolored but was in continuity.

The senior one of us either performed or directly supervised every procedure that was included in the index reconstruction for all patients. The surgeon exposed the calcaneocuboid joint through a longitudinal incision along the dorsolateral aspect of the foot. The peroneal tendons and the sural nerve were retracted, and the muscle belly of the extensor digitorum brevis was elevated dorsomedially. A small joint distractor (Synthes, Paoli, Pennsylvania), applied to Kirschner wires placed in the calcaneus and the cuboid, facilitated preparation of the joint for the arthrodesis and lengthened the lateral column to correct the valgus deformity of the hindfoot. Restoration of the medial longitudinal arch and correction of the calcaneus to a position of slight valgus angulation on visual inspection served as the intraoperative criteria for determining the amount of distraction. A tricortical graft from the posterior-superior iliac crest was inserted into the prepared joint. The graft was a truncated pyramid, shaped as a trapezoid in two planes; it was longer dorsally and laterally in order to correct abduction of the midfoot and plantar flexion of the hindfoot. Each graft was contoured individually to the unique dimensions of the gap created between the calcaneus and the cuboid to correct the flatfoot deformity. Typically, the graft was between eight and twelve millimeters in width. Before the graft was inserted, the foot was rotated in the coronal plane through the transverse tarsal joint to correct the supination of the forefoot. Crossed screws were used to internally fix the site of the distraction arthrodesis in the first thirty-four feet that had the procedure. The site of the arthrodesis was fixed with a cervical plate (Synthes) in the remaining seven feet, after the senior one of us changed his method of internal fixation. Two feet needed a medial displacement calcaneal osteotomy to completely correct residual valgus deformity of the hindfoot that was noted intraoperatively after the distraction arthrodesis.

All patients had additional procedures to correct static and dynamic factors contributing to the symptomatic dorsolateral peritalar subluxation of the foot. Transfer of the flexor digitorum longus was done through a longitudinal incision along the medial border of the foot, from the tip of the medial malleolus and extending beyond the navicular tuberosity. The flexor digitorum longus was passed through the posterior tibial tendon or its stump immediately proximal to the navicular insertion in a plantar-to-dorsal direction and was sutured in place with the ankle and foot in slight plantar flexion and inversion, respectively. In three feet, the flexor digitorum longus was passed plantar to dorsal through an osseous tunnel drilled through the medial cuneiform in conjunction with an excision of the tuberosity of the navicular. Every patient had a percutaneous lengthening of the Achilles tendon, with use of three stab wounds to partially transect the tendon in three locations.

In addition to the tendon transfer, thirty-three feet also had stabilization of the medial column with arthrodesis of the first tarsometatarsal joint or the naviculocuneiform joint, or both, to correct fixed supination of the forefoot and hypermobility of these joints (Table I). Twenty-seven feet had an arthrodesis of the first tarsometatarsal joint, four feet had an arthrodesis of the naviculocuneiform joint with insertion of crossed screws for fixation, and two feet had both procedures³⁸. Whether or not the patient needed an arthrodesis of one or both of these joints in order to realign the supinated forefoot in a plantigrade position was determined on the basis of preoperative radiographs, made with the patient standing, and intraoperative assessment of the medial column of the foot after lengthening of the lateral column. Nine feet had routing of the anterior tibial tendon plantar to the naviculocuneiform joint and plantar to dorsal through an osseous trough in the navicular (Young's suspension)⁴⁷ to correct the plantar wedge-shaped opening noted at this joint on the preoperative radiographs, until the senior one of us discontinued use of this procedure. This procedure was performed as an isolated stabilization procedure in four feet and in conjunction with a tarsometatarsal arthrodesis or a naviculocuneiform arthrodesis in five feet. Four feet had only transfer of the flexor digitorum longus tendon to the medial aspect of the midfoot.

	Results

Top Abstract Introduction Materials and Methods Results Discussion Appendix References

 

Description of the Study Cohort
The mean duration of follow-up was thirty-four months (range, twenty-four to fifty months). The study cohort comprised fifteen men and twenty-one women, who had a mean age of fifty-four years (range, twenty-three to eighty-one years) at the time of the evaluation. The height and weight of the men averaged seventy-one inches (180 centimeters) and 204 pounds (ninety-three kilograms), while those of the women averaged sixty-eight inches (173 centimeters) and 179 pounds (eighty-one kilograms). Six patients had applied for or were receiving Workers' Compensation. Only one patient, a man, reported use of tobacco during the perioperative period. Nine patients recalled an acute, isolated traumatic injury of the foot associated with the onset of the symptoms; two patients (three feet) had rheumatoid arthritis; one patient had juvenile rheumatoid arthritis; and one patient had lupus erythematosus. The remaining patients described an insidious, progressive onset of pain and deformity without an inciting event.

Patient Questionnaire
The patients reported that thirty-six (88 percent) of the forty-one feet were less painful or pain-free, three (7 percent) were unchanged, and two (5 percent) were more painful after the operation. One of the patients who had a more painful foot had chronic reflex sympathetic dystrophy postoperatively, and the other had a stable fibrous nonunion at the site of the lengthening of the lateral column.

Twenty-three (77 percent) of the thirty patients who were employed before the operation returned to work postoperatively, and twenty of these patients resumed the same (or an equally strenuous) job (Table I). Three of the seven patients who did not return to work retired. Of the remaining four patients who did not resume employment, three had an unresolved Workers' Compensation claim.

Twenty-eight patients (78 percent) reported that the procedure allowed them to increase their activities of daily living, and twenty-four (67 percent) described either an increase or no change in their level of recreational activities. Thirty-four patients (94 percent) reported the same or an increased level of walking ability postoperatively, and twenty-eight (78 percent) had the same or an increased ability to walk on uneven ground. Two of the eight patients who had a decreased ability to walk on uneven ground had had bilateral lengthening of the lateral column. Two patients occasionally needed to use a cane, and another two thought that they had a more pronounced limp after the operation. Of the latter four patients, three were severely obese.

According to the patients, the appearance of twenty-nine (71 percent) of the forty-one feet had improved after the procedure and the appearance of ten (24 percent) had not changed. The appearance of the other two feet (5 percent) was considered by the patients to be worse after the operation. Both of these feet had had additional procedures through the lateral incision. In one there was extensive contracture of the scar at the site of the incision, and in the other there was dehiscence. Twenty-eight feet (68 percent) had less or no swelling after the operation; no foot had increased swelling as a result of the procedure.

Overall, thirty-five (85 percent) of the forty-one procedures produced a result that was satisfactory to the patient, and thirty-three (92 percent) of the thirty-six patients (thirty-eight [93 percent] of the forty-one feet) stated that they would have the reconstruction again under the same circumstances. Three of the six patients who were dissatisfied gave a specific reason for their displeasure. One woman (Case 11), who had reflex sympathetic dystrophy, and another woman (Case 37), who had a stable fibrous nonunion, cited ongoing pain as the source of their dissatisfaction. A third woman (Case 31) was unhappy with the outcome of the operation because she was unable to wear shoes with a high heel. Of the three remaining patients who did not attribute their displeasure to a specific problem, two (Cases 1 and 17) had an unresolved Workers' Compensation claim. Three of the six patients who were dissatisfied with the outcome believed that the functional gains achieved as a result of the operation would make it worthwhile to have the procedure again if the circumstances were similar. All five patients who had had bilateral reconstruction were satisfied with the results of both procedures and stated that they would have them again under the same circumstances.

Physical Examination
Thirty-nine (95 percent) of the forty-one feet had neutral or acceptable physiological valgus alignment of the hindfoot (less than 5 degrees) on full weight-bearing. Two feet were overcorrected, as evidenced by slight varus of the hindfoot (less than 5 degrees) when the patient was standing. All patients had maintained subtalar motion with a mean of 6 degrees of eversion. Thirteen feet (32 percent) had either paresthesia or anesthesia in the distribution of the sural nerve, and nine (22 percent) had tenderness on palpation over the dorsolateral aspect of the foot. The incision over the posterior iliac crest healed well in all patients; however, five had mild tenderness on deep palpation.

Radiographic Evaluation
On the anteroposterior radiograph, the talo-first metatarsal angle was corrected from a mean of 26 ± 12 degrees preoperatively to a mean of 10 ± 9 degrees postoperatively; the talocalcaneal angle, from a mean of 32 ± 8 degrees to a mean of 21 ± 8 degrees; and the talonavicular coverage angle, from a mean of 36 ± 11 degrees to a mean of 12 ± 11 degrees (p < 0.0001 for all angles).

On the lateral radiograph, the talo-first metatarsal angle was corrected from a mean of 23 ± 14 degrees preoperatively to a mean of 8 ± 8 degrees postoperatively and the calcaneal pitch angle was corrected from a mean of 13 ± 6 degrees to a mean of 21 ± 6 degrees (p < 0.0001 for both angles). With the numbers available, no significant difference could be detected between the preoperative and postoperative talocalcaneal angles (mean, 39 ± 8 degrees preoperatively compared with 38 ± 10 degrees postoperatively; p = 0.2) on the lateral radiograph (Figs. 1-A, 1-B, 1-C and 1-D).

View larger version (70K): [in this window] [in a new window]   Figs. 1-A through 1-D: Case 40. A woman who had a fourteen-year history of progressive pain and deformity in the right foot. The patient had severe dorsolateral peritalar subluxation secondary to a chronic rupture of the posterior tibial tendon. Fig. 1-A: Anteroposterior radiograph showing a talo-first metatarsal angle of 30 degrees and a talonavicular coverage angle of 40 degrees.

View larger version (53K): [in this window] [in a new window]   Fig. 1-B Lateral radiograph showing a talo-first metatarsal angle of 30 degrees and a calcaneal pitch angle of 10 degrees.

View larger version (70K): [in this window] [in a new window]   Figs. 1-C and 1-D: Forty-one months after the reconstructive procedure, which had been performed when the patient was fifty-seven years old, radiographs showed marked correction of the deformity. The sites of the lateral column lengthening and the arthrodesis of the naviculocuneiform joint were fixed with crossed lag screws, and they healed uneventfully. The patient was satisfied with the result of the procedure and stated that she would have it again if the circumstances were similar. Fig. 1-C: Anteroposterior radiograph showing a talo-first metatarsal angle of 5 degrees and a talonavicular coverage angle of 12 degrees.

View larger version (68K): [in this window] [in a new window]   Fig. 1-D Lateral radiograph showing a talo-first metatarsal angle of 2 degrees and a calcaneal pitch angle of 20 degrees.

Complications and Subsequent Procedures
Eight feet (20 percent) had a nonunion. Three of these feet had a fibrous nonunion that did not necessitate additional operative treatment, and four had a nonunion that healed after bone-grafting and revision of the fixation. The remaining nonunion was in a patient who had a triple arthrodesis at the time of the revision. There were no nonunions in the feet that initially had been fixed with a cervical plate. Three nonunions were in patients who were more than seventy years old at the time of follow-up. In twenty-two (67 percent) of the thirty-three feet that had union, the iliac-crest graft was seen to be fully incorporated on radiographs within six months postoperatively; in the remaining eleven feet, consolidation took longer. In two feet, union was confirmed intraoperatively eleven and fourteen months after the index procedure. The indication for bone-grafting and revision of the internal fixation in those two feet was a presumed nonunion at the site of the lengthening of the lateral column; however, as noted, union was confirmed intraoperatively.

Twenty-nine feet (71 percent) had at least one additional procedure. These procedures included removal of the hardware from twenty feet, bone-grafting to treat a nonunion at the site of the arthrodesis of the calcaneocuboid joint and revision of the hardware in four feet, a medial displacement calcaneal osteotomy because of recurrent valgus angulation of the hindfoot in two feet, a triple arthrodesis because of a nonunion at the site of the calcaneocuboid arthrodesis associated with loss of correction in one foot, revision with a shortening (dorsiflexion-abduction wedge) osteotomy through the site of the distraction arthrodesis because of overcorrection in one foot (Figs. 2-A, 2-B, 2-C, 2-D, 2-E and 2-F), and a Lapidus procedure for the treatment of hypermobility of the tarsometatarsal joint and hallux valgus in one foot (Table I).

View larger version (60K): [in this window] [in a new window]   Figs. 2-A through 2-F: Case 22. A man who had persistent pain in the medial aspect of the right foot several months after sustaining a twisting injury while carrying heavy equipment. At the time of the operation, he had a partial rupture of the posterior tibial tendon and chronic tendinitis. Figs. 2-A and 2-B: Radiographs revealing moderate dorsolateral peritalar subluxation. The talo-first metatarsal angle and the talonavicular coverage angle are 23 and 18 degrees, respectively, on the anteroposterior radiograph (Fig. 2-A), and the talo-first metatarsal angle and the calcaneal pitch angle are 11 and 17 degrees, respectively, on the lateral radiograph (Fig. 2-B).

View larger version (58K): [in this window] [in a new window]   Figs. 2-A and 2-B: Radiographs revealing moderate dorsolateral peritalar subluxation. The talo-first metatarsal angle and the talonavicular coverage angle are 23 and 18 degrees, respectively, on the anteroposterior radiograph (Fig. 2-A), and the talo-first metatarsal angle and the calcaneal pitch angle are 11 and 17 degrees, respectively, on the lateral radiograph (Fig. 2-B).

View larger version (64K): [in this window] [in a new window]   Figs. 2-C and 2-D: Thirty-four months after the index procedure, which had been performed when the patient was forty-three years old, the patient had a revision of the lateral column lengthening. He had been having persistent pain in the sinus tarsi despite removal of the hardware and débridement of the sinus tarsi at nine and twenty-two months after the reconstruction, respectively. The patient consented to the revision after an additional year of intensive physical therapy and three injections of steroids into the sinus tarsi. Fig. 2-C: Anteroposterior radiograph made soon before the revision, demonstrating overcorrection of the forefoot and midfoot into adduction. The talo-first metatarsal angle is -8 degrees, and the talonavicular coverage angle is -14 degrees.

View larger version (61K): [in this window] [in a new window]   Fig. 2-D: Lateral radiograph revealing plantar flexion of the first ray, a talo-first metatarsal angle of -2 degrees, and a large calcaneal pitch angle of 30 degrees.

View larger version (60K): [in this window] [in a new window]   Figs. 2-E and 2-F: Radiographs made six months after removal of the hardware used to stabilize the site of a three-millimeter dorsiflexion-abduction wedge osteotomy through the site of the lateral column arthrodesis, demonstrating proper alignment of the foot. Despite the protracted course and the need for additional procedures, the patient was satisfied with the outcome and stated that he would have the procedure again if the circumstances were the same. Fig. 2-E: Anteroposterior radiograph showing a talo-first metatarsal angle of 2 degrees and a talonavicular coverage angle of 0 degrees.

View larger version (59K): [in this window] [in a new window]   Fig. 2-F: Lateral radiograph showing correction of the talo-first metatarsal and calcaneal pitch angles to 2 and 23 degrees.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion Appendix References

 
Evans believed that the lateral column is the foundation of the skeletal structure of the foot⁸. His observations that equinovarus deformity of a clubfoot was correctable by shortening of the lateral column and that the calcaneovalgus position of an overcorrected clubfoot could be rectified by lengthening of the lateral column with a bone graft led him to conclude that the length of the lateral column relative to the medial column has a major influence on the shape of the foot. The high rate of success associated with lengthening of the lateral column in children and the poor long-term results of triple arthrodesis in adults led to use of this procedure for the treatment of symptomatic acquired flatfoot deformity in adults. In the current study, the early results of the senior one of us (S. T. H., Jr.) with distraction arthrodesis of the calcaneocuboid joint in conjunction with realignment of the medial column for the treatment of dorsolateral peritalar subluxation of the foot were evaluated. The retrospective evaluation comprised a review of the medical chart, a detailed questionnaire completed by the patient, and a physical and radiographic examination.

Lengthening of the lateral column markedly improved the deformities of the foot in the transverse and sagittal planes. A comparison of the preoperative and postoperative radiographs, made with the patient bearing weight, demonstrated significant correction of five of the six parameters that were measured. These corrections are in agreement with those reported in our earlier studies^37,39 and with those described by others who have investigated the effects of lengthening of the lateral column. Both in the current study and in our two previous investigations, the greatest magnitude of correction was noted in the talonavicular coverage and talo-first metatarsal angles. The marked decreases in these angles confirm that lengthening of the lateral column effectively corrects the malalignment of the midfoot and hindfoot associated with dorsolateral peritalar subluxation by biplanar rotation through the talonavicular joint. The significant corrections in the calcaneal pitch and talo-first metatarsal angles (p < 0.0001) that were seen on the lateral radiograph, with no change in the talocalcaneal angle on the lateral radiograph, suggest that lengthening of the lateral column inverts the calcaneus out of planovalgus through the subtalar joint and reconstitutes the longitudinal arch, as we noted previously³⁹. These results support the conclusion that lengthening of the lateral column through distraction arthrodesis of the calcaneocuboid joint corrects the pathological malalignments between the hindfoot, midfoot, and forefoot that are associated with dorsolateral peritalar subluxation of the foot.

Nonunion, which occurred in 20 percent of the forty-one feet, was the major source of morbidity that necessitated a subsequent procedure in this study. This problem has since been solved by a change in the method of fixation of the site of the distraction arthrodesis. The use of a cervical plate resulted in union in the seven feet in this study that had such fixation. It is our clinical impression that complete incorporation of the interposition graft with union at both graft-host interfaces is a prolonged process that is difficult to assess reliably on plain radiographs. Definite fusion can be difficult to confirm radiographically for more than a year postoperatively. The use of prolonged immobilization and restricted weight-bearing until there is unequivocal radiographic confirmation of fusion may affect the overall rehabilitation of the patient, and it is difficult for the patient to comply with such a regimen. Our results suggest that the cervical plate provides satisfactory rigid fixation during consolidation at the site of the arthrodesis of the lateral column and allows the patient to walk before there is radiographic confirmation of union.

Age may be a contributing factor in bone-healing. Three of the eight nonunions were in patients who were more than seventy years old at the time of the evaluation, and one of the three was in the patient who had a triple arthrodesis because of loss of correction associated with the nonunion. This finding suggests that age-related changes in bone quality may adversely affect the rate of union.

The role of obesity with regard to union is less clear. Although both of the men and two of the six women who had a nonunion weighed more than 200 pounds (ninety-one kilograms), union occurred without difficulty in five men and three women who had a similar weight.

A prospective investigation with use of objective functional scores to assess the outcomes of the procedure would have strengthened the design of this study. However, the American Orthopaedic Foot and Ankle Society did not introduce an instrument to evaluate outcomes after operative treatment on the foot and ankle until recently. Although other authors^{14,23,29,30,45} have compared retrospectively acquired preoperative functional scores with scores obtained at the time of the latest follow-up, the accuracy of this methodology has not been determined. We chose to assess the outcomes qualitatively and to report the distribution of the patients' responses to our questionnaire rather than to present quantitative data that had the potential for bias and inaccuracy. More details regarding the preoperative management of the patients would have provided a better description of the study cohort and allowed more specific comparisons with the postoperative results.

Although it was not specifically assessed, we believe that stabilization of the medial column through arthrodesis or tendon transfer, or both, should accompany lengthening of the lateral column so that the most complete and durable restoration of the foot can be achieved. The static corrections that are achieved through realignment and stabilization are preserved and enhanced by tendon transfer and lengthening of the Achilles tendon. At nearly three years postoperatively, only one patient needed a triple arthrodesis to correct malalignment that was due to a nonunion at the site of the lengthening of the lateral column, and no patient who had healing at the site of the index procedure needed a subsequent arthrodesis of the foot or ankle. Transfer of the flexor digitorum longus to the posterior tibial tendon dynamically supports the plantar-medial rotation of the navicular around the talus. Percutaneous lengthening of the contracted Achilles tendon facilitates rotation and medialization of the calcaneus under the talus when the lateral column is lengthened to correct the valgus malalignment of the hindfoot. Pomeroy and Manoli reached similar conclusions in their study of twenty patients who had had lengthening of the lateral column through the anterior process of the calcaneus in conjunction with a medial displacement osteotomy of the tuberosity, transfer of the flexor digitorum longus to the medial cuneiform, and percutaneous lengthening of the Achilles tendon³⁵. Those authors noted remarkable correction of the flatfoot deformity, improvement in the functional rating, and maintenance of the initial satisfactory results in all feet at nearly eighteen months postoperatively. No patient had a nonunion, but twelve (60 percent) had painful hardware necessitating removal and two (10 percent) demonstrated an injury of the sural nerve postoperatively. Pomeroy and Manoli believed that their approach to the treatment of supple flatfoot necessitated less extensive correction at each osseous site and led to a more complete correction of severe pes planovalgus.

In the present study, despite a notable prevalence of nonunion and additional operations, the outcomes of thirty-five of the forty-one procedures were satisfactory to the patient and thirty-three of the thirty-six patients stated that they would have the procedure again if the circumstances were similar. These are favorable results, nearly three years after the reconstruction, in a population of patients who had very severe, symptomatic flatfoot. Two of the three patients who said that they would not have the procedure again had complications: one had severe reflex sympathetic dystrophy, and the other had a stable fibrous nonunion at the site of the lengthening of the lateral column. The third patient was very dissatisfied because of the inability to wear high heels, but she stated that her overall function had improved greatly. We believe that effective relief of pain and an improved appearance of the foot, together with an increased capacity to perform basic, work, and recreational activities postoperatively, account for the high rate of patient satisfaction with lengthening of the lateral column for the treatment of dorsolateral peritalar subluxation of the foot.

	Appendix

Top Abstract Introduction Materials and Methods Results Discussion Appendix References

 

Questionnaire
1. Do you have pain in your foot or ankle?

(a) never

(b) occasionally

(c) more than once a week

(d) daily

(e) all the time

How would you characterize this pain?

(a) not present

(b) mild

(c) moderate

(d) severe

How does this pain compare to the pain you had prior to surgery?

(a) more pain now

(b) unchanged

(c) less pain now

(d) no pain now

2. Can you perform your normal daily activities (work, shopping, etc.)?

(a) significantly limited

(b) moderately limited

(c) mildly limited

(d) not limited

How has this surgery affected your ability to perform your normal daily activities?

(a) significantly decreased

(b) moderately decreased

(c) mildly decreased

(d) no change

(e) mildly increased

(f) moderately increased

(g) significantly increased

3. Were you able to return to work?

(a) same or equally strenuous job

(b) less strenuous job

(c) unable to work

(d) did not work prior to surgery

4. Are you able to participate in recreational activities?

(a) significantly limited

(b) moderately limited

(c) mildly limited

(d) not limited

How has this surgery affected your ability to participate in recreational activities?

(a) significantly decreased

(b) moderately decreased

(c) mildly decreased

(d) no change

(e) mildly increased

(f) moderately increased

(g) significantly increased

5. Do you have swelling in your foot?

(a) none

(b) mild

(c) moderate

(d) severe

Did you have swelling in your foot prior to surgery?

(a) none

(b) mild

(c) moderate

(d) severe

6. Do you use any walking aids?

(a) brace

(b) cane

(c) crutches

(d) walker

(e) wheelchair

If you use a walking aid, how often do you use it?

(a) occasionally

(b) often

(c) always

How often did you use a walking aid prior to surgery?

(a) never

(b) occasionally

(c) often

(d) always

7. Do you use an orthotic (shoe insert), heel lift, or special shoes?

(a) never

(b) occasionally

(c) often

(d) always

How often did you use an orthotic, heel lift, or special shoes prior to surgery?

(a) never

(b) occasionally

(c) often

(d) always

8. Do you walk with a limp?

(a) never

(b) occasionally

(c) often

(d) always

If so, how would you characterize this limp?

(a) mild

(b) moderate

(c) severe

Did you walk with a limp prior to surgery?

(a) never

(b) occasionally

(c) often

(d) always

If so, how would you have characterized this limp?

(a) mild

(b) moderate

(c) severe

9. How far are you able to walk?

(a) a few steps

(b) only indoors

(c) indoors and outdoors, but limited

(d) indoors and outdoors, unlimited

How far were you able to walk prior to surgery?

(a) a few steps

(b) only indoors

(c) indoors and outdoors, but limited

(d) indoors and outdoors, unlimited

10. Do you have difficulty walking on uneven ground?

(a) never

(b) occasionally

(c) often

(d) always

Did you have difficulty walking on uneven ground prior to surgery?

(a) never

(b) occasionally

(c) often

(d) always

How has this surgery affected your ability to walk on uneven ground?

(a) significantly decreased

(b) moderately decreased

(c) mildly decreased

(d) no change

(e) mildly increased

(f) moderately increased

(g) significantly increased

11. Describe your feelings about the appearance of your foot prior to surgery.

(a) unsatisfied

(b) satisfied, with some reservations

(c) very satisfied

12. Describe your feelings about the appearance of your foot after surgery.

(a) unsatisfied

(b) satisfied, with some reservations

(c) very satisfied

13. How do you feel about the results of your surgery?

(a) unsatisfied

(b) satisfied, with some reservations

(c) very satisfied

14. If you had to do it all over again, would you choose to have the surgery?

(a) no

(b) yes

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Section of Orthopaedic Surgery and Rehabilitation Medicine, Department of Surgery, University of Chicago Medical Center, 5841 South Maryland Avenue, MC 3079, Chicago, Illinois 60637. E-mail address: btoolan@surgery.bsd.uchicago.edu.

Department of Orthopaedics, Harborview Medical Center, 325 Ninth Avenue, Box 359798, Seattle, Washington 98104.

	References

Top Abstract Introduction Materials and Methods Results Discussion Appendix References

 

1. Anderson, A. F., and Fowler, S. B.: Anterior calcaneal osteotomy for symptomatic juvenile pes planus. Foot and Ankle, 4: 274-283, 1984.
2. Angus, P. D., and Cowell, H. R.: Triple arthrodesis. A critical long-term review. J. Bone and Joint Surg., 68-B(2): 260-265, 1986.
3. Astion, D. J.; Deland, J. T.; Otis, J. C.; and Kenneally, S.: Motion of the hindfoot after simulated arthrodesis. J. Bone and Joint Surg., 79-A: 241-246, Feb. 1997.[Abstract/Free Full Text]
4. Bennett, G. L.; Graham, C. E.; and Mauldin, D. M.: Triple arthrodesis in adults. Foot and Ankle, 12: 138-143, 1991.
5. Chao, W.; Wapner, K. L.; Lee, T. H.; Adams, J.; and Hecht, P. J.: Nonoperative management of posterior tibial tendon dysfunction. Foot and Ankle Internat., 17: 736-741, 1996.
6. Clain, M. R., and Baxter, D. E.: Simultaneous calcaneocuboid and talonavicular fusion. Long-term follow-up study. J. Bone and Joint Surg., 76-B(1): 133-136, 1994.
7. Deland, J. T.; Arnoczky, S. P.; and Thompson, F. M.: Adult acquired flatfoot deformity at the talonavicular joint: reconstruction of the spring ligament in an in vitro model. Foot and Ankle, 13: 327-332, 1992.
8. Evans, D.: Calcaneo-valgus deformity. J. Bone and Joint Surg., 57-B(3): 270-278, 1975.
9. Fogel, G. R.; Katoh, Y.; Rand, J. A.; and Chao, E. Y. S.: Talonavicular arthrodesis for isolated arthrosis. 9.5 year results and gait analysis. Foot and Ankle, 3: 105-113, 1982.
10. Funk, D. A.; Cass, J. R.; and Johnson, K. A.: Acquired adult flat foot secondary to posterior tibial-tendon pathology. J. Bone and Joint Surg., 68-A: 95-102, Jan. 1986.[Abstract/Free Full Text]
11. Gould, J. S.: Direct repair of the posterior tibial tendon. Foot and Ankle Clin., 2: 275-279, 1997.
12. Graves, S. C.; Mann, R. A.; and Graves, K. O.: Triple arthrodesis in older adults. Results after long-term follow-up. J. Bone and Joint Surg., 75-A: 355-362, March 1993.[Abstract/Free Full Text]
13. Graves, S. C., and Stephenson, K.: The use of subtalar and triple arthrodesis in the treatment of posterior tibial tendon dysfunction. Foot and Ankle Clin., 2: 319-328, 1997.
14. Haddad, S. L.; Myerson, M. S.; Pell, R. F., IV; and Schon, L. C.: Clinical and radiographic outcome of revision surgery for failed triple arthrodesis. Foot and Ankle Internat., 18: 489-499, 1997.
15. Haritidis, J. H.; Kirkos, J. M.; Provellegios, S. M.; and Zachos, A. D.: Long-term results of triple arthrodesis: 42 cases followed for 25 years. Foot and Ankle Internat., 15: 548-551, 1994.
16. Harper, M. C.: Deltoid ligament: an anatomical evaluation of function. Foot and Ankle, 8: 19-22, 1987.
17. Harper, M. C., and Tisdel, C. L.: Talonavicular arthrodesis for the painful adult acquired flatfoot. Foot and Ankle Internat., 17: 658-661, 1996.
18. Jahss, M. H.: Spontaneous rupture of the tibialis posterior tendon: clinical findings, tenographic studies, and a new technique of repair. Foot and Ankle, 3: 158-166, 1982.
19. Johnson, K. A.: Tibialis posterior tendon rupture. Clin. Orthop., 177: 140-147, 1983.
20. Johnson, K. A., and Strom, D. E.: Tibialis posterior tendon dysfunction. Clin. Orthop., 239: 196-206, 1989.
21. Kaye, R. A., and Jahss, M. H.: Tibialis posterior: a review of anatomy and biomechanics in relation to support of the medial longitudinal arch. Foot and Ankle, 11: 244-247, 1991.
22. Kjærsgaard-Andersen, P.; Wethelund, J.-O.; Helmig, P.; and Søballe, K.: Stabilizing effect of the tibiocalcaneal fascicle of the deltoid ligament on hindfoot joint movements: an experimental study. Foot and Ankle, 10: 30-35, 1989.
23. Komenda, G. A.; Myerson, M. S.; and Biddinger, K. R.: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J. Bone and Joint Surg., 78-A: 1665-1676, Nov. 1996.[Abstract/Free Full Text]
24. Koutsogiannis, E.: Treatment of mobile flat foot by displacement osteotomy of the calcaneus. J. Bone and Joint Surg., 53-B(1): 96-100, 1971.
25. McCluskey, L. C.: Talonavicular arthrodeses, calcaneocuboid arthrodeses, double arthrodeses and pantalar arthrodeses. Foot and Ankle Clin., 2: 329-342, 1997.
26. Mann, R. A.: Acquired flatfoot in adults. Clin. Orthop., 181: 46-51, 1983.
27. Mann, R. A., and Thompson, F. M.: Rupture of the posterior tibial tendon causing flat foot. Surgical treatment. J. Bone and Joint Surg., 67-A: 556-561, April 1985.[Abstract/Free Full Text]
28. Mann, R. A.: Flatfoot in adults. In Surgery of the Foot and Ankle, pp. 757-784. Edited by R. A. Mann and M. J. Coughlin. St. Louis, Mosby-Year Book, 1993.
29. Mann, R. A.; Beaman, D. N.; and Horton, G. A.: Isolated subtalar arthrodesis. Foot and Ankle Internat., 19: 511-519, 1998.
30. Markbreiter, L. A., and Thompson, F. M.: Proximal metatarsal osteotomy in hallux valgus correction: a comparison of crescentic and chevron procedures. Foot and Ankle Internat., 18: 71-76, 1997.
31. Mosca, V. S.: Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skewfoot. J. Bone and Joint Surg., 77-A: 500-512, April 1995.[Abstract/Free Full Text]
32. Myerson, M. S.; Corrigan, J.; Thompson, F.; and Schon, L. C.: Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: a radiological investigation. Foot and Ankle Internat., 16: 712-718, 1995.
33. Pedowitz, W. J., and Kovatis, P.: Flatfoot in the adult. J. Am. Acad. Orthop. Surgeons, 3: 293-302, 1995.[Abstract]
34. Phillips, G. E.: A review of elongation of os calcis for flat feet. J. Bone and Joint Surg., 65-B(1): 15-18, 1983.
35. Pomeroy, G. C., and Manoli, A., II: A new operative approach for flatfoot secondary to tibial tendon insufficiency: a preliminary report. Foot and Ankle Internat., 18: 206-212, 1997.
36. Resnick, R. B.; Jahss, M. H.; Choueka, J.; Kummer, F.; Hersch, J. C.; and Okereke, E.: Deltoid ligament forces after tibialis posterior tendon rupture: effects of triple arthrodesis and calcaneal displacement osteotomies. Foot and Ankle Internat., 16: 14-20, 1995.
37. Sands, A. K.; Grujic, L.; Sangeorzan, B. J.; and Hansen, S. T., Jr.: Lateral column lengthening through the calcaneocuboid joint: an alternative to triple arthrodesis for correction of flat foot. Read at the Annual Meeting of the American Orthopaedic Foot and Ankle Society, Orlando, Florida, Feb. 19, 1995.
38. Sangeorzan, B. J., and Hansen, S. T., Jr.: Modified Lapidus procedure for hallux valgus. Foot and Ankle, 9: 262-266, 1989.
39. Sangeorzan, B. J.; Mosca, V. S.; and Hansen, S. T., Jr.: Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot and Ankle, 14: 136-141, 1993.
40. Sarrafian, S. K.: Functional characteristics of the foot and plantar aponeurosis under tibiotalar loading. Foot and Ankle, 8: 4-18, 1987.
41. Sferra, J. J., and Rosenberg, G. A.: Nonoperative treatment of posterior tibial tendon pathology. Foot and Ankle Clin., 2: 261-273, 1997.
42. Shereff, M. J.: Treatment of ruptured posterior tibial tendon with direct repair and FDL tenodesis. Foot and Ankle Clin., 2: 281-296, 1997.
43. Slovenkai, M. P.: Clinical and radiographic evaluation. Foot and Ankle Clin., 2: 241-260, 1997.
44. Stormont, D. M.; Morrey, B. F.; An, K. N.; and Cass, J. R.: Stability of the loaded ankle. Relation between articular restraint and primary and secondary static restraints. Am. J. Sports Med., 13: 295-300, 1985.[Abstract/Free Full Text]
45. Thordarson, D. B., and Krieger, L. E.: Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus; a prospective randomized trial. Foot and Ankle Internat., 17: 2-9, 1996.
46. Wetmore, R. S., and Drennan, J. C.: Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J. Bone and Joint Surg., 71-A: 417-422, March 1989.[Abstract/Free Full Text]
47. Young, C. S.: Operative treatment of pes planus. Surg., Gynec. and Obstet., 68: 1099-1101, 1939.

CiteULike

Connotea

Del.icio.us

Facebook

Technorati

Twitter

This article has been cited by other articles:

				T. M. Philbin, C. Pokabla, and G. C. Berlet Lateral Column Lengthening Using Allograft Interposition and Cervical Plate Fixation Foot & Ankle Specialist, October 1, 2008; 1(5): 288 - 296. [Abstract] [PDF]

				J. E. Johnson and J. R. Yu Arthrodesis Techniques in the Management of Stage-II and III Acquired Adult Flatfoot Deformity J. Bone Joint Surg. Am., August 1, 2005; 87(8): 1865 - 1876. [Full Text] [PDF]

				C. W. DiGiovanni, R. Kuo, N. Tejwani, R. Price, S. T. Hansen Jr., J. Cziernecki, and B. J. Sangeorzan Isolated Gastrocnemius Tightness J. Bone Joint Surg. Am., June 1, 2002; 84(6): 962 - 970. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Free Letters to the Editor: Submit a response Alert me when this article is cited Alert me when Letters to the Editor are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by TOOLAN, B. C. Articles by HANSEN, S. T. Search for Related Content PubMed PubMed Citation Articles by TOOLAN, B. C. Articles by HANSEN, S. T. Social Bookmarking                   What's this?

Stanford University Libraries' HighWire Press (TM) assists in the publication of JBJS Online.
Copyright © 1999 by The Journal of Bone and Joint Surgery, Inc. Online ISSN: 1535-1386.
The Journal of Bone and Joint Surgery®, JBJS®, JB&JS®, and eJBJS® are registered in the U.S. Patent and Trademark Office.