Background: The aim of this investigation was to analyze a nationally representative admissions database to evaluate the effect of diabetes mellitus on the rate of perioperative complications and hospitalization outcomes after ankle arthrodesis (AAD) and total ankle arthroplasty (TAA). Methods: Using the Nationwide Inpatient Sample database, 12 122 patients who underwent AAD and 2973 patients who underwent TAA were identified from 2002 to 2011 based on ICD-9 procedure codes. The perioperative complications and hospitalization outcomes were compared between diabetic and nondiabetic patients for each surgery during the index hospital stay. Results: The overall complication rate in the AAD group was 16.4% in diabetic patients and 7.0% in nondiabetic patients ( P < .001). Multivariate analysis demonstrated that diabetes mellitus was independently associated with an increased risk of myocardial infarction (relative risk [RR] = 3.2, P = .008), urinary tract infection (RR = 4.6, P < .001), blood transfusion (RR = 3.0, P < .001), irrigation and debridement (RR = 1.9, P = .001), and overall complication rate (RR = 2.7, P < .001). Diabetes was also independently associated with a statistically significant increase in length of hospital stay (difference = 0.35 days, P < .001), more frequent nonhome discharge (RR = 1.69, P < .001), and higher hospitalization charges (difference = $1908, P = .04). The overall complication rate in the TAA group was 7.8% in diabetic patients and 4.7% in nondiabetic patients. Multivariate analysis demonstrated that diabetes was independently associated with increased risk of blood transfusion (RR = 9.8, P = .03) and overall complication rate (RR = 4.1, P = .02). Diabetes was also independently associated with a statistically significant increase in length of stay (difference = 0.41 days, P < .001) and more frequent nonhome discharge (RR = 1.88, P < .001), but there was no significant difference in hospitalization charges ( P = .64). Conclusion: After both AAD and TAA, diabetes mellitus was independently associated with a significantly increased risk of perioperative complications, nonhome discharge, and length of hospital stay during the index hospitalization. Level of Evidence: Level III, comparative series.

BACKGROUND:Chronic diastasis of the syndesmosis has been recognized as a cause of persistent pain and dysfunction after a rotational ankle injury. Recently, there has been an increased effort to define the use of computed tomography (CT) imaging in making this diagnosis; however, no clear consensus has been reached on the best way to assess the anatomical integrity of the syndesmosis. In this retrospective case series, we have evaluated the diagnostic capability of 2 novel CT-based measurements.METHODS:Fourteen patients with symptomatic syndesmotic instability received a bilateral ankle CT scan. Two measurements were performed. The first measurement was the angle subtended by 2 lines drawn tangent to the anterior and posterior surfaces of the distal tibia and lateral malleolus 1 cm above the talar dome. The second measurement was the area bound by these lines, the lateral tibia and the medial aspect of the lateral malleolus. The injured and contralateral sides were compared using a Wilcoxon rank sum test with a significance set at P ≤ .05.RESULTS:When comparing the injured to the contralateral ankle, we found a significant decrease in the angular measurement of the syndesmosis (63.4 ± 6.1 degrees vs 68.4 ± 6.6 degrees; P = .018) and a significant increase in the area measurement (1.71 ± 0.44 cm(2) vs 1.21 ± 0.25 cm(2); P = .00003). Eleven of 14 patients had a smaller angular measurement, and all 14 had a larger area measurement in the injured ankle. All patients were confirmed to have instability via manual testing intraoperatively.CONCLUSIONS:This study suggests that a comparison of angular and area measurements will help identify a diastasis of the syndesmosis in patients with persistent pain after a rotational ankle fracture. These measurements are straightforward to perform and rely on landmarks that are easy to identify.LEVEL OF EVIDENCE:Level IV, diagnostic.

Background: The aim of this study was to analyze a validated, nationally representative admissions database in order to compare perioperative complications and hospitalization outcomes associated with ankle arthrodesis (AAD) versus ankle arthroplasty (TAA).Methods: Using the Nationwide Inpatient Sample (NIS) database from 2002 to 2011, 12 250 patients who underwent AAD and 3002 patients who underwent TAA were identified based on International Classification of Diseases, Ninth Revision (ICD-9) codes. The demographics, comorbidities, and perioperative outcomes during the index hospital stay were compared between patients who underwent AAD and TAA. Multivariate analysis was performed to adjust for differences in demographics and comorbidities between the 2 groups.Results: Multivariate analysis demonstrated that TAA was independently associated with a decreased risk of blood transfusion (relative risk [RR] = 0.53, P < .001), non-home discharge (RR = 0.70, P < .001), and overall complication (RR = 0.79, P = .03). There were similar rates of pneumonia, deep vein thrombosis, pulmonary embolus, cerebrovascular accident, myocardial infarction, and mortality. TAA was independently associated with a significantly higher hospital charge (difference = $24 431, P < .001). There was no significant difference in the adjusted length of stay between the 2 groups (P = .13).Conclusion: TAA was independently associated with a lower risk of blood transfusion, non-home discharge, and overall complication when compared to AAD during the index hospitalization period. TAA was also independently associated with a higher hospitalization charge, but length of stay was similar between the 2 groups. Until long-term comparative studies are performed, the optimal treatment for end-stage ankle arthritis remains controversial, this study provides greater clarity with regard to hospitalization outcomes after the 2 procedures and shows no significant difference in risk for the majority of medical perioperative complications.Level of Evidence: Level III, comparative series.

Peter J. Stern, MD, is Norman S. & Elizabeth C.A. Hill Professor and Chairman of Orthopaedic Surgery at the University of Cincinnati College of Medicine; Stephen Albanese, MD, is Professor and Chair of Orthopedic Surgery and Medical Director of Orthopedic Surgery Clinic at SUNY Upstate Medical University; Mathias Bostrom, MD, is Residency Program Director and Academic Director of Orthopaedics at Hospital for Special Surgery and Professor of Orthopaedic Surgery, Weill Cornell Medical College, Helen Hayes Hospital; Charles S. Day, MD, MBA, is Rabkin Fellow in Medical Education, Associate Professor of Orthopedic Surgery at Harvard Medical School, and Chief/Program Director of Hand and Upper Extremity Surgery at Beth Israel Deaconess Medical Center; Steven L. Frick, MD, is Chairman of Orthopedic Surgery at Nemours Children’s Hospital and Professor of Orthopedic Surgery at the University of Central Florida College of Medicine; William Hopkinson, MD, is Professor, Vice-Chair, and Program Director of Orthopaedic Surgery & Rehabilitation at Loyola University Stritch School of Medicine; Shepard Hurwitz, MD, is Executive Director of the American Board of Orthopaedic Surgery and Professor of Orthopaedics at the University of North Carolina; Keith Kenter, MD, is Director of the Orthopaedic Surgery Residency Program, Associate Professor of Orthopaedic Surgery, and Associate Professor of Physical Medicine and Rehabilitation at the University of Cincinnati College of Medicine; John S. Kirkpatrick, MD, is Professor and Chair of Orthopaedic Surgery and Rehabilitation and Program Director of Orthopaedic Surgery Residency at the University of Florida College of Medicine; J. L. Marsh, MD, is Program Director of Residency Training Program and Professor and Carroll B. Larson Chair of Orthopaedics and Rehabilitation at the University of Iowa; Anand M. Murthi, MD, is Chief of Shoulder and Elbow Surgery and Fellowship Director at MedStar Union Memorial Hospital; Lisa A. Taitsman, MD, MPH, is Associate Professor of Orthopaedics and Sports Medicine at the University of Washington; Brian C. Toolan, MD, is Associate Professor of Surgery and Director of the Residency Program of Orthopaedic Surgery at the University of Chicago Medicine; Kristy Weber, MD, is Virginia & William Percy Professor of Orthopaedic Surgery, Division Chief of Orthopaedic Oncology, and Director of the Sarcoma Center at Johns Hopkins School of Medicine; Rick W. Wright, MD, is Dr Asa C. Dorothy W. Jones Professor of Orthopaedic Surgery, Residency Program Director, and Co-Chief of Sports Medicine at Washington University School of Medicine; Pamela L. Derstine, PhD, MHPE, is Executive Director of the Review Committees for Colon and Rectal Surgery, Neurological Surgery, Orthopaedic Surgery, and Otolaryngology at the Accreditation Council for Graduate Medical Education; and Laura Edgar, EdD, CAE, is Senior Associate Director of Outcome Assessment at the Accreditation Council for Graduate Medical Education.

BACKGROUNDFailure to treat an injury of the syndesmosis after an ankle fracture can lead to a poor functional outcome and posttraumatic arthritis. The results after reconstruction of an ankle with an incongruous mortise, chronic diastasis of the syndesmosis, and arthritis remain unknown. The purpose of the present study was to review the radiographic and clinical results of salvaging this condition through reduction and arthrodesis of the distal tibiofibular articulation.METHODSTen patients (mean age, fifty-four years) with chronic syndesmotic instability who underwent salvage by a single surgeon were evaluated retrospectively. Five parameters of mortise and syndesmotic alignment were measured on weight-bearing radiographs that were made preoperatively and at the time of the latest follow-up. The extent of arthritis in the ankle was graded with use of an established classification system. Clinical rating scores that were recorded preoperatively and at the time of the latest follow-up were culled from the medical records and were compared. Each patient's stated satisfaction with the operation and willingness to undergo the operation again were retrieved from the medical records.RESULTSAfter a mean duration of follow-up of forty-one months (minimum, two years), the medial clear space, talocrural angle, and talar tilt had improved. No ankle demonstrated progression of arthritis on the basis of the radiographic grade. The clinical rating score improved significantly because of improvements in the pain, activity, maximum walking distance, and gait subscales. Two patients had a total of three additional procedures. Both had prominent implants removed, and one subsequently underwent an ankle arthroscopy. All patients reported satisfaction with and a willingness to undergo the procedure again. At the time of the latest follow-up, no patient had undergone an ankle arthrodesis.CONCLUSIONSThe significant improvements in the radiographic and functional measures of outcome that were observed in this small cohort suggest that chronic syndesmotic instability after ankle fracture can be salvaged with reduction and arthrodesis of the distal tibiofibular articulation. Furthermore, the reconstruction of an incongruous and arthritic ankle is an alternative to and may postpone the subsequent need for ankle arthrodesis or arthroplasty.

Background. This study compared the effects of lateral column lengthening and medial translational calcaneal osteotomy on pedal realignment and degeneration of adjacent hindfoot joints noted on radiographs. Methods: Forty patients who had either a lateral column lengthening (25 feet) or calcaneal osteotomy (17 feet) to reconstruct a flatfoot were retrospectively reviewed as two groups. Six parameters of foot alignment were measured from weightbearing preoperative, early postoperative, and latest followup radiographs. The magnitude of realignment achieved initially and preserved at latest followup, was determined for each group. The talonavicular and subtalar joints were graded for radiographic evidence of arthritis before the reconstruction and at latest followup. Demographic information, complication rate, and reoperation associated with each group also were determined by chart review. Results: The group that received a lateral column lengthening demonstrated a greater initial realignment than the group treated with a calcaneal osteotomy. The lengthening group also demonstrated greater realignment than the osteotomized group when they were compared at their respective latest followup. The lengthening group had a higher number of adjacent joints with progression of arthritis. The rate of nonunion was higher with a lateral column lengthening; however, the rate of reoperation after an osteotomy was more than twice that observed after a lateral column lengthening. Conclusions: The lateral column lengthening group achieved greater realignment initially and maintained correction better over time than the calcaneal osteotomy group while having a lower reoperation rate despite a higher incidence of nonunion and radiographic progression of adjacent joint arthritis.

In 1934, Paul W. Lapidus published his experience with an operation for the correction of hallux valgus that would later bear his name.10 He did not claim the originality of this operation and readily acknowledged many other surgeons had already reported similar approaches for hallux valgus. With this manuscript, Lapidus intended “to stress the mechanical importance of the metatarsus primus varus, as one of the most frequent and most prominent factors of the hallux valgus deformity.” He described an operation composed of an arthrodesis of the first tarsometatarsal joint, the creation of a bony bridge between the bases of the first and second metatarsals and a distal soft-tissue release and repair similar to the Silver procedure that effectively corrected an atavistic “square foot” that he believed had a congenital predisposition toward hallux valgus. He emphasized the importance of resecting bone only from the lateral portion of the joint while denuding it of its articular cartilage to obtain acceptable correction of the deformity and a condition favorable for fusion. Lapidus refined his indications and modified his operative technique over his career and reported these changes in two subsequent publications.11,12 Over time he concluded that only the subset of the patients with hallux valgus who manifested a fixed metatarsus primus varus and an intermetatarsal angle larger than 15 (later revised to larger than 10 to 12) degrees required more than a distal softtissue procedure. He reported his technique of obtaining an anteroposterior radiograph with the forefoot tightly bandaged to determine the mobility of the first tarsometatarsal joint. He found that leaving the cortical bone chips he had osteotomized from the first and second metatarsals and

Orthobiologics is an ill-defined term that may be described as the clinical application of biologically derived materials engineered to promote the repair or regeneration of musculoskeletal tissue. The initial focus of research in orthobiologics was to develop materials capable of promoting the formation of bone to heal arthrodeses, fractures, nonunions of fractures, and to repair skeletal defects arising from traumatic injuries or tumors. The materials resulting from this research possessed varying degrees of osteoconductive and osteoinductive activity that, when placed in the local environment, enhanced osseous healing. Current research seeks to identify the molecular and cellular constituents of osseous healing and to acquire the ability to manipulate their numerous interactions to gain direct control over the pathways of bone formation. This review summarizes the scientific and clinical information known about the various orthobiologic materials currently available for therapeutic use. Bone morphogenetic proteins and the emerging technology behind orthopaedic gene therapy also are discussed. The purpose of this review is to update the orthopaedic clinician on the current literature guiding the ever-expanding application of orthobiological materials and technologies to patients with orthopaedic injuries and diseases.

Background: A flatfoot deformity alters the contact characteristics of the ankle joint, shifting the location of articulation posterolaterally, increasing pressure, and decreasing the contact area within the ankle. These changes may explain the pattern of articular degeneration and subsequent angulation observed in a long-standing adult acquired flatfoot. Corrective orthoses and surgical reconstruction have been used to realign pes planovalgus feet, but the effects of these treatments on tibiotalar contact characteristics are unknown. We hypothesized that realignment of a flatfoot with either corrective orthosis or surgical reconstruction would restore the contact characteristics of the ankle to the intact state. Methods: The mean value of the contact area, contact pressure, peak contact pressure, and the relative locations of the global contact area and peak pressure within the ankle joint were determined from imprints created on pressure sensitive film for a series of cadaver lower limbs subjected to a weightbearing load in simulated midstance phase of gait. Each limb was loaded sequentially under four conditions: intact, flatfoot, flatfoot realigned with UCBL orthosis, and flatfoot realigned with a medial translational osteotomy of the calcaneus. Results: The use of the UCBL orthosis and calcaneal osteotomy altered the contact characteristics of the ankle when compared with the flatfoot condition. Both interventions significantly decreased the mean global contact pressure from the flatfoot value, with the orthosis, demonstrating a significantly greater correction than the osteotomy. The orthosis also significantly reduced the peak contact pressure from the flatfoot value. Both interventions significantly corrected the lateral shift of the center of the peak contact pressure from the flatfoot value. The shift in the center of the global contact area approached significance when the orthosis was compared with the flatfoot. Conclusions: The changes observed in the magnitude and location of the mean and peak pressures indicate that the UCBL orthosis and calcaneal osteotomy altered hindfoot alignment to significantly influence tibiotalar contact characteristics. The results further suggest that the UCBL orthosis corrected ankle malalignment better than the calcaneal osteotomy in an adult acquired flatfoot. This study provides biomechanical data to support the clinical impression that realignment of the hindfoot corrects the pathologic tibiotalar contact characteristics associated with an adult acquired flatfoot. The results support the conclusion that the clinical management of a pes planovalgus foot with a UCBL orthosis or a medial translational osteotomy of the calcaneus may avert the onset of pantalar disease seen with late-stage posterior tibial tendon dysfunction.

Background: This investigation reviewed the clinical and radiographic results of a biplanar opening-closing wedge osteotomy of the midfoot to revise failed triple arthrodeses with severe rocker-bottom deformity. Five cases were reviewed to determine if this osteotomy corrects the rocker-bottom deformity, improves function and provides satisfaction to the patient. Methods: American Orthopaedic Foot and Ankle Society (AOFAS) clinical ratings scores obtained before and after the procedure were compared to assess the functional outcome. The patients' satisfaction with their results of surgery was also determined. Three parameters of foot alignment were measured from preoperative and postoperative anteroposterior and lateral weightbearing radiographs to assess the correction of the rocker-bottom deformity and the effect of the osteotomy on valgus tilting of the talus was evaluated with weightbearing views of the ankle. Results: All clinical and radiographic measures of outcome significantly improved at a mean follow-up of 18 months (range, 13-32 months). The mean clinical rating score increased from 33 +/- 14 points (range, 14-49 points) to 70 +/- 11 points (range, 62-87 points) after the surgery (p less than or equal to.05). Every patient was satisfied with the result and would repeat the procedure under the same circumstances. All four measures of foot and ankle alignment demonstrated significant correction after surgery. Conclusions: The osteotomy effectively realigned the rocker-bottom deformity. The procedure normalized the angular relationships of the foot by correction of the abduction and dorsiflexion deformities of the midfoot and vaigus deformity of the hindfoot. The reduction in pain, increased functional capacity, and ability to wear conventional shoes, achieved without any major complication, account for the improved clinical rating scores and high rate of the satisfaction observed with this procedure.

Background: Hallux valgus has been reported to recur after surgical correction in patients subsequently diagnosed with hypermobility of the first ray, pronation of the foot, and pes planovalgus. An objective means of assessing the foot for these deformities preoperatively may avert a poor outcome. This investigation evaluated the efficacy of full-length weightbearing radiographs to recognize associated deformities in patients with hallux valgus before surgery. Methods: This study compared five parameters from anteroposterior and four parameters from lateral weightbearing pedal radiographs of patients with moderate to severe hallux valgus to a control group to identify differences in the alignment of the midfoot and the first metatarsal-medial cuneiform joint. An examination for clinical evidence of hypermobility was also performed on both groups. Results: The hallux valgus group demonstrated increased abduction and dorsiflexion of the midfoot. The mean talonavicular coverage angle and lateral talo-first metatarsal angle of this group was greater than the mean values for the controls. Radiographic evaluation also revealed differences in the alignment of the first metatarsal-medial cuneiform joint in the sagittal plane. The hallux valgus group possessed a mean of 2 mm of dorsal translation and 2° of dorsiflexion at this joint compared to the controls. Conclusions: Weightbearing radiographs permit the recognition of associated malalignments of the foot in patients with hallux valgus. The comparisons performed in this study identified deformities consistent with pes planovalgus and hypermobility of the first ray in patients with moderate to severe hallux valgus. The results of our study support a recommendation for a thorough evaluation of full-length, biplanar weightbearing radiographs via the measurement of midfoot and first ray alignment for concomitant deformities of the foot in patients with hallux valgus.

The successful salvage of a failed reconstruction for adult acquired flat foot deformity requires a thorough assessment of the alignment, healing, and function of the entire foot. The pain that is experienced by the patient often emanates from multiple sources. Once identified, the plan of treatment must provide an integrated and comprehensive approach to resolve the origins of pain to restore durable function to the foot. Often, these goals may be achieved through the use of orthotics, physical therapy, and other nonoperative means. Additional or revision surgical procedures may be necessary to complete or correct the previous attempts to reconstruct the foot.

Arthrodesis and realignment of complex deformities of the midfoot requires thorough preoperative evaluation, exacting intraoperative technique, and vigilant postoperative management to achieve a successful functional outcome. An appreciation of the bony and soft-tissue factors contributing to the deformity facilitates a satisfactory functional outcome. Stable fixation in multiple planes with judicious bone grafting achieves union with the most complex deformities and severe bone loss.

The use of retrospectively acquired preoperative AOFAS rating scores in clinical research to assess the outcomes of elective foot and ankle surgery has not been validated. The data obtained utilizing this methodology may misrepresent the results and lead to spurious conclusions. This investigation compared preoperative AOFAS Ankle-Hindfoot scores obtained before and after surgery from patients who had undergone elective surgery to determine if retrospectively acquired scores match those collected prospectively.Only two out of 47 patients (4%) recalled identical AOFAS scores. The mean difference between the preoperative scores (preoperative score obtained after surgery minus preoperative score obtained before surgery) was -5.3 points. Fifteen patients (32%) had preoperative scores that differed by 20 points or more. Kappa statistics found little agreement among the five elements that comprised the two preoperative scores when responses obtained before and after surgery were compared to one another. The results suggest that preoperative clinical rating scores obtained after elective surgery are a poor predictor of the patient's preoperative condition and that studies which employ retrospectively acquired preoperative AOFAS clinical rating scores may overestimate the benefit of surgery.

Summary: Successful treatment of flexible, pediatric pes planovalgus by lengthening the lateral column of the foot with an interpositional bone graft has fostered the use of calcaneo-cuboid distraction arthrodesis for the adult flatfoot. Correction of the deformities by selective arthrodesis of the calcaneo-cuboid joint while preserving the accommodative motion of the hindfoot has made calcaneo-cuboid distraction arthrodesis a promising alternative to triple arthrodesis. The preoperative assessment of pes planovalgus and the specific indications for use of calcaneo-cuboid distraction arthrodesis are discussed in detail. The surgical technique for the procedure and its postoperative management are outlined.

The results of medial column stabilization, lateral column lengthening, and combined medial and lateral procedures were reviewed in the treatment of adult acquired flatfoot secondary to posterior tibialis tendon insufficiency. All bony procedures were accompanied by transfer of the flexor digitorum longus tendon to the medial cuneiform or stump of the posterior tibialis tendon and tendoachilles lengthening or gastrocnemius recession. Medial column fusion was performed for naviculocuneiform and cuneiform first metatarsal sag; lateral column lengthening was performed for calcaneovalgus deformity with a flat pitch angle; and combined procedures were performed for complex combined deformities. At 1 to 4 year followup of 65 feet, 88% of the feet that had lateral column lengthening, 80% that had medial column stabilization, and 88% of the feet that had medial and lateral procedures had a decrease in pain or were pain free. The lateral talar first metatarsal angle improved by 16 degrees in the patients in the lateral column lengthening group, 20 degrees in the patients in the medial column stabilization group, and 24 degrees in the patients in the combined medial and lateral procedures group. The anteroposterior talonavicular coverage angle improved by 14 degrees in the patients in the lateral column lengthening group, 10 degrees in the patients in the medial column stabilization group, and 14 degrees in the patients in the combined medial and lateral procedures group. These techniques effectively correct deformity without disrupting the essential joints of the hindfoot and midfoot.

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 non-union 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.

Numerous reconstructive procedures have been used to address the manifestations of rheumatoid arthritis in the foot and ankle. Clinical studies have documented that these procedures relieve pain, however they often sacrifice motion essential to the normal function of the foot. In the forefoot, metatarsophalangeal joint resection arthroplasty shortens the lever arm of the foot, defunctions the toes, and disables the plantar plate and fat pad. Arthrodesis of the ankle and hindfoot alters gait and the effective transmission of weight-bearing stresses through the foot and ankle. These ablative procedures may provoke the deterioration of adjacent joints and may cripple the long-term function of the lower extremity. The introduction of reconstructive procedures designed to preserve motion in joints essential to function and the recognition and treatment of muscle imbalances associated with bone and joint deformities are recent advances in the surgical management of the rheumatoid foot and ankle.