The result of treatmen transverse flattened flat feet on the AOFAS scale difeerent surgical methods in Izhevsk

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Izhevsk State Medical Academy of the Ministry of Health of the Russian Federation

The result of treatmen transverse flattened flat feet on the aofas scale difeerent surgical methods in Izhevsk

Zlobin A.V.

Post-graduate Student of the Department of Traumatology, Orthopedics and Military Surgery

Fedorov V.G.

Holder of Habilitation degree in Medicine, Associate Professor, Head of the Department of Traumatology, Orthopedics and Military Surgery

Russian Federation

Summary

Relevance. Transverse flattened flat feet takes up to 80% of feet deformities, and more than 400 methods for its correction have been developed. The most common in Izhevsk are Shede, Scarf + Akin and the method of Fedorov VG.

Aim. To evaluate the results of these surgery tactics on the AOFAS scale.

Materials and methods. The study involved 50 patients, 48 women and 2 men operated in Republican Clinical Hospital №1 at the Ministry of Health of Udmurtia, the FBHI of Udmurt Republic 'City Clinical Hospital at the Ministry of Health of Udmurtia №6', the FBHI of Udmurt Republic 'City Clinical Hospital at the Ministry of Health of Udmurtia №3' in the period from 2015 to 2016.

Results. Evaluation of treatment results on the AOFAS scale for a period of one year after the operation: Shede - 65 points, Scarf + Akin - 80 points. While Fedorov's technique with patent number 2517768 is 95 points.

Conclusion. Due to the combination of the above listed classic techniques plus arthrodesis between the medial cuneiform bone and the base of the first and second instep bones, it is possible to achieve the best results.

Key words: transvesrse flattened flat feet, valgus deformation of the great toe, sesamoid bones.

Relevance

Considering the pathogenesis of transverse flattened flat feet from the position of biomechanics the primary component of pathogenesis is the spread between the first and second metatarsal bones among themselves, which reveals in the gradual increase in the angle between the first and second instep bones (M1M2), which is normally 8 degrees [2].. At a later stage the head of the first metatarsal bone in the process of sliding along the metatarsosesamoid joints is pronoted [3] with the formation of the hallux valgus set of symptoms: the valgus of the great toe (hallux valgus); the subluxation of the sesamoid bones, or to be more precise, the disruption of the correct proportion in the metatarsosesamoid joint [4,5], the subluxation of the base of the proximal phalanx of the great toe, the hyperextension of the medial collateral ligament of the first metatarsophalangeal joint, the pronation setting of the first metatarsal bone [6]. The newly revealed aspects of pathogenesis are the following: an increase in the distance between the bases of the first and second metatarsal bones, and not only the change in the angle between them; the spread between the intermediate cuneiform bone and medial cuneiform bone due to the inside shift of the medial cuneiform bone with the formation of an angle of 4.5 ± 1.5 degrees [7,8].

Aim

To evaluate the results of the most common surgical approaches of correction of transversely flattened flat foot in Izhevsk from the point of view of existing ideas about the pathogenesis of the transverse- flattened deformation of the forefoot in terms of newly revealed components of biomechanogenesis in the general pathogenesis of the pathology under study with subsequent rethinking of surgical treatment tactics of this disease [4,5,9].

To evaluate the short-term results of the application of classical tactics of surgical treatment and the tactics developed and applied by us [10], considering all components of pathogenesis.

Materials and methods. The analysis of the results of treatment of patients who underwent the surgery of plasty of the forefoot for transverse flatfoot in the orthopedic department in Republican Clinical Hospital №1 at the Ministry of Health of Udmurtia, the FBHI of Udmurt Republic 'City Clinical Hospital at the Ministry of Health of Udmurtia №6', the FBHI of Udmurt Republic 'City Clinical Hospital at the Ministry of Health of Udmurtia №3', during last 12 months was carried out. flattened feet surgical biomechanics

The study involved 50 people, 48 women and 2 men between the ages of 28 and 76 who considered themselves sick for 2 to 25 years. The results of the research were studied at the period of 3, 6 and 12 months after the surgery.

The following methods of the surgical service were made:

1) surgeries aimed at abolition of one component of the deformation (surgery by Shede, McBride), - 20 cases (40%);

2) surgeries aimed at abolition of two components of the deformation (SCARF, Akin), - 20 cases (40%);

3) surgeries aimed at abolition of three and more components of the transverse flattened flat feet (the combination of the above listed classic techniques plus arthrodesis between the medial cuneform bone and the base of the first and second metatarsal bones), - 10 cases (20%)

In view of the new biomechanogenesis components revealed by us, an X-ray pictures analysis was carried out as well as analysis of computer tomography (CT) results before and after surgery (10 CT), and an evaluation of the clinical and functional result from the Kitaoka score of the American Orthopedic Foot and Ankle Association (AOFAS) [ 11].

According to the AOFAS scale the following aspects are assessed: pain syndrome, range of motions and stability of metatarsal and phalangeal and interpha- langeal joints, foot support ability on a flat surface.

The maximum for the pain severity is 40 points, while 45 points are allocated for the function evaluation and 15 points are for the foot support ability. The reference result of treatment can be estimated at 100 points, which will correspond to the absolute absence of pain, the full range of motions and stability in the interpha- langeal and metatarsophalangeal joints, good foot support and no restrictions in wearing shoes by the patient. The result of treatment using the AOFAS scale is estimated as following: excellent is 95-100 points, good is 75-94, satisfactory is 51-74 and bad is 50 and less points.

Pic. 1. Scale of evaluation of the results of treatment of deformity of the forefoot AOFAS.

Study Results

The primary component of pathogenesis in relation to biomechanics is the spread between the first and second metatarsal bones among themselves, which reveals in the gradual increase in the angle between them (M1M2), which is normally 8 degrees. Due to anatomic features, only the first metatarsal bone deviates, moving in the medial direction, as the second metatarsal bone is unable to move the metatarsal foot bones laterally. The beginning of the separation of the first and second rays is the starting point of the development of the transverse-flattening deformation of the forefoot. As the angle M1M2 increases, the tension of the tendon of the adductor muscle of great toe increases too, and this muscle tries to leave in position the sesamoid bones and the base of the proximal phalanx of the great toe. At a later stage the head of the first metatarsal bone in the process of sliding along the met- atarsosesamoid joints is pronoted, which leads to a sharp increase in the load on the first metatarsal-phalanx and medial-cuneo-metatarsal joints. All while m. adductor hallucis, the attachment point of which is the lateral sesamoid bone and the base of the proximal phalanx of the great toe, shifts the base of the proximal phalanx of the 1st finger laterally, forming an open angle to the outside in the first metatarsophalangeal joint. The result of the multidirectional movement of the head of the first metatarsal bone shifting to the inside and the base of the proximal phalanx of the great toe moving outside is the subluxation of the base of the proximal phalanx of the great toe and the formation of the set of symptoms hallux valgus:

* the valgus of the great toe (hallux valgus),

* sublaxation of the sesamoid bones, the sublux

ation of the base of the proximal phalanx of the great toe, the hyperextension of the medial collateral ligament of the first metatarsophalangeal joint, the pronation setting of the first metatarsal bone [6]. There are 3 degrees [5] (Pic. 2). of subluxation of the sesamoid bones, or to be more precise, solutions of contiguity in the metatarsal joint: 1st degree is subluxation of the sesamoid bones, 2nd degree is dislocation of the sesamoid bones, III degree is dislocation with localization of both sesamoid bones in the 1st intertarsal space.

Pic. 2. Helical CT of the forefoot before surgery II degree according to Mikhnovich [5] and after surgery,

In studies of CT and X-ray pictures, we observed the formation of a cuneal fissure between the bases of Ml and M2 with an increase in the angle M1M2. For every tenth case, a deviation to the inside of the medial sphenoid bone was noted, which resulted in an increase in the distance between the distal segments of the medial (os cuneiforme medialiale-Cm) and the intermediate (os cuneiforme intermedium-Ci) cuneiform bones of the foot with the formation of an angle between them (CmCi) 4.5 ± 1.5 degrees. With a distance of 10 cm from the top of this angle toward the head of the first metatarsal bone, the distance between the sides of the angle increases significantly and, according to our calculations, increases the first web of toes by 6 and more millimeters [9].

Pic. 3. Angle CmCi

Taking into account the aspects revealed by us, the pathogenesis of hallux valgus should include:

• increasing the distance between the bases of the first and second metatarsal bones, and not only changing the angle between them;

• discrepancy between the intermediate cuneiform and medial cuneiform bones due to deviation of the medial cuneiform bone to the inside with the formation of an angle of 4.5 ± 1.5 degrees (Pic. 3).

The following results are obtained on the AOFAS scoring scale:

- the use of classical surgery tactics (Shade, McBride) - 65 points,

- combination of methods Scarf + Akin - 80 points;

- - combination of the above classic techniques plus arthrodesis between the cuneiform and base of the first and second metatarsal bones (Patent RF Patent of the Russian Federation for invention No. 2517768) [10] - 95 points. (Pic. 4).

Pic. 4. Treatment Results on the AOFAS scale

These components should be included in the revealed by us data of pathogenesis hallux valgus.

The evaluation of treatment results on the AOFAS scale gave the following facts. The use of classical surgery tactics leads to satisfactory and good results, while the combination of the above listed classic techniques plus arthrodesis between the medial cuneiform bone and the base of the first and second metatarsal bones leads to good and excellent results.

The conclusion

After evaluating the results of treatment results on the AOFAS scale, we came to the conclusion that the use of classical surgery tactics leads to satisfactory and good results, while the combination of the above listed classical techniques plus arthrodesis between the medial cuneiform bone and the base of the first metatarsal bone, in the absence of significant rotation of I metatarsal bone and large angle in the corner of CmCi, leads to good and excellent results.

When choosing the surgery tactics of treatment of the transverse flattening deformation of the foot, it is rational to take into account the new components revealed by us in the pathogenesis of the origin of this pathology.

It is advisable to include in the preparation for surgery plan helical computer tomography of the forefoot and midfoot.

References

1. Mironov S.P., Kotel'nikov G.P. Ortopediya. Nacional'noe rukovodstvo. GEHOTAR - Media., 2013g.-s. 812

2. YAremenko D.A. Diagnostika i klassifikaciya staticheskih deformacii stop. Ortopediya, travma- tologiya i protezirovanie. 1985. №11. C. 59-67.

3. Il'minskij A.V. Hirurgicheskoe lechenie poperechnoj rasplastannosti stopy i val'gusnoj defor- macii pervogo pal'ca: avtoref. dis. ...kand. med. nauk. Kursk, 2009. 18 s.

4. Kardanov A.A. Hirurgicheskaya korrekciya deformacii stopy. Moskva, 2016. S. 20.

5. Mihnovich E.R. Hirurgicheskoe lechenie poperechnogo ploskostopiya i val'gusnoj deformacii pervogo pal'ca: avtoreferat dis. ... kand. med. nauk. Minsk, 1997. S.7.

6. Karandin A.S. Hirurgicheskaya korrekciya val'gusnogo otkloneniya pervogo pal'ca giperehlastich- noj stopy : avtoref dis. ... kand. med. nauk: 14.01.15. - M., 2016. - S. 28.

7. Fedorov V.G., CHernov A.V. Metody lech- eniya pacientov s poperechnym ploskostopiem v pervoj RKB g. Izhevska. Zdorov'e, demografiya, ehkologiya finno-ugorskih narodov. 2013. № 4. S.73-75.

8. Fedorov V.G., Zlobin A.V. Vnov' vyyavlen- nye pozicii v mekhanizme patogeneza formirovaniya poperechno-rasplastannoj deformacii stopy. Pervyj s"ezd travmatologov-ortopedov CFO. Aktual'nye vo- prosy otechestvennoj travmatologii i ortopedii, 14-15 sentyabrya 2017 goda. Smolensk, 2017. S. 289-291.

9. Fedorov V.G. Novoe v biomekhanogeneze formirovaniya hallux valgus poperechno-rasplastannoj deformacii stopy i principy operativnogo lecheniya s uchetom patogeneza. Sovremennye problemy nauki i obrazovaniya. - 2017. - № 2.

10. Patent RF na izobretenie № 2517768 Fedorov V.G., CHernov A.V. Sposob korrekcii poperechnogo ploskostopiya s uchetom patogeneza. Byul. № 15. 27.05.2014.

11. Kitaoka, H.B., et al., Clinical Rating Systems for the Ankle-Hindfoot, Midfoot, Hallux, and Lesser Toes//Foot Ankle Int, 1994. 15(7): с. 349-353.

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