The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 92, Issue 1

Scientific Articles | January 01, 2010

Plantar Pressures in Patients with and without Lateral Foot Pain After Lateral Column Lengthening

Scott Jacob Ellis, MD¹; Joseph C. Yu, BS¹; A. Holly Johnson, MD²; Andrew Elliott, MD¹; Martin O'Malley, MD¹; Jonathan Deland, MD¹

¹ Department of Foot and Ankle Surgery, The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for S.J. Ellis: elliss@hss.edu
² Pro Sports, 330 Mount Auburn Street, Suite 505, Cambridge, MA 02138

View Disclosures and Other Information

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

A commentary by Saul G. Trevino, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.

Investigation performed at The Hospital for Special Surgery, New York, NY

J Bone Joint Surg Am, 2010 Jan 01;92(1):81-91. doi: 10.2106/JBJS.H.01057

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Abstract

Background:

Lateral column lengthening, a commonly used adjuvant for the reconstruction of adult flatfoot deformity, can lead to postoperative complaints of lateral plantar pain or discomfort. We hypothesized that patients with such symptoms would have increased lateral plantar pressures when compared with matched controls without these symptoms.

Methods:

Ten subjects who had undergone lateral column lengthening and were experiencing pain or discomfort in the plantar-lateral aspect of the foot were selected. Controls who had undergone lateral column lengthening but who were not experiencing such symptoms were matched for age, sex, accessory reconstructive procedures, and time from surgery. At the time of the present study, the patients had been followed for at least two years after the reconstruction and had had removal of hardware. Radiographs of each foot were assessed before and after surgery. The patients completed the Short Form-36 (SF-36) and Foot and Ankle Outcome Score surveys, and standing plantar pressure measurements were obtained. Average mean pressure, peak pressure, and maximum force were assessed at twelve anatomic regions and the two groups were compared.

Results:

There were no significant preoperative differences between the two groups in terms of radiographic parameters. Patients with pain had significantly lower SF-36 Physical Health Summary scores (p < 0.05), SF-36 Physical Function Subscale scores (p < 0.05), and average Foot and Ankle Outcome Scores (p < 0.05). Patients with pain had significantly higher lateral midfoot average mean pressure (p < 0.05), peak pressure (p < 0.05), and maximum force (p < 0.05). No differences were found in the hindfoot or forefoot regions.

Conclusions:

Patients who have undergone lateral column lengthening and who experience lateral plantar pain have increased plantar pressure values in the lateral aspect of the midfoot. The increased pressures in this area cannot be accounted for solely by radiographic or demographic factors.

Level of Evidence:

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Posterior tibial tendon insufficiency, also called adult acquired flatfoot deformity, can lead to disabling pain and deformity. Degenerative change of the tendon and ligaments supporting the medial longitudinal arch can lead to substantial arch collapse, hindfoot valgus with or without lateral impingement, and possibly forefoot abduction. Stage-II insufficiency, as described by Johnson and Strom¹, is arguably the most complex in terms of its surgical treatment. These flexible deformities present the surgeon with many potential interventions. Careful planning is required². In general, combinations of soft-tissue transfers and realignment osteotomies are used to realign the foot and restore its dynamic function^3-12.

Of particular interest to us is the treatment of stage-II deformity with lateral column lengthening, a procedure performed by many foot and ankle surgeons². Although the mechanism is not entirely understood, lateral column lengthening helps to restore the medial longitudinal arch and decreases abduction of the midfoot at the talonavicular joint, which can be associated with the flatfoot deformity¹². At our institution, reconstruction of the flexible flatfoot includes an Evans-type lateral column lengthening in patients demonstrating severe flexible deformities with abduction at the talonavicular joint¹³. Such abduction is manifested by considerable pronation through the proximal part of the midfoot on standing examination with the arch relaxed and by >40% uncoverage of the talar head on an anteroposterior weight-bearing radiograph made directly over the foot with the arch relaxed¹⁴.

Unfortunately, patients can have lateral plantar discomfort or pain after lateral column lengthening^11,15. Although not mentioned in many reports, the prevalence ranged from 8%¹¹ to 45%¹⁶ in two series that described such symptoms, with the higher percentage coming from a study that included any degree of lateral discomfort. Studies involving cadaver models have demonstrated increased lateral plantar pressures after lateral column lengthening¹⁷. A concomitant medializing calcaneal osteotomy, if performed with >1 cm of superior translation of the calcaneal tuber, may exacerbate these changes^18-20. In children undergoing lateral column lengthening, investigators have found a lateral shift in the center-of-pressure excursion index²¹ and other increased lateral plantar pressure parameters²². Fifth metatarsal stress fractures have been reported after lateral column lengthening as well²³.

Guidelines for estimating the amount of lateral column lengthening that is needed intraoperatively are not precise and are, in fact, somewhat lacking in the literature. The degree of lengthening depends on the amount of foot deformity and the nature of the soft tissues in a given patient's foot. The senior author (J.D.) determines the lengthening that is required intraoperatively with trial wedges based on the correction needed to bring the talonavicular joint out of abduction as seen with use of simulated weight-bearing fluoroscopy while retaining eversion in the midfoot.

One way to assess the outcomes of the surgical treatment of acquired flatfoot with lateral column lengthening is with the measurement of plantar foot pressures to determine how evenly pressure is distributed across the plantar aspect of the foot after reconstruction. Waiting at least one year after surgery allows the foot to reach a steady state of weight-bearing before performing such an evaluation.

To our knowledge, no study has assessed plantar pressures in adult patients with postoperative lateral plantar foot pain following flatfoot reconstruction with lateral column lengthening. The goal of the present study was to compare plantar pressures and radiographic findings in patients with and without pain after reconstruction. We hypothesized that patients with pain or discomfort as described above would have increased lateral plantar pressures in comparison with controls without pain.

Materials and Methods

Patient Selection

This prognostic, case-control study was carried out by conducting a computerized database search in order to identify patients who had undergone lateral column lengthening as part of an adult acquired flatfoot deformity reconstruction procedure performed by the three senior surgeons (A.E., M.O., J.D.) at the investigators’ institution. A sample of convenience consisting of ten individuals who had undergone reconstruction between October 2001 and August 2005 and who had lateral plantar pain that had persisted for a minimum of twenty-four months after surgery was selected. The inclusion criteria required the discomfort level to have reached a value of at least 5 on a visual analog scale for pain (with 0 corresponding with no pain and 10 corresponding with the worst pain ever). A single follow-up visit was arranged for each patient between December 2006 and February 2008. The exclusion criteria included pain in the region of the sinus tarsi, the lateral or dorsal aspect of the calcaneocuboid joint, or the dorsal aspect of the anterior part of the calcaneus. In order to exclude lateral hardware as a cause of discomfort, patients were selected only if they had undergone removal of all calcaneal implants prior to enrollment. Patients with isolated screws remaining after successful first tarsometatarsal fusion were not excluded, given that such hardware would be an unlikely cause of lateral plantar pain. Controls without pain who also had lateral column lengthening along with accessory procedures between May 2001 and December 2005 were matched individually on a subject-by-subject basis (Table I). The inclusion criteria for the controls required the discomfort level to have reached a value of no more than 2 on the visual analog pain scale. Secondary criteria for matching included time from surgery, age, and sex when possible. The control patients also presented for a single follow-up visit between August 2007 and February 2008. Graft length, specified in the operative report, was recorded for all patients except for two patients in the group without pain for whom such information was not available. All patients gave informed consent, and the study was approved by the institutional review board at our institution.

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TABLE I Demographic Data of Patients in the Pain Group and Matched Controls in the No-Pain Group

Pain Group						No-Pain Group
Case	Age (yr)	Sex	Lateral Column Lengthening (mm)	Duration of Follow-up (mo)	Procedures	Control	Age (yr)	Sex	Lateral Column Lengthening (mm)	Duration of Follow-up (mo)	Procedures
1	63	F	5.0	62.4	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft	1	55	F	NR*	79.5	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft
2	48	M	8.5	28.7	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus/flexor hallucis longus tenodesis, deltoid ligament repair, peroneal tenolysis	2	69	M	7.0	32.3	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus/flexor hallucis longus tenodesis, deltoid ligament repair, gastrocnemius recession
3	45	F	4.5	39.0	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, excision accessory navicular	3	62	F	5.0	32.8	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus/flexor hallucis longus tenodesis, second metatarsophalangeal release, second proximal interphalangeal resection
4	58	F	5.0	36.5	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, ostectomy excision accessory navicular/cuneiform	4	51	F	6.0	45.2	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft
5	55	M	10.0	30.3	Left posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion	5	51	M	6.0	26.0	Left posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, spring ligament repair, flexor digitorum longus/flexor hallucis longus tenodesis
6	64	M	6.0	26.6	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, flexor digitorum longus/flexor hallucis longus tenodesis, excision accessory navicular, deltoid ligament repair	6	48	M	NR*	32.5	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, flexor digitorum longus/flexor hallucis longus tenodesis, excision accessory navicular
7	58	F	8.5	24.0	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus/flexor hallucis longus tenodesis, gastrocnemius recession	7	47	F	7.0	46.9	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus transfer
8	68	F	6.0	61.7	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion	8	66	F	7.5	70.7	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion
9	45	F	9.5	39.9	Left posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, gastrocnemius recession	9	44	F	7.5	48.8	Left posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, gastrocnemius recession
10	45	F	5.0	54.3	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion	10	69	F	6.0	40.1	Right posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride
Median†	56.5 (45.8, 61.8)		6.0 (5.0, 8.5)	37.8 (29.1, 50.7)		Median†	53.0 (48.8, 65.0)		6.5 (6.0, 7.1)	42.7 (32.6, 48.3)

*NR = not recorded.
†The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses.

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TABLE I Demographic Data of Patients in the Pain Group and Matched Controls in the No-Pain Group

Pain Group						No-Pain Group
Case	Age (yr)	Sex	Lateral Column Lengthening (mm)	Duration of Follow-up (mo)	Procedures	Control	Age (yr)	Sex	Lateral Column Lengthening (mm)	Duration of Follow-up (mo)	Procedures
1	63	F	5.0	62.4	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft	1	55	F	NR*	79.5	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft
2	48	M	8.5	28.7	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus/flexor hallucis longus tenodesis, deltoid ligament repair, peroneal tenolysis	2	69	M	7.0	32.3	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus/flexor hallucis longus tenodesis, deltoid ligament repair, gastrocnemius recession
3	45	F	4.5	39.0	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, excision accessory navicular	3	62	F	5.0	32.8	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus/flexor hallucis longus tenodesis, second metatarsophalangeal release, second proximal interphalangeal resection
4	58	F	5.0	36.5	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, ostectomy excision accessory navicular/cuneiform	4	51	F	6.0	45.2	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft
5	55	M	10.0	30.3	Left posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion	5	51	M	6.0	26.0	Left posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, spring ligament repair, flexor digitorum longus/flexor hallucis longus tenodesis
6	64	M	6.0	26.6	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, flexor digitorum longus/flexor hallucis longus tenodesis, excision accessory navicular, deltoid ligament repair	6	48	M	NR*	32.5	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, flexor digitorum longus/flexor hallucis longus tenodesis, excision accessory navicular
7	58	F	8.5	24.0	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus/flexor hallucis longus tenodesis, gastrocnemius recession	7	47	F	7.0	46.9	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride, Akin osteotomy proximal phalanx, flexor digitorum longus transfer
8	68	F	6.0	61.7	Right posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion	8	66	F	7.5	70.7	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion
9	45	F	9.5	39.9	Left posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, gastrocnemius recession	9	44	F	7.5	48.8	Left posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, gastrocnemius recession
10	45	F	5.0	54.3	Left posterior tibial tendon repair, flexor digitorum longus transfer, spring ligament repair, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion	10	69	F	6.0	40.1	Right posterior tibial tendon repair, flexor digitorum longus transfer, medializing calcaneal osteotomy, lateral column lengthening graft size, iliac crest bone graft, first tarsometatarsal fusion, modified McBride
Median†	56.5 (45.8, 61.8)		6.0 (5.0, 8.5)	37.8 (29.1, 50.7)		Median†	53.0 (48.8, 65.0)		6.5 (6.0, 7.1)	42.7 (32.6, 48.3)

*NR = not recorded.
†The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses.

Lateral Column Lengthening Technique

Lateral column lengthening was performed after temporary fixation of both the medializing calcaneal osteotomy site and other medially based procedures such as a first tarsometatarsal fusion or a medial cuneiform osteotomy. An osteotomy of the anterior part of the calcaneus was made 15 mm proximal to and parallel to the calcaneocuboid joint, which was not stabilized prior to the osteotomy. Trial wedges were then placed in the osteotomy site to determine the amount of lengthening needed on the basis of fluoroscopic reduction of the talonavicular coverage. Overcorrection was prevented by avoiding excessive stiffness to manual eversion testing. A wedge of tricortical autogenous bone was taken from the ipsilateral iliac crest and was cut to exactly match the selected wedge, and permanent fixation was then performed. The flexor digitorum longus, harvested prior to all osseous procedures, was then fixed in a drill hole in the navicular. Deltoid ligament repair, in the few cases in which it was needed, was also performed at this time. The hindfoot was placed in neutral version, not inversion, for both the tendon transfer and the placement of the postoperative splint.

Subjective Evaluation

All data collection occurred during a single follow-up visit in the offices of the senior surgeons (A.E., M.O., J.D.). The validated Short Form-36 Health Survey (SF-36)^24,25 and the Foot and Ankle Outcome Score (FAOS) questionnaires^26,27 were administered to assess the patients’ subjective function. The SF-36 was used as a measure of general health. The FAOS was used to specifically assess foot and ankle function. The patients were asked to indicate the area of their discomfort on diagrams consisting of multiple views of the foot.

Radiographic Evaluation

Preoperative weight-bearing anteroposterior and lateral radiographs were available for six patients in the group with pain and six patients in the group without pain. Postoperative radiographs were made for all patients. Lateral radiographic parameters included the first talometatarsal angle, the length of the calcaneus, and the distance from the base of the fifth metatarsal to the medial cuneiform⁴. The anteroposterior talonavicular coverage angle was also assessed⁴. Preoperative and postoperative parameters along with the overall amount of correction were compared between groups. In addition, the amount of correction obtained within each group was assessed.

Plantar Pressure Assessment

All patients underwent postoperative plantar pressure measurements with use of an EMED-ST plantar pressure platform (Novel, Munich, Germany). This system utilizes a matrix array of force sensors with a resolution of four sensors/cm² and a sampling rate of 50 Hz. The plate was embedded into a large, flat wooden platform to ensure balanced footing. The patients were instructed to assume stance phase with the feet shoulder-width apart and the arms to the side, with the foot of interest placed on the center of the platform. Three trials were performed for thirty seconds each.

The plantar pressure profiles were then divided with use of the Novel "creation of masks" program into twelve regions: (1) great toe, (2) second toe, (3) third, fourth, and fifth toes combined, (4) first metatarsal, (5) second metatarsal, (6) third metatarsal, (7) fourth metatarsal, (8) fifth metatarsal, (9) medial aspect of midfoot, (10) lateral aspect of midfoot, (11) medial aspect of hindfoot, and (12) lateral aspect of hindfoot. In order to eliminate any error that may occur during the automasking process, postoperative radiographs were electronically resized and juxtaposed onto the automasked plantar pressure pictures (Fig. 1). Mask readjustment was performed as necessary. Average mean pressure (N/cm²), peak pressure (N/cm²), and maximum force (N) were assessed at each anatomic region. In order to ensure that increased parameters, when present, were not simply due to increased body weight, all plantar pressures were then normalized to body weight. Average mean pressure is determined by calculating the mean pressure in a particular anatomic region of interest at a specific frame in time and averaging this value over all of the frames in a given trial. Peak pressure and maximum force refer to the highest pressure and force, respectively, detected by any given sensor within an anatomic region of interest over all of the frames tested. Parameter ratios of the lateral aspect to the medial aspect of the hindfoot, the lateral aspect to the medial aspect of the midfoot, and the fifth metatarsal to the first metatarsal were calculated.

Fig. 1

Plantar pressure profile without masking (A), plantar profile with masking (B), and weight-bearing anteroposterior radiograph of the foot with superimposed mask (C) for a representative patient with postoperative lateral plantar foot discomfort (Case 6). The plantar profile demonstrates a focal area of increased pressure that maps to the lateral part of the midfoot. The radiograph suggests that this focus corresponds with load transmitted through the cuboid and the base of the fifth metatarsal.

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Statistical Analysis

Median, twenty-fifth percentile, and seventy-fifth percentile values were determined for all variables. The nonparametric Wilcoxon signed-rank test (two-tailed) was used to determine significant differences in the radiographic measurements, subjective scores, and all plantar pressure parameters between the groups with and without pain.

Because previous work has not assessed static, lateral plantar pressures in patients complaining of lateral plantar discomfort, an a priori power analysis was not possible. In order to determine the power of the study to detect clinically relevant differences in the primary outcome, a post hoc analysis was performed for the plantar pressure values. The threshold for sufficient power was set at 80%.

Source of Funding

We did not receive any outside funding or grants in support of our research.

Results

Demographics

The group with pain consisted of seven women and three men with a median age of 56.5 years who presented for follow-up at a median of 37.8 months (Table I). The group without pain consisted of seven women and three men with a median age of 53.0 years who presented for follow-up at a median of 42.7 months. There were no differences between the two groups with regard to the length of the graft (p = 0.86). The median weight in the group with pain was 94.8 kg (twenty-fifth percentile, 76.5 kg; seventy-fifth percentile, 105.5 kg), and the median weight in the group without pain was 81.7 kg (twenty-fifth percentile, 74.2 kg; seventy-fifth percentile, 83.7 kg).

Radiographic Parameters

The preoperative and postoperative radiographic parameters of the two groups were similar (Table II).

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TABLE II Radiographic Parameters in Pain and No-Pain Groups*

	Preoperative			Postoperative
Radiographic Parameter	Pain Group	No-Pain Group	P Value	Pain Group	No-Pain Group	P Value
Lateral
First talometatarsal angle (deg)	32.4 (28.4, 35.4)	18.5 (12.6, 24.9)	0.16	12.0 (2.7, 17.1)	4.1 (2.4, 9.6)	0.22
Length of calcaneus (cm)	8.6 (8.6, 8.8)	8.5 (8.3, 9.3)	0.49	8.1 (7.8, 8.8)	7.7 (7.6, 7.9)	0.13
Distance base of fifth metatarsal to medial cuneiform (cm)	0.6 (0.5, 1.0)	0.9 (0.7, 1.0)	0.59	1.6 (1.2, 2.0)	1.5 (1.4, 1.6)	0.91
Anteroposterior
Talonavicular coverage angle (deg)	31.9 (27.6, 40.4)	40.2 (37.7, 41.4)	0.70	15.2 (11.3, 24.7)	11.3 (1.6, 20.1)	0.30

*The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses. The Wilcoxon signed-rank two-tailed test was performed for all variables.

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TABLE II Radiographic Parameters in Pain and No-Pain Groups*

	Preoperative			Postoperative
Radiographic Parameter	Pain Group	No-Pain Group	P Value	Pain Group	No-Pain Group	P Value
Lateral
First talometatarsal angle (deg)	32.4 (28.4, 35.4)	18.5 (12.6, 24.9)	0.16	12.0 (2.7, 17.1)	4.1 (2.4, 9.6)	0.22
Length of calcaneus (cm)	8.6 (8.6, 8.8)	8.5 (8.3, 9.3)	0.49	8.1 (7.8, 8.8)	7.7 (7.6, 7.9)	0.13
Distance base of fifth metatarsal to medial cuneiform (cm)	0.6 (0.5, 1.0)	0.9 (0.7, 1.0)	0.59	1.6 (1.2, 2.0)	1.5 (1.4, 1.6)	0.91
Anteroposterior
Talonavicular coverage angle (deg)	31.9 (27.6, 40.4)	40.2 (37.7, 41.4)	0.70	15.2 (11.3, 24.7)	11.3 (1.6, 20.1)	0.30

*The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses. The Wilcoxon signed-rank two-tailed test was performed for all variables.

Subjective Scores

The SF-36 Physical Function Subscale (p < 0.05), SF-36 Physical Health Summary (p < 0.05), and FAOS average (p < 0.05) scores were significantly lower in the group with pain (Table III). The median SF-36 Mental Health Summary measure was 55.8 (twenty-fifth percentile, 50.3; seventy-fifth percentile, 67.2) in the group with pain and 59.9 (twenty-fifth percentile, 58.0; seventy-fifth percentile, 61.0) in the group without pain.

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TABLE III Subjective Outcome Scores in Pain and No-Pain Groups*

	SF-36 Questionnaire†
Group	Physical Function Subscale Score	Mental Health Summary Score	Physical Health Summary Score	FAOS Average‡
Pain	31.0 (27.8, 35.2)	55.8 (50.3, 67.2)	27.6 (24.6, 33.8)	52.7 (45.8, 63.5)
No pain	57.1 (57.1, 57.1)	59.9 (58.0, 61.0)	57.7 (52.4, 58.2)	89.8 (87.4, 93.3)
P value	<0.05	0.717	<0.05	<0.05

*All values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses. The Wilcoxon signed-rank two-tailed test was performed for all variables.
†SF-36 = Short Form-36.
‡FAOS = Foot and Ankle Outcome Score.

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TABLE III Subjective Outcome Scores in Pain and No-Pain Groups*

	SF-36 Questionnaire†
Group	Physical Function Subscale Score	Mental Health Summary Score	Physical Health Summary Score	FAOS Average‡
Pain	31.0 (27.8, 35.2)	55.8 (50.3, 67.2)	27.6 (24.6, 33.8)	52.7 (45.8, 63.5)
No pain	57.1 (57.1, 57.1)	59.9 (58.0, 61.0)	57.7 (52.4, 58.2)	89.8 (87.4, 93.3)
P value	<0.05	0.717	<0.05	<0.05

Plantar Pressures

The average mean pressure in the lateral part of the midfoot was significantly higher in the group with pain for both the non-normalized data (p < 0.05) and the normalized data (p < 0.05) (Table IV, Fig. 2). The values were similar between the groups for the other anatomic regions.

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TABLE IV Average Mean Pressure in Foot Regions*

	Not Normalized to Body Weight (N/cm2)			Normalized to Body Weight (1 × 10-3/cm2)
	Pain Group	No-Pain Group	P Value	Pain Group	No-Pain Group	P Value
First metatarsal	2.0 (1.4, 3.7)	3.1 (2.1, 3.9)	0.53	2.3 (1.8, 3.7)	3.7 (2.9, 4.9)	0.20
Fifth metatarsal	3.7 (2.8, 5.2)	2.8 (2.5, 3.6)	0.14	3.8 (3.6, 7.1)	3.6 (3.3, 4.8)	0.40
Lateral midfoot	5.6 (4.8, 8.1)	2.2 (1.9, 3.1)	<0.05	6.5 (5.3, 7.9)	3.2 (2.6, 4.0)	<0.05
Medial midfoot	2.3 (2.3, 3.9)	2.2 (2.0, 2.7)	0.09	3.7 (2.8, 5.4)	3.2 (2.8, 3.4)	0.53
Lateral hindfoot	8.5 (5.3, 8.9)	5.9 (4.8, 7.9)	0.23	8.4 (6.1, 10.0)	8.2 (7.4, 9.8)	0.91
Medial hindfoot	8.1 (5.7, 10.3)	6.4 (5.2, 8.2)	0.40	9.4 (6.5, 10.8)	9.2 (7.7, 10.4)	0.97

*The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses. The Wilcoxon signed-rank two-tailed test was performed for all variables.

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TABLE IV Average Mean Pressure in Foot Regions*

	Not Normalized to Body Weight (N/cm2)			Normalized to Body Weight (1 × 10-3/cm2)
	Pain Group	No-Pain Group	P Value	Pain Group	No-Pain Group	P Value
First metatarsal	2.0 (1.4, 3.7)	3.1 (2.1, 3.9)	0.53	2.3 (1.8, 3.7)	3.7 (2.9, 4.9)	0.20
Fifth metatarsal	3.7 (2.8, 5.2)	2.8 (2.5, 3.6)	0.14	3.8 (3.6, 7.1)	3.6 (3.3, 4.8)	0.40
Lateral midfoot	5.6 (4.8, 8.1)	2.2 (1.9, 3.1)	<0.05	6.5 (5.3, 7.9)	3.2 (2.6, 4.0)	<0.05
Medial midfoot	2.3 (2.3, 3.9)	2.2 (2.0, 2.7)	0.09	3.7 (2.8, 5.4)	3.2 (2.8, 3.4)	0.53
Lateral hindfoot	8.5 (5.3, 8.9)	5.9 (4.8, 7.9)	0.23	8.4 (6.1, 10.0)	8.2 (7.4, 9.8)	0.91
Medial hindfoot	8.1 (5.7, 10.3)	6.4 (5.2, 8.2)	0.40	9.4 (6.5, 10.8)	9.2 (7.7, 10.4)	0.97

*The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses. The Wilcoxon signed-rank two-tailed test was performed for all variables.

Fig. 2

Plantar pressure profiles for a patient in the pain group (Case 3) (A, B, and C) and a matched control from the no-pain group (Control 3) (D, E, and F). In the plantar profiles without masking, a clear area of increased pressure can be seen in the foot of the patient with pain (A) as compared with the control (D). With masking, the area of increased pressure in the patient with pain (B) as compared with the control (E) maps to the lateral aspect of the midfoot. No gross differences can be found in overall alignment on the anteroposterior radiograph of the foot for the patient with pain (C) as compared with that for the control (F).

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The non-normalized peak pressure was significantly higher in the medial part of the midfoot (p < 0.05) and the lateral part of the midfoot (p < 0.05) in the group with pain (Table V). However, on normalization, only the value for the lateral part of the midfoot remained significantly higher (p < 0.05). The values were similar between the groups for the other anatomic regions.

View Larger

TABLE V Peak Pressure in Foot Regions*

	Not Normalized to Body Weight (N/cm2)			Normalized to Body Weight (1 × 10-3/cm2)
	Pain Group	No-Pain Group	P Value	Pain Group	No-Pain Group	P Value
First metatarsal	3.9 (3.5, 8.7)	10.7 (5.6, 18.8)	0.16	4.8 (3.6, 8.8)	13.4 (7.6, 24.1)	0.14
Fifth metatarsal	7.7 (6.4, 20.8)	6.3 (4.8, 9.9)	0.23	8.2 (6.4, 19.8)	7.9 (5.8, 16.1)	0.79
Lateral midfoot	11.0 (9.3, 15.0)	5.9 (5.0, 6.4)	<0.05	11.7 (10.7, 14.4)	7.8 (6.8, 8.3)	<0.05
Medial midfoot	8.6 (6.1, 10.0)	5.2 (4.3, 5.7)	<0.05	9.4 (6.7, 12.4)	6.7 (6.2, 7.1)	0.08
Lateral hindfoot	16.6 (9.7, 17.4)	12.8 (9.2, 18.5)	0.74	15.3 (12.3, 23.1)	20.6 (12.6, 23.1)	0.99
Medial hindfoot	16.8 (11.4, 17.9)	12.9 (9.9, 20.7)	0.85	15.9 (13.1, 22.9)	21.3 (13.3, 25.4)	0.68

*The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses. The Wilcoxon signed-rank two-tailed test was performed for all variables.

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TABLE V Peak Pressure in Foot Regions*

	Not Normalized to Body Weight (N/cm2)			Normalized to Body Weight (1 × 10-3/cm2)
	Pain Group	No-Pain Group	P Value	Pain Group	No-Pain Group	P Value
First metatarsal	3.9 (3.5, 8.7)	10.7 (5.6, 18.8)	0.16	4.8 (3.6, 8.8)	13.4 (7.6, 24.1)	0.14
Fifth metatarsal	7.7 (6.4, 20.8)	6.3 (4.8, 9.9)	0.23	8.2 (6.4, 19.8)	7.9 (5.8, 16.1)	0.79
Lateral midfoot	11.0 (9.3, 15.0)	5.9 (5.0, 6.4)	<0.05	11.7 (10.7, 14.4)	7.8 (6.8, 8.3)	<0.05
Medial midfoot	8.6 (6.1, 10.0)	5.2 (4.3, 5.7)	<0.05	9.4 (6.7, 12.4)	6.7 (6.2, 7.1)	0.08
Lateral hindfoot	16.6 (9.7, 17.4)	12.8 (9.2, 18.5)	0.74	15.3 (12.3, 23.1)	20.6 (12.6, 23.1)	0.99
Medial hindfoot	16.8 (11.4, 17.9)	12.9 (9.9, 20.7)	0.85	15.9 (13.1, 22.9)	21.3 (13.3, 25.4)	0.68

*The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses. The Wilcoxon signed-rank two-tailed test was performed for all variables.

The maximum force in the lateral part of the midfoot was significantly higher in the group with pain for both the non-normalized (p < 0.05) and normalized (p < 0.05) data (Table VI). The values were similar between the groups for the other anatomic regions.

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TABLE VI Maximum Force in Foot Regions*

	Not Normalized to Body Weight (N)			Normalized to Body Weight (1 × 10^-2) (no units)
	Pain Group	No-Pain Group	P Value	Pain Group	No-Pain Group	P Value
First metatarsal	32.7 (26.7, 54.8)	41.3 (30.6, 58.2)	0.63	3.8 (3.0, 6.9)	5.6 (4.2, 7.0)	0.32
Fifth metatarsal	37.6 (25.8, 57.7)	28.9 (22.8, 32.8)	0.16	3.7 (3.0, 8.1)	3.6 (2.8, 5.2)	0.53
Lateral midfoot	142.8 (100.3, 177.5)	45.2 (39.1, 63.8)	<0.05	15.7 (12.3, 17.3)	6.1 (4.8, 8.1)	<0.05
Medial midfoot	34.4 (15.5, 69.8)	8.5 (7.5, 30.0)	0.14	4.0 (2.0, 6.9)	1.3 (0.9, 3.7)	0.14
Lateral hindfoot	144.5 (97.5, 166.6)	117.2 (84.5, 147.4)	0.32	14.9 (11.2, 20.8)	16.4 (11.4, 17.8)	0.85
Medial hindfoot	116.2 (106.9, 173.4)	96.0 (81.0, 113.2)	0.16	15.9 (12.6, 16.3)	13.3 (12.1, 14.7)	0.97

*The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses. The Wilcoxon signed-rank two-tailed test was performed for all variables.

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TABLE VI Maximum Force in Foot Regions*

	Not Normalized to Body Weight (N)			Normalized to Body Weight (1 × 10^-2) (no units)
	Pain Group	No-Pain Group	P Value	Pain Group	No-Pain Group	P Value
First metatarsal	32.7 (26.7, 54.8)	41.3 (30.6, 58.2)	0.63	3.8 (3.0, 6.9)	5.6 (4.2, 7.0)	0.32
Fifth metatarsal	37.6 (25.8, 57.7)	28.9 (22.8, 32.8)	0.16	3.7 (3.0, 8.1)	3.6 (2.8, 5.2)	0.53
Lateral midfoot	142.8 (100.3, 177.5)	45.2 (39.1, 63.8)	<0.05	15.7 (12.3, 17.3)	6.1 (4.8, 8.1)	<0.05
Medial midfoot	34.4 (15.5, 69.8)	8.5 (7.5, 30.0)	0.14	4.0 (2.0, 6.9)	1.3 (0.9, 3.7)	0.14
Lateral hindfoot	144.5 (97.5, 166.6)	117.2 (84.5, 147.4)	0.32	14.9 (11.2, 20.8)	16.4 (11.4, 17.8)	0.85
Medial hindfoot	116.2 (106.9, 173.4)	96.0 (81.0, 113.2)	0.16	15.9 (12.6, 16.3)	13.3 (12.1, 14.7)	0.97

*The values are given as the median, with the twenty-fifth and seventy-fifth percentiles in parentheses. The Wilcoxon signed-rank two-tailed test was performed for all variables.

The ratios of lateral to medial midfoot average mean pressure and lateral to medial hindfoot peak pressure appeared to be higher in the group with pain, but the differences did not reach significance. There were no differences in the lateral to medial forefoot pressures for average mean pressure or peak pressure. There were also no differences in any of the ratios for maximum force.

The post hoc analysis demonstrated sufficient power to detect a doubling of the values for each of the non-normalized plantar pressure parameters in all anatomic regions, which was considered a clinically relevant change.

Discussion

To the best of our knowledge, this is the first study that has demonstrated a relationship between lateral plantar discomfort and increased plantar pressure parameters following lateral column lengthening. The increased lateral plantar pressures that we found in the present study did not appear to be the result of excessive lengthening according to radiographic parameters. However, this does not imply that patients who have radiographic overcorrection will not have increased lateral plantar pressure. An increase in graft size of 1 or 2 mm may lead to a small change in radiographic parameters but can potentially increase the stiffness or lateral plantar pressure that a patient experiences.

The literature supports the notion that lateral column lengthening potentially leads to subjective complaints of lateral discomfort^11,16,28. Elevated plantar pressures have been demonstrated in a pediatric population managed with Evans lengthening²². In cadaver studies, lateral column lengthening has led to increased lateral forefoot pressures^17,20.

The multiple other procedures that are performed concomitantly with lateral column lengthening reflect the complexity of flatfoot reconstruction. This complexity stems from the variety of associated deformities, including forefoot supination, hallux valgus, and spring ligament compromise. A careful algorithm taking into account these procedures was used to match the patients who had pain with their counterpart controls. However, a selection bias may have existed given that the controls were not chosen randomly, but rather by means of a matching process.

The literature lacks in vivo reports of lateral discomfort or increased plantar pressures after medializing calcaneal osteotomy without a concomitant lateral column lengthening. Increased lateral heel pressure after a medializing calcaneal osteotomy has been shown in a cadaver model¹⁸. The current study, in contradistinction, demonstrated increased pressures in the lateral aspect of the midfoot. Another biomechanical study demonstrated increased lateral forefoot pressures in the setting of a 1-cm superior translation of a medializing calcaneal osteotomy¹⁹. A trend toward decreased lateral pressures was found with only 0.5 cm of superior translation, but no assessment was made of the effect of inferior translation. We generally translate the medializing calcaneal osteotomy inferiorly in order to recreate an arch as well as to avoid potential impingement of the superior process of the calcaneus on the Achilles tendon. This theoretical risk of increasing lateral pressures after a medializing calcaneal osteotomy therefore would be unlikely to apply to the patients in the current study.

It must be noted that seemingly identical procedures may lead to different degrees of correction and therefore different results even in matched patients, which may limit the conclusions that can be drawn from these data. In addition, varying degrees of plantar flexion through a first tarsometatarsal fusion or Cotton osteotomy, bunion or hammertoe correction, or arthritis in the midfoot, hindfoot, and ankle theoretically could lead to increased load transmission through the lateral aspect of the foot. We are not aware of any studies linking flexor digitorum longus transfer, medial cuneiform osteotomy, first tarsometatarsal fusion, spring ligament repair, or any other medially based procedure to increased lateral plantar discomfort or pressure. In a cadaver study, a medial cuneiform osteotomy led to increased pressures in the medial aspect of the forefoot, but no change laterally²⁰. Calcaneocuboid instability, which theoretically occurs when the calcaneocuboid joint is not stabilized prior to lateral column lengthening, could cause discomfort. We do not believe that such instability results, but we cannot prove this on the basis of the data in the present study. It is our experience that lengthening through the anterior aspect of the calcaneus most likely leads to increased lateral plantar pressure.

The present study is indeed limited by its size. Fortunately, most patients undergoing lateral column lengthening do not experience prolonged lateral plantar discomfort at two years of follow-up, and we were therefore limited by the number of patients available for the present study. Such symptoms often are transient and disappear either after hardware removal or after the foot has had a chance to readjust to its corrected position during the first or second postoperative year. All of the patients in this study presented with pain well after the hardware had been removed, which also allowed ample time for this adjustment. We do not believe that hardware left in the first tarsometatarsal joint, as was the case in two of the patients with pain (Cases 7 and 8) and five of the patients without pain (Controls 1, 3, 5, 8, and 10), led to lateral plantar pain. These patients did not complain of pain over the retained hardware.

The present study does not establish an easy measurement for the clinician to employ at the time of reconstruction in order to decrease lateral overload. In an attempt to guide this surgical decision, we have developed a system to reliably collect plantar pressures under simulated weight-bearing conditions in the operating room²⁹. A similar technique recently was reported in the literature^30,31. Alternatively, the senior author (J.D.) has suggested that, among the parameters that are used to judge the amount of lengthening at the time of surgery, maintaining near normal eversion motion in the hindfoot is of high importance. Although logical, it is not clear whether it is possible to assess lateral column motion precisely enough with use of manual range-of-motion testing. The hypothesis that leaving adequate eversion motion in the lateral aspect of the hindfoot leads to a decrease in lateral plantar discomfort needs to be tested.

In conclusion, we confirmed our hypothesis and found that patients who have undergone lateral column lengthening and who experience lateral plantar pain have increased lateral midfoot plantar pressure values. The increased pressures in this area cannot be accounted for solely by radiographic or demographic factors. Concomitantly performed procedures may represent confounding variables and could contribute to lateral plantar pain. However, these procedures are less likely the cause according to the biomechanical and clinical literature. The present study suggests that, in the setting of lateral column lengthening, the surgeon must be careful to minimize increased pressure on the lateral plantar border of the foot. Because discomfort at the lateral part of the plantar aspect of the foot has been linked to increased lateral pressure in the present study, better adjustment at the time of surgery is likely to decrease the prevalence of lateral plantar discomfort postoperatively.

Acknowledgements

Note: The authors thank Stephen Lyman, PhD, Huong Do, MS, Will Aibinder, BS, John Rutledge, PhD, and Howard Hillstrom, PhD, whose contributions have made completing this project possible.

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Topics

forefoot ; pain ; reconstructive surgical procedures ; flatfoot ; foot ; pressure-physical agent ; foot pain ; midfoot ; hindfoot ; mean arterial pressure

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Scott Jacob Ellis, Joseph C. Yu, A. Holly Johnson, Andrew Elliott, Martin O'Malley, Jonathan Deland; Plantar Pressures in Patients with and without Lateral Foot Pain After Lateral Column Lengthening. The Journal of Bone & Joint Surgery. 2010 Jan;92(1):81-91.

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