Computational Modeling to Assess Surgical Procedures for the Treatment of Adult Acquired ...

123 Pages·2016·3.51 MB·English

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Theses and Dissertations Graduate School
2015
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Brian A. Smith
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COMPUTATIONAL MODELING TO ASSESS SURGICAL PROCEDURES
FOR THE TREATMENT OF ADULT ACQUIRED FLATFOOT DEFORMITY

A Thesis submitted in partial fulfillment of the requirements for the degree of Master of Science
in Biomedical Engineering at Virginia Commonwealth University.

By

BRIAN ALEXANDER SMITH
Bachelor of Science, Virginia Commonwealth University, 2013

Director: Jennifer S. Wayne, Ph. D.
Professor, Biomedical Engineering & Orthopaedic Surgery
Director, Orthopaedic Research Laboratory

Virginia Commonwealth University
Richmond, Virginia
August 2015
Acknowledgements

As my time here at VCU comes to an end I am filled with excitement and hesitation
about what the next chapter of my life may hold. However, I know I would not be here today
with the help and assistance from so many people. First and foremost I would like to give largest
and most sincere thanks to my advisor Dr. Jennifer Wayne. Since I was a junior, you have
always been there when I have needed any guidance and assistance and for that I will be forever
grateful. I would also like to thank you for your tireless effort in the adjustment of my
articulation ability. I would also like to thank the other members of my committee Dr. Gerald
Miller and Dr. Adelaar. Dr. Miller, thank you for your assistance with this work as well as your
help and guidance when I first came to VCU. Dr. Adelaar, thank you for your support and
assistance with this work as well as my senior design project.
I would also like to thank my colleagues and friends I have found in lab: Ruchi, Nathan,
Johnny, Meade and EJ. Thank you all for your endless support, advice, and words of
encouragement over these last two years. Ruchi, thank you for enduring, and in some ways
enjoying, my unique banter while still helping me more than I could ever ask for. Johnny, thank
you for passing on some of your statistical prowess and introducing me to “nana’s mints.”
Meade, thank you for all of your tutelage over my academic career as well as answering my
countless questions throughout the course of this work.
To my coworkers at VCU Innovation Gateway: Ivelina, Allen, Magda, Afsar, Clara,
Trish, Lindsay and Livia, thank you for providing me with such a warm and family like
environment to be a part of during my time in grad school. It has been an absolute pleasure
working with all of you.
Lastly, I need to extend the biggest thanks to my family who has been there by my side
throughout this endeavor. First to my parents Greg and Cindy, thank you for being the best role
models a kid could ever ask for. Thank you both for allowing me to chase my dreams while
giving me your full support and encouragement. To my sister Katey, thank you for being there
whenever I needed an ear and always telling me like it is while challenging me to be better every
day. Lastly, to my girlfriend Jessica, thank you for your unwavering support in everything I
have done and what I hope to do.

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Table of Contents
Page
Acknowledgements..........................................................................................................................ii
Table of Contents............................................................................................................................iii
List of Figures..................................................................................................................................v
List of Tables.................................................................................................................................vii
Abstract...........................................................................................................................................ix
Chapter
1 Introduction............................................................................................................1
1.1 Overview of Computation Modeling...........................................................1
1.2 Uses of Computational modeling................................................................1
1.3 Scope of this Thesis.....................................................................................3
2 Foot & Ankle Anatomy.........................................................................................5
2.1 Bony Anatomy.............................................................................................5
2.2 Ligaments...................................................................................................13
2.3 Musculature................................................................................................17
3 Adult Acquired Flatfoot Deformity....................................................................21
3.1 Clinical Presentation and Diagnosis..........................................................21
3.2 Etiology......................................................................................................25
3.3 Stages of AAFD.........................................................................................27
3.4 Treatments..................................................................................................28
4 Methods.................................................................................................................39
iii
4.1 Model Creation..........................................................................................39
4.2 Simulation of AAFD..................................................................................45
4.3 Surgical Interventions................................................................................46
4.3.1 Medializing Calcaneal Osteotomy.................................................46
4.3.2 Evans Osteotomy...........................................................................48
4.3.3 Calcaneocuboid Distraction Arthrodesis.......................................51
4.3.4 Z Osteotomy...................................................................................52
4.4 Measurement Procedure.............................................................................54
5 Results...................................................................................................................58
6 Discussion.............................................................................................................92
7 Conclusion and Future Directions....................................................................102
Literature Cited............................................................................................................................105
Vita...............................................................................................................................................111

iv
List of Figures
Page
Figure 2-1: Tibia and Fibula shown with interosseous membrane.................................................6
Figure 2-2: Bones comprising the foot...........................................................................................8
Figure 2-3: Right foot highlighting the transverse tarsal and tarsometatarsal joints ......................9
Figure 2-4: Right ankle ligaments.................................................................................................14
Figure 2-5: Foot and ankle ligaments on the dorsum of the right foot.........................................16
Figure 2-6: Right Triceps Surae....................................................................................................18
Figure 2-7: Tendons along the medial aspect of the right foot.....................................................19
Figure 2-8: Lateral tendon courses of the right foot.....................................................................20
Figure 3-1: Most commonly used X-ray measures used to diagnose AAFD...............................22
Figure 3-2: Alternate methods used to diagnose AAFD...............................................................24
Figure 3-3: Presentation of AAFD................................................................................................25
Figure 3-4: Non-surgical treatments for AAFD............................................................................29
Figure 3-5: FHL tendon transfer performed on the right foot......................................................31
Figure 3-6: Intraoperative view of a MCO...................................................................................35
Figure 3-7: Example of lateral column procedures.......................................................................36
Figure 3-8: Surgical Procedure for Z osteotomy..........................................................................38
Figure 4-1: Right foot model showing soft tissue constraints and tendon wrapping....................43
Figure 4-2: Creation of the MCO..................................................................................................47
Figure 4-3: Creation of the Evans osteotomy...............................................................................49
Figure 4-4: Standardized procedure used to adduct the foot after LCL procedures.....................50
v
Figure 4-5: CCDA procedure........................................................................................................52
Figure 4-6: Z-osteotomy procedure..............................................................................................53
Figure 4-7: ML radiographic measurements.................................................................................55
Figure 4-8: AP radiographic measurements.................................................................................56
Figure 5-1: Average distance measurements................................................................................60
Figure 5-2: Average angular measurements.................................................................................61
Figure 5-3: Individual measurements for P1................................................................................65
Figure 5-4: Individual measurements for P2................................................................................67
Figure 5-5: Individual measurements for P3................................................................................68
Figure 5-6: Individual measurements for P4................................................................................71
Figure 5-7: Individual measurements for P5................................................................................72
Figure 5-8: Individual measurements for P6................................................................................73
Figure 5-9: Difference in contact forces between measurements.................................................84
Figure 5-10: Difference in plantar force measurements...............................................................86

vi
List of Tables
Page
Table 3-1: Stages of AAFD..........................................................................................................28
Table 4-1: Four-tiered grading scale of AAFD implicated soft tissues........................................45
Table 4-2: Observed patient values of MRI signal attenuation....................................................46
Table 5-1: Average distance measurements.................................................................................58
Table 5-2: Average angle measurements......................................................................................59
Table 5-3: Percent correction for each procedure.........................................................................62
Table 5-4: Best surgical procedure for each patient.....................................................................64
Table 5-5: Percent correction for individual patients...................................................................74
Table 5-6: Joint contact force measurements produced by MCO & Evans..................................77
Table 5-7: Joint contact force measurements produced by MCO & Z Osteotomy......................78
Table 5-8: Ground reaction force measurements produced by MCO & Evans............................78
Table 5-9: Ground reaction force measurements produced by MCO & Z Osteotomy.................78
Table 5-10: Pre-op strain in the plantar fascia for each patient....................................................79
Table 5-11: Plantar fascia strain produced by MCO & Evans......................................................79
Table 5-12: Plantar fascia strain produced by MCO & Z Osteotomy..........................................79
Table 5-13: Pre-op strain in the spring ligament for each patient.................................................80
Table 5-14: Spring ligament strain produced by MCO & Evans..................................................80
Table 5-15: Spring ligament strain produced by MCO & Z Osteotomy......................................80
Table 5-16: Pre-op strain in the deltoid ligament for each patient...............................................81
Table 5-17: Deltoid ligament strain produced by MCO & Evans................................................81
vii
Table 5-18: Deltoid ligament strain produced by the MCO & Z Osteotomy...............................81
Table 5-19: Contact force measurements for pre-op model and surgical simulations.................83
Table 5-20: Difference in contact force measurements between each surgical procedure and the
pre-op model..................................................................................................................................83
Table 5-21: Plantar force measurements for pre-op model and surgical simulations...................85
Table 5-22: Difference in plantar force measurements between each surgical procedure and the
pre-op model..................................................................................................................................85
Table 5-23: Summary table describing ligament strain in the plantar fascia, spring and deltoid
ligaments........................................................................................................................................87
Table 5-24: Plantar fascia strain for the pre-op model and each surgical simulation...................87
Table 5-25: Difference in ligament strain in the plantar fascia....................................................88
Table 5-26: Spring ligament strain for pre-op model and each surgical simulation.....................89
Table 5-27: Difference in spring ligament strain between each surgical simulation and the pre-op
model..............................................................................................................................................89
Table 5-28: Deltoid ligament strain in the pre-op model and each surgical simulation...............90
Table 5-29: Difference in deltoid ligament strain between each surgical simulation and the pre-
op model.........................................................................................................................................91

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