Opening Wedge Medial Cuneiform Osteotomy Research Articles

Peroneus Brevis to Longus Tendon Transfer in the Treatment of the Flexible Progressive Collapsing Foot Deformity: A Cadaveric Study

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Although operative treatment of the flexible progressive collapsing foot deformity (PCFD) remains controversial, correction of residual forefoot varus and stabilization of the medial column are important components of reconstruction. An opening wedge medial cuneiform osteotomy or first tarsometatarsal fusion is traditionally performed to plantarflex the first metatarsal. More recently, tendon transfers such as a peroneus brevis (PB) to peroneus longus (PL) have been proposed. However, there is little data to support their use. The aim of our study was to determine the effect of an isolated PB- to-PL transfer (PBT) on medial column and hindfoot joint kinematics in a simulated PCFD (sPCFD) cadaveric model using a robotic gait simulator. We hypothesized that a PBT in a sPCFD model would partially restore kinematics to the intact state. Methods: A validated six-degree of freedom robot (Baxter et al., 2016) was used to simulate the stance phase of level walking for 6 mid-tibia cadaveric specimens (3 male; age: 72 ± 8 years). An eight-camera motion capture system was used to track reflective markers fixed to bones of the foot and ankle. Three conditions were tested for each specimen: intact, sPCFD (Henry et al., 2022), and after PBT. The PBT was performed by transecting the PB and advancing the proximal stump 1 cm into the PL (Sanhudo, 2019). Outcome measures included kinematics of the talonavicular, subtalar, and first tarsometatarsal joints. Maximum differences between the PBT and sPCFD conditions and 95% confidence intervals (95%CIs) were calculated. The percent deformity correction was determined by dividing the difference between the PB and sPCFD states by the difference between the intact and sPCFD states at the site of maximum deformity correction. Results: Relative to the sPCFD condition, the PBT resulted in a maximum increase in talonavicular plantarflexion of 1.8° (95%CI 0.9°-2.7°) with 159% correction during midstance, decrease in talonavicular abduction of 1.5° (95%CI 0.3°-2.8°) with 65% correction during midstance, and decrease in talonavicular eversion of 2.4° (95%CI 1.2°-3.8°) with 90% correction during mid-to- late stance. All deformities had consistent correction at the talonavicular joint during stance (Figure 1). Additionally, the PBT resulted in a maximum increase in subtalar plantarflexion by 0.8° (95%CI 0.3°-1.8°) with 155% correction in early stance, decrease in subtalar abduction by 0.8° (95%CI 0.5°-1.2°) with 191% correction during early stance, and decrease in subtalar eversion by 1.5° (95%CI 0.5°-2.2°) with 178% correction during mid-stance. There was no effect on first tarsometatarsal joint kinematics. Conclusion: A PB-to-PL transfer in a sPCFD model resulted in the correction of multiple deformities including increased plantarflexion and decreased abduction at the talonavicular joint compared to the sPCFD without the transfer, most notably during PB activation in stance. The PBT also decreased eversion at the talonavicular and subtalar joints. Our results suggest that the addition of a PBT as part of the surgical management of the flexible PCFD contributes to correction of the residual forefoot varus, midfoot abduction, and hindfoot valgus deformities by plantarflexing through the medial column and removing a deforming force on the foot by the PB.

Short-Term Outcomes of the Lapicotton Technique in the Treatment of Progressive Collapsing Foot Deformity

Category:Midfoot/ForefootIntroduction/Purpose:Medial column instability (MCI) in Progressive Collapsing Foot Deformity (PCFD) is not solely determined by forefoot varus (FV). First ray hypermobility, hallux valgus, midfoot arthritis, gapping at the tarsometatarsal joint and dorsal metatarsal migration are findings associated with MCI. Acknowledgement of this instability requires inclusion of a procedure to the medial column in order to correct the forefoot varus, stabilize the ray and bring the foot to a plantigrade tripod position. Cotton opening wedge medial cuneiform osteotomy and Lapidus tarsometatarsal arthrodesis are procedures of choice in these scenarios. We have combined these 2 procedures into one called Lapicotton. The purpose of this study was to present the short-term outcomes of this technique.We hypothesized that Lapicotton will improve both clinical and radiological outcomes.Methods:We performed an IRB-approved retrospective study comprising 3 PCFDs having benefited from a Lapicotton procedure. Clinical outcomes were assessed with the European Foot and Ankle Society Score (EFAS), the Foot Function Index Score (FFI) and the Pain Catastrophizing Scale (PCS). Radiographic outcomes were assessed using weight-bearing computed tomography (WBCT) assessments. Middle Cuneiform Floor distance, Forefoot Arch Angle, Middle Facet uncoverage percentage, Talonavicular Coverage angle and the Foot and Ankle Offset (FAO) were measured. All these data were both preoperatively and postoperatively collected. Comparison between preoperative and postoperative results were done as described below. The Kruskal-Wallis H-test for independent groups was used to compare median values of the EFAS. The Wilcoxon signed-rank test for paired samples was used to compare preoperative and postoperative variables of FFI and PCS. For the radiographic measurements, normality was assessed using Shapiro-Wilk test. Comparisons were made using Student tests for normal variables and Mann-Whitney for non-normals.Results:This small series included 2 female and 1 male, with a mean age of 56 and a mean BMI of 31.8 kg/m2. Mean follow up was 2.9+/-0.2 (range from 2.7 to 3.1) months. 2 out of 3 patients simultaneously benefited of a Medial Calcaneal Displacement Osteotomy (MDCO 10mm) and a Lateral Column Lengthening (LCL 8mm). The wedge sizes used for the Lapicotton were 8 mm in all cases. Regarding clinical outcomes, EFAS (p=0.79) and FFI (p=0.99) did not showed any significant improvement whereas PCS were significantly improved (Δ=-5.67[-9.2–2.2];p=0.03). Regarding radiological outcomes, fusion was present in all the cases at the maximal follow-up. Middle cuneiform floor distance and Forefoot Arch Angle were significantly increase (respectively Δ=6.9;CI95%=[6.4;7.4];p< 0.01 and Δ=7.5;CI95%=[4.3;10.8]p<0.05). Middle Facet uncoverage was significantly improved (Δ=- 28.8;CI95%=[-33.1;-24.5]p< 0.01). Statistical power of the serie did not allowed comparison regarding the Talonavicular Coverage Angle (Δ=-14;CI95%=[-24;-3.9]) and the FAO (Δ=-3.9;CI95%=[-10.7;2.9]).Conclusion:The Lapicotton procedure showed encouraging outcomes with fusion in all cases at 3 months postoperatively, improvement in pain, correction of forefoot varus and of the of the Peritalar subluxation represented by the Middle Facet Uncoverage. These results should be moderate because other procedures (MDCO and LCL) were performed in 2/3 of the patients, and the outcomes were issued from a small cohort with short-term follow-up. Longer follow-up and a larger cohort are needed to confirm these results.

Short- to Intermediate-Term Radiographic Outcomes Following Cotton Osteotomy

The cotton osteotomy or the medial cuneiform opening wedge osteotomy has been a common adjunct procedure in flatfoot reconstruction to correct for forefoot varus or a dorsiflexed first ray. The main goal of the study is to retrospectively review outcomes specifically in the short-intermediate term for the cotton osteotomy. The medical records of a single foot and ankle surgeon (PRB) were reviewed for patients who met inclusion and exclusion criteria. The study period was from January 2006 to October 2018. The analysis was performed using information obtained from chart-review to examine union and complication rates, as well as changes in the cuneiform articular angle based on graft size and type. A total of 71 feet in 61 patients underwent cotton osteotomies for flatfoot reconstruction. Overall complication rate was 5.6% (4/71) with 2 nonunions (2/47) in those that had radiographic follow-up of greater than 9 months. Change in cuneiform articular angle (CAA) showed 0.91° of correction per 1-millimeter increase in graft wedge size from preoperative to 3 weeks. Change for anterior-posterior medial cuneiform bisection dorsal length (AP length) was 0.70 mm per 1 mm of graft used from preoperative to 3 weeks. 6 weeks to 10 weeks showed statistically significant changes in the CAA (p=.01) and the AP length (p=.002). The cotton osteotomy showed statistically significant radiographic loss of correction between the 6- and 10-week time points when patients were allowed to begin weightbearing. Metal grafts may provide maintenance of correction which warrants future studies on their efficacy.

The Role of Surgery in Management of Primary Metatarsus Adductus

Background: Metatarsus adductus is the most common congenital foot deformity in children. Different bone surgical procedures were portrayed to treat severe cases of fixed metatarsus adduction. Objective: To establish a protocol for diagnosis and treatment of forefoot adduction deformity in metatarsus adductus, and to evaluate the results of double column osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) (i.e. lateral column shortening with medial column lengthening) in correction of the foot deformity. Patients and Methods: In this prospective study 16 patients with 17 feet with fixed metatarsus adductus were operated upon for forefoot adduction deformity in Zagazig University Hospitals since 2018. 10 boys and 6 girls from 4-12 years old. The right foot was operated upon in 7 patients and the left foot in 10 patients. All cases underwent double column osteotomy; closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy. Results: According to the grading system applied in this study, there were twelve cases with excellent results (nearly 70%). There was no pain throughout the foot. The forefoot adduction deformity was completely corrected. There was no supination in all cases. All cases manifested no complaints of the footwear or braces. All cases were satisfied and their parents revealed gratification of the foot shape and gait. There were 3 good results (18%), 2 fair results (12%), and no poor result. Conclusion: Double column osteotomy (combined cuboid/cuneiform osteotomy) is a safe operation, which allows satisfying correction of forefoot adduction deformity in severe rigid metatarsus adductus.

Radiographic Outcomes and Complications of Medial Column Correction in Adult Acquired Flatfoot Deformity Using A Titanium Wedge

Category:Hindfoot, Midfoot/Forefoot, FlatfootIntroduction/Purpose:Forefoot varus is a common component of flatfoot deformity that is often surgically addressed. There are multiple options to plantarflex the medial column of the foot, with midfoot fusion and the Cotton osteotomy being the most common. This study analyzes radiographic outcomes and complications when a titanium wedge is used for structural support in a dorsal opening wedge Cotton osteotomy of the medial cuneiform.Methods:Between December 2016 and May 2018, 32 feet in 31 patients were treated with medial column titanium wedges for residual forefoot varus in association with flatfoot corrections. All participants had preoperative and weight-bearing postoperative radiographs examined for analysis of radiographic correction. The average age of the patients was 41.1 years (Range: 12-70). The average follow-up time for patients was 8.1 months (6-17 months). All patients underwent a six-month non-operative treatment course prior to operative intervention. The average time from the initial visit with the primary surgeon (JFD, ARK) to the day of surgical intervention was 211 days (29-1296 days). The choice to use a titanium wedge, versus an alternative method of correction of the medial column, was at the discretion of the primary surgeon (JFD, ARK).Results:A dorsal opening wedge medial cuneiform osteotomy was performed in all patients. All radiographic parameters showed statistically significant correction from preoperative to postoperative. All cases had multiple concomitant procedures performed to address the flatfoot deformity, so it is difficult to isolate the effect of the medial cuneiform osteotomy.30/31 cases went on to successful union of the osteotomy within the study follow-up period. There were no instances of hardware pain requiring implant removal. There was 1 case of plantar gapping at the osteotomy site and implant loosening that required revision to a larger titanium wedge which healed uneventfully. No implants had supplemental fixation or additional bone graft placement at the osteotomy site.Conclusion:To our knowledge, this represents the first reported series on the use of structural titanium wedges with an opening wedge osteotomy of the medial cuneiform. There is limited data regarding the use of metal wedges for flatfoot correction. Nearly every patient in our series underwent concomitant procedures as part of the flatfoot reconstruction. This makes it difficult to isolate the effect of the deformity correction provided solely by the medial column correction. Our study suggests that metal wedges are both safe and effective for use in medial column correction, and future studies comparing titanium wedges to traditional techniques are needed.

Medial Cuneiform Opening Wedge Osteotomy for Correction of Flexible Flatfoot Deformity: Trabecular Titanium vs. Bone Allograft Wedges.

Adult flatfoot is a common pathology characterized by multiplanar deformity involving hindfoot, midfoot, and forefoot. Various surgical techniques have been described for the treatment but may not adequately correct the fixed forefoot varus component. Residual forefoot supination can be addressed by a plantar flexing opening wedge osteotomy of the medial cuneiform, also known as a Cotton osteotomy. Thus, the aims of this study were to compare clinical, radiological, and functional outcome after Cotton osteotomy, in patients treated with bone allograft or metallic implant. Consequently, 36 patients treated with opening wedge osteotomy of the medial cuneiform for forefoot varus were studied retrospectively. Patients were divided into two groups: the bone allograft group (HBG) (n=18) and the metallic implant group with BIOFOAM® Cotton Wedges (TTW) (n=18). Radiographic assessment and clinical scores including American Orthopaedic Foot and Ankle Society score, Foot Function Index, and visual analogue scale for pain were collected before operation and the last follow-up. The difference between baseline and follow-up for both groups was statistically significant for all the clinical scores and radiographic angles (p < 0.05). Most participants (92%) were very satisfied after surgery. Our results showed that Cotton osteotomy with a metallic implant provided both good clinical and radiographic outcomes comparable with bone allograft.

Comparison of screw fixation versus non-fixation in dorsal opening wedge medial cuneiform osteotomy of adult acquired flatfoot

BackgroundThe aim of this study was to compare the radiographic and functional results between fixation and non-fixation in the Cotton osteotomy for the treatment of adult acquired flatfoot. MethodsA retrospective, case-controlled study of consecutive stage IIB posterior tibial tendon dysfunction (PTTD) patients treated with the same bony reconstructive surgery including cotton osteotomy between 2013 and 2017. Meary’s angle, the medial arch sag angle (MASA), and medial cuneiform cobb angle (MCCA) were evaluated pre-operation, at first weight bearing after surgery, and 12 months post operation. ResultsForty feet were included in the study. The cotton osteotomy utilized screw fixation (n = 20) or non-fixation technique (n = 20). No significant differences between groups were found in pre-operative and follow-up radiographic parameters, union rate, and functional results. ConclusionThe non-fixation with press fit technique is a reliable procedure for Cotton osteotomy and as effective as screw fixation. Level of evidenceLevel III, case control study

Cotton Osteotomy in Flatfoot Reconstruction: A Review of Consecutive Cases

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is commonly performed; however, the outcomes are rarely reported owing to the adjunctive nature of the procedure. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical because the preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated by arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus or an iatrogenic deformity after base wedge osteotomy for hallux valgus. We undertook an institutional review board-approved retrospective review of 32 consecutive patients (37 feet) who had undergone Cotton osteotomy as a part of flatfoot reconstruction. All but 1 case (2.7%) had radiographic evidence of graft incorporation at 10 weeks. No patient experienced graft shifting. Three complications (8.1%) were identified, including 2 cases with neuritis (5.4%) and 1 case of delayed union (2.7%) that healed with a bone stimulator at 6 months postoperatively. Meary's angle improved an average of 17.75°, from −17.24°± 8.00° to 0.51°± 3.81°, and this change was statistically significant (p < .01). The present retrospective series highlights our experience with the use of the Cotton osteotomy as an adjunctive procedure in flatfoot reconstructive surgery.

Effect of the additional first ray osteotomy on hindfoot alignment after calcaneal osteotomy for the correction of mild-to-moderate adult type pes plano-valgus.

To determine the effect of the additional first ray osteotomy on hindfoot alignment for the correction of pes plano-valgus. Data obtained from 37 consecutive patients recruited from 2006 to 2014 who underwent medial displacement calcaneal osteotomy (MDCO) alone (group H) or MDCO followed by medial cuneiform opening wedge osteotomy (MCOWO) (group HF) with a minimum 1-year follow-up were reviewed retrospectively. The mean follow-up periods were 34 and 32 months. Degree of decrease of Talonavicular coverage angle (TNCA) via surgery or postoperative TNCA on standing foot AP radiographs were not significantly different between group H and HF ( p = 0.287). The calcaneal pitch angle and medial cuneiform height on the standing foot lateral radiographs was significantly increased after operation in group HF ( p = 0.01), there was a significant difference with group H as well ( p = 0.033). In group HF, the Meary's angle was significantly decreased after operation, a significant difference compared to group H ( p = 0.009). Hindfoot alignment angle on the hindfoot alignment view was decreased after operation in both groups but was not significantly different between both groups ( p = 0.410). Hindfoot alignment ratio was also increased after the operation in both groups, but was not different between two groups ( p = 0.783). The additional first ray osteotomy using MCOWO had no correctional power for hindfoot correction, although it caused improvement in some radiographic parameters.

Surgical treatment results for flexible flatfoot in adolescents

ObjectiveIdiopathic flexible pes planus (IFPP) is a common foot problem in adolescents and young adults. Hypothesis for the present study was that combination of procedures for IFPP can achieve results in adolescents and young adults that are as good as those seen in adult-acquired pes planovalgus (AAPP) treatment in adults. MethodsA total of 21 feet of 18 patients (10 boys, 8 girls) with mean age of 15.6 years underwent surgical reconstruction for flatfoot deformity. Symptomatic patients who had been unresponsive to conservative treatment were included in study group. Mean follow-up time was 39.2 months. American Orthopedic Foot and Ankle Society (AOFAS) scores were calculated for all patients, and based on final results, all families were asked whether or not they would elect to have the surgery again in same circumstances. ResultsAll procedures were performed by the same surgeon: lateral column calcaneal lengthening osteotomy on 21 feet; percutaneous lengthening or gastrocnemius recession for Achilles tendon on 21 feet; medializing calcaneal osteotomy on 15 feet; flexor digitorum longus tendon transfer on 15 feet; medial cuneiform opening wedge osteotomy on 5 feet, spring ligament plication on 3 feet, and accessory navicular bone excision on 2 feet.Preoperative mean AOFAS score increased significantly from 56.76 to 95.29. All parents stated that they were satisfied with surgery results and would choose to have the same surgery performed again. ConclusionSoft tissue and bony procedures used for reconstruction of AAPP can be used safely for IFPP in adolescents and young adults. Level of clinical evidenceLevel IV, Therapeutic study.

FOREFOOT ADDUCTION IN CHILDREN. Management and Treatment.

Forefoot adduction is a common condition between metatarsus adductus, Z-shaped foot and residual clubfoot. This deformity is located in a pure transverse plane at Lisfranc’s joint. Isolated metatarsus adductus is corrected spontaneously for the majority of newborns. In rare uncorrected cases, it could result in Z-shaped foot with a functional hindfoot valgus to equilibrate the resistant metatarsus adductus. As well, in residual clubfoot, recurrent metatarsus adductus varus is observed, usually in children over three years. In flexible metatarsus adductus the treatment is conservative. The surgery is proposed in toddlers and after failure of conservative treatment. Procedures carried out on metatarsals gave good results on short term, but showed a high rate of recurrence and growth disturbance. Osteotomies proximal to the Lisfranc’s joint: calcaneo-cuboid fusion, anterior resection of calcaneus, and opening wedge osteotomy of medial cuneiform, gave permanent correction but they act only on one of the sides of deformity. Therefore, the theory of elongated lateral column associated with a shortened medial column is crucial in dealing with this deformity: combining opening wedge osteotomy of cuneiform with closing wedge osteotomy of cuboid described by Jawish et al. in children over 4 years allows – in all causes of metatarsus adductus stiffness – a lateral shifting of forefoot. Concerning the associated heel’s valgus, it is corrected in Z-shaped foot after the associated heel’s valgus, it is corrected in Z-shaped foot after the double osteotomy cuneiform/cuboid. However, in complicated treated clubfoot a particular treatment for the posterior tarsal is necessary.

Combined double tarsal wedge osteotomy and transcuneiform osteotomy for correction of resistant clubfoot deformity (the "bean-shaped" foot).

PurposeThe “bean-shaped foot” exhibits forefoot adduction and midfoot supination, which interfere with function because of poor foot placement. The purpose of the study is a retrospective evaluation of patients who underwent a combined double tarsal wedge osteotomy and transcuneiform osteotomy to correct such a deformity.MethodsTwenty-seven children with 35 idiopathic clubfeet were treated surgically by combined double tarsal wedge osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) and transcuneiform osteotomy between 2008 and 2012. The age of children at surgery ranged from 4 to 9 years. There were 19 boys and 8 girls. Pre- and postoperative X-rays were used, considering: on the AP radiograph, the calcaneo-fifth metatarsal angle and the talo-first metatarsal angle (indicators of forefoot adduction); on the lateral radiograph, the talo-first metatarsal angle (an indication of supination deformity) and calcaneo-first metatarsal angles (an indication of cavus deformity). These radiological parameters were compared with the clinical results.ResultsFollow-up was conducted for 24–79 months following surgery. Clinical and radiographic improvements in forefoot position were achieved in all cases. An average improvement in the anteroposterior talo-first metatarsal angle of 21°, calcaneo-fifth metatarsal angle of 14°, lateral talo-first metatarsal angle of 10°, and lateral calcaneo-first metatarsal of 12° confirmed the clinically satisfactory correction in all feet. One patient had a wound infection postoperatively, which resolved with removal of the wires and administration of oral antibiotics. Eight patients followed up for more than 5 years had no deterioration of results.ConclusionsCombined double tarsal wedge osteotomy as well as transcuneiform osteotomy is an effective and safe procedure for lasting correction of the bean-shaped foot.

Foot and Ankle Reconstruction for Adult Acquired Flatfoot after Ligamentous Ankle Injury

Introduction: Ankle syndesmosis injuries typically occur when the foot is forced upward and outward. Syndesmosis of the ankle is the joint that connects the tibia and fibula and allows these two bones to work together to provide stability to the lower leg. Case: 24 year old active duty female service member presented to Womack Army Medical Center for left ankle pain approximately 12 weeks after incurring an injury while playing basketball. She reported increased pain with activity and no improvement when using a brace. Imaging studies performed on the weight bearing left leg, ankle, and foot revealed a healed proximal fibular fracture, syndesmosis widening with lateral shift and medial space widening, and decreased longitudinal arch height. A magnetic resonance imaging revealed a deltoid ligament tear and widening of the syndesmosis, but showed no tibialis posterior tendinopathy. The patient was taken to the operating room for open reduction internal fixation of the syndesmosis with a medial displacement calcaneal osteotomy, deltoid ligament repair, gastrocnemius recession, and medial cuneiform opening wedge osteotomy. Discussion: The coexistence of syndesmosis and deltoid ligament injuries modifies ankle joint motion and significantly destabilizes the ankle joint. Radiographs of the affected limb to rule out any fracture are important; however, stress radiographs may be needed to accurately determine stability of the ankle joint as clinical examination cannot assess or diagnose deltoid ligament injury.

Intraosseous and Extraosseous Blood Supply to the Medial Cuneiform

Osteotomies of the medial cuneiform are commonly used to correct forefoot deformity. Bone healing occurs despite periosteal stripping of the dorsal and medial surfaces of this widely articulated bone followed by osteotomy in the midsection of the bone. The objective of this study was to characterize the blood supply of the medial cuneiform. Thirty matched pairs of adult cadaver legs, 60 legs total, were amputated below the knee, and arterial casts were created with India ink and latex. Soft tissues were debrided, allowing visualization of the extraosseous blood vessels. In 53 specimens the vascular supply to the medial cuneiform was photographed and recorded. Forty-nine specimens were then cleared using a modified Spälteholz technique. The intraosseous vascularity of the medial cuneiform was successfully characterized and reviewed in 48 of these specimens. The extraosseous blood supply was similar to previous reports with a middle pedicle branch originating from the dorsalis pedis artery. The medial plantar and superficial medial plantar artery supplied the plantar aspect of the bone. Intraosseous analysis showed a dense capillary network throughout the cuneiform, with typically one central medial major and several minor nutrient arteries noted. Areas of hypovascularity were infrequent and when noted occurred at inconsistent locations. These findings support the clinical suspicion that the medial cuneiform is well vascularized from multiple sources. The plantar blood supply is likely sufficient to allow bone healing after dorsal periosteal exposure and possible injury to the middle pedicle branch of the distal medial tarsal artery. A medial cuneiform opening wedge osteotomy can be used to correct forefoot deformity. This study investigates the blood supply to that bone to better characterize the healing potential of the medial cuneiform.

Radiographic Assessment of Medial Cuneiform Opening Wedge Osteotomy for Flatfoot Correction

Opening wedge osteotomy of the medial cuneiform has become an established intervention for correction of forefoot varus in relation to a flatfoot deformity. The purpose of this study was to use a newly described radiographic measurement to determine the effectiveness and durability of the medial column correction with a plantarflexion opening wedge osteotomy of the medial cuneiform without internal fixation using an allograft. Twenty-three feet underwent medial cuneiform opening wedge osteotomies for correction of forefoot varus associated with flatfoot deformity. The angle between the proximal and distal articular surfaces was measured on lateral radiographs preoperatively, postoperatively prior to weightbearing and at final followup visit. The average angle between the proximal and distal articular surfaces of the medial cuneiform on lateral foot radiographs was 1.0 degree preoperatively (±0.8 degrees). The average angle post-osteotomy, pre-weightbearing, was 8.4 degrees (±3.6 degrees) and at final followup was 7.5 degrees (±2.9 degrees). All patients achieved bony union. We describe a new radiographic measurement to focus on the correction achieved by a plantarflexion osteotomy of the medial cuneiform. It was found to be stable without internal fixation and reliably proceeded to union without significant loss of correction.

Radiographic Analysis of an Opening Wedge Osteotomy of the Medial Cuneiform

Forefoot varus deformity and medial column instability can develop or be present in association with ankle and hindfoot pathology. This study aimed to confirm the utility of medial cuneiform opening wedge osteotomy as part of hindfoot and ankle deformity correction. Patients requiring operative management of flatfoot deformity between January 2002 and December 2007 were prospectively entered in a database. We selected all patients who underwent medial cuneiform opening wedge osteotomy. One hundred and one feet in 86 patients of mean age 36 (range, 9 to 80) years were evaluated. Eighty-one feet had adequate radiographic imaging for assessment. Concomitant procedures were performed. We measured standardized, validated radiographic parameters on pre- and postoperative weightbearing foot radiographs. Variables including concomitant surgical procedures, osteotomy union, malunion, and midfoot arthritis were noted. The mean lateral talus-first metatarsal angle improved from 23 degrees to 1 degrees (p < 0.001); mean medial cuneiform to floor distance improved from 20 mm to 34 mm (p < 0.001); mean talar declination angle improved from 39 degrees to 27 degrees (p < 0.001); mean calcaneal-talar angle improved from 64 degrees to 55 degrees (p < 0.001); calcaneal pitch angle improved from 14 degrees to 23 degrees (p < 0.001); mean first metatarsal declination angle improved from 17 degrees to 26 degrees (p < 0.001); mean talonavicular coverage angle improved from 45 degrees to 18 degrees (p < 0.001); and mean anteroposterior talus-first metatarsal angle improved from 19 degrees to 0 degrees (p < 0.001). Radiographical analysis showed that medial cuneiform opening wedge osteotomy combined with other corrective procedures corrected forefoot varus, elevated first metatarsal and medial column instability radiographic parameters that are most commonly associated with flatfoot deformity.

Double column osteotomy for correction of residual adduction deformity in idiopathic clubfoot

Adduction of the forefoot is the most common residual deformity in idiopathic clubfoot. The 'bean-shaped foot', which is a term used to describe a clinical deformity of forefoot adduction and midfoot supination, is not uncommonly seen in resistant clubfoot. Fifteen children (20 feet) with residual forefoot adduction in idiopathic clubfeet aged 3-7 years were analyzed clinically and radiographically. All of the cases were treated by double column osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) with soft tissue releases (plantar fasciotomy and abductor hallucis release), to correct adduction, supination and cavus deformities. Pre-operative measurements of certain foot angles were compared with their corresponding postoperative values. A grading system for evaluation of the results using a point scoring system was suggested to evaluate accurately both clinical and radiographic results after a follow-up period of an average of 2.3 years. Eight feet (40%) had excellent, eight (40%) good, three (15%) fair, and one (5%) poor outcome. There was no major complication. There was significant improvement in the result (P > 0.04). Double column osteotomy can be considered superior to other types of bone surgeries in correction of residual adduction, cavus and rotational deformities in idiopathic clubfoot.

Radiographic and Pedobarographic Comparison of Femoral Head Allograft versus Block Plate with Dorsal Opening Wedge Medial Cuneiform Osteotomy: A Biomechanical Study

The effect of the Cotton osteotomy has not been studied in isolation, and no alternative to bone graft has been investigated for this osteotomy. We hypothesized that there would be no difference in radiographic and pressure findings using the Cotton osteotomy with bone graft or an opening wedge block plate. Each specimen of eight matched pairs of lower extremities was loaded in simulated double-leg stance via pneumatic cylinders as described previously. Weightbearing lateral and anteroposterior radiographs and medial and lateral pressure measurements were obtained for all intact specimens. Specimens were randomly assigned to receive a Cotton osteotomy with a dorsal opening wedge allograft or an opening wedge plate. Each specimen was cycled at 3 Hz to 720 N for 5000 cycles and measurements were repeated. Calcaneal pitch was lower after the block plate procedure (mean +/- standard error of the mean) (intact, 23.4 +/- 1.2 degrees versus post-procedure, 21.8 +/- 1.1 degrees; p = 0.05). There was a significant difference (p < 0.05) in percentage of total plantar pressure medially and laterally between the intact specimen and the specimen after osteotomy with both methods. Pressure increased medially and decreased laterally. With the numbers available, these methods for performing a Cotton osteotomy did not differ in addressing lateral column overload. Dorsal opening wedge medial cuneiform osteotomy performed with femoral head allograft or a block plate may be effective both in reducing lateral column pressures and increasing medial column pressures when they are deficient preoperatively.

Lateral Column Calcaneal Lengthening, Flexor Digitorum Longus Transfer, and Opening Wedge Medial Cuneiform Osteotomy for Flexible Flatfoot: A Biomechanical Study

Lengthening of the lateral column is commonly used for reconstruction of the adult and pediatric flatfoot, but can result in supination of the foot and symptomatic lateral column overload. The addition of a medial cuneiform osteotomy has been used to redistribute forces to the medial column. The combined use of a lateral column lengthening and medial cuneiform osteotomy in a reproducible cadaver flatfoot model was evaluated. Twelve cadaver specimens were physiologically loaded and each was evaluated radiographically and pedobarographically in the following conditions: 1) intact, 2) severe flatfoot, 3) lateral column lengthening with simulated flexor digitorum longus transfer, and 4) lateral column lengthening and flexor digitorum longus (FDL) transfer with added medial cuneiform osteotomy. The lateral column lengthening was performed with a 10-mm foam bone wedge through the anterior process of the calcaneus, and the medial cuneiform osteotomy was performed with a dorsally placed 6-mm wedge. Lateral column lengthening with simulated FDL transfer on a severe flatfoot model resulted in a significant change as compared with the flatfoot deformity in three measurements: in lateral talus-first metatarsal angle (-17 to -7 degrees; p<0.001), talonavicular angle (46 to 24 degrees; p<0.001), and medial cuneiform height (16 to 20 mm; p<0.001). Lateral forefoot pressure increased from 24.6 to 33.9 kPa (p<0.001) after these corrections as compared with the flatfoot. Adding a medial cuneiform osteotomy decreased the lateral talar-first metatarsal angle from -7 to -4 degrees, decreased the talonavicular coverage angle from 24 to 20 degrees, and increased the medial cuneiform height from 20 to 25 mm. After added medial cuneiform osteotomy, lateral pressure was significantly different from that of the flatfoot (p=0.01) and was not significantly different from that of the intact foot (p=0.14). Medial forefoot pressure was overcorrected as compared with the intact foot with added medial cuneiform osteotomy. Lateral column lengthening increased lateral forefoot pressures in a severe flatfoot model. An added medial cuneiform osteotomy provided increased deformity correction and decreased pressure under the lateral forefoot.

Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity.

Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (-13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.