Opening Wedge Medial Cuneiform 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.

Consensus on Indications for Medial Cuneiform Opening Wedge (Cotton) Osteotomy in the Treatment of Progressive Collapsing Foot Deformity.

Forefoot varus is a physical and radiographic examination finding associated with the Progressive Collapsing Foot Deformity (PCFD). Varus position of the forefoot relative to the hindfoot is caused by medial midfoot collapse with apex plantar angulation of the medial column. Some surgeons use the term forefoot supination to describe this same deformity (see Introduction section with nomenclature). Correction of this deformity is important to restore the weightbearing tripod of the foot and help resist a recurrence of foot collapse. When the forefoot varus deformity is isolated to the medial metatarsal and medial cuneiform, correction is indicated with an opening wedge medial cuneiform (Cotton) osteotomy, typically with interposition of an allograft bone wedge from 5 to 11 mm in width at the base. When the forefoot varus is global, involving varus angulation of the entire forefoot and midfoot relative to the hindfoot, other procedures are needed to adequately correct the deformity. Level V, consensus, expert opinion.

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.

Postoperative Medial Cuneiform Position is Correlated with Patient-Reported Outcomes Following Cotton Osteotomy for Reconstruction of the Stage II Adult Acquired Flatfoot Deformity

Category:Hindfoot, Midfoot/ForefootIntroduction/Purpose:During reconstruction of the stage II adult acquired flatfoot deformity (AAFD), residual supination of the midfoot is often addressed with an opening wedge medial cuneiform (Cotton) osteotomy after adequate correction of the hindfoot valgus deformity. The purpose of this study was to determine if there was a correlation between postoperative alignment of the medial cuneiform using the previously described cuneiform articular angle (CAA) on lateral radiographs and postoperative patient-reported outcomes using the Foot and Ankle Outcome Score (FAOS).Methods:Sixty-three feet in 61 patients with stage II AAFD who underwent a Cotton osteotomy as part of a flatfoot reconstruction were included the study. The CAA, medial arch sag angle (MASA), and lateral talo-first metatarsal (Meary’s) angles were measured on postoperative weightbearing lateral radiographs at a minimum of 40 weeks postoperatively. Pearson’s correlation analysis was used to determine if there was an association between postoperative radiographic angles and FAOS at a minimum of 24 months postoperatively. Patients were also divided into mild plantarflexion (CAA> or =-2 degrees) and moderate plantarflexion (CAA<-2 degrees) groups, and Wilcoxon rank-sum tests were used to identify whether there were differences in clinical outcomes between the two medial cuneiform positions. A postoperative CAA of -2 degrees was chosen because it is two standard deviations from the average postoperative CAA following a flatfoot reconstruction (Castaneda et al. FAI 2012).Results:Postoperative CAA was significantly positively correlated with the postoperative FAOS symptoms (r=.27, P=.03), daily activities (r=.29, P=.02), sports activities (r=.26, P=.048), and quality of life (r=.28, P=.02) subscales. A positive correlation indicates that higher postoperative FAOS scores are associated with a decreased amount of plantarflexion of the medial cuneiform (i.e. a more positive CAA). Patients in the mild plantarflexion group had statistically and clinically better outcomes compared with the moderate plantarflexion group in the FAOS symptoms (P=.04), daily activities (P =.04), and sports activities (P=.01) subscales (Figure 1). Graft size was correlated with postoperative CAA (r =-.30, P = .02) but not correlated with any postoperative FAOS subscale (all P values > .40).Conclusion:Our study suggests that the surgeon should avoid excessive plantarflexion of the medial cuneiform and use the Cotton osteotomy judiciously as part of a flatfoot reconstruction for stage II AAFD.

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.

The Biplanar Effect of the Medial Cuneiform Osteotomy

Background. The "foot-CORA" (center of rotation of angulation) method confirms the medial cuneiform as the site of deformity in most forefoot/midfoot deformities and is therefore the ideal location to correct those deformities. It has been consistently observed intraoperatively by the senior author that there is a secondary, unintentional deformity created in the transverse plane when dorsiflexion and plantar flexion osteotomies of the medial cuneiform are performed to correct pronation and supination forefoot deformities, respectively. These effects may not be desirable. This biplanar effect of medial cuneiform osteotomies has been observed but not studied. The purpose of this study was to perform the 4 commonly used medial cuneiform osteotomy techniques on cadaveric feet to demonstrate their biplanar effects. Methods. Four formaldehyde preserved cadaveric feet were used to perform 4 techniques of medial cuneiform osteotomy: dorsiflexion plantar-based opening wedge, plantar flexion dorsal-based opening wedge, dorsiflexion dorsal-based closing wedge, and plantar flexion plantar-based closing wedge. Photographs and fluoroscopy were used to assess the angular changes in the sagittal and transverse planes. Angular measurements were made using OsiriX software on fluoroscopic images. Results. The medial cuneiform opening wedge osteotomies produced midfoot abduction in addition to the desired dorsiflexion and plantar flexion. The medial cuneiform closing wedge osteotomies produced midfoot adduction in addition to the desired dorsiflexion and plantar flexion. Conclusion. We confirm that intentional sagittal uniplanar osteotomies of the medial cuneiform create obligate biplanar effects. This is likely a result of tethering by ligaments and the joint capsules on the lateral border of the medial cuneiform. The obligate transverse plane effect can be used to one's advantage or result in an undesired effect if not considered during surgical planning and execution. We propose a simple treatment algorithm for selecting the appropriate medial cuneiform osteotomy for forefoot/midfoot deformities. Levels of Evidence: Level V.

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

The Contribution of Medial Cuneiform Osteotomy to Correction of Longitudinal Arch Collapse in Stage IIb Adult Acquired Flatfoot Deformity

Category: Midfoot/Forefoot Introduction/Purpose: Residual forefoot supination present after correcting the hindfoot in Stage IIb adult acquired flatfoot deformity (AAFD) can be addressed with a dorsal opening wedge medial cuneiform (Cotton) osteotomy. The amount of correction is generally judged clinically and there currently are no preoperative guides that can predict the size of graft needed. The aim of this study was to evaluate the relationship between the Cotton osteotomy graft size and other accessory flatfoot reconstructive procedures, and the amount of correction of longitudinal arch collapse. We hypothesized that correction of longitudinal arch collapse, as measured by the cuneiform articular angle (CAA), would primarily be influenced by the Cotton osteotomy performed. More specifically, we hypothesized that the size of the graft would have the largest effect on the CAA. Methods: Seventy-nine feet in 74 patients undergoing Cotton osteotomy as part of flatfoot reconstruction were reviewed retrospectively. Preoperative and minimum 40-week postoperative lateral weightbearing foot radiographs were compared to assess correction of longitudinal arch collapse as measured by 13 radiographic parameters, with particular emphasis on the CAA. Additional demographic and intraoperative variables analyzed for association with radiographic change included age, gender, body mass index (BMI), amounts and graft types of Cotton osteotomy and lateral column lengthening (LCL), and amount of medializing calcaneal osteotomy (MCO). Other concomitant procedures at the time of surgery, namely Achilles lengthening, flexor digitorum longus (FDL) transfer, spring ligament reconstruction, gastrocnemius recession, and excision of accessory navicular were also recorded. Ultimately, a multivariable linear regression model was developed to estimate the effect of Cotton osteotomy on change in the CAA, adjusting for patient and clinical variables. Results: Cotton osteotomy graft size was significantly associated with changes in the CAA (P &lt; .001), calcaneal pitch (P = .03), lateral talo-navicular Cobb angle (P = .03), and lateral naviculo-medial cuneiform Cobb angle (P = .03). Multivariable linear regression models included age at surgery, gender, BMI, and the use of all concomitant procedures (LCL, Achilles lengthening, FDL transfer, gastrocnemius recession, and excision of accessory navicular) except for spring ligament reconstruction, since this was not associated with any of the four radiographic measurements. Cotton graft size was the only factor found to significantly predict a change in the CAA in the final linear regression model (P &lt; .001, R2 = .27), with each millimeter of Cotton corresponding to a 2.1-degree decrease of the CAA (figure 1). Conclusion: Correction of longitudinal arch collapse, as measured by the CAA, was primarily influenced by graft size of the Cotton osteotomy in a linear fashion. The results also demonstrate that the procedure has a more distal effect in correction of longitudinal arch collapse and is of particular importance when the apex of deformity is at the medial cuneiform. Because the relationship between the Cotton osteotomy graft size and the CAA can be modeled linearly, we believe that preoperative measurement of the CAA can be a useful guide in helping surgeons to titrate the proper amount of longitudinal arch collapse correction intraoperatively.

Contribution of Medial Cuneiform Osteotomy to Correction of Longitudinal Arch Collapse in Stage IIb Adult-Acquired Flatfoot Deformity.

Seventy-nine feet in 74 patients undergoing Cotton osteotomy as part of flatfoot reconstruction were reviewed retrospectively. Preoperative and minimum 40-week postoperative lateral foot weightbearing radiographs were compared to assess correction of longitudinal arch collapse as measured by 13 radiographic parameters, with particular emphasis on the cuneiform articular angle (CAA). Additional demographic and intraoperative variables analyzed for association with radiographic change included age, gender, body mass index, amounts and graft types of Cotton osteotomy and lateral column lengthening, and amount of medializing calcaneal osteotomy. A multivariate linear regression model was developed for each variable found to be significant in univariate analysis. The Cotton osteotomy graft size was significantly associated with changes in the CAA ( P < .001), calcaneal pitch ( P = .03), lateral talonavicular Cobb angle ( P = .03), and lateral naviculomedial cuneiform Cobb angle ( P = .03). The Cotton graft size was the only factor found to significantly predict a change in the CAA in the final linear regression model ( P < .001, R2 = 0.27), with each millimeter of Cotton corresponding to a 2.1-degree decrease of the CAA. Correction of longitudinal arch collapse, as measured by the CAA, was primarily influenced by the size of the graft used for the Cotton osteotomy in a linear fashion. The preoperative CAA may help surgeons titrate the proper amount of graft placed intraoperatively. Level IV, Retrospective Case Series.

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.

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.