Medial Displacement Calcaneal Osteotomy Research Articles

A Novel Technique of Medial Displacement Calcaneal Osteotomy Using the Intramedullary Fixation of a Conventional Low-Profile Locking Wedge Plate.

Postoperative heel pain arising from prominent screw heads is a common complication following medial displacement calcaneal osteotomy (MDCO). This study aims to present the clinicoradiographic outcomes of a novel MDCO technique, wherein intramedullary fixation of a conventional low-profile locking wedge plate is employed. A retrospective analysis, involving a comparison of clinical and radiographic parameters among consecutive patients who underwent MDCO was conducted. The patients were subjected to either intramedullary wedge plate fixation through the osteotomy site (IWPF group, n = 45 cases) or conventional cannulated screw fixation from the heel (CCSF group, n = 51 cases). Radiographic evaluation included measurement of hindfoot alignment angle, alignment ratio, and moment arm. Clinical outcomes were measured with the American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and the Foot and Ankle Ability Measure (FAAM) activities of daily living and sports subscales, before and at 6, 12, and ≥24 months postoperatively. The presence of heel pain was evaluated at the postoperative 6 and 12 months in both groups. For both groups, a marked enhancement in all 3 radiographic parameters was observed. The extent of correction for all clinicoradiographic parameters demonstrated no statistically significant divergence between the 2 groups. However, the FAAM-Sports scores at the 6-month postoperative juncture exhibited a significant elevation in the IWPF group relative to the CCSF group. Importantly, no patient reported heel pain at postoperative 6 and 12 months in the IWPF group whereas the rates of patients having heel pain at postoperative 6 and 12 months were 56.8% (29 cases) and 33.3% (17 cases), respectively, in the CCSF group. Both techniques yield analogous postoperative clinical and radiographic enhancements. However, the utilization of IWPF promotes a swifter clinical improvement with respect to sports activities when juxtaposed with the CCSF from the calcaneal tuberosity. Level III, retrospective comparative study.

Biomechanical Effects of Subtalar Joint Fusion and Medial Ligament Reconstruction in Simulated Progressive Collapsing Foot Deformity.

The purpose of this study is to investigate the biomechanical effect of medial displacement calcaneal osteotomy (MDCO), subtalar joint fusion (SF), and medial ligament reconstruction (MLR: deltoid-spring ligament) in a severe flatfoot model. We hypothesized that (1) combination of MDCO and SF improves the tibiotalar and foot alignment in severe progressive collapsing foot deformity (PCFD) cadaver model. (2) However, if a residual valgus heel alignment remains after MCDO and SF, it can lead to increased medial ligament strain, foot malalignment, and tibiotalar valgus tilt, which will be mitigated by the addition of MLR. Ten fresh-frozen cadaveric foot specimens were used to create a severe flatfoot model. The foot alignment changes, including the talo-first metatarsal angle in the axial and sagittal planes, subtalar angle, and tibiotalar angle in the coronal plane, were measured. The angles were measured at the initial condition, after creating the severe flatfoot model, and after each successive reconstructive procedure in the following order: (1) MDCO, (2) SF, and (3) MLR. Tibiotalar valgus tilt was decreased with the MDCO procedure: 4.4 vs 1.0 degrees (P = .04). Adding in situ SF to the MDCO led to increased tibiotalar tilt to 2.5 degrees was different from the initial condition (P = .01). Although the tibiotalar valgus tilt was significantly decreased after adding the MLR to the MDCO/SF procedure compared with the severe flatfoot model (0.8 vs 4.4 degrees, P = .03), no significant difference in the tibiotalar valgus tilt was observed between MDCO/SF and MDCO/SF with MLR. Our results demonstrated that MDCO significantly improved forefoot abduction and medial arch alignment, with no significant additional improvement observed with addition of SF. Following SF, a residual valgus heel alignment can contribute to subsequent tibiotalar valgus tilt. The addition of MLR did not show significantly decreased tibiotalar valgus tilt following SF. Residual valgus heel alignment after subtalar joint fusion in the surgical treatment of PCFD can lead to increased medial ligament strain. Although MLR might be considered for providing medial stability, it may not necessarily prevent the development of tibiotalar valgus tilt.

The Mini Bone Extra-articular Reconstruction System for Progressive Collapsing Foot Deformity—Surgical Technique With Cadaveric Quantification of Surrounding Anatomy

We present a novel surgical technique, the mini Bone Extra-articular Reconstruction (BEAR) system, that involves minimally invasive all BEAR systems. The surgical technique was used to perform the medial displacement calcaneal osteotomy, Evans osteotomy, and Cotton osteotomy on 9 cadaveric feet under fluoroscopic guidance. We also present a case series of patients who have undergone the procedure. We first carefully dissected the sural nerve, superficial peroneal nerve, and its branches from each cadaveric foot and evaluated injuries following the mini-BEAR osteotomy cuts. We then measured and recorded the distance between the osteotomy cuts and these anatomic structures. We believe that this technique can potentially replace the multiple long surgical incisions with minimal ones. Level of Evidence: Level IV.

Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit.

We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents. A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test. The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal. Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

Outcomes of Hindfoot Joint-Sparing Reconstructive Procedures for Flexible Progressive Collapsing Foot Deformity: A Prospective Cohort Study

Category: Hindfoot; Other Introduction/Purpose: Treatment of Progressive Collapsing Foot Deformity (PCFD) is controversial and surgical procedures utilized usually depend on the type and rigidity of deformities present (PCFD classes and stages), degree of soft tissue involvement, and surgeon’s preference. Multiple surgical procedures are usually performed concomitantly to achieve adequate correction. Prospective data regarding the utilization of hindfoot joint-sparing reconstructive procedures in the treatment of flexible PCFD is scarce, and little is known about the influence of the different procedures utilized to treat PCFD in deformity correction and patient-reported outcomes (PROs). The objective of this prospective study was to evaluate the most used hindfoot joint-sparing procedures utilized by a single-surgeon to treat flexible PCFD, and the influence of the utilized procedures in deformity pattern corrections, and PROs. Methods: IRB-approved, prospective, and comparative cohort study. Adult PCFD patients with flexible deformity (stage 1), no history of surgical treatment, and that failed conservative treatment for &gt;3-months were enrolled. Patients underwent surgical treatment by a single-surgeon. Patients were excluded if a hindfoot fusion procedure was needed intra-operatively to achieve correction. Types, numbers, and sizes of surgical procedures utilized were recorded. Weight-bearing CT (WBCT) measurements of overall 3D deformity, Classes A (hindfoot valgus), B (abduction), C (medial column instability), D (peritalar subluxation), and E (ankle valgus tilt) were assessed preoperatively, and at first 3-months WBCT. PROs were recorded preoperatively and at the most recent follow-up. Descriptive statistics were used to report the frequency of deformity and procedures utilized. Pre and postoperative measurements and PROs were compared with paired T-tests/Wilcoxon. Multivariate regression analysis was used to correlate procedures utilized with deformity correction and PROs. P-values of &gt;0.05 were considered significant. Results: A total of 29 patients included (28 feet, 79%F, 21%M), mean age and BMI of respectively 47.6-years and 34kg/m2. Average number of procedures performed was five and mean follow-up was 19.1 months (range, 3 to 40). Frequency and sizes of medial displacement calcaneal osteotomy (MDCO), first ray plantarflexion procedure (Cotton/LapiCoton), and lateral column lengthening (LCL) procedures were, respectively: 100% (8.9mm displacement), 100% (66% Lapicotton/34% Cotton, 8.3mm wedge-opening) and 39% (6.8mm wedge-opening). Soft-tissue procedures performed: 83% Posterior tibial tendon (re-tensioning/FDL transfer/allograft reconstruction), 34% peroneal tendon (brevis-to-longus and brevis lengthening), 76% gastrocnemius-recession, 38% spring ligament (re-tensioning/reconstruction/augmentation) and 31% deltoid ligament (re- tensioning/reconstruction/augmentation). Significant improvement postoperatively was observed in all PCFD measurements performed and PROs (Figure). However, no direct correlation was found between procedures performed/measurement improvements and PROs. Conclusion: In this prospective comparative cohort study of flexible PCFD patients undergoing surgical treatment with hindfoot joint sparing surgical procedures, we observed significant postoperative improvement in all deformity patterns assessed (Classes A, B, C, and D) as well as PROs. MDCO and first ray plantarflexion procedures (Cotton or LapiCotton) were the most commonly utilized procedures and were performed in all cases. Even though deformity correction and PRO improvements were observed postoperatively, no direct correlation was observed between PROs and specific surgical procedures performed or deformity pattern corrections (PCFD classes).

Nonunion Rate of Evans Osteotomy Without Fixation Pediatric Flatfoot

Category: Hindfoot; Other Introduction/Purpose: The Evans osteotomy is a calcaneal lateral column lengthening procedure commonly used to correct flatfoot deformities. Currently, there is no consensus on whether fixation is needed when performing this osteotomy. Also, large sized grafts have been found to lead to degeneration of the calcaneocuboid joint. The aim of this study was to determine the nonunion rate of an unfixed Evans osteotomy with use of an allograft wedge performed in patients undergoing flexible flatfoot reconstruction and if addition of a medial calcaneal slide osteotomy will help limit graft size. Methods: We retrospectively reviewed 39 pediatric patients with idiopathic symptomatic flatfoot deformity who underwent 46 unfixed Evans osteotomies with allogenic bone graft for flatfoot reconstruction between March 2013 and September 2017, with a mean follow-up of 49 (range 9.9- 243.9) weeks. Hospital record, preoperative, follow-up radiographs and complications were reviewed. Results: Of the 46 feet, 42(91.3%) underwent an associated medial displacement calcaneal osteotomy. Mean graft wedge size was 7.2mm(SD 1.6). Mean time to union was 10.3weeks (range, 6.7-13.9)(Table 1). There were no nonunions. There was significant improvement in all radiographic parameters at final follow-up (Table 2). Postoperative calcaneocuboid subluxation occurred in 70% of feet, with no correlation with wedge size(r=0.01,p=0.53). Magnitude of calcaneocuboid subluxation was small and only significant at 6-months (p=0.02), with regression to no significance by 1-year(p=0.3). Mean change in calcaneocuboid subluxation at final follow-up was 1.07mm(SD 2.18), with postoperative subluxation diminishing over time(Table 3). No correlation was observed between wedge size and change in lateral column length (r=0.01,p=0.45). One patient had persistent sinus tarsi pain requiring arthroscopic debridement of fibrosis and graft prominence. Conclusion: An unfixed Evans osteotomy for symptomatic pediatric flatfoot deformity resulted in a significant improvement in the radiographic alignment and achieved 100% union rate with minimal calcaneocuboid subluxation at final follow-up. Performing adjunctive procedures allowed the Evans procedure to be routinely limited to less than 10 mm of lengthening. Mean graft size in our cohort was smaller than that reported by other studies. While calcaneocuboid subluxation was detectable in 70% of feet, it was small in magnitude and diminished with longer postoperative follow-up.

Surgically treated adult acquired flatfoot deformity: Register-based study of patient characteristics, health-related quality of life and type of surgery according to severity

BackgroundPopulation-level data describing patient characteristics and interventions used in surgical treatment of adult acquired flatfoot deformity (AAFD) is lacking. MethodsWe analyzed baseline patient-reported data including PROMs and surgical interventions for patients with AAFD reported to the Swedish Quality Register for Foot and Ankle Surgery (Swefoot) 2014–2021. Results625 feet with primary AAFD surgery were registered. Median age was 60 (range 16–83) years and 64% were women. Mean preoperative EQ-5D index and Self-Reported Foot and Ankle Score (SEFAS) were low. In stage IIa (n = 319) 78% had medial displacement calcaneal osteotomy and 59% had flexor digitorium longus transfer, with some regional variations. Spring ligament reconstruction was less common. In stage IIb (n = 225), 52% had lateral column lengthening, and in stage III (n = 66), 83% had hind-foot arthrodesis. ConclusionsPatients with AAFD have low health-related quality of life before surgery. Treatment in Sweden follows best-available evidence but regional variations exist. Level of evidenceIII

Minimally invasive Vs open medial displacement calcaneal osteotomy. A cadaveric study

Category: Hindfoot; Hindfoot Introduction/ Purpose: Medial displacement calcaneal osteotomy (MDCO) is routinely used to correct hindfoot valgus in flexible pes planovalgus deformities. Classically MDCO was described through a lateral heel oblique incision with soft tissue dissection and the use of sagittal saw. Recently, minimally invasive surgical (MIS) techniques have gained popularity among foot and ankle surgeons, with the aim to reduce wound complications and postoperative pain and swelling. MIS calcaneal osteotomy was reported to be safe and effective as compared to open techniques. The aim of this cadaveric study was to compare the degree of deformity correction (coronal calcaneal displacement) using MIS vs open MDCO. Methods: Eight matched pairs foot and ankle cadaveric specimen were used. All specimens were checked radiographically for any previous foot and ankle operations or deformities. For each pair, one foot (right or left) was randomly assigned to either open or MIS MDCO. After the completion of osteotomy, the calcaneal tuberosity was maximally displaced medially and fixed with 2 mm wire. The displacement was measured manually using a flexible metric ruler. All osteotomies and manual measurement was done by the same Orthopaedic surgeon. Displacement was measured on standardized axial calcaneal radiographs by three blinded foot and ankle Orthopaedic surgeons independently using an image processing software with standard scaling for magnification. The displacement was measured laterally on the anterior body fragment and medially on the posterior tuberosity fragment Figures 1. Data was compared using the Wilcoxon-Mann-Whitney U test with the P value of &lt; 0.05 considered significant. Results: Five right and three left ankles underwent MIS osteotomy. On manual measurement the mean medial displacement was 7.87 mm and 8.66 mm for MIS and open technique respectively P=0.21). On radiographs, on medial measurements the average displacement of MIS osteotomy was 5.83 mm compared to 6.36 mm for the open group with a P value of 0.34. On lateral measurements the average displacement of MIS osteotomy was 5.94 mm compared to 6.17 mm for the open group with a P value of 0.67. Conclusion: This cadaveric study reported comparable coronal displacement using MIS vs open techniques for medical displacement calcaneal osteotomy. MIS calcaneal osteotomy offers a reliable alternative to open techniques with the potential advantages of lower wound related complications.

Medial displacement calcaneal osteotomy: Loss of correction with varying drilling techniques

IntroductionJoint preserving surgery for flatfoot reconstruction utilizes correction of bony malalignment and medial soft tissue reconstruction. A medial displacement calcaneal osteotomy (MDCO) can be an essential adjunct to deformity correction and good patient outcomes. Our cadaveric study compares three different surgical techniques utilizing two cannulated screws to best maintain medial translation of the calcaneal osteotomies. Materials and methodsFifteen above knee fresh-frozen, matched pair cadaveric specimens (30 limbs) were randomized equally to three groups. MDCO were performed on all specimens, followed by manual 10 mm translation. The groups consisted of a “simultaneous drilling,” “staggered drilling,” and a control group, which involved simultaneous drilling of only the near cortex. Following screw fixation, the calcaneal tuberosity was manually translated in a lateral direction. The loss of correction was measured in millimeters. ResultsThe “simultaneous” drilling group experienced the greatest mean loss of correction at 2.6 mm (range 1.37–3.48 mm). The “staggered” group showed an average loss of 1.16 mm (range 0.36–2.67 mm). The control group demonstrated the greatest maintenance of correction with a mean loss of 0.036 mm (range 0.01–0.06 mm). ConclusionsMDCO realigns the hindfoot adding support to the medial soft tissue reconstruction during flatfoot correction. Loss of initial correction may result in residual deformity and poor long-term outcomes. Our study demonstrates that simultaneous drilling of only the tuberosity near cortex prior to screw fixation was the best at maintaining osteotomy correction. Level of evidence: Level V, Cadaveric study

Comparative study between medial displacement calcaneal osteotomy using modified step plate and arthroereisis for management of planovalgus feet

Background: Flexible flatfoot is a common condition that is characterized by hindfoot valgus with longitudinal medial-arch collapse. Many strategies for treatment have been reported but according to the current literature, controversy remains. Objectives: To compare the clinical and radiological outcomes of medializing calcaneal osteotomy utilizing modified step plate and subtalar arthroereisis utilizing conical subtalar implant for patients with symptomatic flexible pes planus. Methods: A prospective, randomized, double center study was conducted between May 2017 and May 2019 at the Foot and Ankle Department of Cairo University Hospital and El Sahel Teaching Hospital on 26 patients (37 feet) with flexible flat feet to compare between medial displacement calcaneal osteotomy using modified locked step plate (group A) compromising 17 feet and arthroereisis using subtalar implant (group B) compromising 20 feet. Results: By the end period of the study, 25 males and 12 females were available for our analysis of results with a mean follow-up period of 10.14 months (range 7–14 months), clinical scoring (American Orthopaedic Foot and Ankle Society score, Foot Functional Index) with radiological analysis revealed a non-significant difference between both groups, the overall complication rate was 16.2%. Conclusion: Both medial displacement calcaneal osteotomy and subtalar arthroereisis significantly improved radiographic and subjective clinical outcome measures in the surgical treatment of painful flexible planovalgus feet. The less-invasive nature and lower potential morbidity suggest that judicious use of arthroereisis implants is an appropriate alternative.

Influence of Isolated and Combined Medial Displacement Calcaneal Osteotomy, Lateral Column Lengthening and Cotton Osteotomy in Three-Dimensional Foot Alignment: A Cadaveric Weightbearing CT Study

Category: Midfoot/Forefoot; Other Introduction/Purpose: Lateral Column Lengthening (LCL), Medial Displacement Calcaneal Osteotomy (MDCO) and Cotton Osteotomy (CO) are considered the work-horse surgical procedures for Progressive Collapsing Foot Deformity (PCFD) correction. The amount of three-dimensional correction induced by each isolated procedure cannot be established in the clinical setting since procedures are frequently performed in combination based on deformity severity and surgeon's preference. Understanding the influence of each one of the procedures, as well as their magnitudes, in the overall 3D correction of the deformity would be extremely helpful in the surgical planning of PCFD. Therefore, our simulated weightbearing cadaveric study aimed to assess the amount of 3D correction induced by different magnitudes of isolated and combined LCL, MDCO, and CO procedures, using weightbearing CT (WBCT) imaging. Methods: In this cadaveric study 12 below-knee specimens with no deformity were used. They were mounted on a frame under 360N of axial load, while keeping conventional stance level tension to tendinous structures. Each group of four specimens underwent isolated and progressive magnitudes of MDCO (6, 10 and 14mm), LCL (6, 8 and 10mm) and CO (4, 8 and 12mm). Following isolated correction, the specimens were randomized into different amounts of combined correction, first with two procedures (only moderate correction; four specimens each combination) and then with three procedures (combined mild, moderate and large corrections; four specimens each). The 3D measurement Foot and Ankle Offset (FAO), representing the relative position between the center of the ankle joint and the weight bearing tripod of the foot, was calculated from WBCT datasets for each specimen in each one of the tested corrected conditions. Comparison between the different conditions was performed using Paired T-Test/Wilcoxon. Results: All isolated performed corrective procedures (MDCO, LCL and CO) significantly influenced FAO measurements (All p- values &lt;0.05). When applied in isolation, every 1mm increase in MDCO, LCL and CO decreased FAO values by respectively 0.8%, 0.36%, and 0.29%, highlighting the importance of the heel position in the overall 3D position of the foot. Combination of two moderate-sized procedures decreased FAO values significantly (p&lt;0.05) and more pronouncedly, with combination of MDCO and LCL decreasing FAO by an average of 7.2%, MDCO and CO by 6.2% and LCL and CO by 3.9%, with no significant differences between the three. As expected, combination of the three procedures lead to pronounced and significant decreased of FAO values by respectively 5.2%, 8.5% and 14.2% for mild, moderate, and large corrections. The combination of the three large sized corrections was significantly higher than mild and moderate corrections (p=0.002). Conclusion: In this cadaveric WBCT study we assessed the influence of different magnitudes of isolated and combined MDCO, LCL and CO in foot and ankle 3D alignment. We found that all isolated procedures significantly decreased FAO measurements, with every 1mm increase in MDCO, LCL and CO decreasing FAO by respectively 0.8%, 0.36%, and 0.29%. Combination of two procedures and three procedures also lead to significant and more pronounced alignment change. The data presented in this study can serve as baseline predictive values of foot alignment correction when planning the use of MDCO, LCL and CO for surgical treatment of PCFD.

Minimally Invasive Foot &amp; Ankle Surgery: A Review and a Novel Technique

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: There has been a growing interest in the utility of minimally invasive surgery (MIS) to correct foot and ankle deformities. MIS is performed using small, targeted incisions rather than large incisions required of open procedures. Proposed benefits of MIS include preservation of blood supply, limited injury to adjacent soft tissue, and fewer wound complications amongst many others. (Neufeld et al, Lu et al). To date, a large number of minimally invasive techniques have been developed to treat common deformities such as hallux valgus, hammertoe, and bunionette. However, there is no brief review that summarizes the literature comparing open surgery with its minimally invasive counterpart. Additionally the options available for MIS treatment of Flexible Adult Acquired Flat Foot/Progressive Collapsing Foot Deformity have failed to keep pace. Methods: We will begin by synthesizing data on MIS in the foot and ankle through analysis of those three aforementioned deformities, summarizing both technique and associated research. Then, we will introduce a novel technique for stage II (flexible) flat foot correction, the Mini-BEAR (bone extra articular reconstruction). Historically treated with the now largely insufficient FDL transfer, we believe this new technique will not only prove biomechanically efficacious but also lead to improved patient safety and lower complication rates. The rapid pace at which novel MIS procedures are developed requires surgeons to be disciplined in conducting and analyzing studies; this synopsis will aim to aid in that process. Results: A novel surgical technique that involves a minimally invasive, all bone extra-articular reconstruction (Mini-BEAR) system. We believe that this technique can potentially replace the multiple long surgical incisions that accompany the traditional medial displacement calcaneal osteotomy, lateral column lengthening, and Cotton procedures with minimal ones, reduce post-operative recovery time, reduce operating room procedure time, and produce a better cosmetic result. Additionally, we believe it will reduce narcotic use secondary to less pain by virtue of less surgical work on the patient. We have also performed a cadaveric anatomic study that qualitatively and quantitatively observed the tendinous and neurovascular structures at risk with the Mini- BEAR procedure. Conclusion: The majority of the publications on the use of MIS to address deformities in the foot and ankle are small cohort studies or retrospective case reviews; many of which lack a control group. Due to this, data showing improvements in MIS vs open techniques is rare. However this is to be expected in a newer, developing field and as larger studies are performed there is optimism that this trend may change. (attached file is example of chart, we have similar format for all 4 deformities discussed in this paper)

Incidence of Lateral Prominence Pain Following Open Medial Displacement Calcaneal Osteotomy and the Efficacy of Crushplasty as a Preventive Technique.

There has been concern about lateral prominence pain at the osteotomy site following medial displacement calcaneal osteotomy (MDCO). However, no study has investigated this complication. This study aimed to investigate the incidence of lateral prominence pain following MDCO and examine the efficacy of crushplasty as a surgical technique to minimize this complication. This was a retrospective cohort study in which 137 patients (148 feet) who underwent MDCO were divided into 2 groups by whether they had concurrent crushplasty at the time of MDCO (crushplasty [n = 81] vs noncrushplasty group [n = 67]). Crushplasty was performed by flattening the bony step-off using a rongeur and bone impactor. Lateral prominence pain was defined as pain or irritating symptoms over the osteotomy site that persisted over 12 months after MDCO. The overall incidence of lateral prominence pain after MDCO and within each group was investigated. Multiple logistic regression analysis was used to determine the influence of possible risk factors on the development of postoperative lateral prominence pain. The overall incidence of lateral prominence pain was 9.5% (14 of 148): 3.4% (3 of 87) in the crushplasty group, and 18% (11 of 61) in the noncrushplasty group, and χ2 analysis showed a statistically significant relationship between crushplasty and lateral prominence pain (P < .05). A relationship between the amount of medial displacement and the development of lateral prominence pain was observed in the noncrushplasty group (OR = 5.31, 95% CI 2.35-16.4, P < .05), but this was not observed in the crushplasty group (P = .641). The amount of medial displacement was an independent risk factor for the development of lateral prominence pain (OR = 2.72, 95% CI 1.54-4.79, P < .05), and concurrent crushplasty had a negative relationship with lateral prominence pain development (OR = 0.12, 95% CI 0.03-0.57, P < .05). This study revealed that lateral prominence pain is a significant complication of MDCO, especially in the setting of a larger displacement. The crushplasty following MDCO may minimize this complication, particularly when a greater degree of hindfoot correction is attempted.

Implant Related Artifact Around Metallic and Bio-Integrative Screws: A CT Scan 3D Hounsfield Unit Assessment

Category:Basic Sciences/Biologics; HindfootIntroduction/Purpose:Implant-related artifact (IRA) represents an important limitation in Computed Tomography (CT) assessment of osteotomy and fracture healing, bone-implant integration, and success of fusion procedures. Metallic implants are the most used in foot and ankle surgery and are recognized as important IRA generators. Absorbable and bio-integrative (BI) implants are attractive options for bone fixation when postoperative CT imaging is likely, particularly in procedures with higher risk for nonunion. However, the literature comparing IRA with metallic and BI implants is scarce. The objective of this study was to assess the degree of IRA around metallic and BI cannulated screws. Our hypothesis was that BI implants would demonstrate significantly decreased IRA around the inserted screws.Methods:In this cadaveric/CT imaging study, 2 below-knee specimens were used. Medial displacement calcaneal osteotomy was performed through a 5-cm long lateral heel approach. Calcaneal tuberosity was displaced medially by 10mm and fixed provisionally with 2 parallel K-wires under fluoroscopic guidance. Specimens were fixed with two headless 4.0 millimeters cannulated screws, either metallic or BI. Cone-beam CT imaging of both specimens was acquired following osteotomy screw fixation (120kVp, 5.5mA, 0.25mm isotropic). Using a dedicated software, the overall dispersion of Hounsfield units (HU) in a 3D cube of 30mm edge length was assessed. Four HU lines were then traced parallel to the screws, crossing the osteotomy site. Lines 1, 2, 3 and 4 were positioned respectively: In close proximity, over, inside the cannulation and away from the implant. The HU dispersion in these lines was measured and compared between metallic and BI implanted specimens, using T-tests/Wilcoxon analysis. P-values<0.05 were considered significant.Results:When compared to the BI implant, the average HU was pronouncedly and significantly increased around metallic implants in the lines with more close proximity (Line 1), over the screw wall (Line 2) and inside the screw cannulation (Line 3), when considering both the whole line extension inside the 3D cube as well as in a selected 8mm line-segment across the calcaneal osteotomy line: Line 1 (entire, 7.26 vs -159; selected, -5 vs -249) Line 2 (entire, 4.846 vs 108; selected, 6286 vs 151.2); Line 3 (entire, 1664 vs 144; selected, -277.7 vs 198.7) selected). However, across Line 4 (away from the implant), the HU dispersion was interestingly and significantly decreased around the metallic implant (entire, -49 vs 178.5; selected, -110 vs 221), potentially as result of beam hardening artifact, concentrating HU close to the metal, and shielding the surrounding cancellous bone from being accurately reconstructed.Conclusion:In this cadaveric imaging study, we compared Implant-related artifact (IRA) around metallic and bio-integrative (BI) implants utilized to fix medial displacement calcaneal osteotomies. We found metallic implants to demonstrate significantly and pronouncedly increased HU dispersion in in close proximity with the implants and significantly decreased dispersion more distantly from the implant, shielding the surrounding cancellous bone, and potentially hindering the assessment of bone density quality and bone/osteotomy/fusion healing in its neighborhood. BI implants represent an alternative to decrease these IRA effects. Additional clinical studies are needed to confirm and expand our findings.

Risk Factors for Complications Associated with Minimally Invasive Medial Displacement Calcaneal Osteotomy

Category:HindfootIntroduction/Purpose:Several minimally invasive medial displacement calcaneal osteotomy (MIS MDCO) techniques have been described utilizing differing methods for creating the osteotomy. However, there are few clinical reports of the safety profile and outcomes after percutaneous MDCO procedures. The purpose of this study was to describe short-term outcomes and complications associated with MIS MDCO for the correction of hindfoot valgus deformities.Methods:A retrospective study was conducted of all patients who underwent consecutive minimally invasive MDCO for the treatment of a hindfoot valgus deformity by a single fellowship-trained foot and ankle orthopaedic surgeon from September 2013 to August 2018. Demographic data, treatment data, and complications were recorded from the electronic medical record for the duration of the patient's follow-up. Univariate statistics were used to determine the relationship between complications and demographic/treatment variables. A p<0.05 was considered significant.Results:Patients who underwent 189 MIS MDCO procedures were included in the study. Median follow-up was 12 months (interquartile range, 7 to 25 months). Osteotomy healing complications were present in 7% of cases. A 12-month cluster of osteotomy healing complications was observed. Healing complication rates were 28% during the cluster and 0.7% outside of the cluster. Osteotomy healing complications were significantly associated with higher American Society of Anesthesiologists (ASA) classification, female sex, current tobacco use, and higher body mass index (BMI). Healing complications were not associated with osteotomy technique (saw vs. burr) or fixation type. Other complications included wound dehiscence (3%), surgical site infection (2%), transient nerve symptoms (6%), and persistent nerve symptoms (2%). Nerve symptoms were significantly associated with an increased number of concomitant procedures.Conclusion:Patients with higher ASA classification, current tobacco use, and higher BMI were at higher risk for osteotomy healing complications after minimally invasive MDCO procedures. Patients were also more likely to develop nerve complications with more extensive surgical procedures. These findings may be useful for surgeons when counseling patients regarding their surgical risks and when optimizing their comorbidities preoperatively.

Biomechanical comparisons of different diagonal screw designs in a novel embedded calcaneal slide plate.

Medial displacement calcaneal osteotomy (MDCO) is frequently used for the surgical correction of flatfoot. This study aims to investigate the biomechanical effect of the different diagonal screw design on a novel-designed embedded calcaneal plate for MDCO using finite element analysis (FEA), mechanical test and digital image correlation (DIC) measurement. Four groups according to the varied implanted plate were set as control group (Group 1), non-diagonal screw (Group 2), one-diagonal screw (Group 3), and two-diagonal screws groups (Group 4). For FEA, A 450 N load was applied to on the anterior process of the calcaneus from top to bottom. Observational indices included the stress on the cortical and cancellous bone of the calcaneus surrounding the implant, the plate itself as well as screws, and the displacement of the overall structure. In addition, this study also used in vitro biomechanics test to investigate the stiffness of the structure after implantation, and used DIC to observe the displacement of the calcaneus structure after external force. Under a simulated load in FEA, there are significant overall instability and high stress concentration on the calcaneal surrounding host bone and the plate/screws system, respectively, in group 2 compared with other groups. Regard to the mechanical testing with DIC system, significant increased rotation stability, maximum force and stiffness with the addition of diagonal screws. In comparison to Group 2, the increase of 112% and 157% in maximum force as well as 104% and 176% in stiffness were found in Group 3 and 4, respectively. For reducing stress concentration and enhancing overall stability, more than one-diagonal screw design is recommended and two-diagonal screws design will be superior. This study provided biomechanical references for further calcaneal implants design to prevent clinical failure after MDCO.

Implant-related artifacts around metallic and bio-integrative screws: a CT scan 3D Hounsfield unit assessment

Objective: To assess the degree of implant-related artifacts (IRA) around metallic and bio-integrative (BI) cannulated screws using Hounsfield units (HU) on computed tomography (CT). Our hypothesis was that BI implants would demonstrate significantly decreased IRA around the inserted screws. Methods: In this cadaveric CT imaging study, we used 2 below-knee specimens. Medial displacement calcaneal osteotomy was performed, and the specimens were fixed with either metallic or BI screws. HU values were measured over 4 different lines that crossed the osteotomy position. Results: The mean HU value was decreased in the BI implants compared to the metallic ones in 3 different positions: near the screw, directly over the screw, and inside the screw cannula. At the line placed 1 cm dorsal to the screw, the HU value for the metallic screw was lower than that for the BI screw. Conclusions: We found metallic implants to demonstrate significantly increased HU values in regions close to the implant and significantly decreased values 1 cm away from the implant, when compared to the BI screw. The decreased HU values 1 cm away from the implant could be due to a shielding effect of the surrounding bone, hindering the assessment of union and healing. BI implants represent an alternative to decrease these IRA effects. Level of Evidence III; Case-Control Study.

Outcomes of Joint Preservation Surgery in Valgus Ankle Arthritis Without Deltoid Ligament Insufficiency.

To date, information about the role of proximal alignment correction in treating nontraumatic valgus ankle arthritis is limited. This study aimed to report outcomes of realignment surgery, including supramalleolar correction in valgus arthritic ankles without evidence of deltoid ligament insufficiency. Thirteen patients (13 ankles) who underwent joint preservation surgery for valgus ankle arthritis without evidence of deltoid ligament insufficiency were reviewed. Medial opening wedge supramalleolar osteotomy (n = 11) and varization supramalleolar dome osteotomy (n = 2) were performed to realign the hip-knee-ankle-hindfoot axis. Concomitant hindfoot correction was accompanied with either medial displacement calcaneal osteotomy (n = 8) or subtalar arthrodesis (n = 5). Pain, functional outcome (Foot Function Index [FFI]), radiographic arthritis grade (grades 0-4), 9 plain radiographic parameters, and 2 weightbearing computed tomography parameters were evaluated pre- and postoperatively. All patients completed a minimum 2-year follow-up. Preoperatively, 10 ankles (77%) demonstrated a varus tibial plafond, and 3 ankles (23%) demonstrated a valgus or neutral tibial plafond. Postoperatively, radiographic arthritis grade improved in all except 1 patient, and the mean talar tilt angle improved from 5.5 to 1.7 degrees. The mean pain score (visual analog scale) decreased significantly from 7.3 to 2.5 (P < .05), and the mean FFI improved significantly from 57.7 to 18.6 (P < .001). None of the patients underwent conversion to joint-sacrificing procedures at the latest follow-up. This study demonstrated a possible relationship between lower limb malalignment and valgus ankle arthritis. Realignment surgery, including supramalleolar osteotomies, which straightens the mechanical axis and decreases the slope of the tibial plafond, may be a reasonable approach in joint preservation of valgus ankle arthritis without deltoid ligament insufficiency. Level IV, case series.

Dynamic medial column stabilization using flexor hallucis longus tendon transfer in the surgical reconstruction of flatfoot deformity in adults

BackgroundA common challenge in flatfoot reconstruction arises when there are multiple locations of collapse within the medial column. An extension of arthrodesis may lead to complications such as stiffness or adjacent joint arthritis. The purpose of this study was to report outcomes of flatfoot reconstruction using the dynamic medial column stabilization (DMCS) technique, which transfers the flexor hallucis longus (FHL) tendon to the first metatarsal base to support the entire medial column. MethodsWe retrospectively reviewed 14 consecutive patients (14 feet) who underwent DMCS as an adjunct to flatfoot reconstruction. In all cases, a medial displacement calcaneal osteotomy and gastrocnemius recession were performed to address hindfoot valgus deformity and heel cord tightness, respectively. Deformity correction was assessed using preoperative and postoperative weightbearing radiographs. The newly defined metatarsal-cuneiform articular angle (MCAA) and naviculo-cuneiform articular angle (NCAA) were measured to assess correction at each medial column joints. Clinical outcomes included the FFI and VAS scores. Any complications related to the surgery were investigated. ResultsAll radiographic parameters significantly improved postoperatively. The sagittal plane correction occurred at all three joints within the medial column. Clinically, both FFI and VAS improved significantly at the final follow-up. One patient developed plantar pain under the first metatarsal head that may have been associated with the overtightening of the transferred tendon. ConclusionDMCS using FHL tendon transfer to the first metatarsal base was a useful technique for restoring the medial arch and correcting three planar deformities in the setting of flatfoot deformity.

Medial Displacement Calcaneal Osteotomy for Unilateral Adult Acquired Flatfoot: Effects of Minimally Invasive Surgery on Pain, Alignment, Functioning, and Quality of Life

We aimed to assess the effects of medial displacement calcaneal osteotomy (MDCO) through a minimal skin incision in terms of pain, function, and alignment in patients with unilateral adult acquired flatfoot. American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scale and Numeric Pain Rating Scale (NPRS) were assessed as outcomes at the baseline (T0), at 6 months (T1), and at 1 year (T2) from surgery. We analyzed data of 20 patients (7 male and 13 female), mean aged 46.6 ± 5.34 years, showed significant differences after 6 months in terms of AOFAS total score (44.30 ± 7.39 vs 96.50 ± 4.89; p = .0001), AOFAS subitems (p < .001), and pain (NPRS: 7.95 ± 1.36 vs 1.05 ± 1.05; p = .0001). At 1 year after surgery (T2), all outcome measures still significantly differ from baseline (p < 01). Therefore, percutaneous MDCO through a minimal skin incision seemed to be safe and effective in the middle and long term in reducing pain and improving function and alignment in patients with unilateral adult acquired flatfoot.