Metatarsal Research Articles

Two rare cases of management of proximal phalanx spina ventosa

Tubercular dactylitis or spina ventosa is the tubercular infection of phalanges, metacarpals and metatarsals termed after cystic swelling of short tubular bones by tubercular infection. Here we presented two rare cases of spina ventosa in a 10 years old female and a 16 years old male patients. In both cases there was swelling of digits with stiffness. The radiographs were suggestive of chronic osteolytic infection with cortical destruction and diffuse sclerosis. We managed them with adequate surgical debridement, splintage and anti-tubercular therapy with good functional recovery. Spina ventosa or tubercular dactylitis is a rare condition and is often missed on diagnosis due to vague non-specific presentation, unavailability of rapid diagnostic tests and can be confused with other mimicking diseases. Any swelling over small tubular bones of hand or feet should raise the suspicion of spina ventosa, especially in endemic countries for tuberculosis. In neglected chronic infections, surgical debridement, curettage and splintage followed by anti-tubercular therapy based on histo-pathological reports is the treatment of choice with high protein diet and vitamin D supplementation ensures good outcome.

Percutaneous minimally invasive osteotomy with 8-shaped bandage and hallux valgus splint fixation for the treatment of moderate hallux valgus

To observe clinical effect of percutaneous minimally invasive osteotomy with 8-shaped bandage and hallux valgus splint fixation in treating moderate hallux valgus. Totally 23 patients with moderate hallux valgus were treated with percutaneous minimally invasive osteotomy with 8-shaped bandage and hallux valgus splint fixation from August 2019 to January 2021, and 1 patient was loss to follow-up, and finally 22 patients(30 feet) were included, 4 males (6 feet) and 18 females(24 feet), aged from 27 to 66 years old with an average of(50.59±11.95) years old. Hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal span (the distance between the first and the fifth metatarsal bones), changed of soft tissue width, American Orthopaedic Foot and Ankle Society(AOFAS) score, and Visual Analogue Scale (VAS) were collected and compared before operation and 6 months after operation. Twenty-two patients were followed up from 5.7 to 6.4 months with an average of (6.13±0.85) months. The first metatarsal osteotomy of patients were obtained bone union, and deformity of the toes was corrected. Complications such as avascular necrosis of metatarsal head and transfer metatarsalgia were not occurred. Postoperative HVA, IMA, metatarsal span, soft tissue width, VAS, AOFAS score at 6 months were significantly improved compared with pre-operation (P<0.01). According to AOFAS score at 6 months after operation, 10 feet were excellent, 18 good and 2 poor. Two feet with poor were excellent after prolonged 8-shaped bandage and hallux valgus splint fixation time. Percutaneous minimally invasive osteotomy with 8-shaped bandage and hallux valgus splint fixation for the treatment of moderate hallux valgus could better correct deformity of hallux valgus, relieve foot symptoms, good recovery of postoperative function, and has a significant clinical efficacy.

Malignant Bone and Soft Tissue Lesions of the Foot.

Malignant tumors of the foot are rare pathologies that can involve the skin, soft tissue, or bone. Due to their rarity, they are often misdiagnosed, resulting in inadequate excision and poor outcomes. A correct approach with a careful examination and radiological study, followed by a properly performed biopsy, is thus mandatory to avoid these pitfalls. The present article reviews the most common malignant bone and soft tissue lesions of the foot region, discussing their clinicopathological presentation, imaging features, and current concepts in treatment.

Clinical and genetic features of Kenny-Caffey syndrome type 2 with multiple electrolyte disturbances: A case report

Hypoparathyroidism, which can be sporadic or a component of an inherited syndrome, is the most common cause of hypocalcemia. If hypocalcemia is accompanied by other electrolyte disturbances, such as hypokalemia and hypomagnesemia, then the cause, such as renal tubular disease, should be carefully identified. An 18-year-old female visited our clinic because of short stature and facial deformities, including typical phenotypes, such as low ear position, depression of the nasal bridge, small hands and feet, and loss of dentition. The lab results suggested normal parathyroid hormone but hypocalcemia. In addition, multiple electrolyte disturbances were found, including hypokalemia, hypocalcemia and hypomagnesemia. The physical signs showed a short fourth metatarsal bone of both feet. The X-ray images showed cortical thickening of long bones and narrowing of the medulla of the lumen. Cranial computed tomography indicated calcification in the bilateral basal ganglia. Finally, the genetic investigation showed a de novo heterogenous mutation of "FAM111A" (c. G1706A:p.R569H). Through a review of previously reported cases, the mutation was found to be the most common mutation site in Kenny-Caffey syndrome type 2 (KCS2) cases reported thus far (16/23, 69.6%). The mutation was slightly more prevalent in females than in males (11/16, 68.8%). Except for hypocalcemia, other clinical manifestations are heterogeneous. As a rare autosomal dominant genetic disease of hypoparathyroidism, the clinical manifestations of KCS2 are atypical and diverse. This girl presented with short stature, facial deformities and skeletal deformities. The laboratory results revealed hypocalcemia as the main electrolyte disturbance. Even though her family members showed normal phenotypes, gene detection was performed to find the mutation of the FAM111A gene and confirmed the diagnosis of KCS2.

Development of an elastic storage-release prosthetic foot that mimics the metatarsal bone head and midtarsal joint

Development of an elastic storage-release prosthetic foot that mimics the metatarsal bone head and midtarsal joint

Minimally invasive Chevron Akin (MICA) osteotomy for severe hallux valgus.

The minimally invasive Chevron Akin (MICA) osteotomy has been widely used to treat hallux valgus (HV). The purpose of this study was to present a case series of patients with severe HV undergoing surgical treatment using the MICA procedure and to evaluate the clinical and radiographic outcomes. Retrospective study including 60 consecutive feet (52 patients) undergoing MICA for severe HV. The data were collected pre- and post-operatively at the last follow-up. Patients were clinically evaluated by the visual analog pain scale (VAS) and AOFAS hallux MTP-IP score. Radiographic assessments included measurements of hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal (MT) length, distal metatarsal articular angle (DMAA), and plantar translation of MT head. The complications were recorded during the follow-up. The mean age was 59.9years, and the mean follow-up was 20.5months. The average AOFAS increased from 41.2 to 90.9 points, and the VAS from 8.1 to 1.3 at the last follow-up. The average HVA decreased from 41.2º to 11.6º, the IMA from 17.1º to 6.9º, and the DMAA from 17.9º to 7.8º. The average shortening of the first metatarsal and the plantar translation of the MT head was 5.1mm and 2.8mm, respectively. The most observed complication was hardware discomfort, observed in 5 feet (8.3%). There were two cases of recurrence (3.3%). MICA technique was demonstrated in this series of cases to be an effective procedure for severe HV, with a low rate of recurrence and an acceptable rate of complications. IV; case series.

Distal osteotomy of the first metatarsal bone for the correction of hallux valgus: comparison of the sagittal stability of two percutaneous techniques—a cadaveric study

BackgroundDistal first metatarsal osteotomy is used to correct mild or moderate hallux valgus (HV). We designed a cadaveric study to compare the resistance to axial load between two percutaneous distal first metatarsal osteotomies: Bösch osteotomy and percutaneous chevron. The first aim of this study was to develop a systematic technique for measuring the sagittal displacement on lateral foot X-rays. Our second objective was to measure the resistance to axial load for both of these osteotomies.MethodsTen pairs of freshly frozen cadaveric feet were randomly assigned to one of the two techniques investigated. Pre- and post-operative lateral X-rays were obtained. After surgery, the feet were placed under progressive axial loads up to 60 kg. Metaphyseo-diaphyseal angle (MDA) and the distance between bone fragments were measured, and the differences between the two techniques were statistically assessed.ResultsThe MDA decreased in both surgical techniques. The mean plantar tilt was −6.90 degrees (SD = 10.251) for chevron osteotomy and −5.34 degrees (SD = 16.621) for Bösch osteotomy. There was no significant difference between the techniques (p = 0.41).Regarding the distance between the bone fragments, the Bösch osteotomy produced more plantar displacement than the chevron osteotomy, which was statistically significant for the 10 and 20 kg loads (p = 0.031 and 0.04, respectively). At loads ≥ 30 kg, the bone fragment distance did not differ significantly between the techniques (p = 0.114).ConclusionsAlthough the chevron technique confers higher stability regarding fragment displacement during axial loading, both techniques increase the plantar angulation of the metatarsal head.Level of evidenceCadaveric study. Level V.

MODERN POSSIBILITIES OF ULTRASOUND SCAN IN DIAGNOSIS OF MORTON'S NEUROMA

About 60% of healthy people at least once in their lives complained of pain in the anterior foot that was diagnosed as Morton's neuroma. According to numerous resources, ultrasound scan is one of the leading methods for diagnosing the condition of the soft tissues in the foot, thus, this diagnostic technique can be considerably helpful in determining the nature and extent of the pathological condition and making the decision about the necessity of surgical treatment. Aim: to assess the potential of ultrasound investigation and to systematize the ultrasound criteria for Morton's neuroma using a two-dimensional mode, colour and energy mapping, and functional ultrasonography. Material and methods. We analyzed the findings obtained by the ultrasound scan of soft tissues in the foot of 26 people who complained of pain in the projection of 3-4 metatarsophalangeal joints. The following echographic data were evaluated: homogeneity, echogenicity, integrity of the soft tissues of the intermetatarsal spaces and tendons of the fingers, the presence of effusion in the articular capsules and tendon sheaths, the number of vascular signals in the affected area during power Doppler mapping. Results and discussion. In the control group of patients, the analysis of ultrasound has revealed the following echographic features: the contour of the cortical layer of the metatarsal bones is represented by a hyperechoic line with a clear acoustic shadow along it in all cases (100%); flexor tendons of the toes are located above the surfaces of the bones (100%); no masses are found in the intermetatarsal spaces in 100% of cases; the width of the intermetatarsal spaces is 5.0–9.0 mm in all cases (100%). In the main group of patients, the analysis of ultrasound findings has revealed the following structural changes: the contour of the cortical layer of the metatarsal bones is represented by a hyperechoic circular line with a clear acoustic shadow along it in 8 cases (30.7%); in 18 cases (69.3%) the contour of the cortical layer is uneven with a fuzzy acoustic shadow; flexor tendons of the toes are of reduced echogenicity and have heterogeneous structure in 16 cases (61.5%); space-occupying formations have been found in the intermetatarsal spaces of the III-IV toes in 24 cases (92.3%), and in the intermetatarsal spaces of the II-III toes and in 2 cases (7.7%); the width of the intermetatarsal spaces at the location of the mass formation in all cases (100%) is 10.0-15.0 mm. Conclusion. At the present, the access to ultrasound, its non-invasiveness, the absence of ionizing radiation, the possibility of dynamic observation, and relatively high accuracy in assessing the tibial nerve put it at the forefront in the diagnostic algorithm for detecting Morton's neuroma.

Septic Shock in the Course of Disseminated Tuberculosis in A COVID-19 Positive Patient with Concomitant AIDS

A 23-year-old male patient presented to the Provincial Hospital for Infectious Diseases in Warsaw, Poland in February 2022 with severe septic shock in the course of COVID-19 infection. The patient’s history and physical exam indicated a suspicion of HIV, TB, and COVID-19 triple coinfection. Numerous ulcers and phlegmon were present on the lower limbs and back with the patient complaining of difficulty walking. Laboratory tests came back positive for COVID-19, saliva tests were positive for active tuberculosis, and blood test results for the CD4 count were &lt; 200 cells/cubic millimeter confirming an AIDS diagnosis. Further testing and imaging revealed disseminated tuberculosis with involvement of bone in the left foot and thoracic spine, confirming Pott’s Disease. Treatment was started immediately for the septic shock with norepinephrine, vancomycin, meropenem, levofloxacin, and aggressive fluid resuscitation. COVID-19 treatment included oxygen mask therapy, systemic steroids and molnupiravir. Tuberculosis treatment was begun with isoniazid, rifampin, ethambutol, and pyrazinamide. Antiretroviral therapy (ART) was begun upon confirmed HIV/AIDS diagnosis using emtricitabine, tenofovir and dolutegravir. The patient was not previously on any ART and was not aware of his HIV/AIDS positive status.

Mechanical comparison of application of locking intramedullary nail to locking compression plate in the ovine metatarsus.

The metatarsal bone is commonly utilized in preclinical fracture models in sheep. A majority of studies achieve fracture stabilization with bone plating, but more recently intramedullary interlocking nails (IMN) have been utilized. The mechanical properties of this unique surgical technique utilizing an IMN has not yet been fully elucidated or compared to the traditional locking compression plating (LCP) technique. We hypothesize that a mid-diaphysis metatarsal critical-sized osteotomy stabilized with an IMN will provide equivalent mechanical stability to LCP with less variance of mechanical properties across specimens. Sixteen ovine hind limbs were transected at the mid tibia with soft tissue intact and utilized for implantation. A 3-cm osteotomy was created in the mid-diaphysis of all metatarsi. For the IMN group, a 147 mm × 8 mm IMN was implanted from distal to proximal through the sagittal septum of the distal metatarsus and the bolts locked in place using an IMN guide system. For the LCP group, a 3.5-mm 9-hole LCP was secured to the lateral aspect of the metatarsus with three locking screws in the proximal and distal holes leaving the central three holes empty. All metatarsal constructs were fitted with three strain gages on proximal and distal metaphyses and the lateral aspect of the IMN or LCP at the osteotomy site. Non-destructive mechanical testing was performed in compression, torsion, and four-point bending. The IMN constructs showed overall greater construct stiffness with less variance in strain between constructs than the LCP constructs in 4-point bending, compression, and torsion. IMN constructs may provide superior mechanical properties for a critical-sized osteotomy model of the ovine metatarsus when compared to lateral LCP constructs. Further in vivo investigation comparing characteristics of fracture healing between IMN and LCP is warranted.

Metatarsal bone model production using 3D printing and comparison of material properties with results obtained from CT-based modeling and real bone.

Using a real bone is very important to find correct results for the biomechanical studies. However, it is very difficult to find the real bone and sometimes artificial bone models can be preferred instead of real bone. The aim of this study is to obtain an easy-to-manufacture, easy-to-customize and inexpensive method the artificial first metatarsal bone model that is similar material properties with the real bone. 3D printer technology was used to produce the artificial bone model. First metatarsal bone was modeled using MIMICS software to produce and determined the mechanical properties. The bone mechanical properties were calculated via MIMICS software using computer tomography images. 3D bone models were produced in different infill density and infill pattern to determine the real bone mechanical properties using 3D printer. The infill density of the bone model was adjusted as 20%, 40%, and 60%. Five different infill pattern types were used as grid, cubic, triangle, trihexagon, and gyroid. The produced models were subjected to torsional test and the elasticity modulus of all models were obtained. The results of the elasticity modulus of all produced (artificial) and modeled (calculated) bone were compared and the optimum bone model was obtained. The optimum infill density and infill pattern was determined as 40% and trihexagon, respectively.

Long-Bone-Regeneration Process in a Sheep Animal Model, Using Hydroxyapatite Ceramics Prepared by Tape-Casting Method.

This study was designed to investigate the effects of hydroxyapatite (HA) ceramic implants (HA cylinders, perforated HA plates, and nonperforated HA plates) on the healing of bone defects, addressing biocompatibility, biodegradability, osteoconductivity, osteoinductivity, and osteointegration with the surrounding bone tissue. The HA ceramic implants were prepared using the tape-casting method, which allows for shape variation in samples after packing HA paste into 3D-printed plastic forms. In vitro, the distribution and morphology of the MC3T3E1 cells grown on the test discs for 2 and 9 days were visualised with a fluorescent live/dead staining assay. The growth of the cell population was clearly visible on the entire ceramic surfaces and very good osteoblastic cell adhesion and proliferation was observed, with no dead cells detected. A sheep animal model was used to perform in vivo experiments with bone defects created on the metatarsal bones, where histological and immunohistochemical tissue analysis as well as X-ray and CT images were applied. After 6 months, all implants showed excellent biocompatibility with the surrounding bone tissue with no observed signs of inflammatory reaction. The histomorphological findings revealed bone growth immediately over and around the implants, indicating the excellent osteoconductivity of the HA ceramic implants. A number of islands of bone tissue were observed towards the centres of the HA cylinders. The highest degree of biodegradation, bioresorption, and new bone formation was observed in the group in which perforated HA plates were applied. The results of this study suggest that HA cylinders and HA plates may provide a promising material for the functional long-bone-defect reconstruction and further research.

Lower Extremity Response to Blast Loading: A Computational Study.

This study has investigated the response of the Total Human Model for Safety (THUMS) lower extremity finite element model under blast loading. Response of the model was estimated in simulated underbody blast (UBB) loading using floorplate impact velocities of increasing severity. Correlation and analysis (CORA) ratings suggested a good match between numerical response and available experimental data. The model response was then investigated in an antipersonnel landmine explosion. The model was found stable in the nearfield blast and sensitive to the threat definition. The lower extremity injury was predicted when detonation occurred below the heel. The model predicted major injuries localized to the hindfoot and midfoot with minimal damage to the forefoot, consistent with the findings in the literature. The damage to the individual bones of the foot was measured in terms of percentage change in mass and element eroded.

Investigation on the site of coronal deformities in Hallux valgus

Hallux valgus (HV) is a common foot deformity that is more prevalent in females, characterised by abnormal adduction of the first metatarsal (MT) and valgus deviation of the phalanx on the transverse plane. Increasing evidence indicates that HV is more than a 2D deformity but a 3D one with rotational malalignment. Pronation deformity is seen during clinical examination for HV patients, but the exact origin of this rotational deformity is still unknown. Some attribute it to first tarsometatarsal (TMT) joint rotation, while others attribute it to intra-metatarsal bony torsion. In addition, the correlation between the rotational and transverse plane deformity is inconclusive. Identifying the origin of the rotational deformity will help surgeons choose the optimal surgical procedure while also enhancing our understanding of the pathophysiology of HV. This study aims to (1) develop an objective method for measuring the first MT torsion and first TMT joint rotation; (2) investigate the exact location of the coronal deformity in HV; (3) investigate the relationship between the severity of deformity on the transverse and coronal planes as well as the correlation between deformity severity and foot function/symptoms in HV. Age-matched females with and without HV were recruited at the Foot and Ankle Clinic of the Department of Orthopaedics and Traumatology. Computed tomography was conducted for all subjects with additional weight-bearing dorsal-plantar X-ray examination for HV subjects. Demographic information of all subjects was recorded, with symptoms and functions related to HV evaluated. The intra-class correlation was used to explore the relationship between deformities on different planes and the deformity severity and functional outcomes, respectively. An Independent t-test was used to compare joint rotation and bone torsion degrees. TMT joint rotation is significantly correlated with foot function. HV patients had more TMT joint rotation but not MT torsion compared to normal controls. No relationship was found between the coronal rotation and the 1,2-intermetatarsal angle (IMA) or Hallux valgus angle (HVA) on the transverse plane. Our results indicate that coronal deformities in HV may originate from TMT joint rotation. In addition, the severity of the TMT joint coronal rotation correlates with worse foot function; thus, multi-plane assessment and examination will be necessary for more precise surgical correction.

Neurogenic Аrthropathy, Сhronic Osteomyelitis, Diabetic Foot: Differential X-Ray and MSCT Diagnostics

X-ray and MSCT-differential diagnostics between neurogenic arthropathy, diabetic osteoneuroarthropathy (DONAP), complicated by osteomyelitis and chronic osteomyelitis, has not been studied enough.The purpose of the study was to study the MSCT semiotics of various variants of neurogenic arthropathy, DONAP complicated by osteomyelitis and chronic post-traumatic osteomyelitis in order to substantiate etiopathogenetic treatment. In 44 patients with neurogenic arthropathy, DONAP, complicated by osteomyelitis and chronic osteomyelitis, the results of polypositional radiography, MSCT were studied before treatment for the purpose of differential diagnosis. Single center retrospective study. MSCT and x-ray revealed differential diagnostics differences between neurogenic arthropathy, DONAP, complicated by osteomyelitis and chronic osteomyelitis. They are manifested by the localization of destructive processes, characteristic changes in the angles of the foot and a violation of the architectonics of the bones, concomitant changes in blood vessels and soft tissues. Neurogenic arthropathy is characterized by disorganization of the joints, bone resorption, giving the impression of surgical amputation, sharpening of the ends of the metatarsal bones, a symptom of «pestle in a mortar», a violation of the structure of spongy bones. DONAP is manifested by pronounced destructive changes in the midfoot, collapse of the tarsal bones with defects, fragmentation, vascular calcifications (Menckeberg), a «pathological» reference line, an increase in the Meary angle, a decrease in the angle of the calcaneus, and a «rocking foot», increased density of the calcaneus. Chronic osteomyelitis is characterized by an isolated lesion of one or more bones; the presence of a fistulous tract, focal disorders of the trabecular pattern, a decrease in the density of adjacent bones, the presence of isolated foci of sclerosis.

An intermediate phenotype in IDH related enchondromatosis spectrum

Mosaic variants of IDH1 (isocitrate dehydrogenase-1) R132 and IDH2 (isocitrate dehydrogenase-2) R172 loci were detected in most of the bone cysts of Ollier and Maffucci series and in the blood and tissue samples of metaphyseal enchondromatosis with D-2-hydroxyglutaric aciduria (MC-HGA) patients. We aimed to report an intermediate phenotype comparing with the reported cases. The proband was a 9-year-old boy with widespread metaphyseal enchondromatosis involving metaphyses of long tubular bones, iliac bones and tubular bones of both hands and feet and sparing spine and flat and short bones. He underwent quad whole exome sequencing (index-both parents-healthy sibling). Sanger sequencing was performed for confirmation and segregation purposes. Heterozygous IDH1 R132H (c.395G > A) variant was detected in his blood via whole exome sequencing and Sanger analysis in mosaic state, 22% of the reads and Sanger signal. He had no D-2-hydroxyglutaric aciduria in urinary organic acid analysis. Our case is unique with the presence of IDH1 R132H variant in blood with metaphyseal enchondromatosis without D-2-hydroxyglutaric aciduria. It was a transitional phenotype. With his phenotype, we expand the IDH1/IDH2 related enchondromatosis phenotypes.

Histopathological Perspectives of Multiple Organs in a Red- Footed Tortoise (Chelonoidis carbonaria) with Suspected Metabolic Bone Disease: A Case Report

Introduction: Exotic pet lovers' interest in keeping tortoises is increasing all over the world, including Indonesia. However, this trend cannot be separated from the potential emergence of various health problems in tortoises. One of the problems that often affects tortoises is metabolic bone disease. Metabolic bone disease (MBD) is a disorder related to the mechanisms of vitamin D and calcium metabolism, which generally occurs in reptiles, especially Chelonia and Lizards. Case Presentation: A 3-month-old redfooted tortoise, which was clinically suspected to have a MBD, was necropsied as an effort to support the provisional diagnosis through histopathological evaluation. The purpose of this examination was to analyze the impact of the disease on various organs microscopically in patients with suspected MBD. The results showed a decrease in the number of trabeculae and hematopoietic cells in the metatarsal bones; moderate myonecrotic changes and atrophy in the skeletal muscle; inflammation of the perineuron; acute tubular necrosis and mild edema of the renal cortex; congestion and an increase in the number of melanomacrophages in the liver; as well as epicarditis and myocarditis in the heart. Conclusion: Several forms of the histopathological changes seem to indicate a pathophysiological relationship between the suspected metabolic bone disease and the multiple organs examined.

An Osteoid Osteoma of the 4th metatarsal mimicking a stress fracture – A case report

Osteoid osteoma is a common benign bone tumor that infrequently affects the metatarsal bones. We present the case of a 29-year-old female that has mistakenly been treated for a stress fracture of the 4th metatarsal bone for almost 3 years. During this period, 4 conventional radiographs, 4 MRIs and 1 CT have been performed. After referral to our institution repeated thorough anamnesis and reevaluation of the diagnostic imaging raised suspicion for an osteoid osteoma. The patient was successfully treated with magnetic resonance-guided focused ultrasound (MRg-FUS). Osteoid osteoma is a rare but important differential diagnosis of stress fractures. Typical clinical presentation and diagnostic pathways should be known by professionals treating patients with nontraumatic foot and ankle pain.

Tenosynovitis of the Anterior Tibialis Tendon: Typical Clinical Radiological Correlation: A Case Report

The Anterior Tibialis Tendon (ATT) is usually the site of minor injuries due to its straight course, however, overuse injuries still possible due to repetitive foot dorsiflexion. This tendon crosses the anteromedial aspect of the ankle running toward the medial border of the foot under the inferior and superior extensor retinacula and inserts at the level of the medial cuneiform and the base of the first metatarsal bone. It can be prone to tendinosis, tenosynovitis, partial or complete tear. In the first cases, the patient experiences a pain and a swelling along the distal part of the ATT worsening while dorsiflexion. The diagnosis may be easily suspected clinically, particularly in significant lesions such a complete tear, but the compensation by the extensor hallucis longus and extensor digitorum longus muscles may delay the diagnosis [1].

The Minimally Invasive SERI Osteotomy for Pediatric Hallux Valgus.

Hallux valgus (HV), one of the most common forefoot pediatric pathologies, is characterized by lateral deviation of the big toe and medial displacement of the first metatarsal bone. Different surgical techniques have been described to correct the deformity, but no consensus has been reached regarding the best surgical option. The aim of this retrospective study was to report the results of the SERI technique in 58 pediatric HV of 45 consecutive patients. Pre- and postoperative VAS, AOFAS score, HVA, IMA and DMAA were collected. Preoperatively 3 patients (5.2%) had a mild deformity, 52 patients (89.6%) had moderate deformity and 3 patients (5.2%) had severe deformity according to Coughlin et al. Mean VAS score decreased from 5.2 ± 2.2 preoperatively to 0.8 ± 0.4 postoperatively. Mean AOFAS score improved from 68.1 ± 6.8 (range 59-75) preoperatively to 96.3 ± 3.2 (range 88-100) postoperatively, mean HVA reduced from 28.4° preoperatively to 13.2° postoperatively, mean IMA decreased from 15.2° preoperatively to 9.5° postoperatively (p &lt; 0.01); mean DMAA decreased from 13.7° preoperatively to 8.2° postoperatively (p &lt; 0.01). SERI technique showed satisfactory results when treating mild to severe pediatric HV deformity. No major complications were reported.