Proximal Closing Wedge Osteotomy Research Articles

A simple method to predict postoperative relative first metatarsal length after proximal closing-wedge osteotomy

Optimal relative first metatarsal length is one of the keys to achieving sufficient results after osteotomy of the first metatarsal. An excessive shortening of the first metatarsal was associated with postoperative metatarsalgia, whereas a long first metatarsal has been implicated as a cause of hallux valgus. To adjust the relative first metatarsal length to the optimal range during surgery, a predictive tool would be beneficial for preoperative planning. However, there is no established tool for predicting relative first metatarsal length. Here, we report a simple method to predict postoperative relative first metatarsal length after proximal rotational closing-wedge osteotomy for rheumatoid forefoot deformities. Two board-certified orthopedic surgeons performed relative first metatarsal length prediction retrospectively on a computed radiography system in nine consecutive cases. Most of them underwent simultaneous modified shortening oblique osteotomy of the second metatarsal (7/9 cases). The interclass correlation coefficients of intraobserver and interobserver reliability for relative first metatarsal length prediction were 0.96 and 0.94, respectively. The mean absolute error on relative first metatarsal length prediction was 1.5 mm at 3-month postoperatively in the same case series. The average time required to perform the relative first metatarsal length prediction was 44.1 s (standard deviation 9.0). Predicting relative first metatarsal length preoperatively in a simple manner, which takes less than a minute to complete, has the potential to improve the surgical outcome of rheumatoid forefoot surgery.

Geometric Comparison of Second Metatarsal Shortening Osteotomy Variations Using 3D Printed Patient-Specific Models

Category: Midfoot/Forefoot Introduction/Purpose: Second metatarsal shortening osteotomy is frequently used in the treatment of metatarsalgia and aims to decrease metatarsophalangeal joint and plantar pressures. Although various proximal, midshaft, and distal metatarsal osteotomy methods have been described for surgical treatment of metatarsalgia, to our knowledge no studies quantitatively compared their resulting geometric corrections. The purpose of our study was to investigate how much each osteotomy variation changed the length of the metatarsal as well as the height and relative location of the metatarsal head (MH) itself. Methods: Following Institutional Review Board approval, three-dimensional computer models of second metatarsals of 5 deidentified clinic patients were extracted from CT scans using Mimics software. Fixed points were plotted on the printed models and a 3D coordinate digitizing arm (Microscribe) was used for precisely determining the 3D (x-y-z) coordinates of each point before and after the osteotomies. Six variations of second metatarsal osteotomies were performed using microsagittal saw and fixed using a 2.4 mm cannulated screw. The following osteotomy variations were performed with 3 and 5 mm translation or wedge resection for each patient model: (1) Classic Weil osteotomy performed at 15° and 25° to the plantar surface; (2) Classic Weil osteotomy performed at 15° and 25° using a double saw blade technique; (3) Classic Weil osteotomy performed at 25° and then a parallel block of 3 or 5 mm was removed; (4) Distal closing wedge osteotomy of the MH at 25°; (5) Proximal closing wedge osteotomy of the MH made at 45° removing a 3 and 5 mm wedge; (6) 45 degree oblique, midshaft, metatarsal osteotomy with 3 and 5 mm of translation. The change in the length of the metatarsal, and vertical and medio-lateral translation of the metatarsal head was calculated then normalized by the osteotomy translation distance. A general linear model with correlated errors and Bonferroni correction was used to assess differences between osteotomies. Results: The maximum metatarsal length shortening per millimeter translation was observed in osteotomy 3- 5 mm block (2.6 mm STD=2.1), while osteotomy 1- 15° caused the least (1.1 mm STD=0.6). Maximum dorsiflexion of the MH occurred with osteotomy 5- 5 mm wedge, 13.2 mm (STD= 4.9 mm) and minimum with osteotomy1- 25°, 0.5 mm (STD= 1.4 mm). No MH plantarflexion was noted with any of the osteotomies. The oblique midshaft osteotomies caused lateral translation of the metatarsal head significantly different from the controls (P <0.05) although not statistically different from one another (2.4 mm vs 4.3 mm). Conclusion: Discussion: Our data shows maximal change in length/millimeter translation by performing a classic Weil osteotomy at 25° to the plantar surface of the foot, 5 mm block resection and then translating 4 mm. This osteotomy also caused the most effective dorsal translation of the MH, thereby making it the most effective osteotomy in terms of affecting both length and MH vertical orientation. Should dorsiflexion of the MH be the surgeon’s only goal, then the proximal closing wedge osteotomy had the greatest impact while minimally changing overall length. With this knowledge, surgeons can tailor operations based on the direction and degree of correction needed to be achieved.

Effectiveness of Percutaneous Proximal Closing Wedge Osteotomy With Akin Osteotomy to Correct Severe Hallux Valgus Determined by Radiographic Parameters.

Therapeutic, Level IV: Case series.

Proximal closing wedge lesser metatarsal osteotomy for metatarsophalangeal joint transverse plane realignment. Surgical technique and outcome

We describe the surgical technique and outcome of a proximal closing wedge osteotomy of the lesser metatarsals, to treat medial or lateral subluxation of the MTP joints, with toe deviation, when dorsiflexion (MTPJ dorsal subluxation) deformity is not present. The principle of surgical correction, is the shift of the metatarsal head in the direction of the deformity, to allow restoration of congruity of the metatarsophalangeal joint. The osteotomies were performed at the proximal metaphyseal level. At the same time, soft tissue release, consisting of division of the inter-metatarsal ligament on the other side of the deformity, allows adequate displacement. Four patients, followed for 12 months, were asymptomatic and very satisfied with the outcome, while clinical and radiographic alignment was maintained. The described surgical technique can be performed in selected patients with transverse plane deformities of the lesser metatarsals.

Proximal Oblique Sliding Closing Wedge Osteotomy for Hallux Valgus

The proximal oblique sliding closing wedge osteotomy (POSCOW) technique was developed to address moderate to severe hallux valgus deformity. We present a retrospective multicenter study to analyze the midterm radiological and clinical outcomes of patients treated with this type of proximal osteotomy fixed with plates. One hundred and forty-four patients (187 feet) were operated on between May 2005 and June 2010 in 2 separate centers. Inclusion criteria were symptomatic moderate to severe incongruent hallux valgus deformity, no significant restriction in the first metatarsophalangeal joint movement, none to minimal degenerative changes in the first metatarsophalangeal or the tarsometatarsal joints, and no hypermobility. The median age was 60 years. The preoperative hallux valgus angle (HV) was 35.6 degrees, intermetatarsal angle (IM) was 15.3 degrees, AOFAS score was 53 points. The median follow-up was 35 months (range, 12-73). A POSCOW osteotomy was performed in all patients and fixed with plates. We recorded the satisfaction rate, postoperative clinical and radiological results, and complications. The patient satisfaction rate was 87%. The mean postoperative HV angle was 12.3 degrees, IM angle 4.8 degrees, AOFAS score 89 points. The mean decrease in the first metatarsal length was 2.2 mm (range, 0-8). Twelve feet (6.4%) with recurrence of the deformity required revision surgeries. Removal of complete or partial hardware was needed in 23 feet (12.3%) for symptomatic hardware. Five feet (2.6%) developed hallux varus but only 2 required surgery. Transfer metatarsalgia was noted in 9 feet (4.8%). The POSCOW osteotomy was an effective and reliable method for relieving pain and improving function. A learning curve was present, as most of the complications happened in the initial cases. To our knowledge, this is the largest reported series of proximal closing wedge osteotomy for hallux valgus deformities. Level IV, case series.

Plate Position and Angular Stability: Mechanical Comparison in Sawbone Osteotomy Models

Proximal metatarsal osteotomies are inherently unstable and difficult to fix. The purpose of this study was to compare the mechanical stiffness in sawbone models of medially versus dorsally placed plates and then to compare semilocked versus nonlocked plates in different osteotomy configurations. Thirty sawbone models were constructed, fixed either with titanium self-locking or steel mini-fragment plates. They were divided in groups and their stiffness was measured. The stiffness of any model fixed with medial titanium or steel plates was on average 158% and 228% greater, respectively, compared to dorsal plates. Adding a dorsal shelf of bone to a proximal closing wedge osteotomy increases its stiffness. Using locked plates increased the mechanical stiffness in only one configuration. The article suggests that models fixed with medial plates have greater resistance to failure than models fixed with dorsal plates. Using locked plates does not increase the mechanical stiffness of the construct.

Management of Severe Hallux Valgus Using Combined Proximal Closing Osteotomy with a Distal Soft Tissue Reconstruction

Background: many surgical procedures were described for correction of hallux valgus and the type of operation is based upon; foot length, width and redressibility of the transverse arch, hallux valgus evaluation of possibility of its passive redression and radiographic examination of foot. Aim of the work: To evaluate the results of hallux valgus surgery combining the distal soft tissue reconstruction (DSTR) or modified McBride procedure and proximal closing wedge osteotomy of the first metatarsal base. Patients and methods: This prospective study, was performed in King Abdul-Aziz Hospital, Taif, Saudi Arabia. The study was approved by the local committee of human research, and all patients gave written informed consent to participation. Ten patients (8 women and 2 men) with mean age of 28 years (18-40 years) were included in the study with 16 surgeries. The mean postoperative follow-up was 36 months (28 – 48). The operative technique performed in these patients was a combination of DSTR with closing osteotomy of the first metatarsal base. Results: The mean pre-operative intermetatarsal 1-2 angle (IMA) revealed by radiographs was surgically corrected from 20.3 degrees at the baseline to the mean degree of 7.9. The mean pre-surgical hallux valgus angle (HVA) was 44.9 degrees proved by radiographs was surgically improved to 11.7 degrees, and 3 years after operation it reached 12.3 degrees (mean). Ninety percent of patients were satisfied with their surgical results and cosmetic improvements were achieved in 93.7 % (15/16 feet in 9 patients). Conclusion: The combination of wedge osteotomy of the first metatarsal base and the distal soft tissue reconstruction (DSTR) or modified McBride procedure is suit­able in the treatment of young patients having severe forms of hallux valgus and minimum arthritic changes in metatarsophalangeal joint with increased IM.

Management of Severe Hallux Valgus Using Combined Proximal Closing Osteotomy with a Distal Soft Tissue Reconstruction

Background: many surgical procedures were described for correction of hallux valgus and the type of operation is based upon; foot length, width and redressibility of the transverse arch, hallux valgus evaluation of possibility of its passive redression and radiographic examination of foot. Aim of the work: To evaluate the results of hallux valgus surgery combining the distal soft tissue reconstruction (DSTR) or modified McBride procedure and proximal closing wedge osteotomy of the first metatarsal base. Patients and methods: This prospective study, was performed in King Abdul-Aziz Hospital, Taif, Saudi Arabia. The study was approved by the local committee of human research, and all patients gave written informed consent to participation. Ten patients (8 women and 2 men) with mean age of 28 years (18-40 years) were included in the study with 16 surgeries. The mean postoperative follow-up was 36 months (28 – 48). The operative technique performed in these patients was a combination of DSTR with closing osteotomy of the first metatarsal base. Results: The mean pre-operative intermetatarsal 1-2 angle (IMA) revealed by radiographs was surgically corrected from 20.3 degrees at the baseline to the mean degree of 7.9. The mean pre-surgical hallux valgus angle (HVA) was 44.9 degrees proved by radiographs was surgically improved to 11.7 degrees, and 3 years after operation it reached 12.3 degrees (mean). Ninety percent of patients were satisfied with their surgical results and cosmetic improvements were achieved in 93.7 % (15/16 feet in 9 patients). Conclusion: The combination of wedge osteotomy of the first metatarsal base and the distal soft tissue reconstruction (DSTR) or modified McBride procedure is suit­able in the treatment of young patients having severe forms of hallux valgus and minimum arthritic changes in metatarsophalangeal joint with increased IM.

Closed wedge osteotomy in 66 patients for the treatment of moderate to severe hallux valgus

The intention of this study was to analyze the long-term results of the proximal closing wedge osteotomy for the correction of hallux valgus deformity, modified by adding a mini L-plate for osteosynthesis. The outcome of a proximal first metatarsal closing wedge osteotomy was retrospectively evaluated after a mean follow-up of 52 months. A total of 66 female patients (86 feet) participated in this study. The AOFAS-score was used to evaluate the postoperative results. Pre- and postoperative weight-bearing radiographs were used to evaluate the osseous development. 95.5% of the patients were satisfied, 3 patients (4.5%) were not satisfied with the overall result of the operation. Transfer metatarsalgia was registered in 7 of 50 cases. The mean improvement of the HV-angle was 22.1 degrees (36.4 degrees to 14.3 degrees ) and the intermetatarsal angle was reduced from a mean of 17.6 degrees to a mean of 6.5 degrees . The mean first metatarsal shortening was 3.2mm. The mean AOFAS-score was 78 points. The results confirm, that the closing wedge osteotomy is indicated for moderate to severe hallux valgus. The shortening of the first ray is comparable with other well-established operative procedures. The risk of transfer metatarsalgia can only be lightly reduced by this procedure.

Scarf versus proximal closing wedge osteotomy in hallux valgus treatment

The aim of this study was to evaluate the distal metatarsal articular angle as a key factor in choosing between the proximal closing wedge osteotomy and scarf osteotomy. The investigation involved 40 feet: 32 females aged 13-68 in whom 24 unilateral and 8 bilateral operations had been performed from 24 to 63 months previously. There were statistically significant differences between groups in the postoperative hallux valgus angle and in first metatarsal shortening. We found an inverse correlation between the preoperative distal metatarsal articular angle and intermetatarsal angle improvement after proximal closing wedge osteotomy and a positive correlation after scarf osteotomy. This study confirmed the value of distal metatarsal articular angle assessment.

Evaluation of hallux valgus surgery with dynamic foot pressure registration with the Fscan system

With the advent of microcomputer technology, in-shoe systems for evaluating dynamic plantar pressure are now available. The use of dynamic registration of hallux valgus patients in floor mounted systems has been shown (Betts, Franks and Duckworth 1991). Twenty-four patients were evaluated preoperatively and 25 months after hallux valgus surgery. Fourteen patients (22 feet) were operated with a chevron osteotomy and 9 (9 feet) with a proximal closing wedge osteotomy. They were evaluated clinically and radiographically. The Fscan system, which uses a thin in-sole to measure plantar pressure was used to evaluate pressure under the five metatarsal heads and the great toe. The plantar pressure measurements of 28 normal feet of 14 healthy volunteers were used for comparison. Nine of the chevron operated patients were completely satisfied with surgery compared to four of the proximal. Shoe fitting was improved for most patients in both groups. A correction of 9° in the hallux valgus angle was achieved in the chevron group, significantly greater than in the proximal group. The pressure under specific areas was related to the sum of all the forefoot areas measured. There was significantly lower pressure under the great toe preoperatively in the hallux valgus patients (57%) compared to the normal controls (64%). Surgery did not normalize this. The pressure under the great toe was still reduced and the pressure under the third metatarsal head was increased postoperatively. Dissatisfied patients had a significantly lower great toe pressure both before and after surgery. Four patients with postoperative metatarsalgia had greater pressure under the lateral metatarsal heads and less pressure under the great toe preoperatively. Postoperatively, the great toe still had reduced pressure. Hallux valgus feet differ from normal feet in having less pressure under the great toe which is not normalized by surgery.

Results after chevron osteotomy and proximal osteotomy for hallux valgus: a prospective, randomized study

In order to evaluate the corrective effect of Chevron osteotomy and proximal closing wedge osteotomy in the treatment of hallux valgus, a consecutive series of patients was randomized to one of the two operations without regard to preoperative radiological angle. Osteoarthritis was excluded. 80 feet (68 patients) with an average age of 49-years were operated with 43 chevron osteotomies and 37 proximal osteotomies and followed up clinically and radiologically after 42 (12–58) months. Proximal osteotomy gave a greater correction of the hallux valgus angle (13° as opposed to 8°) and of the intermetatarsal angle (6° as opposed to 2.4°), and the corrective effect of either osteotomy was the same in all ranges of deformity. However, patient satisfaction with regard to bunion pain and shoe fitting did not differ between the groups, with approximately 91% and 97% satisfied, or satisfied with reservation, in the chevron and proximal group respectively. In 6 of 37 patients operated with proximal osteotomy, there was a significantly greater incidence of metarsalgia of the second metatarsal head. The metatarsalgia was not correlated to the shortening of the first metatarsal but may be secondary to dorsalisation of the first metatarsal head. We found the rate of complications in the proximal osteotomy disturbingly high and the clinical benefits not superior to the chevron osteotomy. Chevron osteotomy remains the preferable primary procedure. Proximal osteotomy may be useful in cases where a first procedure has failed or where the deformity is significant.

Proximal closing wedge osteotomy and adductor tenotomy for treatment of hallux valgus.

After 2 to 4 years, 25 patients (27 feet) who had a proximal closing wedge osteotomy of the first metatarsal and an adductor tenotomy were reviewed. A total of 20 patients (22 of 27 feet) were completely satisfied; 5 patients not completely satisfied had metatarsalgia because of dorsal displacement of the first metatarsal head. Radiographic measurements showed a narrowing of the forefoot rather than a large change in the intermetatarsal angle. The recovery period was long, an average of 11 weeks. Pin inflammation occurred in 5 patients and incisional neuromas in 2 patients. The risk of these complications must be taken into consideration when using this operation.