Lateral Soft Tissue Release Research Articles

Functional and radiographic outcomes of hallux valgus correction by mini-invasive surgery with Reverdin-Isham and Akin percutaneous osteotomies: a longitudinal prospective study with a 48-month follow-up.

BackgroundMinimally invasive surgery (MIS) represents one of the most innovative surgical treatments of hallux valgus (HV). However, long-term outcomes still remain a matter of discussion within the orthopaedic community. The purpose of this longitudinal prospective study was to evaluate radiographic and functional outcomes in patients with mild-to-severe HV who underwent Reverdin-Isham and Akin percutaneous osteotomy, following exostosectomy and lateral release.MethodsEighty patients with mild-to-severe symptomatic HV were treated by MIS. Clinical evaluation was assessed preoperatively, as well as at 3 and 12 months after surgery and at final follow-up of 48 months, using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux grading system. Patient satisfaction and complications were recorded. Computer-assisted measurement of antero-posterior radiographs was taken preoperatively, as well as at 3 and 12 months after surgery and at 48-month follow-up, analysing the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA) and the tibial sesamoid position. Also, the bridging bone/callus formation was evaluated at the different radiographic follow-ups, while the articular surface congruency and the metatarsal index were calculated only preoperatively and at the last follow-up. Patient satisfaction was assessed using the visual analogue score (VAS). Statistical analysis was carried out using the paired t test. Statistical significance was set at p < 0.05.ResultsThe mean AOFAS score was 87.15 points at the final follow-up of 48 months, and the VAS score was 8.35/10. The post-operative radiographic assessments showed a statistically significant improvement compared with preoperative values. The mean corrections of each angular value at the last follow-up were as follows: IMA 3.90°, HVA 12.50°, DMAA 4.72° and a tibial sesamoid position of 1.10. The articular surface was congruent in 77 (96.25%) cases and incongruent only in 3 (3.75%). The complete healing of the osteotomies was achieved in all series at 3-month follow-up. However, the results obtained in the correction of the severe HV deformities were less encouraging.ConclusionsMinimally invasive surgery with Reverdin-Isham and Akin percutaneous osteotomy, in combination with previous exostosectomy and subsequent lateral soft-tissue release, is a safe, effective and reliable procedure for correction of mild-to-moderate HV. However, it requires a long learning curve because of the inherent difficulty of the mixed different surgical procedures.Trial registrationClinicalTrials.gov PRS Protocol Registration and Results System: NCT02886221

Triple osteotomy for the correction of severe hallux valgus deformity: Patient reported outcomes and radiological evaluation

BackgroundSymptomatic Hallux valgus can be treated with metatarsal osteotomy combined with proximal phalangeal osteotomy, however this might not be sufficient to treat severe HV deformities. MethodsFifteen feet in eleven female patients treated with double first metatarsal and proximal phalanx osteotomies without lateral release were prospectively studied and outcome measures including radiological angles and validated patient reported outcome scores collected. ResultsMean radiological follow up was 15 months and PROMs data 17 months. Mean hallux valgus and intermetatarsal angles were corrected from 45 to 24.7° and 18.7 to 7.4° respectively. There was an eight degree recurrence of hallux valgus angle. There was no wound problems, non-unions or evidence of avascular necrosis.The EQ-5D descriptive index showed a non-statistically significant improvement. All three elements of the MOxFQ score showed a statistically significant improvement: Forefoot pain (59–26.8), Walking and Stability (49.9–29.6) and Social Interaction (56.4–33.1) ConclusionTriple osteotomy, without a lateral soft tissue release, leads to good radiological and functional outcomes in those with severe hallux valgus deformity. Patients need to be warned of the recovery time and potential for future metalwork removal. The risk of early recurrence suggests that a lateral release should be included in order to maintain a long lasting correction.

Total knee arthroplasty after failed high tibial osteotomy: a systematic review of open versus closed wedge osteotomy.

Medial opening wedge high tibial osteotomy (HTO) has become increasingly popular as an alternative to lateral closing wedge osteotomy for the treatment of medial compartment knee osteoarthritis with varus deformity. The present systematic review was conducted to provide an objective analysis of total knee arthroplasty (TKA) outcomes following previous knee osteotomy (medial opening wedge vs. lateral closing wedge). A literature search of online databases (MEDLINE, EMBASE, Cochrane Library database) was made, in addition to manual search of major orthopaedic journals. The methodological quality of each of the studies was assessed on the Newcastle-Ottawa Scale and Effective Practice and Organization of Care. A total of ten studies were included in the review. There were eight studies with Level IV and two studies with Level III evidence. Eight studies reported clinical and radiologic scores. Comparative studies between TKA following medial opening and lateral closing wedge HTO did not demonstrate statistically significant clinical and radiologic differences. The revision rates were similar. However, more technical issues during TKA surgery after lateral closing wedge HTO were mentioned than the medial open wedge group. The quadriceps snip, tibial tubercle osteotomy, and lateral soft tissue release were more frequently needed in the lateral closing wedge HTO group. In addition, because of loss of proximal tibia bone geometry in the lateral closing wedge HTO group, concerns such as tibia stem impingement in the lateral tibial cortex was noted. The present systematic review suggests that TKA after medial opening and lateral closing wedge HTO showed similar performance. Clinical and radiologic outcome including revision rates did not statistically differ from included studies. However, there are more surgical technical concerns in TKA conversion from lateral closing wedge HTO than from the medial opening wedge HTO group. IV.

The Relationship Between the Sesamoid Complex and the First Metatarsal After Hallux Valgus Surgery Without Lateral Soft-Tissue Release: A Prospective Study

Some investigators have emphasized restoring the relationship between the sesamoid complex and the first metatarsal head to reduce the risk of hallux valgus recurring after surgical reconstruction. In a prospective study, we analyzed whether the first metatarsophalangeal joint could be realigned after scarf-Akin bunionectomy without lateral soft tissue release. A total of 25 feet, in 22 patients, were prospectively enrolled and analyzed using anteroposterior radiographs and coronal computed tomography scans obtained before and 3 months after surgery. The Yildirim sesamoid position decreased from a preoperative of 2 (range 1 to 3) to a postoperative position of 0 (range 0 to 1; p < .001), the mean first intermetatarsal angle decreased from 12.6° ± 2.4° to 5.8° ± 2.1° (p < .001), and the mean distance between the second metatarsal and the tibial sesamoid changed from 25.7 ± 4.6 to 25.9 ± 4.6 (p = .59). Our findings suggest that dislocation of the sesamoid complex is actually caused by displacement of the first metatarsal. In conclusion, the scarf-Akin bunionectomy adequately restores the alignment of the first metatarsophalangeal joint, including restoration of the sesamoid apparatus, without direct plantar–lateral soft tissue release.

The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction to treat severe hallux valgus

To explore the method of the treatment for hallux valgus with the proximal crescentic osteotomy of the first metatarsal bone, combining with distal lateral soft tissue release. From January 2008 to December 2012, 21 cases 21 hallux valgus feet were treated by operative procedure, included 1 male (1 foot) and 20 females (20 feet), with the mean age of 52 years (range, 36-68 years). Among all patients were followed up for 12 to 26 months, with the mean 16 months. The preoperative, post-operative and final follow-up X-ray films of all patients were collected. The hallux valgus angle, intermetatarsal angle and distal metatarsal articular angle were measured and analyzed. The surgical outcome was evaluated combined with the AOFAS score. The average hallux valgus angle decreased from 42.3° ± 1.8° preoperatively to 14.5° ± 1.8 postoperatively, the average intermetatarsal angle did from 21.9° ± 1.7 to 9.1° ± 1.8°, and the average distal metatarsal articular angle did from 14.9° ± 1.8 to 7.2° ± 1.5, respectively. There were significant differences between the preoperative and postoperative roentgenographic index. AOFAS score was improved from 44.0 ± 1.8 preoperatively to 83.9 ± 2.2 at the final follow-up. The proximal crescentic osteotomy of the first metatarsal bone combined distal soft tissue reconstruction obtained satisfactory results in severe hallux valgus patients with big intermetatarsal angle.

Distal soft-tissue procedure in hallux valgus deformity

Distal, lateral soft tissue release to restore mediolateral balance of the first metatarsophalangeal (MTP) joint in hallux valgus deformity. Incision of the adductor hallucis tendon from the fibular sesamoid, the lateral capsule, the lateral collateral ligament, and the lateral metatarsosesamoid ligament. Hallux valgus deformities or recurrent hallux valgus deformities with an incongruent MTP joint. General medical contraindications to surgical interventions. Painful stiffness of the MTP joint, osteonecrosis, congruent joint. Relative contraindications: connective tissue diseases (Marfan syndrome, Ehler-Danlos syndrome). Longitudinal, dorsal incision in the first intermetatarsal web space between the first and second MTP joint. Blunt dissection and identification of the adductor hallucis tendon. Release of the adductor tendon from the fibular sesamoid. Incision of the lateral capsule, the lateral collateral ligament, and the lateral metatarsosesamoid ligament. Postoperative management depends on bony correction. In joint-preserving procedures, dressing for 3 weeks in corrected position. Subsequently hallux valgus orthosis at night and a toe spreader for a further 3 months. Passive mobilization of the first MTP joint. Postoperative weight-bearing according to the osteotomy. A total of 31 patients with isolated hallux valgus deformity underwent surgery with a Chevron and Akin osteotomy and a distal medial and lateral soft tissue balancing. The mean preoperative intermetatarsal (IMA) angle was 12.3° (range 11-15°); the hallux valgus (HV) angle was 28.2° (25-36°). The mean follow-up was 16.4 months (range 12-22 months). The mean postoperative IMA correction ranged between 2 and 7° (mean 5.2°); the mean HV correction was 15.5° (range 9-21°). In all, 29 patients (93%) were satisfied or very satisfied with the postoperative outcome, while 2 patients (7%) were not satisfied due to one delayed wound healing and one recurrent hallux valgus deformity. There were no infections, clinical and radiological signs of avascular necrosis of the metatarsal head, overcorrection with hallux varus deformity, or significant stiffness of the first MTP joint.

Lateral Soft-Tissue Release with Medial Transarticular or Dorsal First Web-Space Approach Combined with Distal Chevron Osteotomy for Moderate-to-Severe Hallux Valgus.

We describe the medial transarticular and dorsal first web-space soft-tissue approaches, used in combination with an osteotomy, for the surgical correction of painful hallux valgus. Make a medial longitudinal skin incision over the first metatarsophalangeal joint, perform a longitudinal midline capsulotomy, and excise the medial eminence. Distract and widen the first metatarsophalangeal joint, apply manual traction to the great toe, transect the adductor hallucis, and apply varus stress to the first metatarsophalangeal joint. Create a v-osteotomy, displace the capital fragment laterally, and impact it onto the shaft. Patients walk in a postoperative shoe after surgery, and early metatarsophalangeal stretching exercises are encouraged. Make a 3-cm dorsal longitudinal incision centered on the first intermetatarsal web space. Dissect the adductor hallucis tendon, transect the fibular sesamoid-metatarsal and transverse metatarsal ligaments, and perforate the first metatarsophalangeal joint capsule. Perform as for the medial transarticular approach. The same as for the medial transarticular approach. We studied 122 female patients (122 feet) who had undergone distal chevron osteotomy with a distal soft-tissue procedure for the treatment of symptomatic, unilateral, moderate-to-severe hallux valgus.IndicationsContraindicationsPitfalls & Challenges.

Lateral soft-tissue release through a medial incision: Anatomic comparison of two techniques.

The distal soft tissue procedure is an integral part of hallux valgus surgery, providing soft tissue balance and alignment restoration of the first metatarsophalangeal joint. Various approaches have been established to this end. For techniques that do not include a separate dorsal incision, lateral release may be achieved via a transarticular approach or via a medial incision and a dorsal flap over the first metatarsal. Compared to the double-incision technique, these techniques are not only cosmetically superior and thus meet the demands of most surgeons and patients. Using six pairs of frozen cadaveric feet, lateral release was performed using one of the above techniques in a randomized manner with pair comparison. The specimens were then dissected and the completeness of the release as well as any damage to anatomic structures was documented. The transarticular technique enabled complete release of the metatarsal-sesamoid suspensory ligament (MSL) and the transverse and oblique head of the adductor hallucis muscle in five of six specimens. The comparative technique enabled the same in only two of six cases for the adductor hallucis muscle and in four cases for the MSL. The transarticular approach achieved complete release of the lateral joint capsule in three of six specimens, whereas the dorsal approach achieved no release in any specimen. Neither of the methods caused any macroscopic injury to the surfaces of the first metatarsophalangeal joint. The examined arteries, veins, and nerves remained intact in all specimens treated with the transarticular approach, but dorsal release resulted in one documented injury to the first dorsal metatarsal artery and its concomitant veins. Compared to release by dissection superficially to the extensor tendons, transarticular release provides a more complete lateral release and less injuries to neurovascular bundles. Further anatomic and clinical studies are needed, however, before conclusive recommendations can be made.

English

BACKGROUND: Surgical correction of congenital talipes equino varus (ctev) is to address adequately all aspects of this complex foot deformity. Various exposures have been elucidated with varying results and complications. This prospective study discusses the cincinnati approach advocated by Mackay to address the various aspects of clubfoot correction. Objective: To study the adequacy of exposure, wound healing and problems related to Cincinnati approach. To study the effectiveness of primary surgical correction. METHODS: The present prospective study includes treatment of 24 feet in 21 patients with clubfoot treated with posteromedial and lateral soft tissue release by Cincinnati approach and followed up with an average follow up of 6.9 months. 3 (12.5%) were followed up for 1 year and 3 (12.5%) lost for the follow up. 18 (75%) were followed up to 6 months. All were resistant to correction by conservative method. Age at operation averaged 1.6 year, ranged from 9 months to 3 years. RESULTS: Results were evaluated using Laaveg and Ponseti functional rating system of clubfoot. Postoperatively the average arc of movement in ankle joint was 370, which was 50% of normal limb. Inversion, eversion movement of subtalar joint was 230, bimalleolar angle was 770.The functional results were excellent in 6 feet (25%), good in 12 feet (50%), fair in 5 feet (20.83%) and poor in 1 foot (4.17%). In our series complications encountered were post-operative focal necrosis in 3 feet (12.5%) and marginal necrosis in 3 feet (12.5%). CONCLUSION: Cincinnati incision provides an adequate exposure for extensive surgical release under direct vision, there by bony realignment of talus over calcaneus was restored and hence the restoration of normal bimalleolar angle. Skin closure is not found to be a problem in achieving a primary closure. Wound healing leaves only a thin and cosmetically acceptable scar.

Total knee arthroplasty for severe valgus knee deformity

Objective To investigate the surgical methods and clinical effects of total knee arthroplasty (TKA) in patients with severe valgus knee deformity.Methods From January 2007 to December 2012,22 patients with 23 severe valgus knee deformity underwent TKA by means of medial parapatellar approach,standard osteotomy and only lateral soft tissue release with posterior stabilized implants were retrospectively analyzed.They were 7 males and 15 females,aged from 41 to 78 years,with an average age of 65 years.Tibiofemoral angle (angle between the femur and tibia anatomic axis) was 22°-50°,with an average of 34.6±2.4°.Among them,17 cases were osteoarthritis,5 cases were rheumatoid arthritis,3 cases complicated with patella dislocations,1 case complicated with medial instability,3 cases of 4 knees complicated with flexion contracture.Posterior stabilized prosthesis were used in 21 cases of 22 knees,constrained prosthesis were used in 1 case of 1 knee,5 cases accepted intraoperative patellar replacement.Clinical and radiographic evaluations including range of motion (ROM),the Hospital for Special Surgery (HSS)knee score and the tibial and femur angle (T-F angle) were performed at follow-up.Results The duration of follow-up averaged 30.5 months.The average HSS score improved from 19.6±4.7 points preoperatively to 89.7±3.6 points at the time of the last follow up.The average ROM improved from 43.7°-±5.8° preoperatively to 110.6°±7.5°.The average T-F angle was 8.6°±0.8°.We had 5 patella replacements,2 medial instability cured by using articular branches,2 palsies of nervus peroneus communis recovering after 3 months.No complications such as infection,DVT,or component loosening.Conclusion The techniques of medial parapatellar approach,standard osteotomy and only lateral soft tissue release with posterior stabilized implants can deal with a severe valgus knee deformity very successfully in patients undergoing primary total knee arthroplasty,and provide excellent results. Key words: Arthroplasty, replacement, knee; Genu valgum; Osteoarthritis; Arthritis, rheumatoid

Total knee arthroplasty in the valgus knee

Valgus knee deformity is a challenge in total knee arthroplasty (TKA) and it is observed in nearly 10% of patients undergoing TKA. The valgus deformity is sustained by anatomical variations divided into bone remodelling and soft tissue contraction/elongation. Bone tissue variations consist of lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodelling. Soft tissue variations are represented by tightening of lateral structures: lateral collateral ligament, posterolateral capsule, popliteus tendon, hamstring tendons, the lateral head of the gastrocnemius and iliotibial band. Complete pre-operative planning and clinical examination are mandatory to manage bone deformities and soft tissue contractions/elongations and to decide if a higher constrained prosthesis is necessary. Two different approaches have been described to perform TKA in a valgus knee: the anteromedial approach and the anterolateral one. In valgus knee deformity bone cuts can be performed differently in order to correct low-grade deformities and reduce great deformities. There is still debate in the literature on the sequence of lateral soft tissue release to achieve the best alignment without any instability. The aim of this article is to review the anatomical variations underlying a valgus knee, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. We will also review the main approaches and surgical techniques both for bone cuts and soft tissue management. Finally, we will report on our experience and technique.

Proximal Reverse Chevron Metatarsal Osteotomy, Lateral Soft Tissue Release, and Akin Osteotomy Through a Single Medial Incision for Hallux Valgus

Scarring on the dorsal first web space after lateral soft tissue release can be a major contributor to patient dissatisfaction following hallux valgus surgery. We hypothesized that performing distal soft tissue procedure (DSTP), proximal reverse chevron metatarsal osteotomy (PCMO), and Akin osteotomy through a single medial incision would provide better clinical and radiographic results with improved patient satisfaction compared with bunion corrections performed through 2 incisions. The study included 117 feet (of 98 patients) with moderate to severe hallux valgus. Clinically, the preoperative and final follow-up visual analog scale (VAS) pain scores, the preoperative and final follow-up American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal (MTP)-interphalangeal (IP) scores, first MTP joint range of motion (ROM), and patient satisfaction after the surgery were evaluated. Radiographically, the hallux valgus angle (HVA), intermetatarsal angle (IMA), hallux valgus interphalangeal angle (HIA), medial sesamoid position (MSP), and first to fifth metatarsal width (1-5MTW) were analyzed before and after surgery. The mean AOFAS hallux score improved from 56.3 preoperatively to 90.6 at the final follow-up, and the mean VAS pain score decreased from 6.8 preoperatively to 1.5 at the final follow-up (P < .001). Ninety-five percent of the patients were satisfied with the surgery. Radiographically, the mean HVA decreased from 36.1 degrees (range, 16.0 to 44.0 degrees) preoperatively to 5.4 degrees (range, -12.4 to 29.7 degrees) at the final follow-up (P < .001), and the mean IMA decreased from 19.0 degrees (range, 9.0 to 28.0 degrees) preoperatively to 4.5 degrees (range, -5.0 to 14.2 degrees) at the final follow-up (P < .001). The mean 1-5MTW also decreased by 16% (16 mm) from 97.3 mm (range, 85.0 to 110.0 mm) preoperatively to 81.3 mm (range, 70.0 to 95.0 mm) at the final follow-up (P < .001). We achieved very favorable clinical and radiographic outcomes with minimal complications in patients with moderate to severe hallux valgus, by treating hallux valgus using DSTP, PCMO, and Akin osteotomy through a single medial incision. The single medial incision scar improved the cosmetic results by avoiding the formation of a disfiguring dorsal first web space scar. Level IV, retrospective case series.

Reply to comments by Wu et al. regarding our manuscript titled: A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)

Reply to comments by Wu et al. regarding our manuscript titled: A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)

Comment on Giannini et al.: A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)

Dear editor, We read the recent article entitled “A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)” published in the September 2013 issue of International Orthopaedics by Giannini et al. [1] with great interest. They described a novel mini-invasive surgical technique for the treatment for hallux valgus (HV). They analysed a series of 1,000 consecutive cases of HV, surgically treated by the minimally invasive SERI technique, reporting results at mid-term follow-up. They concluded that the SERI technique was effective in treating mild to moderate HV patients in terms of relief from symptoms and functional improvement. However, there are some comments we would like to raise related to this article. First, it is accepted, to correct the HV deformity, a lateral soft tissue release should be performed first, which includes adductor hallucis attachment release, transverse metatarsal ligament release, metatarsal-sesamoid ligament release and the lateral joint capsule release, which can reposition the displaced sesamoids and avoid recurrence of the HV deformities. However, the effect of the soft tissue procedure mentioned in this article, by manually stretching of the adductor hallucis and the lateral soft tissue, is hard to evaluate. There is no consensus or validated standard for this stretching process. The strength of surgeons varies from each individual, which may be either too strong causing iatrogenic vascular, nerve and tendon injuries, or too weak to totally release the soft tissue structure. Moreover, sesamoid dislocation commonly occurs in HV patients, which is quite difficult to correct by mere manual stretching. As a result the dislocated sesamoid may hinder the lateral translational displacement of the first metatarsal head. Commonly, it is difficult to correct sesamoid dislocation and incision of the sesamoid suspensory ligament without open reduction. Second, this surgical technique merely utilized a 1-cm incision at the level of the neck of the first metatarsal bone to perform this procedure. In our opinion, there is still some confusion with this procedure. In order to realign the metatarsosesamoid complex to decrease the first IM angle and correcting the HV deformity, it is necessary to release the lateral soft tissue combined with a medial capsule reefing. Obviously it is quite difficult to complete this step with such incisions. Most of the HV patients suffer from osteophyte around the proximal metatarsal bones, and only by removing the osteophytes can the symptoms be significantly relieved. However the incision in this procedure is away from the first metatarsophalangeal joint. What’s more, it is controversial whether the bunion in the medial side of first metatarsophalangeal joint capsule should be cut off [2]; thus, a 1-cm incision does not satisfy the need for surgery [3]. With regards to the operative technique for the HV deformities, the authors use only one K-wire for fixation. K-wire has its own weakness, such as less capacity to stabilize the osteotomy, pin tract infection, skin irritation, and the necessity of pin removal. Rigid fixation is critical to the osteotomy. Nevertheless, the type of fixation mentioned in this article tended to be easily displaced [4], which could cause bone malunion or nonunion, recurrence and metatarsalgia. Finally, this article just mentioned a mid-term follow-up, however a postoperative research should have an accurate followed-up period.

Early efficacies of total knee arthroplasty for knees with severe lateral instability

To evaluate the outcomes of primary total knee arthroplasty (TKA) in the treatment of knee with severe lateral instability and summarize the essential points of operation and rehabilitation. From February 2005 to August 2010, primary TKA was performed in 27 severe lateral unstable knees (25 cases), including 3 males (3 knees) and 22 females (24 knees). Their mean age was 57.8 (37-71) years. And their primary diseases included rheumatoid arthritis (22 knees in 21 cases) and osteoarthritis (5 knees in 4 cases). Thirteen lateral unstable knees were accompanied with 18.08° ± 5.96°(15-35°) varus deformity; in the rest 14 knees, there was medial instability with 20.71° ± 7.03° (15-35°) valgus deformity. Blood loss volume, operative duration and complications were recorded. During the follow-up period, HSS score, knee stability and varus/valgus status were recorded preoperatively, 1, 3, 6, 12 months and then annually postoperatively. AORI type I bone defect was found at the proximal tibia in 18 knees and distal lateral femoral condyle in 10 knees. All defects were reconstructed with cement or autograft. AORI type II bone defects at proximal tibia in 3 knees were reconstructed with metal augmentation. Blood loss during the first 24 hours were (438.9 ± 109.5) (400-700) ml and operative duration (91.1 ± 11.6) (70-110) min. The mean follow-up period was (41.6 ± 10.9) (27-60) months. At the final follow-up, the HSS score increased from (45.8 ± 5.4) to (85.4 ± 4.5) (t = 30.15, P < 0.01) .Five knees in 5 cases had mild postoperative instability. All cases were allowed to walk with knee orthosis for 4-6 weeks. At the end of follow-up, mild lateral instability of 2 knees persisted. One augmented knee had osteolysis beneath metal block. TKA for knees with severe lateral instability requires a deep understanding of causes and a rational treatment. Proper handling of bone defects and careful release of lateral soft tissue are two critical points for postoperative knee stability. Wearing knee orthosis during the early postoperative stage may be helpful or residual mild instability.

Comparison of Distal Soft-Tissue Procedures Combined with a Distal Chevron Osteotomy for Moderate to Severe Hallux Valgus: First Web-Space Versus Transarticular Approach

There are two surgical approaches for distal soft-tissue procedures for the correction of hallux valgus-the dorsal first web-space approach, and the medial transarticular approach. The purpose of this study was to compare the outcomes achieved after use of either of these approaches combined with a distal chevron osteotomy in patients with moderate to severe hallux valgus. One hundred and twenty-two female patients (122 feet) who underwent a distal chevron osteotomy as part of a distal soft-tissue procedure for the treatment of symptomatic unilateral moderate to severe hallux valgus constituted the study cohort. The 122 feet were randomly divided into two groups: namely, a dorsal first web-space approach (group D; sixty feet) and a medial transarticular approach (group M; sixty-two feet). The clinical and radiographic results of the two groups were compared at a mean follow-up time of thirty-eight months. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scale hallux metatarsophalangeal-interphalangeal scores improved from a mean and standard deviation of 55.5 ± 12.8 points preoperatively to 93.5 ± 6.3 points at the final follow-up in group D and from 54.9 ± 12.6 points preoperatively to 93.6 ± 6.2 points at the final follow-up in group M. The mean hallux valgus angle in groups D and M was reduced from 32.2° ± 6.3° and 33.1° ± 8.4° preoperatively to 10.5° ± 5.5° and 9.9° ± 5.5°, respectively, at the time of final follow-up. The mean first intermetatarsal angle in groups D and M was reduced from 15.0° ± 2.8° and 15.3° ± 2.7° preoperatively to 6.5° ± 2.2° and 6.3° ± 2.4°, respectively, at the final follow-up. The clinical and radiographic outcomes were not significantly different between the two groups. The final clinical and radiographic outcomes between the two approaches for distal soft-tissue procedures were comparable and equally successful. Accordingly, the results of this study suggest that the medial transarticular approach is an effective and reliable means of lateral soft-tissue release compared with the dorsal first web-space approach. Therapeutic level II. See Instructions for Authors for a complete description of levels of evidence.

Comparison of open lateral release and transarticular lateral release in distal chevron metatarsal osteotomy for hallux valgus correction

The aim of this study was to investigate the difference in clinical and radiographic outcomes between conventional open lateral soft tissue release (OLSTR) and transarticular lateral soft tissue release (TLSTR) in patients undergoing distal chevron metatarsal osteotomy (DCMO) for hallux valgus (HV) correction. This study included weight-bearing anteroposterior radiographs of 138 patients (185feet) with HV that underwent DCMO and Akin phalangeal osteotomy at a mean age of 51.7years (21-74) with a mean 26months of follow-up between June 2004 and June 2010. Patients were classified into two groups: OLSTR as group 1 (84feet) and TLSTR as group 2 (101feet). We evaluated clinical and radiographic outcomes between the two groups using the American Orthopaedic Foot and Ankle Society hallux score, visual analogue scale pain score, hallux valgus angle, intermetatarsal angle and complications, pre- and post-operatively. There were no significant differences between the two groups except for post-operative complications such as first metatarsophalangeal joint (MTPJ) stiffness (group 1) and post-operative hallux varus (group 2). Clinical and radiographic outcomes between OLSTR and TLSTR in HV correction using DCMO were not significantly different except for post-operative limitation of motion of the first MTPJ and hallux varus tendency. Different precautions should be taken into account when choosing the type of lateral soft tissue release due to possible complications associated with each technique.

Distal soft tissue procedure in hallux valgus surgery: biomechanical background and technique

The distal soft tissue procedure has evolved into an indispensable additional surgical procedure to increase the corrective effect in hallux valgus surgery. Considering the biomechanical development of hallux valgus deformity, degenerative changes of the soft tissues around the first metatarsophalangeal joint contribute much more to the deformity than changes in the bony structures which can rather be seen as degenerative changes secondary to the deformity. Thus the principles in hallux valgus correction should aim to reverse all pathogenetic steps leading to deformity: release of the contracted lateral soft tissue structures, tightening of the torn-out medial structures and reduction and rebalancing the first metatarsal head onto the sesamoid complex. The scientific discussion over the last decades has clarified the impact of different surgical steps and methods on the efficacy of the lateral release, the risk of creating overcorrection or instability of the joint and the risk of avascular necrosis of the first metatarsal head. According to anatomical and clinical data, a lateral soft tissue release can be combined with a distal metatarsal osteotomy, provided that the osteotomy is performed in a defined safe zone without increasing the risk for avascular necrosis of the first metatarsal head. Transecting the lateral metatarsosesamoid suspensory ligament is the key to a successful lateral release in hallux valgus surgery. Release of the deep transverse metatarsal ligament and the adductor hallucis muscle does not contribute to hallux valgus correction. The lateral short sesamophalangeal ligament and the plantar attachment of the articular capsule should be preserved to avoid possible joint instability. Thus today, the distal soft tissue procedure cannot be seen only as a supplementary surgical procedure in cases where the bony procedure needs additional correction, but rather is an indispensable procedure to restore the physiological situation and function of the first metatarsophalangeal joint.

Comparison of outcomes between proximal and distal chevron osteotomy, both with supplementary lateral soft-tissue release, for severe hallux valgus deformity

Severe hallux valgus deformity is conventionally treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy with an associated soft-tissue procedure can also be used in moderate to severe deformity. We compared the clinical and radiological outcomes of proximal and distal chevron osteotomy in severe hallux valgus deformity with a soft-tissue release in both. A total of 110 consecutive female patients (110 feet) were included in a prospective randomised controlled study. A total of 56 patients underwent a proximal procedure and 54 a distal operation. The mean follow-up was 39 months (24 to 54) in the proximal group and 38 months (24 to 52) in the distal group. At follow-up the hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, tibial sesamoid position, American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal score, patient satisfaction level, and complications were similar in each group. Both methods showed significant post-operative improvement and high levels of patient satisfaction. Our results suggest that the distal chevron osteotomy with an associated distal soft-tissue procedure provides a satisfactory method for correcting severe hallux valgus deformity.

Distal Chevron Osteotomy with Lateral Soft Tissue Release for Moderate to Severe Hallux Valgus Decided Using Intraoperative Varus Stress Radiographs

The purpose of the present study was to investigate the outcomes of distal chevron osteotomy with lateral soft tissue release for moderate to severe hallux valgus. The patients were selected using criteria that included the degree of lateral soft tissue contracture and metatarsocuneiform joint flexibility. The contracture and flexibility were determined from intraoperative varus stress radiographs. From April 2007 to May 2009, 56 feet in 51 consecutive patients with moderate to severe hallux valgus had undergone distal chevron osteotomy with lateral soft tissue release. This was done when the lateral soft tissue contracture was not so severe that passive correction of the hallux valgus deformity was not possible and when the metatarsocuneiform joint was flexible enough to permit additional correction of the first intermetatarsal angle after lateral soft tissue release. The mean patient age was 45.2 (range 23 to 54) years, and the duration of follow-up was 27.5 (range 24 to 46) months. The mean hallux abductus angle decreased from 33.5° ± 3.1° to 11.6° ± 3.3°, and the first intermetatarsal angle decreased from 16.4° ± 2.7° to 9.7° ± 2.1°. The mean American Orthopaedic Foot and Ankle Society hallux-interphalangeal scores increased from 66.6° ± 10.7° to 92.6° ± 9.4° points, and 46 of the 51 patients (90%) were either very satisfied or satisfied with the outcome. No recurrence of deformity or osteonecrosis of the metatarsal head occurred. When lateral soft tissue contracture is not severe and when the metatarsocuneiform joint is flexible enough, distal chevron osteotomy with lateral soft tissue release can be a useful and effective choice for moderate to severe hallux valgus deformity.