Search Results (55)

Hallux valgus is one of the common causes of forefoot pain in the field of foot and ankle surgery. This condition is characterized by valgus and pronation deformities of the first ray, leading to bunion pain, metatarsalgia, callus formation, and gait disturbances. Conventional open osteotomy of the first metatarsal and proximal phalanx of the first toe has been widely performed. Recently, with increasing reports of favorable radiologic and clinical outcomes of minimally invasive surgery, this technique has been performed by many surgeons. Despite the various surgical methods available, there is still no consensus on the optimal treatment of hallux valgus, and the advantages and disadvantages of open versus minimally invasive techniques remain a topic of debate. This narrative review aims to provide a comprehensive overview of the latest radiographic evaluation and surgical treatment for hallux valgus. Full article

Background/Objectives: Limb malalignment disrupts physiological joint forces and predisposes individuals to the development of osteoarthritis. Surgical interventions such as distal femur or high tibial osteotomy aim to restore mechanical balance on weight-bearing joints, thereby reducing long-term morbidity. Accurate alignment is crucial since it cannot be adjusted after stabilization with plates and screws. Recent advances in personalized medicine offer the opportunity to tailor surgical corrections to each patient’s unique anatomy and biomechanical profile. This study evaluates the benefits of 3D planning and patient-specific cutting guides over traditional 2D planning with standard implants for alignment correction procedures. Methods: We assessed limb alignment parameters pre- and postoperatively in patients with varus and valgus lower limb malalignment undergoing acute realignment surgery. The cohort included 23 opening-wedge high tibial osteotomies and 28 opening-wedge distal femur osteotomies. We compared the accuracy of postoperative alignment parameters between patients undergoing traditional 2D preoperative X-ray planning and those using 3D reconstructions of CT data. Outcome measures included mechanical axis deviation and tibiofemoral angles. Results: 3D reconstructions of computerized tomography data and patient-specific cutting guides significantly reduced the variation in postoperative limb alignment parameters relative to preoperative goals. In contrast, traditional 2D planning with standard non-custom implants resulted in higher deviations from the targeted alignment. Conclusions: Utilizing 3D CT reconstructions and patient-specific cutting guides enhances the accuracy of postoperative limb realignment compared to traditional 2D X-ray planning with standard non-custom implants. Patient-specific instrumentation and personalized approaches represent a key step toward precision orthopedic surgery, tailoring correction strategies to individual patient anatomy and potentially improving long-term joint health. This improvement may reduce the morbidity associated with lower limb malalignment and delay the onset of osteoarthritis. Level of Evidence: Therapeutic Level III. Full article

Background: Osteotomies around the knee aim to correct varus or valgus malalignment and improve biomechanics. However, little is known about their effect on knee phenotypes, as defined by the Coronal-Plane-Alignment-of-the-Knee (CPAK) and Hirschmann’s functional classification. This study evaluated pre- and postoperative phenotypes in patients undergoing high-tibial-osteotomy (HTO) or distal-femoral-osteotomy (DFO). Methods: We retrospectively analysed 214 osteotomies around the knee (HTO: 145; DFO: 69) of 188 patients from our institutional registry. Radiographic parameters were measured using a validated artificial intelligence software, with phenotypes classified by CPAK and Hirschmann classification. Preoperative osteotomy planning was compared to postoperative alignment. Regression was used to assess the influence of demographic and radiographic factors. Results: CPAK types changed in 95.3% of cases. Medial opening HTOs most frequently shifted from CPAK type I (73.8%) to VI (42.3%), while medial closing DFOs transitioned from type III (81.5%) to V (24.1%). Concordance between planned and achieved CPAK types was highest for types III, IV, and V. Postoperative angles were generally smaller than planned for joint-line-obliquity (JLO), lateral-distal-femur-angle, and medial-proximal-tibial-angle (p < 0.001). Neutral JLO was restored in only 48.1%. Preoperative phenotypes NEUmLDFA0° (40.1%) and VARmMPTA3° (32.3%) were most common, while postoperative phenotypes included VALmLDFA3° (52.4%) and VALmMPTA3° (37.7%). Age, sex, and BMI significantly influenced alignment outcomes. Conclusions: Postoperative CPAK classifications shifted significantly across all osteotomy types, with minimal retention of preoperative types. Although most procedures achieved correction within the target HKA range, restoration of a neutral JLO was observed in only half of the cases, emphasizing the importance of phenotype-specific planning and highlight potential limitations of CPAK classification. Full article

Background/Objectives: Akin osteotomy, in the context of corrective surgery for hallux valgus, is an effective tool available to surgeons. However, few studies have thoroughly investigated the anatomical and technical characteristics to be considered in order to perform an optimal osteotomy. This cross-sectional observational study aims to identify the ideal site for performing Akin osteotomy and to identify the factors that influence its corrective power. Methods: To this end, an analysis was conducted on a random sample of 100 patients (186 feet) who underwent X-rays without surgical treatment. Variations in the width between the metaphysis and diaphysis were measured at five different points. For each cut level, corresponding to wedge bases of 2, 3 and 4 mm, three corrective angles were calculated. In addition, the distance between the cut line and the joint was recorded. Results: The base width ranged from 12.6 to 23.2 mm, showing greater variability in the metaphyseal region. The corrective power of the osteotomy showed wide variability, ranging from 5.9 to 18.4 degrees. Four determining factors emerged: the width of the base, the inclination of the medial cortex, the height at which the cut is made and the thickness of the wedge of bone removed. The data obtained suggest that osteotomy should not be performed less than 10 mm from the joint line to avoid the risk of joint invasion. Conclusions: In conclusion, there is no universally ideal site for performing an Akin osteotomy: the choice depends on the degree of correction desired, which in turn is influenced by the factors identified in the study. Full article

Background: Skewfoot, also known as Z-foot, is a rare and complex deformity characterized by a combination of forefoot adduction and hindfoot valgus, resulting in a “Z” shape. Due to its rarity, diagnostic criteria and standardized treatment guidelines are lacking. This scoping review aims to systematically map and summarize the current knowledge regarding skewfoot. Methods: A comprehensive literature search of the PubMed, Cochrane Library, and Scopus databases was conducted to identify relevant articles. Patient-specific data were meticulously extracted from eligible studies and analyzed in detail. Results: A total of 12 studies met the inclusion criteria. Each study was independently reviewed, and data on epidemiology, etiology, clinical presentation, imaging assessment, and treatment options were extracted. Conclusions: The true incidence of skewfoot remains unknown. Etiology is likely multifactorial, often associated with systemic and neurological disorders. Skewfoot management ranges from conservative approaches to surgery. A medial cuneiform opening wedge osteotomy is the most used technique; however, the frequent need for additional procedures emphasizes the complexity of the deformity and the importance of a personalized approach. Full article

Background/Objectives: Assessing the learning curve is essential for surgical techniques that require precision and technical adaptation. Although modified Reverdin–Isham and Akin percutaneous osteotomies (RIAOs) are well-established procedures for the treatment of hallux valgus (HV), their percutaneous nature and specific technical demands justify the evaluation of the learning curve. Therefore, this study aimed to assess the learning curve of RIAOs for the HV correction, using for the first time a Bayesian approach. Methods: Modified RIAOs were applied to treat mild-to-moderate HV in patients who were prospectively enrolled. The hallux valgus angle (HVA), inter-metatarsal angle (IMA), distal metatarsal articular angle (DMAA) and tibial sesamoid position were assessed. Clinical outcomes were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, Visual Analog Scale (VAS) and Numerical Rating Scale (NRS). Surgery and fluoroscopy times were recorded. To evaluate the learning curve, a Bayesian analysis using a change point model was performed. Results: Analysis of 142 patients revealed three distinct phases in the learning curve, with a plateau reached after 112 procedures. Over time, the mean operation duration decreased from 55 to 27 min, and fluoroscopy time decreased from 60 to 28 s. Conclusions: A flexible change point model was used to model a learning curve, guaranteeing a robust interpretation of the data. The correction of the HV angles showed similar results in the three phases of the curve, demonstrating that the surgeon achieved positive results from the beginning of the surgery. Full article

Background: Calcaneal osteotomies are a common procedure in foot and ankle surgery for the treatment of the painful flexible Progressive Collapsing Foot Deformity (PCFD). The lateral calcaneal lengthening osteotomy (LCLOT) allows a three-dimensional foot and ankle flatfoot correction with a single osteotomy. The purpose of this article is to review the types of calcaneal lengthening osteotomies. Methods: Review of anatomical, biomechanical and clinical studies and reviews. Results: The LCLOT shall be differentiated from the Evans osteotomy or Z-shaped calcaneal lengthening osteotomy. The LCLOT is performed at the sinus tarsi and corrects at the subtalar joint axis biomechanically the pathological hindfoot valgus, foot abduction, and medial arch collapse. The LCLOT technique might vary regarding graft and fixation type. The LCLOT has good clinical results with high union rates. Conclusions: The LCLOT is a powerful and successful single-site osteotomy for the triplanar correction of the painful flexible flatfoot/PCFD. Full article

Background and Objectives: The Reverdin–Isham osteotomy via minimal incision is a prominent option for the surgical treatment of hallux valgus, a foot deformity characterized by medial deviation of the first metatarsal and lateral deviation of the first toe. This technique is particularly indicated for cases with an elevated proximal articular angle, enabling effective correction and improved foot functionality. However, its efficacy has not been fully established in the scientific literature. Objective: The main objective of this analysis was to evaluate the correction of radiological angles (PASA, IMA, and HVA), the improvement in functionality according to the AOFAS scale, pain reduction, and patient satisfaction. Materials and Methods: A systematic review was conducted following the PRISMA guidelines in scientific databases such as PubMed, Scopus, and Web of Science, assessing publication biases and heterogeneity. Ten studies were included, covering 579 procedures in 500 patients, with an average follow-up of 33.8 months. Results: The results did not show significant improvements in the PASA (p = 0.14; CI [−1.52, 0.32]), not in the AIM (p = 0.05; CI [−2.63, 0.02]), although the meta-regression was statistically significant (p = 0.0022) with a ratio of 61.2%. It did show significant improvements in the AHV (p = 0.0009; CI [−3.14, −1.33]). An increase of 37.4 points in the AOFAS scale was revealed, and a 5.4-point reduction in pain. Patient satisfaction was high, with 89.3% of patients satisfied and 94.7% willing to undergo the procedure again. However, 20 major complications were reported, primarily recurrences. Conclusions: The Reverdin–Isham osteotomy is a safe and effective technique for treating mild-to-moderate hallux valgus. It offers significant improvements in foot functionality and pain reduction, with high patient satisfaction rates. Although recurrences remain the main complication, their low frequency reinforces the validity of the technique as a surgical option for specific deformities. Full article

Background: Hallux valgus is a common painful condition with tri-planar deformity of the first ray. Surgical correction consists of distal osteotomy of the first metatarsal and its lateral translation. However, in the case of hypermobility of the first cuneo-metatarsal joint (TMTJ), the associated Lapidus procedure is indicated to correct deformities along all three anatomical planes. Lapidus procedure is reported to have several contraindications and complications; for this reason, many surgeons proposed technical modification to the original procedure. We present the results of a novel surgical technique for hallux valgus correction with minimally invasive arthrodesis of first TMTJ without proximal correction of deformity, combined with a distal Austin-Chevron procedure. Materials and Methods: We retrospectively evaluated patients who underwent surgical correction of hallux valgus with our technique between January 2010 and January 2020. We collected data on demographics, anesthesiologic technique, associated surgical procedures, post-operative functional results, and complications. Dorso-plantar and lateral radiographs were performed at 6, 12, and 24 weeks after surgery or until fusion was documented. Clinical assessment considered gait analysis, pain or other disturbance, type of shoes worn, and use of orthosis. Results: A total of 240 patients were enrolled. AOFAS score, hallux valgus angle, and inter-metatarsal angle showed a significant improvement. Complications consisted of distal osteotomy non-union (1%), pain or protrusion of the screw (13%), and recurrence of deformity (2%). Overall, patients were very satisfied with the surgery in 192/278 (69%) cases, moderately satisfied in 67/278 (24%) cases, satisfied in 8/278 (3%) cases, and dissatisfied in 11/278 (4%) cases. Conclusions: Our novel surgical technique which combines in situ arthrodesis of the first tarso-metatarsal joint (TMTJ) with a distal Austin-Chevron procedure offers an effective alternative for correcting hallux valgus with first-ray hypermobility, minimizing complications associated with traditional methods. Full article

Background/Objectives: The Chiari pelvic osteotomy (CPO) creates a bony roof by medialization of the acetabulum, thus improving the biomechanics of dysplastic hip joints. Long-term results have already been examined in various studies. However, the impact on the axis of the lower limb has not been investigated yet. The aim of this study was the analysis of changes in the alignment of the lower limb and leg length caused by a CPO and, consecutively, the impact on conversion total hip arthroplasty and primary knee arthroplasty. Methods: A total of 85 patients with 111 CPOs were clinically examined, patient reported outcome measures collected, and long leg standing radiographs analysed according to Paley. Results: The patients were examined an average of 34 years (±7.8; 23–53) after CPO. Unilaterally operated patients (N = 59 hips) showed a pathological MAD in 71% (N = 42) on the operated side (90% valgus, 10% varus). On the unaffected side, we could identify 56% (N = 33 hips) pathological cases (70% valgus, 30% varus). When patients underwent CPO bilaterally (N = 52 hips), the MAD was abnormal in 34 operated hips (65%; 97% valgus, 3% varus). If a leg length discrepancy occurred after the operation, the pelvis and the femur contributed the most to the total leg length discrepancy. Conclusions: Shifts in the mechanical axis following a CPO must be considered in order to inform patients appropriately preoperatively and quantified postoperatively by performing long leg standing radiographs in order to plan following joint replacement therapy adequately and maximize the chance of a successful long-term outcome on a functional level as well as for the patient’s satisfaction. Full article

Subtrochanteric nonunion is especially challenging. Extramedullary fixation using fixed-angle devices with a closing lateral wedge osteotomy is the standard surgical procedure for restoring the hip’s normal alignment and achieving bone union. However, this procedure is technically demanding and relies on devices that facilitate bone union in a non-dynamic manner, along with the limitations that this type of fixation entails, especially in this highly biomechanically stressed area. This paper aims to describe a novel surgical technique to heal subtrochanteric nonunion based on dynamic fixation performed through an over-valgus correction of the hip and fixed with a dynamic hip screw (DHS). Between March 2022 and July 2023, five patients diagnosed with nonunion of a subtrochanteric fracture were operated on by a single surgeon and followed prospectively. The average age of the patients was 64 (range: 34–85). The mean duration of surgery was 112 min (range: 63–153). The femoral neck angle before surgery was 120° (range: 110°–122°) and 147° (range: 142°–150°) after surgery. The mean leg length increased by 8 mm (range: 6–12). The Harris hip score improved from 38 points (range: 30–44) to 90 points (range: 88–96), corresponding to excellent or good results. All patients healed without major complications and were asymptomatic after 12 months of follow-up. In conclusion, over-valgus correction using a DHS is a novel technique that seems helpful for subtrochanteric nonunion. It allows for dynamic fixation, offering the advantages of dynamic fixation, especially in this high-stress area. It is also performed without osteotomy, making it a less demanding technique than the current methods described. Full article

Objectives: To compare the safety and efficacy of open surgery (OS) and minimally invasive surgery (MIS) techniques in the correction of symptomatic hallux valgus (HV). Methods: A systematic review of studies up to January 2024 was conducted, identifying all the relevant literature comparing OS and MIS for symptomatic HV. Searches were performed across major databases including MEDLINE, Cochrane and EMBASE. A total of 32 studies were included, comprising randomised control trials, prospective and retrospective cohort studies as well as grey literature. Key outcomes assessed included radiographic measures such as the hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA), with preoperative and postoperative angles analysed to calculate the power of correction. Secondary outcomes included American Orthopaedic Foot and Ankle Society (AOFAS) scores, operative time, hospital stay duration, radiation exposure and complication rates. Both fixed-effect and random-effects models were applied based on the observed heterogeneity in the data. Results: Thirty-two studies with 2423 patients contributed to the summative outcome. Postoperative HVA and IMA were comparable between OS and MIS groups. However, MIS showed a significantly lower DMAA angle (MD = −0.90, CI: −1.55 to −0.25, p = 0.01). In radiographic correction analysis, MIS demonstrated significantly greater DMAA correction (MD = 1.09, CI: 0.43 to 1.75, p = 0.001). The odds of hardware removal were significantly higher with MIS (OR = 2.37, CI: 1.41 to 4.00, p = 0.001). Functional analysis showed that MIS achieved significantly higher postoperative AOFAS scores (MD = 2.52, CI: 0.92 to 4.13, p = 0.002). MIS was associated with a shorter operative (MD = −12.07 min, CI: −17.02 to −7.11, p < 0.00001) and a significantly shorter hospital stay (MD = −0.76, CI: −1.30 to −0.21, p = 0.007). MIS was linked to higher radiation exposure (MD = 51.18, CI: 28.71 to 73.65, p < 0.00001). Conclusions: There is no definitive superiority between MIS and OS for hallux valgus correction. While MIS offers benefits such as improved DMAA correction, higher functional AOFAS scores, shorter operative times and reduced hospital stays, it also carries risks like increased radiation exposure and a higher rate of hardware removal. The decision between MIS and OS should be personalised, taking into account the specific needs and circumstances of each patient. Larger studies are warranted to validate these findings as newer MIS techniques continue to emerge and evolve. Full article

Background: Hallux valgus is a prevalent foot deformity conventionally treated with open surgical techniques, which carry risk of complications due to extensive soft tissue dissection. Minimally invasive surgeries (MISs) as alternatives offer comparable outcomes, reduced pain, and faster recovery; however, their challenges include the risk of shortening of the first metatarsal. This study aimed to assess the efficacy of our modified MIS hallux valgus correction technique and investigate the factors that affect first metatarsal shortening. Methods: Twenty-nine feet treated with modified MIS hallux valgus surgery between 2017 and 2022 were included with an average follow-up of 29 months. Clinical outcomes were evaluated with the Manchester–Oxford Foot Questionnaire (MOXFQ), Foot Function Index (FFI), and visual analog scale for pain. Radiographic evaluations included the intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), first metatarsal length, and sesamoid grade. Results: Functional and radiographic outcomes were significantly improved (p < 0.0001 and p < 0.001, respectively). Significant correlations between patient satisfaction and the MOXFQ, FFI, and VAS scores were found, with no significant correlations between patient satisfaction and radiographic outcomes. Non-purchasing of the lateral cortex of the proximal osteotomy site was identified to increase risk of first metatarsal shortening (odds ratio [OR] = 22.09, p = 0.0064). Conclusions: Our modified MIS for hallux valgus correction showed favorable radiographic and functional outcomes. Proximal lateral cortex purchasing should be targeted to reduce postoperative shortening of the first metatarsal. Full article

Background: Hallux valgus is a common forefoot disorder with hundreds of proposed management techniques. Distal chevron osteotomy with a modified McBride procedure has been traditionally recommended for mild hallux valgus because of its simple and less invasive nature with fewer complications, faster recovery, and reliable outcomes. In recent years, the indications for this procedure have expanded to include hallux valgus with severe deformities. This study aims to compare the radiographic outcomes of the surgical treatment for moderate versus severe hallux valgus patients from the perspective of sesamoid bone reduction. Materials and Methods: A retrospective review of medical records identified 99 feet from 94 patients that were treated with distal chevron osteotomy with a modified McBride procedure. These feet were divided by the preoperative hallux valgus angle and intermetatarsal angle into the moderate and severe groups. Results: Postoperative radiographic parameters significantly improved in both groups after treatment, indicating adequate deformity correction. Improvement in the sesamoid position was better in the moderate group compared to that in the severe group. The recurrence rate in the severe group was higher than that in the moderate group without statistical significance. Conclusions: Based on the radiographic results of the postoperative position following sesamoid reduction, the distal chevron osteotomy with a modified McBride procedure is effective for treating moderate hallux valgus deformities. However, this treatment strategy may be associated with a higher recurrence rate in cases of severe hallux valgus deformity. A complete reduction in the sesamoids should be emphasized during the management of severe hallux valgus deformity. Full article

Background: Fibrous dysplasia (FD) is a rare condition in which normal spongy and cortical bone is replaced by non-neoplastic fibrous tissue, leading to weakened bone matrix and increased risk of pathological fractures and deformities. Treating these deformities poses a significant challenge for surgeons. While various cases of surgical stabilization and limb lengthening using intramedullary nails have been reported, there is limited evidence on the use of Motorized Intramedullary Limb-Lengthening Nails (MILLNs) in FD patients. This case report presents the clinical history of a patient with FD who underwent multiple surgical interventions to address severe lower limb length discrepancy (LLD) and angular deformity caused by multiple fractures. Case presentation: A sixteen-year-old Caucasian girl with polyostotic FD developed a severe post-traumatic LLD of 10 cm on the right side, associated with coxa vara, valgus knee, and patellar instability. The deformity of the proximal femur was addressed with a valgus and derotational femoral osteotomy. However, this procedure exacerbated the knee’s valgus deformity and only partially corrected the LLD, leading to the decision to proceed with femoral lengthening. A retrograde magnetic intramedullary nail (PRECICE, NuVasive) was utilized for this purpose. Approximately three months postoperatively, radiographs revealed the loosening of the proximal anchoring screw, while the nail had reached maximum distraction. We then proposed reactivating the previously implanted nail. Nine months after the final surgery, standing long-leg radiographs showed a residual shortening of 1 cm, with excellent healing at the fracture sites and the nail and screws remaining securely in place. The patient was monitored regularly, with the latest follow-up occurring four years and five months after the conclusion of the last lengthening procedure. Conclusions: This case report describes the reactivation of a MILLN in a patient with polyostotic fibrous dysplasia. While nail reactivation has been previously described in the literature, to our knowledge, it has not been reported for treating complications arising from FD. In cases of mechanical complications, this approach can equalize leg length discrepancies and correct deformities, avoiding additional invasive surgeries and reducing healthcare costs. As this is an off-label treatment, preoperative consent from both the patient and the parents is required. Full article