Reconstrucción por técnica de Chevron reverso y transferencia tendinosa con técnica no convencional en Hallux Varus Iatrogénico Severo / Reconstruction by reverse Chevron technique and tendon transfer with unconventional technique in severe iatrogenic Hallux Varus

El Hallux Varus Iatrogénico es una complicación de la cirugía correctiva del Hallux Valgus muy poco frecuente. El tratamiento incluye la intervención de los tejidos blandos, y óseos. El propósito de este trabajo es mostrar los resultados clínico-radiológicos del tratamiento quirúrgico del Hallux Varus Iatrogénico Flexible Severo empleando la combinación de técnicas de reconstrucción alternativas en una paciente femenina de 59 años de edad. Se realizó liberación medial de la capsula articular MTF y abductor, osteotomía de Chevron reverso, artrodesis interfalángica izquierda, transferencia tendinosa del extensor largo de Hallux hacia plantar con botón artesanal. De acuerdo a la Escala AOFAS aumentó de 30 a 90 puntos. Se logró la corrección estable de la deformidad en varo y la consolidación de la osteotomía. El Hallux Varus Iatrogénico es una complicación poco frecuente considerada una deformidad mal tolerada, con pocos casos reportados y pocos reportes. Se debe hacer un enfoque de tratamiento paso a paso para abordar todos los elementos involucrados en el Hallux Varus iatrogénico. La corrección quirúrgica del Hallux Varus iatrogénico severo con técnicas de reconstrucción no convencionales tipo Chevron reverso y transferencia tendinosa con botón plantar, es una excelente opción terapéutica de acuerdo a los resultados obtenidos en este caso(AU)

Iatrogenic Hallux Varus is a very rare complication of Hallux Valgus corrective surgery. The treatment includes the intervention of soft tissues and bones. The purpose of this paper is to show the clinical-radiological results of the surgical treatment of Severe Flexible Iatrogenic Hallux Varus using the combination of alternative reconstruction techniques in a 59-year-old female patient. Medial release of the MTF and abductor joint capsule, reverse Chevron osteotomy, left interphalangeal arthrodesis, tendon transfer of the long extensor of Hallux to plantar with artisanal button was performed. According to the AOFAS Scale, it increased from 30 to 90 points. Stable correction of the varus deformity and consolidation of the osteotomy were achieved. Iatrogenic Hallux Varus is a rare complication considered a poorly tolerated deformity, with few reported cases and few reports. A step-by-step treatment approach must be taken to address all the elements involved in iatrogenic Hallux Varus. Surgical correction of severe iatrogenic Hallux Varus with unconventional reconstruction techniques such as reverse Chevron and plantar button tendon transfer is an excellent therapeutic option according to the results obtained in this case(AU)

Cefalea pospunción dural mantenida en el tiempo / Persistent posdural puncture headache

Introducción: La cefalea posterior a la punción de la duramadre es una complicación que se describió conjuntamente con la primera anestesia neuroaxial. Es un cuadro clínico complejo, que con la terapéutica adecuada mejora rápidamente, pero en ocasiones persiste a pesar de los esfuerzos realizados por el equipo médico encargado de tratarla. Objetivo: Describir la evolución clínica de un caso cefalea pospunción dural. Discusión: Se presenta un caso que después de realizarle a una anestesia subaracnoidea para una cirugía de Hallux Varus, sufre una cefalea pospunción dural que persistió por más de 18 días, a pesar de los tratamientos impuestos, tanto conservadores (terapia farmacológica, hidratación, reposo) como intervencionista (hemoparche peridural y colchón hídrico, con dextran 40), el cuadro desapareció por si solo pasado el tiempo expuesto anteriormente. Conclusiones: Se concluye que este cuadro clínico ocasionado por la punción de la duramadre es de resolución rápida con el tratamiento adecuado, pero existen casos en los que a pesar de la terapéutica indicada puede persistir por más tiempo(AU)

Introduction: Headache after dura mater puncture is a complication described together with the first neuraxial anesthesia. A complex clinical picture improves rapidly with adequate therapy, but sometimes persists despite the efforts made by the medical team in charge of treating it. Objective: To describe the clinical evolution of case of postdural puncture headache. Discussion: A case is presented of a patient who, following subarachnoid anesthesia for hallux varus surgery, suffered postdural puncture headache that persisted for more than eighteen days, despite the treatments used, both conservative (pharmacological therapy, hydration, rest) and interventionist (peridural hemopatch and water mattress, with dextran 40). The clinical picture disappeared by itself after the time previously discussed. Conclusions: It is concluded that this clinical picture caused by the dura mater puncture is of rapid resolution if treated appropriately, but there are cases in which, despite the indicated therapy, it may persist for a longer time(AU)

The Results of Modified Lapidus Procedure on Moderate-to-Severe Hallux Valgus with First Tarso-Metatarsal Joint Hypermobility / 대한족부족관절학회지

PURPOSE: The objective of this study was to confirm the results of the modified Lapidus procedure on moderate to severe hallux valgus patients with first tarso-metatarsal joint hypermobility. MATERIALS AND METHODS: A retrospective study was conducted on 42 cases of 35 patients who underwent the modified Lapidus procedure between March 2006 and December 2014. A comparative analysis was performed on the preoperative and postoperative subjective satisfaction of patients and radiologic index. Moreover, the correlation between the follow-up time and patient's operative satisfaction, as well as between the proficiency of the operator and patient's operative satisfaction was analyzed. Complications were also evaluated. RESULTS: Out of the total of 35 patients, 3 were male and 32 were female. The mean age was 61.3 years (range, 34∼79 years), and the mean follow-up time was 22.1 months (range, 6∼90 months). The overall satisfaction level was 67.6% and the mean hallux valgus angle improved from preoperative 40.5° to postoperative 12.2° (p<0.001). The mean 1, 2 intermetatarsal angle improved from preoperative mean of 16.9° to postoperative mean of 7.6° (p<0.001), and the sesamoid position improved significantly, from preoperative 2.7 to postoperative 0.9 (p<0.001). Furthermore, there was no correlation between the follow-up time and the American Orthopaedic Foot and Ankle Society (AOFAS) hallux scale; also no correlation between the year the operation took place and the AOFAS hallux scale. In terms of complications, we observed screw irritation in 6 cases, hallux varus in 2 cases, and recurrence of hallux valgus and nonunion in one case. CONCLUSION: Contrary to our concerns, the level of complications was not high; however, the satisfaction level of patients was also not very high. Therefore, careful selecting of patients and sufficient consultation time is needed before surgery. In addition, since the causes of postoperative dissatisfaction still remain unclear, further studies are necessary.

Complications after Surgical Correction of Hallux Valgus / 대한족부족관절학회지

The goal of surgical correction for hallux valgus is to achieve a painless, shoe-wearable, and relatively straight toe with a balanced joint motion that results in aesthetically and functionally satisfactory toe. To date, there has not been a consensus on the ultimate surgical procedure for hallux valgus correction. Unfortunately, such a consensus may be difficult since it is not uncommon to encounter complications after hallux valgus correction. Postoperative soft tissue complications include difficult wound healing, infection, hypertrophy, or pain of the scar, joint stiffness, and tendon or sensory nerve damage. Postoperative bony complications include malunion, nonunion, failure of fixation, failure of angle correction, recurred deformity, osteomyelitis, and failure of balance between the metatarsal heads. Herein, we review common complications after surgical correction of hallux valgus, such as stiff joint, bony complications, recurrence of the deformity, and hallux varus.

Surgical Treatment of Congenital Hallux Varus

BACKGROUND: The purpose of this study was to report outcomes of congenital hallux varus deformity after surgical treatment. METHODS: We evaluated ten feet of eight patients with a congenital hallux varus deformity, including four feet combined with a longitudinal epiphyseal bracket (LEB). There were seven male patients and one female patient with a mean age of 33 months (range, 7 to 103 months) at the time of surgery. Two patients were bilaterally involved. The mean duration of follow-up was 5.9 years (range, 2.3 to 13.8 years). Clinical outcomes were assessed according to the criteria of Phelps and Grogan. Surgical procedures included the Farmer procedure, the McElvenny procedure or an osteotomy at the first metatarsal or proximal phalanx. RESULTS: The clinical results were excellent in two feet, good in six and poor in two feet. The LEB was associated with hallux varus in four feet and were treated by osteotomy alone or in conjunction with soft tissue procedure. CONCLUSIONS: Congenital hallux varus was successfully corrected by surgery with overall favorable outcome. Preoperatively, a LEB should be considered as a possible cause of the deformity in order to prevent recurrent or residual varus after surgery.

Patient Characteristics and Treatment of Hallux Polydactyly Associated with Varus Deformity / 대한정형외과학회잡지

PURPOSE: To evaluate patient characteristics such as deformity type, associated disease, and family history, and results of treatment of pre-axial polydactyly with hallux varus deformity. MATERIALS AND METHODS: We carried out a retrospective study of 5 patients who presented with preaxial polydactyly with hallux varus deformity, and were treated between 2003 and 2010 at the authors' hospital. Surgeries including extra digit excision, local flap, osteotomy, and interphalangeal joint fusion were performed taking into consideration the deformity types and patient's age. Family history, associated disease, and types of duplication were assessed, and the outcomes of surgery were evaluated with radiographs and appearances of foot. The mean follow-up period was 34 months. RESULTS: All 5 patients had one or more associated anomalies such as congenital anterolateral tibial bowing and polydactyly in three, translocation of chromosome 2 : 13 associated with cryptorchidism in one, pes planovalgus in one, residual poliomyelitis in one, syndactyly of the foot in two, and leg length discrepancy in one patient. There was no family history of hallux polydactyly in any of the cases. All five patients had duplication of the distal phalanx and one of them had a blocked proximal phalanx. The extra digit was completely removed and the varus deformity was corrected in all cases. CONCLUSION: There was a high incidence of associated diseases in patients with hallux polydactyly and varus deformity. Deformity correction could be obtained by surgeries chosen according to the individual deformity type and patient age.

Free Fat Graft for Congenital Hand Differences

BACKGROUND: Free fat graft has been used for the treatment of congenital hand differences. However, there have been a few reports about the outcome of that treatment. In this study, the outcome of free fat grafts for congenital hand and foot differences was investigated. METHODS: Fourteen bones with longitudinal epiphyseal bracket, 3 wrists with Madelung deformity, and 5 cases of osseous syndactyly were treated with free fat graft with osteotomy, physiolysis, or separation of osseous syndactyly. Of the fourteen bones with longitudinal epiphyseal bracket, 9 were treated with open wedge osteotomy with free fat graft and 5 with physiolysis and free fat graft. The Madelung deformity was treated with physiolysis with free fat graft. For osseous syndactyly, syndactyly release with free fat graft was performed five times on four hands. RESULTS: In the fourteen cases with longitudinal epiphyseal bracket, lateral deviation improved in all except two cases after surgery. The average lateral deviation angle changed from 32.5 degrees before surgery to 15.2 degrees after surgery. The average improvement of the lateral deviation angle was 12.2 degrees in the osteotomy group and 20.6 degrees in the physiolysis group. The mean ratio of improvement of the lateral deviation angle to the lateral deviation angle before surgery was 39.4% in the osteotomy group and 51.2% in the physiolysis group. The Madelung deformity improved after surgery in two cases but there was no improvement in one case. For these conditions, the results were not good enough when surgery was done after age 13 or at age four for severely hypoplastic brachymesophalangy. Of the 5 cases of osseous syndactyly, reunion of the separated bones occurred in one case. The grafted free fat should be deep enough to cover the osteotomy site of the bones to prevent reunion of the separated bones. CONCLUSIONS: Physiolysis and free fat graft performed during the growth period can correct the deviation due to longitudinal epiphyseal bracket and Madelung deformity. Free fat graft is also useful to prevent reunion of the bones after separation of osseous syndcatyly, if the grafted fat is securely filled into the space between the separated bones.

Free Fat Graft for Congenital Hand Differences

BACKGROUND: Free fat graft has been used for the treatment of congenital hand differences. However, there have been a few reports about the outcome of that treatment. In this study, the outcome of free fat grafts for congenital hand and foot differences was investigated. METHODS: Fourteen bones with longitudinal epiphyseal bracket, 3 wrists with Madelung deformity, and 5 cases of osseous syndactyly were treated with free fat graft with osteotomy, physiolysis, or separation of osseous syndactyly. Of the fourteen bones with longitudinal epiphyseal bracket, 9 were treated with open wedge osteotomy with free fat graft and 5 with physiolysis and free fat graft. The Madelung deformity was treated with physiolysis with free fat graft. For osseous syndactyly, syndactyly release with free fat graft was performed five times on four hands. RESULTS: In the fourteen cases with longitudinal epiphyseal bracket, lateral deviation improved in all except two cases after surgery. The average lateral deviation angle changed from 32.5 degrees before surgery to 15.2 degrees after surgery. The average improvement of the lateral deviation angle was 12.2 degrees in the osteotomy group and 20.6 degrees in the physiolysis group. The mean ratio of improvement of the lateral deviation angle to the lateral deviation angle before surgery was 39.4% in the osteotomy group and 51.2% in the physiolysis group. The Madelung deformity improved after surgery in two cases but there was no improvement in one case. For these conditions, the results were not good enough when surgery was done after age 13 or at age four for severely hypoplastic brachymesophalangy. Of the 5 cases of osseous syndactyly, reunion of the separated bones occurred in one case. The grafted free fat should be deep enough to cover the osteotomy site of the bones to prevent reunion of the separated bones. CONCLUSIONS: Physiolysis and free fat graft performed during the growth period can correct the deviation due to longitudinal epiphyseal bracket and Madelung deformity. Free fat graft is also useful to prevent reunion of the bones after separation of osseous syndcatyly, if the grafted fat is securely filled into the space between the separated bones.

Alternativa quirúrgica con tutor externo tipo Ilizarov para el tratamiento de pie equino varo hipercorregido / Surgical alternative type Ilizarov external fixator for the treatment of overcorrected clubfoot

Este estudio es un análisis retrospectivo que se realizó a 35 pies de 29 pacientes(11 hembras y 18 varones) con el diagnóstico de pie equino varo congénito hípercorregido, en el hospital ortopédico infantil de Caracas en un period comprendido entre el 03-11-1997 al 26-11-2007, a los cuales se le practicó una cirugía con osteotomías percutáneas supramaleolar de tibia y de medio pie, fijados con un tutor externo multiplanar tipo ilizarov. Se encontró mejoría en los ángulos de kite AP y lateral post-operatorio, promedio pre-operatorio (45,8°) lateral y (43,5°) AP con un post-operatorio de(29,8°) lateral y(28,3°)AP. Tomando en cuenta la disminución del tiempo quirúrgico, días de hospitalización, disminución de la injuria a nivel de los tejidos y reincorporación temprana a las actividades, con un seguimiento promedio de 7 años que al final se mantenía el ángulo de kite del último control con respecto al post-operatorio tardío. Por lo que recomendamos este procedimiento como parte del tratamiento para corrección del pie quino varo congénito hipercorregido.

This study is a retrospective analysis was performed to 35 feet of 29 patients (11 females and 18 males) diagnosed with overcorrected clubfoot in children's orthopedic hospital of Caracas in a period from 11.03.1997 to 26.11.2007, to which she underwent surgery supramalleolar percutaneous tibial osteotomy and mid-foot, fixed with Ilizarov external fixator multiplanar type. There was improvement in kite angles AP and lateral postoperative average pre-operative (45.8 °) and lateral (43.5 °) AP with a post-operative (29.8 °) and lateral (28 , 3 °) AP. Taking into account the reduction of surgical time, hospital stay, decreased level of injury to tissues and early return to activities, with an average follow up of 7 years which ultimately kept the kite angle of ultimate control over the late postoperative period. So we recommend this procedure as a treatment for correction of congenital varus foot overcorrected quino.

Traumatic Dynamic Hallux Varus: A Case Report / 대한족부족관절학회지

The first metatarsophalangeal joint injury is common in professional soldiers and athletes. But this was rarely reported. A professional soldier has varus instability in the first metatarsophalangeal joint due to hyperextension. In the MR Imaging, weavy appearance in lateral collateral ligament and high signal change in plantar plate was shown. So he has surgical treatment using reconstructive procedure. At first, 4th extensor digitorum longus tendon was splitted longitudinally and harvested, second triangular shape reconstruction on lateral joint line was done using harvested tendon. One year later, fifteen degrees was limited compared with intact side. Reconstruction using 4th extensor digitorum longus tendon in traumatic dynamic hallux varus was good method.

Operative Treatment of the Bilateral 1,4th Brachymetatarsia with Painful Callosity and Hallux Varus using Massive Metatarsal Axial Shortening: A Case Report / 대한족부족관절학회지

In general, the operative treatment of the brachymetatarsia is the lengthening of the affected metatarsal bone due to the cosmetic problem rather than the functional one. We experienced 22 year-old female bilateral congenital foot deformities such as hallux varus and 1,4th brachymetatarsia treated with reverse Scarf osteotomy on the hallux varus and massive axial metatarsal shortening Weil osteotomy on the 2,3,5th metatarsals which could reconstruct the normal metatarsal parabola.

Proximal Metatarsal Chevron Osteotomy for Moderate to Severe Hallux Valgus: A Mean Eight Year Follow up / 대한족부족관절학회지

PURPOSE: The purpose of the present study is to evaluate the proximal metatarsal chevron osteotomy outcomes for moderate to severe hallux valgus more than seven year follow up. MATERIALS AND METHODS: Between 1996 and 1998, hallux valgus 61 cases were evaluated. The follow up period was more than seven years. The clinical review analyzed by the hallux metatarsophalangeal-interphalangeal scale of the American Orthopedic Foot and Ankle Society, radiologic review by the hallux valgus angle, first and second intermetatarsal angle. Complication also evaluated. RESULTS: Clinically, preoperative AOFAS score was average 43 points (range; 16~60 points) which significantly improved to 88 points (range; 61~100 points) at last follow up periods. Radiologically, the mean preoperative, postoperative, last follow up hallux valgus angle was 34 degrees, 5.2 degrees, 10.9 degrees. The mean preoperative, postoperative, last follow up intermetatarsal angle was 15.3 degrees, 3.3 degrees, 5.3 degrees. Postoperative angle change were no statistical significance (p>0.05). Complication were hallux varus 6 cases, metatarsophalangeal joint arthritis 2 cases, recurrence 1 case. CONCLUSION: Proximal metatarsal chevron osteotomy shows satisfactory outcome for moderate to severe hallux valgus more than seven year follow up.

Treatment of Moderate Hallux Valgus with Proximal Chevron Metatarsal Osteotomy and Distal Soft Tissue Procedure / 대한족부족관절학회지

PURPOSE: The authors intended to analyze the operative results of moderate hallux valgus with proximal chevron metatarsal osteotomy and distal soft tissue procedure. MATERIALS AND METHODS: Seventy feet of fifty-seven patients were followed for more than 1 year after the proximal chevron metatarsal osteotomy. The mean age was 47.2 years, and the mean follow up period was 2 years and 3 months. Clinically preoperative and postoperative AOFAS MP-IP scale and satisfaction after the surgery were analyzed. Radiologically hallux valgus angle, hallux valgus interphalangeal angle, the intermetatarsal angle and sesamoid position before and after the operation were analyzed. RESULTS: Additional Akin osteotomy was performed 48 out of 70 feet. Clinically AOFAS MP-IP scale was increased from 60.4 points preoperatively to 89.8 points postoperatively. Ninety-four percents of the patients were satisfied with the results. Radiologically hallux valgus angle was decreased from 34.8 degrees preoperatively to 12.8 degrees postoperatively. The intermetatarsal angle was decreased from 15.7 degrees preoperatively to 8.0 degrees postoperatively. Hallux valgus interphalangeal angle was increased from 7.4 degrees preoperatively to 9.8 degrees postoperatively. There were 3 recurrences, 1 hallux varus and 3 minor wound infections. There were no nonunion or malunion of the 1st metatarsal. CONCLUSION: Proximal chevron metatarsal osteotomy with distal soft tissue procedure and additional Akin osteotomy appears to be safe and satisfactory procedure.

Treatment of Hallux Valgus with Modified McBride Procedure and Proximal Metatarsal Crescentic Osteotomy / 대한족부족관절학회지

PROPOSE: This study was retrospectively to review the surgical results for moderate to severe hallux valgus corrected with a modified McBride procedure and proximal metatarsal crescentic osteotomy. MATERIALS AND METHODS: Between August 1997 and August 2001, 15 patients with 22 bunion underwent surgical correction and were followed for an average 29.3 months (range, 18 to 53 months). Clinical results were evaluated with AOFAS clinical rating system for hallux and radiological measurements were done preoperatively and at a minimum of 12 months postoperatively. RESULTS: The average AOFAS clinical rating score improved from 47.5 to 86.0. Union of the osteotomy site occurred at 9.5 weeks except one delayed union. The hallux valgus angle improved an from 36.5 degrees to 15.7 degrees and the intermetatarsal angle improved from 17.4 degrees to 8.6 degrees on average. Dorsiflexion of the first metatarsal at the osteotomy site was present in three (13.6%) with average 4 degrees. Complications were two recurred deformity, one hallux varus and one painful transfer lesion. There was a high level of satisfaction with clinical results in 11 patients (73.3%) with 17 feets and cosmesis in 18 feets (81.8%). CONCLUSION: Modified McBride procedure and proximal metatarsal crescentic osteotomy based on careful patient selection and meticulous technique showed satisfactory outcome for moderate to severe hallux valgus.