Clinical guideline on the third generation minimally invasive surgery for hallux valgus.

Minimally invasive surgery for hallux valgus correction, has been attracting great interests in the recent decades, due to the potential benefits of less pain, decreased recovery times, smaller scars with better cosmesis, and improved early post-operative range of motion. The most recent developments in minimally invasive surgery have evolved into the third generation with modifications of the chevron-type osteotomy. This evidence-based clinical guideline of the third generation minimally invasive surgery for hallux valgus is initiated and developed collectively by the Foot and Ankle Committee of Orthopedic Branch of Chinese Medical Doctor Association, Foot and Ankle Committee of Sports Medicine Branch of Chinese Medical Doctor Association, and Foot and Ankle Expert Committee of Orthopedic Branch of the Chinese Association of the Integrative Medicine. This clinical guideline provides recommendations for indications, contraindications, operative planning and techniques, post-operative management, management of complications, and prognosis of the third generation minimally invasive surgery for hallux valgus. The Translational Potential of this Article This comprehensive guideline aims to establish standardized recommendations for the indications, contraindications, operative techniques, and post-operative management of the third generation minimally invasive surgery for hallux valgus. By adhering to this guideline, the success rate of the procedure could be maximized. This comprehensive guideline serves as a valuable reference for practitioners interested in or preparing to perform minimally invasive surgery for hallux valgus.

Role of Ankle Arthroscopy in Management of Acute Ankle Fracture.

PURPOSE: To report the operative findings of ankle arthroscopy during open reduction and internal fixation of acute ankle fractures. METHODS: This was a retrospective review of 254 consecutive patients with acute ankle fractures who were treated with open reduction and internal fixation of the fractures, and ankle arthroscopy was performed at the same time. The accuracy of fracture reduction, the presence of syndesmosis disruption and its reduction, and the presence of ligamentous injuries and osteochondral lesions were documented. Second-look ankle arthroscopy was performed during syndesmosis screw removal 6 weeks after the key operation. RESULTS: There were 6 patients with Weber A, 177 patients with Weber B, 51 patients with Weber C, and 20 patients with isolated medial malleolar fractures. Syndesmosis disruption was present in 0% of patients with Weber A fracture, 52% of patients with Weber B fracture, 92% of patients with Weber C fracture, and 20% of the patients with isolated medial malleolar fracture. Three patients with Weber B and one patient with Weber C fracture have occult syndesmosis instability after screw removal. Osteochondral lesion was present in no patient with Weber A fracture, 26% of the Weber B cases, 24% of the Weber C cases, and 20% of isolated medial malleolar fracture cases. The association between the presence of deep deltoid ligament tear and syndesmosis disruption (warranting syndesmosis screw fixation) in Weber B cases was statistically significant but not in Weber C cases. There was no statistically significant association between the presence of posterior malleolar fracture and syndesmosis instability that warrant screw fixation. CONCLUSIONS: Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. Direct arthroscopic visualization ensures detection and evaluation of intra-articular fractures, syndesmosis disruption, and associated osteochondral lesions and ligamentous injuries. LEVEL OF EVIDENCE: Level IV, case series.

Achilles tendon infection due to Mycobacterium chelonae.

Atypical tuberculous tenosynovitis of the foot and ankle is extremely rare. The determination of the Mycobacterium species is essential because resistance of atypical mycobacterial strains to antituberculous drugs is often encountered. We report a case of Mycobacterium chelonae paratendinous and intratendinous infection involving the Achilles tendon. Repeat aggressive irrigation and debridement procedures, coupled with removal of foreign materials and the appropriate use of prolonged antibiotic therapy, can result in a successful long-term outcome.

Medial subtalar arthroscopy: a cadaveric study of the tarsal canal portal.

PURPOSE: To study the safety of the tarsal canal portal in medial subtalar arthroscopy. METHODS: Twenty-three fresh frozen foot and ankle specimens were divided into two groups with different orientation of the portal tract. Three types of tarsal canal portals were identified. The relationships of the metal rod and the flexor digitorum longus tendon and the posterior neurovascular bundle were studied. RESULT: In group A, a type 1 tarsal canal portal tract was established in seven specimens, a type 2 portal tract in three specimens, and a type 3 portal tract in two specimens. In group B, a type 1 portal tract was established in ten specimens and a type 2 portal tract in one specimen. No type 3 portal tract was established in group B. There was no statistical significance demonstrated for establishment of a type 1 portal tract and "non type 1" (type 2 or 3) portal tract in group A and group B. The average shortest distance between the rod and the posterior tibial neurovascular bundle was 7 mm in group A and 9 mm in group B. CONCLUSIONS: This study provides the anatomic basis for the establishment of the tarsal canal portal. There is a risk of injury to the flexor digitorum longus tendon and the posterior tibial neurovascular bundle with the tarsal canal portal, and it should be used with great caution.

Breakage of the radiopaque wire from the medullary tube during closed antegrade intramedullary nailing for femoral shaft fracture.

We report a complication of radiopaque wire breakage from the medullary tube during closed antegrade intramedullary nailing for a femoral shaft fracture. To avoid such complication, the medullary tube should be checked carefully for colour changes and surface defects, and tested for flexibility before each use. The medullary tube should also be replaced before 100 exposures to autoclaving.

Endoscopic distal soft-tissue release in the treatment of hallux valgus: a cadaveric study.

PURPOSE: To study the efficacy and safety of the lateral release of the endoscopic distal soft-tissue procedure in the treatment of hallux valgus. METHODS: Twenty fresh-frozen foot and ankle specimens were used. Ligament-sacrificing release was performed in 10 specimens (group 1). Ligament-sparing release was performed in another 10 specimens (group 2). The relation between the metal rod that passed through the toe web and plantar portal wounds and neural structures, degree of completeness of release of the intermetatarsal ligament, adductor hallucis insertion, and lateral capsular structures was studied. RESULTS: The common digital nerve of the first intermetatarsal space ran along the medial side of the rod, the medial digital nerve of the second toe ran obliquely and plantar to the rod just proximal to the proximal edge of the intermetatarsal ligament, and the lateral digital nerve of the hallux ran along the plantar lateral border of the metatarsal head and fibular sesamoid in all specimens. The intermetatarsal ligament, adductor hallucis insertion, and lateral capsular ligamentous structures were released completely in all specimens in group 1. The intermetatarsal ligament was preserved and the lateral capsular ligamentous structures were completely released in all specimens in group 2. The adductor hallucis insertion was completely released in 7 specimens. No nerve injury or cartilage damage was noted in all 20 specimens. CONCLUSIONS: With the release of the intermetatarsal ligament, all lateral capsular ligamentous structures including the adductor were released, but with intermetatarsal ligament preservation, only 70% of the specimens had complete adductor release. There was no neural or articular cartilage damage in either group. CLINICAL RELEVANCE: The study provides an anatomic basis for safe practice of endoscopic distal soft-tissue release in the correction of hallux valgus deformity.

Cadaveric study of zone 2 flexor hallucis longus tendon sheath.

PURPOSE: The purpose of this study was to investigate the anatomy of the zone 2 flexor hallucis longus (FHL) tendon sheath. METHODS: Dissection of the zone 2 FHL tendon sheath was performed in 12 feet of 6 cadavers. The tendon sheath was subdivided into proximal fibrous (zone 2A) and distal fascial (zone 2B) parts. The lengths of the zone 2A and 2B FHL tendon were measured and represented the length of the corresponding tendon sheaths, and the relation of the medial plantar nerve to each part of the zone 2 FHL tendon sheath was studied. RESULTS: In all specimens there were fibrous and fascial components of the zone 2 FHL tendon sheath. The medial plantar nerve crossed the zone 2B tendon sheaths and then became plantar lateral to the sheath in 7 specimens. The distance between the medial plantar nerve and the orifice of the zone 2A tendon sheath averaged 7.6 mm. The distance between the medial plantar nerve and the junction between zones 2A and 2B averaged 3.2 mm. The distance between the medial plantar nerve and the distal end of the zone 2B tendon sheath averaged 4.2 mm. The mean length of the zone 2A tendon sheath was 35.9 mm, and the mean length of the zone 2B tendon sheath was 30.5 mm. CONCLUSIONS: The zone 2 FHL tendon sheath can be subdivided into a proximal fibrous zone (2A) and a distal fascial zone (2B). Because of the close proximity of the medial plantar nerve to the tendon sheath, there is a significant risk of iatrogenic nerve injury when surgical procedures are performed in zone 2B. CLINICAL RELEVANCE: An understanding of the anatomy of the zone 2 FHL tendon sheath is useful for the safe practice of zone 2 FHL tendoscopy.

Portal safety and efficacy of anterior subtalar arthroscopy: a cadaveric study.

Anterior subtalar arthroscopy was performed in 14 feet of 7 cadaveric bodies using the primary visualization and working portals. The cartilage of the anterior/middle calcaneal facet that can be reached was marked. The feet were dissected and the distances between the portals and surrounding cutaneous nerves were measured. Any damage to the ligaments of the sinus tarsi was noted. The percentage area of the articular cartilage that was marked was measured. In all specimens, the primary visualization portal tract passed through the lateral root of the inferior extensor retinaculum. The primary working portal tract passed through the lateral root in nine specimens (64%). Cervical ligament was intact in all specimens. In three specimens (21%), the primary visualization portal tract passed through the posterior edge of the intermediate root of the inferior extensor retinaculum. The interosseous talocalcaneal ligament was intact in all specimens. The primary visualization portal tract passed through the medial root of the inferior extensor retinaculum in eight specimens (57%). The primary working portal tract passed through the medial root of the inferior extensor retinaculum in one specimen. The average working area on the calcaneal facet was 95% +/- 4% of the total articular surface. There was no case of nerve injury in all specimens. In conclusion, anterior subtalar arthroscopy is a minimally invasive approach to deal with pathologies of this joint without the need of extensive resection of the ligamentous structures of the sinus tarsi.

Zone 2 flexor hallucis longus tendoscopy: a cadaveric study.

BACKGROUND: The purpose of this study was to verify the safety and efficacy of zone 2 flexor hallucis longus tendoscopy with the patient in the prone position. MATERIALS AND METHODS: The technique was performed in 12 cadaver feet (6 pairs). The endoscopic findings were compared to an anatomic dissection. The locations of the posteromedial and plantar portals were studied. The relationship between the medial plantar nerve and the tract of FHL tendoscopy was also studied. RESULT: The average distance of the posteromedial portal above the medial malleolar tip was 10.3 mm. The average distance between the posteromedial portal and the posterior tibial nerve was 9.9 mm. The average distance between the plantar portal and the intermalleolar line was 41.5 mm. The average distance between the rod simulating the tenoscope and the nerve was 4.8 mm. The nerve was medial to the rod in 4 specimens and lateral to the rod in 8 specimens. CONCLUSION: Zone 2 flexor hallucis longus tendoscopy was a feasible approach to the deep portion of the flexor hallucis longus tendon in this cadaveric study. There is potential risk of damage to the medial plantar nerve. CLINICAL RELEVANCE: These findings can help guide a surgeon who is considering trying this clinically.

Anatomy of the portal tract for endoscopic decompression of the first branch of the lateral plantar nerve.

PURPOSE: Our purpose is to study the anatomy of the portal tract for endoscopic decompression of the first branch of the lateral plantar nerve. METHODS: The anatomy of the portals and portal tract with endoscopic release of the first branch of the lateral plantar nerve was studied in 12 feet in 6 cadaveric bodies. RESULTS: The proximal portal is located at the fascial opening for the first branch of the lateral plantar nerve and is about 16 mm inferior and 23 mm posterior to the tip of the medial malleolus. The distal portal is located at the inferior edge of the deep fascia of the abductor hallucis muscle and just distal to the medial calcaneal tubercle. The portal tract is deep to the deep surface of the whole width of the deep abductor fascia. In 1 of 12 specimens, the nerve lay superficial to a rod placed between the portals, whereas the nerve was deep to the rod in the remaining 11 specimens. In all specimens the first branch of the lateral plantar nerve, after it pierced the deep fascia of the abductor hallucis at the fascial defect, ran anteriorly and distally, approximately parallel to the direction of the rod. CONCLUSIONS: The proximal portal for endoscopic decompression of the first branch of the lateral plantar nerve is located at the fascial opening for the first branch of the lateral plantar nerve. This can be consistently located with the Wissinger rod technique. The portal tract thus created is effective for deep abductor fascia release. However, percutaneous release without endoscopic visualization of the first branch of the lateral plantar nerve is not safe because of the potential risk of nerve injury, because the nerve can be sandwiched between the instrument and the deep abductor fascia without being noticed. CLINICAL RELEVANCE: The study confirmed the first branch of the lateral plantar nerve can be effectively released endoscopically.

Arthroscopy-assisted correction of hallux valgus deformity.

PURPOSE: Our purpose was to evaluate the clinical and radiologic results of arthroscopy-assisted hallux valgus deformity correction with percutaneous screw fixation. METHODS: Ninety-four feet underwent arthroscopy-assisted hallux valgus deformity correction. Patients in whom the 1,2-intermetatarsal angle could be reduced manually and who had no significant abnormality of the distal metatarsal articular angle were included, and an endoscopic distal soft tissue procedure was performed. Those patients with first tarsometatarsal hypermobility, in whom the 1,2-intermetatarsal angle cannot be reduced manually, or those who had a significantly abnormal distal metatarsal articular angle were excluded. Patients were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale. The pre- and postoperative hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle, and sesamoid position were measured. RESULTS: The mean score on the AOFAS scale was 93 +/- 8 out of 100 points. The hallux valgus angle improved from 33 degrees +/- 7 degrees (range, 20 degrees to 58 degrees ) to 14 degrees +/- 5 degrees (range, 4 degrees to 30 degrees ). The intermetatarsal angle improved from 14 degrees +/- 3 degrees (range, 10 degrees to 26 degrees ) to 9 degrees +/- 2 degrees (range, 5 degrees to 18 degrees ). Complications of hallux varus, skin impingement, screw breakage, and first metatarsophalangeal stiffness were experienced. Two patients with symptomatic recurrence had revision operation performed. CONCLUSIONS: Our study shows that arthroscopic correction of the hallux valgus deformity can achieve good clinical and radiologic results, provided that careful preoperative clinico-radiologic assessment is made to exclude patients contraindicated for the procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Ankle stiffness after Bosworth fracture dislocation of the ankle.

PURPOSE: The purpose of this study is to review the result of patients with Bosworth fracture dislocation of ankle. TYPE OF STUDY: Retrospective case series. METHODS: Four patients with Bosworth fracture-dislocation of ankle are evaluated clinically and radiologically. RESULT: All four cases have failed initial closed reduction of the ankle and open reduction is required. Three patients with delayed presentation suffered from post-traumatic ankle stiffness and subsequently developed ankle degeneration. CONCLUSION: Early recognition and prompt reduction of the dislocated ankle is important in case of Bosworth fracture dislocation in order to prevent late complication. Closed reduction of dislocated ankle is usually not helpful and repeated attempts may be harmful. Emergency operation of open reduction and internal fixation is usually required to reduce the ankle joint without delay.

The arthroscopic management of frozen ankle.

PURPOSE: The purpose of this study was to evaluate a combined anterior and posterior arthroscopic approach in the treatment of frozen ankle. TYPE OF STUDY: Retrospective case series. METHODS: Five patients with post-traumatic frozen ankle were evaluated. RESULTS: After an average follow-up of 32.6 months (range, 24 to 42 months), the average American Orthopaedic Foot and Ankle Society hindfoot-ankle score was improved from 63.8 point (range, 55-74) to 88.6 point (range, 81-100). The average ankle dorsiflexion improved from 1 degrees (range, 0 degrees to 5 degrees) to 19 degrees (range, 15 degrees to 25 degrees). The average ankle plantarflexion improved from 16 degrees (range 10 degrees to 20 degrees) to 39 degrees (range, 30 degrees to 45 degrees). CONCLUSIONS: Combined posterior ankle endoscopy and anterior ankle arthroscopy is effective in the treatment of post-traumatic frozen ankle. LEVEL OF EVIDENCE: Level 4.

Endoscopic distal soft tissue procedure in hallux valgus surgery.

The distal soft tissue procedure is the basis of surgical hallux valgus correction. It involves release of the transverse metatarsal ligament, adductor hallucis, and lateral joint capsule, which permits the proximal phalanx to be realigned on the metatarsal head. The attenuated medial capsule is plicated after the medial bony prominence has been excised. We describe a new endoscopic approach for the distal soft tissue procedure with better cosmetic results.

Arthroscopic Lapidus arthrodesis.

Lapidus arthrodesis is the surgical treatment of choice for symptomatic hypermobility of the medial cuneiform metatarsal joint that is not responding to conservative treatment. The open procedure was criticized for its prolonged healing, high nonunion rate, and the tendency for dorsal angulation of the first metatarsal. We describe an arthroscopic approach that has the advantage of more thorough preparation of the fusion site with minimal bone removal and better control of the arthrodesis position and with less chance of malunion.

Tendoscopic debridement for stage I posterior tibial tendon dysfunction.

Our objective is to assess whether the tendoscopic synovectomy is effective to control the stage I posterior tibial tendon dysfunction. Our study is a retrospective one. The participants, six patients with stage I posterior tibial tendon dysfunction, were treated with tendoscopy with synovectomy for the past 3 years. The results show that this is a safe procedure and we could achieve similar effectiveness as the traditional open procedure. There was no complication found. None of our patients have progressed to stage II or above posterior tibial tendon dysfunction. In conclusion, tendoscopic debridement is a minimal invasive surgery. It is effective to control the stage I posterior tibial tendon dysfunction. In addition, it had the advantages of smaller scars, less wound pain and a short hospital stay.