Midterm Outcomes of Sliding Distal Metatarsal Minimally Invasive Osteotomy to Treat Bunionette Deformity.

BACKGROUND: Bunionette deformity is described as a painful bony prominence on the lateral aspect of the fifth metatarsal head. The present study prospectively assessed the clinical, functional, and radiographic outcomes of sliding distal metatarsal minimally invasive osteotomy (S-DMMO) used in a large series of patients with a midterm follow-up period. METHODS: From December 2015 to December 2018, we evaluated 74 feet (57 patients). Radiologic (4-to-5 intermetatarsal angle, fifth metatarsophalangeal angle, the fifth metatarsal head width, lateral deviation angle, fifth metatarsal length, medial displacement, and elevation), clinician-reported scores (AOFAS score, visual analog scale [VAS]) and patient-reported outcomes measure (Foot and Ankle Ability Measure [FAAM] activities of daily living [ADL], FAAM sports, Manchester-Oxford Foot Questionnaire [MOXFQ], and patient satisfaction survey) were included in the analysis. The time to bone union was also assessed. RESULTS: The average 4-to-5 intermetatarsal angle improved from 11.1 degrees preoperatively to 4.5 degrees postoperatively (P < .001), whereas the average fifth metatarsophalangeal angle improved from 15.7 degrees preoperatively to 4.8 degrees postoperatively (P < .001). The lateral deviation angle was found to be 2.2 degrees. The fifth metatarsal length decreased from 66.6 to 64.3 mm postoperatively. The average initial medial displacement was 4.67 mm preoperatively and 4.54 mm at final follow-up. The elevation of the fifth metatarsal head was 1.08 mm. The American Orthopaedic Foot & Ankle Society score improved from 54.3 ± 20.86 points preoperatively to 93.4 ± 17.3 (P < .001). VAS score decreased from 7.9 to 0.7 (P < .001). Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences (P < .001) between preoperative and postoperative periods. Patients found the procedure excellent in 89.1% of cases, very good in 5.4%, and good in 5.4%. Bone union was obtained at 8.1 weeks. CONCLUSION: The most important finding of the present study is that S-DMMO showed improvement in function and pain associated with a high satisfaction rate. Also, we found substantial capacity to correct deformities and a low incidence of complications. LEVEL OF EVIDENCE: Level IV, case series.

Outcomes of Percutaneous Achilles Repair Compared With Endoscopic Flexor Hallucis Longus Tendon Transfer to Treat Achilles Tendon Ruptures.

BACKGROUND: Both percutaneous and endoscopically assisted methods are reported to produce good results in the surgical management of acute Achilles tendon ruptures. The aim of this retrospective study was to compare between a percutaneous method and a recently described isolated endoscopically assisted flexor hallucis longus (FHL) transfer method as surgical means of management in patients with acute Achilles tendon ruptures. METHODS: One hundred seventeen patients were included in the current study and divided into 2 groups: 59 patients who underwent percutaneous Achilles repair (PAR Group) and 58 patients who underwent isolated endoscopic FHL transfer (FHL Group) were compared. Patients were clinically evaluated using American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score (ATRS), and Achilles tendon resting angle (ATRA) measures. In addition, ankle plantarflexion power, FHL dynamometry, Tegner activity levels, and return to previous levels of activity were also documented for all patients. RESULTS: Nine months after surgery, patients in the FHL transfer group were more likely to be able to return to normal activities (91% vs 73%, P < .01). Thirty months after surgical treatment, we found no difference in ATRS, AOFAS, ATRA, ankle plantarflexion strength, or Tegner activity scores between study groups. Overall complications were reported in 6 patients in the FHL group (10.3%) and in 8 patients in the PAR group (13.6%). No major neurovascular or skin complications were encountered. CONCLUSION: The current study demonstrated satisfactory and comparable results and complications when comparing isolated endoscopic FHL tendon transfer or percutaneous Achilles tendon repairs in the surgical management of acute Achilles tendon ruptures. LEVEL OF EVIDENCE: Level III, retrospective controlled trial.

Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute Achilles Tendon Ruptures in Professional Soccer Players.

BACKGROUND: Acute Achilles tendon ruptures (AATRs) that occur in athletes can be a career-ending injury. The aim of this study was to describe return to play and clinical outcomes of isolated endoscopic flexor hallucis longus (FHL) transfer in active soccer players with AATR. METHODS: Twenty-seven active male soccer players who underwent endoscopically assisted FHL tendon transfer for acute Achilles tendon ruptures were included in this study. Follow up was 46.2 (±10.9) months after surgery. Return to play criteria and clinical outcome measures were evaluated. RESULTS: All players returned to playing professional competitive soccer games. Return to active team training was at a mean of 5.8 (±1.1) months postoperatively. However, return to active competitive match play occurred at a mean of 8.3 (±1.4) months. Twenty-two players (82%) were able to return to their preinjury levels and performances and resumed their professional careers at the same soccer club as their preinjury state. One player (3.7%) shifted his career to professional indoor soccer. At 26 months postoperatively, the mean Tegner activity scale score was 9.7 (±0.4), the mean Achilles tendon total rupture score was 99 (±2), and the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 99 (±3). No patients reported any great toe complaints or symptomatic deficits of flexion strength. CONCLUSION: The current study demonstrated satisfactory and comparable return to play criteria and clinical results with minimal complications when using an advanced endoscopically assisted technique involving FHL tendon transfer to treat acute Achilles tendon ruptures in this specific subset of patient cohort. LEVEL OF EVIDENCE: Level II, prospective cohort case series study.

The Effect of Gastrocnemius Recession and Tendo-Achilles Lengthening on Adult Acquired Flatfoot Deformity Surgery: A Systematic Review.

The purpose of this study was to evaluate the available clinical and radiographic evidence for incorporation of a gastrocnemius recession or tendo-Achilles lengthening into the surgical correction of adult acquired flatfoot deformity. A systematic review of the literature was performed using PubMed, Embase, Cochrane, CINAHL, and Google Scholar. Among the relevant articles, the level of evidence and quality was identified using the Methodological Index for Non-Randomized Studies tool. No study explicitly examined whether clinical or radiographic outcomes after adult acquired flatfoot deformity correction are improved when incorporating a gastrocnemius recession or tendo-Achilles lengthening compared with when no such procedure is performed, nor have they directly compared outcomes between 2 procedures. Studies demonstrated an overall improvement in postoperative range of motion and plantar flexion power after gastrocnemius recession, but such findings are hard to separate from the clinical contribution of concomitant corrective procedures to the foot itself. All studies that analyzed anteroposterior talo-calcaneal angle, anteroposterior lateral talo-first metatarsal angle and calcaneal inclination angle revealed improvement of each parameter postoperatively. There were no high-level evidence studies in the literature explicitly quantifying ankle range of motion, plantar flexion power, or radiographic impact of gastrocnemius recession or tendo-Achilles lengthening on adult acquired flatfoot deformity correction. Although gastrocnemius-soleus complex contractures have certainly been demonstrated to coexist with adult acquired flatfoot deformity, support for lengthening procedures is largely based on expert opinion or case series and is difficult to distinguish from the clinical contribution of associated corrective procedures.

Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute Achilles Tendon Ruptures: A Prospective Case Series Report With a Minimum of 18 Months' Follow-Up.

Acute Achilles tendon rupture can be treated either surgically or nonsurgically. The flexor hallucis longus (FHL) has been used successfully in patients with large chronic Achilles tendon defects. The aim of this study was to describe the clinical outcomes of isolated endoscopic FHL transfer in patients with acute Achilles tendon ruptures at a minimum follow-up of 18 months. Fifty-six male patients with an average age of 36.3 years who underwent endoscopic FHL transfer as a treatment for acute Achilles tendon ruptures were included. Follow-up was for a mean (± standard deviation) of 27.5 ± 7.29 months. At 18 months postoperatively, the Achilles tendon total rupture score mean was 95 ± 4.26, and the American Orthopaedic Foot and Ankle Society score was a mean of 96.4 ± 4.31. The median value for FHL tendon dynamometry on the surgical side was 95.72 (range 70.1 to 142), and 100.7 (range 68 to 161) for the nonoperated side. Mean ankle plantarflexion strength at 18 months was 19.19 ± 2.55 kg • m compared with the uninjured side of 19.27 ± 2.16 kg • m. Relative Achilles tendon resting angle showed a mean of -0.25° ± 2.43°. Magnetic resonance imaging performed at a minimum of 18 months postoperatively showed a homogeneous continuous Achilles tendon signal for 43 patients and heterogeneous signal intensity in 13 patients (23.21%). No patients reported any great toe complaints or symptomatic deficits of flexion strength. No neurovascular or skin complications were encountered. The current study demonstrated satisfactory and comparable results with minimal complications when using the endoscopic FHL tendon transfer in surgical management of acute Achilles tendon ruptures, compared with the currently used methods.