Comparison of 2 Oblique Fifth Metatarsal Osteotomies for the Management of a Bunionette.

BACKGROUND: A bunionette is a painful prominence of the fifth metatarsal head. This study aimed to compare the clinical outcome of 2 corrective osteotomies, namely, the Mau-type and Ludloff-type osteotomies. We report results with regard to correction, healing, complications, and patient-reported outcomes. METHODS: Thirty-two patients who underwent bunionette corrective surgery from March 2011 to May 2017 were included in the study. All patients had pre- and postoperative radiographs. The pre- and postoperative fourth-fifth intermetatarsal angles (IMAs) and postoperative fifth metatarsal bowing angle were measured. Radiographic union was assessed at 12 weeks. All patients completed the Self-Reported Foot and Ankle Score (SEFAS) questionnaire to assess clinical outcome. Thirty-two patients (43 feet) were available for follow-up and completed the SEFAS score. Twenty-two Mau-type and 21 Ludloff-type osteotomies were performed. RESULTS: The mean pre- and postoperative IMA for Mau was 10.5 and 4.3 degrees, respectively, and for the Ludloff was 10.2 and 4 degrees, respectively, with no statistically significant difference between the 2 groups. The Mau caused more bowing with a mean of 9.8 degrees as compared to a mean of 3.5 degrees with the Ludloff. No patients in the Mau group reported clinical problems related to the increased bowing. All osteotomies united. The Mau cohort had a mean SEFAS score of 45 and the Ludloff cohort a mean of 46. No feet had fair or poor outcome scores. CONCLUSION: Patient satisfaction after bunionette correction with an oblique shaft rotational osteotomy was good. Orientation of the osteotomy did not affect outcomes. Postoperative bowing of the fifth metatarsal was greater with the Mau-type osteotomy. Postoperative fifth metatarsal bowing had no negative clinical effects. The trend in our unit has been a preference toward the Mau-type osteotomy as it is perceived to be more stable. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Radiographic Assessment of Relative First Metatarsal Length Following Modified Lapidus Procedure.

BACKGROUND: The modified Lapidus is a surgical procedure for managing moderate to severe hallux valgus, especially in the presence of first tarsometatarsal joint arthritis or hypermobility. It has good long-term results but reportedly can lead to transfer metatarsalgia due to inherent shortening of the first metatarsal. METHODS: A retrospective analysis of all adult patients who underwent a modified Lapidus procedure during a 3-year period was performed. Clinical notes were evaluated to look for nonunion or any other complications related to the surgery. Pre- and postoperative standard weightbearing radiographs were used to establish the relative metatarsal length (RML), intermetatarsal angle (IMA), hallux valgus angle (HVA), and distal metatarsal articular angle (DMMA). A total of 69 modified Lapidus procedures were identified, with 32 included in the study. RESULTS: The mean pre- and postoperative RMLs were -0.8 and -4.9 mm, respectively. The average RML shortening due to the procedure was -4.1 (P < .0001). The mean pre- and postoperative IMAs were 15 and 5 degrees, respectively (P < .0001). The mean pre- and postoperative HVAs were 33 and 9 degrees, respectively (P < .0001). One patient reported transfer metatarsalgia, which was attributed to elevation of the first metatarsal. CONCLUSION: We found a statistically significant degree of shortening of the relative length of the first metatarsal without any clinically significant metatarsalgia. The low rate of transfer metatarsalgia following the modified Lapidus procedure could be attributed to the sagittal plane correction and stability obtained by performing a first tarsometatarsal fusion. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Morphology of the first metatarsal head as a risk factor for hallux valgus interphalangeus.

BACKGROUND: The aetiology of hallux valgus interphalangeus (HVI) is not well understood. First metatarsophalangeal joint stability, influenced by first metatarsal head shape, may be linked to HVI. We hypothesised that first metatarsal head shape is a risk factor for HVI. No published article could be found in the literature investigating this hypothesis. METHODS: 127 standardised foot radiographs were analysed retrospectively. The hallux valgus angle (HVA) and interphalangeus angle (IPA) were measured. The first metatarsal head shape was divided into chevron, round and flat groups. Statistical analysis was then performed to investigate the relationship between first metatarsal head shape and the occurrence of HVI. RESULTS: There was no statistically significant relationship between first metatarsal head shape and the occurrence of HVI. There was however a negative relationship between HVA and HVI. CONCLUSIONS: The morphology of the first metatarsal head does not seem to be a risk factor for HVI. A known negative relationship between HVA and IPA is reinforced. LEVEL OF EVIDENCE: Level III, retrospective cohort.

A radiographic analysis of the contribution of hallux valgus interphalangeus to the total valgus deformity of the hallux.

BACKGROUND: The hallux valgus interphalangeus (HVI) deformity is described as rare, but improved outcomes in hallux valgus (HV) surgery is associated with its surgical correction via an Akin osteotomy. The hypothesis of this study is that HVI is common and makes a significant contribution to the total valgus deformity of the hallux (TVDH). METHODS: 285 pre-operative foot radiographs (193 with HV, 92 non-HV), utilising standardised radiographic and measurement techniques, were analysed retrospectively. The hallux valgus angle (HVA), intermetatarsal angle (IMA), interphalangeal angle (IPA) and distal metatarsal articular angle (DMAA) were measured. The TVDH was calculated as the sum of the HVA and IPA. RESULTS: 163 (57.2%) of the study population were Caucasian, 119 (41.8%) African and 3 Indian (1.0%). 236 (82.8%) of the population was female. There was a statistically significant difference in the proportion of abnormal IPA in the Caucasian population 112 (68.7%) compared to the proportion of abnormal IPA in the African population 64 (53.8%), p=0.01. The average contribution of the IPA to the TVDH across the whole study population was a mean (SD) of 37.9% (21.2). The average contribution of IPA to TVDH was greater in feet without HV (58.0%) when compared to feet with HV (28.3%). HVI is common, particularly in Caucasians (p=0.01) and makes a significant contribution to the TVDH (p<0.01). The contribution to the TVDH is more significant in mild HV. There is an inverse relationship between the IPA and other angular measurements in the foot. CONCLUSION: HVI is a common entity. The significant contribution of the IPA to the TVDH dictates that HVI must be incorporated in management algorithms. The TVDH should replace the isolated concepts of HV and HVI. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Peroneal tendon dislocation/subluxation - Case series and review of the literature.

BACKGROUND: Dislocating or subluxing peroneal tendons is a relatively infrequent injury. Although infrequent it is very debilitating for the athlete. This retrospective study addresses primarily the surgical technique. METHODS: Twenty-three patients between 2005 and 2014 were operated on for symptomatic dislocating or subluxing peroneal tendons. Five patients presented in the acute phase and 18 patients were late cases. Twenty patients were available for follow-up at a mean of 53.1 months. Three patients were classified as Stage III and 17 as Stage I/II. The procedures varied from pure repair of the superior peroneal retinaculum (SPR), reattachment of the SPR, groove-deepening or a combination of the above. No one procedure was favoured over the other. The choice of procedure was decided intraoperatively depending on the findings. RESULTS: The mean postoperative VAS score was 1.5 with a mean AOFAS score of 85. Sixteen patients rated their results as excellent, one as good, one uncertain and two poor. The results showed no one procedure superior to another with respect to chronicity, stage or satisfaction score. CONCLUSIONS: Several procedures have been described for this condition. Most published studies however, comprise of a small cohort of patients with good results following surgery. The surgical techniques vary and depend largely on the surgeon's clinical experience and preference. The authors conclude that the surgical technique described in this article is largely successful with a low complication rate and a high satisfaction rate.

The impact of risk assessment on the implementation of venous thromboembolism prophylaxis in foot and ankle surgery.

BACKGROUND: The purpose of this prospective study was to determine whether the more frequently quoted procedure and patient specific risk factors have any impact in the implementation of venous thromboembolism (VTE) prophylaxis following foot and ankle surgery. METHODS: Two hundred and sixteen patients were included in the study. A variety of operative procedures was carried out with the common denominator being a below knee cast for at least 4 weeks and nonweightbearing for an average of 6 weeks in 130 patients. The remainder of the patients (88) had hallux surgery not requiring a cast and were allowed to weightbear. No patient received any form of thromboprophylaxis postoperatively. All patients were subjected to compression ultrasonography for deep vein thrombosis (DVT) between 2 and 6 weeks postoperatively. RESULTS: There was a 5.09% incidence of VTE (0.9% pulmonary embolism) overall. As no VTE (neither DVT nor pulmonary embolus) developed in the hallux subgroup, i.e. patients not requiring immobilization and were allowed to weightbear, the incidence of VTE in the cast/nonweightbearing group was 8.46%. The results are descriptive and only statistically analyzed where possible, as the sample size of the VTE group was small. There was no significant difference in number of risk factors and no association between gender in the VTE and non VTE groups. 90.9% of patients in the VTE group had a total risk factor score of 5 or more and 73.7% of patients in the non VTE group had a total risk factor score of 5 or more. The average timing to the diagnosis of VTE in this current study was 33.1 days. CONCLUSIONS: In view of the unacceptable incidence of VTE and the average total risk factor score of 5 or more (for which thromboprophylaxis is recommended) in the majority of the patients, the authors feel that the routine use of thromboprophylaxis in foot and ankle surgery requiring nonweightbearing in combination with short leg cast immobilization, is warranted. This prophylaxis should continue until the patient regains adequate mobility either by weightbearing (in or out of the cast) or removal of cast immobilization (weightbearing or nonweightbearing), usually between 28 and 42 days.

The incidence of venous thromboembolism in patients undergoing surgery for acute Achilles tendon ruptures.

BACKGROUND: This retrospective analysis was prompted by the authors' observation of the relatively high incidence of venous thromboembolism (VTE) in the surgical repair of acute Achilles tendon ruptures. METHOD: 88 patients were treated surgically for an acute Achilles tendon rupture. No prophylactic anticoagulation was given to any patients. The incidence of VTE was then reviewed retrospectively. RESULTS: Five patients developed symptomatic deep vein thrombosis (5,7%) and one a near-fatal pulmonary embolus (1.1%). There were no major bleeding or cardiovascular adverse events. One patient developed a thrombus of the lesser saphenous vein (1.1%) and there was one superficial sepsis (1.1%). A temporary peroneal nerve palsy occurred in one patient (1.1%). There were two re-ruptures (2.3%). CONCLUSION: There is no doubt that thromboprophylaxis must be given to the high risk patient and is also recommended for major orthopaedic surgery. Limited data is available for the use of thromboprophylaxis in foot and ankle surgery. In light of the unacceptably high incidence of venous thromboembolism in this study, the authors suggest that routine venous thromboembolism prophylaxis should be considered for these patients.