Treatment of moderate hallux valgus by percutaneous, extra-articular reverse-L Chevron (PERC) osteotomy.

AIMS: The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy. PATIENTS AND METHODS: A total of 38 patients underwent 45 procedures. There were 35 women and three men. The mean age of the patients was 48 years (17 to 69). An additional percutaneous Akin osteotomy was performed in 37 feet and percutaneous lateral capsular release was performed in 22 feet. Clinical and radiological assessments included the type of forefoot, range of movement, the American Orthopedic Foot and Ankle (AOFAS) score, a subjective rating and radiological parameters. The mean follow-up was 59.1 months (45.9 to 75.2). No patients were lost to follow-up. RESULTS: The mean AOFAS score increased from 62.5 (30 to 80) pre-operatively to 97.1 (75 to 100) post-operatively. A total of 37 patients (97%) were satisfied. At the last follow up there was a statistically significant decrease in the hallux valgus angle, the intermetatarsal angle and the proximal articular set angle. The range of movement of the first metatarsophalangeal joint improved significantly.. There was more improvement in the range of movement in patients who had fixation of the osteotomy of the proximal phalanx. CONCLUSION: Preliminary results of this percutaneous approach are promising. This technique is reliable and reproducible. Its main asset is that it maintains an excellent range of movement. TAKE HOME MESSAGE: The PERC osteotomy procedure is an effective approach for surgical management of moderate hallux valgus which combines the benefits of percutaneous surgery with the versatility of the chevron osteotomy whilst maintaining excellent first MTPJ range of motion.

Percutaneous bunionette correction: results of a 49-case retrospective study at a mean 34 months' follow-up.

INTRODUCTION: Bunionette consists in a lateral prominence of the head of the fifth metatarsal (M5), inducing a callus. Toe malpositioning determines the varus, supraductus or infraductus form. HYPOTHESIS: A percutaneous method without osteosynthesis was assessed in 38 patients suffering from this pathology. PATIENTS AND METHODS: A continuous single-operator multicenter series operated on between May 2005 and January 2012 was analyzed with mean follow-up of 34 months. The inclusion criterion was bunionette with or without varus deviation. All patients were operated on percutaneously without tourniquet, on a day-care basis. All were clinically assessed, preoperatively and at latest FU, by visual analog pain scale (VAS), AOFAS and Coughlin scores, and callus status. Standard radiological assessment comprised monitoring of intermetatarsal (M4M5) and metatarsophalangeal (M5P1) angles. RESULTS: VAS decreased from 8 (range, 6-9) preoperatively to 0.3 (range, 0-1) out of 10 at follow-up. AOFAS score increased from 58 (range, 52-75) to 97 (range, 80-100) out of 100. According to the Coughlin score, 97.5% of patients were satisfied or very satisfied. Deformity correction was systematic, with disappearance of preoperative callus. M4M5 and M5P1 angles decreased respectively from 10° (range, 6-13°) and 16.2° (range, 8-24°) preoperatively to 5.5° (range, 4-8°) and 4.3° (range, 2-9°). There was 1 case of complex regional pain syndrome and 1 delayed consolidation. DISCUSSION: This procedure appeared reliable for correcting all types of bunionette deformity. Other minimally invasive methods with comparable results use pin fixation. The advantages over conventional techniques are the quality of results, low morbidity and absence of osteosynthesis material. The percutaneous technique should, we believe, be widely adopted in this indication. LEVEL OF EVIDENCE: IV.

AKILE™ total ankle arthroplasty: Clinical and CT scan analysis of periprosthetic cysts.

INTRODUCTION: Despite good clinical results following total ankle replacement (TAR), the development of large periprosthetic cysts (>400 mm(2)) in the medium-term is a source of concern. OBJECTIVE: The primary objective of this study was to detect any large periprosthetic cysts in a cohort of AKILE™ patients using radiographs and CT scans, and then to compare these findings to published ones. MATERIAL AND METHODS: A total of 127 TAR procedures were performed between June 1995 and January 2012. We retrospectively reviewed 68 cases with the newest AKILE™ implant design that had a minimum follow-up of 36 months. The average follow-up was 81 ± 33 months; eight patients were lost to follow-up. The outcomes consisted of analyzing radiographs (A/P and lateral weight bearing views, Meary view and lateral views of flexion/extension) and helical CT scans, performing clinical evaluations (range of motion, AOFAS score, Foot Function Index, pain levels) and determining the survivorship of TAR implants. RESULTS: TAR survival at 5 years was 79% for in situ implants and 62% for revision-free implants. The AOFAS score improved from 33.7 ± 14.7 to 77.1 ± 15.1 (out of 100) and the pain sub-score was 30.2 ± 9.7 (out of 40) at the last follow-up. The average ankle range of motion was 32.3° ± 12.7° on the radiographs. CT scan revealed Type A cysts (<200 mm(2)) under the talar implant in 52% of cases and in the tibia in 50% of cases; these cysts were smaller than 100 mm(2) in 80% of cases and had no effect on the implants. No periprosthetic cysts larger than 400 mm(2) in size were identified. DISCUSSION: The medium-term functional results and survivorship are comparable to those reported for other TAR designs. The incidence of cysts was low overall and there were no large-diameter cysts, which should improve long-term survival. The implant's design and materials likely played a role in preserving the periprosthetic bone stock. The AKILE™ TAR has distinctive features related to the low rate of large periprosthetic cysts in the medium-term. LEVEL OF EVIDENCE: IV (retrospective case series).

Viscosupplementation of the ankle: a prospective study with an average follow-up of 45.5 months.

INTRODUCTION: Providing pain relief for ankle osteoarthritis and delaying the need for a radical surgery procedure is difficult to achieve with analgesics that have limited efficacy or are not devoid of substantial side effects. HYPOTHESIS: The goals of this study were to evaluate the efficacy of viscosupplementation, explore which factors better predict Patient's response and propose an injection protocol. MATERIALS AND METHODS: Eighteen patients (26 ankles) with ankle osteoarthritis were included, with seven of them having received multiple series of injections. The average age was 60 years. Series of three injections, performed in the operating room under fluoroscopy-guidance, were evaluated after 4 and 12 months and then annually with the AOFAS score; patient satisfaction was also assessed. RESULTS: The average AOFAS score increased significantly from 61.8 ± 15 before the injections to 74.4 ± 14.5 and 73.7 ± 16.6 after 4 and 12 months, respectively. The average follow-up was 45.5 months and 73% of patients were satisfied or very satisfied. There were no adverse effects or intolerance. In patients receiving more than one series of injections, the average delay between series was 27.8 (range 15-43) months. Five patients had a radical surgery procedure after an average of 27 months of effective viscosupplementation. DISCUSSION: This prospective study showed that viscosupplementation had a significant positive effect (P<0.05) in patients with ankle osteoarthritis when a three-injection protocol was used every two years on average. Neither etiology nor severity of the osteoarthritis was predictive of the response. In our opinion, fluoroscopy-guidance is essential for these injections. LEVEL OF EVIDENCE: Level IV cohort study.

Osteochondral lesions of the talus: Current concept.

Osteochondral lesions of the talus (OTL) are among those injuries that we should not fail to recognize, especially following any type of hindfoot injury. They were thoroughly described 15 years ago in a round table session organized by Doré and Rosset for the Société orthopédique de l'Ouest. Their physiopathology has not yet been definitely determined, even though some of the pathogenic mechanisms are known. They are best characterized using the fractures, osteonecroses, geodes (FOG) radiological classification. Both their diagnosis and their surgical treatment remain a challenge to the orthopaedic surgeon: some basic surgical principles apply to all of the lesions, such as cartilage debridement and shaving of necrotic tissues, while others will be used depending on the location and size of the lesions as well as the surgeon's experience. Finally, no specific technique appears to be superior to the others. Arthroscopy appears to be the most effective procedure for lesions smaller than 1 cm(2), whereas larger lesions should be filled, either with cancellous bone or with an osteochondral graft or using autogenous chondrocyte implantation. The data available in the literature should also incite orthopaedists to consider the results of surgical management with some modesty, and conservative management should remain among the therapeutic options.