Percutaneous basal closing wedge osteotomy for hallux valgus deformity.

OBJECTIVE: This article describes the percutaneous technique of a minimally invasive basal closing wedge osteotomy for correction of hallux valgus. INDICATIONS: This procedure allows correction of severe deformity with a minimally invasive approach. CONTRAINDICATIONS: No specific contraindication; a fusion would be preferred for an arthritic tarsometatarsal or metatarsophalangeal joint. SURGICAL TECHNIQUE: The surgical technique is based on the use of burrs specifically adapted for foot surgery. A basal closing wedge osteotomy is performed and fixed percutaneously. Each step is controlled under fluoroscopy. POSTOPERATIVE MANAGEMENT: A postoperative heel shoe is prescribed for 6 weeks with crutches. The foot is elevated during the first 2 weeks. Impact is forbidden for 3 months. RESULTS: The authors report good and excellent results with an average correction of the hallux valgus angle of 26° and an intermetatarsal angle of 8.2°.

Lapidus, a Percutaneous Approach.

Described in the early 1900s by Albrecht and Lapidus, the Lapidus procedure became an important tool in the armamentarium. With the increase of percutaneous techniques, the development of a percutaneous Lapidus seemed obvious.

Treatment of Metatarsalgia with Distal Osteotomies.

Many different distal metatarsal osteotomies have been described in the surgical treatment of metatarsalgia. The surgeon should use such osteotomies judiciously, and indeed, in the author's experience, they are infrequently required and are certainly not a first port of call. In cases where nonoperative treatments have failed, a thorough understanding of the causes of metatarsalgia and a detailed clinical assessment of the patient are essential if good surgical outcomes are to be achieved. If using distal metatarsal osteotomies as part of the surgical plan, then the author favors extra-articular percutaneous osteotomies to minimize postoperative stiffness.

Percutaneous Surgery for Severe Hallux Valgus.

Severe hallux valgus is a challenge to treat. If the basal osteotomy is a well known surgery for severe deformity, the chevron osteotomy is usually used in mild to moderate deformity. With a accurent fixation the chevron can also be used in severe deformity. Both techniques can be performed percutaneously and offer reliable techniques.

Percutaneous Surgery for Metatarsalgia and the Lesser Toes.

The traditional open surgical options for the treatment of metatarsalgia and lesser toe deformities are limited and often result in unintentional stiffness. The use of percutaneous techniques for the treatment of metatarsalgia and lesser toe deformities allows a more versatile and tailor-made approach to the individual deformities. As with all percutaneous techniques, it is vital the surgeon engage in cadaveric training from surgeons experienced in these techniques before introducing them into his/her clinical practice.

Percutaneous Surgery of the Forefoot.

This article describes some of the common techniques used in percutaneous surgery of the forefoot. Techniques such as minimally invasive chevron Akin osteotomy for correction of hallux valgus, first metatarsophalangeal joint cheilectomy, distal minimally invasive metatarsal osteotomies, bunionette correction, and hammertoe correction are described. This article is an introduction to this rapidly developing area of foot and ankle surgery. Less invasive techniques are continually being developed across the whole spectrum of surgical specialties. The surgical ethos of minimizing soft-tissue disruption in the process of achieving surgical objectives remains at the center of this evolution.

Minimally Invasive Surgery Osteotomy of the Hindfoot.

A minimally invasive surgical approach has been developed for hindfoot as well as forefoot procedures. Percutaneous techniques have been evolving for more than 20 years. Many conventional surgical techniques can be performed percutaneously after training. Percutaneous surgical techniques require knowledge specific to each procedure (eg, percutaneous Zadek osteotomy or percutaneous medial heel shift). In the treatment and correction of the hindfoot pathology the surgeon now has percutaneous options including medial or lateral heel shift, Zadek osteotomy, and exostectomy with/without arthroscopy.

Minimally invasive osteotomies.

As orthopedic surgery continues to head in the direction of less invasive surgical techniques, this article explores the application and evolution of minimally invasive/percutaneous techniques in the surgical correction of hallux valgus deformities. Modern techniques are described and available literature is reviewed.

Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs.

BACKGROUND: Plantar fasciitis is the most common cause of heel pain. It may remain symptomatic despite conservative treatment with orthoses and analgesia. There is conflicting evidence concerning the role of extracorporeal shock wave therapy (ESWT) in the management of this condition. QUESTIONS/PURPOSES: We investigated whether there was a significant difference in the change of (1) VAS scores and (2) Roles and Maudsley scores from baseline when treated with ESWT and placebo. Specifically we compared overall improvement from baseline composite VAS, reduction in overall VAS pain, success rate of improving overall VAS pain by 60%, success rate of improving VAS pain by 60% when taking first steps, doing daily activities, and during application of a pain pressure meter. METHODS: MEDLINE, Embase, and CINAHL databases were searched from January 1980 to January 2013 and a double extraction technique was used to obtain relevant studies. Studies had to be prospective randomized controlled trials on adults and must not have used local anesthesia as part of their treatment protocol. Studies must have specifically recruited patients who continued to be symptomatic despite a minimum of 3 months of conservative treatments. All papers were assessed regarding their methodologic quality and a meta-analysis performed. Seven prospective randomized controlled trials were included in this study. There were 369 patients included in the placebo group and 294 in the ESWT group. RESULTS: After ESWT, patients had better composite VAS scores (random effects model, standardized mean difference [SMD] = 0.38; 95% CI, 0.05, 0.72; z = 2.27). They also had a greater reduction in their absolute VAS scores compared with placebo (random effects model, SMD = 0.60; 95% CI, 0.34, 0.85; z = 4.64). Greater success of improving heel pain by 60% was observed after ESWT when taking first steps (random effects model, risk ratio [RR] = 1.30; 95% CI, 1.04, 1.62; z = 2.29) and during daily activities (random effects model, RR = 1.44; 95% CI, 1.13, 1.84; z = 2.96). Subjective measurement of pain using a pressure meter similarly favored ESWT (random effects model, RR = 1.37, 95% CI, 1.06, 1.78; z = 2.41). There was a significant difference in the change to "excellent - good" Roles and Maudsley scores in favor of the ESWT group. CONCLUSIONS: ESWT is a safe and effective treatment of chronic plantar fasciitis refractory to nonoperative treatments. Improved pain scores with the use of ESWT were evident 12 weeks after treatment. The evidence suggests this improvement is maintained for up to 12 months. We recommend the use of ESWT for patients with substantial heel pain despite a minimum of 3 months of nonoperative treatment.

A biomechanical comparison of locking and nonlocking plates for the fixation of calcaneal fractures.

BACKGROUND: Locking plate systems have been developed in an attempt to increase the strength of fracture fixation and, in so doing, allow earlier mobilization and rehabilitation. The purpose of our study was to compare the mechanical integrity of the locking plate and traditional nonlocking plate fixation for calcaneal fractures in a cadaver model. Our hypothesis was that the locking plate construct provides stronger fixation than the nonlocking plate construct. METHODS: We created a Sanders type-IIB fracture in 10 pairs of fresh-frozen cadaver feet (bone mineral density, 0.50 +/- 0.14 g/cm2 age, 69 +/- 16 years). One foot of each pair was fixed with a nonlocking calcaneal plate (Synthes, Paoli, PA), and the contralateral foot was fixed with the Locking Calcaneal Plate (Synthes, Paoli, PA). The specimens then were cyclically loaded through the tibia from 0 to 700 N at 1 Hz on a materials testing machine to simulate weightbearing. Fragment displacement was measured with a three-dimensional kinematic analysis system. Significance was set at p < 0.05. RESULTS: There was no significant difference between the two plating systems with respect to the mean (+/- SD) number of cycles to failure (locking plate, 3261 +/- 2355; nonlocking plate, 2271 +/- 2465). CONCLUSION: In a cadaver model of type-IIB calcaneal fractures, locking plate fixation did not provide a biomechanical advantage over traditional nonlocking plate fixation.

The management of concomitant tears of the peroneus longus and brevis tendons.

BACKGROUND: Concomitant chronic tears of both peroneal tendons rarely are reported. We present our experience in treating these injuries and suggest an algorithm for surgical treatment, determined by the presence of a functioning tendon or tendons, mobility of the remaining peroneal musculature, ankle stability, and position of the heel. METHODS: Twenty-eight consecutive patients (29 feet) were followed postoperatively for a mean of 4.6 (range 1.5 to 8) years. The mean age was 36 (range 19 to 54) years, and all patients had chronic ankle pain with or without instability and with combinations of complete, partial, or longitudinal tears of both tendons. Of the 28 patients, six had hindfoot varus and three had cavovarus. Eight patients had mechanical ankle instability, but there was no correlation between instability and the presence of hindfoot varus. RESULTS: The mean postoperative American Orthopaedics Foot and Ankle Society ankle score was 82 (range 20 to 100) points, and 91% of patients achieved normal or moderate peroneal muscle strength. Ankle instability was successfully corrected in all patients and progressive worsening of varus deformity was prevented. CONCLUSION: The presence of chronic peroneal tendon subluxation or dislocation, chronic ankle instability, or hindfoot varus deformity, in association with retrofibular pain and swelling, should alert the surgeon to the possibility of a tear of the peroneal tendons and is an indication for surgical intervention. At the time of tendon repair, every effort should be made to treat the primary or contributing causes of the tear. Our results suggest that patients with symptomatic concomitant peroneus longus and brevis tendon tears are likely to experience substantial improvement in function if operative treatment is adequate.

Technique Tip: Modification of DuVries's lesser metatarsophalangeal joint arthroplasty to improve joint mobility.

An interposition arthroplasty for the treatment of pain and stiffness in the second metatarsophalangeal joint (MTPJ) is presented. The procedure is a modification of DuVries's lesser MTPJ arthroplasty and is specifically intended to improve limited dorsiflexion not addressed by the original procedure.

Investigation of incidence of superficial peroneal nerve injury following ankle fracture.

The aim of this study was to investigate the incidence of superficial peroneal nerve (SPN) injury following ankle fracture and to establish whether this differed between those treated by open reduction and internal fixation (ORIF) and those treated nonoperatively in a cast. Two hundred eighty patients who had been treated for an ankle fracture either surgically (ORIF group) or nonoperatively (cast group) were identified. Patients were invited for review, assessed using the AOFAS scoring system, and examined for any evidence of SPN injury. The surgical approach was documented and all fractures were classified according to the Weber classification. A total of 120 patients returned for review; 56 patients from the ORIF group and 64 patients from the cast group. The mean time from injury to review was 2 years (range, 12-36 months). Overall, 18 patients (15%) had a symptomatic SPN injury and these patients had a significantly lower AOFAS score. In the cast group, 9% of patients had painful symptoms from an SPN injury, compared to 21% of patients in the ORIF group (p < .05). No evidence of SPN injury was found in those who had a posterolateral approach to the ankle. Surgeons should be aware that the SPN is at risk during lateral approach to the fibula and that injury to this nerve can frequently be identified as a cause of chronic ankle pain.