[Postdural puncture headache after neuraxial anesthesia: incidence and risk factors]. / Postpunktioneller Kopfschmerz nach rückenmarknahen Anästhesieverfahren: Inzidenz und Risikofaktoren.

BACKGROUND/OBJECTIVE: Postdural puncture headache (PDPH) is a severe complication after spinal anesthesia. The aim of this study was to investigate the incidence of PDPH in two different operative cohorts and to identify risk factors for its occurrence as well as to analyze its influence on the duration of hospital stay. MATERIAL AND METHODS: In a retrospective study over a period of 3 years (2010-2012), 341 orthopedic surgery (ORT) and 2113 obstetric (OBS) patients were evaluated after spinal anesthesia (SPA). Data were statistically analyzed using (SPSS-23) univariate analyses with the Mann-Whitney U­test, χ2-test and Student's t-test as well as logistic regression analysis. RESULTS: The incidence of PDPH was 5.9% in the ORT cohort and 1.8% in the OBS cohort. Patients with PDPH in the ORT cohort were significantly younger (median 38 years vs. 47 years, p = 0.011), had a lower body weight (median 70.5 kg vs. 77 kg, p = 0.006) and a lower body mass index (median 23.5 vs. 25.2, p = 0.037). Body weight (odds ratio (97.5 % Confidence Intervall [CI]), OR 0.956: 97.5% CI 0.920-0.989, p = 0.014) as well as age (OR 0.963: 97.5% CI 0.932-0.991, p = 0.015) were identified as independent risk factors for PDPH. In OBS patients, PDPH occurred more frequently after spinal epidural anesthesia than after combined spinal epidural anesthesia (8.6% vs. 1.2%, p < 0.001) and the type of neuraxial anesthesia was identified as an independent risk factor for PDPH (OR 0.049; 97.5% CI 0.023-0.106, p < 0.001). In both groups the incidence of PDPH was associated with a longer hospital stay (ORT patients 4 days vs. 2 days, p = 0.001; OBS patients 6 days vs. 4 days, p < 0.0005). CONCLUSION: The incidence of PDPH was different in the two groups with a higher incidence in the ORT but considerably lower than in the literature. Age, constitution and type of neuraxial anesthesia were identified as risk factors of PDPH. Considering the functional imitations (mobilization, neonatal care) and a longer hospital stay, future studies should investigate the impact of an early treatment of PDPH.

Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome.

PURPOSE: Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery. METHODS: Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48 h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed. RESULTS: Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p = 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p = 0.001), and increased operation time (105 vs. 84 min., p = 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p < 0.001). Complication rate (44 vs. 24%, p = 0.092), mortality (12 vs. 0%, p = 0.061), overall number of surgeries (3.4 vs. 2.4, p = 0.017), enterostomy rate (76 vs. 36%, p = 0.001), and length of hospital stay (25 vs. 18.8 days, p = 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p = 0.005) and with fungal infection (100 vs. 49%, p = 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p < 0.001), enterostomy rate (81 vs. 48%, p = 0.017), and anastomotic leakage (29 vs. 6%, p = 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p = 0.014). CONCLUSION: Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a "Damage Control Strategy".

PURPOSE: Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a "Damage Control Strategy" (DCS). MATERIALS AND METHODS: Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann's procedure) after 24-48 h. RESULTS: Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30-92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n = 17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n = 5), and median postoperative hospital stay was 18.5 days (3-66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%). CONCLUSION: The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.

Patient-related factors influence stiffness of the soft tissue complex during intraoperative gap balancing in cruciate-retaining total knee arthroplasty.

PURPOSE: How much force is needed to pre-tension the ligaments during total knee arthroplasty? The goal of this study was to determine this force for extension and flexion, and for both compartments, and to identify predicting patient-related factors. METHODS: Eighty patients [55 females, mean age 71 (SD 9.7)] were recruited and had a navigated cruciate-retaining total knee arthroplasty. Distraction of the medial and lateral compartments of the extension and flexion gap (90°) with an instrumented bi-compartmental double-spring tensioner took place after finishing the bone cuts. Applied forces and resulting gap distances were recorded by the navigation system, resulting in a force-elongation curve. Lines were fitted with the intersection defined as the stiffness transition point. The slopes (N/mm) represented the stiffness of the ligamentous complex. Linear multiple regression analysis was performed to identify predicting factors. RESULTS: The amount of force at the stiffness transition point was on average 52.3 (CI95 50.7-53.9), 54.5 (CI95 52.7-56.3), 48.3 (CI95 46.2-50.2), and 59.3 (CI95 57.0-61.6) N for the medial and lateral extension and flexion gap, respectively, and varied considerably between patients. The force at the stiffness transition point was significantly different between extension and flexion and both compartments (P < 0.05). Stiffness of the ligaments statistically significantly helped to predict the amount of force at the stiffness transition point, as well as body mass index, gender, and varus-valgus alignment. CONCLUSION: The amount of force at the stiffness transition point varies between 48 and 59 N, depending on flexion/extension and compartment. Patient-related factors influence the stiffness transition point and can help predict the stiffness transition point. When forces higher than 60 N are used for gap distraction, the ligamentous sleeve of the knee might be over-tensioned. LEVEL OF EVIDENCE: Prognostic study, Level I-high-quality prospective cohort study with >80 % follow-up, and all patients enrolled at same time point in disease.

[Patellar bone deficiency in revision total knee arthroplasty]. / Patellarekonstruktion bei defizientem knöchernen Lager.

BACKGROUND: Patellar bone deficiency in revision total knee arthroplasty (TKA) determines the surgical procedure. Different reconstructive and ablative techniques, dependent on the remaining bone stock, are described. INDICATION: The primary patella implant can be retained in up to 50 % of revision situations. Reasons for replacement are aseptic and septic loosening, implant failure, expanding osteolysis, maltracking of the patella and "metal-backed" prosthesis. The aim of the reconstruction is the stable fixation and proper tracking of the implant by restoring the extensor mechanism. SURGICAL PROCEDURE: Dependent on the extent of bone loss and the availability of a patellar rim, the following surgical procedures are recommended. When the remaining bone thickness is 10 mm or more: implantation of a polyethylene "onlay-type" patella; when it is between 6-9 mm and there is an intact patellar rim: reconstruction with a biconvex "inlay-type" patella implant, where the biconvex shape replaces the bone defect partially. When there is deficient bone stock (less than 6 mm) or no cortical patellar rim then augmenting procedures with autologous spongiosa and procedures such as "impaction bone grafting", "trabecular metal" prosthesis, where the trabecular part of the implant serves as the base for the cemented polyethylene button, "gull-wing" osteotomy, which is an adapting and configuring technique of osteotomy; and in exceptional cases patelloplasty or patellectomy are used. CONCLUSION: Regarding the importance of the patellar component in biomechanics of the joint and function of the extensor mechanism, the reconstruction of the patella should be the primary aim. Patelloplasty or patellectomy should be avoided.

Treatment with tetrahydrobiopterin overcomes brain death-associated injury in a murine model of pancreas transplantation.

Brain death (BD) has been associated with an immunological priming of donor organs and is thought to exacerbate ischemia reperfusion injury (IRI). Recently, we showed that the essential nitric oxide synthase co-factor tetrahydrobiopterin (BH4) abrogates IRI following experimental pancreas transplantation. We therefore studied the effects of BD in a murine model of syngeneic pancreas transplantation and tested the therapeutic potential of BH4 treatment. Compared with sham-operated controls, donor BD resulted in intragraft inflammation reflected by induced IL-1ß, IL-6, VCAM-1, and P-selectin mRNA expression levels and impaired microcirculation after reperfusion (p < 0.05), whereas pretreatment of the BD donor with BH4 significantly improved microcirculation after reperfusion (p < 0.05). Moreover, BD had a devastating impact on cell viability, whereas BH4-treated grafts showed a significantly higher percentage of viable cells (p < 0.001). Early parenchymal damage in pancreatic grafts was significantly more pronounced in organs from BD donors than from sham or non-BD donors (p < 0.05), but BH4 pretreatment significantly ameliorated necrotic lesions in BD organs (p < 0.05). Pretreatment of the BD donor with BH4 resulted in significant recipient survival (p < 0.05). Our data provide novel insights into the impact of BD on pancreatic isografts, further demonstrating the potential of donor pretreatment strategies including BH4 for preventing BD-associated injury after transplantation.

[High donor age for liver transplantation : Tackling organ scarcity in Germany]. / Hohes Spenderalter bei Lebertransplantation : Wie begegnen wir dem Organmangel in Deutschland?

BACKGROUND: Liver transplantation is the only curative treatment option for patients with end-stage liver disease; however, the 40% decline of available organ donors in recent years in Germany necessitates the optimization of available resources and possibly extending the criteria to older donors. MATERIAL AND METHODS: All 2652 livers made available to the Charité Universitätsmedizin Berlin from 2010 to 2016 were retrospectively analyzed and the clinical outcome of 526 liver transplantations during this time frame were evaluated. RESULTS: The median age of donors of transplanted organs increased from 49.3 years in 2010 to 57.3 years in 2016 (p = 0.02). Organs from donors ≥65 years were more frequently discarded than organs from younger donors (n = 344, 18.4% vs. n = 220, 28.1%; p = 0.005). Moreover, the older donors had higher rates of diabetes mellitus and hepatic steatosis. Organs from older donors had a higher donor risk index (2.8 vs. 2.2; p < 0.001) and were transplanted more often in patients with preserved liver function and hepatocellular carcinoma and liver cirrhosis (n = 121, 74.7% of indications). The 3­year survival after liver transplantation from donors ≥65 and ≥80 years old was not significantly reduced in comparison to younger donors; however, there was an increased retransplantation rate (28.6%; p = 0.005) after transplantation of organs from donors ≥80 years old. CONCLUSION: Despite conservative organ acceptance there were higher rates of retransplantation after transplantation from very old donors. In the light of an increasing scarcity of suitable organs this mandates caution and highlights the need for adequate assessment instruments for marginal donor organs before transplantation.

The Weil osteotomy: a seven-year follow-up.

We prospectively evaluated the one- and seven-year results of the Weil osteotomy for the treatment of metatarsalgia with subluxed or dislocated metatarsophalangeal joints in 25 feet of 24 patients. Good to excellent results were achieved in 21 feet (84%) after one year and in 22 (88%) after seven years. The American Orthopaedic Foot and Ankle Society score significantly improved from 48 (SD 15) points before surgery to 75 (SD 24) at one year, and 83 (SD 18) at seven years. The procedure significantly reduced pain, diminished isolated plantar callus formation and increased the patient's capacity for walking. Redislocation of the metatarsophalangeal joint was seen in two feet (8%) after one year and in three (12%) after seven years. Although floating toes and restricted movement of the metatarsophalangeal joint may occur, the Weil osteotomy is safe and effective.

[Surgical Techniques for Patella Replacement in Cases of Deficient Bone Stock in Revision TKA]. / Technik des Patellaersatzes bei defizientem Knochenlager.

The patella replacement in revision surgery is a challenge especially in cases of unsufficient bone stock. Depending on the extent of the bone defect, the following videos demonstrate different approaches: Video 1: bone sparing removal of the patella implant: onlay-type patella implants. Video 2: complete cortical bone rim of the patella, residual thickness between 6 to 10 mm: biconvex patella implant. Video 3 and 4: small defects of the cortical bone rim of the patella, residual thickness 1 to 5 mm (patella shell): gull-wing osteotomy, patella bone grafting techniques. Video 5: partial necrosis/defect of the patella shell with incomplete cortical bone rim: porous tantalum patella prosthesis. On account of the various surgical options for different bone defects of the patella, patellectomy and pure patelloplasty should be avoided to prevent functional shortcomings.

Rotationplasty for limb salvage in the treatment of malignant tumors at the knee. A follow-up study of seventy patients.

Seventy patients who had a rotationplasty for treatment of a malignant tumor in the region of the knee (the femur or the tibia) between 1974 and 1987 were followed for two to thirteen years (mean duration of follow-up, four years). Forty-seven patients had a stage-IIB osteosarcoma; the remaining twenty-three patients had a malignant fibrous histiocytoma, a chondrosarcoma, a Ewing sarcoma, or a giant-cell tumor. The most severe postoperative complication was occlusion of the reanastomosed vessels (seven patients), leading to amputation proximal to the knee in three patients. Other complications were problems with wound-healing (eight patients), transient nerve palsy (five patients), irreversible nerve palsy (two patients), pseudarthrosis (four patients), and rotational malalignment (one patient). Late complications included eight fractures, two infections, two delayed unions, and one lymphatic fistula. More than half of the patients were free of complications related to the operative procedure. Forty-four of the patients who had a stage-IIB osteosarcoma could be followed, and their data were analyzed for survival statistics. These patients had a 58 percent rate of disease-free survival and a 70 per cent rate of over-all survival. One patient had a local recurrence five years after the operation.

The chevron osteotomy for correction of hallux valgus. Comparison of findings after two and five years of follow-up.

BACKGROUND: The chevron osteotomy, an accepted method for the correction of mild and moderate hallux valgus, is generally advocated for patients younger than the age of fifty years. The purposes of this prospective study were to compare the short-term (two-year) and intermediate-term (five-year) results of this operation with respect to patient satisfaction, flexion and extension of the metatarsophalangeal joint, maintenance of correction, and development of arthrosis and to determine whether the effectiveness of the procedure was limited by age. METHODS: Between April 1991 and September 1992, the chevron osteotomy was performed for the treatment of mild-to-moderate hallux valgus deformity in sixty-six consecutive feet. Forty-three patients (fifty-seven feet) were available for follow-up at both two and five years postoperatively. The two-year and five-year clinical assessments were based on the American Orthopaedic Foot and Ankle Society's hallux-metatarsophalangeal-interphalangeal scale. RESULTS: Between the two-year and five-year follow-up evaluations, there was only a minimal change in overall patient satisfaction, and the average score on the hallux-metatarsophalangeal-interphalangeal scale was unchanged. The passive range of motion of the first metatarsophalangeal joint decreased between the preoperative assessment and the two-year follow-up evaluation and was unchanged at the five-year follow-up evaluation. Radiographic evaluation showed no changes in the hallux valgus or intermetatarsal angle between the two-year and five-year evaluations, although the number of feet with arthrosis of the metatarsophalangeal joint increased slightly, from eight to eleven. Patients aged fifty years or older did as well as younger patients. CONCLUSIONS: At these two follow-up periods, the chevron osteotomy was found to be a reliable procedure for the correction of mild and moderate hallux valgus deformity, and outcome did not differ on the basis of age.

[Fibrous dysplasia: its appearance in the magnetic resonance tomogram]. / Fibröse Dysplasie: Erscheinungsbild im Magnetresonanztomogamm.

Eleven patients with proven fibrous dysplasia of the skeleton (FD) were examined using magnetic resonance imaging (MRI). Almost constantly T1-weighted hypointense, T2-weighted hyperintense (cystic) as well as T1- and T2-weighted hypointense (fibrous) areas within the lesion could be demonstrated, the latter of which always exhibited either moderate or marked enhancement following intravenous application of Gd-DTPA, resulting in a typical appearance. Furthermore, T1- and T2-weighted hyperintense areas within the lesion were seen in many patients due to focal hemorrhage. No linear time correlation between the clinical symptom pain and focal areas of hemorrhage as shown by MRI, could be established.

[MRT in the follow-up of the healing process of spongy bone transplants--initial experiences]. / MRT zur Kontrolle des Einheilungsvorganges von Spongiosatransplantaten--erste Erfahrungen.

We present our first experience with MR in bone grafts in 23 patients. Graft implantation followed curettage of benign bone lesions. The locations were, rather exclusively, the long tubular bones. T1-and T2-weighted spin echo-sequences including intravenous application of Gadolinium-DTPA were performed (Magnetom 63, 1,5 T). A total of 29 examinations (1 follow-up control in 6 pat.) was divided into 5 groups, with regard to different stages after surgery, which varied from 1 week to more than 3 years postoperatively. The MR results were related to the respective groups. The results show typical stages of bone graft incorporation, but also greater individual variations in the duration of incorporation. Our first results, however, represent only "snapshots" of different patients at different stages after bone graft surgery. Therefore some important questions are still unanswered but may perhaps be explained with the help of subsequent prospective studies.

Modifications of the paraspinous muscle flap: anatomy and clinical application.

Soft-tissue defects of the back, particularly involving the paravertebral tissues, are generally covered with myocutaneous, muscle, or fasciocutaneous flaps. The case of a 64-year-old man with a paravertebral malignant fibrous histiocytoma is reported. To ensure adequately radical margins, the ipsilateral trapezius and latissimus dorsi muscles as well as the costal periosteum and the spinous processes were resected between T9 and T12. The resulting defect was covered with a pedicled latissimus dorsi flap and an island flap of the paravertebral muscles. Prompted by this case, we studied the blood supply of the paravertebral muscles in 10 cadavers. The vasculature was visualized after flushing with colored latex and microsurgical dissection. Another 4 specimens were subjected to angiography and tomography. In the majority of cases (8 of 10), three perforators emerging from the intercostal arteries were identified. These were found to communicate in a longitudinal and vertical direction. Before piercing the fascia, they ramified in three layers matching the layers of the paravertebral muscles. Since the intercostal arteries were shown to communicate through anastomoses of adequate caliber, the paravertebral muscles appear to be useful candidates for proximally or distally pedicled transposition or island flaps.

[Tissue plasminogen activator activity in early prostatic cancer and in bone metastases of prostatic cancer]. / Gewebeplasminogenaktivatoraktivität in virginellen Prostatakarzinomen und ossären Prostatakarzinommetastasen.

Most malignant cells exhibit increased plasminogen activator activity which, in turn, leads to the formation of the fibrinolytically active enzyme, plasmin. Since solid tumours in man are surrounded by a fibrin network, the fibrinolytic activity of the tumour may influence tumour growth and metastasis. In the present study plasminogen activator activity, as assessed in purified extracts, was compared in benign hyperplasia of the prostate (group A, n = 6), non-metastasizing+ prostatic carcinoma (group B, n = 26), and in prostatic carcinoma with bone metastasis (group C, n = 10). Plasminogen activator activity was significantly higher in prostatic carcinoma than in hyperplasia, but there was no significant difference in plasminogen activator activity between prostate carcinoma with or without bone metastasis. However, plasminogen activator activity in the bone metastasis cells was significantly higher than in the primary tumour. If a positive correlation between fibrinolytic activity of the tumour and the metastasizing capacity were postulated, particular importance could be attached to bone metastasis in prostatic cancer.

Acquired hallux varus and clinical tolerability.

This retrospective study was undertaken to determine the long-term clinical problems, residual disability, and need for further surgery in patients with iatrogenic hallux varus. Between 1975 and 1985, in 16 (19 feet) of 83 patients who underwent foot surgery for hallux valgus or metatarsus primus varus, hallux varus deformity was noted at 1-year follow-up on dorsoplantar roentgenograms obtained with the patients bearing weight. Thirteen of those patients (16 feet) were reexamined at an average of 18.3 years (220 months) after surgery. The average hallux varus deformity in this group was 10.1 degrees. Eleven patients (12 feet) rated their results as excellent. The average hallux metatarsophalangeal interphalangeal score for all patients was 91.5 points. Only those with extreme hallux varus deformity were dissatisfied or required further surgery.

Modified Austin procedure for correction of hallux valgus.

The Austin osteotomy is a widely accepted method for correction of mild and moderate hallux valgus. In view of publications by Kitaoka et al. in 1991 and by Mann and colleagues, a more radical lateral soft tissue procedure was added to the originally described procedure. From September 1992 to January 1994, 85 patients underwent an Austin osteotomy combined with a lateral soft tissue procedure to correct their hallux valgus deformities. Seventy-nine patients (94 feet) were available for follow-up. The average patient age at the time of the operation was 47.1 years, and the average follow-up was 16.2 months. The average preoperative intermetatarsal angle was 13.9 degrees, and the average hallux valgus angle was 29.7 degrees. After surgery, the feet were corrected to an average intermetatarsal angle of 5.8 degrees and an average hallux valgus angle of 11.9 degrees. Sesamoid position was corrected from 2.1 before surgery to 0.5 after surgery. The results were also graded according to the Hallux Metatarsophalangeal Interphalangeal Score, and the functional and cosmetic outcomes were graded by the patient. Dissection of the plantar transverse ligament and release of the lateral capsule repositioned the tibial sesamoid and restored the biomechanics around the first metatarsophalangeal joint. There was no increased incidence of avascular necrosis of the first metatarsal head compared with the original technique.

Basal closing wedge osteotomy for correction of hallux valgus and metatarsus primus varus: 10- to 22-year follow-up.

Between 1974 and 1985, 59 patients (83 feet) underwent basal closing wedge osteotomy in combination with a bunionectomy and a lateral soft tissue release for correction of hallux valgus and metatarsus primus varus at this institution. Of the original 59 patients, 42 patients (60 feet) with at least 10 years of follow-up (average, 194 months; range, 144-266 months) were available for this study. Results were analyzed by review of the medical records and plain radiographs, a standardized clinical questionnaire, and physical examination. Of the 60 feet, patients rated outcomes as excellent or good in 51 feet (85%) and rated cosmesis as excellent or good in 44 feet (73%). Radiographically at final follow-up, hallux valgus and intermetatarsal angles averaged 19.9 degrees (range, 0-40 degrees) and 6.7 degrees (range, 0-18 degrees), respectively. The sesamoid position was corrected from an average preoperative grade of 2.6 to a grade of 0.9 at final follow-up. The average shortening of the first metatarsal was 5 mm. The disadvantages of the closing wedge osteotomy are that it is technically demanding and it entails the risk of shortening, dorsal malalignment, and metatarsalgia. In the current study, long-term complications included hallux varus deformity (16 feet), dorsal malalignment (15 feet), and metatarsalgia (14 feet). Despite good correction of the intermetatarsal angle and sesamoid position, the clinical results and the incidence of complications after basal closing wedge osteotomy were not as favorable as those reported for other procedures in the literature. Therefore, alternative procedures, such as the basal crescentic osteotomy or the basal chevron osteotomy, should be used.