Lateral metatarsal osteotomy.

Lateral metatarsal osteotomy (LMO) aims to reposition the affected metatarsals in a chosen position. The approach may be open or percutaneous. There are several types of LMO, according to displacement: shortening, raising, translation or lengthening. Preoperative planning covers type and extent of displacement, osteotomy location and type (open or percutaneous), and number of metatarsals concerned. In the 1990s, older concepts of non-fixed osteotomies gave way to preoperative planning and calculated shortening, including the development of Weil shortening osteotomy. Diaphyseal lengthening or shortening osteotomy is mainly used for brachymetatarsia. The older concept of non-fixed lateral rays made a comeback with percutaneous first-ray surgery. Distal metatarsal minimally invasive osteotomy (DMMO) is the most effective, giving rise to variants such as distal oblique metatarsal minimally invasive osteotomy (DOMMO), to meet the requirements of greater displacement, especially in shortening and translation, and to be applicable in as wide a range of cases as possible. Presently, these percutaneous techniques have not demonstrated superiority over open surgery, and entail specific complications. Even so, they are now part of the armamentarium of forefoot surgery, as their minimal invasiveness corresponds to current trends in surgery, especially in the foot. Level of evidence: V.

Imaging of the post-operative hallux valgus: what do radiologists need to know?

Hallux valgus surgery concerns many patients and various techniques are performed. The assessment of the first toe deformity correction is mainly visual and imaging is required to analyze the intermetatarsal angle and depict complications. However, it is often difficult for the radiologist to distinguish normal and pathological conditions, especially in case of osteotomies which may show various aspects of bone mineralization and healing. In this review, the most relevant imaging features of the post-operative hallux valgus are summarized.

Average 4-Year Outcomes of Distal Oblique First Metatarsal Osteotomy for Stage 1 to 3 Hallux Rigidus.

BACKGROUND: Hallux rigidus is the second most frequent pathology of the first ray. Surgical options for degenerative metatarsophalangeal joint disease are either joint destructive or conservative procedures. The hypothesis was that oblique distal shortening osteotomy of the first metatarsal is an effective conservative technique for the management of stage 1 to 3 hallux rigidus. METHODS: We conducted a retrospective cohort study of 87 feet with Coughlin and Shurnas's stage 1-3 hallux rigidus, operated between 2009 and 2019. The cohort consisted in 72 patients (87 feet) with an average age of 57±9 (30/79) years; 22 of 87 (25.3%) feet had the first metatarsal surgery performed in isolation; 65 of 87 (74.7%) had concomitant forefoot procedures, including 31 of 87 (35.6%) with Akin phalangeal osteotomies and 34 of 87 (39.1%) with Moberg phalangeal osteotomies.We evaluated the American Orthopaedic Foot & Ankle Society (AOFAS) Scale, subjective satisfaction, joint amplitudes, shortening rate, and occurrence of postoperative complications with a mean follow-up of 51 months (16/134). RESULTS: The AOFAS score increased from 54.2±11.3 (25/70) preoperatively to 92.2±7.8 (62/100) postoperatively (P < .001). Patients reported excellent or good outcome in 95.4% of cases. The 40-point self-reported pain subscale score improved from 19.6 (± 10.0) to 37.4 (± 5.4), P < .001.The overall range of motion increased from 61±21 (20/110) degrees to 69±17 (35/120) degrees (P < .001). The mean first metatarsal shortening rate (SRpo) was 9.6%. Neither the Coughlin grade, the metatarsal index, or the SRpo influenced the AOFAS score. At 6-month follow-up, 15 patients had transfer metatarsalgia compared with 5 at last follow-up without requiring another surgical procedure. The risk was not significantly different according to Coughlin's stage, preoperative metatarsal index, or SRpo. CONCLUSION: Oblique distal osteotomy of the first metatarsal for stage 1-3 hallux rigidus, often in combination with other first ray procedures, performed well during our follow-up time period, with a high subjective satisfaction rate and few complications. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Clinical diagnosis of gastrocnemius tightness.

The diagnosis of gastrocnemius tightness is primarily clinical using the Silfverskiold test, which shows an equinus deformity at the ankle with the knee extended but that disappears with the knee flexed. The manner in which the Silfverskiold test is performed must be consistent with respect to the applied strength of the maneuver, correction of a flexible hindfoot valgus deformity while performing the test, and reproducibility. Although this is a diagnosis based on the clinical examination, this article presents additional clinical signs that can help to make the diagnosis when the retraction is not clinically evident. These include knee recurvatum, hip flexion, lumbar hyperlordosis, and forefoot overload.

Technique, indications, and results of proximal medial gastrocnemius lengthening.

Gastrocnemius proximal lengthening was first performed to correct spasticity in children, and was adapted for the patient with no neuromuscular condition in the late 1990s. Since then, the proximal gastrocnemius release has become less invasive and has evolved to include only the fascia overlying the medial head of the gastrocnemius muscle. The indications for performing this procedure are a clinically demonstrable gastrocnemius contracture that influences a variety of clinical conditions in the forefoot, hindfoot, and ankle. It is a safe and easy procedure that can be performed bilaterally simultaneously, and does not require immobilization of the ankle after surgery.

Recurrent metatarsalgia.

Recurrent metatarsalgia has a multifactorial etiology. The analysis of the cause is critical in planning appropriate treatment. Understanding etiology helps understand the mechanism of prevention, which is the best treatment. Recurrent metatarsalgia is often due to poor technique or poor understanding of the underlying problem. In hallux valgus surgery, recurrent metatarsalgia can be a problem of position of the first metatarsal after an inappropriate or poorly done first metatarsal osteotomy or a problem of gastrocnemius tightness not previously recognized. The best treatment is to restore the normal anatomy but that is not always possible, and surgery on affected rays could be the solution.

Joint-preserving surgery in rheumatoid forefoot: preliminary study with more-than-two-year follow-up.

The authors propose a joint-preserving surgery for rheumatoid forefoot deformities as an alternative to the "classic" surgical approach to the rheumatoid forefoot. The main principle is joint preservation by shortening osteotomies of all the metatarsals performed at the primary location of the rheumatoid forefoot lesions, namely the metatarsophalangeal (MTP) joints and metatarsal heads. A scarf osteotomy is normally performed on the first ray. A Weil osteotomy is performed on the lesser metatarsals. Excellent correction of the hallux valgus deformity in the rheumatoid forefoot can be achieved with a scarf osteotomy in 92% of cases without the need for MTP joint arthrodesis. Similarly, 86% of the lateral metatarsal heads can be preserved using Weil osteotomies.

The great toe proximal phalanx osteotomy: the final step of the bunionectomy.

As the final step of correction of hallux valgus deformity, the great toe proximal phalanx osteotomy is useful. It is popular in France and throughout Europe. Our purpose is to distinguish and to describe different locations and three types of osteotomies according to the required final correction of the hallux valgus.