Recurrence rates with long-term follow-up after hallux valgus surgical treatment using shaft metatarsal osteotomies: a systematic review and meta-analysis.

Purpose: Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to synthesize and critically appraise the literature on the long-term outcomes of shaft osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess the long-term HV recurrence rates of studies with a minimum follow-up of 5 years. Methods: This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of shaft osteotomies of the M1 for non-inflammatory and non-degenerative HV having a minimum follow-up of 5 years were included. We found five eligible studies comprising six datasets, all assessed Scarf osteotomies with a mean follow-up that ranged from 8 to 14 years. Results: The HV recurrence rate was 40%, considering the threshold of >15° hallux valgus angle (HVA), 30% having >20°, and 2% having >25°. Conclusion: At a minimum follow-up of 8 years following shaft osteotomies of M1, the HVA was 15.9°, the intermetatarsal angle (IMA) was 7.7°, and the DMAA was 8.3°. Furthermore, the recurrence rates considering the various thresholds of HVA were: 40% having >15°, 20% having >20°, and 2% having >25°. Level of Evidence: Meta-analysis, Level IV.

Correction of progressive collapsing foot deformity classes after isolated arthroscopic subtalar arthrodesis.

INTRODUCTION: Subtalar osteoarthritis in the context of flatfoot (recently renamed Progressive Collapsing Foot Deformity (PCFD)) may be treated through subtalar joint (SJ) arthrodesis with anticipated consequences on three-dimensional bony configuration. This study investigates the correction of PCFD-related deformities achieved after Anterolateral Arthroscopic Subtalar Arthrodesis (ALAPSTA). METHODS: In this retrospective study, we evaluated pre- and post-operative (at 6 months) weight bearing computed tomography (WBCT) images of patients diagnosed with PCFD with a degenerated SJ (2 A according to PCFD classification) and/or peritalar subluxation (2D) with or without associated flexible midfoot and/or forefoot deformities (1B, 1 C and 1E) which underwent ALAPSTA as a standalone procedure between 2017 and 2020. Multiple measurements were used to assess and compare pre and post-operative PCFD classes. RESULTS: Thirtythree PCFD (33 patients, median age 62) were included in the study. Preoperative medial facet subluxation was 28.3 % (IQR, 15.1 to 49.3 %). Overall PCFD 3D deformity improved with a reduction of the foot and ankle offset from 9.3 points (IQR, 7.8 to 12) to 4 (IQR, 0.9 to 7) (p < 0.001). Class A-hindfoot valgus (median tibiocalcaneal angle and median calcaneal moment arm improved by 9.4 degrees (p < 0.001) and 11 mm (p < 0.001), respectively), class B-midfoot abduction (median talonavicular coverage angle improved by 20.5 degrees, p < 0.001) and class C-forefoot varus (median sagittal talo-first metatarsal angle improved by 10.2 degrees (p < 0.001)) were significantly corrected after surgery. Class D was difficult to assess due to the fusion procedure. No patient had a pre-operative valgus deformity at the ankle (no class E), and no significant change of the talar tilt was observed (p = 0.12). CONCLUSION: In this series, ALAPSTA performed as a standalone procedure to treat patients diagnosed with PCFD with a degenerated subtalar joint and/or peritalar subluxation was effective not only at correcting hindfoot alignment but also flexible midfoot abduction and flexible forefoot varus. LEVEL OF EVIDENCE: Level IV, case series.

Spontaneous Reduction in the Intermetatarsal Angle in Distal First Metatarsal Osteotomies with No Lateral Head Displacement in Hallux Valgus.

BACKGROUND: The outcomes of first metatarsal (M1) distal osteotomies in hallux valgus (HV) can be improved, especially for intermetatarsal angle (IMA) correction, which is mainly based on lateral displacement of the M1 head (i.e., translation) through the osteotomy. Conversely, there is a spontaneous reduction in the IMA in first metatarsophalangeal joint (MTP1) arthrodesis. But we do not know whether this can be applied to distal osteotomies. We propose a distal osteotomy, called 3D chevron, which combines supination and varization of the M1 head. This might realign soft tissues around the MTP1, potentially leading to a spontaneous reduction in the IMA by an analogous mechanism to MTP1 fusion. Therefore, our study aimed to assess whether spontaneous reductions in IMAs exist in distal M1 osteotomies in the absence of lateral translations of M1 heads. METHODS: A prospective continuous series of 25 3D chevrons was performed. Two groups were formed during surgery. Patients requiring no M1 head lateral displacement were included in the "successful correction without translation" group, and patients requiring M1 head lateral displacement were included in the "failed correction without translation" group. Radiographic analysis was performed preoperatively and at 1 year postoperatively. RESULTS: Twenty-two women and three men, with a mean age of 44.8 ± 14.2 years and a mean body mass index of 22.6 ± 4.1 kg/m2, underwent follow-up at one year after surgery. The "successful correction without translation" group was composed of HV with milder deformities (13/25 HVs, median preoperative IMA = 13 (IQR 2)) compared to the "failed correction without translation" group (median IMA = 16 (IQR 2.25) p < 0.001). Spontaneous reductions in IMAs were observed in the "successful correction without translation" group, with a median decrease in the IMA of 6 degrees (CI95%[5.5; 8.0]; p < 0.001) between preoperative and 1-year radiographs. CONCLUSION: Distal osteotomies allow for spontaneous reduction in the IMA in HV. First metatarsal head translation through an osteotomy should not be considered as the only procedure to correct IMAs in distal osteotomies.

Risk Factors for Midfoot Arthritis Associated With Medical History by Weight Bearing Computed Tomography.

Tarso-metatarsal joints and naviculocuneiform joints comprising midfoot is the second most commonly involved joints following the first metatarsophalangeal joint in the foot. However, related factors of midfoot arthritis (MA) have been rarely reported. The bony structure and alignment can be more precisely assessed using Weight-Bearing Computed Tomography (WBCT) than conventional radiographs. Therefore, the aim of this study was to investigate risk factors for MA related to medical history and comorbid foot deformities using WBCT. WBCT data from September 2014 to April 2022 were extracted from a single referral hospital. All cases were divided into two groups by the presence of MA. Twenty-five potential related factors including demographics, etiology, and common co-occurring foot deformities were collected for comparison. Six hundred six cases (247 males and 359 females) among consecutive 1316 cases between September 2014 to April 2022 were selected. One hundred thirty-nine male cases (56.3%) and 210 female cases (58.5%) showed MA. In stepwise multiple logistic regression analysis, 5 factors remained statistically significant. The multivariate-adjusted odds ratios for age, laterality, body mass index (BMI), Progressive Collapsing Foot Deformity (PCFD), and lesser toe deformities (LTD) were 1.08, 1.54, 1.05, 6.62, and 3.03 respectively. Risk factors for MA associated with medical history and foot deformities included age, laterality, BMI, PCFD, and LDT.

Proximal row carpectomy versus four-corner arthrodesis: a retrospective comparative study.

BACKGROUND: Four-corner arthrodesis with scaphoid excision (FCA) and proximal row carpal resection (PRC) are frequently performed in wrists with post-traumatic Scaphoid Non- Union Advanced Collapse (SNAC)/Scapho-Lunate Advanced Collapse (SLAC) osteoarthritis. The aim of this study was to compare the clinical outcomes of these two procedures. METHODS: This single-center, retrospective cohort study included all patients who had PRC or FCA between January 1st, 2009 and January 1st, 2019 and who were followed up. Follow-up included: mobility (radial deviation, ulnar deviation, flexion, extension), strength (grip test, pinch test), function (QuickDash, patient-rated wrist evaluation [PRWE]), subjective mobility, and global satisfaction scores. RESULTS: Among 25 patients included, 11 had PRC and 14 had FCA with a mean follow-up of 69.5 months [12-132]. Radial deviation was 18° versus 14° (p = 0.7), ulnar deviation was 21° versus 22° (p = 0.15), flexion was 39° versus 30° (p = 0.32), extension was 32.5° versus 29.5° (p = 0.09), grip test compared to the controlateral side was 72% versus 62% (p = 0.53), Quick Dash score was 12.5 versus 17.6 (p = 0.84), PRWE was 18.7 versus 17.6 (p = 0.38), subjective mobility was 7.8 versus 7.5 (p = 0.23), and satisfaction score was 8.7 versus 9 (p = 0.76), respectively, in the FCA group and the PRC group. Re-operation rates were 14% patients in the FCA group and 0% in the PRC group. CONCLUSION: This study found no significant difference between FCA and PRC on strength, mobility, and function in patients with post-traumatic SLAC or SNAC stage II wrist arthritis. Both FCA and PRC seem to be reliable surgical techniques with good outcomes with more revision in the FCA group.

Ultrasound identification of hand and wrist anatomical structures by hand surgeons new to ultrasonographic techniques.

PURPOSE: Ultrasound is becoming an essential tool for hand surgeons, but most of them are trained on the job, without any diploma or dedicated training. The aim of this study was to assess the ability of hand surgeons new to ultrasound to identify hand and wrist anatomical structures. METHODS: A monocentric study was conducted from January 2022 to April 2022. Ten residents and five attending hand surgeons, ultrasound novices, were involved in this study. The participants underwent two tests, wherein they were required to identify 17 anatomical structures using ultrasound, on the same subject. The second test was similar and carried out 2 to 6 weeks later by all participants. The number of structures successfully identified and if it was the case, the detection time per structure, were recorded. The correlations between participants age, years of surgical experience, surgical background (orthopedic or plastic) and the ability to perform immediately during the first test or to progress between the two tests were also assessed. RESULTS: The average number of structures identified during the first test (T1) was 14.1+/-2.1 (82.9%), versus 16.2+/-0.8 (95.3%) structures during the second test (T2) (p = 0.001). The mean detection time per structure was 53.4 +/- 18.9 s during T1 versus 27.7 +/- 7.2 s during T2 (p < 0.0001). A moderate negative correlation between the progression in the number of anatomical structures identified between the two tests and the years of surgical experience (ρ=-0.56; p = 0.029) was found. The other parameters were neither correlated with the ability to perform at the first test nor with the progression between the two tests. CONCLUSION: Hand surgeons new to ultrasound are most of the time able to identify hand and wrist anatomical structures. Comparison of their first and second tests showed significant potential for improvement in anatomical structure identification and detection time of those, especially in surgeons with limited surgical experience.

Prevalence of midfoot arthritis and lesser toe deformities.

BACKGROUND: The aim of this study was to investigate the epidemiology of Midfoot Arthritis (MA) and Lesser toe deformity (LTD) using Weight-Bearing Computed Tomography (WBCT). METHODS: 606 cases (247 male, 359 female) among 1316 consecutive cases with WBCT data from September 2014 to April 2022 were retrospectively reviewed at a single referral institution. The Cochran-Armitage test was performed to evaluate the trend of prevalence with respect to age group and obesity classification. RESULTS: 139 male (56.3%) and 210 female cases (58.5%) showed MA. 157 male (63.6%) and 222 female cases (61.6%) showed LTD. 115 male (19.0%) and 157 female cases (25.9%) showed both MA and LTD. The prevalence of MA and LTD increased with age in both genders. The incidence of MA in males showed an increasing tendency until obesity class II and then was slightly decreased in obesity class III. This is contrary to females whose prevalence increased with increasing obesity groups. LTD had a similar pattern in both genders to obesity classification. CONCLUSIONS: The prevalence of MA and LTD increased with age and increasing obesity groups for both genders. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Distribution, prevalence, and impact on the metatarsosesamoid complex of first metatarsal pronation in hallux valgus.

BACKGROUND: Previous simulated weight-bearing CT (WBCT) studies classifying first metatarsal (M1) pronation suggested a high prevalence of M1 hyper-pronation in hallux valgus (HV). These findings have prompted a marked increase in M1 supination in HV surgical correction. No subsequent study confirms these M1 pronation values, and two recent WBCT investigations suggest lower normative M1 pronation values. The objectives of our WBCT study were to (1) determine M1 pronation distribution in HV, (2) define the hyperpronation prevalence compared to preexisting normative values, and (3) assess the relationship of M1 pronation to the metatarso-sesamoid complex. We hypothesized that the M1 head pronation distribution would be high in HV. METHODS: We retrospectively identified 88 consecutive feet with HV in our WBCT dataset and measured M1 pronation with the Metatarsal Pronation (MPA) and α angles. Similarly, using two previously published methods defining the pathologic pronation threshold, we assessed our cohort's M1 hyper-pronation prevalence, specifically (1) the upper value of the 95% confidence interval (CI95) and (2) adding two standard deviations at the mean normative value (2 SD). Sesamoid station (grading) was assessed on the coronal plane. RESULTS: The mean MPA was 11.4+/-7.4 degrees and the α angle was 16.2+/-7.4 degrees. According to the CI95 method, 69/88 HV (78.4%) were hyperpronated using the MPA, and 81/88 HV (92%) using the α angle. According to the 2 SD method, 17/88 HV (19.3%) were hyperpronated using the MPA, and 20/88 HV (22.7%) using the α angle. There was a significant difference in MPA among sesamoid gradings (p = 0.025), with a paradoxical decrease in MPA when metatarsosesamoid subluxation was increased. CONCLUSION: M1 head pronation distribution in HV was higher than in normative values, but threshold change demonstrated contradictory hyper-pronation prevalences (85% to 20%), calling into question the previously reported high prevalence of M1 hyper-pronation in HV. An increase in sesamoid subluxation was associated with a paradoxical decrease in M1 head pronation in our study. We suggest that a greater understanding of the impact of HV M1 pronation is warranted before routine M1 surgical supination is recommended for patients with HV. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Advantages of ultrasound identification of the distal insertion of the calcaneofibular ligament during ligament reconstructions.

INTRODUCTION: In lateral ankle instability, anatomical ligament reconstructions are generally performed using arthroscopy. The ligament graft is passed through the talar, fibular and calcaneal tunnels, reconstructing the anterior talofibular and calcaneofibular (CFL) bundles. However, the calcaneal insertion of the CFL needs to be performed in an extra-articular fashion, and cannot be carried out under arthroscopy, thus requiring specific anatomical landmarks. For obtaining these landmarks, methods based on radiography or surface anatomy have already been described but can only offer an approximate identification of the actual CFL anatomical insertion point. In contrast, an ultrasound technique allows direct visualization of the insertion point and of the sural nerve that may be injured during surgery. Our study aimed to assess the reliability and accuracy of ultrasound visualization when performing calcaneal insertion of the CFL with specific monitoring of the sural nerve. MATERIALS AND METHODS: Our anatomical study was carried out on 15 ankles available from a body donation program. Ultrasound identification of the sural nerve was obtained first with injection of dye. A needle was positioned at the level of the calcaneal insertion of the CFL. After dissection, in all the ankles, the dye was in contact with the sural nerve and the needle was located in the calcaneal insertion area of the CFL. The mean distance between the sural nerve and the needle was 4.8 mm (range 3-7 mm). DISCUSSION AND CONCLUSION: A pre- or intra-operative ultrasound technique is a simple and reliable means for obtaining anatomical landmarks when drilling the calcaneal tunnel for ligament reconstruction of the lateral plane of the ankle. This tunnel should preferably be drilled obliquely from the heel towards the subtalar joint (1 h-3 h direction on an ultrasound cross section), which preserves a maximum distance from the sural nerve for safety purposes, while allowing an accurate anatomical positioning of the osseous tunnel.

Are self-reported anthropometric data reliable enough to meet antibiotic prophylaxis guidelines in orthopedic surgery?

BACKGROUND: Surgical site infection is a serious complication in orthopedic surgery. The use of antibiotic prophylaxis (AP) combined with other prevention strategies has been shown to reduce this risk to 1% for hip arthroplasty and 2% for knee arthroplasty. The French Society of Anesthesia and Intensive Care Medicine (SFAR) recommends doubling the dose when the patient's weight is greater than or equal to 100 kg, and the body mass index (BMI) is greater than or equal to 35 kg/m2. Similarly, patients with a BMIgreater than40 kg/m2 orlesser than18 kg/m2 are ineligible for surgery in our hospital. Self-reported anthropometric measurements are commonly used in clinical practice to calculate BMI, but their validity has not been assessed in the orthopedic literature. Therefore, we conducted a study comparing self-reported with systematically measured values and observed the impact these differences may have on perioperative AP regimens and contra-indications to surgery. HYPOTHESIS: The hypothesis of our study was that self-reported anthropometric values differed from those measured during preoperative orthopedic consultations. MATERIALS AND METHODS: This single-center retrospective study with prospective data collection was conducted between October and November 2018. The patient-reported anthropometric data were first collected and then directly measured by an orthopedic nurse. Weight was measured with a precision of 500 g and height was measured with a precision of 1 cm. RESULTS: A total of 370 patients (259 women and 111 men) with a median age of 67 years (17-90) were enrolled. The data analysis found significant differences between the self-reported and measured height [166 cm (147-191) vs. 164 cm (141-191) (p<0.0001)], weight [72.9 kg (38-149) vs. 73.1 kg (36-140) (p<0.0005)] and BMI [26.3 (16.2-46.4) vs. 27 (16-48.2) (p<0.0001)]. Of these patients, 119 (32%) reported an accurate height, 137 (37%) an accurate weight, and 54 (15%) an accurate BMI. None of the patients had two accurate measurements. The maximum underestimation was 18 kg for weight, 9 cm for height, and 6.15 kg/m2 for BMI. The maximum overestimation was 28 kg for weight, 10 cm for height, and 7.2 kg/m2 for BMI. The verification of the anthropometric measurements identified another 17 patients who had contra-indications to surgery (12 with a BMI>40 kg/m2 and 5 with a BMI<18 kg/m2) and who would not have been detected based on the self-reported values. CONCLUSIONS: Although patients underestimated their weight and overestimated their height in our study, these had no impact on the perioperative AP regimens. However, this misreporting failed to detect potential contraindications to surgery. LEVEL OF EVIDENCE: IV; retrospective study with prospective data collection and no control group.

Recurrence Rates With Longer-Term Follow-up After Hallux Valgus Surgical Treatment With Distal Metatarsal Osteotomies: A Systematic Review and Meta-analysis.

BACKGROUND: Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to assess long-term outcomes of distal osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess HV recurrence rates reported in studies that had a minimum follow-up of 5 years. METHODS: This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of distal osteotomies of the M1 for noninflammatory and nondegenerative HV at a minimum follow-up of 5 years. RESULTS: We found 17 eligible studies comprising 18 data sets, reporting outcomes of 4 categories of osteotomies: Chevron, Mitchell, Bösch, and "others." The HV recurrence rate was 64% considering the threshold of >15 degrees hallux valgus angle (HVA), 10% having >20 degrees, and 5% having >25 degrees. CONCLUSION: At a minimum of 5 years following distal osteotomies of the M1, the mean weighted postoperative HVA was significantly higher for Mitchell osteotomies compared with the 3 other osteotomies reviewed. There were otherwise no significant differences in recurrence rates using the 3 HVA thresholds, or intermetatarsal angle among any of the surgical techniques reported in 2 or more studies. The pooled HV recurrence rates considering the various thresholds of HVA were as follows: 64% having >15 degrees, 10% having >20 degrees, and 5% having >25 degrees. The recurrence rates in the long term for all categories of surgical procedures suggest that better understanding of pathogenesis and prognosis of HV is required before modifying or introducing new surgical techniques. LEVEL OF EVIDENCE: Level IV, meta-analysis.

Prevalence and pattern of lateral impingements in the progressive collapsing foot deformity.

INTRODUCTION: The prevalence of lateral bony impingements [i.e., Sinus Tarsi (STI), Talo-Fibular (TFI) and Calcaneo-Fibular (CFI)] and their association with Peritalar Subluxation (PTS) have not been clearly established for progressive collapsing foot deformity (PCFD).This study aims to assess the prevalence of STI, TFI and CFI in PCFD, in addition to their association with PTS. We hypothesized that STI and TFI would be more prevalent than CFI. MATERIALS AND METHODS: Seventy-two continuous symptomatic PCFD cases were retrospectively reviewed. Weightbearing computed tomography (WBCT) was used to assess lateral impingements and classified as STI, TFI and CFI. PTS was assessed by the percent of uncovered and the incongruence angle of the middle facet, and the overall foot deformity was determined by the foot and ankle offset (FAO). Data were collected by two fellowship-trained independent observers. RESULTS: Intra-observer and inter-observer reliabilities for impingement assessment ranged from substantial to almost perfect. STI was present in 84.7%, TFI in 65.2% and CFI in 19.4%. PCFD with STI showed increased middle facet uncoverage (p = 0.0001) and FAO (p = 0.0008) compared to PCFD without STI. There were no differences in FAO and middle facet uncoverage in PCFD with TFI and without TFI. PCFD with CFI was associated with STI in 100% of cases. PCFD with CFI showed decreased middle facet incongruence (p = 0.04) and higher FAO (p = 0.006) compared to PCFD without CFI. CONCLUSIONS: STI and TFI were more prevalent than CFI in PCFD. However, only STI was associated with PTS. Conversely, CFI was associated with less PTS, suggesting a different pathological mechanism which could be a compensatory subtalar behavior caused by deep layer failure of the deltoid ligament and talar tilt.

Does metatarsus primus elevatus really exist in hallux rigidus? A weightbearing CT case-control study.

BACKGROUND: Elevated first metatarsal, Metatarsus primus elevatus (MPE), has been a topic of controversy. Recent studies have supported a significantly elevated first metatarsal in hallux rigidus on weight-bearing radiographs (WBR). However, conventional radiographs have limitations for accurate measurement. Our objective was to comparatively assess MPE and other variables which can affect the spatial relationship of the forefoot in the HR group compared to controls using weight-bearing CT (WBCT). METHODS: In this single-center, retrospective, case-control study, 25 patients (30 feet) with symptomatic HR and 30 controls were selected. WBCT parameters were measured by two independent investigators. Inter-observer reliabilities were assessed using intra-class correlation coefficients (ICCs). MPE was evaluated by measuring the direct distance between 1st and 2nd metatarsals. Independent t tests were performed to compare the two groups. A threshold of MPE to diagnose HR was calculated using the Receiver Operating Characteristic (ROC) curve. RESULTS: HR groups had increased hallux valgus angle (HVA) (8.52° in control vs 11.98° in HR) and MPE (2.92 vs 5.09 mm), decreased 1st metatarsal declination angle (21.09° vs 19.07°) 1st/2nd metatarsal declination ratio (87.45 vs 79.71) indicating elevated first metatarsal compared to controls. Dorsal translation of the first metatarsal at the first tarsometatarsal joint was observed in 21 (70%) patients of the HR group when defined as a step-off or discontinuation of the curvature along the first TMT joint. The threshold of MPE for diagnosis of HR was 4.19 mm with 77% sensitivity and 77% specificity. CONCLUSION: Our results confirmed a significantly elevated first metatarsal in the HR group compared to controls on WBCT. A MPE greater than 4.19 mm was found to be diagnostic for symptomatic HR. Significant number of patients in the HR group (70%) had dorsal translation of the first metatarsal at the first TMT joint which can contribute to increased MPE. CLINICAL RELEVANCE: The present study demonstrated significantly increased MPE in HR on WBCT and MPE greater than 4.19 mm on WBCT can be used as a diagnostic threshold for HR.

A comparison between the Bluman et al. and the progressive collapsing foot deformity classifications for flatfeet assessment.

INTRODUCTION: Bluman et al., flatfoot classification is based on posterior tibial tendon (PTT) dysfunction leading to a chronological appearance of several foot deformities. An expert consensus recently proposed a new classification named Progressive Collapsing Foot Deformity (PCFD) in which the focus was shifted to five different independent foot and ankle deformities and their flexibility or rigidity. The aim of this study was to compare Bluman and PCFD classifications. We hypothesize that both classifications will be reliable and that the PCFD classification will allow a larger distribution of the different types of foot deformity. MATERIALS AND METHODS: We performed a retrospective IRB-approved study including 92 flatfeet. Three foot and ankle surgeons reviewed patient files and radiographs to classify each foot using both classifications. Bluman classification was performed one time as initially described and a second time after removing the Angle of Gissane sclerosis sign. Interobserver reliabilities were determined with Fleiss' kappa values. RESULTS: Interobserver reliabilities of Bluman and PCFD classifications were, respectively, substantial 0.67 and moderate 0.55. PCFD Class C and D reliabilities were, respectively, slight 0.07 and fair 0.28. The 276 readings were spread into 10 substages in Bluman and 65 subclasses in PCFD. The progressivity of the Bluman classification prevented the combination of flexible hindfoot valgus (II Bluman, 1A PCFD), midfoot abduction (IIB, 1B) and medial column instability (IIC, 1C) which was frequent in our study (112/276 readings, 40.6%). By removing the Angle of Gissane sclerosis sign from the Bluman classification, the prevalence of stage III decreased from 44.2 to 10.1%. CONCLUSIONS: Bluman and PCFD classifications were reliable. The PCFD classification showed a larger distribution of different types of flatfeet but Classes C and D need better definition. The progressivity of Bluman classification causes inconsistencies and Gissane angle sclerosis sign is inappropriately used and might lead to incorrect surgical indications.

Fusion and clinical outcomes of lumbar interbody fusion for low-grade isthmic spondylolisthesis.

INTRODUCTION: Low-grade isthmic spondylolisthesis (ISPL) is generally treated by circumferential fusion with interbody graft, although there is no consensus on technique. HYPOTHESIS: The various interbody fusion strategies provide satisfactory fusion rates and clinical results. METHODS: A multicenter retrospective study analyzed lumbar interbody fusion for low-grade ISPL performed between March 2016 and March 2019. Techniques comprised: circumferential fusion on a posterior or a transforaminal approach (PLIF, TLIF: n=57), combined anterior (ALIF)+posterolateral fusion (ALIF+PLF: n=60), and ALIF+percutaneous posterior fixation (ALIF+PPF: n=55). Function was assessed on a lumbar and a radicular visual analog scale (AVS-L, VAS-R), Oswestry Disability Index (ODI) and Short Form 12 (SF12). RESULTS: Among the 129 patients, 85.3% showed fusion (Lenke 1 or 2), with no significant differences between the ALIF-PLF or ALIF-PPF groups and the PLIF or TLIF groups (p=0.3). Likewise, there was no difference in fusion rates between the ALIF-PPF and ALIF-PLF subgroups (p=0.28). VAS-L (p<0.001) and VAS-R (p<0.0001), ODI (p<0.001) and SF12 physical (PCS) (p<0.01) and mental component sores (MCS) (p<0.001) all showed significant improvement at 12months. Combined approaches provided greater clinical efficacy than TLIF or PLIF for lumbar (p<0.0001) and radicular pain (p<0.05), ODI (p<0.0001) and SF12 PCS (p<0.01). At 12months, there was no clinical difference between the ALIF-PPF and ALIF-PLF subgroups. However, patents with interbody non-union (Lenke 3 or 4) had lower SF12 PCS scores (p<0.004) and VAS-L ratings (p<0.001) than Lenke 1-2 patients. CONCLUSION: Low-grade ISPL treated by circumferential arthrodesis and interbody graft showed 85.3% consolidation at 2years, with equivalent outcomes between anterior and posterior techniques. Successful fusion was associated with better clinical results. LEVEL OF EVIDENCE: IV.

Early results and complication rate of the LapiCotton procedure in the treatment of medial longitudinal arch collapse: a prospective cohort study.

INTRODUCTION: Instability/collapse of the medial column has been associated with many conditions, particularly progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA). Restoration of first ray length and sagittal plane alignment to restore the foot tripod is essential when treating these deformities. This study aimed to assess early results, healing, and complication rate of a distraction dorsal opening plantarflexion wedge allograft first tarsometatarsal joint fusion (LapiCotton Procedure) in patients with collapse/instability of the medial column. METHODS: In this prospective cohort study, we included PCFD, HV, and MA patients that underwent a LapiCotton procedure. Fusion site healing was defined by > 50% bone bridging in both interfaces between allograft wedge and host bone using weight-bearing computed tomography (WBCT) after 3 months. First ray collapse radiographic correction and minor and major complications (deep dehiscence, deep infection, and reoperation) were assessed. RESULTS: A total of 22 patients (22 feet) were included (11 PCFD, 6 MA, and 5 of HV patients). Mean follow-up was 5.9 months (range 3-12) and median allograft size was 8 mm (range 5-19 mm). Bone healing was observed in 91% of cases. Two minor complications (9%, both superficial dehiscence) and one major complication (4.5%, deep infection) were observed. Statistically significant improvement of the sagittal plane talus-first metatarsal angle was observed, with mean improvement of 9.4° (95% CI 6.7-12.1°; p < 0.0001). CONCLUSION: In this prospective cohort study of 22 patients treated with the LapiCotton procedure for medial longitudinal arch collapse/instability, we observed a low complication rate (9% minor, 4.5% major), high healing rate after 3 months (91%), one clinically stable radiographic non-union (4.5%) and one unstable non-union (4.5%) needing reoperation. Our results demonstrate promising initial results for LapiCotton technique in treating collapse of the medial longitudinal arch in patients with PCFD, MA and HV deformities. Long-term results are needed to confirm these promising results. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Gait analysis after total hip arthroplasty by direct minimally invasive anterolateral approach: A controlled study.

INTRODUCTION: Clinical and functional improvement after minimally invasive total hip arthroplasty (THA) has become increasingly controversial. The minimally invasive anterolateral approach (MIALA) allows rapid recovery resulting in a reduced need for rehabilitation. Alterations in muscle and static balance have previously been demonstrated. Results in the context of quantified gait analysis (QGA) and MIALA compared to an asymptomatic population remain unknown beyond one year postoperatively. Thus, the main objective of this controlled study was to compare the spatiotemporal parameters of gait, obtained using a QGA, beyond one year postoperatively in subjects operated on for THA by MIALA, with a group of asymptomatic subjects of the same age. The secondary objectives of the study were to compare the other QGA and EMG data acquired in operated subjects with asymptomatic subjects. HYPOTHESIS: We hypothesized that QGA and EMG parameters would not normalize beyond one year postoperatively. PATIENTS AND METHODS: Thirty-one subjects were recruited, including 16 patients (68 years old; IQR: 65-70) who underwent MIALA, at 15.5 months postoperatively (IQR: 13-17) and 15 asymptomatic subjects (62 years old; IQR: 61-71). Subjects underwent QGA and maximal isometric muscle force tests on the gluteus medius, gluteus maximus, Tensor Fascia Lata (TFL) and Sartorius muscles. Spatiotemporal gait parameters were the primary endpoint. The other QGA parameters: kinetics (characteristic values of vertical ground reaction forces, peak hip moments) and kinematics (hip joint amplitudes and pelvic mobility in the frontal and sagittal plane) constituted the secondary criteria. RESULTS: Five subjects were excluded for unrestored offset. Walking speed was lower in operated patients (1.03m/s versus 1.18m/s, p=0.005). Maximal isometric muscle force moments were lower in patients operated on for the gluteus maximus and medius as well as the TFL (p<0.005). The vertical ground reaction forces were lower for the operated patients for the loading phase (FzFCmax, p=0.001), the single stance phase (FzSPmin, p=5.05.10-2) and the swing phase (FzTOmax, p=0.0002). The moments were lower in the sagittal plane for the operated patients (0.6N.m for the operated versus 1.1N.m for the asymptomatic, p=0.02). The pelvic amplitudes in the sagittal plane were lower for operated patients (3.3° versus 7.2°, p=0.05). DISCUSSION: Our hypothesis appears to be validated. Gait deficits persisted beyond one year postoperatively after THA with MIALA. A decrease in walking speed, maximal isometric muscle force of the gluteus medius and gluteus maximus and TFL was observed, as well as a decrease in propulsive force and peak hip moment. Functionally, these results could signify muscle damage following surgery, requiring rehabilitation for improved muscle function. LEVEL OF PROOF: III: Non-randomized controlled trial.

Soft tissue sarcomas of the buttock: A systematic review and meta-analysis.

BACKGROUND: Soft tissue sarcomas of the buttock (BSTS) are historically associated with a poor prognosis. The literature includes retrospective studies with small sample size. It is difficult to estimate the rate of local recurrence (LR), distant metastasis (DM) and overall survival (OS). A systematic review and meta-analysis was deployed to summarize the available information on BSTS patients that underwent surgical treatment. METHODS: The PubMed, EMBASE, Scopus and Google Scholar databases were reviewed for eligible studies following PRISMA guidelines. INCLUSION CRITERIA: (1) primary BSTS confirmed by pathological biopsy (2) indication for surgical treatment (3) reporting either the rate of LR, DM, or OS at 5-year (4) articles published up to December 2021 (5) english language. The Methodological Index for Non-Randomized Studies (MINORS) was applied for the quality appraisal. RESULTS: Six eligible studies with 216 BSTS patients were identified. Most patients underwent surgical resection, associated with radiation therapy. The most represented histological types were liposarcoma (n = 43, 19,9%), rhabdomyosarcoma (n = 27, 12.5%), and undifferentiated pleomorphic sarcoma (n = 23, 10.6%). High-grade tumor rates ranged from 37% to 88.2%, marginal resection rates from 20.3% to 50%, LR rates from 0% to 62.5%, DM rates from 37.5% to 62.5%. The pooled 5-year OS from 1941 to 2002 was 41% (IC95%: 33%-49%). The average MINORS score was 9.3 (range: 6 to 11). CONCLUSIONS: Surgical resection of BSTS had on average dissatisfactory outcomes, and the 5-year overall survival was poor, with high rates of local recurrence and distant metastasis. An effort to collect new data with a higher level of evidence is warranted.

Patients' point of view on the long-term results of total ankle arthroplasty, tibiotalar and tibiotalocalcaneal arthrodeses.

INTRODUCTION: Total ankle arthroplasty (TAA), tibiotalar (TT) arthrodesis and tibiotalocalcaneal (TTC) arthrodesis are common surgical procedures that are sometimes concurrent. The functional results of TTC are deemed to be inferior because of the double joint sacrifice. Patient-Reported Outcome Measures (PROMs), as well as satisfaction scores, are commonly used to assess the outcome of these surgeries, but lack at capturing patients' ability to cope with potential functional limitations. The objective of our study was to compare the results of TAA, TT and TTC arthrodeses according to patients' point of view. We proposed two hypotheses: 1) TAA confer better results than TT arthrodeses, 2) and TT arthrodeses confer better results than TTC arthrodeses, on this specific criterion. MATERIAL AND METHODS: We carried out a retrospective study integrating all TAA, TT and TTC arthrodeses performed in our center from 2010 to 2017. These surgeries were compared using PROMs (Foot Function Index (FFI), Foot and Ankle Outcome Scale (FAOS) and 12-Item Short Form Survey (SF-12)), a satisfaction rating and self-reported perceived recovery state. RESULTS: Fifty-one patients were included in the TAA group, 50 in the TT group and 51 in the TTC group. The mean duration of follow-up was 46±20.8 months. The TAA group had better results than the TT group regarding the FFI score and satisfaction, thus confirming our primary hypothesis. On the other hand, no significant difference was found between the TT group and the TTC group, which invalidated our secondary hypothesis. No significant difference between the groups was found regarding the distribution of patients' perceived recovery state. CONCLUSION: Our hypothesis was not confirmed. In fact, TAAs, TT and TTC arthrodeses presented substantially similar results. Although it is difficult to compare surgeries with different indications, it is surprising to find that the patients' perceived recovery state, deviating from the usual clinical and radiological results, are relatively similar. LEVEL OF EVIDENCE: IV; Retrospective study.

Comparative MRI assessment of three minimally invasive approaches in total hip arthroplasty.

INTRODUCTION: Minimally invasive approaches (direct anterior approach: DAA; minimally invasive anterolateral: MIAL; piriformis-sparing posterior approach: PSPA) are widely used for total hip arthroplasty (THA), with a muscle-sparing objective. There are no published comparative studies of muscle damage secondary to these approaches. The aim of the present study was to compare fatty infiltration (FI) on MRI induced by DAA, MIAL and PSPA in THA 1) in the tensor fasciae latae (TFL) and sartorius muscles, 2) in the gluteal muscles, and 3) in the pelvitrochanteric muscles. HYPOTHESIS: Greater FI is induced by DAA in anterior muscles, by MIAL in gluteal muscles and by PSPA in pelvitrochanteric muscles. MATERIALS AND METHODS: Three continuous prospective series of THA by DAA, MIAL and PSPA included 25 patients each. MRI was performed preoperatively and at 1 year postoperatively. FI was graded on the Goutallier classification in all periarticular hip muscles. Muscles showing ≥2 grade aggravation at 1 year were considered damaged. RESULTS: Nine patients whose preoperative MRI was uninterpretable were excluded. In all, 66 patients (21 DAA, 24 MIAL and 21 PSPA) with 132 MRI scans were analyzed. TFL was damaged in 2/21 DAA patients (9.5%), 1/24 MIAL patients (4.2%) and 0/21 PSPA patients (0%). There were no sartorius lesions. The anterior third of the gluteus medius was damaged in 8/24 MIAL patients (33.3%) and the gluteus minimus in 10/24 (41.7%), compared to 1/21 DAA patients (4.8%) and 0/21 PSPA patients (0%). The mid and posterior thirds of the gluteus medius and the gluteus maximus were never damaged. The piriformis muscle was damaged in 3/21 DAA patients (14.3%), 2/24 MIAL patients (8.3%) and 2/21 PSPA patients (9.5%). The obturator internus was damaged in 4/21 DAA patients (19%), 1/24 MIAL patients (4.2%) and 16/21 PSPA patients (76.2%). The obturator externus and quadratus femoris were mainly damaged in PSPA patients: respectively, 5/21 (23.8%) and 4/21 patients (19%)). CONCLUSION: The muscle-sparing properties of minimally invasive hip approaches are only theoretical. In the present series, there were rare TFL lesions with DAA and MIAL. Gluteus medius and minimus lesions were frequent in MIAL. Pelvitrochanteric muscles lesions were more frequent in PSPA, but found in all 3 approaches. These findings should help guide surgeons in their choice of approach and in informing patients about the damage these minimally invasive approaches can cause. LEVEL OF EVIDENCE: III, prospective comparative study.