Surgical Excision of Intractable Plantar Keratoses (Corns) of the Foot: A Scoping Review.

BACKGROUND: Hyperkeratosis is a hypertrophic thickening of the skin. A callus (tyloma) is considered diffuse thickening, whereas a corn-also known as a clavus, heloma durum, or intractable plantar hyperkeratosis (IPK)-is a more focal, circumscribed hyperkeratotic lesion with a central conical core of keratin. Treatment (including surgical excision) of plantar keratoses is often sought because of pain and discomfort. The aim of this study was to collect and chart data regarding the surgical excision of plantar corns. The emerging themes were then mapped so that suggestions for areas of future research could be made. METHODS: A scoping review of the literature was performed using the six-stage methodologic framework (minus stage 6) proposed by Arksey and O'Malley incorporating the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews reporting guideline. A database search by means of the United Kingdom National Health Service Care Advanced Database Search yielded 1,056 articles, 12 of which appeared to be of potential relevance. After removing five duplicate articles, this total was reduced to seven, which were retrieved as full texts. Three were excluded. Thirteen further articles were found through Google Scholar and reference lists from the full texts retrieved to give 17 articles for review. One was discounted as not being in English/irrelevant; and one article did not relate to IPK excision, leaving 15 articles for data extraction. RESULTS: Iterative charting of the included articles yielded overlapping codes and two main themes. The first theme was closure: by primary intention (with or without a skin flap) or by secondary intention. The second theme was whether excision was performed in combination with IPK excision with other (bony) surgery. CONCLUSIONS: There is modest evidence that excision of the lesion with either primary closure or healing by means of secondary intention can be useful for the management of IPKs. A further consideration is an emerging hypothesis that many of these IPKs are viral in origin, rather than mechanical, which implies that prospective studies are required with cross-reference to lesion excision by anatomical site and histopathologic confirmation of the diagnosis.

Outcome after resection arthroplasty or shortening oblique osteotomy of the lesser metatarsals combined with arthrodesis of the first metatarsophalangeal joint for severe rheumatoid forefoot deformities.

PURPOSE: We investigated objective and patient-reported outcomes after resection arthroplasty or shortening oblique osteotomy (SOO) of the lesser metatarsals combined with arthrodesis of the first metatarsophalangeal (MTP) joint for severe rheumatoid forefoot deformities. METHODS: 17 feet from 14 women (mean age, 67.8 years) underwent resection arthroplasty of the lesser metatarsal heads (MTH resection group), while 13 feet from nine women and two men (mean age, 68.7 years) underwent SOO of the lesser metatarsals (MTH preservation group). Arthrodesis of the first MTP joint was performed in all cases. Mean follow-up in the MTH resection and preservation groups was 25.0 and 21.3 months, respectively. Preoperative and postoperative clinical evaluation included Japanese Society for Surgery of the Foot (JSSF) scale and self-administered foot evaluation questionnaire (SAFE-Q) scores. RESULTS: Mean total JSSF scale significantly improved from 53.4 to 76.4 in the MTH resection group (p < .001) and from 50.1 to 74.2 in the MTH preservation group (p = .002). Pain and pain-related and shoe-related SAFE-Q subscale scores significantly improved after surgery in both groups. In the MTH resection group, recurrence of painful callosities and claw toe deformity was observed in four and three feet, respectively. In the MTH preservation group, one patient experienced recurrence of painful callosities and one underwent revision surgery for IP joint dislocation. CONCLUSION: Resection arthroplasty or SOO of the lesser metatarsals combined with arthrodesis of the first MTP joint achieved significant improvement with respect to pain relief, deformity correction, and footwear comfort.

Effectiveness of Three Scalpel Debridement Techniques on Painful Callus in Older People.

BACKGROUND: Plantar hyperkeratotic lesions are prevalent foot problems in the older population, affecting 30% to 65% of people older than 65 years. Their onset is a common cause of foot pain due to the release of inflammatory mediators. Because of its simplicity, scalpel debridement is the most common treatment. We assessed how the degree of plantar hyperkeratosis debridement affects self-perception of pain in older people. METHODS: Three hundred older participants (mean ± SD age, 76.3 ± 7.4 years) were randomly allocated to receive full debridement (FD) of plantar hyperkeratoses, partial debridement (PD) of plantar hyperkeratoses, or debridement simulation (control group). Plantar hyperkeratotic pain was measured on a visual analog scale before treatment, just after treatment, 24 hours after treatment, and 7 days after treatment. RESULTS: Both FD and PD of plantar hyperkeratoses of the forefoot generate similar levels of self-perception of pain just after treatment (P = .32), 24 hours after treatment (P = .15), and 7 days after treatment (P = .22). Significant differences were found between the groups treated using a scalpel (FD and PD) and the control group just after treatment (P = .04 for FD; P = .05 for PD), 24 hours after treatment (P = .03 for FD; P = .04 for PD), and 7 days after treatment (P = .04 for FD and PD). CONCLUSIONS: The results of this trial suggest that there are no significant differences in pain reduction between PD and FD of forefoot plantar hyperkeratoses in older people.

The plantarward oblique Chevron osteotomy: an optional method to treat hallux valgus with painful plantar callosities.

Hallux valgus (HV) is a foot deformity that can be treated with Chevron osteotomy, and a modified plantarward oblique osteotomy has been proposed in recent years. However, no research has focused on the correctional power of the osteotomy. The aim of this study was to examine the character of this plantarward oblique Chevron osteotomy (POCO) and to determine the rationale of this method.Radiographs and clinical data from 65 HV patients (77 feet) with painful callosities were evaluated. The intermetatarsal angle, hallux valgus angle, and relative height of the second metatarsal were measured, and a valid width of the first metatarsal was proposed. A visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society hallux-metatarsophalangeal interphalangeal scale (AOFAS) were used to evaluate the patients' clinical results.There were significant differences in the HVA and IMA. The decline in the height of the second metatarsal was positively related to the decline in the height of the first metatarsal, but the changes were smaller for the first metatarsal. Painful callosities disappeared in 77 feet, 4 (5.1%) patients had no pain but a remaining plantar callosity, and 2 (2.6%) patient had relieved pain with a plantar callosity after follow-up. The VAS scores improved from 8.58 ± 0.50 to 1.96 ± 0.75 points after the operation (p < 0.001). Significant differences were demonstrated in the AOFAS scores (65.81 ± 4.05 vs 87.88 ± 3.41, p < 0.001). The modified POCO prevents the dorsal migration of the metatarsal head, preserves other lesser metatarsals and provides an opportunity for patients who may possibly need additional future deformity correction. Therefore, POCO is a safe and effective method to treat hallux valgus and offers the superior potential benefits of correction and transfer metatarsalgia.

Description of the surgical technique for condylectomy with minimally invasive surgery to treat interdigital helomas on the lesser toes: a Delphi study.

BACKGROUND: Descriptions of the techniques for condylectomies via minimally invasive surgery (MIS) to treat interdigital helomas of the lesser toes are scarce in the literature. This study aimed to define and describe this surgical technique. METHODS: This observational study was performed using the Delphi method. We collected the anonymous opinions of a multidisciplinary international panel of ten experts by answering a 43-items questionnaire via e-mail. Statements with an average score ≥ 3 were included in the next round, as were those in which none of the three statements reached the minimum score of 3 within the same item. RESULTS: Response rate: 90%. Three rounds were needed to reach consensus on proposed items. A new statement that combined two statements was proposed in round 3. Eleven recommendations regarding the incision and instruments used to perform this surgical technique were obtained based on the expert consensus. CONCLUSIONS: A longitudinal incision to the distal pulp of the toe or an incision to the centre of the plantar aspect of the head of the proximal phalanx should be performed according to the affectation, and a Beaver 64 scalpel blade, a blunt elevator and a Shannon-Isham burr are the most acceptable tools for this kind of surgery.

Successful Treatment of Plantar Hyperkeratosis in the Form of Recurrent Corns With Split-Thickness Sole Skin Graft.

INTRODUCTION: Plantar hyperkeratosis, such as corns and calluses, is common in older people and associated with pain, mobility impairment, and functional limitations. It usually develops on the palms, knees, or soles of feet, especially under the heels or balls. There are several treatment methods for plantar hyperkeratosis, such as salicylic acid plaster and scalpel debridement, and conservative modalities, such as using a shoe insert and properly fitting shoes. METHODS: We present an effective method of reconstructing the wound after corn excision using a split-thickness sole skin graft (STSSG). We harvested the skin graft from the arch of the sole using the dermatome with a skin thickness of 14/1000th inches. RESULTS: Because the split-thickness skin graft, harvested from the sole arch near the distal sole, is much thicker than the split-thickness skin graft from the thigh, it is more resistant to weight and friction. The healed wound with STSSG coverage over the distal sole was intact, and the donor site over the sole arch had healed without complication during the outpatient follow-up, 3 months after surgery. CONCLUSIONS: The recovery time of STSSG for corn excision is shorter than that with traditional treatment. Therefore, STSSG can be a reliable alternative treatment for recurrent palmoplantar hyperkeratosis.

Short-term effect of scalpel debridement of plantar callosities versus treatment with salicylic acid patches: The EMEDESCA randomized controlled trial.

This study compares scalpel debridement versus salicylic acid patches in the treatment of plantar callosities. A randomized clinical trial (ACTRN12614000591651) was performed with 62 patients, divided into two intervention groups. Group A received treatment with salicylic acid patches (Callívoro Marthand® ) and group B underwent scalpel debridement of plantar callosities. Pain was measured on a visual analog scale, and foot pain and disability were evaluated using the Manchester Foot Pain Disability Index (MFPDI) questionnaire (Spanish version). Significant differences were observed in pain measured immediately after treatment (P < 0.001) and at 15 days and 6 weeks after treatment. For some components, the MFPDI questionnaire revealed significantly better outcomes by scalpel debridement at 15 days after treatment. The scalpel debridement of plantar callosities relieves pain more effectively than salicylic acid patches, and patients achieve greater functionality in the initial weeks after debridement.

Analysis of a trial assessing the long-term effectiveness of salicylic acid plasters compared with scalpel debridement in facilitating corn resolution in patients with multiple corns.

This study assesses the effect of salicylic acid plasters on the time to resolution of 324 corns experienced by 201 participants taking part in a randomized controlled trial. While the rate of corn resolution was substantively higher in the treatment group than in the control group, treatment was found to be not significantly related to time to corn recurrence when analyzed over the full 12-month follow-up period. Parametric survival analysis modeling of interval-censored data and incorporating patient-specific frailty terms was utilized, to model correlation of corns within patients (hazard ratio [HR], 1.189; 95% confidence interval [CI], 0.780-1.813; P = 0.422). Median resolution times were 10.0 months for corns in the treatment group and 13.4 months for corns in the control group. Controlling for treatment, corn type was found to be related to resolution time, with dorsal/interdigital (ID) corns showing better resolution than plantar corns (HR, 1.670; 95% CI, 1.061-2.630; P = 0.027). Median resolution times were 5.9 months for dorsal/ID corns and 14.9 months for plantar corns. Secondary measures relating to quality of life (QoL) and foot-related disability, using the EQ-5D questionnaire and the Manchester Foot Pain and Disability Index (MFPDI), were also assessed at the patient level in multivariate models. Treatment was not significantly related to any of these measures over the whole period of analysis. However, a trend analysis revealed a quadratic trend in QoL and MFPDI scores, arising from a substantive initial improvement between baseline and 3 months, followed by a gradual decrease between 3 and 12 months.

Changes in the parameters of gait after a mechanical debridement of a plantar callosities.

INTRODUCTION: Plantar callosities are a common cause of pain in the forefoot and also a cause of alterations in plantar pressure. Mechanical debridement with a scalpel can relieve pain and increase functional capacity. OBJECTIVE: The aim of the study was to analyse if debridement of plantar callosities and corns modify walking. METHODS: Thirty four patients with plantar foot pain due to callosities and corns, and up to 5 in the visual analogical scale (VAS) of pain, (20 women, age 29 ± 11.57 years) were analysed by taking into account the changes of their gait. The outcome measurement was the VAS scale and the Win-track system, cycle of the gait(milliseconds), angle(degrees), cadence(number/minutes) and step(centimetres) were measured, 24 h before and after the debridement with a scalpel. RESULTS: There were significant differences in foot pain (mean 67.7, p < 0.001) but there were no significant differences in measures of gait variables before the debridement of the callosities, and 24 h after the procedure, being all those above 0.05. CONCLUSIONS: Our study shows that the debridement with scalpel does not change the variables of the gait 24 h after the procedure.

A novel modification of the Stainsby procedure: surgical technique and clinical outcome.

BACKGROUND: The 'Stainsby procedure' is an effective salvage procedure for correction of fixed claw toe deformity. A novel approach is described involving the extensor tenotomy step of the procedure, which is easier, faster and safer to perform. METHODS: A retrospective single surgeon review was performed to assess this modification. 37 patients (92 lesser toes in 42 feet) underwent the modified Stainsby procedure. Mean follow-up was 17 months. Patients were interviewed and examined at a dedicated review clinic. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores and Foot and Ankle Outcome (FAO) scores were calculated. RESULTS: Significant improvements in end-points including metatarsalgia, callosity and requirement for insoles or chiropody were noted. Median AOFAS and FAOS scores following the modified Stainsby procedure are reported and compare favourably to previously reported scores. Median FAOS scores were as follows: 92 for the category of pain, 84 for symptoms and stiffness, 96 for activities of daily living, 100 for sports and recreation and 81 for quality of life. Median AOFAS forefoot score was 80. There was a low rate of wound infection of 2.7% (n=1). CONCLUSION: We describe a novel technical modification to the Stainsby procedure and our results support the use of this modification, following assessment of patient outcome. However, limitations to this study were noted in terms of the length of follow-up, the absence of pre-operative clinical scores for comparative purposes, and the variety of surgical procedures performed concomitantly on the 1st ray.

Efficacy of intralesional bleomycin for the treatment of plantar hard corns.

BACKGROUND: Intralesional bleomycin is effective for the treatment of various dermatologic conditions. However, the efficacy of intralesional bleomycin for the treatment of corns has not been established. METHODS: A total of 50 patients with plantar corns were recruited and equally divided between groups A and B. Groups A and B were then treated with intralesional bleomycin (1 mg/ml) after paring the hyperkeratotic tissue and simple paring, respectively. The patients visited our clinic at 3-week intervals and were treated for a maximum of 10 sessions. RESULTS: Patients in groups A and B were treated for 35 and 29 corns, respectively. The curative rates of the patients in groups A and B were 37% (13 of 35) and 7% (three of 29), respectively. The proportions of lesions in groups A and B that demonstrated a decrease in size by >50% were 80% (28 of 35) and 38% (11 of 29), respectively. The total number of patients that demonstrated excellent symptomatic improvement in group A was 15 of 22. Excellent responses were achieved within a small number of treatment sessions, ranging from one to four sessions (average: 2.6). Statistical differences in terms of the degree of size reduction and pain relief were noted between the two groups. CONCLUSIONS: This study provides evidence that intralesional bleomycin (1 mg/ml) injection could be one of the ideal treatments for corn. Intralesional bleomycin is particularly useful for reducing lesional pain and size within a short period.

Abordagem cirúrgica de faixas constritivas em Síndrome de Vohwinkel / Surgical correction of constrictive bands in Vohwinkel syndrome

A Síndrome de Vohwinkel ou ceratodermia hereditária mutilante é uma ceratodermia palmoplantar rara, que se manifesta na infância e se torna mais evidente nas fases de adolescência e idade adulta. Doença de herança preferencialmente autossômica dominante, acomete mais mulheres e caucasianos. A hiperceratose palmoplantar difusa, com aparência de favo de mel; as faixas constritivas digitais conhecidas como pseudoainhum, e as placas ceratósicas em forma de estrela-do-mar no dorso de mãos e pés, podendo acometer cotovelos e joelhos, são os achados clínicos característicos da Síndrome. O presente trabalho trata de um relato de caso de uma paciente com Síndrome de Vohwinkel e a terapêutica cirúrgica realizada nas faixas constritivas.

Vohwinkel syndrome, also known as hereditary mutilating keratoderma, is a rare palmoplantar keratoderma that manifests in childhood and becomes more evident in adolescence and adulthood. This preferential autosomal dominant disease affects more women and Caucasians. Its clinical features are diffuse palmoplantar keratoderma with the appearance of honeycomblike constricting rings in the fingers and toes known as pseudo-ainhum, and starfish-shaped keratotic plaques on the dorsal aspect of the hands and feet that can affect the elbows and knees. The present report describes a case report of a patient with Vohwinkel syndrome and surgical correction of the constrictive bands.

Subungual corn: a tender pigmented subungual lesion in older people.

BACKGROUND: Heloma durum occurs as a tender mass in the distal nail bed beneath the big toenail in older women. OBJECTIVES: To define and report a variant of heloma durum not referenced in the literature. METHODS: This was a retrospective study whereby records, including photographs, of all cases of subungual corn were reviewed. All patients were seen in an outpatient setting. RESULTS: The records of 16 patients [15 women, one man, mean age 68 years (range 49-87)] were examined; history was between 6 and 30 months, none of the patients had received effective treatment. Mycology was negative. All reported discomfort under the big toe nail; 12 had associated subungual haemorrhage. The right big toenail was involved in 10 of 16 patients. Shared clinical features were of a subungual focus of hyperkeratosis (100%) with haemorrhage admixed in 75% of cases. The lesion was in the midline third of the nail in 11 of 16 patients (69%). The affected distal margin of nail was the uppermost point in the lateral profile of the toe (100%). Hyperextension at the distal interphalangeal joint of the affected toe was demonstrated with the patient standing. Local excision was performed when diagnosis was unclear (eight patients); simple clearance of the keratin plug was performed in the other eight patients. There was no relapse in patients who were followed up for > 6 months (n = 7). CONCLUSIONS: Clinical explanation and paring down should be attempted in order to avoid surgery at this poor healing site in the elderly.

Removal of corns by punch incision: a retrospective analysis of 15 patients.

BACKGROUND: Hard corns are firm, small, dome-shaped papules with translucent central cores, which occur on the palmoplantar region of toes and hands due to repeated trauma. Medical management of hard corns is difficult and sometimes requires surgical excision. Punch incision is a technique which is performed using a circular blade or trephine attached to a pencil-like handle. AIM: We hypothesized that it might serve as an alternative method to surgical excision in the treatment of recalcitrant corns and performed the technique to treat 17 corns in 15 patients. The present study aimed to review these 15 patients retrospectively and evaluate the effectiveness of punch incision. METHOD: A total of 15 patients with recalcitrant corns were treated using punch incision between April 2011 and December 2012 and were evaluated by photographs and patient satisfaction questionnaires. RESULTS: Out of the 17 corns, 3 corns persisted after punch incision and the patients were referred to the orthopedic clinic for further treatment; 2 of the 17 corns partially responded and required additional topical treatment; and 12 of the 17 corns responded completely to punch incision. CONCLUSION: Punch incision is a simple and effective technique for the treatment of small corns on the palms and soles.

Effectiveness of scalpel debridement for painful plantar calluses in older people: a randomized trial.

BACKGROUND: Plantar calluses are a common cause of foot pain, which can have a detrimental impact on the mobility and independence of older people. Scalpel debridement is often the first treatment used for this condition. Our aim was to evaluate the effectiveness of scalpel debridement of painful plantar calluses in older people. METHODS: This study was a parallel-group, participant- and assessor-blinded randomized trial. Eighty participants aged 65 years and older with painful forefoot plantar calluses were recruited. Participants were randomly allocated to one of two groups: either real or sham scalpel debridement. Participants were followed for six weeks after their initial intervention appointment. The primary outcomes measured were the difference between groups in pain (measured on a 100-mm visual analogue scale) immediately post-intervention, and at one, three and six weeks post-intervention. RESULTS: Both the real debridement and sham debridement groups experienced a reduction in pain when compared with baseline. Small, systematic between-group differences in pain scores were found at each time point (between 2 and 7 mm favoring real scalpel debridement); however, none of these were statistically significant and none reached a level that could be considered clinically worthwhile. Scalpel debridement caused no adverse events. CONCLUSIONS: The benefits of real scalpel debridement for reducing pain associated with forefoot plantar calluses in older people are small and not statistically significant compared with sham scalpel debridement. When used alone, scalpel debridement has a limited effect in the short term, although it is relatively inexpensive and causes few complications. However, these findings do not preclude the possibility of cumulative benefits over a longer time period or additive effects when combined with other interventions. TRIAL REGISTRATION: Australian Clinical Trials Registry (ACTRN012606000176561).

[Giant cornu cutaneum - a grotesque manifestation of squamosus cell carcinoma in the palm]. / Cornu cutaneum giganteum - groteske Manifestation eines Plattenepithelkarzinoms in der Hohlhand.

Squamous cell carcinoma is the most common maligne primary tumour of the hand. It is almost always located on the dorsum of the hand, an occurrence in the palm is very rare. Usually these tumours are recognised early because of their clinical presentation and visible location. We report on a case in which the patient presented in our hospital only due to a massive mechanical impairment of his hand function through an oversized squamous cell carcinoma. On the basis of this case the therapeutic algorithm for large squamous cell carcinoma in the palm is illustrated and discussed.

Debridement of painful forefoot plantar callosities in rheumatoid arthritis: the CARROT randomised controlled trial.

The objective of this study was to evaluate the long-term benefits of sharp scalpel debridement of painful forefoot plantar callosities in rheumatoid arthritis (RA). The null hypothesis: sharp scalpel debridement would offer no additional long-term advantage in terms of pain and function. Sixty-five people with RA were randomised to receive regular sharp scalpel debridement of painful forefoot plantar callosities in conjunction with a combined therapeutic approach or a combined therapeutic approach alone. The primary outcome measure was change at 18 months in participant-reported forefoot plantar pain measured by a 100-mm visual analogue scale (VAS). Secondary outcome measures were recorded at baseline and study exit and included revised Foot Function Index, Health Assessment Questionnaire, Foot Impact Scale and gait parameters. At 18 months, there were no differences between groups for the primary outcome VAS-measured forefoot plantar pain (left foot (F = 0.23, p = 0.635), right foot (F = 2.14, p = 0.148)). Within-group changes were highly significant (treatment arm, difference = 16.9 (95 % confidence interval (CI) 9.4, 24.4), t = 4.6, p < 0.0001; control arm, difference = 17.5 (95 % CI 9.4, 25.5), t = 4.4, p < 0.0001). There was little change in scores of overall function and foot impact in either group and there were no significant changes in gait parameters noted. The long-term effects of sharp scalpel debridement of painful forefoot plantar callosities in people with RA, when used in conjunction with a combined therapeutic approach, produced no additional benefit over the combined therapeutic approach alone. Trial registration http://www.controlled-trials.com/ISRCTN05190231.

Granuloma annulare mimicking dorsal knuckle pads.

A 37-year-old man underwent excision of what was presumed to be knuckle pads associated with Dupuytren disease. The histology revealed granuloma annulare, which is typically treated nonsurgically. This report includes a discussion of granuloma annulare and its differentiation from knuckle pads.

Analysis of corticalization using the pixel value ratio for fixator removal in tibial lengthening.

BACKGROUND: It is important to define callus maturation and corticalization during distraction osteogenesis. Quantitative methods such as ultrasound and Q-computed tomography are sensitive but expensive. The pixel value ratio (PVR) obtained using a PACS (picture archiving and communication system) is a simple and cost-effective investigation tool. Recently, the issue of whether the PVR is correlated with quantitative methods has been studied. We investigated whether serial PVR is a useful technique for predicting corticalization in each callus segment of the regenerate, and can act as a guide for fixator removal in tibial lengthening without intramedullary nailing. METHODS: A retrospective analysis of 30 tibial segments in 18 patients was performed. The mean age of the patients was 18 years (range 5-48 years). There were 6 male patients and 12 female patients, of whom 8 patients were skeletally mature. Indications for limb lengthening were achondroplasia (8 patients), limb length discrepancy (4 patients), and miscellaneous (6 patients). The interobserver variability of the PVR was measured at each callus segment of the regenerate. Serial PVR at each callus segment was classified according to the callus pathway. RESULTS: The mean interobserver correlation coefficient at the regenerate was high in the posterior callus segment (0.92), the lateral callus segment (0.90), and the medial callus segment (0.70). However, there was low mean interobserver variability in the anterior callus segment (0.49) at the regenerate. A PVR of 1 at the regenerate was achieved first at the lateral callus segment, second at the posterior, third at the medial callus segment, and last at the anterior callus segment. There was no fracture at the regenerate or wire breakage in patients who began fixator removal and full weight bearing when the PVR was 1 in the three callus segments at the regenerate. CONCLUSIONS: In tibial lengthening without nailing, serial measurement of the PVR is a reliable and cost-effective technique to assess the maturity of the callus, especially in the lateral and posterior callus segments, and assessment of the cortical pixel value can safely provide guidelines for fixator removal.