A Radiologic Triangle Sign for Percutaneous Adductor Tendon Release (PATR): Cadaveric Study and Case Series.

Background: Combining osteotomies and soft tissue procedures is believed to reduce sesamoids in their anatomical position and maintain long-term correction when treating hallux valgus deformity. This study determines if a radiologic association exists between a radiolucent sign and a full percutaneous adductor tendon release (PATR), including a cadaveric study and a consecutive case series. Another aim was to determine the intra- and interobserver reliability of these observations. Methods: A prospective observational study was made between 2018 and 2019. First, a PATR was done on cadaveric specimens and, after the procedures, dissected to correlate what was seen fluoroscopically. The clinical group included 39 feet that presented mild-to-moderate HV deformity and were treated with percutaneous osteotomies associated with PATR. Results: Observers 1 and 2 saw a radioscopic radiolucent sign in 100% of cadavers and the patient population. They also observed a triangle-shaped image with an incidence of 75%, which we have named the "triangle sign." Conclusion: The triangle sign may be helpful in the intraoperative confirmation of PATR and latero-plantar capsule release using this percutaneous technique. Level of Evidence: Level II, development of diagnostic criteria.

Intra­ and Interobserver Reliability of Yamaguchi's Method for the Assessment of First Metatarsal Pronation in Hallux Valgus Deformity.

Pronation of the first metatarsal is a risk factor for the formation and progression of the hallux valgus deformity. Recently, Yamaguchi et al published a study that showed how the round sign increases on digitally reconstructed radiography taken from a CT scan when pronation is applied. In this study, the shape of the lateral edge of the first metatarsal head was evaluated on weightbearing dorsoplantar radiographs. Yamaguchi's signs were presented to observers after the visual presentation of each foot as an image. The best-fit circle was drawn using the PACS drawing function. Ninety radiographs of adults presenting hallux valgus deformities were classified as mild-to-moderate, based on hallux valgus angle and intermetatarsal angle. The global average observations were 3.72 ± 3.92 (range 2.3°-4.6°). The interclass correlation (Fleiss Kappa index κ = 0.225) and the Spearman correlation (0.16 of Kappa) coefficients were poor for interobserver measurements and statistically significant. Using the linear model, there was no significant variability between the repetitions corresponding to each observer (t-value -1.527, p value .127). Our findings show that the Yamaguchi method can be very subjective and should not be the exclusive technique to assess the rotation of the first metatarsal or head roundness.

Midterm Outcomes of Sliding Distal Metatarsal Minimally Invasive Osteotomy to Treat Bunionette Deformity.

BACKGROUND: Bunionette deformity is described as a painful bony prominence on the lateral aspect of the fifth metatarsal head. The present study prospectively assessed the clinical, functional, and radiographic outcomes of sliding distal metatarsal minimally invasive osteotomy (S-DMMO) used in a large series of patients with a midterm follow-up period. METHODS: From December 2015 to December 2018, we evaluated 74 feet (57 patients). Radiologic (4-to-5 intermetatarsal angle, fifth metatarsophalangeal angle, the fifth metatarsal head width, lateral deviation angle, fifth metatarsal length, medial displacement, and elevation), clinician-reported scores (AOFAS score, visual analog scale [VAS]) and patient-reported outcomes measure (Foot and Ankle Ability Measure [FAAM] activities of daily living [ADL], FAAM sports, Manchester-Oxford Foot Questionnaire [MOXFQ], and patient satisfaction survey) were included in the analysis. The time to bone union was also assessed. RESULTS: The average 4-to-5 intermetatarsal angle improved from 11.1 degrees preoperatively to 4.5 degrees postoperatively (P < .001), whereas the average fifth metatarsophalangeal angle improved from 15.7 degrees preoperatively to 4.8 degrees postoperatively (P < .001). The lateral deviation angle was found to be 2.2 degrees. The fifth metatarsal length decreased from 66.6 to 64.3 mm postoperatively. The average initial medial displacement was 4.67 mm preoperatively and 4.54 mm at final follow-up. The elevation of the fifth metatarsal head was 1.08 mm. The American Orthopaedic Foot & Ankle Society score improved from 54.3 ± 20.86 points preoperatively to 93.4 ± 17.3 (P < .001). VAS score decreased from 7.9 to 0.7 (P < .001). Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences (P < .001) between preoperative and postoperative periods. Patients found the procedure excellent in 89.1% of cases, very good in 5.4%, and good in 5.4%. Bone union was obtained at 8.1 weeks. CONCLUSION: The most important finding of the present study is that S-DMMO showed improvement in function and pain associated with a high satisfaction rate. Also, we found substantial capacity to correct deformities and a low incidence of complications. LEVEL OF EVIDENCE: Level IV, case series.

Modified Bösch Osteotomy Combined With a Percutaneous Adductor Tendon Release for the Treatment of Hallux Valgus Deformity: Learning Curve.

PURPOSE: The expression "learning curve" indicates the relation between the time needed to learn a new technique and the technique-related outcome. Percutaneous surgery (also called "minimally invasive surgery") has experienced sustained and respectable growth, especially in forefoot deformities. The main purpose was to assess the number of feet necessary to become skilled in a specific minimally invasive surgery (MIS) procedure. METHODS: From January 2015 to June 2018, 46 consecutive patients were evaluated and included in the study. Patients were divided into 2 groups according to the surgery period: first 30 feet (Group 1), and subsequent 30 feet (Group 2) from the whole population evaluated. Age, body mass index, and operative time were evaluated. Hallux valgus angle and the 1 to 2 intermetatarsal angle were also measured. Patients were assessed according to the American Orthopedic Foot and Ankle Society (AOFAS) forefoot scale, the Foot and Ankle Ability Measure activities of daily living (FAAM ADL) subscale and the visual analog scale (VAS). RESULTS: The comparison of the 2 groups showed statistically significant differences in hallux valgus angle (HVA) but not in intermetatarsal angle (IMA). The mean improvement between pre- and postoperative FAAM ADL, VAS, and AOFAS score in Group 1 were 12.83, 3.93, and 24.77 points, respectively. In Group 2, the mean improvement between pre- and postoperative FAAM ADL, VAS, and AOFAS scores were 15.19, 4.3, and 24.5 points, respectively. The differences between groups in FAAM ADL score was statistically significant (P = 0.0364). Group 1 showed a global complication rate of 16.67% (n = 5) while group 2 showed 3,3% (n = 1). CONCLUSION: After the first 30 cases, radiographic, clinical, and functional outcomes substantially improved, and the level of the perioperative complications decreased. The results suggest that the learning curve plateau for performing a percutaneous subcapital osteotomy can be reached after 30 surgeries. LEVELS OF EVIDENCE: Level III.

Percutaneous, intra-articular, chevron osteotomy (PeICO) for the treatment of mild-to-moderate hallux valgus: a case series.

PURPOSE: Treatment for hallux valgus (HV) remains challenging. Third-generation percutaneous procedures try to reproduce chevron-type osteotomies to replicate their benefits, such as intrinsic stability and reproducibility. We report the first results using a percutaneous, intra-articular, chevron osteotomy (PeICO) technique that mimics the classic intra-articular open chevron procedure, associated with a percutaneous adductor tendon release (PATR) for the treatment of mild-to-moderate HV. METHODS: From May 2015 to October 2018, a total of consecutive 114 feet (74 patients) were included. Primary outcome measures included radiographic (hallux valgus and intermetatarsal angles) and clinical parameters such as visual analog scale (VAS), FAAM Activities of Daily Living (ADL), and FAAM Sport, AOFAS Score, and MOXFQ, preoperatively and at final follow-up (Minimum 18 months). A patient satisfaction survey was also performed. Pronation and length of the first metatarsal were also assessed. Secondary outcomes included fluoroscopic time, length of surgery, complications, recurrence, and re-operation rates. RESULTS: At 24.09 months on average, the AOFAS score improved from 52.1 points preoperatively to 91.1 (p < 0.001) at the latest follow-up. VAS decreased from 6.3 to 1. Also, FAAM ALD, FAAM Sport, and MOXFQ showed statistically significant differences (p < 0.001) when comparing pre-operative and post-operative periods. Patients found the procedure to be excellent in 82% and very good in 13.5% of cases. Our global complication and re-operation rates were 5.26% and 3.5% (screw removal), respectively. CONCLUSION: PeICO combined with PATR proved to be a safe, reliable, and effective technique for the correction of mild-to-moderate HV deformity.

Cryptococcus neoformans osteomyelitis of the calcaneus: Case report and literature review.

Cryptococcus neoformans is an encapsulated, yeast-like fungus that can cause a systemic mycosis, particularly in immunocompromised patients. Disseminated infections typically affect the central nervous system, and osseous lesions are infrequent. Only 5%-10% of disseminated cryptococcosis involves bones. A 69-year-old female presented pain, swelling, and a soft tissue mass in her right lateral hindfoot. Her medical history included a kidney transplant (10 years earlier) secondary to chronic disease due to IgA nephropathy. The patient underwent an excisional biopsy, surgical debridement, and secondarily negative pressure wound therapy to achieve skin closure. Biopsy revealed a rare Cryptococcus neoformans osteomyelitis of the calcaneus. The patient then received IV treatment with liposomal amphotericin B at 3 mg/kg/d for 25 days. In conclusion, we present a case of cryptococcal osteomyelitis which, although not a frequent disease, must be considered as one of the differential diagnoses of osteolytic osseous lesions in patients with chronic osteomyelitis. Cryptococcus neoformans may be a potential cause of below-knee infection, mainly in immunocompromised patients.

Correction Power of Percutaneous Adductor Tendon Release (PATR) for the Treatment of Hallux Valgus: A Cadaveric Study.

Osteotomies are commonly used in order to correct hallux valgus deformity. However, soft tissue structures also play an essential role in the etiology, progression, and treatment of hallux valgus (HV). The purpose of the present study was to analyze the correcting power (varus), reduction strength (sesamoid) and rotation of metatarsal and proximal phalanx after percutaneous adductor tendon release (PATR). To date, no study addresses this issue. Eleven cadaveric fresh-frozen below-the-knee cadaveric lower limbs with associated hallux valgus deformity were used. These specimens were subjected to a constant abduction force after PATR. HV and intermetatarsal angles showed statistically significant differences when comparing the preoperative and postoperative periods. PATR showed to be a reliable technique as the adductor tendon was completely released in 9 cases, and 75% released in the remaining 2 feet. The study supports that PATR provides powerful and quantifiable correction of HV deformity and can be accurately performed percutaneously.

Comparison of two forced-air warming devices during foot and ankle surgery: a randomised controlled trial.

Inadvertent perioperative hypothermia is a frequent problem associated with surgical patients which can have significant consequences during surgery and in the immediate postoperative period. We compared 35 randomised patients using over vs. under body forced air heating. There were no statistically significant differences between some demographic and surgical parameters such as: age, weight, height, body mass index, length of anaesthesia and operation. Statistically significant differences were found between the patient's admission to the operating room and 30 minutes and the end of the procedure on the under body patients group. This study analyses a uniform population of patients (Foot and Ankle Surgery) previously not studied and supports the use of under body blankets.

Patient-specific three-dimensional printed hemi talar prostheses for the treatment of talar osteonecrosis, case report and literature review.

We present the case of a 43-year-old boy who presented with progressive pain as a result of history of lateral avascular necrosis of the talus secondary to traumatic open ankle luxation 20 years ago. Conservative treatment (12-month period) prior to surgery failed. It consisted of physiokinetic treatment, insoles and analgesic medication. A diagnostic injection was used in the ankle (positive) and subtalar joint (negative) in order to recognize origin of pain. Hemilateral avascular necrosis of the talus is rare. There are no prior reported cases of the use of hemi-implants. This case highlights the potential use of a patient-specific three-dimensional printed Ti6Al4V prosthesis presented in a complex scenario.

Percutaneous, Intra-articular, Chevron Osteotomy (PeICO) for the Treatment of Hallux Valgus: A Cadaveric Study.

BACKGROUND: Percutaneous surgery is experiencing sustained growth based on third-generation techniques. This cadaveric study was designed with the main goal of exploring the risk of iatrogenic tendon and neurovascular lesions and defining the safe zones in a percutaneous, intra-articular, chevron osteotomy (PeICO) procedure, as well as assessing the accuracy of the osteotomy itself. METHODS: Eight feet from below-knee fresh-frozen specimens were selected. After the procedure, the specimens were dissected, and structures were inspected for damage. RESULTS: The results of the safety measurements were as follows: (1) distance between portal 1 (P1) and the lateral border of the extensor hallucis longus (EHL) tendon: average 17.6 mm (range 12.7-21.3); (2) distance between P1 and the dorsomedial digital nerve (DMDN): average 7.2 mm (range 1.6-10.4); (3) distance between P1 and the metatarsophalangeal joint: average 15.7 mm (range 9.4-20.5); distance between portal 2 (P2), or the osteosynthesis portal, and the metatarsophalangeal joint: average 25.5 mm (range 22-30.4); distance between P2 and the lateral border of the EHL tendon: average 12.7 mm (range 8-16.7); and distance between P2 and the DMDN: average 4.1 mm (range 1.7-8.2). There were no iatrogenic injuries. The osteotomy angulation in the sagittal plane (reproducibility) average was 85.6 degrees. CONCLUSION: There were no iatrogenic injuries on this cadaveric study of PeICO. CLINICAL RELEVANCE: This study will help orthopedic surgeons understand the risks of performing percutaneous surgery by mimicking an accepted open technique (chevron).