Distal osteotomy of the first metatarsal bone for the correction of hallux valgus: comparison of the sagittal stability of two percutaneous techniques-a cadaveric study.

BACKGROUND: Distal first metatarsal osteotomy is used to correct mild or moderate hallux valgus (HV). We designed a cadaveric study to compare the resistance to axial load between two percutaneous distal first metatarsal osteotomies: Bösch osteotomy and percutaneous chevron. The first aim of this study was to develop a systematic technique for measuring the sagittal displacement on lateral foot X-rays. Our second objective was to measure the resistance to axial load for both of these osteotomies. METHODS: Ten pairs of freshly frozen cadaveric feet were randomly assigned to one of the two techniques investigated. Pre- and post-operative lateral X-rays were obtained. After surgery, the feet were placed under progressive axial loads up to 60 kg. Metaphyseo-diaphyseal angle (MDA) and the distance between bone fragments were measured, and the differences between the two techniques were statistically assessed. RESULTS: The MDA decreased in both surgical techniques. The mean plantar tilt was -6.90 degrees (SD = 10.251) for chevron osteotomy and -5.34 degrees (SD = 16.621) for Bösch osteotomy. There was no significant difference between the techniques (p = 0.41). Regarding the distance between the bone fragments, the Bösch osteotomy produced more plantar displacement than the chevron osteotomy, which was statistically significant for the 10 and 20 kg loads (p = 0.031 and 0.04, respectively). At loads ≥ 30 kg, the bone fragment distance did not differ significantly between the techniques (p = 0.114). CONCLUSIONS: Although the chevron technique confers higher stability regarding fragment displacement during axial loading, both techniques increase the plantar angulation of the metatarsal head. LEVEL OF EVIDENCE: Cadaveric study.

Percutaneous hallux valgus surgery: Anatomical study of its safety and effectiveness.

BACKGROUND AND HYPOTHESIS: Although percutaneous hallux valgus surgery is increasing in popularity, concerns about safety regarding neurovascular and tendinous structures remain. The first aim of this body-donor study was to evaluate the safety of three common percutaneous portals. Secondly, to evaluate percutaneous surgery effectiveness in completing adductor tendon release and first ray osteotomies. PATIENTS AND METHODS: Twenty body-donor feet were included and underwent three percutaneous procedures, which are commonly performed in combination: distal metatarsal osteotomy, proximal phalanx osteotomy and adductor tendon release. After surgery, the distance between surgical portals and relevant neurovascular structures was measured. Damage to this neurovascular structures, tendons or articular cartilage was noted. Completion of adductor tendon release and osteotomies was verified. RESULTS: The medial dorsal digital nerve of the hallux was damaged in two specimens. Mild peritendon damage was observed in two feet. The rest of neurovascular and tendinous structures were intact. No cartilage damage was observed. The distance between the adductor tenotomy portal and the lateral dorsal digital nerve of the hallux and the first dorsal metatarsal artery was 3.3mm (SD 1.4) and 2.4mm (SD 1.8), respectively. Complete adductor tenotomy was achieved in 14 feet. CONCLUSIONS: The structure with the highest risk of damage during percutaneous hallux valgus surgery is the medial dorsal digital nerve. The lateral dorsal digital nerve and the first dorsal metatarsal artery might be at risk due to the small distance to the adductor tendon release portal. A deep anatomical knowledge and a meticulous surgical technique are required to avoid lesions to neurovascular and tendinous structures. LEVEL OF EVIDENCE: V, Cadaveric study.

A comparison of two designs of postoperative shoe for hallux valgus surgery: A biomechanical study in a cadaveric model.

BACKGROUND: Hallux Valgus Surgery success depends not only on the operative technique, but also on the care of the foot during the postoperative period. Orthopedic shoes have been developed to decrease the weight load on the first ray, an excess of which might lead to a loss of fixation or pseudoarthrosis. The goal of this study was to determine how the load distribution changed as the forced applied to the foot increased, with and without an orthopedic shoe. Also, we compared to different shoe models. METHODS: Pressure sensors were placed under the first metatarsal head and the heel of twenty specimens of fresh cadaveric adult feet. Two orthopedic shoes were chosen, a double padded (MS) and a reverse camber shoe (RCS). 10 kg loads were progressively applied, up to 60 kg. We first compared three instances: no shoe, MS and RCS. A secondary analysis comparing barefoot versus shoes was performed. A mean comparison was performed (ANOVA/T-student). RESULTS: The mean pressure of the heed and the first metatarsal showed that there were significant differences between groups (P < .005). The secondary analysis (no shoe vs orthopedic shoes) showed that the pressure without shoe was significantly higher than with any orthopedic shoe (P < .005). There were no statistically significant differences between models of shoes (P = .402). CONCLUSION: After a surgical procedure for hallux valgus fixation, postoperative shoes should be indicated to decrease the pressure on the first metatarsal head and heel in order to avoid an overload of the postoperative area. LEVEL OF EVIDENCE: Cadaveric study. Level V.

Modified Tension-Slide Technique for Endoscopy-Assisted Flexor Hallucis Longus Tendon Transfer.

The rupture of the Achilles tendon (AT) usually occurs in high-caliber athletes, but low-demand patients are also are risk, mainly if they are under corticoids or quinolones. The diagnosis of the AT rupture is usually neglected, and this could result in a worse prognosis for the patient if not treated in an appropriate time. For these patients or for those with high surgical risk, an option of minimally invasive surgery remains attractive. Classical techniques consist of direct repair or augmentation with the tendon of the flexor hallucis longus as well as nonanatomical tendon transfers which can generate issues with the donor site. We present a pioneering technique that is analogous to that used for the surgical treatment of distal rupture of the biceps tendon, which consist of a transfer technique of flexor hallucis longus by extracortical fixation interference screw associated to a direct tendon reinsertion performed through a bone tunnel on the superior and posterior aspect of the calcaneus using an extracortical drilling system and an interference screw within the calcaneal tunnel. The arthroscopic approach may be technically challenging, and a high-level of arthroscopic skills are required to complete the procedure but after a learning curve it represents a feasible a safe technique.Levels of Evidence:Therapeutic, Level IX: Evidence from opinion of authorities and/or reports of expert committee.

Severe Sprengel deformity associated with Klippel-Feil syndrome and a complex vascular abnormality that determined the corrective surgery technique.

Sprengel deformity (SD), a congenital condition characterized by elevation of the scapula, is a cause of functional and aesthetic defects that can be improved by surgical correction. Many cases of SD are associated with Klippel-Feil syndrome (KFS), in which there may be abnormalities of the supra-aortic vessels. We present the case of an 11-year-old girl with severe SD and KFS. The left vertebral artery arose from the subclavian artery in a very high cervical location, which made surgical descent of the scapula unfeasible. The patient was treated using a Mears procedure, with osteotomy of the scapula and tenotomy of the long head of the triceps. The appearance and range of motion of the shoulders improved considerably, and there were no vascular complications. A morphologic vascular assessment is essential in children with SD and concomitant KFS to avoid potentially serious iatrogenic vascular injury when performing a scapular-descending surgical technique.