Comparing Outcomes of Acute Versus Gradual Surgical Correction in Brachymetatarsia.

Brachymetatarsia consists of a shortened metatarsal resulting in a shorter toe. Pain with shoe wear and cosmetic concerns are the main reasons for surgical intervention. Surgical techniques to increase metatarsal length include acute lengthening with interpositional bone grafting or gradual lengthening with callus distraction. We performed a retrospective cohort study for 1 surgeon's patients at 1 institution over 10 years. Twenty-nine feet in 22 patients met inclusion criteria for acute correction; 16 feet in 11 patients were included for gradual correction. Mean ages were 26.3 ± 12.1 and 27 ± 10.8 in the acute and gradual groups, respectively (p = .79). Most patients were female: 95.4% of acute cases and 90.1% of gradual cases. Most involved lengthening the fourth metatarsal: 86.7% and 100% of acute and gradual groups, respectively (p = .54). Correction obtained amounted to 14.4 ± 2.97 mm (range, 10-22 mm) in acute cases and 14.8 ± 2.39 mm (range, 10-20 mm) in gradual cases (p = .81). The mean percent increase in metatarsal length was 21.1 ± 14% for acute and 22.6 ± 12.4% for gradual (p = .72). Mean consolidation was 8.9 ± 2.51 weeks for acute and 21.4 ± 10.8 weeks for gradual (p = <.001). Nonunions were most common in the gradual group (37.5%) with need for more revisional surgery (43.5%) compared with the acute group; both were statistically significant. We conclude that acute brachymetatarsia correction can obtain correction similar to the gradual technique with fewer postoperative complications and less osseous consolidation time.

Minimally Invasive Versus Open Hammertoe Correction: A Retrospective Comparative Study.

Hammertoe deformity is a common forefoot pathology, characterized by a progressive deformity with dorsiflexion of the proximal phalanx on the metatarsal head at the metatarsal phalangeal joint (MTPJ) and plantarflexion of the intermediate phalanx on the proximal phalanx at the proximal interphalangeal joint (PIPJ). While there is literature available discussing open techniques for hammertoe correction, there is a lack of publications discussing minimally invasive techniques, therefore the objective of this retrospective comparative study is to evaluate minimally invasive versus open hammertoe surgery in terms of time to osseous union, complications, recurrence, and return to full activity. Sixty eight feet among 41 patients met the inclusion criteria and were surveyed. Among the 68 feet, 54 feet (124 toes) underwent minimally invasive hammertoe correction and 14 feet (22 toes) underwent open hammertoe correction. Time to osseous union (weeks) in the MIS group was 8.76 ± 2.31 weeks with similar outcomes to the open group with union at 8.42 ± 2.31 (p = .65). Return to activity (weeks) was 10.47 ± 3.45 in the MIS group and 9.92 ± 3.03 in the open group with no statistical significance (p = .62). There was 4 recurrent hammertoe deformities in the MIS group (3.23%) with no recurrent hammertoes in the open group (0%). In the MIS group 5 hammertoes had unplanned hardware removal (4.03%) compared to 0 in the open group. There was no statistical significance for both recurrence and unplanned hardware removal (p = 1). Overall, we concluded that both techniques are equivocal with no detectable statistical difference.

Retrospective Comparison of Preoperative and Postoperative Foot Width in Minimally Invasive Hallux Valgus Surgery.

Minimally invasive surgery (MIS) has gained popularity for hallux valgus correction in the adult population. The advantage of reproducibility of this procedure can aid in lower operating room costs, quicker recovery, and fewer complications. The purpose of this retrospective study was to compare preoperative versus postoperative foot widths in patients that underwent MIS hallux valgus correction. The average preoperative foot width was 101.1 ± 5.67 mm and postoperatively the foot width measured at 12-month follow-up was 95.9 ± 4.92 mm, which was statistically significant (p < .001). Overall, there was a 5.03 ± 3.71% reduction in foot width, with a statistically significant linear relationship between preoperative foot width and percent change in width following the procedure (R = -0.46; p = .003). Based on our results, we can conclude that MIS bunion surgery can effectively narrow the foot postoperatively, particularly in patients with a wider forefoot, adding cosmetic benefit to the procedure.

Landmarks for a Minimally Invasive Approach for Haglund's Deformity: A Cadaveric Study.

INTRODUCTION: Haglund's deformity is a posterosuperior calcaneal prominence often associated with a painful bursa and insertional Achilles tendinopathy. Endoscopic debridement has been previously described; however, the aim of this cadaveric study is to describe landmarks of a minimally invasive surgical (MIS) approach to Haglund's deformity. METHODS: Twelve specimens were dissected to identify medial and lateral portals for minimally invasive burr placement and anchor placement. A standard ruler was used to measure the distance in millimeters from the medial and lateral neurovascular structures in relation to medial and lateral portals. A separate 7-cm longitudinal incision posterior to the lateral malleolus and a separate 7-cm longitudinal incision posterior to the medial malleolus were made to identify at-risk neurovascular structures. RESULTS: The average distance from the sural nerve to the lateral portal was 25.7 mm (23-26). The mean distance from the lateral calcaneal branch of the sural nerve to lateral portal was 11.4 mm (10-12). The mean distance from the tibial nerve to the medial portal was 35.3 mm (35-36). Both the medial and lateral incisions were 9.3 mm from the calcaneal tuberosity. CONCLUSION: The results indicate that the MIS approach to Haglund's deformity resection can be performed reliably without neurovascular compromise. LEVELS OF EVIDENCE: Level IV.

The Role of Supramalleolar Osteotomies in Ankle Arthritis.

The supramalleolar osteotomy (SMO) is a joint-preserving surgical procedure that allows realignment of the ankle joint in severe deformity secondary to arthritis. This osteotomy realigns the mechanical axis to provide better weight distribution through the ankle joint. With an aligned mechanical axis, the overloaded asymmetric ankle joint will shift toward the preserved joint area in a valgus or varus ankle joint. The SMO also can be used via a staged approach to correct severe deformity in an end-stage arthritic ankle before total ankle arthroplasty to optimize the implant's longevity and improve overall functional outcomes.

Comparison of Minimally Invasive and Open Approaches for Midfoot Charcot Neuroarthropathy Reconstruction.

Charcot neuroarthropathy (CNA) is a progressive disease affecting the bones and joints of the foot that can lead to instability, breakdown, and collapse. Minimally invasive surgery (MIS) techniques are becoming a popular option within musculoskeletal surgery of the foot and ankle and may be an alternative to aggressive dissection seen during corrective surgery. An MIS approach minimizes vascular disruption, provides structural stability at an osteotomy or arthrodesis site, and encourages early mobilization if indicated. This retrospective study compares 17 patients who underwent an open approach for midfoot CNA reconstruction with 17 patients who underwent an MIS approach for midfoot CNA reconstruction. Preoperative and postoperative radiographic parameters were measured: lateral talus-first metatarsal, anteroposterior (AP) talus-first metatarsal, calcaneal pitch, and cuboid height. Difficulties that occurred during treatment were gathered and sorted into postoperative problems (stage I), obstacles (stage II), and complications (stage III). Changes from preoperative to postoperative radiographic lateral talus-first metatarsal and AP talus-first metatarsal angles were statistically significant (p < .001) for both the MIS and open approach. No true postoperative complications (stage III) were observed at last follow-up. The most common difficulty encountered was pin-site infection (stage I; in 23.5% of patients) in the MIS group. In the open group, the most common complications were wound development (stage I; 23.5%) and nonunions (stage II; 23.5%). Our findings suggest that midfoot CNA reconstruction with MIS methods offers similar outcomes to the open approach.

Minor and Major Amputation Rates Following Midfoot Charcot Reconstructive Surgery.

Charcot neuroarthropathy (CNA) is a progressive disease that affects the bones and joints of the foot. To prevent collapse and loss of stability within the pedal architecture, CNA should be diagnosed and managed early. The objective of this retrospective study was to review patients who underwent midfoot CNA reconstructive surgery and evaluate subsequent rates of minor and major amputations. Secondary objectives include identifying patients that underwent midfoot CAN with and without a subtalar joint (STJ) arthrodesis. Out of the 72 patients, 4 (5.6%) underwent minor (digital, ray) amputation, 2 (2.8%) underwent proximal amputations (either below or above the knee), and none underwent midfoot amputation (transmetatarsal, Lisfranc, Chopart). A Fisher's exact test was employed to compare the outcomes of minor and major amputation rates in our CNA cohort with those who underwent midfoot CNA reconstruction with STJ arthrodesis and found no statistical significance (p = .15). Overall, a total progression to amputation was 8.4% following midfoot CNA reconstruction, with 2.8% of patients undergoing major amputation (below knee or above knee). Despite no statistical significance, we recommend surgeons to consider including an STJ arthrodesis in addition to midfoot CNA reconstruction to establish a stable and plantigrade foot.

Progression to Hindfoot Charcot Neuroarthropathy After Midfoot Charcot Correction in Patients With and Without Subtalar Joint Arthrodesis.

Charcot neuroarthropathy (CNA) is a disabling and progressive disease that affects the bones and joints of the foot. Successful Charcot reconstruction focuses on restoring anatomic alignment, obtaining multiple joint arthrodesis, selecting stable fixation, preserving foot length, and creating a foot suitable for community ambulation in supportive shoegear. Intramedullary fixation arthrodesis of the medial and lateral columns has been previously reported to produce improvement in midfoot Charcot reconstruction. More recently, a growing trend of stabilization of the subtalar joint (STJ) has been incorporated alongside the medial and lateral column fusion. Our objectives were to retrospectively review patients who underwent midfoot Charcot reconstructive surgery, whether with or without accompanying STJ arthrodesis, and establish which patients progressed to ankle CNA. Of the 72 patients who underwent midfoot Charcot reconstruction, 28 (38.9%) underwent STJ arthrodesis, and 22 converted to ankle CNA (30.6%). Fourteen (63.6%) of 22 ankle CNA cases had not undergone STJ arthrodesis; 8 patients (36.4%) had it. A Fisher exact test was performed to identify the relationship between those without STJ arthrodesis and those progressing to ankle CNA; it revealed statistical significance (p = .001). Performing an STJ arthrodesis with midfoot Charcot reconstructive surgery may be beneficial to aiding in hindfoot stability, establishing a plantigrade foot, and providing further insight into the management of midfoot Charcot.

The Prevalence of Bunions in the Setting of Brachymetatarsia.

Brachymetatarsia is caused by premature closure of the physis and is characterized by a short metatarsal. Additional foot conditions may exist in patients presenting with brachymetatarsia, such as hallux valgus (HV). A retrospective study was performed to evaluate the prevalence of HV and brachymetatarsia in the ipsilateral foot. Ninety-seven feet with congenital brachymetatarsia were reviewed in a multi-study cohort of 66 patients who underwent surgical correction between January 2005 and August 2020 at a single institution. The group was comprised of 61 females and 5 males, with a mean age of 27 years. HV deformities were verified with standardized anteroposterior radiographs. HV was present in 29 of 97 feet for a prevalence of 30% in the feet with brachymetatarsia. Our results demonstrate a 30% prevalence of HV associated with brachymetatarsia. This information is helpful for foot and ankle surgeons managing brachymetatarsia to determine appropriate conservative or surgical management of this condition.

The Role of the Shortened Proximal Phalanx in the Setting of Brachymetatarsia.

Brachymetatarsia is a condition in which a metatarsal bone does not grow out to full length. This is caused by premature physeal closure. The proximal phalanx associated with the shortened metatarsal helps achieve the natural parabola of the foot. A hypoplastic proximal phalanx is a common finding in patients with brachymetatarsia. The goal of this study was to determine the length of the proximal phalanx in the setting of brachymetatarsia, and how much the shortening is attributed to the clinically smaller toe. We performed a retrospective study to evaluate the length of the proximal phalanx in the shortened ray. After the metatarsal was brought out to the desired length of correction, the proximal phalanx was measured on radiographs. Ninety-seven feet with congenital brachymetatarsia were reviewed in a cohort of 66 patients who underwent surgical correction between January 2005 and February 2020 at a single institution. The group was comprised of 61 females and 5 males, with a mean age of 27.5 years. The average length of the proximal phalanx associated with the affected metatarsal was noted to be 18.9 ± 3.83 mm for males and 15.6 ± 4.02 mm for females. Our results indicate the shortened proximal phalanx is 5 mm shorter when compared to normal population and is a contributing factor to the shortened clinical appearance of the digit in brachymetatarsia. Treating surgeons should be aware of this to better educate patients on the influence of the digit on the overall shortening seen in cases of brachymetatarsia.

Mechanical Axis Method to Determine First Intermetatarsal Angle and Tibial Sesamoid Position.

Utilizing the mechanical axis can decrease load on the joint and be beneficial when analyzing bony deformities and planning surgical correction with osteotomies. The aim of this study was to identify the normal mechanical axes of the first and second metatarsals and use them to obtain the first/second mechanical intermetatarsal angle (mIMA). The mechanical axis of the first metatarsal was used to obtain the mechanical tibial sesamoid position (mTSP), which provides a mechanical relationship with the sesamoid apparatus. The angular difference between the anatomic and mechanical axis lines (anatomic-mechanical angle [AMA]) was determined for the first metatarsal and for the second metatarsal. The commonly used first/second anatomic intermetatarsal angle (aIMA) and anatomic tibial sesamoid position (aTSP) were also obtained and compared with the first/second mIMA and mTSP. In this retrospective analysis, radiographs of 50 normal feet (40 patients) were assessed. Pearson's correlation coefficients were used to measure reliability between obtained measurements. Mean first/second aIMA was 8.6 ± 3.0 degrees, and first/second mIMA was 8.6 ± 2.6 degrees. First metatarsal AMA was 1.1 ± 1.0 degrees; second metatarsal AMA was 2.0 ± 1.6 degrees. The mTSP was 2.8 ± 1.1, and aTSP was 2.9 ± 1.0. The TSP median was 3 (range, 1-5). Using the mechanical axis method to obtain the first/second mIMA and the mTSP is reproducible and not affected by anatomic changes to the shape of the metatarsal. Unlike the anatomical axis, the mechanical axis does not change, therefore we recommend using the mechanical axis during surgical planning and when obtaining preoperative and postoperative measurements for the long bones of the foot, particularly for forefoot conditions such as hallux valgus.

Tibial Lengthening and Intramedullary Nail Fixation for Hindfoot Charcot Neuroarthropathy.

Hindfoot and ankle Charcot neuroarthropathy is a challenging condition to treat, specifically with segmental bone defects secondary to avascular necrosis or infection. Several techniques exist alongside continued challenges of nonunion and complication rates. The authors assert that combining distal tibial distraction osteogenesis with external fixation in tibiocalcaneal or tibiotalocalcaneal arthrodesis should be considered an effective method for management of complex Charcot neuroarthropathy conditions of the ankle. This staged procedure technique resulted in a high rate of union in patients who are often considered a high risk for nonunion, as well as eradication of infection, minimal soft tissue disruption, and improvement in limb length.

Increased Arthrodesis Rates in Charcot Neuroarthropathy Utilizing Distal Tibial Distraction Osteogenesis Principles.

Charcot neuroarthropathy of the hindfoot and ankle poses substantial challenges due to deformity, segmental bone loss, chronic infection, and difficulty with bracing. Hindfoot or ankle arthrodesis is often employed at high rates of complications and nonunion. This study reports 15 consecutive patients with Charcot neuroarthropathy who underwent tibiotalocalcaneal or tibiocalcaneal fusion with simultaneous distal tibial distraction osteogenesis with a mean follow-up period of 20.2 ± 5.66 months. Arthrodesis rate was 93.3% (14 patients) with mean time to fusion of 4.75 ± 3.4 months. One hypertrophic nonunion occurred at the arthrodesis site. Complete consolidation of 4 cortices was achieved at the distraction site in 93.3% of patients (14 patients) with a mean duration to consolidation of 9.8 ± 3.3 months. One patient experienced hypertrophic nonunion at the regeneration site. The authors report a technique to enhance arthrodesis rates in Charcot neuroarthropathy by combining distal tibial distraction osteogenesis with simultaneous tibiotalocalcaneal or tibiocalcaneal arthrodesis for hindfoot fusion and salvage. Distraction osteogenesis supports enhanced vascularity to the arthrodesis site.Level of Clinical Evidence: Level 4.

Short-Term, Retrospective Radiographic Evaluation Comparing Pre- and Postoperative Measurements in the Chevron and Minimally Invasive Distal Metatarsal Osteotomy for Hallux Valgus Correction.

Various techniques exist for correction of mild to moderate hallux valgus (HAV) deformity. Recently, minimally invasive distal metatarsal osteotomy (MIDMO) has gained popularity for HAV correction. This retrospective radiographic review aims to report the surgical correction obtained by the chevron and MIDMO osteotomies at a single institution between January 2012 and December 2017. Radiographic parameters, such as intermetatarsal angle (IMA), hallux abductus angle (HAA), and tibial sesamoid position (TSP), were compared on weight-bearing anterior-posterior and lateral radiographs. Sixty-one patients who underwent distal first metatarsal osteotomies were separated into 2 groups. Group A included 30 patients with a chevron bunionectomy performed by Surgeon A; Group B consisted of 31 patients who had MIDMO performed by Surgeon B. Mean follow-up was 26.6 months for Group A and 18.7 months for Group B. Both groups had statistically significant radiographic correction for pre- and postoperative IMA, HAA, and TSP. Group A: IMA measured preoperatively 11.6° ± 4.0° to 6.8° ± 4.1° postoperatively, HAA preoperative 22.2° ± 9.1° to 12.3° ± 6.9° postoperative, and TSP preoperative 1.3 ± 0.9 to 0.7 ± 0.6 postoperative. Group B: IMA measured preoperatively 12.0° ± 2.9° to 5.9° ± 3.3° postoperatively, HAA preoperative 27.9° ± 8.6° to 12.0° ± 6.6° postoperative, and TSP preoperative 2.0 ± 0.8 to 0.7 ± 0.6 postoperative. Postsurgical retrospective radiographic review demonstrated chevron and MIDMO procedures provide comparable radiographic correction of IMA, HAA, and TSP.

Radiographic Outcomes of a Percutaneous, Reproducible Distal Metatarsal Osteotomy for Mild and Moderate Bunions: A Multicenter Study.

Hallux valgus is a prevalent condition. Many open surgical methods of correction have been described. We performed a percutaneous, extra-articular distal metatarsal osteotomy for mild to moderate bunion deformity. The minimally invasive technique was used in 217 feet (180 patients; age 49 ± 4.7 years, mean ± standard deviation) at 4 centers in North America (Center 1: November 2012 to March 2017; Center 2: January 2010 to May 2016; Center 3: October 2013 to June 2016; Center 4: January 2015 to June 2017). The procedure was used in simultaneous bilateral cases in 28 patients (15.6%) and in nonsimultaneous bilateral cases in 9 patients (5.0%). Immediate postoperative weightbearing was used in all cases. The mean preoperative intermetatarsal angle, hallux abductus angle, and tibial sesamoid position were 14.6° ± 3.5°, 30.7° ± 7.8°, and 5.4 ± 1.4, respectively. At final follow-up of 9.3 ± 6.1 months, the mean intermetatarsal angle, hallux abductus angle, and tibial sesamoid position were 4.7° ± 2.8°, 8.4° ± 6.1°, and 2.0 ± 1.0, respectively (p < .0001 for all comparisons). No major complications were noted. All 217 osteotomies achieved union; 3 feet (1.4%) in 3 patients (1.7%) experienced asymptomatic malunion. Superficial pin-site infection was seen in 42 (19.4%) of the 217 feet (39 patients, 21.7%). The radiographic results of this percutaneous technique appear to be reproducible across multiple centers, and the technique is useful when correcting intermetatarsal and hallux abductus angles. This percutaneous osteotomy for realignment of the first ray allows immediate postoperative weightbearing and, in this initial review, appears to be safe and effective, even in simultaneous bilateral cases.

Minimally Invasive Bunion Correction.

Hallux valgus is a common condition that results in lateral deviation of the hallux and medial deviation of the metatarsal. When conservative management fails, surgical management is often necessary. More than 150 procedures have been described, and most recommend an open approach. More recently, a minimally invasive approach to bunion correction has gained popularity among surgeons. The authors have been performing a minimally invasive percutaneous method of bunion correction with positive outcomes. This article presents case examples and a systematic approach for correction of this common foot condition.

Midfoot Charcot Reconstruction.

Midfoot Charcot joints are complex problems that are most commonly seen in patients with peripheral neuropathy secondary to diabetes. The goal of management is to prevent pedal collapse, which can lead to ulceration; infection; and in some cases, amputation. Principles of surgical management should be centered on respecting the soft tissue, obtaining correction, maintaining correction, and supplementing with orthobiologics to achieve healing. The authors present strategies, case examples, and tips and tricks to treat this complex condition with external and internal fixation.

Digital planning for foot and ankle deformity correction: Evans osteotomy.

Preoperative planning is commonly performed for many foot and ankle procedures. The purpose of the present study was to prospectively determine the preoperative digital planning accuracy of predicting the calcaneal graft size used during the "Evans" calcaneal osteotomy. Preoperative digital deformity correction planning, using a standard planning method (TraumaCad(®) software), was performed on 10 feet scheduled to undergo an Evans procedure. Of the 10 patients, 6 were female and 4 were male, with an average age of 43 ± 22 years. Digital planning was used to predict the Evans graft size. The surgeon was unaware of the predicted graft size, which was then compared with the actual graft size inserted during the procedure. In addition, the pre- and postoperative radiographic angles were recorded and compared (anteroposterior view, talo-first metatarsal angle, calcaneocuboid abduction; lateral view, calcaneal inclination angle; and axial view, tibial-calcaneal angle). The average preoperative talo-first metatarsal angle, calcaneocuboid angle, calcaneal inclination angle, and tibial-calcaneal angle measured 21° ± 9.6°, 28.3° ± 9.0°, 13.8° ± 5.7°, and 15.3° ± 8.2°, respectively. The preoperative tibial-calcaneal position was 2.8 ± 1.2 mm. The radiographic weightbearing angles measured at an average follow-up of 7.4 (range 6 to 12) months improved to 6.3° ± 7.4° (p = .0015), 12.3° ± 6.1° (p < .001), 21.3° ± 7.7° (p = .0122), and 2.2° ± 3.6° (p = .0019) for the talo-first metatarsal, calcaneocuboid abduction, calcaneal inclination, and tibial-calcaneal angles, respectively. The final tibial-calcaneal position measured 1.4 ± 0.7 mm (p < .001). The preoperative Evans graft measurement (11.8 ± 2.6 mm) compared with the actual graft (12.2 ± 1.3 mm) placed was within 0.4 ± 1.8 mm (p = .51). Preoperative digital planning for Evans calcaneal osteotomy has been shown to be a valuable tool for predicting the surgical graft size for accurate pedal realignment.