A Novel Simulation Model and Training Program for Minimally Invasive Surgery of Hallux Valgus.

BACKGROUND: Minimally invasive surgery (MIS) for hallux valgus (HV) has gained popularity. However, adopting this technique faces the challenges of a pronounced learning curve. This study aimed to address these challenges by developing and validating an innovative simulation model and training program, targeting enhanced proficiency in HV MIS. METHODS: A training program and a high-fidelity simulation model for HV MIS were designed based on experts' recommendations. Four foot and ankle surgeons without experience in MIS formed the novice group and took the program that encompassed six-session instructional lessons, hands-on practice on simulated models, and immediate feedback. The program concluded with a cadaveric surgery. Four foot and ankle experienced MIS surgeons formed the expert group and underwent the same procedure with one simulated model. Participants underwent blind assessment, including Objective Structured Assessment of Technical Skills (OSATS), surgical time, and radiograph usage. RESULTS: Expert evaluation of the simulation model indicated high satisfaction with anatomical representation, handling properties, and utility as a training tool. The expert group consistently outperformed novices at the initial assessment across all outcomes, demonstrating OSATS scores of 24 points (range, 23 to 25) versus 15.5 (range, 12 to 17), median surgical time of 22.75 minutes (range, 12 to 27) versus 48.75 minutes (range, 38 to 60), and median radiograph usage of 70 (range, 53 to 102) versus 232.5 (range, 112 to 280). DISCUSSION: Novices exhibited a significant improvement in OSATS scores from the fifth session onward (P = 0.01), reaching the desired performance of 20 points. Performance at the final training with the simulated model did not differ from cadaveric surgery outcomes for all parameters. CONCLUSION: This study validated a simulation model and training program, allowing nonexperienced HV MIS foot and ankle surgeons to enhance their surgical proficiency and effectively complete a substantial portion of the learning curve at the fifth session, and this performance was successfully transferred to a cadaver model. LEVEL OF EVIDENCE: III.

Biomechanical Effect on Joint Stability of Including Deltoid Ligament Repair in an Ankle Fracture Soft Tissue Injury Model With Deltoid and Syndesmotic Disruption.

BACKGROUND: The current operative standard of treatment for bimalleolar equivalent ankle fracture is open reduction and internal fixation (ORIF) of the lateral malleolus followed by syndesmotic stabilization if indicated. There is controversy surrounding the indication and need for deltoid ligament repair in this setting. The purpose of this study was to quantify the biomechanical effect of deltoid ligament repair in an ankle fracture soft tissue injury model. METHODS: Nine fresh-frozen cadaveric specimens were included in this study. Each leg was tested under 5 conditions: intact, syndesmosis and deltoid ligament sectioned, syndesmosis fixed, deltoid repaired, and both the syndesmosis and deltoid ligament repaired. Anterior, posterior, lateral, and medial drawer and rotational stresses were applied to the foot, and the resulting talus displacement was documented. RESULTS: Isolated deltoid repair significantly reduced anterior displacement to normal levels. Displacement with lateral drawer testing was not significantly corrected until both structures were repaired. Deltoid repair and syndesmosis fixation each reduced internal rotation significantly with further reduction to normal levels when both were repaired. External rotation remained elevated relative to the intact condition regardless of which structures were repaired. CONCLUSION: There is existing controversy regarding the importance of deltoid ligament repair in the setting of ankle fractures. The findings of this biomechanical study indicate that deltoid ligament repair enhances ankle stability in ankle fractures with both syndesmotic and deltoid disruption. CLINICAL RELEVANCE: Concomitant deltoid ligament repair in addition to stabilization of fracture and syndesmosis may improve long-term functioning of the ankle joint and clinical outcomes.

Incidence of and Functional Significance of Floating Toe After Weil Osteotomy.

BACKGROUND: The most frequent complication after Weil osteotomies is a floating toe deformity, but there are no reports about its effect on the patient. In this study, we analyzed the consequences of floating toe deformities after the performance of a modified Weil osteotomy (MWO) or a modified Weil osteotomy with interphalangeal fixation (MWOIF). METHODS: We performed a retrospective review with a prospective follow-up of 50 patients (98% women, 120 rays) who underwent MWO (65 rays) or MWOIF (55 rays), with a mean age of 54 ± 12 years and a minimum follow-up of 4 years (mean of 6 years). We analyzed the presence of floating toe deformity in MWO and MWOIF and the outcomes measured by the subjective satisfaction, Lower Extremity Functional Scale (LEFS), American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, and quality of prehension force between patients with or without floating toe deformity. RESULTS: The mean floating toe incidence was of 57%, with no significant difference between operative techniques (48% MWO, 67% MWOIF; P = .053). Our analysis did not show differences in satisfaction, LEFS and AOFAS scores, or grip strength between the group of patients with or without floating toes. CONCLUSION: The presence of a floating toe deformity was more frequent than generally believed but did not have a meaningful impact on the patient's satisfaction or functional outcomes measured by the AOFAS and LEFS scales. There was no clear correlation between operative technique, floating toe, and quality of prehension force. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Transphyseal anterior cruciate ligament reconstruction in patients with open physes: 10-year follow-up study.

BACKGROUND: The treatment of anterior cruciate ligament (ACL) injuries in skeletally immature patients is controversial. Current evidence supports the view that surgical techniques restore knee stability and prevent progressive articular damage. However, most of the studies on this topic are small case series or they have short- or medium-term follow-up times. PURPOSE: To determine the long-term functional outcomes and secondary complications of transphyseal intra-articular ACL reconstruction with hamstring graft in skeletally immature patients. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Transphyseal ACL reconstruction with autograft hamstrings was performed in 27 skeletally immature patients. The average age at surgery was 13 years (range, 12-16 years), and the average follow-up time was 10.6 years (range, 10-13 years). Clinical outcomes were assessed with preoperative and final follow-up Tegner, International Knee Documentation Committee (IKDC) subjective, and Lysholm scores. Surgery details, return to sports, and ACL reconstruction failures were collected. The anteroposterior knee laxity was assessed by arthrometry, and the presence of deformities and lower limb length discrepancies were evaluated by radiographs. The presence of degenerative signs on anteroposterior and lateral knee radiographs at final follow-up was also evaluated. RESULTS: Transphyseal ACL reconstruction was performed with vertically oriented tunnels, 7 to 10 mm in diameter, using semitendinosus-gracilis autograft. The average preoperative Tegner, IKDC, and Lysholm scores were 7, 55, and 40, respectively. Significant differences in these scores were observed at the time of the final assessment (Tegner, 6 [P = .026]; IKDC, 94 [P < .001]; Lysholm, 92 [P < .001]). Two patients reported instability during sports activity. Three patients had a rupture of the ACL graft. No leg length discrepancy, axis malalignment, or degenerative changes were observed. CONCLUSION: The transphyseal ACL reconstruction in skeletally immature patients is a safe option, with high functional and satisfaction results, without significant growth plate damage in this series of patients.

Mini-open tenorrhaphy of acute Achilles tendon ruptures: medium-term follow-up of 100 cases.

BACKGROUND: The high incidence of soft tissue complications related to open Achilles repair has driven enthusiasm for developing minimally invasive surgical procedures. The Dresden procedure, which reduces wound-healing issues and avoids sural nerve damage, has recently been published and shows good functional results. OBJECTIVE: To evaluate medium-term clinical results of procedures using the Dresden mini-open technique on acute Achilles tendon ruptures. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective analysis was performed on 100 consecutive patients with a mean follow-up of 42.1 months. At follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) score, time to return to work and sports, subjective satisfaction, and complications were registered. An isokinetic test was performed on the first 21 patients of this series at 1 year postoperatively. RESULTS: The mean time to return to work was 56.0 days, and the mean time to return to sports was 18.9 weeks. The mean AOFAS score was 97.7; 98% of patients were satisfied. No complications regarding soft tissues and sural nerve damage were reported. Two reruptures and 5 cases of deep venous thrombosis were observed. The isokinetic evaluation showed good recovery of the involved muscles. CONCLUSION: The excellent functional and satisfaction results, ease of the procedure, and avoidance of sural nerve damage make the mini-open technique a very attractive alternative for acute, spontaneous Achilles tendon ruptures.

Proximal oblique sliding closing wedge osteotomy for hallux valgus.

BACKGROUND: The proximal oblique sliding closing wedge osteotomy (POSCOW) technique was developed to address moderate to severe hallux valgus deformity. We present a retrospective multicenter study to analyze the midterm radiological and clinical outcomes of patients treated with this type of proximal osteotomy fixed with plates. MATERIALS AND METHODS: One hundred and forty-four patients (187 feet) were operated on between May 2005 and June 2010 in 2 separate centers. Inclusion criteria were symptomatic moderate to severe incongruent hallux valgus deformity, no significant restriction in the first metatarsophalangeal joint movement, none to minimal degenerative changes in the first metatarsophalangeal or the tarsometatarsal joints, and no hypermobility. The median age was 60 years. The preoperative hallux valgus angle (HV) was 35.6 degrees, intermetatarsal angle (IM) was 15.3 degrees, AOFAS score was 53 points. The median follow-up was 35 months (range, 12-73). A POSCOW osteotomy was performed in all patients and fixed with plates. We recorded the satisfaction rate, postoperative clinical and radiological results, and complications. RESULTS: The patient satisfaction rate was 87%. The mean postoperative HV angle was 12.3 degrees, IM angle 4.8 degrees, AOFAS score 89 points. The mean decrease in the first metatarsal length was 2.2 mm (range, 0-8). Twelve feet (6.4%) with recurrence of the deformity required revision surgeries. Removal of complete or partial hardware was needed in 23 feet (12.3%) for symptomatic hardware. Five feet (2.6%) developed hallux varus but only 2 required surgery. Transfer metatarsalgia was noted in 9 feet (4.8%). CONCLUSIONS: The POSCOW osteotomy was an effective and reliable method for relieving pain and improving function. A learning curve was present, as most of the complications happened in the initial cases. To our knowledge, this is the largest reported series of proximal closing wedge osteotomy for hallux valgus deformities. LEVEL OF EVIDENCE: Level IV, case series.

Etiologia atipica de lesion ciclope: reporte de un caso / Atipical presentation of ciclops syndrome

El síndrome Cíclope se caracteriza por dolor asociado a la pérdida de la extensión de la rodilla luego de una reconstrucción artroscópica del ligamento cruzado anterior (LCA). Este cuadro clásicamente se debe a la formación de un nódulo fibroso dependiente del injerto, que produce limitación de la extensión articular. Nosotros presentamos el caso de un paciente varón de 22 años, de alta y completamente recuperado luego de su cirugía de reconstrucción del LCA, que presenta 2 años después dolor y pérdida en la extensión de la rodilla operada. El estudio imagenológico resultó compatible con una lesión Cíclope del LCA, sin embargo, tanto la artroscopía como la histología de la lesión no concuerdan con lo clásicamente descrito, ya que esta lesión fue causada por una lesión parcial del injerto semitendinoso/gracilis; por estas razones describimos este caso clínico como atípico.

Etiologia atipica de lesion ciclope: reporte de un caso / Atipical presentation of ciclops syndrome

El síndrome Cíclope se caracteriza por dolor asociado a la pérdida de la extensión de la rodilla luego de una reconstrucción artroscópica del ligamento cruzado anterior (LCA). Este cuadro clásicamente se debe a la formación de un nódulo fibroso dependiente del injerto, que produce limitación de la extensión articular. Nosotros presentamos el caso de un paciente varón de 22 años, de alta y completamente recuperado luego de su cirugía de reconstrucción del LCA, que presenta 2 años después dolor y pérdida en la extensión de la rodilla operada. El estudio imagenológico resultó compatible con una lesión Cíclope del LCA, sin embargo, tanto la artroscopía como la histología de la lesión no concuerdan con lo clásicamente descrito, ya que esta lesión fue causada por una lesión parcial del injerto semitendinoso/gracilis; por estas razones describimos este caso clínico como atípico.(AU)