Minimally invasive Dorsal cheilectomy and Hallux metatarsophalangeal joint arthroscopy for the treatment of Hallux Rigidus.

BACKGROUND: Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus (HR). To reduce some of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can be performed in addition to address the intra-articular pathology associated with Hallux Rigidus. This study aims to examine the effectiveness of MIDC with first MTP arthroscopy in patients with HR with a minimum 1-year follow-up. METHODS: This was a multicenter retrospective review for adult patients with Coughlin and Shurnass Grade 0-3 who were treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of follow-up data. Demographic information, first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ-5D-5 L scores were collected. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant. RESULTS: A total of 31 patients were included in the study. Average follow-up time was 16.5 months (range: 12 to 26.2). There was 1 (3.2%) undersurface EHL tendon tear, 2 (6.5%) conversions to an MTP fusion, and 1 (3.2%) revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient's ROM in dorsiflexion (50 vs 89.6 degrees, P = 0.002), postoperative VAS pain scores (6.4 vs 2.1, P < 0.001), MOXFQ pain scores (58.1 vs 30.7, P = 0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P = 0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P = 0.002), and MOXFQ Index scores (54.7 vs 22.4, P < 0.001). CONCLUSION: We found that MIDC with first MTP arthroscopy was effective at improving patient-reported outcomes at one year with low complication and revision rates. These results suggest that MIDC with first MTP arthroscopy is an effective treatment for early-stage HR. LEVEL OF EVIDENCE: IV.

Cartiva interpositional arthroplasty versus arthrodesis in the treatment of Hallux rigidus: A retrospective comparative study with mean 2 year follow up.

BACKGROUND: Hallux rigidus is a common condition characterised by first metatarsophalangeal joint (MTPJ) degeneration, pain and limited range of motion (ROM). The gold standard surgical treatment is arthrodesis, providing good pain relief, but sacrifices ROM. The Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst preserving range of motion. Current evidence for Cartiva SCI is limited. The aim was to evaluate the clinical outcomes of Cartiva SCI compared to arthrodesis undertaken in our centre. METHODS: A retrospective cohort study was conducted, enrolling all adult patients who underwent primary first MTPJ SCI arthroplasty or arthrodesis for the treatment hallux rigidus. The primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ). Secondary outcomes included EQ-5D, complication rates, VAS Pain and FAAM (ADL). RESULTS: Between 2017 and 2020 there were 33 cases divided into two groups (17 Cartiva SCI, 16 arthrodesis, mean age 59.0 ± 9.9 years) with a mean follow up of 2.3 years. There was no statistically significant difference in any of the MOXFQ, EQ-5D, VAS Pain or FAAM (ADL) outcome scores between the Arthrodesis and SCI groups (p > 0.05). The mean MOXFQ Index score was 7.2 ± 6.4 for the SCI group and 3.9 ± 5.8 for the Arthrodesis group at final follow up (p = 0.15). Although complications were high in both groups, the overall hallux reoperation rate was 29.4 % in the SCI cohort and 0.0 % for arthrodesis. CONCLUSION: This retrospective comparative study found no significant superiority of Cartiva SCI over arthrodesis in terms of PROMs. Due to the higher rate of further surgical intervention in the SCI cohort, we recommend arthrodesis as the preferred surgical option for hallux rigidus. LEVEL OF EVIDENCE: III.

Minimally invasive Chevron-Akin (MICA) osteotomies without Akin fixation in hallux valgus correction: a case series with 2-year follow-up.

PURPOSE: The minimally invasive Chevron-Akin (MICA) is considered the third generation of minimally invasive hallux valgus (HV) surgery, and its original description included fixation of the Akin osteotomy with a screw. The aim of this study is to evaluate a series of patients undergoing HV correction using the MICA technique without screw fixation of the Akin osteotomy. METHODS: We retrospectively evaluated 58 consecutive patients who underwent surgical correction for HV between August 2018 and March 2020. A total of 69 feet were evaluated with a minimum follow-up of 2 years. Clinical outcomes such as pain (VAS), function (AOFAS), range of movement, criteria personal satisfaction and complications were evaluated. RESULTS: The AOFAS score (mean ± standard deviation) significantly improved from 57.0 ± 8.6 preoperatively to 93.9 ± 8.7 postoperatively (p < .001) with a minimum follow-up of 2 years. The VAS score improved from 6.0 ± 1.8 preoperatively to 0.6 ± 1.4 at 2-year follow-up (p < .001), and the hallux valgus angle reduced from 39.7 ± 6.9 to 8.9 ± 9.0 (p < .001). The majority of patients (95.6%) reported the result as excellent or good, and the most common complication was the need to remove the screw (7.2%). CONCLUSIONS: The use of MICA without Akin osteotomy fixation resulted in successful correction of hallux valgus with improvements in clinical and radiographic parameters. LEVEL OF EVIDENCE: IV, case series.

Treatment of hallux rigidus with percutaneous metatarsophalangeal arthrodesis: a case series with a minimum follow-up of 2 years.

BACKGROUND: Percutaneous metatarsophalangeal arthrodesis is an option for the treatment of hallux rigidus in more advanced cases. The aim of this study was to investigate the clinical and radiographic results at least 2 years after percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus. METHODS: This is a case series of consecutive patients undergoing percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus grades III and IV with a minimum of 24 months of clinical and radiographic follow-up. The primary outcome was clinical assessment using the Visual Analog Scale for Pain (VAS). Secondary outcomes included American Orthopedic Foot & Ankle Society (AOFAS) score, patient satisfaction, complications, and bone healing (radiographic analysis). RESULTS: Between August 2017 and February 2020, 29 feet (24 patients) underwent percutaneous metatarsophalangeal arthrodesis. The mean follow-up was 38.4 (range 24-54) months. There was an improvement in the pain (VAS) from 7.8 to 0.6 (p < 0.001) and in the AOFAS score from 49.9 to 83.6 (p < 0.001). There was a rate of bone union of 82.8% and screw removal of 13.8%. All patients considered the result to be excellent or good. CONCLUSION: The treatment of grade III and IV hallux rigidus with percutaneous metatarsophalangeal arthrodesis demonstrated high patient satisfaction and significantly improves in clinical outcomes but the nonunion rate was higher than reported outcomes for open 1st metatarsophalangeal joint arthrodesis. LEVEL OF EVIDENCE: IV, case series.

Halving the usage of rigid-soled postoperative shoes does not affect outcomes in forefoot reconstruction surgery.

BACKGROUND: Postoperative shoes are commonly used after forefoot surgery. This study's aim was to demonstrate that reducing rigid-soled shoe time to 3 weeks neither compromises functional outcomes nor does it produce complications. METHODS: Prospective cohort study: 6 weeks versus 3 weeks of rigid postoperative shoe (100 and 96 patients respectively), after forefoot surgery with stable osteotomies. Manchester-Oxford Foot Questionnaire (MOXFQ) and pain Visual Analog Scale (VAS) were studied preoperative and one year postoperative. Radiological angles were also assessed after removing the rigid shoe and at 6 months. RESULTS: The MOXFQ index and pain VAS depicted similar results in each group (group A: 29.8 and 25.7; group B: 32.7 and 23.7) with no differences between them (p = .43 Vs. p = .58). Moreover, no differences were reported in their differential angles (HV differential-angle p = .44, IM differential-angle p = .18) or in their complication rate. CONCLUSION: In forefoot surgery with stable osteotomies, shortening the postoperative shoe time to 3 weeks, neither impairs clinical results nor the initial correction angle.

Outcome Assessment Performance of the SF-36, Manchester-Oxford Foot Questionnaire and AOFAS in Forefoot Reconstruction Surgery.

The purpose of this study was to investigate the measurement properties of the Short Form 36 (SF-36) to detect real change after forefoot reconstruction surgery. Responsiveness and minimally important change estimates were compared with those from the Manchester-Oxford Foot Questionnaire (MOXFQ) and the American Orthopaedic Foot and Ankle Society (AOFAS) measures. Eighty-three patients awaiting surgery were recruited. Patients completed pre- and 12 months postoperative the SF-36 and the MOXFQ. A surgeon assessed the AOFAS scores. The responsiveness to change was determined using the effect size (ES), the minimal detectable change (MDC) and the minimal clinically important change. Two subscales of the SF-36 demonstrated significant improvement, bodily pain (BP) and mental health. Only the BP domain appeared the most responsive with an ES of 0.73. All domains of the MOXFQ and AOFAS produced much larger effect sizes (ES > 1.5). MDC values for the majority of the SF-36 domains fell within measurement error except for the BP domain. Fewer patients showed significant improvement when compared with the MOXFQ pain domain. In conclusion, the SF-36 measuring tool proved to be neither reliable nor responsive enough to detect real change after forefoot surgery. Though the BP domain appeared to be the most responsive, it failed to detect meaningful change when compared to the MOXFQ-Pain and the Visual Analogue Scale.

Subjective and Objective Outcomes of Surgery for Rheumatoid Forefoot Deformities Under the Current Treatment Paradigm.

We investigated the clinical outcomes of surgical procedures for the treatment of forefoot deformities in patients with rheumatoid arthritis. Twenty feet in 16 women (mean age 62.1 years) underwent corrective osteotomy of the first metatarsal bone with shortening oblique osteotomy of the lesser metatarsophalangeal joints (joint-preservation group), while 13 feet in 12 women (mean age 67.4 years) underwent arthrodesis of the first metatarsophalangeal joint with resection arthroplasty of the lesser metatarsophalangeal joints (joint-sacrifice group); mean follow-up for each group was 25.8 and 23.8 months, respectively. The mean total Japanese Society for Surgery of the Foot (JSSF) scale improved significantly from 64.2 to 89.2 in the joint-preservation group (p < .001), and from 54.2 to 74.2 in the joint-sacrifice group (p = .003). In the joint-preservation group, the postoperative range of motion (ROM) of the joint, walking ability, and activities of daily living scores of the JSSF scale were significantly higher than those in the joint-sacrifice group (p = .001, p = .001, and p = .019, respectively). There were no differences in the subscale scores of the self-administered foot evaluation questionnaire between 2 groups either pre- or postoperatively. No differences in the postoperative complications were found between 2 groups. Although the joint-sacrificing procedure resulted in lower objective outcomes than the joint-preserving procedure regarding the ROM of the joint, the walking ability, and the level of activities of daily living, both procedures resulted in similar treatment outcomes when evaluated by the subjective measures.

Effect of gait protocols and postoperative shoes on off-loading of forefoot in preoperative patients for forefoot disorders.

OBJECTIVES: The purpose of this study was to clarify the effect of gait protocols and postoperative shoes on forefoot load in preoperative patients for forefoot disorders and compare footwear comfort between different types of postoperative shoes. METHODS: Fourteen subjects scheduled to undergo forefoot surgeries were recruited. The maximum force under the forefoot region was measured during 10 m straight walking in two gait patterns with six different shoe types. Visual analogue scale (VAS) scores for footwear comfort, subjective lower thigh pain, and electrical activities of lower thigh muscles were also evaluated. RESULTS: The body weight-normalized maximum force under the forefoot region significantly decreased in step-to gait compared to normal gait regardless of the shoe types used. Under the same gait condition, no significant difference was observed in the forefoot off-loading effect between the different shoe types used. Significantly worse VAS scores, significantly higher tibialis anterior muscle activities, and complaints of lower thigh pain were demonstrated in the gait with the reverse camber shoe. CONCLUSIONS: Gait protocol of step-to gait had more forefoot off-loading effect than postoperative shoes. The forefoot off-loading effect did not differ among the postoperative shoes, suggesting that postoperative shoes can be selected with an emphasis on footwear comfort.

The influence of partial weight bearing on plantar peak forces using three different types of postoperative shoes.

BACKGROUND: Therapeutic shoes and partial weight bearing regimes are used after foot surgery to prevent the operated region from excessive load. It remains unclear to which extent partial weight bearing reduces the plantar peak forces. Therefore, we investigated the correlation of weight bearing and plantar peak forces in commonly used therapeutic shoes. METHODS: Three different weight bearing regimes (20 kg, 40 kg, full weight) were investigated in 20 healthy volunteers. Sensor insoles were used to measure peak forces of the forefoot, midfoot, heel and the complete foot using four kind of shoes (bandage shoe, forefoot relief shoe, short walker and standard sneaker). Peak forces were compared between shoes using one-way ANOVA. The influence of partial weight bearing relative to the peak forces was examined by linear regression analysis. RESULTS: All therapeutic shoes reduced significantly peak forces of the fore- and midfoot when compared to the reference shoe; the largest reduction was achieved by the forefoot relief shoe (-70 % at forefoot). Weight load and the resulting peak force showed a positive linear correlation for all regions and shoe types. Partial weight bearing significantly reduced the forefoot's force ratio compared to full weight bearing for all shoes except the forefoot relief shoe. CONCLUSIONS: Partial weight bearing is a strong instrument to reduce plantar peak forces of the forefoot, additionally to the proven offloading effect of therapeutic shoes.

Time to maximum clinical improvement following minimally invasive chevron and Akin osteotomies (MICA) in hallux valgus surgery.

BACKGROUND: There is increasing evidence of positive improvement in clinical and radiological outcomes following minimally invasive hallux valgus deformity correction surgery (MIS). This study investigated the rate of improvement in clinical patient reported outcome measures (PROMs) following MIS as this is not well understood. METHODS: Between July 2014 and July 2019, data was prospectively collected from consecutive patients pre-operatively and at 6, 12, and 24 months following third-generation minimally invasive chevron and Akin osteotomies (MICA). Radiographic deformity and correction was assessed using weight-bearing radiographs pre-operatively and 6 weeks post-operatively. The primary outcome measure was the change in Manchester Oxford Foot Questionnaire (MOXFQ) score at each time point. Secondary outcomes include radiographic deformity correction, health-related quality of life PROMs and exploration of cases where PROMs did not improve. RESULTS: There were 202 feet with complete PROM data for every time point. There was a statistically significant improvement in MOXFQ Index score at each time point (p < 0.05) following MICA surgery. The majority of the improvement occurred within the first 6 months. A subgroup of 17 feet (8.4%) were identified which had worse MOXFQ Index scores 6 months following MICA. For 14 feet in this subgroup (82.4%), the MOXFQ Index score subsequently improved over time such that by two years, their score had significantly improved compared to their pre-operative score. CONCLUSION: The majority of PROM improvement with MICA is gained by 6 months post-operatively but further significant improvement can be seen up to 2 years. Those patients who have not improved at 6 months, are likely to do so with time. LEVEL OF EVIDENCE: IV.

Minimally invasive surgery for severe hallux valgus in 106 feet.

BACKGROUND: There is widespread variation in the optimal procedure for correction of severe hallux valgus deformity defined as hallux valgus angle (HVA) (≥40°) and/or 1-2 intermetatarsal angle (IMA) (≥20°). There is limited evidence investigating the clinical or radiological outcomes following treatment of severe hallux valgus deformity with third-generation minimally invasive chevron and Akin osteotomies (MICA). METHODS: This was a prospective observational single surgeon series of consecutive patients who underwent primary third-generation MICA with screw fixation for severe hallux valgus. The primary outcome was a validated patient reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ), assessed minimum 2 years following MICA. Secondary outcomes were radiographic deformity correction (assessed 6 weeks post-operatively), complication rates and other quality of life PROMs (EQ-5D and Visual Analogue Pain Scale). RESULTS: Between September 2014 and November 2018, 106 consecutive feet (n = 78 patients; 73 female, 5 male) met the inclusion criteria. Prospectively collected pre-operative and 2 year PROM MOXFQ data was available for 86 feet (81.1%). At two years following surgery, the MOXFQ score significantly improved for the Pain, Walking and Standing and Social Interaction domains from 39.2 to 7.5, 38.2 to 5.9 and 48.6 to 5.5, respectively (p < 0.001). Pre- and 6 week post-operative radiographic data was available for all 106 feet. Mean IMA improved from 18.2° to 6.3° (p < 0.001) whilst mean HVA improved from 45.3° to 10.9° (p < 0.001). The complication rate was 18.8% and the screw removal rate was 5.6%. CONCLUSION: This study has demonstrated third-generation MICA for the treatment of severe hallux valgus deformity enables substantial deformity correction and is associated with significant improvements in clinical PROMs 2 years following surgery.

The impact of hallux valgus on function and quality of life in females.

BACKGROUND: The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity. METHODS: Weight bearing radiographic data (hallux valgus (HVA) angle; intermetatarsal (IM) angle) were measured in consecutive female patients presenting with HV. Each patient prospectively completed the Euroqol EQ-5D-5L questionnaire (EQ-5D), Visual Analogue Scale for Pain (VAS-Pain) and Manchester Oxford Foot Questionnaire (MOXFQ). Data were stratified into age ranges and compared with an EQ-5D United Kingdom general population reference dataset. Pearson R correlation values were calculated for the PROMs and radiographic deformity. RESULTS: Between July 2015 and March 2020, 425 consecutive female patients presented with HV for consideration for surgery. EQ-5D-5L data were prospectively collected for 396 of these patients (93.2%). Females less than 65 years with HV had a statistically significantly worse quality of life compared with females of the same age group in the general population. Above the age of 65, there was no statistically significant difference in EQ-5D-5L Index score between the two groups. Younger females reported higher VAS-Pain scores compared to older patients with 91% of patients reporting some degree of pain symptoms. There was a moderate correlation with MOXFQ Index score and EQ-5D-5L Index (R = -0.51, p < 0.001) and VAS-Pain scores (R = 0.54, p < 0.001). There was no correlation between radiographic HV deformity and HRQOL measures or MOXFQ scores although it was noted that there was a trend of increasing HVA/IMA with age. CONCLUSION: Female patients presenting with HV deformity have a significantly reduced quality of life compared with the UK general population. The radiographic severity of deformity did not correlate with HRQOL measures or foot and ankle specific PROMs. Foot and ankle specific clinical PROMsmoderately correlate with HRQOL and may be a better marker of the negative effect of symptomatic hallux valgus deformity on quality of life. LEVEL OF EVIDENCE: III.

Mid-Term Functionality and Survival of 116 HemiCAP® Implants for Hallux Rigidus.

Hallux rigidus can be treated with a proximal hemiarthroplasty (HemiCAP®) to preserve the motion in the first metatarsophalangeal joint and reduce pain. This study examines the functionality, and survival rates of HemiCAP® implants, with or without a dorsal flange. One hundred and five patients were treated with a HemiCAP® (N = 116 HemiCAPs®) between 2006 and 2014. Revision rates, arthrosis score, hallux valgus (HV), intermetatarsal (IM), distal metaphyseal articular angle (DMAA), visual analog scale (VAS) (1-10 points), American Orthopaedic Foot and Ankle Score (AOFAS) MTP-IP (AOFAS 0-100 points), SF-12, range of motion (ROM), and radiographs were analyzed pre- and postoperatively. Statistics: Kaplan-Meier survival analysis, Cox-regression, and paired t tests. At 2, 4, and 6 years, the implant survival was 87%, 83%, and 81%, respectively. All revised due to pain. Dorsal flange, gender, arthrosis, HV, IM, and DMAA did not influence the results. At the mean 5-year follow-up (n = 47) median (range) dorsal ROM was 45° (10°-75°), AOFAS was mean 87.2 ± 10.8, VAS was 2 ± 1.6, and SEFAS was 42 ± 6 points. The dorsal flange made no significant difference for ROM or patient-reported outcome measures compared to the HemiCAP® with no dorsal flange. Twenty-three patients with preoperative data were re-examined, and preoperative dorsal ROM mean difference (confidence interval [CI]) increased 20.7° (13.9°-27.4°), VAS decreased with a mean difference (CI) of -4.7 (-5.8 to 3.5), and AOFAS increased with a mean difference (CI) 26.2 (20.2-32.2) (for all p < .001). The 6-year survival rate of the HemiCAP® implant was 81%. The design change to dorsal flange was not evident clinically. Unrevised patients had significantly less pain, greater ROM, and better foot and ankle function than preoperatively.

Preoperative Japanese Society for the Surgery of the Foot Lesser toe score and erythrocyte sedimentation rate influence wound healing following rheumatoid forefoot surgery.

OBJECTIVES: Delayed wound healing is one of the most common complications following forefoot surgery in patients with rheumatoid arthritis. We aimed to identify the risk factors for delayed wound healing following rheumatoid forefoot surgery. METHODS: Consecutive patients who underwent primary rheumatoid forefoot surgery (86 feet; 53 patients) between April 2008 and February 2019 were retrospectively evaluated. Clinical data, including smoking history, duration of the disease, presence of diabetes mellitus, medication, white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein, the surgical procedure performed, and the Japanese Society for Surgery of the Foot (JSSF) scores, were collected. RESULTS: Delayed wound healing was identified in 20 of 86 (23.3%) feet. In univariate analysis, participants showing delayed healing were older at the time of surgery (p = .04), their ESR was higher (p = .0006), and their total (p = .019) and pain (p = .016) scores on the JSSF Lesser toe scale were lower than those showing normal healing. In multivariable analysis, both the total preoperative JSSF Lesser toe scale score (p = .0239) and ESR (p = .0126) remained significant risk factors for delayed wound healing. CONCLUSIONS: After rheumatoid forefoot surgery, surgeons should pay more attention to wound care in patients with lower preoperative JSSF Lesser toe score and high ESR.

The Ischemic toe following forefoot surgery: A review of current practices and a proposed approach for management.

Toe hypoperfusion is a commonly encountered concern following forefoot surgery, yet there is limited clinical guidance available to surgeons to aid in management of this scenario. This work aims to review the etiology, pathophysiology and current strategies to address a perioperative ischemic toe. The authors review various interventions to approach this problem based on available evidence and clinical experience. Interventions to restore perfusion can be loosely based on the ischemic causality they intend to address. Described maneuvers to restore perfusion have, in turn, been designed to either chemically (through topical/local medication) or mechanically (bending/removing K-wires, adjusting repair tension) aid in mitigation of the offending cause. Depending upon the type of surgery performed, which may or may not include instrumentation, a surgeon can implement a series of steps to maximize restoration of toe perfusion. LEVEL OF EVIDENCE: V.

Effects of range of motion exercise of the metatarsophalangeal joint from 2-weeks after joint-preserving rheumatoid forefoot surgery.

Objectives: Joint-preserving rheumatoid forefoot surgery improves clinical outcomes, but postoperative range of motion (ROM) of the metatarsophalangeal (MTP) joint remains an issue. The objective of this study was to evaluate the effect of ROM exercise from the early period after lesser toe MTP joint-preserving surgery.Methods: A retrospective, observational study of 22 rheumatoid arthritis patients who underwent modified metatarsal shortening offset osteotomy was completed. Lesser toe scales were administered using the Japanese Society for Surgery of the Foot (JSSF) standard rating system, and the maximum distance of continuous walking was checked to evaluate clinical outcomes. Maximum passive ROM of the lesser toe MTP joints and the extension angle of the 2nd MTP joint at the terminal stance phase during gait were measured and evaluated.Results: Pain scores and ROM-related indices of the JSSF lesser toe scale improved significantly in the exercise group. The extension angle of the 2nd MTP joint at the terminal stance phase during gait was increased, and the maximum distance of continuous walking seemed longer.Conclusion: Passive/active ROM exercise from 2-weeks after surgery can improve a patient's activity and forefoot function through increasing ROM of the MTP joint at the terminal stance phase.

Percutaneous surgery of the forefoot compared with open technique - Functional results, complications and patient satisfaction.

BACKGROUND: The use of percutaneous surgery is currently very common in foot and ankle surgery. The following prospective open-label patient-preference based study compares the traditional open technique versus the percutaneous surgery technique. METHODS: The current study describes the results of 287 patients operated due to forefoot deformities either by open surgery or percutaneously. 96 of them underwent hallux valgus corrective surgery. The rest had lesser toe deformities. They were followed for a period of up to 24 months, to assess the surgery related pain, complications, and patient satisfaction. 112 patients were operated using a conventional open technique were compared to 175 patients treated using a percutaneous technique. Technique choice was left to the patient preference, though older patients with disturbed blood flow, were advised to undergo percutaneous surgery. RESULTS: There is less pain using the percutaneous techniques relative to the open technique during the first 6 post-operative weeks. The 6, and 24 months FAOS score is similar in both groups. Complications are rare in any of the groups, with a significantly higher ASEPSIS score in the open surgery group. CONDCLUSIONS: Percutaneous forefoot surgery appears safe and efficacious, demonstrating equal radiographic (in a 96 strong cohort of hallux valgus patients) and clinical results at six and 24 months. Due to less post-operative pain, and less infection risk it appears that percutaneous techniques are superior to open technique in some respects of treatment and indeed the PGIC of patients was significantly higher in this group.

Radiographic and Clinical Comparison of Proximal Interphalangeal Joint Arthrodesis Between a Static and Dynamic Implant.

Hammertoe deformation is a frequent motive for consultation in forefoot surgery, and proximal interphalangeal joint arthrodesis is a classic treatment for fixed deformation, which tends to be achieved more and more thanks to specific implants. This work evaluated and compared clinical improvement, radiologic fusion, and complication rates between dynamic (Difuse®) and static (TinyFix®) implants from Biotech Ortho. A total of 95 patients (110 feet and 166 toes; 97 static and 69 dynamic implants) were included. Mean age was 63.6 (±12.6) years in the dynamic group and 62.3 (±14.01) years in the static group. Epidemiologic and intraoperative radiologic data were collected. Pain, toes deformity, complications, and radiologic findings (bone fusion and osteolysis) were recorded at 4 months postoperatively and at the last follow-up. Mean follow-up was 11.5 (range 4 to 28) months, and the position of the implants was more often satisfying in the dynamic group (p = .01). Fusion rates at 4 months were 67% and 80% in the dynamic and static groups, respectively (p = .05). Radiologic osteolysis occurred more frequently in the dynamic group (p = .05 at 4 months), and pain was still present in 3% in the dynamic group at the last follow-up compared with 7% in the static group. Complication rate was 7% in the dynamic group (implant fractures) and 4% in the static group. Revision was considered more often in the dynamic group (p = .01). The static titanium implant seems superior to the dynamic memory shape implant in Nitinol alloy with regard to fusion (p = .04), complications (p = .03), and revision rates (p = .01). The literature review seems to support the good results of static implants compared with the rest of the available arthrodesis implant solutions.

Scarf versus long chevron osteotomies for the treatment of hallux valgus: A prospective randomized controlled study.

BACKGROUND: The aim of this study is to compare scarf osteotomy and long chevron osteotomy in treatment of hallux valgus deformity regarding operative time, power of correction and complications. DESIGN: A prospective randomized controlled comparative trial. METHODS: 48 cases with hallux valgus were divided randomly in 2 groups (21 treated by scarf and 22 treated by long chevron osteotomy and 5 were missed during follow up), average age 36 years, follow up time was average of 25.9 months. Patients were assessed clinically, radiologically, and functional scoring system of American College of Foot and ankle Surgeons (ACFAS)was used both pre and postoperatively. RESULTS: Operative time was 69min in scarf group compared to 63min to long chevron group, radiological correction showed no statistically significant difference between both groups while functional improvement in ACFAS score was in favour of long chevron group 69.1% compared to scarf group 57.5% CONCLUSIONS: Both osteotomies possess almost identical corrective power of the IMA (intermetatarsal angle) and similar clinical outcomes with slightly shorter operative time and subjective technical simplicity for the long chevron osteotomy.

Increased rates of delayed union after percutaneous Akin osteotomy.

BACKGROUND: Akin osteotomy is a well-known surgical procedure in forefoot surgery. When performing percutaneously, we have found a lot of delayed unions on follow up X-rays. The objective of this study was to assess the incidence of delayed union when performing a percutaneous Akin osteotomy. METHODS: We report a series of 26 cases who underwent minimally invasive (percutaneous) Akin osteotomy. The mean follow-up duration was 17.6 (range 12 to 24) months. We analys-24) months. We analyzed the time to fusion using standard weight bearing radiographs. All the procedures were uneventful and we had only two skin burns that healed without sequelae. RESULTS: All the procedures were uneventful and we had only two skin burns that healed without sequelae. The average time to fusion in our series was 4.69 months (2-11): seventeen of the 26 osteotomies (65.4%) were considered radiographically healed at an average time of 2,94 months (2-5), whereas 9 patients (34.6%) sustained a delayed-union and healed at an average of 8 months (7-11). CONCLUSIONS: Despite few intraoperative complications and satisfactory clinical and radiological outcomes, our data suggest that a delayed union after Akin osteotomy is very common in the daily practice when performing it through a minimally invasive technique.