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Lopes R, Moussa MK, Hardy A. Percutaneous Calcaneal Osteotomy Combined With Arthroscopic Lateral Ankle Ligament Reconstruction for Chronic Ankle Instability With Hindfoot Varus. Arthrosc Tech 2024; 13:102989. [PMID: 39100272 PMCID: PMC11293359 DOI: 10.1016/j.eats.2024.102989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/17/2024] [Indexed: 08/06/2024] Open
Abstract
Chronic ankle instability is the most frequent complication of lateral ankle sprain. Its reported incidence is approximately 40% after the first episode of instability. Although this rate varies depending on the type of activity, there are also certain risk factors associated with this condition, such as hyperlaxity, static or dynamic postural control deficits, and especially, hindfoot varus. If hindfoot varus is not managed when medical treatment fails and surgery is necessary, treatment may be unsuccessful, resulting in a poorer functional outcome and a higher rate of recurrent instability. Open hindfoot varus correction is often associated with poor wound healing and infectious complications. If ligament repair is also performed, the risk is increased by the numerous incisions. This article presents an arthroscopic lateral ankle ligament anatomic reconstruction technique with the gracilis tendon associated with percutaneous calcaneal osteotomy for the treatment of chronic ankle instability.
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Siddiqui AA, Troyer WD, Bango J, Mustafa MS, Buckner JF, Shi GG, Haupt ET. Lateralizing calcaneal osteotomy performed with a percutaneous burr results in a significantly lower increase in tarsal tunnel pressure. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1865-1870. [PMID: 38431895 DOI: 10.1007/s00590-024-03865-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/16/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE Tarsal tunnel syndrome is well documented following lateralizing calcaneal osteotomy to manage varus hindfoot deformity. Traditionally, calcaneal osteotomy is performed with an oscillating saw. No studies have investigated the effect of alternative surgical techniques on postoperative tarsal tunnel pressure. The purpose of this study was to investigate the difference in tarsal tunnel pressures following lateralizing calcaneal osteotomy performed using a high-torque, low-speed "minimally invasive surgery" (MIS) Shannon burr versus an oscillating saw. METHODS Lateralizing calcaneal osteotomy was performed on 10 below-knee cadaveric specimens. This was conducted on 5 specimens each using an oscillating saw (Saw group) or MIS burr (Burr group). The calcaneal tuberosity was translated 1 cm laterally and transfixed using 2 Kirschner wires. Tarsal tunnel pressure was measured before and after osteotomy via ultrasound-guided percutaneous needle barometer. Mean pre/post-osteotomy pressures were compared between groups. Differences were analyzed using Student's t test. RESULTS The mean pre-procedure tarsal tunnel pressure was 25.8 ± 5.1 mm Hg in the Saw group and 26.4 ± 4.3 mm Hg in the Burr group (p = 0.85). The mean post-procedure pressure was 63.4 ± 5.1 in the Saw group and 47.8 ± 4.3 in the Burr group (p = 0.01). Change in tarsal tunnel pressure was significantly lower in the Burr group (21.4 ± 4.5) compared to the Saw group (37.6 ± 12.5) (p = 0.03). The increase in tarsal tunnel pressure was 43% lower in the Burr group. CONCLUSION In this cadaveric study, tarsal tunnel pressure increase after lateralizing calcaneal osteotomy was significantly lower when using a burr versus a saw. This is likely because the increased width ("kerf") of the 3 mm MIS burr, compared to the submillimeter saw blade width, causes calcaneal shortening. Given the smaller increase in tarsal tunnel pressure, using the MIS burr for lateralizing calcaneal osteotomy may decrease the risk of postoperative tarsal tunnel syndrome. Future research in vivo should explore this.
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Affiliation(s)
- Ali A Siddiqui
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA.
- Department of Orthopaedic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA.
| | - Wesley D Troyer
- Department of Orthopaedic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jugert Bango
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
- Department of Orthopaedic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Moawiah S Mustafa
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
- Department of Orthopaedic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jeannie F Buckner
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida College of Medicine Jacksonville, Jacksonville, FL, USA
- Department of Orthopaedic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Glenn G Shi
- Department of Orthopaedic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Edward T Haupt
- Department of Orthopaedic Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
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Salameh M, Halayqeh S, Levine AR, Abousayed MM, Hsu R, Blankenhorn B. Displacement after Open vs Saw-Based Minimally Invasive Medial Displacement Calcaneal Osteotomy: A Cadaveric Study. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241255350. [PMID: 38827565 PMCID: PMC11143823 DOI: 10.1177/24730114241255350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024] Open
Abstract
Background Medial displacement calcaneal osteotomy (MDCO) is routinely used in hindfoot valgus realignment. Minimally invasive surgery (MIS) calcaneal osteotomies have been reported to be as safe and effective compared to open techniques. The aim of this cadaveric study was to compare the amount of medial tuberosity displacement obtained with fine-cut saw-based MIS vs open MDCO techniques. Methods Eight matched cadaveric specimens had one side randomly assigned to either open or MIS MDCO. The contralateral limb was then assigned to the alternative osteotomy. The amount of medial displacement provided by the osteotomy was measured manually using a flexible metric ruler and radiographically on standardized axial calcaneal radiographs. Results Manual measurements showed that a mean displacement of the MIS osteotomy was 7.9 mm compared with 8.7 mm for the open technique (P = .36). Radiograph measurement showed a mean displacement of the MIS osteotomy was 7.1 mm compared with 7.4 mm for the open technique (P = .83). No significant difference was found on manual and radiographic measurement of medial displacement between MIS and open MDCO. Conclusion In a cadaveric model, we found similar magnitude of calcaneal tuberosity displacement using fine-cut saw-based MIS and open techniques for medial displacement calcaneal osteotomies. Level of Evidence Level V, cadaveric study.
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Affiliation(s)
- Motasem Salameh
- Alpert Medical School at Brown University, Providence, RI, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | | | | | | | - Raymond Hsu
- Alpert Medical School at Brown University, Providence, RI, USA
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Vaggi S, Vitali F, Zanirato A, Quarto E, Colò G, Formica M. Minimally invasive surgery in medial displacement calcaneal osteotomy for acquired flatfoot deformity: a systematic review of the literature. Arch Orthop Trauma Surg 2024; 144:1139-1147. [PMID: 38212588 DOI: 10.1007/s00402-023-05188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/19/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Minimally invasive surgery (MIS) in medial displacement calcaneus osteotomy (MDCO) has been proposed for surgical correction of adult-acquired flat foot deformity (AAFD) to reduce complications of open approaches. The aim of our study is to systematically analyze complications and the clinical and radiological results of MIS- MDCO. METHODS A systematic review of the English literature was performed on 30th October 2023. Randomized controlled trials and non-randomized trials, cohort studies, case-control studies and case series concerning surgical correction of AAFD with MIS-MDCO and with at least 15 patients were included. Case reports, technical notes, animal or cadaveric studies were excluded. The quality and risk of bias of the studies included were evaluated using GRADE and MINORS systems. Complications rate, clinical and radiological results were inferred from the studies included. RESULTS Nine articles were included. A total of 501 cases treated with MIS-MDCO were analysed with a mean follow-up of 11.9 ± 5.1 months. The reported wound infection rate was about 3% and sural neuropathy was rated about 1%. Only 4% of the cases required removal of the screw for pain. In the comparative studies (MIS versus Open MDCO), comparable clinical results but with significant differences (P < 0.001) in infection rates (1% versus 14%) and sural neuropathy (2% versus 1%) were observed. CONCLUSION AAFD correction performed with MIS-MDCO, with the limitation of a poor quality and high risk of bias of the included studies, seems to provide good clinical results and high subjective satisfaction with a lower complication rate compared to open approach. Further high-quality long-term comparative studies could better clarify complications and clinical and radiological outcomes of the MIS technique in the treatment of AAFD. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- S Vaggi
- Dipartimento Di Scienze Chirurgiche E Diagnostiche Integrate, Università Degli Studi Di Genova - DISC, Viale Benedetto XV 6, 16132, Genova, GE, Italy
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
| | - F Vitali
- Dipartimento Di Scienze Chirurgiche E Diagnostiche Integrate, Università Degli Studi Di Genova - DISC, Viale Benedetto XV 6, 16132, Genova, GE, Italy
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
| | - A Zanirato
- Dipartimento Di Scienze Chirurgiche E Diagnostiche Integrate, Università Degli Studi Di Genova - DISC, Viale Benedetto XV 6, 16132, Genova, GE, Italy.
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy.
| | - E Quarto
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
| | - G Colò
- Orthopaedics and Traumatology Unit, SS Antonio and Biagio and Cesare Arrigo Hospital, 15121, Alessandria, Italy
| | - M Formica
- Dipartimento Di Scienze Chirurgiche E Diagnostiche Integrate, Università Degli Studi Di Genova - DISC, Viale Benedetto XV 6, 16132, Genova, GE, Italy
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
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Guirguis J, El Sayad M, Kakwani M, Townshend D, Kakwani R. Safety of the neurovascular bundles when performing minimally invasive calcaneal osteotomy: A cadaveric study. Foot Ankle Surg 2024; 30:161-164. [PMID: 37993357 DOI: 10.1016/j.fas.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/16/2023] [Accepted: 11/01/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Calcaneal osteotomies correct hindfoot deformities and are often performed using a minimally invasive technique. The aim was to compare the safety of three calcaneal osteotomy techniques (oblique, chevron with apex anterior and chevron with apex posterior). METHODS Each osteotomy technique was performed on five cadavers (n = 15). These were then dissected to identify any injury to the neurovascular bundles. The distance between the burr and these structures was measured. RESULTS Using the apex posterior technique, the burr was closer to the medial and lateral neurovascular structures, and in one case the sural nerve was injured. There were no neurovascular injuries using the other techniques. CONCLUSIONS Minimally invasive surgery using a burr is generally a safe, reliable method for performing calcaneal osteotomies. The chevron with apex posterior osteotomy should be performed with caution given the closer relationship between the burr and neurovascular bundles. The other two techniques provide safer alternatives. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- J Guirguis
- Northumbria NHS Foundation Trust, Wansbeck General Hospital Department of Trauma & Orthopaedics, Woodhorn Lane, Northumberland NE63 9JJ, UK.
| | - M El Sayad
- Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Gateshead, Tyne and Wear NE9 6SX, UK.
| | - M Kakwani
- University of Leeds, Woodhouse, Leeds, West Yorkshire LS2 9JT, UK.
| | - D Townshend
- Northumbria NHS Foundation Trust, North Tyneside General Hospital, Rake Lane, Tyne and Wear NE29 8NH, UK.
| | - R Kakwani
- Northumbria NHS Foundation Trust, North Tyneside General Hospital, Rake Lane, Tyne and Wear NE29 8NH, UK.
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Beischl S, Harrasser N, Toepfer A, Scheele C, Smits Sererna R, Walther M, Lenze F, Hörterer H. Feasibility and safety of minimally invasive calcaneal osteotomy (MICO) through a medial approach: a case-control study. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:39-46. [PMID: 38078936 PMCID: PMC10781868 DOI: 10.1007/s00132-023-04460-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Minimally invasive calcaneal osteotomy (MICO) is already an established surgical procedure for correcting hindfoot deformities using a lateral approach. So far, no description of a medial approach for MICO has been published. MATERIAL AND METHODS Between August 2022 and March 2023, 32 consecutive patients (MICO with medial approach, MMICO: n = 15; MICO with lateral approach, LMICO: n = 17) underwent MICO as part of complex reconstructive surgery of the foot and ankle with concomitant procedures. The amount of correction in the axial view of the calcaneus and consolidation rates were evaluated radiographically. Subjective satisfaction, stiffness of the subtalar joint, and pain level (numeric rating scale, NRS) at the level of the heel were assessed clinically. The last follow-up was at 6 months. RESULTS All osteotomies consolidated within 6 months after surgery. Displacement of the tuber was 9 mm on average in either group. Relevant subtalar joint stiffness was detected in 5 MMICO and 6 LMICO patients. No relevant differences between the groups were detected for wound healing problems, nerve damage, heel pain or patient satisfaction. CONCLUSION In this study lateral and medial approaches for MICO were performed. Similar degrees of correction and low complication rates were found in both groups. The medial approach for MICO is safe and can be beneficial regarding patient positioning and arrangement of the C‑arm.
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Affiliation(s)
- S Beischl
- Clinic of Orthopaedics, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - N Harrasser
- Clinic of Orthopaedics, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - A Toepfer
- Orthopaedics and Traumatology, Kantonsspital St. Gallen, Rorschacher Straße 95, 9007, St. Gallen, Switzerland
| | - C Scheele
- Clinic of Orthopaedics, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - R Smits Sererna
- Clinic of Orthopaedics, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - M Walther
- Center for Foot and Ankle Surgery, Schön Clinic Munich Harlaching - FIFA Medical Centre, Harlachinger Straße 51, 81547, Munich, Germany
| | - F Lenze
- Clinic of Orthopaedics, Klinikum rechts der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - H Hörterer
- Center for Foot and Ankle Surgery, Schön Clinic Munich Harlaching - FIFA Medical Centre, Harlachinger Straße 51, 81547, Munich, Germany
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Zaidi R, Lewis TL, Ray R. The Role Of Minimally Invasive Osteotomies In Cavovarus Foot Reconstruction: Detailed Technique And Evidence For Procedures. Foot Ankle Clin 2023; 28:709-718. [PMID: 37863529 DOI: 10.1016/j.fcl.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Percutaneous correction of cavus foot deformity can be achieved with satisfactory correction of foot anatomy and biomechanics. Surgical management of cavovarus foot reconstruction is an individualized combination of surgical procedures designed to correct deformity. Minimally invasive procedures using high-torque low-speed burr can facilitate large deformity correction without extensive soft tissue stripping. This article presents the operative technique for percutaneous cavus foot correction including a lateralizing calcaneal osteotomy and proximal first ray osteotomy. However, methodologically robust evidence to support this procedure is lacking at present, and further research, particularly, focusing on long-term clinical outcomes and follow-up is required.
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Affiliation(s)
- Razi Zaidi
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Thomas Lorchan Lewis
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Robbie Ray
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK.
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Ahankoob N, Washburn F, Fang W, Pyle C. Utilization of minimally invasive burr for surgical correction of calcaneus fracture malunion: A case report describing a novel technique. Int J Surg Case Rep 2023; 110:108612. [PMID: 37572472 PMCID: PMC10428072 DOI: 10.1016/j.ijscr.2023.108612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/14/2023] Open
Abstract
INTRODUCTION Calcaneus fractures pose a significant treatment challenge to orthopaedic surgeons. Nonoperative treatment frequently leads to malunion, persistent pain, and development of subtalar arthritis, while operative treatment increases the risk of surgical-related complications, such as surgical site infection, without demonstrating superior outcomes. PRESENTATION OF CASE A 58-year-old male laborer presented three months after sustaining a left joint-depression type calcaneus fracture. He was initially treated nonoperatively but suffered from significant pain and dysfunction interfering with activities of daily living and inability to return to work. The patient was treated with a novel technique utilizing a minimally invasive burr to correct calcaneus fracture malunion. There were no reported post-operative complications, including infection or additional malunion, patient has returned to normal shoewear and his physically demanding career. DISCUSSION This is one of few studies documenting utilization of a minimally invasive burr for surgical correction of calcaneus fracture malunion. Restoration of calcaneal height and hindfoot alignment were achieved without evidence of subtalar arthritis on postoperative radiographs. Minimally invasive surgical procedures, especially with smaller incisions, have been found to be just as effective as open, though with significantly fewer wound and nerve complications. CONCLUSION Minimally invasive correction of calcaneus fracture malunion may be a viable option for surgical intervention, even in patients who are at higher risk of surgical complications such as infection. The indications for minimally invasive techniques are rapidly expanding and further studies are warranted to evaluate the use of minimally invasive techniques in foot and ankle surgery.
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Affiliation(s)
- Niaz Ahankoob
- Department of Orthopaedic Surgery, Community Memorial Hospital, 147 N. Brent St., Ventura, CA 93003, USA.
| | - Frederic Washburn
- Department of Orthopaedic Surgery, Community Memorial Hospital, 147 N. Brent St., Ventura, CA 93003, USA.
| | - William Fang
- Department of Translational Medicine, Western University of Health Sciences, 309 E. 2(nd) St. Pomona, CA 91766, USA.
| | - Casey Pyle
- Department of Orthopaedic Surgery, Community Memorial Hospital, 147 N. Brent St., Ventura, CA 93003, USA.
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Biz C, Cerchiaro M, Mori F, Rossin A, Ponticiello M, Crimì A, Ruggieri P. Flatfoot over the centuries: the background of current conservative and operative treatments. INTERNATIONAL ORTHOPAEDICS 2023; 47:2357-2368. [PMID: 37222816 PMCID: PMC10439239 DOI: 10.1007/s00264-023-05837-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
PURPOSE Although flatfoot is a widespread human condition, historical medical texts and ancient illustrations on this deformity are extremely rare. Nowadays, doubts regarding its management remain unsolved. This historical review aims to identify the presence of pes planus since the prehistoric era and examine the treatments proposed over the centuries up to the present. METHOD For this propose, we performed an extensive electronic search of the relevant literature, complemented by a manual search of additional sources from archaeological to artistic, literary, historical, and scientific accounts, describing flatfoot and its treatment in different eras. RESULTS Flatfoot accompanied the evolutionary timeline of human species: from Lucy Australopithecus to Homo Sapiens. It was described among various diseases suffered by Tutankhamun (1343-1324 B.C.), while the first anatomical description dates to Emperor Trajan (53-117 A.D.) and the medical studies of Galen (129-201 A.D.). It was also represented in the anatomical drawings of Leonardo da Vinci (1452-1519) and Girolamo Fabrici d'Acquapendente (1533-1619). Historically, the conservative treatment by insoles was the only one proposed until the nineteenth century. Since then, the most popular surgical procedures performed for correction have been osteotomies, arthrodesis, arthrorisis, and tendon lengthening and transfer. CONCLUSION During the centuries, conservative therapeutic strategies have not radically changed in their substance, while operative ones have become the protagonists during the twentieth century up to the present. Nevertheless, after more than 2000 years of history, there is no consensus regarding the best indication for the flatfoot and if it really needs to be treated.
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Affiliation(s)
- Carlo Biz
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Mariachiara Cerchiaro
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Fabiana Mori
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Alessandro Rossin
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Mattia Ponticiello
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Alberto Crimì
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Pietro Ruggieri
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
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Cheng Y, Zou J, Wang C, Xing J, Zhao P, Gao M, Yang H, Zhang H. A comparison of treatment between mini T-plate and headless cannulated compression screw in calcaneal osteotomy. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05840-8. [PMID: 37249628 DOI: 10.1007/s00264-023-05840-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/15/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE In clinical studies, we discovered that when using headless cannulated compression screw fixation, many patients complain of heel pain and frequently need to have the screws removed, whereas this occurrence is uncommon with plate fixation. This study aims to compare the clinical outcome of a mini T-plate and headless cannulated compression screws in calcaneal osteotomy. METHODS We reviewed the medical records of patients who had calcaneal osteotomy performed by one senior chief surgeon in our hospital between January 2014 and May 2021. Thirty-nine patients met the selection criteria: 22 were fixed using a mini T-plate through a modified small "L" incision on the lateral aspect of the calcaneus and 17 were fixed using double screws through an oblique incision on the lateral aspect of the calcaneus. Then, we compared the patient demographics, surgical statistics, and postoperative complications in calcaneal osteotomy between a mini T-plate and double 6.5-mm headless cannulated compressed screws. RESULTS Each patient attained radiographic union. The average age was 49.23±13.80 (range: 24-76) years and the average follow-up duration was 47.07±8.64 (range: 36-66) weeks. The average operation duration and times of intraoperative fluoroscopy were significantly lower in the mini T-plate group (P<0.05). There was a savings of $838.88 per patient when using double screws for fixation. The incidence of hardware-related pain and implant removal was lower in the mini T-plate group (P<0.05). There is no significant difference between the two groups in terms of delayed incision healing and clinical neurological complications (P>0.05). CONCLUSIONS In calcaneal osteotomy, the operation duration, times of intraoperative fluoroscopy, hardware-related pain, and implant removal rate were lower with mini T-plate fixation than with double screws fixation. Therefore, we consider that the mini T-plate would be a good alternative to double screws in calcaneal osteotomy.
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Affiliation(s)
- Yu Cheng
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Jun Zou
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Changbao Wang
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Junhui Xing
- Department of Orthopedics, Dushu Lake Hospital Affiliated to Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Piqian Zhao
- Department of Orthopedics, Dushu Lake Hospital Affiliated to Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Mingyang Gao
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China.
| | - Huiling Yang
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China.
| | - Hongtao Zhang
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China.
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Minimally Invasive Foot and Ankle Surgery: A Primer for Orthopaedic Surgeons. J Am Acad Orthop Surg 2023; 31:122-131. [PMID: 36656273 DOI: 10.5435/jaaos-d-22-00608] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/13/2022] [Indexed: 01/20/2023] Open
Abstract
There is rapidly growing interest in minimally invasive surgery (MIS) of the foot and ankle. Technological advances, specifically with the advent of low-speed high-torque burrs, have enabled the expansion of MIS techniques. Accordingly, there is growing literature reporting excellent outcomes of MIS surgery to address many different pathologies of the foot and ankle. MIS techniques are particularly useful for conducting percutaneous osteotomies and bony débridement. These can be used to address bunion deformity, hammertoes, metatarsalgia, bunionette deformity, bone spurs, and hindfoot deformity. A detailed understanding of the technology, equipment, and techniques is crucial to safely conduct MIS of the foot and ankle. When done safely, MIS provides favorable outcomes with an expedited recovery and limited complications.
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Harrasser N, Toepfer A. [Minimally invasive forefoot surgery: concept and techniques]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:69-81. [PMID: 36547727 DOI: 10.1007/s00132-022-04334-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
Minimally invasive surgery (MIS) has advanced to an established approach in the correction of all deformities of the forefoot. For the first ray the minimally invasive chevron and Akin osteotomy (MICA) shows very good clinical results and provides a broad spectrum of indications in comparison to the classical chevron osteotomy. The minimally invasive treatment of hallux rigidus also seems to achieve comparable results to the open techniques, although the surgical indications must be thoroughly evaluated. Lesser toe deformities are often easier to treat with minimally invasive osteotomy, capsule release and tendon lengthening than with complex open procedures and usually do not require any internal fixation material. Compared to the classical Weil osteotomy, distal metatarsal osteotomy shows a reduced rate of cock-up deformities and does not require internal fixation. In relation to open procedures, minimally invasive approaches should be accepted as a valuable addition and alternative to the classical open techniques due to the reduced rate of wound healing disorders and postoperative pain.
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Affiliation(s)
- N Harrasser
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland. .,ECOM Excellent Center of Medicine, Arabellastr. 17, 81925, München, Deutschland.
| | - A Toepfer
- Klinik für Orthopädische Chirurgie und Traumatologie des Bewegungsapparates, Kantonsspital St. Gallen, Rohrschacher Str. 95, 9007, St. Gallen, Schweiz
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13
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Tonogai I, Tsuruo Y, Sairyo K. Examination of Safe Zone to Avoid Injury of the Lateral Plantar Artery During Calcaneal Osteotomy: A Fresh Cadaveric Study. Foot Ankle Spec 2022; 15:432-437. [PMID: 33090038 DOI: 10.1177/1938640020965084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Calcaneal osteotomy are used to treat various pathologies in the correction of hindfoot deformities. But lateral plantar artery (LPA) pseudoaneurysms have been reported following calcaneal osteotomy, and LPA pseudoaneurysms may be at risk for rupture. Although the vascular structures in close proximity to calcaneal osteotomies have variable courses and branching patterns, there is little information on safe zone for LPA during calcaneal osteotomy. The aims of this study were to identify the safety zone to avoid the LPA injury during calcaneal osteotomy. METHODS Enhanced computed tomography scans of 25 fresh cadaveric feet (male, n = 13; female, n = 12; mean age 79.0 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery. Line A is the landmark line and extends from the posterosuperior aspect of the calcaneal tuberosity to the plantar fascia origin, and the perpendicular distance between the LPA and line A at its closest point was measured on sagittal images. RESULTS The average perpendicular distance between the LPA and line A at its closest point was 15.2 ± 2.9 mm. In 2 cases (8.0 %), the perpendicular distance between the LPA and line A at its closest point was very close, approximately 9 mm. In 18 of 25 feet (72.0%), the point where perpendicular distance from the line A to LPA is the closest was the bifurcation of one of the medial calcaneal branches from LPA, and in 7 feet in 25 feet (28.0%) feet the point where perpendicular distance from the line A to LPA is the closest was the trifurcation of LPA, medial plantar artery, and one of the medial calcaneal branches. CONCLUSIONS Calcaneal osteotomy approximately more than 9 mm from the line A could injure the LPA in overpenetration into the medial aspect of tcalcaneal osteotomy. Completion of the osteotomy on the medial side should be performed with caution to avoid iatrogenic injury of the LPA. LEVELS OF EVIDENCE: Level IV, Cadaveric study.
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Affiliation(s)
- Ichiro Tonogai
- Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Yoshihiro Tsuruo
- Department of Anatomy and Cell Biology, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
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Reddy SC, Schipper ON, Li J. The Effect of Chilled vs Room-Temperature Irrigation on Thermal Energy Dissipation During Minimally Invasive Calcaneal Osteotomy of Cadaver Specimens. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221136548. [PMID: 36386595 PMCID: PMC9659937 DOI: 10.1177/24730114221136548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Minimally invasive (MIS) calcaneal osteotomy has grown in popularity in recent years to address hindfoot deformity. A potential complication is thermal bone necrosis secondary to heat generation from the burr that may lead to osteotomy nonunion. Irrigation is commonly employed to reduce this risk. The effect of irrigation on reducing heat accumulation remains an understudied area. The purpose of this study was to evaluate the effect of cooled vs room-temperature irrigation on thermal energy dissipation during calcaneal osteotomy using a Shannon burr. METHODS Fourteen cadaveric limbs at room temperature (68 °F) were randomized to receive either cooled saline (7 limbs) or room-temperature (7 limbs) irrigation during MIS calcaneal osteotomy. Two thermocouple probes were inserted 5 mm away from the plane of the osteotomy, on the proximal and distal sides, respectively. A 3 × 30-mm Shannon burr was used to perform the osteotomy. The burr was run continuously with continuous irrigation using either room-temperature (68 °F) or chilled (37 °F) irrigation, until the osteotomy was completed. Temperature was recorded at 0, 15, 30, 45, and 60 seconds for the 2 groups and used as a measure of thermal energy accumulation. RESULTS Both room-temperature and chilled irrigation were effective in minimizing temperature change. On the proximal side, an overall mean increase of 2.5 °F with room-temperature irrigation and a mean decrease of 1.0 °F with chilled irrigation were observed at the 60-second interval (P = .004). On the distal side, there was a mean increase of 1.3 °F with room-temperature irrigation and a mean increase of 0.5 °F with chilled irrigation (P = .05). CONCLUSION For the duration of an MIS calcaneal osteotomy, both continuous room-temperature and chilled irrigation can minimize temperature increases and potentially reduce the risk of an osteotomy nonunion. CLINICAL RELEVANCE Both room-temperature and chilled irrigation can minimize bone temperature increases during MIS calcaneal osteotomy.
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Affiliation(s)
- Sudheer C. Reddy
- Shady Grove Orthopaedics, Adventist HealthCare, Rockville, MD, USA
| | | | - Jihui Li
- INOVA Fairfax Hospital, Falls Church, VA, USA
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15
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deMeireles AJ, Guzman JZ, Nordio A, Chan J, Okewunmi J, Vulcano E. Complications After Percutaneous Osteotomies of the Calcaneus. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221119731. [PMID: 36046552 PMCID: PMC9421033 DOI: 10.1177/24730114221119731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Open hindfoot surgery is associated with a relatively high rate of complications, including neurovascular injuries and wound healing problems compared with percutaneous techniques. However, there is a scarcity of literature describing the outcomes of these percutaneous techniques given their relatively recent adoption. The present study aims to assess the rate of postoperative complications for 3 commonly performed percutaneous calcaneal osteotomies. Methods: One hundred eighteen patients (unilateral feet) were treated with one of 3 common percutaneous calcaneal osteotomies. Sixty-five patients (55.1%) were treated with a medializing calcaneal osteotomy for hindfoot valgus, 32 patients with a Zadek osteotomy (27.1%) for insertional Achilles tendinopathy, and 21 patients (17.8%) with a modified Dwyer osteotomy for hindfoot varus. Fisher exact test was used to assess for associations between categorical variables. Results: The mean age was 46.2 years and there was a mean follow-up of 16.1 months. The overall rate of postoperative complications was 3.4% (n = 4), and no significant differences were found between the different osteotomy types. Complications included 2 cases (1.7%) of transient neuritis, 1 case of prolonged wound drainage (0.8%), and 1 nonunion (0.8%). None of the complications were associated with any recorded preoperative comorbidity. Discussion: In this series, we found that percutaneous calcaneal osteotomies are a safe alternative method for the treatment of conditions involving the hindfoot. The rate of postoperative complications may be less when compared to the reported rates of open hindfoot correction and should be considered in patients with a traditionally high risk of developing a postoperative complication. Level of Evidence: Level IV, retrospective analysis.
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Affiliation(s)
- Alirio J. deMeireles
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Javier Z. Guzman
- Leni & Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrea Nordio
- Leni & Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jimmy Chan
- Leni & Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey Okewunmi
- Leni & Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ettore Vulcano
- Columbia University Orthopaedics at Mount Sinai Medical Center, Miami Beach, FL, USA
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16
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Abstract
Calcaneal osteotomy is an extra-articular procedure used for conservative surgical treatment of hindfoot deformity. It has static, architectural and dynamic effects, reorienting the tuberosity action point of the digastric muscle formation of the sural triceps and plantar aponeurosis. Calcaneal osteotomies vary in location, form and displacement, but can be categorized as tuberosity osteotomy, acting on talar position, and cervical osteotomy, acting on Chopart joint-line orientation. We here describe the 3 main calcaneal osteotomies we use for hindfoot deformity: talar varus/valgus, valgus flatfoot, and midfoot abductus/adductus. In each case, we describe our technique, resulting from our responses to the difficulties we have had to deal with: medializing osteotomy: performed percutaneously to limit skin complications, and easily associated to cervical calcaneal osteotomy to manage valgus flatfoot; Hintermann cervical adduction osteotomy: providing excellent angular correction, while conserving a medial cortical hinge; lateralizingosteotomy: performed on a medial approach, to enhance translation capacity and prevent the acute tarsal tunnel syndrome with which we have been otherwise confronted. Correcting foot deformities involves complex, multi-dimensional, multi-tissue surgery that is risky as it concerns a segment with terminal vascularization. The present three techniques need to be mastered, as they are usually associated to other tendon and/or ligament reconstruction procedures, and tourniquet time is limited. LEVEL OF EVIDENCE: V; expert opinion.
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17
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Aurich M, Lenz M, Hofmann GO, Schubert W, Knobe M, Roth KE, Simons P, Klos K. Anatomical Study of Sinus Tarsi-Based Lateral Lengthening Calcaneal Osteotomy. Foot Ankle Int 2022; 43:101-104. [PMID: 34490796 DOI: 10.1177/10711007211041345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral lengthening calcaneal osteotomy (LL-CO) is commonly performed as a treatment for an abducted midfoot in pes planovalgus deformity. The purpose of this study is to investigate potential damage to medial structures with a sinus tarsi LL-CO. METHODS Sixteen cadaver feet were used. Eight feet had an extended lateral approach, and 8 had a limited lateral (sinus tarsi) approach. All underwent a sinus tarsi LL-CO. Specimens were then dissected to identify inadvertent injury to medial structures. RESULTS Sinus tarsi LL-CO was associated with damage to the sustentaculum tali and medial articular facets in 56% and 62.5% of specimens, respectively. No anterior or posterior facet injuries were found, although 56% of specimens had a confluent medial and anterior facet. CONCLUSION Damage to the medial articular facet and sustentaculum is possible with a flat cut sinus tarsi LL-CO due to the curved nature of the relevant sinus tarsi and canal anatomy. CLINICAL RELEVANCE Sinus tarsi LL-CO needs to be performed with caution since damage to the subtalar joint is possible. LEVEL OF EVIDENCE Level II, prospective cohort study.
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Affiliation(s)
- Matthias Aurich
- Section of Trauma and Reconstructive Surgery, Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital Halle, Halle, Saale, Germany.,Department of Trauma and Reconstructive Surgery, Berufsgenossenschaftliche Kliniken Bergmannstrost, Halle, Saale, Germany
| | - Mark Lenz
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | - Gunther O Hofmann
- Department of Trauma and Reconstructive Surgery, Berufsgenossenschaftliche Kliniken Bergmannstrost, Halle, Saale, Germany.,Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | - Wiebke Schubert
- Department of Anesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
| | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | | | | | - Kajetan Klos
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Jena, Jena, Germany.,Gelenkzentrum Rhein-Main, Hochheim, Germany
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18
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Guzman JZ, Schipper O, Vulcano E. Letter Regarding: Risk Factors for Complications Associated With Minimally Invasive Medial Displacement Calcaneal Osteotomy. Foot Ankle Int 2021; 42:1215-1216. [PMID: 34529528 DOI: 10.1177/10711007211033849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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19
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Neurological Injuries after Calcaneal Osteotomies Are Underdiagnosed. J Clin Med 2021; 10:jcm10143139. [PMID: 34300303 PMCID: PMC8304805 DOI: 10.3390/jcm10143139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/05/2021] [Accepted: 07/13/2021] [Indexed: 11/17/2022] Open
Abstract
The incidence of peripheral neurological injuries related to calcaneal osteotomies reported in the literature is low and often described as occasional. The main objective of this study is to determine the incidence of neurological injuries after calcaneal osteotomies and identify which nerve structures are most affected. This retrospective work included 69 patients. Medical records, surgical protocols, and radiographs were analyzed. All patients were summoned to perform current functional tests (EFAS score and SF-12), and a thorough physical examination was performed systematically and bilaterally. The total incidence of neurological injuries was 43.5% (30/69). The percentage of neurapraxias (transient injuries) was 8.7%, while 34.8% of patients presented neurological sequelae (permanent injuries). The most injured nerve or branch was, in decreasing order: sural nerve, medial plantar branch, lateral plantar branch and medial calcaneal branch. Following the so-called "safe zone" clearly decreases the incidence of sural nerve injury (p = 0.035). No significant differences were found between osteotomy site, number of screws, and type of closure and increased neurological injuries. No significant differences were found in the functional tests between the different techniques, nor between patients who presented neurological injuries and those who did not. Neurological injuries after calcaneal osteotomies are underdiagnosed and the incidence is higher than previously reported (43.5%). Such injuries mostly go unnoticed and have no implications in the functional results and patients' satisfaction.
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20
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Wolfe JR, McKee TD, Nicholes M. Use of Calcaneal Osteotomies in the Correction of Inframalleolar Cavovarus Deformity. Clin Podiatr Med Surg 2021; 38:379-389. [PMID: 34053650 DOI: 10.1016/j.cpm.2021.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cavovarus deformity is a complicated condition most commonly resulting from neurologic, posttraumatic, or iatrogenic pathologic conditions. Careful evaluation of the cavovarus patient is necessary in determining appropriate treatment course. Weight-bearing radiographs are necessary, and advances in computed tomographic technology can be beneficial in identifying level of involvement. In the case of operative treatment of inframalleolar deformity, assessment of the subtalar joint position and relation of calcaneocuboid joint can be of assistance. Multiple osteotomies have been described providing uniplanar, biplanar, and triplanar correction and in the appropriate setting can prove beneficial to the surgeon in treating hind-foot cavovarus deformity.
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Affiliation(s)
- Jesse R Wolfe
- Northwest Iowa Bone, Joint, & Sports Surgeons, 1200 1st Avenue E, Suite C, Spencer, IA 51301, USA.
| | - Tyler D McKee
- American Health Network Foot & Ankle Reconstructive Surgery Fellowship, 12188B North Meridian Street, Suite #330, Carmel, IN 46032, USA
| | - Melinda Nicholes
- SSM Health DePaul Hospital Foot and Ankle Surgery Residency, St Louis, MO, USA; SSM Health DePaul Hospital, 12303 DePaul Drive, Bridgeton, MO 63044, USA
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21
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Catani O, Cautiero G, Sergio F, Cattolico A, Calafiore D, de Sire A, Zanchini F. Medial Displacement Calcaneal Osteotomy for Unilateral Adult Acquired Flatfoot: Effects of Minimally Invasive Surgery on Pain, Alignment, Functioning, and Quality of Life. J Foot Ankle Surg 2021; 60:358-361. [PMID: 33472755 DOI: 10.1053/j.jfas.2020.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/18/2020] [Accepted: 11/22/2020] [Indexed: 02/03/2023]
Abstract
We aimed to assess the effects of medial displacement calcaneal osteotomy (MDCO) through a minimal skin incision in terms of pain, function, and alignment in patients with unilateral adult acquired flatfoot. American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scale and Numeric Pain Rating Scale (NPRS) were assessed as outcomes at the baseline (T0), at 6 months (T1), and at 1 year (T2) from surgery. We analyzed data of 20 patients (7 male and 13 female), mean aged 46.6 ± 5.34 years, showed significant differences after 6 months in terms of AOFAS total score (44.30 ± 7.39 vs 96.50 ± 4.89; p = .0001), AOFAS subitems (p < .001), and pain (NPRS: 7.95 ± 1.36 vs 1.05 ± 1.05; p = .0001). At 1 year after surgery (T2), all outcome measures still significantly differ from baseline (p < 01). Therefore, percutaneous MDCO through a minimal skin incision seemed to be safe and effective in the middle and long term in reducing pain and improving function and alignment in patients with unilateral adult acquired flatfoot.
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Affiliation(s)
- Ottorino Catani
- Foot and Ankle Surgeon, Department of Orthopaedic and Traumatology, Casa di Cura S. Maria della Salute, Santa Maria Capua Vetere, Caserta, Italy
| | - Giovanni Cautiero
- Foot and Ankle Surgeon, Department of Orthopaedic and Traumatology, Casa di Cura S. Maria della Salute, Santa Maria Capua Vetere, Caserta, Italy
| | - Fabrizio Sergio
- Foot and Ankle Surgeon, Department of Orthopaedic and Traumatology, Casa di Cura S. Maria della Salute, Santa Maria Capua Vetere, Caserta, Italy
| | - Alessandro Cattolico
- Resident in Orthopaedics, Clinical Orthopaedics, Department of Medical and Surgical Specialties, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Dario Calafiore
- Physiatrist, Neuromotor Rehabilitation Unit, Neuroscience Department, Azienda Socio Sanitaria Territoriale di Mantova, Bozzolo, Mantova, Italy
| | - Alessandro de Sire
- Assistant Professor of Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy; Physiatrist, Rehabilitation Unit, "Mons. L. Novarese" Hospital, Moncrivello, Vercelli, Italy.
| | - Fabio Zanchini
- Assistant Professor of Orthopaedics, Clinical Orthopaedics, Department of Medical and Surgical Specialties, University of Campania "Luigi Vanvitelli", Naples, Italy
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22
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Coleman MM, Abousayed MM, Thompson JM, Bean BA, Guyton GP. Risk Factors for Complications Associated With Minimally Invasive Medial Displacement Calcaneal Osteotomy. Foot Ankle Int 2021; 42:121-131. [PMID: 33449834 DOI: 10.1177/1071100720961094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Few studies have reported the outcomes following minimally invasive medial displacement calcaneal osteotomy (MDCO) for correction of pes planovalgus deformities. METHODS Charts were retrospectively reviewed for consecutive patients who underwent minimally invasive MDCO procedures by a single surgeon from 2013 to 2019 with more than 3 months of follow-up. A total of 160 consecutive patients who underwent 189 minimally invasive MDCO procedures were included in the study. Median follow-up was 12 months (interquartile range, 7-25 months). RESULTS Osteotomy healing complications were present in 7% of cases during the 6-year study period. A 12-month case cluster of osteotomy healing complications was observed. Healing complication rates were 28% during the cluster and 0.7% outside of the cluster. No definitive cause was found for the case cluster, although heat osteonecrosis from the burr was suspected to be involved. Osteotomy healing complications were significantly associated with higher American Society of Anesthesiologists (ASA) classification, female sex, current tobacco use, and higher body mass index (BMI). Healing complications were not associated with osteotomy technique or fixation type. Other complications included wound dehiscence (3%), surgical site infection (2%), transient nerve symptoms (6%), and persistent nerve symptoms (2%). Nerve symptoms were significantly associated with an increased number of concomitant procedures. CONCLUSION Patients with higher ASA classification, current tobacco use, and higher BMI were at higher risk for osteotomy healing complications after minimally invasive MDCO procedures. Patients were also more likely to develop nerve complications with more extensive surgical procedures. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Michelle M Coleman
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Mostafa M Abousayed
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - John M Thompson
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Bryan A Bean
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gregory P Guyton
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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23
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Smith C, Zaidi R, Bhamra J, Bridgens A, Wek C, Kokkinakis M. Subtalar arthroereisis for the treatment of the symptomatic paediatric flexible pes planus: a systematic review. EFORT Open Rev 2021; 6:118-129. [PMID: 33828855 PMCID: PMC8022013 DOI: 10.1302/2058-5241.6.200076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Subtalar arthroereisis has a controversial history and has previously been associated with high failure rates and excessive complications.A database search for outcomes of arthroereisis for the treatment of symptomatic paediatric flexible pes planus provided 24 articles which were included in this review, with a total of 2550 feet operated on.Post-operative patient-reported outcome measures recorded marked improvement. Patient satisfaction was reported as excellent in 79.9%, and poor in 5.3%. All radiological measurements demonstrated improvement towards the normal range following arthroereisis, as did hindfoot valgus, supination, dorsiflexion and Viladot grade.Complications were reported in 7.1% of cases, with a reoperation rate of 3.1%.Arthroereisis as a treatment for symptomatic paediatric flexible pes planus produces favourable outcomes and high patient satisfaction rates with a reasonable risk profile. There is still a great deal of negativity and literature highlighting the complications and failures of arthroereisis, especially for older implants.The biggest flaws in the collective literature are the lack of high-quality prospective studies, a paucity of long-term data and the heterogeneity of utilized outcome measures between studies. Cite this article: EFORT Open Rev 2021;6:118-129. DOI: 10.1302/2058-5241.6.200076.
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Affiliation(s)
| | - Razi Zaidi
- Guys and St Thomas NHS Foundation Trust, London, UK
| | | | - Anna Bridgens
- Evelina Children’s Hospital, Westminster Bridge Road, London, UK
| | - Caesar Wek
- Guys and St Thomas NHS Foundation Trust, London, UK
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24
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Lee DJ, Choi JY, Kim HS, Suh JS. Minimally invasive correction for symptomatic, fixed curly toe deformity. Foot Ankle Surg 2021; 27:60-65. [PMID: 32173282 DOI: 10.1016/j.fas.2020.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/16/2019] [Accepted: 02/06/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Curly toe deformity is a relatively common deformity that generally occurs at the 4th and 5th proximal and/or middle phalanges but rarely presents with symptoms. Although numerous open operative techniques have been introduced, there is no established treatment yet. We report the results of minimally invasive correction for symptomatic, fixed curly toe deformity. METHODS Between 2016 and 2018, 25 consecutive percutaneous dorsolateral closing wedge-shaped osteotomies with Shannon burrs at the proximal and/or middle phalanx were performed. We assessed the postoperative clinical and radiological changes at a mean of 22.51 months of follow-up. RESULTS The locations of osteotomy were at the middle phalanx in 10 cases, proximal phalanx in 13 cases, and both in one case. The mean amount of corrections of varus inclination and shortening were 16.54° and 2.24 mm, respectively. The Foot and Ankle Ability Measure Activities of Daily Living scores significantly improved from 59.09 preoperatively to 74.55 at the last follow-up. There was one case of pin site infection and one case of incision site numbness due to digital nerve injury. CONCLUSIONS Minimally invasive dorsolateral closing wedge-shape osteotomy is a simple, safe, and effective correction for symptomatic, fixed curly toe deformity.
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Affiliation(s)
- Dong Joo Lee
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Jun Young Choi
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Hyung Suh Kim
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea.
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25
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Robinson D, Heller E, Yassin M. Comparing the Temperature Effect of Dedicated Minimally Invasive Motor System to the Discontinuous Use of Rotatory Burrs in the Correction of Hallux Valgus. Foot Ankle Spec 2020; 13:478-487. [PMID: 31793329 DOI: 10.1177/1938640019890225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to compare 2 motor systems for percutaneous osteotomy. The study consisted of 2 stages. In the first stage, bone temperatures during osteotomy using burrs or saw was measured using a thermal camera. In the second stage, the tissue and burr temperature elevation during surgery in 80 consecutive patients (96 feet) with hallux valgus undergoing distal first metatarsal and phalangeal osteotomies (hallux and in 61/96 feet lesser digits) were measured. The burr osteotomy procedure included the use of irrigated 2- or 4.1 mm rotary wedge burrs in discontinuous cutting bursts of less than 20 seconds. Tissue surface temperature was measured with a thermal camera. The temperature generated during the procedure was found to be significantly associated with the burr diameter used but was not affected by the type of motor. At the 6-week visit, thickness of the soft tissues over the first metatarsal head was similar in both groups. Temperature control using a noninvasive thermal camera is recommended to prevent tissue damage associated with heat generated during the use of rotary burrs. A dedicated low-speed high-torque system does not seem to be necessary and standard orthopaedic equipment can be used.Levels of Evidence: Level II: Comparative prospectively collected series.
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Affiliation(s)
- Dror Robinson
- Department of Orthopedics, Hasharon Hospital, Rabin Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Petah Tikwa, Israel
| | - Eyal Heller
- Department of Orthopedics, Hasharon Hospital, Rabin Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Petah Tikwa, Israel
| | - Mustafa Yassin
- Department of Orthopedics, Hasharon Hospital, Rabin Medical Center, affiliated with the Sackler School of Medicine, Tel Aviv University, Petah Tikwa, Israel
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Minnaard J, Kleipool RP, Baars W, Dankelman J, Stufkens S, Horeman T. A new bone-cutting approach for minimally invasive surgery. Med Eng Phys 2020; 87:56-62. [PMID: 33461674 DOI: 10.1016/j.medengphy.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/21/2020] [Accepted: 11/22/2020] [Indexed: 10/22/2022]
Abstract
AIMS Resection of bone is performed in over 75% of all orthopaedic procedures and the electrically powered oscillating saw is commonly used to cut bone. Drawbacks are relatively large incisions and tissue damage due to overshooting often occur. Therefore, the goal of this study is to develop an improved bone-cutting system that has minimally invasive characteristics. METHODS A new reusable sawing system was designed that can be used in Minimally Invasive Surgery (MIS) consisting of a steerable wire passer and a tissue saving wire saw guide. The system was tested during surgery on a human cadaveric tibia and calcaneus. RESULTS A MIS steerable compliant Nitinol needle was built and successfully used in a cadaveric surgery to position the cutting wire around a tibia and calcaneus. A wire saw operating system was built that was successfully used to cut the tibia and calcaneus. CONCLUSION A MIS bone-cutting system was successfully designed, manufactured and used in a cadaver study showing that safe minimally invasive bone-cutting is feasible for two bone types with minimal damage to the surrounding tissue. Design optimization is needed to stabilize the compliant Nitinol needle during wire saw positioning and to allow cutting of bones with smaller diameters.
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Affiliation(s)
- Jeffrey Minnaard
- Department of BioMechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD Delft, the Netherland
| | | | - Wim Baars
- Department of Instrument Development, Leidse instrumentmakers school, Leiden, the Netherlands
| | - Jenny Dankelman
- Department of BioMechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD Delft, the Netherland
| | - Sjoerd Stufkens
- Department of Orthopaedic Surgery, Amsterdam UMC, the Netherlands
| | - Tim Horeman
- Department of BioMechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD Delft, the Netherland.
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Nordio A, Chan JJ, Guzman JZ, Hasija R, Vulcano E. Percutaneous Zadek osteotomy for the treatment of insertional Achilles tendinopathy. Foot Ankle Surg 2020; 26:818-821. [PMID: 31784097 DOI: 10.1016/j.fas.2019.10.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/22/2019] [Accepted: 10/26/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Insertional Achilles tendinopathy (IAT) is a challenging common lower extremity disorder, despite several treatment options described in literature. Open dorsal closing wedge calcaneal osteotomy or Zadek Osteotomy (ZO), for the treatment of the IAT has good clinical results but a high rate of postoperative complications. The purpose of this study is to describe percutaneous ZO for the treatment of the IAT and to evaluate its impact on the clinical and functional postoperative outcomes. METHODS Twenty-six consecutive patients presenting with unilateral IAT refractory to nonoperative measures were treated with percutaneous ZO. Visual Analogue Scale (VAS) and Foot Function Index Score (FFI) were recorded preoperatively and at final follow-up visit (12±3) months. Postoperative complications, satisfaction, and relief of the pain were also recorded. RESULTS The percutaneous ZO showed a significant improvement (p<0.0001) in preoperative to postoperative FFI (from 65±9 to 8±12) and VAS (from 9±1 to 1±2). Two postoperative complications (8%) were observed: a case of symptomatic non-union and hardware pain, both in healthy patients. The overall rate of satisfaction after surgery was (92%). The relief from pain was achieved after an average period of 12 weeks. CONCLUSIONS ZO is a safe and effective procedure for the treatment of IAT. The use of a minimally invasive surgical approach is associated with excellent pain reduction (VAS score) and improved clinical function (FFI score). When compared to the open surgical approach, the percutaneous ZO may decrease recovery time and postoperative complications. LEVEL OF EVIDENCE III, retrospective case series.
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Affiliation(s)
- Andrea Nordio
- Department of Medical Surgical and Health Sciences of Trieste University, Orthopaedics and Traumatology Unit, Cattinara Hospital-ASUITS, Strada Di Fiume 447, Trieste, Italy.
| | - Jimmy J Chan
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 E 98th St, 9th Fl, New York, NY, 10029, United States
| | - Javier Z Guzman
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 E 98th St, 9th Fl, New York, NY, 10029, United States
| | - Rohit Hasija
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 E 98th St, 9th Fl, New York, NY, 10029, United States
| | - Ettore Vulcano
- Leni and Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 E 98th St, 9th Fl, New York, NY, 10029, United States; Foot and Ankle West Hospital Mount Sinai, NY, United States
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Arbab D, Lüring C, Mutschler M, Gutteck N, Bouillon B. Der erworbene Plattfuß des Erwachsenen – Operative Therapie der flexiblen Deformität im frühen Stadium. DER ORTHOPADE 2020; 49:954-961. [DOI: 10.1007/s00132-020-03991-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Adult acquired flatfoot deformity (AAFD) as a consequence of posterior tibial tendon dysfunction is commonly divided in flexible (stages I and II) and fixed (stages III and IV) deformities. The aim of this article is to summarize the evidence available for minimally invasive surgical techniques that can be used in the treatment of flexible AAFD, including tibialis posterior tendoscopy, subtalar arthroereisis, minimally invasive calcaneal osteotomy, and medial proximal gastrocnemius recession. A treatment algorithm and technical tips have also been provided.
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Affiliation(s)
- Alessio Bernasconi
- Department of Public Health, Trauma and Orthopaedics, University of Naples Federico II, Via Pansini 5, Naples 80131, Italy; Foot and Ankle Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK
| | - Robbie Ray
- Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, Orpington, London BR68ND, UK.
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Biomechanical results of percutaneous calcaneal osteotomy using two different osteotomy designs. Foot Ankle Surg 2020; 26:551-555. [PMID: 31371267 DOI: 10.1016/j.fas.2019.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/01/2019] [Accepted: 07/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Percutaneous osteotomy of calcaneus has been proposed to reduce the complication rate and became more and more popular. The bone cut can be performed as a straight or chevron-like (V) osteotomy using a Shannon burr. Comparative studies of straight or V-osteotomy as like as one or two screws in percutaneous calcaneal osteotomies are missing in the literature. We hypothesize that the V-osteotomy will result in a higher stiffness in biomechanical testing as the straight osteotomy using single screw for fixation. METHODS The straight osteotomy (9 fresh-frozen specimens) and V-osteotomy (9 fresh-frozen specimens) was performed and the calcaneal tuberosity was moved 10mm medially and slightly rotated. One 6,5mm cancellous compression screw was used for osteosynthesis. Specimens were preconditioned with 100N over 100 cycles. The force was increased after every 100N by 100N from 200 to 500N. This was followed by cyclic loading with 600N for 500 cycles. RESULTS Despite the higher mean values of the group with V-osteotomy, no significant difference was registered between the two groups regarding the stiffness at all force levels. A higher failure rate was observed in the group with straight osteotomy. CONCLUSION The moderate correlation of bone density and stiffness in the V-group, and significantly lower failure rate with no secondary dislocation in fluoroscopy indicates the superiority of the V-osteotomy in the present study. Whether the demonstrated advantages can be reflected in clinical practice should be investigated in further studies. LEVEL OF CLINICAL EVIDENCE 5.
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Schipper ON, Day J, Ray GS, Johnson AH. Percutaneous Techniques in Orthopedic Foot and Ankle Surgery. Orthop Clin North Am 2020; 51:403-422. [PMID: 32498959 DOI: 10.1016/j.ocl.2020.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article presents the indications, contraindications, preoperative surgical planning, surgical technique, and postoperative management of some of the most common percutaneous procedures in orthopedic foot and ankle surgery. The background of each procedure also is presented, supported by the latest in published literature to educate surgeons. Such topics include percutaneous bunionectomy, lesser toe deformity and bunionette correction, calcaneal osteotomy, cheilectomy, and first metatarsophalangeal joint arthrodesis.
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Affiliation(s)
- Oliver N Schipper
- Anderson Orthopaedic Clinic, 2445 Army Navy Drive, Arlington, VA 22206, USA.
| | - Jonathan Day
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Gabrielle S Ray
- Tufts University School of Medicine, 145 Harrison Avenue, Boston, MA, USA
| | - Anne Holly Johnson
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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Percutaneous surgery of the forefoot compared with open technique - Functional results, complications and patient satisfaction. Foot Ankle Surg 2020; 26:156-162. [PMID: 30737141 DOI: 10.1016/j.fas.2019.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/30/2018] [Accepted: 01/14/2019] [Indexed: 02/04/2023]
Abstract
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.
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Park JH, Park KR, Kim D, Kwon HW, Lee M, Choi YJ, Kim YB, Park S, Yang J, Cho J. The incision strategy for minimizing sural nerve injury in medial displacement calcaneal osteotomy: a cadaveric study. J Orthop Surg Res 2019; 14:356. [PMID: 31718699 PMCID: PMC6852710 DOI: 10.1186/s13018-019-1411-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/14/2019] [Indexed: 12/03/2022] Open
Abstract
Background The skin incision for medial displacement calcaneal osteotomy (MDCO) often damages the sural nerve. We aimed to identify the practical reference area in which the surgeon can incise the skin to minimize the injury of the sural nerve during MDCO. Methods The foot and ankles of 20 cadavers were dissected. The landmarks were the following four anatomical references: point A, the tip of the lateral malleolus; point B, the inferior margin of the calcaneus on the vertical line through point A; point C, the posteroinferior apex of the calcaneus; and point D, the lateral border of the Achilles tendon on the horizontal line through point A. The distances from the sural nerve to points A and B in the vertical direction (lines D1 and D2, respectively), to points A and C in the diagonal direction (lines D3 and D4, respectively), and to points A and D in the horizontal direction (lines D5 and D6, respectively) were measured. Results The median ratios of D1 to D1+D2, D3 to D3+D4, and D5 to D5+D6 were 0.34 (range 0.25 to 0.45), 0.23 (range 0.16 to 0.33), and 0.38 (range 0.26 to 0.50), respectively. Conclusions The distance ratios according to easily identifiable references would be a more practical incision strategy for surgeons to minimize sural nerve injury in both open and minimally invasive/percutaneous MDCO.
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Affiliation(s)
- Jeong-Hyun Park
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Kwang-Rak Park
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Digud Kim
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Hyung-Wook Kwon
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Mijeong Lee
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Yu-Jin Choi
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Yong-Been Kim
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 200-704, Republic of Korea
| | - Suyeon Park
- Department of biostatistics, College of Medicine, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Jinseo Yang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon, Republic of Korea
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 200-704, Republic of Korea.
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Gutteck N, Zeh A, Wohlrab D, Delank KS. Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities. Foot Ankle Int 2019; 40:276-281. [PMID: 30413133 DOI: 10.1177/1071100718809449] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Calcaneal osteotomies are often required in the correction of hindfoot deformities. The traditional open techniques, which include a lateral or oblique incision, are occasionally associated with wound healing problems and neurovascular injury. METHODS: A total of 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. Fifty-eight patients were operated using an open incision technique and 64 patients (66 feet) using a percutaneous technique. Clinical and radiologic assessments were performed preoperatively, at 6 weeks, and 1 year postoperatively. RESULTS: The American Orthopaedic Foot & Ankle Society scale scores and visual analog scale pain scores improved in both groups postoperatively. The difference between the groups was not significant. The results of the radiologic measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in either group. The comparison of both groups showed a significantly lower risk for wound healing problems in the percutaneous group. The hospitalization time was significantly shorter in the percutaneous group. CONCLUSION: Because of the excellent results with the percutaneous calcaneal osteotomy, the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy, especially patients at high risk for wound healing problems. LEVEL OF EVIDENCE: Level III, comparative series.
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Affiliation(s)
- Natalia Gutteck
- 1 Department of Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Alexander Zeh
- 1 Department of Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - David Wohlrab
- 1 Department of Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Karl-Stefan Delank
- 1 Department of Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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SahraNavard B, Hudson PW, de Cesar Netto C, Wills BW, Araoye IB, Bergstresser S, Cone BM, Shah A. A comparison of union rates and complications between single screw and double screw fixation of sliding calcaneal osteotomy. Foot Ankle Surg 2019; 25:84-89. [PMID: 29409301 DOI: 10.1016/j.fas.2017.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/03/2017] [Accepted: 08/28/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND The number of screws used for sliding calcaneal osteotomy fixation has not been examined in the literature. The purpose of this paper is to examine this topic. METHODS Retrospective chart review was performed on 190 patients who met selection criteria. We compared complication risk for single versus double screw, headed versus headless screw, and short versus longitudinal incision cases. RESULTS The mean age was 48.4 (18-83) years and average follow up was 28 (12-150) weeks. All cases achieved radiographic union. Overall complication rate was 19.5% (37/190). Risk of complication did not differ significantly between single and double screw (RR: 1.170; 95% CI: 0.66-2.09; p=0.594) or short and extended incision groups (RR: 0.868; 95% CI: 0.42-1.80; p=0.704). Risk of complication differed significantly between headed and headless screw fixation (RR: 5.558; 95% CI: 2.69-11.50; p<0.0001). CONCLUSIONS Single screw fixation of sliding calcaneal osteotomy achieves similar outcomes as double screw fixation. Headless screws are advantageous for minimizing hardware pain and subsequent hardware removal.
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Affiliation(s)
- Bahman SahraNavard
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Parke W Hudson
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Cesar de Cesar Netto
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Bradley W Wills
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Ibukunoluwa B Araoye
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Shelby Bergstresser
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Brent M Cone
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Ashish Shah
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
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Veljkovic A, Symes M, Younger A, Rungprai C, Abbas KZ, Salat P, Tennant J, Phisitkul P. Neurovascular and Clinical Outcomes of the Percutaneous Endoscopically Assisted Calcaneal Osteotomy (PECO) Technique to Correct Hindfoot Malalignment. Foot Ankle Int 2019; 40:178-184. [PMID: 30304962 DOI: 10.1177/1071100718800983] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Standard open calcaneal osteotomies to correct hindfoot malalignment have been associated with high complication rates, including nerve damage and wound infection. This has resulted in the development of minimally invasive techniques such as the percutaneous endoscopically assisted calcaneal osteotomy (PECO), which in cadaver studies has been shown to be potentially safer than open surgeries. The aim of this study was to demonstrate the safety and effectiveness of PECO in a clinical setting, with regard to neurovascular injury rates, infection, and short-term radiographic and functional outcomes. METHODS: Forty-one (41) patients with planovalgus or cavovarus foot deformities underwent treatment using PECO. Outcomes were analyzed at 6 months and primarily included neurovascular outcomes and wound infection rates. Secondarily, radiographic and functional (visual analog scale for pain [VAS], 36-Item Short Form Medical Outcomes Survey [SF-36], and Foot Function Index [FFI] scores) outcomes were also assessed. RESULTS: There were no reported cases of superficial wound infections, lateral calcaneal or sural nerve dysesthesia. Minor complications occurred in 6/41 feet. The mean postoperative hindfoot correction was 8.3 ± 2.2 mm (range: 6-15mm) compared to preoperative status. Compared to preoperative status, significant improvements ( P = .001 for all) were seen in the VAS, SF-36, and FFI at 6 months postoperatively. CONCLUSIONS: PECO resulted in minimal complications with no lateral calcaneal or sural nerve dysesthesias and no wound complications. It also resulted in significant improvements in postoperative radiographic and functional outcomes from baseline to 6-months postoperatively, demonstrating its use as a safe and effective means of treating hindfoot malalignment. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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Affiliation(s)
- Andrea Veljkovic
- 1 St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Michael Symes
- 1 St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alastair Younger
- 1 St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Peter Salat
- 4 University of Calgary Cumming School of Medicine Department of radiology, Mayfair Diagnostics. Calgary, AB, Canada
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Abstract
Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched.
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Affiliation(s)
- Jensen K. Henry
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Rachel Shakked
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Scott J. Ellis
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Waizy H, Jowett C, Andric V. Minimally invasive versus open calcaneal osteotomies - Comparing the intraoperative parameters. Foot (Edinb) 2018; 37:113-118. [PMID: 30396147 DOI: 10.1016/j.foot.2018.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 06/17/2018] [Accepted: 06/19/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND The calcaneal osteotomies is often performed to correct asymptomatic hindfoot deformities. More recently minimally invasive techniques have been described with promising clinical outcomes. In a prospective study we compared the intraoperative parameters of the open and minimalinvasive (MICO) techniques, which has not previously been reported. METHODS 60 consecutive with calcaneal osteotomy (33 open and 27 MICO) and a minimum follow up of 12 weeks were included. We recorded the following intraoperative parameters: operation time for the osteotomy [min], the fluoroscopy time, the fluoroscopy dose and the skin incision. The clinical (FAOS) and radiological outcome were examined 6 and 12 weeks postoperatively. The Wilcoxon test and the continuity correction were used with alpha=5% value for the statistical significance. RESULTS The minimally invasive group showed a significantly shorter operation time. There was no significant difference between the radiation time and dose in the two groups. The length of the incision in the minimally invasive group was significantly shorter. We found no difference in clinical outcome and radiological follow up. CONCLUSIONS This study reports a significantly shorter operating time and a shorter incision in the MICO group. The radiation exposition was not significantly different between the two groups. A clinical difference could not be shown in our study. However, we see the shorter operating time of the minimally invasive calcaneal osteotomy being beneficial.
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Affiliation(s)
- H Waizy
- Clinic for Foot and Ankle Surgery, Hessing Foundation, Hessing Str. 17, 86199 Augsburg, Germany; Laboratory for Biomechanics and Biomaterials, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
| | - C Jowett
- York Hospitals NHS Foundation Trust, Wigginton Road, York, N Yorkshire YO31 8HE, UK
| | - V Andric
- Clinic for Foot and Ankle Surgery, Hessing Foundation, Hessing Str. 17, 86199 Augsburg, Germany
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Double calcaneal osteotomy with minimally invasive surgery for the treatment of severe flexible flatfeet. INTERNATIONAL ORTHOPAEDICS 2018; 42:2123-2129. [PMID: 29582117 DOI: 10.1007/s00264-018-3910-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 03/16/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Severe flexible flatfoot deformity in children and adolescents is a complex problem. Calcaneal lengthening remains the gold standard for surgical correction at this institution. However, in a minority of patients, inadequate correction of valgus is noted at surgery and a further calcaneal shift osteotomy is done. METHODS We have conducted a retrospective review of ten patients who received 15 combined minimally invasive calcaneal shift and calcaneal lengthening osteotomies, which were all performed by the senior author. All patients had failed conservative treatment. We describe our technique for double calcaneal osteotomy combining minimally invasive surgery (MIS) for the medial calcaneal shift with traditional open calcaneal lengthening osteotomy for treating children and adolescents with severe flexible flatfoot deformity. RESULTS The average shift achieved was 8.07 mm. The average improvement in Meary's angle was 14.99°. All of them had radiological and clinical union at 12 weeks. None of the patients developed sural nerve injury, wound breakdown, or infection of the MIS incision. CONCLUSION In double calcaneal osteotomies, the MIS calcaneal medial shift technique can be used safely with potentially lower risks of wound complications and sufficient medial shift, compared to conventional open extensive surgery. IMPLICATIONS MIS calcaneal shift osteotomy has an advantage over open conventional open technique in cases where the skin is under tension like in combined calcaneal lengthening osteotomy. With experience, the procedure can be faster than an open procedure.
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Abstract
UNLABELLED Minimally invasive techniques are readily applicable to calcaneal osteotomies and have the potential to accomplish hindfoot correction equivalent to open procedures with less morbidity and pain. Use of a guidance jig makes the procedure more predictable. While most anatomic features of the procedure are the same as those with open techniques, special care must be taken to avoid neurovascular injury because there is no open exposure. Anatomic guidelines have been established for appropriately localizing the osteotomy. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
- Thomas I Sherman
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gregory P Guyton
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Sinus tarsi approach versus extensile lateral approach for displaced intra-articular calcaneal fracture: a meta-analysis of current evidence base. J Orthop Surg Res 2017; 12:43. [PMID: 28288661 PMCID: PMC5348794 DOI: 10.1186/s13018-017-0545-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 03/04/2017] [Indexed: 11/17/2022] Open
Abstract
Background The extensile lateral approach (ELA) has been widely performed for displaced intra-articular calcaneal fractures (DIACFs), and wound complications remain a significant problem. As a minimal incision technique, the sinus tarsi approach (STA) was designed to overcome this disadvantage. There were already many reports about this approach but the conclusions were not completely consistent. Based on the current evidence, we performed this meta-analysis to compare the STA with ELA in the management of DIACF and expected to draw a certain and meaningful conclusion. Methods All potentially relevant randomized controlled trials (RCTs) and cohort studies (CSs) were searched in the databases of PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrial.gov. The desirable outcomes including wound complications, excellent and good rate, secondary surgery rate and Böhler’s angle were extracted. RCT studies were assessed using the Risk of Bias Tool recommended by the Cochrane Collaboration, and cohort studies were evaluated using the Newcastle–Ottawa Scale. The data of RCTs and cohorts were pooled respectively using the fixed-effect model or random-effect model. Mean differences with 95% confidence intervals (CIs) were calculated for continuous data, and relative risks (RRs) with 95% CIs were calculated for dichotomous data. Statistical heterogeneity was assessed with the Q test and I2. Sensitivity analysis was developed to assess the reliability of pooled results. Results Seven studies including two RCTs and five CSs were eligible for the meta-analysis. No matter RCTs or CSs, the pooled data all showed that STA group had a lower incidence of wound complications than that in the ELA group and no significant difference was found in excellent and good rate and the recovery of Böhler’s angle between the two groups. The CSs also showed that the STA group had a lower incidence of secondary surgeries than that in the ELA group. Conclusions Through a STA, we not only can reduce the problems in wound healing but also achieve nearly the same adequate restoration of DIACF along with the similar functional outcomes compared with through an ELA.
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Veljkovic A, Tennant J, Rungprai C, Abbas KZ, Phisitkul P. An Anatomic Study of the Percutaneous Endoscopically Assisted Calcaneal Osteotomy Technique to Correct Hindfoot Malalignment. Foot Ankle Int 2017; 38:192-199. [PMID: 27765868 DOI: 10.1177/1071100716674259] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open calcaneal osteotomy using traditional methods is associated with complications such as sural nerve injury and potential wound healing problems. We hypothesized that by using novel minimally invasive techniques, these potential risks could be mitigated. This anatomic cadaveric study serves to assess the safety of percutaneous endoscopically assisted calcaneal osteotomy (PECO) compared to a traditional open osteotomy technique. METHODS Anatomic safety of PECO was assessed using 8 fresh-frozen cadaver below-knee specimens. Lateral calcaneal nerve (LCN) damage was primarily noted and then secondly compared to a potential open surgical incision approach. RESULTS Only 1 of 11 LCN branches (n = 8 limbs) was transected using PECO, compared to up to 8 of 10 LCN branches (n = 6 limbs) that potentially would have been injured during open surgery. CONCLUSIONS Percutaneous endoscopically assisted calcaneal osteotomy is a minimally invasive technique that had fewer nerve injuries in this cadaveric model than traditional open surgery. CLINICAL RELEVANCE Percutaneous endoscopically assisted calcaneal osteotomy due to its less invasive nature may result in fewer neurovascular injuries relative to an open procedure.
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Affiliation(s)
- Andrea Veljkovic
- 1 St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Kaniza Zahra Abbas
- 4 University Health Network-Toronto Western Division, Toronto, ON, Canada
| | - Phinit Phisitkul
- 5 Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
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Minimally invasive calcaneal osteotomy: A cadaveric and clinical evaluation. Foot Ankle Surg 2016; 22:244-247. [PMID: 27810022 DOI: 10.1016/j.fas.2015.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 08/22/2015] [Accepted: 11/06/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND A cadaveric and clinical study was performed to assess whether a minimally invasive technique is a potentially safer alternative compared to a calcaneal osteotomy through an open lateral approach. METHODS Cadaveric: A minimally invasive calcaneal osteotomy (MICO) was performed on nine cadaveric specimens. These were examined to identify any nerve injury and to quantify the displacement achieved with the osteotomy. Clinical: A retrospective review of a sequential case series of medializing MICO's performed by the senior author between October 2011 and November 2014 was undertaken. RESULTS Cadaveric: Neurological structures remained uninjured in all specimens. The distance of the sural nerve and the main trunk of the tibial nerve to the superior limb of the oblique osteotomy was 6.2±4.8mm (range 0-14mm) and 7.3±3.6mm (range 4-12mm), respectively. The mean coronal shift achieved was 16.7±3.4mm (range 12-21mm). Clinical: The senior author carried out 35 medializing MICO procedures. Radiological and clinical union occurred in all 35 cases (100%). There were no neurovascular or wound complications. CONCLUSION Minimally invasive calcaneal osteotomy offers a safe alternative to an open procedure with promising clinical results.
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Abstract
Osteotomies of the calcaneus are powerful surgical tools, representing a critical component of the surgical reconstruction of pes planus and pes cavus deformity. Modern minimally invasive calcaneal osteotomies can be performed safely with a burr through a lateral incision. Although greater kerf is generated with the burr, the effect is modest, can be minimized, and is compatible with many fixation techniques. A hinged jig renders the procedure more reproducible and accessible.
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Affiliation(s)
- Gregory P Guyton
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, 3333 North Calvert Street, Baltimore, MD 21218, USA.
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Die perkutane Kalkaneusverschiebeosteotomie. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2016; 28:309-20. [DOI: 10.1007/s00064-016-0459-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 03/13/2016] [Accepted: 03/15/2016] [Indexed: 11/25/2022]
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