Cristian Ortiz

Cavovarus foot reconstruction.

This article presents a surgical protocol for surgical reconstruction from the subtle cavus foot described by Manoli to the most complicated cases. The goal is to merge together the available surgical options in a comprehensive way to guide surgical decisions.

Early Weight-Bearing After Percutaneous Reduction and Screw Fixation for Low-Energy Lisfranc Injury

Background: Anatomic restoration and postoperative rehabilitation of displaced fracture-dislocations of the tarsometatarsal junction of the foot are essential. Our objective was to report percutaneous reduction and screw fixation results in low-energy Lisfranc fracture dislocation injuries that were treated with early weight-bearing and rehabilitation. Methods: We retrospectively evaluated patients with low-energy Lisfranc injuries who underwent surgery between May 2007 and April 2011. The study reviewed 22 patients (12 men and 10 women) with an average age of 36.2 years (range, 16-50 years) and an average follow-up of 33.2 months (range, 12-50 months). We report the mechanism of trauma; quality of reduction in the postoperative digital radiographs; subjective satisfaction; AOFAS score; time required to return to work, recreational activities, and low-impact sports; and complications. Postoperatively, all of the patients were instructed to be non-weight-bearing for 3 weeks, and the stitches were removed after 2 weeks. At the third postoperative week, the patients were encouraged to bear weight as tolerated. Results: Quality of reduction was anatomic or near anatomic in 100% of cases. The subjective satisfaction reported by patients was very good, with complete satisfaction in 20 of them (90.9%). The AOFAS average was 94 points (range, 90-100 points). Average return to work was at 7 weeks (range, 6-9 weeks), recreational activities 7.2 weeks (range, 6-9 weeks), training for low-impact sports 7.6 weeks (range, 7-8 weeks), and symptom-free sport activities 12.4 weeks (range, 11-13 weeks). Conclusion: In this selected group of patients with low-energy Lisfranc fracture dislocation, anatomic or near-anatomic reduction can be achieved with percutaneous reduction and screw fixation. Early weight-bearing is possible in these patients, and early return to regular activities and low-impact sport can be expected. Level of Evidence: Level IV, retrospective case series.

Proximal Oblique Sliding Closing Wedge Osteotomy for Hallux Valgus

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

Biomechanical evaluation of various suture configurations in side-to-side tenorrhaphy.

BACKGROUND Side-to-side tenorrhaphy is increasingly used, but its mechanical performance has not been studied. METHODS Two porcine flexor digitorum tendon segments of equal length (8 cm) and thickness (1 cm) were placed side by side. Eight tenorrhaphies (involving sixteen tendons) were performed with each of four suture techniques (running locked, simple eight, vertical mattress, and pulley suture). The resulting constructs underwent cyclic loading on a tensile testing machine, followed by monotonically increasing tensile load if failure during cyclic loading did not occur. Clamps secured the tendons on each side of the repair, and specimens were mounted vertically. Cyclic loading varied between 15 N and 35 N, with a distension rate of 1 mm/sec. Cyclic loading strength was determined by applying a force of 70 N. The cause of failure and tendon distension during loading were recorded. RESULTS All failures occurred in the monotonic loading phase and resulted from tendon stripping. No suture or knot failure was observed. The mean loads resisted by the configurations ranged from 138 to 398 N. The mean load to failure, maximum load resisted prior to 1 cm of distension, and load resisted at 1 cm of distension were significantly lower for the vertical mattress suture group than for any of the other three groups (p < 0.031). CONCLUSIONS All four groups sustained loads well above the physiologic loads expected to occur in tendons in the foot and ankle (e.g., in tendon transfer for tibialis posterior tendon insufficiency). None of the four side-to-side configurations distended appreciably during the cyclic loading phase. The vertical mattress suture configuration appeared to be weaker than the other configurations. CLINICAL RELEVANCE For surgeons who advocate immediate loading or motion of a side-to-side tendon repair, a pulley, running locked, or simple eight suture technique appears to provide a larger safety margin compared with a vertical mattress suture technique.

Proximal Oblique Slide Closing Wedge Metatarsal Osteotomy With Plate Fixation for Severe Hallux Valgus Deformities

Proximal metatarsal osteotomies are generally recommended for severe hallux valgus deformities. The most common problems encountered with these osteotomies are overcorrection, that is, hallux varus and dorsal malunion because of either technical errors or fixation failure. We report our first 12 cases of severe hallux valgus deformities treated with a modified proximal metatarsal osteotomy fixed with angular stable plates, with an average American Orthopaedic Foot and Ankle Society preoperative score of 50 points, average intermetatarsal angle of 15 degrees, and metatarsophalangeal angle of 36 degrees. The osteotomy was performed from the dorsal to the plantar aspect of the bone, removing a small bone wedge laterally as determined in the preoperative planning, and translating laterally the distal fragment. In this way, rotation and lateral displacement of the distal fragment was performed until intraoperative parallelism between the first and second metatarsal bone was obtained. The osteotomy was fixed with an angular stable plate, with 2 locked screws proximally and 3 distal nonlocked screws. The geometric model of the osteotomy, preoperative planning, technique, early results, and complications are shown.

Rotational Osteotomy for Hallux Valgus. A New Technique for Primary and Revision Cases

More than 200 different surgical techniques exist for hallux valgus (HV). Some of them are designed for mild, moderate, or severe deformities depending on their correction power. Nevertheless, they all correct only the coronal and/or sagittal plane deformity. Just a handful of them correct the known axial malrotation that exists in most HV cases. This malrotation is one possible factor that could be the source of recurrence of an operated HV as it has been described. We describe a new technique which simultaneously corrects the metatarsal internal rotation and varus deformity by rotating the metatarsal through an oblique plane osteotomy. This is performed with no bone wedge resection. Also, there is a broader bone surface contact than on a transverse proximal osteotomy. This technique is easy to remember and relatively simple to perform in primary and revision cases. The authors results show that it is as safe and effective as other procedures, with some advantages to be discussed. Levels of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

Role of a Limited Transarticular Release in Severe Hallux Valgus Correction

Background: Hallux valgus (HV) treatment is continuously evolving, and no definitive treatment can be recommended. Osteotomies are the main surgical choice for these deformities, but no clear role for soft tissue procedures is available. Objective: To perform a retrospective comparison of the radiographic and clinical outcomes of 2 groups of patients with severe HV operated with the same osteotomy technique but differing on the type of lateral release. Methods: Two groups of patients with symptomatic moderate to severe HV deformities were operated with the same proximal metatarsal osteotomy, which differed on the type of lateral release: group 1 had limited transarticular lateral capsule release (n = 62), and group 2 complete lateral release, including capsule, adductor tendon, and intermetatarsal (IM) ligament (n = 57). We recorded the American Orthopaedic Foot & Ankle Society (AOFAS) score, HV and IM angles, first metatarsal shortening, concomitant metatarsal shortening osteotomies (Weil), Akin osteotomies, and complications. Results: The postoperative AOFAS score in group 1 was similar to that of group 2. The HV and IM angles improved in both groups with no significant difference. The multivariate analysis showed no influence of any variable analyzed on HV or IM angle improvement. Regarding AOFAS score improvement, a limited lateral release was associated with a higher increase in AOFAS score (P = .019). Conclusion: No studies are available to identify which soft tissue structures are involved in HV deformities nor which have to be released, if any. A limited transarticular release can provide similar clinical and radiologic outcomes when compared with a classic open lateral release. Level of Evidence: Level IV, case series.

Modified Diaphyseal Osteotomy With a Proximal Center of Rotation for Moderate to Severe Hallux Valgus

Abstract This study shows a modification of the scarf osteotomy, using a rotational and translational movement with a proximal center of rotation to correct moderate to severe hallux valgus deformities. The mathematical model of the osteotomy and the preoperative planning is presented, using the estimated intermetatarsal angle correction needed. A long oblique diaphyseal osteotomy is performed, with a short distal dorsal arm oriented 90 degrees to the long diaphyseal osteotomy, and a short plantar proximal arm oriented 90 degrees to the long osteotomy line. The distal fragment is rotated around a center of rotation located 15 mm proximal to the metatarsal cuneiform joint and fixed with 3 screws. The short-term results and complications are presented.

Cost effectiveness of different techniques in hallux valgus surgery

BACKGROUND Different surgical techniques are available to correct each type of Hallux Valgus (HV) deformity, and all present similar good results. No information is available relative to the cost of each technique compared to their individual success. OBJECTIVE To determine the cost-effectiveness-ratio (CER) of five different techniques for HV. METHODS We included 245HV surgeries performed in 179 patients. The severity was defined according to radiological parameters. For mild to moderate HV we included the Chevron, Modified-Scarf and Ludloff techniques; for severe HV: either Poscow-osteotomy or Lapidus-arthrodesis fixed with plates or screws. Weighted costs were estimated. CER was expressed in

“Angle to Be Corrected” in Preoperative Evaluation for Hallux Valgus Surgery: Analysis of a New Angular Measurement

US dollars per AOFAS-point. RESULTS The lowest weighted cost was observed for the Chevron-group, and the highest weighted cost was observed in the Poscow-osteotomy and Lapidus-arthrodesis fixed with plate groups. The AOFAS-score improvement was higher in the Chevron and Modified-Scarf groups. The CER found for Chevron and Modified-Scarf techniques were significantly less than for Poscow and Lapidus-techniques. CONCLUSION Cost-Effectiveness-Ratio was lower, and therefore better, in the groups with mild to moderate deformities operated with Chevron or Modified-Scarf techniques. In severe HV, the three techniques investigated presented similar CER. CER analysis is an additional factor that can be included in the decision making analysis in hallux valgus surgery. Level of Evidence Level IV, Retrospective Study.