Nikiforos Pandelis Saragas

Comparative Radiographic Analysis of Parameters in Feet With and Without Hallux Valgus

This study involved the radiographic examination of 118 feet from 110 urban African female patients. Fifty-two of the 118 feet showed radiographic evidence of hallux valgus (valgus angle >15°). The parameters compared between feet with and without hallux valgus were sesamoid position, pes planus deformity, metatarsal length, and the cuneiform-metatarsal articulation. All radiographs were standardized, weightbearing anteroposterior and lateral views. The results were statistically analyzed. The findings showed no difference between the hallux valgus and control groups with respect to sesamoid position relative to the second metatarsal, incidence of pes planus, relative length of the first metatarsal, and the first metatarsal-medial cuneiform articulation.

Proximal opening-wedge osteotomy of the first metatarsal for hallux valgus using a low profile plate.

Background: This retrospective study was conducted to evaluate the results of the proximal (basal) opening-wedge osteotomy of the first metatarsal for correction of symptomatic hallux valgus deformity, using a low profile plate. Materials and Method: The procedure was performed by a single surgeon over an 18-month period. Forty-six patients (64 feet) were treated for symptomatic hallux valgus with an average follow up of 20 months. A proximal opening-wedge osteotomy of the first metatarsal and fixation with a low profile plate in combination with a distal soft tissue release with the same postoperative protocol was used in all the patients. Improvement in the hallux valgus angle (HV) and I—II intermetatarsal angle (IM I—II) as well as the AOFAS forefoot score pre and postoperatively (obtained retrospectively from the medical records), were recorded; in particular, the length of the first metatarsal was noted pre- and postoperatively. Results: The HV and IM I—II angles improved by a mean of 14.7 degrees and 6.4 degrees, respectively. The AOFAS forefoot score improved from a mean of 51.3 to 86.8. The mean increase in the length of the first metatarsal was 2.3 mm. Of the more significant complications, five patients developed a hallux varus (early in the series), one of which was symptomatic, and there was one non-union requiring bone graft. Conclusion: The proximal opening wedge osteotomy of the first metatarsal in combination with a distal soft tissue release and stable fixation of the low profile plate was an effective method for correcting a moderate hallux valgus deformity. Guidance provided by the “First Metatarsal Opening Wedge Angle Reference Chart” was found to be helpful for the IM I–II angle correction. Level of Evidence: IV, Retrospective Case Series

The impact of risk assessment on the implementation of venous thromboembolism prophylaxis in foot and ankle surgery

BACKGROUND The purpose of this prospective study was to determine whether the more frequently quoted procedure and patient specific risk factors have any impact in the implementation of venous thromboembolism (VTE) prophylaxis following foot and ankle surgery. METHODS Two hundred and sixteen patients were included in the study. A variety of operative procedures was carried out with the common denominator being a below knee cast for at least 4 weeks and nonweightbearing for an average of 6 weeks in 130 patients. The remainder of the patients (88) had hallux surgery not requiring a cast and were allowed to weightbear. No patient received any form of thromboprophylaxis postoperatively. All patients were subjected to compression ultrasonography for deep vein thrombosis (DVT) between 2 and 6 weeks postoperatively. RESULTS There was a 5.09% incidence of VTE (0.9% pulmonary embolism) overall. As no VTE (neither DVT nor pulmonary embolus) developed in the hallux subgroup, i.e. patients not requiring immobilization and were allowed to weightbear, the incidence of VTE in the cast/nonweightbearing group was 8.46%. The results are descriptive and only statistically analyzed where possible, as the sample size of the VTE group was small. There was no significant difference in number of risk factors and no association between gender in the VTE and non VTE groups. 90.9% of patients in the VTE group had a total risk factor score of 5 or more and 73.7% of patients in the non VTE group had a total risk factor score of 5 or more. The average timing to the diagnosis of VTE in this current study was 33.1 days. CONCLUSIONS In view of the unacceptable incidence of VTE and the average total risk factor score of 5 or more (for which thromboprophylaxis is recommended) in the majority of the patients, the authors feel that the routine use of thromboprophylaxis in foot and ankle surgery requiring nonweightbearing in combination with short leg cast immobilization, is warranted. This prophylaxis should continue until the patient regains adequate mobility either by weightbearing (in or out of the cast) or removal of cast immobilization (weightbearing or nonweightbearing), usually between 28 and 42 days.

Technique Tip: Preventing “Troughing” with the Scarf Osteotomy

The scarf osteotomy for correction of hallux valgus deformity was popularized in the early 1990s.1,2 It is a demanding procedure that is prone to several complications if not meticulously performed.1,2,4 One such complication is ‘‘troughing’’ with metatarsal collapse and loss of height that causes dorsal displacement of the metatarsal head.1,5 Few articles list this as a complication,1,5 and only one mentions its frequency as being 35%.1 Suggested methods for preventing this complication include avoiding the cancellous bone with the step-cuts,1 using a noncompressing screw,1 making the long limb of the osteotomy from the first metatarsal head to its base parallel to the inferior metatarsal shaft,3 and making the short limbs of the osteotomy 45-degrees to the long limb.3 The scarf osteotomy should be limited to young patients with strong bone;1 osteoporosis is a contraindication to the procedure.5 The technique described allows ‘‘controlled’’ compression and is another effective method for avoiding the complication of troughing of the soft cancellous bone

Peroneal tendon dislocation/subluxation - Case series and review of the literature

BACKGROUND Dislocating or subluxing peroneal tendons is a relatively infrequent injury. Although infrequent it is very debilitating for the athlete. This retrospective study addresses primarily the surgical technique. METHODS Twenty-three patients between 2005 and 2014 were operated on for symptomatic dislocating or subluxing peroneal tendons. Five patients presented in the acute phase and 18 patients were late cases. Twenty patients were available for follow-up at a mean of 53.1 months. Three patients were classified as Stage III and 17 as Stage I/II. The procedures varied from pure repair of the superior peroneal retinaculum (SPR), reattachment of the SPR, groove-deepening or a combination of the above. No one procedure was favoured over the other. The choice of procedure was decided intraoperatively depending on the findings. RESULTS The mean postoperative VAS score was 1.5 with a mean AOFAS score of 85. Sixteen patients rated their results as excellent, one as good, one uncertain and two poor. The results showed no one procedure superior to another with respect to chronicity, stage or satisfaction score. CONCLUSIONS Several procedures have been described for this condition. Most published studies however, comprise of a small cohort of patients with good results following surgery. The surgical techniques vary and depend largely on the surgeons clinical experience and preference. The authors conclude that the surgical technique described in this article is largely successful with a low complication rate and a high satisfaction rate.

A radiographic analysis of the contribution of hallux valgus interphalangeus to the total valgus deformity of the hallux

BACKGROUND The hallux valgus interphalangeus (HVI) deformity is described as rare, but improved outcomes in hallux valgus (HV) surgery is associated with its surgical correction via an Akin osteotomy. The hypothesis of this study is that HVI is common and makes a significant contribution to the total valgus deformity of the hallux (TVDH). METHODS 285 pre-operative foot radiographs (193 with HV, 92 non-HV), utilising standardised radiographic and measurement techniques, were analysed retrospectively. The hallux valgus angle (HVA), intermetatarsal angle (IMA), interphalangeal angle (IPA) and distal metatarsal articular angle (DMAA) were measured. The TVDH was calculated as the sum of the HVA and IPA. RESULTS 163 (57.2%) of the study population were Caucasian, 119 (41.8%) African and 3 Indian (1.0%). 236 (82.8%) of the population was female. There was a statistically significant difference in the proportion of abnormal IPA in the Caucasian population 112 (68.7%) compared to the proportion of abnormal IPA in the African population 64 (53.8%), p=0.01. The average contribution of the IPA to the TVDH across the whole study population was a mean (SD) of 37.9% (21.2). The average contribution of IPA to TVDH was greater in feet without HV (58.0%) when compared to feet with HV (28.3%). HVI is common, particularly in Caucasians (p=0.01) and makes a significant contribution to the TVDH (p<0.01). The contribution to the TVDH is more significant in mild HV. There is an inverse relationship between the IPA and other angular measurements in the foot. CONCLUSION HVI is a common entity. The significant contribution of the IPA to the TVDH dictates that HVI must be incorporated in management algorithms. The TVDH should replace the isolated concepts of HV and HVI. LEVEL OF EVIDENCE Level III, retrospective cohort.

Rotational and Opening Wedge Basal Osteotomies

There are more than 150 different procedures described for correction of the hallux valgus deformity, the treatment of which is usually guided by severity. Moderate to severe hallux valgus has traditionally been managed with a shaft or proximal osteotomy together with distal soft-tissue release. Proximal osteotomies can be classified as translation or rotational. Rotational osteotomies such as the Ludloff and proximal opening wedge have not been popular historically because of instability from lack of fixation, resulting in complications. This article describes modified techniques with modern fixation of these 2 osteotomies, which offer stable fixation and reproducible results.

Clinical tip : Postoperative dressing for hallux valgus surgery

Postoperative dressing after surgery for correction of hallux valgus deformity is of utmost importance in maintaining acceptable correction of the toe until there is sufficient soft-tissue healing. The accepted method is initial compression for the first 12 to 48 hours followed by weekly gauze-and-tape toe spica dressings, maintaining the alignment of the toe in an anatomical position for 6 to 7 more weeks.1,2 This technique (although effective) is time consuming and technically demanding. Appropriate material may not be readily available or cost effective and often is uncomfortable to the patient. The advantages of the described method are as follows:

Schwannoma and neurofibroma of the posterior tibial nerve presenting as tarsal tunnel syndrome: review of the literature with two case reports

We present two case reports of peripheral nerve tumors (schwannoma and neurofibroma) that presented as tarsal tunnel syndrome for many years. There has never been a report of multiple neurofibroma of the posterior tibial nerve presenting as a tarsal tunnel syndrome. Both patients were treated surgically with good outcomes.

The benefit of pharmacological venous thromboprophylaxis in foot and ankle surgery

BACKGROUND Ten percent of patients with a deep-vein thrombosis (DVT) will develop a fatal pulmonary embolism (PE), often initially asymptomatic. The risks and benefits of pharmacological thromboprophylaxis are well documented in respect of total joint arthroplasty and hip fractures, but little is understood about the incidence of venous thromboembolism (VTE) or the potential risks and benefits of chemoprophylaxis in foot and ankle surgery. OBJECTIVE To determine whether prophylactic chemoprophylaxis had any impact on the prevention of VTE in a cohort of foot and ankle surgical patients requiring the combination of below-knee cast immobilisation and non-weightbearing for ≥4 weeks. METHODS Between March 2014 and April 2015, a prospective cohort study of 142 patients was performed. All completed a thrombosis risk assessment form prior to surgery and were commenced on rivaroxaban (Xarelto) 10 mg/d postoperatively. The primary outcome measure was clinical VTE confirmed by compression ultrasonography (DVT) or a ventilation/perfusion scan (PE). RESULTS Three patients (2.1%) developed a clinical DVT. Two did so well beyond the immobilisation and anticoagulation period, and one was non-compliant with therapy. The average risk factor score in this subgroup was 7. No patient had a DVT while on the prescribed regimen of anticoagulant therapy. Five patients (3.5%) developed wound breakdown, two requiring surgical debridement with local skin flap closure. One case of menorrhagia that may have been linked to the anticoagulant therapy was reported. When compared with a previous study, pharmacological thromboprophylaxis significantly reduced VTE risk (p=0.02). CONCLUSIONS Oral pharmacological thromboprophylaxis significantly reduces the risk of VTE in patients requiring cast immobilisation and non-weightbearing following foot and ankle surgery. The risk/benefit ratio favours this treatment as opposed to the treatment of major morbidity following non-fatal VTE.