Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity

BACKGROUND: Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. METHODS: Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). RESULTS: Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (-13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. CONCLUSIONS: Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.     

Dwyer's calcaneal osteotomy for varus deformity of the foot. (A follow-up study including gait analysis) (author's transl)]

A follow-up study on 20 patients one to 9 years after lateral wedge resection of the calcaneus according to Dwyer is reported. In 18 feet with neurogenic varus deformity of the hind foot, the angle between the axis of the lower leg and the heel was altered from 11.4 degrees +/- 1.4 degrees SD varus to a normal value of 5.9 degrees +/- 0.9 degrees SD valgus. The position of the calcaneal tuberosity was changed from 6.7 degrees +/- 1.1 degree SD varus to 0.1 degree +/- SD varus in 7 congenital club feet. The osteotomy reduced accompanying deformities of pes cavus and pes adductus in the operated children.     

Surgical technique for combined Dwyer calcaneal osteotomy and peroneal tendon repair for correction of peroneal tendon pathology associated with cavus foot deformity

Peroneal tendon pathology is commonly seen in patients with underlying pes cavus. The Dwyer calcaneal osteotomy is a useful adjunctive procedure to address the heel varus component of the cavus foot deformity, especially in the presence of concomitant peroneal tendon pathology. The lateralizing heel osteotomy using a wedge resection can effectively reduce future stress on the repaired peroneal tendons, although technical challenges arise when attempting to perform both tendon repair and heel osteotomy through the same incision. Specific principles must be followed to achieve adequate exposure of the desired structures, obtain desired correction of the deformity, and avoid complications such as sural neuritis. In the present report, the surgical principles and technical pearls are highlighted in a pictorial demonstration of preoperative planning for calcaneal wedge resection, incision placement, osteotomy guide pin technique, fixation pearls, and peroneal tendon repair and transfer.     

Evans Calcaneal Osteotomy: Assessment of Multiplanar Correction

Flatfoot deformity consists of collapse of the medial arch, forefoot abduction, increased talonavicular uncoverage, and hindfoot valgus. Although numerous soft tissue and bony procedures have been proposed to correct each plane of deformity, there is a lack of objective data in the literature quantifying the amount of structural correction. The purpose of this study was to quantify the multiplanar deformity correction of the lateral column lengthening osteotomy (Evans) on hindfoot alignment through objective, reproducible, radiographic measurements. We retrospectively reviewed 45 Evans calcaneal osteotomy procedures in 24 female (53%) and 21 male (47%) feet performed on 40 patients (5 bilateral). The mean follow-up was 53 weeks (range, 32-116). The mean age at the time of surgery was 35 years (range, 11-73). Statistically significant improvement in radiographic alignment was found in the calcaneal inclination angle, tibial-calcaneal angle, tibial-calcaneal position, and the anteroposterior talo-first metatarsal angle (p < .0001 for all). Although a direct correlation between graft size and degree of angular correction was not observed, it should be noted the calcaneal graft size (mean, 11.8 mm) and the amount of hindfoot valgus correction (mean, 12.6°) appear to be clinically related. The results of this study support that the Evans calcaneal osteotomy corrects the hindfoot alignment in 3 planes as evidenced by our multiplanar radiographic measurements.     

Salvage of severe ankle varus deformity with soft tissue and bone rebalancing

The etiology of ankle varus is multifactorial. Treatment recommendations after failed conservative care include hindfoot and ankle fusions or total ankle arthroplasty (TAA) with ligament rebalancing. The purpose of this study was to evaluate chronic varus ankle deformities through corrective calcaneal osteotomies and lateral soft tissue reconstruction. All skeletally mature patients with at least 5 degrees of ankle varus were included in the study. Pre and postoperative radiographs were retrospectively reviewed measuring talar tilt. All patients had a lateral closing wedge (Dwyer) calcaneal osteotomy, joint debridement, and lateral ankle ligament reconstruction. Eight feet were included in the study. The average follow-up time was 20.6 months. Six patients (six feet) were asymptomatic and did not have any additional surgery at their most recent follow-up. Two patients failed treatment, requiring surgical intervention for persistent pain and/or deformity. The average postoperative ankle varus correction overall was 4.9 degrees. We found ankle varus on average of less than 10 degrees can be reliably corrected with a combination of lateral ligament reconstruction and calcaneal osteotomy. Approximately 50% of the deformity was corrected when comparing pre and postoperative talar tilt values. In patients with varus deformity greater than 10 degrees preoperatively, persistent varus may occur.     

Preoperative Planning and Intraoperative Technique for Accurate Realignment of the Dwyer Calcaneal Osteotomy

The Dwyer calcaneal osteotomy is an effective procedure for the correction of calcaneal varus deformity. However, no intraoperative method has been described to determine the amount of bone resection. We describe a simple intraoperative method for assuring accurate bone resection and measure the realignment effects of the Dwyer calcaneal osteotomy. We also review radiographic outcomes associated with 20 Dwyer calcaneal osteotomies (in 17 patients) using the intraoperative realignment technique described in this report. Preoperative and postoperative radiographs at a mean of 2.5 (range 1.5 to 5) years taken after Dwyer osteotomy were measured and compared, which revealed a mean reduction in calcaneal varus of 18° (range 2° to 36°) (p < .001), a mean decrease in the calcaneal inclination angle of 5° (range –40° to 7°) (p < .05), a mean decrease in medial calcaneal translation of 10 (range 0 to 18) mm (p < .001) relative to the tibia, and a mean dorsal translation of 2 (range 0 to 7) mm (p = .002). In an effort to attempt to structurally realign the calcaneus to a more rectus alignment, by means of Dwyer osteotomy, we recommend the use of the intraoperative bone wedge resection technique described in this report. Our experience with the patients described in this report demonstrates the usefulness of the intraoperative method that we describe in order to accurately restore the axial tibial and calcaneal relationship.     

Modified Dwyer Osteotomy with Rotation and Reinsertion of Autograft Bone Wedge for Residual Heel Deformity Despite Previous Delayed Subtalar Joint Arthrodesis After Calcaneal Fracture

Calcaneal fracture patterns vary widely, and many factors determine the type and timing of the treatment rendered. Severe calcaneus fractures involving joint damage, loss of heel height, and varus deformity of the tuberosity are ideally treated with open reduction and internal fixation to repair the joint surface and re-establish anatomic structure. This is not always possible owing to delayed presentation, soft tissue compromise, unrelated injuries, unstable medical condition, or lack of expertise by the treating physician. We present the case of a patient who had residual forefoot and rearfoot deformity despite undergoing delayed subtalar joint arthrodesis at an outside hospital 10 years before for a calcaneal fracture that was initially treated nonoperatively. At 4 years of follow-up after modified Dwyer calcaneal osteotomy with rotation and reinsertion of the autograft bone wedge and Cotton midfoot osteotomy, the postoperative gait was relatively normal, other than the expected lack of hindfoot mobility. The lateral column pain was resolved. The patient remained highly satisfied with the outcome at long-term follow-up of 48 months, with improved heel alignment, lack of a wide stance gait, a functional medial column, and a relatively normal gait. This case demonstrates the value of periarticular calcaneal osteotomies without the need to revise the subtalar joint arthrodesis for this challenging clinical situation.     

Osteotomies in the midfoot and the calcaneal part of the foot in relapsed clubfoot

There are no clear guidelines on the treatment of relapsed clubfoot, which is a relatively frequent and difficult problem in paediatric orthopaedics. Numerous operative interventions are mentioned in the literature as suitable for correction of a residual deformity of the food. There are numerous soft tissue procedures (release operations, tendon extensions, tendon transfers and redressement by means of a fixateur externe) and osseous interventions (osteotomies, arthrodeses) that can be carried out in isolation or in combination. In the present article two types of osteotomy are described that make it possible to correct the most frequent forms of relapsed clubfoot: combined closing wedge cuboid and opening wedge cuneiform osteotomy for correction of adductus and supination of the forefoot and the calcaneal osteotomy after Dwyer for correction of varus position of the calcaneal part of the foot. The combined osteotomy in the midfoot involves shortening of the lateral ray with simultaneous lengthening of the medial ray, with the wedge out of the cuboid bone inserted into the medial cuneiform bone, which leads mainly to correction of the adductus, but does also make it possible to achieve partial correction of the supination with an osteotomy right through the cuneiform bone. In the case of rigid foot deformities it is advisable to carry out preliminary stretching by means of a fixateur externe, while in the case of a bean-shaped foot a combination of osteotomy and medial and lateral release is recommended. Results of a follow-up study of our own patients treated with this operation have shown that no revision operations were necessary in any of the patients with idiopathic clubfoot. Other types of osteotomy described in the literature as suitable for correction of residual forefoot adductus and supination are also mentioned in this paper. Thecalcaneal osteotomy after Dwyer, for which a lateral approach is always used, generally leads to satisfactory correction of varus position of the calcaneal part of the foot. It the calcaneus is found to have a short posterior part this osteotomy is modified so that instead of taking the form of a wedge osteotomy with lateral closing it is followed by a lateral displacement. In this way it is possible to prevent making the already short posterior calcaneus even shorter. Both the combined midfoot osteotomy and the calcaneal osteotomy after Dwyer can be performed alone or in combination with each other or with different operative interventions.     

Three-dimensional displacement after a medializing calcaneal osteotomy in relation to the osteotomy angle and hindfoot alignment

BackgroundA medializing calcaneal osteotomy is frequently performed to correct adult-acquired flatfoot deformities, but there is lack of data on the associated three-dimensional variables defining the final correction. The aim of this study was to assess the correlation between the pre-operative hindfoot valgus deformity and calcaneal osteotomy angles and the post-operative calcaneal displacement.MethodsWeight-bearing CT scans obtained pre- and post-operatively were retrospectively analyzed for sixteen patients. Corresponding three-dimensional bone models were used to measure valgus deformity pre- and post-operatively, inclination of the osteotomy and displacement of the calcaneus. Linear regression was conducted to assess the relationship between these measurements.ResultsOn average, the hindfoot valgus changed from 13.1° (±4.6) pre-operatively to 5.7° (±4.3) post-operatively. A mean inferior displacement of 3.2 mm (±1.3) was observed along the osteotomy with a mean inclination of 54.6° (±5.6), 80.5° (±10.7), −13.7° (±15.7) in the axial, sagittal and coronal planes, respectively. A statistically significant positive relationship (p < .05, R² = 0.6) was found between the pre-operative valgus, the axial osteotomy inclination, and the inferior displacement.ConclusionsThis study shows that the degree of pre-operative hindfoot valgus and the axial osteotomy angle are predictive factors for the amount of post-operative inferior displacement of the calcaneus. These findings demonstrate the added value of a computer-based pre-operative planning in clinical practice.Level of evidence II Prospective comparative study.     

Posterior tibial tendon insufficiency. Isolated fusion of the talonavicular joint

In selected patients, fusion of the talonavicular joint can be an effective treatment of adult flatfoot deformity. Restriction of motion and altered hindfoot mechanics, however, are a consequence of talonavicular fusion and can lead to accelerated arthrosis of adjacent joints. In patients with severe long-standing deformity, medial displacement calcaneal osteotomy may be a necessary adjunct to talonavicular fusion for adequate correction of heel valgus.     

Treatment of skewfoot by multiple lesser tarsal osteotomies and calcaneal osteotomy

A 9-year-old male with bilateral skewfoot deformity underwent corrective surgery consisting of multiple abductory, lesser tarsal osteotomies, and medial displacement L-shaped calcaneal osteotomy. The author prefers this surgical approach because it minimizes shortening of the lateral column without limiting the amount of transverse plane correction. The calcaneal osteotomy offers excellent stability in the sagittal plane without limiting frontal or transverse plane correction.     

Hallux valgus and first ray mobility: a cadaveric study

BACKGROUND: Several studies have demonstrated that patients with hallux valgus (HV) deformities have increased first ray sagittal mobility. However, the change in mobility that occurs after surgical correction of HV deformities has not been extensively evaluated. This study was done to determine if surgical realignment of the first ray in cadaver specimens with a proximal crescentic osteotomy and distal soft tissue reconstruction (DSTR) would reduce the first ray sagittal motion as measured with an external-type micrometer (the Klaue device). METHODS: Twelve fresh-frozen below-knee cadaver specimens with an HV deformity (HV angle > 15 degrees, 1-2 IM angle > 9 degrees) were used for the study. Standardized simulated weightbearing radiographs were obtained before and after the surgical correction of the deformity. The first ray sagittal motion was measured with an external micrometer (Klaue device) before correction of the HV deformity and after the procedure. All specimens had correction of the hallux valgus deformity with a DSTR and proximal crescentic osteotomy. Internal fixation was applied to secure the osteotomy site. RESULTS: The HV angle was corrected from a mean of 28.6 degrees to a mean of 11.0 degrees. The 1-2 IM angle was corrected from a mean of 12.9 degrees to a mean of 6.8 degrees. The average preoperative first ray sagittal motion was 11.0 mm (range, 8.5 mm to 13.5 mm). After the surgical repair, the mean sagittal first ray motion was significantly decreased (p <.0005) to a mean of 5.2 mm (range, 3.5 mm to 7.5 mm). CONCLUSION: After correction of HV deformities with a DSTR and a proximal crescentic osteotomy, first ray mobility in cadaver specimens was significantly reduced. The stabilization of first ray mobility that occurred immediately after surgical correction despite leaving the capsule of the first metatarsocuneiform (MC) joint undisturbed suggests that extrinsic anatomic features may play a role in first ray mobility. Additionally, stability of the first ray may be restored with a bunion procedure that does not sacrifice the first MC joint.     

Foot Deformity Correction Planning in the Sagittal Plane Based on the Vitruvian Foot First Metatarsal Mechanical Axis and Calcaneus Anatomic Axis

The aim of the study was to test a novel planning method for simultaneous midfoot and hindfoot deformity correction, based on reference lines and angles (RLA) of the talus, calcaneus and first metatarsal in 64 normal radiographs from 55 patients. Talus Joint Line (TJL), from the border of the articular surface of the talus and the posterior process of talus, and mechanical axis of the first metatarsal form the mechanical Lateral Talometatarsal Angle (mLTMA) = 23.6º (±3.2). The length of the first metatarsal line was measured from its intersections with the TJL and first metatarsal head and it was 4.3 (±0.94) times longer that TJL (k). For hindfoot correction planning, we used an axis of the calcaneus formed by a line starting at the middle of the back of the calcaneal tuberosity and going perpendicular to a line from the top point to the bottom point of the calcaneal tuberosity. The intersection of the calcaneal line and the anterior continuation of TJL form the lateral heel angle (LHA) = 15.2º (±3.4).The following parameters were identified: the length from the intersection point of the lines and anterior point of TJL was 2.56 ± 1.1 longer than TJL (k1). The length from the intersection point and posterior border of the calcaneus was 4.59 ± 1.0 times longer than TJL (k2). Planning using the new method was demonstrated and confirmed on 3 case examples. A novel method for analysis and planning of midfoot and hindfoot sagittal plane deformity correction may be used separately or simultaneously for complex deformity correction.     

Maintenance of Correction of First Metatarsal Closing Base Wedge Osteotomies Versus Modified Lapidus Arthrodesis for Moderate to Severe Hallux Valgus Deformity

A retrospective radiographic review of 57 feet was conducted to compare maintenance of correction of the modified Lapidus arthrodesis with the first metatarsal closing base wedge osteotomy for moderate to severe hallux valgus deformity. Radiographic parameters were measured on the preoperative, early postoperative, and greater than 11-month postoperative weightbearing radiographs. These measurements included the intermetatarsal angle, the hallux abductus angle, and the tibial sesamoid position. The patients who underwent the closing base wedge osteotomy had an average initial intermetatarsal correction of 10.4 degrees; for the modified Lapidus arthrodesis, it was 7.6 degrees. The patients who underwent the closing base wedge osteotomy had an average loss of intermetatarsal correction of 2.55 degrees from early to late postoperative radiographs; for the modified Lapidus arthrodesis, it was 1.08 degrees. Our results demonstrated that the modified Lapidus arthrodesis maintains correction to a greater degree than the first metatarsal closing base wedge osteotomy with statistical significance (P = .0039). Both the modified Lapidus arthrodesis and the first metatarsal closing base wedge osteotomy are effective procedures with respect to degree of radiographic correction for moderate to severe hallux valgus deformities.     

Preoperative planning and computer assisted surgery in ankylosing spondylitis

AIM: The following study describes a technique for preoperative planning and computer-assisted correction osteotomy in the treatment of ankylosing spondylitis. The effect on the overall sagittal profile is evaluated. METHOD: Kyphosis was corrected by a posterior closing wedge osteotomy. Angle and localisation of the wedge were exactly planned preoperatively and transferred to a navigation system. The osteotomy was then performed along the premarked lines with image-guided tools. Nine patients aged 40 to 61 years (average 46 years) were operated on. Follow-up time averaged 12 months (1 to 33 months). RESULTS: The planned angle of the wedge osteotomy was an average of 30 degrees (range 24 degrees to 40 degrees ) preoperatively. Postoperatively, the angle averaged 30 degrees as well (range 22 degrees to 41 degrees ). The individual difference between real and planned angle was an average of 2.7 degrees (range 1 degrees to 6 degrees ). Sacral inclination was 23 degrees preoperatively (range-- 6 degrees to 40 degrees ) and was corrected to 40 degrees (range 27 degrees to 49 degrees ). Anterior displacement of the gravity line averaged 112 mm preoperatively (range 47 to 196 mm) and was corrected to 31 mm (range--7 to 135 mm) postoperatively and 38 mm (range-- 21 to 137 mm) at latest follow-up. CONCLUSION: Precise preoperative planning and correction osteotomy exactly according to this planning allow for an excellent correction of the sagittal profile even in severe ankylosing spondylitis. Pelvic tilt and gravity line are normalised, the patient is able to adopt an ergonomic upright position. Navigation facilitates the intraoperative transfer of the preoperative planning.     

Lateral Column Lengthening for Revision Triple and Double Arthrodesis and Severe End-Stage Flatfoot Deformity

Few options exist for the treatment of revision and severe cases of end-stage flatfoot deformity. Triple arthrodesis or medial-approach double arthrodesis have been the standard but often do not provide enough correction of the deformity. Lateral column lengthening is a powerful procedure performed either with an Evans calcaneal osteotomy or calcaneocuboid distraction arthrodesis that can be used as an adjunct in realigning the flatfoot. We performed a retrospective radiographic review and looked at 11 consecutive cases of patients who underwent hindfoot arthrodesis with a lateral column lengthening procedure. We matched these patients with 11 control patients who underwent isolated medial-approach double arthrodesis. For the patients who underwent a lateral column lengthening procedure, we found a significant improvement in calcaneal inclination angle (p = .001) and greater correction in talar declination angle, cuboid abduction angle, and talocalcaneal angle when compared with the control group. Lateral column lengthening is a useful adjunct to hindfoot arthrodesis in the correction of revision and severe end-stage flatfoot deformity.     

Posterior calcaneal osteotomy. Effect, technique, and indications

Posterior calcaneal osteotomy is a technically simple procedure that may be used to correct frontal, transverse, or sagittal plane displacement of the calcaneus associated with flatfoot deformity. In selected individuals, subluxation about the oblique axis of the midtarsal joint may be stabilized. Forefoot supinatus may be expected to reduce secondary to the reduction of heel valgus obtained, although with deformity chronicity, adaptive midtarsal joint changes may necessitate medial column stabilization. Posterior calcaneal osteotomy increases rotational stability of the subtalar joint in a supinatory direction. In addition, displacement of the posterior calcaneal fragment effects a dynamic correction force by translocation of the Achilles tendon and its posterior relation to the axis of the subtalar joint.     

Management of fixed sagittal plane deformity: results of the transpedicular wedge resection osteotomy

STUDY DESIGN: Retrospective review of a consecutive clinical series. OBJECTIVES: To evaluate the efficacy of the transpedicular wedge resection osteotomy as a technique for correction of sagittal and coronal deformity and to assess the clinical value of the procedure as assessed by patient satisfaction. SUMMARY OF BACKGROUND DATA: The transpedicular wedge resection osteotomy is a well-established procedure for management of fixed sagittal deformity in ankylosing spondylitis. The utility of the procedure for applications in fixed deformity other than ankylosing spondylitis has not been demonstrated, and the efficacy of the procedure in the correction of coronal deformity has not been reported. METHODS: A total of 13 consecutive cases undergoing transpedicular wedge resection osteotomy for the management of sagittal deformity of any etiology were reviewed. Radiographic studies, complications, and satisfaction assessment using the modified Scoliosis Research Society instrument were the outcome parameters measured. RESULTS: Etiologies of deformity included postsurgical, ankylosing spondylitis, idiopathic, and infectious. Measurement of C7 sagittal plumb line to sacrum improved 63% at the most recent follow-up. Lumbar lordosis increased from -15.5 degrees to -45.4 degrees. Coronal balance was improved in all patients who had preoperative imbalance, with an average improvement of 60% maintained at follow-up. Patient satisfaction was high in all patients and not dependent on the etiology of deformity. CONCLUSIONS: The transpedicular wedge resection osteotomy is an effective procedure for the management of fixed sagittal deformity and is generalizable for multiple etiologies. Simultaneous correction of coronal deformity is possible. The clinical value of the procedure is demonstrated in high rates of patient satisfaction.     

Proximal metatarsal osteotomies: a comparative geometric analysis conducted on sawbone models

We evaluated the change in position of the first metatarsal head using a three-dimensional digitizer on sawbone models. Crescentic, closing wedge, oblique shaft (Ludloff 8 degrees and 16 degrees), reverse oblique shaft (Mau 8 degrees and 16 degrees), rotational "Z" (Scarf), and proximal chevron osteotomies were performed and secured using 3-mm screws. The 16 degrees Ludloff provided the most lateral shift (9.5 mm) and angular correction (14.5 degrees) but also produced the most elevation (1.4 mm) and shortening (2.9 mm). The 8 degrees Ludloff provided lateral and angular corrections similar to those of the crescentic and closing wedge osteotomies with less elevation and shortening. Because the displacement osteotomies (Scarf, proximal chevron) provided less angular correction, the same lateral displacement, and less shortening than the basilar angular osteotomies, based upon this model they can be more reliably used for a patient with a mild to moderate deformity, a short first metatarsal, or an intermediate deformity with a large distal metatarsal articular angle. These results can serve as recommendations for selecting the optimal osteotomy with which to correct a deformation.     

Effect of increasing distal medial closing wedge metatarsal osteotomies on the distal metatarsal articular angle

The recognition, definition, and management of the congruent hallux valgus deformity continue to evolve. To correct the skeletal deformity and maintain joint congruity, many authors have emphasized the importance of extra-articular procedures. One such procedure is a distal medial closing wedge osteotomy of the first metatarsal. Unfortunately, there are few guidelines to help determine the pre- and intraoperative size of the medial wedge to obtain the desired correction of the distal metatarsal articular angle (DMAA). The purpose of this study was to quantify the effects of increasing distal medial closing wedge osteotomies on the DMAA in an in vitro cadaver model. In this study, a closing wedge osteotomy was performed 2 cm proximal to the articular surface, removing wedges measuring 2 mm, 4 mm, and 6 mm in width. The mean preoperative DMAA was 8.5 degrees, and the mean postoperative DMAAs after 2-mm, 4-mm, and 6-mm closing wedge osteotomies were -2.6 degrees, -10.2 degrees, and -20.2 degrees, respectively. The data showed that for every 1 mm of closing wedge osteotomy, the DMAA decreased by 4.7 degrees +/- 0.6 degrees. These results can be used for pre- and intraoperative planning when surgically correcting a congruent hallux valgus deformity with a distal medial closing wedge osteotomy of the first metatarsal. Additional information obtained from this cadaver study includes (1) increased shortening of the first metatarsal and (2) incongruity produced at the joint after the medial-based osteotomy. The amount of shortening of the first metatarsal correlated directly with the size of the medial-based wedge. The second point indicates that a lateral soft-tissue release may still be required when using this method of reorienting the DMAA.