Anterior tarsal resection (Cole osteotomy)

The topic of pes cavus has, for many years, been the object of much discussion, with numerous literary works dedicated to its etiology and treatment. Anterior tarsal resection was presented in the literature over 50 years ago. The authors describe a rationale for performing this procedure as well as other adjunct soft tissue procedures for the correction of a rigid anterior global cavus with its apex at the navicular cuneiform joint.     

The Maquet osteotomy.

First proposed in 1963, the Maquet osteotomy can be used successfully for the treatment of selected patients with patellofemoral pain. A strict patient selection process must be used to achieve optimal clinical results. The complication rate can be limited, but not eliminated, by the use of meticulous surgical technique. Further prospective clinical studies, employing both subjective and objective evaluation methods, should be performed to optimize the interpretation of the clinical results.     

'Z' metatarsal osteotomy: modified Mitchell's osteotomy for hallux valgus.

The Mitchell's osteotomy is an established and successful operation for hallux valgus. We report a previously undescribed procedure comprising a step or 'Z' osteotomy that is a simplified version of the Mitchell's osteotomy which involves less extensive soft tissue dissection and avoids opening the first metatarsophalangeal (MTP) joint. In total, 51 operations in 40 patients were reviewed with a mean follow-up of 4.7 years. The results were compared with those reported by Mitchell in his paper of 1958, using the same criteria. The mean age was 24 years and 82% of patients were women. In 88% of patients the results were rated excellent or good and there were no serious complications. These results suggest that this procedure is as successful as the Mitchell osteotomy in young patients, and it may have long-term benefits.     

Metatarsal osteotomy for metatarsalgia.

An oblique osteotomy in the distal half of the metatarsal shaft is described for the treatment of metatarsalgia due to prolapse of one or more of the middle three metatarsal heads. Thirty-eight patients who have had this operation have been followed up for a period of from two to five years. The operation is simple, recovery is rapid and symptoms have been well relieved.     

Complications of trochanteric osteotomy.

Trochanteric osteotomy continues to have an important role in total hip replacement, but more so as a useful adjunct in selected instances rather than as a necessary and integral part of every arthroplasty. Improved exposure is the most important benefit of and indication for trochanteric osteotomy. Trochanteric nonunion per se has little adverse effect on the final result, but most clinically significant complications of trochanteric osteotomy are a consequence of nonunion. Migration or total separation of the greater trochanter is usually preceded by nonunion. Either can result in impaired abductor function manifested as impaired gait and, occasionally, as subluxation or dislocation. Limp and decreased walking endurance are often mild and generally do not warrant specific treatment. However, when they are severe and accompanied by either pain or instability, trochanteric reattachment is indicated. Trochanteric bursitis may or may not be directly related to the presence of prominent fixation devices and, therefore, may not resolve with their removal. Likewise, pain localized to the trochanteric region may in fact be due to other causes, such as component loosening or the presence of infection. Pain unresponsive to a local anesthetic agent warrants a thorough search for alternative causes. Careful patient selection optimizes the benefits and minimizes the risks of trochanteric osteotomy. The procedure is technically demanding, and meticulous attention to detail is essential to avoid complications. We prefer a sliding trochanteric osteotomy for its versatility and for the resistance to trochanteric migration it provides.     

Closing base wedge osteotomy.

The authors have completed a retrospective study on closing base wedge osteotomies. This review includes preoperative and postoperative clinical and radiographic evaluation. A total of 61 procedures were evaluated on 47 patients. All procedures were performed at The Podiatry Hospital of Pittsburgh. Subjective analysis of patient acceptance is included, as well as an in-depth discussion of surgical technique, with emphasis on fixation.     

Complications of periacetabular osteotomy.

There was a statistically significant decrease in major complications from 17% to 2.9% when comparing the first 35 cases with the second 35 cases of periacetabular osteotomy performed by one surgeon. There were no cases of intraarticular fracture, conversion to total hip replacement, or deaths in this series. Of considerable significance was that almost all major complications, as defined for disclosure in this report, left the patients with no permanent sequelae after either successful treatment, as in intraoperative bleeding, or with observation with time, as for recovery of sciatic nerve function. The complication rate of periacetabular osteotomy decreases significantly in proportion to increasing experience, as documented in this study. Patients in ongoing studies completed the Western Ontario and McMaster Universities Osteoarthritis Index and the Short Form- 36 preoperatively, which will add to the authors' ability to comment on functional outcomes in future reports.     

Compression osteotomy of the tibia.

Compression osteotomy of the tibia is to allow knee motion postoperatively without case immobilization. Rigid internal stabilization by axial compression and tension band wiring enhances union. The rigid internal stabilization prevents loss of position of the osteotomy, often seen in other techniques. The benchmark for this osteotomy operation is no fractures of the osteotomy fragments, no position loss, no thromboemboli, and no deep wound infections.     

Computer simulation of periacetabular osteotomy.

A simple static three-dimensional mathematical model of an adult hip in one-legged stance was used to evaluate the mechanical situation after periacetabular osteotomy. We found that the hip joint rotation center shifted as a consequence of the osteotomy. This may have considerable effects on the hip joint resultant force and therefore also on the pressure on the femoral head, which could cause the development of arthrosis.     

Chevron osteotomy for hallux valgus.

The chevron osteotomy for realignment of the first metatarsal head in metatarsus primus varus deformity has been utilized at the Mayo Clinic since 1976 on 26 feet (18 patients). Follow-up evaluation disclosed excellent relief of pain, good cosmetic correction, and overall patient satisfaction. Radiographic evaluation demonstrated reduction in the angle between the phalanx and the metatarsal bone of the great toe as well as narrowing of the forefoot with a decreased angle between the first and the second metatarsal bones. The stability of the osteotomy, the technical ease, and the absence of secondary difficulties such as transfer metatarsalgia make this procedure preferable when osteotomy of the distal portion of the first metatarsal bone is used for correction of moderate deformity.     

Tibial rotational osteotomy for idiopathic torsion. A comparison of the proximal and distal osteotomy levels.

A retrospective analysis was done of 52 rotational tibial osteotomies (RTOs) performed on 35 patients with severe idiopathic tibial torsion. Thirty-nine osteotomies were performed at the proximal or midtibial level. Thirteen were performed at the distal tibial level with a technique previously described by one of the authors. Serious complications occurred in five (13%) of the proximal and in none of the distal RTOs. For severe and persisting idiopathic tibial torsion, the authors recommend correction by RTO at the distal level. Proximal level osteotomy is indicated only when a varus or valgus deformity required concurrent correction.     

Double lateral osteotomy in aesthetic rhinoplasty.

Lateral osteotomy is a very important step in a cosmetic rhinoplasty; it allows the surgeon to narrow the nose, to close the open roof created after hump removal, and to achieve symmetry of an asymmetrical nasal bony framework. In most patients a single lateral osteotomy reaches the expected result, with excellent cosmetic outcome, good stability, and rapid healing. We find that double lateral osteotomy is useful in managing severe asymmetry of nasal walls in patients with too prominent and thick maxillary processes that join asymmetrically together with nasal bones. It is also valuable in correcting very large and wide noses. We review our experience of about 1660 rhinoplasties with more than one year follow-up. Two hundred and ten cases (12.65%) had been treated with monolateral, or bilateral double osteotomy. We evaluate postoperative aesthetic and functional results.     

Proximal tibial osteotomy. A survivorship analysis

Proximal tibial osteotomy is generally accepted as a treatment for the patient with unicompartmental arthritis. However, a few reports of the long-term results of this procedure are available in the literature, and none have used the technique known as survivorship analysis. This technique has an advantage over conventional analysis because it does not exclude patients for inadequate follow-up, loss to follow-up, or patient death. In this study, survivorship analysis was applied to 78 proximal tibial osteotomies, performed exclusively by the senior author for the correction of a preoperative varus deformity, and a survival curve was constructed. It was concluded that the reliable longevity of the proximal tibial osteotomy is approximately 6 years.     

Anterior femoroacetabular impingement after periacetabular osteotomy.

As experience with the Bernese periacetabular osteotomy has grown, an unexpected observation in a group of patients has alerted the authors to the risk of a secondary impingement syndrome that may occur some time after the periacetabular osteotomy. This possibly may explain residual pain and limited range of motion in a larger group of patients. The impingement is produced by abutment of the femoral head or head to neck junction on the anterior rim of the properly aligned acetabulum. The symptoms are those of restricted flexion, and limited or absent internal rotation in flexion, with variable groin pain. Magnetic resonance imaging studies may reveal acetabular labral disease and adjacent cartilage damage associated with the impingement. Lack of anterior or anterolateral offset between the femoral neck and head results in neck to rim contact when the hip is flexed and/or internally rotated. Before the periacetabular osteotomy this is compensated by the lack of anterior acetabular coverage, but after proper correction the mismatch becomes apparent. The authors recently have devised a routine during the periacetabular osteotomy procedure whereby after the acetabular fragment is corrected into the desired position, the joint is opened, visually inspected, and palpated for impingement with the hip flexed and internally rotated. When necessary, a resection osteoplasty of the femoral neck to head junction is performed to improve the head and neck offset and reduce the anterior contact. This, in the short term, has provided satisfactory prevention of postoperative impingement.