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.     

Combined cuboid/cuneiform osteotomy for correction of residual adductus deformity in idiopathic and secondary club feet

We used a combined cuboid/cuneiform osteotomy to treat residual adductus deformity in idiopathic and secondary club feet. The mean follow-up for 27 feet (22 idiopathic, four arthrogrypotic and one related to amniotic band syndrome) was 5.0 years (2.0 to 9.8). All healed uneventfully except for one early wound infection. No further surgery was required in the 22 idiopathic club feet but four of five with secondary deformity needed further surgery. At follow-up all patients with idiopathic and two with secondary club feet were free from pain and satisfied with the result. In the idiopathic feet, adductus of the forefoot, as measured by the calcaneal second metatarsal angle, improved on average from 20.7 +/- 2.0 degrees to 8.9 +/- 1.8 degrees (p < 0.05). In four feet, with a follow-up of more than six years, there was complete recurrence of the deformity. In the secondary club feet, there was no improvement of the adductus. We conclude that in most, but not all, idiopathic club feet a cuboid/cuneiform osteotomy can provide satisfactory correction of adductus deformity. Those with secondary deformity require other procedures.     

Opening wedge osteotomy of the medial cuneiform before age 4 years in the treatment of forefoot adduction

Thirty-seven feet in 25 children (12 girls, 13 boys) treated surgically with medial cuneiform opening wedge osteotomy to correct forefoot adduction were assessed. Thirteen patients had unilateral deformity. Primary diagnoses were congenital clubfoot (33 feet), congenital forefoot adduction (3 feet), and skewfoot (1 foot). All children underwent operation before age 4 years. The age at operation ranged from 21 to 47 months (mean 35). In 18 feet, allografts were used. In 5 feet, autograft was used. In 14 feet, ceramic material was inserted as opening wedge. Follow-up ranged from 3 to 8 years (mean 4). In four feet, the ossification center of the medial cuneiform was invisible. The correction of the deformity was assessed clinically and radiographically. The first ray angle and talo-first metatarsal angle were evaluated on anteroposterior radiographs, the latter was evaluated on lateral radiographs, also. In 26 feet, normal position of the forefoot was achieved. In five feet, overgrowth of the medial cuneiform in comparison with the normal side was observed. Forefoot adduction persisted in six feet. The ossification center was often divided into two parts by bone graft, and subsequent independent growth of both parts was observed. This technique is safe and useful for correction of forefoot adduction in young children. It can be performed even in cartilaginous bone. The osteotomy causes overgrowth of the medial cuneiform and the medial ray.     

Transcuneiform and opening wedge medial cuneiform osteotomy with closing wedge cuboid osteotomy in relapsed clubfoot

Ten patients (13 feet) aged 4 to 11 years with idiopathic clubfeet underwent bony correction for resistant supination and adduction deformities. A closing wedge cuboid osteotomy and medial cuneiform opening wedge and transcuneiform osteotomy were performed in all cases. The average improvement in anteroposterior talo-first metatarsal angle of 22 degrees, calcaneo-fifth metatarsal angle of 13 degrees, and lateral calcaneo-first metatarsal of 9 degrees confirmed the clinically satisfactory correction in all feet. However, one foot required repeat surgery 2 years after the index procedure.     

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.     

Treatment of severe residual clubfoot deformity by trans-midtarsal osteotomy.

This study reviews the preliminary results of transmidtarsal osteotomy performed on 11 patients (12 feet) who previously underwent surgery for resistant clubfoot and needed further surgery for severe residual deformities. Opening wedge medial cuneiform osteotomy, closing wedge cuboid osteotomy, and truncated wedge middle and lateral cuneiform osteotomy were performed. The procedure was performed initially on normal cadaver feet. The average improvement of anteroposterior talo-first metatarsal angle was 20 degrees and lateral calcaneo-first metatarsal angle was 16 degrees. The authors conclude that with this simple procedure, angular and rotational correction in three planes can be obtained simultaneously in severe residual clubfoot deformity without the need for extensive soft tissue release.     

Ludloff截骨治疗中重度拇外翻的临床疗效观察

目的研究Ludloff截骨术对中、重度拇外翻的治疗效果。方法 2007年9月至2008年10月对26例（34足）中、重度拇外翻患者使用Ludloff截骨配合远端软组织手术进行矫形手术治疗,截骨使用螺钉固定。男4例,女22例,年龄48～67岁,平均58岁。术后采用AOFAS评分对患足进行临床功能评价,同时拍负重位足的正侧位X线片进行影像学评价,比较术后AOFAS评分及跖拇角和第一二跖间角的变化,了解患者的满意程度。结果平均随访时间25个月（19～36个月）。在最后一次随访时,31足基本无痛,3足偶有疼痛或轻微疼痛。患者对拇外翻畸形纠正满意。AOFAS评分为从术前的51分（27～65分）提高到术后的88分（72～96分）,HVA从术前的31°（21°～42°）改善为10.3°（7°～15°）,IMA从术前的17°（16°～23°）改善为术后的7.8°（6°～10°）。23例（31足）患者对治疗效果满意,3例（3足）比较满意。所有患者均对外形满意。没有严重的并发症出现。结论 Ludloff截骨术是治疗中重度拇外翻可靠有效的方法。     

Opening wedge osteotomy of the first cuneiform for the treatment of hallux valgus

We performed an opening wedge osteotomy of the first cuneiform for the correction of all degrees of hallux valgus deformities. A wedge-shaped graft maintained the open wedge osteotomy and decreased the metatarsocuneiform joint inclination to correct the main angles of the hallux valgus. This procedure was performed for 101 feet of 63 patients (two men and 61 women). Fifteen feet benefited from a shortening of P1. The average age was 42 (16 to 84) years with a mean follow-up of 7.7 (1.5 to 14.8) years. We evaluated the M1-P1 and the M1-M2 angles, the joint congruency and the position of the lateral sesamoid. The clinical examination was graded by the AOFAS score which includes comprehensive assessment of pain, function and alignment and the subjective assessment of patients. The clinical AOFAS score improved from 35.24 points preoperatively to 86.36 postoperatively and from 33.25 to 88.03 points in severe deformity. The subjective rating was 44.44% excellent, 41.27% good, 9.52% fair and 4.76% poor. The M1-P1 angle improved from 29.38° to 16.28° and the M1-M2 angle from 14.36° to 10.34°. In the 42 severe feet deformity, these angles improved respectively from 45.58° to 19.58° and from 18.51° to 11.16°. This technique allowed an accurate correction of the main angles of hallux valgus with different degrees of deformity and avoided the complications related to different types of osteotomies achieved along the first metatarsal. After a long follow-up, we demonstrated a durable result while 86% of patients proved excellent and good results according to the AOFAS score.     

Combined double tarsal wedge osteotomy and transcuneiform osteotomy for correction of resistant clubfoot deformity (the “bean-shaped” foot)

Purpose

The “bean-shaped foot” exhibits forefoot adduction and midfoot supination, which interfere with function because of poor foot placement. The purpose of the study is a retrospective evaluation of patients who underwent a combined double tarsal wedge osteotomy and transcuneiform osteotomy to correct such a deformity.

Methods

Twenty-seven children with 35 idiopathic clubfeet were treated surgically by combined double tarsal wedge osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) and transcuneiform osteotomy between 2008 and 2012. The age of children at surgery ranged from 4 to 9 years. There were 19 boys and 8 girls. Pre- and postoperative X-rays were used, considering: on the AP radiograph, the calcaneo-fifth metatarsal angle and the talo-first metatarsal angle (indicators of forefoot adduction); on the lateral radiograph, the talo-first metatarsal angle (an indication of supination deformity) and calcaneo-first metatarsal angles (an indication of cavus deformity). These radiological parameters were compared with the clinical results.

Results

Follow-up was conducted for 24–79 months following surgery. Clinical and radiographic improvements in forefoot position were achieved in all cases. An average improvement in the anteroposterior talo-first metatarsal angle of 21°, calcaneo-fifth metatarsal angle of 14°, lateral talo-first metatarsal angle of 10°, and lateral calcaneo-first metatarsal of 12° confirmed the clinically satisfactory correction in all feet. One patient had a wound infection postoperatively, which resolved with removal of the wires and administration of oral antibiotics. Eight patients followed up for more than 5 years had no deterioration of results.

Conclusions

Combined double tarsal wedge osteotomy as well as transcuneiform osteotomy is an effective and safe procedure for lasting correction of the bean-shaped foot.     

Treatment of residual clubfoot deformity--the "bean-shaped" foot--by opening wedge medial cuneiform osteotomy and closing wedge cuboid osteotomy. Clinical review and cadaver correlations

Six patients (seven feet) previously treated surgically for clubfoot had a "bean-shaped" foot. Opening wedge medial cuneiform and closing wedge cuboid osteotomies were done, resulting in good resolution of the prominent midfoot supination and forefoot adductus without significant soft tissue dissection and invasion of growing areas in the foot. Cadaver reproductions show that the cuboid closing wedge is responsible for the change in the midfoot, whereas the cuboid and cuneiform osteotomies both contribute to the change in the forefoot.     

Scarf osteotomy in hallux valgus: a review of 72 cases

The Scarf osteotomy is now widely used for the correction of hallux valgus. The aim of our study was to evaluate the results after Scarf osteotomy considering patient's satisfaction as well as the clinical and radiological results. Between 1996 and 1999, 72 feet underwent a Scarf osteotomy of the first metatarsal and, in 11 feet, an additional Akin osteotomy of the proximal phalanx, for the correction of hallux valgus (55 patients: 49 female, 6 male; mean age: 52 years). The hallux valgus angle improved significantly, from 32 degrees preoperatively to 18 degrees at follow-up (minimal follow-up: 6 years; mean: 7.5 years). A second operation was necessary in two patients because of recurrence of hallux valgus, and a fusion of the first metatarsophalangeal joint was performed in two patients. At the time of latest follow-up 78% of the patients were satisfied or very satisfied with the result. The Scarf osteotomy combined with Akin's closing wedge osteotomy is a safe and effective procedure for the treatment of moderate hallux valgus deformities.     

Treatment of Relapsed Idiopathic Clubfoot by Complete Subtalar Release Combined With the Ilizarov Method

This study presents the clinical and radiographic outcomes of 6 feet (4 patients) with relapsed idiopathic clubfoot that were treated with a combination of subtalar release and the Ilizarov method. The mean patient age at the time of the surgery was 7.4 years (range, 4.5-10.5 years), and the mean follow-up was 5.1 years (range, 2.0-7.3 years). All cases achieved a plantigrade foot, better walking ability, and parental satisfaction with the result. Ankle joint range of motion increased from a mean of 17 degrees (range, 10-30 degrees) preoperatively to 45 degrees (range, 35-65 degrees) at final follow-up. The talocalcaneal angle improved from a mean of 26 degrees (range, 15-34 degrees) preoperatively to 55 degrees (range, 47-65 degrees) at follow-up. The mean tibiocalcaneal angle improved from 95 degrees (range, 87-115 degrees) preoperatively to 80 degrees (77-83 degrees) at follow-up, whereas the talometatarsal angle improved from a preoperative mean of -19 degrees (range, -35 to -10 degrees) to 3.5 degrees (range, -5 to 7 degrees) at follow-up. Recurrence was observed in only 1 foot with forefoot adductus, caused by a pin tract infection and early fixator removal. These cases suggest the Ilizarov method combined with subtalar release are beneficial for the treatment of relapsed idiopathic clubfoot.     

Combination of Evans calcaneal osteotomy and STA-Peg arthroreisis for correction of the severe pes valgo planus deformity.

Twenty patients with 25 symptomatic severe flexible pes valgo planus were treated with a combined surgical technique. All patients underwent an Evans calcaneal osteotomy with allogenic bone graft and subtalar joint arthroreisis (STA-Peg) procedure. Adjunctive procedures as deemed necessary included Achilles tendon lengthening, navicular-cuneiform fusion, Lapidus first metatarsal cuneiform fusion, Cotton medial cuneiform plantarflexory wedge osteotomy with allogenic bone graft, plantarflexory medial cuneiform osteotomy, and excision of os tibiale externum. A retrospective pre- and postoperative radiographic evaluation revealed the following mean changes: lateral talo-first metatarsal angle, 16.9 degrees to -0.6 degrees; calcaneal cuboid abduction angle, 24.8 degrees-2.8 degrees; anterior posterior talocalcaneal angle, 25.3 degrees-15.4 degrees; talonavicular coverage angle, 22.7 degrees-5.2 degrees; calcaneal inclination angle, 10.6 degrees-18.6 degrees; talar declination angle, 32.4 degrees-16.4 degrees; lateral talocalcaneal angle, 18.3 degrees-5.2 degrees. A subjective questionnaire revealed that 100% of the patients stated they were satisfied or very satisfied with the surgery and achieved an average score of 93 based on a 100-point scale.     

Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency

26 patients with 28 pes planovalgus feet secondary to Johnson stage 2 posterior tibial tendon insufficiency were treated with flexor digitorum longus tendon transfer, lateral column lengthening, medial displacement calcaneal osteotomy, and heel cord lengthening. The mean patient age at surgery was 48.5 years. The AOFAS ankle-hindfoot scale was applied postoperatively to assess clinical outcome. Preoperative and postoperative standing radiographs of the foot and ankle were analyzed to determine radiographic correction of the pes planovalgus deformities. The mean follow-up to date is 5 years. The mean ankle-hindfoot score was 90 postoperatively. The medial cuneiform to fifth metatarsal distance improved from -0.2 mm preoperatively to 7.6 mm postoperatively. Similarly, the talonavicular distance improved from 19.4 mm preoperatively to 10.9 postoperatively. There were no nonunions. Four feet (14%) displayed radiographic signs of calcaneocuboid arthritis at follow-up. Only one was symptomatic requiring calcaneocuboid joint fusion. The double osteotomy technique provides symptomatic relief and lasting correction of the pes planovalgus deformity associated with stage 2 posterior tibial tendon insufficiency at intermediate follow-up. It has a high patient satisfaction based on the AOFAS ankle-hindfoot scale and radiographic measurements demonstrate maintenance of correction of the adult acquired flatfoot.     

Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency

The surgical treatment of flexible pes planovalgus deformities resulting from Stage 2 posterior tibial tendon insufficiency is controversial and many techniques have been proposed. We retrospectively reviewed the results of subtalar arthrodesis combined with spring ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular. There were sixteen patients (seventeen feet) with an average follow-up of 27 months (9-52). All deformities were passively correctable. The average age was 56 yrs (39-78). All patients had failed conservative management, 88% had previously been treated with orthotics, and 53% had lateral pain from subfibular impingement. Two patients were noted to have degenerative changes of the subtalar joint. Successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5-24). The average AOFAS hindfoot score and Maryland foot score postoperatively was 82 and 86 respectively. Standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6 degrees (24 degrees preoperative, 18 degrees postoperative). The talonavicular coverage angle improved an average of 17 degrees (34 degrees preoperative, 17 degrees postoperative). The lateral talo-1st metatarsal angle improved an average of 10 degrees (18 degrees preoperative, 8 degrees postoperative). The lateral talocalcaneal angle decreased an average of 21o (55 degrees preoperative, 34 degrees postoperative). The distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively (avg. improvement 6mm). The combination of the flexor digitorum longus tendon transfer and spring ligament repair with subtalar arthrodesis is an effective and reliable procedure which provides excellent correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the longitudinal arch. These results compare favorably with flexor transfer combined with either calcaneal osteotomy or lateral column lengthening.     

Metatarsal osteotomy in rheumatoid arthritis

Thirty-eight feet in 28 patients with rheumatoid forefoot deformity were operated on with a proximal valgus osteotomy of the first metatarsal bone to reduce splaying of the forefoot. Each patient also underwent additional surgical procedures for associated conditions of the forefoot. The mean follow-up period was 3.7 years. Both the entire forefoot and the medial border of the foot were substantially improved in all but 2 cases. Residual symptoms were slightly more pronounced in the anterior footpad and the lesser toes (5 cases). A proximal valgus osteotomy of the first metatarsal bone, performed in combination with other surgical procedures, affords a good correction of the rheumatoid foot deformity with long-term improvement.     

Lateral column calcaneal lengthening, flexor digitorum longus transfer, and opening wedge medial cuneiform osteotomy for flexible flatfoot: a biomechanical study

BACKGROUND: Lengthening of the lateral column is commonly used for reconstruction of the adult and pediatric flatfoot, but can result in supination of the foot and symptomatic lateral column overload. The addition of a medial cuneiform osteotomy has been used to redistribute forces to the medial column. The combined use of a lateral column lengthening and medial cuneiform osteotomy in a reproducible cadaver flatfoot model was evaluated. METHODS: Twelve cadaver specimens were physiologically loaded and each was evaluated radiographically and pedobarographically in the following conditions: 1) intact, 2) severe flatfoot, 3) lateral column lengthening with simulated flexor digitorum longus transfer, and 4) lateral column lengthening and flexor digitorum longus (FDL) transfer with added medial cuneiform osteotomy. The lateral column lengthening was performed with a 10-mm foam bone wedge through the anterior process of the calcaneus, and the medial cuneiform osteotomy was performed with a dorsally placed 6-mm wedge. RESULTS: Lateral column lengthening with simulated FDL transfer on a severe flatfoot model resulted in a significant change as compared with the flatfoot deformity in three measurements: in lateral talus-first metatarsal angle (-17 to -7 degrees; p<0.001), talonavicular angle (46 to 24 degrees; p<0.001), and medial cuneiform height (16 to 20 mm; p<0.001). Lateral forefoot pressure increased from 24.6 to 33.9 kPa (p<0.001) after these corrections as compared with the flatfoot. Adding a medial cuneiform osteotomy decreased the lateral talar-first metatarsal angle from -7 to -4 degrees, decreased the talonavicular coverage angle from 24 to 20 degrees, and increased the medial cuneiform height from 20 to 25 mm. After added medial cuneiform osteotomy, lateral pressure was significantly different from that of the flatfoot (p=0.01) and was not significantly different from that of the intact foot (p=0.14). Medial forefoot pressure was overcorrected as compared with the intact foot with added medial cuneiform osteotomy. CONCLUSIONS: Lateral column lengthening increased lateral forefoot pressures in a severe flatfoot model. An added medial cuneiform osteotomy provided increased deformity correction and decreased pressure under the lateral forefoot.     

Metatarsal osteotomy in rheumatoid arthritis

Thirty-eight feet in 28 patients with rheumatoid forefoot deformity were operated on with a proximal valgus osteotomy of the first metatarsal bone to reduce splaying of the forefoot. Each patient also underwent additional surgical procedures for associated conditions of the forefoot. The mean follow-up period was 3.7 years. Both the entire forefoot and the medial border of the foot were substantially improved in all but 2 cases. Residual symptoms were slightly more pronounced in the anterior footpad and the lesser toes (5 cases).

A proximal valgus osteotomy of the first metatarsal bone, performed in combination with other surgical procedures, affords a good correction of the rheumatoid foot deformity with long-term improvement.     

Short- to Intermediate-Term Radiographic Outcomes Following Cotton Osteotomy

The cotton osteotomy or the medial cuneiform opening wedge osteotomy has been a common adjunct procedure in flatfoot reconstruction to correct for forefoot varus or a dorsiflexed first ray. The main goal of the study is to retrospectively review outcomes specifically in the short-intermediate term for the cotton osteotomy. The medical records of a single foot and ankle surgeon (PRB) were reviewed for patients who met inclusion and exclusion criteria. The study period was from January 2006 to October 2018. The analysis was performed using information obtained from chart-review to examine union and complication rates, as well as changes in the cuneiform articular angle based on graft size and type. A total of 71 feet in 61 patients underwent cotton osteotomies for flatfoot reconstruction. Overall complication rate was 5.6% (4/71) with 2 nonunions (2/47) in those that had radiographic follow-up of greater than 9 months. Change in cuneiform articular angle (CAA) showed 0.91° of correction per 1-millimeter increase in graft wedge size from preoperative to 3 weeks. Change for anterior-posterior medial cuneiform bisection dorsal length (AP length) was 0.70 mm per 1 mm of graft used from preoperative to 3 weeks. 6 weeks to 10 weeks showed statistically significant changes in the CAA (p = .01) and the AP length (p = .002). The cotton osteotomy showed statistically significant radiographic loss of correction between the 6- and 10-week time points when patients were allowed to begin weightbearing. Metal grafts may provide maintenance of correction which warrants future studies on their efficacy.