Effectiveness of a Locking Plate in Preserving Midcalcaneal Length and Positional Outcome after Evans Calcaneal Osteotomy: A Retrospective Pilot Study

When using the Evans calcaneal osteotomy for repair of a calcaneovalgus deformity, lengthening of the lateral column of the foot is the method by which the procedure acts to correct the deformity. Therefore, maintaining the length is a priority. In our experience, substantial length is lost soon after surgery using the traditional nonfixated procedure. To test this hypothesis, a retrospective study was undertaken in which we compared the calcaneal length before and after the Evans procedures in 22 patients treated without fixation and 13 patients in whom the graft was fixated with a small locking plate to bridge the osteotomy and reduce the compressive forces on the graft. Within the first 10 days after surgery, the increase in calcaneal length from the preoperative length was 6.3 mm in the nonfixated group and 6.8 mm in the fixated group (p = .54 for the 0.5-mm difference). At 12 weeks after surgery, the mean amount of shortening from the value observed at 1 week was 2.45 (range 0 to 6) mm in the nonfixated group and 1.0 (range 0 to 3) mm in the internal fixation group (p = .48). Also, at 12 weeks, distal calcaneal migration or dorsal anterior calcaneal displacement of more than 3 mm occurred in 5 patients (23%) in the nonfixated group and 1 patient (8%) in the fixated group (p = .04). Our results suggest that locking plates do preserve the correction obtained with the Evans calcaneal osteotomy.     

Posterior calcaneal osteotomy with wedge: cadaver testing of a new procedure for insufficiency of the posterior tibial tendon.

Insufficiency of the posterior tibial tendon is challenging to treat. When the deformity is flexible, treatment options have included tendon transfer, often combined with a medial slide calcaneal osteotomy and/or a lengthening of the lateral column. Posterior calcaneal osteotomy has been shown to give correction, although not full correction. Lengthening of the lateral column also has been shown to give correction and has been used in the more severe flexible deformities, but it involves either fusion of the calcaneocuboid joint or risk of arthritis at this joint. An osteotomy combining the calcaneal medial slide with a lengthening of the lateral column at the same osteotomy site has been tested in the laboratory. This combined osteotomy provides a lengthening of the lateral column, but it is positioned away from the calcaneocuboid joint. In this study, the osteotomy was compared with a medial slide calcaneal osteotomy and an Evans lengthening of the lateral column, using a cadaver flatfoot model. Radiographic measurements were made to evaluate correction of the planovalgus deformity after each of these procedures. There was statistically significant improved correction with the new osteotomy compared with that in a standard medial slide, and correction was comparable to that in the lengthening of the lateral column. This combined osteotomy may be a reasonable alternative when more correction is desired than can be obtained from a medial slide alone and when the surgeon wishes to avoid an osteotomy near the calcaneocuboid joint.     

A comparison of lateral column lengthening and medial translational osteotomy of the calcaneus for the reconstruction of adult acquired flatfoot

BACKGROUND: This study compared the effects of lateral column lengthening and medial translational calcaneal osteotomy on pedal realignment and degeneration of adjacent hindfoot joints noted on radiographs. METHODS: Forty patients who had either a lateral column lengthening (25 feet) or calcaneal osteotomy (17 feet) to reconstruct a flatfoot were retrospectively reviewed as two groups. Six parameters of foot alignment were measured from weightbearing preoperative, early postoperative, and latest followup radiographs. The magnitude of realignment achieved initially and preserved at latest followup was determined for each group. The talonavicular and subtalar joints were graded for radiographic evidence of arthritis before the reconstruction and at latest followup. Demographic information, complication rate, and reoperation associated with each group also were determined by chart review. RESULTS: The group that received a lateral column lengthening demonstrated a greater initial realignment than the group treated with a calcaneal osteotomy. The lengthening group also demonstrated greater realignment than the osteotomized group when they were compared at their respective latest followup. The lengthening group had a higher number of adjacent joints with progression of arthritis. The rate of nonunion was higher with a lateral column lengthening; however, the rate of reoperation after an osteotomy was more than twice that observed after a lateral column lengthening. CONCLUSIONS: The lateral column lengthening group achieved greater realignment initially and maintained correction better over time than the calcaneal osteotomy group while having a lower reoperation rate despite a higher incidence of nonunion and radiographic progression of adjacent joint arthritis.     

Plantar pressure analysis in cadaver feet after bony procedures commonly used in the treatment of stage II posterior tibial tendon insufficiency

BACKGROUND: Bony procedures play an essential role in the operative treatment of stage II posterior tibial tendon insufficiency and often substantially alter the loading characteristics of the foot. METHODS: Eight matched pairs of cadaver lower extremities were axially loaded onto a TekScan HR Mat. (TekScan, Inc., South Boston, MA) After intact testing, each specimen had a lateral column lengthening (either a calcaneocuboid distraction arthrodesis [CCDA] or Evans procedure), a medializing calcaneal osteotomy (MCO), and a plantarflexion (Cotton) osteotomy of the medial cuneiform. The measured plantar pressures were divided into three forefoot regions, two midfoot regions, and two hindfoot regions. For each region, average pressure, peak pressure, and contact area data were collected. RESULTS: Despite the fact that both lateral column lengthening procedures resulted in increased lateral forefoot pressures, no significant differences were noted between the CCDA and the Evans procedure. The addition of a MCO did not significantly alter the plantar pressures measured after the lateral column lengthening alone. Although the Cotton osteotomy resulted in increased average pressures within the medial forefoot, a compensatory significant decrease in lateral forefoot pressures was not observed. CONCLUSIONS: The present study demonstrated increased lateral forefoot pressures after a combined lateral column lengthening and MCO and does not support the idea that a Cotton osteotomy significantly reduces loading of the lateral forefoot. CLINICAL RELEVANCE: The incidence of lateral forefoot pain and fifth metatarsal stress fractures subsequent to either lateral column lengthening procedure may not significantly decline after a Cotton osteotomy.     

Revision lateral ankle reconstruction

BACKGROUND: Symptomatic lateral ankle instability is a common source of disability in an active population. While most incidences are successfully treated by conservative measures, some individuals require lateral ankle reconstruction. A commonly performed procedure is the Gould modification of the Brostr?m lateral ankle reconstruction. Despite its success, some individuals experience recurrent instability through reinjury. Revision surgery often involves nonanatomic reconstruction using tendon grafts that may restrict normal ankle and subtalar motion and can result in persistent postoperative pain and disability. The purpose of this study was to demonstrate an equivalent success rate using a more anatomic revision lateral ankle reconstruction based on the Gould modification of the Brostr?m concept. METHODS: We retrospectively reviewed 15 consecutive patients who had a revision lateral ankle reconstruction between 1992 and 2000. All procedures were done by a single surgeon (FGL). Patients who exhibited hindfoot varus and dynamic heel rollout had a valgus calcaneal osteotomy. Patients were asked to complete a 100-point questionnaire postoperatively. RESULTS: All patients reported improvement in ankle function, decreased pain, and no episodes of instability compared to preoperative assessments. Excellent results were achieved in 12 of 15 patients which was consistent with published data from index Brostr?m reconstructions. Four patients who had fixed hindfoot varus and dynamic ankle rollout had valgus calcaneal osteotomies. All patients returned to an active lifestyles including sports and military service. CONCLUSION: Our findings suggest that a revision anatomic lateral ankle reconstruction is an effective option. A thorough clinical evaluation was mandatory to assess hindfoot valgus with dynamic ankle rollout for which a valgus calcaneal osteotomy was included in the procedure. We believe that tendon sacrificing procedures can be avoided in most patients, but soft-tissue structures must be assessed intraoperatively and the surgical approach planned to allow for conversion if necessary.     

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.     

The Evans calcaneal osteotomy

The Evans calcaneal osteotomy is currently the premier procedure for lateral column lengthening of the flexible flatfoot deformity. It has withstood the test of time, proving itself an effective procedure for the correction of pediatric flexible flatfoot. Current understanding of the osteotomy has allowed the Evans calcaneal osteotomy to become a useful tool in the correction of the adult flexible flatfoot as well.     

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.     

Operative treatment of the difficult stage 2 adult acquired flatfoot deformity

In the flexible pes planovalgus deformity of stage 2 posterior tibial tendon dysfunction, osteotomies appear to have a significant role in operative management by restoring more normal biomechanics, allowing tendon transfers to function successfully. The options when considering osteotomies for stage 2 disease include lateral column lengthening, medial displacement calcaneal osteotomy, and combined double osteotomy technique. The tight Achilles tendon should be lengthened as well. Lateral column lengthening has been used extensively for treatment of flexible flatfeet. It has been shown clinically and radiographically to address all 3 components of the pes planovalgus deformity present in stage 2 posterior tibial tendon dysfunction. Lateral column lengthening is used in combination with a medial soft tissue rebalancing procedure. The mechanism of action is still speculative but clearly is not owing to tensioning of the plantar fascia as previously thought. Despite the excellent correction of foot posture obtained by use of lateral column lengthening for adult acquired flatfoot, many clinicians have reservations about its use because of reported secondary increases in the calcaneocuboid joint pressures. This increase in pressure has been shown to occur experimentally, increasing the potential risk of calcaneocuboid joint arthrosis. This experimental evidence is supported by Phillips' study of the original Evans procedure, which resulted in a 65% incidence of calcaneocuboid joint arthrosis at 13-year follow-up. Mosier-LaClair et al reported a 14% incidence of calcaneocuboid joint arthritis at 5-year follow-up after double osteotomy for stage 2 posterior tibial tendon dysfunction. This incidence has not been proved true in the remainder of the literature surrounding this procedure and its use for flexible flatfoot. To address the concern regarding potential calcaneocuboid arthrosis secondary to lateral column lengthening, calcaneocuboid joint distraction arthrodesis has been explored as an alternative technique. The results show good initial correction, but the follow-up is extremely limited, and one study reported loss of correction over time. Longer follow-up is needed to determine whether or not this technique would provide the lasting correction seen with the Evans procedure. Calcaneocuboid joint lengthening arthrodesis does result in some limitation of adjacent hindfoot motion. Although this limitation is significantly less compared with talonavicular and subtalar joint fusion, this procedure may result in increased local pressures and arthrosis of the midfoot or hindfoot. For the above-mentioned reasons, longer follow-up studies are needed to determine whether calcaneocuboid joint distraction arthrodesis would prove to be a reliable and safe alternative for lateral column lengthening in the treatment of adult acquired flatfoot. Medial displacement calcaneal osteotomy has been used for correction of the pes planovalgus foot in posterior tibial tendon dysfunction. It has been used extensively for the surgical treatment of flexible flatfoot throughout the literature. Medial displacement osteotomy, in combination with flexor digitorum longus tendon transfer, can address all 3 components of adult acquired flatfoot. It does not recreate the medial longitudinal arch in all patients, however. Although the mechanism of action of medial displacement calcaneal osteotomy is unknown, it has been proved that it is not through the tightening of the plantar fascia in a windlass effect as previously thought. In contrast to lateral column lengthening, however, medial displacement calcaneal osteotomy does address the deforming valgus force of the Achilles tendon. Functionally transferring the insertion of the Achilles tendon medially removes a constant valgus-deforming force. The osteotomy can then act as a double tendon transfer with the flexor digitorum longus tendon to aid in foot inversion. For stage 2 posterior tibial tendon insufficiency, the authors favor the combination double osteotomy technique with a flexor digitorum longus tendon-to-medial cuneiform tendon transfer, débridement or removal of the posterior tibial tendon, and percutaneous heel cord lengthening. Early results were positive at 1.5 years after surgery with respect to maintenance of correction and functional improvement with no evidence of calcaneocuboid arthrosis. More recently, the intermediate 5-year follow-up has been assessed for this combination of procedures, and similar results were found. There was a high rate of patient satisfaction and functional improvement, and surgical correction of the flatfoot deformity was maintained and compared favorably with the contralateral normal foot. Although the intermediate follow-up found a 14% incidence of calcaneocuboid arthrosis, 50% of these patients had preoperative evidence of calcaneocuboid joint arthritis. (ABSTRACT TRUNCATED)     

Evans Osteotomy and Risk to Subtalar Joint Articular Facets and Sustentaculum Tali: A Cadaver Study

The Evans lateral column lengthening procedure allows correction of abduction, improved talar head coverage, decreased forefoot and rearfoot valgus, and improvement of medial column arch height. However, identifying the structures at risk when performing this osteotomy has proved difficult in vivo. Using 10 cadaveric lower limbs, we performed the Evans calcaneal osteotomy and determined whether violation of the calcaneal facets and the sustentaculum tali occurred. Based on our findings, we recommend directing the osteotomy from posterolateral to anteromedial.     

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.     

Effectiveness of calcaneal osteotomy in surgical treatment of foot conditions: A Prisma statement guidelines compliant systematic review

Calcaneal osteotomy is a commonly established method used to correct various foot malalignment surgery problems that produce varus and valgus hindfoot abnormality as well as Haglund''s deformity, cavovarus foot reconstruction, flatfoot deformity, plantar fasciitis, posterior tibial tendon insufficiency and planovalgus foot. After decades, several procedures in orthopaedic foot surgery have been suggested for reducing the risk of wound and neurovascular complications. The goal of this Prisma statement guidelines compliant systematic review was to establish the effectiveness and safety of calcaneal osteotomy in foot surgery. We have performed a novel systematic review of the current published literature in order to evaluate the scientific evidence now available on this association, assigning predefined exclusion and inclusion criteria. Eight investigations were selected which had 191 cases. The adult flatfoot, tibialis posterior reconstruction and cavovarus foot deformity were treated with different procedures of calcaneal osteotomy techniques. The adequate level of effectiveness of calcaneal osteotomy is associated with the kind and location of the incision, with or without screw application, in each specific foot condition. There is a limited number of scientific investigations of the effectiveness and safety of the different kinds of calcaneal osteotomy in foot surgery, and there is the need to enhance outcome knowledge on this foot surgery technique.     

Double calcaneal osteotomy in treatment of flexible planovalgus foot deformity in ambulatory cerebral palsy. A case series study

BackgroundThe aim of this prospective non randomized case series study was to assess the intermediate-term outcomes of double calcaneal osteotomy (lateral column lengthening and medial slide calcaneal osteotomy) use in ambulatory cerebral palsy with flexible planovalgus feet.Methods16 cases with planovalgus feet were surgically treated by double calcaneal osteotomy and observed over an average of 33.5 months. The mean age at the time of surgery was 10.74 years. The functional outcomes were assessed clinically and radiologically.ResultsThere were a statistical improvement of clinical heel valgus and all radiological parameters as regard talar head uncoverage, calcaneal pitch, talo-calcaneal angle, and talus 1st metatarsal angle at the end of follow up period.ConclusionDouble calcaneal osteotomy is a good option in the treatment of flexible planovalgus feet in ambulatory cerebral palsy patients.     

Radiographic Analysis of the Lateral Column Lengthening Procedure in Stage II Adult Acquired Flatfoot Deformity

Adult acquired flat foot deformity (AAFD) is a progressive, tri-planar deformity involving collapse of the medial longitudinal arch, valgus deformity of the rear foot, and abduction of the mid-foot on the rear foot. There are a wide variety of surgical treatment options for this deformity, including lateral column lengthening (LCL) which results in tri-planar correction of AAFD. We retrospectively reviewed weightbearing preoperative radiographs and weight-bearing 6-week postoperative radiographs of 34 patients with stage II AAFD who underwent LCL (with and without concurrent procedures) with a minimum of 1-year of follow up. Outcomes, including complications and postoperative differences in 6 types of angle measurements were evaluated. Radiographic evaluation showed statistically significant differences in preoperative and postoperative measures in the following angles: calcaneal inclination, Meary's, Simmons, talocalcaneal, and metatarsus adductus (each p ≤ .05). Postoperative Engel's angle difference did not reach statistical significance (p = .07). Paired t tests showed TN coverage angles increased greater with LCL plus a Cotton osteotomy as compared to isolated LCL. Additionally, there was no significant difference in TN coverage angle based on LCL graft size (p = .20). Furthermore, the distance of the osteotomy from the calcaneocuboid joint on anteroposterior and lateral radiographs did not significantly predict TN coverage angle change.Our study suggests that LCL corrects AAFD in three planes while decreasing the metatarsus adductus angle. LCL appears to be more effective when performed with a Cotton osteotomy. Wedge size (6 mm, 8 mm, 10 mm) and osteotomy location did not demonstrate a relationship with postoperative TN coverage angle or incidence of lateral column overload.     

The Treatment of Posterior Tibial Tendon Insufficiency Using the Double Heel Osteotomy and Soft Tissue Reconstruction: The “All-American Procedure”

BackgroundMultiple treatment options have been proposed for the treatment of flexible (stage II) flatfoot with posterior tibial tendon insufficiency (PTTI). This article describes the rationale and technique of our joint-sparing approach to this problem with a combination of osteotomies and soft tissue reconstruction.MethodsLengthening of the lateral column (LCL) through the anterior calcaneal process diminishes the abduction of the forefoot related to the hindfoot, plantarflexes the first ray by tightening the peroneus longus tendon, and causes the arch to rise. Hindfoot valgus is addressed with a medializing calcaneal osteotomy (MCO). Additional soft tissue procedures include transfer of the flexor digitorum longus tendon (FDL), substituting for the diseased posterior tibial tendon and a percutaneous heel cord lengthening (HCL).Results and ConclusionsThe combination of a double heel osteotomy (LCL and MCO) and a soft tissue reconstruction (FDL transfer and HCL) has proven to be an excellent operation for supple PTTI in our practice for 25 years in approximately 1000 patients. Paying careful attention to the described details of the LCL portion of the procedure improves the results of the reconstruction. Removal of the LCL screw and any remaining osteophytes at the calcaneocuboid joint seems to solve the problem of lateral column pain and some overcorrection after the initial procedure.     

足外侧柱延长术联合内侧软组织重建术治疗成人ⅡB期获得性扁平足

背景：成人Ⅱ期获得性扁平足的治疗在临床上是难点。由于Ⅱ期获得性扁平足分型复杂,临床上应根据不同分型制定手术方案。目的：探讨足外侧柱延长术联合内侧软组织重建术治疗成人ⅡB期获得性扁平足的临床疗效。方法：回顾性分析2006年9月至2012年3月采用足外侧柱延长术联合内侧软组织重建术治疗的23例ⅡB期获得性扁平足患者的临床资料。男12例,女11例;年龄19~72岁,平均52.6岁;左足12例,右足11例。致畸原因：胫后肌腱功能进行性不良。其中14例行趾长屈肌腱转位加强术,6例行三角韧带修补术,3例行跟舟韧带修补术。外侧柱延长时,7例应用Evans截骨延长法,3例应用Hintermann截骨延长法,9例应用跟骨“Z”型截骨延长法,4例应用跟骰关节撑开融合延长法。术后采用美国足与踝关节协会（American Orthopaedic Foot and Ankle Society,AOFAS）踝与足评分标准对手术前后足部功能进行评估。结果：19例患者获得随访,随访时间10~56个月,平均26.5个月。末次随访时AOFAS踝与足评分为70~100分,其中优6例,良11例,可2例,优良率为89%（17/19）。所有患者前足外展畸形、足弓高度均得到良好恢复,能穿普通鞋,可正常行走,术后X线片测量扁平足特征角度明显改善（P＜0.01）。弓高平均增加约11 mm,侧位距跟角减少约18°,前后位距跟角减少约12°,侧位第1跖距角减少约15°,跟骨倾斜角增加约11°,距舟覆盖角减少约7°。18例患者畸形纠正满意。1例患者术后5个月因跟骰关节炎而发生足外侧疼痛。未发生伤口感染、骨不连等严重并发症。结论：对于ⅡB期伴有前足外展畸形的成人获得性扁平足,跟骨截骨外侧柱延长术联合足内侧软组织修复重建术的临床效果良好。     

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.     

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.     

Increased displacement maximizes the utility of the distal chevron osteotomy for hallux valgus deformity correction

BACKGROUND: Correction of hallux valgus deformity with distal chevron osteotomy is limited by the amount of lateral translation achieved. Since 1999, the senior author has performed a modified technique referred to as increased displacement distal chevron osteotomy in which the distal fragment is translated laterally as far as necessary to obtain correction. This technique can be applied to a deformity with an intermetatarsal angle of up to 18 degrees. The surgical technique and results of this modified procedure are reported. MATERIALS AND METHODS: The senior author's (JLB) database was searched for correction of hallux valgus deformity by distal chevron osteotomy performed over a 2-year period. Patients having undergone lateral displacement greater than 50% of the width of the head were studied. At a minimum of two years after surgery, patients were invited to participate in a telephone interview and a final followup office visit. RESULTS: Sixty-two patients underwent 72 procedures during the investigation period. Thirty-three patients having undergone 39 procedures completed comprehensive followup at an average of 34 (range, 24 to 47) months. No patients were dissatisfied and all patients would have surgery again under similar circumstances. AOFAS score averaged 93 with a standard deviation of 8.7 (range, 65 to 100). Radiographic union occurred in all 39 feet. Lateral translation averaged 8.2 mm (60%). No cases of radiographic avascular necrosis or advancement of degenerative joint disease were noted. Correction of the hallux valgus angle (HVA) averaged 22.2 degrees, intermetatarsal angle (IMA) 7.9 degrees, and sesamoid position 1.6 stages. Nine complications were identified in nine feet, two of which required additional surgery. CONCLUSION: Increasing the displacement achieved with distal chevron osteotomy resulted in reliable correction including moderate to severe deformity. At 2 years, patients displayed a high rate of satisfaction, good clinical outcomes scores, and a complication rate similar to other techniques.     

高弓马蹄内翻足术后复发与跟骨截骨

目的 探讨高弓内翻足手术治疗后的内翻复发,跟骨截骨外移的矫正度与内翻复发的关系.方法 23例(31足)成人高弓内翻足患者,年龄13～59岁,平均36岁.以术前Coleman试验可否矫正、经内侧软组织和(或)肌腱松解后后足内翻被动矫正情况以及是否行跟骨截骨,将患足分为4组.并以被动可矫正至中立位和外翻5°以上为两个界限.进行统计.跟骨截骨可以为跟骨轴位水平方向上的截骨外移,截骨外移后的欠状面上的上移,以及跟骨的楔形闭合截骨.结果 内翻复发9足,5°以下5足,5°以上4足,平均4.23°±2.15°.末行跟骨截骨12足中,术前Coleman试验可矫正至中立位3足均复发,术前Coleman试验可矫正至外翻5°以上的4足均未复发.术前Coleman试验不町矫正,术中经软组织松解后可矫正至中立位的2足,术后均复发;术前Coleman试验不可矫正,术中可矫正至外翻5°以上的3足,内翻复发1足.行跟骨外移截骨19足中,术前Coleman试验可矫正至中立位9足,1足内翻复发;术前Coleman试验不可矫正,术中可矫正至中立位的7足,术后2足复发;术前Coleman试验不可矫正,术中可矫正至外翻5°以上者3足,无内翻复发.结论 Coleman试验能否矫正后足的内翻,并非是否行跟骨外移截骨术的依据;而被动手法矫正是判断是否行跟骨截骨的关键,外翻5°是一个重要的指标.