Cotton Osteotomy in Flatfoot Reconstruction: A Case Report Highlighting Surgical Technique and Modified Incision to Protect the Medial Dorsal Cutaneous Nerve

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is rarely performed in isolation. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical, because preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated with arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus, or iatrogenic deformity after base wedge osteotomy in hallux valgus. We present the case of an adolescent patient who underwent flatfoot reconstruction, including Cotton osteotomy for correction of forefoot varus that was accentuated after double heel osteotomy. This case highlights our preferred procedure technique, including the use of a nerve-centric incision design. The use of an oblique dorsal medial incision is primarily intended to minimize the risk of trauma to the medial dorsal cutaneous nerve. At 20 months postoperatively for the right extremity and 12 months postoperatively for the left extremity, sensation remained intact, and the patient had not experienced any postoperative nerve symptoms. The patient had returned to playing sports without pain or restrictions.     

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.     

Radiographic Analysis and Clinical Efficacy of Hindfoot Arthrodesis With Versus Without Cotton Osteotomy in Stage III Adult Acquired Flatfoot Deformity

Forefoot varus develops as a result of longstanding adult-acquired flatfoot deformity (AAFD). This occurs with varying degrees of deformity and flexibility. Residual forefoot varus following hindfoot realignment in AAFD can lead to lateral column loading and a persistent pronatory moment in efforts to reestablish contact between the forefoot and the ground. The Cotton osteotomy may serve as a reasonable adjunct procedure to help avoid complications and poor outcomes associated with residual forefoot varus in patients undergoing hindfoot arthrodesis for stage III AAFD. The aim of this study was to compare the radiographic outcomes in patients undergoing isolated hindfoot arthrodesis to patients undergoing hindfoot arthrodesis with adjunctive cotton osteotomy. We retrospectively reviewed 47 patients matched based upon age, sex, and comorbidities who underwent hindfoot reconstruction for the treatment of stage III AAFD between 2015 and 2019. A retrospective radiographic review was performed on standard weightbearing radiographs including anterior-posterior and lateral views preoperatively, postoperatively at the initiation of full weightbearing, and at final follow-up. Statistical analysis utilizing paired t test to calculate p values where <.05 was statistically significant. At final follow-up, radiographic measurements showed statistically significant differences in CAA, calcaneal inclination, talo-calcaneal, and talar tilt (p value <.05). The Cotton osteotomy group showed a quicker return to presurgical activity level and a decreased incident of tibiotalar valgus. Our study suggests that the Cotton osteotomy can address residual forefoot varus and potentially prevent further progression of ankle valgus in AAFD when used in combination with hindfoot arthrodesis.     

Talar neck osteotomy for the treatment of severe structural flatfoot deformities

A new surgical procedure for the treatment of severe structural flatfoot with forefoot varus is presented. The talar osteotomy for flatfoot deformity and the pathology in the talus with medial column forefoot varus is described. The flatfoot considerations, adjunctive deformities, and the surgical reduction are presented. The talar osteotomy has been performed on 47 feet with a follow-up that is intermediate in length from 1 to 7 years. The results indicate that the procedure is specific and allows for good reduction when indicated in the majority of the cases.     

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.     

Medial column procedures in the correction of adult acquired flatfoot deformity

AAFD is a complex problem with a wide variety of treatment options. No single procedure or group of procedures can be applied to all patients with AAFD because of the variety of underlying etiology and grades of deformity. As the posture of the foot progresses into hindfoot valgus and forefoot abduction through attenuation of the medial structures of the foot, the medial column begins to change shape. The first ray elevates and the joints of the medial column may begin to collapse. Careful physical examination and review of weight-bearing radiographs determines which patients have an associated forefoot varus deformity that may require correction at the time of flatfoot reconstruction. Correction of an AAFD requires a combination of soft-tissue procedures to restore dynamic inversion power and bony procedures to correct the hindfoot and midfoot malalignments. If after these corrections forefoot varus deformity remains, the surgeon should consider use of a medial column procedure to recreate the “triangle of support” of the foot that Cotton described.5 If the elevation of the medial column is identified to be at the first NC or the first TMT joint, then the joint should be carefully examined for evidence of instability, hypermobility, or arthritic change. If none of these problems exist, then the surgeon can consider use of the joint-sparing Cotton medial cuneiform osteotomy to correct residual forefoot varus. However, if instability, hypermobility, or arthritic change is present, then the surgeon should consider use of an arthrodesis of the involved joint to correct residual forefoot varus. Either procedure provides a safe and predictable correction to the medial column as part of a comprehensive surgical correction of AAFD.     

Proximal abduction–supination osteotomy of the first metatarsal for adolescent hallux valgus: a preliminary report

Background

Surgical treatment of adolescent hallux valgus has been a challenging intervention because of high rates of postoperative recurrence. The purposes of this study were to describe a proximal abduction–supination osteotomy of the first metatarsal and prospectively review preliminary results of this procedure for correction of adolescent hallux valgus.

Methods

Eleven patients (12 feet) who had had a proximal abduction–supination osteotomy of the first metatarsal combined with a distal soft-tissue procedure to correct an adolescent hallux valgus deformity were prospectively reviewed clinically and radiologically. The average duration of follow-up was 22 months. The average age at the time of surgery was 17 years.

Results

The mean score on the Japanese Society for Surgery of the Foot standard rating system for hallux improved significantly, from 62.0 points preoperatively to 99.2 points postoperatively (p = 0.002). All patients were satisfied and would choose to have the same procedure again. The mean hallux valgus angle decreased significantly, from 32.3° preoperatively to 12.2° postoperatively (p = 0.002); mean intermetatarsal angle decreased significantly from 14.0° preoperatively to 6.2° postoperatively (p = 0.002). No feet had postoperative recurrence of hallux valgus (a hallux valgus angle ≥20°). There were no occurrences of nonunion or transfer lesions.

Conclusions

The clinical and radiological results of this study demonstrate that a proximal abduction–supination osteotomy with a distal soft-tissue procedure, which described in this study, achieved significant correction of an adolescent hallux valgus deformity, significant improvement in pain and function, and reduction in rate of recurrence.     

Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release

Between 1991 and 1995, 96 patients (114 feet) were treated with a proximal crescentic metatarsal osteotomy and distal soft-tissue procedure for moderate to severe hallux valgus deformity [intermetatarsal (IM) angle > 15°, or hallux valgus (HV) angle > 30°]. At an average follow-up of 26 months, 8 men and 62 women (86 feet) with a mean age of 53.2 years were retrospectively reviewed. The HV angle averaged 41.1° preoperatively and 14.6° postoperatively. The respective values for the IM angle were 17.8° and 7.8°. Neither the average metatarsal shortening of 3 mm nor the dorsal angulation at the osteotomy site seen in 9% of cases evidenced any clinical significance at follow-up. Patient satisfaction was excellent or good in 91%, and the mean Mayo Clinic Forefoot Score (total 75 points) improved from 37.2 to 61.1 points. Complications included 8 cases of hallux varus and 5 cases of hardware failure. Based on this first study exclusively focusing on moderate to severe hallux valgus deformity, we conclude that proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus (IM angle > 15° or HV angle > 30 °). Received: 28 July 1999     

Rheumatoid Forefoot Reconstruction in Nonrheumatic Patients: Lesser Metatarsal Head Resection versus Osteotomy

In the literature, first metatarsophalangeal joint arthrodesis with lesser metatarsal head resection seems to be a reliable procedure in rheumatoid foot deformity. Maybe this procedure could be proposed in nonrheumatoid severe forefoot deformity (hallux valgus angle >40° and lesser metatarsophalangeal dislocation). The aim of this study was to compare radiological and clinical outcomes between lesser metatarsal head resection and lesser metatarsal head osteotomy in nonrheumatoid patients. Thirty-nine patients (56 feet) suffering from well-defined nonrheumatoid severe forefoot deformity were retrospectively enrolled in our institution between 2009 and 2015. Metatarsal head resection and metatarsal head osteotomy represented 13 patients (20 feet) and 26 patients (36 feet), respectively. In this observational study, a rheumatoid population (21 patients) was included as the control. The clinical outcome measures consisted of American Orthopaedic Foot and Ankle Society score, Foot and Ankle Ability Measurement, and Short Form-36. The radiological outcomes were: intermetatarsal angle, hallux valgus angle, and metatarsophalangeal alignment. Mean follow-up was 24 months. Satisfaction rate was, respectively, 92% for resection, 91% for osteotomy procedure, and 80% for surgery in rheumatoid patients. Short Form-36 global score was, respectively, 80.7 (52.5-96.4), 76 (57.7-93), and 68.3 (22.6-86). No functional outcome difference was found between resection and osteotomy procedures, except that the metatarsal head resection group had poorer results in sports activities than the osteotomy group. Complications were similar between osteotomy and resection (p > .05). The radiological outcomes were improved significantly from preoperative to postoperative. First metatarsophalangeal joint arthrodesis with lesser metatarsal head resection in nonrheumatoid severe forefoot deformity might be a good therapeutic option.     

Basal medial opening wedge first metatarsal osteotomy stabilized with a low profile wedge plate

Twenty patients underwent 25 basal medial opening wedge osteotomies of the first metatarsal stabilized using a low-profile wedge plate in combination with a distal soft tissue release, distal metatarsal osteotomy and Akin osteotomy as required for correction of a hallux valgus deformity. The mean clinical and radiographic follow-up was 12.2 months. Pre- and post operative radiographs available in 15 cases showed that the median hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were corrected from 45.5 to 13.1, 17.7 to 9.2 and 243 to 10.0 degrees respectively (p < 0.001). Final radiographic assessment for the whole series showed a median final HVA and IMA of 14.1 and 9.1 respectively. Radiographic union was noted in all but one case which was asymptomatic. One wound infection was treated with oral antibiotics, one hallux varus deformity required soft tissue reconstruction and there was one recurrence. The outcome was reported as good or satisfactory by the patients for 20 of 25 feet. Three patients reported stiffness in the first MTP joint, which improved with joint injection and manipulation. Two plates were removed for prominence. The basal medial opening wedge osteotomy stabilized with a low profile wedge plate was an effective addition for correcting a moderate to severe hallux valgus deformity as part of a double or triple first ray osteotomy.     

Pedal ectrodactyly: a case report with a new surgical management.

A case report is presented regarding a patient with type IV bilateral ectrodactyly treated with a double surgical approach: in forefoot to correct the malformation and in rearfoot to prevent secondary deformity of the subtalar joint. The forefoot was enlarged and in particular the second and third rays were absent. There was also a metatarsus primus varus with interphalangeal hallux abductus. The second cuneiform bone was removed with a wedge resection of the midfoot. The reduction in transverse diameter of the forefoot was obtained by cerclage of the first and fourth metatarsal bones. For hallux valgus, a percutaneous distal osteotomy of the proximal phalanx was performed. Several months after the forefoot correction, subtalar joint pronation was noted secondary to the altered forefoot mechanics and was treated with a subtalar Arthroereisis. The contralateral foot was addressed using similar techniques, except all procedures were done in a single surgical session. A favorable outcome for the patient 1 year and 6 months after surgery seems to justify this approach.     

Scarf and Weil osteotomies for correction of rheumatoid forefoot deformities: A review of 20 cases

The forefoot is commonly affected in rheumatoid arthritis. Little has been written of the results of metatarsophalangeal joint preservation in rheumatoid arthritis. We describe the results of the Scarf and Weil osteotomy for correction of forefoot deformities in patients with rheumatoid arthritis. Between 1996 and 1999, 17 patients (20 feet) underwent a Scarf osteotomy for their hallux valgus deformity and in 17 feet a Weil osteotomy of the lesser metatarsophalangeal joints. Radiographic examination was performed preoperatively and at a mean follow up of 65 months. A questionnaire was used at a minimum follow up of 6 years. The hallux valgus angle improved from 41° to 28° at follow up. The majority of the patients (79%) were satisfied with the result during follow-up. We found no wound infections, neuralgia or osteonecrosis of the first metatarsal. In three patients, a fusion of the first MTP joint was performed at follow up.In conclusion, the Scarf and Weil osteotomy is a useful method for MTP joint preserving surgery in rheumatoid forefoot deformities without severe impairment of the MTP joints.     

Distal Chevron Osteotomy with Lateral Soft Tissue Release for Moderate to Severe Hallux Valgus Decided Using Intraoperative Varus Stress Radiographs

The purpose of the present study was to investigate the outcomes of distal chevron osteotomy with lateral soft tissue release for moderate to severe hallux valgus. The patients were selected using criteria that included the degree of lateral soft tissue contracture and metatarsocuneiform joint flexibility. The contracture and flexibility were determined from intraoperative varus stress radiographs. From April 2007 to May 2009, 56 feet in 51 consecutive patients with moderate to severe hallux valgus had undergone distal chevron osteotomy with lateral soft tissue release. This was done when the lateral soft tissue contracture was not so severe that passive correction of the hallux valgus deformity was not possible and when the metatarsocuneiform joint was flexible enough to permit additional correction of the first intermetatarsal angle after lateral soft tissue release. The mean patient age was 45.2 (range 23 to 54) years, and the duration of follow-up was 27.5 (range 24 to 46) months. The mean hallux abductus angle decreased from 33.5° ± 3.1° to 11.6° ± 3.3°, and the first intermetatarsal angle decreased from 16.4° ± 2.7° to 9.7° ± 2.1°. The mean American Orthopaedic Foot and Ankle Society hallux-interphalangeal scores increased from 66.6° ± 10.7° to 92.6° ± 9.4° points, and 46 of the 51 patients (90%) were either very satisfied or satisfied with the outcome. No recurrence of deformity or osteonecrosis of the metatarsal head occurred. When lateral soft tissue contracture is not severe and when the metatarsocuneiform joint is flexible enough, distal chevron osteotomy with lateral soft tissue release can be a useful and effective choice for moderate to severe hallux valgus deformity.     

Shortening Proximal Chevron Metatarsal Osteotomy for Patients With a Hallux Valgus Deformity With Advanced Arthritis

To correct hallux valgus deformities in patients with advanced arthritis of the first metatarsophalangeal joint, we designed a new reverse chevron-type shortening osteotomy technique that could be used to correct valgus deformities at the proximal metatarsal level, as well as shorten and lower the metatarsal, in a 1-time procedure. Sixteen feet in 16 patients with a minimum of 18 months follow-up who underwent a shortening proximal chevron metatarsal osteotomy for a hallux valgus deformity with advanced arthritic change between January 2014 and March 2016 were reviewed in this study. Double chevron osteotomies with 20° of plantar-ward obliquity at the proximal metatarsal level were made at 5-mm intervals for simultaneous valgus correction and metatarsal shortening. An additional Weil osteotomy of the second metatarsal was performed in all feet. Patients’ mean age was 57.88 ± 6.55 years. The deformity was satisfactorily corrected by the operation. The first metatarsal was shortened by approximately 8.75 mm, and the relative length of the second metatarsal did not differ significantly postoperatively (p?=?.179). The relative second metatarsal height, as seen on forefoot axial radiographs, was maintained constantly, with no significant difference (p?=?.215). No painful plantar callosity or transfer metatarsalgia under the second metatarsal head was observed postoperatively. A shortening proximal chevron metatarsal osteotomy for hallux valgus deformities with advanced arthritic change showed a good result with respect to deformity correction and pain relief. Appropriate lowering and an additional Weil osteotomy effectively prevented postoperative pain and painful callosity under the second metatarsal head.     

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.     

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.     

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.     

Surgical treatment of hallux valgus associated with flexible flatfoot during growing age

Purpose

During growth, hallux valgus could present associated with flatfoot. Considering the current disagreement about correction of hallux valgus during growth and the lack of reports about simultaneous correction of hallux valgus associated with flexible flatfoot, we present simultaneous treatment of both deformities during growth combining subtalar arthroeresis and SERI first metatarsal osteotomy, reporting results at an average five-year follow-up.

Methods

Thirty-two children (64 feet, age range 8–12 years) affected by hallux valgus associated with flexible flatfoot underwent surgical treatment combining SERI first metatarsal osteotomy and subtalar arthroereisis with bioabsorbable endorthotic implant. Clinical evaluation was summarized with AOFAS score, and standard standing radiographs were performed.

Results

AOFAS score ranged from 86?±?2 to 98?±?2 (hindfoot) and from 80?±?4 to 98?±?2 (forefoot). HVA ranged from 21°?±?2 to 5°?±?2, IMA from 14°?±?2 to 7°?±?2, DMAA from 18°?±?2 to 2°?±?2, and Meary’s angle from 162°?±?11 to 175°?±?4. Complications included one case of delayed wound healing, inflammatory skin reaction around the outlet of the percutaneous Kirschner wire in two cases, displacement of the endorthotic implant in one case, and a second surgery to replace the implant.

Conclusions

SERI osteotomy and subtalar arthroereisis resulted in an effective, technically simple and easily combined approach, with a high rate of good results and low rate of complications at mid-term follow-up. These techniques performed simultaneously represent a viable option in case of hallux valgus associated with flexible flatfoot during growth. Nevertheless, considering the limitations of this study, we believe that a larger case series and a longer follow-up should be desirable.

     

Different faces of the triple arthrodesis

Patients with severe pes planovalgus or cavovarus foot deformities who fail conservative treatment may require a triple arthrodesis. Modifying the triple arthrodesis to include extended bone wedge resections allows for improved correction. The goal of each procedure is to obtain a less painful, plantigrade foot, and to improve function. Additional hindfoot or midfoot osteotomies may be needed in the modified triple arthrodesis. Midfoot or forefoot cavus can be addressed with either the Japas, Cole, or Jahss osteotomies, as described above. Residual hindfoot valgus can be adequately corrected with a medial displacement osteotomy of the calcaneus. Residual hindfoot varus is preferably corrected through a lateral closing wedge calcaneal osteotomy. This allows for adequate correction without the need for bone graft or an extended medial incision in the area of the tibial neurovascular bundle. Good results have been obtained with these types of complicated reconstructive procedures.