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.     

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.     

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 midfoot osteotomy for severe forefoot adductus

A one-stage procedure combining a closing wedge osteotomy of the cuboid with an opening wedge of the medial cuneiform was used for the treatment of severe forefoot adductus. Results were reviewed in 33 patients (50 feet) followed-up for at least 2 years postoperatively. Clinical and radiographic improvement in forefoot position was achieved in 90% of cases. The mean calcaneo-second metatarsal angle improved from 37 degrees preoperatively to 18 degrees at final follow-up. The mean talo-first metatarsal angle improved from 15 degrees preoperatively to 3 degrees at final follow-up. The medial to lateral column ratio demonstrated 33% improvement after surgical treatment. Two feet were unimproved because of graft migration. Patients younger than age 5 years without a well-defined medial cuneiform ossific nucleus had a high rate of medial graft extrusion with loss of correction. This procedure should be reserved for patients aged 5 years or older. Ten patients followed-up for more than 6 years had no deterioration in results. This procedure provides effective, safe, predictable, and lasting correction of forefoot adductus.     

Treatment of residual adduction deformity in clubfoot: the double osteotomy.

Forefoot adduction is the most common residual deformity after clubfoot surgery. Surgical treatment of this deformity is often required for moderate and severe cases. This study reports the results of a closing wedge osteotomy of the cuboid and opening wedge osteotomy of the medial cuneiform in 39 feet. The average follow-up was 4.8 years. Clinical and radiographic improvement was seen in all patients, and no complications were seen. Surgery is advocated in children older than age 4, or when the medial cuneiform ossific nucleus is well developed.     

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 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.     

Talo-navicular arthrodesis for residual midfoot deformities of a previously corrected clubfoot

Triangular navicular, dorsal-lateral subluxation of the talo-navicular (TN) joint with a secondary forefoot cavovarus deformity, and degenerative changes of the TN joint are frequent causes of residual clubfoot deformity and pain in the midfoot after surgical correction. This study investigates the usefulness of TN arthrodesis to correct these deformities and to resolve symptoms resulting from these deformities. During the period from 1991-1996, the senior author performed 19 TN fusions (16 patients) for the above residual clubfoot deformities involving a painful TN joint. Eight of the procedures (seven patients) also required a lateral column shortening with a calcaneal wedge osteotomy to allow for a complete correction of the TN joint. The procedure was only performed in cases involving a hindfoot that was adequately aligned during a previous clubfoot correction. The average age of the patients at the time of surgery was 11 years (range: 4-20). One patient (bilateral procedures) was lost to follow-up. Fifteen patients (17 procedures) were followed-up for an average of four years (range: 2-6). All patients reported symptomatic improvement after the TN arthrodesis. Fourteen of the patients (15 procedures) were completely satisfied. The remaining patient (bilateral procedures) was only partially satisfied due to the subsequent development of navicular-cuneiform osteoarthritis in both feet. Two cases (2 patients) developed complications requiring a second procedure for satisfactory results. In addition, the procedure resulted in an improvement of the talus-first metatarsal angle on both antero-posterior and lateral radiographs. TN arthrodesis produced a correction of the residual clubfoot deformities of the midfoot and resulted in satisfactory clinical improvement in all the patients.     

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.     

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.     

改良Ludloff截骨术的几何形态学基础及其临床应用

目的 探讨Ludloff截骨术治疗母外翻后出现跖骨短缩、抬高及远端旋转的解决方案.方法 30例正常足,摄足部正侧位X线片,测量第一跖骨的长度及矢状面截骨角.计算在不同截骨条件下跖骨的抬高、短缩及旋前的理论值.根据该理论值,设计Ludloff截骨术的手术方案治疗??外翻.18例23足??外翻患者,如第一跖骨头内旋<3°,行单纯Ludloff截骨术;内旋角度为3°~6°,需行有冠状面截骨角的Ludloff截骨术;内旋角度>6°,行基底在外侧的楔形截骨;其中8足同时行第一跖骨远端截骨术以矫正跖骨远端关节角.采用??趾跖趾-趾间关节评分表及二至五趾跖趾-趾间关节评分表(AOFAS)进行疗效评定.结果 正常足第一跖骨的长度为4.60~6.90cm,平均(6.09±0.43)cm;矢状面截骨角为20.7°~31.3°,平均25.58°±2.73°.18例患者均获得随访,随访时间6~24个月,平均18个月.??趾跖趾-趾间关节评分:90~100分18足(78%),80~89分3足(13%),70~79分足2例(9%),评分平均增加36分(术前56分,术后92分);二至五趾跖趾-趾间关节评分:90~100分5足(22%),80~89分7足(30%),70~79分11足(48%),评分平均增加21分(术前59分,术后80分).结论 根据??外翻患者第一跖骨头不同的内旋角度,选取有冠状面截骨角或有基底在外侧的楔形截骨的Ludloff截骨术,可取得较理想的临床疗效.     

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.     

Calcaneal derotation osteotomy for clubfoot revision surgery

To describe a derotation calcaneal osteotomy technique and assess its efficacy in the correction of relapsed clubfoot. Twenty-one osteotomies were performed in 20 children with recurrent clubfoot. Nineteen children had been previously treated operatively. The derotation osteotomy was the first procedure performed in one case. The procedure combined medial and plantar releases, followed by a curvilinear osteotomy of the calcaneus. Patients were evaluated clinically and with standing dorsoplantar and lateral radiographs preoperatively, postoperatively and at follow-up. The talocalcaneal angle was considered as the most important criteria to evaluate the deformity correction. The clubfoot was idiopathic in 16 cases and neurological in five cases. Mean age at surgery was 7 years old (range 3.4-12 years). Total number of procedures per foot averaged 2.4 (range 4-1). The mean postoperative follow-up period was 2.8 years (range 2-6 years). The talocalcaneal angle increased significantly after the procedure (P<0.001), and no significant loss of correction was seen at latest follow-up (P=0.17). Two scarring complications occurred. Only one foot underwent further surgery after the calcaneal osteotomy for residual forefoot adduction, associated to a cavus and severe fibrosis. The calcaneal curvilinear osteotomy, in which the calcaneoforefoot unit derotation is performed around the talus but within the calcaneus, is a safe and efficient technique that can be proposed for clubfoot revision surgery.     

First cuneiform closing abductory osteotomy for reduction of metatarsus primus adductus.

The closing subtraction osteotomy of the first cuneiform effectively reduces pronounced obliquity of the first metatarsal cuneiform joint and predictably reduces the intermetatarsal angle in patients with metatarsus primus adductus. This osteotomy is combined with other procedures in surgical realignment of the first ray. Cases best suited for this procedure must be selected carefully. The procedure involves resecting the existing bone block from the opposing surfaces of the first and second metatarsal bases and from the distal one half of the opposing surfaces of the first and second cuneiforms. A triangular-shaped wedge of bone is then resected from the midbody of the first cuneiform while retaining a medial hinge. Closure of the first cuneiform osteotomy should require only minimal pressure. Two threaded Steinman pins transfix the osteotomy site. The vascular cancellous bone of the first cuneiform assures adequate healing of the osteotomy site.     

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 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.     

Comparison of Lateral Opening Wedge Calcaneal Osteotomy and Medial Calcaneal Sliding-opening Wedge Cuboid-closing Wedge Cuneiform Osteotomy for Correction of Planovalgus Foot Deformity in Children

The purpose of the present study was to compare the clinical and radiographic results between 2 procedures, lateral opening wedge calcaneal osteotomy (LCL) and medial calcaneal sliding-opening wedge cuboid-closing wedge cuneiform osteotomy (3C) in patients with planovalgus foot deformity. A total of 38 patients who underwent either LCL (18 patients, 28 feet) or 3C (20 patients, 32 feet) were included in the present study. The etiology of the planovalgus foot deformity was idiopathic in 16 feet and cerebral palsy in 44 feet. The 2 procedures used in the present study were indicated in symptomatic (pain or callus) children in whom conservative treatment, such as shoe modifications or orthotics, had been applied for more than 1 year but had failed. The patients were evaluated preoperatively, postoperatively, and at the last follow-up visit, both clinically and radiologically, and the interval to union and postoperative courses were compared between the 2 groups. In the LCL group, 19 of the 28 feet (68%) showed a satisfactory outcome and 9 (32%) an unsatisfactory outcome. In the 3C group, 28 of the 32 feet (88%) showed a satisfactory outcome and 4 (12%) an unsatisfactory outcome. The clinical results were not significantly different between the 2 groups, with mild to moderate pes planovalgus deformity. However, the clinical results were better in the 3C group with severe pes planovalgus deformity than in the LCL group with severe pes planovalgus deformity. All 4 radiographic parameters were improved at the last follow-up visit in both groups. In particular, the talar–first metatarsal angle and the calcaneal pitch angle on the weightbearing lateral radiographs were significantly improved in the 3C group with mild to moderate planovalgus foot deformity. All 4 parameters were significantly improved in the 3C group with severe planovalgus foot deformity. No significant differences were observed between the 2 groups in terms of the interval to union and postoperative care. No case of postoperative deep infection or nonunion was encountered in either group. 3C is a more effective procedure than LCL for the correction of pes planovalgus deformity in children, especially severe pes planovalgus deformities.     

Plantar opening-wedge osteotomy of cuneiform bones combined with selective plantar release and dwyer osteotomy for pes cavovarus in children

Neurological pes cavovarus is a challenging deformity to treat during childhood. Based on physiopathology, we propose the following original surgical procedure. Plantar-opening wedge osteotomy of the three cuneiform bones, preceded by selective plantar release, corrects forefoot pronation which is the primum movens of the deformity, and corrects the cavus at its apex. A calcaneal valgisation closing wedge osteotomy, is indicated if pre-operative planning revealed subtalar joint stiffness, incompatible with secondary hind foot realignment in valgus. The follow-up had to be at least 5 years or to reach skeletal maturity. Twenty-six children (36 feet) satisfied these criteria. Mean age at surgery was 10.3 years old. All the children had a neurological disease which was progressive for 65% of them (75% of the feet). Mean follow-up was 6.9 years. This treatment was effective, with a mean percentage of cavus correction of 74%, reaching 100% for 31% of the feet. Complete or partial cavus correction was still observed at last follow-up for 75% of the feet. At last follow-up, global result was satisfactory in 63.9% and non satisfactory in 36.1% of feet. Flat-foot was observed, of minor type, in only 2 cases. Apart from triple arthrodesis, iterative surgery relative to residual deformity (foot adduction, plantar sticking of the first metatarsal head) was indicated for 4 feet (11%). A triple arthrodesis was required in 12 cases (33%). In conclusion, this treatment provides mid-term satisfactory correction of the cavus and may allow avoiding triple arthrodesis at skeletal maturity.     

Is Double Metatarsal Osteotomy Superior to Proximal Chevron Osteotomy in Treatment of Hallux Valgus With Increased Distal Metatarsal Articular Angle?

We compared the results of proximal chevron osteotomy and double metatarsal osteotomy for hallux valgus with an increased distal metatarsal articular angle (DMAA). From October 2008 to December 2012, first metatarsal osteotomies were performed in 64 patients (69 feet) with symptomatic hallux valgus associated with an increased DMAA. Proximal chevron with Akin osteotomy and lateral soft tissue release was performed in 46 feet (PCO group); double metatarsal osteotomy and Akin osteotomy without lateral soft tissue release was performed in 23 feet (DMO group). Clinical assessments were performed using the American Orthopaedic Foot and Ankle Society (AOFAS) scale and visual analog scale (VAS). The hallux valgus angles, intermetatarsal angles, sesamoid positions, metatarsus adductus angles, and DMAAs were compared at different postoperative times. Postoperative shortening of first the metatarsal and complications were compared. The mean AOFAS scale and VAS scores showed significant improvement in both groups after surgery; however, no significant difference was observed between the 2 groups. The immediate postoperative hallux valgus angle and sesamoid position were significantly larger in DMO group; however, no intergroup difference was observed at the last follow-up visit, with the hallux valgus angle gradually increasing in the PCO group. The postoperative DMAA was significantly smaller in the DMO group. The mean shortening of the first metatarsal after surgery was significantly larger in the DMO group than in the PCO group. Transfer metatarsalgia developed in 1 foot (2.2%) in the PCO group and 2 feet (8.7%) in the DMO group. Partial avascular necrosis of the metatarsal head with advanced arthritis of the first metatarsophalangeal joint developed in 1 foot (4.3%) in the DMO group. In conclusion, no differences in the clinical and radiographic results were observed between the 2 groups for hallux valgus deformity with an increased DMAA.     

The natural history and longitudinal study of the surgically corrected clubfoot.

Surgical treatment for clubfoot has been largely directed at finding the best one-stage operation for the resistant clubfoot. Eighteen patients with 27 clubfeet (average follow-up 11 years since first surgery; range, 3.5-24 years) were reviewed. More than one clubfoot operation was required in 56% of cases. Forty-six percent were corrected after one surgery; 33% required a second surgery and 14% required a third operation. One patient with particularly severe feet required a fourth operation on each foot. The mean age at the time of surgery was 1.26 years, 5.12 years, and 8 years for the first, second, and third operations, respectively. The first operation consisted of a soft-tissue release. The second and third operations consisted of more extensive soft-tissue release and various rearfoot and forefoot procedures. Radiographic values revealed an AP talocalcaneal angle of 18 degrees, AP talo-first metatarsal angle of 6 degrees, lateral talocalcaneal angle of 29.6 degrees, lateral talo-first metatarsal angle of 15 degrees, and calcaneo-first metatarsal angle of 143 degrees. At follow-up all patients had adequate function as determined by personal interview and clinical examination. We conclude that correction of resistant congenital clubfoot often requires more than one surgery, not because of a "failed first operation," but due to dynamic muscle imbalances that may not be fully recognized in infancy and early childhood. Thus, the need for a second operation should not be perceived as a failure of the first, but as part of the natural history of congenital clubfoot.