Many surgical techniques based on a distal osteotomy are used for the treatment of the symptomatic hallux valgus. We review the results of percutaneous distal osteotomy retrospectively. Between 1998 and 2003, 52 patients were operated on using a distal osteotomy for symptomatic hallux valgus. We investigated 35 females and nine males for a mean follow-up time of 4.6 years. We performed a percutaneous distal osteotomy (PDO) with a 2-mm Kirschner wire. Radiological analysis consisted of measuring the hallux valgus angle (HV) and the angle between the first and the second metatarsal (M). Clinical evaluation was performed with the AOFAS scale. Good bony contact was achieved and all the osteotomies united and no aseptic necrosis was found. According to the questionnaire, the pre-operative AOFAS score was 44.3 and 92.5 at the follow-up examination. Radiological analysis showed that the pre-operative HV angle was 13.7° and 9.8° at follow-up. The pre-operative M angle was 24.1° and 13.6° at follow-up. The PDO technique gives good results at a mean follow-up of 4.6 years. The positive aspects of this technique are: short surgical time, low incidence of complications and high patient compliance. A single 2-mm Kirschner wire is enough to achieve adequate stabilisation of the osteotomy, is less expensive than other surgical instruments for hallux valgus and is very easy to remove

The intermetatarsal angle is widely used to determine whether a basal or distal metatarsal osteotomy should be used to correct a hallux valgus deformity. We have noticed that the point of intersection of the long axes of the first and second metatarsals on standard pre-operative weight-bearing AP radiographs consistently predicts the type of osteotomy required. A basal osteotomy is generally recommended if the inter-metatarsal angle is ≥14°, whereas a distal osteotomy is usually sufficient if the angle is less than 14°. Sixty standardised pre-operative AP weight bearing in-patients undergoing hallux valgus correction were included in our study. The intermetatarsal angle was measured in a standard fashion. The point of intersection in the foot was recorded in terms of the distance from the talonavicular joint. Using a Pearson’s Correlation coefficient, our study revealed that an intermetatarsal angle of 14° or more consistently intersected either within the talar head or distal to thetalonavicular joint. We propose that this as an accurate and simple method of pre-operatively determining the choice of metatarsal osteotomy

Introduction. Hallux valgus is a common orthopaedic complaint with multiple surgical options. There are many methods available for assessing whether sufficient translation of the first metatarsal can be achieved with a metatarsal translational osteotomy alone. None of the current methods take into account the breadth of the metatarsal. With current PACS technology a radiograph can be zoomed to any size and we postulate that by using the surgeon's thumb (or any suitable digit), as a sizing tool, a safe clinical decision can be made concerning whether a translational metatarsal osteotomy alone will provide sufficient correction. Method. We reviewed the preoperative radiographs (weightbearing AP) of twenty patients who had scarf and akin osteotomies and twenty patients with a deformity too great for scarf and akin osteotomies. The senior author (CC) taught the rule of thumb to one consultant and two registrars (total two registrars and two consultants). The radiographs were blindly randomised and the participants assessed each radiograph and decided whether sufficient translation could be achieved with a translational metatarsal osteotomy alone. The process was repeated three months later. Twenty patients were deemed sufficient for intra-user variability and significance based on a recent JBJS(A) article concerning radiographic measurements post proximal crescentic osteotomy (Shima et al. 2009). Results. Good inter- and intra- user variability was demonstrated and using the rule of thumb is a safe way of determining whether a distal osteotomy alone will provide sufficient correction

Introduction: Distal osteotomy of the first metatarsal is indicated in the surgical treatment of mild-to-moderate hallux valgus deformity. The aim of this study was to evaluate the results of a subcapital distal osteotomy of the first metatarsal using a percutaneous technique. Methods: From 1996 to 2001 118 consecutive percutaneous distal osteotomies of the first metatarsal were performed in 82 patients for the treatment of painful mild-to-moderate hallux valgus. Patients were assessed at a mean follow-up of 35.9 months employing a clinical and radiographic protocol. The American Orthopedic Foot and Ankle Society’s hallux-metatarsophalangeal-interphalangeal scale was used for the clinical assessment. Results: in 107 of the 118 cases (90.7%), patients were satisfied with the procedure. The mean score obtained in the clinical assessment using the AOFAS scale was 88.2 ± 12.9. The radiographic assessment showed significant changes (P< 0.05) in the values of the hallux valgus angle, first intermetatarsal angle, distal metatarsal articular angle and the sesamoid position at the postoperative assessment compared to preoperative values. Recurrence of the valgus deformity was observed in 3 cases (2.5%), non-painful stiffness of the first metatarsophalangeal joint in 7 (5.9%) and a deep infection resolved by antibiotic therapy in 1 (0.8%). Conclusions: The percutaneous procedure proved to be a reliable technique for the correct execution of a distal linear osteotomy of the first metatarsal for the correction of painful mild-to-moderate hallux valgus deformity. The clinical results appear to be comparable to those obtainable with the traditional open techniques, with the additional advantages of a minimally invasive procedure, substantially shorter operating times and a reduced risk of complications related to surgical exposure

Distal osteotomy of the first metatarsal can be performed by a percutaneous minimally invasive procedure when indicated for the surgical treatment of hallux valgus. The intermediate-term results of percutaneous distal uniplanar osteotomy of the first metatarsal were assessed in 118 feet in 82 patients (36 bilaterally) to determine the effectiveness of the percutaneous procedure. A modified Lamprecht – Kramer – Boesh technique was performed under distal nerve trunk anaesthesia (ankle block) without a tourniquet, using a K-wire for stabilisation of the osteotomy. No surgical approaches and no soft-tissue procedures were required. Post-operatively adhesive tape was applied and immediate weight-bearing allowed. The patients were followed for an average of 36 months (range 24 to 78 months). Clinical assessment was based on the American Orthopaedic Foot and Ankle Society, hallux-metatarsal-phalangeal-interphalangeal (AOFAS) scale. Anteroposterior and lateral weight-bearing radiographs were performed pre- and post-operatively, and the hallux valgus angle, the first intermetatarsal angle, the distal metatarsal articular angle (DMAA) and the position of the sesamoid were recorded. The average score according to the AOFAS scale was 86.6±12.9. Patients were satisfied with the result of the procedure in 90.7% of cases. The results confirm the effectiveness of the percutaneous procedure to achieve a satisfactory distal osteotomy of the first metatarsal without the need for soft-tissue procedures in the surgical management of symptomatic hallux valgus

Though there are many techniques utilised in the correction of hallux valgus (HV), no single approach has been reported to be ideal for all patients to date. A great deal of controversy remains concerning the type of osteotomy, method of fixation, and inclusion of soft tissue procedures. Herein, we compared the outcomes of two different operative techniques, the minimally-invasive modified percutaneous technique and the distal chevron osteotomy, used to treat mild to moderate hallux valgus. This study was conducted in line with the CONSORT 2010 guidelines. 41 patients (58 feet) with mild to moderate hallux valgus were randomly assigned by computer to two different groups. The first group containing 24 patients (33 feet) was treated by the modified percutaneous technique, whereas the second group included 17 patients (25 feet) treated by distal chevron osteotomy. In the modified percutaneous group, after a mean follow up of 43 months, the mean correction of hallux valgus angle (HVA) was 26.69° (P=0.00001), the mean correction of intermetatarsal angle (IMA) was 9.45° (P=0.00001), and the mean improvement of AOFAS score was 47.94 points (P=0.00001). In the chevron osteotomy group, after a mean follow up of 44 months, the mean correction of hallux valgus angle was 26.72° (P=0.00001), the mean correction of intermetatarsal angle was 9° (P=0.00001), and the mean improvement of AOFAS score was 44.76 points (P=0.00001). In our study, the modified percutaneous technique proved to be equally effective as the distal chevron osteotomy, but with fewer complications and a higher rate of patient satisfaction

This study was designed to investigate distal radial osteotomy performed from a volar approach for dorsal deformity. In the past conventional dorsal approaches have led to extensor tendon synovitis and a volar approach was thus appealing. A prospective analysis of 8 consecutive patients with distal radial malunions with residual dorsal angulation was performed. In each case a volar approach was used and a locked distal radial plate was applied. Laic crest bone graft was used. In each case an acceptable correction was obtained. Union occurred in 6–8 weeks. Pain and grip strength were improved in all 8 cases. The author concludes that a volar approach and locked plate fixation is useful for the correction of dorsal deformity in distal radial malunions. Implant problems with this approach

Purpose of the study: Different metatarsal osteotomies performed via a percutaneous approach can be used to correct hallux valgus. The purpose of this work was to analyse the clinical and radiographic results of percutaneous treatment of hallux valgus using a distal wedge osteotomy of the metatarsal. Material and methods: This was a consecutive prospective series of 125 cases of hallux valgus treated by the same surgical technique, distal wedge osteotomy of the metatarsal without fixation. Percutaneous lateral arthrolysis and percutaneous varus correction of the first phalanx were associated. The AOFAS function score for the forefoot was determined preoperatively and at last follow-up. Time to normal shoe wearing and to resumption of occupational activities were also noted. Angle correction was determined on the anteroposterior weight-bearing image. All patients were reviewed at mean 20 months (range 12–40). Results: The AOFAS forefoot function score was 46/100 preoperatively and 87/100 at last follow-up. Mean motion of the metatarsophalangeal joint was 95 preoperatively and 80 postoperatively. Mean metatarsophalangeal valgus was 30 preoperatively and 12 at last follow-up. The mean intermetatarsal angle improved from 13 to 8 and the orientation of the joint surface of the first metatarsal (DMAA) improved from 11 to 7. The metatarsophalangeal joint of the first ray was congruent in 45% of the feet preoperatively and in 88% postoperatively. Mean time to wearing normal shoes was seven weeks for the treatment of hallux valgus alone and three months for surgery of the first ray and lateral rays. Discussion: Percutaneous treatment of mild to moderate hallux valgus by distal wedge osteotomy of the metatarsal enables good clinical and radiographic improvement. The surgical technique requires experience with percutaneous surgery of the forefoot to avoid the main complications: secondary displacement in elevates and excessive shortening of the first metatarsal. This technique restores metatarsophalangeal congruence of the first ray compared with Isham-Reverdin osteotomy

Purpose of the study: The purpose of using distal metaphyso-epiphyseal osteotomy to shorten the ulna is to reduce healing time compared with diaphyseal shortening and to adapt the osteotomy to the distal radioulnar anatomy and associated conditions by using a variably oblique cut. Material and methods: Oblique metaphyso-eiphyseal osteotomy of the distal ulna was performed in sixteen patients since 2000. Fourteen presented ulnocarpal pain. Among these, eight had associated distal radioulnar pain. Two patients had pain essentially limited to the distal radioulnar area. Radiographically, there was ulnocarpal impingement in fourteen wrists, and signs of early-stage distal radioulnar osteoarthritis in five. Local regional anesthesia was used in thirteen patients who underwent surgery in an outpatient clinic. The dorsoulnar approach was used. The direction of the osteotomy cut depended on the individual condition, and distal radioulnar anatomy and stability. Two headless canulated screws were used for fixation. The elbow and wrist were immobilized for three weeks followed by self-education of pronosupination beginning with a removable orthesis to stabilize the wrist. Results: Outcome was assessed at maximum follow-up of four years. Preoperative pain had totally resolved in fourteen wrists with residual pain at forced pronosupination in two. Wrist motion was not modified in the frontal and sagittal planes. Complete pronosupination range of motion was achieved in thirteen patients, two patients had supination limited to 20° and one had pronation and supination limited to 30°. Force was 90% compared to the opposite side. Bone healing was achieved in all patients, in 3–4 weeks for fourteen wrists and after two months of elbow and wrist immobilization in two. Discussion: Oblique metaphyso-epiphyseal osteotomy of the distal ulna reduced the healing time compared with diaphyseal shortening osteotomies. This technique enables adaptation of the direction and orientation of the ulnar cut to the individual distal radioulnar anatomy. Favorable clinical outcome in patients with early-stage distal radioulnar osteoarthritis has led us to progressively abandon certain indications for distal resection of the ulna and the Sauvé-Kapankji operation

In the correction of hallux valgus, there are many different treatments with the aim to resume angular values I MF (metatarsal-phalangeal), I IM (intermetatarsal), PASA (proximal articular set angle), sesamoid position, to improve transferring metatarsal pain and the aesthetics of the forefoot. From November 2001 to November 2003, in the 1. st. Clinica Ortopedica at Bari University, 40 patients were treated for hallux valgus (nine males and 31 females). The age ranges from 17 to 82 years of age (median age: 50 years). The correction technique is based on a distal metatarsal osteotomy (modified Chevron techniques) and fixation with ‘hallux splint’ interfragmentation dynamic and compression device (Waldemar Link GmbH & Co Hamburg, Germany). This technique give intra-operative stability of the osteotomy, giving free weight-bearing from the beginning in the post-operative phase and the complete resumption of daily activities in a short period of time. At a median follow-up of 2 months, a significant improvement in the angular values is shown by radiological evaluation. Therefore, the result shows that this surgical technique is valid in the correcting hallux valgus

Introduction: The main goal of surgical correction of hallux valgus is the morphological and functional rebalance of the first ray and correcting all the characteristics of the deformity. Historically, distal metatarsal osteotomies and SCARF have been indicated in cases of mild or moderate deformity with inter-metatarsal angles up to 20° and are procedures widely used for correction of hallux valgus. The aim of this study is to compare a distal metatarsal osteotomy recently described (SERI) with SCARF osteotomy in a clinical prospective randomised study. Methods: 20 patients with bilateral hallux valgus similar on both sides regarding clinical and radiographic assessment were included. Clinical evaluation using American Orthopaedic Foot and Ankle Score (AOFAS) and radiographic assessment were considered before surgery up to 2 years follow-up. All patients were operated bilaterally in the same surgical sitting, and received at random SCARF osteotomy on one side, and on the other a SERI osteotomy performed through a 1 cm skin incision under tdirect view control and fixed with one Kirschner wire. Duration of surgery was recorded. Postoperative care was similar in both groups and consisted of gauze bandage and weight bearing with talus shoes for 30 days. Results: No statistical differences were observed in preoperative HVA, IMA, DMAA in both groups. Average surgical time was 17 minutes in SCARF and 3 minutes in SERI (p< 0.0005). No complications were observed in the series, with no wound dehiscence. All osteotomies healed uneventfully. At 2 year follow up, no statistical differences were observed in HVA, IMA, DMAA comparing SCARF with SERI. Average AOFAS score was 87±12 in SCARF and 89±10 in SERI (p=0.07). Conclusions: Both SCARF and SERI techniques proved effective in the correction of hallux valgus, however SERI, performed with a shorter skin incision, in less surgical time, fixed with a cheaper device (one Kirschner wire), resulted in a better clinical outcome

Aims: The purpouse of the study is to review a series of hallux valgus treated by minimally invasive distal metatarsal osteotomy with a simple, effective, rapid, inexpensive (SERI) technique. Methods: 54 consecutive feet in 37 patients, aged 48 ± 23 years affected by hallux valgus deformity less than 40û with an intermetatarsal angle up to 20û were reviewed at 5 years follow up. Surgical technique consisted of a 1 cm medial incision at the metatarsal neck, then an osteotomy was performed using an oscillating saw. With a direct line of vision, all characteristics of the deformity (HVA, IMA, DMAA) were corrected by lateral displacement of the metatarsal head; contemporary plantar or dorsal displacement was performed according to insufþciency or overloading of the þrst ray. The osteotomy was stabilized by a 2 mm Kirschner wire. All patients were clinically (AOFAS score) and radiographically checked at an average follow up of 5 years. Results: The clinical score at follow up was (91±12). The pre-op hallux valgus angle was 32.5±9, while post-op it was 22±7 (p< 0.0001), pre-op inter-metatarsal angle was 13±3, while post op it was 9±3 (p< 0.0001), the pre-op distal metatarsal articular angle was 19±10, while post-op it was 9±7 (p< 0.0001). Conclusions: Clinical and radiographic þndings showed that SERI osteotomy permitted an adequate correction of all the pathologic characteristics of the deformity, and this factor is responsible for our satisfactory results

Purpose: We compare the accuracy and precision of patient-specific plastic guides versus computer-assisted navigation for distal radius osteotomy (DRO). We hypothesize that guides would provide similar accuracy and precision compared to computer-assisted surgery, and that they would be faster to use than navigated surgery. Method: We used CT scans, computer models, and planned corrections of radii from seven patients who had previously received computer-assisted DRO. The planned correction included the locations and directions of the screw holes for the fixation plate on the intact deformed radius. Using computer-assisted technique, the surgeon drills the holes for the fixation plate using computer navigation before performing the osteotomy; after cutting the radius, the plate is fixated to the distal radius, and the distal radius is distracted until the holes in the proximal radius align with the holes of the fixation plate. A patient-specific guide can be manufactured that fits on the intact deformed radius to guide the drilling of the screw holes. The guide is designed so that it mates exactly with the dorsal surface of the radius. Each guide was designed using custom software and manufactured in ABS plastic using a 3D printer. The surgeon places the guide on the radius and uses a metal drill sleeve in each guide hole to guide the drilling of the plate screw holes. We manufactured urethane plastic phantoms of the seven deformed radii. Our laboratory experiment had six surgeons each perform four computer-assisted and four patient-specific guide procedures on the phantom radii; the specimen and type of guidance were randomly chosen. The time from the start of the procedure to when the shaping of the distal radius was completed was recorded; we did not record the time required to cut and fixate the radius because this time does not depend on the type of guidance used. The plated phantoms were assessed for errors in ulnar variance, radial inclination, and volar tilt as compared to the planned correction. Results: The results for the computer-assisted procedures were: ulnar variance error (−0.2 +/ − 2.0 mm), radial inclination error (−0.9 +/ − 6.1 deg), volar tilt error (−0.9 +/ − 1.9 deg). The results for the customized jig procedures were: ulnar variance error (−0.7 +/ − 0.6 mm), radial inclination error (−1.0 +/ − 1.4 deg), volar tilt error (−0.4 +/ − 2.2 deg). There were no significant differences detected in the means of the measurements (significance level 0.05) using the two-sample t-test. Significant differences were detected in the variances of the ulnar variance and radial inclination errors (significance level 0.05) using Levene’s test. It took (705 +/ − 144 sec) to perform the computer-assisted procedures and (214 +/ − 98 sec) to perform the customized guide procedures. The differences between the means and variances were statistically significant. Conclusion: Patient-specific guides are as accurate, more precise, and require less time than computer-assisted navigation for DRO

Purpose: The purpose of this clinical trial was to investigate the accuracy of a novel method for computer-assisted distal radius osteotomy, in which computer-generated patient-specific plastic guides were used for intra-operative guidance. Our hypothesis was that these guides combine the accuracy and precision of computer-assisted techniques with the ease of use of mechanical guides. Method: In a consecutive series of 9 patients we tested the accuracy of the proposed method. Prior to surgery, CT scans were obtained of both radii and ulnae in neutral rotation. Three-dimensional virtual models for both the affected and unaffected radius and ulna were created. The models of the unaffected radius and ulna were reflected to serve as a template for the correction. Custom-made software was used to plan the correction. The locations of the distal and proximal drill holes for the plate were saved and the locations of the distal holes before the osteotomy were determined. The design of a patient-specific instrument guide was calculated, into which a mirror image of intra-operative accessible bone structure of the distal radius was integrated. This allowed for unique positioning of the guide intra-operatively. For each planned drill location a guidance hole was incorporated into the guide. A plastic model of the guide was created using a rapid prototyping machine. Intra-operatively, a conventional incision was made and the guide was positioned on the distal end of the radius. The surgeon drilled the holes for the plate screws into the intact radius. The guide was removed and the surgeon performed the osteotomy using the conventional technique and shaved the bone from the distal radius fragment to accommodate the plate. Using the pre-drilled holes the plate was affixed to the distal radius fragment. The distal fragment was reduced until the proximal screw holes in the plate aligned with the pilot holes in the bone. To analyze the accuracy of the intra-operative procedure we compared the post-operative alignment of the radius with the planned alignment. A lateral and an A/P digitally reconstructed radiograph (DRR) of the plan were calculated. These DRRs were used to evaluate the radial inclination, the volar tilt and the ulnar variance of the planned alignment. Post-operative lateral and A/P X-Rays were used to determine the same three post-operative radiographic indices. The post-operative values were compared with the planned values. Results: We found an average deviation for the radial inclination of 0.5°(StDev 1.8), for the volar tilt of 0.7°(StDev 2.3), and for the ulnar variance of 0.8mm (StDev 1.9). Conclusion: These results show that the computer-generated instrument guides accurately achieved the planned alignment. The guides were easy to integrate into the surgical workflow and eliminated the need for intra-operative fluoroscopy for guidance of the procedure

INTRODUCTION: Distal metatarsal osteotomies have been described for surgical treatment of hallux valgus with good results. The aim of this study is to review the results of our first 1000 consecutive hallux valgus cases treated by minimally invasive distal metatarsal osteotomy, SERI (Simple Effective Rapid Inexpensive). MATERIAL AND METHODS: 1000 feet in 641 patients (359 bilateral), aged between 20 and 65 years (mean 49) affected by hallux valgus without arthritis were studied. Inclusion criteria were deformity less than 40° and intermetatarsal angle up to 18°. A 1-cm medial incision at the metatarsal neck, and a complete osteotomy were performed using an oscillating saw. With the naked eye all characteristics of the deformity were corrected by displacement of the metatarsal head (HVA, IMA, PASA, dorsal or plantar displacement). The osteotomy was stabilized by a 2-mm Kirschner wire. Immediate weight bearing was allowed with gauze bandage and talus shoes for 4 weeks. All patients were checked at an average follow-up of 37 months. RESULTS: All osteotomies healed, delayed consolidation was observed in 25 feet. Slight stiffness was observed in 31 feet. Mean AOFAS score was 48+15 pre-op and 89+13 at follow up. The pre-op HVA was 32+8, while at follow-up it was 18+8 (p< 0.005), pre-op IMA was 14+3, while at follow-up it was 6+4 (p< 0.005), the pre-op PASA was 21+9, while at follow-up was 9+8(p< 0.005). DISCUSSION AND CONCLUSION: SERI osteotomy was simple, effective, rapid and inexpensive in correcting hallux valgus deformity. Clinical and radiographical findings showed an adequate correction of the deformity

OBJECTIVE OF THE STUDY: Metatarsal osteotomies are common procedures for correction of hallux valgus. The aim of this study is to compare linear distal metatarsal osteotomy (LDMO) with SCARF osteotomy a clinical prospective randomised study. METHODS: Forty patients affected by bilateral hallux valgus similar in both sides regarding clinical and radiographic assessment were included. X-rays, AOFAS, Maryland Foot Score (MFS) were considered before surgery up to 4 years follow-up. All patients were operated bilaterally, and received SCARF osteotomy in one side, and in the other LDMO performed through a 1 cm skin incision under the direct view control. Duration of surgery was recorded. Postoperative care was similar in both groups and consisted of gauze bondage and weight bearing with talus shoes for 4 weeks. RESULTS: No statistical differences were observed in preoperative HVA, IMA, PASA in both groups. Average surgical time was 17 minutes in SCARF and 3 minutes in LDMO (p< 0.0005). No complications were observed in the series, with no wound dehiscence. All osteotomies healed. At 4 year follow up, no statistical differences were observed in HVA, IMA, PASA comparing SCARF with LDMO. Average AOFAS score was 87±12 in SCARF and 89±10 in LDMO (p=0.07), and MFS was 86±7 in SCARF and 90±3 in SERI (p=0.08). CONCLUSION: Both SCARF and LDMO techniques resulted effective in the correction of hallux valgus, however SERI, a minimally invasive technique, performed with a shorter skin incision, more rapid surgical time, fixed with a less expensive device (one kirshner wire), resulted in a better clinical outcome

This case series aim to report our experience with the use of fragment specific fixation plating system and cancellous bone autograft in the elective treatment of distal radius malunions.

Fourteen patients who underwent distal radial corrective osteotomy by one surgeon were followed up retrospectively. All patients had elected for this procedure for the treatment of malunions of previous distal radial fracture. The follow up assessments include each patient’s subjective functional outcomes, the objective strength and range of motion testing, and the radiographic parameters. These subjective functional outcome data collected as measured by the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) were compared with each patient’s pre-operative status. The motion, strength and radiographic appearances were assessed in relevance to the contralateral arm.

Background: Locking plates are used frequently in distal tibial fractures. We tested two different types of locking compression plates (LCP): the metaphyseal plate (MP) and the distal tibial plate (DTP). We evaluated the strain imposed on an experimental tibial osteotomy, and the stability of plate-tibia (composite bone) construct using LCP-MP and LCP-DTP.

Materials and methods: Twin strain gauged special composite tibial bones were used to simulate the human tibiae. We tested 5 tibiae: one was used as control, two tibiae were tested using LCP-MP, and two with LCP-DTP. Strain was measured by subjecting each construct to a cyclic load of 700 N at 3 Hz in neutral, flexion, extension and torsion to simulate the normal walking cycle.

Results: When compared with the control tibia, strain during the neutral moment at the proximal and distal strain gauge site in the LCP-MP and LCP-DTP constructs decreased by 6.4%/−41.5% and −39%/−47%, respectively. In flexion, the strain increased consistently in both the proximal and distal strain gauge sites using the LCP-MP by 34% and 109%. Using the LCP-DTP, the strain at the proximal strain gauge site decreased by 0.2% and increased by 18% at the distal strain gauge site. In extension, strain decreased by 25% at the proximal strain gauge site, and by 60% at the distal strain gauge site in the LCP –MP construct. In the LCP-DTP construct, the strain decreased by 13% at the proximal strain gauge site, and by 21% at the distal strain gauge site. There were no statistically significant torsional differences between LCP-MP and LCP-DTP group (P=0.121). In this experimental setup, the LCP-DTPs offer greater control of strain than LCP-MPs. They also confer greater resistance to fracture macro-movements, and improved stiffness consistently in neutral, flexion, and torsion than LCP-MPs.

Conclusion: The strain from osteotomised tibiae stabilised with LCP-MPs and LCP-DTPs were close to the strain of the control tibia. Both these locking plates were equally good and conferred greater stiffness in all loading positions.

The Kramer osteotomy for hallux valgus deformity was described in 1990 and has been performed by the senior author in our unit since 1999. The procedure involves a wedge excision of bone and lateral displacement of the first metatarsal head. The osteotomy is splinted by a K-wire passed medially to the phalanges and metatarsal head into the metatarsal diaphysis.

During the period October 1999 to December 2001 this procedure was performed on 26 feet in 24 patients. Case notes were reviewed retrospectively to assess the subjective outcome following the operation. Patients were invited to attend a follow up clinic to assess the outcome using the Hallux Metatarsal-Interphalangeal Scale (HMIS) of the American Orthopaedic Foot and Ankle Society and weight bearing radiographs of the foot. Twelve patients (13 feet) were seen at this follow up.

Discharge from hospital was on the day following surgery in 20/24 patients with three days maximum stay. K-wires and plaster boots were left in situ for 41 days on average (30–50 days range). From the case notes, using absence of hallux pain, deformity, hallux stiffness and footwear problems as outcome measures, 20 feet (77%) had a good outcome, five feet (19%) had a fair outcome and one foot (4%) had a poor outcome. At the follow up clinic at a mean time from operation of 134 weeks (range 56–153 weeks), the average HMIS score was 86/100 (Range 60–100) with 77% scoring 85 or more out of 100. Average postoperative intermetatarsal, hallux valgus and distal metatarsal articular angles were 6.9, 15.8 and 11 degrees respectively. Other than six cases of minor infection of skin, treated empirically with antibiotics, no other complications were seen. All patients were happy they had received this treatment.

In conclusion the Kramer osteotomy is a technically simple operation which gives good results with few complications.

Abstract. Introduction. To investigate the impact medial opening wedge high tibial osteotomy (MOWHTO) has on the progression of patellofemoral OA, patella height and contact pressure within the patellofemoral joint (PF). Methods. A systematic review was conducted in January 2022 according to PRISMA guidelines. Each study was graded as per the MINORS criteria for non-randomised trials. The ICRS cartilage grade of the PF joint at the initial MOWHTO surgery and at second look surgery was compared and relative risk of progression of PF OA was calculated. Evaluation of patella height was assessed by Caton-Deschamps index, Blackburne-Peel index or Insall-Salvati ratio pre and post MOWHTO. Cadaveric studies assessing contact pressures in the PF after MOWHTO were included. Results. Forty-two studies comparing 2,419 patients were included. The mean age was 53.1 years (16–84), 61.3% female. The risk of progression of PF OA was highest in the uniplanar and biplanar MOWHTO with proximal tubercle osteotomy groups (RR= 1.28-1.51, I2= 0%), compared to biplanar MOHWTO with distal tubercle osteotomy (RR= 0.96-1.04, I2 = 0%). Patella height was not affected after biplanar MOWHTO and distal tubercle osteotomy. (P<0.001). Cadaveric studies demonstrate that PF contact pressures increase with more severe corrections (10°) but suggest biplanar MWOHTO and distal tubercle osteotomy induces lower contact pressures within the PF joint than other OWHTO techniques. Conclusion. This novel systematic review demonstrates that biplanar MOWHTO and distal tubercle osteotomy causes lower contact pressures in the PF joint, less severe progression of PF OA and has minimal impact on patella height