Müller Weiss disease (MWD) is characterized by lateral navicular necrosis which is associated with a varus alignment of the subtalar joint, varying degrees of arthritis of the talonavicular-cuneiform joints and a paradoxical flatfoot deformity in advanced cases. Although arthrodesis of the hindfoot is commonly used, we present the results of a previously unreported method of treatment using a calcaneus osteotomy incorporating a wedge and lateral translation. Fourteen patients with MWD who were treated with a calcaneus osteotomy were retrospectively reviewed. There were seven females and seven males with an average age of 56 years (range 33–79), and included one grade 5, five grade 4, four grade 3 and four grade 2 patients. Patients had been symptomatic for an average of eleven years (range 1–14), and all underwent initial conservative treatment with an orthotic support that posted the heel into valgus. The primary indication for surgery was a limited but positive response to the use of the orthotic support, and a desire to avoid an arthrodesis of the hindfoot. Patients were followed for an average of three years following the procedure (range 1 – 7 years). Patients rated their pain on a visual analogue pain scale as an average of 8 (range 6–9) prior to surgery and an average of 2 postoperatively (range 0–4). The AOFAS scores improved from a mean of 29 (range 25 – 35) preoperatively to a mean of 79 (range 75–88) postoperatively. Hindfoot range of motion remained and the extent of arthritis of the navicular complex was unchanged. No patient has since required an arthrodesis. Since the majority of MWD patients respond to an orthotic support which changes the load of the hindfoot and forefoot, we believed that patients would respond positively to a calcaneal osteotomy as an alternative treatment.Results
In order to regain preinjury activities following an Achilles tendon rupture while reducing the potential complications of open surgery and non-operative treatment, we developed a new protocol that involved the use of a modified local anaesthetic technique, percutaneous repair and early function. We prospectively treated 32 patients with acute Achilles tendon ruptures according to our protocol with a 12 month minimal follow-up. Surgery was performed on an outpatient basis and within 48 hours from rupture for all cases. Our local anaesthetic technique allowed us to have a comprehensive control over sural nerve location by the definition of a “safe area” (video will be shown) and has proved to be effective to avoid sural nerve damage during surgery. The 28 male and 4 female patients had a mean age of 35 years (range, 26 to 47 years). The percutaneous repair was performed with a #2 nonabsorbable monofilament. Patients began range-of-motion exercise at 48 hours, used a posterior splint for 2 weeks, and then began ambulation with crutches and a 2 cm heel wedge incorporated on sport shoes or alternatively country boots. At 5 weeks, the wedge shoe was discontinued, full weight-bearing was allowed, and progressive resistive exercises were initiated. There were no reruptures, wound infections, sural nerve damage, recurrent pain, or skin necrosis in our group of patients. One patient (with an hemathological disorder) developed a deep venous thrombosis that resolved uneventfully. Mean AOFAS score was 80 at 6 months and reached 98 at 12 months. High-demand patients (police officer, firemen, athletes, professional soccer player) returned to their activities by 5–6 months. Patients were very satisfied with the procedure and subjetive evaluation turned to be very good or excellent for all cases. Achilles tendon management using our protocol is an efficacious method demonstrating a low morbidity rate together with a return to preinjury level by 6 months. In addition, this protocol is cost effective (saves on hospital admission, anaesthesia, complications) and athletes in our group were able to obtain their athletics goals with minimal or no deficits.
