Introduction

Multiple ACL revisions represent an extremely demanding surgery, due to the presence of enlarged or malpositioned tunnels, hardware, injuries to the secondary stabilizers and difficulties in retrieving autologous tendons. An anatomical ACL reconstruction is not always possible. We analyzed the results in a series of patients operated with over the top reconstruction (OTTR) and lateral extra-articular plasty to the Gerdy's tubercle (LP) using Achilles (AT) or tibialis posterior tendon (TPT) allografts.

Osteocondritis dissecans (OCD) is a relatively common cause of knee pain. Ideal treatment is still controversial. Aim of this exhibit is to describe the outcomes of 5 different surgical techniques in a series of 63 patients.

63patients (age 22.5±7.4 years) affected by OCD of the femoral condyle (45 medial and 17 lateral) were treated by either osteochondral autologous transplantation, autologous chondrocyte implantation with bone graft, biomimetic nanostructured osteochondral scaffold (Maioregen) implantation, bone-cartilage paste graft or bone marrow derived cells transplantation “one-step” technique. Patient evaluation included IKDC score, eq-vas score, X-Rays and MRI preoperatively and at follow-up.

Global mean IKDC improved from pre-operative 40.1±14.6 to 77.2±21.3 (p<0.0005) at mean 5.3±4.7 years follow-up, while eq-vas improved from 51.7±17.0 to 83.5±18.3(p<0.0005). No influence of age, size of the lesion, length of follow-up and associated surgeries on the result was found. No differences were found between the results obtained with different surgeries except a slight tendency of better improvement in the result following autologous chondrocyte implantation (p<0.01). Control MRI evidenced a satisfactory repair of cartilaginous layer and subchondral bone.

The techniques described were effective in providing good clinical and radiographic results in the treatment of OCD and confirmed the validity of autologous chondrocyte implantation over time. Newer techniques such as Maioregen implantation and “one-step” base on different rationales, the first relying on the characteristics of the scaffold and the second on the regenerative potential of mesenchymal cells. Both of them have the advantages to be minimally invasive surgeries and to require a single operation.

ACL (anterior cruciate ligament) partial tears include various types of lesions, and an high rate of these lesions evolve into complete tears. Most of the techniques described in literature for the surgical treatment of chronic partial ACL tears, don't spare the intact portion of the ligament. Aim of this study was to perform a prospective analysis of the results obtained by augmentation surgery using gracilis and semitendinosus tendons to treat partial sub-acute lesions of the ACL. This technique requires an “over the top” femoral passage, which enables salvage and strengthening of the intact bundle of ACL. The study included 97 patients treated consecutively at our Institute from 1993 to 2004 with a mean injury-surgery interval of 23 weeks (12–39). Patients were followed up by clinical and instrumental assessment criteria at 3 months, 1 year and 5 years after surgery. Clinical assessment was performed with the IKDC form. Subjective and functional parameters were assessed by the Tegner activity scale. Instrumental evaluation was done using the KT-2000 instrument: the 30 pound passive test and the manual maximum displacement test were performed. We obtained good to excellent results in 95.9% of cases. We didn't observed recurrences in ligamentous laxity. We believe that the described technique has the advantage of being little invasive, compatible with the ACL anatomy, and enables very rapid functional recovery and return to sport.

INTRODUCTION

Fresh bipolar shell osteochondral allograft (FBOA) is a controversial treatment option for post-traumatic ankle arthritis. Immunological response to transplanted cartilage may play a role in failure. Aim of the study is to compare two groups of patients who received FBOA in association or not to immunosuppressive therapy.

Introduction: Ideal treatment of osteochondral lesions of the talus (OLT) is still controversial.

Aim of this study is to review the 10 years follow-up clinical and MRI results of open field Autologous Chondrocytes Implantation in the treatment of OLT.

Methods: From December 1997 to November 1999, 10 patients, age 25.8 +/−6.4 years, affected by OLT, received open field Autologous Chondrocytes Implantation. The mean size of the lesions was 3.1 cm² (2.2 – 4.3).

All patients were evaluated clinically (AOFAS score), radiographically and by MRI pre-operatively and at established intervals up to a mean follow-up of 119+/−6.5 months. At the final follow-up MRI T2 mapping evaluation was performed. A bioptic sample was harvested in 5 cases during hardware removal 12 months after implantation.

Results: Before surgery the mean score was 37.9 +/−17.8 points, at 24 months it was 93.9 +/−8.5, while at final follow-up it was 92.7 +/−9.9 (p< 0.0005).

Bioptic samples showed cartilaginous features at various degrees of remodelling, positivity for collagen type II and for proteoglycans expression. No degenerative changes of the joint at follow-up were found radiographically.

MRI showed well-modelled restoration of the articular surface. The regenerated cartilage showed a mean T2 mapping value of 46 msec with no significant difference compared to that of normal hyaline cartilage.

Conclusions: The clinical and histological results have confirmed the validity of the technique utilized with a durability of the results over time. T2 mapping was adequate in detecting the quality of the regenerated tissue coherently with the bioptic results.

Introduction: Qualitative evaluation of postoperative outcome in cartilage repair techniques is an issue due to morbidity of bioptic second look. T2 mapping is becoming increasingly popular in the knee, providing information about the histological and biochemical contents of healthy or reparative tissue. Nevertheless, little is known about its applicability to the ankle due to thinner cartilage layer.

Aim of this study was to investigate the validity of T2 mapping in ankle cartilage characterization.

Materials and Methods: 20 healthy volunteers and 30 patients affected by osteochondral lesions of the talus and previously treated by different cartilage repair techniques, were evaluated by T2 mapping. Reparative procedures included microfractures, Autologous Chondrocyte Implantation (open or arthroscopic) and Bone Marrow Derived Cell’s Transplantation. DPFSE with or without fat suppression, T2FSE with or without fat suppression, 3D SPGR and T2-Mapping using a dedicated phased array coil and 1.5 T MR scanner were used as MRI acquisition protocol.

MRI results were correlated with clinical score (AOFAS) in the cases who received a cartilage reconstruction treatment.

Results: A statistically significant correlation (p< 0.05) was shown between MRI and clinical results. A reduced mean T2 value, suggestive for fibrocartilage features, was shown at repair sites in microfractures, whereas no significative differences with healthy hyaline cartilage mean T2 value, were found in other repair techniques with good to excellent clinical score.

Conclusions: T2 mapping demonstrated to be adequate in characterizing cartilage tissue in the ankle. Further studies are required to implement a tool which may over time be a valuable non-invasive alternative to bioptic evaluation.

Introduction: In situ subtalar arthrodesis cannot restore anatomical shape of the hindfoot in severe flat foot deformities. Purpose of this paper is to evaluate the result of 250 feet consecutively operated by subtalar arthrodesis with distraction and insertion of a mini structural bone block (SAMBB).

Material and Methods: 178 patients (250 feet), mean age 55+/−11 years affected by acquired adult flat foot with subtalar arthritis were evaluated clinically and radiographically and selected to receive SAMBB.

Arthrodesis was performed through a 2.5 cm incision, with partial cartilage removal and insertion of a structural corticocancellous block (2 × 1cm), harvested from the proximal ipsilateral tibia, vertically positioned into the sinus tarsi. Associate procedures were Achilles tendon lengthening (124), SERI procedure (61), hind-foot deformity correction (32). Postoperatively plaster-cast without weight-bearing for 4 weeks followed by walking boot was advised. All patients were reviewed at a minimum follow-up of 5 years.

Results: Before surgery the mean AOFAS score was 42+/−15, while it was 90+/−8 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+/−8° preoperatively and 6°+/−5° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 160°+/−11° preoperatively and 174°+/−8 at follow-up. No complications were found. No or minimal arthritis progression was observed in the ipsilateral foot joints at follow up.

Conclusions: SAMBB resulted in an adequate correction of the deformity, with restoration of the anatomical shape of the hind foot and correction of the relationship with the midtarsal joint with no need of hardware. Consequent reduced arthritis progression and excellent clinical result were obtained.

Anterior bony impingement of the ankle is a common cause of chronic ankle pain, and it represents an important indication to arthroscopic treatment.

The purpose of the study was to analyze the factors affecting the clinical outcome of surgical treatment and to describe a new classification based upon the arthroscopic assessment, considering prognostic factors and rationale for treatment.

84 consecutive patients with a mean age of 32.6 years were treated between 2000 and 2005. The impinging lesions were divided into localized (antero-medial, antero-lateral and syndesmotic) or diffuse. The status of the chondral layer (A – Normal; B – Focal ICRS grade I–II; C - Focal ICRS grade III–IV; D – Diffuse ICRS grade I–II; E – Diffuse ICRS grade III–IV) was documented, as well as the presence of altered foot morphology (cavus or flat) or ligament lesions. Previous traumas or surgery were considered. Patients were evaluated after a 24–87 months follow-up, following the AOFAS scale.

The pre-operative AOFAS score was 39.4, while at follow-up it scored 80.1(p< 0.05). Patients with diffuse anterior impingement obtained the best result in terms of improvement. Patients with normal cartilage had a better outcome but among cartilage lesions the better improvement was obtained in patients with diffuse severe cartilage damage. Associated regenerative treatment for focal chondral grade III–IV lesions provided the better results. Patients with associated surgically repaired ligament lesions had the better clinical outcome with respect to intact ligaments.

On the basis of the results we purpose a new classification, based upon the prognostic factors, into 2 types: I – Localized; II - Diffuse. Further classification was made into subtypes A to E according to the associated chondral lesions. Finally the presence of associated conditions such as ligament lesions, previous sprains or surgery was considered, being relevant as prognostic factors.

The aim of this study is to present guidelines for treatment of acquired adult flat foot (AAFF) and review the results of a series of patients consecutively treated. 180 patients (215 feet), mean age 54? 12 years affected by AAFF were evaluated clinically, radiographically and by MRI to chose the adequate surgical strategy. Tibialis posterior dysfunctions grade 1 were treated by tenolysis and tendon repair (48 cases), grade 2 by removal of degenerated tissue and tendon augmentation (41 cases), grade 3 by flexor digitorum longus tendon transfer (23 cases); in these cases subtalar pronation without arthritis was corrected by addictional procedures consisting of either calcaneal osteotomy (66 cases), subtalar athroereisis (25 cases) or Evans procedure (21 cases) in case of severe midfoot abduction. Subtalar arthrodesis (82 cases) or triple arthrodesis (21 cases) were performed in case of subtalar arthritis isolated or associated with midtarsal arthritis respectively. Postoperatively plastercast without weight-bearing for 4 weeks followed by walking boot for 4 weeks was advised. All patients were followed up to 5 years. Before surgery the mean AOFAS score was 48+\−11, while it was 89+\−10 at follow-up (p< 0.005). Mean heel valgus deviation at rest was 15°+\−5° preoperatively and 8°+\−4° at follow-up (p< 0.005). Mean angulation of Meary’s line at talonavicular joint level was 165°+\−12° preoperatively and 175°+\6 at follow-up. Surgical strategy in AAFF should include adequate treatment of tibialis posterior disfunction and osteotomies for correction of the skeletal deformities if joints are arthritis free; arthrodesis should be considered in case of severe joint degeneration

Objective: Different

Methods: have been proposed to date to achieve the regeneration of hyaline cartilage in osteochondral lesions of the talus (OLT). The aim of this study was to present a new one-step arthroscopic procedure with the use of mesenchimal stem cells (MSC) supported on a collagen scaffold and Platelet Rich Fibrin (PRF).

Methods: 14 patients with a diagnosis of OLT underwent this procedure. The MSC were harvested from the posterior iliac crest and concentrated directly in the operating room. An ankle arthroscopy was performed with lesion detection and curettage. The cell concentrate was mixed with a collagen paste as scaffold and with PRF as a pool of growth factors in order to have a final composite to fill the lesion site. Partial weight bearing for 2 months and early ROM was advised postoperatively.

Results: According to the American Orthopaedic Foot and Ankle Score (AOFAS) system the patients had a preoperative score of 65.1 (range 35–79), a postoperative of 69.4 (range 61–97) at 6 months and of 83.6 (range 65–100) at 12 months follow up. MRI control at 6 and 12 months showed a progression of the reparative process in the osteochondral lesions. Histological and immuno-hystochemical analysis on a sample biopsed during a control arthroscopy at 12 months confirmed the hyaline quality of the regenerated cartilage.

Conclusions: This one-step technique demonstrated to be capable to regenerate hyaline cartilage, with the advantages of a reduced surgical time, lower costs and lower patient’s morbidity.

INTRODUCTION: Post-traumatic arthritis of the ankle in the young active patient represents a reconstructive challenge. Fresh total shell osteochondral allografts are an increasingly popular option in the reconstruction of various amounts of cartilage defects, although concerns for bipolar allografting are reported. The purpose of this study is to describe the preliminary results of a series of 18 bipolar shell ankle allografts performed by using a specifically designed instrumentation.

METHODS: 18 patients, 13 males and 5 females (mean age 31±10 years) affected by post traumatic arthritis of the unilateral ankle joint grade III received bipolar shell allograft of the ankle. The mean follow-up was 12 months (range 24–8). The ideal patient to allograft match was permitted through CT scan and x-rays. Two steps surgery, one for allograft preparing and one for the recipient site, were performed by using specifically designed jigs. Patients evaluation was carried out clinically by AOFAS and radiographically by X-Rays, CT scans, MRI.

RESULTS: No intraoperative, complications occurred. All the patients demonstrated good consolidation rates of the allograft at X-Rays, CT scan and MRI controls performed at 4, 6, 8, and 12 months. At 8 months follow-up, all the patients were allowed complete weight bearing. Normal ROM of the ankle and regular gait with no pain and no need of support was resumed in 13 patients. In 2 patients a fracture of the fibula was reported. In one case, cause of the fracture was patient non compliance to the weight-bearing restriction. In the other case the fracture occurred distal to the osteotomy site, possibly due to a trauma. Both the cases required revision of the graft which appeared damaged in the lateral site. In the first case an ankle arthrodesis was performed. A bioptic harvest of the transplanted cartilage in 5 patients at 1 year follow up demonstrated chondrocytes vitality > 90%.

DISCUSSION: Accurate preoperative planning, sizing, and the use of specifically designed jigs makes viable and reproducible the bipolar shell allograft in the ankle joint in selected cases. Although preliminary results are encouraging, longer follow-up is required in order to confirm longer term cartilage viability and the validity of the technique.

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.

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.

INTRODUCTION: Displaced comminuted intra-articular calcaneal fractures (DCCF) need anatomic reduction to avoid painful subtalar joint, deformities, tendon or nerve impingment. Open reduction and internal fixation has been extensively reported, but all series reported considerable rate of skin complications, infections and need of additional plastic procedure. The aim of this study is to review a series of DCCF operated by minimally invasive technique.

MATERIAL AND METHODS: 66 DCCF type Sanders II-III were selected in 63 patients aged 18–57 years. X-ray and CT scan were performed. Surgery consisted of percutaneous traction-reduction of the calcaneal body by bone forceps and fixation by K-wires under image intensifier. Then, a lateral 3 cm skin incision was performed to reduce subtalar joint and to fix it by 1 or 2 screws. In case of involvement of the calcano-cuboid joint, the incision was distally extended and a 4-hole plate was applied. K-wires were removed 5 weeks after surgery and weight bearing was permitted 12–16 weeks after surgery. Patients were evaluated clinically by AOFAS score and radiographically at 4 years follow-up (3–7).

RESULTS: No skin complications or infections were encountered in the series. All fractures healed. Mean postoperative Bohler angle was 29±5°. AOFAS score was 89±11. 31 cases were excellent, 22 good, 9 fair and 4 poor. 25 cases presented radiographic signs of subtalar joint arthritis, painful only in 4.

DISCUSSION AND CONCLUSION: Minimally invasive surgical treatment resulted adequate for treating DCCF, in fact if soft tissues are preserved by surgical trauma, dangerous complications like infections and skin problems can be avoided.

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.

Introduction Osteochondral lesions of the talus are a common occurrence especially in sports injuries. The biomechanical nature of the ankle joint makes it susceptible to sprains which can cause damage not only to the capsulo-ligamentous structures, but also to the joint cartilage and subchondral bone. As it is known, joint cartilage is a highly specialized and multitask tissue. Because joint cartilage has poor reparative capability, damage may be irreversible and as a consequence, can also lead to osteoarthritis. The purpose of this study is to review the results of a series of patients treated with autologous chondrocytes implantation (A.C.I.) and to describe the evolution in surgical technique that we have been implemented in the last 8 years.

Methods Thirty-nine patients with a mean age of 27 8 years affected by osteochondral lesions of the talus > 1.5 cm2, were treated by autologous chondrocyte implantation. All patients were checked clinically and by MRI up to 4 years follow-up. The first 9 patients received the ACI by open technique and the remaining 30, arthroscopically. In the last 10 patients the cartilage harvested from the detached osteochondral fragment was used for the colture. All patients were checked clinically (AOFAS score), radiographically and by MRI, before surgery, at 12 months and at follow-up. Eleven patients underwent a second arthroscopy with a bioptic cartilage harvest at 1 year follow-up. Samples were stained with Safranin-O and Alcian Blue. Immunohistochemical analysis for collagen type II was also performed

Results Before surgery the mean score was 48.4 17 points, at 12 months 90.9 12 (p< 0.0005), while at follow up was 93.8 8 (p< 0.0005) demonstrating an improvement over time. The histological and immunohistological analyses performed on the cartilage samples using Safranin-O, Alcian Blue staining and anti-human collagen type II antibody respectively showed a typical cartilage morphology, were positive for collagen type II and for proteoglycans expression.

Conclusions The clinical and histological results have confirmed the validity of the technique utilized, with laboratory data confirming the newly formed cartilage was of hyaline type for all the cases evaluated.

The purpose of this study is to demonstrate the validity of the autologous chondrocytes transplantation (A.C.T.) technique implemented over the last 6 years in the treatment of osteochondral lesions of the talus.

Our case study included 22 patients (12 males and 10 females), with an average age of 27 years affected by osteochondral lesions of the talus surface. All lesions were > 1.5 cm2, monofocal, and post-traumatic in origin. The first 9 patients received ACT (Genzyme technique) and the remaining 13 patients received ACT with an arthroscopic technique. In 6 of the patients, the cartilage harvested from the detached osteochondral fragment was used for culturing, avoiding the first step arthroscopy in the knee. Before surgery, all patients were assessed clinically, radiographically, and using MRIs. For clinical evaluation patients were assessed using the American Foot & Ankle Society 100 point score. Before surgery the mean score was 48.4 points. 11 patients underwent second-look arthroscopy at one year during which a biopsy was harvested for histologic analysis of the reconstructed cartilage. Of these, 9 patients (Genzyme technique) also had hardware removed.

The mean follow-up of the 22 patients was 36 months. At follow-up, all patients but one were satisfied with their results. With regards to the clinical results evaluated using the American Foot and Ankle Society score, an average of 90.5 was obtained at 24 months, while at 36 months the average score (19 patients) was 94.0 (range 54–100). During follow-up arthroscopy, 4 patients had mild fibrosis and 1 patient required regularization of flap overgrowth causing pain.

The clinical and histological results have confirmed the validity of the surgical technique utilized with no subjective nor objective complications. An improvement of the symptoms and of articular function has also been observed: laboratory data confirmed the histological appearance of the newly formed hyaline cartilage in all cases evaluated. Immunohistochemistry showed a positive staining for collagen type II located in the extracellular matrix and in the chondrocytes in the healthy and transplanted cartilage biopsies. All the specimens studied were also positive for proteoglycans expression as was the Alcian blue reaction, which highlighted the presence of these fundamental components of a cartilaginous matrix.

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.