Aim. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers. Methods. Consecutive patients, who presented with forefoot ulcers since February 2019 were treated with a 2-stage treatment pathway. The first stage of this is an out-patient tendo-Achilles lengthening (TAL). The second stage is surgical proximal dorsal closing wedge metatarsal osteotomy for patients with persistent or recurrent ulcers. Patients were followed for a minimum of 12 months. Results. 112 patients (146 feet) underwent TAL by 3 consultants. Of these, 96 patients were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 patients (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with 1. st. metatarsal and 5. th. metatarsal head ulcers respectively. In 12 patients (10%), the ulcer failed to heal or recurred. MRI scan in these patients showed plantar flexed metatarsals from progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy of the metatarsal/s, with no recurrence at a minimum 12months of follow-up. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after the first stage out-patient percutaneous TAL

The June 2024 Foot & Ankle Roundup. 360. looks at: First MTPJ fusion in young versus old patients; Minimally invasive calcaneum Zadek osteotomy and the effect of sequential burr passes; Comparison between Achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional Achilles tendinopathy; Revision ankle arthroplasty – is it worthwhile?; Tibiotalocalcaneal arthrodesis or below-knee amputation – salvage or sacrifice?; Fusion or replacement for hallux rigidus?

Introduction. The current treatment for Freiberg's osteochondrosis centres around either: simple debridement or debridement osteotomy. The main principle of the osteotomy is to rotate normal articular cartilage into the affected area. We recommend the use of CT scanning to delineate the amount of available, unaffected cartilage available to rotate into the affected space. Methods. We retrospectively reviewed 32 CT scans of new Freiberg's diagnoses in Sheffield over a 10 year period using the PACS system. We identified the sagittal CT slice that displayed the widest portion of proximal articular margin of the proximal phalanx and measured the diseased segment of the corresponding metatarsal head as an arc (in degrees). This arc segment was divided by 360°. This gave a ratio of the affected arc in the sagittal plane. Results. 28 out of 32 cases involved the 2nd metatarsal with the remaining 4 involving the 3rd metatarsal head. Of 32 cases, 18 had fragmentation. Surgically, 20 had debridement only, 5 also had an osteotomy and 1 had a fusion. 6 of the 32 cases were managed non-operatively. 11 cases out of 32 had an arc ratio of < 0.3. Of these, only 3 had an osteotomy, 3 had no procedure and 5 had a simple debridement. Of those that had osteotomies (5/32), 3 of the 5 cases had an arc ratio of < 0.3 with the other 2 being 0.42 and 0.38. Discussion. We hypothesise that those cases with an arc ratio of less 0.3 would be amenable to a dorsal closing wedge osteotomy and those with a ratio of more than 0.4 would be better suited to a simple debridement. For those cases between 0.3–0.4, we feel either option is viable. Further work to prove or disprove outcomes related to our classification is required

Aim. To describe a 2-stage treatment pathway for managing neuropathic forefoot ulcers and the safety and efficacy of percutaneous tendo-Achilles lengthening (TAL) in out-patient clinics. Methods. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressure. Plantar flexed metatarsal heads secondary to progressive claw toe deformity and hindfoot equinus from changes within the gastrocnemius-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus, secondary to motor neuropathy results in progressive increase in forefoot plantar pressures. Consecutive patients, who presented to our Diabetic Foot clinic since February 2019 with forefoot ulcers or recurrent forefoot callosity were treated with TAL in the first instance, and in patients with recurrent or non-healing ulcers, by proximal dorsal closing wedge osteotomy; a 2-stage treatment pathway. Patients were followed up at 3, 6, and 12 months to assess ulcer healing and recurrence. Results. One hundred and twelve patients (146 feet) underwent TAL by 3 consultants in the out-patient clinics. Of these, 96 feet were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 feet (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. In 12 feet (10%), the ulcer failed to heal or recurred, the MRI scan in these patients showed plantar flexed metatarsals secondary to progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy. In patients with osteomyelitis, the intramedullary canal was curetted and filled with local antibiotic eluting agents such as Cerament G. ®. The osteotomy site was stabilised with a percutaneous 1.6mm k-wire. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after out-patient percutaneous TAL alone. TAL is a safe and effective initial out-patient procedure with improved patient outcomes

The December 2022 Foot & Ankle Roundup³⁶⁰ looks at: Evans calcaneal osteotomy and multiplanar correction in flat foot deformity; Inflammatory biomarkers in tibialis posterior tendon dysfunction; Takedown of ankle fusions and conversion to total ankle arthroplasty; Surgical incision closure with three different materials; Absorbable sutures are not inferior to nonabsorbable sutures for tendo Achilles repair; Zadek’s osteotomy is a reliable technique for treating Haglund’s syndrome; How to best assess patient limitations after acute Achilles tendon injury; Advances in the management of infected nonunion of the foot and ankle.

Abstract. The aim is to describe the safety and efficacy of TAL in out-patient clinics when managing diabetic forefoot ulcers. Patients and Methods. Consecutive patients, who underwent TAL and had minimum 12m follow-up were analysed. Forceful dorsiflexion of ankle was avoided and patients were encouraged to walk in Total contact cast for 6-weeks and further 4-weeks in walking boot. Results. 142 feet in 126 patients underwent this procedure and 86 feet had minimum follow-up of 12m. None had wound related problems. Complete transection of the tendon was noted in 3 patients and one-patient developed callosity under the heel. Ulcers healed in 82 feet (96%) within 10 weeks however in 12 feet (10%), the ulcer recurred or failed to heal. MRI showed plantar flexed metatarsals with joint subluxation. The ulcer in this subgroup healed following proximal dorsal closing wedge osteotomy. Conclusion. Tightness of gastroc-soleus-Achilles complex and subluxed MTP joint from soft tissue changes due to motor neuropathy result in increased forefoot plantar pressures. A 2-stage approach as described result in long-term healing of forefoot ulcers, and in 96% of patients, the ulcer healed following TAL alone. TAL is a safe and effective out-patient procedure with improved patient satisfaction outcomes

Aims

There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure.

Treatment for Freiberg's disease is largely conservative. For severe disease and refractory cases, there are various surgical options. Most studies are from the Far-Eastern population and have short follow-up. The purpose of this study was to report the 5 year clinical outcomes of a dorsal closing wedge osteotomy in the treatment of advanced Freiberg´s disease in a Caucasian population. Twelve patients (12 feet), with a mean age of 30.7 years (range 17–55), were treated with a synovectomy and a dorsal closing wedge osteotomy of the affected distal metatarsal. There were 10 females and 2 males. All patients were born in the United Kingdom. Clinical outcomes were independently evaluated pre and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and a subjective satisfaction score. Nine (75%) feet involved the 2. nd. metatarsal and 3 feet (25%) involved the 3. rd. metatarsal. According to the Smillie classification, 6 feet were Grade IV and 6 feet were grade V. Radiological union was evaluated postoperatively. No patients were lost to follow up and the mean follow-up time was 5.2 years (4–7). AOFAS scores improved from 48.1 +/− 7.4 to 88.9 +/− 10.1 postoperatively (p< 0.001) giving a mean improvement of 40.8. 92% of patients were satisfied with their operation at latest follow-up, reporting excellent or good results. All patients had postoperative radiological union. One patient had a superficial postoperative infection that was successfully treated with oral antibiotics. A dorsal closing wedge osteotomy is an effective treatment of advanced Freiberg´s disease in a Caucasian population, with good outcomes and few complications

Introduction:. The dorsal closing wedge calcaneal osteotomy has been described for the treatment of insertional pathology of the tendo-achilles. The aim of this study was to evaluate the efficacy of the technique using outcome measures. Method:. This was a prospective case series. Patients were included if they had tendo-achilles insertional pathology (calcific tendonitis, bursitis or Haglund's deformity). A short extended lateral approach was used and a 1 cm dorsally based closing wedge osteotomy of the calcaneus performed. Fixation was with 2 staples. Patients were scored pre-operatively and at 6 and 12 months post-operatively using the VISA-A and AOFAS ankle-hindfoot scores. Results were analysed with the paired student t-test. Results:. Twenty five feet in 23 patients were enrolled in the study February 2011 – May 2013. 22 patients underwent the osteotomy (9 males and 14 females). Average age was 47.2 years (range 19–62 years). 12 feet have been followed up for 1 year, 6 for 6 months, 5 less than 6 months. Average VISA-A improvement was 27.87 points (−13–71) at 6 months p=0.001 and 38 (−13–81) at 12 months p=0.001. Average AOFAS improvement was 11 points (−8–31) at 6 months p=0.005 and 11 (−18–42) at 12 months p=0.04. 82.3% of patients would have the procedure again. Complications included minor wound problems (3), sural nerve symptoms (1) and plantar fasciitis (3). All complications have resolved. Conclusion:. The results of this study show that the use of the Zadek osteotomy of the calcaneus can provide consistent symptomatic relief from insertional Achilles pathology by altering the biomechanics of the tendon without disrupting the bursa. There is a small risk of minor complications, which should be included in the consent process

The purpose of this study was to compare the results of proximal and distal chevron osteotomy in patients with moderate hallux valgus.

We retrospectively reviewed 34 proximal chevron osteotomies without lateral release (PCO group) and 33 distal chevron osteotomies (DCO group) performed sequentially by a single surgeon. There were no differences between the groups with regard to age, length of follow-up, demographic or radiological parameters. The clinical results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and the radiological results were compared between the groups.

At a mean follow-up of 14.6 months (14 to 32) there were no significant differences in the mean AOFAS scores between the DCO and PCO groups (93.9 (82 to 100) and 91.8 (77 to 100), respectively; p = 0.176). The mean hallux valgus angle, intermetatarsal angle and sesamoid position were the same in both groups. The metatarsal declination angle decreased significantly in the PCO group (p = 0.005) and the mean shortening of the first metatarsal was significantly greater in the DCO group (p < 0.001).

We conclude that the clinical and radiological outcome after a DCO is comparable with that after a PCO; longer follow-up would be needed to assess the risk of avascular necrosis.

Cite this article: Bone Joint J 2013;95-B:649–56.

Introduction. Freiberg's infarction poses a challenge to foot and ankle surgeons. Several surgical and non surgical treatment methods are described. We performed a dorsal closing wedge osteotomy, debridement and microfracture of the metatarsal head. Dorsal closing wedge osteotomy helps in bringing the smooth plantar articular surface of the metatarsal head to articulate with the phalangeal articular cartilage whilst offloading the damaged dorsal articular cartilage. Debridement and Microfracture of the metatarsal head helps in regeneration of the damaged cartilaage via subchondral stem cells. Materials and Methods. Total of 15 patients (12F, 3M) underwent the above surgery between year 2002 and 2008. Mean age was 35yrs (range14-60). All of them had an extraarticular dorsal closing wedge osteotomy fixed with a single screw along with debridement of the joint and mocrofracture of the damaged cartilage. Post operatively heel weight bearing was allowed with a special shoe for 6 weeks. Serial radiological assessments were done to assess healing of the osteotomy and reshaping of metatarsal head. Patients had a mean follow up of 2.5 yrs (Range 1-6). All patients were assessed using subjective patient satisfaction scores (scale 0-10) and AOFAS scores. Results. 2nd metatarsal was involved in 14 and 3rd in one patient. All the osteotomies healed at a mean period of 10 weeks (range6-18). The mean patient satisfaction score was 8 (range5-10). The mean pre and post operative AOFAS scores were 54 and 82. One patient developed post operative haematoma which resolved spontaneously. No other complications noted. Conclusions. A combination of dorsal closing wedge osteotomy, debridement and microfracture is a simple, reproducible and effective method of treating Freiberg's disease with no major complications

Introduction: Freiberg’s infarction poses a challenge to foot and surgeons. Several surgical and non surgical treatment Methods: are described. We performed a dorsal closing wedge osteotomy, debridement and microfracture of the metatarsal head. Dorsal closing wedge osteotomy helps bringing the smooth plantar articular surface of the metatarsal head to articulate with the phalangeal articular cartilage whilst offloading the damaged dorsal articular cartilage. Debridement and Microfracture of the metatarsal head helps in regeneration of the damaged cartilaage. Materials and Methods: Total of 15 patients (12F, 3M) underwent the above surgery between year 2002 and 2008. Mean age was 35yrs (range14–60). All of them had an extraarticular dorsal closing wedge osteotomy fixed with a single screw along with debridement of the joint and mocrofracture of the damaged cartilage. Post operatively heel weight bearing was allowed with a special shoe for 6 weeks. Serial radiological assessments were done to assess healing of the osteotomy and reshaping of metatarsal head. Patients had a mean follow up of 2.5 yrs (Range 1–6). All patients were assessed using subjective patient satisfaction scores (scale 0–10) and AOFAS scores. Results: 2nd metatarsal was involved in 14 and 3rd in one patient. All the osteotomies healed at a mean period of 10 weeks (range 6–18). The mean patient satisfaction score was 8 (range 5–10). The mean pre and post operative AOFAS scores were 54 and 82. One patient developed post operative haematoma which resolved spontaneously. No other complications noted. Conclusions: A combination of dorsal closing wedge osteotomy, debridement and microfracture is an effective method of treating Freiberg’s disease