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 2nd metatarsal and 3 feet (25%) involved the 3rd 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.
Subjective and objective review of our early experience with scarf osteotomy for correction of Hallux valgus
Scarf joint is a technique used by carpenters to increase the size of entrance by longitudinally joining beams of timbers. Scarf osteotomy of the first metatarsal is a ‘Z’-osteotomy with inherent stability. The convalescence is short and complications of avascular necrosis and non-union are rarely reported. The combination of soft tissue procedure with the osteotomy consistently gives good correction of hallux valgus.
The records, radiographs were reviewed and the subjective assessment by telephone interview. Forty-one patients had a scarf procedure but only 31 patients (37 scarf procedures) could be contacted by telephone. All patients were females with a mean age of 44.6(16–76) years. Mean follow-up was 14 months(12 to 18 months). The results were reviewed using the guideline recommended by the Research Committee of American Orthopaedic Foot and Ankle Society. Mean preoperative hallux valgus angle (HVA) was 30.4°(20–48°) and the postoperative HVA was 14.6°(9–22°). The mean pre-operative intermetatarsal angle (IMA) was 4.1°(10–22°) and postoperatively was 8.4°(5–12°). There was significant correction of the tibia sesamoid position (p=0.001). There was no avascular necrosis or non-union. Eighty-eight percent of patients were satisfied; two patients had infection and two stiff MTP joints.
Scarf osteotomy gives very good correction of hallux valgus and tibia sesamoid position. Patient satisfaction was good with a low complication rate, the fixation after the osteotomy was very stable and no post-operative splint was required.
Pedicle screws allow for biomechanically secure fixation of the spine. However if they are misplaced they may effect the strength of the fixation, damage nerve roots or compromise the spinal cord. For these reasons image guidance systems have been developed to help with the accuracy of screw placement. The accuracy of pedicle screw placement outside the lumbar spine is not well published. To determine the accuracy of pedicle screw placement using CT scanning post operatively. Cortex perforations were graded in 2mm steps. Prospective observational study. Plain x-rays are inaccurate for determining screw placement and therefore high definition CT scanning was used. The screw positioning on the post-operative CT scans was independently determined by a research registrar who was not present at the time of surgery. Screw position and clinical sequelae of any malposition. Thirty patients (13 F:17 M) with segmental instability. Twelve were for metastatic disease, seven for trauma, seven for spondylolisthesis, three for atlanto-axial instability and one for a vertebral haemangioma. All patients were operated on by the senior author. One hundred and seventy six pedicle screws were inserted in the thirty patients over the 20 month study period. Six screws violated the lateral cortex of the pedicle but none perforated the medial cortex. There were no adverse neurological sequelae. The findings from this study will serve as a good comparison with future studies on pedicle screw placement, which may claim to improve accuracy and safety by the use of image guidance systems, electrical impedance or malleable endoscopes.
