Abstract. INTRODUCTION. Fracture neck of femur is aptly called as “the fracture of necessity” owing to the various factors responsible for its non-union. Pauwel's inter-trochantric valgus osteotomy is a useful approach to deal with such fractures. AIM. The aim of this study is to evaluate the functional outcome of valgus osteotomy in treatment of neglected and non-union fracture neck of femur using Harris Hip Scoring system (HHS). MATERIAL AND METHODS. This observational study included 25 patients of the age between 25 years and 50 years with more than 3 weeks since injury and the patients with failed primary fixation. Valgus osteotomy using120° double angled blade plate was done. The patients were followed up till one year. The patients' functional outcome was evaluated with pre-operative and post-operative Harris Hip Score (HHS) at 6 months and one year. RESULTS. Outcome was excellent in 14 patients (HHS>90), good in 8 patients (HHS between 80–90) and fair in one patient (HHS=75.6). Two patients ended up in non-union with blade cut out. The mean HHS at the end of one year was 89.18 + 7.822. The mean change in HHS values pre-operatively and one year post-operatively came out to be 69.58 + 20.032. CONCLUSION. We conclude that for the patients under 50 years of age with neglected fracture of the femoral neck, the Pauwel's osteotomy produces many good results

Hallux Valgus (HV) surgery is the most common surgery performed in the foot. The Cochrane review done in 2004 showed that no osteotomy is superior to another, however, surgery was shown to be superior to conservative or no treatment for Hallux Valgus deformity. We performed a postal survey in August 2005, to determine the most common procedures performed for HV deformity, type of anaesthesia used, and the length of stay for Hallux Valgus surgery across the United Kingdom. A list of foot and ankle surgeons was obtained from the BOFAS register and a questionnaire was sent. We received 122 (61%) responses from 200 questionnaires sent. Out of which 4 had retired and 118 were available for analysis. The table below demonstrates the common procedures performed by those who replied. Eight-eight percent of the surgeons used foot block along with GA, 9% used GA only and 3% performed the surgery under regional anaesthesia only. Forty percent of surgeons performed the surgery on an overnight stay basis and 30% performed the surgery as a day case. Twenty-five percent of surgeons mentioned that they performed unilateral surgery as a day case and bilateral surgery on an overnight stay basis. Less than 5% kept the patients for more than 2 days. From the responses, most surgeons in the United Kingdom perform Scarf osteotomy with or without Akin osteotomy for Hallux Valgus correction. The majority performed it on an overnight stay basis or as a day case. Most commonly, foot block along with NSAID’s were used for post-operative pain relief

Aim: We report radiological outcome following percutaneous minimally invasive corrention of Hallux Valgus using K-wire fixation. Methods: We followed 15 patients (11 bilateral operations) who had above procedure for Hallux Valgus deformity correction. All patients had pre operative and post operative x-rays assessed for Hallux Valgus angle, 1st Intermetatarsal angle and Distal Metatarsal Articular angle. We also collected clinical data including deformity correction and complications. Results: Mean age of the patients was 55.47(SD 14.27). Of the 15 procedures 11 had bilateral operations and 4 had only one side operated (total 14 right sided 12 left sided operations). Mean duration of follow up was 85.47 days (range 29 to 259). The pre operative mean Hallux Valgus angle was 37.05(SD 6.49, range 28 to 49) where as post operative it was 11.32(SD 9.07, range 0 to 33). The pre operative mean 1st Intermetatarsal angle was 16.46(SD 2.74, range 11 to 21) where as post operative it was 5.48(SD 3.62, range 1 to 16). The pre operative mean Distal metatarsal articular angle was 35.36(SD 8.38, range 18 to 51) where as post operative it was 8.29(SD 9.13, range 0 to 38). Clinically one great toe had infection post operatively requiring early removal of K-wires resulting in residual deformity. One had mild bilateral recurrence, two had mild unilateral recurrence. These patients did not require any further surgery. Conclusion: Above results indicate that Percutaneous Minimally invasive Hallux Valgus correction using K-wire fixation showed good radiological correction in various angles measured to quantify Hallux Valgus deformity

The aim of the study was to assess the clinical, radiological and paedobarographic outcome following modified Silver’s McBride’s procedure, in the treatment of Hallux Valgus. Between 1997 and 1999, Modified Silver’s McBrides procedure for Hallux Valgus was performed on 38 foot in 28 patients (18 unilateral and 10 bilateral). The median age was 60 years. The median follow up was 26 weeks. Clinical outcome measures consisted of pain, deformity, mobility, walking ability and shoe wear. Radiological outcome measures were Hallux Valgus angle, Intermetatarsal angle, 1st to 5th Metatarsal distance, 1st to 2nd metatarsal distance, and the DMAA (Distal Metatarsal Articular Angle). Paedobarographic (Musgrave) outcome of peak pressure, total force, time from heel strike to toe lift off post operatively were analysed. Preoperative visual analogue pain score was 5–8 and 0–4 postoperatively (p< 0.001). 34 feet had pain on walking preoperatively and only 11 had pain post-operatively. 12 were wearing special shoes pre- operatively and 5 post-operatively. Hallux Valgus angle was 34 pre-operatively and 19 post-operatively (p< 0.001). IMT angle was 14.53 pre-op and 10.88 postop (p< 0.001). 1st-5th MT distance was 67mm pre- op and 63mm post-op (p=0.001). 1st-2nd MT distance was 15 pre-op and 10 post-op (p=0.004). DMAA was 24.7 degrees. 21 foot an obliquity of the 1st tarsometatarsal joint was seen indicating an anatomical cause of metatarsus varus. Foot pressure studies showed a peak pressure of 1.37kg/cm2 , heel to toe off- time was 936.9ms and maximum load was 65.2 kg. There were 3 cases of superficial wound problems. One patient developed Hallux varus deformity, with no functional disability. Conclusion: Modified Silver’s McBride procedure for the treatment of Hallux Valgus is a soft tissue procedure and is a safe alternative to the commonly practiced osteotomies for correction of this disorder

Abstract. OBJECTIVES. Valgus high tibial osteotomy (HTO) represents an effective treatment for patients with medial compartment osteoarthritis (OA) in a varus knee. However, the mechanisms which cause this clinical improvement are unclear. Previous studies suggest a wider stance gait can reduce medial compartment loading via reduction in the external knee adduction moment (KAM); a measure implicated in progression of medial compartment OA. This study aimed to measure whether valgus HTO is associated with a postoperative increase in static stance width. METHODS. 32 patients, recruited in the Biomechanics and Bioengineering Centre Versus Arthritis HTO study, underwent valgus (medial opening wedge) HTO. Weightbearing pre- and post- operative radiographs were taken showing both lower limbs. The horizontal distance, measured from a fixed point on the right talus to the corresponding point on the left, was divided by the talus width to give a standardised “stance width” for each radiograph. The difference between pre- and post- operative stance width was compared for each patient using a paired sample t-test. RESULTS. Preoperatively, mean stance was 4.00 talar-widths but postoperatively this increased to 5.41. This mean increase of 1.42 talar-widths was statistically significant (p=0.001) and represents a mean proportional increase in stance width of 35.5% following HTO. Of the 32 patients, 23 showed increased stance width and 9 decreased (range −4.64 to 6.00 talar-widths). CONCLUSIONS. These findings indicate an association of frontal plane surgical realignment at the proximal tibia via a medial opening wedge HTO with an increased stance width on postoperative radiographs. Considering both wider stance gait and HTO have been shown to affect the progression of medial compartment OA, these results may explain one mechanism contributing to the efficacy of HTO surgery. However, the range of changes in stance width suggests significant variability in how patients adapt at a whole-limb and whole-body level following HTO. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

INTRODUCTION. Hallux Valgus is a common foot condition, which may affect mobility and lifestyle. Corrective surgery is performed as a day case procedure, however, post-operatively; patients remain limited in their ability to drive for a variable period. In the laboratory settings, emergency brake response time after first metatarsal osteotomy has been studied but there is no published study of patients’ experience of driving after this surgery. This study was aimed at assessing patients’ driving ability and comfort after Hallux Valgus corrective surgery. METHODS. Fifty consecutive patients who underwent first metatarsal corrective osteotomy from January 2009 to July 2010 were reviewed. The operation type, foot side operated, postoperative complications and other conditions affecting driving were recorded from charts and operation notes. A telephonic survey was then conducted and information was recorded in a predesigned questionnaire. The questions included driving advice given by the medical staff, time interval to begin driving postoperatively, and how long the patient took to gain full confidence at driving. It was also noted whether patients required changing the type of car from manual to automatic. RESULTS. Of 50 patients, 10 never drove and were excluded. One patient had expired from unrelated health conditions. Two discontinued driving after surgery due to other (social) reasons, and one could not be contacted. The remaining thirty-six patients were analyzed. The mean age was 56.8+/-9.8 years with range of 36–74 years. Most were females (n=33, 91.7%), and the right side was operated upon in 17 (44.4%) patients. SCARF osteotomy was performed in 19 (52.8%) patients, basal osteotomy in 5 (13.9%), chevron osteotomy in 5 (13.9%) and other procedures (bunionectomy, Akin, soft tissue correction etc) were done in 7 (19.4%) patients. Out of the 28 patients driving manual cars, one required changing to automatic vehicle. The average post-operative period when patients resumed driving was 8.6 weeks with a range of 4 to 16 weeks. After SCARF, this average was 8.3 weeks (range 6–16), which was against 7.6(range 6–16) and 7.8 (range 4–12) weeks after basal and chevron procedures respectively (p=0.408). The mean period when patients reported comfortable foot control was 1.06 weeks after they had begun to drive for all groups. With SCARF this was 1.3 weeks, and 1.4 and 2.2 for basal and chevron groups respectively (p=0.162). Of the two patients that resumed driving after 16 weeks, one had infection and swelling of the foot postoperatively and the other had bilateral basal osteotomy performed simultaneously and was on crutches for 16 weeks. CONCLUSION. The mean time to resumption of automobile driving after corrective Hallux Valgus surgery is 8.6 weeks, and, on average patients takes another week to attain full confidence and comfort at driving postoperatively. There is no statistically significant difference between the types of surgery performed

Background. Authors sought to determine the degree of lateral condylar hypoplasia of distal femur was related to degree of valgus malalignment of lower extremity in patients who underwent TKA. Authors also examined the relationships between degree of valgus malalignment and degree of femoral anteversion or tibial torsion. Methods. This retrospective study included 211 patients (422 lower extremities). Alignment of lower extremity was determined using mechanical tibiofemoral angle (mTFA) measured from standing full-limb AP radiography. mTFA was described positive value when it was valgus. Patients were divided into three groups by mTFA; more than 3 degrees of valgus (valgus group, n = 31), between 3 degrees of valgus to 3 degrees of varus (neutral group, n = 78), and more than 3 degrees of varus (varus group, n = 313). Condylar twisting angle (CTA) was used to measure degree of the lateral femoral condylar hypoplasia. CTA was defined as the angle between clinical transepicondylar axis (TEA) and posterior condylar axis (PCA). Femoral anteversion was measured by two methods. One was the angle formed between the line intersecting femoral neck and the PCA (pFeAV). The other was the angle formed between the line intersecting femoral neck and clinical TEA (tFeAV). Tibial torsion was defined as a degree of torsion of distal tibia relative to proximal tibia. It was determined by the angle formed between the line connecting posterior cortices of proximal tibial condyles and the line connecting the most prominent points of lateral and medial malleolus. Positive values represented relative external rotation. Negative values represented relative internal rotation. Results. Greater lateral femoral condylar hypoplasia was related to increased valgus alignment of lower extremity. Correlation coefficient between mTFA and CTA was 0.253 (p < 0.001). Valgus group showed increased CTA, which was 10.2° ± 1.9°. CTA was 7.4° ± 2.5° in neutral group and 6.6° ± 4.8° in varus group. There was significant positive correlation between the degree of valgus alignment and the degree of femoral anteversion (r = 0.145, p = 0.003). pFeAV was 16.7° ± 5.8° in valgus group, 12.1° ± 6.0° in neutral group and 10.9° ± 7.0° in varus group. There was no correlation between degree of valgus alignment and degree of femoral anteversion (r = 0.060, p = 0.218). In terms of tibial torsion, increased valgus malalignment was associated with increased tibial torsion (r = 0.374, p < 0.001). Valgus group showed increased tibial torsion than other groups. Tibial torsion was 32.6° ± 6.2° in valgus group, 26.3° ± 6.9° in neutral group and 22.6° ± 7.2° in varus group. Conclusions. Increased valgus alignment of lower extremity was related to greater lateral femoral condylar hypoplasia. However, increased valgus alignment was not related to degree of femoral anteversion whereas it was related to increased external tibial torsion. Our findings should be considered when determining proper rotational alignment in TKA

Introduction. Valgus deformity in an end stage osteoarthritic knee can be difficult to correct with no clear consensus on case management. Dependent on if the joint can be reduced and the degree of medial laxity or distension, a surgeon must use their discretion on the correct method for adequate lateral releases. Robotic assisted (RA) technology has been shown to have three dimensional (3D) cut accuracy which could assist with addressing these complex cases. The purpose of this work was to determine the number of soft tissue releases and component orientation of valgus cases performed with RA total knee arthroplasty (TKA). Methods. This study was a retrospective chart review of 72 RATKA cases with valgus deformity pre-operatively performed by a single surgeon from July 2016 to December 2017. Initial and final 3D component alignment, knee balancing gaps, component size, and full or partial releases were collected intraoperatively. Post-operatively, radiographs, adverse events, WOMAC total and KOOS Jr scores were collected at 6 months, 1 year and 2 year post-operatively. Results. Pre-operatively, knee deformities ranged from reducible knees with less than 5mm of medial laxity to up to 12° with fixed flexion contracture. All knees were corrected within 2.5 degrees of mechanical neutral. Average femoral component position was 0.26. o. valgus, and 4.07. o. flexion. Average tibial component position was 0.37. o. valgus, and 2.96. o. slope, where all tibial components were placed in a neutral or valgus orientation. Flexion and extension gaps were within 2mm (mean 1mm) for all knees. Medial and lateral gaps were balanced 100% in extension and 93% in flexion. The average flexion gap was 18.3mm and the average extension gap was 18.7mm. For component size prediction, the surgeon achieved their planned within one size on the femur 93.8% and tibia 100% of the time. The surgeon upsized the femur in 6.2% of cases. Soft tissue releases were reported in one of the cases. At latest follow-up, radiographic evidence suggested well seated and well fixed components. Radiographs also indicated the patella components were tracking well within the trochlear groove. No revision and re-operation is reported. Mean WOMAC total scores were improved from 24±8.3 pre-op to 6.6±4.4 2-year post-op (p<0.01). Mean KOOS scores were improved from 46.8±9.7 pre-op to 88.4±13.5 2-year post-op (p<0.01). Discussion. In this retrospective case review, the surgeon was able to balance the knee with bone resections and avoid disturbing the soft tissue envelope in valgus knees with 1–12° of deformity. To achieve this balance, the femoral component was often adjusted in axial and valgus rotations. This allowed the surgeon to open lateral flexion and extension gaps. While this study has several limitations, RATKA for valgus knees should continue to be investigated. For any figures or tables, please contact authors directly

The aetiology of hallux valgus is well published and largely debated. Hypermobility at the TMTJ was initially described by Morton, but it was not till Lapidus that its association with hallux valgus was hypothesized. However, little has been published on the anatomy of the tarsometatarsal joint. Our aim was to determine whether there was an anatomical basis for the coronal hypermobility in hallux valgus. Method. Anatomical dissection was completed on 42 feet from 23 bodies. Presence of hallux valgus was noted (displacement of sesamoids). Measurements and photographs were taken of the first tarsometatarsal joint and all differences noted. Observations. The TMTJ articular morphology is variable. There were 3 separate subtypes identified of the metatarsal articular surface. Results. The articular subtypes identified were called called A, B and C. Type A, was uni-facet with a single flat articular surface, Type B was bi-facet with two distinct flat articular surfaces, and Type C was tri-facet, with the presence of a lateral eminence on inferolateral surface of metatarsal. Type A was found exclusively in bodies with Hallux Valgus and Type C exclusively in bodies without Hallux Valgus. Type B was found in both groups. Type C was more common in males and type B was more common in females. The third facet was much more common in men. Another anomaly was found; measurements taken from the lowest to highest point of joint surface (mm) revealed a significantly flatter joint surface in bodies with hallux valgus. Conclusion. Coronal plane motion in varus is a consistent feature of hallux valgus. The lateral eminence acts as a sliding dovetail joint and prevents coronal plane motion and rotation. We believe we have identified a joint type that is protective of the development of hallux valgus

Background and Purpose of Study. The Valgus knee in total knee Arthroplasty, is considered a more demanding procedure, often with ligament balance a greater challenge than seen with neutral or Varus knees. It has also frequently been suggested that prostheses with higher levels of constraint be used to avoid late-onset instability. Various lateral release techniques have also been suggested in the literature. This study is aimed at assessing the outcomes of an unconstrained, rotating platform designed prosthesis, the LCS, using our technique, in the management of severe valgus deformity. Methods. 44 knees in 42 patients with a pre-operative valgus deformity of more than 10 degrees were included in our retrospective series. We analyzed the radiographs for the degree of correction, the angle of tibial tray implantation, and femoral implantation angle, tibial slope, as well as the presence (or degree) of lift off and any complications were noted. In this group, 7 had a Valgus deformity of greater than 25 degrees, with a mean Valgus deformity of 17,36 degrees. The mean age at operation was 65. Clinical and radiological analysis was done Pre-hospital discharge and again post-operatively 6 weeks. Results. The mean coronal alignment was corrected from 17,36 degrees to 5 degrees of Valgus post operatively. 2 knees were corrected past neutral to varus alignment. There was 1 case of bearing spin out experienced early on in the series. The mean tibial implant angle was 1,7 degrees from neutral. Lift off in the early post-operative X-rays was seen in 6 patients, however at 3 month follow up the knees appeared to be well balanced. There were no infections or revisions for wear, one re-operation for bearing dislocation, and no cases of loosening in our series. There were no cases of delayed instability. Patient satisfaction was 86 %. Conclusions. The rotating platform, mobile bearing prosthesis, using our technique, provided a reproducible correction of deformity in Valgus knees, a well-balanced knee, a low complication rate, and an excellent degree of patient satisfaction. NO DISCLOSURES

Introduction: We present the long term results in 204 cases of Hallux Valgus deformity correction using a modified Mitchell’s osteotomy. Methods: 168 patients (204 feet) that had Mitchell’s osteotomies between 1986 and 2001 were recalled for clinical and radiological evaluation. The patients had hallux valgus angles of up to 50o and intermetatarsal angles of up to 20o. They all had a modified procedure using two crossed Kirschner wires to fix the capital fragment into plantar displacement and angulation. Lateral soft tissue release was performed when deemed necessary during the procedure. Mild to moderate arthritis of the 1st metatarsophalangeal joint was not a contraindication. The AOFAS scores as well as any complications were recorded and the Xrays were used to measure hallux valgus and intermetatarsal angles. Mann-Whitney U test was used to analyze data. Results: The mean follow up was 12.9 years. The mean AOFAS score improved from a preoperative of 49.6 to a postoperative of 87.9 points (p=0.004), due to improvement in the pain (14.2 Vs 37.6, p=0.001) and function (30.6 Vs 39.8, p=0.043) parameters. 57 cases (27.9%) had Hallux Valgus angles > 40o. Lateral soft tissue release was performed in only 16 of these cases with no significant difference in the postoperative Hallux Valgus angle compared to the ones not requiring soft tissue release (21.3o Vs 20.8o, p=0.08). There was a decrease in the pre-operative Vs post-operative incidence of lateral metatarsalgia and symptomatic callosities (18.33% Vs 11.8%, p=0.023). We had only one case of avascular necrosis. Discussion/Conclusion: Mitchell’s osteotomy is a reliable technique with successful outcomes and minimal complications when performed with accurate surgical technique, stable fixation and lateral soft tissue release when appropriate. It may also be successfully performed for Hallux Valgus angles > 40o. We believe that it has still got a role in the treatment of Hallux Valgus

Introduction: We present the long term results in 204 cases of Hallux Valgus deformity correction using a modified Mitchell’s osteotomy. Methods: 168 patients (204 feet) that had Mitchell’s osteotomies between 1986 and 2001 were recalled for clinical and radiological evaluation. The patients had hallux valgus angles of up to 50o and intermetatarsal angles of up to 20o. They all had a modified procedure using two crossed Kirschner wires to fix the capital fragment into plantar displacement and angulation. Lateral soft tissue release was performed when deemed necessary during the procedure. Mild to moderate arthritis of the 1st metatarsophalangeal joint was not a contraindication. The AOFAS scores as well as any complications were recorded and the Xrays were used to measure hallux valgus and intermetatarsal angles. Mann-Whitney U test was used to analyze data. Results: The mean follow up was 12.9 years. The mean AOFAS score improved from a preoperative of 49.6 to a postoperative of 87.9 points (p=0.004), due to improvement in the pain (14.2 Vs 37.6, p=0.001) and function (30.6 Vs 39.8, p=0.043) parameters. 57 cases (27.9%) had Hallux Valgus angles > 40o. Lateral soft tissue release was performed in only 16 of these cases with no significant difference in the postoperative Hallux Valgus angle compared to the ones not requiring soft tissue release (21.3o Vs 20.8o, p=0.08). There was a decrease in the pre-operative Vs post-operative incidence of lateral metatarsalgia and symptomatic callosities (18.33% Vs 11.8%, p=0.023). We had only one case of avascular necrosis. Discussion/Conclusion: Mitchell’s osteotomy is a reliable technique with successful outcomes and minimal complications when performed with accurate surgical technique, stable fixation and lateral soft tissue release when appropriate. It may also be successfully performed for Hallux Valgus angles > 40o. We believe that it has still got a role in the treatment of Hallux Valgus

Purpose of the study: To evaluate the medium-term results of Valgus High tibial osteotomy using tomofix plate in patients with medial compartment arthritis with varus deformity. Method: A total of 46 patients (50 knees) underwent Valgus High tibial osteotomy. The mean duration of follow-up was 60 months (36 – 72 months). The mean age was 39.5 (range 30–49) and all were male. The patients were assessed on the basis of pre and post-operative Oxford and Knee society score, range of motion, radiological evidence of healing of the osteotomy site and alignment of the extremity. Indication for the operation was medial compartment degeneration associated with varus malalignment. The mean preoperative oxford knee score was 48 (range 38–54) and postoperative score was 22 (range 17–31). The knee score improved from the preoperative mean of 38 (range 30 – 55) to postoperative mean of 82 points (range 45 – 92). The mean preoperative functional score was 35 (range 25 – 55) and mean postoperative functional score was 75 points (range 50 – 95). The preoperative average knee flexion was 110 (Range 90 –130) which at the final follow-up remained unchanged. The mean preoperative Tibio-Femoral angle (mechanical) was 7 degrees varus (range 6–10) and mean postoperative Tibio-Femoral angle was 6.5 deg valgus (range 7–11). There were no non-unions at the osteotomy site and the medial open-wedge filled-in without any need for bone graft or its substitutes. Conclusion: Our study shows that Valgus High tibial osteotomy for medial compartment arthritis using Tomofix plate gives good medium-term resutls. Longer-term follow-up is needed to establish its effectiveness in deferring joint replacement surgery

Valgus knees present a surgically demanding challenge. Dissimilar bone and soft-tissue deformities compared to varus knees complicate restoration of proper alignment, positioning of components, and attainment of joint stability. Our study examined the relationship between tourniquet time and valgus deformity. A prospective study of all valgus knees were implanted over a 30 month period with Emotion Ortho-pilot version 4.2 Navigation system (BBraun Aesculap, Tutlingen). They were done by a single knee surgeon. Tourniquet times (TT) were recorded digitally with fixed timing criteria. The software recorded all pre- and post-operative deformities. We performed the lateral parapatella approach for all valgus knees. No patella resurfacing was done but all tibiae were cemented. There were a total of 56 valgus knees (1° to 22°, Mean 5.9°, SD 4.9). The TT varied from 42 min to 121 min (mean 72 min, SD 17.4). There was a statistically significant relationship between TT and Valgus deformity. Tourniquet Time = 59.6 + 2.1 * Pre-operative Valgus (p= < 0.0001, R. 2. = 36.4%). Thirty six percent of the observations were explained by this analysis. Other factors will need to be considered in future studies. This equation can be used as a guide in the allocation of theatre time. It applies to a specific surgical team and we would expect different teams to have different coefficients. This may be useful in comparisons of different teams

Short scarf osteotomy (SSO) retains the versatility of standard scarf in treating moderate and severe hallux valgus deformity with the added benefit of less invasiveness translated into less soft-tissue stripping, reduced exposure, less metalwork, less operative time and reduced cost. We present our medium-term clinical, radiographic and patient satisfaction results. All patients who underwent SSO between January 2015 and December 2017 were eligible (98). Exclusion criteria were: follow up less than a year, additional 1st ray procedures, inflammatory arthropathy, infection, peripheral vascular disease and hallux rigidus. Eighty-four patients (94 feet) were included: 80 females / 4 males with average age of 51-year-old (24–81). Minimum follow up was 12 months (12–28). Weight-bearing x-rays and AOFAS score were compared pre- and postoperatively. Non-parametric Mann-Whitney U test assessed statistical significance of our results. Hallux valgus angle (HVA) improved from preoperative mean of 30.8° (17.4°–46.8°) to 12° (4°–30°) postoperatively (p=0.0001). Intermetatarsal angle (IMA) improved from preoperative mean of 15.1° (10.3°–21.1°) to 7.1° (4°–15.1°) postoperatively (p=0.0001). Average sesamoid coverage according to Reynold's tibial sesamoid position improved from average grade 2.18 (1–3) to 0.57 (0–2) (p=0.0001). Average AOFAS score improved from 51.26 (32–88) to 91.1 (72–100) (p=0.0001). Ninety percent of patients were satisfied and 83% wound recommend the surgery. No troughing phenomenon or fractures. Four overcorrections were found 3 of which did not require surgery. One recurrence at 18 months was treated with standard scarf. We believe that this technique offers a safer, quicker and equally versatile way of dealing with Hallux Valgus

Management of a knee with valgus deformities has always been considered a major challenge. Total knee arthroplasty requires not only correction of this deformity but also meticulous soft tissue balancing and achievement of a balanced rectangular gap. Bony deformities such as hypoplastic lateral condyle, tibial bone loss, and malaligned/malpositioned patella also need to be addressed. In addition, external rotation of the tibia and adaptive metaphyseal remodeling offers a challenge in obtaining the correct rotational alignment of the components. Various techniques for soft tissue balancing have been described in the literature and use of different implant options reported. These options include use of cruciate retaining, sacrificing, substituting and constrained implants. Purpose. This presentation describes options to correct a severe valgus deformity (severe being defined as a femorotibial angle of greater than 15 degrees) and their long term results. Methods. 34 women (50 knees) and 19 men (28 knees) aged 39 to 84 (mean 74) years with severe valgus knees underwent primary TKA by a senior surgeon. A valgus knee was defined as one having a preoperative valgus alignment greater than 15 degrees on a standing anteroposterior radiograph. The authors recommend a medial approach to correct the deformity, a minimal medial release and a distal femoral valgus resection of angle of 3 degrees. We recommend a sequential release of the lateral structures starting anteriorly from the attachment of ITB to the Gerdy's tubercle and going all the way back to the posterolaetral corner and capsule. Correctability of the deformity is checked sequentially after each release. After adequate posterolateral release, if the tibial tubercle could be rotated past the mid-coronal plate medially in both flexion and extension, it indicated appropriate soft tissue release and balance. Fine tuning in terms of final piecrusting of the ITB and or popliteus was carried out after using the trial components. Valgus secondary to an extra-articular deformity was treated using the criteria of Wen et al. In our study the majority of severe valgus knees (86%) could be treated by using unconstrained (CR, PS) knee options reserving the constrained knee / rotating hinge options only in cases of posterolateral instability secondary to an inadequate large release or in situations with very lax or incompetent MCL. Results. The average follow up was 10 years (range 8 to 14 years). The average HSS knee scores improved from 48 points preoperatively (range 32 to 68 points) to 91 points (range 78 to 95 points) postoperatively. The average postoperative range of motion measured with a goniometer was 110 degrees (range 80 to 135 degrees) which was a significant improvement over the preoperative levels (average 65 degrees). None of the patients were clinically unstable in the medioloateral or anteroposterior plane at the time of final follow up. The average preoperative valgus tibiofemoral alignment was 19.6 degrees (range 15 degrees to 45 degrees). Postoperatively the average tibio-femoral alignment was 5 degrees (range 2 degrees to 7 degrees) of valgus. No patient in the study was revised. Conclusion. Adequate lateral soft tissue release is the key to successful TKA in valgus knees. The choice of implant depends on the severity of the valgus deformity and the extent of soft tissue release needed to obtain a stable knee with balanced flexion and extension gaps. The most minimal constraint needed to achieve stability and balance was used in this study. In our experience the long term results of TKR on severe valgus deformities using minimal constrained knee have been good

Background. In the adolescent population, operative management of hallux-valgus is controversial. Operations may be less successful than in adults and post-operative recurrence is more common before full skeletal maturity. This study assesses the radiographic, functional and qualitative outcomes of surgical Hallux Valgus correction in adolescents. Methods. Three independent reviewers retrospectively analysed pre and post-operative radiological markers of hallux valgus severity for 44 operations on patients age 13–18. The patient cohort were also asked the Manchester-Oxford foot questionnaire (MOXFQ) to assess functional outcome via telephone interview and patient notes were reviewed for any evidence of complications. Results. There was no evidence of NICE recognised complications from any of the operations performed, however there was persistence or recurrence in 20.8%, requiring a second operation in 10.3%. Radiologically, all operations performed resulted in a reduction in hallux valgus severity. The hallux valgus angle showed a mean reduction of 18.0 degrees (16.3–19.7) and the inter-metatarsal angle by 7.3 degrees (6.55–8.14). 93% of operations resulted in a good MOXFQ outcome score of less than 20 out of a possible 80 negative functional outcome points. This score worsened with age in a statistically significant manner (p=0.03) but had no significant correlation with BMI. Conclusion. Surgical correction of adolescent hallux valgus reduces the radiographic severity, which correlates with good long term outcome. This surgery provides beneficial results to the patient, however there is a high recurrence rate, correlating with younger age and this must be taken into account

To assess the outcome of Wilson’s osteotomy of the first metatarsal to correct Hallux Valgus. Two hundred and forty feet in 172 patients who had surgery for pain were reviewed clinically and radiologically. Age ranged from 28 to 82 years (mean 55 years) and duration of follow-up ranged from 2 to 15 years (mean 6 years). A mini external fixation was used to stabilize the osteotomy. The average AOFAS score improved from 51.6 to 89.5 points at the last follow-up. In 96% of the cases, the final outcome was satisfactory as far symptomatic improvement was concerned. A 4% only was dissatisfied with the outcome of the surgery due to metatar-salgia, restricted first metatarsophalangeal joint motion or lack of correction. There were no cases of avascular necrosis of the metatarsal head. We had five cases of delayed union but they didn’t need further surgery. The average preoperative HVA and IMA were 34.80 (range: 180–540) and 15.10 (range: 100–290), while the average postoperative HVA and IMA were 16.10 (range: 70–280) and 7.20 (range: 30–90) respectively. Wilson’s osteotomy as a method of treatment of Hallux Valgus is technically straightforward, effective and with a predictable outcome. We believe that the external fixation offered increased stability at the osteotomy site and could be the reason why patients had a very low incidence of postoperative metatarsalgia and returned to their normal activities faster, thus giving a higher satisfaction rate

Aim: To evaluate results of fully congruent Mobile bearing knee arthroplasty for valgus arthritic knees using lateral capsular approach and realignment of vastus lateralis. Material and Method: We reviewed results of 50 mobile bearing total knee arthroplasties performed consecutively between 2001 and 2006 for Valgus arthritic knees, using lateral capsular approach and realignment of vastus lateralis. Patients were evaluated using oxford and International knee society Score. Radiographs were examined for alignment of the component, evidence of loosening and scanograms assessed to evaluate the restoration of mechanical axis. Results: The study group consisted of 47 patients, 20 men and 27 women who received fifty knees. The mean age at the primary operation was 71.57 years (range 47–82 years; SD, 9.5). The mean follow up was 4.2 years (range 1–6 years; SD, 1.35). The mean Valgus deformity was 15.92° (rang from 15–20 SD 1.89). Fixed flexion deformity was seen in 15 knees. The mean Oxford Knee Society ratings was 52 (range 47–55; SD, 3.18) preoperatively, and 19 (range 14–24; SD, 3.72) at final follow up. The pre op mean range motion was 84.28° (range 45°–120°; SD 21.73). At final follow up the average range of motion was 107.5° (range 95°–120°; SD 8.93). According to the system of the Knee Society, the average knee score was 94 points and the average functional score was 89 points at final follow up. There were no clinical failures or cases of postoperative instability and no cases of radiographic loosening or wear. Radiological evaluation: None of these knees had radiographic evidence of loosening or osteolysis. Mechanical axis was restored in all the patients. Conclusion: This study demonstrates satisfactory results of Mobile bearing knee arthroplasty using lateral parapatellar with proximal realignment of vastus lateralis for Valgus arthritic knees

Aims: Surgical treatment of forefoot deformities is a common procedure. The vast majority comprising surgery for Hallux Valgus. The indication for surgical intervention varies from pain to cosmetic reasons and footwear problems. Evidence for the effectiveness of different surgical methods is limited. The aims of this study were to perform a cross sectional population based prevalence study of surgery for forefoot deformities in Sweden and to analyze the surgical methods in use. Methods: Data on forefoot surgery were collected from the National Swedish Patient Registry between 1997 and 2000. Both ambulatory surgery (2000) and in-patient surgery (1997–2000) were collected. The data were processed to quantify the frequency of different surgical methods. Results: In 2000, a total of 4409 procedures for forefoot deformities were reported in ambulatory surgery. 82% were female and 18% were male. During 1997–2000, a total of 2547 procedures were performed performed in hospitalised patients. The gender distribution in this group was similar; 84% were female and 16% were male. The frequency distribution between different forefoot deformities will be presented. Discussion: Forefoot surgery is a common procedure, Hallux Valgus being the most frequent deformity to be corrected. The choice of surgical methods will be discussed and a validation of the National Swedish Patient Registry against the Local Reimbursement Registry in the Stockholm area will be presented

Failed Hallux Valgus Surgery Aim. We aim to explore the reasons behind long term failure of hallux valgus surgery. Patients & Methods. A series of patients with problems following failed hallux valgus surgery presenting to a tertiary referral unit is presented. There were 47 patients with 55 problematic feet, 45 were female. The mean age was 59 years (Range 25–79). The failed bunions were compared to a prospectively collected series of 80 patients with successful 1st metatarsal osteotomies, 40 ludloff and 40 scarf osteotomies. Before the index surgery, all the patients in the failed group, the predominant symptom was pain. Only 53% admitted deformity was an issue. A wide spectrum of procedures were performed, 13 Wilson's, 11 Keller's, 8 Chevron, 3 Bunionectomy, 2 Scarf, 1 Basal and 1 Mitchell's. In 16 patients the original procedure was unknown. The mean time to developing problems was 9.4 years (Range 0–45) with mean time to presentation 13.6 years. (Range 0–47) Radiographs revealed 2/3 of patients had relative shortening of the first metatarsal. Over 80% of x-rays demonstrated evidence of degenerative change. The mean AOFAS score deteriorated with increased shortening. The failed bunions had statistically significantly different AOFAS pain scores (15.1 vs 31.9 p < 0.05), function scores (25.02 vs 31.9 p < 0.05). Additionally, the hallux valgus angle was significantly higher (24 vs 11.7 p < 0.05) although there was no change in DMMA between the two groups (13 vs 7.6 p > 0.05). There was a significantly higher incidence of first ray shortening (12% vs 0% p < 0.05). Discussion. This represents an unusual series, with nothing similar in the literature. Problems following hallux valgus surgery do not present for over 10 years. Functional Scores deteriorate with increasing shortening. MTPJ degeneration is common and from our data we are unable to explain why

Valgus deformity is less common than varus. There is an associated bone deformity in many cases – dysplasia of the lateral femoral condyle. There are also soft tissue deformities, including tightness of the lateral soft tissues, and stretching of those on the medial side. Unlike varus, where the bone deformity is primarily tibial, in valgus knees it is most often femoral. There is both a distal and a posterior hypoplasia of the lateral femoral condyle. This results in a sloping joint line, and failure to correct this results in valgus malalignment. Posterior lateral bone loss also results in accidental internal rotation of the femoral component, which affects patellar tracking. Using the trans-epicondylar axis and Whiteside's line helps to position the femoral component in the correct rotation. Soft tissue balancing is more complex in the valgus knee. Releases are performed sequentially, depending on the particular combination of deformities. It is important to note whether the knee is tight in flexion, in extension, or both. Tightness in extension is the most common, and is corrected by release of the iliotibial band. Tightness in flexion as well as extension requires that the lateral collateral ligament +/− the popliteus tendon be released. Cruciate substituting designs are helpful in many cases, and in extreme deformity with medial stretching, a constrained or “total stabilised” design is needed. Patellar maltracking is common, and a lateral retinacular release may be needed. Beware of over-releasing the posterolateral corner, as excessive release may cause marked instability. Use the pie-crust technique of Insall

We studied, clinically and radiologically, the growth and remodelling of 21 hips after valgus femoral osteotomy with both rotational and sagittal correction for hinge abduction in 21 patients (mean age, 9.7 years) with Perthes’ disease. The exact type of osteotomy performed was based on the pre-operative clinical and radiological assessment and the results of intra-operative dynamic arthrography. The mean IOWA hip score was 66 (34 to 76) before surgery and 92 (80 to 100) at a mean follow-up of 7.1 years (3.0 to 15.0). Radiological measurements revealed favourable remodelling of the femoral head and improved hip joint mechanics. Valgus osteotomy, with both rotational and sagittal correction, can improve symptoms, function and remodelling of the hip in patients with Perthes’ disease

In moderate and severe Hallux Valgus metatarsus varus and incongruency of the joints are often important features. Basal osteotomy and distal soft tissue release can often achieve adequate correction of intermetatarsal angle (IMA) and joint alignment.. We retrospectively evaluated the results of Basal Osteotomy in 26 feet in 20 patients between January 1999 and December 2003. American Orthopaedics Foot & Ankle Society Score (AOFAS) was used for assessment. A subjective grading system was used to check patient’s satisfaction. The surgical technique consisted of crescentic basal osteotomy, lateral distal soft tissue release and medial capsular plication according to Roger Mann. Fourteen osteotomies were fixed with K wires that needed second operation to remove them. Barouk Screw was used to fix the osteotomy in 12 feet. Patients were mobilised in High heeled shoe postoperatively. Average age was 55.2 years and average follow-up was 25.8 months. The average preoperative Hallux Valgus Angle (HVA) and IMA were 37.38° and 17.27° respectively. At follow-up the HVA and IMA averaged 13.3° and 6.4° respectively. Sixteen feet had incongruent joint preoperatively that became congruent after surgery. In 25 feet sesamoid position improved after surgery. Average AOFAS score was 88.8. 94% patients were highly satisfied and graded their results as good to excellent. One patient had AOFAS score of < 50 due to her generalised poly-arthralgia and osteoporosis. K wire was broken across the TMT joint in one case and needed removal under GA. This lead to change of our practice as we started using Barouk screw to fix the osteotomy. Other complications consisted of decreased sensations over medial side of toe in three and mild metatarsalgia in one foot. Basal osteotomies with distal soft tissue release in the treatment of Hallux valgus give good correction of the deformity and high patient satisfaction. Barouk screw provides stable fixation

Valgus deformity of the hindfoot can occur at the subtalar joint, the ankle joint, or at both sites. In children suffering from spina bifida, the ankle is often the main site of deformity. Thirty-five ankles with valgus deformity of the hindfoot were studied in 23 children with spina bifida. A radiological triad was observed in all patients: shortening of the fibula, lateral wedging of the distal tibial epiphysis, and lateral tilt of the talus at the ankle mortise . There was a definite correlation between the severity of wedging and the degree of talar tilt, and a fair correlation between the severity of wedging and the extent of fibular shortening. The results of operation in 12 feet are presented. It is concluded that any operations performed below the ankle on these patients (subtalar fusion or triple arthrodesis) is unlikely to succeed; the deformity needs to be corrected above the ankle (by epiphysiodesis or supramalleolar osteotomy). Radiological assessment of the ankle by taking weight-bearing films in the anteroposterior plane is essential to determine the true extent of the deformity before undertaking any operation

The purpose of this retrospective study was to report the results using scarf, first metatarsal osteotomies, in correcting Hallux Valgus deformity with H-V angle > 35°. During the period 2003–2008 we did 23 scarf, first metatarsal osteotomies in 15 patients (8 bilateral).In order to evaluate the effectiveness of this operation, patients were clinically (aofas score) and radiologically (X –ray in 4, 8, 12 weeks) assessed. Mean follow up was 32 months. The results evaluated with the aofas score in order to study the function, the pain and the overall satisfaction of the patients. We had excellent results in 13 %, very good in 48 % good 32% and poor 7 %.There was only one complication and no one infection. According the above results it seems that scarf osteotomy is quite reliable surgical treatment of severe Hallux – Valgus deformity with an increased IM angle

Background:. Varus or Valgus malpositioning of tibial prosthetic components in total knee replacement (TKR) surgery may lead to early failure due to increased polyethelene wear, soft tissue imbalancing, aseptic loosening and eventually revision surgery. Therefore, the clinical success of total knee arthroplasty (TKA) correlates with good component alignment. Conventional methods of coronal tibial alignment result in an acceptable range of prosthetic alignment in relation to the anatomical axis (tibial tangent angle). The measurement ranges from 90° ± 3°, but literature quotes that there is up to 27% of cases with coronal tibial alignment deviation of greater than 3°. Many studies show that the use of conventional intramedullary rod alignment versus extramedullary rod alignment gives similar results. The tibial alignment and overall prosthetic alignment in TKA has improved remarkably by using computerized navigation assisted surgery (CAS), with tibial tangent angle of 90° ± 3 in up to 97% of cases. However, the success of accurate tibial and femoral alignment depends on the surgeon and the data fed to the computer. Also long term results on survival rates of TKR using CAS is still pending. It is clear that assessing tibial alignment (ie. anatomical axis) with whatever method used faces challenges which will affect the tibial bony cuts and the final tibial tangent angle. To achieve a 90° tibial cut in relation to the anatomical axis we made use of fluoroscopy intra-operatively to assess the anatomical axis of the tibia and the correct alignment of the tibial cutting block. Methods:. TKR's were performed on 36 consecutive patients over a 4 month period. The aim was to assess the coronal tibial alignment of the tibial component intra-operatively using fuloroscopy. A conventional manual extramedullary alignment rod with its tibial cutting block was used and the final positioning was confirmed with an image intensifier. The tibial cutting block must be at 90° to the anatomical axis of the tibia. The rest of the TKR procedures were performed as routinely described. Post-operative radiographs were taken on the same day as the surgery and again at six week follow up visit when the tibial tangent angle was measured. Results:. The coronal tibial angulation was consistent at 0° in 32 knees with a 1°–2° deviation in 4 knees. Conclusion:. We conclude that the use of fluoroscopy intra-operatively can improve the tibial component alignment and thus decrease the cumulative errors which have significant and dramatic effects on the function and the longevity of the total knee prosthesis

Background

The effect of hallux valgus (HV) on health-related quality of life (HRQOL) and the relationship between radiographic severity of deformity and patient reported outcome measures (PROMs) is poorly understood. The aim of this study was to compare the HRQOL of female patients with HV to the UK population. The secondary aim was to assess the correlation between PROMs, including HRQOL, with radiographic severity of deformity.

Valgus extension osteotomy (VGEO) is a salvage procedure for ‘hinge abduction’ in Perthes’ disease. The indications for its use are pain and fixed deformity. Our study shows the clinical results at maturity of VGEO carried out in 48 children (51 hips) and the factors which influence subsequent remodelling of the hip. After a mean follow-up of ten years, total hip replacement has been carried out in four patients and arthrodesis in one. The average Iowa Hip Score in the remainder was 86 (54 to 100). Favourable remodelling of the femoral head was seen in 12 hips. This was associated with three factors at surgery; younger age (p = 0.009), the phase of reossification (p = 0.05) and an open triradiate cartilage (p = 0.0007). Our study has shown that, in the short term, VGEO relieves pain and corrects deformity; as growth proceeds it may produce useful remodelling in this worst affected subgroup of children with Perthes’ disease

Femoral head deformity with flattening and lateral protrusion can occur secondary to epiphyseal dysplasia or avascular necrosis of any aetiology in childhood. This causes painful impingement of the lateral femoral head on the acetabular lip, a phenomenon known as hinge abduction. We aimed to review our experience of valgus extension osteotomy in the treatment of hinge abduction in children and young adults with avascular necrosis. Twenty patients undergoing valgus osteotomy for hinge abduction performed by a single specialist were clinically and radiologically reviewed. The aetiology was Perthes disease in 16 patients and treatment of DDH in 4 patients. The indication for the procedure was pain and limited abduction. The mean follow-up was 4.5 years. Patients were assessed using modified Iowa hip scores at final follow-up. The procedure corrected some leg shortening and improved the abduction range of the affected hip. Overall 80 % of patients did well. The mean Iowa hip score in Perthes group was 84 at final follow-up. Four patients preoperatively had cysts/ defects in their femoral head. These were seen to fill up during their postoperative follow-up. Poorer outcome was associated with preoperative hip stiffness and surgery before stabilisation of the avascular process. Conclusion: Valgus osteotomy is an effective procedure for relieving hinge abduction with associated additional benefits including improvement of leg shortening and improvement in hip abduction. The procedure should be avoided in stiff hips

Stickler’s syndrome, also called Hereditary Progressive Arthro-Ophthalmopathy, is an autosomal dominant connective tissue disorder with strong expressivity, characterised by ocular, orofacial, skeletal, cardiac, and auditory features. We describe a case of valgus slipped capital femoral epiphysis in a 13 year-old boy with Stickler’s syndrome. He presented at routine rheumatology clinic follow-up with a 1-month history of progressively worsening right hip pain, which radiated to the knee. He underwent insitu cannulated screw fixation of the right slipped capital femoral epiphysis. Joint pains are a common manifestation in Stickler’s syndrome and this might delay the diagnosis of slipped capital femoral epiphysis. Valgus slipped capital femoral epiphysis is a rare entity. Obesity and the increased femoral anteversion are predisposing factors. Insitu fixation with a single cannulated screw is the treatment of choice

Eighteen children between the ages of 6 and 12 years with unilateral non-united femoral neck fractures were treated by valgus intertrochanteric osteotomy with bone grafting between January 1995 and December 2000. Twelve fractures were judged as Pauwel 3, and 6 as Pauwel 2, and 5 children had avascular necrosis in addition to non-union. The initial treatment included internal fixation in 14 fractures, conservative treatment in 2 fractures, and no treatment in 2. The average interval from injury to osteotomy was 10 months (8-14 months). In each case we used a 90° child or adolescent hip plate modified by making an angle of 120 0 between the blade and shaft portions to simulate an adult Osteotomy plate. All fractures healed after osteotomy and bone grafting; the average time to radiological union was 12 weeks (8-24 weeks). At an average follow-up of 3.5 years (2-6 years), 15 cases were rated good, 2 fair, and 1 poor based on Ratliff’s criteria. Valgus osteotomy with bone grafting provided successful results in treatment of non-united femoral neck fractures in children, even in the presence of avascular necrosis

A significant number of hallux valgus is associated with valgus deviation of 2nd, 3rd and 4th toes. We recommend correction of the valgus deformity of all four rays simultaneously., because recurrence of the hallux valgus is very frequent if only the first ray is realigned.

From 1978 to 1990 a series of 236 feet were operated upon for hallux valgus deformity using a distal osteotomy of the first rnetatarsal. These cases were followed up for a mean of 6, 1 years and showed that the recurrence rate was as high as 28%. Our observation was that, in the majority’ of cases, recurrence of the deformity occurred in those feet in which hallux valgus was combined with valgus deformity of the lesser toes due to varus deviation of the corresponded metatarsals. From 1990 to 1998, another series of 386 feet were operated for hallux valgus. In more than one third of them (142 feet in 96 patients) hallux valgus was associated by valgus deformity of the 2nd, 3rd, and 4th toes. These cases were operated using a distal osteotomy of the first rnetatarsal combined with osteotomies of lesser metatarsals aiming not only to face metatarsalgia, but to correct valgus deformity of the lesser toes simultaneously. These patients were followed up for a mean of 4.8 years.

The results were excellent in 73 feet, good in 47, fair in 17 and poor in 5. The recurrence rate dropped to 7%.

If hallux valgus is combined with valgus deformity of the lesser toes, correction of only the first ray creates a gap between first and second toe. Consequently there is no blocking effect toward valgus deviation of the great toe due to the gap remaining between the first and second toe.

The above combined procedure seems to give better results with low recurrence rate in comparison with the results of single correction of the first ray.

Introduction

Recurrence after surgical correction of hallux valgus may be related to coronal rotation of the first metatarsal. The scarf osteotomy is a commonly used procedure for correcting hallux valgus but has limited ability to correct rotation. Using weightbearing computed tomography (WBCT), we aimed to measure the coronal rotation of the first metatarsal before and after a scarf osteotomy, and correlate these to clinical outcome scores.

We evaluated growth and remodeling of the 21 hips after valgus osteotomy with rotational and sagittal components for hinge abduction in 21 patients (mean, 9.7 years) with Legg-Calvé-Perthes disease (LCPD) both clinically and radiologically. The type of osteotomy was determined by assessing the hinge movement three-dimensionally using preoperative gait assessment, 2-dimensional/3-dimensional computed tomography (2D/3D-CT), and intraoperative dynamic arthrography. The Iowa hip score averaged 66 (34 to 76) before operation and 92 (80 to 100) at a mean follow-up of 7.1 years (3.0 to 15.0). Radiographic measurements revealed favorable remodeling of the femoral head and improved hip joint mechanics. Valgus osteotomy with rotational and sagittal components results in sustained improvement in symptoms and functions and beneficially influences remodeling of the hip. Preoperative gait assessment, 2D/3D-CT, and intra-operative dynamic arthrography are helpful for assessing the spatial features of the femoral capital hump and for determining the optimal congruent position of the hip

Introduction. Hallux Valgus was thought to alter the forefoot function with defuctioning of the first ray with a resulting overloading of the second ray. The scarf osteotomy is a z-osteotomy of the first metatarsal and is proposed to correct anatomical and functional deformities of hallux valgus. This study was conducted to evaluate forefoot pressures using the Musgrave foot print system following this procedure in a district general hospital. Method. We prospectively collected the data from 43 feet in 31 consecutive patients. We evaluated the forefoot function using peak pressure, force time integral and pressure time integral parts of pedobarographs (Musgrave) pre-operatively, three and six months postoperatively. Results. The mean peak pressure under the first metatarsal head was reduced from 3.09 (95% CI 2.49 −3.70) to 2.25 (95% CI1.80–2.71) at six months. The mean peak pressure under the second metatarsal head was reduced from 6.29 (95% CI 5.44–7.13) to 5.01 (95% CI 3.98–6.05) at six months. Force time integral under the first metatarsal head was reduced from 1.34 (95% CI 1.06–1.62) to 0.97 (95% CI 0.74–1.19)) at six months. Force time integral under the second metatarsal head also reduced from 2.66 (95% CI 2.27–3.06) to 2.41(95% CI 1.98–2.85). Pressure time integrals also showed similar changes. Conclusion. Scarf osteotomy produced decrease in the forefoot pressures under the medial part of forefoot. We have not noticed significant alteration of forefoot pressures under the lateral part of forefoot

Preoperative talar valgus deformity increases the technical difficulty of total ankle replacement (TAR) and is associated with an increased failure rate. Deformity of ≥15° has been reported to be a contraindication to arthroplasty. The goal of the present study was to determine whether the operative procedures and clinical outcomes of TAR for treatment of end-stage ankle arthritis were comparable for patients with preoperative talar valgus deformity of ≥15° as compared to those with <15°. We will describe the evolving surgical technique being utilized to tackle these challenging cases.

Fifty ankles with preoperative coronal-plane tibiotalar valgus deformity of ≥15° “valgus” group) and 50 ankles with valgus deformity of <15° (“control” group) underwent TAR. The cohorts were similar with respect to demographics and components used. All TARs were performed by a single surgeon. The mean duration of clinical follow-up was 5.5 years (minimum two years). Preoperative and postoperative radiographic measurements of coronal-plane deformity, Ankle Osteoarthritis Scale (AOS) scores and Short Form (SF)-36 scores were prospectively recorded. All ancillary (intraoperative) and secondary procedures, complications and measurements were collected.

The AOS pain and disability subscale scores decreased significantly in both groups. The improvement in AOS and SF-36 scores did not differ significantly between the groups at the time of the final follow-up. The valgus group underwent more ancillary procedures during the index surgery (80% vs 26%). Tibio-talar deformity improved significantly toward a normal weight-bearing axis in the valgus group. Secondary postoperative procedures were more common in the valgus group (36%) than the controls (20%). Overall, re-operation was not associated with poorer patient outcome scores. Metal component revision surgery occurred in seven patients (three valgus and four controls). These revisions included two deep infections (2%), one in each group, which were converted to hindfoot fusions. Therefore, 94% of the valgus group retained their original components at final follow-up

Thus far, this is the largest reported study that specifically evaluates TAR with significant preoperative valgus alignment, in addition to having the longest follow-up. Satisfactory midterm results were achieved in patients with valgus mal-alignment of ≥15°. The valgus cohort required more procedures during and after their TAR, as well as receiving more novel techniques to balance their TAR. Whilst longer term studies are needed, valgus coronal-plane alignment of ≥15° should not be considered an absolute contraindication to TAR if the associated deformities are addressed.

Aims

The extensive variation in axial rotation of tibial components can lead to coronal plane malalignment. We analyzed the change in coronal alignment induced by tray malrotation.

Background

Recent large studies of third-generation minimally invasive hallux valgus surgery (MIS) have demonstrated significant improvement in clinical and radiological outcomes. It remains unknown whether these clinical and radiological outcomes are maintained in the medium to long-term. The aim of this study was to investigate the five-year clinical and radiological outcomes following third-generation MIS hallux valgus surgery.

Valgus deformity is a relatively common occurrence in rheumatic or degenerative disease of the tarsus. Frequently the angular deformity can exceed 25° ; in these situations dislocations of talo-calcaneal and/or talo-navicular joints can be observed. These conditions are usually progressive and affect the walking ability of the patient The goal of the study is to present a series of patients surgically treated in order to evaluate the best solutions and the problems of the surgical technique. In the period 1996–2002, 22 patients were treated for significant valgus deformity of the rearfoot; 16 were affected by rheumatoid arthritis and six by a degenerative pathology. In all cases combined talo-navicular and talo-calcaneal arthrodesis was performed. In seven patients a bone graft was used to fill bone defects. The follow-up was 5.3 years. The results were evaluated using the AOFAS score for rearfoot; fusion was achieved in all but one case (talo-navicular joint). All patients were satisfied regarding subjective results (pain and function). Combined arthrodesis of talo-calcaneal and talo-navicular joints is an effective method of treating significant valgus deformity of the hindfoot; fixation by screws for talo-calcaneal joint and by staples or screw for talo-navicular joint is the recommended method for synthesis

We present the long-term results of a single institute’s experience of the Mann 3 in 1 procedure. This prospective study initially selected 36 feet (25 patients) with severe hallux valgus, classified by a HV angle < 40° or IM angle> 15°, for the Mann 3 in 1 procedure. Preoperative and postoperative standing radiographs were taken to calculate the correction of the deformity, and a postoperative subjective questionnaire was completed which was based on the assessment criteria suggested by the American Orthopaedic Foot and Ankle Society in 1984. The initial follow-up was completed at up to one year. The original cohort of patients was contacted again at 10 years (range 9–11 years) to repeat the same questionnaire and radiographs. In total 19 patients (27 feet) were contactable with an average age of 51 years (range 34–74). The questionnaire revealed one patient unable to perform the same occupation and three patients unable to perform the same activities due to ongoig problems with the operated feet. Thirteen patients had to wear modified footwear but only 2 required specially made shoes. Sixteen of the nineteen (84%) were pleased or satisfied with pain relief and appearance following the procedure, with 14 stating that they would undergo the procedure again given the same circumstance and 5 patients that would not. The complications included 8 patients requiring screw removal, 2 patients with metatarsalgia, one patient undergoing multiple further corrective procedures and one requiring a second ray amputation for osteomyelitis. Sixteen patients (23 feet) were available for repeat radiographic assessment. This revealed that there had been some recurrence of the deformity with the initial correction of the HV angle being a mean of 40° (range 36–51°) to 15° (9–23°) at up to one year and 23° (0–52°) at ten years. Similarly with the mean IM angle initially corrected from 18° (15–25°) to 8.5°(6–12°), being 14° (7–20°) at ten years. In conclusion, despite some recurrence of the deformity on x-ray the subjective satisfaction with this procedure is good. Care should be taken in patient selection but the Mann 3 in 1 appears to be a good procedure for the correction of severe Hallux Valgus

Introduction

Fibula contributes to weight bearing and serves as a lateral buttress to the talus. Fibular shortening leads to ankle valgus, distal tibial epiphyseal wedging and ankle instability. Trauma, infection and skeletal dyplasias are the common causes of fibular shortening in children. Aim was to review this cohort who underwent fibular lengthening and ankle reconstruction

Purpose

The aim of this study was to compare the accuracy of limb alignment and component positioning after total knee arthroplasty(TKA) performed using fixed or individual distal femoral valgus correction angle(VCA)in valgus knees.

Purpose: There are many different operations for hallux valgus and it is often difficult to know which one to perform. Many of the patients who present with hallux valgus have first ray hypermobility. We use the metatarsocuneiform arthrodesis for the treatment of symptomatic Hallux Valgus with hypermobility of the first ray. We present a retrospective evaluation of the results for a consecutive series from one surgeon. Methods: The patients were evaluated using the American Orthopedic Foot and Ankle Society Score (AOFAS) post operatively. The post operative complications were recorded and the surgical correction measured on the pre and post operative radiographs. Results: 41 metatarsocuneiform arthrodeses were performed in 40 patients. The average hallux valgus angle was 36.8 pre operatively and 7.3 post operatively. The average intermetatarsal angle was 17.3 pre operatively and 6.9 post operatively. The average post operative AOFAS score was 86.4. There were no problems with wound healing. All the arthrodeses had fused at 3 months. Two patients required screw removal. Conclusions: Metatarsocuneiform arthrodesis gives good clinical and radiological results in patients with hallux valgus and a hypermobile first ray

Purpose: The advantages of the Scarf osteotomy are the greater ROM and the ability of better Stabilisation. We had compared our results with this theory. Methods-Results: At 41 patients with mean age 52,5, y(16–70) we made 47 Scarf osteotomies. At 25 patients we made also corrective osteotomies at the kleiner toes. The preoperative criteria for our study were degenerative Osteoarthritis of the 1st MP joint, HV angle> 40° or IM I-II angle> 20°. The postoperative and radiologic control was continued for 11–18 months(M. 18m). 38 patients were very satisfied with the results,2 sat-isfied, 1 patient was claimed for reduced ROM of the 1st PIP joint. The mean rehabilitation time was 2,9 months(1,5–6M). Pre- and postoperative compare had shown a change at AOFAS score from 48 (19–80) to 87 (35–100),change of the HVA from 35,2° (29°–48°) to 16°(4°–33°) and change of the IM I-II angle from 14,7°(11°–19°) to 8,4°(6°–12°). The DMAA didn’t show any particular change. The major shortening of the 1st Metatarsal was 3mm. A t 1 patient we find early osteoarthitic changes, but we have seen no pseudarthrosis or Metatarsal Head Necrosis. At 10 patients we measured the 1st MP joint ROM< 75° and at 1 patient < 30°. Conclusions: The Scarf osteotomy with the modified Mc Bride procedure is an effective method for the treatment of Hallux Valgus

Introduction

Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results.

Aim. To determine differences in knee valgus angles produced during a single leg squat and hip muscle strength between healthy subjects and patients with patellofemoral pain (PFP). To determine correlations between variables of hip muscle strength, knee valgus angle and pain. Study design: Observational study of 20 (8 male 12 female) healthy (H) subjects, matched for age height and weight with 20 (8 male 12 female) PFP patients (mean symptom duration 46.75 weeks). All subjects fulfilled specific inclusion and exclusion criteria. Appropriate Ethical approval was obtained. Measures for both groups were Knee valgus angle during a single leg squat using 2D motion capture and SiliconCoach software for measurement of knee valgus angles, hip abduction, internal and external rotation muscle strength using hand held dynamometry, visual analogue scale for pain. Strength was reported as a percentage of body weight. All measures were taken on the affected leg for PFP subjects and matched for the equivalent leg in healthy group. SiliconCoach was determined to be reliable for intra-rater reliability of knee valgus angle (ICC.996). Results. There were no significant differences in age, height and weight (p=.59,.51,.26 respectively). Significant differences existed in hip abduction strength p=.001(PFP 19.93(9.2), H 32.22(8.26)), Hip internal rotation p=0.001 (PFP 12.94(4.35), H 19.53(6.36)), Hip external rotation p=0.001(PFP 10.00(3.07), H 16.26 (4.62)), Knee Valgus Angles p=0.001(PFP 5.31(2.59), H 2.29 (2.35)). No correlations existed between any of the variables including pain. This preliminary study shows that patients with PFP have larger knee valgus angles when doing a single leg squat and significantly weaker hip muscle strength when compared to healthy subjects. The reason for larger knee angles during single leg squat could be hypothesised as being due to weak hip abductor muscles not sufficiently controlling the alignment of the femur. However no correlations were found for these measures, nor were they found for any of the other variables including pain level. In summary the results indicate that hip musculature strengthening of the rotators and abductors and measures to reduce knee valgus angle should be included in the rehabilitation programme of patients with PFP. Further research with larger numbers of subjects should be developed to investigate this subject

Adolescent hallux valgus is a progressive deformity of childhood. Patients with this disorder complain of pain, deformity, redness at the site of deformity, shoewear limitation and altered cosmesis. Surgery to correct the bunion is considered as pain gets worst, deformity increases or significant shoe wear limitation is present. However, there is still not an uniformly satisfying surgical treatment for the adolescent hallux valgus. This kind of surgery has been often associated with a high rate of recurrence and poor results. The adolescent condition often includes significant metatarsus primus varus as a primary element. This is the reason why isolated soft tissue procedures frequently fail. Surgical treatment often combines first metatarsal osteotomy with a soft tissue realignement of the first metatarsal phalangeal joint. Simmonds and Menelaus in 1960 reported their results with an osteotomy of the base of the first metatarsal in addition to McBride’s soft tissue recostruction. The procedure addresses the three main components of the adolescent hallux valgus deformity: the medial eminence, the hallux valgus and the metatarsus primus varus. Although Simmonds and Menelaus did not use any internal fixation to fix the osteotomy site, they performed a complete transverse osteotomy at the base of the first metatarsus. Besides they used an immobilization for six weeks in the post operative period. We describe a modified procedure where the osteotomy is performed incompletely at the base of the first metatarsal bone and we shortened the post operative immobilization period with a cast for three weeks. Simmonds’ procedure does not interfere with the sesamoid bones while in our method a repositioning of the sesamoids below the metatarsal head has been performed. Materials and methods: From 1997 to 2000, 22 feet in 12 female and 1 male patients were treated surgically with the modified Simmonds-Menelaus bunion procedure. A primary operation was performed on all feet treated. The average age at surgery was 12.4 years (range 10.5 – 14.6 years). Preoperative, postoperative and final follow up evaluation included history, physical examination, record of range of motion of the first metatarsophalangeal joint, anteroposterior and lateral radiograph of the feet in the weight bearing position. Results: Lenght of follow up averaged 3.9 years. The average pre operative Hallux Valgus Angle (HVA) was 31.2°. The average pre operative Inter Metatarsal Angle ( IMA) was 13.5°. The average HVA was reduced to 17.8°; the IMA was reduced to 11.3°. Of the 22 feet with preoperative subluxation of the sesamoids, all feet were improved after operation and none were worse. In order to assess our outcomes we used the duPont bunion rating score, which incorporates objective and subjective criteria. We had 5 excellent and 17 good results. There were no fair or poor results. Conclusion: Our proposed modified procedure is easy to perform and does not need any internal fixation device. The complications linked to the use of the hardware are removed. Our proposed procedure does not interfere with the shape or the length of the first metatarsal and does not preclude the possibility of further surgical correction

Correction of fixed valgus is a challenge in primary TKA. Achieving patello-femoral and femoral-tibial stability requires superficial/deep lateral side releases if non-constrained prostheses are utilized. The medial approach has disadvantages with more reported complications. The direct lateral approach, with/without tubercle osteotomy, is an approach option utilized in two reporting centers. Methods: 255 valgus TKAs with 5- to15-year follow-up were reviewed. Demographics included 91% females, 15% rheumatoid, mean age 69. Prostheses utilized were LCS mobile-bearing (meniscal PCL-retaining/rotating PCL-sacrificing). Patella was non-resurfaced in 90%; cementless fixation in 86%. The direct lateral approach with similar lengthening techniques was used with tubercle osteotomy in one center and osteo-periosteal joint exposure in another. Results: Good/excellent 91%, modified HSS score improvement 57 to 85. Deformity (12) improved < 8 to 12 points (> 15o valgus to < 5o valgus). ROM improved from mean 11o/97o to 1/110o latest. Technical/prosthetic-related complications included: 7 bearing failures (5 meniscal, 2 rotating platform), 2 aseptic loosenings (tibial), 1 patella ligament rupture and 2 screw loosenings in the osteotomy group, 1 patella re-dislocation in a 75-year-old female with dislocation since age 15 (non-osteotomy group), 2 infections, and 1 re-operation for arthrofibrosis . Discussion/Conclusion: Valgus TKA using LCS move-able bearings implanted via a direct lateral approach are highly successful regarding stability and patella tracking. Failures correlate with inadequate/de-stabilizing releases and meniscal PCL-retaining prostheses. Rotating bearings allow for better stability and self-adjustment of common mal-rotation variables. The lateral approach allows for direct (step-wise) lengthening releases, improved patellar tracking, and precise gap balancing

Purpose

To explore the relationship in terms of time scale between pre-operative expectations and postoperative outcomes and satisfaction after Hallux valgus surgery.

Introduction and Objectives: The technique modified by Regnauld makes it possible to correct the MTP angle and the DASA, shorten the first phalange preserving the MTP joint, and its articular congruence and functionality. Assessment of results at 2 years follow-up of 147 cases treated with this technique. Materials and Methods: Causes: Hallux Valgus 111; Hallux Rigidus 36. Sex: Women 114, men 33. mean age 70 years. Associated surgery: Proximal chevron-type osteotomy of the first MTT: 23; Scarft-type diaphyseal osteotomy: 1; osteotomy of the base of the first MTT: 11; double osteotomy: 5; subcapital Weils-type osteotomy: 15. Preoperative AOFAS test score 39.6. Mean follow-up 2.3 years. Pre and postoperative measurement of metatarsophalangeal angles. Postoperative assessment at 1 month, 6 m, 1 year and 2 years with X-ray, AOFAS scale. Results: Postoperative assessment using the AOFAS scale: < 1 month: 65, < 6 months: 78, < 1 year: 89, < 2 year: 82. AOFAS scale at 2 years: Moderate pain 2%. Narrow shoes 11%. Moderate MTP restriction 35%. Severe MTP restriction 2%. Infrequent mobility with severe IP restriction 9%. Asymptomatic malalignment 5%. Subjective assessment: Very satisfied 25%. Satisfied 68%. Not very satisfied 5% (occasional pain). Unsatisfied 2% (daily pain). The evolution of the values of the MTP angle were: preoperative MTP angle 34.7°, MTP angle 4 weeks postoperatively 8.1°, MTP angle at 1 year 14.7°, MTP angle at 2 years18.1°. Discussion and Conclusions: Satisfactory results (93%). This technique corrects the MTP angle, preserves the MTF joint and makes it possible to associate with it other surgical techniques to modify the intermetatarsal angle. By preserving the MTP joint we prevent early evolution of hallux rigidus. Very little loss of MTP correction at 2 years (10°), with no clinical correlation

Aims: Correction of fixed valgus is a challenge in primary TKA. The direct lateral approach, with/without tubercle osteotomy, is an approach option utilized in two reporting centers. Methods: 255 valgus TKA with 5- to15- year follow-up were reviewed. Demographics included 91% females, 15% rheumatoid, mean age 69. Prostheses utilized were LCS mobile-bearing (meniscal PCL-retaining/rotating PCL-sacrificing). Patella was non-resurfaced in 90%; cementless fixation in 86%. Results: Good/excellent 91%, modified HSS score improvement 57 to 85. Deformity (12) improved < 8 to 12 points (> 15° valgus to < 5° valgus). ROM improved from mean 11°/97° to 1/110° latest. Technical/prosthetic-related complications included: 7 bearing failures (5 meniscal, 2 rotating platform), 2 aseptic loosenings (tibial), 1 patella ligament rupture and 2 screw loosenings in the osteotomy group, 1 patella re-dislocation in a 75-year-old female with dislocation since age 15 (non-osteotomy group), 2 infections, and 1 re-operation for arthrofibrosis. Conclusion: Valgus TKA using LCS moveable bearings implanted via a direct lateral approach are highly successful regarding stability and patella tracking. Failures correlate with inadequate/de-stabilizing releases and meniscal PCL-retaining prostheses. Rotating bearings allow for better stability and self-adjustment of common mal-rotation variables. The lateral approach allows for direct (stepwise) lengthening releases, improved patellar tracking, and precise gap balancing

Introduction:. Correction of fixed valgus is a challenge in primary TKA. Achieving patello-femoral and femoral-tibial stability requires superficial/deep lateral side releases if non-constrained prostheses are utilized. The medial approach has disadvantages with more reported complications. The direct lateral approach, with/without tubercle osteotomy, is an approach option utilized in two reporting centers. Methods:. 255 valgus TKAs with 5- to15-year follow-up were reviewed. Demographics included 91% females, 15% rheumatoid, mean age 69. Prostheses utilized were LCS mobile-bearing (meniscal PCL-retaining/rotating PCL-sacrificing). Patella was non-resurfaced in 90%; cement-less fixation in 86%. The direct lateral approach with similar lengthening techniques was used with tubercle osteotomy in one center and osteo-periosteal joint exposure in another. Results:. Good/excellent 91%, modified HSS score improvement 57 to 85. Deformity (12) improved < 8 to 12 points (> 15o valgus to < 5o valgus). ROM improved from mean 11o/97o to 1/110o latest. Technical/prosthetic-related complications included: 7 bearing failures (5 meniscal, 2 rotating platform), 2 aseptic loosenings (tibial), 1 patella ligament rupture and 2 screw loosenings in the osteotomy group, 1 patella re-dislocation in a 75-year-old female with dislocation since age 15 (non-osteotomy group), 2 infections, and 1 re-operation for arthrofibrosis. Discussion/Conclusion:. Valgus TKA using LCS moveable bearings implanted via a direct lateral approach are highly successful regarding stability and patella tracking. Failures correlate with inadequate/de-stabilizing releases and meniscal PCL-retaining prostheses. Rotating bearings allow for better stability and self-adjustment of common mal-rotation variables. The lateral approach allows for direct (stepwise) lengthening releases, improved patellar tracking, and precise gap balancing

Abstract

Background

There are many different procedures described for the correction of hallux valgus deformity. Minimally invasive surgery has become increasingly popular, with clinical and radiological outcomes comparable to traditional open osteotomy approaches. There is increasing interest in hallux valgus deformity correction using third-generation minimally invasive chevron akin osteotomy (MICA) technique.

Abstract

The lateral compartment is predominantly affected in approximately 10% of patients with osteoarthritis of the knee. The anatomy, kinematics and loading during movement differ considerably between medial and lateral compartments of the knee. This in the main explains the relative protection of the lateral compartment compared with the medial compartment in the development of osteoarthritis. The aetiology of lateral compartment osteoarthritis can be idiopathic, usually affecting the femur, or secondary to trauma commonly affecting the tibia. Surgical management of lateral compartment osteoarthritis can include osteotomy, unicompartmental knee replacement and total knee replacement. This review discusses the biomechanics, pathogenesis and development of lateral compartment osteoarthritis and its management.

Cite this article: Bone Joint J 2013;95-B:436–44.

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach.

Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption.

During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively.

For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control.

Purpose: It was demonstrated in 1986 that to obtain a good radioclinical result at 10–13 years after valgus tibial osteotomy for the treatment of medial femorotibial osteoarthritis that the frontal valgus at this follow-up had to be 3–6°. In 1995, it was demonstrated that the side of deterioration in knees initially aligned between 2° varus and 2° valgus or with genu valgum (≥ 3° valgus) depended on the tibiofemoral axis: a positive index (tibial torsion greater than femoral torsion) favouring medial femorotibial deterioration and progressive varisation, and a negative index favouring lateral femorotibial deterioration and progressive valgisation. Can the post-osteotomy valgus be modified by the tibiofemoral index and prevent obtaining ideal correction at 10–13 years?

Material and methods: Forty-five knees with femortibial deterioration of the medial compartment were treated between 1987 and 1990 by tibial medial opening osteotomy for valgisation. Functional outcome in the 45 knees was assessed at a mean follow-up of 11 years (range 10–13 years). Postoperative frontal axis after healing and frontal axis at last follow-up was measured by goniometry in the standing position for all knees. A scan in the torsion position was obtained for 36 knees to measure the tibiofemoral index.

Results: At maximum follow-up, outcome was good in 58% of the knees, fair in 24%, and poor in 18%, differences which were not statistically different. Frontal axis changed with time. Among the 36 knees which had been realigned correctly (3–6° valgus) after healing, four exhibited an increase in valgus beyond 6° and five lost valgus passing below 3°. But ideal valgus was achieved at last follow-up for three of five knees which had been undercorrected, Among the 38 knees for which a torsion scan was available, 33 were correctly realigned postoperatively and 22 were well aligned at last follow-up. There was no statistical difference between knees with good, fair, or poor outcome among the 33 knees well corrected postoperatively (3–6° valgus). There was however a statistical difference between the good (64%), fair (27%), and poor (9%) functional results among knees with ideal valgus at last follow-up (p = 0.03).

The variation between the postoperative and last follow-up goniometry data exhibited a statistical correlation with the tibiofemoral index (p = 0.0005). If the index was less than 13°, most of the knees showed an increase in valgus (13 out of 19 knees); if valgus was greater than or equal to 13°, valgus was lost (for 12 of 19 knees).

Conclusion: To have the best chance of obtaining a good functional result 10 to 13 years after tibial osteotomy for valgisation, the valgus at this follow-up must be between 3° and 6°. But to achieve this valgus, the postoperative valgus must be modulated in relation to the tibiofemoral index. For an index ≥ 13°, the postoperative valgus should be pushed towards 6°; for an index < 13°, valgisation should aim at achieving a 3° postoperative valgus or less.

Abstract

Internal lengthening devices in the femur lengthen along the anatomical axis, potentially creating lateral shift of the mechanical axis. We aimed to determine whether femoral lengthening along the anatomical axis has an inadvertent effect on lower limb alignment. Isolated femoral lengthening using the Intramedullary Skeletal Kinetic Distractor was performed in 27 femora in 24 patients (mean age 32 years (16 to 57)). Patients who underwent simultaneous realignment procedures or concurrent tibial lengthening, or who developed mal- or nonunion, were excluded. Pre-operative and six-month post-operative radiographs were used to measure lower limb alignment. The mean lengthening achieved was 4.4 cm (1.5 to 8.0). In 26 of 27 limbs, the mechanical axis shifted laterally by a mean of 1.0 mm/cm of lengthening (0 to 3.5). In one femur that was initially in varus, a 3 mm medial shift occurred during a lengthening of 2.2 cm.

In a normally aligned limb, intramedullary lengthening along the anatomical axis of the femur results in a lateral shift of the mechanical axis by approximately 1 mm for each 1 cm of lengthening.

Introduction

Acquiring adaptive soft-tissue balance is one of the most important factors in total knee arthroplasty (TKA). However, there have been few reports regarding to alteration of tolerability of varus/valgus stress between before and after TKA. In particular, there is no enough data about mid-flexion stability. Based on these backgrounds, it is hypothesized that alteration of varus/valgus tolerance may influence post-operative results in TKA. The purpose of this study is an investigation of in vivo kinematic analyses of tolerability of varus/valgus stress before and after TKA, comparing to clinical results.

Deformity correction is a fundamental goal in total knee arthroplasty. Severe valgus deformities often present the surgeon with a complex challenge. These deformities are associated with abnormal bone anatomy, ligament laxity and soft tissue contractures. Distorted bone anatomy is due to bone loss on the lateral femoral condyle, especially posteriorly. To a lesser extent bone loss occurs from the lateral tibia plateau. The AP axis (Whiteside's Line) or epicondylar axis must be used as a rotational landmark in the severely valgus knee. Gap balancing techniques can be helpful in the severely valgus knee, but good extension balance must be obtained before setting femoral rotation with this technique. Coronal alignment is generally corrected to neutral or 2- to 3-degree overcorrection to mild mechanical varus to unload the attenuated medial ligaments.

The goal of soft tissue releases is to obtain rectangular flexion and extension gaps. Soft tissue releases involve the IT band, posterolateral corner/arcuate complex, posterior capsule, LCL, and popliteus tendon. Assessment of which structures is made and then releases are performed. In general, pie crust release of the IT band is sufficient for mild deformity. More severe deformities require release of the posterolateral corner / arcuate and posterior capsule. I prefer a pie crust technique, while Ranawat has described the use of electrocautery to perform these posterior/ posterolateral releases. In most cases the LCL is not released, however, this can be released from the lateral epicondyle, if necessary.

Good ligament balance can be obtained in most cases, however, some cases with severe medial ligament attenuation require additional ligament constraint such as a constrained condylar implant.

Deformity correction is a fundamental goal in total knee arthroplasty. Severe valgus deformities often present the surgeon with a complex challenge. These deformities are associated with abnormal bone anatomy, ligament laxity and soft tissue contractures. Distorted bone anatomy is due to bone loss on the lateral femoral condyle, especially posteriorly. To a lesser extent bone loss occurs from the lateral tibia plateau. The AP Axis (Whiteside's Line) or Epicondylar axis must be used as a rotational landmark in the severely valgus knee. Gap balancing techniques can be helpful in the severely valgus knee, but good extension balance must be obtained before setting femoral rotation with this technique. Coronal alignment is generally corrected to neutral or 2- to 3-degree overcorrection to mild mechanical varus to unload the attenuated medial ligaments.

The goal of soft tissue releases is to obtain rectangular flexion and extension gaps. Soft tissue releases involve the IT band, Posterolateral Corner/Arcuate Complex, Posterior Capsule, LCL, and Popliteus Tendon. Assessment of which structures is made and then releases are performed. In general Pie Crust release of the ITB is sufficient for mild deformity. More severe deformities require release of the Posterolateral Corner/Arcuate Complex and Posterior Capsule. I prefer a pie crust technique, while Ranawat has described the use of electrocautery to perform these posterior/ posterolateral releases. In most cases the LCL is not released, however, this can be released from the lateral epicondyle, if necessary.

Good ligament balance can be obtained in most cases, however, some cases with severe medial ligament attenuation require additional ligament constraint such as a constrained condylar implant.

Introduction

The deformity in osteoarthritis (OA) of the knee has been evaluated mainly in the frontal plane two dimensional X-ray using femorotibial angle. Although the presence of underlying rotational deformity in the varus knee and coexisting hip abnormality in the valgus knee have been suggested, three dimensional (3D) deformities in the varus and valgus knee were still unknown. We evaluated the 3D deformities of the varus and valgus knee using 3D bone models.

Introduction

The management of adolescent hallux valgus (AHV) remains controversial, with reservations about both conservative and surgical treatments. Non-operative management has a limited role in preventing progression. Surgical correction of AHV has, amongst other concerns, been associated with a high prevalence of recurrence of deformity after surgery. We conducted a systematic review to assess clinical and radiological outcomes following surgery for AHV.

Background

Plate fixation is one of several options available to surgeons for the management of pediatric femur fractures. Recent literature reports distal femoral valgus can be a complication following lateral plate fixation of femur fractures. We report on a case of extreme distal femoral valgus deformity and a lateral dislocation of the patella four years after having plate fixation of a left distal femoral fracture.

The management of adolescent hallux valgus presents a considerable challenge for the orthopaedic foot surgeon. Those presenting fall into two groups, idiopathic and neuromuscular. The management of the symptomatic hallux in neuromuscular cases is more clearly defined with arthrodeses of the first metatarsal-phalangeal joint being the treatment of choice. This affords the most consistent long-term results and the greatest degree of correction.

In the idiopathic symptomatic hallux valgus the treatment is more variable depending on the severity of the deformity and the underlying pathological changes. The demographics of adolescent hallux valgus and its associated abnormalities are discussed. There is a higher incidence of an increase in the distal metatarsal articular angle in severe cases where combined surgical intervention in the form of double and triple osteotomies may be required to achieve long-term correction and a treatment algorithm is presented. Since approximately half of symptomatic patients will be under 10 years of age with significant residual growth early surgical intervention has a higher recurrence than in the mature foot.

Objectives

Our objective was to perform a systematic review of the literature and conduct a meta- analysis to investigate the effect of initial varus or valgus displacement of proximal humerus on the outcomes of patients with proximal humerus fractures treated with open reduction and internal fixation.

Aims

The aim of this retrospective study was to measure and determine variation in VCA between the two limbs in a patient with windswept deformity on preoperative full-length, standing, hip-to-ankle radiographs. We hypothesised that there will be significant difference in VCA between the two limbs of a patient with arthritic windswept deformity and therefore it is necessary to individualise VCA for each limb preoperatively on full-length radiographs during TKA.

Precise biomechanical knowledge of individual components of the MCL is critical for proper MCL release during TKA. This study was to define the influences of the deep MCL and the POL on valgus and rotatory stability in TKA using six cadaveric knees with sequential sectioning sequence. A CT-free navigation system monitored motion after application of valgus loads and internal and external rotation torques at 0°, 20°, 30°, 60°, and 90°of knee flexion. Significant increases of rotatory instability were seen on release of the deep MCL. And, rotatory instability further increased after release of the POL. Surgical approach of retaining the deep MCL and POL has a possibility to improve the outcome after primary TKA.

The cementless Oxford unicompartmental knee replacement has been demonstrated to have superior fixation on radiographs and a similar early complication rate compared with the cemented version. However, a small number of cases have come to our attention where, after an apparently successful procedure, the tibial component subsides into a valgus position with an increased posterior slope, before becoming well-fixed. We present the clinical and radiological findings of these six patients and describe their natural history and the likely causes. Two underwent revision in the early post-operative period, and in four the implant stabilised and became well-fixed radiologically with a good functional outcome.

This situation appears to be avoidable by minor modifications to the operative technique, and it appears that it can be treated conservatively in most patients.

Cite this article: Bone Joint J 2014;96-B:345–9.

1. An operation suitable for the correction of hallux valgus in adolescents is described.

2. The results of thirty-three operations performed in children between the ages of nine and eighteen years are analysed.

3. Twenty-six operations are considered to have produced a good result, four a moderate result, and three a poor result.

4. It is suggested that the operation is best performed between the ages of eleven and fifteen years.

1. The anatomy of the forefoot in hallux valgus is compared with the normal, with a review of the literature and descriptions of anatomical preparations, observations at operation and radiographs.

2. The early and essential lesions are stretching of the ligaments on the medial side of the metatarso-phalangeal joint that attach the medial sesamoid and basal phalanx to the metatarsal, and erosion of the ridge that separates the grooves for the sesamoids on the metatarsal head.

3. In established hallux valgus a sagittal groove, formed where the cartilage is free from pressure by either the phalanx or the ligaments, cuts off a medial eminence, which articulates with the stretched ligaments, from a restricted area for the phalanx.

4. Apart from osteophytic lipping which squares off the outline of the eminence as it is seen in radiographs and a small amount of lipping of the ridge on the metatarsal there is no evidence of new bone growth. In chronic cases the eminence may degenerate or disappear.

5. The articular surfaces at the cuneo-metatarsal joint become adapted to the changed positions of the metatarsal without gross pathological change.

6. The four deep transverse ligaments that bind together the five plantar pads of the metatarso-phalangeal joints are not unduly stretched, so that as the metatarsals spread it is the ligaments that bind the pads to the heads of the metatarsals that give way.

7. The plantar metatarsal artery to the first space pursues a tortuous course between the two heads of the flexor hallucis brevis. In hallux valgus the course becomes still more tortuous and part of the pain experienced may be due to ischaemic effects.

A survey of this type cannot be used to point to any definite factor or factors predisposing to the development of hallux valgus. Nevertheless, a comparison of measurements in the morbid and control groups shows several outstanding differences:

1) There was a high degree of correlation between valgus and intermetatarsal angle in the two groups combined (coefficient, 0·7) but the correlation was higher in those cases with a degree of valgus greater than 25 degrees than in the remainder (coefficients, 0·36 and 0·53).

2) In the control group the first metatarsal was longer than tile second by a mean measure of 2 millimetres; in the morbid group by a mean measure of 4 millimetres. For a high degree of valgus and a low intermetatarsal angle the first metatarsal tends to be longer than the second by a significantly greater amount than when the high valgus is associated with iligh intermetatarsal angle.

3) In 90 per cent of the control cases there was a lateral displacement of the medial sesamoid of the first metatarsal of 3 degrees or less, whereas 88 per cent of the morbid group showed a displacement of 4 degrees or more. There was very little overlap in the distributions of this observation in the two groups. There was a high correlation between the degree of this displacement and the severity of hallux valgus.

4) Rotation of the hallux was not observed among the controls; in the morbid group those cases showing rotation had an average degree of valgus of 36 degrees while the rest had an average of 19 degrees. The mean degree of valgus in the morbid group was 32·0 degrees and that of the controls 15·5 degrees. The mean angle between the axes of the first and second metatarsals was 13·0 degrees in the morbid group and 8·5 degrees in the controls.

Since tile morbid group consisted largely of women (98 per cent) it is important to know that in the control group the only measure showing a statistically significant sex difference is that of intermetatarsal angle, but that, even so, the mean difference is only 1·3 degrees. Thus tile sex difference between the two groups is probably only of minor importance. The role of age in influencing the observations cannot be clearly elucidated from the data at present available. It can only be stated that there is no positive indication that age is a controlling factor in the departure observed in the morbid group from the control observations.

Introduction

Hallux valgus surgical correction has a variable but significant risk of recurrence. Symptoms result from an iatrogenic first brachymetatarsia following the index surgical procedure. First metatarsal shortening has been shown to correlate with the onset of transfer metatarsalgia. We describe the use of the scarf osteotomy to both correct the recurrent deformity and lengthen the shortened first metatarsal.

Background

We have performed total knee arthroplasties for valgus and varus in the knees of one person and investigate the clinical characteristics of these patients and the relationship between the kind of deformity and postoperative result.

Valgus knee unloader braces are often prescribed as treatment for knee osteoarthritis (OA). These braces are designed to redistribute the loading in the knee, thereby reducing medial contact forces. Patient response to bracing is variable; some patients experience improvements in joint loading, pain, and function, others see little to no effect. We hypothesised that patients who experienced beneficial response to the brace, measured by reductions in medial contact force, could be predicted based on static and dynamic measures.

Participants completed a WOMAC questionnaire and walked overground with and without an OA Assist knee brace in a motion capture lab. Eighteen patients with medial compartment OA (8 female, 53.8±7.0 years, BMI 30.3±4.1, median Kellgren-Lawrence grade 4 (range 1–4)) were evaluated. The abduction moment applied by the brace was estimated by multiplying brace deflection by the pre-determined brace stiffness. A generic musculoskeletal model was scaled for each participant based on standing full length radiographs and anatomical markers. Inverse kinematics, inverse dynamics, residual reduction, and muscle analysis were completed in OpenSim 3.2. A static optimisation was then performed to estimate muscle forces and then tibiofemoral contact forces were calculated. Brace effectiveness was defined by the difference in the first peak of the medial contact force between braced and unbraced conditions. Principal component analysis was performed on the hip, knee, and ankle angles and moments from the unbraced walking condition to extract the principal component (PC) scores for these variables. A linear regression procedure was used to determine which variables related to brace effectiveness. Potential regressors included: hip-knee-ankle angle and medial joint space measured radiographically; KL grade; mass; WOMAC scores; unbraced walking speed; and the first two principal component scores for each of the unbraced hip, knee, and ankle joint angles and moments.

KL grade, walking speed, and hip adduction moment PC1, which represented the magnitude of the first peak were all found to be correlated with change in medial contact force. The brace was more successful in reducing medial contact force in subjects with higher KL grades, faster self-selected walking speeds, and larger peak external hip adduction moments. The R2 value for the overall regression model was 0.78.

The best predictor of brace effectiveness was the hip adduction moment, indicating the need to consider dynamic measures. Participants who had hip adduction moments and walking speeds similar to those of their healthy counterparts saw a greater reduction in medial contact force. Thus, those who responded to bracing had more severe OA as measured by the KL grade but had not experienced changes in their hip adduction moment due to OA. The results of this study suggest that there is potential for an objective criterion for valgus knee brace use to be established.

In hallux valgus (HV), toe pronation is frequently seen, although there may be some with no pronation.

This paper tests the null hypothesis that there is no difference in recurrence for mild and moderate hallux valgus treated with Scarf osteotomy in the presence of a disrupted Meary's line compared to an intact line.

At a minimum of 3 months follow up we retrospectively analysed radiographs, theatre and clinic notes of 74 consecutive patients treated with Scarf osteotomy for mild and moderate hallux valgus at a single centre. The patients were divided into Group A (n=30) – patients who on pre-operative weight bearing radiographs had a disrupted Meary's line, and Group B (n=44) – those with a normal Meary's line on pre-operative weight bearing radiographs.

Our results demonstrate a statistically significant higher recurrence in group A compared to Group B with an odds ratio of 5.2 p = 0.006 [95% CI 1.6–6]. The association between a disrupted Meary's line and increased risk of recurrence for Scarf osteotomy remains valid and strengthened to an odds ratio of 7.1 p = 0.015 [95% CI 1.46 −34.4] when adjusted for confounding variables of age, sex and pre-operative IMA. On this basis we reject the Null hypothesis.

In group A two out of 30 patients required revision surgery whilst none of the 44 patients in group B needed revision. In Group A the degree of IMA correction achieved equalled 8.1 degrees with a pre and post IMA of 16.0 and 7.9 degrees respectively. For Group B the degree of correction was 8.0 degrees with a pre and post IMA of 14.3 and 6.3 degrees respectively. Eight complications were reported in Group A and 9 in Group B.

Our results demonstrate a statistically significant increased risk of recurrence when scarf osteotomy is performed for mild and moderate hallux valgus in the presence of a disrupted Meary's line.

Introduction

Proper alignment of the components and soft tissue balance are the two factors that determine the long term outcome of total knee arthroplasty (TKA). On the femoral side a distal cut made perpendicular to the MA will restore the MA of the leg. Different methods are commonly used to resect the femur perpendicular to its MA. In uncomplicated cases, most surgeons routinely use a fixed valgus cut angle (VCA) of 5° or 6°. Various studies have questioned the use of fixed valgus angle resection to restore the mechanical axis. The purpose of this prospective study is to analyze the variability in the valgus angle following computer assisted TKA.

Introduction:

It has been shown that inadequate reduction of the sesamoids can lead to recurrent hallux valgus. It can be difficult however to assess the sesamoid position. We propose a simple method of grading sesamoid position; the sesamoid width ratio. We aim to assess for a difference in ratio between those with and without hallux valgus and subsequent correlation with increased deformity. The new grading system can then be tested for inter-observer reliability.

Congenital hallux varus had been a well-described condition for many years before acquired hallux varus as a condition arising from bunion correction was not described until 1935. In that year, McBride discussed this potential problem when describing this as a potential problem from his described technique, identifying possible mechanisms to prevent the disorder from occurring. Authors such as Joplin and Kelikian echoed the concept in the early 1960's, spawning a series of corrective procedures. Miller brought this to common practice in 1975, describing the tendon imbalance seen across the precarious 1^st MTP joint.

The first metatarsophalangeal joint moves in the sagittal plane, dorsiflexion and plantarflexion only. Four intrinsic muscles stabilize the digit, with the abductor and adductor hallucis taking the lion share of this function. The abductor tendon actually functions primarily as a plantarflexor of the first metatarsophalangeal joint 83% of the time (Thompson) due to its primary plantar location. This fact, in combination with the pronation generally seen in severe bunion deformities, contributes to acquired hallux varus following bunion correction. Besides the obvious cause of over-correction of the metatarsal osteotomy creating hallux varus, imbalance of the tendon complex post-operatively can create an equally catastrophic circumstance. Hawkins demonstrated that severing the adductor tendon complex (the conjoined tendon) will not product hallux varus when the hallux is not rotated. However, in more severe hallux valgus, pronation of the hallux may be proportional to the deformity of the hallux itself. This rotational deformity places the insertions of the abductor (and medial insertion of the flexor brevis) more plantarward and lateral, increasing the valgus deformity. If the entire conjoined tendon is sectioned and the internal rotation deformity corrected the insertion of the contracted abductor moves medially, pulling the toe into varus. If the center of the base of the proximal phalanx is brought beyond the mid-point of the first metatarsal head, the extensor hallucis longus will bowstring, pulling the great toe into varus while creating a hallux flexus deformity. Finally, if the lesser toes are in varus and not corrected, this deforming force will create hallux varus following bunion correction with a lateral release. The message is clear: not all patients require a lateral release, and, if done, should be done with caution.

Once present, correction can be difficult. Tendon transfers utilizing the extensor hallucis longus (Johnson) or extensor hallucis brevis (Myerson) only have beneficial effects in non-arthritic, mobile first metatarsophalangeal joints. In addition, if metatarsal deformity is not corrected, the deformity will recur. Thus, in many circumstances, arthrodesis of the first metatarsophalangeal joint becomes the treatment of choice, and is commensurate with a disappointed patient who underwent a primary bunion correction and was left with a fused great toe.

This lecture will explore the above mechanism and salvage situations, in hopes of eliminating this unwelcomed outcome from your practice.

Sugioka trans-trochanteric valgus osteotomy (TVO) has originally been described for advanced osteoarthritis of hip. This has many advantages over conventional subtrochanteric osteotomies such as early union with simple fixation and preserving proximal femoral geometry to enable standard femoral components for a future hip replacement. Lateral displacement and distalisation of the greater trochanter increases the lever arm and improves abductor limp. The use of TVO has never been reported in children. We report our experience of TVO for hinge abduction in children (mostly in Perthes' disease).

Twenty four patients of mean age 10.2 years at surgery, (range 7- 17 years) underwent TVO between 1998 and 2007. The diagnosis was Perthes' disease in 19 and avascular necrosis from other causes in the remaining five. Average follow-up was 4.4 years (18 months to 11 years). All patients had pre-operative confirmation of hinge abduction by arthrogram. Osteotomies were performed at inter-trochanteric level and fixed with screws and wire.

The neck shaft angle increased by mean 11.75 degrees (range 6 to 23). Migration index increased by mean 3.88% (-14% to + 29%). Average limb length discrepancy at final follow-up was 10.8 mm (range -30 to +10mm). Final articulo-trochanteric distance was 4.5mm (range -15 to +21 mm) less than the opposite side. Functional assessment was carried out using the Modified IOWA hip scores. The mean hip score was 75.1 (range 38.8 to 97.6). Complications were one case of trochanteric non-union requiring further surgery, one case of stiffness which responded to manipulation under anaesthesia.

Our results indicate that Sugioka TVO is a successful procedure for hinge abduction of the hip.

1. Arthrodesis of the first metatarso-phalangeal joint combined with excision of those lesser metatarsal heads with fixed subluxation and painful callosities is an excellent treatment for painful hallux valgus with metatarsalgia.

2. A series of thirty feet in twenty-five patients is reported in which this combined operation was done.

1. A survey has been made of 518 operations for hallux valgus and hallux rigidus.

2. The methods of critical examination used in this survey are described.

3. The results obtained have led to the formulation of certain views on etiology and modes of treatment.

4. In hallux valgus in the adolescent, operations aimed at correcting the primary deformity are justifiable when correctly performed, though the exact form such operations should take still requires further study.

5. In hallux valgus in the adult, arthroplasty offers a reasonably good solution in the well chosen case, though no one should consider that the results are so good as to make unnecessary any further research in this field. Metatarsal osteotomy has in the adult only a limited sphere of application.

6. In hallux rigidus arthroplasty alone has no place in the treatment of the adult cases showing metatarsus primus elevatus, nor in the adolescent case. The possibilities of other methods of operative treatment, notably osteotomy, are discussed.

Objectives

The approach in total knee arthroplasty (TKA) with severe valgus deformity is controversial. The lateral parapatellar approach has been proposed for several years, but surgical technique of this approach was unusual and difficult. Therefore, we have consistently been selected medial parapatellar approach (MPP) for all cases. In this study, we investigated the short term results of TKA for severe valgus deformity with MPP about clinical and radiographic assessment.

Purpose of the study: Static metatarsalgia is a common complaint in podology surgery. Most cases are related to the great toe, but in certain cases, isolated metatarsal disharmony, without hallux vlgus, can be observed. We report 45 such cases.

Material and methods: This was a retrospective analysis of isolated metatarsal disharmony observed in patients who underwent metatarsal surgery between 1986 and 2003. There were 36 women and 9 men, mean age 49 years. Three subgroups were distinguished: posttraumatic disharmony, isolated disharmony of the second ray, iatrogenic disharmony. Conditions related to rheumatoid disease, aseptic osteonecrosis of the metatarsal heads, and rear foot disorders were excluded. Surgical treatment was osteotomy of the base of the metatarsal for 24 patients, and Weil’s osteotomy for 21. Clinical and radiological assessment used the Kitaoko and Maestro criteria.

Results: Mean preoperative score was 38 (range 21–58). Mean gain one year after osteotomy was 35 points. The score was 76 after osteotomy of the metatarsal base and 79 after Weil osteotomy. The less favorable results were observed in the group of posttraumatic metatarsalgias. Outcom was less satisfactory in the male population where residual metatarsalgia was noted in 75%. Reflex dystrophy occurred in 15% of the patients who had multiple osteotomies. Radiographically, The SM4 line was centered with progressive geometry in 50%.

Discussion: While the short-term results obtained with these two surgical methods were similar, osteotomy of the metatarsal base offers better long-term outcome. The osteotomy improved the functional score, even without improvement of radiological criteria. Initial treatment of metatarsal fractures should attempt to restore correct alignment of the metatarsals because of the poor results obtained with corrective osteotomy for posttraumatic misalignment.

Conclusion: When metatarsal disharmony is symptomatic, we propose osteotomy of the base of the metatarsals for the median rays in order to avoid transfer metatarsalgia. Complementary osteotomy of the fifth metatarsal is not always necessary.

Introduction: Hallux valgus is a common foot deformity. A widely used method for correction of mild and moderate hallux valgus is a distal metatarsal (Chevron) osteotomy. The purpose of this study was to assess the results of a percutaneous chevron osteotomy two years after my first communication in Arcachon.

Patients and method: The operation is performed by one senior surgeon. The patient is placed in the supine position. The foot is allowed to overhang the end of the table. No tourniquet is used. The procedure is controlled by fluoroscopy. The chevron osteotomy is undertaken with a Shannon burr of 12 mm and a 20 mm for the last case. The axis of translation is determined preoperatively and adapted to the foot: more or less plantar displacement of the metatarsal head, or, more or less shortening of the metatarsal itself. The translation of the head is controlled by a temporary intramedullary K-wire inserted medially. The fixation is with an absorbable k-wire for one part and by screw for the other part. The medial exostosis is not systematically removed. The procedure is completed by an Akin osteotomy in 90%. A lateral release procedure is performed percutaneously.

Results: The mean age of the patients was 55 years at time of operation. At the follow-up of 3 months all patients are examined and X-Ray’s taken. The Kitaoka score increased from 45 to 89. The hallux valgus angle decreases from 37° to 10°. The metatarsus varus is 10°. Three patients need a new surgery for a secondary displacement. Our results are comparable to those published for open chevron osteotomy in terms of correction of the HV and intermetatarsal angles.

To assess the reliability of the pre-operative measurement methods used in the management of the hallux valgus deformity, five observers assessed 50 pre-operative standing foot radiographs on two occasions in order to assess the reliability of radiological hallux valgus assessment using the inter-metatarsal angle (IMA), hallux valgus angle (HVA) and joint congruency. Five published methods of angle measurements described by Hawkins, Venning and Hardy, Mitchell, Miller and Nestor were used.

Kappa statistics were used to assess the reliability of the diagnosis of congruency. Regarding IMA and HVA, mean values between the methods were assessed by one-way ANOVA. The differences between the methods and observers were assessed by two-way ANOVA.

Results: Diagnosis of congruency showed good agreement (k=0.608) over two occasions, although this did vary by observer.

The mean IMA and HVA measurements varied significantly between methods on both occasions (p< 0.0001). Mitchell’s method had the lowest and Miller’s the highest mean values.

Analysis of variance showed both method and observer variations were significant for IMA. But HVA measurements differed significantly only by observers.

Conclusion: The reliability of IMA and HVA measurements is poor whichever measuring method is used and these methods are not interchangeable. Study papers should state the measurement method used. For the pre- and post-operative assessment the same method should be used.

Hallux valgus is a common condition often leading to significant symptoms. However, its correction has recently been suggested, to be a procedure of limited clinical value. Scarf osteotomy is one of the most commonly performed operations for hallux valgus correction. Although technically demanding, it is powerful in its capacity to correct the hallux valgus deformity and sufficiently robust with internal fixation to allow early weight bearing.

We prospectively collected data for consecutive scarf osteotomies between 2008 and 2011. Preoperative and 6 week postoperative assessment was made using radiographic measurements HVA (hallux-valgus angle) and IMA (inter metatarsal angle). We evaluated 130 scarf osteotomies. The mean HVA improved from 29.5 pre-operatively to 12.6 post correction. The mean IMA improved from 12.4 pre-operatively to 8.1 post correction. The AOFAS hallux scores improved from an average of 55 pre op to 79 post operation.

The results suggest that hallux valgus correction does have clinical value and that scarf osteotomy is a reproducible procedure, with a generally good to excellent results in the short term.

Deformity correction is a fundamental goal in Total Knee Arthroplasty. Severe valgus deformities often present the surgeon with a complex challenge. These deformities are associated with abnormal bone anatomy, ligament laxity and soft tissue contractures. Distorted bone anatomy is due to bone loss on the lateral femoral condyle, especially posteriorly. To a lesser extent bone loss occurs from the lateral tibia plateau. The AP Axis (Whiteside's Line) or Epicondylar axis must be used as a rotational landmark in the severely valgus knee. Gap balancing techniques can be helpful in the severely valgus knee, but good extension balance must be obtained before setting femoral rotation with this technique. Coronal alignment is generally corrected to neutral or 2 to 3 degree overcorrection to mild mechanical varus to unload the attenuated medial ligaments.

The goal of soft tissue releases is to obtain rectangular flexion and extension gaps. Soft tissue releases involve the IT band, Posterolateral corner/Accurate Complex, Posterior Capsule, LCL, and Popliteus Tendon. Assessment of which structures is made and then releases are performed. In general Pie Crust release of the ITB is sufficient for mild deformity. More severe deformities require release of the Posterolateral corner/Accurate Complex and Posterior Capsule. I prefer a pie crust technique, while Ranawat has described the use of electrocautery to perform these posterior/ posterolateral releases. In most cases the LCL is not released, however, this can be released from the lateral epicondyle if necessary.

Good ligament balance can be obtained in most cases, however, some cases with severe medial ligament attenuation require additional ligament constraint such as a constrained condylar implant.

Introduction

Knee joint should be aligned for reconstruction of the function in Total Knee Replacement(TKR). Although a surgeon try to correct the alignment of a knee joint, sometimes varus/valgus alignment has been tried in order to reconstruct function of knee joint. As a result, the varus or valgus alignment affects to ligaments and soft tissue, and the contact condition is changed between femoral component and tibial insert. One of important factor, wear characteristics of an implant can be changed due to the contact condition. In this study, we performed static contact tests from extension to flexion in varus and valgus to define the effect to contact condition when the alignment is varus or valgus.

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.

Purpose: Scarf osteotomies are commonly performed in adults with symptomatic bunions. We have reported the radiological and clinical outcome of this procedure in the treatment of moderate to severe hallux valgus among adolescent children.

Methods: Data was collected retrospectively from a tertiary referral children hospital between April 2001 and June 2006. The pre and postoperative intermetatarsal angle (IMA), hallux valgus angle (HVA) and distal metatarsal articular angle (DMAA) were determined. Patients were followed up for a mean of 8.6 months (3–18).

Results: 23 scarf osteotomies were performed in 16 patients with a mean age of 14.3 years (12–18). The mean pre operative IMA of 14.4 degrees was improved to a postoperative value of 9.3 degrees, p< 0.0001. The mean HVA angle was improved from 34.7 to 16.5 degrees, p< 0.0001. The DMAA was improved from 13.1 to 8 degrees, p< 0.0001. There were 2 cases of superficial wound infections successfully treated with oral antibiotics. One patient developed a complex regional pain syndrome that resolved with physiotherapy and analgesia.

Conclusion: We believe that scarf osteotomy is a safe and effective option for the management of the adolescent symptomatic bunions.

Significance: There are no published reports in the English literature of scarf osteotomy in the management of adolescent children with symptomatic hallux valgus. The aim of this paper is to report the radiological and clinical outcome of scarf osteotomy in the treatment of moderate to severe hallux valgus among adolescent children.

Background

Metatarsus adductus is the most common forefoot deformity. Variable prevalence values were reported in literature using different techniques in different populations.

Numerous radiological measurements have been proposed to assess this deformity with a paucity of studies reporting the reliability of these methods.

The metatarsus adductus angle was shown to correlate with the severity of hallux abductovalgus in normal feet and preselected populations of juvenile hallux valgus.

Safely obtaining adequate exposure is an integral step in successfully performing a Total Knee Arthroplasty. In this study, we look at approaching the valgus knee through a lateral arthrotomy and tibial tubercle osteotomy.

20 knees in 19 consecutive patients with valgus deformities are included in this study (2006 to 2010). LCS mobile bearing prostheses were implanted by a single senior surgeon (GF). Navigation was used for all the knees. The knee is approached throught a skin incision 5–10mm more lateral than the standard midline incision. The lateral arthrotomy is made to Gerdy's tubercle 7–10cm distal to Tibial Tendon insertion. 7cm long and 2cm wide osteotomy is performed. Richards staples are used to fix the osteotomy once the prosthesis is fixed. All patients were followed up by the operating surgeon.

All osteotomies united. 2 postoperative complications were encountered during follow up. One patient had a postoperative haematoma that was washed out. A second patient had a fall 6/52 post-op and sustained a minimally displaced fracture at the navigation pin site (Tibia). This was treated in a cylinder cast and went onto full union.

Our technique of lateral arthrotomy and TTO in the valgus knee is safe and predictable. It delivers wider exposure, facilitates soft tissue management, preserves viability of the extensor mechanism and allows some movement of the tibial tubercle for improved patella tracking. We recommend planning this procedure preoperatively for best results.

This study was designed to assess the utility of the scarf osteotomy in the management of symptomatic adolescent hallux valgus.

During a 3-year period in which 348 hallux valgus correction were performed, 10 patients with symptomatic hallux valgus deformity underwent triple osteotomies. All the 10 patients had intermetatarsal 1–2 angle of over 20 degrees and DMAA angle of over −10 degrees and no degenerative changes at MTP joint. They were studied retrospectively at an average follow-up of 9.7 months.

The surgical technique comprised a proximal open medial based wedge first metatarsl osteotomy and a distal closing medial based wedge first metatarsal osteotomy and a closing medial basal wedge phalangeal osteotomy. The average age of the patients at the time of surgery was 53.4 years.

At final follow-up, the average hallux valgus correction measured 22 degrees and the average intermetatarsal 1–2 angle correction was 9 degrees postoperatively. The DMAA averaged −4 degrees postoperatively the average length of the 1st metatarsal was shorter 2.43 mm postoperatively.

The average of the (VAS FA) score was improved from 55 preoperatively to 83.9 postoperatively.

8 patients were very satisfied, one patient was satisfied and one patient was unsatisfied. A hallux valgus deformity with an increased 1–2 intermetatasal angle over 20 degrees can be successfully treated with triple first ray osteotomies that maintain articular congruity of the the first metatarsophalangeal joint.

The five different methods of measuring hallux valgus (HVA) and intermetatarsal angles (IMA) and the diagnosis of congruency of first MTP joint were studied on 50 pre-operative standing foot radiographs, to test if these methods were reliable and the results reproducible enough to be used in a treatment algorithm for hallux valgus.

Analysis of variance (ANOVA) was used to examine the difference between the five methods and between the five observers. Kappa test was used to measure agreement in diagnosing congruency between two occasions.

The mean IMA and HVA varied significantly (p< 0.00001). The ANOVA model showed that method and observer variations were both significant for IMA; there was no significant difference between measurement methods for HVA. Congruency had good (k=0.608) intraobserver and fair (k=0.261) interobserver reliability. A second IMA measurement will lie between 4.2° less and 4.6° more than the first IMA measurement 95% of the time. A second HVA measurement will lie between 6° less and 5.6° more than the first HVA measurement 95% of the time.

Overall, there was no advantage to any of the measurement methods, although some observers were better than others. All methods had considerable inter- and intra-observer variability that makes these measurements unreliable.