Postoperative Considerations in the Management of Hallux Valgus
Postoperative management of hallux valgus varies widely. Setting preoperative expectations is an important aspect of attaining a successful outcome, but this is not routinely reviewed in the literature. This chapter offers suggestions on successfully navigating this area of patient care. Current concepts focus on pain control, immobilization, and return to activities. This chapter also reviews the current literature in these areas and sets out the authors ’ preferred management in the postoperative setting. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - January 23, 2020 Category: Orthopaedics Authors: William A. Hester, David I. Pedowitz Source Type: research
Current Controversies in the Approach to Complex Hallux Valgus Deformity Correction
FOOT AND ANKLE CLINICS (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - January 23, 2020 Category: Orthopaedics Authors: Sudheer C. Reddy Source Type: research
Evolution of Thinking of the Lapidus Procedure and Fixation
The evolution of Lapidus fixation has been strongly associated with the understanding of the anatomy and function of the first tarsometatarsal joint, the mechanism of hypermobility of the first tarsometatarsal joint, and cause of the hallux valgus deformity in 3 dimensions. Some methods, such as plantar plating, nitinol staples, and intramedullary fixation, have proven to be stronger biomechanically in cadaveric testing. Theoretically, stable fixation will reduce the rate of complications, in particular, that of nonunion and allow for early postoperative weight-bearing. Further clinical studies are needed to examine whethe...
Source: Foot and Ankle Clinics - December 19, 2019 Category: Orthopaedics Authors: Shuyuan Li, Mark S. Myerson Source Type: research
Intraoperative and Postoperative Evaluation of Hallux Valgus Correction
The hallux valgus is one of the most challenging foot and ankle deformities to correct. The current concept is to consider the hallux valgus as a triplane deformity, and the parameters in transverse, sagittal, and frontal planes must be considered. The hallux valgus angle, intermetatarsal angle, tibial sesamoid position, and lateral edge of the first metatarsal head are valuable parameters to evaluate to understand the magnitude of the deformity. Diaphyseal corrections, such as scarf, and proximal interventions, such as crescentic osteotomy and Lapidus arthrodesis, are the most powerful techniques to address triplane defor...
Source: Foot and Ankle Clinics - December 4, 2019 Category: Orthopaedics Authors: Roberto Zambelli, Daniel Baumfeld Source Type: research
Role of Coronal Plane Malalignment in Hallux Valgus Correction
Coronal malalignment is an important deformity parameter in hallux valgus feet. Approximately 90% of patients with hallux valgus have some degree of metatarsal pronation. In operated hallux valgus, persistent metatarsal pronation is an independent deformity relapse factor. Coronal malalignment can be identified through an anteroposterior (AP) weight-bearing foot radiograph and a weight-bearing forefoot scan. The AP foot view can identify 3 levels of rotation: mild, moderate and severe metatarsal pronation. Regarding the treatment options, some techniques are capable of rotational correction, such as the proximal rotational...
Source: Foot and Ankle Clinics - November 30, 2019 Category: Orthopaedics Authors: Pablo Wagner, Emilio Wagner Source Type: research
Evolution of Minimally Invasive Surgery in Hallux Valgus
Minimally invasive (MIS) or percutaneous surgery has evolved rapidly through the development of novel techniques with precise description, correct indications, and the incorporation of modifications of safe and effective techniques described in open surgery. The correct term to describe these procedures should be percutaneous and MIS should be reserved for procedures between percutaneous and open surgery (eg, osteosynthesis). According to results, third-generation techniques are useful, effective, and easier than open procedures. It seems that MIS surgery has an extensive learning curve, and therefore it may be difficult t...
Source: Foot and Ankle Clinics - November 30, 2019 Category: Orthopaedics Authors: Jorge Javier Del Vecchio, Mauricio Esteban Ghioldi Source Type: research
Controversies in the Approach to Complex Hallux Valgus Correction
Hallux valgus continues to remain a challenging condition to treat despite the myriad techniques available. Perhaps in no other disorder are the results as apparent to both the clinician and the patient. Successes and failures are apparent for both to see. Symptomatic hallux valgus can create frequent problems for the patient, including difficulty with shoe wear, walking, cosmetic concerns, and lesser toe pathologic conditions. Every aspect of management continues to be debated from the evaluation to the intraoperative and postoperative treatment. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - November 30, 2019 Category: Orthopaedics Authors: Sudheer Reddy Tags: Preface Source Type: research
Management of Complications After Hallux Valgus Reconstruction
Complications following hallux valgus (HV) reconstruction will have an expected incidence of between 10% and 55% of cases. The more commonly reported complications include undercorrection/recurrence, overcorrection (hallux varus), transfer metatarsalgia, nonunion, malunion, avascular necrosis, arthritis, hardware removal, nerve injury, and ultimately patient dissatisfaction. The presence of arthritis will be an indication for fusion, whereas osteotomies will be the procedure of choice if the first metatarsophalangeal joint is healthy. Wide experience in primary HV surgery is advised before dealing with complex cases of fai...
Source: Foot and Ankle Clinics - November 29, 2019 Category: Orthopaedics Authors: Manuel Monteagudo, Pilar Mart ínez-de-Albornoz Source Type: research
Cost-Effectiveness of Surgical Techniques in Hallux Valgus
Health care costs are increasing. Funding is not increasing at a commensurate rate. Demonstrable cost-effectiveness is critical when selecting operation and implant type. Clinicians must justify their decision on surgery and implant type, providing patient-reported outcome measures (PROM). Providing such data on cost and PROM forms the basis of future cost-effectiveness analysis (CEA). Such analysis is complex. Future research should analyze cost variables individually. Day case surgery, multimodal analgesia, and simultaneous surgery for bilateral cases show promise in reducing cost. With evidence of increased recurrence, ...
Source: Foot and Ankle Clinics - November 28, 2019 Category: Orthopaedics Authors: Andy Molloy, Gavin Heyes Source Type: research
Hypermobility in Hallux Valgus
The interaction between hypermobility and hallux valgus remains both contemporary and incendiary. The difficulty in setting clinical and radiological parameters to diagnose and the complexity of questions that circumnutate the philosophy among etiology and denouement, fires up the debate regarding these conditions. Outcomes among procedures that address or neglect ray instability are still used as argument for any group of believers or nonbelievers. Through proving the true existence of hypermobility and its relationship with bunions, our colleges and professors have produced an incredible amount of excellent data that hel...
Source: Foot and Ankle Clinics - November 26, 2019 Category: Orthopaedics Authors: Nacime Salom ão Barbachan Mansur, Caio Augusto de Souza Nery Source Type: research
Complications after Metatarsal Osteotomies for Hallux Valgus
Avascular necrosis (AVN), nonunion, malunion, and metatarsophalangeal (MTP) osteoarthritis following hallux valgus osteotomies, as well as pathophysiology, diagnosis, prevention strategies, and treatment are discussed in this article. AVN and nonunion are very infrequent, and they can be effectively prevented taking into consideration local anatomy preservation, biomechanics, and patient comorbidities. Shortening, elevation, plantarflexion, varus/valgus, and rotational of the first metatarsal are the most common types of malunion. They can lead to pain, stiffness, deformity recurrence, and transfer metatarsalgia. MTP osteo...
Source: Foot and Ankle Clinics - November 26, 2019 Category: Orthopaedics Authors: Jorge Filippi, Jorge Briceno Source Type: research
Management of Hallux Valgus in Metatarsus Adductus
Metatarsus adductus is common clinical entity with an estimated prevalence of approximately 30%. Multiple radiographic methods exist to evaluate the extent of the deformity, with the Sgarlato and Engel methods most commonly used. Surgical treatment varies, consisting of proximal versus distal metatarsal osteotomies, TMT arthrodesis, and realignment of the lesser rays. Particularly in severe cases, addressing all deformities is critical to obtaining a good outcome. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - November 21, 2019 Category: Orthopaedics Authors: Sudheer Reddy Source Type: research
Current Trends in Anesthesia Management in Hallux Valgus
Anesthesia management during hallux valgus surgery trends toward multimodal pain control. Locoregional anesthesia with peripheral nerve blocks and wound instillation increase pain control. Peripheral nerve blocks as first-line analgesia are effective with minimal side effects. Local wound instillation has a variable but positive effect with minimal negative side effects. Nonsteroidal anti-inflammatory drugs in bone-to-bone healing remain controversial; however, they reduce opiate requirements and enhance patient satisfaction. Opiate agonists remain the mainstay for postoperative pain; long-acting formulations minimize pain...
Source: Foot and Ankle Clinics - November 20, 2019 Category: Orthopaedics Authors: Max Seiter, Amiethab Aiyer Source Type: research
Current Trends in Fixation Techniques
Hallux valgus is an extremely common and often disabling deformity. In addition to valgus deformity of the hallux, varying degrees of varus and supination of the first metatarsal and instability in the metatarsophalangeal and metatarsocuneiform joints are frequently present. Because of the complexity and multiplicity of deformities, surgical techniques and fixation methods continue to be developed to obtain better results. Recent studies have focused on correcting pronation of the first metatarsal as a way of correcting and equalizing the metatarsal sesamoid bones in a more horizontal and stable position, possibly minimizi...
Source: Foot and Ankle Clinics - November 20, 2019 Category: Orthopaedics Authors: Jos é Antônio Veiga Sanhudo, Tomás Araújo Prado Pereira Source Type: research
Use of Advanced Weightbearing Imaging in Evaluation of Hallux Valgus
Hallux valgus (HV) represents a progressive 3-dimensional deformity that includes bone malalignment, hypermobility of the first ray, and imbalanced soft-tissue structures of the midfoot and forefoot. Conventional radiographs provide sectorized and limited information of the deformity in different planes. The literature evidence supporting the use of cone beam weightbearing computed tomography in the assessment of HV has been growing. It demonstrates important advances that include the ability to reliably perform traditional measurements such as HV angle and intermetatarsal angle in the 3-dimensional setting. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - November 19, 2019 Category: Orthopaedics Authors: Cesar de Cesar Netto, Martinus Richter Source Type: research
Scientific Evidence in the Treatment of Metatarsalgia
Metatarsalgia is a common foot disease with a multitude of causes. Proper identification of underlying diseases is mandatory to formulate an adequate treatment. Multiple surgical solutions are available to treat metatarsalgia. Only limited scientific evidence is available in the literature. However, most of the techniques used in the treatment of metatarsalgia seem to be reasonable with acceptable results. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 23, 2019 Category: Orthopaedics Authors: Georg Klammer, Norman Espinosa Source Type: research
Distal Minimally Invasive Metatarsal Osteotomy ( “DMMO” Procedure)
The use of a Shannon burr facilitates an osteotomy of the lesser metatarsals without requiring an open approach to the metatarsal. The end result that is aimed for is the same as for open surgery and therefore care needs to be taken to perform the bone cut in the appropriate manner. A description is provided of the surgical technique for distal minimally invasive osteotomy and its newer modifications —the distal intracapsular minimally invasive osteotomy and the distal oblique metatarsal osteotomy. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 23, 2019 Category: Orthopaedics Authors: Olivier Laffen être, Anthony Perera Source Type: research
Current Concepts of Treatment of Metatarsalgia
Metatarsalgia is a frequent complaint in our day-to-day practice. Unfortunately, sometimes we face the frustrating scenario of dealing with an unpredictable malady. This situation is probably explained by the fact that constitutes a complex entity that is not enough appraised. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 23, 2019 Category: Orthopaedics Authors: Gast ón Slullitel Tags: Preface Source Type: research
Current Concepts of Treatment of Metatarsalgia
FOOT AND ANKLE CLINICS (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 23, 2019 Category: Orthopaedics Authors: Gast ón Slullitel Source Type: research
Current Controversies in the Approach to Complex Hallux Valgus Deformity Correction (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 23, 2019 Category: Orthopaedics Source Type: research
Freiberg ‘s Infraction
Freiberg ’s infraction is an uncommon condition of the lesser metatarsophalangeal joints. Onset is usually between the 11th and 17th year of age. It is the only osteochondrosis that dominantly affects females with a reported female-to-male ratio of 5.1. The second metatarsal is most frequently involved (68 %) followed by the third metatarsal (27%), and the fourth (3%). Surgical treatment options can be categorized in joint destructive and joint preserving procedures. Studies reveal complete resolution of pain and full return to activities in 70% after joint destructive procedure and more than 90% afte r joint preserv...
Source: Foot and Ankle Clinics - October 8, 2019 Category: Orthopaedics Authors: Hans-J örg Trnka, Javier Serrano Lara Source Type: research
Mechanical Basis of Metatarsalgia
The 3-rocker mechanism of gait provides a framework to understand why patients have mechanical metatarsal pain and to differentiate between the various types of metatarsalgia. Clinical examination of the patient together with radiological findings allows identification of the type of metatarsalgia and the pathomechanics involved, and the planning of surgical treatment. Second-rocker/nonpropulsive metatarsalgia is related with an abnormal inclination of a metatarsal in the sagittal plane, either anatomic or functional (equinism). Third-rocker/propulsive metatarsalgia is related to an abnormal length of a certain metatarsal ...
Source: Foot and Ankle Clinics - October 8, 2019 Category: Orthopaedics Authors: Ernesto Maceira, Manuel Monteagudo Source Type: research
Evolution of the Weil Osteotomy
Weil osteotomy (WO) is the most common technique worldwide for the treatment of mechanical metatarsalgia. The main indication for WO is propulsive/third rocker metatarsalgia that is in relation with an abnormal length of a certain metatarsal with respect to the neighboring metatarsals in the frontal plane. Most clinical studies have showed good to excellent results after WO. However, complications such as floating toes led to evolution of WO and the development of the triple-cut WO that allows for shortening coaxial to the shaft without plantar translation of metatarsal head. Other variations of WO may treat other forefoot...
Source: Foot and Ankle Clinics - October 8, 2019 Category: Orthopaedics Authors: Manuel Monteagudo, Ernesto Maceira Source Type: research
is a rare deformity with controversial clinical presentation. Multiple acute and gradual lengthening surgical techniques have been described for correction of this type of foot deformity. All techniques try to create a better appearance, facilitate shoeing, or solve possible transfer metatarsalgia. Either acute lengthening (1-stage procedure) or gradual lengthening (2 stages) is selected based on the patient ’s deformities, concerns, and clinical needs. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - October 8, 2019 Category: Orthopaedics Authors: Andr é Perin Shecaira, Rodrigo Mota Pacheco Fernandes Source Type: research
Metatarsalgia in Metatarsus Adductus Patients
We present a review regarding the epidemiology, pathomechanics, and a comprehensive surgical treatment algorithm to optimize the management of patients with MA, HV, lesser toe deformity, and metatarsalgia. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 25, 2019 Category: Orthopaedics Authors: Matthew Varacallo, Amiethab Aiyer Source Type: research
Historically, metatarsalgia was approached as a forefoot condition, most often associated with hallux valgus. Consequently, surgical treatments were limited to that anatomic zone, disregarding more proximal structures. In order to assess this entity properly, it is necessary to consider anatomic and biomechanical factors, as well as general and local conditions of the affected patients. A thorough understanding of the multiple potential causal factors is essential to ensure selection of the optimal treatment. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 25, 2019 Category: Orthopaedics Authors: Valeria Lopez, Gaston Slullitel Source Type: research
State of the Art in Lesser Metatarsophalangeal Instability
Advancements in lesser metatarsophalangeal (MTP) instability have involved the use of minimally invasive surgery techniques, synthetic augmentation of existing transfers, and use of arthroscopy for both diagnosing and addressing MTP disorder. Advances in imaging modalities, particularly MRI, have aided in diagnosing subtle instability. Clinical outcomes seem to be similar to traditional approaches as the indications and applicability continue to evolve. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 25, 2019 Category: Orthopaedics Authors: Sudheer C. Reddy Source Type: research
Gastrocnemius Recession in the Setting of Metatarsalgia
A fundamental etiologic component of metatarsalgia is the repetitive loading of a locally concentrated force in the forefoot during gait. In the setting of an isolated gastrocnemius contracture, weight-bearing pressure is shifted toward the forefoot. If metatarsalgia is considered an entity more than a symptom, evaluation of gastrocnemius contracture must be a part of the physical examination, and gastrocnemius recession via the Baumann procedure alone, or in combination with other procedures, considered as an alternative treatment in an attempt to restore normal foot biomechanics. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 17, 2019 Category: Orthopaedics Authors: Gast ón Slullitel, Juan Pablo Calvi Source Type: research
Resection arthroplasty for metatarsalgia is a selective procedure primarily indicated for patients with rheumatoid arthritis. These patients present with significant forefoot deformities, poor bone quality, and loss of soft tissue integrity. Resection of the metatarsal heads and correction of lesser toe deformities improve pain and decrease transfer metatarsalgia. Patients with concurrent hallux valgus may benefit from a lapidus procedure or hallux metatarsophalangeal fusion in an effort to improve outcomes and decrease incidence of recurrent hallux valgus. In rare cases, diabetics with neuropathy may require resection art...
Source: Foot and Ankle Clinics - September 17, 2019 Category: Orthopaedics Authors: Javier Z. Guzman, Ettore Vulcano Source Type: research
The Role of First Ray Insufficiency in the Development of Metatarsalgia
Two theories exist in the development of central or transfer metatarsalgia. First, as the severity of hallux valgus increases, there is mechanical overload of the second metatarsal. Second, increased relative lesser metatarsal length is thought to contribute to metatarsalgia. It is imperative, in the treatment of first ray disorders (hallux valgus or hallux rigidus), to not overshorten the first ray when addressing the first ray pathologic condition. Treatment of metatarsalgia in the setting of failed hallux valgus correction can be treated with both conservative and surgical options. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - September 5, 2019 Category: Orthopaedics Authors: Angela K. Walker, Thomas G. Harris Source Type: research
Anatomical and Functional Considerations in Achilles Tendon Lesions
The pathologic conditions of the Achilles tendon are best understood in the context of its unique anatomy and functional demands. Some of these unique considerations include its high physiologic load demands, microscopic tissue composition, muscular origin spanning the knee joint, intimate insertional relationship with the plantar fascia, sensory innervation, and vascular supply with watershed areas. Risks of both acute rupture and chronic tendinopathy are affected by the tendon ’s anatomy and its functional demands. The tendon’s functional anatomy changes with advancing age, notably in its collagen composition...
Source: Foot and Ankle Clinics - July 30, 2019 Category: Orthopaedics Authors: Katherine M. Dederer, Joshua N. Tennant Source Type: research
Updates in the Management of Acute and Chronic Lesions of the Achilles Tendon
FOOT AND ANKLE CLINICS (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - July 30, 2019 Category: Orthopaedics Authors: Phinit Phisitkul Source Type: research
Functional Rehabilitation for Nonsurgical Treatment of Acute Achilles Tendon Rupture
This article describes a high-quality accelerated functional rehabilitation program that begins with early diagnosis and appropriate patient selection to allow initiation of the nonoperative protocol. Complications with nonoperative treatment of Achilles ruptures are significantly lower than with operative treatment; however, re-rupture and elongation of the tendon resulting in decreased strength are problematic and more common if patients are non-compliant. These can be minimized with good patient education, close supervision, and good communication between physical therapist and physician. (Source: Foot and Ankle Clinics)
Source: Foot and Ankle Clinics - June 22, 2019 Category: Orthopaedics Authors: Mark Glazebrook, Daniela Rubinger Source Type: research
Open Reconstructive Strategies for Chronic Achilles Tendon Ruptures
Chronic Achilles tendon ruptures typically are treated with surgical intervention except in low-demand patients or patients who are unable to tolerate surgery. Although several treatment strategies are described, most literature is case reports and case series. There is no widely accepted algorithm or gold standard for surgical treatment of chronic Achilles tendon ruptures. Treatment strategy depends on the size of the tendon gap after excision of nonviable tissue and scar tissue. Smaller gaps can be treated with direct end-to-end repair. Medium-sized gaps can be treated with tendon-lengthening procedures. Tendon transfers...
Source: Foot and Ankle Clinics - June 18, 2019 Category: Orthopaedics Authors: Christopher Chen, Kenneth J. Hunt Source Type: research
Surgical Strategies for the Treatment of Insertional Achilles Tendinopathy
Insertional Achilles tendinopathy is one of the most common Achilles tendon disorders and often results in substantial heel pain and functional disability. There is consensus that treatment of insertional Achilles tendinopathy should start with nonoperative modalities. Surgery should be reserved for patients who fail exhaustive conservative treatment for a period of 3 months to 6 months and include débridement of insertional calcifications. Intratendinous degenerative tissue should be débrided and any Haglund deformity resected. Different surgical techniques have been described for reattachment of the d...
Source: Foot and Ankle Clinics - June 18, 2019 Category: Orthopaedics Authors: Alexej Barg, Todd Ludwig Source Type: research
Minimally Invasive Treatments of Acute Achilles Tendon Ruptures
Achilles tendon rupture is a common injury to the lower extremity that requires appropriate treatment to minimize functional deficit. Available treatments of Achilles tendon ruptures include nonoperative, open surgical repair, percutaneous repair, and minimally invasive repair. Open surgical repair obtains favorable functional outcomes with significant potential for deep soft tissue complications, calling into question the value of open repair. Percutaneous repair is an alternative option with comparable functional results and minimal soft tissue complications; however, sural nerve injury is a complication. Minimally invas...
Source: Foot and Ankle Clinics - June 18, 2019 Category: Orthopaedics Authors: Milap S. Patel, Anish R. Kadakia Source Type: research