Medial Cuneiform Opening Wedge Osteotomy for Correction of Flexible Flatfoot Deformity: Trabecular Titanium vs. Bone Allograft Wedges

Clinical, Radiographic, and Patient-Reported Outcomes of First Metatarsophalangeal Interposition Arthrodesis Using Porous Titanium Wedges

BACKGROUND

First metatarsophalangeal (MTP) arthrodesis is a common surgical procedure for addressing hallux MTP pathology. In the setting of revision procedures with significant bone loss, porous titanium wedges may provide an alternative to structural bone autograft or allograft.

OBJECTIVE

The purpose of this study is to report the clinical and radiographic outcomes achieved in first MTP interposition arthrodesis using porous titanium wedges.

METHODS

A retrospective analysis of 9 patients with a mean age 65.4 years (45-82 years) who underwent first MTP interposition arthrodesis with the use of porous titanium wedges from February 2014 to September 2017 was performed. Outcomes were assessed using both plain-film radiographs and computed tomography (CT) scans, as well as patient-reported outcome measures, including Foot and Ankle Ability Measure (FAAM) (Sports and Activities of Daily Living), pain Visual Analogue Scale (VAS), and 36-Item Short Form Survey (SF-36). Average follow-up time was 34.2 months (14-72 months).

RESULTS

At final follow-up, the average FAAM score was 91.1 ± 14.7 (75.1 ± 5.3 FAAM Activities of Daily Living; 17.9 ± 9.9 FAAM Sports). Average pain VAS score was 1.9 ± 1.7. Postoperative computed tomography (CT) imaging was obtained for 5 patients, all of which demonstrated good bony apposition or osseous integration of the wedge. Four patients underwent subsequent surgical procedures, including 3 isolated dorsal fixation revisions, and 1 complete MTP arthrodesis revision.

CONCLUSION

To our knowledge, this study represents the first reported clinical and radiographic outcomes in patients undergoing first MTP interposition arthrodesis with use of porous titanium wedges. While we found this technique to be a viable alternative to bone grafting for this difficult problem, further research should focus on comparative data with other commonly performed operative techniques.

LEVEL OF EVIDENCE

Level IV: Case series.

Short- to Intermediate-Term Radiographic Outcomes Following Cotton Osteotomy

The cotton osteotomy or the medial cuneiform opening wedge osteotomy has been a common adjunct procedure in flatfoot reconstruction to correct for forefoot varus or a dorsiflexed first ray. The main goal of the study is to retrospectively review outcomes specifically in the short-intermediate term for the cotton osteotomy. The medical records of a single foot and ankle surgeon (PRB) were reviewed for patients who met inclusion and exclusion criteria. The study period was from January 2006 to October 2018. The analysis was performed using information obtained from chart-review to examine union and complication rates, as well as changes in the cuneiform articular angle based on graft size and type. A total of 71 feet in 61 patients underwent cotton osteotomies for flatfoot reconstruction. Overall complication rate was 5.6% (4/71) with 2 nonunions (2/47) in those that had radiographic follow-up of greater than 9 months. Change in cuneiform articular angle (CAA) showed 0.91° of correction per 1-millimeter increase in graft wedge size from preoperative to 3 weeks. Change for anterior-posterior medial cuneiform bisection dorsal length (AP length) was 0.70 mm per 1 mm of graft used from preoperative to 3 weeks. 6 weeks to 10 weeks showed statistically significant changes in the CAA (p = .01) and the AP length (p = .002). The cotton osteotomy showed statistically significant radiographic loss of correction between the 6- and 10-week time points when patients were allowed to begin weightbearing. Metal grafts may provide maintenance of correction which warrants future studies on their efficacy.

Bony Procedures for Correction of the Flexible Pediatric Flatfoot Deformity

The pediatric flexible flatfoot is a common foot shape that is most often asymptomatic and may be a physiologic variant of normal. Surgery is only indicated when nonoperative interventions have failed to resolve symptoms. The goal of surgery is to alleviate symptoms by improving hindfoot alignment and restoring the medial arch while preserving joint mobility. This article focuses on the common bony techniques for surgical correction of the pediatric flexible flatfoot that has failed nonoperative management, including calcaneal, midfoot, and supramalleolar osteotomies and distal tibial hemiepiphyseodesis.

Radiographic Outcomes of Cotton Osteotomy in Treatment of Adult-Acquired Flatfoot Deformity

BACKGROUND

We investigated the long-term radiographic outcomes of the Cotton osteotomy performed at our institution by the 2 senior authors in conjunction with other reconstruction procedures to correct adult-acquired flatfoot deformity (AAFD).

METHODS

We retrospectively studied patients who underwent Cotton osteotomy between 2005 and 2010 with minimum 4-year follow-up. Radiographic assessment was made on weightbearing radiographs taken at 4 different time intervals: preoperative, early (first postoperative full weightbearing), intermediate (between 1 and 4 years postoperatively), and final (over 4 years postoperatively).

RESULTS

Nineteen patients were included. Final follow-up was 8.6 ± 2.6 years. The lateral talus-first metatarsal angle improved significantly from preoperative to early radiographs (n = 15; mean change: 30 degrees, 95% CI, 21.6-38.7; P < .0001). A significant loss of correction was observed between intermediate and final radiographs (n = 11; mean change: 17 degrees, 95% CI, 8.1-26.4; P < .0001). Of 14 patients with early radiographs, 8 lost >50% of the correction initially achieved. Medial column height decreased by 3.0 mm (95% CI, 1.80-7.90; P = .35) between early radiographs and final follow-up.

DISCUSSION

This is the longest reported radiographic follow-up of the Cotton osteotomy performed to address forefoot varus deformity as part of AAFD. The Cotton osteotomy achieved radiographic correction of the medial longitudinal arch at early follow-up, but approximately half of the patients had lost over 50% of that correction at final follow-up. The lengthened angular shape of the cuneiform did not collapse, implying that further collapse occurred through the medial column joints.

LEVEL OF EVIDENCE

Level IV, case series.

The Importance of the Medial Column in Progressive Collapsing Foot Deformity: Osteotomies and Stabilization

Adult acquired flatfoot deformity is a complex pathologic condition that requires considerate and thoughtful surgical solutions. Medial column procedures are often supplemented by a medializing calcaneal osteotomy and/or a lateral column lengthening because of the complex nature of progressive collapsing foot deformity and its resultant peritalar instability. Other osteotomies and fusions include a Cotton osteotomy and first tarsometatarsal fusion.

[Surgical procedures for the correction and stabilization of pes planovalgus]

The medial column of the foot is a relevant factor of the pathogenesis of pes planovalgus. Crucial anatomic structures are the tibiocalcaneonavicular ligament complex, the naviculocuneiform joints, including the ossa cuneiformia, and the first tarsometatarsal joint. A combination of bony and soft tissue reconstructive techniques must, therefore, be taken into account when treating pes planovalgus. The present article presents stabilizing and correcting surgical procedures for the medial column of the foot, including basic anatomy and biomechanics.

Consensus on Indications for Medial Cuneiform Opening Wedge (Cotton) Osteotomy in the Treatment of Progressive Collapsing Foot Deformity

RECOMMENDATION

Forefoot varus is a physical and radiographic examination finding associated with the Progressive Collapsing Foot Deformity (PCFD). Varus position of the forefoot relative to the hindfoot is caused by medial midfoot collapse with apex plantar angulation of the medial column. Some surgeons use the term forefoot supination to describe this same deformity (see Introduction section with nomenclature). Correction of this deformity is important to restore the weightbearing tripod of the foot and help resist a recurrence of foot collapse. When the forefoot varus deformity is isolated to the medial metatarsal and medial cuneiform, correction is indicated with an opening wedge medial cuneiform (Cotton) osteotomy, typically with interposition of an allograft bone wedge from 5 to 11 mm in width at the base. When the forefoot varus is global, involving varus angulation of the entire forefoot and midfoot relative to the hindfoot, other procedures are needed to adequately correct the deformity.

LEVEL OF EVIDENCE

Level V, consensus, expert opinion.