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Choi JY, Yu OJ, Suh JS. A Novel Technique of Medial Displacement Calcaneal Osteotomy Using the Intramedullary Fixation of a Conventional Low-Profile Locking Wedge Plate. Foot Ankle Int 2024; 45:506-516. [PMID: 38389308 DOI: 10.1177/10711007241230990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
BACKGROUND Postoperative heel pain arising from prominent screw heads is a common complication following medial displacement calcaneal osteotomy (MDCO). This study aims to present the clinicoradiographic outcomes of a novel MDCO technique, wherein intramedullary fixation of a conventional low-profile locking wedge plate is employed. METHODS A retrospective analysis, involving a comparison of clinical and radiographic parameters among consecutive patients who underwent MDCO was conducted. The patients were subjected to either intramedullary wedge plate fixation through the osteotomy site (IWPF group, n = 45 cases) or conventional cannulated screw fixation from the heel (CCSF group, n = 51 cases). Radiographic evaluation included measurement of hindfoot alignment angle, alignment ratio, and moment arm. Clinical outcomes were measured with the American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and the Foot and Ankle Ability Measure (FAAM) activities of daily living and sports subscales, before and at 6, 12, and ≥24 months postoperatively. The presence of heel pain was evaluated at the postoperative 6 and 12 months in both groups. RESULTS For both groups, a marked enhancement in all 3 radiographic parameters was observed. The extent of correction for all clinicoradiographic parameters demonstrated no statistically significant divergence between the 2 groups. However, the FAAM-Sports scores at the 6-month postoperative juncture exhibited a significant elevation in the IWPF group relative to the CCSF group. Importantly, no patient reported heel pain at postoperative 6 and 12 months in the IWPF group whereas the rates of patients having heel pain at postoperative 6 and 12 months were 56.8% (29 cases) and 33.3% (17 cases), respectively, in the CCSF group. CONCLUSION Both techniques yield analogous postoperative clinical and radiographic enhancements. However, the utilization of IWPF promotes a swifter clinical improvement with respect to sports activities when juxtaposed with the CCSF from the calcaneal tuberosity. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Oh Jun Yu
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, South Korea
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Vaggi S, Vitali F, Zanirato A, Quarto E, Colò G, Formica M. Minimally invasive surgery in medial displacement calcaneal osteotomy for acquired flatfoot deformity: a systematic review of the literature. Arch Orthop Trauma Surg 2024; 144:1139-1147. [PMID: 38212588 DOI: 10.1007/s00402-023-05188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 12/19/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Minimally invasive surgery (MIS) in medial displacement calcaneus osteotomy (MDCO) has been proposed for surgical correction of adult-acquired flat foot deformity (AAFD) to reduce complications of open approaches. The aim of our study is to systematically analyze complications and the clinical and radiological results of MIS- MDCO. METHODS A systematic review of the English literature was performed on 30th October 2023. Randomized controlled trials and non-randomized trials, cohort studies, case-control studies and case series concerning surgical correction of AAFD with MIS-MDCO and with at least 15 patients were included. Case reports, technical notes, animal or cadaveric studies were excluded. The quality and risk of bias of the studies included were evaluated using GRADE and MINORS systems. Complications rate, clinical and radiological results were inferred from the studies included. RESULTS Nine articles were included. A total of 501 cases treated with MIS-MDCO were analysed with a mean follow-up of 11.9 ± 5.1 months. The reported wound infection rate was about 3% and sural neuropathy was rated about 1%. Only 4% of the cases required removal of the screw for pain. In the comparative studies (MIS versus Open MDCO), comparable clinical results but with significant differences (P < 0.001) in infection rates (1% versus 14%) and sural neuropathy (2% versus 1%) were observed. CONCLUSION AAFD correction performed with MIS-MDCO, with the limitation of a poor quality and high risk of bias of the included studies, seems to provide good clinical results and high subjective satisfaction with a lower complication rate compared to open approach. Further high-quality long-term comparative studies could better clarify complications and clinical and radiological outcomes of the MIS technique in the treatment of AAFD. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- S Vaggi
- Dipartimento Di Scienze Chirurgiche E Diagnostiche Integrate, Università Degli Studi Di Genova - DISC, Viale Benedetto XV 6, 16132, Genova, GE, Italy
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
| | - F Vitali
- Dipartimento Di Scienze Chirurgiche E Diagnostiche Integrate, Università Degli Studi Di Genova - DISC, Viale Benedetto XV 6, 16132, Genova, GE, Italy
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
| | - A Zanirato
- Dipartimento Di Scienze Chirurgiche E Diagnostiche Integrate, Università Degli Studi Di Genova - DISC, Viale Benedetto XV 6, 16132, Genova, GE, Italy.
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy.
| | - E Quarto
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
| | - G Colò
- Orthopaedics and Traumatology Unit, SS Antonio and Biagio and Cesare Arrigo Hospital, 15121, Alessandria, Italy
| | - M Formica
- Dipartimento Di Scienze Chirurgiche E Diagnostiche Integrate, Università Degli Studi Di Genova - DISC, Viale Benedetto XV 6, 16132, Genova, GE, Italy
- Clinica Ortopedica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
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Cychosz CC, Eisenberg J, Glass N, Fleury I, Buckwalter V JA, Phisitkul P, Femino JE. Outcomes of Surgical Treatment for Sural Neuritis: A Retrospective Case Series. Foot Ankle Int 2023; 44:845-853. [PMID: 37477149 DOI: 10.1177/10711007231184472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
BACKGROUND Somatic nerve pain is one of the most common complications following surgery of the foot and ankle but may also arise following traumatic injury or chronic nerve compression. The sural nerve is a commonly affected nerve in the foot and ankle; it is at risk given the proximity to frequently used surgical approaches, exposure to crush injuries, and traction from severe ankle inversion injuries. The purpose of this study is to investigate the outcomes of sural nerve neurectomy with proximal implantation for sural neuromas (SN) and chronic sural neuritis (CSN). METHODS Patients that underwent neurectomy with proximal implantation (20 muscle, 1 adipose tissue) by 2 foot and ankle specialists for isolated SN- and CSN-related pain at a single tertiary institution were included. Demographic data, baseline outcomes including 36-Item Short Form Health Survey (SF-36), Foot and Ankle Ability Measure (FAAM), and visual analog scale (VAS) were recorded. Final follow-up questionnaires using Patient Reported Outcomes Measurement Information System (PROMIS) lower extremity function, pain interference (PI), and neuropathic pain quality, FAAM, and VAS were administered using REDCap. Perioperative factors including neuropathic medications, diagnostic injections, the use of collagen wraps, and perioperative ketamine were collected from the medical record. Descriptive statistics were performed and potential changes in patient-reported outcome measure scores were evaluated using Wilcoxon signed-rank tests. RESULTS The 21 patients meeting inclusion criteria for this study had a median age of 47 years (interquartile range [IQR], 43-49) and had median follow-up duration of 33.7 months (IQR, 4.5-47.6). Median FAAM activities of daily living score improved from 40.6 (38.7-50.7) preoperatively to 66.1 (53.6-83.3) postoperatively, P = .032. FAAM sports scores improved from 14.1 (7.8-21.9) to 41.1 (25.0-60.9) postoperatively, P = .002. VAS scores improved from a median of 9.0 (8.0-9.0) to 3.0 (3.0-6.0), P < .001. At final follow-up, patients reported PROMIS lower extremity function score median of 43.8 (35.6-54.9), PROMIS neuropathic pain quality score of 54.1 (43.6-61.6), and PROMIS PI of 57.7 (41.1-63.8). Patients with both anxiety and depression reported less improvement in pain and physical. Other perioperative factors lacked sufficient numbers for statistical analysis. CONCLUSION Sural nerve neurectomy and proximal implantation (20 muscle, 1 adipose) provided significant improvement in pain and function for patients with sural neuromas and chronic sural neuritis at median follow-up of 33.7 months. Anxiety and depression were associated with significantly poorer outcomes following surgery. Patients with CRPS as well as recent nicotine use tended to report less improvement in pain and worse function after surgery, although this sample size was too limited for statistical analysis of these variables. Further research is needed to identify the ideal surgical candidates and perioperative factors to optimize patient outcomes. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | - Joshua Eisenberg
- University of Iowa Department of Orthopaedics and Rehabilitation, Iowa City, IA, USA
| | - Natalie Glass
- University of Iowa Department of Orthopaedics and Rehabilitation, Iowa City, IA, USA
| | - Ignacio Fleury
- University of Iowa Department of Orthopaedics and Rehabilitation, Iowa City, IA, USA
| | - Joseph A Buckwalter V
- University of Iowa Department of Orthopaedics and Rehabilitation, Iowa City, IA, USA
| | | | - John E Femino
- University of Iowa Department of Orthopaedics and Rehabilitation, Iowa City, IA, USA
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Saraiva D, Knupp M, Rodrigues AS, Tulha J, Gomes TM, Oliva XM, Diaz T. Outcomes of Combined Posterior Tibial Tendon Tendoscopy and Medializing Calcaneal Osteotomy for Stage IA Progressive Collapsing Foot Deformity. Foot Ankle Int 2023; 44:629-636. [PMID: 37209035 DOI: 10.1177/10711007231167364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Posterior tibial tendon (PTT) tendoscopy and medializing calcaneal osteotomy (MCO) are among the available techniques for patients presenting with symptomatic flexible hindfoot valgus (stage IA) progressive collapsing foot deformity (PCFD). The aim of this study was to determine clinical and radiographic outcomes of combined PTT tendoscopy and MCO for patients presenting with symptomatic stage IA PCFD. METHODS A retrospective cohort study was performed in order to determine clinical and radiographic outcomes of 30 combined PTT tendoscopies and MCO on 27 patients presenting with symptomatic stage IA PCFD, with a minimum follow-up of 24 months. Patient satisfaction was assessed at last available follow-up as very satisfied, satisfied, and unsatisfied. Clinical assessment was performed evaluating preoperative and last available follow-up visual analog scale for pain (VAS-P), Foot and Ankle Outcome Score (FAOS), and the 36-Item Short Form Health Survey (SF-36). Magnetic resonance imaging (MRI) was performed preoperatively on all patients. Standard weightbearing anteroposterior, lateral, and long axial view radiographs of the foot and ankle were taken preoperatively, immediate postoperatively, at 6 weeks, 3 months, 6 months, 1 year postoperatively, and last follow-up evaluation available for each patient. RESULTS The mean follow-up was 38.6 (range, 26-62) months. We registered 27 very satisfied, 1 satisfied, and 2 unsatisfied patients. There was statistically significant improvement on all clinical scores (VAS-P, FAOS and SF-36), as well as on lateral talo-first metatarsal and hindfoot alignment angles. We found low-grade PTT tears in 5 patients (16.67%) in whom preoperative MRI documented PTT tenosynovitis alone. CONCLUSION We found that combined PTT tendoscopy and MCO provide significant clinical and radiographic improvement for patients presenting with symptomatic stage IAB PCFD. PTT tendoscopy should be considered in the treatment of all surgically addressed flexible valgus feet as it detects tendon tears which are frequently missed on an MRI. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Daniel Saraiva
- Hospital da Prelada, Porto, Portugal
- Foot and Ankle Unit, Department of Anatomy and Human Embryology, Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Markus Knupp
- Mein Fusszentrum, Basel, Switzerland
- Faculty of Medicine, University of Basel, Switzerland
| | | | | | - Tiago Mota Gomes
- Foot and Ankle Unit, Department of Anatomy and Human Embryology, Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Xavier Martín Oliva
- Foot and Ankle Unit, Department of Anatomy and Human Embryology, Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Tania Diaz
- Molecular Oncology and Embryology Laboratory, Department of Anatomy and Human Embryology, Faculty of Medicine and Health Sciences, University of Barcelona, Spain
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Cheng Y, Zou J, Wang C, Xing J, Zhao P, Gao M, Yang H, Zhang H. A comparison of treatment between mini T-plate and headless cannulated compression screw in calcaneal osteotomy. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05840-8. [PMID: 37249628 DOI: 10.1007/s00264-023-05840-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/15/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE In clinical studies, we discovered that when using headless cannulated compression screw fixation, many patients complain of heel pain and frequently need to have the screws removed, whereas this occurrence is uncommon with plate fixation. This study aims to compare the clinical outcome of a mini T-plate and headless cannulated compression screws in calcaneal osteotomy. METHODS We reviewed the medical records of patients who had calcaneal osteotomy performed by one senior chief surgeon in our hospital between January 2014 and May 2021. Thirty-nine patients met the selection criteria: 22 were fixed using a mini T-plate through a modified small "L" incision on the lateral aspect of the calcaneus and 17 were fixed using double screws through an oblique incision on the lateral aspect of the calcaneus. Then, we compared the patient demographics, surgical statistics, and postoperative complications in calcaneal osteotomy between a mini T-plate and double 6.5-mm headless cannulated compressed screws. RESULTS Each patient attained radiographic union. The average age was 49.23±13.80 (range: 24-76) years and the average follow-up duration was 47.07±8.64 (range: 36-66) weeks. The average operation duration and times of intraoperative fluoroscopy were significantly lower in the mini T-plate group (P<0.05). There was a savings of $838.88 per patient when using double screws for fixation. The incidence of hardware-related pain and implant removal was lower in the mini T-plate group (P<0.05). There is no significant difference between the two groups in terms of delayed incision healing and clinical neurological complications (P>0.05). CONCLUSIONS In calcaneal osteotomy, the operation duration, times of intraoperative fluoroscopy, hardware-related pain, and implant removal rate were lower with mini T-plate fixation than with double screws fixation. Therefore, we consider that the mini T-plate would be a good alternative to double screws in calcaneal osteotomy.
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Affiliation(s)
- Yu Cheng
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Jun Zou
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Changbao Wang
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Junhui Xing
- Department of Orthopedics, Dushu Lake Hospital Affiliated to Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Piqian Zhao
- Department of Orthopedics, Dushu Lake Hospital Affiliated to Soochow University; Soochow University, Suzhou, Jiangsu, China
| | - Mingyang Gao
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China.
| | - Huiling Yang
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China.
| | - Hongtao Zhang
- Department of Orthopedics, the First Affiliated Hospital of Soochow University; Soochow University, Suzhou, Jiangsu, China.
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Muacevic A, Adler JR, Alnajjar R, Mohammed W, McLeod A. Types of Sliding Calcaneal Osteotomy Fixation: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e32795. [PMID: 36694522 PMCID: PMC9858884 DOI: 10.7759/cureus.32795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Different methods are used to fix a sliding calcaneal osteotomy for hindfoot varus and valgus deformity. However, information about the effectiveness and limitations of each method is limited. In this meta-analysis, we compare the hardware removal rate, union rate, and complications of three different methods of fixation: plate, headed screw, and headless screw. Methods A systematic review and meta-analysis of published articles were carried out, following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We investigated diverse databases, Web of Science, PubMed, the Cochrane Library, Excerpta Medica database (EMBASE), and Cumulative Index of Nursing and Allied Health Literature (CINAHL), to search articles reporting the use of different calcaneal osteotomy fixations from database inception to October 2021. The primary outcome was the hardware removal rate, and the secondary outcomes of interest were the union rate and complications. Results Of 1,903 articles identified, eight met the inclusion criteria. The highest risk ratio (RR) of the hardware removal rate was detected in the headed screw method (RR: 0.39, 95% confidence interval (CI): 0.26-0.58). However, the highest RR of nonunion was detected in the plate method (RR: 0.02, 95%CI: 0.01-0.07). Regarding complications (infections), the headed screw method presented the highest RR of infection (RR: 0.24, 95%CI: 0.06-0.97). Conclusion This comprehensive review and meta-analysis revealed that the headless screw method may be the most effective fixation option for calcaneal osteotomy with the lowest risk of hardware removal rate, nonunion rate, and complications. Obviously, further studies are needed on a larger number of patients to confirm this finding.
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Kim J, Kim CH, Day J, Seilern Und Aspang J, Rajan L, Kumar P. Incidence of Lateral Prominence Pain Following Open Medial Displacement Calcaneal Osteotomy and the Efficacy of Crushplasty as a Preventive Technique. Foot Ankle Int 2022; 43:1300-1307. [PMID: 35778871 DOI: 10.1177/10711007221108098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There has been concern about lateral prominence pain at the osteotomy site following medial displacement calcaneal osteotomy (MDCO). However, no study has investigated this complication. This study aimed to investigate the incidence of lateral prominence pain following MDCO and examine the efficacy of crushplasty as a surgical technique to minimize this complication. METHODS This was a retrospective cohort study in which 137 patients (148 feet) who underwent MDCO were divided into 2 groups by whether they had concurrent crushplasty at the time of MDCO (crushplasty [n = 81] vs noncrushplasty group [n = 67]). Crushplasty was performed by flattening the bony step-off using a rongeur and bone impactor. Lateral prominence pain was defined as pain or irritating symptoms over the osteotomy site that persisted over 12 months after MDCO. The overall incidence of lateral prominence pain after MDCO and within each group was investigated. Multiple logistic regression analysis was used to determine the influence of possible risk factors on the development of postoperative lateral prominence pain. RESULTS The overall incidence of lateral prominence pain was 9.5% (14 of 148): 3.4% (3 of 87) in the crushplasty group, and 18% (11 of 61) in the noncrushplasty group, and χ2 analysis showed a statistically significant relationship between crushplasty and lateral prominence pain (P < .05). A relationship between the amount of medial displacement and the development of lateral prominence pain was observed in the noncrushplasty group (OR = 5.31, 95% CI 2.35-16.4, P < .05), but this was not observed in the crushplasty group (P = .641). The amount of medial displacement was an independent risk factor for the development of lateral prominence pain (OR = 2.72, 95% CI 1.54-4.79, P < .05), and concurrent crushplasty had a negative relationship with lateral prominence pain development (OR = 0.12, 95% CI 0.03-0.57, P < .05). CONCLUSION This study revealed that lateral prominence pain is a significant complication of MDCO, especially in the setting of a larger displacement. The crushplasty following MDCO may minimize this complication, particularly when a greater degree of hindfoot correction is attempted.
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Affiliation(s)
| | - Chul-Ho Kim
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jonathan Day
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, USA
| | | | - Lavan Rajan
- Hospital for Special Surgery, New York, NY, USA
| | - Prashanth Kumar
- Columbia Vagelos College of Physicians and Surgeons, New York, NY, USA
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Tonogai I, Tsuruo Y, Sairyo K. Examination of Safe Zone to Avoid Injury of the Lateral Plantar Artery During Calcaneal Osteotomy: A Fresh Cadaveric Study. Foot Ankle Spec 2022; 15:432-437. [PMID: 33090038 DOI: 10.1177/1938640020965084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Calcaneal osteotomy are used to treat various pathologies in the correction of hindfoot deformities. But lateral plantar artery (LPA) pseudoaneurysms have been reported following calcaneal osteotomy, and LPA pseudoaneurysms may be at risk for rupture. Although the vascular structures in close proximity to calcaneal osteotomies have variable courses and branching patterns, there is little information on safe zone for LPA during calcaneal osteotomy. The aims of this study were to identify the safety zone to avoid the LPA injury during calcaneal osteotomy. METHODS Enhanced computed tomography scans of 25 fresh cadaveric feet (male, n = 13; female, n = 12; mean age 79.0 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery. Line A is the landmark line and extends from the posterosuperior aspect of the calcaneal tuberosity to the plantar fascia origin, and the perpendicular distance between the LPA and line A at its closest point was measured on sagittal images. RESULTS The average perpendicular distance between the LPA and line A at its closest point was 15.2 ± 2.9 mm. In 2 cases (8.0 %), the perpendicular distance between the LPA and line A at its closest point was very close, approximately 9 mm. In 18 of 25 feet (72.0%), the point where perpendicular distance from the line A to LPA is the closest was the bifurcation of one of the medial calcaneal branches from LPA, and in 7 feet in 25 feet (28.0%) feet the point where perpendicular distance from the line A to LPA is the closest was the trifurcation of LPA, medial plantar artery, and one of the medial calcaneal branches. CONCLUSIONS Calcaneal osteotomy approximately more than 9 mm from the line A could injure the LPA in overpenetration into the medial aspect of tcalcaneal osteotomy. Completion of the osteotomy on the medial side should be performed with caution to avoid iatrogenic injury of the LPA. LEVELS OF EVIDENCE: Level IV, Cadaveric study.
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Affiliation(s)
- Ichiro Tonogai
- Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Yoshihiro Tsuruo
- Department of Anatomy and Cell Biology, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Institute of Biomedical Science, Tokushima University Graduate School, Tokushima, Japan
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Reddy SC, Schipper ON, Li J. The Effect of Chilled vs Room-Temperature Irrigation on Thermal Energy Dissipation During Minimally Invasive Calcaneal Osteotomy of Cadaver Specimens. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221136548. [PMID: 36386595 PMCID: PMC9659937 DOI: 10.1177/24730114221136548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Minimally invasive (MIS) calcaneal osteotomy has grown in popularity in recent years to address hindfoot deformity. A potential complication is thermal bone necrosis secondary to heat generation from the burr that may lead to osteotomy nonunion. Irrigation is commonly employed to reduce this risk. The effect of irrigation on reducing heat accumulation remains an understudied area. The purpose of this study was to evaluate the effect of cooled vs room-temperature irrigation on thermal energy dissipation during calcaneal osteotomy using a Shannon burr. METHODS Fourteen cadaveric limbs at room temperature (68 °F) were randomized to receive either cooled saline (7 limbs) or room-temperature (7 limbs) irrigation during MIS calcaneal osteotomy. Two thermocouple probes were inserted 5 mm away from the plane of the osteotomy, on the proximal and distal sides, respectively. A 3 × 30-mm Shannon burr was used to perform the osteotomy. The burr was run continuously with continuous irrigation using either room-temperature (68 °F) or chilled (37 °F) irrigation, until the osteotomy was completed. Temperature was recorded at 0, 15, 30, 45, and 60 seconds for the 2 groups and used as a measure of thermal energy accumulation. RESULTS Both room-temperature and chilled irrigation were effective in minimizing temperature change. On the proximal side, an overall mean increase of 2.5 °F with room-temperature irrigation and a mean decrease of 1.0 °F with chilled irrigation were observed at the 60-second interval (P = .004). On the distal side, there was a mean increase of 1.3 °F with room-temperature irrigation and a mean increase of 0.5 °F with chilled irrigation (P = .05). CONCLUSION For the duration of an MIS calcaneal osteotomy, both continuous room-temperature and chilled irrigation can minimize temperature increases and potentially reduce the risk of an osteotomy nonunion. CLINICAL RELEVANCE Both room-temperature and chilled irrigation can minimize bone temperature increases during MIS calcaneal osteotomy.
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Affiliation(s)
- Sudheer C. Reddy
- Shady Grove Orthopaedics, Adventist HealthCare, Rockville, MD, USA
| | | | - Jihui Li
- INOVA Fairfax Hospital, Falls Church, VA, USA
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Abstract
Calcaneal osteotomy is an extra-articular procedure used for conservative surgical treatment of hindfoot deformity. It has static, architectural and dynamic effects, reorienting the tuberosity action point of the digastric muscle formation of the sural triceps and plantar aponeurosis. Calcaneal osteotomies vary in location, form and displacement, but can be categorized as tuberosity osteotomy, acting on talar position, and cervical osteotomy, acting on Chopart joint-line orientation. We here describe the 3 main calcaneal osteotomies we use for hindfoot deformity: talar varus/valgus, valgus flatfoot, and midfoot abductus/adductus. In each case, we describe our technique, resulting from our responses to the difficulties we have had to deal with: medializing osteotomy: performed percutaneously to limit skin complications, and easily associated to cervical calcaneal osteotomy to manage valgus flatfoot; Hintermann cervical adduction osteotomy: providing excellent angular correction, while conserving a medial cortical hinge; lateralizingosteotomy: performed on a medial approach, to enhance translation capacity and prevent the acute tarsal tunnel syndrome with which we have been otherwise confronted. Correcting foot deformities involves complex, multi-dimensional, multi-tissue surgery that is risky as it concerns a segment with terminal vascularization. The present three techniques need to be mastered, as they are usually associated to other tendon and/or ligament reconstruction procedures, and tourniquet time is limited. LEVEL OF EVIDENCE: V; expert opinion.
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Wang SP, Lai WY, Lin YY, Lin TW, Tsai MT, Yang YP, Hsu CE, Chen CP, Lee CH, Su KC. Biomechanical comparisons of different diagonal screw designs in a novel embedded calcaneal slide plate. J Chin Med Assoc 2021; 84:1038-1047. [PMID: 34596083 DOI: 10.1097/jcma.0000000000000625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Medial displacement calcaneal osteotomy (MDCO) is frequently used for the surgical correction of flatfoot. This study aims to investigate the biomechanical effect of the different diagonal screw design on a novel-designed embedded calcaneal plate for MDCO using finite element analysis (FEA), mechanical test and digital image correlation (DIC) measurement. METHODS Four groups according to the varied implanted plate were set as control group (Group 1), non-diagonal screw (Group 2), one-diagonal screw (Group 3), and two-diagonal screws groups (Group 4). For FEA, A 450 N load was applied to on the anterior process of the calcaneus from top to bottom. Observational indices included the stress on the cortical and cancellous bone of the calcaneus surrounding the implant, the plate itself as well as screws, and the displacement of the overall structure. In addition, this study also used in vitro biomechanics test to investigate the stiffness of the structure after implantation, and used DIC to observe the displacement of the calcaneus structure after external force. RESULTS Under a simulated load in FEA, there are significant overall instability and high stress concentration on the calcaneal surrounding host bone and the plate/screws system, respectively, in group 2 compared with other groups. Regard to the mechanical testing with DIC system, significant increased rotation stability, maximum force and stiffness with the addition of diagonal screws. In comparison to Group 2, the increase of 112% and 157% in maximum force as well as 104% and 176% in stiffness were found in Group 3 and 4, respectively. CONCLUSION For reducing stress concentration and enhancing overall stability, more than one-diagonal screw design is recommended and two-diagonal screws design will be superior. This study provided biomechanical references for further calcaneal implants design to prevent clinical failure after MDCO.
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Affiliation(s)
- Shun-Ping Wang
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Sports Recreation and Health Management Continuing Studies-Bachelor's Degree Completion Program, Tunghai University, Taichung, Taiwan, ROC
- College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Wei-Yi Lai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Yin Lin
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Tzu-Wei Lin
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Ming-Tzu Tsai
- Department of Biomedical Engineering, Hungkuang University, Taichung, Taiwan, ROC
| | - Yi-Ping Yang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Cheng-En Hsu
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Sports Recreation and Health Management Continuing Studies-Bachelor's Degree Completion Program, Tunghai University, Taichung, Taiwan, ROC
| | - Chao-Ping Chen
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Health Services Administration, China Medical University, Taichung, Taiwan, ROC
- Department of Acupressure Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan, ROC
| | - Cheng-Hung Lee
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
- Department of Food Science and Technology, Hungkuang University, Taichung, Taiwan, ROC
| | - Kuo-Chih Su
- Department of Biomedical Engineering, Hungkuang University, Taichung, Taiwan, ROC
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Chemical and Materials Engineering, Tunghai University, Taichung, Taiwan, ROC
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12
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Ilyas AM, Mahoney JM, Bucklen BS. A Mechanical Comparison of the Compressive Force Generated by Various Headless Compression Screws and the Impact of Fracture Gap Size. Hand (N Y) 2021; 16:604-611. [PMID: 31565968 PMCID: PMC8461202 DOI: 10.1177/1558944719877890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: There is evidence that interfragmentary fracture gap size may affect the compression achievable with a modern headless compression screw (HCS). This mechanical study compared the compression achieved by 3 commercial HCS systems through various fracture gaps: CAPTIVATE Headless (Globus Medical, Inc, Audubon, Pennsylvania), Synthes (DePuy Synthes, Westchester, Pennsylvania), and Acumed Acutrak 2 (Acumed LLC, Hillsboro, Oregon). Methods: Screws were inserted into a custom test fixture composed of polyurethane synthetic bone foam fragments, separated by a layer of easily compressible polyurethane foam simulating a fracture gap. Compression was measured after final insertion and countersinking. The effect of the interfragmentary fracture gap size on the compression generated was also investigated. Results: The CAPTIVATE Headless 3.0 mm screw (70.1 ± 5.7 N) and the Synthes 3.0 mm screw (64.9 ± 7.3 N) achieved similar compressive forces after final countersink. Similar comparisons were found for the CAPTIVATE Headless 2.5 mm and Synthes 2.4 mm screws, and the CAPTIVATE Headless 4.0 mm and Acutrak 2 Standard screws. The final compression of the CAPTIVATE Headless 2.5 mm and Synthes 2.4 mm screws was not significantly affected when the fracture gap was doubled from 2 to 4 mm, but was reduced significantly by 95.9% with the Acutrak 2 Micro screw. Conclusion: When comparing like-sized screws, the CAPTIVATE, Synthes, and Acutrak 2 HCS systems demonstrated similar potential compressive forces. However, compared with the CAPTIVATE Headless and Synthes HCS systems, which are inserted with a compression sleeve that is not gap distance-dependent, the Acutrak 2 HCS system demonstrated less compression when the simulated fracture gap size was increased to 4 mm.
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Affiliation(s)
| | - Jonathan M. Mahoney
- Globus Medical Inc, Audubon, PA, USA,Jonathan M. Mahoney, Musculoskeletal Education and Research Center, Globus Medical, Inc, 2560 General Armistead Avenue, Audubon, PA 19403, USA.
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Calcaneal Osteotomies in the Treatment of Progressive Collapsing Foot Deformity. What are the Restrictions for the Holy Grail? Foot Ankle Clin 2021; 26:473-505. [PMID: 34332731 DOI: 10.1016/j.fcl.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The progressive collapsing foot deformity is a complex three-dimensional deformity, including valgus malalignment of the heel. The medial displacement calcaneal osteotomy is an established surgical procedure reliably resulting in an efficient correction of the inframalleolar alignment. However, complications are common, including undercorrection of underlying deformity, progression of hindfoot osteoarthritis and/or deformity, and/or symptomatic hardware.
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Coleman MM, Abousayed MM, Thompson JM, Bean BA, Guyton GP. Risk Factors for Complications Associated With Minimally Invasive Medial Displacement Calcaneal Osteotomy. Foot Ankle Int 2021; 42:121-131. [PMID: 33449834 DOI: 10.1177/1071100720961094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Few studies have reported the outcomes following minimally invasive medial displacement calcaneal osteotomy (MDCO) for correction of pes planovalgus deformities. METHODS Charts were retrospectively reviewed for consecutive patients who underwent minimally invasive MDCO procedures by a single surgeon from 2013 to 2019 with more than 3 months of follow-up. A total of 160 consecutive patients who underwent 189 minimally invasive MDCO procedures were included in the study. Median follow-up was 12 months (interquartile range, 7-25 months). RESULTS Osteotomy healing complications were present in 7% of cases during the 6-year study period. A 12-month case cluster of osteotomy healing complications was observed. Healing complication rates were 28% during the cluster and 0.7% outside of the cluster. No definitive cause was found for the case cluster, although heat osteonecrosis from the burr was suspected to be involved. Osteotomy healing complications were significantly associated with higher American Society of Anesthesiologists (ASA) classification, female sex, current tobacco use, and higher body mass index (BMI). Healing complications were not associated with osteotomy technique or fixation type. Other complications included wound dehiscence (3%), surgical site infection (2%), transient nerve symptoms (6%), and persistent nerve symptoms (2%). Nerve symptoms were significantly associated with an increased number of concomitant procedures. CONCLUSION Patients with higher ASA classification, current tobacco use, and higher BMI were at higher risk for osteotomy healing complications after minimally invasive MDCO procedures. Patients were also more likely to develop nerve complications with more extensive surgical procedures. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Michelle M Coleman
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Mostafa M Abousayed
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - John M Thompson
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Bryan A Bean
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gregory P Guyton
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Boren M, Steginsky B, Suhling M, Vora A. Cost of Headless vs Headed Screw Fixation for Calcaneal Osteotomy and Subtalar Arthrodesis. FOOT & ANKLE ORTHOPAEDICS 2021; 6:2473011420977864. [PMID: 35097422 PMCID: PMC8702910 DOI: 10.1177/2473011420977864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Screw head prominence in the heel following fixation for calcaneal osteotomy or subtalar arthrodesis has resulted in high rates of symptomatic hardware and screw removal. A cost analysis was performed to determine the financial implications of screw removal. Furthermore, we compared the rate of nonunion following fixation. Methods: Current Procedural Terminology codes were used to identify all patients who had a subtalar arthrodesis or calcaneal osteotomy (with screw fixation) performed between 2010 and 2016. The cohort was divided into 2 groups: 7.0-mm headless screw or 6.7-mm headed screw. The primary outcome measure was the rate of symptomatic screw removal. Secondary outcomes included the rate of nonunion. The expense associated with symptomatic hardware removal was determined by cost analysis. Results: Seventy-six patients underwent headless screw fixation, and 2 patients (2.6%) required screw removal. Fifty-four patients underwent headed screw fixation and 12 patients (22.2%) required screw removal. Symptomatic hardware removal was performed more frequently in the headed screw group (P < .001). There was no difference in the rate of nonunion after subtalar arthrodesis between the 2 groups (P = .363). The calcaneal osteotomy united in 100% of patients. There was a $51 755 cost savings per 100 cases using headless screw fixation. Conclusion: The rate of symptomatic screw removal was lower with headless screw fixation. The calcaneal osteotomy healed in 100% of patients, and there was no difference in the rate of subtalar nonunion between the 2 groups. Cost analysis demonstrated a significant benefit when the expense of hardware removal was considered. Level of Evidence: Level III, retrospective cohort study.
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Affiliation(s)
- Morgan Boren
- Illinois Bone and Joint Institute, Libertyville, IL, USA
| | | | | | - Anand Vora
- Illinois Bone and Joint Institute, Libertyville, IL, USA
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16
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Biomechanical results of percutaneous calcaneal osteotomy using two different osteotomy designs. Foot Ankle Surg 2020; 26:551-555. [PMID: 31371267 DOI: 10.1016/j.fas.2019.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/01/2019] [Accepted: 07/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Percutaneous osteotomy of calcaneus has been proposed to reduce the complication rate and became more and more popular. The bone cut can be performed as a straight or chevron-like (V) osteotomy using a Shannon burr. Comparative studies of straight or V-osteotomy as like as one or two screws in percutaneous calcaneal osteotomies are missing in the literature. We hypothesize that the V-osteotomy will result in a higher stiffness in biomechanical testing as the straight osteotomy using single screw for fixation. METHODS The straight osteotomy (9 fresh-frozen specimens) and V-osteotomy (9 fresh-frozen specimens) was performed and the calcaneal tuberosity was moved 10mm medially and slightly rotated. One 6,5mm cancellous compression screw was used for osteosynthesis. Specimens were preconditioned with 100N over 100 cycles. The force was increased after every 100N by 100N from 200 to 500N. This was followed by cyclic loading with 600N for 500 cycles. RESULTS Despite the higher mean values of the group with V-osteotomy, no significant difference was registered between the two groups regarding the stiffness at all force levels. A higher failure rate was observed in the group with straight osteotomy. CONCLUSION The moderate correlation of bone density and stiffness in the V-group, and significantly lower failure rate with no secondary dislocation in fluoroscopy indicates the superiority of the V-osteotomy in the present study. Whether the demonstrated advantages can be reflected in clinical practice should be investigated in further studies. LEVEL OF CLINICAL EVIDENCE 5.
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17
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Schipper ON, Day J, Ray GS, Johnson AH. Percutaneous Techniques in Orthopedic Foot and Ankle Surgery. Orthop Clin North Am 2020; 51:403-422. [PMID: 32498959 DOI: 10.1016/j.ocl.2020.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article presents the indications, contraindications, preoperative surgical planning, surgical technique, and postoperative management of some of the most common percutaneous procedures in orthopedic foot and ankle surgery. The background of each procedure also is presented, supported by the latest in published literature to educate surgeons. Such topics include percutaneous bunionectomy, lesser toe deformity and bunionette correction, calcaneal osteotomy, cheilectomy, and first metatarsophalangeal joint arthrodesis.
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Affiliation(s)
- Oliver N Schipper
- Anderson Orthopaedic Clinic, 2445 Army Navy Drive, Arlington, VA 22206, USA.
| | - Jonathan Day
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Gabrielle S Ray
- Tufts University School of Medicine, 145 Harrison Avenue, Boston, MA, USA
| | - Anne Holly Johnson
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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18
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DeHeer PA, Patel S, Standish SN. Procedure-Specific Hardware Removal After Evans Osteotomy. J Am Podiatr Med Assoc 2020; 110:436381. [PMID: 32556224 DOI: 10.7547/17-096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Evans osteotomy is a widely used procedure for the correction of adult and pediatric flexible flatfoot deformity. Locking plates are commonly used to stabilize the osteotomy and the allograft. However, there have been incidences of soft-tissue irritation caused by the hardware, requiring subsequent hardware removal. Therefore, we sought to review whether age, sex, or laterality of the procedure had any correlation with the rate of hardware removal. METHODS A retrospective review was performed of 47 consecutive patients who underwent an Evans calcaneal osteotomy between October 1, 2013, and October 1, 2016. Data were collected and analyzed based on age, sex, laterality, and the need for hardware removal. RESULTS All of the 47 patients met the inclusion criteria. Seventy procedures were performed, and hardware removal was required in 16 patients and 21 feet (30%). The only statistically significant finding was that 11 females and only five males required either unilateral or bilateral hardware removal (P = .039). All 16 patients reported complete pain relief after hardware removal. CONCLUSIONS Females are twice as likely as males to develop symptoms after locking plate application over an Evans osteotomy and may require hardware removal. Despite the low-profile nature of the locking plate to fixate the Evans osteotomy, the hardware can be a source of significant pain. Patients, especially females, should be cautioned about potential hardware-related pain and a possible follow-up procedure to remove the hardware.
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Affiliation(s)
- Patrick A DeHeer
- Department of Podiatric Surgery, St. Vincent's Hospital, Indianapolis, IN
| | - Shrunjay Patel
- Department of Podiatric Surgery, St. Vincent's Hospital, Indianapolis, IN
| | - Sarah N Standish
- Department of Podiatric Surgery, St. Vincent's Hospital, Indianapolis, IN
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Abstract
BACKGROUND The calcaneal slide osteotomy is a common procedure used for the surgical correction of heel varus and valgus deformities. A variety of fixation methods exist including screws and plates. The literature shows a high rate of hardware prominence with screws leading to subsequent removal of hardware. Few studies have examined the use of plates for fixation of a calcaneal osteotomy. The purpose of this study was to assess outcomes following fixation of a calcaneal osteotomy with a calcaneal slide plate. METHODS This is a retrospective consecutive case series of all patients who underwent either a medial or lateral calcaneal slide osteotomy using the specialized calcaneal slide plate between September 2013 and December 2018 by a single surgeon. The primary outcome measures were the rate of hardware removal, healing of the calcaneal osteotomy, and any associated complications such as infection or incision healing delays. Patient baseline demographics and procedure-related data were recorded. The minimum follow-up was 4 months. A total of 81 procedures were performed using this calcaneal slide plate. RESULTS All of the patients had one or more additional procedures at the same time as the calcaneal osteotomy. All of the calcaneal osteotomies healed without displacement. Only 1 patient (1.2%) returned to the operating room and had removal of the calcaneal slide plate, which was after osteotomy union for an infected wound. There were no cases of hardware failure or removal due to it being symptomatic. CONCLUSION A specialized calcaneal slide plate was an effective fixation device for both medial and lateral calcaneal slide osteotomies for a variety of foot and ankle conditions. The union rate was 100% and none of the patients had hardware symptoms, which is an improvement on published reports of symptomatic hardware after calcaneal slide osteotomy. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Erin K Haggerty
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephanie Chen
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David B Thordarson
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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20
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Park JH, Park KR, Kim D, Kwon HW, Lee M, Choi YJ, Kim YB, Park S, Yang J, Cho J. The incision strategy for minimizing sural nerve injury in medial displacement calcaneal osteotomy: a cadaveric study. J Orthop Surg Res 2019; 14:356. [PMID: 31718699 PMCID: PMC6852710 DOI: 10.1186/s13018-019-1411-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/14/2019] [Indexed: 12/03/2022] Open
Abstract
Background The skin incision for medial displacement calcaneal osteotomy (MDCO) often damages the sural nerve. We aimed to identify the practical reference area in which the surgeon can incise the skin to minimize the injury of the sural nerve during MDCO. Methods The foot and ankles of 20 cadavers were dissected. The landmarks were the following four anatomical references: point A, the tip of the lateral malleolus; point B, the inferior margin of the calcaneus on the vertical line through point A; point C, the posteroinferior apex of the calcaneus; and point D, the lateral border of the Achilles tendon on the horizontal line through point A. The distances from the sural nerve to points A and B in the vertical direction (lines D1 and D2, respectively), to points A and C in the diagonal direction (lines D3 and D4, respectively), and to points A and D in the horizontal direction (lines D5 and D6, respectively) were measured. Results The median ratios of D1 to D1+D2, D3 to D3+D4, and D5 to D5+D6 were 0.34 (range 0.25 to 0.45), 0.23 (range 0.16 to 0.33), and 0.38 (range 0.26 to 0.50), respectively. Conclusions The distance ratios according to easily identifiable references would be a more practical incision strategy for surgeons to minimize sural nerve injury in both open and minimally invasive/percutaneous MDCO.
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Affiliation(s)
- Jeong-Hyun Park
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Kwang-Rak Park
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Digud Kim
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Hyung-Wook Kwon
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Mijeong Lee
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Yu-Jin Choi
- Department of Anatomy & Cell Biology, Graduate School of Medicine, Kangwon National University, Kangwon, Republic of Korea
| | - Yong-Been Kim
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 200-704, Republic of Korea
| | - Suyeon Park
- Department of biostatistics, College of Medicine, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Jinseo Yang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon, Republic of Korea
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 200-704, Republic of Korea.
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Gutteck N, Zeh A, Wohlrab D, Delank KS. Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities. Foot Ankle Int 2019; 40:276-281. [PMID: 30413133 DOI: 10.1177/1071100718809449] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Calcaneal osteotomies are often required in the correction of hindfoot deformities. The traditional open techniques, which include a lateral or oblique incision, are occasionally associated with wound healing problems and neurovascular injury. METHODS: A total of 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. Fifty-eight patients were operated using an open incision technique and 64 patients (66 feet) using a percutaneous technique. Clinical and radiologic assessments were performed preoperatively, at 6 weeks, and 1 year postoperatively. RESULTS: The American Orthopaedic Foot & Ankle Society scale scores and visual analog scale pain scores improved in both groups postoperatively. The difference between the groups was not significant. The results of the radiologic measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in either group. The comparison of both groups showed a significantly lower risk for wound healing problems in the percutaneous group. The hospitalization time was significantly shorter in the percutaneous group. CONCLUSION: Because of the excellent results with the percutaneous calcaneal osteotomy, the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy, especially patients at high risk for wound healing problems. LEVEL OF EVIDENCE: Level III, comparative series.
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Affiliation(s)
- Natalia Gutteck
- 1 Department of Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Alexander Zeh
- 1 Department of Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - David Wohlrab
- 1 Department of Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Karl-Stefan Delank
- 1 Department of Orthopedic and Trauma Surgery, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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SahraNavard B, Hudson PW, de Cesar Netto C, Wills BW, Araoye IB, Bergstresser S, Cone BM, Shah A. A comparison of union rates and complications between single screw and double screw fixation of sliding calcaneal osteotomy. Foot Ankle Surg 2019; 25:84-89. [PMID: 29409301 DOI: 10.1016/j.fas.2017.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/03/2017] [Accepted: 08/28/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND The number of screws used for sliding calcaneal osteotomy fixation has not been examined in the literature. The purpose of this paper is to examine this topic. METHODS Retrospective chart review was performed on 190 patients who met selection criteria. We compared complication risk for single versus double screw, headed versus headless screw, and short versus longitudinal incision cases. RESULTS The mean age was 48.4 (18-83) years and average follow up was 28 (12-150) weeks. All cases achieved radiographic union. Overall complication rate was 19.5% (37/190). Risk of complication did not differ significantly between single and double screw (RR: 1.170; 95% CI: 0.66-2.09; p=0.594) or short and extended incision groups (RR: 0.868; 95% CI: 0.42-1.80; p=0.704). Risk of complication differed significantly between headed and headless screw fixation (RR: 5.558; 95% CI: 2.69-11.50; p<0.0001). CONCLUSIONS Single screw fixation of sliding calcaneal osteotomy achieves similar outcomes as double screw fixation. Headless screws are advantageous for minimizing hardware pain and subsequent hardware removal.
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Affiliation(s)
- Bahman SahraNavard
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Parke W Hudson
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Cesar de Cesar Netto
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Bradley W Wills
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Ibukunoluwa B Araoye
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Shelby Bergstresser
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Brent M Cone
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
| | - Ashish Shah
- University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL 35205, USA.
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23
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Wills B, Lee SR, Hudson PW, SahraNavard B, de Cesar Netto C, Naranje S, Shah A. Calcaneal Osteotomy Safe Zone to Prevent Neurological Damage: Fact or Fiction? Foot Ankle Spec 2019. [PMID: 29532743 DOI: 10.1177/1938640018762556] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Calcaneal osteotomy is a commonly used surgical option for the correction of hindfoot malalignment. A previous cadaveric study described a neurological "safe zone" for calcaneal osteotomy. We performed a retrospective chart review to evaluate the presence of neurological injuries following calcaneal osteotomies and the location of the osteotomy in relation to the reported safe zone. METHODS In this retrospective study, we reviewed charts of patients who underwent calcaneal osteotomy at our institution from 2011 to 2015. All immediate postoperative radiographs were examined and the shortest distance between the calcaneal osteotomy line and a reference line connecting the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia was measured. If the osteotomy line was positioned within an area 11.2 mm anterior to the reference line, it was considered to be inside the neurological safe zone. We correlated the positioning of the osteotomy with the presence of postoperative neurological complications. RESULTS We identified 179 calcaneal osteotomy cases. Of the 174 (97.2%) nerve injury-free cases, 62.6% (109/174) were performed inside the defined "safe zone" while 37.4% (65/174) outside. A total of 5 (2.8%) nerve complications were identified: 3 (60%) were inside the safe zone and 2 (40%) outside the safe zone. Osteotomies outside the safe zone had a 1.114 relative risk of nerve injury with a 95% CI of 0.191 to 6.500 and showed no statistically significant difference ( P = .9042). CONCLUSION Our findings suggest that the clinical "safe zone" in calcaneal osteotomies may not actually exist, likely because of wide anatomical variation of the implicated nerves, as described in prior studies. Patients should be properly counseled preoperatively on the low, but seemingly fixed, risk of nerve injury before undergoing calcaneal osteotomy. LEVELS OF EVIDENCE Level III: Retrospective comparative study.
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Affiliation(s)
- Bradley Wills
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Sung Ro Lee
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | - Sameer Naranje
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashish Shah
- University of Alabama at Birmingham, Birmingham, Alabama
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Veljkovic A, Symes M, Younger A, Rungprai C, Abbas KZ, Salat P, Tennant J, Phisitkul P. Neurovascular and Clinical Outcomes of the Percutaneous Endoscopically Assisted Calcaneal Osteotomy (PECO) Technique to Correct Hindfoot Malalignment. Foot Ankle Int 2019; 40:178-184. [PMID: 30304962 DOI: 10.1177/1071100718800983] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Standard open calcaneal osteotomies to correct hindfoot malalignment have been associated with high complication rates, including nerve damage and wound infection. This has resulted in the development of minimally invasive techniques such as the percutaneous endoscopically assisted calcaneal osteotomy (PECO), which in cadaver studies has been shown to be potentially safer than open surgeries. The aim of this study was to demonstrate the safety and effectiveness of PECO in a clinical setting, with regard to neurovascular injury rates, infection, and short-term radiographic and functional outcomes. METHODS: Forty-one (41) patients with planovalgus or cavovarus foot deformities underwent treatment using PECO. Outcomes were analyzed at 6 months and primarily included neurovascular outcomes and wound infection rates. Secondarily, radiographic and functional (visual analog scale for pain [VAS], 36-Item Short Form Medical Outcomes Survey [SF-36], and Foot Function Index [FFI] scores) outcomes were also assessed. RESULTS: There were no reported cases of superficial wound infections, lateral calcaneal or sural nerve dysesthesia. Minor complications occurred in 6/41 feet. The mean postoperative hindfoot correction was 8.3 ± 2.2 mm (range: 6-15mm) compared to preoperative status. Compared to preoperative status, significant improvements ( P = .001 for all) were seen in the VAS, SF-36, and FFI at 6 months postoperatively. CONCLUSIONS: PECO resulted in minimal complications with no lateral calcaneal or sural nerve dysesthesias and no wound complications. It also resulted in significant improvements in postoperative radiographic and functional outcomes from baseline to 6-months postoperatively, demonstrating its use as a safe and effective means of treating hindfoot malalignment. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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Affiliation(s)
- Andrea Veljkovic
- 1 St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Michael Symes
- 1 St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Alastair Younger
- 1 St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Peter Salat
- 4 University of Calgary Cumming School of Medicine Department of radiology, Mayfair Diagnostics. Calgary, AB, Canada
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Abstract
Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched.
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Affiliation(s)
- Jensen K. Henry
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Rachel Shakked
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Scott J. Ellis
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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26
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Angers-Goulet M, Beauchamp-Chalifour P, Laflamme N, Bouchard M, Laflamme M. Risk Factors for Removal of Calcaneus Screws: A Retrospective Study. J Foot Ankle Surg 2018; 57:701-706. [PMID: 29703456 DOI: 10.1053/j.jfas.2017.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Indexed: 02/03/2023]
Abstract
Although techniques using calcaneus screws have shown high union rates, posterior heel pain due to prominent hardware at the posterior and plantar aspect of the calcaneal tuberosity seems to be a significant complaint that often leads to hardware removal. The purpose of the present study was to identify the clinical and radiologic risk factors associated with calcaneus screw removal. A retrospective study of adult patients who required calcaneus screw fixation from January 2008 to December 2016 was conducted. We reviewed the medical records and radiographs to evaluate the risk factors for screw removal. Of the 123 patients included in the present study, 63 were male and 60 were female. The mean age was 55.0 ± 6.0 years, and the mean body mass index was 31.0 ± 6.0 kg/m2. The removal rate was 8.8% (10 of 114 evaluated) at the 1-year follow-up point and 13.6% (12 of 88 evaluated) at the 2-year follow-up point. The mean interval to removal was 1.23 ± 1.22 years. A total of 16 screws (72.7%) were removed for heel pain. At the 1-year follow-up examination, the removal rate due to inflammatory arthritis was 25.0% (p = .07). Moreover, the proportion of screw removal was greater at 2 years in illicit drug users (p = .008). Screw sizes ≤6.5 mm showed a tendency (p = .12) toward a lower rate of removal at the 2-year follow-up point. Calcaneus screws should be used with caution in specific patient populations such as illicit drug users and those with inflammatory arthritis. The use of smaller diameter calcaneus screws might be an option to lower the rate of screw removal due to heel pain.
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Affiliation(s)
- Mathieu Angers-Goulet
- Orthopaedic Resident, Department of Orthopaedic Surgery, CHU de Québec-Centre Hospitalier de l'Université Laval (CHUL), Québec, QC, Canada
| | | | - Nathalie Laflamme
- Epidemiologist, Centre de recherche CHU de Québec-Université Laval, Québec, QC, Canada
| | - Marc Bouchard
- Clinical Professor, Department of Orthopaedic Surgery, CHU de Québec-Centre Hospitalier de l'Université Laval (CHUL), Québec, QC, Canada
| | - Mélissa Laflamme
- Clinical Professor, Department of Orthopaedic Surgery, CHU de Québec-Centre Hospitalier de l'Université Laval (CHUL), Québec, QC, Canada.
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Kunzler D, Shazadeh Safavi P, Jupiter D, Panchbhavi VK. A Comparison of Removal Rates of Headless Screws Versus Headed Screws in Calcaneal Osteotomy. Foot Ankle Spec 2018; 11:420-424. [PMID: 29192509 DOI: 10.1177/1938640017744640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Calcaneal osteotomy has been used to successfully treat both valgus and varus hindfoot deformities. Pain associated with implanted hardware may lead to further surgical intervention for hardware removal. Headless screws have been used to reduce postoperative hardware-associated pain and accompanying hardware removal, but data proving their effectiveness in this regard is lacking. The purpose of this study is to compare the rates of removal of headed and headless screws utilized in calcaneal osteotomy. METHODS We conducted a retrospective chart review of 74 patients who underwent calcaneal osteotomy between January 2010 and December 2014. The cohort was divided into 2 groups by fixation method: a headed screw and a headless screw group. Bivariate associations between infection or hardware removal, and screw type, screw head width, gender, smoking status, alcohol, hypertension, diabetes, hyperlipidemia, age, and body mass index were assessed using t-tests and Fisher's exact/χ2 tests for continuous and discrete variables, respectively. RESULTS Headed screws were removed more frequently than headless screws (P < .0001): 15 of 30 (50%) feet that received headed screws and 4 of 44 (9%) of feet that received headless screws underwent subsequent revision for screw removal. In all cases, screws were removed because of pain. The calcaneal union rate was 100% in both cohorts. CONCLUSION The rate of screw removal in calcaneal osteotomies is significantly lower in patients who receive headless screws than in those receiving headed screws. LEVELS OF EVIDENCE Level IV.
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Affiliation(s)
- Daniel Kunzler
- University of Texas Medical Branch at Galveston, Dickinson, Texas (DK, PS).,Preventative Medicine and Community Health, University of Texas Medical Branch at Galveston, Dickinson, Texas (DJ).,Division of Foot and Ankle Surgery, Department of Orthopedics, University of Texas Medical Branch, Galveston, Texas (VKP)
| | - Pejma Shazadeh Safavi
- University of Texas Medical Branch at Galveston, Dickinson, Texas (DK, PS).,Preventative Medicine and Community Health, University of Texas Medical Branch at Galveston, Dickinson, Texas (DJ).,Division of Foot and Ankle Surgery, Department of Orthopedics, University of Texas Medical Branch, Galveston, Texas (VKP)
| | - Daniel Jupiter
- University of Texas Medical Branch at Galveston, Dickinson, Texas (DK, PS).,Preventative Medicine and Community Health, University of Texas Medical Branch at Galveston, Dickinson, Texas (DJ).,Division of Foot and Ankle Surgery, Department of Orthopedics, University of Texas Medical Branch, Galveston, Texas (VKP)
| | - Vinod K Panchbhavi
- University of Texas Medical Branch at Galveston, Dickinson, Texas (DK, PS).,Preventative Medicine and Community Health, University of Texas Medical Branch at Galveston, Dickinson, Texas (DJ).,Division of Foot and Ankle Surgery, Department of Orthopedics, University of Texas Medical Branch, Galveston, Texas (VKP)
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Donald SM, Niu R, Jones CW, Smith BJ, Clarke EC, Lawson RD. Effects of Removal and Reinsertion of Headless Compression Screws. J Hand Surg Am 2018; 43:139-145. [PMID: 29137829 DOI: 10.1016/j.jhsa.2017.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/30/2017] [Accepted: 10/02/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE This study investigates the loss of compression when 3 commonly used headless compression screws are backed out (reversed), and assesses the ability to re-establish compression with screws of greater diameter. METHODS Two investigators tested 3 screw designs (Acutrak 2, Synthes HCS, Medartis SpeedTip CCS) in 2 diameters and lengths. Each design had 10 test cycles in a polyurethane foam bone model with compression recorded using a washer load cell. A 28-mm screw of the narrower diameter was inserted until 2 mm recessed and then reversed 30°, 60°, 90°, 180°, 270°, 360°, and 720°. After this the screw was removed completely and a 24-mm screw of greater diameter inserted until recessed 2 mm with the compressive force again recorded. RESULTS All screws showed an immediate, statistically significant loss of compression at 30° of reversing. The Acutrak 2 Micro screw demonstrated not only the greatest mean compressive force, but also the fastest compressive loss. Insertion of the shorter screw of greater diameter was associated with re-establishment of compression to levels comparable with the original screw. CONCLUSIONS This study reaffirms the importance of establishing the correct screw length before insertion due to the immediate loss of compression with reversal of these devices. CLINICAL RELEVANCE If a headless compression screw penetrates the far joint surface, the screw should be completely removed and replaced with a shorter screw of greater diameter.
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Affiliation(s)
- Simon M Donald
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Rui Niu
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Christopher W Jones
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Belinda J Smith
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Elizabeth C Clarke
- Murray Maxwell Biomechanics Laboratory, Kolling Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Richard D Lawson
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia.
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29
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Abstract
UNLABELLED Minimally invasive techniques are readily applicable to calcaneal osteotomies and have the potential to accomplish hindfoot correction equivalent to open procedures with less morbidity and pain. Use of a guidance jig makes the procedure more predictable. While most anatomic features of the procedure are the same as those with open techniques, special care must be taken to avoid neurovascular injury because there is no open exposure. Anatomic guidelines have been established for appropriately localizing the osteotomy. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
- Thomas I Sherman
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gregory P Guyton
- 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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30
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Veljkovic A, Tennant J, Rungprai C, Abbas KZ, Phisitkul P. An Anatomic Study of the Percutaneous Endoscopically Assisted Calcaneal Osteotomy Technique to Correct Hindfoot Malalignment. Foot Ankle Int 2017; 38:192-199. [PMID: 27765868 DOI: 10.1177/1071100716674259] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open calcaneal osteotomy using traditional methods is associated with complications such as sural nerve injury and potential wound healing problems. We hypothesized that by using novel minimally invasive techniques, these potential risks could be mitigated. This anatomic cadaveric study serves to assess the safety of percutaneous endoscopically assisted calcaneal osteotomy (PECO) compared to a traditional open osteotomy technique. METHODS Anatomic safety of PECO was assessed using 8 fresh-frozen cadaver below-knee specimens. Lateral calcaneal nerve (LCN) damage was primarily noted and then secondly compared to a potential open surgical incision approach. RESULTS Only 1 of 11 LCN branches (n = 8 limbs) was transected using PECO, compared to up to 8 of 10 LCN branches (n = 6 limbs) that potentially would have been injured during open surgery. CONCLUSIONS Percutaneous endoscopically assisted calcaneal osteotomy is a minimally invasive technique that had fewer nerve injuries in this cadaveric model than traditional open surgery. CLINICAL RELEVANCE Percutaneous endoscopically assisted calcaneal osteotomy due to its less invasive nature may result in fewer neurovascular injuries relative to an open procedure.
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Affiliation(s)
- Andrea Veljkovic
- 1 St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Kaniza Zahra Abbas
- 4 University Health Network-Toronto Western Division, Toronto, ON, Canada
| | - Phinit Phisitkul
- 5 Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
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Talusan PG, Cata E, Tan EW, Parks BG, Guyton GP. Safe Zone for Neural Structures in Medial Displacement Calcaneal Osteotomy: A Cadaveric and Radiographic Investigation. Foot Ankle Int 2015; 36:1493-8. [PMID: 26231200 DOI: 10.1177/1071100715595696] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to define reference lines on standard lateral ankle radiographs that could be used intraoperatively to minimize iatrogenic nerve injury risk in medial displacement calcaneal osteotomy. METHODS Forty cadaveric specimens were used. In 20 specimens, the sural, medial plantar (MP), and lateral plantar (LP) nerves were sutured to radiopaque wire, and a lateral ankle radiograph was obtained. On the radiograph, a line was drawn from the posterior superior apex of the calcaneal tuberosity to the origin of the plantar fascia and labeled as the "landmark line." A parallel line was drawn 2 mm posterior to the most posterior nerve, and the area between these lines was defined as the safe zone. In 20 additional specimens, an osteotomy was performed 1 cm anterior to the landmark line using a percutaneous or open technique. Dissection was performed to assess for laceration of the sural, MP, LP, medial calcaneal (MC), or lateral calcaneal (LC) nerves. RESULTS The safe zone was determined to be within the area 11.2 ± 2.7 mm anterior to the landmark line. After open osteotomy, lacerations were found in 3 of 10 MC nerves and 3 of 10 LC nerves. After percutaneous osteotomy, lacerations were found in 2 of 10 MC nerves and 1 of 10 LC nerves. No lacerations of the sural, MP, or LP nerves were found with either osteotomy. CONCLUSIONS The safe zone extended 11.2 ± 2.7 mm anterior to the described landmark line. The MC and LC nerves were always at risk during medial displacement calcaneal osteotomy. CLINICAL RELEVANCE Nerve injury to both major and minor sensory nerves is likely underrecognized as a source of morbidity after calcaneal osteotomy. The current study provides a ready intraoperative guideline for minimizing this risk.
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Affiliation(s)
- Paul G Talusan
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA Department of Orthopaedic Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Ezequiel Cata
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Eric W Tan
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Brent G Parks
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gregory P Guyton
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
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32
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Peterson KS, Overley BD, Beideman TC. Osteotomies for the Flexible Adult Acquired Flatfoot Disorder. Clin Podiatr Med Surg 2015; 32:389-403. [PMID: 26117574 DOI: 10.1016/j.cpm.2015.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Flexible adult acquired flatfoot disorder is commonly treated with the use of osteotomies in the calcaneus and medial column. The combination of these joint-preserving osteotomies with additional soft-tissue procedures allows realignment of the hindfoot with the goal of preventing further deformity or degenerative joint disease. A thorough understanding of each patient's condition allows the surgeon to match the correct osteotomy to the clinical indication, while also successfully executing the planned surgery.
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Affiliation(s)
- Kyle S Peterson
- Suburban Orthopaedics, 1110 West Schick Road, Bartlett, IL 60103, USA.
| | - Benjamin D Overley
- Division of Orthopedics, Pottstown Medical Specialists, Inc, 1610 Medical Drive, Pottstown, PA 19464, USA
| | - Thomas C Beideman
- Mercy Suburban Hospital, 2701 Dekalb Pike, Norristown, PA 19401, USA
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33
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Protzman NM, Wobst GM, Storts EC, Mulhern JL, McCarroll RE, Brigido SA. Mid-Calcaneal Length After Evans Calcaneal Osteotomy: A Retrospective Comparison of Wedge Locking Plates and Tricortical Allograft Wedges. J Foot Ankle Surg 2015; 54:900-4. [PMID: 25998470 DOI: 10.1053/j.jfas.2015.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Indexed: 02/03/2023]
Abstract
Evans calcaneal osteotomy remains a cornerstone in the correction of the flexible flatfoot. Although multiple techniques have been used to maintain the length of the lateral column, a low profile wedge locking plate was recently introduced as an alternative to the traditional tricortical allograft wedge. We hypothesized that the wedge locking plate would better maintain the mid-calcaneal length compared with the tricortical allograft wedge. To test this hypothesis, after Evans osteotomy, the mid-calcaneal length was measured in the immediate postoperative period and again at 3 and 6 months. A total of 24 patients met the inclusion criteria. The mean patient age was 48.1 years (range 11 to 66). Of the 24 patients, 9 (37.5%) were treated with a tricortical allograft wedge and 15 (62.5%) with a wedge locking plate. At 3 months postoperatively, the mean decrease in mid-calcaneal length was similar for the tricortical allograft wedge group (1.3 ± 1.9 mm) and the wedge locking plate group (0.5 ± 0.9 mm, p = .275). At 6 months postoperatively, however, the mean decrease in mid-calcaneal length was greater for the tricortical allograft wedge group (2.8 ± 1.7 mm) than for the wedge locking plate group (0.6 ± 0.7 mm, p = .004). The 2 groups demonstrated a similar incidence of dorsally displaced distal calcaneal fragments throughout the study endpoint (p ≥ .052). These results suggest that the wedge locking plate better maintains the mid-calcaneal length over time compared with the tricortical allograft wedge.
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Affiliation(s)
- Nicole M Protzman
- Research Associate, Clinical Education and Research Department, Coordinated Health, Allentown, PA
| | - Garrett M Wobst
- Attending Physician, Avera Orthopedic Surgery Specialists, Aberdeen, SD
| | - Eric C Storts
- Resident, Podiatric Residency Program, New York Methodist Hospital, Brooklyn, NY
| | - Jennifer L Mulhern
- Fellow, Foot and Ankle Reconstruction, Coordinated Health, Bethlehem, PA
| | - Raymond E McCarroll
- Attending Physician, Foot and Ankle Department, Coordinated Health, Bethlehem, PA
| | - Stephen A Brigido
- Fellowship Director and Department Chair, Foot and Ankle Reconstruction, Foot and Ankle Department, Coordinated Health, Bethlehem, PA.
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Lucas DE, Simpson GA, Berlet GC, Philbin TM, Smith JL. Screw size and insertion technique compared with removal rates for calcaneal displacement osteotomies. Foot Ankle Int 2015; 36:395-9. [PMID: 25413309 DOI: 10.1177/1071100714559073] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The calcaneal displacement osteotomy is frequently used by foot and ankle surgeons to correct hindfoot angular deformity. Headed compression screws are often used for this purpose, but a common complication is postoperative plantar heel pain from prominent hardware. We evaluated hardware removal rates after calcaneal displacement osteotomies and analyzed technical factors including screw size, position, and angle. We hypothesized that larger screws placed more plantarly would have been removed more frequently. We also believed that although 2 smaller screws cost more initially, when removal rates and cost are accounted for, savings would be demonstrated with this technique. METHODS We retrospectively collected data on type of fixation, cost of fixation, and frequency of removal. After exclusions we had 30 patients in our screw removal cohort and 119 in our screws retained cohort. A basic cost analysis and statistical analysis was performed. RESULTS The small screw group had a hardware removal rate of 9% (4/43) compared to 25% (26/104) of the larger screw group (P = .032). While the cost of 2 smaller screws is more than that of 1 larger screw, when the cost of removal and the rates of doing so are considered, the smaller screws resulted in substantial cost savings. CONCLUSION Technical considerations for the medial displacement calcaneal osteotomy, including the use of multiple smaller screws, provided for a lower rate of hardware removal and likely decreased long-term costs. LEVEL OF EVIDENCE Level III, comparative series.
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Affiliation(s)
- Douglas E Lucas
- Orthopedic Foot and Ankle Department, Stanford University School of Medicine, Stanford, CA, USA
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35
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Lucas DE, Simpson GA, Philbin TM. Comparing fixation used for calcaneal displacement osteotomies: a look at removal rates and cost. Foot Ankle Spec 2015; 8:18-22. [PMID: 25380837 DOI: 10.1177/1938640014557073] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The calcaneal displacement osteotomy is a procedure frequently used by foot and ankle surgeons for hindfoot angular deformity. Traditional techniques use compression screw fixation that can result in prominent hardware. While the results of the procedure are generally good, a common concern is the development of plantar heel pain related to prominent hardware. The primary purpose of this study is to retrospectively compare clinical outcomes of 2 fixation methods for the osteotomy. Secondarily a cost analysis will compare implant costs to hardware removal costs. METHODS Records were reviewed for patients who had undergone a calcaneal displacement osteotomy fixated with either lag screw or a locked lateral compression plate (LLCP). Neuropathy, previous ipsilateral calcaneus surgery, heel pad trauma, or incomplete radiographic follow-up were exclusionary. RESULTS Thirty-two patients (19.4%) required hardware removal from the screw fixation group compared to 1 (1.6%) of the LLCP group, which is significant (P < .05). Time to radiographic healing was not significantly different (P = .87). The screw fixation group required more follow-up visits over a longer period of time (P < .05). Implant cost was remarkably different with screw fixation costing on average $247.12, compared to the LLCP costing $1175.59. Although the LLCP cost was significantly higher, cost savings were identified when the cost of removal and removal rates were included. CONCLUSION This study demonstrates that this device provides adequate stabilization for healing in equivalent time to screw fixation. The LLCP required decreased rates of hardware removal with fewer postoperative visits over a shorter period of time. Significant savings were demonstrated in the LLCP group despite the higher implant cost. LEVELS OF EVIDENCE Therapeutic, Level III, Retrospective Comparative Study.
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Affiliation(s)
- Douglas E Lucas
- Doctor's Hospital, Columbus, Ohio (DEL)Orthopedic Foot and Ankle Center, Westerville, Ohio (GAS, TMP)
| | - G Alex Simpson
- Doctor's Hospital, Columbus, Ohio (DEL)Orthopedic Foot and Ankle Center, Westerville, Ohio (GAS, TMP)
| | - Terrence M Philbin
- Doctor's Hospital, Columbus, Ohio (DEL)Orthopedic Foot and Ankle Center, Westerville, Ohio (GAS, TMP)
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36
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Abstract
UNLABELLED Calcaneal tuberosity osteotomies are commonly used to treat coronal plane deformities of the hindfoot. Assessing hindfoot alignment can be difficult and there is little evidence to guide the physician when considering the surgical treatment of these deformities. The indications for a calcaneal osteotomy are unclear in the literature because most of the published studies supporting their use are confounded by concurrent procedures such as in adult-acquired flatfoot correction or cavovarus reconstruction. For the same reason, the biomechanical consequences, long-term effects, and performance in vivo are largely unknown. LEVEL OF EVIDENCE Expert opinion, Level V.
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37
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Sayres SC, Gu Y, Kiernan S, DeSandis BA, Elliott AJ, O'Malley MJ. Comparison of rates of union and hardware removal between large and small cannulated screws for calcaneal osteotomy. Foot Ankle Int 2015; 36:32-6. [PMID: 25189540 DOI: 10.1177/1071100714549191] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The calcaneal osteotomy is a common procedure to correct hindfoot malalignment. Reported union rates are high, utilizing fixation methods including staples, plates, and most commonly cannulated screws. We began our practice using 6.5 mm and 7.3 mm cannulated screws, but complaints of postoperative posterior heel pain led to hardware removal in many patients. A switch to smaller 4.5 mm cannulated screws resulted in fewer symptoms, thus we hypothesized that using a smaller screw would decrease screw removal while maintaining an equally high union rate. METHODS The records of patients who underwent a calcaneal osteotomy by 2 surgeons between January 1996 and April 2012 were retrospectively reviewed. The rates of hardware removal and union were compared between osteotomies held with two 7.3 mm, 6.5 mm, and 4.5 mm cannulated screws. RESULTS There were 272 feet that met the inclusion criteria. The hardware removal rate for 130 osteotomies held with two 7.3 mm screws was 29.2% and the removal rate for 115 osteotomies held with 4.5 mm screws was 13.0%, which was significantly different (P < .05). The removal rate for 27 osteotomies with 6.5 mm screws was 33.3%. The union rate for all groups was 100%. CONCLUSION Fixation of calcaneal osteotomies with two 4.5 mm screws is advantageous over larger screws with respect to future hardware removal. There was no loss of position from the smaller screws and we feel that the 4.5mm cannulated screw provides sufficient compression and achieves a high rate of union equal to that of the larger screws. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
| | - Yang Gu
- Georgetown School of Medicine, Washington DC, USA
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38
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Abstract
The use of locking plate technology in foot and ankle surgery has increased over the last decade. Reported applications include fracture repair, deformity correction, and arthrodesis. There is limited evidence, however, to guide clinicians with regard to the appropriate and optimal use of this technology. This work aims to examine the current biomechanical and clinical evidence comparing locking construct technology to other forms of fixation in the field of foot and ankle surgery.
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