Comparison of rates of union and hardware removal between large and small cannulated screws for calcaneal osteotomy

Optimizing Subtalar Arthrodesis: A Human Cadaveric Evaluation of a Novel Partially-Threaded Screw Combination in the Delta Configuration

Background and Objectives: Despite the established role of subtalar joint arthrodesis (SJA) for treatment of subtalar osteoarthritis, achieving bone union remains challenging, with up to 46% non-union rates. Adequate compression and stable fixation are crucial for successful outcomes, with internal screw fixation being the gold standard for SJA. The delta configuration, featuring highly divergent screws, offers stability, however, it can result in hardware irritation in 20-30% of patients. Solutions to solve this complication include cannulated compression screw (CCS) countersinking or cannulated compression headless screw (CCHS) application. The aim of this biomechanical study was to investigate the stability of a delta configuration for SJA utilizing either a combination of a posterior CCHS and an anterior CCS or a standard two-CCS combination. Materials and Methods: Twelve paired human cadaveric lower legs were assigned pairwise to two groups for SJA using either two CCSs (Group 1) or one posterior CCHS and one anterior CCS (Group 2). All specimens were tested under progressively increasing cyclic loading to failure, with monitoring of the talocalcaneal movements via motion tracking. Results: Initial stiffness did not differ significantly between the groups, p = 0.949. Talocalcaneal movements in terms of varus-valgus deformation and internal-external rotation were significantly bigger in Group 1 versus Group 2, p ≤ 0.026. Number of cycles until reaching 5° varus-valgus deformation was significantly higher in Group 2 versus Group 1, p = 0.029. Conclusions: A delta-configuration SJA utilizing a posterior CCHS and an anterior CCS is biomechanically superior versus a standard configuration with two CCSs. Clinically, the use of a posterior CCHS could prevent protrusion of the hardware in the heel, while an anterior CCS could facilitate less surgical time and thus less complication rates.

Minimally invasive surgery in medial displacement calcaneal osteotomy for acquired flatfoot deformity: a systematic review of the literature

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.

Outcomes of Combined Posterior Tibial Tendon Tendoscopy and Medializing Calcaneal Osteotomy for Stage IA Progressive Collapsing Foot Deformity

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.

A comparison of treatment between mini T-plate and headless cannulated compression screw in calcaneal osteotomy

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.

Types of Sliding Calcaneal Osteotomy Fixation: A Systematic Review and Meta-Analysis

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.

Biomechanical comparisons of different diagonal screw designs in a novel embedded calcaneal slide plate

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.

Outcomes of Idiopathic Flexible Flatfoot Deformity Reconstruction in the Young Patient

Background:

Operative correction of flatfoot deformity has been well studied in the older population. There is a subset of younger patients without congenital foot deformity that also develop a collapsing flatfoot. However, assessment of outcomes across age groups is limited, especially in the young demographic. The purpose of our study was to compare operative outcomes of flatfoot reconstruction between these 2 age groups.

Methods:

Seventy-six feet (41 left, 35 right) in 71 patients who underwent flexible flatfoot reconstruction were divided into 2 groups based on age: ≤30 years (n = 22) and >30 years (n = 54). Exclusion criteria included congenital causes of flatfoot (tarsal coalition, vertical talus, overcorrected clubfoot). Average age was 20.8 years (range, 14-30) and 55.4 years (range, 35-74) in the younger and older cohorts, respectively. Preoperative and minimum 2-year postoperative Patient-Reported Outcomes Measurement Information Systems (PROMIS) scores were compared. Five radiographic parameters were assessed pre- and postoperatively: talonavicular coverage angle, lateral talo–first metatarsal angle, lateral talocalcaneal angle, calcaneal pitch, and hindfoot moment arm. Procedures performed and incidence of minor (removal of symptomatic hardware) and major (revision) reoperations were compared.

Results:

Younger patients were less likely to undergo flexor digitorum longus transfer, first tarsometatarsal fusion, spring ligament repair, and posterior tibial tendon repair (all P < .05). Both younger and older cohorts demonstrated significant improvement in multiple PROMIS domains at an average follow-up of 30.6 (range, 24-44) and 26.8 (range, 24-45) months, respectively ( P = .07). Younger patients demonstrated significantly higher pre- and postoperative Physical Function (mean difference postoperatively, 4.6; 95% confidence interval, 1.5-7.8; P = .03). There were no differences in radiographic parameters postoperatively. There were 8 (36.4%) reoperations (all minor) in the younger group, and 21 (38.9%) reoperations (6 major, 15 minor) in the older group ( P = .84).

Conclusion:

Our data suggest that age may play a role in clinical outcomes, procedures indicated, and subsequent corrective reoperations. Younger patients maintained greater physical function with comparable radiographic correction, with less frequent indication for tendon transfers, arthrodesis, and additional corrective surgeries.

Level of Evidence:

Level III, retrospective comparative study.

Review of Calcaneal Osteotomies Fixed With a Calcaneal Slide Plate

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.

A comparison of union rates and complications between single screw and double screw fixation of sliding calcaneal osteotomy

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.

Adult-Acquired Flatfoot Deformity

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.

Risk Factors for Removal of Calcaneus Screws: A Retrospective Study

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.

Minimally invasive versus open calcaneal osteotomies - Comparing the intraoperative parameters

BACKGROUND

The calcaneal osteotomies is often performed to correct asymptomatic hindfoot deformities. More recently minimally invasive techniques have been described with promising clinical outcomes. In a prospective study we compared the intraoperative parameters of the open and minimalinvasive (MICO) techniques, which has not previously been reported.

METHODS

60 consecutive with calcaneal osteotomy (33 open and 27 MICO) and a minimum follow up of 12 weeks were included. We recorded the following intraoperative parameters: operation time for the osteotomy [min], the fluoroscopy time, the fluoroscopy dose and the skin incision. The clinical (FAOS) and radiological outcome were examined 6 and 12 weeks postoperatively. The Wilcoxon test and the continuity correction were used with alpha=5% value for the statistical significance.

RESULTS

The minimally invasive group showed a significantly shorter operation time. There was no significant difference between the radiation time and dose in the two groups. The length of the incision in the minimally invasive group was significantly shorter. We found no difference in clinical outcome and radiological follow up.

CONCLUSIONS

This study reports a significantly shorter operating time and a shorter incision in the MICO group. The radiation exposition was not significantly different between the two groups. A clinical difference could not be shown in our study. However, we see the shorter operating time of the minimally invasive calcaneal osteotomy being beneficial.

A Comparison of Removal Rates of Headless Screws Versus Headed Screws in Calcaneal Osteotomy

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.

Percutaneous Posterior Calcaneal Osteotomy

Different types of posterior calcaneal osteotomy are used for calcaneal realignment in the management of hindfoot deformity. We describe a percutaneous technique of posterior calcaneal osteotomy that can be either a Dwyer-type closing wedge osteotomy or displacement osteotomy.