Return to Sports and Physical Activities After the Modified Lapidus Procedure for Hallux Valgus in Young Patients

Correlation of Clinical Outcomes and Relative Position of the First Metatarsal After the Modified Lapidus Procedure

BACKGROUND

Hallux valgus is a complex 3-dimensional deformity, and the modified Lapidus is a commonly used procedure to correct moderate to severe cases. Shortening and elevation of the first ray can occur with this procedure, which may result in increased pressure on the lesser metatarsal heads. However, there is currently no consensus regarding an accepted length and elevation of the first ray following the modified Lapidus. Therefore, the purpose of this study is to evaluate the impact of the position of the first ray on patient-reported outcome measures.

METHODS

This retrospective study identified 68 patients (72 feet) who underwent the modified Lapidus bunionectomy over a 4-year period at a single institution with a median follow-up of 24 months (range, 11-35.6 months). Patients were included if they were over 18 years of age, had pre- and postoperative weightbearing computed tomography (WBCT) scans, and preoperative and minimum 1-year postoperative Patient-Reported Outcome Measurement Information System (PROMIS) scores. PROMIS scores from 6 domains including physical function, pain interference, pain intensity, global physical health, global mental health, and depression were evaluated and compared pre- and postoperatively. Radiographic parameters were measured and compared before and after surgery. Paired t tests were used to evaluate the significance of pre- to postoperative changes. Differences between cohorts were compared using Mann-Whitney U test for continuous variables or Fisher exact test for categorical variables. Correlation between radiographic measurements and patient-reported outcomes were assessed using the Spearman rank rho estimate and visualized with scatterplots with a linear regression.

RESULTS

PROMIS physical function, pain interference, pain intensity, and global physical health improved significantly following the modified Lapidus (all P < .001); however, scores did not show any significant correlation with shortening of the first ray up to a maximum shortening of 4.8 mm. The length of the first metatarsal relative to the second decreased by an average of 2.7 mm following the procedure when measured on WBCT (P < .001), and 2.6 mm when measured on plain radiographs (P < .001). No significant elevation of the first ray was observed postoperatively.

CONCLUSION

This study revealed that the Lapidus bunionectomy resulted in significantly improved pain and physical function at short-term follow-up. The amount of first ray shortening and elevation that occurred in this cohort did not adversely affect patient-reported outcomes.

Return to Sport After First Metatarsophalangeal Arthrodesis: A Systematic Review

BACKGROUND

First metatarsophalangeal (MTP) arthrodesis is a common surgical intervention for addressing MTP pain and deformity. Despite great interest on the topic of return to sport (RTS) after first MTP arthrodesis in the literature, no systematic review exists on this topic. The purpose of this systematic review is to investigate RTS after first MTP arthrodesis.

METHODS

This study is a systematic review using PubMed, Web of Science, CINAHL, and MEDLINE from database inception until May 10, 2023. Search algorithm used was (MTPJ OR MTP OR "hallux rigidus" OR cheilectomy OR metatarsal OR metatarsophalangeal) AND (arthrodesis OR fusion) AND sport. Inclusion criteria were surgical intervention of first MTP arthrodesis and outcomes related to sport.

RESULTS

Ten articles were included out of 249 articles initially retrieved. Patients (n = 450) had a frequency weighted mean (FWM) age of 58.6 ± 5.1 years with a FWM follow-up time of 32.1 ± 18.9 months. A total of 153 patients (reported in 34.0% of patients) had a FWM postoperative Foot and Ankle Ability Measure Sport score of 70.4 ± 21.8 at final follow-up. For sporting activities reported by multiple studies (running, yoga, golf, hiking, tennis, elliptical, and biking), about 9.8% to 28.1% of patients (n = 69 reports) stated that sporting activity difficulty decreased, 67.2% to 87.5% of patients (n = 340 reports) stated that sporting activity remained the same, and 1.8% to 8.5% of patients (n = 23 reports) stated that sporting activity difficulty increased after first MTP arthrodesis depending on the sporting activity. One article reported RTS time of 11.7 ± 5.1 weeks after first MTP arthrodesis (n = 39).

CONCLUSION

RTS after first MTP arthrodesis is highly variable depending on patient and sport. Numerous different sporting activities have high rates of RTS after first MTP arthrodesis, with a majority of patients reporting similar or increased ability to perform sporting activities after surgery.

What Proportion of Active-duty Servicemembers Functionally Improve at 1 Year Post Hallux Valgus Correction?

BACKGROUND

When the symptoms of hallux valgus persist despite nonoperative management, surgical intervention may be considered to improve pain and restore function. Although most patients return to full or near-full activity after surgery, this is not always the case in higher-demand populations. In fact, little is known about the likelihood of a military servicemember returning to running or military duty, which is analogous to a recreationally active adult, after hallux valgus correction.

QUESTIONS/PURPOSES

(1) What percentage of military servicemembers are able to return to full duty, including the ability to run 1.5 to 2 miles, 1 year after hallux valgus surgery? (2) What demographic, radiographic, and surgical variables are associated with an increased likelihood of return to full duty?

METHODS

This was a retrospective study of all military servicemembers who underwent surgical correction of hallux valgus deformities at a single tertiary institution from January 2005 to December 2016. We considered military servicemembers who were treated by four fellowship-trained foot and ankle orthopaedic surgeons and who had at least 1 year time-in-service remaining as potentially eligible. A total of 229 people underwent hallux valgus correction during this timeframe, but only 28% (64 of 229) of patients remained eligible: 41% (93 of 229) were excluded because they were not military members, 28% (64 of 229) were ineligible because they had less than 1 year remaining in service, 2% (4 of 229) were excluded because of prior surgery on the ipsilateral extremity, and 2% (4 of 2292) had an incomplete dataset. Interventions included a modified McBride procedure (9% [6 of 64]), distal metatarsal osteotomies (51% [33 of 64]), proximal metatarsal osteotomies (13% [8 of 64]), and Lapidus procedures (27% [17 of 64]). No bilateral procedures were performed. The mean age of our patients was 40 ± 10 years, and the mean BMI was 28 ± 9 kg/m 2 . In addition, 23% (15 of 64) of patients were nicotine users, 38% (24 of 64) were officers, and 45% (29 of 64) were women. The indication for surgery was functionally limiting pain that persisted despite 4 to 6 months of activity modifications, accommodative footwear, and orthotics. Cosmesis was not an indication for surgery. Before surgery, all patients were unable to complete a 1.5- to 2-mile timed run due to pain. The primary outcome measure was the proportion of patients who returned to full duty, which was defined as the ability to complete a 1.5-mile to 2-mile run for a military fitness test in a fixed time allotment, which varies by age and gender, and the ability to perform military-specific physical tasks at 1 year postoperatively. A secondary analysis according to demographic, radiographic, and surgical variables sought to determine any differences between those who did and did not return to full duty; this was assessed using univariable statistical comparisons at a p value of less than 0.01.

RESULTS

A total of 28% (18 of 64) of patients who underwent surgery returned to full duty by 1 year after surgery as determined by the ability to complete a time-allotted 1.5- to 2-mile fitness test run. Of the factors we explored, we did not identify any variables associated with return to full duty. We note that our analysis may have been underpowered to detect differences among factors that could be clinically important, like BMI, age, and comparisons of officers versus enlisted servicemembers.

CONCLUSION

Although this study analyzed the functional outcomes of a group of military servicemembers after hallux valgus correction, we believe our findings may also apply to recreationally active adults in the general population. Only a minority of military servicemembers (28% [18 of 64]) returned to duty 1 year after hallux valgus correction, as determined by the ability to complete a timed 1.5- to 2-mile run. We believe surgeons can use the findings of this study to set realistic expectations for recreationally active adults, particularly runners, after hallux valgus correction.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Development of a preoperative questionnaire to improve satisfaction with hallux valgus repair: A Delphi study

BACKGROUND

Satisfaction with hallux valgus repair is often poor, despite good surgical outcomes. Many tools have been developed to assess the outcome of the procedure; however none evaluate the association between the initial motive for repair and the reasons for post-surgical dissatisfaction. The aim of this study was to develop a new tool to analyse the subjective and objective expectations of individuals during a pre-operative consultation for hallux valgus repair in order to improve post-surgical satisfaction.

METHODS

We first collected the reasons for dissatisfaction with repair from the medical files of dissatisfied individuals. Then, a steering committee of 4 French experts in the management of hallux valgus designed a questionnaire based on the reasons for dissatisfaction. We then used the DELPHI method to validate the questionnaire: we submitted the questionnaire to a panel of 34 francophone experts in hallux valgus repair for rating in 4 rounds.

RESULTS

The medical files of 853 individuals were reviewed and a 52-item questionnaire relating to expectations from hallux valgus surgery was drafted. After the 4 rounds, a final 44 item questionnaire reached consensus. Thirteen items related to clinical and psychological profile, 5 to pain, 9 to physical activity, 4 to aesthetics and 13 to footwear.

CONCLUSION

This tool should facilitate gathering of individuals' expectations from hallux valgus repair to ensure realistic goals and reduce post-surgical dissatisfaction.

Return to Physical Activity Following Flatfoot Reconstruction

BACKGROUND

Progressive collapsing foot deformity (PCFD) is a debilitating condition encompassing several interrelated, progressive deformities requiring a combination of reconstructive procedures. Few studies investigate returns to activity following flatfoot reconstruction, and existing studies only examine 1 or 2 of the numerous procedures employed. This study aims to provide the first generalizable assessment of returns to sports and physical activity following reconstruction surgery in patients with flexible flatfoot deformity.

METHODS

Patients aged 18-60 years who underwent reconstructive surgery between February 16 and May 19 for symptomatic flexible-stage flatfoot deformity were identified by registry review. Eighty-two of 113 eligible patients (73%) were reached at a mean 2.9 years (range, 2.0-5.4) of follow-up with mean age at surgery of 48.9 years (range, 18-59). Returns to physical activity were evaluated with a sports-specific survey. Clinical outcomes were evaluated with Patient-Reported Outcomes Measurement Information System (PROMIS) scores.

RESULTS

Patients reported participation in 21 specific sports and activities. One-fourth (25.6%) of patients (21/82) reported increased difficulty with physical activities postoperatively, 15.9% reported equal difficulty, and 58.5% (48/82) reported decreased difficulty. Median return times were 9-12 months for participation and 12-18 months to reach maximum preoperative participation levels. Improvements in Physical Function (P= .001), Pain Interference (P < .001), Pain Intensity (P <.001), and Global Physical Health (P = .004) were associated with increased satisfaction with respect to sports and physical activities.

DISCUSSION

This study investigated participation in specific sports and physical activities following flatfoot reconstruction. Our findings suggest mixed outcomes, where many patients reported life-changing improvements but many also experienced prolonged pain and difficulty after surgery. Some patients reported increased difficulty or inability to return to their preoperative maximum level of participation, indicating that flatfoot reconstructions can lead to athletic limitations.

CONCLUSION

Although flatfoot reconstruction can be a powerful tool to increase patients' capacity to engage in physical activity, in our cohort many patients had reduced physical activity outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Return to run rates following hallux valgus correction: A retrospective comparison of metatarsal shaft osteotomies versus the modified lapidus procedure

BACKGROUND

Hallux valgus affects 23-36% in general populations. The purpose of this study was to evaluate return to run following either a modified Lapidus procedure or a metatarsal osteotomy. We hypothesized that there would be no difference in the ability to return to running.

METHODS

A Retrospective review of a consecutive series of patients at a single institution with surgical correction was performed. 51 patients were identified. 35 were treated with a metatarsal shaft osteotomy and 16 with a modified Lapidus.

RESULTS

No difference was found between the cohorts in terms of age, sex, or preoperative hallux valgus angle (HVA). 27/35 (77%) with metatarsal shaft osteotomy were able to return to running versus 13/16 (81%) with modified Lapidus. There was no significant difference in the ability to return to running between cohorts (p =1.00).

CONCLUSION

Our study showed no statistical difference for the modified Lapidus versus metatarsal osteotomies relative to return to running.

Modified Lapidus vs Scarf Osteotomy Outcomes for Treatment of Hallux Valgus Deformity

BACKGROUND

The Lapidus procedure and scarf osteotomy are indicated for the operative treatment of hallux valgus; however, no prior studies have compared outcomes between the procedures. The aim of this study was to compare clinical and radiographic outcomes between patients with symptomatic hallux valgus treated with the modified Lapidus procedure versus scarf osteotomy.

METHODS

This retrospective cohort study included patients treated by 1 of 7 fellowship-trained foot and ankle surgeons. Inclusion criteria were age older than 18 years, primary modified Lapidus procedure or scarf osteotomy for hallux valgus, minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores, and minimum 3-month postoperative radiographs. Revision cases were excluded. Clinical outcomes were assessed using 6 PROMIS domains. Pre- and postoperative radiographic parameters were measured on anteroposterior (AP) and lateral weightbearing radiographs. Statistical analysis utilized targeted minimum-loss estimation (TMLE) to control for confounders.

RESULTS

A total of 136 patients (73 Lapidus, 63 scarf) with an average of 17.8 months of follow-up were included in this study. There was significant improvement in PROMIS physical function scores in the modified Lapidus (mean change, 5.25; P < .01) and scarf osteotomy (mean change, 5.50; P < .01) cohorts, with no significant differences between the 2 groups (P = .85). After controlling for bunion severity, the probability of having a normal postoperative intermetatarsal angle (IMA; <9 degrees) was 25% lower (P = .04) with the scarf osteotomy compared with the Lapidus procedure.

CONCLUSION

Although the modified Lapidus procedure led to a higher probability of achieving a normal IMA, both procedures yielded similar improvements in 1-year patient-reported outcome measures.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Sport activity levels following ankle fusion

PURPOSE

Ankle arthrodesis (AA) is frequently employed in the treatment of end-stage ankle arthritis, which is common following trauma and athletic injuries. While AA remains a popular therapeutic option, little data exists about activity and sporting capacity following AA. The objective of this research was to determine functional outcomes and sporting activity levels in patients following Ankle Arthrodesis.

METHODS

Validated questionnaires were emailed to 35 patients with a history of AA at an average follow-up of 52 months. Functional outcomes were assessed using the Foot and Ankle Disability Index (FADI), as well as the associated FADI-Sport. Responses were compared to those from a control population of RESULTS: 24 patients scheduled for AA, at an average pre-operative visit of three months. Activity levels were assessed prior to injury as well as pre- and post-operatively using the Tegner activity level scale. Average Tegner scores of the 35 surgical patients decreased from 3.82 ± 0.38 before their injury, to 1.15 ± 0.19 immediately pre-op, with recovery to 2.67 ± 0.26 following fusion. Average post arthrodesis FADI and FADI-sport scores in our patients were 76.5 ± 3.19% and 33.8 ± 23.06%. For the pre-operative control population, corresponding scores were 47.41 ± 2.61% and 22.24 ± 1.03%. Following AA, we found that patients improved upon their pre-op Tegner score, although they did not return to their pre-injury level of sporting participation. Additionally, patients reported that they had no current dysfunction with their lower leg.

CONCLUSION

Patients undergoing Ankle Arthrodesis should expect improved lower leg function, though will not likely return to their pre-injury level of activity.

Outcomes of Nitinol Compression Staples in Tarsometatarsal Fusion

BACKGROUND

Tarsometatarsal (TMT) arthrodesis is commonly performed in the management of midfoot arthritis, trauma, or deformity. The purpose of this study was to collect aggregate data (demographic, surgical, and perioperative outcomes) on patients who previously had a TMT fusion with BME compression staples.

METHODS

Sixty-six patients underwent TMT fusion with BME compression staples. Outcomes included demographics, surgical information, the Veterans Rand VR-12 Health Survey, Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), Revised-Foot Function Index (FFI-R), Ankle Osteoarthritis Scale (AOS), patient satisfaction survey scores, radiographic fusion rate, level of pain reduction, and complications. Sixty-six patients (68 feet) were analyzed (59 females) with an average age of 64 years (range, 18-83). The mean latest follow-up was 35.9 (range, 6-56.6 months).

RESULTS

The average surgical time was 38.1±14.3 minutes (range, 11-75). All outcomes improved significantly (P < .001) from preoperative to latest follow-up except for the VR-12 Mental and Physical score. The average time to fusion determined by radiographs was 8.4 weeks (range, 6.1-46.1 weeks). Wound complications were not seen. Indications for subsequent surgeries (26.5%, 18/68 feet) in this current study included pain (n = 14), broken staples, and nonunion (n = 3).

CONCLUSIONS

The fusion rate in this study, 89.7%, was similar to values reported in the literature. The patient satisfaction score of 81.9 at latest follow-up is consistent with patient satisfaction for other methods of fusion.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Classification of Hallucal Sesamoid Bone Correlated with Hallux Valgus Severity

The hallucal sesamoid bones (HSBs), having an important role in reducing load per unit area on the first metatarsal head, can be injured commonly which also affected the first metatarsophalangeal joint and the surrounding structure. Meanwhile, differences among each HSB type may be a major factor affecting the occurrence and development of HV. So far, many researchers had learned that there are three different conditions in hallucal sesamoid bone affecting the choice of clinical surgery corresponding to different solutions in clinic. Thus, it is necessary to study the anatomical morphological characteristics of the HSB which can be helpful in clinical diagnosis and treatment, especially hallux valgus (HV). 150 X-ray and three-dimensional (3D) computed tomographic (CT) images consist of 72 left and 78 right metatarsals were applied in this anatomic study between two variables and showed by a simple scatter plot. The first metatarsophalangeal joint is divided into four different types: type I (no HSB, 1.3%), type II (with one HSB, 0.07%), type IIIa (with two HSBs when THB is bigger, 28%), type IIIb (with two HSBs when FHB is bigger, 65.3%), and type IV (with three HSBs, 4.7%). There was no statistical difference between the left and right sides, except HVA, Meary, and pitch (P < 0.05); all a, b, c, d, and i have statistical difference between male and female (P < 0.05). Meanwhile, HVA and IMA and HVA and type group have a significant correlation. In summary, HVA and IMA and HVA and classification of HSBs have significant correlations. The classification and location of HSBs can be an important basis to choose operation methods and postoperation evaluation.

Postoperative Considerations in the Management of Hallux Valgus

Postoperative management of hallux valgus varies widely. Setting preoperative expectations is an important aspect of attaining a successful outcome, but this is not routinely reviewed in the literature. This chapter offers suggestions on successfully navigating this area of patient care. Current concepts focus on pain control, immobilization, and return to activities. This chapter also reviews the current literature in these areas and sets out the authors' preferred management in the postoperative setting.

Outcomes of Reconstruction of the Flexible Adult-acquired Flatfoot Deformity

Reconstruction of the flexible adult-acquired flatfoot deformity (AAFD) is controversial, and numerous procedures are frequently used in combination, including flexor digitorum longus transfer, medializing calcaneal osteotomy (MCO), heel cord lengthening/gastrocnemius recession, lateral column lengthening (LCL), Cotton osteotomy or first tarsometatarsal fusion, and spring ligament reconstruction. This article summarizes recent studies demonstrating that patients have significant improvements after operative treatment of flexible AAFD. It reviews current literature on clinical and radiographic outcomes of the MCO, LCL, and Cotton osteotomies. The authors describe how this information can be used in surgical decision making in order to tailor operative treatment to an individual patient's deformity.

Return to Sports and Physical Activities After First Metatarsophalangeal Joint Arthrodesis in Young Patients

BACKGROUND

Arthrodesis of the first metatarsophalangeal (MTP) joint has been shown to be effective in alleviating pain and correcting deformity in hallux rigidus. However, outcomes in specific sports and physical activities remain unclear. The aim of this study was to assess sports and physical activities in young patients following first MTP joint arthrodesis and to compare these results with clinical outcomes.

METHODS

Patients between ages 18 and 55 years who underwent MTP arthrodesis were identified by review of a prospective registry. Fifty of 73 eligible patients (68%) were reached for follow-up at a mean of 5.1 (range, 2.2-10.2) years with a mean age at surgery of 49.7 (range, 23-55) years. Physical activity was evaluated with a previously developed sports-specific, patient-administered questionnaire. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score (FAOS).

RESULTS

Patients participated in 22 different sports and physical activities. The most common were walking, biking, weightlifting, swimming, running, and golf. Compared to preoperatively, patients rated 27.4% of activities as less difficult, 51.2% as the same, and 21.4% as more difficult. Patients returned to 44.6% of preoperative physical activities in less than 6 months and reached their maximal level of participation in 88.6% of physical activities. Ninety-six percent of patients (48/50) were satisfied with the procedure regarding return to sports and physical activities. Improvements in the FAOS Symptoms subscore were associated with increased postoperative running and walking duration, and improvements in FAOS Pain subscores were associated with greater patient satisfaction.

CONCLUSION

Patients were able to participate in a wide variety of sports and physical activities postoperatively. Some patients reported increased difficulty, but were nonetheless satisfied with the procedure regarding physical activity participation. These findings suggest that first MTP joint arthrodesis is a reasonable option in young, active patients, and may be used to guide postoperative expectations.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Hallux Valgus Surgery in the Athlete: Current Evidence

Hallux valgus is a common disorder characterized by a medial deviation of the 1st metatarsal, eventually leading to subluxation and pain of the 1st metatarsophalangeal joint. This can inhibit sports activity. Despite being a common forefoot pathology, debate exists regarding the appropriate surgical approach in the athletic population. Paucity in literature exists with reporting of outcomes of 1st metatarsal procedures leading to best outcomes. This review was able to identify 5 studies of surgical correction of hallux valgus in athletes published to date. The aim is to guide the physician in treating athletes with hallux valgus deformity. Currently, the literature supports distal 1st metatarsal osteotomy (Chevron) with a return to activity of approximately 3 months for mild to moderate deformity, and the Ludloff osteotomy for moderate to severe deformity at a slightly slower time frame of return to sports. At best, the Lapidus procedure allows approximately 80% of patients to return to activity. Studies need to document activity level and return to sport in order to help guide treatment.

Minimally Important Difference in the Foot and Ankle Outcome Score Among Patients Undergoing Hallux Valgus Surgery

BACKGROUND

Patient-reported outcomes are increasingly used as measures of effectiveness of interventions. To make the tools more useful, therapeutic thresholds known as minimally important differences have been developed. The objective of this study was to calculate minimally important differences for the domains of the Foot and Ankle Outcome Score for hallux valgus surgery.

METHODS

The study was based on a retrospective analysis of patients newly scheduled for bunion correction surgery and completing patient-reported outcomes between October 2013 and January 2018. This study used anchor- and distribution-based approaches to calculate the minimally important difference for the instrument's 5 domains. Confidence intervals were calculated for each approach. There were 91 participants included in the study.

RESULTS

Using anchor- and distribution-based approaches, the minimally important difference for the pain domain ranged from 5.8 to 10.2, from 0.3 to 6.9 for the symptoms domain, 8.3 to 10.3 for the activities of daily living domain, 7.4 to 11.1 for the quality of life domain, and from 7.0 to 15.7 for the sports and recreation domain. Small differences in the activities of daily living domain may be more clinically important for patients with better function.

DISCUSSION

The range of minimally important difference values for each domain indicate how the Foot and Ankle Outcome Score corresponded to bunion correction surgery. The sports and recreation domain showed considerable variability in the range of values and may be associated with the domain's lack of responsiveness. Overall, most minimally important difference values for the domains of FAOS ranged from above 4 to below 16.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Hallux Valgus/Medial Column Instability and Their Relationship with Posterior Tibial Tendon Dysfunction

Historically, bunions have focused on the coronal plane; however, there is tension and compression failure in the sagittal plane of the midfoot during arch collapse. Correction of all 3 planes of deformity, coronal, sagittal, and rotational, can be achieved in several ways. Taking a big picture of global foot mechanics by recognizing the common types of conditions associated with arch collapse, including hallux valgus deformities, can serve as a useful roadmap for navigating more complicated deformities where hallux valgus exists.

[Lapidus arthrodesis]

The tarso-metatarsal 1 joint (TMT-I) arthrodesis is a treatment option or moderate to severe hallux valgus (HV) deformities. Instability of the TMT1 joint is still a debatable indication. Using stable osteosynthesis techniques allows early postoperative weight bearing. Plantar plating combined with a lag screw is the biomechanical most stable construct. An additional intermetatarsal screw can improve the horizontal stability. Clinical results are good and radiological parameters stay constant, even in the long term.