Intraoperative Radiation Exposure to U.S. Podiatric and Medicine Surgery Residents Annually: How Much Are We Really Getting?

As the number and complexity of operative techniques taught at U.S. podiatric medicine and surgical residencies (PMSR) with the added credential in reconstructive rearfoot and ankle (RRA) surgery has continued to increase, so to has the use of intraoperative fluoroscopy. The purpose of the present prospective observational pilot study was to quantify and compare the shallow dose equivalent (SDE), deep dose equivalent (DDE), and lens of the eye dose equivalent (LDE) exposures for podiatric medicine and surgery residents at a single PMSR-RRA over 12 consecutive months. Shallow-dose equivalent, DDE, and LDE exposures (in millirems) were measured using Landauer Luxel dosimeters from July of 2018 to July of 2019. Dosimeters were exchanged monthly, and mean monthly/annual SDE, DDE, and LDE exposures were calculated and compared. Overall, residents averaged 19 operative cases per month and 222 per year. More than half (53%) required intraoperative fluoroscopy, for which a mini C-arm was used in most cases. Monthly SDE, DDE, and LDE exposures averaged 7.3, 9.3, and 7.0 mrem, respectively; whereas annual SDE, DDE, and LDE exposures averaged 87.3, 112, and 84 mrem, respectively. No significant monthly (P = 1.0, P = .70, and P = .74) or annual (P = .67, P = .67, and P = .33) differences were identified between residents. The annual SDE, DDE, and LDE for residents at a single PMSR-RRA were well below the recommended dose limits of 50,000 mrem/year (SDE), 5,000 mrem/year (DDE), and 15,000 mrem/year (LDE) set by the National Council on Radiation Protection. However, given that the stochastic effects from low levels of ionizing radiation are cumulative, not well studied long-term, and relate both to the degree and duration of exposure, mini-C arm fluoroscopy, radiation tracking, and use of personal protective equipment provide simple means for residents to reduce any long-term potential for risk.

Does Proximal Placement of the Syndesmotic Reduction Clamp Affect the Optimal Position for the Medial Tine? A Cadaveric Pilot Study

Sagittal plane syndesmotic malreduction is associated with off-axis, eccentric reduction clamping and preferential placement of the medial tine anteriorly has been proposed to minimize the malreduction risk. Although clamp placement 1cm proximal to the plafond is recommend, no previous study has assessed whether differences in the anatomic position of the fibula within the incisura (eccentric 1cm superior and concentric 2 cm superior to the tibial plafond) affect the optimal position for the clamps medial tine during reduction of the syndesmosis. The purpose of the present cadaveric pilot study was to evaluate and compare the sagittal syndesmotic malreduction rate with various clamping vectors, 1cm and 2cm from the tibial plafond, respectively. Six through the knee cadaveric specimens were obtained. Kirschner wires and a surgical maker were used to denote placement of the reduction clamp laterally on the peroneal ridge of the fibula, and medially within the anterior, middle, and posterior thirds (Zones A, B, C) of tibia's width; 1 cm and 2 cm from the plafond. CT scans were obtained as controls, followed by destabilization of the syndesmosis. Reductions were then performed sequentially at each level (1 cm, 2 cm) and zone (A, B, C); and CT scans repeated for assessment. In most specimens (n = 5), an eccentric (1 cm) to concentric (2 cm) positional transition was observed within incisura fibularis. The transition altered the resulting fibular displacements in some specimens (2A anterior, vs 2B posterior), resulting in a higher malreduction rate with anterior (zone 2A, 33%) vs central (Zone 2B, 17%) positioning of medial tine. Although no definitive conclusions can be reached from the present pilot study, future studies with a greater number of specimens and clamping vectors are warranted to determine whether positional transitions of the fibula within the incisura fibularis affect the optimal position for the clamps medial tine.

An Innovative Application of a Computer Aided Design and Manufacture Implant for First Metatarsal Phalangeal Joint Arthrodesis: A Case Report

The definitive treatment to correct the deformity of hallux abducto valgus involves surgical fixation. This pathological condition focuses on combined abnormalities of the first metatarsal phalangeal joint (MPJ), medial progression of the first metatarsal, and lateral deviation of the hallux. In most known literature described to date, a computer aided design/manufacture implant has not yet been reported as a viable salvage tool used as an inter-positional structural implant for a first MPJ arthrodesis. The fundamentals of this salvage procedure are to restore anatomical length of the first ray, furnish continuity to the forefoot parabola, administer a robust inter-positional implant^TM (Additive Orthopaedics, Little Silver, NJ) of optimal strength, and provide biomechanical reclamation of the tripod foot. This case study describes a procedural technique that required a 2-stage surgical approach consisting of primary external fixation with a SideKick^TMCoreTrack^TM (Wright Medical, Memphis, TN) tube fixator monorail to expand soft tissues for approximately 1 month.  Followed by a secondary procedure utilizing BioCUE® (Biomet Orthopaedics, Warsaw, Indiana) Bone Marrow Aspiration Concentration system, Augment® Injectable (Wright Medical, Memphis, TN), and custom GAME PLAN^TM (Additive Orthopaedics, Little Silver, NJ) Technology with computer assisted design/manufacture first MPJ inter-positional caged implant^TM arthrodesis.  We present the case of a 46-y-old active female who suffered avascular necrosis of her left foot first metatarsal head from a previous Austin bunionectomy correctional procedure.

Patient-Perceived Recovery and Outcomes after Bipolar Radiofrequency Controlled Ablation with Platelet-Rich Plasma Injection for Refractory Plantar Fasciosis

Previous studies have documented persistent postoperative symptoms and limitations following plantar fasciotomy using patient-reported outcome measures (PROMs). The incomplete recovery (resolution) has been theorized to occur from altered foot biomechanics, and alternative treatment methods have continued to gained popularity for addressing refractory plantar fasciosis (RPF). The purpose of the present study was to assess patient-perceived recovery (PPR) and outcomes after bipolar radiofrequency controlled ablation (BRC) with platelet-rich plasma (PRP) injection for RPF. From July 2006 to July 2016, 43 patients (52 procedures) were enrolled. PROMS were prospectively obtained and compared between patients who perceived themselves as recovered without/residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure were recorded. Overall, 67.4% perceived themselves as recovered-resolved, 23.3% as recovered-not resolved, and 9.3% as not recovered. Holistic and procedure specific satisfaction were high (90.7% and 88.4%), with a mean modified Foot Function Index of 11.65, visual analog scale for pain 1.5, and failure rate of 9.3% at a median of 53 months (interquartile range 33 to 83). In the present study, outcomes with BRC with PRP injection compared favorably to the long-term outcomes reported for partial and complete plantar fasciotomy. Although 14 patients (32.6%) continued to have some postoperative symptoms, 71% indicated that they were satisfied with their symptoms, and 64% would undergo a similar procedure again. Therefore, despite the study's shortcomings, a patient's ability to cope appears to have a role in recovery from RPF.

Perceptions of Burnout, Personal Achievement, and Anxiety Among US Podiatric Medicine and Surgery Residents: A Cross-Sectional Pilot Study

The prevalence of physician burnout among doctors of podiatric medicine (DPM) in the United States remains unknown. The purpose of the present pilot study was to assess perceptions of burnout, personal accomplishment, anxiety, and experiences of shame among DPMs training at Podiatric Medicine and Surgery Residency programs accredited by the Council on Podiatric Medical Education. An anonymous 35-question cross-sectional online survey was developed using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and the Hospital Anxiety and Depression Scale-Anxiety (HADS-A). Demographic data (sex, age, marital status, postgraduate year) and experiences of shame were also recorded. On December 31, 2018, the survey was distributed for completion. Univariate and bivariate analyses were conducted to obtain summary measures of the predictors and outcomes. Multinomial logistic regression models were obtained to evaluate the associations, and a 2-sided p < .05 was considered statistically significant. A total of 155 responses were eligible for inclusion. Forty-six percent of respondents reported high burnout, and nearly half (54%) reported low personal achievement and moderate to severe anxiety. Most had experienced ≥1 shame event during residency, which was associated with a greater level of anxiety (p < .001). Overall, lower burnout and higher personal achievement scores using the MBI-HSS were associated with lower anxiety scores using the HADS-A questionnaire (p < .001) and the absence of an experienced shame event (p = .039). Given that a potential relationship appears to exist between anxiety/experiences of shame and burnout/personal achievement in the present pilot study, additional longitudinal studies are warranted to discern any causal relationships.

Comparison of Different Magnitudes of Applied Syndesmotic Clamp Force: A Cadaveric Study

Overcompression of the ankle syndesmosis was once thought to be improbable. Recent studies using computerized tomography (CT) however, have demonstarted otherwise; raising pertinent questions regarding the factors associated with and consequences of syndesmotic overcompression. The purpose of the present study was to directly compare different magnitudes of applied clamp force on the coronal reduction of ankle syndesmosis. Eight through-the-knee cadaveric specimens were obtained. Fiducial cannulated screws were placed in the tibia and fibula to standardize placement of the reduction clamp's tines. CT scans were obtained as baseline controls, followed by destabilization of the syndesmosis. Reductions were then performed using a clamp equipped with an inline load cell, and objective forces (60, 80, 100, 120, 140, and 160 N) applied sequentially to each of the specimens. The syndesmosis was fixed with a single quadricortical screw, and CT were scans repeated. Applied clamp forces of 60 and 80 N resulted in lateral fibular displacement and undercompression (42.9% and 57.1%, respectively), whereas forces of 140 and 160 N resulted in medial fibular displacement (p = .011 and p = .001) and overcompression (100%). The smallest mediolateral displacements were observed with 100 and 120 N, respectively. Malreduction assessment with CT was superior to traditional radiographs [r(54) = 0.22; 95% confidence interval -0.04 to 0.45; p = .101]. In our cadaveric model, an applied clamp force of 100 N most effectively mitigated iatrogenic coronal syndesmotic malreduction from under- or overcompression. Although additional research is warranted, based on the data, inherent variabilities in the applied clamp force by surgeons appear to contribute to the unacceptably high coronal syndesmotic malreduction rate.

Hallux Varus Interphalangeus Following Osteochondral Fracture of the Proximal Phalanx: A Case Report

Hallux valgus interphalangeus deformity has been previously reported in the literature following trauma and first metatarsophalangeal joint fusion. However, to the best of our knowledge, hallux varus interphalangeus deformity has not been previously reported. We present the case of a 26-year-old skeletally mature woman who sustained an acute, open hallux varus interphalangeus injury following an osteochondral fracture of the medial head of the proximal phalanx.

Factors Associated with and Barriers to the Journal Publication of Oral Abstracts from the American Podiatric Medical Association

Not all abstracts accepted for oral presentation at the annual conference of the American Podiatric Medical Association ultimately go on to successfully navigate the peer-review process to achieve journal publication despite its obvious merits. The purpose of the present study was to identify the factors associated with and barriers to journal publication and time to publication for oral abstracts from the American Podiatric Medical Association conference from 2010 to 2014. Databases containing information on the abstracts were procured and predictor variables categorized as abstract- or author-specific. Bivariate analysis was conducted using the Mann-Whitney U test, Fisher's exact test, chi-square test of independence, or Spearman rank correlation. Multivariable logistic regression and generalized linear regression models were used to analyze predictor variables. A questionnaire was distributed to the primary authors of any unpublished abstracts to determine the current status of the abstract, in addition to the reasons for the failure to pursue or achieve journal publication. Overall, oral abstracts by authors without a formal research degree were published more often than abstracts by authors with a research degree, as were funded projects (P = .031). No other associations were identified between any of the abstract- and author-specific variables and successful conversion of an oral abstract to a journal publication or the time to publication. Six barriers questionnaires were completed. At the time of the survey, two oral abstracts had since achieved publication, two had been submitted for publication but were rejected, and two had never been submitted. The principal reason cited by the authors for the failure to pursue or achieve journal publication was insufficient time for manuscript preparation.

The Visual Analogue Scale for Pain: A Comparison of Scores Reported to Residents Versus an Attending Foot and Ankle Surgeon

Background. Recent studies have raised concerns regarding the usefulness of the visual analogue scale (VAS) as an effective outpatient patient-reported outcome measure (PROM), with disparate scores reported during the same encounter to a nurse versus physician. The purpose of present study was to assess the VAS reported by new patient referrals to 2 different physicians of varying training levels (resident, attending), during the same initial outpatient encounter. Methods. One hundred and one patients treated by a single foot and ankle surgeon were included in the retrospective cohort. Each patient was asked to rate their pain intensity by a resident, and then by the attending surgeon using a standard horizontal VAS 0 to 10, from "no pain" to the "worst pain." Differences in reported scores were analyzed. Results. Overall, the mean VAS reported to the residents (4.97 ± 2.75) and the attending surgeon (5.02 ± 2.71) were not significantly different (P = .61). On the 11-point scale, the mean difference accounted for only 0.05 points. Conclusion. Taken into consideration with previous studies, the data suggest collection personnel may influence the reported VAS, possibly owing to patients' preferences and perception of their care. Although the exact reasons remain unclear, our findings lend credence to the previous concerns expressed regarding the subjective nature of the VAS. Levels of Evidence: Level III: Comparative study.

Publication Barriers of Oral Abstracts From the American College of Foot and Ankle Surgeons: 2010-2014

Despite possessing the highest oral abstract publication incidence for any national foot and ankle society conference to date (76.9%), it remains unclear why almost a quarter of the oral abstracts accepted to the annual American College of Foot and Ankle Surgeons (ACFAS) conference fail to achieve journal publication. The purpose of the present study was to assess the publication barriers of oral abstracts from the ACFAS conference: 2010 to 2014. Unpublished oral abstracts from the temporal period were procured from a database. A questionnaire was then distributed to the primary authors to determine the current status of the abstract, as well as the reasons for the failure to pursue or achieve journal publication. Of the 25 oral abstracts that failed to achieve journal publication before July 1, 2017, a total of 11 questionnaires were completed. At the time of the survey, 4 oral abstracts had since been published in a journal, 1 had been published outside of a journal, and 6 had never been submitted for publication consideration. An insufficient amount of time for manuscript preparation (42%), difficulties with co-authors (30%), and a low perceived priority (17%) were the 3 primary reasons authors cited for the failure to publish. Based on the principal barriers identified, a series of recommendations have been proposed to improve the future publication incidence of oral abstracts from the ACFAS conference and research productivity amongst foot and ankle surgeons.

Factors Associated With the Journal Publication of Oral Abstracts From the American College of Foot and Ankle Surgeons: 2010 to 2014

The oral abstract publication incidence (76.9%) of the American College of Foot and Ankle Surgeons (ACFAS) is currently the highest reported for any national foot and ankle society conference to date. However, factors associated with the conversion of an abstract to a journal publication (JP) remain undetermined. The purpose of the present study was to identify the factors associated with the JP and time to publication for oral abstracts from the ACFAS conference from 2010 to 2014. Databases containing information on the abstracts were procured, and predictor variables were categorized as abstract or author specific. Bivariate analysis was conducted using the Mann-Whitney U test, Fisher's exact test, chi-square test of independence, or Spearman's rank correlation. Multivariable logistic regression and generalized linear regression models were utilized to analyze predictor variables. Oral abstracts by authors without a formal research degree were >12 times (95% confidence interval 2.25 to 71.67) more likely to achieve JP compared to abstracts by authors with a research degree. The author-specific variable was the only significant predictor of future JP (p = .002); however, trends with respect to other variables (funding, prior publications, and ACFAS regional division) were also identified. Abstracts originating from academic institutions (p = .042) and those involving fewer centers (p = .03) were associated with a significantly shorter time to publication. Although the present study broadens our understanding on the publication incidence and time to publication for oral abstracts from the ACFAS from 2010 to 2014, it remains unclear why almost a quarter of the abstracts accepted ultimately failed to achieve JP. Identifying the publication barriers of those abstracts remains a necessary first step in helping to form recommendations aimed at improving the future publication incidence for oral abstracts presented at the ACFAS conference.

Publication Rates for Oral and Poster Abstracts from the American Podiatric Medical Association: 2010-2014

BACKGROUND

The quality of national society conferences is often assessed indirectly by analyzing the journal publication rates for the abstracts presented. Studies have reported rates from 67.5% to 76.7% for oral abstracts and 23.2% to 55.8% for poster abstracts presented at national foot and ankle society conferences. However, no study has evaluated the abstract to journal publication rate for the American Podiatric Medical Association's (APMA's) annual conference.

METHODS

All presented abstracts from the 2010 to 2014 conferences were compiled. PubMed and Google Scholar searches were performed, and the number of abstracts presented, publication rate, mean time to publication, and most common journals of publication were determined. These results were then compared with those for the 2010 to 2014 American College of Foot and Ankle Surgeons' conferences.

RESULTS

Of 380 abstracts presented, 142 (37.4%) achieved publication, most often in the Journal of the American Podiatric Medical Association. The oral abstract publication rate was 45.2% (14 of 31), with a mean time to publication of 24.2 months (range, 0-47 months). The poster publication rate was 36.7% (128 of 349), with a mean time to publication of 16.3 months (range, 0-56 months). Significant differences were identified between the two societies.

CONCLUSIONS

The overall abstract to journal publication rate for the 2010 to 2014 APMA conferences was 37.4%, and, expectedly, oral abstracts achieved publication more often than posters. Moving forward, a concerted effort between competing societies seems necessary to increase research interest, institutional support, and formal mentorship for future generations of foot and ankle specialists.

Patient-Perceived Recovery and Outcomes After Silastic Implant Arthroplasty

In some chronic musculoskeletal conditions, patients with persistent pain and disability have still achieved recovery through behavioral adaptations (readjustment) or cognitive coping (redefinition). Although the pendulum shift from physician-reported clinical indicators to patient-reported outcomes measures (PROMs) has recently focused on quantifying residual pain and disability to determine recovery (resolution), whether patients are capable of coping with any ongoing deficits and achieving other forms of recovery has not been considered. We performed a retrospective case series to assess patient-perceived recovery and outcomes after silastic implant arthroplasty for hallux rigidus. From July 2006 to July 2016, 28 patients at a single institution were enrolled. PROMs were prospectively obtained and compared between patients considering themselves recovered without or with residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure rates were recorded. Overall, 50.0% perceived themselves as recovered-resolved, 43% as recovered-not resolved, and 7% as not recovered. The mean modified Foot Function Index was 17.26, the verbal analog scale for pain score was 2.03, and implant survivorship 100% at a median of 67 (interquartile range 28.4 to 103.5) months. Although only 50% of patients reported complete symptom resolution, satisfaction was high, and most perceived themselves as recovered, suggesting recovery in hallux rigidus might not always be predicated by the complete resolution of all symptomatology. Although PROMs relying on pain inference and functional disability will continue to be utilized with increasing frequency, foot and ankle surgeons should be cognizant of their inherent limitations in assessing other forms of recovery.

A Formal Work Hour Analysis of the Resident Foot and Ankle Surgeon

As new documentation requirements by governments and third-party payees increasingly occupy physicians' time, duty hour restrictions have continued to restrict the work hours of residents, leaving programs tasked to produce proficient foot and ankle surgeons (FASs) in less time. The purpose of the present study was to quantify the workday of resident FASs at our institution to identify areas suited for revision to improve efficiency and training. A resident from each postgraduate year (PGY) was recruited and consented for minute-to-minute observation by 4 independent observers over 5 consecutive workdays. The time recorded was placed into a predefined work model consisting of 9 categories (education, research, operating room, patient care, documentation/administration, communications, transit, basic needs, and standby) within 1 of 3 value groups (positive, neutral, or negative). A fifth independent observer reviewed and recorded all collected data. Over 5 consecutive days, ancillary staff frequently disrupted the PGY-1 resident's workflow. The interruptions fragmented the resident's thoughts, increased inefficiency, and resulted in the largest proportion of the resident's time (16.7%) being occupied by documentation/administration duties. For the PGY-2 and PGY-3 residents, unexpected trends in standby were identified during the preoperative period. Secondary analysis revealed that during unexpected preoperative delays, resident efficiency was poor. To maximize efficiency and improve training, residents must increase their awareness of self-inefficiency while minimizing unnecessary interruptions and the time occupied by duties of lesser value. It is our hope that the present study will aid other institutions in facilitating similar improvements to the education and training of our fellow resident FASs.

Onychomatricoma: A Rare and Potentially Underreported Tumor of the Nail Matrix

Onychomatricoma is a rare benign neoplasm of the nail matrix first described by Baran and Kint in 1992. Fewer than 80 cases of onychomatricoma have been described in the literature, 15 of which were initially misdiagnosed and treated as onychomycosis. We present the case of a 66-year-old male with thickening and linear xanthonychia of the hallux nail plate secondary to an onychomatricoma misdiagnosed as onychomycosis. Following biopsy for histopathologic analysis, the lesion and proximal nail matrix were surgically excised. At 12 months post-excision, the patient remains asymptomatic without evidence of recurrence. The purpose of the present case report is to make foot and ankle surgeons more cognizant of the pathology, highlight the nonspecific clinical and radiologic findings, and emphasize the importance of interdisciplinary communication for an accurate clinicopathologic correlation and diagnosis of the lesion. Although rare, onychomatricoma should be considered in the differential diagnosis for patients presenting with onychomycosis failing to respond to antimycologic treatment. The clinical index of suspicion for onychomatricoma should increase when only a singular dystrophic nail is involved. Following diagnostic confirmation by histopathology, complete surgical excision is the treatment of choice.

Publication Rates for Oral Manuscript and Poster Presentations From the American College of Foot and Ankle Surgeons: 2010 to 2014

The American College of Foot and Ankle Surgeons (ACFAS) annual conference has served as a premiere platform to disseminate the latest innovations and research in the field of foot and ankle surgery. The quality of national society conferences is often assessed indirectly by analyzing the the journal publication rate of the abstracts presented. The purpose of this retrospective study was to assess the journal publication rate for abstracts (oral manuscripts and posters) accepted for presentation at the ACFAS conference from 2010 to 2014. All accepted abstracts from this period were compiled by the ACFAS office. PubMed, Google Scholar, and Scopus searches were performed using abstract titles and author names. Overall, the journal publication rate was 76.9% (83 of 108) for oral manuscripts and 23.2% (258 of 1113) for poster abstracts. The mean time to publication was 9.6 (range 0 to 44) months and 19.8 (range 0 to 66) months for oral and poster abstracts, respectively. The most common journal for abstract publication was The Journal of Foot and Ankle Surgery. Notably, the ACFAS oral manuscript publication rate from 2010 to 2014 (76.9%) exceeded its previously reported rate from 1999 to 2008 (67.5%) and the American Orthopaedic Foot and Ankle Society podium publication rate from 2008 to 2012 (73.7%). To the best of our knowledge, the publication incidence for oral abstracts presented at the ACFAS conference is now the highest reported of any national foot and ankle society conference to date.

A Case Report of Heel Pain Mimicking Plantar Fasciitis and Osteosarcoma: A Unique Presentation of a Nora's Lesion

Bizarre parosteal osteochondromatous proliferation, otherwise known as "Nora's lesion," is a rare benign neoplasm first described by Nora in 1983. The exact etiology of this neoplasm remains unknown, and its presentation in the lower extremity presents a diagnostic challenge, as both clinical and radiologic features cannot fully differentiate it from other neoplasms. We present the case of a 48-year-old female with plantar heel pain secondary to Nora's lesion mimicking plantar fasciitis and periosteal osteosarcoma. Following bone biopsy for histopathologic analysis, the patient's symptoms spontaneously resolved, and she returned to activity with complete resolution of symptoms 18 months post biopsy. Bizarre parosteal osteochondromatous proliferation as an etiology for plantar heel pain has not been previously described in the literature. Although rare, it should be considered in the differential diagnosis for patients presenting with plantar heel pain, especially after failed conservative treatment. Following diagnostic confirmation by histopathology, complete surgical excision is the treatment of choice.

Criteria for combined procedure selection in the surgical correction of the acquired flatfoot

Surgical correction of the flexible acquired flatfoot has long been subject to procedures based on an unsound understanding of the true pathomechanics of the deformity. With the advent of modern biomechanics and the concept of planal dominance, procedure selection can become a more exacting science. A classification system based on the progression of symptoms, used in concert with a firm understanding of the primary and compensatory deformities can simplify the process of selecting combined procedures to deal with a particular foot type.

A comparative analysis of conservative versus surgical treatment of Morton's neuroma

The authors present a study of the treatment of Morton's neuroma. Sixty patients, involving 65 feet treated, were studied. Conservative treatments were compared to surgical excision of the neuroma. As a result of the findings in this study, the authors recommend surgical excision as the initial treatment of choice.

Preoperative criteria for hallux valgus surgery and use of convergent angled base wedge osteotomy

A discussion is presented about objective correction criteria for hallux abducto valgus surgery. A historical review of commonly used procedures performed for correction at various levels of first ray deformity is related. Based on ideal criteria for base wedge osteotomies, a new template and procedure for base wedge osteotomies derived from computer-augmented graphics is described in detail. This procedure has been referred to as a convergent angled osteotomy (CAO) and effectively reduces the metatarsus primus adductus angle with minimal loss of length, cortex to cortex apposition in closure, relative lengthening with plantarflexion if desired, and a capacity for very stable rigid internal fixation that optimizes recovery from base wedge reduction. Case histories are also presented.

Radiographic criteria in the assessment of hallux abductus deformities

The pathomechanics of hallux abducto valgus involve a complex series of interactions. The interpretation of these requires a sound understanding of anatomy, biomechanics, and radiographic criteria. This paper attempts to describe these relationships through the parameters allowed by conventional roentgenographic techniques and to provide insight into their analysis.