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Background: Evidence concerning the complex foot trauma, especially its definitive management, is scarce. Soft tissue envelope sequalae are the primary parameters that delay or make internal fixation implausible. Stability conferred by external fixators makes them a reasonable initial treatment choice. Although AO or circular fixators can be applied around the foot, this can involve a learning curve and substantial costs, especially for the circular fixator. There is little evidence as to how well external fixators work as a definite method of fixation in patients where progression to internal fixation cannot be made. Methods: We prospectively evaluated 10 adult patients with severe and complex foot trauma who were consecutively treated at our clinic. Initial reduction and stabilization were performed with an external fixator that was initially conceived for distal radius fractures, applied during the initial procedure and mantained throughout the treatment. Results: Fracture healing was obtained in all 10 cases, and both internal and external column length was restored. One of the patients developed chronic osteomyelitis. At the 1-year follow-up visit, these patients averaged 45.6 points in the physical and 44.8 points on the mental status sections of the 12-Item Short Form Health Survey (SF-12). The Foot Function Index findings for pain, disability, and daily activities limitations were 33.3, 39, and 41.5, respectively, which suggest moderate residual impairment. Conclusion: In this relatively small case series of complex foot trauma, we found that the use of simple external fixation as definitive treatment worked reasonably well. Level of Evidence: Level III, prospective cohort study.

Background: Hindfoot coronal alignment is an important factor in the assessment of patients with many different foot and ankle complaints. A number of clinical and radiographic techniques have been described to measure hindfoot coronal alignment, but none of them are widely accepted. The purpose of the present study was to assess the correlation between clinical and radiographic hindfoot alignment measures and to evaluate the reproducibility of each. Methods: We evaluated 85 patients with foot and/or ankle symptoms. Hindfoot clinical alignment was measured from photographs. Each patient was placed at a distance of 1 m from the observer, with both feet placed parallel. Four photographs were taken, at a height of 40 cm: a posterior view of both lower limbs including knees, a posterior view focalized on the studied hindfoot, an anterior view of the foot, and the last view of the medial aspect of the foot. Radiographic alignment was quantified on long axial view radiographs. Patients were lying over the film cassette with a focus distance of 1 m and the beam pointed to the ankle joint. The inclination angle of the beam was 45 degrees to the floor. Measurements were independently made by 2 observers, who were asked to classify pictures into 3 categories: varus, neutral, and valgus. Radiographic measurements were made using the angle measurement tool on the radiograph viewer. The intraclass correlation coefficients (ICCs) and the 95% confidence interval (CI) of the ICC were used to quantify the inter- and intraobserver reliability for clinical assessment. Radiographic parameters were correlated by calculating the Pearson correlation coefficient (r). Results: The intraobserver ICC for clinical analysis was good for both observers, while the interobserver ICC was moderate for both measurements. Regarding radiographic assessment, there was significant intra- and interobserver reliability. The correlation between both methods was weak for both observers. Conclusions: We found only weak intra- and interobserver correlations between the clinical and radiographic assessment of hindfoot coronal alignment. It is therefore necessary to complement the clinical evaluation of hindfoot alignment with an objective measurement method such as a long axial view radiograph. Further studies comparing different measurement methods need to be performed to establish the most objective evaluation. Level of Evidence: Level III, diagnostic study.

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus treatment by the means of decompressive osteotomy would theoretically be able to alleviate pain and improve function. The Youngswick osteotomy is a procedure conceived for relatively long first metatarsals, a characteristic that has been associated with the pathogenesis of hallux rigidus. Nevertheless, studies of this procedure that assessed the overall results and further need of a first metatarsal arthrodesis over the years are lacking. After using the Youngswick first metatarsal decompressive osteotomy for many years, we decided to review a retrospective series of patients. The purpose of this study was to evaluate the need for first metatarsophalangeal joint arthrodesis or any other secondary procedures in the long term follow up in patients with stage II and III hallux rigidus. Methods: A retrospective review of 61 consecutive patients (61 feet) who had undergone decompressive osteotomy by the same surgical team during a period of 156 months was performed. The candidates for inclusion into the present study underwent a clinical evaluation preoperatively, and the clinical data recorded in the patients’ medical records were reviewed retrospectively. All clinical measurements were taken at the initial preoperative examination and at the final follow-up visit. Patients underwent Youngswick first metatarsal osteotomy as described in previous publication. The clinical examination included the the Foot and Ankle Outcome Score (FAOS), total range of motion of the first MTPJ. Radiographic examinations (AP and lateral weightbearing) were performed preoperatively, immediately postoperatively, and at each patient’s last follow-up visit by another member who was unaware of the clinical results. The need of any secondary procedure of the first metatarsal or subsequent need of first MTPJ arthrodesis was also recorded. Results: Decompressive osteotomy was performed in 61 patients, including 41 right feet and 20 left feet, with no bilateral procedures. The patient population consisted of 45 females (78%), with an average age of 53.8 years (range 29 to 72) years. The mean follow-up time was 54.8 months (range 12 to 150). 74% (45 patients) were classified as grade II and 16 patients (26%) as grade III. All patients who underwent this procedure had improvement their visual analog scale foot and ankle score, with all achieving postoperative scores >75 points. Evaluation at the last follow-up visit showed that 91% of patients would recommend the same procedure to a family member. In our group of patients there were no further needs of first MTPJ arthrodesis. Conclusion: We found significant visual analog scale foot and ankle score, providing evidence that good outcomes and high levels of patient satisfaction can be achieved, and that this results would maintain over time. Secondary procedures mainly hardware removal were somewhat usual, however no first MTPJ arthrodesis was needed in the medium term.

Category: Bunion Introduction/Purpose: Surgical correction of hallux valgus rebalances the first ray, correcting the various features of the deformity. While several surgical methods are available, consensus regarding the best management has yet to be established. In the last decades, there was an increasing interest in mini-invasive procedures. In this scenario the Bosch technique appears to be a reproducible DMO to achieve proper correction. Theoretically, it allows for fast and safe correction of the deformity, however it was criticized for its unstable nature. We describe a new distal metatarsal osteotomy (DMO) that it is a combination of the (traditional) chevron and the (mini-invasive) Bosch-SERI techniques. The purpose of this investigation is to describe the surgical technique and report the results of this modified procedure at a minimum 2-year follow-up. Methods: Between January 2016 and June 2018, 63 consecutive patients, with mild to moderate hallux valgus deformity underwent corrective surgery using the BC technique. Preoperatively, each patient’s data was recorded and all patients underwent an assessment of functional limitation and pain level as well as a physical examination that included measurement of the passive range of motion of the first metatarsophalangeal joint. At final follow up, the patients were assessed using the American Orthopaedic Foot & Ankle Society’s (AOFAS) hallux- metatarsophalangeal and interphalangeal scale. Additionally, patients were asked to rate their satisfaction with regard to the overall result of the operation according to the Coughlin overall satisfaction scale. Anteroposterior and lateral weight-bearing radiographs were made preoperatively as well as at the short-term and intermediate-term follow-up evaluations. The HVA, the first IMA, and the congruency of the first metatarsophalangeal joint were measured with the technique recommended by the AOFAS. Results: BC osteotomy was performed in 62 patients, including 33 right feet and 29 left feet, with no bilateral procedures. The patient population consisted of 50 females (79%), with an average age of 50.4 years (range 19 to 75) years. The mean follow-up time was 36.5 months (range 23 to 59). The mean AOFAS score improved from 69.3 preoperatively to 88 postoperatively (p

Category: DTV prophylaxis Introduction/Purpose: Thromboembolic complications during lower-limb immobilization after Achilles tendon ruptures are common. Both operative and nonoperative treatments of Achilles tendon rupture include a period of immobilization which is a well-documented risk factor for distal vein thrombosis (DVT). The term DVT refers to the anterior/posterior tibial or the peroneal veins, and comprise the deep venous system. More recently, the role of muscular vein thrombosis (MVT) or isolated gastrocnemius or soleus vein thrombosis has been reported. However, there is no report of MVT associated with Achilles tendon rupture either before or after the initiation of treatment. We present a prospective series of patients treated for a rupture of the Achilles tendon and who were all evaluated with ultrasound for diagnosis of venous compromise prior to initiation of treatment. Methods: 21 patients who consecutively presented for treatment for an Achilles tendon rupture at the emergency department were included. All patients sustained the injurie while playing some kind of sport. 20 of 21 patients were male, and their average age was 48.8 years (range 34 to 62 years). Our prospective protocol included a routine ultrasound prior to the initiation of treatment to identify the location of the Achilles tendon rupture and simultaneously, a color Doppler ultrasound. Upon diagnosis, all patients were immobilized in an equinus cast while waiting for definitive treatment. Patients were treated either non operatively if a diagnosis of DVT was made, or with percutaneous surgical treatment in the absence of DVT. Upon DVT diagnosis patients were enrolled in a four week LWMH at curative doses therapy supervised by our team hematologist, in order to obtain an international normalized ratio (INR) of between 2 and 3. Results: Nine in the group of twenty one patients (42%) were diagnosed with a DVT in the Doppler ultrasound prior to the initial immobilization. In six of the nine patients diagnosed with a distal vein thrombosis thrombi was allocated in the muscular veins, two of the nine in the gastrocnemius veins and the remaining one in one of the posterior tibial vein. All of the patients had some kind of comorbidity, however only three of them had risk factors previously associated with the occurrence of distal vein thrombosis. In our evaluated cohort there were no cases of progression to pulmonary embolism (PE). Conclusion: To the authors knowledge this is the first publication that links the MVT diagnosis to the moment previous to the immobilization in Achilles tendon rupture. It is our perspective that although not well stablished there is at least a theoretical risk of further propagation to the profound venous system and subsequently to the pulmonary system, and this fact not only conditions the treatment of MVT itself, but also the treatment of the Achilles rupture. Clearly this is just a speculative concept and further evidence needs to be gathered in order to have a better understanding.

Category: Midfoot/Forefoot Introduction/Purpose: Limited ankle dorsiflexion associated with an isolated gastrocnemius contracture is one of the key impairments present in some chronic foot and ankle pathologies. The Baumann procedure consists of a gastrocnemius recession through an incision along the proximal medial calf performed in the interval between the gastrocnemius and soleus fascia. The advantages of the technique is that isolates the lengthening to the gastrocnemius muscle and preserves muscle strength. It is performed in supine decubitus, making unnecessary to switch position of the patient. We performed it in a minimally invasive fashion through a 4 cm approach. Our purpose was to evaluate the functional results and satisfaction of patients after performing a release of the gastrocnemius through the Baumann minimally invasive procedure in different foot and ankle pathologies. Methods: 34 patients (37 procedures) whom presented with forefoot or midfoot or rearfoot pathologies that were suspected to be associated with gastrocnemius contracture between 2015 and 2017 were retrospectively evaluated (Table 1). All patient demographic information; such as age, sex, diagnosis and date of surgical, was retrieved from clinical charts. Patients included were to have an isolated gastrocnemius contracture as determined by a positive Silfverskiold test. Patients underwent Bauman gastrocnemius recession alone or in combination with other procedures according to each patient´s primary diagnosis. A supervised physical therapy program that consisted on stretching and flexibility of the posterior chain, was started as soon as possible depending on the underlying pathology, when possible, during the first postoperative week. Results: Thirty-seven procedures belonging to thirty-four patients were included in this investigation. The mean age of the patients was 47.13 years (range 26-78 years). The mean follow-up was 21.6 months (range 7-42 months). The average initial amount of ankle dorsiflexion measured was 108 (range 95 to 120) degrees. After gastrocnemius muscle recession, the average ankle dorsiflexion measured was 91 (range 84 to 95) degrees. Therefore, an overall improvement of 17 degrees was obtained. There were significant differences in the dorsiflexion angle measured pre and post-surgery (p < 0.05). 88.9% of the patients were satisfied and would undergo the same surgery if necessary. 91.7% would recommend the procedure to a friend or family member. Conclusion: There exists reasonably convincing evidence to support the use of gastrocnemius recession as a therapeutic intervention for isolated foot pain associated with an overload syndrome, justifying a grade of recommendation B. It is our perspective that the Bauman procedure offers a chance to lengthen the musculotendinous unit in a predictable manner, through a small incision avoiding the potential risks of over lengthening the gastrocnemius-soleus complex.

Background: Hindfoot coronal alignment is an important factor in the assessment of patients with many different foot and ankle complaints. A number of clinical and radiographic techniques have been described to measure hindfoot coronal alignment, but none of them are widely accepted. The purpose of the present study was to assess the correlation between clinical and radiographic hindfoot alignment measures and to evaluate the reproducibility of each. Methods: We evaluated 85 patients with foot and/or ankle symptoms. Hindfoot clinical alignment was measured from photographs. Each patient was placed at a distance of 1 m from the observer, with both feet placed parallel. Four photographs were taken, at a height of 40 cm: a posterior view of both lower limbs including knees, a posterior view focalized on the studied hindfoot, an anterior view of the foot, and the last view of the medial aspect of the foot. Radiographic alignment was quantified on long axial view radiographs. Patients were lying over the film cassette with a focus distance of 1 m and the beam pointed to the ankle joint. The inclination angle of the beam was 45 degrees to the floor. Measurements were independently made by 2 observers, who were asked to classify pictures into 3 categories: varus, neutral, and valgus. Radiographic measurements were made using the angle measurement tool on the radiograph viewer. The intraclass correlation coefficients (ICCs) and the 95% confidence interval (CI) of the ICC were used to quantify the inter- and intraobserver reliability for clinical assessment. Radiographic parameters were correlated by calculating the Pearson correlation coefficient (r). Results: The intraobserver ICC for clinical analysis was good for both observers, while the interobserver ICC was moderate for both measurements. Regarding radiographic assessment, there was significant intra- and interobserver reliability. The correlation between both methods was weak for both observers. Conclusions: We found only weak intra- and interobserver correlations between the clinical and radiographic assessment of hindfoot coronal alignment. It is therefore necessary to complement the clinical evaluation of hindfoot alignment with an objective measurement method such as a long axial view radiograph. Further studies comparing different measurement methods need to be performed to establish the most objective evaluation. Level of Evidence: Level III, diagnostic study.

Category: Ankle Introduction/Purpose: Hindfoot coronal alignment has to be considered in the assessment of patients with foot and ankle complaints, since it guides treatment of certain pathologies. Even when there are multiples techniques described for clinical and radiographic analysis, none of them are widely accepted. The purpose of the present study was to assess the correlation between clinical and radiographic hindfoot alignment measures and to evaluate the reproducibility of both methods. Methods: We evaluated 85 patients with foot and/or ankle symptoms. Hindfoot clinical alignment was evaluated through photographs and radiographic alignment was quantified on Long Axial View radiographs. Measurements were made by two observers. Results: Intraobserver ICC for clinical analysis was good for both observers (ICC 0.78 for each one). Interobserver ICC was moderate for both measurements (ICC 0.58 and 0.56). Regarding radiographic assessment, there was significant intraobserver reliability (observer 1: r = 0.95 and observer 2: r = 0.99; P =

Category: Ankle Introduction/Purpose: Thromboembolic complications during lower-limb immobilization after Achilles tendon ruptures are common. Both operative and nonoperative treatments of Achilles rupture include a period of immobilization which is a well- documented risk factor for distal vein thrombosis. Curiously, there is a gap in literature linking the diagnosis of thromboembolic events to the Achilles rupture previous to the inmobilization. The term DTV refers to the anterior/posterior tibial or the peroneal veins, i.e. those that correspond to arterial structures and comprise the profound vein system. Although still with little agreement, the role of muscular vein thrombosis or isolated gastrocnemius or soleus vein thrombosis are gaining relevance within the current published data, despite there is no report of it association with tendo Achilles rupture before or after the initiation of treatment. Methods: Case report: Five consecutive patients with a diagnosis of traumatic Achilles rupture were evaluated. All patients sustained non traumatic injuries. One of the patients was a heavy smoker, and two of them had BMI over 25. We routinely execute an ultrasound to locate the rupture site and at the same time color ultrasound Doppler was performed by an expert in vascular echography, before the initiation of treatment. In all cases a thrombosis of the calf muscle veins was found. Surgical treatment was not advice in any of the patients and definitive treatment was conservative. Results: Calf muscle veins are deep veins in the distal lower extremity that are nonpaired and not associated with named tibial arteries. These veins make up a complex venous system of the musculature of the posterior leg and include the soleal and gastrocnemius veins that run as sinusoids within the muscles of the same name. The soleal sinusoids may drain into the midperoneal or posterior tibial veins, whereas the gastrocnemius sinusoids may empty directly into the popliteal vein. Although the real incidence of MVT is extremely variable, in patients presenting with symptoms and signs suspicious for distal vein thrombosis, muscular veins have been shown to be the most common location for thrombosis with 23% to 41% of all patients. Conclusion: Our group of patients was diagnosed before immobilization was established. One plausible explanation could be that the muscle trauma associated with the tendinous rupture may have some influence in the thrombi generation triggering endothelial dysfunction, or affecting the calf muscle pump creating venous stasis, conditions that favour the VTE appearance. It is our perspective that although not well stablished there is at least a theoretical risk of further propagation to the profound venous system and subsequently to the pulmonary system, and this fact not only conditions the treatment of MVT itself, but also the treatment of the Achilles rupture.

Category: Midfoot/Forefoot Introduction/Purpose: There are two concepts that tried to explain the etiology of metatarsalgia in hallux valgus patients: First, the one that states that as the magnitude of hallux valgus increases, there is a mechanical overload of the lesser metatarsals. Second, that an increased relative lesser metatarsal length is a factor in the development of metatarsalgia. However there is no current evidence that these facts predisposes for primary metatarsalgia. The purpose of the study was to evaluate the factors associated with metatarsalgia in hallux valgus patients. Methods: A cross-sectional study of 121 consecutive adult patients with non-arthritic hallux valgus was carried out. Binary logistic regression was performed to identify the effect of the clinical and demographic factors on the occurrence of metatarsalgia. Results: One hundred twenty one patients (184 feet) with hallux valgus were analyzed. The median weight was 65 Kg (IQR 58 – 72). Metatarsalgia was present in 84 (45.6%) feet. The binary logistic regression showed that lesser toe deformity (OR 2.6 IC95% 0.2-0.5), gastrocnemius shortening (OR 5.8 IC95% 2.8-12.3), metatarsal index (OR 0.3 IC95% 0.2-0.5) and weight (OR 2.5 IC95% 1.2-5.3) were significantly associated. Conclusion: Metatarsalgia occurs in almost a half of hallux valgus patients. It has a multifactorial etiology. Our finding questions the common theory that both the magnitude of hallux valgus deformity and an increased length of a lesser metatarsal by themselves, predisposes for primary metatarsalgia. Metatarsalgia was associated with Achilles shortening, excessive weight and associated lesser toe deformity. These factors should be addressed in order to treat this disorder adequately.