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Level of Evidence: Level V.

Background Achilles non-insertional tendinopathy is usually treated with conservative means. If resistant to a rehabilitation protocol surgical treatment could be proposed. The aim of this research is to report the mid-term clinical results of endoscopic assisted surgery for patients suffering from recalcitrant painful non-insertional Achilles tendinopathy. Methods A consecutive series of 11 patients (6 men and 5 women), median age of 54 (range 40–67) years, with chronic recalcitrant painful non-insertional Achilles tendinopathy were included. All patients completed at least 20 physical therapy sessions and 6 months of no sports activities before surgery. All underwent Achilles tendoscopy, without tendon excision or transfer with a median follow-up of 87 (27–105) months. We report the preoperative symptoms duration, treatment before surgery, complications and satisfaction after surgery, return to previous sport level, and postoperative VISA-A score. Results Mean preoperative symptoms duration was 1 year, having all performed at least 20 physical therapy sessions. No postoperative complications were reported, achieving a complete satisfaction in 10 of 11 patients. All patients returned to their preoperative sports level with a median postoperative VISA-A functional score of 100 (30–100) points. Conclusions The mid-term results of Achilles tendoscopy in patients with chronic painful non-insertional Achilles tendinopathy are satisfactory with a rapid rehabilitation. This procedure is safe and has a low complication rate. Level of Evidence: IV. Retrospective case series.

Background: Ankle hemiarthroplasty is a 1-piece implant system replacing the talar side of the tibiotalar joint. Hemiarthroplasty offers limited bone resection and may provide easier revision options than joint-ablating procedures. Methods: Prospective, multicenter, noncomparative, nonrandomized clinical study with short term follow-up on patients undergoing hemiarthroplasty of the ankle. Radiologic and functional outcomes (Foot and Ankle Outcome Score FAOS, Foot and Ankle Ability Measure [FAAM], Short Form–36 Health Survey [SF-36], Short Musculoskeletal Functional Assessment [SMFA], and visual analog scale [VAS] pain scores) were obtained at 3 and 12 months and the last follow-up (mean 31.9 months). Results: Ten patients met the inclusion criteria. Three were converted to total ankle replacement at 14, 16, and 18 months. Pain VAS scores improved on average from 6.8 to 4.8 ( P = .044) of the remaining 7 at a mean of 31.9 months’ follow-up. For these 7 in the Survival Group, we found that SF-36 physical health component improved from 25.03 to 42.25 ( P = .030), SMFA dysfunction and bother indexes improved from 46.36 to 32.28 ( P = .001), and from 55.21 to 30.14 ( P = .002) in the Survival Group, and FAAM sports improved from 12.5 to 34.5 ( P = .023). Conclusion: Patients undergoing hemiarthroplasty of the ankle joint for talar-sided lesions had a 30% failure rate by 18 months. Those who did not have an early failure exhibited modest pain reduction, functional improvements, and better quality of life in short-term follow-up. This procedure offers a possible alternative for isolated talar ankle cartilage cases. Level of Evidence: Level IV, prospective case series.

One of the most common orthopedic problems in the authors' practice is flatfoot and, although it is most commonly treated conservatively, there is still lack of consensus about the type of surgical treatment that is best recommended in a specific patient. Keeping in mind that medial soft tissue reconstruction alone has not proved enough as an isolated procedure and that osteotomies and arthrodesis are considered more invasive surgery, arthroereisis is a quick, easy, and reproducible technique that seems to have good results without major complications in the correct patient. Indications, biomechanical principles, and technique are described in this article.

Many different surgeries have been proposed for hallux valgus treatment, osteotomies being the currently recommended ones. Because of high recurrence rates, distal, diaphyseal and proximal osteotomies have been used to improve alignment and sesamoid reduction. The center of rotation of angulation (CORA) concept applies to any deformity and helps to completely realign 2 bone segments. When used with proximal osteotomies, bone displacement and angulation is performed obtaining complete deformity correction. The proximal oblique sliding closing wedge (POSCOW) osteotomy follows the CORA concept and permits preoperative planning. Future directions must include the correction of the pronation deformity of the metatarsal.

Instability is a common sequela after repeated ankle sprains. When nonoperative treatment fails, open lateral ligament complex repair and reinforcement with the inferior extensor retinaculum has been the gold standard procedure. The recent advancements in arthroscopic techniques have created comparable biomechanical and functional results to open procedures. The authors’ modification to the standard arthroscopic technique permits ligament approximation to the distal fibula over a larger surface area, using knotless anchors to avoid the need of an accessory portal and limit potential suture knot–related complications. Level of Evidence: Level V, expert opinion.

[Introduction][1] Arthrodesis of the first metatarsophalangeal joint is the most reliable surgical option, with a low complication rate, for hallux rigidus from end-stage osteoarthritis. [Step 1: Surgical Approach][2] Make a medial approach, following the mid-axis of the joint. [Step 2: Joint Preparation][3] Using a cup-cone configuration provides excellent bone exposure, construct stability, and metatarsophalangeal joint congruity. [Step 3: Positioning of Arthrodesis][4] Fix the toe in 5° to 10° of valgus and elevated 5 mm from the floor to achieve desired dorsiflexion. [Step 4: Application of Implants][5] Achieve a stable construct with a crossed lag screw and a dorsal locking plate (a hybrid construct). [Step 5: Closure][6] Perform a standard soft-tissue closure. [Step 6: Postoperative Care][7] Allow weight-bearing as tolerated after two weeks and impact exercises only after bone healing has been shown on radiographs, which can take up to ten weeks. [Results][8] Arthrodesis of the metatarsophalangeal joint in the hallux provides good results in terms of patient satisfaction and function, as demonstrated in many studies, most of them retrospective. [Indications][9] [Contraindications][10] [Pitfalls & Challenges][11] [Introduction][1] Arthrodesis of the first metatarsophalangeal joint is the most reliable surgical option, with a low complication rate, for hallux rigidus from end-stage osteoarthritis. [Step 1: Surgical Approach][2] Make a medial approach, following the mid-axis of the joint. [Step 2: Joint Preparation][3] Using a cup-cone configuration provides excellent bone exposure, construct stability, and metatarsophalangeal joint congruity. [Step 3: Positioning of Arthrodesis][4] Fix the toe in 5° to 10° of valgus and elevated 5 mm from the floor to achieve desired dorsiflexion. [Step 4: Application of Implants][5] Achieve a stable construct with a crossed lag screw and a dorsal locking plate (a hybrid construct). [Step 5: Closure][6] Perform a standard soft-tissue closure. [Step 6: Postoperative Care][7] Allow weight-bearing as tolerated after two weeks and impact exercises only after bone healing has been shown on radiographs, which can take up to ten weeks. [Results][8] Arthrodesis of the metatarsophalangeal joint in the hallux provides good results in terms of patient satisfaction and function, as demonstrated in many studies, most of them retrospective. [Indications][9] [Contraindications][10] [Pitfalls & Challenges][11] [1]: #sec-10 [2]: #sec-11 [3]: #sec-12 [4]: #sec-13 [5]: #sec-14 [6]: #sec-15 [7]: #sec-16 [8]: #sec-17 [9]: #sec-19 [10]: #sec-20 [11]: #sec-21

Background: The most common methods for assessing severity of hallux valgus deformity and the effects of an operative procedure are the angular measurements in weightbearing radiographs, specifically the hallux valgus angle and intermetatarsal angle (IMA). Our objective was to analyze the interobserver variability in hallux valgus patients of a new angle called the “angle to be corrected” (ATC), and to compare its capacity to differentiate between different deformities against IMA. Methods: We included 28 symptomatic hallux valgus patients with 48 weightbearing foot x-rays. Three trained observers measured the 1 to 2 IMA and the ATC. We then identified retrospectively 45 hallux valgus patients, which were divided into 3 operative technique groups having used the ATC as reference, and analyzed the capacity of the IMA to differentiate between them. Results: The IMA average value was 13.6 degrees, and there was a significant difference between observer 3 and observer 1 ( P = .001). The average value for the ATC was 8.9 degrees, and there was no difference between observers. Both angles showed a high intraclass correlation. Regarding the capacity to differentiate between operative technique groups, the ATC was different between the 3 operative technique groups analyzed, but the IMA showed differences only between 2. Conclusions: The ATC was at least as reliable as the intermetatarsal angle for hallux valgus angular measurements, showing a high intraclass correlation with no interobserver difference. It can be suggested that the ATC was better than the IMA to stratify hallux valgus patients when deciding between different operative treatments. Level of Evidence: Level III, comparative study.

Background: No clear guideline or solid evidence exists for peroneal tendon tears to determine when to repair, resect, or perform a tenodesis on the damaged tendon. The objective of this study was to analyze the mechanical behavior of cadaveric peroneal tendons artificially damaged and tested in a cyclic and failure mode. The hypothesis was that no failure would be observed in the cyclic phase. Methods: Eight cadaveric long leg specimens were tested on a specially designed frame. A longitudinal full thickness tendon defect was created, 3 cm in length, behind the tip of the fibula, compromising 66% of the visible width of the peroneal tendons. Cyclic testing was initially performed between 50 and 200 N, followed by a load-to-failure test. Tendon elongation and load to rupture were measured. Results: No tendon failed or lengthened during cyclic testing. The mean load to failure for peroneus brevis was 416 N (95% confidence interval, 351–481 N) and for the peroneus longus was 723 N (95% confidence interval, 578–868 N). All failures were at the level of the defect created. Conclusion: In a cadaveric model of peroneal tendon tears, 33% of remaining peroneal tendon could resist high tensile forces, above the physiologic threshold. Clinical Relevance: Some peroneal tendon tears can be treated conservatively without risking spontaneous ruptures. When surgically treating a symptomatic peroneal tendon tear, increased efforts may be undertaken to repair tears previously considered irreparable.

More than 200 different surgical techniques exist for hallux valgus (HV). Some of them are designed for mild, moderate, or severe deformities depending on their correction power. Nevertheless, they all correct only the coronal and/or sagittal plane deformity. Just a handful of them correct the known axial malrotation that exists in most HV cases. This malrotation is one possible factor that could be the source of recurrence of an operated HV as it has been described. We describe a new technique which simultaneously corrects the metatarsal internal rotation and varus deformity by rotating the metatarsal through an oblique plane osteotomy. This is performed with no bone wedge resection. Also, there is a broader bone surface contact than on a transverse proximal osteotomy. This technique is easy to remember and relatively simple to perform in primary and revision cases. The authors results show that it is as safe and effective as other procedures, with some advantages to be discussed. Levels of evidence Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

Background: The proximal oblique sliding closing wedge osteotomy (POSCOW) technique was developed to address moderate to severe hallux valgus deformity. We present a retrospective multicenter study to analyze the midterm radiological and clinical outcomes of patients treated with this type of proximal osteotomy fixed with plates. Materials and Methods: One hundred and forty-four patients (187 feet) were operated on between May 2005 and June 2010 in 2 separate centers. Inclusion criteria were symptomatic moderate to severe incongruent hallux valgus deformity, no significant restriction in the first metatarsophalangeal joint movement, none to minimal degenerative changes in the first metatarsophalangeal or the tarsometatarsal joints, and no hypermobility. The median age was 60 years. The preoperative hallux valgus angle (HV) was 35.6 degrees, intermetatarsal angle (IM) was 15.3 degrees, AOFAS score was 53 points. The median follow-up was 35 months (range, 12-73). A POSCOW osteotomy was performed in all patients and fixed with plates. We recorded the satisfaction rate, postoperative clinical and radiological results, and complications. Results: The patient satisfaction rate was 87%. The mean postoperative HV angle was 12.3 degrees, IM angle 4.8 degrees, AOFAS score 89 points. The mean decrease in the first metatarsal length was 2.2 mm (range, 0-8). Twelve feet (6.4%) with recurrence of the deformity required revision surgeries. Removal of complete or partial hardware was needed in 23 feet (12.3%) for symptomatic hardware. Five feet (2.6%) developed hallux varus but only 2 required surgery. Transfer metatarsalgia was noted in 9 feet (4.8%). Conclusions: The POSCOW osteotomy was an effective and reliable method for relieving pain and improving function. A learning curve was present, as most of the complications happened in the initial cases. To our knowledge, this is the largest reported series of proximal closing wedge osteotomy for hallux valgus deformities. Level of Evidence: Level IV, case series.

The ankle represents the most commonly injured weightbearing joint in the human body. They are typically the result of low-energy, rotational injury mechanisms. However, ankle fractures represent a spectrum of injury patterns from simple to very complex, with varying incidence of posttraumatic arthritis. Stable injury patterns can be treated nonoperatively; unstable injury patterns are typically treated operatively given that they could lead to severe arthritis if not properly addressed.

Efforts are currently being made to improve results in hallux valgus treatment. Different studies to design procedures that are more stable and efficient to correct deformities are underway, and new techniques will be presented in the following years. Better fixation devices will offer reliability in corrections, and hopefully will allow faster rehabilitation with fewer restrictions. Understanding the concept of correction power is important when deciding which technique to use. The origin of hallux valgus is not known, but evidence exists to assume that a correct skeletal and soft tissue balance is important to prevent recurrence and obtain good function. We think that a correct metatarsophalangeal reduction, in which the final position of the hallux is defined mainly by the skeletal alignment and not soft tissues, will dictate the final result. Pushing the metatarsal bone over the sesamoids and not moving the sesamoids under the metatarsal head is a new concept and it may allow better results for our patients. It is hoped that understanding of biomechanics will continue to evolve, and radiological measurements and corrections will produce better functional results for patients.

We tested four types of surgical repair for load to failure and distraction in a bovine model of Achilles tendon repair. A total of 20 fresh bovine Achilles tendons were divided transversely 4 cm proximal to the calcaneal insertion and randomly repaired using the Dresden technique, a Krackow suture, a triple-strand Dresden technique or a modified oblique Dresden technique, all using a Fiberwire suture. Each tendon was loaded to failure. The force applied when a 5 mm gap was formed, peak load to failure, and mechanism of failure were recorded. The resistance to distraction was significantly greater for the triple technique (mean 246.1 N (205 to 309) to initial gapping) than for the Dresden (mean 180 N (152 to 208); p = 0.012) and the Krackow repairs (mean 101 N (78 to 112; p < 0.001). Peak load to failure was significantly greater for the triple-strand repair (mean 675 N (453 to 749)) than for the Dresden (mean 327.8 N (238 to 406); p < 0.001), Krackow (mean 223.6 N (210 to 252); p < 0.001) and oblique repairs (mean 437.2 N (372 to 526); p < 0.001). Failure of the tendon was the mechanism of failure for all specimens except for the tendons sutured using the Krackow technique, where the failure occurred at the knot. The triple-strand technique significantly increased the tensile strength (p = 0.0001) and gap resistance (p = 0.01) of bovine tendon repairs, and might have advantages in human application for accelerated post-operative rehabilitation.

This article presents a surgical protocol for surgical reconstruction from the subtle cavus foot described by Manoli to the most complicated cases. The goal is to merge together the available surgical options in a comprehensive way to guide surgical decisions.

Background: Arthroscopic ankle lateral ligament repair techniques have recently been developed and biomechanically as well as clinically validated. Although there has been 1 anatomic study relating suture and anchor proximity to anatomic structures, none has evaluated the ArthroBroström procedure. Purpose: To evaluate the proximity of anatomic structures for the ArthroBroström lateral ankle ligament stabilization technique and to define ideal landmarks and “safe zones” for this repair. Study Design: Descriptive laboratory study. Methods: Ten human cadaveric ankle specimens (5 matched pairs) were screened for the study. All specimens underwent arthroscopic lateral ligament repair according to the previously described ArthroBroström technique with 2 suture anchors in the fibula. Three cadaveric specimens were used to test the protocol, and 7 were dissected to determine the proximity of anatomic structures. Several distances were measured, including those of different anatomic structures to the suture knots, to determine the “safe zones.” Measurements were obtained by 2 separate observers, and statistical analysis was performed. Results: None of the specimens revealed entrapment by either of the suture knots of the critical anatomic structures, including the superficial peroneal nerve (SPN), sural nerve, peroneus tertius tendon, peroneus brevis tendon, or peroneus longus tendon. The internervous safe zone between the intermediate branch of the SPN and sural nerve was a mean of 51 mm (range, 39-64 mm). The intertendinous safe zone between the peroneus tertius and peroneus brevis was a mean of 43 mm (range, 37-49 mm). On average, a 20-mm (range, 8-36 mm) safe distance was maintained from the most medial suture to the intermediate branch of the SPN. The amount of inferior extensor retinaculum (IER) grasped by either suture knot varied from 0 to 12 mm, with 86% of repairs including the retinaculum. Conclusion: The results indicate that there is a relatively wide internervous and intertendinous safe zone when performing the ArthroBroström technique for lateral ankle stabilization. While none of the critical anatomic structures was entrapped by the suture knots, it was evident that the IER was included in a majority of the repairs. This study further defines the proximity of adjacent anatomic structures and establishes the anatomic safe zones for the ArthroBroström lateral ankle stabilization procedure. Clinical Relevance: By defining this relatively risk-free zone, surgeons who are not as experienced with arthroscopic lateral ligament repair techniques may approach arthroscopic suture passage with more confidence.

Background: Hallux valgus (HV) treatment is continuously evolving, and no definitive treatment can be recommended. Osteotomies are the main surgical choice for these deformities, but no clear role for soft tissue procedures is available. Objective: To perform a retrospective comparison of the radiographic and clinical outcomes of 2 groups of patients with severe HV operated with the same osteotomy technique but differing on the type of lateral release. Methods: Two groups of patients with symptomatic moderate to severe HV deformities were operated with the same proximal metatarsal osteotomy, which differed on the type of lateral release: group 1 had limited transarticular lateral capsule release (n = 62), and group 2 complete lateral release, including capsule, adductor tendon, and intermetatarsal (IM) ligament (n = 57). We recorded the American Orthopaedic Foot & Ankle Society (AOFAS) score, HV and IM angles, first metatarsal shortening, concomitant metatarsal shortening osteotomies (Weil), Akin osteotomies, and complications. Results: The postoperative AOFAS score in group 1 was similar to that of group 2. The HV and IM angles improved in both groups with no significant difference. The multivariate analysis showed no influence of any variable analyzed on HV or IM angle improvement. Regarding AOFAS score improvement, a limited lateral release was associated with a higher increase in AOFAS score ( P = .019). Conclusion: No studies are available to identify which soft tissue structures are involved in HV deformities nor which have to be released, if any. A limited transarticular release can provide similar clinical and radiologic outcomes when compared with a classic open lateral release. Level of Evidence: Level IV, case series.

Background Different surgical techniques are available to correct each type of Hallux Valgus (HV) deformity, and all present similar good results. No information is available relative to the cost of each technique compared to their individual success. Objective To determine the cost-effectiveness-ratio (CER) of five different techniques for HV. Methods We included 245HV surgeries performed in 179 patients. The severity was defined according to radiological parameters. For mild to moderate HV we included the Chevron, Modified-Scarf and Ludloff techniques; for severe HV: either Poscow-osteotomy or Lapidus-arthrodesis fixed with plates or screws. Weighted costs were estimated. CER was expressed in $US dollars per AOFAS-point. Results The lowest weighted cost was observed for the Chevron-group, and the highest weighted cost was observed in the Poscow-osteotomy and Lapidus-arthrodesis fixed with plate groups. The AOFAS-score improvement was higher in the Chevron and Modified-Scarf groups. The CER found for Chevron and Modified-Scarf techniques were significantly less than for Poscow and Lapidus-techniques. Conclusion Cost-Effectiveness-Ratio was lower, and therefore better, in the groups with mild to moderate deformities operated with Chevron or Modified-Scarf techniques. In severe HV, the three techniques investigated presented similar CER. CER analysis is an additional factor that can be included in the decision making analysis in hallux valgus surgery. Level of Evidence Level IV, Retrospective Study

Background Tibialis posterior (TP) tendon transfer through the interosseous membrane is commonly performed in Charcot-Marie-Tooth disease. In order to avoid entrapment of this tendon, no clear recommendation relative to the interosseous membrane (IOM) incision size has been made. Objective Analyze the TP size at the transfer level and therefore determine the most adequate IOM window size to avoid muscle entrapment. Methods Eleven lower extremity magnetic resonances were analyzed. TP muscle measurements were made in axial views, obtaining the medial-lateral and antero-posterior diameter at various distances from the medial malleolus tip. The distance from the posterior to anterior compartment was also measured. These measurements were applied to a mathematical model to predict the IOM window size necessary to allow an ample TP passage in an oblique direction. Results The average tendon diameter (confidence-interval) at 15cm proximal to the medial malleolus tip was 19.47mm (17.47–21.48). The deep posterior compartment to anterior compartment distance was 10.97mm (9.03–12.90). Using a mathematical model, the estimated IOM window size ranges from 4.2 to 4.9cm. Conclusion The IOM window size is of utmost importance in trans-membrane TP transfers, given that if equal or smaller than the transposed tendon oblique diameter, a high entrapment risk exists. A membrane window of 5cm or 2.5 times the size of the tendon diameter should be performed in order to theoretically diminish this complication.

Category: Basic Sciences/Biologics, Midfoot/Forefoot Introduction/Purpose: Metatarsal osteotomies for Hallux Rigidus (HR) is a treatment option when neither a cheilectomy nor an arthrodesis are indicated. Different osteotomies exist that elevate, shorten or depress the metatarsal head. No biomechanical information exists that evaluates the effect of osteotomies on hallux range of motion (ROM) and stiffness. Our objective was to evaluate, in a cadaveric model, the first metatarsophalangeal joint (MTPJ) stiffness and kinematics changes, after three different metatarsal osteotomies. Methods: 8 cadaveric foot-ankle–distal tibia specimens were prepared, identifying all extensor and flexor tendons proximally. The skin and subcutaneous tissue was kept intact. Each specimen was mounted on a special frame and luminous markers were attached to the skin (Oxford Foot Model). A dead weight equal to 50% of the stance phase force was applied to each tendon, except for the Achilles tendon and the posterior tibialis. Each specimen served as its own control, testing hallux dorsiflexion when pulling the extensor hallucis longus tendon. 10 cycles were performed for every condition: control (A), and three different metatarsal extraarticular neck osteotomies: vertical osteotomy with 5 mm of depression (B), 5 mm of shortening (C) and 5 mm of shortening and depression (D). All osteotomies were performed on a Hallux Rigidus cadaveric model. We registered the MTPJ stiffness and kinematic changes after each intervention using a tensile testing machine and high definition cameras. Results: B and C were significantly stiffer than group A and D (p0.05). Groups B, C and D achieved similar kinematics (range of motion) to group A (p>0.05). Conclusion: Different metatarsal osteotomies exist for HR. The osteotomy of choice, should be one that recreates the healthy MTPJ motion and stiffness. According to our study, the osteotomy of choice should be one that results in metatarsal head depression and shortening. A possible explanation to our finding, is that a pure shortening or depression osteotomy is really elevating or depressing the head respectively, hence altering the tendon pull and relative head position. Only with metatarsal shortening and depression, the Hallux MTPJ biomechanics in a Hallux Rigidus cadaver model, returns to a healthy state.

Category: Bunion Introduction/Purpose: Hallux Rigidus (HR) is characterized initially by a decrease in Hallux metatarsophalangeal joint (MTPJ) dorsiflexion, decreasing the total range of motion. To be able to study different surgical treatment options, a cadaveric model has to be developed that recreates the limited range of motion. Our objective was to develop an Hallux Rigidus cadaveric model by shortening the plantar fascia (PF). Hallux MTPJ range of motion and joint stiffness were evaluated. Methods: 8 cadaveric foot- ankle – distal tibia specimens were prepared, identifying all extensor and flexor tendons proximally. The skin and subcutaneous tissue was kept intact. Each specimen was mounted on a special frame and luminous markers were attached to the skin (Oxford Foot Model). A dead weight equal to 50% of the stance phase force was applied to each tendon, except for the Achilles tendon and the posterior tibialis. 10 Hallux MTPJ dorsiflexion-plantarflexion cycles were performed by pulling the Extensor Hallucis longus tendon using an tensile testing machine (Kinetecnics). A Hallux Rigidus model was then developed by shortening the PF by 6 mm using a triple fiberwire suture technique. The same 10 cycles were repeated with a shortened PF. Each specimen served as its own control. Hallux metatarsophalangeal stiffness and kinematics were tested using a tensile testing machine and high definition cameras. Results: The group with a shortened PF significantly reduced the hallux dorsiflexion (18.6 degrees) compared to the native foot (23.7 degress) (p0.05). Conclusion: To create a HR model is vital to allow further understanding of the pathology. The cadaveric model should not alter the joint stability (intact periarticular soft tissues) but has to limit Hallux range of motion. The model we present successfully recreates HR by limiting MTPJ dorsiflexion. The absence of stiffness change shows that joint congruity and isometry were not modified. There are a few reports that state a PF shortening as the first stage in HR. This would lead to a hinge-like MTPJ dorsiflexion, creating a dorsal metatarsal head impingement that could evolve to a dorsal exostosis.

The use of tendon transfers in the cavovarus foot is a common surgical procedure because of the muscular imbalance present in this pathologic condition. Therefore, deforming forces are transferred to obtain movement and function. General principles must be followed for transfers to work; depending on the muscle deficiency and the function to restore, different tendon transfer options exist. The authors do not recommend tendon transfers for forefoot deformities in this setting. Postoperatively tendon transfers should be protected in a removable boot, but early protected weight bearing and motion is stimulated to obtain a well-functioning transfer and not a tenodesis.

Background: Side-to-side tenorrhaphy is increasingly used, but its mechanical performance has not been studied. Methods: Two porcine flexor digitorum tendon segments of equal length (8 cm) and thickness (1 cm) were placed side by side. Eight tenorrhaphies (involving sixteen tendons) were performed with each of four suture techniques (running locked, simple eight, vertical mattress, and pulley suture). The resulting constructs underwent cyclic loading on a tensile testing machine, followed by monotonically increasing tensile load if failure during cyclic loading did not occur. Clamps secured the tendons on each side of the repair, and specimens were mounted vertically. Cyclic loading varied between 15 N and 35 N, with a distension rate of 1 mm/sec. Cyclic loading strength was determined by applying a force of 70 N. The cause of failure and tendon distension during loading were recorded. Results: All failures occurred in the monotonic loading phase and resulted from tendon stripping. No suture or knot failure was observed. The mean loads resisted by the configurations ranged from 138 to 398 N. The mean load to failure, maximum load resisted prior to 1 cm of distension, and load resisted at 1 cm of distension were significantly lower for the vertical mattress suture group than for any of the other three groups (p < 0.031). Conclusions: All four groups sustained loads well above the physiologic loads expected to occur in tendons in the foot and ankle (e.g., in tendon transfer for tibialis posterior tendon insufficiency). None of the four side-to-side configurations distended appreciably during the cyclic loading phase. The vertical mattress suture configuration appeared to be weaker than the other configurations. Clinical Relevance: For surgeons who advocate immediate loading or motion of a side-to-side tendon repair, a pulley, running locked, or simple eight suture technique appears to provide a larger safety margin compared with a vertical mattress suture technique. Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

Background: The high incidence of soft tissue complications related to open Achilles repair has driven enthusiasm for developing minimally invasive surgical procedures. The Dresden procedure, which reduces wound-healing issues and avoids sural nerve damage, has recently been published and shows good functional results. Objective: To evaluate medium-term clinical results of procedures using the Dresden mini-open technique on acute Achilles tendon ruptures. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis was performed on 100 consecutive patients with a mean follow-up of 42.1 months. At follow-up, the American Orthopaedic Foot and Ankle Society (AOFAS) score, time to return to work and sports, subjective satisfaction, and complications were registered. An isokinetic test was performed on the first 21 patients of this series at 1 year postoperatively. Results: The mean time to return to work was 56.0 days, and the mean time to return to sports was 18.9 weeks. The mean AOFAS score was 97.7; 98% of patients were satisfied. No complications regarding soft tissues and sural nerve damage were reported. Two reruptures and 5 cases of deep venous thrombosis were observed. The isokinetic evaluation showed good recovery of the involved muscles. Conclusion: The excellent functional and satisfaction results, ease of the procedure, and avoidance of sural nerve damage make the mini-open technique a very attractive alternative for acute, spontaneous Achilles tendon ruptures.

Background:Anatomic restoration and postoperative rehabilitation of displaced fracture-dislocations of the tarsometatarsal junction of the foot are essential. Our objective was to report percutaneous reduction and screw fixation results in low-energy Lisfranc fracture dislocation injuries that were treated with early weight-bearing and rehabilitation.Methods:We retrospectively evaluated patients with low-energy Lisfranc injuries who underwent surgery between May 2007 and April 2011. The study reviewed 22 patients (12 men and 10 women) with an average age of 36.2 years (range, 16-50 years) and an average follow-up of 33.2 months (range, 12-50 months). We report the mechanism of trauma; quality of reduction in the postoperative digital radiographs; subjective satisfaction; AOFAS score; time required to return to work, recreational activities, and low-impact sports; and complications. Postoperatively, all of the patients were instructed to be non-weight-bearing for 3 weeks, and the stitches were removed after 2 weeks. At the third postoperative week, the patients were encouraged to bear weight as tolerated.Results:Quality of reduction was anatomic or near anatomic in 100% of cases. The subjective satisfaction reported by patients was very good, with complete satisfaction in 20 of them (90.9%). The AOFAS average was 94 points (range, 90-100 points). Average return to work was at 7 weeks (range, 6-9 weeks), recreational activities 7.2 weeks (range, 6-9 weeks), training for low-impact sports 7.6 weeks (range, 7-8 weeks), and symptom-free sport activities 12.4 weeks (range, 11-13 weeks).Conclusion:In this selected group of patients with low-energy Lisfranc fracture dislocation, anatomic or near-anatomic reduction can be achieved with percutaneous reduction and screw fixation. Early weight-bearing is possible in these patients, and early return to regular activities and low-impact sport can be expected.Level of Evidence:Level IV, retrospective case series.

Treatment of rigid claw toe is still subject to discussion and evolution. Arthrodesis or arthroplasty of the PIPJ is apparently the most reliable procedure. K wire seems be the most reliable way to solve this clinical issue, but different implants specifically created to treat PIPJ deformities are being developed, and still have to be tested clinically. The use of screws to fix the PIPJ is a valid alternative, although some problems remain to be solved, specifically pain in relation to the tip of the screw. Longer follow-up studies are needed to increase our knowledge of the treatment of this specific deformity.

Treatment of neuromas in the foot and ankle is evolving. A paucity of studies deals with neuromas in this region; most knowledge comes from hand surgery. A trend toward reconstructive surgery using nerve grafts and conduits for nerves with critical function is being seen. For noncritical nerves, generally accepted treatment is neuroma resection and burial into a tissue bed. A clear knowledge of neural anatomy is paramount, together with correct identification of all the nerves involved in the pain-generation process. More studies dealing with neuromas in this area are needed for evidence-based information.