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Category: Bunion Introduction/Purpose: The minimally invasive Chevron Akin (MICA) osteotomy have been widely used treating hallux valgus (HV). The purpose of this study was to present a case series of patients with severe HV undergoing surgical treatment using the MICA procedure, and to evaluate the clinical and radiographic outcomes Methods: Sixty consecutive feet (52 patients) undergoing MICA for severe HV were included. Patients were assessed pre and postoperatively. Clinically evaluation was realized by visual analogue pain scale (VAS) and American Orthopaedic Foot & Ankle Society Score (AOFAS). Radiographic assessments included measurement of hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsal (MT) length and plantar offset of MT head. Results: The mean age was 59.9 years and follow-up were 18.5 months. The average AOFAS increased from 41.2 to 90.9 points and the VAS decreased from 8.1 to 1.3 at the last follow up. Average HVA decreased from 41.2° to 11.6° and IMA reduced from 17.1° to 6.8°. Average shortening of the first metatarsal and the plantar offset of MT head was 3.9 mm and 2.8 mm respectively. There was significant improvement (p

Category: Arthroscopy Introduction/Purpose: The arthroscopic techniques used to treat chronic lateral ankle instability have developed greatly in recent years. The purpose of this work is to present clinical and functional results of patients with chronic ankle instability submitted to surgical treatment by all-inside arthroscopic repair of the anterior talofibular ligament (ATFL). Methods: This is a series of cases of 18 consecutive patients who underwent the all-inside arthroscopic ATFL repair technique, a surgical treatment for chronic lateral ligament instability of the ankle, after the failure of conservative treatment performed for 6 months. The evaluation was made using the American Orthopaedic Foot and Ankle Score (AOFAS), visual analog pain scale (VAS), anterior drawer and talar tilt tests. Surgical complications and patient satisfaction indices were also evaluated. Results: All 18 patients were evaluated for a mean follow-up period of 12 months. There was an improvement in the AOFAS (p< 0.001), with the mean improving from 69.6 points to 98.1, and in the mean VAS score, from 5.0 to 0.5 points (p < 0.001). All ankles were stable, as assessed by the anterior drawer test and talar tilt test. The only complication found was neurapraxia of the superficial fibular nerve in one patient (5%). All of the patients classified the treatment as good or excellent and returned to daily and sports activities without limitations. Conclusion: Treatment of chronic ankle ligament instability by the all inside arthroscopic ATFL repair technique was able to restore ankle stability and showed good clinical results and high satisfaction rates.

Category: Bunion Introduction/Purpose: Minimally Invasive Chevron Akin (MICA) can be used to treat hallux valgus (HV) associated with a hypermobility of the first metatarsal-cuneiform joint (1MTCJ). The aim of this study was to perform a radiographic analysis of the MICA, focused on evaluating the 1MTCJ. Methods: Forty patients (50 feet) with moderate to severe HV underwent a MICA procedure. Radiographic analysis included hallux valgus angle (HVA), intermetatarsal angles between the first and second rays (IMA), the intermetatarsal angle between the proximal fragment of the osteotomy and the second ray (IAPF) and the distance between a point 3 cm distal from the base of the second metatarsal and a point located at the same height for the first metatarsal base (Dist 1-2). The IAPF was compared with the preoperative IMA and the other parameters were compared pre and post-operatively. The radiographic complications were also recorded Results: The majority of patients were female (92%). The mean age was 50.4 years (SD =16.1) and the mean follow-up was 16.1 months (SD = 3.5). The average HVA improved from 32.5 to 7.3 degrees and the average IMA from 14.2 to 4.2 degrees. The IAPF and Dist1-2 values showed an increase of 4.8 and 3.2mm respectively. There were no radiographic complications Conclusion: Minimally Invasive Chevron Akin: Locking the Metatarsal-Cuneiform Joint.

Category: Basic Sciences/Biologics; Ankle Introduction/Purpose: The lateral ligament complex of the ankle has been extensively studied. Recently an anatomical study described a connection between anterior talofibular ligament inferior fascicle (ATFLif) and calcaneofibular ligament (CFL). The applicability and the mechanical role of these connections have not yet been studied and need to be clarified. The purpose of this study is to evaluate the connection between ATFLif and CFL through a dynamic measurement analysis. Methods: An anatomical study was performed in 13 fresh-frozen below-the-knee ankle specimens. Each specimen was dissected in a protocolized manner until the lateral ligaments were exposed. A complete injury to both ATFL's fascicles was created in the proximal third of the ligament. A displacement transducer specifically design was inserted in the CFL and in the lateral part of the calcaneus to test its lengthening. A traction of 1 kg weight (9.8 N) was applied to ATFLif while the transducer measured the lengthening that this force created in the CFL. Results: A total of 13 ankle specimens were carefully dissected. One specimen with signals of a prior traumatic injury of the ATFLif was excluded. A total of 12 specimens were included, 7 females and 5 males with an average age of 74 years (52-88 years). The right ankle was dissected in 6 specimens. ATFL was identified as a two-fascicled ligament in all cases. The fibers connecting the ATFLif and CFL were observed in all specimens. The displacement transducer showed lengthening in the CFL in all measurements with a median of 0.59 mm (SD 0.34). Conclusion: Connecting fibers between ATFLif and CFL are robust enough to transmit tension from one structure to the other.In the case of associated proximal lesions of the ATFLif and CFL, ligaments repair with a single suture may be considered. This can be applied in surgical procedures in patients with lateral ankle instability.

Category: Basic Sciences/Biologics; Ankle Introduction/Purpose: Recently an anatomical study described a medial connection between the anterior talofibular ligament inferior fascicle (ATFLif), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). Therefore, there is no research evaluating the lateral ligaments and their relationships through a three-dimensional view achieved by a digital marking of their foot prints. The authors hypothesize that a three-dimensional analysis made only by an accurately digital analysis can clarify the lateral collateral ligaments (LCL) connections and their foot prints relations. This work aims to carry out an anatomical study in cadaveric pieces in which the lateral ankle ligaments were dissected and evaluated by a tridimensional scanner that allows a digitally and three-dimensional assessment of their foot prints and connections. Methods: An anatomical study was performed in 11 fresh-frozen ankle specimens. Each ankle was dissected to achieve the amputation of the calcaneus, talus and fibula, keeping the inserts of the footprints of LCL. After that, each bone piece with the insertion remnants of the LCL was submitted to an evaluation by a scanner machine. Surface scans for these bones were collected using a structured light scanner. Each bone piece was set on a 3D automatic turntable to capture a 360° scan and was scanned in two orientations, with 6 scans per orientation. Finally, all the scans were aligned and final fused models were created using the HP DAVID software package and exported to a wavefront 3D object file. The 3D models were imported into Geomagic Studio to calculate surface area of the LCL foot prints. Results: A total of 11 units of each, talus, fibula and calcaneus were dissected from 11 ankles specimens. The ATFL was identified as a two-fascicled ligament and the fibers connecting fibers between the ATFLif and CFL was present in all specimens. In two talus there was only one insertion of the ATFL. After scanning the bones, the authors observed that the foot prints of ATFLif, CFL and PTFL were contiguous at medial side of the fibula, with an average of the surface area of 486,7 mm 2 . The foot print of the CFL on the calcaneus was located at the junction of a vertical line tangent to the highest point of the posterior subtalar with a horizontal line extending from the sinus tarsi in all specimens. Conclusion: This study demonstrated by a 3D analysis that the LCL of the ankle share the same foot print at medial side on the fibula and are all connected since the foot prints of the ATFL inf, CFL and PTFL were contiguous. In the case of associated proximal lesions of the ATFLif and CFL, ligaments repair with a single suture may be considered. This can be applied in surgical procedures in patients with lateral ankle instability.fig

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The Minimally Invasive Chevron-Akin (MICA) technique has already demonstrated efficacy compared with other known surgical treatments for mild to moderate Hallux Valgus (HV) deformities. MICA combines percutaneous osteotomies with the benefits of modern rigid internal fixation. By minimizing soft-tissue disruption and allowing large translation of the metatarsal head up to 100%, surgeons have used this technique to address severe deformities as well. The study aim was to evaluate the radiographic parameters, clinical improvement, and potential complications in moderate to severe hallux valgus cases, operated using the MICA technique. Methods: This is a retrospective study conducted between January 2017 and December 2020, that included patients with moderate to severe HV, who underwent surgical correction using the MICA technique. The sample size calculation was based on the AOFAS questionnaire. Thus, to obtain the 0.8 power, including 70 cases in this study, was necessary. The AOFAS score and weight-bearing AP radiographic views for hallux valgus evaluation were applied pre-operatively, after a follow-up period of 6 months, after one year of follow-up, and after two years of follow-up. Visual Analogic Scale (VAS) was applied pre-operatively, after 1 year of follow-up, and after 2 years of follow-up. The following radiographic parameters were measured: metatarsophalangeal hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), and intermetatarsal angle (IMA) between the first and second metatarsals. To compare the measurements over time, Friedman's test was used. p

Background: The impact of pronation and sesamoid coverage on clinical outcomes following percutaneous hallux valgus surgery are not currently known. The aim of this study was to investigate if sesamoid coverage was associated with worse clinical outcomes at 12-month follow-up following percutaneous hallux valgus surgery. Methods: Retrospective comparative observational study of clinical and radiographic outcomes based on a previously published prospective dataset. Patients were stratified into 3 cohorts based on the degree of sesamoid coverage (normal, mild, or moderate) on 12-month weightbearing radiographs following fourth-generation percutaneous hallux valgus surgery. Primary outcome was a validated patient-reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ). Secondary outcomes included Euroqol-5D, VAS Pain, and radiographic deformity correction. Results: Forty-seven feet underwent primary fourth-generation HV surgery and were stratified into 3 cohorts. There were 19, 16, and 12 feet in the normal, mild, and moderate cohorts respectively. There was no significant difference in either pre- or postoperative foot function (all MOXFQ domains, P > .05) or health-related quality of life (EQ-5D Index or VAS, P > .05). The MOXFQ Index preoperatively was as follows: normal cohort, 56.1 ± 26.9; mild cohort, 54.1 ± 17.9; and severe cohort, 49.6 ± 23.8; and postoperatively was as follows: normal cohort, 15.6 ± 21.5; mild cohort, 11.4 ± 15.5; and severe cohort, 11.4 ± 13.6 ( P = .737-.908). There was significantly worse hallux valgus angle (HVA) and intermetatarsal angle (IMA) between the cohorts ( P

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Progressive collapsing foot deformity (PCFD), Hallux Valgus (HV), and Midfoot Arthritis (MA) are diseases that benefit from the Lapidus procedure due to its capability to provide a stable medial column while correcting the underlying deformity. However, the technique does not go without complications. First metatarsal shortening/dorsiflexion are not uncommon, which could be exacerbated by local anatomy/revision surgery settings. Restoring length and sagittal plane position (plantarflexion) of the first ray when treating these pathologies is paramount. Performing a primary distraction and plantarflexion fusion with an allograft wedge (LapiCotton) has been advocated in the literature, potentially allowing improved deformity correction, but with the risk of increased non-union rate. The objective of this study was to report medium-term follow-up results of the LapiCotton in patients with collapsed feet. Methods: This IRB-approved comparative prospective study assessed patients diagnosed with PCFD, HV, and MA undergoing a Lapidus bone-block fusion (LapiCotton) between August 2020 and November 2022. All patients were operated on by a single fellowship-trained foot and ankle surgeon after clinical evaluation and a weight-bearing computed tomography (WBCT). After adequate joint preparation and trials, a Lapidus pre-shaped wedge allograft was placed and fixed using available implants. Adjunctive procedures were carried out as needed. Patients were kept non-weight bearing for six weeks and followed clinically, performing a WBCT at three months and subsequent follow-up. Non-Union and complications were documented. Bone healing was determined by at least 50% of bone trabeculae crossing both graft interfaces at the WBCT. Forefoot arch angle (FFA), Meary’s angle, talonavicular coverage angle (TNCA), middle facet subluxation (MFS), and foot and ankle offset (FAO) were also obtained. Two fellowship-trained readers performed all assessments. P-values >0.05 were considered significant. Results: Fifty-eight patients (60 feet) were included, mean age 53.87 (range:18-77)/BMI 31.70 (SD:7.96). Twenty-four PCFD, 19 HV, and 17 MA had an average 15.47 months (4-31) follow-up. Cuneiform-Post implants were used in 62%, plates/screws in 25%, and Lapidus nails in 13%. Median allograft size was 9mm (mode:8mm,5-19mm). Minor complications were observed in 3% (two superficial dehiscences) and major in 7% (three deep infections [5%], and one EHL contracture [2%]). Healing at the 3-month WBCT occurred in 94.8% and only in 66% at the most-recent WBCT (mean:11.08 months; 6-20). The clinical non-union rate demanding reoperation was eight clinical non-unions 13%. Mean FFA (pre:6.89,SD:6.63; postop:14.21,SD:5.48; p< 0.001), Meary (pre:15.17,SD:8.12; postop:6.31,SD:5.61; p< 0.001), TNCA (pre:26.75,SD:11.77; postop:11.59,SD:7.91; p< 0.001), MFS (pre:36.3,SD:26; postop:23.49,SD:17.35; p< 0.001), and FAO (pre:6.71,SD:5.81; postop:2.2,SD:4.33; p< 0.001) improved after the interventions. Conclusion: Although the Lapidus bone-block arthrodesis (LapiCotton) restored many of the markers associated with foot collapse and alignment, non-union rated was noted in 13% what is on the top range of non-union rates reported in the literature for Lapidus arthrodesis. The use of allograft wedges in the fusion site probably explains our findings. The fact that the sample was heterogeneous and composed of considerably severe deformities should also be considered. Also, important to highlight that WBCT findings of fusion site healing was initially 94% at 3-months and only 66% at most recent follow-up). Additional studies and longer-term follow up are needed.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Minimally invasive surgery (MIS) Chevron-osteotomy for HV treatment offers a surgical alternative to open surgery with minimal surgical dissection and a hypothetical decreased risk for soft-tissue complications. During this procedure, there is a concern regarding the injury to the blood supply of the 1st-metatarsal-head. The objective of this study was to assess the incidence of injuries: (1) to the soft-tissue envelope around the first metatarsal head complex and, (2) to the blood supply of the first metatarsal head and also by using Micro-CT, (3) looking for safe zones close to the first metatarsal head to perform MIS Chevron osteotomy. We hypothesized that the MIS Chevron-type osteotomy procedure would preserve the soft-tissue envelope of the first-metatarsal-head complex and the blood supply of the 1st-metatarsal-head. Methods: Sixteen HV deformity cadaveric specimens were used to perform MIS Chevron-type osteotomy of the first metatarsal head. Anatomical dissection of all specimens was then performed to assess macroscopic injury to the first metatarsal head complex soft-tissue structures, including Extensor Hallucis Longus (EHL) tendon, Extensor Hallucis Brevis (EHB) tendon, Flexor Hallucis Longus (FHL) tendon, Flexor Hallucis Brevis (FHB) tendon, Abductor Hallucis tendon, Adductor Hallucis tendon, Sesamoid complex, Dorsolateral and Dorsomedial digital branches of the first toe and the Dorsomedial digital branch to the second. Macroscopic injuries were classified using a calibrated digital caliper. Any chondral damage to the first metatarsal head was quantified in mm². To assess the amount of first metatarsal head blood supply, specimens were perfused with 200 ml of a low viscosity radiopaque polymer, MV 117 (Flowtech), preoperatively, followed by Micro-CT assessment. Descriptive statistics and percentages were utilized for categorical data. Results: We did not find injuries in the EHL, EHB, FHL, Abductor-Hallucis, and Adductor-Hallucis tendons. We found a 2mm injury in the FHB tendon in one specimen. No injuries were found in the Dorsomedial and Dorsolateral nerves of the first-toe, the Dorsomedial-nerve of the second-toe, and Medial branch of the dorsomedial-nerve of the first-toe. In 3 cases, we found an injury on first-metatarsal-head (1mm) due to the passage of the K-wire and, in 1 case, due to the inadvertent passage of the drill (4.41mm). Macroscopically and using Micro-CT, we did not observe injuries in the First-Dorsal-Metatarsal-Artery (FDMA), Lateral-Dorsal-Branch of FDMA, and Plantar-Metatarsal-Artery. Micro-CT helped estimate a safe distance to finish the proximal exit of Chevron-osteotomy (25mm from the most distal point of the first metatarsal head). Conclusion: In this study, the minimally invasive Chevron osteotomy for treating HV seems to be a technically safe procedure, presenting a low rate of iatrogenic injuries with a low degree of severity. In addition, using Micro-CT promoted a better visualization of the microvasculature that nourishes the first metatarsal head. We observed that a proximal distance of 25 mm from the most distal part of the first metatarsal head could be a safe place to finalize the Chevron osteotomy, minimizing the risk of injury to the blood supply of the first metatarsal head.

Category: Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Women wearing high heels for 20 years without Hallux valgus angle alterations make it debatable that causes Hallux valgus deformation. A recent systematic review determined that 4.13 ± 0.34 cm of heel height would improve foot weight-bearing . Wearing high heels would realign the foot, causing an inversion of the foot, which locked the navicular-cuneiform and cuneo-metatarsal joints rather than primarily rotate the metatarsophalangeal joint. Nowadays, weight-bearing scans could favor understanding the alignment mechanism involved in the foot and ankle with different shoe heights. Therefore, we aimed to determine the acute foot alignment in non-frequent HH users without Hallux valgus during stand posture. Here, we hypothesize that high heels studied by weight-bearing scans shows radiology changes linked to hindfoot alignment rather than primary forefoot rotation. Methods: This comparative cross-sectional study, participants were randomly submitted to a tridimensional weight-bearing CT. Foot alignment for barefoot and wearing custom high heels of 3, 6, and 9 cm. Forty-one feet from twenty-one participants (11 males and 10 females, aged 30.8 ± 8.9 years, and Body Mass Index 25.5 ± 2.0 m kg-2) were submitted to a tridimensional weight- bearing scan in barefoot and wearing high heels of 3, 6, and 9 cm. The inclusion criteria were: Aged between 20 and 50 years, and no regular wearing of heels.Participants were instructed to bear weight in their regular standing upright posture, dispensing the body weight uniformly between the lower limbs with the feet set at shoulder width. Declination talar, forefoot arch, foot ankle offset, 1st, 2nd, and 3rd metatarsophalangeal dorsiflexion, and metatarsal rotation and sesamoid rotation angles were compared with repeated measurement analysis and multiple comparisons as well as the raters intraclass coefficient. Results: When height increases, the declination talar angle decrease (p < 0.001), the foot ankle offset decreases (p < 0.001), the 1st, 2nd, and 3rd dorsiflexion angle increases (p < 0.001), and metatarsal rotation angle (p=0.696) and sesamoid rotation angles (p=0.649) did not change. The forefoot arch for 6 cm was higher than 3 cm (p < 0.001) and then 9 cm (p=0.001), and the forefoot arch for 9 cm was higher than 3 cm (p=0.049). Conclusion: The main finding was that increased forefoot arch, lower ankle offset, no metatarsal rotation angle, and no sesamoid rotation angle strongly suggest an acute primary hindfoot alignment adaptation mechanism rather than forefoot rotation with increase of heel heigth. The most critical mechanism combines the activation of the windlass mechanism together with a stiffer alignment of Hindfoot. Our interpretation here is supported by the lower FAO, and increased forefoot arch and metatarsophalangeal joints, giving insight into pathology foot deformation like Hallux valgus. Thus, our findings suggest that it is debatable that wearing high heels can trigger forefoot deformity,

Category: Bunion Introduction/Purpose: The original fixation for minimally invasive Chevron-Akin ( MICA) was described with two screws: a proximal screw reaching two cortices before fixing the metatarsal head and a distal parallel screw that can reach only one cortical before fixing the head. Despite this, some authors questioned the need for two screws and were able to reproduce good results from this technique using only one screw to fix the osteotomy. Notably, no biomechanical studies evaluate this osteotomy's most stable and safe fixation. This work aims to perform a biomechanical analysis based on finite element analysis (FEM) to compare different MICA fixation configurations using screws. Our hypothesis is that the fixation of the original technique with two screws is the safest. Methods: A Three-dimensional (3D) virtual model of a foot computer tomography (CT) image was made using the Rhinoceros™ program. The element finite analysis was performed with the SimLab™ program using the Optistruct solver. From these 3D virtual models, an extracapsular chevron osteotomy with 130 degrees with 70% of lateral translation was done and fixated. Five internal fixation configurations with screws were used for fixation of MICA and assessed by FEM -: original MICA fixation with 2 screws, 2 intramedullary screws, 2 bicortical screws, 01 intramedullary screw, and 01 bicortical screw. The simulated 150 N and 300 N loads were applied to the middle foot. The FEM evaluated the total and localized displacements of the osteotomy site. For the analysis of stresses, the variables maximum principal (traction) and minimum principal (compression) were used. The equivalent von Mises stress (VMS -S) was used for the metallic implants and for the bone (VMS -O). Results: The classical fixation for MICA showed the lowest values for total and localized displacement, minimum and maximum total stress, and VMS-S and VMS-o in both conditions( 150 and 300 N). The localized displacement was statistically lower for MICA screws compared to the other fixation configurations (p < 0.05) The maximum total stress was statistically lower for MICA screws compared to the other fixation configurations (p < 0.05) Conclusion: The classical fixation for MICA yields better results in terms of total and localized displacement, minimum and maximum total stress, and VMS in both conditions. These results demonstrate that the classical fixation for MICA described in the original technique is biomechanically the most efficient and safe.

Category: Hindfoot; Sports Introduction/Purpose: Zadek's procedure is a surgical option to treat insertional Achilles tendinopathy(IAT). This procedure consists of a closing wedge osteotomy of the calcaneus with biomechanical consequences. Great modifications in the hindfoot alignment can result in poor functional outcomes for athletes. Additionally, some authors stated that Zadek osteotomy is a good choice for patients with IAT associated with cavovarus foot. This study aims to analyze the hindfoot alignment and the parameters related to Haglund's syndrome after Zadek's osteotomy using a virtual surgical simulation by specific software. The authors hypothesize that the Zadek is an effective technique to decompress the Achilles tendon against the Haglund deformity without major modifications in the alignment. Methods: A total of 20 WBCT scans of patients with IAT were included. The WBCT images were run through the Foot & Ankle module of Disior's BonelogicTM software, creating a 3D virtual model. With this 3D model built into this software, 20 virtual Zadeck osteotomies standardized with a 10 mm resection wedge were performed using the virtual osteotomy module of Bonelogic®. The Calcaneal Inclination angle (sagittal view)7; Talocalcaneal angle (sagittal view)8; Talocalcaneal angle (axial view)8; Saltzman angle (45 degrees view)9; Saltzman angle (20 degrees view)9; Hindfoot moment arm angle;10 Hindfoot angle10; Fowler Philips angle11 and the calcaneal length7 were measured before and after the virtual osteotomy. These results were compared and statistically analyzed. Results: A virtual Zadek osteotomy was realized in 20 WBCT from patients with an insertional Achilles tendinopathy. Most of the patients were female, and the mean age was 55 years. There were significant statistical differences in the average of the calcaneal length (79 mm to 73 mm), Fowler Philips angle (57º to 43º), calcaneal pitch ( 24º to 20º ), sagittal talocalcaneal angle (55º to 47º ), and the hindfoot moment arm angle (20 º to 21,8º). The axial talocalcaneal angle, Saltzman view 45 º and 20 º, and Hindfoot moment arm showed subtle modifications. Conclusion: The virtual analysis of Zadek's osteotomy decreased the Fowler Philips angle, shortened the calcaneus, and modified the alignment in the sagittal view. It suggests that Zadek's procedure reduces the bone impingement with Achilles and the Achilles push. The effect of this osteotomy in Hindfoot Alignment was subtle, modifying only the sagittal plane.