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Background: Combining osteotomies and soft tissue procedures is believed to reduce sesamoids in their anatomical position and maintain long-term correction when treating hallux valgus deformity. This study determines if a radiologic association exists between a radiolucent sign and a full percutaneous adductor tendon release (PATR), including a cadaveric study and a consecutive case series. Another aim was to determine the intra- and interobserver reliability of these observations. Methods: A prospective observational study was made between 2018 and 2019. First, a PATR was done on cadaveric specimens and, after the procedures, dissected to correlate what was seen fluoroscopically. The clinical group included 39 feet that presented mild-to-moderate HV deformity and were treated with percutaneous osteotomies associated with PATR. Results: Observers 1 and 2 saw a radioscopic radiolucent sign in 100% of cadavers and the patient population. They also observed a triangle-shaped image with an incidence of 75%, which we have named the “triangle sign.” Conclusion: The triangle sign may be helpful in the intraoperative confirmation of PATR and latero-plantar capsule release using this percutaneous technique. Level of Evidence: Level II, development of diagnostic criteria.

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

Category: Lesser Toes Introduction/Purpose: The correction of lesser toe deformities has been traditionally performed in an open fashion. With minimal-invasive foot surgeries becoming increasingly popular, correction of lesser toe deformities via percutaneous soft-tissue procedures and osteotomies is frequently performed. The aim of this study was to evaluate the site of percutaneous proximal phalanx osteotomy of the lesser toes in relation to the metatarsophalangeal joint line when performed without fluoroscopy guidance. Methods: In this experimental cadaver study, the metatarsophalangeal joints of the lesser toes of 20 cadaver samples (=80 toes) were palpated. A plantar skin stab incision was made just distal to the joint line without fluoroscopic control. Plantar closing osteotomies of the proximal phalanx were performed with a Shannon burr. Adorsoplantar view was taken with fluoroscopy. The location of the osteotomy and the relative distance from the metatarsophalangeal joint line was evaluated. Results: The majority (78/80; 97.5 %) of the osteotomies were localized in the metaphyseal region. No osteotomy violated the metatarsophalangeal joint. Conclusion: Percutaneous osteotomy of the proximal phalanx of the lesser toes guided by palpation without using the image intensifier is a safe procedure and does not violate the metatarsophalangeal joint.

Category: Midfoot/Forefoot Introduction/Purpose: Bunionette refers to painful lateral prominence at the fifth metatarsal head. For refractory cases, surgical intervention is indicated. Several operative treatments have been used to treat this deformity. Open surgery has been associated with wound healing problems, symptomatic hardware and infection. Recently, there has been a growing interest in the u utilization of minimally invasive surgery (MIS) essentially because of its inherent advantages, including less surgical trauma and preservation of blood supply. This has a direct impact in the patient leading to lower morbidity rates and faster recovery with immediate weight bearing. The purpose of the study was to describe both clinical and radiographic medium-term results of a sliding distal metatarsal minimally invasive osteotomy (S-DMMO) for correction of bunionette deformity. Methods: This is a retrospective review of patients who underwent S-DMMO to treat symptomatic bunionette deformity. We studied 46 feet from 36 patients, who were treated between Feb 2012 and March 2016. The surgeries were performed by two surgeons trained in minimally invasive surgery or percutaneous. The average follow-up was 49,74 years (33-70). The average age was 48 years (25-76). Radiographic measurements and clinical assessment were obtained preoperatively, six weeks postoperatively, and at final follow-up. Radiographic assessment includes evaluation of the fifth metatarsophalangeal angle, 4-5 intermetatarsal angles and medial osteotomy displacement (mm). Clinical evaluation included the lesser toe American Orthopaedic Foot and Ankle Society (AOFAS) score. The subjective satisfaction rate was measured using the Coughlin Score. Results: The mean 4-5 intermetatarsal angles was reduced from 10,88° to 7,1° and the fifth metatarsophalangeal angle was reduced from 14,7° to 6,47° postoperatively. Functional and clinical outcome, as assessed by a postoperative lesser toe AOFAS score showed good and excellent results (80-100 points) in all feet. The mean AOFAS score improved from 62,81pre-operatively to 92,42 points at final follow-up. Consolidation of the osteotomy site was achieved in all cases with a periosteal callus. According to the Coughlin classification system patient’s subjective assessments were: excellent (32 feet), good (12 feet) and fair (2 feet). No mayor complications were seen. One patient required reoperation (resection of symptomatic residual fifth metatarsal). Other complications found were: 1 superficial infection and 1 wound dehiscence. Conclusion: Our results showed that S-DMMO to be a safe and reliable technique for surgeons trained in MIS surgery. The mentioned is a novel, extrarticular and epiphasary technique that doesn´t need to be stabilized with osteosynthesis and provides a definite advantage over other techniques described. It is necessary to emphasize the importance of prevention of complications by a careful preoperative planning, a correct surgical procedure (specific instruments are required) and a strict postoperative control.

Category: Bunion Introduction/Purpose: Percutaneous or minimally invasive surgery (MIS) forefoot surgery has experienced a vertiginous and sustained growth especially in the last decade. This is supported by numerous studies among which can be mentioned: clinical series, comparative studies, technique reports, radiological validations. Two cadaveric studies considered percutaneous forefoot surgery safe and has reported minimal risk which is consistent with clinical studies. We can consider that MIS forefoot surgery is transiting a sustained and responsible experience based on Third generation (TG) techniques (Open Chevron like). The purpose of this cadaveric study was to investigate the risk of iatrogenic neurovascular and tendon injury in a TG technique. Particularly, this study evaluated the Percutaneous, Intraarticular, Chevron Osteotomy (PICO) for the correction of hallux valgus. Methods: Eight unpaired feet, from Caucasian fresh frozen voluntary donor specimens were carefully dissected. One surgeon (JJDV) performed all of the procedures. In each foot, the surgeon performed a PICO and a lateral release of the first metatarsophalangeal joint (MTPJ). To evaluate the safety of the procedure the following data was obtained: 1. Distance between (DB) PICO portal (PP) and lateral border of the extensor hallucis longus (EHLT); 2. DB PP and dorsomedial digital nerve (DMDN); 3. DB PP and MTPJ; 4. DB Osteosynthesis portal (OP) and MTPJ; 5. DB OP and lateral border of EHLT; 6. DB OP and DMDN. This anatomical study also assessed if any arterial plexus damage was present via an indirect method by examination of the capsule and soft tissue around the first metatarsal. In addition, the following measurements were taken: angulation of osteotomy in the sagittal plane (Reproducibility) and IMA and HV angles (Correction power). Results: Two independent observers made all the assessments. The results of the safety measurements were as follow: 1. Average: 17,64 (range: 12,72-21,31); 2. Average: 7,29 (range:1,62-10,41); 3. Average: 15,72 (range: 9,48-20,52); 4. Average: 25,55 (range: 22,06-30,44); 5. Average: 12,77 (range: 8,04-16,71); 6. Average: 4,14 (range:1,72-8,20). There were no iatrogenic injuries. Nevertheless, the DB OP and DMDN showed the lowest average distance. With respect of the osteotomy angulation in the sagittal plane (Reproducibility), the average was: 85,62º (range: 78-100). Mean preoperative intermetatarsal angle (IMA) was 9,75° (range: 8-18°), and postoperatively the mean IMA was 8° (range: 4-13°). Before surgery the mean hallux valgus angle (HVA) was 22° (range: 13-40°) and the average postoperative HVA was 13,5° (range: 6-34°). Conclusion: The “Third generation” (TG) techniques reliably mimics the open Chevron procedure with all its known virtues whilst does not reproduce its disadvantages and complications. Also, according to several studies, these surgeries are useful, effective and (maybe) easier than open procedures. The proposed surgery (PICO) has shown to be safe, reproducible and have effective correction power when performed by a single surgeon (Trained in MIS surgery). We emphasize that percutaneous surgery has an extensive learning curve and therefore it may be difficult to reproduce the results initially.

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.