Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Treatment for symptomatic hallux valgus encompasses a spectrum of surgical options to appropriately address the degree of deformity. The modified Lapidus has emerged as a powerful surgical option to address moderate to severe deformity as well as hallux valgus with 1st ray hypermobility. Unlike metatarsal osteotomies, the literature is lacking in clinical and radiographic outcomes. Previous retrospective series have reported recurrence rates less than 15%, but our experience found a higher recurrence rate. We aimed to evaluate the effect of radiographic recurrence on patient reported outcome measures and satisfaction. Methods: After obtaining institutional board review approval, patients were identified by procedural billing codes from 2012- 2016. Only primary Lapidus surgeries were included. All patients were contacted and invited to return to obtain patient reported outcome scores (AOFAS, FAAM) and assess satisfaction. HVA>=20 at final follow-up was used to define recurrence. Data was analyzed utilizing statistical analysis software (SAS v9.4).328 surgeries were identified with 255 eligible and contacted for follow-up. 77 surveys were completed in person and 50 were completed over the phone or via email with total response rate of 50%. Results: Average follow-up was 59 months. 38% had radiographic recurrence (48/127), 24% perceived recurrence (30/125), and 9.5% had reoperation for recurrence (12/126). AOFAS scores were lower with radiographic recurrence (p=0.01) and perceived recurrence (p=0.003). FAAM-ADL scores were not different in radiographic recurrence (p=0.79) but were lower in perceived recurrence (p=0.001). Overall, satisfaction was good-excellent in 74% and fair-poor in 26%. For radiographic (p=0.03) and perceived recurrence (p<0.0001), there was lower satisfaction reported. 78% would repeat surgery. Decision to repeat surgery was not different for radiographic recurrence with 81% without vs 74% with recurrence (p=0.37) saying they would have surgery again. However, it was different for perceived recurrence with 84% without vs 59% with recurrence saying they would have surgery again (p=0.01). Conclusion: Despite a high radiographic recurrence rate (38%), only a portion perceived a recurrence (24%) and an even smaller proportion (9.5%) had a reoperation for the recurrence. Nonetheless, these results suggest radiographic and clinical outcomes are not as high as previously reported for the modified Lapidus procedure.

Background: Residual equinus deformity in toddlers with a history of clubfoot can be managed with soft tissue release, provided there is no articular incongruity. Distal tibia osteotomy is a reasonable choice in mature patients with a flattened talus provided the growth plate is closed. Anterior distal tibia hemi-epiphysiodesis is an option for children with articular incongruity who have substantial growth remaining. The aim of this study is to evaluate radiographic and clinical outcomes of this method. Methods: Fourteen clubfoot patients (20 ankles) with residual equinus deformity were treated between 2010-2015 with anterior distal tibial hemi-epiphysiodesis utilizing size appropriate modular plate and screw constructs. Patients were evaluated clinically and radiographically. Oxford Ankle Foot Questionnaire for Children (and caregivers) with supplemental questions were requested at most recent follow-up. Results: There were 12 males and 2 females, mean age 10 years at surgery (50-152 months), with the minimum 18 months of radiographic follow-up (Mean 34 months). Pre-surgical mean radiographic anterior distal tibial angle (ADTA) was 87.8 degrees (79-100) and mean maximum dorsiflexion was -5.7 degrees (-40-7). At follow-up, mean improvement of radiologic ADTA was 18 degrees and mean clinical dorsiflexion improvement was 8.4 degrees. On the Oxford Ankle Foot Questionnaire, children reported a mean functional score of 47% in the “Physical” domain, 71% in “School and Play”, 70% in “Emotional”, and 38% in footwear. Parents reported mean scores of 45% in Physical, 69% in School and Play, 56% in Emotional, and 28% in footwear. Sixty percent of parents reported increased foot flexibility, 80% noted improvement in their child’s walking, and 100% would choose this surgery again. Conclusions: Anterior distal tibial hemi-epiphysiodesis is a viable option for treatment of residual equinus in children with a clubfoot history and open growth plates. Radiographic improvement was at least 2x greater than the clinically measured improvements of dorsiflexion; yet each family would undergo the surgery again as they perceived an improvement in function.

Background: For hallux rigidus, dorsal cheilectomy remains a treatment option even with advances in interposition techniques and devices. Cheilectomy aims to alleviate dorsal impingement and improve pain and function as well as range of motion. Cryopreserved umbilical cord allograft, with properties to mitigate inflammation and scar formation, has theoretical benefit for improving outcomes following cheilectomy. In this first prospective randomized and blinded cheilectomy study reported, we aimed to compare outcomes between cheilectomy alone and cheilectomy with umbilical cord allograft. Methods: Patients were randomized to cheilectomy alone (CA) or cheilectomy with cryopreserved umbilical cord (ie, amniotic membrane–umbilical cord [AM-UC]). Patients were evaluated with American Orthopaedic Foot & Ankle Society (AOFAS), Foot Function Index (FFI), and visual analog scale (VAS) pain outcomes collected preoperatively and at 6 months and 1 year postoperatively. In addition, radiographic range of motion data were collected using stress radiographs. Fifty-one patients (26 AM-UC, 25 CA) completed the study, with 5 bilateral surgeries in the AM-UC group and 2 in the CA group, totaling 31 and 27 feet, respectively. Results: The AM-UC group had statistically significant improved AOFAS and FFI scores at 1 year compared with the CA group, but there was no difference at 6 months. There was no significant difference between groups for VAS-pain scores at any time point, but overall VAS-pain improved in both groups from preoperative values. There was no significant difference in range of motion (total arc) between groups and changes in range of motion (total arc) in both groups from preoperative to 1 year postoperative were small. Conclusion: We present the results of the first randomized and blinded prospective study of cheilectomy surgery patients. When appropriately selected, cheilectomy remains a good option for patients with symptomatic hallux rigidus. Cryopreserved umbilical cord is a potential adjuvant to cheilectomy, with 1-year results showing improvements in functional outcome scores. Level of Evidence: Level II, prospective comparative study.

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Treatment for symptomatic hallux valgus encompasses a spectrum of surgical options to appropriately address the degree of deformity. The modified Lapidus has emerged as a powerful surgical option to address moderate to severe deformity as well as hallux valgus with 1st ray hypermobility. Unlike metatarsal osteotomies, the literature is lacking in clinical and radiographic outcomes. Previous retrospective series have reported recurrence rates less than 15%, but our experience suggested recurrence rates were higher. Methods: After obtaining institutional board review approval, patients were identified by procedural billing codes from 2012- 2016. Only patients who underwent a primary Lapidus surgery with greater than 1 year radiographic follow-up were included. Larger midfoot fusions and flatfoot reconstructions were excluded. Charts were reviewed to identify complications and reoperations. Radiographs were reviewed and HVA, IMA, sesamoid position (0-4), and Meary’s angle measured on preoperative, 1st weigh-bearing post-operative, and final follow-up radiographs. Data was analyzed utilizing statistical analysis software (SAS v9.4). Results: 114 patients were identified with 12 undergoing bilateral surgery (126 surgeries). There were 106 females and 8 males, and median age was 57.5 years at time of surgery. Median follow-up from index surgery was 2.9 years. Using HVA>=20 as cutoff for recurrence, 58 (46%) recurrences were identified, but only 15 (12%) underwent revision surgery. There were 32 total reoperations, including 8 nonunions ( table 1A ). Median preoperative HVA was greater in group with recurrence than group without recurrence (38 vs 30, p<0.0001, table 1B ). In addition, less correction of HVA and IMA was seen in group with recurrence (ΔHVA=20 vs 22, p<0.0001; ΔIMA 6 vs 9, p<0.0001, table 1B ). When there was recurrence at final follow-up, it appears corrected IMA was maintained while HVA increased (ΔIMA=2, ΔHVA=10, table 1B ). We used a receiver operative curve (ROC) to define the HVA cut-off of HVA>=30 with an AUC of 0.75. That indicated that in 75% of cases, preoperative HVA>=30 predicted recurrence. We identified that HVA<30 has a reduced odds of recurrence (OR=0.165; 95% CI=0.062-0.536). Preoperative IMA and arch alignment were not associated with risk of recurrence ( table 1C ). [Table: see text] Conclusion: As has been determined in other hallux valgus series evaluating metatarsal osteotomies, increased HVA>=30 is a risk factor for recurrence. Despite being acknowledged as a powerful operation for hallux valgus correction, the modified Lapidus still had a high rate (46%) of radiographic recurrence when used to treat severe deformity. However, only 12% underwent revision surgery in our series. This is important when counseling patients before surgery as the modified Lapidus operation does not obviate the risk of recurrence as has been previously suggested, but the lower revision rate suggests radiographic outcomes alone do not drive satisfaction. Further outcome measures are needed on this cohort to better identify surgical variables associated with maintained correction, other risk factors for recurrence, as well as patient reported outcomes.

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