The effect on radiographic parameters of Dwyer s osteotomy and 1 st metatarsal osteotomy for pes cavo-varus correction

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1 The effect on radiographic parameters of Dwyer s osteotomy and 1 st metatarsal osteotomy for pes cavo-varus correction Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, South Korea *W Institute for foot and ankle disease and trauma, W Hospital, Daegu, South Korea *Jun Young Choi, Ji Woong Yeom, Jin Soo Suh

2 The effect on radiographic parameters of Dwyer s osteotomy and 1 st metatarsal osteotomy for pes cavo-varus correction Jun Young Choi, Ji Woong Yeom, Jin Soo Suh My disclosure is in the Final AOFAS Mobile App. I have no potential conflicts with this presentation.

3 Bony procedures to correct pes cavo-varus 1 st Ray dorsi-flexion osteotomy - Dorsal closing osteotomy of the medial cuneiform (reversed Cotton osteotomy) - Dorsal closing osteotomy of the 1 st MT bone Calcaneal osteotomy - Dwyer osteotomy - Z osteotomy Mid-tarsal osteotomy - Dorsal wedge osteotomy of navicular, cuneiform, and cuboid bone. (Cole osteotomy) - V shaped osteotomy within tarsal bones Triple arthrodesis - Severe, fixed postural deformity in hindfoot Purpose of this study A retrospective study to compare the radiographic parameters of Dwyer s osteotomy and 1 st MT osteotomy for pes cavo-varus correction

4 Materials & Method From Apr, 2006 ~ Aug, 2014, Minimum follow-up : 1 year 28 cases in 27 patients 3 Groups - Group H (8) : Dwyer s osteotomy only - Group F (5) : 1 st MT osteotomy only - Group HF (15) : Dwyer + 1 st MT osteotomy Exclusion criteria : Concomitant / previous operation affecting lower extremity alignment Mean age Mean follow up (month) Group H (8) 45.36± ±4.12 Group F (5) 44.82± ±2.21 Group HF (15) 38.73± ±3.45 Main Symptoms - Visible (equino-) cavo-varus foot deformity - Lateral foot pain on weight bearing Predisposing factor - Group H (8) : Idiopathic (3), Post-traumatic (5) - Group F (5) : Idiopathic (2), Post-traumatic (2), Polio (1) - Group HF (15) : Idiopathic (3), Post-traumatic (4), Polio (3),CMT (2), Gout (2)

5 Materials & Method Radiologic parameters assessment 1. The length of 1 st ray on standing AP/lateral images 2. Medial cuneiform height (MCH) on standing lateral images 3. Tarso-1 st metatarsal angle (Meary angle) 4. Calcaneal pitch angle (CPA) on standing lat images for degree of Pes cavus correction 5. Hindfoot alignment angle (HAA) 6. Hindfoot alignment ratio (HAR) for degree of Hind-foot varus correction on hindfoot alignment images Clinical outcome assessment : AOFAS Hallux scale, Postop complications

6 Results Meary angle ( o, degree) CPA ( o, degree) Group H (8) 15.65± ±6.16 Group F (5) 13.62± ±6.06 Group HF (15) 14.27± ±6.76 Group H (8) 37.36± ±6.24 Group F (5) 35.20± ±5.42 Group HF (15) 36.95± ±7.45 MCH (mm) Group H (8) 33.11± ±4.12 Group F (5) 35.82± ±3.28 Group HF (15) 38.33± ±5.42 Amount of correction Group H: Group F : Group HF = 2.7 : 2.9 : 4.1

7 Results (1 st ray length ) Group H (8) 60.81± ±6.94 AP Group F (5) 60.62± ±3.39 Group HF (15) 64.73± ±6.48 Lat Group H (8) 44.11± ±7.24 Group F (5) 50.62± ±4.29 (mm) Group HF (15) 48.73± ±5.42

8 Results (HAA & HAR) HAA Group H (8) ± ±2.55 Group F (5) ± ±5.02 Group HF (15) ± ±2.94 HAR ( o, degree) Group H (8) 0.65± ±0.16 Group F (5) 0.64± ±0.21 Group HF (15) 0.66± ±0.11

9 Clinical outcome AOFAS Group H (8) 49.63± ±15.59 Group F (5) 47.60± ±8.90 Group HF (15) 45.80± ±10.29 complications 1) Persistent pain (HF: 1, H: 1, F: 1) Triple arthrodesis (1) (Postop. 1.5 yrs) 2) EHL weakness (HF: 1) EHL adhesiolysis + shortening (Postop. 3yrs)

10 Discussion Meary angle correction power Dwyer s osteotomy << 1 st MT osteotomy = Dwyer + 1 st MT osteotomy CPA correction power 1 st MT osteotomy << Dwyer s osteotomy = Dwyer + 1 st MT osteotomy MCH correction power Dwyer s osteotomy = 1 st MT osteotomy << Dwyer + 1 st MT osteotomy Degree of 1 st ray shortening Dwyer s osteotomy << 1 st MT osteotomy = Dwyer + 1 st MT osteotomy Hindfoot correction power (HAA, HAR) 1 st MT osteotomy << Dwyer s osteotomy = Dwyer + 1 st MT osteotomy Limitations of our study 1) Small number of each group 2) Retrospective study design 3) Short term follow up

11 Conclusion Different characteristics per each surgical option Combined (forefoot and hindfoot) surgery took the largest correction power for all radiologic parameters. Meticulous choice to osteotomize pes cavo-varus deformity is essential.

12 References 1. Knupp M, Horisberger M, Hintermann B. A new z-shaped calcaneal osteotomy for 3-plane correction of severe varus deformity of the hindfoot. Tech Foot Ankle Surg. 2008;7(2): Dwyer FC. Osteotomy of the calcaneum for pes cavus. J Bone Joint Surg Br. 1959;41-b(1): Lamm BM, Gesheff MG, Salton HL, Dupuis TW, Zeni F. Preoperative planning and intraoperative technique for accurate realignment of the Dwyer calcaneal osteotomy. J Foot Ankle Surg. 2012;51(6): Zhou Y, Zhou B, Liu J, Tan X, Tao X, Chen W, et al. A prospective study of midfoot osteotomy combined with adjacent joint sparing internal fixation in treatment of rigid pes cavus deformity. J Orthop Surg Res. 2014;9: Bariteau JT, Blankenhorn BD, Tofte JN, DiGiovanni CW. What is the role and limit of calcaneal osteotomy in the cavovarus foot. Foot Ankle Clin. 2013;18: