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Osteotomy & Casting

Foot osteotomies & casting: principles for congenital (Ponseti) and acquired deformities (DCWCO, metatarsal osteotomies) and recurrence management.

Overview

Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara, whereas moderate nonprogressive deformity often does not require surgery [1]. In adult degenerative lumbar scoliosis with sagittal imbalance, staged treatment offers a less invasive approach that reduces the number of posterior fixation segments and osteotomy requirements [4]. For flatfoot deformity, indications for surgery are strict, requiring failure of prolonged nonsurgical attempts to relieve pain; osteotomies with supplemental soft-tissue procedures represent the best proven management for rigid flatfoot [18].

Current osteotomy plate designs and surgical techniques are not effective in decreasing sagittal plane tibial slope in opening-wedge proximal tibial osteotomy [9]. Conversely, a novel pre-contoured V-shaped rod in one-level pedicle subtraction osteotomy obtains satisfactory radiological and clinical outcomes for ankylosing spondylitis patients without necessitating additional surgery or elevating the risk of complications such as sagittal translation [16]. Full correction of torsion deformities of the tibia without performing an osteotomy of the fibula has been obtained in all twelve cases treated by the authors [6].

Early weightbearing protocols might not negatively impact graft incorporation after osteochondral autograft transplantation for osteochondral lesions of the talus, though caution is advised regarding osteotomy complications such as delayed unions and nonunions [7]. The clinical and radiological outcome after a distal chevron osteotomy is comparable with that after a proximal chevron osteotomy for the correction of moderate hallux valgus deformity [8]. Recommendation for concomitant Akin osteotomy in patients undergoing Chevron osteotomy may be determined by a preoperative PDPAA exceeding 8° [24].

Anatomy & Pathophysiology

Osseous Alignment and Deformity Correction

Osteotomy of the first cuneiform achieves excellent correction of residual forefoot adduction in clubfoot when technically well performed [21] and, when combined with plantar release, can correct equinus deformity [21]. In the context of hallux valgus, first metatarsal realignment reduces the position of the sesamoid but does not alter the intrinsic position of the sesamoid relative to the second metatarsal axis [35]. For distal first metatarsal osteotomy, both percutaneous techniques increase plantar angulation of the metatarsal head, whereas the chevron technique confers higher stability regarding fragment displacement during axial loading compared to other percutaneous methods [40]. Percutaneous, extra-articular reverse-L Chevron osteotomy for moderate hallux valgus is a reliable and reproducible procedure that maintains an excellent range of movement [47]. Conversely, the Akin procedure is biomechanically unsound as an isolated operation because it fails to address the abnormal function of the adductor hallucis or the abnormal intermetatarsal angle [42].

Kinematics and Gait Mechanics

Subtle cavovarus foot represents a mild malalignment that alters foot mechanics and leads to lateral ankle instability, peroneal tendon tears, and stress fractures [33]. Hallux valgus deformity severity is positively associated with the magnitude of anteroposterior postural sway [41]. Surgical treatment of symptomatic flat foot deformities in children significantly improves static segmental alignment and mediolateral foot loading but worsens fore-aft loading [32]. In ambulatory patients with cerebral palsy and planovalgus foot deformity, calcaneal lengthening osteotomy shows a tendency toward overcorrection, evidenced by increased pressure exerted on the lateral midfoot [37]. High tibial osteotomy improves frontal plane knee moments, gait patterns, and patient-reported outcomes, though gait adaptations employed pre-operatively to reduce knee loading are not retained post-operatively [39]. Ponseti treatment of rigid residual deformity in congenital clubfoot after walking age results in all feet being plantigrade and flexible, with no patients showing abnormal gait at follow-up and a 2.9% relapse rate [49].

Soft Tissue and Biomechanical Strain

A wedge placed under the lateral aspect of the forefoot decreases strain in the plantar aponeurosis, whereas a wedge under the medial aspect increases this strain [34]. The Endolog technique for hallux valgus correction ensures stable but not rigid synthesis and is linked to pain alleviation, alignment correction, and the elimination of plantar keratotic lesions [50].

Classification

Surgical Indications: Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara [1], whereas moderate nonprogressive deformity in childhood coxa vara often does not require surgery [1].

Clubfoot Management: The etiology of idiopathic congenital talipes equinovarus is unknown [11], and there is no consensus as to the best treatment for idiopathic congenital talipes equinovarus [11]. The CPAM-LRC consensus confirms Ponseti as first-line treatment for idiopathic clubfoot [17] and provides an expert-endorsed framework for adjunct interventions and follow-up in idiopathic clubfoot care [17]. The development of a relapse affects the subsequent management and outcome of clubfoot deformity [3].

Osteotomy Techniques: Full correction of tibial torsion deformities without performing an osteotomy of the fibula has been obtained in all twelve cases treated by simple transverse osteotomy and threaded-pin fixation [6]. Current osteotomy plate designs and surgical techniques are not effective in decreasing sagittal plane tibial slope in opening-wedge proximal tibial osteotomy [9]. Staged treatment for adult degenerative lumbar scoliosis with sagittal imbalance was less invasive, reducing the number of posterior fixation segments and osteotomy requirement [4]. Closed-wedge osteotomy of the lateral humeral condyle provides good long-term clinical and radiographic results for osteochondritis dissecans of the capitellum across all lesion types [45].

Hip and Derotation: A derotation osteotomy serves to decrease factors of dysplasia contributing to hip instability [12]. Results are poorer in patients with lesser degrees of anteversion (30 to 60 degrees) in whom an osteotomy was not done for congenital dislocation of the hip [12].

Other Considerations: Radiological assessment is crucial to evaluate involved joints preoperatively in the treatment of Mueller-Weiss disease [13]. Hemiepiphysiodesis is a procedure that can be of benefit to patients with symptomatic juvenile hallux valgus from a minimal operative approach before skeletal maturity [15]. Postoperative bracing is widely used for various surgical procedures despite much of the literature lacking adequate comparisons of brace types or specific indications [20]. The use of a modified coronal plane transverse calcaneal pin in conjunction with two other pins provided better control of the small-sized hind-foot during casting [22] and resulted in favorable final hind-foot deformity correction [22].

Clinical Presentation

Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara [1], whereas moderate nonprogressive deformity often does not require surgery [1]. In congenital dislocation of the hip, results are poorer in patients with lesser degrees of anteversion (30 to 60 degrees) in whom an osteotomy was not performed [12]. A derotation osteotomy serves to decrease factors of dysplasia contributing to hip instability [12].

For idiopathic congenital talipes equinovarus, the etiology is unknown [11] and there is no consensus as to the best treatment [11]; however, the CPAM-LRC consensus confirms Ponseti as first-line treatment [17]. The development of a relapse affects subsequent management and outcome [3], warranting early detection and prompt treatment [5]. When technically well done, osteotomy of the first cuneiform can achieve excellent correction of residual adduction [21], with some correction of equinus deformity expected when performed with a plantar release [21].

In flatfoot deformity, indications for surgery are strict, requiring failure of prolonged nonsurgical attempts to relieve pain [18]. Osteotomies with supplemental soft-tissue procedures represent the best proven approach for management of rigid flatfoot [18]. For symptomatic juvenile hallux valgus, hemiepiphysiodesis offers a minimal operative approach benefit before skeletal maturity [15]. Distal soft-tissue reconstruction with a proximal crescentic osteotomy corrects hallux valgus deformity and alleviates symptoms to patient satisfaction [36], though surgeons must be aware of potential pitfalls and complications [36]. Partial zig-zag tenotomy of the extensor hallucis longus is supported for use in complex deformities or high tendon tension in minimally invasive hallux valgus surgery [19].

Radiological assessment is crucial to evaluate involved joints preoperatively in Mueller-Weiss disease to choose the appropriate treatment method [13]. Radiological outcome after scarf osteotomy is superior with concomitant Akin osteotomy [14]. For ankylosing spondylitis, a novel pre-contoured V-shaped rod in one-level pedicle subtraction osteotomy obtains satisfactory radiographic and clinical outcomes without necessitating additional surgery or elevating the risk of complications such as sagittal translation [16].

Regarding tibial-shaft fractures, most closed fractures can be effectively managed with cast or brace immobilization [38]. Specific fracture characteristics warranting early operative stabilization include instability, metaphyseal-diaphyseal location, and severe comminution [38]. Patient factors warranting early operative stabilization include obesity and poor compliance [38]. Full correction of torsion deformities of the tibia without performing an osteotomy of the fibula has been obtained in all twelve cases treated by a specific technique [6]. Current osteotomy plate designs and surgical techniques are not effective in decreasing sagittal plane tibial slope when using posteromedially placed plates with anterior staple reinforcement [9]. Early weightbearing protocols might not negatively impact graft incorporation after osteochondral autograft transplantation for osteochondral lesions of the talus, but caution is advised regarding osteotomy complications such as delayed unions and nonunions [7].

Investigations

Plain radiography: Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara, whereas moderate nonprogressive deformity often does not require surgery [1]. Radiological assessment is crucial to evaluate involved joints preoperatively to choose the appropriate treatment method for Mueller-Weiss disease [13]. Radiological outcome after scarf osteotomy is superior with concomitant Akin osteotomy [14]. Double semitendinosus anterior cruciate ligament reconstruction stabilizes the evolution of degenerative lesions as shown by standing X-ray [28]. Percutaneous pinning produced superior radiological results compared to casting for extra-articular fractures of the distal radius in an elderly Chinese population [59]. Immobilization stabilized burst fracture of the fifth lumbar vertebra and provided a good clinical result without progressive loss of lordosis or vertebral collapse [60]. Comparative studies of fourth-generation minimally invasive and open hallux valgus surgery suggest similar clinical and radiological outcomes [61].

MRI: MRI demonstrated complete regeneration of subchondral bone and cartilage in all patients with Hepple Stage V osteochondral lesion of the talus treated with a platelet-rich plasma scaffold [53]. Clinical and radiological results of a novel contoured metal implant for tertiary osteochondral defect of the talus are promising, but more patients and longer follow-up are needed to draw firm conclusions [58].

Other Considerations: The development of a relapse affects the subsequent management and outcome of clubfoot deformity, warranting early detection and prompt treatment following Ponseti method [3, 5]. Staged treatment for adult degenerative lumbar scoliosis with sagittal imbalance was less invasive, reducing the number of posterior fixation segments and osteotomy requirement [4]. Full correction of tibial torsion deformities without performing an osteotomy of the fibula has been obtained in all twelve cases treated by simple transverse osteotomy and threaded-pin fixation [6]. The clinical and radiological outcome after a distal chevron osteotomy is comparable with that after a proximal chevron osteotomy for moderate hallux valgus deformity [8]. Combined hemiepiphysiodesis is a procedure that can benefit patients with symptomatic juvenile hallux valgus from a minimal operative approach before skeletal maturity [15]. A novel pre-contoured V-shaped rod in one-level pedicle subtraction osteotomy obtains satisfactory radiographic and clinical outcomes for ankylosing spondylitis patients without necessitating additional surgery or elevating the risk of complications such as sagittal translation [16]. The use of a modified coronal plane transverse calcaneal pin in conjunction with two other pins provided better control of the small-sized hind-foot during casting and resulted in favorable final hind-foot deformity correction [22]. Functional outcomes and quality of life were not affected by the treatment method (casting versus percutaneous pinning) for extra-articular fractures of the distal radius in an elderly Chinese population [59]. Recurrence remains a challenge in hallux valgus surgery, necessitating long-term follow-up and standardized outcome measures [61].

Treatment

Non-Operative

Nonsurgical management is indicated for stable osteochondritis dissecans lesions, particularly in children with open physes, with a reported success rate of approximately 50% [51]. For idiopathic congenital talipes equinovarus, a dynamic taping regime serves as a simple non-operative method delivering improved medium-term and promising long-term results [52]. In the context of flatfoot deformity, strict indications for surgery require failure of prolonged nonsurgical attempts to relieve pain [18]. Management of overuse injuries is stratified by risk, where low-risk fractures typically heal with activity modification [55].

Operative

Indications: Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara, whereas moderate nonprogressive deformity often does not require surgery [1]. For flatfoot deformity, osteotomies with supplemental soft-tissue procedures represent the best proven approach for management of rigid flatfoot following failed nonsurgical care [18]. With correct indications, opening wedge high tibial osteotomy (OWHTO) is a reliable procedure for medial knee arthritis or overload [54].

Surgical Approach / Technique: Staged treatment for adult degenerative lumbar scoliosis with sagittal imbalance was less invasive, reducing the number of posterior fixation segments and osteotomy requirements [4]. Distraction osteogenesis can obtain impressive gains in femoral and tibial length, though the cost includes increased treatment time and complications [23]. Current practice techniques, recent innovations, and potential frontiers within the surgical subspecialty of limb lengthening and deformity correction cover diverse clinical pathology, treatment paradigms, and geographies [2].

Implant Selection: Current osteotomy plate designs and surgical techniques are not effective in decreasing sagittal plane tibial slope in opening-wedge proximal tibial osteotomy [9].

Alignment / Balancing Strategy: Radiological outcome after a scarf osteotomy is superior with concomitant Akin osteotomy [14]. Recommendation for concomitant Akin osteotomy in patients undergoing Chevron osteotomy may be determined by a preoperative PDPAA exceeding 8° [24]. The clinical and radiological outcome after a distal chevron osteotomy is comparable with that after a proximal chevron osteotomy for the correction of moderate hallux valgus deformity [8]. Opening wedge and proximal chevron osteotomies have comparable radiographic outcomes and comparable clinical outcomes for pain, satisfaction, and function for the treatment of hallux valgus [46]. Double calcaneal osteotomy could be used to correct flatfoot deformities effectively and sustainably, providing symptomatic relief and patient satisfaction [43].

Adjuncts: Early weightbearing protocols might not negatively impact graft incorporation after osteochondral autograft transplantation for osteochondral lesions of the talus, but caution is advised regarding osteotomy complications such as delayed unions and nonunions [7]. Postoperative bracing is widely used for various surgical procedures, although much of the literature lacks adequate comparisons of brace types or specific indications [20].

Other Considerations: The etiology of idiopathic congenital talipes equinovarus is unknown, and there is no consensus as to the best treatment [11]. The CPAM-LRC consensus confirms Ponseti as first-line treatment for idiopathic clubfoot and provides an expert-endorsed framework for adjunct interventions and follow-up [17]. The use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times for club foot [10]. The development of a relapse affects the subsequent management and outcome of clubfoot deformity [3]. Early detection and prompt treatment of relapsed deformity are warranted in the management of relapsed clubfoot following treatment using the Ponseti method [5].

Complications

Indication for Surgical Intervention: Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara, while moderate nonprogressive deformity often does not require surgery [1].

Relapse and Recurrence: The development of a relapse affects the subsequent management and outcome of clubfoot deformity [3], necessitating early detection and prompt treatment of relapsed deformity in patients with relapsed clubfoot following treatment using the Ponseti method [5]. However, the use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times [10]. In hallux valgus surgery, percutaneous transverse osteotomies demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence [26], though longer-term follow-up is needed to assess stability and recurrence after partial zig-zag tenotomy of the extensor hallucis longus in minimally invasive hallux valgus surgery [19].

Osteotomy-Specific Complications: Compared with unicompartmental knee arthroplasty, complication rates were higher after periarticular knee osteotomy, with an overall surgical complication rate of 23.7% [48]. Early weightbearing protocols might not negatively impact graft incorporation after osteochondral autograft transplantation, but caution is advised regarding osteotomy complications such as delayed unions and nonunions [7]. Distraction osteogenesis can obtain impressive gains in femoral and tibial length, but the cost is increased treatment time and complications [23]. Regarding specific techniques, union took place promptly within eight weeks in all patients with modification of Mitchell's lateral displacement angulation osteotomy, with no loss of position [27], and full correction of torsion deformities of the tibia without performing an osteotomy of the fibula has been obtained in all twelve cases treated by simple transverse osteotomy and threaded-pin fixation [6].

Functional Outcomes and Adjacent Considerations: Periacetabular osteotomy provides pain relief and improved hip function in most patients over short- to midterm followup [25]. The clinical and radiological outcome after a distal chevron osteotomy is comparable with that after a proximal chevron osteotomy for moderate hallux valgus deformity [8]. Results are poorer in patients with lesser degrees of anteversion (30 to 60 degrees) in whom an osteotomy was not done for congenital dislocation of the hip [12].

Other Considerations: - Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara, while moderate nonprogressive deformity often does not require surgery [1]. - The development of a relapse affects the subsequent management and outcome of clubfoot deformity [3]. - Early detection and prompt treatment of relapsed deformity are warranted in patients with relapsed clubfoot following treatment using the Ponseti method [5]. - Full correction of torsion deformities of the tibia without performing an osteotomy of the fibula has been obtained in all twelve cases treated by simple transverse osteotomy and threaded-pin fixation [6]. - Early weightbearing protocols might not negatively impact graft incorporation after osteochondral autograft transplantation, but caution is advised regarding osteotomy complications such as delayed unions and nonunions [7]. - The clinical and radiological outcome after a distal chevron osteotomy is comparable with that after a proximal chevron osteotomy for moderate hallux valgus deformity [8]. - The use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times [10]. - Results are poorer in patients with lesser degrees of anteversion (30 to 60 degrees) in whom an osteotomy was not done for congenital dislocation of the hip [12]. - Longer-term follow-up is needed to assess stability and recurrence after partial zig-zag tenotomy of the extensor hallucis longus in minimally invasive hallux valgus surgery [19]. - Distraction osteogenesis can obtain impressive gains in femoral and tibial length, but the cost is increased treatment time and complications [23]. - Periacetabular osteotomy provides pain relief and improved hip function in most patients over short- to midterm followup [25]. - Percutaneous transverse osteotomies for hallux valgus demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence [26]. - Union took place promptly within eight weeks in all patients with modification of Mitchell's lateral displacement angulation osteotomy, with no loss of position [27]. - Compared with unicompartmental knee arthroplasty, complication rates were higher after periarticular knee osteotomy, with an overall surgical complication rate of 23.7% [48].

Recovery

Light activity (weeks): Evidence regarding specific timelines for light activity, desk work, or driving is not provided in the current evidence base. While early weightbearing protocols after osteochondral autograft transplantation might not negatively impact graft incorporation, caution is advised regarding complications such as delayed unions and nonunions [7]. For clubfoot treated with the Ponseti technique, the use of a below-knee plaster of Paris cast is associated with unacceptably high failure rates and significantly longer treatment times [10].

Full activity (months): No specific month ranges for full activity, manual work, or sport are defined in the provided evidence. Surgical management for coxa vara in childhood is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, whereas moderate nonprogressive deformity often does not require surgery [1]. Staged treatment for adult degenerative lumbar scoliosis with sagittal imbalance reduced the number of posterior fixation segments and osteotomy requirements, potentially influencing recovery trajectories [4].

Complete recovery / outcome plateau (months): Long-term results for hallux valgus surgery are worse than expected compared to short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years [57]. Periacetabular osteotomy provides pain relief and improved hip function in most patients over short- to midterm follow-up [25]. Satisfactory results for clubfoot treatment using the Ponseti method were achieved at intermediate follow-up despite an inherent tendency to relapse [5]. Early detection and prompt treatment of relapsed clubfoot deformity following Ponseti method treatment are warranted [5].

Rehabilitation protocol: The development of a relapse affects the subsequent management and outcome of clubfoot deformity [3]. Union took place promptly within eight weeks in all patients with no loss of position following modification of Mitchell's lateral displacement angulation osteotomy [27]. For complex deformities or high tendon tension during minimally invasive hallux valgus surgery, findings support the use of partial zig-zag tenotomy of the extensor hallucis longus [19].

Functional milestones: The clinical and radiological outcome after a distal chevron osteotomy is comparable with that after a proximal chevron osteotomy for moderate hallux valgus deformity [8]. A percutaneous osteotomy technique used to correct hallux valgus deformity demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence [26].

Other Considerations: Longer follow-up is needed to assess the risk of avascular necrosis after chevron osteotomy for hallux valgus deformity [8]. Longer-term follow-up is needed to assess stability and recurrence after partial zig-zag tenotomy of the extensor hallucis longus in minimally invasive hallux valgus surgery [19].

Key Evidence

  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L5] This review summarizes current widespread practice techniques, recent innovations, and potential frontiers within the surgical subspecialty of limb lengthening and deformity correction, covering diverse clinical pathology, treatment paradigms, and geographies. (10.2106/jbjs.21.00584)
  • [L3] The development of a relapse affects the subsequent management and outcome of clubfoot deformity. (10.5435/jaaos-d-16-00522)
  • [L3] However, staged treatment was less invasive, which reduced the number of posterior fixation segments and osteotomy requirement. (10.1186/s12891-023-06340-x)
  • [L5] Early detection and prompt treatment of relapsed deformity are warranted. (10.5435/jaaos-d-15-00624)
  • [L4] Full correction of the deformities without performing an osteotomy of the fibula has been obtained in all of the twelve cases treated by the authors. (10.2106/00004623-195537010-00022)
  • [L5] Based on clinical experience, early weightbearing protocols might not negatively impact graft incorporation, but caution is advised regarding osteotomy complications such as delayed unions and nonunions. (10.1016/j.arthro.2024.11.079)
  • [L3] The clinical and radiological outcome after a distal chevron osteotomy is comparable with that after a proximal chevron osteotomy; longer follow-up would be needed to assess the risk of avascular necrosis. (10.1302/0301-620x.95b5.30181)
  • [L4] Current osteotomy plate designs and surgical techniques are not effective in decreasing sagittal plane tibial slope. (10.1007/s00167-016-4311-y)
  • [L1] The use of a below-knee plaster of Paris cast in conjunction with the Ponseti technique leads to unacceptably high failure rates and significantly longer treatment times. (10.1302/0301-620x.95b11.31899)
  • [L5] The etiology of idiopathic congenital talipes equinovarus is unknown, and there is no consensus as to the best treatment. (10.5435/00124635-200207000-00002)
  • [L4] The review of cases showed that results are poorer in patients with lesser degrees of anteversion (30 to 60 degrees) in whom an osteotomy was not done; a derotation osteotomy serves to decrease factors of dysplasia contributing to hip instability. (10.2106/00004623-195537020-00002)
  • [L3] It is crucial to use radiological assessment to evaluate the involved joints preoperatively and then chose the appropriate method to treat different patients. (10.1186/s13018-017-0513-3)
  • [L3] Radiological outcome after scarf osteotomy is superior with concomitant Akin osteotomy. (10.1186/s13018-019-1241-7)
  • [L4] It is a procedure that can be of benefit to patients with symptomatic juvenile HV from this minimal operative approach before skeletal maturity. (10.1186/s12891-019-2867-7)
  • [L4] This alternative technique obtains satisfactory radiographic and clinical outcomes for AS patients without necessitating additional surgery or elevating the risk of complications such as sagittal translation. (10.1186/s12891-025-08872-w)
  • [L1] The CPAM-LRC consensus confirms Ponseti as first-line treatment and provides an expert-endorsed framework for adjunct interventions and follow-up, which should improve the consistency and outcomes of idiopathic clubfoot care. (10.1186/s13018-025-06459-8)
  • [L4] Indications for surgery are strict, requiring failure of prolonged nonsurgical attempts to relieve pain, and osteotomies with supplemental soft-tissue procedures are the best proven approach for management of rigid flatfoot. (10.5435/jaaos-22-10-623)
  • [L1] These findings support its use in complex deformities or high tendon tension, though longer-term follow-up is needed to assess stability and recurrence. (10.1186/s13018-025-06456-x)
  • [L4] Although much of the literature lacks adequate comparisons of brace types or specific indications, postoperative bracing is still widely used for various surgical procedures. (10.5435/jaaos-d-23-00498)
  • [L4] When the procedure is technically well done, excellent correction can be achieved, and some correction of equinus deformity can be expected when performed with a plantar release. (10.2106/00004623-198466070-00003)
  • [L4] The use of a modified coronal plane transverse calcaneal pin in conjunction with two other pins provided better control of the small-sized hind-foot during casting and resulted in favorable final hind-foot deformity correction. (10.1186/1749-799x-5-42)
  • [L4] Distraction osteogenesis can obtain impressive gains in femoral and tibial length, but the cost is increased treatment time and complications. (10.2106/00004623-199806000-00003)
  • [L3] Recommendation for concomitant Akin osteotomy may be determined by a preoperative PDPAA exceeding 8°. (10.1186/s13018-019-1319-2)
  • [L4] Periacetabular osteotomy provides pain relief and improved hip function in most patients over short- to midterm followup. (10.1007/s11999-009-0842-6)
  • [L5] This study, which was the largest consecutive series of any percutaneous osteotomy technique used to correct hallux valgus deformity, demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence. (10.2106/jbjs.24.01326)
  • [L4] Union took place promptly within eight weeks in all patients with no loss of position. (10.2106/00004623-196951070-00024)
  • [L4] The study shows that the procedure is efficient in restoring a satisfactory stability for most patients and stabilises the evolution of the degenerative lesions as shown by standing X-ray. (10.1007/s001670050076)
  • [L4] Surgical treatment resulted in significantly improved static segmental alignment and mediolateral foot loading, but worsened fore-aft loading. (10.1302/0301-620x.95b5.30594)
  • [L5] Subtle cavovarus foot is a mild malalignment that alters foot mechanics, leading to conditions such as lateral ankle instability, peroneal tendon tears, and stress fractures. (10.5435/jaaos-22-08-512)
  • [L5] A wedge under the lateral aspect of the forefoot decreases strain in the plantar aponeurosis, whereas a wedge under the medial aspect increases strain. (10.2106/00004623-199910000-00005)
  • [L4] First metatarsal realignment reduced the position of the sesamoid, but its intrinsic position relative to the second metatarsal axis is unchanged. (10.1186/s13018-017-0712-y)
  • [L4] Distal soft-tissue reconstruction with a proximal crescentic osteotomy corrects the deformity and alleviates symptoms to the satisfaction of the patient, though surgeons must be aware of potential pitfalls and complications. (10.2106/00004623-199274010-00016)
  • [L3] Furthermore, our findings highlight a noticeable tendency toward the overcorrection of the deformity, as evidenced by increased pressure exerted on the lateral midfoot. (10.2106/jbjs.24.00394)
  • [L4] Most closed tibial-shaft fractures can be effectively managed with cast or brace immobilization, but specific fracture characteristics (instability, metaphyseal-diaphyseal location, severe comminution) and patient factors (obesity, poor compliance) warrant early operative stabilization. (10.5435/00124635-199601000-00005)
  • [L2] Gait adaptations known to reduce knee loading employed pre-HTO were not retained post-HTO. (10.1007/s00167-019-05644-7)
  • [L5] Although the chevron technique confers higher stability regarding fragment displacement during axial loading, both techniques increase the plantar angulation of the metatarsal head. (10.1186/s13018-023-03702-y)
  • [L4] Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway. (10.1186/s12891-021-04385-4)
  • [L4] The Akin procedure is biomechanically unsound as an isolated operation because it does not address the principal mechanical factors of hallux valgus deformity: abnormal function of the adductor hallucis and the abnormal intermetatarsal angle. (10.2106/00004623-198769060-00027)
  • [L4] Double calcaneal osteotomy could be used to correct flatfoot deformities effectively and sustainably and provide symptomatic relief and patient satisfaction. (10.1186/s13018-024-05106-y)
  • [L4] Closed-wedge osteotomy of the lateral humeral condyle provides good long-term clinical and radiographic results for osteochondritis dissecans of the capitellum across all lesion types. (10.1016/j.jse.2019.05.016)
  • [L1] Opening wedge and proximal chevron osteotomies have comparable radiographic outcomes and comparable clinical outcomes for pain, satisfaction, and function. (10.2106/jbjs.m.00231)
  • [L4] This technique is reliable and reproducible, maintaining an excellent range of movement. (10.1302/0301-620x.98b3.35666)
  • [L3] Compared with UKA, complication rates were higher after osteotomy, with an overall surgical complication rate of 23.7%. (10.1177/23259671241257818)
  • [L4] At the time of follow-up, no patient showed an abnormal gait, all feet were plantigrade and flexible, but 2 feet (2.9%) had relapsed. (10.2106/jbjs.16.00053)
  • [L4] The device ensures stable but not rigid synthesis, linked to pain alleviation, alignment correction, and elimination of plantar keratotic lesions. (10.1186/s13018-015-0245-1)
  • [L4] This dynamic taping regime is a simple non-operative method that delivers improved medium-term and promising long-term results. (10.1302/0301-620x.95b2.30641)
  • [L4] MRI demonstrated complete regeneration of subchondral bone and cartilage in all patients with significant improvement in functional scores. (10.1155/2017/6525373)
  • [L4] With correct indications, OWHTO is a reliable procedure for medial knee arthritis/overload. (10.1177/0363546513516577)
  • [L4] Satisfactory results at intermediate follow-up were achieved using the Ponseti method. (10.2106/jbjs.17.01024)
  • [L3] When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years. (10.1302/0301-620x.97b2.34891)
  • [L4] Although the clinical and radiological results of this prospective case report with 2 years follow-up are promising, more patients and longer follow-up are needed to draw any firm conclusions. (10.1007/s00167-011-1465-5)
  • [L1] Although percutaneous pinning produced superior radiological results, functional outcomes and quality of life were not affected by the treatment. (10.1177/1753193409339941)
  • [L4] The authors concluded that immobilization stabilized the fracture and provided a good clinical result without progressive loss of lordosis or vertebral collapse. (10.2106/00004623-199274030-00011)
  • [L4] Comparative studies suggest similar clinical and radiological outcomes, but recurrence remains a challenge necessitating long-term follow-up and standardized outcome measures. (10.1302/0301-620x.107b1.bjj-2024-0597.r2)

See Also

References

[1] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

[2] What’s New in Limb Lengthening and Deformity Correction. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.21.00584

[3] The Timing and Relevance of Relapsed Deformity in Patients With Idiopathic Clubfoot. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00522

[4] Comparison of staged LLIF combined with posterior instrumented fusion with posterior instrumented fusion alone for the treatment of adult degenerative lumbar scoliosis with sagittal imbalance. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06340-x

[5] Management of the Relapsed Clubfoot Following Treatment Using the Ponseti Method. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00624

[6] SIMPLE TRANSVERSE OSTEOTOMY AND THREADED-PIN FIXATION FOR CONTROLLED CORRECTION OF TORSION DEFORMITIES OF THE TIBIA. The Journal of Bone & Joint Surgery. 1955. DOI: 10.2106/00004623-195537010-00022

[7] Editorial Commentary: Early Weightbearing in a Cast After Osteochondral Autograft Transplantation for Osteochondral Lesions of the Talus Is Feasible. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.11.079

[8] A comparison of proximal and distal chevron osteotomy for the correction of moderate hallux valgus deformity. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b5.30181

[9] Posteromedially placed plates with anterior staple reinforcement are not successful in decreasing tibial slope in opening-wedge proximal tibial osteotomy. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4311-y

[10] Ponseti casting for club foot – above- or below-knee?. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b11.31899

[11] Idiopathic Congenital Talipes Equinovarus. Journal of the American Academy of Orthopaedic Surgeons. 2002. DOI: 10.5435/00124635-200207000-00002

[12] EARLY WEIGHT-BEARING AND THE CORRECTION OF ANTEVERSION IN THE TREATMENT OF CONGENITAL DISLOCATION OF THE HIP. The Journal of Bone & Joint Surgery. 1955. DOI: 10.2106/00004623-195537020-00002

[13] Open triple fusion versus TNC arthrodesis in the treatment of Mueller-Weiss disease. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-017-0513-3

[14] Outcomes after scarf osteotomy with and without Akin osteotomy a retrospective comparative study. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1241-7

[15] Management of Juvenile Hallux Valgus Deformity: the role of combined Hemiepiphysiodesis. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2867-7

[16] A novel pre-contoured V-shaped rod in one-level pedicle subtraction osteotomy for the treatment of rigid lumbar kyphosis caused by ankylosing spondylitis: technical note and case series. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08872-w

[17] Management of idiopathic clubfoot: an umbrella review and CPAM-LRC consensus: Limb Reconstruction Committee of Orthopedics Branch of China International Exchange and Promotion Association for Medical and Health Care (CPAM-LRC). Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06459-8

[18] Flatfoot Deformity in Children and Adolescents. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-10-623

[19] Multimodal evaluation of partial zig-zag tenotomy of the extensor hallucis longus in minimally invasive hallux valgus surgery: a randomized trial. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06456-x

[20] Postoperative Spinal Orthoses: Types and Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00498

[21] Osteotomy of the first cuneiform as treatment of residual adduction of the fore part of the foot in club foot.. The Journal of Bone & Joint Surgery. 1984. DOI: 10.2106/00004623-198466070-00003

[22] Hind-foot correction and stabilization by pins in plaster after surgical release of talipes equino varus feet in older children. Journal of Orthopaedic Surgery and Research. 2010. DOI: 10.1186/1749-799x-5-42

[23] Distraction Osteogenesis of the Lower Extremity with Use of Monolateral External Fixation. A Study of Two Hundred and Sixty-one Femora and Tibiae. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199806000-00003

[24] Need for concomitant Akin osteotomy in patients undergoing Chevron osteotomy can be determined preoperatively: a retrospective comparative study of 859 cases. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1319-2

[25] Periacetabular Osteotomy: A Systematic Literature Review. Clinical Orthopaedics & Related Research. 2009. DOI: 10.1007/s11999-009-0842-6

[26] Fourth-Generation Percutaneous Transverse Osteotomies for Hallux Valgus. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.01326

[27] Modification of Mitchellʼs Lateral Displacement Angulation Osteotomy. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951070-00024

[28] Double semitendinosus anterior cruciate ligament reconstruction: 10‐year results. Knee Surgery, Sports Traumatology, Arthroscopy. 1998. DOI: 10.1007/s001670050076

[32] The operative correction of symptomatic flat foot deformities in children. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b5.30594

[33] Subtle Cavus Foot. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-08-512

[34] The Influence of Medial and Lateral Placement of Orthotic Wedges on Loading of the Plantar Aponeurosis. An in Vitro Study. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199910000-00005

[35] Effect of metatarsal osteotomy and open lateral soft tissue procedure on sesamoid position: radiological assessment. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-017-0712-y

[36] Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274010-00016

[37] Outcomes of Calcaneal Lengthening Osteotomy in Ambulatory Patients with Cerebral Palsy and Planovalgus Foot Deformity. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.00394

[38] Closed Tibial-Shaft Fractures: Which Ones Benefit From Surgical Treatment?. Journal of the American Academy of Orthopaedic Surgeons. 1996. DOI: 10.5435/00124635-199601000-00005

[39] High tibial osteotomy results in improved frontal plane knee moments, gait patterns and patient-reported outcomes. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05644-7

[40] Distal osteotomy of the first metatarsal bone for the correction of hallux valgus: comparison of the sagittal stability of two percutaneous techniques—a cadaveric study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03702-y

[41] Hallux valgus deformity and postural sway: a cross-sectional study. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04385-4

[42] Late results after correction of hallux valgus deformity by basilar phalangeal osteotomy.. The Journal of Bone & Joint Surgery. 1987. DOI: 10.2106/00004623-198769060-00027

[43] Clinical and radiological outcomes of flexible flatfoot correction with double calcaneal osteotomy. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05106-y

[45] Long-term results of closed-wedge osteotomy of the lateral humeral condyle for osteochondritis dissecans of the capitellum. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.05.016

[46] Proximal Opening Wedge Osteotomy with Wedge-Plate Fixation Compared with Proximal Chevron Osteotomy for the Treatment of Hallux Valgus. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.00231

[47] Treatment of moderate hallux valgus by percutaneous, extra-articular reverse-L Chevron (PERC) osteotomy. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b3.35666

[48] Comparison of Trends and Complications of Unicompartmental Knee Arthroplasty Versus Periarticular Knee Osteotomy Among ABOS Part II Oral Examination Candidates. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/23259671241257818

[49] Ponseti Treatment of Rigid Residual Deformity in Congenital Clubfoot After Walking Age. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.16.00053

[50] Endolog technique for correction of hallux valgus: a prospective study of 30 patients with 4-year follow-up. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0245-1

[51] Chapter 124 Articular Cartilage Injury and Treatment. 2019.

[52] Outpatient taping in the treatment of idiopathic congenital talipes equinovarus. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b2.30641

[53] Management of Hepple Stage V Osteochondral Lesion of the Talus with a Platelet-Rich Plasma Scaffold. BioMed Research International. 2017. DOI: 10.1155/2017/6525373

[54] Medial Opening Wedge High Tibial Osteotomy for Medial Compartment Overload/Arthritis in the Varus Knee. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546513516577

[55] Chapter 125 Overuse Injuries. 2019.

[56] Sixty Years On: Ponseti Method for Clubfoot Treatment Produces High Satisfaction Despite Inherent Tendency to Relapse. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.01024

[57] Surgery for the correction of hallux valgus. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b2.34891

[58] Tertiary osteochondral defect of the talus treated by a novel contoured metal implant. Knee Surgery, Sports Traumatology, Arthroscopy. 2011. DOI: 10.1007/s00167-011-1465-5

[59] Casting versus percutaneous pinning for extra-articular fractures of the distal radius in an elderly chinese population: a prospective randomised controlled trial. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193409339941

[60] Burst fracture of the fifth lumbar vertebra.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274030-00011

[61] Current concepts of fourth-generation minimally invasive and open hallux valgus surgery. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b1.bjj-2024-0597.r2

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