Background: Hallux valgus is a common foot condition with numerous surgical techniques described. Minimally invasive surgery is becoming more popular, with resultant development of suitable fixation devices. The aim of this systematic review was to evaluate the evidence on the use of intramedullary devices in hallux valgus first metatarsal corrective osteotomies, and describe clinical and radiological outcomes, with an overview of techniques and implants used. Methods: We searched PubMed, Medline, Embase and EMCare databases, conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Radiological outcomes including the hallux valgus angle (HVA) and intermetatarsal angle (IMA) were recorded, as well as clinical outcome scores and complications. Methodological quality of included studies was assessed using the MINORS score. Results: Ten studies were included, comprising 696 feet in 745 patients. Data pooling and metanalysis was not possible due to overall low quality of evidence. Four implants were reported (Endolog, ISO Plate, V-Tek Plate, Link Fixator) and used with distal first metatarsal osteotomies, with improvement in HVA, IMA, and clinical outcome scores comparable to other fixation techniques. There were no reported cases of nonunion. Complication rates were variable (all cause range of 0-21%) across all studies, with an overall low rate. Conclusion: Intramedullary devices are viable and safe to use for hallux valgus first metatarsal osteotomies, with comparable radiological and functional outcomes to other techniques. Current evidence base is of low methodological quality, therefore high quality studies are required to further evaluate these devices. Crown Copyright (c) 2021 Published by Elsevier Ltd on behalf of European Foot and Ankle Society. All rights reserved.

Category: Ankle; Other Introduction/Purpose: In the aftermath of the first wave of COVID-19, there was a significant backlog of elective orthopaedic cases. To address this problem, efficient running of theatres with optimal theatre utilisation was paramount. However, as new processes were introduced to reduce transmission risk, 'last-minute' cancellations of patients were inevitable. We report our experience of resuming elective work, with particular focus on surgical cancellations, and lessons learned. Methods: This was a retrospective, single centre audit at a specialist elective orthopaedic hospital. We identified and examined all cancellations in foot and ankle cases between June and October 2020. Data was analysed and cancellations were categorised into groups by reason of cancellation. Results: There were 36 cancellations out of 193 patients listed (19%). Twenty-one cancellations (57%) were directly related to COVID-19 and its processes. These comprised six patients (17%) with COVID-19 swab related issues including: booking errors, transport problems, non-attendance, and invalid swabs. Three patients (8%) contracted COVID-19 preoperatively. Nine patients (25%) cancelled their procedure at short notice amidst fears of contracting COVID-19 perioperatively. Three (8%) cancellations were due to the patient being unfit on the day of surgery - these issues were not routinely identified at pre-assessment appointments as face-to-face pre-assessment clinics had been suspended. A further 15 cancellations (42%) were due to non- COVID-19 reasons including lack of beds, unwell patients, and patients cancelling for other personal reasons. Conclusion: Mitigation of cancellations is a key factor in maintaining theatre utilisation. Based on our experience we recommend thorough counselling of patients regarding the importance of self-isolation prior to surgery and of the pre-operative swab. Having a designated team to manage COVID-19 swabs is also critical. Reinstatement of face-to-face pre-operative assessments may help identify evolving issues and prevent last-minute cancellations. These lessons are pertinent to trusts, particularly as we emerge from subsequent waves of COVID-19.

Background: The importance of the rotational profile of the first metatarsal is increasingly recognized in the surgical planning of hallux valgus. However, rotation in the normal population has only been measured in small series. We aimed to identify the normal range of first metatarsal rotation in a large series using weightbearing computed tomography (WBCT). Methods: WBCT scans were retrospectively analyzed for 182 normal feet (91 patients). Hallux valgus angle, intermetatarsal angle, anteroposterior/lateral talus–first metatarsal angle, calcaneal pitch, and hindfoot alignment angle were measured using digitally reconstructed radiographs. Patients with abnormal values for any of these measures and those with concomitant pathology, previous surgery, or hallux rigidus were excluded. Final assessment was performed on 126 feet. Metatarsal pronation (MPA) and α angles were measured on standardized coronal computed tomography slices. Pronation was recorded as positive. Intraobserver and interobserver reliability were assessed using intraclass correlation coefficients (ICCs). Results: Mean MPA was 5.5 ± 5.1 (range, –6 to 25) degrees, and mean α angle was 6.9 ± 5.5 (range, –5 to 22) degrees. When considering the normal range as within 2 standard deviations of the mean, the normal range identified was −5 to 16 degrees for MPA and −4 to 18 degrees for α angle. Interobserver and intraobserver reliability were excellent for both MPA (ICC = 0.80 and 0.97, respectively) and α angle (ICC = 0.83 and 0.95, respectively). There was a moderate positive correlation between MPA and α angle (Pearson coefficient 0.68, P < .001). Conclusion: Metatarsal rotation is variable in normal feet. Normal MPA can be defined as less than 16 degrees, and normal α angle can be defined as less than 18 degrees. Both MPA and α angle are reproducible methods for assessing rotation. Further work is needed to evaluate these angles in patients with deformity and to determine their significance when planning surgical correction of hallux valgus. Level of Evidence: Level III, retrospective comparative study.

BACKGROUNDTo present the first known reported case of late onset idiopathic scoliosis with concomitant neural anomalies, treated with sequential distraction using magnetic growth rod, had significant improvement in both cranio-cervical and intraspinal anomaly.METHODSA caucasian, growing female child (at the age of ten) presented with moderately progressive late onset right thoracic scoliosis. She was found to have Chiari type I malformation and a cervicothoracic syrinx on routine pre-operative MRI scanning. We treated this child by inserting magnetic growing rod (MGR) system. After 48 months of follow up with serial distractions, the metalwork (MGR) was removed due to aseptic wound breakdown and granuloma formation. Subsequently due to the progression of deformity, a definitive posterior instrumented spinal fusion was done. A repeat MRI Scan of the Spine was done prior to this definitive procedure to assess for any residual neural anomalies.RESULTSThe Chiari type I malformation appeared to have completely resolved, with no cerebellar tonsillar herniation seen, and a significant improvement in the size of the cervicothoracic syringomyelia effectively downgrading it to a prominent central canal.CONCLUSIONSThis is a unique case of progressive late onset idiopathic scoliosis with associated Chiari malformation and syringomyelia, showing an improvement in these neural anomalies after gradual and protracted distractive lengthening of the spine with MGR.