BACKGROUND:Intraoperative fluoroscopy has become essential in orthopaedic surgery, particularly with the rise of minimally invasive surgery (MIS) techniques. As MIS techniques depend more on intraoperative imaging, MIS techniques may necessitate increased fluoroscopy use compared with open procedures. Despite the advantages of minimally invasive foot and ankle surgery, MIS techniques raise concerns about radiation exposure to both patients and surgical staff. The purpose of this study was to evaluate fluoroscopy time and radiation dose (cumulative air kerma) associated with open versus MIS bunion correction, comparing the open modified Lapidus procedure and the minimally invasive distal first metatarsal transverse osteotomy and akin osteotomy (META). It was hypothesized that the META procedure would be associated with increased radiation dose and fluoroscopy time compared with the open modified Lapidus procedure. METHODS:A retrospective review was conducted for patients who underwent bunion surgery between January 2021 and June 2025 by two fellowship-trained orthopaedic foot and ankle surgeons at a single academic institution. A total of 294 patients met inclusion criteria. Of these, 258 patients underwent a META procedure and 36 underwent an open modified Lapidus procedure. Fluoroscopy time (minutes) and radiation dose (mGy) were compared between the groups. RESULTS:A mean fluoroscopy time of 2.13 ± 1.27 (range, 0.06 to 7.05) minutes and a radiation dose of 2.02 ± 1.30 (range, 0.05 to 7.52) mGy were observed in the META cohort. An average fluoroscopy time of 1.63 ± 1.83 (range, 0.08 to 7.70) minutes and a radiation dose of 1.31 ± 1.43 (range, 0.07 to 5.98) mGy were observed in the open modified Lapidus cohort. Fluoroscopy time between the cohorts did not differ markedly ( P = 0.123); however, the META group demonstrated a higher radiation dose than the open modified Lapidus group ( P = 0.007). CONCLUSION:The META procedure had a markedly higher radiation dose compared with the open modified Lapidus procedure, although both remain substantially below the International Commission on Radiological Protection recommended occupational exposure of less than 20.00 mSv per year. Despite the META procedure generating an average radiation dose of 2.02 mGy per case, surgeons receive only 0.50% of the dose; thus, nearly 1,980 procedures would be required to exceed the 20.00 mSv annual occupational limit. These findings suggest that concerns about radiation exposure should not necessarily deter providers from performing the META technique for bunion correction. LEVEL OF EVIDENCE:III (Retrospective Comparative Study).

Background: Fluoroscopy is a vital imaging technique in orthopaedic surgery, particularly with the growing adoption of minimally invasive surgery (MIS). Because of their increased reliance on intraoperative imaging, MIS techniques may necessitate greater use of fluoroscopy and radiation compared with open procedures; therefore, the use of modern mini C-arm systems is recommended to mitigate radiation exposure. Although MIS offers significant benefits, its use also raises concerns regarding radiation exposure for both patients and surgical staff. This study evaluated radiation dose and fluoroscopy time comparing 2 common procedures used to treat insertional Achilles tendinitis: the percutaneous Zadek osteotomy (ZO) and the open midline Achilles tendon splitting Haglund resection (HR). We hypothesized that the percutaneous ZO would be associated with increased radiation dose and fluoroscopy time in comparison to the open HR but would be below the recommended occupational exposure limits. Methods: A retrospective review was conducted of all patients who underwent a percutaneous ZO or an open HR between January 2021 and July 2025. All procedures were performed by one of 2 fellowship-trained foot and ankle surgeons at a single academic institution. Radiation exposure was assessed using total radiation dose (mGy) and total fluoroscopy time (minutes). Results: A total of 139 patients met inclusion criteria. Sixty patients underwent a percutaneous ZO, whereas 79 underwent an open HR. The percutaneous ZO cohort demonstrated a mean fluoroscopy time of 2.83 ± 1.64 (range, 0.70-7.17) minutes and an average radiation dose of 3.25 ± 2.06 (range, 0.55-8.07) mGy. Meanwhile an average fluoroscopy time of 0.42 ± 0.19 (range, 0.03-0.90) minutes was observed in the open HR cohort, which had a mean radiation dose of 0.38 ± 0.20 (range, 0.02-1.17) mGy. The percutaneous ZO cohort demonstrated a significantly higher radiation dose ( P < .001) and fluoroscopy time ( P < .001). Conclusion: The percutaneous ZO was associated with a significantly higher radiation dose than the open HR; however, despite being statistically significant, this may not be clinically relevant. As surgeons receive only 0.50% of the dose, approximately 1225 percutaneous ZO procedures would be required to exceed annual safety limits. These findings suggest that radiation exposure during the percutaneous ZO technique remains well below the International Commission on Radiological Protection’s annual occupational limit of 20.00 mSv. Consistent with the ALARA principle, low-dose mini C-arm settings and protective equipment help minimize radiation exposure to patients and surgical staff. Level of Evidence: Level III, retrospective comparative study.

The gold standard intervention for insertional Achilles tendinopathy with or without Haglund's deformity has been the open midline Achilles tendon splitting approach for many years. While this is a successful and highly vetted technique, this open hindfoot procedure has been associated with several complications and an extensive post-operative recovery. In comparison, the percutaneous Zadek osteotomy (ZO) has demonstrated safe and effective healing in patients with insertional Achilles tendinopathy with or without Haglund's deformity, with very minimal complications. Additionally, patients who undergo ZO experience a relatively early return to function and activity.

Background: Limited literature is available to guide surgeons on which patients with insertional Achilles tendinopathy (IAT) may be the best candidates for minimally invasive dorsal closing wedge calcaneal Zadek osteotomy (MIS ZO). We hypothesized that the severity of IAT on preoperative magnetic resonance image (MRI) may correlate with post-operative functional outcomes and help guide patient selection for treatment with MIS ZO. Methods: Patients who underwent MIS ZO for IAT ± Haglund deformity were identified and retrospectively analyzed. IAT severity was graded on preoperative MRI. Patient Reported Outcome Measurement Information System (PROMIS) scores, complications, and revisions were recorded. Continuous data were compared by analysis of variance with Bonferroni post hoc analysis. Results: Seventeen patients treated with MIS ZO, with follow-up >6 months, and preoperative MRI met our inclusion criteria. PROMIS pain scores significantly improved in patients with IAT grades 1-3, with 5, 5, and 7 patients, respectively, in each subgroup. In this small series we only identified statistically significant improvements in PROMIS function ( P = .031), and mobility ( P = .009) scores were only observed in patients with grade 2 pathology. Sixteen of 17 patients (94.2%) were very satisfied with their procedure and would undergo it again. Conclusion: In this pilot study, we did not find preoperative MRI findings to correlate well with patient-reported outcome scores following MIS ZO. Level of Evidence: Level IV, case series.

BACKGROUND:Insertional Achilles tendinopathy (IAT) is difficult to manage despite multiple surgical options. Two of the surgical options include an open midline Achilles tendon-splitting Haglund resection and a percutaneous Zadek osteotomy (ZO). The current study compared the patient-reported outcomes and complications of open vs percutaneous procedures in patients with IAT ± Haglund deformity. METHODS:A retrospective comparative study of consecutive patients who underwent either an open midline Achilles tendon-splitting Haglund resection or percutaneous ZO for IAT ± Haglund deformity at a single institution with minimum 12 months' follow-up was performed. Preoperative and postoperative Patient-Reported Outcome Measurement Information System (PROMIS) scores and complications were recorded for each patient and compared between cohorts. RESULTS:Forty-three patients were treated with an open midline Achilles tendon-splitting Haglund resection and 34 patients were treated with a percutaneous ZO for IAT ± Haglund deformity. PROMIS function (P < .001), pain (P < .001), and mobility (P < .001) scores significantly improved in patients who received either procedure. In the open midline Achilles tendon-splitting Haglund resection cohort, a significant increase in wound complications (11/43, 25.6%) was observed in comparison to the percutaneous ZO group (1/34, 2.9%; P = .007).ConclusionBoth techniques yielded clinically meaningful improvements in PROMIS scores. In this modest retrospective cohort, the percutaneous ZO was associated with fewer minor wound complications; however, this observation should be interpreted cautiously given the limited sample size, short follow-up, and potential selection bias. LEVEL OF EVIDENCE:Level III, retrospective cohort study.

Hallux valgus deformity frequently presents with an increased distal metatarsal articular angle (DMAA) which may require additional correction. Minimally invasive hallux valgus surgery is often used in patients with increased DMAA. We hypothesized that the triplanar correction with the minimally invasive extra-articular metaphyseal distal transverse osteotomy (META) would improve the DMAA, in addition to the hallux valgus angle (HVA), intermetatarsal angle (IMA), and patient-reported outcomes. A retrospective chart review was performed on patients who underwent an META procedure for hallux valgus correction. The DMAA, HVA, IMA were measured on preoperative, 2-week postoperative, and final follow-up radiographs. Patient demographics, complications, and Patient-Reported Outcomes Measure Information System (PROMIS) pain, function, and mobility scores were recorded. Univariate analysis and t-test were used to describe measurements between DMAA, HVA, and IMA. Twenty-seven META osteotomies were performed on 25 patients. At the final follow-up, mean DMAA, HVA, IMA decreased from 9.73 ± 1.96 to 4.35 ± 0.85 degrees, 30.45 ± 7.91 to 6.59 ± 2.75 degrees, and 15.37 ± 3.67 to 3.72 ± 1.84 degrees, respectively (P < .001). The PROMIS pain scores significantly improved from 58.96 ± 6.00 to 49.69 ± 9.35 at the final follow-up (P < .001). These observations imply successful resolution of hallux valgus, with a single META procedure. This approach may be an alternative to open or multiple corrections of hallux valgus, while preserving improvement in functional outcomes.Level of Evidence: Level IV.

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy , Calcaneus , Syndrome , Insertional , Achilles tendon , and Tendinopathy . Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund’s deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Introduction/Purpose: Insertional Achilles tendinopathy (IAT) is a common source of posterior heel pain treated by orthopaedic foot and ankle surgeons. Traditional surgical treatment consists of an open Achilles tendon debridement with re-attachment as well as excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. However, frequent complications include wound healing issue, scar pain, weakness and sural nerve injury. Accordingly, the percutaneous ZO is gaining popularity in the field as an alternative to an open midline splitting approach. Limited literature exists describing outcomes of the percutaneous ZO using a larger sample size. The purpose of this study was to analyze patient reported outcomes and complications after percutaneous ZO with a minimum two-year follow-up period. Methods: One hundred and eight cases treated with percutaneous ZO were retrospectively reviewed across October 2017-July 2021 and outcomes data was available for 104 cases with a minimum two-year follow-up. Patient sex, age, and pertinent comorbidities were recorded. Postoperative complications and patient satisfaction following intervention were evaluated. Foot Function Index score (FFI) was utilized to measure patients’ pain and functional outcomes. Visual Analyzing Scale score (VAS) was also utilized to evaluate pain. These measurements were taken at preoperative and final follow-up. Statistical comparisons were performed using two-tailed, paired t-test with p< 0.05. Results: Mean follow-up time was 41.2±13.1 months (range 24-65 months). The mean FFI score improved from 56.1±5.9 (range 47-88) preoperatively to 11.0±5.1 (range 7-59) postoperatively (p < 0.001). Average VAS score improved in patients receiving percutaneous ZO from 7.6±1.3 (range 5-10) to 0.4±0.9 (range 0-7) postoperatively (p < 0.001). The overall complication rate was 3.8% (N =4). Of 104 cases, 98.1% of patients were satisfied with their procedure (102/104). Conclusion: The percutaneous ZO is a safe and highly effective intervention for treatment of IAT. At a minimum of two-years follow-up, this intervention is associated with minimal complications, improved functional outcomes, reduced pain, and high patient satisfaction. Table 1 Functional and subjective pain preoperative and postoperative scores as evaluated by functional foot index (FFI) and visual analogue scale (VAS), respectively

Background: Surgical treatment of insertional Achilles tendinopathy (IAT) historically consists of Achilles tendon debridement with reattachment and excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. Zadek osteotomy (ZO) is an alternative to an open midline splitting approach. The purpose of this study was to analyze patient-reported outcomes and complications after percutaneously performed ZO with minimum 2 years’ follow-up. Methods: One hundred eight cases treated with percutaneous ZO with a minimum 2-year follow-up were retrospectively reviewed. Postoperative complications and patient satisfaction were evaluated. Foot Function Index (FFI) and visual analog scale (VAS) scores were recorded at preoperative and follow-up appointments to measure patients’ functional outcomes and pain, respectively. Results: Mean follow-up was 41.2 months (range, 24-65). Mean age was 51.8 years (range, 28-81). The mean FFI score improved from 56.1 (range, 47-88) to 11.0 (range, 7-59) postoperatively ( P < .001). The mean VAS score improved from 7.7 (range, 5-10) to 0.4 (range, 0-7) postoperatively ( P < .001). The overall complication rate was 3.8% (n = 4). Of 104 cases, 98.1% of patients said they were satisfied with their procedure (n = 102) when asked if they were satisfied with their ZO and recovery. Conclusion: We found the percutaneous ZO to be a safe and effective intervention for treatment of IAT. At a minimum of 2-year follow-up, this intervention is associated with minimal complications, improved function, reduced pain, and a high rate of patient satisfaction.

BACKGROUND:Hallux valgus is a common deformity encountered but remains a complex clinical entity. Fourth-generation minimally invasive surgery (MIS) techniques consisting of a percutaneous distal metatarsal transverse osteotomy combined with an Akin osteotomy have been used to address mild to severe hallux valgus deformities. The benefits of an MIS approach include improved cosmesis, faster recovery, lower opiate requirement, immediate weightbearing, and favorable outcomes relative to a traditional, open procedure. An understudied area with respect to hallux valgus correction is the effect that osteotomies can have on the articular contact properties of the first ray following correction. METHODS:Sixteen paired cadaveric specimens were dissected to include the first ray and tested in a customized apparatus. Specimens were randomized to receive a distal transverse osteotomy translated either 50% or 100% of the width of the first metatarsal shaft. The osteotomy was performed with either a 0° or 20° distal angulation of the burr relative to the shaft in the axial plane. Specimens were tested in the intact state and following the distal first metatarsal osteotomy for peak pressure, contact area, contact force and center of pressure at the first metatarsophalangeal (MTP) and first tarsometatarsal (TMT) joints. An Akin osteotomy was then performed on each specimen, and peak pressure, contact area, contact force, and center of pressure were recalculated. RESULTS:There was a notable decrease in peak pressure, contact area, and contact force across the TMT joint with greater shifts of the capital fragment. However, at 100% translation of the capital fragment, distal angulation of the osteotomy by 20° appears to improve loading across the TMT joint. Addition of the Akin osteotomy at 100% translation also aids in increasing the contact force across the TMT joint. The MTP joint is less sensitive to changes in shifts and angulation of the capital fragment. The Akin osteotomy also leads to increased contact force across the MTP joint when the capital fragment is translated 100%. CONCLUSION:While the clinical significance is unknown, larger shifts of the capital fragment lead to greater load alterations at the level of the TMT joint than the MTP joint. Distal angulation of the capital fragment and the addition of an Akin osteotomy can aid in reducing the size of those changes. The Akin can lead to increased contact forces at the MTP joint with 100% translation of the capital fragment. LEVEL OF EVIDENCE:Not applicable, Biomechanical study.

Insertional Achilles tendinopathy (IAT) is a common surgical pathology treated by orthopaedic surgeons.4 IAT may be associated with Haglund deformity, and several surgical approaches exist to correct IAT; the most frequently used technique is the open midline splitting approach. More recently, minimally invasive surgery (MIS) to address common foot and ankle conditions has increased in use and popularity. The Zadek dorsal closing wedge calcaneal osteotomy (DCWCO) was first published by Zadek in 1939 for treatment of Haglund syndrome and was performed through an open approach.8 The Zadek osteotomy includes the reduction of the Achilles tendon impingement by rotating the posterosuperior corner of the calcaneal tuberosity anterior and elevating the Achilles tendon insertion.4 This technique has been used to treat IAT, with or without associated Haglund deformity. More recently, this strategy has been modified through the use of minimally invasive techniques, including the percutaneous Zadek osteotomy.5 A percutaneous approach, in comparison to the standard open technique, allows for fewer postoperative complications, improved clinical function, and decreased pain.5,6 Accordingly, we present a novel technique for performing the percutaneous Zadek osteotomy in an effort to improve accuracy of resection and selection of appropriate incisions.

Background:Minimally invasive (MIS) calcaneal osteotomy has grown in popularity in recent years to address hindfoot deformity. A potential complication is thermal bone necrosis secondary to heat generation from the burr that may lead to osteotomy nonunion. Irrigation is commonly employed to reduce this risk. The effect of irrigation on reducing heat accumulation remains an understudied area. The purpose of this study was to evaluate the effect of cooled vs room-temperature irrigation on thermal energy dissipation during calcaneal osteotomy using a Shannon burr.Methods:Fourteen cadaveric limbs at room temperature (68 °F) were randomized to receive either cooled saline (7 limbs) or room-temperature (7 limbs) irrigation during MIS calcaneal osteotomy. Two thermocouple probes were inserted 5 mm away from the plane of the osteotomy, on the proximal and distal sides, respectively. A 3 × 30-mm Shannon burr was used to perform the osteotomy. The burr was run continuously with continuous irrigation using either room-temperature (68 °F) or chilled (37 °F) irrigation, until the osteotomy was completed. Temperature was recorded at 0, 15, 30, 45, and 60 seconds for the 2 groups and used as a measure of thermal energy accumulation.Results:Both room-temperature and chilled irrigation were effective in minimizing temperature change. On the proximal side, an overall mean increase of 2.5 °F with room-temperature irrigation and a mean decrease of 1.0 °F with chilled irrigation were observed at the 60-second interval (P = .004). On the distal side, there was a mean increase of 1.3 °F with room-temperature irrigation and a mean increase of 0.5 °F with chilled irrigation (P = .05).Conclusion:For the duration of an MIS calcaneal osteotomy, both continuous room-temperature and chilled irrigation can minimize temperature increases and potentially reduce the risk of an osteotomy nonunion.Clinical Relevance:Both room-temperature and chilled irrigation can minimize bone temperature increases during MIS calcaneal osteotomy.

Direct-to-consumer advertising (DTCA) has played an important, though controversial, role in orthopaedics over the years. DTCA refers to any advertisement that is intended toward the final recipient of the product being publicized.8 Initial forays into this in health care were based on pharmaceuticals, and spending on targeted drug advertisements has increased exponentially since their inception.1 The average television viewer can see approximately 9 advertisements in a day.14 It has had a profound effect on the physicianpatient relationship as patients who have requested specific medications are more likely to receive them from a prescribing physician.8 Within the orthopaedic device industry, DTCA was initially used to promote total joint replacements, both the implants themselves and techniques for implantation. Although DTCA promotes awareness of devices and technologies, the device or technology promoted may or may not be suitable for a particular patient, creating challenges for surgeons.

Category: Hindfoot; Basic Sciences/Biologics; Other Introduction/Purpose: Minimally Invasive (MIS) calcaneal osteotomy has grown in popularity in recent years to address hindfoot deformity. A potential complication is thermal bone necrosis secondary to heat generation from the burr, leading to nonunion of the osteotomy. Irrigation is commonly employed to reduce this risk. The effect of irrigation on reducing this risk remains an understudied area. The purpose of this study was to evaluate the effect of cooled versus room-temperature irrigation on thermal energy dissipation on a temperature curve during calcaneal osteotomy using a Shannon burr. Methods: Ten cadaveric limbs (5 pairs) at room temperature (68 0F) were randomized to receive either cooled saline or room temperature irrigation during MIS calcaneal osteotomy. Two thermocouple probes (EL-USB-TC-LCD, Lascar Electronics) were inserted 5mm away from the plane of the osteotomy, on proximal and distal sides respectively (Fig. 1). The probes were inserted to a depth of 2cm. A 3 x 30mm Shannon burr was used to perform the osteotomy. The burr was run continuously under continuous irrigation using either room temperature (680F) and chilled (370F) irrigation, until the osteotomy was completed. All osteotomies were performed in approximately 60 seconds. Temperature was recorded at 15sec, 30sec, 45 sec and 60 sec for the two groups and used as a measure of thermal energy generation. Results: Both room temperature and chilled irrigation were effective in minimizing temperature change. On the proximal side, an overall mean increase of 2.60F (70.60F) with room temperature irrigation and a mean increase of 0.70F (68.70F) with chilled irrigation were observed at the 60 sec interval (p=0.09). On the distal side both irrigation methods were more effective in heat control (70.20F vs 67.10F; p=0.17). Conclusion: For the duration of a MIS calcaneal osteotomy, both continuous room temperature and chilled irrigation can reduce thermal energy generation. Use of chilled irrigation can be considered for osteotomies of denser bone that may take longer to perform and generate higher temperatures. Keywords Calcaneal Osteotomy , Minimally Invasive , Adult Acquired Flatfoot Deformity

JM: Minimally invasive surgery (MIS) is a technique used by foot and ankle surgeons to correct specific foot and ankle conditions with very small incisions. The basic principles of tissue repair/fracture repair/deformity correction/fusion are respected while minimizing soft tissue insult typically needed in traditional open surgery. The goal is less morbidity including wound complications, post-operative pain, swelling, stiffness, neuritis, and quicker recovery time.

BACKGROUND:With the development of the COVID-19 pandemic, elective foot and ankle surgeries were delayed throughout the United States to divert health care resources and limit exposure. Little is known about the impact of COVID-19 on patient's willingness to proceed with elective procedures once restrictions are lifted and factors contributing to such decision.METHODS:Patients across 6 US orthopedic institutions who had their elective foot and ankle surgeries cancelled secondary to the pandemic were given a questionnaire. Specifically, patients were asked about their willingness to move forward with surgery once restrictions were lifted and if not why. Pain-level and pain medication use were also assessed. Univariate analysis was used to identify factors that contribute to patient's decisions.RESULTS:A total of 150 patients participated in this study. Twenty-one (14%) opted not to proceed with surgery once restrictions were lifted. Forty-three percent (n = 9) listed concern for COVID infection as the reason; however, 14% of them would proceed if procedures were performed in surgery center. Twenty-nine (19% of the total cohort) patients had increased pain and 11% of patients were taking more pain meds because of the delay to their procedure. Patients who decided not to proceed with surgery reported pain reduction (3% vs 14%) and lower increase in pain medication used (5% vs 12%).CONCLUSION:COVID-19 has made a significant impact on the health care system. Delay of elective foot and ankle procedures impact patient quality of life and outcomes. Access to surgery centers may provide a partial solution during the pandemic.LEVEL OF EVIDENCE:Level III.