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Treatment of moderate and severe hallux valgus by performing percutaneous double osteotomy of the first metatarsal bone
Tratamiento del hallux valgus moderado y severo mediante doble osteotomía percutánea del primer metatarsiano
R. Díaz Fernández
Servicio de Cirugía Ortopédica y Traumatología, Hospital de Manises, Valencia, Spain
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Díaz Fernández" "autores" => array:1 [ 0 => array:2 [ "nombre" => "R." 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Noventa y siete casos con seguimiento medio de 12 años" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1476 "Ancho" => 1502 "Tamanyo" => 363705 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Composition of a GCTB of the third metacarpal which recurred after curettage 6 months earlier. The image shows the treatment through block resection and reconstruction with interposed graft. (a) Simple radiograph showing an expansive lithic lesion in the third metacarpal, which inflates and thins out the cortical. The magnetic resonance scan clearly shows soft tissue involvement. (b) Identification under scopy of the area affected by the tumor and marking with Kirschner wires. The lower right corner shows the bone graft prior to its section, along with the resection piece. (c) Prior reconstruction of the metacarpal intermediate graft with an osteosynthesis plate and screws for subsequent placement in the resection bed. (d) Subsequent radiographic control.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Abat, M. Almenara, A. Peiró, L. Trullols, S. Bagué, I. Grácia" "autores" => array:6 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Abat" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Almenara" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Peiró" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Trullols" ] 4 => array:2 [ "nombre" => "S." "apellidos" => "Bagué" ] 5 => array:2 [ "nombre" => "I." "apellidos" => "Grácia" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1888441514001611" "doi" => "10.1016/j.recot.2014.06.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1888441514001611?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1988885614001308?idApp=UINPBA00004N" "url" => "/19888856/0000005900000001/v1_201501110043/S1988885614001308/v1_201501110043/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S1988885614001321" "issn" => "19888856" "doi" => "10.1016/j.recote.2014.11.009" "estado" => "S300" "fechaPublicacion" => "2015-01-01" "aid" => "521" "copyright" => "SECOT" "documento" => "article" "subdocumento" => "fla" "cita" => "Rev Esp Cir Ortop Traumatol. 2015;59:44-51" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 180 "formatos" => array:2 [ "HTML" => 126 "PDF" => 54 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Results of polyurethane implant for persistent knee pain after partial meniscectomy with a minimum of two years follow-up" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "44" "paginaFinal" => "51" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados de un implante de poliuretano para el tratamiento del dolor persistente de rodilla tras meniscectomía parcial con un mínimo de dos años de seguimiento" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 800 "Ancho" => 1000 "Tamanyo" => 216621 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin and eosin (400×) staining of the biopsy taken from the central part of the implant showing the growth of the fibrocartilage.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Martín-Hernández, M. Ranera-García, J.V. Díaz-Martínez, M.P. Muniesa-Herrero, L.J. Floría-Arnal, M. Osca-Guadalajara, D. García-Aguilera" "autores" => array:7 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Martín-Hernández" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Ranera-García" ] 2 => array:2 [ "nombre" => "J.V." "apellidos" => "Díaz-Martínez" ] 3 => array:2 [ "nombre" => "M.P." "apellidos" => "Muniesa-Herrero" ] 4 => array:2 [ "nombre" => "L.J." "apellidos" => "Floría-Arnal" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Osca-Guadalajara" ] 6 => array:2 [ "nombre" => "D." "apellidos" => "García-Aguilera" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1888441514001647" "doi" => "10.1016/j.recot.2014.07.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1888441514001647?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1988885614001321?idApp=UINPBA00004N" "url" => "/19888856/0000005900000001/v1_201501110043/S1988885614001321/v1_201501110043/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Treatment of moderate and severe hallux valgus by performing percutaneous double osteotomy of the first metatarsal bone" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "52" "paginaFinal" => "58" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "R. Díaz Fernández" "autores" => array:1 [ 0 => array:3 [ "nombre" => "R." "apellidos" => "Díaz Fernández" "email" => array:2 [ 0 => "rdiaz@hospitalmanises.es" 1 => "rdiaz@hospitalmanises.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital de Manises, Valencia, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento del hallux valgus moderado y severo mediante doble osteotomía percutánea del primer metatarsiano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1090 "Ancho" => 2334 "Tamanyo" => 175697 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Double osteotomy with correction of the DMAA (PASA) and base osteotomy fixed with a Kirschner wire (left) and 1 needle (right), in both cases associated to Weil type osteotomies of the lesser metatarsals.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Elective <span class="elsevierStyleItalic">hallux valgus</span> surgery is indicated in patients reporting pain due to deformity or difficulty to use normal footwear in specific cases. Among the scope of existing techniques to treat <span class="elsevierStyleItalic">hallux valgus</span>, are those considered as minimal-incision or percutaneous techniques.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–14</span></a> These techniques are increasingly demanded by patients themselves as their popularity increases, largely due to the esthetic advantage of smaller incisions compared to open techniques.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However, in addition to the advantages associated with percutaneous surgery, we must also take into account the complications and limitations inherent to their use.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> The isolated use of distal osteotomies may not be enough for the treatment of moderate or severe <span class="elsevierStyleItalic">hallux valgus</span> associated to intermetatarsal angles over 16–18° between the first and second metatarsals.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,17</span></a> Isolated proximal osteotomies can worsen the distal joint angle of the first metatarsal (distal metatarsal articular angle [DMAA] or proximal articular set angle [PASA]) and increase the risk of elevation and shortening of the first metatarsal.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The use of combined percutaneous proximal and distal osteotomies increases the surgical indications, enabling their use to correct a large range of angulations.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,18</span></a> The advantages of percutaneous surgery would be: a shorter surgery time, reduced tissue dissection, no use of permanent fixation material and a shorter scarring period.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The purpose of this study is to show that double percutaneous osteotomy can be a reproducible and effective technique for the treatment of moderate to severe <span class="elsevierStyleItalic">hallux valgus</span>.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We operated on 44 <span class="elsevierStyleItalic">hallux valgus</span> in 41 patients during the period between 1st May 2009 and 27th March 2013. We included deformities considered from moderate to severe, that is, with a <span class="elsevierStyleItalic">hallux valgus</span> angle (HVA) of 30° and an intermetatarsal angle (IMA) of 14° between the first and second metatarsals, according to the classification of Mann and Coughlin.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The respective upper limit intervened recorded in this study was an IMA of 20° and an HVA of 58°. We lost 2 cases who did not attend follow-up controls.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We excluded from the study all those cases of <span class="elsevierStyleItalic">hallux valgus</span> considered as mild, which according to our algorithm were treated through isolated distal osteotomies, patients with previous Keller–Brandes type interventions, arthrosis of the first metatarsophalangeal joint, as well as the 2 patients mentioned who did not attend review in outpatient consultation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The indication for surgery was only established in patients who reported pain and significant involvement for leisure and daily living activities.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We operated on a total of 36 females and 5 males, with a mean age of 61 years at the time of the intervention (range: 20–75 years). Of these, 3 patients underwent bilateral interventions in deferred procedures. Patients were referred to our unit after having received conservative treatment with modification of footwear, orthesis, etc., with no improvement and with an evolution of pain of at least 1 year. Only 5 did not undergo Weil type osteotomies of the lesser metatarsals. We believe it advisable to carry out this procedure both in case of transfer metatarsalgia and shortening of the first ray after conducting osteotomies. In 25 patients we also percutaneously corrected any deformities of the lesser toes which could coexist at the time of surgery, through osteotomies or tenotomies. All surgical procedures were conducted by the same orthopedic surgeon at the same center.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Postoperative evolution was controlled clinically and radiographically at 6 weeks, 3 months, 6 months, 1 year and 2 years after the intervention, with the frequency of visits being increased in case of complications. The mean evolution of recorded cases was of 24.02 months (range: 12–51 months), with 16 operated feet presenting an evolution of 2 years or more and 27 feet a minimum evolution of 1 year. Preoperatively, we observed the IMA, HVA and DMAA values in an anteroposterior radiograph whilst under load, as well as the postoperative results of the angles 6 months after the intervention.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We recorded the scores in the American Orthopedic Foot and Ankle society (AOFAS) scale pre- and postoperatively.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The recorded data underwent statistical analysis consisting in a Student <span class="elsevierStyleItalic">t</span> test for paired data, using the statistics software package SPSS Statistics version 22 (IBM, Armonk, USA).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique</span><p id="par0050" class="elsevierStylePara elsevierViewall">Patients were placed in the supine position with both lower limbs projecting from the lower part of the table, in order to use the minifluoroscope, essential for the percutaneous procedure. The anesthetic technique consisted in distal sensory block of the ankle or a block at the level of the popliteal fossa depending on the judgment of the anesthesiologist. All patients received a dose of 2<span class="elsevierStyleHsp" style=""></span>g cefazolin as antibiotic prophylaxis in an interval between 1<span class="elsevierStyleHsp" style=""></span>h and 30<span class="elsevierStyleHsp" style=""></span>min before starting the procedure. We did not use ischemia in any of the procedures.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Following the technique described by De Prado et al.,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> we initially carried out a cutaneous incision 3<span class="elsevierStyleHsp" style=""></span>mm in length with a percutaneous surgery scalpel with a Beaver 64 (Waltham, USA) blade, proximal and plantar to the bunion. After creating a working space by opening a cavity between the bone and capsule, we used the motorized drill at a speed no higher than 5000<span class="elsevierStyleHsp" style=""></span>rpm in order to prevent bone necrosis during the buniectomy. Next, we assessed the possibility of conducting a Reverdin-Isham type distal osteotomy to correct DMAA (PASA), making an incision with the drill from distal dorsal to proximal plantar, behind the sesamoids, at an angle of 45° (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). We performed a percutaneous tenotomy of the <span class="elsevierStyleItalic">abductor hallucis</span> with lateral capsulotomy and Akin osteotomy in all patients.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">To perform the osteotomy of the base of the first metatarsal, we palpated the <span class="elsevierStyleItalic">extensor hallucis longus</span> tendon and, laterally to it, used the fluoroscope to find a point located approximately 1.5<span class="elsevierStyleHsp" style=""></span>cm from the base of the metatarsal, where we made an incision with a Beaver 64 scalpel. Next, we slid a scraper through the lateral aspect of the metatarsal to remove the periosteum and began to cut the bone with a Shannon 44 drill (Vilex Inc., McMinnville, TN, USA). We made the cut in an intermediate plane between the plane which would be the floor in a position of load and that corresponding to the axial of the first metatarsal. We attempted to respect the medial cortical. Next, using a Wedge Burr type drill (Vilex Inc., McMinnville, TN, USA), we drilled a sufficiently large cavity to allow closure and achieve correction of the IMA. We distally introduced a Kirschner wire 2<span class="elsevierStyleHsp" style=""></span>mm in diameter perpendicularly to the diaphysis, and then brought it closer converging on the angle to the axis of the metatarsal, in an intramedullary direction from distal to proximal (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b) whilst at the same time pressing on the metatarsal closing the wedge and bringing it closer to the second metatarsal. Lastly, we crossed the site of the osteotomy with the Kirschner wire and fixed to the base of the metatarsal or to the first wedge (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Optionally, depending on the quality of the fixation, we introduced another Kirschner wire to provide additional stability (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Subsequently, depending on the shortening of the first metatarsal which was necessary to correct the angle or the presence of metatarsalgia in the previous clinical assessment, we carried out percutaneous Weil osteotomies and corrections in the lesser toes. After suturing the surgical incisions, we placed a functional bandage with hypercorrection of the <span class="elsevierStyleItalic">hallux valgus</span> to maintain alignment of the osteotomies which were not fixed, and this was maintained for 6 weeks with weekly changes in our outpatient consultation by the nursing staff. Load with postoperative footwear was authorized from the first day. The use of normal, comfortable footwear was authorized after 6 weeks. All patients received 10 days of low molecular weight heparin as antithrombotic prophylaxis, and we did not detect any case of deep vein thrombosis. Postoperative analgesia consisted in etoricoxib 120<span class="elsevierStyleHsp" style=""></span>mg once per day for days 4 associated to a combination of 37.5<span class="elsevierStyleHsp" style=""></span>mg tramadol hydrochloride and 325<span class="elsevierStyleHsp" style=""></span>mg paracetamol with 1–3 daily doses depending on the pain.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">After 6 weeks, the Kirschner wires were removed by the nursing staff in outpatient consultation after ensuring the start of bone callus in radiographs under load and the use of normal footwear was authorized, reminding patients to perform mobilization exercises for the metatarsophalangeal joint and contrast baths to reduce edema.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding the radiographic results (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), we observed an improvement in the IMA from 16.88<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.01 to 8.18<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.23 and in the HVA from 40.02<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.50 to 10.51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.55 with statistically significant values, applying a 95% confidence interval. The value of the DMAA showed a mean improvement of 6.56<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.09 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The measurements were made in radiographs whilst standing, 6 months after the procedure. Consolidation of the osteotomies was confirmed radiographically in all patients except for 1 case within 6 months. In general, it was possible to observe the start of a fracture callus radiographically after 6–8 weeks evolution.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Regarding complications, 3 patients suffered recurrence of the deformity (HVA<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>20°). We registered 3 cases of elevation of the metatarsal in the sagittal plane regarding the previous radiographs, both cases with a follow-up of 2 years and with no clinical significance. There were no cases of necrosis of the metatarsal head. There was 1 case of mobilization of the osteosynthesis in the immediate postoperative period, which required reintervention through open surgery, and another one required reintervention through open surgery due to pseudoarthrosis of the osteotomies, both in the base and Weil type after 1.5 years follow-up. We also detected 1 case of mild <span class="elsevierStyleItalic">hallux varus</span> with good tolerance by the affected patient, who refused another intervention. Lastly, we registered 1 deep infection which responded adequately to antibiotic treatment. The postoperative AOFAS score was 91.28<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.73 (range: 65–100), recorded after 1 or 2 years of the intervention (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The result of 91.28<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.73 points obtained in the postoperative AOFAS (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) demonstrates similar results to those with other percutaneous<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–9,13,22,23</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) and open techniques.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,10,12,14,24</span></a> Double osteotomy for the correction of <span class="elsevierStyleItalic">hallux valgus</span> was first described by Logroscino in 1948. Other authors, like Peterson and Johnson, reported double osteotomies in adolescents en 1993.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> In 1999, Coughlin published results of 18 feet intervened through open double osteotomy of the first metatarsal for <span class="elsevierStyleItalic">hallux valgus</span> with increased DMAA, fixed with Kirschner wires and cannulated screws. He did not use the AOFAS scale, but reported that 14 out of 18 patients were satisfied with the surgical result. Regarding the angles, he achieved mean corrections of 34–12° for the HVA and 15–6° for the IMA. As complications, he registered 1 case of deep vein thrombosis, 1 loss of internal fixation in osteotomy of the base and 1 case of <span class="elsevierStyleItalic">hallux varus</span> which required reintervention. In cases where an Akin osteotomy was added, the technique is described as “triple osteotomy”.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">At present, several open techniques have been described, both distal (Hohmann, Wilson, Mitchell and Chevron) and proximal, as well as Mann,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Ludloff or scarf osteotomies, with results which are comparable to the technique described. In 2000, Trnka et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> carried out the Chevron technique on 66 feet with a follow-up of 2–5 years and an AOFAS score of 90–92 points, as he divided the patients into age groups over and under 50 years. As complications, 3 patients suffered non-union with deformity of the osteotomy, 1 deep infection and 1 case of type I RSD (reflex sympathetic dystrophy).</p><p id="par0090" class="elsevierStylePara elsevierViewall">In 2000, Zettl et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> intervened 114 feet through crescentic type osteotomy of the base of the first metatarsal with an open technique and distal reefing of soft tissues in moderate to severe <span class="elsevierStyleItalic">hallux valgus</span> (IMA<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>15° and HVA<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>30°) with good results in 91% of patients but with 8 cases of <span class="elsevierStyleItalic">hallux varus</span> and 5 cases of failure of the osteosynthesis material.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Focusing on percutaneous techniques, Isham proposed a double osteotomy when the IMA exceeded 18°<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> and De Prado proposed carrying out percutaneous double osteotomies in moderate or severe <span class="elsevierStyleItalic">hallux valgus</span>, without specifying their angular measurements.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,21</span></a> In 2010,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Chaparro et al. presented 73 feet intervened through a double percutaneous osteotomy, fixing the proximal osteotomy with a cannulated screw and a mean reported result of 90.8 points in the AOFAS scale. The indication for a double osteotomy was established from 15° IMA. As complications he reported 2 failures of the osteosynthesis with iatrogenic fracture at the site of introduction of the screws, 2 cases of type I RSD, and 1 case of mobilization of the distal osteotomy. De Lavigne et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> published a prospective study in 6 patients with IMA between 18° and 29° with good results (postoperative AOFAS of 84 points). As a surgical technique he employed a distal Chevron osteotomy and a proximal subtraction osteotomy, with both performed percutaneously.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Double osteotomy enables the correction of moderate–severe IMA and DMAA (PASA).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Other percutaneous techniques based only on distal osteotomies have been reported. However, some negative results have also been published in connection with these kinds of techniques.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Magnan et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> published corrections of preoperative IMA of up to 20° using an isolated percutaneous subcapital osteotomy, modifying the technique described initially by Bösch et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding the more consolidated open techniques, the results have been similar.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In our case, the technique popularized in our country by De Prado is more reproducible and only requires provisional fixation with Kirschner wires and a functional bandage to maintain the distal osteotomies. The perforation to allow introduction of a screw in the base of the metatarsal can be associated to perioperative fractures,<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,26</span></a> in addition to implanting a foreign material, with the complications that this may cause.</p><p id="par0120" class="elsevierStylePara elsevierViewall">As contraindications for this technique, we considered the presence of arthrosis or various grades of <span class="elsevierStyleItalic">hallux rigidus.</span></p><p id="par0125" class="elsevierStylePara elsevierViewall">The radiographic and clinical results obtained with a follow-up period of between 1 and 2 years have achieved satisfactory corrections in the deformities described.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The theoretical problems faced include the possibility of elevation of the first metatarsal, osteonecrosis of the head of the first metatarsal, metatarsophalangeal joint rigidity, non-union (pseudoarthrosis) and the technical difficulty of carrying out a 3D osteotomy based on 2D imaging. Regarding the possible elevation of the metatarsal, the intraoperative use of the fluoroscope with a lateral image whilst standing and achieving a stable fixation with 1 or 2 Kirschner wires should be enough to avoid this complication. Osteonecrosis of the head of the first metatarsal was not detected in our series. Non-union and skin burn problems can be prevented by a careful technique and avoiding high-speed drilling when conducting the osteotomies. Loss of mobility in the metatarsophalangeal joint is observed frequently and can be related to the release of the lateral capsule, non-compliance by patients regarding postoperative exercises, and the presence of intraarticular bone debris particles.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Given the shortening of the first metatarsal when conducting a closure double osteotomy, in most cases we recommend carrying out Weil osteotomies of the lesser rays to achieve a correct metatarsal formula and thus avoid transfer metatarsalgias.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">This study demonstrates that the technique described can be considered as a valid alternative to currently existing techniques, both open and percutaneous. The indication for percutaneous techniques can be extended to severe <span class="elsevierStyleItalic">hallux valgus</span>. The use of Kirschner wires as osteosynthesis material can represent an economic advantage, in addition to avoiding the permanent implantation of material.</p><p id="par0145" class="elsevierStylePara elsevierViewall">We conclude that, with adequate training, it is possible to achieve shorter surgical times, less soft tissue damage entailing less scarring time of the surgical wounds and the advantage of being able to perform the procedure on an outpatient basis by increasing the range of indications of percutaneous <span class="elsevierStyleItalic">hallux valgus</span> surgery to moderate and severe cases.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Level of evidence</span><p id="par0150" class="elsevierStylePara elsevierViewall">Level of evidence IV.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical responsibilities</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of people and animals</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidentiality of data</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that this work does not reflect any patient data.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that this work does not reflect any patient data.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres407917" "titulo" => array:6 [ 0 => "Abstract" 1 => "Objective" 2 => "Materials and methods" 3 => "Results" 4 => "Discussion" 5 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec384134" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres407916" "titulo" => array:6 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Discusión" 5 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec384133" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Level of evidence" ] 11 => array:3 [ "identificador" => "sec0040" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Right to privacy and informed consent" ] ] ] 12 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-14" "fechaAceptado" => "2014-07-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec384134" "palabras" => array:5 [ 0 => "Severe hallux valgus" 1 => "Percutaneous surgery" 2 => "Minimally invasive surgery" 3 => "Double osteotomy" 4 => "Reverdin-Isham osteotomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec384133" "palabras" => array:5 [ 0 => "Hallux valgus severo" 1 => "Cirugía percutánea" 2 => "Cirugía mínimamente invasiva" 3 => "Doble osteotomía" 4 => "Osteotomía de Reverdin-Isham" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the clinical and radiological results in the surgical treatment of moderate and severe hallux valgus by performing percutaneous double osteotomy.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on 45 feet of 42 patients diagnosed with moderate–severe hallux valgus, operated on in a single center and by the same surgeon from May 2009 to March 2013. Two patients were lost to follow-up. Clinical and radiological results were recorded.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">An improvement from 48.14<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.79 points to 91.28<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.73 points was registered using the American Orthopedic Foot and Ankle Society (AOFAS) scale. A radiological decrease from 16.88<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.01 to 8.18<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.23 was observed in the intermetatarsal angle, and from 40.02<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.50 to 10.51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.55 in hallux valgus angle. There was one case of hallux varus, one case of non-union, a regional pain syndrome type <span class="elsevierStyleSmallCaps">I</span>, an infection that resolved with antibiotics, and a case of loosening of the osteosynthesis that required an open surgical refixation.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Percutaneous distal osteotomy of the first metatarsal, when performed as an isolated procedure, shows limitations when dealing with cases of moderate and severe hallux valgus. The described technique adds the advantages of minimally invasive surgery by expanding applications to severe deformities.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Percutaneous double osteotomy is a reproducible technique for correcting severe deformities, with good clinical and radiological results with a complication rate similar to other techniques with the advantages of shorter surgical times and less soft tissue damage.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Evaluar los resultados clínicos y radiológicos en el tratamiento del hallux valgus moderado y grave mediante la realización de una doble osteotomía percutánea.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Material y métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se presenta un estudio retrospectivo de 45 pies intervenidos en 42 pacientes diagnosticados de hallux valgus moderado-severo, operados en un solo centro y por el mismo cirujano entre mayo del 2009 y marzo del 2013. Dos pacientes no acudieron a los controles posquirúrgicos. Se registraron los resultados clínicos y radiológicos.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Según la escala de la American Orthopedic Foot and Ankle Society (AOFAS) se obtuvo una mejoría de la puntuación de 48,14<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4,79 puntos a 91,28<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8,73 puntos. Radiográficamente se obtuvo una disminución en el AIM de 16,88<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2,01 a 8,18<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3,23 y en el AHV de 40,02<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6,50 a 10,51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6,55. Hubo un caso de hallux varus, un caso de seudoartrosis, un síndrome doloroso regional complejo tipo <span class="elsevierStyleSmallCaps">I</span>, una infección que se resolvió con antibióticos y un caso de movilización de la osteosíntesis usada que requirió reintervención abierta.</p> <span class="elsevierStyleSectionTitle" id="sect0055">Discusión</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Las osteotomías percutáneas distales aisladas del primer metatarsiano muestran limitaciones a la hora de enfrentarse a casos de hallux valgus moderado y severo. La técnica descrita añade las ventajas de la cirugía mínimamente invasiva, ampliando las indicaciones a deformidades severas.</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La doble osteotomía percutánea es una técnica reproducible que permite la corrección de deformidades severas con buenos resultados clínicos y radiológicos y con una tasa de complicaciones similares a otras técnicas, con tiempos operatorios más cortos y menor daño de partes blandas.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Díaz Fernández R. Tratamiento del hallux valgus moderado y severo mediante doble osteotomía percutánea del primer metatarsiano. Rev Esp Cir Ortop Traumatol. 2015;59:52–58.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1280 "Ancho" => 975 "Tamanyo" => 176277 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Percutaneous double osteotomy surgical technique. (a) Introduction of a Kirschner wire and closure of the osteotomy. (b) Fixation of the wire to the first wedge. (c) Lateral view of the double osteotomy and Akin osteotomy.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1090 "Ancho" => 2334 "Tamanyo" => 175697 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Double osteotomy with correction of the DMAA (PASA) and base osteotomy fixed with a Kirschner wire (left) and 1 needle (right), in both cases associated to Weil type osteotomies of the lesser metatarsals.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1196 "Ancho" => 3000 "Tamanyo" => 258589 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Comparative radiographs in a 20-year-old patient who was intervened through the technique described with excellent results.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">AOFAS: American Orthopedic Foot and Ankle Society scale; DMAA: distal metatarsal articular angle; HVA: <span class="elsevierStyleItalic">hallux valgus</span> angle; IMA: intermetatarsal angle between the first and second metatarsals.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">IMA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">HVA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">DMAA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">AOFAS \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.88<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.02<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.09<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48.14<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.18<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.52<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>6.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91.28<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>8.73 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Improvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.77<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.20<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.56<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.12<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>23.65 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab635653.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Radiographic and American Academy of Foot and Ankle Surgery (AOFAS) scale results, along with mean pre- and postoperative values.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">AOFAS: American Orthopedic Foot and Ankle Society scale; HVA: <span class="elsevierStyleItalic">hallux valgus</span> angle; IMA: intermetatarsal angle between the first and second metatarsals.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Number of patients (feet) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Technique \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">IMA improvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">HVA improvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">AOFAS improvement \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Magnan et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82 (118) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percutaneous subcapital osteotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.8° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88.2 (postop.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Merino Pérez et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (70) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subcapital osteotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.3° (postop.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.7° (postop) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chaparro et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 (73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percutaneous double osteotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.34° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.53° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.91 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bauer et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82 (104) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reverdin-Isham \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cano et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mini tight-rope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">De Lavigne et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percutaneous double osteotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Serie actual \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44 (49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percutaneous double osteotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.77° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.20° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab635652.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Comparison with published studies which used a percutaneous double osteotomy or percutaneous distal osteotomy in moderate or severe cases of <span class="elsevierStyleItalic">hallux valgus</span>.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:26 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento quirúrgico percutáneo del <span class="elsevierStyleItalic">hallux valgus</span> mediante osteotomías múltiples" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. De Prado" 1 => "P.L. Ripoll" 2 => "J. Vaquero" 3 => "P. Golanó" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Cir Ortop Traumatol" "fecha" => "2003" "volumen" => "47" "paginaInicial" => "406" "paginaFinal" => "416" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous distal metatarsal osteotomy for correction of <span class="elsevierStyleItalic">hallux valgus</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Magnan" 1 => "L. Pezzè" 2 => "N. Rossi" 3 => "P. Bartolozzi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Bone Joint Surg" "fecha" => "2005" "volumen" => "87-A" "paginaInicial" => "1191" "paginaFinal" => "1199" "itemHostRev" => array:3 [ "pii" => "S014521261200046X" "estado" => "S300" "issn" => "01452126" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous double metatarsal osteotomy for correction of severe <span class="elsevierStyleItalic">hallux valgus</span> deformity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. De Lavigne" 1 => "Q. Rasmont" 2 => "B. Hoang" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Acta Orthop Belg" "fecha" => "2011" "volumen" => "77" "paginaInicial" => "516" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21954762" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous hallux valgus surgery: a prospective multicenter study of 189 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T. Bauer" 1 => "C. De Lavigne" 2 => "D. Biau" 3 => "M. De Prado" 4 => "S. Isham" 5 => "O. Laffenétre" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ocl.2009.05.002" "Revista" => array:6 [ "tituloSerie" => "Orthop Clin North Am" "fecha" => "2009" "volumen" => "40" "paginaInicial" => "505" "paginaFinal" => "514" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19773056" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous <span class="elsevierStyleItalic">hallux valgus</span> correction using the Reverdin-Isham osteotomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Bauer" 1 => "D. Biau" 2 => "A. Lortat-Jacob" 3 => "P. Hardy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.otsr.2010.01.007" "Revista" => array:6 [ "tituloSerie" => "Orthop Traumatol Surg Res" "fecha" => "2010" "volumen" => "96" "paginaInicial" => "407" "paginaFinal" => "416" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20488776" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous distal metatarsal osteotomy versus distal chevron osteotomy for correction of mild-to-moderate hallux valgus deformity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Y.A. Radwan" 1 => "A.M. Mansour" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00402-012-1585-5" "Revista" => array:6 [ "tituloSerie" => "Arch Orthop Trauma Surg" "fecha" => "2012" "volumen" => "132" "paginaInicial" => "1539" "paginaFinal" => "1546" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22821414" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Hallux valgus</span> surgery: the minimally invasive bunion correction (SERI)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Giannini" 1 => "F. Ceccarelli" 2 => "R. Bevoni" 3 => "F. Vannini" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Tech Foot Ankle Surg" "fecha" => "2003" "volumen" => "2" "paginaInicial" => "11" "paginaFinal" => "20" ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Minimally invasive <span class="elsevierStyleItalic">hallux valgus</span> correction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Oliva" 1 => "U.G. Longo" 2 => "N. Maffulli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ocl.2009.06.005" "Revista" => array:7 [ "tituloSerie" => "Orthop Clin North Am" "fecha" => "2009" "volumen" => "40" "paginaInicial" => "525" "paginaFinal" => "530" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19773058" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0145212612003839" "estado" => "S300" "issn" => "01452126" ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Hallux valgus</span> correction by the method of Bösch: a new technique with a seven-to-ten-year follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Bösch" 1 => "S. Wanke" 2 => "R. Legenstein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Foot Ankle Clin" "fecha" => "2000" "volumen" => "5" "paginaInicial" => "485" "paginaFinal" => "498" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11232393" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento de <span class="elsevierStyleItalic">hallux valgus</span> moderado con sistema mini TightRope<span class="elsevierStyleSup">®</span>: técnica modificada" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.A. Cano-Martínez" 1 => "F. Picazo-Marín" 2 => "J. Bento-Gerard" 3 => "G. Nicolás-Serrano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Cir Ortop Traumatol" "fecha" => "2011" "volumen" => "55" "paginaInicial" => "358" "paginaFinal" => "368" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Resultados a largo plazo de la osteotomía percutánea del metatarso distal (técnica de Bösch modificada) para la corrección del <span class="elsevierStyleItalic">hallux valgus</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Merino Pérez" 1 => "I. Ibor Ureña" 2 => "J.M. Rodríguez Palomo" 3 => "L.M. Fernández Rioja" 4 => "N. Martín Larrañaga" 5 => "J.I. Vicinay Olabarria" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cir Ortop Traumatol" "fecha" => "2010" "volumen" => "54" "paginaInicial" => "174" "paginaFinal" => "178" "itemHostRev" => array:3 [ "pii" => "S0145212611003584" "estado" => "S300" "issn" => "01452126" ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteotomies for <span class="elsevierStyleItalic">hallux valgus</span> correction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H.J. Trnka" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.fcl.2004.10.002" "Revista" => array:6 [ "tituloSerie" => "Foot Ankle Clin" "fecha" => "2005" "volumen" => "10" "paginaInicial" => "15" "paginaFinal" => "33" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15831256" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Technik und erste Ergebnisse der subkutanen distalen metatarsale-I-osteotomie" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Bösch" 1 => "H. Markowski" 2 => "V. Rannicher" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Orthop Prax" "fecha" => "1990" "volumen" => "26" "paginaInicial" => "51" "paginaFinal" => "56" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Die Kramer Osteotomie zur behandlung des <span class="elsevierStyleItalic">hallux valgus</span> und des digitus quintus varus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Kramer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Operat Orhop Traumat" "fecha" => "1990" "volumen" => "2" "paginaInicial" => "29" "paginaFinal" => "38" ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiographic results after percutaneous distal metatarsal osteotomy for correction of <span class="elsevierStyleItalic">hallux valgus</span> deformity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.R. Kadakia" 1 => "J.P. Smerek" 2 => "M.S. Myerson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3113/FAI.2007.0355" "Revista" => array:6 [ "tituloSerie" => "Foot Ankle Int" "fecha" => "2007" "volumen" => "28" "paginaInicial" => "355" "paginaFinal" => "360" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17371659" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "First metatarsal osteotomy nonunion and malunion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.M. Vora" 1 => "M.S. Myerson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.fcl.2004.10.001" "Revista" => array:6 [ "tituloSerie" => "Foot Ankle Clin" "fecha" => "2005" "volumen" => "10" "paginaInicial" => "35" "paginaFinal" => "54" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15831257" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparing proximal and distal metatarsal osteotomy for moderate to severe hallux valgus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "B. Chuckpaiwong" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00264-012-1656-9" "Revista" => array:6 [ "tituloSerie" => "Int Orthop" "fecha" => "2012" "volumen" => "36" "paginaInicial" => "2275" "paginaFinal" => "2278" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22986505" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ambulante kombinierte subcapitale und proximale opening wedge Osteotomie bei <span class="elsevierStyleItalic">Hallux valgus</span> und Metatarsus primus varus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "W. Willauschus" 1 => "M. Schneider" 2 => "W. Schaaf" 3 => "W. Graham-Schaaf" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "FussSprungg" "fecha" => "2006" "volumen" => "4" "paginaInicial" => "36" "paginaFinal" => "46" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hallux valgus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.J. Coughlin" 1 => "R.A. Mann" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "titulo" => "Surgery of the foot and ankle" "paginaInicial" => "226" "paginaFinal" => "227" "edicion" => "8.a edición. Tomo I." "serieFecha" => "2007" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical rating systems for ankle, hindfoot, midfoot, hallux, and lesser toes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H.B. Kitaoka" 1 => "I.J. Alexander" 2 => "R.S. Adelaar" 3 => "J.A. Nunley" 4 => "M.S. Myerson" 5 => "M. Sanders" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Foot Ankle Int" "fecha" => "1994" "volumen" => "15" "paginaInicial" => "349" "paginaFinal" => "353" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7951968" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hallux valgus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. De Prado" 1 => "P.L. Ripoll" 2 => "P. Golanó" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:6 [ "titulo" => "Cirugía percutánea del pie. 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Rubíes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev ABTPé" "fecha" => "2010" "volumen" => "4" "paginaInicial" => "67" "paginaFinal" => "75" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.J. Coughlin" 1 => "R.E. Carlson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Foot Ankle Int" "fecha" => "1999" "volumen" => "20" "paginaInicial" => "762" "paginaFinal" => "770" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10609703" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0145212609000307" "estado" => "S300" "issn" => "01452126" ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Chevron osteotomy for correction of hallux valgus – comparison of findings after two and five years of follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H.J. Trnka" 1 => "A. Zembsch" 2 => "M.E. Easley" 3 => "M. Salzer" 4 => "P. Ritschl" 5 => "M.S. Myerson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J. Bone Joint Surg Am" "fecha" => "2000" "volumen" => "82" "paginaInicial" => "1373" "paginaFinal" => "1378" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11057464" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R. Zettl" 1 => "H.J. Trnka" 2 => "M. Easley" 3 => "M. Salzer" 4 => "P. Ritschl" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Orthop Trauma Surg" "fecha" => "2000" "volumen" => "120" "paginaInicial" => "397" "paginaFinal" => "402" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10968526" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Reverdin-Isham procedure for the correction of the hallux aductu valgus – a distal metatarsal osteotomy procedure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S. Isham" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Pediatr Med Surg" "fecha" => "1991" "volumen" => "8" "paginaInicial" => "81" "paginaFinal" => "94" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/19888856/0000005900000001/v1_201501110043/S198888561400128X/v1_201501110043/en/main.assets" "Apartado" => array:4 [ "identificador" => "7577" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/19888856/0000005900000001/v1_201501110043/S198888561400128X/v1_201501110043/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S198888561400128X?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 1 | 10 |
| 2024 October | 60 | 13 | 73 |
| 2024 September | 109 | 81 | 190 |
| 2024 August | 57 | 21 | 78 |
| 2024 July | 47 | 8 | 55 |
| 2024 June | 30 | 11 | 41 |
| 2024 May | 39 | 12 | 51 |
| 2024 April | 40 | 6 | 46 |
| 2024 March | 58 | 9 | 67 |
| 2024 February | 76 | 26 | 102 |
| 2024 January | 84 | 31 | 115 |
| 2023 December | 73 | 28 | 101 |
| 2023 November | 66 | 25 | 91 |
| 2023 October | 123 | 46 | 169 |
| 2023 September | 91 | 15 | 106 |
| 2023 August | 67 | 10 | 77 |
| 2023 July | 123 | 45 | 168 |
| 2023 June | 107 | 24 | 131 |
| 2023 May | 162 | 29 | 191 |
| 2023 April | 164 | 36 | 200 |
| 2023 March | 110 | 29 | 139 |
| 2023 February | 64 | 10 | 74 |
| 2023 January | 59 | 13 | 72 |
| 2022 December | 71 | 10 | 81 |
| 2022 November | 67 | 13 | 80 |
| 2022 October | 56 | 15 | 71 |
| 2022 September | 81 | 17 | 98 |
| 2022 August | 68 | 9 | 77 |
| 2022 July | 51 | 6 | 57 |
| 2022 June | 44 | 12 | 56 |
| 2022 May | 89 | 15 | 104 |
| 2022 April | 46 | 9 | 55 |
| 2022 March | 88 | 18 | 106 |
| 2022 February | 82 | 8 | 90 |
| 2022 January | 103 | 12 | 115 |
| 2021 December | 60 | 11 | 71 |
| 2021 November | 64 | 18 | 82 |
| 2021 October | 75 | 11 | 86 |
| 2021 September | 49 | 14 | 63 |
| 2021 August | 47 | 5 | 52 |
| 2021 July | 42 | 14 | 56 |
| 2021 June | 56 | 11 | 67 |
| 2021 May | 69 | 10 | 79 |
| 2021 April | 129 | 26 | 155 |
| 2021 March | 41 | 10 | 51 |
| 2021 February | 31 | 25 | 56 |
| 2021 January | 18 | 6 | 24 |
| 2020 December | 1 | 0 | 1 |
| 2018 February | 29 | 4 | 33 |
| 2018 January | 33 | 2 | 35 |
| 2017 December | 20 | 2 | 22 |
| 2017 November | 37 | 1 | 38 |
| 2017 October | 25 | 4 | 29 |
| 2017 September | 28 | 4 | 32 |
| 2017 August | 29 | 10 | 39 |
| 2017 July | 8 | 6 | 14 |
| 2017 June | 12 | 3 | 15 |
| 2017 May | 7 | 0 | 7 |
| 2017 April | 10 | 4 | 14 |
| 2017 March | 15 | 62 | 77 |
| 2017 February | 8 | 1 | 9 |
| 2017 January | 2 | 9 | 11 |
| 2016 November | 0 | 1 | 1 |
| 2016 October | 0 | 1 | 1 |
| 2016 September | 0 | 5 | 5 |
| 2016 August | 0 | 1 | 1 |
| 2016 July | 0 | 2 | 2 |
| 2016 June | 0 | 7 | 7 |
| 2016 May | 0 | 7 | 7 |
| 2016 April | 0 | 9 | 9 |
| 2016 March | 0 | 12 | 12 |
| 2016 February | 0 | 14 | 14 |
| 2016 January | 0 | 9 | 9 |
| 2015 December | 0 | 11 | 11 |
| 2015 November | 0 | 12 | 12 |
| 2015 October | 0 | 10 | 10 |
| 2015 September | 0 | 6 | 6 |
| 2015 August | 0 | 3 | 3 |
| 2015 July | 0 | 2 | 2 |
| 2015 June | 1 | 1 | 2 |
| 2015 April | 0 | 1 | 1 |
| 2015 February | 2 | 2 | 4 |
| 2015 January | 7 | 2 | 9 |
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