Surgeon point of view
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Surgeon point of view Congruent joint Joint space (degenerative joint disease) Metatarsal length Patient point of view: Patient point of view: No bump Straight toe Cosmetic scar Good motion…enough to wear high hell No pain Almost: restituo ad integrum… Stretching the indications (too big deformity for the procedure) Stretching the indications (too big deformity for the procedure) Wrong procedure for the problem Bad technique of an adequate procedure Inadequate Medial capsule plication Inadequate soft tissue release ( Transverse lig., ADD.H.) Inadequate post-op. dressing An expected complication for that procedure An expected complication for that procedure A complication non specific to the procedure A misunderstanding of the expected results …….Patient versus Surgeon expectation…. Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complication after Keller Resection Arthroplasty Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complication after Keller Resection Arthroplasty Recurrent deformity Recurrent deformity Malunion Stiffness Recurrent deformity Recurrent deformity Malunion Stiffness Avascular necrosis 1. Plane of osteotomy 1. Plane of osteotomy 2. DMAA 3. Too big deformity for the procedure 4. Loose capsulorraphy 5. …Lateral soft tissue release Avoid: Avoid: Doing the osteotomy in line at right angle with the first metatarsal ; It is more unstable et tend to go back to it’s previous position Tend to the bone length (Stiffness) Instead right angle to the foot But: Avoid shortening Here the osteotomy was done to done in the axis of the bone, instead of the foot: Here the osteotomy was done to done in the axis of the bone, instead of the foot: Result: 4 weeks post-op: distal fragment back to it’s original position So if needed to lenghten the bone: a good fixation needed Remove the Medial Eminence parallel to the foot, not the metatarsal. Primo: Primo: Danger: Make a straight toe with an incongruent joint out of a valgus toe but congruent joint With time will displace HV angle < 30 ° IM angle < 14 ° Tension should be just enough to prevent lateral displacement Tension should be just enough to prevent lateral displacement With Akin : no over correction Without Akin : minimal overcorrection But Too tight capsulorraphy might lead to stiffness. Multiple studies: Multiple studies: STR with distal osteotomy : Safe Incidence of AVN is so low, ≤ 1 % (periosteal stripping is more a concern), Most expert : Caution… if a STR is needed The indication is probably stretch… * Proximal osteotomy … * Adding a Akin procedure are safer. Recurrent deformity Recurrent deformity Malunion Stiffness Avascular necrosis Improper cuts may lead to instability Improper cuts may lead to instability Dorsiflexion or Plantarflexion Lateral tilt if the translation too big If the cut is at right angle to the foot or slightly caudal (shortening) usually these are very stable and some do not fix them… For more security a fixation is advisable. Orthosorb : If only translational instability Otherwise: a more secure fixation Shortening of 1rst Metatarsal: Shortening of 1rst Metatarsal: Excessive impaction (osteopenic) Plane of osteotomy too caudal Transfer Metatarsalgia Treatment: (beside orthosis) Lengthening of 1st Metatarsal (Rarely) Shortening lesser Metatarsal ( Better) Recurrent deformity Recurrent deformity Malunion Stiffness Avascular necrosis If after correction the join is incongruent If after correction the join is incongruent Faillure to recognise the elevated DMAA > 10 ° Do a biplane Chevron Avoid Dorsal incisions Careful not to damage sesamoid apparatus Recurrent deformity Recurrent deformity Malunion Stiffness Avascular necrosis Avascular necrosis Avascular necrosis Less than 1% after STR In fact, it is the excessive periosteal stripping, but… Difficult salvage: Resection arthroplasty MTP Fusion 1. Transfer Metatarsalgia 1. Transfer Metatarsalgia 2. Mal-Union Dorsi-Flexion Plantar-Flexion Medial or Lateral tilt 3. Delay, Non-Union If there is no malunion but only metatarsalgia from a short first metatarsal: If there is no malunion but only metatarsalgia from a short first metatarsal: Lengthening of 1rst Metatarsal Rarely indicated (risk of stiffness and osteoarthrisis) Shortening Lesser Metatarsal Important to restore the normal cascade pattern Usually M2, but always check M3 for shortening osteotomy 1st Metatarsal shortening 1st Metatarsal shortening Dorsi-Flexion mal-union Long 2nd metatarsal M2>M1 Long 2nd metatarsal M2>M1 Look at M-3… Healing in medial rotation Healing in medial rotation Lateral rotation Rarely : non union Rarely : non union If the alignment is good, be patient, delay union (poor fixation) usually heal (in metaphyseal area) So to avoid all these displacement: So to avoid all these displacement: A fixation is needed (not the cerclage wire) Selective Indications and Principles Selective Indications and Principles Metatarsal length absolute Need a long 1st Metatarsal or Need to shorten at the same time the 2nd ( and 3rd PRN If the 1st is not longer than the 2nd or 3rd HV angle <40° ( 30-40) IM angle <14° Need a Internal fixation ________________________Ideal Indication: H Valgus with some degenerative changes That some decompression is needed Might be osteoporotic ( witch is a contra-indication for screw fixation like in Ludloff, Scarf, Mann osteotomies) Long term FU (Mean:21 years) n=105 Long term FU (Mean:21 years) n=105 72% Totally satisfied 16% Reservation: Pain, 6% Look, 3% ROM AOFAS-Hallux MTP Score Compare to author 4 categories Excellent group: AOFAS score: 95.2 37 % Good : “ : 86.3 28.2% 65% = Excellent +Good 92.4 % would agree to undergo the operation again Salvage treatment of failed Hallux Valgus operation with proximal first metatarsal osteotomy and distal soft- tissue reconstruction Salvage treatment of failed Hallux Valgus operation with proximal first metatarsal osteotomy and distal soft- tissue reconstruction Journal Foot & Ankle Int. Volume 19 number 3 March 1998 Harold B. Kitaoka, Gary l. Pazer 15 patients after failed Distal proceducre ( Silver or Chevron) TX: Crescentic Mann Osteotomy and Soft-tissue release HV angle 33° 14 ° IM angle 12.6 ° 5.7 ° Complications: 44% 3 Transfer Metatarsalgia 2 Mal-Union 1 Hallux Varus 1 Non-Union K. Johnson Classical: EHL tranfert: K. Johnson Classical: EHL tranfert: IP Fusion & Total EHL cut distal Modification: Half of EHL No need to fuse IP joint Silver Bunionectomy (1923)Silver Bunionectomy (1923)Medial Eminence removal + Adductor Hallucis divided + Distal Capsular flap + Overlapping Plantar & Dorsal capsule Will it come back Doctor? Will it come back Doctor? This is one of the reasons of the bad reputation of Hallux Valgus surgery McBride (1928)McBride (1928)Medial Eminence removal + Release of Conjoint tendon TRANSFER Conjoint tendon to 1st Meta. Head + Removal of fibular sesamoid Duvries-Mann modification of McBride Adductor tendon cut and transfer to 1st Meta, head ( not the Conjoint tendon) Suture Medial capsule of 2nd Meta to lat. Capsule of 1st Metatarsal head No fibular sesamoid excision First MTP fusion First MTP fusion Modified Keller resection arthroplasty Valenti arthroplasty Dorsi-Flexion: 10-15 ° to the floorDorsi-Flexion: 10-15 ° to the floorValgus : 10 ° - 15°Fusion rate : 88 % after failed H. Valgus surgery 94% – 100 % at initial surgery 94 % 2 Steinmann pins 96 % 2 (3.5mm) cross screws 97 % Multiple threaded K-wirws 100% conical reamming and plate Less with Interpositionnal Bone Graf after Failed Keller Late IP Degeneration: 15 % (3 time more in Women) increase with HV angle >20° First MTP fusion First MTP fusion Modified Keller resection arthroplasty Valenti arthroplasty First MTP fusion First MTP fusion Modified Keller resection arthroplasty Valenti arthroplasty NB. The lower part of the joint and sesamoid apparatus are left intact Salvage of a failed Keller Resection Arthroplasty Salvage of a failed Keller Resection Arthroplasty MACHANECK JR., FELIX; EASLEY, MARK E; GRUBER,FLORIAN ; RITSCHL, PETER; TRNKA, HANS-JORGJBJS A June 2004, Volume 86-A, Number 6 1131-1138 They recommend fusion ( they do not lengthen with a bone graft. 15 °of valgus, 20°Dorsiflexion ( M1-P1) With 2 cross cannulated 3.0 mm screws Often associated with metatarsal shortening osteotomy (mostly Weil osteotomy) NB. Fusion rate with interposition graft is lower & more difficult After more than 90 minutes of surgery… After more than 90 minutes of surgery… Some controversy Some controversy Classical: Lapidus fusion 1st M-Cuneiform+ STR Signs of Ligamentous Laxity (Breighton criteria) D-Flex small finger : 1 point per side Thumb-Forearm : “ Elbow hyperextension >10° : “ Knee hyperextension >10° : “ Palm-Floor : 1 point Value >5 : LIGAMENTOUS LAXITY Squeeze test: If there is a total correction of the Hallux Valgus suggest Hypermobity Otherwise: more rigid deformity Tarso-Metatarsal Clinical Test: >4° in Saggital plane Klaue device ( M.Caughlin) >9 mm (sagittal plane)Radiologic signs: Radiologic signs: Dorsal elevation 1st Meta - Thickening 2nd Metatarsal medial cortical shaft - Arthritis of 2nd TM joint Some recent studies didn’t show any difference with Osteotomy (proximal or distal) and Lapidus procedure ! Some recent studies didn’t show any difference with Osteotomy (proximal or distal) and Lapidus procedure ! Faber, Frank W.M., Mulder, Paul, Verhaar, Jan Role of first Ray Hypermobility in the outcome of the Hohmann and the Lapidus Procedure. A prospective Randomizeial Involving One Hundred and One Feet JBJS March 2004 Volume 86-A, number 3 Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complication after Keller Resection Arthroplasty What would you do?
5 Months after
Mal-Union Mal-Union Dorsi-Flexion Plantar-Flexion Non-Union Excessive Shortening Under-correction Over-correction Mal-Union: the most common complication (Dorsi-Flexion,Recurrence Mal-Union: the most common complication (Dorsi-Flexion,Recurrence 1. Incorrect orientation of the osteotomy When patent lie supine: Hips are in external Rotation the cut tend to be PROXIMAL-MEDIAL to DISTAL-LATERAL elevation of Metatarsal head 2. Positioning of the Osteotomy (ideal: 10-12 mm) Too distal: * cortical bone… Heals less readily * Narrow shaft .… More unstable Too Proximal: Fixation is difficult or impossible _ 3. Fixation of the Osteotomy * Fixation is problematic Proximal: cancellous, short. Distal: Hard cortical Screw best Mal-Union Mal-Union Dorsi-Flexion: Sometimes difficult to correct TX: Some type of plantar osteotomy If excessive shortening: BONE GRAFTING - Plantar-Flexion: * Dorsi-Flexion osteotomy To avoid shortening : a crescentic osteotomy can be done in the sagittal plane * Non-Union: rarely. If occurs: Bone grafting Mal-Union Mal-Union Dorsi-Flexion Plantar-Flexion Non-Union Excessive Shortening Under-correction Over-correction Excessive Shortening Excessive Shortening Can be a significant problem Similar as after Mitchell Oseotomy Sometimes: Lengthening 1st meta Generally: Shortening 2nd ( ? + 3rd ) Mal-Union Mal-Union Dorsi-Flexion Plantar-Flexion Non-Union Excessive Shortening Under-correction Over-correction Under-correction (of IM angle)Under-correction (of IM angle)TX: another Crescentic Osteotomy or an Open wedge Osteotomy Over-correction: Often result in a HALLUX VARUS Indications for Proximal Osteotomy Indications for Proximal Osteotomy IM angle > 14 ° (13-15 °) + STR HV angle > 40 ° (30-40 °) Goal: To correct the intermetatarsal angle) Contraindication: 1st MTP Osteoarthritis DMAA >15-20° ( Unless Double osteotomy) (Severe H Valgus with Hypermobility) Excessive Lateral Soft Tissue Release *Interruption of Lateral Conjoint Tendon Excessive Lateral Soft Tissue Release *Interruption of Lateral Conjoint Tendon (Overpull of Abductor Hallucis) Excision of Lateral sesamoid Excessive medial capsule tightening Excessive Medial Eminence removing Overcorrection of IM angle Excessive Overcorrection with Postop dressing Excessive Lateral Soft Tissue Release Excessive Lateral Soft Tissue Release *Interruption of Lateral Conjoint Tendon (Overpull of Abductor Hallucis) Excision of Lateral sesamoid Excessive medial capsule tightening Excessive Medial Eminence removing Overcorrection of IM angle Excessive Overcorrection with Post-op dressing TECHNIC 1 TECHNIC 1 1. Adductor Hallucis Identified and isolated from Flexor Hallucis Brevis with Hemostat clamp. No need to relocate on Meta. neck (Conjoint tendon: Add. Hallucis + FHB) 2. Metatarso-Sesamoid suspensor Lig. (to free the fibular sesamoid, that can after be relocated under the Metatarsal head Not cutting the: Metatarso-Phalangial Lig. (Collateral lig.) re.: Risk of H. Varus N.B. Deep Transverse Metatarso-phalangial Ligament doesn’t need to be cut TECHNIC 2 TECHNIC 2 1. Conjoint tendon ( PIB: Phalangial Insertion Band) 2. Metatarso-Sesamoid suspensor Lig. (to free the fibular sesamoid, that can after be relocated under the Metatarsal head Not cutting the: Metatarso-Phalangial Lig. (Collateral lig.) re.: Risk of H. Varus N.B. Deep Transverse Metatarso-phalangial Ligament doesn’t need to be cut Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complication after Keller Resection Arthroplasty General Indications: General Indications: Same as Proximal Osteotomy IM >14-18° More versatile More stable More demanding Barouk, L.S., SCARF OSTEOTOMY FOR HALLUX VALGUS CORRECTION Barouk, L.S., SCARF OSTEOTOMY FOR HALLUX VALGUS CORRECTION Foot and Ankle Clinics, Volume 3, September 2000, 525-580 * Results: (123 feet, 76 patients) FU 3 to 46 months (13) HVA: 35.2° 16.4 ° IMA: 17.4° 10.2° ROM: 75 ° (DF: 65° PF: 10°) Complications: 2 Stress fractures ( at proximal osteotomy site) 4 Recurrences (HVA >25°) 2 need capsuloplasty 5 Over-correctionHallux Varus (Learnig curve: 8%3%) 3% Prominent Hardware, less with Threaded head screws. 3 Osteonecrosis ( 2 need arthrodesis) Rare : Under-correction or Stiffness (early mobilization) Off 244 patients refer by GP after all 152 (66 %) :Failed first ray Surgery 42% : After Mitchell Procedure 14% : After Keller 14% : After First MTP Fusion 8.6% : After Silver ( Bumpectomy+ STR) Diagnosis ( 244 patients) 34% : Transfer Metatarsalgia 26% : Recurrent H. Valgus 18% : Lesser digit deformity 5% : Continued pain over 1 MTP Revision surgery Revision surgery 32%: Lesser Metatarsal surgery 23%: Lesser Toe surgery 21%: First Metatarsal-Phalanx 4% : First & Lesser Metatarsal Scarf-Akin and Weil or Schwartz 86% Might have been avoid Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complication after Keller Indication for Lapidus Procedure: Indication for Lapidus Procedure: Severe Hallux Valgus, With Hypermobility (Instability of the Metatarso-Cuneiform joint) in saggital plane, particularly with Generalize Ligamentous Laxity mostly in: Hallux Valgus Juvenile with High 1-2 Inter-Metatarsal angle IM angle >18° OA 1st TMT Sometime in adult flatfoot from PTTD Should not 1. Non-union 2. Mal-Union: Dorsi-Flexion (mostly) 3. Excessive Shortening 1. Non-UNION (10-12%....7% to 50%!!) 1. Non-UNION (10-12%....7% to 50%!!)Significantly more common than Mal-Union Very high rates Frequently symptomatic Need: Multiple screw fixation and Cast Immobilisation and A period of non-weight bearing ( 4-6 weeks)(Union rate better with Bone Grafting) Popularize by Sig. Hansen Popularize by Sig. Hansen Minimal articular resection C1 M1 M1 M2 Big Screws (4.0-4.5) Lag Screw tech. Local Bone Graft Ian M. Thompson; Donald R. Bohay; John G. Anderson Ian M. Thompson; Donald R. Bohay; John G. Anderson Foot & Ankle Int. Volume 26 Number 9, September 2005 201 feet Non-Union : 4 % ( 8 cases) 5 Had previous Bunion Surgery 2 Smokers 1 diabetic Of 201 feet, 25 (12%) had Recurrence after Previous Bunion Surgery. Out of these: 20% had Non-Union after Modified Lapidus 2. MAL-UNION 2. MAL-UNION Technically difficult re.: Dorsal incision : Poor visualisation Re.: depth of bone ۩ MEDIAL INCISION Some Plantar-Flexion of the ray usually require to compensate the shortening ( too much sesamoid pain) 3. SHORTENING: Relative to joint resection Complications after distal metatarsal osteotomy Complications after distal metatarsal osteotomy Complications after proximal osteotomy Complication after Scarf osteotomy Complications after Lapidus procedure Complication after Keller Resection Arthroplasty Salvage of a Failed Keller Resection Arthroplasty Salvage of a Failed Keller Resection Arthroplasty Machacek Lr., Felix and all. JBJS-A Vol. 86-A, Number 6, June 2005 Complications: Cock-up toe, Recurrent H Valgus, Flail toe, metatarsalgia.Group A- Treated with Fusion (29 feet), FU: 36 months 90% healed. AOFAS score: 76/90 Needed surgery: 17% need refusion (3 Mal-Union & 2 non-union) 62% Needed Lesser Metatarsal shortening ( Weil,Helal,etc.) Group B- Re-Keller or STR (EHL Z-Lenghtening) (18 feet), FU:74 monhs AOFAS score: 46/90 Non-Satisfied: 61% Cock-up: 67 % Recurrence:39% Rigidus:11% Conclusion: Fusion much better, but more demanding The Lapidus procedure as salvage After Failed Surgical Treatmen of Hallux Valgus. A Prospective Cohort Study The Lapidus procedure as salvage After Failed Surgical Treatmen of Hallux Valgus. A Prospective Cohort Study COETZEE, J.CHRIS;, RESIG,SCOTT G.,; KUSKOWSKI,MICHAEL; SALEH, KHALED J. JBJS-A January 2003,Volume 85-A Number 1 60-65 Here it is only recurrent H. Valgus AOFAS score 47.687.9 Visual Analog Pain Scale 6.2 1.4 Very satisfied: 77% Satisfied : 4% Somewhat satisfied: 19% Dissatisfied: 0 C1M1 & M1M2 Grimes, J.S., Coughlin, M. Foot & Ankle InternationalVol.27, No. 11 / 887-893/ Nov. 2006 Grimes, J.S., Coughlin, M. Foot & Ankle InternationalVol.27, No. 11 / 887-893/ Nov. 2006 The only well documented long-term results of salvage of failed hallux valgus procedures by arthrodesis of the first MTP Here M.J. Coughlin expose his results for Failed H. Valgus treated with fusion and not only for those with arthrosis Here M.J. Coughlin expose his results for Failed H. Valgus treated with fusion and not only for those with arthrosis 55% recurrence H. Valgus, 24% H. Varus, etc. AOFAS score of 73 (Excellent 39%, Good 33% Fair 24% , Poor 3%) 79% would have the surgery again Review of All Orthopaedic surgeries witch led to litigation: (USA- Glyn Thomas) Review of All Orthopaedic surgeries witch led to litigation: (USA- Glyn Thomas) Most: Foot surgery : 23 % 64% : Lesser metatarsal neck Osteotomy Good discussion Good discussion Need to repeat and repeat When they listen…( i.e. Not looking at their Question list, or not thinking at their next question, most do not really understand the technical explanations. They tend to underestimate minor warnings So… you need to be clear and need to emphasis mostly on what would be a realistic result. 1. Recognize why the first surgery failed 1. Recognize why the first surgery failed Don’t repeat the initial error… 2. Look the Whole Foot (re. Lesser Metatarsals) 3. Look if there are Degenerative changes Osteotomy parallel to the sole of the foot Osteotomy parallel to the sole of the foot Ex.: 5 mm shortening = 2 mm plantar displacement The problem in rigid foot with IPK, tend to displace the “BUMP” more proximal With a wedge resection above the 25° cut With a wedge resection above the 25° cut 5 mm shortening = 0.8 mm plantar displacement The problem: the toe is higher and do not touch the ground (but: no functional signification; cosmetic concern only) A complete removal of 2 to 3 mm slice A complete removal of 2 to 3 mm slice At an angle of 15 to 20 ° Can correct sub-luxation MTP and IPK in many cases. Not indicated in very osteoporotic patients) All healed, except ~ 1 % ( screw loosening or fracture) Results & Complications: Results & Complications: KH. Kristen, C. Berger, S. Steizig, E. Thaihammer, M. Posch, A. Engel The SCARF Osteotomy for the Correction of Hallux Valgus Deformities Foot and Ankle surgery Volume 23 Number 3 220-228, March 2003 89 patients Post-op HV: 19° IM: 6.6 ° Return to Work: 6 weeks, to Sports: 8.3 weeks Complications: 7 Recurrence 6% 4 Hallux Limitus (ROM <40°) 2 Superficial infections 1 Dislocation of distal fragment Results & Complications Results & Complications Rippstein, P; ZUnd, I: Clinical and radiological midterm results of 61 scarf osteotomies for hallux valgus deformity. Synopsis book, Second internat. AFCP spring meeting, Bordeaux May, 2000 2 years FU HV angle 32°11° IM angle 14°6° Complications: 1 Osteonecrosis Meta. Head 1 Painful Over-correction Results & Complications : Results & Complications : Valentin, B; Leemrijse, Th: Scarf osteotomy of the first metatarsal: A review of the first 56 cases (5 years follow-up) and improvement of the surgical technique. Synopsis book, Second internat. AFCP spring meeting, Bordeaux May, 2000 56 patients 5 years FU HV 38.5° 19° IM 16.6° 11° Complications: Results & Complications Results & Complications Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf osteotomies using differentiated therapy of hallux valgus. Foot and Ankle surgery 6:105-112, 2000 53 cases 14 months FU HV angle: 43° 23° IM angle : 16°8° Complications: 2 Fractures of 1st Metatarsal ( at distal screw level) Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf osteotomies using differentiated therapy of hallux valgus. Foot and Ankle surgery 6:105-112, 2000 Wagner, A; Fuhrmann, R; Abramovsky, I: Early results of Scarf osteotomies using differentiated therapy of hallux valgus. Foot and Ankle surgery 6:105-112, 2000 Rippstein, P; ZUnd, I: Clinical and radiological midterm results of 61 scarf osteotomies for hallux valgus deformity. Synopsis book, Second internat. AFCP spring meeting, Bordeaux May, 2000 Valentin, B; Leemrijse, Th: Scarf osteotomy of the first metatarsal: A review of the first 56 cases (5 years follow-up) and improvement of the surgical technique. Synopsis book, Second internat. AFCP spring meeting, Bordeaux May, 2000 The SCARF Osteotomy for the Correction of Hallux Valgus Deformities KH. Kristen, C. Berger, S. Steizig, E. Thaihammer, M. Posch, A. Engel Foot Ankle International Volume 23 number 3 march 2002 Long term FU (Mean:21 years) n=105 Long term FU (Mean:21 years) n=105 72% Totally satisfied 16% Reservation: Pain 6% Reservation: Apparence 3% Reservation: ROM 4% Not satisfied AOFAS-Hallux MTP Score Compare to author 4 categories Excellent group: AOFAS score: 95.2 37 % Good : “ : 86.3 28.2% 65% = Exc.+Good Satisfactory : “ : 67.7 21.4% Poor : “ : 55.4 13.6% Initially At FU Initially At FU Mean HV angle 33° 17° Mean IM angle 22.5 ° 21% recurred over medial eminence 13.3 IPK under 2nd Metatarsal Overall satisfaction at 21 y. FU: Excellent +Good: 65% 92.4 % would agree to undergo the operation again Dostları ilə paylaş:
