Proximal Supination Osteotomy for Hallux Valgus: Comparison of Clinical and Radiologic Outcomes for the Most Severe Deformities

BACKGROUND

There is little available information regarding the difference in outcomes between severe hallux valgus (S-HV), defined as 40 degrees ≤ hallux valgus angle (HVA) < 50 degrees, and what we consider to be "super-severe HV" (SS-HV), defined as >50 degrees, following a proximal metatarsal osteotomy. We aimed to retrospectively compare the outcomes of a proximal metatarsal osteotomy in S- and SS-HV.

METHODS

The series consisted of 57 female patients (57 feet) treated with a proximal supination osteotomy for symptomatic S- and SS-HV (33 and 24 feet, respectively). The outcome measures included radiographic parameters and for 45 patients included the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) score, and a visual analog scale pain score (VAS-PS) preoperatively and at a minimum follow-up of 12 months with a median of 26 months. No significant differences were found in age, body mass index, and the duration of follow-up between patients with S-HV and SS-HV (P > .10 for all comparisons) with the numbers available.

RESULTS

Preoperative HVA in patients with S- and SS-HV was significantly improved at the final follow-up (P < .0001 for both comparisons). No significant differences in postoperative HVA and IMA were observed between patients with S- and SS-HV (P = .51 and .50, respectively). All 5 preoperative subscale scores of SAFE-Q in patients with S- and SS-HV significantly improved postoperatively (P < .01 for all comparisons). Preoperative VAS-PS in patients with S- and SS-HV significantly improved postoperatively (P < .0001 and <.009, respectively). There were no significant differences in preoperative and postoperative scores of all the SAFE-Q subscales and VAS-PS between patients with S-HV and SS-HV (P > .10 for all) with the numbers available.

CONCLUSION

We found for this patient group that a proximal supination osteotomy can achieve a large correction for SS-HV as well as S-HV and significantly improve radiologic and clinical outcomes in SS-HV. The outcomes between patients with S- and SS-HV were not different in this series.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Operative outcomes of hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joints

BACKGROUND

Hallux valgus is sometimes accompanied by osteoarthritis of the lesser tarsometatarsal joint. However, information on the operative procedures and outcomes for the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint simultaneously is limited. We aimed to describe this operative procedure and evaluate the outcomes of the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint.

METHODS

Fifteen patients (17 feet; average age, 66.9 years; average follow-up, 59.4 months; and minimum follow-up, 24 months) with symptomatic hallux valgus accompanied by painful osteoarthritis of the lesser tarsometatarsal joint were enrolled. All feet showed osteoarthritis of the second and/or third tarsometatarsal joint on dorsoplantar weight-bearing radiograph. The operative procedure included a proximal osteotomy of the first metatarsal and arthrodesis of the lesser tarsometatarsal joint with an autologous bone graft.

RESULTS

The mean Japanese Society for Surgery of the Foot hallux metatarsophalangeal-interphalangeal score significantly improved from 54.8 points preoperatively to 91.7 points postoperatively (P <0.001). The mean postoperative visual analog score (15 feet) was 1.0 (0-3.9). Preoperative midtarsal pain disappeared in 14 feet and decreased in one foot postoperatively. Preoperative metatarsalgia was found in five feet, of which, it disappeared in two feet, decreased in two feet, and transferred to another region in one foot at the latest follow-up. The mean hallux valgus and intermetatarsal angles were 42.4° and 18.4° preoperatively, which decreased significantly to 12.5° and 6.9° postoperatively, respectively (P <0.001, all). Recurrence of hallux valgus (hallux valgus angle ≥20°) was observed in two feet (11.8%). Nonunion of the third tarsometatarsal joint was observed in one foot (3.1% among 32 joints).

CONCLUSIONS

The clinical and radiographic results indicated that operative treatment for hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joint significantly improves forefoot and midfoot pain and function and has low complication rates.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Radiological characteristics of hallux valgus with metatarsus adductus: A matched case-control study

BACKGROUND

No evidence has been found to support the hypothesis that there is a correlation between hallux valgus (HV) and intermetatarsal (IM) angles in HV with metatarsus adductus (MA) and that IM angle in HV with MA is lower than that in HV without MA. The present study aimed to analyze the radiographic characteristics of HV with MA compared to matched controls and to clarify the differences between HV with MA and without MA.

METHODS

Preoperative radiographs of 126 female patients (164 feet) who underwent hallux valgus surgery were reviewed. The HV, IM, and MA angles were measured. The MA was defined as MA angle of 20° or greater. Of all the feet, 37 (22.6%) had HV with MA (MA group). Control A (111 feet) having HV without MA was matched by age, gender, and BMI to MA group; Control B (79 feet) having HV without MA was matched by age, gender, BMI, and HV angle to the sub-MA group (31 feet) having HV with MA.

RESULTS

The correlation coefficient between the HV and IM angles in the MA group was considered negligible (r = 0.08, p = 0.63), whereas the correlation coefficient in Control A was considered moderate (r = 0.57, p < 0.00001). The correlation coefficient in the MA group was significantly smaller than in Control A (p < 0.01). There was no significant difference in the HV angle between the sub-MA group and Control B (p = 0.23), but the IM angle was significantly smaller than in Control B (p = 0.002).

CONCLUSION

There is no significant correlation between the HV and IM angles in HV with MA, as there is in HV without MA. HV with MA has a significantly smaller IM angle for the HV angle compared to HV without MA.

Comparison of outcomes of different osteotomy sites for hallux valgus: A systematic review and meta-analysis

BACKGROUND

Hallux valgus (HV) is a common foot deformity for which several corrective surgical procedures, with different osteotomy sites, have been reported. The purpose of the present study was to systematically review randomized (RCTs) or controlled (CCTs) clinical trials and perform meta-analysis on outcomes of different osteotomy sites of the first metatarsal.

METHODS

An extensive literature search was conducted in PubMed and the Cochrane Library from January 1983 to July 2020. Studies were identified using the terms "hallux valgus" and "osteotomy". We included RCTs or CCTs comparing different locations of osteotomy for the first metatarsal bone (distal vs. mid-shaft, distal vs. proximal, and mid-shaft vs. proximal). The surgical outcomes included postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), American Orthopaedic Foot and Ankle Society (AOFAS) score, pain visual analog scale (VAS) score, perioperative complications and recurrence of deformity. We enrolled 10 studies with a total of 793 feet in the qualitative synthesis following full-text screening.

RESULTS

A majority of patients included in the enrolled trials showed mild to moderate deformity, with mean HVA <40°. Out of the 10 enrolled studies; six compared distal osteotomies with mid-shaft osteotomies and showed no significant differences in the surgical outcomes between the scarf and chevron groups; three RCTs compared distal osteotomies with proximal osteotomies with conflicting results, one RCT showed the superiority of proximal osteotomy while the other two RCTs showed equivalent outcomes; one study that compared between mid-shaft and proximal osteotomies showed equivalent outcomes between the groups.

CONCLUSION

For the management of mild to moderate HV deformity, we found no significant clinical and radiological differences between patients treated with scarf and chevron osteotomies. Further controlled trials comparing different sites of osteotomies for moderate to severe HV deformity are needed.

Prevalence and radiological characteristics of the dislocation of the second metatarsophalangeal joint in patients undergoing hallux valgus surgery; a matched control study

BACKGROUND

Hallux valgus (HV) is occasionally associated with chronic subluxation or dislocation (CS/D) of the second metatarsophalangeal joint (2MTPj). The present study aimed to radiographically investigate the prevalence and characteristics of HV with CS/D of the 2MTPj compared with matched controls.

METHODS

Dorsoplantar and lateral weight-bearing radiographs of 79 female patients (79 feet) who had HV with an age of 50 years or more were reviewed. All feet were treated with a proximal supination osteotomy for correction of HV. CS/D of the 2MTPj was evaluated on preoperative dorsoplantar and lateral radiographs. HV and intermetatarsal (IM) angles were measured. Seventy-nine feet were divided into two groups: Group CD (16 feet) had HV with CS/D of the 2MTPj, and Group non-CD had HV without the CS/D of the 2MTPj (63 feet). The severity of HV was divided into two grades according to the HV angle: moderate deformity (Group M, 36 feet, HV angle of less than 40°) and severe deformity (Group S, 43 feet, HV angle of 40° or greater). Group CD and non-CD, and Group M and S were matched by age, gender, and BMI.

RESULTS

The prevalence of CS/D of the 2MTPj was 20.3%. Group CD had a significantly higher HV angle (p = 0.0001) and a significantly higher IM angle (p = 0.042) than Group non-CD. The prevalence of CS/D of the 2MTPj in Group S (34.9%) were significantly higher than that in Group M (2.8%) (p < 0.001).

CONCLUSIONS

CS/D of the 2MTPj was significantly associated with greater HV and IM angles compared with matched controls. The prevalence of CS/D of the 2MTPj (34.9%) in Group S was significantly higher than that in Group M. Severe HV can be at higher risk of acquiring CS/D of the 2MTPj in middle-aged and older females.

Effect of coordinator-based osteoporosis intervention on quality of life in patients with fragility fractures: a prospective randomized trial

We examined the effects of the coordinator-based intervention on quality of life (QOL) in the aftermath of a fragility fracture, as well as factors predictive of post-fracture QOL. The coordinator-based interventions mitigated the decrease in QOL. Secondary fracture after primary fracture, however, was a significant predictor of lower QOL.

PURPOSE

This study aimed to determine the effects of the coordinator-based intervention on QOL in the aftermath of a fragility fracture, as well as factors predictive of post-fracture QOL, in an Asian population.

METHODS

Patients with new fractures in the intervention group received the coordinator-based intervention by a designated nurse certified as a coordinator, within 3 months of injury. QOL was evaluated using the Japanese version of the EuroQol 5 Dimension 5 Level (EQ-5D-5L) scale  before the fracture (through patient recollections) and at 0.5, 1, and 2 years after the primary fracture.

RESULTS

Data for 141 patients were analyzed: 70 in the liaison intervention (LI) group and 71 in the non-LI group. Significant intervention effects on QOL were observed at 6 months after the fracture; the QOL score was 0.079 points higher in the LI group than in the non-LI group (p=0.019). Further, the LI group reported significantly less pain/discomfort at 2 years after the fracture, compared to the non-LI group (p=0.037). In addition, secondary fractures were found to significantly prevent improvement and maintenance of QOL during the recovery period (p=0.015).

CONCLUSION

Short-term intervention effects were observable 6 months after the primary fracture, with the LI group mitigated the decrease in QOL. Few patients in the LI group reported pain/discomfort 2 years after the fracture, but there is uncertainty regarding its clinical significance. Secondary fracture after initial injury was a significant predictor of lower QOL after a fracture.

Efficiency of coordinator-based osteoporosis intervention in fragility fracture patients: a prospective randomized trial

We examined the effectiveness of coordinators' interventions to prevent secondary fractures in patients with fragility fractures. These coordinator-based interventions improved bone density assessment implementation and treatment rates, and enhanced treatment persistence rates in the early stages following fractures.

INTRODUCTION

This study aimed to determine the efficiency of coordinator-based osteoporosis intervention in fragility fracture patients during a 2-year period.

METHODS

A prospective intervention randomized control study was conducted at seven medical facilities from January 2015 to March 2017. Postmenopausal women and men over 50 years old with fragility fractures were randomly divided into the coordinator intervention (LI; 70 patients) and without intervention (non-LI; 71 patients) groups. The osteoporosis treatment rate, osteoporosis treatment persistence rate, fall rate, fracture incidence rate, and bone density measurement rate 3 months, 6 months, 1 year, and 2 years after registration were compared between the two groups. Non-parametric tests were used to analyze data at each inspection period.

RESULTS

The osteoporosis treatment initiation rate was significantly higher in the LI group than in the non-LI group (85.7% vs. 71.8%; p = 0.04). The LI group had significantly higher bone density assessment implementation rates than the non-LI group at the time of registration (90.0% vs. 69.0%; p = 0.00) and 6 months after registration (50.0% vs. 29.6%; p = 0.01), but not 1 or 2 years after registration. In addition, no significant differences in fall or fracture incidence rates were found between the two groups.

CONCLUSION

The coordinator-based interventions for fragility fractures improved bone density assessment implementation and treatment rates and enhanced treatment persistence rates in the early stages following bone fractures. The findings suggest that liaison intervention may help both fracture and osteoporosis physicians for the evaluation of osteoporosis and initiation and continuation of osteoporosis medication.

Operative Treatment for Hallux Valgus With Moderate to Severe Metatarsus Adductus

BACKGROUND

Operative treatment is indicated for patients who have symptomatic hallux valgus (HV) with moderate to severe metatarsus adductus (MA). However, there is limited information available on the operative procedures and outcomes for the treatment of HV with MA. We aimed to investigate the average 10-year follow-up clinical and radiologic outcomes.

METHODS

Seventeen patients (21 feet, average age: 60.1 years) with symptomatic HV with moderate to severe MA were operatively treated. Mean postoperative follow-up duration was 114.4 (24-246) months. All feet had metatarsus adductus angle ≥20 degrees on dorsoplantar weight-bearing radiograph. The procedure included a proximal crescentic osteotomy of the first metatarsal and abduction osteotomy of the proximal third of the second and third metatarsals.

RESULTS

The mean American Orthopaedic Foot & Ankle Society scale score improved significantly postoperatively ( P < .001). The mean postoperative visual analog scale score (17 feet) was 2.0 (0-6). Preoperative metatarsalgia was severe in 2 feet, moderate in 17, and mild in 2. At the most recent follow-up evaluation, 11 feet had no pain, 9 had mild pain, and 1 had moderate pain. The mean hallux valgus angle, intermetatarsal angle, and metatarsus adductus angle significantly decreased postoperatively ( P < .001 for all). Recurrence of HV (HV angle ≥ 20 degrees) was observed in 4 feet.

CONCLUSION

The clinical and radiologic results indicated that our novel operative treatment for HV with moderate to severe MA can achieve significant correction of HV with MA deformities and significant improvement in pain and function.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Proximal Supination Osteotomy of the First Metatarsal for Hallux Valgus

Postoperative recurrence of hallux valgus is a relatively common complication and is associated with unsatisfactory surgical outcomes. Risk factors for postoperative recurrence include a round lateral edge of the first metatarsal head (a positive round sign) and incomplete reduction of the sesamoids. These risk factors may relate to residual pronation of the first metatarsal following surgery. A novel technique of a proximal supination osteotomy, in which varus and pronation of the first metatarsal can be corrected simultaneously, can achieve significant correction in moderate or severe hallux valgus deformity and a low rate of hallux valgus recurrence.

Responsiveness of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) in patients with hallux valgus

BACKGROUND

In this study, we investigated the responsiveness of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) for patient's assessment before and after hallux valgus surgery.

METHODS

Patient-reported answers on the SAFE-Q and Short Form-36 (SF-36) before and at a mean of 3-4 and 9-12 months after hallux valgus surgery were analyzed. Data of 100 patients (92 women, eight men) from 36 institutions throughout Japan were used for analysis.

RESULTS

In all subscales of the SAFE-Q, the trend of increased scores after surgery was statistically significant (P < 0.001). Among the patients with available scores both before and at 9-12 months after surgery (n = 66), the largest effect sizes (ESs) were observed for shoe-related (1.60), pain and pain-related (1.05), and general health and well-being (0.84) scales. In the SF-36 (n = 64), the largest ES was observed for the bodily pain scale (0.86). Less notable changes were observed for the remaining SF-36 domains.

CONCLUSION

The SAFE-Q is the first patient-reported outcome measure which includes a quality of life assessment of shoes. In our cohort, the most remarkable responsiveness was observed for the shoe-related subscale. Based on its responsiveness, the SAFE-Q appears to be sufficient for evaluation of foot-related quality of life before and after surgery.

Proximal supination osteotomy of the first metatarsal for hallux valgus

BACKGROUND

Risk factors for hallux valgus recurrence include postoperative round-shaped lateral edge of the first metatarsal head and postoperative incomplete reduction of the sesamoids. To prevent the occurrence of such conditions, we developed a proximal supination osteotomy of the first metatarsal. Our aim was to describe this novel technique and report the outcomes in this report.

METHODS

Sixty-six patients (83 feet) underwent a distal soft tissue procedure combined with a proximal supination osteotomy. After the proximal crescentic osteotomy, the proximal fragment was pushed medially, and the distal fragment was abducted, and then the distal fragment of the first metatarsal was manually supinated. Outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and radiographic examinations. The average follow-up duration was 34 (range, 25 to 52) months.

RESULTS

The mean AOFAS score improved significantly from 58.0 points preoperatively to 93.8 points postoperatively (P < .0001). The mean hallux valgus and intermetatarsal angle decreased significantly from 38.6 and 18.0 degrees preoperatively to 11.0 and 7.9 degrees postoperatively, respectively (both, P < .0001). Sixty-nine feet (69/83, 83%) had a positive round sign preoperatively, and 66 feet (66/83, 80%) had a negative round sign postoperatively. According to the Hardy's classification of position of the sesamoids, all feet were classified as grade V or greater preoperatively, and 49 feet (49/83, 59%) were classified as grade IV or less postoperatively. Three feet (3/83, 4%) had recurrence of hallux valgus, defined as a hallux valgus angle ≥ 25 degrees.

CONCLUSION

The rates of occurrence of a positive round sign and incomplete reduction of the sesamoids significantly decreased postoperatively, which may have contributed to the low hallux valgus recurrence rates. We conclude that a proximal supination osteotomy was an effective procedure for correction of hallux valgus and can achieve a low rate of hallux valgus recurrence.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Proximal abduction-supination osteotomy of the first metatarsal for adolescent hallux valgus: a preliminary report

BACKGROUND

Surgical treatment of adolescent hallux valgus has been a challenging intervention because of high rates of postoperative recurrence. The purposes of this study were to describe a proximal abduction-supination osteotomy of the first metatarsal and prospectively review preliminary results of this procedure for correction of adolescent hallux valgus.

METHODS

Eleven patients (12 feet) who had had a proximal abduction-supination osteotomy of the first metatarsal combined with a distal soft-tissue procedure to correct an adolescent hallux valgus deformity were prospectively reviewed clinically and radiologically. The average duration of follow-up was 22 months. The average age at the time of surgery was 17 years.

RESULTS

The mean score on the Japanese Society for Surgery of the Foot standard rating system for hallux improved significantly, from 62.0 points preoperatively to 99.2 points postoperatively (p = 0.002). All patients were satisfied and would choose to have the same procedure again. The mean hallux valgus angle decreased significantly, from 32.3° preoperatively to 12.2° postoperatively (p = 0.002); mean intermetatarsal angle decreased significantly from 14.0° preoperatively to 6.2° postoperatively (p = 0.002). No feet had postoperative recurrence of hallux valgus (a hallux valgus angle ≥20°). There were no occurrences of nonunion or transfer lesions.

CONCLUSIONS

The clinical and radiological results of this study demonstrate that a proximal abduction-supination osteotomy with a distal soft-tissue procedure, which described in this study, achieved significant correction of an adolescent hallux valgus deformity, significant improvement in pain and function, and reduction in rate of recurrence.

Supination stress of the great toe for assessing intraoperative correction of hallux valgus

BACKGROUND

We have devised a new intraoperative technique (supination stress of the great toe) in which correction of hallux valgus and metatarsus primus varus, and reduction of the sesamoids could be simultaneously obtained at hallux valgus surgery. The purpose of this study was to prospectively investigate the efficacy of supination stress for assessing intraoperative correction of hallux valgus.

METHODS

Thirty patients (31 feet) with an average age of 59.8 years who had hallux valgus were treated with a proximal metatarsal osteotomy. Supination stress under traction was manually applied to the great toe after release of the distal soft tissues and a proximal metatarsal osteotomy. C-arm fluoroscopy was used to verify correction of hallux valgus and to obtain dorsoplantar non-weightbearing images under supination stress. The dorsoplantar non-weightbearing fluoroscopic images were assessed preoperatively and at the time of intraoperative supination stress. The hallux valgus and intermetatarsal angles were measured. The position of the medial sesamoids was classified with a grading system ranging from I to VII as described by Hardy and Clapham. We defined a grade of IV or less as the normal position of the sesamoids and grade V or greater as lateral displacement of the sesamoids.

RESULTS

The average hallux valgus angle was 34.3° preoperatively and 11.9° at the time of intraoperative supination stress. The average intermetatarsal angle was 16.4° preoperatively and 5.5° at the time of intraoperative supination stress (p < 0.0001, p < 0.0001, respectively). At the time of intraoperative supination stress, the hallux valgus angle was 20° or less in all feet, and the intermetatarsal angle was 10° or less in all feet. Preoperatively, all feet were classified as having lateral displacement of the sesamoids. At the time of intraoperative supination stress, all feet were classified as having normal positioning of the sesamoids.

CONCLUSIONS

Supination stress of the great toe was an effective maneuver for assessing intraoperative correction of hallux valgus and metatarsus primus varus, and reduction of the sesamoids.

Development of the patient-based outcome instrument for the foot and ankle. Part 1: project description and evaluation of the Outcome Instrument version 1

BACKGROUND

The Clinical Outcomes Committee of the Japanese Society for Surgery of the Foot conducted a field survey using a novel foot and ankle outcome instrument. We report the development and evaluation of the Outcome Instrument version 1.

MATERIALS AND METHODS

A total of 108 potential questions were extracted from literature published in the interval between 1990 and 2006. Tentative subscales proposed were "Degree of Foot Pain," "Foot Pain-related," "Physical Functioning and Daily Living," "Social Functioning" and "General Health and Well-being." After pre-testing in two different groups of patients, the Outcome Instrument version 1, which was composed of 46 items selected from the 108 questions, was administered to 256 patients (111 men and 145 women) with foot-and-ankle-related pathologic conditions and 243 healthy volunteers (125 men and 118 women). Cronbach's alpha coefficients were used for assessment of internal consistency of the instrument. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were utilized for evaluation of construct validity.

RESULTS

Neither a ceiling nor floor effect was observed in the responses from the patients. Significant differences were found in the responses to all of the questions between the patients and volunteers (P < 0.01 each). The Cronbach's alpha coefficients for each of the expected subscales indicated high reliability for most of the items and subscales. However, EFA extracted an additional subscale that should be interpreted as something related to shoe or shoe-fit. Further, both EFA and CFA indicated that "Degree of Foot Pain" and "Foot Pain-related" subscales were barely discernable with a factor correlation coefficient of 0.927.

CONCLUSIONS

The Committee partly revised the instrument, and the new subscales are as follows: "Foot Pain and Pain-related," "Physical Functioning and Daily Living," "Social Functioning," "General Health and Well-being" and "Shoe-related." Evaluation of the Outcome Instrument version 2 will be reported in the following paper.

Genotyping of Edwardsiella ictaluri isolates in Japan using amplified-fragment length polymorphism analysis

AIM

The major objective of the present study was to clarify genetic relationship of isolates of Edwardsiella ictaluri in Japan, which was first found from ayu Plecoglossus altivelis in Japanese rivers in 2007.

METHODS AND RESULTS

Ten isolates of Edw. ictaluri in 2007-2008 from ayu and the 1 isolate from bagrid catfish Pelteobagrus nudiceps in Japan were subjected to amplified-fragment length polymorphism (AFLP) analysis. The strains isolated from catfish in United States (ATCC strains) or Indonesia were used as reference strains. The AFLP profiles were all the same among the isolates from Japan, while the polymorphic DNA bands were observed among the strains from United States or Indonesia. The isolates from Japan and Indonesia constituted a genogroup different from the ATCC strains on a dendrogram constructed from the AFLP profiles.

CONCLUSION

No DNA polymorphisms were found among Japanese Edw. ictaluri isolates.

SIGNIFICANCE AND IMPACT OF THE STUDY

A single clonality of the Edw. ictaluri isolates in Japan suggests the single source of the organism, and the infection in ayu is in the early stage of epidemics.

Postoperative incomplete reduction of the sesamoids as a risk factor for recurrence of hallux valgus

BACKGROUND

It is unknown whether postoperative incomplete reduction of the sesamoids is a risk factor for the recurrence of hallux valgus. The purpose of the present study was to clarify the relationship between the postoperative relative sesamoid position and the recurrence of hallux valgus.

METHODS

Dorsoplantar weight-bearing radiographs of sixty normal feet (the control group) and sixty-five feet with hallux valgus (the hallux valgus group) in a study of adult women were reviewed. The feet in the hallux valgus group were treated with a proximal metatarsal osteotomy, and the radiographs were assessed preoperatively, at the early follow-up interval (at a mean of 3.1 months), and at the most recent follow-up interval (at a mean of forty-five months). The position of the medial sesamoid was classified with a grading system ranging from I through VII as described by Hardy and Clapham. In the feet with hallux valgus, we defined a grade of IV or less as the normal position of the medial sesamoid (the normal-position group) and grade V or greater as lateral displacement of the sesamoid (the displacement group).

RESULTS

Fifty feet (83%) in the control group were classified as grade IV or less and ten, as grade V. All feet in the hallux valgus group were classified as grade V or greater preoperatively, forty-eight feet (74%) were classified as grade IV or less at the early follow-up evaluation, and forty-two feet (65%) were classified as grade IV or less at the most recent follow-up evaluation. The average hallux valgus angle in the hallux valgus group was 38.3 degrees (range, 25 degrees to 60 degrees ) preoperatively, 11.9 degrees (range, 4 degrees to 28 degrees ) at the time of the early follow-up, and 13.9 degrees (range, 0 degrees to 33 degrees ) at the time of the most recent follow-up. There was no significant difference in the average hallux valgus angle between the early and most recent follow-up evaluations in the feet that were considered to be in the normal-position group at the time of the early follow-up (p = 0.084). In the feet that were considered to be in the displacement group at the time of the early follow-up, the average hallux valgus angle at the time of the most recent follow-up was significantly greater than that at the time of the early follow-up (19.5 degrees +/- 8.4 degrees compared with 15.0 degrees +/- 5.8 degrees ) (p = 0.0082). The feet that were in the displacement group at the time of the early follow-up had a greater risk of having recurrence of the hallux valgus at that time than did those in the normal-position group (odds ratio, 10.0; 95% confidence interval, 2.75 to 36.33).

CONCLUSIONS

Postoperative incomplete reduction of the sesamoids can be a risk factor for the recurrence of hallux valgus. The identification of incomplete reduction of the sesamoids intraoperatively may allow modification of surgical procedures and improvement of the surgical results.

Radiographic measurements in patients with hallux valgus before and after proximal crescentic osteotomy

BACKGROUND

Radiographic measurements such as those of the hallux valgus angle and the intermetatarsal angle are essential parameters for assessing the severity of hallux valgus deformities and the extent of surgical correction required. However, to our knowledge, no study has investigated the reliability of the measurements that are made radiographically before and after a proximal crescentic osteotomy of the first metatarsal. The purpose of the present study was to investigate the intraobserver and interobserver reliability of different methods that are used to measure the angles and to determine the most reliable method.

METHODS

We selected twenty preoperative and twenty postoperative dorsoplantar weight-bearing radiographs for patients who had undergone a proximal crescentic osteotomy of the first metatarsal. Three foot and ankle surgeons measured the hallux valgus angle and the intermetatarsal angle with use of five different methods. We calculated the intraobserver and interobserver correlation coefficients and agreement to determine the most reliable method.

RESULTS

Significant differences were observed among the methods with regard to the postoperative hallux valgus angle (p < 0.05) and the preoperative and postoperative intermetatarsal angles (p < 0.01 for both). The method in which a line connecting the centers of the first metatarsal head and the proximal articular surface of the first metatarsal was used to define the longitudinal axis of the first metatarsal yielded the highest intraobserver and interobserver correlation coefficients for the preoperative hallux valgus and intermetatarsal angles and the postoperative hallux valgus angle. For this method alone, the intraobserver and interobserver agreements for the angular measurements were found to be >80%.

CONCLUSIONS

A line connecting the centers of the first metatarsal head and the proximal articular surface of the first metatarsal to define its longitudinal axis yields the best intraobserver and interobserver reliability for the measurement of the hallux valgus and intermetatarsal angles. Therefore, this method can be recommended for evaluating radiographs before and after a proximal crescentic osteotomy performed for the treatment of hallux valgus.

Proximal metatarsal osteotomy for hallux valgus: comparison of outcome for moderate and severe deformities

BACKGROUND

We compared the results of a distal soft-tissue procedure with a proximal crescentic osteotomy of the first metatarsal for moderate and severe hallux valgus.

MATERIALS AND METHODS

The series consisted of 54 feet treated with this procedure. The average followup was 30 months. Fifty-four feet were divided into two groups including Group M (moderate) (24 feet, preoperative hallux valgus angle of 40 degrees or less and preoperative intermetatarsal angle of less than 18 degrees) and Group S (severe) (30 feet, preoperative hallux valgus angle of greater than 40 degrees or preoperative intermetatarsal angle of 18 degrees or greater).

RESULTS

The difference between Group M and S was not significant with regard to the age of patients, duration of followup, or postoperative pain and function scores on the American Orthopaedic Foot and Ankle Society scale. However, postoperative alignment score in Group M was significantly greater than that in Group S (p = 0.038). Postoperative hallux valgus and intermetatarsal angles in Group S were significantly greater than those in Group M, respectively (p = 0.025, p = 0.001). The prevalence of recurrent hallux valgus (hallux valgus angle of 20 degrees or greater) in Group S was significantly higher than that in Group M (p = 0.013).

CONCLUSION

This procedure is an effective method for relieving pain and improving function regardless of the severity of hallux valgus. However, the correction of moderate hallux valgus is likely to be better than that of severe hallux valgus.

The shape of the lateral edge of the first metatarsal head as a risk factor for recurrence of hallux valgus

BACKGROUND

The relationship between the shape of the first metatarsal head and hallux valgus deformity remains controversial. The purpose of the present study was to retrospectively analyze differences in the radiographic appearance of the shape of the lateral edge of the first metatarsal head between women with normal feet and those with hallux valgus and to clarify the relationship between the shape of the lateral edge and the postoperative recurrence of hallux valgus deformity.

METHODS

Dorsoplantar weight-bearing radiographs of sixty normal feet in women (the control group) and sixty feet in women with hallux valgus (the hallux valgus group) were reviewed. The feet in the hallux valgus group were treated with a proximal metatarsal osteotomy, and the radiographs of those feet were assessed preoperatively, at the time of early follow-up (mean, 3.4 months), and at the time of the most recent follow-up (mean, forty-eight months). The shape of the lateral edge, which was defined as consisting of the articular and lateral surfaces of the first metatarsal head, was examined. The shape of the lateral edge was classified as one of three types: round (type R), angular (type A), and intermediate (type I). We defined the round sign as being positive when the shape of the lateral edge was classified as type R.

RESULTS

Prior to surgery, the prevalence of the type-R shape was significantly greater in the hallux valgus group than it was in the control group (78.3% compared with 1.7%; p < 0.0001) and the prevalence of type-A shape was significantly lower in the hallux valgus group than in the control group (3.3% compared with 81.7%; p < 0.0001). In the hallux valgus group, the prevalence of the type-R shape at the time of the early follow-up after surgery was significantly lower than that before surgery (p < 0.0001). Feet with a positive round sign at the time of the early follow-up had a greater risk of having recurrence of the hallux valgus deformity at the time of the most recent follow-up than did those without a round sign at the time of the early follow-up (odds ratio, 12.71; 95% confidence interval, 3.21 to 50.36).

CONCLUSIONS

There is a significant relationship between a round-shaped lateral edge of the first metatarsal head and hallux valgus, and a positive round sign after a proximal first metatarsal osteotomy can be a risk factor for the recurrence of hallux valgus.

Reconstruction of chronic achilles tendon rupture with the use of interposed tissue between the stumps

BACKGROUND

The gap between the tendon stumps in chronic Achilles tendon rupture has reportedly been filled with interposed scar tissue. In the authors' clinical experience, this interposed tissue is often thick and resists tension, so they considered it was possible to use the interposed tissue for reconstruction of Achilles tendon rupture.

HYPOTHESIS

Scar tissue interposed between the tendon stumps has the capacity to form tendon-like repair tissue in patients with chronic Achilles tendon rupture.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Six patients with chronic rupture of the Achilles tendon underwent tendon reconstruction with the use of interposed tissue between the stumps. The average time from the primary injury to surgery was 22 weeks (range, 9 to 30 weeks). Preoperative magnetic resonance imaging (MRI), histology of the interposed tissue, and clinical results were evaluated. The average postoperative follow-up period was 31 months (range, 24 to 43 months).

RESULTS

Preoperative T2-weighted MRI in all cases revealed that chronically ruptured Achilles tendons were thickened and fusiform-shaped with diffuse intratendinous high-signal alterations throughout. Longitudinal high-signal bands were seen throughout the tendon, except at the musculotendinous junction and insertion on the calcaneus. Histologically, scar tissue interposed between the tendon stumps consisted of dense collagen fibers, and degenerative changes were not seen. After surgery, no patient had difficulty in walking or stair climbing, and all were able to perform a single-limb toe raise. The mean preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were 88.2 and 98.3 points, respectively; the difference was statistically significant (P = .0277).

CONCLUSION

Interposed tissue between the tendon stumps is suitable for repair of chronic Achilles tendon rupture if preoperative MRI shows a thickened fusiform-shaped Achilles tendon with diffuse intratendinous high-signal alterations throughout.

Tarsal tunnel syndrome in athletes

BACKGROUND

The details of the occurrence of tarsal tunnel syndrome in athletes have not been well documented in the literature, and more data on tarsal tunnel syndrome related to sporting activity are necessary to enable better recognition of this condition.

HYPOTHESIS

Sporting activities make athletes vulnerable to the occurrence of tarsal tunnel syndrome under specific conditions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 1986 and 2002, 18 patients with tarsal tunnel syndrome related to sporting activities were surgically treated, of whom 15 patients (21 feet; mean age, 17.8 years) were competitive athletes and 3 were recreational sports amateurs (4 feet; mean age, 52.7 years). To assess the role of physical factors and sporting activities in making athletes vulnerable to the occurrence of tarsal tunnel syndrome, the authors reviewed the medical charts and evaluated the results of treatment. The mean duration of follow-up was 58.6 months.

RESULTS

Activities that triggered tarsal tunnel syndrome were those that applied a heavy burden on the ankle joint such as sprinting, jumping, and performing ashibarai in judo under specific physical conditions. Predisposing underlying physical factors were flatfoot deformity and an existence of talocalcaneal coalition, accessory muscles, and bony fragments around the tarsal tunnel. The majority of patients were able to return to the same sport after treatment.

CONCLUSION

Tarsal tunnel syndrome occurs in athletes involved in strenuous sporting activities, especially when predisposing physical factors are present.

Anatomy of ligamentous structures in the tarsal sinus and canal

BACKGROUND

The descriptive morphology of the interosseous talocalcaneal ligament and other structures in the tarsal sinus and canal vary. An anatomical investigation of the ligamentous structures in the tarsal sinus and canal identified two distinct ligaments, the interosseous talocalcaneal ligament and the anterior capsular ligament, and three components of the medial root of the inferior extensor retinaculum.

METHODS

Forty embalmed cadaver feet were examined. After disarticulation of the ankle joint, the posterior half of the talus was removed. The length, width, and thickness of the two ligaments and the three components of the extensor retinaculum in the tarsal canal and sinus were measured with calipers. Anatomical variations were recorded.

RESULTS

The interosseous talocalcaneal ligament was band-like in 92.5% (38 of 40) of examined specimens, and the anterior capsular ligament was present in 95% (39 of 40) of specimens. The interosseous talocalcaneal ligament, the medial component of the inferior extensor retinaculum, and the talar component of the inferior extensor retinaculum had one or two distinct anatomical variations of morphology and attachments. The interosseous talocalcaneal ligament and the medial component of the extensor retinaculum formed a V shape in the tarsal sinus and canal.

CONCLUSION AND CLINICAL RELEVANCE

We demonstrated the morphology and dimensions of the ligaments and components of the extensor retinaculum in the tarsal sinus and canal. Precise anatomy of the structures in the tarsal sinus and canal will strengthen our understanding of their function in the motion or stabilization of the subtalar joint. There may be a functional link between the medial component of the inferior extensor retinaculum and the interosseous talocalcaneal ligament.

Pathogenesis of tendinous xanthoma: histopathological study of the extremities of Watanabe heritable hyperlipidemic rabbits

BACKGROUND

Tendinous xanthomas associated with heritable hyperlipidemia are clinically well known. Nevertheless, there have been few basic investigations of the pathogenesis of these xanthomas. To clarify the pathogenesis of these xanthomas, we examined the localization and histopathological features of xanthomatous tissues in the extremities of Watanabe heritable hyperlipidemic (WHHL) rabbits.

METHODS

Twenty-six WHHL rabbits at 1-31 months of age were dissected to observe the localization of xanthomas. In the histopathological study, tendons and ligaments that included xanthomatous tissues were sectioned and stained with hematoxylin and eosin, Masson's trichrome, and toluidine blue. Immunohistochemical staining was performed with RAM-11, a monoclonal antibody specific for rabbit macrophages, and CD31, a monoclonal antibody specific for endothelial cells.

RESULTS

At necropsy examination, spontaneous development of xanthomas was observed in the plantar side of the plantaris tendon, the flexor retinaculum of the carpus, and around the digital flexor tendons of each joint level. Xanthoma formation was observed from 10 months of age and progressed with advancing age. The histomorphological study revealed that xanthomas had developed in superficial paratenon of the tendons that wrap around bony or fibrous pulleys. Many fibrocartilage cells were observed in the deep side of affected tendons. A large number of blood vessels were seen in the xanthomatous tissues of these WHHL rabbits. Immunohistochemical evaluation revealed that the xanthoma plaques contained endothelial cells and macrophages.

CONCLUSIONS

It is likely that mechanical stress and extensive vascularization are essential factors for xanthoma formation. Moreover, endothelial cells and macrophages cells are principal contributors to the pathogenesis of tendinous xanthomas and to atherogenesis.

Proximal metatarsal osteotomy: relation between 1- to greater than 3-years results

We analyzed the relationship between the 1-year and greater than 3-years results of a distal soft tissue procedure with a proximal osteotomy for hallux valgus in the same patient population. The series consisted of 55 feet treated with this procedure. The results at 1 year and greater than 3 years were evaluated. The final followup was greater than 3 years. Patients with pain in the first metatarsophalangeal joint at the 1-year followup had a greater risk of having pain at the final followup than did patients without pain at the 1-year followup. Patients with metatarsalgia at the 1-year followup had a greater risk of having metatarsalgia at the final followup than did patients without metatarsalgia at the 1-year followup. The extension of the first metatarsophalangeal joint at the final followup was greater than extension at the 1-year followup. In 48 feet (87%), radiologic evaluation showed no or minimal changes in the hallux valgus and intermetatarsal angles between 1 year and greater than 3 years followup. The data suggest the 1-year results predict those beyond 3 years, although the extension of the first metatarsophalangeal joint may increase 1 year after surgery.

LEVEL OF EVIDENCE

Prognostic study, Level III. See the Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic findings in chronic lateral ankle instability: do focal chondral lesions influence the results of ligament reconstruction?

BACKGROUND

There are few studies that have assessed the influence of focal chondral lesions on the results of ligament reconstruction for chronic lateral ankle instability.

HYPOTHESIS

Focal chondral lesions do not influence the results of ligament reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Arthroscopic examination of the ankle was performed on 30 consecutive patients immediately before ligament reconstruction using the palmaris longus tendon. Clinical assessment was performed using the Karlsson scoring scale. A radiologic assessment was performed on stress radiographs of the ankle. Preoperative anteroposterior and lateral weightbearing radiographs of the ankle did not show any joint space narrowing in any ankle. The mean duration of follow-up was 38 months.

RESULTS

On arthroscopy, focal chondral lesions were found in 19 ankles (63%). Chondral lesions were located on the medial side of the tibial plafond in 13 ankles (43%), on the lateral side in 2 ankles (7%), on the lateral side of the talar dome in 3 ankles (10%), and on the medial side in 9 ankles (30%). Postoperative mean Karlsson scores in patients without chondral lesions and in those with chondral lesions were 99.1 and 98.4 points, respectively. Postoperative mean talar tilt angles in patients without chondral lesions and in those with chondral lesions were 5.9 degrees and 4.7 degrees , respectively. There were no significant differences in the clinical and radiologic results between patients with chondral lesions and those without chondral lesions.

CONCLUSIONS

Reconstruction of the lateral ligament can be successful regardless of the presence of focal chondral lesions in patients with chronic lateral ankle instability when preoperative weightbearing radiographs of the ankle do not show any joint space narrowing.

Tibialis spastic varus foot caused by osteoid osteoma of the calcaneus

Tibialis spastic varus foot is an extremely rare condition. A 30-year-old man had tibialis spastic varus foot caused by juxtaarticular osteoid osteoma of the calcaneus. The correct diagnosis was delayed because the symptoms were similar to arthritis and the nidus was difficult to detect on plain radiographs. Curettage of the tumor was done, and the osseous defect was filled with interporous hydroxyapatite. The pain was relieved immediately after surgery. The varus deformity of the foot and spasm of the tibialis anterior muscle gradually improved. Three years 10 months after surgery, the patient was pain-free and the spasm of the tibialis anterior muscle had disappeared. The varus deformity and motion of the foot improved, but a restricted range of motion remained. To the authors' knowledge, there have been no published descriptions of tibialis spastic varus foot caused by juxtaarticular osteoid osteoma of the calcaneus.

Tarsal tunnel syndrome associated with an accessory muscle

Between 1986 and 1999, we surgically treated 41 patients (49 feet) with Tarsal Tunnel Syndrome (TTS) in whom seven (eight feet) were associated with an accessory muscle. An accessory flexor digitorum longus muscle was present in six patients, and an accessory soleus muscle was in one patient (both feet). Three of them were males and four females, with the mean age of 33.1 years (12 to 59 years). The mean interval from the onset of symptoms to operation was 7.5 months (range, six to nine months). All patients with an accessory muscle had a history of trauma or strenuous sporting activity. The diagnosis of TTS was made based on physical findings in all the patients (eight feet) and confirmed in five patients (six feet) by electrophysiological examination. Imaging examinations (radiography, ultrasonography, MRI) revealed abnormal bone and soft tissue lesions in and around the tarsal tunnel. Preoperative signs and symptoms disappeared average 4.1 months after decompression of the tibial nerve in addition to excision of the muscle. No functional deficit was observed at final follow-up (24 to 88 months).

Adult hallux valgus with metatarsus adductus: a case report

It is difficult to surgically treat a hallux valgus deformity with significant metatarsus adductus, because the space between the first and second metatarsals is too narrow to correct the metatarsus primus varus with a first metatarsal osteotomy. A 55-year-old woman had severe hallux valgus with significant adduction of the second and third metatarsals. A distal soft tissue procedure and a proximal crescent-shaped osteotomy of the first metatarsal combined with corrective osteotomies of the second and third metatarsals were done. The patient's symptoms disappeared, and hallux valgus and adduction of the second and third metatarsals were corrected. To the authors' knowledge, there is no previous description of surgical treatment including correction of metatarsus adductus and hallux valgus for adult hallux valgus with metatarsus adductus.

Proximal dome-shaped osteotomy for symptomatic bunionette

The results of a dome-shaped osteotomy of the proximal third of the fifth metatarsal in patients with symptomatic bunionette deformity were reviewed. The series was comprised of eight patients (10 feet; mean age of patients, 21 years). The average followup was 30 months. All patients were free from pain at the fifth metatarsophalangeal joint and were satisfied with the results of this procedure. The mean angle between the longitudinal axes of the fifth metatarsal and the proximal phalanx was 18.9 degrees before surgery and 2.6 degrees after surgery. The mean angle between the longitudinal axes of the fourth and fifth metatarsals was 12.2 degrees before surgery and 4.8 degrees after surgery. The overall results were good in all 10 feet. Three feet had delayed union at the osteotomy site, but union was obtained in all feet. The osteotomy site of the fifth metatarsal in feet with delayed union was more proximal than that of the other feet. Therefore, proximal osteotomy of the fifth metatarsal should be done not at the base, but at the proximal site of the diaphysis to prevent delayed union. A proximal dome-shaped osteotomy corrects the deformity and relieves the symptoms, but careful attention should be paid to the osteotomy site.

The dorsiflexion-eversion test for diagnosis of tarsal tunnel syndrome

BACKGROUND

The clinical diagnosis of tarsal tunnel syndrome lacks objectivity and consistency. We have devised a new diagnostic physical examination test in which the tibial nerve is compressed as it runs beneath the flexor retinaculum behind the medial malleolus. In this test, the ankle is passively maximally everted and dorsiflexed while all of the metatarsophalangeal joints are maximally dorsiflexed and held in this position for five to ten seconds.

METHODS

We performed this test on fifty normal volunteers (100 feet) and on thirty-seven patients (forty-four feet) treated operatively for tarsal tunnel syndrome between 1987 and 1997. We performed the maneuver both preoperatively and postoperatively and recorded any consequent changes in the signs and symptoms; during the operation we observed the altered anatomical relationships in the tarsal tunnel that were produced by the maneuver. The average duration of follow-up was three years and eleven months.

RESULTS

Before the operation, the signs and symptoms of tarsal tunnel syndrome were intensified or induced by the maneuver in fifteen of the twenty feet of the patients who reported numbness, in fifteen of the seventeen feet of those who reported pain alone, and in six of the seven feet of those who had combined numbness and pain. Local tenderness was intensified in forty-two of forty-three feet, and it was induced in one foot in which it had been previously absent. A Tinel sign became more pronounced in forty-one feet, and the sign was induced in three feet in which it had been absent previously. During the operation, the tibial nerve was stretched and compressed beneath the laciniate ligament when the ankle was dorsiflexed, the heel was everted, and the toes were dorsiflexed. Preoperative signs and symptoms disappeared on an average of 2.9 months after the operation, and they could not be induced by repeating the test except in three patients, all of whom had tarsal tunnel syndrome subsequent to a fracture of the calcaneus. In the normal volunteers, no symptoms or signs could be induced by the test.

CONCLUSION

This new physical examination test is effective in facilitating the diagnosis of tarsal tunnel syndrome.

[History of Polish pharmacy]

Doctoral thesis (in French) by Monika Debska-Donnet, entitled "History of pharmacy and pharmaceutical art collections in Poland" which was presented to Paris XI University (Faculty of Pharmaceutical and Biological Sciences) in 1991, was translated into Japanese and summarized. In this report, histories of pharmacy education, pharmacists, community pharmacies, pharmacopoeiae, pharmaceutical industries in Poland were described, and four representative Polish museums of history of pharmacy were also explained.

Supercritical fluid extraction of halogenated monoterpenes from the red alga Plocamium cartilagineum

Supercritical fluid extraction (SFE) of the marine red alga Plocamium cartilagineum, which is known to contain complex mixtures of halogenated monoterpenes, was investigated. P. cartilagineum samples were extracted by SFE with carbon dioxide and modified carbon dioxide containing up to 10% methanol at different pressure and temperature conditions to establish the optimum conditions for extraction. These conditions were then used in the extraction of halogenated monoterpenes from 2 different samples of P. cartilagineum: one from Davenport, CA, and the other from Casa Beach (San Diego, CA). Several halogenated monoterpenes isolated by conventional solvent extraction with methanol and purified by column chromatography were used as the reference compounds for the determination of the extraction efficiency in the SFE experients. Plocamium cartilagineum belongs to the red alga family--Plocamiaceae, and has been found to contain a large number of halogenated monoterpenes, whose structures typically contain 1-6 bromine and/or chlorine atoms. P. cartilagineum grows along the Pacific coast from Washington to Chile, the British Isles, Australia, and Spain. Interestingly, P. cartilagineum collected from different geographical areas in the world are all reported to produce halogenated monoterpenes, but of different structural types and halogen substitution patterns. Most of these halogenated monoterpenes have been found to exhibit varied biological activities, including antifungal, antimicrobial, and molluscicidal activity.

Surgical treatment for hallux valgus with painful plantar callosities

We retrospectively reviewed the results of a distal soft-tissue procedure and proximal crescentic osteotomy of the first metatarsal combined with a proximal shortening osteotomy of the second and/or third metatarsal. This was in patients who had hallux valgus with painful plantar callosities. The review covered seven years of procedures (1989-1996) in 12 patients (14 feet) averaging 53 years of age. Average follow-up was 52 months. All patients had pain at the first metatarsophalangeal joint and had metatarsalgia preoperatively. At follow-up, 11 feet had no pain at the first metatarsophalangeal joint, and three had some improvement of pain. Ten feet had no metatarsalgia, two had improvement of metatarsalgia, and two feet had transfer lesions postoperatively and required reoperation. The angle of hallux valgus averaged 40 degrees preoperatively and 13 degrees postoperatively. The intermetatarsal angle averaged 18 degrees preoperatively and 6 degrees postoperatively. Mean decreases in length of the second and third metatarsal after surgery were 5.4 mm and 4.8 mm, respectively. Our results suggested that this combined procedure for hallux valgus with painful plantar callosities may be successful, in carefully selected patients.

Distal soft tissue procedure and proximal metatarsal osteotomy in hallux valgus

The results of a distal soft tissue procedure and a proximal metatarsal osteotomy in patients with symptomatic hallux valgus deformity were reviewed. The series consisted of 33 patients (47 feet; mean age of patients, 44 years). The average followup period was 48 months. At followup, 41 feet (29 patients, 85%) were free from pain at the first metatarsophalangeal joint. In six feet (four patients), the pain was improved but persisted. The mean hallux valgus angle was 38 degrees before surgery and 13.8 degrees after surgery. The mean intermetatarsal angle was 17.7 degrees before surgery and 7 degrees after surgery. The postoperative hallux valgus angle and intermetatarsal angle in patients who had pain at the first metatarsophalangeal joint after surgery were greater than those in patients without pain after surgery. This procedure corrects the hallux valgus deformity and relieves the symptoms, but careful attention should be paid to the surgical technique to obtain consistent and satisfactory results.

Addition of antibacterial agents to MMA-TBB dentin bonding systems--influence on tensile bond strength and antibacterial effect

To produce a bonding system which has both high bond strength and antibacterial properties, an antibacterial agent (vancomycin: VCM or metronidazol: MN) was added to the PMMA powder of 4-META/MMA-TBB resin (CB). The influence of the addition of an antibacterial agent on tensile bond strength to dentin and the antibacterial effect were investigated in this study. Forty-seven freshly extracted bovine first or second incisors were used to measure the tensile bond strength to dentin. The bond strengths to bovine dentin were not significantly decreased by addition of VCM (1%, 2%, 5%), or MN (1%) to CB (p < 0.05). The antibacterial effect of CB containing antibacterial agent on six strains of bacteria was investigated by the agar plate diffusion method, analyzing the appearance of the inhibition zone around a resin disk following anaerobic culturing. The resin disks containing VCM showed antibacterial effects on all of the strains examined; the widths of the inhibition zones were 4-15 mm. The resin disks containing MN showed antibacterial effects on three strains; the widths of the inhibition zones were 0-4 mm. It was thus possible to produce a bonding system with both antibacterial effect and high tensile bond strength by addition of VCM to PMMA powder.

Reconstruction for chronic lateral ankle instability using the palmaris longus tendon: is reconstruction of the calcaneofibular ligament necessary?

The palmaris longus tendon was used to reconstruct the anterior talofibular ligament (ATFL) in 27 ankles with chronic lateral instability. The mean age of the patients at surgery was 23 years, and the follow-up was more than 2 years. The functional evaluation showed excellent or good results in all ankles. Twenty-seven ankles were divided into two groups according to operative findings: group A consisted of 11 ankles with old isolated injury of the ATFL, and group B consisted of 16 ankles with old combined injuries of the ATFL and the calcaneofibular ligament. There were no significant differences in clinical results between group A and group B. The preoperative mean talar tilt angles on stress radiograph in group B were significantly larger than those in group A. At follow-up, there were no significant differences in the mean talar tilt angles between group A and group B. We demonstrate that reconstruction of the calcaneofibular ligament along with the ATFL is not necessary for patients with chronic combined lateral ligament instability.

Calcitonin cells in the intestine of goldfish and a comparison of the number of cells among saline-fed, soup-fed, or high Ca soup-fed fishes

Calcitonin-immunoreactive cells were found in the intestine of goldfish. These cells were distributed mainly in the anterior part of the intestine, dispersed in the intestinal epithelium. The nucleus was located in the basal portion of the serosal side, and the cytoplasm was elongated to the luminal side. From the anterior part of the intestine, cDNA fragments with the same nucleotide sequence as that of the goldfish calcitonin gene were amplified by RT-PCR method. After administration of one of three kinds of solutions (saline, consommé soup, or high Ca consommé soup) into the digestive tract of the goldfish, the number of those cells was the largest in the consommé group at 6 h after ingestion, although blood Ca levels were the highest in the high Ca consommé group. The function of calcitonin cells in the intestine may be to restrain the acute absorption of nutrients and not to control blood Ca levels.

Osteochondral lesions of the proximal phalanx of the great toe: a report of two cases

Two cases of osteochondral lesions of the proximal phalanx of the great toe at the interphalangeal joint are presented. This condition is characterized by pain, swelling, and tenderness at the interphalangeal joint. The roentgenographic characteristics resemble osteochondritis dissecans. Curettage and bone grafting to the lesion is effective. These conditions in adolescent soccer players may be caused by chronic repetitive overloading of the interphalangeal joint using soccer shoes with soft, supple, and narrow toe boxes.

Decomposition kinetics of cisplatin in human biological fluids

Cisplatin is metabolized to high- and low-molecular mass complexes by exchanging of one or both chloride ligands with nucleophilic species. The decomposition of cisplatin and the formation of its metabolites in human biological fluids was investigated in-vitro. In nucleophile-free medium, cisplatin was decomposed by a reversible chloride ligand exchange reaction, which was dependent upon both chloride ion concentration and medium pH. The effect of pH was observed in the second-order rate constant for cisplatin re-formation, which was far smaller in neutral and alkaline media than in acidic media. In the medium containing nucleophilic species (glutathione, human albumin and globulin), cisplatin was irreversibly decomposed according to apparent first-order kinetics. The linear relationship between apparent decomposition rate constant and concentration of nucleophilic species suggested that nucleophilic species in biological fluids might react with cisplatin directly. Both high- and low-molecular mass metabolites were formed in human plasma and ascites; however, only a low-molecular mass metabolite was produced in urine. The faster decomposition of cisplatin and the greater ratio of fixed and mobile metabolites formed in plasma were mainly attributed to higher albumin concentration in plasma than in ascites and urine. The in-vitro decomposition of unchanged cisplatin and formation of high- and low-molecular mass metabolites in human biological fluids were simultaneously evaluated according to the kinetic model which combined both pathways via hydrolysis and by the direct reaction process with nucleophilic species.

On the developing periodontal ligament of rats, using a new specimen preparation method for SEM in comparison with histochemistry

To visualize the cells and fibers of the developing periodontal ligament (PDL) by scanning electron microscope (SEM), we examined a new tissue preparation method including decalcification, sectioning by cryomicrotome, and chemical treatment for removal of cells or collagen fibers. The advantages of this method were as follows: (1) it was possible to expose the restricted area, (2) it caused no damage by heat or various embedding agents such as paraffin or resin, and (3) it was possible to make comparisons the SEM observation with histochemical or immunohistochemical observation using the neighboring sections. We could classify the development of PDL into three stages by alkaline phosphatase (ALPase) activity and observe each stage by this method. Stage I was the zone of dental follicle proper that showed negative ALPase activity. Stage II was the tissue surrounding the disrupted Hertwig's epithelial root sheath (HERS) which evinced intense ALPase activity, and stage III was the further advanced zone of differentiation that displayed moderate ALPase activity. Using this new method for SEM, cells with many processes and thin fibers were seen irregularly at stage II. On the other hand, at stage III, fibers were seen as interconnecting meshworks of thick bundles and cells that showed regularly arranged rows running obliquely to the surface of the root and alveolar bone. At the transition between stages II and III, the thickness and orientation of fibers changed abruptly.

Acid profiles and pH of carious dentin in active and arrested lesions

Organic acids in caries lesions play important roles in initiation and progress of dental caries. We investigated relationships between clinical types of dentin caries and acid profile or pH in the lesions. Caries lesions in dentin from 76 permanent teeth were classified into active, arrested, situated beneath a restoration, and unclassified types. The pH of carious dentin was distinctly lower than that of sound dentin (p < 0.001). Carious dentin with a high percentage of lactate had a lower pH than that with a high percentage of acetate and propionate (p < 0.001). Dentin from active lesions showed a mean pH of 4.9, and the dominant acid was lactate (mean percentage, 88.2). In contrast, carious dentin from arrested lesions showed a higher pH, 5.7, with acetate and propionate as the dominant acids (mean percentages of acetate and propionate, 64.0 and 18.2, respectively). The acid profile (mean percentages of acetate and propionate, 54.0 and 27.7, respectively) and pH (mean 5.8) of carious dentin sampled from lesions beneath a restoration were similar to those of dentin from arrested lesions. This study showed a clear relationship between clinical classification of dentin caries and acid profile and pH, suggesting that both factors are important in dentin caries etiology.

The distribution of amyloid beta precursor protein in canine brain

The distribution of amyloid beta precursor protein (APP) in canine brain was investigated. By immunoblot analysis, APP-positive bands corresponding to proteins of 105-120 kilodalton were recognized in all canine brains regardless of the individual age of the dogs. Bands of similar molecular mass were also detected in the meninges, cerebrospinal fluid, and several visceral organs. Immunohistochemical studies were performed using cryostat and paraffin-embedded sections pretreated with formic acid or by the hydrated autoclave method. In the normal canine brain, APP was found to be distributed in the neurons and vascular system. In the brains with SP, obvious accumulation of APP was observed in swollen neurites within amyloid plaques, although the relationship between APP and diffuse plaques was unclear. APP accumulation in swollen axons was also seen around necrotic foci in the brain of one dog with necrotizing purulent encephalitis. These studies revealed that distribution of APP in canine tissues, especially in the brain, and the accumulation of APP in swollen neurites or axons.

Double-labeling immunohistochemical studies on canine senile plaques and cerebral amyloid angiopathy

The relationship of senile plaques to neuronal cells, neurites, glial cells, or capillaries was examined using double labeling-immunostaining methods on the Bouin's solution-fixed serial brain sections from dogs. Compact deposits of beta protein (amyloid plaques) in the cerebral cortex always contained microvessels labeled by anti-collagen type IV antibody and some of them might be formed as the result of fusion of several perivascular beta amyloid deposits. In the periphery of those plaques swollen neurites recognized with anti-neurofilament antibody were sometimes present, but the relation between such plaques and neuronal cells or glial cells were unclear. Diffuse deposition of beta protein (diffuse plaques) was frequently developed beside neuronal cells, while most plaques did not contain glial cells. Some of those plaques were closely contact with microvessels, but some had no relation. Intact or irregularly arranged neurites were present in diffuse plaques. Such irregularity of the neurites were obvious in the plaques in the hippocampus as compared with those in the cerebral cortex. These results indicate the possibility that canine amyloid plaques would be formed as the result of amyloid degeneration of cortical capillaries, and diffuse parenchymal deposition of beta protein would originate from neuronal or neuritic processes.

Osteonectin inhibiting de novo formation of apatite in the presence of collagen

The effect of bone matrix protein of osteonectin on de novo formation of apatite was studied in a wide range of calcium phosphate solutions in the presence of collagen. In every solution, from which amorphous calcium phosphate, octacalcium phosphate, or apatite precipitated as a possible initial phase, osteonectin at concentrations less than 1 microM retarded the precipitation, subsequent transformation to apatite, and ripening crystal growth of apatite. Collagen present as either reconstituted or denatured form had no effect on the osteonectin-associated reactions as well as osteonectin-free reactions, and no structural correlation was observed between collagen fibrils and any of the calcium phosphates that appeared in our system. Direct measurement of free calcium levels in the solutions suggested that the reduction in calcium activity due to complexing with osteonectin hardly explained the inhibitory activity of osteonectin in retarding the formation of apatite. Instead, our transmission electron microscopic (TEM) observation strongly suggested that the primary mechanism for osteonectin to inhibit the formation of apatite is to block growth sites of calcium phosphates nucleated. The apatite thus formed in the presence of osteonectin showed less resolved X-ray diffraction patterns, partly because of smaller crystallites as suggested by TEM.