Dot in circle sign on MRI in foot mycetoma

Mycetoma or Maduramycosis is a chronic granulomatous infectious condition encountered mostly in tropical and subtropical regions. It affects the deep subcutaneous tissues, which may progress to involve the muscles and bones later in the course of the disease. It can be caused by fungi (eumycetoma), and bacteria (actinomycetoma) predominantly affecting the foot. Demonstration of the causative agent by biopsy and microbiological studies helps to establish a confirmative diagnosis, and choosing correct antimicrobial therapy. However, it may be delayed resulting in increased patient morbidity. Thus, imaging plays a vital role in early recognition & prompt treatment, especially MRI which is a non-invasive procedure demonstrating the hallmark dot in circle sign. Here we report a case of mycetoma foot with pathognomic MRI findings.

Morbidity Associated With Distal Tibial Autograft Harvest

Distal tibial autograft harvesting has been studied in the past, but morbidity at the level of the donor site is unclear. The purpose of this retrospective review is to assess morbidity in distal tibial autograft harvesting associated with foot and ankle arthrodesis procedures. A retrospective analysis was performed utilizing patients treated in the last 13 years at a large, multicenter, academic, tertiary referral, research institution. Included patients were between the ages of 18 and 80 years old. One-hundred and seven patients (39 male; 68 female) underwent ipsilateral distal tibial bone graft (n = 110) harvesting to augment the index procedure. Patients were followed for an average of 11.2 months after surgery (Range: 1-73 months). The incidence rate of distal tibial stress fractures was 4.5%, with an overall postoperative complication rate of 8.2%. Overall, low complication rates associated with distal tibial autograft harvesting were found, supporting the use of the distal tibia as an appropriate site for autograft harvesting in foot and ankle surgery.

3D isotropic MRI of ankle: review of literature with comparison to 2D MRI

The ankle joint has complex anatomy with different tissue structures and is commonly involved in traumatic injuries. Magnetic resonance imaging (MRI) is the primary imaging modality used to assess the soft tissue structures around the ankle joint including the ligaments, tendons, and articular cartilage. Two-dimensional (2D) fast spin echo/turbo spin echo (FSE/TSE) sequences are routinely used for ankle joint imaging. While the 2D sequences provide a good signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) with high spatial resolution, there are some limitations to their use owing to the thick slices, interslice gaps leading to partial volume effects, limited fluid contrast, and the need to acquire separate images in different orthogonal planes. The 3D MR imaging can overcome these limitations and recent advances have led to technical improvements that enable its widespread clinical use in acceptable time periods. The volume imaging renders the advantage of reconstructing into thin continuous slices with isotropic voxels enabling multiplanar reconstructions that helps in visualizing complex anatomy of the structure of interest throughout their course with improved sharpness, definition of anatomic variants, and fluid conspicuity of lesions and injuries. Recent advances have also reduced the acquisition time of the 3D datasets making it more efficient than 2D sequences. This article reviews the recent technical developments in the domain 3D MRI, compares imaging with 3D versus 2D sequences, and demonstrates the use-case scenarios with interesting cases, and benefits of 3D MRI in evaluating various ankle joint components and their lesions.

Coxa pedis: can calcaneal pronation angle be considered a predictive sign of medial plantar arch overload?

PURPOSE

To assess whether a correlation between the calcaneal pronation angle and the presence of internal plantar arch overload signs (such as upper-medial spring ligament lesion, posterior tibial tendon tenosynovitis, etc.) could lead to a better understanding of coxa pedis pathology.

MATERIAL AND METHODS

One hundred ankle MRIs of consecutive patients were retrospectively reviewed measuring the calcaneal pronation angle and either the presence or absence of internal plantar arch overload signs. Next, the association of overload signs with increasing pronation angle was evaluated to establish a cut-off point beyond which coxa pedis pathology could be defined.

RESULTS

The tibial-calcaneal angle values in patients with and without effusion proved to be significantly different (p < 0.0001). The tibial-calcaneal angle values in patients with and without oedema also demonstrated a significant difference (p < 0.0056). Regarding posterior tibial tendon, a significant difference was found between the two groups (p < 0.0001). For plantar fascia enthesopathy, the result was borderline significant (p < 0.054). A linear correlation was found between the value of pronation angle and the extent of spring ligament injury (p < 0.0001). In contrast, no correlation with age was found.

CONCLUSION

In conclusion, the literature associates medial longitudinal plantar arch overload with posterior tibial tendinopathy and spring ligament complex injuries. Our data show that both injuries are highly correlated with increased calcaneal pronation angle, which could be considered a predictive sign of internal plantar arch overload, prior to the development of the associated signs.

[Tibiotalocalcaneal arthrodesis for end-stage ankle and hindfoot arthropathy: Short- and mid-term clinical outcomes]

OBJECTIVE

To analyze the clinical data of patients with end-stage ankle and hindfoot arthropathy who underwent tibiotalocalcaneal (TTC) arthrodesis by the same surgeon, explore the short- and mid-term clinical results, complications and functional improvement, and discuss the clinical prognosis and precautions of TTC arthrodesis.

METHODS

Retrospective analysis was made on the clinical data of 40 patients who underwent TTC arthrodesis by the same surgeon from March 2011 to December 2020. In this study, 23 males and 17 females were included, with an average age of (49.1±16.0) years. All the patients underwent unilateral surgery. The clinical characteristics, imaging manifestations, main diagnosis and specific surgical techniques of the patients were recorded. The clinical outcomes were evaluated by comparison of the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and visual analogue scale (VAS) between pre-operation and at the last follow-up. The fusion healing time, symptom improvement (significant improvement, certain improvement, no improvement or deterioration) and postoperative complications were also recorded.

RESULTS

The median follow-up time was 38.0 (26.3, 58.8) months. The preoperative VAS score was 6.0 (4.0, 7.0), and the AOFAS score was 33.0 (25.3, 47.3). At the last follow-up, the median VAS score was 0 (0, 3.0), and the AOFAS score was 80.0 (59.0, 84.0). All the significantly improved compared with their preoperative corresponding values (P < 0.05). There was no wound necrosis or infection in the patients. One patient suffered from subtalar joint nonunion, which was syphilitic Charcot arthropathy. The median bony healing time of other patients was 15.0 (12.0, 20.0) weeks. Among the included patients, there were 25 cases with significant improvement in symptom compared with that preoperative, 8 cases with certain improvement, 4 cases with no improvement, and 3 cases with worse symptoms than that before operation.

CONCLUSION

TTC arthrodesis is a reliable method for the treatment of the end-stage ankle and hindfoot arthropathy. The function of most patients was improved postoperatively, with little impact on daily life. The causes of poor prognosis included toe stiffness, stress concentration in adjacent knee joints, nonunion and pain of unknown causes.

Are enlarged peroneal tubercle and accessory anterolateral talar facet associated with calcaneal spur?

BACKGROUND

As the anatomical variations of the foot, enlarged peroneal tubercle (EPT) and accessory anterolateral talar facet (AALTF) have attracted the attention of foot surgeons in recent years. However, EPT and AALTF have not been examined for a relationship with calcaneus spur (CS) as a common osteophyte.

METHODS

The subjects were 369 individuals who died in northeastern Thailand and were preserved as skeletal specimens. The authors examined for the presence of left and right EPT, AALTF, and calcaneus spur (CS). We divided the EPT (+) group with EPT and the EPT (-) group without it and also divided the AALTF (+) group with AALTF and the AALTF (-) group without it. The age at death and the presence of CS were compared statistically between the EPT (+) and EPT (-) groups and between the AATLF (+) and AALTF (-) groups.

RESULTS

Out of the total 369 cases, EPT was found in 117 cases (31.7%), AALTF was positive in 91 cases (24.7%), and CS was found in 194 cases (52.3%). In comparison between EPT (+) and EPT (-) groups, CS was significantly higher (p < 0.0001) in the EPT (+) group, but there was no significant difference in age at death. In comparison between AALTF (+) and AALTF (-) groups, there was no significant difference in age at death or CS.

CONCLUSION

This study showed a strong relationship between EPT and CS, and the prevalence of EPT and AALTF by age in Thailand was first reported. We believe it helps to know the pathogenesis and biomechanism of EPT and AALTF.

TRIAL REGISTRATION

Not applicable.

An examination of negative one-star patient reviews for foot and ankle orthopedic surgery: A retrospective analysis

BACKGROUND

Despite the questionable validity of online-based physician review websites (PRWs), negative reviews can adversely affect a provider's practice. Several investigations have explored the effect of extremely negative "one-star" reviews across subspecialties such as adult reconstruction, sports medicine, and orthopaedic traumatology; however, to date, no study has explored one-star reviews in foot and ankle surgery. The goal of this study was to characterize factors that contribute to extremely negative, one-star reviews for foot and ankle surgeons on Vitals.com.

METHODS

A retrospective analysis of negative one-star reviews with corresponding patient complaints for foot and ankle surgeons (both orthopaedic surgeons as well as podiatrists) in the United States. Physicians included were selected within a 10-mile radius of the top ten largest cities in the United States. Data was stratified by patient type (e.g., those receiving surgery and those not undergoing surgical intervention) and binned according to type of patient complaint, as previously described.

RESULTS

Of the 2645 foot and ankle surgeons identified in our initial query, 13.8% of surgeons contained one-star reviews eligible for analysis. Patient complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly 50% of the complaints related to surgical patients.

CONCLUSION

In conclusion, complaints related to bedside manner and patient experience are the causative factors accounting for 41.5% of the one-star reviews of foot and ankle surgeons for nonsurgical-related complaints. Surgical complications and other outcomes-related factors comprised roughly half of the complaints related to surgery. This data serves to inform practicing foot and ankle surgeons as to the influences behind patients leaving extremely negative reviews on PRWs.

LEVEL OF CLINICAL EVIDENCE

IV.

Epidemiology and Characteristics of Ankle and Foot Injuries in Electric Scooter-Related Accidents

Background

The use of electric scooters (e-scooters) continues to increase as a simple, inexpensive means of transport, resulting in a sharp increase in the incidence of scooter-related accidents. No study to date has closely examined the injury extent to the lower leg, joints, and extremities from e-scooter-related accidents. Here, we investigated the epidemiology and injury patterns of such accidents, focusing on injuries to the ankle and foot.

Methods

Based on data from a single tertiary hospital's database, the demographics of 563 patients with scooter-associated injuries were analyzed retrospectively. Among the patients, 229 patients who were injured by e-scooter riding were further investigated. Based on the data, the general demographics of whole scooter-associated injuries and the injury characteristics and fracture cases of the lower leg, ankle, and foot were analyzed.

Results

During the 4-year study period, the number of patients injured by e-scooters increased every year. Lower extremities were the most common injury site (67.2%) among riders, whereas injuries to the head and neck (64.3%) were more common in riders of non-electric scooters. Among the lower leg, ankle, and foot injuries of riders (52 cases), the ankle joint (53.8%) was the most commonly injured site, followed by the foot (40.4%) and lower leg (21.2%). The fracture group scored significantly higher on the Abbreviated Injury Scale than the non-fracture group (p < 0.001). Among the fracture group (20 cases), ankle fractures (9 cases) were most common, including pronation external rotation type 4 injuries (4 cases) and pilon fractures (2 cases). Five patients (25%) had open fractures, and 12 patients (60%) underwent surgical treatment.

Conclusions

The ankle and foot are the most common injury sites in e-scooter-related accidents. Given the high frequency and severity of e-scooter-related ankle and foot injuries, we suggest that more attention be paid to preventing these types of injuries with greater public awareness of the dangers of using e-scooters.

Patients' perspectives on systemic sclerosis-related Raynaud's phenomenon in the feet: A qualitative study from the OMERACT Foot and Ankle Working Group

OBJECTIVE

To explore, from patients' perspectives, the symptoms and impact of Raynaud's phenomenon (RP) on the feet of patients with systemic sclerosis (SSc-RP), and to identify which foot-related domains are important to patients.

METHODS

Forty participants (34 women) with SSc-RP took part in one of six focus groups held in the United Kingdom or United States. Participants were purposively sampled to ensure diversity in disease type, duration, and ethnicity. The topic guide included questions on RP impact, self-management, and treatment expectations. Qualitative content analysis was employed to identify key concepts in the data relating to foot-specific symptoms and their impact. Themes were organized by corresponding domains of potential importance.

RESULTS

Twenty-eight participants (70 %) reported experiencing RP in their feet. Five themes were identified corresponding to domains of potential importance: temperature changes, pain, cramping and stiffness, numbness, and color changes. These issues negatively affected participants' lives, impairing walking, driving, and socializing, and causing issues with footwear and hosiery.

CONCLUSIONS

This large qualitative study exploring the experiences of patients with SSc-RP in the feet identified several key domains of high importance to patients. SSc-RP is common in the feet, presents in several patterns, and impacts multiple aspects of patients' lives. These findings indicate where future foot-specific interventions for RP could be targeted. Findings from this study improve understanding of what domains are important to patients with SSc-RP affecting the feet and will contribute to the development of a core outcome set for foot and ankle disorders in rheumatic and musculoskeletal diseases.

The impact of pre-operative mental health on outcomes of foot and ankle surgery: A scoping review

BACKGROUND

Evidence suggests that certain groups of orthopaedic patients have an increased prevalence of mental health disorders than the general population. This scoping review aims to evaluate the effect of pre-operative mental health on outcomes of foot and ankle surgery.

METHODS

A literature search was performed in four databases. Studies investigating a relationship between preoperative mental health and postoperative patient reported outcome measures (PROMs), complications, readmissions or reoperations were included.

RESULTS

Of the 19 studies investigating the effect of preoperative mental health on PROMs, 16 (84.2%) reported a significant relationship between poorer preoperative mental health and inferior postoperative PROMs. Poorer mental health was associated with an increased rate of complications, readmissions and/or reoperations in four studies.

CONCLUSIONS

Poorer preoperative mental health is associated with significantly inferior outcomes following foot and ankle surgery. Clinicians should evaluate mental health to stratify likely outcomes and aid in the management of patient expectations.

LEVEL OF EVIDENCE

Level IV: Scoping review of Level II-IV studies.

Prospective Surgical Cohort Analysis

A well-conducted prospective cohort study has the potential to change the way in which surgeons practice. However, not all are equal. In this article, we provide many of the tools needed to critically appraise this powerful study design. We advocate for using a 3-step approach that centers on understanding the study's generalizability, results, and validity. We illustrate how this process is applied into practice regularly at our hospital section's journal club sessions.

Anatomical analysis of ligaments surrounding calcaneocuboid joint; implications for role in foot stability

PURPOSE

The calcaneocuboid joint is located in the lateral part of the foot and acts as a major stabilizer for the foot. Injuries to this joint often occur in association with ankle or foot injuries and are frequently overlooked, subsequently causing chronic pain or osteoarthritis. However, the relationship between ligaments surrounding the joint and joint instability remains unclear. Therefore, this study aimed to clarify the morphology and position of the ligaments surrounding the calcaneocuboid joint, and to reveal the relationship between the ligament structure.

METHODS

The position and morphology of the bifurcate ligament (subdivided into calcaneonavicular and calcaneocuboid ligaments), dorsal calcaneocuboid ligament, lateral calcaneocuboid ligament, long plantar ligament, and short plantar ligament were measured (N = 11 feet in 6 Japanese cadavers). The circumference of the joint was quartered, while the ligament-uncovered area and the estimated cross-sectional area of each ligament were compared between the four sides. Furthermore, the estimated cross-sectional area of each ligament was calculated as an index for the ligament strength.

RESULTS

The inferolateral side of the calcaneocuboid joint had the most uncovered area (54.63%) by the ligaments. In addition, the cross-sectional area of the ligaments on the lateral side was considerably smaller than that on the medial side.

CONCLUSION

Our results suggest that ligament weakness on the inferolateral side may cause instability of the calcaneocuboid joint, especially after an inversion sprain injury, and may decrease the lateral longitudinal arch function, which results in chronic foot pain.

Recommendations for management of diabetes and its complications during Hajj (Muslim Pilgrimage) - 2024 update

Hajj is an obligatory duty for all healthy adult Muslims once in the lifetime subjected to the ability. Considering the 10.5 % global prevalence of diabetes coupled with the numbers of Muslims performing the Hajj, ∼ 1.8 million in 2023, it is estimated that Muslims with diabetes performing Hajj may exceed 340,000 this year. During Hajj the pattern and amount of their meal, fluid intake and physical activity are markedly altered. Many people with diabetes insist on doing the Hajj duty, thereby creating a medical challenge for themselves and their health care providers. It is therefore important that medical professionals be aware of the potential risks that may be associated with Hajj. People with diabetes may face many health hazards during Hajj including but not limited to the killer triad which might occur during Hajj: Hypoglycemia, Foot injury and Infections. Many precautions should be taken to prevent and treat these potentially serious complications. Risk stratification, medication adjustments, proper clinical assessment, and education before doing Hajj are crucial.

Fatigue of the intrinsic foot core muscles had a greater effect on gait than extrinsic foot core muscles: A time-series based analyze

BACKGROUND

The Heel Rise endurance (HRE) which indicates the extrinsic foot core (ECO) muscle's performance and the paper grip endurance (PGE) which indicates the intrinsic foot core (ICO) muscle's performance are essential components of a healthy foot function. However, the foot core muscles' fatigue response on spatial and temporal gait parameters after the HRE and the PGE tests were not adequately investigated. The purpose of this study was to determine whether the fatigue of the ICO and the ECO muscles affect gait parameters.

MATERIAL AND METHODS

A prospective, cross-sectional study was conducted on 22 sedentary individuals (44 feet). Gait was investigated pre and after the Heel Rise (HR) endurance test and the paper grip (PG) endurance test by inertial sensors. At least 500 consecutive steps were collected for each individual. Spatial-temporal gait parameters were used as outcome measures.

RESULTS

ECO fatigue and ICO fatigue led to increases in the step length (p < 0.05) and the stride lengths (p < 0.05), the single support (p < 0.05), and the terminal stance durations (p < 0.05). It was also seen that ICO fatigue had a greater effect on gait than ECO fatigue. The ECO fatigue had a medium to large effect on the gait parameters (d=0.313-0.646). The ICO fatigue affected gait with a large effect (d=0.524-2.048).

CONCLUSION

The ECO fatigue and the ICO fatigue led to clinically important changes in long-range gait parameters and the ICO fatigue had a greater effect on gait than ECO fatigue. It was suggested that clinicians add ICO muscle endurance training to improve the physical performance of individuals.

Impact of foot functionality in patients with systemic sclerosis: Cross-sectional study

BACKGROUND

Progressive systemic sclerosis or systemic scleroderma (SS) is a chronic and rare autoimmune disease that mainly affects the skin and various internal organs. Raynaud's phenomenon and digital ulcers are some of the symptoms that affect the foot, causing a decrease in the quality of life of patients. The objective of this study is to determine the functionality of the feet in patients with SS and determine the impact on their daily lives.

METHODS

A sample of 165 patients (154 women, 11 men) diagnosed with SS with a mean age of 46.29 ± 11.36 years and a mean body mass index (BMI) of 24.90 ± 5.77 was recruited. Each participant completed the Foot Function Index (FFI) questionnaire and the Systemic Sclerosis Questionnaire (SySQ). A multivariate analysis was performed to determine which factors were related to a higher score in both questionnaires.

RESULTS

32.1% of the participants (n = 53) had claw toe deformities, 79.4% (n = 131) Raynaud's disease and 20% (n = 33) a history of foot ulcers. 51.5% of the participants (n = 85) presented symptoms in their nails, the most frequent sign being thickening, hardening and yellow coloration. The final score of the FFI questionnaire was 3.51 ± 2.41 (0-9.9), the pain subscale being the highest, with a score of 5.06 ± 2.75, followed by foot disability (3.26 ± 2.91) and difficulty performing activities (1.55 ± 2.22). The final score of the SySQ questionnaire was 0.95 ± 0.45 (0.18-2.45), and the subscales with the highest score were symptom frequency (1.30 ± 0.47), symptom intensity (1.11 ± 0.55), and general skill limitation (0.47 ± 0.51). A high correlation was observed between the final FFI score and the final SySQ score (r = 0.712; p=<0.001). Also, between foot activity limitation and general skill limitation (r = 0.658; p=<0.001). A moderate correlation was observed between foot pain score and overall symptom intensity (r = 0.482; p=<0.001). Also, between foot disability and overall symptom frequency (r = 0.556; p=<0.001). The multivariate analysis (R2 0.51) showed that the final FFI score had a significant relationship with the final SySQ score (p < 0.001). No significant correlation was found between age (p = 0.15), gender (p = 0.49), BMI (p = 0.74) or time of diagnosis (p = 0.57) and FFI.

CONCLUSION

SS is a disease that affects foot functionality in patients, with a greater impact on the pain scale. There is a correlation between the final FFI score and the final SySQ score, so improving foot functionality could help to improve the overall functionality of the patient with sclerosis.

Endovenous laser ablation vs phlebectomy of foot varicose veins

OBJECTIVE

The aim of this study was to compare the outcomes and complications of selected patients treated with endovenous laser ablation (EVLA) or ambulatory phlebectomy for foot varicose veins.

METHODS

From October 2016 to February 2022, selected patients undergoing EVLA (using 1470-nm with radial-slim or bare-tip fibers) or phlebectomy of foot varicose veins for cosmetic indications were analyzed, and the outcomes were compared. Patients were classified according to the Clinical, Etiologic, Anatomical, and Pathophysiological (CEAP) classification. Anatomic criteria provided the basis for the decision to perform EVLA or phlebectomy. Clinical and ultrasound assessments were performed on postoperative days 7, 30, and 90 for visualization of the sapheno-femoral and sapheno-popliteal junctions and the deep venous system. Disease severity was graded with the Venous Clinical Severity Score (VCSS), and quality of life was measured with the Aberdeen Varicose Vein Questionnaire (AVVQ) before and after treatment. Treatment outcomes were evaluated based on changes in VCSS and AVVQ scores. The groups were also compared for procedure-related complications. Data were statistically analyzed in SPSS v. 20.0 using the χ2, Student t test, Mann-Whitney test, Wilcoxon test, and analysis of variance. The results were presented as mean (standard deviation or median (interquartile range).

RESULTS

The study included 270 feet of 171 patients. Mean patient age was 52.3 (standard deviation, 13.1) years, ranging from 21 to 84 years; 133 (77.8%) were women. Of 270 feet, 113 (41.9%) were treated with EVLA and 157 (58.1%) with phlebectomy. The median preoperative CEAP class was 2 (interquartile range, 2-3) in the phlebectomy and EVLA groups, with no statistically significant difference between the groups (P = .507). Dysesthesia was the most common complication in both groups. Only transient induration was significantly different between EVLA (7.1%) and phlebectomy (0.0%) (P = .001). The two approaches had an equal impact on quality of life and disease severity.

CONCLUSIONS

Treatment complications were similar in phlebectomy and EVLA and to those previously described in the literature.

Subject-specific material properties of the heel pad: An inverse finite element analysis

Individuals with diabetes are at a higher risk of developing foot ulcers. To better understand internal soft tissue loading and potential treatment options, subject-specific finite element (FE) foot models have been used. However, existing models typically lack subject-specific soft tissue material properties and only utilize subject-specific anatomy. Therefore, this study determined subject-specific hindfoot soft tissue material properties from one non-diabetic and one diabetic subject using inverse FE analysis. Each subject underwent cyclic MRI experiments to simulate physiological gait and to obtain compressive force and three-dimensional soft tissue imaging data at 16 phases along the loading-unloading cycles. The FE models consisted of rigid bones and nearly-incompressible first-order Ogden hyperelastic skin, fat, and muscle (resulting in six independent material parameters). Then, calcaneus and loading platen kinematics were computed from imaging data and prescribed to the FE model. Two analyses were performed for each subject. First, the skin, fat, and muscle layers were lumped into a single generic soft tissue material and optimized to the platen force. Second, the skin, fat, and muscle material properties were individually determined by simultaneously optimizing for platen force, muscle vertical displacement, and skin mediolateral bulging. Our results indicated that compared to the individual without diabetes, the individual with diabetes had stiffer generic soft tissue behavior at high strain and that the only substantially stiffer multi-material layer was fat tissue. Thus, we suggest that this protocol serves as a guideline for exploring differences in non-diabetic and diabetic soft tissue material properties in a larger population.

Midfoot width changes after first metatarsal osteotomy in hallux valgus surgery: A biomechanical effect?

Hallux valgus is a challenging pathology characterized by a valgus deformity in the metatarsophalangeal area of the first ray. The aim of this study was to analyze the influence of first metatarsal osteotomy on the relationship between midfoot bones in patients with hallux valgus. The sample consisted of patients from the orthopedics and traumatology outpatient clinic who underwent surgical treatment for hallux valgus. Preoperative and postoperative X-rays were compared regarding the width of the midfoot and the tarsometatarsal joint. The sample consisted of 17 women, with 22 feet assessed in each group. The distance from the medial cuneiform to the cuboid, the distance from the intermediate cuneiform to the cuboid, the distance between the first and fifth metatarsals, and the distance between the second and fifth metatarsals reduced significantly between pre- and postoperative assessments. Hallux valgus correction through osteotomy of the first metatarsal leads to a structural change in the midfoot. Further studies should determine whether these changes persist over time.

Chronic Pain in the Lower Extremities and Low Back is Associated With Recurrent Falls in Community-Dwelling Japanese People Aged 40-74 Years

OBJECTIVE

To determine the longitudinal association between chronic pain in the lower extremities and low back and the odds of recurrent falls in middle-aged and older people.

DESIGN

A cohort study.

SETTING

Communities in Japan.

PARTICIPANTS

Participants were 7540 community-dwelling volunteers aged 40-74 years (N=7540). The baseline survey was a self-administered questionnaire conducted between 2011-2013. Predictors were presence of chronic pain in the knee, foot or ankle, and low back, with the degree of pain categorized as none, very mild/mild, moderate, or severe/very severe. Covariates in the multivariate model of chronic pain in a site were demographics, body mass index, physical activity level, disease history, and chronic pain in the other 2 sites. Logistic regression analysis was used to calculate odds ratios (ORs).

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Recurrent falls in the year before the 5-year follow-up survey.

RESULTS

Mean participant age was 60.2 years. Higher degrees of chronic pain were associated with higher odds of recurrent falls for the knee (P=.0002) with a higher OR of 1.48 (95% CI: 1.11-1.97), for the foot or ankle (P=.0001) with a higher OR of 1.97 (95% CI: 1.36-2.86), and for the low back (P=.0470) with a higher OR of 1.45 (95% CI: 1.09-1.91) in those with any degree of pain relative to those without pain. Higher degrees of chronic knee pain were associated with higher odds of recurrent falls in women (P=.0005), but not in men (P=.0813). Meanwhile, higher degrees of chronic low back pain were associated with the odds of recurrent falls in men (P=.0065), but not in women (P=.8735).

CONCLUSIONS

Chronic pain in the knee, foot or ankle, and lower back was independently and dose-dependently associated with a higher risk of recurrent falls. A marked sex-dependent difference was also noted in the association.

Ultrasound guided injections in ankle and foot

Ultrasound guidance is particularly useful for percutaneous injections in the diagnosis and management of painful conditions of the ankle and foot. The injectates used include steroids and local anesthetics, such as lidocaine, mepivacaine, bupivacaine, ropivacaine, and platelet-rich plasma. Osteoarthritis is the main indication for joint injections. Joints amenable to being injected include the tibiotalar, subtalar, midtarsal, and metatarsophalangeal joints. Tendon injections mainly involve the Achilles, peroneus, extensors, and tibialis tendons, while plantar fascia injections are useful for treating plantar fasciitis and plantar fibromatosis. Forefoot injections include joint arthritis, intermetatarsal bursitis, and Morton neuroma. The standardized approaches and doses reviewed in this paper are based on the authors' experience and can lead to high success in symptomatic relief for various conditions. These injections can be curative or serve as a guide to identify the source of pain when surgery or other therapeutic options are planned.

Lateral metatarsal osteotomy

Lateral metatarsal osteotomy (LMO) aims to reposition the affected metatarsals in a chosen position. The approach may be open or percutaneous. There are several types of LMO, according to displacement: shortening, raising, translation or lengthening. Preoperative planning covers type and extent of displacement, osteotomy location and type (open or percutaneous), and number of metatarsals concerned. In the 1990s, older concepts of non-fixed osteotomies gave way to preoperative planning and calculated shortening, including the development of Weil shortening osteotomy. Diaphyseal lengthening or shortening osteotomy is mainly used for brachymetatarsia. The older concept of non-fixed lateral rays made a comeback with percutaneous first-ray surgery. Distal metatarsal minimally invasive osteotomy (DMMO) is the most effective, giving rise to variants such as distal oblique metatarsal minimally invasive osteotomy (DOMMO), to meet the requirements of greater displacement, especially in shortening and translation, and to be applicable in as wide a range of cases as possible. Presently, these percutaneous techniques have not demonstrated superiority over open surgery, and entail specific complications. Even so, they are now part of the armamentarium of forefoot surgery, as their minimal invasiveness corresponds to current trends in surgery, especially in the foot. Level of evidence: V.

Imaging characteristics of too-long anterior process syndrome in children and adolescents

BACKGROUND

In the presence of pain over the lateral aspect of the foot or recurrent ankle sprain in children, medical imaging is often employed to investigate potential causes, such as a calcaneonavicular coalition or a too-long anterior process (TLAP) of the calcaneus. Diagnosis and categorization of calcaneonavicular coalitions (synostosis, synchondrosis, or synfibrosis) is generally facilitated through imaging, in contrast to TLAP, which lacks well-defined semiological characteristics, apart from a calcaneonavicular space measurement of less than 5 mm. However, this measurement initially performed on an oblique view radiograph can be subject to a lack of precision due to positional variations of the foot and overlapping bones. Furthermore, the differentiation between TLAP as an anatomical variant and TLAP syndrome (characterized by symptomatic presentation), remains a subject of uncertainty.

OBJECTIVE

The objective of our retrospective study was to investigate the imaging diagnosis of TLAP syndrome.

MATERIALS AND METHODS

A retrospective unmatched case-control study was conducted, covering data from February 2014 to January 2021. All patients, included retrospectively and consecutively, were initially managed in our hospital with radiography and/or computed tomography (CT) and/or magnetic resonance imaging (MRI). Two radiologists independently reviewed the images taken (radiographs, CT scans, and MRIs) of patients undergoing treatment in pediatric orthopedics for TLAP syndrome and control subjects, utilizing a standardized questionnaire. The control group consisted of subjects with no features suggestive of TLAP syndrome. The questionnaire included measurements of the calcaneonavicular space and identification of indirect signs associated with calcaneonavicular coalitions, as described in the related literature.

RESULTS

A total of 128 patients who met the inclusion criteria were included in the analysis, including 38 patients and 90 controls. The prevalence of TLAP was 71.5% in the study population and 62.6% among controls. A threshold measurement of the calcaneonavicular space at 3.2 mm favored TLAP syndrome (sensitivity=97%, specificity=70%, area under the curve [95% confidence interval] =0.881[0.812-0.949]), with better precision using CT. Three indirect signs were significant: the "anteater nose" sign, the talar beak, and the tapered anterior calcaneal process. These signs demonstrated an even stronger association with TLAP syndrome when observed in conjunction with a reduction in the calcaneonavicular space, particularly in CT scans.

CONCLUSION

TLAP is common among control subjects. Therefore, a variant appears to be the most plausible explanation and it can be considered a mild form of calcaneonavicular coalition. However, in conjunction with symptoms suggestive of TLAP syndrome, the diagnosis is further supported by imaging, specifically with a calcaneonavicular space measurement of less than 3.2 mm. This measurement is most accurately obtained using CT with 2-dimensional reconstructions in all three planes. The simultaneous presence of the "anteater nose" sign, the talar beak, or the tapered anterior calcaneal process provides additional diagnostic evidence. In the diagnostic approach of calcaneonavicular coalition, oblique foot radiography seems useful in initially detecting abnormal coalition (bony or not), and complementarily, CT emerges as the best modality to characterize TLAP syndrome.

Juxta articular myxoma of the foot: An exceptional entity

INTRODUCTION

Myxoma, a benign and uncommon tumor, is primarily characterized by undifferentiated spindle cells and a myxoid matrix with muscular infiltration. While the intramuscular form is predominant, the juxta-articular variant is rare, especially in the foot. Juxta-articular myxomas had a heightened risk of recurrence post-surgical excision, emphasizing the need for effective management strategies.

CASE PRESENTATION

We report the first description in the literature of a myxoma in the foot with bone invasion in a 59-year-old male with a ten-month history of a progressively enlarging antero-internal swelling near the base of the first metatarsal in the left foot. Clinical examination and imaging revealed erosive changes in the bone, prompting excision-curettage. Histopathological examination confirmed the presence of a juxta-articular myxoma, an exceptionally rare localization. The patient exhibited satisfactory outcomes at the 13-month follow-up.

DISCUSSION

Myxomas, primarily occurring around the knee, are infrequently found in the foot, with juxta-articular presentation being exceptionally rare. Traumatic causes and osteoarthritis are debated etiopathogenic factors. Radiologically, bone involvement is atypical, and magnetic resonance imaging aids in diagnosis. Treatment involves surgical excision, often requiring additional procedures. Juxta-articular myxomas, despite sharing characteristics with intramuscular myxomas, are distinguished by location and a higher recurrence rate.

CONCLUSION

This case contributes to the limited literature on myxomas localized in the foot, particularly with bone invasion. Histological diagnosis is crucial, and surgery is the mainstay of treatment despite the substantial recurrence risk. This report underscores the importance of vigilance in managing myxomas, especially in rare anatomical presentations, and advocates for ongoing research to enhance understanding and therapeutic approaches.

Plantar pressures in people with midfoot osteoarthritis: cross-sectional findings from the Clinical Assessment Study of the Foot

BACKGROUND

Midfoot osteoarthritis (OA) is a common condition, however its aetiology is not well understood. Understanding how plantar pressures differ between people with and without midfoot OA may provide insight into the aetiology and how best to manage this condition.

RESEARCH QUESTION

To compare plantar pressures between people with and without symptomatic radiographic midfoot OA.

METHODS

This was a cross-sectional study of adults aged ≥ 50 years registered with four UK general practices who reported foot pain in the past year. Symptomatic radiographic midfoot OA was defined as midfoot pain in the last four weeks, combined with radiographic OA in one or more midfoot joints. Cases were matched 1:1 for sex and age ( ± 5 years) to controls. Peak plantar pressure and maximum force in 10 regions of the foot were determined using a pressure platform (RSscan International, Olen, Belgium) and compared between the groups using independent samples t-tests and effect sizes (Cohen's d).

RESULTS

We included 61 midfoot OA cases (mean age 67.0, SD 8.1, 31 males, 30 females) and matched these to 61 controls (mean age 66.0, SD 7.9). Midfoot OA cases displayed greater force (d=0.79, medium effect size, p = <0.001) and pressure at the midfoot (d=0.70, medium effect size, p = <0.001), greater force at the fourth metatarsophalangeal (MTP) joint (d=0.28, small effect size, p = 0.13), and fifth MTP joint (d=0.37, small effect size, p = 0.10) and greater pressure at the fifth MTP joint (d=0.34, small effect size, p = 0.13). They also displayed lower force (d=0.40, small effect size, p = 0.02) and pressure at the hallux (d=0.50, medium effect size, p = <0.001) and lower force (d=0.54, medium effect size, p = <0.001) and pressure at the lesser toes (d=0.48, small effect size, p = <0.001) compared with controls.

SIGNIFICANCE

Midfoot OA appears to be associated with lowering of the medial longitudinal arch, greater lateral push off and less propulsion at toe off. Longitudinal studies are needed to establish causal relationships.

Radiographic Evaluation of the Association between Foot Deformities and Ankle Medial Osteoarthritis

Background

Foot deformities can cause abnormal biomechanics of the ankle joint and the development of osteoarthritis. It was hypothesized that foot deformities would be related to medial ankle osteoarthritis, and this study investigated this relationship using radiographic measurements.

Methods

Seventy-six ankles of 76 patients (32 men and 44 women; mean age, 69.0 years) with medial ankle osteoarthritis were included. Eleven radiographic measurements evaluated ankle joint orientation (tibial plafond inclination [TPI], medial distal tibial angle [MDTA], and anterior distal tibial angle [ADTA]), ankle joint incongruency (tibiotalar tilt [TT]), foot deformities (lateral talo-first metatarsal angle [Lat talo-1MT], anteroposterior talo-first metatarsal angle [AP talo-1MT], and talonavicular coverage), talar body migration (medial talar center migration [MTCM] and anterior talar center migration [ATCM]), internal rotation (IR) of the talus, and mechanical tibiofemoral angle. All were statistically analyzed using Pearson's correlation coefficients and regression analyses.

Results

Ankle joint orientation to the ground (TPI, p = 0.002), increased foot arch (Lat talo-1MT, p < 0.001), and IR of the talus (p = 0.001) were significantly associated with ankle joint incongruency (TT) in linear regression analysis. Ankle joint incongruency (TT, p = 0.003), medial talar body migration (MTCM, p = 0.042), and increased foot arch (Lat talo-1MT, p = 0.022) were significantly associated with IR of the talus in the binary logistic regression analysis. MTCM was significantly correlated with TPI (r = 0.251, p = 0.029), TT (r = 0.269, p = 0.019), MDTA (r = 0.359, p = 0.001), ATCM (r = -0.522, p < 0.001), and AP talo-1MT (r = 0.296, p = 0.015). ATCM was significantly correlated with TPI (r = -0.253, p = 0.027), ADTA (r = 0.349, p = 0.002), and Lat talo-1MT (r = -0.344, p = 0.002).

Conclusions

Ankle joint orientation, foot deformities, and talar rotation were associated with ankle joint incongruency in medial ankle osteoarthritis when evaluated radiographically. These findings need to be considered during surgical treatment for medial ankle osteoarthritis. However, the biomechanical significance of these radiographic measurements requires further investigation.

Does using 3D printed models for pre-operative planning improve surgical outcomes of foot and ankle fracture fixation? A systematic review and meta-analysis

PURPOSE

The systematic review aims to establish the value of using 3D printing-assisted pre-operative planning, compared to conventional planning, for the operative management of foot and ankle fractures.

METHODS

The systematic review was performed according to PRISMA guidelines. Two authors performed searches on three electronic databases. Studies were included if they conformed to pre-established eligibility criteria. Primary outcome measures included intraoperative blood loss, operation duration, and fluoroscopy time. The American orthopaedic foot and ankle score (AOFAS) was used as a secondary outcome. Quality assessment was completed using the Cochrane RoB2 form and a meta-analysis was performed to assess heterogeneity.

RESULTS

Five studies met the inclusion and exclusion criteria and were eventually included in the review. A meta-analysis established that using 3D printed models for pre-operative planning resulted in a significant reduction in operation duration (mean difference [MD] = - 23.52 min, 95% CI [- 39.31, - 7.74], p = 0.003), intraoperative blood loss (MD = - 30.59 mL, 95% CI [- 46.31, - 14.87], p = 0.0001), and number of times fluoroscopy was used (MD = - 3.20 times, 95% CI [- 4.69, - 1.72], p < 0.0001). Using 3D printed models also significantly increased AOFAS score results (MD = 2.24, 95% CI [0.69, 3.78], p = 0.005), demonstrating improved ankle health.

CONCLUSION

The systematic review provides promising evidence that 3D printing-assisted surgery significantly improves treatment for foot and ankle fractures in terms of operation duration, intraoperative blood loss, number of times fluoroscopy was used intraoperatively, and improved overall ankle health as measured by the AOFAS score.

The transcriptomic and biochemical responses of blood clams (Tegillarca granosa) to prolonged intermittent hypoxia

The blood clam (Tegillarca granosa), a marine bivalve of ecological and economic significance, often encounters intermittent hypoxia in mudflats and aquatic environments. To study the response of blood clam foot to prolonged intermittent hypoxia, the clams were exposed to intermittent hypoxia conditions (0.5 mg/L dissolved oxygen, with a 12-h interval) for 31 days. Initially, transcriptomic analysis was performed, uncovering a total of 698 differentially expressed genes (DEGs), with 236 upregulated and 462 downregulated. These genes show enrichments in signaling pathways related to glucose metabolism, sugar synthesis and responses to oxidative stress. Furthermore, the activity of the enzyme glutathione peroxidase (GPx) and the levels of gpx1 mRNA showed gradual increases, reaching their peak on the 13th day of intermittent hypoxia exposure. This observation suggests an indirect protective role of GPx against oxidative stress. The results of this study make a significantly contribute to our broader comprehensive of the physiological, biochemical responses, and molecular reactions governing the organization of foot muscle tissue in marine bivalves exposed to prolonged intermittent hypoxic conditions.

Effects of rigid and kinesio taping on plantar pressure distribution in patients with Lisfranc fracture sequelae

BACKGROUND

Patients with Lisfranc fractures may regain functional status after anatomical fixation, but they may experience sequelae such as flatfoot deformity and pain associated with foot pressure distribution during weight-bearing.

RESEARCH QUESTION

What is the impact of Lisfranc fracture sequelae on both the injured and uninjured sides, and how does the antipronation taping affect plantar pressure distribution parameters?

METHODS

Twenty-six patients who underwent anatomical fixation for Lisfranc fracture, displaying pronation on the injured side based on the Foot Posture Index-6 test, as well as 15 healthy subjects, participated in this study. Plantar pressure distribution measurements were conducted during barefoot walking for the healthy subjects. In the patient group, measurements were taken under two antipronation taping conditions (kinesio and rigid taping), as well as during barefoot walking.

RESULTS

Participants who received anatomical fixation after Lisfranc fracture exhibited significant alterations in plantar pressure distribution parameters on both the injured and uninjured sides, as compared to the control group. After the application of Kinesio Taping to the injured side, there was no significant change observed in the plantar pressure distribution values (p > 0.05). The analysis of the rigid taping on the injured side revealed statistically worse values in peak pressure of the hindfoot (p = 0.027) and maximum force of the midfoot and toes (p = 0.005 and p = 0.013, respectively) compared to the injured barefoot condition.

SIGNIFICANCE

Lisfranc fracture sequelae affected plantar pressure distribution on both injured and uninjured sides. Anti-pronation taping (kinesio and rigit), commonly used for foot conditions, did not lead to foot pressure distribution becoming more similar to that of the control group.

Identification of fractures on pediatric foot radiographs: do localization cues improve diagnostic accuracy and reduce interpretation time?

OBJECTIVE

To investigate the diagnostic accuracy and time in the detection of fractures on pediatric foot radiographs marked without and with localization cues.

METHOD

One-hundred randomly selected foot radiographic examinations that were performed on children (<18 years old) after injury and with at least 4 weeks of follow-up were included. Blinded to history and diagnosis, 4 readers (one each: medical student, pediatrician, pediatric orthopedic surgeon, and pediatric musculoskeletal radiologist) retrospectively and independently reviewed each examination twice (without and with cue, at least 1 month apart, and after randomization). Each reader recorded the presence or absence of a fracture, fracture location, diagnostic confidence, and the total (interpretation) time spent on each study. Diagnostic accuracy, reader confidence, and interpretation time were compared between examinations without and with cues.

RESULTS

Our study included 59 examinations without and 41 with fractures (21 phalangeal, 18 metatarsal, and 2 tarsal fractures). Localization cues improved inter-reader agreement (κ=0.36 to 0.64), overall sensitivity (68 to 72%), specificity (66 to 73%), and diagnostic accuracy (67 to 73%); thus, overcalled and missed rates also improved from 34 to 27% and 32 to 28%, respectively. Reader confidence improved with cue (49 to 61%, p<0.01) with higher incremental improvement with younger children (30% for 1-6 years; 14% for 7-11 years; and 10% for 12-17 years). Interpretation time decreased by 40% per examination (40±22 s without to 24±13 s with cues, p<0.001).

CONCLUSION

Localization cues improved diagnostic accuracy and reader confidence, reducing interpretation time in the detection of pediatric foot fractures.

Predictive factors for foot pain in the adult population

BACKGROUND

Foot pain has been associated to factors like: fat, body mass index, age increased, female gender and the presence of pathologies. Although evidence is limited. The purpose is to determine the predictive factors for foot pain in the adult population.

METHODS

From January to December 2021, 457 patients were > 18 years, gave signed informed consent to take part to this cross sectional study. All completed demographic data and various questionnaires related to pain: Foot Function Index, EuroQoL-5D and Visual Analogue Scale (foot pain). Anthropometric measurements were obtained using McPoil platform and foot posture was assessed by the Foot Posture Index (FPI). To determine whether a volume change is a predictive factor for foot pain, a parameter was established: the volumetric index for footwear (VIF). Factors linked to the presence of pain, including the considered VIF variables, were analyzed through multivariable logistic regression.

RESULTS

Among the study population, 40.7% were male and 59.3% female. The mean age of 39.06 years and a body mass index of 25.58 Kg/cm2. The logistic regression model had a classification capability of 72.4%, a sensitivity of 72.3% and a specificity of 73%, in which, the predictors considered were the variables found to have a significant association with FFI-pain > 45 points,, showed that younger women, with a higher BMI, higher values of right FPI (pronation), poorer overall perceived health and with problems in walking were more likely to experience foot pain.

CONCLUSION

Predictive factors for foot pain in the adult population include gender, age, Body Mass Index, FPI on the right foot, perceived health and mobility. Clinical implication, the presented measure aids physicians in assessing their patients´ foot pain likelihood.

Similar outcomes following scarf-Akin osteotomy compared to scarf-alone osteotomy for the treatment of hallux valgus: A systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review and meta-analysis was to compare the clinical and radiographic outcomes between patients undergoing scarf osteotomy and scarf-Akin osteotomy for the management of hallux valgus deformity.

METHODS

A systematic review of the MEDLINE, EMBASE and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical data following scarf osteotomy and scarf-Akin osteotomy for the treatment of hallux valgus were included and assessed. The level and quality of evidence of the included studies were also evaluated.

RESULTS

Four studies were included. In total, 388 patients (408 toes) underwent scarf osteotomy alone and 287 patients (295 toes) underwent scarf-Akin osteotomy for the treatment of hallux valgus deformity. There was no difference in postoperative American orthopedic foot and ankle society scores (p = 0.7828), visual analog scale scores (p = 0.4558), hallux valgus angle (p = 0.5116), intermetatarsal angle (p = 0.4830), proximal to distal phalangeal articular angle (p = 0.2411) between the scarf alone cohort and the scarf-Akin cohort. Similarly, there was no difference in complication rates (p = 0.6881) nor secondary surgical procedure rates (p = 0.3678) between the 2 cohorts. Finally, there was a higher recurrence rate in the scarf-alone cohort (11.4%) compared to the scarf-Akin cohort (5.7%), but this was not statistically significant (p = 0.4414).

CONCLUSION

This systematic review demonstrates lower recurrence rates following scarf-Akin osteotomy compared to scarf osteotomy alone for the treatment of hallux valgus deformity. No difference in complication rates were noted between the 2 cohorts. Our review demonstrates that both the scarf osteotomy and the scarf-Akin osteotomy may be effective and safe procedures, however, the scarf-Akin osteotomy may provide more long-term benefit in the setting of moderate to severe hallux valgus.

Tourniquet use in ankle arthroscopy: A systematic review

BACKGROUND

Ankle arthroscopy is commonly performed using a thigh tourniquet and is thought to improve visibility and reduce operative time. However, the current evidence is unclear as to whether the use of a tourniquet provides these benefits. The aim of this study was to investigate whether there is any clinical benefit of using a tourniquet in ankle arthroscopy.

METHODS

A systematic review following PRISMA guidelines was undertaken. All clinical studies published in Medline, Embase, PubMed and the Cochrane Library Database from inception until January 2023 reporting on the use of a tourniquet in ankle arthroscopy were included.

RESULTS

180 studies were identified of which 3 (164 patients) met the inclusion criteria. All studies showed no statistically significant difference in mean surgical time and complication rate between the tourniquet and non-tourniquet groups. Overall, the quality of the evidence was moderate to poor without data in favour or against the routine use of tourniquets in ankle arthroscopy.

CONCLUSION

The current literature suggests that there are no significant differences in mean surgical time and complication rate between the tourniquet and non-tourniquet groups.

"Antero-medial load shift" in unilateral plantar heel pain - A cross-sectional exploratory study

BACKGROUND AND PURPOSE

Plantar foot pressure provides an insightful data in the ankle and foot complex which may aid in the detection of underlying pathology. Since individuals with unilateral plantar heel pain (PHP) tend to develop compensatory loading strategies, this study aimed to observe the foot loading pattern compared to the asymptomatic side and its relationship with the morphological variations in individuals with unilateral PHP.

METHODS

It was a prospective cross-sectional study done on 17 participants with unilateral PHP. The calcaneal inclination and calcaneal first metatarsal angles were measured using lateral weight-bearing radiographs for both symptomatic and asymptomatic feet. Static and dynamic plantar foot pressures for both sides were obtained using a "Portable baropodometry platform 0, 5 m Entry Level footscan®.

RESULTS

On the symptomatic side, the pressure in the lateral heel was reduced by 65% in static and 67% in dynamic measurements, while in the medial heel, it was reduced by 16 % in static and 47 % in dynamic measurements compared to that of the asymptomatic side. There was a transfer of pressure from the hind foot to the forefoot by 44 % in static and 46 % in dynamic measurements resulting in anterior load shift. It was also observed that the prevalence of PHP was higher in the normal arched foot (59%).

CONCLUSION

Based on the observations, compared to the asymptomatic side, patients with unilateral plantar heel pain exhibited an anteromedial load shift (AMLS) in their plantar pressures. PHP was reported higher in the foot with normal morphology.

LEVEL OF EVIDENCE

Level 4.

Innovative biochemisurgical treatment for stabilisation of an end-stage chronic wound in a complex vascular compromized patient

INTRODUCTION

Treating advanced peripheral arterial occlusive disease (e.g. PAOD IV) poses a significant challenge, as conventional treatments quite often fall short at this stage. However, a range of interventions can be considered to postpone amputation. This study presents an example of advanced stage of Peripheral Artery Occlusive Disease (PAOD) stage IV, encompassing a history of a high thigh amputation on the left side, coupled with pronounced wound healing disorders.

PRESENTATION OF CASE

Our patient, 55 years old, smoker and ASA Class III is in a left sided above-the knee-amputation situation. He presented to our outpatient clinic with blistering in the stump area, caused by non-proportinate pressure from the prosthesis. With an emerging septic course and advanced peripheral arterial occlusive disease (PAOD) at Fontaine class IV, revascularization was unfeasible in the left iliac artery axis and groin arteries. Additionally, a stage PAOD IV presents itself with poorly healing wounds on the right side which our patient still uses to support his transfers in and out bed and his wheelchair. Multiple surgical stump revisions and femur shortenings and diverse wound treatments were performed all were unsatisfying for patient and practitioners. We introduced a novel biochemisurgical treatment in our teaching hospital.

DISCUSSION

Desiccating-agent-A is an innovative dehydrating agent with potent desiccating characteristics upon application to organic substances. Its formulation involves blending 83% methane sulfonic acid with proton acceptors and dimethyl sulfoxide, as outlined in patent application. The case description results in an illustrated follow up period of 16 months and is presented in line with the recommendations of the consensus-based surgical case reporting guideline development.

CONCLUSION

The goal of achieving a secondary healing trend is to establish stability within the wound area or achieve complete healing. This endeavor becomes particularly intricate when severe blood circulation compromise exists. Nonetheless, progress in wound treatment measures has made it feasible to achieve this aim by fostering the formation of dry and clean necrotic tissue. This dry and clean wound is now manageable in a patient's home situation, allowing for effective care and a better chance at preventing further severe complications.

Ultrasound imaging and Fascial Manipulation®: 'Adding a twist' on the ankle retinacula

BACKGROUND

Retinacula of the ankle are thickening of the deep fascia of the leg (crural fascia) and foot i.e. inseparable structures. Recent studies report their crucial role in functional stability and proprioception of the ankle.

CASE PRESENTATION

A 38-yr-old Caucasian man - with a history of lateral malleolus fracture 12 years ago, obesity and right ankle osteoarthritis - was referred to a physiatrist for a right ankle pain that had significantly worsened over the last year. During walking, the patient experienced stinging pain in the area of tibialis anterior and peroneus tertius muscles, and the superior extensor retinaculum. Magnetic resonance imaging and ultrasonography showed clear thicknening (2.05 mm) of the oblique superomedial band of the inferior extensor retinaculum. Sonopalpation was performed to precisely evaluate/confirm the site of maximum pain. Foot function index (FFI) score was 42.

RESULTS

Subsequently, the patient was prescribed fascial manipulation, and he had clinical improvement after the first session (FFI: 21). At 1-month follow-up, the patient was still asymptomatic without any functional limitation (FFI: 24). US imaging confirmed the decreased thickness of the oblique superomedial band of the extensor retinaculum (1.35 mm).

CONCLUSION

Fascial Manipulation® appears to be a useful tool to reduce thickness, stiffness, and pain in this case as displayed by the ultrasound Imaging.

Relations between maternal height, shoe size, and the success of vaginal delivery in birth weight over 4000 g

OBJECTIVE

Macrosomia is associated with increased risk of fetal and maternal complications such as trauma during birth, cesarean delivery, postpartum hemorrhage, and shoulder dystocia. Sonographic estimation of fetal weight is imprecise particularly in excessively large fetuses, prompting the need for additional measures to assess the feasibility of vaginal delivery of a macrosomic newborn and thus improve prenatal consultation.

MATERIALS AND METHODS

This retrospective case-control study included women who delivered a singleton macrosomic newborn (birth weight>4,000 g), either vaginally (N = 762) or by urgent cesarean delivery during labor (N = 109). Using multivariable analysis, we examined correlations of maternal height≥170 cm and shoe size≥40 with successful vaginal delivery.

RESULTS

Women who delivered vaginally had lower mean intrapartum BMI (p < 0.001) and lower rate of gestational diabetes (p = 0.003). Women with a shoe size≥40 were 2.2 times more likely to give birth vaginally. Cesarean section rate was 5.9 % among women with height≥170 cm and shoe size≥40; and 16.5 % among women with height<170 cm and shoe size<40. Multivariable analysis, adjusted for gestational diabetes, parity, and BMI, revealed that shoe size≥40 and maternal height≥170 cm correlated with success in vaginal delivery, OR = 3.1 (95%CI 1.3-7.3, p = 0.009).

CONCLUSION

Shoe size and maternal height may help predict success of vaginal birth of the macrosomic newborns.

Supination resistance variations in foot and ankle musculoskeletal disorders: implications for diagnosis and customised interventions with wedged insoles

BACKGROUND

Supination resistance is a clinical outcome that estimates the amount of external force required to supinate the foot. A greater supination resistance may indicate greater loads on structures responsible for generating internal supination moments across the subtalar joint during static and dynamic tasks. As such, greater supination resistance may be an expected finding in medial foot and ankle musculoskeletal disorders, such as plantar fasciopathy (PF) and posterior tibial tendon dysfunction (PTTD), whereas reduced supination resistance may be present in lateral ankle disorders, such as chronic ankle instability (CAI). However, no studies have yet investigated the changes in supination resistance across these foot and ankle musculoskeletal disorders. This study aimed to quantify supination resistance in individuals with PF, PTTD and CAI compared to healthy controls. Additionally, this study aimed to explore the changes in supination resistance following the simulation of varus and valgus wedges, which are commonly used interventions for these disorders.

METHODS

Fourteen participants with PF, fourteen with PTTD, fourteen with CAI and fourteen healthy controls were recruited. Supination resistance was quantified on a level surface and on a 10-degree inclined surface with varus and valgus positions.

RESULTS

Supination resistance was lower for the injured foot for CAI (p < 0.001) and greater for PTTD (p < 0.001) compared to the healthy foot. There was no significant between-foot difference observed for PF (p = 0.275) and controls (p = 0.970). In the injured foot, CAI exhibited lower supination resistance compared to controls (p < 0.001), PF (p = 0.012) and PTTD (p = 0.014). Regardless of the groups, supination resistance increased when tested on a surface with valgus inclination (p < 0.001) and decreased when tested on a surface with varus inclination (p < 0.001).

CONCLUSIONS

Varus and valgus inclinations to the surface were effective in modifying supination resistance in PTTD and CAI, respectively. Supination resistance seemed unchanged in PF, and thus inclining the standing surface leads to greater between-feet asymmetries. This study also highlights the potential of wedged insoles as a mean to customise treatments and modify tissue stresses in these disorders. The findings contribute to the understanding of foot and ankle biomechanics and may aid in the development of more effective management and rehabilitation strategies.

Cavovarus Deformity: Why Weight-Bearing Computed Tomography Should Be a First-Line Imaging Modality

Cavovarus foot is a complex three-dimensional deformity, which includes a wide range of clinical conditions from subtle deformities to disabling feet. In this article, the authors discuss the role of weight-bearing computed tomography, which might enable to avoid double imaging (radiographs + tomography) in patients for which a detailed osteoarticular assessment is required, with the advantage to obtain tomographic images in standing position and a reduction of radiation exposure.

Artificial intelligence in foot and ankle surgery: current concepts

The twenty-first century has proven that data are the new gold. Artificial intelligence (AI) driven technologies might potentially change the clinical practice in all medical specialities, including orthopedic surgery. AI has a broad spectrum of subcomponents, including machine learning, which consists of a subdivision called deep learning. AI has the potential to increase healthcare delivery, improve indications and interventions, and minimize errors. In orthopedic surgery. AI supports the surgeon in the evaluation of radiological images, training of surgical residents, and excellent performance of machine-assisted surgery. The AI algorithms improve the administrative and management processes of hospitals and clinics, electronic healthcare databases, monitoring the outcomes, and safety controls. AI models are being developed in nearly all orthopedic subspecialties, including arthroscopy, arthroplasty, tumor, spinal and pediatric surgery. The present study discusses current applications, limitations, and future prospective of AI in foot and ankle surgery.

Actinomycosis of the sole of the foot (Madura foot): A rare case report and literature review

INTRODUCTION AND IMPORTANCE

Actinomycosis of the foot is a rare, chronic, granulomatous infectious ailment affecting the skin, dermis, and subcutaneous tissues. It is caused by a fungal or actinomycotic agent, resulting in a pseudotumoral appearance. This pathology typically progresses slowly, leading to delayed diagnosis. The primary objective of this report is to emphasize the rarity and clinical significance of this highly uncommon medical condition.

CASE PRESENTATION

We present the case of a 45-year-old woman with a mass on the sole of her right foot. The condition was treated through excisional biopsy along with combined antibiotic therapy. Histopathology of the excised mass confirmed the presence of actinomycosis, ultimately confirming the diagnosis. The patient's progress was satisfactory, with no recurrence observed over a 2-year follow-up period.

CLINICAL DISCUSSION

Actinomycosis of the foot is a common pathology in tropical and subtropical regions where climatic conditions promote its emergence. It is a chronic, granulomatous infection of exogenous origin, caused by either fungal (eumycetoma) or bacterial (actinomycetoma) agents. When left unrecognized, these infections can lead to complications, including osteoarticular lesions, with a severe impact on the functional prognosis. The presence of foot swelling should raise suspicion of mycetoma as a diagnosis, with confirmation relying on histological analysis. Management typically involves the aggressive control of invasive soft-tissue masses, often followed by prolonged antibiotic treatment. Skin grafting is a standard method for closing Madura foot defects, and continuous surveillance is necessary due to the potential for actinomycosis recurrence.

CONCLUSION

In the context of Morocco, actinomycosis of the foot remains sporadic. Identifying these conditions presents significant diagnostic challenges, leading to unfortunate treatment delays. These largely unrecognized conditions have the potential to become more complex by causing osteoarticular damage and lesions, ultimately worsening the functional outlook. Early vigilance is advisable upon observing foot swelling, considering the possibility of actinomycosis of the foot. A definitive diagnosis requires histological analysis, a critical step.

Prospective observational analysis of intraoperative radiation exposure with a mini C-arm intensifier in percutaneous forefoot surgery

INTRODUCTION

Percutaneous forefoot surgery has been associated with higher radiation exposure than the conventional approach. However, there is little data on forefoot surgery using a mini C-arm intensifier. We, therefore, conducted a prospective study to (1) evaluate the intraoperative radiation received by the surgeon during percutaneous forefoot surgery with a mini C-arm; (2) compare the radiation received by the surgeon with the guidelines for occupational exposure issued by the International Commission on Radiological Protection (ICRP) (20 millisieverts per year [mSv/year] for the whole body, 500mSv/year for the hands, and 20mSv/year for the lens of the eye); and (3) compare the radiation received during percutaneous forefoot surgery with that of the open approach, which has already been reported in the literature.

HYPOTHESIS

The radiation received by the surgeon during percutaneous forefoot surgery with a mini C-arm is lower than the ICRP guidelines, and the findings reported in the literature.

MATERIALS AND METHODS

This prospective single-center study was conducted from September 2020 to May 2021. A total of 639 feet (i.e., 435 patients) were included. Of these 639 feet, 336 (52%) were hallux valgus repairs, 49 (8%) were stand-alone procedures of the lateral rays, and 124 (19%) were a combination of both. The radiation dose data was retrieved from the mini C-arm daily: dose-area product (DAP) in centigray per square centimeter (cGy/cm2) and radiation exposure duration in seconds. The doses received by the surgeon were collected every month by 4 passive dosimeters (hand, eye lens, and chest [on and under the lead apron]) and 2 active dosimeters (on and under the lead apron).

RESULTS

The DAP emitted by the mini C-arm during an operating day was 0.10±0.01cGy/cm2 (range, 0.0-3.9), and the mean daily radiation duration was 34.7±19.3seconds (range, 0.7-226.8). There was a mean of 8±8 (range, 1-18) elective procedures per operating day. The daily reading on the active dosimeter worn on the lead apron was 0.002±0 microSv (range, 0-0.04), while the one worn under the apron was 0.001±0 microSv (range, 0-0.03). The equivalent doses over the 7-month study period for the hand, eye lens, and chest (over and under the apron) were 0.14mSv, 0mSv, 0.22mSv, and 0mSv, respectively.

DISCUSSION/CONCLUSION

The radiation exposure in percutaneous forefoot surgery with a mini C-arm intensifier observed in our study was lower than the ICRP recommendations and literature findings during open surgery.

LEVEL OF EVIDENCE

IV; prospective study without a control group.

Impact of fibromyalgia and related factors on foot function and quality of life: Cross-sectional study

BACKGROUND

The aim of study is to examine the factors that may influence pain, disability and the limitation of activity due to the presence of fibromyalgia in the foot.

METHODS

323 patients diagnosed with fibromyalgia were recruited. Each participant completed the Foot Function Index questionnaire (FFI) and the Revised Fibromyalgia Impact Questionnaire (FIQR). A multivariate analysis was performed to determine the factors associated with high scores in each of these questionnaires.

RESULTS

In both questionnaires, the subscales presenting the highest scores were foot pain (FFI score: 71.18 ± 20.40) and symptom intensity (FIQR score: 36.23 ± 8.04). According to the multivariate analysis, foot function is influenced by age (p = <0.001), BMI (p = 0.001), lack of physical activity (p = <0.001), the presence of rheumatoid arthritis (p = 0.012), retirement due to disability (p = <0.001) and being unemployed (p < 0.001).

CONCLUSION

Fibromyalgia affects foot function, provoking significant pain. Related factors include age, BMI, lack of physical activity, the presence of rheumatoid arthritis, and employment status.

Compartment syndrome of the foot: A case report

Background

Exercise-induced compartment syndrome is a condition characterized by elevated pressure within a muscle compartment, resulting from repetitive loading or participation in sports activities. Primarily affecting the medial compartment of the foot, this rare condition manifests as sudden-onset pain in the medial aspect of the foot, without a discernible history of trauma, occurring during or after physical exertion. Diagnosis is primarily clinical in nature, as diagnostic imaging techniques provide limited utility.

Conclusions

Exercise-induced compartment syndrome is a rare syndrome with prolonged implications such as contractures, claw toes, muscle weakness, and sensory neuropathy. Hence, it is imperative for orthopedic surgeons to be familiar with this condition in order to facilitate timely diagnosis and treatment.

The prevalence of foot pain and association with baseline characteristics in people participating in education and supervised exercise for knee or hip osteoarthritis: a cross-sectional study of 26,003 participants from the GLA:D® registry

BACKGROUND

Osteoarthritis (OA) affecting the knee or hip is highly prevalent in the general population and has associated high disease burden. Early identification of modifiable risk factors that prevent, limit, or resolve disease symptoms is critical. Foot pain may represent a potentially modifiable factor however little is known about the prevalence of foot pain in people with knee or hip OA nor whether foot pain is associated with clinical characteristics. The main aim of this study was therefore to determine the prevalence of foot pain in people with knee or hip OA attending an education and supervised exercise-based intervention in Denmark (GLA:D®) and determine if baseline demographic or clinical characteristics are associated with foot pain.

METHODS

Analysis was conducted on baseline data of 26,003 people with symptomatic knee or hip OA completing a pain mannequin as part of the Good Life with osteoArthritis in Denmark (GLA:D®) primary care programme. Odds Ratios (OR) and 95% confidence intervals (CI) were calculated to estimate the strength of association between baseline clinical characteristics (including pain severity in worst knee/hip joint, number of painful knee/hip joints, pain medication use and physical activity level) and the presence of baseline foot pain.

RESULTS

Twelve percent of participants (n = 3,049) reported foot pain. In those people with index knee OA (n = 19,391), knee pain severity (OR 1.01 CI 1.00, 1.01), number of painful knee/hip joints (OR 1.67 CI 1.58, 1.79), and use of pain medication (OR 1.23 CI 1.12, 1.36) were statistically associated with foot pain. Excluding use of pain medication, similar associations were seen in those with index hip OA.

CONCLUSION

Twelve percent of people with knee or hip OA participating in GLA:D® had foot pain. Those with worse knee/hip pain, and greater number of painful joints were more likely to report foot pain. This study is the first to demonstrate a significant relationship between clinical characteristics and foot pain in people with knee or hip OA participating in education and supervised exercise. Future investigation should consider the role that foot pain may play on knee and hip related outcomes following therapeutic intervention.

Prevention and management of foot and lower limb health complications in adults undergoing dialysis: a scoping review

BACKGROUND

Foot and lower limb health complications are common among patients undergoing dialysis; but a summary of prevention and management evidence is not available. The aim of this scoping review was to summarise study characteristics and the nature of results regarding strategies to prevent and manage peripheral arterial disease (PAD), foot ulceration, amputation, associated infection and associated hospital admission in adults undergoing dialysis.

METHODS

MEDLINE, Embase, CINAHL and AMED databases were searched for longitudinal experimental and observational studies. Eligible studies included adults undergoing dialysis (≥10 dialysis patients, with separate results or ≥ 75% of the cohort). Any interventions relating to PAD, foot ulceration, amputation, associated infection, and associated hospital admission were included.

RESULTS

The review included 212 studies, of which 199 were observational (94%) and 13 were experimental (6%). Sixteen studies (8%) addressed the prevention of foot and lower limb health complications, 43 (20%) addressed management, and 153 (72%) addressed both. The main intervention type in each study was surgery (n = 159, 75%), care from one or more health professionals (n = 13, 6%), screening by a health professional (n = 10, 5%), medication (n = 9, 4%) and rehabilitation (n = 5, 2%). No studies were identified where exercise, offloading or education were the main intervention. Results for PAD were reported in 137 (65%) studies, foot ulceration in 54 (25%), amputation in 171 (81%), infection in 7 (3%), and admission in 26 studies (12%). Results for more than one foot or lower limb outcome were reported in 141 studies (67%), with each study reporting on average two outcomes. Results varied and spanned positive, negative, and neutral outcomes following intervention.

CONCLUSIONS

Identified studies frequently aimed to both prevent and manage foot and lower limb health complications. A variety of interventions were identified and studies often reported results for more than one foot or lower limb health outcome. Findings from this review can be used to guide future research, with a goal to support improved patient outcomes.

The history of orthopaedic use of nitinol compression staples

INTRODUCTION

The use of nitinol continuous compression staples has shown clinical utility in the management of various orthopaedic injuries. While literature is most robust in the realm of foot/ankle and spine surgery, the use of nitinol staples has been documented in fixation of wrist, olecranon, patella, and pelvis fractures.

METHODOLOGY

A narrative review was conducted by searching three online databases - PubMed, Web of Science, and Cochrane using the terms "Nitinol" and "Staple" published between 2003 and 2023. A total of 42 articles met inclusion/exclusion criteria and were included in this review.

REVIEW

Literature outside of foot/ankle and spine surgery is largely limited to biomechanical studies, case reports, and finite element analyses. The literature is summarized within this review by anatomic location including foot/ankle, lower extremity, hand, upper extremity, spine, and pelvis.

CONCLUSION

Existing literature demonstrates a diverse array of applications for nitinol continuous compression staples in both axial and appendicular orthopaedic care. Advantages of these implants include ease of application, ability to capture small bony fragments, continuous compression across a fracture or arthrodesis, and full coaptation which maximizes the surface area for healing and/or fusion.

MRI evaluation of interconnections between flexor hallucis longus and flexor digitorum longus around the Master knot of Henry

OBJECTIVES

To demonstrate the magnetic resonance imaging (MRI) findings of interconnections between flexor hallucis longus (FHL) and flexor digitorum longus (FDL) around the Master knot of Henry (MKH).

METHODS

Fifty-two MRI scans of adult patients were retrospectively analyzed. The types and subtypes of interconnections between the FHL and FDL were evaluated using the classification suggested by Beger et al based on the direction and number of the tendon slips and contributions to the lesser toes. The layering organization formed by the FDL, quadratus plantae, and tendon slip from the FHL was evaluated. The distance between bony landmarks and the branching site of tendon slips and the cross-sectional area (CSA) of the tendon slips were measured. Descriptive statistics were reported.

RESULTS

MRI scans revealed that type 1 interconnection was the most common (81%), followed by type 5 (10%) and types 2 and 4 (4% each). All tendon slips from the FHL contributed to the second toe, and 51% of the tendon slips contributed to the second and third toes. For the layering organization, the two-layered type was the most common (59%), followed by the three-layered (35%) and single-layered (6%) types. The mean distance between the branching site and bony landmarks was longer in the FDL to FHL cases than that in the FHL to FDL cases. The mean CSA of the tendon slips from the FHL to FDL was larger than that of the FDL to FHL.

CONCLUSIONS

MRI could provide detailed information about the anatomical variations around the MKH.

CLINICAL RELEVANCE STATEMENT

In lower extremity reconstruction surgery, the flexor hallucis longus and flexor digitorum longus tendons serve as donor tendons. A preoperative MRI scan could provide information on anatomical variations around the Master knot of Henry, which can help predict postoperative functional outcomes.

KEY POINTS

• Normal anatomical variations around the Master knot of Henry were not extensively studied in the radiology literature before. • MRI identified the various types, sizes, and locations of interconnections between the flexor digitorum longus tendon and the flexor hallucis longus tendon. • MRI is a useful noninvasive tool for evaluating the interconnections between the flexor digitorum longus tendon and the flexor hallucis longus tendon.