Comparison of triplanar chevron osteotomy with chevron osteotomy in hallux valgus treatment for the prevention of transfer metatarsalgia

Hallux valgus (HV) is often accompanied by metatarsalgia. This study compared the radiological and clinical outcomes of new triplanar chevron osteotomy (TCO) and chevron osteotomy (CO) in the treatment of HV, especially for patients with plantar callosities and metatarsalgia. In this retrospective analysis, 90 patients (45 patients per group) with mild to moderate HV and plantar callosities were treated with TCO and CO from July 2020 to January 2022. In both procedures, the apex was located in the center of the head of the first metatarsal bone, and the CO was oriented towards the fourth MTPJ at a 60° angle. Plantar-oblique chevron osteotomy was defined as chevron osteotomy and a 20° plantar tilt; TCO was defined as plantar-oblique chevron osteotomy-based metatarsal osteotomy with a 10° tilt towards the metatarsal head. Primary outcome measures included preoperative and postoperative hallux valgus angle, 1 to 2 intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), first metatarsal length (FML), and second metatarsal head height X-ray images; clinical measurements, including visual analogue scale and American Orthopaedic Foot & Ankle Society (AOFAS) scores; changes in callosity grade and area; and changes in the number of people with metatarsalgia. Secondary outcomes included complications, recurrence rates, and cosmetic appearance. The hallux valgus angle, IMA, and DMAA were significantly lower after surgery (P  < .001) in all patients. In the TCO group, the mean FML and second metatarsal head height increased significantly postoperatively (P < .001). The AOFAS and visual analogue scale scores improved postoperatively in both groups (P < .001). All patients experienced satisfactory pain relief and acceptable cosmesis. The plantar callosity areas were smaller postoperatively in both the TCO and CO groups, but the change in the area (Δarea) in the TCO group significantly differed from that in the CO group (P < .001). The number of postoperative patients with metatarsalgia and the plantar callosity grade were both significantly lower in the TCO group than in the CO group after osteotomy (P < .05). TCO prevents dorsal shift of the metatarsal head and preserves and even increases FML, thereby preventing future metatarsalgia in patients. Therefore, compared with CO, TCO has better orthopedic outcomes and is an effective method for treating mild to moderate HV and preventing transfer metatarsalgia.

Morphology variations with medial cuneiform in hallux valgus

The hypermobility of the first tarsometatarsal joint has been identified as a key factor in the development of hallux valgus. Previous research found a link between the tarsometatarsal joint obliquity and the hallux valgus angle. Nevertheless, most studies relied on radiographs that lack 3D evidence. This study used 3D analysis to investigate the morphological differences in the medial cuneiform between hallux valgus and normal feet. In this study, twenty-three hallux valgus feet and twenty-three normal feet were scanned with computed tomography and 3D models of medial cuneiforms were reconstructed. Medial cuneonavicular and the first tarsometatarsal joint surfaces of the medial cuneiform were manually extracted. To obtain the obliquity angle of the medial cuneiform and curvature of the medial cuneonavicular joint, the joint surfaces were approximated to planes and spheres. Furthermore, the orientations of two joint surfaces were accessed through a novel positioning method. No significant difference was found in the cuneiform obliquity between hallux valgus and normal feet. Hallux valgus and normal groups did not differ significantly in any of the medial cuneiform joint orientations. The medial cuneiform in hallux valgus had a larger curvature diameter of the medial cuneonavicular joint (P = 0.029), indicating a flatter surface. The results demonstrated that the generally supported atavism (i.e., tarsometatarsal joint obliquity) does not exist in the hallux valgus feet. A flatter medial cuneonavicular joint surface was found in hallux valgus feet. This study contributes to the comprehensive understanding of the etiological factors with hallux valgus.

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.

Relationship Between Diabetes-Related Large-Fiber Neuropathy and Dorsiflexion Range of Motion at the Ankle and First Metatarsophalangeal Joints

BACKGROUND

Diabetes-related peripheral neuropathy (DPN) and limited joint mobility of the foot and ankle are implicated in the development of increased plantar pressures and diabetes-related foot ulcers. The extent of this relationship has not been conclusively established. We aimed to determine the relationship between ankle joint and first metatarsophalangeal joint dorsiflexion range of motion and DPN using a cross-sectional observational study design.

METHODS

Primary outcomes were DPN status, ankle joint range of motion (extended and flexed knee lunge tests), and nonweightbearing first metatarsophalangeal joint range of motion. Correlations were performed using Pearson r, and hierarchical regression analyses were undertaken to determine the independent contribution of DPN to the variance in dorsiflexion range of motion of ankle and first metatarsophalangeal joints using standardized β regression coefficients, controlling for age, sex, body mass index, diabetes duration, and hemoglobin A1c level.

RESULTS

One hundred one community-dwelling participants (mean ± SD age, 65.0 ± 11.2 years; 55 men; 97% type 2 diabetes; mean ± SD diabetes duration, 8.7 ± 7.8 years; 23% with DPN) were recruited. Diabetes-related peripheral neuropathy demonstrated significant correlations with reduced range of motion at the ankle joint (knee extended: r = -0.53; P < .001 and knee flexed: r = -0.50; P < .001) and the first metatarsophalangeal joint (r = -0.37; P < .001). Also, DPN made significant, unique contributions to the regression models for range of motion at the ankle joint (knee extended: r2 change = 0.121; β = -0.48; P < .001 and knee flexed: r2 change = 0.109; β = -0.45; P < .001) and first metatarsophalangeal joint (r2 change = 0.037; β = -0.26; P = .048).

CONCLUSIONS

These findings suggest that DPN contributes to reduced ankle and first metatarsophalangeal joint range of motion. Due to the established link between reduced ankle and first metatarsophalangeal joint range of motion and risk of diabetes-related foot ulcer, we recommend that clinicians assess dorsiflexion range of motion at these joints as part of routine foot assessment in people with diabetes, especially those with DPN. Globally, approximately 436 million adults aged 20 to 79 years are living with diabetes.1 Diabetes is the leading cause of lower-limb amputation and is associated with a lifetime incidence of diabetes-related foot ulcer (DFU) of up to 34%.2 Diabetes-related peripheral neuropathy (DPN) affects approximately 30% to 50% of people with diabetes3 and is one of the most significant risk factors for the development of DFU and amputation.4 Diabetes-related peripheral neuropathy occurs as a result of neural ischemia and perineural edema causing neural demyelination, affecting nerve conductivity.5 In the presence of DPN, intrinsic foot muscle wasting can lead to the development of foot deformities such as digital clawing, which, when coupled with structural and functional changes to the skin, make it less resistant to shear forces and further increase plantar pressure and risk of DFU.6,7.

A multi-professional survey of UK practice in the use of intra-articular corticosteroid injection for symptomatic first metatarsophalangeal joint osteoarthritis

BACKGROUND

The first metatarsophalangeal joint is the most common site of osteoarthritis (OA) in the foot and ankle. Intra-articular corticosteroid injections are widely used for this condition, but little is known about their use in practice. This study explored current practice within the UK National Health Service (NHS) relating to the administration of intra-articular corticosteroids for people with painful first metatarsophalangeal joint (MTPJ) OA.

METHODS

A cross-sectional survey using Qualtrics online survey platform (Qualtrics, Provo, UT, USA), distributed through professional bodies, special interest groups, and social media.

RESULTS

One hundred forty-four healthcare professionals responded, including podiatrists (53/144; 39%), orthopaedic surgeons (28/144; 19%), podiatric surgeons (26/144; 17%) and physiotherapists (24/144; 16%). Half of respondents administered up to 25 corticosteroid injections per year (67/136; 49%) but some administered more than fifty (21/136; 15%). Injections were administered across the healthcare system but were most common in hospital settings (64/136; 44%) followed by community (38/136; 26%), with less delivered in primary care (11/136; 8%). Half of respondents routinely used image-guidance, either ultrasound or x-ray/fluoroscopy (65/136; 48%) although over one third used none (52/136; 38%). Imaging guidance was more common amongst medical professionals (21/31; 68%) compared to non-medical health professionals (45/105; 43%). Overall, methylprednisolone acetate was the most common corticosteroid used. Medical professionals mostly injected methylprednisolone acetate (n = 15/27; 56%) or triamcinolone acetonide (n = 11/27; 41%), whereas premixed methylprednisolone acetate with lidocaine hydrochloride was the most common preparation used by non-medical health professionals (41/85; 48%). When injecting non premixed steroid, lidocaine hydrochloride (15/35; 43%) was the most common choice of local anaesthetic for non-medical health professionals but medical professionals showed more variation between lidocaine hydrochloride (8/23; 35%) levobupivacaine hydrochloride (9/23; 39%) and bupivacaine hydrochloride (5/23; 22%).

CONCLUSIONS

Multiple professional groups regularly administer intra-articular corticosteroids for symptomatic first MTPJ OA across a range of NHS healthcare settings. Overall, methylprednisolone acetate was the most commonly administered steroid and lidocaine hydrochloride the most common local anaesthetic. There was large variation in the use of imaging guidance, type and dose of steroid, local anaesthetic, and clinical pathways used in the intra-articular injection of corticosteroids for people with first MTPJ OA.

Evaluation of first ray instability using the double dorsiflexion test: A prospective observational case-controlled study

BACKGROUND

First-Ray (FR) stability allows for foot propulsion in-stance, taking 60% weight. First-ray instability (FRI) is associated with middle column overload, synovitis, deformity and osteoarthritis. Clinical detection can still be challenging. We propose to develop a clinical test that helps identify FRI using two simple manual manoeuvres.

METHODS

10 patients with unilateral FRI were recruited. Unaffected contralateral feet were used as controls. Stringent exclusion criteria were applied including hallux MTP pain, laxity, inflammatory arthropathy and collagen disorders. A Klauemeter directly measured the sagittal plane dorsal first metatarsal head translation of affected vs unaffected feet. Maximum passive proximal phalanx 1st MTP joint dorsiflexion was measured using a video capture and Tracker motion software analysis with and without applying a dorsal force at the 1st metatarsal head using a Newton meter. Proximal phalanx motion was compared in affected vs unaffected feet with and without dorsal metatarsal head force application and compared to direct measurements using the Klaumeter. P value of < 0.05 was considered significant.

RESULTS

FRI feet had dorsal translation greater than 8 mm (median, 11.94; interquartile range [IQR], 10.23-13.81) vs 1.77 for unaffected control feet was (median, 1.77; interquartile range [IQR], 1.23-2.96) using the Klauemeter. The percentage reduction in 1st MTP joint dorsiflexion ROM when applying the double dorsiflexion test FRI (mean reduction of 67.98%) when compared to control feet (mean reduction of 28.44%)(P < 0.01). Receiver operating characteristic (ROC) analysis showed that a 50% reduction in dorsiflexion ROM of 1st MTPJ when performing the double dorsiflexion test achieved a specificity of 100% and sensitivity of 90% (AUC =0.990, 95%CI [0.958-1.000], P > 0.0001).

CONCLUSION

The double dorsiflexion (DDF) is easy to perform with two relatively simple manual manoeuvres that avoids the need for complex instrumented and radiation-based assessment. Greater than 50% decrease in proximal phalanx motion has an over 90% sensitivity in identifying feet with FRI.

LEVEL OF EVIDENCE

This was a prospective case-controlled study of consecutive cases of a level II evidence.

Foot arch rigidity in walking: In vivo evidence for the contribution of metatarsophalangeal joint dorsiflexion

Human foot rigidity is thought to provide a more effective lever with which to push against the ground. Tension of the plantar aponeurosis (PA) with increased metatarsophalangeal (MTP) joint dorsiflexion (i.e., the windlass mechanism) has been credited with providing some of this rigidity. However, there is growing debate on whether MTP joint dorsiflexion indeed increases arch rigidity. Further, the arch can be made more rigid independent of additional MTP joint dorsiflexion (e.g., when walking with added mass). The purpose of the present study was therefore to compare the influence of increased MTP joint dorsiflexion with the influence of added mass on the quasi-stiffness of the midtarsal joint in walking. Participants walked with a rounded wedge under their toes to increase MTP joint dorsiflexion in the toe-wedge condition, and wore a weighted vest with 15% of their body mass in the added mass condition. Plantar aponeurosis behavior, foot joint energetics, and midtarsal joint quasi-stiffness were compared between conditions to analyze the mechanisms and effects of arch rigidity differences. Midtarsal joint quasi-stiffness was increased in the toe-wedge and added mass conditions compared with the control condition (both p < 0.001). In the toe-wedge condition, the time-series profiles of MTP joint dorsiflexion and PA strain and force were increased throughout mid-stance (p < 0.001). When walking with added mass, the time-series profile of force in the PA did not increase compared with the control condition although quasi-stiffness did, supporting previous evidence that the rigidity of the foot can be actively modulated. Finally, more mechanical power was absorbed (p = 0.006) and negative work was performed (p < 0.001) by structures distal to the rearfoot in the toe-wedge condition, a condition which displayed increased midtarsal joint quasi-stiffness. This indicates that a more rigid foot may not necessarily transfer power to the ground more efficiently.

Surgical Repair of Posttraumatic Hallux Valgus Deformity in a Collegiate Football Player: A Case Report

CASE

We report a rare case of posttraumatic hallux valgus in a collegiate football player after an acute medial collateral ligament tear of the first metatarsophalangeal joint. The patient was treated with a modification of the modified McBride technique, using an all-suture anchor for the medial ligamentous complex repair. There was return to sport at 5 months and a Foot and Ankle Outcome Score of 95% at 10 months.

CONCLUSION

A modified McBride procedure further modified with the utilization of an all-suture anchor for the medial ligamentous complex repair can result in correction of deformity, pain-free movement and return to sport.

Treatment of hallux rigidus (HARD trial): study protocol of a prospective, randomised, controlled trial of arthrodesis versus watchful waiting in the treatment of a painful osteoarthritic first metatarsophalangeal joint

INTRODUCTION

Hallux rigidus is a common problem of pain and stiffness of the first metatarsophalangeal joint (MTPJ) caused mainly by degenerative osteoarthritis. Several operative techniques have been introduced for the treatment of this condition without high-quality evidence comparing surgical to non-surgical care. In this trial, the most common surgical procedure, arthrodesis, will be compared with watchful waiting in the management of hallux rigidus.

METHODS AND ANALYSIS

Ninety patients (40 years or older) with symptomatic first MTPJ osteoarthritis will be randomised to arthrodesis or watchful waiting in a ratio of 1:1. The primary outcome will be pain during walking, assessed using the 0-10 Numerical Rating Scale (NRS) at 1 year after randomisation. The secondary outcomes will be pain at rest (NRS), physical function (Manchester-Oxford Foot Questionnaire), patient satisfaction in terms of the patient-acceptable symptom state, health-related quality of life (EQ-5D-5L), activity level (The Foot and Ankle Ability Measure Sports subscale), use of analgesics or orthoses and the rate of complications. Our null hypothesis is that there will be no difference equal to or greater than the minimal important difference of the primary outcome measure between arthrodesis and watchful waiting. Our primary analysis follows an intention-to-treat principle.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ethics Committee of Helsinki and Uusimaa Hospital District, Finland. Written informed consent will be obtained from all the participants. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.

PROTOCOL VERSION

21 June 2021 V.2.0.

TRIAL REGISTRATION NUMBER

NCT04590313.

FACTORS INFLUENCING RESULTS OF SURGICAL TREATMENT OF METATARSALGIA AND THEIR PROGNOSTIC VALUE

Objective - to determine the prognostic value of factors that affect the long-term result of surgical treatment of metatarsalgia, to develop a system for predicting the results of surgical treatment of metatarsalgia. A prospective trial of long-term results of surgical treatment of 172 patients with metatarsalgia was conducted from 2000 to 2019. Two study groups were formed: the core study group comprising of 107 patients who underwent Weil-osteotomy, metatarsals proximal osteotomy. The control group consisted of 65 patients who underwent another surgical treatment (metatarsophalangeal resection arthroplasty, surgery of capsular-ligamentous and tendon apparatus of metatarsophalangeal joints, as well as the surgical therapy intended to remove only hammer 2-4 toes deformities). Clinical, instrumental and statistical (correlation-regression analysis) research methods were used. The factors that influenced the end result of treatment were identified. The statistically significant influence of age, sex, BMI < 25, "index minus" and hammer 2-4 toes on the prevalence of positive treatment results were determined. The estimation of the informative nature of the presented factors for the probability of achieving positive results of treatment, the calculation of the prognostic coefficients and their sum were determined. The system for predicting treatment results of metatarsalgia involves the possibility of obtaining a high, medium and low probability of a positive result when applying surgical treatment. The long-term result of surgical treatment of metatarsalgia under the heads of 2 - 4 metatarsals depends on age and factor "hammer 2-4 toes". A high prognostic evaluation of a successful treatment outcome should be expected with a total prognosis of + 6 to +16; a total estimate of prognostic coefficients from + 6 to +16 determines the average probability of positive treatment results; the sum of the prognostic coefficients from - 10 to - 2 determines the low probability of achieving positive treatment results.

Two stage surgical treatment of cuboid osteomyelitis. A case report and review of the literature

Isolated osteomyelitis of the cuboid bone is an extremely rare condition. A 32 year old man was evaluated for a painful and swollen right foot after a penetrating trauma and the presence of a sinus in the lateral aspect the midfoot. MRI findings were consistent with the presence of cuboid osteomyelitis. The patient underwent a two stage procedure which included partial excision of the cuboid bone, the use of a cemented spacer for lateral column length preservation, followed by arthrodesis of the calcaneocuboid joint with a tricortical autologous bone graft harvested from the ilium and preservation of the cuboid-metatarsal joints. At 4 years follow up, the patient is asymptomatic. Diagnosis of isolated cuboid osteomyelitis requires high clinical suspicion and a two stage procedure is an effective approach for symptomatic patients who do not respond to conservative treatment. LEVEL OF CLINICAL EVIDENCE: IV.

[Hallux Rigidus: first metatarsophalangeal arthrosis Symptoms and current treatments]

Metatarsophalangeal arthritis of the first ray of the foot, also known as hallux rigidus, is an invalidating cause of walking that is still underestimated. It is associated to a local deformation of the first ray with a limitation of the dorsal mobilization of the joint, affecting thus the propulsion of the foot. Several stages of the disease exist, and symptoms as well as the treatment will depend on the moment of the consultation. In this paper, we present the different clinical pictures and adapted treatments according to the stage of the disease, and we share our results of a new modality of surgery that conserves the articular mobility of the joint.

[Diagnosing and treating hallux rigidus]

This review summarises the present knowledge of diagnosing and treating hallux rigidus in Denmark. Hallux rigidus is a degenerative disease of the first metatarsophalangeal joint. The pathology of the joint can be visualised on standing radiograph of the foot. If conservative treatment measures fail to provide adequate pain relief, surgery will be an option for most patients. Several procedures are adequate for the treatment of hallux rigidus, and especially surgery show good or excellent results for most patients.

[Minimally Invasive Hallux Valgus Surgery: First Experience]

PURPOSE OF THE STUDY The Minimally Invasive Chevron Akin (MICA) is a percutaneous technique used to correct hallux valgus deformity. The combination of distal osteotomy of the first metatarsal and the proximal phalanx of the big toe stabilized with internal fixation was used over the last decade. The retrospective study presents the results of measurements performed on preoperative and postoperative X-rays and offers a comparison with conventional osteotomies. MATERIAL AND METHODS The study population consists of 76 patients who underwent 93 operations between 2015 and 2018 at the Department of Orthopaedics, 1st Faculty of Medicine, Charles University in Prague. The mean age of patients was 50.2 years (range 18-74 years). The study evaluates and measures the parameters and the attributes of interest on weight-bearing X-rays of the foot before and after the operation at 6-week or 3-month follow-ups. The first intermetatarsal angle was measured according to the mechanical and the anatomic axis of the first metatarsal bone. Apart from that, the displacement of the first metatarsal head in the osteotomy, hallux valgus angle and distal metatarsal articular angle were analysed. The position of the medial sesamoid bone and the congruency of the first metatarsophalangeal joint were evaluated as well. RESULTS The mean hallux valgus angle was 33.2° ± 7.3° and 10.2° ± 5.8° postoperatively. The mean value of the first mechanical intermetatarsal angle decreased from 12.4° ± 2.8° to 7.4° ± 2.5° postoperatively. The mean value of the first anatomic intermetatarsal angle increased from 13.7° ± 3.6° to 17.4° ± 4.6°. The used technique restored the congruency of the first metatarsophalangeal joint in 85 cases (91%). The mean lateral displacement of the metatarsal head fragment was 50% of its width (range 18% to 84%). The mean X-ray exposure during the operation was 0.58 mGy and the personnel were exposed to radiation for 79 seconds on average. DISCUSSION One of many questions raised with regard to hallux valgus surgery is the choice of the right technique in order to achieve proper position of the big toe. The surgeon should have the opportunity to use a technique that provides the possibility to change orientation of the metatarsal head articular surface in three anatomic planes. Our study found out that the displacement of the metatarsal head using the MICA technique in transversal plane is from 4 mm to 18 mm (in 20 mm diameter of the head). The method thus offers a possibility to correct mild, moderate and partially severe deformities as well. The main disadvantage of the method is the necessity to use a C-arm at the operating theatre. CONCLUSIONS The Minimally Invasive Chevron Akin (MICA) is a percutaneous technique to correct hallux valgus deformity based on two extraarticular osteotomies of the proximal phalanx of the big toe and the distal part of the first metatarsal bone. The method using stable internal fixation with two screws offers a possibility to change the orientation of the articular surface of the metatarsal head in sagittal, transversal, and even in frontal plane, and is useful to correct mild and moderate deformities. Key words: hallux valgus, minimally invasive technique, percutaneous technique, chevron osteotomy, Akin osteotomy.

[Traumatic Turf-Toe: challenging diagnosis and controversial treatment]

INTRODUCTION

Turf-Toe includes a wide variety of traumatic injuries of the metatarsophalangeal joint of the first toe (MTF1). It is a potentially severe injury and there is no consensus for surgical management. The objective of this case report was to describe a patient with traumatic Turf-Toe injury grade III with a sesamoid fracture treated surgically.

CLINICAL CASE

24-year-old male with motorcycle fall with hyperflexion of the MTF1 joint, presented pain, edema and functional limitation; the radiographs showed soft tissue edema, lateral displacement of lateral sesamoid with fracture. Traumatic Turf-Toe was established. The ultrasound of the MTF1 joint showed breakage of the plantar plate and collateral ligaments. Patient was surgically managed with sesamoid reduction and plantar plate repair; postoperative evolution was satisfactory. At 8 weeks the patient was assessed with the AOFAS forefoot scale, obtaining 82 points, SF-12 with 87% and VAS of two and returned to his daily activities.

CONCLUSION

We describe a patient with traumatic Turf Toe grade III injury, not related to sports practice; first report in the literature of the use of ultrasound in the evaluation of patients with lesion of the metatarso-phalangic joint of the first toe.

Rheumatoid Arthritis and Tenosynovitis at the Metatarsophalangeal Joints: An Anatomic and MRI Study of the Forefoot Tendon Sheaths

Background Although tenosynovitis in the hands is associated with rheumatoid arthritis (RA), it is unknown whether tenosynovitis of the forefoot is associated with RA. Purpose To determine the anatomy of tendon sheaths of the forefoot and the relationship between MRI-detected tenosynovitis at metatarsophalangeal (MTP) joints and RA. Materials and Methods Fourteen forefeet of donated bodies were examined at flexor tendons and extensor tendons for the presence and course of tendon sheaths. In the prospective study between June 2013 and March 2016, newly presenting patients with RA, patients with other early arthritides, and healthy control participants all underwent MRI of unilateral MTP joints 1-5. MRI studies were scored by two independent readers for tenosynovitis, synovitis, and bone marrow edema. The association between the presence of these features and RA was examined by using logistic regression. Results Macroscopically, all extensor and flexor tendons crossing MTP joints demonstrated sheaths surrounding tendons. Microscopically, a synovial sheath was present. MRI evaluation was performed in 634 participants: 157 newly presenting patients with RA (109 women; mean age, 59 years ± 11 [standard deviation]), 284 patients with other early arthritides (158 women; mean age, 56 years ± 17), and 193 healthy control participants (136 women; mean age, 50 years ± 16). MRI-detected tenosynovitis was associated with RA, both when compared with patients with other arthritides (odds ratio [OR], 2.5; 95% confidence interval [CI]: 1.7, 3.9; P < .001) and healthy control participants (OR, 46; 95% CI: 14, 151; P < .001). The association was OR of 2.4 (95% CI: 1.5, 3.8; P < .001) for flexor tendons and OR of 3.1 (95% CI: 1.9, 5.2; P < .001) for extensor tendons. The sensitivity of tenosynovitis in RA was 65 of 157 (41%; 95% CI: 35%, 50%). The specificity for RA was 63 of 284 (78%; 95% CI: 72%, 82%) compared with other arthritides, and three of 193 (98%; 95% CI: 96%, 99%) compared with healthy control participants. Conclusion Tendons at metatarsophalangeal joints are surrounded by tenosynovium. MRI-detected tenosynovitis at metatarsophalangeal joints was specific for rheumatoid arthritis when compared with findings in patients with other arthritides and findings in healthy control participants. © RSNA, 2020 Online supplemental material is available for this article.

The Adolescent Bunion

The management of bunion deformities in adolescent patients is often a source of consternation for orthopaedic surgeons. Reports of recurrence and surgical failure along with a multitude of procedures to choose from create a wariness to manage the problem surgically. The biggest challenge in managing this problem is a lack of understanding by orthopaedic surgeons that adolescent bunions and adult bunions frequently arise from two distinct etiologies. The main difference between the two is that unlike adult bunion deformities, the hallux metatarsophalangeal joint in the adolescent bunion is congruent as the deformity is caused by a dysplasia of the metatarsal head. This dysplasia results in a valgus orientation of the first metatarsal articular surface (ie, elevated DMAA [distal metatarsal articular angle]). The recognition of this difference has implications for the evaluation and treatment of these deformities in adolescents.

[Hallux metatarsophalangeal arthrodesis: retrospective comparison between blocked plate and cannulated screws]

INTRODUCTION

There are multiple methods and implants used for the metatarsophalangeal arthrodesis of hallux without evidence in favor of one or the other in the bibliography. The goal was to compare the clinical and radiological results of 2 methods and implants used in our center.

MATERIAL AND METHODS

Retrospective review of 37 feet between 2013 and 2017 (22 feet by plate and 15 by cannulated screws). Clinical and radiological variables were collected and the AOFAS and Manchester-Oxford scales were applied. Variables were studied descriptively and analytically through the SPSSv15 program.

RESULTS

The group intervened by plate was composed of 77% of women, with an average age of 65 years and a distribution by diagnosis of severe hallux valgus (HV) (36%), hallux valgus relapse (HVR) (36%) and hallux rigidus (HR) (28%), compared to 80% of women, 68 years old and HV (34%), HVR (46%) HR (20%) in the group of cannulated screws. No significant differences were found in the correction of angles for HV or HVR. The rate of painful pseudoarthrosis was 13% in both and the re-intervention was 18% in the plate group and 26% in the screw group. Both the AOFAS and M-O scales were better in the plate group 63.8 vs 52.6 (p = 0.07); 30.1 vs 41.0 (p = 0.10); as well as patient satisfaction 86% vs 66% (p 0.05) and postoperative pain 3.68 vs 5.58 (p 0.05).

CONCLUSION

Small study groups, not implant randomization, both options are functional without being able to find a preferred one.

[Evaluation of radiographic results in geriatric population with moderate to severe degree hallux valgus intervened with surgical technique of Lelièvre and Vidalot]

BACKGROUND

Hallux valgus (HV) defines a valgo deviation from the metatarsophalangeal joint and in a varo of the first metatarsal. The surgery aims to restore joint congruence, correct deformity and decrease pain. There is little literature on the results in the geriatric population. The purpose of this study is intended to demonstrate that the open surgical technique of Lelièvre and Vidalot achieves acceptable radiographic results in that population.

MATERIAL AND METHODS

68 patients between 60 and 85 years of age were involved with Lelièvre Technique and Vidalot for moderate to severe HV of Isham, between January 2014 and January 2017. Immediate postoperative and six month radiographs were evaluated with conventional radiometry for this condition; All measurements were made in digital system. The data was entered in Microsoft Excel. p values 0.05 were considered statistically significant.

RESULTS

Out of 68 patients (54 women and 14 men), average age 68.0 years. 12 had bilateral concern. 28 second finger claw. The metatarsphasopalangic angle with a preoperative mean was 36.6o, increased by 100% of cases of intermetatarsal angle 1-2, with a correlation p 0.05 between intermetatarsal angle and metatarsal angle increase. Immediate and six-month post-surgical results with a correlation of p = 0.3107.

CONCLUSIONS

The treatment of moderate to severe HV in our geriatric population under technique Lelièvre and Vidalot achieves an acceptable correction demonstrated radiographically in the immediate postoperative period and at six month, this translates a viable option of surgical treatment in these population.

Comparison of efficacy and safety of single versus repeated intra-articular injection of allogeneic neonatal mesenchymal stem cells for treatment of osteoarthritis of the metacarpophalangeal/metatarsophalangeal joint in horses: A clinical pilot study

The purpose of this prospective study was to evaluate the effects of single and repeated intra-articular administration of allogeneic, umbilical cord-derived, neonatal mesenchymal stem cells (MSC) in horses with lameness due to osteoarthritis (OA) of a metacarpophalangeal joint (MPJ).

Twenty-eight horses were included. Horses were divided into two groups. Horses in group MSC1 received an MSC injection at M0 and a placebo injection at M1 (1 month after M0). Horses in group MSC2 received MSC injections at M0 and at M1. Joint injections were performed with a blinded syringe. Clinical assessment was performed by the treating veterinarian at M1, M2 and M6 (2 and 6 months after M0), including lameness evaluation, palpation and flexion of the joint. Radiographic examination of the treated joints was performed at inclusion and repeated at M6. Radiographs were anonymized and assessed by 2 ECVDI LA associate members. Short term safety assessment was performed by owner survey. A 2-month rehabilitation program was recommended to veterinarians. There was a significant improvement of the total clinical score for horses in both groups. There was no significant difference in the total clinical score between groups MSC1 and MSC2 at any time point in the study. There was no significant difference in the total radiographic OA score, osteophyte score, joint space width score and subchondral bone score between inclusion and M6. Owner-detected adverse effects to MSC injection were recorded in 18% of the horses. Lameness caused by OA improved significantly over the 6-month duration of the study after treatment with allogeneic neonatal umbilical cord-derived MSCs combined with 8 weeks rest and rehabilitation. There is no apparent clinical benefit of repeated intra-articular administration of MSCs at a 1-month interval in horses with MPJ OA when compared to the effect of a single injection.

Gait Symmetry Can Reduce Dependence on the Intact Limb during Walking with Constraint of Unilateral Metatarsophalangeal Joints

Our previous research showed that healthy subjects exhibited asymmetrical walking gait when their unilateral metatarsophalangeal (MTP) joints were constrained. They relied more on their intact limb for the compensation of missing functions of their constrained limb, which may result in poor balance, increased metabolic cost, and higher risks of falls. We examined how subjects would respond if gait asymmetry in stance time was improved using a split-belt treadmill. Twelve healthy subjects were instructed to walk on a split-belt treadmill at comfortable and fast speeds with their unilateral MTP joints constrained. The walking trials were performed in two conditions, i.e., tied-belt walking (TBW, both belts moved at the same speed), and split-belt walking (SBW, the speed of the belt on the constrained leg was appropriately slower than that of the contralateral leg). The ground reaction forces (GRF) and electromyography (EMG) data during walking were collected. Results showed that the GRF and impulses on the constrained foot at fast speed SBW significantly increased, compared with TBW, and the activation of medial gastrocnemius and soleus of the intact lower limb decreased significantly, which suggest that improved symmetry in stance time may reduce dependence on the intact limb for humans with the constraint of unilateral MTP joints.

Accuracy of Sonography in Plantar Plate Tears in Cadavers

OBJECTIVES

Sonography is often used in the evaluation of forefoot disorders, and its use has been suggested in the diagnosis of plantar plate tears. This study aimed to assess the accuracy of sonography in the diagnosis of plantar plate tears of the lesser digits using gross dissection as the reference standard.

METHODS

The second through fifth digits of 6 cadavers were examined with sonography to evaluate for plantar plate tears. The examination was performed by a single musculoskeletal radiologist in longitudinal and short axes, and plates were graded as torn or intact. The digits were then dissected by a single podiatrist blinded to the prior sonographic results to assess the integrity of the plates.

RESULTS

Ten plantar plates were graded as torn by sonography, all occurring in the distal plate near the phalangeal insertion. Seven of these plates were identified as torn on direct inspection. Fourteen plantar plates were found to be intact on sonography, 12 of which were intact on gross inspection. Overall, the accuracy, sensitivity, and specificity of sonography were 79.2%, 77.8%, and 80.0%, respectively. No correlation was seen between the accuracy of sonography and plate size, using plate number as a surrogate marker for plate size (P = .822).

CONCLUSIONS

Sonography is an appropriate modality in the setting of suspected plantar plate tears, with acceptable accuracy, sensitivity, and specificity. No decline in accuracy was seen with smaller plates. Thus, sonography may be especially useful when small anatomy or technical factors make magnetic resonance imaging challenging to perform and interpret.

Effects of balance taping using kinesiology tape in a patient with moderate hallux valgus: A case report

BACKGROUND

Hallux valgus, an increased angle of lateral deviation in the big toe, can cause pain and difficulties in balancing and walking. This study aimed to investigate the effects of balance taping using elastic therapeutic tape on moderate hallux valgus.

METHODS

When she walked with shoes, she complained of pain over the medial eminence of the hallux metatarsophalangeal (MTP) joint. Balance taping using kinesiology tape was applied for 3 months (average, 16hours/d) to both big toes of a 26-year-old woman with moderate hallux valgus.

RESULTS

On the right side, the hallux valgus angle (HVA) decreased from 21° to 14° and the intermetatarsal angle (IMA) decreased from 15° to 14.5°. On the left side, the HVA decreased from 22° to 11° and the IMA decreased from 15° to 12°. Furthermore, the patient was able to walk long distances in shoes without pain in the medial eminence of the hallux metatarsophalangeal joint.

CONCLUSION

This study suggested that repeated balance taping with kinesiology tape could be used as a complementary treatment method for moderate hallux valgus.

Metatarsal pain and plantar hyperkeratosis in the forefeet of female professional flamenco dancers

OBJECTIVES

The objectives of this study were to determine the frequency of metatarsal pain and of hyperkeratosis on the plantar forefoot in female professional flamenco dancers, and to determine whether there is a relationship between the two disorders.

METHOD

Forty-four female professional flamenco dancers, with a minimum activity of 25 hrs/wk, participated in this cross-sectional study. The presence or absence of metatarsal pain while dancing was recorded, and plantar pressures were measured on a pressure platform, both barefoot and shod with the usual dance shoe. The heel height of the dance shoe was also measured.

RESULTS

Of the dancers, 80.7% experienced metatarsal pain while dancing, and 84.1% presented with plantar hyperkeratosis. Plantar hyperkeratosis coincided with the presence of metatarsal pain in 67.04% of the feet studied. The maximum load point in the feet when the dancers were barefoot was located 59.5% in the rearfoot and 40.5% in the forefoot; when dancers wore their specific flamenco dancing shoes, it was located 52.4% in the rearfoot and 47.6% in the forefoot.

CONCLUSIONS

Metatarsal pain and plantar hyperkeratosis in the forefoot are common foot disorders in female flamenco dancing. The incidence of the maximum load point being located in the forefoot, and the difference between the results of the tests while shod or barefoot, are both too low to support the idea that the raised heels of flamenco shoes are a major contributing factor for these injuries. Therefore, these disorders may be caused by chronic repetitive trauma suffered during the practice of footwork dancing.

Metatarsophalangeal joint arthroplasty with implantation of Osteomed Interflex IPG system: our experience

The Osteomed Interflex IPJ system is a stemmed flexible implant specifically designed for replacement of metatarso-phalangeal joints of the lesser toes. The indication for use is a semi-rigid or rigid hammertoe deformity, impaired function and stability, metatarsal pain. The purpose of the study is the result of 45 implants, in 29 patients (27 women and 2 men). The average of the patients at the time of the operations was 65 years. The follow-up is 30 months. In our experiences this surgical replacement is a good solutions in selectionated cases of metatarso-phalangeal deformity.

Etiology and management of lesser toe metatarsophalangeal joint instability

The terms crossover toe and lesser metatarsophalangeal joint instability both describe a deterioration of the soft tissue structures that give stability to the lesser MTP joints. Initial treatment regimens focused on indirect repair of the instability without addressing the primary pathology. A staging system of the clinical examination and a grading system of the surgical findings are now available to help surgeons classify and treat the plantar plate insufficiency. Improved imaging techniques and direct surgical repair techniques through a dorsal approach have changed the treatment and possibly the results of this difficult condition.

[Repair of traumatic metacarpophalangeal joint defect by metatarsophalangeal joint composite tissue flap autograft]

OBJECTIVE

To investigate the surgical method and effectiveness of repairing traumatic metacarpophalangeal joint defect by the composite tissue flap autograft of the second metatarsophalangeal joint.

METHODS

Between June 2005 and December 2009, 6 cases (6 fingers) of traumatic metacarpophalangeal joint defect were treated with the composite tissue flap autograft of second metatarsophalangeal joint (containing extensor tendon, flexor tendon, proper digital nerve, planta or dorsal flap). All patients were males, aged 18-48 years, including 3 cases of mechanical injury, 2 cases of crush injury, and 1 case of penetrating trauma. The 2nd, 3rd, and 4th metacarpophalangeal joints were involved in defects in 2 cases, respectively, and defects ranged from 1.5 cm x 1.5 cm to 3.0 cm x 2.5 cm in size. All patients had skin and soft tissue defects, and defects ranged from 4 cm x 2 cm to 5 cm x 4 cm in size; and 5 cases complicated by extensor tendon defect (2.5-5.0 cm in length), 3 cases by flexor tendon rupture, and 3 cases by common palmar digital nerve injury. The time from injury to admission was 2-6 hours.

RESULTS

The composite tissue flaps and skin grafts survived in all cases. All incisions healed by first intention. All patients were followed up 1-5 years. The X-ray films showed good healing between the transplanted metatarsophalangeal joint and metacarpals and phalanges at 9-14 weeks postoperatively. The appearance, colour, and texture of the skin flap were satisfactory, and the senses of pain and touch were recovered. The palmar flexion range of transplanted metacarpophalangeal joints was 50-70 degrees, and the dorsal extension range was 5-10 degrees at last follow-up. According to the functional assessment criteria of upper limb formulated by the Hand Surgery Branch of Chinese Medical Association, the results were excellent in 4 cases, good in 1 case, and fair in 1 case, and the excellent and good rate of 83.3%. No dysfunction of the donor foot was observed.

CONCLUSION

The metatarsophalangeal joint composite tissue flap can provide bone, nerve, skin, muscles, and tendons, so it is an effective approach to repair the metacarpophalangeal joint defect and to recover the function of the injured joints in one operation.

The intra-articularly located ligament variation of the first metatarsophalangeal joint

An intra-articularly located ligament in the first metatarsophalangeal joint of the left foot has been detected in a patient. The intra-articular ligament was dorsomedially attached to the head of the first metatarsal and to the inferior part of the articular face of the base of the proximal phalanx of the big toe. In a literature search we could not find any report of a ligament located intra-articularly in this particular joint. Such a variation may have a role in the etiology of hallux valgus.

Arthroscopy of the hallux

Arthroscopy of the first MTP joint is a useful, minimally invasive technique in treating a number of pathologies about the hallux MTP joint. However, it is a technically demanding procedure for which there is a learning curve. The small arthroscope and instrumentation are delicate and vulnerable to damage. Practice on cadavers is very useful in shortening this learning curve, and experience with arthroscopy in other joints facilitates the transition to the hallux. In the future, additional studies will help to more specifically define the indications and expected outcomes of treatment as such will help to further elucidate the potential benefits over open surgery.

Time required for disappearance of urate crystals from synovial fluid after successful hypouricaemic treatment relates to the duration of gout

OBJECTIVES

To determine whether hypouricaemic treatment results in the disappearance of urate crystals from gouty joints and to define the time required.

METHODS

In 18 patients with monosodium urate (MSU) crystal proven gout, and after the initiation of successful serum uric acid (SUA)-lowering treatment, an arthrocentesis of the asymptomatic signal joint (11 knees, 7 first metatarsophalangeal joints) was performed every 3 months to obtain a synovial fluid (SF) sample. The sample was then analysed for the presence of MSU crystals, and the number of crystals/400x field was noted. SUA levels and the duration of gout were also noted.

RESULTS

MSU crystals disappeared from the SF of all 18 joints after reduction of SUA to normal levels. The time required for disappearance ranged from 3 to 33 months; disappearance time correlated with the duration of gout (r(s) = 0.71; p<0.01). The median number of MSU crystals in the SF samples before urate-lowering treatment was 7.5 (2.5-11) crystals/400x field, reducing to 3 (1-6.5) crystals/400x field (p<0.05) at 3 months. Crystal counts continued to decrease after 3 months.

CONCLUSIONS

In gout, reduction of SUA to normal levels results in disappearance of urate crystals from SF, requiring a longer time in those patients with gout of longer duration. This indicates that urate crystal deposition in joints is reversible. Normalisation of SUA levels results in a decrease in the concentration of MSU crystals in SF in the asymptomatic gouty joints. This may partially explain the reduced frequency of gouty attacks when a patient has been treated with SUA-lowering drugs.

Latent foreign body synovitis

The differential diagnosis for monoarticular arthritis is extensive. Patient omissions from the history can compound this broad diagnostic dilemma. A case report is presented of a 32-year-old female with an eight-month history of isolated right first metatarsophalangeal joint (MTPJ) pain, after exhaustive, non-specific diagnostic evaluation. An open biopsy was performed, and a 3.5 cm wooden foreign body, believed to be the result of an injury 18 years prior, was excised from the 1st MTP. Open biopsy may be required as an important part of the workup for definitive diagnosis of a foreign body synovitis. A discussion regarding the presentation, clinical and diagnostic findings follows.

Engraftment of cutaneous fibroblasts within synovial membrane in a nonhuman primate: Short-term results

OBJECTIVES

Gene therapy using cells as vectors to achieve secretion of therapeutic proteins may hold promise in the treatment of chronic diseases. Cell-based gene therapy with xenogeneic cells secreting antiinflammatory cytokines (IL-4, IL-13, or IL-1 receptor type II) has been found effective in mice with collagen-induced arthritis (CIA), a model for human rheumatoid arthritis. Autologous cells engineered to produce antiinflammatory cytokines were also effective in the mouse CIA model. In all these experiments, the cells were grafted into the subcutaneous tissue of the back, resulting in systemic treatment. To evaluate the feasibility of cell-based gene therapy confined to the joints, we performed intraarticular injections of autologous cells in a rhesus monkey with CIA, a model more similar to human RA.

METHODS

We prepared ex vivo cultures of skin fibroblasts from the animal then transfected the cells with a plasmid carrying the lacZ gene. We injected these marker cells into metacarpophalangeal, metatarsophalangeal, and interphalangeal joints.

RESULTS

Kinetic evaluation of synovial tissue X-gal labeling, which reflected reported gene expression by skin fibroblasts present within the synovium, showed significant labeling by transfected cells up to 6 days after intraarticular injection. Xenogeneic fibroblasts (Chinese hamster ovary cells) injected intraarticularly were also detected within synovial specimens; however, labeling intensity was less marked than with autologous cells. Our findings establish the feasibility of skin fibroblast grafting into the synovium.

CONCLUSION

This preliminary study opens the door to studies of heterotopic autologous transfected cells for the treatment of CIA in monkeys by direct gene transfer within joints.

Positive hindfoot valgus and osteoarthritis of the first metatarsophalangeal joint

BACKGROUND

The aim of this retrospective cohort study was to evaluate the association between increased hindfoot valgus and the subsequent development of osteoarthritis of the first metatarsophalangeal (MTP) joint. Specifically, our hypothesis was that among individuals free from first MTP joint osteoarthritis, those who have positive hindfoot valgus are more likely to develop first MTP joint osteoarthritis than are those individuals with normal hindfoot alignment.

METHODS

Our sample consisted of 1592 men and women, 40 years of age or older, participating in the Clearwater Osteoarthritis Study (1988 to 2001). Biennial physical examinations, including serial radiographs, were conducted. The Kellgren and Lawrence ordinal scale was used to determine radiographic evidence (grades 2+) of the study outcomes and incidence of first MTP joint osteoarthritis. Standing hindfoot valgus was assessed visually by a registered nurse, with a hindfoot valgus measurement of more than 5 degrees classified as a positive hindfoot valgus.

RESULTS

Individuals with hindfoot valgus were 23% more likely to subsequently develop first MTP joint osteoarthritis than were those without hindfoot malalignment (risk ratio = 1.23; p-value < 0.006). This risk estimate reflects the potential influence of age, gender, and body mass index.

CONCLUSIONS

Our data suggest that hindfoot valgus may increase the risk of developing foot osteoarthritis. The association of hindfoot valgus with first MTP joint osteoarthritis in this epidemiological assessment is supportive of the mechanical theory for the development of osteoarthritis. The authors speculate that future, related studies may determine that osteoarthritis prevention strategies can be broadened to include individuals with positive hindfoot valgus.

Freiberg's Infraction — Treatment with Metatarsal Neck Dorsal Closing Wedge Osteotomy: Report of Two Cases

Freiberg's infraction is a disease of avascular necrosis that most commonly involves the head of the second or third metatarsal. Several mechanisms have been proposed for its pathogenesis, but stress overloading is the most widely accepted etiology. Nonoperative treatment is thought to be effective in the early stages but not in the late stages of the disease. The methods of operative treatment for symptomatic Freiberg's infraction remain controversial. We report two cases of late stage Freiberg's infraction treated by metatarsal neck dorsal closing wedge osteotomy with good results, and we infer that this operation may be recommended for patients with symptomatic Freiberg's infraction in whom conservative treatments have little effect.

[Anatomic basis and clinical application of modified peroneal arterial cutaneous branch nutritional flap]

OBJECTIVE

To observe the anatomic basis and the clinical application of the modified peroneal arterial cutaneous branch nutritional flap.

METHODS

Twenty sides of lower limb of adult colyseptic cadavers and 5 sides of lower limb of adult fresh cadavers were used to detect the cutaneous branches of the peroneal artery. The position where the cutaneous branches come from the peroneal artery and the diameter of the cutaneous branches were recorded. From September 2003 to June 2005, 10 cases of skin and soft tissue defects in the region of metatarsophalangeal point with the modified peroneal arterial cutaneous branch nutritional flap, in which the cutaneous branches from the peroneal artery 11.0 +/- 1.7 cm upon the lateral malleolus were added. The defect size was 10 cm x 6 cm to 15 cm x 10 cm. The flap size was 11.0 cm x 6.5 cm to 16.0 cm x 11.0 cm.

RESULTS

There is a stable cutaneous branches from peroneal artery 11.0 +/- 1.7 cm upon the lateral malleolus. The diameter of this cutaneous branches at the origin is 1.45 +/- 0.12 mm. The distance between the cutaneous branches entrance of the deep fascia and the line of the sural nerve nutritional artery flap was 15.70 +/- 1.20 mm. All 10 flaps survived. The blood supply and venous return of the skin flaps were good. The 10 patients were followed up from 6 to 12 months. The shape of the flaps was satisfactory. The texture and the color and luster of the flaps were similar to the adjacent skin. The functions of the feet were good. The two-point discrimination was 11-18 mm.

CONCLUSION

The modified peroneal arterial cutaneous branch nutritional flap has good blood supply. It can reverse to a long distance and can repair large skin defects.

Classic article: foot & ankle 1:15, 1980 traumatic dislocations of the first metatarsophalangeal joint

The mechanics, anatomy, and pathomechanics of traumatic dorsal dislocation of the first metatarsophalangeal joint are discussed. There are two basic types of dislocations. In Type I, dislocation of the hallux with the sesamoids occurs without disrupting the sesamoid mass. Such cases are usually irreducible on closed reduction, the metatarsal head being incarcerated by the conjoined tendons with their intact sesamoids. In Type II, there is either associated disruption of the intersesamoid ligament (Type IIA) or a transverse fracture of one of the sesamoids (Type IIB). In Type II, the sesamoid disruption usually permits closed reduction.

Comparison of fixed flexion, fluoroscopic semi-flexed and MTP radiographic methods for obtaining the minimum medial joint space width of the knee in longitudinal osteoarthritis trials

OBJECTIVE

To compare three radiographic techniques (fluoroscopic semi-flexed [Fluoro], fixed flexion [FF], and semi-flexed metatarsophalangeal joint [MTP] views) for measuring medial joint space width (JSW) of the knee in longitudinal osteoarthritis (OA) trials and to identify the percentage of patients with detectable progression.

DESIGN

Retrospective summary of the progression and variability of the change in JSW in knee OA.

MATERIAL AND METHODS

Data from the placebo arms of three separate, structure modifying, knee OA trials were compared including gender, age, baseline JSW, change from baseline in JSW, duration of observation, and number and percent of patients with joint space narrowing of various degrees. Computer evaluation of the joint space at its narrowest point in the medial compartment was used in the studies. It is important to note that the narrowest joint space at baseline may not be in the same anatomic location at subsequent evaluations. No statistical tests were performed.

RESULTS

The average observation times were 0.98, 0.68 and 0.82 years for the Fluoro, FF, and MTP studies, respectively. The amount of progression was different among the three studies. The Fluoro study showed the greatest magnitude of OA structural progression and the lowest variability. The Fluoro study was expected to show the greatest magnitude of structural progression since it was conducted for the longest duration. For all patients, the standard deviation of the change in JSW was 0.42, 0.63, and 0.53 mm for the Fluoro, FF, and MTP studies, respectively. The percent of patients with detectable progression was similar across studies.

CONCLUSION

With these data, information was not sufficient to control for duration of observation and differences in inclusion criteria for the three study populations. Therefore, no definitive conclusions can be made regarding the degree of progression of OA over specific time intervals. However, the data indicate that all three studies contain a cohort of patients that exhibit detectable progression.

[Metatarsal osteotomies for hallux valgus]

In the surgical treatment of hallux valgus, proximal, diaphyseal, and distal osteotomies of the first metatarsal bone are commonly used. In an overview article different procedures are described as well as our own stage-adapted concept. Deformities with congruent articulation of the metatarsophalangeal joint are successfully treated with a distal chevron osteotomy. In an incongruent joint a distal soft tissue procedure is required for reduction of the joint. The metatarsus varus displacement is corrected with a proximal osteotomy of the first metatarsal bone. The indications and details of the surgical techniques are described as well as postoperative treatment, results, and possible complications.

Eikinella corrodens wound infection in a diabetic foot: a brief report

Eikinella corrodens normally forms part of the flora of the oral cavity and mucous membranes of the respiratory tract. It is usually associated with dental, head and neck infections (Cohen, Powderly, 2004, Infectious Diseases) and is considered to be an unusual cause of orthopaedic infections. We recently treated a diabetic patient with E. corrodens osteomyelitis of the fifth metatarsophalangeal joint, a phenomenon which has been reported in only three cases previously (Konugres et al., 1987, E. corrodens as a cause of osteomyelitis in the feet of the diabetic patients. Report of three cases). We recommend including E. corrodens in the spectrum of causative pathogens in diabetic foot infections.

The role of toe flexor-to-extensor transfer in correcting metatarsophalangeal joint instability of the second toe

BACKGROUND

The purpose of the study was to evaluate the outcome of flexor digitorum longus (FDL) transfer to the dorsum and to identify a possible continued role for this transfer in conjunction with additional surgeries for second metatarsophalangeal joint (MTPJ) instability.

METHODS

We carried out a retrospective analysis on patients with second MTPJ instability for which the FDL transfer was done as the primary procedure between 1996 and 2001. The patients were examined for functional status, residual pain, and satisfaction.

RESULTS

A total of 64 feet (59 patients) were evaluated, with an average followup period of 45.2 (16 to 82) months. A cross-over second toe deformity was present in 56 feet (87%) with a stage II deformity being the most common (18 feet). There also were seven feet with vertical subluxation. An additional second metatarsal Weil osteotomy was done in 29 feet (45%), a proximal interphalangeal (PIP) joint resection arthroplasty in 22 feet, and a PIP joint fusion in nine feet. At final followup of the 59 feet that were physically examined, 22 (37%) had residual second MTPJ dorsiflexion contracture and 16 feet had persistent medial deviation. The second toe was stable to stress manipulation in 46 feet (78%). The mean toe pulp to ground distance on standing was 3 mm, and strong toe grasp was possible in 45 feet. There were 20 complications in 64 feet. Twenty-five patients (29 feet) were very satisfied, 15 satisfied with minor reservations, six with major reservation, and 14 patients were unhappy with the outcome. The American Orthopaedic Foot and Ankle Society functional score was on average 82 points (47 to 100) at final followup.

CONCLUSION

Although the function of the second toe improved in most patients as a result of pain relief, a substantial number of the patients in this study remained dissatisfied because of residual stiffness of the toe. The flexor tendon transfer remains an important procedure in correction of second toe instability but must be used with a full understanding of potential complications and patient dissatisfaction.