Relationship between arthritis of the second and third tarsometatarsal joints and incongruity of the first tarsometatarsal joint in patients with hallux valgus

OBJECTIVES

Hallux valgus is associated with tarsometatarsal arthritis; its pathophysiology remains unknown. Therefore, we aimed to elucidate the relationship between arthritis of the second and third tarsometatarsal joints and incongruity of the first tarsometatarsal joint in the sagittal plane.

METHODS

Forty-three patients (64 feet) with hallux valgus who underwent surgery at University Hospital Kyoto Prefectural University of Medicine were included and divided into two groups: control (without second and third tarsometatarsal joint degeneration) and osteoarthritis (with second and third tarsometatarsal joint degeneration). Intergroup comparisons of the incongruity of the first tarsometatarsal joint in the sagittal plane, age, body mass index, hallux valgus angle, first-second intermetatarsal angle, metatarsus adductus angle, Meary's angle, and calcaneal pitch angle were performed.

RESULTS

The proportion of patients with incongruity of the first tarsometatarsal joint was significantly higher in the osteoarthritis group than in the control group. Logistic regression analysis identified incongruity of the first tarsometatarsal joint and metatarsus adductus angle as significant related factors for arthritis of the second and third tarsometatarsal joints.

CONCLUSIONS

Incongruity of the first tarsometatarsal joint in the sagittal plane was involved in the development of arthritis of the second and third tarsometatarsal joints in patients with hallux valgus.

Mechanics of the foot and ankle joints during running using a multi-segment foot model compared with a single-segment model

The primary purpose of this study was to compare the ankle joint mechanics, during the stance phase of running, computed with a multi-segment foot model (MULTI; three segments) with a traditional single segment foot model (SINGLE). Traditional ankle joint models define all bones between the ankle and metatarsophalangeal joints as a single rigid segment (SINGLE). However, this contrasts with the more complex structure and mobility of the human foot, recent studies of walking using more multiple-segment models of the human foot have highlighted the errors arising in ankle kinematics and kinetics by using an oversimplified model of the foot. This study sought to compare whether ankle joint kinematics and kinetics during running are similar when using a single segment foot model (SINGLE) and a multi-segment foot model (MULTI). Seven participants ran at 3.1 m/s while the positions of markers on the shank and foot were tracked and ground reaction forces were measured. Ankle joint kinematics, resultant joint moments, joint work, and instantaneous joint power were determined using both the SINGLE and MULTI models. Differences between the two models across the entire stance phase were tested using statistical parametric mapping. During the stance phase, MULTI produced ankle joint angles that were typically closer to neutral and angular velocities that were reduced compared with SINGLE. Instantaneous joint power (p<0.001) and joint work (p<0.001) during late stance were also reduced in MULTI compared with SINGLE demonstrating the importance of foot model topology in analyses of the ankle joint during running. This study has highlighted that considering the foot as a rigid segment from ankle to MTP joint produces poor estimates of the ankle joint kinematics and kinetics, which has important implications for understanding the role of the ankle joint in running.

Changes in Relative Work of the Lower Extremity and Distal Foot Joints After Total Ankle Replacement: An Exploratory Study

Ankle osteoarthritis does not only led to lower ankle power generation, but also results in compensatory gait mechanics at the hip and Chopart joints. Much of previous work explored the relative work distribution after total ankle replacement (TAR) either across the lower extremity joints where the foot was modelled as a single rigid unit or across the intrinsic foot joints without considering the more proximal lower limb joints. Therefore, this study aims, for the first time, to combine 3D kinetic lower limb and foot models together to assess changes in the relative joint work distribution across the foot and lower limb joints during level walking before and after patients undergo TAR. We included both patients and healthy control subjects. All patients underwent a three-dimensional gait analysis before and after surgery. Kinetic lower limb and multi-segment foot models were used to quantify all inter-segmental joint works and their relative contributions to the total lower limb work. Patients demonstrated a significant increase in the relative ankle positive joint work contribution and a significant decrease in the relative Chopart positive joint work contribution after TAR. Furthermore, there exists a large effect toward decreases in the relative contribution of the hip negative joint work after TAR. In conclusion, this study seems to corroborate the theoretical rationale that TAR reduces the compensatory strategy in the Chopart and hip joints in patients suffering from end-stage ankle osteoarthritis.

The Posttraumatic Tarsometatarsal Joints

Tarsometatarsal joint injuries can be painful and debilitating and are most commonly due to direct or indirect trauma. Posttraumatic arthritis is a well-known long-term complication, with incidence as high as 58%. Conservative treatment options include shoe modifications, orthotic inserts, topical or oral anti-inflammatories, and intra-articular corticosteroid injections. There are various joint prep and fixation techniques reported in the literature, many with positive clinical and radiographic outcomes. This article discusses nonoperative and operative management of posttraumatic tarsometatarsal joint arthritis, reviews available literature, and includes the authors' tips and techniques.

The Role of First Tarsometatarsal Joint Morphology and Instability in the Etiology of Hallux Valgus: A Case-Control Study

BACKGROUND

The morphology of foot joints is widely accepted as a significant factor in the development of various foot disorders. Nevertheless, the role of the first tarsometatarsal joint (TMT1) morphology in hallux valgus (HV) remains unclear, and its impact on TMT1 instability has not been fully explored. This study aimed to investigate the TMT1 morphology and its potential correlation with HV and TMT1 instability.

METHODS

Weightbearing computed tomography (WBCT) scans of 82 consecutive feet with HV and 79 controls were reviewed in this case-control study. Three-dimensional (3D) models of TMT1 were constructed using Mimics software and WBCT scans. The height of the TMT1 facet (FH) and the superior, middle, and inferior facet width (SFW, MFW, and IFW) were measured on anteroposterior view of the first metatarsal base. On the lateral view, the inferior lateral facet height and angle (ILFH and ILFA) were measured. TMT1 instability was evaluated using the TMT1 angle.

RESULTS

Compared with the control group, the HV group had a significantly wider MFW (9.9 mm in HV, 8.7 mm in control), lower ILFH (1.7 mm in HV, 2.5 mm in control), smaller ILFA (16.3 degrees in HV, 24.5 degrees in control), and larger TMT1 angle (1.9 degrees in HV, 0.9 degrees in control) (all P < .05). No significant differences were found between the 2 groups in FH, SFW, and IFW (all P > .05). The study identified 4 types of TMT1 morphology: continuous-flat, separated-flat, continuous-protruded, and separated-protruded. The continuous-flat type possessed significantly larger HVA, IMA, and TMT1 angles compared with other types (all P < .001).

CONCLUSION

This study indicates a potential association between TMT1 morphology and the severity of HV and identifies 4 TMT1 types. Notably, the continuous-flat type is found to be associated with more severe HV and TMT1 instability.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Foot Sole Contact Forces vs. Ground Contact Forces to Obtain Foot Joint Moments for In-Shoe Gait-A Preliminary Study

In-shoe models are required to extend the clinical application of current multisegment kinetic models of the bare foot to study the effect of foot orthoses. Work to date has only addressed marker placement for reliable kinematic analyses. The purpose of this study is to address the difficulties of recording contact forces with available sensors. Ten participants walked 5 times wearing two different types of footwear by stepping on a pressure platform (ground contact forces) while wearing in-shoe pressure sensors (foot sole contact forces). Pressure data were segmented by considering contact cells' anteroposterior location, and were used to compute 3D moments at foot joints. The mean values and 95% confidence intervals were plotted for each device per shoe condition. The peak values and times of forces and moments were computed per participant and trial under each condition, and were compared using mixed-effect tests. Test-retest reliability was analyzed by means of intraclass correlation coefficients. The curve profiles from both devices were similar, with higher joint moments for the instrumented insoles at the metatarsophalangeal joint (~26%), which were lower at the ankle (~8%) and midtarsal (~15%) joints, although the differences were nonsignificant. Not considering frictional forces resulted in ~20% lower peaks at the ankle moments compared to previous studies, which employed force plates. The device affected both shoe conditions in the same way, which suggests the interchangeability of measuring joint moments with one or the other device. This hypothesis was reinforced by the intraclass correlation coefficients, which were higher for the peak values, although only moderate-to-good. In short, both considered alternatives have drawbacks. Only the instrumented in-soles provided direct information about foot contact forces, but it was incomplete (evidenced by the difference in ankle moments between devices). However, recording ground reaction forces offers the advantage of enabling the consideration of contact friction forces (using force plates in series, or combining a pressure platform and a force plate to estimate friction forces and torque), which are less invasive than instrumented insoles (which may affect subjects' gait).

Addressing Medial Column Instability in Flatfoot Deformity

A stable medial column is important to the normal function of the foot and ankle. Medial column instability and forefoot varus can result in compensatory hindfoot motion leading to stress along the medial soft-tissue structures. Medial column stabilization should therefore be considered when (1) forefoot varus deformity is identified following hindfoot realignment; (2) pronounced medial column instability is present, even in the absence of forefoot varus; and (3) when degenerative changes are present within the medial column articulations. Common surgical procedures include arthrodesis of the talonavicular joint, naviculocuneiform joint, and first tarsometatarsal joint, as well as osteotomy of the medial cuneiform (Cotton osteotomy).

Decoding foot deformity and joint-destruction pathways in diabetes: Emerging insights from in-vivo foot joint kinetic measures

BACKGROUND

A comprehensive insight into the effect of longstanding diabetes mellitus and neuropathy on foot joint kinetics during walking is lacking. Our goal was to assess the in-vivo kinetics of major foot joints in persons with diabetes.

METHODS

Three groups, matched for age, sex and walking speed were recruited in this study: 1) people with diabetic peripheral neuropathy, 2) people with diabetes without peripheral neuropathy, and 3) control subjects without diabetes. Participants were instrumented with retroreflective markers on both feet and lower limbs and underwent a barefoot gait analysis using a state-of-the-art multi-segment kinetic foot modelling approach in order to provide accurate joint loading measures at the ankle, midtarsal, tarso-metatarsal and hallux joints.

FINDINGS

The group with neuropathy showed reduced ankle peak plantarflexion angular velocity compared to the control group (P = 0.002). Both groups with diabetes showed a significantly reduced midtarsal peak plantarflexion angular velocity, peak power generation and positive work compared to the control group (p < 0.01). Groups showed significant differences with respect to the tarsometatarsal peak dorsiflexion (p = 0.006) and plantarflexion angular velocity (P < 0.05).

INTERPRETATION

This study shows that both diabetes groups have similar joint loading and power absorption capacity but seem to lose their power generation capacity especially at the midtarsal joint. This loss of power generation capacity and the resulting decreased net mechanical work of the foot potentially embodies a foot that poorly supplements the body's mechanical energy during push-off. This phenomenon may cause excessive tissue stresses that contribute to foot deformity and joint-destruction mechanisms.

Coper has altered foot joint coordination pattern compared to individuals with chronic ankle instability during running

BACKGROUND

There is limited information regarding the cause for the different etiologies in individuals with initial lateral ankle sprains (LAS) who have chronic ankle instability (CAI) and no recurrence or instability for > 12 months (copers) following initial LAS. Assessing the movement patterns of copers and individuals with CAI and LAS recurrence is essential for identifying the mechanical factors that affect patient outcomes.

RESEARCH QUESTION

Does coordination and coordination variability of rearfoot, midfoot, and forefoot present a potentially causative pattern for CAI or coper?

METHODS

This cross-sectional study included 35 males who were divided into the CAI (n = 13), coper (n = 12), and control group (n = 10). Participants performed rearfoot strike running on the treadmill at a fixed speed of 3.5 m/s. The coupling angle between the rearfoot, midfoot, and forefoot, representing intersegmental coordination, was calculated using the modified vector coding technique and categorized into four coordination patterns. The coupling angle standard deviation served represented coordination variability during the stance phase.

RESULTS

One control participant and one CAI participant were excluded, and final analyses were performed on the CAI (n = 12), coper (n = 12), and control (n = 9) groups. During late stance, the coper group showed a significantly greater proportion of in-phase with distal dominancy (p = 0.02, effect size=0.17) and a significantly lower proportion of in-phase with proximal dominancy (p = 0.05, effect size=0.17), than the CAI group. During the early stance, the coper group showed a significantly lower proportion of anti-phase with distal dominancy than the CAI group (p = 0.03, effect size=0.18). There were no differences in intra-foot variability among the groups.

SIGNIFICANCE

The intra-foot coordination observed in the coper group suggests that this movement pattern may reduce the risk of ankle sprains.

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.

Quantitative evaluation of the vertical mobility of the first tarsometatarsal joint during stance phase of gait

We determined how the in vivo mobility of the first tarsometatarsal (TMT) joint can be quantified during gait. Twenty-five healthy participants (12 females) with no history of foot disorders were included. Non-invasive ultrasound (US) with a three-dimensional motion analysis (MA) system was used to evaluate the kinematic characteristics of first TMT joint during stance phase of gait. US probe was positioned longitudinally above the first TMT joint and adjusted to its proximal dorsal prominence. Gait analysis was conducted by the MA system starting with the activation of B-mode US video at 80 frames per second and 60-mm depth for simultaneous capture. During stance phase, the first metatarsal was translated dorsally with respect to the medial cuneiform, returning to a neutral level at toe-off in all subjects. During middle stance phase, the medial cuneiform was stable in males but displaced in the plantar direction in females and was the primary contributor to the differences in sagittal mobility observed between groups. Quantitatively measuring sagittal mobility of the first TMT joint could be useful for the early detection of foot abnormalities. The dynamic characteristics of the medial cuneiform during gait in healthy females may be associated with a high prevalence of hallux valgus.

Midfoot Charcot Neuro-arthropathy Precipitated by First or Fifth ray Amputation

BACKGROUND

Charcot Neuro-arthropathy (CN) can occur spontaneously in a neuropathic foot but is often precipitated by an insult to the foot, such as trauma. We noted an association between 1st and 5th ray amputations and the development of midfoot CN in our clinics. We therefore set out to analyse our data over a 6-year period to evaluate and improve our practice.

METHODS

Our project encompassed all diabetic adults with peripheral neuropathy undergoing an amputation of the first or fifth ray between January 2013 and January 2019. Patient demographics, stump length, progression to CN, imaging reports, the need for further operative management, length of stay and operating specialty were collected. Cases that developed CN after 1st or 5th ray amputation ("CN group") were compared with a cohort composed of patients that did not ("non-CN group").

RESULTS

We identified 92 patients (98 surgical episodes) who had previous 1st or 5th ray amputations [77 males (83.7%), 15 females (16.3%), mean age 61.5 ± 13.5]. Midfoot CN developed in 16 cases (17.4%; nine following 1st ray and seven following 5th ray amputation). This represented 30.9% of all our new CN cases. CN was diagnosed within six months in six cases and up to three years in the remaining 12. Five of the 1st ray amputations were conducted with a stump length of ≤10 mm from the tarsometatarsal joint and a further one had resorbed down to it before the Charcot process. Three of the 5th ray amputations were carried out leaving a stump length ≤25 mm. Receiver Operator Curve (ROC) analysis showed no obvious diagnostic value of stump length in predicting CN (area under the curve 0.42 (95% CI 0.26 - 0.59)). Following a logistic regression analysis into effect of age, gender and peripheral vascular disease, only age was found to significantly affect the risk of developing CN (Nagelkerke R² = 0.122, p = 0.013).

CONCLUSION

This is the first report of midfoot CN developing after 1st or 5th ray amputations. The foot could be destabilised following these procedures, leading to increased pressures across the midfoot. Our small sample was unable to demonstrate a significant correlation between stump length and CN risk. However, more work is needed to ascertain this. Meanwhile, we believe this translates clinically into a need for enhanced foot protection following 1st and 5th ray amputations in our practice.

The LISFRANC JUT: A physical finding of subtle LISFRANC injuries

INTRODUCTION

Low-energy Lisfranc injuries are uncommon and are often misdiagnosed as sprains. This results in a delay for the definitive treatment. The aim of this study is to discuss the physical finding of a midfoot "jut," that can be used to help diagnose subtle Lisfranc injuries, in patients who present with persistent midfoot pain after low-energy trauma.

PATIENTS AND METHODS

Between January 2015 through December 2019, patients previously diagnosed with a sprain, who were at least six weeks after their original injury, and presented with midfoot pain, were identified. All had a bony prominence on the medial border of the first tarsometatarsal joint, defined as a "jut", which produced pain. Standing radiographs demonstrated subluxation of the tarsometatarsal joint(s).

RESULTS

Seven patients (5 females/2 males) presented as isolated injuries, with a mean age of 40.4 years. Mechanisms of injury were five falls, one from a sporting event, and one twisting injury. Time to diagnosis, from their date of injury, averaged 9.9 weeks. All underwent fixation. Follow-up averaged 13.7 months. At final follow-up none of the patients developed surgical site infections, wound dehiscence, loosening of implants, loss of reductions or a recurrence of the "jut". None of the patients demonstrated arthrosis and only one patient had a broken screw and declined further surgical intervention.

DISCUSSION AND CONCLUSIONS

Patients presenting with a history of low-energy trauma, a diagnosis of sprain, continued complaint of foot pain, and a "jut" on the medial border of the midfoot, should be evaluated for a subtle Lisfranc injury.

Association of IBD specific treatment and prevalence of pain in the Swiss IBD cohort study

Background

Extraintestinal manifestations (EIM) contribute significantly to the burden of disease in inflammatory bowel disease (IBD). Pain is a leading symptom in IBD and could be seen as an EIM itself. Treatment of IBD associated pain is challenging and insufficiently studied. A better knowledge on the association of pain and IBD specific treatment is warranted to improve the management of IBD patients.

Methods

All patients of the Swiss IBD Cohort Study (SIBDCS) (n = 2152) received a questionnaire regarding pain localization, pain character, and the use of IBD specific medication.

Results

1263 completed questionnaires were received. Twenty-one out of 184 patients (10%) receiving anti-TNF treatment compared to 142 out of 678 patients (21%) not receiving anti-TNF medication reported elbow pain (p = 0.002) while 28 out of 198 patients (14%) receiving steroid treatment significantly more often reported elbow pain compared to 59 from 696 patients (8%) not receiving steroids (p = 0.021). Furthermore, we found significantly more female patients under anti-TNF treatment to report knee/ lower leg pain and ankle/ foot pain compared to their male counterparts (36% vs. 20% and 22% vs. 10%, respectively, p = 0.015 for both comparisons). The frequency of knee, lower leg, ankle and foot pain was especially low in male patients under anti-TNF treatment, indicating a high benefit of male patients from anti-TNF therapy regarding EIM.

Conclusions

The frequency of elbow pain was lower in IBD patients treated with anti-TNF but higher in patients treated with steroids.

Analysis of cases of Lyme arthritis in patients hospitalized in Infectious Diseases Department, University Hospital in Cracow

Lyme disease is an emerging problem in Poland. Analysis has been undertaken of the medical documentation of 86 patients hospitalized in the Infectious Diseases Department, University Hospital in Cracow in 2013-2016, suspected of Lyme arthritis. It has especially considered medical history including potential exposure to the infection, detailed characteristics of the symptoms, diagnostic challenges and results of the treatment. Only some patients had a history of erythema migrans and not all of them recalled tick-bite. The majority of the patients had affected large joints, especially knee joints, and polyarthritis was rarely observed. Symptoms were resolved completely or partially after antibiotic treatment in most patients. The diagnosis of Lyme arthritis in areas endemic for Lyme disease is still a diagnostic challenge in patients with other rheumatic diseases, including osteoarthritis.

Tibiotalocalcaneal Arthrodesis for Foot and Ankle Deformities

Tibiotalocalcaneal arthrodesis is a safe and viable option to treat patients with arthridities affecting ankle and subtalar joints, neuromuscular disorders, avascular necrosis of the talus, failed ankle arthrodesis, instability, and Charcot neuroarthropathy. Choice of incision and fixation is based on deformity, pathology, prior surgery and hardware, and surgeon comfort and preference. Intramedullary nails offer high primary stability, reduce sustained soft tissue damage, and may allow for earlier return to activities than traditional plate or screw constructs. Peri- and postoperative fractures, malunion, nonunion, and infections are potential complications. Postoperative recovery is a vital component for an overall successful outcome.

Degenerative arthritis of pseudoarticulation between the os peroneum and cuboid: a rare cause of lateral foot pain

The painful os peroneum syndrome is widely recognized. It is often the result of trauma. However degenerative changes between the os peroneum and the articular facet is much rarer and we could only find two other case reports in the literature. This report concerns a middle aged woman with chronic plantar-lateral foot pain and a limp secondary to degenerative changes between the os peroneum and its articular facet with cuboid. The aim of this study is to remind to orthopaedic surgeons about painful os peroneum syndrome and to highlight the rarity of our case. In our case the mid term result of the excision of the os peroneum with painful articulation appear good, providing symptomatic pain relief with little alteration in the function of the foot.

Charcot neuroarthropathy of the foot and ankle: diagnosis and management strategies

This article reviews current literature discussing the etiology, pathophysiology, diagnosis and imaging, and conservative and surgical treatment of Charcot osteoarthropathy. The treatment of Charcot osteoarthropathy with concurrent osteomyelitis is also discussed.

Strategies to reduce the configuration time for a powered knee and ankle prosthesis across multiple ambulation modes

Recently developed powered lower limb prostheses allow users to more closely mimic the kinematics and kinetics of non-amputee gait. However, configuring such a device, in particular a combined powered knee and ankle, for individuals with a transfemoral amputation is challenging. Previous attempts have relied on empirical tuning of all control parameters. This paper describes modified stance phase control strategies - which mimic the behavior of biological joints or depend on the instantaneous loads within the prosthesis - developed to reduce the number of control parameters that require individual tuning. Three individuals with unilateral transfemoral amputations walked with a powered knee and ankle prosthesis across five ambulation modes (level ground walking, ramp ascent/descent, and stair ascent/descent). Starting with a nominal set of impedance parameters, the modified control strategies were applied and the devices were individually tuned such that all subjects achieved comfortable and safe ambulation. The control strategies drastically reduced the number of independent parameters that needed to be tuned for each subject (i.e., to 21 parameters instead of a possible 140 or approximately 4 parameters per mode) while relative amplitudes and timing of kinematic and kinetic data remained similar to those previously reported and to those of non-amputee subjects. Reducing the time necessary to configure a powered device across multiple ambulation modes may allow users to more quickly realize the benefits such powered devices can provide.

Systematic review of contracture reduction in the lower extremity with dynamic splinting

Introduction

Joint contractures are relatively common disorders that can result in significant, long-term morbidity. Initial treatment is non-operative and often entails the use of mechanical modalities such as dynamic and static splints. Although widely utilized, there is a paucity of data that support the use of such measures. The purpose of this systematic review was to evaluate the safety and efficacy of dynamic splinting as it is used to treat joint contracture in lower extremities, and to determine if duration on total hours of stretching had an effect on outcomes.

Methods

Reviews of PubMed, Science Direct, Medline, AMED, and EMBASE websites were conducted to identify the term ‘contracture reduction’ in manuscripts published from January 2002 to January 2012. Publications selected for inclusion were controlled trials, cohort studies, or case series studies employing prolonged, passive stretching for lower extremity contracture reduction. A total of 354 abstracts were screened and eight studies (487 subjects) met the inclusion criteria. The primary outcome measure was change in active range of motion (AROM).

Results

The mean aggregate change in AROM was 23.5º in the eight studies examined. Dynamic splinting with prolonged, passive stretching as home therapy treatment showed a significant direct, linear correlation between the total number of hours in stretching and restored AROM. No adverse events were reported.

Discussion

Dynamic splinting is a safe and efficacious treatment for lower extremity joint contractures. Joint specific stretching protocols accomplished greater durations of end-range stretching which may be considered to be responsible for connective tissue elongation.

Surgical correction of midfoot arthritis with and without deformity

The goals of midfoot reconstruction are to create a painless, functional, and plantigrade foot, which are generally accomplished with arthrodesis and realignment as indicated. The latter requires not only the correction of midfoot deformity when present, but also coexisting hindfoot and forefoot deformities. Once the initial decisions have been made regarding the need for realignment and which joints to include in the arthrodesis, the surgical plan needs to account for the approach, arthrodesis preparation, order of fixation, and choice of fixation.

[The pathology of the foot in the atherosclerotic damage of lower extremities vessels in patients with type 2 diabetes mellitus]

The results of examination of 116 patients with atherosclerotic damage of lower extremities arteries caused by type 2 diabetes mellitus are presented. At the base of data of X-Ray examination the character, frequency and localization of damage of osteoarticular apparatus of the feet were been analyzed in disorders of main blood flow in cases with diabetes mellitus. Pathologic changes were recorded in 89.9% of cases with prevalence of isolated or combined hypertrophic processes. Destructive alterations, typical for osteoarticular apparatus of the feet in diabetes mellitus (diabetic osteoarthropathy), were absent. X-Ray signs of deformating osteoarthrosis of foot articulations were revealed in 48.4% of cases with maximal rate of damage of metatarsophalangeal joints. No relationship of osteoarticular apparatus lesions rate and a grade of circulation disorder in atherosclerotic vascular disturbances in type 2 diabetes mellitus was revealed (p > 0.05). The frequency of a set of X-Ray signs of osteoarthrosis--narrowing of joint space, subchondral osteosclerosis is associated with duration of diabetes mellitus more than 10 years. The relationship between frequency of development of atrophic processes (osteoporosis) of osteoarticular apparatus of the feet in cases with main vascular disorders and severity of course of diabetes mellitus (p < 0.01). Statistically confident prevalence of rate of osteoarticular apparatus of the foot was recorded in aggravation of metabolic disturbances.

Pigmented villonodular synovitis of the foot and ankle: Forty years of experience from the Scottish bone tumor registry

Fourteen cases of pigmented villonodular synovitis (PVNS) of the foot and ankle accrued from the Scottish Bone Tumor Registry are presented with an average follow-up of 4.6 years. This study analyzed the clinical, radiological, and histopathological features and investigated their clinical behavior and the factors influencing recurrence. The mean age of the patients was 26.4 years (range, 8-52 years). There were 8 women and 6 men. The mean delay in presentation was 10.3 months. The anatomical sites were phalanges (n = 2), tarso-metatarsal area (n = 3), and hindfoot (n = 9) (6 extraarticular soft tissue swellings around the ankle, 2 ankle, 1 subtalar joint). Eight (57.1%) cases presented with a painless lump, 5 (35.7%) patients had painful masses, and 1 case had a lump associated with toe deformity. Peri-articular tissue invasion and cortical infiltration were found in one third on plain films. Magnetic resonance imaging findings were suggestive of synovial sarcoma in 2 cases because of extensive low-signal soft tissue hypertrophy and bone erosion. Excision of the lump was performed in 4 cases with a complete recovery. Phalangeal lesions were treated with toe amputation through the metatarsophalangeal joint, and no cases had recurrence. There were 2 recurrences affecting the ankle and the subtalar joint. There was a 14.3% recurrence rate, while complete recovery was achieved in 85.7% cases (12/14). A high index of suspicion for PVNS should be observed for cases presenting with a painless or painful mass in the foot and ankle region. Complete recovery can be achieved in the majority by complete excision. Toe amputation may be considered for foot phalangeal PVNS.

Neuropathic arthropathy of the foot with and without superimposed osteomyelitis: MR imaging characteristics

PURPOSE

To determine retrospectively the magnetic resonance (MR) findings associated with pedal neuropathic arthropathy with and without superimposed osteomyelitis and to identify any useful discriminating features.

MATERIALS AND METHODS

Investigational review board approval was obtained and allowed review of records and images without informed consent. HIPAA compliance was observed. Contrast-enhanced MR images in patients with diabetic neuropathic arthropathy of the foot were examined by two reviewers in consensus. Affected joints were examined for marrow, articular, periarticular, and soft-tissue findings. Presence of superimposed osteomyelitis was documented. A subgroup that had undergone MR before infection was evaluated for comparison; chi(2) and t tests were used to evaluate the associations.

RESULTS

Of 128 neuropathic joints in 63 patients (24 female, 39 male; aged 31-78 years), 43 had superimposed osteomyelitis. Effusion was common in all neuropathic joints, but thin rim enhancement was more common in noninfected joints (62% vs 21%, P < .001) and diffuse joint fluid enhancement was more common with infection (47% vs 26%, P = .052). Subluxation, bone proliferation, fragmentation, and erosion were seen in both groups, but intraarticular bodies were more common in noninfected joints (53% vs 12%, P < .001). In the periarticular soft tissues, edema, enhancement, and ulceration were common in both groups. Fluid collections in the soft tissues were more commonly associated with infected joints (95% vs 48%, P < .001) and, when present next to an infected joint, were larger than those next to noninfected neuropathic joints (2.6 cm(2) [range, 0.3-8.6 cm(2)] vs 1.6 cm(2) [range, 1.0-2.4 cm(2)]). Soft-tissue fat replacement (68% vs 36%, P = .002) and sinus tracts (84% vs 0%, P < .001) were also more common with infection. In the marrow, periarticular signal intensity abnormality was common in both groups, but the extent was greater with infection. Subchondral cysts were seen almost exclusively in noninfected joints (76% vs 2%, P < .001). Similar results were obtained in the subgroup of 21 joints (15 patients) with both pre- and postinfection MR images.

CONCLUSION

Sinus tract, replacement of soft-tissue fat, fluid collection, and extensive marrow abnormality are MR imaging features indicating superimposed infection. Thin rim enhancement of effusion, presence of subchondral cysts, or intraarticular bodies indicate absence of infection.

The algorithmic approach to pediatric flexible pes planovalgus

The author presents an alternative approach to the pediatric flexible pes planovalgus patient. Hopefully, this algorithm can serve as a guide and not as a rule. It is meant to serve the foot and ankle surgeon as a means of eliminating the arbitrary assignment of a flatfoot to procedures. Instead, the algorithm assigns procedures to a type of flatfoot. The specific procedures listed are a guide to reduce our failures while continually improving our successes.

Pigmented villonodular synovitis of the foot and ankle

BACKGROUND

Pigmented villonodular synovitis (PVNS) is a rare disease of uncertain etiology usually affecting the synovium of weightbearing joints.

METHODS

We retrospectively evaluated 11 patients who were diagnosed and treated for PVNS of the ankle and foot over a 13-year period with a minimum of 2-year followup. Four patients with ankle joint PVNS and one patient with PVNS of the fifth metatarsophalangeal joint were seen initially at our institution and were treated with surgery alone. Six patients with ankle joint PVNS were referred to our institution for recurrent PVNS lesions; two of these patients were treated with excision alone, and the other four patients had surgical excision followed by radiation therapy with dosages ranging from 3600-4000 cGy.

RESULTS

No recurrence was noted at a mean followup of 9 years for primary lesions and 3.5 years for recurrent lesions.

CONCLUSION

Based on these results, surgical excision of primary lesions and excision with postoperative radiation for recurrent lesions are recommended.

Tumoral calcinosis with unusual presentation. A case report

A case of multiple para-articular calcific masses involving the elbow, hand, back, knee and the feet was encountered. Pathology after surgical excision of all the masses revealed tumoral calcinosis. The unusual feature was the huge size of the lumbar and knee masses, and the distal location of the swellings in the hand and the foot; there was no disturbance of calcium and phosphorus metabolism, which was an unusual feature of the condition in this patient.

Course of radiographic damage over 10 years in a cohort with early rheumatoid arthritis

OBJECTIVE

To investigate development of radiographic damage in hands and feet of patients with early rheumatoid arthritis (RA) monitored prospectively for 10 years, and to search for prognostic factors.

PATIENTS AND METHODS

181 patients with early RA (mean disease duration one year) were assessed annually with radiographs of hands and feet during years 0-5 and at year 10. Radiographs were evaluated according to Larsen (range 0-200). Predictive factors for progressive disease for years 0-5 and 5-10 were evaluated by logistic regression analyses.

RESULTS

82/168 (49%) patients had erosions at inclusion and almost all became erosive with time (90% after two years and 96% after 10 years). Radiographic progression was most rapid during the first two years and 75% of all damage occurred during the first five years. The median Larsen score increased from 6 at inclusion to 41 after five years and 54 after 10 years. Only 5.3% of all evaluated joints became maximally eroded, the second metacarpophalangeal joint being the most commonly affected. Mean ESR during the first three months and rheumatoid factor status were significant predictors for radiographic progressive disease, it was not possible to predict non-progressive disease.

CONCLUSIONS

Joint damage in hands and feet developed early and progression was most rapid during the first years of disease. The different rates of progression at different stages should be considered in the design of trials of drugs aimed at retarding joint damage. Disease activity at study start influenced the degree of joint damage during the entire 10 years.

Smoking and osteoarthritis: is there an association? The Clearwater Osteoarthritis Study

OBJECTIVE

To evaluate the association between cigarette smoking and the subsequent development of osteoarthritis (OA) at four separate sites: knee, hand, foot and cervical spine.

METHODS

This cohort study examined 2505 men and women aged 40 years and older participating in the longitudinal Clearwater Osteoarthritis Study (1988-current). Biennial physical exams, including serial radiographs, as well as historical information, were collected. The Lawrence and Kellgren ordinal scale was used to determine radiological evidence of the study outcome, OA. Self-reported history of smoking behavior was used to determine the study exposure. Smoking was classified using four approaches: (1) ever/never, (2) former/never, (3) current/never, and (4) dose.

RESULTS

Among the individuals at study entry, radiologically confirmed incident OA was detected during the follow-up period at four sites: knee (32%), hand (49%), foot (28%), and cervical spine (52%). Approximately 11% were self-reported current smokers. Unadjusted analyses indicated that individuals classified as current smokers demonstrated significant levels of protection from OA at all four sites investigated. However, adjusted point estimates ranging from 0.60-1.48 were suggestive of no association between smoking and the development of OA at any of the four sites investigated.

CONCLUSION

Based upon the findings of this prospective study, smoking does not appear to convey a clinically significant level of protection against the development of radiologically-confirmed OA. While these findings corroborate previous studies indicating no association between smoking and OA, anecdotal evidence warrants investigation into the role that cigarette smoking may play in the symptomatology of OA.

The diabetic foot: basic mechanisms of disease

There remains vast truth in the statement "neuropathy causes diabetic foot pathology." However, if it were really that straightforward and if our understanding were complete, it is doubtful that ulceration and neuroarthropathy would be the public health problems that they are today. Diabetes is an insidious disease, and almost every component of the spectrum of hyperglycemic complications is active in creating foot lesions. These include dramatic alterations in all components of the peripheral nerves, the mechanical characteristics of bones and soft tissues, gait kinematics, the vasculature at both a microscopic and a macroscopic level, the immune system, and the fundamental processes of wound healing. Clinical treatments that address the biologic aspects of the problem without considering the mechanics, or vice versa, can sometimes be effective but fail to take advantage of all of the potential means to succeed. The greatest potential for future clinical advance lies in understanding and simultaneously addressing the many synergistic factors that cause both ulceration and neuroarthropathy.