Angioleiomyoma mimicking a swollen bursa on first metatarsophalangeal joint accompanying with hallux valgus deformity

We present a case of a patient who underwent a modified scarf osteotomy and tumour excision based on a preoperative diagnosis of hallux valgus deformity and accompanying bursitis. Subsequent histopathological examination revealed that the tumour was an angioleiomyoma. While tumours around the first metatarsophalangeal (MTP) joint are typically associated with gouty nodules, infections, or swollen bursa (bursitis) in patients with hallux valgus deformity, the occurrence of soft tissue tumours in this area is rare. Moreover, angioleiomyoma is an even rarer form of soft tissue tumour and is seldom suspected prior to resection. To our knowledge, there have been no reports of angioleiomyoma arising in the first MTP joint. However, it is important to consider the possibility of an atypical tumour in cases where soft tissue masses are present, even in patients with hallux valgus deformity, and to perform at least imaging tests such as ultrasound and magnetic resonance imaging before surgery. This prospect should always be kept in mind.

Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet

BACKGROUND

Scarf osteotomy has been widely used to restore axial orientation of the first ray in the treatment of hallux valgus deformity. The aim of the study was to present our radiological outcomes of bunion reconstruction, identify surgical complications in early follow-up, and assess to what extent a shortening of the first metatarsal is present after surgery as a possible cause of postoperative metatarsalgia.

METHODS

We enrolled 106 patients (118 feet) and assessed patients' pre- and postoperative measurements of hallux valgus and intermetatarsal angles on weightbearing X-ray images. Three different methods of measuring metatarsal length were compared and early postoperative complications noted.

RESULTS

Hallux valgus angle decreased significantly by an average of 18.7 degrees and the intermetatarsal angle by 7.8 degrees. Using three methods of measuring metatarsal length, all showed significant shortening of the first metatarsal. Mean relative lengthening of the second metatarsal averaged 0.45mm. The Coughlin method showed the highest interrater reliability (ICC=0.96).

CONCLUSIONS

Significant reduction of the hallux valgus angle and intermetatarsal angle was demonstrated with a low complication rate. There was significant shortening of the first metatarsal. The Coughlin method clearly demonstrated an excellent interrater reliability.

LEVEL OF EVIDENCE

Level IV.

The Endolog technique for moderate to severe hallux valgus treatment: Clinical and radiographic analysis of 194 patients

BACKGROUND

Endolog is an intra-medullary titanium device used for a minimally-invasive hallux valgus correction. The aim of this study was to evaluate clinical and radiographic outcomes of this device.

METHODS

A retrospective study with a prospective data collection was conducted. Patients underwent to Endolog procedures from September 2009 to April 2017 were enrolled. Mild HV deformity (HVA ≤ 19° and IMA ≤ 13°) or associated procedure to Endolog technique were excluded. The radiological (HVA, IMA and PASA) and clinical (AOFAS score) pre and post-operative data were compared through Wilcoxon Signed-Rank test.

RESULTS

194 feet (144 moderate and 50 severe HV) underwent HV correction respecting study's criteria. AOFAS scores significantly improved from 31.0 ± 12.7 points preoperatively to 88.5 ± 8.0 at 24 months. Even all radiographic measurements significantly improved during 2 years' follow-up. Only 6 patients experienced complications: 4 cases of HV recurrence and 2 cases of intolerance device-related pain.

CONCLUSIONS

Endolog technique proved to be a valid option in the moderate-to-severe hallux valgus treatment, comparable to other surgical techniques described in literature.

Comparison of contact surface areas of metatarsal diaphyseal osteotomies for correction of hallux valgus: Experimental study

OBJECTIVE

This study aimed to determine, pre-correction, the potential change in the osteotomy-site bony contact surface area that would occur during standard metatarsal diaphyseal procedures with the Baran-Unal modification of Mau osteotomy and then to compare it, post-correction, with the actual osteotomy-site bony contact surface area changes for a standard degree of deformity correction.

METHODS

A total of 30 standard, same sized, biomechanically equivalent, left first metatarsal sawbones were included in this experimental study. They were divided equally into five groups for each of the planned osteotomy techniques: Myerson's modification of Ludloff, Mau, scarf, Offset V, and Baran-Unal modification of Mau osteotomy. The normal osteotomy for each sample was considered as the control, while the corrective osteotomy was the test. Computerized tomography scans and three-dimensional (3D) reconstruction imaging were performed for objective and accurate measurements. The techniques of the osteotomy and post-corrective osteotomy bony contact surface areas were investigated by the two independent research assistants.

RESULTS

There was a statistically significant difference between the contact surface area changes of all pre- and post-corrective osteotomy groups (P<0.05). When the pre- and post-correction contact surface areas of any one group were compared with the other groups, the differences were or were not statistically significant. Mean differences between pre-correction and post-correction areas for Ludloff, Mau, scarf, Offset V, and Baran-Unal osteotomies were 180.7, 122.3, 226.2, 191.9, and 68.9 mm2, and the percentages of area loss were 22.9%, 15.5%, 28.6%, 24.3%, and 8.7%, respectively. The most bony contact area was found in the scarf osteotomy group (mean pre-correction area: 490.5 mm2 and mean post-correction area: 264.3 mm2), but the Baran-Unal modification group has significantly the highest post-correction bony contact area among the all other groups (mean pre-correction area: 413.3 mm2 and mean post-correction area: 344.4 mm2).

CONCLUSION

Metatarsal diaphyseal osteotomies for hallux valgus deformity have the potential not only for deformity correction, but also for contact surface area preservation. This study reaffirms the considerable potential of this new Baran-Unal modification to confer outstanding contact surface area values, even with the operative correction of hallux valgus deformity.

Development of a quantitative measurement system for three-dimensional analysis of foot morphology using a smartphone

Existing techniques for measuring foot morphology are invasive or cumbersome. A new technique was developed using a smartphone, which can measure foot morphology to within 1 mm. This is shown to be applicable to the prediction of hallux valgus, which allows for early intervention.

Effect of sesamoid position on functional outcome of operated hallux valgus

INTRODUCTION

The loss of correct relationships between the sesamoid and the first metatarsal is one of the architectural consequences of the hallux valgus (HV). The reduction of this dislocation by lateral soft tissue release (LSTR) is one of the objectives of surgery.

AIM

To study the relationship between postoperative position of sesamoid and clinical outcome at one-year postoperative follow-up.

METHODS

It's a retrospective study including patients operated for evolved HV performed in la Rabta orthopedic department in Tunis. These patients had a Scarf osteotomy associated with at least one Weil osteotomy. The functional evaluation was based on the AOFAS score (American-orthopedic-foot-and-ankle-society). We classified the sesamoid position according to 3 scores: Hardy & Clapham , RCAOFAS and the Agrawal. We compared each score of the sesamoid position to the clinical outcome.

RESULTS

We collected 46 cases of HV in 45 patients. The mean AOFAS score increased from 60,9 to 85,5/100 postoperatively. Our patients were divided into 2 groups: group A whose result was excellent and group B whose result was good, fair and poor. The analytical study of this work concluded that there was no relationship between the postoperative sesamoid position and the clinical outcome, regardless of the radiological classification used (p=0,361, p=0,222, p=0,260).

CONCLUSION

Sesamoids that remain in postoperative dislocation are not necessarily predictive of a poor clinical outcome at one year of the surgical cure.

Factors influencing medial sesamoid arthritis in patients with hallux valgus deformity: Magnetic resonance imaging evaluation

BACKGROUND

The importance of preoperative evaluation of the position and degree of arthritic changes of the medial sesamoid bone before hallux valgus correction is emerging. This is an observational study to evaluate the magnetic resonance imaging (MRI) findings of hallux valgus deformity, and assess the severity of and identify the factors that influence the arthritic changes in medial sesamoid-metatarsal (mSM) joints.

METHODS

We reviewed weight-bearing anteroposterior radiographs, forefoot axial radiographs and MR images of 514 feet of 405 patients who underwent hallux valgus correction. On MRI, the degrees of the arthritic changes in the first metatarsophalangeal (MTP) and mSM joints were categorized into 5 classes. Binary logistic regression analysis was performed to identify the factors affecting the arthritic changes.

RESULTS

The binary logistic regression analysis showed that advanced age, more lateralized position of medial sesamoid bone on forefoot axial radiograph, and higher MRI grade of arthritic change of the 1st MTP joint were significant factors contributing to medial sesamoid arthritis (P<0.001, 0.001. 0.006, respectively).

CONCLUSIONS

Medial sesamoid arthritis can be assessed using MRI. The position of medial sesamoid bone on forefoot axial radiographs can strongly help predict the possibility of mSM joint arthritis.

LEVEL OF EVIDENCE

III, observational study.

Reliability of a new dynamic ultrasound test for quantifying first-ray mobility

BACKGROUND

First-ray hypermobility (FRHM) is a documented abnormality whose pathogenic role is controversial. FRHM has been suggested to participate in many common disorders such as paediatric hallux valgus and recurrence after hallux valgus surgery. The controversy is due to lack of functional data on the first tarso-metatarsal joint (TMT1) in real-life situations, to its major anatomical variability, and to the absence of simple investigation methods. The objective of this study was to assess the feasibility and the inter- and intra-observer reproducibility of a new dynamic ultrasound test that quantifies TMT1 mobility and is simple to use provided a good-quality ultrasound machine is available.

HYPOTHESIS

The new ultrasound TMT1 mobility test is reproducible.

MATERIAL AND METHODS

The 32 feet of 16 consecutive patients whose first ray was considered normal were included. Ultrasonography was performed at rest and during a stress test consisting in causing TMT1 gaping by applying a distal dorsal drawer movement to the first metatarsal. The two plantar bony prominences on either side of the TMT1 were identified, and the distance between them was measured at rest and during the stress test. The stress/rest ratio was computed. Each foot was tested twice by two different examiners, for a total of 128 tests.

RESULTS

Mean TMT1 gaping distance was 1.38mm (range, 1.01-2.02mm) at rest and 1.67mm (range, 1.12-2.95mm). The mean stress/rest ratio was 1.21 (range, 1.02-1.62). Both inter- and intra-observer reliability was strong for all measured parameters.

DISCUSSION

A simple and reproducible ultrasound test for measuring TMT1 mobility is described for the first time. The good reproducibility confirms the working hypothesis. This preliminary study was designed to validate the new test. The measured values need to be assessed in various disorders including FRHM, for which the test was designed. Should the results prove conclusive, the TMT1 gaping test may become a pivotal diagnostic tool.

LEVEL OF EVIDENCE

IV, diagnostic study.

Medial and lateral exostoses of the distal phalanx of the hallux: A potentially painful bunion-like structure. Part 1: Incidence and clinical application

BACKGROUND

Exostoses at the base of the distal phalanx of the great toe are usually asymptomatic. The literature has not generally considered them as the origin of a possible problem resulting from a pressure conflict between hallux and shoe (medial aspect) or second toe (lateral aspect) nor a potential complication of surgical correction of hallux valgus deformity. No studies, to our knowledge, have evaluated its possible correlation with other foot disorders. When one of these neglected exostoses became painful after surgical correction of hallux valgus, we decided to start a study to determine their possible origin, prevalence in daily practice and histo-pathological morphology.

METHODS

Two hundred and fifty-four feet of patients (average age 41.7y.) were enrolled in the study from January 2007 to June 2009. Dorsoplantar weight-bearing radiographs were used to analyze the presence of exostoses and their correlation with the distal phalanx morphology, metatarsal formula (or transverse plane orientation of the metatarsal heads parabola) and hallux valgus angles. Patients were classified according to their age and main symptom for consultation. Four exostoses removed from cadaver feet were also analyzed microscopically.

RESULTS

Osseous excrescences arising on the medial or lateral aspect at the proximal part of the terminal phalanx of the hallux were observed in 132 feet (51.9%). Thirty-five feet out of these 132 (13.7%) had exostoses on both sides of the phalanx.A statistically significant positive correlation was found between the presence of a medial exostosis of the phalanx and the severity of HVA. Patients with higher IPH and asymmetry angles have a lower prevalence of medial exostoses (p<0.05). Amongst the different morphologies of the second phalanx, exostoses were most likely found in the standard form.

CONCLUSIONS

Prevalence of exostoses at the base of the distal phalanx is high (51.9% of the studied feet). Histological findings would suggest that these exostoses could be considered a mechanical reactive process, produced by a chronic irritation by shoes. We encourage surgeons to be aware of its potential clinical implications. Direct resection is very simple and the most appropriate treatment for symptomatic cases.

The value of axial loading three dimensional (3D) CT as a substitute for full weightbearing (standing) 3D CT: Comparison of reproducibility according to degree of load

BACKGROUND

Full weightbearing (WB) three dimensional computed tomography (3D CT) is an excellent imaging tool. However, due to its high cost, it is only used in a few hospitals. We evaluated the usefulness and cost-effectiveness of axial loading (AL) 3D CT by comparing bony alignments with standing radiographs, and assessed reproducibility according to the degree of AL.

METHODS

Eighty patients (156 feet), who underwent standing radiographs and 3D CT with an AL device from January 2016 to May 2017, were investigated. According to the degree of AL (AL force×100/body weight), the patients were randomly assigned to three groups: Group A (30-50%; n=21, 40 feet), Group B (50-70%; n=32, 63 feet), and Group C (70-100%; n=27, 53 feet). The following angles were measured three times by two orthopedists: hallux valgus (HVA), 1st-2nd intermetatarsal (IMA1-2), and talo-navicular coverage (TNCA), calcaneal pitch (CPA), talo-1st metatarsal (T1MA), and talo-calcaneal angle (TCA). Agreements between the two imaging methods were analyzed and compared according to the degree of axial loading in each group.

RESULTS

Intra- and interobserver reliability was excellent (>0.75). In Group A (30-50% AL), all of the angles except HVA and IMA1-2 differed (p<.05). In Group B (50-70%), TNCA (p=.023), T1MA (p=.017), and TCA (p=.035) differed. In Group C (70-100%), none of the angles differed between the two imaging methods (p>.05). Higher agreement between the two imaging methods was realized when 70% or more(>70%) AL was applied.

CONCLUSIONS

AL 3D CT with >70% axial load has full WB effects and can be substituted for expensive full WB 3D CT.

Is generalized ligamentous laxity a prognostic factor for recurred hallux valgus deformity?

BACKGROUND

This study was performed to evaluate the intermediate-term clinical outcomes after proximal chevron osteotomy for hallux valgus in patients with generalized ligamentous laxity, and to determine the effect on postoperative recurrence of deformity.

METHODS

There were 23 cases in laxity group (Beighton score ≥5 points) and 175 in non-laxity group with a mean followup of 46.3 months. Clinical evaluation consisted of the AOFAS score, Foot and Ankle Ability Measure (FAAM), and radiographic measurement of hallux alignment. Risk factors associated with postoperative recurrence were evaluated using univariate analysis.

RESULTS

Recurrence rates were 21.7% in the laxity group and 17.1% in non-laxity group (P=.218). There were no significant differences in clinical and radiographic measurements at final followup between the 2 groups. Preoperative HVA and IMA were found to be predictive factors of recurrence (OR=6.3, 4.2; P=.001, .018, respectively).

CONCLUSION

There were no statistical differences in the clinical and radiographic outcomes between hallux valgus with and without generalized ligamentous laxity. Generalized ligamentous laxity demonstrated no definitive effects on postoperative recurrence of hallux valgus deformity.

Common Foot Problems: Over-the-Counter Treatments and Home Care

Most foot disorders do not require podiatry referral or complex interventions. After the clinical diagnosis is made, these conditions can typically be managed with over-the-counter (OTC) and home remedies, with guidance from the primary care physician. Stretching and strengthening exercises, along with the use of heel cups, resolve most plantar fasciitis cases and are at least as effective as nonsteroidal anti-inflammatory drugs or steroid injections. Hallux rigidus is best managed with a hard-soled shoe or rigid insert that relieves pain by restricting motion across the metatarsophalangeal joint. Hallux valgus responds to use of wide toe box shoes, and surgery is not clearly beneficial beyond one year. Plantar warts can be treated effectively at home with OTC salicylic acid and cryotherapy topical agents, which have equal effectiveness to liquid nitrogen. In patients with corns and calluses, OTC topical salicylic acid has short-term benefits, and pads and inserts that more evenly redistribute contact forces have long-term benefits. Inserts are commonly recommended to redistribute forefoot pressure and relieve pain. Several OTC preparations are available for the treatment of tinea pedis, with topical allylamines being the most effective. Although OTC topical treatments have been widely used for onychomycosis, they have poor long-term cure rates compared with prescription oral medications.

Is the Rotational Deformity Important in Our Decision-Making Process for Correction of Hallux Valgus Deformity?

Rotational deformity in hallux valgus is a recognized component and a demonstrated recurrence factor in patients who have undergone surgery. More than 20 years ago, publications started reporting metatarsal pronation as part of the hallux valgus pathology. Identifying metatarsal pronation should be part of the preoperative angular measurements. The proximal metatarsal rotational osteotomy and Lapidus fusion are some of the few techniques that reliably correct metatarsal pronation. They have good results, with more nonunions reported for the Lapidus. The authors present their hallux valgus treatment algorithm that includes metatarsus varus severity, tarsometatarsal instability, and rotational deformity among its variables.

Surgical correction of hallux valgus deformity in children with cerebral palsy

Objective

This study aimed to present a treatment algorithm for the correction of the hallux valgus deformity in Cerebral Palsy (CP) patients and to discuss the outcomes based on our clinical and radiological results.

Methods

29 patients (45 feet) were included in the study. The mean age of the patients at the time of the surgery was 14 (range 6–22) years. The mean follow-up was 33 (range 22–59) months. A reconstructive procedure was performed on 19 patients (27 feet); a soft tissue surgery and exostectomy of the bunion in six patients (11 feet); and MTP joint arthrodesis in four patients (7 feet). The hallux valgus angle (HVA) and the anteroposterior intermetatarsal angle (IMA) were used for radiologic evaluation and the DuPont Bunion Rating Score was used for clinical evaluation.

Results

The follow-up period was 36 (range 22–59) months in reconstructive group, 27 (range 24–29) months in soft tissue group, and 29 (range 23–41) months in MTP arthrodesis group. Significant improvements were detected in hallux valgus angle in three groups postoperatively but in soft tissue group correction loss was observed during follow up. Best results were achieved in arthrodesis group and worse in soft tissue group in terms of clinical evaluation.

Conclusion

According to our results isolated soft tissue procedures are ineffective in CP patients. Soft tissue procedure combined with metatarsal osteotomy has satisfactory results.

Level of evidence

Level IV, therapeutic study.

[Clinical and radiographic evaluation of a new percutaneous technique for moderate to severe hallux valgus deformity]

Hallux valgus is considered the most common musculoskeletal deformity, with a prevalence of 88%. There are more than 130 surgical techniques for its treatment; currently, percutaneous ones are popular; however, they do not take into account the metatarsal-phalangeal correction angle. The aim of this study is to propose a modified technique for the correction of the percutaneous metatarsal-phalangeal and inter-metatarsal angles and to evaluate its clinical and radiological results.

MATERIAL AND METHODS

An experimental, prospective and longitudinal study in 10 patients with moderate to severe hallux valgus according to the classification of Coughlin and Mann were collected; the results were evaluated with the AOFAS scale at 15, 30, 60 and 90 days. The McBride technique and the technique of percutaneous anchor with the proposed amendment were performed.

RESULTS

The AOFAS scale was applied as described, finding a progressive increase of the rating; the average correction of the inter-metatarsal angle was 8.8 degrees and of the metatarsal-phalangeal, 9.12.

DISCUSSION

The modified technique of percutaneous anchor showed clear clinical and radiographic improvements in the short term. Our modified technique is proposed for future projects, including a large sample with long-term follow-up.

Consensus on Surgical Management of Hallux Valgus from China

Hallux valgus deformity is one of the most common diseases in foot and ankle surgery. Satisfactory outcomes tend to be achieved only through operative correction. However, selection of the optimal surgical strategy is always a controversial topic, and the rate of dissatisfied patients postoperativelyis still very high. It is well known that there are various pathological changes in hallux valgus deformity, so it is impossible to use one specific procedure to solve all the problems. It requires a careful preoperative physical examination and radiographic assessment to choose the best operation for each kind of deformity according to each pathalogical change, combined with good postoperative dressing, immobilization and proper rehabilitation and follow up, to improve surgical outcomes and reduce postoperative rate of complication and dissatisfaction. In order to achieve these goals, a Consensus on the Operative Correction of Hallux Valgus has been developed by the Foot and Ankle Working Committee, Orthopaedic Branch, Chinese Association of Orthopaedic Surgeons. Foot and ankle surgeons following this consensus must be fully aware of their patients' desires, carefully evaluate different pathological processes and clinical symptoms and be skilled in various procedures. Then these procedures can be easily selected, converted and combined based on preoperative plans and intraoperative conditions.

Effects of ballet training of children in Turkey on foot anthropometric measurements and medial longitudinal arc development

OBJECTIVE

To investigate the effects of ballet training on foot structure and the formation of the medial longitudinal arc in childhood, and the association of body mass index with structural change secondary to ballet training.

METHODS

This study was conducted at Öykü Ballet and Dance School and Trakya University, Edirne, Turkey, from September 2007 to November 2008, and comprised girl students who were taking ballet classes, and a group of those who were not taking such who acted as the controls. Static footprints of both feet of all participants were taken with an ink paedogram. Parameters evaluated from footprints included foot length, metatarsal width, heel width and medial longitudinal arch. The relationship between the parameters, the ballet starting age, training duration and body mass index was investigated.

RESULTS

Of the 67 participants, there were 36(53.7%) in the experimental group and 31(48.3%) in the control group. The difference between age, height, weight and body mass index between the two groups was insignificant (p>0.05). The average ballet starting age was 6.47±1.55 years and duration was 4.36±2.002 years. Positive correlations were found between body mass index and foot length, metatarsal width, heel width, medial longitudinal arch contact width and halluxvalgus angle; between ballet starting age and metatarsal width, heel width; between duration of training and foot length, metatarsal width and hallux valgus angle (p?0.05 each).

CONCLUSIONS

Evidence supporting the education in children on foot anthropometric measurements and medial longitudinal arc development could not be found.

[Results of application of a new method for the treatment of hallux valgus of the first toe]

BACKGROUND

The aim of the present article was to report our experience with the treatment of patients with hallux valgus and to perform comparative analysis of the results of the newly proposed and standard methods for its surgical correction.

METHODS

The data on 70patients (101 feet) with hallux valgus that were operated on between 2011 and 2015 in St. Petersburg Hospital No 2 using the new and standard methods were analysed. The functional assessment (AOFAS score) and X-ray examination were performed preoperatively, 3 and 12 months after the procedure. Comparative analysis between patients undergoing surgical correction by the new and standard methods has been undertaken.

RESULTS

We did not find any significant difference between the two groups in mean AOFAS score 12 months after surgery. Nevertheless, the function score of the patients treated by the newly proposed method (79.4±6.5 in 3 months) was significantly better than in those given the standard treatment (72.2±7.6 in 3 months). Mean intermetatarsal angle 12 months after surgery by standard and new methods was 9,7±0,7° and 8,6±0,7° (p<0.05), mean metatarsophalangeal angle 13,6±0,9° and 13,0±1,1° (p<0,05) respectively.

CONCLUSION

According to the data obtained, the original method of hallux valgus surgical correction allows to improve its functional and x-ray results.

Adolescent hallux valgus revisited

Treatment of adolescent hallux valgus with first metatarsal double osteotomy is well described in the literature. Unfortunately, first metatarsal phalangeal joint stiffness and deformity recurrence have been reported at relatively high rates. The authors revisit a technique aimed at preventing these complications.

Hallux valgus

Hallux valgus is a common foot problem whose cause and progression is multifactorial, complex, and poorly known. Hallux valgus shows a predilection toward women. It is a progressive disorder with no treatment known to slow or stop progression. Surgery is indicated in healthy individuals when nonoperative measures fail. Adverse effects of surgery include infection and recurrence. Many procedures have been described, including soft tissue and bony reconstruction of the first ray. The procedure that is indicated depends on the severity of the deformity.

The treatment of hallux valgus

BACKGROUND

Hallux valgus is the commonest forefoot deformity, with an estimated prevalence of 23% to 35%. It causes symptoms on the medial edge of the foot, the sole, and the small toes. Non-operative treatment may alleviate symptoms but does not correct the deformity of the big toe. Surgery is indicated if the pain persists. The correct operation must be selected from a wide variety of available techniques.

METHODS

In this article, we selectively review the pertinent literature, including the recommendations of medical societies in Germany and abroad, in the light of our own clinical experience.

RESULTS

There have been many clinical trials of various treatments for hallux valgus, but very few of these were randomized, and the case numbers were generally small. Mild deformities are best treated by distal first metatarsal osteotomies, e.g. the Chevron osteotomy. Severe deformities require a soft-tissue procedure at the first metatarsophalangeal joint and a proximal first metatarsal osteotomy. In case of osteoarthritis, and in elderly patients, a resection arthroplasty is preferred; arthrodesis is performed in physically active patients. After correction of hallux valgus, patients can usually bear their full weight on the treated foot while wearing a flat surgical shoe. Proper surgical treatment results in a good or very good outcome in 85% of patients and a satisfactory result in a further 10%.

CONCLUSION

The clinical outcome of present treatments seems to be good in most cases, but large-scale randomized trials are still needed to verify the efficacy of the wide variety of operations and fixation techniques that are currently being offered.

Fibrodysplasia ossificans progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder of the connective tissue characterized by progressive disability as a result of extensive extra skeletal enchondral bone formation and malformed big toes which are often monophalangic. Occasional features include short thumbs, fifth finger clinodactyly, malformed cervical vertebrae and mild mental retardation. Beginning during childhood, FOP progressively immobilizes all the joints through adult life, rendering movement impossible. Currently, there is no effective prevention or cure for this debilitating disease. Since it has an autosomal dominant inheritance, our concern is to highlight prompt genetic counseling in the concerned families although many sporadic cases have also been identified.

[Hallux valgus--several ways to treat]

Hallux valgus is a progressive exertional metatarsal disturbance altering the kinematics of walking. It may be accompanied by other problems of the foot, such as hammer toe or flatfoot syndrome, symptoms of metatarsalgia or arthrosis of the small joints of the foot. Conservative treatment aims to reactivate the muscles of the foot. Operatively, placement of the 1st metatarsal to its anatomical position over the sesamoid bones is attempted to support the action of the foot muscles. When choosing the operative technique the extent and severity of the disorder as well as the objectives and risk factors of the treatment should be considered.

Clinical and radiographic analysis of the operative procedure results according to the method of Mitchell and Keller used for correction of hallux valgus deformities

The aim of this study is to make a correlation of the clinical and radiographic results after performing two different surgical procedures for correction of hallux valgus deformity.

MATERIAL AND METHODS

The study included 70 patients having hallux valgus deformity of the foot, and they were divided into two groups. The first group (Group 1) was composed of 35 patients who were treated by osteotomy of the I-st metatarsal bone according to Mitchell, while the second group (Group 2) was also composed of 35 patients who were treated by resectional arthroplasty according to Keller. Clinical (pain and metatarsalgia, as well as most dominant symptoms) and radiographic examinations (I metatarsophalangeal angle and I intermetatarsal angle) were analysed comparatively during the evaluation. The analysis of the clinical and radiographic results was performed pre-operatively and post-operatively for the two groups.

RESULTS

According to their sex, the patients were 5 men and 65 women. Using the method of Mitchell, pain as a clinical symptom post-operatively was found in only 3 patients out of the 35 with operated feet, while in the other group of patients treated by the method of Keller, there was no presence of pain in any of the patients. Comparatively, this does not present a statistically significant difference (p>0.05). Nor do, the differences in the distribution of metatrsalgia incidence show a statistical significance between the two groups (p>0.05). There is no significant difference (p>0.05) in the patients of the two groups concerning the pre-operative mean dimension values of the I metatarsophalangeal angle and I intermetatarsal angle. However, the radiographic analysis of the same angles in both groups, one year post-operatively, showed a high statistically significant difference (p<0.001).

SUMMARY

Mitchell's operative technique could be recommended as an effective procedure for the correction of hallux valgus and metatarsus primus varus in young and middle-aged patients, while the resection arthroplasty according to the method of Keller is recommended for older patients with arthrotic changes.

Plantar pressures determinants in mild Hallux Valgus

While podobarometric techniques have been applied to the study of pressures in Hallux Valgus (HV), little is known about its clinical and radiological determinants. So, the aim of the present study was to determine the plantar pressure pattern in participants with mild HV, comparing to a control group, and their clinical and anthropometric determinants. Biofoot/IBV(®) in-shoe system was used to evaluate 79 participants with mild HV. Computerized measurements of the 1st intermetatarsal angle (IMA) and the hallux abductus angle (HAA) were made on antero-posterior radiographs. The clinical outcome was assessed using the AOFAS score. The dependent baropodometric variables and the independent clinical and anthropometric variables were subjected to a multiple regression analysis. In both groups, the highest average pressure was in the 2nd metatarsal head (MTH). The mean pressure under the Hallux was significantly higher in HV group (controls, 146.5±92.5kPa; HV, 328.5±113.2kPa; p<0.001). An 18.6% of average pressure under the 1st MTH was accounted for pain, first ray alignment and total AOFAS score. Variations of the HAA explained 26.8% of the mean Hallux pressure. Women with mild HV present with pathologically increased pressure under the Hallux, which is caused by the altered alignment of the first ray. Pain and clinical result were associated with the pressure under the 1st MTH and the remaining variables were only moderate predictors of dynamic plantar pressures.

[Pedobarographic evaluation of the foot after Keller's procedure for Hallux valgus and Hallux rigidus]

Hallux valgus and hallux rigidus are common foot deformities. One of possible procedures is Keller's surgery. The purpose of this study is to evaluate the use of pedobarography for postoperative evaluation of the foot. Group. We examined 54 patients aged 48 to 82 (average 60.4) after surgical treatment of Hallux valgus (78 feet) or Hallux Rigidus (15 feet). Methods. Retrospective pedobarographic evaluation 1 to 11 years after surgery was performed using PEL-38 system. Clinical results. All patients had markedly increased pressure under the 2nd and 3rd metatarsal heads comparing to other forefoot regions. Only 17% of feet had distal dynamic transverse arch during stance phase of gait. There was severe impairment of function of the great toe in entire group. In 82.7% of feet there was no ground contact of the great toe in dynamic evaluation of the stance phase. Conclusion. Pedobarographic examination has good value in postoperative functional assessment of the foot. It's a valuable addition to physical and radiological examination.

Surgical correction of moderate and severe hallux valgus: proximal metatarsal osteotomy with distal soft-tissue correction and arthrodesis of the metatarsophalangeal joint

Hallux valgus correction by distal soft-tissue release and proximal metatarsal osteotomy is the procedure of choice for most patients with moderate and severe hallux valgus deformity. Complications can be avoided by selecting a procedure that provides adequate correction of the intermetatarsal angle and ensuring proper balancing of the metatarsophalangeal joint though lateral soft-tissue releases and medial joint plication. Arthrodesis should be considered when revision of failed surgery is planned, degenerative joint disease is present, and where the likelihood of failure of a bunion procedure is high (such as in elderly individuals with osteoporosis, severe deformity with significant involvement of the lesser metatarsophalangeal joint, and when spasticity is present). A review of biomechanical data, clinical studies, and surgical techniques is important for successful treatment of moderate and severe hallux valgus deformity.

Validation of a self-report instrument for assessment of hallux valgus

OBJECTIVES

To validate an instrument for self-reported hallux valgus (HV).

METHODS

The self-report instrument consists of five line drawings for each foot depicting a sequential increase in HV angle of 15 degrees developed from a photograph of a normal foot. Participants were asked to select the picture which best represented their left and right feet in turn. Four hundred and fifty-nine subjects completed the self-report instrument: 100 attending a hospital rheumatology clinic and 359 who participated in a community questionnaire study. Three hundred and eighty-four completed it on two occasions (1-2 months apart in 71 subjects and 3-6 months apart in 313) and were assessed once by a blinded observer. Twenty-five subjects were assessed by the blinded observer on two occasions. Validity of the instrument was assessed by the weighted kappa statistic for subject-observer agreement and reliability by the weighted kappa statistics for subject repeatability and observer repeatability. These analyses were repeated for HV dichotomised as present or absent.

RESULTS

For the five-grade HV scale, weighted kappa scores (left and right feet combined) were 0.45 for subject-observer agreement, 0.53 at 1-2 months and 0.51 at 3-6 months for subject repeatability, and 0.82 for observer repeatability. For the dichotomised scale (left and right feet combined), sensitivity was 75% and specificity was 82%: kappa scores were 0.55 for subject-observer agreement, 0.63 at 1-2 months and 0.61 at 3-6 months for subject repeatability and 0.83 for observer repeatability.

CONCLUSIONS

The HV self-report instrument provides a valid and reliable assessment of the presence and severity of HV and appears suitable for use in epidemiological studies.

Decision making in the treatment of hallux valgus

The surgeon must determine the pathologic elements that need correction. Close observation for an increased HV angle, increased IM angle, pronation of the first toe, increased DMAA, enlarged medial eminence, and subluxation of the sesamoids must be performed. While there are a large number of procedures available for the management of HV, no one method sufficiently corrects all HV deformities. The upper limits of deformity correction for each procedure vary with the surgeon and their familiarity with each procedure. Ultimately, the surgeon must attempt to maintain a flexible first MTP joint and preserve the normal weightbearing pattern of the forefoot. Patient education also can be assistive in avoiding aggravating activities and making better choices in shoe wear. Tracings of the weightbearing foot and the shoe can be used to demonstrate to patients the size differences between the natural size and shape of the foot and that of the shoe, both pre- and postoperatively.

Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study

BACKGROUND

Many techniques exist for arthrodesis of the first metatarsophalangeal (MTP) joint, as well as, indications for each method. The purpose of this study was to determine the results of one method using dome-shaped reamers to prepare the joint surfaces and a low-profile dorsal titanium plate for internal fixation. To date, no prospective studies have reported patient outcomes of arthrodesis of the first MTP joint using this technique.

METHODS

Fifty patients (54 feet) had first MTP joint arthrodesis from January, 2004, through January, 2005. All patients were evaluated preoperatively for underlying pathology, pain, function, and radiographic findings. First MTP joint arthrodesis was fixed with a dorsal titanium plate with preset valgus and dorsiflexion after the joint surfaces were prepared with matching male and female dome-shaped power reamers to achieve congruous cancellous bone surfaces. At a minimum of 1-year followup, patients returned for postoperative evaluation. In addition to evaluation of pain, function, and radiographic findings, patients were asked how long they remained off work, how long swelling persisted, and whether the hardware caused symptoms.

RESULTS

Forty-nine of 53 patients returned for followup at an average of 16 months after surgery. American Orthopaedic Foot and Ankle Society (AOFAS) scores improved significantly (z = -6.301, p > 0.01) from an average of 51 points preoperatively (range 24 to 97) to 82 points postoperatively (range 47 to 90). Pain scores at final followup demonstrated a significant improvement (z = -6.154, p > 0.01) from a mean of 6.3 to a mean of less than 1 point on the visual analog pain scale. Time off work averaged 3 weeks, while swelling persisted for an average of 11 weeks. Thirty-five feet in 32 patients (66%) were rated as excellent, 16 feet in 16 patients (30%) were rated as good, and two feet (4%) in one patient were rated as fair, with none reporting a poor result. There were four nonunions (8%), with one being a fibrous union having no progression of deformity. Three of four patients with a nonunion reported a good result subjectively with the fourth reporting a fair result.

CONCLUSIONS

The 96% satisfaction rate in 49 patients indicates that first MTP joint arthrodesis with a low-profile contoured dorsal titanium plate and crossed lag screws after joint preparation with dome-shaped reamers is both reliable and reproducible. The union rate was high (92%), and the revision rate was low (4%).

Scarf osteotomy for hallux valgus deformity: an intermediate followup of clinical and radiographic outcomes

BACKGROUND

The scarf osteotomy is a versatile and reproducible procedure for the correction of moderate to severe hallux valgus deformity (intermetatarsal angle 12 to 20 degrees hallux valgus angle 20 to 46 degrees).

METHODS

We evaluated the results of 27 consecutive scarf osteotomies at an average followup of 16.1 months. Radiographic parameters, foot pressure analysis, and AOFAS scores were analyzed before and after surgery.

RESULTS

Hallux valgus angles improved from 34.5 to 16.9 degrees, intermetatarsal angles improved from 15.4 to 10.1 degrees, AOFAS scores improved from 54.5 to 86.5. There was no change between the preoperative and postoperative relative lengths of the first and second metatarsals, defined as the difference between the first and second metatarsal lengths. The measurement was based on the anteroposterior standing radiographs and measured by a line intersecting the midway point at the diaphyseal-metaphyseal junction of the metatarsal and extending from the most proximal to distal aspects of the bone. The angle of Meary (talo-first metatarsal angle) did not change, except in one patient. Foot pressure analysis showed no evidence of transfer metatarsal lesions. The complication rate was 1.1% including superficial infection and recurrence.

CONCLUSIONS

The scarf osteotomy provides a predictable and effective correction of moderate to severe hallux valgus deformities.

Surgical treatment of mild hallux valgus deformity: the state of practice among academic foot and ankle surgeons

BACKGROUND

The purpose of this study was to determine the operative procedure of choice among academic foot and ankle surgeons practicing in the United States for treatment of mild hallux valgus deformity.

METHODS

A hypothetical patient was created: a 60-year-old woman with a mild hallux valgus deformity (first intermetatarsal angle of 11 degrees and hallux valgus angle of 22 degrees). The patient complained of pain around the bunion, nonoperative treatment had failed, and she desired operative correction. The case was sent to academic foot and ankle surgeons to identify their operative treatment of choice. The overall response rate was 83.7% (128 of 153). To be included in the study group each surgeon had 1) foot and ankle patients comprising 50% or more of their clinical practice and 2) direct responsibility for teaching orthopaedic surgery residents. One hundred and three respondents met the inclusion criteria and formed the study group.

RESULTS

Eighty-seven percent (90 of 103) reported that they would use a distal chevron osteotomy as their primary procedure to correct the mild hallux valgus. Ten percent (10 of 103) reported that they would also add an Akin osteotomy of the proximal phalanx to enhance correction.

CONCLUSIONS

Most respondents chose a distal chevron osteotomy as their primary procedure to correct the mild hallux valgus deformity.

Correction of moderate to severe hallux valgus deformity by a modified chevron shaft osteotomy

BACKGROUND

Hallux valgus is one of the most common foot deformities in women. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use, especially for severe deformities. Proximal osteotomies have long been done for severe deformities; however, diaphyseal osteotomies have gained popularity because of the greater degree of correction and stability obtained.

METHODS

This study retrospectively assessed the radiographic and clinical outcomes in 50 feet (34 patients) that had a modified chevron shaft osteotomy for moderate to severe hallux valgus. Additionally, an Akin medial closing wedge osteotomy of the proximal phalanx was done in most patients. Mean followup was 30 months (minimum 13 months). All patients in the study had either moderate or severe deformities. Patients with mild deformities had correction by other techniques.

RESULTS

There was a mean AOFAS score improvement of 39.6 (44.5 to 84.1) points. The hallux valgus angle and intermetatarsal angle improved a mean of 22.7 degrees and 10.4 degrees, respectively. Hallux valgus persisted in one foot; however, the patient was not dissatisfied. Two feet developed hallux varus. Revision was necessary in two patients; one needed revision because of loss of fixation and the other because of symptomatic hallux varus.

CONCLUSION

Based on radiographic correction and clinical outcomes, this procedure is indicated for the treatment of moderate to severe hallux valgus deformities.

[Methodology of pedobarographic examination--own experiences and review of literature]

The pedobarographic examination is the method that allows estimation of underfoot pressure distribution. The aim of the study was presentation of methodology of pedobarographic examination basing on own experiences and review of the literature. The estimation of underfoot pressure distribution on the basis of pedobarographic examinations is helpful in diagnostics of musculoskeletal system in healthy persons and patients with pathology of lower extremities and vertebral column and allows evaluation of musculoskeletal system biomechanics.

Kindliche Fußfehlformen

During the skeletal development of the axis and foot of the child physiological specialties can occur. Those are thick fatty sole, increased valgus in the ankle joint, tibial varus as a toddler with first varus, later on valgus in the knee, increased laxity of the ligaments, increased anteversion of the femoral neck with "kneeing in" and "toeing in", and with knees first in flexion, later on hyperextension. The knowledge of those specialties is important to be able to diagnose and treat deformities of the foot during childhood. Included are club foot, flexible flatfoot, vertical talus, pes adductus, equinus, cavus foot and talipes calcaneovalgus. If treated at the right time, those disorders of the feet can resolve completely. If an operation can't be avoided, the indication has to be chosen with care.

Kleinzehendeformitäten

Whereas in the past resection arthroplasty was - in analogy to hallux valgus surgery - the preferred therapy to correct lesser toe deformities, the point of view has undergone a change. Much interest is directed toward functional aspects that require reconstructive management. Whenever possible the integrity of joint play should be saved. Above all the metatarsophalangeal joint of the lesser toes is worth being preserved to prevent a severe disturbance of the biomechanics of the foot. Tendon transfers and subtle corrective osteotomies such as the Weil procedure allow restricting resection procedures to contraction deformities.

Druckverteilungsmessung nach Scarf-Osteotomie bei Hallux valgus

AIM

This study evaluates the pressure distribution, the radiological and clinical results in patients before surgery and 6 months after scarf osteotomy for hallux valgus.

METHODS

29 patients were examined before surgery and 6 months after surgery for symptomatic hallux valgus. Pedographic analysis was performed by dividing the footprint of the patients into 8 regions of interest. For each region the maximum mean pressure and the peak pressure were evaluated. Moreover, clinicofunctional results (AOFAS score) and radiological results were evaluated.

RESULTS

6 months postoperatively, maximum mean pressure increased significantly under the medial forefoot where as the peak pressure in this region revealed indifferent results. Significant improvement of clinicofunctional results and a significant reduction of the intermetatarsal and metatarsophalangeal angle could be seen.

CONCLUSION

These results confirm the clinical and radiological findings of other studies, but this study shows for the first time an increase of pressure under the first ray of the foot after hallux valgus surgery and an adaptation to the pressure distribution of normal feet.

Goniometric versus computerized angle measurement in assessing hallux valgus

BACKGROUND

Digital workstations with high-resolution monitors are replacing standard radiographs for image evaluation and interpretation. Radiographic angles in the foot have been evaluated for interobserver and intraobserver reliability with plain films, but use of digital workstations has not been validated. Because the 1-2 intermetatarsal (IM) and hallux valgus (HV) angles help determine the most appropriate bunion procedure, the reliability of these measurements is important.

METHODS

The HV and 1-2 IM angles were evaluated on preoperative radiographs of 25 patients who subsequently underwent bunion procedures. A standardized technique using a film marker and goniometer on plain film was compared with use of a mouse and computerized angle measurement software at a digital workstation. Three foot and ankle surgeons conducted these measurements at various intervals. Completion of three readings of each radiograph in each format by each observer totaled 1,800 measurements.

RESULTS

Computerized measurement gave better overall reliability. For the HV angle, interobserver agreement (measurements within 2 degrees) improved from 66% with plain films to 81% with the digital workstation (p < 0.001). Intraobserver agreement increased from 72% to 80%. The 1-2 IM angle was similarly reliable with both methods for inter- and intraobserver agreement.

CONCLUSIONS

This study validates the use of computer-assisted angle measurement on digital radiographs for assessment of HV and 1-2 IM angles. Computerized measurement may result in more reliable readings because it eliminates the error inherent with use of a goniometer and facilitates adjustment of radiographic lines on the computer to ensure correct alignment.

[Sagittal mobility study on the first tarsometatarsal joint in hallux valgus patients and its clinical values]

OBJECTIVE

To study sagittal mobility about the FTJ (first tarsometatarsal joint) and its relationship with the pathophysiology and treatment of hallux valgus patients.

METHODS

According to Lee's method, FTJ sagittal mobility of 300 normal feet and 200 hallux valgus was measured, and its correlative factors were statistically analysed.

RESULTS

FTJ sagittal mobility of 300 normal feet was 8.4 degrees +/- 2.3 degrees , and that of 200 hallux valgus was 11.7 degrees +/- 3.2 degrees , the difference was significant. The normal range of FTJ sagittal mobility was less than 13 degrees . The sagittal overmotion of FTJ had relation to the anatomical configuration of FTJ (P < 0.05), intercuneiform splitting (P < 0.01), transferred pain under the second metatarsal head (P < 0.01), and FTJ osteoarthritis (P < 0.01) had no relation to HVA (hallux valgus angle), IMA (intermetatarsal angle), second metatarsus medial diaphyseal cortex hypertrophy (P > 0.05).

CONCLUSION

Lee's method is convenient and accurate. Both HVA and IMA can not represent the sagittal mobility measurement of FTJ, which should be routinely evaluated, especially for hallux valgus patients with type I FTJ. Lapidus procedure should be considered for patients with larger FTJ in combination with transferred pain under the second metatarsal head, intercuneiform splitting, FTJ osteoarthritis.

A new mutation of the noggin gene in a French Fibrodysplasia ossificans progressiva (FOP) family

A new mutation of the Noggin gene in a French Fybrodysplasia ossificans progressiva (FOP) family: Fibrodysplasia ossificans progressiva (FOP) is a very rare disease characterized by congenital malformation of the great toes and progressive heterotopic ossification of the muscles. We previously located a FOP gene in the 17q21-22 region and described several mutations of the noggin (NOG) gene (located in 17q22) in four FOP patients, including the G91C mutation which is transmitted dominantly in a Spanish FOP family. We describe in the present study a new mutation of the NOG gene in a French FOP family. This new mutation is a guanine to adenine change at nucleotide 283 (283G --> A) of the NOG gene, and is transmitted in the family (in the heterozygote form) by the affected mother to her two affected children. At the peptide level this mutation (A95T) substitutes an Alanine residue by a Threonine at position 95 of the Noggin protein. The Alanine mutated residue is located just adjacent to the myristoylation site of the protein, where all the mutations we described until now are located.

The influence of personality traits on the subjective outcome of operative hallux valgus correction

We studied prospectively the influence of personality traits on the subjective outcome of a chevron osteotomy in 42 patients with hallux valgus. The mean age of patients was 48.3 (20-70) years. Personality traits were evaluated by the means of the Freiburg Personality Inventory (FPI-R). Three months postoperatively 37 patients were satisfied, and five patients not satisfied with the operative procedure. The preoperative AOFAS Score improved from an average of 48.7 (30-65) points to 87.9 (50-100) points. A comparison of satisfied and dissatisfied patients revealed statistically significant differences in the personality traits aggressiveness (p=0.003), extraversion (p=0.001) and health worries (p=0.04). The postoperative hallux valgus angle was 12.2+/-7.8 degrees and 13.4+/-8.3 degrees (p=0.74) among satisfied and not satisfied patients, respectively, and the intermetatarsal angle (I-II) was 7.4+/-2.5 degrees and 7.6+/-4 degrees (p=0.89), respectively. The results suggest that the patient's subjective result after the operative correction may be influenced by some individual, personality profiles.

Hallux valgus – ein Atavismus?

Als Atavismus versteht man ein rückschlägiges Entwicklungsphenomen, das phenotypisch auftritt. Die Phylogenie lehrt uns heute, dass der erste Strahl in sub-humanen Spezies immer sehr stabil angelegt war. Der prähensile Ur-Fuß erfuhr dann in seinem lateralen Anteil eine progressive Adduktion, Pronation und Extension, zusammen mit einer Valgisation des Kalkaneus mit einer festeren Verankerung an den Talus. Homo sapiens erhielt an der oberen Extremität eine Hand, die sehr beweglich, aber wenig belastbar, an der unteren Extremität hingegen einen Fuß, mit weniger Beweglichkeit aber mehr Belastbarkeit. Trotzdem verblieb am ersten Strahl die Entwicklung einer Bandstruktur, zum zweiten metatarsus aus. Stabilität des ersten Strahls ist somit besonders durch die Muskulatur gewährleistet. Es wurde eine Relation zwischen instabilem, oder hypermobilem erstem Strahl und symptomatischem Hallux valgus gefunden. Zusätzliche Faktoren, die zum schmerzhaften Hallux valgus führen, sind der ägyptische Morphotyp und der funktionelle Spitzfuß. Die Klinik zeigt oft ausgedehnte Vorfußprobleme mit Metatarsus primus varus, Metatarsalgien und Hammerzehen. Die logische Behandlung von der relevanten Hallux valgus Deformität ist die tarso-metatarsale Reorientierungsarthrodese mit oder ohne intermetatarsaler 1–2 Komponente. Osteotomien sind in schweren Fällen unsicherer, besonders langfristig. Atavismus kann man bei der Hallux valgus Deformität verneinen, da die Klinik nicht mit dem archaischen prähensilen Fuß und dessen Entwicklung übereinstimmt. Beim Hallux valgus handelt es sich um eine Deformität an einer schwachen Stelle eines entwicklungsmäßig jungen, hochspezialisierten Organs.