Arthroscopic Sesamoidectomy for Hallux Sesamoid Disorders

Insertional Achilles tendinopathy: A radiographic cross-sectional comparison between symptomatic and asymptomatic heel of 71 patients

Purpose

This retrospective study aimed to investigate whether the standard radiographic indicators for Haglund's syndrome are applicable to insertional Achilles tendinopathy.

Methods

Patients who underwent surgery for insertional Achilles tendinopathy in one heel and experienced no pain in the other heel were enrolled in this study. Preoperative calibrated radiographs of the lateral view of the calcaneus were assessed using (1) calcaneal pitch angle, (2) Fowler-Phillip angle, (3) posterior calcaneal angle, (4) Chauveau-Liet angle, (5) X/Y ratio, (6) Haglund's deformity height, (7) Haglund's deformity peak angle, (8) calcification length, (9) calcification width, (10) parallel pitch test, and (11) presence of free body. The Wilcoxon signed rank test and McNemar's test were used for statistical analyses.

Results

Seventy-one patients (52 males; mean age, 57.2; mean body mass index, 27.1) were included. Mean values for each index in the symptomatic and asymptomatic heels were as follows, respectively: (1) 23.5, 23.0 (p = 0.30); (2) 58.9, 57.8 (p < 0.05); (3) 7.6, 9.2 (p < 0.05); (4) 15.8, 13.9 (p < 0.05); (5) 2.8, 2.8 (p = 0.87); (6) 5.4, 5.0 (p < 0.05); (7) 99.6, 99.0 (p = 0.44); (8) 10.5, 7.6 (p < 0.001); and (9) 5.1, 4.4 (p < 0.05). The sensitivity, specificity, and area under curve of significant indicators were as follows, respectively: (2) 0.78, 0.37, 0.55; (3) 0.45, 0.72, 0.58; (4) 0.63, 0.54, 0.57; (6) 0.45, 0.69, 0.59; (8) 0.48, 0.80, 0.66; and (9) 0.63, 0.54, 0.59. The presence of free body also showed a significant difference between both heels (p < 0.05).

Conclusion

Some radiographic indicators for Haglund's syndrome are applicable to the diagnosis of insertional Achilles tendinopathy. A comparison of the parameters of Haglund's syndrome with those of insertional Achilles tendinopathy may illuminate the etiology and pathology of insertional Achilles tendinopathy and lead to novel treatments.

Foot pain in children and adolescents: a problem-based approach in musculoskeletal ultrasonography

Various etiologies and risk factors contribute to foot pain in children and adolescents, including conditions such as Kohler's disease, Sever's disease, Iselin's disease, rigid flat foot, accessory navicular, Freiberg's disease, sesamoiditis, os trigonum syndrome, and more. High-frequency musculoskeletal ultrasonography can show both the bone surface and the surrounding soft tissue clearly from various angles in real-time, thereby providing a higher level of detail that is helpful for identifying the etiology of foot pain and monitoring disease progression compared with other imaging modalities. This review provides an overview of the epidemiology, pathophysiology, clinical manifestations and characteristic ultrasonographic findings of select foot pain conditions in children and adolescents.

Arthroscopic Sesamoidectomy and Plantar Metatarsal Head Bone Shaving in Management of First Metatarsal Head Metatarsalgia After First Metatarsophalangeal Fusion

First metatarsophalangeal arthrodesis has been used to treat end-stage arthritis of the great toe (e.g., gout, post-traumatic, infection), severe hallux valgus deformity, hallux valgus caused by neuromuscular disorders, rheumatoid forefoot deformity, primary hallux varus, and rigid plantarflexion deformities, as well as a salvage procedure for failed previous operation of the great toe. As with any arthrodesis procedure, proper positioning of the hallux in first metatarsophalangeal arthrodesis is of utmost importance for good clinical outcome. The chief problem tends to be sagittal alignment. In case of the significant dorsiflexion malunion of the fusion site with excessive plantar pressure of the first metatarsophalangeal joint and abutment of the hallux to the shoebox, corrective osteotomy is indicated. If there is isolated excessive plantar pressure of the first metatarsophalangeal joint without hallux problem, arthroscopic sesamoidectomy and bone shaving of the plantar side of the first metatarsal head is another surgical option. The purpose of this technical note is to describe the details of arthroscopic sesamoidectomy and bone shaving of the plantar side of the first metatarsal head.

Fluoroscopic and Endoscopic Calcaneal Exostosis Resection and Achilles Tendon Debridement for Insertional Achilles Tendinopathy: Surgical Techniques

This Technical Note describes the minimally invasive surgical techniques for insertional Achilles tendinopathy: fluoroscopic and endoscopic calcaneal exostosis resection and Achilles tendon debridement. First, two portals are placed 1 cm proximal and distal to the exostosis on the lateral heel. Next, blunt dissection around the exostosis and exostosis resection is performed under fluoroscopic guidance. The remaining space after the exostosis resection is used as the working space for endoscopy. Finally, the degenerated Achilles tendon is debrided endoscopically.

Plantar pressures values related with appearance of mechanical hyperkeratosis before and after surgery of mild hallux valgus

Background

Hyperkeratoses are thickenings of the stratum corneum, provoked by deviation of the ray and excessive plantar pressures. They are very common under the first metatarsal head (MTH) and on the big toe when there exists hallux valgus. The objective of this study was to assess plantar pressures pre- and post-surgery to try to define the threshold values that could determine the appearance of keratopathies.

Materials and methods

Seventy-nine patients (100 feet) who had undergone percutaneous distal soft-tissue release and the Akin procedure were evaluated prospectively. The BioFoot/IBV^® in-shoe system was used for objective baropodometric functional evaluations of the heel, midfoot, first through fifth MTHs, hallux, and lesser toes. The presence or absence of a hyperkeratosis (HK) or plantar callus under the first MTH or hallux was recorded. The average follow-up time at which the measurements were repeated was 28.1 months.

Results

Pre-surgery, 62 feet presented a painful HK on the big toe, while post-surgery, only 9 of the feet presented the same lesion. Patients who presented a prior HK at the first metatarsophalangeal (MTP) joint had a mean pressure of 417.2 ± 254.5 kPa as against a value of 359.6 ± 185.1 kPa for the rest. Post-surgery, these values dropped to 409.8 and 346.3 kPa, respectively.

Conclusion

Patients with HK presented an 11% greater mean pressure than those without. The values obtained with the BioFoot/IBV^® system in the present study can therefore be considered predictive of the appearance of HK under the first MTH and on the side of the big toe.

Sliding Oblique Metatarsal Osteotomy Fixated With K-Wires Without Cheilectomy for All Grades of Hallux Rigidus: A Case Series of 76 Patients

Background

Studies on decompression metatarsal osteotomy without cheilectomy for hallux rigidus are limited. This study aimed to review the data of patients who underwent this surgery for all grades of hallux rigidus.

Methods

The medical records of patients who underwent this surgery between August 2017 and January 2021 were retrospectively reviewed. The outcomes were assessed using the visual analog scale (VAS), the Japanese Society for Surgery of the Foot (JSSF) score, and the hallux dorsiflexion angle. Patients who were followed up for more than 2 years were included. The plantar shift of the first metatarsal head (PS) and the shortening of the first metatarsal (SH) were measured to supplementally investigate the associations with other measurements.

Results

A total of 76 patients (female, 42; male, 34; mean age, 60.3 years; mean body mass index, 23.1) with 80 feet were enrolled. Six patients (7.5%) were grade 1, 20 (25.0%) were grade 2, 30 (37.5%) were grade 3, and 24 (30.0%) were grade 4. The mean follow-up duration was 3.5 years. Overall, the mean VAS score improved from 63.2 to 6.2, the mean JSSF score from 59.0 to 82.6, and the mean dorsiflexion angle from 37.3 to 56.3 degrees. These measures improved for all grades, but the dorsiflexion angles and JSSF scores decreased as the grade advanced. No clear associations were found between the postoperative VAS and the PS and SH. Eight patients (10.5%) had complications: 4 (5.2%) had occasional plantar discomfort under the metatarsal head, 2 (2.6%) required shoe modification, 1 (1.3%) had wound pain, and 1 (1.3%) experienced breakage of a K-wire.

Conclusion

The VAS scores, dorsiflexion angles, and JSSF scores improved for all grades of hallux rigidus within a relatively short period of follow-up; however, the dorsiflexion angles and JSSF scores decreased as the grade advanced.

Level of Evidence

Level IV, retrospective case series.

Endoscopic Plantar Fascia Release Combined With Calcaneal Spur Resection: A Case Series of 40 Patients

PURPOSE

To review the cases of patients treated using endoscopic plantar fascia release (PFR) with calcaneal spur resection (CSR) and examine why the combined procedures cause complications.

METHODS

The medical records of patients treated with endoscopic PFR with CSR from November 2017 to December 2019 with a follow-up of >2 years were reviewed.

RESULTS

A total of 40 feet in 40 patients (22 females, 18 males) were enrolled. The mean age and body mass index were 51.1 years and 24.7 kg/m2, respectively. The mean follow-up duration was 5.7 years. The visual analog scale for pain improved from 80.7 to 8.8 mm, and the Japanese Society for Surgery of the Foot score improved from 44.7 to 95.6 points (Wilcoxon signed rank test, P < .001 for both). Complications occurred in 8 patients (20%): 3 had flatfoot, 3 had an injury to the first branch of the lateral plantar nerve, 1 had scar pain, and 1 had a wound infection.

CONCLUSION

The 40 patients treated with endoscopic PFR with CSR for plantar fasciitis had good outcomes with a high complication rate; the invasiveness of creating the working space for the combined procedures was thought to be responsible.

LEVELS OF EVIDENCE

Level IV: Case series.

Arthroscopic Autologous Bone Grafting for Hallux Sesamoid Fracture Nonunion Results in a High Rate of Complete Resolution

Purpose

To review the outcomes of patients with hallux sesamoid fracture nonunion who underwent arthroscopic autologous bone grafting.

Methods

Medical records of patients who underwent surgery between July 2017 and April 2020 were reviewed. The inclusion criterion was 2 years or more of follow-up. The exclusion criterion was less than 2 years of follow-up. Outcomes were assessed using the visual analog scale (VAS) for pain and the Japanese Society for Surgery of the Foot (JSSF) score. Improvements after surgery were analyzed using the Wilcoxon signed-rank test.

Results

Eleven patients (3 women and 8 men) were enrolled. The mean age was 18.6 years (standard deviation [SD] ± 10.3 years), and the mean body mass index was 21.9 kg/m² (SD ± 2.5 kg/m²). The mean follow-up duration was 3.2 years (SD ± 0.8 years). One patient had fracture nonunion in the fibular sesamoid and a hypoplastic tibial sesamoid. Another patient had fracture nonunion in the distal part of the congenital bipartite sesamoid. The other patients had fracture nonunion in the normal tibial sesamoids. The mean duration until bone union was 2.9 months (SD ± 0.8 months). The mean duration until returning to sports was 5.3 months (SD ± 3.6 months). The VAS score improved from 72.1 (SD ± 15.2) preoperatively to 12.0 (SD ± 26.7) postoperatively. The JSSF score improved from 58.7 (SD ± 15.8) preoperatively to 95.0 (SD ± 11.0) postoperatively (P < 0.01, respectively). All patients except the two previously described achieved a VAS score of 0 and a JSSF score of 100 postoperatively. The remaining 2 patients with congenitally distinct sesamoids and fractures had poor outcomes. No complications were observed.

Conclusions

Nine of the 11 patients reported complete resolution. The remaining two patients with congenitally distinct sesamoids and fractures had poor outcomes.

Fluoroscopic and Endoscopic Calcaneal Exostosis Resection and Achilles Tendon Debridement for Insertional Achilles Tendinopathy Results in Good Outcomes, Early Return to Sports Activities, and Few Wound Complications

Purpose

To review the outcomes of patients with insertional Achilles tendinopathy who underwent a minimally invasive surgery: fluoroscopic and endoscopic calcaneal exostosis resection and Achilles tendon debridement.

Methods

The medical records of consecutive patients who underwent this surgery from February 2017 to July 2019 were reviewed. The inclusion criterion was ≥2-year follow-up. The exclusion criterion was another surgery performed on the ipsilateral or contralateral foot. Haglund deformity resection was not combined with this surgery. The outcomes were assessed using the visual analog scale (VAS) score and the Japanese Society for Surgery of the Foot (JSSF) scores for all patients and the Victorian Institute of Sport Assessment self-administered Achilles (VISA-A) scores for patients participating in sports activities. The Wilcoxon signed-rank test and the thresholds of minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were used for statistical analyses.

Results

Forty-four patients with a mean age of 55.7 ± 11.0 years and mean body mass index of 26.0 ± 4.0 kg/m² were included. The mean follow-up duration was 2.8 ± 0.7 years. Of all participants, 22 participated in sports activities. The overall median VAS and JSSF scores improved from 64.5 to 6.5 mm and from 67.0 to 100 points, respectively (P < .001). The percentages of patients who achieved the MCID for the VAS, JSSF, and VISA-A scores were 100%, 93.2%, and 100%, respectively, and the percentages of patients who achieved the PASS for the VAS, JSSF, and VISA-A scores were 77.3%, 86.4%, and 81.8%, respectively. The median VISA-A scores improved from 40.5 to 95.0 points (P < .001). The median time to return to sport was 4.5 months. Complications included five cases of reoperation and two cases of scar sensitivity.

Conclusion

For patients with insertional Achilles tendinopathy, fluoroscopic and endoscopic calcaneal exostosis resection and Achilles tendon debridement resulted in good outcomes, early return to sports activities, and few wound complications.

Level of Evidence

IV, therapeutic case series

Fluoroscopic and Endoscopic Calcaneal Spur Resection Without Plantar Fascial Release for Recalcitrant Plantar Fasciitis

Background

Studies on endoscopic calcaneal spur resection (CSR) without plantar fascial release (PFR) are limited. This study aimed to review the data of patients who underwent fluoroscopic and endoscopic CSR without PFR for plantar fasciitis with a calcaneal spur to assess the effectiveness of CSR.

Methods

Medical records of consecutive patients with plantar fasciitis with ≥2 mm calcaneal spur who underwent endoscopic CSR without PFR from November 2017 to December 2019 were reviewed. Patients with ≥2 years of follow-up were included, whereas those who underwent another surgery on the operated foot were excluded. Age, body mass index (BMI), follow-up duration, calcaneal spur length, duration to full weightbearing postoperatively, Japanese Society for Surgery of the Foot (JSSF) score, visual analog scale (VAS) score for pain, and complications were assessed.

Results

The mean follow-up duration was 2.7 years. A total of 47 patients (31 female, 16 male; mean age, 56.4 years; mean BMI, 25.5) were included. The mean calcaneal spur length was 5.7 mm. The VAS score improved from 79.6 ± 12.9 mm preoperatively to 5.3 ± 7.3 mm postoperatively. The JSSF score improved from 54.0 ± 19.1 points preoperatively to 97.5 ± 5.7 points postoperatively (Wilcoxon signed-rank test, P < .001, respectively). The mean duration to full weightbearing postoperatively was 4.4 ± 4.2 days. Two patients presented with tenderness, and one presented with hypesthesia at the portal site.

Conclusion

Endoscopic CSR without PFR resulted in good outcomes, early return to full weightbearing, and few complications in patients with plantar fasciitis with ≥2 mm calcaneal spur. The results suggested that CSR was sufficient to relieve symtoms and improve function. PFR may not be necessary for treating plantar fasciitis with calcaneal spur.

Level of Evidence

Level IV, retrospective case series.