Medium-Long-Term Clinical and Radiographic Outcomes of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) for Central Primary Metatarsalgia: Do Maestro Criteria Have a Predictive Value in the Preoperative Planning for This Percutaneous Technique?

Differences and Similarities in the Feet of Metatarsalgia Patients with and without Rheumatoid Arthritis in Remission

Objectives: Metatarsalgia continues to be a problem in patients with rheumatoid arthritis (RA) in remission (remRA), as well as in the non-rheumatic population, with a mechanical origin. Identify and compare clinical, morphological, disability, synovitis (ultrasound), and radiological osteoarticular damage characteristics in two groups of patients with lesser-ray metar-tarsalgia, with remRA, and without RA. Methods: Cross-sectional study with 84 patients with remRA (mRA) and 60 patients without RA (nmRA). The study evaluated five clinical variables (pain, Foot Function Index (FFI), joint mobility, digital deformities, and foot type), a radiological variable (osteoarticular damage), and an ultrasound variable (metatarsal synovitis). The data were analysed using descriptive and correlational techniques. Results: There were no significant differences in sex, age, body mass index (BMI), or degree of pain. Both groups showed a high prevalence of limited joint mobility for the ankle and first metatarsal phalanx (DF1st MTPJ) and digital deformities, with no statistically significant differences. Similarly, there were no differences in lesser-ray synovitis. On the other hand, there were differences in mRA with greater disability and activity limitation (FFI), LDD (lesser-ray digital deformities) stiffness, first-ray deformities, radiological damage, synovitis in 1st MTPJ, and positive Doppler (five patients). Conclusions: Metatarsalgia presents similarities in both populations. Biomechanical factors may influence the symptoms and presence of synovitis in patients with RA in remission. Other characteristics are more frequent in mRA, which could be related to the disease; thus, future research should include both biomechanical and ultrasound exploration of the foot in the valuation of patients in remission.

Impact of Minimally Invasive Intra-Capsular Metatarsal Osteotomy on Plantar Pressure Decrease: A Cross-Sectional Study

Background: Metatarsalgia is a common pathology that is initially treated conservatively, but failure to do so requires surgery, such as the minimally invasive distal metatarsal osteotomy (DICMO). Methods: In this prospective study of 65 patients with primary metatarsalgia who underwent DICMO, plantar pressures, American Orthopaedic Foot and Ankle Society MetaTarsoPhalangeal-InterPhalangeal scale (AOFAS-MTP-IP) and Visual Analog Scale (VAS) were evaluated pre-operatively and post-operatively and there was a subgroup in which an inclinometer was used to observe the importance of the inclination of the osteotomy. Results: The results show a significant reduction in plantar pressures after DICMO surgery without overloading the adjacent radii, especially in the subgroup with an inclinometer to guide the osteotomy. The AOFAS-MTP-IP scale evidenced a marked improvement in metatarsal function and alignment with scores close to normal. The VAS scale showed a substantial decrease in pain after DICMO osteotomy. Conclusions: DICMO, with an inclinometer for a 45° osteotomy, proved to be a safe and effective procedure for primary metatarsalgia, although further comparative studies are needed to confirm its superiority.

Radiographic Evidence of Sufficient Transverse Plane Alignment after Weil Osteotomy without Screw Fixation

Weil osteotomy is a proven procedure to restore the harmonic distal parabola of the forefoot. In addition to the proximal displacement of the head in the sagittal plane, a displacement in the transverse plane may be necessary, with the refixation of the displaced metatarsal head historically performed by screw fixation. We aimed to determine the radiological differences among 136 feet of 127 patients with 256 Weil osteotomies retrospectively enrolled and divided into groups with (n = 182) and without (n = 74) screw fixation. Demographic data, radiographic union, pre- and postoperative metatarsal angles, and differences in the dorsoplantar view were evaluated. The mean follow-up period was 3.6 months. The mean preoperative metatarsophalangeal angle was 9.24°, and the mean postoperative angle was 12.99°. The restoration of the transversal alignment plane was equally successful in both groups, with a mean extent of angle correction of 10.58°. No nonunions of the osteotomized metatarsals were observed. The radiographic comparisons revealed no significant difference between the groups (p > 0.05). However, visibility of the joint space of the metatarsophalangeal joint was achieved significantly more often in the group without screw fixation (p < 0.05). In the absence of bony malunion and the satisfactory restoration of a harmonious parabola of the forefoot, apparently there does not appear to be a necessity for regular screw fixation after Weil osteotomy based on the available data from the present study.

The Controversial Definition of Normal Toe Alignment

"Normal" and "abnormal" are frequently used in surgical planning and to evaluate surgical results of the forefoot. However, there is no objectifiable value of metatarsophalangeal angles (MTPAs) 2-5 in the dorsoplantar (DP) view with which to objectively evaluate lesser toe alignment. We aimed to determine which angles are considered to be "normal" by orthopedic surgeons and radiologists. Thirty anonymized radiographs of feet were submitted twice in randomized order to determine the respective MTPAs 2-5. After six weeks, the anonymized radiographs and photographs of the same feet without apparent affiliation were presented again. The terms "normal," "borderline normal," and "abnormal" were assigned by the observers. Viewers considered MTP-2 alignment from 0° to -20° to be normal, and below -30° abnormal; MTP-3, 0° to -15° to be normal and below -30° abnormal; MTP-4, 0° to -10° normal and below -20° abnormal. Between 5° valgus and 15° varus was the range of MTP-5 recognized as normal. High intra-observer but low interobserver reliability with overall low correlation of clinical and radiographic aspects was observed. The assessment of the terms "normal" or "abnormal" are subject to a high degree of variation. Therefore, these terms should be used cautiously.

Percutaneus intermetatarsal ligament release and minimally invasive distal metatarsal osteotomy for treatment second intermetatarsal space syndrome

BACKGROUND AND OBJECTIVE

Since the description of the syndrome of the second intermetatarsal space, this is a common diagnosis among foot and ankle surgeons. However, no series have been published that consider this syndrome as its own entity. The objective of this study is to evaluate the clinical and radiological results of the release of the intermetatarsal ligament and minimally invasive distal metatarsal osteotomy in patients diagnosed with second space syndrome.

MATERIALS AND METHODS

An observational, longitudinal, retrospective study was carried out in patients with a clinical diagnosis of second space syndrome operated on using a minimally invasive technique. For the clinical results, the visual analog scale (VAS) for subjective pain, the Manchester-Oxford Foot Questionnaire (MOXFQ) and the scale for minor metatarsals and interphalangeals of the American Orthopedic Foot and Ankle Society (AOFAS-LMTS) were used for clinical-functional assessment. Consolidation or not of osteotomies was recorded and complications were recorded.

RESULTS

Twenty-nine feet in 29 patients were included in the study. After a mean follow-up of 39 months (25-50), clinically and statistically significant improvement was obtained in the scores: pain VAS, scales and subscales of the MOXFQ and the AOFAS-LMTS (p < 0.0001). All osteotomies healed at the end of follow-up and no major complications were recorded.

CONCLUSIONS

Percutaneous or minimally invasive surgery, in patients with second intermetatarsal space syndrome, obtains good clinical, functional and subjective results, with few complications. Therefore, we consider it an effective, safe and recommended technique in the hands of experienced surgeons.

Establishment and Validation of a Predictive Nomogram for Hallux Valgus with Pain Under the Second Metatarsal

Objective

To investigate the risk factors for hallux valgus complicated with pain under the second metatarsal and construct an effective model and method for predicting hallux valgus complicated with pain under the second metatarsal based on risk factors.

Methods

A total of 545 patients with hallux valgus who were admitted to our hospital were divided randomly into a training set and a validation set. The demographic characteristics, imaging indices and gait test indices of the patients were collected. The risk factors were identified by univariate and multivariate logistic regression analyses. A risk prediction model for hallux valgus with pain under the second metatarsal was established, and the area under the curve (AUC) of the receiver operating characteristic and a decision curve analysis were used for verification and identification. The value of the model was tested in the verification group.

Results

Second metatarsal length, second metatarsal peak pressure, hallux valgus angle (HVA), intermetatarsal angle 1–2 (IMA1–2) and weight were the risk factors for hallux valgus complicated with pain under the second metatarsal. Based on the weighting of these seven risk factors, a prediction model was established. The AUC of the prediction model was 0.84 (95% confidence interval [CI]: 0.802~0.898, P < 0.05), and the results of a Hosmer–Lemeshow test showed a good degree of calibration (χ² = 10.62, P > 0.05). The internal validation of the AUC was 0.83 (95% CI: 0.737–0.885, P < 0.05). The model had obvious net benefits when the threshold probability was 10%–70%.

Conclusion

Second metatarsal length, second metatarsal peak pressure, HVA, IMA1–2 and weight were the risk factors for hallux valgus combined with second metatarsal pain. The risk prediction model for hallux valgus complicated with pain under the second metatarsal based on these seven variables was proven effective.

Level of Evidence

Level III, retrospective comparative study.

Symptomatic Bunionette Treated with Sliding Oblique Metatarsal Osteotomy-Case Series

Background: The purpose of this study is to investigate the clinical and radiological results of a sliding oblique metatarsal osteotomy (SOMO) to correct bunionette deformity. Methods: We retrospectively reviewed 44 patients (51 feet, left/right: 29/22) from December 2010 to December 2018 who underwent SOMO and compared radiographic measurements and clinical outcome scores preoperatively and postoperatively. Radiographic measurements included 4th and 5th intermetatarsal angle (IMA), metatarsophalangeal angle (MTPA), and lateral deviation angle (LDA). Clinical outcome measurements included The American Orthopedic Foot and Ankle Society (AOFAS) score for lesser metatarsophalangeal procedures and visual analog scale (VAS) pain score. The mean follow-up period was 26.6 months (minimum 18 months). Based on Coughlin and Fallat classification, all cases were separated into four subtypes: 6 type I, 10 type II, 12 type III, 23 type IV cases included.) Results: All radiographic parameters significantly improved after SOMO procedure (IMA/MTPA/LDA, p value < 0.001). Clinical scores also showed a significant improvement in AOFAS and VAS scores (p value < 0.001). In terms of subgroup based on each type, both radiographic measurements and clinical scores revealed significant improvements in each subgroup (p value < 0.05), except LDA of type I subgroup (p value = 0.09). Three cases reported pin-tract infection but recovered with good healing after removal of the K-wire and a prescription of oral antibiotic. Conclusion: The SOMO procedure may be considered as a reliable and simple treatment for most types of bunionette deformity with satisfactory outcomes and no severe complications. Level of Evidence: Level IV, case series.

The use of abaloparatide to treat nonunion following dorsal closing wedge osteotomy for Freiberg's disease: A case report

A middle-aged woman who was previously a long-distance trail runner presented with chronic right forefoot pain and was diagnosed with Freiberg's disease. She suffered from nonunion after undergoing a dorsal closing wedge osteotomy. The nonunion achieved full osseous union after treatment with abaloparatide. Patient reported outcome measures taken at 19 months postoperatively indicated good to excellent clinical outcomes and satisfaction. The aim of this case is to report on the effectiveness of abaloparatide to treat nonunion and support fracture healing.

Influence of Foot Type on the Clinical Outcome of Minimally Invasive Surgery for Metatarsalgia. A Prospective Pilot Study

Background and aims: Surgical procedures for central metatarsalgia seek to harmonise the metatarsal parabola with osteotomies that can be performed by minimally invasive techniques. However, the possible relationship of the foot type and the mid-term postoperative outcome is poorly described. The objective of this prospective pilot study was therefore to determine whether the foot type (pronate, neutral, or supinate) conditions the postoperative mid-term functional outcome.

Methods: A series of 28 patients (6 men, 22 women) were treated for primary central metatarsalgia by means of minimally invasive distal metaphyseal osteotomy (DMMO).

Results: Their functional outcomes at 6 and 12 months were assessed by the self-reporting AOFAS scale. Pre-surgery, the patients' scores were 42.82 ± 15.60. Scores improved at 6 months to 86.50 ± 8.6 and to 92.93 ± 8.6 at 12 months (p < 0.001 in both cases). There were no differences either by sex or by foot type in these overall values, although there was only a slight limitation of interphalangeal mobility in the supinated feet (p = 0.03) at 6-month follow-up as compared to other foot types.

Conclusion: Hence, DMMO provides an optimal clinical and functional outcome for the surgical treatment of metatarsalgia, regardless of the patient's foot posture. The occurrence of adverse events was minimal and clinically irrelevant.

Trial registration: The study was authorised by the Research Ethics Committee of the Universidad Católica de Valencia San Vicente Mártir, with the registry UCV/2018-2019/019.

A Novel Radiographic Measurement Method for the Evaluation of Metatarsophalangeal Joint Dislocation of the Lesser Toe in Patients with Rheumatoid Arthritis

Dorsal dislocation of metatarsophalangeal (MTP) joints of the lesser toe frequently occurs in patients with rheumatoid arthritis (RA), and may cause painful and uncomfortable plantar callosities and ulceration. The current study examined the reliability and clinical relevance of a novel radiographic parameter (the MTP overlap distance [MOD]) in evaluating the severity of MTP joint dislocation. The subjects of the current study were 147 RA patients (276 feet; 1104 toes). MOD, defined as the overlap distance of the metatarsal head and the proximal end of the phalanx, was measured on plain radiographs. The relationship between the MOD and clinical complaints (forefoot pain and/or callosity formation) was analyzed to create a severity grading system. As a result, toes with callosities had a significantly larger MOD. ROC analysis revealed that the MOD had a high AUC for predicting an asymptomatic foot (−0.70) and callosities (0.89). MOD grades were defined as follows: grade 1, 0 ≤ MOD < 5 mm; grade 2, 5 ≤ MOD < 10 mm; and grade 3, MOD ≥ 10 mm. The intra- and inter-observer reliability of the MOD grade had high reproducibility. Furthermore, the MOD and MOD grade improved significantly after joint-preserving surgeries for lesser toe deformities. Our results suggest that MOD and MOD grade might be useful tools for the evaluation of deformities of the lesser toe and the effect of surgical intervention for MTP joints in patients with RA.

Lateralising DMMO (MIS) for simultaneous correction of a pes adductus during surgical treatment of a hallux valgus

The surgical correction of a hallux valgus deformity presenting with a pes adductus has long proven to be a difficult undertaking. The medial shift of the metatarsal bones limits the scope for surgical correction and leads to inherently high reoccurrence rates. Current invasive treatments often give rise to profound soft tissue trauma and prolonged swelling, while requiring strict relief from weight-bearing in the affected foot. In this paper, it is aimed to introduce an easy and useful modification of the Distal Metatarsal Minimal-invasive Osteotomy (DMMO) to perform the effective, simultaneous correction of a pes adductus during surgical treatment of a hallux valgus. We followed-up 143 patients with a hallux valgus and simultaneous pes adductus deformity who underwent one of three additional interventions contemporaneous to the lateralising DMMO: The assessment of radiological and clinical outcomes after a follow-up period of 12-25 months showed a sustained and effective correction of the pes adductus with a well-aligned hallux. The surgery was characterised by a low incidence of postoperative complications and high patient satisfaction while allowing for pain-adapted, post-operative weight-bearing. Level of Clinical Evidence: 3.

Treatment of an Intractable Forefoot Ulcer Using Realignment Osteotomy in a Patient with Rheumatoid Arthritis

Forefoot deformities are common among patients with rheumatoid arthritis (RA). Herein, we describe a case of intractable ulceration on the dorsomedial aspect of the right 5^th digit, secondary to forefoot deformity, in a 76-year-old woman with a 35-year history of RA. The ulcer was due to a persistent subcutaneous infection. Although the infection was controllable with antibiotics, there was concern of relapse because of the abnormal pressure on the skin due to an overlap of the 4^th and 5^th digits. We proceeded with surgical correction of the forefoot alignment, including shortening oblique osteotomy of metatarsals 2 through 5, rather than amputation of the 5^th digit. Following surgery, targeted antibiotic treatment was provided. The postoperative course was unremarkable, and the patient recovered weight-bearing function without recurrence of pain or ulceration. Forefoot realignment is a feasible option that should be considered for treating intractable foot pain and ulceration secondary to long-lasting RA.