Imaging of Müller-Weiss Disease

Müller-Weiss disease (MWD) is the result of a dysplasia of the tarsal navicular bone. Over the adult years, the dysplastic bone leads to the development of an asymmetric talonavicular arthritis with the talar head shifting laterally and plantarly, thus driving the subtalar joint into varus. From a diagnostic point of view, the condition may be difficult to differentiate from an avascular necrosis or even a stress fracture of the navicular, but fragmentation is the result of a mechanical impairment rather than a biological dysfunction.Standardized weight-bearing radiographs (anteroposterior and lateral views) of both feet are usually enough to diagnose MWD. Other imaging modalities such as multi-detector computed tomography and magnetic resonance imaging in early cases for the differential diagnosis can add additional details on the amount of cartilage affected, bone stock, fragmentation, and associated soft tissue injuries. Failure to identify patients with paradoxical flatfeet varus may lead to an incorrect diagnosis and management. Conservative treatment with the use of rigid insoles is effective in most patients. A calcaneal osteotomy seems to be a satisfactory treatment for patients who fail to respond to conservative measures and a good alternative to the different types of peri-navicular fusions. Weight-bearing radiographs are also useful to identify postoperative changes.

Mechanical Basis of Metatarsalgia

The 3-rocker mechanism of gait provides a framework to understand why patients have mechanical metatarsal pain and to differentiate between the various types of metatarsalgia. Clinical examination of the patient together with radiological findings allows identification of the type of metatarsalgia and the pathomechanics involved, and the planning of surgical treatment. Second-rocker/nonpropulsive metatarsalgia is related with an abnormal inclination of a metatarsal in the sagittal plane, either anatomic or functional (equinism). Third-rocker/propulsive metatarsalgia is related to an abnormal length of a certain metatarsal with respect to the neighboring metatarsals in the transverse plane.

Evolution of the Weil Osteotomy: The Triple Osteotomy

Weil osteotomy (WO) is the most common technique worldwide for the treatment of mechanical metatarsalgia. The main indication for WO is propulsive/third rocker metatarsalgia that is in relation with an abnormal length of a certain metatarsal with respect to the neighboring metatarsals in the frontal plane. Most clinical studies have showed good to excellent results after WO. However, complications such as floating toes led to evolution of WO and the development of the triple-cut WO that allows for shortening coaxial to the shaft without plantar translation of metatarsal head. Other variations of WO may treat other forefoot disorders.

Management of Müller-Weiss Disease

Müller-Weiss disease (MWD) is a dysplasia of the tarsal navicular. The shifting of the talar head laterally over the calcaneus drives the subtalar joint into varus. Failure to identify patients with paradoxic flatfoot varus may lead to the incorrect diagnosis and management. Conservative treatment with the use of rigid insoles with medial arch support and a lateral heel wedge is effective in most patients. Dwyer calcaneal osteotomy combined with lateral displacement seems to be a satisfactory treatment for patients who had failed to respond to conservative measures and a good alternative to the different types of perinavicular fusions.

Efficacy of Calcaneus Osteotomy for Treatment of Symptomatic Müller-Weiss Disease

BACKGROUND

Various methods of midfoot and hindfoot arthrodesis for treating symptomatic Müller-Weiss disease (MWD) have been reported in the literature. In this study, we present the results of a previously unreported method of treatment using a calcaneal osteotomy incorporating a wedge and lateral translation.

METHODS

Thirteen patients (14 feet) with MWD were treated with a calcaneal osteotomy and retrospectively reviewed. These included 7 females and 6 males, with an average age of 56 years (33-79 years), and an average symptoms duration of 10.6 years (1-16 years). The disease was staged according to Maceira, which included 5 feet in stage II, 4 feet in stage III, 4 feet in stage IV, and 1 foot in stage V. Pre- and postoperative visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS), radiologic examination, and patients' satisfaction rate of the surgery were evaluated at an average of 3.7 years (range, 1-8.5 years) following surgery.

RESULTS

The final follow-up visit showed satisfactory outcomes, with VAS score reducing from the preoperative 8 (7-9) to postoperative 2 (0-4), whereas the AOFAS score improved from the preoperative 29 (20-44) to the postoperative 79 (70-88). The patient's subjective ratings showed excellent results in 4 feet, good results in 8 feet, and fair outcomes in 2 feet. The hindfoot range of motion remained unchanged, as did the extent of the navicular complex arthritis, and no patient required an arthrodesis since surgery.

CONCLUSION

A calcaneal osteotomy can be used as an alternative treatment option for selected MWD patients regardless of the radiologic stage of the disease.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Foot and ankle tendoscopies: current concepts review

Tendoscopy is an apparently safe and reliable procedure to manage some foot and ankle disorders.The most common foot and ankle tendoscopies are: Achilles; peroneal; and posterior tibial tendon.Tendoscopy may be used as an adjacent procedure to other techniques.Caution is recommended to avoid neurovascular injuries.Predominantly level IV and V studies are found in the literature, with no level I studies still available.There are many promising and evolving endoscopic techniques for tendinopathies around the foot and ankle, but studies of higher levels of evidence are needed to strongly recommend these procedures. Cite this article: EFORT Open Rev 2016;1:440-447. DOI: 10.1302/2058-5241.160028.

The Use of Calcaneus Osteotomy for Treatment of Symptomatic Muller Weiss Disease

Category:

Hindfoot

Introduction/Purpose:

Muller Weiss disease (MWD) is characterized by lateral navicular necrosis which is associated with a varus alignment of the subtalar joint, a short 1st metatarsal, varying degrees of arthritis of the talonavicular-cuneiform joints and a paradoxical flatfoot deformity in advanced cases. The literature is replete with various methods of arthrodesis of the hindfoot for treatment of refractory painful deformity. We present the results of a unique, previously unreported, method of treatment using a calcaneus osteotomy incorporating a wedge and lateral translation.

Methods:

Fourteen patients with MWD who were treated with a calcaneus osteotomy were retrospectively reviewed. There were seven females and seven males with an average age of 56 years (range 33-79). Using Maceira’s grading we found the following: one grade 5, five grade 4, four grade 3 and four grade 2 patients. Patients had been symptomatic for an average of eleven years (range 1-14), and all underwent initial conservative treatment with an orthotic support that posted the heel into valgus. The primary indication for surgery was a limited but positive response to the use of the orthotic support, and a desire to avoid an arthrodesis of the hindfoot. Other than the described calcaneus osteotomy, no additional procedures were performed.

Results:

Patients were followed for an average of three years following the procedure (range 1 – 7 years). Patients rated their pain on a visual analogue pain scale as an average of 8 (range 6-9) prior to surgery and an average of 2 postoperatively (range 0-4). The AOFAS scores improved from a mean of 29 (range 25 – 35) preoperatively to a mean of 79 (range 75-88) postoperatively. Hindfoot range of motion remained unchanged, so too the extent of arthritis of the navicular complex. One patient experienced ipsilateral knee pain for 6 months postoperatively which resolved following physical therapy. One patient experienced intermittent midfoot pain and felt that the surgery was not successful. No patient has since required an arthrodesis.

Conclusion:

While the traditional treatment of Muller Weiss disease has been various types of hindfoot arthrodesis, it has been our experience that these procedures are not ideal unless the heel varus is simultaneously corrected. Since the majority of MWD patients respond to an orthotic support which changes the load of the hindfoot and forefoot, we believed that selected patients would respond positively to a calcaneal osteotomy as an alternative treatment. Although the follow up in this series is relatively short, the patients responded remarkably well to the use of a calcaneus osteotomy, however we cannot predict if an arthrodesis will be necessary in the future.

Subtalar anatomy and mechanics

Understanding subtalar joint biomechanics and pathomechanics provides a framework for understanding both common pathologic hindfoot and forefoot conditions and surgical planning. It is important to identify mechanical impairment and to define what mechanical effect is needed to change a pathologic condition. It is also important to know what the initial problem is and what the consequences are in terms of soft tissue or bony stress leading to peritalar injury. Whenever possible, one should try to operate to change pathomechanics and facilitate spontaneous repair of stressed structures.

Posterior tibial tendoscopy

The posterior tibial tendon (PTT) helps the triceps surae to work more efficiently during ambulation. Disorders of the PTT include tenosynovitis, acute rupture, degenerative tears, dislocation, instability, enthesopathies, and chronic tendinopathy with dysfunction and flat foot deformity. Open surgery of the PTT has been the conventional approach to deal with these disorders. However, tendoscopy has become a useful technique to diagnose and treat PTT disorders. This article focuses on PTT tendoscopy and tries to provide an understanding of the pathomechanics of the tendon, indications for surgery, surgical technique, advantages, complications, and limitations of this procedure.

Functional hallux rigidus and the Achilles-calcaneus-plantar system

Functional hallux rigidus is a clinical condition in which the mobility of the first metatarsophalangeal joint is normal under non-weight-bearing conditions, but its dorsiflexion is blocked when first metatarsal is made to support weight. In mechanical terms, functional hallux rigidus implies a pattern of interfacial contact through rolling, whereas in a normal joint contact by gliding is established. Patients with functional hallux rigidus should only be operated on if the pain or disability makes it necessary. Gastrocnemius release is a beneficial procedure in most patients.

Transfer metatarsalgia post hallux valgus surgery

Metatarsalgia, pain around the metatarsophalangeal joints, may arise from mechanical causes spontaneously or iatrogenically. Nonunion or malunion of the first metatarsal can transfer weight-bearing forces and overload the lesser metatarsals. Transfer metatarsalgia after failed hallux valgus surgery is troublesome and more prevalent than would be expected. Clinical examination of the patient allows identifying the type of transfer metatarsalgia and pathomechanics involved. This review focuses on transfer metatarsalgia after hallux valgus surgery and provides a basic understanding of the pathomechanics, clinical examination, and image studies. It also addresses the options for both conservative and surgical treatment of this challenging condition.

Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession

PURPOSE

The purpose of this study was to compare results of partial proximal fasciotomy (PPF) with proximal medial gastrocnemius release (PMGR) in the treatment of chronic plantar fasciitis (CPF).

METHOD

This retrospective study compares 30 patients with CPF that underwent PPF with 30 that underwent isolated PMGR. Both groups were matched in terms of previous treatments and time from onset of symptoms to surgery. Different standardised evaluation scales (VAS, Likert, AOFASh) were used to evaluate results.

RESULTS

Plantar fasciotomy had satisfactory results in just 60 % of patients, with an average ten weeks needed to resume work and sports. Patient satisfaction in the PMGR group reached 95 %, being back to work and sports at three weeks on average. Functional and pain scores were considerably better for PMGR and fewer complications registered.

CONCLUSION

In our series, isolated PMGR is a simple and reliable procedure to treat patients with CPF. It provides far better results than conventional fasciotomy with less morbidity and better patient satisfaction, and thus has become our surgical procedure of choice in recalcitrant CPF.

Arthrodesis of the talonavicular-cuneiform joints in Müller-Weiss disease

Several surgical treatments have been proposed to correct the deformity associated with MWD and alleviate the pain; however, no technique can be named the gold standard. TNC arthrodesis is a safe and effective technique for the treatment of the MWD and can be performed with a dorsal or medial approach;we recommend the dorsal approach. We believe that autologous bone graft provides sufficient stability and internal fixation is not needed. Treatment of MWD is not well-documented in literature; more studies are needed to determine the optimum surgical treatment for this rare disease.

Müller-Weiss disease: clinical and biomechanical features

Müller-Weiss disease is a rare condition that is characterized by an odd deformation of the tarsal navicular, which may appears queezed and eventually fragmented between the talar head and the lateral cuneiforms. Because the head of the talus protrudes laterally, the subtalar joint remains in an inverted position. The plantar arch may correspond to that of a normal, cavus, or flat foot. The disease is not the consequence of a osteonecrotic process but results from impaired development of the bone, in most instances because of stressing environmental factors during childhood. Isolated cases that are due to individual predisposing factors are rare, although most of the patients can be grouped together as late collateral damage of war or poverty.