Tension Side Fixation for Lapidus Arthrodesis: A Retrospective Analysis

Moderate to severe hallux valgus deformity often requires a Lapidus procedure (first-tarsometatarsal arthrodesis). Traditional methods include a dorsal approach with dorsal or medial fixation. However, studies demonstrate plantar/tension-side fixation, provides superior load to failure and fixation strength. This could improve outcomes, address comorbidities, and accelerate postoperative protocols; however, a paucity exists for patient outcomes in the literature regarding tension-side-fixation. The purpose of this study is to report the outcomes for tension-side Lapidus fixation. A retrospective analysis was performed of 81 patients who underwent tension-side-fixation Lapidus. Data collection consisted of: time to weight-bear, time to return to regular shoegear, hardware removal rate, revision rate, recurrence rate, relative metatarsal shortening, and nonunion rates. Mean patient age was 44 years old (range: 16-82). There were 65 females, and 16 males. The average time to weightbearing was 10.4 days. Time to return to regular shoegear was a mean of 6 weeks (ranging 2-10 weeks). Hardware removal rate was 1.2%. The recurrence rate was 8.6% (7 of 81 patients) and 5 of those 7 patients experienced recurrence before frontal-plane-correction was adopted by the surgeon. The revision rate was 0% and despite 8.6% recurrence, no patients were dissatisfied or requested a revisional procedure. The first-metatarsal shortening was a mean of 0.42 mm. The complications were as follows: 7% superficial dehiscence, 1.2% superficial wound infection, 0% deep infection, and 1.2% asymptomatic nonunion. This study suggests tension-side-fixation for Lapidus arthrodesis may allow for safe early return to weightbearing, early return to regular shoegear, low hardware removal rate, low revision rate, low metatarsal shortening, and low nonunion rate.

Factors Influencing PROMIS Scores and Patient Reported Outcomes Following Surgical Intervention of Isolated Lisfranc Injury: Minimum 2 Year Follow-up

Lisfranc injuries are rare but significant foot injuries, as they often result from polytrauma patients, and are often misdiagnosed, which further complicate their evaluation and contribute to their propensity towards disability. It is recommended that, on diagnosis, Lisfranc injuries be treated as soon as possible to decrease the risk of future chronic pain, disability, or osteoarthritis. Our study evaluated patients who completed the patient reported outcome measurement information systems (PROMIS) along with the foot function index (FFI) following operative fixation for Lisfranc injury. Fifty-one patients between 2010 and 2020 met inclusion criteria and were selected for this study, with completion. Utilizing the electronic medical record (EMR), patient charts were reviewed to obtain basic patient demographic information and comorbidities. Operative reports were reviewed to determine which procedure was performed for definitive fixation. Primary arthrodesis was associated with a significant decrease in complication rates (p = .025) when compared to ORIF. Females, arthrodesis, and procedures using a home run (HR) screw were independent risk factors for significantly higher reports of PROMIS pain interference. Arthrodesis also was associated with lower PROMIS pain interference scores. Arthrodesis and males exhibited higher scores in all FFI categories. Our results provide evidence that patient reported outcomes following Lisfranc surgery reported via PROMIS, FFI and VAS scores are independently influenced by patient demographics, comorbidities, and surgical variables. Analysis of potential associations between these patient characteristics and PROMIS and FFI scores provides evidence for physicians to manage patient expectations prior to operative treatment of a nonpolytraumatic Lisfranc injury.

Radiographic Comparison of Open and Minimally Invasive Distal Chevron Metatarsal Osteotomy in Patients With Hallux Valgus

This study aimed to compare radiographic outcomes of open and minimally invasive surgery (MIS) in patients with hallux valgus. We reviewed data of patients with hallux valgus who underwent open or minimally invasive distal chevron osteotomy at our institution. Radiographic assessment was completed preoperatively, immediate postoperatively, and one year postoperatively using eight weight bearing parameters . The classic distal chevron osteotomy method was used for open surgery and a modified method that added percutaneous K-wire fixation to the minimal invasive Chevron-Akin (third-generation MIS) was used for correction of the distal metatarsal articular angle (DMAA). A total of 65 feet (33 open surgeries and 32 MIS) were included. The HVA, IMA, and DMAA improved significantly following surgery regardless of surgical method (p<0.001). Other radiographic indicators showed no statistically significant differences after surgery. DMAA improved by 71.0±14.2% after surgery, and the open surgery group showed less significant reduction in DMAA (49.7±25.7%, p<0.001). Other parameters showed no difference between the two groups regarding relative postoperative changes. The MIS group showed shorter operation time (p<0.001) and hospitalization period (p=0.034) than did the open surgery group. Therefore, the MIS group is expected to be cost-effective. Radiographic measurements revealed comparable outcomes of MIS compared with open surgery. Additionally, adding percutaneous K-wire fixation during MIS had an advantage in correcting DMAA compared with open surgery. Furthermore, the correction of DMAA could reduce recurrence of valgus deformity of the hallux.

Frontal Plane Correction of Hallux Valgus Deformity With a Minimally Invasive Third Generation Tecnique: Short-Term Radiographic Outcomes of a Prospective Case Series

A number of minimally invasive osteotomies have been described for the repair of hallux abducto valgus (HAV) deformities. However, there are no known published studies that evaluate the effects of minimally invasive surgery techniques on the reduction of frontal plane rotation in patients with HAV. The purpose of this study was to assess correction in the transverse and frontal planes in patients undergoing surgical repair of HAV deformity utilizing a modified percutaneous technique. One hundred and five feet in 105 patients with HAV deformity were treated with a third generation minimally invasive technique using a first metatarsal osteotomy that allowed for frontal plane correction in conjunction with an Akin osteotomy. The minimum follow-up time was 12 months. Preoperative and postoperative anteroposterior weightbearing x-ray images were assessed and four measurements were evaluated: hallux abductus angle (HAA), intermetatarsal angle (IMA), tibial sesamoid position and frontal plane rotation of the first metatarsal. There were statistically significant differences for each of the assessments between the preoperative and postoperative radiographs (p < .001). There was a mean reduction in the HAA of 23.5° ± 9.6°, in the IMA, 7.0° ± 3.5°, in the tibial sesamoid position, 2.6 ± 1.3, and an improvement in the assessment of first metatarsal pronation (1.4 ± 0.9). The overall complication rate was 18.1%, with 5.7% of the feet requiring reoperation. The minimally invasive procedure employed by the authors demonstrated suitable outcomes in reducing deformity in both the transverse and frontal planes.

Combined Distal Metatarsal and Akin Osteotomies for Concomitant Metatarsophalangeal and Interphalangeal Hallux Valgus: Clinical and Radiological Outcomes

Combined metatarsal and Akin-type proximal phalanx osteotomies represent a surgical solution for concomitant metatarso-phalangeal and inter-phalangeal hallux valgus. This retrospective observational study aimed to evaluate clinical and radiographic outcomes following combined distal linear metatarsal and Akin osteotomies. The study included 42 feet from 37 patients, with a mean follow-up of 27.1 (range 24-37) months. Mean surgical time was 16.54 ± 4.17 minutes. Pre- and postoperative clinical scores and radiological parameters were collected. Positive outcomes with a low recurrence and complications rates were reported. A statistically significant improvement in the Manchester-Oxford foot questionnaire, the EuroQol 5D-5L dimensions instrument, the visual analogue scale, the intermetatarsal angle, the hallux valgus angle, the distal metatarsal articular angle, and the interphalangeal angle correction was observed. Despite the results reported, further prospective studies are needed to identify the most suitable patients for this combined osteotomy approach.

Nonunion Rate Following Primary Arthrodesis for Acute Lisfranc Injuries

Injury to the tarsometatarsal joint (TMT) results in instability throughout the midfoot that does not often improve with conservative management. If instability is identified, surgical intervention is frequently recommended, either open reduction and internal fixation (ORIF) or primary arthrodesis (PA). These 2 treatment options have been compared in the literature multiple times, often reporting similar outcomes. Due to this, as well as the need for subsequent hardware removal after ORIF has led many surgeons towards PA at the index surgery. Concern for nonunion is a leading concern with surgeons who advocate instead for ORIF. The purpose of this study is to review patients who underwent PA and observe nonunion rates. Nonunion at the TMT has been previously studied, but only in the chronic setting. We performed a retrospective study of 34 patients who had PA in the management of an acute Lisfranc injury. The average age in our study was 43.9 years old (range 19-72, SD 17.4) with an average follow-up of 9.4 months (range 4-33, SD 6.2). Radiographs were evaluated for signs of nonunion at regular postoperative intervals. Within the patients included in the study, a total of 71 TMT joints were fused. Overall successful fusion rate was 95.8% at an average of 7.9 weeks (range 6-12, SD 1.4) postoperatively. Individual nonunion rates at the first, second, and third TMT were 0%, 1.4% and 2.8% respectively. Our study demonstrates that primary arthrodesis provides a predictable outcome with low nonunion rates in the management of acute Lisfranc injury.

[Effectiveness of transverse double "8"-shaped tension band technique for Lawrence zone fracture of the fifth metatarsal base]

Objective

To explore the effectiveness of transverse double "8"-shaped tension band technique in the treatment of Lawrence zoneⅠfracture of the 5th metatarsal base.

Methods

Between February 2019 and October 2021, 15 patients with Lawrence zoneⅠfracture of the 5th metatarsal base were treated with transverse double "8"-shaped tension band technique. There were 8 males and 7 females, with a median age of 40 years (range, 23-59 years). The fractures were caused by sprains. The time from injury to operation was 3-7 days (mean, 4.1 days). X-ray films were taken to observe the fracture healing and the anchor looseness and detachment. The foot function was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, and the eversion angle of the calcaneal talus joint.

Results

The incisions healed by first intention after operation in 14 cases and the incision healed poorly in 1 case. All patients were followed up 8-12 months (median, 10 months). The imaging examination showed that all fractures healed well, with a healing time of 10-14 weeks (mean, 11.7 weeks). At last follow-up, AOFAS score was 82-100 (median, 98); 13 cases were excellent and 2 cases were good, with an excellent and good rate of 100%. VAS score was 0-3 (median, 1). Three cases had mild limited ankle joint range of motion, while 12 cases had normal range of motion. The eversion angle of the calcaneal talus joint was 25°-32° (median, 30°).

Conclusion

The application of transverse double "8"-shaped tension band technique for Lawrence zone Ⅰ fracture of the 5th metatarsal base has advantages such as simple operation, avoidance of secondary operation, and reduction of foreign body sensation, with definite effectiveness.

Effect of sequential burr passes on minimally invasive akin and first metatarsal dorsiflexion osteotomies

BACKGROUND

Minimally invasive surgical (MIS) osteotomies are increasing as a surgical option for treating midfoot and forefoot conditions. This study aimed to evaluate the impact of each burr pass on the degree of correction, gap size, and alignment in MIS Akin and first metatarsal dorsiflexion osteotomies (DFO).

METHODS

MIS Akin and first metatarsal DFO were performed on ten cadaveric specimens. Fluoroscopic measurements included the metatarsal dorsiflexion angle (MDA), dorsal cortical length (MDCL), first phalangeal medial cortical length (PCML) and proximal to distal phalangeal articular angle (PDPAA).

RESULTS

The average decrease in PCML with each burr pass was as follows: 1.53, 1.33, 1.27, 1.23 and 1.13 mm at the 1st to 5th pass, respectively. The MDCL sequentially decreased by 1.80, 1.59, 1.35, 0.75, and 0.60 mm. The MDA consistently decreased, and the PDPAA incrementally became more valgus oriented.

CONCLUSION

On average, a first metatarsal dorsal wedge resection of 4.7 mm and first phalangeal medial wedge resection of 2.9 mm was achieved after 3 and 2 burr passes, respectively. This data may aid surgeons determine the optimal number of burr passes required to achieve the desired patient-specific surgical correction.

Analysis of Nonweightbearing MRI Fat Pad Thickness Under Central Metatarsals in Patients With and Without Metatarsalgia

BACKGROUND

Metatarsalgia is a common diagnosis for patients with forefoot pain. Many have proposed metatarsal fat pad atrophy is a cause of metatarsalgia and therefore have suggested fat grafting instead of distal metatarsal osteotomies to treat metatarsalgia. For fat grafting to be a viable treatment, fat pad atrophy should correlate with metatarsalgia. This study looked to determine the relationship between metatarsal fat pad thickness and metatarsalgia and the correlation between metatarsal fat pad thickness and patient-reported outcomes.

METHODS

We conducted a retrospective review of patients with metatarsalgia and those with foot or ankle osteoarthritis who had a nonweightbearing MRI performed between February 1, 2021, and March 1, 2023. Data collected included demographics, PROMIS scores, metatarsal fat pad thickness in the second and third rays of the affected foot, and thinnest area on coronal section, measured on MRI. Student t test was used to compare continuous variables, whereas the χ2 test was used to compare categorical variables. Multivariable linear regression models were used to control for potential confounding factors.

RESULTS

A total of 112 patients were included in this study. Patients with metatarsalgia were significantly more likely to have a lower body mass index (29.3 vs 32.0, P = .03) than patients with osteoarthritis, but this finding was not present when controlling for confounding variables. We found no significant difference in fat pad thickness between patients with metatarsalgia vs patients with foot or ankle osteoarthritis (P = .43). We found no correlation between metatarsal fat pad thickness and pain interference (P = .59), physical function (P = .64), or mobility (P = .94) PROMIS scores.

CONCLUSION

In this retrospective comparative study of a relatively small cohort we found no significant difference in metatarsal fat pad thickness for patients with metatarsalgia vs patients with foot and ankle osteoarthritis based on nonweightbearing MRI, and no association between metatarsal fat pad thickness and patient-reported outcomes.

LEVEL OF EVIDENCE

Level III, case control study.

Is Surgical Treatment Necessary for the Treatment of a Jones Fracture?: A Retrospective Study

Background

Jones fractures are common injuries that can be treated conservatively or surgically. However, the optimal treatment approach remains controversial. This study aimed to compare the clinical outcomes of conservative and operative treatments for Jones fractures and determine whether surgical treatment is necessary.

Methods

A retrospective study was conducted on 69 patients with Jones fractures treated at our hospital. The patients were divided into 2 groups: conservative (C group; n = 46) and operative (O group; n = 23) treatments. Patients were followed up after 2, 6, and 12 weeks, and every 3 months thereafter. However, outpatient follow-ups were conducted between 8 and 10 weeks as needed. The mean follow-up period was 14.5 weeks (range, 12-24 weeks). In group C, the patients were treated with a non-weight-bearing cast for 4-6 weeks, followed by additional weight-bearing boot immobilization before returning to exercise. In group O, patients were treated surgically using a bicortical screw or intramedullary internal fixation. Time to radiologic union, clinical union, return to sports, visual analog scale (VAS), Foot Function Index-Revised Short Form (FFI-RS), and American Orthopedic Foot and Ankle Society (AOFAS) scores were evaluated.

Results

Sixty-nine patients were included in the analysis. There were statistically significant differences in the time to radiologic union and return to sports, VAS score in the second week, and FFI-RS score in the 12th week. In group C, favorable outcomes were observed in terms of the time to return to sports, VAS score in the second week, and FFI-RS score in the 12th week. Contrastingly, in group O, better results were observed in time to radiologic union. The AOFAS score was excellent at the final follow-up, with no significant differences between groups. Complication rates were 10.8% and 13% in groups C and O, respectively.

Conclusions

Surgical treatment is sometimes necessary for Jones fractures, but conservative treatment should also be considered because of the favorable outcomes. Conservative treatment can be a good option for patients who are risk-averse and place a high value on fracture healing without surgery.

[Clinical comparative study on resection and non-resection of the fifth metatarsal to rheumatoid forefoot deformity]

OBJECTIVE

To explore clinical effect of the fifth metatarsal head excision and non-excision in rheumatoid arthritis (RA) forefoot deformity reconstruction.

METHODS

Retrospective analysis was performed on 50 patients (76 feet) with moderate to severe forefoot deformity caused by RA treated from May 2015 to January 2019. According to degeneration of the fifth metatarsophalangeal joint,the fifth metatarsal head was retained or excised by wind-like forefoot reconstruction,and divided into the fifth metatarsal head preservation group (preservation group) and the fifth metatarsal head resection group (resection group). Twenty-four female patients in preservation group,aged from 47 to 81 years old with an average of (60.37±8.60) years old;the course of disease ranged from 13 to 22 years with an average of (19.00±3.06) years;body mass index (BMI) ranged from 21 to 28 kg·m-2 with an average of (23.53±2.47) kg·m-2;six patients (6 feet) with moderate hallux valgus deformity and 18 patients (30 feet) with severe hallux valgus deformity;treated with the first metatarsophalangeal joint fusion combined with the second th the fourth metatarsophalangeal joint arthroplasty and the fifth metatarsophalangeal joint cleanup. Twenty-six female patients in resection group were female,aged from 30 to 80 years old with an average of (58.53±13.70) years old;the course of disease ranged from 8 to 25 years with an average of (17.94±3.92) years;BMI raged from 20 to 28 kg·m-2 with an average of (24.60±2.03) kg·m-2;4 patients (4 feet) with moderate bunion valgus deformity and 22 patients (36 feet) with severe bunion valgus deformity;treated by the first metatarsophalangeal joint fusion combined with the second th the fifth metatarsophalangeal joint resection of the metatarsophalangeal head. Operation time and postoperative complications between two groups were observed,hallux valgus angle (HVA),intermetatarsal angles between the first and the second metatarsals (IMAFS),intermetatarsal angles between the first and fifth metatarsals (IMAFF),Japanese Society for Surgery of Foot (JSSF) score before surgery and at the latest follow-up were compared.

RESULTS

Fifty patients were followed-up from 14 to 46(25.30±8.83) months in resection group and 12 to 48 with an average of (24.30±11.12) months in preservation group,while no significant difference between two groups (P>0.05). There were no significant difference in operation time and postoperative complications between two groups (P>0.05). JSSF scores,HVA,IMAFS and IMAFF in fesection group were improved from (45.09±3.35) points,(38.90±13.67) °,(12.88±1.72) °,(32.50±2.99) ° before operation to (81.60±3.27) points,(15.40±0.90),(9.06±2.27) °,(22.20±1.98) ° at the latest follow-up (P<0.05);preservation group were improved from (47.09±3.96) points,(43.30±12.65) °,(13.99±3.13) °,(33.20±6.14) ° to (83.10±3.66) points,(15.20±1.54) °,(8.99±1.02) °,(24.70±1.88) °,respectively. There were no significant difference in JSSF score,HVA,IMAFS and IMAFF between two groups before operation and the latest follow-up (P>0.05). At the latest follow-up,there were statistically significant differences in pain and deformity in JSSF scores between two groups (P<0.05).

CONCLUSION

Both rheumatoid anterior foot reconstruction and anterior foot reconstruction fifth metatarsophalangeal joint debridement showed significant improvement in clinical efficacy and imaging results. Compared with rheumatoid prefoot reconstruction,the fifth metatarsophalangeal joint reconstruction for the treatment of moderate and severe deformity of rheumatoid prefoot showed better improvement in pain,but worse improvement in deformity. For the moderate to severe deformity of the forefoot caused by rheumatoid disease,patients with mild to moderate degenerative deformity of the articular surface of the fifth metatarsal phalanges may be considered for use.

New Classification for Pediatric Proximal Fifth Metatarsal Fractures

Proximal fifth metatarsal fractures are the most common foot fractures in children. Attempts to classify these injuries are misapplied and inadequately predict outcomes. This is the first study to identify factors associated with healing in pediatric fifth metatarsal fractures. In this retrospective cohort study (N = 305), proximal fifth metatarsal fractures were classified on radiographs by location on the bone, alignment (transverse or oblique), displacement (>2 mm), and completion through the bone. Based on the literature, they were secondarily sorted by category: apophyseal, intra-articular metaphyseal, extra-articular metaphyseal, and diaphyseal. Primary outcomes included times to healing, indicated by clinical symptoms, immobilization, and return to sports, as well as radiographic callus formation, bridging, and remodeling. Healing times were compared by ANOVA and linear regression. Location had a significant effect on times of immobilization and return to sports, but alignment, displacement, and completion were not associated with healing. When re-classified, the categories were also associated with immobilization and return to sports. Apophyseal fractures healed fastest and diaphyseal fractures required the most time to heal. There was no difference between extra- and intra-articular fractures. For every year of age, symptoms resolved about 2 days sooner. Neither gender nor body mass index (BMI) was positively or negatively associated with healing times. In conclusion, classifying fractures by apophyseal, metaphyseal, and diaphyseal is the most concise, accurate, and useful system. This is the largest series of nonoperatively treated proximal fifth metatarsal fractures in children and a robust standard to which surgical management can be compared.

First tarsometatarsal arthrodesis for severe hallux valgus using the tension band principle - Technical tip and case series

BACKGROUND

Hallux valgus (HV) is a common foot pathology. Severe HV in the presence of Tarsometatarsal joint (TMTJ) instability is often managed with arthrodesis of the 1st TMTJ. There are concerns regarding non-union and malunion (particularly the early loss of inter-metatarsal angle correction before complete arthrodesis). We report our medium-term results of a small series of patients that underwent an evolved surgical technique utilising orthogonal staples and a transverse suture button fixation to address biomechanical concerns with traditional Lapidus arthrodesis.

METHODS

A retrospective study of a consecutive series of patients who underwent this surgical technique between February 2017 and May 2022. Clinical outcomes were validated through Patient-reported outcomes measures (PROMS); EuroQol-5 Dimension (EQ-5D) and Manchester-Oxford Foot Questionnaires (MOXFQ). Radiographic parameters (hallux valgus (HVA), intermetatarsal (IMA), distal metatarsal articular angle (DMAA)) were assessed. Union of the arthrodesis and complications were recorded.

RESULTS

During the study period, 9 feet underwent the procedure. Radiographic data was available for all nine and PROMS data for seven (77.8%). Significant improvement occurred in all radiographic deformity parameters at mean 6-month follow-up. Mean ± standard deviation correction calculated preoperatively as HVA 40.2°, IMA 19.3° and DMAA 15.8°, corrected to HVA 15.4°, IMA 5.8° and DMAA 5.9° postoperatively. (HVA; P < 0.001, IMA; P < 0.001, DMAA; P < 0.001) Clinical PROMs at mean follow-up of 2 years were MOXFQ 34.4 ± 25.2, EQ-5D-5 L 0.819 ± 0.150 and VAS pain 13.6 ± 13.6. There were no cases of non-union, Tibialis anterior tendon irritation or hallux varus. Complications included first MTPJ stiffness in one case and CRPS and dorsiflexion malunion of the first ray in another patient.

CONCLUSION

This preliminary study of the procedure used in this series confirm this is a safe surgical technique to address severe HV with a low rate of non-union and significant radiographic improvements. A larger patient dataset is needed to evaluate this procedure robustly.

Evidence-Based Treatment Algorithm for Freiberg Disease

Freiberg disease is a type of osteonecrosis of the metatarsal head that predominantly occurs in young females and adolescents, although it may occur at any age. The pathophysiology is multifactorial and may involve trauma, altered foot biomechanics, systemic disorders, and arterial insufficiency. The most typical location is the second metatarsal head, but Freiberg disease may also occur in other lesser toes. Nonoperative treatment is best applied in the early stage of the disease; if this is ineffective, surgical treatment is recommended. Currently available surgical procedures include debridement, osteotomy, osteochondral grafting, microfracture, interposition arthroplasty, implant arthroplasty, and metatarsal shortening arthroplasty. In this article, we propose a treatment algorithm for Freiberg disease based on the current literature and expert opinion.

Midfoot width changes after first metatarsal osteotomy in hallux valgus surgery: A biomechanical effect?

Hallux valgus is a challenging pathology characterized by a valgus deformity in the metatarsophalangeal area of the first ray. The aim of this study was to analyze the influence of first metatarsal osteotomy on the relationship between midfoot bones in patients with hallux valgus. The sample consisted of patients from the orthopedics and traumatology outpatient clinic who underwent surgical treatment for hallux valgus. Preoperative and postoperative X-rays were compared regarding the width of the midfoot and the tarsometatarsal joint. The sample consisted of 17 women, with 22 feet assessed in each group. The distance from the medial cuneiform to the cuboid, the distance from the intermediate cuneiform to the cuboid, the distance between the first and fifth metatarsals, and the distance between the second and fifth metatarsals reduced significantly between pre- and postoperative assessments. Hallux valgus correction through osteotomy of the first metatarsal leads to a structural change in the midfoot. Further studies should determine whether these changes persist over time.

Hallux Valgus: The Influence of Intersesamoid Crista's Osteoarthritis on Frontal Plane Pronation

A frontal plane metatarsal rotational (pronation) has been documented in a high percentage of hallux valgus patients. Pathoanatomical concepts leading to pronation are still debated. Nevertheless, there is no consensus on how to measure this component of the deformity. The aim of the present study was to find potential associations between sesamoid's crista osteoarthritis and the frontal plane deformity in HV cases. Our study showed a moderate correlation between the crista's OA and the intermetatarsal angle (IMA), the hallux valgus angle (HVA) and the alpha angle. In severe hallux vulgus deformed specimens, with an eroded intersesamoid crista, frontal plane pronation was not as prevalent nor severe as in those without osteoarthritic degeneration. Severe hallux valgus cases with a completely eroded crista, showed lower pronation, and higher IMA, when compared to specimens with a preserved anatomy. This brings to light the intersesamoid crista's unique function in retaining the IMA. Understanding the role the frontal plane plays in hallux valgus' biomechanics and in its radiographic appearance is vital to change the current paradigm.

Radiological Analysis of the Syndesmosis Concept in Metatarsus Primus Varus and Hallux Valgus Deformities Recurrence Prevention

Hallux valgus (HV) is a common deformity of the foot. Its postoperative recurrence is not uncommon and is closely related to the recurrence of its underlying metatarsus primus varus (MPV) deformity. The syndesmosis procedure uses 1 to 2 intermetatarsal cerclage sutures to realign the first metatarsal and then induces a biological bonding between the 2 metatarsals to prevent the MPV deformity from recurring. This radiological study aimed to assess its effectiveness in long-term MPV and HV deformities recurrence prevention. Ninety-two feet of 51 consecutive patients had syndesmosis procedures that were prospectively followed up for more than 1 y and up to 14 y, averaging 100.5 (SD 45.2) months. Patients underwent X-ray examinations regularly at fixed intervals of their feet. We used Hardy's methods in measuring the intermetatarsal angle (IMA), hallux valgus angle (HVA), and medial sesamoid position from standing foot X-rays. More than 450 relevant X-ray and photo images were submitted as Supplementary Material for online viewing and reference. There was a significant final correction of IMA from 14.30° (SD 2.70) to 6.70° (SD 1.75) (p < .0001). There was no significant increase in IMA after the sixth postoperative month to their final follow-up endpoints, regardless of their lengths. There was a significant final correction of HVA from 31.95° (SD 7.45) to 19.1° (SD 7.45) (p < .0001). This study reconfirmed past findings that the MPV deformity could be corrected without osteotomies. Creating a syndesmosis-like intermetatarsal bonding was effective for long-term MPV recurrence prevention. Three feet had postoperative stress fracture of the second metatarsal. However, the HV deformity correction was less satisfactory, and the reasons were explained.

Comparing Outcomes of Acute Versus Gradual Surgical Correction in Brachymetatarsia

Brachymetatarsia consists of a shortened metatarsal resulting in a shorter toe. Pain with shoe wear and cosmetic concerns are the main reasons for surgical intervention. Surgical techniques to increase metatarsal length include acute lengthening with interpositional bone grafting or gradual lengthening with callus distraction. We performed a retrospective cohort study for 1 surgeon's patients at 1 institution over 10 years. Twenty-nine feet in 22 patients met inclusion criteria for acute correction; 16 feet in 11 patients were included for gradual correction. Mean ages were 26.3 ± 12.1 and 27 ± 10.8 in the acute and gradual groups, respectively (p = .79). Most patients were female: 95.4% of acute cases and 90.1% of gradual cases. Most involved lengthening the fourth metatarsal: 86.7% and 100% of acute and gradual groups, respectively (p = .54). Correction obtained amounted to 14.4 ± 2.97 mm (range, 10-22 mm) in acute cases and 14.8 ± 2.39 mm (range, 10-20 mm) in gradual cases (p = .81). The mean percent increase in metatarsal length was 21.1 ± 14% for acute and 22.6 ± 12.4% for gradual (p = .72). Mean consolidation was 8.9 ± 2.51 weeks for acute and 21.4 ± 10.8 weeks for gradual (p = <.001). Nonunions were most common in the gradual group (37.5%) with need for more revisional surgery (43.5%) compared with the acute group; both were statistically significant. We conclude that acute brachymetatarsia correction can obtain correction similar to the gradual technique with fewer postoperative complications and less osseous consolidation time.

Surgical Treatment for Isolated Closed Multi-metatarsal Fractures: At Least 2-Year Outcomes in 79 Feet

Multimetatarsal fractures are a particular type possibly associated with worse functional outcomes. Existing studies are scarce, fragmented, and lack control for confounders. This study aimed to explore the functional prognosis of isolated closed extra-articular multimetatarsal fractures and the different outcomes between the plate-screw and K-wire fixation. This retrospective study included 79 patients who underwent surgery for isolated closed extra-articular multimetatarsal fractures from May 2017 to December 2020. We recorded baseline characteristics. The primary outcome measure was Visual Analogue Scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) score, and Foot and Ankle Outcome Score (FAOS). Exploratory correlation analysis of the variables with VAS, AOFAS score, and FAOS was performed. The differences between the plate-screw group (n = 58) and K-wire group (n = 21) were compared. Seventy-nine patients (79 feet) were included with a follow-up of (47.3 ± 12.7) months (range, 26-70). Full weight bearing time was (11.7±5.3) weeks. VAS was (1.4±1.8) points, AOFAS score was (86.4±13.3) points, and FAOS was (79.0±11.1) points. Complications were observed in 17 cases (21.5%). According to exploratory correlation analysis, VAS was weakly associated with fixation method and gender, AOFAS was weakly associated with fixation method, FAOS was weakly associated with trauma mechanism. When the plate-screw group (n = 58) was compared with the K-wire group (n = 21), we found the former was superior to the latter in terms of full weight bearing time, VAS, AOFAS score, and malunion rate (all p < .05). FAOS was nonsignificant (p = .056). Operative treatment of isolated closed extra-articular multimetatarsal fractures showed good mid-term results. Plate-screw fixation was associated with faster rehabilitation as well as a lower malunion rate. The mid-term follow-up results showed patients with plate-screw fixation had better VAS and AOFAS scores.

Medial sesamoid position in moderate to severe hallux valgus: Correlation between three radiographic measurements

BACKGROUND

In hallux valgus surgery, it is essential to accurately assess the position of the sesamoids both pre- and postoperatively. Weight-bearing foot anteroposterior, tangential sesamoid, and semi-weight-bearing computed tomography axial views are radiographic methods used to assess the medial sesamoid position. This study aimed to measure the medial sesamoid position and evaluate the correlation between these three radiographic methods.

METHODS

This retrospective study comprised 59 feet from 49 patients who underwent hallux valgus surgery. The mean age of patients was 54.6 (range, 22-70) years. We took preoperative and postoperative measurements using the weight-bearing anteroposterior, tangential sesamoid, and semi-weight-bearing computed tomography axial views to assess the medial sesamoid position.

RESULTS

The mean grades of the medial sesamoid position preoperatively and 6 months postoperatively were 2.5 and 0.8, 1.6 and 0.4, and 1.3 and 0.3 points based on the anteroposterior, tangential sesamoid, and computed tomography axial views, respectively (P < 0.001). Preoperatively, there was a strong positive correlation between the computed tomography axial and tangential sesamoid views (P < 0.001, r = 0.645) and anteroposterior and computed tomography axial views (P < 0.001, r = 0.468). In contrast, the tangential sesamoid and anteroposterior views showed a weak positive correlation (P = 0.03, r = 0.283). Six months postoperatively, there was a positive correlation between the computed tomography axial and tangential sesamoid views (P < 0.001, r = 0.473), anteroposterior and computed tomography axial views (P < 0.001, r = 0.470), and tangential sesamoid and anteroposterior views (P < 0.001, r = 0.480).

CONCLUSIONS

We observed that the anteroposterior view exhibited a higher degree of medial sesamoid position displacement than the computed tomography axial and tangential sesamoid views. For the preoperative evaluation of the medial sesamoid position, the correlation between the computed tomography axial and tangential sesamoid views was stronger than that between the tangential sesamoid and anteroposterior views. However, all three views showed strong correlations postoperatively.

Correlation Between Traditional Anteroposterior Radiographic Measurements With Lateral Radiographic Measurements Following Triplanar Correction of Hallux Valgus and With Patient-Reported Outcomes From a Prospective Multicenter Trial

Hallux valgus (HV) is a common condition in which the first ray is deformed, leading to pain and altered joint mechanics. A variety of radiographic measurements are used to evaluate HV. Little is known about measurements used in the assessment of HV on lateral radiographs compared to anteroposterior (AP) radiographs. The primary aim of this study was to correlate lateral measurements with AP measurements pre and postoperatively. The secondary aim was to correlate lateral measurements with patient-reported outcome measures (PROMs) pre and postoperatively. One hundred eighty-three patients were initially enrolled in the study. Two fellowship-trained musculoskeletal radiologists independently performed all measurements. On AP radiographs, hallux valgus angle (HVA) and intermetatarsal angle (IMA) were measured. On lateral radiographs, sagittal IMA, Meary's angle, and sagittal first ray length were measured. Measurements were recorded at baseline and 6, 12, and 24 months postoperatively. Intraclass correlation coefficients (ICCs) were used for inter-reader analysis. ICCs were moderate to very strong among readers. There were significant but weak correlations between lateral measurements and AP measurements. For at least 1 timepoint, IMA correlated with sagittal IMA, sagittal first ray length, and Meary's angle. HVA only correlated with sagittal first ray length. These correlations were all weak in magnitude. There were a few significant but weak correlations between the measurements in the study and PROMs. This study showed that sagittal IMA, sagittal first ray length, and Meary's angle are not predictive of AP measurements or patient outcomes and are not useful in preoperative assessment of HV.

How Important Is a Lesser Metatarsal Osteotomy in Preventing Second Hammertoe Recurrence?

Hammertoes with greater preoperative transverse plane deformity are more likely to recur after corrective surgery; however, it is unclear whether this represents an inherent (fixed, nonmodifiable) risk, or whether steps can be taken intraoperatively to mitigate this risk. In this study, we examined whether transverse plane transposition and/or shortening of the second metatarsal during second hammertoe surgery influenced recurrence. We performed a secondary analysis of pre-existing data from patients that had previously undergone second hammertoe surgery at our institution between January 1, 2011 and December 31, 2013. One hundred two patients (137 toes) were followed for a mean 28 ± 7.8 months postoperatively. Thirty-seven toes required, at the surgeon's discretion, an additional/concomitant Weil metatarsal osteotomy. Magnitude of transverse plane transposition and shortening of the second metatarsal, and joint angular measurements were obtained from the second metatarsophalangeal joint on weightbearing AP radiographs preoperatively and at 6 to 10 weeks postoperatively. Cox regression analysis was used to identify predictors of hammertoe recurrence using these new variables and a set of known predictors. In the final regression model, failure to establish a satisfactory postoperative metatarsal parabola (i.e., long second metatarsal; Nilsonne values <-4 mm, multivariate hazards ratio [HR] 1.96, p = .097), and intraoperative lateral transposition of the metatarsal head (multivariate HR 3.45, p = .028) seemed to confer additional risk for hammertoe recurrence. We conclude that shortening osteotomies may be assistive in some individuals, while further inquiry is still needed to determine whether similar benefits can be derived from medial head transposition in medial toe deformities.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Biomechanical comparison of two surgical methods for Hallux Valgus deformity: Exploring the use of artificial neural networks as a decision-making tool for orthopedists

Hallux Valgus foot deformity affects gait performance. Common treatment options include distal oblique metatarsal osteotomy and chevron osteotomy. Nonetheless, the current process of selecting the appropriate osteotomy method poses potential biases and risks, due to its reliance on subjective human judgment and interpretation. The inherent variability among clinicians, the potential influence of individual clinical experiences, or inherent measurement limitations may contribute to inconsistent evaluations. To address this, incorporating objective tools like neural networks, renowned for effective classification and decision-making support, holds promise in identifying optimal surgical approaches. The objective of this cross-sectional study was twofold. Firstly, it aimed to investigate the feasibility of classifying patients based on the type of surgery. Secondly, it sought to explore the development of a decision-making tool to assist orthopedists in selecting the optimal surgical approach. To achieve this, gait parameters of twenty-three women with moderate to severe Hallux Valgus were analyzed. These patients underwent either distal oblique metatarsal osteotomy or chevron osteotomy. The parameters exhibiting differences in preoperative and postoperative values were identified through various statistical tests such as normalization, Shapiro-Wilk, non-parametric Wilcoxon, Student t, and paired difference tests. Two artificial neural networks were constructed for patient classification based on the type of surgery and to simulate an optimal surgery type considering postoperative walking speed. The results of the analysis demonstrated a strong correlation between surgery type and postoperative gait parameters, with the first neural network achieving a remarkable 100% accuracy in classification. Additionally, cases were identified where there was a mismatch with the surgeon's decision. Our findings highlight the potential of artificial neural networks as a complementary tool for surgeons in making informed decisions. Addressing the study's limitations, future research may investigate a wider range of orthopedic procedures, examine additional gait parameters and use more diverse and extensive datasets to enhance statistical robustness.

Improving the Accuracy of Metatarsal Osteotomies in Minimally Invasive Foot Surgery Using a Digital Inclinometer: Preliminary Study

Minimally invasive foot surgery (MIS) has become a common procedure to treat various pathologies, and accuracy in the angle of metatarsal osteotomies is crucial to ensure optimal results. This randomized controlled trial with 37 patients investigates whether the implementation of a digital inclinometer can improve the accuracy of osteotomies compared to traditional freehand techniques. Patients were randomly allocated to group A (n = 15) receiving inclinometer-assisted surgery or group B (n = 22) receiving conventional surgery. Osteotomies were performed and outcomes were evaluated using an inclinometer. The inclinometer group showed a significant decrease in plantar pressure from 684.1 g/cm2 pretreatment to 449.5 g/cm2 post-treatment (p < 0.001, Cohen's d = 5.477). The control group decreased from 584.5 g/cm2 to 521.5 g/cm2 (p = 0.001, Cohen's d = 0.801). The effect size between groups was large (Cohen's d = -2.572, p < 0.001). The findings indicate a significant improvement in accuracy and reduction in outliers when using an inclinometer, suggesting that this technology has the potential to improve surgical practice and patient outcomes in minimally invasive metatarsal osteotomies.

Lateral metatarsal osteotomy

Lateral metatarsal osteotomy (LMO) aims to reposition the affected metatarsals in a chosen position. The approach may be open or percutaneous. There are several types of LMO, according to displacement: shortening, raising, translation or lengthening. Preoperative planning covers type and extent of displacement, osteotomy location and type (open or percutaneous), and number of metatarsals concerned. In the 1990s, older concepts of non-fixed osteotomies gave way to preoperative planning and calculated shortening, including the development of Weil shortening osteotomy. Diaphyseal lengthening or shortening osteotomy is mainly used for brachymetatarsia. The older concept of non-fixed lateral rays made a comeback with percutaneous first-ray surgery. Distal metatarsal minimally invasive osteotomy (DMMO) is the most effective, giving rise to variants such as distal oblique metatarsal minimally invasive osteotomy (DOMMO), to meet the requirements of greater displacement, especially in shortening and translation, and to be applicable in as wide a range of cases as possible. Presently, these percutaneous techniques have not demonstrated superiority over open surgery, and entail specific complications. Even so, they are now part of the armamentarium of forefoot surgery, as their minimal invasiveness corresponds to current trends in surgery, especially in the foot. Level of evidence: V.

Proximal Supination Osteotomy for Hallux Valgus: Comparison of Clinical and Radiologic Outcomes for the Most Severe Deformities

BACKGROUND

There is little available information regarding the difference in outcomes between severe hallux valgus (S-HV), defined as 40 degrees ≤ hallux valgus angle (HVA) < 50 degrees, and what we consider to be "super-severe HV" (SS-HV), defined as >50 degrees, following a proximal metatarsal osteotomy. We aimed to retrospectively compare the outcomes of a proximal metatarsal osteotomy in S- and SS-HV.

METHODS

The series consisted of 57 female patients (57 feet) treated with a proximal supination osteotomy for symptomatic S- and SS-HV (33 and 24 feet, respectively). The outcome measures included radiographic parameters and for 45 patients included the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) score, and a visual analog scale pain score (VAS-PS) preoperatively and at a minimum follow-up of 12 months with a median of 26 months. No significant differences were found in age, body mass index, and the duration of follow-up between patients with S-HV and SS-HV (P > .10 for all comparisons) with the numbers available.

RESULTS

Preoperative HVA in patients with S- and SS-HV was significantly improved at the final follow-up (P < .0001 for both comparisons). No significant differences in postoperative HVA and IMA were observed between patients with S- and SS-HV (P = .51 and .50, respectively). All 5 preoperative subscale scores of SAFE-Q in patients with S- and SS-HV significantly improved postoperatively (P < .01 for all comparisons). Preoperative VAS-PS in patients with S- and SS-HV significantly improved postoperatively (P < .0001 and <.009, respectively). There were no significant differences in preoperative and postoperative scores of all the SAFE-Q subscales and VAS-PS between patients with S-HV and SS-HV (P > .10 for all) with the numbers available.

CONCLUSION

We found for this patient group that a proximal supination osteotomy can achieve a large correction for SS-HV as well as S-HV and significantly improve radiologic and clinical outcomes in SS-HV. The outcomes between patients with S- and SS-HV were not different in this series.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A Cadaveric Study Verifying the Potential of a Rotational Biplanar Chevron Osteotomy to Correct the 3-Dimensional Hallux Valgus Deformity

INTRODUCTION

Metatarsal pronation is present in 87% of patients with hallux valgus (HV) deformity. The chevron osteotomy is commonly used worldwide to correct mild to moderate HV deformities. Many modifications have been described, but few address the rotational deformity of the first metatarsal. The rotational biplanar chevron osteotomy (RBCO), described by M. Prado et al, presents a variation of a biplanar chevron osteotomy that can be used to address first metatarsal rotation. The objective of this study is to investigate and verify the technique of the RBCO.

METHODS

We conducted our study performing an RBCO on 9 cadaveric limbs. The technique uses a medial-based wedge parallel to the plantar limb of the osteotomy to make the distal fragment free to correct rotation. A goniometer was used by 2 individual surgeons to control the rotational correction achieved.

RESULTS

The osteotomy was considered simple to perform and we experienced no complications, such as fractures or instability. The result was satisfactory alignment and adequate stability. On average, a 2 mm wedge resulted in 11° of rotational correction.

CONCLUSION

We predict that RBCO can safely be used for correcting the metatarsal rotation when necessary in mild to moderate HV deformity foot.

LEVELS OF EVIDENCE

Level IV.

Percutaneous Fifth Metatarsal Osteotomy for Bunionette Deformity Without Fixation or Strapping: A Retrospective Study

BACKGROUND

Bunionette deformity (BD) is a painful condition of the fifth metatarsal characterized by an osseous prominence and fifth toe varus deformity. The purpose of this study is to assess the clinical, functional, and radiographic outcomes of percutaneous distal metatarsal metaphyseal osteotomy (DMMO) without fixation or postoperative strapping of the foot.

METHODS

A retrospective case series was performed on 111 patients (132 feet) with symptomatic BD who underwent percutaneous DMMO of the fifth metatarsal from September 2020 to January 2022 by an experienced minimally invasive surgeon. According to the Shimobayashi classification, we treated 1 type I deformity, 37 type II deformities, 52 type III deformities, 42 feet with type IV deformity, and no patient with a type V deformity. Ninety patients (81%) underwent unilateral osteotomy, and 21 (19%) had bilateral osteotomies. Most cases included other procedures including treatment of 114 associated deformities of the same feet: 68 bunions, 12 lesser metatarsal osteotomies (2-3-4 metatarsals), and 34 hammertoes (20 second hammertoes, 10 third hammertoes, 1 fourth hammertoes, 2 fifth hammertoes). Patient-reported clinical outcome measures, including the Foot Function Index (FFI) questionnaire, the visual analog score (VAS), and overall satisfaction were collected. Fourth-to-fifth intermetatarsal angle (IMA) correction, time to bone union, and complication rates were assessed in all patients.

RESULTS

Mean follow-up was 24.1 months (range, 14-39 months). Both radiographic parameters and patient-reported outcome measures significantly improved after DMMO procedure. The average fourth-to-fifth IMA improved from 12.2 degrees, preoperatively, to 4.4 degrees, postoperatively (P < .001). Patient outcomes reflect the overall outcomes of the combined surgeries on a per-patient basis. Preoperatively, patients had a mean VAS score of 7.6, which improved to 0.6 at the last follow-up (P < .001). Furthermore, the average FFI significantly decreased from pre- to postoperation from 19.2 to 4.4, respectively (P < .001). Overall, 108 of 111 patients reported being satisfied with the outcomes of the procedure. Average bone union was achieved at 12.6 weeks postoperation, with a minimum of 12 and a maximum of 25 weeks. The complication rate was 1.5%, including 1 case of an asymptomatic cock-up deformity and 1 case of lateral fifth metatarsal shaft bone overhang pain, which resolved with an exostectomy.

CONCLUSION

The results of this study of patients who had minimally invasive surgery from an experienced surgeon suggest that percutaneous DMMO of the fifth metatarsal without internal fixation or postoperative immobilization or strapping can be effective at improving radiographic alignment, pain, function, and overall satisfaction with minimal rates of complication.

LEVEL OF EVIDENCE

Level IV, case series.

Treatment of two or more metatarsal fractures

INTRODUCTION

Metatarsal fractures are the most common type of foot fracture. When surgical treatment is needed, pinning is typically used, either percutaneous or open. However, this fixation method has been criticized by some authors who lament residual malunion and prefer to use plate and/or screws. The primary objective of our study was to compare the outcomes of K-wire versus plate and/or screw fixation for the surgical treatment of two or more metatarsal fractures. The secondary objective was to evaluate the factors that contribute to poor outcomes and complications. We hypothesized that plate and/or screw fixation will produce better functional outcomes than K-wire fixation.

MATERIALS AND METHODS

This was a prospective and retrospective multicenter study carried out between 1 January 2010 and 1 June 2018 with a minimum follow-up of 12 months. Three functional scores were determined (AOFAS, FAAM and SF12 physical and mental) preoperatively, postoperatively and at the final assessment. We evaluated the outcomes in the entire study population and in four injury type subgroups, including one with isolated metatarsal fractures to control analysis bias.

RESULTS

Our analysis compiled data from 165 patients (123 men, 42 women) who had a mean age of 38 years (16-82). The mean follow-up time was 27.9months (10-120). There were no complications in 130 patients (79%). Skin necrosis occurred in 25 patients (15%). The FAAM score was significantly higher in the plate and/or screw group 70.2 (17-84) versus 60.3 (31-84) in the K-wire group (P=0.033). The 78 (19-100) AOFAS was higher, but not significantly, in the plate and/or screw group versus 70 (12-100) in the K-wire group (P=0.144).

CONCLUSION

Trauma to the foot that causes a fracture in two or more metatarsals often occurs due to a crush injury (39%). The frequency of associated bone lesions means that a preoperative CT scan should be done routinely to analyze the injury pattern and determine the best treatment. The fixation method should be adapted to the local conditions; when possible, it is preferable to use rigid fixation with plates and/or screws as it yields better functional outcomes.

LEVEL OF EVIDENCE

IV; study with retrospective component.

Common Foot Fractures

Foot fractures account for about one-third of lower extremity fractures in adults. They are typically caused by a crush injury or an axial or twisting force on the foot. Patients usually present with bony point tenderness and swelling of the affected area. Weight-bearing varies based on the extent of the fracture and the patient's pain tolerance. When a foot or toe fracture is suspected, anteroposterior, lateral, and oblique radiography with weight-bearing should be obtained. The Ottawa foot and ankle rules can help determine the need for radiography after an acute ankle inversion injury. Many foot fractures can be managed with a short leg cast or boot or a hard-soled shoe. Weight-bearing and duration of immobilization are based on the stability of the fracture and the patient's pain level. Most toe fractures can be managed nonsurgically with a hard-soled shoe for two to six weeks. Close attention should be paid to the great toe because of its role in weight-bearing, and physicians should follow specific guidelines for orthopedic referral. Meta-tarsal shaft fractures are managed with a boot or hard-soled shoe for three to six weeks. The proximal aspect of the fifth metatarsal has varied rates of healing due to poor blood supply, and management is based on the fracture zone. Lis-franc fractures are often overlooked; radiography with weight-bearing should be obtained, and physicians should look for widening of the tarsometatarsal joint. Other tarsal bone fractures can be managed with a short leg cast or boot for four to six weeks when nonsurgical treatment is indicated. Common foot fracture complications include arthritis, infection, malunion or nonunion, and compartment syndrome.

Comparison of triplanar chevron osteotomy with chevron osteotomy in hallux valgus treatment for the prevention of transfer metatarsalgia

Hallux valgus (HV) is often accompanied by metatarsalgia. This study compared the radiological and clinical outcomes of new triplanar chevron osteotomy (TCO) and chevron osteotomy (CO) in the treatment of HV, especially for patients with plantar callosities and metatarsalgia. In this retrospective analysis, 90 patients (45 patients per group) with mild to moderate HV and plantar callosities were treated with TCO and CO from July 2020 to January 2022. In both procedures, the apex was located in the center of the head of the first metatarsal bone, and the CO was oriented towards the fourth MTPJ at a 60° angle. Plantar-oblique chevron osteotomy was defined as chevron osteotomy and a 20° plantar tilt; TCO was defined as plantar-oblique chevron osteotomy-based metatarsal osteotomy with a 10° tilt towards the metatarsal head. Primary outcome measures included preoperative and postoperative hallux valgus angle, 1 to 2 intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), first metatarsal length (FML), and second metatarsal head height X-ray images; clinical measurements, including visual analogue scale and American Orthopaedic Foot & Ankle Society (AOFAS) scores; changes in callosity grade and area; and changes in the number of people with metatarsalgia. Secondary outcomes included complications, recurrence rates, and cosmetic appearance. The hallux valgus angle, IMA, and DMAA were significantly lower after surgery (P  < .001) in all patients. In the TCO group, the mean FML and second metatarsal head height increased significantly postoperatively (P < .001). The AOFAS and visual analogue scale scores improved postoperatively in both groups (P < .001). All patients experienced satisfactory pain relief and acceptable cosmesis. The plantar callosity areas were smaller postoperatively in both the TCO and CO groups, but the change in the area (Δarea) in the TCO group significantly differed from that in the CO group (P < .001). The number of postoperative patients with metatarsalgia and the plantar callosity grade were both significantly lower in the TCO group than in the CO group after osteotomy (P < .05). TCO prevents dorsal shift of the metatarsal head and preserves and even increases FML, thereby preventing future metatarsalgia in patients. Therefore, compared with CO, TCO has better orthopedic outcomes and is an effective method for treating mild to moderate HV and preventing transfer metatarsalgia.

Comparative effects of modified rotary scarf osteotomy and traditional scarf osteotomy in treating moderate to severe hallux valgus: a retrospective cohort study

BACKGROUND

Traditional Scarf osteotomy (TSO) is an effective procedure with a good record in moderate to severe hallux valgus (MSHV) surgery. In order to overcome shortcomings of TSO, Modified Rotary Scarf osteotomy (MRSO) was introduced in this study, which aimed to compare the clinical and radiological outcome in the patients treated with MRSO or TSO.

METHODS

Of 175 patients (247 feet) with MSHV, 100 patients (138 feet) treated with MRSO and 75 patients (109 feet) treated with TSO were evaluated according to relevant indicators in twenty-four months follow-up. Pre-surgical and post-surgical HVA, IMA, DMAA, MTP-1 ROM, sesamoid grade and AOFAS (American Orthopaedic Foot and Ankle Society) scores and postsurgical complications were evaluated.

RESULTS

Both groups manifested similar baseline characters. The mean follow-up was of 25.9 (range, 22-37) months. Significantly lower IMA, lower Sesamoid grade and higher DMAA at six months, twelve months and twenty-four months post-surgically had been showed in MRSO group compared to TSO group. There was no significant difference in HVA, MTP-1 ROM and AOFAS data at each follow-up time point post-surgically between the two groups. No major complications occurred in either group.

CONCLUSION

MRSO showed comparable results to TSO, and improved IMA and sesamoid grade to a greater extent, with a lower probability of throughing effect. Although DMAA could be increased by MRSO, MRSO could still be a reproducible, non-dangerous and efficacious alternative procedure for treating HV patients which do not have severe DMAA.

Is there a tolerance for extension of the first metatarsal after the Lapidus procedure? A clinical, functional, and hindfoot radiographic analysis

PURPOSE

Based on the tripod concept of load distribution, our study aimed to evaluate whether a slight extension of first metatarsal (M1) that may occur after the Lapidus procedure (LP) could alter the radiographic measurements of the hindfoot and influence clinical and functional outcomes.

METHODS

Twenty-five patients (27 feet) were reviewed. Hindfoot radiographic analysis was based on seven measurements. Clinical and functional outcomes were evaluated with self-reported questionnaires. Transfer metatarsalgia was also assessed. Correlation analysis was performed according to variations of the studied variables.

RESULTS

The average extension of the M1 was 4.26 degrees (p < 0.001). None of the hindfoot radiographic measurements changed significantly (p = 0.13, p = 0.50, p = 0.19, p = 0.70, p = 0.11, p = 0.36, p = 0.83). Patients improved on most questionnaires (p < 0.001). None presented transfer metatarsalgia. No correlation between M1 extension and clinical and functional outcomes was found.

CONCLUSION

Possibly there is a tolerance of M1 extension in which it does not alter the radiographic measurements of the hindfoot, overload the lesser metatarsals, or compromise clinical and functional outcomes.

Fracturing the Lateral Hinge Improves Radiographic Alignment and Does Not Affect Clinical Outcomes of the Minimally Invasive Akin Osteotomy

BACKGROUND

Intraoperative fracture of the lateral cortex is common during Akin osteotomy. In a recent study, lateral cortex fracture did not impede healing or result in loss of correction in a combined cohort of open and percutaneous osteotomies stabilized by K-wire fixation. We hypothesize that undesired lateral cortex fracture will not affect radiographic correction and patient-reported outcomes in a percutaneous cohort stabilized by permanent, rigid screw fixation.

METHODS

Consecutive patients with hallux valgus who underwent first metatarsal osteotomy and percutaneous Akin osteotomy stabilized by permanent, rigid screw fixation between May 2020 and January 2022 were retrospectively reviewed. Patients were stratified based on fractured lateral cortex (FC) or its absence (nonfractured cortex [NFC]). Visual analog scale (VAS) and Foot Function Index (FFI) were used to assess pain and patient-reported outcomes at 1-year follow-up. Patients were polled for satisfaction at 1-year follow-up by yes/no survey.

RESULTS

Ninety-eight patients (89% female) were reviewed (98 feet; 43 NFC, 55 FC). Mean age was 48.3 years (range, 18-83 years). Mean preoperative VAS score was 7.5 and 7.7 in NFC and FC groups, which significantly decreased to 0.6 (P < .01) and 0.6 (P < .01), respectively. Mean total FFI was 53.9 and 54.2 and decreased to 17.9 (P < .01) and 17.2 (P < .01) in the NFC group and FC group, respectively. Overall, 97.8% of the NFC group and 96.4% of the FC group reported satisfaction.Mean HVA improved from 27.2 (16-42) degrees to 10.7 degrees (4-12) postoperatively in the NFC group. And in the FC group, HVA improved from 29.3 (19-39) degrees to 7.1 (4-12) degrees postoperatively. Postoperative HVA was significantly lower in the FC group (P < .05).

CONCLUSION

In an exclusively percutaneous surgical cohort with correction maintained by rigid screw fixation, fracture of the lateral cortex is associated with improved postoperative radiologic alignment without detriment to patient-reported outcomes.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Radiological outcome of hallux valgus deformity correction with metatarsal osteotomy from a single-center cohort - Best results achieved by foot and ankle surgeons

BACKGROUND

To evaluate the radiological outcome, especially undercorrection of hallux valgus deformity correction with first metatarsal osteotomy.

PATIENTS AND METHODS

439 1st metatarsal osteotomies including 241 distal (55 %), 175 midshaft (40 %), and 23 proximal (5 %) were available for analysis with median follow-up time was 48 days (range 27-990 days).

RESULTS

The postoperative HVA was normal in 237 (54 %), mild in 110 (25 %), moderate in 87 (20 %), and severe in 5 (1 %) of the cases. BMI (p = 0.0127), sex (p = 0.0004), preoperative HVA (p = 0.0028), and surgeons experience (p < 0.0001) were associated with radiological outcome, whereas age, hospital, and type of osteotomy had no effect. Foot and ankle surgeons achieved normal postoperative HVA in 76 %, general orthopedic surgeons in 41 %, and residents in 47 % of the operations.

CONCLUSION

Radiological undercorrection was common. As foot and ankle surgeons achieved best radiological correction, hallux valgus deformity should be operated by specialists.

Subchondral bone sequestrum formation in the proximal intra-articular and osteochondral region of the third metatarsal bone of an Appaloosa mare treated for septic arthritis

OBJECTIVE

To raise awareness of the potential for intra-articular subchondral bone sequestrum formation secondary to a traumatic or septic process to enable more rapid identification of this uncommon but possible outcome in future cases.

ANIMAL

A client-owned 12-year-old Appaloosa mare.

CLINICAL PRESENTATION, PROGRESSION, AND PROCEDURES

The mare had a wound to the lateral aspect of the fourth metatarsal bone (MT4) that communicated with the distal tarsal joints. Radiographs revealed a displaced, comminuted fracture of MT4.

TREATMENT AND OUTCOME

The horse underwent aggressive debridement of the wound and MT4 as well as, on 2 occasions, needle joint lavage. Systemic, regional, and IA antibiotic therapy was also performed together with a bone graft from the tuber coxae. The horse's comfort improved, and the wound appeared to be healing. Five weeks following discharge, the horse re-presented with a non-weight-bearing lameness and radiographs revealed marked osteomyelitis of the tarsometatarsal and distal intertarsal joints. Postmortem examination of the limb identified a sequestrum within the proximal articular surface of the third metatarsal bone.

CLINICAL RELEVANCE

The present report highlights the importance of arthroscopic lavage to visualize the cartilage surface and the benefits of advanced imaging to detect associated changes within the bone earlier than conventional radiographs. To our knowledge, no reports exist of intra-articular subchondral bone sequestra in the tarsometatarsal joint in horses.

Immediate Weightbearing Following First Metatarsal Phalangeal Joint Arthrodesis With 2 Nickel Titanium Alloy Staples

The use of staples has been shown to be a reasonable fixation technique to achieve stability of a first MTPJ arthrodesis. Although it has been shown to be a weaker construct than crossed screws or plate and screw combinations, their ease of insertion, low profile, and stability make them a desirable choice for first MTPJ arthrodesis fixation. However, because of this relative weakness, the question remains whether immediate weightbearing when using staples is advisable. The aim of this study is to determine whether the use of 2 nickel-titanium alloy (NITINOL) staples, placed at 90 degrees to one another is a stable enough construct to support full, immediate weightbearing following first MTPJ arthrodesis. We performed a retrospective chart review of patients undergoing first MTPJ arthrodesis by a single surgeon utilizing 2 NITINOL staples placed at 90 degrees to one another. Patients were allowed to be fully weightbearing immediately postoperatively. Forty-seven of 50 (94%) patients achieved complete radiologic consolidation of fusion at 12 weeks, with only 3 requiring revision surgery for nonunion. All of the patients requiring revision surgery for nonunion, had preoperative diagnosis of hallux abducto valgus. We concluded that the use of 2 NITINOL staples placed at 90 degrees to one another is a viable option for first MTPJ arthrodesis, and immediate weightbearing does not increase rate of nonunion or incidence of revision surgery when compared to other fixation techniques.

Retrospective Analysis of Radiographic Outcomes After Closing Base Wedge Osteotomy for Correction of Bunion Deformity

BACKGROUND

Closing base wedge osteotomy (CBWO) is a common procedure to correct severe bunion deformities with high intermetatarsal angles. There are few data demonstrating the radiographic success of CBWOs.

METHODS

We evaluated the radiographic outcomes of a CBWO. The primary aim was to assess the change in elevatus after a CBWO. Secondary aims included measuring the change in hallux abductus (HA) and intermetatarsal angles after the osteotomy. The medical records of 24 consecutive patients across 4 years were reviewed. All of the CBWOs were fixated with either one screw and one Kirschner wire or two screws. We hypothesized that the CBWO would reduce the amount of elevatus present.

RESULTS

The mean patient age was 35 years. Average preoperative HA and intermetatarsal angles were 35.2° and 15.7°, respectively. Mean postoperative HA and intermetatarsal angles at last radiographic follow-up were 13.3° and 6.1°, respectively. The change in HA and intermetatarsal angles was 21.9° and 9.6°, respectively. All of the patients achieved clinical union. Mean radiographic follow-up was 6 months; median radiographic follow-up was 5 months. The mean preoperative elevatus measurement was 3.5 mm; the mean postoperative elevatus measurement was 2.0 mm (difference, -1.6 mm; P = .0282), indicating that the osteotomy plantarflexed the first metatarsal. Three patients had radiographic evidence of postoperative elevatus; they were asymptomatic at the last clinical follow-up.

CONCLUSIONS

Although clinical concern persists for the development of postoperative elevatus with CBWO, this case series showed plantarflexion of the CBWO. The CBWO is a powerful yet stable procedure for severe bunion deformities and should be viewed as a viable alternative to the Lapidus procedure.

Retrospective Comparison of Preoperative and Postoperative Foot Width in Minimally Invasive Hallux Valgus Surgery

Minimally invasive surgery (MIS) has gained popularity for hallux valgus correction in the adult population. The advantage of reproducibility of this procedure can aid in lower operating room costs, quicker recovery, and fewer complications. The purpose of this retrospective study was to compare preoperative versus postoperative foot widths in patients that underwent MIS hallux valgus correction. The average preoperative foot width was 101.1 ± 5.67 mm and postoperatively the foot width measured at 12-month follow-up was 95.9 ± 4.92 mm, which was statistically significant (p < .001). Overall, there was a 5.03 ± 3.71% reduction in foot width, with a statistically significant linear relationship between preoperative foot width and percent change in width following the procedure (R = -0.46; p = .003). Based on our results, we can conclude that MIS bunion surgery can effectively narrow the foot postoperatively, particularly in patients with a wider forefoot, adding cosmetic benefit to the procedure.

Foot Surgery Using Resorbable Magnesium Screws

The use of bioabsorbable magnesium (Mg) screws is new in foot surgery. Their relative merit over conventional titanium screws has not yet been proven. This prospective case series study was conducted to compare the clinical and radiological outcomes of bioabsorbable Mg screws and titanium screws. A consecutive series of patients (n = 60; 11 men and 49 women) underwent corrective hallux valgus surgery. The minimum follow-up period was 1 year. The assessment was based on a patient questionnaire, including the American Orthopedic Foot and Ankle Society (AOFAS) hallux valgus score, visual analog scale, patient's global impression of change (PGIC), and fifth metatarsus circumference (IF5C). The radiographic assessment included the intermetatarsal and hallux valgus angles, as well as time to osteotomy union and hardware failure. At 1 year, similar results were obtained radiographically. The healing of the osteotomies was significantly faster in the Mg group. Hardware failure was common in the Mg group (5/26) than in the TI group (0/34) but hardware removal was more common in the TI group (6/34) versus the MG group (0/26). IF5C increased by 8 ± 2 mm in the Mg group. The AOFAS and PGIC scores at 6 months were similar. Validated foot scores and radiographic analysis indicated that there was no detectable difference between the groups. The fast achievement of osteotomy union compensates for a high rate of hardware failure, resulting in patient satisfaction and avoiding reoperation for hardware removal.

Evaluate the Influencing Factors of Congruency of the First Metatarsophalangeal Joint in Hallux Valgus Based on Weightbearing CT

The purpose of this study was to explore the difference between congruency and incongruency of the first metatarsophalangeal (MTP) joint in hallux valgus using weightbearing CT (WBCT) and to identify the risk factors for incongruency. From January 2019 to January 2021, WBCT scans were retrospectively analyzed for 110 (191 feet) consecutive patients. According to whether the metatarsal articular surface and phalanx articular surface were parallel, they were divided into congruency (73 feet) and incongruency groups (118 feet). The age, intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular surface angle (DMAA), first metatarsal coronal pronation angle (α angle), tibial sesamoid 7 positions (TSP), and tibial sesamoid coronal grading (TSCG) were compared between the 2 groups. Binary logistic regression was used to analyze the influencing factors of incongruency. Receiver operating characteristic (ROC) curve analysis was applied to determine the cutoff value. There were significant differences in IMA, HVA, DMAA, α angle, age, TSP, and TSCG between congruency and incongruency groups (p < .05). Binary logistic regression analysis showed that TSCG, HVA, α angle were the influencing factors of incongruency. ROC curve analysis demonstrated that the cutoff values for incongruency were 1 position for TSCG (sensitivity: 0.835; specificity: 0.884) with the area under curve (AUC) of 0.892, 30° (sensitivity: 0.795; specificity: 0.812) for HVA with the AUC of 0.878, and 24° (sensitivity: 0.530; specificity: 0.797) for α angle with the AUC of 0.686. Incongruency of the first MTP joint indicated a more severe hallux valgus, and was associated with increased HVA, α angle, and TSCG.

Anthropometric measurements of the foot cannot predict the screw diameter for fifth metatarsal fractures intramedullary fixation

PURPOSE

The present study aimed to evaluate the accuracy of anthropometric foot measurements in predicting the diameter of the intramedullary screw for fifth metatarsal fracture fixation. Secondary aim was to identify whether the fifth metatarsal intramedullary canal diameter is correlated to the fifth metatarsal length and the foot dimensions.

METHODS

In 29 cadaveric feet, the maximum length of the plantar surface of the foot (PL) and the perimeter of the foot at the level of the fifth metatarsal base (PBFM) were measured using a measuring tape. Subsequently, the fifth metatarsal was excised. Using Computed Tomography scan, the metatarsal length (FML), and the horizontal (HDI) and vertical diameter (VDI) at the isthmus level were measured. The HDI values were grouped in 5 mm increments to correspond to the recommended screw diameter (RSD) for intramedullary fixation. A univariate linear regression analysis considered RSD and HDI as the dependent variables and FML, PL, PBFM as the independent variables. A multivariate regression analysis was performed to examine the predictive value of the two anthropometric measurements. A p-value < 0.05 was considered statistically significant.

RESULTS

All six univariate analyses revealed that the dependent variable was significantly correlated with the independent variable. However, the multivariate regression models showed that the anthropometric measurements were not significantly correlated with the RSD and HDI.

CONCLUSION

The current study found an association between the fifth metatarsal intramedullary canal diameter and the fifth metatarsal length and foot anthropometric dimensions. However, the anthropometric measurements of the foot presented a low predictive value for the decision of an intramedullary screw diameter in the treatment of fractures of the base of the fifth metatarsal.

Treatment of Freiberg's disease using a reverse pedicled metatarsal bone flap: Case report

Despite no surgical procedures receiving unanimous support for treating Freiberg's disease, several surgical treatment options have been described. For the past few years, bone flaps have been shown in children to present promising regenerative properties. We report a novel technique using a reverse pedicled metatarsal bone flap from the first metatarsal to treat one case of Freiberg's disease in a 13-year-old female. The patient presented 100% involvement of the second metatarsal head, with a 6 × 2 mm defect, unresponsive to 16 months of conservative measures. A 7 mm × 3 mm pedicled metatarsal bone flap (PMBF) was obtained from the lateral proximal first metatarsal metaphysis, mobilized and pedicled distally. It was inserted at the dorsum of the distal metaphysis of the second metacarpal towards the center of the metatarsal head, reaching the subchondral bone. Initial favorable clinical and radiological results were maintained for over 36 months during the last follow-up. Based on the powerful vasculogenic and osteogenic properties of bone flaps, this novel technique could effectively induce bone revascularization and prevent further collapse of the metatarsal's head.

Positron emission tomography assessment of metacarpal/metatarsal condylar fractures post surgical repair: Prospective study in 14 racehorses

OBJECTIVES

To assess 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) findings associated with metacarpal/metatarsal condylar fractures at the time of fracture repair and through healing.

STUDY DESIGN

Prospective descriptive study.

ANIMALS

Fourteen Thoroughbred racehorses.

METHODS

18F-NaF PET was performed within 4 days of surgical metacarpal/metatarsal condylar fracture repair, on both the injured and contralateral limb. Follow-up PET scans were offered at 3- and 5-months post fracture repair. Areas of abnormal uptake were assessed using a previously validated grading system.

RESULTS

Eight fractures were located in the parasagittal groove (PSG) (six lateral and two medial) and six fractures were located abaxial to the PSG (non-PSG) through the palmar/plantar condyle (all lateral). All horses in the latter group had uptake in the lateral palmar condyle of the contralateral limb suggestive of stress remodeling. Three horses with PSG fractures had uptake in a similar location in the contralateral limb. Horses with lateral condylar fracture only presented minimal or mild uptake in the medial condyle, which is considered atypical in the front limbs for horses in full training. Four horses developed periarticular uptake in the postoperative period suggestive of degenerative joint disease, three of these horses had persistent uptake at the fracture site. These four horses did not return to racing successfully.

CONCLUSION

The findings of this study provide evidence of pre-existing lesions and specific uptake patterns in racehorses suffering from metacarpal/metatarsal condylar fractures.

CLINICAL SIGNIFICANCE

PET has a possible role in the prevention, diagnosis, and postoperative monitoring of metacarpal/metatarsal condylar fractures in racehorses.

Operative outcomes of hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joints

BACKGROUND

Hallux valgus is sometimes accompanied by osteoarthritis of the lesser tarsometatarsal joint. However, information on the operative procedures and outcomes for the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint simultaneously is limited. We aimed to describe this operative procedure and evaluate the outcomes of the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint.

METHODS

Fifteen patients (17 feet; average age, 66.9 years; average follow-up, 59.4 months; and minimum follow-up, 24 months) with symptomatic hallux valgus accompanied by painful osteoarthritis of the lesser tarsometatarsal joint were enrolled. All feet showed osteoarthritis of the second and/or third tarsometatarsal joint on dorsoplantar weight-bearing radiograph. The operative procedure included a proximal osteotomy of the first metatarsal and arthrodesis of the lesser tarsometatarsal joint with an autologous bone graft.

RESULTS

The mean Japanese Society for Surgery of the Foot hallux metatarsophalangeal-interphalangeal score significantly improved from 54.8 points preoperatively to 91.7 points postoperatively (P <0.001). The mean postoperative visual analog score (15 feet) was 1.0 (0-3.9). Preoperative midtarsal pain disappeared in 14 feet and decreased in one foot postoperatively. Preoperative metatarsalgia was found in five feet, of which, it disappeared in two feet, decreased in two feet, and transferred to another region in one foot at the latest follow-up. The mean hallux valgus and intermetatarsal angles were 42.4° and 18.4° preoperatively, which decreased significantly to 12.5° and 6.9° postoperatively, respectively (P <0.001, all). Recurrence of hallux valgus (hallux valgus angle ≥20°) was observed in two feet (11.8%). Nonunion of the third tarsometatarsal joint was observed in one foot (3.1% among 32 joints).

CONCLUSIONS

The clinical and radiographic results indicated that operative treatment for hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joint significantly improves forefoot and midfoot pain and function and has low complication rates.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A 28-Year-Old Woman with Down Syndrome, Congenital Heart Disease, and a History of Knee Surgery and Plantar Fasciitis, with Hallux Abducto Valgus (Bunion) and Lapiplasty Three-Dimensional Correction Surgery

BACKGROUND Tarsometatarsal joint (TMJ) arthrodesis is common method used for correcting hallux abductus valgus (HAV). Its popularity has grown due to studies revealing HAV's triplanar deformity with frontal plane rotation. This case report presents a 28-year-old woman with Down syndrome, congenital heart disease, and a history of knee surgery and plantar fasciitis, with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. CASE REPORT Examination revealed severe foot deformities, and radiographic studies confirmed the condition. A surgical intervention was planned, and the patient's cardiologist confirmed she was fit for the procedure. The modified Lapidus technique with frontal plane rotational correction included realigning the metatarsal joint, resecting spurs, osteosynthesis material, and arthrosis in the sinus tarsi. After surgery, the patient underwent a recovery period without support for 8 weeks and received appropriate medical care. Radiographs showed successful alignment, and the patient gradually resumed her daily activities. The patient had an uneventful recovery, and postoperative radiographs showed good alignment in all planes. CONCLUSIONS The hyperlaxity associated with Down syndrome makes the incidence of HAV more frequent, and TMJ fusion is preferable to correction by osteotomy. The modified Lapidus technique with frontal plane rotational correction could be a good technique to achieve satisfactory correction in patients with severe HAV deformity and flexible valgus flatfoot associated with ligamentous hyperlaxity. TMJ fusion is indicated when severe or recurrent rotational component is observed in X-rays.

The potentially dangerous zone of the dorsomedial cutaneous nerve in minimally invasive surgery for hallux valgus: a cadaveric study

BACKGROUND

This study aims to describe the distribution of the dorsomedial cutaneous nerve (DMCN) in the middle and proximal parts of the metatarsal from a lateral view. The purpose is to provide guidance to surgeons in protecting the nerve during the 3rd and 4th generation minimally invasive surgery (MIS) for hallux valgus (HV).

METHODS

A total of 20 cadaveric feet were dissected to expose the course of the DMCN and sentinel vein. Measurements of the distances between the nerve/vein and the upper border of the metatarsal, as well as the height of the metatarsal, were taken from a lateral view. The distribution area was then described in proportion.

RESULTS

At the base of the metatarsal, the DMCN was distributed in the upper 25.7% of the area. When it reached the middle of the metatarsal, the DMCN was distributed in the upper 13.2-47.2% of the area. As for the sentinel vein, it was distributed in the upper 23.5-71.9% and upper 4.1-52.7%, respectively, at these two positions.

CONCLUSIONS

The area, which is above the line connecting the upper 1/4 point at the base of the first metatarsal and the 1/2 point at the middle of the first metatarsal, is a dangerous zone for the DMCN. Avoiding the zone is recommended during MIS for HV.

Successful treatment of advanced Freiberg's disease with a modified Weil osteotomy, 5-year follow up: A Pilot case series with a review of the literature

INTRODUCTION

Treatment for Freiberg's disease is largely conservative. For severe disease and refractory cases, there are various surgical options. The purpose of this study was to report the 5-year clinical outcomes of a modified Weil osteotomy in the treatment of advanced Freiberg's disease.

METHODS

Twelve patients (12 feet), with a mean age of 30.7 years (range 17-55), were treated with synovectomy and modified Weil osteotomy of the affected distal metatarsal head. There were 10 females and 2 males. Clinical outcomes were independently evaluated pre and postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system and a subjective satisfaction score. Radiological union was evaluated postoperatively. Nine (75%) feet involved the 2nd metatarsal and 3 feet (25%) involved the 3rd metatarsal. According to the Smillie classification, 6 feet were Grade IV and 6 feet were grade V.

RESULTS

No patients were lost to follow up and the mean follow-up time was 5.2 years (4-7). AOFAS scores improved from 48.1 + /- 7.4-88.9 + /- 10.1 postoperatively giving a mean improvement of 40.8 (p < 0.001). In total, 92% of patients were satisfied with their operation at latest follow-up, reporting excellent or good results. All patients had postoperative radiological union. One patient had a superficial postoperative infection that was successfully treated with oral antibiotics.

CONCLUSION

Modified Weil osteotomy is an effective treatment for advanced Freiberg's disease with good outcomes and few complications.

Biomechanical Comparison between Rotational Scarf Osteotomy and Translational Scarf Osteotomy: A Finite Element Analysis

OBJECTIVE

Rotational Scarf osteotomy has its unique advantages in treating hallux valgus, but it also has certain drawbacks. The biomechanical differences between rotational Scarf and translational Scarf osteotomy are not clear evaluates the correction ability and biomechanical difference of two surgical methods for hallux valgus by finite element analysis.

METHODS

The computerized tomography data of a hallux valgus patient were selected to establish a finite element model. The standard Scarf osteotomy was simulated based on the model, and the rotation and translation were performed, respectively. The size of the intermetatarsal angle, contact area, distal metatarsal articular angle and the absolute length of the first metatarsal was compared between the two groups. We completed the cartilage, ligament and other tissues on the bone model to establish a full foot model. We analyzed the troughing, plantar aponeurosis tension, plantar soft tissue, and ground stress and also observed the stability of the fracture site by a three-point bending test.

RESULTS

Both surgical methods may effectively correct the intermetatarsal angle. After rotational osteotomy, the contact area increased, and the length of the first metatarsal bone initially increased and then decreased compared to that in the translational group. Furthermore, rotational Scarf significantly increased the distal metatarsal articular angle. Mechanical analysis showed that the cancellous bone in the contact part of the fracture site in the translation group had greater stress, which was the reason for the occurrence of the troughing. Stress distribution of plantar aponeurosis, plantar soft tissue, and the ground showed no significant difference. The three-point bending test showed that the separation of the broken ends of the rotational Scarf osteotomy model (0.133 mm) was slightly smaller than the translational group (0.147 mm).

CONCLUSION

Both surgical methods can successfully correct intermetatarsal angle (IMA). Compared to traditional translational Scarf osteotomy, rotational Scarf osteotomy is more conducive to postoperative stability and healing, but it also has certain drawbacks. In clinical practice, individualized surgical methods still need to be selected for different types of patients with hallux valgus.