There is increased evidence of first metatarsal hyperpronation in patients with hallux valgus, but its impact on the stability of the first metatarsophalangeal and metatarsosesamoid joints is ...unknown. A previous biomechanical study showed that an increase in hallucal pronation might lead to medial soft tissue failure of the first metatarsophalangeal joint. Conversely, dynamic studies on hallux valgus have shown that the first tarsometatarsal joint moves in supination during weightbearing, and supination was associated with an increase in the intermetatarsal angle (IMA) and hallux valgus angle (HVA).
(1) Does an increase in first metatarsal pronation cause an increase in hallucal pronation? (2) Can an intrinsic increase in first metatarsal pronation lead to first ray supination during weightbearing? (3) Can a combination of intrinsic first metatarsal hyperpronation and first metatarsophalangeal medial soft tissue failure increase supination of the first ray during weightbearing? (4) Is first ray supination during weightbearing associated with an increase in the IMA and HVA?
Twelve transtibial, nonpaired cadaver specimens without deformities were used. Each specimen underwent six weightbearing CT scans under different conditions. The first three CT examinations were performed without any osteotomy of the first metatarsal. The first was a simulated nonweightbearing condition. The second was a simulated weightbearing condition. The third was a simulated weightbearing condition with medial soft tissue release. Subsequentially, a 30° pronation osteotomy of the first metatarsal was performed, and the same sequence of weightbearing CT images was obtained. On each weightbearing CT image, the HVA, IMA, sesamoid rotation angle, metatarsal pronation angle (MPA), metatarsosesamoid rotation angle, and hallucal pronation (HP) were measured. Motions were calculated based on the differential values of these angular measurements produced by the six different conditions (weightbearing, medial soft tissue release, 30° pronation osteotomy, and combinations of these conditions). We compared means using a t-test for normally distributed variables and the Mann-Whitney U test for nonnormally distributed variables. Correlations were assessed with Pearson product-moment correlation coefficients.
We found that 30° pronation osteotomy of the first metatarsal increased the MPA and HP by 28° ± 4° and 26° ± 6°, respectively, in the nonweightbearing condition. No differences between the increase in MPA and the increase in HP were noted (mean difference 2° 95% CI -1° to 5°; p = 0.20). Therefore, an increase in first metatarsal pronation caused an increase in hallucal pronation. When a 30° pronation osteotomy of the first metatarsal was performed, the first ray motion during weightbearing went from pronation to supination (4° ± 2° in pronation without osteotomy versus 4° ± 2° in supination after the osteotomy, mean difference 8° 95% CI 6° to 9°; p < 0.001). Therefore, an intrinsic increase in pronation of the first metatarsal led to a first ray supination motion during weightbearing. When a first metatarsophalangeal medial soft tissue release was performed in addition to the 30° osteotomy of the first metatarsal, the supination motion of the first ray increased (4° ± 2° without medial soft tissue release versus 11° ± 7° after the release, mean difference 8° 95% CI 3° to 12°; p = 0.003). Therefore, a combination of intrinsic first metatarsal hyperpronation and first metatarsophalangeal medial soft tissue failure increased supination of the first ray during weightbearing. Regarding static angular measurements, the HVA and IMA were not correlated with the MPA (ρ = 0.20; p = 0.09 and ρ = 0.22; p = 0.07, respectively). Regarding motions, as the HVA and IMA increased from nonweightbearing to weightbearing the pronation decreased, with strong correlations (ρ = -0.82; p < 0.001 and ρ = -0.77; p < 0.001, respectively). Therefore, a first ray supination during weightbearing was associated with an increase in the HVA and IMA.
The combination of first metatarsal intrinsic hyperpronation and first metatarsophalangeal medial soft tissue failure led to a hallux valgus deformity in this cadaveric study. The static measurement of first metatarsal head pronation relative to the ground (MPA) did not reflect the real intrinsic pronation of the first ray, and foot and ankle specialists should be careful when interpreting these measurements. Hallux valgus is a dynamic condition, and the deformity could be more correlated with motions during weightbearing than with plain static measurements.
First ray supination compensating for first metatarsal intrinsic hyperpronation might be an important factor in the hallux valgus pathogenesis. Further in vivo studies involving nonweightbearing and weightbearing comparative assessments of hallux valgus and controls should be performed to confirm this pathomechanism.
Metatarsal osteotomy is a major means of treating mechanical metatarsalgia. Open techniques are widely used, and notably that described by Weil. They have, however, certain drawbacks, and new types ...of osteotomy have been developed. Percutaneous techniques are presently very much in favor, and Distal Metatarsal Minimally Invasive Osteotomy (DMMO) has emerged as a treatment for metatarsalgia. Although very widely used, it is poorly codified in the literature.
The present study detailed DMMO techniques and their variants (oblique and reverse), with corresponding indications and treatment decision-tree.
Initial findings seem encouraging, with functional results comparable to those of open surgery. Postoperative edema and radiologic bone healing time seem to be longer in DMMO. There is, on the other hand, no difference regarding stiffness.
DMMO is an effective option to treat metatarsalgia, with variants enabling adaptation to foot morphology, but needing confirmation by studies with higher levels of evidence.
Background:
Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, ...as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to assess long-term outcomes of distal osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess HV recurrence rates reported in studies that had a minimum follow-up of 5 years.
Methods:
This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of distal osteotomies of the M1 for noninflammatory and nondegenerative HV at a minimum follow-up of 5 years.
Results:
We found 17 eligible studies comprising 18 data sets, reporting outcomes of 4 categories of osteotomies: Chevron, Mitchell, Bösch, and “others.” The HV recurrence rate was 64% considering the threshold of >15 degrees hallux valgus angle (HVA), 10% having >20 degrees, and 5% having >25 degrees.
Conclusion:
At a minimum of 5 years following distal osteotomies of the M1, the mean weighted postoperative HVA was significantly higher for Mitchell osteotomies compared with the 3 other osteotomies reviewed. There were otherwise no significant differences in recurrence rates using the 3 HVA thresholds, or intermetatarsal angle among any of the surgical techniques reported in 2 or more studies. The pooled HV recurrence rates considering the various thresholds of HVA were as follows: 64% having >15 degrees, 10% having >20 degrees, and 5% having >25 degrees. The recurrence rates in the long term for all categories of surgical procedures suggest that better understanding of pathogenesis and prognosis of HV is required before modifying or introducing new surgical techniques.
Level of Evidence:
Level IV, meta-analysis.
Category:
Bunion; Midfoot/Forefoot
Introduction/Purpose:
The outcomes of Hallux Valgus (HV) surgical treatment are perfectible.
First ray dysmorphia in HV appears to incorporate a first metatarsal ...(M1) hyperpronation and a valgus deviation of M1 distal articular surface. Those could play a role in first ray destabilization and misalignment in HV. However, we do not know whether correction of these deformities could improve HV surgical treatment outcomes.
Therefore, we performed a study to assess the impact of M1 distal supination osteotomy, M1 distal varization osteotomy, and combination of both on HV clinical and radiological outcomes.
We hypothesized that M1 distal supination osteotomies would improve surgical outcomes in HV.
Methods:
We conducted an IRB-approved multicenter randomized control trial.
HV with an indication for surgical correction were included. HV requiring surgery of the lesser metatarsals were excluded. Feet were randomly divided into 4 groups corresponding to 4 different types of surgery (Figure):
1. Control, classical M1 distal chevron.
2. Supination M1 distal chevron
3. Varization M1 distal chevron
4. Combination of the latter two.
Preoperative evaluation and 6-months follow-up were performed. Demographics, AOFAS score, complications, and patient satisfaction (Likert Scale) were collected.
On conventional weight-bearing radiographs before and 6 months after surgery, we measured the Hallux Valgus Angle(HVA), the Intemetatarsal Angle(IMA) the Distal Metatarsal Articular Angle(DMAA), the Okuda's M1 head shape classification(from round to angular) and the sesamoid position according to Hardy and Clapham.
Normality of different variables was assessed using the Shapiro-Wilk test. Groups were compared using ANOVA for normal and Kruskall Wallis for nonnormal variables. Post-hoc pairwise analyses were performed with Dunn-Bonferoni’s test.
Results:
100 HV were included. 8 were lost to follow-up.
The Control (n=24), Supination (n=20), Varization (n=26) and Combination (n=22) groups were comparable on age, gender, BMI, and preoperative radiological parameters.
At 6 months, there was no difference on AOFAS improvement (p=0.39) and patients satisfaction (p=0.14) whereas there were significant differences on HVA (p < 0.001), IMA (p < 0.001), DMAA (p < 0.001), Okuda's classifcation (p < 0.001) and sesamoid position (p < 0.001) between groups.
We found lower HVA values for Combination VS Control (p < 0.001), Combination VS Varization (p < 0.001), Supination VS Control (p < 0.001) and Supination VS Varization (p = 0.005).
Asymptomatic recurrences (HVA>15°) were present in 5 cases in Control (20.8%), and 2 in Varization (7.7%). Asymptomatic Hallux Varus (HVA < 0°) were present in 4 cases in Combination (18.2%), and 1 in Supination (5%).
Conclusion:
Distal M1 supination osteotomies showed better improvement in radiological parameters without showing clinical benefit.
The combination of supination and varization osteotomies could lead to overcorrection while the classic M1 distal chevron could lead to insufficient corrections.
Routinely performing a supination osteotomy in HV surgical management may lead to erroneous correction and we recommend an à la carte treatment.
These results are preliminary and we recommend more patients and longer follow-up to confirm these findings.
BACKGROUNDFactors that may affect surgical decompression results in tarsal tunnel syndrome are not known. METHODSA retrospective single-center study included patients who had undergone surgical ...tibial nerve release. The effectiveness of decompression was evaluated according to whether the patient would or would not be willing to undergo another surgical procedure in similar preoperative circumstances. RESULTSThe patients stated for 43 feet (51%) that they would agree to a further procedure in similar circumstances. Six feet with space-occupying lesions on imaging had improved results, but neurolysis failed in 9 feet with bone-nerve contact. Neurolysis was significantly less effective when marked hindfoot valgus (p = 0.034), varus (p = 0.014), or fasciitis (p = 0.019) were present. CONCLUSIONSIf imaging reveals a compressive space-occupying lesion, surgery has a good prognosis. In feet with static hindfoot disorders or plantar fasciitis, conservative treatment must be optimized. Bone-nerve contact should systematically be sought.
Purpose:
The purpose of this study was to obtain information on safety and short-term efficiency of a single intra-articular injection of mannitol-modified cross-linked hyaluronic acid (HANOX-M-XL) ...in patients with painful first metatarsophalangeal joint osteoarthritis (1stMTPJ-OA).
Methods:
The study involved an observational, single-arm, prospective multicentre trial, with a 3-month follow-up. Inclusion criteria were patients with symptomatic 1st MTPJ-OA not relieved by analgesics and / or non-steroidal-anti-inflammatory drugs and / or foot orthotic. All patients received a single, imaging-guided intra-articular (IA) injection of 1 mL of HANOX-M-XL in the 1st MTPJ. The primary outcome was the change in pain between the date of injection and month 3. The secondary outcomes were the patient assessment of effectiveness, the decrease in painkiller use and the influence of the radiographic score on the clinical efficacy.
Results:
Sixty-five participants (72.3% women, mean age = 60) were included in the trial. Coughlin-Shurnas radiological grade was 1 in 28 patients, 2 in 29, and 3 in 6. At baseline and month 3, the average pain (0-10) was 6.5 ± 1.8 and 2.8 ± 2.3, respectively. The change in pain score was highly significant (−3.1 ± 2.9; P < .0001). At baseline there was no statistically difference in pain between the radiological stages (P = .69). At endpoint, the average pain score was 2.0 ± 1.9 in x-ray stage 1, 3.1 ± 2.3 in stage 2 and 3.3 ± 2.4 in stage 3 (P = .001). Mild to moderate adverse reactions were reported by 15 patients. All were a transient increase of the hallux pain that occurred immediately and up to 6 hours after injection and resolved in 1 to 7 days.
Conclusion:
This pilot study suggests that a single IA injection of HANOX-M-XL is safe and mainly benefits patients with mild moderate 1st MTPJ-OA. Further randomized controlled trials are necessary to confirm these preliminary encouraging results.
Tarsal Tunnel Syndrome: Outcome According to Etiology Lalevée, Matthieu; Coillard, Jean-Yves; Gauthé, Rémi ...
The Journal of foot and ankle surgery,
May-June 2022, 2022 May-Jun, 2022-05-00, 20220501, 2022-05-01, Letnik:
61, Številka:
3
Journal Article
Recenzirano
Surgical results in tarsal tunnel syndrome are variable, and etiology seems to be a factor. Three possible etiologies can be distinguished. The aim of the present study was to compare surgical ...results according to etiology. Three continuous retrospective series (45 patients overall) of tarsal tunnel syndrome were compared. Group 1 presented a permanent intra- or extra-tunnel space-occupying compressive structure. Group 2 presented intermittent intra-tunnel venous dilatations. Group 3 comprised idiopathic tarsal tunnel syndrome. The mean follow-up was 3.6 +/- 1.8 years. The main endpoint was subjective postoperative improvement on Likert scale. Group 1 reported greater improvement than groups 2 and 3. Preoperative neuropathy on ultrasound was associated with poorer improvement, which was not the case for neuropathy on electromyography. Surgical treatment of tarsal tunnel syndrome provides better results in etiologies involving structural compression.
First metatarsophalangeal (MTP1) joint arthrodesis, described as a safe and effective procedure, has complications that may require surgical revision. These complications are rarely studied. The aim ...of this study was to determine the incidence and outcomes of revision surgery after MT1 arthrodesis.
The incidence of surgical revision after MTP1 arthrodesis is not insignificant; however, the outcomes are satisfactory.
In this multicenter retrospective study between January 2014 and December 2015, 190 forefoot revisions in patients who had previously undergone MTP1 arthrodesis were included by 8 surgeons. There were no exclusion criteria and all patients had at least 1 year of follow-up. Over the same period, 958 primary MTP1 arthrodesis procedures were performed.
The mean time to revision was 4.6±10.9 years. At a mean follow-up of 20.5±7.4 months, 158 cases were available for analysis in 135 women and 20 men who had a mean age of 67.1±10.5 years. These revision procedures were carried out because of discomfort related to the hardware at the arthrodesis site (n=86, 54%), nonunion (n=22, 14%), malunion (n=13, 8%) metatarsalgia or claw toe (n=18, 11%) and first interphalangeal (IP1) joint disorders (n=13, 8%). The mean postoperative scores were 75±13.9 for the AOFAS and 65±19.6 for the SF36 total. In the nonunion cases, removal of the hardware led to better outcomes than repeating the arthrodesis procedure. Osteotomy in the malunion cases healed successfully. In the cases of IP1 osteoarthritis, secondary arthrodesis or arthroplasty led to good outcomes.
Relative to published results of primary MTP1 arthrodesis, the outcomes in our series of revision MTP1 arthrodesis surgery cases are practically equivalent, thus considered acceptable.
IV, Retrospective study.
Background:
Hammertoe and claw toe are among the most common foot deformities. Proximal interphalangeal (PIP) joint realignment can be performed using specifically designed intramedullary implants. ...The aim of this study was to assess the clinical outcome of patients with lesser toes deformities undergoing PIP joint realignment using an intramedullary implant.
Methods:
Patients requiring PIP joint realignment were included in this prospective multicenter observational study and followed for 12 months. A total of 156 toes, in 117 patients were implanted with the implants. Complications and radiological and functional outcome were assessed.
Results:
The proportion of joints fused on X-rays was 83.8% (95% CI: 77.8, 89.7) after 1 year. American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal-interphalangeal scale (AOFAS-LMIS) improved from 40.4 (SD = 18.3) preoperatively to 85.5 (SD = 9.2) after 1 year. The proportion of patients with pain was 15.5% after 6 weeks and decreased to 4.7% after 1 year. Of the patients, 98% were satisfied about the operation. In patients with incomplete fusion of the PIP joint after 1 year, AOFAS-LMIS improved from 36.7 (SD = 18.9) preoperatively to 84.2 (SD = 10.1) 1 year postoperatively, while pain was reported by 2 patients (8.3%) after 1 year. Toe malalignment and lack of toe pulp-contact were reported slightly more frequently than for the whole group of patients, but not for the majority of the cases. Overall, complications were reported intraoperatively in 1.3% of the patients (2 cases) and postoperatively in 3.2% (5 cases). Revision was required in 1 case. Mallet toe deformity was found in 2.0% of the patients after 1 year.
Conclusion:
This study showed that the use of an intramedullary implant for PIP realignment led to a high rate of fusion and a good outcome. No need of reoperation was reported for patients with incomplete joint fusion who had a stable joint with no pain.
Level of Evidence:
Level IV, prospective case series.
Category:
Midfoot/Forefoot; Bunion
Introduction/Purpose:
Hyperpronation of the first metatarsal (M1) is present in Hallux Valgus (HV) but its impact is still unknown. A previous biomechanical study ...showed that an increase in hallucal pronation might lead to a medial soft tissue failure of the first metatarsophalangeal joint (MTP1). Conversely, an increase in supination and adduction of the first ray when weight-bearing is present in case of HV. The objective of our study was to sequentially answer the following questions: (1) Does an increase in M1 pronation cause an increase in hallucal pronation? (2) Can a combination of intrinsic M1 hyperpronation and MTP1 medial soft tissue failure induce a supination motion of the first ray during weight-bearing? (3) Can a first ray supination motion during weight- bearing be accompanied by an increase in IMA and HVA?
Methods:
A cadaveric model allowing a simulated standing position was developed and secured with a radiolucent frame (Figure 1). A midshaft osteotomy of M1 was performed allowing either 0° or 30° in pronation. MTP1 medial soft tissue release was performed to simulate failure. Twelve specimens underwent 6 Weight-Bearing CT acquisitions under different conditions listed below. The first 3 acquisitions had 0° pronation of M1:1. Simulated non-weight-bearing condition (Figure 2a) 2. Simulated weight- bearing condition (Figure 2b) 3. Simulated weight-bearing condition with medial soft tissue failure (Figure 2c). The next 3 WBCT acquisitions followed the same sequence but with 30° pronation of M1 (Figure 2d to 2f). On each WBCT acquisition, the HVA, IMA, Metatarsal Pronation Angle (MPA, M1 head pronation relative to the ground) and the hallucal pronation (HP) were measured (Figure 3). Motions were indirectly calculated from the differential values of these angular measurements produced by these 6 different conditions.
Results:
1.The increase in MPA and HP induced by the 30° pronation osteotomy of M1 in simulated non weight bearing- conditions were respectively 27.6+/-4.1 and 25.5+/-5.6 degrees (p=0.202). 2.The first ray motion induced by weight-bearing without pronation osteotomy combined with a MTP1 medial soft tissue failure was 3.7+/-3.6 degrees pronation (differential value on MRA between Figure 2a and 2c) compared to 11+/-7.5 degrees supination after the 30 degrees pronation osteotomy of M1 combined with a MTP1 medial soft tissue failure (p<0.01) (differential value on MPA between Figure 2d and 2f). 3.Regarding the static angular measurements, the HVA and the IMA presented fair positive linear correlations with the MPA (respectively ρ=0.2 and ρ=0.22). Regarding the motions, the increase of the HVA and the IMA during weight-bearing presented respectively a very strong negative (ρ=-0.82) and a strong negative (ρ=-0.77) linear correlations with the pronation motion of the first ray during weight-bearing.
Conclusion:
The combination of M1 intrinsic hyperpronation and MTP1 medial soft tissue failure led to an HV deformity in our cadaveric study. The static measurement of M1 head pronation relative to the ground (MPA) does not reflect the real intrinsic pronation of the first ray and foot and ankle specialists should be careful when interpreting these measures. HV is a dynamic condition, and the deformity could be more correlated with motions when WB than with plain static measurements. The first ray supination motion compensating a M1 intrinsic hyperpronation might be an important factor in the HV pathogenesis.
PDF
