Category:
Midfoot/Forefoot; Bunion
Introduction/Purpose:
The most common indications for revision of 1st Metatarsophalangeal (MTP) joint surgery are symptomatic failures of prior fusion, failed ...hallux valgus correction, and failed MTP arthroplasty implants. The outcome of revision 1st MTP fusion has rarely been studied. The purpose of this study was to compare the clinical, radiographic, and patient-reported outcomes of revision MTP fusion for different indications.
Methods:
A retrospective chart review was performed for patients who underwent revision 1st MTP fusion between January 2015 and December 2019 in a single-center, by 4 fellowship-trained foot and ankle surgeons. The complication, revision, and non- union rates as well as VAS and PROMIS scores and pre-operative and post-operative radiographs were analyzed and compared between the different indication groups. Univariate and multivariate analysis and logistic regression models were used to obtain odds ratio of the explanatory variables for outcome measures.
Results:
A total of 79 cases of revision MTP fusion were included. Thirty-eight cases of hallux valgus corrections salvage, 22 failed MTP arthroplasty implants, 6 failed polyvinyl alcohol hydrogel implants, 13 prior MTP fusion non-unions. The mean follow-up time was 350 days (Median 226, SD 306). Seven cases (8.9%) required structural iliac-crest bone graft during the revision. Seven cases (8.9%) required allograft augmentation. The overall complication rate was 40.7%. Fifteen patients (18.5%) were classified as Clavien-Dindo grade 3, which represents a complication that may require a revision surgery (i.e. non-union, deep infection, loss of correction). Eventually, 7 cases (8.9%) underwent further revision surgery. The logistic regression model demonstrated that indication for revision was not significantly related to union rate (p=0.280). Visual-Analogue-Scale significantly improved at 6 weeks, 3 months, and at last follow-up in all indications for revision (p=0.001). PROMIS-10 Physical and PROMIS-10 Mental did not change significantly during follow-up (p=0.860, p=0.589).
Conclusion:
Treatment of 1st MTP joint surgery failures is a clinical challenge in orthopaedic surgery. In our study, revision of 1st MTP joint surgery with MTP fusion had higher non-union rates and higher overall complication rates compared to primary 1st MTP fusion. Nevertheless, revision rates remained comparable to primary 1st MTP fusion. Complication rates and patient- reported outcomes were similar between the different indications for revision groups. Visual-analogue-scale improved significantly during follow-up in all groups. Diabetes mellitus had a significant impact on non-union rates and overall complication rates.
Category:
Sports; Midfoot/Forefoot
Introduction/Purpose:
Low-energy Lisfranc injury is increasingly reported in the literature. While there is a relatively large body of studies discussing the high ...energy Lisfranc injuries, the evidence available on this low-energy injury in active individuals with high demand remains scarce and mostly retrospective. The injury can range from a non-displaced ligamentous sprain to fracture-dislocations, and management varies from non-operative management to primary arthrodesis with a multitude of variables potentially affecting the return to play (RTP) and return to duty (RTD). This study aims to report on return to play (RTP) rate and time with regard to the type of the injury, whether bony or ligamentous, management whether non-operative, open reduction and internal fixation (ORIF) or the increasingly debated primary arthrodesis (PA).
Methods:
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, relevant studies in English literature were identified between database inceptions to June 2019. Electronic based search on MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases using the following keywords with their synonyms: ('Lisfranc' AND 'athlete' AND 'midfoot sprain'). In addition, the reference lists from previous review articles were searched manually to check for eligible studies. Two investigators (AA, KM) independently reviewed all titles, abstracts, and the full text of articles that were potentially eligible based on the abstract review. The eligible studies were selected according to the inclusion and exclusion criteria. Any disagreement was resolved by the senior author (DF). The primary outcomes were (1) return to play rate and (2) time to return to play, whereas the secondary outcomes were (1) games missed, (2) time out of practice, (3) midfoot arthritis, and reoperation.
Results:
15 studies were eligible for meta-analysis with a total of 441 subjects. Out of 441 subjects, a total of 380 (86.16%) were able to return to play and duty. There were no statistically significant difference in RTP comparing op vs. non-op OR=0.714, CI: 0.17-2.88,I2=0% nor ORIF vs. PA OR=0.780, CI: 0.310-1.963, I2=0%. The overall RTP in bony and ligamentous injuries were 82.1% CI:70.9-93.4%, I2=0% and 95.8% CI:92.6-99.1%, I2=0%, respectively with no statistically significant differences OR=1.909, CI=0.64- 5.64, I2=37%. The mean time out in non-op and op. groups were 58.01 CI:13.6-102.4, I2=98.03% and 116.4 CI:62.4-170.4; I2=99.45% days, respectively. The mean time out in bony and ligamentous injury groups were 98.8 CI:6.1- 191.6, I2=99.82% and 76.4 CI:37.9-115.02; I2=99.83% days, respectively with statistically significant differences SMD:3.621, CI:- 5.7-13, I2=83.17%.
Conclusion:
Our meta-analysis on low-energy Lisfranc injuries in high demand individuals found an overall excellent RTP/RTD rate. The time out was not affected by the management, bony or ligamentous nature of the injury nor players' position. However, the low level of evidence and significant heterogeneity of the included studies precludes making conclusions regarding the exact time out or optimal management. Superior quality studies on low energy Lisfranc are needed.
Biological erosion is a key process for the recycling of carbonate and the formation of calcareous sediments in the oceans. Experimental studies showed that bioerosion is subject to distinct temporal ...variability, but previous long-term studies were restricted to tropical waters. Here, we present results from a 14-year bioerosion experiment that was carried out along the rocky limestone coast of the island of Rhodes, Greece, in the Eastern Mediterranean Sea, in order to monitor the pace at which bioerosion affects carbonate substrate and the sequence of colonisation by bioeroding organisms. Internal macrobioerosion was visualised and quantified by micro-computed tomography and computer-algorithm-based segmentation procedures. Analysis of internal macrobioerosion traces revealed a dominance of bioeroding sponges producing eight types of characteristic Entobia cavity networks, which were matched to five different clionaid sponges by spicule identification in extracted tissue. The morphology of the entobians strongly varied depending on the species of the producing sponge, its ontogenetic stage, available space, and competition by other bioeroders. An early community developed during the first 5 years of exposure with initially very low macrobioerosion rates and was followed by an intermediate stage when sponges formed large and more diverse entobians and bioerosion rates increased. After 14 years, 30 % of the block volumes were occupied by boring sponges, yielding maximum bioerosion rates of 900 g m−2 yr−1. A high spatial variability in macrobioerosion prohibited clear conclusions about the onset of macrobioerosion equilibrium conditions. This highlights the necessity of even longer experimental exposures and higher replication at various factor levels in order to better understand and quantify temporal patterns of macrobioerosion in marine carbonate environments.
Background:
Hyperpronation of the first metatarsal in hallux valgus (HV) is poorly understood by conventional weightbearing radiography. We aimed to evaluate this parameter using weightbearing ...computed tomography (WBCT) and to understand its association with other standard measurements.
Methods:
Retrospective evaluation of WBCT and weightbearing radiographs (WBXRs) was performed for 20 patients with HV feet and 20 controls with no such deformity. Axial computed tomography images of both groups were compared for the first metatarsal pronation angle (alpha angle) and tibial sesamoid subluxation (TSS) grades. The HV angle (HVA), first-second intermetatarsal angle (IMA), first metatarsal-medial cuneiform angle (MMCA), Meary’s angle, and calcaneal pitch (CP) angle of the study and control groups were compared on both WBXR and the corresponding 2-dimensional images of WBCT. All measurements were independently performed by 1 musculoskeletal radiology fellow and 1 foot and ankle surgical fellow. Measurements were averaged and interobserver reliability was calculated.
Results:
The HV group demonstrated significantly higher values for TSS grade (P < .001) but not for alpha angle (P = .121) compared with controls. Likewise, significantly elevated HVA and IMA were noted in the HV group on both imaging modalities, while no such differences were observed for the CP angle. Higher MMCA and Meary’s angle in the HV group were evident only on WBXR (MMCA, P = .039; Meary’s, P = .009) but not on WBCT (MMCA, P = .183; Meary’s, P = .171).
Among all, the receiver operating characteristic (ROC) curves demonstrated the greatest area under the curve (AUC) for HVA, followed by IMA. The alpha angle performed only just outside the range of chance (AUC, 0.65; 95% CI, 0.52-0.69). The Pearson’s correlations of the alpha angle, in the HV group, revealed a significant linear relationship with TSS grade and with HVA on WBXR, and only trended toward a weak linear relationship with IMA and with HVA on WBCT.
Conclusion:
The alpha angle, a measure of abnormal hyperpronation of the first metatarsal, was an independent factor that may coexist with other parameters in HV, but in isolation had limited diagnostic utility. “Abnormal” alpha angles were even observed in individuals without HV. Increases in IMA and MMCA were not necessarily associated with similar increases in alpha angle, despite moderate correlations with TSS grade and HVA on WBXR. Nevertheless, the WBCT was a useful method for assessing hyperpronation and guiding surgical management in individual cases.
Level of Evidence:
Level III, retrospective comparative study.
Category:
Ankle, Trauma, Epidemiology
Introduction/Purpose:
The most frequent cause of traumatic foot and ankle fractures is a fall to the ground. Alcohol consumption, especially in excess, has the ...potential to impart a significant fall risk on patients by reducing postural control resulting in imbalance. However, the relationship between the consumption of alcohol and the risk of traumatic foot and ankle fracture is poorly characterized. The purpose of this study was to report national estimates, injury mechanisms, and demographic characteristics of patients presenting to U.S. emergency departments (EDs) with traumatic foot and ankle fractures associated with alcohol consumption.
Methods:
This cross-sectional, retrospective epidemiological study analyzes case narratives in the National Electronic Injury Surveillance System (NEISS) database to examine national estimates of traumatic foot and ankle fractures associated with alcohol consumption presenting to U.S. emergency departments between 2000 and 2017, sampling in two-year intervals. Data from the Organisation for Economic Co-operation and Development (OECD) on the “Value for Total U.S. Adult Alcohol Consumption in Liters/Capita” was used in a simple regression model to demonstrate how increased alcohol consumption in the United States has predicted changes in the national number of alcohol-associated foot and ankle fractures over time.
Results:
Nationally, alcohol-associated foot and ankle fractures increased significantly between the 2000-2001 (N=2,878; C.I. 1,869-3,887) and 2016-2017 (N=8,778; C.I. 6,751-10,806) periods (p<0.001). Simple regression (R2 = 0.87; p<0.001) demonstrated that in the U.S., a one-tenth increase in the total liters of alcohol consumed per capita predicted an additional 606 alcohol-associated foot and ankle fractures presenting to U.S. EDs. About two-thirds of patients suffered ankle fractures (65.6%; C.I. 61.1%-70.1%). Fractures were commonly sustained by male patients (58.4%; C.I. 53.9%-62.9%) at home (46.5%; C.I. 40.9%- 52.2%); roughly one-third of patients required admission to the hospital (29.7%; C.I. 24.5%-34.9%). The most common injury mechanisms for alcohol-associated foot and ankle fractures were falls to the ground from standing height (33.0%; C.I. 28.8%- 37.2%), and falls down stairs or steps (31.0%; C.I. 26.1%-35.9%).
Conclusion:
Falls to the ground mechanistically link alcohol consumption to traumatic fractures of the foot and ankle. These new findings highlight how the negative societal impacts of alcohol – and potentially other substances – may be overlooked. As a result, this information should serve as an impetus to direct national attention towards awareness and preventative measures. Furthermore, our findings may help clinicians identify, educate, and counsel patients with certain demographic risk factors for alcohol-associated foot and ankle fractures.
Russell–Silver syndrome (RSS) is a heterogeneous disorder characterized mainly by pre- and postnatal growth retardation and characteristic dysmorphic features. The genetic cause of this syndrome is ...unknown. However, two autosomal translocations involving chromosome 17q25 were reported in association with RSS. Molecular analysis of the breakpoint on chromosome 17 of the de novo translocation previously described as t(1;17)(q31;q25) enabled us to refine the localization of the chromosome 17 breakpoint to 17q23–q24. Since no detailed mapping data were available for this region, we established a contig of yeast artificial chromosomes, P1 artificial chromosomes, bacterial artificial chromosomes, and cosmid clones for a 17q segment flanked by the sequence-tagged site (STS) markers D17S1557 and D17S940. This contig covers a physical distance of 4–5 Mb encompassing several novel markers. A transcript map was constructed by assigning genes and expressed sequence tags to the clone contig, and altogether 74 STS markers were mapped. Furthermore, the locus order and content provide insight into several duplication events that have occurred in the chromosomal region 17q23–q24. On the basis of our refined map, we have reduced the translocation breakpoint region to 65 kb between the newly derived markers 58T7 and CF20b. These data provide the molecular tools for the final identification of the RSS gene in 17q23–q24.
Category:
Bunion; Midfoot/Forefoot
Introduction/Purpose:
The majority of hallux valgus corrections are performed via a two dimensional approach with 1st metatarsal osteotomy and translation in the ...transverse plane. This approach has demonstrated high long-term recurrence rates. Recent research demonstrates that 87% of hallux valgus deformities are three-dimensional with abnormal frontal-plane rotation of the metatarsal, which cannot be completely addressed with a two dimensional metatarsal osteotomy alone. While correction at the 1st tarsometatarsal (TMT) joint may provide the optimal surgical approach for 3D anatomic restoration at the apex of the deformity, 1st TMT fusion historically entails an extended period of non-weightbearing. This study evaluated the clinical, radiographic, and patient-reported outcomes in patients undergoing instrumented triplanar 1st TMT arthrodesis (TMTA) with a biplanar plating system and protected near-immediate weightbearing.
Methods:
This is a prospective multicenter study that will continue for 60 months post-operatively. Patients between 14-58 years old with symptomatic hallux valgus (intermetatarsal and hallux valgus angles between 10.0-22.0° and 16.0-40.0°, respectively) and no prior hallux valgus surgery on the operative foot were eligible for this study. Patients were treated with an instrumented TMTA procedure using a biplanar plating system with protected near-immediate weightbearing. Several outcomes (radiographic, return to weightbearing and activities, pain measured by visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOxFQ), and Patient Reported Outcomes Measurement Information System (PROMIS)) were evaluated post-operatively. Two independent fellowship trained musculoskeletal radiologists reviewed all radiographic data. These interim results are limited to patients completing at least 6 months of follow-up.
Results:
165 patients underwent TMTA with at least 6 months follow-up (mean (SD): 17.8 (7.7); min, max: 5.8, 37.3). Mean age was 41.0 (range:14-58) years; 91.5% of patients were female. Mean (SD) days to protected weightbearing in CAM boot and return to full work were 8.4 (7.7) and 56.8 (45.6), respectively. Significant improvements from baseline in HVA, IMA, and TSP (Table 1), VAS score, MOxFQ and PROMIS domains were observed as early as 6 weeks post-procedure. At 12 months, mean (95% CI) change in VAS was -3.7(-4.0, -3.3); Walking/Standing (MOxFQ) change was -35.2 (-39.6, -30.8); and Physical Function (PROMIS) change was 8.7 (7.1, 10.3). Fifteen (9.1%) patients experienced hardware complications, yet maintained radiographic correction to date. No patients (0/58) with 24 months follow-up have experienced recurrence.
Conclusion:
These interim findings support that TMTA with biplanar plating is successful in correcting the 3D hallux valgus deformity with early return to weightbearing while demonstrating favorable clinical and patient-reported outcomes. Patients exhibited meaningful pain reduction after surgery and were able to return to full, unrestricted work and activities in less than two months, on average. Statistically significant improvements in patients' health-related quality of life were observed at 6 and 12 months, post-operatively. Patients will continue to be followed for up to 60 months with additional evaluations for complications, 24-month recurrence, and patient satisfaction.
The Achilles tendon is the strongest tendon in the human body and, as such, has its share of problems. Although many conditions affecting this tendon can be treated nonoperatively, surgical ...intervention is often necessary. Local, regional, distant, and allograft tendon can be used to supplement or enhance reconstruction or repair of the Achilles tendon. Specific techniques are explored and described and the published results from the literature summarized. This article explores the use of tendon transfers and supplementation in the treatment of insertional and noninsertional Achilles tendinosis as well as in cases of neglected or chronic ruptures of the tendoachilles.
Category:
Bunion; Midfoot/Forefoot
Introduction/Purpose:
The pathogenesis of the hallux valgus deformity is still poorly understood. Consistent observations of the 1st tarsometatarsal (TMT) joint as ...the CORA of hallux valgus raises questions about pathology associated with that joint. Mason and Tanaka studied the 1st TMT joint in cadaveric specimens in 2012, observing three morphological subtypes to the 1st cuneiform articular surface. They noted that specimens with hallux valgus had either a unifacet (37%) or bifacet (63%) appearance, where normal feet had a trifacet appearance. This observation suggests that these bony differences may be responsible for 'instability' that generates the metatarsal deviation into varus, and thus the development of hallux valgus. If true, surgical corrections for hallux valgus deformity should address this TMT joint pathology.
Methods:
This study was designed to correlate the morphological differences of the TMT joint with symptomatic hallux valgus patients who are seeking surgery. The hypothesis was that the hallux valgus patients would show a majority unifacet and bifacet morphology and have an inclination towards unifacet in younger patients and patients with a larger deformity. The cohort of patients who are in the registered longitudinal study Align3D had their TMT joints harvested in a standard fashion as part of their surgical treatment. These specimens were analyzed for the number of facets by the surgeon at the time of their surgical procedure. This cohort therefore only includes symptomatic hallux valgus patients and eliminates hallux valgus associated with metatarsus adductus. Standard weight-bearing x-rays taken pre-operatively were analyzed for severity of deformities. Functional and Patient Reported Outcome measures were obtained pre-operatively and post-operatively.
Results:
In this study we observed 143 specimens. Unifacet was observed in 116 specimens (81.1%), bifacet was observed in 26 specimens (18.2%), and trifacet was observed in 1 specimen. Neither X-Ray findings, age, nor Functional Scores suggested a trend in severity in relation to morphological type. Mason & Tanaka's cadaveric study was limited in some respects because of the hardening effect of formaldehyde preservations. Their study represented an elderly population, mean age 86 years, whereas this study represented a much younger population, mean age 40.6, in which patients were able to participate in both X-Ray and clinical scoring. To the best of our knowledge, this is the first time that morphology of the TMT joint has been studied in symptomatic hallux valgus patients who underwent surgery.
Conclusion:
Symptomatic hallux valgus deformities are associated with a higher likelihood of having a unifacet morphology than previously reported in cadavers (81.1% vs 37%). This morphology may predispose patients to decreased stability resulting in more symptomatic deformity. The number of facets does not seem to correlate with severity of deformity on X-Ray evaluation, nor does it correlate with age. However, the younger age group in our study as compared to Mason and Tanaks's study suggests that morphological differences may even be congenital, leading to later development of deformity.
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