Imaging of Müller-Weiss Disease.

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

Tibiotalocalcaneal Arthrodesis in Severe Hindfoot Deformities.

Tibiotalocalcaneal arthrodesis (TTCA) is the most common and reliable procedure in the treatment of patients with end-stage ankle arthritis combined with severe deformity. Many of these patients present with difficult previous sequelae that include nonunion, malunion, broken implants, vascular deficiencies, skin problems, or a combination of the previous. In that complex scenario, sometimes the only alternative treatment is a below-the-knee amputation. Image studies--weightbearing X-rays, tomography, and magnetic resonance - are fundamental to evaluate alignment and bone stock. When all conservative treatments fail to alleviate pain and dysfunction, the combination of osteotomies and arthrodesis is the procedure of choice. Surgical planning needs to be very detailed and thorough with a special focus on bone loss after debridement of non-healthy tissue and removal of metalwork. TTCA with grafting allows for the preservation of the limb in more than 80% of cases but at the expense of many complications with nonunion rates of approximately 20% of cases. There is controversy about the use of a retrograde nail versus specific TTCA plate and screws but results from biomechanical studies do not show a clear superiority of one specific construct. Amputation rates are close to 5% of cases after repeated failed surgeries. Bulk allografts increase the rate of nonunions but apparently do not have an influence on postoperative infections. Valgus positioning of the ankle/hindfoot is paramount to allow for maximal sagittal plane compensation from the midtarsal joints. Most patients are satisfied with the results of these salvage operations. The studies presented in this article have a considerable wide array of different scenarios that obviously bias some of the results, complications, and outcomes but together they present a persuasive pattern toward considering TTC with grafting and nail or plate fixation as a good salvage procedure that may help the patients to maintain their foot and ankle with a better alignment, function, and pain relief.

Navicular Fracture.

The tarsal navicular is an essential component of the Chopart joint and crucial for most of hindfoot motion. Most fractures are low-energy dorsal avulsions that may be treated nonoperatively. Displaced comminuted fractures require open reduction and internal fixation, sometimes with external fixation, bridge plating, and bone grafting. Diagnosis of stress fractures is commonly delayed. Conservative treatment is associated with good results, but surgery allows for quicker return-to-play in athletes. Nonunion in acute and stress fractures needs open debridement, grafting, and stable fixation. Müller-Weiss disease may present with a fragmented navicular and mimic an acute or a stress fracture.

Deciding Between Ankle and Tibiotalocalcaneal Arthrodesis for Isolated Ankle Arthritis.

After isolated ankle (tibiotalar) arthrodesis, the triceps progressively shifts the subtalar joint into varus thus blocking compensatory motion from the midtarsal joints. In a tibiotalocalcaneal arthrodesis, the subtalar may be fixed with the correct valgus. Comparison between ankle and tibiotalocalcaneal arthrodesis does not clearly favor one over another for pain relief, satisfaction, and gait analysis. Compensatory sagittal plane motion through the midtarsal joints when the subtalar is fixed in valgus may be responsible for these results. Tibiotalocalcaneal arthrodesis has become our procedure of choice over isolated tibiotalar for end-stage ankle arthritis regardless of the radiographic state of the subtalar.

Progressive Collapsing Foot Deformity. Is There Really a Johnson and Strom Stage I?

Johnson and Strom stage I posterior tibialis tendon dysfunction presents with pain and swelling but preserved function and no deformity. Diagnosis is clinical. Pathomechanics explains the overloading of the tendon that may be worsened by a tight gastrocnemius, but systemic inflammatory disease may also be responsible for a stage I condition. Medial heel wedged orthoses are effective in most patients. Surgery usually consists of an open/endoscopic tenosynovectomy. In cases of complete tendon rupture, flexor digitorum longus tendon transfer may be considered. Stage I patients with a higher risk of progression-inflammatory conditions, excessive laxity, obese-may benefit from a "prophylactic" medializing calcaneal osteotomy.

Management of Complications After Hallux Valgus Reconstruction.

Complications following hallux valgus (HV) reconstruction will have an expected incidence of between 10% and 55% of cases. The more commonly reported complications include undercorrection/recurrence, overcorrection (hallux varus), transfer metatarsalgia, nonunion, malunion, avascular necrosis, arthritis, hardware removal, nerve injury, and ultimately patient dissatisfaction. The presence of arthritis will be an indication for fusion, whereas osteotomies will be the procedure of choice if the first metatarsophalangeal joint is healthy. Wide experience in primary HV surgery is advised before dealing with complex cases of failed HV surgery.

Mechanical Basis of Metatarsalgia.

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

Evolution of the Weil Osteotomy: The Triple Osteotomy.

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

Management of Müller-Weiss Disease.

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

Plantar fasciopathy: A current concepts review.

Plantar fasciopathy is very prevalent, affecting one in ten people in their lifetime.Around 90% of cases will resolve within 12 months with conservative treatment.Gastrocnemius tightness has been associated with dorsiflexion stiffness of the ankle and plantar fascia injury.The use of eccentric calf stretching with additional stretches for the fascia is possibly the non-operative treatment of choice for chronic plantar fasciopathy.Medial open release of approximately the medial third of the fascia and release of the first branch of the lateral plantar nerve has been the most accepted surgical treatment for years.Isolated proximal medial gastrocnemius release has been reported for refractory plantar fasciopathy with excellent results and none of the complications of plantar fasciotomy. Cite this article: EFORT Open Rev 2018;3:485-493. DOI: 10.1302/2058-5241.3.170080.

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

BACKGROUND: Various methods of midfoot and hindfoot arthrodesis for treating symptomatic Müller-Weiss disease (MWD) have been reported in the literature. In this study, we present the results of a previously unreported method of treatment using a calcaneal osteotomy incorporating a wedge and lateral translation. METHODS: Thirteen patients (14 feet) with MWD were treated with a calcaneal osteotomy and retrospectively reviewed. These included 7 females and 6 males, with an average age of 56 years (33-79 years), and an average symptoms duration of 10.6 years (1-16 years). The disease was staged according to Maceira, which included 5 feet in stage II, 4 feet in stage III, 4 feet in stage IV, and 1 foot in stage V. Pre- and postoperative visual analog scale (VAS) score, American Orthopaedic Foot & Ankle Society (AOFAS), radiologic examination, and patients' satisfaction rate of the surgery were evaluated at an average of 3.7 years (range, 1-8.5 years) following surgery. RESULTS: The final follow-up visit showed satisfactory outcomes, with VAS score reducing from the preoperative 8 (7-9) to postoperative 2 (0-4), whereas the AOFAS score improved from the preoperative 29 (20-44) to the postoperative 79 (70-88). The patient's subjective ratings showed excellent results in 4 feet, good results in 8 feet, and fair outcomes in 2 feet. The hindfoot range of motion remained unchanged, as did the extent of the navicular complex arthritis, and no patient required an arthrodesis since surgery. CONCLUSION: A calcaneal osteotomy can be used as an alternative treatment option for selected MWD patients regardless of the radiologic stage of the disease. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Foot and ankle tendoscopies: current concepts review.

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

Subtalar anatomy and mechanics.

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

Posterior tibial tendoscopy.

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

Functional hallux rigidus and the Achilles-calcaneus-plantar system.

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

Transfer metatarsalgia post hallux valgus surgery.

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

Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession.

PURPOSE: The purpose of this study was to compare results of partial proximal fasciotomy (PPF) with proximal medial gastrocnemius release (PMGR) in the treatment of chronic plantar fasciitis (CPF). METHOD: This retrospective study compares 30 patients with CPF that underwent PPF with 30 that underwent isolated PMGR. Both groups were matched in terms of previous treatments and time from onset of symptoms to surgery. Different standardised evaluation scales (VAS, Likert, AOFASh) were used to evaluate results. RESULTS: Plantar fasciotomy had satisfactory results in just 60 % of patients, with an average ten weeks needed to resume work and sports. Patient satisfaction in the PMGR group reached 95 %, being back to work and sports at three weeks on average. Functional and pain scores were considerably better for PMGR and fewer complications registered. CONCLUSION: In our series, isolated PMGR is a simple and reliable procedure to treat patients with CPF. It provides far better results than conventional fasciotomy with less morbidity and better patient satisfaction, and thus has become our surgical procedure of choice in recalcitrant CPF.