Comparison of 4 different techniques in first metatarsophalangeal joint arthrodesis.

AIMS: The aim of this study was to evaluate outcomes and fusion rates of 4 different methods of first metatarsophalangeal joint (MTPJ) arthrodesis. METHODS: We performed a retrospective analysis of first MTPJ fusion using Bold® and Acutrak® compression screws, universal 1/3 tubular plate and Hallu®-S non-locking plate in 6 hospitals in Dublin over 4 years. A cohort of 300 patients (351 feet) was operated on by 3 feet and ankle fellowship trained orthopaedic surgeons (PK, MMS, JVMcK) over 4 years. Mean age was 62.4 years. There were 261 females and 39 males. One hundred three patients had a fusion of first MTPJ using two Acutrak® screws and 90 with two Bold® screws. Sixty-five were fused with the Hallu-S® plate and 42 with the universal 1/3 tubular plate. Patients were evaluated clinically and radiographically at 6 weeks, 3 months and 12 months. RESULTS: Functional outcome scores performed using Manchester-Oxford Foot Questionnaire (MOXFQ). Failure rate in those fused with the Hallu®-S plate was 0%, Acutrak® screws 2.4%, Bold® screws 9.5% and universal 1/3 tubular plate 12.5% (p > 0.12). All treatment groups demonstrated significantly reduced MOXFQ scores (p value < 0.05). CONCLUSION: In this retrospective study for first MTPJ fusion, a low profile, pre-contoured plate in combination with a screw mode had the best results with no failure rates and improved MOXFQ scores. LEVEL OF CLINICAL EVIDENCE: IV, retrospective study.

Primary ankle arthrodesis for neglected open Weber B ankle fracture dislocation.

Primary ankle arthrodesis used to treat a neglected open ankle fracture dislocation is a unique decision. A 63-year-old man presented to the emergency department with a 5-day-old open fracture dislocation of his right ankle. After thorough soft tissue debridement, primary arthrodesis of the tibiotalar joint was performed using initial Kirschner wire fixation and an external fixator. Definitive soft tissue coverage was later achieved using a latissimus dorsi free flap. The fusion was consolidated to salvage the limb from amputation. The use of primary arthrodesis to treat a compound ankle fracture dislocation has not been previously described.

Quality of life in individuals with chronic foot conditions: a cross sectional observational study.

BACKGROUND: Chronic foot conditions have been reported to be a significant cause of impairment and disability to individuals affected. However, studies to date have particularly focussed on patient satisfaction with outcomes following surgery. OBJECTIVES: The aim of this study is to examine the impact of three common foot conditions on the levels of impairment and quality of life prior to surgery. Three conditions include Hallux Valgus (HV), Hallux Rigidus (HR) and Hammer Toe (HT). METHODS: This was a pilot cross-sectional observational study of people who were radiologically and clinically diagnosed with one of the three common foot pathologies: HV, HR and HT. Age and gender matched controls were also recruited. Self-reported quality of life was measured. RESULTS: The SF-36 scores did not differ significantly between the groups. There was a significant difference in self reported impairment between the groups on the Global Foot and Ankle Scale indicating that the 'bilateral foot group' perceived themselves to be significantly more impaired than their counterparts in the control group. CONCLUSION: Patient quality of life is now recognised as one of the most important outcomes of surgery. These findings serve to highlight the level of impairment and quality of life of individuals prior to surgery.

Foot and ankle surgery--the Achilles heel of medical students and doctors.

BACKGROUND: Numerous studies have shown that deficiencies exist in orthopaedic and musculoskeletal medical training resulting in students and doctors regularly failing basic orthopaedic exams. However, there have not been any studies addressing the attitudes of medical students towards the orthopaedic subspecialties. OBJECTIVES: This study aimed (i) to determine if foot and ankle surgery was the orthopaedic specialty with which students and doctors have the most difficulty, (ii) to appraise attitudes towards teaching of foot and ankle surgery, and (iii) to suggest ways teaching might be improved. METHODS: A questionnaire on orthopaedic teaching was given to 238 medical students in Ireland. Perceived difficulties with foot and ankle surgery were compared to seven other orthopaedic subspecialties and the results were analysed. Other aspects of teaching were assessed including why foot and ankle surgery is perceived as difficult and ways teaching could be improved. RESULTS: Foot and ankle surgery is the orthopaedic subspecialty with which medical students and doctors have the most difficulty, least confidence and poorest knowledge in. This was due to: perceived complexity; insufficient exposure; and a lack of teaching. CONCLUSION: Foot and ankle surgery is the least popular of the orthopaedic subspecialties and considerable deficiencies exist in its education.

Correction of severe hallux valgus using a basal chevron osteotomy and distal soft tissue release.

BACKGROUND: There are many procedures described for the correction of severe hallux valgus. This is the first to examine the role of a basal osteotomy with distal soft tissue release. METHODS: 26 patients with severe hallux valgus underwent a basal chevron osteotomy with distal soft tissue release. All were reviewed at an average of 38 months. RESULTS: The mean AOFAS score improved from 24 to 82 points (p<0.001). The IMA improved from an average of 23.90 to 130 (p<0.01). The HVA improved from an average of 490 to 170 (p<0.005). The correlation coefficient between the AOFAS score and various radiological angles was low (0.47). CONCLUSIONS: Good clinical outcomes in cases of severe hallux valgus can be achieved without full restoration of normal radiological values. Furthermore, a basal chevron osteotomy with a distal soft tissue release offers a high satisfaction rating with regards to both clinical and functional outcomes in the short to medium-term. LEVEL OF EVIDENCE: Level IV - Case series.

Idiopathic toe walking and contractures of the triceps surae.

Toe walking is a common feature in immature gait and is considered normal up to 3 years of age. As walking ability improves, initial contact is made with the heel. Toe-walkers will stand out as different once heel-strike is achieved by most of their peers. This difference gives rise to parental concern. Therefore toe-walkers are often referred at 3 years of age. This article examines the evidence for the management of children who have idiopathic toe walking and reviews the literature on surgery for the lengthening of a calf contracture.

Giant cell tumour in the foot of a skeletally immature girl: a case report.

We present a case of delayed diagnosis of a benign giant cell tumour (GCT) of the third metatarsal in a skeletally immature girl. The patient underwent en bloc excision of the tumour. The tumour had replaced the third metatarsal and had infiltrated the surrounding soft tissue and the second and fourth metatarsal bases. Deep, lateral and medial margins were all involved. A high index of suspicion is needed when evaluating any tumours of the foot, because the compact structure of the foot may delay diagnosis. Early detection is important for avoiding amputation, as the hindfoot and midfoot are classified as one compartment and radical resection is impossible to achieve. Tumours grow faster in the foot than in other bones. GCT in this location and age-group are rare and should be considered in the differential diagnosis of a destructive bony lesion in skeletally immature patients.

Intermetatarsal angle after first metatarsophalangeal joint arthrodesis for hallux valgus.

BACKGROUND: First metatarsophalangeal (MTP) joint arthrodesis is commonly done for hallux valgus with an arthritic joint. In patients with a wide preoperative first intermetatarsal (IM) angle an important question is whether the metatarsus varus will be corrected by the first MTP joint fusion alone or whether an additional basal osteotomy is necessary. METHODS: The charts and radiographs of 20 patients who had arthrodesis of the first MTP joint were retrospectively reviewed. All 20 patients were female with a mean age of 54.2 (range 42 to 78) years. Either a Hallu-S plate (Integra Life Sciences, Nudeal, France) or two crossed screws were used to stabilize the arthrodesis. The IM angles were measured independently by two individuals on weightbearing preoperative, 6-week postoperative, and final followup films. The final followup radiographs were taken at an average of 13.7 (range 6 to 30) months after surgery. A Student t-test was used to evaluate the changes in the IM angle and interobserver variations. RESULTS: The mean preoperative IM angle was 16.65 (range 12 to 26) degrees. The mean postoperative IM angle was 10.35 (range 6 to 15) degrees. The mean IM angle at final followup was 8.67 (range 5 to 12) degrees. The mean change between preoperative IM angle and IM angle at final followup was 8.22 (range 4 to 14) degrees. This change of the IM angle was statistically significant (p < 0.0001). CONCLUSIONS: These results indicate that in patients with severe hallux valgus and first MTP joint degeneration arthrodesis can significantly correct the IM angle without the addition of a basal osteotomy.

Foot deformities in children with hereditary motor and sensory neuropathy.

The authors reviewed 104 feet from 52 consecutive children with hereditary motor and sensory neuropathy (HMSN) seen for the first time in clinics in two pediatric institutions between 1996 and 2003. Sixty-nine feet had a cavovarus deformity, 23 feet had a planovalgus deformity, and 12 feet had no significant deformity. All cases with deformity had bilateral involvement, and of those with deformity, only 45% had symmetric involvement. In HMSN I, III, IV, V, and X-linked HMSN, cavovarus was the most common deformity. However, in HMSN II, 55% of feet had a planovalgus deformity, 36% had a cavovarus deformity, and 9% had no deformity. In all, 43 feet underwent surgery of some type. Surgery, and in particularly combined bony and soft tissue procedures, was performed much more frequently on feet with cavovarus than planovalgus deformities. Soft tissue surgery alone was performed at an earlier age than combined bony and soft tissue surgery.

The role of hamstring tightness in plantar fasciitis.

BACKGROUND: Plantar fasciitis is a repetitive microtrauma overload injury of the attachment of the plantar fascia at the inferior aspect of the calcaneus. Several etiological factors have been implicated in the development of plantar fasciitis; however, the role of hamstring tightness has not been evaluated. METHODS: Fifteen volunteers (mean age 32.6 +/- 4.7 years) were prospectively analyzed for differences in forefoot loading using a Don-Joy brace (dj Orthopedics, Vista, CA) applied to each knee simultaneously. The brace was locked at varying degrees of knee flexion (0 degrees, 20 degrees, and 40 degrees). Their mean popliteal angle was 6.5 degrees. Fifteen patients (mean age 40 +/- 16.5 years) with a diagnosis of chronic plantar fasciitis were similarly analyzed on the pedobarograph. These patients also had their hamstring tightness evaluated by measuring the popliteal angle. The mean popliteal angle was 23 degrees. RESULTS: Increasing the angle of flexion from 0 to 20 degrees at the knee joint led to a statistically significant increase in pressure in the forefoot phase by an average of 0.08 K/cm(2)s (p < 0.05). An increase from 20 to 40 degrees led to increased forefoot phase pressure of 0.08 kg/cm(2)s (p < 0.05). The percentage of time spent in contact phase decreased from 35.37% to 30.87% to 26.37% with increasing flexion (p < 0.05). However there was an inverse increase in the time spent in the forefoot phase 46.6% to 55.6 to 61.25% with increasing degrees of flexion (p < 0.05). CONCLUSION: The results indicate that an increase in hamstring tightness may induce prolonged forefoot loading and through the windlass mechanism be a factor that increases repetitive injury to the plantar fascia.

Arthrodesis of the first metatarsophalangeal joint using a dorsal titanium contoured plate.

BACKGROUND: Arthrodesis of the first metatarsophalangeal joint (MTPJ) is used to treat a variety of foot pathologies. Numerous methods of internal fixation and bone end preparation have been reported. In an effort to bring together the best features of the various internal fixation devices, a low-profile contoured titanium plate (LPCT) using a compression screw was designed to be used with a ball-and-socket bone end preparation. A prospective study was carried out to determine the efficacy of this technique. METHODS: First MTPJ arthrodesis using an LPCT was done in 12 patients (10 women and two men) either as an isolated procedure (seven patients) or in conjunction with other forefoot procedures (five patients). The changes in the level of pain and activities of daily living were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score and the Short-Form 36 (SF-36) score. Time to bone union also was assessed. Mean followup was 18 months (+/-6 months). RESULTS: Statistically significant increases in the AOFAS hallux score and the SF-36 score were noted (p = .002 and .001, respectively). All radiographs showed bone union at 6 weeks and an appropriate degree of hallux dorsiflexion in relation to the first metatarsal (20 to 25 degrees). CONCLUSION: The combination of the LPCT plate and a ball-and-socket bone-end preparation has both operative and biomechanical advantages over other fixation techniques. This combination ensures that the anatomical length of the first ray is only minimally shortened and the angle of plantarflexion of the first metatarsal is maintained, resulting in preservation of medial column stability and a better functional result.

Flexor hallucis longus tendon transfer: evaluation of postoperative morbidity.

Clinical and pedobarograph evaluation was performed on 16 patients following flexor hallucis longus (FHL) tendon transfers to determine the resulting morbidity due to the loss of FHL function. All patients underwent FHL tendon transfer for either chronic tendon Achilles rupture or chronic Achilles tendinosis. Clinical evaluation of hallux function was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, the SF-36 score, and a clinical questionnaire to assess alteration in the clinical function of the hallux during activities of daily living. Pedobarography was carried out using the Musgrave pedobarograph system to detect changes in forefoot loading in comparison to the contralateral normal foot. Fourteen of the 16 patients scored maximally on the hallux metatarsophalangeal-interphalangeal scale and none of the patients noticed functional weakness of the hallux during activities of daily living at a mean follow-up of 43.6 months (range, 5-120 months). Pedobarograph readings showed a trend toward reduction in peak pressure loading on the distal phalanx, but this was not significant for the numbers of patients studied. There was no significant increase in loading of the first or second metatarsophalangeal joints to suggest that transfer metatarsalgia may complicate FHL tendon transfer. According to the results of the study morbidity from FHL transfer should be clinically insignificant.