Prevalence and diagnostic accuracy of in-toeing and out-toeing of the foot for patients with abnormal femoral torsion and femoroacetabular impingement: implications for hip arthroscopy and femoral derotation osteotomy.

AIMS: Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT. PATIENTS AND METHODS: A retrospective, institutional review board (IRB)-approved, controlled study of 85 symptomatic patients (148 hips) with FAI or hip dysplasia was performed in the gait laboratory. All patients had a measurement of FT (pelvic CT scan), TT (CT scan), and FPA (optical motion capture system). We allocated all patients to three groups with decreased FT (< 10°, 37 hips), increased FT (> 25°, 61 hips), and normal FT (10° to 25°, 50 hips). Cluster analysis was performed. RESULTS: We found a specificity of 99%, positive predictive value (PPV) of 93%, and sensitivity of 23% for in-toeing (FPA < 0°) to detect increased FT > 25°. Most of the hips with normal or decreased FT had no in-toeing (false-positive rate of 1%). Patients with increased FT had significantly (p < 0.001) more in-toeing than patients with decreased FT. The majority of the patients (77%) with increased FT walk with a normal foot position. The correlation between FPA and FT was significant (r = 0.404, p < 0.001). Five cluster groups were identified. CONCLUSION: In-toeing has a high specificity and high PPV to detect increased FT, but increased FT can be missed because of the low sensitivity and high false-negative rate. These results can be used for diagnosis of abnormal FT in patients with FAI or hip dysplasia undergoing hip arthroscopy or femoral derotation osteotomy. However, most of the patients with increased FT walk with a normal foot position. This can lead to underestimation or misdiagnosis of abnormal FT. We recommend measuring FT with CT/MRI scans in all patients with FAI. Cite this article: Bone Joint J 2019;101-B:1218-1229.

Prevalence of musculoskeletal normal variations of the lower limbs in pediatric orthopedic clinic.

OBJECTIVES: To determine the rate of pediatric orthopedic clinic visits attributable to normal musculoskeletal (MSK) variations in children less than 12 years of age; to characterize the etiology and to characterize the etiology and management plan in this group in an attempt to identify areas that could be improved in pediatric orthopedic clinical practice. METHODS: The study was a retrospective evaluation of 2,321 consecutive patients who visited a private pediatric orthopedic specialty clinic in Jeddah, Saudi Arabia between 2011-2016. All consultations were recorded in accordance with the standard protocol  via data record form. RESULTS: We identified 764 (32.9%) patients with normal variation of the lower limbs, age birth to 12 years old. No significant association between gender and normal variation was noticed. The following types of normal variation were registered: 189 (24.7 %) genu varus or valgus, 257 (33.6%) in-toe gait, and 318 (41.6%) flexible flat foot. Seven hundred and thirty-seven (96.5%) cases were normal variations, while only 27 cases (3.5%) were deemed pathological and required further treatment. CONCLUSION: Normal variations represent the most common complaint in pediatric orthopedic private practice. Inappropriate referrals, useless follow-up visits, and excessive investigations were a common practice, overloading the health care system. None of the previous efforts made any notable improvement.

Operative Treatment for Hallux Valgus With Moderate to Severe Metatarsus Adductus.

BACKGROUND: Operative treatment is indicated for patients who have symptomatic hallux valgus (HV) with moderate to severe metatarsus adductus (MA). However, there is limited information available on the operative procedures and outcomes for the treatment of HV with MA. We aimed to investigate the average 10-year follow-up clinical and radiologic outcomes. METHODS: Seventeen patients (21 feet, average age: 60.1 years) with symptomatic HV with moderate to severe MA were operatively treated. Mean postoperative follow-up duration was 114.4 (24-246) months. All feet had metatarsus adductus angle ≥20 degrees on dorsoplantar weight-bearing radiograph. The procedure included a proximal crescentic osteotomy of the first metatarsal and abduction osteotomy of the proximal third of the second and third metatarsals. RESULTS: The mean American Orthopaedic Foot & Ankle Society scale score improved significantly postoperatively ( P < .001). The mean postoperative visual analog scale score (17 feet) was 2.0 (0-6). Preoperative metatarsalgia was severe in 2 feet, moderate in 17, and mild in 2. At the most recent follow-up evaluation, 11 feet had no pain, 9 had mild pain, and 1 had moderate pain. The mean hallux valgus angle, intermetatarsal angle, and metatarsus adductus angle significantly decreased postoperatively ( P < .001 for all). Recurrence of HV (HV angle ≥ 20 degrees) was observed in 4 feet. CONCLUSION: The clinical and radiologic results indicated that our novel operative treatment for HV with moderate to severe MA can achieve significant correction of HV with MA deformities and significant improvement in pain and function. LEVEL OF EVIDENCE: Level IV, retrospective case series.