Foot & ankle specialist最新文献

Background: Hallux valgus is a common deformity encountered but remains a complex clinical entity. Fourth-generation minimally invasive surgery (MIS) techniques consisting of a percutaneous distal metatarsal transverse osteotomy combined with an Akin osteotomy have been used to address mild to severe hallux valgus deformities. The benefits of an MIS approach include improved cosmesis, faster recovery, lower opiate requirement, immediate weightbearing, and favorable outcomes relative to a traditional, open procedure. An understudied area with respect to hallux valgus correction is the effect that osteotomies can have on the articular contact properties of the first ray following correction.

Methods: Sixteen paired cadaveric specimens were dissected to include the first ray and tested in a customized apparatus. Specimens were randomized to receive a distal transverse osteotomy translated either 50% or 100% of the width of the first metatarsal shaft. The osteotomy was performed with either a 0° or 20° distal angulation of the burr relative to the shaft in the axial plane. Specimens were tested in the intact state and following the distal first metatarsal osteotomy for peak pressure, contact area, contact force and center of pressure at the first metatarsophalangeal (MTP) and first tarsometatarsal (TMT) joints. An Akin osteotomy was then performed on each specimen, and peak pressure, contact area, contact force, and center of pressure were recalculated.

Results: There was a notable decrease in peak pressure, contact area, and contact force across the TMT joint with greater shifts of the capital fragment. However, at 100% translation of the capital fragment, distal angulation of the osteotomy by 20° appears to improve loading across the TMT joint. Addition of the Akin osteotomy at 100% translation also aids in increasing the contact force across the TMT joint. The MTP joint is less sensitive to changes in shifts and angulation of the capital fragment. The Akin osteotomy also leads to increased contact force across the MTP joint when the capital fragment is translated 100%.

Conclusion: While the clinical significance is unknown, larger shifts of the capital fragment lead to greater load alterations at the level of the TMT joint than the MTP joint. Distal angulation of the capital fragment and the addition of an Akin osteotomy can aid in reducing the size of those changes. The Akin can lead to increased contact forces at the MTP joint with 100% translation of the capital fragment.

Level of evidence: Not applicable, Biomechanical study.

Introduction: Hallux valgus is a commonly treated condition by foot and ankle surgeons with more than 200 different described correction techniques. Recurrence rates range from 5% to 50%, with increasing support of the theory that arthrodesis procedures may have a lower recurrence rate than osteotomies. Arthrodesis procedures to the first metatarsophalangeal (MTP) joint or tarsometatarsal (TMT) joint for correction of hallux valgus deformity are becoming more commonly utilized. The purpose of this study is to investigate the surgical incidence and revision rates of hallux valgus deformities corrected by arthrodesis compared to osteotomy in the state of South Carolina.

Methods: The South Carolina Revenue and Fiscal Affairs Office was queried from 2000 to 2017 to identify all surgically treated hallux valgus deformities. Data extraction included patient demographics, ICD-9 diagnoses, CPT procedure codes, and dates of surgery. A logistic regression model was used for statistical inference.

Results: A total of 22 199 feet had surgical treatment for hallux valgus during this time period, with 20 422 (92.0%), 592 (2.7%), and 1185(5.3%) receiving an osteotomy, arthrodesis, or other procedure at initial treatment, respectively. There was an all-cause revision rate of 5.6% in the osteotomy group and 6.4% in the arthrodesis group. Demographic factors such as female sex, white race, and surgery pre-2010 were associated with higher revision rates. Multiple comorbidities were correlated with higher revision rates such as tobacco use, hypothyroidism, osteoarthritis, recurrent dislocations, hallux rigidus, lesser toe deformities, metatarsus varus, and talipes cavus.

Conclusion: Despite the recent increase in arthrodesis procedures for the treatment of hallux valgus deformity, our results suggest that osteotomy procedures are more commonly performed and there is no difference in all-cause revision surgery. However, there are multiple patient demographics and comorbidities that are associated with higher rates of revision surgery and should be considered and discussed during the preoperative planning period.

Level of evidence: Level IV.

Background: This study aimed to evaluate the reliability and validity of the American Orthopaedic Foot and Ankle Society Metatarsophalangeal-Interphalangeal (AOFAS MTP-IP) score in patients with hallux valgus in Singapore.

Method: A total of 121 English-literate patients with hallux valgus identified between October 2017 and May 2020 were analyzed. Reliability was assessed via Cronbach α. Construct validity was evaluated through 20 a priori hypotheses by correlating the AOFAS MTP-IP score for hallux and lesser toes with other patient-reported outcome measures (PROMs). Standardized response means (SRMs) were calculated to evaluate responsiveness at 6 months postoperative. Structural validity was evaluated via confirmatory factor analysis (CFA) whereby a good fit was indicated when comparative fit index (CFI) is >0.95, Tucker-Lewis index (TLI) is >0.95 and standardized root mean residual (SRMR) is <0.08.

Results: The AOFAS MTP-IP score demonstrated reliability with a Cronbach α of 0.837. Convergent construct validity was confirmed when all a priori hypotheses were fulfilled. Structural validity was established with our AOFAS MTP-IP score model that displayed good fit for a 1-factor structure (CFI = 0.988, TLI = 0.960, SRMR = 0.034). Responsiveness of the AOFAS MTP-IP score for hallux was demonstrated by an SRM score of 1.28.

Conclusion: The AOFAS MTP-IP score displayed adequate reliability and validity among English-literate patients in Singapore with an operatively managed hallux valgus.

Level of evidence: Level III: Retrospective cohort study.

Background: While metatarsophalangeal joint (MTPJ) arthrodesis is regarded as the gold standard treatment option for end-stage hallux rigidus (HR), synthetic cartilage implant (SCI) resurfacing has gained popularity. This study aimed to identify the SCI resurfacing failure rate for a single surgeon, while also comparing clinical outcomes of patients who underwent SCI replacement or MTPJ arthrodesis after failed index SCI resurfacing.

Methods: Health records were queried from 2016 to 2021 for patients with HR who were treated with SCI resurfacing by a single surgeon. Preoperative and postoperative range of motion, visual analog scale (VAS) pain scores, and hallux valgus angles were compared. A subgroup analysis was performed on patients who underwent revision with SCI replacement or MTPJ arthrodesis. SCI replacement included the use of bone graft, bone putty, or a custom 3D printed baseplate to prevent implant subsidence.

Results: A total of 219 SCI resurfacing procedures were performed by a single surgeon, including 23 revisions. When analyzing index procedures, an 8.2% revision rate was determined. The revision cohort (n = 23) consisted of 19 female patients and presented with a mean body mass index of 29.5 ± 5 kg/m², mean age of 52.8 ± 11 years, mean follow-up duration of 22.3 (range, 3-54) months, and mean time to a revision surgery of 12.1 ± 12 (range, 1-50) months. Specifically, 12 procedures resulted in an SCI replacement, while 11 procedures resulted in arthrodesis. While all patients experienced significant improvement in their VAS pain scores (P < .001), the arthrodesis cohort experienced a greater improvement than the SCI revision cohort (P = .04).

Conclusion: When analyzing SCI revision procedures, MTPJ arthrodesis reduced pain more significantly than SCI replacement.

Levels of evidence: Level IV: Retrospective case series.

Minimally invasive surgery (MIS) is a growing technique that favors faster recovery and cosmetic results. We propose a recommended osteotomy position or "MIS Sweet Spot" to make the procedure more reproducible and lessen the learning curve to improve outcomes. A total of 211 patients from 3 surgeons between 2 different study centers were included in a retrospective radiograph measurement analysis and a cadaveric dissection to confirm the safety of nearby anatomical structures. An average distance of 2.2 cm proximal from the first metatarsophalangeal joint was found as the "Sweet Spot" to perform the transverse osteotomy. At this distance, neurovascular and tendinous structures were unharmed and the osteotomy remained extracapsular. Furthermore, an average of 10.7° of intermetatarsal angle reduction and a reduction of tibial sesamoid position of 3 points were achieved. A predictable and measurable distance for osteotomy placement will help to provide more confidence in producing the bunionectomy osteotomy with the specialized tools used in MIS and can help to reduce operative time and improve results.Level of Clinical Evidence (LOCE): 3.

Background: There are various deformities described in the spectrum of Progressive Collapsing Foot Deformity (PCFD) which not only have adverse effects on the foot but also on the entire lower limb. Early lower limb muscular fatigue and pain during exertion is the most common complaint of patients with PCFD. Surface electromyography (sEMG) provides an accurate assessment of muscle activity. In this study, we aim to compare the activities of quadriceps, hamstrings, and gastrosoleus muscle groups of adult patients with PCFD with normal lower limbs and correlate the radiological parameters and functional effects of PCFD with the activities.

Methods: Thirty patients with bilateral PCFD and 30 controls underwent weight-bearing anteroposterior (AP), lateral, and hindfoot alignment radiographs of the foot. Radiographic parameters of PCFD were assessed. Surface electromyography was used to assess the quadriceps, hamstrings, and gastrosoleus activities, and this was compared between the 2 groups and correlated with radiological measurements of PCFD. Tegner activity questionnaire was used to assess the functional effects of collapsed arch.

Results: Electrical activities of all muscle groups were significantly higher in cases than controls. Meary's angle and hindfoot moment arm had significant correlations with hamstring activity (P = .013) and gastrosoleus activity (P = .027), respectively. Tegner scores of cases were significantly lower than those of controls (P = .041).

Conclusions: The PCFD causes an increase in activity of large muscles of the affected lower limb which act on joints other than those in the foot. This finding may be due to several compensatory mechanisms that counteract the deforming forces. This may be a cause for the frequent complaint, early fatigue, and hence functional impairment. However, most radiological parameters did not correlate with muscle activities and larger study size may be required for further association.

Levels of evidence: Diagnostic: Level 3.

Introduction: Studies have suggested a strong association between depression and poor outcomes following various orthopaedic surgeries. However, depression's impact on complications following open reduction/internal fixation (ORIF) of trimalleolar fractures has not been elucidated. Therefore, this study aimed to determine whether depression is associated with higher rates of readmissions and medical complications following ORIF of trimalleolar fractures.

Methods: A database query from January, 2020, through March, 2021, identifying adults who underwent trimalleolar ORIF generated 50 154 patients. Those with depression were matched 1:1 to controls without depression by age, sex, chronic obstructive pulmonary disease, anxiety, and other prominent comorbidities. Primary endpoints compared 90-day all-cause readmissions and medical complications. Odds ratios (ORs) of the effect of depression on readmissions and medical complications were calculated.

Results: Patients with depression who underwent ORIF of trimalleolar fractures had significantly higher odds of being readmitted within 90 days of the initial procedure (OR: 1.37; P < .0001). Ninety-day odds of developing medical complications were significantly higher (OR: 4.61; P < .0001) in patients with depression compared with patients within the control group.

Conclusion: Patients with depression undergoing trimalleolar ORIF face an increased risk of readmission and multiple postoperative complications. Orthopaedic surgeons should factor depression into their preoperative evaluation, given the already high burden of complications following ORIF of trimalleolar fractures.

Level of evidence: Level III: Retrospective cohort study.

Background: Minimally invasive (MIS) treatment of hallux valgus (HV) deformity is increasing in popularity. A 2-mm diameter burr is used to create a distal first metatarsal osteotomy prior to capital fragment translation and fixation. The metatarsal will shorten by the burr's diameter (2 mm). Plantar or dorsal capital fragment displacement may also cause load transference and possibly transfer metatarsalgia. The purpose of this study is to examine the effect of MIS HV on forefoot loading mechanics with respect to metatarsal shortening and sagittal plane displacement.

Methods: Four lower-limb cadaveric specimens were studied. A pedobarography pressure-sensing mat was used to record forefoot plantar pressure in a controlled weight-bearing stance position. Control and postosteotomy measurements were obtained with the capital fragment fixated in 3 possible positions: 0 mm, 5 mm dorsal, and 5 mm plantar displacement. Pedobarography data yielded pressure data within measurable graphical depictions. Raw mean contact pressure measurements were taken under the first and fourth metatarsal heads to establish medial and lateral forefoot loading pressure ratios. An a priori power analysis was performed based on previous peer-reviewed pedobarographic data, and our study was adequately powered.

Results: Around 40 measurements were recorded, and ratios of medial-to-lateral forefoot loading were constructed. Medial forefoot pressure control versus 0 mm displacement, and control versus dorsal displacement were not found to be statistically significant (p = 0.525, p = 0.55, respectively). Medial pressure significantly increased when comparing control versus plantar displacement (P = .006). Lateral pressure significantly increased with dorsal displacement of the osteotomy (P = .013).

Conclusion: Our study found that MIS HV correction did not cause an increase in lateral forefoot pressure loading when sagittal plane displacements were controlled. Plantar displacement increased medial loading, and dorsal displacement increased lateral loading. It may be valuable for surgeons to consider metatarsal head position postosteotomy, as a decrease in medial loading and subsequent increase in lateral loading may lead to lateral forefoot pain and transfer metatarsalgia.

Levels of evidence: IV.

Bunionette deformity is an incredibly pervasive issue in our society with almost a quarter of individuals being affected by it. As it is so common, there are numerous techniques and approaches to correct the deformity. Currently, there is a growing trend that favors percutaneous osteotomy of the bunionette. As there are multiple osteotomy sites, there are anatomical considerations that must be made at each one. The purpose of this study was to investigate the anatomic structures at risk during distal osteotomy of bunionette deformity using a Shannon burr. Using 11 fresh cadaver specimens, the fifth metatarsal was accessed through a carefully marked portal. A Shannon burr was employed for the osteotomy. Dissections were performed to assess potential damage to critical structures, including the lateral dorsal cutaneous nerve (LDCN), abductor digiti minimi (ADM), and extensor digitorum longus (EDL). Measurements were taken from the osteotomy site to each structure. The distal osteotomy site was on average greater than 8 mm from the EDL and ADM, whereas it was 1.64 mm from the LDCN. The Shannon burr made contact with and transected the LDCN on 2 occasions. However, previous studies have highlighted potential anatomical variations of the LDCN that arise distally. The study underscored the challenges posed by minimally invasive approaches to treating bunionette deformity and highlighted the need for cautious consideration when using percutaneous methods.Level of Clinical Evidence: 5.

A transtibial amputation is the traditional primary staged amputation for source control in the setting of non-salvageable lower extremity infection, trauma, or avascularity prior to progression to proximal amputation. The primary aim of the study is to compare preoperative risk factors and postoperative outcomes between patients who underwent transtibial amputation versus ankle disarticulation in staged amputations. A retrospective review of 152 patients that underwent staged below the knee amputation were compared between those that primarily underwent transtibial amputation (N = 70) versus ankle disarticulation (N = 82). The mean follow-up for all 152 patients was 2.1 years (range = 0.04-7.9 years). The odds of incisional healing were 3.2 times higher for patients with guillotine amputation compared to patients with ankle disarticulation (odds ratio [OR] = 3.2, 95% confidence interval [CI] = 1.437-7.057). The odds of postoperative infection is 7.4 times higher with ankle disarticulation compared to patients with guillotine amputation (OR = 7.345, 95% CI = 1.505-35.834). There were improved outcomes in patients that underwent staged below the knee amputation with primarily guillotine transtibial amputation compared to primarily ankle disarticulation. Ankle disarticulation should be reserved for more distal infections, to allow for adequate infectious control, in the aims of decreasing postoperative infection and improving incisional healing rates.Levels of Evidence: 3, Retrospective study.