Ultrasound identification of hand and wrist anatomical structures by hand surgeons new to ultrasonographic techniques.

PURPOSE: Ultrasound is becoming an essential tool for hand surgeons, but most of them are trained on the job, without any diploma or dedicated training. The aim of this study was to assess the ability of hand surgeons new to ultrasound to identify hand and wrist anatomical structures. METHODS: A monocentric study was conducted from January 2022 to April 2022. Ten residents and five attending hand surgeons, ultrasound novices, were involved in this study. The participants underwent two tests, wherein they were required to identify 17 anatomical structures using ultrasound, on the same subject. The second test was similar and carried out 2 to 6 weeks later by all participants. The number of structures successfully identified and if it was the case, the detection time per structure, were recorded. The correlations between participants age, years of surgical experience, surgical background (orthopedic or plastic) and the ability to perform immediately during the first test or to progress between the two tests were also assessed. RESULTS: The average number of structures identified during the first test (T1) was 14.1+/-2.1 (82.9%), versus 16.2+/-0.8 (95.3%) structures during the second test (T2) (p = 0.001). The mean detection time per structure was 53.4 +/- 18.9 s during T1 versus 27.7 +/- 7.2 s during T2 (p < 0.0001). A moderate negative correlation between the progression in the number of anatomical structures identified between the two tests and the years of surgical experience (ρ=-0.56; p = 0.029) was found. The other parameters were neither correlated with the ability to perform at the first test nor with the progression between the two tests. CONCLUSION: Hand surgeons new to ultrasound are most of the time able to identify hand and wrist anatomical structures. Comparison of their first and second tests showed significant potential for improvement in anatomical structure identification and detection time of those, especially in surgeons with limited surgical experience.

Risk Factors for Midfoot Arthritis Associated With Medical History by Weight Bearing Computed Tomography.

Tarso-metatarsal joints and naviculocuneiform joints comprising midfoot is the second most commonly involved joints following the first metatarsophalangeal joint in the foot. However, related factors of midfoot arthritis (MA) have been rarely reported. The bony structure and alignment can be more precisely assessed using Weight-Bearing Computed Tomography (WBCT) than conventional radiographs. Therefore, the aim of this study was to investigate risk factors for MA related to medical history and comorbid foot deformities using WBCT. WBCT data from September 2014 to April 2022 were extracted from a single referral hospital. All cases were divided into two groups by the presence of MA. Twenty-five potential related factors including demographics, etiology, and common co-occurring foot deformities were collected for comparison. Six hundred six cases (247 males and 359 females) among consecutive 1316 cases between September 2014 to April 2022 were selected. One hundred thirty-nine male cases (56.3%) and 210 female cases (58.5%) showed MA. In stepwise multiple logistic regression analysis, 5 factors remained statistically significant. The multivariate-adjusted odds ratios for age, laterality, body mass index (BMI), Progressive Collapsing Foot Deformity (PCFD), and lesser toe deformities (LTD) were 1.08, 1.54, 1.05, 6.62, and 3.03 respectively. Risk factors for MA associated with medical history and foot deformities included age, laterality, BMI, PCFD, and LDT.

Prevalence of midfoot arthritis and lesser toe deformities.

BACKGROUND: The aim of this study was to investigate the epidemiology of Midfoot Arthritis (MA) and Lesser toe deformity (LTD) using Weight-Bearing Computed Tomography (WBCT). METHODS: 606 cases (247 male, 359 female) among 1316 consecutive cases with WBCT data from September 2014 to April 2022 were retrospectively reviewed at a single referral institution. The Cochran-Armitage test was performed to evaluate the trend of prevalence with respect to age group and obesity classification. RESULTS: 139 male (56.3%) and 210 female cases (58.5%) showed MA. 157 male (63.6%) and 222 female cases (61.6%) showed LTD. 115 male (19.0%) and 157 female cases (25.9%) showed both MA and LTD. The prevalence of MA and LTD increased with age in both genders. The incidence of MA in males showed an increasing tendency until obesity class II and then was slightly decreased in obesity class III. This is contrary to females whose prevalence increased with increasing obesity groups. LTD had a similar pattern in both genders to obesity classification. CONCLUSIONS: The prevalence of MA and LTD increased with age and increasing obesity groups for both genders. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

A comparison between the Bluman et al. and the progressive collapsing foot deformity classifications for flatfeet assessment.

INTRODUCTION: Bluman et al., flatfoot classification is based on posterior tibial tendon (PTT) dysfunction leading to a chronological appearance of several foot deformities. An expert consensus recently proposed a new classification named Progressive Collapsing Foot Deformity (PCFD) in which the focus was shifted to five different independent foot and ankle deformities and their flexibility or rigidity. The aim of this study was to compare Bluman and PCFD classifications. We hypothesize that both classifications will be reliable and that the PCFD classification will allow a larger distribution of the different types of foot deformity. MATERIALS AND METHODS: We performed a retrospective IRB-approved study including 92 flatfeet. Three foot and ankle surgeons reviewed patient files and radiographs to classify each foot using both classifications. Bluman classification was performed one time as initially described and a second time after removing the Angle of Gissane sclerosis sign. Interobserver reliabilities were determined with Fleiss' kappa values. RESULTS: Interobserver reliabilities of Bluman and PCFD classifications were, respectively, substantial 0.67 and moderate 0.55. PCFD Class C and D reliabilities were, respectively, slight 0.07 and fair 0.28. The 276 readings were spread into 10 substages in Bluman and 65 subclasses in PCFD. The progressivity of the Bluman classification prevented the combination of flexible hindfoot valgus (II Bluman, 1A PCFD), midfoot abduction (IIB, 1B) and medial column instability (IIC, 1C) which was frequent in our study (112/276 readings, 40.6%). By removing the Angle of Gissane sclerosis sign from the Bluman classification, the prevalence of stage III decreased from 44.2 to 10.1%. CONCLUSIONS: Bluman and PCFD classifications were reliable. The PCFD classification showed a larger distribution of different types of flatfeet but Classes C and D need better definition. The progressivity of Bluman classification causes inconsistencies and Gissane angle sclerosis sign is inappropriately used and might lead to incorrect surgical indications.

Prevalence and pattern of lateral impingements in the progressive collapsing foot deformity.

INTRODUCTION: The prevalence of lateral bony impingements [i.e., Sinus Tarsi (STI), Talo-Fibular (TFI) and Calcaneo-Fibular (CFI)] and their association with Peritalar Subluxation (PTS) have not been clearly established for progressive collapsing foot deformity (PCFD).This study aims to assess the prevalence of STI, TFI and CFI in PCFD, in addition to their association with PTS. We hypothesized that STI and TFI would be more prevalent than CFI. MATERIALS AND METHODS: Seventy-two continuous symptomatic PCFD cases were retrospectively reviewed. Weightbearing computed tomography (WBCT) was used to assess lateral impingements and classified as STI, TFI and CFI. PTS was assessed by the percent of uncovered and the incongruence angle of the middle facet, and the overall foot deformity was determined by the foot and ankle offset (FAO). Data were collected by two fellowship-trained independent observers. RESULTS: Intra-observer and inter-observer reliabilities for impingement assessment ranged from substantial to almost perfect. STI was present in 84.7%, TFI in 65.2% and CFI in 19.4%. PCFD with STI showed increased middle facet uncoverage (p = 0.0001) and FAO (p = 0.0008) compared to PCFD without STI. There were no differences in FAO and middle facet uncoverage in PCFD with TFI and without TFI. PCFD with CFI was associated with STI in 100% of cases. PCFD with CFI showed decreased middle facet incongruence (p = 0.04) and higher FAO (p = 0.006) compared to PCFD without CFI. CONCLUSIONS: STI and TFI were more prevalent than CFI in PCFD. However, only STI was associated with PTS. Conversely, CFI was associated with less PTS, suggesting a different pathological mechanism which could be a compensatory subtalar behavior caused by deep layer failure of the deltoid ligament and talar tilt.

Does metatarsus primus elevatus really exist in hallux rigidus? A weightbearing CT case-control study.

BACKGROUND: Elevated first metatarsal, Metatarsus primus elevatus (MPE), has been a topic of controversy. Recent studies have supported a significantly elevated first metatarsal in hallux rigidus on weight-bearing radiographs (WBR). However, conventional radiographs have limitations for accurate measurement. Our objective was to comparatively assess MPE and other variables which can affect the spatial relationship of the forefoot in the HR group compared to controls using weight-bearing CT (WBCT). METHODS: In this single-center, retrospective, case-control study, 25 patients (30 feet) with symptomatic HR and 30 controls were selected. WBCT parameters were measured by two independent investigators. Inter-observer reliabilities were assessed using intra-class correlation coefficients (ICCs). MPE was evaluated by measuring the direct distance between 1st and 2nd metatarsals. Independent t tests were performed to compare the two groups. A threshold of MPE to diagnose HR was calculated using the Receiver Operating Characteristic (ROC) curve. RESULTS: HR groups had increased hallux valgus angle (HVA) (8.52° in control vs 11.98° in HR) and MPE (2.92 vs 5.09 mm), decreased 1st metatarsal declination angle (21.09° vs 19.07°) 1st/2nd metatarsal declination ratio (87.45 vs 79.71) indicating elevated first metatarsal compared to controls. Dorsal translation of the first metatarsal at the first tarsometatarsal joint was observed in 21 (70%) patients of the HR group when defined as a step-off or discontinuation of the curvature along the first TMT joint. The threshold of MPE for diagnosis of HR was 4.19 mm with 77% sensitivity and 77% specificity. CONCLUSION: Our results confirmed a significantly elevated first metatarsal in the HR group compared to controls on WBCT. A MPE greater than 4.19 mm was found to be diagnostic for symptomatic HR. Significant number of patients in the HR group (70%) had dorsal translation of the first metatarsal at the first TMT joint which can contribute to increased MPE. CLINICAL RELEVANCE: The present study demonstrated significantly increased MPE in HR on WBCT and MPE greater than 4.19 mm on WBCT can be used as a diagnostic threshold for HR.

Early results and complication rate of the LapiCotton procedure in the treatment of medial longitudinal arch collapse: a prospective cohort study.

INTRODUCTION: Instability/collapse of the medial column has been associated with many conditions, particularly progressive collapsing foot deformity (PCFD), hallux valgus (HV), and midfoot arthritis (MA). Restoration of first ray length and sagittal plane alignment to restore the foot tripod is essential when treating these deformities. This study aimed to assess early results, healing, and complication rate of a distraction dorsal opening plantarflexion wedge allograft first tarsometatarsal joint fusion (LapiCotton Procedure) in patients with collapse/instability of the medial column. METHODS: In this prospective cohort study, we included PCFD, HV, and MA patients that underwent a LapiCotton procedure. Fusion site healing was defined by > 50% bone bridging in both interfaces between allograft wedge and host bone using weight-bearing computed tomography (WBCT) after 3 months. First ray collapse radiographic correction and minor and major complications (deep dehiscence, deep infection, and reoperation) were assessed. RESULTS: A total of 22 patients (22 feet) were included (11 PCFD, 6 MA, and 5 of HV patients). Mean follow-up was 5.9 months (range 3-12) and median allograft size was 8 mm (range 5-19 mm). Bone healing was observed in 91% of cases. Two minor complications (9%, both superficial dehiscence) and one major complication (4.5%, deep infection) were observed. Statistically significant improvement of the sagittal plane talus-first metatarsal angle was observed, with mean improvement of 9.4° (95% CI 6.7-12.1°; p < 0.0001). CONCLUSION: In this prospective cohort study of 22 patients treated with the LapiCotton procedure for medial longitudinal arch collapse/instability, we observed a low complication rate (9% minor, 4.5% major), high healing rate after 3 months (91%), one clinically stable radiographic non-union (4.5%) and one unstable non-union (4.5%) needing reoperation. Our results demonstrate promising initial results for LapiCotton technique in treating collapse of the medial longitudinal arch in patients with PCFD, MA and HV deformities. Long-term results are needed to confirm these promising results. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Advantages of ultrasound identification of the distal insertion of the calcaneofibular ligament during ligament reconstructions.

INTRODUCTION: In lateral ankle instability, anatomical ligament reconstructions are generally performed using arthroscopy. The ligament graft is passed through the talar, fibular and calcaneal tunnels, reconstructing the anterior talofibular and calcaneofibular (CFL) bundles. However, the calcaneal insertion of the CFL needs to be performed in an extra-articular fashion, and cannot be carried out under arthroscopy, thus requiring specific anatomical landmarks. For obtaining these landmarks, methods based on radiography or surface anatomy have already been described but can only offer an approximate identification of the actual CFL anatomical insertion point. In contrast, an ultrasound technique allows direct visualization of the insertion point and of the sural nerve that may be injured during surgery. Our study aimed to assess the reliability and accuracy of ultrasound visualization when performing calcaneal insertion of the CFL with specific monitoring of the sural nerve. MATERIALS AND METHODS: Our anatomical study was carried out on 15 ankles available from a body donation program. Ultrasound identification of the sural nerve was obtained first with injection of dye. A needle was positioned at the level of the calcaneal insertion of the CFL. After dissection, in all the ankles, the dye was in contact with the sural nerve and the needle was located in the calcaneal insertion area of the CFL. The mean distance between the sural nerve and the needle was 4.8 mm (range 3-7 mm). DISCUSSION AND CONCLUSION: A pre- or intra-operative ultrasound technique is a simple and reliable means for obtaining anatomical landmarks when drilling the calcaneal tunnel for ligament reconstruction of the lateral plane of the ankle. This tunnel should preferably be drilled obliquely from the heel towards the subtalar joint (1 h-3 h direction on an ultrasound cross section), which preserves a maximum distance from the sural nerve for safety purposes, while allowing an accurate anatomical positioning of the osseous tunnel.

Distribution, prevalence, and impact on the metatarsosesamoid complex of first metatarsal pronation in hallux valgus.

BACKGROUND: Previous simulated weight-bearing CT (WBCT) studies classifying first metatarsal (M1) pronation suggested a high prevalence of M1 hyper-pronation in hallux valgus (HV). These findings have prompted a marked increase in M1 supination in HV surgical correction. No subsequent study confirms these M1 pronation values, and two recent WBCT investigations suggest lower normative M1 pronation values. The objectives of our WBCT study were to (1) determine M1 pronation distribution in HV, (2) define the hyperpronation prevalence compared to preexisting normative values, and (3) assess the relationship of M1 pronation to the metatarso-sesamoid complex. We hypothesized that the M1 head pronation distribution would be high in HV. METHODS: We retrospectively identified 88 consecutive feet with HV in our WBCT dataset and measured M1 pronation with the Metatarsal Pronation (MPA) and α angles. Similarly, using two previously published methods defining the pathologic pronation threshold, we assessed our cohort's M1 hyper-pronation prevalence, specifically (1) the upper value of the 95% confidence interval (CI95) and (2) adding two standard deviations at the mean normative value (2 SD). Sesamoid station (grading) was assessed on the coronal plane. RESULTS: The mean MPA was 11.4+/-7.4 degrees and the α angle was 16.2+/-7.4 degrees. According to the CI95 method, 69/88 HV (78.4%) were hyperpronated using the MPA, and 81/88 HV (92%) using the α angle. According to the 2 SD method, 17/88 HV (19.3%) were hyperpronated using the MPA, and 20/88 HV (22.7%) using the α angle. There was a significant difference in MPA among sesamoid gradings (p = 0.025), with a paradoxical decrease in MPA when metatarsosesamoid subluxation was increased. CONCLUSION: M1 head pronation distribution in HV was higher than in normative values, but threshold change demonstrated contradictory hyper-pronation prevalences (85% to 20%), calling into question the previously reported high prevalence of M1 hyper-pronation in HV. An increase in sesamoid subluxation was associated with a paradoxical decrease in M1 head pronation in our study. We suggest that a greater understanding of the impact of HV M1 pronation is warranted before routine M1 surgical supination is recommended for patients with HV. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Impact of First Metatarsal Hyperpronation on First Ray Alignment: A Study in Cadavers.

BACKGROUND: There is increased evidence of first metatarsal hyperpronation in patients with hallux valgus, but its impact on the stability of the first metatarsophalangeal and metatarsosesamoid joints is unknown. A previous biomechanical study showed that an increase in hallucal pronation might lead to medial soft tissue failure of the first metatarsophalangeal joint. Conversely, dynamic studies on hallux valgus have shown that the first tarsometatarsal joint moves in supination during weightbearing, and supination was associated with an increase in the intermetatarsal angle (IMA) and hallux valgus angle (HVA). QUESTIONS/PURPOSES: (1) Does an increase in first metatarsal pronation cause an increase in hallucal pronation? (2) Can an intrinsic increase in first metatarsal pronation lead to first ray supination during weightbearing? (3) Can a combination of intrinsic first metatarsal hyperpronation and first metatarsophalangeal medial soft tissue failure increase supination of the first ray during weightbearing? (4) Is first ray supination during weightbearing associated with an increase in the IMA and HVA? METHODS: Twelve transtibial, nonpaired cadaver specimens without deformities were used. Each specimen underwent six weightbearing CT scans under different conditions. The first three CT examinations were performed without any osteotomy of the first metatarsal. The first was a simulated nonweightbearing condition. The second was a simulated weightbearing condition. The third was a simulated weightbearing condition with medial soft tissue release. Subsequentially, a 30° pronation osteotomy of the first metatarsal was performed, and the same sequence of weightbearing CT images was obtained. On each weightbearing CT image, the HVA, IMA, sesamoid rotation angle, metatarsal pronation angle (MPA), metatarsosesamoid rotation angle, and hallucal pronation (HP) were measured. Motions were calculated based on the differential values of these angular measurements produced by the six different conditions (weightbearing, medial soft tissue release, 30° pronation osteotomy, and combinations of these conditions). We compared means using a t-test for normally distributed variables and the Mann-Whitney U test for nonnormally distributed variables. Correlations were assessed with Pearson product-moment correlation coefficients. RESULTS: We found that 30° pronation osteotomy of the first metatarsal increased the MPA and HP by 28° ± 4° and 26° ± 6°, respectively, in the nonweightbearing condition. No differences between the increase in MPA and the increase in HP were noted (mean difference 2° [95% CI -1° to 5°]; p = 0.20). Therefore, an increase in first metatarsal pronation caused an increase in hallucal pronation. When a 30° pronation osteotomy of the first metatarsal was performed, the first ray motion during weightbearing went from pronation to supination (4° ± 2° in pronation without osteotomy versus 4° ± 2° in supination after the osteotomy, mean difference 8° [95% CI 6° to 9°]; p < 0.001). Therefore, an intrinsic increase in pronation of the first metatarsal led to a first ray supination motion during weightbearing. When a first metatarsophalangeal medial soft tissue release was performed in addition to the 30° osteotomy of the first metatarsal, the supination motion of the first ray increased (4° ± 2° without medial soft tissue release versus 11° ± 7° after the release, mean difference 8° [95% CI 3° to 12°]; p = 0.003). Therefore, a combination of intrinsic first metatarsal hyperpronation and first metatarsophalangeal medial soft tissue failure increased supination of the first ray during weightbearing. Regarding static angular measurements, the HVA and IMA were not correlated with the MPA (ρ = 0.20; p = 0.09 and ρ = 0.22; p = 0.07, respectively). Regarding motions, as the HVA and IMA increased from nonweightbearing to weightbearing the pronation decreased, with strong correlations (ρ = -0.82; p < 0.001 and ρ = -0.77; p < 0.001, respectively). Therefore, a first ray supination during weightbearing was associated with an increase in the HVA and IMA. CONCLUSION: The combination of first metatarsal intrinsic hyperpronation and first metatarsophalangeal medial soft tissue failure led to a hallux valgus deformity in this cadaveric study. The static measurement of first metatarsal head pronation relative to the ground (MPA) did not reflect the real intrinsic pronation of the first ray, and foot and ankle specialists should be careful when interpreting these measurements. Hallux valgus is a dynamic condition, and the deformity could be more correlated with motions during weightbearing than with plain static measurements. CLINICAL RELEVANCE: First ray supination compensating for first metatarsal intrinsic hyperpronation might be an important factor in the hallux valgus pathogenesis. Further in vivo studies involving nonweightbearing and weightbearing comparative assessments of hallux valgus and controls should be performed to confirm this pathomechanism.

3D imaging has good specificity but poor sensitivity for the diagnosis of pathologies of the long head of the biceps: a systematic review and meta-analysis.

PURPOSE: To systematically review and meta-analyse the literature to determine which three-dimensional (3D) imaging modality provides the best diagnostic accuracy to detect pathologies of the long head of the biceps tendon (LHBT). MATERIALS AND METHODS: A search was performed on PubMed, Embase®, and Cochrane. Studies that compared the diagnostic accuracy of 3D imaging modalities versus arthroscopy for the assessment of LHBT pathologies were included. Studies assessing superior labral anterior posterior (SLAP) lesions were excluded. RESULTS: Fifteen studies were included; nine were eligible for meta-analysis. Six studies on instability indicated a sensitivity of 0.68 (CI 0.46-0.84) and specificity of 0.76 (CI 0.68-0.82). Four studies on full-thickness tears indicated a sensitivity of 0.56 (CI 0.28-0.81) and specificity of 0.97 (CI 0.93-0.99). Four studies on partial-thickness tears indicated a sensitivity of 0.52 (CI 0.20-0.82) and specificity of 0.64 (CI 0.25-0.91). Two studies on any tear indicated a sensitivity of 0.58 (CI 0.28-0.83) and specificity of 0.99 (CI 0.93-1.00). Only one study on other pathologies indicated a sensitivity of 0.61 and specificity of 0.84. CONCLUSION: To diagnose LHBT pathologies, 3D imaging modalities overall have low-to-moderate sensitivity, but high-to-excellent specificity. The consistency in reported sensitivity is generally poor, while the consistency and reported specificity is good for the detection of instability, full-thickness tears and any tear, but poor for the detection of partial-thickness tears. 3D imaging may be adequate to rule out LHBT pathologies, but are not sufficiently reliable to confirm the presence of such pathologies. LEVEL OF EVIDENCE: III.

Multiplanar instability of the first tarsometatarsal joint in hallux valgus and hallux rigidus patients: a case-control study.

BACKGROUND: Hypermobility of the first ray has been considered associated with various forefoot diseases including hallux valgus (HV) and hallux rigidus (HR). Weightbearing CT scan can be a reliable method for analysis of the first tarsometatarsal (TMT) joint in axial, sagittal, and coronal planes. Our objective was to comparatively investigate signs of instability of the first TMT joint on weightbearing CT between three groups (control, HV, and HR). METHODS: In this single-centre, retrospective, case-control study, 27 HV patients (30 feet; mean age 54.2 years), 26 HR patients (30 feet; mean age 56.6 years), and 30 controls (30 feet; mean age; 43 years) were enrolled. Measurements of signs of instability were performed in multiplanes including first TMT angle, dorsal translation of the first metatarsal (M1) at the first TMT joint, plantar distance between the medial cuneiform (C1) and M1 in sagittal plane, hallux valgus angle (HVA), intermetatarsal angle (IMA) in axial plane, rotational profiles of C1 and M1 in coronal plane. Analysis of variance (ANOVA) test and chi-square test were performed to compare each parameter between the three groups. Interobserver reliabilities were assessed using interclass correlation coefficients (ICCs). RESULTS: The HV group had significantly increased first TMT angle (0.23° in controls, 1.15° in HV, 0.19° in HR, p < 0.001), HVA (7.52°, 33.50°, 11.21°, p < 0.001), IMA (9.46°, 16.98°, 11.87°, p < 0.001), C1-M1 angle (22.44°, 29.46°, 23.74°, p < 0.001), and rotational profile of the distal M1 (7.06°, 17.88°, 9.85°, p < 0.001) compared with the control and HR groups. Dorsal translation of M1 (23% in controls, 63% in HV, 70% in HR, p < 0.001) was frequently found in the HV and HR groups with significantly increased plantar distance (0.37 mm, 1.14 mm, 1.46 mm, p < 0.001) compared with controls. CONCLUSIONS: Multiplanar instability of the first TMT joint was confirmed using weightbearing CT in HV and HR groups compared with controls. HV group demonstrated instability mainly in sagittal and axial planes; HR group had sagittal instability predominantly. Our measurement of rotational instability at the first TMT joint was not able to detect differences between groups. A surgical correction of the instability at the first TMT joint can be an option to address HV and HR. CLINICAL RELEVANCE: First ray hypermobility at the first TMT joint is an important consideration when addressing HV and HR, a surgical correction of the instability at the first TMT joint should be taken in consideration as an option.

Flexor tenodesis procedure in the treatment of lesser toe deformities.

In this technical report study, we describe the use of a flexor tenodesis procedure in the treatment of lesser toe deformities (LTD). Using a specific implant, both the flexor digitorum longus and brevis tendons are attached to the plantar aspect of the proximal phalanx, allowing dynamic correction of flexible deformities of metatarsophalangeal and interphalangeal joints. Good clinical results and absence of complications were observed in a series of 3 patients, with considerable correction of the LTD, and absence of substantial residual floating toe or metatarsophalangeal joint stiffness. LEVEL OF EVIDENCE: V - Technical Report/Case Report/Expert Opinion.

Tarsal Tunnel Syndrome: Outcome According to Etiology.

Surgical results in tarsal tunnel syndrome are variable, and etiology seems to be a factor. Three possible etiologies can be distinguished. The aim of the present study was to compare surgical results according to etiology. Three continuous retrospective series (45 patients overall) of tarsal tunnel syndrome were compared. Group 1 presented a permanent intra- or extra-tunnel space-occupying compressive structure. Group 2 presented intermittent intra-tunnel venous dilatations. Group 3 comprised idiopathic tarsal tunnel syndrome. The mean follow-up was 3.6 +/- 1.8 years. The main endpoint was subjective postoperative improvement on Likert scale. Group 1 reported greater improvement than groups 2 and 3. Preoperative neuropathy on ultrasound was associated with poorer improvement, which was not the case for neuropathy on electromyography. Surgical treatment of tarsal tunnel syndrome provides better results in etiologies involving structural compression.

Does tibialis posterior dysfunction correlate with a worse radiographic overall alignment in progressive collapsing foot deformity? A retrospective study.

BACKGROUND: Posterior Tibial Tendon (PTT) dysfunction is considered to have an important role in Progressive Collapsing Foot Deformity (PCFD). The objective of our study was to assess the relationship between PTT status and three-dimensional foot deformity in PCFD. METHODS: Records from 25 patients with PCFD were included for analysis. The PTT was considered deficient in patients with a positive single heel rise test or a deficit in inversion strength. Three-dimensional foot deformity was assessed using the Foot and Ankle Offset (FAO) from Weight-Bearing-CT imaging. Hindfoot valgus, midfoot abduction and medial longitudinal arch collapse were assessed on X-Rays using hindfoot moment arm, talonavicular coverage angle and Meary's angle respectively. Deland and Rosenberg MRI classifications were used to classify PTT degeneration. RESULTS: PCFD with PTT deficit (13/25) had a mean FAO of 7.75 + /- 3.8% whereas PCFD without PTT deficit had a mean FAO of 6.68 + /- 3.9% (p = 0.49). No significant difference was found between these groups on the hindfoot moment arm and the talonavicular coverage angle (respectively p = 0.54 and 0.32), whereas the Meary's angle was significantly higher in case of PCFD with PTT deficit (p = 0.037). No significant association was found between PTT degeneration on MRI and FAO. CONCLUSION: PCFD associated three-dimensional deformity, hindfoot valgus and midfoot abduction were not associated with PTT dysfunction. PTT dysfunction was only associated with a worse medial longitudinal arch collapse in our study. Considering our results, it does not appear that PTT is the main contributor to PCFD. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Study.

Diagnostic accuracy of measurements in progressive collapsing foot deformity using weight bearing computed tomography: A matched case-control study.

BACKGROUND: We aimed to investigate the diagnostic accuracy of known two-dimensional (2D) and three-dimensional (3D) measurements for Progressive Collapsing Foot Deformity (PCFD) in weight-bearing computed tomography (WBCT). We hypothesized that 3D biometrics would have better specificity and sensitivity for PCFD diagnosis than 2D measurements. METHODS: This was a retrospective case-control study, including 28 PCFD feet and 28 controls matched for age, sex and Body Mass Index. Two-dimensional measurements included: axial and sagittal talus-first metatarsal angles (TM1A and TM1S), talonavicular coverage angle (TNCA), forefoot arch angle (FFAA), middle facet incongruence angle (MF°) and uncoverage percentage (MF%). The 3D Foot Ankle Offset (FAO) was obtained using dedicated semi-automatic software. Intra and interobserver reliabilities were assessed. Receiver Operating Characteristic (ROC) curves were calculated to determine diagnostic accuracy (Area Under the Curve (AUC)), sensitivity and specificity. RESULTS: In PCFD, mean MF% and MF° were respectively 47.2% ± 15.4 and 13.3° ± 5.3 compared with 13.5% ± 8.7 and 5.6° ± 2.9 in controls (p < 0.001). The FAO was 8.1% ± 3.8 in PCFD and 1.4% ± 1.7 in controls (p < 0.001). AUCs were 0.99 (95%CI, 0.98-1) for MF%, 0.96 (95%CI, 0.9-1) for FAO, 0.90 (95%CI, 0.81-0.98) for MF°. For MF%, a threshold value equal or greater than 28.7% had a sensitivity of 100% and specificity of 92.8%. Conversely, a FAO value equal or greater than 4.6% had a specificity of 100% and a sensitivity of 89.2%. All other 2D measurements were significantly different in PCFD and controls (p < 0.001). CONCLUSIONS: MF% and FAO were both accurate measurements for PCFD. MF% demonstrated slightly better specificity. FAO better sensitivity. A combination of threshold values of 28.7% for MF% and 4.6% for FAO yielded 100% sensitivity and specificity.

Risks of injury in distal metatarsal minimally invasive osteotomy when comparing standard and modified techniques: A cadaveric study.

BACKGROUND: The objectives of the study were to evaluate the structures at risk in distal metatarsal mini-invasive osteotomy (DMMO) and to compare standard and intraosseous approaches. METHODS: DMMO was performed on the second and fourth metatarsals of 11 fresh-frozen cadaveric specimens. The standard technique was performed in 11 metatarsals. It was then compared to a modified intraosseous technique that entails starting inside the bone in 11 other metatarsals. The cadavers were dissected to identify unintentional injury to soft tissue structures. RESULTS: In the standard group the most injured structures were the metatarsal joint capsules (MJC) (27%), extensor digitorum longus (EDL) (18%), and extensor digitorum brevis (EDB) (9%). The modified intraosseous group injured the EDL (27%), not the MJC (0%) and the EDB (0%). Distances between osteotomies and the dorsal metatarsal head articular surface (DMHAS) were 6.08 ± 3.99 mm in the standard and 9.92 ± 3.42 mm in the modified (p = 0.02). CONCLUSION: The DMMO techniques most frequently injured the EDL. Intra-articular positioning of the osteotomy was more observed in the standard. Overall, it appears the modified method could be an alternative to the standard DMMO. CLINICAL RELEVANCE: The modified minimally invasive DMMO has a comparable rate of potential iatrogenic injuries. This intraosseous procedure may present as an option when planning surgery to the lesser metatarsals. LEVEL OF EVIDENCE: Level III. Comparative Cadaveric Study.

Comparison between Weightbearing-CT semiautomatic and manual measurements in Hallux Valgus.

BACKGROUND: Radiographic measurements are an essential tool to determine the appropriate surgical treatment and outcome for Hallux Valgus (HV). HV deformity is best evaluated by weight-bearing computed tomography (WBCT). The objective was (1) to assess the reliability of WBCT computer-assisted semi-automatic imaging measurements in HV, (2) to compare semi-automatic with manual measurements in the setting of an HV, and (3) to compare semi-automatic measurements between HV and control group. METHODS: In this retrospective IRB (ID# 201904825) approved study, we assessed patients with hallux valgus deformity. The sample size calculation was based on the hallux valgus angle (HVA). Thus to obtain the 0.8 power, including 26 feet with HV in this study, was necessary. Our control group consisted of 19 feet from 19 patients without HV. Raw multiplanar data was evaluated using software CubeVue®. In the axial plane, hallux valgus angle (HVA), intermetatarsal angle (IMA), and interphalangeal angle (IPA) were measured. The semiautomatic 3D measurements were performed using the Bonelogic®Software. Inter-rater reliabilities were performed using ICC. Agreement between methods was tested using the Bland-Altman plots. The difference between Patologic and Control cases using semi-automatic measurements was assessed with the Wilcoxon signed-rank test. Alpha risk was set to 5% (α = 0.05). P ≤ 0.05 were considered significant. RESULTS: Reliabilities utilizing ICC were over 0.80 for WBCT manual measurements and WBCT semi-automatic readings. Inter and intraobserver agreement for Manual and Semi-automatic WBCT measurements demonstrated excellent reliability. CONCLUSIONS: Semi-automatic measurements are reproducible and comparable to measurements performed manually. The software differentiated pathological from non-pathological conditions when subjected to semi-automatic measurements. The development of advanced semi-automatic segmentation software with minimal user intervention is essential for the establishment of big data and can be integrated into clinical practice, facilitating decision-making.

Predictive factors of effective tibial nerve release in tarsal tunnel syndrome.

BACKGROUND: Factors that may affect surgical decompression results in tarsal tunnel syndrome are not known. METHODS: A retrospective single-center study included patients who had undergone surgical tibial nerve release. The effectiveness of decompression was evaluated according to whether the patient would or would not be willing to undergo another surgical procedure in similar preoperative circumstances. RESULTS: The patients stated for 43 feet (51%) that they would agree to a further procedure in similar circumstances. Six feet with space-occupying lesions on imaging had improved results, but neurolysis failed in 9 feet with bone-nerve contact. Neurolysis was significantly less effective when marked hindfoot valgus (p = 0.034), varus (p = 0.014), or fasciitis (p = 0.019) were present. CONCLUSIONS: If imaging reveals a compressive space-occupying lesion, surgery has a good prognosis. In feet with static hindfoot disorders or plantar fasciitis, conservative treatment must be optimized. Bone-nerve contact should systematically be sought.

Correlation between indirect radiographic parameters of first metatarsal rotation in hallux valgus and values on weight-bearing computed tomography.

PURPOSE: To verify if indirect radiographic signs of first metatarsal pronation, determined by the head round sign, correspond to weight-bearing computed tomography (WBCT) measurements. METHODS: In this case-control retrospective study, we analyzed 26 hallux valgus (HV) feet and 20 controls through conventional radiograph (CR) and WBCT images. Two blinded orthopaedic foot and ankle surgeons performed the measurements. Pronation classification (head roundness), head diameter (HD), traditional HV angles, arthritis, sesamoid positioning, and first metatarsal rotation angle (MRA) (alpha angle) were evaluated. Comparisons were performed by Student's T-test and a multivariate regression was executed. P-values less than 0.05 were considered significant. RESULTS: Mean values were higher in HV patients than controls when evaluating MRA (11.51 [9.42-13.60] to 4.23 [1.84-6.62], 95%CI), HD (22.35 [21.52-23.18] to 21.01 [20.07-21.96]), and sesamoid rotation angle (SRA) (26.72 [24.09-29.34] to 4.56 [1.63-7.50]). The MRA had a low influence in head roundness classification (R2: 0.15). Changes in the pronation classification were explained chiefly by the sesamoid station (SS) (R2: 0.37), where stations 4 to 7 were found to be strong predictors of roundness classifications 2 and 3. CONCLUSION: Indirect signs of metatarsal pronation, determined by the head round sign, correlate weakly with the alpha angle measured in WBCT. The presence of arthritis and sesamoids displacement might modify the perception of first head roundness. The influence of MRA in the classification was low, where SS from 4 to 7 was strong predictors of a higher pronation classification.