First ray mobility in hallux rigidus, hallux valgus, and normal feet based on weightbearing computed tomography and three-dimensional analysis: A case-control study.

BACKGROUND: Hallux valgus and hallux rigidus are disorders affecting the first ray and are associated with hypermobility of this structure. This study aimed to investigate the three-dimensional mobility of each joint of the first ray between feet with hallux valgus or hallux rigidus and healthy feet using weightbearing and nonweightbearing computed tomography (CT). METHODS: This case-control study analyzed 17 feet of 11 healthy volunteers (control group), 16 feet of 16 patients with hallux valgus (HV group), and 16 feet of 11 patients with hallux rigidus (HR group). First, nonweightbearing foot CT imaging was performed in the supine position on a loading device with no load applied, with the legs extended and the ankle in the neutral position. Next, a load equivalent to body weight was applied for weightbearing CT imaging. Distal bone displacement relative to the proximal bone was quantified three-dimensionally under both conditions. RESULTS: In the HV group, the talonavicular joint showed significantly greater eversion (P = 00.011) compared with the control group and significantly greater dorsiflexion (P = 00.027) and eversion (P < 00.01) compared with the HR group. In the medial cuneiform joint, the HV group showed significantly greater eversion (P < 00.01) and abduction (P = 00.011) than the control group. For the first tarsometatarsal joint, the HV group showed significantly greater dorsiflexion (P = 00.014), inversion (P = 00.028), and adduction (P < 00.01) than the control group, and greater inversion (P < 00.01) and adduction (P < 00.01) than the HR group. Dorsiflexion of the first tarsometatarsal joint was significantly greater in the HR group compared with the control group (P = 00.026). CONCLUSION: Hypermobility of the first ray appears to be three-dimensional: in hallux valgus, it is centered at the first tarsometatarsal joint, while in hallux rigidus it is mainly in the sagittal plane at the first tarsometatarsal joint only. This difference may explain the different deformities ultimately observed in each condition.

Correction of Equinus Deformity by Ilizarov Frame Using the Matsushita Method and Achilles Tendon Lengthening: A Case Report.

CASE: The patient was an 18-year-old man who had sustained diaphyseal fractures of the left femur and tibia in a traffic accident and underwent surgery at another hospital. A severe left foot equinovarus deformity developed in the early after surgery. The patient's left foot deformity was addressed using unconstrained gradual external fixator correction (the Matsushita method) in combination with soft-tissue contracture through Achilles tendon lengthening and was maintained after removing the external fixation. CONCLUSION: The Matsushita method can be effective in the correction of post-traumatic equinovarus foot deformities.

Ganglion Cysts in the Hallux: A Report of Two Cases.

We experienced two cases of intractable hallux ganglion. Case 1 was a 70-year-old woman with a recurrent ganglion and severe pain on the plantar aspect of the hallux. The continuity between the mass and the distal flexor hallucis longus (FHL) tendon sheath was confirmed. The ganglion was resected along with part of the tendon sheath, and the tendon sheath was incised as proximally as possible. Case 2 was a 69-year-old woman with a ganglion on the dorsal aspect of the interphalangeal joint that repeatedly ruptured due to thinning of the skin. The ganglion was contiguous with the joint capsule but not with the FHL tendon sheath, and the entire capsule was resected. There was no recurrence one year after surgery in either case. The risk of recurrence of an intractable hallux ganglion can be reduced by blocking the synovial supply route and lowering the pressure inside the joint or tendon sheath.

Residual Medial Ankle Pain After the Delayed Union of a Lateral Malleolus Fracture: A Case Report.

A 17-year-old girl sprained her left ankle and was diagnosed with a lateral malleolar fracture. She was treated conservatively for six months but had medial ankle pain with activity. Imaging revealed an oblique lateral malleolar fracture, with posterolateral displacement and partial fusion of the bone fragments, and bone marrow edema on the medial articular surface of the talus and medial malleolus. We diagnosed ankle instability due to delayed union with a displacement of the lateral malleolus, which caused an osteochondral lesion. We performed arthroscopic and open surgery eight months after the injury, reducted the lateral malleolus anatomically, and fixed it with a plate. Postoperatively, the pain improved rapidly, and the bone marrow edema had almost disappeared on an MRI. In this case, we think rotational instability of the ankle mortise caused abnormal pressure and continuous stress on the medial malleolus after injury, which may have contributed to persistent medial ankle pain.

Three Cases of Gouty Tophus in the Foot Treated by Resection.

We encountered three cases of gouty tophus in the foot that required resection. All patients were male and aged 44-68 years at the time of surgery. The lesions were located on the great toe, second toe, and lateral malleolus and were causing ulceration and destruction of the joints. One patient had normal uric acid levels, and another patient had hyperuricemia but no history of attacks and no significant inflammatory symptoms around the gouty tophus, which was attributed to the physical containment of uric acid crystals by the gouty tophus. Given that the crystals were adherent to the surrounding fibrous tissue and cartilage surface, we resected them as far as possible to reduce the total amount of crystals and treated the remaining crystals with uric acid-lowering therapy. There were no complications at the time of surgery. The swelling and bone destruction subsided with continued medical treatment, resulting in significant improvement in quality of life. Patients with gouty tophus should be treated aggressively with medication and monitored to prevent severe joint destruction and ulceration. Excision of the nodule should be considered in cases of exacerbation.

Three-Dimensional Analysis of the Windlass Mechanism Using Weightbearing Computed Tomography in Healthy Volunteers.

BACKGROUND: The windlass mechanism (WM) increases the longitudinal arch of the foot via tension of the plantar aponeurosis during dorsiflexion of the metatarsophalangeal (MTP) joint. The purpose of this study was to perform a 3-dimensional evaluation of the displacement of each joint and the height of the navicular during dorsiflexion of the first MTP joint by using weightbearing computed tomography (CT). METHODS: Participants were 6 men and 8 women with 23 healthy feet. CT of the foot with a load equivalent to the participant's body weight was performed. The first MTP joint was in the neutral position and dorsiflexed 30 degrees. Between the conditions, we measured the (1) rotation of each bone, (2) rotation of the distal bone with respect to the proximal bone at each joint, and (3) height of the navicular. RESULTS: With respect to the tibia, the calcaneus was at 0.8 ± 0.7 degrees dorsiflexion and 1.4 ± 0.9 degrees inversion, while the talus was at 2.0 ± 1.2 degrees dorsiflexion and 0.1 ± 0.8 degrees eversion. The navicular was at 1.3 ± 1.2 degrees dorsiflexion and 3.2 ± 2.1 degrees inversion, whereas the medial cuneiform was at 0.3 ± 0.6 degrees plantarflexion and 1.3 ± 1.1 degrees inversion. At the talonavicular joint, the navicular was at 0.7 ± 1.3 degrees plantarflexion, whereas at the cuneonavicular joint, the medial cuneiform bone was at 1.4 ± 1.4 degrees plantarflexion. The height of the navicular increased by 1.1 ± 0.6 mm. CONCLUSION: We 3-dimensionally confirmed the dynamics of WM and found that the calcaneus, navicular, and medial cuneiform moved in all 3 planes. The results suggest that the cuneonavicular joint has the greatest movement among the joints. We believe that these findings will help to elucidate the pathogenesis of WM-related diseases and lead to advances in treatments for pathologies involving the longitudinal arch. LEVEL OF EVIDENCE: Level IV, case series.

Simultaneous Glomus Tumors of the Third and Fourth Toes: A Case Report.

CASE: A glomus tumor of the toes is rare, and as far as we know, there has been no report of simultaneous occurrence in 2 toes. A 45-year-old woman presented with forefoot pain. Based on imaging findings, glomus tumors of the third and fourth toes were suspected. Tumor resection was performed, and pathological examination confirmed the diagnosis of glomus tumors. CONCLUSION: In this case, it was difficult to recognize the tumors because they occurred simultaneously in 2 toes. Even for sites where a glomus tumor is rare, it is important to understand the characteristic symptoms through a detailed interview and examination.

Comparison of outcomes of different osteotomy sites for hallux valgus: A systematic review and meta-analysis.

BACKGROUND: Hallux valgus (HV) is a common foot deformity for which several corrective surgical procedures, with different osteotomy sites, have been reported. The purpose of the present study was to systematically review randomized (RCTs) or controlled (CCTs) clinical trials and perform meta-analysis on outcomes of different osteotomy sites of the first metatarsal. METHODS: An extensive literature search was conducted in PubMed and the Cochrane Library from January 1983 to July 2020. Studies were identified using the terms "hallux valgus" and "osteotomy". We included RCTs or CCTs comparing different locations of osteotomy for the first metatarsal bone (distal vs. mid-shaft, distal vs. proximal, and mid-shaft vs. proximal). The surgical outcomes included postoperative hallux valgus angle (HVA), intermetatarsal angle (IMA), American Orthopaedic Foot and Ankle Society (AOFAS) score, pain visual analog scale (VAS) score, perioperative complications and recurrence of deformity. We enrolled 10 studies with a total of 793 feet in the qualitative synthesis following full-text screening. RESULTS: A majority of patients included in the enrolled trials showed mild to moderate deformity, with mean HVA <40°. Out of the 10 enrolled studies; six compared distal osteotomies with mid-shaft osteotomies and showed no significant differences in the surgical outcomes between the scarf and chevron groups; three RCTs compared distal osteotomies with proximal osteotomies with conflicting results, one RCT showed the superiority of proximal osteotomy while the other two RCTs showed equivalent outcomes; one study that compared between mid-shaft and proximal osteotomies showed equivalent outcomes between the groups. CONCLUSION: For the management of mild to moderate HV deformity, we found no significant clinical and radiological differences between patients treated with scarf and chevron osteotomies. Further controlled trials comparing different sites of osteotomies for moderate to severe HV deformity are needed.

Refractory peroneal spastic flat foot successfully treated with a cast in a girl.

An 11-year-old girl presented with pain in the sinus tarsi and a foot deformity after spraining her left foot. She had flat foot due to spasticity of the peroneal tendon, which was difficult to correct manually. An imaging study revealed an accessory anterolateral talar facet (AALTF) and bone marrow oedema at the lateral aspect of the posterior talocalcaneal joint. We diagnosed peroneal spastic flat foot with possible involvement of sinus tarsi syndrome and AALTF. When conservative therapy failed, we applied a cast with the foot in full plantar flexion and an inverted position. After 4 weeks, the patient had a normal range of motion in the foot, the pain had resolved completely and the peroneal spasticity had disappeared. Orthopaedic treatment with a cast may be worth attempting before surgery in such cases.

Lateralizing Calcaneal Osteotomy and First Metatarsal Dorsiflexion Osteotomy for Cavovarus Foot and Peroneal Sheath Release with Peroneus Brevis Repair for Peroneal Tendinopathy in Chronic Ankle Instability and Sprain.

A 47-year-old male presented with an eight-year history of pain in the posterior inferior part of the lateral malleolus, ankle instability, and repeated right-sided ankle sprains. He had pes cavus and hind-foot varus in his right foot, which is an unknown congenital entity or acquired with tenderness in the inferior peroneal retinaculum. There is no deformity in his left foot. The pain was elicited by the movement of the subtalar joint. Imaging revealed a high medial longitudinal arch, an enlarged peroneal tubercle, thinning of the peroneus brevis tendon, and hypertrophy of the peroneus longus tendon. We diagnosed peroneal tendinopathy with cavovarus foot in a chronic ankle sprain. The supination generated by pes cavus was thought to be aggravating the peroneal tendinopathy and causing the ankle sprains. Incision of the peroneal tendon sheath, repair of the peroneus brevis tendon, lateralizing calcaneal osteotomy, and first metatarsal dorsiflexion osteotomy were performed. At the one-year follow-up, Meary's angle was corrected to 0°, the calcaneal pitch was corrected to 20°, and the hindfoot varus was improved. He was pain-free and reported no further instability when walking. His Japanese Society of Surgery of the Foot ankle-hindfoot scale score improved from 59 preoperatively to a maximum of 100 and the Self-Administered Foot Evaluation Questionnaire gave an almost perfect score for non-sports-related items and a score of 83.3 for sports-related items. We believe that the addition of treatment of the pes cavus, which was the center of the pathology, as well as treatment of the peroneal tendon, resulted in a good outcome.

Nontraumatic Bilateral Recurrent Peroneal Tendon Dislocation with Pes Planovalgus: A Case Report.

CASE: Peroneal tendon dislocation is a relatively infrequent problem. Most cases are traumatic, and nontraumatic cases are rare. In this case, a 21-year-old man had nontraumatic bilateral recurrent peroneal tendon dislocation on standing and pes planovalgus. We performed medial displacement osteotomy of the calcaneus for the pes planovalgus and reattachment of the retinaculum and groove deepening for the peroneal tendon dislocations. CONCLUSION: The dislocations were attributed to the force of the tendon riding up the lateral malleolus on standing because of pes planovalgus. A good outcome was achieved by surgical intervention for both the pes planovalgus and peroneal tendon dislocations.

Dislocation of the first metatarsophalangeal joint concomitant with Lisfranc joint dislocation in a 45-year-old man.

A 45-year-old man presented with severe pinch-point crush injury to his left foot. Plain radiographs revealed dislocation of the first metatarsophalangeal joint and dorsolateral dislocation of the basal phalanx and sesamoids. The first tarsometatarsal joint was subluxed in the plantar direction and the second to fourth tarsometatarsal joints were subluxed dorsally. The sesamoids were displaced dorsolateral to the metatarsal head. There was a longitudinal tear of the joint capsule at the medial margin of the medial sesamoid, which was sutured together with the abductor hallucis tendon and collateral ligament. The Lisfranc and dorsal ligaments in the tarsometatarsal joint were torn and repaired after reduction and fixed with a plate. One year after surgery, there was contracture of the first metatarsophalangeal joint, but the patient had no pain and was able to run.

Gouty Tophus in the Foot without Hyperuricemia Diagnosed by Dual-energy Computed Tomography: A Case Report.

Introduction: Gouty tophi are relatively simple to diagnose because they almost always occur in patients with persistent hyperuricemia. Treatment typically consists mainly of oral medication, and surgical intervention is necessary for only a small number of patients. Case Presentation: We present a case of 66-year-old Japanese man presented with a painful gouty tophus diagnosed by dual-energy computed tomography in the right foot without hyperuricemia that had gradually increased in size over the past 20 years. The tophus was removed and the patient's plantar pain disappeared after surgery and there was no recurrence. Conclusion: We obtained a favorable outcome through surgical intervention for a gouty tophus of the foot diagnosed by dual-energy computed tomography in a patient without hyperuricemia. Our experience suggests that proactive surgical removal of gouty tophi should be considered for symptomatic cases and to prevent further joint destruction.

Weightbearing Computed Tomography and 3-Dimensional Analysis of Mobility Changes of the First Ray After Proximal Oblique Osteotomy for Hallux Valgus.

BACKGROUND: Hypermobility of the first ray has been evaluated using various methods and has conventionally been considered to be involved in the pathology of hallux valgus. We hypothesized that hypermobility of the first ray in hallux valgus could be decreased by simply correcting foot alignment without arthrodesis. This study sought to evaluate first-ray mobility using weightbearing computed tomography (CT) before and after proximal oblique osteotomy and also in healthy volunteer's feet. METHODS: Subjects were 11 feet of 11 patients with primary hallux valgus who underwent surgery with a plantarly applied anatomic precontoured locking plate and 22 feet of 11 matched healthy volunteers. We performed nonweightbearing and weightbearing (using a load equivalent to body weight) CT scans using an original loading device preoperatively and 1-1.5 years postoperatively. Three-dimensional displacement of the distal bone relative to the proximal bone was quantified for each joint of the first ray by comparing nonweightbearing and weightbearing CT images. RESULTS: At baseline, there were significant differences in hallux valgus angle (P < .001) and 1-2 intermetatarsal angle (P < .001) between healthy volunteer's feet and preoperative hallux valgus feet. Hallux valgus angle (P < .001) and 1-2 intermetatarsal angle (P < .001) differed significantly between before and after surgery. All first ray joint displacement under loading decreased postoperatively to within 2° of that in healthy volunteer's feet and showed no significant difference between postoperatively hallux valgus feet and healthy volunteer's feet (P > .05). CONCLUSIONS: We found that first metatarsal osteotomy even without arthrodesis corrected deformity and decreased mobility of the first ray after hallux valgus surgery. LEVEL OF EVIDENCE: Level III, case-control study.

New Method for the Quantitative Assessment of Sensory Disturbances in Cervical Myelopathy: Application for Neurological Level Diagnosis.

INTRODUCTION: Cervical myelopathy frequently manifests as sensory disturbances, including numbness, and their distribution pattern aids in neurological level diagnosis. However, the objective assessment of sensory disturbances is challenging. In this study, we attempted to quantitatively evaluate sensory symptoms in patients with cervical myelopathy according to lesion level using PainVisionⓇ. METHODS: Dermal sensations were evaluated in patients (n = 158) and healthy volunteers (n = 100) using PainVisionⓇ PS-2100, which measured the current perception threshold (CPT). The results were analyzed for their correlation with magnetic resonance imaging (MRI) data, visual analog scale (VAS) scores, and patient functional status assessed by the Japanese Orthopaedic Association (JOA) and JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) scores. RESULTS: Forearm and palm CPT values were significantly higher in patients with cervical myelopathy (both sites, P < 0.001) and were negatively correlated with the JOA score (forearm, r = -0.33; palm, r = -0.35; P < 0.001) and the JOACMEQ scores for upper extremity function (forearm, r = -0.37; palm, r = -0.39; P < 0.001), lower extremity function (forearm, r = -0.39; palm, r = -0.40; P < 0.001), and quality of life (forearm r = -0.27, P = 0.0025); however, no correlation was observed with the VAS score. Stratification of patients according to their lesion levels determined by MRI revealed that the C3/C4 subgroup had significantly higher forearm CPT values than the C4/C5 (P = 0.024) and C5/C6 (P = 0.0013) subgroups and higher palm CPT values than the C5/C6 subgroup (P = 0.009). CONCLUSIONS: Quantitative measurements of sensory disturbances using the PainVisionⓇ device correspond to the degree of patient functional disability and the lesion level. This indicates that both the distribution and intensity of sensory abnormalities are important for neurological level diagnosis in patients with cervical myelopathy.

Efficacy of Laminoplasty in Improving Sensory Disturbances in Patients with Cervical Spondylotic Myelopathy: A Prospective Study.

OBJECTIVE: Upper extremity sensory disturbances are primary symptoms that affect the quality of life (QOL) of patients with cervical spondylotic myelopathy. Although laminoplasty is 1 of the surgical options, its effects on sensory disturbances have remained unclear. We aimed to determine whether surgical intervention would improve the sensory disturbances of patients with cervical spondylotic myelopathy. METHODS: We conducted a prospective clinical trial of 101 patients who had undergone open door laminoplasty. For an objective sensory assessment, we measured the current perception thresholds (CPTs) in the patients' forearms and palms using PainVision PS-2100. For a subjective sensory assessment, numbness in the upper extremities was rated using a visual analog scale (VAS). Using the VAS scores, the patients were divided into those with improvement and without improvement. Their self-reported 36-item short-form health survey and Japanese Orthopaedic Association cervical myelopathy evaluation questionnaire scores were compared. RESULTS: The postoperative CPTs in relationship to the preoperative CPTs at 3, 6, and 12 months was 99.3%, 98.1%, and 93.8% in the forearm and 93.6%, 90.6%, and 87.8% in the palm, respectively. The corresponding postoperative numbness VAS scores were 63.8%, 50.5%, and 48.0%. At 12 months postoperatively, the 36-item short-form health survey physical and role component summary scores, cervical spine function effectiveness rates, upper and lower extremity function, and QOL items in the Japanese Orthopaedic Association cervical myelopathy evaluation questionnaire were significantly higher in the improvement group. CONCLUSIONS: Our findings have indicated that improvement in postoperative subjective sensory disturbances will occur relatively earlier and will be significantly greater than the improvement in objective sensory disturbances. Furthermore, improvement in the subjective sensory disturbances contributes to functional spinal cord recovery and patients' health-related QOL.

A Type III Monteggia Injury with Ipsilateral Fracture of the Distal Radius and Ulna in a Child: Case Report Followed for 21 Years.

Bado type III Monteggia injuries complicated by ipsilateral forearm fractures are extremely rare. We report a case of a 6-year-old boy who sustained such an injury after falling from the top of a 3 m climbing pole. He was diagnosed with a Bado type III Monteggia fracture and forearm fractures. Manual reduction was attempted on the day of injury. However, because it was difficult to maintain the reduction of the radial head, open and percutaneous procedures were performed to reduce and fixate the fractures with Kirschner wires. The postoperative course was favorable. Twenty-one years later, the patient, now 27 years old, had no decreased range of joint motion or problems with activities of daily living. The fracture morphology observed in this case is rare, and this is the only case for which long-term follow-up has been carried out to adulthood.

Proximal oblique metatarsal osteotomy for hallux valgus using a plantar locking plate.

BACKGROUND: The purpose of this retrospective study was to evaluate the clinical and radiological results of hallux valgus surgery using a plantar locking plate. METHODS: Proximal oblique metatarsal osteotomy combined with distal soft tissue treatment was performed in 59 adult patients (68 feet) with hallux valgus, using an anatomically pre-contoured plantar locking plate for fixation of the osteotomy. The median age was 64.0 years and the median follow-up period was 16.5 months. RESULTS: The mean JSSF scale improved significantly from 56.0 points preoperatively to 95.8 points postoperatively. The mean intermetatarsal angle and hallux valgus angle decreased from 16.4° and 41.8° preoperatively to 4.2° and 10.8° postoperatively, respectively. The mean inclination angle was 19.9° preoperatively and 20.5° postoperatively. Removal of hardware was needed in 2 feet (2.9%). CONCLUSIONS: Proximal oblique metatarsal osteotomy is an effective method for relief of pain and improvement of function in correction of hallux valgus deformity. Use of a plantar locking plate provides sufficient maintenance of the correction, and complications associated with the hardware are rare.

Comparison of Intercuneiform 1-2 Joint Mobility Between Hallux Valgus and Normal Feet Using Weightbearing Computed Tomography and 3-Dimensional Analysis.

BACKGROUND: An association has been reported between hallux valgus and hypermobility of the first ray, but subluxation of the intercuneiform 1-2 joint was also suspected in some cases. However, dynamics of the intercuneiform 1-2 joint has seldom been investigated. This study used weightbearing computed tomography (CT) and a 3-dimensional (3D) analysis system to evaluate displacement of the intercuneiform 1-2 joint, intercuneiform 2-3 joint, and second cuneonavicular joint due to weightbearing in hallux valgus and normal feet. METHODS: Patients were 11 women with hallux valgus (mean age, 56 years; mean hallux valgus angle, 43 degrees; mean first-second intermetatarsal angle, 22 degrees) and 11 women with normal feet (mean age, 57 years; mean hallux valgus angle, 14 degrees; mean first-second intermetatarsal angle, 9 degrees). Each patient was placed supine with the lower limbs extended, and CT was performed under nonweightbearing and weightbearing conditions (load equivalent to body weight). 3D models reconstructed from CT images were used to compare displacement of the intermediate cuneiform relative to the medial cuneiform under nonweightbearing and weightbearing conditions. RESULTS: Relative to the medial cuneiform, the middle cuneiform was displaced by 0.1 and 0.8 degrees due to dorsiflexion, 0.2 and 1.0 degrees due to inversion, and 0.7 and 0.7 degrees due to abduction in normal feet and feet with hallux valgus, respectively, with the latter having significantly greater dorsiflexion ( P = .0067) and inversion ( P = .0019). There was no significant intergroup difference at the intercuneiform 2-3 joint and second cuneonavicular joint. CONCLUSION: This study clarified the detailed load-induced displacement of the cuneiform 3-dimensionally. Compared with normal feet, hallux valgus feet had significantly greater mobility of the intercuneiform 1-2 joint, suggesting hypermobility of this joint. LEVEL OF EVIDENCE: Level III, case-control study.