[Degenerative cartilage changes in metatarsosesamoidal joint and Scarf procedure results for hallux valgus: a prospective study of 100 cases]. / Les lésions cartilagineuses métatarsosésamoïdiennes dans les résultats de l'ostéotomie Scarf: A propos d'une série prospective de 100 cas.

PURPOSE OF THE STUDY: Sesamoid bones of the hallux play a major role in the biomechanics of the metatarsophalangeal complex. Due to the deformations resulting from hallux valgus, the sesamoid system is exposed to abnormal stress forces. Mapping the degenerative cartilage shows the significant prevalence of these lesions and their relation with the anatomic deformation. The purpose of this work was to determine the impact of these metatarsosesamoidal joint changes on the results of Scarf procedure for hallux valgus. MATERIAL AND METHODS: This series included 89 patients (100 feet) who underwent Scarf osteotomy with complementary phalangeal osteotomy. We distinguished two groups in this cohort: 78 cases of surgery not involving the lateral metatarsals (group A), and 22 cases with associated lateral metatarsal osteotomy (group B). Mean follow-up was 2.3 years; minimal follow-up 16 months. The study protocol was prospective, with preoperative and last follow-up radiological and clinical assessment by an independent operator. Joint lesions noted intraoperatively by one senior operator were noted. The clinical work-up included the AOFAS score. A 15 degrees anteroposterior weight-bearing view was used to determine the degree of sesamoid dislocation and measure the following angles: first metatarsophalangeal angle (M1P1), first intermetatarsal space (M1M2), proximal articular set angle (PASA). Eleven zones were described to map the joint surfaces. The statistical analysis was used to search for links between joint lesions and the radiographic and clinical findings. RESULTS: The joint cartilage analysis revealed lesions involving the sesamoid bones in 72 cases, with a preferential involvement of the medial sesamoid bone (67%). The plantar joint surface of the first metatarsal presented lesions in the medial gutter in 72 cases, and in the lateral gutter in 68. Complete absence of the intersesamoid crest was noted in 38%. The metatarsophalangeal compartment presented degenerative lesions in 15 cases. The preoperative assessment noted a positive significant correlation between the AOFAS overall score and the absence of lesions involving the lateral sesamoid bone (p=0.015), between the AOFAS pain score and the absence of lesions involving the lateral sesamoid bone (p=0.022), between the AOFAS pain score and the complete absence of the intersesamoid crest (p=0.001), between the AOFAS deviation score and the absence of lesion involving the lateral gutter (p=0.001), between the M1P1 angle and the absence of an intersesamoid crest (p=0.001). At last follow-up, there was a positive significant correlation between the absence of lesions involving the medial sesamoid bone and a better overall AOFAS score (p=0.014), between absence of a lateral sesamoid lesion and better postoperative sentering of the sesamoids (p=0.014), between the absence of lesion in the medial gutter and a higher postoperative M1P1 angle (p=0.002), between the absence of lesions involving the lateral gutter and more favorable overall AOFAS score (p=0.005) for function (p=0.022), and deviation (p=0.018), between the absence of intersesamoid crest lesions and better radiographic sesamoid recentering (p=0.020). Distinct analysis of groups A and B did not demonstrate a significant difference compared with the overall cohort. Comparison of the two groups only demonstrated three significant differences involving radioclinical parameters. DISCUSSION: Hallux valgus is associated with very frequent metatarsosesamoid lesions. The distribution of these lesions is a function of the anatomic and biomechanical features of the metatarsosesamoid joint surfaces. Lesions to the lateral compartment would be a poor prognostic factor for Scarf procedure.

[Degenerative changes of the metatarso-sesamoido-phalangeal complex]. / Lésions dégénératives du complexe métatarso-sésamoïdo-phalangien.

OBJECTS: The aim of this work was to determine the frequency and the location of the degenerative lesions of the hallucal metatarsophalangeal joint in an elderly population. Our results help us to precise the anatomic characteristics of that articular complex. METHODS: Our material comprised 21 feet from embalmed cadaver specimens. We studied the morphometrical parameters for the anatomic description of the first metatarsophalangeal joint of the forefoot. After complete dissection, a specific articular zone-mapping was made with a quantitative evaluation of the chondral lesions. MAIN RESULTS: The measurements of the morphometrical parameters were in accordance with the literature data. The sesamoidal chondral lesions were more frequent for the medial sesamoid and at the proximal zone of the articular surface. The plantar metatarsal lesions were very frequent with diffuse or distal groove damage, and crista damage linked to the sesamoidal strap dislocation. The lesions involving the metatarsophalangeal compartment were less frequent and rather at the dorsal zone. CONCLUSIONS: The degenerative lesions of the metatarso-sesamoido-phalangeal complex are nearly systematic in n elderly population. The morphological aspect of these lesions is very characteristic of the articular function and allows us to precise the biomechanic constraints.

The role of quality standards--accreditation in redressing asymmetry of information in health care markets.

Asymmetry of information presents major difficulties for the efficient operation of markets in health care. The use of accreditation schemes may reduce these difficulties by enhancing the availability of reliable, accessible information on aspects of service quality considered important by service users and their agents. The UK's Patients' Charter with its associated Charter Marks has the potential to perform such a function in respect of inpatient services. In as much as it refers to aspects of service valued by service users which are specified in contracts by service procurers and appear not to be negatively correlated with other aspects of service quality, it can be seen to provide unambiguous signals of service quality. Given the Charter is currently under review, it seems appropriate that such attributes are borne in mind by policy makers in their deliberations as to its future.

Efficacy of first metatarsophalangeal joint lateral release in hallux valgus surgery.

INTRODUCTION: Lateral release of the sesamoid ligament complex is one of the key step to the surgical treatment of hallux valgus. Although numerous techniques are available to perform this procedure, there is no accepted consensus on the method of choice. The goal of this study was to evaluate the efficacy of sequential release of lateral soft tissue structures for correction of hallux valgus deformity. PATIENTS AND METHODS: This study included 40 patients, mean age 50.9 years old (±17.4), with 49 hallux valgus deformities from mechanical causes. The first metatarsophalangeal angle (M1P1), the intermetatarsal angle (M1M2) and the position of the sesamoids in relation to mechanical axis of M (according to the Research Committee of the American Orthopedic Foot and Ankle Society) were determined on preoperative X-rays. During the procedure, lateral release was performed in several steps: sectioning the metatarsosesamoid suspensory ligament then sectioning the phalangeal insertional band (PIB) and complete detachment of the adductor on the fibular sesamoid ligament. We measured the changes in the M1P1 and M1M2 angles during this step-by-step release. RESULTS: The M1P1 angle decreased during each step of release and went from 29.9° to 11.1° (P<0.001). The M1M2 decreased by 1.70° following medial capusolorrhaphy. Simple capsulorrhaphy reduced the hallux valgus deformity by 8.2° (44%). Release of the metatarsosesamoid suspensory ligament resulted in a decrease of 3.9° (or 21% of total release), release of the PIB in a decrease of 5.1° (27%) and complete detachment of the adductor in a decrease of 1.5° (8%). Thirty six percent of the sesamoids were reduced after metatarsosesamoid ligament resection, 56% after PIB release, and 60% after adductor release. DISCUSSION: Lateral soft tissue release is ensured in most cases by sectioning the metatarsosesamoid suspensory ligament and the PIB. Release of the adductor from the fibular sesamoid has a limited effect. CONCLUSION: Lateral soft tissue release should include sectioning the metatarsosesamoid suspensory ligament and detaching the PIB. This release should be enough to correct the deformity without performing any osteotomy in hallux valgus with M1P1<27° and M1M2<10°, as long as a stable medial plane can be obtained. LEVEL OF EVIDENCE: Level IV.

Osteochondral transfer using a transmalleolar approach for arthroscopic management of talus posteromedial lesions.

Characterizing osteochondral lesions of the talus has enabled the strategies of surgical management to be better specified. The main technical problem is one of access for arthroscopy instruments to posteromedial lesions. A range of techniques and approaches has been described in ankle arthroscopy in general, and a transmalleolar approach provides reliable and efficient access in these cases. It is frequently used for transchondral drilling, but also enables satisfactory implant positioning in autologous osteochondral mosaicplasty procedures. We report our technique and results on five cases with a minimum 1.2 years' follow-up.

Management of massive traumatic compound defects of the foot.

The management of high-energy trauma to the foot often requires multiple tissues reconstructive procedures with various technical options. The authors report the case of a patient presenting an extensive defect of the medioplantar region of the right foot involving an almost complete (90%) medial cuneiform bone loss. A deferred operation with saphenous cross-leg flap and interposition of a cement spacer was first performed. Reconstruction of the bone defect with corticocancellous iliac bone graft was subsequently carried out at two months post-trauma. At four months follow-up, the bone and soft tissues healing were good. At 24 months follow-up, the patient could return to normal professional and sports activities. The saphenous cross-leg flap has proven to be a reliable reconstructive procedure. The use of the modified Masquelet technique ensured an anatomical reconstruction and a satisfying final functional outcome.

Issues in cost function specification for neonatal care: the Fordham case.

BACKGROUND: Econometric techniques have been used to examine the relationship between costs of provision, case mix and unit size for health care providers. Estimation of cost functions in a health care context is complicated by poor understanding of the underlying production relationship and the constraints under which production takes place. Different results and policy implications can follow from different model specifications. This underscores the need for care in the construction of such functions and the interpretation of their results. METHODS: Cost and activity data from a study of neonatal care for an English Regional Health Authority are re-examined. Cost functions are estimated using alternative functional forms, and average cost per day is estimated and compared for two of these functions [one produced by Fordham et al. (J Publ Hlth Med 1992; 14(2): 127-130) and the other based more explicitly in economic and econometric theory]. RESULTS: It is shown that estimates of average cost per day are sensitive to model specification. Such are the differences in cost that significantly different policy implications could follow from the different models. CONCLUSION: We conclude that care must be taken in the construction and estimation of cost functions and that the assumptions upon which they rest be made explicit so that results can be properly interpreted.