Instability of the first metatarsal-cuneiform joint: diagnosis and discussion of an independent pain generator in the foot.

BACKGROUND: First metatarsocuneiform (MC) instability is recognized as a pathologic contributor to hallux valgus. There are no studies identifying the first MC joint as an independent pain generator in the foot that may require surgical arthrodesis for its management. MATERIALS AND METHODS: The authors reviewed the records of all patients with this newly described pathology in the first MC joint. There were 61 patients with 85 feet who underwent a fluoroscopically guided local anesthetic injection into the first metatarsocuneiform joint to assess pain relief. Patient's complaints, physical exam findings, treatment decisions, patient characteristics, and radiographic findings were evaluated. RESULTS: Seventy-nine percent of patients (67/85) injected had relief of their symptoms. Eight or these 67 patients were eventually treated with first MC arthrodesis with complete relief of symptoms. The average time from onset of symptoms to presentation was 21 (range, 1 to 72) months. Eighty-five percent of feet (72/85) had multiple previous diagnoses. Radiographic plantar widening of the first M-C joint on weightbearing views was inconsistent with pathology. CONCLUSION: The first MC joint is an independent pain generator in the foot that can have variable presentations. Radiographic data can often be helpful, but clinical exam findings are paramount in the diagnosis. Fluoroscopically-guided long acting local anesthetic injections of this joint are helpful in the diagnosis, especially in the patient with multiple possible pain generators in the foot and ankle. Failure to recognize the first MC joint as a source of pain may lead to delay in treatment, misdiagnosis, and mistreatment of foot pathology.

The treatment of unstable ankle fractures in patients over eighty years of age.

BACKGROUND: The current study examined the outcomes of operative treatment of unstable ankle fractures in patients at least 80 years old at the time of injury. METHODS: Of 2,682 patients who presented for treatment of ankle fractures, 17 patients met the study criteria. These patients had open reduction and internal fixation after sustaining 15 closed and two open unstable ankle fractures. There were 11 type B fractures and six type C fractures by the Danis-Weber classification, and 12 supination-external rotation and five pronation-external rotation fractures by the Laugen-Hansen classification systems. RESULTS: When noncompliant patients who developed complications were removed from analysis, the fixation failure and deep infection rates were 0% each. CONCLUSIONS: These results highlight the importance of patient compliance and non-weightbearing status in the treatment of ankle fractures in patients over 80 years.

Stress fracture as a complication of autogenous bone graft harvest from the distal tibia.

BACKGROUND: Autogenous bone graft from the distal tibia provides cancellous bone graft for foot and ankle operations, and it has osteogenic and osteoconductive properties. The site is in close proximity to the foot and ankle, and published retrospective studies show low morbidity from the procedure. METHODS: One-hundred autografts were obtained from the distal tibia between 2000 and 2003. In four cases the distal tibial bone graft harvest resulted in a stress fracture. There were three women and one man. RESULTS: The average time of diagnosis of the stress fracture from the operation was 1.8 months. All stress fractures healed with a short course (average 2.4 months) of cast immobilization. CONCLUSIONS: This study demonstrated that a stress fracture from the donor site of autogenous bone graft of the distal tibia occurs and can be successfully treated nonoperatively.

Comparison of MRI and local anesthetic tendon sheath injection in the diagnosis of posterior tibial tendon tenosynovitis.

BACKGROUND: The modalities currently available to clinicians to confirm the clinical suspicion of posterior tibial tendinitis include MRI, CT, sonography, tenography, and local anesthetic tendon sheath injections. There are no reports in the literature comparing local anesthetic tendon sheath injection to MRI as tools for diagnosing posterior tibial tenosynovitis. METHODS: The authors reviewed the records of all patients with stage 1 posterior tibial tendon dysfunction between the dates of September 1, 2001, to November 21, 2004. Fifteen patients (17 ankles) had a local anesthetic injection into the posterior tibial tendon sheath and MRI for clinically suspected tenosynovitis of the posterior tibial tendon. RESULTS: Seventeen (100%) of 17 ankles had complete relief of symptoms after the local anesthetic tendon sheath injections. Fifteen (88%) of 17 ankles had abnormally increased fluid signal within the posterior tibial tendon sheath seen on MRI. Two of two ankles (100%), after having negative MRI findings, had complete relief with a local anesthetic tendon sheath injection. In addition, conservative treatment failed in these two patients, and they subsequently had tenosynovectomy with gross confirmation at surgery of inflammatory changes within the tendon sheath. These two patients had complete symptom relief after tenosynovectomy. CONCLUSIONS: Local tendon sheath injections and MRI are both reliable diagnostic tools. Injection of the posterior tibial tendon is an accurate, safe, and sensitive modality useful in patients in whom MRI studies are negative in the face of continued clinical suspicion.

Value of radiographs in the initial evaluation of nontraumatic adult heel pain.

BACKGROUND: Adult patients with nontraumatic plantar heel pain often present to orthopaedic surgeons for evaluation. A thorough history and physical examination are often sufficient for diagnosis, yet radiographs usually are ordered during the initial evaluation. The purpose of this study was to evaluate the value and cost-effectiveness of these radiographs. METHODS: A retrospective chart and radiographic review of 157 consecutive adults (215 heels) presenting with nontraumatic heel pain was done to evaluate the utility of routine radiographs in the initial evaluation. RESULTS: The most common diagnosis was plantar fasciitis (80.9%, 174 of 215). Radiographs were normal in (17.2%, 37 of 215), and incidental radiographic findings were observed in 81.4% (175 of 215). The most common incidental findings were plantar calcaneal spurs (59.5%, 128 of 215) and Achilles spurs (46.5%, 100 of 215). Only (2%, 4 of 215) of all patients had abnormal findings that prompted further evaluation. CONCLUSIONS: Routine radiographs are of limited value in the initial evaluation of nontraumatic plantar heel pain in adults and were not necessary in the initial evaluation. Radiographs should be reserved for patients who do not improve as expected or present with an unusual history or confounding physical findings.

Ipsilateral arthrodesis of the metatarsophalangeal and interphalangeal joints of the hallux.

BACKGROUND: Arthrodesis of the metatarsophalangeal joint of the hallux is frequently used for treatment of a variety of disorders. However, occasionally patients who have complex deformities or degenerative changes of the hallux require reconstruction of both the metatarsophalangeal and interphalangeal joints. There is concern that arthrodesis of both the metatarsophalangeal and ipsilateral interphalangeal joints could be problematic, interfering with the toe-off phase of gait or with shoewear. METHODS: A retrospective evaluation of seven feet in five patients who had simultaneous arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux was undertaken. These cases represented all the patients who had this procedure within the practice of three orthopaedic foot and ankle specialists, totaling over 50 surgeon-years of experience. The indication for surgery in all patients was moderate to severe pain with ambulation with severe fixed deformity of both the interphalangeal and metatarsophalangeal joints of the hallux. All patients had pain that limited their ambulation and interfered with their daily activities. All patients required modified shoewear to accommodate their foot deformity. The mean age of patients was 53 years. The patients were evaluated by questionnaire and radiographic examination. RESULTS: At an average of 46 months followup, all patients had resolution of their pain and were able to wear nonprescription shoes. All had limitations that interfered with full athletic activities but had no limitation of daily activities. Three patients who were employed returned to their occupations and two who were not employed were able to continue housework. CONCLUSION: Arthrodesis of the metatarsophalangeal and ipsilateral interphalangeal joints of the hallux results in painless function in patients with moderate demands.

Incidence of foot and ankle injuries in West Point cadets with pes planus compared to the general cadet population.

BACKGROUND: The relationship between pes planus and injuries of the lower extremity is controversial. However, few studies have used standardized means of evaluating and defining pes planus, and none have had a controlled patient population. The objective of this study was to evaluate an ideal population of physically active individuals to establish a potential correlation between pes planus, as defined by a standardized method, and injuries to the lower extremity. METHODS: A standardized technique for evaluating arch height, based on a midfoot ratio established by Harris mat print calculations, was used to assess a consecutive series of 512 newly entered West Point cadets. Pes planus was defined as more than 2 standard deviations above the mean midfoot ratio of the population. After 46 months, a retrospective chart review was done to identify lower extremity injuries sustained in this group of young healthy patients. The results of the footprint analysis were correlated with the medical record findings. RESULTS: Thirty-three cadets were found to have pes planus; 13 had only left foot involvement, 15 had right foot only involvement, and five had bilateral pes planus. There were no cavus feet. Statistically significant relationships were seen between the degree of pes planus and total number of injuries sustained (p = 0.007), the overall size of the foot and total number of injuries (p = 0.041), left flat feet and left midfoot injuries (p = 0.028), left pes planus and right midfoot injuries (p = 0.008), left pes planus and left knee injuries (p = 0.038), and right pes planus and right knee injuries (p = 0.027). Women had smaller feet (p = 0.000), smaller midfoot ratios (right, p = 0.013; left p = 0.003), yet they had an increased number of injuries (Pearson's coefficient -0.119; p = 0.007). CONCLUSIONS: The current study found significant relationships between pes planus and number of injuries sustained over a 4-year period at West Point. While women were found to have smaller feet and lesser degrees of pes planus, they sustained more injuries than men.

A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers.

OBJECTIVE: The purpose of this study was to compare the effectiveness of a removable cast walker (RCW) rendered irremovable (iTCC) with the total contact cast (TCC) in the treatment of diabetic neuropathic plantar foot ulcers. RESEARCH DESIGN AND METHODS: In a prospective, randomized, controlled trial, 41 consecutive diabetic patients with chronic, nonischemic, neuropathic plantar foot ulcers were randomly assigned to one of two groups: a RCW rendered irremovable by wrapping it with a single layer of fiberglass casting material (i.e., an iTCC) or a standard TCC. Primary outcome measures were the proportion of patients with ulcers that healed at

The radiographic morphology of foot deformities in patients with fibrodysplasia ossificans progressiva.

BACKGROUND: The most consistent deformities that allow early diagnosis of fibrodysplasia ossificans progressiva are the presence of bilateral short first rays and hallux valgus. The purpose of this study was to describe the radiographic features observed in the feet of patients with fibrodysplasia ossificans progressiva. METHODS: The radiographs of 26 feet (15 patients with fibrodysplasia ossificans progressiva) were reviewed to evaluate the radiographic changes that occur in the first ray. Variables analyzed were the hallux valgus (HV) angle, the distal metatarsal articular (DMA) angle, the proximal phalangeal articular (PPA) angle, the intermetatarsal (IM) angle, ratio of the lengths of the first and second metatarsal lengths (MT1:MT2), and the first and second ray length ratio. The length ratios were then subtracted from similar ratios in radiographs of age- and gender-matched normal patients previously reported. RESULTS: The proximal phalanx was consistently shortened but morphologically dissimilar from subject to subject. Asymmetry was noted in some patients with bilateral radiographs. The mean HV angle was 28 degrees, and the mean IM angle was 10 degrees. The mean DMA angle was 33 degrees, and the mean PPA angle was 14 degrees. The MT1:MT2 ratio was 0.89, and the mean first ray to second ray length ratio was 0.87. The mean of the differences in the MT1:MT2 and first and second ray length ratios in patients with fibrodysplasia ossificans progressiva compared to the normal controls were 0.05 and 0.01, respectively. Fusion occurred between the abnormal tibial epiphysis of the proximal phalanx and metatarsal head with advancing age, and 68% of the metatarsal heads were fused with the abnormal proximal phalangeal epiphysis. CONCLUSIONS: Foot pathology in patients with fibrodysplasia ossificans progressiva is variable but consistently involves an abnormality of the tibial aspect of the proximal phalangeal epiphysis of the hallux. This results in the clinical observation of hallux valgus in these patients. The first metatarsal is consistently shortened, and fusion between the epiphysis of the abnormal proximal phalanx and the shortened first metatarsal head occurs with advancing age.

Subtalar Joint Arthrography.

The purpose of this study was to determine the accuracy and the specificity of an optimum technique of posterior talocalcaneal/posterior subtalar (PST) joint arthrography and anesthetic injection in patients with hindfoot pain. Fifty-five PST joints were studied in 55 patients. The posteromedial approach was used in the first 24 patients, followed by an anterolateral approach in 31 patients. The ease of performance, success of confirming PST needle position, and adverse effects were noted. After contrast injection, a combination of 1% lidocaine and 0.5% bupivacaine was injected. Results consisted of 47 arthrographically confirmed PST injections. The posteromedial approach was deemed more difficult; three patients had tendon sheath opacification and four had unwanted anesthesia of the toes. The anterolateral approach was technically easier and no extra-articular structures were visualized or anesthetized. Therefore, PST arthrography with anesthetic injection is optimized with an anterolateral approach.

Evaluation and treatment of chronic ankle pain.

The evaluation and treatment of chronic ankle pain presents a challenge to the orthopaedic surgeon. A detailed history helps to determine causative factors resulting from earlier trauma or surgery. A careful physical examination and radiographic studies also are helpful in making an accurate diagnosis, which is the basis for choosing a specific and effective treatment regimen.

Technique tip: a revised method of the Cotton test for intra-operative evaluation of syndesmotic injuries.

The Cotton test assists the orthopaedic surgeon in the intra-operative evaluation of potential incompetence of the ankle syndesmosis. A variation of this test is proposed that simplifies this test, while providing a direct distraction force to the syndesmotic ligamentous complex.

Lesser metatarsophalangeal joints: intra-articular distension, volumetric measurements, and changes of position.

Plantarflexion of the second metatarsophalangeal (MTP) joint with intra-articular injection has previously been observed and commented upon, and the purpose of this study was to determine motion of the lesser toes with direct fluid infusion into the lesser MTP joints. Fluid distension was found to cause variable postural changes in all lesser toes; the most consistent change was plantarflexion of the second metatarsophalangeal joint. Dorsiflexion of the third, fourth, and fifth MTP joints was observed, but less reliable than plantarflexion of the second MTP joint. The average volume in each of the lesser MTP joints was less than 1 cc. Plantarflexion of the second MTP joint was usually, but not always, indicative of intra-articular distention. Aspiration of these joints (given their small volume capacity) may not be a reliable or therapeutically useful technique.

Foot and ankle experience in orthopaedic residency.

BACKGROUND: Dedicated orthopaedic residency training in the musculoskeletal discipline of foot and ankle is an important contribution to the development of a well-rounded orthopaedic surgeon. Current residency training guidelines are vague and do not require specific experience or proficiency in this discipline. METHODS: A one-page questionnaire on commitment to foot and ankle education in American Orthopaedic Surgery residency training programs was completed by all 148 program directors. RESULTS: Eighty of the programs (54.1%) had a single faculty member dedicated to foot and ankle orthopaedics, while 21 (14.2%) did not have a faculty member with a specific interest or commitment to problems related to the foot and ankle. Fifteen programs (10.1%) did not have a committed faculty member, nor did their residents have a clinical rotation dedicated to foot and ankle. Ninety-six programs (64.9%) had at least one clinical rotation dedicated to foot and ankle. Fifty-two (35.1%) did not. Thirty-three (34.7%) of those programs with a dedicated foot and ankle experience assigned residents during at least two periods of their training. Of those programs with a single foot-specific rotation, the most common year for training was in the PGY3 year (27 of 63, 42.9%). Of the 60 months' duration of most orthopaedic residency programs, 39 of 96 (40.6%) programs with a dedicated clinical foot and ankle rotation allocated an average of 12 weeks to foot and ankle. Twenty-six (27.1%) allocated less than 3 total months, and 31 (32.3%) allocated 16 to 24 weeks of dedicated foot and ankle experience. CONCLUSIONS: Current residency training in the United States does not universally require a commitment to foot and ankle education. A large number of residency programs do not have a faculty member committed to foot and ankle education, and almost one-third have no time specifically allocated to foot and ankle education.

What's new in foot and ankle surgery.

This update summarizes recent research pertaining to orthopaedic foot and ankle surgery that was published or presented between August 2011 and July 2012. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes); Foot and Ankle International; and the proceedings of Specialty Day at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), on February 11, 2012, in San Francisco, California, and the summer meeting of the American Orthopaedic Foot & Ankle Society (AOFAS), on June 20 through 23, 2012, in San Diego, California.

What's new in foot and ankle surgery.

This update summarizes recent research pertaining to the subspecialty of orthopaedic foot and ankle surgery that was published or presented between August 2009 and July 2010. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes), Foot & Ankle International, and the proceedings of Specialty Day at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS), held on March 13, 2010, in New Orleans, Louisiana, and the summer meeting of the American Orthopaedic Foot & Ankle Society (AOFAS), held on July 7 through 10, 2010, in National Harbor, Maryland.