Surgical Treatment of Metatarsalgia and Severe Instability of Lesser Metatarsophalangeal Joints.

The main object of this prospective cohort study was to compare surgical treatment options for primary metatarsalgia and the severe instability of lesser metatarsophalangeal joints. The outcomes of triple Weil osteotomy combined with direct plantar plate repair and triple Weil osteotomy, performed with proximal interphalangeal joint arthrodesis, are analyzed and compared. One hundred thirteen patients (117 feet) were enrolled in the study. They were split into 2 groups. In the first group, undergoing Weil osteotomy, combined with the plantar plate repair, good results, including complete pain reduction, elimination of hyperkeratosis, and American Orthopedic Foot and Ankle Society Score improvement, were achieved in 84.7% of the cases. The second group, where the combination of Weil osteotomy and proximal interphalangeal joint K-wire arthrodesis was used, demonstrated good results in 52.4% of the cases. Weil osteotomy, combined with the plantar plate repair, achieves better results in comparison to osteotomy, performed with the interphalangeal joint arthrodesis.

The use of polyvinyl alcohol hydrogel implants in the lesser metatarsal heads. Is it safely doable? A cadaveric study.

BACKGROUND: The use of synthetic polyvinyl alcohol hydrogel (PVAH) implants for treatment of lesser toe metatarsophalangeal joint (MTPJ) arthritis is promising and currently limited by the size of implants available. The primary objective of this cadaveric study was to investigate the maximum drilling size and largest PVAH implant dimension that could be safely introduced while still preserving an intact bone rim of the lesser metatarsal heads. METHODS: Height and width of all lesser metatarsals were measured on CT and during anatomic dissection. Sequential reaming of the second to fourth metatarsals was performed. Maximum reaming size, largest implant inserted, and failure of the metatarsal head were recorded. Metatarsal head sizes were compared and a multiple regression analysis evaluated measurements that influenced maximum drilling and implant size. RESULTS: CT and anatomical measurements demonstrated significant correlation (ICC range, 0.-0.85). Mean values for height and width of the metatarsal heads were respectively: second (14.9 mm and 9.9 mm), third (14.8 mm and 8.8 mm), fourth (14.0 mm and 8.7 mm) and fifth (12.3 mm and 9.3 mm). All the second, third and fourth metatarsal heads could be safely drilled up to 7.5 mm, preserving an intact bone rim. At 80% of the time, the heads could be safely drilled up to 8.0 mm. Height of the metatarsal heads was the only factor to significantly influence the size of maximum reaming and implant introduced. In respectively 20%, 40% and 50% of the second, third, and fourth metatarsal heads, neither 8 mm nor 10 mm PVAH implants could be used. CONCLUSIONS: Our cadaveric study found that the even though the majority of the lesser metatarsal heads could be safely drilled up to 8 mm, the smallest PVAH implant size currently available in most countries (8 mm) could be inserted in most of the second, but only in about half of the third and fourth metatarsal heads. The remaining bone rim around inserted implants was considerably thin, usually measuring less than 1 mm. In order to optimize the use PVAH in lesser metatarsal heads, smaller implant options are needed.

Prevalence of feet and ankle arthritis and their impact on clinical indices in patients with rheumatoid arthritis: a cross-sectional study.

BACKGROUND: We aimed to evaluate the prevalence of foot and/or ankle arthritis (FAA) and its impact on clinical indices in patients with rheumatoid arthritis (RA). METHODS: This cross-sectional study used data from the Korean College of Rheumatology Biologics & Targeted therapy registry to observe clinical outcomes of patients undergoing biologics therapy and conventional therapy. FAA was defined as ≥1 tender or swollen joint in the ankle and/or 1st-5th metatarsophalangeal (MTP) joints. Disease Activity Score 28 (DAS28), Routine Assessment of Patient Index Data 3 (RAPID3), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI) were assessed. RESULTS: Among 2046 patients, 598 had FAA. The ankle joint was the most commonly involved joint in FAA (tender joint, 71.4%; swollen joint, 59.5%), followed by the third and second MTP joints. Patients with FAA showed higher DAS28, RAPID3, SDAI, and CDAI scores. FAA presence was significantly associated with non-remission as per DAS28-ESR (odds ratio, 3.4; 95% confidence interval, 2.0-5.8), DAS28-CRP (3.6, 2.4-5.3), SDAI (6.3, 2.8-14.6), CDAI (7.6, 2.4-24.3), and RAPID3 (5.6, 2.7-11.5) indices on adjusting for age, sex, disease duration, presence of rheumatoid factor, presence of anti-cyclic citrullinated peptide antibody, lung disease, use of methotrexate, and previous use of biological disease-modifying anti-rheumatic drugs. Patients with FAA were less likely to achieve remission of SDAI (n = 6, 1.0%) and CDAI (n = 3, 0.5%) than that of DAS28-ESR (n = 21, 3.5%), DAS28-CRP (n = 38, 6.4%), and RAPID3 (n = 12, 2.0%). CONCLUSIONS: FAA represents a severe disease activity and is an independent risk factor for non-remission in patients with RA.

[Malalignment of the first ray : Clinical and radiological diagnostics]. / Fehlstellungen des ersten Strahls : Klinische und radiologische Diagnostik.

Clinical and radiological examination of the foot are mandatory before surgical correction of the forefoot. The clinical examination includes leg axis, position of the hind foot, deformity of the first ray as well as skin conditions, pulse status and possible sensitive deficits. A shortening of the gastrocnemius muscle can be identified using the Silfverskiöld test. Discomfort in the midfoot can indicate pathologies of the tarsometatarsal joint and the same applies for osteophyte infiltration around the Lisfranc joint line, whereby the second tarsometatarsal joint often shows more advanced degenerative arthritis than the first tarsometatarsal joint. Callosities under the second and third metatarsal heads correlate with a faulty load transmission of the first ray. A limitation of the range of movement of the first metatarsophalangeal joint is usually associated with degenerative arthritis in X­ray imaging. Under weight bearing, X­rays of the foot in two planes represent the standard imaging examination. In addition to the intermetatarsal angle, the hallux valgus angle and the interphalangeal angle as well as the width of the first metatarsal bone influence the therapy decision. The same applies to degenerative changes or an obvious instability of the first tarsometatarsal joint. In many cases, initial signs of degenerative arthritis can be found in the metatarsophalangeal joint and around the sesamoid bones, although these often do not correlate to clinical symptoms.

[Lapidus arthrodesis]. / Lapidus-Arthrodese.

The tarso-metatarsal 1 joint (TMT-I) arthrodesis is a treatment option or moderate to severe hallux valgus (HV) deformities. Instability of the TMT1 joint is still a debatable indication. Using stable osteosynthesis techniques allows early postoperative weight bearing. Plantar plating combined with a lag screw is the biomechanical most stable construct. An additional intermetatarsal screw can improve the horizontal stability. Clinical results are good and radiological parameters stay constant, even in the long term.

Metatarsophalangeal joint pain in psoriatic arthritis: a cross-sectional study.

OBJECTIVE: The aim of this study was to identify independent predictors of pain at the MTP joints in patients with PsA. METHODS: Thirty-four consecutive patients with PsA (mean age 45.3 years, 65% female, mean disease duration 9.9 years) and 22 control participants (mean age 37.9 years, 64% female) underwent clinical and US examination to determine the presence of pain, swelling, synovitis, erosions, effusions and submetatarsal bursae at the MTP joints. Mean barefoot peak plantar pressures were determined at each MTP joint. Levels of pain, US-determined pathology and peak pressures were compared between groups. Binary logistic regression was used to identify demographic, clinical examination-derived, US-derived and plantar pressure predictors of pain at the MTP joints in the PsA group. RESULTS: The presence of pain, deformity, synovitis, erosions (P < 0.001) and submetatarsal bursae and peak plantar pressure at MTP 3 (P < 0.05) were significantly higher in the PsA group. MTP joint pain in PsA was independently predicted by high BMI, female gender and the presence of joint subluxation, synovitis and erosion. CONCLUSION: These results suggest local inflammatory and structural factors, together with systemic factors (gender, BMI), are predominantly responsible for painful MTP joints in PsA, with no clear role for plantar pressure characteristics.

First cuneo-metatarsal arthrodesis (Modified Lapidus) with plantar plate for the treatment of hallux valgus: clinical and radiological outcomes at one year follow-up.

INTRODUCTION: The modified Lapidus arthrodesis, involving the first cuneo-metatarsal joint, is a well-established surgical method and widely utilized for treating moderate to severe hallux valgus deformities with hypermobility in the first tarsometatarsal joint. The purpose of this study was to assess the rate of union following the Lapidus procedure using a plantar plate and an immediate full weight-bearing protocol. Secondary objectives included examining radiological corrections and potential associated complications. METHODS: A retrospective study included 66 patients (80 feet) who underwent a modified Lapidus procedure for the treatment of hallux valgus associated with hypermobility of the first ray, performed by a single senior surgeon at our institution between May 2013 and November 2019. All patients had a minimum follow-up of 12 months. Patients were clinically assessed at 3 weeks, 3 months, and 1 year. Radiological measurements were taken on weight-bearing dorsoplantar views preoperatively, at 3 months, and at 12 months postoperatively. RESULTS: Bone union was achieved in 79 cases (98.75%). There was one case of non-union, two wound complications (one infection and one dehiscence), two cases of symptomatic hardware requiring hardware removal, and one stress fracture associated with recurrence of hallux valgus that required revision. The mean hallux valgus angle (HVA) improved from 30.5 ° ±10.4 ° to 10.1 ° ±6.6 ° (p < .001), the mean intermetatarsal angle (IMA) improved from 13.4 ° ±3.6 ° to 5.6 ° ±2.9 (p < .001), The average sesamoid position improved from stage 5.9 ± 1.6 to stage 2.6 ± 1.2 (p < .001). The mean shortening of the first metatarsal was 3.6 mm ± 1.8. There was no significant difference between measurements at 3 and 12 months postoperatively. CONCLUSION: Modified Lapidus with a planter plate and compression screw is a reliable method of fixation with a high union rate, permit an immediate protected weight bearing and a low complications rate. LEVEL OF EVIDENCE: IV; Retrospective study.

Ossification timeline of sesamoid bones at metatarsophalangeal joints.

Ossification timeline is a critical issue in studies regarding sesamoid bones at metatarsophalangeal (MTP) joints, but actual knowledge is still incomplete. The present study determines the cutoff age of sesamoids ossification at MTP joints. We conducted a retrospective review of radiographs of the feet from 5553 males and 3225 females between November 2005 and September 2012 to identify presence of sesamoids at 5 MTP joints and 3 variations of hallucal sesamoids. Age-specific prevalence of each presence and variations was calculated and clustered to produce latent age groups corresponding to the sesamoid ossification process in males and females, respectively. Males older than 7 years of age were divided into 5 age groups (8-11, 12-15, 16-29, 30-76, and 77-92 years), while females were classified into 4 age groups (8-11, 12-26, 27-76, and 77-92 years). According to the characteristics of sesamoid prevalence in each age group, the pre-ossification stage was defined at age 1-7 years in both genders and the ossifying stage was defined at age 8-29 years in males and 8-26 years in females. We also defined ossified stage as age 30-92 years in male and 27-92 years in females. The ossifying and ossified stages include 2 or 3 substages in both genders. A clustering analysis provided novel cutoff age points as ossification timelines for the sesamoid bones at MTP joints in males and females, which may have an impact on future sesamoid and skeletal development research.

Partite hallux sesamoid bones: Relationship with sesamoid bones at other metatarsophalangeal joints.

Partite hallux sesamoids are clinically meaningful but their association with other sesamoids is not clear. The objective was to relate the prevalence of the partite hallux sesamoid bones to sesamoid bones at other metatarsophalangeal (MTP) joints. We conducted a retrospective review of plain radiographs of 7946 adult feet between November 2005 and September 2012 to identify partite hallux sesamoids and sesamoids at other MTP joints. Coexistence patterns of the partition and extra sesamoids were studied. Presence or absence of sesamoids at other MTP joints as well as sex and laterality were compared between the feet with and without partite hallux sesamoids using Pearson Chi-square test. Association between age and partition was evaluated using Spearman's correlation coefficient. Overall partite prevalence rate is 6.82%, and coexistence with extra MTP sesamoids was 0.42%. One pattern was partition in hallux sesamoid only, and 4 patterns were coexistence with extra sesamoids. The prevalence rates of partite hallux sesamoids were 7.17% (508/7081) and 3.93% (34/865) in feet without and with extra sesamoids, respectively. The relative risk of 1.889 (95% CI, 1.325-2.693) of partite hallux sesamoids was noted in feet without than with extra sesamoids (Χ2 = 12.759, P < 0.001). A negative correlation between age and distribution of partition was identified (r = -0.061, P < 0.001). Partition of hallux sesamoid bones is a developmental variation, it can coexist with sesamoids at other MTP joints following a certain pattern; and its prevalence rate is almost twice higher in feet without than with extra MTP sesamoids. Anat Rec, 2017. © 2017 Wiley Periodicals, Inc. Anat Rec, 301:34-38, 2018. © 2017 Wiley Periodicals, Inc.

Lesser Metatarsophalangeal Joint Instability: Treatment with Tendon Transfers.

Complex digital deformities and metatarsophalangeal joint instability encompass a wide range of pathology, and we must identify the different degrees of ligamentous disruption. It is important to address a combination of procedures to treat gross deformities of the lesser toes. Surgical treatment should be individualized and requires a sequential process for adequate reduction and deformity correction. There is no gold standard procedure for every deformity. Although residual stiffness can result from tendon transfer, overall patient satisfaction levels remain high when it is performed under the proper indications and concomitantly with other procedures to gain full correction of these challenging deformities.

MR Imaging of the Plantar Plate: Normal Anatomy, Turf Toe, and Other Injuries.

The metatarsophalangeal (MTP) joint complex is a weight-bearing structure important to the biomechanics of the standing position, walking, shoe wearing, and sport participation. Acute dorsiflexion injury of the first MTP joint, "turf toe," is common among American football and soccer players. The first and lesser MTP joint complexes can be affected by degenerative or inflammatory arthritis, infarct, and infection. These conditions can lead to plantar plate disruption. Imaging studies help physicians to properly diagnose and treat this condition. This article reviews the anatomy, diagnostic imaging, and clinical management of injury and pathology of the first and lesser MTP joint complexes.

Metatarsophalangeal joint stability: a systematic review on the plantar plate of the lesser toes.

BACKGROUND: Instability of the metatarsophalangeal (MTP) joints of the lesser toes (digiti 2-5) is increasingly being treated by repair of the plantar plate (PP). This systematic review examines the anatomy of the plantar plate of the lesser toes, and the relation between the integrity of the plantar plates of the lesser toes and lesser MTP joint stability. METHODS: The databases of Embase.com, Medline (Ovid), Web of Science, Scopus, Cochrane, Pubmed not medline, Cinahl (ebsco), ProQuest, Lilacs, Scielo and Google Scholar were searched in June 2015 from inception. Studies were included if they were in English, contained primary data, and had a focus on plantar plate anatomy of the lesser toes or on the relationship between integrity of the plantar plate and MTP joint (in)stability. Study characteristics were extracted into two main tables and descriptive anatomical and histological data were summarized into one schematic 3D drawing of the plantar plate. RESULTS: Nine studies were included in this systematic review, of which five addressed plantar plate anatomy as such and four focused directly and indirectly on plantar plate integrity related to MTP joint stability. CONCLUSION: This is the first systematic review regarding plantar plate anatomy related to MTP joint stability of the lesser toes. This review iterates the importance of plantar plate anatomy and integrity for MTP joint stability, and it delineates the lack of primary data regarding plantar plate anatomy of the lesser toes and MTP joint stability.

An MRI compatible loading device for the reconstruction of clinically relevant plantar pressure distributions and loading scenarios of the forefoot.

The purpose of this study is to demonstrate a new MRI compatible loading device capable of reconstructing realistic loading scenarios of the human foot for research in the field of foot biomechanics. This device has two different configurations: one used to compress the forefoot and one to bend the metatarsophalangeal joints. Required plantar pressure distribution under the metatarsal heads can be achieved by modifying the distribution of the dorsally applied forces. To validate the device, subject-specific plantar pressures were measured and then reconstructed using the device. For quiet stance the peak pressure reconstruction error was 3% while for mid-stance phase of gait it was 8%. The device was also used to measure the passive bending stiffness of the metatarsophalangeal joints of one subject with low intra-subject variability. A series of preliminary MRI scans confirmed that the loading device can be used to produce static weight-bearing images of the foot (voxel size: 0.23 mm × 0.23 mm × 1.00 mm). The results indicate that the device presented here can accurately reconstruct subject specific plantar pressure distributions and measure the foot's metatarsophalangeal passive stiffness. Possible future applications include the validation of finite element models, the investigation of the relationship between plantar pressure and internal stresses/strains and the study of the foot's inter-segmental passive stiffness.