Percutaneous correction of persistent severe metatarsus adductus in children.

BACKGROUND: Percutaneous techniques for the correction of foot deformities are gaining popularity in the adult population, but remain poorly explored in children. Of the several surgical techniques described to treat persistent severe metatarsus adductus (MA) deformity in children, neither was percutaneous. The purpose of the study was to describe a percutaneous technique for MA correction in children, to report the outcomes, and to discuss the advantages it offers. METHODS: We designed a prospective study on 34 consecutive feet with MA deformity from 26 children undergoing percutaneous correction. All operated feet had severe, rigid MA deformities, most of which were components of residual/recurrent clubfoot deformities. The mean age at surgery was 5.7 years and the mean follow-up was 55.2 months. For clinical evaluation, we used the bisector method; the first cuneometatarsal angle and metatarsal-metaphyseal angle measured in weight-bearing radiographs and AOFASf score were determined preoperatively and postoperatively. In unilateral cases, we used the contralateral foot measurements as control. The operating time and the hospitalization time were also recorded. The surgical technique consisted of performing the Cahuzac procedure for MA correction with a percutaneous approach. RESULTS: At the final follow-up all feet presented a normal heel bisector line. Radiologic parameters were normalized when compared with control feet. The mean surgical and hospitalization time was 14 minutes and 6 hours, respectively. Mean AOFAS score improved from 78 to 98. CONCLUSIONS: A minimally invasive percutaneous technique allowed a successful correction of MA deformity in children and resulted in a substantive decrease in both surgical and hospitalization time and better cosmetic results. LEVEL OF EVIDENCE: Level II.

Resistant metatarsus adductus: prospective randomized trial of casting versus orthosis.

BACKGROUND: Metatarsus adductus is a common pediatric foot deformity related to intrauterine molding. It is usually a mild deformity that responds well to simple observation or minimal treatment with a home program of stretching. Resistant cases may need a more aggressive approach such as serial casting or special bracing to avoid the need for surgical intervention. We compared clinical outcomes using serial casting with orthoses for resistant metatarsus adductus. METHODS: We prospectively treated 27 infants (43 feet) between the ages 3 and 9 months who failed home stretching treatment. Patients were randomized to either serial plaster casting or Bebax orthoses. Footprints and simulated weight-bearing anteroposterior and lateral view radiographs were made at entry and follow-up. RESULTS: There was no statistical difference between casting and Bebax for the following parameters: age at study entry, length of treatment, number of clinic visits, follow-up, and follow-up maintenance treatments. Both groups showed improvement in footprint and radiographic measurements post-treatment, without worsening of heel valgus. The Bebax group had greater improvement in the footprint heel bisector measurement than the casting group. The Bebax treatment requires more active parental cooperation. A simulated cost analysis of materials and office visit charges, however, revealed that Bebax treatment was significantly less expensive, about half the cost of casting. CONCLUSION: Because of the cost savings and virtually identical clinical results, we recommend the Bebax orthosis for resistant metatarsus in pre-walking infants with parents who are compliant. Other considerations include specific insurance plans, which may pay for casts but not orthoses.

Foot structure and function in older people with radiographic osteoarthritis of the medial midfoot.

OBJECTIVE: To investigate whether foot structure and dynamic foot function differ between older people with and without radiographically confirmed osteoarthritis (OA) of the talo-navicular joint (TNJ) and navicular-first cuneiform joint (N1(st)CJ). METHOD: Dorso-plantar and lateral weighbearing foot radiographs (right feet) were obtained from 205 older people aged 61-94 years, and the presence of OA in the TNJ and N1(st)CJ was determined using a standardized atlas. Foot structure was assessed using a clinical measure (the arch index [AI]) and two radiographic measures (calcaneal inclination angle [CIA] and calcaneal-first metatarsal angle [C1MA]). Dynamic plantar pressure assessment during walking was undertaken using the Tekscan MatScan system. RESULTS: Thirty-five participants exhibited radiographic OA in the TNJ and N1(st)CJ. There were no significant differences between the groups in relation to age, sex, weight or walking velocity. Compared to those without OA in these joints, those with OA had significantly flatter feet, as evidenced by larger AI (0.26+/-0.05 vs 0.25+/-0.05, P=0.02), smaller CIA (18.5+/-6.3 vs 21.3+/-5.4 degrees, P<0.01) and larger C1MA (137.0+/-9.3 vs 132.4+/-8.0 degrees, P<0.01), and exhibited significantly higher maximum forces in the midfoot (15.2+/-7.3 vs 11.2+/-7.0 kg, P<0.01; 36% increase). CONCLUSION: Older people with radiographic OA of the TNJ and N1(st)CJ exhibit flatter feet and increased loading of the plantar midfoot when walking. Excessive loading of the midfoot may predispose to OA by increasing dorsal compressive forces, although prospective studies are required to confirm whether this relationship is causal.

Orthoses alter in vivo segmental foot kinematics during walking in patients with midfoot arthritis.

OBJECTIVE: To assess the effect of a 4-week intervention with a full-length carbon graphite (FL) orthosis on pain and function in patients with midfoot arthritis, and to identify alterations in in vivo foot kinematics accompanying FL use in patients with midfoot arthritis. These results have immediate application for enhancing patient care through effective orthotic recommendations. DESIGN: Experimental laboratory study supplemented by a case series. SETTING: University based clinical research laboratory. PARTICIPANTS: Patients (n=30) with midfoot arthritis and age-, sex-, and body mass index-matched control subjects (n=20). INTERVENTION: Four-week intervention with FL orthoses. MAIN OUTCOME MEASURES: Pain and function were assessed using the Foot Function Index-Revised (FFI-R). In vivo foot kinematics were quantified as peak and total range of calcaneal eversion, forefoot abduction, first metatarsal plantarflexion, and first metatarsophalangeal joint dorsiflexion during walking in 2 conditions: with FL orthoses and with shoes only. A paired t test and repeated-measures analysis of variance were used to assess statistical significance (alpha=.05) of change in FFI-R score and in vivo foot kinematics, respectively. RESULTS: Significant improvements in pain and function, discerned as lower FFI-R scores (P<.001), were noted after the 4-week intervention with FL orthoses. During walking, FL orthosis use resulted in decreased first metatarsophalangeal joint dorsiflexion (P=.024) and first metatarsal plantarflexion range of motion (P=.038), compared with the shoe-only condition. CONCLUSIONS: Orthotic intervention emphasizing a "stiffening" strategy of the first metatarsal and first metatarsophalangeal joint may be valuable in patients with midfoot arthritis and early degenerative changes.

Ankle and foot kinematics associated with stage II PTTD during stance.

BACKGROUND: Subjects with stage II posterior tibial tendon dysfunction (PTTD) exhibit abnormal foot kinematics; however, how individual segment kinematics (hindfoot (HF) or first metatarsal (first MET) segments) influence global foot kinematics is unclear. The purpose of this study was to compare foot and ankle kinematics and sagittal plane HF and first MET segment kinematics between stage II PTTD and controls. MATERIALS AND METHODS: Thirty patients with stage II PTTD and 15 healthy controls were evaluated. Kinematic data from the tibia, calcaneus, and first MET were collected during walking using three dimensional motion analysis techniques. A three-segment foot model (HF, calcaneus; first MET, first metatarsal, and tibia) was used to calculate relative angles (ankle, HF relative to tibia; midfoot, first MET relative to HF) and segment angles (HF and first MET relative to the global). A mixed effect ANOVA model was utilized to compare angles between groups for each variable. RESULTS: Patients with PTTD showed greater ankle plantarflexion (p = 0.02) by 6.8 degrees to 8.4 degrees prior to or at 74% of stance; greater HF eversion (p < 0.01) across stance (mean difference = 4.5 degrees); and greater first MET dorsiflexion (p < 0.01) across stance (mean difference = 8.8 degrees). HF and first MET segment angles revealed greater HF dorsiflexion (p = 0.01) during early stance and greater first MET dorsiflexion (p = 0.001) across stance. CONCLUSION: Abnormal HF and first MET segment kinematics separately influence both ankle and midfoot movement during walking in subjects with stage II PTTD. CLINICAL RELEVANCE: These abnormal kinematics may serve as another measure of response to clinical treatment and/or guide for clinical strategies (exercise, orthotics, and surgery) seeking to improve foot kinematics.

In-toeing in children with type I osteogenesis imperfecta: an observational descriptive study.

BACKGROUND: Osteogenesis imperfecta is an autosomal-dominant disorder of the connective tissue. Also known as brittle bone disease, it renders those affected susceptible to fractures after minimal trauma. Therefore, it is important to minimize the risk of falls and subsequent fractures in patients with this disease. In-toeing is a common condition in children that can result from various pathologic entities, including anteversion, internal tibial torsion, and metatarsus adductus. These conditions can result in frequent tripping and other functional problems. METHODS: A descriptive study was undertaken to determine the prevalence of in-toeing gait attributable to tibial or femoral torsion or metatarsus adductus in children with type I osteogenesis imperfecta. The study involved orthopedic and biomechanical examination of 15 children (9 girls and 6 boys) aged 4 to 9 years with confirmed type I osteogenesis imperfecta. Patients who used assistive ambulatory devices, such as canes, crutches, and wheelchairs, were excluded from the study. RESULTS: Of the 15 children studied, 12 (80%) demonstrated previously undiagnosed in-toeing gait attributable to torsional deformity or metatarsus adductus in all but one child. CONCLUSIONS: Many children with confirmed type I osteogenesis imperfecta have in-toeing gait caused by torsional deformity or metatarsus adductus. Detection and control of in-toeing gait in children with osteogenesis imperfecta is important to prevent fractures resulting from trauma directly related to these conditions.

Plantar Pressure Measurements and Geometric Analysis of Patients With and Without Morton's Neuroma.

BACKGROUND: The purpose of this research was to see if there were any differences in peak pressure, contact time, pressure-time integrals, and geometric variables such as forefoot width, foot length, coefficient of spreading, and arch index between subjects with Morton's neuroma (MN) and control subjects. METHODS: Dynamic peak plantar pressure, contact time, pressure-time integral, and geometric data were extracted using the EMED-X platform in 52 subjects with MN and 31 control subjects. Differences in peak pressure, contact time, pressure-time integral, and geometric data between participants with and those without MN were determined using independent-samples t tests. There were no significant differences in age, weight, height, and body mass index between patients with MN and control subjects. RESULTS: There were no significant differences in the peak pressures of all masked areas and pressure-time integrals under metatarsal 2 to 4 heads between patients with MN and control subjects. In addition, no significant differences were observed between patients with MN and control subjects in geometric measurements of forefoot length, width, coefficient of spreading, foot progression angle, and arch index. CONCLUSION: No relationship was found in this study between peak pressure, contact time, and pressure-time integral under the metatarsal heads, forefoot width, foot length, coefficient of spreading, and foot progression angle in a symptomatic MN group compared with a control group. The need to perform osteotomies to treat MN not associated with other lesser metatarsal phalangeal joint pathologies is questionable. LEVEL OF EVIDENCE: Level III, Case-Control Study.

Numerical simulation of the plantar pressure distribution in the diabetic foot during the push-off stance.

The primary objective of conservative care for the diabetic foot is to protect the foot from excessive pressures. Pressure reduction and redistribution may be achieved by designing and fabricating orthotic devices based on foot structure, tissue mechanics, and external loads on the diabetic foot. The purpose of this paper is to describe the process used for the development of patient-specific mathematical models of the second and third rays of the foot, their solution by the finite element method, and their sensitivity to model parameters and assumptions. We hypothesized that the least complex model to capture the pressure distribution in the region of the metatarsal heads would include the bony structure segmented as toe, metatarsal and support, with cartilage between the bones, plantar fascia and soft tissue. To check the hypothesis, several models were constructed with different levels of details. The process of numerical simulation is comprised of three constituent parts: model definition, numerical solution and prediction. In this paper the main considerations relating model selection and computation of approximate solutions by the finite element method are considered. The fit of forefoot plantar pressures estimated using the FEA models and those explicitly tested were good as evidenced by high Pearson correlations (r=0.70-0.98) and small bias and dispersion. We concluded that incorporating bone support, metatarsal and toes with linear material properties, tendon and fascia with linear material properties, soft tissue with nonlinear material properties, is sufficient for the determination of the pressure distribution in the metatarsal head region in the push-off position, both barefoot and with shoe and total contact insert. Patient-specific examples are presented.

Individual metatarsal and forefoot kinematics during walking in people with diabetes mellitus and peripheral neuropathy.

The purpose of this study was to compare in-vivo kinematic angular excursions of individual metatarsal segments and a unified forefoot segment in people with Diabetes Mellitus and peripheral neuropathy (DMPN) without deformity or ulceration to a healthy matched control group. Thirty subjects were recruited. A five- segment foot model (1st, 3rd, and 5th metatarsals, calcaneus, tibia) was used to examine relative 3D angular excursions during the terminal stance phase of walking. Student t-tests were used to assess group differences in kinematics. Pearson correlations and cross-correlations were used to assess relationships between the motion of the individual metatarsals and the unified forefoot. Significant reductions of DMPN group sagittal plane angular excursions were detected in all individual metatarsals and the unified forefoot (p < 0.01). Frontal plane 3rd metatarsal excursion was reduced (p = 0.04) in the DMPN group. The 3rd and 5th metatarsal and the unified forefoot excursions were reduced (p ≤ 0.02) in the DMPN group in the transverse plane. In both groups, coupling of individual metatarsal and unified forefoot motion was strongest in the sagittal plane. This study illustrates that multiple individual metatarsals have reduced motion in people with DMPN. Differences in the magnitude and coupling between individual metatarsal motion and unified forefoot motion supports the use of a two segment forefoot modeling approach in future kinematic analyses. Further study is recommended to determine if the observed kinematic profile is related to the development and location of deformity and tissue breakdown in people with DMPN.

An innovative ultrasound foot scanner system for measuring the change in biomechanical properties of plantar tissue from sitting to standing.

The present study investigated the reliability of an innovative ultrasound foot scanner system in assessing the thickness and stiffness of plantar soft tissue and the comparison of stiffness and thickness in sitting and standing. Fifteen young healthy individuals were examined. The target sites on the foot sole for investigation included the heel pad, the fifth metatarsal head, the second metatarsal head, the first metatarsal head, and the pulp of the hallux. The test (day 1) and retest (day 2) were performed 1 week apart at the exact time with humidity and temperature of the assessment room under control. The thickness and stiffness of the plantar soft tissue obtained in sitting and standing positions on day 1 were used for comparison. The results showed significant test-retest reliability [intraclass correlation coefficient(3,2)>0.90, P<0.001] at all five sites in both sitting and standing positions. When changing from sitting to standing, the plantar soft tissue became significantly thinner (with decrease ranging from 10 to 14% at various sites) and stiffer (with increase ranging from 123 to 164% at various sites, all P<0.05). The present innovative system is a reliable device for the measurement of the thickness and stiffness of plantar soft tissue in either the sitting or the standing position. The change in positions from sitting to standing resulted in a significant thinning and stiffening of plantar soft tissues. This system could be a potential clinical device to monitor the biomechanical properties of plantar tissue in the elderly or in patients with diseases such as diabetes to estimate the risk of developing foot ulcer or other foot complications.

Treatment of Freiberg's disease by Gauthier's dorsal cuneiform osteotomy: Retrospective study of 30 cases.

INTRODUCTION: Freiberg's disease is osteonecrosis of the dorsal side of a metatarsal head. The gold-standard surgical treatment is the osteotomy procedure first described by Gauthier. HYPOTHESIS: Gauthier osteotomy for Freiberg's disease will restore the joint space and lead to long-term clinical improvement. A retrospective study was carried out to verify this hypothesis. MATERIAL AND METHODS: This study involved 30 consecutive cases treated by a single surgeon in 28 patients having a mean age of 61.2 years. These patients underwent the Gauthier osteotomy procedure with one or two dorsal staples used for fixation. Patients were reviewed 15 days, 45 days and 3 months after the procedure, and then at the last follow-up to look for any complications and determine patient satisfaction, the AOFAS score, metatarsophalangeal range of motion (ROM), sphericity of the metatarsal head, bone union and metatarsal shortening. RESULTS: The average follow-up was 6.5 years ± 2.2. The second metatarsal was affected in 27 cases and the third metatarsal in 3 cases. Discomfort related to the staples was noted in five cases; the staples were removed in three of them. There was one case of severe stiffening (< 20° ROM). At the last follow-up, 17 cases were very satisfied, 11 were satisfied and 2 were moderately satisfied. The average AOFAS score was 83.8 points ± 11.8 at the last follow-up. A mean loss of 15° plantar flexion and 10° dorsiflexion was noted. Bone union and metatarsal head sphericity were achieved in all cases. The average shortening was 2 mm ± 1.4. CONCLUSIONS: The Gauthier osteotomy procedure results in recovery of the metatarsal head's sphericity in every case of this series, with good clinical results and low morbidity.

Lactose intolerance associated with fractures of weight-bearing bones in Finnish women aged 38-57 years.

Lactose intolerance (LI) often results in decreased calcium intake. To test if long-term low intake of calcium affects bone strength, we examined fracture risks related to LI in women aged 38-57 years. The 11,619 Finnish women aged 47-56 years who responded to the baseline postal inquiry of the Kuopio Osteoporosis Risk Factor and Prevention Study in 1989 formed the study population. In all, 896 women reported LI and 1299 women reported a fracture in 1980-1989. Current intake of dairy calcium was lower in women with LI (570 mg/d) than in the other women (850 mg/d) (p < 0.0001). The fracture risk in general was slightly elevated in women with LI compared with the other women, with an odds ratio (OR) (95% CI) of 1.33 (1.09-1.62). However, the fractures at the three most common sites (wrist, ankle, and rib) were not related to LI. In contrast, fractures at the tibia and metatarsal were strongly related to LI with ORs of 3.31 (1.51-7.24) and 2.84 (1.47-5.50), respectively. The adjusted OR for nonankle lower body fractures combined was 2.15 (1.53-3.04), whereas that for all upper body fractures combined was 1.15 (0.88-1.54). The 10 women with LI and a tibial or metatarsal fracture showed a 19% lower femoral BMD than all the other women in the densitometry subsample of 3222 women (p < 0.001). Long-term premenopausal calcium deficiency differentially affects bones with weight-bearing nonankle bones being at the greatest risk of suffering reduced strength.

The shock attenuation role of the ankle during landing from a vertical jump.

Three landing surfaces were used to examine a hypothesized increased shock attenuation role of the ankle with increased damping demands. Eleven male recreational basketball players performed three symmetric barefoot countermovement vertical jumps on each surface. Two externally mounted low mass accelerometers (medial calcaneus and distal anterio-medial tibia), a piezoelectric force platform, and high speed cinematography recorded the landing. Accelerometer signal distortion was corrected through the application of a linear spring/damper model of the accelerometer attachment. The model indicated that raw acceleration data were overestimated 68% at the calcaneal attachment and 8% at the tibial attachment. Peak corrected acceleration at metatarsal contact varied little across landing surfaces, and, across surfaces, mean (SD) peak accelerations of 20.8 (9.3) and 14.3 (3.6) g's were recorded at the calcaneus and tibia, respectively. Peak vertical force and ankle joint motion varied little across the surfaces, suggesting that the entrenched kinematics of landing surpassed the introduced range of surface cushioning. Separation of the data by post-metatarsal contact landing style indicated that seven subjects landed with heel contact, with the remaining four attenuating the impact without heel contact. By avoiding the transient associated with the cessation of downward heel motion, the nonheel contact landers effectively reduced exposure to transients by nearly 50%.

Roentgenographic study of cavus foot deformity in Friedreich ataxia patients: preliminary report.

The preliminary results based on a three year retrospective study in cavus foot deformity of forty-four Friedreich ataxia patients regularly seen at the Neuromuscular Disease Clinic of Sainte-Justine Hospital have been presented. An accurate "weight-bearing" foot stereoradiographic technique has been recently developed by our group. Since the follow-up period with this device is not sufficient to provide statistical information, the conventional non-weight bearing technique has been utilized in this study to enable a possible comparison between the radiographs of ambulant and non-ambulant patients. Due to the present technique, the results of this study must be interpreted with caution. For 132 pairs of radiographs, 28 parameters have been analyzed. Four of these, namely the calcaneal inclination angle, the first metatarsal inclination angle, the inferior cortex of calcaneus-first metatarsal angle and the first-fifth metatarsals angle, were of particular interest. From these parameters, a preliminary quantitative description of cavus foot deformity in Friedreich's ataxia has been attempted. Three stages of evolution have been tentatively identified for this type of neurological disorder.

Rehabilitation factors following transmetatarsal amputation.

Despite the occurrence of approximately 10,000 transmetatarsal amputations (TMAs) a year in the United States, there are few reports describing rehabilitation for this patient group. The purposes of this clinical perspective are (1) to identify common problems encountered during rehabilitation of patients with TMA, (2) to identify factors that may contribute to these problems, and (3) to propose methods to manage these problems. A review of the literature and biomechanical models of the residuum, footwear, and orthotic devices are provided to help accomplish these purposes. Common problems encountered during rehabilitation of patients with TMA are skin breakdown and instability during functional activities. Decreased foot length and peripheral neuropathies appear to contribute to these problems. Solutions focus on attempting to provide a substitute for the plantar-flexor lever arm and protection of the insensitive residual foot. Suggestions for additional research are presented.

Rheumatoid metatarsus. The original evolution of the first metatarsal.

Three hundred and eight unselected rheumatoid feet underwent a weight-bearing X-ray examination. If the malformations of the forefoot studied here present a statistical association, the primus metatarsus adductus is closely connected with tarsal arthritis and flattened foot but does not depend on the duration of the disease. The spread forefoot is indeed related to the duration of the disease and the presence of a metatarsal erosion at the foot level, but is not affected by the lesions of the midfoot. It appears then that an early orthopaedic treatment should be prescribed, once the first signs of involvement of the first ray or pronounced pronation of the hindfoot are noticed; it must affect the hindfoot, the midfoot and the first ray which progress together.

Use of an in-shoe pressure measurement system in the management of patients with neuropathic ulcers or metatarsalgia.

Many injuries to the foot appear to be caused by repeated, excessive plantar pressures. In-shoe pressure systems are capable of measuring pressures at the interface between the shoe or orthotic and the plantar foot during a given functional activity. The purpose of this article is to describe the use of an in-shoe pressure system as a tool to aid physical therapists in the management of patients with foot problems as a result of excessive plantar pressures. Case histories are provided that describe the application of an in-shoe pressure device in the management of one patient with a neuropathic ulcer and one patient with metatarsalgia. A discussion of the primary clinical and equipment considerations of using this type of device is included.

Mobility of the first tarsometatarsal joint in relation to hallux valgus deformity: anatomical and biomechanical aspects.

Hypermobility of the first tarsometatarsal (TMT 1) joint is suggested to be an important factor in the cause and progression of hallux valgus deformity. Hypermobility of the TMT 1 joint is tested clinically in the sagittal plane, but an important deformation also exists in the transversal plane: metatarsus primus varus. This in vitro study was undertaken to investigate the relation between the mobility of the TMT 1 joint in these two planes and to investigate the correlation of the mobility with morphological variables. A second aim was to study the possible stabilizing effect of the tibialis anterior muscle, flexor hallucis longus muscle, and peroneus longus muscle on the TMT 1 joint. Nine embalmed human specimens were tested under standardized conditions. A 30-N force was applied to the head of the first metatarsal (MT 1) to pull in either the dorsal or medial direction. To simulate muscle force, 21 N was applied to the three tendons: all seven possible combinations of muscle action were tested in each plane of motion. Angular displacements were measured using 2-dimensional LED video registration. TMT 1 mobility is a relevant factor in MT 1 mobility in the sagittal and transversal planes, the peroneus longus has a stabilizing effect on this joint, and the effect of the flexor hallucis longus on this joint is different in both planes. When considering a Lapidus procedure for surgically correcting a hallux valgus, the mobility of MT 1 in the transversal plane should also be assessed, but so far no objective clinical test in this plane has been described.

Lesser metatarsal osteotomies. A biomechanical approach to metatarsalgia.

As with most other orthopedic conditions, a firm understanding of the normal and pathologic biomechanics of the lesser metatarsals is essential when contemplating treatment of metatarsalgia. Despite its prevalence, metatarsalgia remains a technically demanding surgical challenge. Some of the difficulty with treatment of this problem arises because of some of the controversies discussed previously. Many lesser metatarsal osteotomies have been described, and their success depends on many factors. Alleviating the correct amount of pressure underneath the metatarsal head without adversely affecting the biomechanics of the region demands an exacting osteotomy that is stable and readily heals. Much of the research done to date has not proved which procedure can achieve these goals reproducibly for patients. It is hoped that future investigations will guide treatment choices and allow patients to obtain relief from this difficult problem with greater success.