Foot and ankle deformities in stroke: relationship with ambulation, balance, and daily living activities: a cross-sectional study.

BACKGROUND: Ankle-foot deformities play a critical role in functional capacity and therefore activities of daily living in stroke patients. AIM: This is the first study to evaluate all foot deformities in stroke patients together. The primary aim of this study is to determine the frequency of ankle-foot deformities in stroke patients. The secondary aim is to investigate the relationships between ankle-foot deformities and ambulation, postural control, balance, spasticity, and activities of daily living. MATERIAL AND METHODS: The Functional Ambulation Classification was used to assess ambulation status, Postural Assessment Scale for Stroke Patients was used to assess postural control and balance. Lower extremity spasticity was evaluated with Modified Ashworth Scale. Activities of daily living were evaluated with Barthel Index. RESULTS: Ankle-foot deformity was detected in 77 (42%) of 184 cases. The incidence of pes equinovarus was 48%, pes equinus was seen in 22%, claw toe in 19.5%, and pes varus in 10.4%. Pes equinovarus and claw toe were seen together in 8 cases. In the group with ankle-foot deformity, the disease duration was longer and the rate of spasticity in the lower extremity was statistically higher (p = 0.29, p = 0.023). There was no difference in Functional Ambulation Classification, Barthel Index, and Postural Assessment Scale for Stroke Patients scores between patients with or without ankle-foot deformity (p = 0.811, 0.321, 0.385). CONCLUSION: It is important to detect ankle-foot deformities in stroke patients. Ankle-foot deformities are associated with spasticity in patients with stroke and are an important factor to be considered when determining the rehabilitation program.

The influence of concomitant hammertoe correction on postoperative outcomes in patients undergoing hallux valgus correction.

BACKGROUND: Patients with hallux valgus often develop secondary hammertoe deformities of the lesser toes. Operative management of bunions with hammertoe can be more extensive; however, it is unclear whether this affects patient-reported outcomes. The aim of this study was to compare postoperative patient-reported outcome measures and radiographic outcomes between patients who underwent isolated bunion correction and patients who underwent simultaneous bunion and hammertoe correction. METHODS: Preoperative, postoperative, and change in Patient-Reported Outcomes Measurement Information System (PROMIS) scores were compared between patients who underwent isolated hallux valgus correction and those who underwent concomitant hammertoe correction. Radiographic measures including hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal-articular angle (DMAA), and Meary's angle were also compared. Targeted minimum-loss estimation (TMLE) was used for statistical analysis to control for confounders. RESULTS: A total of 221 feet (134 isolated bunion correction, 87 concomitant hammertoe correction) with a minimum of 12 months follow-up were included in this study. Both cohorts demonstrated significant improvements in the physical function, pain interference, pain intensity, and global physical health PROMIS domains (all p < 0.001). However, patients in the concomitant hammertoe cohort had significantly less improvements in pain interference and pain intensity (p < 0.01, p < 0.05 respectively). The concomitant hammertoe cohort also had significantly higher postoperative pain interference scores than the isolated bunion cohort (p < 0.01). Radiographic outcomes did not differ between the two groups. CONCLUSION: While both isolated bunion correction and concomitant hammertoe correction yielded clinically significant improvements in patient reported outcomes and normalized radiographic parameters, patients undergoing simultaneous bunion and hammertoe correction experienced substantially less improvement in postoperative pain-related outcomes than those who underwent isolated bunion correction.

Treatment of metatarsalgia based on claw toe deformity through soft tissue release of the metatarsophalangeal joint and resection of the proximal interphalangeal joint: Evaluation based on foot kinematics and plantar pressure distribution.

INTRODUCTION: This study investigated the effect of operative claw toe correction with release of the metatarsophalangeal (MTP) joint, repositioning of the plantar fat pad and resection of the proximal interphalangeal joint on foot kinematics, plantar pressure distribution and Foot Function Index (FFI). METHODS: Prospective experimental study with pretest-posttest design. The plantar pressure, 3D foot kinematics and the FFI of 15 patients with symptomatic claw toes were measured three months before and 12months after surgery. Mean pressure, peak pressure and pressure time integral per sensor and various foot angles were calculated for the pre- and posttest and compared to a control group (N=15). RESULTS: Claw toe patients have increased pressure under the distal part of the metatarsal head and less pressure under the proximal part of the metatarsal heads compared to healthy controls. After surgery, there was a redistribution of pressure, resulting in a significant decrease of pressure under the distal part and an increase under the proximal part of the metatarsal head, providing a more equal plantar pressure distribution. Except for some small areas under the forefoot, heel and toes, there were no significant differences in pressure distribution between the operated feet and controls. Small, but significant differences between the pre- and postoperative condition were found for the lateral arch angle, calcaneus/malleolus supination and tibio-talar flexion. The score on the FFI improved statistically significant. DISCUSSION: These findings imply that the present operative procedure results in a more equal distribution of the plantar pressure under the forefoot and decrease of pain and offers successful treatment of metatarsalgia based on claw toe deformity.

Impact of crossover second toe on the postoperative outcome of distal chevron osteotomy for moderate to severe hallux valgus.

BACKGROUND: Crossover second toe is often presented in moderate to severe hallux valgus. However, its clinical impact on the postoperative outcome of hallux valgus is still unknown. METHODS: Thirty-five patients who had moderate to severe hallux valgus with crossover second toe were matched with 35 controls who did not have crossover second toe, according to preoperative hallux valgus angle and first-second intermetatarsal angle. Radiological parameters, Foot Function Index (FFI), and Visual Analog Scale (VAS) were assessed as postoperative outcomes at 3, 6, and 12 months after surgery. RESULTS: At 3 months, the FFI in the crossover second toe group was lower than in the control group (p=0.001), while other outcomes were similar. On the other hand, there were no significant differences between the groups at 6 and 12 months, in terms of radiological parameters, FFI, and VAS. CONCLUSIONS: Patients who had moderate to severe hallux valgus with crossover second toe were at risk for slow functional recovery after surgical treatment in the short term, but, in the long-term, there was no difference in overall postoperative outcomes in patients with and without crossover second toe. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Effect of Percutaneous Flexor Tenotomy on Healing and Prevention of Foot Ulcers in Patients With Claw Deformity of the Toe.

Claw deformity of the foot is frequently seen in patients with diabetes mellitus. Percutaneous flexor tenotomy is a simple surgical procedure for the treatment of foot ulcers on the distal end of the toe caused by this deformity. This procedure can also be performed to prevent ulcers in claw toes that are at risk of ulceration. The aim of this study is to investigate whether percutaneous flexor tenotomy is an effective surgical method for treatment and prevention of toe ulcers in patients with claw deformity. This retrospective study, with a median follow-up of 13.4 (1 to 66.7) months, included all consecutive patients who underwent percutaneous flexor tenotomy in 2 hospitals between July 2012 and April 2017. In total, 101 feet underwent flexor tenotomy: 84 (83.3%) therapeutic and 17 (16.7%) prophylactic. Of the 84 therapeutic procedures, 95.1% healed, with a median healing time of 27 days. In 11 (13.3%) therapeutic procedures, a reulceration was recorded. In the therapeutic group, 4 (4.8%) infections and 1 (1.2%) amputation of the digit occurred. In the 17 prophylactic procedures, local bleeding was recorded in 1 (5.9%). In the prophylactic group, 2 ulcers occurred. In 77 (76.2%) of all procedures, patients had diabetes mellitus. In conclusion, percutaneous flexor tenotomy is an effective, safe, and minimally invasive procedure for the treatment and prevention of toe ulcers in patients with claw deformity.

Assessing forefoot bursitis in rheumatoid arthritis: a comprehensive approach with ultrasound, MRI, and baropodometry.

AIM: In rheumatoid arthritis (RA), forefoot bursitis is prevalent, with limited studies comparing ultrasonography (US) and Magnetic Resonance Imaging (MRI). This study aims to evaluate these bursae, providing a comparative analysis of US and MRI, and explore associations with demographic, disease-related factors, pain, clinical examination, and baropodometryin RA patients. MATERIAL AND METHODS: Participants with RA were recruited from the day-hospital clinic. The forefeet were assessed clinically, and the selected foot was examined by US and MRI to evaluate intermetatarsal (IMB) and submetatarsal bursitis (SMB). Baropodometry assessed plantar pressures and contact surfaces. RESULTS: Thirty-five RA patients were enrolled, 85.7% females, mean age 59.2 (11.3) years, mean body mass index (BMI) 26.5 (5.7) kg/m2, median disease duration of 36.0 (16.5-114.0) months, and 34.3% with painful forefoot. A total of 140 intermetatarsal and 175 submetatarsal spaces were evaluated. Agreement between US and MRI was high (PA=97.14%, k=0.801, p<0.001), and interobserver reliability for both modalities was excellent (US: PA=98.73%, k=0.888, p<0.001; MRI: PA=98.41%, k=0.900, p<0.001). IMB was negatively associated with disease duration (the only independent predictor) and linked to clinical signs like the opening toes sign and hammer toe deformity. SMB showed an association with BMI and erosions. Baropodometric analysis indicated no significant differences in plantar pressures for IMB, and larger contact surfaces in SMB regions. CONCLUSIONS: US and MRI are valuable tools for forefoot bursitis evaluation. IMB is associated with disease duration (negative association), the opening toes sign, and hammer toe deformity, while SMB correlates with BMI, erosions, and foot architectural deformity. Baropodometry revealed larger contact surfaces in regions with SMB.

An investigation into the hammer toe effects on the lower extremity mechanics and plantar fascia tension: A case for a vicious cycle and progressive damage.

Hammer toes are one of the common deformities of the forefoot that can lead to compensatory changes during walking in individuals with this condition. Predicting the adverse effects of tissue damage on the performance of other limbs is very important in the prevention of progressive damage. Finite element (FE) and musculoskeletal modeling can be helpful by allowing such effects to be studied in a way where the internal stresses in the tissue could be investigated. Hence, this study aims to investigate the effects of the hammer toe deformity on the lower extremity, especially on the plantar fascia functions. To compare the joint reactions of the hammer toe foot (HTF) and healthy foot (HF), two musculoskeletal models (MSM) of the feet of a healthy individual and that of a participant with hammer toe foot were developed based on gait analysis. A previously validated 3D finite element model which was constructed using Magnetic Resonance Imaging (MRI) of the diabetic participant with the hammer toe deformity was processed at five different events during the stance phase of gait. It was found that the hammer toe deformity makes dorsiflexion of the toes and the windlass mechanism less effective during walking. Specifically, the FE analysis results showed that plantar fascia (PF) in HTF compared to HF played a less dominant role in load bearing with both medial and lateral parts of PF loaded. Also, the results indicated that the stored elastic energy in PF was less in HTF than the HF, which can indicate a higher metabolic cost during walking. Internal stress distribution shows that the majority of ground reaction forces are transmitted through the lateral metatarsals in hammer toe foot, and the probability of fifth metatarsal fracture and also progressive deformity was subsequently increased. The MSM results showed that the joint reaction forces and moments in the hammer toe foot have deviated from normal, where the metatarsophalangeal joint reactions in the hammer toe were less than the values in the healthy foot. This can indicate a vicious cycle of foot deformity, leading to changes in body weight force transmission line, and deviation of joint reactions and plantar fascia function from normal. These in turn lead to increased internal stress concentration, which in turn lead to further foot deformities. This vicious cycle cause progressive damage and can lead to an increase in the risk of ulceration in the diabetic foot.

Treatment outcome of local injection of botulinum toxin for claw toe: Differences between cerebral hemorrhage and infarction.

BACKGROUND: Some patients with post-stroke claw toe respond well to botulinum toxin (BoNT) treatment while others do not. This study was designed to assess the impact of stroke type (cerebral hemorrhage and cerebral infarction) on the outcome of BoNT treatment for claw toe. METHODS: We retrospectively examined the medical records of patients who received local BoNT (onabotulinumtoxin A) injections into the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles. All patients suffered stroke-related leg paralysis and spasticity. RESULTS: The study participants were 58 patients (mean age, 61.4 ± 10.3 years, ± SD) with time since stroke of 6.7 ± 4.4 years. The stroke type was cerebral hemorrhage (n = 38) and cerebral infarction (n = 20). After a total of 124 BoNT administrations with medical records entries on the subjective symptoms, the odds for symptomatic improvement was approximately 5.8 times higher in patients of the infarction group compared with the hemorrhage group (OR = 5.787, 95% CI = 2.369-14.134, p = 0. 000). Fifty-one patients (32 with cerebral hemorrhage, 19 with cerebral infarction) received the first local BoNT injection and had available medical records, analysis of which showed a significantly higher rate of symptomatic improvement in patients of the infarction group than those of the hemorrhage group (p = 0.006). After adjustment by factors known to influence treatment outcome (degree of spasticity and paralysis, BoNT dosage, and extent of FDL muscle control of toe movements), the treatment effect was predominantly higher in patients with cerebral infarction. CONCLUSION: The BoNT treatment response was better for claw toes in cerebral infarction patients than in hemorrhage patients, possibly suggesting that claw toe is associated with more severe spasticity in this group of patients.

The efficacy of adjustable toe splint on decreasing metatarsalgia in patients with lesser toe deformity: a prospective, randomized single-blinded controlled trial.

OBJECTIVE: To study the effectiveness in application of adjustable toe splint in decreasing metatarsalgia in patients with lesser toe deformity and the complication of adjustable toe splint usage. MATERIAL AND METHOD: Thirty-six patients who had claw toes or hammer toes with metatarsalgia were enrolled in aprospective, randomized single-blinded controlled trial at the Out Patient Rehabilitation Medicine Clinic, Siriraj Hospital, Bangkok, Thailand between March and September 2011. Patients were randomized into two groups, the study group (using adjustable toe splint for 2 weeks) and the control group. Patients in both groups were advised as well to use proper shoes. RESULTS: All patients in each group completed the study. The baseline characteristics of the patients in both groups were similar The present study group reported more decrease pain at metatarsal heads and dorsum of toes than the control group (p < 0.05). Two patients reported complications from toe splint usage as toe abrasions. CONCLUSION: Using adjustable toe splint can decrease the metatarsalgia in patient with lesser toe deformity.

Common foot examination features of 247 Iranian patients with diabetes.

BACKGROUND: Iran is a Middle Eastern country with a 70 million population. There are 3 million Iranians with diabetes mellitus (DM) and there is a high incidence of non traumatic amputation in this population. Amputation is often preceded by foot deformity or ulceration. We evaluated the routine foot examination of persons with diabetes (PWD) attending an outpatient Diabetic Clinic to identify the clinical characteristics that might be early warning signs of individuals at a high risk of developing a foot ulcer or having a subsequent non traumatic amputation. METHODS: A prospective, descriptive, clinic-based study was conducted on 247 patients with diabetes mellitus in 2005. The objectives of the study were to define the abnormal features of the foot examination in PWD which could be risk factors for ulceration or amputation. RESULTS: The mean age of patients with diabetes was 52 +/- 12. The prevalence of callus in the enrolled patients was 12% and heel fissures were noted in 50%. There was a significant relationship between callus formation and the absence of tibialis posterior pulse (odds ratio 5), the presence of the hammer toe deformity (odds ratio 4), and foot ulceration (odds ratio 3). The prevalence of foot ulcers in PWD was 4%. CONCLUSION: A diabetic screening program identifying callus formation, absent pulses, and hammer toe are important early signs of individuals at an increased risk for foot ulcers. This program will facilitate early treatment to decrease the loss of limbs.

Reversal of toe clawing in the patient with neuropathy by neurolysis of the distal tibial nerve.

The distinction between hammer toes and clawed toes is poorly emphasized. The neural origin of clawing in the foot is related to the lateral plantar nerve, and suggests that surgical treatment directed at decompression or neurolysis of the lateral plantar nerve may either reverse or prevent progression of intrinsic motor paralysis. The purpose of this report is to provide criteria to distinguish between the musculoskeletal imbalances that creates hammer versus clawing of the toes, and to demonstrate examples of improvement in clawing that resulted from neurolysis of the tibial nerve and the lateral plantar nerve.

Complication Rates and Short-Term Outcomes After Operative Hammertoe Correction in Older Patients.

BACKGROUND: Hammertoe deformities are the most common lesser toe deformity. To date, no studies have looked at outcomes of operative management in the geriatric population, which may be at greater risk for complications or functional compromise because of comorbidities. METHODS: Data on 58 patients undergoing operative correction of hammertoe deformities were prospectively collected. Clinical outcomes were assessed using preoperative and postoperative visual analogue scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of 6-month follow-up. Patients were divided into 2 groups on the basis of age at the time of surgery: younger than 65 and 65 and older. Complication rates and mean VAS and SF-36 improvement were compared. Forty-seven patients met inclusion criteria (7 men, 40 women), with 26 patients (37 toes) in the younger cohort and 21 patients (39 toes) in the older cohort. RESULTS: Overall, patients demonstrated significant improvement from baseline to 6 and 12 months postoperatively in VAS ( P < .001 and P < .001) and SF-36 ( P < .001 and P < .001) scores. Mean improvement in VAS and SF-36 scores was not significantly different between the groups at 6 and 12 months postoperatively. Complications occurred in 13.5% and 10.3% of patients in the younger and older cohorts, respectively. CONCLUSIONS: Outcomes of operative correction of hammertoe deformities in older patients were similar to outcomes in younger patients after greater than 6 months of follow-up. Overall improvement in VAS and SF-36 was statistically significant for both cohorts. There was no associated increase in complications for older patients. LEVEL OF EVIDENCE: Level, III comparative series.

[Diagnosis and treatment of warts, corns, and clavi]. / Was Iässt die Hornhaut an den Füssen wuchern?

The term keratosis covers a variety of growths such as warts and pressure-induced callosities. Warts develop in the absence of pressure, and often clear up again after a certain period, usually without treatment. Clavi can develop as a result of wearing poorly fitting shoes, but also deformed toes or other anatomical deformities affecting the foot. The resulting non-anatomical stressing leads to the formation of pressure callosities and even to pressure sores.

Relationship of Radiographic and Clinical Parameters With Hallux Valgus and Second Ray Pathology.

BACKGROUND: Hallux valgus is frequently associated with additional forefoot pathologies, including hammertoes and midfoot osteoarthritis (OA). However, the pathogenesis of these concurrent pathologies remains to be elucidated. We sought to determine whether there is a relationship between demographic and radiographic parameters and the incidence of secondary pathologies in the setting of a bunion, with an emphasis on second tarsometatarsal (TMT) OA and hammertoes. METHODS: A total of 153 patients (172 feet) who underwent reconstruction for hallux valgus were divided into 3 groups: (1) bunion only (61 patients), (2) bunion with hammertoe without second TMT joint OA (78 patients), and (3) bunion with second TMT joint OA (14 patients). Preoperative age, sex, and body mass index (BMI) as well as hallux valgus angle (HVA), intermetatarsal angle (IMA), metatarsus adductus angle (MAA), ratio of second to first metatarsal length, and Meary's angle were recorded. One-way analysis of variance (normality demonstrated) and Kruskal-Wallis (normality not demonstrated) tests were used to assess differences in continuous variables. Post hoc tests were conducted with the Bonferroni technique. Associations between discrete variables and the study groups were analyzed using χ2 tests. Following the univariate analysis, multinomial logistic regression models were built to determine potential risk factors for hammertoe or TMT OA group placement. RESULTS: Patients in the hammertoe and TMT OA groups were significantly older than patients in the bunion only group ( P < .001 for both pairwise comparisons) and had significantly higher BMIs ( P = .024 and P < .001, respectively). Patients in the TMT OA group had a significantly higher mean HVA than patients in the bunion-only group ( P = .004) and a significantly higher mean MAA relative to both other study groups ( P ≤ .001 for both comparisons). IMA, Meary's angle, and the ratio of second to first metatarsal length did not differ significantly between groups. In the multivariate analysis, hammertoe group assignment was predicted only by age and HVA, while midfoot OA group assignment was predicted by age, HVA, BMI, and MAA. CONCLUSION: Our data show that older age and increased HVA were predictors of both second ray pathologies studied. Higher BMI and MAA were predictive only of TMT joint OA. These data may help identify patients with hallux valgus who are at greater risk for developing secondary pathologies. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Multiplanar Correction of the Lesser Digital Deviation and Indirect Plantar Plate Rupture Repair Using a Braided Polyethylene Nylon Suture: A Technique Guide.

Forefoot and lesser digital pathology continues to be a challenging area of surgical correction for foot and ankle surgeons. Many techniques for the correction of digital deformities secondary to plantar plate rupture, regardless of planal dominance, have been described including direct repair and metatarsal shortening osteotomies for repair. The authors present a new technique for multiplanar correction of deformed lesser digits without direct repair of the plantar plate rupture utilizing a specialty suture. The technique utilizes a braided synthetic polyethylene Nylon suture, which has been traditionally used for open or arthroscopic shoulder labrum repair, for the stabilization of the lesser metatarsophalangeal joint. This novel technique guide for the correction of transverse and sagittal plane deformities of the digit at the metatarsophalangeal joint negates the need for a plantar incisional approach for plantar plate repair or metatarsal head osteotomy from a dorsal approach with augmented stabilization. LEVELS OF EVIDENCE: Level V: Expert opinion.

Elevated plantar pressures in neuropathic diabetic patients with claw/hammer toe deformity.

Elevated plantar foot pressures during gait in diabetic patients with neuropathy have been suggested to result, among other factors, from the distal displacement of sub-metatarsal head (MTH) fat-pad cushions caused by to claw/hammer toe deformity. The purpose of this study was to quantitatively assess these associations. Thirteen neuropathic diabetic subjects with claw/hammer toe deformity, and 13 age- and gender-matched neuropathic diabetic controls without deformity, were examined. Dynamic barefoot plantar pressures were measured with an EMED pressure platform. Peak pressure and force-time integral for each of 11 foot regions were calculated. Degree of toe deformity and the ratio of sub-MTH to sub-phalangeal fat-pad thickness (indicating fat-pad displacement) were measured from sagittal plane magnetic resonance images of the foot. Peak pressures at the MTHs were significantly higher in the patients with toe deformity (mean 626 (SD 260)kPa) when compared with controls (mean 363 (SD 115) kPa, P<0.005). MTH peak pressure was significantly correlated with degree of toe deformity (r=-0.74) and with fat-pad displacement (r=-0.71) (P<0.001). The ratio of force-time integral in the toes and the MTHs (toe-loading index) was significantly lower in the group with deformity. These results show that claw/hammer toe deformity is associated with a distal-to-proximal transfer of load in the forefoot and elevated plantar pressures at the MTHs in neuropathic diabetic patients. Distal displacement of the plantar fat pad is suggested to be the underlying mechanism in this association. These conditions increase the risk for plantar ulceration in these patients.

The direct plantar plate repair technique.

Lesser metatarsophalangeal (MTP) joint instability is a common and painful condition that can severely limit activity and recreation. Synovitis and joint effusion may be seen early on with progression of instability to encompass predislocation and eventual complete dislocation of the MTP joint. Various surgical techniques have been described to treat lesser MTP joint instability and associated hammertoe deformities. Many surgeons experience frustration with the surgical outcome of metatarsal osteotomies and flexor transfers commonly used for this condition. The plantar plate apparatus is felt to be at the heart of the pathomechanics of this condition in many instances and is often misunderstood or even overlooked. Indirect dorsal approaches to plantar plate repair often require reliance on complex instrumentation and provide a limited view of the involved structures. The authors describe a direct plantar approach technique for plantar plate repair with realignment of the lesser MTP joint and hammertoe pathologies.