Quantitative Assessment of the Obliquity of the First Metatarsal-Medial Cuneiform Articulation.

The so-called obliquity of the first metatarsal-medial cuneiform articulation has been described as an atavistic trait of human foot morphology, and it is commonly proposed as a relative risk factor for development of the hallux abductovalgus (HAV) deformity. The objectives of this investigation were to 1) provide descriptive normative radiographic data on a series of first metatarsal-medial cuneiform articulations and 2) correlate these findings to other common radiographic parameters used to define the HAV deformity. We measured radiographic parameters including the first intermetatarsal angle, hallux abductus angle, tibial sesamoid position, Engel's angle, and 2 measures of obliquity in the transverse and sagittal planes on a consecutive series of 136 weightbearing foot radiographic projections from subjects without a history of foot/ankle surgery or fracture/dislocation. Measurements were considered as continuous variables, graphically depicted against each other on frequency scatter plots, and analyzed by means of Pearson correlation coefficients. Only 1 bivariate comparison demonstrated a weak negative correlation (Engel's angle versus Obliquity_1 [Pearson -0.259; p = .002]). The results of this investigation did not demonstrate a statistically significant or clinically substantial relationship between the obliquity of the first metatarsal-cuneiform joint and common radiograph parameters of the HAV deformity. Although not specifically studied here, these results might potentially indicate function, as opposed to structure, in the developmental pathogenesis of the HAV deformity.

Naviculocuneiform and Second and Third Tarsometatarsal Articulations: Underappreciated Normal Anatomy and How It May Affect Fluoroscopy-Guided Injections.

OBJECTIVE: Because the second and third tarsometatarsal (TMT) and naviculocuneiform joints normally communicate, the least arthritic or technically most straightforward joint was injected when a fluoroscopically guided therapeutic injection was ordered for one or both joints. We hypothesized that pain relief would be equivalent regardless of the joint injected and would result in less radiation and a lower steroid dose compared with patients who had both articulations injected. MATERIALS AND METHODS: Seventy-eight patients were divided into four joint groups: naviculocuneiform requested and injected (n = 15), nonrequested naviculocuneiform or second and third TMT injected (n = 25), both injected (n = 23), and TMT requested and injected (n = 15). Variables recorded included patient age and sex, fluoroscopy time, steroid dose, pre- and postprocedural pain, osteoarthrosis (OA) grade, and confidence of intraarticular injection. Statistical analysis compared mean pain level change before and after injection, mean fluoroscopy time, and mean steroid dose between groups. The mean OA grade of the nonrequested joint was compared with that of the requested joint in patients whose injected and requested joints did not match (group 2). RESULTS: Pre- and postinjection pain reduction (p = 0.630) and postinjection pain (p = 0.935) were not significantly different. Mean steroid dose (p < 0.001) and fluoroscopy time (p = 0.0001) were significantly increased for the both joint injection group. Within the nonrequested naviculocuneiform or second and third TMT injection group, there was a significant difference in OA grade between injected (least arthritic) and requested joints (p = 0.001). CONCLUSION: When faced with challenging naviculocuneiform or second and third TMT joint injections, choosing the technically most straightforward joint may result in less radiation and steroid dose without compromising quality of care or pain reduction.

Foot and Ankle Injuries in Soccer.

The ankle is one of the most commonly injured joints in soccer and represents a significant cost to the healthcare system. The ligaments that stabilize the ankle joint determine its biomechanics-alterations of which result from various soccer-related injuries. Acute sprains are among the most common injury in soccer players and are generally treated conservatively, with emphasis placed on secondary prevention to reduce the risk for future sprains and progression to chronic ankle instability. Repetitive ankle injuries in soccer players may cause chronic ankle instability, which includes both mechanical ligamentous laxity and functional changes. Chronic ankle pathology often requires surgery to repair ligamentous damage and remove soft-tissue or osseous impingement. Proper initial treatment, rehabilitation, and secondary prevention of ankle injuries can limit the amount of time lost from play and avoid negative long-term sequelae (eg, osteochondral lesions, arthritis). On the other hand, high ankle sprains portend a poorer prognosis and a longer recovery. These injuries will typically require surgical stabilization. Impingement-like syndromes of the ankle can undergo an initial trial of conservative treatment; when this fails, however, soccer players respond favorably to arthroscopic debridement of the lesions causing impingement. Finally, other pathologies (eg, stress fractures) are highly encouraged to be treated with surgical stabilization in elite soccer players.

Anatomy, biomechanics, and surgical approach to synovial folds within the joints of the foot.

The presence of synovial folds in various joints of the foot has been previously documented. The function and clinical significance of these structures within the joint have not been established. Histologically they are considered anatomically different from a meniscus primarily owing to their makeup of loose connective tissue with nerve fibrils and several synovial cell layers. We hypothesize that the function of these folds is similar to that of the menisci: to increase joint congruity and stability. We further hypothesize that these folds will be present in joints of the foot that require greater stability. To demonstrate this, 41 fixated cadaveric feet were sectioned in the sagittal plane and the incidence and locations of the synovial folds were documented. Three fixated cadaveric feet were evaluated using a materials testing machine. The first metatarsophalangeal joint was incised, and the presence of the synovial fold was documented. The joint was then taken through its range of motion with and without the synovial fold while data on the force and displacement were collected. The steps were then repeated for the ankle joint. The results showed statistically stiffer ankle and first metatarsophalangeal joints with the synovial fold present, as determined by the stress-strain curve. On the basis of the presence and location of these synovial folds, we demonstrated arthroscopic surgical approaches to many of the documented joints that contain these folds. Because the folds contain synovial cells and vascular tissue, damage to them can result in considerable pain. In such cases, arthroscopic surgery would be of benefit. Further research may indicate whether they need to be salvaged during joint procedures to facilitate normal joint function or should be removed to reduce postoperative complications.

Evaluation of the anterior and middle talocalcaneal articular facets and the Evans osteotomy.

The purpose of this study was to determine the occurrence of discrete anterior and middle talocalcaneal facets and the distance of these facets from the anterior border of the calcaneus as it relates to the Evans osteotomy. Seven hundred sixty-eight calcanei were examined from the human osteology archive at the Cleveland Museum of Natural History. Measurements taken included: 1) distance from the proximal border of the anterior facet to the anterior border of the calcaneus (DTAF), 2) distance from the distal border of the middle facet to the anterior border of the calcaneus (DTMF), and 3) width of facet separation (WFS). The results revealed that 310 of 755 (41.06%) had discrete anterior and middle facets and 423 of 755 (56.03%) had a conjoined facet. In those with discrete facets, the mean DTAF, DTMF, and WFS were 11.04 mm, 15.47 mm, and 3.85 mm, respectively. In those with discrete facets, an osteotomy begun between 11.5 mm and 15 mm from the calcaneocuboid joint should pass between the anterior and middle facets and avoid damaging these articular surfaces. This information may aid the foot and ankle surgeon in patient selection and in attaining optimal surgical outcome for the Evans lateral column lengthening procedure.