Ultrasonography-Based Quantitative Evaluation of Second Metatarsophalangeal Joint Instability in Female Patients With Hallux Valgus.

BACKGROUND: Patients with moderate to severe hallux valgus (HV) sometimes exhibit second metatarsophalangeal (MTP) joint dislocation. Second MTP joint instability due to plantar plate (PP) injury has been suggested as one of the causes. However, there have been no reports that quantitatively evaluate this instability. This study aimed to evaluate second MTP joint instability in patients with HV without dislocation via ultrasonography and investigate its relationship with the presence of PP injury or foot form. METHODS: Between May 2018 and July 2023, symptomatic female patients with HV without any lesser toe deformity were included in this study. Second MTP joint instability was defined as the dorsal displacement ratio (DDR) of the passively subluxated proximal phalangeal articular surface on the metatarsal head articular surface. The presence of PP injury was assessed using ultrasonography. Foot "form" was determined by measuring standard foot bony angles on weight-bearing foot-ankle radiographs. The relationship between DDR or PP injury and radiographic measurements was investigated. RESULTS: Sixty-four patients (100 feet) were included. The average DDR of the second MTP joint in patients with HV without dislocation was 35.7%. There was an increase in the probability of PP injury, above a cutoff DDR value r of 35.4% (area under the curve = 0.712). The sensitivity, specificity, positive predictive value, and negative predictive value for the presence of PP injury based on this cutoff level were 63.9%, 74.4%, 79.6%, and 56.9%, respectively. Metatarsalgia was reported in 21 feet (21.0%), of which 15 feet (71.4%) showed PP injury. An increase in DDR was weakly associated with increased metatarsus adductus angle and decreased second metatarsal height. CONCLUSION: In female patients with HV without second MTP dislocation, we found ultrasonographic evidence of second MTP plantar plate injury and joint instability to be a relatively common finding with a high prevalence in those with localized metatarsalgia. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria based on consecutive patients.

Low-Intensity Pulsed Ultrasound for Symptomatic Pseudarthrosis After Toe Fracture with Symphalangism: A Report of 2 Cases.

CASE: Distal phalangeal fractures are often treated conservatively. However, some patients experience residual pain. We report 2 cases of patients who underwent low-intensity pulsed ultrasound (LIPUS) therapy for pseudarthrosis after fracture of the distal phalanx of the fifth toe with symphalangism. Both patients (female, 63 and 33-year-old, respectively) underwent conservative treatment with buddy-taping fixation; however, bone union failed, and LIPUS therapy was initiated. In both cases, bone union was achieved and pain resolved after 3 months. CONCLUSION: Bone union occasionally fails after conservative treatment of distal phalangeal fractures. LIPUS is a useful treatment of symptomatic pseudarthrosis after such fractures.

Plantar Pressure Distribution Before and After Surgery for Lesser Metatarsophalangeal Joint Dislocation With Hallux Valgus.

Hallux valgus surgery and open reduction of the lesser metatarsophalangeal joints with metatarsal shortening osteotomy help treat severe hallux valgus concomitant with the lesser metatarsophalangeal joint dislocation; however, pre- and postoperative plantar pressure distribution and its effect on the foot remain unclear. The pre- and postoperative groups comprised 16 patients with moderate-to-severe symptomatic hallux valgus with lesser metatarsophalangeal joint dislocation. All feet underwent open reduction and collateral ligament reconstruction of the second metatarsophalangeal joint and proximal metatarsal shortening osteotomy under the second metatarsal with proximal osteotomy of the first metatarsal. Twenty healthy participants (20 feet) were included in the control group. The plantar pressure distribution was determined by measuring the peak pressure, maximum force, contact area, and force-time integral for 12 regions. Under the second toe, all measurements in the preoperative group were significantly lower than those of the control group. The peak pressure, maximum force, and contact area of the postoperative group were significantly greater than those of the preoperative group. However, no differences were observed between the postoperative and control groups. Under the second metatarsal head, the peak pressure of the preoperative group was significantly higher than that of the control group. The peak pressure of the postoperative group was significantly lower than that of the preoperative group and showed no differences from the control group. Open reduction and collateral ligament reconstruction of the lesser metatarsophalangeal joints and proximal metatarsal shortening osteotomy with proximal osteotomy of the first metatarsal in hallux valgus with lesser metatarsophalangeal joints dislocation cases may improve operative outcomes, including favorable foot function.

Morphology of the asymptomatic Αchilles tendon: Measurement of tendon length and shape using magnetic resonance imaging, and investigation of related factors.

BACKGROUND: One of the severe complications of Achilles tendon (AT) rupture is muscle weakness due to tendon lengthening. It is very important to prevent tendon lengthening during treatment; however, data on the length, thickness, and width of normal ATs are scarce. Furthermore, no studies have investigated the factors related to the AT length and shape. We aimed to determine the normal AT length and shape and to investigate any correlating factors. METHODS: We measured the AT length, thickness, and width of 100 asymptomatic patients using magnetic resonance imaging. We also investigated the correlation between the AT length, thickness, and width and factors including age, sex, height, body weight, body mass index, history of sports activities, and the area of Kager's fat pad. RESULTS: The mean AT length was 42.1 ± 12.9 mm. The AT length in 73% of the patients was within the range of 30-55 mm. Individual differences in the tendon length were large, but there was no correlation between the tendon length and patient height (P = 0.505). There was a strong correlation between the AT length and area of Kager's fat pad on magnetic resonance imaging (r = 0.734, P < 0.001). Furthermore, the correlation coefficient between the area of Kager's fat pad on magnetic resonance imaging and the area of Kager's triangle on radiography was extremely high (r = 0.851, P < 0.001). CONCLUSIONS: The AT length can be predicted based on the area of Kager's triangle of the unaffected ankle on radiography. If the AT length is > 55 mm or longer than the length measured directly or calculated from the estimated area of Kager's triangle, tendon lengthening should be suspected. Our findings could provide an important indicator for the evaluation of AT lengthening not only in daily clinical situations but also in clinical studies.

Operative outcomes of hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joints.

BACKGROUND: Hallux valgus is sometimes accompanied by osteoarthritis of the lesser tarsometatarsal joint. However, information on the operative procedures and outcomes for the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint simultaneously is limited. We aimed to describe this operative procedure and evaluate the outcomes of the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint. METHODS: Fifteen patients (17 feet; average age, 66.9 years; average follow-up, 59.4 months; and minimum follow-up, 24 months) with symptomatic hallux valgus accompanied by painful osteoarthritis of the lesser tarsometatarsal joint were enrolled. All feet showed osteoarthritis of the second and/or third tarsometatarsal joint on dorsoplantar weight-bearing radiograph. The operative procedure included a proximal osteotomy of the first metatarsal and arthrodesis of the lesser tarsometatarsal joint with an autologous bone graft. RESULTS: The mean Japanese Society for Surgery of the Foot hallux metatarsophalangeal-interphalangeal score significantly improved from 54.8 points preoperatively to 91.7 points postoperatively (P <0.001). The mean postoperative visual analog score (15 feet) was 1.0 (0-3.9). Preoperative midtarsal pain disappeared in 14 feet and decreased in one foot postoperatively. Preoperative metatarsalgia was found in five feet, of which, it disappeared in two feet, decreased in two feet, and transferred to another region in one foot at the latest follow-up. The mean hallux valgus and intermetatarsal angles were 42.4° and 18.4° preoperatively, which decreased significantly to 12.5° and 6.9° postoperatively, respectively (P <0.001, all). Recurrence of hallux valgus (hallux valgus angle ≥20°) was observed in two feet (11.8%). Nonunion of the third tarsometatarsal joint was observed in one foot (3.1% among 32 joints). CONCLUSIONS: The clinical and radiographic results indicated that operative treatment for hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joint significantly improves forefoot and midfoot pain and function and has low complication rates. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Is rehabilitation effective in preventing decreased functional status after community-acquired pneumonia in elderly patients? Results from a multicentre, retrospective observational study.

OBJECTIVES: This study was designed to evaluate the effect of rehabilitation in preventing decreased functional status (FS) after community-acquired pneumonia (CAP) in elderly patients. DESIGN: This was a retrospective observational study. SETTING: Multicentre study was conducted in two medical facilities from January 2016 to December 2018. PARTICIPANTS: Hospitalised patients with CAP aged over 64 years were enrolled. FS was assessed by the Barthel Index (BI) (range, 0-100, in 5-point increments) at admission and before discharge and graded into three categories: independent, BI 80-100; semidependent, BI 30-75; and dependent, BI 0-25. Multivariable analysis of factors contributing to decreased FS was conducted with two groups: with a decrease of at least one category (decreased group) or without a decrease of category (maintained group). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the effect of rehabilitation in preventing decreased FS. The secondary outcomes were factors associated with decreased FS. RESULTS: The maintained and decreased groups included 400 and 138 patients, respectively. A high frequency of rehabilitation therapy was observed in the decreased group (189 (47.3%) vs 104 (75.4%); p<0.001). Multivariable analysis showed that the factors affecting FS were aspiration pneumonia, Pneumonia Severity Index (PSI) category V, length of stay and age (OR 2.66, 95% CI 1.58 to 4.49; OR 1.92, 95% CI 1.29 to 3.44; OR 1.05, 95% CI 1.04 to 1.07; and OR 1.05, 95% CI 1.02 to 1.09, respectively). After adjusting for factors contributing to decreased FS, rehabilitation showed a limited effect in preventing decreased FS in 166 matched pairs by McNemar's test (p=0.327). CONCLUSIONS: Aspiration and PSI played important roles in reducing FS. The effect of rehabilitation remains unclear in CAP. TRIAL REGISTRATION NUMBER: UMIN000046362.

Joint preserving procedures for painful plantar callosities in patients with flexible cavovarus foot.

BACKGROUND: The outcome of a constant joint preserving procedure for painful plantar callosities with cavovarus foot remains unclear. METHODS: Eleven patients (11 feet) who underwent lateral displacement calcaneal osteotomy (LDCO), dorsiflexion first metatarsal osteotomy (DFMO), and plantar fasciotomy (PF), simultaneously were included. The presence of painful callosities, heel alignment of standing (HA), and the Japanese Society for Surgery of the Foot ankle/hindfoot (JSSF) score were evaluated. Radiographically, the talonavicular coverage angle (TNCA), lateral talo-first metatarsal angle (LTMA), calcaneal pitch angle (CPA), and heel alignment angle (HAA) were measured. RESULTS: Postoperatively, painful plantar callosities disappeared in 10 patients and remained in one patient. The postoperative HA and JSSF score significantly improved. The postoperative TNCA, LTMA, CPA, and HAA significantly improved. CONCLUSIONS: In patients with flexible cavovarus foot, LDCO, DFMO, and PF yielded good outcomes at mid-term follow-up with preservation of the foot and ankle joints.

Dislocations of the second and third metatarsophalangeal joints after local steroid injection in patients with refractory metatarsalgia: A case report.

Local steroid injections are frequently administered to patients with refractory metatarsalgia. No reports have described dislocation of the second and third metatarsophalangeal joints after local steroid injections. A 46-year-old woman had suffered from metatarsalgia and received multiple local steroid injections for over 2 years. The second and third metatarsophalangeal joints revealed dorsal dislocations on the lateral radiograph. Therefore, collateral ligament reconstruction of the metatarsophalangeal joints was performed. Intraoperative findings suggested that the rupture of the plantar plate may have caused dorsal dislocation of both joints. Thus, unnecessary multiple steroid injections around the lesser metatarsophalangeal joint should be avoided.

Declined Functional Status Prolonged Hospital Stay for Community-Acquired Pneumonia in Seniors.

PURPOSE: Among senior community-acquired pneumonia (CAP) survivors, functional status after hospitalization is often decreased. This study investigated the change of functional status affecting delayed discharge. PATIENTS AND METHODS: This retrospective observational study was conducted in two medical facilities from January 2016 to December 2018. Hospitalized CAP patients >64 years old were divided into two groups: an early group discharged ≤1 week after ending antibiotic treatment and a delayed group discharged >1 week after ending antibiotic treatment. The primary outcome was decline in functional status. RESULTS: The early group comprised 170 patients and the delayed group comprised 155 patients (median age: 78 vs 82 years; p = 0.007). Distribution of the causative microorganisms and initial prescription of antibiotics showed no significant differences in the two groups (p=0.38; p=0.83, respectively) More patients showed decline in functional status in the delayed group than the early group (16 (9.4%) vs 49 (31.6%), p<0.001), even if rehabilitation was more frequently conducted (77 (45.3%) vs 118 (76.1%); p<0.001). Higher medical expenses were observed in the delayed group ($8631 vs $3817, respectively; p<0.001). Multivariable regression analysis of factors contributing delayed discharge revealed that decreased functional status, pneumonia severity index (PSI) categories, rehabilitation enrolled, aspiration and age were independently associated with delayed discharge (odds ratio 4.31, 95% confidence interval (CI) 2.32-7.98; 2.34, 95% CI 1.43-3.82; 15.96, 95% CI 4.56-55.82 (PSI V vs II); 2.48, 95% CI 1.11-5.98; and 1.03, 95% CI 1.01-1.06; respectively). CONCLUSION: Functional status decline was independently associated with extended hospitalization.

[A Case of Significant Ejection Fraction Reduction and Heart Failure Induced by Osimertinib].

BACKGROUND: In recent years, osimertinib has been increasingly used as a therapeutic drug for epidermal growth factor receptor(EGFR)mutation-positive lung cancer, with heart failure rarely reported as an adverse event. We report here a case of a significantly decreased ejection fraction and heart failure that were induced by osimertinib. We consider the case important and include a discussion of relevant previous reports. CASE: The patient was a 73-year-old woman who had been on oral gefitinib as first-line treatment for EGFR mutation-positive(exon19 deletion)non-small cell lung cancer for approximately 1 year and 2 months. Thereafter, she tested positive for an EGFR resistance mutation(T790M); and accordingly, oral osimerti- nib was started at 80mg/day as second-line treatment. After continuing this treatment for 6 months with no particular adverse events, she visited our hospital and was found to have dyspnea on exertion and increased pleural effusion. Based on these findings, cancer relapse was suspected, and the patient was hospitalized for detailed examinations. She was diagnosed with heart failure based on the elevated BNP level that was found in a blood test and CT and echocardiography findings, and her ejection fraction deteriorated to 19% from a pretreatment level of 59%. The conditions improved after diuretic and b- blocker treatment. Given the absence of any possible cause of heart failure or reduced ejection fraction in her past history of illness and medication, we concluded that these conditions were induced by osimertinib. CONCLUSION: While heart failure induced by EGFR-TKIs has been rarely reported, osimertinib may cause cardiomyopathy due to human epidermal growth factor receptor type 2(HER2)inhibitory activity.

[A case with double primary cancers in both lung and nasal cavity].

Our patient, a 77-year-old male, underwent a medical examination for lower back pain. A careful investigation revealed two large tumors both in his lung and nose. The diagnosis was well-differentiated squamous cell carcinoma by biopsy in both sides. Radiation therapy(36 Gy)was performed on his nasal cavity, and nasal tumor volume was reduced considerably. Because the primary lesion could not be determined we used docetaxel chemotherapy which can be applied for both lung cancer and head and neck cancer. As a result, dissociation of the treatment's effect was seen, and we suspected the presence of overlapping cancer in both lung and nasal cavity. We could not use immunostaining to identify the primary lesion in squamous cell carcinoma as we did for adenocarcinoma. In this case we could infer the presence of overlapping cancer over the course of treatment with chemotherapy.

The efficacy of high-dose penicillin for community-acquired pneumonia diagnosed by pneumococcal urine antigen test.

We analyzed the efficacy of both the Streptococcus pneumoniae urine antigen test as a quick diagnostic tool and the administration of high-dose penicillin in response to a positive S. pneumoniae urine antigen test. We conducted a retrospective analysis of 48 cases of pneumococcal pneumonia, in which the patients were treated with high-dose penicillin. All the cases were diagnosed by a positive urine antigen test. Treatment with high-dose penicillin was effective in 43 of the 48 patients. This treatment was also effective in 12 of 16 culture-confirmed cases with low susceptibility to penicillin. Eleven patients who were positive for the S. pneumoniae urine antigen test but culture-negative showed clinical improvement with high-dose penicillin. Pneumonia caused by S. pneumoniae appeared to be treated safely and effectively with high-dose penicillin based on positive results of the urine antigen test, as penicillin resistance was unlikely to be a problem.