How Important Is a Lesser Metatarsal Osteotomy in Preventing Second Hammertoe Recurrence?

Hammertoes with greater preoperative transverse plane deformity are more likely to recur after corrective surgery; however, it is unclear whether this represents an inherent (fixed, nonmodifiable) risk, or whether steps can be taken intraoperatively to mitigate this risk. In this study, we examined whether transverse plane transposition and/or shortening of the second metatarsal during second hammertoe surgery influenced recurrence. We performed a secondary analysis of pre-existing data from patients that had previously undergone second hammertoe surgery at our institution between January 1, 2011 and December 31, 2013. One hundred two patients (137 toes) were followed for a mean 28 ± 7.8 months postoperatively. Thirty-seven toes required, at the surgeon's discretion, an additional/concomitant Weil metatarsal osteotomy. Magnitude of transverse plane transposition and shortening of the second metatarsal, and joint angular measurements were obtained from the second metatarsophalangeal joint on weightbearing AP radiographs preoperatively and at 6 to 10 weeks postoperatively. Cox regression analysis was used to identify predictors of hammertoe recurrence using these new variables and a set of known predictors. In the final regression model, failure to establish a satisfactory postoperative metatarsal parabola (i.e., long second metatarsal; Nilsonne values <-4 mm, multivariate hazards ratio [HR] 1.96, p = .097), and intraoperative lateral transposition of the metatarsal head (multivariate HR 3.45, p = .028) seemed to confer additional risk for hammertoe recurrence. We conclude that shortening osteotomies may be assistive in some individuals, while further inquiry is still needed to determine whether similar benefits can be derived from medial head transposition in medial toe deformities.

Initial Experience With Subchondral Stabilization for Grade II Stress Fractures of the Midfoot and Forefoot.

Stress fractures of the foot are often preceded by magnetic resonance imaging evidence of bone marrow edema. While new evidence suggests intraosseous injection of calcium phosphate ("subchondral stabilization") can alleviate symptoms associated with bone marrow edema, no data yet exist regarding its use in developing mid- and forefoot stress fractures. Fifty-four patients who underwent subchondral stabilization of various midfoot/forefoot bones in our practice were observed over a 5-year period. All patients were unresponsive to standard nonoperative measures for at least 6 weeks, and all had clinical exams and advanced imaging consistent with a Kaeding-Miller Grade II stress fracture. Forty patients were included with a mean age of 54.3 ± 14.9 years and mean follow-up of 14.1 ± 6.9 months. Patients saw a significant decrease in visual analog scale (VAS) pain as early as 1 month postoperatively (p < .05). Mean postoperative VAS at 12 months was 2.11 ± 2.50, and mean reduction in VAS pain from preoperative to 12 months postoperative was -5.00 (95% CI -3.44 to -6.56, p < .05). Fourteen patients (34%, 14/41) were entirely pain free at 12 months. Higher preoperative VAS pain scores (unadjusted odds ratio [OR] 2.13 [95% CI 1.20-3.77], p = .010) and treatment of more than 1 bone (unadjusted OR 6.23 [95% CI 1.39-27.8], p = .017) were associated with a greater likelihood of not achieving a pain free status at 12 months. Our initial experience with subchondral stabilization suggests the procedure may be safe and effective for use in many Kaeding-Miller Grade II stress fractures of the mid- and forefoot.

Validation of the Foot and Ankle Outcome Score for Use in Infracalcaneal Heel Pain.

There is growing interest in adopting validated and reliable patient-reported outcome measures following surgery. While the Foot and Ankle Outcome Score (FAOS) has previously been validated for use in multiple foot/ankle conditions, it has not yet been validated in patients with infracalcaneal heel pain. In this study we aimed to validate the FAOS by looking at 4 psychometric properties of the survey: construct validity, content validity, reliability, and responsiveness, using patients in our practice with a clinical diagnosis of plantar fasciitis. A total of 150 patients (mean age 49.7 ± 12.1 years [36 men and 114 women]) were included in one or more of the 4 components of this study. All FAOS subscales demonstrated adequate construct validity when compared with the physical health component of the 12-Item Short Form Health Survey (SF-12), and 2 out of 5 subscales demonstrated moderate correlation with the mental health component of SF-12 (all Spearman rho >0.3, and p values <0.05). Most FAOS subscales demonstrated content validity and were found to contain relevant questions from the patient's perspective. All 5 subscales demonstrated good test-retest reliability with intraclass correlation coefficients ≥ 0.827. Finally, 4 out of the 5 subscales (all but other symptoms) were responsive to change at a mean follow up of 12.2 months after surgery (p < .05). We conclude that the FAOS is a responsive, reliable, and valid instrument for use in infracalcaneal heel pain. We believe that due to its ease of use and broad applicability, the FAOS could be more widely adopted in foot/ankle practices as patient-centered healthcare delivery and research becomes increasingly prioritized in the US and abroad.

Comparison of Regenerative Injection Therapy and Conventional Therapy for Proximal Plantar Fasciitis.

Treatment of subacute and chronic heel pain often presents a unique challenge to the physician. Regenerative therapies, such as injectable amnion and connective tissue matrix, may represent a promising new approach in these patients, and have become increasingly popular in the United States. However, little literature exists evaluating these injections compared to conventional nonoperative means. As such, we designed a retrospective comparative study evaluating patients in our practice who received a standardized plantar fascial treatment protocol only (standard therapy), and those who received regenerative plantar fascial injections in addition to standard therapy. A total of 54 patients were followed over a 3-month observation period (91.7 ± 73.9 days), with numeric pain rating (NPR) serving as the primary outcome. Both groups saw an improvement in NPR at the end of the observation period, but patients in the regenerative therapy group demonstrated lower pain scores than those receiving standard therapy alone (mean NPR 2.1 ± 2.3 vs 4.4 ± 2.8, p = .004). Additionally, those in the standard therapy group were significantly more likely to proceed onto surgical intervention compared to the regenerative therapy group (unadjusted odds ratio 15.6, 95% CI 3.0-27.9). The use of regenerative injections for subacute and chronic plantar fasciitis showed promise in our study, and may help mitigate against the need for invasive surgical intervention.

Are Radiographs Associated With Patient Satisfaction After Scarf Bunionectomy?

There are over 350,000 bunion surgeries performed in the USA annually, making it one of the most common elective forefoot surgeries. Studies have suggested that as many as 10% of patients remain dissatisfied after bunion surgery. The purpose of this study is to evaluate if radiographic variables are associated with patient satisfaction at 1 year postoperatively. We performed a secondary analysis of prospectively collected data on 69 consecutive adult patients (mean age 45 ± 14 years, 91% female [63/69]) who underwent isolated hallux valgus surgery from January 2016 to January 2017. Subjects completed a standardized 4-item survey inquiring about their satisfaction with regards to pain relief, overall operative result, cosmetic appearance, and ability to wear desired shoe gear. Conventional radiographic indices for hallux valgus were examined preoperatively and 3 months postoperatively. An association model using backward stepwise logistic regression was utilized to determine which variables, if any, are most important in explaining patient satisfaction after surgery. Sixty-nine subjects completed the 4-item satisfaction survey with 53.6% (37/69) of subjects answering they were fully satisfied on all aspects of the survey at 12 months postoperatively. In the final regression model, no radiographic or demographic variables were associated with patient satisfaction including shoe gear, cosmetic appearance, pain relief, and overall operative result. Radiographic variables did not appear to be associated with patient satisfaction at one year postoperatively in our study. Factors such as quality of life, anxiety levels, fear of surgery, and/or preoperative expectations may offer more insight into satisfaction; however, further research should be performed to examine this further.

Diagnostic accuracy of magnetic resonance imaging (MRI) versus dynamic ultrasound for plantar plate injuries: A systematic review and meta-analysis.

BACKGROUND: Previous literature has suggested both MRI and ultrasound can accurately diagnose plantar plate tears. There is a significant cost difference between these two modalities, sparking interest for which should be the preferred method for diagnosis. PURPOSE: The purpose of this study was to examine the diagnostic accuracy of MRI and dynamic, musculoskeletal ultrasound for lesser metatarsal plantar plate injuries using a systematic review and meta-analysis. METHODS: MEDLINE, CINAHL, and Clinicaltrials.gov were searched thru May 2020. We included studies evaluating the diagnostic accuracy of MRI or ultrasound for detecting plantar plate tears, using intraoperative confirmation as the gold standard comparison. Sensitivity and specificity were obtained and pooled from included studies. Summary receiver operating curves were formed for each diagnostic test to compare accuracy. Study quality was assessed using the QUADAS-2 scoring system. RESULTS: Eleven studies met our inclusion criteria, representing 227 plantar plates for MRI and 238 plantar plates for ultrasound. MRI displayed a pooled sensitivity of 89% (95% CI 0.84, 0.93) and specificity of 83% (95% CI 0.64, 0.94). Ultrasound displayed a sensitivity and specificity of 95% (95% CI 0.91, 0.98) and 52% (95% CI 0.37, 0.68), respectively. CONCLUSION: MRI was superior to ultrasound in diagnosing plantar plate injuries overall, however, ultrasound was more sensitive than MRI, suggesting a negative ultrasound would likely rule out a plantar plate injury in the presence of an equivocal physical exam. Determining the grade of the injury is best served with MRI which can provide added insight into the joint's supporting structures (e.g. collateral ligaments) and integrity.

Treatment of Lesser Metatarsophalangeal Joint Instability With Plantar Plate Repair: A Systematic Review and Meta-Analysis.

Recognition of metatarsophalangeal joint plantar plate injuries has improved over time as the condition has become more widely understood and identified. With the diagnosis of a plantar plate injury as a subset of metatarsalgia becoming more common place, there are multiple surgical options that have been utilized to address the condition. Direct repair of the plantar plate has emerged as the treatment of choice for foot surgeons with a tendency to favor a direct dorsal approach for the repair. We performed a systematic review and meta-analysis using preferred reporting items for systematic reviews and meta-analysis guidelines, to determine the magnitude of change that can be expected in visual analog scale pain and American Orthopedic Foot and Ankle Society scores postoperatively. A total of 12 studies involving 537 plantar plate tears were included who underwent direct repair of the plantar plate through either a dorsal (10 articles) or plantar approach (2 articles). Summary estimates were calculated which revealed improvement in visual analog scale pain (pooled mean change of -5.01 [95%CI -5.36, -4.66] pre-to postoperative) and improvement in American Orthopedic Foot and Ankle Society scores (pooled postoperative mean improvement 40.44 [95%CI 37.90, 42.97]) of patients within the included studies. Random effects models were used for summary estimates. I2 statistic was used to assess for heterogeneity. We concluded there is a predictable level of improvement in pain and function in patients undergoing a direct dorsal approach plantar plate repair with follow-up out to 2 years.

Do Patient Personality Traits and Self-Reported Physical and Psychosocial Symptoms Help to Predict Hallux Valgus Surgery Outcomes?

As many as 10% of patients remain unsatisfied after hallux valgus surgery. We explored the effects of patient personality traits and other preoperative patient characteristics on patient-reported outcomes following surgery. Eighty consecutive adult patients (mean age 45 ± 14 years, 91% female [73/80]) undergoing scarf bunionectomy at our practice were prospectively enrolled from January 2016 to January 2017 and followed for 12 months. Predictor variables included preoperative physical and psychosocial complaints (determined via Brief Battery for Health Improvement-2 questionnaire), patient aggression level, and personality traits (extraversion, agreeableness, conscientiousness, emotional stability and openness). Primary outcome measures included the Foot and Ankle Outcome Score (FAOS) with its 5 subscales, and patient satisfaction. Multiple multivariable regression models were used to determine preoperative patient characteristics associated with FAOS outcome and satisfaction at 12 months. Seventy subjects (70/80, 87.5%) completed the study. All patients experienced technically successful surgery. In the multivariable regression analyses, none of the combinations of potentially important predictor variables explained more than 19.8% of the variance in any of the 5 FAOS subscales at 12 months (range: 6.1%-19.8%). Furthermore, no predictor was associated with patient satisfaction in either the univariate or multivariable analyses. We conclude that patient personality traits, aggression level, and self-reported physical and psychological symptoms do very little to predict outcomes in hallux valgus surgery. As healthcare delivery in the United States has increasingly prioritized patient satisfaction, we will need to broaden the quest for predictors associated with our best (and worst) patient-reported outcomes after hallux valgus surgery.

Effects of Hallux Valgus Surgery on Balance and Gait in Middle Aged and Older Adults.

Hallux valgus is associated with balance deficits, and has been implicated as an independent risk factor for falls in older adults. However, it is unknown what effect hallux valgus surgery has on static and dynamic (i.e., while walking) balance in older adults. We enrolled 13 middle-aged and older aged adults (mean age 54.3 ± 12.7 years, range 47 to 70) who underwent isolated hallux valgus surgery and followed them for 12 months. Preoperative and postoperative gait and balance performance was assessed using non-invasive body worn sensors with standardized and validated testing protocols. Visual analog scale (VAS) for pain and radiographic angles were also assessed. All subjects reported improvements in pain (VAS mean change -38.3 ± 10.3 mm), and all subjects demonstrated improvements in their hallux valgus angles and first/second intermetatarsal angles (mean change 16.3 ± 8.8°, and 5.5 ± 3.0°, respectively). While standing in full tandem, center of mass (COM) sway was improved upon by 59% at 1 year postoperative (p < .05, paired t-test). While most gait parameters demonstrated little change postoperatively, patients tended to spend less time in double support (p = .08, paired t-test), while gait variability increased by 55% (p = .03, paired t-test) and medial-lateral sway while walking increased by 43% (p = .08, paired t-test) 12 months postoperatively. Balance improved after hallux valgus surgery in our population, particularly when subjects were forced to rely on their operative foot for support (e.g., full tandem). Patients also seemed to walk with greater variability in stride velocity and with greater medial-lateral sway postoperatively, suggesting perhaps increased ambulatory confidence after successful hallux valgus surgery.

Comparison of Calcaneal Subchondral Injection of Calcium Phosphate and Plantar Fasciotomy vs Plantar Fasciotomy Alone for Refractory Infracalcaneal Heel Pain.

BACKGROUND: Treatment of chronic refractory heel pain has evolved to consider calcaneal structural fatigue as a component of the symptom profile. While concomitant calcium phosphate injection has become a method of addressing the accompanying calcaneal bone marrow edema (BME) frequently seen in this population, there is no literature supporting its use compared to traditional fasciotomy. METHODS: Consecutive patients with symptoms of refractory infracalcaneal heel pain and calcaneal BME were treated in our practice by either surgical fasciotomy (n = 33) or fasciotomy plus calcium phosphate injection (n = 31) between 2014 and 2019. Outcomes were retrospectively assessed via Foot and Ankle Outcome Scores (FAOS), return to activity, and complication rate. RESULTS: Sixty-four patients (64 feet) were included with a mean age of 50.3 ± 12.9 years and mean follow-up of 23.2 ± 22.3 months. No differences were observed between groups preoperatively. Significant improvements in 4 of 5 FAOS subscales were observed postoperatively in both groups (P < .05 for all, paired t test). However, patients undergoing concomitant calcium phosphate injection reported significantly better scores for both activities of daily living (ADL; mean difference +10.2; 95% confidence interval [CI] 0.07-20.2) and foot-specific QOL (mean difference +21.9, 95% CI 7.0-36.6) at final follow-up compared with those undergoing plantar fasciotomy alone. All patients returned to their desired level of activity, and the frequency of complications did not differ between groups (P > .05, Fisher exact test). CONCLUSION: In patients presenting with recalcitrant infracalcaneal heel pain accompanied by calcaneal BME, calcium phosphate injection into the calcaneus, when combined with plantar fasciotomy, was safe and more effective than traditional plantar fasciotomy alone. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comparison of Combination Weil Metatarsal Osteotomy and Direct Plantar Plate Repair Versus Weil Metatarsal Osteotomy Alone for Forefoot Metatarsalgia.

Although many surgeons believe that shortening osteotomies are appropriate in patients with metatarsalgia and long second metatarsals, there remains ambiguity regarding when to repair the injured plantar plate and when to leave it alone. We prospectively assessed consecutive adult subjects who underwent an isolated second Weil metatarsal osteotomy (WMO) or a WMO plus plantar plate repair (WMO + PPR) for sub-second metatarsophalangeal joint pain during a 3.5-year period at our practice. Eighty-six patients (86 feet: 21 WMO only and 65 WMO + PPR) with a mean age of 61 ± 11 years were followed for 1 year. Patients were assessed via use of the Foot and Ankle Outcome Score and radiographic parabola/alignment of the operative digit preoperatively and postoperatively. Patients in the WMO + PPR group demonstrated significant improvements preoperatively to postoperatively in 4 of the 5 FAOS subscales (Pain, Other Symptoms, Sport and Recreation Function, and Ankle- and Foot-Related Quality of Life [QoL], all p < .05) and had higher QoL and Pain subscale scores at 1 year compared with those in the WMO-only group (QoL: 68.6 ± 26.7 versus 49.7 ± 28.5, respectively [p = .01]; Pain: 83.2 ± 14.5 versus 73.6 ± 19.9, respectively [p = .04]). The WMO + PPR group tended to have higher-grade tears on intraoperative inspection (median 3, range 0 to 4) compared with those in the WMO group (median 1, range 0 to 3). There were otherwise no group differences in preoperative or postoperative radiographic parabola, alignment of the second toe, or complication rates. Our findings suggest that when a shortening osteotomy is performed, imbricating/repairing and advancing the plantar plate may be valuable regardless of injury grade in the plate.

Risk Factors for Failure in Hammertoe Surgery.

BACKGROUND: Hammertoe correction is perhaps the most common elective surgery performed in the foot, yet rates of symptomatic recurrence and revision surgery can be high. In this study, we aimed to identify patient and provider risk factors associated with failure after hammertoe surgery. METHODS: Consecutive patients with a minimum of 6 months' follow-up undergoing hammertoe surgery within a single, urban foot and ankle practice between January 1, 2011, and December 31, 2013, served as the basis of this retrospective cohort study. Cox regression analysis was used to identify important predictor variables obtained through chart and radiographic review. One hundred fifty-two patients (311 toes) with a mean age of 60.8 ± 11.2 years and mean follow-up of 29.5 ± 21.2 months were included. RESULTS: Statistically significant predictors of failure were having a larger preoperative transverse plane deviation of the digit (hazard ratio [HR], 1.03 for each degree; P < .001; 95% CI, 1.02, 1.04), operating on the second toe (vs third or fourth) (HR, 2.23; P = .003; 95% CI, 1.31, 3.81), use of a phalangeal osteotomy to reduce the proximal interphalangeal (PIP) joint (HR, 2.77; P = .005; 95% CI, 1.36, 5.64), and using less common/conventional operative techniques to reduce the PIP joint (HR, 2.62; P = .03; 95% CI, 1.09, 6.26). Concomitant performance of first ray surgery reduced hammertoe recurrence by 50% (HR, 0.51; P = .01; 95% CI, 0.30, 0.87). CONCLUSION: We identified risk factors that may provide guidance for surgeons during preoperative hammertoe surgery consultations. This information may better equip patients with appropriate postoperative expectations when contemplating surgery. LEVEL OF EVIDENCE: Level III, retrospective case series.

Correlation of Preoperative Radiographic Severity With Disability and Symptom Severity in Hallux Valgus.

BACKGROUND: Some US insurance companies have recently started to require minimum angular measurements, for coverage decisions, in patients seeking operative correction for symptomatic hallux valgus. This logic naturally assumes that the magnitude of radiographic bunion deformity is related to the magnitude of patient's presenting symptoms and/or disability. METHODS: We conducted an analysis of existing data in our practice to determine whether patient-reported symptoms and disability prior to bunion surgery correlated with preoperative radiographic measurements commonly used to quantify hallux valgus severity. Symptoms and disability level were determined using patient-reported preoperative Foot and Ankle Outcome Score (FAOS), a validated instrument commonly used in hallux valgus assessment. Spearman correlation coefficient was then used to quantify the strength of any correlations. Preoperative data from 107 patients (107 feet) with mean age of 49.3 ± 13.8 years who underwent isolated osseous hallux valgus surgery within our practice between June 1, 2016, and July 30, 2018, were available. RESULTS: No radiographic variable achieved even a moderate correlation with any of the FAOS subscales with the exception of tibial sesamoid position with FAOS Pain (rho=0.402, P = .01) in patients aged 56 years and older. The direction of this correlation was positive, indicating that greater preoperative sesamoid abnormalities were paradoxically associated with less presenting pain (ie, higher FAOS Pain scores). CONCLUSION: It would appear that radiographic severity of bunion deformity is not well correlated with symptom level and/or disability and, we would argue, should not play a role in coverage decisions for patients presenting for hallux valgus surgery. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Correlation of Radiographic Measurements With Patient-Centered Outcomes in Hallux Valgus Surgery.

BACKGROUND:: Evaluation of patients undergoing hallux valgus surgery has historically emphasized radiographic angles and relationships. However, patient-reported outcomes are increasingly important as health care systems trend towards a "value-based" delivery approach. METHODS:: We conducted a retrospective analysis of pre-existing data in our practice to examine whether patient-reported outcomes after bunion surgery, determined via Foot and Ankle Outcome Scores (FAOS), correlated with radiographic parameters commonly measured in hallux valgus deformity. Pearson correlation statistics and simple and multiple linear regression models were used to identify important radiographic predictors. There were 80 patients (80 feet) with mean follow-up of 59.3 ± 11.6 weeks (median 55, range 45.7-96.3 weeks) with complete data. RESULTS:: No radiographic measurement/variable achieved anything more than a weak correlation with any of the FAOS subscale scores at final follow-up; the study's best was postoperative first-second intermetatarsal (IM) angle with sports and recreation scores ( r = -0.328, P = .005). There was no correlation found between change in hallux valgus angle, change in first-second IM angle, magnitude of preoperative hallux valgus angle or magnitude of preoperative first-second IM angle ( P > .05 for all). Furthermore, none of the study's final multivariable models achieved an R2 > 0.24, and nearly all fell between 0.10 and 0.17. CONCLUSION:: We conclude that radiographic angles were not well correlated with patient-centered outcomes in hallux valgus surgery. This study calls into question the current emphasis that is placed on x-ray values both pre- and postoperatively. LEVEL OF CLINICAL EVIDENCE:: Level III, comparative study.

Triplane Hallux Abducto Valgus Classification.

One of the most common procedures performed in the foot and ankle is correction of hallux abducto valgus deformity or "bunion surgery." Most foot and ankle surgeons recognize the challenges associated with defining each patient's individual deformity and selecting the optimal procedure for the best long-term results. Using current 2-dimensional algorithms that focus on the severity of the transverse plane deformity, surgical outcomes have varied. In the past 10 years, high recurrence and complication rates for popular procedures have been reported. In the same period, the reported data have elucidated an evolving anatomic understanding of the bunion deformity, with an expansion to 3 dimensions, including the frontal/coronal plane. We present a new classification and approach for the evaluation and procedure selection for bunion surgery. We hope this conceptual treatise on hallux abducto valgus based on clinical consensus and current data will stimulate academic discussion and further research. This anatomic classification is based on the 3-dimensional anatomy of the first ray.

Percutaneous Kirschner Wire Versus Commercial Implant for Hammertoe Repair: A Cost-Effectiveness Analysis.

Hammertoe deformities are one of the most common foot deformities, affecting up to one third of the general population. Fusion of the joint can be achieved with various devices, with the current focus on percutaneous Kirschner (K)-wire fixation or commercial intramedullary implant devices. The purpose of the present study was to determine whether surgical intervention with percutaneous K-wire fixation versus commercial intramedullary implant is more cost effective for proximal interphalangeal joint arthrodesis in hammertoe surgery. A formal cost-effectiveness analysis using a decision analytic tree model was conducted to investigate the healthcare costs and outcomes associated with either K-wire or commercial intramedullary implant fixation. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. Costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. Our results found that commercial implants were minimally more effective than K-wires but carried significantly higher costs. The total cost for treatment with percutaneous K-wire fixation was $5041 with an effectiveness of 0.82 QALY compared with a commercial implant cost of $6059 with an effectiveness of 0.83 QALY. The incremental cost-effectiveness ratio of commercial implants was $146,667. With an incremental cost-effectiveness ratio of >$50,000, commercial implants failed to justify their proposed benefits to outweigh their cost compared to percutaneous K-wire fixation. In conclusion, percutaneous K-wire fixation would be preferred for arthrodesis of the proximal interphalangeal joint for hammertoes from a healthcare system perspective.

Association Between Second Metatarsal Length and Forefoot Loading Under the Second Metatarsophalangeal Joint.

BACKGROUND: Metatarsal length is believed to play a role in plantar plate dysfunction, although the mechanism through which progressive injury occurs is still uncertain. We aimed to clarify whether length of the second metatarsal was associated with increased plantar pressure measurements in the forefoot while walking. METHODS: Weightbearing radiographs and corresponding pedobarographic data from 100 patients in our practice walking without a limp were retrospectively reviewed. Radiographs were assessed for several anatomic relationships, including metatarsal length, by a single rater. Pearson correlation analyses and multiple linear regression models were used to determine whether metatarsal length was associated with forefoot loading parameters. RESULTS: The relative length of the second to first metatarsal was positively associated with the ratio of peak pressure beneath the respective metatarsophalangeal joints ( r = 0.243, P = .015). The relative length of the second to third metatarsal was positively associated with the ratios of peak pressure ( r = 0.292, P = .003), pressure-time integral ( r = 0.249, P = .013), and force-time integral ( r = 0.221, P = .028) beneath the respective metatarsophalangeal joints. Although the variability in loading predicted by the various regression analyses was not large (4%-14%), the relative length of the second metatarsal (to the first and to the third) was maintained in each of the multiple regression models and remained the strongest predictor (highest standardized ß-coefficient) in each of the models. CONCLUSIONS: Patients with longer second metatarsals exhibited relatively higher loads beneath the second metatarsophalangeal joint during barefoot walking. These findings provide a mechanism through which elongated second metatarsals may contribute to plantar plate injuries. LEVEL OF EVIDENCE: Level III, comparative study.

Cost-Effectiveness Analysis of Primary Arthrodesis Versus Open Reduction Internal Fixation for Primarily Ligamentous Lisfranc Injuries.

The purpose of the present study was to determine whether surgical intervention with open reduction internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries is more cost effective. We conducted a formal cost-effectiveness analysis using a Markov model and decision tree to explore the healthcare costs and health outcomes associated with a scenario of ORIF versus PA for 45 years postoperatively. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. The costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. ORIF was always associated with greater costs compared with PA and was less effective in the long term. When calculating the cost required to gain 1 additional QALY, the PA group cost $1429/QALY and the ORIF group cost $3958/QALY. The group undergoing PA overall spent, on average, $43,192 less than the ORIF group, and PA was overall a more effective technique. Strong dominance compared with ORIF was demonstrated in multiple scenarios, and the model's conclusions were unchanged in the sensitivity analysis even after varying the key assumptions. ORIF failed to show functional or financial benefits. In conclusion, from a healthcare system's standpoint, PA would clearly be the preferred treatment strategy for predominantly ligamentous Lisfranc injuries and dislocations.

Forefoot Adduction Is a Risk Factor for Jones Fracture.

Jones fractures are among the most common fractures of the foot; however, much remains unknown about their etiology. The purpose of the present study was to further examine the risk factors of forefoot and hindfoot alignment on Jones fractures using an epidemiologic study design. We used a retrospective, matched, case-control study design. Cases consisted of patients with acute, isolated Jones fractures confirmed on plain film radiographs seen at our institute from January 2009 to December 2013. Patients presenting with pain unrelated to metatarsal fractures served as controls. Controls were matched to cases by age (±2 years), gender, and year of presentation. Weightbearing foot radiographs were assessed for 13 angular relationships by a single rater. Conditional multivariable logistic regression was used to identify important risk factors. Fifty patients with acute Jones fractures and 200 controls were included. The only significant variables in the final multivariable model were the metatarsus adductus angle (odds ratio [OR] 1.16, 95% confidence interval [CI] 1.08 to 1.25) and fourth/fifth intermetatarsal angle (OR 0.69, 95% CI 0.57 to 0.83)-both measures of static forefoot adduction. The presence of metatarsus adductus (defined as >15°) on foot radiographs was associated with a 2.4 times greater risk of a Jones fracture (adjusted OR 2.4, 95% CI 1.2 to 4.8). We have concluded that the risk of Jones fracture increases with an adducted forefoot posture. In our population, which consisted primarily of patients presenting after a fall (10 of 50; 20%) or misstep/inversion injury (19 of 50; 38%), the hindfoot alignment appeared to be a less important factor.

Association of Abnormal Metatarsal Parabola With Second Metatarsophalangeal Joint Plantar Plate Pathology.

BACKGROUND: Plantar plate pathology is common, yet it is unclear whether, and to what extent, the length of the second metatarsal contributes to this problem. METHODS: We conducted a retrospective case-control (1:2) study to examine radiographic risk factors for plantar plate tears. One hundred patients (age 55.7 ± 12.3 years) with plantar plate injuries and 200 healthy controls (age 56.3 ± 11.3 years) were included. Cases were defined as patients with nonacute, isolated, plantar plate pathology of the second metatarsophalangeal joint confirmed by intraoperative inspection at a single foot and ankle specialty practice from June 1, 2007, to January 31, 2014. Patients presenting for pain outside of the forefoot served as the control group. Controls were matched on age (±2 years), gender, and year of presentation. Weight-bearing foot x-rays were assessed for several predetermined angular relationships by a single rater. Conditional logistic regression was used to identify risk factors for plantar plate injury. RESULTS: A long second metatarsal, defined as a metatarsal protrusion index less than -4 mm, was the only significant risk factor for plantar plate pathology in both the univariate and multivariable analyses (multivariate odds ratio 2.5 [95% confidence interval 1.8 to 3.3], P = .002). CONCLUSION: We found that a long second metatarsal was a risk factor for developing second metatarsophalangeal joint plantar plate tears. This knowledge may aid foot and ankle surgeons when contemplating the need for second metatarsal shortening osteotomies (eg, Weil osteotomy) during plantar plate surgery and when deciding on the amount of shortening for second metatarsal osteotomies. LEVEL OF EVIDENCE: Level III, retrospective comparative study.