A Radiologic Triangle Sign for Percutaneous Adductor Tendon Release (PATR): Cadaveric Study and Case Series.

Background: Combining osteotomies and soft tissue procedures is believed to reduce sesamoids in their anatomical position and maintain long-term correction when treating hallux valgus deformity. This study determines if a radiologic association exists between a radiolucent sign and a full percutaneous adductor tendon release (PATR), including a cadaveric study and a consecutive case series. Another aim was to determine the intra- and interobserver reliability of these observations. Methods: A prospective observational study was made between 2018 and 2019. First, a PATR was done on cadaveric specimens and, after the procedures, dissected to correlate what was seen fluoroscopically. The clinical group included 39 feet that presented mild-to-moderate HV deformity and were treated with percutaneous osteotomies associated with PATR. Results: Observers 1 and 2 saw a radioscopic radiolucent sign in 100% of cadavers and the patient population. They also observed a triangle-shaped image with an incidence of 75%, which we have named the "triangle sign." Conclusion: The triangle sign may be helpful in the intraoperative confirmation of PATR and latero-plantar capsule release using this percutaneous technique. Level of Evidence: Level II, development of diagnostic criteria.

Republication of "How Accurate Is Clinical Evaluation in Hindfoot Coronal Alignment?"

Background: Hindfoot coronal alignment is an important factor in the assessment of patients with many different foot and ankle complaints. A number of clinical and radiographic techniques have been described to measure hindfoot coronal alignment, but none of them are widely accepted. The purpose of the present study was to assess the correlation between clinical and radiographic hindfoot alignment measures and to evaluate the reproducibility of each. Methods: We evaluated 85 patients with foot and/or ankle symptoms. Hindfoot clinical alignment was measured from photographs. Each patient was placed at a distance of 1 m from the observer, with both feet placed parallel. Four photographs were taken, at a height of 40 cm: a posterior view of both lower limbs including knees, a posterior view focalized on the studied hindfoot, an anterior view of the foot, and the last view of the medial aspect of the foot. Radiographic alignment was quantified on long axial view radiographs. Patients were lying over the film cassette with a focus distance of 1 m and the beam pointed to the ankle joint. The inclination angle of the beam was 45 degrees to the floor. Measurements were independently made by 2 observers, who were asked to classify pictures into 3 categories: varus, neutral, and valgus. Radiographic measurements were made using the angle measurement tool on the radiograph viewer. The intraclass correlation coefficients (ICCs) and the 95% confidence interval (CI) of the ICC were used to quantify the inter- and intraobserver reliability for clinical assessment. Radiographic parameters were correlated by calculating the Pearson correlation coefficient (r). Results: The intraobserver ICC for clinical analysis was good for both observers, while the interobserver ICC was moderate for both measurements. Regarding radiographic assessment, there was significant intra- and interobserver reliability. The correlation between both methods was weak for both observers. Conclusions: We found only weak intra- and interobserver correlations between the clinical and radiographic assessment of hindfoot coronal alignment. It is therefore necessary to complement the clinical evaluation of hindfoot alignment with an objective measurement method such as a long axial view radiograph. Further studies comparing different measurement methods need to be performed to establish the most objective evaluation. Level of Evidence: Level III, diagnostic study.

Abordaje del seno del tarso para el tratamiento de las fracturas de calcáneo: una técnica de creciente difusión / Sinus tarsi approach for the treatment of calcaneus fractures: an increasingly used technique

Objetivo: Describir los resultados radiográficos y funcionales, y las complicaciones de la osteosíntesis de fracturas de calcáneo mediante el abordaje del seno del tarso. Materiales y Métodos: Se evaluaron 54 fracturas articulares de calcáneo desplazadas en 50 pacientes con radiografías de pie, de frente y de perfil, y tomografía computarizada preoperatorias. Se tomaron radiografías de pie, de frente y de perfil sin carga en el posoperatorio inmediato y con carga a las semanas 6 y 12, y al final del seguimiento. Se midió el ángulo de Böhler y se cuantificó el grado de artrosis subastragalina y calcaneocuboidea. Se determinó el puntaje de la AOFAS y se registraron las complicaciones de la herida, las lesiones neurológicas y la necesidad de cirugías adicionales, como retiro del material de osteosíntesis y artrodesis subastragalina. Resultados: El seguimiento fue de 30.8 meses. La serie estaba formada por 8 mujeres y 42 hombres, con una edad de 39.40 ± 14 años (rango 18-65). Cuarenta fracturas eran Sanders tipo II, 13 tipo III y 1 tipo IV. El puntaje de la AOFAS fue: excelente (12 casos), bueno (25 casos), regular (12 casos) y malo (5 casos). El ángulo de Böhler preoperatorio era de 10,8 ± 10,4° y 30,77 ± 8,24° al final del seguimiento (p <0,00001). El 3,7% tuvo complicaciones menores de la herida y el 5,6%, complicaciones mayores. Conclusión: El abordaje del seno del tarso permite una reducción aceptable con resultados buenos y excelentes en la mayoría de los pacientes y escasas complicaciones de partes blandas. Nivel de Evidencia: IV

Objective: To describe functional and radiographic outcomes, and complications of osteosynthesis in calcaneus fractures with the sinus tarsi approach. Materials and Methods: 54 displaced articular calcaneus fractures in 50 patients were assessed through preoperative foot radiographs (anteroposterior and lateral) and computerized tomography. AP and lateral radiographs were obtained in the immediate postoperative period (without weightbearing), after 6 and 12 weeks (with weightbearing), and at the end of follow-up, measuring the Böhler angle and quantifying the degree of subtalar and calcaneocuboid osteoarthritis. The AOFAS score was determined, registering wound complications, neurological injuries and necessary additional surgeries -such as osteosynthesis and subtalar arthrodesis hardware removal. Results: Follow-up time was 30.8 months. The series consisted in 8 women and 42 men. The patients' average age was 39.40±14 years (18-65). There were 40 Sanders type II, 13 type III, and 1 type IV fractures. The AOFAS score was excellent (12 patients), good (25), regular (12), and poor (5). The Böhler angle was 10.8°±10.4° before surgery, and 30.77°±8.24° at the end of follow-up (p<0.00001). 3.7% of the patients presented minor wound complications, while 5.6% presented major wound complications. Conclusion: The sinus tarsi approach allows for acceptable reduction with good and excellent outcomes in most patients, coupled with few soft-tissue complications. Level of Evidence: IV

Current Concepts in Treatment of Acute Deltoid Instability.

Although far less common than lateral ankle injuries, medial ankle sprains have been reported to result in significantly greater time lost and long-term disability when not diagnosed and treated accurately. Adequate diagnosis is paramount and the most important aspect is to determine whether the lesion is stable or unstable. Evidence confronting surgical versus conservative treatment in acute deltoid ligament lesions is largely anchored in the setting of ankle fractures. Ultimately treatment decisions rely on the clinical and imaging appraisal of each individual patient. This article discusses the isolated acute deltoid ligament impairment.

Factores asociados con dolor severo en pacientes con fascitis plantar: Un análisis de relaciones / Factors associated with severe pain in patients with plantar fasciitis: An association analysis

Objetivo: Describir los factores asociados con niveles de dolor mas severo en una cohorte de pacientes con fascitis plantar. El objetivo secundario fue analizar cuales de estos factores estaban asociados con niveles mas altos de mejoria clinica luego del tratamiento conservador. Materiales y Métodos: Se evaluo a una cohorte prospectiva de pacientes con diagnostico de fascitis plantar. Cada participante completo una escala ordinal visual de dolor (del 1 al 10) para dolor del primer paso y dolor al final del dia y encuestas FFI-R (Foot Function Index-Revised). Tambien se realizo una evaluacion demografica. La dorsiflexion de la articulacion del tobillo, el rango de movilidad de la primera articulacion metatarsofalangica, la rigidez del gastrocnemio y el angulo popliteo tambien se evaluaron de manera estandar. Resultados: Se incluyo a 214 pacientes. El 64% eran hombres (118 pacientes), la media de la edad era de 49.67 anos (DE 13.16) y el indice de masa corporal promedio, de 28,53 (DE 5,18). En el analisis multivariado, se observo que el riesgo de un puntaje ≥8 en la escala de dolor aumento cuando el paciente refirio estar de pie por mas de 6 h (OR 1,17; p = 0,03; IC95% 1,02-1,35). El riesgo de un puntaje >8 fue mayor cuando el grado de dorsiflexion del tobillo fue <0° (OR 1,20; p = 0,03; IC95% 1,02-1,41). Conclusión: Nuestros hallazgos apoyan indirectamente la hipotesis de que la dorsiflexion limitada del tobillo juega un papel como factor de riesgo asociado a un puntaje ≥8 en la escala de dolor, en los casos de fascitis plantar. Nivel de Evidencia: IV

Objective: The main purpose of our study was to describe the factors associated with more severe pain levels in a cohort of patients with plantar fasciitis (PF). The secondary purpose of this study was to determine which of these factors were associated with higher levels of clinical improvement after conservative therapy. Materials and Methods: We conducted a prospective study in a cohort of patients with PF. Each participant completed an ordinal pain scale (1-10) for first-step pain and end-of-day pain, and Foot Function Index-Revised (FFI-R) surveys at enrollment. Also, patient demographics were evaluated. The ankle joint dorsiflexion, the range of motion (ROM) for the first metatarsophalangeal joint (MTPJ), the gastrocnemius tightness, and the popliteal angle were evaluated through standard tests. Results: Our study included 214 participants, of which 64% (118 patients) were males, the average age was 49.67 years (SD 13.16) and the average BMI was 28.53 (SD 5.18). The multivariate analysis showed that the risk of having a Visual Analog Scale (VAS) score ≥8 increased when the patient reported standing for more than 6 hours (OR=1.17; P=0.03; CI95%: 1.02-1.359). The risk of a >8-VAS score was higher when the level of ankle dorsiflexion was <0 (OR=1.20; P=0.03; CI95%: 1.02-1.41). Conclusion: Our findings indirectly support the hypothesis that limited ankle dorsiflexion ROM plays a role as a risk factor associated with VAS scores ≥8 in PF patients. Level of Evidence: IV

Mini thigthrope® fixation of unstable bony avulsion of the extensor hallucis longus tendon.

Reports of isolated avulsion fracture of the distal phalanx of the hallux that comprise the functionality of the extensor hallucis longus tendon (EHL) are scarce and treatment for such injury has only been described in isolated single case reports. Two patients with an unstable avulsion fracture of the distal phalanx treated with reinsertion of the EHL with a Mini ThigthRope® system are presented in this paper. Two patients whom suffered an extreme plantarflexion mechanism sought attention in our clinic. Plain x-rays depicted a displaced and angulated bony avulsion fracture of the base of the distal phalanx of the hallux. The interphalangeal joint was in a slightly plantarflexed position and the patient was not able to perform active extension upon request. Surgical fixation performed with Mini ThigthRope® system without transarticular immobilization of the interphalangeal joint. In the two patients the Mini ThigthRope® system provided adequate reduction of the displaced articular fragment, restored the extensor function and allowed early postoperative mobilization of the IP joint. Removal of the implants was not necessary and patients were able to resume their previous activity levels. Level of Evidence: IV.

Gastrocnemius Recession in the Setting of Metatarsalgia: The Baumann Procedure.

A fundamental etiologic component of metatarsalgia is the repetitive loading of a locally concentrated force in the forefoot during gait. In the setting of an isolated gastrocnemius contracture, weight-bearing pressure is shifted toward the forefoot. If metatarsalgia is considered an entity more than a symptom, evaluation of gastrocnemius contracture must be a part of the physical examination, and gastrocnemius recession via the Baumann procedure alone, or in combination with other procedures, considered as an alternative treatment in an attempt to restore normal foot biomechanics.

Effect of First Ray Insufficiency and Metatarsal Index on Metatarsalgia in Hallux Valgus.

BACKGROUND: Two concepts have been proposed to explain the etiology of metatarsalgia in hallux valgus patients: First, as the magnitude of hallux valgus increases, there is a mechanical overload of the lesser metatarsals. Second, increased relative lesser metatarsal length is a factor in the development of metatarsalgia. However, there is no current evidence that these structural factors lead to primary metatarsalgia. The purpose of the study was to evaluate the factors associated with metatarsalgia in hallux valgus patients. METHODS: A cross-sectional study of 121 consecutive adult patients with non-arthritic hallux valgus was carried out. Binary logistic regression was performed to identify the effect of the clinical and demographic factors on the occurrence of metatarsalgia. One hundred twenty-one patients (184 feet) with hallux valgus were analyzed. The median weight was 65 kg (interquartile range 58-72). RESULTS: Metatarsalgia was present in 84 (45.6%) feet. The binary logistic regression showed that lesser toe deformity (OR 2.6, 95% CI 0.2-0.5), gastrocnemius shortening (OR 5.8, 95% CI 2.8-12.3), metatarsal index (OR 0.3, 95% CI 0.2-0.5), and weight (OR 2.5, 95% CI 1.2-5.3) were significantly associated. CONCLUSION: Metatarsalgia occurs in almost half of hallux valgus patients. It has a multifactorial etiology. Our findings contradict the common theory that both the magnitude of hallux valgus deformity and an increased length of the lesser metatarsals, by themselves, lead to primary metatarsalgia. Metatarsalgia was associated with Achilles shortening, excessive weight, and associated lesser toe deformity. These factors should be addressed in order to treat this disorder adequately. LEVEL OF EVIDENCE: Level III, comparative series.