Small Joint Arthroscopy of the Foot.

Recently, there have been new advances in the arthroscopic approach to small joints of the foot. This is directly related to the improvement of surgical equipment, new techniques, and publications. These improvements led to broadening indications as well as minimizing complications. Several articles recently presented the uses of arthroscopic surgery in the small joints of the foot; however, the use is still relatively limited. Arthroscopic evaluation of the small joints of the foot includes the first metatarsophalangeal, lesser metatarsophalangeal, tarsometatarsal, talonavicular, and calcaneocuboid joints as well as the interphalangeal joint to the great toe and lesser toes.

Fusion of the Tarsometatarsal Joints: A Focus on Lateral Column Fusion Nonunion Rates.

The literature has previously criticized lateral column arthrodesis, stating this procedure should be avoided to preserve biomechanical function. For patients with recurrent pain secondary to posttraumatic degenerative joint disease (PT-DJD) or dysfunction secondary to Charcot tarsometatarsal collapse, however, this procedure could provide a positive alternative to conservative measures. In our study, 37 patients underwent fourth and/or fifth metatarsal to cuboid arthrodesis, either in isolation or in combination with other tarsometatarsal arthrodeses, with an average follow-up of 27.7 ± 28.5 months. Of the 37 patients, 4 (10.8%) had purely isolated lateral column arthrodesis procedures, and 33 (89.2%) had additional fusions. Twenty patients (54.0%) were in the Charcot neuroarthropathy cohort and 17 (45.9%) in PT-DJD. Radiographs were reviewed to confirm osseous union and measure the lateral column position in both sagittal and transverse planes, using radiographic angles to measure angular correction in the transverse and sagittal planes. Postoperative patient satisfaction outcome measures were obtained via written survey, and 10-cm visual analog scale (VAS) was scored pre- and postoperatively. There was a statistically significant reduction in pain postoperatively (p < .001) and an 89% patient satisfaction rate. The incidence of revision for osseous nonunion was 10.8%. Our study shows that lateral column arthrodesis, either in isolation or combination, provides significant pain relief, high patient satisfaction, and a low incidence of revision per previous literature. This challenges past evidence-based medicine regarding lateral column fusions. The surgical procedures completed in this study suggest reproducible results with a low revision rates and high patient satisfaction for lateral column arthrodesis.

Jones Tendon Transfer.

Hallux malleus is a deformity of the great toe. There is a dorsiflexion contracture at the metatarsophalangeal joint and plantar flexion of the interphalangeal joint. The deformity is commonly attributed to muscular imbalances of the various structures acting on the great toe. Jones tendon transfer is a procedure used to remove the deforming force to the clawed hallux. It is most often performed in conjunction with a hallux interphalangeal joint fusion. Typically there is a neurologic component causing a deformity to the entire foot, necessitating adjunct procedures. The Jones tendon transfer has shown to have reproducible results.

Procedure selection for the flexible adult acquired flatfoot deformity.

Adult acquired flatfoot represents a spectrum of deformities affecting the foot and the ankle. The flexible, or nonfixed, deformity must be treated appropriately to decrease the morbidity that accompanies the fixed flatfoot deformity or when deformity occurs in the ankle joint. A comprehensive approach must be taken, including addressing equinus deformity, hindfoot valgus, forefoot supinatus, and medial column instability. A combination of osteotomies, limited arthrodesis, and medial column stabilization procedures are required to completely address the deformity.

Small joint arthroscopy of the foot.

The arthroscopic approach to small joints of the foot has made many advances in recent years, which can be directly related to the improvement of the surgical equipment. This improvement has led to more indications for the use of arthroscopy as well as minimizing the complications. Several articles recently have presented experiences in arthroscopic surgery in the small joints of the foot; however, its use is still relatively limited. Approaches to small joints of the foot involve the first metatarsophalangeal joint, tarsometatarsal joint, and Chopart joint, as well as the interphalangeal joint to the great toe and lesser toes.

Hallux interphalangeal joint arthrodesis.

Multiple osteotomies and forms of fixation have been proposed for arthrodesis of the hallucal interphalangeal joint. In this brief article, the authors present their preferred "V"-shaped osteotomy combined with the use of internal fixation to allow for intrinsic stability and compression across the fusion site. The authors propose that this basic technique be considered in order to obtain reproducible results in patients requiring hallux interphalangeal joint arthrodesis.

Complications and salvage of elective central metatarsal osteotomies.

In order to provide proper treatment intervention, the foot and ankle surgeon must develop a further understanding of the pathoanatomy and pathomechanics leading to specific surgical complications of central metatarsal osteotomies. In addition to providing the authors' experiences and potential solutions with regard to these complications, a clear definition of the progression of the complication course is presented. The specific complications of floating toe deformity, metatarsalphalangeal joint stiffness, recurrent metatarsalgia, transfer lesions, malunions, and nonunions are discussed.

A plantar-flexor-shortening osteotomy for hallux rigidus: a retrospective analysis.

This retrospective study reported the clinical and radiographic findings of a plantar-flexor-shortening first metatarsal osteotomy for treatment of hallux rigidus. Twenty-six patients (33 feet) were evaluated with a mean 34.4 months follow-up (range, 18-65 months). Assessment consisted of clinical measurements of total range of first metatarsophalangeal joint motion and radiographic measurements of first metatarsophalangeal joint space, including plantarflexion and shortening of the first metatarsal. Patients were evaluated postoperatively using the American Orthopedic Foot and Ankle Society's Hallux Metatarsophalangeal-Interphalangeal Scoring System. The mean preoperative first metatarsophalangeal joint total range of motion was 33.5 degrees (5 degrees -60 degrees ), and postoperatively increased to 72.1 degrees (50-100 degrees ), a mean increase of 38.6 degrees at follow-up (range, 25 degrees -60 degrees ) (P < .001). This range of motion was observed despite a lack of significant improvement in radiographic joint space measurements, (preoperative mean 1.26; postoperative mean 1.82). Postoperative radiographs also demonstrated 1-4 mm of plantarflexion of the first metatarsal head, and a mean 6.1 mm shortening of the first metatarsal. At last follow-up, 85% (22/26) of patients rated their result as very good to excellent, 8% (2/26) reported a good result, 4% (1/26) a fair result, and 4% (1/26) a poor result. The mean postoperative rating scale score was 78.1/100. No patient required revisional surgery for hallux rigidus. Four patients had postoperative lesser metatarsalgia, 3 of which were self-limiting, and one that resolved following surgery. The results of this study show the plantar-flexor-shortening first metatarsal to be an effective surgical treatment for hallux rigidus with reproducible deformity correction and patient satisfaction.

The bone morphogenic protein.

The molecular and cellular process to promote bone formation has been examined extensively in recent years in an attempt to minimize delayed unions and nonunions. Bone morphogenetic proteins (BMPs) have been determined to play an intricate role in the bone formation cascade. Over 14 BMPs have been isolated and more are being discovered as investigation progresses. BMP-2 and BMP-7 are being produced commercially for clinical use with specific indications. Continuing research is investigating the optimal carrier that will give the best results. This article reviews the most current information regarding BMPs.