Interdigital vs Transarticular Lateral Release With Scarf Osteotomy.

BACKGROUND: We compare the clinical and radiographic outcomes of the interdigital approach vs the medial transarticular approach for lateral release combined with scarf osteotomy. METHODS: Seventy-seven feet with moderate to severe hallux valgus underwent scarf osteotomy and lateral soft tissue release, using an interdigital approach (n = 36) vs medial transarticular approach (n = 41). The clinical measurements (range of motion, American Orthopaedic Foot & Ankle Society [AOFAS] score) and radiographic data were evaluated preoperatively and at final follow-up (93-124 months postoperatively). Additionally, the numeric pain rating scale and Foot and Ankle Outcome score [FAOS] were assessed postoperatively. RESULTS: The AOFAS score improved from 60 (q1 = 54, q3 = 70) to 93 (q1 = 85, q3 = 98) in the transarticular group, and from 59 (q1 = 50, q3 = 64) to 95 (q1 = 85, q3 = 100) in the interdigital group. The hallux valgus angle improved from 35.7±6.5 degrees to 15.5±7.6 degrees in the transarticular group, and from 36.0±6.8 degrees to 12.9±13.0 degrees in the interdigital group. The intermetatarsal angle improved from 16.5±2.5 degrees to 6.5±2.7 degrees within the transarticular group and from 17.2±2.5 degrees to 7.3±4.3 degrees in the interdigital group. None of the clinical or radiographic parameters showed any significant differences between the treatment groups. CONCLUSION: Comparison of outcomes between the interdigital approach and the transarticular approach for lateral soft-tissue release with scarf osteotomy are equally successful. The transarticular approach can thus be considered safe and effective, with the additional benefits of just one scar as opposed to 2. LEVEL OF EVIDENCE: Level III, therapeutic.

Reliability of ultrasonography measurement of the anterior talofibular ligament (ATFL) length in healthy subjects (in vivo), based on examiner experience and patient positioning.

BACKGROUND: The most common cause of ankle injury is the supination trauma, inflicting a partial or complete rupture of the anterior talofibular ligament (ATFL). Among conventional diagnostic tools and procedures of sports injuries, the method of stress-ultrasonography is reportedly a promising diagnostic tool for examining injuries of the lateral ligaments of the ankle. Preceding studies predominantly examined the comparability of stress-ultrasonography and other established diagnostic tools in terms of efficacy, viability and quality. The purpose of this study was to assess the reliability of stress-ultrasonography of the ATFL based on varying examiner experience and patient positioning. METHOD: Sixteen healthy subjects were examined by four examiners with differing levels of skill and experience in ultrasonography, ranging from laymen to specialist. Measurements were recorded and interrater correlation coefficient (ICC) was applied in four positions, including a neutral position (A), medial rotation (B), plantar flexion (C) and inversion of the foot (D). RESULTS: The length of the ATFL was 14.958 ± 2.145 mm in position A, 15.886 ± 1.994 mm in position B, 16.270 ± 1.858 mm in position C and 15.170 ± 1.781 mm in position D. The average length change was 0.928 ± 0.804 mm (6.656 ± 6.299%) in position B, 1.313 ± 1.266 mm (9.746 ± 9.484%) in position C and 0.213 ± 1.807 mm (2.604 ± 12.308%) in position D. The correlation of the combined results of all four investigators was 0.333 for position A, 0.386 for position B, 0.320 for position C and 0.517 for position D. The highest ICC (0.811) was recorded between the orthopedic specialist and the radiology specialist. The lowest ICC (0.299) was recorded between the laymen and the radiology specialist. CONCLUSION: The reliability of the ATFL examination seems to be exceedingly dependent on the examiner's experience and skill in ultrasonographic (US) diagnostic. Moreover, the inversion positioning of the foot, described by the European Society of Musculoskeletal Radiology (ESSR) yielded the highest measurement reliability.

The Scarf Osteotomy with Minimally Invasive Lateral Release for Treatment of Hallux Valgus Deformity: Intermediate and Long-Term Results.

BACKGROUND: Little is known about the long-term results of surgical correction of hallux valgus deformity, in particular, the recurrence rate and factors leading to recurrence. METHODS: Of one hundred and eight patients (115 feet) who underwent a Scarf osteotomy, ninety-three patients (ninety-three feet) were examined at an average duration of follow-up of 124 months. Clinical examination before surgery and at the time of final follow-up included an evaluation of range of motion, pain as measured with a visual analog scale, and American Orthopaedic Foot & Ankle Society (AOFAS) scores. The Foot and Ankle Outcome Score (FAOS) was also assessed postoperatively. Radiographic data were evaluated preoperatively, at six weeks postoperatively, and at the time of final follow-up. Additional radiographic data were available for seventy-nine patients of the same patient cohort at an average of twenty-seven months postoperatively. RESULTS: The median overall AOFAS score improved from 57 points preoperatively to 95 points at the time of final follow-up. All radiographic measurements (hallux valgus angle [HVA], intermetatarsal angle [IMA], distal metatarsal articular angle [DMAA], and sesamoid bone position) showed significant (p < 0.05) improvement at the time of final follow-up compared with preoperatively. The rate of recurrence (an HVA of ≥20°) at the time of final follow-up was 30%. We were unable to determine if recurrence resulted in functional impairment or consequences for quality of life. CONCLUSIONS: The recurrence rate after ten years was 30%, and a higher final HVA resulted in higher pain levels. The limitations imposed by nonvalidated outcome measures precluded conclusions about the influence of HVA on function or quality of life.

Imaging of posterior tibial tendon dysfunction--Comparison of high-resolution ultrasound and 3T MRI.

PURPOSE: Posterior tibial tendon dysfunction is the most common cause of acquired asymmetric flatfoot deformity. The purpose of this study was to determine and compare the diagnostic value of MRI and high-resolution ultrasound (HR-US) in posterior tibial tendon dysfunction (PTTD), and assess their correlation with intraoperative findings. MATERIALS AND METHODS: We reviewed 23 posterior tibial tendons in 23 patients with clinical findings of PTTD (13 females, 10 males; mean age, 50 years) with 18MHz HR-US and 3T MRI. Surgical intervention was performed in nine patients. RESULTS: HR-US findings included 2 complete tears, 6 partial tears, 10 tendons with tendinosis, and 5 unremarkable tendons. MRI demonstrated 2 complete tears, 7 partial tears, 10 tendons with tendinosis, and 4 unremarkable tendons. HR-US and MRI were concordant in 20/23 cases (87%). Image findings for HR-US were confirmed in six of nine patients (66.7%) by intraoperative inspection, whereas imaging findings for MRI were concordant with five of nine cases (55.6%). CONCLUSION: Our results indicate that HR-US can be considered slightly more accurate than MRI in the detection of PTTD.

Plantar pressure distribution after tibiotalar arthrodesis.

INTRODUCTION: Arthrodesis is a well-established treatment option for end-stage osteoarthritis of the ankle. Osteoarthritis of the ankle can alter plantar pressure distribution. However, surprisingly little is known about the effect of ankle arthrodesis to alter plantar pressure distribution. The purpose of this study was to determine plantar pressure distribution in a selected group of patients with unilateral arthrodesis of the ankle joint. METHODS: 20 patients with an average age of 60 years who underwent isolated unilateral ankle arthrodesis using a 3-crossed screw technique by a single surgeon were included. After a mean of 25 months (range 12-75 months) post surgery plantar pressure distribution was determined in five regions of the foot. The outcome was evaluated clinically, using the American Orthopaedic Foot and Ankle Society hindfoot score, as well as radiographically. The contralateral normal foot was used as a control. FINDINGS: Comparing the foot that underwent tibiotalar arthrodesis to the contralateral normal foot, differences were found in the peak pressure and maximum force in the toe region and the lateral midfoot region. In addition, a decrease in the contact time in the forefoot region and a decrease of the contact area in the toe region of the operated foot were identified. The other regions did not show a significant difference. The mean American Orthopaedic Foot and Ankle Society score of the operated leg was 79 (range 46-92) at the last follow up, and the mean fixation angle of the arthrodesis on lateral weight bearing radiographs was 90° (range 86°-100°). INTERPRETATION: Our results indicate that arthrodesis of the ankle joint can provide high levels of function with minimal changes in the plantar pressure distribution.

Biomechanics of postoperative shoes: plantar pressure distribution, wearing characteristics and design criteria: a preliminary study.

BACKGROUND: Modern concepts in the postoperative treatment of first metatarsal osteotomies include special shoes that should decrease stress in the forefoot region. The purpose of this study was to determine plantar pressure distribution, wearing characteristics and stress-reducing effectiveness of five different types of commonly used postoperative shoes. Additionally, we wanted to modify the shoe that revealed the most favourable results in a way that improves forefoot relief as well as provides comfort to the patients. METHODS: Eight persons consented to participate in the study. Plantar pressure distribution in five different types of postoperative shoes (Rathgeber(®) normal, Rathgeber(®) modified, 4. Darco(®) flat, Darco(®) VFE, Wocker(®)) was assessed using Mediologic(®) insoles. Also, subjective criteria considering wearing comfort, stability and rolling characteristics were evaluated. Based on the postoperative shoe revealing the most favourable results, further prototypes were developed. Each new model was targeted to meet the given requirements, minimal forefoot pressure, in a different way. RESULTS: The Rathgeber(®) modified model revealed the most favourable results concerning plantar pressure distribution as well as subjective wearing characteristics. Therefore, it was chosen for further modifications. After adding an extra layer of high elastic and springy material for shock absorption at the hallux region, forefoot relief and wearing characteristics showed improved results. CONCLUSION: The results of the present study indicate that damping material in the hallux region of postoperative shoes minimises stress in this region and improves patient's comfort.

Abnormal findings in hallucal sesamoids on MR imaging-Associated with different pathologies of the forefoot? An observational study.

BACKGROUND: To evaluate the prevalence and localization of abnormalities in the hallucal sesamoids detectable by magnetic resonance (MR) imaging in patients with forefoot pain and to determine which pathologies of tarsus, metatarsus and phalanges are associated with these abnormalities. MATERIALS AND METHODS: The forefoot MRI examinations of 50 consecutive patients (32 females, 18 males; mean age 51 years, age range 20-86 years) were retrospectively analyzed by two musculoskeletal radiologists. A minimum of coronal and sagittal T1-weighted images and STIR images or T2-weighted images with fat saturation were performed on a 1.5-T scanner. Abnormal findings in the sesamoids were correlated with pathology in the I.MTP (metatarsal-phalangeal) joint, pathology in other parts of the forefoot and clinical information. RESULTS: Signal abnormalities of the sesamoids were found in 7 patients out of 50 (14%). Two patients presented a bone marrow edema (BME) in both sesamoids, in 1 patient only the lateral one was affected; all three associated with pathology and pain in the I.MTP joint. In four patients only the medial sesamoid was affected, not associated with pathology in the I.MTP joint but with pathology in other parts of the forefoot. CONCLUSION: The prevalence of signal abnormalities in hallucal sesamoids was 14%. BME of the lateral sesamoid or of both were predominantly associated with pathology in the I.MTP joint. In contrast, signal abnormalities of the medial sesamoid, without affection of the lateral one, were associated with pathology in other parts of the forefoot suggesting an overuse injury as a result of compensating posture.

Rehabilitation after hallux valgus surgery: importance of physical therapy to restore weight bearing of the first ray during the stance phase.

BACKGROUND: Operative treatment of people with hallux valgus can yield favorable clinical and radiographic results. However, plantar pressure analysis has demonstrated that physiologic gait patterns are not restored after hallux valgus surgery. OBJECTIVE: The purpose of this study was to illustrate the changes of plantar pressure distribution during the stance phase of gait in patients who underwent hallux valgus surgery and received a multimodal rehabilitation program. DESIGN: This was a prospective descriptive study. METHODS: Thirty patients who underwent Austin (n=20) and scarf (n=10) osteotomy for correction of mild to moderate hallux valgus deformity were included in this study. Four weeks postoperatively they received a multimodal rehabilitation program once per week for 4 to 6 weeks. Plantar pressure analysis was performed preoperatively and 4 weeks, 8 weeks, and 6 months postoperatively. In addition, range of motion of the first metatarsophalangeal joint was measured, and the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot questionnaire was administered preoperatively and at 6 months after surgery. RESULTS: The mean AOFAS score significantly increased from 60.7 points (SD=11.9) preoperatively to 94.5 points (SD=4.5) 6 months after surgery. First metatarsophalangeal joint range of motion increased at 6 months postoperatively, with a significant increase in isolated dorsiflexion. In the first metatarsal head region, maximum force increased from 117.8 N to 126.4 N and the force-time integral increased from 37.9 N.s to 55.6 N.s between the preoperative and 6-month assessments. In the great toe region, maximum force increased from 66.1 N to 87.2 N and the force-time integral increased from 18.7 N.s to 24.2 N.s between the preoperative and 6-month assessments. LIMITATIONS: A limitation of the study was the absence of a control group due to the descriptive nature of the study. CONCLUSIONS: The results suggest that postoperative physical therapy and gait training may lead to improved function and weight bearing of the first ray after hallux valgus surgery.

Transient bone marrow edema syndrome of the knee: clinical and magnetic resonance imaging results at 5 years after core decompression.

PURPOSE: We report on 24 cases of transient bone marrow edema syndrome in 18 patients who underwent core decompression of the knee. METHODS: Diagnosis was made with the use of radiographs, magnetic resonance imaging (MRI), and core biopsy testing. Arthroscopic surgery and core decompression were carried out in all patients, and MRI was performed again, 5 years after surgery was performed. RESULTS: Medial and lateral femoral condyles were affected in 15 and 7 knees, respectively. In all, 6 patients presented with bilateral involvement of the knees (migrating transient bone marrow edema syndrome). Two of these patients had affections of the medial and lateral compartments within the same knee at different times, consistent with intra-articular regional bone marrow edema syndrome. Core biopsy specimens showed areas of bone marrow edema and vital trabeculae covered by osteoblasts and osteoid seams. Resolution of symptoms and normalization of MRI findings occurred in all patients within 12 weeks after surgery. CONCLUSIONS: Migrating bone marrow edema was found in a high percentage (33%) of patients at 5-year follow-up; however, all patients were clinically asymptomatic, and signal alterations on MRI had resolved completely. The high incidence of migrating bone marrow edema, the lack of osteonecrotic regions in our specimens, and the fact that none of these cases progressed to spontaneous osteonecrosis seem to further support the contention that bone marrow edema syndrome of the knee is a distinct entity. LEVEL OF EVIDENCE: Level II, diagnostic study; development of diagnostic criteria on the basis of consecutive patients and with universally applied reference gold standard.

Comparison of biochemical markers of bone metabolism in serum and femur aspirates.

In 27 patients undergoing arthroscopy of the knee for treatment of meniscal diseases, biochemical markers of bone metabolism were measured in cancellous bone, and levels were compared with concentrations obtained from peripheral blood. Bone-specific alkaline phosphatase, osteocalcin, and collagen Type I metabolites (procollagen Type I N-terminal peptide and carboxy-terminal cross-linked telopeptide) were studied simultaneously in serum and in the distal femur using a radioimmunoassay. Although levels of bone-specific alkaline phosphatase and osteocalcin did not differ between serum and cancellous bone, concentrations of collagen Type I metabolites were elevated significantly in healthy cancellous bone. The close correlations between bone and serum concentrations confirmed accuracy of results obtained from cancellous bone. The mean bone-to-serum ratio for alkaline phosphatase and osteocalcin was 1.1 and 1.2, respectively. Collagen Type I metabolite ratios of 2.2 (for carboxy-terminal cross-linked telopeptide) and 2.3 (for procollagen Type I N-terminal peptide) indicate that these markers are formed locally and then released into the circulation. Bone seems to be a major contributor of collagen Type I metabolites to the serum pool.