The Effect of the Lateral First Metatarsal Head Shape on Hallux Valgus in Forced Turnout in Pre-Pointe Female Ballet Dancers: A Pilot Study.

BACKGROUND: A rounded lateral first metatarsal head shape is associated with higher rates of hallux abducto valgus recurrence following corrective surgery; however, the effect of the lateral first metatarsal head shape on the hallux abduction angle (HAA) has not yet been explored in a nonpathologic, pre-pointe ballet dancer population. The primary purpose of this study was to investigate the effect of the lateral first metatarsal head shape on the HAA when pre-pointe female dancers force their turnout. METHODS: Seventeen female, pre-pointe ballet students (mean age, 10.8 ± 0.95 years) participated in this study. Fluoroscopic images of each dancer's dominant foot were taken, and the lateral first metatarsal head shape was classified visually. Each dancer performed three consecutive stances of natural double-leg upright posture: both functional and forced turnout. HAAs were obtained by marking medial bony landmarks on paper and were compared to photographic measurements. RESULTS: No significant difference was found between the round and angular lateral first metatarsal head shape for the change in HAA from natural double-leg upright posture to forced turnout. Hallux abduction angle significantly increased by 4.6° (P < .001) in forced turnout compared to the natural double-leg upright posture for the photographic method, whereas the paper method demonstrated an increase of 2.6° (P = .007). No statistical differences were found between the paper and photographic methods in measuring the HAA for all stances. CONCLUSIONS: Our findings suggest no association between the HAA and lateral first metatarsal head shape; however, HAA does increase when a dancer assumes forced turnout. The paper method demonstrated similar reliability to the photographic method and shows the potential for future use as a clinical tool in assessing hallux abducto valgus.

The inter- and intra-rater reliability of the Maestro and Barroco metatarsal length measurement techniques.

BACKGROUND: The relationship between metatarsal length and various forefoot pathologies is a topic of contention in Orthopaedics. The results of such investigations have been shown to depend on the method of metatarsal length measurement used. The aim of this study was to assess the inter- and intra-rater reliability of the Maestro and Barroco metatarsal length measurement techniques. METHODS: A retrospective and quantitative study was performed on 15 randomly selected radiographs to determine the reliability of the two measurement techniques across all five metatarsals (M1 to M5). This was done at one week apart for three weeks by three raters. The intraclass correlation coefficient (ICC), and the 95% lower confidence limit (95% LCL) were calculated. RESULTS: The Maestro and Barroco techniques produced high to very high ICC vlaues for length measurements across all metatarsals. The 95% lower confidence limit for inter-rater measurements ranged between 0.92-0.98 for Maestro's and 0.86-0.99 for Barroco's technique. For intra-rater measurements the 95% LCL ranged between 0.83-0.99 for Maestro's and 0.75-0.99 for Barroco's technique. CONCLUSIONS: Our study found that both the Maestro and Barroco methods of measurements produced high to very high inter- and intra-rater reliability. Both methods may be suitable for the use of peri-operative planning and clinical research relating metatarsal length and forefoot pathology. Besides having a more simplistic method of application, the novel Barroco technique is comparable to the more established Maestro method in both repeatability and reproducibility.

Plantar Pressure Measurements and Geometric Analysis of Patients With and Without Morton's Neuroma.

BACKGROUND: The purpose of this research was to see if there were any differences in peak pressure, contact time, pressure-time integrals, and geometric variables such as forefoot width, foot length, coefficient of spreading, and arch index between subjects with Morton's neuroma (MN) and control subjects. METHODS: Dynamic peak plantar pressure, contact time, pressure-time integral, and geometric data were extracted using the EMED-X platform in 52 subjects with MN and 31 control subjects. Differences in peak pressure, contact time, pressure-time integral, and geometric data between participants with and those without MN were determined using independent-samples t tests. There were no significant differences in age, weight, height, and body mass index between patients with MN and control subjects. RESULTS: There were no significant differences in the peak pressures of all masked areas and pressure-time integrals under metatarsal 2 to 4 heads between patients with MN and control subjects. In addition, no significant differences were observed between patients with MN and control subjects in geometric measurements of forefoot length, width, coefficient of spreading, foot progression angle, and arch index. CONCLUSION: No relationship was found in this study between peak pressure, contact time, and pressure-time integral under the metatarsal heads, forefoot width, foot length, coefficient of spreading, and foot progression angle in a symptomatic MN group compared with a control group. The need to perform osteotomies to treat MN not associated with other lesser metatarsal phalangeal joint pathologies is questionable. LEVEL OF EVIDENCE: Level III, Case-Control Study.

Radiographic Analysis of Feet With and Without Morton's Neuroma.

BACKGROUND: The aim of this research was to investigate the association of various structural measurements of the forefoot with Morton's neuroma (MN). METHODS: Weightbearing anteroposterior and lateral foot radiographs of subjects attending the University of Western Australia (UWA) Podiatry Clinic and the first author's private practice were included in this study. A single assessor measured the following angles: lateral intermetatarsal angle (LIMA), intermetatarsal angle (IMA), hallux valgus angle (HVA), digital divergence between the second and third digits (DD23), digital divergence between the third and fourth digits (DD34) and relative metatarsal lengths of the first to fifth metatarsals (Met1-5), and the effect of MN size as measured by ultrasonograph on digital divergence. Intratester reliability of all radiographic measurements was assessed on all radiographic measurements. The study included 101 subjects, of whom 69 were diagnosed with MN and 32 were control subjects without MN. The mean (± standard deviation) age of MN subjects was 52 (±15) years and for control subjects, 48 (±12) years. RESULTS: When comparing all feet, there were no significant differences in the LIMA, HVA, IMA, digital divergence angles and the relative metatarsal distances between subjects with MN and control subjects. No relationship between MN size and digital divergence was found in either foot, or in either neuroma location. CONCLUSION: We were unable to demonstrate any relationship in this study between radiographic metatarsal length and angular measurements in a symptomatic MN group compared to a control group. In addition, we did not find any correlation between the size of MN as measured from ultrasonographic images and radiographic evidence of digital divergence. LEVEL OF EVIDENCE: Level III, case control study.

The relationship between foot posture index, ankle equinus, body mass index and intermetatarsal neuroma.

BACKGROUND: The main purpose of this study was to investigate the presence of an association between intermetatarsal neuroma and foot type, as measured by the Foot Posture Index. The study also examined whether there was a relationship between foot type and the interspace affected with intermetatarsal neuroma, and whether ankle equinus or body mass index had an effect. METHODS: In total, 100 participants were recruited from The University of Western Australia's Podiatry Clinic, 68 of whom were diagnosed with inter-metatarsal neuroma from 2009 to 2015. There were 32 control participants recruited from 2014 to 2015. The age of subjects was recorded, as were weight and height, which were used to calculate body mass index. The foot posture index and ankle dorsiflexion were measured using standard technique. Independent t-tests and Kruskal-Wallis tests were used to compare differences in foot posture index, body mass index and ankle dorsiflexion between the inter-metatarsal neuroma and control groups. Multivariable logistic regression was also used to model relationships for outcome. RESULTS: The 68 intermetatarsal neuroma subjects had a mean age of 52 years (range 20 to 74 years) and comprised of 56 females and 12 males. The 32 control subjects had a mean age of 49 years (range 24 to 67 years) with 26 females and six males. There were no significant differences between the control and the intermetatarsal neuroma groups with respect to the mean foot posture index scores of the left and right foot (p = 0.21 and 0.87, respectively). Additionally no significant differences were detected between the affected intermetatarsal neuroma interspace and foot posture index (p = 0.27 and 0.47, respectively). There was no significant difference in mean body mass index between the intermetatarsal neuroma (26.9 ± 5.7) and control groups (26.5 ± 4.1) (p = 0.72). There was, however, a significant difference in mean ankle dorsiflexion between the intermetatarsal neuroma and control groups (p < 0.001 for both feet). Logistic regression models, adjusted for age, sex, foot posture index and body mass index estimated that the odds of having an intermetatarsal neuroma in the right foot increased by 61% (OR 1.61; 95% CI 1.32-1.96) with each one degree reduction of ankle dorsiflexion, and in the left foot by 43% (OR 1.43; 95% CI 1.22-1.69). CONCLUSION: No relationships were found between foot posture index and body mass index with intermetatarsal neuroma, or between foot posture index and the interspaces affected. However, a strong association was demonstrated between the presence of intermetatarsal neuroma and a restriction of ankle dorsiflexion.

A New Measure of Tibial Sesamoid Position in Hallux Valgus in Relation to the Coronal Rotation of the First Metatarsal in CT Scans.

BACKGROUND: We aimed to find a new radiographic measurement for evaluating first metatarsal pronation and sesamoid position in hallux valgus (HV) deformity. METHODS: Data from a clinical study of 19 control patients (19 feet) with no HV deformity were compared with preoperative data of 138 patients (166 feet) with HV deformities. Using a weightbearing plain radiograph in anteroposterior (AP) view, the intermetatarsal angles (IMAs) and the hallux valgus angles (HVAs) of the control and study groups were measured. Using a semi-weightbearing coronal computed tomography (CT) axial view, the α angle was measured in the control and study groups. In addition, the tibial sesamoid grades in plain radiograph tangential view and the CT axial view were measured. The tibial sesamoid position in an AP view was checked preoperatively. Based on these measurements, 4 types of HV deformities were defined. RESULTS: The mean values of the α angle in the control and HV deformity groups (control group µ = 13.8 degrees, study group µ = 21.9 degrees) was significantly different. Among 166 HV feet, 145 feet (87.3%) had an α angle of more than 15.8 degrees, which is the upper value of the 95% confidence interval of the control group, indicating the existence of abnormal first metatarsal pronation in HV deformity. Four types of HV deformities were defined based on their α angles and tibial sesamoid grades in CT axial view (CT 4 position). Among 25.9% (43/166) of the study group, abnormal first metatarsal pronation with an absence of sesamoid deviation from its articular facet was observed. The prominent characteristic of this group was that they had high grades in the AP 7 position (≥5); however, in the CT 4 position, their grade was 0. This group was defined as the "pseudo-sesamoid subluxation" group. CONCLUSIONS: Patients with HV deformities had a more pronated first metatarsal than the control group, with a greater α angle. Pseudo-subluxation of the sesamoids existed in 25.9% of our study group. From our results, we suggest that the use of the CT axial view in assessments of HV deformity may benefit surgeons when they make operative choices to correct these deformities. With regard to the pseudo-sesamoid subluxation group, the use of the distal soft tissue procedure is not surgically recommended. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Description of total population hospital admissions for Morton's metatarsalgia in Australia.

BACKGROUND: Morton's metatarsalgia is a painful perineural fibroma of a plantar nerve, most commonly of the second or third intermetatarsal spaces of the forefoot. The aim of this study was to investigate hospital admissions with a diagnosis of Morton's metatarsalgia in the Australian population from 1998 to 2008. METHODS: Data regarding admissions with a diagnosis code of ICD-10 G57.6 were extracted from the Australian Institute of Health and Welfare databases of hospital morbidity from 1998 to 2008. The event of interest was an admission with ICD-10 G57.6 (Morton's metatarsalgia). The explanatory variables included sex and age group. Rates were calculated using the estimated resident population counts to determine denominators. RESULTS: Morton's metatarsalgia admissions were almost three-fold higher for women in the population compared to men. The rate of admissions for Morton's metatarsalgia was the highest for the total population in the 55- to 59-year-old age group. Among women admitted for Morton's metatarsalgia, the highest rate was in the 50- to 54-year-old age group; among men, the highest rate was in the slightly older 55- to 59-year-old age category. CONCLUSIONS: Population-level information on admissions for Morton's metatarsalgia show that admissions were three times higher among women compared to men. The highest admission rate was in the 50- to 55-year-old age group.

Needling versus liquid nitrogen cryotherapy for the treatment of pedal warts a randomized controlled pilot study.

BACKGROUND: We hypothesized that needling of a pedal wart creates local inflammation and a subsequent cell-mediated immune response (CMIR) against human papillomavirus. The primary objective of this study was to investigate whether needling to induce a CMIR against human papillomavirus is an effective treatment for pedal warts compared with liquid nitrogen cryotherapy. A secondary objective was to investigate whether the CMIR induced by needling is effective against satellite pedal warts. METHODS: Eligible patients with pedal warts were randomly allocated to receive either needling or liquid nitrogen cryotherapy. Only the primary pedal wart was treated during the study. Follow-up was 12 weeks, with outcome assessments made independently under blinded circumstances. RESULTS: Of 37 patients enrolled in the study, 18 were allocated to receive needling and 19 to receive liquid nitrogen cryotherapy. Regression of the primary pedal wart occurred in 64.7% of the needling group (11 of 17) and in 6.2% of the liquid nitrogen cryotherapy group (1 of 16) (P =  .001). No significant relationship was found between needling of the primary pedal wart and regression of satellite pedal warts (P = .615) or complete pedal wart regression (P = .175). There was no significant difference in pain, satisfaction, or cosmesis between the two groups. CONCLUSIONS: The regression rate of the primary pedal wart was significantly higher in the needling group compared with the liquid nitrogen cryotherapy group.

Needling versus liquid nitrogen cryotherapy for the treatment of pedal warts: A randomised controlled trial pilot study.

Abstract Background: The hypothesis of this study was that needling of a pedal wart would create local inflammation and a subsequent cell-mediated immune response against human papillomavirus. The primary objective of this study was to investigate if needling to induce a cell-mediated immune response against human papillomavirus is an effective treatment of pedal warts in comparison to liquid nitrogen cryotherapy. A secondary objective of this study was to investigate if the cell-mediated immune response induced by needling is effective against satellite pedal warts. Methods: Eligible participants presenting to the University of Western Australia Podiatry Clinic with pedal wart/s were randomly allocated to treatment - either needling or liquid nitrogen cryotherapy. Only the primary pedal wart was treated during the study. Participant follow-up was twelve weeks with outcome assessments made independently under blinded circumstances. Results: Thirty-seven participants were enrolled in the study, 18 allocated to needling and 19 to liquid nitrogen cryotherapy. Regression of the primary pedal wart occurred in 64.7% (11/17) of the needling group and 6.2% (1/16) of the liquid nitrogen cryotherapy group (p=0.001). There was no significant relationship found between needling of the primary pedal wart and regression of satellite pedal warts (p=0.615) or complete pedal wart regression (p=0.175). There was no significant difference in pain, satisfaction or cosmesis between the two groups. Conclusions: The regression rate of the primary pedal wart was significantly higher in the needling group compared to the liquid nitrogen cryotherapy group.