Midfoot width changes after first metatarsal osteotomy in hallux valgus surgery: A biomechanical effect?

Hallux valgus is a challenging pathology characterized by a valgus deformity in the metatarsophalangeal area of the first ray. The aim of this study was to analyze the influence of first metatarsal osteotomy on the relationship between midfoot bones in patients with hallux valgus. The sample consisted of patients from the orthopedics and traumatology outpatient clinic who underwent surgical treatment for hallux valgus. Preoperative and postoperative X-rays were compared regarding the width of the midfoot and the tarsometatarsal joint. The sample consisted of 17 women, with 22 feet assessed in each group. The distance from the medial cuneiform to the cuboid, the distance from the intermediate cuneiform to the cuboid, the distance between the first and fifth metatarsals, and the distance between the second and fifth metatarsals reduced significantly between pre- and postoperative assessments. Hallux valgus correction through osteotomy of the first metatarsal leads to a structural change in the midfoot. Further studies should determine whether these changes persist over time.

Low Donor Site Morbidity Associated With Tricortical Calcaneal Bone Graft.

BACKGROUND: Autologous grafting is widely used in orthopaedic surgery because of its high osteogenic capacity, immunologic compatibility, for the absence of risk of disease transmission, and for not requiring a bone bank. The posterior-superior calcaneal tuberosity is an option for obtaining a cortical and cancellous structural bone. This study aims to describe the operative technique and complications observed at the donor site of the posterior-superior calcaneal tuberosity. METHODS: Patients who underwent graft harvesting from the posterior-superior calcaneal tuberosity were retrospectively evaluated by pain outcomes, imaging tests, and intra- and postoperative complications. RESULTS: Twenty patients with a median age of 69 years (range 48-77) and follow-up of 16 months (12-26) were assessed. Median postoperative pain at the donor site was 0 (0-6), with 2 patients reporting persistent local pain. No case of Achilles tendon rupture or intra- or postoperative calcaneal fracture were identified. One patient developed a superficial infection that was quickly resolved using oral antibiotic therapy. CONCLUSION: The posterior-superior calcaneal tuberosity is an alternative source of autologous graft with low donor site morbidity. LEVEL OF EVIDENCE: Level IV, case series.

Current Trends in Fixation Techniques.

Hallux valgus is an extremely common and often disabling deformity. In addition to valgus deformity of the hallux, varying degrees of varus and supination of the first metatarsal and instability in the metatarsophalangeal and metatarsocuneiform joints are frequently present. Because of the complexity and multiplicity of deformities, surgical techniques and fixation methods continue to be developed to obtain better results. Recent studies have focused on correcting pronation of the first metatarsal as a way of correcting and equalizing the metatarsal sesamoid bones in a more horizontal and stable position, possibly minimizing the chance of recurrence of the deformity.

Does Hallux Valgus Exhibit a Deformity Inherent to the First Metatarsal Bone?

Hallux valgus is a common condition, and it still poses some challenges. The identification of factors associated with the development of the deformity is of paramount importance in obtaining a full correction of the disorder. Hallux pronation is one of the frequently found components, especially in larger deformities, but the cause and exact location of this condition are not fully understood. The aim of the present study was to investigate whether there is a rotational deformity inherent to the first metatarsal bone. A case-control study was conducted on patients with and without hallux valgus who were subjected to computed tomography with multiplanar reconstruction. Statistical analysis was performed by means of a mixed model adjusted for foot and gender to compare metatarsal rotation between cases and controls. Correlations between numerical quantitative measurements were investigated by means of Pearson's correlation coefficient obtained in a linear mixed model. A total of 82 feet (tests) were analyzed in the hallux valgus group and 64 feet (tests) in the control group (N = 146). The hallux valgus group was significantly different from the control group (p< .001). Mean metatarsal bone rotation was 15.36° (range 1.65° to 32.52°) in the hallux valgus group and 3.45° (range -7.40° to 15.56°) in the control group. The difference between the means was 11.9° (confidence interval 9.2° to 14.6°). In conclusion, patients with hallux valgus exhibited increased exclusive bone rotation of the first metatarsal toward pronation compared with the population without this condition.

Dynamic correction for forefoot varus in stage II-A adult flatfoot: Technique tip.

Posterior tibial tendon dysfunction (PTTD) is a progressive disorder and a common cause of adult acquired flatfoot deformity, and forefoot varus is a frequent component in advanced cases. The author proposes peroneus brevis-to-longus transfer as an additional step to correct the forefoot varus component of stage II-A posterior tibial tendon dysfunction. We have performed this dynamic correction of forefoot varus in 12 patients at our institution, and observed promising clinical and radiographic improvement. It is a soft tissue procedure that avoids additional incisions and represents a favorable alternative to more demanding techniques, such as osteotomy or arthrodesis.

Comparison between Simple Radiographic and Computed Tomographic Three-Dimensional Reconstruction for Evaluation of the Distal Metatarsal Articular Angle.

The hallux valgus is a pathologic condition in the forefoot that often causes pain and functional limitations. Assessing all deformity components, such as the distal metatarsal articular angle (DMAA) is essential to hallux valgus treatment. Nevertheless, interobserver agreement of DMAA is poor on plain radiographs. The present study compared computed tomographic (CT) 3-dimensional (3D) reconstruction with plain radiographic measurements for measuring the DMAA. We included 43 consecutive patients (77 feet), diagnosed with hallux valgus at the orthopedic outpatient clinic at Hospital de Clínicas de Porto Alegre (Porto Alegre, Brazil) from April 2014 to June 2015 in our prospective study. The DMAAs were measured by 2 observers using CT 3D reconstruction. The results were compared between observers and with the plain radiographic measurements using the concordance correlation coefficient and the Bland-Altman plot to determine the agreement between the 2 methods. The interobserver agreement of the CT 3D measurements was high (concordance correlation coefficient 0.90; p < .001). Significant agreement was found between the plain radiographic and CT measurements (concordance correlation coefficient 0.667; p < .001). The Bland-Altman plot showed that the difference between the plain radiographic and CT measurements increased when greater DMAA values were associated with the presence of metatarsal rotation. The interobserver agreement of DMAA measurements was greater on CT 3D reconstruction than on plain radiography. The poor interobserver agreement of the radiographic DMAA might have resulted from metatarsal rotation.

Association between leg length discrepancy and posterior tibial tendon dysfunction.

BACKGROUND: Leg length discrepancy (LLD) is associated with a variety of orthopaedic disorders and biomechanical gait changes that involve possible overload of the posterior tibial tendon (PTT). In view of the biomechanical disturbances induced by LLD, an association may exist between LLD and PTT dysfunction (PTTD). PURPOSE: To compare the frequency and magnitude of LLD between subjects with and without PTTD and ascertain whether associations exist between clinical features and presence of dysfunction. STUDY DESIGN: Case-control study. METHODS: A total of 118 patients with a diagnosis of PTTD were seen between January 2009 and September 2012 and compared with 118 gender-matched and race-matched volunteers. The frequency of LLD, the mean absolute LLD, and the mean relative LLD were measured by conventional (radiographic) or computed tomography scanography and compared between cases and controls. RESULTS: The prevalence of LLD and mean absolute and relative LLD values were significantly greater in the case group (94.9%, 5.64 mm and 7.36%, respectively) than in the control group (79.7%, 3.28 mm and 4.18%, respectively) (P < .001). CONCLUSION: The findings of this study demonstrate a relationship between LLD and PTTD. In light of the major biomechanical changes it induces, LLD may be a predisposing factor for development of PTTD.

Tratamento da neuropatia de Morton pela liberação do ligamento intermetatarsal / Treatment of Morton?s neuroma by intermetatarsal ligament

Entre agosto de 2005 e junho de 2006 17 pés, de 13 pacientes, foram submetidos ao tratamento do neuroma de Morton pela liberação do ligamento intermetatarsiano. Entrevista, exame clínico e exames de imagem (radiografia e ultrassonografia) foram realizados pré-operatoriamente e entrevista e exame clínico foram realizados na revisão, com uma média de 19 meses de seguimento. Resultados: Doze dos 13 pacientes operados estavam satisfeitos com a cirurgia, um deles com ressalvas pela persistência de sintomas residuais leves. Um paciente se apresentava insatisfeito no seguimento por não apresentar melhora com a cirurgia. Uma avaliação clínica específica foi utilizada: antes da cirurgia o escore médio foi de 14,1 pontos. O escore pós-operatório médio foi de 65,9 pontos, com uma melhora média de 51,8 pontos. Conclusão: Embora a causa da metatarsalgia de Morton permaneça obscura, os resultados preliminares deste trabalho reforçam a teoria de que a entidade seja uma neuropatia compressiva. O diagnóstico e a localização pré-operatória do neuroma de Morton podem ser realizados pelo exame ultrassonográfico e um resultado clínico favorável pode ser esperado sem remoção do segmento de nervo acometido em casos selecionados.

Correction of moderate to severe hallux valgus deformity by a modified chevron shaft osteotomy.

BACKGROUND: Hallux valgus is one of the most common foot deformities in women. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use, especially for severe deformities. Proximal osteotomies have long been done for severe deformities; however, diaphyseal osteotomies have gained popularity because of the greater degree of correction and stability obtained. METHODS: This study retrospectively assessed the radiographic and clinical outcomes in 50 feet (34 patients) that had a modified chevron shaft osteotomy for moderate to severe hallux valgus. Additionally, an Akin medial closing wedge osteotomy of the proximal phalanx was done in most patients. Mean followup was 30 months (minimum 13 months). All patients in the study had either moderate or severe deformities. Patients with mild deformities had correction by other techniques. RESULTS: There was a mean AOFAS score improvement of 39.6 (44.5 to 84.1) points. The hallux valgus angle and intermetatarsal angle improved a mean of 22.7 degrees and 10.4 degrees, respectively. Hallux valgus persisted in one foot; however, the patient was not dissatisfied. Two feet developed hallux varus. Revision was necessary in two patients; one needed revision because of loss of fixation and the other because of symptomatic hallux varus. CONCLUSION: Based on radiographic correction and clinical outcomes, this procedure is indicated for the treatment of moderate to severe hallux valgus deformities.

Modificação da osteotomia em "chevron" para correção do hálux valgo moderado a grave / A modification of the chevron osteotomy for moderate to severe hallux valgus

Analisar a capacidade de correção da osteotomia tipo chevron modificada para deformidades em hálux valgo de intensidades moderada a grave. Material: Foram apresentadas correções radiográficas do hálux valgo em 50 pés (34 pacientes), submetidos à osteotomia tipo chevron modificada. O seguimento mínimo foi de 13 meses e o médio, de 30 meses. Todos os pacientes apresentaram deformidade moderada ou grave. Pacientes com deformidade leve foram submetidos à correção por outra técnica, sendo, portanto, excluídos deste estudo. Resultados: Foram analisados radiologicamente o ângulo de hálux valgo (AHV) e o ângulo intermetatarsal (AIM), que melhoraram, em média, 22,2'graus' e 10,7'graus', respectivamente. Persistência de hálux valgo foi observada em um pé; em dois pés foi observado hálux varo na radiografia pós-operatória. Dois pacientes necessitaram reintervenção: um por hálux varo e outro por perda da fixação da osteotomia. Conclusão: A técnica em chevron é eficaz para correção de hálux valgo de intensidades moderada a grave

Tenossinovite estenosante do flexor longo do hálux na região dos sesamóides: relato de caso / Stenosing tenosynovitis of the flexor hallucis longus at the sesamoid area: a case report

The author presents a case of stenosing tenosynovitis of the flexor hallucis longus tendon at the sesamoid area of the great toe due to trauma of the hallux. Although stenosing tenosynovitis of the flexor hallucis longus tendon is not so rare, mainly in ballet dancers, the entrapment at the sesamoid area has rarely been described in the literature. Early recognition is very important for prompt and correct treatment. The case reported did not respond to conservative treatment and surgical tenolysis was very successful to relieve the symptoms.

O uso de parafusos de osteossíntese nas artrodeses do tarso / Use of osteosynthesis screws in tarsal arthrodesis

Os autores apresentam os resultados obtidos com triplice artrodese do tarso em 18 pés, seguidos por período médio de 34,6 meses. Em todos os casos utilizaram-se parafusos de esponjosa de 6,5mm para estabilizar a artrodese. Foi obtida consolidaçäo em todos os casos e o índice de resultados satisfatórios foi de 88,8 por cento. Sendo a tríplice artrodese cirurgia ainda largamente utilizada, recomenda-se o uso de parafusos de osteossíntese para fixaçäo interna por torná-la mais estável, assegurando que o alinhamento obtido na mesa operatória seja mantido, possibilitando mobilizaçäo mais precoce e tornando seus resultados mais previsíveis.

Avaliaçäo a longo prazo da instabilidade femoropatelar tratada pela técnica de Elmslie-Trillat / Long term evaluation of femoropatellar instablity treated with the Elmslie-Trillat technique

O procedimento de Elmslie-Trillat foi executado em 20 joelhos de 18 pacientes para realinhamento patelar com acompanhamento mínimo de dez anos. Resultados excelentes foram obtidos em 20 por cento; bons em 65 por cento e satisfatórios em 15 por cento dos casos. Nenhum dos pacientes piorou da sintomatologia inicial após a cirurgia ou devido a ela. Observamos nao ter havido, pelo menos com este seguimento, deterioraçao evidente dos resultados com o passar dos anos. Concluímos, entao, que esta técnica é boa escolha nos casos refratários ao tratamento conservador, pois foram obtidos resultados excelentes e bons em 85 por cento dos casos.