Comparison of the three-dimensional bone morphology of the first proximal phalanx and first metatarsal between normal and hallux valgus foot using the homologous model technique.

Bone morphology is one of the factors involved in hallux valgus development. However, previous studies have not evaluated the overall bone shape in three dimensions. This study aimed to compare the overall shape of the first proximal phalanx and first metatarsal in hallux valgus with those of normal feet.Homologous models were created from computed tomography data of the first proximal phalanx and first metatarsal of 75 healthy men and 53 women in the control group and 10 men and 71 women in the hallux valgus group. Principal component analysis was performed to examine the differences in bone morphology between the control and hallux valgus groups. In men and women with hallux valgus, the proximal articular surface of the first proximal phalanx was characterized by a more lateral inclination and torsion of the pronated first metatarsal. Additionally, the first metatarsal head was characterized by a more lateral inclination in male hallux valgus. This study is the first to reveal the morphological characteristics of the first metatarsal and first proximal phalanx in hallux valgus as a whole bone using a homologous model technique. These characteristics are considered possible causes of hallux valgus development. The shapes of the first proximal phalanx and first metatarsal in hallux valgus were different from those in normal feet. This finding should be useful when considering the pathogenesis and treatment development for hallux valgus.

The effect of Scarf osteotomy on the distal metatarsal articular angle in hallux valgus: a case series.

BACKGROUND: Hallux valgus is a deformity of the forefoot involving a phalangeal valgus and a metatarsal adductus. In most cases its correction requires surgical treatment with different types of osteotomies. The best known is Scarf osteotomy. AIM: To study the effet of Scarf osteotomy on distal metatarsal articular angle (DMAA) as well as the validitiy of this angle and the value of its correction after review of the literature. METHODS: It was a retrospective study including patients operated on for severe hallux valgus by a Scarf osteotomy. The clinical assessment was based on the the American-Orthopedic-Foot-and-Ankle-society (AOFAS) score. Radiologically, we calculated the metatarsophalangeal angle, the inter-metatarsal angle and the DMAA. This assessment was performed preoperatively and one year postoperatively. RESULTS: We collected 37 cases of evolved hallux valgus. The average AOFAS score went from 60.7 to 85.8 / 100 postoperatively with a gain of 25 points. We've noted a significant correction of the 3 angular measurements at one year postoperatively (the metatarsophalangeal angle, the inter-metatarsal angle and the DMAA) which went from 38.8° to 20.5°, from 17° at 10° and 13.5° to 8.5° respectively (p<0.05). CONCLUSION: The literature has shown that there is no consensus regarding the effect of HV surgery on the DMAA. As for the accuracy, reproducibility and interest of correcting this angle we deduce that the DMAA is an interesting measure in the pathology of HV. Its correction seems not to be necessary in order not to hamper the correction of metatarsus varus. But in cases where the preoperative DMAA is high (> 15 °), efforts should be made to correct it to avoid recurrence.

Biomechanical Cadaveric Evaluation of the Role of Medial Column Instability in Hallux Valgus Deformity.

BACKGROUND: Medial column instability is a frequent finding in patients with flatfeet and hallux valgus, within others. The etiology of hallux valgus is multifactorial, and medial ray axial rotation has been mentioned as having an individual role. Our objective was to design a novel cadaveric foot model where we could re-create through progressive medial column ligament damage some components of a hallux valgus deformity. METHODS: Ten fresh-frozen lower leg specimens were used, and fluorescent markers were attached in a multisegment foot model. Constant axial load and cyclic tibial rotation (to simulate foot pronation) were applied, including pull on the flexor hallucis longus tendon (FHL). We first damaged the intercuneiform (C1-C2) ligaments, second the naviculocuneiform (NC) ligaments, and third the first tarsometatarsal ligaments, leaving the plantar ligaments unharmed. Bony axial and coronal alignment was measured after each ligament damage. Statistical analysis was performed. RESULTS: A significant increase in pronation of multiple segments was observed after sectioning the NC ligaments. Damaging the tarsometatarsal ligament generated small supination and varus changes mainly in the medial ray. No significant change was observed in axial or frontal plane alignment after damaging the C1-C2 ligaments. The FHL pull exerted a small valgus change in segments of the first ray. DISCUSSION: In this biomechanical cadaveric model, the naviculocuneiform joint was the most important one responsible for pronation of the medial column. Bone pronation occurs along the whole medial column, not isolated to a certain joint. Flexor hallucis longus pull appears to play some role in frontal plane alignment, but not in bone rotation. This model will be of great help to further study medial column instability as one of the factors influencing medial column pronation and its relevance in pathologies like hallux valgus. CLINICAL RELEVANCE: This cadaveric model suggests a possible influence of medial column instability in first metatarsal pronation. With a thorough understanding of a condition's origin, better treatment strategies can be developed.

Influence of the length of the first and second metatarsal bone measured distal from Maestro line upon severity of hallux valgus deformity.

To examine the influence of the configuration of the first and second metatarsal (MT) bones on the development of hallux valgus deformity. To determine the extent to which the difference in the lengths of the first and second MT bones, measured distal to the Maestro line, contribute to the severity of the hallux valgus (HV) deformity defined by the size of the hallux valgus angle (HVA) and inter-metatarsal angle (IMA). On a sample of 319 feet with HV deformity the difference of measured lengths R = d (I MT) - d (II MT) was calculated The influence of differences (R) on the values of IMA and HVA as well as on the severity of deformities according to the formed groups was investigated. The influence of age on the development of deformities was examined separately as well as in conjunction with the determined difference in lengths. In 203 feet or 63.7%, a shorter MT bone was measured, while in 80 feet or 25.1% the first MT bone was longer than second ones and only in 36 feet or 11.3% there is no difference in the length of the 1st and 2ndMT bones distal to the Maestro line. A statistically significant correlation was found between the difference between the measured lengths of 1st and 2nd MT bones and IMA, while this correlation with HVA was not statistically significant. There is no statistically significant correlation or the effect of the difference in measured lengths (R) on the severity of hallux valgus deformity classified into three groups. A statistically significant correlation and impact of the age on the intensity of the deformity are established. A shorter 1st MT bone in correlation to the 2nd MT bone is accompanied by an increase in IMA and this correlation and impact are statistically significant. It was not established that there was a statistically significant influence of the length of the first and second metatarsal bone measured distal from Maestro line upon the values of HVA and severity of HV deformity. Age significantly contributes to the severity of the deformity.

Effect of lentivirus-mediated miR-182 targeting FGF9 on hallux valgus.

The pathogenesis of hallux valgus is not clearly understood. However, genetics research about hallux valgus is rare. Therefore, the present study aimed to explore the pathogeny of hallux valgus from the perspective of genetics. Human samples were collected from normal bone tissue and hallux valgus region bone tissue. The bone samples were studied using real time-PCR, western blot and immunohistochemical. Lentivirus-mediated miR-182 transfected osteoblasts and tested the expression of FGF9 mRNA with real time-PCR. To test alkaline phosphatase activity, number of calcium nodules and proliferation of osteoblast with enzymatic activity analysis, calcium nodules stained and MTT assay. We found that (1) FGF9 expressed in hallux valgus region bone tissue was significantly higher than normal bone tissue. (2) miR-182 expression levels in hallux valgus region bone tissue were notably lower than those of normal bone tissue. (3) miR-182 could negatively regulate the expression of FGF9 in osteoblasts. (4) FGF9 may enhance osteoblasts proliferation. We have demonstrated that miR-182 promotes the formation of bone by targeting FGF9, implicating an essential role of miR-182 in the etiology of hallux valgus. Moreover, miR-182 might potentially be a therapeutic target for hallux valgus treatment.

The functional capacity and morphological characteristics of the intrinsic foot muscles in subjects with Hallux Valgus deformity: A systematic review.

BACKGROUND: The intrinsic foot muscles are vital for maintaining normal foot function. This study was conducted to systematically review the literature on the functional capacity and morphological characteristics of the intrinsic foot muscles in subjects with Hallux Valgus (HV) deformity. METHODS: A search was carried out in all available electronic databases, including Pub Med, Scopus, Embase and Web of Science, for identifying any relevant studies published from 1990 to October 2018. RESULTS: Three studies had investigated intrinsic foot muscle size using ultrasound imaging; two had reported electromyography parameters and four had measured the muscle force capacity. The results of the present review suggested that the functional capacity and morphological characteristics of intrinsic foot muscles are different in subjects with HV compared to those without this deformity. CONCLUSION: This review found scientific evidence on muscle performance impairment in the abductor hallucis and flexor hallucis brevis in subjects with HV deformity.

Foot structural factors and ground reaction force in hallux valgus grades.

BACKGROUND: Little attention has been paid to foot structural factors and ground reaction force in hallux valgus. Investigating the structural factors in detail and determining their biomechanical effects can help to better manage hallux valgus. METHODS: In this case-control study, 120 females, 90 hallux valgus and 30 healthy, were recruited. Hallux valgus grades (mild, moderate, severe), first metatarsal mobility, foot pronation, hallux rotation, and pain were assessed by clinical tests. Ground reaction forces were measured in barefoot and shod conditions for both feet and analyzed using mixed within-between MANOVA. The association between structural factors and pain with force was analyzed using Spearman correlation coefficient. RESULTS: The frequency of foot structural factors and pain severity were reported in hallux valgus grades. A significant difference was seen in the force values between groups (P<0.001). Bonferroni post hoc test indicated that the mean of the first peak for the severe group was significantly higher than the mild group (P=0.013) and the mean of second peak for the moderate group was higher than that of the healthy group (P=0.009). The force values were affected by wearing shoe (P<0.001) but not by foot side (P=0.086). There was a medium, positive correlation between the hallux rotation and force in the moderate group (r=0.39, P=0.03) and also between the pronation and force in the severe group (r=0.36, P=0.04). CONCLUSION: Foot structural factors, pain, and force were different in each hallux valgus grads. Similar force in both feet, and increased force by wearing shoe were seen. The relationship between the pronation and hallux rotation with force revealed the importance of these factors from the biomechanical viewpoint.

Mechanical stress promotes angiogenesis through fibroblast exosomes.

BACKGROUND: Mechanical stress can induce multiple functional changes in vascular endothelial cells, including proliferation, differentiation, and migration. Furthermore, human fibroblasts are susceptible to external mechanical stress. In this work, we investigated whether mechanical stress can induce exosome secretion from fibroblasts to modulate angiogenesis. METHODS: A CCK-8 cell proliferation assay was used to determine mechanical parameters. Then, exosomes from fibroblasts were isolated and characterized with regard to concentration and markers. We subsequently explored the effect of exosomes on proliferation, migration, and angiogenesis. Additionally, high-throughput sequencing was used to screen differentially expressed miRNAs in the mechanical stress-induced exosomes. RESULTS: A static stretching of 15% significantly enhanced the cell viability of the fibroblasts (p < 0.05) and significantly induced the secretion of exosomes from the fibroblasts, which had a stronger internalization ability. Further experiments demonstrated that the presence of static stretching-induced exosomes significantly increased cell proliferation, migration, and angiogenesis by regulating the Erk1/2 signaling pathway. Additionally, 12 up-regulated and 12 down-regulated candidate miRNAs were discriminated in the static stretching-induced exosomes. CONCLUSION: Our findings conclusively demonstrate that static stretching-derived exosomes from fibroblasts promote angiogenesis through differentially expressed miRNAs, providing novel insights into the molecular mechanism by which mechanical stress influences angiogenesis.

Percutaneous Lateral Release in Hallux Valgus: Anatomic Basis and Indications.

In the last decade, minimally invasive or percutaneous surgery has evolved rapidly through the development of novel techniques. Treatment of hallux valgus deformity is one of the indications for percutaneous surgery, both for bony and soft tissue correction. The release of the structures on the lateral part of the first metatarsophalangeal joint (lateral release) is one of the best indications for percutaneous surgery in the forefoot. In this article, a detailed description of the anatomy of the metatarsophalangeal joint is provided, along with the indications and tips to perform a safe percutaneous lateral release.

Variable pulmonary manifestations in Chitayat syndrome: Six additional affected individuals.

Hand hyperphalangism leading to shortened index fingers with ulnar deviation, hallux valgus, mild facial dysmorphism and respiratory compromise requiring assisted ventilation are the key features of Chitayat syndrome. This condition results from the recurrent heterozygous missense variant NM_006494.2:c.266A>G; p.(Tyr89Cys) in ERF on chromosome 19q13.2, encoding the ETS2 repressor factor (ERF) protein. The pathomechanism of Chitayat syndrome is unknown. To date, seven individuals with Chitayat syndrome and the recurrent pathogenic ERF variant have been reported in the literature. Here, we describe six additional individuals, among them only one presenting with a history of assisted ventilation, and the remaining presenting with variable pulmonary phenotypes, including one individual without any obvious pulmonary manifestations. Our findings widen the phenotype spectrum caused by the recurrent pathogenic variant in ERF, underline Chitayat syndrome as a cause of isolated skeletal malformations and therefore contribute to the improvement of diagnostic strategies in individuals with hand hyperphalangism.

Histopathological Evaluation of Mechanoreceptors in the Metatarsophalangeal Joint Capsule in Hallux Valgus.

To date, we could find no study concerning the relationship between mechanoreceptors in the joint capsule of the first metatarsophalangeal joint and hallux valgus deformity. We aimed to investigate the presence of mechanoreceptors in samples obtained from the first metatarsophalangeal joint capsules of patients with hallux valgus deformity to improve our understanding of the clinical and histopathological features of the disease. Samples were taken from the first metatarsophalangeal joint capsules of 13 fresh-frozen cadavers with normal anatomy (controls) and 29 patients undergoing surgery for hallux valgus (cases). For light microscopy, excised specimens were fixed in 10% formaldehyde and processed for routine histopathological investigation. All samples were dehydrated in a series of ethanol, cleared in xylene, and embedded in paraffin. Orientation of collagen fibers was determined on Masson's trichrome-stained sections, and mechanoreceptors were evaluated on S-100-immunostained sections. In the sections stained with Masson's trichrome, the orientation of collagen fibers was regular in the control group. However, coarse and disoriented collagen bundles were observed in the hallux valgus cases (P ≤ .05). S-100 immunostaining was positive in the sections of both the cases and controls. Finally, free nerve endings were more abundant in the samples obtained from the capsules of hallux valgus cases than from the control group (P ≤ .05). An increase in the number of free nerve endings within the capsules of the first metatarsophalangeal joints in feet with hallux valgus deformity might have a role in the development of clinically relevant joint pain and instability.

Sex- and age-related morphological variations in the talar articular surfaces of the calcaneus.

BACKGROUND: The prevalence of foot pathologies, such as flatfoot deformity and hallux valgus, is higher in women and increases with age. It has been reported that these types of foot disorders may also be linked to excessive mobility of the subtalar joint to the eversion direction during weight bearing. Given that the mobility of the joint is determined by its articular morphology, sex- and age-related variations in the subtalar articular surface morphology are possible. The purpose of this study was to investigate the orientation and the curvature radii of the talar articular facets of the calcaneus in relation to age and sex using three-dimensional computer tomography. METHODS: Fifty-six feet without subtalar injuries or disorders were included in this study. The orientations of the talar articular surfaces of the calcaneus were quantified in the sagittal and coronal planes. The curvature radii of the articular surfaces of the calcaneus were also assessed based on the approximations of the sphere surfaces. RESULTS: The talar articular surface was oriented more anteriorly and medially in the females than in the males. The curvature radius of the calcaneal posterior facet in the females exhibited a positive correlation with age, indicative of increased articular surface flattening. CONCLUSIONS: The morphological features of the female calcaneus could induce excessive eversion and could lead to a higher prevalence of foot disorders, including flatfoot and hallux valgus, in elderly females. This study contributes to an understanding of the sexual dimorphism of the articular surfaces of the calcaneus and provides insight into the mechanisms that underline various foot disorders.

Relationship Between Hallux Valgus and Pes Planus: Real or Fiction?

Hallux valgus is one of the most common and painful deformities, occurring due to adductor/abductor imbalance of the big toe. Many structural foot disorders have been suggested as the cause of hallux valgus deformity. In this study, we aimed to show the relationship between hallux valgus and pes planus in adult males. A total of 213 patients were included in this study between May 2013 and May 2014. 54 patients with hallux valgus angle (HVA) >20° and intermetatarsal angle (IMA) >9° were evaluated in the case group and 159 patients randomly selected from those admitted for a recent foot ankle trauma with the HVA <15° and IMA <9° were the control group. All patients' HVA, IMA, and talonavicular coverage angle on anteroposterior (AP) foot radiographs and talar-first metatarsal angle (Meary's angle), calcaneal pitch angle, and lateral talocalcaneal angle on lateral foot radiographs were measured. There was no significant difference in talonavicular and Meary's angles between the groups. Calcaneal pitch angle was significantly lower in the case group, whereas talonavicular angle was higher in the control group. Calcaneal pitch angle and lateral talocalcaneal angle showed significant negative correlation with HVA and IMA. There are few reports in the literature about the relationship between pes planus and hallux valgus. Our results strongly showed a high correlation between pes planus and hallux valgus. Further larger patient cohort studies are needed to support our results.

Intra- and Interobserver Agreement in Hallux Valgus Angle Measurements on Weightbearing and Non-Weightbearing Radiographs.

The choice of treatment of hallux valgus deformity is influenced by angles measured on radiographs. Angles of interest are the hallux valgus angle (HVA), 1,2-intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA), as well as the presence of first metatarsophalangeal joint (MTPJ) subluxation. Guidelines for measuring those angles have been distributed by American Orthopaedic Foot and Ankle Society (AOFAS), although the influence of weightbearing on these angles and its clinical relevance is not clear. We conducted a study to determine the influence of weightbearing and the inter- and intraobserver agreement in the measurement. A total of 104 patients were enrolled in this study. Both weightbearing and non-weightbearing radiographs were obtained. In 2 rounds, 2 orthopedic surgeons and 2 musculoskeletal radiologists measured the angles in blinded digital radiographs according to AOFAS guidelines. Agreement on measurement of HVA, IMA, and DMAA in both weightbearing and non-weightbearing radiographs, as well as the presence of MTPJ subluxation, was calculated using the linear-weighted kappa coefficient and the intraclass correlation coefficient (ICC). Examiner agreement strength was defined according to the guidelines of Landis and Koch. HVA decreases significantly with weightbearing, whereas IMA significantly increases. The change in magnitude was 1° to 2° on average. No significant influence on DMAA could be noted. Interobserver agreement was excellent in both weightbearing and non-weightbearing radiographs for HVA (ICC 0.99 and ICC 0.99, respectively), IMA (ICC 0.98 and ICC 0.86, respectively), and DMAA (ICC 0.95 and ICC 0.97, respectively). The agreement on presence of subluxation was moderate to good (Fleiss kappa 0.50 to 0.63). Weightbearing alters forefoot geometry significantly. Adhering to AOFAS guidelines yields excellent interobserver agreement on HVA, IMA, and DMAA. First MTPJ subluxation presence is not an alternative for DMAA. The magnitude of change in IMA and HVA is small and therefore not clinically important. Both weightbearing and non-weightbearing radiographs can be used for determination of the correct treatment of hallux valgus deformity.

Hallux valgus assessment on X-ray and Magnetic resonance Imaging (MRI): Correlation with qualitative soft tissue and internal derangement findings on MRI.

AIM: Radiographs (X-rays) are used for the preoperative assessment of hallux valgus (HV). Our purpose was to determine how well quantitative measurements of HV on radiographs and MRI correlate with the qualitative soft tissue and internal derangement findings on MRI. MATERIALS AND METHODS: After IRB approval, 56 consecutive patients with MRI and radiographs of the foot were retrospectively reviewed. Two trained readers independently evaluated radiographs, measuring hallux valgus angle (HVA) and intermetatarsal angle (IMA). Two separate readers assessed qualitative MRI data by evaluating 21 different soft tissue and bony features. Statistical analysis included inter-reader reliability (IRR) and correlation of quantitative and qualitative findings. RESULTS: Excellent IRR (ICC = 0.89-0.96) was observed for radiograph and MRI measurements of the hallux valgus severity. For qualitative assessments on MRI, IRR was good to excellent for all features (ICC = 0.63-0.9). No significant difference was found for HVA or IMA between normal and abnormal qualitative MRI features. No statistically significant correlation between the severity of hallux valgus and injury to hallux joints and supporting structures was found. CONCLUSION: Hallux valgus measurements are reliable on x-rays and MRI and qualitative findings of 1st MTP joint show good to excellent inter-reader agreement on MRI. No statistically significant correlations exist between the severity of hallux valgus and qualitative MRI findings.

Mechanical properties and morphologic features of intrinsic foot muscles and plantar fascia in individuals with hallux valgus.

BACKGROUND: The aim of the present study was to investigate the morphologic features and mechanical properties of plantar fascia (PF), flexor hallucis brevis (FHB), flexor digitorum brevis (FDB), and abductor hallucis (AbH) muscles in individuals with halluks valgus (HV) and to compare the results with individuals without HV. METHODS: A total of 30 participants (27 female, 3 male) between the ages of 19-58 years with HV deformity and 30 individuals without HV (27 female, 3 male) between the ages of 20-58 years were included in the study. AbH, PF, FHB, and FDB thickness, cross-sectional area and stiffness were measured with an ultrasonography device. For stiffness measurements, Shear Wave Velocity (SWV) of the assessed soft tissues was calculated using a customized software program. RESULTS: Mean and standard deviation of SWV of PF, AbH, FHB, FDB, and thickness of PF, AbH, FHB, FDB, and cross-sectional area of AbH, FHB, FDB in individuals with HV were 7.6 ± 1.0 m/sec, 2.8 ± 0.3 m/sec, 2.6 ± 0.4 m/sec, and 3.4 ± 0.2 m/sec, 3.3 ± 0.5 mm, 11.4 ± 2.2 mm, 16.5 ± 1.9 mm, 8.9 ± 1.8 mm, 2.4 ± 0.5 cm2, 2.7 ± 0.5 cm2, 1.9 ± 0.6 cm2, respectively. Mean and standard deviation of SWV of PF, AbH, FHB, FDB and thickness of PF, AbH, FHB, FDB, and cross-sectional area of AbH, FHB, FDB in controls groups were 7.6 ± 1.2 m/sec, 2.3 ± 0.3 m/sec, 2.3 ± 0.4 m/sec, and 3.4 ± 0.4 m/sec, 3.3 ± 0.5 mm, 9.7 ± 2.1 mm, 14.5 ± 1.4 mm, 9.7 ± 1.2 mm, 2.1 ± 0.3 cm2, 2.3 ± 0.4 cm2, 2.1 ± 0.4 cm2, respectively. Individuals with HV had lower AbH and FHB thickness, cross-sectional area and SWV, however FDB thickness and cross-sectional area were higher in individuals with HV compared to that of individuals without HV (p < 0.05). PF thickness (p = 0.273), SWV of PF (p = 0.979) and FDB (p = 0.295) were similar in both groups. CONCLUSION: Our results suggest that individuals with HV had lower AbH and FHB stiffness, however PF and FDB stiffness were similar in HV and control group. In addition, AbH and FHB thickness and cross-sectional area were lower in individuals with HV; however, FDB thickness and cross-sectional area were higher in individuals with HV compared to that of individuals without HV. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

Critical limb ischemia in a patient with systemic lupus erythematosus: a case report.

BACKGROUND: Peripheral vascular disease is the rarest vascular complication in systemic lupus erythematosus. Some theories propose that immune complexes may promote inflammation in the vessel, and disrupt it in a manner that may cause ischemia. CASE PRESENTATION: A 14-year-old Asian girl presented with intermittent claudication as the chief complaint followed by discoloration of her left big toe for 2 weeks prior to admission. Her medical history showed that 1 month prior to admission she had photosensitivity, rash, and arthralgia, with positive antinuclear antibody test, positive anti-double-stranded DNA test, positive anti-ribosomal protein P, and complement C4 (7.4 mg/dL); she was diagnosed as having systemic lupus erythematosus and started therapy. A local examination of her left toe showed black discoloration, low pulsation, localized tenderness, and decreased sensation. Laboratory results showed C-reactive protein of 1.16 mg/dL and D-dimer of 2.28 uG/mL. A computed tomography angiogram showed near total occlusion of her popliteal artery; critical limb ischemia was confirmed. Peripheral arteriography was performed with invasive strategy. After the procedure, the flow was improved to distal, but there was inflammation in the vessel, so we decided to stop the procedure because of the risk of dissection. Our patient was given atorvastatin and warfarin, and we maximized her systemic lupus erythematosus therapy with prednisone. There were two follow-ups. The first follow-up was 1 week after the procedure. Our patient attended her first follow-up at our out-patient department with no symptoms and improvement in her toe's discoloration; warfarin was stopped, and clopidogrel and cilostazol were added for thrombus prevention therapy, she was then scheduled for debridement. The second follow-up was done 2 months after the first follow-up and discoloration was improved. The third follow-up, 5 months after the second follow-up, showed improvement. CONCLUSION: Critical limb ischemia is a rare complication of systemic lupus erythematosus that requires immediate treatment. Due to our limited resources, we improvised a strategy to achieve the best possible outcome in our patient by using a combination of invasive treatment and medication.

Nonradiographic Measurement of Hallux Valgus Angle Using Self-photography.

BACKGROUND: Radiographs of the feet are the reference standard for measuring the hallux valgus angle. However, the availability and use of radiographs are constrained due to cost and radiation exposure. Less invasive, nonradiographic assessments have been proposed, although measurement using self-photography has not been reported. OBJECTIVES: To determine (1) reliability of photographic hallux valgus angle (pHVA) measurement using the same photographs of the feet, (2) reliability of repeated self-photography trials, and (3) measurement error when the radiographic hallux valgus angle (rHVA) is estimated using the pHVA. METHODS: In this reliability study, participants took photographs of their own feet using a digital camera. The intrarater and interrater reliability of pHVA measurements were then assessed using the intraclass correlation coefficient (ICC) and 95% minimum detectable change (MDC). The participants took photographs twice, and the reliability of repeated self-photography trials was examined. Participants also received radiographs of their feet, from which the rHVA was measured. The measurement error was assessed using the mean difference and 95% limits of agreement. RESULTS: The intrarater and interrater ICC of pHVA measurement was 0.99, with MDCs less than 2°. The ICC of pHVA measurement for repeated self-photography was 0.96, and the MDC was 6.9°. The pHVA was systematically lower than the rHVA, by 5.3°. CONCLUSION: Measurement of the pHVA using self-photography was reproducible, although pHVA measurement underestimated the rHVA. The pHVA can be a useful nonradiographic method to quantify hallux valgus deformity. J Orthop Sports Phys Ther 2019;49(2):80-86. Epub 12 Sep 2018. doi: 10.2519/jospt.2019.8280.

Outcome of Second-Ray Pathologies Following Weil Osteotomy in Patients Treated for Hallux Valgus.

Background: We hypothesized that the cause of second-ray pathology with hallux valgus is excessive relative length of the second metatarsal and performed Weil osteotomy to shorten it, with correction of hallux valgus. The purpose of this study is to evaluate the outcome of second-ray pathology after distal chevron osteotomy (DCO) with Weil osteotomy to correct metatarsal parabola. Methods: We performed concomitant Weil osteotomy of the second metatarsal with DCO of the first metatarsal as part of hallux valgus with second-ray pathology correction surgery in 45 feet (40 patients). Second-ray pathologies were claw toe deformity, painful plantar callosity, second metatarsophalangeal joint (MTPJ) dislocation, and osteoarthritis (OA) of the second MTPJ. We measured projection of the second metatarsal (PSM), metatarsal protrusion index (MPI), and metatarsal protrusion distance (MPD). The second-ray surgery outcome was assessed by patient satisfaction. Results: Patient satisfaction was good in claw toe deformity and OA (satisfaction rate: 60% [23 patients] and 71% [7 patients], respectively) and fair in painful plantar callosity and second MTP joint dislocation (satisfaction rate: 44% [9 patients] and 33% [6 patients], respectively). Total patient satisfaction rate was higher when the PSM, MPI, and MPD ranged between 7 and 12 mm, -5 and 0 mm, and 0 and 4 mm, respectively. Conclusions: We concluded that simultaneous performance of hallux valgus correction and Weil osteotomy in patients with second-ray pathologies associated with hallux valgus was safe as well as effective. Correcting the metatarsal parabola within the appropriate range after surgery is associated with second-ray pathology outcome. Levels of Evidence: Therapeutic studies, Level VI: Case series.

Effect of sesamoid position on functional outcome of operated hallux valgus.

INTRODUCTION: The loss of correct relationships between the sesamoid and the first metatarsal is one of the architectural consequences of the hallux valgus (HV). The reduction of this dislocation by lateral soft tissue release (LSTR) is one of the objectives of surgery. AIM: To study the relationship between postoperative position of sesamoid and clinical outcome at one-year postoperative follow-up. METHODS: It's a retrospective study including patients operated for evolved HV performed in la Rabta orthopedic department in Tunis. These patients had a Scarf osteotomy associated with at least one Weil osteotomy. The functional evaluation was based on the AOFAS score (American-orthopedic-foot-and-ankle-society). We classified the sesamoid position according to 3 scores: Hardy & Clapham , RCAOFAS and the Agrawal. We compared each score of the sesamoid position to the clinical outcome. RESULTS: We collected 46 cases of HV in 45 patients. The mean AOFAS score increased from 60,9 to 85,5/100 postoperatively. Our patients were divided into 2 groups: group A whose result was excellent and group B whose result was good, fair and poor. The analytical study of this work concluded that there was no relationship between the postoperative sesamoid position and the clinical outcome, regardless of the radiological classification used (p=0,361, p=0,222, p=0,260). CONCLUSION: Sesamoids that remain in postoperative dislocation are not necessarily predictive of a poor clinical outcome at one year of the surgical cure.