Contrast administration via ultrasound-guided injection of the cranial tibial artery results in contrast enhancement of the soft tissues of the metatarsus in horses undergoing CT.

Delivery of mesenchymal stem cells (MSC) via intravascular techniques to treat diffuse and/or inaccessible soft tissue injuries has grown in popularity. The purpose of the current prospective, analytical pilot study was to utilize CT to validate this novel technique and provide additional evidence to support its use for injectate delivery to specific soft tissue structures. Of particular interest was the proximal suspensory ligament, which presents a challenging injection target. Six adult horses without lameness underwent CT of the distal hindlimbs. Scans were obtained prior to ultrasound-guided catheterization of the cranial tibial artery, in addition to early and delayed scans acquired following intra-arterial contrast administration. Region of interest analysis of the superficial and deep digital flexor tendons and suspensory ligament was used to assess contrast enhancement within these structures. Linear mixed models were used to determine statistical significance. Significant (P < 0.05) mean contrast enhancement was seen in all postinjection time points in all soft tissue structures of interest. This indicates that ultrasound-guided injection of the cranial tibial artery results in perfusion of injectate throughout the distal hind limb, including the major soft tissue structures of the metatarsus. This provides further support for this technique as a method of MSC delivery to multifocal or inaccessible injury of these structures, including the proximal suspensory ligament.

Evaluation of Radiographic Features Including Metatarsus Primus Elevatus in Hallux Rigidus.

The etiology of hallux rigidus remains a controversial issue in foot and ankle surgery, i.e., the relationship between metatarsus primus elevatus (MPE) and hallux rigidus. The purpose of this study was to evaluate several radiographic parameters including first metatarsal elevation in patients with hallux rigidus compared to a matched control group. A retrospective case control study was performed including 50 feet, 25 feet with and 25 feet without hallux rigidus. In the patients with hallux rigidus, the first metatarsal was more elevated than in the control group (8.3 ± 1.7 mm vs 3.0 ± 2.0 mm, p < .001) and in 60% of patients with hallux rigidus MPE was diagnosed, compared to zero patients in the control group (p < .001). The lateral 1 to 2 intermetatarsal angle was higher in patients with hallux rigidus (3.6 ± 2.5 vs -0.7 ± 2.8; p < .001). The first metatarsal declination angle was not different between the 2 groups. Intraclass correlation coefficient between 2 observers for measuring the first metatarsal elevation was 0.929 (p < .001). In the current study, increased elevation of the first metatarsal, a higher incidence of MPE and increased lateral 1 to 2 intermetatarsal angle were found in patients with hallux rigidus compared to the control group. These findings support the theory of an association between MPE and hallux rigidus. Further high reliability of first metatarsal elevation measurement was found in our study.

Metatarsal Head Restoration With Tendon Autograft in Freiberg's Disease: A Case Report.

Freiberg's disease is a form of osteochondrosis of a metatarsal head that often affects the second metatarsophalangeal joint, and that affects females more often than males. Repetitive microtrauma, osteonecrosis, and stress overload are the main factors in its pathophysiology. Surgical intervention is indicated in advanced cases wherein nonoperative treatment has failed. In this report, we describe the case of a young female who had Freiberg's disease localized to the third metatarsal head bilaterally and who was successfully treated with peroneus longus tendon transplantation.

Diagnosis and Operation Results for Chronic Lateral Ankle Instability with Subtle Cavovarus Deformity and a Peek-A-Boo Heel Sign.

Cavovarus deformity is considered an anatomical risk factor for chronic lateral ankle instability (CLAI). However, subtle deformity can be difficult to detect, and its correction is controversial. The current study aimed to evaluate clinical and radiographic outcomes of a modified Broström procedure (MBP) with additional procedures for CLAI with subtle cavovarus deformity and a positive peek-a-boo heel sign. We reviewed the records of 15 patients who underwent MBP with additional procedures for CLAI with a positive peek-a-boo heel sign between August 2009 and April 2015. Consecutive physical and radiographic examinations were performed. The visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the Karlsson-Peterson (KP) ankle score were applied to assess clinical outcomes. Weight bearing radiographs, hindfoot alignment view, and ankle stress radiographs were also examined. The mean follow-up period was 58.5 months. Calcaneal lateral closing wedge osteotomy was performed in seven patients to correct fixed hindfoot varus, and first metatarsal dorsiflexion osteotomy was performed in 11 patients to correct plantarflexion of the first ray. Three patients underwent both procedures. Mean VAS, AOFAS, and KP ankle scores improved significantly (p=0.001), and instability did not recur. Radiographically, all stress parameters improved significantly (p=0.007). Simultaneous correction of a positive peek-a-boo heel sign and cavovarus deformity with MBP for CLAI improves clinical outcomes and prevents recurrent instability. A comprehensive evaluation and cautious approach for subtle cavovarus deformity should be followed when treating patients with CLAI. This trial is registered on Clinical Research Information Service (CRiS, KCT0003287).

The influence of hallux valgus and flatfoot deformity on metatarsus primus elevatus: A radiographic study.

BACKGROUND: Metatarsus primus elevatus (MPE), a dorsal elevation of the first metatarsal in relation to the lesser metatarsals on lateral-view radiographs, is an indicator of hallux rigidus. The angle between the articular surfaces of the base of the first metatarsal and the anterior part of the medial cuneiform (M1C1A) reflects the sagittal instability of the first tarsometatarsal (TMT) joint. MPE may also indicate instability of the first metatarsal. The purpose of this study was to identify the influence of hallux valgus (HV) and flatfoot (FF) deformities on measurements obtained from first metatarsal-related radiographic images. METHODS: Standing radiographic images of 134 feet were investigated. In dorsoplantar-view radiographs, HV and intermetatarsal angles were evaluated. The position of the medial sesamoid was classified with a grading system (Hardy score). In lateral-view radiographs, MPE, M1C1A, and Meary's angle were measured. The subjects were divided into 4 groups: the normal group (G1), HV(-)FF(-); the HV group (G2), HV(+)FF(-); the FF group (G3), HV(-)FF(+); and the dual group (G4), HV(+)FF(+). The radiographic parameters were compared among the groups. RESULTS: MPE in the HV patients (G2 and G4) was less than that in the non-HV participants (G1 and G3). MPE in G4 was less than that in G3. The odds ratios of the Hardy score were higher in G2, G3 and G4 than in G1. The ratios were higher in the FF patients (G3 and G4) than in the non-FF participants (G1 and G2) and were higher in G4 than in G2. CONCLUSIONS: FF affects sesamoid dislocation, and the combination of HV and FF further increases sesamoid dislocation. Combined with M1C1A and the Hardy score, MPE may be a useful indicator of three-dimensional instability of the first TMT joint. First TMT joint-related operations may be considered for severe HV treatment in G4 patients.

Computed tomographic lymphangiography of the thoracic duct by subcutaneous iohexol injection into the metatarsal region.

OBJECTIVE: To evaluate the efficacy of subcutaneous iohexol injection into the metatarsal region for thoracic duct lymphangiography in dogs and to determine the minimum effective dose. STUDY DESIGN: Experimental study and clinical report. ANIMALS: Five healthy beagle dogs and one dog with chylothorax. METHODS: For the experimental study, iohexol was injected subcutaneously into the metatarsal region of five dogs at three doses (0.5, 0.75, and 1 mL/kg), and the injection sites were massaged gently. Computed tomography (CT) was performed 1, 3, 5, 7, 10, 15, and 20 minutes after iohexol injection. Subjective quality was assessed, and Hounsfield unit values were measured at several regions of interest (T1, T4, T8, T13, and L3). In the dog with chylothorax, iohexol (1.0 mL/kg) was injected into the right metatarsal region prior to CT. RESULTS: The thoracic duct was visualized and enhanced by contrast in all dogs after injection of 0.75 and 1.0 mL/kg of iohexol, and in two dogs after injection of 0.5 mL/kg at 3, 5, and 7 minutes. The thoracic duct was gradually attenuated with increasing doses of iohexol. In the dog with chylothorax, the entire thoracic duct was well enhanced and dilated, and tortuous cranial mediastinal lymphatics were detected. CONCLUSION: The thoracic duct was visualized when at least 0.75 mL/kg of iohexol was injected subcutaneously into the metatarsal region of dogs. CLINICAL SIGNIFICANCE: Subcutaneous injection of iohexol into the metatarsal region offers a simple alternative to conventional thoracic duct lymphangiography.

Standing low-field MRI of the equine proximal metacarpal/metatarsal region is considered useful for diagnosing primary bone pathology and makes a positive contribution to case management: A prospective survey study.

High-field MRI of the proximal metacarpal/metatarsal region has been associated with great diagnostic potential and clinical reports of standing low-field MRI of the forelimb suggest the same. To better understand diagnostic outcomes with standing low-field MRI of the proximal suspensory region, a prospective survey study was conducted and users of a widely available system questioned on their experience, operating procedures, and interpretation of standing low-field MRI findings. Response data included scores on a modified Likert scale from which weighted ratings were calculated for statistical analyses. Depending on the question, responses were obtained from 17 to 29 of the 38 invited facilities. Users indicated that standing low-field MRI was most frequently performed in the face of equivocal diagnostic findings; compared to Sports horses, general purpose riding horses were thought less likely to have detectable abnormalities and standing low-field MRI was rated most useful for the detection of primary bone pathology in the proximal metacarpal region. Standing low-field MRI signal change involving both the suspensory ligament and adjacent bone concurrently was rated most relevant and abnormalities solely affecting the muscle/adipose tissue bundles least relevant for diagnosing suspensory ligament injury. Transverse scans and in decreasing order T1-weighted gradient echo, short-tau inversion recovery FSE, T2*-weighted gradient echo, and T2-weighted FSE sequences were most frequently acquired and judged most useful by the majority of users experienced in imaging of the target area. This survey supports the relevant impact of standing low-field MRI on clinical case management, particularly in the context of imaging the proximal metacarpal region.

Gross osteology and radiology of the pelvic limb of the adult small East African goat.

The aim of this study was to provide the detailed normal gross osteology and radiographic anatomy of the pelvic limb in adult small East African goats as a reference for clinical use, biomedical research and teaching. Radiography of the pelvic limb was performed in five adult small East African goats. Bone specimens of four skeletally mature small East African goats were used for gross osteological study. The ilial wing was wide. The ischiatic tuberosity was prominent and well developed. The acetabulum was rounded. The minor trochanter was located caudomedially, and the femoral trochlea was deep and narrow. The lateral and medial condyles of the femur were approximately of the same size. The tibial tuberosity was prominent, and the cochlea grooves were deep with a pronounced intermediate ridge. The trochlea of the talus was deep. The patella presented a prominent tuberosity on the cranial surface. The metatarsal sesamoid bone was seen in all animals. The observed gross osteology and radiographic anatomy of the pelvic limb of small East African goats was consistent with the presence of strong extensor muscles of the hip, stifle and tarsus for propulsion during terrestrial walking and trotting.

Distances from the deep plantar arch to the lesser metatarsals at risk during osteotomy: a fresh cadaveric study.

BACKGROUND: The deep plantar arch is formed by anastomosis of the lateral and deep plantar arteries. Osteotomy of the lesser metatarsals is often used to treat metatarsalgia and forefoot deformity. Although it is known that some blood vessels supplying the lesser metatarsals are prone to damage during osteotomy, there is little information on the distances between the deep plantar arch and the three lesser metatarsals. The aims of this study were to identify the distances between the deep plantar arch and the lesser metatarsals and to determine how osteotomy could damage the arch. METHODS: Enhanced computed tomography scans of 20 fresh cadaveric feet (male, n = 10; female, n = 10; mean age 78.6 years at the time of death) were assessed. The specimens were injected with barium via the external iliac artery, and the distance from the deep plantar arch to each lesser metatarsal was measured on axial and sagittal images. RESULTS: The shortest distances from the deep plantar arch to the second, third, and fourth metatarsals in the axial plane were 0.5, 2.2, and 2.8 mm, respectively. The shortest distances from the distal epiphysis to a line passing through the deep plantar arch perpendicular to the longitudinal axis of the lesser metatarsal in the sagittal plane were 47.0, 45.7, and 46.4 mm, respectively, and those from the tarsometatarsal joint were 23.0, 21.0, and 18.6 mm. The deep plantar arch ran at the level of the middle third, within the proximal portion of this third in 11/20 (55.0%), 7/20 (35.0%), and 5/16 (31.2%) specimens, respectively, and at the level of the proximal third in 9/20 (45.0%), 13/20 (65.0%), and 11/16 (68.8%). CONCLUSIONS: Overpenetration into the medial and plantar aspect of the second metatarsal or the proximal and plantar aspect of the fourth metatarsal during shaft or proximal osteotomy could easily damage the deep plantar arch. Shaft or proximal osteotomy approximately 45-47 mm proximal to the distal epiphysis or 18-23 mm distal to the tarsometatarsal joint on the plantar aspect could interrupt blood flow in the deep plantar arch.

Foot Width Changes Following Hallux Valgus Surgery.

BACKGROUND: Hallux valgus (HV) adversely affects quality of life. Patients frequently express concerns regarding postoperative foot appearance, foot width and footwear anticipations. However, only scarce data are available regarding postoperative foot width. MATERIALS AND METHODS: Seventy-one cases with moderate to severe HV treated with scarf osteotomy were included. The average age was 55.7 years (range, 20-76), with average follow-up of 20.7 months (range, 6-96). Patients' medical records were reviewed for demographic, operative, and radiographic data. Foot width was assessed radiographically by measuring both bone (distance between the first and fifth metatarsal heads) and soft tissue width (maximal distance of the soft tissue outline). RESULTS: Preoperative HV deformity (mean hallux valgus angle [HVA] 35.8 degrees, intermetatarsal angle [IMA] 14.1 degrees, and distal metatarsal articular angle [DMAA] 15.2 degrees) was successfully corrected (postoperative mean HVA 13.7 degrees, IMA 6.9 degrees, and DMAA 7.7 degrees). Overall bony foot width was reduced by 5% and soft tissue foot width by 2%. Further analysis showed that 13 feet (18.3%) had increased (>5%) bone width, 26 feet (36.6%) with no change (±5%), and 32 feet (45.1%) for which the width decreased (>5%) postoperatively. Angular deformity (HVA, IMA, and DMAA) showed low correlation with postsurgery foot width. CONCLUSION: HV surgery effect on foot width was very limited, overall reducing foot width by 2%. Furthermore, in only about half of the patients, the postoperative foot width decreased, regardless of angular deformity magnitude. Patients with the widest feet had a decrease in foot width following surgery, whereas patients with the narrowest feet had an increase in foot width. LEVEL OF EVIDENCE: Level III, comparative series.

Comparison of Pedal Soft Tissue Thickness Between Those With and Without Diabetes.

Ulceration is a serious consequence of diabetes that can lead to disability in patients with diabetes. One of the risk factors for ulceration is high foot pressure. The thickness of the pedal soft tissue is important because it has a cushioning effect. Soft tissue atrophy causes elevation in the plantar pressure, which, in turn, causes ischemia. Therefore, we investigated the severity of pedal soft tissue atrophy caused by diabetes and aging. From February 2009 to February 2016, we examined the feet of 261 patients treated in our hospital using magnetic resonance imaging. We divided the patients enrolled in the study into 2 groups. The first group included 52 patients with diabetes but without peripheral arterial disease and the second group included 47 patients without diabetes. We measured the vertical distances under all patients' metatarsal heads using T1-weighted magnetic resonance imaging and measured the pedal soft tissue thickness using the PACS workstation (m-view). We compared the soft tissue thicknesses of the 2 groups and performed statistical analyses of the relationships between these data and other parameters using 2-way analysis of variance. The soft tissue under the first to fourth metatarsal heads was thinner in the diabetic patients than in the nondiabetic patients (first metatarsal, 6.4 versus 8.69; second metatarsal, 8.85 versus 10.64; third metatarsal, 8.15 versus 9.21; fourth metatarsal, 7.38 versus 8.54; p < .05). Aging had no effect on pedal soft tissue atrophy in either group. In conclusion, our study confirmed that diabetic patients experience more severe plantar soft tissue atrophy than nondiabetic patients. We have developed a standard procedure to enable the prediction of pedal soft tissue atrophy severity in diabetic patients.

Fully automated determination of arch angle on weight-bearing foot radiograph.

BACKGROUND AND OBJECTIVE: Flatfeet can be evaluated by measuring the calcaneal-fifth metatarsal angle on a weight-bearing lateral foot radiograph. This study aimed to develop an automated method for determining the calcaneal-fifth metatarsal angle on weight-bearing lateral foot radiograph. METHOD: The proposed method comprises four processing steps: (1) identification of the regions including the calcaneus and fifth metatarsal bones in a foot image; (2) delineation of the contours of the calcaneus and the fifth metatarsal; (3) determination of the tangential lines of the two bones from the contours; and (4) determination of the calcaneal-fifth metatarsal angle between the two tangential lines as arch angle. RESULTS: The proposed method was evaluated using 300 weight-bearing lateral foot radiographs. The arch angles determined by the proposed method were compared with those measured by a radiologist, and the errors between the automatically and manually determined angles were used to evaluate the precision of the method. The average error in the proposed method was found to be 1.12°â€¯±â€¯1.57° In the study, in 73.33% of the cases, the arch angles could be determined automatically without redrawing any tangential lines; in 23.00% of the cases, the angles would be correctly determined by redrawing one of the tangential lines; further, in only 3.67% of the cases, both the calcaneal and fifth metatarsal tangential lines needed to be redrawn to determine the arch angles. CONCLUSION: The results revealed that the proposed method has potential for assisting doctors in measuring the arch angles on weight-bearing lateral foot radiographs more efficiently.

MAGNETIC RESONANCE IMAGING, GROSS POSTMORTEM, AND HISTOLOGICAL FINDINGS FOR SOFT TISSUES OF THE PLANTAR ASPECT OF THE TARSUS AND PROXIMAL METATARSAL REGION IN NON-LAME HORSES.

Injuries of the plantar soft tissues of the tarsus and proximal metatarsus can be a source of lameness in horses, however published information is lacking on high field MRI characteristics of these tissues. Objectives of the current anatomic study were to (1) describe high-field MRI features of the plantar tarsal and proximal metatarsal soft tissues; and (2) compare MRI findings with gross and histological appearances of selected structures for a sample of cadaver limbs from non-lame horses. Single hindlimbs for 42 horses, and right and left hindlimbs for eight horses were scanned using high-field MRI. The MRI findings were described for the 50 single limbs; and the MRI, gross postmortem and histological findings were compared for the eight pairs of hindlimbs. The superficial digital flexor tendon had uniform low signal intensity, surrounded by the flexor retinaculum of intermediate to high signal intensity on all sequences. The lateral digital flexor tendon had slightly higher signal intensity, enclosed on the plantaromedial aspects by the low signal intensity metatarsocalcaneal ligament. The accessory ligament of the deep digital flexor tendon varied in size and signal intensity. The proximal and distal plantar ligaments, accessory ligament of the suspensory ligament, and calcaneoquartal ligament had low signal intensity. The long plantar ligament comprised a number of related parts, separated by lines of high signal intensity corresponding with fibrous septae seen in gross anatomical specimens. The plantar aspect of the ligament had uniform low signal intensity in all sequences, but the dorsal half was more heterogeneous with multifocal spots or lines of higher signal intensity.

The Nature of Foot Ray Deficiency in Congenital Fibular Deficiency.

BACKGROUND: Absent lateral osseous structures in congenital fibular deficiency, including the distal femur and fibula, have led some authors to refer to the nature of foot ray deficiency as "lateral" as well. Others have suggested that the ray deficiency is in the central portion of the midfoot and forefoot.We sought to determine whether cuboid preservation and/or cuneiform deficiency in the feet of patients with congenital fibular deficiency implied that the ray deficiency is central rather than lateral in patients with congenital fibular deficiency. METHODS: We identified all patients with a clinical morphologic diagnosis of congenital fibular deficiency at our institution over a 15-year period. We reviewed the records and radiographs of patients who had radiographs of the feet to allow determination of the number of metatarsals, the presence or absence of a cuboid or calcaneocuboid fusion, the number of cuneiforms present (if possible), and any other osseous abnormalities of the foot. We excluded patients with 5-rayed feet, those who had not had radiographs of the feet, or whose radiographs were not adequate to allow accurate assessment of these radiographic features. We defined the characteristic "lateral (fifth) ray present" if there was a well-developed cuboid or calcaneocuboid coalition with which the lateral-most preserved metatarsal articulated. RESULTS: Twenty-six patients with 28 affected feet met radiographic criteria for inclusion in the study. All affected feet had a well-developed cuboid or calcaneocuboid coalition. The lateral-most ray of 25 patients with 26 affected feet articulated with the cuboid or calcaneocuboid coalition. One patient with bilateral fibular deficiency had bilateral partially deficient cuboids, and the lateral-most metatarsal articulated with the medial remnant of the deformed cuboids. Twenty-one of 28 feet with visible cuneiforms had 2 or 1 cuneiform. CONCLUSIONS: Although the embryology and pathogenesis of congenital fibular deficiency remain unknown, based on the radiographic features of the feet in this study, congenital fibular deficiency should not be viewed as a global "lateral lower-limb deficiency" nor the foot ray deficiency as "lateral." LEVEL OF EVIDENCE: Level IV-prognostic study.

Combined Innovative Portal Arthroscopy and Fluoroscopy-Assisted Reduction and Fixation in Subtle Injury of the Lisfranc Joint Complex: Analysis of 10 Cases.

Subtle injuries of the Lisfranc joint complex are uncommon and difficult to diagnose clinically and thus are easily missed even by experienced orthopedic doctors. Misdiagnosed injuries can lead to chronic disability until eventual fusion surgery. We describe 10 cases diagnosed with subtle injury of the Lisfranc joint that were treated with combined innovative portal arthroscopy and fluoroscopy-assisted reduction and percutaneous screw fixation in an interfragmentary fashion. The distance between the first and second metatarsals (the Lisfranc distance) and that between the medial cuneiform and fifth metatarsal base (foot arch height) was measured before and after surgery. The American Orthopaedic Foot and Ankle Society function score was evaluated perioperatively. The average preoperative and postoperative Lisfranc distance was 4.38 ± 0.39 mm and 2.68 ± 0.9 mm, the foot arch height was 12.63 ± 2.75 mm and 21.80 ± 3.50 mm, and the American Orthopaedic Foot and Ankle Society score was 59.1 ± 5.69 and 86.8 ± 10.1, respectively. Of the 10 patients, 3 had excellent outcomes, 6 had good outcomes, and 1 had a fair outcome. In conclusion, we report a useful and minimally invasive surgery for acute, subacute, and even chronic subtle injury of the Lisfranc joint. The Lisfranc distance, foot arch height, and function of the foot were restored clinically, and all measurements showed statistically significant differences.

Long-term Follow-up of Dorsal Wedge Osteotomy for Pediatric Freiberg Disease.

BACKGROUND: Treatment for Freiberg disease has been largely conservative despite availability of various operative options for severe or refractory cases. The aim of this study was to evaluate the long-term results of pediatric patients with symptomatic Freiberg disease treated with intra-articular dorsal wedge osteotomy. METHODS: Pediatric patients treated for Freiberg disease with surgery between January 1982 and 1999 were identified and selected for long-term clinical evaluation. Patients were evaluated regarding operative satisfaction and clinical outcome, performed according to the American Orthopaedic Foot & Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal scale and range of motion (ROM) of metatarsophalangeal (MTP) joint. Patients had radiographic assessment of degenerative joint status with anteroposterior and oblique foot x-ray. Twenty patients (18 female, 2 male; mean age 15.2 years; range 12-17 years) were identified. The mean follow-up period was 23.4 (range 15-32) years. RESULTS: The clinical outcomes of our patients were classified as excellent in 16 (80%) and good in 4 (20%). The AOFAS mean score was 96.8 (range 91-100) points at the last clinical appointment. A negative correlation between AOFAS score and time of follow-up (r's = -0.61, P < .001) was found. Also, a strong negative correlation was found between Smillie classification and AOFAS final score (r's = -0.88, P < .001). CONCLUSION: The patients were very satisfied with pain and quality of life at a mean follow-up time of 23.4 years. To our knowledge, this is the first long-term follow-up report supporting the procedure described by Gauthier and Elbaz as a good option for operative treatment of Freiberg disease. LEVEL OF EVIDENCE: Level IV, retrospective case series.

An innovative ultrasound foot scanner system for measuring the change in biomechanical properties of plantar tissue from sitting to standing.

The present study investigated the reliability of an innovative ultrasound foot scanner system in assessing the thickness and stiffness of plantar soft tissue and the comparison of stiffness and thickness in sitting and standing. Fifteen young healthy individuals were examined. The target sites on the foot sole for investigation included the heel pad, the fifth metatarsal head, the second metatarsal head, the first metatarsal head, and the pulp of the hallux. The test (day 1) and retest (day 2) were performed 1 week apart at the exact time with humidity and temperature of the assessment room under control. The thickness and stiffness of the plantar soft tissue obtained in sitting and standing positions on day 1 were used for comparison. The results showed significant test-retest reliability [intraclass correlation coefficient(3,2)>0.90, P<0.001] at all five sites in both sitting and standing positions. When changing from sitting to standing, the plantar soft tissue became significantly thinner (with decrease ranging from 10 to 14% at various sites) and stiffer (with increase ranging from 123 to 164% at various sites, all P<0.05). The present innovative system is a reliable device for the measurement of the thickness and stiffness of plantar soft tissue in either the sitting or the standing position. The change in positions from sitting to standing resulted in a significant thinning and stiffening of plantar soft tissues. This system could be a potential clinical device to monitor the biomechanical properties of plantar tissue in the elderly or in patients with diseases such as diabetes to estimate the risk of developing foot ulcer or other foot complications.

Computed tomography assisted determination of optimal insertion points and bone corridors for transverse implant placement in the feline tarsus and metatarsus.

OBJECTIVE: Describe optimal corridors for mediolateral or lateromedial implant placement in the feline tarsus and base of the metatarsus. METHODS: Computed tomographic images of 20 cadaveric tarsi were used to define optimal talocalcaneal, centroquartal, distal tarsal, and metatarsal corridors characterized by medial and lateral insertion points (IP), mean height, width, length and optimal dorsomedial-plantarolateral implantation angle (OIA). RESULTS: Talocalcaneal level: The IP were at the head of the talus and plantar to the peroneal tubercle of the calcaneus and OIA was 22.7° ± 0.3. Centroquartal level: The IP were at the centre of the medial surface of the central tarsal bone and dorsoproximal to the tuberosity of the fourth tarsal bone and OIA was 5.9° ± 0.06. Distal tarsal level: The IP were at the centre of the medial surface of the tarsal bone II and dorsodistal to the tuberosity of the fourth tarsal bone and OIA was 5.4° ± 0.14. Metatarsal level: The IP were at the dorsomedial surface of the proximal end of the metatarsal bone II and at the dorsolateral surface of metatarsal bone V and OIA was 0.5° ± 0.06. Significant positive correlation was found between body weight and the length of each corridor. CLINICAL SIGNIFICANCE: Most of the corridors obtained in this study had a diameter between 1.5 mm and 2 mm with a length of 15 mm to 18 mm, which stresses the importance of their accurate placement.

Prevalence of metatarsus adductus in patients undergoing hallux valgus surgery.

BACKGROUND: Metatarsus adductus (MA) is a congenital condition in which there is adduction of the metatarsals in conjunction with supination of the hindfoot through the subtalar joint. It is generally believed that MA precedes the development of hallux valgus. Historically, studies have demonstrated that patients with a history of MA were ~3.5 times more likely to develop hallux valgus. The purpose of this study was to identify the relative prevalence of MA in patients undergoing surgery for symptomatic hallux valgus. METHODS: Between 2002 and 2012, 587 patients who underwent hallux valgus surgery were retrospectively identified following IRB approval and parameters including the hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the metatarsus adductus angle (MAA) were recorded. The MAA was considered abnormal if the value was greater than 20 degrees. Interobserver and intraobserver reliability studies for the measurement of the MAA were completed as well. RESULTS: Using the modified Sgarlato technique for measurement of the MAA, there was a high interobserver and intraobserver reliability. The interclass and intraclass coefficients were greater than .90. The prevalence of MA in this patient population was found to be 29.5%. Of those patients with MA, 23 males and 150 females were identified. This gave a male to female ratio of 1:6.5 (P < .00001). Lesser toe deformities (claw toes, hammertoes) were the most commonly associated diagnoses identified. When stratified by severity, 113 (65%) patients had an MAA between 21 and 25 degrees, 41 (23.7%) had an MAA between 26 and 30 degrees, 8 (4.6%) patients had an MAA between 31 and 35 degrees, and 11 (6.3%) patients had an MAA greater than 36 degrees. CONCLUSION: Historically the prevalence of MA in patients with hallux valgus has been reported to be 35%. The data in this study indicate a comparable prevalence at 29.4%. The presence of concomitant MA may portend different outcomes for operative treatment of hallux valgus. Further research needs to delineate rates of persistence of deformity in this patient population to guide operative management. LEVEL OF EVIDENCE: Level IV, case series.

A reappraisal of the relationship between metatarsus adductus and hallux valgus.

BACKGROUND: A causal link between the metatarsus adductus and hallux valgus is not clear. The aim of this study was to investigate the configurations of the metatarsus adductus deformity by radiological measurements and reappraise the relationship between hallux valgus and metatarsus adductus. METHODS: The first step was evaluation of the relationship between metatarsus adductus and hallux valgus on 143 dorsoplantar weight-bearing radiographs diagnosed as hallux valgus which was also known as bunions. Measurements including the hallux valgus angle (HVA), the intermetatarsal angle (IMA), the Kilmartin angle (KA), the tibial sesamoid position (TSP), and metatarsus adductus angle were taken. The metatarsus adductus angle is defined by Sgarlato's angle (SMA) and Engel's angle (EMA) respectively. RESULTS: The metatarsus adductus angle positively correlates with the HVA (r = 0.590, P = 0.000) and KA (r = 0.601, P = 0.000), yet negatively correlates with the grade of TSP, (r = -0.348, P = 0.000). Contradiction of diagnosis existed in 22 (22/100) subjects diagnosed as metatarsus adductus by SMA yet normal by EMA. In this group, the correlation between HVA and metatarsus adductus angle was negative (r = -0.472, P = 0.027). CONCLUSIONS: EMA and SMA defined metatarsus adductus by different deformity apexes. Metatarsus adductus configurations in that the apex of the deformity lay in either the base of metatarsals or tarsus. They respectively correlate positively or negatively to the HVA.