Surgical Treatment of Metatarsalgia and Severe Instability of Lesser Metatarsophalangeal Joints.

The main object of this prospective cohort study was to compare surgical treatment options for primary metatarsalgia and the severe instability of lesser metatarsophalangeal joints. The outcomes of triple Weil osteotomy combined with direct plantar plate repair and triple Weil osteotomy, performed with proximal interphalangeal joint arthrodesis, are analyzed and compared. One hundred thirteen patients (117 feet) were enrolled in the study. They were split into 2 groups. In the first group, undergoing Weil osteotomy, combined with the plantar plate repair, good results, including complete pain reduction, elimination of hyperkeratosis, and American Orthopedic Foot and Ankle Society Score improvement, were achieved in 84.7% of the cases. The second group, where the combination of Weil osteotomy and proximal interphalangeal joint K-wire arthrodesis was used, demonstrated good results in 52.4% of the cases. Weil osteotomy, combined with the plantar plate repair, achieves better results in comparison to osteotomy, performed with the interphalangeal joint arthrodesis.

Clinical and biomechanics effects of modified Helal osteotomy with screw fixation in forefoot reconstruction.

PURPOSE: The object of this study was to assess the efficacy of Helal metatarsal osteotomy with screw fixation in patients with hammertoe deformities. METHODS: Thirty-five patients (66 feet, 66 metatarsals) with hammertoe deformity underwent Helal osteotomy with screw fixation after first ray reconstruction. Pre- and postoperative AOFAS scale results, podobarometry (in-shoe plantar pressure), and X-ray (angular) parameters were analyzed. The patients were examined before the operation and two, six, and 24 months postoperatively. RESULTS: The average AOFAS score was 59 (± 2.4) preoperatively and 96 (± 1.2) in 12 months after the operations. Pressure under the second and third metatarsal heads was decreased from 396 (± 52.3) kPa preoperatively to 240 (± 22.3) kPa 12 months postoperatively. Lateral subluxation of the second and third toes before the operation was observed in 62 (94%) feet, average metatarsophalangeal angle was 28.1 (± 3.3) degrees. While it was not found in any case 12 months after operation, in four (6.1%) feet, it became recurrent 24 months postoperatively; the average metatarsophalangeal angle was 5° (± 0.6). CONCLUSION: Helal osteotomy with screw fixation demonstrated good-to-excellent results in 24 months postoperatively. It allows for a three-dimension lesser rays reconstruction: shortening, elevating, and lateral or medial displacement of the metatarsal head.

Comparing Clinical Examination and Radiological Evaluation in the Preoperative Diagnosis and Location of Symptomatic Interdigital (Morton's) Neuroma.

This study investigates whether clinical examination is as sensitive as ultrasound and magnetic resonance imaging (MRI) in the diagnosis and localization of symptomatic interdigital neuroma. A retrospective cohort study was conducted at two tertiary centers on all consecutive patients who underwent excision by a single foot and ankle specialist surgeon for a presumed interdigital neuroma between January 2008 and December 2020. Investigators collected preoperative clinical findings, radiological investigations, and postoperative outcomes. Sensitivity and positive predictive values were calculated and Z-score for 2 populations proportions was performed. One hundred fourteen consecutive patients were operated on for 131 suspected interdigital neuroma. Thirteen patients were excluded due to lack of adequate clinical documentation. Of the remaining 101 patients with 118 suspected interdigital neuroma, 115 were confirmed histologically (97.5%). The sensitivity of clinical assessment to accurately diagnose and place an interdigital neuroma in the correct space was calculated as 96.5%. The most common preoperative clinical feature was pain (99.2%). The calculated sensitivity for ultrasound to accurately diagnose an interdigital neuroma was 83.6%, and to correctly locate neuroma was 79.5% respectively, which were both statistically different compared to clinical assessment (p value: <.001 and p value: <.001). The calculated sensitivity for MRI to accurately diagnose an interdigital neuroma was 93.6%, which was statistically different to clinical assessment (p value: .005). Preoperative clinical assessment has the highest sensitivity to accurately diagnose interdigital neuroma when compared to MRI and ultrasound. Preoperative clinical assessment has higher sensitivity to accurately locate interdigital neuroma when compared to ultrasound.

Plantar Pressure Distribution Before and After Surgery for Lesser Metatarsophalangeal Joint Dislocation With Hallux Valgus.

Hallux valgus surgery and open reduction of the lesser metatarsophalangeal joints with metatarsal shortening osteotomy help treat severe hallux valgus concomitant with the lesser metatarsophalangeal joint dislocation; however, pre- and postoperative plantar pressure distribution and its effect on the foot remain unclear. The pre- and postoperative groups comprised 16 patients with moderate-to-severe symptomatic hallux valgus with lesser metatarsophalangeal joint dislocation. All feet underwent open reduction and collateral ligament reconstruction of the second metatarsophalangeal joint and proximal metatarsal shortening osteotomy under the second metatarsal with proximal osteotomy of the first metatarsal. Twenty healthy participants (20 feet) were included in the control group. The plantar pressure distribution was determined by measuring the peak pressure, maximum force, contact area, and force-time integral for 12 regions. Under the second toe, all measurements in the preoperative group were significantly lower than those of the control group. The peak pressure, maximum force, and contact area of the postoperative group were significantly greater than those of the preoperative group. However, no differences were observed between the postoperative and control groups. Under the second metatarsal head, the peak pressure of the preoperative group was significantly higher than that of the control group. The peak pressure of the postoperative group was significantly lower than that of the preoperative group and showed no differences from the control group. Open reduction and collateral ligament reconstruction of the lesser metatarsophalangeal joints and proximal metatarsal shortening osteotomy with proximal osteotomy of the first metatarsal in hallux valgus with lesser metatarsophalangeal joints dislocation cases may improve operative outcomes, including favorable foot function.

Comparison of modified Mitchell and Chevron osteotomies for hallux valgus.

BACKGROUND: Good clinical and radiological outcomes in mild-moderate hallux valgus (HV) can be achieved with Chevron osteotomy (CO) and modified-Mitchell osteotomy (MMO). The main goal of the present study was to compare the clinical and radiological outcomes after CO and MMO in HV. METHODS: The study included 45 patients, comprising 40 females with a mean follow-up of 87.5 ± 27.8 months. The outcome measurements of metatarsal length (MT1), HV angle (HVA), intermetatarsal angle (IMA), clinical outcomes, and metatarsalgia were evaluated pre- and postoperatively. RESULTS: No significant difference was determined between the MMO and CO groups in respect of metatarsalgia and AOFAS scores. The CO resulted in a significantly larger decrease in the MT1. The mean HVA and IMA correction was significantly greater after MMO than after CO. CONCLUSION: Since MMO may prevent MT1 shortening, which is a typical problem in the Mitchell osteotomy, MMO may be preferred over CO in patients with preoperative shortened first metatarsal.

Percutaneus intermetatarsal ligament release and minimally invasive distal metatarsal osteotomy for treatment second intermetatarsal space syndrome.

BACKGROUND AND OBJECTIVE: Since the description of the syndrome of the second intermetatarsal space, this is a common diagnosis among foot and ankle surgeons. However, no series have been published that consider this syndrome as its own entity. The objective of this study is to evaluate the clinical and radiological results of the release of the intermetatarsal ligament and minimally invasive distal metatarsal osteotomy in patients diagnosed with second space syndrome. MATERIALS AND METHODS: An observational, longitudinal, retrospective study was carried out in patients with a clinical diagnosis of second space syndrome operated on using a minimally invasive technique. For the clinical results, the visual analog scale (VAS) for subjective pain, the Manchester-Oxford Foot Questionnaire (MOXFQ) and the scale for minor metatarsals and interphalangeals of the American Orthopedic Foot and Ankle Society (AOFAS-LMTS) were used for clinical-functional assessment. Consolidation or not of osteotomies was recorded and complications were recorded. RESULTS: Twenty-nine feet in 29 patients were included in the study. After a mean follow-up of 39 months (25-50), clinically and statistically significant improvement was obtained in the scores: pain VAS, scales and subscales of the MOXFQ and the AOFAS-LMTS (p < 0.0001). All osteotomies healed at the end of follow-up and no major complications were recorded. CONCLUSIONS: Percutaneous or minimally invasive surgery, in patients with second intermetatarsal space syndrome, obtains good clinical, functional and subjective results, with few complications. Therefore, we consider it an effective, safe and recommended technique in the hands of experienced surgeons.

Long-term comparison between blind and ultrasound-guided corticoid injections in Morton neuroma.

OBJECTIVES: This work compares the effectiveness of blind versus ultrasound (US)-guided injections for Morton neuroma (MN) up to 3 years of follow-up. METHODS: This is an evaluator-blinded randomised trial in which 33 patients with MN were injected by an experienced orthopaedic surgeon based on anatomical landmarks (blind injection, group 1) and 38 patients were injected by an experienced musculoskeletal radiologist under US guidance (group 2). Patients were assessed using the visual analogue scale and the Manchester Foot Pain and Disability index (MFPDI). Injections consisted of 1 ml of 2% mepivacaine and 40 mg triamcinolone acetonide in each web space with MN. Up to 4 injections were allowed during the first 3 months of follow-up. Follow-up was performed by phone calls and/or scheduled consultations at 15 days, 1 month, 45 days, 2 months, 3 months, 6 months and 1, 2 and 3 years. Statistical analysis was performed using unpaired Student's t tests. RESULTS: No differences in age or clinical measures were found at presentation between group 1 (VAS, 8.5 ± 0.2; MFPDI, 40.9 ± 1.1) and group 2 (VAS, 8.4 ± 0.2; MFPDI, 39.8 ± 1.2). Improvement in VAS was superior in group 2 up to 3 years of follow-up (p < 0.05). Improvement in MFPDI was superior in group 2 from 45 days to 2 years of follow-up (p < 0.05). Satisfaction with the treatment was higher in group 2 (87%) versus group 1 (59.1%) at 3 years of follow-up. CONCLUSION: Ultrasound-guided injections lead to a greater percentage of long-term improvement than blind injections in MN. KEY POINTS: • Ultrasound-guided corticosteroid injections in Morton neuroma provide long-term pain relief in more than 75% of patients. • Ultrasound-guided injections in Morton neuroma led to greater long-term pain relief and less disability than blind injections up to 3 years of follow-up. • The presence of an ipsilateral neuroma is associated with worse long-term disability score.

A versatile method for dorsal-approach plantar plate repair using standard operative instruments.

BACKGROUND: The plantar plate is an important static stabilizer of the lesser metatarsophalangeal joints, and disruptions of the plantar plate can lead to significant instability and lesser toe deformities. In recent years, direct plantar plate repair has been proposed. Although direct repair via a dorsal approach is attractive, a torn plantar plate is small and difficult to access using regular instruments in a restricted operative field. METHODS: In this report, a unique method for plantar plate repairs was used to repair various configurations of plantar plate tears with standard operative instruments that are available in most operating rooms. RESULTS: Using this method, 10 patients underwent plantar plate repairs, and the mean follow-up period was 24 (range, 14-38) months. The mean visual analog scale score for pain preoperatively was 4.1 (range, 0-6) and decreased to 0.6 (range, 0-3) at last follow-up. Postoperatively, the mean visual analog scale score for satisfaction was 9.6 (range, 8-10) and the mean American Orthopedic Foot and Ankle Society forefoot score was 88.8 (range, 75-100). CONCLUSIONS: Our study proposes an inexpensive and versatile method for plantar plate repair via a dorsal approach that uses standard operative instruments. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04949685 . July 2, 2021 - Retrospectively registered, LEVEL OF CLINICAL EVIDENCE: 4.

Effectiveness of the Fixtoe Device® in plantar pressure reduction: a preliminary study.

BACKGROUND: Metatarsalgia is a common foot condition. The metatarsophalangeal stabilizing taping technique described by Yu et al. has shown good clinical results as a provisional treatment in propulsive metatarsalgia. 35 The Fixtoe Device®, a novel orthopedic device, intends to simulate stabilizing tape. However, to date, there is no evidence of its effectiveness. The aim of this study was to assess plantar pressure changes using the Fixtoe Device®, in comparison with the traditional method (stabilizing tape) in a young, healthy sample thorough a cross-sectional study. METHODS: Maximal pressure (Kpa) and pressure-time integral (Kpa/s) in the second metatarsal head were measured in twenty-four healthy volunteers. Registers were taken in four different conditions: barefoot, traditional stabilizing tape, Fixtoe Device® without metatarsal pad, and Fixtoe Device® with metatarsal pad. RESULTS: Mean second metatarsal head maximal pressure and mean pressure-time integral showed statistical difference among the four analyzed conditions (p < 0.0001 in both cases). The improvement in maximal pressure and pressure-time integral obtained in each intervention also showed significance (p < 0.0001 in both cases). Comparing the improvement of the Fixtoe Device® with and without metatarsal pad with that of tape condition showed a moderate to high and moderate effect size for both peak pressure and pressure-time integral reduction. CONCLUSIONS: The Fixtoe Device® reduces median maximal pressure and median pressure-time integral under the second metatarsal head in healthy young individuals. The Fixtoe Device® shows higher effectiveness than the traditional second metatarsophalangeal joint stabilizing taping technique. To our knowledge, this is the first investigation proving the effectiveness of the recently developed Fixtoe Device® in terms of plantar pressure modification, which leads the way to its use in clinics.

Shortening effect influence of Distal Minimally Invasive Metatarsal Osteotomy in primary metatarsalgia.

PURPOSE: In primary metatarsalgia, Distal Minimally invasive Metatarsal Osteotomy (DMMO) achieves a correct load distribution which is a factor in pain relief, but contrary to the elevation of the metatarsal head, shortening the metatarsal length has no influence on plantar-loading parameters, while the increased metatarsal length is a factor in the development of metatarsalgia. Thus, we hypothesized that metatarsalgia could be partly related to a functional imbalance between bone structure and soft tissues and pain relief after DMMO results from soft tissue relaxation. METHODS: Many authors have highlighted the correlation between joint pressure and periarticular soft tissue tension. To test our hypothesis, we measured intra-operatively the MTPJ pressure of 19 patients suffering from primary metatarsalgia, before and after DMMO. This pressure is being analyzed as a reflection of joint decompression and forefoot soft tissue release. Many authors have highlighted the correlation between joint pressure and periarticular soft tissue tension. RESULTS: Lower metatarsals presenting metatarsalgia show a significantly lower MTPJ pressure compared to asymptomatic rays, and DMMO induces a significant increase of MTPJ pressure. CONCLUSION: Those variations reflect the functional imbalance between bone structure and soft tissue in primary metatarsalgia. The biomechanical rationale of the shortening effect of DMMO could therefore be explained by the release of forefoot soft tissue, which could take part in the pain relief by restoring this balance.

Clinical and radiological outcomes of modified Mitchell's osteotomy using three-point fixation for hallux valgus.

PURPOSE: This study examined the clinical and radiographic outcomes of modified Mitchell's osteotomy using three-point fixation with a full-thread headless screw. This technique was described to resolve the problem of excessive shortening and overshifting of the metatarsal. METHODS: A total of 33 feet of 26 patients underwent modified Mitchell's osteotomy with three-point fixation for hallux valgus. Clinical and radiographic outcomes were assessed preoperatively and at specific time points of follow-up by using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, hallux valgus angle (HVA), and intermetatarsal angle (IMA). RESULTS: The global AOFAS scale score (0-100) significantly improved from 50.7 ± 9.9 preoperatively to 84.4 ± 8.7 at the final follow-up. The HVA significantly improved from 30.2 [Formula: see text]± 6.0 [Formula: see text] to 9.0 [Formula: see text] ± 5.0 [Formula: see text], and the IMA significantly improved from 14.2 [Formula: see text] ± 2.6 [Formula: see text] to 5.1 [Formula: see text] ± 2.0 [Formula: see text]. None of the patients experienced nonunion and transfer metatarsalgia. Complications were observed in two feet, and one foot had recurrence of hallux valgus. CONCLUSION: Modified Mitchell's osteotomy using three-point fixation with a full-thread headless screw is a reliable alternative treatment for hallux valgus, even in patients with severe deformities.

Influence of the Length Ratio Between Second and Third Metatarsals After Modified Weil Osteotomy on Clinical Outcomes.

Metatarsalgia is a frequent foot disorder. The objective was to evaluate whether the length ratio between the second and the third metatarsals after Weil osteotomy influences clinical outcomes. This retrospective study included 37 patients (53 feet). Preoperative planning consisted of keeping the second metatarsal greater than or equal to the third metatarsal after Weil osteotomy of the second metatarsal or the second and third metatarsals. Based on postoperative weightbearing and digital AP radiographs after Weil osteotomy, we divided the patients into 2 groups: group 1, the second metatarsal was longer than or equal to the third metatarsal; and group 2, the second metatarsal was shorter than the third metatarsal. We investigated whether there were differences between the groups. In 35 (66%) feet, the second metatarsal was longer than or equal to the third metatarsal (group 1), and in 18 (34%) feet, the second metatarsal was shorter than the third metatarsal (group 2). Postoperative American Orthopaedic Foot and Ankle Society scores were 86.2 and 82.7, respectively (p = .32). Postoperative Visual Analog Scale scores were 1.26 and 1.67, respectively (p = .39). The sample showed 11.3% of transfer metatarsalgia to the third metatarsal. Group 1 had 9% of transfer metatarsalgia, whereas group 2 had 17% of transfer metatarsalgia (p = .40). The presence of a second metatarsal shorter than the third metatarsal, after Weil osteotomy of the second metatarsal or the second and third metatarsals, does not influence outcomes or incidence of transfer metatarsalgia to the third metatarsal.

Treatment of Lesser Metatarsophalangeal Joint Instability With Plantar Plate Repair: A Systematic Review and Meta-Analysis.

Recognition of metatarsophalangeal joint plantar plate injuries has improved over time as the condition has become more widely understood and identified. With the diagnosis of a plantar plate injury as a subset of metatarsalgia becoming more common place, there are multiple surgical options that have been utilized to address the condition. Direct repair of the plantar plate has emerged as the treatment of choice for foot surgeons with a tendency to favor a direct dorsal approach for the repair. We performed a systematic review and meta-analysis using preferred reporting items for systematic reviews and meta-analysis guidelines, to determine the magnitude of change that can be expected in visual analog scale pain and American Orthopedic Foot and Ankle Society scores postoperatively. A total of 12 studies involving 537 plantar plate tears were included who underwent direct repair of the plantar plate through either a dorsal (10 articles) or plantar approach (2 articles). Summary estimates were calculated which revealed improvement in visual analog scale pain (pooled mean change of -5.01 [95%CI -5.36, -4.66] pre-to postoperative) and improvement in American Orthopedic Foot and Ankle Society scores (pooled postoperative mean improvement 40.44 [95%CI 37.90, 42.97]) of patients within the included studies. Random effects models were used for summary estimates. I2 statistic was used to assess for heterogeneity. We concluded there is a predictable level of improvement in pain and function in patients undergoing a direct dorsal approach plantar plate repair with follow-up out to 2 years.

Ultrasound-guided distal minimally invasive metatarsal osteotomies (US-DMMO): A cadaveric study about its safety and accuracy.

BACKGROUND: Distal minimally invasive metatarsal osteotomies have become increasingly popular. This technique requires fluoroscopic control, but recently, an ultrasound-guided procedure has been described. The aim of this anatomical study was to assess the quality safety of ultrasound-guided minimally invasive metatarsal osteotomies. METHODS: Ultrasound-guided distal minimally invasive metatarsal osteotomies were performed in 9 cadaveric pieces. The location of the osteotomy, its angulation, and the adjacent anatomical structures injuries was evaluated RESULTS: Thirty-six osteotomies were performed. The osteotomy was metaphyseal in 97.2% of the cases, the average angulation was 47.67° (±4.49, 40-59°) and the average distance to the articular cartilage was 3.22 mm (±1.27, 1-7 mm). One osteotomy (2.8%) was intraarticular and there was one joint capsule lesion (2.8%). The failure, the extreme point distance and angulation values, and the joint capsule injury correspond to a fifth metatarsal. CONCLUSIONS: The ultrasound-guided technique is safe and allows a correct location and angulation of the osteotomies.

Hallux valgus with second metatarsalgia: Is second metatarsal Weil osteotomy necessary?

BACKGROUND: The role of concomitant Weil osteotomy to address second toe metatarsalgia during hallux valgus correction is unclear. We aimed to critically analyse outcomes of an additional Weil osteotomy versus isolated Scarf osteotomy.in the management of hallux valgus and second metatarsalgia. METHODS: Patients with second toe metatarsalgia who underwent first metatarsal Scarf osteotomy for hallux valgus were enrolled retrospectively. Demographics, radiographic measurements and functional outcomes were assessed at baseline, 6-months and 2-years postoperatively. Between-group significance was established with Fisher exact test, Chi-square or Mann-Whitney U test. Within-group changes from baseline were assessed with paired t-test and Wilcoxon signed-rank test. RESULTS: 48 feet (34 isolated Scarf, 14 concomitant Weil osteotomy) were included. Both cohorts demonstrated significant improvements across all measures of functional outcome. However, patients with additional Weil osteotomy reported poorer short-term outcomes. CONCLUSION: Superiority of additional Weil osteotomy versus isolated Scarf osteotomy in addressing second toe metatarsalgia or improving functional outcomes was not demonstrated.

Iatrogenic second transfer metatarsalgia and the first metatarsal shortening and elevation after Scarf osteotomy.

BACKGROUND: Transfer metatarsalgia is a potential complication of hallux valgus surgery. This study aimed to investigate the shortened first metatarsal length and elevation and to compare groups with and without second transfer metatarsalgia after Scarf osteotomy. METHODS: The first metatarsal length of 123 feet was measured via the Maestro's method using the metatarsal axial length and the relative second metatarsal protrusion to the first metatarsal. Metatarsal elevation was measured using the first metatarsal angle. RESULTS: Second transfer metatarsalgia occurred after Scarf osteotomy in 11 (8.9%) feet. When baseline characteristics were considered in propensity score matching, the 11 feet were compared with the 33 feet in the control group. The group with transfer metatarsalgia showed a more shortened first metatarsal axial length (-4.1 ± 1.8 mm vs. -2.5 ± 2.2 mm, p = 0.032), a significantly longer relative second metatarsal protrusion (+5.8 ± 2.6 mm vs. +1.2 ± 2.6 mm, p < 0.001), and a significantly lower first metatarsal angle (18.1 ± 4.3° vs. 21.5 ± 4.0°, p = 0.012) than the control group postoperatively. CONCLUSIONS: To avoid iatrogenic transfer metatarsalgia, first metatarsal length shortening should be minimized to at least less than 4.0 mm. Furthermore, the metatarsal parabola should be retained.

Patient reported outcomes following revision neurectomy through a dorsal approach for recurrent interdigital neuroma.

Interdigital neuroma is one of the commonest causes of metatarsalgia. The reported success rate after excision of a primary neuroma is 74%. Recurrent symptoms after neurectomy can be due to a recurrent interdigital neuroma. Recurrent interdigital neuromas can be diagnosed using sound clinical examination and ultrasonography. Surgical excision is the best treatment modality with varying success reported in the literature. We report on the clinical outcome following surgical excision of recurrent interdigital neuromas through a dorsal approach. All patients who had undergone excision of a recurrent interdigital neuroma by a single surgeon between 01/2010 and 12/2019 were identified. Inclusion criteria included patients having a preoperative ultrasound and postoperative histology report. The exclusion criteria were preexisting neuropathy or tarsal tunnel syndrome. Demographic data was collected, and a self-reported foot and ankle score questionnaire (SEFAS) was completed by the patient at their most recent follow-up. Twenty-three patients (25 feet) were included in the study. Mean time of follow-up was 75 (range 14-189) months. The mean age was 49 (range 15-71) years. Eleven (44%) recurrent neuromas were excised from the second webspace and 14 (56%) were excised from the third webspace. All excised masses were confirmed as recurrent neuromas histologically. Regarding the SEFAS score, 17 (73.93%) patients scored as excellent, one (4.34%) as good, three (13.04%) as fair, and two (8.69%) as poor. This long term follow-up study on outcomes after surgery for recurrent interdigital neuroma suggests that excision through a dorsal approach is an effective treatment option with a high patient satisfaction.

Correlation of first metatarsal sagittal alignment with clinical and functional outcomes following the Lapidus procedure.

BACKGROUND: The purpose of this study was to evaluate the effect of the variation of the first metatarsal (M1) sagittal alignment after the Lapidus procedure (LP) on clinical and functional outcomes, and transfer metatarsalgia. METHODS: Twenty-nine patients who underwent a LP, with a mean follow-up of 20 months, were reviewed. Radiographic, clinical and functional measurements were compared. Clinical and functional questionnaires applied were the visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) scale, lower extremity functional scale (LEFS) and SF-12, which is divided in physical (PCS-12) and mental-health (MCS-12) scales. Radiographic analysis of M1 sagittal alignment was based on the first metatarsal declination angle (FMDA) and Meary Angle (MA). Intermetatarsal angle (IMA) and hallux valgus angle (HVA) were also measured. RESULTS: FMDA, IMA and HVA showed significant variation, but MA did not. Clinical and functional improvements were observed, except in MCS-12. No patient developed transfer metatarsalgia. A direct correlation was found between Δ-FMDA with Δ-PCS-12 and Δ-LEFS, meaning that excessive M1 dorsiflexion as measured by FMDA led to a decrease in PCS-12 and LEFS. Patients with Δ-FMDA of up to 3.2° of dorsiflexion were those who had significant improvements. CONCLUSION: Dorsiflexion of M1 can lead to decreased outcomes as measured by PCS-12 and LEFS. However, satisfactory outcomes can be obtained even with some dorsal deviation of the M1. LEVEL OF EVIDENCE: IV, retrospective case series.

Risks of injury in distal metatarsal minimally invasive osteotomy when comparing standard and modified techniques: A cadaveric study.

BACKGROUND: The objectives of the study were to evaluate the structures at risk in distal metatarsal mini-invasive osteotomy (DMMO) and to compare standard and intraosseous approaches. METHODS: DMMO was performed on the second and fourth metatarsals of 11 fresh-frozen cadaveric specimens. The standard technique was performed in 11 metatarsals. It was then compared to a modified intraosseous technique that entails starting inside the bone in 11 other metatarsals. The cadavers were dissected to identify unintentional injury to soft tissue structures. RESULTS: In the standard group the most injured structures were the metatarsal joint capsules (MJC) (27%), extensor digitorum longus (EDL) (18%), and extensor digitorum brevis (EDB) (9%). The modified intraosseous group injured the EDL (27%), not the MJC (0%) and the EDB (0%). Distances between osteotomies and the dorsal metatarsal head articular surface (DMHAS) were 6.08 ± 3.99 mm in the standard and 9.92 ± 3.42 mm in the modified (p = 0.02). CONCLUSION: The DMMO techniques most frequently injured the EDL. Intra-articular positioning of the osteotomy was more observed in the standard. Overall, it appears the modified method could be an alternative to the standard DMMO. CLINICAL RELEVANCE: The modified minimally invasive DMMO has a comparable rate of potential iatrogenic injuries. This intraosseous procedure may present as an option when planning surgery to the lesser metatarsals. LEVEL OF EVIDENCE: Level III. Comparative Cadaveric Study.

Ultrasound findings of plantar plate tears of the lesser metatarsophalangeal joints.

Lesser metatarsophalangeal (MTP) joint plantar plate tears are a common and increasingly recognised cause of metatarsalgia, MTP joint instability and forefoot deformity. Increased interest in early accurate diagnosis of plantar plate tears follows recent surgical innovations allowing direct plantar plate repair. The purpose of this review is to describe the ultrasound features of normal lesser MTP joint plantar plates and to characterise and illustrate the direct and indirect ultrasound findings of plantar plate tears. Lesser MTP joint plantar plate tears are most commonly located at the 2nd MTP joint, involving the lateral distal plantar plate insertion with variable propagation medially and proximally. The most common ultrasound appearance of a plantar plate tear is a discrete partial or full thickness hypoechoic defect in the plate substance. Flattening and attenuation or non-visualisation of the plantar plate represent more extensive tears. Dynamic imaging with toe dorsiflexion improves visualisation of tears and augments MTP joint subluxation. A common indirect finding is pericapsular fibrosis along the MTP joint capsule adjacent to a plantar plate tear, which requires differentiation from Morton's neuroma, and key distinguishing features at ultrasound are described. Other indirect findings include the cartilage interface sign, flexor tendon subluxation onto the metatarsal head or medial to the midline, flexor tenosynovitis, proximal phalangeal enthesophytes or avulsion and MTP joint synovitis. Ultrasound offers several advantages over MR imaging but requires a meticulous ultrasound examination, and optimisation of scanning technique is described.