Biomechanical consequences of plantar fascial release or rupture during gait. Part II: alterations in forefoot loading

With a model using feet from cadavers, we tested the hypothesis that plantar fascial release or rupture alters the loading environment of the forefoot during the latter half of the stance phase of gait. The model simulated the position and loading environment of the foot at two instants: early in terminal stance immediately after heel-off and late in terminal stance just preceding contralateral heel strike. Eight feet were loaded at both positions by simulated plantar flexor contraction, and the distribution of plantar pressure was measured before and after progressive release of the plantar fascia. Strain in the diaphysis of the second metatarsal was also measured, from which the bending moments and axial force imposed on the metatarsal were calculated. Cutting the medial half of the central plantar fascial band significantly increased peak pressure under the metatarsal heads but had little effect on pressures in other regions of the forefoot or on second metatarsal strain and loading. Dividing the entire central band or completely releasing the plantar fascia from the calcaneus had a much greater effect and caused significant shifts in plantar pressure and force from the toes to beneath the metatarsal heads. These shifts were accompanied by significantly increased strain and bending in the second metatarsal. Complete fasciotomy increased the magnitude of strain in the dorsal aspect of the second metatarsal by more than 80%, suggesting that plantar fascial release or rupture accelerates the accumulation of fatigue damage in these bones. Altered forefoot loading may be a potential complication of plantar fasciotomy.     

Second metatarsal osteotomies for metatarsalgia: A robotic cadaveric study of the effect of osteotomy plane and metatarsal shortening on plantar pressure

Symptom relief of recalcitrant metatarsalgia can be achieved through surgical shortening of the affected metatarsal, thus decreasing plantar pressure. Theoretically an oblique metatarsal osteotomy can be oriented distal to proximal (DP) or proximal to distal (PD). We characterized the relationship between the amount of second metatarsal shortening, osteotomy plane, and plantar pressure. We hypothesized that the PD osteotomy is more effective in reducing metatarsal peak pressure and pressure time integral. We performed eight DP and eight PD second metatarsal osteotomies on eight pairs of cadaveric feet. A custom designed robotic gait simulator (RGS) generated dynamic in vitro simulations of gait. Second metatarsals were incrementally shortened, with three trials for each length. We calculated regression lines for peak pressure and pressure time integral vs. metatarsal shortening. Shortening the second metatarsal using either osteotomy significantly affected the metatarsal peak pressure and pressure time integral (first and third metatarsal increased, p < 0.01 and <0.05; second metatarsal decreased, p < 0.01). Changes in peak pressure (p = 0.0019) and pressure time integral (p = 0.0046) were more sensitive to second metatarsal shortening with the PD osteotomy than the DP osteotomy. The PD osteotomy plane reduces plantar pressure more effectively than the DP osteotomy plane. Published 2013 by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 32:385–393, 2014.     

Effects of medializing calcaneal osteotomy on Achilles tendon lengthening and plantar foot pressures

Posterior tibial tendon insufficiency, or adult acquired flatfoot deformity, involves collapse of the longitudinal arch of the foot with ensuing changes in the bony architecture of the foot as well. While it is generally accepted that a medializing calcaneal osteotomy (MCO) is a very useful treatment for restoring the fallen arch, questions regarding the effects of this procedure upon plantar foot pressures and Achilles tendon length changes need to be answered. This study focuses on changes in plantar foot pressures and Achilles tendon length as the result of performing a MCO. Fourteen fresh-frozen cadaver legs were used to test the effects of MCO on Achilles tendon length changes 2 cm proximal to the Achilles tendon insertion on the calcaneus. Differential variable reluctance transducers were anchored in ventromedial, dorsomedial, dorsolateral, and ventrolateral positions of the Achilles tendon at the aforementioned level. The effects of the MCO on plantar foot pressures were assessed simultaneously using the Tekscan HR Mat. Axial loading (100 lbs) of each specimen was performed in neutral and dorsiflexion (15 degrees). Data were gathered for Achilles tendon length changes and plantar foot pressures for three trials in both the neutral and dorsiflexed positions. A medializing calcaneal osteotomy (1 cm medial translation) was then performed and testing was repeated in the fashion outlined heretofore. Analysis of the data revealed that there was no significant increase in Achilles tendon length as a result of the MCO. The data also showed that average pressure over the first and second metatarsal regions of the forefoot decreased significantly after MCO. At the same time there was a significant increase in average pressure over the medial and lateral aspect of the heel. These findings suggest that the Achilles tendon aids in inversion of the forefoot without undergoing a significant increase in length change of Achilles tendon fibers in any of the regions tested.     

The influence of foot position on stretching of the plantar fascia

BACKGROUND: A recent study found nonweightbearing stretching exercises specific to the plantar fascia to be superior to the standard program of weightbearing Achilles tendon-stretching exercises in patients with chronic plantar fasciitis. The present study used a cadaver model to demonstrate the influence of foot and ankle position on stretching of the plantar fascia. METHODS: Twelve fresh-frozen lower-leg specimens were tested in 15 different configurations representing various combinations of ankle and metatarsophalangeal (MTP) joint dorsiflexion, midtarsal transverse plane abduction and adduction, and forefoot varus and valgus. Measurements were recorded by a differential variable reluctance transducer (DVRT) implanted into the medial band of the plantar fascia, and primary measurement was a percent deformation of the plantar fascia (stretch) with respect to a reference position (90 degrees ankle dorsiflexion, 0 degrees midtarsal and forefoot orientation, and 0 degrees MTP dorsiflexion). RESULTS: Ankle and MTP joint dorsiflexion produced a significant increase (14.91%) in stretch compared to the position of either ankle dorsiflexion alone (9.31% increase, p < 0.001) or MTP dorsiflexion alone (7.33% increase, p < 0.01). There was no significant increase in stretch with positions of abduction or varus (2.49%, p = 0.27 and 0.55%, p = 0.79). CONCLUSION: This study provides a mechanical explanation for enhanced outcomes in recent clinical trials using plantar fascia tissue-specific stretching exercises and lends support to the use of ankle and MTP joint dorsiflexion when employing stretching protocols for nonoperative treatment in patients with chronic proximal plantar fasciitis.     

Surgical treatment for hallux valgus with painful plantar callosities

We retrospectively reviewed the results of a distal soft-tissue procedure and proximal crescentic osteotomy of the first metatarsal combined with a proximal shortening osteotomy of the second and/or third metatarsal. This was in patients who had hallux valgus with painful plantar callosities. The review covered seven years of procedures (1989-1996) in 12 patients (14 feet) averaging 53 years of age. Average follow-up was 52 months. All patients had pain at the first metatarsophalangeal joint and had metatarsalgia preoperatively. At follow-up, 11 feet had no pain at the first metatarsophalangeal joint, and three had some improvement of pain. Ten feet had no metatarsalgia, two had improvement of metatarsalgia, and two feet had transfer lesions postoperatively and required reoperation. The angle of hallux valgus averaged 40 degrees preoperatively and 13 degrees postoperatively. The intermetatarsal angle averaged 18 degrees preoperatively and 6 degrees postoperatively. Mean decreases in length of the second and third metatarsal after surgery were 5.4 mm and 4.8 mm, respectively. Our results suggested that this combined procedure for hallux valgus with painful plantar callosities may be successful, in carefully selected patients.     

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.

     

The effects of a medializing calcaneal osteotomy with and without superior translation on Achilles tendon elongation and plantar foot pressures

BACKGROUND: The medial calcaneal osteotomy (MCO) is a frequently used corrective procedure for posterior tibial tendon (PTT) insufficiency; however, patients often complain of lateral foot pain postoperatively. Published findings have documented the usefulness of MCO in off-loading the plantar surface of the first and second metatarsal heads but with a concomitant increase in peak pressure over the lateral forefoot and heel. Achilles tendon elongation revealed a trend toward shortening of the ventromedial aspect of the tendon. It was then hypothesized that translating the osteotomized posterior aspect of the calcaneus medially and superiorly would reduce lateral forefoot pressure and decrease the amount of lengthening of the Achilles tendon while continuing to relieve medial forefoot pressure. METHODS: Twenty-eight fresh-frozen cadaver legs were axially loaded on a load-frame device to 100 lbs to assess the effects of a 1-cm MCO in conjunction with either 0.5-cm or 1-cm superior translation on plantar foot pressures and Achilles tendon elongation. RESULTS: The 0.5-cm superior translation resulted in a greater off-loading of the first and second metatarsals than the MCO alone with a trend toward decreased pressures in the lateral forefoot. The 1-cm superior translation continued to unload the first and second metatarsals; however, lateral forefoot and midfoot pressures were increased. Achilles tendon lengthening remained unchanged in the cadaver foot model. CONCLUSIONS: Our findings suggest that the addition of a 0.5-cm superior translation to the traditional 1-cm MCO should allow some degree of off-loading of the medial forefoot without increasing lateral forefoot or heel pressures.     

The modified Wilson osteotomy for hallux valgus

The modified Wilson osteotomy for hallux valgus is a double oblique osteotomy through the metatarsal shaft. The distal fragment is displaced laterally and plantarward. The lateral displacement corrects the varus position of the metatarsal, while the plantar displacement prevents the distal fragment from tilting dorsally into a metatarsus elevatus deformity that could produce metatarsalgia. Seventy-four cases of hallux valgus treated by this method were reviewed five years postoperatively. Sixty-six cases (89%) were graded as satisfactory and eight (11%) as unsatisfactory. Roentgenographic analysis in 61 cases showed the operation had reduced the hallux valgus angle by an average of 15 degrees and the intermetatarsal angle by an average of 4 degrees. The operation shortened the first metatarsal by an average of 5 mm. Although this caused callosities on the forefoot, it did not produce metatarsalgia. The operation is technically uncomplicated and yields a high percentage of satisfactory results.     

Plantar pressure and load in cadaver feet after a Weil or chevron osteotomy

BACKGROUND: Since metatarsal osteotomy was first used to treat metatarsalgia in the early twentieth century, many techniques have been described to accomplish the basic aim of reduction of load transmission through the operated metatarsal and reduction of localized high pressure on the plantar surface of the metatarsal. Our study examined two popular distal metatarsal neck osteotomies used for the relief of central metatarsalgia and the biomechanical changes that result from their use in a cadaver forefoot model. METHODS: After applying 445 N (100 lbs) of axially directed force, we measured plantar pressure using the TekScan HR Mat (TekScan, Inc., South Boston, MA) in twelve paired, thawed, fresh-frozen intact cadaver legs, then after either a Weil or chevron osteotomy of the second metatarsal and finally after the addition of the same osteotomy of the third metatarsal. RESULTS: Load in the forefoot was not significantly affected by the Weil osteotomy. A significant increase in load was produced in the first metatarsal region, and significant decreases in load were produced beneath the operated metatarsal heads after the chevron osteotomy. Average pressure in the contact area of the forefoot showed similar trends; however, load and pressure changes occurred independently, owing to the changes in contact area produced by the osteotomies. No significant changes were observed in the nonoperated metatarsal regions. CONCLUSIONS: In this model, the chevron osteotomy more effectively reduced load and plantar pressure in the operated metatarsal regions; however, increases in load and pressure were observed in the first metatarsal region. The increase in pressure without a change in load in region 3 (third metatarsal) after a Weil osteotomy of the third metatarsal was attributed to the creation of a plantar prominence. This study did not show a reduction in load transmission as a result of the Weil osteotomy, which contradicts the proposed mechanism of clinical benefit. An intact first ray likely prevents transfer of load or pressure to adjacent lesser metatarsals with chevron osteotomy.     

Consequences of partial and total plantar fascia release: a finite element study

BACKGROUND: Plantar fasciotomy, a common operative procedure to relieve chronic heel pain, has been suggested to decrease foot arch stability. A systematic evaluation of the biomechanical consequences of partial or total plantar fascia release is essential to the understanding of the biomechanical rationale behind these operative procedures. METHODS: A geometrical detailed three-dimensional (3-D) finite element (FE) model of the human foot and ankle, incorporating geometrical and contact nonlinearities, was constructed by 3-D reconstruction of MR images. Partial and complete plantar fascia releases were simulated to evaluate the corresponding biomechanical effects on load distribution of the bony, ligamentous, and encapsulated soft-tissue structures. RESULTS: Partial and total plantar fascia release may decrease arch height but did not necessarily cause total collapse of the foot arch even with additional dissection of the long plantar ligament. Operative release of the plantar fascia was compromised by increased strains of the plantar ligaments and intensified stress in the midfoot and metatarsal bones. Load redistribution among the centralized metatarsal bones and focal stress relief at the calcaneal insertion were predicted with different types of fasciotomy. CONCLUSIONS: The FE model suggested that plantar fascia release may provide relief of focal stress and therefore could relieve associated heel pain. However, these operative procedures may pose a risk to arch stability and clinically may produce dorsolateral midfoot pain. The initial strategy for treating plantar fasciitis should be nonoperative. If surgery is necessary, partial release of less than 40% of the fascia is recommended to minimize the effect on arch instability and maintain normal foot biomechanics.     

Comparison of plantar pressure, clinical, and radiographic changes of the forefoot after biplanar Austin osteotomy and triplanar Boc osteotomy in patients with mild hallux valgus

BACKGROUND: Boc's modification of the Austin procedure is a triplane distal osteotomy that achieves shortening and plantarflexion of the first metatarsal with a lateral translation of the metatarsal head. The clinical results and influence of the Austin and Boc osteotomies on plantar pressure have been compared retrospectively. MATERIALS AND METHODS: The patients were divided into two groups: 30 Austin and 30 Boc osteotomies were performed with a mean followup of 37 (range, 29 to 56) months. RESULTS: Sixty patients with mild hallux valgus deformities and central metatarsalgia, took part in the study. Pressure measurements were performed with a Diagnostic Support system footplate. The average postoperative American Orthopaedic Foot and Ankle Society score of the Austin group was 81.9 and 86.4 for the Boc group. The pressure distributions under the fourth and fifth metatarsal head were comparable in both groups (p>0.05). The Austin group showed decreased load bearing under the hallux and the first metatarsal head (p<0.01), consistent with a persistent overloading of the second and third metatarsal head (p>0.05). The Boc group showed decreased weightbearing under the hallux with better load distribution beneath the second and the third metatarsal head (p<0.05). Correlation of the American Orthopaedic Foot and Ankle Society scores and pressure variables confirmed a significant negative correlation with altered hallux and central metatarsal head loading (p<0.01). CONCLUSION: The Boc triplane osteotomy seems to restore more physiologic loading of the forefoot in comparison to the Austin procedure, reducing the incidence of painful callus under the second and third metatarsal head.     

Modifications of the Weil osteotomy have no effect on plantar pressure

Previous studies have shown that increasing angulation of the Weil osteotomy produces greater plantar translation of the metatarsal head. Modifications have been proposed to reduce plantar translation. However, there is no evidence that the increased plantar translation with a Weil osteotomy is clinically significant or that these modifications are required. Ten lower extremities consisting of five matched pairs were used to evaluate whether different configurations of the Weil osteotomy altered plantar pressure in a dynamic cadaver model. For each pair, an oblique Weil osteotomy with a 5-mm shift was done on one side and a standard (parallel) Weil osteotomy with a 5-mm shift was done on the matched foot. A 4-mm slice resection and a metatarsal head resection then were done sequentially. Plantar pressures were measured with cyclic loading to 700 N at a frequency of 1 Hz with an F-scan in-shoe sensor on the intact specimens and after each intervention. Increased plantar translation of the metatarsal head with a more oblique Weil osteotomy did not significantly increase plantar pressure, and the 4-mm slice resection did not significantly unload the metatarsal head. Only complete metatarsal head resection significantly unloaded the metatarsal head.     

Shortening Proximal Chevron Metatarsal Osteotomy for Patients With a Hallux Valgus Deformity With Advanced Arthritis

To correct hallux valgus deformities in patients with advanced arthritis of the first metatarsophalangeal joint, we designed a new reverse chevron-type shortening osteotomy technique that could be used to correct valgus deformities at the proximal metatarsal level, as well as shorten and lower the metatarsal, in a 1-time procedure. Sixteen feet in 16 patients with a minimum of 18 months follow-up who underwent a shortening proximal chevron metatarsal osteotomy for a hallux valgus deformity with advanced arthritic change between January 2014 and March 2016 were reviewed in this study. Double chevron osteotomies with 20° of plantar-ward obliquity at the proximal metatarsal level were made at 5-mm intervals for simultaneous valgus correction and metatarsal shortening. An additional Weil osteotomy of the second metatarsal was performed in all feet. Patients’ mean age was 57.88 ± 6.55 years. The deformity was satisfactorily corrected by the operation. The first metatarsal was shortened by approximately 8.75 mm, and the relative length of the second metatarsal did not differ significantly postoperatively (p?=?.179). The relative second metatarsal height, as seen on forefoot axial radiographs, was maintained constantly, with no significant difference (p?=?.215). No painful plantar callosity or transfer metatarsalgia under the second metatarsal head was observed postoperatively. A shortening proximal chevron metatarsal osteotomy for hallux valgus deformities with advanced arthritic change showed a good result with respect to deformity correction and pain relief. Appropriate lowering and an additional Weil osteotomy effectively prevented postoperative pain and painful callosity under the second metatarsal head.     

两种第二趾切取游离移植对供足足底应力影响的生物力学研究

目的 探讨第2足趾切取游离移植对供足足底应力的影响.方法 取6具正常成人新鲜尸体足标本,根据不同状态分3组:完整组(A组)、第2趾截除(保留跖骨头)组(B组)及带部分跖骨的第2趾截除(跖骨远l/3处)组(C组).应用电子万能试验机以2 mm/min的速度从胫骨远端施加轴向压载,加载载荷分别为0、600、1200 N.通过F-Scan足底压力测量系统检测足底应力变化,并对数据进行统计学分析.结果 足底应力随轴向压载的增加而增大.A组(足母)指及5个跖骨头的峰值压强以第2跖骨头最大,600 N垂直载荷时为(37.33±7.34)kPa,1200 N垂直载荷时为(112.33±10.33)kPa.同一载荷下,A组与B组的(足母)指及5个跖骨头的峰值压强差异均无统计学意义(P>0.05).同一载荷下,A组、B组分别与C组比较,(足母)指及5个跖骨头的峰值压强差异均有统计学意义(P<0.05).结论 第2跖骨的完整对足底应力正常分布及维持足弓具有重要意义.保留跖骨头的第2趾切取对供足足底应力分布影响较小,带部分跖骨的第2趾切取可导致供足足底应力的异常分配.     

Gastrocnemius fascia release under local anaesthesia as a treatment for neuropathic foot ulcers in diabetic patients: a short series

Background: Diabetic foot ulceration is the leading cause of major amputation in the developed world. Plantar neuropathic ulcers at the forefoot can be managed conservatively with off-loading, but treatment is not invariably successful. Achilles tendon lengthening procedures aim at increasing dorsiflexion and decreasing forefoot pressure but can be associated with complications and require prolonged postoperative immobilization to prevent tendon rupture. We assessed the feasibility and clinical outcome of a comparative minimal invasive procedure: the gastrocnemius fascia release. This technique targets the same goals but is performed under local anaesthesia and allows immediate postoperative weight bearing and ambulation.

Methods: Diabetic patients with plantar neuropathic ulcers Wagner grade 2 or 3 were recruited from our diabetic foot clinic. Patients with infected wounds or untreatable peripheral arterial disease were excluded from the study. Conservative treatment with off-loading and local wound care was attempted for six weeks and surgical procedure only contemplated upon failure. Primary end-points were improved range of dorsiflexion and time to healing. Secondary end-points were local ulcer recurrences, new plantar ulcers, and minor or major amputation. Post-operative follow-up was 12 months.

Results: Seven patients were included in the study. An improvement in dorsiflexion of 10.4° (mean) was recorded post-operatively (p?Conclusions: Gastrocnemius fascia release under local anaesthesia can be performed safely in diabetic patients with plantar neuropathic ulcers under the metatarsal heads. Clinical outcome is excellent and long-term results promising.     

Effect of first metatarsal shortening and dorsiflexion osteotomies on forefoot plantar pressure in a cadaver model

BACKGROUND: Metatarsalgia of the second ray is a common problem associated with disorders of the first metatarsal. It also occurs after the operative treatment of those disorders. Plantar pressure changes from alteration of the static and dynamic structure of the forefoot may be associated with this condition. This study evaluated changes in plantar forefoot pressure especially under the second metatarsal head after three operative procedures on the first ray. METHODS: Each of 12 cadaver foot specimens was cyclically loaded on the servohydraulic MTS Mini Bionix test frame (MTS Systems Corp., Eden Prairie, MN) with traction on the Achilles tendon. Plantar forefoot pressure was measured by the F-scan system (Tekscan, Inc., S. Boston, MA) with the foot intact, after a first metatarsal base dorsal closing-wedge osteotomy with 5-mm base length to simulate dorsal malunion, and after 5-mm and 10-mm metatarsal shortening procedures. Paired Student t-test analysis was used to compare data for the intact foot with data after each intervention. One form of Bonferroni's correction was done to establish a new alpha level to tighten the analysis and to compensate for multiple paired Student t-tests. The significance level was calculated to be 0.016 based on an original alpha level of 0.05. RESULTS: As compared with the intact foot, all three procedures on the first metatarsal resulted in significant decreases in plantar pressure under the first metatarsal head (p < 0.016). Plantar pressure under the second metatarsal head increased significantly as compared with the intact foot (p < 0.016) after all three procedures. Pressures under the third-fourth metatarsal heads increased significantly compared with the intact foot after the 5-mm and 10-mm shortenings (p < 0.016). Plantar pressure under the fifth metatarsal did not change significantly after any of the three procedures. CONCLUSIONS: Dorsiflexion osteotomy and shortening of the first metatarsal are associated with significant forefoot plantar pressure changes in a cadaver model.     

Osteotomies of the fifth metatarsal.

Although the literature is limited primarily to retrospective small case series of the operative technique of fifth metatarsal osteotomies with a short follow-up, some important information can be learned. Stabilization of the osteotomy with Kirschner wire fixation appears to decrease dorsal displacement of the distal fragment and distal osteotomies; this leads to decreased incidence of transfer metatarsalgia. Kirschner wire fixation is advocated. The proximal chevron osteotomy of the fifth metatarsal, although stable, has a 20% delayed union rate, most likely resulting from the unique vascular anatomy in this region. The radiographic and clinical results appear to be compatible between distal and proximal osteotomies. Based on this information, primary use of a proximal osteotomy technique is not recommended. The oblique diaphyseal osteotomy technique requires an incision for the osteotomy as well as a distal incision at the metatarsophalangeal joint for correction of this joint. Hardware removal was performed in most patients, and the complications included two cases of delayed union. Time to healing was reported to be 8 weeks, 1.5 times the reported time to healing in distal chevron osteotomies. A significant radiographic correction was noted with the oblique diaphyseal osteotomy; however, radiographic measurements can be altered with foot position and lack of x-ray standardization and technique. Kitaoka et al found no correlation with the degree of radiographic correction and post-operative clinical symptoms. The authors agree with Kitaoka et al that the oblique diaphyseal osteotomy should be reserved for patients who fail an initial distal osteotomy technique. Distal oblique osteotomies appear to have less stability and more complications with malunion, transfer metatarsalgia, and delayed union and should be abandoned for a more stable chevron technique. The distal chevron osteotomy has a small incidence of transfer metatarsalgia; however, it appears to improve the clinical radiographic appearance of [table: see text] the foot with a shortened time to healing (4 to 6 weeks). A biplanar technique can be employed with a distal chevron osteotomy to improve plantar callosity symptoms. More studies are needed to examine critically patient outcomes with uniplanar and biplanar techniques using the distal chevron osteotomy.     

Treatment of metatarsalgia based on claw toe deformity through soft tissue release of the metatarsophalangeal joint and resection of the proximal interphalangeal joint: Evaluation based on foot kinematics and plantar pressure distribution

IntroductionThis study investigated the effect of operative claw toe correction with release of the metatarsophalangeal (MTP) joint, repositioning of the plantar fat pad and resection of the proximal interphalangeal joint on foot kinematics, plantar pressure distribution and Foot Function Index (FFI).MethodsProspective experimental study with pretest-posttest design. The plantar pressure, 3D foot kinematics and the FFI of 15 patients with symptomatic claw toes were measured three months before and 12 months after surgery. Mean pressure, peak pressure and pressure time integral per sensor and various foot angles were calculated for the pre- and posttest and compared to a control group (N = 15).ResultsClaw toe patients have increased pressure under the distal part of the metatarsal head and less pressure under the proximal part of the metatarsal heads compared to healthy controls. After surgery, there was a redistribution of pressure, resulting in a significant decrease of pressure under the distal part and an increase under the proximal part of the metatarsal head, providing a more equal plantar pressure distribution. Except for some small areas under the forefoot, heel and toes, there were no significant differences in pressure distribution between the operated feet and controls. Small, but significant differences between the pre- and postoperative condition were found for the lateral arch angle, calcaneus/malleolus supination and tibio-talar flexion. The score on the FFI improved statistically significant.DiscussionThese findings imply that the present operative procedure results in a more equal distribution of the plantar pressure under the forefoot and decrease of pain and offers successful treatment of metatarsalgia based on claw toe deformity.     

Clinical results with the Ludloff osteotomy for correction of adult hallux valgus

BACKGROUND: Biomechanically, the Ludloff osteotomy fixed with lag screw compression has been shown to be more rigid than proximal crescentic and other proximal first metatarsal osteotomies for correction of symptomatic hallux valgus with a moderate to severe increase in the first intermetatarsal angle. The Ludloff osteotomy may, therefore, have a lower incidence of dorsal malunion and transfer metatarsalgia than other proximal first metatarsal osteotomies, such as the crescentic or chevron. METHODS: We reviewed the results of 82 consecutive cases of moderate to severe hallux valgus deformities corrected with the Ludloff oblique metaphyseal-diaphyseal osteotomy of the first metatarsal combined with a distal soft-tissue procedure and medial eminence resection. RESULTS: Follow-up was possible in 70 cases (85%) at an average of 30 months (range, 18 to 42 months). Preoperatively, the mean hallux valgus and first intermetatarsal angles were 31 degrees and 16 degrees, respectively. Postoperatively, these values improved to an average of 11 degrees and 7 degrees. In the sagittal plane, the first metatarsal was plantarflexed by an average of 1 mm, and there were no symptomatic transfer lesions of the second metatarsal. The mean AOFAS hindfoot score improved from 54 to 91 points. Complications included prominent hardware requiring removal (5), hallux varus (4), delayed union (3), superficial infection (3), and neuralgia (3). CONCLUSIONS: The use of the Ludloff oblique first metatarsal osteotomy resulted in excellent correction of the first intermetatarsal angle in patients with moderate to severe hallux valgus. With the plane of the osteotomy and rigidity of fixation, immediate ambulation was possible with minimal risk of dorsiflexion malunion of the first metatarsal.     

The Weil osteotomy for the treatment of painful plantar keratoses

Management of painful plantar corns remains challenging. Failure of conservative treatment may necessitate surgical intervention. The aim of this study was to assess the effectiveness of the Weil osteotomy in the treatment of painful plantar corns. A total of 29 patients (33 feet) underwent Weil osteotomy combined with plantar lesion excision of a single metatarsal of either the second, third or fourth metatarsals. These were reviewed post-operatively at an average of 42.4 months. At final review, nine feet (27%) presented with a corn. Four feet (12%) developed transfer metatarsalgia with a total of seven feet (21%) requiring revision surgery. The average metatarsal shortening was 4.5 mm. Requirement for regular clinical lesion reduction fell from an average of 5.6 weeks to 12 weeks (P<0.001) between treatments and the American Orthopaedic Foot And Ankle Society clinical rating scale improved by an average of 48 points (P<0.001). The Weil osteotomy is a moderately effective intervention which should be considered in planning the treatment of intractable plantar corns.