Proximal opening wedge metatarsal osteotomy for correction of moderate to severe hallux valgus deformity using a locking plate

Purpose

Hallux valgus is a complex deformity of the first metatarsophalangeal joint, with varus angulation of the first metatarsal, valgus deviation of the great toe and lateral displacement of the sesamoids and the extensor tendons. The aim of the surgery is to achieve correction of the varus deviation of the 1st metatarsal which is considered by some as the primary intrinsic predisposing factor to hallux valgus deformity.

Methods

We retrospectively reviewed 85 patients (107 feet) who underwent an opening wedge osteotomy of the 1st metatarsal for correction of moderate to severe hallux valgus and metatarsus primus varus. A medially applied anatomic pre-contoured locking plate was used for fixation of the osteotomy.

Results

The mean IMA was decreased from 15.8 (range 12–22) degrees to 7.8 (range 0–12) degrees. The mean pre-operative HVA was 39 (range 21–52) degrees and the mean postoperative HVA was 11.8 (6–19) degrees. The pre-operative AOFAS score was 52 (SD 3.1) and the postoperative score was 85 (SD 5.2).

Conclusion

The proximal opening wedge metatarsal osteotomy is a safe, effective and reproducible technique for correction of moderate to severe hallux valgus deformity. The use of a locking plate provides enough control at the fragments, enhancing healing of osteotomy and maintenance of the correction even with a violated proximal lateral cortex.     

Treatment principles for osteochondral lesions in foot and ankle

Osteochondral lesion of the talus (OLT) is a broad term used to describe an injury or abnormality of the talar articular cartilage and adjacent bone. A variety of terms have been used to refer to this clinical entity, including osteochondritis dissecans (OCD), osteochondral fracture and osteochondral defect. Whether OLT is a precursor to more generalised arthrosis of the ankle remains unclear, but the condition is often symptomatic enough to warrant treatment. In more than one third of cases, conservative treatment is unsuccessful, and surgery is indicated. There is a wide variety of treatment strategies for osteochondral defects of the ankle, with new techniques that have substantially increased over the last decade. The common treatment strategies of symptomatic osteochondral lesions include nonsurgical treatment, with rest, cast immobilisation and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical options are lesion excision, excision and curettage, excision combined with curettage and microfracturing, filling the defect with autogenous cancellous bone graft, antegrade (transmalleolar) drilling, retrograde drilling, fixation and techniques such as osteochondral transplantation [osteochondral autograft transfer system (OATS)] and autologous chondrocyte implantation (ACI). Furthermore, smaller lesions are symptomatic and when left untreated, OCDs can progress; current treatment strategies have not solved this problem. The target of these treatment strategies is to relieve symptoms and improve function. Publications on the efficacy of these treatment strategies vary. In most cases, several treatment options are viable, and the choice of treatment is based on defect type and size and preferences of the treating clinician.     

A biomechanical study of two postoperative prostheses for transtibial amputees: a custom-molded and a prefabricated adjustable pneumatic prosthesis

We evaluated an adjustable pneumatic prefabricated prosthesis and a rigid custom-molded prosthesis for immediate postoperative use. Twelve transtibial amputations were performed on cadaver limbs. Differential variable reluctance transducers were placed subcutaneously across the wound edge medially and laterally. The limbs were then placed in either the pneumatic prosthesis (five limbs) or the rigid prosthesis (seven limbs). The specimens underwent static and cyclic loading to simulate weight bearing. The strain readings for static and cyclic loading were greater in the rigid prosthetic group. Only the mean medial strain measurement after cyclic loading was statistically significant. The results demonstrate that the pneumatic prosthesis places less strain across the wound than a rigid prosthesis.     

Hypermobility of the first ray

Hypermobility of the first ray is one of the causative components in common foot problems (such as hallux valgus) with a large intermetatarsal angle and metatarsus primus varus. Although not always associated with hallux valgus, hypermobility is a predisposing factor for this deformity, especially in conjunction with extrinsic factors, such as disruption of the plantar first metatarsal cuneiform ligament and tendon-muscle imbalance. Hypermobility is also frequently found in adolescents with hallux valgus, especially when associated with a large intermetatarsal angle. Motion at the first metatarsocuneiform joint occurs in the sagittal and transverse planes. Most studies agree that greater than 4 degrees and greater than 8 degrees, respectively, constitutes excessive motion. Clinically, hypermobility is evaluated by determining sagittal motion (the grasping test) and transverse motion (the clinical squeeze test) and by identifying signs such as the presence of a dorsal bunion, intractable plantar keratosis beneath the second metatarsal head, and arthritis of the first and second metatarsocuneiform joint. Radiographically, hypermobility is evaluated by measurements from the modified Coleman block test (for sagittal motion) and the radiographic squeeze test (for transverse motion) and by the identification of signs, such as cortical hypertrophy along the medial border of the second metatarsal shaft, a cuneiform split, the presence of os intermetatarseum, and the round shape and increased medial slope of the first metatarsocuneiform joint. Usually, treatment for hypermobility of the first ray is operative, but surgery is contraindicated for patients less than 20 years of age (especially when the epiphysis is not closed) and for patients with generalized ligamentous laxity, short first metatarsal, and arthritis of the hallux MTP joint. The authors' surgical treatment of choice is arthrodesis of the tarsometatarsal joint (as part of the hallux valgus correction), exostectomy, capsulorraphy, and distal soft tissue release to correct and stabilize the first metatarsal at the apex of the deformity. The authors have found it unnecessary to include the base of the second metatarsal. The main complications associated with the Lapidus procedure and its modifications are nonunion, malunion, and dorsal elevation of the first metatarsal. Although radiographic nonunion is the most frequent complication, only 25% of the patients with this condition have associated clinical findings; the results have been defined as good or excellent in two series. These results closely equal those in rheumatoid or sedentary patients managed with newer, modified, less traumatic techniques that stabilize the first metatarsocuneiform joint with screws rather than with arthrodesis.     

Multifocal Epithelioid Hemangioendothelioma of the Foot and Ankle Developing a Postoperative Infection—Long-term Outcome: A Case Report

A case of rare epithelioid hemangioendothelioma with multiple foot and ankle lytic lesions in a 41-year-old male is reported. The patient presented to our hospital after having received treatment elsewhere and developing a local postoperative infection. After thorough investigations and establishing the diagnosis, we initially treated the local infection and highlighted the potential risk of malignancy. Finally, respecting the patient's wishes, he was treated with consideration mostly of the pending foot and ankle fractures rather than the risk of malignancy. At 9.5 years postoperatively, the patient was clinically well and asymptomatic, without clinical, laboratory, or radiologic signs of malignancy, and the previous infection might have even played a remote role in that outcome. A review of the published data regarding the treatment of this unpredictable neoplasm is also presented.     

The acquired midtarsus deformity classification system--interobserver reliability and intraobserver reproducibility

A radiographic classification (Schon's) divides Charcot midtarsus deformities into four types identified by Roman numerals (I to IV), according to the anatomical location of the pathological process,11 and an objective method of severity staging using radiographic criteria is introduced and tested. A beta stage is assigned if one of the following criteria is met: 1. a dislocation is present; 2. the lateral talar-first metatarsal angle is > or = 30 degrees; 3. the lateral calcaneal-fifth metatarsal angle > or = 0; or 4. the AP talar-first metatarsal angle is > or = 35 degrees. An alpha stage can be assigned when all four features are absent. Clinical features useful in assessing and managing these deformities have been associated with the various types and stages. To determine whether the classification system is valid, a study was performed. Two examination booklets and an instructional booklet designed to teach the method were distributed to 75 orthopaedic surgeons at the AOFAS summer meeting to test for intraobserver reproducibility and interobserver reliability. Information about the participants was recorded, and the tests were scored. The highest scores for correct responses were achieved by foot and ankle fellows, followed by orthopaedic residents. Attending orthopaedic surgeons achieved the lowest scores. The most common error was a type I deformity misidentified as a type II. The interobserver reliability for correctly classifying the deformities was 81%, and the intraobserver reproducibility was 97%. We concluded that this classification system, intended to clarify the patterns of acquired midfoot collapse, permits assignment of both anatomic type (I to IV) and degree of severity (alpha-beta) with high reliability and reproducibility. It can therefore be used as a tool for diagnosis, planning treatment, and assessing the prognosis.     

Foot malignancies: a multidisciplinary approach

Malignant osseous and soft tissue tumors of the foot are rare and should be considered in patients who have foot-related symptoms. Most sarcomas affect patients who are older than 55 years; however, many young patients who are otherwise healthy, may present with malignant foot and ankle lesions. In addition to benign and malignant neoplasms, pseudotumorous conditions mimic neoplastic lesions and should be differentiated before any treatment is undertaken. Invasiveness is a characteristic of sarcomas. The foot is a terminal anatomic structure, with closed and tight compartments and well-vascularized tissues, that predispose it to hematogenous and lymphatic metastases. Patients who have a malignant foot tumor should be referred to an orthopedic oncologist for further evaluation and treatment. The goals of treatment include local tumor control, restoration of function and stability during standing and walking, long-term survival, and improved quality of life. In most cases, wide surgical margins require a ray, Syme, midtarsal, or below-the-knee amputation. Recent advances in chemotherapy and radiotherapy have allowed limb salvage procedures with wide tumor resections. Because overall survival is greatly improved in these patients, the reconstruction of skeletal defects needs to be more functional and durable. After tumor resection, reconstruction of the skeletal and soft tissue defects is possible by using bone allografts or vascularized autografts, arthrodesis, and free vascularized musculocutaneous flaps.     

Subject Index to Volume 3 (2005)

SUBJECT INDEX TO VOLUME 3 (2005)

Subject Index to Volume 3 (2005)     

The effect of different skin-ankle brace application pressures on quiet single-limb balance and electromyographic activation onset of lower limb muscles

Background  

Several studies have been carried out in order to investigate the effect of ankle bracing on ankle joint function and performance. However, no study so far has examined the role of skin-brace interface pressure in neuromuscular control. The aim of this study was to investigate the effect of different skin-ankle brace interface pressures on quiet single limb balance and the electromyographic (EMG) activation sequence of four lower limb muscles.     

Foot and ankle injuries during the Athens 2004 Olympic Games

The Athens Olympic Games in 2004 represented a significant sporting and medical challenge. Major, rare and complex incidents can occur at any mass gathering sporting festival and team medical staff should be appropriately prepared for these. During the 2004 Olympic Games, injuries in all sport tournaments (both men and women) were analyzed. A total of 624 injuries (520 soft tissue injuries and 99 bony injuries) were reported. The most prevalent diagnoses were contusions, sprains, fractures, dislocations and lacerations. Significantly more injuries in men athletes (68%) versus women athletes (32%) were recorded. The incidence, diagnosis, and causes of injuries differed substantially between the team sports. This study concerns an epidemiologic analysis to determine the incidence rate of foot and ankle injuries as well as the treatment options of these lesions in the field and in short term during the time frame of the Games. Also analyze the function modalities of the Foot and Ankle Clinic and the cooperation of the different medical specialities that dealing with foot and Ankle Sport Injuries.