Effects of restriction of forefoot rocker functions by immobilisation of metatarsophalangeal joints on kinematics and kinetics during walking

ObjectiveThis study was conducted to investigate the effects of restriction of forefoot rocker (FFR) functions by immobilisation of unilateral metatarsophalangeal joints (MPJs) on kinematic and kinetic factors during walking.MethodsEighteen healthy young adults participated in this study. To immobilise the MPJs of the right leg, an aluminium sole plate (AS) was fixed on the sole of the foot. Kinematic and kinetic data were collected while each subject walked at a comfortable speed with the AS and without.ResultsIn the AS condition, the walking speed and contralateral step length were significantly decreased, and an asymmetrical centre of mass (COM) movement was observed. The range of plantarflexion motion and positive work by the ankle joint were decreased markedly during the late stance of the AS limb. In contrast, maximum hip and knee flexion angles in the swing phase of the AS limb and positive work by the bilateral hip joints over the gait cycle were increased.ConclusionsThe results suggested that MPJ immobilisation may result in marked motion limitation of ankle plantarflexion and inhibition of push-off by the ankle joint despite no restrictions on the ankle joint. These changes may interfere with gait speed and a smooth and symmetrical COM shift during walking.     

Closed Transverse Pinning for Reduction and Fixation of Metatarsal Neck Fractures: Surgical Technique

Most metatarsal neck fractures can be successfully treated non-operatively in a cast boot. Displaced metatarsal neck fractures tend to be less stable and have a propensity for the distal fragment to angulate, secondary to the strong flexor tendons, which often forces the distal fracture fragment in a plantar direction and leads to relative metatarsal shortening. Most literature is focussed on antegrade fixation of metatarsal neck fractures using pre-bent K wires or thin elastic nails. Apart from the technical challenges, this technique is limited when bones are osteoporotic as the pre-bent distal end of the K-wire may penetrate the plantar cortex of the proximal metatarsal and prevent the wire from entering the medullary canal of the metatarsal and advancing to the fracture site. Furthermore, when the medullary canal is narrow especially in Asian patients, it may be difficult to pass a bent K-wire through the isthmus of the metatarsal shaft. We describe an innovative technique of closed transverse wiring of the metatarsal head necks that has a distinct advantage in Asian population with osteoporotic bones. With percutaneous manipulation using digital pressure, closed reduction of fracture fragments of the most displaced fracture is done under fluoroscopic guidance to achieve a satisfactory alignment followed by closed transverse wiring of the metatarsal heads. With this procedure, adjacent fractures remain stable within an acceptable range because of intermetatarsal ligaments connected to the adjacent intact head. Our technique has a relatively short operating time and allows for early motion of the metatarso-phalangeal joint. This is especially useful for those with osteoporosis, narrow canal, soft tissue compromise, intra-operative failure of ante-grade pinning and in scenarios of limited surgical equipment/expertise.     

Effects of running-induced fatigue on plantar pressure distribution in runners with different strike types

BackgroundRunning induced-fatigue is an important factor in running related injuries. Runners with different strike types have different running mechanics and suffer from different injury patterns. Underlying mechanism of this difference is not well understood.Research questionThe aim of this study was to examine the effects of running-induced fatigue on plantar pressure distribution in runners with different strike types.Methods30 rearfoot (age = 21.56 ± 2.28 years; height = 1.67 ± 0.08 m; mass = 61.43 ± 11.57 kg; BMI = 21.77 ± 2.9 kg∙m⁻²) and 30 forefoot (age = 19.73 ± 1.68 years; height = 1.71 ± 0.08 m; mass = 65.7 ± 13.45; BMI = 22.53 ± 3.39 kg∙m⁻²) strike male and female recreational runners were recruited to this study. Participants ran in 3.3 m/s barefoot along the plantar pressure measuring device (Footscan®, Rsscan International) before and after running-induced fatigue. Fatigue protocol was performed on a treadmill. Peak plantar pressure and peak plantar force (% body weight), contact time and medio-lateral force ratio were calculated while running. Repeated measures ANOVA test was used to investigate the effect of running-induced fatigue on plantar pressure variables (p ≤ 0.05).ResultsAfter running-induced fatigue, in the rearfoot strike group, increases in loading of medial and lateral portions of the heel, first metatarsal and big toe was observed, and in lesser toes and in the forefoot push off phase, the medio-lateral force ratio decreased. While, in the forefoot strike group first to third metatarsals loading increased and fifth metatarsal loading decreased after fatigue, and medio-lateral force ratio in the foot flat and forefoot push off phase increased. In both groups contact time increased after fatigue.SignificanceOur data indicate that running-induced fatigue has different effects on plantar pressure distribution pattern in runners with different strike type. These different effects reflect different adaptation strategies in runners with different strike types, and could explain existence of different injury patterns in runners with different strike types.     

Reprint: Sehnentransfers in der Vorfußchirurgie

The aim of the current forefoot surgery is to retain function or to restore lost function. In contrast, in the past resection arthroplasty or amputation of the lesser toes were common. Included in the repertoire of every specialist are different operation techniques especially the tendon surgery, in addition to experience in indication and rehabilitation. It is important, that the focus during history taking, clinical examination and choice of treatment should not only be on the forefoot but also on the axis of the leg and the hindfoot position and function. As an example, the recruitment of the extensor digitorum longus – meaning the excessive support by the toe extension for forefoot extension – over time results in hammer toes. In some cases this excessive recruitment is the result of the rupture of the tibialis anterior tendon. Therefore, one should address the cause and repair the tibialis anterior tendon by suture and/or augmentation and not operate on the hammer toes in isolation.     

Comparison between resection arthroplasty alone and resection arthroplasty with arthrodesis of the first MTP joint for rheumatoid forefoot deformities

It has been reported that nearly 90% of patients with rheumatoid arthritis (RA) have problems with their feet. Several methods of treating hallux valgus deformity in RA have previously been reported, including arthrodesis and joint resection, and good results have been observed with surgical procedures. In this report, we compare the clinical and radiological outcomes of resection arthroplasty alone (the first method) and resection arthroplasty with arthrodesis of the first MTP joint (the second method) for the treatment of forefoot deformities of RA patients. On clinical assessment, the American Orthopaedic Foot and Ankle Society (AOFAS) scale score significantly improved in both methods; however, the second method gave better results than the first method in relation to the footwear and alignment components. On radiographic assessment, in the first method there were no significant changes in the valgus angle (H–V angle) and the fifth metatarsal bone (M1/5) angle between preoperation and last follow-up. In contrast, these angles were decreased in the second method. One of the most important issues in the treatment of forefoot deformities in RA patients is to correct splaying foot deformity. We believe that the second method, which can correct splaying foot deformity, is currently the most reliable treatment method.     

Foot pronation during walking is associated to the mechanical resistance of the midfoot joint complex

BackgroundThe demonstration of the relationship between midfoot passive mechanical resistance and foot pronation during gait may guide the development of assessment and intervention methods to modify foot motion during gait and to alter midfoot passive mechanical resistance.Research questionIs foot pronation during the stance phase of gait related to the midfoot passive mechanical resistance to inversion?MethodsThe resistance torque and stiffness provided by midfoot soft tissues of 33 participants (21 females and 12 males) with average of 26.21 years were measured. In addition, the participants’ forefoot and rearfoot kinematic data during the stance phase of gait were collected with the Qualisys System (Oqus 7+). Correlation Coefficients were calculated to test the association between kinematic variables representing pronation (forefoot-rearfoot inversion, forefoot-rearfoot dorsiflexion and rearfoot-shank eversion) and maximum resistance torque and maximum stiffness of the midfoot with α = 0.05.ResultsReduced maximum midfoot resistance torque was moderately associated with increased forefoot-rearfoot inversion peak (p = 0.029; r = 0.38), with forefoot-rearfoot dorsiflexion peak (p = 0.048; r = −0.35) and with rearfoot-shank eversion peak (p = 0.008; r = −0.45). Maximum midfoot stiffness was not associated to foot pronation.SignificanceThe smaller the midfoot resistance torque, the greater the forefoot-rearfoot inversion and dorsiflexion peaks and the rearfoot-shank eversion peak during gait. The findings suggest the existence of a relationship between foot pronation and midfoot passive mechanical resistance. Thus, changes in midfoot passive mechanical resistance may affect foot pronation during gait.     

Beiträge der Österreichischen Fußchirurgie zum Thema Osteotomien an den distalem Metatarsalia 2-5

Metatarsalgia is a common and well-known problem in the orthopedic office. Since 1916 metatarsal osteotomies are described for the treatment of this pathology. Austrian orthopedic surgeons and Foot & Ankle specialists have worked on this topic. A special focus was on the clinical and biomechanical analysis of the Weil osteotomy. Also, the next step of the evolution of the treatment of metatarsalgia, the DMMO (Distal Metaphyseal Metatarsal Osteotomy) was accompanied with clinical studies. Recent literature shows that if the criteria of indications are respected, the DMMO is a reproducible and safe technique. Since this technique has shown a learning curve, thorough training is necessary.     

Minimally invasive surgery for severe hallux valgus in 106 feet

BackgroundThere is widespread variation in the optimal procedure for correction of severe hallux valgus deformity defined as hallux valgus angle (HVA) (≥40°) and/or 1–2 intermetatarsal angle (IMA) (≥20°). There is limited evidence investigating the clinical or radiological outcomes following treatment of severe hallux valgus deformity with third-generation minimally invasive chevron and Akin osteotomies (MICA).MethodsThis was a prospective observational single surgeon series of consecutive patients who underwent primary third-generation MICA with screw fixation for severe hallux valgus. The primary outcome was a validated patient reported outcome measure (PROM), the Manchester-Oxford Foot Questionnaire (MOXFQ), assessed minimum 2 years following MICA. Secondary outcomes were radiographic deformity correction (assessed 6 weeks post-operatively), complication rates and other quality of life PROMs (EQ-5D and Visual Analogue Pain Scale).ResultsBetween September 2014 and November 2018, 106 consecutive feet (n = 78 patients; 73 female, 5 male) met the inclusion criteria. Prospectively collected pre-operative and 2 year PROM MOXFQ data was available for 86 feet (81.1%). At two years following surgery, the MOXFQ score significantly improved for the Pain, Walking and Standing and Social Interaction domains from 39.2 to 7.5, 38.2 to 5.9 and 48.6 to 5.5, respectively (p < 0.001). Pre- and 6 week post-operative radiographic data was available for all 106 feet. Mean IMA improved from 18.2° to 6.3° (p < 0.001) whilst mean HVA improved from 45.3° to 10.9° (p < 0.001). The complication rate was 18.8% and the screw removal rate was 5.6%.ConclusionThis study has demonstrated third-generation MICA for the treatment of severe hallux valgus deformity enables substantial deformity correction and is associated with significant improvements in clinical PROMs 2 years following surgery.     

Assessment of the severity of curly toe

BackgroundCurly/underlapping toe involves flexion, adduction, and varus deformity of the interphalangeal joints. There are no previous reports showing the relationship between physical examination and X-ray findings among patients with curly toe deformity.MethodsWe investigated the clinical findings of 116 consecutive patients associated with 239 underlapping toes. We compared the age and affected toes between patients whose deformities were pointed out at a pediatric medical examination (group 1) and those referred for medical treatment (group 2). The degree of curly toe deformity was graded by a physical examination and X-ray.ResultsThe average age at presentation was 2.7 years. The affected toes were significantly different between groups 1 and 2 (p < .001). The morbidity of each toe differed significantly in group 2 (p < .005) but not in group 1. The correlation between the appearance grading and classification by X-ray was very strong using Spearman's rank correlation coefficient. The severity of curly toe was divided into mild in 104 toes, moderate in 105 toes, and severe in 17 toes. The methods of conservative treatment were observation only in 15 cases, manipulations in 30 cases, taping in 67 cases, and a brace in 9 cases. Surgery was performed in 8% of cases.ConclusionCurly toe deformity of the third or fourth toes tend to be referred for medical treatment because of the abnormality. Our grading system using a physical examination and classification by X-ray was useful for assessing the severity of curly toe.     

Midfoot and forefoot osteoarthritis

BackgroundFoot osteoarthritis (OA) is linked with chronic foot pain and functional impairment.ObjectiveTo review the current knowledge on midfoot and forefoot OA.MethodsPubMed, CINAHL, PEDro, and the ISI Web of Science databases (1950–2013) were searched for keywords: foot OA, midfoot OA, forefoot OA and metatarsal OA. The search was limited to reports in human subjects and English language. Published cohort, cross-sectional studies and clinical trials relating to epidemiology, clinical features, functional impairment, risk factors and treatment were included.ResultsWe found heterogeneity in the design, radiographic views and grading systems used among studies. Most of the literature focused on radiographic OA, being the prevalence between 0.1% and 61%, depending on gender, age and joint evaluated. The age and female gender were the main associated factors, whereas structural (bone length) and mechanical factors (hypermobility, altered tarso-metatarsal stress, etc.) seemed to be related. Various treatments are widely used, i.e. physical therapy, orthotics, steroid injection, analgesics and arthrodesis. However, scarce research supports their efficacy.ConclusionMost of the current knowledge comes from observational and small case–control studies. Future population-based studies as well as controlled studies are essential to understand the risk factors and to evaluate the effectiveness of treatment options.