1st Metatarsophalangeal Joint Research Articles

Musculoskeletal ultrasound abnormalities in asymptomatic hyperuricemic patients: Association with cardiovascular risk factors

To assess the relation between musculoskeletal ultrasound (MSUS) abnormalities and cardiovascular risk factors in asymptomatic and symptomatic hyperuricemic patients. The study included 66 hyperuricemic patients. 33 were asymptomatic and 33 were symptomatic. The socio-demographic features, body mass index (BMI), blood pressure measurement and musculoskeletal examination were recorded. Serum uric acid (SUA), serum creatinine (s.Cr.), total cholesterol, high density lipoprotein (HDL) and triglycerides (TG) were measured and estimated glomerular filtration rate (e GFR) was calculated using chronic kidney disease-epidemiology collaboration (CKD-EPI). Cardiovascular risk was calculated using Systematic Coronary Risk Evaluation of the European Society of Cardiology (SCORE/ESC) and Atherosclerotic Cardiovascular Disease of American College of Cardiology (ASCVD/ACC). MSUS of the knees, ankles and 1st metatarsophalangeal joints (MTPs) was performed and specific gout signs (aggregates, double contour and tophi) were assessed. There was no association between MSUS abnormalities and either individual or overall cardiovascular risk factors except the negative correlation between the age and the high density lipoprotein (HDL) level and the positivity of the patients (presence of at least one of the specific gout sign "aggregates, double contour or tophi" in at least one out of the six assessed joints "both knees, ankles and 1st MTPs" among the symptomatic group. The association between MSUS abnormalities and cardiovascular risk factors in the hyperuricemic patients is not yet clear and further studies are needed to introduce it as a screening modality for these patients.

Evolution of the first metatarsophalangeal joint replacement

Introduction The diseases of the first metatarsophalangeal (1 MTP) joint that require surgical treatment include osteoarthritis (69 %), rheumatoid arthritis (26 %), tumors, tumor-like diseases and purulent arthritis (5 %). The treatment of arthritic 1 MTP is aimed at reducing pain and improving function. Joint replacement implants are meant to support body weight, maintain the length of the first metatarsal, provide metatarsal‑sesamoid joint functioning and restore joint motion. The purpose of the work was to analyze data from foreign and domestic literature on endoprosthetics of the 1 MTP, and briefly present analytical data on the results of using various implants.Material and methods The article presents the summary of the Russian and foreign publications on 1 MTP joint replacement. The original literature search was conducted on key resources including PubMed, eLIBRARY, MedLine, Scopus. The search strategy was comprised of keywords: “replacement of the first metatarsophalangeal joint”, “surgical treatment of hallux rigidus”, “osteoarthrosis of the first metatarsophalangeal joint”, “results of endoprosthetics of the 1st metatarsophalangeal joint”, "modernization of implants of the 1st metatarsophalangeal joint". Publications brought out between 1968 and 2022 inclusive were analyzed.Results and discussion The ideal implant should restore functional range of motion, improve function, maintain joint stability, distribute the stress across joint surfaces being wear-resistant. Over the years, various materials have been used to provide simple and reliable designs. Implants have been improved and divided into groups based on material and design, limited degrees of freedom, tribological pair composition, and the amount of articular surface replacement.Conclusion New generation implants have a more durable design, anatomical shape and improved osseointegration. The advances in joint replacement have resulted in greater patient satisfaction and increased service life. The complication rate for replacement of the 1 MTP joint remains high. This indicates the need for continued research and further work to improve implants to make them more effective and easier to use.

Long-term outcomes of first metatarsophalangeal hemiarthroplasty for hallux rigidus

Hallux rigidus (HR) is arthritis of the first metatarsophalangeal joint.First metatarsophalangeal joint hemiarthroplasty surgery is one of the treatment options for end stage hallux rigidus.The aim of this study is to evaluate the long-term outcomes of hemiarthroplasty of the first MTPJ with a metallic implant in patients with end-stage HR. Patients who underwent hemiarthroplasty surgery with the diagnosis of HR were included in the study. Self-Administered Foot Evaluation Questionnaire (SAFE-Q) and Foot and Ankle Disability Index (FADI) scores were used in pre-operative and post-operative final follow-ups to evaluate the clinical status of the patients. Post-operative 1st metatarsophalangeal joint range of motion was measured and recorded separately for each patient. The intra-hospital and follow-up complications and revision surgeries of the patients were recorded. Thirty-five patients with a mean follow-up of 8.1 years were included in the study. There was a statistically significant positive change in both FADI and SAFE-Q scores compared to the pre-operative process(p = 0.0001). The average dorsiflexion angle at the final follow-up was 22.0 ± 8.2. Thus, it was determined that the 5-year and 8-year survival rates of patients in this study were 97.1% and 87.8%, respectively. In conclusion, the long-term results show that the use of hemiarthroplasty in the treatment of end-stage HR leads to high patient satisfaction, increased range of motion and a high survival rate.

High-resolution ultrasound and MRI in the evaluation of the forefoot and midfoot.

Radiography is the appropriate initial imaging modality to assess for midfoot and forefoot pathology before turning to advanced imaging techniques. While most lesions of the mid- and forefoot can be diagnosed clinically, the exact nature and severity of the pathology is often unclear. This review addresses the use of the ultrasound, as well as the added value of magnetic resonance imaging, in diagnosing conditions of the midfoot and forefoot. Ultrasound allows a dynamic assessment as well as enabling imaging-guided interventions for diagnostic and therapeutic purposes. Practical tips for optimal examination of this area with ultrasound and magnetic resonance imaging are provided. Metatarsal stress fracture, Chopart's injury, Lisfranc injury, as well as the 1st metatarsophalangeal joint injury and lesser metatarsophalangeal plantar plate injury are injuries unique to the mid- and forefoot. The imaging anatomy of the 1st and lesser metatarsophalangeal joints is reviewed, as such knowledge is key to correctly assessing injury of these joints. Characteristic imaging features of masses commonly encountered in the mid- and forefoot, such as ganglion cyst, Morton neuroma, gouty tophus, plantar fibroma, foreign body granuloma, and leiomyoma are reviewed. The use of ultrasound and magnetic resonance imaging in assessing degenerative and inflammatory joint disorders, and in particular rheumatoid arthritis, of the mid- and forefoot region is also reviewed. In summary, when necessary, most lesions of the mid-and forefoot can be adequately assessed with ultrasound, supplemented on occasion with radiographs, computed tomography, or magnetic resonance imaging.

Comparable Outcomes of Cartiva Implant, Cheilectomy, and Fusion for Hallux Rigidus of the 1st Metatarsophalangeal Joint: A Matched Cohort Study

Category: Midfoot/Forefoot; Other Introduction/Purpose: The primary goal of treating hallux rigidus of the 1st metatarsophalangeal (MTP) joint of the foot is to reduce pain. Treatment options include cheilectomy, interposition arthroplasty, and arthrodesis for more severe disease. Recently, the use of a synthetic cartilage implant (Cartiva, Stryker Inc., MI, USA) has been introduced with the advantage of motion preservation. While a Level 1 study has demonstrated similar outcomes of fusion and Cartiva, other comparative studies have shown less favorable results for the Cartiva implant. The purpose of this study was to evaluate minimum 2-year patient reported outcomes (PROs) of the Cartiva implant for the treatment of hallux rigidus in the 1st MTP joint in comparison to a matched cohort of patients treated with fusion or cheilectomy. Methods: Patients >18 years old who underwent surgery for treatment of 1st MTP joint hallux rigidus with Cartiva implant, cheilectomy, or fusion performed by two surgeons (T.O.C. or C.T.H.) between January 2009 and January 2020 were identified. A 2:1 matched control cohort of patients who underwent cheilectomy or fusion was constructed using a nearest neighbor, greedy algorithm based on age, sex, prior surgery, and Coughlin osteoarthritis grade. Minimum 2-year follow-up was obtained with patients completing subjective questionnaires including Foot and Ankle Ability Measure (FAAM) with Activities of Daily Living (ADL) and Sport subscales, Short Form-12 (SF-12), Tegner activity scale, and patient satisfaction with surgical outcome. Demographics and patient-reported outcomes were compared between groups. Results: Follow-up was obtained for 22/27 (82%) Cartiva patients (mean age 54±19) at median 4.3 years and 41/49 (84%) control patients (mean age 58±11) at median 3.5 years. Prevalence of Coughlin grade was similar between Cartiva and control groups (6 vs 10 grade 1, 8 vs 15 grade 2, 2 vs 6 grade 4, 6 vs 10 grade 5; p=.93), respectively. There was no significant difference in median post-operative FAAM-ADL (96 vs 95, p=.53), FAAM-Sport (92 vs 89, p=.89), SF-12 PCS (56 vs 51, p=.054), SF-12 MCS (56.3 vs 57.5, p=.50), Tegner score (4 vs 3, p=.30), or patient satisfaction (9 vs 9, p=.91) between Cartiva and control cohorts, respectively. Revision surgery was required for 3 (14%) Cartiva patients and 4 (10%) control patients (p=.70). Conclusion: Patients treated with a Cartiva synthetic cartilage implant for 1st MTP joint hallux rigidus had similar patient-reported outcomes and revision rate compared to patients treated with cheilectomy or fusion for Coughlin grade 2-5 osteoarthritis.

Three-Dimensional Analysis of Windlass Mechanism Using Loading Computed Tomography in Patients With Hallux Rigidus and Healthy Volunteers

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: The windlass mechanism (WM) increases the height of the medial longitudinal arch (MLA) of the foot by tensing the plantar aponeurosis during dorsiflexion of the metatarsophalangeal (MTP) joint. We speculated that this mechanism may be deeply involved in the pathogenesis of forefoot diseases such as hallux rigidus (HR). These conditions are three- dimensional (3D) deformities including rotational deformity, but the role of the WM has been evaluated only two-dimensionally by measuring the height of the navicular on lateral plain radiographs. The purpose of this study was to analyze in detail the WM of normal and HR feet in 3D. Methods: Participants were 14 patients with HR (17 feet) and 13 volunteers (21 feet). The volunteers had no history of foot disease or trauma, whereas the patients with HR had Coughlin and Shurnas classification I or II. Computed tomography (CT) of the foot with a load equivalent to the participant’s body weight was performed. Imaging was performed with the 1st MTP joint in the neutral position and dorsiflexed 30 degrees. 3D models were created using the software Mimics Research 17.0. Next, we used the iterative closest point (ICP) algorithm, which allows 3D objects to be superimposed without specifying anatomical feature points. Then, we performed 3D measurements of the (1) rotation of each bone in the MLA with respect to the tibia, (2) rotation of the distal bone in each joint of the MLA, and (3) changes in the height of the geometric center of the navicular. Results: At the calcaneus, navicular and medial cuneiform, the HR group showed less inversion, adduction than healthy group. (P < 0.05) At the talonavicular joint, the navicular was 3.7° inversion, 2.9° adduction in the healthy group and 2.4°inversion, 1.3° adduction in the HR group. At the talocalcaneal joint, the calcaneus was 1.7° inversion, 1.5° adduction in the healthy group and 0.9°inversion, 0.6° adduction in the HR group. In the talonavicular and talocalcaneal joint, the HR group showed less inversion and adduction than control. (P < 0.05) With dorsiflexion of the hallux, the height of the navicular increased by 2.1 mm in the healthy group and 1.3 mm in the HR group. There was a significant difference (P < 0.05) between the two groups. Conclusion: In both groups, the calcaneus, navicular, and medial cuneiform bones moved not only in the sagittal plane but also in the frontal plane. But the movement of the talonavicular and talocalcaneal joints and the change in height of the navicular were significantly reduced compared with the healthy group. In other words, in the HR group, the motion of the midfoot and hindfoot was limited, suggesting that there may be a close relationship between WM dysfunction and midfoot and hindfoot motion. This study indicates that the dysfunction of the WM may have been a clue to the cause of HR.

Three-dimensional Weight-Bearing CT Distance and Coverage Mapping Assessment of the 1st MTPJ and Sesamoid Joints in Patients with Hallux Valgus Deformity

Category: Bunion Introduction/Purpose: Three-dimensional (3D) Distance-Mapping (DM) and Coverage-Mapping (CM) use WBCT images to evaluate multiplanar elements of Hallux Valgus (HV), such as sesamoid subluxation, through analyzing joint space and joint coverage across entire bony interfaces. Previous methods have struggled to characterize sesamoid subluxation consistently, and the reliable assessment of these deformity patterns is essential in guiding HV treatment and impacts recurrence rates following correction. The objective was to (1) develop a 3D WBCT CM and DM algorithm to characterize the surface interaction of the 1st metatarsophalangeal-joint (MTPJ) and metatarsal-sesamoid joints in HV patients and controls (2) correlate DM and CM measurements with WBCT semi-automatic angular measurements in HV patients and controls (3) correlate DM, CM, and angular measurements with Visual Analog Scale (VAS) scores in HV patients. Methods: Retrospective case-control study assessing HV patients. 51-feet with HV who underwent a WBCT of the affected foot and 54-feet were included. Semi-automatic segmentation protocol extracted bone models, which were analyzed with specialized software. The 1st-MTPJ surface was divided into two-by-two grids to provide a more detailed analysis. Distance measurements obtained were used to create color-coded distance maps. Blue color represented expected distances in joint interaction (1 to 5 mm), red or yellow color represented arthritis or impingement (0 to 1mm), and pink color represented subluxation (>5mm). Further, color-coded coverage maps highlighted areas of relative coverage ( < 5mm) or uncoverage (>5mm) contrasting areas with normal joint interaction or subluxation (Figure). Pearson’s correlations were used to describe association between intraarticular distances, or JSW (joint space width), and coverage measurements with the following: intermetatarsal angle (IMA), Hallux-Valgus- Angle (HVA), Distal-Metatarsal-Articulation-Angle (DMAA), Visual-Analog-Scale (VAS), and Body-Mass-Index (BMI). P-values less than 0.05 were statistically significant. Results: Interobserver reliability was high for 1st-metatarsal-head (ICC 0.846,p < 0.001), medial-sesamoid-articulation (ICC 0.854,p < 0.001), and lateral-sesamoid-articulation (ICC 0.832,p < 0.001). HV patients demonstrated significantly decreased coverage in comparison to controls (42.7% vs. 50.1%,p < 0.001) and a relative decrease in 1st-MTPJ-coverage (-14.7%,p < 0.001) in comparison to controls. In HV, articular coverage was higher in patients for the plantar lateral quadrant (HV 88.6% vs. 83.0% Controls,p=0.0002) and decreased in dorsal-medial (HV 8.8% vs. 18.7% Controls,p < 0.0001) and plantar-medial quadrants. (HV 46.2% vs. 78.8% Controls,p < 0.0001). Significantly decreased coverage was observed in HV-patients in both the medial sesamoid- articulation (HV 31.1% vs. 54.4%, p< 0.0001) and lateral sesamoid-articulation (HV 22.6% vs. 46.0%,p < 0.0001). Correlations between the first-metatarsal-head distance/coverage measurements and BMI, pre-op VAS, IMA, HVA, and DMAA are summarized in figure. Conclusion: We developed a quantifiable WBCT distance and coverage map algorithm to assess 3D-joint-interaction, joint- coverage, and subluxation in patients with HV. We observed significant subluxation of the 1st-MTPJ in patients with HV when compared to controls, as well as significant subluxation of the metatarsal-sesamoid joint at the medial and lateral sesamoid-joints, with an apparent medial and dorsal deviation of the first-metatarsal, lateral and plantar deviation of the proximal-hallux-phalanx and Lateral subluxation of the sesamoids. Increased coverage of the 1st-metatarsal-head was associated with decreased IMA and DMAA. However, we found no significant correlation between the Visual-Analogue-Scale-(VAS) and DM, CM, and semi-automatic measurements.

Treatment of hallux rigidus with percutaneous metatarsophalangeal arthrodesis: a case series with a minimum follow-up of 2 years.

Percutaneous metatarsophalangeal arthrodesis is an option for the treatment of hallux rigidus in more advanced cases. The aim of this study was to investigate the clinical and radiographic results at least 2 years after percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus. This is a case series of consecutive patients undergoing percutaneous metatarsophalangeal arthrodesis in patients with hallux rigidus grades III and IV with a minimum of 24months of clinical and radiographic follow-up. The primary outcome was clinical assessment using the Visual Analog Scale for Pain (VAS). Secondary outcomes included American Orthopedic Foot & Ankle Society (AOFAS) score, patient satisfaction, complications, and bone healing (radiographic analysis). Between August 2017 and February 2020, 29 feet (24 patients) underwent percutaneous metatarsophalangeal arthrodesis. The mean follow-up was 38.4 (range 24-54) months. There was an improvement in the pain (VAS) from 7.8 to 0.6 (p < 0.001) and in the AOFAS score from 49.9 to 83.6 (p < 0.001). There was a rate of bone union of 82.8% and screw removal of 13.8%. All patients considered the result to be excellent or good. The treatment of grade III and IV hallux rigidus with percutaneous metatarsophalangeal arthrodesis demonstrated high patient satisfaction and significantly improves in clinical outcomes but the nonunion rate was higher than reported outcomes for open 1st metatarsophalangeal joint arthrodesis. IV, case series.

Postoperative Opioid Consumption Following Hallux Valgus and Rigidus Surgery: A Guide to Postoperative Prescription Writing

Prescribing post-operative pain medications is essential to foot and ankle surgery, however, prescribing an amount that results in an excess of pills has shown to lead to opioid abuse. The opioid epidemic has forced surgeons to analyze how we manage post-operative pain with a goal to prescribe the optimal number of pills that will reduce a patient's pain while limiting the amount that is left over. The purpose of this study was to develop a guideline for prescribing post-operative pain medication for hallux valgus and rigidus procedures. One hundred eighty-five opioid naive patients were followed after undergoing surgery for hallux valgus or hallux rigidus. The number of opioids consumed was obtained and compared to a number of variables. There were 28 different prescriptions given during the study. As the number of pills given decreased, so did the number of pills consumed (p=0.08). Of the 185 patients, 14 (7.56%) received a refill.Ninety-five patients were available for opioid consumption data analysis. Those patients consumed a median of 36.7% and 39.1% of their prescription for hallux valgus and hallux rigidus procedures respectively. Smokers consumed 2.4 times the number of narcotics compared to nonsmokers (p=0.002). The median number of 5-325 mg hydrocodone-acetaminophen pills consumed was 8.5 for distal metatarsal osteotomies and 10 for 1st metatarsophalangeal joint procedures.Body mass index, gender, number of procedures performed did not have a statistical difference in the number of opioids taken.Foot and ankle surgeons can reduce the amount of excess opioids by decreasing the initial prescription and educating the patient on proper pain management modalities. Level of Evidence III.

Converting 1st metatarsophalangeal joint fusion to interposition arthroplasty. Mid-term results of a case series

BackgroundFusion of the first metatarsophalangeal (MTP) joint has been considered as the gold standard for treatment of advanced hallux rigidus. The main disadvantage is the restriction of movement which may not be as favorable as anticipated by several patients. The purpose of this study was to report clinical and functional outcomes on patients who were treated with interposition arthroplasty after a 1st MTP joint fusion which had not fulfilled their expectations. MethodsBetween 2009 and 2014, 11 patients who were not satisfied by 1st MTP joint fusion for hallux rigidus, underwent a conversion to interposition arthroplasty. After removal of hardware, the fusion was taken down by removal of a bone block from the fused joint. A fascia lata graft was interposed. Intraoperative and postoperative complications, range of motion of the first MTP joint, length of first ray, and patients’ satisfaction were recorded as the primary outcomes. ResultsMean age was 34 years (range, 24–42 y). The mean ± SD AOFAS/H/MTP/IP score was 61 ± 5.5 preoperatively, 90.5 ± 4.5 at one year and 92 ± 4 at five years postoperatively (p < 0.001). The mean ± SD VAS-FA score was 91 ± 3.5 preoperatively, 94.5 ± 2.5 at one year and 95 ± 2.5 at five years postoperatively (p > 0.05). Mean ROM at the final follow-up was 58° ± 5° of dorsiflexion and 27° ± 4° of plantarflexion. No inter- or postoperative complications were encountered. The length of the hallux was decreased by a mean of 1.5 mm (range, 1–2.5 mm). All patients were satisfied with the overall outcome, walking ability and shoe-wear convenience and graded their condition as excellent (9 cases) or good (2 cases). ConclusionsConverting a 1st MTP joint fusion to interposition arthroplasty with a fascia lata allograft could be a safe alternative with promising results in selected cases especially in relatively young and athletic population. Level of evidenceLevel IV retrospective case series.

발 내재근 운동이 엄지발가락가쪽휨증의 엄지벌림근에 미치는 효과 비교

This study aimed to investigate the most effective exercise in relation to the effect on the cross-sectional area (CSA) and muscle tone of the abductor hallucis in patients with hallux valgus. Thirty-six patients (18 men, 18 women )with a mean age of 22.14 years (standard deviation of 2.47 years) participated voluntarily in this study. Hallux valgus was defined as an angle >15° of the 1st metatarsophalangeal joint(MPJ). A goniometer was used to determine the angle of the 1st MPJ. In addition, an ultrasound system and Myotone Pro were used to collect the CSA and muscle tone of the abductor hallucis of the dominant foot. CSA and muscle tone of the abductor hallucis were measured in four positions: resting position, during short foot (SF) exercise, during toe-spread-out (TSO) exercise, and during towel-curl(TC) exercise. For all data, one-way repeated analysis of variance test was used to compare the dependent variables according to the three exercise methods, and a post-hoc test was performed using the Bonferroni modification method. The significance level was set to p < .05. The CSA and muscle tone of the abductor hallucis were significantly increased in the TSO and SF exercises. In addition, a more significant increase was found in the TSO than in the SF exercise. However, no significant difference was found in TC. In conclusion, the TSO exercise is the most effective for selectively contracting the abductor hallucis than other exercises.

Effects of foot and ankle mobilisations combined with home stretches in people with diabetic peripheral neuropathy: a proof-of-concept RCT

IntroductionPeople with diabetic peripheral neuropathy (DPN) and limited joint mobility syndrome (LJMS) can experience increased forefoot peak plantar pressures (PPPs), a known risk factor for ulceration. The aim of this study was to investigate whether ankle and 1st metatarsophalangeal (MTP) joint mobilisations and home-based stretches in people with DPN improve joint range of motion (ROM) and reduce forefoot PPPs.Design and methodsSixty-one people with DPN (IWGDF risk 2), were randomly assigned to a 6-week programme of ankle and 1st MTP joint mobilisations (n = 31) and home-based stretches or standard care only (n = 30). At baseline (T0); 6-week post intervention (T1) and at 3 months follow-up (T2), a blinded assessor recorded dynamic ankle dorsiflexion range using 3D (Codamotion) motion analysis and the weight bearing lunge test, static 1st MTP joint dorsiflexion ROM, dynamic plantar pressure and balance.ResultsAt T1 and T2 there was no difference between both groups in ankle dorsiflexion in stance phase, plantar pressure and balance. Compared to the control group, the intervention group showed a statistically significant increase in static ankle dorsiflexion range (Left 1.52 cm and 2.9cms, Right 1.62 cm and 2.7 cm) at 6 (T1) and 18 weeks (T2) respectively p < 0.01). Between group differences were also seen in left hallux dorsiflexion (2.75°, p < 0.05) at T1 and in right hallux dorsiflexion ROM (4.9°, p < 0.01) at T2 follow up. Further, functional reach showed a significant increase in the intervention group (T1 = 3.13 cm p < 0.05 and T2 = 3.9 cm p < 0.01). Intervention adherence was high (80%).ConclusionsCombining ankle and 1st MTP joint mobilisations with home-based stretches in a 6-week programme in people with DPN is effective in increasing static measures of range. This intervention may be useful for improving ankle, hallux joint mobility and anteroposterior stability limits in people with diabetes and neuropathy but not for reducing PPP or foot ulcer risk.Trial registrationhttps://classic.clinicaltrials.gov/ct2/show/NCT03195855.

Comparative study of internal fixation and external fixation after osteotomy of hallux valgus: A protocol for meta-analysis of comparative studies

Hallux valgus (HV) is a common clinical deformity of the forefoot, primarily a deformity of the 1st metatarsophalangeal joint in which the bunion is deflected laterally relative to the 1st metatarsal, often in combination with a medial bunion or pain at the head of the 1st metatarsal. For HV bunions that do not respond to conservative treatment, surgical intervention is required, which generally involves osteotomy of the first metatarsal or the first phalanx. However, the choice of fixation method after osteotomy is controversial. Most scholars choose screws or plates for internal fixation (IF) to achieve strong and reliable fixation, while some experts do not perform IF after osteotomy, but reposition the osteotomized end and perform external fixation (EF) with a figure-of-eight bandage between the 1st and 2nd toes, which has been advocated by some scholars because it requires only local anesthesia and has the characteristics of minimally invasive and no additional material for IF, and has achieved good clinical results. Therefore, it is necessary to compare the choice of IF or EF after HV osteotomy to evaluate whether there is a difference between the 2 and to conduct a meta-analysis to provide a reliable basis for clinical guidance. We will search articles in 7 electronic databases including Chinese National Knowledge Infrastructure, Wanfang Data, Chinese Scientific Journals Database, Chinese databases SinoMed, PubMed, Embase, and Cochrane Library databases. All the publications, with no time restrictions, will be searched without any restriction of language and status, the time from the establishment of the database to October 2022. We will apply the risk-of-bias tool of the Cochrane Collaboration for randomized controlled trials to assess the methodological quality. Risk-of-Bias Assessment Tool for Non-randomized Studies was used to evaluate the quality of comparative studies. Statistical analysis will be conducted using RevMan 5.4 software. This systematic review will evaluate the functional outcomes and radiographic results of internal versus EF after HV osteotomy. The findings of this study will provide evidence to determine whether IF or external fixation is more effective after HV osteotomy.

Double Contour Sign In Early Detection Of Gout Among Asymptomatic Hyperuricemic Filipino Patients: A Single Center Tertiary Hospital Observational Study

Objective. Double contour sign (DCS) is considered part of the new gout classification. This study aims to determine the agreement of blinded musculoskeletal sonologists in identifying the double contour sign among asymptomatic hyperuricemic patients. Methods. Participants with asymptomatic hyperuricemia (n=65) underwent a gray-scale ultrasound assessment of both of their 1st metatarsophalangeal joints (MTPJs) done on 3 positions (dorsal, medial, plantar) in longitudinal view. The static images were read by 2 independent blinded sonologists for presence of double contour sign. Results. Among the 130 1st MTPJs, the sonologists were able to positively identify DCS on 48R and 52L, negative in 10R and 10L, with discordant readings in 7R, 3L. The overall kappa agreement was statistically significant at 0.674 (substantial agreement) and 0.842 (almost perfect agreement) on the right and left respectively, (both p&lt;0.001). Conclusion and Recommendation. There is a high proportion of positive double contour sign seen among persistently asymptomatic hyperuricemic patients. It might be prudent to perform musculoskeletal ultrasound early on to detect monosodium urate crystal deposits in similar patients. A close follow up to monitor clinical gouty arthritis may be necessary or consider utility of urate lowering drugs in crystal dissolution in prospective studies.

Surgical treatment of severe valgus deformity of the first finger of foot for adults

Treatment of static deformations of the forefoot with valgus deformation of the first toe remains relevant today. Objective. Toanalyze the results of surgery with severe hallux valgus using corrective proximal wedge-shaped osteotomy of the I metatarsalbone and corrective Lapidus arthrodesis. Methods. The results of surgical treatment of 104 women (147 feet) with severe halluxvalgus according to the Mann classification were evaluated. Age — 27‒65 years, follow-up period — from 10 months up to5 years. Performed: 65 (56.0 %) cases — corrective proximal wedge-shaped osteotomy of the first metatarsal bone with fixationwith LCP-plate or screws; 51 (44.0 %) — corrective arthrodesis of the first metatarsal-sphenoid joint with LCP-platefixation. All patients underwent Schede operation and lateral release of the 1st metatarsophalangeal joint capsule with tenoadductorotomy. The results of treatment were evaluated on the basis of X-ray data and the AOFAS scoring scale. Results.After osteotomy of the I metatarsal bone in 58 (89.2 %) patients, the treatment result was classified as good, in 7 (10.8 %) — satisfactory. The improvement of the average score was 42 points. After the application of Lapidus arthrodesis, the treatment result was good in 47 (92.2 %) cases, satisfactory in 4 (7.8 %), improvement of the average score was 40 points. Conclusions. Under the conditions of surgical treatment of hallux valgus, the proximal corrective wedge-shaped osteotomy of the first metatarsal bone should in some cases be combined with the distal corrective osteotomy of the first metatarsal bone due to the increase in the PASA angle. The Lapidus arthrodesis technique allows to minimize possible relapses of the deformity, in contrast to traditional corrective osteotomies of the first metatarsal bone due to the formation of ankylosis of the metatarsal sphenoid joint, but has longer consolidation periods and risks of non-union.

The Role of Ultrasound in Evaluating the Effect of Urate-lowering Drugs in Gout Patients.

Gout is one of the most common inflammatory arthritis, where identification of MSU crystals in synovial fluid is a widely used diagnostic measure. Ultrasonography has a great sensitivity in detecting signs of MSU deposits, such as tophi and double contour (DC), as mentioned in the latest gout criteria, allowing early clinical diagnosis and therapy. The objective of this study was to evaluate the changes in ultrasound of gout patients' knee and 1st metatarsophalangeal joint (MTP1) after initiation of urate-lowering therapy (ULT) drugs in the six-month period. Forty-three patients, fulfilling the ACR/EULAR 2015 criteria of gout with a score of >8, were enrolled; they were in between attacks and not on ULT for the last 6 months, or SUA concentration (SUA) of >6.0 mg/dL. Full examination, evaluation of joints pain by visual analog scale (VAS), ultrasonography (US) for tophus and DC at the knee, and MTP1 were performed at baseline and at 3 and 6 months (M3, M6) after starting ULT. After 6 months of treatment, patients reached the target SUA level showed higher disappearance of DC sign (p<0.05) and a decrease in tophus size (p<0.05). The percentage of tophus size at 6th month was 26.4% and 3% for DC sign disappearance, which was more at MTP1. Ultrasound examination in screening for gout tophi or DC sign before starting ULT and during follow-up is important and complements clinical examination.

Finite Element Analysis for First Metatarsophalangeal Joint Arthrodesis Demonstrates Reduction in Stress Across Bio-Integrative Fixation Over Traditional Metal Fixation

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: During each step-in gait, the first metatarsophalangeal joint (MTPJ) is stressed by 90% of body weight, while loading the metatarsal head and base with up to 29% (228N/80Kg patient) of body weight (188N) during each foot push-off. To withstand these high mechanical forces, a successful fusion is dependent on joint preparation and rigid fixation. In this study we assessed a novel bio-integrative fiber-reinforced screw and nail construct. This material technology may provide improved mechanical fixation profile through its high flexural strength and flexural modulus that is closely matched to that of cortical bone. Finite Element Analysis (FEA) was performed to evaluate the mechanical strength and stress concentrations acting on the 1st MTPJ fusion following the use of these implants, compared to conventional metal fixation. Methods: CT-based FEA of the 1st MTPJ fusion fixed by two fixation methods was simulated for mechanical strength and stress concentrations acting on the surrounding cortical bone. The 1st MTPJ of an adult male weighing 80kg was segmented from a left foot CT scan (120 KVP, SL 1mm) and was incorporated in a 3-dimensional CAD model. Bio-integrative fiber-reinforced 4.0mm partially threaded headless compression screw, and a 3.0mm fiber-reinforced cannulated nail were inserted in this computational model in crossed fashion (Fig. 1A). The bio-integrative implants are composed of continuous reinforcing mineral fibers (50% w/w), comprised of elements found in native bone and bound together by a degradable polymer [poly (L-lactide-co- D,L-lactide), PLDLA]. Two 4.0mm partially threaded headless titanium screws were inserted in similar trajectories and served as control (Fig. 1B). The FEA algorithm was based on published known forces acting on the first ray during push-off. Post-processing was performed on FEA results. Results: The relative displacement between the Metatarsal and Phalangeal heads upon simulated loading was 1.6mm for metal fixation and 0.2mm for the fiber-reinforced bio-integrative fixation, demonstrating this technology to be mechanically stable at least as conventional metal fixation. In both models, the Von-Mises maximum stresses were found between the implant thread and shank. However, maximum localized stresses in cortical bone regions interacting with the metal implants were substantially higher (up to 8 times) compared to the bio-integrative implant-bone interactions. Moreover, stresses in the implant body were remarkably higher with metal implants compared to bio-integrative fixation (Fig. 1C, D&amp;E). These results indicate that for physiological loading conditions applied on the 1st MTPJ, the use of bio-integrative fixation construct may reduce stress concentrations at the implant-cortical bone interface. Conclusion: FEA results indicate that bio-integrative screw-nail construct provides equivalent mechanical fixation strength to metal fixation, while resulting in lower bone-implant stress concentrations. The closely matched flexural modulus of the bio- integrative material to that of cortical bone, decreases implant-bone resistance level and the probability of bone/implant failure and risk for implant loosening, all common complications in foot and ankle surgery. This study demonstrates a new methodology of CT-FEA for the evaluation of 1st MTPJ fusion arthrodesis and suggests the bio-integrative screw-nail combination as an alternative to traditional metal fixation. This model is currently being investigated in an ongoing clinical series.

Impact of BMI on Outcomes after First Metatarsophalangeal Joint Arthrodesis

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: First metatarsophalangeal joint (MTPJ) arthrodesis is a commonly performed procedure for patients with various disorders of the first ray including hallux rigidus, severe hallux valgus, failed 1st MTPJ replacement, and failed hallux valgus correction. Outcomes are generally favorable and similar outcomes have been shown in the young and elderly. It is well documented that medical comorbidities have deleterious effects on outcomes in foot and ankle surgery. Obesity - in particular - has been broadly studied among the foot and ankle literature and has been associated with increased complications. Presently, there is a paucity of studies examining obesity's effect on outcomes of 1st MTPJ arthrodesis. This study's purpose was to evaluate outcomes following 1st MTPJ arthrodesis in obese vs non-obese patients. Methods: A retrospective cohort study of 94 patients undergoing first MTPJ fusion over the age of 18 with a diagnosis of hallux valgus or hallux rigidus was performed. Surgical and postoperative outcomes, Visual Analog Pain scale (VAS), and Short Form 36 (SF-36) surveys were examined and stratified into 2 patient groups: BMI &lt; 30 and 3 30, with sub-analyses conducted between Obesity class I (30-34.9) and Obesity class II (35-39.9) patients. Continueous, normally distributed data were compared with independent sample t-tests, while comparisons of categorical data were made using chi-squared tests. Alpha and beta were assumed to be 0.05 and 0.8, respectively. Results: Average overall VAS and SF-36 physical component scores improved significantly at 6 months (P&lt; 0.0001, 0.006) and 1- year postoperative visits (P &lt;0.0001, 0.007) following 1st MTP fusion in the cohort as a whole. No differences in VAS or SF-36 scores were found between the obese (BMI &gt; 30) or non-obese cohorts. Amongst BMI classified subgroups, significantly greater changes in preoperative to 6-month and 1-year postoperative VAS pain were observed in the Obesity class I patients vs. Obsesity class II or greater (P=0.043, 0.022). Conclusion: Our study showed first MTPJ fusion reliably improves pain and physical quality-of-life in arthritic obese and non- obese patients without differences in nonunion, complications, or patient-reported measures. Additionally, we observed that obese patients experienced comparable improvements in VAS pain and SF-36 physical function scores as their non-obese peers. Our findings asset that first MTPJ fusion is an effective procedure for correction of MPTJ pathology in the obese.

Does a 1st Metatarsophalangeal Fusion in a Patient with Pes Planus Improve the Pes Planus Deformity? A Retrospective Case Series

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: A pes planus deformity is a pathology relating to the loss of normality of the complex interaction of the bones and joints of the foot resulting in a flattening of the medial longitudinal arch with or without abduction of the midfoot. The distal aspect of the medial longitudinal arch can be a feature of the deformity. The fusion of the 1st metatarsophalangeal joint (MTPJ) is a common operation. In patients with concomitant pes planus deformity, it is unknown if reducing and stabilising the distal aspect of the medial ray through a 1st MTPJ fusion can subsequently improve the pes planus deformity. We sought to analyse the pes planus deformity pre and post 1st MTPJ fusion with the null hypothesis that there was no difference. Methods: We identified patients who had undergone 1st MTPJ fusion using our electronic database from January 2011 to October 2021. To meet the inclusion criteria, cases required pre- and post-operative weightbearing plain radiographs, with a Meary's angle of &gt;4 degrees on pre-operative imaging. Routine pes planus measurements were undertaken by 2 independent observers. Pre- and post-operative measurements were tested for significant change using Wilcoxon Signed Rank Test or Paired T-Test depending on the normality testing of the data. Routine demographic data was also collected. Data was analysed using IBM SPSS v.27. Results: Following radiographic analysis, 25 feet fitted the inclusion criteria. The mean patient age was 63 years. There was no pre-operative correlation between Meary's angle and the hallux valgus angle (Kendall's tau p=.441). Pre-operatively, Meary's line broke at the talo-navicular and navicular-cuneiform joints in 12 cases each; the remaining case broke at the tarsal-metatarsal joint. A statistically significant improvement between the pre- and post-operative measurements was identified in Meary's angle, calcaneal pitch angle, talo-navicular coverage angle, intermetatarsal angle and talo-navicular angle (see table). Significant changes were also noted in the medial cuneiform height (mean increase of 2.74mm; p=.022). A post-operative Meary's angle of &lt;4°was only achieved in 4/25 (16%) of cases. Of the remaining 21 cases, the point at which Meary's line broke moved proximally one joint in 4 and distally one joint in 3 cases; it remained at the same joint in 14 cases. Conclusion: Our results suggest that 1st MTPJ fusion improves axial alignment of the foot as well as reducing Meary's angle by a statistically significant amount, although diagnostic criteria for pes planus remained in most cases.

Effect of Obesity on Patient-Perceived Outcomes After First Metatarsophalangeal Joint Arthrodesis.

While first metatarsophalangeal joint (MTPJ) arthrodesis is a common and effective procedure, there is a paucity of studies examining obesity's effect on outcomes of 1st MTPJ arthrodesis. This study's purpose was to evaluate patient-reported outcomes following 1st MTPJ arthrodesis in obese versus non-obese patients. A retrospective cohort study of 94 patients undergoing first MTPJ fusion over the age of 18 with a diagnosis of hallux valgus or hallux rigidus was performed. Surgical and postoperative outcomes were examined preoperatively and at 6 and 12 months follow-up via Visual Analog Pain scale (VAS), and Short Form 36 (SF-36) surveys, and data were stratified into 2 patient groups: BMI < 30 (n = 62, mean age 63.9 ± 9.1 and ≥ 30 (n = 32, mean age 61.9 ± 8.4). Average overall VAS and SF-36 physical component scores improved significantly at 6 months (P < .001, .006) and 1 year postoperative visits (P < .001, .007) with no differences in survey scores, outcomes, or complications between weight groups. Our study showed first MTPJ fusion improves short-term pain and physical quality-of-life in arthritic obese and non-obese patients without differences in nonunion, complications, or patient-reported measures. Level III, Prognostic, Case-Control Study.