2nd Metatarsals Research Articles

Effect of forefoot transverse arch stiffness on foot biomechanical response--based on finite element method.

The plantar vault, comprising the transverse and longitudinal arches of the human foot, is essential for impact absorption, elastic energy storage, and propulsion. Recent research underscores the importance of the transverse arch, contributing over 40% to midfoot stiffness. This study aimed to quantify biomechanical responses in the ankle-foot complex by varying the stiffness of the deep metatarsal transverse ligament (DTML). Using CT image reconstruction, we constructed a complex three-dimensional finite element model of the foot and ankle joint complex, accounting for geometric complexity and nonlinear characteristics. The focus of our study was to evaluate the effect of different forefoot transverse arch stiffness, that is, different Young's modulus values of DTML (from 135MPa to 405MPa), on different biomechanical aspects of the foot and ankle complex. Notably, we analyzed their effects on plantar pressure distribution, metatarsal stress patterns, navicular subsidence, and plantar fascial strain. Increasing the stiffness of the DTML has significant effects on foot biomechanics. Specifically, higher DTML stiffness leads to elevate von Mises stress in the 1st, 2nd, and 3rd metatarsals, while concurrently reducing plantar pressure by 14.2% when the Young's modulus is doubled. This stiffening also impedes navicular bone subsidence and foot lengthening. Notably, a 100% increase in the Young's modulus of DTML results in a 54.1% decrease in scaphoid subsidence and a 2.5% decrease in foot lengthening, which collectively contribute to a 33.1% enhancement in foot longitudinal stiffness. Additionally, doubling the Young's modulus of DTML can reduce the strain stretch of the plantar fascia by 38.5%. Preserving DTML integrity sustains the transverse arch, enhancing foot longitudinal stiffness and elastic responsiveness. These findings have implications for treating arch dysfunction and provide insights for shoe developers seeking to enhance propulsion.

Extended finite element analysis for the 2nd and 3rd metatarsals stress fracture during push-off

Metatarsal stress fractures (MSF), particularly the 2nd and 3rd MSF, are common injuries among athletes. Although there are several practices to reduce foot and ankle injuries, there is no injury prevention program specifically designed to minimize MSF. This is mainly due to the lack of information about the loadings/postures that cause MSF. Therefore, this study aimed to investigate dangerous loadings/postures potentially causing MSF during push-off (PO). The analysis was conducted with Finite Element Modelling (FEM), calibrated with the three-point bending test, and validated with peak plantar pressure (PPP) and fracture force measurement. Extended Finite Element Method was used for MSF simulation such that ten different foot and ankle configurations were designed, with five for each of the 2nd and 3rd MSF under pure vertical loadings. A more complex loading, ankle eversion/inversion during PO, was also examined for the MSF. The average error percentage for the calibration of the model with the three-point bending test was 3.05%. The average error percentages for the validation of the model with PPP and fracture force measurements were 18% and 30%, respectively. The outcomes of pure vertical loadings indicated the higher potential for the 2nd and 3rd MSF at 30% PO and 70% PO, respectively. The results of ankle eversion/inversion loadings represented that the most dangerous posture for MSF was 30° ankle eversion for the 3rd metatarsal at 70% PO. These results provide a guide, including what postures to avoid for the 2nd and 3rd MSF among people who are at high risk of MSF.

Curved carbon-plated shoe may further reduce forefoot loads compared to flat plate during running

Using a curved carbon-fiber plate (CFP) in running shoes may offer notable performance benefit over flat plates, yet there is a lack of research exploring the influence of CFP geometry on internal foot loading during running. The objective of this study was to investigate the effects of CFP mechanical characteristics on forefoot biomechanics in terms of plantar pressure, bone stress distribution, and contact force transmission during a simulated impact peak moment in forefoot strike running. We employed a finite element model of the foot-shoe system, wherein various CFP configurations, including three stiffnesses (stiff, stiffer, and stiffest) and two shapes (flat plate (FCFP) and curved plate (CCFP)), were integrated into the shoe sole. Comparing the shoes with no CFP (NCFP) to those with CFP, we consistently observed a reduction in peak forefoot plantar pressure with increasing CFP stiffness. This decrease in pressure was even more notable in a CCFP demonstrating a further reduction in peak pressure ranging from 5.51 to 12.62%, compared to FCFP models. Both FCFP and CCFP designs had a negligible impact on reducing the maximum stress experienced by the 2nd and 3rd metatarsals. However, they greatly influenced the stress distribution in other metatarsal bones. These CFP designs seem to optimize the load transfer pathway, enabling a more uniform force transmission by mainly reducing contact force on the medial columns (the first three rays, measuring 0.333 times body weight for FCFP and 0.335 for CCFP in stiffest condition, compared to 0.373 in NCFP). We concluded that employing a curved CFP in running shoes could be more beneficial from an injury prevention perspective by inducing less peak pressure under the metatarsal heads while not worsening their stress state compared to flat plates.

Biomarkers of chronic kidney disease-mineral bone disorder (CKD-MBD) in the diabetic foot: A medical record review

AimsDetermine the prevalence and relative risk of having single and combinations of biomarkers of chronic kidney disease-mineral bone disorder (CKD-MBD) syndrome in the diabetic foot from an electronic medical record (EMR) review. MethodsReview of 152 patients with one foot radiograph and diagnoses of both diabetes mellitus (DM) and chronic kidney disease (CKD) stages 1–5. Presence/absence of peripheral neuropathy (PN), targeted serum markers, and both pedal vessel calcification (PVC) and buckling ratio (BR) of 2nd and 5th metatarsals from radiographs were recorded. Prevalence of single and combinations of foot biomarkers are reported as count and percentage. Risk ratios (RR) with 95% confidence intervals (95% CI) were calculated to assess risk of foot biomarkers in each stage of CKD-MBD. ResultsPrevalence and RR of PVC, PN, and BR ≥ 3.5 biomarkers, both single and in combination, all increase with progression of CKD. The RR increases to 9.6 (95 % CI: 3, 26; p < 0.001) when all 3 biomarkers present in stage 5. ConclusionsPVC, PN, and BR ≥ 3.5 are prognostic biomarkers of CKD–MBD syndrome in the diabetic foot. Recognition of these foot biomarkers may allow earlier interventions to help reduce nontraumatic lower extremity amputation in individuals with diabetic CKD-MBD.

Results of Minimally Invasive Distal Metatarsal Osteotomies (Dmmo) Limited to the 2nd and 3rd Rays: About 112 Cases

Category: Lesser Toes Introduction/Purpose: The objective of this study was to evaluate the clinical and radiological results of DMMO limited to the second and third rays in patients suffering from metatarsalgia with lesion of the plantar plate of the second ray associated with a hallux valgus. Our hypothesis was that this gesture allowed an improvement of the clinical and paraclinical symptoms Methods: For this retrospective, single-center, single-operator study, 112 patients (mean age 65.52 years, 91% women, 127 feet) operated between June 2015 and October 2020 were included based on the following criteria: metatarsalgia complicated by lesion of the plantar plate with hallux valgus. Secondary metatarsalgia, congenital malformation, pes cavus, Freiberg's disease, gastrocnemius retraction were excluded The surgery began with DMMOs of the 2nd and 3rd metatarsals, then a minimally invasive chevron osteotomy adjusted the length of the 1st metatarsal in relation to the lateral rays. The position of the toes was guided by a bandage for 2 weeks relayed by a molded orthoplasty for 4 weeks. Support was complete with a rigid flat shoe. At a mean follow-up of 3 years (14-80 months), the AOFAS functional score and radiographic measurements (Maestro criteria, bone consolidation) were evaluated. Results: The clinical improvement was significant with an AOFAS score going from 44.9 to 91.8 (p&gt;0.05)We observed 8.7% of complications: 4 transfer metatarsalgia on the 4th or 5th metatarsal, 1 asymptomatic callus under M4, 1 asymptomatic nonunion of M2, 5 spontaneously resolving delayed consolidation, 1 algodystrophy.The radiographic improvement was significant on our morphotypes which were disharmonious in 92% with M45 hypoplasia in 76% and long M23 in 16%.Indeed, the DMMO limited to the 2nd and 3rd metatarsal allowed a significant reduction in the difference in length between the 3rd and 4th metatarsal (p&gt;0.05)Our 4 cases of transfer metatarsalgia under M4 or under M5 were not explained radiologically by relative length anomaly. Conclusion: Performing DMMO limited to the 2nd and 3rd metatarsals appears to be a reliable solution in the management of metatarsalgia by lesion of the plantar plate associated with hallux valgus, the risk of transfer metatarsalgia was not increased compared to the data of literature.

Comparison Between Hallux Rigidus Parameters Assessed by Conventional Radiographs and Weight- Bearing CT

Category: Midfoot/Forefoot; Other Introduction/Purpose: The etiology of hallux rigidus (HR) is not well understood and its association with first-ray hypermobility, hallux valgus and metatarsus primus elevatus (MPE) has not been clearly proven. Recent studies have supported MPE in HR by measuring on weightbearing radiographs (WBR), but there are limitations of WBR due to variation in X-ray projection and superimposed metatarsals. WBCT represent a reliable tool for radiographic analysis of the first ray and can be important for the study pathologies such as HR, which involve several anatomical points to be evaluated for a correct clinical- radiographic diagnosis Our objective was to evaluate radiographic parameters associated with Hallux Rigidus via WBR and WBCT for convergent validity and to evaluate the use of the classification system used in conventional radiography with WBCT. Methods: This is a single-center, retrospective study from prospectively collected data. 20 symptomatic hallux rigidus patient with weightbearing radiograph and WBCT were enrolled from October 2014 to December 2020. Measured parameters included hallux valgus angle (HVA), intermetatarsal angle (IMA), 1st TMT joint version, First and second metatarsal lengths, 2nd cuneiform- 2nd metatarsal angle, Talus-1st Metatarsal angle, First and second metatarsal declination angles, and MPE. MPE was measured as the direct distance between 1st and 2nd metatarsals (modified Horton index). All patients were graded according to the radiographic criteria of Coughlin and Shurnas classification on radiographs and WBCT, separately. Paired T-test was performed to compare radiographic measurements with WBCT. Results: Mean age was 55.9. HVA (15.73° in X-ray vs 14.04° in WBCT), AP first TMT version (16.25° vs 16.47°), 2nd cuneiform- 2nd metatarsal angle (24.54° vs 26.60°), Talus-1st Metatarsal Angle (-7.67° vs -7.89°) were not different between radiograph and WBCT. MPE was measured higher in WBCT by 0.86 mm compared to radiograph. First metatarsal declination angle was lower in WBCT by 2.9° indicating increased MPE. When graded with radiographic findings, 5 (25%) patients were grade 1, 5 (25%) patients were grade 2 and 10 (50%) grade 3, when graded with WBCT, 1 (5%) patient had grade 1, 3 (15%) patients were grade 2 and 16 (80%) grade 3. When graded radiologically, subchondral cyst in proximal phalanx and metatarsal head were better delineated resulting in higher radiographic grade with WBCT. Dorsal subluxation/translation of first metatarsal at first TMT joint was observed 3 (15%) in radiograph and 9 (45%) in WBCT. Conclusion: Hallux Valgus Angle, AP first TMT version, 2nd cuneiform-2nd metatarsal angle, Talus-1st Metatarsal Angel demonstrated consistent measurements in radiograph and WBCT. MPE was measured higher in WBCT when measured with direct distance (0.86 mm) between the first and second metatarsals using modified Horton index and first metatarsal declination angle (2.9°). When graded with WBCT, the subchondral cyst in the proximal phalanx and metatarsal head were better delineated leading to higher grade in WBCT which infer WBCT grading system for HR can aid in early detection of advanced HR with high radiographic grades and potentially guide treatment accordingly.

Reconstruction of large midfoot bone loss using titanium spinal mesh cage with bone graft: A case report

High energy trauma injuries in the lower extremity represent unique challenges to surgeons and often involve complex, limb threatening wounds with extensive soft tissue and bone loss. In this case report, we present a case of a 20 year old male who was presented to us with a history of 8 months old high impetus road traffic trauma which resulted in multiple open fracture of the midfoot with ipsilateral closed tibial - fibular shaft and medial malleolar fracture. Open midfoot injury with severe bone loss included complete loss of navicular, all three cuneiforms, base of 1st and 2nd metatarsals. For reconstructing this severe midfoot defect, we have utilized a titanium mesh cage which is routinely used in spinal surgeries. This innovative technique and orthoplastic approach has given the patient a stable plantigrade foot with a near normal midfoot biomechanics and ultimately, restoration of this patient's quality of life.

The discrepancy between radiographically-assessed and self-recognized hallux valgus in a large population-based cohort

BackgroundThere has been a paucity of literature revealing the discrepancy between self-recognition about hallux valgus (HV) and radiographically-evaluated foot configuration. Knowing this discrepancy will help to make a comparative review of the findings of previous literatures about epidemiological studies about the prevalence of HV.Questions/purposes(1) Is there a discrepancy between radiographically-assessed and self-recognized HV in the general population? (2) What factors affect the self-recognition of HV in the general population?MethodsThe fifth survey of the Research on Osteoarthritis/Osteoporosis against Disability study involved 1996 participants who had undergone anterior-posterior radiography of bilateral feet and answered a simple dichotomous questionnaire on self-recognition of HV. Measurements of the HV angle (HVA), interphalangeal angle of the hallux (IPA), and intermetatarsal angle between 1st and 2nd metatarsals (IMA) were performed using radiographs. Radiographic diagnosis of HV was done using the definition of hallux valgus angle of 20° or more. After univariate comparison of the participant backgrounds and radiographic measurements between participants with or without self-recognition of HV, multivariable logistic regression analysis was conducted in order to reveal independent factors affecting self-recognition.ResultsSignificant difference was found between the prevalence of radiographically-assessed and self-recognized HV (29.8% vs. 16.5%, p < 0.0001). The prevalence of self-recognized HV increased with the progression of HV severity from a single-digit percentage (normal grade, HVA < 20°) up to 100% (severe grade, HVA ≥ 40°). A multivariable logistic regression analysis demonstrated that HVA, IMA, and female sex were independent positive factors for self-recognition of HV (HVA [per 1° increase]: OR, 1.18; 95% CI, 1.15–1.20; p < 0.0001; IMA [per 1° increase]: OR, 1.15; 95% CI, 1.09–1.20; p < 0.0001; and female sex [vs. male sex]: OR, 3.47; 95% CI, 2.35–5.18; p < 0.0001).ConclusionsThere was a significant discrepancy between radiographically-assessed and self-recognized HV which narrowed with the progressing severity of HV. HVA, IMA, and female sex were independent positive factors for self-recognition of HV. Attention needs to be paid to potentially lowered prevalence of HV in epidemiological studies using self-reporting based on self-recognition.

Weightbearing CT Analysis of Hallux Rigidus: Does Metatarsus Primus Elevatus Really Exist?

Category:Midfoot/ForefootIntroduction/Purpose:The etiology of hallux rigidus has been unknown. Metatarsus primus elevates (MPE), elevated first metatarsal has been controversial. Recent studies have supported significantly elevated first metatarsal in hallux rigidus patients. Bouaicha reported MPE greater than 5 mm could be a predictive factor of hallux rigidus. Lateral weightbearing radiographs has been used to evaluate MPE, However, there are limitations of conventional radiography including variation in X-ray projection angle and foot position and superimposition of metatarsals. Cheung assessed foot alignment utilizing 3D reconstructions from WBCT and concluded that hallux rigidus patients had increased MPE. Our objective was to assess MPE and anatomical characteristics in foot alignment of hallux rigidus patients compared to a control group using WBCT. This is the first study measuring MPE on WBCT.Methods:This is a single-center, retrospective study from prospectively collected data. 20 patients with hallux rigidus and WBCT data were enrolled from October 2014 to December 2020. As a control group, 20 patients with various foot and ankle pathologies were selected. Measured WBCT parameters included 1st TMT joint version, HVA, IMA, DMAA, 1st and 2nd metatarsal lengths, Foot width, Sesamoid station and rotation angle, 1st-5th Metatarsal Angle, Metatarsus adductus angle, 2nd cuneiform-2nd metatarsal angle, Talus-1st Metatarsal Angel, 1st Metatarsal-Proximal Phalanx Angle, 1st and 2nd metatarsal declination angles and ratio, and MPE. MPE was measured as a direct distance between 1st and 2nd metatarsals using a line tangential to the first metatarsal and another perpendicular line at the metadiaphyseal junction to reach second metatarsal on parasagittal view. A Cut-off value of MPE was calculated using receiver operating characteristic curve. Two investigators independently assessed each WBCT.Results:Mean age was 43.3 in control group (45% male, 55% female) and 55.9 in HR group (60% male, 40% female). Significant differences were found in several facets of foot anatomy between HR and control groups including HVA (7.57 in control vs 14.05 in HR), DMAA (3.89 vs 8.06), forefoot width (92.96 vs 95.47), 1st MT declination angle (20.17 vs 17.82), 1st/2nd MT declination ratio (83.52 vs 76.02), and MPE (3.24 mm vs 5.40 mm). MPE was significantly higher in hallux rigidus group in all three parasagittal views (unmodified, parallel to 1st metatarsal and 2nd metatarsal). Dorsal subluxation/translation of the first metatarsal was observed at 1st TMT joint in the parasagittal view of WBCT in 9 (45%) patients of hallux rigidus group suggesting sagittal instability. No patient in control group had dorsal subluxation/translation. A cut-off value of MPE was 4.56 mm with 80% sensitivity and 90% specificity.Conclusion:To evaluate MPE on WBCT, we used a new direct measurement on parasagittal views. We found a significant difference in MPE in HR. Our WBCT results are consistent with other studies using conventional radiographs. A cut-off value of WBCT MPE for diagnosis of HR was 4.56 mm in our cohort. Considering 45% patients of the HR group had dorsal subluxation/translation of first metatarsal at 1st TMT and increased HVA, Hallux rigidus may be associated with first ray instability predominantly in sagittal plane with resultant MPE with varying degree of combined coronal plane instability resulting in increased HVA.

Comparative Assessment of Hallux Rigidus using Conventional Radiograph and Weightbearing CT

Category:Midfoot/ForefootIntroduction/Purpose:The etiology of hallux rigidus (HR) is not well understood and Its association with first-ray hypermobility, hallux valgus and metatarsus primus elevatus (MPE) has not been clearly proven. MPE, elevated first metatarsal has been a topic of debate since Lambrinudi`s first description. Recent studies have supported MPE in hallux rigidus by measuring with various methods on wightbearing lateral radiographs, but there are limitations of conventional radiography due to variation in X- ray projection and superimposed metatarsals regardless of the methods of measurement. Our objective was to assess MPE and other associated parameters with hallux rigidus via radiography and WBCT for convergent validity and to evaluate the use of classification system used in conventional radiography with WBCT.Methods:This is a single-center, retrospective study from prospectively collected data. 20 symptomatic hallux rigidus patient with weightbearing radiograph and WBCT were enrolled from October 2014 to December 2020. Measured parameters included hallux valgus angle (HVA), intermetatarsal angle (IMA), hallux interphalangeal angle (HIPA), distal metatarsal articular angle (DMAA), 1st TMT joint version, First and second metatarsal lengths, Metatarsus adductus angle, 2nd cuneiform-2nd metatarsal angle, Talus-1st Metatarsal Angel, First and second metatarsal declination angles, and MPE. MPE was measured as the direct distance between 1st and 2nd metatarsals (modified Horton index). All patients were graded according to the radiographic criteria of Coughlin and Shurnas classification on radiographs and WBCT, separately. Paired T-test was performed to compare radiographic measurements with WBCT.Results:Mean age was 55.9, 12 males and 8 females. HVA (15.73 in X-ray vs 14.04 in WBCT), AP first TMT version (16.25 vs 16.47), 2nd cuneiform-2nd metatarsal angle (24.54 vs 26.60), Talus-1st Metatarsal Angel (-7.67 vs -7.89) were not different between radiograph and WBCT. MPE was measured higher in WBCT by 0.86 mm compared to radiograph. First metatarsal declination angle was lower in WBCT by 2.9° indicating increased MPE. When graded with radiographic findings, 5 (25%) patients were grade 1, 5 (25%) patients were grade 2 and 10 (50%) grade 3, when graded with WBCT, 1 (5%) patient had grade 1, 3 (15%) patients were grade 2 and 16 (80%) grade 3. Dorsal subluxation/translation of first metatarsal at first TMT joint was observed 3 (15%) in radiograph and 9 (45%) in WBCT.Conclusion:HVA, AP first TMT version, 2nd cuneiform-2nd metatarsal angle, Talus-1st Metatarsal Angel demonstrated consistent measurements in radiograph and WBCT. MPE was measured higher in WBCT when measured with direct distance (0.86 mm) between the first and second metatarsals using modified Horton index and first metatarsal declination angle (2.9°). When graded with WBCT, the subchondral cyst in the proximal phalanx and metatarsal head were better delineated leading to higher grade in WBCT. Further studies are needed for inter-rater reliability and discriminant validity of the measurements determined by differences between different groups (HR vs control).

Homolateral Lisfranc Fracture/Dislocation of 1st - 5th Metatarsals in a Collegiate Quarterback: A Case Study

Category:Sports; Midfoot/ForefootIntroduction/Purpose:Lisfranc injuries encompass a spectrum of injuries to the tarsometatarsal (TMT) joint complex from ligamentous sprains to fractures with dislocation. While studies have shown it is possible to return to sport (RTS) after low- energy injuries, no literature exists demonstrating RTS after homolateral fracture/dislocation of all 5 metatarsals. We present a novel surgical technique for repair of homolateral Lisfranc fracture/dislocation of the 1st-5th metatarsals. Fusion of the 2nd and 3rd TMT joints provides stability of the middle column. Internal bracing of the 1st TMT joint gives stability while preserving greater physiologic motion in a high-level athlete.Methods:A dorsal approach is used for fusion of the 2nd and 3rd TMT joints with medial approach for internal bracing of the 1st TMT joint. 2nd and 3rd metatarsals were denuded of cartilage, and the fusion site was fully prepared. Rigid fixation was applied to the fusion sites. Guidewire for the cannulated Internal Brace system is inserted into the base of the 1st metatarsal. Fluoroscopic imaging confirmed positioning and the 3.4mm drill is passed over the wire, followed by the cannulated tap. A 4.75mm Swivelock anchor with Fibertape suture is inserted into the metatarsal base. The guidewire is placed in a reciprocating position on the medial cuneiform. The 2.7 mm drill is passed over the wire, followed by the 3.5 mm tap. A 3.5 mm Swivelock is then loaded with the Fiberwire from the 1st metatarsal. Tensioning is performed, and the 3.5 mm Swivelock is inserted into the medial cuneiform.Results:The athlete was cleared to return to full competition 9 months following surgery with physical exam demonstrating stability in both dorsiflexion and abduction. Weight bearing x-rays showed no evidence of hardware failure and no instability in the 1st TMT joint. CT scan demonstrated solid fusion of 2nd and 3rd TMT joints and maintained anatomic reduction of the 1st TMT joint. At 1-year post-op, patient was having pain over the 4th TMT joint. He had a second surgery to remove an exostosis at the 4th TMT joint as well as remove the screw from the 3rd metatarsal to the middle cuneiform. His pain had resolved at most recent follow up. He returned to game action in the final game of his senior season.Conclusion:The literature demonstrates return to sport is possible for athletes with Lisfranc injuries though the data focuses on either purely ligamentous injuries or Myerson type B and C fractures. This case study demonstrates a novel surgical approach to homolateral fracture/dislocation. While return to sport in this athlete took longer than lower-energy injuries, it is possible for athletes with homolateral displacement to return to full competition.

Effect of the manual stretching maneuver for hallux valgus

BackgroundHallux valgus (HV), which is one of the most common musculoskeletal abnormalities of the foot, is defined as the medial deviation of the first metatarsophalangeal (MTP) joint and the lateral deviation of the great toe. ObjectsThis study aimed to investigate the immediate effects of a manual stretching maneuver (MSM) in subjects with HV. MethodsTwenty-five subjects with a total of 25 feet with mild HV participated in the study. The MSM, consisting of global stretching of the foot and toes, traction of the hallux, local stretching for hallux, and mobilization of the MTP joint of the hallux. The HV angle between the line of the first metatarsal bone and the proximal phalanx were measured using a goniometer. The cross-sectional area (CSA) of the AbdH was measured using ultrasonography. Zebris FDM was used to measure the static plantar pressure and the movement of the center of pressure (COP) standing on one foot. The dependent variables before and after treatment were compared using paired t-tests. The significance level was set at .05. ResultsThe HV angle significantly decreased from 20.25° to 16.96°. The CSA of the AbdH significantly increased from 14.00 mm2 to 16.11 mm2. The peak pressure on the hallux and 1st, 2nd and 3rd metatarsals increased significantly. The contact area and total pressure on the hallux significantly increased. The sway of the COP on the length of the minor axis and velocity significantly decreased. ConclusionThis study suggests that the MSM can be effective in decreasing the HV angle in subjects with mild HV. However, further longitudinal clinical studies are required to investigate the long-term effects of the MSM in subjects with HV.

Homolateral Lisfranc Dislocation 1-5 in a Collegiate Quarterback: A Case Study

Background: Lisfranc injuries encompass a spectrum of injuries to the tarsometatarsal (TMT) joint complex from ligamentous sprains to fractures with dislocation. While studies have shown it is possible to return to sport (RTS) after low-energy injuries, no literature exists demonstrating RTS after homolateral fracture/dislocation of all 5 metatarsals. Indications: We present a novel technique for repair of homolateral Lisfranc fracture/dislocation of metatarsals 1-5 which may be used in high-level athletes attempting to return to competition. Technique Description: A dual approach is utilized, with a dorsal approach to allow for fusion of the 2nd and 3rd TMT joints and medial approach for internal bracing of the 1st TMT joint. The 2nd and 3rd metatarsals were denuded of all cartilage and the fusion site was fully prepared. Rigid fixation was applied to the fusion sites and then stability of the 1st TMT was reassessed. A guidewire for the cannulated InternalBrace (Arthrex; Naples, FL) system is initially inserted into the base of the 1st metatarsal. Positioning is confirmed with fluoroscopic imaging and the 3.4 mm drill is passed over the wire, followed by the cannulated tap. A 4.75 mm SwiveLock anchor (Arthrex; Naples, FL) with FiberTape suture (Arthrex; Naples, FL) is then inserted into the metatarsal base. The guidewire is placed in a reciprocating position on the medial cuneiform. The 2.7 mm drill is passed over the wire, followed by the 3.5 mm tap. A 3.5 mm SwiveLock anchor is then loaded with the FiberTape suture from the 1st metatarsal. Tensioning is performed, and the 3.5 mm SwiveLock anchor is inserted into the medial cuneiform. Results: The athlete was cleared to return to full competition 9 months following surgery. Physical examination demonstrated stability in dorsiflexion and abduction. Both weight-bearing x-rays and computed tomography scans showed no evidence of hardware failure, no instability of the 1st TMT joint, and solid fusion of the 2nd and 3rd TMT joints. Discussion/Conclusion: Current literature demonstrates that RTS is possible for athletes suffering from low-energy Lisfranc injuries. This novel surgical technique is the first to demonstrate return to sport of a high-level athlete from homolateral fracture/dislocation of all 5 metatarsals.

English

BACKGROUND Foot problems are a leading cause of hospitalization for patients having diabetes mellitus all over the world. Foot ulcers in diabetes precede 85 % of nontraumatic lower-extremity amputations. Fifteen percent develop foot ulcers during their lifetime. Individuals who develop foot ulcers have a decreased health-related quality of life and consume a lot of healthcare resources. Foot abnormalities is a frequently missed diagnosis and a focus in this area of medical education has never been optimal despite its frequency of presentation. In this study, we wanted to determine clinical and radiographic foot abnormalities in diabetic patients. METHODS A cross-sectional study was carried out on 180 type 2 diabetic patients diagnosed as per ADA definition of diabetes, they were categorized into three groups, the first consisted of 60 diabetic patients without neuropathy or foot ulcers, the second had 60 diabetic patients with neuropathy and the third had 60 diabetic patients with both neuropathy and foot ulcer. Based on the clinical examination of the foot and foot X-ray oblique and lateral view of the affected feet along with other relevant investigations were obtained and analysed using descriptive and inferential statistical analysis. RESULTS We observed that poor glycaemic control and duration of diabetes were important risk factors for foot complications in diabetic patients which were statistically significant. Among patients with only diabetes, 3.3 % had HbA1c less than 6, 35 % had HbA1c between 6 - 9 and 61.7 % with HbA1c of more than 9. Among the patients with diabetes and neuropathy, 1.7 % of people had Hba1c of less than 6, 20 % with Hba1c between 6 - 9 and 78.3 % with Hba1c of more than 9. In patients who had diabetes and neuropathy with foot ulcers, 6.7 % had HbA1c of less than 6, among the same cohort 8.3 % had HbA1c between 6 - 9 and 85 % had HbA1c above 9. The prevalence of various radiological abnormalities of the foot was more common in diabetic patients with both neuropathy and foot ulceration (group lll) (83.3 %). The most common abnormality as observed from our study was Osteopenia with osteoporotic changes seen in 36.7 % of Group III patients VS 16.7 % of Group II (patients with diabetes and neuropathy ) and only in 10 % of Group I patients (patients with diabetes without any complications). Vascular calcifications were observed in 26.7 % VS 16.7 % VS 6.7 % in Group III, Group II, Group I respectively. Periosteal reactions were also more common in Group III patients (6.7 %). Subluxation of 2nd, 3rd, 4th, and 5th metatarsals was observed only in 3.3 % of Group III patients. CONCLUSIONS Diabetic foot is one of the most devastating complications of diabetes. Preventing the diabetic foot should be the first priority. This can be achieved by identifying the high-risk individuals with the above said risk factors by proper clinical examination and use of foot X-ray. KEY WORDS Diabetic Foot, Foot Problems, Foot Infections.

Does metatarsus primus elevatus really exist in hallux rigidus? A weightbearing CT case-control study.

Elevated first metatarsal, Metatarsus primus elevatus (MPE), has been a topic of controversy. Recent studies have supported a significantly elevated first metatarsal in hallux rigidus on weight-bearing radiographs (WBR). However, conventional radiographs have limitations for accurate measurement. Our objective was to comparatively assess MPE and other variables which can affect the spatial relationship of the forefoot in the HR group compared to controls using weight-bearing CT (WBCT). In this single-center, retrospective, case-control study, 25 patients (30 feet) with symptomatic HR and30 controls were selected. WBCT parameters were measured by two independent investigators. Inter-observer reliabilities were assessed using intra-class correlation coefficients (ICCs). MPE was evaluated by measuring the direct distance between 1st and 2nd metatarsals. Independent t tests were performed to compare the two groups. A threshold of MPE to diagnose HR was calculated using the Receiver Operating Characteristic (ROC) curve. HR groups had increased hallux valgus angle (HVA) (8.52° in control vs 11.98° in HR) and MPE (2.92 vs 5.09mm), decreased 1st metatarsal declination angle (21.09° vs 19.07°) 1st/2nd metatarsal declination ratio (87.45 vs 79.71) indicating elevated first metatarsal compared to controls. Dorsal translation of the first metatarsal at the first tarsometatarsal joint was observed in 21 (70%) patients of the HR group when defined as a step-off or discontinuation of the curvature along the first TMT joint. The threshold of MPE for diagnosis of HR was4.19mm with 77% sensitivity and 77% specificity. Our results confirmed a significantly elevated first metatarsal in the HR group compared to controls on WBCT.A MPE greater than 4.19mm was found to be diagnostic for symptomatic HR. Significant number of patients in the HR group (70%) had dorsal translation of the first metatarsal at the first TMT joint which can contribute to increased MPE. The present study demonstrated significantly increased MPE in HR on WBCT and MPE greater than 4.19mm on WBCT can be used as a diagnostic threshold for HR.

The Positive Association Between Metatarsal Length and Meary’s Angle and Hammertoe Deformity

Category:Lesser Toes; Midfoot/ForefootIntroduction/Purpose:Hammertoe deformities are the most common pathology of the forefoot, accounting for up to 48% of all forefoot operations. There is currently limited evidence documenting differences in foot radiographs and radiographic measurements that may represent a predisposition to developing hammertoe deformity. The purpose of this study was to investigate whether patients with hammertoe deformity demonstrate increased radiographic measurements of first, second, or third metatarsal (MT) lengths as well as Meary’s angle compared to a healthy control group.Methods:Following IRB approval, an institutional radiology database was queried from January 2009-2018 for patients with ICD- 9 and ICD-10 diagnosis codes for hammertoe deformity of the 2nd or 3rd phalange. Control cases were selected using diagnosis codes for acute plantar fascial pain in the same timeframe with medical record review to exclude patients with prior lower extremity injury, surgery or pathology. 234 hammertoe and 110 control patients met inclusion and exclusion criteria. Automated 1:1 case-control matching was performed to control for age, sex and laterality. Following matching, the sample size consisted of 80 patients in each cohort. Proximal to distal end-to-end articular surface radiographic lengths were documented for metatarsals and phalanges of the 1st, 2nd and 3rd rays on anteroposterior radiographs. Lateral talar-first metatarsal (Meary’s) angle was measured using weightbearing sagittal radiographs by calculating the angle formed by lines that bisect the talar neck and anatomic neck of the first metatarsal.Results:A total of 160 patients (80 cases and 80 controls) were included in the study. Mean age was 47.7 years among hammertoe cases and 47.5 years among controls (p=0.92). 54 of 80 cases in each group were female. There was a statistically significant increase in the average Meary’s angle among hammertoe patients (5.23 +- 8.60°) compared to controls (2.15 +- 5.96°) (p<0.01). The average length for the 1st, 2nd and 3rd metatarsals were 65.6, 80.0, and 76.7 mm, respectively for the hammertoe patients and 62.8 mm, 76.0 mm, and 73.5 mm among control cases, respectively. For all three metatarsals, this difference was statistically significant (p<0.01; Table 1). There was no statistically significant difference between lengths of the proximal or distal phalanges.Conclusion:Patients with hammertoe deformity were associated with an increased length on the 1st, 2nd and 3rd metatarsals. Also, these patients demonstrated an increased Meary’s angle creating pes planus deformity. These results illustrate the importance of both medial column instability and long metatarsal length in the development of hammertoe deformity.

Correlations between weight-bearing 3D bone architecture and dynamic plantar pressure measurements in the diabetic foot

BackgroundMeasurements of plantar loading reveal foot-to-floor interaction during activity, but information on bone architecture cannot be derived. Recently, cone-beam computer tomography (CBCT) has given visual access to skeletal structures in weight-bearing. The combination of the two measures has the potential to improve clinical understanding and prevention of diabetic foot ulcers. This study explores the correlations between static 3D bone alignment and dynamic plantar loading.MethodsSixteen patients with diabetes were enrolled (group ALL): 15 type 1 with (N, 7) and without (D, 8) diabetic neuropathy, and 1 with latent autoimmune diabetes. CBCT foot scans were taken in single-leg upright posture. 3D bone models were obtained by image segmentation and aligned in a foot anatomical reference frame. Absolute inclination and relative orientation angles and heights of the bones were calculated. Pressure patterns were also acquired during barefoot level walking at self-selected speed, from which regional peak pressure and absolute and normalised pressure-time integral were worked out at hallux and at first, central and fifth metatarsals (LOAD variables) as averaged over five trials. Correlations with 3D alignments were searched also with arch index, contact time, age, BMI, years of disease and a neuropathy-related variable.ResultsLateral and 3D angles showed the highest percentage of significant (p < 0.05) correlations with LOAD. These were weak-to-moderate in the ALL group, moderate-to-strong in N and D. LOAD under the central metatarsals showed moderate-to-strong correlation with plantarflexion of the 2nd and 3rd phalanxes in ALL and N. LOAD at the hallux increased with plantarflexion at the 3rd phalanx in ALL, at 1st phalanx in N and at 5th phalanx in D. Arch index correlated with 1st phalanx plantarflexion in ALL and D; contact time showed strong correlation with 2nd and 3rd metatarsals and with 4th phalanx dorsiflexion in D.ConclusionThese preliminary original measures reveal that alteration of plantar dynamic loading patterns can be accounted for peculiar structural changes of foot bones. Load under the central metatarsal heads were correlated more with inclination of the corresponding phalanxes than metatarsals. Further analyses shall detect to which extent variables play a role in the many group-specific correlations.

PO 18042 - Surgical treatment of moderate and severe hallux valgus

Introduction: Hallux valgus is a multifactorial disease, and heredity is the main associated factor. Pain and discomfort when using closed-toed shoes occur in many cases, adversely affecting quality of life. Surgical treatment is indicated when pain and disability persist after conservative treatment. Currently, more than 150 surgical techniques are described for hallux valgus correction, with no consensus regarding the best treatment. With the advent of minimally invasive techniques for hallux valgus correction, Vernois developed the percutaneous chevron osteotomy. This technique allows up to 100% lateral translation of the contact area of the osteotomy. Objective: the objective of the present study was to assess the correction of radiographic parameters, clinical improvement and potential complications of the first 30 cases of moderate and severe hallux valgus operated on at our hospital using the percutaneous chevron technique. Methods: A total of 26 patients (30 feet) underwent surgery. The following parameters were measured in the pre- and postoperative periods: the first metatarsophalangeal (MTP) angle, the intermetatarsal angle between the 1st and 2nd metatarsals (IMA), the distal metatarsal articular angle (DMAA) and the pre- and postoperative American Orthopedic Foot and Ankle Society (AOFAS) scores, with a minimum follow-up period of 6 months. Results: The mean age of the patients was 52.3 years. During the preoperative period, the mean AOFAS score was 45.6; it increased to 90.3 after the procedure, indicating a statistically significant improvement. The mean MTP angle, IMA and DMAA were 29.7°, 14.2° and 14.2° before surgery and 12.8°, 8.2° and 11.1° after surgery, respectively. The improvements in the MTP angle and the IMA were also significant. There was no decrease in angles or worsening of AOFAS scores during follow-up. Conclusion: The percutaneous chevron technique was safe and effective for correcting cases of moderate and severe hallux valgus, with significant improvements in clinical and radiological parameters and a low rate of postoperative complications.

T2 relaxation time measurements in tibiotalar cartilage after barefoot running and its relationship to ankle biomechanics

The influence of ankle kinematics and plantar pressure from mid-range barefoot running on T2 relaxation times of tibiotalar cartilage is unknown. This study aimed to quantitatively evaluate the T2 relaxation time of tibiotalar cartilage and ankle biomechanics following 5 km barefoot running. Twenty healthy runners (who had no 5 km barefoot running experience) underwent 3.0-Tesla magnetic resonance (MR) scans and assessment of running gait before and after 5 km barefoot running. Participants were divided into two groups consisting of marathon-experienced (n = 10) and novice (n = 10) with equal number of males and females in each group. Three musculoskeletal radiologists measured T2 relaxation times in 18 regions of the ankle cartilage: anterior zone, central zone, and posterior zone, or lateral, middle, and medial sections in the sagittal plane. Three-dimensional ankle kinetics, kinematics, and plantar pressure were all also assessed during barefoot running. In the novice group, the T2 relaxation time in the posterior zone of tibial cartilage (p = 0.001) and lateral section in both tibial (p = 0.02) and talar (p = 0.02) cartilage were significantly increased after barefoot running. Ankle kinematics exhibited significant changes in females. Plantar loading was shifted from the medial to lateral aspect after running. This included a significant reduction in the loading under the toes and the 1st, 2nd and 3rd metatarsals, with a significant increase under the 4th and 5th metatarsals and lateral midfoot. The results suggest that plantar pressure may directly lead to local increases in cartilage T2 signal, which was not associated with changes in ankle kinematics.

Surgical treatment of moderate and severe hallux valgus: 30 cases undergoing surgery using the percutaneous Chevron technique

Objective: To evaluate the radiographic parameter correction and clinical improvement of moderate and severe hallux valgus deformities treated by percutaneous Chevron osteotomy. Methods: Twenty-six patients (30 feet) underwent surgery. The following were measured preoperatively and postoperatively: hallux metatarsophalangeal (MTP) angle, intermetatarsal angle between the 1st and 2nd metatarsals (IMA), distal metatarsal joint angle (DMJA) and pre- and postoperative AOFAS scores with a minimum of 6 months of follow-up. Results: The mean patient age was 52.3 years. Preoperatively, the mean AOFAS score was 45.6, which rose to 90.3 after the procedure, showing a statistically significant improvement. The preoperative mean MTP, IMA and DMJA angles were 29.7°, 14.2° and 14.2°, respectively, and the postoperative values were 12.8°, 8.2° and 11.1°, respectively. The improvements in MTP and IMA angles were also statistically significant. There were no losses in angular parameters or worsening of AOFAS scores during follow-up. Conclusion: The percutaneous Chevron surgical technique proved to be safe and effective for the correction of moderate and severe hallux valgus cases and achieved significant improvements in clinical and radiographic parameters and low rates of postoperative complications. Level of Evidence III; Retrospective Comparative Study.