Medial Cuneiform Research Articles

Relationship between insertions of the tibialis anterior and peroneus longus and first tarsometatarsal joint degeneration

BackgroundThe purpose of this study was to clarify the relationships of the tibialis anterior tendon (TAT) and peroneus longus tendon (PLT) with articular cartilage degeneration on the medial cuneiform and first metatarsal.MethodsWe examined 100 feet from 50 Japanese cadavers. The TAT was classified into 4 types based on attachment site area and number of fiber bundles: Type I, two fiber bundles with equal (within 20%) attachment site areas on the first metatarsal and medial cuneiform; Type II, with two fiber bundles and a larger (>20%) attachment site area on the medial cuneiform than on the first metatarsal; Type III, with two fiber bundles and a larger (>20%) attachment site area on the first metatarsal than on the medial cuneiform; and Type IV, with three fiber bundles. The PLT was classified into 2 types, following previous studies: Type I, insertion only to the base of the first metatarsal; Type II, insertion to the medial cuneiform and first metatarsal. The severity of articular cartilage degeneration was assessed in five stages using the International Cartilage Repair Society scale.ResultsNo significant difference in severity of articular cartilage degeneration was evident among types of TAT and PLT.ConclusionOur results suggested that anatomical variations in the TAT and PLT might not affect joint stability, indicating that strengthening of these muscles could potentially enhance stability regardless of morphological variations in the insertions.

Coronal Plane Alignment of the Medial Column in Isolated Hallux Valgus, Isolated Flatfoot, and Combined Hallux Valgus-Flatfoot.

To provide improved treatment for hallux valgus (HV), we sought to understand more about the pathophysiologic connection between flatfoot deformity and HV by comparing coronal plane alignment of the medial column of the foot for patients with isolated HV, isolated flatfoot, and combined HV-flatfoot vs controls. This study retrospectively assessed a consecutive series of 33 patients with combined symptomatic and radiographic HV and flatfoot, 33 isolated symptomatic HV, 33 isolated symptomatic flatfoot, and 33 controls. The medial column alignment was assessed in the coronal plane using 3-dimensional weightbearing computed tomography (WBCT); rotation was measured for the navicular, medial cuneiform, and first metatarsal (M1). The position of the first naviculocuneiform (NC) and tarsometatarsal (TMT) joints were determined. M1 intrinsic pronation was significantly greater in patients with combined HV-flatfoot (-12.0 ± 7.0 degrees; P < .001), isolated HV (-12.1 ± 6.6 degrees; P < .001), and isolated flatfoot (-11.8 ± 8.5 degrees; P < .001), compared with control patients (-19.4 ± 6.7 degrees). TMT was significantly more pronated in patients with combined HV-flatfoot (30.9 ± 6.2 degrees) compared with isolated flatfoot (25.3 ± 9.3 degrees; P = .007), and control (25.9 ± 5.2 degrees; P = .005), as it was in patients with isolated HV (33.2 ± 8.2 degrees) compared with isolated flatfoot (P < .001), and control (P < .001). NC was significantly more supinated in patients with combined HV-flatfoot (-23.7 ± 3.9 degrees) compared to isolated flatfoot (-18.0 ± 9.8 degrees; P = .001), and control (-18.0 ± 4.5 degrees; P < .001), as it was for patients with isolated HV (-24.8 ± 7.1 degrees) compared with isolated flatfoot (P = .003), and control (P < .001). In our study, we found that patients with isolated HV, isolated flatfoot, or combined HV-flatfoot presented a similar increase in M1 intrinsic pronation of approximately 7.5 degrees, compared with controls. Moreover, patients with isolated HV or combined HV-flatfoot had greater TMT pronation and NC supination, compared with patients with isolated flatfoot and controls.

Association between clinical and MRI-detected imaging findings for people with midfoot pain, a cross-sectional study.

Midfoot pain is common but poorly understood, with radiographs often indicating no anomalies. This study aimed to describe bone, joint and soft tissue changes and to explore associations between MRI-detected abnormalities and clinical symptoms (pain and disability) in a group of adults with midfoot pain, but who were radiographically negative for osteoarthritis. Community-based participants with midfoot pain underwent an MRI scan of one foot and scored semi-quantitatively using the Foot OsteoArthritis MRI Score (FOAMRIS). Foot pain and disability were recorded using visual analog scales (VAS) and the Modified-Manchester Foot Pain Disability Index (MMFPDI). Associations were assessed for continuous data using Spearman's Rho, and for categorical data, a Wilcoxon signed rank test. Linear regression was used to explore the association between participant-reported measures and MRI abnormalities, adjusted for age, sex and BMI. Sixty-one participants (70% female, mean age 48.5years, median BMI 28.6kg/m2) were included. Median VAS pain was 31/100mm (IQR 21-47) and median disability was 30/48 (IQR 26-36). There was a moderate association between midfoot pain severity and the number of joints exhibiting joint space narrowing; adjusted results suggested 31% (95% confidence interval 3%-68%) worse VAS pain with each additional affected joint. Greater numbers of joints with cysts were associated with worse VAS pain [14% (0%-31%)] and disability [1.1 units (0-2.2)]. Effusion/synovitis was associated with MMFPDI pain. No other MRI abnormalities were associated with sex, body mass and foot pain/disability measures. Bone marrow lesions, joint space narrowing, cysts and osteophytes occurred more frequently with age. MRI abnormalities were common, particularly in the talo-navicular joint, first and second cuneo-metatarsal joints. Those with dorsal foot pain had more multi-joint involvement, bone marrow lesions, joint space narrowing and cysts and for those with pain on midfoot movement, bone marrow lesions and cysts were reported. In people with midfoot pain, MRI-detected features of osteoarthritis and soft-tissue abnormalities were found, clustered in the medial and intermediate cuneiform joints. These features were more common with age but not associated with pain or disability measures. Younger people with dorsal midfoot pain exhibited early signs of bone and joint features of osteoarthritis and we recommend further imaging studies to determine the clinical and diagnostic significance.

An examination of commingled first tarsometatarsal and atlantoaxial joints by deviation analysis.

This study follows up on previous research conducted by Litavec (J Forensic Sci., 68, 2023, 1780) on sorting commingled sacroiliac joints using deviation analysis. In the present report, the results of this technique are expanded to separating commingled first tarsometatarsal and atlantoaxial joints. Following the methods of Litavec (J Forensic Sci., 68, 2023, 1780), virtual models were created at the University of Tennessee-Knoxville Donated Skeletal Collection from 69 atlases and axes, 66 first metatarsals, and 64 medial cuneiforms using an EinScan-Pro 2x+ Handheld Surface Scanner. The shape and congruency of the articular surfaces were analyzed using a deviation analysis in Geomagic Wrap 2021. Receiver operating characteristic curves were conducted on reference samples composed of 200 commingled and non-commingled bone pairs per joint to identify threshold values for sorting the remains. Validation samples of 225 pairs were subsequently analyzed to identify the efficacy of this method on a sample of unknown individuals. The statistical analyses confirmed that deviation analysis values from commingled first tarsometatarsal and atlantoaxial joint pairs were significantly larger than those from non-commingled individuals (p < 0.0001). 87%-92% of first tarsometatarsal pairs and 63%-66% of atlantoaxial joint pairs were correctly sorted based on the selected threshold values. This study increases the number of joints able to be sorted by deviation analysis and reemphasizes its value as a technique for resolving commingled human remains.

Foot pain as first presenting symptom of renal cell carcinoma, due to metastatic lesion in medial cuneiform

Foot pain as first presenting symptom of renal cell carcinoma, due to metastatic lesion in medial cuneiform

Osteoma osteoide de localización atípica en cuneiforme lateral, tratado mediante ablación alcohólica: A propósito de un caso.

Osteoid osteoma is a benign tumor that rarely affects the bones of the foot. There are many pathologies that can produce foot pain in children and adolescents and therefore, reaching the diagnosis of OO can be delayed. It is important to have a high clinical suspicion of OO in the foot since the symptomatology is atypical, often without nocturnal pain, and radiographic tests are difficult to assess. We present the case of an OO in the distal dorsal aspect of the third cuneiform of the foot treated by alcoholic ablation with ethanol. So far, there are only 20 cases described in the literature of OO affecting the cuneiform bones. The treatment performed in the previous cases was by open surgery or radiofrequency ablation. Our case is the only OO of the lateral cuneiform treated by alcoholic ablation with ethanol with good postoperative results and no recurrence. In conclusion, CT-guided percutaneous alcohol ablation is a valid alternative for the treatment of an OO located in the foot. It is a minimally invasive, simple, effective and low-cost technique.

A recommended sampling strategy for genetic identification of Second World War victims in Slovenia

Skeletonized human remains from Second World War mass graves in Slovenia are a major challenge in genetic identification, and bones with a high DNA yield must be selected for successful identification. The goal of this study was to construct skeletal sampling strategy recommendations through comparison of the most appropriate groups of skeletal elements. Altogether, 566 bones and teeth from the same mass grave were compared, half analyzed in this study and half in previous studies performed by our group. After anthropological examination, mechanical and chemical cleaning was performed, followed by bone and tooth powdering. Total demineralization of 0.5 g of bone and tooth was followed by extraction and purification of DNA with a Biorobot EZ1 device (Qiagen). The qPCR PowerQuant kit (Promega) was used to measure the amount of DNA, and statistical analysis was performed. Skeletal elements were selected according to known better preservation of DNA in the human body, and they were arranged in seven groups: petrous bone, long bones (femur and tibia), torso bones (first rib and 12th vertebra), metacarpals, metatarsals, short and sesamoid bones (talus, navicular, medial cuneiform, cuboid, calcaneus, and patella), and teeth. Sampling strategy recommendations were constructed based on DNA quantity and quality results. The petrous bone group, metacarpal group, torso bone group, and short and sesamoid bone group produced the highest DNA yields. Accordingly, in addition to standard sampling of long bones (femurs and tibias) and teeth, those additional bone types should be collected for Slovenian Second World War victim identification.

Tibialis Anterior Tendon Transfer for Clubfoot Deformity: Cuboid Versus Lateral Cuneiform.

Tibialis anterior tendon transfer in relapsing clubfoot deformity is a well-known treatment option for dynamic forefoot supination and adduction deformities. The tibialis anterior tendon can be anchored to the lateral cuneiform or the cuboid. A complication of this surgery is overcorrection to a flatfoot deformity or undercorrection that maintains the clubfoot deformity. We compared reoperation rates and clinical outcomes between these 2 groups. This is a retrospective study performed from 2005 to 2020. The primary outcome was repeat operation. The secondary outcome included clinical appearance scores described by Garceau and Palmer. There were 114 clubfeet (111 patients) treated in our study. Of them, 67 (58.8%) had a transfer to the lateral cuneiform, whereas 47 (41.2%) had a transfer to the cuboid. Nine patients had reoperations which included 4 (44.4%) in the lateral cuneiform group and 5 (55.6%) in the cuboid group which was not statistically significant (P=0.485). Clinical appearance scores revealed significantly better clinical appearance in the lateral cuneiform group after surgery compared with the cuboid group (P=0.0172). There were no clinically significant differences in reoperation rates between transfers to the lateral cuneiform versus the cuboid. We did find better clinical appearance in the lateral cuneiform group after surgery compared with the cuboid group. Level III retrospective comparative study.

Comparative Analysis of Structural Differences in Progressive Collapsing Foot Deformities with and without Hallux Valgus

Category: Bunion; Hindfoot Introduction/Purpose: Progressive collapsing foot deformity (PCFD) and Hallux Valgus (HV) are common foot and ankle pathologies, each associated with over-pronation. Although hindfoot pronation is known to potentially increase forefoot pronation, not all patients with PCFD ultimately develop HV deformity. This study aims to explore the structural differences in patients with PCFD, with and without HV deformities, using weight-bearing computed tomography (WBCT). We hypothesize that specific structural variations exist, which could potentially inform and enhance future therapeutic strategies and preventive measures for HV deformity in patients with PCFD. Methods: Adult PCFD patients underwent WBCT at our institution between May 2023 and December 2023 were included. Semi-automatically measured parameters include Meary angle (axial and sagittal), calcaneal inclination angle, hindfoot moment arm, hindfoot angle, axial talonavicular angle, intermetatarsal angle, HV angle were recorded. WBCT manual measurement include foot and ankle offset, angle between inferior facet of the talus and the ground (inftal-hor), angle between inferior and superior facets of the talus (inftal-suptal), angle between inferior facet of the talus and superior facet of the calcaneus (inftal-supcal), and forefoot arch angle. Additionally, using the ground as a reference, the coronal plane pronation of the navicular, medial cuneiform, first metatarsal base, and first metatarsal head were also recorded. HV deformity was defined as having a Hallux Valgus Angle (HVA) greater than 15 degrees. Pronation/valgus were defined as positive values. Results: Our study included 58 patients (72 feet), 33 feet with HV and 39 without HV. In the coronal plane, the PCFD with HV group exhibited higher inftal-suptal angle (p=0.001), and higher pronation of the first tarsal-metatarsal joint (p=0.006), first metatarsal bone(p=0.002), and first metatarsal head(p&lt; 0.001). Additionally, this group also demonstrated higher navicular-cuneiform joint supination (p &lt; 0.001). In axial plane, the axial talar-1st metatarsal angle higher in the PCFD without HV group (p=0.043). Nominal logistic regression analysis indicated parameters include 1st metatarsal head rotation (p&lt; 0.001), medial cuneiform rotation(p&lt; 0.001), inftal-suptal angle (p&lt; 0.001), axial talar-1st metatarsal angle (p&lt; 0.001), navicular rotation (p=0.007), first metatarsal base rotation (p=0.012), and inftal-hor angle (p=0.016) are significantly correlated with the presence of HV in PCFD patients. (R2 (U)=0.79) Conclusion: Our findings reveal distinct structural differences in PCFD patients with HV compared to those without, which corroborates our hypothesis. Significant correlations exist between HV presence and rotation of the navicular, medial cuneiform, first metatarsal base, and first metatarsal head. Talus morphology, including inftal-suptal and inftal-hor angles, also correlated with HV deformity. Talar-first metatarsal angle was the only traditional two-dimensional radiographic parameter that correlated with HV deformity. Based on our findings, PCFD patients displaying these features might need HV preventive measures. Prospective longitudinal studies or dynamic research may be required to further elucidate the relationships between these two deformities.

Effect of Arthrodesis of the First-Metatarsophalangeal Joint on the Alignment and Stability of the First-Tarsometatarsal Joint: A Large Sample-Sized Radiographic Study

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: The hallux metatarsophalangeal (MTP) joint plays an important role in maintaining mobility of the first ray and arthrodesis of this joint is used to treat a variety of deformities. Intuitively, fusion of a joint may cause instability of an adjacent joint, however, recent studies have shown that hallux MTP arthrodesis in patients with hallux valgus can improve the stability of the first-tarsometatarsal (TMT) joint. The goal of this study was to investigate the impacts of hallux MTP arthrodesis on the alignment of the first TMT joint in a large sample-sized cohort. Methods: This was a retrospective study that included one group of patients without hallux valgus (Control Group ) and one group with hallux valgus deformity. Pre-operative and six-month post-operative weight-bearing radiographs were used to evaluate the alignment of the hallux and the first TMT joint. The parameters included the hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), first metatarsal–medial cuneiform angle (1MCA), medial cuneiform–first metatarsal angle (MC1A), relative cuneiform slope (RCS), and distal medial cuneiform angle (DMCA). A paired t-test was used to study the impact of first MTP arthrodesis on the above parameters, and an independent t-test was used to compare the difference of the surgical effect on those parameters between the two groups. Possible linear regression relationship was analyzed among those variants. Results: There were 32 patients in the control group (age 57.93 ±9.07) and 62 patients in hallux valgus group (age 65.26± 12.84). In control group, except for HVA, there was no change in any of the above parameters between the pre and post surgical images; while in hallux rigidus group, the HVA, IMA, 1MCA, MC1A, and RCS were significantly reduced after surgery (p &lt; 0.05). The RCS increased slightly in control group, but decreased significantly in hallux rigidus group (p &lt; 0.05). Between the two groups, there was a significant difference in the impact of surgery on HVA, IMA, MC1A and RCS. In hallux rigidus group, correlation detected between pre-post operative IMA with HVA and MC1A, HVA with 1MCA, 1MCA with RCS and DMCA, MC1A with RCS, RCS with DMCA. Conclusion: Hallux MTP arthrodesis improved the alignment of the first-TMT joint in patients with hallux valgus, but this change had no correlation with either the pre and postoperative IMA or HVA changes. There was no significant improvement nor worsening of the TMT alignment in patients without hallux valgus.

The Use of Diastasis to Determine Lisfranc Instability

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc injuries have a reported incidence of 1 in 55,000 people. However, given the subtle displacement present in some of these injuries, up to one third are missed on initial diagnosis. Weightbearing imaging is the gold standard for evaluation and diagnosis of the Lisfranc complex, and diastasis between the medial cuneiform and second metatarsal (C1-M2) is the most commonly discussed parameter. However, no explicit consensus on precisely where within the Lisfranc complex to measure the diastasis has been established. Therefore, the aim of this study was to determine what specific diastasis measurement is most sensitive in diagnosing Lisfranc instability using weightbearing radiographs and computed tomography (WBCT). Methods: A total of 159 adult patients with bilateral foot WBCTs were included: 44 with confirmed Lisfranc instability and 115 controls. A subset had unilateral weightbearing X-rays (38 and 83 patients, respectively). Lisfranc instability was confirmed intraoperatively or by physical exam. Exclusion criteria were: prior midfoot surgery, Charcot arthropathy, severe midfoot arthropathy, cuneiform fractures, and significantly displaced 1st-3rd metatarsal base fractures. In the axial plane, C1-M2 diastasis was measured on weightbearing radiograph and WBCT. In the coronal plane, diastasis was measured at different levels between C1-M2 (dorsal, interosseus, plantar, planter apex) and C1-M3 (plantar apex) on WBCT. For WBCT measurements, percent difference between feet was calculated. Case and control measurements were compared with Mann-Whitney U tests (p &lt; 0.05). Diagnostic cutoffs were determined using receiver operator curves (ROC) and minimum distance to the corner. Sensitivity, specificity, negative and positive predictive values, and area under the curve were calculated for each cutoff value. Results: A significant portion of the subjects were female (Lisfranc instability: 60% and controls: 61%). Average age was 39±17 years and 44±17 years for the Lisfranc instability and control groups, respectively. Mann-Whitney U testing revealed a significant difference between groups for all measurements except plantar C1-M2 (p=0.13), C1-M2 plantar apex (p=0.69) and C1-M3 plantar apex (p=0.07). Figure 1 summarizes the diagnostic cutoff values and the associated efficacy measures. Axial WBCT diastasis was the most effective diagnostic measure, followed by dorsal coronal WBCT diastasis. Using a percent difference cutoff of 34%, axial WBCT diastasis (AUC=0.90) demonstrated outstanding diagnostic capability. Dorsal coronal WBCT diastasis with a percent difference cutoff of 46% (AUC=0.80) demonstrated excellent capability. The remaining measurements provided less reliable diagnostic capability, including diastasis on radiograph (AUC=0.77). Conclusion: Axial WBCT diastasis and dorsal coronal WBCT diastasis both effectively diagnose Lisfranc instability on WBCT, with axial WBCT diastasis demonstrating outstanding diagnostic capability. The traditional method of C1-M2 diastasis on weightbearing radiograph is not as effective as either of these WBCT measurements and only provides adequate diagnostic capability. Our results emphasize the value of diastasis measurements using bilateral WBCT imaging to diagnose Lisfranc instability. These results also suggest that diastasis measurements should be performed in the axial plane and on the dorsal aspect of the Lisfranc complex.

Can early treatment of lisfranc injuries without planned re-intervention be safely performed

The Lisfranc complex is a unique combination of ligamentous and osseous relationships between the medial cuneiform and second metatarsal base that is often injured by high energy mechanisms. Fixation for these injuries is often operative; however, the optimal timing of surgical treatment has been debated. All patients who underwent operative fixation of a Lisfranc injury at a single urban tertiary care center were reviewed. Patient were split into two groups based on timing to fixation with one group being less than 24 h from presentation and a second group being greater than 24 h. There were 58 patients who underwent what was planned as final operative stabilization of their Lisfranc injury in less than 24 h and 41 patients who underwent fixation after more than 24 h. The early treatment of Lisfranc injuries did not lead to significant increases in follow up time, infections, time to weight bearing, union rates, or time to union compared patients treated with delayed fixation. There was a higher rate of superficial infection in the early intervention group, but it did not reach statistical significance. We believe our findings demonstrate that delayed fixation is not superior to early treatment of Lisfranc injuries. Level of evidenceLevel 3 Therapeutic retrospective comparative study.

Maintenance of Hallux Valgus Correction Treated with Modified Lapidus Procedure: Intermetatarsal Miniature Suture Button vs First Metatarsal to Intermediate Cuneiform Cross-Screw Fixation

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Over time our understanding of Hallux valgus deformity has continued to improve since Lapidus published his series in 1960, however, recurrence remains as high as 38%. Fixation of the first tarsometatarsal joint has been known to improve the rigidity of the construct and reduce recurrence. While some authors employ an inter-cuneiform screw between the medial and intermediate cuneiform others provide fixation using a suspensory fixation device (Arthrex mini tightrope). However, this is limited information comparing the modified Lapidus first metatarsal arthrodesis using the suture button fixation (MT1-2 SB) and the first metatarsal intermediate cuneiform screw (MT1C2 Screw). We hypothesize that the intermediate screw fixation would have better radiographic outcomes compared to the suture button fixation. Methods: This was a retrospective comparative study between patients who underwent surgical management of hallux valgus using the MT1-2 SB and the MT1C2 screw between January 2015 to January 2023. Exclusion criteria were as follows: revision or prior hallux valgus corrective surgery on the same foot, patients who received additional procedures (i.e. midfoot fusion, or flatfoot reconstruction), and incomplete medical records. Demographic variables including age, sex, body mass index (BMI), diabetes status, and smoking status were collected. Recurrence rate, union rate, hardware removal, infection rate, and patient-reported outcomes were also collected. The radiographic variables are first metatarsal declination angle (MTD), intermetatarsal angle (IMA), hallux valgus angle (HVA), and sesamoid station. Results: We had a total of 269 patients in the MT1-2 SB cohort and 93 in the MT1C2 Screw cohort. The MT1-SB group achieved a better radiographic correction for IMA (5.37 +/- 3.21 vs 6.65 +/- 3.36, p= &lt; 0.001), HVA (16.03 +/-7.89 vs 19.81 +/- 8.47, p= &lt; 0.001), and sesamoid stations (0.52 +/- 0.81 vs 0.76 +/- 0.90, p= 0.19). MT1-SB had a better correction at final follow-up. Diabetes status was associated with greater postoperative pain, while smoking status was associated with worse postoperative FAAM ADL score (p= 0.011 and 0.003 respectively). Smoking was associated with a greater postoperative and final HVA in addition to an increased revision rate (15.8% vs 3.5%, p=0.037). A greater recurrence rate was also seen among smokers (15.8% vs 4.4%, p=0.061). Conclusion: Suture button fixation and first metatarsal intermediate cuneiform screw fixation demonstrated similar clinical outcomes, union rates, deformity correction, and maintenance of correction at the final follow-up. Smoking was associated with a higher rate of recurrence, revision, and worse patient-reported outcomes.

Effect of Hallux Valgus Correction Osteotomies on Flatfoot Deformity

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Flatfoot deformity is frequent in patients with hallux valgus deformity (HVD). Prior studies have shown that distal correction of HVD such as first metatarsophalangeal (MTP) fusion is capable of improving some radiologic parameters of flatfoot deformity, reinforcing the theory that the recovery of the tension of the distal medial arch is fundamental for stabilizing the first tarsometatarsal joint, preventing the arch collapse and the failure of HV correction. However, to our knowledge, it is unknown whether the first metatarsal osteotomies can generate a similar phenomenon. The purpose of this study was to evaluate if the first metatarsal osteotomies for HVD can improve the radiologic parameters of flatfoot deformity. Methods: A retrospective review of consecutive patients treated with open surgery for HVD between 2018 and 2021 at a single institution was performed. Inclusion criteria were moderate hallux valgus angle (HVA) &gt;20º, open first metatarsal osteotomy (i.e chevron and scarf osteotomies), concomitant flatfoot deformity (Meary angle&gt;4º), pre-and postoperative weightbearing foot radiographs, and at least 3 months of follow-up. Exclusion criteria were HVD treated with any type of first ray fusion, first MTP or TMT arthritis, prior surgery, or complications (malunion, infections). The following variables were collected by two fellowship trained-foot and ankle orthopaedic surgeons: Meary angle (MA), calcaneal pitch (CP), medial cuneiform height (MCH), talonavicular coverage angle (TNCA), anteroposterior talo-first metatarsal angle (TFMA), hallux valgus angle (HVA), and 1-2 intermetatarsal angle (IMA). The Wilcoxon signed-rank test was used to compare the variables pre and post-surgery. P value&lt; 0.05 was considered significant. Results: A total of 225 patients were initially evaluated, of which 23 patients fulfilled the eligibility criteria. The mean age was 40.9 (+-19.1) years and all patients were female. A significant decrease was observed in the HVA and IMA (p&lt; 0.001). The median and interquartile ranges of pre-and postoperative variables were: MA, 8.2º (6.8-12.7) to 5.7º (4.3-11.2); CP, 16.7º (13.4-20.2) to 17.5º (14.1-19.8); MCH, 27.7mm (25.9-32.5) to 29.9mm (26.4-34.2); TNCA, 19.7º (13.8-25.5) to 17.2º (13.8-22.7), and TFMA, 7.3º (6.2-9.9) to 12.3º (6.3-15.1). A significant change after first metatarsal osteotomy was observed in the MA (p=0.04), CP (p=0.03), TNCA (p=0.03), and TFMA (p=0.01), but not in the MCH. Conclusion: This study demonstrated that HVD correction through first metatarsal osteotomy is capable of significantly improving the radiological parameters commonly altered in flatfoot deformity. These findings, concordant with prior studies on first MTP fusion, reinforce the important role that soft tissue tension plays in foot alignment. However, the clinical importance and its applicability in the treatment of patients with symptomatic flat feet must be determined by future work.

Effect of dorsoplantar miniscrew fixation of the second metatarsal base fracture on residual diastases in acute lisfranc fracture-dislocation.

This study aimed to evaluate and compare the clinico-radiographic outcomes between two techniques for acute Lisfranc fracture-dislocation with a large, displaced second metatarsal base plantar fracture: isolated Lisfranc screw fixation versus Lisfranc joint fixation with dorsoplantar miniscrew fixation of the second metatarsal base. We retrospectively compared the clinico-radiographic outcome between patients who underwent isolated Lisfranc screw fixation (Group 1, 26 patients) and those who underwent Lisfranc joint fixation with dorsoplantar miniscrew fixation of the second metatarsal base (Group 2, 23 patients). The main outcome measurements were the postoperative distance between the medial cuneiform and second metatarsal base on standing anteroposterior foot radiographs, known as the C1-M2 distance. Residual diastasis was defined as C1-M2 distance ≥ 2mm on the affected side compared with that on the contralateral side. We also assessed the Foot and Ankle Ability Measure (FAAM)-activities of daily living (ADL) and sports subscale scores at three, six and ≥ 18 months postoperatively. At the final follow-up, the mean C1-M2 distance on the affected side compared with that on the contralateral side was significantly greater in Group 1 than in Group 2 (3.9 versus 0.7mm, P = 0.027). Furthermore, Group 1 showed a higher incidence of residual diastases at the final follow-up (69.2%) than the Group 2 (13.0%, P < 0.001). The FAAM-ADL scores at the final follow-up did not differ significantly between the groups (P = 0.518), but the FAAM Sports score was significantly higher in Group 2 than in Group 1 (P = 0.001). The postoperative C1-M2 distance was better maintained with Lisfranc joint fixation with dorsoplantar miniscrew fixation of the second metatarsal base than with isolated Lisfranc screw fixation. We recommend that surgeons exercise caution when dealing with a second metatarsal plantar fracture and consider performing secure fixation using the dorsoplantar miniscrew technique for improved clinical outcomes.

Lisfranc Injury: A Case Report and Literature Review

Lisfranc injuries are relatively rare, accounting for only 0.2% of all injuries, and few case reports have been published on this topic. In this report, we present a case of a Lisfranc injury in a healthy 30-year-old male who fell down a staircase, landing on his left foot. The diagnosis was made using X-rays and computed tomography (CT). The X-rays showed dislocation of the tarsometatarsal joint with lateral displacement of the M4, M3, M2, and M1 metatarsals. The CT scan revealed a fracture-dislocation of the second metatarsal, with detachment of intra- and extra-articular bone fragments associated with a fracture of the medial cuneiform bone. Surgical management, in the form of open reduction and internal fixation, was performed. The patient followed an expected postoperative course and was doing well, without pain or limitation of activities, at his 3-month postoperative visit. Additionally, we provide a brief review of similar published cases and an overview of Lisfranc injuries.

Méary's angle decoded: 3D analysis of first ray plantarflexion deformity in Charcot-marie-tooth disease

BackgroundThe typical cavovarus deformity seen in patients with Charcot-Marie-Tooth (CMT) involves plantarflexion of the first ray. The exact apex of the deformity has never been proven, although it is presumed to be within the medial cuneiform. The aim of this study was to utilize weight-bearing computed tomography (WBCT) to localize and quantify first ray plantarflexion deformity in CMT patients. MethodsWBCTs of 16 CMT patients with lateral Méary’s angle > 20 degrees were compared to controls utilizing semi-automated analysis software. A local coordinate system based on the first metatarsal was used to avoid bias of proximal deformity. The tarsometatarsal angle was subdivided into components (cuneiform-cuneiform joint normal, tarsometatarsal joint and metatarsal-metatarsal joint normal) and compared between CMT and controls. CMT patient’s first, second and third rays were also compared. Means were compared with a 2-sample t test (p < .05). ResultsCMT patients had significantly more plantarflexion of the first ray than controls (16.4 versus 8.8 degrees respectively(p < 0.001)). The largest difference of was found at the medial cuneiform with 20.6 degrees of plantarflexion in CMT patients versus 14.8 degrees in controls (p < .0001). There was also approximately 2 degrees of plantarflexion at the TMT joint (p < .001). ConclusionsPlantarflexion deformity in CMT patients is primarily an osseous deformity at the level of the medial cuneiform with a lesser contribution from the tarsometatarsal joint. Level of evidenceIII Retrospective comparative study

Morphological and morphometric analysis of tarsal bones according to sex.

Our aim in the study is to measure the area and volume of the tarsal bones and examine the typing of the talus and calcaneus joint surfaces according to sex. In our study, the area and volume measurements of 630 tarsal bones and the morphology of the talus/calcaneus were analyzed by transferring thin-section Computed Tomography (CT) images to the 3D Slicer program. The volume and area sizes of the foot bones are calcaneus, talus, cuboid, navicular, medial cuneiform, lateral cuneiform, and intermediate cuneiform, respectively. All area and volume values of males were statistically higher than females (p < 0.05). The right side calcaneus area, intermediate cuneiform area, and lateral cuneiform area values were statistically higher than the left side (p < 0.045, p < 0.044, p < 0.030, respectively). There was no statistical relationship between age and area/volume values (p > 0.05). Three different types were seen in the calcaneus and seven in the talus. The most common type in the calcaneus was B1 (40%), and the least common type was A (27.8%). Regardless of the subgroups, the most common type in the talus was type B (37.8%), while the least common type was E2 (1.1%). Although morphometric measurements of tarsal bones differed according to sex, they did not differ according to age. The frequency of occurrence of the types of articular surfaces of the talus and calcaneus varies according to populations. We think that the morphometry and morphology of tarsal bones will contribute to invasive procedures regarding tarsal bones and surrounding structures, and that three-dimensional bone modeling can be used to create educational materials.

The vertical mobility of the first tarsometatarsal joint during demi-plié with forced turnout in ballet dancers

The forced turnout has a perceived risk of development of hallux valgus (HV) in ballet dancers. We determined how the forced turnout affects the sagittal mobility of the first tarsometatarsal (TMT) joint, which is one of the pathogenic factors of HV development. Seventeen female ballet dancers (body mass index: 18.2 ± 1.8 kg/m2) were included and performed demi-plié in control, functional turnout, and forced turnout conditions. Ultrasound imaging synchronized with a three-dimensional motion analysis system was used for measuring the vertical locations of the first metatarsal and medial cuneiform (MC) to evaluate the first TMT joint mobility. Plantar displacement of MC and the first TMT joint mobility in the forced turnout were the greatest among the 3 conditions. Multiple regression analysis indicated that the greater extent of the forcing angle might increase the displacement of MC and the first TMT joint mobility. Evaluating the sagittal mobility of the first TMT joint in the forced turnout can assist in understanding the association between inappropriate techniques including the forced turnout and HV development in ballet dancers. Since the excessive mobility of the first TMT joint is a factor in HV development, the acquirement of adequate active turnout may have the potential to prevent HV development in ballet dancers.

Tarsals from the Sima de los Huesos Middle Pleistocene site (Atapuerca, Burgos, Spain).

Here, we provide a complete, updated, and illustrated inventory, as well as a comprehensive study, of the tarsals (rearfoot) recovered from the Middle Pleistocene site of Sima de los Huesos (SH, Atapuerca, Spain) in comparison to other Homo comparative samples, both extant and fossil. The minimum number of individuals (MNI) estimated from the tarsals has been established as 15, which represents 51.7% of the 29 dental individuals identified within the SH sample. Within the SH hominin foot sample, an exclusive combination of primitive or plesiomorphic and derived or autapomorphic traits can be observed when compared with other Homo individuals/populations. Other characters are shared among SH hominins and Neandertals that might represent shared derived or autapomorphic traits for this evolutionary line, and most are likely related to robusticity (e.g., rectangular-like trochlea of the talus, broad calcanei, broad naviculars, and short lateral cuneiforms). Additionally, we observed some exclusive autapomorphic traits in the SH tarsal sample (e.g., narrow head of the talus and short intermediate cuneiforms). A few exclusive traits in SH tarsal remains are even more robust than in Neandertals (e.g., broad lateral malleolar facet in talus, more projected sustentaculum tali, and broad medial cuneiform). These traits could suggest a slightly higher level of gracilization in the tarsal bones of Neandertals compared to the SH sample that is also supported by other anatomical postcranial skeleton elements. Additionally, some paleobiological inferences are made in relation to body size (stature and body mass) and some associations are proposed within the SH sample. In conclusion, the morphology of the SH tarsi confirms an evolutionary relationship of sister groups between this population and Neandertals, probably representing a morphotype similar to the Neandertal ancestors.