Second Toe Research Articles

The distal metatarsal screw is not always necessary in third-generation MICA: a case-control study.

To evaluate the clinical and radiological results after fixation of the first metatarsal head (MTH) with one or two screws as part of the third-generation minimally invasive Chevron-Akin osteotomy (MICA) for hallux valgus deformities. Between August 2020 and November 2021, 55 MICA procedures (50 patients, male:female = 7:43), 22 with two (MICA2), 33 with one screw (MICA1) were performed for mild to severe hallux valgus deformities. Exclusion criteria were a concomitant pes adductus (Sgarlato angle > 20°) or hindfoot/midfoot deformities requiring treatment. In 27 cases, additional procedures on the forefoot (small toe corrections or metatarsal osteotomies II-V) were necessary. Pre- and post-operatively, hallux valgus angle (HVA) and intermetatarsal I/II angle (IMA) were measured. Clinically, subjective satisfaction, range of motion (ROM) of the first metatarsophalangeal joint (MTPJ), and pain level (NRS score) were evaluated. The minimum follow-up was 12months. Displacement of MTH was 70-90% on average, all osteotomies showed full consolidation at latest follow-up. In one case of either group, a slight subsidence of MTH was documented. The radiological and clinical parameters showed no differences between the groups. The pain level improved by an average of three points. The mobility of the MTPJ showed a slight reduction in nine casesafter threemonths (4 MICA2, 5 MICA1)which persisted in three cases. Fifty-two of 55 patients (95%) would opt again for the operation. Fixation of the first MTH with a single bicortical screw in MICA with moderate lateralization of MTH shows stable anchoring and good clinical results. The routine use of a second metatarsal screw can be omitted.

Minimal-invasive Vorfußchirurgie: Konzept und Techniken

Minimally invasive surgery (MIS) has advanced to an established approach in the correction of all deformities of the forefoot. For the first ray the minimally invasive chevron and Akin osteotomy (MICA) shows very good clinical results and provides a broad spectrum of indications in comparison to the classical chevron osteotomy. The minimally invasive treatment of hallux rigidus also seems to achieve comparable results to the open techniques, although the surgical indications must be thoroughly evaluated. Lesser toe deformities are often easier to treat with minimally invasive osteotomy, capsule release and tendon lengthening than with complex open procedures and usually do not require any internal fixation material. Compared to the classical Weil osteotomy, distal metatarsal osteotomy shows areduced rate of cock-up deformities and does not require internal fixation. In relation to open procedures, minimally invasive approaches should be accepted as avaluable addition and alternative to the classical open techniques due to the reduced rate of wound healing disorders and postoperative pain.

Minimally invasive surgery for pedal digital deformity: a systematic review

Objective: The interest and application of minimally invasive surgery (MIS) in treating lesser toe deformities have increased worldwide. The symptoms are often attributed to callosities and localized pressure. Conservative treatment may improve comfort, but its success largely depends on the level of deformity. When conservative treatment fails, surgery may be indicated. This study explores the available evidence and reviews in the literature seeking to examine the efficacy of MIS in lesser toe pathology. Methods: A systematic review was performed, and the search included the following databases: Cochrane Library, CINAHL, MEDLINE®, PUBMED, Science Direct, and other relevant peer-reviewed sources between September 2019 and June 2022. In addition, a manual search was conducted in Australian, American, British, and European orthopedic and podiatric scientific data for relevant studies. Results: The search for potentially eligible information for this systematic review yielded 92 unique studies. All studies identified were obtained and reviewed. An updated search was performed in July 2022, resulting in no additional studies that satisfied the inclusion criteria. After considering all potentially eligible studies, five (5.4%) met the inclusion criteria. One thousand one hundred eighty-six lesser toe procedures (500 patients) were included. The overwhelming majority of patients were female (80.5%). The patient’s mean age was 56.9 (range 18-91) years, and the mean follow-up was 19.6 (range 6-33) months. All of the studies included early mobilization in the postoperative protocol. Conclusion: There is a need for more research using a combination of validated patient-reported outcomes to evaluate the effectiveness of MIS procedures in treating lesser toe deformities alongside the development of validated and tested treatment algorithms to guide surgical decision-making. Level of Evidence III; Therapeutic Studies; Systematic Review.

Minimally invasive surgery for lesser toe deformity: a clinical audit of a proposed treatment algorithm

Objective: There is increasing interest in the performance of minimally invasive foot surgery (MIS); however, limited evidence and treatment algorithms are available to support its use and guide surgical decision-making. The aim of this prospective clinical audit was to report the efficacy of a treatment algorithm used to treat patients presenting with lesser toe deformities using MIS techniques. Methods: A prospective clinical audit of 38 patients who underwent 55 MIS procedures for complex and simple lesser toe deformities was conducted between April 2018 and June 2022. All patients were followed up for a minimum of 12 months post operatively. The audit was conducted following the National Research Ethics Service (NRES) guidelines on clinical audit. Results: Mean pre-operative Visual Analogue Pain (VAS) score was 3.95 with a median of 5.00. The mean post-operative VAS scores improved to 0.23 after six weeks and 0.43 after 12 weeks. A Mann-Whitney U test concluded that this improvement was statistically significant (p<0.05). Conclusion: This algorithm appears effective in treating lesser toe deformities independent of deformity classification, concomitant surgery, gender or whether the surgery was performed in a hospital or private clinical setting. Level of Evidence V; Therapeutic Study; Expert Opinion.

Clinical diagnosis and treatment of subungual exostosis in children.

To analyze and summarize the clinical characteristics and treatment effects for subungual exostosis in children. Clinical data for children with subungual exostosis treated in our department from January 2008 to September 2022 were evaluated. Forty children with subungual exostosis were evaluated, comprising 31 boys (77.5%) and 9 girls (22.5%) with a median age of 9 years (4-17 years). The median disease course was 6 months (1-48 months). Seven patients (17.5%) had definite trauma history and 5 (12.5%) had infection. The toe or finger nail appearance was abnormal in 36 patients and normal in 4 patients. Twenty-seven patients (67.5%) had pain when wearing shoes and walking, and 25 (62.5%) had toenail tenderness. The lesions were located in the distal phalanxes of the toes in 37 patients (92.5%), with 14 patients affected on the left side and 23 on the right side. Twenty-two patients had lesions in the great toe, 6 in the second toe, 6 in the third toe, and 3 in the fourth toe. The lesions in the other 3 patients (7.5%) were located in the distal phalanxes of the fingers, with 2 patients affected in the second finger and 1 in the third finger. Regarding the relationship between lesion location and nail bed, 4 patients were type I, 21 were type II, and 15 were type III. All 40 patients received surgical treatment, with nail removal in 15. The median maximum lesion diameter was 1.0 cm (0.8-2 cm), median operation time was 25 min (20-45 min), median blood loss was 1 ml (1-2 ml), and median postoperative hospital stay was 2 days (1-4 days). All cases were histopathologically confirmed as subungual exostosis. The median follow-up time was 24 months (3-60 months), with normal appearance of the toe or finger nail. There were no complications in 38 patients (95.0%). Two patients (5.0%) relapsed at 3 months postoperatively and underwent a secondary operation, with no subsequent recurrence during 12 months of follow-up. Subungual exostosis in children is a rare benign disease that often occurs in the toes. Selection of the appropriate incision and nail bed treatment based on the relationship between lesion location and nail bed is helpful for improving the treatment effect.

Conduction block and positive sharp waves/fibrillation potentials in entrapment neuropathies of the ulnar, radial, and peroneal nerves

Introduction: Entrapment mononeuropathies can cause motor conduction block, positive sharp waves, and fibrillation potentials. Aim: The study aims to find whether there is a relationship between positive sharp waves/fibrillation potentials and conduction block observed in entrapment mononeuropathies. Materials and methods: Patients with ulnar neuropathy at the elbow, radial neuropathy at the spiral groove, and peroneal neuropathy at the fibular head were included in this retrospective study. Nerve conduction study and needle electromyography results of the patients were analysed. Results: The study included a total of patients with 67 ulnar neuropathy, 8 radial neuropathy, and 27 peroneal neuropathy. All radial and peroneal neuropathy patients and 30 ulnar neuropathy patients had positive sharp waves/fibrillation potentials in at least one muscle. Twenty-three ulnar neuropathy patients with these potentials, 6 radial neuropathy patients, and 18 peroneal neuropathy patients had conduction block (p < 0.001). The reduction of compound muscle action potential amplitude in percentage recorded from the abductor digiti quinti/first dorsal interosseous across the elbow segment in ulnar neuropathy patients with and without positive sharp waves/fibrillation potentials was 41.9 ± 35.9/46.6 ± 36.1% and 7.6 ± 16.5/10.4 ± 16.5%, respectively (p < 0.001/p < 0.001). The distal compound muscle action potential amplitudes of ulnar neuropathy patients with these potentials were lower than those of ulnar neuropathy patients without these potentials (p = 0.029 – abductor digiti quinti, p = 0.017 – first dorsal interosseous). No correlation was found between the severity of positive sharp waves/fibrillation potentials and muscle strength in patients with these potentials (p > 0.05). Conclusions: Positive sharp waves/fibrillation potentials and motor conduction block can be seen together in patients with entrapment mononeuropathies. We concluded that there may be no relationship between the severity of these potentials and muscle strength.

Premature Peripheral Arterial Disease with the 5th Toe Necrotizing Lesion after Workout: A Case Report

Premature Peripheral Arterial Disease with the 5th Toe Necrotizing Lesion after Workout: A Case Report

Premature Peripheral Arterial Disease with the 5th Toe Necrotizing Lesion after Workout: A Case Report

Premature Peripheral Arterial Disease with the 5th Toe Necrotizing Lesion after Workout: A Case Report

СПОСОБ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ МОЛОТКООБРАЗНОЙ ДЕФОРМАЦИИ ПАЛЬЦЕВ СТОПЫ, СОПРЯЖЕННОЙ С HALLUX VALGUS

Abstract. Introduction. The results of treatment of patients with hammer-toe deformity of the small toes associated with hallux valgus were analyzed. Disadvantages and complications of known methods of treatment are revealed. A new pathogenetic method was proposed, including the sequential execution of two osteotomies. Aim. To evaluate the effectiveness of the proposed method of surgical treatment of patients with hammer-toe deformity associated with hallux valgus. Material and methods. The proposed method of hammer-toe surgical treatment includes two osteotomies: diaphyseal osteotomy of the metatarsal bone and osteotomy of the proximal phalanx of the finger. The angle of open- wedge proximal phalanx osteotomy is equal to the angle of the residual rear deviation of the toe. Placement of the formed auto- or allo- bone grafts in the space of open-wedge proximal phalanx osteotomy. 36 patients were operated with this method. The effectiveness of this method was evaluated by comparative analysis with a group of 40 patients operated on by the Helal osteotomy. Results and discussion. The proposed method made it possible to eliminate the hammer-toe deformity of the second toe, significantly reduce the number of cases of residual rear deviation and significantly improve the functional result, eliminate hyperkeratosis on the foot, increase patient satisfaction. The values of the achieved correction of the rear deviation of the second finger in the metatarsophalangeal joint were determined, defining the repositionable capabilities of surgical methods equal to (40,17±2,32) degrees when using the proposed method, and (18,70± 3,27) degrees when performing osteotomy according to Helal osteotomy. Conclusion. The use of the proposed method of surgical treatment of patients with hammer-toe deformity associated with hallux valgus allows to increase the effectiveness of treatment, achieve permanent correction of deformation and correction of excessive dorsal deviation of the small toe in the metatarsophalangeal joint, improve the appearance of the foot, anatomical and functional result, reduce the risk of residual deformation in the form of a dorsal deviation of the finger.

Reconstruction of polysyndactyly of the fused fifth toe with the fourth toe.

Polysyndactyly of the fused fifth toe with the fourth toe is a common subtype of postaxial polydactyly. The aim of the study was to present an operative technique for cosmetic improvement and reconstruction of polysyndactyly of the fused fifth toe with the fourth toe. We retrospectively reviewed the details of 22 patients with postaxial polydactyly treated from January 2018 to May 2021. The operation involved medial toe excision and web space reconstruction using a dorsal rectangular flap without skin grafting and simultaneous correction of a valgus deformity by chondroplasty and soft tissue balancing without an osteotomy. The web shape, scar, and aesthetic outcomes were evaluated on the criteria of the D'Arcangelo, Vancouver Scar Scale score, and satisfactory questionnaire, respectively. The patients were followed up for 7-43 months. At the last follow-up, valgus deformity was completely corrected without recurrence. On the basis of the criterion of D'Arcangelo, the height and width of the webs were good in 24 of the feet, fair in four of the feet, and poor in none of the feet. The mean Vancouver Scar Scale score was 1.55. All parents and patients were satisfied with the appearance and function. The described medial toe excision technique and reconstruction of the web space without a skin graft corrected the valgus deformity and were able to satisfy functional and cosmetic requirements.

Accessory Hand Muscles Over the Transverse Carpal Ligament: An Obstacle in Carpal Tunnel Surgery

Carpal tunnel syndrome (CTS) is an entrapment neuropathy caused by compression of the median nerve throughout the carpal tunnel. It is the most common entrapment neuropathy, with an estimated prevalence of 4%-7%. Surgical management is more effective in moderate to severe and severe CTS. CTS recurs in approximately 20% of patients, and up to 12% of these patients require reoperation. Knowledge of normal anatomy and variations would improve the success rate of the index surgery. Atypical causes of CTS were reported, including ganglion cysts, synovial hypertrophy, lipomas, bone fracture, bone fragments, tumor of soft tissues or bones, neurofibromas, neuromas, vascular malformations, and accessory muscles. Accessory muscles are commonly detected in upper limbs. However, their concomitant presentation with CTS has rarely been reported. We aimed to present different accessory muscles diagnosed during CTS surgery through a systematic review of the literature with our exemplary case. A systematic review/meta-analysis was performed concomitant with a case presentation. Accessory muscles associated with CTS were as follows: palmaris longus, 28.6%; lumbrical muscles, 19.3%; palmaris profundus, 17.8%; flexor digitorum superficialis, 16.1%; transverse carpal muscle, 5%; flexor digitorum indicis, 4.2%; flexor superficialis indicis, 4.2%; flexor sublimis, 0.8%; accessory superficialis longus, 0.8%; flexor pollicis longus, 0.8%; abductor digiti minimi, 0.8%; abductor digiti quinti, 0.8%; and flexor digitorum superficialis brevis, 0.8%. Accessory muscles were mostly noticed during CTS surgery (88.2%). Knowledge of possible variations within the carpal tunnel would improve the surgeon's capability during CTS surgery.

The Prevalence of Biphalangealism for Each Toe in the Turkish Population: An Epidemiologic Study.

Biphalangealism has been evaluated in many studies and has been shown as a common variant. Its frequency varies according to the populations. This epidemiological study aimed to determine the prevalence of biphalangealism for each toe in the Turkish population and compare it with other populations. The local hospital radiological database was searched for all consecutive foot radiographs, obtained between 2014 and 2018. Anteroposterior (AP) and oblique radiographs obtained to evaluate trauma or foot pathologies were included. Two-phalangeal toes according to radiographical views were defined as biphalangeal and other three-phalangeal toes were defined as normal. A total of 2,881 radiographs of 2,710 adult patients met the incusion criteria. There were 1,558 (57.5%) female and 1,152 (42.5%) male patients. The cases were unilateral in 2,539 patients and bilateral in 171 patients. The overall prevalence of biphalangeal third toe was 0.29%, fourth toe was 1.29%, and fifth toe was 23.3%. The presence of pedal biphalangealism is a common variant and its frequency varies according to the populations. The exact cause is still unclear. Further studies are required to assess the clinical impact of biphalangealism.

Hidden diversity of rock geckos within the Cnemaspissiamensis species group (Gekkonidae, Squamata): genetic and morphological data from southern Thailand reveal two new insular species and verify the phylogenetic affinities of C.chanardi and C.kamolnorranathi.

Two new insular rock geckos in the genus Cnemaspis are described from Ko Samui in Surat Thani Province and Ko Similan in Phang-nga Province, southern Thailand, based on a combination of morphological and mitochondrial NADH dehydrogenase subunit 2 (ND2) data. Both new species represent divergent lineages within the Cnemaspissiamensis species group. Cnemaspissamui sp. nov. is distinguished from other species in the group by having eight or nine supralabial and infralabial scales; 5-8 pore-bearing precloacal scales in males, pores rounded; 25-27 paravertebral tubercles, arranged randomly; 22-25 subdigital lamellae under 4th toe; enlarged median subcaudal scale row present; gular region, abdomen, limbs and subcaudal region yellowish only in males, and uncorrected pairwise divergences of 8.86-26.83% from all other species in the C.siamensis species group. Cnemaspissimilan sp. nov. is distinguished from other species in the group by having eight or nine supralabial and seven or eight infralabial scales; one pore-bearing precloacal scale in males, pore rounded; 24 or 25 paravertebral tubercles, arranged randomly; 23 or 24 subdigital lamellae under 4th toe; no enlarged median subcaudal scale row; pale yellow reticulum on head, neck, flanks, belly and limbs in male only, and uncorrected pairwise divergences of 9.34-27.11% from all other species in the C.siamensis species group. Cnemaspissamui sp. nov. is found along granitic rocky stream outcrops of Hin Lad Waterfall, Ko Samui, Gulf of Thailand, while Cnemaspissimilan sp. nov. occurs in granitic rocky outcrops near Ao Nguang Chang Bay, Ko Similan, Andaman Sea. The phylogenetic analyses confirmed that C.chanardi and C.kamolnorranathi are also nested within the C.siamensis species group, as previously hypothesized from morphology and color pattern characters.

Does the Radiographic Lateral View of the Lesser Toe Matter in a Trauma? A Retrospective Analyses of 378 Radiographs

Category: Trauma; Lesser Toes Introduction/Purpose: Evaluate the importance of a radiographic lateral view in diagnosing lesser toes traumatic conditions. Methods: Between January 2018 and March 2018, 378 radiographs of 126 patients evaluated in an emergency care hospital for trauma in the lesser toe were retrospectively evaluated for presence of lesser toes traumatic conditions. Patients were selected if a complete series of radiographs were performed, anteroposterior (AP), lateral (LA) and Oblique (OB). Radiographs of the same patient were duplicated and divided in two groups: standard group (AP and OB) and complete group (AP + LA + OB). Images were examined by four independent examiners with different degrees of experience. Each examiner randomly evaluated the same patient twice (one for each group). Kappa index was used to evaluate intra and inter-examiner concordance, and the two- proportion equality test was used to calculate statistical significance. Results: Mean age of patients was 37,2 years (4-85yr), 144 injuries were diagnosed in standard group (28,6%) and 266 injuries (52,8%) in complete group (p<0,001). Individually, each examiner had an improvement in the number of lesions diagnosed when comparing group assessment (p<0,001). Kappa index was superior to 0,60 for all examiners in standard group. Conclusion: Addition of true lateral view was able to detect misdiagnosed injuries in lesser toes trauma and improved the number of diagnosed lesions in 84,6%.

Incidence and Functional Impact of Floating Toe after Distal Metatarsal Minimal Invasive Osteotomy Compared to Open Modified Weil Osteotomy

Category: Lesser Toes; Hindfoot Introduction/Purpose: Distal metatarsal osteotomies for metatarsalgia are one of the most frequent procedures in foot and ankle surgery, however, sometimes their results are not so favorable, with sequelae such as floating toe or loss of toe grip. The open modified Weil osteotomy (OWO) is considered the first alternative in metatarsalgia cases for many surgeons, nevertheless, in recent years, minimally invasive surgery (MIS) has become an attractive alternative for the management of this pathology. To date, there is scarce literature that compares clinical and functional results between both techniques. The objective of this study is to compare the clinical and functional outcomes between OWO and minimally invasive distal metatarsal osteotomy (DMMO), with and without lesser toe procedures. Methods: We performed a retrospective review of 77 patients who underwent OWO or DMMO, with at least 12 month follow up. We excluded patients with incomplete data, previous forefoot surgery, and patients with neuromuscular or rheumatological diseases. Our main outcome was to evaluate the presence of floating toe. Our secondary outcomes were to evaluate toe grip strength (paper pullout test), functional scores (LEFS and AOFAS) and satisfaction. All patients were clinically evaluated by one foot and ankle surgeon who did not participate in any of the surgical procedures. Statistical analysis was performed using Student's t-test, Fisher's test, and Chi-square. Results: 77 patients (188 rays) were included. 120 rays received OWO, and 68 rays DMMO. 95% women, with a mean age of 57 years. The mean follow-up was 39.4 months. The floating toe incidence was 56.7% in the OWO group (67.3% when a DuVries procedure was added), which was significantly higher (p=0.001) than the 25% in the DMMO group (37.9% when P1 MIS osteotomy was added). When comparing lesser toe grip strength between both groups, the DMMO patients had significantly greater grip strength (p=001) Significant differences were obtained between both groups when comparing satisfaction (p=0.04), LEFS (p=0.001), and AOFAS scores (p=0.001), being better in the DMMO group. Conclusion: In our series, the DMMO procedure had significantly lower incidence of floating toe, greater toe grip strength, better functional outcomes and superior satisfaction scores than the OWO. When a bone procedure in the lesser toe is added (MIS osteotomy or DuVries) the floating toe incidence is increased, but not with statistical significance.

Vascular Supply to the Proximal Plantar Plate of Lesser Toe Metatarsophalangeal Joint is Primarily Supplied by the Attachment to the Metatarsal: A Nano-CT Microvasculature Study

Category: Lesser Toes Introduction/Purpose: Lesser toe metatarsophalangeal (MTP) instability is implicated in common forefoot pain and deformities. The plantar plate is a major stabilizing structure of the MTP joint with instability frequently occurring after a tear or attenuation of this structure. Previous studies have demonstrated that the blood supply to the proximal plantar plate comes from both the metatarsal and the plantar fascia. Commonly, a McGlamry elevator is used to strip the plantar plate from the plantar surface of the metatarsal to improve exposure of the MTP joint. The vascular consequence of stripping the plantar plate from the metatarsal is not yet well understood. The purpose of this study is to quantify the relative contribution of blood supply to the proximal plantar plate from the metatarsal and plantar fascia. Methods: Twelve fresh-frozen human adult cadaver lower extremity specimens were utilized for this study, resulting in 35 lesser MTP joints that were studied. All specimens were between the ages of 18 and 65 years and had no history of diabetes, peripheral vascular disease, or connective tissue disorders. Specimens with a history of trauma to the foot or ankle, prior foot or ankle surgery, or evidence of clinical deformity of less toes upon inspection were excluded. The specimens were prepared as described previously in Finney et al. The anterior and posterior tibial arteries were perfused with a barium solution and counterstained with phosphomolybdic acid. The second through fourth MTP joints of 12 feet were imaged with nano-computed tomography (nano- CT) at 14-micron resolution. Reconstructed 3D and 2D CT images were utilized for analysis of the volume of vasculature along the metatarsal pedicle and plantar fascia of the proximal plantar plate. Results: Based on nano-CT imaging, the plantar plate specimen demonstrated microvascular infiltration at the proximal attachments of the metatarsal neck, interosseous muscles, periosteum, and plantar fascia (Figure 1). An average of 63.5% of the vascular supply to the proximal portion of the plantar plate entered from the metatarsal pedicle in 35 lesser toe specimens analyzed. The remaining 36.5% of the vascular supply entered from the plantar fascia. The second toes, third toes, and fourth toes had an average of 64.7%, 59.0%, and 67.1% of vasculature supply from the metatarsal pedicle, respectively. The average volume of vasculature from the metatarsal pedicle to the proximal plantar plate was 0.38 mm3, while the average volume of vasculature from the plantar fascia to the proximal plantar plate was 0.19 mm3. Conclusion: The vascular supply of the proximal plantar plate is supplied from both the metatarsal pedicle and plantar fascia. Using the McGlamry elevator for exposure of the MTP joint disrupts the dominant tributary for proximal plantar plate perfusion.

Analysis of the Foot and Ankle Questions on the Orthopaedic In-Training Examination Over a 10-Year Period (2012-2021)

Category: Other; Ankle; Hindfoot; Midfoot/Forefoot Introduction/Purpose: The Orthopaedic In-Training Examination (OITE) was first administered in 1963 by the American Academy of Orthopaedic Surgeons to evaluate and monitor the training and knowledge of orthopaedic surgery residents. After various iterations of the exam, the current OITE consists of 275 questions covering foot and ankle, hip and knee, shoulder, and elbow, spine, sports medicine, trauma, and basic science. The most recent investigation of the foot and ankle OITE questions evaluated content, references, and treatment methods included on the exams from 2006-2010. This study evaluates OITE test questions over a 10-year period from 2012-2021 for topic, taxonomy, treatment tested, imaging modality, and references cited. The goal of this analysis is to inform and optimize foot and ankle education among orthopaedic residency and fellowship programs. Methods: OITE questions between 2012 and 2021 were obtained through the AAOS 'ResStudy' online question bank. Each question was manually evaluated by each author for foot and ankle content. The total number of questions pertaining to foot and ankle were recorded for each year and the topic of each question was classified under broader topic areas: trauma, deformity, tendon disorder, diabetic foot, sports, great toe, lesser toe, pediatric foot, heel pain, arthritis, and tumor. Imaging techniques were classified as radiographs, magnetic resonance imaging (MRI), computerized tomography, and clinical photo or video. Question taxonomy was classified using criteria in a previous OITE question analysis with three groups2. Taxonomy 1 (T1): knowledge (requires recall of orthopaedic practice or literature); T2: comprehension (interpretation of information and/or diagnosis); T3: application (formulation of a treatment plan from provided information). References provided by AAOS were identified by journal title and publication date or textbook title and editors. Results: Overall, foot and ankle questions comprised of 11.5% (308/2679) of all the graded OITE questions. In recent years, the proportion of foot and ankle questions has decreased. From 2012-2017 the average proportion of foot and ankle questions was 12.6% per test, and from 2018-2021, the average proportion was 9.8%. The most common question taxonomy from 2012-2017 was T3 (application) comprising 60.9% of the question, however, from 2018-2021, T3 questions made up only 29.4% of foot and ankle questions. In total, 59.1% (182/308) of the questions required knowledge of treatment modalities, most commonly open reduction internal fixation and arthrodesis procedures. Imaging modalities were tested 67.9% (209/308) of the time, with radiographs appearing in 47.4% (146/308) of all questions. The most common journals cited were Foot and Ankle International, Journal of the American Academy of Orthopaedic Surgeons, and the Journal of Bone and Joint Surgery American Volume. Conclusion: The proportion of foot and ankle questions on the OITE has decreased over the past 10 years and there has been a reduced emphasis on application questions with a more balanced distribution among knowledge, comprehension and application questions recently. Residents and residency programs should ensure proficiency in interpreting radiographs, which are tested on almost half of all foot and ankle OITE questions.

Extensive Lesser Toes Plantar Plate Tears Reconstruction

Category: Lesser Toes Introduction/Purpose: The plantar plate is a fibrocartilaginous structure that plays a fundamental role in the sagittal stability of the metatarsophalangeal joint (MTPJ). Traumatic and degenerative lesions affecting the plantar plate have the potential to cause instability, swelling, pain and deformity. Extensive plantar plate tears (grade IV) still challenge surgeons as primary repair is impossible, demanding a reconstructive procedure which, unfortunately, can be associated with high morbidity such as stiffness, persistence of discomfort, vascular compromise to the digit and amputation. The purpose of this work is to describe a new technique that uses a synthetic tape and one absorbable screw to achieve the MTPJ stabilization in plantar plate grade IV tears. We believe that this procedure can achieve better results than other techniques described in the literature. Methods: Two bone tunnels are made at the base of the proximal phalanx. Both medial and lateral tunnels are directed in a light oblique fashion from a distal-dorsal entry point to a proximal, justarticular plantar exit. Two new oblique dorsal-plantar bone tunnels - medial and lateral - are made at the distal metaphyseal metatarsal area. A #2 FiberTape is passed through the bone tunnels guided by a Nitinol wire, creating a mesh for the plantar stabilization of the MTPJ. Then both Fiber Tapes limbs are driven, with the help of a nitinol loop, through the plantar orifices of corresponding sides of the metatarsal bone tunnels, exiting in its dorsal aspect. One of the limbs of the tape is passed from dorsal to plantar trough the other metatarsal orifice. Both limbs are tensioned, and the toe should be kept at neutral sagittal position (flexion-extension). Fixation is made with a Biotenodesis screw. Results: Only a few patients were submitted to this technique. At one year follow up, none of them presented with complaints or complications. Conclusion: The surgical technique described in this article can change the way physicians treat plantar complex plantar plate tears when there is no viable biologic tissue to repair. A lesser complication rate it's also expected. Nonetheless comparative, and biomechanical studies are still needed to confirm our hypothesis.

Hallux Valgus Angular Measurements using WBCT Semiautomatic and Manual Assessments

Category: Bunion; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Radiographic measurements are an essential tool to determine the appropriate surgical treatment and outcome for Hallux Valgus (HV). WBCT already demonstrates significant advances that include the ability to perform traditional measurements for HV in the 3D setting reliably, as well as a more complete and accurate evaluation of the deformity. In addition, new software with an advanced semi-automated segmentation system obtains semi-automatic 3D measurements of WBCT scan data sets, minimizing the errors in reading angular measurements. The objective was (1) to assess the reliability of WBCT computer-assisted semi-automatic imaging measurements in HV, (2) to compare semi-automatic with manual measurements in the setting of an HV, and (3) to compare semi-automatic measurements between HV and control group. Methods: In this retrospective IRB (ID# 201904825) approved study, we assessed patients with hallux valgus deformity. The sample size calculation was based on the hallux valgus angle (HVA). Thus, to obtain the 0.8 power, including 26 feet with HV in this study, was necessary. Our control group consisted of 19 feet from 19 patients without HV. Raw multiplanar data was evaluated using software CubeVue. In the axial plane, hallux valgus angle (HVA), intermetatarsal angle (IMA), and interphalangeal angle (IPA) were measured. The semiautomatic 3D measurements were performed using the Bonelogic Software. Inter-rater reliabilities were performed using ICC. Agreement between methods was tested using the Bland-Altman plots. The difference between Pathologic and Control cases using semi-automatic measurements was assessed with the Wilcoxon signed-rank test. Alpha risk was set to 5% (α = 0.05). P<= 0.05 was considered significant. Results: Intraobserver and Interobserver agreement and consistency for Manual and Semi-automatic WBCT measurements assessed by ICC demonstrated excellent reliability in both cases. However, when comparing Manual and Semi-automatic measurements for HVA, IMA, and IPA, Semi-automatic measurements showed the highest values. Agreement between manual (M) and semi-automatic (SA) methods was tested for HVA, IMA and IPA using the Bland-Altman plots. The results indicated a high correlation between the parameters calculated from the manual and semi-automatic measurements, and a strong agreement between the readers and the software. Comparison between pathological group with HV and control (standard) group without HV using semi-automatic measurements was capable of differentiating pathological (HV) from non-pathological conditions for the HVA and IMA angles (p < 0,05). Conclusion: Semi-automatic measurements are reproducible and comparable to measurements performed manually. The software differentiated pathological from non-pathological conditions when subjected to semi-automatic measurements. The development of advanced semi-automatic segmentation software with minimal user intervention is essential for the establishment of big data and can be integrated into clinical practice, facilitating decision-making.

Metatarsophalangeal and Metatarso-Sesamoid Joint Interaction in Hallux Valgus Deformity: A Case- Control Study

Category: Bunion; Lesser Toes; Midfoot/Forefoot Introduction/Purpose: Hallux valgus deformity (HVD) is a complex 3D distortion that involves varus, dorsiflexion and pronation of the first metatarsal. Deformity is usually assessed by conventional 2D measurements such as hallux valgus and intermetatarsal angle. Weightbearing CT (WBCT) 3D Distance Mapping (DM) and Coverage Mapping (CM) allow assessment of relative positioning between opposing articular surfaces, providing information in regards to articular coverage and joint subluxation, that can potentially influence development of arthritic degeneration and symptoms, as well as dictate outcomes. The aim of this study was to develop a DM and CM algorithm to assess metatarsophalangeal (MTP) and metatarso-sesamoid (MS) joint interaction in HVD patients and compare it to healthy controls. We hypothesized that significant MTP and MS joints lateral subluxation would be observed. Methods: In this IRB-approved study, we included 9 HVD patients (mean age 37.1y; 6F/3M) and 5 controls (mean age 39y; 4F/1M) that underwent foot WBCT foot. Bone segmentation of WBCT images for the first and second metatarsals, first and second proximal phalanxes as well as tibial and fibular sesamoids was performed using specific software. Joint interaction with DM and CM of the first and second MTP joints, as well as MS joints were calculated. The surface of the MTP joints were divided in a 2x2 grid using principal axes to provide a more detailed analysis. DMs were color coded to facilitate data interpretation (Figure). Blue color represented expected normal joint interaction (distances from 1 to 3 mm), yellow/red color symbolized increased joint distances (distances from 3 to 5 mm) and pink color indicate completely uncovered articular areas (distances >5mm). Comparisons were performed with independent t-tests/Wilcoxon. P values <.05 were considered significant. Results: Examples of coverage maps for an HVD patient and a control are presented in the attached Figure, demonstrating the obvious lateral and dorsal displacement of the distance maps for joint interaction of the first MTP joint, with decreased articular coverage of the medial aspect of the joint. When comparing first MTP joint articular coverage (CMs), HVD patients demonstrated significantly decreased coverage of the dorsomedial quadrant (77%, p=0.0002), and significantly increased coverage of the plantarlateral (182%, p=0.005) and dorsolateral quadrants (44.9%, p=0.035). Findings are consistent with lateral first MTP joint subluxation and dorsiflexion of the first metatarsal. The second MTP joint demonstrated findings consistent with early hammertoe dorsiflexion contracture and dorsolateral joint subluxation, with significantly decreased articular coverage of the plantarmedial quadrant (88%, p=0.01). No significant changes in joint coverage were observed for the MS joints, however a significant widening of the fibular MS joint was noticed (76.7%, p=0.013). Conclusion: In this case-control study, we developed a Distance and Coverage Map WBCT Algorithm to objectively assess 3D joint interaction, articular coverage and subluxation in HVD. We observed significant amount of first and second MTP joint subluxation in HVD patients when compared to controls, with a plantarmedial and dorsolateral direction for respectively the first and second MTP joints. No significant joint subluxation of the metatarso-sesamoid joint was noted. Our hope is that DM and CM can optimize diagnosis, staging, and assessment of treatment and outcomes in hallux valgus and lesser toe deformities. Additional prospective and appropriately sized studies are needed.