Forefoot Problems Research Articles

Orthopaedic and plastic surgery collaboration in resolution of plantar heloma and metatarsalgia using lipofilling: a retrospective evaluation.

Plantar heloma is a keratotic disorder that can be described as a circumscribed area of thickening with a central core that may penetrate the dermis. Although often considered a minor complaint, longstanding lesions can be debilitating and severely impact on person's quality of life. We present the first retrospective case series at long-term follow-up about the use of plantar lipofilling as a treatment for metatarsalgia caused by plantar heloma. Six patients affected by plantar heloma associated to external metatarsalgia underwent plantar lipofilling. The surgical session was performed as an outpatient procedure. Clinical evaluation was performed using the AOFAS lesser metatarsophalangeal-interphalangeal (MTP-IP) score. Mean AOFAS lesser MTP-IP score improved from a preoperative score of 66.6 ± 3.2 points (range 47-77 points) to a post-operative score of 92.8 ± 2.7 points (range 86-95 points); all patients were satisfied with the outcome at the final follow-up. Post-operative clinical examination at final follow-up showed an increase in thickness of the subcutaneous layer and a decrease of dermal layer thanks to the supporting and trophic action of fat cells. Plastic regenerative procedures applicated to a typical foot and ankle surgery field, such as metatarsal overloading, metatarsalgia and forefoot problems, should be encouraged to allow new treatment horizons.

Are Static Foot Posture Measures Related to Static and Dynamic Plantar Pressure Parameters?

A few studies have investigated the relationship between foot posture measures and plantar pressure parameters, but no study has investigated the correlation of foot posture measures with all primary parameters consisting of contact area (CA), maximum force (MF), and peak pressure (PP). We aimed to determine the relationship of the Foot Posture Index-6 (FPI-6) and navicular drop (ND) with plantar pressure parameters during static standing and preferred walking. Seventy people were included. Navicular drop and the FPI-6 were used to assess foot posture. Plantar pressure parameters including CA, MF, and PP were recorded by a pressure-sensitive mat during barefoot standing and barefoot walking at preferred speed. All assessments were repeated three times and averaged. Pearson correlation coefficients below 0.300 were accepted as negligible and higher ones were interpreted. Navicular drop was moderately correlated with dynamic CA under the midfoot and second metatarsal; also, the FPI-6 was moderately correlated with dynamic CA under the midfoot (0.500 < r < 0.700). The other interpreted correlations were poor (0.300 < r < 0.500). Both measures were correlated with dynamic CA under the second and third metatarsals; dynamic CA and MF under the midfoot; and static CA, MF, and PP under the first metatarsal and hallux (P < .01). Navicular drop was also correlated with dynamic MF under the first metatarsal and dynamic CA under the fourth metatarsal (P < .01). Furthermore, ND was correlated with static CA and PP under the second metatarsal and static PP under the fifth metatarsal (P < .01). The FPI-6 was also correlated with dynamic MF and PP under the hallux (P < .01). The correlations between foot posture measures and plantar pressure variables are poor to moderate. The measures may be useful in the clinical assessment of medial forefoot problems related to prolonged standing and midfoot complaints related to high force during walking. Furthermore, the FPI-6 may provide valuable data regarding hallux complaints related to the high loads during walking.

The Role of Cavovarus Deformity in the Pathogenesis of Peroneal Tendon Tears

Category:Other; SportsIntroduction/Purpose:While it is a commonly accepted principle peroneal tendon (PT) tears are associated with cavovarus deformity, this is the first study that both quantifies deformity in patients with surgically proven tears using sophisticated and reproducible methods to compare radiographic measurements to a matched control group. Understanding of the anatomy and mechanism of injury affecting the PTs has led to greater recognition of PT tears as an important cause of lateral sided foot and ankle pain. The literature reports a presumed correlation between the cavus foot and PT tears. Little data exist quantifying the correlation between PT tears and the alignment of the foot. We hypothesize the cavovarus foot applies stress over the lateral border of the foot leading to degenerative changes in PTs.Methods:A cohort of 252 consecutive patients operatively treated for peroneal tendon tears (PT) were compared to an age- and sex- matched control (C) group of 104 outpatients treated for isolated forefoot problems. Calcaneal pitch, calcaneal - first metatarsal, talometatarsal, and talocalcaneal angles were compared on standing lateral radiographs. Talometatarsal and talocalcaneal angles, and talonavicular coverage, were compared on standing anteroposterior radiographs. Published radiographic criteria were used to determine cavovarus. ANOVA analysis detected statistically significant differences between patients and controls and a subsequent Tukey-Kramer test compared the control group with each type of PT tear. An a prioripower analysis was performed to calculate the minimum sample size in each cohort to detect a 90% effect size for a significance level of p<0.05.Results:Radiographic cavovarus was found in 9.4% (74/252) of PT group, and 6.7% (7/104) in controls. On lateral radiographs a significant greater calcaneal pitch (p=0.0001), and significant smaller calcaneal-first metatarsal angle (p=0.0084) was noted with PT tears (p=0.0001). On anteroposterior radiographs a significant smaller talometatarsal angle (p=0.0001) and talonavicular coverage (p=0.0001) were noted in PT tears. AP talocalcaneal and lateral talometatarsal and talocalcaneal angles were not correlated with PT tears. Patients treated for PT tears, isolated peroneus brevis tears (PB) accounted for 67.9% (171/252), isolated peroneus longus (PL) tendon tears were 7.5% (19/252), PB and PL tears accounted for 17.5% (44/252). A smaller talometatarsal angle on the AP was associated with PL (0.0098) and combined PB and PL tears (<0.0001) but not PB tears alone (0.1162).Conclusion:The correlation between cavovarus and peroneal pathology in the literature is highly anecdotal. Few studies report objective measures. This is the first study to our knowledge comparing nature and severity of cavovarus according to location of peroneal tear. This study proves and quantifies objective measures of cavovarus that correlate with peroneal tendon tears, when compared to a cohort of matched controls.

Analysis of Gait and Footprint in Patients with Hallux Valgus

Category: Midfoot/Forefoot Introduction/Purpose: Hallux valgus (HV) is one of the most common forefoot problems. HV is defined as a hallux valgus angle of more than twenty degrees. HV can lead to alterations of the plantar pressure pattern and clinical gait. This study examined the relationship between gait alterations and HV deformities. Methods: We examined 500 residents (161 men and 339 women; &gt;50 years of age) of Miyagawa village in Mie, Japan in 2009, 2011 and 2013. They performed a 6-meter walk test at normal and maximum speed. We examined gait speed, the number of steps, and footprint between patients with normal (HV angle &lt;20; n=350) and HV (HV angle &gt;20; n=150), and between normal-to-mild (HV angle &lt;30; n=436) and moderate-to-severe (HV angle &gt;30; n=64). Their plantar pressure patterns were measured using a gait analyzer (Walk Way MW 1000; Anima, Tokyo, Japan, Figure.1). Statistical analyses were performed using the chi-square test according to sex and use of the hallux ball; the t-test according to age, height, and weight; and logistic regression analysis adjusted for age, sex, and height according to gait speed and the number of steps. P value less than 0.05 was considered significant. Results: With regard to the plantar pressure pattern, the percentage of subjects in the HV group who left a footprint of the hallux ball was significantly lower than that in the normal group. The percentage of subjects in the moderate-to-severe group who left a footprint of the hallux ball was even lower. Analysis of the footprint revealed that the HV group used the hallux ball significantly less during toe-off than the normal group. At both normal and maximum speed, the number of steps and gait speed did not differ significantly between the normal and HV groups. However, when we compared normal-to-mild and moderate-to-severe groups, the number of steps in the moderate-to-severe group was significantly greater than in the normal-to-mild group at maximum walking speed. Conclusion: Analysis of the footprint revealed that the percentage of subjects in the HV group who was able to use the hallux ball during toe-off was significantly less than that in the normal group. The percentage of subjects in the moderate-to-severe group who could use the hallux ball in toe-off was even lower. HV can cause footprint alterations. Moderate-to-severe HV can cause not only footprint alterations but also gait alterations, especially when walking at maximum speed.

Prevalence estimation and familial tendency of common forefoot deformities in Turkey: A survey of 2662 adults

ObjectiveThis survey was designed to evaluate the prevalence estimations of HV, bunionette, hammertoe as well as their relations to shoe wearing and also familial tendency, in Turkey. Material and MethodsTwo thousand six hundred sixty two volunteers (1615 females and 1047 males) with a mean age of 34.15 ± 14.23 (range; 18 to 96) years were asked to answer the predetermined questionnaire between January and June, 2016. Hallux valgus, hammertoe and bunionette images were provided as references and every adult participant without any known forefoot problems or past forefoot surgery history was asked to rate his/her foot and to respond the questions about family history and shoe wearing habits. Responses were statistically analyzed. ResultsThe prevalence estimations of hallux valgus, bunionette and hammertoe were calculated as 54.3%, 13.8% and 8.9% and positive family history rates were 53.2%, 61.2% and 56.1%, respectively. All three deformities were more common in females than in males (p < 0.001). Nonetheless the older age group reported significantly higher prevalence rates for only HV (p < 0.001). Likewise, among the three deformities, females reported a higher rate of positive family history only in HV compared to men (p < 0.001). Constricting shoe wear was found to affect HV incidence in women (p < 0.001) and bunionette incidence in both sexes (p < 0.01). ConclusionThis study concludes that forefoot deformities are common with high familial tendency. Hence it is worthwhile to work on molecular genetics and this may enable the anticipation of forthcoming deformities in order to take early action in prevention, in nearly the half of the population.

Resection or preservation of the metatarsal heads in rheumatoid forefoot surgery? A randomised clinical trial

BackgroundDespite impressive results of the pharmacological management of rheumatoid arthritis, still certain patients suffer from rheumatoid forefoot problems. Surgical treatment of these forefoot deformities can be an option. In literature no high-quality studies on this topic can be found.The goal of present study is to compare the results of a metatarsal head (MTH) resecting technique with a MTH preserving technique in the operative treatment of severe rheumatoid forefoot deformity. MethodsPatients suffering from well-defined rheumatoid forefoot deformity were prospectively enrolled in three institutions. This non-blinded study had a randomised clinical design and eligible patients were randomly assigned to undergo either resection of preservation of the MTH. The primary outcome measure consisted of the AOFAS score. Secondary outcome measures were: the FFI, the VAS for pain and the SF-36. ResultsTwenty-three patients (10 in MTH preservation group) were included and analysed. After one year follow-up no significant differences in AOFAS score and additional outcome factors were found. A total of 10 complications in 23 patients were reported. ConclusionsThis randomised clinical study did not show significant clinical difference between a MTH resecting and a preserving procedure in patients suffering from rheumatoid forefoot deformity. Both procedures resulted in considerable improvement of pain and activity scores.

Correction of Hallux Valgus Interphalangeus With an Osteotomy of the Distal End of the Proximal Phalanx (Distal Akin Osteotomy).

Operative correction of a symptomatic hallux valgus interphalangeus (HVI) deformity is often achieved with an osteotomy at the proximal end of the proximal phalanx (Akin osteotomy). However, the apex of the typical HVI deformity (center of rotation angle) is at the interphalangeal joint of the hallux. This study was done to evaluate the results of performing a medial closing wedge osteotomy at the distal end of the proximal phalanx. Thirty-three patients (33 feet) underwent an osteotomy at the distal end of the proximal phalanx for correction of HVI. All of the patients had other forefoot deformities which were corrected at the same time. Eight of these were revision procedures of prior forefoot operations. The length of follow-up was determined by the associated procedures with a minimum follow-up of 4 months. The preoperative hallux valgus interphalangeus angle averaged 16 degrees of valgus (range 7-32 degrees) and was corrected to an average of 2 degrees of valgus (range 5 degrees valgus to 5 degrees varus). All of the patients were satisfied with the postoperative appearance and function of the first toe. Because of simultaneous correction of numerous other forefoot problems, it was not possible to specifically isolate or evaluate the effects and benefits of this osteotomy using outcomes measures. There was one intraoperative complication resulting in a fracture extending into the adjacent IP joint. Correction of an HVI deformity can be achieved with an osteotomy at the distal end of the proximal phalanx. This was a safe technique with few complications and with good results in terms of both correction and patient satisfaction. Level IV, retrospective case series.

Gait Analysis of Patients Suffering From Hallux Valgus

Category: Midfoot/Forefoot Introduction/Purpose: Hallux valgus that is defined as HVA (hallux valgus angle) &gt;20 is one of the most common forefoot problems and can lead to alterations of the plantar pressure pattern. In addition, it can cause clinically gait alterations. Hence, we investigated the plantar pressure pattern and the gait-related factors using the gait analyzer. The purpose of this study was to examine the relationship between gait alterations or motor function and hallux valgus deformity. Methods: In 2009, we examined 309 inhabitants (male, 105; female, 204; age, &gt;65 years) of Miyagawa village in Mie, Japan and compared the plantar pressure pattern between the subjects who has hallux valgus (HVA, &gt;20; n=88) and those who does not have hallux valgus (HVA, &lt; 20; n = 221). Furthermore, we compared gait-related factors among mild group (20&lt; HVA &lt; 30; n=88), moderate group (30&lt; HVA &lt; 40; n=24), and severe group (HVA, &gt;40; n=9). If the right and left hallux valgus varied in severity, we selected severe side. The plantar pressure pattern and the gait-related factors such as stride, step width, foot angle (Figure 1), and gait speed were measured using the gait analyzer (Walk way MW 1000; Anima, Tokyo, Japan). Statistical analyses were performed using t-test, Chi-Square test, or logistic analysis adjusted age, gender and height. P &lt; 0.05 was considered significant. Results: The average weight and height of hallux valgus group were significantly lower, and age of hallux valgus group were significantly higher than those of normal group. About the plantar pressure pattern, ratio of the subjects in hallux valgus group who can use the hallux ball in toe off were significantly less than those of normal group. However, the gait-related factors were not significantly different between 2 groups. On the other hand, when we compared by severity, step width tended to increase with progression of hallux valgus. Moreover, stride, gait speed, and foot angle of severe group were the lowest among 4 groups (normal, mild, moderate, and severe). Especially stride of severe group was significantly lower than those of other 3 groups. Conclusion: Mild hallux valgus can cause alterations of the plantar pressure pattern, but didn’t cause motor functional decline. However, when hallux valgus become severe, hallux valgus can cause not only gait alterations but also motor functional decline.

Distal Metatarsal Minimal Invasive Osteotomy (DMMO) for the Treatment of Metatarsalgia

The aim of the surgical treatment of metatarsalgia is to decrease the pressure under the metatarsal (MT) head. Percutaneous surgery of the foot, also known as minimal invasive surgery, allows interventions to be carried out through extremely small incisions without direct exposure of the surgical field under radiologic monitoring. The current authors present their experience with the distal MT minimal invasive osteotomy, in the context of the indications, the technique, postoperative management, and the outcome. Percutaneous osteotomy has proven to be a valid technique, providing satisfactory clinical and anatomic results, similar to open osteotomy, for the treatment of metatarsalgia and other forefoot problems. Level of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

Characterization of gait in female patients with moderate to severe hallux valgus deformity

BackgroundHallux valgus is one of the most common forefoot problems in females. Studies have looked at gait alterations due to hallux valgus deformity, assessing temporal, kinematic or plantar pressure parameters individually. The present study, however, aims to assess all listed parameters at once and to isolate the most clinically relevant gait parameters for moderate to severe hallux valgus deformity with the intent of improving post-operative patient prognosis and rehabilitation. MethodsThe study included 26 feet with moderate to severe hallux valgus deformity and 30 feet with no sign of hallux valgus in female participants. Initially, weight bearing radiographs and foot and ankle clinical scores were assessed. Gait assessment was then performed utilizing pressure insoles (PEDAR®) and inertial sensors (Physilog®) and the two groups were compared using a non-parametric statistical hypothesis test (Wilcoxon rank sum, P<0.05). Furthermore, forward stepwise regression was used to reduce the number of gait parameters to the most clinically relevant and correlation of these parameters was assessed with the clinical score. FindingsOverall, the results showed clear deterioration in several gait parameters in the hallux valgus group compared to controls and 9 gait parameters (effect size between 1.03 and 1.76) were successfully isolated to best describe the altered gait in hallux valgus deformity (r2=0.71) as well as showed good correlation with clinical scores. InterpretationOur results, and nine listed parameters, could serve as benchmark for characterization of hallux valgus and objective evaluation of treatment efficacy.

An evaluation of retrospective outcome scores in elective foot and ankle surgery

BackgroundPatient reported outcome measures are becoming more popular in their use. Retrospective scoring is not yet a validated method of data collection but one that could greatly decrease the complexity of research projects. We aim to compare preoperative and retrospective scores in order to assess their correlation and accuracy. Methods36 patients underwent elective foot and ankle surgery. All patients were scored preoperatively using the SF-12 (including both the physical and mental subsets) and FFI. Patients then recorded both PROMs at the 3-month follow up (av. 139 days). Results were then analyzed for statistical significance. Results36 patients (av. age 54.6): completed both sets of questionnaires. There were 15 hindfoot and 21 forefoot procedures. No retrospective scores were identical.The mean percentage difference between the preoperative scores was −7.9% (−17.3 to 1.6%, 95% CI) for Physical Component of SF12, −3.2% (−10.3 to 3.9%, 95% CI) for mental component of SF12 and 40.7% (25.3 to 56.1%, 95% CI) for FFI. This retrospective accuracy was statistically significant (p<0.001). When the scores were plotted against each other, the outcome measurements showed positive correlations (Physical SF 12 p=0.48, Mental SF 12 p=0.80 and FFI p=0.81).With both PROMs mean percentage differences combined, patients undergoing hindfoot procedures (3.5%; −5.0 to 12.1%, 95% CI) were more accurate with retrospective scoring than their forefoot counterparts (17.5%; 5.0 to 30.0%, 95% CI). This was not statistically significant (p=0.07).Using regression analysis, we found no significant statistical difference in the retrospective accuracy when compared against both time to retrospective scoring and the outcome measure at 3 months post operatively. ConclusionRetrospective scoring appears to lack accuracy when compared to prospective methods. However, our data shows the SF12 is recalled more accurately than the FFI (p<0.001) and both the mental and physical components are recalled to within 10% of the pre-operative score. These results show patients tend to recall their symptoms at a worse level preoperatively than originally described, especially those with forefoot problems.

Process evaluation of podiatric treatment of patients with forefoot pain

BackgroundFoot pain is a common problem for people aged 50 and over and occurs more often in women than in men. About 60% of the foot problems are forefoot problems and slightly more than half of these patients seek medical help, mainly in the form of podiatric care. Podiatric treatment of forefoot problems is known to be heterogeneous. The aims of the present study are to describe the podiatric treatment of patients with forefoot pain and to evaluate the podiatric examination and treatment using an expert panel.MethodWe invited twenty-five randomly selected subjects with forefoot problems who had received podiatric treatment in a pragmatic randomised clinical trial to participate in an analysis of their treatment by an expert panel. The panel retrospectively established the cause of the foot problem as well as the therapeutic goals and evaluated the treatment. These findings were compared to those reported by the treating podiatrist.ResultsTwo fundamentally different approaches were found in approach of podiatric examination; a functional approach (n =13) and a non-functional approach (n =12). In nine cases the expert panel agreed with the cause recorded by the podiatrist. In five other cases the expert panel concluded that the treatment of the podiatrist was not consistent with the cause of the problem recorded by the podiatrist. Of the 10 patients for whom the podiatrist had recorded to have given shoe advice, only two were able to recollect the proper advice. Three patients did not remember receiving advice at all.ConclusionIn this study almost half of the podiatrists worked according to a non-functional approach where the other half (like the expert panel) chose a functional strategy that analyses the underlying problem. Fundamental differences in treatment plans and thus heterogeneous treatments could be a consequence.

Indian Foot and Ankle Scenario

Huge population of aggressively developing country like India is catered by more than 20,000 orthopedic surgeons but with very few dedicated foot & ankle surgeons. This area of orthopedics has not yet established its place as a specialty of medicine. Most of newer treatment concepts & methodologies are yet to establish its place in India in spite of huge suffering population. Challenges are late presentations, delayed diagnosis, neglected cases, malunions, complex deformities & diabetic foot issues. Commonly seen forefoot, midfoot & hindfoot problems in India & their routine care is discussed. Article also addresses very tough but interesting journey of first foot & ankle surgeon of India & story of rise & fall of first Indian foot & ankle centre of excellence. Contribution in form of educational efforts & deep market penetration is deemed from west to uplift Indian foot & ankle scenario which is summed up as: lack of awareness, opportunity and negligence.

Regional plantar foot pressure distributions on high-heeled shoes-shank curve effects

Forefoot pain is common in high-heeled shoe wearers due to the high pressure caused by the center of body mass moving forward and the increased arch height with heel elevation. Sufficient arch support could reduce the high pressure over forefoot. However, too much arch support could lead to abnormal foot alignment and pain over midfoot. Little information is reported on the relationship among plantar arch height, shank curve design and plantar pressure. This study aimed at quantifying the plantar arch height changes at different heel heights and investigating the effect of shank curve on plantar pressure distribution. The plantar arch height increased to (7.6±1.3)mm at heel height of 75 mm. The Chinese standard suggests the depth of last should be 8.5mm for heel height of 75 mm. When a shank curve with higher depth of last (11 mm) was used, the peak pressure over forefoot further decreased in midstance phase, which might ease the forefoot problems, while the peak pressure over midfoot increased but not exceeded the discomfort pressure thresholds. To achieve a more ideal pressure distribution in high-heeled shoes, a higher than expected depth of last would be suggested that would not cause discomfort over midfoot.

Estudio en axial de las cabezas metatarsales y huesos sesamoideos en la metatarsalgia

The study of forefoot problems has been made easier with the technique of axial projection of the metatarsal heads, particularly in their weight-bearing projection. To obtain the diagnostic images we have a high bench and radio-transparent slings available which hold the foot in the required position. The resulting radiographic projection enables the metatarsal heads to be seen which, together with the clinical picture and other diagnostic parameters, helps us to assess the possible problems. It is also worthwhile making a comparison while in the non-weight-bearing position to reinforce the diagnosis. The ease of executing this projection gives a boost to the study of metatarsalgia.

First Ray Resection Arthroplasty versus Arthrodesis in the Treatment of the Rheumatoid Foot

Different options exist for the operative treatment of forefoot problems and deformities in rheumatoid arthritis (RA). The current study compared first ray and resection arthroplasty with respect to patient satisfaction, clinical and functional outcome. In a retrospective study 53 RA patients were investigated with a minimum followup of 2 years after corrective forefoot surgery. Two patient groups were distinguished: One group had been treated with arthrodesis of the first metatarsophalangeal (MTP) joint whereas the other group had been treated with a first ray resection arthroplasty. Both groups underwent resection arthroplasty at the lesser metatarsal heads. Our arthrodesis patients were significantly younger than patients with resection arthroplasty. Five patients had been treated bilaterally so that the results of 58 feet were analyzed. Patient satisfaction was lower in the arthrodesis group as compared to the resection arthroplasty patients. However, the arthrodesis patients revealed better functional results and showed a push-off from the hallux. No significant radiographic difference was seen in the mean hallux valgus angles. Younger patients revealed a higher disease activity and a worse general health status than older patients. Pedobarographic results demonstrated significant differences in selected foot regions, predominantly in the hallux. Peak pressures were significantly higher in the lateral midfoot and the hallux after arthrodesis as compared to the resection arthroplasty group. Patients with arthrodesis revealed better foot function during the dynamic roll-over process even though the resection arthroplasty patients were subjectively more satisfied.

Treatment of forefoot problems in older people: study protocol for a randomised clinical trial comparing podiatric treatment to standardised shoe advice

BackgroundFoot problems in general and forefoot problems in particular can lead to a decrease in mobility and a higher risk of falling. Forefoot problems increase with age and are more common in women than in men. Around 20% of people over 65 suffer from non-traumatic foot problems and 60% of these problems are localised in the forefoot. Little is known about the best way to treat forefoot problems in older people. The aim of this study is to compare the effects of two common modes of treatment in the Netherlands: shoe advice and podiatric treatment. This paper describes the design of this study.MethodsThe study is designed as a pragmatic randomised clinical trial (RCT) with 2 parallel intervention groups. People aged 50 years and over who have visited their general practitioner (GP) with non traumatic pain in the forefoot in the preceding year and those who will visit their GP during the recruitment period with a similar complaint will be recruited for this study. Participants must be able to walk unaided for 7 metres and be able to fill in questionnaires. Exclusion criteria are: rheumatoid arthritis, neuropathy of the foot or pain caused by skin problems (e.g. warts, eczema). Inclusion and exclusion criteria will be assessed by a screening questionnaire and baseline assessment. Those consenting to participation will be randomly assigned to either a group receiving a standardised shoe advice leaflet (n = 100) or a group receiving podiatric treatment (n = 100). Primary outcomes will be the severity of forefoot pain (0-10 on a numerical rating scale) and foot function (Foot Function 5-pts Index and Manchester Foot Pain and Disability Index). Treatment adherence, social participation and quality of life will be the secondary outcomes. All outcomes will be obtained through self-administered questionnaires at the start of the study and after 3, 6, 9 and 12 months. Data will be analysed according to the "intention-to-treat" principle using multilevel level analysis.DiscussionStrength of this study is the comparison between two common primary care treatments for forefoot problems, ensuring a high external validity of this trial.Trial registrationNetherlands Trial Register (NTR): NTR2212

Footwear Characteristics and Foot Problems in Older People

Background:Foot problems are common in older people, however the contribution of incorrectly fitting footwear and heel elevation to the development of foot pain and deformity has not been fully evaluated. Objectives: To examine the relationship between footwear characteristics and the prevalence of common forefoot problems in older people. Methods:Presence of foot pain and deformity were identified in 176 people (56 men and 120 women) aged 62–96 years (mean 80.09, SD 6.42) using a questionnaire and clinical assessment. Shoe fit was determined by comparing length, width and area measurements of shoes with foot measurements. Past and present use of high heels in women was documented, and heel elevation of footwear was measured. Results: Most subjects wore shoes narrower than their feet. Women wore shoes that were shorter, narrower and had a reduced total area compared to their feet than men. Wearing shoes substantially narrower than the foot was associated with corns on the toes, hallux valgus deformity and foot pain, whereas wearing shoes shorter than the foot was associated with lesser toe deformity. Wearing shoes with heel elevation greater than 25 mm was associated with hallux valgus and plantar calluses in women. Conclusion: Incorrectly fitting footwear is common in older people and is strongly associated with forefoot pathology and foot pain. These findings highlight the need for footwear assessment in the management of foot problems in older people.

Fusion of the first metatarsophalangeal joint, a review of techniques and considerations: Presentation of our results in 22 cases

Fusion of the first metatarsophalangeal joint (MTP 1) may be a rewarding approach to many MTP 1 joint related forefoot problems. The outcome, however may be impaired by malposition, malunion or deterioration of the interphalangeal joint. To avoid this, meticulous effort must be made to achieve accurate angles, to prepare the joint surfaces and to fix the fusion in an optimal manner. We have here tried to penetrate and analyse considerations concerning these aspects and describe our choice of method, in which we used the rounded cup and cone technique for preparation, a guide-plate for positioning aid and two crossed screws for fixation. This method resulted in 21 out of 22 cases healed in an adequate position.

Failure of hallux MP preservation surgery for rheumatoid arthritis.

Eight patients underwent surgery on 15 feet for rheumatoid forefoot problems. Thirteen of the 15 feet that were operated upon had an attempt to preserve the hallux metatarsophalangeal joint while resectional arthroplasty was performed on the lesser MP joints. All of the 13 feet that had the MP joint preserved had a well-preserved joint space preoperatively and no active signs of inflammation at the time of this procedure. Eight feet underwent a distal Chevron osteotomy to realign the great toe, two feet underwent an IP fusion as only the IP joint had evidence of erosive changes, and one foot underwent a combination of a Chevron osteotomy and a proximal phalangeal osteotomy (Akin procedure). Two patients had no surgery on their first ray as it was well aligned with no evidence of erosive changes. Of the 13 feet that did not have a fusion performed, 11 had development of a valgus deformity or inflammatory erosions. The average time to failure was 24 months (range, six to 36 months). The Chevron/Akin procedure remained successful at 18 months and one of the IP fusions was successful at six years after surgery. Although patients with rheumatoid forefoot disease may on occasion have a well-preserved hallux MP joint with minimal or no deformity and no active inflammation, with severe lesser toe involvement, most of these patients will fail a surgical procedure which does not involve fusion of the hallux MP joint.