Intermetatarsal Ligament Research Articles

Factors Associated with Symptom Recurrence Following Operative Treatment of Interdigital Neuroma

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Interdigital Neuroma (IN) is a benign enlargement of tissue surrounding the common plantar digital nerve. Traditionally, neurectomy has been performed as the standard surgical treatment for IN. However, recent attention has been given to less invasive surgical decompression by intermetatarsal ligament (IML) release with neurolysis. This study aims to compare the outcomes of IML release with neurolysis to traditional interdigital neurectomy. Methods: A retrospective chart review was conducted on 350 consecutive patients who underwent surgical treatment for IN. Patients who satisfied our inclusion and exclusion criteria were categorized into two groups based on the surgical treatment received: IML release with neurolysis or interdigital neurectomy. Inclusion criteria were patients older than 18 years with symptomatic IN, having an indication for surgical treatment following at least three months of unsuccessful conservative treatment, and at least 12 months of postoperative follow-up. Patients with concurrent procedures at the time of surgery, multiple affected web spaces, trauma to the affected forefoot, or asymptomatic IN without clear indications for surgical treatment were excluded from the study. Evaluated outcomes included recurrence of symptoms, rate of revision surgery, and postoperative wound infection. Results: Out of the 350 patients screened, 127 fulfilled the inclusion and exclusion criteria. Forty (32%) patients experienced recurrence of symptoms within a 12-month follow-up period with an overall mean time-to-recurrence of 3.96 +/- 3.15 months. Patients who underwent IML release with neurolysis had a significantly higher recurrence rate (48%) and mean time-to-recurrence of 4.61 +/- 3.22 months compared to those who underwent interdigital neurectomy (24%) with a mean time-to-recurrence of 3.47 +/- 3.08 months (P< 0.01). The rate of postoperative wound infection was similar between the two groups. The rate of revision surgery among those with symptom recurrence in the IML release group (16%) and neurectomy group (4%) was not statistically significant between both groups (P=0.49). Conclusion: IML release with neurolysis appears to have a higher risk of symptom recurrence compared to interdigital neurectomy. However, patients who did experience symptom recurrence in either operative group had similar rates of revision surgery, which may be due to mild recurrent symptoms in the IML release group that did not warrant revision surgery in these patients. No patient-specific factors were identified as being associated with symptom recurrence. Future studies should consider objective symptom recurrence severity and patient satisfaction.

Refinement of Modified Endoscopic Lateral Soft-Tissue Procedure for Correction of Hallux Valgus Deformity

Hallux valgus is a common orthopaedic problem, and surgical correction frequently is indicated for symptomatic deformity. The modified endoscopic distal soft-tissue procedure has been reported to provide a minimally invasive approach of hallux valgus correction with augmentation of the medial metatarsosesamoid suspensory ligament and intermetatarsal ligament. The purpose of this Technical Note is to describe the refinements of the modified endoscopic distal soft-tissue procedure to achieve more anatomical augmentation of the medial metatarsosesamoid ligament and intermetatarsal ligament, which can provide more stable reconstruction and prevent stiffness of the first metatarsophalangeal joint.

Factors Associated With Symptom Recurrence After Surgical Treatment of Interdigital Neuroma: A Retrospective Chart Review of 127 Patients.

Interdigital neuroma (IN) is a benign enlargement of tissue surrounding the common plantar digital nerve. Although the standard surgical treatment of IN remains debated, recent attention has been given to less-invasive surgical decompression by intermetatarsal ligament (IML) release with neurolysis. This study aimed to compare the outcomes of IML release with neurolysis with standard interdigital neurectomy. A retrospective chart review was conducted on 350 consecutive patients who underwent surgical treatment of IN. Patients who satisfied our inclusion and exclusion criteria were categorized into two groups based on the surgical treatment received: IML release with neurolysis or interdigital neurectomy. Outcomes assessed included recurrence of symptoms, rate of revision surgery, and postoperative wound infection. Of the total sample, 40 patients (31.5%) reported recurrence of symptoms within a 12-month follow-up period. Patients who underwent IML release with neurolysis had a markedly higher recurrence rate (47.50%) than those who underwent interdigital neurectomy (24.14%). The rate of postoperative wound infection was similar between the two groups. Binary logistic regression revealed that only the surgical technique was associated with the recurrence of symptoms. Despite the higher rate of symptom recurrence in the IML release with neurolysis patient group, the rate of revision surgery in those with symptom recurrence was similar between both groups. IML release with neurolysis seems to have a higher risk of symptom recurrence than interdigital neurectomy. No patient-specific factors were identified as being associated with symptom recurrence. However, patients who did experience symptom recurrence in either surgical group had similar rates of revision surgery, which may be due to mild recurrent symptom severity in the IML release group that does not warrant revision surgery in these patients. Future studies should consider objective symptom recurrence severity and patient satisfaction. Level III.

Modified Endoscopic Distal Soft Tissue Procedure (mEDSTP) and Arthroscopic Lapidus Arthrodesis for Correction of Severe Hallux Valgus

Hallux valgus is one of the most common forefoot deformities faced by foot and ankle surgeons. Symptomatic deformity usually needs surgical correction. Endoscopic techniques of hallux valgus correction have been reported that are based on the same principle of the classic distal soft tissue procedure. Recently, the technique has been modified to include reconstruction of the medial metatarsosesamoid ligament and augmentation of the intermetatarsal ligament. In severe deformity or the presence of hypermobility or painful degeneration of the first tarsometatarsal joint, Lapidus arthrodesis of the joint is indicated. Arthroscopic Lapidus arthrodesis has been reported to reduce the complications associated with open procedure, including first metatarsal shortening, metatarsal elevatus, and nonunion. In this technical note, the technical details of a combined modified endoscopic distal soft tissue procedure and arthroscopic Lapidus arthrodesis is described. This is a minimally invasive approach for correction of severe hallux valgus deformity, especially that associated with ligamentous laxity.

Modified Endoscopic Distal Soft Tissue Procedure With Medial Metatarsosesamoid Ligament and Intermetatarsal Ligament Augmentation

Hallux valgus is one of the most common foot and ankle conditions faced by orthopaedic surgeons. Surgical correction of hallux valgus is frequently indicated for symptomatic deformity. Recently, the endoscopic technique of hallux valgus correction has been reported, which is basically an endoscopic approach to the classic distal soft tissue procedure. In this technical note, the technical details of the modified endoscopic distal soft tissue procedure with medial metatarsosesamoid ligament and intermetatarsal ligament augmentation is described. In this modified technique, the intact intermetatarsal ligament, plantar capsule of the first metatarsophalangeal joint (including the sesamoid apparatus), and medial metatarsosesamoid ligament form a soft tissue envelop that can wrap around the first metatarsal head to stabilize the first metatarsal in the reduced position.

Consilient evidence affirms expansive stabilizing ligaments in the tyrannosaurid foot

Tyrannosaurid dinosaurs were ecologically unique vertebrates as the sole clade of large terrestrial carnivores (adults >400 kg) in their continent-spanning habitats. Expanded ligaments between metatarsals, inferred by gross morphology of attachment correlates, have been hypothesized to have strengthened their specialized arctometatarsus. We tested the hypothesis of ligament presence with scanning electron microscopy and histological thin sections of putative attachment sites in a third metatarsal of the tyrannosaurid Gorgosaurus libratus, compared with a thin section from the unspecialized metatarsals of the early theropod Coelophysis bauri. In the Gorgosaurus metatarsal, Sharpey´s fibers and rough, pitted surface textures consistent with ligament coalescence occur at expansive distal regions and localized rugosities are ideally located for resisting torsional loading on the foot. Sparser Sharpey’s fibers occur at expected locations in other arctometatarsus-bearing coelurosaurs. In contrast, the Coelophysis metatarsal lacked Sharpey’s fibers or rugosity at the sectioned location, acting as a definitive negative control for identifying these features in tyrannosaurids. With soft-tissue correlates confirmed as ligament entheses, we conclude that tyrannosaurids possessed distinctive and specific ligament attachments to the third metatarsal lacking in other large carnivorous dinosaurs. Histological evidence for extensive distal intermetatarsal ligaments is consistent with greater inferred agility in derived tyrannosaurid dinosaurs than in earlier lineages of large theropods.

Degenerative Injuries of the Metatarsophalangeal Plantar Plate on Magnetic Resonance Imaging: A New Perspective

Category: Lesser Toes Introduction/Purpose: The magnetic resonance imaging diagnostic criteria for a complete tear of metatarsophalangeal plantar plate are well-established. However, more subtle abnormalities can also occur and be a source of pain. The objectives of this study are to determine the prevalence of degenerative plantar plate injuries in patients with metatarsalgia who underwent magnetic resonance imaging examination of the forefoot and describe the main abnormalities found. Our hypothesis is that mild capsular fibrosis will have high sensitivity but low specificity for plantar plate degenerative injuries. Methods: A retrospective cross-sectional study was conducted with 85 consecutive individuals (105 feet) with metatarsalgia who underwent forefoot magnetic resonance imaging examinations using a specific protocol to study metatarsophalangeal plantar plate. An experiment observer classified second toe plantar plate as normal, complete rupture or degenerative lesion and described the main MRI findings. Results: A normal plantar plate was observed in 75 (71.4%) of the 105 feet assessed, in 25 (24%) feet there were degenerative plantar lesions, and in 5 (4.6%) feet there were complete ruptures. Degenerative injury of the plantar plate was best identified in coronal short-axis intermediate-weighted images, with high sensitivity (92%). Pericapsular fibrosis below the intermetatarsal ligament was identified in 96% of cases, with high sensitivity (96%) for diagnosis of degenerative plantar plate injury. Conclusion: Degenerative lesions of the metatarsophalangeal plantar plate were more prevalent than complete ruptures and were best viewed in coronal short-axis intermediate-weighted sequences. Pericapsular fibrosis below the intermetatarsal ligament was the indirect finding most strongly associated with degenerative plantar plate injury.

A Method for Entubulating Exposed Nerve Ends Following Neurectomy Using a Porcine Extracellular Matrix Nerve Cap.

Compression and irritation at the plantar aspect of the transverse intermetatarsal ligament may lead to a compressive neuropathy called Morton's neuroma. There are many treatment options for Morton's neuroma, with the most common surgical option being traction neurectomy. While there has been success in many surgical procedures, up to 35% of patients treated with traction neurectomy have recurrent pain and up to one-third of these patients have a recurrent stump neuroma. These neuromas are caused by abnormal axonal growth during regeneration, leading to an unorganized mass of fibrotic collagenous tissues, Schwann cells, and axons. More recent surgical treatments of neuromas have included nerve capping, which has been proposed to prevent painful neuroma formation by isolating the nerve end from external chemosignaling and reducing disorganized axonal outgrowth. An off-the-shelf, biocompatible porcine small intestine submucosa (pSIS) derived nerve cap with internal chambering has been investigated in a rodent study, which showed less pain sensitivity and less axonal swirling indicative of reduced likelihood of neuroma formation. Furthermore, a recent clinical study indicated that patients experienced a significant reduction in pain 3 months after Morton's neuroma excision followed by repair using a nerve cap. This article describes the surgical technique of the aforementioned clinical study to mitigate neuroma formation, where a Morton's neuroma is excised, and the remaining proximal nerve stump is inserted within a nerve cap and buried in the surrounding muscle.Level of Evidence: Level V: Expert opinion.

Supraligamentous Approach of Lateral Release in Endoscopic Lateral Soft Tissue Procedure

Many surgical methods are available for hallux valgus, but consensus regarding the best management has yet to be established. Minimally invasive techniques are gaining popularity with the potential advantages of better cosmetic outcome, less postoperative pain, and decreasing recovery time because surgical exposure and deep soft tissue dissection are less extensive and possibly gentler. Recently, techniques of the endoscopic distal soft tissue procedure have been reported, in which an endoscopic approach of the classic distal soft tissue procedure is described. The intermetatarsal ligament, adductor hallucis insertion, and the lateral capsuloligamentous complex of the first metatarsophalangeal joint is released during the endoscopic lateral release. However, the intermetatarsal ligament does not contribute to development of the hallux valgus deformity, and release of the ligament is not necessary for correction of the deformity. Instead, preservation of the intermetatarsal ligament may protect the interdigital nerve and reduce the risk of nerve injury during endoscopic lateral release. In this technical note, the technical details of supraligamentous approach of lateral release in endoscopic lateral soft tissue procedure (or EDSTP) is described. This approach can help to reduce the risk of injury to the interdigital nerve during endoscopic lateral release.

Degenerative injuries of the metatarsophalangeal plantar plate on magnetic resonance imaging: a new perspective.

ABSTRACTObjective The magnetic resonance imaging diagnostic criteria for a complete tear of metatarsophalangeal plantar plate are well-established. However, more subtle abnormalities can also occur and be a source of pain. The objective of this study is to determine the prevalence of degenerative plantar plate injuries in patients with metatarsalgia who underwent forefoot magnetic resonance imaging and describe the main abnormalities found. The hypothesis is that mild capsular fibrosis will have high sensitivity but low specificity for plantar plate degenerative injuries.Methods A retrospective cross-sectional study was conducted with 85 patients (105 feet) with metatarsalgia who underwent forefoot magnetic resonance imaging using a specific protocol to study metatarsophalangeal plantar plate. The experiment observer classified second toe plantar plate as normal, complete rupture or degenerative lesion and described the main magnetic resonance imaging findings.Results A normal plantar plate was observed in 75 (71.4%) of the 105 feet assessed, in 25 (24%) feet there were degenerative plantar lesions, and in 5 (4.6%) feet there were complete ruptures. Degenerative injury of the plantar plate was best identified in coronal short axis intermediate-weighted images, with high sensitivity (92%). Pericapsular fibrosis below the intermetatarsal ligament was identified in 96% of cases, with high sensitivity (96%) for diagnosis of degenerative plantar plate injury.Conclusion Degenerative lesions of the metatarsophalangeal plantar plate were more prevalent than complete ruptures and were best viewed in coronal short axis intermediate-weighted sequences. Pericapsular fibrosis below the intermetatarsal ligament was the indirect finding most strongly associated with degenerative plantar plate injury.

Intermetatarsal ligament section assisted with sonography for the percutaneous surgery of Morton’s disease: Cadaveric study

BackgroundSurgical treatment of Morton’s neuroma remains controversial. Several surgical techniques have been described including percutaneous transection of the deep metatarsal transverse ligament (DMTL). PurposeTo evaluate the efficacy and safety of percutaneous release of the DMTL under ultrasound guidance for the treatment of Morton’s syndrome. Materials and methodologyPercutaneous release of the DMTL was performed with ultrasound guidance in 48 intermetatarsal spaces of 16 cadaveric specimens. Specimens were then dissected to assess the completion of the release and the presence of any injuries of the neurovascular and tendinous adjacent structures. ResultsThe DMTL was visualized with ultrasound in all cases. Complete release of the ligament was achieved in 87.5% (42/48) cases. One case of interdigital nerve injury was found. ConclusionPercutaneous release of DMTL with ultrasound guidance for the treatment of Morton’s disease has an acceptable rate of complications but care must be taken to ensure the complete release of the ligament.

Mirror Foot: Surgical Approach for Esthetic and Functional Improvement.

Mirror foot is a rare congenital anomaly on to the spectrum of complex foot polydactyly. It may occur in isolation or associated with other malformations or genetic syndromes. This is a subject little described in the literature, with few publications on its treatment. We herein report the case of a 4-year-old female patient who presented with a left foot with 8 fingers, without other associated deformities, whose complaints included the impossibility of wearing shoes and social stigma. Radiographically, eight metatarsi with their respective phalanges, five cuneiform bones, and absence of bone deformities in the hindfoot were verified. The surgical approach was chosen in order to promote functional and esthetic improvement, as well as a better adaptation to the use of closed shoes, according to the patient's and family's desire. A dorsal and plantar V incision was performed, with resection of three supranumerary rays, including three central metatarsi with their nine corresponding phalanges, two cuneiform bones, tendons and extra digital nerves, followed by suture of the intermetatarsal ligaments, preserving the fingers with normal appearance, decreasing the width of the foot, and maintaining proper support. The reduction was maintained through transmetatarsal fixation with Kirschner wires. The postoperative period went on with the use of a walking boot and zero load, without complications, with removal o the Kirschner wires and allowing load on the limb after twelve weeks.

Long-term results of dorsal neuroma/nerve transposition in the surgical management of Morton\u2019s neuroma and correlation with intraoperative anatomical variations

BackgroundMorton's neuroma (MN) is a common cause of forefoot pain. After failure of conservative management, surgical procedures include neurectomy or neuroma preserving procedures; resection of deep transverse intermetatarsal ligament only (DTIML), dorsal neurolysis, dorsal nerve transposition (DNT).ObjectivesThis retrospective study evaluates the long-term results of open DNT, and it also reports anatomical variants in the plantar interdigital nerve.Material and methodsThe study included 39 patients (30 females and 9 males) who were treated for MN between 2002 and 2016.ResultsThe mean pre-operative Giannini score of 13 (0–30) improved to 61 (20–80) (p < .0001), with only 6 patients scoring less than 50 (poor). Using Coughlin’s criterion for overall satisfaction, 9 patients (23%) reported excellent, 18 patients (46%) good, 6 patients (15%) fair and 6 patients (15%) reported poor results. In the long term, 25 patients (64%) had no pain, 8 patients (20%) had mild pain, and 6 patients (16%) had severe pain. Ten patients (26%) reported normal sensitivity in their toes, 26 patients (66%) had numbness, and 3 patients (8%) reported dysesthesia in their toes. Twenty-two patients (56%) could wear fashionable shoes, 11 patients (28%) comfortable shoes, and 6 patients (16%) modified shoes. Regarding walking distance, 30 patients (77%) had no limitation, and 9 patients (23%) reported some limitation. Nineteen per cent regretted having surgery. Around 40% (17 out of 43 web spaces) showed anatomical variations in either the nerve or in the web space and we could not identify any specific risk factors in relation to the outcome.ConclusionDividing the DTIML or dorsal neurolysis should be considered as the primary surgical treatment and, if this fails, neurectomy would be an option. DNT can be considered if one is concerned about stump neuroma, but this may be technically demanding and in some patients it may not be possible.Level of Evidence: Level IV - Case Control Retrospective study.

Importance of Midfoot Ligaments in a Hallux Valgus Cadaveric Model

Category:BunionIntroduction/Purpose:Hallux valgus (HV) is of uncertain origin. Even though a huge amount of treatment options are available, no clear cause for this deformity exist. To be able to further understand this frequent pathology, a cadaveric model should be developed. A cadaveric model was developed trying to obtain similar deformities to the ones observed in Hallux valgus (first ray varus and pronation). The objective of this research is to recreate some characteristics of a HV deformity, through sequential ligaments sectioning.Methods:8 fresh frozen lower leg specimens were used. Markers were attached to the medial and middle foot ray bones, including talus. A constant tibial axial load of 25 kg was used. Cyclic tibial rotation (to simulate gait phases) and 5 kg pull on the extensor and flexor hallucis tendons (EHL and FHL) were applied to the specimen. Limited and sequential medial and middle column ligamentous sectioning were performed, including the, dorsal and interosseous naviculo-cuneiform, intercuneiform, metatarso-cuneiform and intermetatarsal ligaments. After each ligament damage, bony alignment was measured including frontal (bone divergence) and axial plane (bone rotation).Results:After intercuneiform, Lisfranc and naviculo-cuneiform ligaments sectioning, a significant angular increase was found in the naviculo-cuneiform, intercuneiform and naviculo-metatarsal angles (p=0.001). Specifically, for bone rotation, the biggest change was found for the intercuneiform and naviculo-cuneiform angles. Regarding bone divergence, the biggest increase was found in the talo-metatarsal angle. No additional angular change was found after adding metatarso-cuneiform ligament damage. No change in the sagittal alignment was found.Conclusion:This model was able to recreate some parameters of the hallux valgus deformity. No flatfoot deformity was produced. Surprisingly, no significant angular change was produced after metatarso-cuneiform ligament damage. Most significant changes were found after intercuneiform and naviculocuneiform damage. Our findings suggest that midfoot instability has to be present to recreate a hallux valgus deformity.

Operative treatment options for Morton’s neuroma other than neurectomy − a systematic review

BackgroundThe effectiveness of operative treatments other than neurectomy for Morton’s neuroma remains debatable despite several reported studies. This review aimed to evaluate the effects of operative treatments for Morton’s neuroma other than neurectomy using an algorithmic approach and a structured critical framework to assess the methodological quality of reported studies. MethodsSeveral electronic databases were searched for articles published until August 2021 that evaluated the outcomes of operative treatments other than neurectomy in patients diagnosed with Morton’s neuroma. Data searches, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the clinical outcomes were evaluated using objective, subjective, and negative outcomes; complications; and reoperation rate and type. ResultsAfter reviewing 11,213 studies, 22 studies were finally included. Although a number of studies with high level of evidence are limited, we divided them according to four categories: (1) neurolysis with or without nerve transposition, (2) minimally invasive nerve decompression, (3) metatarsal osteotomy, and (4) additional procedures after nerve transection or neurectomy. All categories showed reliable outcomes except minimally invasive nerve decompression. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy. ConclusionWhether the alternative procedures were superior to neurectomy remains unclear as the number of good quality studies was limited. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy. Furthermore, performing simultaneous dorsal transposition of the nerve along with neurolysis is more recommended than neurolysis alone. Surgeons should be more careful with minimally invasive deep transverse intermetatarsal ligament release and metatarsal shortening osteotomy as their effectiveness remains inconclusive. Finally, we strongly recommend performing intramuscular embedding or intermuscular transposition of the nerve cutting end if neurectomy or nerve transection is inevitable. Level of evidenceLevel III, systematic review

Indirect fixation of the third tarsometatarsal joint for high-energy Lisfranc injury

To evaluate the effectiveness of indirect fixation of the 3rd tarsometatarsal joint in the treatment of high-energy Lisfranc injury. Between February 2015 and February 2019, 15 patients with high-energy Lisfranc injury were treated. There were 12 males and 3 females with an average age of 44.8 years (range, 29-73 years). The average time from injury to admission was 8.8 hours (range, 2-28 hours). According to Myerson classification, there were 6 cases of type A, 4 cases of type B2, 1 case of type C1, and 4 cases of type C2; 8 cases were open injury. The 3rd tarsometatarsal joint was injured in all patients, including intact intermetatarsal ligament in 7 cases, the 2nd-3rd intermetatarsal ligament injury in 6 cases, the 3rd-4th intermetatarsal ligament injury in 1 case, and the 2nd-3rd-4th intermetatarsal ligament injury in 1 case. Among them, the 3rd tarsometatarsal joint was not fixed directly and indirectly fixed by stabilized the 2nd and 4th tarsometatarsal joints in 13 cases. The 3rd tarsometatarsal joint was fixed with Kirschner wire in 2 cases for 1 patient had complete injury of the intermetatarsal ligament and the other 1 had comminuted fracture of the base of the 3rd metatarsal. The reduction of fracture and dislocation was evaluated by X-ray films, focusing on the re-displacement of the 3rd tarsometatarsal joint. The effectiveness was evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score. Thirteen of the 15 patients were followed up 12-26 months, with an average of 15.6 months. One case had superficial infection of the incision and healed after symptomatic treatment; the other incisions healed by first intention. At last follow-up, the VAS score was 0-3 (mean, 1.1) and the AOFAS score was 70-99 (mean, 87.5). Twelve patients achieved anatomical reduction and 1 patient had increased talar-first metatarsal angle and the mild forefoot abduction. During the follow-up, no loss of reduction of the 3rd tarsometatarsal joint was found, while the spontaneous fusion of the joint was observed in 2 patients. In high-energy Lisfranc injury, as long as the intermetatarsal ligament is not completely destroyed and the bony structure of the tarsometatarsal joint is intact, the 3rd tarsometatarsal joint does not need to be fixed routinely, the stability of the joint can be obtained indirectly by fixing the adjacent tarsometatarsal joint.

Ultrasound-Guided Decompression of the Intermetatarsal Nerve for Morton's Neuroma: A Novel Closed Surgical Technique.

This study describes the technique for decompression of the intermetatarsal nerve in Morton's neuroma by ultrasound-guided surgical resection of the transverse intermetatarsal ligament. This technique is based on the premise that Morton's neuroma is primarily a nerve entrapment disease. As with other ultrasound-guided procedures, we believe that this technique is less traumatic, allowing earlier return to normal activity, with less patient discomfort than with traditional surgical techniques. We performed a pilot study on 20 cadavers to ensure that the technique was safe and effective. No neurovascular damage was observed in any of the specimens. In the second phase, ultrasound-guided release of the transverse intermetatarsal ligament was performed on 56 patients through one small (1- to 2-mm) portal using local anesthesia and outpatient surgery. Of the 56 participants, 54 showed significant improvement and two did not improve, requiring further surgery (neurectomy). The postoperative wound was very small (1-2 mm). There were no cases of anesthesia of the interdigital space, and there were no infections. The ultrasound-guided decompression of intermetatarsal nerve technique for Morton's neuroma by releasing the transverse intermetatarsal ligament is a safe, simple method with minimal morbidity, rapid recovery, and potential advantages over other surgical techniques. Surgical complications are minimal, but it is essential to establish a good indication because other biomechanical alterations to the foot can influence the functional outcome.

Novel Hallux Valgus Cadaveric Model: Role of Ligament Damage and Tendon Pull in Recreating the Deformity

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Hallux valgus (HV) is of uncertain origin, which explains the plethora of treatment options available. In the last few years it has been shown that it is not a one plane deformity, but a multiplanar one. It is the authors belief that Hallux Valgus originates from instabilities located at medial ray joints. To be able to further understand this frequent pathology, a cadaveric model should be developed. Through specific and limited medial column ligament damage, a model was developed trying to obtain similar deformities to the ones observed in real life, i.e. first ray varus and pronation.Methods:7 fresh frozen lower leg specimens were used without evident foot and ankle pathology. Tibio-talar and talo-navicular joints were fixed. Luminous markers were attached to the medial and middle foot ray bones, including talus. A constant tibial axial load of 25 kg was used. Cyclic tibial rotation (to simulate gait phases) and 5 kg pull on the extensor and flexor hallucis tendons (EHL and FHL) were applied to every specimen. Limited and sequential medial and middle column ligamentous sectioning were performed, including the naviculocuneiform, intercuneiform, metatarsocuneiform, metatarsophalangeal medial capsule and intermetatarsal ligaments. After each ligament damage, 3D bony alignment was registered using high speed high definition infrared cameras.Results:After ligament sectioning, an increase in intermetatarsal angle was observed of 2.5 degrees (range 0.8-5) (p=0.001), with 1 degree (0-3) (p=0.02) of further increase when Hallucis tendons pull was applied. Intercuneiform angle increased 2.3 degrees (0- 6) (p=0.01), with no change with tendons pull. Regarding bone rotation, the metatarsal pronated in relation to the navicular (metatarso-navicular angle) 6.3 degrees (3-20) (p=0.015) and the cuneiform pronated in relation to the navicular (naviculo- cuneiform angle) 3.3 degrees (0.5-6) (p=0.005). At the metatarso-cuneiform joint, a non-significant rotation was identified (1 degree (p=0.39). Hallucis tendons pull did not significantly affect any rotation angle. An evident hallux valgus deformity could be created, which further deformed with hallucis tendons pull.Conclusion:After sequential medial and middle ray ligament sectioning, a progressive and simultaneous increase in medial column varus and pronation were observed. Hallucis tendons pull, increased the medial column varus, but appeared not to play a role in bone rotation. Bone rotation occurs along the medial column joints, not isolated to the tarsometatarsal joint. Progressive medial ray ligamentous sectioning was able to recreate a Hallux valgus deformity, including medial ray varus and pronation.

Isolated Intermetatarsal Ligament Release as Primary Operative Management for Morton's Neuroma: Short-term Results.

Although the precise pathoetiology of Morton's neuroma remains unclear, chronic nerve entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional operative management entails neuroma excision but risks unpredictable formation of stump neuroma. Medical records were examined for adult patients who failed at least 3 months of conservative treatment for symptomatic and recalcitrant Morton's neuroma and who then underwent isolated IML decompression without neuroma resection. A total of 12 patients underwent isolated IML decompression for Morton's neuroma with an average follow-up of 13.5 months. Visual Analog Pain Scale averaged 6.4 ± 1.8 (4-9) preoperatively and decreased to an average of 2 ± 2.1 (0-7) at final follow-up (P = .002). All patients reported significant improvement. Isolated IML release of chronically symptomatic Morton's neuroma shows promising short-term results regarding pain relief, with no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation. Level IV: Case series.

Closed Transverse Pinning for Reduction and Fixation of Metatarsal Neck Fractures: Surgical Technique.

Most metatarsal neck fractures can be successfully treated non-operatively in a cast boot. Displaced metatarsal neck fractures tend to be less stable and have a propensity for the distal fragment to angulate, secondary to the strong flexor tendons, which often forces the distal fracture fragment in a plantar direction and leads to relative metatarsal shortening. Most literature is focussed on antegrade fixation of metatarsal neck fractures using pre-bent K wires or thin elastic nails. Apart from the technical challenges, this technique is limited when bones are osteoporotic as the pre-bent distal end of the K-wire may penetrate the plantar cortex of the proximal metatarsal and prevent the wire from entering the medullary canal of the metatarsal and advancing to the fracture site. Furthermore, when the medullary canal is narrow especially in Asian patients, it may be difficult to pass a bent K-wire through the isthmus of the metatarsal shaft. We describe an innovative technique of closed transverse wiring of the metatarsal head necks that has a distinct advantage in Asian population with osteoporotic bones. With percutaneous manipulation using digital pressure, closed reduction of fracture fragments of the most displaced fracture is done under fluoroscopic guidance to achieve a satisfactory alignment followed by closed transverse wiring of the metatarsal heads. With this procedure, adjacent fractures remain stable within an acceptable range because of intermetatarsal ligaments connected to the adjacent intact head. Our technique has a relatively short operating time and allows for early motion of the metatarso-phalangeal joint. This is especially useful for those with osteoporosis, narrow canal, soft tissue compromise, intra-operative failure of ante-grade pinning and in scenarios of limited surgical equipment/expertise.