Lateral Foot Research Articles

Passive Eversion Assessment for Progressive Collapsing Foot Deformity After Lateral Column Lengthening: A Cadaveric Biomechanical Study.

Reduced hindfoot eversion motion has been proposed as a cause of increased lateral foot pressure following lateral column lengthening (LCL) for progressive collapsing foot deformity (PCFD). A subjective intraoperative assessment of passive eversion has been suggested to help evaluate correction; however, it is unclear how passive eversion correlates with objective measurements of foot stiffness. Our objectives were to quantify the relationship between the maximum passive eversion in hindfoot joints following LCL with plantar pressure during stance and to determine the influence of wedge size on these outcomes. Ten cadaveric specimens extending from the mid-tibia distally were tested on a 6-degrees-of-freedom robot to simulate the stance phase of level walking. Five conditions were tested: intact, simulated PCFD, and 3 LCL wedge conditions (4, 6, and 8 mm). Outcomes included the lateral-to-medial forefoot plantar pressure (LM) ratio during stance and the maximum passive eversion measured in the hindfoot joints. Simple linear regressions were performed to evaluate relationships between outcomes and wedge sizes. A strong negative relationship was found between passive subtalar eversion and the LM ratio during stance (r[38] = -0.46; p = 0.0007), but not between passive talonavicular eversion and the LM ratio (r[38] = -0.02; p = 0.37). Wedge size was strongly related to subtalar eversion (r[38] = -0.77; p < 0.0001), talonavicular eversion (r[38] = -0.55; p = 0.0003), and the LM ratio (r[38] = 0.70; p < 0.0001). Increased wedge size resulted in average decreases in subtalar and talonavicular eversion of 1.0° (95% confidence interval [CI]: 0.8° to 1.3°) and 1.2° (95% CI: 0.6° to 1.6°), respectively. Increased wedge size also increased the LM ratio by 0.38 (95% CI: 0.25 to 0.50), indicating a lateral shift in plantar pressure. Decreased hindfoot eversion following LCL was related to increased lateral plantar pressure during stance. Increasing wedge size correlated with decreasing passive hindfoot eversion and increasing lateral plantar pressure, suggesting that intraoperative preservation of eversion motion may be important for preventing excessive lateral loading. To avoid overcorrection or undercorrection of the deformity, hindfoot eversion assessment in addition to radiographic evaluation may be important for optimizing the amount of lengthening to achieve successful LCL.

Extensive Posteromedial Soft Tissue Release for Skeletally Mature Patients With Rigid Pes Cavus Deformity

Introduction: Adult-onset cavovarus foot deformity is a highly disabling condition that can seriously interfere with daily activities. Charcot-Marie-Tooth is the most common etiology associated with cavus foot. Patients and Methods: We reviewed 30 feet in skeletally mature patients with rigid cavovarus deformities who were treated with extensive posteromedial soft tissue release without performing osteotomies or internal fixation. Clinical evaluation was done using the Foot Function Index for the pain, disability, and limitation of movement. The radiologic assessment was done by measurement of the lateral talo-first metatarsal angle, the lateral calcaneal-first metatarsal angle, and the lateral tibio-calcaneal angle in standing lateral foot radiographs. All patients were followed up for a mean of 36 months postoperatively. Results: Throughout the course of the study, the Foot Function Index for pain, disability, and limitation improved from an average of 51.46 points, 47.06 points, and 22.6 points preoperatively to postoperative averages of 23.65 points, 21.88 points, and 10.2 points, respectively. Radiologically, the talo-first metatarsal angle, the calcaneo-first metatarsal angle, and the tibio-calcaneal angles had preoperative values of 28.9 degrees, 132.4 degrees, and 62.35 degrees which improved postoperatively to 7.55 degrees, 117.65 degrees and 50.35 degrees, respectively. Conclusion: The outcomes of this study shed light on the use of pure soft tissue release without associated osteotomies as a simple, safe, and effective technique in treating rigid cavovarus deformities in skeletally mature patients. This could carry some advantages regarding preserving foot function as it preserves the integrity of foot joints. Level of Evidence: Level IV.

Metatarsals and foot phalanges from the Sima de los Huesos Middle Pleistocene site (Atapuerca, Burgos, Spain).

This study provides a complete, updated and illustrated inventory, as well as a comprehensive study, of the metatarsals and foot phalanges (forefoot) recovered from the Middle Pleistocene site of Sima de los Huesos (SH, Atapuerca, Spain) in comparison to other Homo comparative samples, both extant and fossils. This current updated review has established a minimum number of individuals (MNI) of 17, which represent 58.6% of the 29 dental individuals identified within the SH sample. An exclusive or autoapomorphic combination of traits can be recognized within the SH hominin foot sample. A few traits appear primitive or plesiomorphic when compared with earlier Homo individuals and other recent modern humans. There are other metrical and morphological traits that SH hominins and Neandertals have in common that sometimes represent shared derived traits in this evolutionary line, most of which are probably related to robusticity. Furthermore, some exclusive autoapomorphic traits are observed in the SH sample: a very broad first metatarsal, long and broad hallucal proximal foot phalanges and possibly extremely robust lateral distal foot phalanges compared to those of Neandertals and modern humans. In these last traits, the SH metatarsals and pedal phalanges are even more robust than in Neandertals. They are herein named as "hyper-Neandertal" traits, which could suggest a slight gracilization process in this evolutionary line, at least in the hallux toe. Finally, some paleobiological inferences are made in relation to body size (stature and body mass) and some associations are proposed within the SH sample.

Design and evaluation of a wedge-shaped adaptive knee orthosis for the human lower limbs.

The incidence of knee osteoarthritis (KOA) is moderately correlated with age and body weight and increases with life span and weight gain, associated with tearing and wearing the knee joints. KOA can adjust the force through the human lower limbs, redistribute the load of the knee joint, reduce the pain, and restore mobility when the arthritis changes are mild. However, most of the existing knee orthosis cannot be adjusted adaptively according to the needs of patients. This study establishes a biomechanical model of the knee joint to analyze the medial and lateral forces acting on the joint. The new adjustable knee orthosis is designed. It applies the principle of four-point bending to apply pressure to both sides of the knee joint, thereby adjusting the varus angle and modifying the medial and lateral forces on the knee joint. Through structural optimization, the prototype of the knee orthosis weighs only 324g. Utilizing three-dimensional scanning technology, discrete point cloud data of the leg surface is obtained, reconstructed, and processed to create a 3D model of the human leg surface. The design ensures a close fit to the human leg surface, offering comfortable wear. A pressure sensing film system is employed to build a pressure sensing test system, where the knee orthosis is worn on a prosthesis for pressure testing to evaluate its ability to adjust knee joint forces. The pressure test results demonstrate that the knee orthosis can stably provide an adjustment angle of 0-7° and sustain a maximum force of 10N on both sides of the knee joint over extended periods. A self-developed 8-channel plantar pressure sensing insole is calibrated against commercial plantar pressure sensors. Human wear tests on 15 subjects show that during the operation of the knee orthosis, it significantly adjusts plantar pressures, reducing lateral foot pressures by 22% overall, with more pronounced corrective effects observed in lighter participants. In this study, a wedge-shaped adaptive knee orthosis was provided for KOA patients. The four-point force principle was used to balance the force between femurs and tibia and adjust the meniscus contact gap. The orthotic appliance has the advantages of simple mechanical structure, adjustable correction Angle and good wearing comfort.

Cuboid Cobbles Hinder Elite Youth Football Player.

We describe an elite youth football player who developed lateral foot pain of previously unknown origin. A thorough patient history and physical examination as well as an in-depth presentation of radiographic findings on Computed tomography (CT) and Magnetic Resonance Imaging (MRI) scan were described. Through this combination, the puzzle was resolved and a rare peroneus longus tendinopathy due to bony spurs in the cuboid groove was diagnosed. A peroneus longus exploration, release and reduction of the cuboidal bone spurs was performed and intensive rehabilitation phase followed. The patient successfully returned to performance and set a career in professional football.

Performance Factors in Sport Climbing: A Systematic Review

Background: Our aim was understanding and identifying the main performance factors involved in sport climbing. Methods: A systematic review was conducted using the Google Scholar, Dialnet, Scielo, and Redalyc databases. Results: After establishing the selection criteria, a total of 27 documents related to the subject of study were examined. A limited number of publications with scientific evidence related to performance factors in sport climbing were found, despite the rise of sport climbing following its inclusion in the Olympic Games in Tokyo 2020. The results have been organized based on different performance factors analyzed, such as strength, muscular endurance, psychological factors, etc. Key determinants in climbing performance, and thus those present in elite athletes, include improved climbing efficiency, greater ability to apply maximum force or finger and palm pressure resistance, and increased arm locking strength. Additionally, it has been observed that those who can apply higher and more consistent loads experience better muscle oxygenation and have greater flexibility and lateral foot reach. Conclusions: Climbing performance is the result of factors that can be enhanced through training. Therefore, further research is needed to understand the performance factors involved in this sports discipline and how to improve them.

Plantar calcaneal spurs and their connection with lumbar herniating discs

Introduction: Calcaneal spurs are bony triangular projections of varying sizes that are found on the calcaneum. By analyzing the incidence of plantar spurs and lumbar herniated disks, the current research aims to provide a reliable baseline for determining the pathological significance of spurs with herniated disks. Methods: Consecutive patients who had visited a local physiotherapy clinic for plantar calcaneal spurs between October 2022 and February 2023 with no self-reported comorbidities such as diabetes or vascular diseases were qualified for the study. Of the eligible subjects, a total of 84 patients were randomly selected from the clinic’s database. All 84 patients were subjected to weight-bearing lateral foot radiographs and magnetic resonance imaging scans. A Visual Analog Scale (VAS) was used to measure heel pain. Associations between the presence of spurs, herniated disks, sex, body mass index (BMI), and heel pain were then explored. Results: Of the 84 patients, 40 were males (48%) and 44 females (52%), with a mean age of 64.2 ± 5.6 years. The mean BMI was 28.5 ± 5.2 kg/m2. From the analysis of the imaging examination results, of the 84 patients with calcaneal spurs, 40 (48%) had lumbar disk herniation at L5-S1, 38 (45%) at L4-L5, 1 (1%) high lumbar herniations, and 5 (6%) no hernia. Women accounted for 45% of L5-S1 herniations and 41% of L4-L5 herniations. Pearson correlation between the variables speaks for a positive weak (r = 0.33) and significant relationship between VAS and weight and between VAS and BMI (r = 0.436, p &lt; 0.001). Conclusion: Given the high percentage of patients suffering concomitantly from plantar calcaneal spurs and discal hernias (94%), we assume that there might be a probable link between the two disorders.

Flexibility and mobility parameters in climbers and non-climbers

Purpose: In recent years, climbing has become increasingly popular and now has more enthusiasts and research interest than ever before. However, no study has yet considered the relationships between the functional mobility of the upper and lower limbs, climbing experience, climbing-specific hip mobility, and muscle strength. The purpose of this study was to determine whether functional mobility (measured using shoulder mobility and active straight leg raise tests) or climbing-specific hip mobility (measured using an adapted Grant foot raise test [hip flexion] and lateral foot reach test [hip abduction and external rotation determines climbing skills. Methods: A total of 59 volunteer climbers in 3 groups (elite climbers, intermediate climbers, and non-climbers) were assessed according to anthropometry, muscle strength, functional mobility, and hip mobility. Results: Elite climbers performed significantly better than intermediate climbers and non-climbers in tests of the external mobility of the left shoulder (p = .043; η2 = 0.112) and in the adapted Grant foot raise test (p = .023; η2 = 0.126). Conclusions: Elite climbers have greater hip mobility than intermediate climbers and non-climbers. Functional shoulder mobility, especially external rotation, may play a role in effective climbing.

Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit.

We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents. A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test. The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal. Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

Flatfeet Severity-Level Detection Based on Alignment Measuring.

Flat foot is a postural deformity in which the plantar part of the foot is either completely or partially contacted with the ground. In recent clinical practices, X-ray radiographs have been introduced to detect flat feet because they are more affordable to many clinics than using specialized devices. This research aims to develop an automated model that detects flat foot cases and their severity levels from lateral foot X-ray images by measuring three different foot angles: the Arch Angle, Meary's Angle, and the Calcaneal Inclination Angle. Since these angles are formed by connecting a set of points on the image, Template Matching is used to allocate a set of potential points for each angle, and then a classifier is used to select the points with the highest predicted likelihood to be the correct point. Inspired by literature, this research constructed and compared two models: a Convolutional Neural Network-based model and a Random Forest-based model. These models were trained on 8000 images and tested on 240 unseen cases. As a result, the highest overall accuracy rate was 93.13% achieved by the Random Forest model, with mean values for all foot types (normal foot, mild flat foot, and moderate flat foot) being: 93.38 precision, 92.56 recall, 96.46 specificity, 95.42 accuracy, and 92.90 F-Score. The main conclusions that were deduced from this research are: (1) Using transfer learning (VGG-16) as a feature-extractor-only, in addition to image augmentation, has greatly increased the overall accuracy rate. (2) Relying on three different foot angles shows more accurate estimations than measuring a single foot angle.

Evaluating the Utility of Plain Radiograph and Computerised Tomography Scanning in Identifying Concomitant Foot Fractures in Patients with Unstable Lisfranc Injuries

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc fracture dislocations are uncommon injuries, which frequently require surgical intervention. Currently, there is varying evidence on the diagnostic utility of plain radiographs (XR) and CT in identifying Lisfranc injuries and concomitant fractures. Our aim was to identify the utility of XR as compared to CT, with the nul hypothesis that there was no difference in fracture identification. Methods: A retrospective assessment of patients who had sustained a Lisfranc injury between 2013 and 2022 across two trauma centres within the United Kingdom who underwent surgery. Pre-operative XR and CT images were reviewed independently by 2 reviewers to identify the presence of associated fractures. Results: A total of 175 patients were included. Our assessment identified that XR images significantly under-diagnosed all metatarsal and midfoot fractures. The largest discrepancies between XR and CT in their rates of detection were in fractures of the cuboid (5.7% vs 28%, p&lt; 0.001), medial cuneiform (20% vs 51%, p=0.008), lateral cuneiform (4% vs 36%, p=0.113), second metatarsal (57% vs 82%, p&lt; 0.001), third metatarsal (37% vs 61%, p&lt; 0.001) and fourth metatarsal (26% vs 43%, p&lt; 0.001). As compared to CT, the sensitivity of XR was low. The lowest sensitivity for identification however was lateral foot injuries, specifically fractures of the lateral cuneiform (sensitivity 7.94%, specificity 97.3%), cuboid (sensitivity 18.37%, specificity 99.21%), fourth (sensitivity 46.7%, specificity 89.80%) and fifth metatarsal (sensitivity 45.00%, specificity 96.10%). Conclusion: From our analysis, we can determine that XR significantly under-diagnoses associated injuries in patient sustaining an unstable Lisfranc injury, with lateral foot injuries being the worst identified. We advised the use of CT imaging in all cases for appropriate surgical planning.

INSPIIRE - A Modular and Passive Exoskeleton to Investigate Human Walking and Balance.

Powered exoskeletons for SCI patients are mainly limited by their inability to balance dynamically during walking. To investigate and understand the control strategies of human bipedal locomotion, we developed INSPIIRE, a passive exoskeleton. This device constrains the movements of able-bodied subjects to only hip and knee flexions and extensions, similar to most current active exoskeletons. In this paper, we detail the modular design and the mechanical implementation of the device. In preliminary experiments, we tested whether humans are able to handle dynamic walking without crutches, despite the limitation of lateral foot placement and locked ankles. Five healthy subjects showed the ability to stand and ambulate at an average speed of 1 m/s after 5 minutes of self-paced training. We found that while the hip abduction/adduction is constrained, the foot placement was made possible thanks to the pelvis yaw and residual flexibility of the exoskeleton segments in the lateral plan. This result points out that INSPIIRE is a reliable instrument to learn sagitally-constrained human locomotion, and the potential of investigating more dynamic walking, which is shown as possible in this implementation, even if only flexion/extension of the hip and knee are allowed.

560 Evaluating the Utility of Plain Radiograph and Computerised Tomography Scanning in Identifying Concomitant Foot Fractures in Patients with Unstable Lisfranc Injuries

Abstract Aim Lisfranc fracture dislocations are uncommon injuries. There is varying evidence on the utility of plain radiographs (XR) and CT in identifying Lisfranc injuries and concomitant fractures. Our aim was to identify the utility of XR as compared to CT, with the nul hypothesis that there was no difference in fracture identification. Method A retrospective assessment of patients who had sustained a Lisfranc injury between 2013 and 2022 across two trauma centres within the United Kingdom who underwent surgery. Pre-operative images were reviewed independently by 2 reviewers to identify the presence of injuries. Results A total of 175 patients were included. We found that XR images significantly under-diagnosed metatarsal and midfoot fractures. The largest discrepancies between XR and CT in their rates of detection were in fractures of the cuboid (5.7% vs 28%, p&amp;lt;0.001), medial cuneiform (20% vs 51%, p = 0.008), lateral cuneiform (4% vs 36%, p = 0.113), second metatarsal (57% vs 82%, p&amp;lt;0.001), third metatarsal (37% vs 61%, p&amp;lt;0.001) and fourth metatarsal (26% vs 43%, p&amp;lt;0.001). As compared to CT, the sensitivity of XR was low. The lowest sensitivity for identification however was lateral foot injuries, specifically fractures of the lateral cuneiform (sensitivity 7.94%, specificity 97.3%), cuboid (sensitivity 18.37%, specificity 99.21%), fourth (sensitivity 46.7%, specificity 89.80%) and fifth metatarsal (sensitivity 45.00%, specificity 96.10%). Conclusions From our analysis, we can determine that XR significantly under-diagnoses associated injuries in patient sustaining an unstable Lisfranc injury, with lateral foot injuries being the worst identified. We advised the use of CT imaging in all cases for appropriate surgical planning.

Sonographic imaging and assessment of the sural nerve

AbstractThe sural nerve is a sensory nerve which innervates the posterolateral distal calf and lateral foot. It can be demonstrated using high resolution ultrasound and travels near the small saphenous vein throughout most of its course. There are variations in its origin and relative position through the posterior distal calf, lateral ankle, and foot. To allow this nerve and any potential pathology or injury to be sonographically demonstrated, a good understanding of the sonographic relative anatomy, course, and common anatomical variations, as well as the sonographic normal appearances throughout need to be appreciated and these are reviewed in this paper.

Unmasked Neuropathic Pain After Neurectomy: A Case Series and Review of the Literature

Summary: Localization of neuropathic pain to a specific peripheral nerve origin relies on patient history, physical examination, and nerve blocks. Neurectomy of the involved nerve(s) can successfully alleviate patients’ pain. However, a subset of patients postoperatively describe persistent pain, but say that the pain “moved” to a new location (eg, from the dorsum of the foot to the lateral foot). This may be viewed as a treatment failure by the patient and surgeon alike. Further investigation, however, may localize the new pain to an additional, separate peripheral nerve injury, which was previously unrecognized by both parties. The mechanism involved is that of pain masking and unmasking. Successful treatment of the more prominent pain stimulus allows for recognition of a second, less-offending peripheral nerve injury. As the field of surgical treatment of chronic peripheral neuropathic pain advances, it is important to identify and define specific nuances of diagnosis and treatment via neurectomy. The term “diffuse noxious inhibitory control,” used to describe the pain-inhibits-pain pathway, may help explain the phenomenon of masking, whereby one pain generator is more prominent and shields another site from recognition and subsequent diagnosis. In this context, unmasked pain should be considered as a potential source of surgical treatment failure. We present a series of patients who, following improvement in the initial location of their pain, reported pain in a distinctly new peripheral nerve distribution, leading to reoperation.

Hindfoot fusion with various auxiliary techniques in Charcot’s management

Abstract Introduction: Management of Charcot’s arthropathy of the hindfoot (Sanders/Frykberg Type IV) is a challenging situation to address. Complex deformities linked with ankle/hindfoot Charcot’s disease are frequently multiplanar. Due to the collapse of the distal tibia and the two bones of the hindfoot, the talus, and calcaneus, the limb frequently shortens when the skeletal architecture is damaged. A varus ankle or heel results in increased lateral column plantar pressure of the foot due to changed foot pressure loading, predisposing the patient to develop lateral foot ulceration. Collapse and secondary avascular necrosis of the talus; additional stress on the injured bone exacerbates these deformities and contributes to ulcers in the foot, instability during walking, and limb-length discrepancy. Management: The primary indication for surgical ankle stabilization is a foot that cannot be braced and is unstable during walking. Other surgical indications include imminent ulceration, nonhealing ulcers, recurring ulcers, osteomyelitis, and/or severe pain. Achieving ankle and/or hindfoot arthrodesis and correcting these complex multiplanar deformities in this location stabilizes the hindfoot. Various auxiliary techniques that can be combined with Tibio-talo-calcaneal (TTC) are tricortical iliac crest graft and femoral head allograft to build hindfoot, plate augmentation, distally mobilized fibula as biological augmentation and multiple 6.5-mm screws. The choice between internal or exterior fixation is mostly determined by the presence or absence of an active infection and the quality of the bone. Conclusion: Surgical stabilization with TTC nail for Charcot’s arthropathy of the ankle and hindfoot is associated with good clinical outcomes. Despite the high likelihood of complications, limb salvage rates are between 80% and 90%. A meticulous selection of cases, a diligent multimodal strategy, and an experienced team are required to attain this result. Assessment of vascular status, glycemic control, optimum foot care, use of protective footwear during the acute inflammatory phase to prevent inadvertent trivial foot injuries, correction of calcium and vitamin D deficiencies, and cessation of tobacco and alcohol use are preoperative factors that can improve outcomes. Various auxiliary techniques can be combined with TTC nailing for optimum results.

Republication of "Proximal Rotational Metatarsal Osteotomy for Hallux Valgus (PROMO): Short-term Prospective Case Series With a Novel Technique and Topic Review".

Hallux valgus deformity consists of a lateral deviation of the great toe, metatarsus varus, and pronation of the first metatarsal. Most osteotomies only correct varus, but not the pronation of the metatarsal. Persistent postoperative pronation has been shown to increase deformity recurrence and have worse functional outcomes. The proximal rotational metatarsal osteotomy (PROMO) technique reliably corrects pronation and varus through a stable osteotomy, avoiding fusing any healthy joints. The objective of this research is to show a prospective series of the PROMO technique. Twenty-five patients (30 feet) were operated with the PROMO technique. The sample included 22 women and 3 men, average age 46 years (range 22-59), for a mean prospective follow-up of 1 year (range 9-14 months). Inclusion criteria included symptomatic hallux valgus deformities, absence of severe joint arthritis, or inflammatory arthropathies, with a metatarsal malrotation of 10 degrees or more, with no tarsometatarsal subluxation or arthritis on the anteroposterior or lateral foot radiograph views. The mean preoperative and postoperative Lower Extremity Functional Scale (LEFS) score, metatarsophalangeal angle, intermetatarsal angle, metatarsal malrotation, complications, satisfaction, and recurrence were recorded. The mean preoperative and postoperative LEFS scores were 56 and 73. The median pre-/postoperative metatarsophalangeal angle was 32.5/4 degrees and the intermetatarsal angle 15.5/5 degrees. The metatarsal rotation was satisfactorily corrected in 24 of 25 patients. An Akin osteotomy was needed in 27 of 30 feet. All patients were satisfied with the surgery, and no recurrence or complications were found. PROMO is a reliable technique, with good short-term results in terms of angular correction, satisfaction, and recurrence. Long-term studies are needed to determine if a lower hallux recurrence rate occurs with the correction of metatarsal rotation in comparison with conventional osteotomies. IV, prospective case series.

Left femoral hypoplasia associated with congenital fibular agenesis – A rare case report

Background and objectives. Unilateral or bilateral femoral hypoplasia represents a rare clinical entity and it can be isolated or associated with otherlimb malformations such as: congenital absence of the fibula (the most common association), the absence of lateral foot rays or clubfoot, or other organ defects such asspinal dysraphism, or congenital cardiac malformations. Only a few cases have been detected by antenatal ultrasonography so far. Materials and methods. We present the case of a newborn admitted at birth in the Neonatology Department of County Emergency Clinical Hospital of Constanta, diagnosed prenatally with left femur hypoplasia, confirmed postnatally. Results. The subject is a full-term female neonate, born at 38 weeks gestational age, with a birth weight of 2600 g, Apgar Score of 9. The mother is 39-year-old, Gravida-I, Para-I, with no medical history of consanguinity, genetic or congenital abnormalities, exposure to toxins, teratogen drugs, or viral infections. The 14 weeks and 16 weeks ultrasound revealed a shortened left femur, below the 5th percentile, with no other facial morphology, cardiac, neurologic, gastrointestinal, or genitourinary system abnormalities mentioned. A cesarean section was performed at 38 gestational weeks (premature rupture of membranes, breech presentation). The diagnosis was confirmed postpartum by X-ray. Conclusions. The presented case emphasizes the importance of prenatal care and early detection of skeletal abnormalities for parental education and genetic counseling, offering an informed choice whether to continue with the pregnancy and planning for postnatal care with a multidisciplinary team: obstetrics and gynecology, neonatology, and pediatric orthopedic surgery.

Mönckeberg's medial calcific sclerosis in diabetic and non-diabetic foot infections.

The aim of this study was to evaluate the prevalence and extent of lower extremity Mönckeberg's Medial Calcific Sclerosis (MMCS) in patients with and without diabetes in patients admitted to the hospital for foot infections. This study retrospectively reviewed 446 patients admitted to the hospital with a moderate or severe foot infection. We defined diabetes based on ADA criteria and reviewed electronic medical records for demographics, medical history and physical examination data. Anterior-posterior and lateral foot radiographs were examined to identify the presence and extent of vascular calcification. We categorised MMCS based on anatomical location: ankle joint to the navicular-cuneiform joint, Lis Franc joint to metatarsophalangeal joints and distal to the metatarsophalangeal joints. The prevalence of MMCS was 40.6%. The anatomic extent of MMCS was 19.3% in the toes, 34.3% in the metatarsals and 40.6% in the hindfoot/ankle. Calcification was not common solely in the dorsalis pedis artery (DP) (3.8%) or solely in the posterior tibial artery (PT) (7.0%). Usually, both DP and PT arteries were affected by MMCS (29.8%). The prevalence of MMCS was higher in people with diabetes (in hindfoot and ankle [50.1% vs. 9.9%, p ≤ 0.01]; metatarsals [42.6% vs. 5.9%, p ≤ 0.01]; and toes [23.8% vs. 4.0%, p ≤ 0.01]). People with diabetes were 8.9 (CI: 4.5-17.8) times more likely to have MMCS than those without diabetes. This is a group that often has poor perfusion and needs vascular assessment. The high prevalence of MMCS raises questions about the reliability of the conventional segmental arterial Doppler studies to diagnose PAD.

Quantitative assessment of plantar pressure patterns in relation to foot deformities in people with hereditary motor and sensory neuropathies

BackgroundHereditary motor and sensory neuropathies (HMSN), also known as Charcot-Marie-Tooth disease, are characterized by affected peripheral nerves. This often results in foot deformities that can be classified into four categories: (1) plantar flexed first metatarsal, neutral hindfoot, (2) plantar flexed first metatarsal, correctable hindfoot varus, (3) plantar flexed first metatarsal, uncorrectable hindfoot varus, and (4) hindfoot valgus. To improve management and for the evaluation of surgical interventions, a quantitative evaluation of foot function is required. The first aim of this study was to provide insight into plantar pressure of people with HMSN in relation to foot deformities. The second aim was to propose a quantitative outcome measure for the evaluation of surgical interventions based on plantar pressure.MethodsIn this historic cohort study, plantar pressure measurements of 52 people with HMSN and 586 healthy controls were evaluated. In addition to the evaluation of complete plantar pressure patterns, root mean square deviations (RMSD) of plantar pressure patterns from the mean plantar pressure pattern of healthy controls were calculated as a measure of abnormality. Furthermore, center of pressure trajectories were calculated to investigate temporal characteristics. Additionally, plantar pressure ratios of the lateral foot, toes, first metatarsal head, second/third metatarsal heads, fifth metatarsal head, and midfoot were calculated to measure overloading of foot areas.ResultsLarger RMSD values were found for all foot deformity categories compared to healthy controls (p < 0.001). Evaluation of the complete plantar pressure patterns revealed differences in plantar pressure between people with HMSN and healthy controls underneath the rearfoot, lateral foot, and second/third metatarsal heads. Center of pressure trajectories differed between people with HMSN and healthy controls in the medio-lateral and anterior-posterior direction. The plantar pressure ratios, and especially the fifth metatarsal head pressure ratio, differed between healthy controls and people with HMSN (p < 0.05) and between the four foot deformity categories (p < 0.05).ConclusionsSpatially and temporally distinct plantar pressure patterns were found for the four foot deformity categories in people with HMSN. We suggest to consider the RMSD in combination with the fifth metatarsal head pressure ratio as outcome measures for the evaluation of surgical interventions in people with HMSN.