Medial Deviation Research Articles

A three-dimensional comparative study on the scapulohumeral relationship in normal and osteoarthritic shoulders

Eccentric loading due to humeral translation is associated with worse clinical outcomes in hemiarthroplasty and total shoulder arthroplasty. The purpose of this study was to evaluate the 3-dimensional relationship of the humeral head to the scapula (scapulohumeral relationship) in nonpathologic shoulders and in shoulders with primary osteoarthritis. Three-dimensional reconstructions of computed tomography scans of 151 nonpathologic shoulders (control group) and 110 shoulders with primary glenohumeral arthritis (OA group) were analyzed by measuring the anterior-posterior, inferior-superior, and medial-lateral position of the humeral head in relation to the scapula. Shoulders were classified as centered (type A) or posteriorly subluxed (type B) according to the Walch classification of glenoid morphology. Reproducibility and differences in scapulohumeral relationship were statistically analyzed. The scapulohumeral relationship could be determined reliably: the intraclass correlation coefficient ranged between 0.780 and 0.978; the typical error of measurement ranged between 2.4% and 5.0%. Both type A and type B shoulders showed significant posterior translation of the humeral head (P <.001). Type B shoulders had significantly more posterior translation than type A shoulders (P <.001). A tendency of inferior translation was noted, although with only marginal statistical significance (P = .051). In each morphology class, a medial deviation of the humeral head, representing a reduced glenohumeral distance, was measured (P <.001). The main characteristics of primary glenohumeral osteoarthritis are posterior humeral head translation relative to the scapula, reduced glenohumeral distance, and a tendency toward inferior humeral head translation in both type A and type B shoulders.

Anatomical Safety of the U.S.S. Pedicular Hook-Screw in the Adult Thoracic Spine

Introduction Pedicle hooks have been extensively used in spine surgery. One of the major concerns of such instrumentation is the pullout of the implants. Recently, a screw that anchors the pedicle was added to secure the hook, and to improve both pullout strength as well as purchase. An anatomical study was performed on human cadavers to assess the anatomical safety of these implants. From this study, we can conclude that the use of screws to hold the pedicle hooks is generally safe. Further studies should be done to assess this in deformed spines. Materials &amp; Methods: Eleven embalmed human cadavers with a mean age of 76 years (6 male bodies and 5 female bodies) were used for this study. The same staff spine surgeon performed all surgical procedures. The thoracic pedicles were instrumented bilaterally starting from T1 down to T12 with an AO Universal Spine System Pedicular Hook Screw. Abandoning the procedures was permitted whenever the safety of any neural structures was jeopardized or the implant could not be placed correctly. The surgeon's comments were documented. For subsequent analyses after instrumentation, the spines were harvested en-bloc and later dissected into individual vertebrae. Two independent blinded observers did a visual inspection to grade the hook and screw positions. All specimens were then radiographed individually in three dimensions (antero-posterior, medio-lateral &amp; cranio-caudal). Two blinded observers independently evaluated the hook and screw positions following the visual classification system. Only the antero-posterior and lateral radiographs were provided, because only these would be available in a clinical situation. Results Thirty-five implant placements (ten in T11, eighteen in T12 and seven in all other levels) were abandoned prior to the surgical procedure. Six hooks were requested to be repositioned. Four implant placements were abandoned after drilling the screw hole (three screws with a medial deviation, and one screw with a lateral deviation). Of the remaining 225 implants, 29 were lost during harvesting and preparation, leaving 196 implants for further evaluation. One hundred and eighty three implants were considered safe by the surgeon at the end of the surgical procedure, 13 were believed not to be safe and were removed. No screws were found to be disrupting the integrity of the neural structures in the canal or in the foramen. A comparison between the visual and radiological evaluations of both the screw and hook positions was performed. The visual evaluation showed an inter-observer agreement of 85% for the hooks and 78% for the screws. The radiographic evaluation showed an agreement of 75% for the hooks, and of 43% for the screw between observers, a value considerably lower than expected. When comparing each of the two radiological evaluations to the “gold standard,” only 62% to 67% of the hooks and 42% to 48% of the screws had an agreement. Conclusion Overall, the use of U.S.S. pedicle hook-screws is suggested to be safer than either the conventional pedicle hook, which is often malpositioned inside the canal, or the classical pedicle screw, which is too large for the thoracic pedicles.

Effective conservative treatment for managing Painful Hallux valgus

Hallux valgus (HV) is a foot disorder manifesting by lateral deviation of the great toe and medial deviation of the first metatarsal. HV not only affects foot appearance, but also causes functional disability, including foot pain, impaired gait patterns, balance disorders, which further lead to easily falling and impaired quality of life. It affects approximately 23% of adults, but so far effective conservative interventions are limited. Patients generally receive conservative treatments when having a mild (<30°) HV angle, including night splints, foot exercises, and orthotic application. But previous studies suggested that the effectiveness of orthotic devices and night splints were no superior to no treatment at all for mild-to-moderate HV patients. In recent studies, conservative treatment such as using foot insoles with fixed toe separator and managing with Botulinum toxin type A (BTA) could lead to sustained relief of symptoms. The procedure was less invasive than surgical intervention and relatively easy to perform.

Center of mass trajectories during turning in patients with Parkinson's disease with and without freezing of gait

BackgroundDespite the strong relationship between freezing of gait (FOG) and turning in Parkinson's disease (PD), few studies have addressed specific postural characteristics during turning that might contribute to freezing. MethodsThirty participants with PD (16 freezers, 14 non-freezers) (all tested OFF medication) and 14 healthy controls walked 5 meters and turned 180° in a 3D gait laboratory. COM behavior was analyzed during four turning quadrants of 40° between 10° and 170° pelvic rotation and during 40° before actual FOG episodes. These pre-FOG segments were compared with similar turning sections in turns of freezers without FOG. Outcome parameters were turn time, COM distance, COM velocity, step width and the medial- and anterior COM position. ResultsTurn time was increased in freezers compared to non-freezers (p=.000). No differences were found regarding COM distance and velocity during turning quadrants between groups and between freezers’ pre-FOG segments and similar turning segments without FOG. Medial COM deviation was reduced in PD patients compared to controls (p=.004), but no differences were found between freezers and non-freezers. In turns with freezing, turn time increased (p=.005) and step width decreased (p=.025) pre-FOG. Freezers also showed a less medial (p=.020) and more anterior (p=.016) COM position pre-FOG compared to turning sections without FOG. ConclusionsOur results revealed no subgroup differences in COM behavior during uninterrupted turning. However, we found a reduced medial deviation, a forward COM shift and a decreased step width in freezers just before FOG episodes. These abnormalities may play a causal role, as they could hamper stability and fluent weight shifting necessary for continued stepping during turning.

Role of Ultrasound in Determining the Severity of Hallux Valgus: Ultrasonic Characteristics of Abductor Hallucis Muscle

H Valgus is a forefoot deformity involving progressive lateral deviation of the hallux and medial deviation of the first metatarsal resulting in a medial prominence at the first metatarsophalangeal joint [1]. Such a deformity is more common in older population with estimated prevalence of 36% in those over 65, while the prevalence rate in adults between 18 and 65 years is 23% [2]. Although the deformity may remain asymptomatic, it has been associated with cosmetic appearance concerns, pain and reduced health-related quality of life [3]. Previous studies introduced some risk factors, which involve hallux valgus including increasing age, being female, a positive family history of hallux valgus, abnormal hind foot kinematics, wearing high heels or tight footwear [4-6]. Bony abnormalities (roundshaped first metatarsal head, long first metatarsal, bipartite medial sesamoids) and muscular abnormalities (accessory extensor hallucis longus tendon and accessory tibialis posterior tendon) have also been linked to the deformity [7-9]. Despite the involvement of abductor hallucis muscle in the pathomechanics of this deformity, a limited number of studies have investigated the abductor hallucis muscle with hallux valgus [4]. Although studies indicated that the computed tomography and magnetic resonance imaging as well as EMG are the choice tools in the evaluation of musculoskeletal disorders [9], evidence has also shown that ultrasound proves similar validity to EMG and manual muscle testing in assessing neuromuscular pathologies in extrinsic and intrinsic foot muscles with an added advantage in its ability to visualize muscle atrophy [10]. Hence, the aim of this study is to employ musculoskeletal ultrasound to determine significant differences between dorsoplantar (DP) thickness, medio-lateral (ML) width and cross-sectional area (CSA) of the abductor hallucis muscle among different severities of hallux valgus. This cross-sectional study was performed on 50 participants aged over 20 years attending Boo-Ali hospital in Tehran, Iran from April 2014 to April 2015. The study was approved by the ethical committee of Azad University and written informed consent for participation was obtained. Exclusion criteria included history of foot or ankle surgery, current trauma to the foot and ankle, a neuromuscular condition or a diagnosis of inflammatory arthritis or diabetes mellitus. Hallux valgus was measured using Manchester Scale which utilizes four photographs of increasing severity of hallux valgus (Figure1). This tool has been shown to have excellent reliability and validity in both clinical assessment and self-assessment of hallux valgus [2]. The scale is graded 0 for no deformity, 1 for mild deformity, 2 for moder-

The association between loss of ankle dorsiflexion range of movement, and hip adduction and internal rotation during a step down test

A pattern of excessive hip adduction and internal rotation with medial deviation of the knee has been associated with numerous musculo-skeletal dysfunctions. Research into the role that ankle dorsiflexion (DF) range of motion (ROM) play in lower limb kinematics is lacking. The objective of this cross-sectional, observational study was to investigate the relationship between ankle DF ROM, and hip adduction and hip internal rotation during a step-down test with and without heel elevation in a healthy female population. Hip and ankle ROM was measured kinematically using a ten-camera Optitrack motion analysis system. Thirty healthy female participants (mean age = 20.4 years; SD = 0.9 years) first performed a step-down test with the heel of the weight bearing foot flat on the step and then with the heel elevated on a platform. Ankle DF, hip adduction and hip internal rotation were measured kinematically for the supporting leg. Participants who had 17° or less of ankle DF ROM displayed significantly more hip adduction ROM (p = 0.001; Cohen's d effect size = 1.2) than the participants with more than 17° of DF during the step-down test. Participants with limited DF ROM showed a significant reduction in hip adduction ROM during the elevated-heel step-down test (p = 0.008). Hip internal rotation increased in both groups during the EHSD compared to the step-down test (p > 0.05) Reduced ankle DF ROM is associated with increased hip adduction utilised during the step-down test. Ankle DF should be taken into account when assessing patients with aberrant frontal plane lower limb alignment.

Radiomorphometric assessment of the pterygoid hamulus as a factor promoting the pterygoid hamulus bursitis.

The pterygoid hamulus (PH) is a small protrusion on the base of the pterygoid process of the sphenoid bone. PH is a site of insertion of many muscles and ligaments. Its topography can determine predilection for developing the pterygoid hamulus bursitis (PHB). The study was conducted based on the morphometric analysis of 100 PHs on cone beam computed tomography scans. Based on statistical analysis, we found numerous significant correlations between the morphometric parameters. Considering our results, it can be concluded that the main pathogenic factor in PHB is an extensive medial deviation of the pterygoid hamulus in the frontal plane.

Functional restoration and risk of non-union of the first metatarsocuneiform arthrodesis for hallux valgus: A finite element approach

First metatarsocuneiform arthrodesis is one of the surgical interventions to correct hallux valgus, especially those with hypermobile first ray. There is lacking of biomechanical investigations to assess this operation. The objective of this study was to explore the functional restoration and the risk of non-union after the surgery via finite element analysis.A three-dimensional foot model was constructed from a female aged 28 via magnetic resonance imaging. Thirty bones and encapsulated bulk tissue were modeled. Walking stance was simulated by the gait analysis data of the same participant. Parts of the first metatarsal and cuneiform were resected and the bone graft was assigned with the same stiffness as adjacent bones to resemble the surgery of first metatarsocuneiform arthrodesis.The third principal stress of the first metatarsal at midstance (25% stance) and push off (60% stance) was increased by 76% and 139% respectively after the operation, while that of the second metatarsal was decreased by 14% and 66%. The operation reduced the medial deviation of the first metatarsal head by about 3.5mm during initial push off (60% stance). Besides, the bone graft could experience tensile stress inferiorly (26.51MPa).In conclusion, the increase of stress on the first metatarsal and the reduced medial excursion of the first metatarsal head after the simulated operation reflected that metatarsocuneiform arthrodesis could restore the load-bearing function of the first ray. However, inter-fragmentary compression could not be guaranteed. The appropriate course of hardware and non-weight-bearing protocol should be noted and further investigated.

Scarf osteotomy without osteosynthesis in hallux valgus treatment

Hallux valgus is the most frequent deformity of the forefoot pathology, especially among the female population. This deformation involves a medial deviation of the first metatarsal head and a lateral deflection, with often, a pronation to hallux. Hallux valgus is for more than a century and a half, a forefoot osteoarticular deformity, which has most fired the imagination of surgeons who were interested in this disease and its treatment. Many surgical techniques and variants have been described over the years reaching about 150 therapeutic procedures. Scarf osteotomy technique was first described by Burutaran in 1976, developped by Weil and Borelli in 1990 and popularized in France by Barouk. We use for the treatment of hallux valgus an osteotomy Scarf without using internal fixation (osteosynthesis). This technique has been described by Maestro in 1999. In our retrospective series of 35 feet operated in our department, we investigated the clinical and radiological results in order to evaluate our results and demonstrate the reliability and reproducibility of the technique we use. Technical changes to the classic Scarf made by Maestro consist in the realization of a proximal transverse and oblique osteotomy, the realization of a cutout in the medial side of the metatarsal head where is embedded the distal side corner of the proximal fragment, the replacement of the distal bone screw by an osteosuture and the replacement of the proximal screw by the isolation of the bone area, resected to the detriment of the proximal fragment after lateral shifting at the proximal portion of the osteotomy. Scarf osteotomy without osteosynthesis, fulfills all the requirements for being a technique of choice in the treatment of hallux valgus providing excellent results for a low complication rate.

Analysis of medial deviation of center of pressure after initial heel contact in forefoot varus.

After initial heel contact, the rearfoot everts and causes medial deviation of the center of pressure (CoP). Although rearfoot angle in single-limb stance has been associated with forefoot varus (FV)≥8°, medial CoP deviation has not. After 12 participants with FV<8° (neutral group) and 11 participants with FV≥8° (FV group) stepped one heel initially onto an array of pressure sensors parallel to its Y coordinate axis, when the CoP of array deviated most medially, the X coordinate of the CoP of each row was calculated to find the most medial CoP of the row. Starting since the row with the most medial CoP just began to have the same sensors with pressures >0kPa as when it had the most medial CoP, the medial deviations of the CoP of the array, the most medial CoP of the row, and its relative position in the row (CoP%), were compared between neutral and FV groups. The medial deviations of the most medial CoP of the row (1.1±0.6 vs. 1.6±0.3mm, p=0.049) and CoP% (2.9±1.4 vs. 4.2±1.1%, p=0.023) were significantly different between neutral and FV groups, whereas that of the CoP of the array (1.1±0.6 vs. 1.4±0.6mm, p=0.36) was not. The most medial CoP of the row and CoP% detected increased medial CoP deviation in FV≥8°, and may be applied to other clinical conditions where rearfoot angle and CoP of the array after initial heel contact cannot detect significant differences.

Perioperative risk factors in patients with 22q11.2 deletion syndrome requiring surgery for velopharyngeal dysfunction.

Objective : To determine the prevalence of cardiac, cervical spine, and carotid artery abnormalities in patients with 22q11.2 deletion syndrome (22q11.2DS) undergoing surgery for velopharyngeal dysfunction (VPD), associations between the presence of these abnormalities, and whether these abnormalities caused changes in surgical management or perioperative complications. Design : Retrospective review. Setting : Tertiary pediatric hospital. Patients : Seventy patients with 22q11.2DS with complete preoperative cervical vascular and spine imaging and cardiac evaluation between 1998 and 2011. Main Outcome Measures : Incidence of cardiac, cervical spine, and vascular abnormalities; related perioperative complications; and resulting changes in surgical, anesthetic, or perioperative management plan. Results : Cardiac abnormalities occurred in 45 patients (64.3%), and 8 patients required cardiac anesthesia. Thirty-eight patients (54.3%) had at least one vascular abnormality of the neck, and 14% had medial deviation of the internal carotid artery. Surgery was not performed in one patient, and the surgical plan was altered in three patients because of carotid anomalies. Cervical spine abnormalities were found in 24 patients (34.3%); 8 patients demonstrated radiographic evidence of cervical instability and were treated with spinal precautions during surgery. The presence of one anomaly was not predictive of any other finding, and there were no complications related to the heart, cervical spine, or carotid arteries. Conclusions : Anomalies of the heart, cervical spine, and cervical vasculature occur frequently in 22q11.2DS, vary drastically in severity, and are impossible to predict based on other features of the syndrome. Preoperative diagnosis of these comorbidities with routine imaging can minimize the risk of avoidable surgical complications.

Nevus Comedonicus Syndrome.

A case of nevus comedonicus syndrome with atypical cutaneous presentation (widespread involvement without any particular pattern, midline lesions involving lower abdomen and involvement of bilateral pinna), and some unusual skeletal (adduction deformity involving bilateral metatarsal along with medial deviation at the level of tarsometatarsal joint), central nervous system (agenesis of corpus callosum with a interhemispheric cyst), visceral (pancreatic cyst) and neurological manifestations have been illustrated.

Risk stratification of vertebral artery vulnerability during surgery for congenital atlanto-axial dislocation with or without an occipitalized atlas.

Variability in dimensions and course of vertebral artery (VA) makes it vulnerable to injury during surgery for congenital atlanto-axial dislocation (AAD) with or without an occipitalized atlas. This prospective study attempts to define anatomical variations that render VA at the craniovertebral junction (CVJ) vulnerable to injury during transoral decompression and posterior stabilization procedures; and, to propose a classification that helps in preoperative risk stratification. A prospective study. 104 patients (65 with AAD; 39 controls) underwent a three-dimensional multiplanar computed tomographic angiogram to study anatomical variations in VA size, course, and anomalous medial deviation as well as in the type of axial isthmus and rotational deformity/tilt at the CVJ. The VA/foramen transversarium diameter; "stretched loop" sign of VA; and C1-2 facet joint angle were also assessed. A medial VA deviation that brought it in close proximity to the trajectory of the surgical approach was evaluated (P ≤ 0.05 significant). An increased predisposition to VA injury was present in 23 (35.4%) patients (persistent first intersegmental artery [n = 20; 30%]; fenestrated VA [n = 1; 1.53%], and low-lying posterior inferior cerebellar artery [n = 2; 3.0%]) where VA crossed the C1-2 facet joint; 8 (12%) with an anomalous medial deviation; 12 (18%) with a high-riding VA at C2 and a narrow axial isthmus; and 13 (20%) with rotation/tilt at the CVJ. A normal score of 5 was obtained in 21 patients; and a score of 6-9 (that progressively indicated an increased vulnerability of VA to iatrogenic injury) in 44 patients. The "AAD with an occipitalized atlas" group was associated with a significant medial deviation of VA (right: P = 0.00 and left: P = 0.001). A preoperative detailed risk assessment of anatomical variations in the size and course of VA at the CVJ significantly reduces chances of its iatrogenic injury.

Uncinate process deviation in patients with odontogenic sinusitis: a computed tomographic evaluation

The uncinate process of the ethmoidis is one of the anatomic boundaries of osti- omeatal complex. Its relationship with the maxillary sinus ostium makes it the key landmark for endoscopic sinus surgery. Many authors denied a direct role of the uncinate process in the development of sinonasal infections (1). Nevertheless, chronic sinonasal diseases are often accompanied by an uncinate process antero-medialization, most notably in presence of an odontogenic etiology. This study aimed to retrospectively analyze uncinate process anatomy on computed tomographic (CT) scans, defining the association between uncinate process inclination and sinonasal health status. Sinonasal CT examinations of 46 individuals were reviewed, comparing patients without clinical and radiographic signs of sinonasal diseases (Group I), and patients diagnosed with odontogenic sinusitis according to the criteria proposed by Felisati et al. (2)(Group II). Uncinate process inclination was calculated by Radiant Dicom Viewer software, as the angle between the straight line connecting the antero- superior and the postero-inferior part of uncinate process, and the axis of symmetry, passing through sphenoidal rostrum and perpendicular to bizygomatic line. For each patient three axial scans (the most cranial, median, the most caudal), in which uncinate process was clearly detectable, were selected and a mean value was computed. Descriptive statistics of uncinate process inclination were calculated separately in the two groups. In Group I the mean angle was13.18° ± 10.33°with confidence limits (CL) (99%) between 6.21° and 20.15°,in Group II the mean angle was 29.89°±9.56° with CL between 24.44° and 35.34°. From these preliminary results, a marked medial devia tion of uncinate process was identified in odontogenic sinusitis compared to healthy sites. Additional assessments are required to confirm the role of this anatomical varia- tion in the pathogenesis of odontogenic sinusitis.

Laryngeal collapse as a primary disease in English Bull Terriers

Laryngeal collapse is a progressive condition characterised by a loss of cartilage rigidity which allows medial deviation of the rostral laryngeal cartilages (Pink and others 2006, Torrez and Hunt 2006,...

Diagnostic Availability of Pedobarography and Correlation of Radiographic and Pedobarographic Measurements in Pediatric Flexible Flatfoot

Purpose: The purpose of this study was to analyze the diagnostic availability and to examine the co-relation between pedobaragraphy and radiography of pediatric flexible flatfoot. Materials and Methods: Seventeen patients and ten normal children were studied. In radiographic evaluation, the talo-1st metatarsal angle was measured on anteroposterior radiographs; and the talo-1st metatarsal angle, the talo-horizontal angle, the calcaneal pitch, and the talocalcaneal angle were measured on lateral radiographs. In pedobarography, foot pressures were subdivided into eight areas for measurement of contact time, ratio of measured area and to investigate the relation between the degree of the medial deviation of the Center of pressure line and the radiographic measurements. Results: Flat foot group and normal group showed statistically significant difference in every angle measured in lateral radiographs. The foot pressure ratios of the lateral sides in forefoot and the medial and lateral sides of midfoot and the medial side of hindfoot between the flexible flatfoot group and normal group showed statistically significant difference in pedobarography and ratio of contact area in forefoot and hindfoot showed significant change in statistics but no changes in contact time. The relation between pedobarography and radiography was investigated: foot pressure of the medial and lateral side of forefoot and the talocalcaneal angle showed significant relation in statistics and foot pressure of the medial and lateral side of mid foot and every angle measured in lateral radiographs showed significant relation in statistics. Contact time of midfoot and every radiographic value measured in lateral radiograph showed significant relation in statistics and contact area of forefoot and midfoot showed significant relation with every radiographic value measured in lateral radiographs. In addition, medial deviation of center of pressure line showed significant relation in statistics with talus-first metatarsal angle measured on anteroposterior radiographs and talo-horizontal angle and talus-first metatarsal angle measured on lateral radiographs. Conclusion: The results of this study showed correlation between radiologic methods and pedobarography in diagnosis of pediatric flexible flatfoot and pedobarography is an useful tool in quantitative and qualitative analysis of the degree of foot deformity and medial deviation of center of pressure line.

A Rare Combination of Brachymetatarsia and Congenital Hallux Varus:

Hallux varus is defined as a medial deviation of the phalanx at the first metatarsophalangeal joint and can be congenital or acquired. Brachymetatarsia is defined as shortening of the metatarsal bones. A combination of hallux varus and brachymetatarsia is rare. A 15-year-old girl presented to our outpatient clinic complaining of problems with her feet. A distinctive hallux varus was present bilaterally combined with a brachymetatarsia of the first metatarsals. The patient reported discomfort. She was restricted in her activities and had severe psychological strain owing to the deformity. We decided on surgery. First, a Pennig MiniFixator for callus distraction of the first metatarsal bone was applied. Owing to the increased plantar subluxation of the phalanx during distraction, an extension of the external fixator was administered so that the hallux could be repositioned to a physiologically satisfying position. After sufficient callus formation, the hardware was removed 14 weeks after surgery. Thereafter, the phalanx moved back to the subluxed position. Finally, an arthrodesis of the first metatarsophalangeal joint was performed with a locking plate. Surgery should not be made only for cosmesis and associated psychological aspects; but, discomfort should be the deciding factor. The postoperative clinical and cosmetic results in our case were good, and the patient was quite satisfied. There was no longer any preoperative discomfort and pain.

Diagnosis and Pathophysiology of Hallux Valgus

Hallux valgus is a lateral deviation of the first phalanx and medial deviation of the first metatarsal at the first metatarsophalangeal (MP) joint. Its incidence has increased due to developing footwear. The etiologies include fashion footwear, genetic causes, anatomical abnormality around the foot, rheumatoid arthritis, and neuromuscular disorders. Physiologic alignment of the first MP joint is maintained by congruent and symmetric alignment of the articular surface of the first proximal phalanx and first metatarsal head, physiologic relationship of the distal first metatarsal articular surface and the first metatarsal shaft axis, and stable balance of soft tissue around the first MP joint and stable tarsometatarsal joint. Several factors have been associated with hallux valgus, including pes planus, hypermobility of the first tarsometatarsal joint, flattened shape of the first metatarsal head, increased distal metatarsal articular angle, and deformation of the medial capsular integrity. History and physical examination are very important to diagnosis of hallux valgus. Simple radiography provides information on deformity, particularly in weight-bearing anteroposterior and lateral radiographs. Understanding the etiologies and pathophysiology is very important for success in treatment of patients with hallux valgus.

Internal Carotid Artery Variations in Velocardiofacial Syndrome Patients and Its Implications for Surgery

Medially displaced internal carotid arteries in velocardiofacial syndrome carry a risk during pharyngeal flap surgery. This study was designed to evaluate the frequency of medially deviated internal carotid arteries in both velocardiofacial syndrome patients and the general pediatric population and to assess the minimum distance to the pharyngeal walls to define the potential risk of internal carotid artery injury during pharyngeal surgery. Twenty-three consecutive patients with velocardiofacial syndrome who underwent posterior pharyngeal flap surgery and 21 control subjects who did not have velocardiofacial syndrome but who underwent oropharynx magnetic resonance imaging were reviewed. Medial deviation of at least one internal carotid artery was documented in 10 velocardiofacial syndrome patients (43.5 percent), compared with three patients (14.3 percent) in the control group (p=0.034). The mean±SD minimum distance to the posterior pharyngeal wall was 3.78±1.86 mm in velocardiofacial syndrome patients and 9.17±2.94 mm in the control group (p=0.014). Only one patient had significant medial dislocation of the internal carotid artery, and the closest distance from the pharyngeal wall was 0.86 mm. In velocardiofacial syndrome patients, medial dislocation of the internal carotid artery was common, and the minimum distance to the pharyngeal wall was short compared with the control group. However, in most of the authors' patients, the course of the cervical portion of the internal carotid artery is irrelevant to pharyngeal flap surgery. The authors conclude that preoperative vascular imaging study is not cost-effective in velocardiofacial syndrome patients but that intraoperative use of ultrasound imaging is still valuable for the purpose of planning pharyngeal flap surgery. Risk, II.

Nonoperative Treatment of Congenital Hallux Valgus: A Case Report.

Hallux valgus is a deformity of the metatarsophalangeal joint of the great toe that may be accompanied by increased medial deviation of the first metatarsal1,2. The evolution of congenital hallux valgus is progressive, especially in childhood. The association of congenital hallux valgus with fibrodysplasia ossificans progressiva (FOP), also known as Munchmeyer disease, is well known. FOP is a rare autosomal dominant disease that is defined by progressive ectopic ossification and characteristic skeletal malformations and is the most frequent cause of congenital hallux valgus (rather than isolated hallux valgus)3. The patient’s parents were informed that data concerning the case would be submitted for publication, and they provided consent. A two-month-old infant was referred to the pediatric rehabilitation unit by his pediatrician because of positional deformities of the feet. He was born at term by normal delivery, with a birth weight of 3880 g. There had not been any complications in the neonatal period, but he had been hospitalized for pneumonia when he was forty days old. The family history was positive for juvenile hallux valgus. On general examination, the child was healthy in appearance; no substantial abnormalities were noted about the head and the neck. The upper extremities and trunk were normal. The …