Tarsal-metatarsal Joint Research Articles

Does a 1st Metatarsophalangeal Fusion in a Patient with Pes Planus Improve the Pes Planus Deformity? A Retrospective Case Series

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: A pes planus deformity is a pathology relating to the loss of normality of the complex interaction of the bones and joints of the foot resulting in a flattening of the medial longitudinal arch with or without abduction of the midfoot. The distal aspect of the medial longitudinal arch can be a feature of the deformity. The fusion of the 1st metatarsophalangeal joint (MTPJ) is a common operation. In patients with concomitant pes planus deformity, it is unknown if reducing and stabilising the distal aspect of the medial ray through a 1st MTPJ fusion can subsequently improve the pes planus deformity. We sought to analyse the pes planus deformity pre and post 1st MTPJ fusion with the null hypothesis that there was no difference. Methods: We identified patients who had undergone 1st MTPJ fusion using our electronic database from January 2011 to October 2021. To meet the inclusion criteria, cases required pre- and post-operative weightbearing plain radiographs, with a Meary's angle of >4 degrees on pre-operative imaging. Routine pes planus measurements were undertaken by 2 independent observers. Pre- and post-operative measurements were tested for significant change using Wilcoxon Signed Rank Test or Paired T-Test depending on the normality testing of the data. Routine demographic data was also collected. Data was analysed using IBM SPSS v.27. Results: Following radiographic analysis, 25 feet fitted the inclusion criteria. The mean patient age was 63 years. There was no pre-operative correlation between Meary's angle and the hallux valgus angle (Kendall's tau p=.441). Pre-operatively, Meary's line broke at the talo-navicular and navicular-cuneiform joints in 12 cases each; the remaining case broke at the tarsal-metatarsal joint. A statistically significant improvement between the pre- and post-operative measurements was identified in Meary's angle, calcaneal pitch angle, talo-navicular coverage angle, intermetatarsal angle and talo-navicular angle (see table). Significant changes were also noted in the medial cuneiform height (mean increase of 2.74mm; p=.022). A post-operative Meary's angle of <4°was only achieved in 4/25 (16%) of cases. Of the remaining 21 cases, the point at which Meary's line broke moved proximally one joint in 4 and distally one joint in 3 cases; it remained at the same joint in 14 cases. Conclusion: Our results suggest that 1st MTPJ fusion improves axial alignment of the foot as well as reducing Meary's angle by a statistically significant amount, although diagnostic criteria for pes planus remained in most cases.

Effectiveness of the Lapidus plate system in foot surgery: A PRISMA compliant systematic review.

Lapidus arthrodesis is an established standard procedure to correct various foot surgery problems and hallux limitus, hypermobility of the first ray, hallux abductus valgus, and symptomatic lesser metatarsal. After decades, many fixation methods in the orthopaedic surgery industry have been developed for decreasing complications and improving this technique. The aim of this PRISMA compliant systematic review is to analyse the effectiveness of several lapidus plate systems in foot surgery. We have carried out the first systematic review of the relevant published literature so as to systematically evaluate the scientific knowledge available now on this association, assigning predefined eligibility criteria. Fourteen studies were selected which had an overall of 738 cases. The first tarsal metatarsal joint and hallux valgus were treated by the application of different types of Lapidus plate system. The optimal level of the fixation in these procedures is related with the type and system insertion place of the plate with or without screw in each specific foot disease. There is an insufficient number of studies about the effectiveness of the different types of Lapidus plate system in foot surgery, and there is a need to increase outcomes knowledge on the level of the fixation, sort of the system, and insert place in foot surgery.

Persistent instability in pure ligamentous Lisfranc joint injuries

IntroductionLisfranc injuries refer to a specific group of injuries which lead to instability of the tarsalmetatarsal joint. Our hypothesis is that persistent instability is permanent and asymptomatic in subtle unstable injuries of the medial column which have been fixed percutaneously. ObjectiveTo describe the persistent instability of pure ligamentous Lisfranc joint injuries treated with anatomic reduction and percutaneous screws fixation by comparative radiographs of both feet. Materials and methodsBetween 2014 and 2018, 14 patients diagnosed with subtle unstable Lisfranc injury were evaluated. Indications for surgery included widening (diastasis) greater than 2mm between the first and second metatarsal bases, and subluxation greater than 1mm of a metatarsal base from its respective tarsal bone. ResultsPersistent instability was found on the stress radiographs of 11 patients (78.57% 95% CI: 48.60–95.07%) but without clinical connotations. The average AOFAS score evaluated at 18 months post-operatively was of 97.14 (SD±4.68) points. The median follow-up was 24 (RIQ: 18–24) months. In all patients, anatomical reduction on radiographs was evident. ConclusionWe observed a persistent instability of the Lisfranc joint, without clinical connotations.Subtle unstable Lisfranc injuries treated with percutaneous screw fixation have a good clinical and functional outcome.Level of evidence: IV.

P.641 Anxiety and insomnia as correlates of major depressive disorder with mixed features

The hypermobility theory of the first ray is the reason for the popularization of procedures such as the modified Lapidus procedure involving arthrodesis of the first tarsal–metatarsal joint for correction of hallux valgus deformity. Although many studies have involved motion of the first ray in hallux valgus patients, the presence and clinical significance of hypermobility in the first ray remains controversial. We performed a systematic review and meta-analysis to evaluate the difference in the first ray range of motion between patients with or without hallux valgus deformity. The databases used for the present review included Ovid EMBASE, Ovid MEDLINE, CINAHL, and the Cochrane Database. We searched for comparative studies that had evaluated the motion of the first ray in patients with or without hallux valgus. After screening for inclusion and exclusion criteria, we identified 3 studies that were relevant to our study question. All 3 studies showed more first ray motion in the hallux valgus group. Our quantitative synthesis showed a mean difference in the range of motion of the first ray of 3.62 mm (95% confidence interval 2.26 to 4.98) between those with and without hallux valgus deformity. Thus, we found statistically significantly increased first ray motion in patients with hallux valgus deformity compared with those without hallux valgus deformity. However, the clinical significance of this small amount of increased sagittal plane motion as a response to or a cause of hallux valgus remains unanswered.

Appropriate MRI Evaluation of Lisfranc Ligaments: How to Avoid Missing Ligamentous Lisfranc Injuries

Knowledge of injuries at the tarsal metatarsal joints continues to evolve. Fractures and ligamentous injuries at the tarsal metatarsal joints, also known as the Lisfranc joint complex, are uncommon yet can be of great clinical significance. The initial radiographic findings, suspected mechanism of injury, and physical examination findings can result in varying diagnoses and recommendations. Subtle or ligamentous injuries can be missed and result in the potential of midfoot instability and rapid progression to posttraumatic osteoarthritis. The imaging features of injury at the Lisfranc joint are reviewed, and guidance is provided as to the appropriate use and interpretation of weight bearing radiographs, computed tomography, and magnetic resonance imaging. This will include a description on the utilization of magnetic resonance imaging in evaluating ligamentous Lisfranc injuries to aid clinicians in successfully diagnosing a ligamentous or subtle injury.

Potential of plant stress hormone methyl Jasmonate against lipopolysaccharide attenuated oxidative stress and arthritis in experimental animals

Introduction: Methyl jasmonate is a plant stress hormone indicated in the treatment of various cancers. The purpose of the current study is to investigate the anti-arthritic and antioxidant activity in experimental animals. Materials and Methods: Methyl jasmonate was screened in two doses (20 mg/kg and 40 mg/kg) against lipopolysaccharide (LPS) induced arthritis in rats. The assessment of arthritis such as paw thickness, paw volume, and body weight was assessed on 0th, 7th, 14th, 21st, and 28th days. The percent change in paw thickness, body weight, and arthritis index was calculated on 7th, 14th, 21st, and 28th days. The estimation of serum marker enzymes such as alkaline phosphatase, alanine transaminase, and aspartate aminotransferase was carried out on 14th and 28th days. The antioxidant enzyme such as superoxide dismutase, catalase, GST, glutathione peroxidase, and lipid peroxidation activity in articular cartilage tissues was carried out on the 28th day. White blood cell (WBC), red blood cell (RBC), and erythrocyte sedimentation rate were determined on the 28th day. Free radical scavenging activity was carried out using 2,2-diphenyl-1-picrylhydrazyl (DPPH) method and alpha-tocopherol used as a standard for comparison. After completion of the treatment period, tarsal-metatarsal joints were subjected to histopathology. Results: MJ significantly reduces arthritis which was evident from the assessment of arthritis such as paw volume, paw thickness, arthritis index, and body weight. Significant reduction in lipid peroxidation and serum marker enzymes was observed in MJ-treated rats as compared to the disease control group. Significant antioxidant activity was exhibited by MJ-treated group. Dose-dependent DPPH radical scavenging was observed which assess free radical scavenging potential of MJ. Erythrocyte sedimentation rate and WBC count are significantly reduced whereas RBC count was compensated similarly to control compared to the diseased group. Conclusion: Methyl jasmonate exhibits significant anti-arthritic and antioxidant activity through a reduction in paw volume, thickness, serum marker enzyme, ESR, WBC count, increase in RBC count, and gain in body weight. The reduction in inflammation and cell damage may be due to antioxidant, free radical scavenging, and antilipid peroxidative effect which is supported by histopathological studies.

Plate Alone Versus Plate and Lag Screw for Lapidus Arthrodesis: A Biomechanical Comparison of Compression.

Background. Arthrodesis of the first tarsal metatarsal joint can be accomplished in many ways. The compressive force attained between various constructs remains unclear. This study compares compression achieved through a locking/compression Lapidus plate both with and without the addition of a lag screw. Methods: A dorsal medial Lapidus/locking compression plate (Total Compression Plate System, OrthoPro, Salt Lake City, UT, now Wright Medical) was applied to one cadaveric limb, while the same plate with the addition of a 4.0-mm cannulated lag screw was applied to the contralateral limb for a total of 5 matched pairs of cadaveric specimens. Compressive force was recorded over time and compared between the constructs using a compression sensor (8" FlexiForce Resistive Force Sensor, Phidgets Inc, Calgary, Alberta, Canada). Results: Compression was maintained for 45.4 minutes in the plate only construct, and 317 minutes with the addition of the lag screw (P = .010). The mean time to 50% peak compression for the plate only construct was 4.90 minutes compared with 15.11 minutes for plate with lag screw construct (P = .012). Conclusion: The addition of a lag screw is recommended for extending the length of compression and possibly reducing nonweightbearing time and the risk of nonunion. Levels of Evidence: Level V.

Comparison of Tibial Sesamoid Position on Anteroposterior and Axial Radiographs Before and After Triplane Tarsal Metatarsal Joint Arthrodesis

We reviewed the radiographic results of a group of patients who had undergone triplane correctional tarsometatarsal arthrodesis for symptomatic hallux abducto valgus with metatarsus primus abducto valgus. Of the 21 feet included in the present review, 17 (81%) displayed radiographic findings of metatarsal pronation preoperatively based on axial sesamoid views and positive lateral round sign on anteroposterior radiographs. At a mean follow-up period of 5.2 ± 1.6 months, a significant improvement in the tibial sesamoid position (TSP) on both anteroposterior (AP) and axial radiographs was measured. A negative metatarsal round sign, indicating correction of coronal plane metatarsal rotation, was observed in 20 of the 21 feet (95.2%) on AP radiographic evaluation. All 21 patients (100%) had obtained resolution of sesamoid subluxation on the sesamoid axial view at the final follow-up examination. The sesamoid axial position was consistently normal when the round sign was absent, and the TSP was in the normal range of 1 to 3 on the AP radiograph. Sesamoid subluxation from the normal position with the tibial sesamoid on or lateral to the crista was noted in 4 feet (19%) preoperatively and 0 feet postoperatively. This confirmed that lateral round sign of the first metatarsal head and a high TSP noted on the AP radiograph are both related to metatarsal pronation and can be corrected concurrently with coronal plane varus rotation of the first metatarsal as a part of the procedure.

Sarcoid Associated with Infection by Habronema spp. in Equines in Brazil

Background: Equine sarcoid, supposed to be caused by infection with bovine papillomavirus type 1 or 2, is usually observedin previously traumatized skin areas, including lesions of habronemosis due to inoculation of third stage larvae in ulcerated wounds by Musca domestica or Stomoxys calcitrans. Little is known about the occurrence of diseases associated with equine sarcoid, mainly because limitations on clinical diagnosis, due to the different skin diseases that have to beconsidered as differential diagnoses. This report aimed to describe three cases of equine sarcoid associated with habronemosis in horses in the semiarid region of Northeastern Brazil.Cases: Three cases of sarcoid associated with habronemosis in equines were diagnosed at the Animal Pathology Laboratory of the Veterinary Hospital of the Federal University of Campina Grande, Patos, Paraíba. Case 1. A 5-year-old female showed in the ventral branch of the mandible a nodule of 3 cm in diameter, partially covered with skin and hair intercepted by areas of irregular surface with yellow-red ulcerations. The cut surface was formed by whitish and firm tissue. Case 2. It was a biopsy from a 4-year-old mare, who was not informed of the macroscopic characteristics of the lesion. Case 3. A 5-year-old horse presenting a nodular mass in the region of the tarsal-metatarsal joint, measuring 8.0x5.0x3.0 cm with an irregular, ulcerated, red-blackish surface. The cut surface was firm and whitish with brownish punctate areas. Microscopicallyall the lesions were classified as equine sarcoid of mixed type with abundant collagen fibers and randomly extensive proliferation of fibroblasts in the dermis. These fibroblasts had an elongated and weakly eosinophilic cytoplasm, rounded nucleus and prominent nucleoli. There were low mitotic activity. Hyperplasia, hyperkeratosis and sometimes ulcerated areas covered by serous cellular scabs were observed in the skin. Multifocal coalescing, granulomatous and eosinophilic lesions were observed within the neoplastic tissue. Cylindrical structures with an elongated thick eosinophilic outer cuticle and obvious side spicules, morphologically compatible with larvae Habronema spp, surrounded by inflammatory cells and cellular debris were observed in Cases 1 and 2. In case 3, intralesional larvae were not observed, but histologic lesions had a similar pattern than cases 1 and 2.Discussion: In these cases the affected animals presented simultaneously a mixed lesion of sarcoid and habronemosis, which leads to complications in clinical diagnosis and difficulties to institute appropriate therapy. Histopathological examination of such lesions is necessary because should characterize their morphology and the causative agent, discarding the other differential diagnoses. The combination of these two conditions can probably be related to the fact that sarcoid may develop up in places previously traumatized, such us lesions of habronemosis. It is important to differentiate these lesions from other skin diseases such as granulation tissue, pythiosis, squamous cell carcinoma and fibroid. Though the occurrence of sarcoid and simultaneous habronemosis in horses is rare in equine medicine, clinicians and pathologists who work with diagnosis may sporadically encounter similar cases, hence the importance of histopathologic analysis of skin samples, as this may help definition of the a etiology and also the institution of therapeutic measures and prognosis of affected animals.Keywords: equine skin disease, skin neoplasms, parasitic infection.

In Situ Tarsal Metatarsal Dowel Arthrodesis with Trephine Reamers and Cancellous Bone Plugs: A Technique Guide and Case Report

Tarsalmetatarsal (TMT) osteoarthritis is encountered frequently. Pathology at the TMT joints play a role in continued foot fatigue and further compensation of gait laterally to avoid discomfort over the medial and central columns of the midfoot. Sequeula and further pathology to the central TMT joints are multifactorial. Recalcitrant pain, subtle instability, and arthrosis are commonly observed. Patients who fail nonoperative treatment are subjective to reconstructive surgical treatment. We present a straightforward stepwise technique for an in situ arthrodesis of the central TMT joints. We focus on the principles of the dowel arthrodesis with trephine reamers, cancellous bone plugs, and compressive locking plate fixation for a reproducible corrective midfoot fusion.

Quantitative Analysis of the Degree of Frontal Rotation Required to Anatomically Align the First Metatarsal Phalangeal Joint During Modified Tarsal-Metatarsal Arthrodesis Without Capsular Balancing

The data from 35 consecutive patients with hallux valgus undergoing triplane arthrodesis at the first tarsal metatarsal joint were studied to determine the amount of first metatarsal frontal plane rotation (supination) needed to anatomically align the first metatarsal phalangeal joint on an anterior posterior radiograph without soft tissue balancing at the first metatarsal phalangeal joint. Radiographs were measured both pre- and postoperatively to assess the 1-2 intermetatarsal angle, hallux abductus angle, and tibial sesamoid position (TSP). The mean amount of varus (supination) rotation performed during correction was 22.1° ± 5.2° and the mean amount of intermetatarsal angle reduction achieved after completion of the procedure was 6.9° ± 3.0°. The TSP changed by a mean of 3.3° ± 1.2°. A series of univariate linear regression analyses was performed to analyze the relationship between the frontal plane rotation of the first metatarsal performed during the operation and the preoperative intermetatarsal angle, hallux abductus angle, and TSP. Greater preoperative TSP scores were associated with greater intraoperative varus (supination) rotation required for joint alignment. Direct observation of the alignment changes at the first metatarsal phalangeal joint after metatarsal rotation without distal procedures strengthened the notion that the frontal plane rotational position plays an important role in the bunion deformity.

Malformações, abortos e mortalidade embrionária em ovinos causada pela ingestão de Mimosa tenuiflora (Leguminosae)

Para determinar a teratogenicidade de Mimosa tenuiflora, 15 ovelhas, distribuídas em dois grupos, foram introduzidos em área invadida pela planta. O Grupo 1, com seis ovelhas prenhes, foi introduzido na área experimental 20 dias após o acasalamento. O Grupo 2, formado por nove ovelhas não prenhes e um carneiro, foi introduzido na área experimental no início do experimento. O experimento começou no mês de outubro de 2009, período de estiagem, quando M. tenuiflora estava sementando. Nesse período as plantas foram rebaixadas a 40 cm de altura e os galhos com folhas e sementes foram disponibilizados para os ovinos na mesma área onde M. tenuiflora foi rebaixada. M. tenuiflora começou a rebrotar ainda na estação seca antes do período de chuvas. No período de rebrota, as ovelhas ficavam livres para pastar M. tenuiflora e recebiam concentrado em quantidade equivalente a 1% do peso vivo. Após as primeiras chuvas, em meados de janeiro do ano seguinte, quando o estrato herbáceo apareceu, essas ovelhas foram confinadas em baias, onde M. tenuiflora foi fornecida até o fim do experimento. A cada 15 dias eram realizados exames ultrassonográficos para acompanhamento da gestação. No Grupo 1, três ovelhas abortaram, cada uma um feto sem malformações. Outra ovelha pariu dois cordeiros, um com hiperflexão na articulação inter-falangeana proximal no membro torácico direito e outro sem malformações. Outra ovelha pariu um cordeiro com hiperflexão dos dois membros pélvicos na região da articulação tarso-metatársica. No grupo formado pelas ovelhas que foram acasaladas na área experimental, uma ovelha abortou um feto sem malformações e cinco pariram cordeiros normais. Três das ovelhas desse grupo não emprenharam durante todo o período experimental, mostrando retornos repetidos ao cio, sugerindo perda embrionária. Trinta e duas ovelhas e um carneiro, que permaneceram numa área vizinha a área experimental e foram utilizados como controle, pariram cordeiros normais. Conclui-se que M. tenuiflora, além de causar malformações causa, também, mortalidade embrionária e abortos em ovelhas.

MIDFOOT CHARCOT ARTHROPATHY IN DIABETIC PATIENTS: COMPLICATION OF AN EPIDEMIC DISEASE

Objectives: To outline the epidemiological profile of diabetic patients with Charcot arthropathy affecting the midfoot alone or extending from the midfoot to the hindfoot; To assess the results from the treatment that these patients undergo, according to a preestablished protocol, over the medium term. Methods: We retrospectively evaluated 88 patients (110 extremities) with Charcot arthropathy of the midfoot. The minimum follow-up period was 12 months. We included 45 patients with Charcot arthropathy affecting the tarsal-metatarsal joints (51%); 20 patients in whom the talonavicular, calcaneocuboid and subtalar joints were affected (23%); and 23 patients in whom both the midfoot and hindfoot were affected (26%), as described by Brodsky and Trepman. We defined the treatment as successful when a functional foot was preserved; and unsuccessful when the foot was amputated. Results: From treating Charcot arthropathy primarily involving the midfoot were satisfactory in the cases of 75 patients (85%) treated according to our protocol. For the patients with severe lesions affecting both the midfoot and the hindfoot, a greater number of complex operations (i.e. arthrodesis) were needed in order to obtain the same overall rate of satisfactory results. The osteoarticular lesions originating in the midfoot probably extended progressively to the hindfoot because of delayed diagnosis with inadequate early treatment. Conclusion: It was possible to preserve a functional extremity in 85% of the patients. Severe lesions involving the midfoot and extending to the hindfoot required a greater number of surgical procedures to treat them.

The Diagnostic Accuracy of Radiographs in Lisfranc Injury and the Potential Value of a Craniocaudal Projection

The purpose of this study is to determine the diagnostic accuracy of radiographs in the diagnosis of Lisfranc injury. In addition, a foot phantom was investigated to determine the optimum degree of craniocaudal angulation on the anteroposterior radiograph to best show the joint. The angle of the joint in patients with midfoot injury was investigated to determine the optimum degree of craniocaudal angulation. Sixty patients examined by CT had their radiographs evaluated independently and by consensus opinion by two observers, and the diagnostic performance was calculated using CT as the reference standard. A foot phantom was radiographed with varying degrees of craniocaudal angulation, and the radiograph that best revealed the joint was determined. This was compared with the angle of the joint as measured on CT. The angle of the joint in all 60 patients was measured on CT. The radiographs correctly identified 31 of the 45 cases (68.9%) of Lisfranc injury, with a positive predictive value of 84.4%, a negative predictive value of 53.3%, a sensitivity of 84.4%, and a specificity of 53.3%. Twenty degrees of craniocaudal angulation best showed the second tarsal-metatarsal joint of the phantom, and this correlated with a 20° angle measured by CT. The mean (± SD) angle of the joint in the patients was 28.9° ± 5.7°. Conventional radiographs miss a significant number of cases of Lisfranc injury. Craniocaudal angulation can better show the joint, and an angle of 28.9° is likely to optimally visualize the joint in the majority of patients.

An Easily Overlooked Injury: Lisfranc Fracture

We report a case of a 16-year-old male who sustained a Lisfranc (tarsal metatarsal joint) fracture after a minor fall. His emergency department (ED) presentation, clinical course, and operative repair are presented as well as a discussion of Lisfranc fractures to include historical significance. Even after minor trauma, an emergency department physician must consider the often elusive diagnosis of a Lisfranc fracture in any patient with foot pain.

Orthosphere® Zirconia Ceramic Implant for Arthroplasty in Fifth Tarso-Metatarsal Joint Arthritis of the Foot: A Case Presentation

A case describing the use of the Orthosphere® Zirconia Ceramic Implant (Wright Medical Technology, Arlington, TN )is presented. The tarso-metatarsal joints in the foot are common sites for degenerative arthritis and pain secondary to trauma and biomechanical abnormalities. Often, conservative treatment is unsuccessful in relieving symptoms, and surgical intervention is required. The clinical presentation and surgical indications for use of the implant is described. A case is presented describing the indications and surgical technique. This implant has practical and promising implications for use in tarsal-metatarsal joint arthritis.

Extent of ossification at the amputation plane is correlated with the decline of blastema formation and regeneration in Xenopus laevis hindlimbs.

Xenopus laevis larvae gradually lose the ability to regenerate lost hindlimb structures as they progress through metamorphosis. Previous studies have suggested that this loss of regenerative capacity occurs in a proximal-to-distal fashion. We assessed the quality of overall regeneration and early bud blastema formation in order to evaluate previous explanations for this loss of regenerative ability in Xenopus. We further examined the extent to which epidermis, basement membrane, dermis, cartilage, bone, periosteum, and accumulated mesenchyme within the blastema are involved in the decline of regenerative abilities during mid-metamorphic stages of development. Each tissue was scored based on its contributions to the regeneration blastema, in accordance with previously reported blastemal descriptions. Tadpoles amputated at the ankle and tarsal-metatarsal joints scored objectively higher within the overall regeneration and blastema quality rating systems. Both joint sites met more criteria associated with regeneration-capable blastemas than tadpoles amputated through the middle of the tarsus, especially at later stages of metamorphosis. The three amputation sites studied began to vary in their ability to regenerate skeletal elements and to generate productive blastemas during the same stages at which we initially observed ossification of the tarsus. These results suggest that the decline of Xenopus hindlimb regeneration does not occur in a strictly proximal-to-distal fashion but rather is dependent at later stages on the state of ossification of the structure through which amputation occurs. Our morphological and cellular observations reveal specific times and places during Xenopus hindlimb development at which further investigations into tissue-specific molecular events during early regeneration should be focused.