Tissue Tension Research Articles

Treatment Of Hypoxic Tumours With Plasma Jets

A challenge in cancer therapy is the destruction of tumours, where there is the potential issue of cancer cells residing within hypoxic tissue. The concept of hypoxic regions within tumours dates back to 1909 and it has long been suspected that under low oxygen tension, cells are “afforded” radiation protection. It has been shown many decades ago, that raising the concentration of oxygen in tissues can significantly improve the outcomes in radiotherapy. For example, in 1953, a meta-analysis of 83 randomised trials showed a clear benefit from raising tissue oxygen tension during radiation therapy, with the clearest benefits seen in cancers of neck and head [1]. However, there are only a limited number of ways to raise oxygen tension in tissues, which include breathing pure oxygen at or above standard temperature and pressure, or hypoxic modification by the means of an administered drug (e.g. nimorazole) [2, 3, 4]. Recently, we (and other research groups) have shown that cold atmospheric plasma jets not only readily deliver reactive oxygen and nitrogen species (RONS) into tissue, but concomitantly raise the oxygen tension in tissue. Combined RONS and oxygen delivery, may significantly elevate oxidative stress in cancer cells, resulting in destruction of these cells within hypoxic tumours. In this presentation, I will provide a brief historical overview of research on the modification of hypoxia in cancers; I will then discuss results that have shown how plasma jets can be used to treat hypoxia in tumours (through delivery of RONS and oxygen into tissues). I will also discuss the potential opportunities, challenges and limitations of the plasma technology for treatment of hypoxic cancer tumours.

Application of a Porous Polyethylene Spreader Graft for Nasal Lengthening in Asian Patients.

Rhinoplasty maneuvers to lengthen the nose include placing an alloplastic implant, caudally rotating the lower lateral cartilage (LLC), and stretching the soft tissue skin envelope (STSE) downward. Tissue tension associated with these procedures can result in implant extrusion or tip retraction. The authors performed rhinoplasty with implantation of porous polyethylene (Medpor). The Medpor device enabled transfer of tension from the LLC and STSE to the juncture of the septal cartilage and upper lateral cartilage (ULC), thereby stabilizing the nasal structures. Twenty-six patients who underwent rhinoplasty with nasal augmentation and lengthening were evaluated in a prospective study. Two pieces of Medpor were placed as a spreader graft, and a third piece was inserted as a columellar strut. The released LLC was rotated caudally, and the domal segments were wrapped over the caudally projected tip of the implant. Surgical outcomes were assessed with a patient satisfaction questionnaire and by photogrammetry. Patients were monitored for an average of 9.6 months. The patients' mean nasolabial angle (NLA) was 106.2° ± 4.7° preoperatively and 94.3° ± 3.7° postoperatively (t < 0.0001). Most patients were fairly or completely satisfied with the operative outcome. One patient had impending implant extrusion and underwent explanation. Medpor material is easy to shape and is sufficiently strong to function as a spreader graft and withstand the tension associated with repositioning of the LLC and STSE.

Anisotropic Continuum Stored Energy Functional Solved by Lie Group and Differential Geometry

An anisotropic continuum stored energy (CSE), which is essentially composed of invariant component groups (ICGs), is postulated to be balanced with its stress work done, constructing a partial differential equation (PDE). The anisotropic CSE PDE is generally solved by the Lie group and the ICGs through curvatures of elasticity tensor are particularly grouped by differential geometry, representing three general deformations: preferred translational deformations, preferred rotational deformations, and preferred powers of ellipsoidal deformations. The anisotropic CSE constitutive models have been curve-fitted for uniaxial tension tests of rabbit abdominal skins and porcine liver tissues, and biaxial tension and triaxial shear tests of human ventricular myocardial tissues. With the newly defined second invariant component, the anisotropic CSE constitutive models capture the transverse effects in uniaxial tension deformations and the shear coupling effects in triaxial shear deformations.

Reconstruction Plate-Based Antibiotic Cement Spacers: Clinical Outcomes and Description of Technique.

The standard of care for chronic deep peri-prosthetic hip infection is a two-stage exchange with placement of a temporary antibiotic cement spacer and treatment with intravenous antibiotics. Several commercially available cement spacer options exist. We report on a novel antibiotic spacer that may be an efficient, cost-effective alternative. Medical records of all patients treated for deep peri-prosthetic hip infection after total hip arthroplasty between 2004 and 2012 were reviewed. Each antibiotic spacer was constructed from a 12- to 16-hole recon plate bent to provide adequate soft tissue tension and a cement ball that matched the acetabulum. Premature failure of the plate and duration of implantation were measured. Failure was defined as fracture of the plate or dissociation of the cement head from the plate. Costs were compared with commercially available cement spacers. A total of 24 spacers were identified in 21 patients (mean age 68.9 years, mean body-mass index 26.4). The mean time between spacer placement and re-implantation was 6.4 months (range: 1.8-18 months). One patient had an indolent infection that was unresponsive to antibiotic therapy and required a hip disarticulation. At the time of reimplantation, 17 of 17 handmade spacers had no failures. Of the premade spacers, six of the seven had no failures. One premade spacer fractured at the femoral component trunion. The cost of the plate and antibiotic cement was $909-1000, approximately $5000 less than premade spacers. Antibiotic spacers can be readily constructed intraoperatively and offer good clinical outcomes with a low incidence of failure. This type of spacer saved $5000 per patient.

Reverse Shoulder Arthroplasty With Proximal Humeral Replacement for the Management of Massive Proximal Humeral Bone Loss

Background Substantial proximal humeral bone loss may compromise reverse shoulder arthroplasty secondary to limited implant support, insufficient soft tissue tension due to shortening, lack of attachment sites for the posterosuperior cuff when present, and lack of lateral offset of the deltoid. In these circumstances, use of a proximal humeral replacement may be considered. Patients/Methods Between 2012 and 2014, 34 consecutive reverse shoulder arthroplasties were performed using a proximal humeral replacement system. The indications were failed shoulder arthroplasty (15), oncology reconstruction (9), humeral malunion/nonunion (7), prior resection arthroplasty (2), and intraoperative fracture (1). All patients were included in the survival analysis. Twenty-two patients with minimum 2-year follow-up were included in analysis of clinical results. Results Among the cohort of 34 patients, there were 8 additional reoperations: humeral loosening (3), periprosthetic fracture (2), irrigation and debridement (2), and glenoid loosening (1). Humeral component loosening occurred exclusively in patients undergoing revision shoulder arthroplasty. The 4 patients had an average 3.75 prior procedures before the proximal humeral replacement. Two of the revisions were from cemented to uncemented stems. Among the 23 patients with minimum 2-year follow-up, there was significant improvement in pain scores (4.1 vs 0.6), forward elevation (31 vs 109) degrees, and 81% were satisfied. Conclusion Use of a proximal humeral replacement when performing a reverse shoulder arthroplasty in the complex setting of substantial proximal humerus bone loss provides good clinical results and a particularly low dislocation rate. However, the rate of loosening of the humeral component in the revision setting suggests that proximal humeral replacement components should be cemented when revising a previously cemented stem. IRB 16-006966.

Novel Antibiotic-Loaded Cement Femoral Head Spacer for the Treatment of Advanced Pyogenic Arthritis in Adult Hip

BackgroundThe aim of this study is to present a treatment for end-stage pyogenic arthritis of the hip using a novel cement spacer. This spacer caused less damage to the proximal femoral bone and made the conversion to total hip arthroplasty (THA) more convenient while maintaining the advantages of current cement spacers loaded with antibiotics. MethodsWe retrospectively reviewed 10 consecutive cases of hip pyogenic arthritis with joint destruction. These cases occurred from September 2009 to June 2015. In these cases, we used an antibiotic-loaded, cement spacer that was formed in the shape of the femoral head. This spacer rested on multiple screws that were inserted in the remaining neck of the femur. Once the infection subsided, a conversion to THA was performed in all cases. Evaluation included clinical and radiologic outcomes and the development of complications. ResultsThe mean interval between spacer insertion and conversion to THA was 101.6 days (range, 59-187 days). The mean follow-up period from initial spacer insertion was 44.9 months (range, 15-95 months). All cases underwent noncemented THA following the resolution of the initial infection. The mean Harris Hip Scores at initial visit, before conversion to THA, and on final follow-up were 58.8, 71.0, and 92.5, respectively. No case had any spacer-related complications, recurrence of infection, or dislocation. ConclusionThe treatment of advanced pyogenic arthritis with this novel femoral head spacer technique significantly reduced pain, preserved proximal femoral bone and soft tissue tension, controlled infection, improved function, and allowed for easier conversion to THA.

Soft tissue complications and timing of surgery in patients with a tongue-type displaced intra-articular calcaneal fracture: An international retrospective cohort study

IntroductionTongue-type displaced intra-articular calcaneal fractures (DIACF) are associated with a specific pattern of fracture displacement in contrast to joint depression fractures. This may result in tension of soft tissue in the posterior part of the heel. Tension-induced ischemia can result in skin necrosis. The objectives of this study were to investigate whether patients with tongue-type calcaneal fractures exert a higher risk of complications, especially of the posterior soft tissues, than joint depression type fractures. Also, late interventions (e.g., antibiotics, debridements, and amputations) and the effect of timing of surgery on the complication rate was assessed. MethodsIn this international retrospective cohort study, data of adult patients with a DIACF in the period January 1, 2005–December 31, 2015 were extracted from patients’ medical files. Descriptive, univariate, and multivariable analyses were performed in SPSS. ResultsA total of 560 patients with 632 DIACF were included (295 tongue-type and 337 non-tongue-type fractures). At hospital presentation, 20.3% of the patients with a tongue-type fracture had compromised posterior soft tissue versus 12.8% with non-tongue-type fractures (p = 0.032). However, corrected for potential confounders the risk was no longer statistically significant (OR 1.497; 95% CI 0.831–2.696). Patients with a TT-DIACF had a 1.2–3.4-fold higher rate of any local wound complication (deep infections, and full thickness lesions, p < 0.03). In addition they had 2.0–8.0-fold more intravenous antibiotics, debridements, soft tissue coverage procedures and amputations (p < 0.03). Patients who underwent surgery within two days after trauma had a higher risk to develop any complication, in particular superficial infections, when compared to surgery between 3–7 days, but no significant difference between 3 and 7 and ≥8 days could be demonstrated. ConclusionDespite the fact that patients with a tongue-type fracture developed posterior skin and soft tissue compromise nearly twice as often, this difference disappeared after correction for confounders. The overall complication risk was increased in patients with tongue-type calcaneal fractures as compared to patients with a non-tongue-type fracture. Whether or not patients with tongue-type fractures require immediate surgery cannot be concluded from the data.

Modelling the helium plasma jet delivery of reactive species into a 3D cancer tumour

Cold atmospheric plasmas have attracted significant worldwide attention for their potential beneficial effects in cancer therapy. In order to further improve the effectiveness of plasma in cancer therapy, it is important to understand the generation and transport of plasma reactive species into tissue fluids, tissues and cells, and moreover the rates and depths of delivery, particularly across physical barriers such as skin. In this study, helium (He) plasma jet treatment of a 3D cancer tumour, grown on the back of a live mouse, induced apoptosis within the tumour to a depth of 2.8 mm. The He plasma jet was shown to deliver reactive oxygen species through the unbroken skin barrier before penetrating through the entire depth of the tumour. The depth and rate of transport of He plasma jet generated H2O2, NO3− and NO2−, as well as aqueous oxygen [O2(aq)], was then tracked in an agarose tissue model. This provided an approximation of the H2O2, NO3−, NO2− and O2(aq) concentrations that might have been generated during the He plasma jet treatment of the 3D tumour. It is proposed that the He plasma jet can induce apoptosis within a tumour by the ‘deep’ delivery of H2O2, NO3− and NO2− coupled with O2(aq); the latter raising oxygen tension in hypoxic tissue.

Prevalence of haptic feedback in robot-mediated surgery: a systematic review of literature.

With the successful uptake and inclusion of robotic systems in minimally invasive surgery and with the increasing application of robotic surgery (RS) in numerous surgical specialities worldwide, there is now a need to develop and enhance the technology further. One such improvement is the implementation and amalgamation of haptic feedback technology into RS which will permit the operating surgeon on the console to receive haptic information on the type of tissue being operated on. The main advantage of using this is to allow the operating surgeon to feel and control the amount of force applied to different tissues during surgery thus minimising the risk of tissue damage due to both the direct and indirect effects of excessive tissue force or tension being applied during RS. We performed a two-rater systematic review to identify the latest developments and potential avenues of improving technology in the application and implementation of haptic feedback technology to the operating surgeon on the console during RS. This review provides a summary of technological enhancements in RS, considering different stages of work, from proof of concept to cadaver tissue testing, surgery in animals, and finally real implementation in surgical practice. We identify that at the time of this review, while there is a unanimous agreement regarding need for haptic and tactile feedback, there are no solutions or products available that address this need. There is a scope and need for new developments in haptic augmentation for robot-mediated surgery with the aim of improving patient care and robotic surgical technology further.

Physical Therapy for Groin Pain following Pubic Ramus Fracture-A Case Report

Background and Purpose: Non-displaced pubic fracture often spontaneously heals without treatment. Occasionally, inguinal or pubic pain may develop due to irritation of the abundant neurovascular structures in the pelvic area. Scarce literature described conservative management for this condition. Methods: A 58-yearold woman initially visited emergency room for groin pain owing to motor-vehicle accident. Plain radiograph revealed left superior and inferior pubic rami fracture. The orthopedic physician prescribed bedrest and analgesics. However, intractable inguinal pain persisted after two months of rest, resulting in impaired mobility and job performance. She was referred to the physiatrist, who ordered manual therapy, strengthening, and shortwave. Palpation disclosed multiple tender points around the groin and hip. The therapist then applied extra-vaginal soft tissue mobilization to the according areas. Manual techniques incorporated 60 seconds of sustained pressure on each trigger point, as well as myofascial release to lengthen the restricted tissues. Facilitating pelvic and hip stabilizers were also performed. Results: After nine sessions of physical therapy, the subjective pain decreased from 10 to 2 in the 10-point-pain-scale. Walking ability improved from relying on walker to ambulating without device. She could even perform single leg standing and take stairs without symptoms. She was able to return to work by the third months and then discontinued therapy. Conclusion: Manual therapy as an adjunct to other modalities in resolving abnormal tissue tension in the pubic area was promising. Even simple pubic fracture deserves early evaluation and intervention. Clinical Relevance: For cultural concern, careful extra-vaginal manual therapy may serve as an acceptable method to treat myofascial and neuropathic pain.

The Posterior Capsular Ligamentous Complex Contributes to Hip Joint Stability in Distraction

BackgroundLaxity of soft tissues after total hip arthroplasty is considered to be a cause of accelerated wear of bearing surfaces and dislocation. The purpose of this study is to assess the contribution of the anterior and posterior capsular ligamentous complexes and the short external rotators, except the quadratus femoris, on the stability of the hip against axial traction. MethodsThe study subjects comprised 7 fresh cadavers with 12 normal hip joints. In 6 hips, soft tissues surrounding the hip joint were resected in the following order to simulate the anterior approach: anterior capsule, posterior capsule, piriformis, conjoined tendon, and external obturator. In the remaining 6 hips, soft tissues were resected in the following order to simulate the posterior approach: piriformis, conjoined tendon, external obturator, posterior capsule, and anterior capsule. Soft tissue tension was measured by applying traction amounting to 250 N with joints in the neutral position. ResultsThe separation distance between the femoral head and acetabulum during axial leg traction significantly increased from 4.0 to 14.5 mm on average after circumferential resection of the capsule via the anterior approach. Subsequent resection of the short external rotators increased the separation distance up to 19.0 mm, but the differences did not reach statistical significance. Resection of the short external rotators via the posterior approach did not significantly increase the separation distance; it significantly increased from 6.0 to 11.4 mm after the resection of the anterior capsule and further to 20.5 mm after the resection of the posterior capsule. ConclusionThe posterior capsule, in addition to the anterior capsule, significantly contributes to hip joint stability in distraction regardless of whether the short external rotators, except the quadratus femoris, were preserved or resected.

Hyperbaric oxygen treatment did not significantly affect radiation injury in the mandibular area of rats

Hyperbaric oxygen therapy (HBOT) has been used to enhance microcirculation and thereby oxygen tension in tissues. The present study aimed to investigate the effect of HBOT on radiation injury in the mandibular area of rats. The left mandibles of rats were irradiated by external radiotherapy (15 Gy every other week for a total of 75 Gy). Four HBOT strategies were used: 2 prophylactic groups receiving HBOT either between each radiation treatment or immediately following terminated radiation treatment, and 2 therapeutic groups receiving HBOT after the latent period of 6 weeks after irradiation either every day (standard HBOT protocol) or 3 days a week for 6 weeks. Tissue samples of the irradiated area were taken from skin, the salivary gland, and the mandible. All tissues were stained with hematoxylin and eosin for morphologic examination. Furthermore, skin samples were stained with CD31 for blood vessel analysis. There was no change in blood vessel density or morphology between controls and HBOT tissues after radiation. The dentin of 2 of the 5 rats that received HBOT either normalized or was not affected by irradiation. HBOT did not affect radiation injury of the mandibular area in rats within 12 weeks after irradiation.

Tissue Force Programs Cell Fate and Tumor Aggression.

Biomechanical and biochemical cues within a tissue collaborate across length scales to direct cell fate during development and are critical for the maintenance of tissue homeostasis. Loss of tensional homeostasis in a tissue not only accompanies malignancy but may also contribute to oncogenic transformation. High mechanical stress in solid tumors can impede drug delivery and may additionally drive tumor progression and promote metastasis. Mechanistically, biomechanical forces can drive tumor aggression by inducing a mesenchymal-like switch in transformed cells so that they attain tumor-initiating or stem-like cell properties. Given that cancer stem cells have been linked to metastasis and treatment resistance, this raises the intriguing possibility that the elevated tissue mechanics in tumors could promote their aggression by programming their phenotype toward that exhibited by a stem-like cell.Significance: Recent findings argue that mechanical stress and elevated mechanosignaling foster malignant transformation and metastasis. Prolonged corruption of tissue tension may drive tumor aggression by altering cell fate specification. Thus, strategies that could reduce tumor mechanics might comprise effective approaches to prevent the emergence of treatment-resilient metastatic cancers. Cancer Discov; 7(11); 1224-37. ©2017 AACR.

Effects of long-term low oxygen tension in human chondrosarcoma cells.

The cell-based therapies could be potential methods to treat damaged cartilage tissues. Instead of native hyaline cartilage, the current therapies generate mainly weaker fibrocartilage-type of repair tissue. A correct microenvironment influences the cellular phenotype, and together with external factors it can be used, for example, to aid the differentiation of mesenchymal stem cells to defined types of differentiated adult cells. In this study, we investigated the effect of long-term exposure to 5% low oxygen atmosphere on human chondrosarcoma HCS-2/8 cells. This atmosphere is close to normal oxygen tension of cartilage tissue. The proteome was analyzed with label-free mass spectrometric method and further bioinformatic analysis. The qRT-PCR method was used to gene expression analysis, and ELISA and dimethylmethylene blue assays for type II collagen and sulfated glycosaminoglycan measurements. The 5% oxygen atmosphere did not influence cell proliferation, but enhanced slightly ACAN and COL2A1 gene expression. Proteomic screening revealed a number of low oxygen-induced protein level responses. Increased ones included NDUFA4L2, P4HA1, NDRG1, MIF, LDHA, PYGL, while TXNRD1, BAG2, TXN2, AQSTM1, TNFRSF1B, and EPHX1 decreased during the long-term low oxygen atmosphere. Also a number of proteins previously not related to low oxygen tension changed during the treatment. Of those S100P, RPSS26, NDUFB11, CDV3, and TUBB8 had elevated levels, while ALCAM, HLA-B, EIF1, and ACOT9 were lower in the samples cultured at low oxygen tension. In conclusion, low oxygen condition causes changes in the cellular amounts of several proteins.

The thermal shrinkage force in perimysium from different beef muscles is not affected by post-mortem ageing

Differences in the thermal shrinkage and collagen solubility between bovine Semitendinosus (ST) and Pectoralis profundus (PP) muscles and their interactions with ageing were evaluated by studying collagen solubility, hydrothermal isometric tension and thermal denaturation properties of intramuscular connective tissue after 5–20days post-mortem storage at 4°C.Collagen solubility was higher in ST than in PP muscle at 5–13days, but the differences between the two muscles decreased at longer ageing times. A small decrease in the peak denaturation temperature of perimysium occurred with increasing ageing times in both muscles. Maximum force in isometrically-heated perimysium was broadly equivalent in both muscles. Although the amount and solubility of collagen varies between muscles and ageing decreases the stability of some of the collagen, thermal shrinkage forces in heated perimysium are not significantly diminished by ageing.These findings support the idea of one collagen fraction easily degraded by ageing and heat, and another more resistant fraction that determines the physical properties of the tissue after ageing and cooking.

Standard versus physiologic bone preparation in total knee arthroplasty and the effect on joint space opening

BackgroundTotal knee arthroplasty is an effective treatment for osteoarthritis. Restoration of physiologic varus alignment may restore the native soft tissue tension and improve outcomes. MethodsSix paired fresh-frozen knee specimens were used to perform total knee arthroplastys. The left and right sides of were randomly assigned to have either a physiologic alignment cut or a standard of care neutral alignment bony cut prior to the implantation. Loads of 100 and 200N were applied at 0, 30, 60, and 90° of flexion and the magnitude of the medial and lateral compartment distraction was measured. The loads were applied with the knee specimen intact and post arthroplasty. FindingsThe physiologic alignment had no difference between medial and lateral gaps at either load. With 100N of load the physiologic alignment had a greater gap at 90° than at full extension while the standard alignment had significantly more gap at 60° of flexion than full extension. The physiologic alignment had a significantly greater gap with the implant compared to the intact condition at both loads. The standard alignment had no significant difference in overall gap between the implant and intact condition with any load. InterpretationAlthough performing a physiologic aligned TKA resulted in medial-lateral soft tissue balance, the flexion gap was found to have greater magnitude than the intact knee. Notably, a neutral aligned TKA was found to be balanced, but also was found to recreate the intact knee flexion gaps. These results suggest that coronal plane stability can be achieved with physiologic alignment objectives, but the clinician needs to be aware of the potential to have greater laxity than the intact and neutral alignment surgical objectives.

Middle and Long -term Clinical Results of Dorsiflexion Osteotomy for Severe Hallux Rigidus

Category: Bunion Introduction/Purpose: Total arthroplasty or arthrodesis is often used as a surgical procedure for severe case of hallux rigidus. However, because these procedures involve problems such as loss of joint function, age, and postoperative motion restriction, joint-preserving surgery is desirable for achieving a better quality of life. To resolve these problems, we have performed dorsiflexion osteotomy of the first metatarsal head since 2000, yielding favorable outcomes. We report about middle to long-term follow-up for our clinical results and radiographic findings. Methods: The study involved 31 feet of 30 patients (20 male,11 female) with Grade 2 (joint space narrowed to about 1/2 or less) or Grade 3 according to the Hattrup and Johnson classification. The mean age at surgery was 61.6 years (range: 53-77). Surgical techniques: We have used dorsal approach and conducted closed wedge osteotomy of the first metatarsal bone neck. Then, the bone head was flexed dorsally to form an articular surface and fixation. PWB was permitted 3 weeks after surgery. Mean postoperative follow-up period was 4 years and 2 months (range: 3-13 years). Clinical outcomes, range of motion (ROM), and radiographic findings were investigated. Results: Clinical outcomes were rated as excellent in 24 feet, good in 7, and fair/poor in none. All patients returned to normal daily life. Stiffness while walking was noted in 10 feet. As for ROM, most patients had a 1/2 to 2/3 of the normal range. No complications such as infection, nonunion, or transfer metatarsalgia were seen in any case. An X-ray film showed joint space narrowing in about half of all cases. None of the patients experienced pain relapse requiring arthrodesis again. Conclusion: The mechanism of pain relief is Dorsiflexion osteotomy is by bone shortening, make a decreasing joint pressure and regaining of normal articular to the dorsal side so that it faces the articular surface of the proximal phalanx. The postoperative restriction of ROM may be attributable to changes in the bone alignment and in the tension of soft tissue around the joint as compared to the healthy condition. None of the patients experienced pain relapse. Our procedure appears to be useful as joint- preserving surgery for severe cases with hallux rigidus.

Regeneration Tensed Up: Polyploidy Takes the Lead

The cellular mechanisms allowing tissues to efficiently regenerate are not fully understood. In this issue of Developmental Cell, Cao etal. (2017) discover that during zebrafish heart regeneration, epicardial cells at the leading edge of regenerating tissue undergo endoreplication, possibly due to increased tissue tension, thereby boosting their regenerative capacity.

Measuring Joint Flexibility in Hallux Rigidus Using a Novel First Metatarsophalangeal Joint Flexibility Jig

Category: Midfoot/Forefoot Introduction/Purpose: Range of motion measurements of the first metatarsophalangeal joint (MTPJ) are an essential component in assessing and classifying hallux rigidus (HR). However, they provide little information about joint function and are limited by variability in technique. As an alternative, measuring joint flexibility can characterize intrinsic properties of the joint—aside from simply maximum dorsiflexion and plantarflexion—that may prove more clinically meaningful. No prior study has assessed hallux MTPJ flexibility in patients with HR. The purpose of this study was therefore to assess the reliability of a custom flexibility device and to compare flexibility between HR patients and controls. Methods: Fifteen patients with Coughlin stage II or III HR indicated for cheilectomy and 20 healthy controls were recruited prospectively. Each of two raters performed a series of seated and standing tests on each subject with the device. Dorsiflexion angle and applied torque were plotted against each other to generate a flexibility curve. “Early flexibility” and “late flexibility” were defined as the slope of the curve in the first 25% and last 25% of motion, respectively. From these two parameters, three additional parameters were calculated: laxity angle, laxity torque, and torque angle (Figure). Differences between (1) HR patients and controls and (2) sitting and standing testing positions were assessed with t-tests. Intra-rater test-retest reliability, remove- replace reliability, and inter-rater reliability were assessed with intraclass correlation coefficients (ICCs). Results: Patients in the HR group were older than patients in the control group (p &lt; 0.001) and had significantly lower maximum dorsiflexion (p &lt; 0.001). HR patients were less flexible as measured by three of the five flexibility parameters: early flexibility (p = 0.027), laxity angle (p &lt; 0.001), and torque angle (p = 0.002). After controlling for age on seated measurements, only laxity angle and maximum dorsiflexion differed significantly between HR patients and controls (p &lt; 0.001). Generally, patients were more flexible in the seated position than in the standing position, with this effect being more marked in HR patients. All parameters had good or excellent intra- and inter-rater reliability (ICC = 0.60). Conclusion: This is the first study to demonstrate a reliable method of measuring first MTPJ flexibility in patients with HR. We found that flexibility, even early in the arc of motion, is impaired in patients with HR. Moreover, significant differences between sitting and standing measurements suggest that soft tissue tension may be a major contributor to this finding. We do not know yet how flexibility of the joint relates to symptomatology, or if the surgeries performed for HR affect flexibility. Further research will be required to determine the clinical utility of these measurements.

Hallux Varus and Plantar Plate Repair

One of the most frequent problems encountered in foot and ankle are hallux valgus and lesser toes deformities. One of the complications after hallux valgus treatment is a iatrogenic hallux varus. This deformity can be solved at 2 levels, namely the skeletal level, through a metatarsal osteotomy to correct the varus component of the bone and at the soft tissue level, to compensate and rebalance soft tissue tension surrounding the metatarsophalangeal (MTP) joint. The soft tissue reconstruction may include capsular releases, capsulorraphies, tendon transfers, and augmentations such as nonreabsorbable suture reinforcement of some MTP capsular components. Lesser toe deformities have historically shown moderate to low levels of satisfaction after surgical treatment. Ten years ago the MTP component of lesser toes deformity was solved with some type of metatarsal shortening osteotomy and soft tissue release, specially including dorsal structures over the metatarsal head. Over the last few years’ knowledge from a series of articles have shown the importance in recognizing and repairing the MTP plate to regain stability and alignment at the joint. Different alternatives of repair exist at this level, and some of them are discussed in this article. Level of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.