Transverse Metatarsal Ligament Research Articles

Is endoscopic decompression for Morton's neuroma a safe technique?

IntroductionMorton's neuroma is predominantly attributed to chronic nerve entrapment within third space adjacent metatarsals, the deep transverse metatarsal ligament (DTML), and the plantar skin. While conservative treatments are of election, failures require alternative interventions such as ultrasound-guided injections and various surgical procedures, including minimally invasive neurectomy and DTML release. This study aimed to anatomically assess the risks associated with the endoscopic dorsal surgical decompression of Morton's neuroma. Materials and methodsTwenty feet from ten fresh-frozen cadaveric specimens underwent a dorsal percutaneous approach for endoscopic access. Surgical procedures were monitored by three foot and ankle surgeons. Post-surgical anatomical dissections were conducted to evaluate potential risks to surrounding structures. ResultsThe endoscopic technique successfully sectioned the DMTL in all specimens (100%) without iatrogenic injury of tendons, nerves, or arteries, while lumbricals may be at risk. ConclusionEndoscopic dorsal decompression of Morton's neuroma presents as an accessible minimally invasive surgical option with low risk of collateral associated injuries.

Are sesamoids and proximal phalanx of metatarsus primus varus deformity of hallux valgus feet displaced? A radiological study.

The hallux valgus deformity is made up of misaligned first metatarsal, hallux, and sesamoids. Their angular deformities are well-studied, but not their positional displacements. A few available reports claimed the proximal end of the proximal phalanx and sesamoids were not shifted medially along with the first metatarsal head. However, the general observation is otherwise. This study revisits the issue. A radiological study of 189 feet with and without the hallux valgus deformity was carried out to analyze the first metatarsal, hallux, and sesamoid positional changes in relation to the second metatarsal and among themselves. A total of 194 X-ray images with all relevant measurements that formed the raw database for this study were submitted for online viewing and reference. There was a statistically significant change in the first metatarsal, hallux, and sesamoid positions of feet with hallux valgus deformity compared to normal feet. All have migrated medially but to different degrees. It was contrary to the past findings of no change in sesamoid and hallux positions. We agree with past findings that the metatarsus primus varus deformity is directly related to the failed medial metatarsosesamoid ligament. We also believe in the failure of the deep 1-2 transverse metatarsal ligament responsible for the sesamoid migration.

Minimally invasive surgical technique for deep transverse metatarsal ligament release secondary to painful neuroma using the Arthrex® NanoScopeTM system

Neuromas are a common cause of forefoot pain that can be treated surgically via neurolysis, which entails decompression of the deep transverse metatarsal ligament (DTML). This study details a novel technique in which the Arthrex® NanoScopeTM System is utilized for DTML release to treat a painful neuroma in a minimally invasive fashion. This technique is unique because it allows for a quick and easy percutaneous procedure where the DTML can be visualized by the surgeon both prior to and during transection.

Role of lateral soft tissues release in percutaneous hallux valgus correction: A medium term retrospective study.

In the field of minimally invasive surgery (MIS) for the treatment of hallux valgus (HV), different techniques have begun to emerge in the literature concerning the distal osteotomy of the first metatarsal bone, the synthesis or not of the metatarsal head, the possible association with lateral soft tissues release (LSTR) and osteotomy of the base of the first phalanx. To evaluate the role of LSTR on percutaneous HV correction, evaluating functional and radiographical results. From January 2012 to May 2016 a total of 396 patients with mild to moderate symptomatic HV treated with the MIS technique were included in this retrospective study. The technique provides no internal fixation (WOS). Patients were divided into the LSTR group and no LSTR group (LSTR N). This surgical procedure (LSTR) was reserved for insufficient HV angle (HVA) correction during fluoroscopic control. Patients were evaluated at each follow-up by two other authors after appropriate training by senior authors (first practitioners). Clinical evaluation was performed before surgery, 6 mo after surgery, and 48 mo follow-up. American Orthopaedic Foot and Ankle Society (AOFAS) and visual analog scale (VAS) score was used to evaluate pain and function, and complications were recorded. In addition, the incidence of relapses and the degree of joint range of motion (ROM) with the association with the LSTR (capsule, adductor tendon, phalanx-sesamoid ligament, and the deep transverse metatarsal ligament) were evaluated. Radiological parameters included HVA and intermetatarsal angle (IMA). Patient satisfaction was assessed. Student t-test and Fisher exact test were used to assess statistical analysis. From our study it is clear that no differences in term of HVA, VAS, IMA correction, rate of complications, and AOFAS score were found between groups, while a significant improvement of the same variables was found in each group between pre and postoperative values. A significant improvement in ROM at 6 mo (P = 0.018) and 48 mo (P = 0.02) of follow-up was found in LSTR N group. Complications were rare in both groups. LSTR procedure on percutaneous HV correction seems to increase postoperative joint stiffness with a comparable incidence of relapse and a low incidence of complications.

Treatment of a patient with chronic causalgia after surgical removal of the neuroma in the second interdigital space

BACKGROUND: Mortons neuroma is a common pathology of the forefoot. Etiopathologically, this disease can be attributed to nerve fibrosis, not a tumor. We now have various therapeutic options for neuromas, the most frequent of which is traction neurectomy. Recurrent pain affects up to 35% of patients with traction neurectomy, and one-third have recurrent stump neuroma produced by the proliferation of fibrous scar tissue around the remaining nerve elements. Conservative treatment methods are more commonly used to treat recurrent neuromas and residual pain, but surgical therapy is required in some cases. Despite the relatively high prevalence, the treatment of such patients is a challenging task for orthopedic traumatologists.
 CLINICAL CASE DESCRIPTION: We show the effective treatment of a patient with stump neuroma and primary Mortons neuroma in two stages. The second interdigital space nerve was transposed, and the deep, transverse metatarsal ligament of the third interdigital space was dissected in the first stage. The second stage consists of removing the sensitive scar, resecting the plantar nerve of the third interdigital space, and performing a Weil osteotomy.
 CONCLUSION: Consistent use of conservative surgical procedures, appropriate revision of the subcutaneous nerve, and excision of a sensitive scar allows for a successful therapeutic outcome, pain alleviation, and the ability to wear normal shoes.

Značaj mekotkivnih hirurških intervencija na distalnom dijelu stopala u liječenju hallux valgus-a

Since pathological anatomical changes in the distal soft tissues of the front part of the foot in hallux valgus deformity are degenerative in nature and more pronounced than changes in the bony structures, interventions on ligamentous, capsular and tendinous structures are an indispensable part of its surgical treatment. A consensus has not been established regarding the nature and method of performing distal soft tissue interventions. To avoid the risk of consequent aseptic necrosis of the first metatarsal bone head in case of simultaneous osteotomy at its distal level, it is necessary that the osteotomy be performed in a safe place and the plantar and dorsal segments of this capsule must remain preserved. To avoid the occurrence of iatrogenic hallux varus deformity, lateral sesamophalangeal ligament, lateral sesamoid and associated part of the plantar aponeurosis must remain preserved. Since the deep transverse metatarsal ligament keeps the sesamoid apparatus in the anatomical position, its release should be avoided. Lateral release of adductor tendons of the thumb, lateral collateral ligament and associated part of the capsule facilitate correction of the position of the thumb with a modest contribution to the overall correction of deformity and allow access to the shortened lateral metatarsosesamoid ligament, which must be completely released, making the greatest contribution to overall correction. At the same time, the mentioned interventions are safe from the aspect of risk of possible complications, especially when performed using a special dorsal intermetatarsal approach. Reconstructive interventions on the soft tissues of the medial side of the metatarsophalangeal joint of the thumb include their tightening while stabilizing the thumb in a neutral position.

Treatment of Morton's neuroma with minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) and percutaneous release of the deep transverse metatarsal ligament (DTML): a case series with minimum two-year follow-up.

The optimal treatment of symptomatic Morton's neuroma remains unclear; conservative methods are sometimes ineffective and neurectomy has significant rates of patient dissatisfaction. The aim of this study was to evaluate the outcome of minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) and percutaneous release of the deep transverse metatarsal ligament (DTML) in patients with Morton's neuroma. Between January 2018 and November 2019, 27 patients (29 feet) diagnosed with Morton's neuroma after clinical and radiological evaluation underwent DMMO and percutaneous DTML release. The primary clinical outcomes were pain (VAS) and function (AOFAS score). Secondary outcomes included patient satisfaction, complications, and radiographic outcomes. Patients were followed up for a minimum of twoyears. The median age of the participants was 66years (range 48-79) and the follow-up time was 28months (24-47). There was a decrease of 5.7 points in the VAS for pain (p < .001) and an increase of 19.9 in AOFAS (p < .001) after the surgical procedure. There was one case of superficial infection and one patient required resection of the neuroma (neurectomy). The majority of patients (89.7%) were satisfied and considered the procedure outcome as excellent or good. Treatment of Morton's neuroma with minimally invasive distal metatarsal metaphyseal osteotomy and percutaneous release of the deep transverse metatarsal ligament showed significant improvement in pain and function with a low incidence of complications and a high rate of personal satisfaction.

Anatomy of the Plantar Intermetatarsal Tunnel: A Cadaveric Study

The contents of the plantar intermetatarsal tunnel (PIMT) and the relationship between the common plantar interdigital nerve (CPIN) and the PIMT were recorded. The width of the PIMT was measured at the metatarsal neck (MTN), metatarsophalangeal (MTP) joint and the base of the proximal phalanx (BPP). The length of the deep transverse metatarsal ligament (DTML), the PIMT and the intracapsular ligament (ICL) were also measured. The PIMT was revealed to be a narrow osseofibrous tunnel divided into 3 segments by the DTML: the distal section, the area under the DTML (middle) and the proximal section. The length of the middle section was 12.77 mm in the second intermetatarsal (IM) space and 10.18 mm in the third IM space. The lengths of the distal sections were 15.52 and 14.95 mm in the second and third IM spaces, respectively. There was some soft tissue between the CPIN and PIMT, and the CPIN was observed not to glide freely within the tunnel. The widths of the PIMT at the MTN, MTP joint and BPP were respectively 2.87, 2.56, and 3.42 mm in the second IM space and 3.10, 2.68 and 3.61 mm in the third IM space. The ICL lies between the capsules of the MTP joint, and the length of the ICL was 2.76 and 3.03 mm in the second and third IM spaces, respectively. The PIMT was found to be a complex spatial structure, and the ICL might prevent the CPIN from being squeezed into the IM space.

Study of the Anatomical Association between Morton’s Neuroma and the Space Inferior to the Deep Transverse Metatarsal Ligament Using Ultrasound

Morton’s neuroma (MN) is a common condition in clinical practice. The compressive etiology is the most accepted, in which compression occurs in the tunnel formed by the adjacent metatarsals, the deep transverse metatarsal ligament (DTML) and the plantar skin. Ultrasound (US) is a reliable method of study. The presence of insufficient space under the DTML may be related to the appearance of MN. Objectives: To verify the relationship between MN and the space under the DTML between the metatarsal heads of the third (M3) and the fourth (M4) metatarsals using US. Methods: This is a cross-sectional epidemiological study. The research study using the ultrasound (US) technique was carried out on 200 feet belonging to 100 patients aged 18 to 65 of both sexes, with a control group formed by 62 patients and a study group formed by 38 patients diagnosed with MN. Results: The presence of MN and the factors associated with it were studied in 100 patients using ultrasound (US). The assessment and comparison with US of the space inferior to the DTML between M3 and M4 in control groups and patients with MN show that patients with MN have a smaller size in the variable “h” (height or distance DTML-plantar skin), in the variable “b” (base or intermetatarsal distance M3 and M4) and in the variable “s” (surface of the parallelogram “h” × “b”). The predictors of MN are a decrease in dimension “b” and an increase in weight. Sitting in an office chair and the use of a bicycle, due to equinus, have an influence on the space below the DTML, reducing it and promoting the appearance of MN. Conclusions: The two US measurements (“h” and “b”) in the space below the DTML are smaller in patients with MN than in the asymptomatic group. A shorter distance between M3 and M4, and an increase in BMI are predictors of MN.

Novel Ultrasound Anatomical Measurement of the Deep Transverse Metatarsal Ligament: An Intra-Rater Reliability and Inter-Rater Concordance Study.

Insufficient space below the Deep Transverse Metatarsal Ligament (DTML) could be an etiological factor for Morton’s Neuroma (MN). To date, there is a lack of studies measuring the space below the DTML. For this reason, this study assesses the intra- and inter-rater concordance and reproducibility of measurements of the space below the DTML between the third and the fourth metatarsal heads (M3 and M4) using ultrasound imaging to assess and verify the reliability and reproducibility of measurements of the space under the DTML. Forty feet from twenty patients were examined using ultrasound by three trained evaluators at two different times. The two measurements taken on each foot were: base (b)—distance between M3 and M4, and height (h)—distance between the DTML and the plantar skin surface. This was a quantitative, observational, analytical study. The concordance rate between observers for measurements of height and base were 98.5% and 99.5%, respectively. The mean area obtained of the space was 54.6 mm2 and 57.2 mm2 for both the left and right foot (p > 0.05). Reproducibility over time calculated in pre- and post-measurements showed an intraclass correlation coefficient of 1.00 (95%CI: 0.99–1.00), which leads us to conclude that the measurements are perfectly reproducible. Both measurements (height and base) of the space under the DTML, performed by ultrasound, are reliable and reproducible.

Iatrogenic Damage to Neurovascular and Soft Tissue Structures During Lateral Release of Hallux Valgus: A Comparative Anatomical Study of Minimally Invasive Versus Open Surgical Techniques

Lateral release is often an integral step in surgical correction of hallux valgus and can be performed using open or minimally invasive techniques. We investigated whether these techniques cause iatrogenic damage to arteries, nerves, tendons, or joint capsules. In this cadaver study, lateral release was performed on 9 pairs of specimens by a specialized foot surgeon. The specimens were randomly assigned to each group. The operations were followed by anatomical preparation, data collection, photo documentation, and statistical analysis. Iatrogenic damage to arteries, nerves, tendons, or joint capsules was rare, regardless of the surgical technique used. However, with the minimally invasive technique, the tendon of the extensor hallucis longus muscle and the sensitive terminal branches of the fibular nerve were at risk due to their anatomical proximity to the access portal. The deep transverse metatarsal ligament was potentially at risk if the adductor hallucis muscle was completely detached from the lateral sesamoid. When the deep transverse metatarsal ligament was transected there was risk of damaging the underlying plantar neurovascular structures. Both surgical techniques are safe in terms of the risk of injury to neighboring neurovascular and soft tissue structures.

Anatomic basis for a new ultrasound-guided, mini-invasive technique for release of the deep transverse metatarsal ligament.

IntroductionMorton's neuroma is an entrapment neuropathy of the third common plantar digital nerve, caused by the deep transverse metatarsal ligament (DTML). Minimally invasive or percutaneous surgery is a very common procedure, but surgical effectivity of this technique remains controversial. The goal of our study was to prove the effectiveness and safety of a new ultrasound‐guided technique for DTML‐release in a cadaver model.Materials, Methods, and ResultsThe DTML was visualized in 10 fresh frozen donated body to science‐feet (eight male and two females, five left and five right) using an US device (GE Logic R7; 13 MHz linear probe, Madrid, Spain). Consecutively, minimally invasive ultrasound‐guided surgery was performed. Exclusion criteria of the donated bodies to science were previous history of forefoot surgery and space occupying mass lesions. The complete release of the ligament was achieved in all specimens without damage of any important anatomical structures as proven by anatomical dissection.ConclusionsThe results of this study indicate that our novel approach of an ultrasound‐guided release of the DTML is safer and more effective compared to blind techniques. The DTML could reliably be visualized and securely cut through a dorsal, minimally invasive surgical incision of only 2 mm.

Anatomical Study of Minimally Invasive Lateral Release Techniques for Hallux Valgus Treatment.

Lateral release (LR) for the treatment of hallux valgus is a routinely performed technique, either by means of open or minimally invasive (MI) surgery. Despite this, there is no available evidence of the efficacy and safety of MI lateral release. Our aim was to study 2 popular techniques for MI LR in cadavers by subsequently dissecting the released anatomical structures. Twenty-two cadaveric feet were included in the study and allocated into 2 groups, 1 for each procedure: 1 group underwent a MI adductor tendon release (AR), and in the other group, an extensive percutaneous lateral release (EPLR) (adductor tendon, suspensory ligament, phalanx-sesamoid ligament, lateral head of flexor hallucis brevis, and deep transverse metatarsal ligament) was performed. Anatomical dissection was performed to identify neurovascular injuries and to verify the released structures. Both techniques demonstrated to be effective in reproducing a MI LR. A satisfactory release of the adductor tendon was achieved equally in both techniques (P = .85), being partial in most EPLR cases and full in the majority of AR cases. The EPLR was successful in releasing the intended additional structures (P < .05). One case of inadvertent complete section of the flexor hallucis longus was identified in the percutaneous adductor tendon release group. No cases of dorsolateral nerve injury were seen with either of the techniques. Percutaneous lateral release was a reliable and accurate technique in this cadaveric model. The MI AR proved to be more effective in fully releasing the adductor tendon while the ER was intended and able to release a number of other structures. MI LR is a safe procedure that could obviate the need for open surgery to achieve the same surgical goal. It can be associated to either open or MI osteotomies in the correction of hallux valgus.

Unusual anatomical variations in plantar metatarsal arteries and plantar arterial arch with surgical significance

Background: Critical limb ischemia (CLI) has been a burden on society where revascularization of arteries is the first line of treatment. If the antegrade approach is not possible, retrograde approach through pedal–plantar loop can be done, resulting in better prognosis. For the same reason, assessment of blood vessels of foot in general is practiced before any intervention. Having information about normal anatomy and anatomical variants of these blood vessels could be of great help to the interventionist to reduce the postoperative complications. Context: The authors studied formation of plantar arterial arch, normal anatomy, and anatomical variations in plantar metatarsal arteries (PMTAs) regarding their origin in 50 formalinized adult cadaveric feet. Results and Conclusion: Variations in formation of plantar arterial arch as predominant lateral plantar artery supplying to most of the PMTAs were noted. Common stump of origin for the first and second, then for second and third, and also for the third and fourth PMTAs was found. In two feet, we found common stump of origin for the first PMTA and first dorsal metatarsal artery originating from deep plantar arch. Medial branch from medial plantar artery joined the first PMTA to supply the great toe deep to the transverse metatarsal ligament. In about 28% of specimens, the foot length was ranging from 21.1 cm to 22 cm and the distance between the plantar arterial arch and the posterior margin of heel was ranging between 12 and 13.5 cm. Fibular plantar marginal artery was present in all specimens. Implications: In the retrograde approach for the revascularization in cases with CLI, most of the surgeons are trying the approach through plantar pedal loop or direct puncture of metatarsal arteries. Data collected on plantar metatarsal normal anatomy and anatomical variations can be kept in mind while doing any intervention with better prognosis.

Surgical Repair of an Unstable Third Metatarsophalangeal Joint Dislocation via Direct Plantar Plate Repair: A Simple and Effective Technique

Traumatic dislocation of a lesser metatarsophalangeal (MTP) joint is a rare case for a foot and ankle surgeon to encounter. These dislocations can be difficult to reduce due to the surrounding connective tissues that may be interposed in the joint space. These include the plantar plate, deep transverse metatarsal ligament, flexor tendons, and lumbricals. When the clinician is unable to reduce the phalanx, surgery is required to prevent sequelae such as further swelling, ecchymosis, joint damage, and impingement of the neurovascular bundle. In this case report, we present the case of a 53-year-old female who suffered a traumatic dislocation after a low-energy trip and fall injury.

Anatomy of the Lateral Plantar Ligaments of the Transverse Metatarsal Arch

Category: Midfoot/Forefoot Introduction/Purpose: The anatomy of the Lisfranc complex is well understood. In contrast, the lateral tarsometatarsal ligamentous structures are under-investigated. Our study aimed to identify the plantar ligamentous structures of the lateral tarsometatarsal joints and their significance in transverse metatarsal arch injuries. Methods: We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures of the plantar aspect of the transverse metatarsal arch. Results: In all specimens, the long plantar ligament blended with a transverse metatarsal ligament spanning from the 2nd to the 5th metatarsal. This transverse metatarsal ligament formed the basis of the roof and distal aspect of the peroneus longus canal. The separate long plantar ligament formed the floor of the peroneus longus canal. In addition, separate intermetarsal ligaments were identifiable connecting each metatarsal. The long plantar ligament provides a connection through the transverse metatarsal ligament, connecting the transverse and longitudinal arches of the foot Conclusion: The plantar ligamentous structures of the lateral tarsometatarsal joints are a combination of individual intermetatarsal ligaments and a transverse metatarsal ligament. This explains the homogenous nature of a divergent tarsometatarsal joint injury and why middle and lateral columns move as one. It also has clinical significance in the observation that in some cases lateral column instability can be overcome when the middle column is stabilised.

Deep Transverse Metatarsal Ligament Transection in Morton's Neuroma Excision: A Cadaveric Study Examining Effects on Metatarsal Alignment.

In the dorsal incisional approach for Morton's neuroma, it is required to transect the deep transverse metatarsal ligament (DTML) that lies in the interspace between the third and fourth metatarsal heads. The purpose of this study was to evaluate the relationship between transection of the DTML in the third intermetatarsal space and the metatarsal alignment. Nine human cadaveric lower extremity limbs were used for this study. Each limb was mounted to the MTS 858 Mini Bionix biomechanical test system and loaded to 120% of the donor's documented body weight at a rate of 15 lbf/s, in order to simulate peak weightbearing ground reactive forces on the forefoot. Preoperative and immediate postoperative radiographs were obtained. Cyclic loading was then performed to simulate 1 month of full weightbearing. Radiographs were repeated and metatarsal alignment was analyzed. A statistically significant difference was noted with intermetatarsal angle (IMA) 1-2 and IMA 1-4. The IMA 1-2 after 1 month cycling time showed statistical significant difference from those found immediately postoperatively (P < .05). Average increase in IMA 1-2 from preoperative to 1 month cycling time was 2.18°. The power of the analyses for IMA 1-2 was 0.992. Regarding the IMA 1-4, data recorded at 1 week and 1 month cycling times showed a statistically significant difference compared to the preoperative IMA 1-4 (P < .05). Average increase in IM 1-4 angles from preoperative to 1 month cycling time was an increase of 1.79°. The power of the analyses for IM 1-4 angles was 0.953. Technically, 2.18° increase in IMA 1-2 or 1.79° increase in IM 1-4 would be considered an abnormal widening of the forefoot, but clinically, these values could not be detected; nor should they deter a surgeon or patient from undergoing a Morton's neurectomy via a dorsal incisional approach. Level V: Cadaveric study.

Effectiveness of Lateral Soft Tissue Release of the 1st Metatarsophalangeal Joint Through a Medial Transarticular Approach – A Cadaver Study

Category: Bunion Introduction/Purpose: First metatarsophalangeal joint lateral soft tissue release is frequently performed during corrective surgery for hallux valgus deformity. Surgical approaches include an open dorsal approach as well as a medial transarticular approach. The medial transarticular approach avoids the need for a second incision while also attenuating the risk of avascular necrosis of the first metatarsal head. However, this method is limited by the poor visualization of the lateral structures through the joint. The objective of this study was to evaluate the effectiveness of the medial transarticular approach for lateral soft tissue release in the 1st metatarsophalangeal joint. Methods: Ten below-the-knee fresh-frozen cadaveric specimens were used (6 females, 4 males). The mean age was 73.4 years. Two specimens had moderate hallux valgus deformity. None of the samples had considerable degenerative changes of the first metatarsophalangeal joint. Lateral soft tissue release was performed using a single 2.5 cm medial incision. Lateral soft tissue release targeted the lateral collateral ligament, lateral capsule, adductor hallucis muscle tendon and lateral metatarsosesamoid suspensory ligament. A single surgeon performed all procedures. An extended lateral dissection of the 1st intermetatarsal space was carried out to examine the accuracy of the technique. Successful release of each targeted structure (4 total) was recorded for each specimen. Thus, the percentage of successful release was computed for each specimen. Injuries to important non-targeted structures were also registered. Results: All four targeted structures were successfully released (100%) in seven of the ten cadavers. Three out of four structures were released (75%) in one cadaver, while two of the four and one of the four targeted structures were successfully released in the other two cadavers (50% and 25% success respectively). Lateral collateral ligament was successfully released in all cadavers. Lateral joint capsule, adductor hallucis muscle tendon, and lateral metatarsosesamoid suspensory ligament were released in 80% of the specimens. 1st metatarsal head chondral and unintended release of lateral head of the flexor hallucis brevis occurred respectively in 40% and 50% of the procedures. No injuries to the flexor hallucis longus tendon, neurovascular bundle, deep transverse metatarsal ligament or chondral damage to the proximal phalanx were recorded. Conclusion: Lateral soft tissue release of the first metatarsophalangeal joint can be successfully performed through a medial transarticular approach. Inadvertent release of the lateral head of the flexor hallux brevis and chondral damage of the 1st metatarsal head are complications to be considered.

Plantar plate pathology is associated with erosive disease in the painful forefoot of patients with rheumatoid arthritis

BackgroundDisease-related foot pathology is recognised to have a significant impact on mobility and functional capacity in the majority of patients with rheumatoid arthritis (RA). The forefoot is widely affected and the metatarsophalangeal (MTP) joints are the most common site of symptoms. The plantar plates are the fibrocartilaginous distal attachments of the plantar fascia inserting into the five proximal phalanges. Together with the transverse metatarsal ligament they prevent splaying of the forefoot and subluxation of the MTP joints. Damage to the plantar plates is a plausible mechanism therefore, through which the forefoot presentation, commonly described as ‘walking on pebbles’, may develop in patients with RA.The aims of this study were to investigate the relationship between plantar plate pathology and clinical, biomechanical and plain radiography findings in the painful forefoot of patients with RA. Secondly, to compare plantar plate pathology at the symptomatic lesser (2nd-5th) MTP joints in patients with RA, with a group of healthy age and gender matched control subjects without foot pain.MethodsIn 41 patients with RA and ten control subjects the forefoot was imaged using 3T MRI. Intermediate weighted fat-suppressed sagittal and short axis sequences were acquired through the lesser MTP joints. Images were read prospectively by two radiologists and consensus reached. Plantar plate pathology in patients with RA was compared with control subjects. Multivariable multilevel modelling was used to assess the association between plantar plate pathology and the clinical, biomechanical and plain radiography findings.ResultsThere were significant differences between control subjects and patients with RA in the presence of plantar plate pathology at the lesser MTP joints. No substantive or statistically significant associations were found between plantar plate pathology and clinical and biomechanical findings. The presence of plantar plate pathology was independently associated with an increase in the odds of erosion (OR = 52.50 [8.38–326.97], p < 0.001).ConclusionThe distribution of plantar plate pathology at the lesser MTP joints in healthy control subjects differs to that seen in patients with RA who have the consequence of inflammatory disease in the forefoot. Longitudinal follow-up is required to determine the mechanism and presentation of plantar plate pathology in the painful forefoot of patients with RA.

Tensile Properties of the Deep Transverse Metatarsal Ligament in Hallux Valgus: A CONSORT-Compliant Article.

The deep transverse metatarsal ligament (DTML) connects the neighboring2 metatarsal heads and is one of the stabilizers connecting the lateral sesamoid and second metatarsal head. In this study, we aimed to determine the tensile properties of the DTML in normal specimens and to compare these results with hallux valgus specimens. We hypothesized that the tensile properties of the DTML would be different between the 2 groups of specimens.The DTML in the first interspace was dissected from 12 fresh frozen human cadaveric specimens. Six cadavers had bilateral hallux valgus and the other 6 cadavers had normal feet. The initial length (L0) and cross-sectional area (A0) of the DTML were measured using a digital caliper, and tensile tests with load failure were performed using a material testing machine.There were significant between-groups differences in the initial length (L0) P = 0.009 and cross-sectional area (A0) of the DTML P = 0.007. There were also significant between-groups differences for maximum force (N) P = 0.004, maximum distance (mm) P = 0.005, maximum stress (N/mm2) P = 0.003, and maximum strain (%) P = 0.006.The DTML is an anatomical structure for which the tensile properties differ in hallux valgus.