Weight-bearing Anteroposterior Radiographs Research Articles

TL 18086 - Forefoot axial radiographic study for the evaluation of metatarsal head alignment in the coronal plane

Introduction: Many authors consider differences in the relative length of metatarsal bones in the axial plane a cause of inadequate load distribution during gait, leading to metatarsalgia. The goal of surgical treatment is to realign the metatarsal formula. However, many studies have shown a 15% metatarsalgia recurrence rate after reconstructing the advocated metatarsal formula in the axial plane, questioning the importance of the alignment of the metatarsal heads in the coronal plane. Objective: To evaluate the alignment pattern of the metatarsal heads in the coronal plane in individuals with and without metatarsalgia. Methods: This cross-sectional study evaluated individuals aged 30 to 65 years, dividing them into 2 groups, one without foot pain, deformities or callosities and another with metatarsalgia between the 2nd, 3rd and 4th metatarsal bones. The individuals were selected according to inclusion and exclusion criteria and were included in the study after signing an informed consent form. After the selection, the subjects underwent one weight-bearing forefoot axial radiograph evaluating the coronal plane to measure the heights of the metatarsal heads and a weight-bearing anteroposterior foot radiograph to determine the length of each ray. Statistical analysis was performed to compare the measurements of the 2 groups. Results: In total, 106 individuals were divided into 2 groups, each comprising 106 feet, and evaluated. In the group with metatarsalgia, 32% patients were men, the mean age was 49.5 years, and 33 feet had hallux valgus. In the group without metatarsalgia, 51% patients were male, and the mean age was 44.6 years. The measured anthropometric variables did not differ significantly between groups. In both groups, the metatarsal heads were distributed in a curved line in the coronal plane, following the formula M1<M2>M3>M4=M5. The distal support of the 1st ray was in a more plantar position in the group of patients with metatarsalgia (p=0.000). Conclusion: The metatarsal heads of the individuals of both groups were aligned in the coronal plane following the formula M1<M2>M3>M4=M5. However, M1, M4 and M5 were at the same height in the group without metatarsalgia, whereas the M1 weight-bearing point was more plantar in the feet of patients with metatarsalgia.

Radiographic analysis of lower limb alignment in professional football players.

To radiographically analyze lower limb alignment in adult asymptomatic professional football players and to correlate these values to clinical measurements. Twenty-four asymptomatic players [24.2 (3.6) years] were enrolled. Standard bilateral lower limb anteroposterior weight-bearing radiographs were acquired and clinical measurement of intercondylar/intermalleolar (ICD/IMD) distance was performed. Coronal plane mechanical alignment was assessed by five angles: leg mechanical axis (LMA), lateral proximal femoral angle (LPFA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), and lateral distal tibial angle (LDTA). Their values were compared to the reference values for adult population. An inter-individual comparison between right/left and dominant/non-dominant leg was added. The sum of bilateral LMA was correlated against ICD/IMD and against ICD/IMD adjusted for body height. Football players presented with ICD/IMD of 46.5 (19.8) mm. Two, out of five, lower leg coronal angles showed significant differences (p < 0.001) compared to reference data from literature: LMA 5.8 (3.0)º vs.1.2 (2.2)º and MPTA 83.5 (2.6)º vs. 87.2 (1.5)º. No significant differences between left/right leg and dominant/non-dominant leg were established. Summed up bilateral LMA showed a high correlation to IMD/ICD (r = 0.8395; R2 = 0.7048), and even higher to ICD/IMD adjusted for body height (r = 0.8543; R2 = 0.7298). This study was radiographically confirming increased varus of elite football players toward general population. Apex of the varus deformity was located in the proximal tibia. Clinical measurement of ICD/IMD adjusted for body height highly correlated with the radiographic values of coronal alignment; therefore, it may be used in population studies.

Patterns of cartilage degeneration in knees with medial tibiofemoral offset

To determine if radiographic medial tibiofemoral offset (MTFO) is associated with: (1) magnetic resonance imaging (MRI) pathology of cartilage, meniscus, and ligament; and (2) a distinct pattern of lateral cartilage degeneration on MRI. Three hundred consecutive adult knee MRIs with anteroposterior (AP) radiographs were retrospectively reviewed, and 145 studies were included. MTFO was defined as a medial extension of the medial femoral condyle beyond the articular surface of the medial tibial plateau on weight-bearing AP radiographs. The patients were then divided into the MTFO (n = 61) or no-offset (n = 84) groups. On MRI data obtained on a 1.5-Tesla system, articular cartilage of the femoral condyle and tibial plateau were graded using a modified Outerbridge classification (36 sub-regions similar to whole-organ MRI Score (WORMS) system). In addition, MR pathology of the ACL, MCL, LCL, medial and lateral menisci, were determined. Significantly increased (ANOVA p < 0.007) MR grade of the ligaments, menisci, and cartilage in the MTFO group (ranging from 0.3 to 2.5) compared to the control group (0.2 to 1.1). Color maps of the cartilage grades suggested a marked difference in both severity of degeneration and regional variations between the groups. MTFO group exhibited focally increased cartilage grades in the central, non-weight regions of lateral compartment (region p = 0.07 to 0.12, interaction p = 0.05 to 0.1). MTFO is associated with overall degeneration of the knee and features a distinct lateral cartilage degeneration pattern, which may reflect non-physiologic contact of the cartilage between the lateral tibial eminence and lateral central femoral condyle.

Weight-bearing anteroposterior radiograph of the ankle underestimates the severity of osteoarthritis when there is anterior subluxation of the talus

Category: Ankle Arthritis Introduction/Purpose: On weight-bearing lateral radiograph, anterior aspect of the ankle shows more narrowing than posterior aspect in the ankle osteoarthritis with anterior subluxation of the talus. However, weight-bearing anteroposterior radiograph of the ankle osteoarthritis with anterior subluxation of the talus often shows less severe joint space narrowing than the joint space in the narrowest anterior aspect of the ankle joint. (Fig.1). The purposes of this study were to compare the degree and shape of joint space narrowing in the anterior, middle and posterior aspect of the ankle by using weight-bearing CT and to investigate which area of the ankle was shown on plain weight-bearing ankle anteroposterior radiograph in the ankle osteoarthritis with anterior subluxation of the talus. Methods: We retrospectively evaluated patients who underwent surgery for ankle osteoarthritis in our clinic from January, 2017 to May, 2017. We included patients who showed ankle osteoarthritis with anterior subluxation of the talus in weight-bearing lateral radiograph. We determined anterior, posterior and middle coronal images in sagittal image of the weight-bearing CT.(Fig.1) Talar tilt, medial width of superior clear space(SCS), lateral width of SCS, width of medial clear space and obliteration ratio were measured on plain weight-bearing anteroposterior ankle radiograph, and the three coronal images. The obliteration ratio was obtained by obliteration-width / talus-width * 100.(Fig.1) The radiographic parameters of the anterior coronal image were compared with those on the middle and the posterior coronal image by using paired T-test. The intraclass coefficient was used to investigate which of the three coronal images showed best match with degree and shape of ankle osteoarthritis on the plain weight-bearing ankle anteroposterior radiograph Results: Seventy-one ankles from 71 patients were included in this study. The average age of patients in this study was 62.6 years (range: 19-82). The talar tilt on the anterior coronal image was significantly lower than that on the middle and posterior coronal images. The lateral width of SCS and the width of medial clear space on the anterior coronal image was significantly narrower than those on the middle and the posterior coronal image. The obliteration ratio on the anterior coronal image was significantly higher than that of the middle and the posterior coronal images (Fig.2). The intraclass coefficients indicated that the radiographic parameters on plain weight-bearing anteroposterior radiograph was most reliable with those on the middle coronal image among the three coronal images. Conclusion: Anterior area of ankle shows the most severe osteoarthritis and plain weight-bearing anteroposterior radiograph shows the best match to the middle portion of the ankle, when ankle osteoarthritis has anterior subluxation of the talus. Because middle area of ankle has less severe ankle osteoarthritis than anterior area of ankle in that kind of ankle osteoarthritis, plain weight-bearing radiograph may underestimate the severity of ankle osteoarthritis.

Factors influencing medial sesamoid arthritis in patients with hallux valgus deformity

Category: Midfoot/Forefoot Introduction/Purpose: The importance of preoperative evaluation of the position and degree of arthritic changes of the medial sesamoid bone before hallux valgus correction is emerging. This is an observational study to evaluate the magnetic resonance imaging (MRI) findings of hallux valgus deformity, and assess the severity of and identify the factors that influence the arthritic changes in medial sesamoid-metatarsal (mSM) joints. Methods: We reviewed weight-bearing anteroposterior radiographs, forefoot axial radiographs and MR images of 514 feet of 405 patients who underwent hallux valgus correction. On MRI, the degrees of the arthritic changes in the first metatarsophalangeal (MTP) and mSM joints were categorized into 5 classes. Binary logistic regression analysis was performed to identify the factors affecting the arthritic changes. Results: The binary logistic regression analysis showed that advanced age, more lateralized position of medial sesamoid bone on forefoot axial radiograph, and higher MRI grade of arthritic change of the 1st MTP joint were significant factors contributing to medial sesamoid arthritis (P &lt;0.001, 0.001. 0.006, respectively). Conclusion: Medial sesamoid arthritis can be assessed using MRI. The position of medial sesamoid bone on forefoot axial radiographs can strongly help predict the possibility of mSM joint arthritis.

Factors influencing medial sesamoid arthritis in patients with hallux valgus deformity: Magnetic resonance imaging evaluation

BackgroundThe importance of preoperative evaluation of the position and degree of arthritic changes of the medial sesamoid bone before hallux valgus correction is emerging. This is an observational study to evaluate the magnetic resonance imaging (MRI) findings of hallux valgus deformity, and assess the severity of and identify the factors that influence the arthritic changes in medial sesamoid-metatarsal (mSM) joints. MethodsWe reviewed weight-bearing anteroposterior radiographs, forefoot axial radiographs and MR images of 514 feet of 405 patients who underwent hallux valgus correction. On MRI, the degrees of the arthritic changes in the first metatarsophalangeal (MTP) and mSM joints were categorized into 5 classes. Binary logistic regression analysis was performed to identify the factors affecting the arthritic changes. ResultsThe binary logistic regression analysis showed that advanced age, more lateralized position of medial sesamoid bone on forefoot axial radiograph, and higher MRI grade of arthritic change of the 1st MTP joint were significant factors contributing to medial sesamoid arthritis (P<0.001, 0.001. 0.006, respectively). ConclusionsMedial sesamoid arthritis can be assessed using MRI. The position of medial sesamoid bone on forefoot axial radiographs can strongly help predict the possibility of mSM joint arthritis.Level of evidence: III, observational study.

New insights into the natural course of knee osteoarthritis: early regulation of cytokines and growth factors, with emphasis on sex-dependent angiogenesis and tissue remodeling. A pilot study

This study was conducted to identify cytokine profiles associated with radiographic phenotypes of knee osteoarthritis (rKOA) with a focus on early stage of the disease. The pilot population study involved 60 middle-aged patients (mean age 50±7.3y.). Standardized weight-bearing anteroposterior and axial radiographs were used to assess rKOA severity in tibiofemoral (TFJ) of patellofemoral joint (PFJ) by grading system (grades 0-3). Luminex (xMAP®) technology was used to simultaneously assess 60 biomarkers (BMs). Several pathways of angiogenic (CXCL10/IP-10, FGF1/2, PDGF-AA/BB, ANG1, RANTES), tissue remodeling/fibrosis (MMP1/3, TIMP2/3/4, TGFβ), and fat tissue (leptin) BMs associated with rKOA severity already in very early phase (grade 1). We identified several sets of cytokines as key markers of early knee osteoarthritis (KOA) predicting radiographic features in logistic-regression models (AUC=0.80-0.97). Marked sex-specificity of rKOA course was detected: upregulation of angiogenesis dominated in females, whereas the activation of tissue remodeling was dominant in males. Several of these shifts, e.g., decrease of CXCL10/IP-10, took place only in grade 1 KOA and disappeared or reversed in later stages. OA of different knee-joint compartments has distinct profiles of cytokines. A broad list of BMs (TIMP2/3/4, MMP1/3, TGFβ1/2, vWF-A2, sE-selectin and leptin) associated with OA in the PFJ. Our results demonstrate that substantial and time-limited shifts in the angiogenic and TIMP/MMP systems occur in the early stage of KOA. Our study findings highlight the sex-, grade- and compartment-dependent shifts in above processes. The data may contribute to the individualized prevention of KOA in the future.

Undercorrection of planovalgus deformity after calcaneal lengthening in patients with cerebral palsy.

Level III, therapeutic study.

Changes in Rearfoot Alignment in Chronic Plantar Heel Pain

Plantar heel pain is a common disabling condition in adults. Biomechanical factors are important in the development of plantar heel pain. Quantitative changes in rearfoot alignment in patients with plantar heel pain have not been previously investigated. From April 2016 to March 2017, 100 patients with plantar heel pain and 100 healthy individuals were recruited. The foot posture index was used for the measurement of foot alignment. The generalized joint hypermobility condition was assessed using the Beighton scale. The transverse plane talocalcaneal angle, calcaneocuboid angle, talonavicular uncovering angle, calcaneal inclination angle (CIA), talar declination angle, talar–first metatarsal angle, and sagittal talocalcaneal angle were measured on standard weightbearing anteroposterior and lateral foot radiographs. The body mass index was recorded electronically. The distribution of sex, age, weight, body mass index, side, foot posture index score, and Beighton scale were comparable between groups (p > .05). The mean calcaneocuboid angle (p = .009), talonavicular uncovering angle (p = .000), CIA (p = .000), talar declination angle (p = .039), and talar–first metatarsal angle (p = .000) were significantly higher in the plantar heel pain group. In conclusion, our study has demonstrated a relationship between chronic plantar heel pain and the CIA.

Imaging of the Tibionavicular Ligament, and Its Potential Role in Adult Acquired Flatfoot Deformity.

The spring ligament is an important medial arch stabilizer. However, when disrupted, it does not cause planovalgus deformity until the foot is cyclically loaded. We propose that the tibionavicular (TN) ligament plays an important role. However, this ligament is not imaged in routine magnetic resonance imaging (MRI) sequences. A prospective case-control study using a novel MRI sequence to image the TN ligament in 20 normal feet creating a baseline appearance of the ligament. We then scanned 20 patients with adult acquired flatfoot deformity (AAFD). All patients had weightbearing anteroposterior and lateral radiographs. We followed up patients, the end point being surgery or 18 months' follow-up. The normal ligament was reliably identified on the novel sequences. It had a reproducible appearance in 2 views, and consistent length and width. Two groups of patients were identified in the AAFD cohort: Normal TN (11/20) (The mean Meary angle was 6.8 degrees) and Abnormal TN (9/20). The ligament was thickened proximally, with distal attenuation and intrasubstance edema. On sagittal sequence, it had dorsal bulging and high signal. The mean Meary angle was 13.2 degrees ( P = .013). All patients had posterior tibial tendon dysfunction and 8 had spring ligament complex attenuation. Five patients have undergone corrective surgery compared to none in the other group. This study adds to the evidence that AAFD is multifactorial. With this imaging technique, we were able to reliably image the TN ligament. We hope that including this sequence into routine scanning will help us understand its role in flatfoot deformity. This poses the question of whether this structure will play a role in reconstructive surgery in future. Level II, prospective comparative study.

A Case of Simultaneous Total Knee Arthroplasty in Congenital Dislocation of the Patella

The gonarthrosis with congenital dislocation of the patella is rare condition. This paper will report about total knee arthroplasty (TKA) for the valgus knee with bilateral congenital dislocation of the patella. A 52-year-old woman presented to our hospital with progressive pain in bilateral knees. Both knee showed severe valgus deformity and lateral dislocation of the patella. Anteroposterior weight-bearing radiographs showed osteoarthritic changes in the lateral compartment with 7 valgus deformity at the right and 15 at the left. A bilateral TKA with cruciate retained components (NAKASHIMA FINE) was performed. Good tracking of the patella was achieved by using a lateral parapatellar approach and vastus medialis plication. There are no normative guidelines of operative procedure about TKA for osteoarthritis of valgus knee with congenital dislocation of the patella. With some referencing to current literature, strategies to good patella tracking are discussed.

Coronal Knee Alignment 40 Years after Total Meniscectomy in Adolescents: A Prospective Cohort Study.

Introduction:Meniscectomies result in altered knee biomechanics and increase contact forces on the operated knee joint.Methods:We assessed coronal knee alignment in relation to radiological osteoarthritis grading, clinical range of movement and patient reported outcome measures 40 years after total open meniscectomies in adolescence. Thirty eight knees (30 patients) that underwent total open meniscectomy were assessed on standardised weight-bearing anteroposterior radiographs for deviation from ‘physiological valgus angle’ in either direction (magnitude of malalignment). These values were analysed as per site of meniscectomy for correlations with radiographic scoring systems, range of motion and patient reported outcome measures.Results:Tibiofemoral angle was significantly more varus, and the magnitude of malalignment was significantly higher for the medial meniscectomy patients. The range of flexion was lower for those patients who underwent medial and lateral meniscectomies of the same knee. The patients who underwent meniscectomies of both knees had worse scores for IKDC and KOOS quality of life. Tibiofemoral angle, magnitude of malalignment and range of flexion strongly correlated with Ahlback, and Kellgren and Laurence scores, but patient reported that outcome measures did not correlate.Conclusion:Meniscectomy induced malalignment corresponds to the site of meniscectomy and the radiographic degree of osteoarthritis. While malalignment and reduced range of movement correlate well with worsening radiographic signs of arthritis, patient reported outcome measures do not correlate.

Weightbearing vs Gravity Stress Radiographs for Stability Evaluation of Supination-External Rotation Fractures of the Ankle.

Isolated lateral malleolar fractures may result from a supination-external rotation (SER) injury of the ankle. Stable fractures maintain tibiotalar congruence due to competent medial restraints and can be treated nonoperatively with excellent functional results and long-term prognosis. Stability might be assessed with either stress radiographs or weightbearing radiographs. A consecutive series of patients with closed SER fractures (presumed AO 44-B1) were prospectively enrolled from 2008 to 2015. Patients with clearly unstable fractures (medial clear space more than 7 mm) on the initial nonweightbearing radiograph were excluded and operated on. All other patients were examined with a gravity stress and a weightbearing anteroposterior radiograph. Borderline instability of the fracture was assumed when the medial clear space was 4 to 7 mm. Those were treated nonoperatively. Of 104 patients with isolated lateral malleolar fractures of the SER type, 14 patients were treated operatively because of clear instability (displacement) on the initial radiographs. Of the nonoperative patients, 44 patients demonstrated borderline instability on the gravity stress but stability on the weightbearing radiograph ("gravity borderline"); the remaining 46 were stable in both tests ("gravity stable"). At an average follow-up of 23 months, no significant differences were seen in the American Orthopaedic Foot & Ankle Society hindfoot score (92 points gravity-borderline group vs 93 points gravity-unstable group), the Foot Functional Index score (11 vs 10 points), the Short Form 36 (SF-36) physical component (86 vs 85 points), and SF-36 mental component (84 vs 81 points). Radiographically, all fractures had healed with anatomic congruity of the ankle. Weightbearing radiographs provided a reliable basis to decide about stability and nonoperative treatment in isolated lateral malleolar fractures of the SER type with excellent clinical and radiographic outcome at short-term follow-up. Gravity stress radiographs appear to overrate the need for operative treatment. Level III, prospective comparative study.

Association between serum and synovial fluid Dickkopf-1 levels with radiographic severity in primary knee osteoarthritis patients.

Primary knee osteoarthritis (OA) contributes to disability among middle-aged and elderly people. Dickkopf-1 (Dkk-1) and sclerostin are inhibitors of Wnt/β-catenin signaling pathway implicated in regulation of cartilage homeostasis and bone formation, respectively. We aim to investigate the association between the serum(s) and synovial fluid (SF) Dkk-1 and sclerostin levels and disease severity in patients with primary knee OA. Forty patients aged 56-87years with primary knee OA and 20 healthy individuals were recruited. Weight-bearing anteroposterior radiographs of the affected knee were used to determine the disease severity according to Kellgren and Lawrence criteria. Dkk-1 and sclerostin levels in serum and SF were measured by ELISA. SF Dkk-1 levels were significantly higher in the OA, compared to control group (180±182 vs 128±330pg/ml, p<0.001). However, OA patients did not differ significantly regarding the sDkk-1 concentrations compared to healthy controls (1289.8pg/ml vs 1214.1, respectively, p=0.630). SF Dkk-1 levels in Kellgren and Lawrence (KL) grade 4 were significantly elevated compared to those of KL grades 2 and 3 (1.97 vs 2.23pg/ml, p=0.017, log transformed because data were not normally distributed), whereas sDkk-1 levels between those groups demonstrated marginally statistically significant difference (1111.8 vs 1415.9pg/ml, p=0.057). SFSclerostin and sSclerostin levels did not have any significant difference between the OA and control groups. SF Dkk-1 levels are positively related to the severity of joint damage in knee OA. Sclerostin levels failed to substantiate an association to knee OA progression. Dkk-1 could play a potential role in the degenerative process of OA. Thus, DKK-1 may emerge as a promising future therapeutic manipulation of OA.

Factors Associated with the Use of Hyaluronic Acid and Corticosteroid Injections among Patients with Radiographically Confirmed Knee Osteoarthritis: A Retrospective Data Analysis

PurposeDespite the rapid proliferation of hyaluronate (HA) and corticosteroid (CO) injections and clinical guidelines regarding their use in osteoarthritis (OA), information on the characteristics of people receiving these injections is scarce. We describe the use of injections among adults with radiographically confirmed knee OA and identify factors associated with injection use. MethodsWe used publicly available data from the Osteoarthritis Initiative (OAI), an international collaboration sponsored by the National Institutes of Health, and included participants with ≥1 radiographically confirmed knee OA (Kellgren-Lawrence grade ≥2 [definite osteophytes and possible joint space narrowing (JSN) on anteroposterior weight-bearing radiograph]) at baseline. We matched 415 participants who received at least 1 HA and/or CO injection during the 6-month interval before 1 of the first 7 annual follow-up assessments to 1841 injection nonusers by randomly selecting a study visit to match the distribution observed in the injection users. Multinomial logistic regression models were used for identifying factors associated with injection use, including sociodemographic and clinical/functional factors. FindingsEighteen percent of the 2256 patients identified as having knee OA had received at least 1 injection (years 1–7, 16.9%, 13.7%, 16.6%, 13.5%, 15.9%, 13.5%, and 9.9%, respectively), most commonly with CO (68.4%). HA and CO were more commonly injected in those with a higher annual household income (adjusted odds ratio [aOR] [95% CI] with HA, US ≥$50,000 vs <$25,000, 3.63; [1.20–10.99]) and less commonly in black patients (HA, 0.19 [0.06–0.55]). Greater Kellgren-Lawrence grade (grade 4 vs 2) was associated with an increased likelihood (aOR [95% CI]) of having received HA (4.79 [2.47–9.30]), CO (1.56 [1.04–2.34]), or both (4.94 [1.99–12.27]). ImplicationsThe receipt of HA or CO injection may be associated with higher socioeconomic positioning and indicators of greater disease severity in patients with knee OA.

Radiographic Analysis of Feet With and Without Morton's Neuroma.

The aim of this research was to investigate the association of various structural measurements of the forefoot with Morton's neuroma (MN). Weightbearing anteroposterior and lateral foot radiographs of subjects attending the University of Western Australia (UWA) Podiatry Clinic and the first author's private practice were included in this study. A single assessor measured the following angles: lateral intermetatarsal angle (LIMA), intermetatarsal angle (IMA), hallux valgus angle (HVA), digital divergence between the second and third digits (DD23), digital divergence between the third and fourth digits (DD34) and relative metatarsal lengths of the first to fifth metatarsals (Met1-5), and the effect of MN size as measured by ultrasonograph on digital divergence. Intratester reliability of all radiographic measurements was assessed on all radiographic measurements. The study included 101 subjects, of whom 69 were diagnosed with MN and 32 were control subjects without MN. The mean (± standard deviation) age of MN subjects was 52 (±15) years and for control subjects, 48 (±12) years. When comparing all feet, there were no significant differences in the LIMA, HVA, IMA, digital divergence angles and the relative metatarsal distances between subjects with MN and control subjects. No relationship between MN size and digital divergence was found in either foot, or in either neuroma location. We were unable to demonstrate any relationship in this study between radiographic metatarsal length and angular measurements in a symptomatic MN group compared to a control group. In addition, we did not find any correlation between the size of MN as measured from ultrasonographic images and radiographic evidence of digital divergence. Level III, case control study.

Effectiveness of Percutaneous Proximal Closing Wedge Osteotomy With Akin Osteotomy to Correct Severe Hallux Valgus Determined by Radiographic Parameters.

Therapeutic, Level IV: Case series.

Tibial Sesamoid Position Influence on Functional Outcome and Satisfaction After Hallux Valgus Surgery.

During hallux valgus surgery, the abnormal position of the first metatarsal bone relative to the sesamoids is addressed. Our study aimed to investigate the influence of postoperative tibial sesamoid position (TSP) on functional outcome and patient satisfaction after hallux valgus surgery. Between February 2007 and November 2011, 250 patients who underwent hallux valgus surgery at our tertiary hospital were followed for 2 years after surgery. They were categorized into 2 groups based on Hardy and Clapham's TSP classification, recorded on postoperative weight-bearing anteroposterior (AP) radiographs: (1) normal (grades I-IV) and (2) outliers (grades V-VII). The mode TSP improved from grade VII preoperatively to grade IV postoperatively (P < .001). The visual analog scale for pain was 1 (95% CI 0, 1) point better in the normal group compared to the outlier group at 2 years after surgery (P = .050), whereas the American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale was 6 (95% CI 2, 11) points higher in the normal group (P = .009). Patients in the outlier group were also more likely to be dissatisfied with the surgery performed when compared to the normal group (OR 3.881, 95% CI 1.689, 8.920, P = .001). We recommend correcting the TSP to grade of IV or less to improve functional outcome and satisfaction after hallux valgus surgery. Level III, retrospective comparative series.

Do Radiographic and Clinical Parameters in the Setting of a Bunion Predict Second Ray Pathology?

Category: Bunion Introduction/Purpose: Hallux valgus deformity is well known to cause second ray pathology, commonly manifested as a second hammertoe or second tarsometatarsal (TMT) joint osteoarthritis (OA). This likely results from decreased weight-bearing capacity of the first metatarsal in the setting of worsening metatarsus primus varus, TMT joint hypermobility, or an excessively long second metatarsal or second toe. It is not known for sure, however, which radiographic and clinical factors in the setting of hallux valgus are protective of second ray pathology and which lead to second hammertoe, TMT joint OA, or both. We hypothesized that the formation of second ray pathology would be correlated with increasing age, increased body mass index (BMI), increased hallux valgus angle (HVA), increased intermetatarsal angle (IMA), and increased second metatarsal length. Methods: All consecutive patients who underwent operative reconstruction for symptomatic hallux valgus from January 2007 to July 2015 by the senior author were included. Patients were grouped into those with 1) bunion only 2) bunion with hammertoe and 3) bunion with second TMT joint OA. Preoperative age, sex, and BMI were recorded. Pre-operative HVA, IMA, metatarsus adductus angle (MAA), and first and second metatarsal lengths were measured on weight-bearing anteroposterior (AP) radiographs. Talar-first metatarsal angle was measured on weight-bearing lateral radiographs. One-way analysis of variance (normality demonstrated) and Kruskal-Wallis (normality not demonstrated) were used to assess differences in continuous variables. Post hoc tests were conducted with Bonferroni technique. Associations between discrete variables and the study groups were analyzed using chi-square tests. Results: Increased age was associated with both hammertoe (P = 0.000) and TMT joint OA (P = 0.006). Increased BMI was associated with TMT joint OA (P = 0.016). Increased HVA was associated with both hammertoe (P = 0.039) and TMT joint OA (P = 0.038). When analyzed categorically, 29.7% of patients with TMT joint OA had a moderate HVA (30.0-39.9 degrees) whereas 22.2% of patients with a bunion only had a moderate HVA (P &lt; 0.05). A one-degree increase in HVA was associated with a 5% chance of having a hammertoe as compared to a bunion only. MAA correlated with TMT joint OA (P = 0.048) (Table 1). Conclusion: Our data suggests that increased age (a surrogate for bunion duration) and increased HVA may predispose patients with hallux valgus to second hammertoe and TMT joint OA formation. Increased BMI may lead to the development of TMT joint OA. Increased MAA may predispose to hammertoe formation. Increased MAA may lead to TMT joint OA. Alternatively, increased MAA could result as a consequence of midfoot cartilage and bone loss in the setting of hallux valgus. This data can help surgeons better inform patients about the optimal timing of bunion reconstruction with or without concomitant second ray surgery.

Diagnosis of Deltoid Ligament Contracture in Varus Ankle Osteoarthritis

Category: Ankle Arthritis Introduction/Purpose: In total ankle replacement arthroplasty, ligament balancing is important to obtain a stable ankle joint and to prevent edge loading which would lead to asymmetric accelerated polyethylene wear and component loosening. Deltoid ligament release is recognized as an essential step in surgical technique for correcting varus instability. However, necessity of deltoid ligament release in every ankles with varus deformity is suspected recently because varus deformity could be corrected without deltoid ligament release in several ankles. The aims of this study were to assess the prevalence of deltoid ligament contracture and to identify the radiographic parameters that could predict the deltoid ligament contracture in ankle osteoarthritis which needs total ankle arthroplasty. Deltoid ligament contracture was determined when valgus stress radiograph showed talar tilt ≥ 0.5° and medial clear space ≤ 4 mm in this study. Methods: The plain weight-bearing radiograph and the valgus stress radiograph of 118 ankles (103 patients) with osteoarthritis were retrospectively evaluated. The 118 ankles were comprised 68 ankles of asymmetric varus-osteoarthritis(OA) group which showed medial joint space obliteration and tibiotalar angle ≥ 10°, 37 ankles of end-stage neutral-OA group which showed overall superior joint space obliteration and tibiotalar angle ≤ 10° and 13 ankles with end-stage varus-OA group which showed overall superior joint space obliteration and tibiotalar angle ≥ 10°. Various radiographic parameters of plain weight-bearing anteroposterior radiograph – talar tilt, distance from medial malleolus to talar dome (MM-T distance), talus center migration – were investigated. The individual associations between the deltoid ligament contracture and these radiographic parameters and the most important radiographic parameter were determined using logistic regression analysis. The optimal threshold of the most important radiographic parameters for predicting deltoid ligament contracture was determined with use of receiver operating characteristic curve analysis. Results: Thirty-seven ankles in the asymmetric varus-OA group (54%) had deltoid ligament contracture, while one ankle of the end-stage neutral-OA group (2.7%) and one ankle of the end-stage varus-OA group (7.7%) had deltoid ligament contracture. Among the 118 ankles, the talar tilt (Exp(B): 1.239, P=0.000) and the MM-T distance (Exp(B): 1.141, P=0.016) were significantly associated with the deltoid ligament contracture in the univariate logistic regression analysis. And only the talar tilt (Exp(B): 1.251, P=0.000) was significantly associated with the deltoid ligament contracture between the two significant radiographic parameters in the multivariate logistic regression analysis. The optimal threshold for predicting deltoid ligament contracture was 8.9° of the talar tilt, with a sensitivity of 76.9% and a specificity of 77.2%. Conclusion: This study showed that half of varus ankle osteoarthritis and most of end-stage ankle osteoarthritis did not have deltoid ligament contracture and the talar tilt could predict the deltoid ligament contracture. During total ankle arthroplasty, clinicians should determine deltoid ligament contracture before deltoid ligament release by using the talar tilt, because there may be a risk of valgus instability when deltoid ligament was released in ankles without deltoid ligament contracture.