Hallux Valgus Recurrence After Simple Bunionectomy: Algorithm Treatment

Background: Recurrences of hallux valgus can be difficult to manage, especially after a prior simple bunionectomy. This study aimed to present a treatment algorithm for the correction of recurrences after a simple bunionectomy.Methods: This was a single-center, descriptive, and retrospective comparative study. Thirty-four consecutive patients were classified according to the bone stock and the presence or absence of end-stage arthritis of the first metatarsophalangeal joint (MTPJ). According to our algorithm, we only performed an osteotomy as the salvage procedure in cases with sufficient bone stock and absence of or mild arthritis. In the other cases, we performed an MTPJ fusion. Exceptionally, we chose a Keller-Brandes arthroplasty for patients with advanced age and comorbidities. Results: We performed 17 scarf osteotomies (50%), 15 MTPJ arthrodeses (44.1%), and 2 Keller-Brandes arthroplasties (5.9%). Following the algorithm, we achieved an improvement of the AOFAS score of >30 points without severe complications in all groups.Conclusions: The proposed operative algorithm successfully addresses the recurrences considering the lack of bone stock and the presence of MTPJ arthritis.Level of EvidenceLevel 3: retrospective comparative study

Effect of Displacement Degree of Distal Chevron Osteotomy on Metatarsal Stress: A Finite Element Method

Background: The stress of foot bone can effectively evaluate the functional damage caused by foot deformity and the results of operation. In this study, the finite element method was used to investigate the degree of displacement of distal chevron osteotomy on metatarsal stress and metatarsophalangeal joint load; Methods: Four finite element models of displacement were established by using the CT images of a patient with moderate hallux valgus (hallux valgus angle and intermetatarsal angle were 26.74° and 14.09°, respectively), and the validity of the model was verified. Each finite element model consisted of bones and various cartilage structures, ligaments, and plantar fascia, as well as encapsulated soft tissue. Except for soft tissue, the material properties of other parts were isotropic linear elastic material, and the encapsulated soft tissue was set as nonlinear hyperelastic material. The mesh was tetrahedral mesh. Link elements were used in ligament and plantar fascia. A ground reaction force with a half-body weight was applied at the bottom of the floor to simulate the ground reaction when standing. The upper surfaces of the encapsulated soft tissue, distal tibia, and distal fibula were fixed. The stress distribution of metatarsals and the stress of cartilage of the first metatarsophalangeal joint were compared and analyzed; Results: Compared with the hallux valgus without osteotomy, the stress of the first metatarsals and second metatarsals of 2–4 mm decreased, and the stress of the interarticular cartilage of the first metatarsophalangeal joint with 4 mm was reduced. In the case of 6 mm, the stress value between the first metatarsal and the first metatarsophalangeal joint increased, and 4 mm was the most suitable distance; Conclusions: Compared with the hallux valgus without osteotomy, the stress of the first metatarsals and second metatarsals of 2–4 mm decreased, and the stress of the interarticular cartilage of the first metatarsophalangeal joint with 4 mm was reduced. In the case of 6 mm, the stress value between the first metatarsal and the first metatarsophalangeal joint increased, and 4 mm was the most suitable distance. For the degree of displacement of the distal chevron osteotomy, the postoperative stability and the stress distribution of metatarsal bone should be considered. Factors such as hallux valgus angle, intermetatarsal angle, patient’s age, body weight, and metatarsal width should be considered comprehensively. The factors affecting osteotomy need to be further explored. The degree of displacement of osteotomy can be evaluated by FE method before the operation, and the most suitable distance can be obtained.

Concept, etiology, and pathomechanics of hallux rigidus

There is a continuous anatomical, functional and pathomechanical roadmap from functional hallux limitus to hallux rigidus. Although many etiologies for hallux rigidus have been studied it is very probable that it has a primary origin with less-than-ideal movement when we are born. Upon a restricted range of motion, symptoms may arise depending on the amount of work and how compensatory mechanisms work around the first metatarsophalangeal joint. Changes occurring at the joint that allow the transition from a sliding movement mechanism (physiological) to a rolling mechanism (pathological) may trigger anatomical and functional changes resulting in pain and dysfunction. Any surgical technique that is able to restore the sliding mechanism to the first metatarsophalangeal joint will have a positive impact on pain and function in a patient with a symptomatic functional hallux limitus/rigidus. Level of Evidence V; Therapeutic Study; Expert opinion.

Medially positioned plate in first metatarsophalangeal joint arthrodesis

Objective The purpose of this study was to biomechanically compare the stability of first metatarsophalangeal (MTP1) joint arthrodesis with dorsally and medially positioned plates. Methods A physical model of the MTP1 joint consists of printed synthetic bones, a titanium locking plate and screws. In the experiments, samples with dorsally and medially positioned plates were subjected to loading of ground load character in a universal testing machine. Force-displacement relations and relative displacements of bones were recorded. The obtained results were used to validate the corresponding finite element models of the MTP1 joint. Nonlinear finite element simulations of the toe-off phase of gait were performed to determine the deformation and stress state in the MTP1 joint for two positions of the plate. Results In numerical simulations, the maximum displacement in the dorsal direction was noticed at the tip of the distal phalanx and was equal to 19.6 mm for the dorsal plate and 9.63 mm for the medial plate for a resultant force of 150 N. Lower relative bone displacements and smaller plastic deformation in the plate were observed in the model with the medial plate. Stress values were also smaller in the medially positioned plate and locking screws compared to fixation with the dorsal plate. Conclusions A medially positioned locking plate provides better stability of the MTP1 joint than a dorsally positioned plate due to greater vertical bending stiffness of the medial plate. Smaller relative bone displacements observed in fixation with the medial plate may be beneficial for the bone healing process. Moreover, lower stress values may decrease the risk of complications associated with hardware failure.

Symptomatic Medial Bone Excrescence in the Distal Phalanx of the Hallux after the First Metatarsophalangeal Joint Arthrodesis: A Case Report and Radiographic Reviews

Medial bone excrescence at the base of the distal phalanx of the hallux is a common manifestation which is rarely painful. In this case report, we described the first case of the excrescence becoming symptomatic one year after a metatarsophalangeal (MTP) joint arthrodesis of the great toe in a 74-year-old female. The medial bony excrescence which was obscure preoperatively became obvious postoperatively in the anteroposterior foot radiographs. The patient was successfully treated by an excision of the excrescence. In order to clarify the pathology of the excrescence, we reviewed the radiographs with respect to the excrescence before and after hallux surgeries including 97 metatarsal osteotomies and 33 MTP joint arthrodesis. The width of the excrescence measured in the anteroposterior foot radiographs displayed substantial increment one month after the hallux surgeries (osteotomy group: 0.9 ± 0.7 vs. 1.5 ± 0.7 mm , p < 0.01 ; arthrodesis group: 1.3 ± 0.8 vs. 1.8 ± 1.0 mm , p < 0.01 ). However, there was no significant difference in the width of the excrescence between one month after surgery and at the most recent follow-up of around 20 months in average after the surgery (osteotomy group: 1.5 ± 0.7 vs. 1.4 ± 0.7 mm , p = 0.62 ; arthrodesis group: 1.8 ± 1.0 vs. 1.8 ± 0.7 mm , p = 0.37 ). The present case and our radiographic review suggested that the postoperative medial bony excrescence was not the result of change of position of the preexisting excrescence. The correction of pronation deformity through hallux surgeries could emphasize the medial bony excrescence and cause symptomatic irritation upon shoe contact.

Distribution of bony erosions in feet and performance of two bone erosion scores: A dual-energy computed tomography study of 61 patients with gout

Objectives To assess the distribution of bone erosions and two erosion scores in the feet of patients with gout and analyze the association between erosion scores and monosodium urate (MSU) crystal deposition using dual-energy computed tomography (DECT). Materials and methods We included all patients who underwent DECT of both feet between 2016 and 2019 in our radiology department, with positive detection of MSU deposits. Data on sex, age, treatment, serum urate, and DECT urate volumes were obtained. CT images were analyzed to score bone erosions in 31 sites per foot by using the semi-quantitative method based on the Rheumatoid Arthritis MRI Scoring (RAMRIS) system and the Dalbeth-simplified score. Reproducibility for the two scores was calculated with intraclass correlation coefficients (ICCs). Correlations between clinical features, erosion scores and urate crystal volume were analyzed by the Spearman correlation coefficient (r). Results We studied 61 patients (mean age 62.0 years); 3,751 bones were scored. The first metatarsophalangeal joint and the midfoot were the most involved in terms of frequency and severity of bone erosions. The distribution of bone erosions was not asymmetrical. The intra- and inter-observer reproducibility was similar for the RAMRIS and Dalbeth-simplified scores (ICC 0.93 vs 0.94 and 0.96 vs 0.90). DECT urate volume was significantly correlated with each of the two erosion scores (r = 0.58–0.63, p < 0.001). There was a high correlation between the two scores (r = 0.96, p < 0.001). Conclusions DECT demonstrates that foot erosions are not asymmetric in distribution and predominate at the first ray and midfoot. The two erosion scores are significantly correlated with DECT urate volume. An almost perfect correlation between the RAMRIS and Dalbeth-simplified scores is observed.