Foot & Ankle International

We reviewed the results of reconstruction of the fore part of the foot in rheumatoid patients by arthrodesis of the first metatarsophalangeal joint. The follow-up averaged 4.1 years (range, 2.0 to 7.25 years). Eighteen feet in eleven women were operated on. Twelve feet underwent total reconstruction of the fore part: arthrodesis of the first metatarsophalangeal joint and excision of all of the lesser metatarsophalangeal joints. Six feet underwent subtotal reconstruction, which included arthrodesis of the first metatarsophalangeal joint. The results were classified as excellent in fourteen feet, good in two, and fair in two. There were no poor results. Metatarsophalangeal bone fusion was achieved in all but one foot (fusion rate, 94 per cent). The one fibrous ankylosis was painless, with satisfactory function. Interphalangeal degenerative joint disease was a radiographic but not a clinical sequela. Arthrodesis of the first metatarsophalangeal joint provided stability that permanently corrected deformity, permitted the patients to wear ordinary shoes, and, in combination with excisional arthroplasty of involved lesser metatarsophalangeal joints, relieved disabling pain in the fore part of the foot.

Thirty patients (37 feet) with severe hallux rigidus underwent resection arthroplasty of the first metatarsophalangeal joint with our modification (reattachment of the extensor hood and extensor brevis to the flexor hallucis brevis as a capsular interposition arthroplasty, with minimal bone resection). Pain and function were significantly improved. Transfer metatarsalgia was not seen. All patients had at least 4/5 plantarflexion strength and averaged 50° of dorsiflexion. In patients with severe hallux rigidus and nearly equal length of first and second metatarsals, capsular interpostion arthroplasty offers a surgical option that relieves pain without sacrificing motion or strength.

We retrospectively evaluated the results of 50 hallux valgus reconstructions in 36 patients for moderate to severe deformities, performed by the senior author (F. M. T.). All feet were treated at the metatarsophalangeal joint with a distal soft tissue realignment. The first 25 feet were corrected proximally with a crescentic osteotomy fixed with an AO screw; these cases had an average follow-up of more than 5 years (range, 40–141 months). The second 25 feet underwent a basal osteotomy with a proximally directed chevron osteotomy; these cases had an average follow-up of 21.4 months (range, 12–33 months). The average hallux valgus correction in the crescentic osteotomy group went from 37.6° to 11.4°, and in the chevron osteotomy group, the hallux valgus angle was reduced from 31.3° to 11.6°. The intermetatarsal angle in the crescentic group was corrected from 16.2° to 6°, and in the chevron group the intermetatarsal angle was reduced from 15.1° to 5.4°. The fibular sesamoid subluxation was reduced from 92% to 24% in the crescentic group and from 88% to 18% in the chevron group. All patients were assessed using the American Orthopaedic Foot and Ankle Society scale, in which 100 points are used to compare pre- and postoperative pain, function and range of motion, shoewear comfort and activity levels, and alignment. In the crescentic group, the score improved from 46.8 points to 93.1 points; in the chevron group, the score changed from 53.4 points to 92.7 points. In all parameters studied, there were no statistically significant differences using the Student's t-test. We conclude that the two operative techniques offer equivalent results, which are excellent and predictable. The proximal chevron osteotomy is technically easier, eliminates the proximal dorsal scar, and does not require postoperative metal removal.

The Mitchell distal metatarsal stepcut osteotomy for the treatment of hallux valgus is a technically demanding procedure with a high complication rate. Reported complications include metatarsal shortening with lateral metatarsalgia, partial avascular necrosis of the distal fragment, and loss of position with incomplete correction. Nonunion, however, has only rarely been reported. We describe our experience with the treatment of three nonunions of Mitchell osteotomies reconstructed using a tricortical iliac crest bone graft.

Seventeen adult fresh-frozen below-knee amputation cadaver specimens were studied. Calcific Achilles tendinitis was present in three specimens. After exposing the Achilles tendon insertion on the calcaneus, the insertion was outlined with waterproof paint. The specimens were photographed on a special plexiglass apparatus to highlight important findings. For the purpose of showing the length of insertion on lateral radiographs, lead beads were placed on the most superior and most inferior aspects of the insertion.

All specimens showed that the tendon terminated at the medial and lateral bone borders of the calcaneus without significant extension around the medial or lateral wall. All specimens revealed a greater distance of insertion on the medial calcaneus than on the lateral side. In the specimens that had calcific Achilles tendinitis, the posterior bone surface of the spurs was devoid of tendinous insertion. Instead, the insertion occurred between the spur and the posterior wall of the calcaneus. All spurs were located laterally at the most inferior border of the tendon insertion.

Bilateral weightbearing anteroposterior and lateral radiographs were analyzed in 43 patients with a clinical diagnosis of posterior tibial tendon insufficiency by two independent observers. The radiographs of each patient's asymptomatic foot was considered to serve as the control for the preexistance of pes planus. The radiographs were assessed for the severity of flatfoot deformity, the degree of talonavicular coverage, the talometatarsal angle, the calcaneometatarsal angle, the cuneiform to ground height and the cuneiform to fifth metatarsal height. Interobserver correlatations were assessed. Results indicated that there was a high interobserver correlation for the values measured, making these angles reproducible among observers. Strong correlations were found in the degree of severity of flatfoot deformity between the asymptomatic and symptomatic feet as well as the values used to assess pes planus (i.e., similar radiographic measurements on the opposite side). The data suggest that patients with posterior tibial tendon insufficiency often have a preexisting flatfoot. This substantiates our belief that a preexisting flexible flatfoot, although far from the determining factor, is one of several etiological factors in the development of posterior tibial tendon insufficiency.

Macrodystrophia lipomatosa is a distinct clinical entity often misdiagnosed as other forms of macrodactyly. The most specific finding is an overabundance of fibrofatty tissue on the plantar aspect of the foot. Three cases, with the diagnoses made from tissue specimens, are presented in this article. The clinical, pathologic, and roentgenographic findings are discussed and a review of the literature is provided.

The Ruiz-Mora procedure has been advocated for treatment of congenital overlapping fifth toes, fifth hammertoe, and clavus deformities. This study evaluated the results of the Ruiz-Mora procedure in 12 patients with an average follow-up of more than 4 years. The data indicate the majority of patients are satisfied with the results of the procedure. Unacceptable cosmesis was the primary complaint of all dissatisfied patients. Assessment of preoperative versus postoperative symptoms indicate an improvement in symptoms as well as maintenance of stability and function. The average shortening of the toe was 12.8 mm. This presented no functional problems to the patients. Three patients had transient skin healing problems which resolved with local care. Based on this series, the Ruiz-Mora procedure is effective in dealing with the problem of the cock-up fifth hammertoe and is associated with few complications. Because of patient dissatisfaction with cosmesis, consideration should be given to showing patients postoperative photographs of the procedure before surgery and reserving this procedure for salvage of iatrogenic cock-up deformities, recalcitrant hard corns, and congenital cock-up deformities.

Five patients with osteoid osteomas of the talar neck were treated at the Hospital for Special Surgery between 1981 and 1992. The course of care leading to definitive diagnosis and treatment was reviewed.

All five of the patients had night pain relieved by aspirin or nonsteroidal anti-inflammatory drugs. One of the five reported associated trauma. The average time from onset of symptoms to correct diagnosis was 2.5 years. Juxta-articular osteoid osteoma can cause a small spur that resembles a traction spur on the neck of the talus. Anterior ankle impingement was the most common misdiagnosis. Initial treatments included arthroscopic spur debridement or synovectomy, casting for fracture, and repeated nerve blocks for reflex sympathetic dystrophy. The five patients were cured by en bloc excision of the lesion.

In the diagnosis of osteoid osteoma, a history of relief of pain with aspirin is important. Plain radiographs and a bone scan are useful. Fine cut computed tomography scanning or magnetic resonance imaging are the best studies for making a definitive diagnosis. Localization by computed tomography guided needle placement or intraoperative radionuclide scanning are recommended to find the lesion for excision. Intraoperative radiographs of the excised lesion should be used to confirm complete removal.