Foot & Ankle International

The results of hallux valgus correction were reviewed for 34 male patients (41 feet). The severity of the preoperative deformity determined the operative technique of correction. A distal soft tissue procedure with proximal first metatarsal osteotomy was performed in 30 patients (35 feet) with an average correction of the hallux valgus angle of 22°. A chevron procedure was performed in five cases and a McBride procedure in one other case, all with less severe deformities. Complications included one deep wound infection, one broken screw at the metatarsal osteotomy site, and three cases of hallux varus. No patients underwent reoperation. Undercorrection was noted in 10 of 35 cases (29%) where a distal soft tissue procedure with proximal first metatarsal osteotomy was performed.

A nonsubluxated (congruent) metatarsophalangeal (MTP) joint associated with a hallux valgus deformity was present in 15 of 41 (37%) of all cases and 10 of 35 (29%) of cases that underwent a distal soft tissue procedure with proximal metatarsal osteotomy (DSTR with PMO). A subluxated (noncongruent) MTP joint associated with hallux valgus was present in 26 of 41 (63%) of all cases and 25 of 35 (71 %) of cases undergoing a DSTR with PMO. There was a highly significant difference in the average distal metatarsal articular angle (DMAA) as measured in the nonsubluxated (congruent) MTP joints (20.7°) and the subluxated (noncongruent) MTP joints with hallux valgus (10°) (P = 0.0001). The average distal metatarsal articular angle for all cases undergoing DSTR with PMO was 13°. When the postoperative hallux valgus angle was compared with the DMAA, the average residual hallux valgus angle was 10.1°. With a subluxated (noncongruent) first MTP joint with hallux valgus (a low DMAA), the percent of hallux valgus correction (hallux valgus correction [in degrees])preoperative hallux valgus deformity [in degrees]) was 77%. In patients with a nonsubluxated (congruent) first MTP joint with hallux valgus (a high DMAA), the percent correction was 46%, an almost twofold difference in percent correction.

There was a close correlation between the preoperative DMAA and the postoperative hallux valgus angle in both the subluxated and congruent subgroups (P = 0.0003). With an intra-articular repair (a DSTP with PMO), the magnitude of correction of a hallux valgus deformity is limited at the MTP joint by the distal metatarsal articular angle.

Thirteen patients presenting with symptomatic pathologic variations or congenital deformities of the subtalar joint are presented. These variations included: four abnormal posterior talar processes, five patients with asymmetric subtalar joint development, and four congenital complete subtalar coalitions with a secondary ball-and-socket joint. In each case these adult patients had been unaware of the variation and had been symptom free until “awakening” sprain or fracture trauma brought about symptoms. The nonoperative and operative management of these variations is reviewed.

Current literature consistently precludes the chevron osteotomy for bunion correction in patients older than age 50 years. We retrospectively reviewed 47 patients (73 bunions) with an average age of 62 years (range, 55–81 years old) who had a chevron-Akin double osteotomy. The mean follow-up was 4 years, 6 months (range, 2 years, 3 months to 8 years, 2 months). The overall satisfaction rate was 95%. No significant pain or stiffness in the first metatarsophalangeal joint occurred in comparison with other bunion procedures. Radiographic results were better for patients with a preoperative intermetatarsal angle of less than 15° and tibial sesamoid position of less than or equal to 2.

We disagree with the current recommendation that age older than 50 years is a contraindication to a chevron procedure. The Akin osteotomy adds additional intraoperative correction of the hallux angulation and rotation; thus, the chevron-Akin double osteotomy is a useful combination procedure. We recommend this procedure for the mild to moderate bunion deformity even in elderly patients.

The main objective of this study was to compare subtalar inversion stress views using the Brodén view with inversion stress views on helical computed tomography (CT). One of the drawbacks of routine radiography is the imaging of three-dimensional structures in a two-dimensional plane. We investigated whether the use of helical CT would lead to a more objective and clearer measurable method to determine the amount of tilt in the subtalar joint. A group of 15 patients with unilateral chronic instability complaints and clinically suspected subtalar instability was examined. The contralateral asymptomatic foot was used as control.

A variable amount of subtalar tilt (range, 4° to 18°) was demonstrated in all cases on stress radiographs, without finding significant difference between the symptomatic and asymptomatic feet. However, contrary to the findings at the talocrural level, subtalar tilt was found in none of the patients using helical CT. Thus, we now doubt that the tilt seen during stress examination using the Brodén view is the true amount of tilt. It may be that the lateral opening, seen on these radiographs, largely results from imaging two planes that have made a translatory and rotatory movement relative to each other in an oblique direction. It is concluded that the Brodén stress examination might not be useful for screening patients with subtalar instability.

Associated anomalies not visible on the radiographs were detected by helical CT. In four cases, narrowing of the articular cartilage and irregular and hypertrophic bone formation at the middle facet joint of the subtalar joints were found. It is likely that these changes cause disturbance of function of this joint and it is suggested that the subjective complaint of instability with “giving way” is not only caused by hypermobility, but can be caused by other disturbances of normal motion.

Between 1987 and 1994, we treated 33 patients with surgical revision for failed triple arthrodesis, 28 (29 feet) of whom returned for final examination (mean, 4.4 years; range, 2–7 years). The average age of these 16 women and 12 men was 46 years (range, 14–69 years). Before the revision procedure, patients had undergone nonoperative therapies for an average of 3.7 years (range, 0.5–12 years) and an average of three foot operations (range, 1–6 operations) after the primary triple arthrodesis.

All patients were managed with rigid internal fixation via cannulated screws and power staples. Calcaneal osteotomy and/or revision of the transverse tarsal arthrodesis via appropriate saw cuts and bone wedges were used. Iliac crest bone graft was added, when a bone block arthrodesis was required, for those patients with nonunion or ankle impingement.

Arthrodesis was achieved in all 29 feet, although 4 patients (4 feet) (14%) required additional procedures for malunion (2 patients), deformity recurrence (1 patient), deep infection (1 patient), and skin graft (1 patient). Comparison of the average pre- (retrospective) and postoperative American Orthopaedic Foot and Ankle Society 94-point hindfoot and ankle scores showed a significant improvement: 31 points (range, 13–61 points) versus 59 points (range, 24–91 points), respectively (P < 0.05). On a scale of 0 to 10 points, average patient satisfaction was 7.8 points (range, 2–10 points).

This study demonstrated a satisfactory improvement in patient outcome after surgical correction of failed triple arthrodesis. We conclude that such a revision, although complex, may be attempted to establish a plantigrade foot free of infection and able to wear shoes without an orthosis or brace.

The recommended treatment for macrodactyly of the foot will often include epiphysiodesis of the proximal phalanx in an attempt to halt further longitudinal growth of the toe. Nine patients who underwent open epiphysiodesis and debulking of the excess soft tissue involving 11 toes were reviewed to evaluate the effectiveness of this procedure. In 9 of 11 toes, overall length of the proximal phalanx did not change after surgery. Two toes demonstrated continued growth; one of these toes underwent a repeat epiphysiodesis of the phalanx, and the other foot underwent epiphysiodesis of the affected metatarsal. Overall, this surgical approach led to radiographic results that satisfied the surgical goals.

Pigmented nodular synovitis is an uncommon condition of the foot. In this case history, we report a case of pigmented nodular synovitis in the first metatarsophalangeal joint, treated by arthroscopic synovectomy. Pigmented nodular synovitis to our knowledge has not been described in the first metatarsophalangeal joint. We report successful treatment of the condition by arthroscopic removal of the tissue, with the patient being asymptomatic 2 years after surgery.

This study investigates the vascularization of the Achilles tendon in 32 lower limbs of human neonates by injecting colored latex with subsequent microdissection. Because of its biomechanical significance (achilleo-calcaneal-plantar system) and the lack of descriptions in the literature, we analyzed the vascularization of the attachment area in the calcaneus, describing the achilleo-calcaneal vascular network, which is always well supplied in contrast to other tendinous areas.

A medially directed force was applied to the first metatarsal in 10 cadaver feet. The peroneus longus tendon was subjected to a pull of 5 pounds. The soft tissues between the first and second metatarsals were cut sequentially, starting with the skin on the dorsal and plantar aspect, followed by the intermetatarsal ligament and adductor hallucis tendon, and, finally, the peroneus longus tendon at its distal insertion. Dorsoplantar radiographs while weightbearing were taken after each sectioning. A statistically significant varus displacement of the first metatarsal was observed only after transection of the peroneus longus tendon. It was concluded that the peroneus longus tendon is a strong retaining mechanism of the first metatarsal.

Thirty-two cases of ankle fractures associated with fibular fractures above the distal tibiofibular syndesmosis were studied. All were treated with open reduction and internal fixation. The average follow-up was 25 months. The results of the postoperative evaluation were rated, based on subjective clinical criteria, as good, fair, and poor. According to the Lauge-Hansen classification, there were 17 (53%) cases of supination-external rotation injury (2 stage 2 and 15 stage 4), 9 (28%) cases of stage 3 pronation-abduction injury, and 6 (19%) cases of pronation-external rotation injury (3 stage 3 and 3 stage 4). All cases could be classified as Weber type C or as suprasyndesmotic, fibular diaphyseal fracture (44-C) according to the Orthopaedic Trauma Association classification. In 18 (56%) cases, the fracture was associated with ankle dislocation. There were seven (22%) open fractures (two grade I, four grade II, and one grade IIIA). Syndesmotic screws were used in 23 (72%) cases (12 supination-external rotation injury, 6 pronation-external rotation injury, and 5 pronation-abduction injury). The syndesmotic screw was removed after an average of 9 weeks. Four (13%) nonunions and two (6%) delayed unions of the fibula were treated with bone grafting and/or hardware revision and eventually healed. Three of the nonunions had poor clinical results because of degenerative ankle joint arthritis in two (one of them ended in arthrodesis) and deep infection, which was eventually cured, in the third. The fourth nonunion had a fair result. One of the delayed unions had a fair result (an obese patient) and the other had a good result. Two patients developed deep infections; one ended in gangrene and amputation in a diabetic patient, and the other was a patient with fibular nonunion that eventually healed. Three patients had superficial infections that were treated successfully. Of the 32 cases, 23 (72%) showed good results, 4 (13%) showed fair results, and 5 (16%) showed poor results. The cases with poor results included three fibular nonunions, one deep infection, and one recurrent superficial infection and wound dehiscence after hardware removal. A syndesmotic screw is usually needed in cases of fracture-dislocations. Two patients with occult fibular nonunions developed diastasis of the syndesmosis after removal of the syndesmotic screw. It was found that reduction and temporary pinning of the distal tibiofibular joint helps achieve fibular length, which is crucial to restoring the biomechanics of the ankle joint. It seems advisable not to remove the syndesmotic screw until there are signs of healing of fibular fracture to avoid diastasis of the distal tibiofibular joint. Bone grafting should be considered in high energy fractures with comminution. These complex injuries are associated with higher rates of complications. Poor results can be attributed to fracture factors, e.g., open fractures, infections; patient factors, e.g., obesity, lowered immunity as in diabetes, and noncompliance; and iatrogenic factors, e.g., early removal of syndesmotic screws.