Introduction:. All reported RA forefoot deformities in the literature so far have arisen from shoe wearing populations. Our aim in this study was to compare hallucal deformities seen in a shod to a non-shod population. Methods:. A case-control study was undertaken in two specialist foot and ankle units, one in India and one in the UK. All patients suffering from RA and attending for consideration of forefoot surgery from January 2007 to October 2013 were included in this study. Standardized anteroposterior weight bearing radiographs were obtained to measure the hallux valgus, inter-metatarsal and metatarsus primus varus angles. Results:. In the shod population, there was 1 hallux varus deformity, 10 without hallucal deformity and 90 feet with varying degrees of hallux valgus deformity. In contrast, in the unshod population, there were 19 hallux varus deformities and 6 hallux valgus deformities. There was great variability in the lesser toe deformity seen. In the shod population, it was most common to see dorsal subluxation or dislocation, with the 5. th. toe in a varus position. This was seen in 95% (n=96) of the shod population. In the unshod population, the most common lesser toe deformity seen was varus deviation or dislocation. This was present in 80% (n=20) of the unshod population. Conclusion:. Instability of the metatarsophalangeal joint in the rheumatoid foot predisposes it to significant deformity. External forces of shoe wear dictate the deformity, with hallux valgus being the most likely scenario in a shoe-wearing patient. In the non-shoe wearing population, intrinsic forces and weight bearing forces determine the deformity, with hallux varus being the most common presenting problem

Background. The cavovarus foot is a complex 3-dimensional deformity. Although a multitude of techniques are described for its surgical management, few of these are evidence based or guided by classification systems. Surgical management involves realignment of the hindfoot and soft tissue balancing, followed by forefoot balancing. Our aim was to classify the pattern of residual forefoot deformities once the hindfoot is corrected, to guide forefoot correction. Methods. We included 20 cavovarus feet from adult patients with Charcot-Marie-Tooth who underwent weightbearing CT (mean age 43.4 years, 14 males). Patients included had flexible deformities, with no previous surgery. Previous work established majority of rotational deformity in cavovarus feet occurs at the talonavicular joint, which is often reduced during surgery. Using specialised software (Bonelogic 2.1, Disior) a 3-dimensional, virtual model was created. Using data from normal feet as a guide, the talonavicular joint of the cavovarus feet was digitally reduced to a ‘normal’ position. Models of the corrected position were exported and geometrically analysed using Blender 3.6 to identify anatomical trends. Results. We identified 3 types of cavovarus forefoot morphotypes. Type 1 was seen in 13 cases (65%) and was defined as a foot where only the first metatarsal was relatively plantarflexed to the rest of the foot, with no significant residual adduction after talonavicular correction. Type 2 was seen in 4 cases (20%) and was defined as a foot where the second and first metatarsals were progressively plantarflexed, with no significant adduction. Type 3 was seen in 3 cases (15%) and was defined as a foot where the metatarsals were still adducted after talonavicular de-rotation. Conclusion. We classify 3 forefoot morphotypes in cavovarus feet. It is important to recognise and anticipate the residual forefoot deformities after hindfoot correction as different treatment strategies may be required for different morphotypes to achieve balanced correction

Forefoot involvement in rheumatoid arthritis (RA) is extremely common and the majority of the patients with RA have active foot symptoms and signs of the disease. This rertospective study was undertaken to assess the outcomes and complications in the surgery of the forefoot RA. Seventeen patients (27 feet) with RA underwent surgical correction for the forefoot deformities. Antero-posterior and lateral weight bearing radiographs of all feet were taken preoperatively. The forefoot deformities seen with RA varied and included hallux valgus with subluxed metatarsophalangeal (MTP) joint in 23 feet, hallux valgus with dislocation of the MTP in 4, hammer or claw toes in 12 and 8 feet respectively. In addition, all 27 feet presented with variable levels of intermetatarsal deviations or widening. All the patients with hallux valgus underwent first MTP joint arthrodesis with various techniques. Deformities of the lesser toes were treated in all but 3 cases with resection arthroplasty, while the remaining 3 feet received a Weil osteotomy. Postoperatively the toes and the MTP joints were stabilised with K-wires for 6–8 weeks. All patients have been studied for a minimum follow up of 9 months. Twenty six patients were satisfied by the outcome of the surgical treatment. Only one patient complained of persistent metatarsalgia postoperatively. The surgical complications included 2 cases of delayed union, 5 cases of delayed wound healing, 2 cases of wound infection, and 4 cases of plantar callosity. Overall, 4 patients required reoperation. Even though complications occur in patients with RA who undergo surgical correction of the forefoot deformities, most of these complications can be treated successfully. Thus, the overall outcome of the surgical treatment is good leading to satisfactory correction of the forefoot deformities and to pain elimination

Aims: Surgical treatment of forefoot deformities is a common procedure. The vast majority comprising surgery for Hallux Valgus. The indication for surgical intervention varies from pain to cosmetic reasons and footwear problems. Evidence for the effectiveness of different surgical methods is limited. The aims of this study were to perform a cross sectional population based prevalence study of surgery for forefoot deformities in Sweden and to analyze the surgical methods in use. Methods: Data on forefoot surgery were collected from the National Swedish Patient Registry between 1997 and 2000. Both ambulatory surgery (2000) and in-patient surgery (1997–2000) were collected. The data were processed to quantify the frequency of different surgical methods. Results: In 2000, a total of 4409 procedures for forefoot deformities were reported in ambulatory surgery. 82% were female and 18% were male. During 1997–2000, a total of 2547 procedures were performed performed in hospitalised patients. The gender distribution in this group was similar; 84% were female and 16% were male. The frequency distribution between different forefoot deformities will be presented. Discussion: Forefoot surgery is a common procedure, Hallux Valgus being the most frequent deformity to be corrected. The choice of surgical methods will be discussed and a validation of the National Swedish Patient Registry against the Local Reimbursement Registry in the Stockholm area will be presented

Aims. To assess if older symptomatic children with club foot deformity differ in perceived disability and foot function during gait, depending on initial treatment with Ponseti or surgery, compared to a control group. Second aim was to investigate correlations between foot function during gait and perceived disability in this population. Methods. In all, 73 children with idiopathic club foot were included: 31 children treated with the Ponseti method (mean age 8.3 years; 24 male; 20 bilaterally affected, 13 left and 18 right sides analyzed), and 42 treated with primary surgical correction (mean age 11.6 years; 28 male; 23 bilaterally affected, 18 left and 24 right sides analyzed). Foot function data was collected during walking gait and included Oxford Foot Model kinematics (Foot Profile Score and the range of movement and average position of each part of the foot) and plantar pressure (peak pressure in five areas of the foot). Oxford Ankle Foot Questionnaire, Disease Specific Index for club foot, Paediatric Quality of Life Inventory 4.0 were also collected. The gait data were compared between the two club foot groups and compared to control data. The gait data were also correlated with the data extracted from the questionnaires. Results. Our findings suggest that symptomatic children with club foot deformity present with similar degrees of gait deviations and perceived disability regardless of whether they had previously been treated with the Ponseti Method or surgery. The presence of sagittal and coronal plane hindfoot deformity and coronal plane forefoot deformity were associated with higher levels of perceived disability, regardless of their initial treatment. Conclusion. This is the first paper to compare outcomes between Ponseti and surgery in a symptomatic older club foot population seeking further treatment. It is also the first paper to correlate foot function during gait and perceived disability to establish a link between deformity and subjective outcomes. Cite this article: Bone Joint Open 2020;1-7:384–391

[Objectives] Hallux valgus, dorsal sublaxation or dislocation of metatarsophalangeal joints and clawing of the lateral toes are seen frequently in patients with rheumatoid arthritis (RA). Resection arthroplasty of the metatarsophalangeal joints (MTP joints) are widely used to correct these forefoot deformities and the clinical results are almost good. However lateral toes tend to displace dorsally and painful callosity tends to recur. We used the metatarsal shortening offset osteotomy for shortening and dorsal/medial displacement of the prominent metatarsal head. In this report, we introduce the surgical techniques of shortening offset osteotomy and postoperative changes of plantar pressure measured with F-scan system (Tekscan, Inc. ), and review the short term result during 1 to 4 year follow-up. [Materials and Methods] This study involved 26 feet of 18 patients with RA which were performed with the metatarsal osteotomy for lateral toes and followed more than 1 year (average follow-up 29 months, range 14–46 months). The average age of the 17 women and 1 man was 61 years (range, 51–77 years). The mean duration from the onset of RA to operation on the forefoot was 17 years (range, 7–42 years). Skin incision was placed on the dorsum of the foot and the extensor digitorum brevis and longus were severed (or elongated). After reposition of MTP joint, transverse osteotomy of distal fifth of the lateral metatarsal bone was performed with resection of few millimeters length metaphysial bone. Cortical bone of the distal end of the proximal stump was chiseled into a small rod between two ditches with rongeur and then the rod was put into medullary canal mortise of distal stump. This procedure make offset shift of metatarsal head medially or dorsally. Swanson implant arthroplasty, distal osteotomy was performed on the great toe. Postoperative clinical and radiological results were evaluated with AOFAS rating system. We measured dynamic plantar pressure before and one year after operation in one representative case. [Results] At the time of follow-up, the mean AOFAS score was 80 points (59–95) and the mean pain score was 36 points. The recurrence of painful callosity was one case. Nevertheless, the range of motion of the MTP joint remained low: 30 degrees and less in 16 feet (62%) including 3 bony ankylosis of MTP joints. There was no nonunion case. [Discussion]. Resection arthroplasty has been accepted as the treatment of choice for forefoot deformities in RA patients. Recent advance of drug therapy against RA encouraged us to preserve the joint in correction of forefoot deformities. Our technique aimed at preservation of the function of the MTP joints and is suitable for mild deformities in which only one or two rays are involved. Furthermore it is easy to correct the deformity of spray foot and reduce the plantar prominence of metatarsal head. This study revealed the good clinical result in short term follow-up. Although the long term result must to be waited, this method is one of recommendable options for RA patients with forefoot deformities

Introduction. The arch of the foot has been described as a truss where the plantar fascia (PF) acts as the tensile element. Its role in maintaining the arch has likely been underestimated because it only rarely torn in patients with progressive collapsing foot deformity (PCFD). We hypothesized that elongation of the plantar fascia would be a necessary and sufficient precursor of arch collapse. Method. We used a validated finite element model of the foot reconstructed from CT scan of a female cadaver. Isolated and combined simulated ligament transection models were created for each combination of the ligaments. A collapsed foot model was created by simulated transection of all the arch supporting ligaments and unloading of the posterior tibial tendon. Foot alignment angles, changes in force and displacement within each of the ligaments were compared between the intact, isolated ligament transection, and complete collapse conditions. Result. Isolated release of the PF did not cause deformity, but lead to increased force in the long (142%) and short plantar (156%), deltoid (45%), and spring ligaments (60%). The PF was the structure most able to prevent arch collapse and played a secondary role in preventing hindfoot valgus and forefoot abduction deformities. Arch collapse was associated with substantial attenuation of the spring (strain= 41%) and interosseous talocalcaneal ligaments (strain= 27%), but only a small amount in the plantar fascia (strain= 10%). Conclusion. Isolated PF release did not cause arch collapse, but arch collapse could not occur without at least 10% elongation of the PF. Simulated transection of the PF led to substantial increase in the force in the other arch supporting ligaments, putting the foot at risk of arch collapse over time. Chronic degeneration of the PF leading to plantar fasciitis may be an early sign of impending PCFD

Aim:. To review the short to medium term radiological, clinical and functional outcomes of reconstructive surgery for severe forefoot deformities in patients with Rheumatoid arthritis. Methods:. We conducted a review of prospectively collected data of patients with Rheumatoid arthritis who received reconstructive surgery for forefoot deformities. Patients requiring metatarso-phalangeal joint arthrodesis and excision of the lesser metatarsals for hallux valgus, dislocation of the lesser metatarso-phalangeal joints and intractable plantar keratosis were included. The patients were followed up at 2 weeks, 6 weeks, 3 months and 6 months. X-Rays were performed preoperatively, postoperatively, at 6 weeks, 3 months and 6 months follow-up. Patients completed a SF36, and AOFAS (American Orthopaedic Foot and ankle Score) forefoot score preoperatively and at 6 months postoperatively. Results:. Ten feet in eight patients were included in the study. Follow-up was for a minimum of 6 months. All patients were female, with an average age of 58 years (34–69 years). Radiologically there was an average correction in the hallux valgus angle from 48 degrees to 15 degrees. The inter-metatarsal angle improved from 14 to 9 degrees. Objective scores were significantly improved. The mean SF36 score pre-operatively was 36 (24–54) and 67 (54–82) post operatively (P < 0.05). The AOFAS score improved from a mean of 32 (28–50) pre operatively to 74 (64–78) post-operatively (p < 0.05). One patient required re-operation for further metatarsal shortening due to ongoing pain and two patients required oral antibiotics for minor superficial wound infections. All hallux metatarsophalangeal joint arthrodesis procedures united in a mean time of 3.5 months. Conclusion:. Forefoot reconstruction in these very symptomatic, disabled patients resulted in significant deformity correction and improvement in function and pain. The complication rate was low. Adequate resection of the lesser metatarsals is necessary to avoid ongoing pain from the phalanx articulating with the metatarsal

Introduction:. The cavovarus foot is a complex deformity caused by muscle imbalance, soft-tissue contracture and secondary bony abnormality. It is a combination of hindfoot, midfoot and forefoot deformity and the decision making process for surgical management can be difficult. The process of deciding which combination of procedures is required is often poorly understood. We present an algorithm to assist with this decision making. Methods:. We have analysed a single surgeon's experience of cavovarus foot correction, from a consecutive series of 50 patients over 5 years, to develop an algorithm to guide operative decision making. Cases included cavovarus deformity secondary to cerebral palsy, Friedreich's ataxia, Charcot Marie Tooth disease, post-traumatic contracture, post-cerebrovascular accident, iatrogenic post-surgery and physiological cavus. We have taken a systematic approach to each component of the deformity in order to generate the algorithm. Results:. To assist in rationalising the traditional ‘a-la-carte’ approach, our algorithm describes what we believe are the indications for a variety of surgical interventions, including soft tissue contracture release, osteotomies of the hindfoot, midfoot and forefoot, tendon transfer and soft tissue balancing, and arthrodesis. We detail the decision making process for each surgical option and give the reasons for each decision. We have also reviewed the available literature on this topic, to produce an evidence-based and useable tool for surgical planning. Conclusion:. The surgical decision making process in the management of the cavovarus foot is complex. We believe that this algorithm, based on extensive personal experience and up-to-date published evidence, provides a clear and proven framework on which surgical decision making can be guided and justified

The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. Its effect on sesamoid function and the pathomechanics of this joint have not been described. Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in various positions of dorsiflexion and plantarflexion using a MicroScribe, enabling quantitative analyses in a virtual 3D environment. In 75% of specimens, there was some degree of chondral loss within the metatarsosesamoid articulation. The metatarsal surface was more commonly affected. These changes most frequently involved the tibial metatarsosesamoid joint. The tibial sesamoid had an average excursion of 14.2 mm in the sagittal plane when the 1st MTP joint was moved from 10 degrees of plantarflexion to 60 degrees of dorsiflexion; the average excursion of the fibular sesamoid was 8.7 mm. The sesamoids also move in a medial to lateral fashion when the joint was dorsiflexed. The excursion of the tibial sesamoid was 2.8 mm when the joint was maximally dorsiflexed while that of the fibular sesamoid was 3.2 mm. There appears to be differential tracking of the hallucal sesamoids. The tibial sesamoid has comparatively increased longitudinal excursion whilst the fibular sesamoid has comparatively greater lateral excursion. This greater excursion of the tibial sesamoid could explain the higher incidence of sesamoiditis in this bone. The differential excursion of the 2 metatarsosesamoid articulations is also a factor that should be considered in the design and mechanics of an effective hallux MTP joint arthroplasty

Objective. High grade hallux rigidus is a forefoot deformity characterized by a limitation of dorsiflexion of the first toe associated with pain, and severe damage of the first metatarsophalangeal joint. Most authors recommended resection arthroplasty or arthrodesis of the first metatarsophalangeal joint. The aim of this study was to present the results of our series of 42 consecutive cases of severe hallux rigidus treated by resection of the first metatarsal head and implant of a poly D-L lactic (PDLLA) bioreabsorbable spacer to promote the interposition of fibrous tissue to preserve the range of motion of the joint. Material and methods. Forty-two feet in 27 patients affected by high grade hallux rigidus were included in the study. Surgical treatment consisted of resection of the first metatarsal head and positioning of a poly D-L lactic acid (PDLLA) bioreabsorbable implant. Post-operative care consisted in gauze bandage of the forefoot, and immediate weight-bearing with talus shoes for 3 weeks. All patients were clinically and radiographically evaluated preoperatively and checked at a mean 6 (5–7) year follow-up. Results. No intraoperative complication occurred. No sinus formation were observed. All implants resulted well tolerated by the patients. Mean AOFAS score was 42±14 preoperatively and 81±9 postoperatively. Mean preoperative metatarsophalangeal joint ROM was 27±17 degrees and mean postoperative metatarsophalangeal joint ROM was 75±8 degrees. Conclusions. First metatarsophalangeal joint arthroplasty using bioreabsorbable implant demonstrated to be an effective surgical option for treatment of high grade hallux rigidus, thank to its ability to promote fibrous tissue formation during its reabsorption

Background. Metatarsus adductus is the most common forefoot deformity. Variable prevalence values were reported in literature using different techniques in different populations. Numerous radiological measurements have been proposed to assess this deformity with a paucity of studies reporting the reliability of these methods. The metatarsus adductus angle was shown to correlate with the severity of hallux abductovalgus in normal feet and preselected populations of juvenile hallux valgus. Materials & Methods. Weight bearing dorsoplantar radiographs of 150 feet were examined for 5 angles commonly used in assessing metatarsus adductus: angle between the second metatarsus and the longitudinal axis of the lesser tarsus (using the 4th or 5th metatarso-cuboid joint as a reference), Engel's angle and modified angle's angle. The prevalence of metatarsus adductus was assessed according to published criteria for different techniques. Inter and intra-observer reliabilities of these angles were evaluated on 50 X-rays. Linear regression tests were used to assess the correlation between hallux valgus and different angles used in assessing metatarsus adductus. Results. Intraclass correlation coefficients were high for intra- as well as inter-observer reliability for the 5 angles tested. Prevalence of metatarsus adductus ranged (45–70%) depending on the angle used in the same population. Only the metatarsus adductus angle using the 4th metatasro-cuboid joint as a reference demonstrated significant correlation between metatarsus adductus and hallux abductovalgus angles. Conclusions. Five techniques commonly used in assessing metatarsus adductus demonstrated high inter and intra-observer reliability values. Prevalence of metatarsus adductus and the correlation between the severity of this deformity and hallux valgus angle is sensitive to the assessment method

Introduction. Forefoot deformities are common in the rheumatoid population and lead to abnormal loading, plantar callosities and metatarsalgia. First MTP joint arthrodesis with lesser toe Stainsby procedures has become a popular method of reconstructing the rheumatoid forefoot but there is little data that reviews the clinical or biomechanical results of combining the two procedures. Materials & Methods. A prospective observational study was set up to review 10 rheumatoid patients (20 feet) undergoing bilateral first MTP joint arthrodesis via a medial approach with Stainsby procedures to all lesser toes via curved incisions with resection of two thirds of the proximal phalanx, repositioning of plantar fat pad, extensor to flexor interposition and temporary stabilisation with k wires. Clinical scoring and dynamic pedobarograph pressure measurements were taken pre operatively and at one year post surgery. Results. Nine female and one male patient with a mean age of 60.2 years were reviewed. Pre operatively there were 11 abnormal high pressure areas in 10 feet, reducing to 8 abnormal areas in 6 feet following surgery. Post operatively the mean pressure time integral increased under the first metatarsal and decreased under lesser metatarsals. Following surgery no patient suffered significantly from callosities or metatarsalgia and AOFAS scores improved. Conclusion. The post operative pressure time integrals suggest the medial weightbearing column is recreated with a reduction of abnormal pressures under the lesser metatarsal heads. These results show that first MTP joint arthrodesis with lesser toe Stainsby procedures reduces the number of abnormal high pressure areas under the forefoot and should be considered for deformity correction in the rheumatoid forefoot

Introduction. The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints. Methods. Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in positions ranging from 10 degrees of dorsiflexion to 60 degrees of plantarflexion using a MicroScribe, enabling quantitative analyses in a virtual 3D environment. Results. The sesamoids demonstrated excursion both in the sagittal and coronal plane. The tibial sesamoid had a mean saggital excursion of 14.2 mm; the mean excursion of the fibular sesamoid was 8.7 mm. The mean coronal excursion of the tibial sesamoid was 2.8 mm while that of the fibular sesamoid was 3.2 mm. We also describe the mean saggital and coronal excursion of the sesamoids during smaller, incremental motions of the MTP joint. Conclusion. There appears to be differential tracking of the hallucal sesamoids. The tibial sesamoid has comparatively increased longitudinal excursion whilst the fibular sesamoid has comparatively greater lateral excursion. Clinical relevance. The greater excursion of the tibial sesamoid could explain the higher incidence of pathology in this bone. The differential excursion of the sesamoids is also a factor that should be considered in the design and mechanics of an effective hallux MTP joint arthroplasty

Introduction. The anatomy of the first metatarsophalangeal (MTP) joint and, in particular, the metatarsosesamoid articulation remains poorly understood. The movements of the sesamoids in relation to the metatarsal plays a key role in the function of the first MTP joint. Although the disorders affecting the sesamoids are described well, the movements of the metatarsosesamoid joints and the pathomechanics of these joints have not been described. We have performed a cadaver study detailing and quantifying the three dimensional movements occurring at these joints. Methods. Fresh frozen cadaveric specimens without evidence of forefoot deformity were dissected to assess the articulating surfaces throughout a normal range of motion. The dissections were digitally reconstructed in positions ranging from 10 degrees of dorsiflexion to 60 degrees of plantarflexion using a Micro Scribe, enabling quantitative analyses in a virtual 3D environment. Results. The sesamoids demonstrated excursion both in the sagittal and coronal plane. The tibial sesamoid had a mean saggital excursion of 14.2 mm; the mean excursion of the fibular sesamoid was 8.7 mm. The mean coronal excursion of the tibial sesamoid was 2.8 mm while that of the fibular sesamoid was 3.2 mm. We also describe the mean saggital and coronal excursion of the sesamoids during smaller, incremental motions of the MTP joint. Conclusion. There appears to be differential tracking of the hallucal sesamoids. The tibial sesamoid has comparatively increased longitudinal excursion whilst the fibular sesamoid has comparatively greater lateral excursion. Clinical relevance. The greater excursion of the tibial sesamoid could explain the higher incidence of pathology in this bone. The differential excursion of the sesamoids is also a factor that should be considered in the design and mechanics of an effective hallux MTP joint arthroplasty

We present our results with a modified Mann-Thompson procedure in 47 patients (86 feet). Minimum follow up was 24 months. All patients had moderate to advanced forefoot deformities. Methods:. M:F=12:35. 43/47 bilateral. Simultaneous procedures in bilateral cases. Popliteal block analgesia used routinely. Technique:. Medial incision centered on MTP1 joint. Minimal bony and soft tissue resection. Fixation carried out with staples (78 feet),K-wires (8 feet). Transverse incision centered on the lesser MTP joints made. Combination of soft tissue release, lesser MT head resection in cascade fashion from dorsal distal to proximal plantar performed. Lesser toe deformities treated by a combination of closed osteoclasis, soft tissue release and bony resection. Transarticular K-wire fixation then performed for all lesser toes. Bulky postop dressing and post op shoes used. Immediate FWB permitted. Transarticular K-wires removed at 4/52. Results:. AOFAS Forefoot Scores assessed at preop,6/12,12/ 12,and24/12. Subjective patient assessment of procedure requested. Average AOFAS scores improved from 37to72(67 – 84). 40 patients extremely pleased with the results. 5 patients pleased with reservations and 2 patients disappointed with the outcome. Complications:. 3 superficial wound infections. 2 metal work related problems. 2 early loss of lesser toe correction. 3 late deformities of lesser metatarsals requiring surgery. Conclusion: This procedure offers excellent, reproducible biomechanical correction with high rates of patient satisfaction

Introduction Rheumatoid arthritis commonly produces disabling forefoot deformities. Surgical interventions include hallux metatarsophalangeal (MTP) joint fusion with lesser toe metatarsal head and/or proximal phalanx base excisions. Here we describe our experience of combining first MTP joint fusion using a plate with Weil metatarsal osteotomies (WMO) of the lesser toes. WMO preserve and reduce lesser MTP joints thus enhancing stability and relocating the plantar fat pads. Plate fusion of the first MTP joint protects against recurrent deformity. Our aim was to assess the outcome of this procedure. Method Twelve female patients (21 feet) underwent the procedure with no loss to follow up. Informed consent was given and ethics approval obtained. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scale and visual analogue scale scores were recorded post-operatively only. Pre- and post-operative plain radiographs were compared. Results Mean age at operation was 62.5 years (range 48–75). Mean follow up was 25.9 months (range 2–54). The mean post-operative AOFAS scale score was 70.6/100 (range 34–90). The mean hallux valgus angle was reduced from 39.6 degrees to 31.8 degrees and the second MTP angle from 28.3 degrees to 19.4 degrees. Pre-operatively 28% of the lesser toe MTP joints were aligned compared with 83% post-operatively. All of the WMOs fused. Two first MTP joint fusions resulted in non-unions and required successful revision surgery. In five cases metalwork was removed from the hallux because of discomfort. In two cases, metalwork was removed because of superficial wound infection. Infection subsequently resolved after a course of oral antibiotics. Nine patients stated they would recommend the procedure. Conclusion First MTP joint plate arthrodesis and WMOs of the lesser toes provides good symptomatic relief and restoration of forefoot mechanics. It is a useful procedure in delaying more radical and final surgery for this progressive, destructive disease

The outcomes of the Berman-Gartland osteotomy in 26 feet (20 children) from 1995 to 1999 were evaluated. Average age at time of operation: 8 years, 3 months (range 37 to 194 months). Average age at follow-up: 2 years, 5 months (range 2 to 70 months). The osteotomy is performed in tourniquet from three lengthwise incisions and fixed by Kirschner wires and plaster of Paris for six weeks. Only patients with idiopathic PEC were included in this study. Average age at time of primary operation was ten months. For analysis, the type and percentage of preceding operations were: pantalar release (40%), posterior release (12%), and tendo calcaneus elongation (8%). Eight feet (30%) were not primarily surgically treated. Indicated for metatarsal osteotomy were: footwear difficulty (92%), gait instability (65%), and muscle spasm (56%). Average adduction deformity of the forefoot was clinically assessed as 30 degrees (20 to 45 degrees). Forefoot rigidity was evaluated according to Black as grade II (14 feet) and grade III (12 feet). Radiograph assessment was made by the use of T-I.MTT and C-V.MTT angle changes in the dorsoplantar weight-bearing view. We succeeded in correcting the average values of T-I.MTT angle from 28 degrees (range 20 to 43 degrees) preoperatively to 4 degrees (range 2 to 15 degrees) postoperatively, and C-V.MTT angle from 16 degrees (range 8 to 24 degrees) to 2 degrees (range -5 to 7 degrees). Isolated metatarsal varus deformity was found in 12 feet, in combination with talo-navicalar joint hypercorrection in nine feet, and in combination with residual talo-navicular joint subluxation in five feet. Calcaneocuboid joint displacement was classified as grade I and II in 16 and 3 feet respectively. Preoperative residual displacement was not found in seven feet. Complications were noted in three metatarsal nonunions (2% of 130 osteotomized metatarses), four pin migrations, one superficial infection, and one persistent forefoot swelling. At final follow-up, clinical findings and outcomes were assessed as excellent in 16 feet (62%) and good in 10 feet (38%). We recorded no inferior result. An apparent relationship was not found between the type and timing of preceding operations and varus forefoot deformity persistence. In 19 feet (73%), residual grade I and grade II tibial subluxation of the cuboid bone was found

Purpose: Correction of residual clubfoot deformities remains a great surgical challenge, and treatment failure is not uncommon. Open surgical reconstruction often leads to more scarring, risk of neurovascular injury, and a stiff foot. The Ilizarov external fixator allows for osseous realignment without open incisions. The Taylor spatial frame (TSF) is a relatively new external fixator that is capable of simultaneous six-axis deformity correction. Our method applies the Ponseti principles of clubfoot correction to a two-stage TSF correction (i.e., varus and internal rotation correction and then equinus correction). The Ponseti type 1 frame is programmed to correct varus and internal rotation first and then equinus. The Ponseti type 2 frame follows the same sequence as the type 1 frame but includes a final phase in which the foot ring is cut on two sides to allow separate correction of forefoot cavus and adductus. We present our initial multicenter experience with this Ponseti-inspired method. Methods: During a five-year period, seventeen patients (22 feet) were treated for residual clubfoot deformities with the TSF. Nine patients had idiopathic clubfoot, five had arthrogryposis, one had myelomeningocele, one had developmental clubfoot, and one had clubfoot associated with fibular hemimelia. Eight boys and nine girls were treated. The average age was 6.5 years (age range, 1.75–15 years). Equinus, internal rotation, and varus were addressed in nine patients (Ponseti type 1 frame), equinus, internal rotation, and forefoot deformity (adduction and/or cavus) in six patients (Ponseti type 2 frame), and equinus only in two patients. All patients underwent correction with standard two-ring frames using a long bone program. Results: All frames were removed after an average of 3.6 months (range, 3–8 months). One patient had under correction of residual equinus, but all others achieved full correction of deformities. Complications included superficial pin site infection in nine patients, talar subluxation in one patient, and subluxation of the first metatarsophalangeal joint in two patients. Infections were successfully treated with oral antibiotics. The one case of talar subluxation was reduced by the residual TSF program. The subluxated great toe was pinned in a separate surgery in two cases. Conclusions: We believe that the Ponseti sequence of correction can be applied to older children with residual club-foot deformities even if they have previously undergone surgery. Our method with the TSF is a safe, accurate (computer-based), and effective treatment. It does not require open surgery, so the potential for scarring is minimized. It also allows for any subsequent treatments as needed. Significance: The Ponseti-inspired method of residual club-foot deformity correction with the TSF is accurate and is a viable alternative to repeat open surgical procedures

Our approach to reconstructing forefoot deformities in patients with rheumatoid arthritis was as follows. In the lateral toes with mild or moderate joint destruction, shortening oblique osteotomy of the metatarsals is performed. With severe joint destruction, metatarsal head is resected. Arthrodesis of the first MTP joint is performed as a rule with resection arthroplasty in the lateral toes. When shortening oblique osteotomy in the lateral toes is indicated, the great toe is managed as follows: in young patients with mild joint destruction in the great toe (Larsen grades I and II) and who are able to ambulate well, Mitchell’s osteotomy is done. In older patients, or in patients with moderate or severe joint destruction (Larsen grades III to V), flexible hinge toe prosthesis is implanted. Between 1987 and 2000, Mitchell’s osteotomy was performed on 47 feet in 31 patients, whose mean age was 53 years, Larsen grade was 2.5 and hallux valgus angle (HVA) was 35.0 (SD11.9). Arthroplasty with flexible hinge toe prosthesis was performed on 31 feet in 23 patients, 58 years, Larsen grade was 3.7 and HVA was 45.3 (SD12.9). After 1995, grommets were used in 17 feet. In 2002, we studied clinical results of them. 40 feet of Mitchell’s osteotomy had no pain and 7 feet had some pain. 26 feet of arthroplasty with flexible hinge toe prosthesis had no pain and 5 feet had some pain. Radiologically, HVA was 17.2 (SD10.3) in Mitchell’s osteotomy and 12.1 (SD6.3) in arthroplasty with flexible hinge toe prosthesis. Maintenance of correction by arthroplasty with flexible hinge toe prosthesis was better than Mitchell’s osteotomy significantly, especially more than 30 degrees of HVA. Without grommets, grade 0 was 8 feet, grade I was 3, and grade II was 3 feet judged by Granberry’s grade. But no revision surgery was performed by silicone synovitis or fracture of implant. With grommets, there were no fractures. We added degree of HVA to management of operation after 2002. More than 40 degrees of HVA was considered flexible hinge toe prosthesis. After 2002, Mitchell’s osteotomy was performed on 7 feet in 6 patients, 53.7 years, Larsen grade was 2.4 and HVA was 32.3 (SD6.8). Arthroplasty with flexible hinge toe prosthesis was performed on 14 feet in 10 patients, 60.7 years, Larsen grade was 3.9 and HVA was 42.5 (SD7.5). Radiological result in these patients at 2005, HVA was 14.6 (SD4.9) in Mitchell’s osteotomy and 14.9 (SD2.5) in arthroplasty with flexible hinge toe prosthesis