The June 2024 Foot & Ankle Roundup³⁶⁰ looks at: First MTPJ fusion in young versus old patients; Minimally invasive calcaneum Zadek osteotomy and the effect of sequential burr passes; Comparison between Achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional Achilles tendinopathy; Revision ankle arthroplasty – is it worthwhile?; Tibiotalocalcaneal arthrodesis or below-knee amputation – salvage or sacrifice?; Fusion or replacement for hallux rigidus?.

Aims

The Manchester-Oxford Foot Questionnaire (MOxFQ) is an anatomically specific patient-reported outcome measure (PROM) currently used to assess a wide variety of foot and ankle pathology. It consists of 16 items across three subscales measuring distinct but related traits: walking/standing ability, pain, and social interaction. It is the most used foot and ankle PROM in the UK. Initial MOxFQ validation involved analysis of 100 individuals undergoing hallux valgus surgery. This project aimed to establish whether an individual’s response to the MOxFQ varies with anatomical region of disease (measurement invariance), and to explore structural validity of the factor structure (subscale items) of the MOxFQ.

Data was collected for patients referred to the orthopaedic department at Forth Valley Royal Hospital with metatarsalgia who subsequently received an ultrasound. Patients found to have a Morton's neuroma were divided into groups based on its size. A total of 90 patients received an ultrasound scan and neuroma was confirmed in 58 with an alternative diagnosis found in 32 patients and a total of 42 were included in the final analysis. All 14 patients with neuroma < 6mm reported resolution of symptoms. 4 (28.5%) underwent surgical excision as first line, 1 (7%) received a single corticosteroid injection and 9 (64%) were treated with metatarsal bars. There were 27 patients with neuroma > 6mm; 8 (29.6%) underwent surgical excision as first line treatment, 5 (18.5%) received metatarsal bars and 14 (51.9%) received injections. 7 (25.9%) patients reported resolution of symptoms after 1 injection, 1 (3.7%) patient required 2 injections and 1 (3.7%) patient required 3 injections to achieve resolution. 5 (18.5%) patients required surgical excision following ongoing symptoms despite non-surgical treatment. 9 (33.3%) reported resolution of symptoms following injection. 5 (18.5%) reported resolution of symptoms following use of metatarsal bars. A total of 71% of patients with a neuroma measuring < 6mm reported full resolution of symptoms with non-surgical treatment. For patients with neuroma >6mm, 64.3% had resolution of symptoms with injections alone and 18.5% required surgical excision despite injection. In conclusion, there is a benefit to offering non-surgical treatment as first line in patients with a neuroma regardless of size

Aims

The purpose of this study is to examine the adductus impact on the second metatarsal by the nonosteotomy nonarthrodesis syndesmosis procedure for the hallux valgus deformity correction, and how it would affect the mechanical function of the forefoot in walking. For correcting the metatarsus primus varus deformity of hallux valgus feet, the syndesmosis procedure binds first metatarsal to the second metatarsal with intermetatarsal cerclage sutures.

Aims. Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR. Methods. We conducted a retrospective review of 108 consecutive implants in 76 patients, between January 2005 and December 2016, with a minimum follow-up of two years. The mean age of the patients at the time of surgery was 61.6 years (42 to 84). There were 104 females and four males. Clinical, radiological, patient reported outcome measures (PROMS) data, a visual analogue score (VAS) for pain, and satisfaction scores were collected. Results. The survivorship at a mean follow-up of 5.3 years (2.1 to 14.1) was 97.2%. The mean Manchester Oxford Foot and Ankle Questionnaire (MOXFQ) scores improved from 78.1 to 11.0, and VAS scores for pain from 7/10 to 1.3/10. The rate of satisfaction was 90.6%. Three implants (2.8%) required revision; one for infection, one-month postoperatively, and two for stem breakage at 10.4 and 13.3 years postoperatively. There was a 1.9% reoperation rate other than revision, 23.1% of patients developed a minor complication, and 21.1% of patients had non-progressive and asymptomatic cysts on radiological review. Conclusion. We report a 97.2% survivorship at a mean follow-up of 5.3 years with this implant. We did not find progressive osteolysis, as has been previously reported. These results suggest that this double-stemmed silastic implant provides a predictable and reliable alternative with comparable outcomes to arthrodesis for the treatment of end-stage HR. Cite this article: Bone Joint J 2020;102-B(2):220–226

Aims

Gastrocnemius tightness predisposes to musculoskeletal pathology and may require surgical treatment. However, it is not clear what proportion of patients with foot and ankle pathology have clinically significant gastrocnemius tightness. The aim of this study was to compare the prevalence and degree of gastrocnemius tightness in a control group of patients with a group of patients with foot and ankle pathology.

Freiberg's Infraction; osteonecrosis of the metatarsal head, is the fourth most common intra-articular osteonecrosis in the body. Surgical intervention is usually reserved for late stage of the disease process (III-V) or failure of conservative management. We evaluated the outcomes of patients treated with primary Interpositional Arthroplasty technique using periosteum and fat for adequate surfacing and as a spacer for Freiberg's Disease. Twenty-three cases (21 patients) were performed from February 2009 – March 2016 (18 women, 5 men). Mean age at surgery was 51.1 years (range 19 – 70.5 years) with 91% affecting the second metatarsal. Twenty-one cases were primary and two cases were revision. Five cases were stage III, 10 were in stage IV and 8 were stage V. All patients underwent Interpositional Arthroplasty using periosteum and fat graft from affected metatarsal inserted as joint spacer and secured with sutures. Patients were followed up by postal questionnaires using two validated questionnaires; MOXFQ and AOFAS. Mean follow-up was 3.7 years (0.6 – 7.6 years). Paired two-tailed student t tests were used to assess clinical significance. The left and right foot was affected in 12 and 11 cases respectively. There were no postoperative infections, non-unions or transfer metatarsalgia. Surgery allowed 8 patients to wear normal footwear, 9 wearing fashion shoes, 5 wearing dress shoes and 5 patients returned to sporting activities. Mean pre-operative and post-operative VAS pain scores were 6.7 (range 4–10) and 3.2 (range 0–0) (p< 0.05). Mean peri-operative AOFAS scores were 43.8 (range 14–14) and 71.3 (range 10–10) (p< 0.05). Mean peri-operative MOXFQ scores were 62.9 (range 23–23) and 31.8 (range 0–0) (p< 0.05). We recommend our novel Interpositional Arthroplasty using periosteum and fat spacer for late stage Freiberg's disease as it can result in significant improvement in pain, prevents donor site morbidity and produces significant functional improvement and patient satisfaction

Introduction. Arthroplasty for treatment of end stage hallux rigidus is controversial. Arthrodesis remains the gold-standard, but this procedure is not without complications, with up to 10% non-union, 14% re-operation and 10% transfer metatarsalgia rates reported. The aim of this study was to analyse the outcome of the double-stemmed silastic implant (Wright-Medical) for end stage hallux rigidus. Method. We conducted a retrospective review of a consecutive series of 108 silastic 1. st. MTPJ implanted in our Unit (January 2005 – December 2016). Data was collected from our research databases, patient notes, PACS and PROMS. No patient was lost to follow-up. Results. Average age was 60.1 years (range 42–42 years; 104F; 4M). Results show a 98.1% survivorship at an average 5.1 years follow up (range 6 months-12 years). Average pre- and post-operative MOXFQ scores were 78.8/100 and 11.0/100 respectively and VAS scores improved from 7/10 to 1.3/10, with an average post-operative range of movement of 26.3°. Overall satisfaction rate was 90.6%. 2 patients (1.9%) required revision; 1 for early infection (2 months) and 1 for stem breakage (10 years). There were 15 complications (13.9%) in the group, 5 lateral metatarsalgia, 7 patients stiffness and ongoing pain in the index joint occurred in 2.7%. There was a 20% incidence of radiological cyst formation or demarcation, but this was neither progressive, symptomatic, nor affected clinical outcome. Conclusions. The authors believe these results are superior to results of other published implants for hallux rigidus (BioPro and Cartiva). Additionally, these results do not confirm progressive osteolysis, previously reported for this implant in other series, as being a mechanism of failure. Finally, these results suggest the double stemmed silastic 1. st. MTPJ replacement provides a reliable alternative, with at least comparable outcomes, to that of fusion, for the treatment of end stage hallux rigidus

Introduction. The management of adolescent hallux valgus (AHV) remains controversial, with reservations about both conservative and surgical treatments. Non-operative management has a limited role in preventing progression. Surgical correction of AHV has, amongst other concerns, been associated with a high prevalence of recurrence of deformity after surgery. We conducted a systematic review to assess clinical and radiological outcomes following surgery for AHV. Methods & Materials. A comprehensive literature search was performed in the Cochrane Library, CINAHL, EMBASE, Google Scholar, and Pubmed. The study was performed in accordance with the recommendations of the PRISMA guidelines. Demographic data, radiographic parameters, and results of validated clinical scoring system were analysed. Results. Nine contemporary studies reporting on 201 osteotomies in 140 patients were included. The female to male ratio was 10:1. Mean age at operation was 14.5 years (10.5–22). Mean follow-up was 41.6 months (12–134). The mean post-operative AOFAS score was 85.8 (sd ±7.38). The mean AOFAS patient satisfaction showed that 86% (sd ± 11.27) of patients satisfied or very satisfied with their outcome. On the DuPont BRS, 90% rated their outcome as good or excellent. There was a statistically significant improvement in the IMA (p=0.0003), HVA (p<0.0001), and DMAA (p=0.019). The main complication was persistent pain (12%); others included infection (2%), scar hypersensitivity (4.5%), and non-union, metatarsalgia, and CRPS (each at 0.5%), and no reports of metatarsal head AVN. Conclusion. Based on the most current published evidence, surgery for AHV shows excellent clinical and radiological outcomes, with high patient satisfaction. The rates of recurrence and other complications are lower than the historically reported figures. There is, however, a need for high level, multi-centre collaborative studies with prospective data to establish the long-term outcomes and optimal surgical procedure(s)

Aim. To examine the mid-term survival, clinical and patient reported outcomes of the silastic 1. st. metatarsophalangeal joint replacement for the treatment of end stage hallux rigidus. Methods. We reviewed 83 consecutive silastic arthroplasties performed in 79 patients for end stage hallux rigidus. There were 3 men and 76 women; mean age 63 years (range 45–78 years). No patient was lost to follow up. Average follow-up was 5.3 years (1.1–11.3 years). The EQ 5D–5L Health index, Manchester-Oxford Foot Questionnaire (MOXFQ), visual analogue scale (VAS) of pain and overall satisfaction rate (Likert scale) were collected for patient reported outcomes. Results. 2 patients required revision; 1 for early infection (2 months) and 1 for stem breakage (10 years 1 month). 5 patients reported lateral metatarsalgia, 2 patients reported neuropathic pain, 6 patients developed superficial infection which fully responded to oral antibiotics, and 1 patient developed interphalangeal joint pain. 2 patients died in the cohort. Pre-operative mean MOXFQ was 44, mean EQ5D Index was 0.564 and VAS was 6.97. At mean follow-up of 5.3 years, the mean MOXFQ was 12.7 (0–57), the mean EQ5D Index was 0.851 (−0.02–1) and the mean VAS was 1.67 (0–8). The mean range of motion was 35° (30° dorsiflexion and 5° plantarflexion). The overall satisfaction rate was 90.2%. The implant survival rate was 97.6%. Conclusions. The silastic big toe arthroplasty offers excellent clinical mid term survival and functional outcomes and could be considered as an attractive alternative to traditional fusion for end stage hallux rigidus

Aims

This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton’s neuroma.

Aims

The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus.

Aims

The purpose of this study was to analyse the biomechanics of walking, through the ground reaction forces (GRF) measured, after first metatarsal osteotomy or metatarsophalangeal joint (MTP) arthrodesis.

The April 2015 Foot & Ankle Roundup³⁶⁰ looks at: Plantar pressures linked to radiographs; Strength training for ankle instability?; Is weight loss good for your feet?; Diabetes and foot surgery complications; Tantalum for failed ankle arthroplasty?; Steroids, costs and Morton’s neuroma; Ankle arthritis and subtalar joint

The February 2015 Foot & Ankle Roundup³⁶⁰ looks at: Syndesmosis screw removal in randomised controlled trial; Diagnostic value of Hawkins sign; Chevron rules supreme?; Diabetes and ankle replacement; Fixed-bearing ankle replacement; Fusion for osteomyelitis of the ankle; ‘Reformed’ fallers.