Aims. The first metatarsal pronation deformity of hallux valgus feet is widely recognized. However, its assessment relies mostly on 3D standing CT scans. Two radiological signs, the first metatarsal round head (RH) and inferior tuberosity position (ITP), have been described, but are seldom used to aid in diagnosis. This study was undertaken to determine the reliability and validity of these two signs for a more convenient and affordable preoperative assessment and postoperative comparison. Methods. A total of 200 feet were randomly selected from the radiograph archives of a foot and ankle clinic. An anteroposterior view of both feet was taken while standing on the same x-ray platform. The intermetatarsal angle (IMA), metatarsophalangeal angle (MPA), medial sesamoid position, RH, and ITP signs were assessed for statistical analysis. Results. There were 127 feet with an IMA > 9°. Both RH and ITP severities correlated significantly with IMA severity. RH and ITP were also significantly associated with each other, and the pronation deformities of these feet are probably related to extrinsic factors. There were also feet with discrepancies between their RH and ITP severities, possibly due to intrinsic torsion of the first metatarsal. Conclusion. Both RH and ITP are reliable first metatarsal pronation signs correlating to the metatarsus primus varus deformity of hallux valgus feet. They should be used more for preoperative and postoperative assessment. Cite this article: Bone Jt Open 2024;5(11):1037–1040

Background. The Manchester-Oxford Foot Questionnaire (MOxFQ) is a condition specific patient reported outcome measure (PROM) for foot and ankle surgery. It consists of 16 items across three subscales measuring distinct, but related traits: walking/standing ability, pain, and social interaction. Although it is the most used foot and ankle PROM in the UK, initial MOxFQ validation involved analysis of only 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. Methods. This was a single-centre, prospective cohort study involving 6640 patients (mean age 52, range 10–90 years) presenting with a wide range of foot and ankle pathologies between 2013 and 2021. Firstly, to assess whether the MOxFQ responses vary by anatomical region of foot and ankle disease, we performed multi-group confirmatory factor analysis. Secondly, to assess the structural validity of the subscale items, exploratory and confirmatory factor analyses were performed. Results. Measurement invariance by pathology was confirmed suggesting the same model can be used across all foot and ankle anatomical regions. Exploratory factor analysis demonstrated a 2–3 factor model, and suggested that item 13 (inability to carry out my work/everyday activities) and item 14 (inability to undertake social/recreational activities) loaded more positively onto the walking/standing subscale than their original social interaction subscale. Conclusions. This large-cohort study supports the current widespread use of the MOxFQ across a broad range of foot and ankle pathologies. Items 13 and 14 might be better moved from the “social interaction” to the “walking/standing” subscale and this may have future implications for deriving/analysing subscale scores

Background. Hallux rigidus is a common condition characterised by first metatarsophalangeal joint (MTPJ) degeneration, pain and limited range of motion (ROM). The gold standard surgical treatment is arthrodesis, providing good pain relief but sacrifices ROM. Recently the Cartiva synthetic cartilage implant (SCI) has been utilised as an interpositional arthroplasty, aiming to reduce pain whilst preserving range of motion. Current evidence for Cartiva SCI is largely based on a single cohort with mixed outcomes. We sought to evaluate the clinical outcomes of Cartiva SCI compared to arthrodesis undertaken in our centre. Methods. Retrospective review of patients undergoing Cartiva SCI or arthrodesis for treating hallux rigidus was conducted. Preoperative arthritis was radiographically graded using the Vanore classification. Patient reported outcomes (PROMs) were assessed using EuroQol 5-dimension score (EQ-5D-5L) and Manchester-Oxford Foot Questionnaire (MOXFQ). Results. Between 2017 and 2020 there were 33 cases (17 Cartiva, 16 arthrodesis, mean age 59.0±9.9 years) with a mean follow up of 2.3 years. For the first MTPJ arthrodesis cohort, the MOXFQ domain scores were: Index 3.9±5.8, Walking/Standing 5.1±7.6, Pain 3.2±5.0, and Social Interaction 2.6±4.0. EQ-5D-5L Index score was 0.828±0.270 and the EQ-VAS was 72.5±23.3. For the Cartiva cohort, the MOXFQ domain scores were: Index 7.7±6.0, Walking/Standing 8.9±7.9, Pain 7.1±5.0, and Social Interaction 6.4±5.4. EQ-5D-5L Index score was 0.631±0.234 and the EQ-VAS was 74.8±20.8. There was no statistically significant difference between any MOXFQ domain or EQ-5D-5L scores. However, a negative trend in MOXFQ domains was identified for the Cartiva group, as well as a reoperation rate of 23.5%. Conclusions. The Cartiva SCI demonstrated no advantage over arthrodesis in PROMs, despite the presumed benefit of preserved ROM. A significant reoperation rate was also observed. Surgeons should be cautious in the use of this novel implant

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. Methods. This was a single-centre, prospective cohort study involving 6,637 patients (mean age 52 years (SD 17.79)) presenting with a wide range of foot and ankle pathologies between January 2013 and December 2021. To assess whether the MOxFQ responses vary by anatomical region of foot and ankle disease, we performed multigroup confirmatory factor analysis. To assess the structural validity of the subscale items, exploratory and confirmatory factor analyses were performed. Results. Measurement invariance by pathology was confirmed, suggesting the same model can be used across all foot and ankle anatomical regions. Exploratory factor analysis demonstrated a two- to three-factor model, and suggested that item 13 (inability to carry out work/everyday activities) and item 14 (inability to undertake social/recreational activities) loaded more positively onto the “walking/standing” subscale than their original “social interaction” subscale. Conclusion. This large cohort study supports the current widespread use of the MOxFQ across a broad range of foot and ankle pathologies. Our analyses found indications that could support alterations to the original factor structure (items 13 and 14 might be moved from the “social interaction” to the “walking/standing” subscale). However, this requires further work to confirm. Cite this article: Bone Joint J 2024;106-B(3):256–261

Background. There are many different procedures described for the correction of hallux valgus deformity. Minimally invasive surgery has become increasingly popular, with clinical and radiological outcomes comparable to traditional open osteotomy approaches. There is increasing interest in hallux valgus deformity correction using third-generation minimally invasive chevron akin osteotomy (MICA) technique. Objective. To assess the radiographic correction and 2 year clinical outcomes of third-generation MICA using validated outcome measures. Methods. This is a prospective single-surgeon case series of 420 consecutive feet undergoing MICA surgery between July 2014 and November 2018. Primary clinical outcome measures included the Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D, and the Visual Analogue Pain Scale. Secondary outcome measures included radiographic parameters, and complication rates. Results. Pre-operative and 2 year post-operative patient reported outcomes were collected for 334 feet (79.5%). At minimum 2 year follow-up, the MOXFQ scores (mean ± standard deviation (SD)) had improved for each domain: pain; pre-operative 43.9±21.0 reduced to 9.1±15.6 post-operatively (p<0.001), walking and standing; pre-operative 38.2±23.6 reduced to 6.5±14.5 post-operatively (p<0.001) and social interaction; pre-operative 47.6±22.1, reduced to 6.5±13.5 post-operatively (p<0.001). At 2 year follow-up, the VAS Pain score (mean ± SD) improved from a pre-operative of 31.3±22.4 to 8.3±16.2 post-operatively (p<0.001). 1–2 intermetatarsal angle (mean ± SD) reduced from 15.4°±3.5° to 5.8°±3.1° (p<0.001) and hallux valgus angle reduced from 33.1°±10.2° to 9.0°±5.0° post-operatively (p<0.001). Conclusion. Third-generation MICA showed significant improvement in clinical outcomes at 2 year follow-up and can be successfully used for correction of a wide range of hallux valgus deformities

Introduction. Total ankle replacement as a valid treatment for end stage ankle arthritis, is gaining popularity and every year there is an increasing number of procedures. With revision rates as high as 21% at 5 years and 43% at 10 years there is a need for understanding and reporting the outcome of revision ankle replacement. Our aim was to study the patient reported outcomes following revision TAR with a minimum of 2 year follow up. Methods. All patients that underwent a revision total ankle replacement between 2012 and 2016 were included in the study. All patients received a post-operative questionnaire comprising of MOX-FQ score, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) and patients satisfaction questionnaire with a minimum of 2 years follow up. Results. 33 patients had a revision total ankle replacement between 2012 and 2016. 2 patients were deceased therefore 31 patients were included in the study. 4 patients declined participation for completing questionnaires. We received 15/27 (55.5%) completed questionnaires. The mean MOX-FQ average domain score for pain was (50.6 ± 26.9), walking/standing (62.4 ± 36.5) and social function was (43.7± 31.0). The mean FAOS scores were (52.5 ± 30.6; pain), (54.5 ± 29.2; symptoms), (62.1 ± 30.5; ADL) and (35.5 ± 28.2; for quality of life). The mean overall health score today for EQ-5D was 73.9/100. 50% of patients were satisfied with the pain relief and return to sports and recreation obtained following the operation, 57% were satisfied with the improved in daily activities. 78.5% were overall satisfied with the results from surgery. Conclusion. Revision total ankle replacement gives overall satisfactory results demonstrated from patients reported outcomes at a minimum of 2 years following surgery

Background. Treatment of arthrogrypotic clubfoot (AC) presents a challenging problem. Over time many different methods have been proposed, with variable rates of success, recurrence and other complications. In this study we describe our 20-year experience in treatment of AC. Materials and methods. Between 1996 and 2016, 165 AC in 90 children (51 males and 39 females) were treated in our department. Their mean age was 7.6 years (3 months-16 years). Ponseti casting and Achilles tendon release (PCATR) was performed on 38 children (68 feet) and soft tissue release and casting (STRC) on 35 children (67 feet). The remaining 17 children (30 feet) underwent wide soft tissue release and correction using the Ilizarov method (STRIL). The results of each subgroup were graded according to clinical (pain, foot appearance, residual deformities, walking and standing status and shoe modifications) and radiological (anteroposterior and lateral talocalcanear angles, the angle between longitudinal axes of talus and the first metatarsal and the position of talus in the lateral view) criteria. Results. The average follow up was 6.4 (2–10) years. Results were excellent (plantigrade, painless, properly loaded feet, without deformities, adapted to common shoes) in 56 PCATR group feet, 59 STRC group feet and 23 STRIL group feet. Good results (required orthopaedic shoes) were obtained in 10 PCATR group feet, 6 STRC group feet and 7 STRIL group feet. Fair results (residual temporary pain and/or mild deformity) presented 2 PCATR group feet and 1 STRC group foot, while bad results (reoccurrence of clubfoot) were found in 1 STRC group foot. Conclusions. On the basis of our 20-year clinical experience we believe that pediatric AC can be successfully treated with PCATR in the age of less than 1 year old (y.o), with STRC between 1–5 y.o. and with STRIL in children over the age of 5 y.o

Aims. Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views. Patients and Methods. A retrospective analysis was undertaken of 50 male and 50 female patients (200 feet) aged 18 years or more, who underwent bilateral, simultaneous imaging of their lower legs while standing in an upright, weight-bearing position in a pedCAT machine between June 2013 and July 2017. At the time of imaging, the mean age of male patients was 47.1 years (18 to 72) and the mean age of female patients was 57.8 years (18 to 83). We employed a previously described technique to obtain six lengths and one angle, as well as calculating three further measurements, to provide information on the relationship between the fibula and tibia with respect to translation and rotation. Results. The upper limit of lateral translation in un-injured patients was 5.27 mm, so values higher than this may be indicative of syndesmotic injury. Anteroposterior translation lay within the ranges 0.31 mm to 2.59 mm, and -1.48 mm to 3.44 mm, respectively. There was no difference between right and left legs. Increasing age was associated with a reduction in lateral translation. The fibulae of men were significantly more laterally translated but data were inconsistent for rotation and anteroposterior translation. Conclusion. We have established normal ranges for measurements in cross-sectional syndesmotic anatomy during weight-bearing and also established that no differences exist between right and left legs in patients without syndesmotic injury. Age and gender do, however, affect the anatomy of the syndesmosis, which should be taken into account at time of assessment. Cite this article: Bone Joint J 2019;101-B:348–352

Aims:. With the advent of standing CT and MRI scans, there is increasing interest in establishing the role and usefulness of these investigations. When ordering a standing investigation, we assume that 100% of body weight is loaded through the limb, but most machines have handlebars for support and some have seats to allow patients the opportunity to sit. The aim of this study was to evaluate the amount of load going through the lower limbs in various positions supported and unsupported, to explore the range and variation in measurements obtained. Methods:. Following ethics and local IRB approval, 40 healthy volunteers were asked to stand on an electronic weighing scales and be measured for height. They were then asked to stand on an identical electronic weighing scale on the PedCAT standing CT. Their weight was measured single and double leg stance, with the hands supported and unsupported on the side bars. The subjects were then asked to sit with a single and then both legs on the scale. Results:. 40 subjects participated. 28 were female, average BMI 25.8 (4.98). By holding on to the hand rails between 10–20% (2.0) of body weight was removed. Single stance meant 85% (4.0) of body weight went through the single limb and by sitting, with the single limb on the scanner only 8.8% (2.3) of body weight goes through the limb. Conclusions:. Standing CT and MRI are increasing in popularity. We now know that in standing the majority of body weight is transferred to the limbs, but if the subject is holding onto support up to 20% of body weight is removed. If the subject is sitting then only 9% of body weight goes through the single limb. This information will help inform future studies that use weight bearing MRI or CT

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The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures.

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Osteochondral lesions of the talus (OLT) are a common cause of disability and chronic ankle pain. Many operative treatment strategies have been introduced; however, they have their own disadvantages. Recently lesion repair using autologous cartilage chip has emerged therefore we investigated the efficacy of particulated autologous cartilage transplantation (PACT) in OLT.

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The Cartiva synthetic cartilage implant (SCI) entered mainstream use in the management of first metatarsophalangeal joint (MTPJ) arthritis following the positive results of large trials in 2016. Limited information is available on the longer-term outcomes of this implant within the literature, particularly when independent from the originator. This single-centre cohort study investigates the efficacy of the Cartiva SCI at up to five years.

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Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm². However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus.

Aims. Morton’s neuroma is common condition of the forefoot, but its aetiology remains unclear. Our aim was to evaluate the relationship between the width of the forefoot and the development of a Morton’s neuroma. . Patients and Methods. Between January 2013 and May 2016, a total of 84 consecutive patients (17 men, 67 women) with a unilateral Morton’s neuroma were enrolled into the study. The involved and uninvolved feet of each patient were compared. A control group of patients with symptoms from the foot, but without a neuroma who were matched for age, gender, affected side, and web space location, were enrolled. The first to fifth intermetatarsal distance, intermetatarsal angle and intermetatarsal distance of involved web space on standing radiographs were assessed. Results. The inter- and intra-observer reliability was excellent. The three parameters did not differ significantly between the involved and uninvolved feet. Neither did they differ significantly between the patients and the controls. Conclusion . We conclude that there is no significant relationship between the width of the forefoot and the development of a Morton’s neuroma. Cite this article: Bone Joint J 2017;99-B:365–8

This study sought to determine the medium-term patient-reported and radiographic outcomes in patients undergoing surgery for hallux valgus. A total of 118 patients (162 feet) underwent surgery for hallux valgus between January 2008 and June 2009. The Manchester-Oxford Foot Questionnaire (MOXFQ), a validated tool for the assessment of outcome after surgery for hallux valgus, was used and patient satisfaction was sought. The medical records and radiographs were reviewed retrospectively. At a mean of 5.2 years (4.7 to 6.0) post-operatively, the median combined MOXFQ score was 7.8 (IQR:0 to 32.8). The median domain scores for pain, walking/standing, and social interaction were 10 (IQR: 0 to 45), 0 (IQR: 0 to 32.1) and 6.3 (IQR: 0 to 25) respectively. A total of 119 procedures (73.9%, in 90 patients) were reported as satisfactory but only 53 feet (32.7%, in 43 patients) were completely asymptomatic. The mean (SD) correction of hallux valgus, intermetatarsal, and distal metatarsal articular angles was 18.5° (8.8°), 5.7° (3.3°), and 16.6° (8.8°), respectively. Multivariable regression analysis identified that an American Association of Anesthesiologists grade of > 1 (Incident Rate Ratio (IRR) = 1.67, p-value = 0.011) and recurrent deformity (IRR = 1.77, p-value = 0.003) were associated with significantly worse MOXFQ scores. No correlation was found between the severity of deformity, the type, or degree of surgical correction and the outcome. When using a validated outcome score for the assessment of outcome after surgery for hallux valgus, the long-term results are worse than expected when compared with the short- and mid-term outcomes, with 25.9% of patients dissatisfied at a mean follow-up of 5.2 years. Cite this article: Bone Joint J 2015;97-B:208–14

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This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years.

Objectives. The Manchester–Oxford Foot Questionnaire (MOXFQ) is a validated 16-item, patient-reported outcome measure for evaluating outcomes of foot or ankle surgery. The original development of the instrument identified three domains. This present study examined whether the three domains could legitimately be summed to provide a single summary index score. . Methods. The MOXFQ and Short-Form (SF)-36 were administered to 671 patients before surgery of the foot or ankle. Data from the three domains of the MOXFQ (pain, walking/standing and social interaction) were subjected to higher order factor analysis. Reliability and validity of the summary index score was assessed. Results. The mean age of the participants was 52.8 years (. sd. 15.68; 18 to 89). Higher order principle components factor analysis produced one factor, accounting for 74.7% of the variance. The newly derived single index score was found to be internally reliable (α = 0.93) and valid, achieving at least moderate correlations (r ≥ 0.5, p < 0.001) with related (pain/function) domains of the SF-36. Conclusions. Analyses indicated that data from the MOXFQ can be presented in summary form. The MOXFQ summary index score (MOXFQ-Index) provides an overall indication of the outcomes of foot and ankle surgery. Furthermore, the single index reduces the number of statistical comparisons, and hence the role of chance, when exploring MOXFQ data

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The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

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This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes.

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In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.