Titulo y resumen de publicaciones de la especialidad en revistas y publicaciones médicas
Autores: Realizadas por médicos asociados a SAMeCiPP
Background: Two concepts have been proposed to explain the etiology of metatarsalgia in hallux valgus patients: First, as the magnitude of hallux valgus increases, there is a mechanical overload of the lesser metatarsals. Second, increased relative lesser metatarsal length is a factor in the development of metatarsalgia. However, there is no current evidence that these structural factors lead to primary metatarsalgia. The purpose of the study was to evaluate the factors associated with metatarsalgia in hallux valgus patients.
Methods: A cross-sectional study of 121 consecutive adult patients with non-arthritic hallux valgus was carried out. Binary logistic regression was performed to identify the effect of the clinical and demographic factors on the occurrence of metatarsalgia. One hundred twenty-one patients (184 feet) with hallux valgus were analyzed. The median weight was 65 kg (interquartile range 58-72).
Results: Metatarsalgia was present in 84 (45.6%) feet. The binary logistic regression showed that lesser toe deformity (OR 2.6, 95% CI 0.2-0.5), gastrocnemius shortening (OR 5.8, 95% CI 2.8-12.3), metatarsal index (OR 0.3, 95% CI 0.2-0.5), and weight (OR 2.5, 95% CI 1.2-5.3) were significantly associated.
Conclusion: Metatarsalgia occurs in almost half of hallux valgus patients. It has a multifactorial etiology. Our findings contradict the common theory that both the magnitude of hallux valgus deformity and an increased length of the lesser metatarsals, by themselves, lead to primary metatarsalgia. Metatarsalgia was associated with Achilles shortening, excessive weight, and associated lesser toe deformity. These factors should be addressed in order to treat this disorder adequately.
Level of Evidence: Level III, comparative series.
© The Author(s) 2015.
The purpose of this study was to evaluate the clinical and radiological results in a group of patients who underwent firstmetatarsophalangeal joint arthrodesis with an endomedullary screw fixation technique (MPA-E).
Between 2003 and 2009, 101 metatarsophalangeal arthrodesis were performed in 76 patients. There were 64 women and 12 men with an average age of 68 years. The indication for surgery was osteoarthritis with severe pain and functional limitation. Patients were evaluated radiologically and with the American Orthopaedic Foot & Ankle Society scoring system (AOFAS) at an average follow-up of 32 months (range, 24-92 months).
The success rate was 93%, with an increase of the average preoperative AOFAS from 38.5 points to 85.5 points postoperatively (P < .0001). The consolidation rate after radiological evaluation was 90.1%; there were 5 cases (5.0%) with asymptomatic nonunion and 5 cases (5.0%) with poor results because of symptomatic nonunion. Screw removal was needed in 4 feet (4.0%), and 2 feet (2.0%) had acute postoperative superficial infection. No implant cutout was observed.
The MPA-E technique provided consistent and high functional outcomes. This valid and effective alternative should be considered as an option for hallux metatarsophalangeal arthrodesis.
LEVEL OF EVIDENCE:
Level IV, retrospective case series.
first metatarsophalangeal arthrodesis; fusion; hallux rigidus; hallux valgus
Hallux rigidus is a complex disorder, and numerous surgical procedures have been described for its management. Although the optimal technique has yet to be defined, it is important to individualize the degree of arthritis as well as other clinical features (metatarsal index, pain characteristics, and so forth) of each patient to achieve optimal results. The authors firmly believe that for patients with only dorsal pain, a cheilectomy is the ideal choice because good and reliable results can be achieved. When pain is also present around the joint
or is combined, which is the most common scenario, their main choice now is to perform a decompressive osteotomy. The biomechanics of the joint are more adequately restored, soft tissues are relaxed, and remodeling of the contracted tissues is allowed. More investigation has still to be performed to elucidate the origin of this abnormality.
Copyright © 2012 Elsevier Inc. All rights reserved.
Congenital talonavicular coalition is reported less frequently than talocalcaneal or calcaneonavicular coalition and represent approximately 1% of all tarsal coalitions. Although reportedly transmitted as an autosomal-dominant disorder, tarsal coalition may be inherited as an autosomal-recessive trait. It has been associated with various orthopaedic anomalies, including symphalangism, clinodactyly, a great toe shorter than the second toe, clubfoot, calcaneonavicular coalition, talocalcaneal coalition, and a ball-and-socket ankle. Patients with talonavicular coalitions are usually asymptomatic and rarely undergo surgical treatment. We report the case of a 24-year-old woman with symptomatic bilateral talonavicular coalitions and previously unreported associated anomalies (nail hypoplasia and metatarsus primus elevatus) and review the relevant literature. The patient underwent surgery (calcaneocuboid joint distraction arthrodesis and a proximal plantar flexion osteotomy with a dorsal open wedge of the first metatarsal). At 1-year followup, she was pain-free with better alignment of both feet and showed radiographic consolidation of the arthrodesis. Although this condition is less likely to be clinically important than other tarsal fusions, it sometimes can be painful enough for the patient to undergo surgery.
Minimally invasive surgical techniques are an alternative with potential advantages in the treatment of forefoot deformities.
Several surgical techniques have been described for the treatment of hallux valgus and lesser toe deformities.1-4 However, lack of agreement exists regarding which technique is the most efficacious.
Minimally invasive techniques have become increasingly popular in orthopedics. The application of these concepts in hallux valgus has been questioned in the past, in part due to the lack of scientific validation. However, recent studies have shown satisfactory results using these techniques.
This article describes the minimally invasive techniques we use at the Italian Hospital of Buenos Aires and their indications in the treatment of hallux valgus and lesser digital deformities. All techniques are performed as outpatient procedures under ankle or popliteal block with the patient supine and the operative foot positioned off the end of the table.8 Fluoroscopy is useful to monitor the performance of some of the steps.
The Bösch technique is used to treat mild to moderate hallux valgus with an intermetatarsal angle of 10° to 20° and a distal metatarsal articular angle <10°.
A 2-mm incision is made in the medial side of the great toe, approximately 5 mm plantar to the proxima dge of the nail. The wire entrance may be located dorsally when plantar metatarsal head displacement is desired, and plantarly if dorsal metatarsal head displacement is chosen. A second incision is made at the subcapital region of the first metatarsal, equidistant between the dorsal and plantar aspects of the bone. A 2-mm Kirschner wire is inserted retrograde from the first to the second incision. The K-wire must be placed subcutaneously and extraperiosteally to perform the metatarsal head displacement at the osteotomy site.
In the proximal incision, the periosteum is detached dorsally and plantarly with a small elevator, preserving its continuity to protect the soft tissues during the osteotomy.
The osteotomy is made in the first metatarsal subcapital region under fluoroscopic control, using an end cutting burr Shannon 44 (Miltex Instrument Co Inc, York, Pa). First, a pilot hole is made from medial to lateral. Using the hole as a guide, the bone cutter is swept around the dorsal and plantar cortex, trying to maintain the same angle proximally and distally. The osteotomy is performed perpendicular to the metatarsal shaft in the sagittal plane. In the frontal plane, the mediolateral obliquity of the osteotomy can be varied to shorten or lengthen the first metatarsal according to the preoperative plan. Furthermore, the metatarsal head can be rotated in the axial plane to correct rotational components of the deformity. Once the osteotomy is finished, mobility at the osteotomy site is checked under fluoroscopy.
Osteoid osteoma of the foot can pose particular problems in diagnosis, especially when positioned in a juxta-articular location. It can cause reactive synovitis and simulate arthritis without periostitis. An atypical presentation may delay diagnosis and thus delay treatment. Different modes of treatment have been described including medical management with nonsteroidal, antiinflammatory drugs, and open surgical resection with intralesional, marginal, or wide surgical margins. In recent years, several computed tomography-guided percutaneous techniques have been used to achieve ablation of the nidus with minimal tissue invasion. We report a case of a 39-year-old man with an 8-month history of persistent foot pain who underwent percutaneous radiofrequency ablation of an osteoid osteoma involving the calcaneus. The patient related an immediate relief of pain and had no recurrence of symptoms or the lesion at 3-year follow-up.
The majority of foot and ankle operations are performed on an outpatient basis and often under some form of regional anesthesia. In this prospective, randomized study of 51 patients undergoing elective unilateral forefoot procedures, we compared 2 different anesthetic techniques: the peripheral foot blockade and the popliteal sciatic nerve block. Variables assessed included the quality of surgical anesthesia, postoperative analgesia, and the incidence of postoperative complications. The anesthesia was classified as effective if it was the sole anesthetic technique for the forefoot surgery. We found successful results in both groups: 92% in the foot block group and 96% in the popliteal block group.
Analysis of time required to perform the anesthetic procedure showed a significant difference between the 2 groups, with foot block being considerably faster (14.3 minutes vs 19.2 minutes for popliteal block) (P = .0078). Foot block patients demonstrated 10.96 hours of analgesia, whereas popliteal block patients exhibited 14.32 hours (P = .132). With a mean follow-up of 5.7 months, we did not find anesthesia-related complications in any of the patients. Both techniques showed a high level of safety and efficacy, with no significant difference detected between them. Our patients showed a high rate of satisfaction with both procedures (96% for foot block patients and 96.1% for popliteal block patients) and reported a good discharge disposition. These data show that both procedures are safe and effective anesthetic techniques and well suited to forefoot ambulatory surgery.
BACKGROUND: The Weil osteotomy for treatment of central metatarsalgia is an oblique osteotomy of the metatarsal neck and shaft parallel to the ground that provides controlled shortening of the metatarsal without additional depression.
It offers many advantages over more traditional osteotomies, including stability and a large area of bone-to-bone contact. However, a floating-toe deformity appears to be a common complication after this osteotomy.
METHODS: Between February, 2000 and February, 2003, 70 Weil osteotomies (in 26 patients) were done at one institution. Follow-up averaged 18.3 (6 to 36) months.
Weightbearing radiographs were examined for shortening, subluxation, and for evidence of nonunion or malunion of the metatarsal head. Floating-toe deformity and mild recurrent tenderness were noted in the history and physical examination. The American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Metatarsophalangeal-Interphalangeal Scale (LMIS) was used for outcome rating. At final follow-up, nonunion and malunion also were evaluated.
RESULTS: The median score of the AOFAS scale was 81 (19 to 95) points. Fifty-four percent of the osteotomies were done with a proximal interphalangeal (PIP) joint arthrodesis of the same ray, and we observed a higher occurrence of floating-toe deformity in this group of patients.
CONCLUSION: Although it may be associated with some complications, the Weil osteotomy is an effective and safe procedure for the treatment of central metatarsalgia. We conclude that floating-toe deformity is a common complication associated with PIP joint arthrodesis. Although it appears not to cause a functional impairment, concurrent PIP arthrodesis should be avoided to reduce the occurrence of floating toes.
ABSTRACT: Classical ballet is an art form requiring extraordinary physical activity, characterised by rigorous training. These can lead to many overuse injuries arising from repetitive minor trauma. The purpose of this paper is to report our experience in the diagnosis and treatment of stress fractures at the base of the second and third metatarsal bones in young ballet dancers. We considered 150 trainee ballet dancers from the Ballet Schools of "Teatro Alla Scala" of Milan from 2005 to 2007. Nineteen of them presented with stress fractures of the base of the metatarsal bones. We treated 18 dancers with external shockwave therapy (ESWT) and one with pulsed electromagnetic fields (EMF) and low-intensity ultrasound (US); all patients were recommended rest. In all cases good results were obtained. The best approach to metatarsal stress fractures is to diagnose them early through clinical examination and then through X-ray and MRI. ESWT gave good results, with a relatively short time of rest from the patients’ activities and a return to dancing without pain.