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PubMed2003

[Continuous popliteal block with ropivacaine via a stimulant catheter for postoperative analgesia after foot surgery].

Three patients underwent foot surgery to correct hallux valgus and other toe deformities. Postoperative analgesia was provided by a sciatic nerve block in the popliteal fossa through a 21-gauge 64 mm needle and a 50 cm catheter connected to a nerve stimulator. Ropivacaine 0.125% was perfused continuously at a rate of 7 mL/h for 48 h. All 3 patients were very satisfied with the level of analgesia, given that the intensity of pain upon movement was never more than slight. Hallux valgus surgery causes intense postoperative pain that can be prevented by a peripheral nerve block. A continuous popliteal block through a catheter equipped with a nerve stimulator is an easy technique that provides very good pain management after this type of surgery, with few undesirable side effects.

Adolescent↗
PubMed2005

Effect of metatarsophalangeal joint position on the reliability of the tangential sesamoid view in determining sesamoid position.

BACKGROUND: Lateral displacement of the sesamoids of the first toe relative to the metatarsal head is a common finding in hallux valgus deformity. Several methods have been described for quantifying the amount of subluxation from anteroposterior radiographs but a tangential sesamoid radiograph has been determined to be the best view to evaluate sesamoid displacement. METHOD: We evaluated the sesamoid position at different angles of the first metatarsophalangeal (MTP) joint to determine the effect of first MTP joint dorsiflexion on sesamoid position when tangential sesamoid view radiographs are made. Sesamoid positions of 22 feet with hallux valgus were graded from the short axis computed tomography (CT) images obtained with the MTP joint in 0, 35, and 70 degrees of dorsiflexion. RESULTS: Approximation of the sesamoids to reduction was apparent as dorsiflexion of the first MTP joint increased. CONCLUSION: Different dorsiflexion degrees of the first MTP joint when tangential sesamoid radiographs are made modulate the position of the sesamoids and may lead to misclassification on grading.

Hallux Valgus↗
PubMed1997

The chevron osteotomy: a clinical and radiographic analysis.

This is a retrospective study of the chevron osteotomy for hallux valgus. Subjective and objective postoperative results were evaluated. Differences in the postoperative correction of the intermetatarsal 1-2 angle and the first metatarsophalangeal angle were noted using two accepted measurement methods. Seventeen patients (23 feet) with an average age of 39 years (range, 15-51 years) and an average follow-up of 3 years (range, 1-5 years) were studied. The average preoperative intermetatarsal 1-2 angle was 11 degrees (range, 8 degrees to 14 degrees), and the average hallux valgus angle was 23 degrees (range, 7 degrees to 39 degrees). The apparent postoperative correction differed depending on the method of measurement used. One method consistently indicated a greater amount of correction in both the intermetatarsal and metatarsophalangeal angles. The chevron procedure resulted in an overall satisfactory improvement of symptoms, function, and cosmesis. Four feet exhibited postoperative radiographic changes that could be construed as avascular changes, but there was no collapse noted, nor were there clinical symptoms of avascular necrosis. No nonunions, malunions, or infections developed, and no cases of hallux varus occurred.

Adolescent↗
PubMed1998

Bunion correction using proximal chevron osteotomy: a single-incision technique.

Proximal chevron first metatarsal osteotomy with lateral capsulotomy, adductor tenotomy, and binding of the first and second metatarsals was reviewed in 88 consecutive cases. Seventy-two cases in 55 patients are reported, with an average clinical follow-up of 41 months. The hallux valgus angle improved an average of 15 degrees , from 32.0 degrees preoperatively to an average of 17.0 degrees postoperatively. The intermetatarsal I-II angle improved an average of 5.5 degrees, from 15.3 degrees preoperatively to 9.0 degrees postoperatively. The lateral plantar first metatarsal angle did not change. First metatarsal length was decreased by 2.0 mm. Union occurred at an average of 2 months. Sesamoid position improved 49%, from a preoperative average subluxation of 80% to a postoperative average subluxation of 29%. Subjective foot score profiles improved from a preoperative average of 70.1/100 to a postoperative average of 94.4/100 with respect to pain, deformity, motion, disability, and cosmesis. There were 10 patients with complications, including three patients with delayed unions, two with second metatarsal stress fractures, one with hallux varus, two with hallux limitus, one with progressive arthritis, one with cellulitis, and one with hallux elevatus. Eighty-four percent of the patients stated that they would undergo the procedure again without reservation, 9% would proceed with reservation, and 7% would not proceed with surgery again if offered. This technique provides reliable successful long-term results for the treatment of moderate and severe symptomatic bunion, hallux valgus, and metatarsus primus varus.

Adult↗
PubMed2005

Distal ligamentous restraints of the first metatarsal. An in vitro biomechanical study.

BACKGROUND: Hypermobility or instability of the first metatarsal is associated with increased hallux valgus deformity and greater risk of recurrence after surgery. The objective of this in vitro study was to determine the ranges of movement, under directional loading, of the normal first metatarsal and the effect of the longitudinal plantar aponeurosis and the transverse tie-bar ligamentous system. METHODS: A model has been developed to quantify the influence of the first intermetatarsal ligament and plantar aponeurosis on movements of the first metatarsal. All muscular structures controlling movements of the first ray in cadaver feet were detached and static ligament structures retained for study. Using a specially designed test system, a static load was applied to the metatarsal to produce flexion, extension, abduction or adduction moments. The first intermetatarsal ligament and the plantar aponeurosis were detached sequentially and a movement map of the first metatarsal in the frontal plane was obtained using the Isotrak II magnetic measuring system. RESULTS: The first intermetatarsal ligament was shown to be an important stabiliser of the first metatarsal in all directions. The plantar aponeurosis was shown to be a secondary stabiliser resisting medial and dorsal rotation of the metatarsal after division of the first intermetatarsal ligament. INTERPRETATION: Recognition of the importance of the plantar aponeurosis and the first intermetatarsal ligament in the normal foot has implications for our understanding of hallux valgus.

Biomechanical Phenomena↗
PubMed2002

How to report and monitor the performance of waiting list management.

OBJECTIVES: Potential problems concerning waiting list management are often monitored using mean waiting times based on empirical samples. However, the appropriateness of mean waiting time as an indicator of access can be questioned if a waiting list is not managed well, e.g., if the queue discipline is violated. This study was performed to find out about the queue discipline in waiting lists for elective surgery to reveal potential discrepancies in waiting list management. METHODS: There were 1,774 waiting list patients for hallux valgus or varicose vein surgery or sterilization. The waiting time distributions of patients receiving surgery and of patients still waiting for an operation are presented in column charts. The charts are compared with two model charts. One model chart presents a high queue discipline (first in-first out) and another a poor queue discipline (random) queue. RESULTS: There were significant differences in waiting list management across hospitals and patient categories. Examples of a poor queue discipline were found in queues for hallux valgus and varicose vein operations. CONCLUSIONS: A routine waiting list reporting should be used to guarantee the quality of waiting list management and to pinpoint potential problems in access. It is important to monitor not only the number of patients in the waiting list but also the queue discipline and the balance between demand and supply of surgical services. The purpose for this type of reporting is to ensure that the priority setting made at health policy level also works in practise.

Censuses↗
PubMed1990

Modified McBride's procedure: long-term results.

This paper presents the long-term results of using a modified version of McBride's procedure for the treatment of hallux valgus. The operation used in this group of patients is that described by McBride where the adductor hallucis tendon is detached from the base of the proximal phalanx. Our modification has been to augment this with a medial capsular reef, the adductor tendon is taken through a hole in the metatarsal neck and attached to the medial capsule. We did not remove the sesamoid bone. Twenty-nine feet have been followed up for up to 12 years and the results graded using Bonney and MacNab's scoring system. In a group of women aged 51-71 years 93% still have a satisfactory result up to 12 years after their operation. This operation would appear to be a reasonable option in the treatment of hallux valgus in patients with significant pain and deformity as long as they do not have major arthritic changes in the first metatarsophalangeal joint.

Aged↗
PubMed1992

Mitchell's osteotomy using internal fixation and early mobilisation.

We present the results of a prospective trial of osteotomy of the metatarsal neck for hallux valgus in 31 feet of 23 women, using a new stapling device with no plaster splintage and early weight-bearing. Surgery was performed for pain (29 feet) and difficulty with footwear (nine feet). The average time for return to light work was 3.3 weeks, and to full work 8.3 weeks after operation. Seventeen patients had full recovery within three months and 21 of the 23 patients had complete relief of pain. Shoes were more comfortable in 17 feet and 9 patients could wear narrower shoes. Only two patients were unsatisfied with the appearance of the foot. All the osteotomies united, and the average hallux valgus angle was improved on radiographs from 35 degrees to 23 degrees. The mean first metatarsal angle was reduced from 16 degrees to 11 degrees. The new technique allows more accurate surgery and easier postoperative management.

Adolescent↗
PubMed1996

Application of a NiTi staple in the metatarsal osteotomy.

Thirty-six metatarsal osteotomies using internal fixation of a shape memory metal compression staple for hallux valgus were performed in 21 women with a mean age of 42.3 years (30-66 years). The time for return to light work averaged 19.0 days, and to full work and normal walk 41.2 days after the operation. Twenty patients (35 feet) had complete relief from pain. Only in one foot, the pain was transferred under the second metatarsal head. The appearance of the feet was apparently improved and the width of the forefeet was decreased by a mean of 0.90 cm after the operation. Radiographic analysis of feet showed that all osteotomies united, and the average angle of hallux valgus was improved from 31.2 degrees to 16.3 degrees and the mean intermetatarsal angle from 12.0 degrees to 6.4 degrees. No external fixation of plaster splintage was needed and the distal fragment during healing of the osteotomy was stable. The time of bone healing was shortened and patients were allowed to bear weight at an early time.

Adult↗
PubMed1998

Surgical treatment of patients with painful instability of the second metatarsophalangeal joint.

An unstable second metatarsophalangeal joint may produce pain in the forefoot. Eighteen patients (20 feet) had a transfer of the flexor digitorum longus to the extensor side of the base of the proximal phalanx performed as the primary procedure to stabilize this painful joint. Most patients had a hallux valgus deformity that also required correction, because it either was also symptomatic or was preventing adequate reduction of the second toe. A ruptured plantar plate of the second metatarsophalangeal joint was demonstrated in 13 feet and in these joints appeared to be the cause of the vertical instability. However, all feet showed an unstable joint upon clinical examination. A vertical-stress test almost always reproduced the patient's pain while demonstrating instability in the joint; this was the most prominent physical finding in these patients. Eleven patients (13 feet) had an excellent result. Seven patients (seven feet) had a fair result, but they complained only of mild and occasional pain at the joint on exertion. Although difficult to quantify, it appears that postoperative stiffness in the joint provided some of the joint stability seen in our patients. The flexor tendon transfer appears to be a satisfactory method to treating the unstable metatarsophalangeal joint and of relieving patients' pain, but may not, however, restore a normal alignment of the second toe. Correction of other forefoot deformities as hallux valgus and hammertoes may also be important in restoring metatarsophalangeal stability.

Adult↗
PubMed2006

Metatarsophalangeal joint arthrodesis after failed Keller-Brandes procedure.

BACKGROUND: Keller-Brandes resection arthroplasty for correction of symptomatic hallux valgus deformity can obtain early good results, but late complications, such as recurrence of the deformity and instability of the first ray, have been described. Arthrodesis of the first metatarsophalangeal, (MTP) joint can be done as a salvage procedure. The aim of this prospective study was to evaluate the clinical outcome of the arthrodesis and its effect on the biomechanics of the first ray. METHODS: Between October, 1999, and December, 2002, arthrodesis of the MTP joint was done after a failed Keller-Brandes procedure in 28 feet of 26 consecutive patients. Twenty patients (22 feet) with a minimum of 24 months followup were available for clinical and radiographic assessment. Pedobarographic measurements were obtained at latest followup in 16 patients (17 feet). RESULTS: Sixteen feet (72%) were pain-free and six feet (28%) had mild, occasional pain. The American Orthopaedic Foot and Ankle Society (AOFAS) forefoot score increased from a preoperative 44 (range 29 to 67) points to 85 (range 73 to 90) points at longest clinical followup (average 34 months, range 23 to 48, p < 0.001). The average hallux valgus angle was corrected from 24.0 (range 7 to 47) degrees preoperatively to 16.0 (range 0 to 40) degrees postoperatively (p < 0.001). Two feet had pseudoarthroses. Biomechanically, the MTP joint arthrodesis could not fully restore the function of the hallux but produced a significant improvement, allowing a more physiologic loading pattern under the hallux and the metatarsal heads. CONCLUSIONS: First MTP joint arthrodesis after a failed Keller-Brandes procedure is a technically safe and reliable technique. It resulted in a marked reduction of pain and gain of function that produced high patient satisfaction.

Aged↗
PubMed1991

The Keller resection arthroplasty: a 13-year experience.

The clinical results following Keller resection arthroplasty were reviewed in 54 feet with a 2- to 10-year follow-up. Patients were evaluated by radiographs, physical examination, and questionnaire. The primary indication for surgery was painful hallux valgus with associated degenerative changes of the first metatarsophalangeal joint. Additionally, rheumatoid arthritis was the underlying diagnosis in four feet. Seventy-five percent of all patients had complete relief of their symptoms. There was significant (P less than .01) improvement in both the metatarsophalangeal and intermetatarsal angles, but a decreased range of motion in the first metatarsophalangeal joint, with a complete lack of plantarflexion in 67%. Application of the Bonney and MacNab2 grading system yielded a 72% rate of good and excellent results. The subjective patient satisfaction rate was 87.5%. Patient satisfaction was most strongly associated with the use of a K-wire for postoperative fixation (P = .03), and a limited resection of the proximal phalanx (P = .03). We conclude that the Keller resection arthroplasty is a reasonable alternative for the treatment of hallux valgus in the presence of degenerative changes in the first metatarsophalangeal joint.

Aged↗
PubMed2003

[Functional CT imaging: Load-dependent visualization of the subchondral mineralization by means of CT osteoabsorptiometry (CT-OAM)].

PURPOSE: Functional computed tomography for visualization and quantification of subchondral bone mineralization using CT osteoabsorptiometry (CT-OAM). MATERIALS AND METHODS: Tarsometatarsal (TMT) and metatarsophalangeal (MTP) joints of 46 human hallux valgus (HV) specimens were examined (sagittal 1/1/1 mm) on a single slice CT scanner SCT (Somatom Plus 4, Siemens AG). Subchondral bone pixels were segmented and assigned to 10 density value groups (Delta 100 HU, range 200 - 1200 HU) the pixels using volume rendering technique (VRT). The data analysis considered the severity of HV as determined by the radiographically measured HV-angle (a. p. projection). RESULTS: CT-OAM could generate reproducible densitograms of the distribution pattern of the subchondral bone density for all four joint surfaces (TMT and MTP joints). The bone density localization enables the assignment to different groups, showing a characteristic HV-angle-dependent distribution of the maximum bone mineralization of the load-dependent densitogram (p < 0.001). CONCLUSION: CT-OAM is a functional CT technique for visualizing and quantifying the distribution of the subchondral bone density, enabling a noninvasive load-dependent assessment of the joint surfaces. Load-dependent densitograms of hallux valgus specimens show a characteristic correlation with an increase of the HV-angle.

Absorptiometry, Photon↗
PubMedDate not supplied

Effect of proximal articular set angle-correcting osteotomies on the hallucal sesamoid apparatus: a cadaveric and radiographic investigation.

A cadaveric and radiographic study was undertaken to demonstrate the change in intersesamoidal crista architecture after an osteotomy that corrects the proximal articular set angle (PASA). Three cadaveric first metatarsals with hallux valgus deformity were utilized. Separate Kirschner wires representing the longitudinal axis bisection, PASA, and the long axis of the crista were placed into each specimen. After osteotomy, the metatarsal heads were translated laterally, rotated parallel to the transverse plane to correct PASA, and impacted. The relationship between the crista and the long axis of the metatarsal was determined. A deviation in the alignment between the intersesamoidal crista and the long axis of the metatarsal following the osteotomy was observed. The radiographic portion of this study correlated intermetatarsal angle, PASA, and tibial sesamoid position with intersesamoidal crista appearance on sesamoidal axial radiographs. Radiographic parameters in 19 patients (34 feet) were compared and two distinct patterns were evident: 1) A proximal articular set angle greater than 15 degrees was associated with complete crista erosion in 10 feet (91% of this subgroup); 2) a tibial sesamoid position greater than three was associated with partial or complete erosion in 17 feet (100% of this subgroup). A higher deviation of PASA and increased displacement of the sesamoidal apparatus correlated with crista erosion. These findings suggest that the crista fails to adapt with PASA as hallux valgus progresses and undergoes erosion instead. This study suggests that when correcting the PASA, misalignment of the sesamoid apparatus may lead to sub-first metatarsal arthrosis.

Cadaver↗
PubMed2000

Combined sciatic-femoral nerve block with 0.75% ropivacaine: effects of adding a systemically inactive dose of fentanyl.

To evaluate the effects of adding low-dose fentanyl to 0.75% ropivacaine during peripheral nerve blocks, 30 ASA physical status I-II patients undergoing hallux valgus repair under combined sciatic-femoral nerve block were randomly allocated in a double-blind fashion to receive nerve block placement with 30 mL of either 0.75% ropivacaine alone (group: ropivacaine, n = 15) or 0.75% ropivacaine plus fentanyl 1 microg kg(-1) (group: ropivacaine-fentanyl, n = 15). A blinded observer recorded haemodynamic variables and sedation, as well as the time required to achieve surgical block and the first request for analgesia. Readiness to surgery required 10 min (5-20 min) with 0.75% ropivacaine and 10 min (3-20 min) with the ropivacaine-fentanyl mixture. No differences in the degree of sedation, peripheral oxygen saturation, and haemodynamic variables were observed between the two groups. The degree of pain measured at first analgesic request, and the consumption of postoperative analgesics, was similar in the two groups, while the mean time from block placement to the first request for pain medication was 13.7 h (25-75th percentiles: 11.8-14.5 h) in the ropivacaine group and 13.9 h (25-75th percentiles: 10.5-14.5 h) in the ropivacaine-fentanyl group (P = not significant). We conclude that adding fentanyl 1 microg kg(-1) to 0.75% ropivacaine did not provide clinically relevant advantages in terms of onset time, quality and duration of combined sciatic-femoral nerve block in patients undergoing elective hallux valgus repair.

Adjuvants, Anesthesia↗
PubMed2005

Proximal metatarsal osteotomy: relation between 1- to greater than 3-years results.

UNLABELLED: We analyzed the relationship between the 1-year and greater than 3-years results of a distal soft tissue procedure with a proximal osteotomy for hallux valgus in the same patient population. The series consisted of 55 feet treated with this procedure. The results at 1 year and greater than 3 years were evaluated. The final followup was greater than 3 years. Patients with pain in the first metatarsophalangeal joint at the 1-year followup had a greater risk of having pain at the final followup than did patients without pain at the 1-year followup. Patients with metatarsalgia at the 1-year followup had a greater risk of having metatarsalgia at the final followup than did patients without metatarsalgia at the 1-year followup. The extension of the first metatarsophalangeal joint at the final followup was greater than extension at the 1-year followup. In 48 feet (87%), radiologic evaluation showed no or minimal changes in the hallux valgus and intermetatarsal angles between 1 year and greater than 3 years followup. The data suggest the 1-year results predict those beyond 3 years, although the extension of the first metatarsophalangeal joint may increase 1 year after surgery. LEVEL OF EVIDENCE: Prognostic study, Level III. See the Guidelines for Authors for a complete description of levels of evidence.

Adolescent↗
PubMed2000

Doppler imaging of vibrations as a tool for quantifying first tarsometatarsal joint stiffness.

OBJECTIVE: To assess whether first tarsometatarsal joint stiffness can be measured by Doppler imaging of vibrations and if so, to assess reference values. DESIGN: Repeated in vivo Doppler imaging of vibrations measurements at the first tarsometatarsal joint in healthy persons. BACKGROUND: Clinical hypermobility of the first tarsometatarsal joint is an important factor in a hallux valgus deformity. No objective and non-invasive test is available to quantify first tarsometatarsal joint mobility. Doppler imaging of vibrations, a technique recently developed to measure joint stiffness, might be an effective tool to quantify stiffness of this joint. METHODS: Vibrations were applied to the head of the first metatarsal in 46 feet of 23 healthy subjects and picked up by a transducer at both sides of the first tarsometatarsal joint. A pilot study was performed on three patients with hypermobility of the first tarsometatarsal joint. Measurements are expressed in threshold units related to colour Doppler imaging. RESULTS: The values of the threshold units were found to be very similar in healthy persons, with a good repeatibility; 95% of the healthy persons had a threshold unit below 3.4. No significant difference was found between the left and right foot, or between male and female subjects. Also there was no significant correlation with age or weight of the subjects. In the three patients with first tarsometatarsal hypermobility we found threshold units above 5. CONCLUSIONS: With Doppler imaging of vibrations first tarsometatarsal joint stiffness can be measured in healthy persons in a non-invasive and objective way. In a pilot study, three patients with first tarsometatarsal hypermobility showed lower stiffness values than the healthy subjects. Relevance This study presents a new method for quantification of first tarsometatarsal joint stiffness and provides reference values in healthy persons. First measurements on patients gave promising results to future use of this method for assessment of clinical hypermobility in hallux valgus patients.

Adolescent↗
PubMed1999

Effect of increasing distal medial closing wedge metatarsal osteotomies on the distal metatarsal articular angle.

The recognition, definition, and management of the congruent hallux valgus deformity continue to evolve. To correct the skeletal deformity and maintain joint congruity, many authors have emphasized the importance of extra-articular procedures. One such procedure is a distal medial closing wedge osteotomy of the first metatarsal. Unfortunately, there are few guidelines to help determine the pre- and intraoperative size of the medial wedge to obtain the desired correction of the distal metatarsal articular angle (DMAA). The purpose of this study was to quantify the effects of increasing distal medial closing wedge osteotomies on the DMAA in an in vitro cadaver model. In this study, a closing wedge osteotomy was performed 2 cm proximal to the articular surface, removing wedges measuring 2 mm, 4 mm, and 6 mm in width. The mean preoperative DMAA was 8.5 degrees, and the mean postoperative DMAAs after 2-mm, 4-mm, and 6-mm closing wedge osteotomies were -2.6 degrees, -10.2 degrees, and -20.2 degrees, respectively. The data showed that for every 1 mm of closing wedge osteotomy, the DMAA decreased by 4.7 degrees +/- 0.6 degrees. These results can be used for pre- and intraoperative planning when surgically correcting a congruent hallux valgus deformity with a distal medial closing wedge osteotomy of the first metatarsal. Additional information obtained from this cadaver study includes (1) increased shortening of the first metatarsal and (2) incongruity produced at the joint after the medial-based osteotomy. The amount of shortening of the first metatarsal correlated directly with the size of the medial-based wedge. The second point indicates that a lateral soft-tissue release may still be required when using this method of reorienting the DMAA.

Aged↗