Hiroaki Shima

Postoperative Incomplete Reduction of the Sesamoids as a Risk Factor for Recurrence of Hallux Valgus

BACKGROUND It is unknown whether postoperative incomplete reduction of the sesamoids is a risk factor for the recurrence of hallux valgus. The purpose of the present study was to clarify the relationship between the postoperative relative sesamoid position and the recurrence of hallux valgus. METHODS Dorsoplantar weight-bearing radiographs of sixty normal feet (the control group) and sixty-five feet with hallux valgus (the hallux valgus group) in a study of adult women were reviewed. The feet in the hallux valgus group were treated with a proximal metatarsal osteotomy, and the radiographs were assessed preoperatively, at the early follow-up interval (at a mean of 3.1 months), and at the most recent follow-up interval (at a mean of forty-five months). The position of the medial sesamoid was classified with a grading system ranging from I through VII as described by Hardy and Clapham. In the feet with hallux valgus, we defined a grade of IV or less as the normal position of the medial sesamoid (the normal-position group) and grade V or greater as lateral displacement of the sesamoid (the displacement group). RESULTS Fifty feet (83%) in the control group were classified as grade IV or less and ten, as grade V. All feet in the hallux valgus group were classified as grade V or greater preoperatively, forty-eight feet (74%) were classified as grade IV or less at the early follow-up evaluation, and forty-two feet (65%) were classified as grade IV or less at the most recent follow-up evaluation. The average hallux valgus angle in the hallux valgus group was 38.3 degrees (range, 25 degrees to 60 degrees ) preoperatively, 11.9 degrees (range, 4 degrees to 28 degrees ) at the time of the early follow-up, and 13.9 degrees (range, 0 degrees to 33 degrees ) at the time of the most recent follow-up. There was no significant difference in the average hallux valgus angle between the early and most recent follow-up evaluations in the feet that were considered to be in the normal-position group at the time of the early follow-up (p = 0.084). In the feet that were considered to be in the displacement group at the time of the early follow-up, the average hallux valgus angle at the time of the most recent follow-up was significantly greater than that at the time of the early follow-up (19.5 degrees +/- 8.4 degrees compared with 15.0 degrees +/- 5.8 degrees ) (p = 0.0082). The feet that were in the displacement group at the time of the early follow-up had a greater risk of having recurrence of the hallux valgus at that time than did those in the normal-position group (odds ratio, 10.0; 95% confidence interval, 2.75 to 36.33). CONCLUSIONS Postoperative incomplete reduction of the sesamoids can be a risk factor for the recurrence of hallux valgus. The identification of incomplete reduction of the sesamoids intraoperatively may allow modification of surgical procedures and improvement of the surgical results.

The Shape of the Lateral Edge of the First Metatarsal Head as a Risk Factor for Recurrence of Hallux Valgus

BACKGROUND The relationship between the shape of the first metatarsal head and hallux valgus deformity remains controversial. The purpose of the present study was to retrospectively analyze differences in the radiographic appearance of the shape of the lateral edge of the first metatarsal head between women with normal feet and those with hallux valgus and to clarify the relationship between the shape of the lateral edge and the postoperative recurrence of hallux valgus deformity. METHODS Dorsoplantar weight-bearing radiographs of sixty normal feet in women (the control group) and sixty feet in women with hallux valgus (the hallux valgus group) were reviewed. The feet in the hallux valgus group were treated with a proximal metatarsal osteotomy, and the radiographs of those feet were assessed preoperatively, at the time of early follow-up (mean, 3.4 months), and at the time of the most recent follow-up (mean, forty-eight months). The shape of the lateral edge, which was defined as consisting of the articular and lateral surfaces of the first metatarsal head, was examined. The shape of the lateral edge was classified as one of three types: round (type R), angular (type A), and intermediate (type I). We defined the round sign as being positive when the shape of the lateral edge was classified as type R. RESULTS Prior to surgery, the prevalence of the type-R shape was significantly greater in the hallux valgus group than it was in the control group (78.3% compared with 1.7%; p < 0.0001) and the prevalence of type-A shape was significantly lower in the hallux valgus group than in the control group (3.3% compared with 81.7%; p < 0.0001). In the hallux valgus group, the prevalence of the type-R shape at the time of the early follow-up after surgery was significantly lower than that before surgery (p < 0.0001). Feet with a positive round sign at the time of the early follow-up had a greater risk of having recurrence of the hallux valgus deformity at the time of the most recent follow-up than did those without a round sign at the time of the early follow-up (odds ratio, 12.71; 95% confidence interval, 3.21 to 50.36). CONCLUSIONS There is a significant relationship between a round-shaped lateral edge of the first metatarsal head and hallux valgus, and a positive round sign after a proximal first metatarsal osteotomy can be a risk factor for the recurrence of hallux valgus.

Radiographic measurements in patients with hallux valgus before and after proximal crescentic osteotomy.

BACKGROUND Radiographic measurements such as those of the hallux valgus angle and the intermetatarsal angle are essential parameters for assessing the severity of hallux valgus deformities and the extent of surgical correction required. However, to our knowledge, no study has investigated the reliability of the measurements that are made radiographically before and after a proximal crescentic osteotomy of the first metatarsal. The purpose of the present study was to investigate the intraobserver and interobserver reliability of different methods that are used to measure the angles and to determine the most reliable method. METHODS We selected twenty preoperative and twenty postoperative dorsoplantar weight-bearing radiographs for patients who had undergone a proximal crescentic osteotomy of the first metatarsal. Three foot and ankle surgeons measured the hallux valgus angle and the intermetatarsal angle with use of five different methods. We calculated the intraobserver and interobserver correlation coefficients and agreement to determine the most reliable method. RESULTS Significant differences were observed among the methods with regard to the postoperative hallux valgus angle (p < 0.05) and the preoperative and postoperative intermetatarsal angles (p < 0.01 for both). The method in which a line connecting the centers of the first metatarsal head and the proximal articular surface of the first metatarsal was used to define the longitudinal axis of the first metatarsal yielded the highest intraobserver and interobserver correlation coefficients for the preoperative hallux valgus and intermetatarsal angles and the postoperative hallux valgus angle. For this method alone, the intraobserver and interobserver agreements for the angular measurements were found to be >80%. CONCLUSIONS A line connecting the centers of the first metatarsal head and the proximal articular surface of the first metatarsal to define its longitudinal axis yields the best intraobserver and interobserver reliability for the measurement of the hallux valgus and intermetatarsal angles. Therefore, this method can be recommended for evaluating radiographs before and after a proximal crescentic osteotomy performed for the treatment of hallux valgus.

Proximal Metatarsal Osteotomy for Hallux Valgus: Comparison of Outcome for Moderate and Severe Deformities

Background: We compared the results of a distal soft-tissue procedure with a proximal crescentic osteotomy of the first metatarsal for moderate and severe hallux valgus. Materials and Methods: The series consisted of 54 feet treated with this procedure. The average followup was 30 months. Fifty-four feet were divided into two groups including Group M (moderate) (24 feet, preoperative hallux valgus angle of 40 degrees or less and preoperative intermetatarsal angle of less than 18 degrees) and Group S (severe) (30 feet, preoperative hallux valgus angle of greater than 40 degrees or preoperative intermetatarsal angle of 18 degrees or greater). Results: The difference between Group M and S was not significant with regard to the age of patients, duration of followup, or postoperative pain and function scores on the American Orthopaedic Foot and Ankle Society scale. However, postoperative alignment score in Group M was significantly greater than that in Group S (p = 0.038). Postoperative hallux valgus and intermetatarsal angles in Group S were significantly greater than those in Group M, respectively (p = 0.025, p = 0.001). The prevalence of recurrent hallux valgus (hallux valgus angle of 20 degrees or greater) in Group S was significantly higher than that in Group M (p = 0.013). Conclusion: This procedure is an effective method for relieving pain and improving function regardless of the severity of hallux valgus. However, the correction of moderate hallux valgus is likely to be better than that of severe hallux valgus.

Proximal Supination Osteotomy of the First Metatarsal for Hallux Valgus

Background: Risk factors for hallux valgus recurrence include postoperative round-shaped lateral edge of the first metatarsal head and postoperative incomplete reduction of the sesamoids. To prevent the occurrence of such conditions, we developed a proximal supination osteotomy of the first metatarsal. Our aim was to describe this novel technique and report the outcomes in this report. Methods: Sixty-six patients (83 feet) underwent a distal soft tissue procedure combined with a proximal supination osteotomy. After the proximal crescentic osteotomy, the proximal fragment was pushed medially, and the distal fragment was abducted, and then the distal fragment of the first metatarsal was manually supinated. Outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and radiographic examinations. The average follow-up duration was 34 (range, 25 to 52) months. Results: The mean AOFAS score improved significantly from 58.0 points preoperatively to 93.8 points postoperatively (P < .0001). The mean hallux valgus and intermetatarsal angle decreased significantly from 38.6 and 18.0 degrees preoperatively to 11.0 and 7.9 degrees postoperatively, respectively (both, P < .0001). Sixty-nine feet (69/83, 83%) had a positive round sign preoperatively, and 66 feet (66/83, 80%) had a negative round sign postoperatively. According to the Hardy’s classification of position of the sesamoids, all feet were classified as grade V or greater preoperatively, and 49 feet (49/83, 59%) were classified as grade IV or less postoperatively. Three feet (3/83, 4%) had recurrence of hallux valgus, defined as a hallux valgus angle ≥ 25 degrees. Conclusion: The rates of occurrence of a positive round sign and incomplete reduction of the sesamoids significantly decreased postoperatively, which may have contributed to the low hallux valgus recurrence rates. We conclude that a proximal supination osteotomy was an effective procedure for correction of hallux valgus and can achieve a low rate of hallux valgus recurrence. Level of Evidence: Level IV, retrospective case series.

Tibialis spastic varus foot caused by osteoid osteoma of the calcaneus

Tibialis spastic varus foot is an extremely rare condition. A 30-year-old man had tibialis spastic varus foot caused by juxtaarticular osteoid osteoma of the calcaneus. The correct diagnosis was delayed because the symptoms were similar to arthritis and the nidus was difficult to detect on plain radiographs. Curettage of the tumor was done, and the osseous defect was filled with interporous hydroxyapatite. The pain was relieved immediately after surgery. The varus deformity of the foot and spasm of the tibialis anterior muscle gradually improved. Three years 10 months after surgery, the patient was pain-free and the spasm of the tibialis anterior muscle had disappeared. The varus deformity and motion of the foot improved, but a restricted range of motion remained. To the authors’ knowledge, there have been no published descriptions of tibialis spastic varus foot caused by juxtaarticular osteoid osteoma of the calcaneus.

Direct Repair of Chronic Achilles Tendon Ruptures Using Scar Tissue Located Between the Tendon Stumps

BACKGROUND Several surgical procedures for chronically ruptured Achilles tendons have been reported. Resection of the interposed scar tissue located between the tendon stumps and reconstruction using normal autologous tissue have been well described. We developed a direct repair procedure that uses scar tissue, which obviates the need to use normal autologous tissue. METHODS Thirty consecutive patients with Achilles tendon ruptures with a delay in diagnosis of >4 weeks underwent removal of a section of scar and healing tissue with direct primary suture of the ends of the tendon without the use of allograft or autograft. Patients were followed for a mean time of 33 months. Preoperative and postoperative clinical outcomes were measured with the Achilles Tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. In addition, the patients underwent preoperative and postoperative functional measurements and magnetic resonance imaging. Lastly, we evaluated the histology of the interposed healing tissue. RESULTS The mean AOFAS scores were 82.8 points preoperatively and 98.1 points postoperatively. The mean postoperative ATRS was 92.0 points. At the time of the latest follow-up, none of the patients had experienced tendon reruptures or difficulties in walking or climbing stairs, and all except 2 patients could perform a single-limb heel rise. All athletes had returned to their pre-injury level of sports participation. Preoperative T2-weighted magnetic resonance imaging showed that 22 Achilles tendons were thickened with diffuse intratendinous high-signal alterations, and 8 Achilles tendons were thinned. Postoperative T2-weighted magnetic resonance imaging findings included fusiform-shaped tendon thickening and homogeneous low-signal alterations of the tendons in all patients. Histologically, the interposed scar tissue consisted of dense collagen fibers. CONCLUSIONS Shortening of the tissue between the 2 tendon ends that included healing scar and direct repair of healing tendon without allograft or autograft can be effective for treatment-delayed or neglected Achilles tendon rupture. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The effect of platelet-rich plasma on Achilles tendon healing in a rabbit model

Objective The aim of the present study was to evaluate the effects of PRP on Achilles tendon healing in rabbits during the inflammatory, proliferative, and remodeling phases by histological examination and quantitative assessments. Methods Fifty mature male Japanese albino rabbits with severed Achilles tendons were divided into two equal groups and treated with platelet-rich plasma (PRP) or left untreated. Tendon tissue was harvested at 1, 2, 3, 4, and 6 weeks after treatment, and sections were stained with hematoxylin-eosin and monoclonal antibodies against CD31 and type I collagen. Results Collagen fibers proliferated more densely early after severance, and subsequent remodeling of the collagen fibers and approximation of normal tendinous tissue occurred earlier in the PRP group than in the control group. The fibroblast number was significantly higher in the PRP group than in the control group at 1 and 2 weeks. Similarly, the area ratio of CD31-positive cells was significantly higher in the PRP group than in the control group at 1 and 2 weeks. Positive staining for type I collagen was more intense in the PRP group than in the control group after 3 weeks, indicating tendon maturation. Conclusion Administration of PRP shortened the inflammatory phase and promoted tendon healing during the proliferative phase.

Comparison of plantar pressure distribution in patients with hallux valgus and healthy matched controls

BACKGROUND Detailed information regarding differences in plantar pressure distribution between hallux valgus and healthy feet is unavailable. The purposes of the present study were to clarify the characteristics of the plantar pressure distribution in patients with hallux valgus compared with healthy matched controls and to determine whether hallux valgus leads to dysfunction of the great toe during walking. METHODS The study consisted of 25 patients with symptomatic moderate-to-severe hallux valgus (HV group) and 13 healthy matched volunteers (C group) without hallux valgus. All patients and volunteers were women. The HV and C groups did not differ significantly in age, height, weight, and body mass index. Plantar pressure during walking was measured using F-scan. The plantar aspect of the foot was divided into eight regions. The peak pressure (Peak-P), maximum force (Max-F), contact time (Con-T), contact area (Con-A), and force time integral (FTI) were measured in each region. RESULTS The Peak-P of the great toe did not differ significantly between the HV and C groups. However, all other parameters: Max-F, Con-T, Con-A, and FTI of the great toe in the HV group were significantly lower than in the C group. In the central forefoot, the Peak-P and Max-F in the HV group were significantly higher than in the C group. CONCLUSION The present study demonstrated that a moderate-to-severe hallux valgus deformity leads to dysfunction of the great toe during walking and may increase mechanical loading on the central forefoot.

Simultaneous Reconstruction of the Medial and Lateral Collateral Ligaments for Chronic Combined Ligament Injuries of the Ankle

Background: Objective data on chronic injuries of the medial collateral ligament (MCL) of the ankle are scarce. Chronic MCL injuries are frequently associated with lateral collateral ligament (LCL) injuries. For patients with chronic combined MCL and LCL injuries, the authors have performed simultaneous surgery of the 2 ligaments. Hypothesis: Simultaneous surgery of the 2 ligaments may be effectively used to treat chronic combined MCL and LCL injuries. Study Design: Case series; Level of evidence, 4. Methods: Surgical outcomes were evaluated in 29 consecutive patients presenting with chronic MCL and LCL injuries (30 ankles; 15 men and 14 women; mean age, 31 years; 13 competitive and 10 recreational athletes). Preoperative and postoperative clinical outcomes were measured with the Karlsson score and the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score. The patients underwent preoperative and postoperative functional measurements and a radiological examination. In addition, preoperative magnetic resonance imaging (MRI) results, arthroscopic findings, and histology of the MCL were evaluated. Results: Preoperatively, the deep fibers of the MCL did not appear striated in 29 ankles, and high-intensity signal changes were observed in 23 ankles on T2-weighted or gradient echo MRI. MCL ruptures were confirmed with arthroscopic surgery. Medial impingement lesions and focal chondral lesions were confirmed in 10 and 21 ankles, respectively. Histology of the reconstructed MCL showed dense collagen fibers with vessels. The mean postoperative follow-up period was 30 months (range, 24-52 months). There was a significant change between preoperative and postoperative Karlsson scores (69.0 vs 96.1 points, respectively; P < .0001) and JSSF scores (69.8 vs 94.5 points, respectively; P < .0001). On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperative anterior displacement on stress radiography was significantly lower than preoperative anterior displacement. Postoperatively, all 23 athletes returned to their preinjury level of sports participation. Conclusion: MCL insufficiency resulted from medial ankle instability and medial impingement lesions. Outcomes in the patients indicated that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined MCL and LCL injuries of the ankle.