Junichi Morikawa

The dorsiflexion-eversion test for diagnosis of tarsal tunnel syndrome

Background: The clinical diagnosis of tarsal tunnel syndrome lacks objectivity and consistency. We have devised a new diagnostic physical examination test in which the tibial nerve is compressed as it runs beneath the flexor retinaculum behind the medial malleolus. In this test, the ankle is passively maximally everted and dorsiflexed while all of the metatarsophalangeal joints are maximally dorsiflexed and held in this position for five to ten seconds. Methods: We performed this test on fifty normal volunteers (100 feet) and on thirty-seven patients (forty-four feet) treated operatively for tarsal tunnel syndrome between 1987 and 1997. We performed the maneuver both preoperatively and postoperatively and recorded any consequent changes in the signs and symptoms; during the operation we observed the altered anatomical relationships in the tarsal tunnel that were produced by the maneuver. The average duration of follow-up was three years and eleven months. Results: Before the operation, the signs and symptoms of tarsal tunnel syndrome were intensified or induced by the maneuver in fifteen of the twenty feet of the patients who reported numbness, in fifteen of the seventeen feet of those who reported pain alone, and in six of the seven feet of those who had combined numbness and pain. Local tenderness was intensified in forty-two of forty-three feet, and it was induced in one foot in which it had been previously absent. A Tinel sign became more pronounced in forty-one feet, and the sign was induced in three feet in which it had been absent previously. During the operation, the tibial nerve was stretched and compressed beneath the laciniate ligament when the ankle was dorsiflexed, the heel was everted, and the toes were dorsiflexed. Preoperative signs and symptoms disappeared on an average of 2.9 months after the operation, and they could not be induced by repeating the test except in three patients, all of whom had tarsal tunnel syndrome subsequent to a fracture of the calcaneus. In the normal volunteers, no symptoms or signs could be induced by the test. Conclusion: This new physical examination test is effective in facilitating the diagnosis of tarsal tunnel syndrome.

Tarsal tunnel syndrome associated with an accessory muscle.

Between 1986 and 1999, we surgically treated 41 patients (49 feet) with Tarsal Tunnel Syndrome (TTS) in whom seven (eight feet) were associated with an accessory muscle. An accessory flexor digitorum longus muscle was present in six patients, and an accessory soleus muscle was in one patient (both feet). Three of them were males and four females, with the mean age of 33.1 years (12 to 59 years). The mean interval from the onset of symptoms to operation was 7.5 months (range, six to nine months). All patients with an accessory muscle had a history of trauma or strenuous sporting activity. The diagnosis of TTS was made based on physical findings in all the patients (eight feet) and confirmed in five patients (six feet) by electrophysiological examination. Imaging examinations (radiography, ultrasonography, MRI) revealed abnormal bone and soft tissue lesions in and around the tarsal tunnel. Preoperative signs and symptoms disappeared average 4.1 months after decompression of the tibial nerve in addition to excision of the muscle. No functional deficit was observed at final follow-up (24 to 88 months).

Distal soft tissue procedure and proximal metatarsal osteotomy in hallux valgus.

The results of a distal soft tissue procedure and a proximal metatarsal osteotomy in patients with symptomatic hallux valgus deformity were reviewed. The series consisted of 33 patients (47 feet; mean age of patients, 44 years). The average followup period was 48 months. At followup, 41 feet (29 patients, 85%) were free from pain at the first metatarsophalangeal joint. In six feet (four patients), the pain was improved but persisted. The mean hallux valgus angle was 38° before surgery and 13.8° after surgery. The mean intermetatarsal angle was 17.7° before surgery and 7° after surgery. The postoperative hallux valgus angle and intermetatarsal angle in patients who had pain at the first metatarsophalangeal joint after surgery were greater than those in patients without pain after surgery. This procedure corrects the hallux valgus deformity and relieves the symptoms, but careful attention should be paid to the surgical technique to obtain consistent and satisfactory results.

Reconstruction for chronic lateral ankle instability using the palmaris longus tendon: is reconstruction of the calcaneofibular ligament necessary?

The palmaris longus tendon was used to reconstruct the anterior talofibular ligament (ATFL) in 27 ankles with chronic lateral instability. The mean age of the patients at surgery was 23 years, and the follow-up was more than 2 years. The functional evaluation showed excellent or good results in all ankles. Twenty-seven ankles were divided into two groups according to operative findings: group A consisted of 11 ankles with old isolated injury of the ATFL, and group B consisted of 16 ankles with old combined injuries of the ATFL and the calcaneofibular ligament. There were no significant differences in clinical results between group A and group B. The preoperative mean talar tilt angles on stress radiograph in group B were significantly larger than those in group A. At follow-up, there were no significant differences in the mean talar tilt angles between group A and group B. We demonstrate that reconstruction of the calcaneofibular ligament along with the ATFL is not necessary for patients with chronic combined lateral ligament instability.

Proximal Dome-shaped Osteotomy for Symptomatic Bunionette

The results of a dome-shaped osteotomy of the proximal third of the fifth metatarsal in patients with symptomatic bunionette deformity were reviewed. The series was comprised of eight patients (10 feet; mean age of patients, 21 years). The average followup was 30 months. All patients were free from pain at the fifth metatarsophalangeal joint and were satisfied with the results of this procedure. The mean angle between the longitudinal axes of the fifth metatarsal and the proximal phalanx was 18.9° before surgery and 2.6° after surgery. The mean angle between the longitudinal axes of the fourth and fifth metatarsals was 12.2° before surgery and 4.8° after surgery. The overall results were good in all 10 feet. Three feet had delayed union at the osteotomy site, but union was obtained in all feet. The osteotomy site of the fifth metatarsal in feet with delayed union was more proximal than that of the other feet. Therefore, proximal osteotomy of the fifth metatarsal should be done not at the base, but at the proximal site of the diaphysis to prevent delayed union. A proximal dome-shaped osteotomy corrects the deformity and relieves the symptoms, but careful attention should be paid to the osteotomy site.

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

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.

Surgical treatment for hallux valgus with painful plantar callosities.

We retrospectively reviewed the results of a distal soft-tissue procedure and proximal crescentic osteotomy of the first metatarsal combined with a proximal shortening osteotomy of the second and/or third metatarsal. This was in patients who had hallux valgus with painful plantar callosities. The review covered seven years of procedures (1989–1996) in 12 patients (14 feet) averaging 53 years of age. Average follow-up was 52 months. All patients had pain at the first metatarsophalangeal joint and had metatarsalgia preoperatively. At follow-up, 11 feet had no pain at the first metatarsophalangeal joint, and three had some improvement of pain. Ten feet had no metatarsalgia, two had improvement of metatarsalgia, and two feet had transfer lesions postoperatively and required reoperation. The angle of hallux valgus averaged 40 degrees preoperatively and 13 degrees postoperatively. The intermetatarsal angle averaged 18 degrees preoperatively and 6 degrees postoperatively. Mean decreases in length of the second and third metatarsal after surgery were 5.4 mm and 4.8 mm, respectively. Our results suggested that this combined procedure for hallux valgus with painful plantar callosities may be successful, in carefully selected patients.

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.

Adult hallux valgus with metatarsus adductus: A case report

It is difficult to surgically treat a hallux valgus deformity with significant metatarsus adductus, because the space between the first and second metatarsals is too narrow to correct the metatarsus primus varus with a first metatarsal osteotomy. A 55-year-old woman had severe hallux valgus with significant adduction of the second and third metatarsals. A distal soft tissue procedure and a proximal crescent-shaped osteotomy of the first metatarsal combined with corrective osteotomies of the second and third metatarsals were done. The patient’s symptoms disappeared, and hallux valgus and adduction of the second and third metatarsals were corrected. To the authors’ knowledge, there is no previous description of surgical treatment including correction of metatarsus adductus and hallux valgus for adult hallux valgus with metatarsus adductus.

Osteochondral Lesions of the Proximal Phalanx of the Great Toe: A Report of Two Cases:

Two cases of osteochondral lesions of the proximal phalanx of the great toe at the interphalangeal joint are presented. This condition is characterized by pain, swelling, and tenderness at the interphalangeal joint. The roentgenographic characteristics resemble osteochondritis dissecans. Curettage and bone grafting to the lesion is effective. These conditions in adolescent soccer players may be caused by chronic repetitive overloading of the interphalangeal joint using soccer shoes with soft, supple, and narrow toe boxes.