Matthias Walcher

Treatment of hallux valgus deformity

Hallux valgus deformity is a very common pathological condition which commonly produces painful disability. It is characterised as a combined deformity with a malpositioning of the first metatarsophalangeal joint caused by a lateral deviation of the great toe and a medial deviation of the first metatarsal bone. Taking the patient’s history and a thorough physical examination are important steps. Anteroposterior and lateral weight-bearing radiographs of the entire foot are crucial for adequate assessment in the treatment of hallux valgus. Non-operative treatment of the hallux valgus cannot correct the deformity. However, insoles and physiotherapy in combination with good footwear can help to control the symptoms. There are many operative techniques for hallux valgus correction. The decision on which surgical technique is used depends on the degree of deformity, the extent of degenerative changes of the first metatarsophalangeal joint and the shape and size of the metatarsal bone and phalangeal deviation. The role of stability of the first tarsometatarsal joint is controversial. Surgical techniques include the modified McBride procedure, distal metatarsal osteotomies, metatarsal shaft osteotomies, the Akin osteotomy, proximal metatarsal osteotomies, the modified Lapidus fusion and the hallux joint fusion. Recently, minimally invasive percutaneous techniques have gained importance and are currently being evaluated more scientifically. Hallux valgus correction is followed by corrective dressings of the great toe post-operatively. Depending on the procedure, partial or full weight-bearing in a post-operative shoe or cast immobilisation is advised. Post-operative radiographs are taken in regular intervals until osseous healing is achieved. Cite this article: Fraissler L, Konrads C, Hoberg M, Rudert M, Walcher M. Treatment of hallux valgus deformity. EFORT Open Rev 2016;1:295-302. DOI: 10.1302/2058-5241.1.000005.

High Prevalence of Vitamin D Deficiency in Patients With Bone Marrow Edema Syndrome of the Foot and Ankle.

Background: Bone marrow edema syndrome (BMOS) is a phenomenon primarily affecting the lower extremity. It is characterized by a sudden onset of pain and an ill-defined osseous hyperintense signal in magnetic resonance imaging. The main cause of BMOS is still largely unknown. Its pathophysiology is presumably multifactorial and it has recently been demonstrated that it usually involves an increase in bone turnover and alterations within the bone microenvironment. Vitamin D plays a pivotal role in maintaining a healthy and well-balanced bone microenvironment. However, to date only limited information has been reported on vitamin D status in patients with BMOS. Moreover, it is still uncertain whether hypovitaminosis D is associated with the etiology and course of the disease. For this reason, the aim of this study was to determine serum vitamin D levels (25(OH)D) of patients diagnosed with BMOS of the foot and ankle. Methods: Patients were identified and laboratory results collected by retrospective review of the medical records between year 2011 and 2015. Diagnosis was based on clinical examination, the existence of prolonged foot pain, the presence of abnormal bone marrow signal intensity in T1- and T2-weighted magnetic resonance imaging, and the patient’s medical history. All patients who demonstrated other concomitant diagnoses were excluded from the study. Results: Overall, 31 patients were affected by BMOS with a mean age of 44.4 (range, 18-76) years. Notably, 84% of patients (26/31) had low vitamin D levels with a mean 25(OH)D level of 19.03 ng/mL. Specifically, 61% of patients (19/31) were vitamin D deficient, 23% (7/31) vitamin D insufficient, and only 5 patients (16%) had sufficient vitamin D levels. Statistical analysis showed no significant difference comparing vitamin D levels with patient age, sex, and time of diagnosis. Moreover, there was no correlation between vitamin D status and the number of bony foci or location of BMOS. Conclusion: We found a widespread rate of vitamin D deficiency in patients presenting with BMOS of the foot and ankle. Comparing these data to the vitamin D status of the general population in Germany and to patients living in comparable latitudes, this raises the possibility that BMOS might be associated with low vitamin D status. Level of Evidence: Level IV, retrospective case series.

Total Ankle Replacement in Varus Ankle Osteoarthritits

About 50% of the cases with degenerative osteoarthritis of the ankle are asymmetric. Varus ankle osteoarthritis is far more frequent than valgus ankle osteoarthritis. Most of the cases of ankle osteoarthritis have posttraumatic aetiology. It is important to understand the deformity completely, and to distinguish simple deviations in the coronal plane from more-dimensional, complex cavovarus deformities involving the midfoot and the forefoot. Concomitant ligament and tendon imbalances and pathologies need to be identified and analysed. Correction planning needs to include the mechanical axis of the complete leg. Muscular imbalances need to be identified. Even substantial deformities in varus ankle osteoarthritis can be treated with total ankle replacement successfully, if a plantigrade foot with balanced ligaments and tendons can be achieved. The corrective procedure may include realigning osteotomies, fusions, and correction of tendon and ligament pathologies.

Sprunggelenk und Fuß

Der strukturierte Weg zur orthopadischen Diagnose von Sprunggelenk und Fus beginnt mit der Uberprufung des Schuhwerks. Dann folgt die Inspektion, welche Gewolbeformen (unter Belastung), die Fersenbeinachse (Kalkaneusstellung), die Knochelachse (Talusstellung), die Vorfusstellung, die Stellung von Klein- und Groszehen umfasst, bevor eine Ganganalyse durchgefuhrt wird. Wahrend der Palpation werden palpatorische »landmarks« am medialen und lateralen Fus untersucht und eine Metatarsalgiediagnostik durchgefuhrt. Die Bewegungsprufung umfasst Groszehengrundgelenk, Dorsalextension/Plantarflexion im oberen Sprunggelenk, Supination/Pronation des Vorfuses und die Eversion/Inversion (subtalare Beweglichkeit). Spezielle Funktionstests stehen zur Verfugung: Ausenrotationstest nach Frick, Untersuchung von seitlicher Aufklappbarkeit, Talusvorschub und der intermetatarsale Drucktest bei Morton-Neurom sowie der Thompson-Drucktest (Wadenkneiftest). Die neurologische Untersuchung rundet die Diagnostik ab.

Biomechanical Principles of Foot and Ankle

This Chapter presents biomechanics of foot and ankle with a particular focus on biomechanics in sports, and the influence of surgical procedures on biomechanics. A thorough biomechanical understanding is necessary for successful treatment strategies for foot and ankle pathologies. Any treatment should aim to restore physiological biomechanics or get biomechanics as close to normal as possible. Impaired function and range of motion of joints of the foot and ankle overloads adjacent joints, disturbs gait and increases energy consumption. Certain sports require more than a physiological performance of the foot or overuse structures of the foot even when performed correctly and with an excellent and well-balanced technique and training schedule. In sports biomechanical demands on the foot and ankle are high. This is why even small deformities and abnormities that usually would not cause any problems can lead to overuse or make prone for specific injuries.