Paul Dayton

Reduction of the intermetatarsal angle after first metatarsophalangeal joint arthrodesis in patients with moderate and severe metatarsus primus adductus

A radiographic review of first metatarsophalangeal joint (MPJ) arthrodesis in patients who had preoperative intermetatarsal angles greater than 15 degrees is presented. The average reduction of the intermetatarsal angle was measured. Twenty-one patients with 22 fusions, with ages ranging from 43 to 79 years old, underwent first MPJ arthrodesis with screw or pin fixation as determined appropriate by their age and bone quality. Preoperative intermetatarsalangles averaged 17.27 degrees with a range of 15 degrees - 21 degrees. An overall reduction in the intermetatarsal angle of 6.41 degrees was noted. Mechanical factors affecting the reduction of the intermetatarsal angle following first MPJ arthrodesis are discussed.

Observed Changes in Radiographic Measurements of the First Ray after Frontal and Transverse Plane Rotation of the Hallux: Does the Hallux Drive the Metatarsal in a Bunion Deformity?

It is well known that the pathologic positions of the hallux and the first metatarsal in a bunion deformity are multiplanar. It is not universally understood whether the pathologic changes in the hallux or first metatarsal drive the deformity. We have observed that frontal plane rotation of the hallux can result in concurrent positional changes proximally in the first metatarsal in hallux abducto valgus. In the present study, we observed the changes in common radiographic measurements used to evaluate a bunion deformity in 5 fresh frozen cadaveric limbs. We measured the tibial sesamoid position, 1-2 intermetatarsal angle, and first metatarsal cuneiform angle on anteroposterior radiographs after frontal and transverse plane manipulation of the hallux. When the hallux was moved into an abducted and valgus position, a statistically significant increase was found in the tibial sesamoid position (p = .016). However, we did not observe a significant increase in the intermetatarsal angle (p = .070) or medial cuneiform angle (p = .309). When the hallux was manipulated into an adducted and varus position, a statistically significant decrease in the intermetatarsal angle (p = .02) and a decrease in the tibial sesamoid position (p = .016) was seen, with no significant change in the medial cuneiform angle (p = .360). We also observed a consistent rounding of the lateral aspect of the first metatarsal head and an increase in the concavity of the lateral metatarsal shaft, with valgus rotation of the hallux. From these observations, it is possible that the hallux could drive the proximal changes in the first ray that lead to metatarsus primus adducto valgus deformity.

Clarification of the Anatomic Definition of the Bunion Deformity

Evolution of the terminology applied to the bunion deformity has progressed in parallel with our changing understanding of the deformity itself. Along this path of progression have been multiple terms, sometimes with multiple meanings. Hallux valgus and metatarsus primus varus are 2 of the most common terms for the deformity. Although commonly used, these descriptors can have multiple meanings, and inconsistencies in interpretation can lead to confusion. We propose a more detailed terminology to provide a more accurate description of the entire bunion deformity in 3 planes and for both the hallux and the metatarsal component of the deformity. The term we propose is hallux abducto valgus with metatarsus primus adducto valgus. An accurate understanding of the multiplanar position of the deformed foot is important for planning deformity correction. The descriptors in the terminology proposed will keep in the forefront the aspects of correction required for the first ray and hallux to be returned to an anatomically correct position.

Reduction of the Intermetatarsal Angle after First Metatarsal Phalangeal Joint Arthrodesis: A Systematic Review

Arthrodesis of the first metatarsophalangeal joint (MTPJ) has commonly been used for the treatment of a variety of first MTPJ disorders, including hallux valgus. We undertook a systematic review of the electronic databases and other relevant sources to identify material relating to the reduction of the first intermetatarsal angle (IMA) after first MTPJ arthrodesis. Fifteen studies with a total of 701 first MTPJ arthrodesis procedures were identified that met the inclusion criteria. Our results showed the mean preoperative IMA was 13.74° and the mean postoperative IMA was 9.38°, for a mean change in the IMA of 4.36°. The data were analyzed further in 2 subsets. The first subset included 8 studies (434 procedures) that reported a mean preoperative IMA of less than 15°. The mean change in the IMA in this group was 3.70°. The second subset included 7 studies (267 procedures) that reported a mean preoperative IMA of greater than 15°. The mean change in the IMA in this group was 5.42°. The results of the present systematic review have confirmed that a significant reduction of the first IMA can be achieved by first MTPJ arthrodesis alone and that additional procedures to correct the IMA will not be necessary.

Incidence of Surgical Site Infection in the Foot and Ankle with Early Exposure and Showering of Surgical Sites: A Prospective Observation

The incidence of postoperative surgical site infection (SSI) reported in the published data for foot and ankle surgery has been 1.0% to 5.3%. A variety of interventions have been used before, during, and after surgery to decrease the patients risk of acquiring an infection at the surgical site. Foot and ankle surgeons often keep the incision site dry and covered until the sutures and pins have been removed, with the goal of preventing a SSI, despite the lack of available published evidence to support this practice. We undertook a prospective observation of 110 elective surgical patients to determine the rate of SSI when early surgical site exposure and showering were allowed. The risk factors for infection were recorded, and a series of logistic regression analyses was performed to determine the associations between the infection rate and early showering. The patients were evaluated at each postoperative appointment for signs of infection. For the present study, mild infection was defined as the subjective presence of erythema and/or swelling beyond that typically expected in the early postoperative period. These cases of presumed or mild SSI were managed with oral antibiotics until they had resolved. Major infection was defined as any infection altering the course of recovery or requiring admission or additional surgery. The overall infection rate was 4.5%, with all infections considered mild. Logistic regression analysis showed that none of the recorded risk factors significantly predicted infection. The results of the present study suggest that early daily showering of a surgical site after foot and ankle surgery will not be significantly associated with an increased risk of infection.

Does Postoperative Showering or Bathing of a Surgical Site Increase the Incidence of Infection? A Systematic Review of the Literature

Infection is one of the many postoperative complications a surgeon must attempt to control during the perioperative period. Surgeons have used a variety of modalities to prevent surgical site infection and have adhered to a variety of protocols. It has been common for foot and ankle surgeons to recommend that a patient keep the surgical incision covered and dry and to instruct the patient to avoid bathing and showering until the sutures have been removed. Surgeons have theorized that this will reduce contamination of the surgical site and help to prevent infection. We questioned the evidence basis for this practice and undertook a systematic review of electronic databases and other relevant sources regarding the incidence of infection when patients had been allowed to wet their surgical incision site by showering or bathing before suture removal. Nine studies involving 2150 patients met our inclusion criteria. No increased incidence of infection was found in the patients allowed to shower or bathe as a part of their normal daily hygiene before suture removal compared with those who were instructed to keep the site dry until suture removal.

Complications of Metatarsal Suture Techniques for Bunion Correction: A Systematic Review of the Literature

To better understand the safety of suture techniques to reduce the intermetatarsal angle in patients with hallux valgus deformity, we undertook a systematic review of the complications associated with the use of this technique. The suture procedures of 197 patients were analyzed for complications. The number of complications in the total group (n = 197) at a pooled mean follow-up period of 23.2 months was 39 (19.8%) and included 21 fractures (10.7%), 11 cases of hardware failure (5.6%), and 7 cases of hallux varus (3.6%). The cohort of patients was further categorized by the specific procedure technique. The number of complications in the Mini TightRope(®) group (n = 132) at a pooled mean follow-up period of 16.2 months was 33 (25%) and included 18 fractures (13.6%), 10 cases of hardware failure (7.6%), and 5 cases of hallux varus (3.8%). The number of complications in the syndesmosis technique group (n = 65) at a pooled mean follow-up period of 56.1 months was 6 (9.2%) and included 3 fractures (5%), 1 case of hardware failure (1.5%), and 2 cases of hallux varus (3%). From our review of the published experience with this technique, a high complication rate can be expected.

Use of the Z Osteotomy for Tailor Bunionectomy

The authors present a unique use of the Z osteotomy in the fifth metatarsal for correction of Tailor bunion. The rotational capabilities of the Z osteotomy are exploited to provide correction of fifth metatarsal lateral bowing and to decrease intermetatarsal angles. The osteotomy is inherently stable, and the design facilitates internal fixation.

Technique for Minimally Invasive Reduction of Calcaneal Fractures Using Small Bilateral External Fixation

Soft tissue complications are well known after extensile exposure of the calcaneus for open reduction internal fixation of fractures. A variety of recommendations have been proposed to reduce soft tissue healing issues and infection. Despite these recommendations, some surgeons believe that soft tissue complication rates have remained unacceptably high with lateral extensile incisions. Recently, interest in minimally invasive repair techniques for calcaneal fractures has increased. These techniques have been purported to avoid some of the common soft tissue problems seen with calcaneal open reduction internal fixation. The focus of the present communication is to share a minimally invasive surgical method for the reduction and fixation of calcaneal fractures. Percutaneous fixation of the posterior facet fragments can be facilitated by distraction of the fractured calcaneus using skeletal traction and a small bilateral external fixator. Final stability is achieved with a combination of the external fixator and percutaneous screws and/or wires. We present our technique and discuss recent published studies on minimally invasive repair of calcaneal fractures.

Hallux Varus as Complication of Foot Compartment Syndrome

Hallux varus can present as a congenital deformity or it can be acquired secondary to trauma, surgery, or neuromuscular disease. In the present report, we describe the presence of hallux varus as a sequela of calcaneal fracture with entrapment of the medial plantar nerve in the calcaneal tunnel and recommend that clinicians be wary of this when they clinically, and radiographically, evaluate patients after calcaneal fracture.