Ramón Viladot

Hallux Valgus and First Ray Mobility: A Cadaveric Study

Background: Several studies have demonstrated that patients with hallux valgus (HV) deformities have increased first ray sagittal mobility. However, the change in mobility that occurs after surgical correction of HV deformities has not been extensively evaluated. This study was done to determine if surgical realignment of the first ray in cadaver specimens with a proximal crescentic osteotomy and distal soft tissue reconstruction (DSTR) would reduce the first ray sagittal motion as measured with an external-type micrometer (the Klaue device). Methods: Twelve fresh-frozen below-knee cadaver specimens with an HV deformity (HV angle > 15 degrees, 1-2 IM angle > 9 degrees) were used for the study. Standardized simulated weightbearing radiographs were obtained before and after the surgical correction of the deformity. The first ray sagittal motion was measured with an external micrometer (Klaue device) before correction of the HV deformity and after the procedure. All specimens had correction of the hallux valgus deformity with a DSTR and proximal crescentic osteotomy. Internal fixation was applied to secure the osteotomy site. Results: The HV angle was corrected from a mean of 28.6 degrees to a mean of 11.0 degrees. The 1-2 IM angle was corrected from a mean of 12.9 degrees to a mean of 6.8 degrees. The average preoperative first ray sagittal motion was 11.0 mm (range, 8.5 mm to 13.5 mm). After the surgical repair, the mean sagittal first ray motion was significantly decreased (p <.0005) to a mean of 5.2 mm (range, 3.5 mm to 7.5 mm). Conclusion: After correction of HV deformities with a DSTR and a proximal crescentic osteotomy, first ray mobility in cadaver specimens was significantly reduced. The stabilization of first ray mobility that occurred immediately after surgical correction despite leaving the capsule of the first metatarsocuneiform (MC) joint undisturbed suggests that extrinsic anatomic features may play a role in first ray mobility. Additionally, stability of the first ray may be restored with a bunion procedure that does not sacrifice the first MC joint.

Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study.

Background: Ligamentous and capsular insufficiency of the second metatarsophalangeal joint has been surgically treated for over two decades, mainly with indirect surgical repairs, which stabilize adjacent soft tissue and shorten or decompress the osseous structures. While ligamentous insufficiency has been described and recognized, degeneration of the plantar plate and tears of the capsule have rarely been documented. The purpose of this study was to document and describe the presence and pattern of plantar plate tears in specimens with crossover second toe deformities, and based on this, to develop an anatomical grading system to assist in the assessment and treatment of this condition. Methods: Sixteen below-knee cadaveric specimens with a clinical diagnosis of a second crossover toe deformity were examined, and dissected by removing the metatarsal head. The pathologic findings of plantar plate and capsular pathology, as well as ligamentous disruption, were observed and recorded. Demographics of the specimens were recorded, and simulated weightbearing radiographs were obtained prior to dissection so that pertinent angular measurements could be obtained. Results: Demographics demonstrated a high percentage of female specimens, and a typically older population that has been reported for this condition. Radiographic findings documented a high percentage of hallux valgus and hallux rigidus deformities. The MTP-2 and MTP-3 angles were divergent consistent with a crossover toe deformity. We consistently found transverse tears in the plantar plate region immediately proximal to the capsular insertion on the base of the proximal phalanx. With increasing deformity, wider distal transverse tears extending from lateral to medial were found. Midsubstance tears, collateral ligament tears, and complete disruption of the plantar plate were found in more severe deformities. Conclusion: In this largest series of cadaveric dissections of crossover second toe deformities, we describe the types and extent of plantar plate tears associated with increasing deformity of the second ray. We present, based on these findings, an anatomic grading system to describe the progressive anatomic changes in the plantar plate.

First Metatarsophalangeal Joint Motion After Hallux Valgus Correction: A Cadaver Study

Background: Surgical correction of hallux valgus deformities often results in decreased first metatarsophalangeal joint (MTPJ) range of motion. Loss of motion has been shown to affect patient satisfaction. The purpose of this study was to evaluate the immediate change in MTPJ range of motion that occurs after a distal soft-tissue reconstruction (DSTR) and proximal metatarsal osteotomy (PMO). Methods: DSTR and PMO were done on 16 below-knee cadaver specimens with clinically apparent hallux valgus deformities. Two examiners assessed preoperative and postoperative dorsiflexion (DF), plantarflexion (PF), and the total range of motion of the first MTPJ. The hallux valgus angle (HVA) and 1–2 intermetatarsal angle (1–2 IMA) were measured on simulated weightbearing radiographs before and after operative correction. Changes in motion were analyzed and correlated with the angular measurements. Results: The mean total range of motion preoperatively was 85.4 degrees (DF 70.5 degrees, PF 14.9 degrees) and significantly decreased (p < 0.005) 23.2 degrees to a postoperative value of 62.2 degrees (DF 47.9 degrees, PF 14.3 degrees). There was a significant (p < 0.005) decrease in DF (22.6 degrees) with the operative correction, but the loss of PF (0.6 degrees) was not significant (p = 0.7). There was no correlation between the magnitude of correction (HVA, 1–2 IMA) and the change in PF, DF, or total motion. Conclusions: Correction of a hallux valgus deformity with a DSTR and PMO is associated with an immediate loss of range of motion that primarily affects the DF arc of the first MTPJ. The selective loss of DF may be related to a nonisometric capsular repair or tight intrinsic musculature, although there was no correlation with the magnitude of angular correction. The immediate decrease in motion observed in this cadaver study underscores the importance of early postoperative joint mobilization to prevent long-term stiffness after bunion surgery.

Subtalar Arthroereisis in Pediatric Flatfoot Reconstruction

Pediatric and juvenile flatfoot is a common problem in childhood, present in one in nine children. The morphologic characteristics of this condition are heel valgus and flattening of the medial longitudinal arch. Other characteristics are usually observed, such as supination and abduction of the forefoot, tightening of the Achilles tendon, and hypertonia of the peroneal muscles. Most children with flatfoot will undergo spontaneous correction or become asymptomatic; those that are symptomatic require treatment. Subtalar arthroereisis, often combined with Achilles tendon lengthening, is a simple and effective way to treat flexible flatfoot in children. Mid- and long-term results are good, and the procedure does not prevent future treatments.

Tendoscopic treatment of intrasheath subluxation of the peroneal tendons.

Background: Intrasheath subluxation of the peroneal tendons does not have an injury of the proximal retinaculum. The aim of this study was to describe the tendoscopic technique and preliminary results. Methods: Six patients with intrasheath subluxation of the peroneal tendons were treated tendoscopically. All patients had preoperative pain and a clicking sensation at the lateral retromalleolar area. Mean followup was 18.3 (range, 14 to 24) months. These six patients included three males and three females, with a mean age of 23.5 (range, 18 to 33) years. The AOFAS and Visual Analog Score for pain were used to evaluate the patients. Results: During tendoscopy, two patients had a peroneus quartus tendon which was removed; three had a low-lying peroneus brevis muscle that was resected; and in two cases deepening of the peroneal groove was performed. At followup, all patients reported excellent results, without pain or clicking sensation. The mean AOFAS score increased from 79 to 99, and Visual Analog Score at followup was 0 in four patients and 1 in two patients. Conclusion: Tendoscopic treatment of these pathologies led to improved function in a less aggressive manner than open surgery. Level of Evidence: IV, Retrospective Case Series

Tendoscopic groove deepening for chronic subluxation of the peroneal tendons.

Introduction: Recurrent subluxation of the peroneal tendons over the lateral malleolus is an uncommon disabling condition in young people involved in sports. Injury to the superior peroneal retinaculum, sometimes in association with a shallow fibular groove, can lead to this condition. There are several surgical treatments for recurrent peroneal tendon subluxation, but no tendoscopy technique has been reported to date. The aim of this study was to describe a tendoscopic groove-deepening technique and its results for treating patients with recurrent subluxation of the peroneal tendons. Methods: Seven patients (3 women and 4 men; mean age 26.4 [21-32] years) with chronic subluxation of the peroneal tendons were treated with a tendoscopic procedure. All patients experienced pain at the lateral retromalleolar area and recurrent subluxation of the peroneal tendons. The right ankle was affected in 4 patients. Mean follow-up was 15.4 (8-25) months. Results: On tendoscopic examination, all patients had a flat fibular groove, and the superior peroneal retinaculum was found to be detached in 4 cases. Three patients had a superficial injury of the peroneus brevis tendon which was debrided. Tendoscopic deepening of the peroneal groove without superior peroneal retinaculum repair was performed in all cases. None of the patients experienced recurrent subluxation during follow-up. The AOFAS score increased from 75 preoperatively to 93 at final follow-up. No complications were reported in any case. Conclusion: Tendoscopic deepening of the fibular groove was a reproducible, minimally invasive technique that provided a favorable outcome for recurrent subluxation of the peroneal tendons in our limited number of patients. Level of Evidence: Level IV, retrospective case series.

The importance of the length of the first metatarsal and the proximal phalanx of hallux in the etiopathogeny of the hallux rigidus

The purpose of this study was to determine if the relative length of the first metatarsal and the proximal phalanx of the hallux, in respect to the total foot length, were associated with the incidence of hallux rigidus. For this retrospective study, lateral radiographs from 132 cases with hallux rigidus and a control group of 132 normal feet were reviewed. We measured the following parameters: the index between the foot length and first metatarsal length, the proximal phalanx of the hallux length, and the sum of the first metatarsal length and the proximal phalanx of the hallux length. We found a statistically significant difference (p: 0.002) between the two groups in the Foot L/1st Mtt L index, and no statistical difference in the Foot L/Phalanx L index. We think that a greater length of first metatarsal is involved in the etiopathogeny of hallux rigidus.

First metatarsocuneiform joint mobility: Radiographic, anatomic, and clinical characteristics of the articular surface

Background: The first metatarsocuneiform joint is involved in first ray biomechanics and related forefoot pathology. The purpose of this study was to evaluate the first metatarsocuneiform joint radiographic findings in relation to angular position of the radiographic beam, and to assess the joint mobility as it relates to the anatomic orientation of the facets on both radiographic imaging and gross anatomic dissection. Methods: Thirty-nine cadaveric lower extremity limbs were stratified as normal, mild, moderate, or severe hallux valgus deformity. Mobility of the first metatarsocuneiform joint for each specimen was assessed using the Klaue device. The medial inclination angle (obliquity) of the first metatarsocuneiform joint was determined on both 10-degree and 20-degree anteroposterior radiographs. The lateral inclination angle of both the dorsal and plantar facets was determined on lateral radiographs. Each specimen was then dissected to directly inspect the metatarsocuneiform joint. Results: The metatarsocuneiform joint mean height was 28.3 mm and the mean width was 13.1 mm. Twenty-three feet demonstrated a continuous cartilaginous surface, 15 feet demonstrated a bilobed cartilaginous surface, and 1 foot demonstrated completely separated facets. Dorsal facets were curved in 37 specimens and flat 2 specimens. Plantar facets were flat in 30 specimens and curved in 9 specimens. The medial inclination angle measured 15.8 degrees on the 10-degree radiograph and 2.6 degrees on the 20-degree radiograph. We were unable to establish any correlations of metatarsocuneiform joint angles or facet contour with mobility measured by the Klaue device. Conclusions: The metatarsocuneiform joint has a height to width ratio of nearly 2:1. Continuous and bilobed facets are both very common anatomic variants. The contour of the dorsal facet was predominantly curved and the contour of the plantar facet was predominantly flat. First metatarsocuneiform joint mobility does not appear to be dependent on the contour of the facets or the degree of medial inclination of the joint. Clinical Relevance: Anatomic and radiographic findings with regard to mobility of the first metatarsocuneiform joint may assist the surgeon in interpreting the joint’s relationship to hallux valgus deformity and to aid in clinical decision making. Our findings suggest that radiographic interpretation of medial inclination is unreliable and should not be used to determine the appropriateness of specific operative procedures.

Comparison of Radiographic and Anatomic Distal Metatarsal Articular Angle in Cadaver Feet

Background: A few studies report correlations between radiographic and anatomic measurements of the distal metatarsal articular angle (DMAA). However, little is known about how the DMAA correlates with the hallux valgus angle (HVA) and with anatomic and clinical radiographic measurements. Methods: We dissected, measured, and radiographed 39 cadaveric feet for evidence of hallux valgus and the DMAA. We then correlated these values with paired clinical radiographic measurements made by physician evaluators. Results: Physician measurement of DMAA and anatomic measurement of DMAA were significantly correlated with a mean r = 0.64 (evaluator range, 0.44-0.66). Pairwise correlation between physician evaluators ranged from r = 0.63 to 0.84. Sixty-six percent of physician-measured DMAAs were within 5 degrees of anatomic DMAA. Conclusion: The percentage of radiographic DMAAs that were within 5 degrees of anatomic DMAAs was only 66%. Additionally, the DMAA was increased in the specimens with moderate and severe hallux valgus compared with those with normal or mild hallux valgus angles. Clinical Relevance: The DMAA is an important consideration in patients with hallux valgus. While it is less reliable than other radiographic measures, it was correlated to deformity severity in specimen with hallux valgus.

Articular chondral damage of the first metatarsal head and sesamoids: Analysis of cadaver hallux valgus

Background: Evidence of successful correction on postoperative hallux valgus imaging studies may not always correlate with patient satisfaction. Recent attention to the association of cartilaginous degeneration and hallux valgus may provide new insight into treatment algorithms and patient expectations. The purpose of this cadaveric study was to evaluate the degree of chondral damage as it relates to increasing hallux valgus deformity. Methods: A total of 39 cadaver first metatarsophalangeal joints were evaluated by radiography, and then dissected to evaluate for chondral damage. Chondral lesion grade, size, and location were recorded and then analyzed based on patient demographics and hallux valgus angle. Results: Twenty-nine of 39 specimens were considered to have hallux valgus characterized by a hallux valgus angle of 15 degrees or greater. Four of 39 (10%) specimens revealed absence of chondral lesions, and 3 of those were found in the group with a hallux valgus angle of less than 15 degrees. Chondral lesions of increasing size and grade were seen more commonly with a more severe hallux valgus deformity. Particular locations on the metatarsal head appeared to be more prone to cartilaginous lesions when compared to other locations. Conclusion: Assessment of first metatarsophalangeal joint articular damage with regard to hallux valgus may be an important clinical parameter for consideration. Clinical Relevance: Operative intervention to realign the first metatarsophalangeal joint may correct malalignment and relieve pressure on the widened forefoot, but residual pain within the joint may emanate from preexisting articular cartilaginous lesions. These findings support the concept that earlier intervention with operative realignment of a hallux valgus deformity and specifically the sesamoid complex may diminish degenerative changes.